Mediterranean Diet in Axial Spondyloarthritis

An Observational Study in an Italian Monocentric Cohort

Francesca Ometto; Augusta Ortolan; Davide Farber; Mariagrazia Lorenzin; Giulia Dellamaria; Giacomo Cozzi; Marta Favero; Romina Valentini; Andrea Doria; Roberta Ramonda


Arthritis Res Ther. 2021;23(219) 

In This Article

Abstract and Introduction


Background: Little evidence is available about the impact of diet on disease activity of axial spondyloarthritis (axSpA). This study evaluated the impact of a 6-month nutritional advice based on the Mediterranean diet on the disease activity of axSpA.

Methods: We prospectively collected the information of a group of axSpA patients who were offered nutritional advice for a 6-month period, who were compared to axSpA patients followed at the same center who were not on a specific diet. A nutritionist gave suggestions for dietary modification at baseline and thereafter every 2 months until month 6. Adherence to the Mediterranean diet was evaluated with the PREDIMED questionnaire ranging from 0 (no adherence) to 10 (optimal adherence); disease activity was evaluated with ASDAS-CRP. A multivariable regression analysis was conducted to identify independent predictors of PREDIMED and of ASDAS-CRP improvement (improvement ≥ 20% of each score).

Results: A total of 161 patients were included: 81 receiving nutritional advice and 80 controls; 47 in the nutritional group and 63 controls had complete information until month 6. Overall, 40 (36.4%) were females, the mean age was 51.7 ± 1.3 years, and 58 (52.7%) were affected with psoriasis. No relevant change of anthropometric or laboratory measures was observed in either group. Adherence to the Mediterranean diet was moderate (PREDIMED score 6.7 ± 1.8 at baseline; 7.6 ± 2.1 at month 6) and improved more in the nutritional group compared to controls (p = 0.020). Predictors of a PREDIMED improvement ≥ 20% were receiving nutritional advice (OR 4.53, 1.36–15.1, p = 0.014), age (per 10-year increase OR 1.05, 1.02–1.68, p = 0.007), and BMI (OR 0.77, 0.63–0.9, p = 0.006). An ASDAS-CRP improvement ≥ 20% was more frequent in the nutritional group compared to controls (p = 0.020). A PREDIMED improvement ≥ 20% was associated with a ASDAS-CRP improvement ≥ 20% (OR 6.75,1.8–25.3, p = 0.005). Psoriasis and disease duration were negatively but not significantly associated to the ASDAS-CRP improvement.

Conclusions: Improving adherence to the Mediterranean diet may have a beneficial impact on the activity of axSpA. Patients with a lower BMI and older patients are less prone to modify their diet towards the Mediterranean diet following nutritional advice. Patients with psoriasis may have a limited benefit from dietary improvement.

Study registration: Protocol No. 52723, Padova Hospital Medical Ethical Committee (October 11, 2010).


Axial spondyloarthritis (axSpA) is a group of debilitating, chronic, rheumatic diseases characterized by inflammation and new bone formation, mainly involving the spine and the sacroiliac joints. People living with axSpA often turn to lifestyle interventions to complement pharmacological treatment with a particular interest on diet.[1] Among environmental factors, diet has been suggested as a potential modifiable factor to improve inflammation in different rheumatic conditions.[2–7] Mediterranean diet (MD) has shown a protective role in terms of cardiovascular morbidity and overall mortality.[6,8] MD involves high consumption of olive oil, unrefined carbohydrates, fresh and dried fruit, vegetables, and fish; reduced intake of dairy products and red meat; and moderate red wine consumption; MD is very rich in antioxidants and particularly n-3 polyunsaturated fats, alpha-linoleic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). There is evidence that in rheumatoid arthritis, these nutrients may have a beneficial effect by reducing inflammation, reducing pain and structural damage, and possibly reducing the incidence of the disease.[8–13]

There is an unmet need to understand the effects of MD on axSpA, characterized by an increased cardiovascular risk.[14–16] A considerable issue in studies concerning the MD is to assess the adherence to MD. In the PREDIMED trial, a large case-control study on cardiovascular risk, a 14-item questionnaire was introduced with this aim: PREDIMED is consistent with other dietary questionnaires to evaluate MD and is more feasible in clinical practice.[17]

We conducted a prospective study in a monocentric cohort of axSpA patients who received a 6-month nutritional advice based on the MD. We evaluated the impact of the nutritional advice on dietary habits, assessed with the PREDIMED questionnaire, and on axSpA disease activity in these patients compared to controls.