Managing Auto-Immune Disease with Diet

Dr. Jaime Schehr

Goals & Objectives

• Identify how diet plays a major role in disease management specific to immune disorders

• List specific questions practitioners should ask when evaluating diet in auto-immune disease

• Learn key facts for dietary management of specific auto-immune diseases

• Take an In-depth look at management of IBD

Where to Start

• Does patient have diagnosis or do you suspect?

• Has patient yet made dietary modifications for this condition?

• Diet? lifestyle ? exercise? Supplementation?other

The “Other” Important Questions

Beyond diet recalls and diet diaries….

• Environment • Gut • Energy • Medications • Family History • Food allergies vs. sensitivities • Trigger Event / Emotional

How to Chose the diet Rx

Disease/Condition

Symptomatic/Active

Clean / Remove / Avoid

exacerbating foods

Restore / Repair

Managed

Clean/Whole Foods / Avoid Allergens /

Not all Food is Created Equal

Grant Cornett for The New York Times

Immune Supportive Foods

• Fermented Foods / Probiotics

• Nutrient Dense (ANDI, Superfoods)

• Anthocyanidins, flavonoids (insert food sources)

Immune Disruptive Foods

• Pro-Inflammatory Foods

• Food Sensitivities / Food Allergens

• Chemically Altered Foods

• False or Fake Foods

3 Ways to Identify Food Sensitivities

Elimination diet

• Involves avoiding top food allergens for total of 6 weeks. Reintroduce foods one group at a time at least 2-3x day for 3 days. Avoid symptom positive foods for 90 days

Modified Elimination diet

• Removing one or two problematic foods at a time to reduce symptom picture and allow gut healing

Blood Testing

• IgG food antibodies* • IgE food antibodies* • *know the difference between these two

Oligoallergenic Dietaka Allergy Elimination Diet

Oligoallergenic Diet: This diet is exactly what its name sounds like: a small number of foods which are deemed unlikely to cause an allergic reaction are eaten for a period of time. If this diet is used as a diagnostic tool, then foods are gradually added back one at a time to see if symptoms reappear. Examples of foods commonly used on this diet include lamb, rice, turkey, and pears, all of which are considered unlikely to cause allergic reactions.

Why introduce an allergy elimination diet?

The immune barrier aspect of gastrointestinal health is important in evaluating adverse immune reactions to food and predicting overall intestinal health. Assessments of food reactions offer practical information regarding food choices that enhance health restoration in the patient with compromised GI function.

Elimination Diet

Foods to Avoid

Dairy WheatCorn SoyEggCitrus Caffeine AlcoholSugar Food Additives Frequently eaten foods Processed foodsKnown Allergens Peanuts

Foods to Include

Gluten-free grains and flours FruitsVegetablesLegumes Meat proteins Nuts Seeds Oils (not corn or canola)Fats (non-dairy)

Anti-Inflammatory Foods• Anti-inflammatory diet – whole foods, plant based, low glycemic load

• Foods with high omega-3 fatty acids, such as cold water fish, flaxseeds, walnuts

A balanced intake of omega-6 and omega-3 fatty acids is anti-inflammatory Overconsumption of omega-6 fats in relation to omega-3 fats leads to

inflammation Most appropriate ratio of omega-6 to omega-3 fatty acids is approximately 4:1.

This requires increasing the intake of omega-3s and decreasing intake of omega-6s

• Foods with high levels of antioxidants, such as vegetables, citrus fruits, cherries, garlic, onion and tea

• Spices, in particular, ginger, garlic, rosemary, turmeric, oregano, cayenne, clove and nutmeg

• Low glycemic index/load foods

Food Category Foods to Eat Foods to Avoid

Vegetables: Eat mostly lower carbohydrate vegetables. Lower carbohydrate foods turn to sugar more slowly in the body. Steaming vegetables improves the utilization or availability of the food nutrients allowing the GI mucosa to repair itself.

Asparagus, bean sprouts, beet greens, broccoli, red and green cabbage, cauliflower, celery, Swiss chard, cucumber, endive, lettuce (green, red, romaine, mixed greens), mustard and dandelion greens, radishes, spinach, and watercress.String beans, beets, bok choy, Brussels sprouts, chives, collards, eggplant, kale, kohlrabi, leeks, onion, parsley, red pepper, pumpkin, rutabagas, turnips, and zucchiniArtichoke, parsnip, green peas, squash, and carrotYams and sweet potatoes

TomatoesPotatoesEgg plantGreen peppers

Grains: Include 1-2 cups of cooked grains per day

Amaranth, barley, buckwheat, millet, oatmeal, quinoa, basmati or brown rice, rye, and teff.Rice crackers and wasa crackers are also o.k.

All wheat products including breads, cereals, white flour, and pasta made from wheat.

Seafood: Deep sea-ocean fish are an excellent source of essential fatty acids and should be eaten 3-4 times per week.

Wild salmon, cod, haddock, halibut, mackerel, sardines, tuna, trout, and summer flounder. Poach, bake, or broil wild cold water fish (vs. farmed).

Shellfish: Shrimp, crab, lobster, and clams.

Meat: Eating protein with every meal helps to regulate and maintain steady blood sugar and energy.

Eat only the meat and not the skin of organic or free-range chicken and turkey. Wild game, venison, elk, and lamb are also fine.

Beef PorkSome organic beef/buffalo is OK in small amounts

Spices Add any favorite natural spice to enhance the flavor of your food

Adobo, sazon, seasonal, salt seasonings bullion cubes

Fruit: Eat only 1-2 pieces of practically any fruit per day.

Cantaloupe, rhubarb, melons, and strawberriesApricot, blackberries, cranberries, papaya, peach, plum, raspberries, and kiwiApple, blueberries, cherries, grapes, pear, pineapple, pomegranate

Citrus fruits.Lemon is OK

Sweeteners: Use sweeteners only occasionally

raw honey or stevia or raw organic agave nectar Avoid Sugar, Splenda, Nutra-sweet, Equal, Sweet & Low, Sugar substitites

Butter and oils   

extra virgin olive oil to use as a spread or for cooking. coconut oil only for bakingnut or seed or olive oils for salads earth balance buttery spread

Peanut oil

Nuts and seeds  

Ground flax, pumpkin, sesame, or sunflower seeds and add to steamed vegetables, cooked grains, etc. Most nuts and seeds are OK including nut butters.

Peanuts and peanut butter.

Drinks WATER. A small amount of rice, oat, almond, or soy milk are ok. Herbal teas can be great coffee and juice substitutes.

Coffee, soda, juice, caffeinated teas, or alcohol.

Anti-inflammatory Food Choices Chart

Vegetable ANDI Score

1. Mustard/Turnip/Collard Greens

1000

2. Kale 1000

3. Swiss Chard 1000

4. Upland/Watercress 1000

5. Bok Choy/Baby Bok Choy

865

6. Chinese/Napa Cabbage

714

7. Spinach 7078. Arugula 604

9. Lettuce, Green Leaf 585

10. Chicory 516

Vegetable ANDI Score

1. Radish 502

2. Turnip 473

3. Carrots 458

4. Acorn Squash 444

5. Broccoflower 444

6. Cabbage 434

7. Bell Pepper, Yellow or Orange 371

8. Kholrabi 352

9. Cauliflower 315

10. Rutabaga 296

Nutrient Value of Foods Important in Auto-Immune Diseases

Rheumatoid Arthritis

• Optimize omega 3:6 ratio to reduce jt. stiffness & tenderness

• Turmeric, 1 tsp (5 mL) each meal as spice or capsules.

• Polyphenols (e.g. from grapes) (preliminary evidence)

• Lower red meat • High antioxidant foods, e.g. green tea, soy,

cherries, garlic, ginger • Folic acid 1 mg/d

Rheumatoid Arthritis

• Optimize Vitamin D – consider maintaining higher levels, e.g. 50 – 70 ng/mL

• Pomegranate extract • Green tea extract • Selenium: Dosage: 200 mcg daily is standard

and 400 mcg daily is the maximum.• CoQ10• Probiotics

Hashimoto’s

• High protein breakfast

• Correct nutrient deficiencies

• Avoid Food Sensitivities

• Wheat free (not-gluten free)

• Foods with thyroid co-factors (brazil nuts, seaweed)

Celiac Disease

Beyond Gluten Free:

- high sources glutamine for gut repair

- r/o food sensitivities – common dairy sensitivity

- B12/B6 supplement vs. food; nutritional yeast

- constipation post gluten elimination non-gluten sources digestible fibers

An In-depth Look ….

• The following slides will take an in-depth look at integrative nutrition management of an auto-immune disease:

Irritable Bowel Disease

Irritable Bowel Disease

Chrons Disease

• inflammation in the bowel• can affect any part of (GI)

tract• most commonly SI• inflammation through the

entire thickness of the intestinal wall

• Sx: abdominal pain, bloody diarrhea, fever weight loss

Ulcerative Colitis

• inflammation in the bowel

• usually involves only the colon

• inflammation limited to inner surface layers of the intestine

• Sx: abdominal pain, weight loss, diarrhea

Clinical Management must be differentiated from IBS

Irritable Bowel Disease

• Diagnosis includes activation of the immune system (think genetic ask about family) (think environmental ask about lifestyle)

• Some theories correlate activation of disease to food allergens or food sensitivities

• Some theories suggest possible correlation to microbiome

• Active disease positive for elevated immune cells in intestinal tissue (i.e lymphocytes, macrophages).

• Elevated levels of inflammatory cytokines such as interleukin-1 (IL-1), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor alpha (TNF-alpha) may be present

IBD: Symptomology

• Common for sx to relapse & remit : Be careful not to associate this with “cure” and thus change diet too quickly

• Patient can be symptom free for months/years

• Acute attack can last weeks to months

IBD Dietary Management

• Restore Nutrient deficiencies

• May require vegetables to be cooked

• Avoid Stimulant Foods (spicy foods, coffee)

IBD Management

• Essential Fatty Acids - anti-inflammatory and immunomodulatory effects

• Probiotics – as immuno-modulators (by stimulating lymphocyte and macrophage activity and cytokine production and increasing IgA

• Psyllium - fermentation in gut produces butyrate. Butyrate (a SCFA) has an anti-inflammatory effect and inhibits cytokine production

• Antioxidants

IBD: Nutrient Deficiencies

Widespread nutrient deficiency possible secondary to absorption difficulties:

• Calcium • Vitamin B12• Folic Acid • Magnesium • Niacin • Vitamin B1• Vitamin D• Vitamin K• Zinc• Vitamin A• Vitamin E • Iron • Glutamine

IBD: Red Flags

• Severe acute colitis may require hospitalization for adequate nutrition and bowel rest

• Patients with severe colitis are also at risk for toxic megacolon

• NSAIDs may impair GI healing; avoid in patients with IBD

• Patients with UC may have difficulty absorbing folate

IBD: Clinical Pearls

• Patients with UC using sulfasalazine therapy will need folate supplement. (Sulfasalazine inhibits absorption of folic acid in the intestine)

Conclusion

• Most AI diseases will benefit from whole foods plant based approach

• Always rule out food sensitivities

• Supplement therapy may be critical for these patients

• Diet Therapies can have profound improvement on patient symptoms