Mediterranean diet and SPA treatment: A healthy association?

1.1Thermal therapies

The thermal spa vacation is to find balance in well-being and beauty. The modern SPA responds to the new concept of health, as a state of complete psychic, physical and social wellness and not just only the absence of illness.

The thermal water of Abano Terme has many therapeutic effects [1, 2], like high-salinity antiseptic action, endocrine action, increasing thyroid activity and stimulating the synthesis of gonadotropins and maturation of ovarian follicles, promoting regularization of the menstrual cycle, stimulation of the immune system, anti-inflammatory action and antifibrotic action.

The mud, characteristic of the Euganean basin, is a complex system consisting of three different components, a solid one (the clay), a mineral one (the salt dissolved in the water) and the biologic one [3, 4]. The beneficial effects of mud, therefore, are not only attributable to the heat and the presence of electrolytes in solution, but mainly depend on what happens during its maturing process: the chemical-physical characteristics of the mud change and community of specific microorganism grow [5–9]. A cyanobacter, the Phormidium sp. ETS-05 [10] produces glycogenic and sulfo-glycolipidic substances, in particular monogalactosildiacyglycerol, with in vitro anti-inflammatory activity equivalent or even superior to traditional anti-inflammatory drugs such as indomethacin and betamethasone [11–13]. In addition, high concentrations of carotenoids, such as beta-carotene, lutein and lycopene, are in the mud, produced by the vegetable felt. In addition, there are high concentrations of C-ficocyanine with a strong antioxidant, antitumor activity, and C-allooxycianine, with antioxidant and anti-inflammatory activities [14]. After 12 mature mud treatment with thermal bath, there is a reduction in the serum concentrations of IL1, transferrin [14] and TNFα [16] and an increased level of IGF1 [15]. In addition, the mudpack therapy affects bone metabolism, especially if associated with physical activity, increasing osteoblastic activity [17].

Recent studies found a significant decrease in leptin and visfatin in patients who underwent two weeks of mud pack [18, 19]. Because of this the mud therapy could also have a role in the treatment of obesity and metabolic syndrome [20].

1.2Overweight and obesity

In 2014, around 1.9 billion adults over the age of 18 were overweight and over 600 million were obese (BMI equal to or greater than 30). The prevalence of obesity in industrialized countries has gradually increased since the first half of the 20th century, becoming in the United States and Europe a primary public health problem. Severe overweight and obesity are one of the major risk factors for the development of many chronic diseases such as respiratory diseases, type 2 diabetes and cardiovascular diseases (arrhythmia, hypertension, heart failure and stroke) [21–23]. There is also an association between overweight and some forms of cancer (colon, breast, endometrial, ovarian and uterine cancer, prostate cancer) [24] as well as psychological problems, such as risk of early death.

The development of overweight and obesity has a multifactorial genesis that includes genetic factors, environmental and behavioral factors, aging and pregnancy, comorbidity with some endocrine or autoimmune disorders, chronic intake of some drugs and a high caloric diet rich in fat [25–27] and sedentary lifestyle [28, 29]. Therefore, nutrition (in terms of quantity and quality of the foods and their modes and times of intake) and physical activity greatly influence the equilibrium of energy balance and are those on which an effective intervention is possible.

The risk of developing one of the aforementioned pathologies is linked to the relative amount of excess weight, the localization of body fat, the importance of weight gain in adulthood and the amount of physical activity. It’s possible to avoid these problems with a relatively modest weight loss (10–15%), especially when combined with an increase in physical exercise.

The anthropometric indexes (BMIs, pliers, waist circumference …) are designed to evaluate in a simple but precise way the amount of body fat and its distribution, so they are an easily applicable method in any clinic because there is no difficulty in execution and no risk for patient.

1.3The mediterranean diet

The Mediterranean Diet is rich in vegetable foods (fruit, cereals, vegetable, legumes, dried fruits, seeds and olives) with olive oil as the main source of added fat, coupled with a moderate consumption of fish and seafood, eggs, cheese and yoghurt, reduced consumption of red meat and moderate alcohol intake.

Some studies show that adherence to the Mediterranean diet reduces up to 50% the risk of metabolic syndrome and reduces the risk of mortality for up to 20 years [30, 31]. Because of this, the Mediterranean Diet can be an intervention to prevent cardiovascular diseases, to reduce the incidence of type 2 diabetes and peripheral vascular disease, atrial fibrillation rate, metabolic syndrome, as well as to reduce blood pressure, hypertensive risk and carotid atherosclerosis. The World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) recommend to eat more fruits and vegetables, like in Mediterranean Diet, as part of a healthy diet to prevent various types of cancer [32–35].

3.1Patients

We enrolled 275 people in this study, from January 2014 to September 2016 (Table 1). 193 people of these were female (70%) and the other 82 was male (30%). Most diet-requiring patients were over 50 years of age, like the medium standard of clients who goes to the Italian spa centers. In particular, patients younger than 30 years represented the 4% of the sample, those between 30 and 39 years were the 9%, those between 40 and 49 years were the 15% and older than 50 were the 72% of the sample (24% of those aged 50 to 59 years, 24% between 60 and 69 years, and 22% between 70 and 79 years). Regarding the origin of patients who have undergone a diet, the 38% of them were from Russian countries (ex USSR), 29% were Italians, 19% were French and 14% from the rest of the world. As for the history, 21 patients (11 females and 10 males) were smokers, 101 women (52%) were menopausal, and 57 (20,6%) suffered of chronic constipation. Considering their pathologies, 129 patients reported evidence of chronical arthritis in one or more districts (46,7 %), although all referred the presence of more or less constant and widespread ‘pains’. Furthermore, 79 patients were on pharmacological treatment (no diuretic) for Hypertension (28,6 %), 37 for Hypercholesterolemia (13,4 %), 4 for Metabolic Syndrome, 16 for Hypothyroidism (5,8 %), 9 for Type I2 Diabetes (3,2 %), 9 for Obstructive Sleep Apnea (3,2 %). The average number of nights spent was 8.6, and 62 % of clients underwent a 6-day treatment cycle, so only 6 days of diet. In fact most of those who required a diet for this limited time was looking for an occasion to detoxify the body more than losing weight (despite a weight loss very often would be needed).

All participants gave written consent to participate in the study.

3.2Interventions

Spa therapy consisted in 1 or 2 week program performed at the Borile Group Thermal Spa in Abano (Italy). For 200 patients the program included 6, 10 or 14 daily mud-pack applications, thermal bath, and some massage; 75 patients didn’t undergo mud-pack applications.

The mud-pack was applied on the whole body except head and heart areas for 15 minutes at the initial temperature of 45°C. After this application there was a thermal bath in mineral water at the temperature of 36°C for 10 minutes with a light hydromassage.

All the patients in the period of the study were on a 1000–1500 kcal diet (according to their basal metabolism: 1000 Kcal to a baseline metabolism of 1300 kcal/day, 1200 Kcal per metabolism between 1400 and 1800 and 1500 kcal for basal metabolism values above 1800 kcal/die). We chose a Mediterranean diet. We proposed one or two portions of cereal per day (preferring whole grains), two or more portions of vegetables per meal per day, and two portions of fruit per meal per day. The extra virgin olive oil, which is located at the center of the pyramid, was the main source of lipids for both cooking and condiment. We prepared dishes with spices, herbs, garlic and onions, thus reducing salt consumption and thus introducing a good dose of micronutrients and antioxidants in the diet. Weekly fish and seafood (two or more portions), white meat (two portions), eggs (two or four portions), red meat (once a week) was the consumption of proteins of animal origin. The combination of legumes and cereals (a great source of protein and fat) was a great meal.

3.3Data collection

Data collected in the beginning were gender, age, height, nationality, medical history, medications, dietary and physical activity, blood pressure, pulse, tobacco and alcohol consumption, basal metabolism.

3.4Outcome

Patients were assessed at basal time and at the end of the study for clinical parameters: weight, BMI (weight/height² (Kg/m²)) waist circumference (cm), waist/hip ratio (WHR), BIA.

The weight was always measured with a mechanical balance in the morning before breakfast, two hours after the mudpack treatment.

The BIA for the assessment of the fat percentage was collected in the same moment with the Omron Fat Loss Monitor, that can accurately and easily track body fat percentage and body mass index (BMI). The fat loss monitor can also be set to two separate modes, either normal or athletic depending on client activity level.

We have used Microsoft Excel for the statistical analysis.