One of the most frequent questions I’m asked at autoimmune patient forums is about diet, anti-inflammatory foods, and autoimmunity.
There’s a lot of popular pseudo-science out there claiming that the right diet can “cure” autoimmune disease. Much of the “evidence” I’m asked about is anecdotal, largely based on reports of how patients were helped – or not – by eating -- or not eating -- certain foods (notably gluten). It’s difficult to argue with success stories and equally difficult to prove real cause and effect.
However, there’s plenty of solid scientific evidence to support the idea of an anti-inflammatory diet.
Much of what we know about the relationship between diet and inflammation comes from studies about the effects of the Mediterranean diet (and its components) in reducing inflammatory markers in cardiovascular disease (CVD)1 – a well-established risk in autoimmune diseases including rheumatoid arthritis (RA), lupus, and inflammatory bowel disease.
The Mediterranean diet encompasses many anti-inflammatory foods, notably omega-3 fatty acids found in olive and other oils, cold-water fatty fish (like salmon, mackerel, and sardines), nuts, and flax seeds. Olives and olive oil also contain compounds that act similarly to non-steroidal anti-inflammatory drugs (NSAIDs).2 Additionally, the diet includes lots of fresh fruits and vegetables rich in anti-inflammatory plant chemicals.
The diet has been shown to lower inflammatory markers in blood tied to both CVD and autoimmune diseases, including C-reactive protein (CRP), interleukins,and tumor-necrosis factor alpha (TNF-α).1 Studies also show that it helps reduce pain, joint swelling, and other symptoms of RA and other autoimmune diseases – and has beneficial effects on the immune system itself (such as moderating T-cell activity).3
It’s been suggested for years that our “Western” diet high in saturated fats and red meat may not only play a role in CVD but also in autoimmune diseases.4 Indeed, in one study, RA patients assigned to a Mediterranean diet showed a reduction in inflammatory activity and an increase in physical function compared to those assigned to a “Western” diet. 5
THE BIG FOUR INFLAMMATION FIGHTERS
•Fatty Fish & Omega 3's
Of all inflammation fighting foods in the Mediterranean diet, we know the most about fatty fish and fish oil, which contain the omega polyunsaturated fats (PUFAS) eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA).
As far back as 1991, researchers suggested that the omega-3 fats in fish may help reduce disease severity in lupus.6 More recently we’ve learned that omega 3’s may help protect against RA. A prospective study of more than 32,000 older Swedish women in 2013 found that eating one or more servings of fatty fish a week was associated with a 29% lower risk of developing RA and long-term intake of high-dose fish oil decreased the risk of RA by 52%).7
A recent British review reported that eating more fish high in omega-3s modestly reduced joint swelling, pain and morning stiffness in RA, leading to less use of NSAIDs.8 A randomized, controlled trial in people with early RA found that around 40% of those given high-dose fish oil to take with their conventional disease modifying anti-rheumatic drugs DMARDs)were in remission after a year.9
However, fairly high amounts of fish oil are needed to achieve an effect (about 3 grams of EPA and DHA in a concentrated fish oil supplement). Fish oil is also an anticoagulant and doesn’t agree with everyone.10 So consult your doctor before adding it to your diet.
Other types of omega-3 fats can be are found in olives, flax seeds, pumpkin seeds and walnuts.
•Olives & Olive Oil
Certain anti-inflammatory properties in olives and olive oil may be a big reason why the Mediterranean diet helps in autoimmune diseases.
Olives and virgin olive oil have been found to contain a polyphenol compound called oleocanthal, which blocks production of the pro-inflammatory enzymes and cyclooxygenase-2 (COX-1 and COX-2) much as NSAIDs do. In fact, research shows oleocanthal has properties similar to ibuprofen.11
The fruit of the olive tree, Olea europaea, also contains oleic acid, a monounsaturated fatty acid which also helps modulate the immune system.12
Olive oil, as well as nuts, sunflower and flax seeds, and avocados are also packed with vitamin E, which helps prevent cell damage in joints and may have anti-inflammatory properties as well.
•Fresh Fruits & Vegetables
The Mediterranean-style diet includes plenty of fresh fruits, vegetables, and beans rich in fiber plus inflammation-fighting plant chemicals (phytochemicals) and antioxidants such as vitamin A, beta carotene, vitamin E, zinc and selenium.
In particular, raspberries and cherries are packed with antioxidants called anthocyanins and vegetables containing flavonoids like onions and garlic are thought to regulate expression of key inflammatory enzymes.
•Green Tea
I meet many autoimmune patients who swear by green tea, which is a good source of antioxidant polyphenols.
Its active ingredient, epigallocatechin-3-gallate (EGCG), has been shown to improve symptoms and reduce the pathology in some animal models of autoimmune diseases.
The effects of EGCG help suppress production of autoreactive T cells and also pro-inflammatory cytokines (such as interleukin-1).13 A recent study showed that EGCG improved rheumatoid arthritis in mice, while another showed effects in lab rats. But there’s an unfortunate lack of research in humans for this healthy beverage.
GLUTEN: GUILTY AS CHARGED?
There are a number of experts who claim that any anti-inflammatory diet must exclude gluten.
There’s no question that gluten, a naturally-occurring protein in wheat, barley and rye, causes celiac disease in genetically susceptible individuals. Gluten triggers an autoimmune inflammatory reaction that damages the small finger-like projections in the small intestine (villi) which absorb many nutrients.
The only treatment for celiac disease is eliminating gluten. It can stop the symptoms of chronic diarrhea, stomach pain, bloating, and gas and help repair damage to the villi. Intestinal healing can take three to six months in children and several years in adults, according to the National Institutes of Health.14
Some people are allergic to wheat or have non-celiac gluten sensitivity and experience severe GI symptoms. While neither problem damages the small intestine, for these people going gluten-free also makes sense.
What’s not so clear is gluten’s effects elsewhere in the body (like the brain) and whether going gluten-free helps other autoimmune diseases, prevents or even “cures” them.
“There is no evidence that a gluten free diet helps autoimmune diseases such as Hashimoto's thyroiditis. Celiac disease is the one autoimmune disease that is appropriate for the gluten-free diet,” Peter H.R. Green, MD, director of the Celiac Disease Center at Columbia University told me in an email. “It is as though celiac disease has given the gluten-free a medical legitimacy that other diet trends lack.”
As a result of what he terms a “media epidemic,” “almost a third of all American and UK consumers are trying to avoid gluten,” many of them unnecessarily, he writes in a new book, “Gluten Exposed,” (2016, William Morrow, NY).15
VEGETARIAN AND VEGAN DIETS
Any elimination diet can have adverse effects, Dr. Green adds, cutting out crucial nutrients such as fiber and essential vitamins and minerals.
The Arthritis Foundation, the Sjögren’s Syndrome Foundation, and other organizations, report that studies since the 1990s have found vegetarian diets to be beneficial for some autoimmune patients. However, you need to get plenty of plant protein from legumes and beans, among other things.
A vegan diet -- which excludes meat, fish, dairy or other animal products -- may also be helpful, possibly because of the types of polyunsaturated fatty acids included in the diet, say British arthritis researchers.10
However, if you go vegan make sure you get vital nutrients you need, especially calcium, vitamin B12, vitamin D, zinc, and selenium.
References
1 Giugliano D, Ceriello A, and Esposito K, The Effects of Diet on Inflammation. Journal of the American College of Cardiology. 2006;48(4):677–85. doi:10.1016/j.jacc.2006.03.052.
2 Rahmani AH, Abutti AS, and Ali SM. Therapeutics role of olive fruits/oil in the prevention of diseases via modulation of anti-oxidant, anti-tumour and genetic activity. Int J Clin Exp Med. 2014. 7(4 ):799-808. PMCID: PMC4057827. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4057827/ Accessed July 20, 2016.
3 Shepshelovich D and Shoenfeld Y.Prediction and prevention of autoimmune diseases: additional aspects of the mosaic of autoimmunity. Lupus. 2006. 15(3):183-190. doi: 10.1191/0961203306lu2274rr s
4 Manzel A, Muller DN, Hafler DA et al., Role of “Western Diet” in Inflammatory Autoimmune Diseases. Curr Allergy Asthma Rep. 2014;14:404. DOI 10.1007/s11882-013-0404-6.
5 Sköldstam L, Hagfors L, Johansson G. An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis. Ann Rheum Dis. 2003;62:208–214.
6 Walton AJ, Snaith ML, Locniskar M, et al. Dietary fish oil and the severity of symptoms in patients with systemic lupus erythematosus. Ann Rheum Dis. 1991; 50:463–466.
7 Di Giuseppe D, Wallin A, Bottai M, et al., Long-term intake of dietary long-chain n-3 polyunsaturated fatty acids and risk of rheumatoid arthritis: a prospective cohort study of women. Ann Rheum Dis. 2014 Nov;73(11):1949-53. doi: 10.1136/annrheumdis-2013-203338.
8 Miles EA, Calder PC, Influence of marine n-3 polyunsaturated fatty acids on immune function and a systematic review of their effects on clinical outcomes in rheumatoid arthritis. Br J Nutr. 2012 Jun;107 Suppl 2:S171-84. doi: 10.1017/S0007114512001560.
9 Proudman SM, James MJ, Spargo LD, et al. Fish oil in recent onset rheumatoid arthritis: a randomised, double-blind controlled trial within algorithm-based drug use. Ann Rheum Dis. 2015. 74:89-95 doi:10.1136/annrheumdis-2013-204145.
10 Arthritis Research UK, Diet and Supplements. http://www.arthritisresearchuk.org/arthritis-information/complementary-and-alternative-medicines/complementary-therapies/diet-and-supplements.aspx#sthash.g3ajjiyB.dpuf Accessed July 19, 2016.
11 Lucas L, Russell A, Keast R. Molecular mechanisms of inflammation. Anti-inflammatory benefits of virgin olive oil and the phenolic compound oleocanthal. Curr Pharm Design. 2011;17(8):754–68. DOI: 10.2174/138161211795428911. http://www.ncbi.nlm.nih.gov/pubmed/21443487 Accessed July 19, 2016.
12 Sales-Campos H, Souza PR, Peghini BC, et al., An Overview of the Modulatory Effects of Oleic Acid in Health and Disease. Mini Reviews in Medicinal Chemistry. 2013;13(2):201-210. DOI: 10.2174/13895575113130220003.
13 Wu D, Wang J, Pae M, Meydani SN. Green tea EGCG, T cells, and T cell-mediated autoimmune diseases. Mol Aspects Med. 2012 Feb;33(1):107-18. doi: 10.1016/j.mam.2011.10.001. Epub 2011 Oct 14. http://www.ncbi.nlm.nih.gov/pubmed/22020144. Accessed July 19, 2016.
14 Treatment for Celiac disease. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/celiac-disease/Pages/treatment.aspx Accessed July 19, 2016.
15 Green PR, Jones R. “Gluten Exposed: The Science Behind the Hype and How to Navigate A Healthy, Symptom-Free Life,” (2016, William Morrow, NY).
16 The Arthritis Foundation: Eat Right for Your Type of Arthritis. http://www.arthritis.org/living-with-arthritis/arthritis-diet/anti-inflammatory/eat-to-beat-inflammation.php Accessed July 19, 2016
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There’s a lot of popular pseudo-science out there claiming that the right diet can “cure” autoimmune disease. Much of the “evidence” I’m asked about is anecdotal, largely based on reports of how patients were helped – or not – by eating -- or not eating -- certain foods (notably gluten). It’s difficult to argue with success stories and equally difficult to prove real cause and effect.
However, there’s plenty of solid scientific evidence to support the idea of an anti-inflammatory diet.
Much of what we know about the relationship between diet and inflammation comes from studies about the effects of the Mediterranean diet (and its components) in reducing inflammatory markers in cardiovascular disease (CVD)1 – a well-established risk in autoimmune diseases including rheumatoid arthritis (RA), lupus, and inflammatory bowel disease.
The Mediterranean diet encompasses many anti-inflammatory foods, notably omega-3 fatty acids found in olive and other oils, cold-water fatty fish (like salmon, mackerel, and sardines), nuts, and flax seeds. Olives and olive oil also contain compounds that act similarly to non-steroidal anti-inflammatory drugs (NSAIDs).2 Additionally, the diet includes lots of fresh fruits and vegetables rich in anti-inflammatory plant chemicals.
The diet has been shown to lower inflammatory markers in blood tied to both CVD and autoimmune diseases, including C-reactive protein (CRP), interleukins,and tumor-necrosis factor alpha (TNF-α).1 Studies also show that it helps reduce pain, joint swelling, and other symptoms of RA and other autoimmune diseases – and has beneficial effects on the immune system itself (such as moderating T-cell activity).3
It’s been suggested for years that our “Western” diet high in saturated fats and red meat may not only play a role in CVD but also in autoimmune diseases.4 Indeed, in one study, RA patients assigned to a Mediterranean diet showed a reduction in inflammatory activity and an increase in physical function compared to those assigned to a “Western” diet. 5
THE BIG FOUR INFLAMMATION FIGHTERS
•Fatty Fish & Omega 3's
Of all inflammation fighting foods in the Mediterranean diet, we know the most about fatty fish and fish oil, which contain the omega polyunsaturated fats (PUFAS) eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA).
As far back as 1991, researchers suggested that the omega-3 fats in fish may help reduce disease severity in lupus.6 More recently we’ve learned that omega 3’s may help protect against RA. A prospective study of more than 32,000 older Swedish women in 2013 found that eating one or more servings of fatty fish a week was associated with a 29% lower risk of developing RA and long-term intake of high-dose fish oil decreased the risk of RA by 52%).7
A recent British review reported that eating more fish high in omega-3s modestly reduced joint swelling, pain and morning stiffness in RA, leading to less use of NSAIDs.8 A randomized, controlled trial in people with early RA found that around 40% of those given high-dose fish oil to take with their conventional disease modifying anti-rheumatic drugs DMARDs)were in remission after a year.9
However, fairly high amounts of fish oil are needed to achieve an effect (about 3 grams of EPA and DHA in a concentrated fish oil supplement). Fish oil is also an anticoagulant and doesn’t agree with everyone.10 So consult your doctor before adding it to your diet.
Other types of omega-3 fats can be are found in olives, flax seeds, pumpkin seeds and walnuts.
•Olives & Olive Oil
Certain anti-inflammatory properties in olives and olive oil may be a big reason why the Mediterranean diet helps in autoimmune diseases.
Olives and virgin olive oil have been found to contain a polyphenol compound called oleocanthal, which blocks production of the pro-inflammatory enzymes
The fruit of the olive tree, Olea europaea, also contains oleic acid, a monounsaturated fatty acid which also helps modulate the immune system.12
Olive oil, as well as nuts, sunflower and flax seeds, and avocados are also packed with vitamin E, which helps prevent cell damage in joints and may have anti-inflammatory properties as well.
•Fresh Fruits & Vegetables
The Mediterranean-style diet includes plenty of fresh fruits, vegetables, and beans rich in fiber plus inflammation-fighting plant chemicals (phytochemicals) and antioxidants such as vitamin A, beta carotene, vitamin E, zinc and selenium.
In particular, raspberries and cherries are packed with antioxidants called anthocyanins and vegetables containing flavonoids like onions and garlic are thought to regulate expression of key inflammatory enzymes.
•Green Tea
I meet many autoimmune patients who swear by green tea, which is a good source of antioxidant polyphenols.
Its active ingredient, epigallocatechin-3-gallate (EGCG), has been shown to improve symptoms and reduce the pathology in some animal models of autoimmune diseases.
The effects of EGCG help suppress production of autoreactive T cells and also pro-inflammatory cytokines (such as interleukin-1).13 A recent study showed that EGCG improved rheumatoid arthritis in mice, while another showed effects in lab rats. But there’s an unfortunate lack of research in humans for this healthy beverage.
GLUTEN: GUILTY AS CHARGED?
There are a number of experts who claim that any anti-inflammatory diet must exclude gluten.
There’s no question that gluten, a naturally-occurring protein in wheat, barley and rye, causes celiac disease in genetically susceptible individuals. Gluten triggers an autoimmune inflammatory reaction that damages the small finger-like projections in the small intestine (villi) which absorb many nutrients.
The only treatment for celiac disease is eliminating gluten. It can stop the symptoms of chronic diarrhea, stomach pain, bloating, and gas and help repair damage to the villi. Intestinal healing can take three to six months in children and several years in adults, according to the National Institutes of Health.14
Some people are allergic to wheat or have non-celiac gluten sensitivity and experience severe GI symptoms. While neither problem damages the small intestine, for these people going gluten-free also makes sense.
What’s not so clear is gluten’s effects elsewhere in the body (like the brain) and whether going gluten-free helps other autoimmune diseases, prevents or even “cures” them.
“There is no evidence that a gluten free diet helps autoimmune diseases such as Hashimoto's thyroiditis. Celiac disease is the one autoimmune disease that is appropriate for the gluten-free diet,” Peter H.R. Green, MD, director of the Celiac Disease Center at Columbia University told me in an email. “It is as though celiac disease has given the gluten-free a medical legitimacy that other diet trends lack.”
As a result of what he terms a “media epidemic,” “almost a third of all American and UK consumers are trying to avoid gluten,” many of them unnecessarily, he writes in a new book, “Gluten Exposed,” (2016, William Morrow, NY).15
VEGETARIAN AND VEGAN DIETS
Any elimination diet can have adverse effects, Dr. Green adds, cutting out crucial nutrients such as fiber and essential vitamins and minerals.
The Arthritis Foundation, the Sjögren’s Syndrome Foundation, and other organizations, report that studies since the 1990s have found vegetarian diets to be beneficial for some autoimmune patients. However, you need to get plenty of plant protein from legumes and beans, among other things.
A vegan diet -- which excludes meat, fish, dairy or other animal products -- may also be helpful, possibly because of the types of polyunsaturated fatty acids included in the diet, say British arthritis researchers.10
However, if you go vegan make sure you get vital nutrients you need, especially calcium, vitamin B12, vitamin D, zinc, and selenium.
References
1 Giugliano D, Ceriello A, and Esposito K, The Effects of Diet on Inflammation. Journal of the American College of Cardiology. 2006;48(4):677–85. doi:10.1016/j.jacc.2006.03.052.
2 Rahmani AH, Abutti AS, and Ali SM. Therapeutics role of olive fruits/oil in the prevention of diseases via modulation of anti-oxidant, anti-tumour and genetic activity. Int J Clin Exp Med. 2014. 7(4 ):799-808. PMCID: PMC4057827. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4057827/ Accessed July 20, 2016.
3 Shepshelovich D and Shoenfeld Y.Prediction and prevention of autoimmune diseases: additional aspects of the mosaic of autoimmunity. Lupus. 2006. 15(3):183-190. doi: 10.1191/0961203306lu2274rr s
4 Manzel A, Muller DN, Hafler DA et al., Role of “Western Diet” in Inflammatory Autoimmune Diseases. Curr Allergy Asthma Rep. 2014;14:404. DOI 10.1007/s11882-013-0404-6.
5 Sköldstam L, Hagfors L, Johansson G. An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis. Ann Rheum Dis. 2003;62:208–214.
6 Walton AJ, Snaith ML, Locniskar M, et al. Dietary fish oil and the severity of symptoms in patients with systemic lupus erythematosus. Ann Rheum Dis. 1991; 50:463–466.
7 Di Giuseppe D, Wallin A, Bottai M, et al., Long-term intake of dietary long-chain n-3 polyunsaturated fatty acids and risk of rheumatoid arthritis: a prospective cohort study of women. Ann Rheum Dis. 2014 Nov;73(11):1949-53. doi: 10.1136/annrheumdis-2013-203338.
8 Miles EA, Calder PC, Influence of marine n-3 polyunsaturated fatty acids on immune function and a systematic review of their effects on clinical outcomes in rheumatoid arthritis. Br J Nutr. 2012 Jun;107 Suppl 2:S171-84. doi: 10.1017/S0007114512001560.
9 Proudman SM, James MJ, Spargo LD, et al. Fish oil in recent onset rheumatoid arthritis: a randomised, double-blind controlled trial within algorithm-based drug use. Ann Rheum Dis. 2015. 74:89-95 doi:10.1136/annrheumdis-2013-204145.
10 Arthritis Research UK, Diet and Supplements. http://www.arthritisresearchuk.org/arthritis-information/complementary-and-alternative-medicines/complementary-therapies/diet-and-supplements.aspx#sthash.g3ajjiyB.dpuf Accessed July 19, 2016.
11 Lucas L, Russell A, Keast R. Molecular mechanisms of inflammation. Anti-inflammatory benefits of virgin olive oil and the phenolic compound oleocanthal. Curr Pharm Design. 2011;17(8):754–68. DOI: 10.2174/138161211795428911. http://www.ncbi.nlm.nih.gov/pubmed/21443487 Accessed July 19, 2016.
12 Sales-Campos H, Souza PR, Peghini BC, et al., An Overview of the Modulatory Effects of Oleic Acid in Health and Disease. Mini Reviews in Medicinal Chemistry. 2013;13(2):201-210. DOI: 10.2174/13895575113130220003.
13 Wu D, Wang J, Pae M, Meydani SN. Green tea EGCG, T cells, and T cell-mediated autoimmune diseases. Mol Aspects Med. 2012 Feb;33(1):107-18. doi: 10.1016/j.mam.2011.10.001. Epub 2011 Oct 14. http://www.ncbi.nlm.nih.gov/pubmed/22020144. Accessed July 19, 2016.
14 Treatment for Celiac disease. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/celiac-disease/Pages/treatment.aspx Accessed July 19, 2016.
15 Green PR, Jones R. “Gluten Exposed: The Science Behind the Hype and How to Navigate A Healthy, Symptom-Free Life,” (2016, William Morrow, NY).
16 The Arthritis Foundation: Eat Right for Your Type of Arthritis. http://www.arthritis.org/living-with-arthritis/arthritis-diet/anti-inflammatory/eat-to-beat-inflammation.php Accessed July 19, 2016
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