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Managing Auto-Immune Disease with Diet Dr. Jaime Schehr Naturopathic Doctor Registered Dietitian Owner Schehr Nutrition PLLC 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 the patient have a diagnosis or do you suspect it? • Has patient yet made dietary modifications for this condition? • Diet? lifestyle ? exercise? Supplementation?readiness to change 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 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 (berries, red grapes, red cabbage, red onion) 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 Diet aka 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 Wheat Corn Soy Egg Citrus Caffeine Alcohol Sugar Food Additives Frequently eaten foods Processed foods Known Allergens Peanuts Foods to Include Gluten-free grains and flours Fruits Vegetables Legumes 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, cherries, garlic, onion and tea • Spices, in particular, ginger, garlic, rosemary, turmeric, oregano, cayenne, clove and nutmeg • Low glycemic index/load foods Anti-inflammatory Food Choices Chart 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 zucchini Artichoke, parsnip, green peas, squash, and carrot Yams and sweet potatoes Tomatoes Potatoes Egg plant Green 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. Meat: Eating protein with every meal helps to regulate and maintain steady blood sugar and energy. 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. 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. Spices Add any favorite natural spice to enhance the flavor of your food Fruit: Eat only 1-2 pieces of practically any fruit per day. Cantaloupe, rhubarb, melons, and strawberries Apricot, blackberries, cranberries, papaya, peach, plum, raspberries, and kiwi Apple, blueberries, cherries, grapes, pear, pineapple, pomegranate raw honey or stevia or raw organic agave nectar Beef Pork Some organic beef/buffalo is OK in small amounts Adobo, sazon, seasonal, salt seasonings bullion cubes Citrus fruits. Lemon is OK Sweeteners: Use sweeteners only occasionally Butter and oils Nuts and seeds Drinks extra virgin olive oil to use as a spread or for cooking. coconut oil only for baking nut or seed or olive oils for salads earth balance buttery spread Ground flax, pumpkin, sesame, or sunflower seeds and add to steamed vegetables, cooked grains, etc. Most nuts and seeds are OK including nut butters. WATER. A small amount of rice, oat, almond, or soy milk are ok. Herbal teas can be great coffee and juice substitutes. Avoid Sugar, Splenda, Nutra-sweet, Equal, Swee & Low, Sugar substitites Peanut oil Peanuts and peanut butter. Coffee, soda, juice, caffeinated teas, or alcohol. Nutrient Value of Foods Important in Auto-Immune Diseases Vegetable ANDI Score Vegetable ANDI Score 1. Mustard/Turnip/Collard 1000 Greens 1. Radish 502 2. Turnip 473 2. Kale 1000 3. Carrots 458 3. Swiss Chard 1000 4. Acorn Squash 444 4. Upland/Watercress 1000 5. Broccoflower 444 5. Bok Choy/Baby Bok Choy 865 6. Cabbage 434 6. Chinese/Napa Cabbage 714 7. Bell Pepper, Yellow 371 or Orange 7. Spinach 8. Arugula 707 604 9. Lettuce, Green Leaf 585 10. Chicory 516 8. Kholrabi 352 9. Cauliflower 315 10. Rutabaga 296 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 (selenium, foliv acid, vitamin D) • 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 (dietary or supplemental) - 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 autoimmune disease: Inflammatory Bowel Disease Inflammatory Bowel Disease Clinical Management must be differentiated from IBS Crohn’s 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 Inflammatory 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 Nutrition: • hypoallergenic/rotation diet • Avoid Stimulant Foods (spicy foods, coffee) • correct nutrients deficiencies • provide adequate calories • short (3-5 day) fasts possibly recommended (as an alkaline juice fast) • all foods must be eaten slowly, chewed and salivated well; • May require vegetables to be cooked; eat more steamed vegetables than raw ones • Avoid artichoke, grape skins and seeds, roughage, raw foods, cold foods IBD Medicinal Food 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 – as calcium citrate or malate Vitamin B12 - IM Folic Acid – methylated Magnesium – glycinate / oxide Vitamin B1 Vitamin D – dose to restore / maintain optimal levels Vitamin K Zinc – divide dose to 15mg/max at one time if possible 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) In Conclusion • Most AI diseases will benefit from whole foods plant based approach • Always rule out food sensitivities • Counsel on what you know (if you don’t know it, it doesn’t mean its wrong) • Supplement therapy may be critical for these patients • Diet Therapies can have profound improvement on patient symptoms Thank you!