Mediterranean Gluten-Free Diet

Combining the Mediterranean Diet and the Gluten-Free Diet

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What are the major principles of the Mediterranean Diet?

The Mediterranean Diet (Med. Diet) is a commonly recommended diet that is based on the eating pattern of people in the Mediterranean region. It suggests the high intake of vegetables, fruits, whole grains, legumes, healthy fats, and water; a moderate consumption of seafood, poultry, and dairy; and a low intake of sweets and processed or red meat. The Med. Diet is associated with many positive health benefits. For patients with celiac disease, the Med Diet can help provide important nutrients that a typical gluten-free diet may lack—without the significant risk of undesired weight gain that can lead to overweight or obesity.^1,2 And the diet can easily be made gluten-free. 

Health Benefits of the Mediterranean Diet

Research has shown that the Med. Diet offers a wide range of health benefits.

• Lowers blood pressure³
• Reduces the number of pre-cancerous colorectal polyps⁴
• Lowers risk of early menopause⁵
• Decreases risk for developing Alzheimer’s disease^6,7 and other forms of dementia.
• May improve cognitive performance⁸
• Decreases obesity risk⁹
• Reduces risk for chronic diseases¹⁰
• Increases life expectancy¹¹
• Increases chances of healthy aging¹²
• Reduces risk of cholecystectomy (removal of gall bladder)¹³
• Decreases risk of developing breast cancer¹⁴
• Reduces risk of cardiovascular disease and type 2 diabetes¹⁵
• For more information on the health benefits of the Med. Diet, check out: Oldways' health studies database or Adopt a Mediterranean diet now for better health later

The Med. Diet first became popular following the creation of the Med. Diet Pyramid by Oldways in conjunction with the Harvard School of Public Health and the World Health Organization in 1993. The Med. Diet has continued to grow in popularity, and the 2015 U.S. Dietary guidelines recommend a Mediterranean-Style Eating Pattern.  The Med. Diet Pyramid, outlines the basic principles of the diet.

Base of pyramid: physical activity and social interaction (dancing, sports, sharing meals)

Next level of pyramid: foods that should be eaten every day (whole grains, fruits, vegetables, legumes (lentils, dried peas, and beans), seeds, herbs, nuts, spices, and healthy fats such as olive oil and avocado)

Third level: Fish and seafood should be eaten twice a week

Fourth level: Dairy, (particularly fermented dairy including yogurt or kefir), eggs, and poultry should be eaten in moderate servings daily to weekly

Fifth level: Red meat and sweets should only be eaten on rare occasions

Drinking water is encouraged.

Wine, in moderation, is also part of the Med. Diet* (no more than one 5 oz. glass of wine per day for women, and 2 per day for men) You should not start drinking alcohol if you do not already do so. Alcohol is not recommended with some  medications and conditions, such as pregnancy, breast feeding, liver disease, and kidney disease, among others. Please consult your physician and dietitian before adding alcohol to your diet. Source: Oldways

How does the Mediterranean Diet differ for those on a gluten-free diet?

Those on a gluten-free diet, such as those with celiac disease, will only need to make some minor modifications to maintain their dietary needs. The most significant change is substituting gluten-free whole grains for any gluten-containing grains, such as whole wheat, typically included in the Med. Diet¹⁶. Some suitable gluten-free whole grain substitutes can be found below. 

• Make sure that all gluten-free grain and flour substitutes are labeled gluten-free. Remember to check other foods you eat while on the Med. Diet, such as nuts, seeds, and spices for gluten. Contact the manufacturer when necessary to ensure that they are gluten-free.
• Remember to make these dietary changes slowly and start with small steps. It is important to add fiber slowly, and increase water intake with added fiber, to help the gut adjust to these changes in diet.
• Iron deficient anemia is common in celiac disease. Since iron can be challenging to obtain from the Med. Diet, women, in particular, should pay close attention to choosing iron-rich foods, such as lentils, spinach, almonds, lean red meat and dark meat poultry.
• Visit with a registered dietitian skilled in celiac disease/gluten-free diet to ensure that you are getting all of your vitamins and minerals, in particular, calcium, vitamin D, iron, B vitamins, and zinc.

Sample Menu: Gluten-Free Mediterranean Diet (~2000 Calories) GF=gluten-free

Breakfast: 

• 1 cup cooked GF whole grain (*quinoa, amaranth, and/or buckwheat) with 1 cup mixed berries and 8 almonds or cashews
• 5 oz. plain low-fat Greek yogurt
• 12 oz. water or tea

*Gluten-free grains must be labeled gluten-free. 

Lunch:

• 1 cup baby spinach leaves
• 1/4 medium avocado
• 8 cherry tomatoes
• 1/2 cup sliced cucumber
• 1/4 cup feta cheese
• 1 hard-boiled egg
• 1/3 cup chickpeas
• 2 tbsp. dressing for salad (olive oil, balsamic vinegar or lemon juice, and herbs of choice)

Snack:

• 1 baked sweet potato with tbsp. olive oil and salt and pepper to taste
• 8 oz. water

Dinner:

• 3 oz. grilled salmon
• 1/2 cooked brown rice
• 1 cup broccoli sautéed in 2 tsp. olive oil
• 12 oz. water

Snack:

• 1 medium banana
• 1 tbsp. natural peanut butter
• 8 oz. water

Gluten Free Mediterranean Diet Recipe Ideas

• Sorghum Pasta Salad with Oregano, Feta Cheese, and Cucumbers
• Spinach Pasta Chickpea Salad with Salmon (*Use gluten-free pasta)
• Baked Snapper with Tomatoes and Olives
• Split Pea and Melted Eggplant Soup (*Use gluten-free chicken or vegetable broth)
• Spicy Salmon (Serve with a side of buckwheat or lentils)
• Vegetable Frittata
• Israeli Cucumber and Tomato Salad
• Lemon-Garlic Shrimp and Vegetables (Serve with a side of gluten-free quinoa or brown rice)
• Apple-Cinnamon Oatmeal with an Egg Boost (*Remember to use uncontaminated, labeled gluten-free oats.)
• Walnut and Cucumber Gazpacho
• Quinoa Stuffed Bell Peppers
• Maple Candied Walnuts
• Chocolate Walnut Macaroons

Remember to check recipes for gluten-containing ingredients and make the necessary gluten-free substitutions. More gluten-free recipes can be found at Oldways.

Gluten-Free "Have on Hand" Items for the Mediterranean Diet

Additional Resources: 

• “Oil Change” – A conversion chart from butter to olive oil
• “Fresh Fridays” – Subscribe to a bi-weekly e-newsletter with recipe ideas and Med. Diet research
• “Mediterranean Bean Basics” – Health benefits of eating beans and bean recipe ideas

Authors: Emma M. Clerx and Melinda Dennis, MS, RDN
Revision Date: August 31, 2018
Editors: Amy Keller, MS, RDN, LD and Jocelyn Silvester, MD, PhD

References: 

1. Jones, A. “Follow the Mediterranean Example: A Diet Rich in Grains, Veggies and Fish That's Easily Made Gluten-Free.” Gluten-Free Living, Whole Grains Council, 17 Aug. 2017.
2. Barone M et al. A comparison of the nutritional status between adult celiac patients on a long-term, strictly gluten-free diet and healthy subjects. Eur. J. Clin. Nutr. 70, 23–27 (2016).
3. Davis CR et al. Mediterranean diet lowers blood pressure. Am J Clin Nutr. 105, 1305-1313 (2017).
4. Isakov NF et al. Mediterranean diet linked with fewer signs of precancerous colorectal polyps. Presented at the European Society for Medical Oncology’s 19th World Congress on Gastrointestinal Cancer. Barcelona, Spain (2017).
5. Boutot ME et al. Vegetable protein linked with lower risk of early menopause. Am J Epidemiol. (2017, Epub ahead of print).
6. Miranda A, Gomez-Gaete C & Mennickent S. Role of mediterranean diet on the prevention of Alzheimer disease. Rev. Med. Chil. 145, 501–507 (2017).
7. D’Cunha NM et al. Evaluation of dietary and lifestyle changes as modifiers of S100β levels in alzheimer's disease. Nutritional Neuroscience. (2017, Epub ahead of print).
8. Anastasiou CA et al. Mediterranean diet and cognitive health: initial results from the Hellenic Longitudinal Investigation of ageing and diet. PLoS One 12, e0182048 (2017).
9. Sanz J et al. Plant-based diet can reduce obesity risk by 43%. Presented at the European Congress on Obesity. Porto, Portugal (2017).
10. Subhan FB, Chan CB. Review of dietary practices of the 21st Century: facts and fallacies. Can J Diabetes. 40, 348-354 (2016).
11. Sotos-Prieto M et al. Association of changes in diet quality with total and cause-specific mortality. N. Engl. J. Med. 377, 143–153 (2017).
12. Samieri C et al. The relation of midlife diet to healthy aging: a cohort study. Ann Intern Med. 159, 584-59 (2013).
13. Barre A et al. Diet and risk of cholecystectomy: a prospective study based on the French E3N cohort. Am. J. Gastroenterol. (Epub ahead of print, 2017).
14. Shapira N. The potential contribution of dietary factors to breast cancer prevention. Eur. J. Cancer Prev. 26, 385–395 (2017).
15. Bruno E et al. Adherence to mediterranean diet and metabolic syndrome in BRCA mutation carriers. Integr. Cancer Ther. (Epud ahead of print, 2017).
16. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition, pp. 35-36; 83-85 (2015).
    http://health.gov/dietaryguidelines/2015/guidelines