Does the Mediterranean Diet Protect the Spine? The Answer Is Yes, for Women

A Spanish team analyzed data from a 3-year randomized trial, PREDIMED-Plus, involving 924 people aged 55–75 with metabolic syndrome and overweight/obesity. Those who followed a hypocaloric version of the Mediterranean diet and increased physical activity were better able to preserve bone mineral density (BMD) in the lumbar spine compared with a group that received only general advice to “eat like a Mediterranean” without calorie counting or activity goals. The effect was particularly noticeable in women. At the same time, total bone mineral content (BMC) and the proportion of people with low BMD did not differ significantly between the groups over 3 years. The study was published in JAMA Network Open.

What exactly was compared?

• Intervention: Mediterranean diet with a ~30% calorie deficit plus physical activity support (goal ≥150 min moderate/vigorous activity per week: daily walking ~45 min, 2 days strength training, 3 days flexibility/balance exercises) and behavioral motivation.
• Control: ad libitum Mediterranean diet - no calorie restriction and no planned "pumping up" of activity.
• Assessments: BMD (DXA) at three points - lumbar spine (L1-L4), total hip, femoral trochanter - at baseline, after 1 and 3 years; plus total BMC and "low BMD" status (osteopenia/osteoporosis).

Who was included?

• 924 participants (average age 65.1 years), almost equally divided between men and women.
• All of them have metabolic syndrome and are overweight.

Main results

• Weight loss was greater in the intervention group: approximately -2.8 kg after 1 year and -2.2 kg after 3 years relative to control, a moderate but steady reduction.
• Bones:
  • In the lumbar spine, the calorie deficit + activity group showed better maintenance of BMD over 3 years (the overall effect was borderline significant in the entire sample; clearly significant in women).
  • No significant gains were shown for men.
  • No differences were found in overall BMC and the proportion of people with low BMD.
• In additional analyses, women also showed positive results in the femur, but these are not the main signals, but rather supporting ones.

Why is this important?

Weight loss in older people is often accompanied by bone loss – exactly what we fear because of the risk of fractures. Here it is shown that if you lose weight against the background of a high-quality diet (Mediterranean) and regular exercise, you can mitigate the age-associated “sag” in BMD, at least in the lumbar region – and especially in women with metabolic syndrome.

What can work to your advantage:

• Nutrient density of the Mediterranean diet (vegetables, legumes, whole grains, fish, olive oil, nuts) with a moderate calorie deficit.
• Skeletal loading: Walking, strength training, and balance/flexibility exercises support bone metabolism and reduce the risk of falls.

Limitations that are honest

• This is a secondary analysis of an RCT (bone was not the primary endpoint of the original protocol).
• DXA measurements were performed in only 4 centers; some data on the femoral neck were not collected (the “total femur compartment” was used).
• The controls also followed a healthy diet, so the differences between the groups may have been smoothed out.
• The improvement was shown primarily by women; no such advantage was recorded for men.
• Fractures and “hard” clinical outcomes were not studied; we are talking about the dynamics of BMD.

What does this mean for me/my patients?

If you or your patient is 55–75 years old, overweight, and has metabolic syndrome, the goal of “losing weight without harming bones” looks realistic if you act on two fronts:

1. Mediterranean Diet Calorie Deficit
   • Plate base: vegetables/greens (half), whole grains/legumes, fish/seafood/poultry, extra virgin olive oil; nuts in portioned quantities.
   • Protein at every meal, adequate calcium and vitamin D (from diet; supplements as directed by physician).
   • Soft deficit - guideline - 300...-500 kcal/day, without “strict” diets.
2. Regular physical activity (as in the study)
   • Walking: ~45 min/day (or ≥150 min/week in total).
   • Strength: 2 times/week (legs, back, core; 8–10 exercises, 2–3 sets).
   • Balance/flexibility: 3x/week (yoga/tai chi/targeted routines).

As a bonus, you will also receive metabolic benefits: control of sugar, blood pressure, lipids and weight.

For whom is it especially relevant?

• For postmenopausal women with excess weight and signs of metabolic syndrome.
• For those who are already planning to lose weight and are afraid of losing their “bone capital”.

When to see a doctor

If you have had fractures with minimal trauma, have osteopenia/osteoporosis according to DXA, are taking glucocorticoids/aromatase inhibitors/PPIs, or have chronic bowel/thyroid disease, it is better to discuss the strategy with your doctor and possibly include drug prophylaxis for osteoporosis.

Conclusion

Losing weight in midlife doesn’t have to be hard on the bones. When a calorie deficit is achieved through a quality Mediterranean diet and accompanied by regular walking, strength training, and balance training, BMD—at least in the lumbar region—is better preserved, especially in women. It’s not a panacea or a replacement for osteoporosis therapy, but it is a workable, realistic basis for a long-term health strategy.