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 fibre gap is more prominent in western countries than in developing countries and rural areas where they consume fiber-rich diets.
A balanced diet rich in fibre may lead to a more healthy gut microbiota with a less active immune system and inflammatory reactions in the gut, thus leading to less inflammation overall.
The chronic consumption of the SAD diet leads to release of pro-inflammatory substances causing more inflammation, pain, and fatigue:
Is The Mediterranean Diet (MedDiet) Still Relevant?
I am a big fun of the MedDiet lifestyle to reduce inflammation. The MedDiet is well-balanced, provide a wide range of macro and micronutrients, and is tasty:
Promotes grains, fruits, vegetables, nuts and legumes (fibre)
Preference for seasonal fruits and vegetables, locally grown or organic if possible
Preference for seafood, fish, legumes, nuts as main source of protein
Encourages moderate consumption of poultry, eggs, cheese and yogurt
Discourages the consumption of red meats and refined sugars
Uses Extra Virgin Olive Oil which is associated with anti-inflammatory markers
Encourages the use of anti-inflammatory condiments and herbs (e.g., cinnamon, curcumin, cumin) and less salt
Encourages physical activity
Promotes enjoyment of meals with friends and family
Just like in the 1900s "A cheerful atmosphere should be maintained during the actual progress of meals because unquiet meals make ill digestion"
5 Steps to Getting Started with the MedDiet
1. Planning your meals ahead
2. Include vegetables or fruit in every meal. Cook a meatless dinner or lunch once a week
3. Enjoy some fermented dairy products
4. Switch to whole grains (i.e. Wild rice, Amaranth, Millet, Quinoa, Teft, Millet). I personally follow a gluten free diet.
5. Enjoy extra-virgin olive oil, nuts, sunflower seeds, olives, avocados as main source of fats.
What else is in the Anti-Inflammatory Diet toolbox?
A review on emerging nutrients shows some promising anti-inflammatory effects on the Gut Microbiome and these are commonly used ingredients such as red hot chilli peppers and cocoa.
Red Hot Chilli Peppers (Capsain) and spicy foods seems to play anti-inflammatory roles, modulating the neuroimmune response and decreasing neurogenic pain.
Cocoa is another nutrient raising interest because of its antioxidant properties due to its high content of flavonoids.
In animal studies, nanopowdered red ginseng when used together with methotrexate significantly reduced the production of pro-inflammatory cytokines. Although human studies are needed.
What's Next?
I am excited to see the results of the Swedish study "A randomized controlled cross-over trial investigating the effect of anti-inflammatory diet on disease activity and quality of life in rheumatoid arthritis: the Anti-inflammatory Diet In Rheumatoid Arthritis (ADIRA) study protocol"
The ADIRA study is one of a kind protocol that aims to provide evidence as to whether an anti-inflammatory diet in patients with moderate RA will improve their disease progress and their quality of life.
My reflection
We are fortunate that the pharmacological management of inflammatory arthritis has evolved in the last century. Many people with Rheumatoid Arthritis can live a "new normal" life, work, study, have family. However, there are no real answers for those with moderate to severe rheumatic disease activity when it comes to chronic fatigue, brain fog, muscle pain, depression, isolation, digestive issues, and many more.
According to a new study, despite patients showing positive outcomes in inflammation markers after initiating treatment, this does not always translate in improvement of pain and fatigue. A holistic approach to care is necessary, complementary therapies such as diet, physiotherapy, occupational therapy, relaxation techniques, aromatherapy, even medicinal cannabis can an integral part of the management of inflammatory arthritis.
Although there are controversies on whether the MedDiet helps reducing pain or disease activity in RA due to faulty research methodology. Overall, the MedDiet is still consider one of the healthiest diet lifestyles to prevent cardiovascular disease due to its balance of macro and micro-nutrients as well as a great compliance and sustainability in the long term.
I believe that until we find a cure to autoimmune diseases, we cannot expect quick fixes that can further deteriorate our health status. We need to adopt a lifestyle that is realistic and sustainable in the long term.