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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
?
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
?
?
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
?
?
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
?
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
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
.
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
?
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?
?
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
