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Supporting clients with autoimmune disease in clinical practice
The document outlines strategies for supporting clients with autoimmune diseases, including dietary adjustments like the Autoimmune Protocol diet and specific carbohydrate diet, alongside lifestyle changes and supplements. It highlights the link between environmental factors, diet, and the immune system in autoimmune conditions, emphasizing improvements in symptoms through targeted nutrition and lifestyle interventions. Additionally, it reviews studies supporting these approaches, demonstrating their efficacy in clinical settings.
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Supporting clients with autoimmune disease in clinical practice
- 1. Dr Danielle CridaMBChB, Dip Nutr Nutritionist, Igennus Healthcare Nutrition 1 Supporting clients with autoimmune disease in clinical practice
- 2. Contents 1. Overview ofautoimmune disease and causal mechanisms 2. Diet and autoimmune disease 3. Lifestyle and autoimmune disease 4. Supplements in autoimmune disease 5. Support summary
- 3. 1. Overview ofautoimmune disease
- 4. Genetics TriggerEnvironment • Females • Stress •Lack of sunlight/ vitamin D • Smoking • Alcohol • Obesity • Metabolic syndrome • Hygiene hypothesis • Western diet • Micronutrient deficiencies • Infections (EBV, HS1&2, E Coli) • Gut dysbiosis • Increased gut permeability • Chemicals • Heavy metals • Toxins Protective: Polyunsaturated fats, fibre, parasitic worms
- 5.
- 7. Foreign substance/microbe resembles the body Body cellsare altered e.g. by a virus, to look foreign Body substance enters the bloodstream B cells malfunction and make abnormal antibodies Mechanisms: Creation of an autoimmune reaction
- 8. The Balance ofTh17 versus Treg Cells in autoimmunity Th1 • Drives autoimmunity Th17 • Drives autoimmunity and inflammation • Pathogen clearance Treg • Maintain immune homeostasis Naive T cell
- 9. Jörg S, GrohmeDA, Erzler M, et al. Environmental factors in autoimmune diseases and their role in multiple sclerosis. Cell Mol Life Sci. 2016;73(24):4611–4622. doi:10.1007/s00018-016-2311-1
- 10. 2. Diet andautoimmune disease • Gluten • Salt • Sugar • Fat • Paleo and Autoimmune Protocol • Specific Carbohydrate Diet (SCD) • Anti-inflammatory diet • Wahls Protocol • Fasting • Vegan • Semi-vegetarian
- 11. Gluten & autoimmunedisease: 3 possible mechanisms • Intestinal permeability • Inflammation • Molecular mimicry
- 12. Sodium & autoimmune disease •2 ways sodium may drive autoimmune disease: • Activation of Th17 + Th1 cells • Activation of inflammatory monocytes, increased proinflammatory cytokines and decreased anti-inflammatory cytokines (Yi 2015) • Increased disease activity in multiple sclerosis • Salt alters gut microbiome composition, predisposing to obesity (Binger 2015)
- 13. Glucose & autoimmunity •High glucose intake exacerbates colitis and MS by activatingTh17 cells • Increased mitochondrial ROS which induce TGF-β activation and Th17 related inflammation (Zhang 2019)
- 14. Dietary fat, obesityand autoimmunity High fat diet Altered gut microbiome Improved capacity for energy harvest and storage Increased gut permeability and inflammation Autoimmune and other disease risk High calorie intake Obesity Leptin T cell proliferation Th1 response Raised omega-6:3 ratio Inflammatory eicosanoids activate Th17 response
- 15. Image from Paleomom.com Paleoand Autoimmune Protocol Diet
- 16. The Autoimmune Protocol •In addition to the grains, legumes, dairy and soy avoided by standard Paleo diet, AIP also eliminates eggs, chocolate, coffee, nuts & seeds, nightshades and alcohol • Elimination phase • Maintenance • Reintroduction Focus areas: • 1. Nutrient density • 2. Gut health • 3. Hormone regulation • 4. Immune system regulation
- 17. Trial: Efficacy ofthe Autoimmune Protocol Diet for Inflammatory Bowel Disease • Adults with active Crohn’s disease and ulcerative colitis (non-coeliac) • Mean duration 19 years, active biological use 47% • Clinical remission in 73% by week 6, maintained through week 11 • Mean faecal calprotectin improved from 471 to 112 • This % of remission rivals most drugs for IBD (Konijeti G 2017)
- 18. • Women withHashimoto’s thyroiditis • 6-week transition onto AIP with 4 weeks maintenance • Significant improvement in quality of life scores • Clinical symptom burden decreased from 92 to 29 on MSQ • Reductions in CRP and white cell counts (Abbott R 2019) Trial: Autoimmune protocol in Hashimoto’s thyroiditis
- 19. Specific Carbohydrate Diet •Used in (paediatric) inflammatory bowel disease • Used by some people to manage IBD, cystic fibrosis and autism • Included: animal products without additives, certain legumes incl. dried beans, lentils, split peas, most nuts, certain dairy products (encouraging homemade live yoghurt), most veg, all fruit, most nuts, most oils, tea, coffee, honey • Prohibited: sugar & sweeteners, grains, some legumes, seaweed, starchy tubers (potatoes, sweet potatoes, turnips), additives, milk & milk products high in lactose
- 20. • Suskind 2014:7 children with Crohn’s on no immunosupressants. On diet for on average 14 months. All children clinical remission after 3 months. Blood results normalised/significantly improved • Cohen 2014: 10 children with Crohn’s, 12 weeks on SCD. Clinical and mucosal improvement • Suskind 2016: Survey of IBD and SCD: 417 respondents. 33% reported remission at 2 months, 42% at 6 & 12 months. SCD in Crohn’s and IBD
- 21. An anti-inflammatory dietas treatment for inflammatory bowel disease • IBD-AID 5 basic components, introduced in different phases: 1. Modification of certain carbohydrates incl lactose + refined carbohydrates. Soluble fibre encouraged (bananas, oats, flax meal) 2. Inclusion of pre and probiotics (soluble fibre - bananas, oats, flax meal, leeks, onions, fermented foods) 3. Fats 4. Correction of missing nutrients, diagnoses of intolerances 5. Modified texture of foods (blended/ground/cooked) as per symptoms to improve nutrient absorption and minimise intact fibre • 33% chose not to attempt diet, others used diet for 4 weeks, at 70% or more compliance to diet • 24/27 had good/very good response to diet • 3/27: mixed results • 100% able to discontinue • 100% decreased symptoms
- 22. Wahls Protocol inMS • Paleo-like diet protocol • Study included supplements (optional fish oil), stretching & strengthening exercises, meditation, massage • 1 year study, 10 subjects – 8 completed study, 6 fully adherent • Average adherence to diet 90% of days, exercise 75% or days. Average daily meditation 13 mins, massage 7 mins • Significant improvement in fatigue (Bischt 2014) Dr Terry Wahls
- 24. MS and fasting Multiplesclerosis is an autoimmune disorder of the central nervous system during which the immune system attacks and destroys the myelin sheath around nerve axons. Most treatments for multiple sclerosis are immunosuppressive and do not alleviate autoimmunity or regenerate the damage already caused. New research hopes to determine the role diet and nutrition could have on overcoming multiple sclerosis.
- 25. Diet mimicking fastingpromotes regeneration and reduces autoimmunity and multiple sclerosis symptoms Choi 2016
- 27. Controlled fasting followedby 1-year gluten-free vegan, then vegetarian diet in RA • 4-week stay at health farm • Initial 7-10 day subtotal fast • Gluten-free, vegan diet for 3.5 months • Gradually changed to lactovegetarian diet • Significant improvements vs control group (Kjeldsen-Kragh 1991)
- 28. Low-fat vegan dietin rheumatoid arthritis • 4 weeks • Very low fat – 10% • Blinded rheumatologist • Significant decrease in almost all measures of RA symptomatology • Significant decrease in weight • Rheumatoid factor decreased by 10% • CRP decreased 16% (McDougall 2002)
- 29. Semi-vegetarian diet in Crohn’s •Allowing milk and eggs, fish once per week, and other meat once every 2 weeks • Adults who had achieved medical or surgical remission • Compliance 73% • Remission 94% after 2 yrs vs 33% in control group (Chiba 2010)
- 30. 3. Lifestyle andautoimmune disease • Cigarette smoking • Exercise • Sleep • Stress • Mindfulness & meditation • Cold exposure
- 31. Smoking and autoimmunedisease • Strongly linked to development and severity of many autoimmune diseases • Affects both innate and adaptive immune systems • Increases pro-inflammatory cytokines; decreases anti-inflammatory cytokines • Activates macrophage and dendritic cell activity • Stimulates production of auto-antibodies (Arnson 2009)
- 32. Exercise in autoimmunedisease • Boosts energy • Releases endorphins – natural painkiller • Reduces inflammation • Combats depression and anxiety • Helps manage weight • Moderate, low-impact exercise
- 33. • Elevation inTreg cells • Decreased Th1 • Decreased immunoglobulin secretion • Promotes IL-6 release from muscle (Sharif 2018) Physical activity and autoimmune disease
- 34. Sleep • Chronic insomniaincreases risk of autoimmune condition and vice versa • Increased sleep disorders in autoimmune conditions • Symptoms cause disturbed sleep (Zielinksi 2019) • Melatonin dysregulation involved in pathogenesis of autoimmune conditions • Melatonin therapy–modulates Th1/Th2 balance, and cytokine production (Zin 2013)
- 35. Stress Stress - trigger Autoimmune disease Mental health issues/Stress Up to80% of patients reported uncommon emotional stress before disease onset (Stojanovich 2010)
- 36. Mindfulness-based interventions and theimmune system • Reduced NF-κB • Reduced CRP in ulcerative colitis • Increased IL-10 in UC • Reduced TNF-α in ulcerative colitis • Reduced NF-κB • Increased telomere length • Dosage dependent (Black 2016)
- 37. Wim Hoff method • Breathingexercises, cold water exposure and meditation • Proved that autonomic and innate nervous system can be actively influenced • Safety and anti-inflammatory effects in patients with axial spondyloarthritis • ESR,CRP and calprotectin declined relative to control group (Buijze 2019)
- 38. 4. Supplements inautoimmune disease • Omega-3 • Curcumin • Vitamin D • Astaxanthin • Probiotics
- 39. • Influence amountand type of immunomodulatory eicosanoids • Act on intracellular pathways, transcription factors and gene expression • Decrease the high levels of IL-1 common to autoimmune diseases and CVD, depression, ageing and cancer (Simopoulos 2002) Omega-3 supplementation
- 40. Therapeutic potential ofomega-3s in human autoimmune disease • Rheumatoid arthritis: Many studies showing improvement in symptoms and decreased inflammatory cytokines • SLE: DHA supplementation preventative (Wieringa 2019). Improvement in endothelial function, disease activity and inflammatory markers after >12 weeks of treatment • Type 1 diabetes: Preventative (high-risk children) and therapeutic • Multiple sclerosis: Most studies show decreased exacerbation and disability Preventative role (Li 2019)
- 41. Curcumin • 3 studiesin ulcerative colitis, 2 of which yielded significant improvement in disease remission, outcome ~ dose used (ineffective low dose) • 2 clinical trials on RA – 1 decreased disease activity & CRP. Other – only 2 weeks • 1 Lupus nephritis – decreased proteinuria, hematuria and blood pressure even at low dose 3 times daily • 2 on MS looking at lab outcomes. Curcumin able to restore expression pattern of dysregulated miRNA. Other study – significant decrease in Th 17 and IL-17, which may improve disease progression • Modulation of the eicosanoid pathway towards a more anti-inflammatory pathway • Modulation of serum lipids towards a favourable profile • Yang (2019) - Curcumin in Autoimmune and Rheumatic Diseases. Review article
- 42. Vitamin D • MS:risk factor, and lower blood levels of vitamin D, especially during relapses • Type 1 DM: Supplementation reduces risk and protects pancreatic cells • SLE: Risk factor, and supplementation decreases fatigue (Yang 2013) • Vitamin D receptor in immune cells • Inhibits Th1 cells and their inflammatory cytokines • Promotes shift to Th2 response with more regulated, anti- inflammatory response • Suppresses Th17 response and increases Treg activity
- 43. Astaxanthin • Role ofantioxidants in autoimmune disease not fully researched • Nurses health study – no link between reported anti- oxidant intake and development of RA or lupus • Increased oxidative stress in autoimmune conditions • Free radicals cause damage to cell membranes and tissues • Vitamins A and E can become pro-oxidant in certain circumstances Astaxanthin is a good choice if you want an antioxidant • Highest ORAC value • Never becomes pro-oxidant • Acts intra- and extra-cellularly • Inhibits NF-Kappa-B • Flexible dosing • Promise in pain in RA
- 44. Probiotics • Studies usingdifferent probiotics in different conditions have shown various amount of success • 1 study suggesting that L. reuteri improves symptoms and quality of life in human MS • VSL #3, an eight-strain probiotic which includes lactobacilli, bifidobacilli, and Streptococcus thermophilus, is effective in UC (Liu, 2018)
- 45. Metal toxicity • Metaltoxicity is a risk factor for autoimmunity (Stejskal J 1999) • 71% of patients with autoimmune disease showed improved health 6 months after amalgam replacement (Prochazkova, 2004)
- 46. • Healthy weight •Prioritise gut health • Low sugar and refined carbs • Avoid excessive salt • Lower fat especially saturated fat • Increase vegetables • Avoid processed food • Avoid gluten • Consider specialised diet guided by research and client preferences • Supplements: Omega-3, Curcumin, Vitamin D +/- Astaxanthin, probiotics • Stop cigarette smoking • Optimise sleep • Exercise – correct balance • Stress reduction e.g. meditation 5. Support summary
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