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Mediterranean Diet and Women’s Health

Cuilin Zhang MD, PhD

Chair Professor and Director

Global Centre for Asian Women’s Health (GloW)

Yong Loo Lin School of Medicine, National University of Singapore

Professor of Nutrition (Adjunct), Harvard T.H. Chan School of Public Health

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Why the Mediterranean Diet?

The Mediterranean Diet (MED) is globally recognized for its health benefits

Its principles can be adapted to various food cultures, including Asian cuisines

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Mediterranean Diet and Health Benefits

Reduces the risk of type 2 diabetes

Helps with weight management

Supports heart health

Promotes longevity

* Proposed mechanisms: anti-inflammation, anti-oxidative stress, reduce insulin resistance, and weight control

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Mediterranean Diet and Women’s Health?

Why Focus on Women?

Women’s health is unique due to the various life stages and reproductive health needs
Heathy and happy women, is corner tone of healthier and happy family, and happy and health societies
Cardiovascular disease is the leading cause of death in women worldwide, and diet plays a significant role in prevention

The Relevance of MED:

Its components (healthy fats, fruits, vegetables, and whole grains) offer protective effects, especially for conditions like heart disease, diabetes, and fertility-related issues

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Mediterranean Diet and Women’s Health: Study Overview

Aim: To evaluate the effects of the Mediterranean diet on female reproductive health and pregnancy outcomes
Study Method: Meta-analysis of 32 studies

9 randomized controlled trials (RCTs): 1 fertility-related, 8 pregnancy-related
22 prospective cohort studies: 6 fertility-related, 12 pregnancy-related, and 4 other reproductive outcomes-related
1 nested case-control study: fertility-related

Population: 103,204 women across diverse populations

Predominantly Caucasian: Europe, United States, and Australia

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Fertility-related Outcomes and MED in RCTs

RCT (N=1 at a fertility clinic, Italy)

Six-week RCT supplemented EVOO and omega-3 fatty acid and vitamin D drinks vs. control diet

Better embryo development in MED vs. control

Cohort studies (N=6 at various fertility clinics):

Suggestively positive associations for success of pregnancy

Case-control studies (N=1 in general population)

Higher MD adherence -> lower risk of self-reported difficulty conceiving

First we examined fertility-related outcomes with MD in RCTs
One RCT at a fertility clinic in Italy found no significant difference in pregnancy outcomes but did show improved embryo development in women following the Mediterranean Diet.
Cohort studies suggest a positive association between higher adherence to the diet and higher rates of clinical pregnancy and live birth.
The case control study reported greater adherence to MD with lower risk of self-reported difficulty conceiving.

Notes from older version:

First, for Mediterranean diet and female fertility

There was only one RCT that evaluated MD and female fertility.

In a study of females attending a fertility clinic in Italy, they found no effects of MD on clinical fertility outcomes,

but better embryo development was seen in the MD group vs the control group.

Cohort studies:

All the fertility-related cohort studies were among women attending fertility clinics

Although there were no significant overall associations between MD and clinical fertility outcomes, two individual studies conducted in Europe reported significant associations of greater adherence to MD with higher rates of clinical pregnancy and live birth.

Case-control studies:

There was one nested case-control study among the general population in Spain, that is, not population seeking for fertility assistance. The study reported greater adherence to MD with lower risk of self-reported difficulty conceiving.

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Pregnancy-related Outcomes and MED in RCTs

N=8 evaluating in-pregnancy MD

Mediterranean Diet significantly reduced the risks of gestational diabetes & preterm birth
Stronger benefits for earlier MED initiation

*

Stronger benefits with earlier MD initiation

Next, we examined pregnancy-related outcomes with MD in RCTs.
We found that in-pregnancy adherence to the Mediterranean Diet significantly reduced the risks of gestational diabetes and preterm birth.
Interestingly, the benefits were stronger when the diet was initiated earlier in pregnancy.
No RCTs on pre-conception MD were found.�

Notes from older version:�Next - when we examined MD with pregnancy outcomes,

First on the evidence coming from the RCTs:

Nearly all the identified RCTs evaluated in-pregnancy MD with pregnancy outcomes.

MD during pregnancy significantly reduced the risks of gestational diabetes, preterm birth, and borderline reduced the risk of gestational hypertension

Interestingly, for GDM and preterm birth: stronger benefits of in-pregnancy MD was seen among those RCTs with an earlier initiation in gestation.

No RCTs on pre-conception MD were found.

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Pregnancy-related Outcomes and MED (Cohort Studies)

Cohort studies (N=12, 3 pre-pregnancy, 9 in-pregnancy MD)

Adherence to the MED, particularly pre-pregnancy🡪 lower risks of gestational diabetes, preterm birth, and gestational hypertension

In the pregnancy-related cohort studies we found that adherence to the Mediterranean Diet, particularly pre-pregnancy, was associated with lower risks of gestational diabetes, preterm birth, and gestational hypertension

Notes from older version:

Meta-analysis results based on 12 cohort studies showed inverse associations between adherence to pre-pregnancy or in-pregnancy MD and risks of GDM, preterm birth, gestational hypertension, and preeclampsia – consistent with the findings from RCTs

Of highlight, for gestational hypertension and preeclampsia, while summarized RRs were significant - study-specific RRs were significant only in studies examining pre-pregnancy MD but not in-pregnancy MD – suggesting that timing of the diet may play a role in modulating the degree of benefits of Mediterranean diet on pregnancy health.

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Other Reproductive Outcomes

^a Luteal phase deficiency: luteal phase <10 days as a result of insufficient progesterone secretion

^b PCOS-like phenotype: high testosterone and high AMH; both among non-PCOS individuals

Cohort studies (N=4)

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Key Takeaways: MED and Women’s Health

Fertility: suggested benefits on female fertility among women with infertility
Pregnancy:

In-pregnancy -> lower risk of GDM and preterm birth and possibly maternal weight management
Pre-pregnancy -> may be beneficial on GDM, gestational hypertension, and pre-eclampsia

Potential benefits on other female reproductive outcomes:

Puberty development
Relief of vasomotor menopausal symptoms

Practical implications for the food industry: creating healthy, �balanced meals that support women’s health.

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Summary and Implications

MED Diet is important for the health of women over their lifespan

Cardiometabolic health
Reproductive health
Overall health (including cognitive development, immune function, bone health, mental health, etc.)

Implementation - Improve diet and lifestyle in practice

Customized for different populations
Multi-disciplinary joint efforts

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Nutrition and Women’s Health – �over lifespan and across generations

Global Centre for Asian Women’s Health (GloW)

Yong Loo Lin School of Medicine,

National University of Singapore

glownus.org

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Education Programs

Empowering leaders to tackle health challenge through

preventative nutrition and lifestyle medicine

Master of Science in Nutrition and Lifestyle Medicine (MSc graduate program)

1 year (full-time) or 2 years (part-time)
Compulsory core modules, elective modules, and capstone project

Experiential Learning and Mentorship

Engage students in projects and multidisciplinary international collaborations

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Through GloW and the School of Medicine at NUS we are launching a Master of Science in Nutrition and Lifestyle Medicine. This program is the first in Asia to promote preventive medicine through nutrition.
Our program offers a multidisciplinary approach with core modules, electives, and capstone projects.
Through Experiential Learning and Mentorship, students engage in hands-on projects and international collaborations, gaining direct involvement in solving health challenges.

Older notes:

The first and the only Master Programme in Asia advocating Preventative Medicine through Nutrition and Lifestyle

Career Opportunities: Roles include clinicians, nutrition consultants, health coaches, public health advocates, workplace wellbeing managers, policymakers, health and wellness managers, and educators.

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Translational Research Programmes

A+ MEAL Study: a randomized controlled trial evaluating the effects of Asian-Mediterranean diet on Asian women’s health in Singapore

100% Mediterranean dietary principles, 75-80% Asian ingredients with Asian flavours

OVERARCHING AIMS:

To develop a feasible, acceptable, and tasty Asian healthy diet for improving Asian women’s health and health of their families, establishing sustainable nutrition at populational level

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Thank You

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Key Components of the Mediterranean Diet�

High

Healthy fats: Extra-virgin olive oil (EVOO), nuts
Fruits, vegetables, legumes, whole grains

Moderate

Dairy products, fish, poultry, red wine

Limited or no consumption

Red meat, sugary foods and �sugar-sweetened beverages

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Overview of Reproductive Health

Reproductive health is a key pillar of women’s overall health
Women’s reproductive lifespan has increased to an average of 37 years
Rising rates of reproductive health issues, especially in Asia, driven by:

Lifestyle changes, poor diet, stress, and environmental factors
Delayed maternal age and family planning

Nutrition and lifestyle play a critical role in optimizing reproductive health
MD supports reproductive health through anti-inflammatory and metabolic benefits