• Cristina Montoya, RD

Do Not Ignore Nutrition in Autoimmune Rheumatic Diseases!

In recent years, an explosion of “anti-inflammatory” diets has been bombarding the web with the ultimate nutrition plans to prevent, manage and even cure autoimmune diseases. No wonder why we are so confused about the type of foods and diet to follow. Are the nightshades safe? Should I eat gluten-free, dairy free, soy free? What about the Autoimmune Protocol Diet? Should I go Keto?

Before we get into the nitty gritty, let’s start with the basics and review a little bit of the past and present of diet interventions in inflammatory arthritis, particularly Rheumatoid Arthritis (RA).

In 1909, the article "Diet in Rheumatoid Arthritis" described dietary instructions to manage RA during and after an arthritis attack. According to Dr. R. Llewellyn Jones, patients with RA often presented with gastrointestinal disturbances, so it was believed that diet could modify the intestinal flora that was leading to chronic toxemia or poisoning of the body causing pain. Drinking milk for the first 24 hours of the acute phase was the main treatment, if milk was not tolerated, then “sour milk” or fermented milk was recommended. It suggested that lactic acid bacilli reduced intestinal putrefaction. A pint of Whisky was part of the protocol! I guess alcohol helped to knock off the pain in those rotten bodies.

Picture 1. Pierre-August Renoir (1841-1919) and Rheumatoid Arthritis (A famous impressionist artist suffered from RA most of his life)

Once the attack had passed a patient could eat three meals a day with a reasonable quantity of alcohol, and milk should be taken between meals and before bedtime to aid with sleep. A reintroduction of foods that were gentle on the digestive system such as oysters, lightly boiled fish, minced meats, cooked vegetables and fruits, fresh butter was encouraged. Limited intake of bread, potatoes, sugar and salads was also recommended for people with severe digestive distress. The main goal was to prevent gastro-intestinal imbalances which was considered a source of pain and complications.

I’ve found particularly fascinating a remark on the brain-gut connection to reduce digestive disturbances The beneficial effect of rest, both before and after meals, for a period varying from half an hour to an hour, for the purpose of promoting digestion and assimilation, should be taken advantage of. No less important is that a cheerful atmosphere should be maintained during the actual progress of meals because unquiet meals make ill digestions”.

Fast forward to the present time, in 2019 (120 years later!) the gastrointestinal tract is back on the spotlight. It’s interesting how it took over 100 years to refocus on the impact of the gut flora in the management of inflammatory arthritis.

A recent review on the interactions between microbiota and diet in the inflammatory response in rheumatoid arthritis highlights the role of diet and specific nutrients on modulating the inflammatory response in rheumatic diseases, suggesting an integrated and holistic approach to manage these conditions.

Microbiota and the Immune Response

The gut microbiota is the complex group of microorganisms that live in the digestive tract and mainly focuses on the degradation of indigestible dietary fibres through fermentation producing Short-Chain Fatty Acids (SCFAs) such as acetate, propionate and butyrate. The latter are especially important to nourish the gut cells, regulate gut permeability and control the mucosal inflammation.

A recent study found patients in the early stages of RA with intestinal dysbiosis (imbalance in the gut microorganisms) characterized by the presence of Prevotella Copri, which seems to be associated with RA onset and severity.

Growing evidence is explaining the role of dysbiosis of the gut microbiota as possible lead to the onset and disease progression of several autoimmune/inflammatory rheumatic diseases, such as Rheumatoid Arthritis, Spondyloarthritis (SpA), Psoriatic Arthritis (PsA), and Systemic Lupus Erythematosus (SLE).

Some evidence shows intestinal permeability or leaky gut caused by the interaction between microbes, diet, antibiotics, toxins, physical and emotional stress that allow the entry of harmful pathogens from the gut barrier into the blood stream. Those interactions lead to mucosal inflammation and may exacerbate the response of autoimmune diseases, including RA.

Do Probiotics help?

The World Health Organization defines probiotics as “a living micro-organism that when ingested in sufficient quantities, provides beneficial effects on the health of its consumer”, probiotics means "for life" and are good bacteria for our bodies. In RA, particularly Lactobacillus helveticus may stimulate anti-inflammatory cytokines, thus reducing the inflammatory process and severity. It looks like Dr. R. Llewellyn in the 1900s wasn’t too far off after all.

As I search for probiotics, Probiotics and Prebiotics by Intelligent Labs caught my attention and will add it to my supplement list.

How Does Diet Impact the Gut Microbiota?

The modern Western diet or the Standard American Diet (SAD) is leading to a substantial depletion of the human gut microbiome. The S.A.D diet is characterized by a high consumption of refined carbohydrates, added sugars, vegetable oils rich in omega-6 fatty acids, red and processed meats, salty foods and decreased consumption of long-chain omega-3 fatty acids. Additionally, low intake of fibre or so called the