For centuries, various cultures have used food as medicine for optimal health and healing. We are currently dealing with an explosion of knowledge and research on the benefits of food, specifically with regard to phytonutrients, and learning that some cultural food traditions have supporting evidence for optimal health. We are also learning that the “western” diet that is currently the default eating pattern for most Americans is not good for our health or that of our children. The western diet is epitomized by fast food, processed food, and prepackaged food, which although convenient is not necessarily healthy) and evidence is emerging that the chemicals, emulsifiers, and preservatives that are added to food to increase their shelf life and taste, most likely affect our microbiota with negative consequences.1 Mindfulness has been shown to counterbalance the effects of stress and modern living, and eating mindfully is important. It has been shown that if we pay attention to the benefits of specific foods, we can start to make better choices, and if we pay attention as we eat we are likely to eat less and to better digest what we do eat.2 There has been an increase in rates of diseases linked to a western diet: obesity, type 2 diabetes, heart disease, and some forms of cancer. Inflammation is involved in the pathogenesis of some of these conditions. Acute inflammation (which is the way the body responds to stress) can become chronic if unchecked, thus paving the way for the development of chronic diseases. Therefore, there is an interest in diets that do not contribute to inflammation as well as diets that can be used to treat and prevent inflammation.
There was an observational study of men called the Seven Countries Study3 that took place in the United States, Finland, Japan, Greece, Italy, Netherlands, and Yugoslavia from 1958 to 1970 in which health outcomes and diets were monitored. Dietary patterns in Italy, Greece, and Japan were associated with lower rates of coronary heart disease and all-cause mortality.3 Additionally, in the elderly, healthy diet and lifestyle were associated with a low risk of cardiovascular disease and all-cause mortality, decreased risk of depression, and delayed onset of cognitive decline. This landmark study provided evidence for the concept that there are sick and healthy populations, major cardiovascular risk factors are universal, diets can lead to heart disease (diet-heart hypothesis), cardiovascular disease is preventable, and that a healthy lifestyle may promote different aspects of health. The next big study was the China project,4 a large observational study in the 1980s in rural China undertaken by Cornell and Oxford Universities in collaboration with the Chinese government. Diet, lifestyle, and disease characteristics were studied in 6,500 people in 65 rural communities. The study found a high consumption of animal-based foods resulted in a higher death rate from cancer, demonstrating a relationship between diet and cancer. Western diets (high in fat and meat and low in dietary fiber) were strongly associated with the incidence of colon and breast cancer.4 Migrants who moved to areas of different cancer risks acquired the risk of the place to which they moved to, regardless of their ethnic or genetic background.4 Subsequently, the Lyons study5 confirmed the impact of diet on cardiovascular health and showed that people who had suffered a heart attack could reduce the risk of a second heart attack by following a Mediterranean diet.
What is the Anti-Inflammatory Diet?
The Mediterranean diet is primarily plant-based and rich in fruits, vegetables, whole grains, minimally processed cereals, and legumes. The fat sources consist of olive oil, olives, nuts, and seeds. Spices, herbs, garlic, and onions are used liberally. There is a moderate ingestion of lower-fat dairy products (yogurt and cheeses) and fish and shellfish. The diet is low in saturated fat, eggs, and white meats. Water is consumed regularly with infrequent ingestion of small amounts of potatoes, red meat, cured meats, and sweets. Another population, the Okinawans, have low rates of cardiovascular disease, some cancers, diabetes, and several other age-associated chronic diseases.6 Their diet is low in fat, and high in fruit and vegetables. There is an emphasis on fish and lean proteins including whole soy foods, fermented foods, and mushrooms. Vegetables are the entrée with fish or soy, and meat is eaten in small quantities. Turmeric, fennel, and green seaweed are used liberally. Based on the data from these diets, the anti-inflammatory diet pyramid, created by Andrew Weil,7 combines the best of the Okinawan and Mediterranean diets (Figure 1). Table 1 provides a comparison of these diets, including the standard western diet. A pediatric version of the anti-inflammatory diet pyramid was created (Figure 2) and adjusted for the needs of growing children. It should be stated that the Mediterranean diet is not just a diet but is a pattern of living traditionally followed by people of the Mediterranean region (ie, Greece, Crete, southern France, and parts of Italy). The diet represents a diverse range of locally grown foods eaten in season. Conviviality, culinary activities, physical activity, and rest are also emphasized. The anti-inflammatory diet is also a “whole foods” approach in which there is minimal commercial processing of food, which minimizes loss of micronutrients and phytochemicals. In addition, there is a more hands-on, “human touch” approach to the food. Organic produce (grown without toxic herbicides and insecticides) is the basis of the diet. Other features include the importance of the community; families that cook together; the interconnectedness of the food, people, and land; a farm-to-table feature that supports local farmers and cooperatives; and a sustainable agricultural model. The Mediterranean diet has been shown to reduce the burden and even prevent the development of cardiovascular disease, breast cancer, depression, colorectal cancer, diabetes, obesity, asthma, and cognitive decline in adults.8 However it is not clear whether the benefits are related to individual components or in aggregate.9 Research on the Mediterranean diet and microbiome has shown that the diet is associated with a favorable microbiome.10,11
Adult anti-inflammatory pyramid. Reprinted with permission of the Arizona Board of Regents, University of Arizona. © Arizona Board of Regents.
Pediatric anti-inflammatory pyramid. Reprinted with permission of the Arizona Board of Regents, University of Arizona. © Arizona Board of Regents.
Mechanism of Action
So how does the anti-inflammatory diet work? Polyphenols (found in foods such as berries, cocoa, and tea) protect against oxidative processes. Flavonoids, (found in foods such as fruits and nuts), anthocyanins, and catechins (present in tea) provide oxidative protection, modulate inflammation, and improve vascular function. Walnuts help decrease low-density lipoprotein cholesterol, total cholesterol, triglycerides, interleukin-6, and tumor necrosis factor-alpha levels. Olive oil, which is high in oleic acid and monounsaturated fatty acid, is anti-atherogenic and its anti-inflammatory properties improve lipid profiles. Polyunsaturated fatty acids (eicosapentaenoic acid and docosahexaenoic acid) are present in fish and help with hemostatic regulation, preservation of cognitive function, protection from cancer, and decreasing diastolic blood pressure. The high fiber content of the diet results in a low glycemic index and decreased intestinal inflammation. Resveratrol, which is present in red wine, has been shown to decrease C-reactive protein levels and interleukin-6, and magnesium, found in foods such as whole grains, spinach, quinoa, and black beans, is associated with decreased inflammation.12
Data regarding diet in pediatric patients are primarily based on the Mediterranean diet and mainly are from Mediterranean countries. Beneficial effects have been noted with regard to obesity, cardiorespiratory fitness, diabetes, fatty liver, academic performance, attention-deficit/hyperactivity disorder (ADHD), asthma, and allergies. In a large cross-sectional study in 1,643 adolescents age 11 to 16 years, Mistretta et al.13 showed that vegetable intake was negatively associated with obesity, whereas higher intake of fast foods, sweets, and sugar-sweetened beverages was positively associated with being overweight/obese. Good adherence to the Mediterranean diet resulted in a 30% decreased risk of being overweight/obese, and there was an inverse correlation between adherence, body mass index, waist circumference, and fat mass.13 Similar effects were seen in younger children in the Assessing Fitness in Preschoolers study,14 in which lower waist circumference was related to better adherence and cardiorespiratory fitness. In another study, significant reductions in total cholesterol, low-density lipoprotein, and carotid intima-media thickness were seen in prepubertal children on the Mediterranean diet.15 With regard to fatty liver, poor adherence to the Mediterranean diet was seen in patients with fatty liver, and this correlated with liver damage and increased C-reactive protein levels, fasting insulin, and insulin resistance.16 Esteban-Cornejo et al.17 evaluated adherence to the Mediterranean diet children age 10 to 14 years and showed that higher adherence to the diet was related to better academic performance. Rios-Hernandez et al.18 showed that in children newly diagnosed with ADHD, lower adherence to the diet was associated with higher consumption of sugar, candy, cola beverages, and non-cola soft drinks; lower frequency of consuming fruit, vegetables, pasta, and rice; and higher frequency of skipping breakfast and eating at fast-food restaurants. In 2011, Arvaniti et al.19 described an inverse relationship between adherence to the Mediterranean diet and the prevalence of asthma in school-aged children. A meta-analysis in 2014 showed that the Mediterranean diet had a protective effect on childhood asthma.20 However, there was no beneficial effect with the diet in preventing atopic eczema, rhinitis, or atopy.21 In Peruvian children, adherence to the diet was inversely associated with having asthma.22 In Serbia and Lithuania, higher adherence was associated with higher self-rated health, socioeconomic status, and physical activity, and lower adherence was associated with female sex, higher body mass index, psychological distress, and sedentary behavior in adolescents.23
Maternal ingestion of the Mediterranean diet while pregnant may have beneficial effects on infants and children. Protective effects on asthma (but not on atopy and eczema) have been seen in infants until age 1 year.21 Maternal ingestion of the Mediterranean diet with folic acid and vitamin supplements during pregnancy was associated with a decreased rate of acute lymphocytic leukemia in children.24 Maternal higher adherence to the Mediterranean diet in early pregnancy was associated with favorable neurobehavioral outcomes (depression, maladaptive behaviors, autism spectrum behaviors, anxiety) in their children.25
Is the Diet Adequate?
Data support the nutrient adequacy of the diet in adults and children, and better adherence results in adequate micronutrient status. In 2001, Serra-Majem et al.26 showed that Spanish children and young adults age 6 to 24 years consuming a Mediterranean diet had adequate nutrition. Higher adherence to the diet resulted in better intake of fiber, calcium, iron, magnesium, potassium, phosphorus, and all vitamins except vitamin E. Seiquer et al.27 in 2008 showed a significant increase in calcium absorption and retention and a decrease in urinary calcium excretion in male adolescents. Messias et al.28 in 2009 showed that healthy male adolescents in Spain age 11 to 14 years had adequate zinc levels despite high dietary phytate content. However, with continued “westernization” of these parts of Europe, fewer children in Mediterranean countries are consuming the same diet their grandparents did. In terms of adherence, Papadaki and Mavrikaki29 in 2014 showed that positive predictors of adherence to the diet included maternal educational level, living with both parents and residing in a smaller city. Negative predictors included age, more than 4 hours per day of computer use, and lack of physical activity.29 In a large meta-analysis, adherence was directly associated with physical activity and inversely with sedentary behavior.30
The anti-inflammatory diet has been shown to have beneficial effects in adults, with most of the evidence to date primarily from the Mediterranean diet. Pediatric data are limited but evolving.
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- Fung TT, Long MW, Hung P, Cheung LWY. An expanded model for mindful eating for health promotion and sustainability: issues and challenges for dietetics practice. J Acad Nutr Diet.2016;116(7):1081–1086. doi:. doi:10.1016/j.jand.2016.03.013 [CrossRef]
- Keys A, Menotti A, Arvanis C, et al. The Seven Countries study: 2,289 deaths in 15 years. Prev Med. 1984;13(2):141–154. doi:10.1016/0091-7435(84)90047-1 [CrossRef]
- Cornell University. The China project: studying the link between diet and disease. http://www.cornell.edu/video/playlist/the-china-project-studying-the-link-between-diet-and-disease. Accessed May 15, 2019.
- Kris-Etherton P, Eckel RH, Howard BV, et al. Nutrition Committee Population Science Committee and Clinical Science Committee of the American Heart Association. AHA Science Advisory: Lyon diet heart study. Benefits of a Mediterranean-style, National Cholesterol Education Program/American Heart Association step I dietary pattern on cardiovascular disease. Circulation. 2001;103:1823–1825. doi:10.1161/01.CIR.103.13.1823 [CrossRef]
- Willcox DC, Scapagnini G, Willcox BJ. Healthy diets other than the Mediterranean: a focus on the Okinawan diet. Mech Ageing Dev. 2014;136–137:148–162. doi:10.1016/j.mad.2014.01.002 [CrossRef].
- Weil A. Anti-inflammatory diet and pyramid. https://www.drweil.com/diet-nutrition/anti-inflammatory-diet-pyramid/#. Accessed May 15, 2019.
- Martinez-Gonzalez MA, Salas-Salvado J, Estruch R, et al. Benefits of the Mediterranean diet: insights from the PREDIMEN study. Prog Cardiovasc Dis. 2015;58(1):50–60. doi:. doi:10.1016/j.pcad.2015.04.003 [CrossRef]
- Widmer RJ, Flammer AJ, Lerman LO, et al. The Mediterranean diet, its component, and cardiovascular disease. Am J Med. 2015;128(3):229–238. doi:. doi:10.1016/j.amjmed.2014.10.014 [CrossRef]
- Mitsou EK, Kakali A, Antonopoulou S, et al. Adherence to the Mediterranean diet is associated with the gut microbiota pattern and gastrointestinal characteristics in an adult population. Br J Nutr. 2017;117(12):1645–1655. doi:. doi:10.1017/S0007114517001593 [CrossRef]
- De Fillippis F, Pellegrini N, Vannini L, et al. High-level adherence to a Mediterranean diet beneficially impacts the gut microbiota and associated metabolome. Gut. 2016;65(11):1812–1821. doi:. doi:10.1136/gutjnl-2015-309957 [CrossRef]
- Castro-Quezada I, Roman-Vinas B, Serra-Majem L. The Mediterranean diet and nutritional adequacy: a review. Nutrients. 2014;6:231–248. doi:. doi:10.3390/nu6010231 [CrossRef]
- Mistretta S, Marventanoa S, Antocia M, et al. Mediterranean diet adherence and body composition among Southern Italian adolescents. Obes Res Clin Pract. 2017;11:215–226. doi:. doi:10.1016/j.orcp.2016.05.007 [CrossRef]
- Labayen Goñi L, Arenaza L, Medrano M, et al. Associations between the adherence to the Mediterranean diet and cardiorespiratory fitness with total and central obesity in preschool children: the PREFIT project. Eur J Nutr. 2018;57(8):2975–2983. doi:. doi:10.1007/s00394-017-1571-3 [CrossRef]
- Giannini C, Diesse L, D'Adamo E, et al. Influence of the Mediterranean diet on carotid intima-media thickness in hypercholesterolaemic children: a 12-month intervention study. Nutr Metab Cardiovasc Dis. 2014;24:75–82. doi:. doi:10.1016/j.numecd.2013.04.005 [CrossRef]
- Della Corte C, Mosca A, Vania A, et al. Good adherence to the Mediterranean diet reduces the risk for NASH and diabetes in pediatric patients with obesity: the results of an Italian Study. Nutrition. 2017;39–40:8–14. doi:10.1016/j.nut.2017.02.008 [CrossRef].
- Esteban-Cornejo I, Izquierdo-Gomez R, Gomez-Martinez S, et al. Adherence to the Mediterranean diet and academic performance in youth: the UP&DOWN study. Eur J Nutr. 2016;55:1133–1140. doi:. doi:10.1007/s00394-015-0927-9 [CrossRef]
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|Dietary Component||Typical Western Diet||Okinawan Diet||Mediterranean Diet||Anti-Inflammatory Diet|
|Vegetables and fruits||Vegetable and fruit intake poor but fruit intake better||Large amount of vegetables, especially yellow root and green leafy vegetables||Large amounts of fruits and vegetables||Large amounts of diverse colorful vegetables; good fruit intake|
|Protein||Red meat, eggs, cured meats||Large amount of legumes (soy), small to moderate amounts of fish and meat||Fish, shellfish, nuts, and legumes; low in eggs; small amounts of meat||Plant based including legumes, soy, nuts, seeds, fatty fish, and some lean meats|
|Carbohydrate||Refined carbohydrates, high-fructose corn syrup, added simple sugar||Small amounts of rice and noodles; less sugar and few refined grains||Whole grains; pasta cooked “al dente”||Whole grains in small amounts, high fiber with limited refined carbohydrates and sweets|
|Dairy||Large amounts of high-fat dairy sources||Less dairy||Less dairy||Less dairy|
|Fat||High in saturated fats: butter, cream, meats with fat||Lower fat||Lower fat; olive oil, low saturated fat||Plant-based fats with added olive oil|
|Other components||Fast food, processed foods with preservatives, emulsifiers, artificial sweeteners, and chemicals||Broth-based soups, mushrooms, fermented foods, herbs, locally grown seasonal foods||Herbs, locally grown seasonal foods||Herbs, ginger, turmeric, garlic, and other anti-inflammatory spices, locally grown seasonal foods, mushrooms|
|Beverages||Soda, sugar-containing beverages (juice, sports drinks, vitamin waters, iced tea)||Green tea and moderate alcohol intake in adults||Water and moderate amounts of red wine in adults||Water and nonprocessed beverages; red wine in adults|
|Cultural||Overeating, eating on the run, erratic mealtimes||Low calorie, highly ritualistic||Highly social and family eating experiences||Mindful eating: quality over quantity|
|Pediatric data||Present||Not available||Present||Present (mainly as the Mediterranean diet)|