Nutritional Care vs. Autoimmune Diseases
By Joel Fuhrman, M.D.
his issue of the newsletter is about rheumatologic disease: diseases such as psoriasis, lupus, rheumatoid arthritis, and connective tissue disease, but there are about a hundred clinical syndromes considered autoimmune disease. The term rheumatoid arthritis was coined in 1858 to differentiate this type of joint pain and bodily symptoms from gouty arthritis, which was more common in those days among wealthier Europeans eating rich foods.
Rheumatologic diseases refer to a group of systemic illnesses characterized by the immune system’s attacks on joints and other parts of the body. Today, the words autoimmune and rheumatologic are interchangeable; they are marked by inflammatory markers in the blood. Inflammatory bowel diseases, such as Crohn’s and ulcerative colitis, also are autoimmune diseases, but they are not classified as rheumatologic because they typically are cared for by gastroenterologists, not rheumatologists. Nevertheless, they are diseases where inflammatory markers are visible in the blood and are of the same class as systemic autoimmune disorders.
Autoimmune diseases are caused by an inflammatory process regulated by our immune system. Inflammation normally protects the host from foreign invaders by isolating and destroying bacteria, viruses, and other toxic or foreign agents. It is a highly complex process involving many types of cells, a number of enzymes, and many physiologically active materials that alter local blood flow and cell behavior.
In Pathological Basis of Disease, the leading pathology text used by most medical students, inflammation is explained poetically:
“The inflammatory response is closely intertwined with the process of repair. Inflammation serves to destroy, dilute, or wall off the injurious agent, but in turn sets into motion a complex series of events that, as far as possible, heal and reconstitute the damaged tissue. Repair begins during the early phase of inflammation but reaches completion usually after the injurious influence has been neutralized....Humans owe to inflammation their ability to contain injuries and heal defects. Without inflammation, infections would go unchecked, wounds would never heal, and injured organs would remain permanent festering sores.”
Understanding biology and pathology helps us to understand how immune system disorders can be treated and how nutritional therapy works. Poisoning the immune attack into submission with toxic drugs is one avenue of attack. This leads to a continual and increased buildup of toxic and irritating immune system stimulating substances, which could increase the requirement for more drugs down the road and make for a more severe response if the medications are discontinued. The road less traveled is to attempt to remove the noxious and injurious influences promoting the excessive immune attack and to normalize the excessive immune system response by adopting a program of nutritional excellence.
In most of the rheumatologic diseases, the inciting agent stimulating an excessive immune attack is unknown, and the inflammatory reaction becomes detrimental to the host. Unfortunately, in untreated autoimmune illnesses, the immune attack against unknown stimuli does not stop and leads to destructive, harmful sequelae (aftereffects). Our complicated immune response is controlled with a system of checks and balances, just like our democratic government. Many components are involved in this immune-mediated attack. First, our antibodies label areas worthy of attack, then other cells work to call out the alarm—secreting substances that attract and promote proliferation of other attacking cells. Finally, there are cells that control the attack, modify it, and turn it off at the precise moment to prevent an excessive response. In autoimmune disorders such as lupus, we have an immune response that reacts in an uncontrollable fashion,a response that is not properly immuno-regulated.
Increased Understanding
As our understanding of the mechanism and causes of inflammation increases, so does our ability to understand the factors that create a favorable environment for improvement and healing of autoimmune disease. The scientific basis for the nutritional treatment of autoimmune disease hinges on the removal of cellular toxins, bacterial-elaborated toxins from our digestive tract, food excesses, and food toxins, while at the same time supplying a high level of nutritional factors that help normalize a malfunctioning (excessive) immune response that overreacts to stimuli and does not shut off.
In spite of excellent clinical results and the publication of case studies and medical journal articles documenting favorable outcomes, medical authorities and major research centers are not interested in studying nutritional excellence as a therapy for rheumatologic diseases. It is difficult to move against an entrenched status quo that wrongly assumes that medications are the only option. If my approach to autoimmune illnesses was taught in medical schools and residency programs, primary care physicians could begin this nutritional approach at the earliest signs of autoimmune illness with their patients, instead of prescribing a lifetime of medications that have dangerous side effects.
How My Program Works
Dietary intervention is my chief component of care. Achieving superior health via nutritional excellence gives a person with an autoimmune disorder the only opportunity for a complete drug free remission. In many cases, a vegetarian diet alone helps substantially. It is important to keep in mind that food is our major contact with the external environment, and food choices can negatively or positively modulate the immune system. In addition to inherently toxic substances that may be ingested, intact peptides and proteins (partially digested animal proteins) can bridge the walls of the digestive tract and can be absorbed into the circulation, playing a significant role in promoting an excessive antibody response, contributing to autoimmune diseases.
However, in most cases, more specific dietary modifications, along with nutritional supplements, are required to maximize the therapeutic response. Over the past fifteen years, having treated and helped hundreds of patients with autoimmune disease, I have found that the greatest percentage of patients achieve excellent results if they utilize a high-nutrient dietary program rich in greens and especially the cruciferous vegetables such as cabbage, broccoli, and kale in conjunction with some helpful nutritional supplements.
The protocol has nine important features:
1. High-nutrient, vegan diet, rich in green vegetables
2. Blended salads and blended soups (utilizing leafy greens) to increase absorption of favorable phytochemical compounds
3. Fresh vegetable juice (carrots, beets, parsley, kale, and other greens)
4. High-dose fish oils or plant-derived EPA and DHA
5. Beneficial bowel flora
6. Natural anti-inflammatory herbs such as turmeric, quercetin, ginger, and bioflavonoids.
7. Multivitamin/mineral, plus additional vitamin D supplementation
8.Water-only fasting, used periodically, if necessary
9. Dietary avoidance of salt, wheat, and oil
Fueling Your Immune System with Greens
I recommend the daily consumption of a thick vegetable soup, which can be made in advance in large amounts so it is readily available to use for lunch the entire week. Zucchini, leeks, and leafy greens such as chard, cabbage, kale, bok choy, or broccoli are added to a liquid base made from freshly-squeezed vegetable juice and water. Vegetables such as parsnips, carrots, mushrooms, lentils, split peas, and spices can be added, too. What makes this soup unique is that the leeks, zucchini, and other greens are blended until smooth into the soup liquid (veggie juice), increasing the absorption of the beneficial compounds. Softening vegetables via soup cooking has been shown to increase the bioavailability of beneficial phytochemical compounds. I also encourage the use of freshly-squeezed vegetable juice using carrots, parsley, beets, cabbage, and kale before dinner as well. Pomegranate juice is also a favorable addition.
Last, but not least, I teach patients how to make a raw spinach and lettuce blended salad, with fruits and nuts or avocado added to make a great tasting, high-nutrient treat. Blending the salad to a creamy consistency has the dramatic effect of increasing absorption of beneficial phytochemicals over 500 percent compared with eating salad.
High Dose Fish Oils
High doses of EPA (eisosapentaenoic acid) and DHA (docosahexaenoic acid) have been shown to lower immune reactivity and to inhibit inflammatory response. These supplements make important contributions in the recovery of many patients. Dosages in the range of 1.2 to 4 grams of the active components (EPA + DHA) typically are needed. Not all patients with autoimmune disorders are fish oil responsive, and the anti-inflammatory effect should not be expected to lead to striking improvements without implementing all of the other components of the dietary and nutritional program.
These EPA and DHA (long-chain omega-3) fatty acids are used in conjunction with a dietary program that is low in omega-6 fats and saturated fat. This fatty acid environment suppresses the production of pro-inflammatory substances that normally are produced from increased amounts of arachidonic acid, derived from omega-6 fats.
Omega-3 long-chain fatty acids also have been found to suppress production of inflammatory cytokines and cartilage degradation enzymes. Their beneficial anti-inflammatory effects have been demonstrated in hundreds of randomized, double blinded, placebo-controlled trials. It is difficult to understand why well-studied, effective, natural substances are generally ignored by the medical community. Perhaps it is that these substances do not provide the industry with the opportunity for substantial profit compared to what is possible with patented prescription items.
Taking high doses of fish oil is not without any risk, but compared to drugs, the potential drawbacks are slight. Fish oils are also susceptible to contamination with lipophilic organic chemicals that are now ubiquitous contaminants of marine ecosystems. Some fish-derived products cannot be recommended for this reason.
Recently, I have addressed this concern by developing an all-plant-derived EPA and DHA supplement. As far I can tell, it is the only all-vegan EPA and DHA available anywhere in the world. It enables people to get the same beneficial fats in fish (including the EPA) without the possibility of pollutants and mercury. It is also freeze-dried to extend shelf life and prevent rancidity.
Supplemental Bowel Flora
The hundreds of billions of bacteria cells that inhabit our bowels play a critical role in the health of our immune system. Seventy percent of the immune system is located in the gastrointestinal (GI) tract. The micro-flora of the GI tract constitute a complex ecosystem that can be viewed as an organ of the body, as these microbes profoundly influence physiologic processes of the host. Certain normal metabolic functions and enzyme activities can be attributed to the micro-flora, and these play a role in metabolizing nutrients, vitamins, drugs, endogenous hormones, and carcinogens; synthesizing short-chain fatty acids; preventing colonization of pathogens; and modulating the normal immune response.
The bowel offers some degree of protection from harmful materials which are ingested. The process of absorption takes place via the micro-villi of the intestinal walls. Normal bowel permeability permits assimilation of nutrients while providing protection against pathogens being absorbed into the systemic circulation. Food-enriched blood from the bowel is processed in the liver where most immune complexes are removed. The other pathway of intestinal absorption is through lymphatic circulation. Absorption of antigens via the intestinal lymphatics may be a significant source of systemic autointoxication.
Researchers increasingly acknowledge that there is a link between digestive processes and arthritis. In patients with altered bowel anatomy, chronic bacterial overgrowth can lead to the formation of circulating immune complexes that deposit in the joint membranes, causing inflammation. Changes in bowel permeability due to local gut inflammation may expose the host immune system to microbial or food antigens and even bacterial translocation. In some cases, bacterial elaborated toxins derived from the presence of pathogenic bacteria such as Klebsiella, Proteus, Pseudomonas, Citrobacter, and Clostridium difficile may play a direct role in the induction of arthritis.
The use of beneficial flora has been shown to antagonize the replication of potentially pathogenic microorganisms that have been implicated in promoting inflammation. Lactobacilli and Bifidobacteria are well established as offering intrinsic benefit and aiding digestion while helping to prevent overgrowth of abnormal flora. Three frequently identified organisms—Lactobacilli, Bifidobacteria, and Escherichia coli—are sometimes measured in the stool as indicators of healthy overall bowel flora.
Vitamin D Supplementation
The active form of vitamin D has been shown to suppress the development of autoimmune problems. Geographical areas of the world with less sunlight (and correspondingly lower vitamin D levels) correlate with a higher incidence of autoimmune diseases. Vitamin D deficiency also increases the severity of experimental autoimmune disease in animal studies.
In the Iowa Women’s Health Study, researchers found greater intake of vitamin D associated with the lowest incidence of rheumatoid arthritis and lowest intake with the highest incidence of rheumatoid arthritis. Medical studies done on patients with rheumatoid arthritis illustrate that low levels of vitamin D accelerate the destructive arthritic process, and low levels of the biologically active form of vitamin D are found more often in patients with autoimmune disease.
Water-Only Fasting
Water-only fasting is known to be an effective means of lessening the symptoms of autoimmune illnesses, and is actually well documented in the medical literature. Fasting can facilitate the mobilization and elimination of noxious stimuli from fat and tissue stores. Mobilizing retained antibody-antigen complexes stored in tissues also may be involved, as well as other poorly understood mechanisms.
The challenge, however, is to maintain the benefits of the fast after the reintroduction of foods. A common opinion expressed in the rheumatology literature is that the relief of symptoms that occurs during a fast is quickly lost. Those studies that have shown no long-term benefit to fasting have allowed unrestricted food intake after the fasting period. In other words, patients were put back on the diet that caused the problem in the first place.
My extensive experience in this field has demonstrated that fasting is an important adjunct to nutritional therapy and in many cases, especially with lupus, can make the difference in resetting the immune system to normal, enabling a complete recovery.
One long fast of 14-24 days or multiple short fasts of 3-7 days can be used as an adjunct to the nutritional program to facilitate a recovery, especially in cases that do not resolve with dietary modifications. In 2001, I published a series of cases where complete remission occurred as a result of the combination of fasting and nutritional excellence. These cases included rheumatoid arthritis, lupus, connective tissue disease, and fibromyalgia. (Fuhrman J, Sarter B,Calabro DJ.“Case Studies of Medically Supervised Water-only Fasting Resulting in Remission of Autoimmune Disease.”Alternative Therapies Sept./Oct. 2001;Number 8 Volume 4).
Conclusion
Working with patients with autoimmune diseases is one of the most rewarding aspects of my medical practice. The ability to achieve substantial improvement and, in most cases, complete remission of these supposedly incurable illnesses is exciting. Patients with these conditions usually are highly motivated to get well and amiable to any health-supporting changes that may facilitate their recovery.
References:
Cleland LG, James MJ, Proudman SM. The role of fish oil in the treatment of rheumatoid arthritis. Drugs 2003;63(9):845-63.
McCarty MF. Upregulation of lymphocyte apoptosis as a strategy for preventing and treating autoimmune disorders: a role for whole-food vegan diets, fish oil and dopamine agonists. Med Hypotheses 2001;57 (2): 258-75.
Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune disease. J Am Coll Nutr 2002; 21(6): 495-505.
Ergas D, Eilat E, Mendlovic S, Sthoeger ZM. N-3 fatty acids and the immune system in autoimmunity. Isr Med Asoc J 2002;4(1):34-8. Leiba A, Armital H, Gershwin ME, Shoenfeld Y. Diet and Lupus. Lupus (England) 2001;10(3):246-8. Kelley DS. Modulation of human immune and inflammatory responses by dietary fatty acids. Nutrition 2001;17(7):669-73.
Cantona MT. Vitamin D and autoimmunity: is vitamin D status an environmental factor affecting autoimmune disease prevalence? Proc Soc Exp Biol Med 2000: 223(3):230-3.
Merlino LA, Curtis J, Mikuls TR, et al. Vitamin D intake is inversely associated with rheumatoid arthritis: results from the Iowa Women’s Health Study. Arthritis Rheum 2004; 50(1):72-7.
Oelzner P, Muller A, Deschner F, et al. Relationship between disease activity and serum levels of vitamin D metabolites and PTH in rheumatoid arthritis. Calcif Tissue Int 1998 62(3):193-8.
Dunne C, Murphy L, Flynn S, et al. Probiotics: from myth to reality. Demonstration of functionality in animal models of disease and in human clinical trials. Antonie Van Leeuwenhoek 1999;76(1 4):279-92.
Review articles:
Vitamin D3 metabolism in patients with rheumatic diseases: low serum levels of 25 hydroxyvitamin D3 in patients with systemic lupus erythematosus. Clin Rheumatol 1995 14(4):397-400.
Role of the enteric microflora in the pathogenesis of intestinal inflammation and arthritis. Aliment Pharmacol Ther 1997;11(Supple 3:17-22):discussion 22-3.