Women’s Cardiovascular Nutrition Across the Lifespan

Women’s Cardiovascular Nutrition Across the Lifespan

Medical Disclaimer

This content is for educational purposes only and does not constitute medical advice, diagnosis, or treatment. Information is based on current medical literature and clinical guidelines but may not apply to your specific situation. Individual responses vary based on personal medical history and concurrent conditions. Always consult qualified healthcare providers for medical decisions. Never delay seeking medical care based on content you’ve read. If experiencing a medical emergency, seek immediate medical attention.

These articles provide education to enhance your healthcare partnership. All treatment decisions should involve your healthcare team. Use this knowledge to have informed discussions, not replace medical care.

In Brief

• The same eating patterns that protect men’s hearts—Mediterranean and DASH-style—protect women’s hearts too. The foundation does not change with sex. What changes is the context in which you apply it.
• Women have heart-related factors men don’t: monthly iron loss, PCOS, the cardiovascular stress test of pregnancy, and the metabolic shift of menopause. Each one changes what to watch for and when.
• Some pregnancy complications—preeclampsia, gestational diabetes, preterm birth—are early signals of future heart risk. This history belongs in your medical record permanently, not just in your obstetric notes.
• Perimenopause is a turning point. Cholesterol and blood pressure rise, fat shifts to the abdomen, and muscle is harder to keep. It is the time to intensify, not relax, cardiovascular nutrition.
• Women’s heart disease is more often missed and undertreated. Knowing your own risk-enhancing factors is one of the most useful things you can bring to a medical appointment.

Introduction

Heart disease is the leading cause of death in women in the United States.[1] Despite that, cardiovascular disease in women remains underdiagnosed, undertreated, and under-researched.

Part of the reason is historical. Early landmark cardiovascular trials enrolled mostly men, and women were underrepresented in key analyses for decades.[2] Diagnostic criteria were built around male presentation patterns. Women’s symptoms are more likely to be attributed to anxiety. And conditions that signal future cardiovascular risk in women—preeclampsia, gestational diabetes, polycystic ovary syndrome—often fall through the cracks between obstetrics, endocrinology, and cardiology.

There is also a life-course pattern worth understanding. Before menopause, estrogen offers some cardiovascular protection: premenopausal women tend to have lower LDL cholesterol, higher HDL, and more favorable blood vessel function than age-matched men. After menopause, estrogen levels fall, LDL and blood pressure rise, body fat shifts toward the abdomen, and cardiovascular risk climbs.[3] That is why perimenopause is such an important window for nutrition and lifestyle.

One more piece of context. Many women reach midlife with decades of dieting, weight cycling, and body criticism behind them. Repeated crash diets, severe restriction, and shame-based eating can damage metabolic health and blur the line between healthy eating and disordered eating. The approach here is the opposite of that: patterns that support cardiovascular health without extreme restriction.

A practical note before the specifics: women carry a disproportionate caregiving burden—for children, aging parents, and partners—which shapes stress, sleep, and what and how they eat. If life circumstances are the main obstacle to eating well, read this alongside Article 12: Heart-Healthy Eating When Life Is Hard.

What Stays the Same

Regardless of life stage, the foundation of heart-protective eating is the same for women and men: a Mediterranean or DASH-style pattern built around vegetables, fruits, whole grains, beans, nuts, fish, and minimally processed foods; limited sugary drinks and ultra-processed foods; and alcohol, if any, in modest amounts.

The dietary patterns that reduce cardiovascular events in men—Mediterranean, DASH—also reduce events in women.[4] The rest of this article is about how female-specific factors change the way that foundation gets applied across the lifespan.

Why Women’s Cardiovascular Disease Is Different

The sections that follow are a brief, nutrition-focused orientation to how women’s heart disease differs. For the clinical side in depth—how symptoms present, why some heart attacks show no blockages, and the syndromes that disproportionately affect women—see the companion Women and Cardiovascular Health series, which is devoted entirely to these questions.

The diagnosis gap

Women with heart disease are less likely than men to receive guideline-recommended preventive care.[4] Part of this stems from symptom differences. While men typically experience crushing chest pain with exertion, women more often experience:

• Fatigue, sometimes profound, for days before an event
• Shortness of breath
• Nausea or indigestion
• Pain in the jaw, neck, shoulder, or back
• Chest discomfort that may be less intense or atypical

These symptoms are more easily written off as stress or anxiety, which delays diagnosis. If you’re a woman with risk factors and these symptoms are new, worsening, or simply feel “not normal,” they deserve the same urgency as classic chest pain. (The Women and Cardiovascular Health series article Heart Attack Symptoms in Women covers presentation and when to seek emergency care in detail.)

Non-obstructive heart disease

Women are more likely than men to have heart attacks without large blockages on angiogram—conditions such as myocardial infarction with non-obstructive coronary arteries (MINOCA), small-vessel disease, or spontaneous coronary artery dissection (SCAD). These are real heart conditions. Nutrition and lifestyle still matter for blood pressure, vessel health, and inflammation. The Women and Cardiovascular Health series covers these in dedicated articles—Microvascular Angina and INOCA and Heart Attacks Without Blockages: SCAD, MINOCA, and Takotsubo—and they are worth reading if you’ve been told your arteries are “clean” but still feel unwell.

The treatment gap

Women, especially younger women, experience sex-based differences in cardiovascular care and tend to have worse outcomes after a heart attack than men.[5] In practice, women are also consistently less likely than men to be referred to and to complete cardiac rehabilitation. If you’re a woman with cardiovascular risk factors or symptoms, it’s reasonable to ask whether your treatment matches guideline-level care.

Reproductive Years

Iron and menstruation

Women who menstruate lose iron every month. Iron deficiency is common and can cause fatigue and reduced exercise capacity, sometimes before it ever progresses to anemia.[6]

To improve absorption of plant-based iron, eat vitamin C-rich foods at the same meal: citrus, bell peppers, tomatoes.

When to check iron levels: fatigue, shortness of breath with exertion, or heavy periods warrant evaluation. Ask for ferritin (stored iron) in addition to hemoglobin.

Calcium and bone health

Peak bone mass is reached by the late 20s. Adequate calcium and vitamin D during the reproductive years help protect against osteoporosis later. Women with osteoporosis tend to carry higher cardiovascular risk, in part because the two conditions share common risk factors.[7]

Discuss calcium and vitamin D targets with your healthcare team. Food sources include dairy, fortified plant milks, sardines with bones, tofu made with calcium sulfate, and leafy greens like kale and bok choy.

The foundation pattern

For most reproductive-age women without specific conditions, the dietary recommendations are the same as for the general population: a Mediterranean or DASH pattern, adequate protein, limited ultra-processed foods, and modest alcohol if any. See Articles 2–5 for detailed guidance.

Contraception and cardiovascular health

Contraceptive choice intersects with heart health. If you have heart disease, hypertension, diabetes, migraine with aura, or a history of stroke or blood clots, contraceptive choice needs discussion with both your cardiologist and OB-GYN. Combined hormonal contraception (estrogen-containing pills, patches, rings) carries higher stroke and clot risk in some women.

If you take medications that can cause birth defects (certain blood pressure medications, statins), reliable contraception is itself part of cardiovascular care. For a fuller treatment of how contraceptive choice interacts with heart and clot risk, see the Women and Cardiovascular Health series article Birth Control and Cardiovascular Risk.

PCOS: A Cardiovascular Risk Condition

What PCOS is

Polycystic ovary syndrome (PCOS) is one of the most common hormonal disorders in reproductive-age women. It’s defined by a combination of irregular periods, elevated androgens, and polycystic ovaries on ultrasound.[8] PCOS is not just a reproductive condition—it’s a metabolic and cardiovascular risk condition.

The cardiovascular connection

Women with PCOS have higher rates of insulin resistance, type 2 diabetes, dyslipidemia, hypertension, and metabolic syndrome.[9] This risk exists independent of weight—lean women with PCOS also show elevated metabolic risk compared with weight-matched peers.

Even if cycles later become more regular or symptoms ease, the underlying metabolic tendency in PCOS often persists, so long-term cardiovascular monitoring still matters.

Nutritional approach

Lifestyle modification is first-line treatment for PCOS and its metabolic complications. Discuss specific targets with your healthcare team. The general principles supported by evidence:

• Modest weight loss (if overweight): in women with overweight and PCOS, losing 5–10% of body weight often improves insulin sensitivity, menstrual regularity, and lipid profiles—and the benefit comes from the weight loss itself rather than any particular diet composition.[10]
• Carbohydrate quality: no single macronutrient ratio has proven superior for PCOS. What appears to matter is choosing low-glycemic-index carbohydrates (whole grains, legumes, non-starchy vegetables), avoiding sugar-sweetened beverages, spreading carbohydrates across meals, and pairing them with protein, fat, or fiber.
• Anti-inflammatory patterns: greater adherence to a Mediterranean-style diet is associated with better insulin sensitivity and lower inflammation in women with PCOS.[11]
• Physical activity: both aerobic exercise and resistance training improve insulin sensitivity in PCOS.

In practice, this often means building meals around fiber plus protein—oats with Greek yogurt and berries, or beans with vegetables and olive oil—rather than chasing exact macronutrient percentages.

Cardiovascular monitoring

If you have PCOS, discuss cardiovascular screening with your healthcare team: a lipid panel, fasting glucose or A1c, and blood pressure monitoring. PCOS is a reason for earlier cardiovascular risk assessment. Even if your periods become regular or symptoms fade with age, your history of PCOS still matters for long-term prevention and should remain in your medical record.

Pregnancy Complications as Cardiovascular Warning Signs

Pregnancy is a metabolic and vascular stress test. Certain complications unmask underlying cardiovascular risk—often appearing decades before clinical heart disease.[12] Yet this information frequently fails to follow women from obstetric care into primary care and cardiology.

Major cardiology guidelines now classify preeclampsia and other adverse pregnancy outcomes as cardiovascular “risk enhancers.” The Women and Cardiovascular Health series devotes a full article to this—Pregnancy as a Cardiovascular Stress Test—covering the long-term risk signals in more depth than the nutrition focus here allows.

Preeclampsia

Preeclampsia—high blood pressure with protein in the urine or organ dysfunction during pregnancy—affects roughly 2–8% of pregnancies.

Women with a history of preeclampsia have about double the long-term risk of hypertension, coronary heart disease, and stroke compared with women whose pregnancies were uncomplicated.[13] The earlier and more severe the preeclampsia, the higher the future risk.

Gestational diabetes

Gestational diabetes (GDM) affects roughly 6–9% of pregnancies and reflects underlying insulin resistance.

Women with GDM have substantially higher risk of developing type 2 diabetes within 5–10 years, and higher cardiovascular risk over time. Notably, that elevated cardiovascular risk appears even in women who don’t go on to develop diabetes.[14]

What this means for nutrition

During a pregnancy affected by GDM, work with your obstetric and diabetes team on specific targets. General principles include spreading carbohydrates across the day, choosing high-fiber low-glycemic carbohydrates, pairing carbohydrates with protein and fat, and avoiding sugary drinks.

After pregnancy, the core eating pattern that works during a GDM pregnancy is much the same as the one that protects your heart afterward: high-fiber, mostly unprocessed carbohydrates; regular meals; limited sugary drinks; a Mediterranean or DASH-style pattern.

Other pregnancy complications that signal risk

• Preterm delivery (before 37 weeks)
• A small-for-gestational-age baby
• Placental abruption

What to do with this information

Tell every new provider. This history belongs in your medical record permanently, not just in your obstetric notes. A simple way to raise it: “I had preeclampsia (or gestational diabetes) in pregnancy. I understand it affects future heart risk. How should we monitor my blood pressure, cholesterol, and blood sugar over time?”

Request cardiovascular screening. Major cardiology and stroke guidelines recommend follow-up of blood pressure, lipids, and blood sugar within the first year after a pregnancy affected by preeclampsia or GDM, with continued monitoring over time.[15]

Get postpartum follow-up testing. A glucose test is usually recommended 6–12 weeks after delivery for women who had GDM. If it’s normal, you still need repeat diabetes screening every 1–3 years.

After pregnancy

The months and years after pregnancy are when many women establish long-term patterns.

• Weight: modest weight retention is common. Extreme crash diets are usually counterproductive. Aim for gradual change built around whole foods once your clinician clears you.
• Breastfeeding: when possible, breastfeeding is associated with lower risk of later type 2 diabetes in mothers in observational studies.[16] It may support long-term cardiometabolic health more broadly, though the strongest evidence so far is for diabetes risk.
• Postpartum mood: depression and anxiety after birth are common and affect appetite, food choices, and activity. If you are persistently down, anxious, or overwhelmed, treatment helps you regain basic self-care.

Perimenopause and Menopause

What happens to cardiovascular risk

The menopause transition (typically ages 45–55) brings changes that accelerate cardiovascular risk:[17]

• Lipids: total and LDL cholesterol tend to rise, HDL may decrease slightly, and triglycerides increase.
• Weight and body composition: fat redistributes toward the abdomen and lean muscle mass declines. Many women gain weight during the transition.
• Blood pressure: systolic blood pressure tends to rise.
• Insulin resistance: fasting glucose tends to rise, and the risk of type 2 diabetes increases.

Because these shifts often first appear during perimenopause, many experts recommend at least one cardiovascular check-in during the transition—blood pressure, fasting lipids, and glucose or A1c—then periodic follow-up based on your numbers and risk factors. The Women and Cardiovascular Health series article Menopause and the Cardiovascular Transition unpacks these physiologic changes in more detail.

Nutritional priorities

This is not the time to neglect cardiovascular health. The 5–10 years around menopause are a critical window for establishing protection.

• Calorie needs may fall, but nutrient needs don’t. As metabolic rate drops, nutrient-dense eating becomes more important, not less—protein, calcium, vitamin D, and fiber all remain essential.
• Protein becomes more important. To counter accelerating muscle loss, many experts recommend higher protein intake in midlife and beyond. See Article 13 for detailed guidance.
• Calcium and vitamin D for bone protection. Discuss targets with your healthcare team; food sources are generally preferable to supplements for calcium.
• Address the lipid shift through diet. The same patterns that lower cholesterol apply: a Mediterranean or DASH pattern, an emphasis on soluble fiber (oats, beans, barley), fish, nuts, and limited saturated fat. See Article 5 for detail.
• Limit alcohol. Alcohol worsens hot flashes, disrupts sleep, and adds empty calories. Even low levels of alcohol—up to about one drink a day—are associated with a higher risk of breast cancer in women in observational studies.[18] If you drink, keeping it to one drink or less per day is prudent.
• Manage weight proactively. Weight gain during menopause is not inevitable, but it does require attention. Focus on sustainable patterns rather than crash diets, which worsen muscle loss.

Hot flashes and diet

• Phytoestrogens (soy): a meta-analysis found that soy isoflavones modestly reduced hot flash frequency and severity, though results across individual trials are inconsistent and responses vary by person.[19] If you want to try, use whole soy foods (tofu, edamame, tempeh) rather than supplements. Even if hot flashes don’t improve, soy foods are worth including for protein and fiber. If you have a history of estrogen-receptor-positive breast cancer, discuss soy foods with your oncology team.
• Triggers: some women find hot flashes triggered by alcohol, caffeine, spicy foods, or hot beverages. A little personal experimentation can help.

Hormone therapy

Menopausal hormone therapy (MHT) is not recommended for preventing heart disease. Current guidelines recommend using MHT only for bothersome symptoms, at the lowest effective dose and shortest duration needed. If you’re considering it, discuss the cardiovascular implications with your clinician. Whatever you decide, the nutrition and lifestyle foundations in this article still apply and remain central to cardiovascular prevention. The evidence on hormone therapy and the heart—which has been substantially reinterpreted over the past two decades—is examined in the Women and Cardiovascular Health series article Hormone Therapy: What We Know and What We Don’t.

Special Situations

Autoimmune conditions

Several autoimmune conditions are more common in women and carry elevated cardiovascular risk: rheumatoid arthritis, systemic lupus erythematosus, psoriatic arthritis, and inflammatory bowel disease. The common thread is chronic inflammation. (How these conditions—along with diabetes and postmenopausal hypertension—quietly move women from average to high risk is the subject of the Women and Cardiovascular Health series article Conditions That Amplify Women’s Cardiovascular Risk.)

Nutritionally, anti-inflammatory dietary patterns—particularly the Mediterranean diet—may improve disease activity in conditions like rheumatoid arthritis, and the same pattern supports cardiovascular health.[20] Omega-3 fatty acids from fish may help reduce inflammation, and vitamin D deficiency is common and worth monitoring.

If you have rheumatoid arthritis, lupus, or another chronic inflammatory disease, ask: “Does my condition count as a cardiovascular risk enhancer, and how should that change our screening or prevention plan?”

Breast cancer therapies

Some chemotherapy agents, HER2-targeted therapies, and left-sided chest radiation can increase long-term cardiovascular risk. Some treatments also affect cholesterol, blood pressure, or heart muscle function.

If you’ve been treated for breast cancer, make sure your oncology history is part of your cardiovascular risk discussion. You don’t need a special diet, but you have more reason than most to follow heart-protective eating and to have your blood pressure, lipids, and glucose checked regularly.

Eating disorders

Eating disorders carry cardiovascular consequences that are often under-recognized:

• Anorexia nervosa can cause a slow heart rate, low blood pressure, arrhythmias, and electrolyte abnormalities.
• Bulimia nervosa can cause dangerous electrolyte disturbances and arrhythmias.
• Binge eating disorder is associated with obesity, type 2 diabetes, hypertension, and dyslipidemia.

If you have an eating disorder, cardiovascular nutrition advice has to be adapted to your specific situation within specialized treatment. The standard “heart-healthy eating” guidance in this article is not designed for people with active eating disorders and should not be used as a self-directed treatment plan; any nutrition changes should be made within a specialized treatment program.

If you recognize yourself in these descriptions and are not in treatment, please reach out to a healthcare provider or the National Alliance for Eating Disorders, which runs a free helpline staffed by licensed therapists at 1-866-662-1235 (allianceforeatingdisorders.com).

Female-Specific Cardiovascular Risk Enhancers

Major cardiology guidelines now classify adverse pregnancy outcomes (especially preeclampsia, gestational diabetes, and preterm birth), premature menopause (before age 40), PCOS, and chronic inflammatory diseases as “risk-enhancing factors” when estimating cardiovascular risk and deciding on preventive therapies.

If any of these apply to you, it’s worth discussing cardiovascular screening with your healthcare team—even if your current numbers look normal:

The Bottom Line

Women’s cardiovascular disease is underdiagnosed and undertreated, but the dietary foundation is not a mystery: the same Mediterranean and DASH patterns that protect men protect women too. What changes across the lifespan is the context.

In the reproductive years, build the foundation with balanced nutrition and adequate iron—and if PCOS is present, treat it as the cardiovascular risk condition it is. In pregnancy and after, treat preeclampsia, gestational diabetes, and other complications as warning signs that deserve lifelong attention, and make sure that history follows you into primary care and cardiology. Through perimenopause and menopause, when lipids shift, weight redistributes, and blood pressure rises, intensify rather than relax your cardiovascular nutrition; hormone therapy is for symptom relief, not heart protection. And in special situations—autoimmune disease, a history of breast cancer treatment—recognize that the cardiovascular risk is higher and the case for heart-protective eating is stronger.

The single most useful habit is advocacy: know your own risk-enhancing factors, request cardiovascular assessment, and don’t accept having your symptoms dismissed. Your heart is worth that persistence.

Continue to Article 15: Vegetarian and Vegan Heart Health.

Key Terms

• Cardiovascular risk enhancer — a factor that raises long-term heart risk beyond standard calculators. For women, these include a history of preeclampsia or gestational diabetes, PCOS, early menopause, and chronic inflammatory disease.
• Preeclampsia — high blood pressure with protein in the urine or organ dysfunction during pregnancy. It signals elevated future cardiovascular risk.
• Gestational diabetes (GDM) — high blood sugar first appearing in pregnancy; a marker of underlying insulin resistance and higher future risk of type 2 diabetes and heart disease.
• Polycystic ovary syndrome (PCOS) — a common hormonal condition defined by some combination of irregular periods, elevated androgens, and polycystic ovaries; it carries metabolic and cardiovascular risk.
• Perimenopause / menopause — the transition (typically ages 45–55) when ovarian estrogen production declines, bringing lasting changes to lipids, blood pressure, body composition, and glucose.
• MINOCA / SCAD — heart attack with non-obstructive coronary arteries, and spontaneous coronary artery dissection; heart conditions that occur more often in women and may not show large blockages on angiogram.
• Phytoestrogens — plant compounds (notably soy isoflavones) with mild estrogen-like activity.
• Menopausal hormone therapy (MHT) — estrogen, with or without progestogen, used to treat menopausal symptoms. It is not a tool for preventing heart disease.

References

1. Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation. 2020;141(9):e139-e596.
2. Scott PE, Unger EF, Jenkins MR, et al. Participation of women in clinical trials supporting FDA approval of cardiovascular drugs. J Am Coll Cardiol. 2018;71(18):1960-1969.
3. Garcia M, Mulvagh SL, Bairey Merz CN, Buring JE, Manson JE. Cardiovascular disease in women: clinical perspectives. Circ Res. 2016;118(8):1273-1293.
4. Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circulation. 2011;123(11):1243-1262.
5. Bucholz EM, Strait KM, Dreyer RP, et al. Sex differences in young patients with acute myocardial infarction: a VIRGO study analysis. Eur Heart J Acute Cardiovasc Care. 2017;6(7):610-622.
6. World Health Organization. Iron deficiency anaemia: assessment, prevention and control. A guide for programme managers. Geneva: WHO; 2001.
7. Farhat GN, Cauley JA. The link between osteoporosis and cardiovascular disease. Clin Cases Miner Bone Metab. 2008;5(1):19-34.
8. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81(1):19-25.
9. Wild RA, Carmina E, Diamanti-Kandarakis E, et al. Assessment of cardiovascular risk and prevention of cardiovascular disease in women with the polycystic ovary syndrome: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome (AE-PCOS) Society. J Clin Endocrinol Metab. 2010;95(5):2038-2049.
10. Moran LJ, Ko H, Misso M, et al. Dietary composition in the treatment of polycystic ovary syndrome: a systematic review to inform evidence-based guidelines. J Acad Nutr Diet. 2013;113(4):520-545.
11. Barrea L, Arnone A, Annunziata G, et al. Adherence to the Mediterranean diet, dietary patterns and body composition in women with polycystic ovary syndrome (PCOS). Nutrients. 2019;11(10):2278.
12. Rich-Edwards JW, Fraser A, Lawlor DA, Catov JM. Pregnancy characteristics and women’s future cardiovascular health: an underused opportunity to improve women’s health? Epidemiol Rev. 2014;36(1):57-70.
13. Wu P, Haththotuwa R, Kwok CS, et al. Preeclampsia and future cardiovascular health: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2017;10(2):e003497.
14. Kramer CK, Campbell S, Retnakaran R. Gestational diabetes and the risk of cardiovascular disease in women: a systematic review and meta-analysis. Diabetologia. 2019;62(6):905-914.
15. Bushnell C, McCullough LD, Awad IA, et al. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(5):1545-1588.
16. Schwarz EB, Brown JS, Creasman JM, et al. Lactation and maternal risk of type 2 diabetes: a population-based study. Am J Med. 2010;123(9):863.e1-6.
17. El Khoudary SR, Aggarwal B, Beckie TM, et al. Menopause transition and cardiovascular disease risk: implications for timing of early prevention: a scientific statement from the American Heart Association. Circulation. 2020;142(25):e506-e532.
18. Cao Y, Willett WC, Rimm EB, Stampfer MJ, Giovannucci EL. Light to moderate intake of alcohol, drinking patterns, and risk of cancer: results from two prospective US cohort studies. BMJ. 2015;351:h4238.
19. Taku K, Melby MK, Kronenberg F, Kurzer MS, Messina M. Extracted or synthesized soybean isoflavones reduce menopausal hot flash frequency and severity: systematic review and meta-analysis of randomized controlled trials. Menopause. 2012;19(7):776-790.
20. Petersson S, Philippou E, Rodomar C, Nikiphorou E. The Mediterranean diet, fish oil supplements and rheumatoid arthritis outcomes: evidence from clinical trials. Autoimmun Rev. 2018;17(11):1105-1114.