NUTRITIONAL INFLUENCES ON RHEUMATIC...

NUTRITIONAL INFLUENCES ON RHEUMATIC

DISEASES

Daniel Lewis

Daniel Lewis Rheumatology Centre

73 Chapel St St Kilda

www.daniellewis.com.au

www.pathways2wellbeing.com.au

Daniel Lewis

Rheumatology

Centre

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The Breadth of Rheumatic Diseases

Inflammation

Rheumatoid arthritis

SLE

Psoriatic arthritis

Ankylosing spondylitis

Scleroderma

Myositis

Polymyalgia rheumatica

Daniel Lewis

Rheumatology

Centre

Breadth of Rheumatic diseases

Pain and CNS disorders

Fibromyalgia/

ME/CFS

Spinal pain

myofascial pain

Daniel Lewis

Rheumatology

Centre

Inflammation

RA/ SLE/ psoriatic/ ankylosing spondylitis/ scleroderma/ myositis / PMR

Breadth of Rheumatic diseases

Inflammation

RA/ SLE/ psoriatic/ ankylosing spondylitis/ scleroderma/ myositis / PMR

Osteoarthritis

Osteoporosis

Tendonopathies

Pain and CNS disorders

Fibromyalgia/ ME/CFS

Spinal pain

myofascial pain

Cartilage and bone disorders

Osteoarthritis

Tendinopathies

Osteoporosis

Daniel Lewis

Rheumatology

Centre

An essential aspect of Lifestyle Medicine

Foods: What to eat... What not to eat … How to cook

Special diets

Allergy and food sensitivity, gut inflammation

Nutrition and rheumatic diseases.

Daniel Lewis

Rheumatology

Centre

Nutrition and rheumatic diseases

Gut permeability or ―leaky gut syndrome‖

Nutrition and rheumatic diseases

The Microbiom and Dysbiosis

Daniel Lewis

Rheumatology

Centre

Nutrition and rheumatic diseases

Macronutrients and Micronutrients

Supplements

Daniel Lewis

Rheumatology

Centre

Nutrition and rheumatic diseases

Constipation

IBS

Daniel Lewis

Rheumatology

Centre

Nutrition and rheumatic diseases

Neutrigenomics

Diagnostics

Daniel Lewis

Rheumatology

Centre

The Agenda

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Nutrition - a component of Lifestyle medicine

www.pathways2wellbeing.com.au

Daniel Lewis

Rheumatology

Centre

Pathways to Wellbeing

Optimal Nutrition

Eating is an enjoyable

experience

Tsunami of Chronic Disease

According to the

WHO

46% of global

disease burden

59% of global

mortality are due

to chronic

diseases.

Chronic Disease

Most chronic diseases are interrelated. Contain an element of increased inflammatory response.

Daniel Lewis

Rheumatology

Centre

Inflammation

The increase in ‗inflammatory tonus‘ is

mainly the result of lifestyle and

nutritional habits, making the increase

controllable.

Bengmark S. Acute and ‗chronic‘ phase response: a mother of disease. Clin Nutr 2004; 23:1256–1266. The World Health Report 2002: reducing risks, promoting healthy lifestyle. Geneva: World HealthOrganization, 2002

Inflammation

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Tsunami of Chronic Disease

Inflammation

Cellular damage

Telomere shortening

Accumulation of advanced glycation end

(AGE)products.

Daniel Lewis

Rheumatology

Centre

Tsunami of Chronic Disease

Inflammation

Cellular damage

Telomere shortening

Accumulation of advanced glycation end

(AGE)products.

Daniel Lewis

Rheumatology

Centre

Are proteins or lipids formed

Exogenously when sugars are

cooked with proteins or fats at high

temperature.

Endogenously by normal metabolism

ageing.

Advanced Glycation End-Products. (AEGs)

Daniel Lewis

Rheumatology

Centre

Typically formed when sugars are

cooked with proteins or fats at

high temperature.

Accumulate over time.

Advanced Glycation End-Products. (AEGs)

Daniel Lewis

Rheumatology

Centre

AGEs are:

Typically formed when sugars are

cooked with proteins or fats.

Accumulate over time.

Strongly associated with ageing,

chronic diseases and other markers of inflammation.

Advanced Glycation End-Products. (AEGs)

Daniel Lewis

Rheumatology

Centre

AGEs are:

typically formed when sugars are

cooked with proteins or fats.

accumulate over time.

strongly associated with ageing,

chronic diseases and other markers

of inflammation.

binding of AGEs lead to

subsequent expression of

NF-[kappa]B-regulated cytokines.

AGE's generate free radicals.

Advanced Glycation End- Products (AGEs)

Daniel Lewis

Rheumatology

Centre

AGEs are:

Typically formed when sugars are

cooked with proteins or fats.

Accumulate over time.

Strongly associated with ageing,

chronic diseases and other markers of inflammation.

Endothelial damage

Advanced Glycation End-Products. (AEGs)

Daniel Lewis

Rheumatology

Centre

Advanced Glycation End-Products (AGEs)

Inhibited by

Pyridoxamine 50 mg (B6)

Benfotiamine 50ug (B12) twice daily

Methylcobalamin 50 mg (B1)

.

Syngle A et al; Advanced glycation end product inhibition improves endothelial dysfunction in rheumatoid Int J

Rheum 2012; 15:45-55

Daniel Lewis

Rheumatology

Centre

Foods: What to eat... What not to eat

What we eat and how we cook can have a profound

effect on our health.

Foods: What to eat... What not to eat

What we eat and how we cook can have a profound effect on our

health.

The majority in society are

overfed but undernourished.

Nutrition is an.

Hippocrates said,

"Let food be thy medicine and medicine be thy food".

VS

Foods: What to eat... What not to eat

Daniel Lewis

Rheumatology

Centre

Foods: What to eat... What not to eat

Inverse relation to CRP

26% of patients are discharged from hospital

with a lower nutritional status than they had

prior to admission.

VS

Daniel Lewis

Rheumatology

Centre

Burgos et al Prevalence of malnutrition and its etiological factors in hospitals. Nutr

Hosp 21 . 2012 Apr;27(2):469-76.

Soil Health

Soil health affects the mineral

content of food.

?? soil health and genetic

modifications

Picture of alkalinity

Daniel Lewis

Rheumatology

Centre

Soil Health

Soil health affects the mineral

content of food.

?? soil health and genetic

modifications

Be involved in the

debate !

Picture of alkalinity

Daniel Lewis

Rheumatology

Centre

Research

Broadly speaking the research has been focused on four separate but related questions:

Is any diet helpful in inducing or maintaining remission?

(eg. elemental or food allergy avoidance)

Is there a nutritional cause?

Can specific nutrient supplements aid in treatment?

What is the role of nutrition support?

Daniel Lewis

Rheumatology

Centre

Special Diets

Despite numerous studies over decades the evidence in still lacking power and is not well collated and presented.

Daniel Lewis

Rheumatology

Centre

Special Diets

Shatin R: Preliminary report for the treatment of rheumatoid arthritis

with high protein gluten-free diet and supplements.

Med J Aust 1964;2:169-72.

Special Diets

A vegan diet free of gluten improves the signs and symptoms of rheumatoid

arthritis: the effects on arthritis correlate with a reduction in antibodies to

food antigens.

Hafström I, Rheumatology 2001;40(10):1175-9.

Foods to avoid

Prostaglandin E-2 has an inflammatory action it is

derived from arachadonic acid

Meats (the average omnivore ingests between 200-1,000 milligrams of

arachadonic acid each day)

Linoleic acid, which comes from cooking oils, particularly corn,

sunflower, safflower, and cottonseed

Azadbakht L Red meat intake is associated with metabolic syndrome and the plasma C-reactive protein concentration in women.

J Nutr. 2009 Feb;139(2):335-9.

Elimination Diet

The Elimination diet is based on the foods least likely to cause problems

such as:

sweet potatoes

brown rice

non citrus fruits

green and yellow vegetables

Water as beverage

If improvement is found (usually within 1 to 2 weeks), then foods are added

back one at a time to see if there is an adverse reaction. van de Laar MAFJ, van der Korst JK. Food intolerance in rheumatoid arthritis. I. A double blind, controlled trial of the

clinical effects of elimination of milk allergens and azo dyes. Ann Rheum Dis 1992;51:298-302.

All thoroughly cooked

Special Diets

Common thread with variations

Whole starches, vegetable, and fruits.

No gluten

No meat

No dairy

Alkaline

Special Diets

Common thread with variations

Whole starches, vegetable, and fruits.

No gluten

No meat

No dairy

Alkaline

Special Diets

The Alkaline Diet: Is there evidence that

an alkaline Ph diet benefits health?

Picture of alkalinity

Daniel Lewis

Rheumatology

Centre

Gerry Schwalfenberg. The Alkaline Diet: Is there evidence that an alkaline pH

diet benefits health? ; J Environ Public Health. 2012;727630

Special Diets

Acidosis and high sodium results in

osteoporosis, loss of muscle mass

Alkaline diet increases intracellular mg-

reduces HT and stroke

Alkaline diet and Vit D improved chronic

low back and pain

Picture of alkalinity

Daniel Lewis

Rheumatology

Centre Gerry Schwalfenberg. The Alkaline Diet: Is there evidence that an alkaline pH diet benefits health?.

J Environ Public Health. 2012;727630

Special Diets

There is almost no data on inflammation, or any specific rheumatic disorder.

Picture of alkalinity

Daniel Lewis

Rheumatology

Centre

The Alkaline Diet: Is there evidence that an alkaline Ph diet benefits health?

Gerry Schwalfenberg. J Enviton Public Health. 2012;727630

Alkaline Mineral Supplementation de\creases pain in Rheumatoid Arthritis

patients: a Pilot Study The Open Nutrition Journal 2008 2 100-105

Fasting is a high risk, short term treatment.

Only a limited number of studies have shown fasting to transiently

reduce joint pain in RA.

No studies have shown persistence of improvement for greater than ten days.

Fasting followed by Vegan diet improved symptoms over 12 months.

Kjeldsen-Kragh J, Haugen M, Borchgrevink CF, et al. Controlled trial of fasting and one-year vegetarian diet in

rheumatoid arthritis. Lancet 1991;338:899-902.

Kjeldsen-Kragh J, Haugen M, Borchgrevink CF, Forre O. Vegetarian diet for patients with rheumatoid arthritis—status: two years after introduction of the diet. Clin Rheum 1994;13:475-82.

Special Diets- Fasting

Daniel Lewis

Rheumatology

Centre

Special Diet- My Experience

10 patients with active stable RA on DMARDs and put them on a 3 month elimination diet

Many isolated examples.

12 Weeks

n ACR

4 50

3 20

3 No Change

Daniel Lewis

Rheumatology

Centre

Eat an anti-inflammatory diet

Eat 6 vegetable and 4 fruits ( relatively uncooked) per day.

Reduce refined carbohydrates and high GI foods

Increase complex carbohydrates and fibre

Reduce saturated fat, reduce inflammatory omega 6 fats and

eliminate trans fats.

Increase omega 3 ( fish & supplements)

Increase omega 9 (Oil and nuts) Daniel Lewis

Rheumatology

Centre

Eat an anti-inflammatory diet

Eat 6 vegetable and 4 fruits ( relatively uncooked) per day.

Reduce refined carbohydrates and high GI foods

Increase complex carbohydrates and fibre

Reduce saturated fat, reduce inflammatory omega 6 fats and eliminate trans fats.

Increase omega 3 ( fish & supplements)

Increase omega 9 (Oil and nuts) Daniel Lewis

Rheumatology

Centre

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Inflammation- Is there a nutritional cause?

Environmental trigger

Genetic susceptibility Intestinal hyper permeability

It is likely that 3 factors must be present simultaneously

Fasano A : Nat Clin Pract Gastroenerol Hepatol 2005; 2(9): 416-422

Daniel Lewis

Rheumatology

Centre

Leaky Gut Syndrome- Intestinal permeability

Leaky gut or intestinal permeability

refers to a loss of integrity in the

cell wall whereby bacteria,

allergens and incompletely

digested proteins can enter the

systemic circulation resulting in

immunological response.

Tight junction dysfunction is

mediated by a protein called

zonulin or

haptoglobin 2 precursor

Zonulin and Its Regulation of Intestinal Barrier Function: The Biological Door to Inflammation, Autoimmunity, and Cancer Fasano c; Physiol rev 2011 Jan;91(1):151-75

Leaky Gut Syndrome- Intestinal permeability

Leaky gut

Inflammation

allergic, inflammatory,

autoimmune diseases.

Daniel Lewis

Rheumatology

Centre

When the zonulin pathway is deregulated in

genetically susceptible individuals,

autoimmune disorders can occur.

Fasano A; Clin Rev Allergy Immunol. 2012 Feb;42(1):71-8

Leaky Gut Syndrome- Intestinal permeability

Daniel Lewis

Rheumatology

Centre

There are a range of nutritional

protocols to reverse this process.

No definite data in clinical trials.

Van der Hulst Glutamine and the preservation of gut integrity Lancet 8857;1 1993 1363-1365

Gut Dysbiosis and Inflammation

There are roughly 4000

bacterial species in the

intestine where they help

digest nutrients

produce vitamins

anti inflammatory compounds

Ref: Human Microbiome Project Consortium

Gut, Dysbiosis and Inflammation

Microbial cells out number human cells 10:1

The genes in these microbes number millions compared with

23000 genes in the human genome.

Patients with autoimmune and inflammatory conditions have

a microbial profile that differs substantially from healthy

subjects

The evidence for causality is lacking and disease is likely to

be poly microbial in nature.

Proal et al. Immunostimmulation in the era of the metagenome ; Cellular and Molecular Immunol pub online Jan 2011

Daniel Lewis

Rheumatology

Centre

Gut, Dysbiosis and Inflammation

Stress can induce changes in the gut.

Nutrition influences the gut microbiome

Symbiosis leads to regulation and homeostasis.

Dysbiosis can lead to inability to fight infection.

Daniel Lewis

Rheumatology

Centre

Kau AL , Human Nutrition, the gut microbiome and the immune system

Nature 2011; 474, 327-336.

GIT Subclinical inflammation

RA - Perpetuates the systemic inflammatory processes

Ank Spond - Induces IL 23 in the enthesis driving inflammation

FM ME/CFS - circulating cytokines explain many of the symptoms

Hamer et al Cell; 1990 63 1099

Daniel Lewis

Rheumatology

Centre

Leaky Gut Syndrome- Intestinal permeability

Daniel Lewis

Rheumatology

Centre

There are a range of nutritional

protocols to reverse this process.

No definite data in clinical trials

Watch this space closely !

Nutritional Influences on Rheumatic Diseases

How do you make sense of all these nutrition messages?

What do I do ?

Daniel Lewis

Rheumatology

Centre

Nutritional Assessment

3 day food and drink diary

Medication including supplements

Symptom questionnaire

Evaluation of body weight (casual)

Self esteem and internal locus of control (complience)

UNDERSTANDING

Nutrition - a component of Lifestyle medicine

www.pathways2wellbeing.com.au Daniel Lewis

Rheumatology

Centre

Wellbeing Library

Facebook

Healtheletter

Personal Health

record

SKILLS

How to observe symptoms and make

adjustments to diet

How to shop

How to cook

How to eat

Manage supplements

An ongoing conversation.

INSPIRATION

Rheumatoid Arthritis- what do I do.

Inflammation

Food sensitivities

Leaky gut

Associated Diseases

Anti Inflammatory Diet

Alkaline Diet

Supplements

Daniel Lewis

Rheumatology

Centre

Rheumatoid Arthritis- what do I do.

Inflammation

medical emergency!

We have only 6 months to

prevent disability.

Daniel Lewis

Rheumatology

Centre

Rheumatoid Arthritis- what do I do.

Inflammation

Food sensitivities Associated diseases

infection

Daniel Lewis

Rheumatology

Centre

Food Sensitivity

Many studies have shown that,

if testing is done with sufficient care,

dietary sensitivities can be identified in

20-60% of subjects with RA.

Hvatum M et al.GutThe gut-joint axis: cross reactive food antibodies in rheumatoid arthritis.

. 2006 Sep;55(9):1240-7

Kokkonen J. Intestinal immune activation in juvenile idiopathic arthritis and connective

tissue disease. Scand J Rheumatol. 2007 Sep-Oct;36(5):386-9. Daniel Lewis

Rheumatology

Centre

Food Sensitivity

Many studies have shown that,

if testing is done with sufficient care,

dietary sensitivities can be identified in

20-60% of subjects with RA.

Elimination diet ?

Daniel Lewis

Rheumatology

Centre

Rheumatoid Arthritis- what do I do.

Inflammation

Food sensitivities

Leaky gut

Associated Diseases

Anti Inflammatory Diet

Alkaline Diet

Supplements

Daniel Lewis

Rheumatology

Centre

Rheumatoid Arthritis- what do I do.

Inflammation

Food sensitivities

Leaky gut

Associated Diseases

Anti Inflammatory Diet

Alkaline Diet

Supplements

Daniel Lewis

Rheumatology

Centre

Rheumatoid Arthritis- what do I do.

Associated Diseases

osteoporosis

cardiovascular risk

infection

osteoarthritis

Daniel Lewis

Rheumatology

Centre

Rheumatoid Arthritis- what do I do.

Inflammation

Food sensitivities

Leaky gut

Associated Diseases

Anti Inflammatory Diet

Alkaline Diet Supplements

Daniel Lewis

Rheumatology

Centre

Rheumatoid Arthritis- what do I do.

Inflammation

Food sensitivities

Leaky gut

Associated Diseases

Anti Inflammatory Diet

Alkaline Diet

Supplements

Daniel Lewis

Rheumatology

Centre

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Daniel Lewis

Rheumatology

Centre

Rheumatoid Arthritis

Abundant research in RA

Omega 3

Krill Oil Antarctic Krill (Ephausia Superba)

Novel marine phospholipid carriers of EPA & DHA

and potent antioxidant, Astaxanthin.

Astaxanthin inhibits the production of

pro inflammatoryprostaglandins (PGE2) and TNF

Is the most abundant biomass on Earth.

Daniel Lewis

Rheumatology

Centre

Omega 3

Krill Oil

Deutsch L. J Am Coll Nutr. 2007 Feb;26(1):39-48. Evaluation of the effect of Neptune Krill Oil on chronic inflammation and arthritic symptoms.

90 patients with CVD/RA/OA and elevated CRP. 300mg/day

30.9% in CRP at one month(p < 0.001).

Pain and WOMC

Omega 6: Borage oil

A quarter-teaspoon supplies 300 milligrams of GLA.

It can take several weeks for these oils to work, and

up to six months to see their full effect.

Leventhal LJ, Boyce EG, Zurier RB. Treatment of rheumatoid arthritis with gammalinolenic acid. Ann Int

Med 1993;119:867-73.

Herbs: Ginger

The spice ginger has been used in Indian ayurvedic medicine for centuries as an arthritis treatment.

In vitro and In vivo studies show that it does indeed have anti-inflammatory effects.

An anti-inflammatory effect persisted for several days.

Dose. 1/2-1 teaspoon (1-2 grams) of powdered ginger each day. 4 to 12 weeks for benefits to appear.

Srivastava KC, Mustafa T. Ginger (Zingiber officinale) in rheumatism and musculoskeletal disorders. Med Hypoth 1992;39:342-8.

Herbs: Tumeric

Curcumin

is a component of the spice turmeric.

COX-2 inhibition

Anti tumour

Anti oxidant

Chopra., et al., Randonmised double blind trial of Ayurvedic olant derived formulation for the treatment of rheumatoid artrhritis. J Rheum 2000;27 1365-

72

Funk, et al., Tumeric extraxts containing curcuminoids prevent experimental rheumatoid arthritis.2006; j Nat Prod 69(3) 351-5

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Osteoarthritis

Inflammation

Cartilage loss

Obesity

Daniel Lewis

Rheumatology

Centre

Osteoarthritis

Inflammation

Cartilage loss Obesity

Daniel Lewis

Rheumatology

Centre

Osteoarthritis

Cartilage loss

Glucosamine & Chondroitin- Inconsistent results. More evidence for CS

Lukas MW. Condroitin sulphate reduced both cartilage volume and bone marrow lesions in knee osteoarthritis

patients starting as early as 6 months after initiation of therapy: a randomised ,double blind placebo-controlled pilot

study using MRI. Ann Rheum Dis 2011 70(6) 982-989.

Daniel Lewis

Rheumatology

Centre

Osteoarthritis

Pain and Inflammation

Daniel Lewis

Rheumatology

Centre

Herbs: Tumeric

Curcumin is a component of the spice turmeric.

.COX-2 inhibition

. Anti tumour

. Anti oxidant

Greg Tooley, Luke Xantidis & Daniel Lewis 2008

A double-blind, randomised, placebo controlled trial of the analgesic properties of curcumin (Nalgesic® Active

Ingredient Cumerone 1200®) in osteoarthritis of the hand.

Daniel Lewis

Rheumatology

Centre

Tumeric: A double-blind, randomised, placebo

controlled trial of Nalgesic.

Pain Associated with Gripping Range of Movement

Osteoarthritis

Obesity

Obesity is an inflammatory disorder

Is an factor in progressive

disease independent of the weight bearing

effects.

Daniel Lewis

Rheumatology

Centre

Yousef E . Metabolic factors in osteoarthritis: obese people do not walk on their hands.

Arthritis Res Ther 2012 Jul 19;14(4):123

How far have we gone?

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Summary

Nutrition a dominant part of lifestyle medicine

What to eat... What not to eat

Special diets

Allergy and food sensitivity dysbiosis leaky gut

Nutrigenomics

Supplements

Summary Continued

Nutrition for: Inflammation

OA

Gout

Cardiovascular risks

Fibromyalgia

Osteoporosis

Obesity

Daniel Lewis

Rheumatology

Centre

Daniel Lewis

Rheumatology

Centre

THANK YOU

daniel.lewis@daniellewis.com.au