I have an interesting research paper for you today. The article is called, Potential Effects of a Modified Mediterranean Diet on Body Composition in Lipoedema. It was performed by a group of researchers in Rome, Italy, and was published in the journal Nutrients in January 2021.
This research is of interest to me because its aim was to examine the effects of a modified Mediterranean diet on the weight and body composition of women with lipedema compared to the effects of this diet on healthy controls.
Let’s unpack this research by talking about its methods and materials.
What outcomes were measured?
The primary outcome measure in this study was the effect of diet on body composition including percent body fat and total fat mass, levels of intra and extracellular water, and total lean body mass. Other outcomes that were measured included neck, waist, and hip circumferences, waist-to-hip ratio, BMI, changes seen in general health status, pain perception, fatigue, and quality of life. Eating habits were measured prior to and during the intervention using a diet record and food frequency questionnaires.
Who were the participants?
The participants of this study were divided into two groups: the first group was composed of 14 women with lipedema while the second group was a control group of 15 women who did not have lipedema.
What methods were used?
The two groups received the same amount of calorie restriction, which was 20% less than recommended daily intake calculated individually for each participant. Everyone used the modified Mediterranean diet. Would the outcomes be different for those with lipedema versus those without?
First, let me describe to you the diet composition. Daily macronutrient intake was broken down as follows:
- 40 – 45% of total calories/day of carbohydrates
- 25 – 30% of total calories/day of proteins (>50% of them vegetable derived)
- 25 – 30% of total calories/day of fats
The participants were encouraged to eat primarily plant-based foods such as seasonal fruits and vegetables, whole grains, legumes, and nuts; “healthy fats” instead of butter, such as olive oil; herbs and spices instead of salt; and foods rich in polyunsaturated fats. Preserved and processed foods such as cold cuts, cured meats, canned products, frozen ready meals, cheese, potatoes, high glycemic index carbohydrates, and sweetened beverages (both alcoholic and non-alcoholic) were all avoided. Furthermore, plant-based sources were favored over animal-based sources of protein.
Food quality was assessed using the Mediterranean Adequacy Index (MAI) and oxygen radical absorbance capacity (ORAC) assay. The MAI is a measure of how closely foods align with the Healthy Reference National Mediterranean Diet. The ORAC is a lab test for antioxidant capacity of a food.
What were the results?
Average values for baseline measures for the lipedema group largely reflected what we would expect to see associated with a diagnosis of lipedema. The lipedema group had higher values for leg and arm fat and a lower waist to hip ratio compared to the control group, which matches the typical areas of fat deposition with lipedema. Also expected was the increased extracellular water in the lipedema group, as we have seen in many studies that there is increased water content in lipedema fat.
Both groups lost weight, with the control group losing an average of 4 kg and the lipedema group losing a little less at 3 kg. The major differences between the two groups were in how and where body composition changed. The control group showed decreases in all body composition parameters and body measurements while the lipedema group showed an insignificant change in all measures except for decreases in lean mass in the trunk. The lipedema group also lost more muscle in their legs. Despite this lack of improvement in body composition, the lipedema group reported a higher perceived quality of life at the conclusion of the study.
What are my thoughts about this study?
The diet used in this study was low-calorie, plant-based, moderate to high carb, and low-fat, not unlike a mainstream weight-loss diet. The participants were encouraged to eat five times a day (3 full meals and 2 snacks), a common byproduct of moderate to high carb intake. This way of eating results in higher insulin levels which stimulates hunger. Frequent eating would facilitate better adherence to a diet like this. The authors must have acknowledged this themselves on some level because they limited the length of the intervention to four weeks in order to “avoid dropout and ensure maximum adherence to treatment.”
A word on food quality: The utility of the MAI, judging a food by how closely it adheres to a Mediterranean diet, is based on the idea that this way of eating is superior, a subjective opinion at best as there is very little empirical data to support this opinion. For this reason, I don’t believe this is a valid measure of food quality. The ORAC as a lab assay can be a more objective measure of food quality based on the antioxidant value, but the unanswered question remains: Are we actually getting reactive oxygen species (“free radicals”) from the very same foods that have an antioxidant benefit? Spinach, for example, is one of the best sources for the antioxidant lutein. However, spinach is also a high source of iron, which is considered one of the biggest free radical sources. In other words, is the food recommendation also the source of the problem?
The lipedema group significantly increased their intake of omega-3 fatty acids, antioxidants, and fiber intake, which are all reported to decrease inflammation. The authors surmised that the anti-inflammatory effect of these foods must have reduced inflammation and pain in the lipedema group and improved their quality of life. Unfortunately, this study did not have any data, such as pre- and post-intervention blood draws of inflammatory markers, to support this conclusion.
The outcomes in this study are similar to other studies that show that even a modest reduction in carbohydrate consumption can have beneficial effects on symptoms of lipedema. Overall, this was an interesting study and a good addition to the discussion of how to best manage lipedema.