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Inflammatory diseases and
       role of diet
  Farhan Tahir MD, FACR
     Consultant Rheumatologist
  Rheumatic Disease Associates, Ltd.
    Abington Memorial Hospital
       Doylestown Hospital
What is Inflammation?
   Inflammation is immune system’s response to
    injury or infection

   Autoimmune disease are result of an unhealthy
    disordered immune system

   Inflammation results in pain, swelling, heat and
    redness of joints and tendons
Role of inflammatory in arthritis
   Inflammation is a cascade of biological process
    which leads to production of harmful chemicals ;
    cytokines
   Cytokines detrimental to body are (IL)-1, IL-6,
    tumor necrosis factor (TNF)-alpha, gamma
    interferon (INF-gamma)
   Cells produce reactive oxygen species (ROS)
    harmful to cartilage and joint structures leading
    to destruction
Chronic Inflammatory Diseases
   More than 40 distinct autoimmune diseases
   24 million Americans are affected (NIH Autoimmune
    Disease Coordinating Committee, June 2005)
   Examples: Asthma, Cohn's disease, Rheumatoid
    arthritis, SLE, Celiac disease
   Examples of chronic conditions with an inflammatory
    component include atherosclerosis, obesity, diabetes,
    cancer, and perhaps even Alzheimer’s disease
Evolution of Nutrition
   Primitive humans; wild game or vegetarian
   Refining; loss of fiber and micronutrients
   Western diet had 75% decline in fiber, 5 fold
    increase in sugar and four fold increase in fats
   Our hunter-gatherer ancestors consumed equal
    amounts of omega-6s and omega-3s
   Todays’s diet has been estimated to contain 14-
    25 times as much omega-6 as omega-3 fat
Overfed and Undernourished
   “Snack” and “fast” food: high fat, high sugar
   Western diet leads to “Overfed and
    undernourished” state
   Increase weight, decreased essential nutrients
   60% Americans: high waist/hip ratio (WHR) and
    BMI
   Alarming rates of diabetes, cancer, metabolic
    syndrome, heart and autoimmune diseases are
    linked to western diet
Western diet;
    Standard American Diet (SAD)
   High in red and processed animal meats, saturated fats,
    trans fats, sweets, desserts, fired food and refined
    grains and low in fiber

   Low in low-glycemic carbohydrates, fruits,
    vegetables, fish and legumes

   12 yr relative risk of colon cancer 1.46, 8 yr heart
    disease risk 64%, 1.3 RR of all cause mortality
Nutrition and Autoimmunity
   Inflammation and immune dysfunction starts in
    the intestinal track

   Presence of antibodies of intestinal bacteria like
    Proteus mirabilis have been linked to RA

   Lower antigen load, intake of vegetables, fruits
    and dietary vitamin C reduce risk, e.g.
    Norwegian and Mediterranean diets
High Glycemic Carbohydrates

   Negative impact on lipid and sugar metabolism
   Doubles reactive oxidative radicals production;
    increases peripheral vascular disease
   Depressed immunity and impairs white blood
    cell function
    Autoimmunity : Crohns disease, Rheumatoid
    arthritis
Impact of unhealthy Fats
   Trans and saturated fats are associated with
    depressed immunity
   Doubles risk cataract
   Atherosclerosis
   Heart arrhythmias
   Cancers
   Decreases bone mineral density osteoporosis
Arthritis and Nutrition
   RA is a common autoimmune type of arthritis
   1 in 100 persons, affects women more than
    males
   Cause is combination of genetic makeup and
    environmental cause or infection
   Main stay of treatment is allopathic medications
   Use of anti inflammatory diet and
    complementary therapy can be of immense help
Osteoarthritis and Nutrition
   It is degenerative type of arthritis, most
    common form of arthritis
   Affects weight bearing joints; knees, hips also
    affects hands and spine
   Loss and damage of cartilage and joint structure
   Leads to loss of smooth gliding, pain and
    swelling, improves with rest
   Weight loss, conditioning exercises with anti
    inflammatory nutrition has great potential
Role of diet in arthritis

   Elimination
   Anti inflammatory approach
   Anti oxidants
   Probiotics
   Herbal supplements
Elimination diet for food triggers
   Arthritis linked to food sensitivities
   Dairy products, wheat, and nightshade vegetables
    (bell pepper, eggplant, tobacco, tomato, and white
    potato) may be culprits
   Eliminating and gradual re-introduction of the
    culprit foods will allow identification
   High intake of coffee is linked to increased risk of
    RA, 4 or more cups/day
   UltraInflamX® is an anti-inflammatory medical
    food
Anti-inflammatory approach
      Diet and supplements
   Mediterranean diet; vegetables, whole
    grains, nuts
   Vitamin B6 and folic acid
   Omega-3 , EPA, DHA
   Anti oxidants
   Probiotics
   Herbal, Spices
   Bone supplements: Vitamin D, Calcium,
    Boron
Essential fatty acids
   Humans are unable to synthesize the fatty acids
    linoleic acid and linolenic acid
   Must be obtained through the foods
   Both of these fats are polyunsaturated, meaning
    they will be liquid rather than solid at room
    temperature
   Linoleic acid belongs to the family of omega-6
    fats and is readily available
Sources of Omega 3
Sources of Omega 6
Polyunsaturated fatty acids
          Omega 3 Fatty acids
   Remember EPA and DHA
   Produce resolvin which is anti inflammatory
   Clinical trials in RA, Lupus and Ankylosing
    spondylitis have proven benefit
   Improved patient reported pain, morning
    stiffness, number of painful and tender joints
   Average recommended dose , EPA 30mg/kg,
    DGA 50mg/kg or total 3.5g/day
Omega 6 versus Omega 3
   In general, omega-6 fats tend to promote
    inflammation, constriction of the blood vessels,
    and formation of blood cell clots
   Omega-3 fats are anti-inflammatory, relax the
    blood vessels, and protect against blood cells
    aggregating together into clots

Fat Guidelines
   Use coconut oil, canola, or olive oil (extra virgin
    is best) for cooking
   Make your own salad dressing with extra virgin
    olive oil, and red wine or balsamic vinegar
   Flax seeds and oil, sardines, ocean salmon, and
    walnuts
   Use a daily supplement of 1-4 grams of high
    EPA/DHA fish oils
Decrease pro inflammatory foods
   Trans fats, arachadonic acid and sugar may
    promote inflammation, so an anti-inflammatory
    diet is low in trans fats, arachadonic acid and
    sugar.
   Commercial meat and eggs are rich sources of
    arachidonic acid;
   Omega-3 eggs and pasture-fed beef have lower
    amounts of arachidonic acid.
Fats for life
      Healthy choices
   Extra virgin olive oil
   Expeller-pressed organic canola oil
   Nuts, Walnut and hazelnut oils in salads
   Avocados
   Seeds - freshly ground flaxseed.
   Cold water fish
   Dark roasted sesame oil as a flavoring
    for soups and stir-fries
   Superior quality supplements
Role of Omega 6 in
           Rheumatoid arthritis
   Omega 6: LA and ARA driven chemicals are
    pro- inflammatory, role confirmed in RA
   LA: vegetable oils; corn, sunflower, safflower
   ARA: animal products, abundant in beef (grain
    fed), conventionally produced eggs
   GLA : has anti inflammatory properties,
    sources, Oils of evening primrose, borage and
    black currant
   Dose 1.5-3g/day
Protein Guidelines
   Have protein with each meal and snack if
    possible
   Limit red meat or eliminate it unless it is free-
    range, grass-fed beef or lamb
   Avoid charring/browning proteins/meats
   Use free-range eggs for protein but avoid
    browning the eggs
   Avoid lunch meats that have sodium nitrate or
    nitrites, consider nitrite free turkey
Protein Guidelines
   Use walnuts as snack, good protein and omega-3
    fats source
   Use mixed nuts and seeds (pumpkin, sunflower)
   Consider nut butters ; almond, cashew,
    macadamia
   Soy products good sources of protein
   Organic milk products (milk, cheese, and yogurt)
   For milk substitutes, use soy, rice, almond, or oat
    milk
Add Color to your
          plate

   Flavonoids and carotenoids, antioxidant and
    anti-inflammatory activity
   Lightly cooked dark leafy greens (spinach, collard
    greens, kale, Swiss chard)
   Cruciferous vegetables (broccoli, cabbage,
    brussels sprouts, kale, cauliflower)
   Carrots, beets, onions, peas, squashes, sea
    vegetables and washed raw salad greens
BEANS & LEGUMES


 Rich in folic acid, magnesium, potassium and
  fiber
 They are a low-glycemic-load food
 1-2 servings per day (one serving is equal to ½
  cup cooked beans or legumes)
 Beans like Anasazi, black, chickpeas, black-
  eyed peas and lentils
 Well-cooked either whole or like hummus
New Life Eating Plan (NLEP)
   Diet for OA sufferers
   Nutrient-dense; hypoallergenic; nightshade-free;
    yeast-free; high in alkalinity, fiber, essential fatty
    acids, and phytonutrients (e.g., berries, cherries,
    and green and yellow vegetables); and low in
    land-animal products.
   Elimination of possible food allergens,
    stabilization of insulin levels, and correction of
    leaky gut and imbalanced bacterial flora in the
    bowel
Antioxidants
   Inflammation leads to reactive oxygen radicals
   Oxidative damage to the joint and cartilage
    destruction
   Antioxidants defend against this process
   Increased anti oxidants consumption may
    prevent or relieve pain in RA and OA
   Vitamin E & C
   Selenium, Quecertain, Resveratrol
Top Anti oxidants
                 1 cup: Numbers refer to ORAC
           (Oxygen Radical Absorbance Capacity) values


   Wild blueberry, 13427
   Blueberry, 9019
   Cranberry, 8983
   Artichoke hearts, 7904
   Blackberry, cultivated, 7701
   Raspberry, 6058
   Strawberry, 5938
   Sweet cherry, 4873
Fruit as a healthy snack


   Fruits are rich in flavonoids and carotenoids with
    both antioxidant and anti-inflammatory activity
   3-4 servings per day
   Raspberries, blueberries, strawberries,
    pomegranates blackberries, cherries, all lower in
    glycemic load than most tropical fruits
Vitamin E
   Animal studies showed less arthritis with
    antioxidants
   Framingham study showed an associated of
    reduced risk of OA and vitamin E intake
   Pain controlling effects
   Mixed tocopherols, gamma type is most potent
   Daily dose 600-800IU
Vitamin C
   Positive effects of vitamin C on health of immune
    system
   Reducing risk of Rheumatoid arthritis and OA
   May reduce risk of cartilage and progression
   A study of 640 patients showed three fold decrease
    in OA progression
   An Australian study found an inverse relationship in
    incidence of OA and intake of vitamin C and fruits
   A study stated high risk of RA with lowest intake
Resveratrol (grape extract)
   Present in various fruits especially skin of grapes
   Potent antioxidant properties protects cells
   Has anti inflammatory and prevents cartilage cell
    death
   Several animal studies are proven helpful and
    many human studies are underway
Selenium
   The mineral selenium chelates mercury in the
    body, and the chelated selenium-mercury
    complex is eliminated in the stool.
   Thus consumption of one or two Brazil nuts (a
    rich source of selenium) with a meal of fatty fish
    is advisable
Vitamin D
   Vitamin D has a vital role in regulation immune
    system and association with RA, SLE and OA
   Vitamin D receptors are present on the immune
    cells, synovial and cartilage cells
   Framingham data suggests 3x risk of progression
    of OA with lower intake
   Another study showed lower levels associated
    with cartilage loss, increased risk of hip OA
Vitamin D
   Iowa women health study found lower levels of
    vitamin D associated with higher risk of
    developing RA, more tender, swollen joints and
    HAQ scores
   Nurses health survey linked higher level of
    vitamin D with healthier lifestyles
   Dose: Vitamin D3- 2000-4000IU a day
Vitamin K
   Important bone regulator
   A recent study showed that low levels of vitamin
    K1(phylloquinone) associated with an increased
    prevalence of OA hand and knee
   Framingham study found lower levels associated
    with x-ray findings of OA hands and knees
   Vitamin K2 is also helpful in osteoporosis
Dietary deficiency
             Vitamin B6 and folic acid

   Lower levels of B6 and folate found in red
    blood cells of RA patients
   Low B6 is also associated with homocysteine
    levels which is associated with heart disease in
    RA
   Level of folic acid is low since disease modifying
    drug competitively inhibit its absorption
   Recommended dose B6 50mg, folic acid 1mg
Probiotics
   Probiotics are live microorganisms, also known
    as “friendly bacteria,”
   Help maintain the natural balance of organisms
    (microflora) in the human gut
   Vital for a healthy immune system, protect
    against disease-causing microorganisms,
   The most well- known probiotics are Lactobacillus
    acidophilus, occurring naturally in yogurt, and
    Bifidobacterium
Natural supplements
               Glucosamine
   Synthesized from chitin in shellfish exoskeletons
   Hypothesized to rebuild damaged cartilage by
    stimulating the synthesis and inhibiting the
    degradation of glycosaminoglycans and
    proteoglycans
   Glucosamine sulfate is absorbed and distributed
    to the joint tissues
   It has anti-inflammatory and anabolic properties
   1500 mg, best to dose glucosamine once a day
Natural supplements
                     Chondroitin
   Chondroitin contributes to the resilience and
    elasticity of cartilage
   It is a building block for the formation of the joint
    matrix structure
   Bovine or shark cartilage. Animal studies suggest
    functions as an anti-inflammatory agent
   Trials showed variable results, combination seem
    to work better, delayed progression
   120omg/day, good safety data
Natural supplements
                  MSM
   Being popularly market for arthritis, found in
    may foods we eat, effectiveness needs
    confirmation
   Clinical data is still inconclusive for
    effectiveness, but combination of glucosamine
    and Chondroitin is more effective than used
    alone
   Dose is 1500mg, up to 3-4 times/day
   No toxicity issues reported
Natural supplements
                  SAMe
   SAMe has scientific evidence to support its
    effectiveness in double blind clinical trials
   Has anti inflammatory properties, compared to
    Naproxen, Piroxicam and Celebrex
   Typical dose is 200-400mg 3-4x/day
   Works slowly and has been also found to have
    beneficial effects for depression and
    fibromyalgia
Spice up your taste buds


HEALTHY HERBS & SPICES
Why: Use these herbs and spices generously to
 season foods. Turmeric and ginger are powerful,
 natural anti-inflammatory agents
Healthy choices: Turmeric, curry powder (which
 contains turmeric), ginger and garlic (dried and
 fresh), chili peppers, basil, cinnamon, rosemary,
 thyme
Herbal or Botanical
               approach
   Avocado/Soybean      Evening Primrose Oil
    Unsaponifiables      Ginger
   Ashwagandha          Garlic
   Boswellia            Rose hip
   Bormelain            Thunder God Vine
   Curcumin             Willow
   Cats claw
   Devil’s claw
Ginger
   May have efficacy in RA by inhibiting
    inflammatory chemicals (prostaglandins)
   Dosage, root 1g, 2-3x/day or as tea
   Avoid if have history of gall bladder stones
Turmeric (Curcumin)
   Clinical trial has shown efficacy similar to Nsaids
   Powdered root, 500mg-1000mg, 2-3x/day
   Avoid if risk of bleeding, GI intolerance and
    impaired fertility
Boswellia
   Inhibits the synthesis of pro inflammatory
    chemicals
   It is suggested to have efficacy in OA
   A study of 30 patients with knee OA found
    improvements in pain and walking distance
Avocado soybean oil extract
   Recent studies have showed that ASU has
    promising beneficial role in OA hips and knees
   It has effects on type 2 collagen synthesis
   4 major clinical studies suggested benefit with 6
    months of use
   No major adverse effects noted
   Dose: 300m/day for 3-6 months
Thank You
References
   Libby P: Inflammatory mechanisms: the molecular basis of inflammation and
    disease. Nutr Rev 2007; 65(12 Pt 2): S140-6. (PubMed)
   2. Calder PC: Polyunsaturated fatty acids and inflammation. Prostaglandins
    Leukot Essent Fatty Acids 2006; 75(3): 197-202. (PubMed)
   3. Scott A, Khan KM, Roberts CR, Cook JL, Duronio V: What do we mean
    by the term "inflammation"? A contemporary basic science update for sports
    medicine. Br J Sports Med 2004; 38(3): 372-80. (PubMed)
   (Osteoarthritis Cartilage. 1998;6[Suppl A]:14-21)
   (Rheum Dis Clin North Am. 1999;25:379-395)
   Institute of functional Medicine.

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Nutrition And Inflammation

  • 1. Inflammatory diseases and role of diet Farhan Tahir MD, FACR Consultant Rheumatologist Rheumatic Disease Associates, Ltd. Abington Memorial Hospital Doylestown Hospital
  • 2. What is Inflammation?  Inflammation is immune system’s response to injury or infection  Autoimmune disease are result of an unhealthy disordered immune system  Inflammation results in pain, swelling, heat and redness of joints and tendons
  • 3. Role of inflammatory in arthritis  Inflammation is a cascade of biological process which leads to production of harmful chemicals ; cytokines  Cytokines detrimental to body are (IL)-1, IL-6, tumor necrosis factor (TNF)-alpha, gamma interferon (INF-gamma)  Cells produce reactive oxygen species (ROS) harmful to cartilage and joint structures leading to destruction
  • 4. Chronic Inflammatory Diseases  More than 40 distinct autoimmune diseases  24 million Americans are affected (NIH Autoimmune Disease Coordinating Committee, June 2005)  Examples: Asthma, Cohn's disease, Rheumatoid arthritis, SLE, Celiac disease  Examples of chronic conditions with an inflammatory component include atherosclerosis, obesity, diabetes, cancer, and perhaps even Alzheimer’s disease
  • 5. Evolution of Nutrition  Primitive humans; wild game or vegetarian  Refining; loss of fiber and micronutrients  Western diet had 75% decline in fiber, 5 fold increase in sugar and four fold increase in fats  Our hunter-gatherer ancestors consumed equal amounts of omega-6s and omega-3s  Todays’s diet has been estimated to contain 14- 25 times as much omega-6 as omega-3 fat
  • 6. Overfed and Undernourished  “Snack” and “fast” food: high fat, high sugar  Western diet leads to “Overfed and undernourished” state  Increase weight, decreased essential nutrients  60% Americans: high waist/hip ratio (WHR) and BMI  Alarming rates of diabetes, cancer, metabolic syndrome, heart and autoimmune diseases are linked to western diet
  • 7. Western diet; Standard American Diet (SAD)  High in red and processed animal meats, saturated fats, trans fats, sweets, desserts, fired food and refined grains and low in fiber  Low in low-glycemic carbohydrates, fruits, vegetables, fish and legumes  12 yr relative risk of colon cancer 1.46, 8 yr heart disease risk 64%, 1.3 RR of all cause mortality
  • 8. Nutrition and Autoimmunity  Inflammation and immune dysfunction starts in the intestinal track  Presence of antibodies of intestinal bacteria like Proteus mirabilis have been linked to RA  Lower antigen load, intake of vegetables, fruits and dietary vitamin C reduce risk, e.g. Norwegian and Mediterranean diets
  • 9. High Glycemic Carbohydrates  Negative impact on lipid and sugar metabolism  Doubles reactive oxidative radicals production; increases peripheral vascular disease  Depressed immunity and impairs white blood cell function  Autoimmunity : Crohns disease, Rheumatoid arthritis
  • 10. Impact of unhealthy Fats  Trans and saturated fats are associated with depressed immunity  Doubles risk cataract  Atherosclerosis  Heart arrhythmias  Cancers  Decreases bone mineral density osteoporosis
  • 11. Arthritis and Nutrition  RA is a common autoimmune type of arthritis  1 in 100 persons, affects women more than males  Cause is combination of genetic makeup and environmental cause or infection  Main stay of treatment is allopathic medications  Use of anti inflammatory diet and complementary therapy can be of immense help
  • 12. Osteoarthritis and Nutrition  It is degenerative type of arthritis, most common form of arthritis  Affects weight bearing joints; knees, hips also affects hands and spine  Loss and damage of cartilage and joint structure  Leads to loss of smooth gliding, pain and swelling, improves with rest  Weight loss, conditioning exercises with anti inflammatory nutrition has great potential
  • 13. Role of diet in arthritis  Elimination  Anti inflammatory approach  Anti oxidants  Probiotics  Herbal supplements
  • 14. Elimination diet for food triggers  Arthritis linked to food sensitivities  Dairy products, wheat, and nightshade vegetables (bell pepper, eggplant, tobacco, tomato, and white potato) may be culprits  Eliminating and gradual re-introduction of the culprit foods will allow identification  High intake of coffee is linked to increased risk of RA, 4 or more cups/day  UltraInflamX® is an anti-inflammatory medical food
  • 15. Anti-inflammatory approach Diet and supplements  Mediterranean diet; vegetables, whole grains, nuts  Vitamin B6 and folic acid  Omega-3 , EPA, DHA  Anti oxidants  Probiotics  Herbal, Spices  Bone supplements: Vitamin D, Calcium, Boron
  • 16. Essential fatty acids  Humans are unable to synthesize the fatty acids linoleic acid and linolenic acid  Must be obtained through the foods  Both of these fats are polyunsaturated, meaning they will be liquid rather than solid at room temperature  Linoleic acid belongs to the family of omega-6 fats and is readily available
  • 19. Polyunsaturated fatty acids Omega 3 Fatty acids  Remember EPA and DHA  Produce resolvin which is anti inflammatory  Clinical trials in RA, Lupus and Ankylosing spondylitis have proven benefit  Improved patient reported pain, morning stiffness, number of painful and tender joints  Average recommended dose , EPA 30mg/kg, DGA 50mg/kg or total 3.5g/day
  • 20. Omega 6 versus Omega 3  In general, omega-6 fats tend to promote inflammation, constriction of the blood vessels, and formation of blood cell clots  Omega-3 fats are anti-inflammatory, relax the blood vessels, and protect against blood cells aggregating together into clots 
  • 21. Fat Guidelines  Use coconut oil, canola, or olive oil (extra virgin is best) for cooking  Make your own salad dressing with extra virgin olive oil, and red wine or balsamic vinegar  Flax seeds and oil, sardines, ocean salmon, and walnuts  Use a daily supplement of 1-4 grams of high EPA/DHA fish oils
  • 22. Decrease pro inflammatory foods  Trans fats, arachadonic acid and sugar may promote inflammation, so an anti-inflammatory diet is low in trans fats, arachadonic acid and sugar.  Commercial meat and eggs are rich sources of arachidonic acid;  Omega-3 eggs and pasture-fed beef have lower amounts of arachidonic acid.
  • 23. Fats for life Healthy choices  Extra virgin olive oil  Expeller-pressed organic canola oil  Nuts, Walnut and hazelnut oils in salads  Avocados  Seeds - freshly ground flaxseed.  Cold water fish  Dark roasted sesame oil as a flavoring for soups and stir-fries  Superior quality supplements
  • 24. Role of Omega 6 in Rheumatoid arthritis  Omega 6: LA and ARA driven chemicals are pro- inflammatory, role confirmed in RA  LA: vegetable oils; corn, sunflower, safflower  ARA: animal products, abundant in beef (grain fed), conventionally produced eggs  GLA : has anti inflammatory properties, sources, Oils of evening primrose, borage and black currant  Dose 1.5-3g/day
  • 25. Protein Guidelines  Have protein with each meal and snack if possible  Limit red meat or eliminate it unless it is free- range, grass-fed beef or lamb  Avoid charring/browning proteins/meats  Use free-range eggs for protein but avoid browning the eggs  Avoid lunch meats that have sodium nitrate or nitrites, consider nitrite free turkey
  • 26. Protein Guidelines  Use walnuts as snack, good protein and omega-3 fats source  Use mixed nuts and seeds (pumpkin, sunflower)  Consider nut butters ; almond, cashew, macadamia  Soy products good sources of protein  Organic milk products (milk, cheese, and yogurt)  For milk substitutes, use soy, rice, almond, or oat milk
  • 27. Add Color to your plate  Flavonoids and carotenoids, antioxidant and anti-inflammatory activity  Lightly cooked dark leafy greens (spinach, collard greens, kale, Swiss chard)  Cruciferous vegetables (broccoli, cabbage, brussels sprouts, kale, cauliflower)  Carrots, beets, onions, peas, squashes, sea vegetables and washed raw salad greens
  • 28. BEANS & LEGUMES  Rich in folic acid, magnesium, potassium and fiber  They are a low-glycemic-load food  1-2 servings per day (one serving is equal to ½ cup cooked beans or legumes)  Beans like Anasazi, black, chickpeas, black- eyed peas and lentils  Well-cooked either whole or like hummus
  • 29. New Life Eating Plan (NLEP)  Diet for OA sufferers  Nutrient-dense; hypoallergenic; nightshade-free; yeast-free; high in alkalinity, fiber, essential fatty acids, and phytonutrients (e.g., berries, cherries, and green and yellow vegetables); and low in land-animal products.  Elimination of possible food allergens, stabilization of insulin levels, and correction of leaky gut and imbalanced bacterial flora in the bowel
  • 30. Antioxidants  Inflammation leads to reactive oxygen radicals  Oxidative damage to the joint and cartilage destruction  Antioxidants defend against this process  Increased anti oxidants consumption may prevent or relieve pain in RA and OA  Vitamin E & C  Selenium, Quecertain, Resveratrol
  • 31. Top Anti oxidants 1 cup: Numbers refer to ORAC (Oxygen Radical Absorbance Capacity) values  Wild blueberry, 13427  Blueberry, 9019  Cranberry, 8983  Artichoke hearts, 7904  Blackberry, cultivated, 7701  Raspberry, 6058  Strawberry, 5938  Sweet cherry, 4873
  • 32. Fruit as a healthy snack  Fruits are rich in flavonoids and carotenoids with both antioxidant and anti-inflammatory activity  3-4 servings per day  Raspberries, blueberries, strawberries, pomegranates blackberries, cherries, all lower in glycemic load than most tropical fruits
  • 33. Vitamin E  Animal studies showed less arthritis with antioxidants  Framingham study showed an associated of reduced risk of OA and vitamin E intake  Pain controlling effects  Mixed tocopherols, gamma type is most potent  Daily dose 600-800IU
  • 34. Vitamin C  Positive effects of vitamin C on health of immune system  Reducing risk of Rheumatoid arthritis and OA  May reduce risk of cartilage and progression  A study of 640 patients showed three fold decrease in OA progression  An Australian study found an inverse relationship in incidence of OA and intake of vitamin C and fruits  A study stated high risk of RA with lowest intake
  • 35. Resveratrol (grape extract)  Present in various fruits especially skin of grapes  Potent antioxidant properties protects cells  Has anti inflammatory and prevents cartilage cell death  Several animal studies are proven helpful and many human studies are underway
  • 36. Selenium  The mineral selenium chelates mercury in the body, and the chelated selenium-mercury complex is eliminated in the stool.  Thus consumption of one or two Brazil nuts (a rich source of selenium) with a meal of fatty fish is advisable
  • 37. Vitamin D  Vitamin D has a vital role in regulation immune system and association with RA, SLE and OA  Vitamin D receptors are present on the immune cells, synovial and cartilage cells  Framingham data suggests 3x risk of progression of OA with lower intake  Another study showed lower levels associated with cartilage loss, increased risk of hip OA
  • 38. Vitamin D  Iowa women health study found lower levels of vitamin D associated with higher risk of developing RA, more tender, swollen joints and HAQ scores  Nurses health survey linked higher level of vitamin D with healthier lifestyles  Dose: Vitamin D3- 2000-4000IU a day
  • 39. Vitamin K  Important bone regulator  A recent study showed that low levels of vitamin K1(phylloquinone) associated with an increased prevalence of OA hand and knee  Framingham study found lower levels associated with x-ray findings of OA hands and knees  Vitamin K2 is also helpful in osteoporosis
  • 40. Dietary deficiency Vitamin B6 and folic acid  Lower levels of B6 and folate found in red blood cells of RA patients  Low B6 is also associated with homocysteine levels which is associated with heart disease in RA  Level of folic acid is low since disease modifying drug competitively inhibit its absorption  Recommended dose B6 50mg, folic acid 1mg
  • 41. Probiotics  Probiotics are live microorganisms, also known as “friendly bacteria,”  Help maintain the natural balance of organisms (microflora) in the human gut  Vital for a healthy immune system, protect against disease-causing microorganisms,  The most well- known probiotics are Lactobacillus acidophilus, occurring naturally in yogurt, and Bifidobacterium
  • 42. Natural supplements Glucosamine  Synthesized from chitin in shellfish exoskeletons  Hypothesized to rebuild damaged cartilage by stimulating the synthesis and inhibiting the degradation of glycosaminoglycans and proteoglycans  Glucosamine sulfate is absorbed and distributed to the joint tissues  It has anti-inflammatory and anabolic properties  1500 mg, best to dose glucosamine once a day
  • 43. Natural supplements Chondroitin  Chondroitin contributes to the resilience and elasticity of cartilage  It is a building block for the formation of the joint matrix structure  Bovine or shark cartilage. Animal studies suggest functions as an anti-inflammatory agent  Trials showed variable results, combination seem to work better, delayed progression  120omg/day, good safety data
  • 44. Natural supplements MSM  Being popularly market for arthritis, found in may foods we eat, effectiveness needs confirmation  Clinical data is still inconclusive for effectiveness, but combination of glucosamine and Chondroitin is more effective than used alone  Dose is 1500mg, up to 3-4 times/day  No toxicity issues reported
  • 45. Natural supplements SAMe  SAMe has scientific evidence to support its effectiveness in double blind clinical trials  Has anti inflammatory properties, compared to Naproxen, Piroxicam and Celebrex  Typical dose is 200-400mg 3-4x/day  Works slowly and has been also found to have beneficial effects for depression and fibromyalgia
  • 46. Spice up your taste buds HEALTHY HERBS & SPICES Why: Use these herbs and spices generously to season foods. Turmeric and ginger are powerful, natural anti-inflammatory agents Healthy choices: Turmeric, curry powder (which contains turmeric), ginger and garlic (dried and fresh), chili peppers, basil, cinnamon, rosemary, thyme
  • 47. Herbal or Botanical approach  Avocado/Soybean  Evening Primrose Oil Unsaponifiables  Ginger  Ashwagandha  Garlic  Boswellia  Rose hip  Bormelain  Thunder God Vine  Curcumin  Willow  Cats claw  Devil’s claw
  • 48. Ginger  May have efficacy in RA by inhibiting inflammatory chemicals (prostaglandins)  Dosage, root 1g, 2-3x/day or as tea  Avoid if have history of gall bladder stones
  • 49. Turmeric (Curcumin)  Clinical trial has shown efficacy similar to Nsaids  Powdered root, 500mg-1000mg, 2-3x/day  Avoid if risk of bleeding, GI intolerance and impaired fertility
  • 50. Boswellia  Inhibits the synthesis of pro inflammatory chemicals  It is suggested to have efficacy in OA  A study of 30 patients with knee OA found improvements in pain and walking distance
  • 51. Avocado soybean oil extract  Recent studies have showed that ASU has promising beneficial role in OA hips and knees  It has effects on type 2 collagen synthesis  4 major clinical studies suggested benefit with 6 months of use  No major adverse effects noted  Dose: 300m/day for 3-6 months
  • 53. References  Libby P: Inflammatory mechanisms: the molecular basis of inflammation and disease. Nutr Rev 2007; 65(12 Pt 2): S140-6. (PubMed)  2. Calder PC: Polyunsaturated fatty acids and inflammation. Prostaglandins Leukot Essent Fatty Acids 2006; 75(3): 197-202. (PubMed)  3. Scott A, Khan KM, Roberts CR, Cook JL, Duronio V: What do we mean by the term "inflammation"? A contemporary basic science update for sports medicine. Br J Sports Med 2004; 38(3): 372-80. (PubMed)  (Osteoarthritis Cartilage. 1998;6[Suppl A]:14-21)  (Rheum Dis Clin North Am. 1999;25:379-395)  Institute of functional Medicine.