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Your carbohydrate tolerance – is it written in your genes? AMY1 copy numbers

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Salivary amylase protein

Low carb or high carb – what diet is right for you? The AMY1 gene test.

Before I knew anything about the effect of diet on my health and hunger, I did notice that an hour or 2 after eating refined starch foods I suffered low blood sugar and was ravenously hungry.

Back in the day (1995) as I’ve written about previously, I discovered the zone diet, it was literally life changing for me.

Through following this eating plan I discovered that refined carbohydrates, particularly those from grains and sugars played havoc with my blood sugar regulation. The Zone diet reduces carbohydrates, for me it was down to around 70 – 100 grams a day, divided to around 20 – 30 grams per meal.  Vegetable and low glycemic index (GI) carbohydrates are encouraged over refined grains and high GI carbs.

I’ve followed this principal for 20 years now, and found limiting carbohydrates, and adding animal protein to each meal is critical for both my well-being and appetite regulation. I’ve since found that 50 to 100 grams of carbs per day works well for me, and carbohydrate quality is important. This works out to 1 to 2 grams per kg body weight per day.

I’ve often wondered why I seem to be so sensitive to carbohydrates, while others don’t suffer the dysregulated blood sugars and reactive hypoglycemia and consequent carbohydrate cravings that I do.

The answer may be in my genes. I recently had a gene test to find out how many copies of the AMY1 gene I have, this a gene that codes for salivary amylase.

What is Salivary Amylase?

The suffix or ending -ase when referring to a word related to biology tells us that this means an enzyme. The first part of the word shows us what the enzyme acts on. Amyl-ase. Amyl refers to amylum or starch. A starch is comprised of a large number of glucose units linked together with a particular bond called a glycosidic bond.

starch-link

The amylase breaks this bond so that the starch is converted into glucose molecules.

starch-to-glucose

You can think of amylase as being like scissors (source )

starch-scissors

Getting back to the AMY1 gene

The AMY1 gene is a gene that is linked with how much amylase you have in your saliva.

What does copy number mean?

A gene is a segment of information on a chromosome. In the case of AMY1 copy numbers, some people have many repeats of this gene and some only one. This post in Wikipedia explains copy numbers

Copy numbers, repeated segments of the same DNA
Copy numbers, repeated segments of the same DNA

As the AMY1 gene codes for (i.e. gives instructions to make) salivary amylase, the more copy numbers you have the more salivary amylase you make. Copy numbers have been counted from 1 copy up to 20, more typically from 2 to 16. On average humans have 6 copy numbers.

The importance of AMY1 copy numbers

Your copy number affects the amount and activity of amylase in your saliva, this in turn is related to how well a person metabolises and tolerates dietary starch.

People with low copy numbers – between 1 and 4 produce low levels of amylase, and the activity of amylase is low.

Only 10% of the population measure 9 or more copy numbers, these individuals produce more amylase and it has high activity. These people are better able to metabolise and likely suit a higher starch diet.

Research on AMY1 copy numbers

Increased copy numbers appear to be an adaptive response to a starch rich diet in humans. The longer a population is exposed to a diet higher in starch the more copy numbers people in those populations are likely to have (Perry et al, 2007)

Diet and AMY1 copy number variation. (a) Comparison of qPCR-estimated AMY1 diploid copy number frequency distributions for populations with traditional diets that incorporate many starch-rich foods (high-starch) and populations with traditional diets that include little or no starch (low-starch).
Diet and AMY1 copy number variation. (a) Comparison of qPCR-estimated AMY1 diploid copy number frequency distributions for populations with traditional diets that incorporate many starch-rich foods (high-starch) and populations with traditional diets that include little or no starch (low-starch).

amy1-001perry

(Source of above graphic DOI:10.1038/ng1007-1188)

Low copy numbers of the salivary amylase gene predisposes to obesity

Falchi and co  tested 6,200 people and found there was a positive correlation between both body mass index (BMI) and fat mass, and low AMY1 copy numbers. They found an 8 fold difference in the risk of obesity between people with a copy number of less than 4 compared to a copy number of greater than 9.

However a more recent study by Usher designed to replicate this result using another method  to measure copy numbers, failed to reproduce this relationship (Usher, 2105  )

Other studies have also found relationships between AMY1 copy numbers and obesity:

A Mexican study measuring copy numbers in children found all children with copy numbers greater than 10 were normal weight. The authors think that high copy numbers of AMY1 protect against the obesogenic effect of a high starch diet (Mejía-Benítez et al, 2015)

A study in Finland showed that low copy numbers of AMY1 was associated with early-onset female obesity (Viljakainen, 2015)

How does the AMY1 copy number affect how starch is digested?

When starch enters your mouth – the amylase starts the process of breaking it down into glucose. If there is more amylase then more starch is converted to glucose in the mouth. High salivary amylase is associated with a rapid insulin response, this results in insulin acting sooner on the glucose as it enters the blood stream, as a result glucose does not go as high as those with lower copy numbers who have a more delayed release of insulin.

Low AMY1 copy numbers are associated with insulin resistance in a study of asymptomatic Korean men (Choi, 2015 ) .

The following study shows the difference in glycemic responses to starch ingestion, those with high copy numbers had significantly lower post prandial (post meal) blood glucose concentrations at 45, 60 and 90 minutes compared to those with low copy numbers (Mandel 2012 ).

The first graph above shows the plasma (blood) glucose response at top (A). The low amylase (LA) group has a higher response and then a steeper drop, in fact it goes lower than baseline. This is typical of a high glycemic index food. The graphs (B and C) shows the insulin response also differs. In C you notice that the high amylase (HA) group starts to release insulin within minutes of consuming starch, it is stimulated by starch in the mouth, whereas the LA group it is a more delayed response. In B insulin then increases far more after 20 minutes in the LA group, this probably leads to the steep reduction and fall below baseline of blood glucose seen.
The first graph above shows the plasma (blood) glucose response (A). The low amylase (LA) group has a higher response, glucose goes higher, and then a steeper drop, in fact blood glucose drops lower than baseline.
The graphs (B and C) show the insulin response also differs. In (C) you notice that the high amylase (HA) group starts to release insulin within minutes of consuming starch, it is stimulated by starch in the mouth, whereas the LA group it is a more delayed response. In (B) insulin then increases far more after 20 minutes in the LA group, this probably leads to the steep reduction and fall below baseline of blood glucose seen.

 

These studies suggest that people with a higher salivary amylase have a better glycemic tolerance to dietary starch than those with low salivary amylase. They also have an overall lower blood insulin. Neither high blood glucose or insulin are desirable. They may be at greater risk for insulin resistance and diabetes if they eat a diet chronically high in starch.

How do you get your copy numbers measured?

I got my AMY 1 tested through FitGenes in Australia. I have consequently trained as a FitGenes practitioner, and if you are in Auckland, NZ you can get this test done through me. Otherwise look at the website for practitioners in other areas.

What diet is suggested with respect to copy numbers?

All these studies suggest the lower your copy number the less starch you should eat. I have very low copy numbers, 2, this came as no surprise to me. The diet that transformed my health, allowing me to lose weight without hunger, get great blood sugar control and manage my appetite (no more blood sugar crashes after carbs) was the Zone diet.

Tips if you have low copy numbers (1-4)

You are probably best avoiding refined carbohydrates altogether, I find any starch is a problem for me, including all flours, even the non grain ones like tapioca starch. If carbohydrates are needed e.g. for exercise, root vegetables are better choices.

Don’t eat carbohydrates by themselves, eat them in a way that lowers the glycemic index.

Citric acid on your tongue for a minute will increase salivary amylase

A Chinese study found that you can increase your salivary amylase (sAA) with citric acid, the study involved placing a piece of filter paper soaked in citric acid on the tip of the tongue for 1 minute – the citric acid induced significant increase in sAA activity, total sAA amount. (Yang, 2015  )

Representative of variations of AMY1 copy number, total and glycosylated sAA amount from three subjects. The AMY1 copy number (A) was estimated by qPCR. Total (B) and glycosylated (D) sAA amount of unstimulated (u) and stimulated (s) saliva were estimated by the method mentioned in Materials and Methods. A Western blot image (C) is served as representative.
Results from 3 people in the study, A shows the AMY1 copy numbers before and after the citric acid stimulation (no change). B shows the amount of amylase (sAA) before and after acid stimulation.

Tip-Before you eat your main meal or any starch – start your meal with some vinegar or acid it increases your salivary amylase: Swish mouth with lemon juice or vinegar or have a salad with an acid dressing on before you start your meal.

Exercise increases salivary amylase for up to 2.5 hours

Exercise increases serum amylase, a high intensity intermittent exercise bout caused a five-fold increase in alpha-amylase activity (P<0.01 compared with pre-exercise) and a three-fold increase in total protein concentration (P<0.01). These returned to pre-exercise values within 2.5 h post-exercise. (Walsh, 1999 ) A recent review indicates that exercise consistently increases mean salivary α-amylase activities and concentrations, particularly at an intensity of >70% VO2max in healthy young individuals (Koibuchi 2015).

Tip: the best time to eat starch is after you have done exercise at a high intensity, eat within 2 hours

Other tips to lower the Glycemic Index (GI) of a meal:

Protein, non starch vegetables and fat slow the digestion of carbohydrates, start your meal with the protein and eat the starch after that.

Eat your non starch vegetables before any starch

One study showed that blood glucose rises were lower if vegetables were eaten before starches, this effect was pronounced for people with type 2 diabetes, (T2D), and even more pronounced for people with normal glucose tolerance (NGT) (Imai,2013 )

Blood g;ucose levels, eating vegetables before or after the starch. T2D = tye 2 diabetes. NGT = normal glucose tolerance
Blood glucose levels, eating vegetables before or after the starch. T2D = type 2 diabetes. NGT = normal glucose tolerance

 

Even better- eat your protein and your non starch vegetables before your starch

In the table below both blood glucose and insulin are substantially reduced when protein and non starch vegetables are eaten before starch foods, compared with the other way round (Shukla, 2015)

 

The effect on blood glucose and insulin when protein and non starch vegetables are eaten prior to starch foods
The effect on blood glucose and insulin when protein and non starch vegetables are eaten prior to starch foods

Chew, chew, chew

And lastly, the more you chew your starchy food, the longer it will be in contact with amylase, so take your time when eating starches.

References

Falchi M., El-Sayed Moustafa J.S., Takousis P., Pesce F., Bonnefond A., Andersson-Assarsson J.C., Sudmant P.H., Dorajoo R., Al-Shafai M.N., Bottolo L., et al. (2014) Low copy number of the salivary amylase gene predisposes to obesity. Nat. Genet., 46, 492–497. [PubMed]
Imai S, Fukui M, Kajiyama S. Effect of eating vegetables before carbohydrates on glucose excursions in patients with type 2 diabetes. J Clin Biochem Nutr. 2014 Jan;54(1):7-11. doi: 10.3164/jcbn.13-67. Epub 2013 Dec 27. Review. PMID:24426184 Free PMC Article
Koibuchi E, Suzuki Y. Exercise upregulates salivary amylase in humans (Review). Exp Ther Med. 2014 Apr;7(4):773-777. Epub 2014 Jan 23. PMID:24669232 Free PMC Article
Mandel AL, Peyrot des Gachons C, Plank KL, Alarcon S, Breslin PA. Individual differences in AMY1 gene copy number, salivary α-amylase levels, and the perception of oral starch. PLoS one. 2010 Oct 13;5(10):e13352. doi: 10.1371/journal.pone.0013352.PMID:20967220 Free PMC Article
Mandel AL, Breslin PA. High endogenous salivary amylase activity is associated with improved glycemic homeostasis following starch ingestion in adults.J Nutr. 2012 May;142(5):853-8. doi: 10.3945/jn.111.156984. Epub 2012 Apr 4.PMID:22492122 Free PMC Article
Mejía-Benítez MA, Bonnefond A, Yengo L, Huyvaert M, Dechaume A, Peralta-Romero J, Klünder-Klünder M, García Mena J, El-Sayed Moustafa JS, Falchi M, Cruz M, Froguel P. Beneficial effect of a high number of copies of salivary amylase AMY1 gene on obesity risk in Mexican children. Diabetologia. 2015 Feb;58(2):290-4. doi: 10.1007/s00125-014-3441-3. Epub 2014 Nov 14.
Perry G.H., Dominy N.J., Claw K.G., Lee A.S., Fiegler H., Redon R., Werner J., Villanea F.A., Mountain J.L., Misra R., et al. (2007) Diet and the evolution of human amylase gene copy number variation. Nat. Genet., 39, 1256–1260. [PMC free article] [PubMed]
Usher CL, Handsaker RE, Esko T, Tuke MA, Weedon MN, Hastie AR, Cao H, Moon JE, Kashin S, Fuchsberger C, Metspalu A, Pato CN, Pato MT, McCarthy MI, Boehnke M, Altshuler DM, Frayling TM, Hirschhorn JN, McCarroll SA. Structural forms of the human amylase locus and their relationships to SNPs, haplotypes and obesity. Nat Genet 2015; 47: 921-925 [PMID: 26098870 DOI: 10.1038/ng.3340]
Viljakainen H, Andersson-Assarsson JC, Armenio M, Pekkinen M, Pettersson M, Valta H, Lipsanen-Nyman M, Mäkitie O, Lindstrand A. Low Copy Number of the AMY1 Locus Is Associated with Early-Onset Female Obesity in Finland. PLoS One 2015; 10: e0131883 [PMID: 26132294 DOI: 10.1371/journal.pone.0131883]
Walsh NP, Blannin AK, Clark AM, Cook L, Robson PJ, Gleeson M. The effects of high-intensity intermittent exercise on saliva IgA, total protein and alpha-amylase. J Sports Sci. 1999 Feb;17(2):129-34. PMID: 10069269
Yang ZM, Chen LH, Zhang M, Lin J, Zhang J, Chen WW, Yang XR. Age Differences of Salivary Alpha-Amylase Levels of Basal and Acute Responses to Citric Acid Stimulation Between Chinese Children and Adults.Front Physiol. 2015 Nov 18;6:340. doi: 10.3389/fphys.2015.00340. eCollection 2015.Free PMC Article

 

Eating habits in France, what we should copy

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Rates of obesity in France are a lot lower than in New Zealand or USA.

Source: OECD (2014), OECD Health Statistics 2014, forthcoming, www.oecd.org/health/healthdata.
Source: OECD (2014), OECD Health Statistics 2014, forthcoming, www.oecd.org/health/healthdata.

A week ago I was enjoying the balmy summer weather in Collioure, a gorgeous but somewhat touristy small town on the coast in the south of France. Whilst there I couldn’t help but notice the difference in the sizes of people compared to London and Glasgow where I’d been the previous week.

How do the French eat differently?

It was easy to spot many differences in the way the French eat compared to New Zealand and the UK.

People do not eat when they are walking around, they sit down and eat a meal

There is a noticeable absence of fast food places. There were simply no McDonald’s and KFC and other fast food outlets in Collioure. In Paris in the area we stayed there was just one small McDonald’s. There were however numerous cafes and restaurants and bars. And a scattering of Patisseries. People sat down and ate at tables, with their friends or family. They lingered over the meal. They ate slowly enjoying the food. I saw almost no-one buying food and then walking around and eating it. Eating food was an event not a ‘stuffing your face’ refuel that it has become in our society.

If people weren’t eating in a cafe they might be having a picnic or making an event of their meal like this group on the local beach.

A study by the vending machine industry noted:

“Ninety percent of the French population still strongly believe a meal should be consumed in a traditional setting, sitting down around a table, as often as possible. This traditional view contrasts with other countries, in Russia only 50% adheres to the belief of consuming a meal around a table and the American on-the-go-lifestyle was again confirmed by only 34% of the American citizens holding on to the traditional meal setting.”

People in France do not snack continuously, in fact they do not snack

The local beach was crammed with people. Not one of them was eating, most only had a bottle of water. In our society people seem to be constantly snacking in every situation. Where ever one goes children are being plied with snacks to keep them occupied, people are eating in buses, trains, in front of the TV, while driving. I simply did not see this in France. Snacking is not seen as necessary, 3 meals and an after school snack for children are still typical (Read this great article on how the French children eat).

Because no-one is eating when out and about, or snacking, I would have felt extremely self conscious if I had eaten other than sitting at a cafe. It reminded me that when I was a kid growing up in the 60’s and 70’s eating on the street was considered ill-mannered.

I never saw anyone eat on the beach, not even children
I never saw anyone eat on the beach, not even children
There were no drunk people or youths on the streets drinking

In London I saw so many drunk and drinking young people littering the town in the evening. Not once did I see a person in France walking around drinking from a can. They only sipped from a glass whilst at a bar or cafe. Many people were drinking at almost every meal, even breakfast, but no-one was drunk.

Processed food appeared to make up a much smaller part of the diet

Meals typically were made of some kind of protein with vegetables. Ultra-processed snacks and treat food did not appear to be a big part of the French diet. This could be related to the tendency not to snack. Snack foods tend to be of ultra-processed and the least healthy part of our diets in NZ.

The picture below is the closest we got to eating fast food in Paris, the chain EXKI, cabinets were filled with premade fresh food meals, huge salads, hot meals or soups. They cater for all needs; vegetarian, vegan, dairy and gluten free, all meals are labelled – so easy to find what you need. It was extremely popular.

IMG_1310
EXKI, fast food in Paris, cabinets full of fresh whole food catering for all needs. Gluten free was easy to find.

We did visit a Patisserie one day as I heard they had gluten free pastries. In comparison to a bakery in New Zealand, the portions were tiny. You can see this in reference to the hand next to the eclairs.

What can we learn from the French way of eating?

  1. Don’t snack. At all. Eat 3 balanced meals, and snack only if needed.
  2. Planned snacks are fine, children always have an after school snack, or small meal in France. Treat the snack with the same respect as you would a meal.
  3. Don’t eat anywhere other than at a table. Don’t eat walking around, at your desk, in front of the TV, or snack out of the fridge. Prepare, then eat a meal at a table, preferably with company and actually experience the process of savoring your food. Eat slowly.
  4. Choose food freshly prepared from whole ingredients like protein, fruit and vegetables.
  5. Model eating like this to your children, and don’t push them into our bad habits. Enjoy family meals together at the table without any screens or phones.
  6. Treat food is fine, savor a small portion if you wish.
  7. Water should be the main drink, wine in moderation can be enjoyed with meals if desired

This article outlines the French way of eating:The French eating habits the world should learn from

Why French takeaway food is almost non existent

 

What kind of diet might be most effective for rheumatoid arthritis?

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There are a number of reasons why the AIP protocol is effective for auto-immune disease including rheumatoid arthritis (RA). However it is important to point out that not all will respond to AIP, there are many factors that contribute to auto-immune disease apart from diet. AIP is not the only diet that works, in fact for some it may make their disease worse. This is due to consuming more of a food that the individual reacts to – for example mammal meats. An example of this is that many people with Hashimotos (auto-immune thyroid disease) have increased levels of an antibody against a carbohydrate Neu5Gc found in red meats (Eleftheriou, P et al, 2014).

 

With respect to RA; fasting, both water and fruit and vegetable juice fasts typically reduce symptoms and improve clinical markers in as few as 7 days, this leads us to conclude that food has an effect in RA (Skoldstam et al., 1979, Skoldstam, 1986, Kjeldsen-Kragh et al., 1991). A diet which removes foods that exacerbate the disease process and increasing foods that improve health would theoretically be effective.

When I looked at a large number of research studies about RA the following aspects appear to be of importance with respect to a diet that improves the symptoms and clinical markers of RA:

  • It reduces inflammatory markers – for example ESR and CRP. An anti-inflammatory diet is low in saturated fat and arachidonic acid, low in refined grains and sugar, high in fruit & vegetables, and high in seafood for omega 3 (Adam et al., 2003)
  • It reduce or eliminates exacerbating foods, which may act as possible antigens. An appropriately structured elimination, re-introduction protocol is critical to success(Kjeldsen-Kragh, 1999). Certain anti-body tests may show some food intolerances such as gliadin or ß-lactalbumin (Hafstrom et al., 2001).  I looked at over 20 elimination diet and case studies which when taken together show the most problematic foods are: wheat, corn, dairy, beef, pork, grains/ cereals, eggs, oranges/ citrus, coffee, sugar, tomatoes, peanuts, chicken. It is interesting to note that AIP does not remove foods which appear to be problematic for some people.
  • It improves gut microbiome by reducing bacterial flora linked with RA, which may be acting as antigens. A diet high in plant fibre and polyphenols with the addition of fermented foods may offer the best solution( T. Nenonen et al., 1998). Changing from acellular carbohydrates such as grain starch and sugars to cellular starches found in root vegetables is theorised to provide a better substrate for gut bacteria, as well as reduce inflammation (Spreadbury, 2012).
  • It improves gut epithelial integrity, reducing the intestinal permeability that allows antigens to cross the gut barrier in intact sequences of amino acids (Sundqvist et al., 1982).
  • A diet that improves gut microbiome, as well as removing foods which are shown to increase intestinal inflammation and permeability, for example gluten grains and dairy (for some). Cordain suggests all grains and legumes have certain lectins contributing to intestinal permeability ( Cordain, Toohey, Smith, & Hickey, 2000) and should be avoided.
  • It decreases red cell membrane ratio of arachidonic acid to omega 3 EPA ratio; this reduces inflammatory eicosanoid hormones and increases anti-inflammatory ones. This is achieved by reducing dietary sources of AA such as egg yolks and fatty meat, and increasing EPA by eating seafood or adding supplemental marine omega 3 (Adam et al., 2003).
  • A diet that reduces the support of the growth of urinary bacteria proteus mirabilis linked with RA, possibly a diet high in plant foods (Kjeldsen-Kragh, Rashid, et al., 1995).
Adam, O., Beringer, C., Kless, T., Lemmen, C., Adam, A., Wiseman, M., . . . Forth, W. (2003). Anti-inflammatory effects of a low arachidonic acid diet and fish oil in patients with rheumatoid arthritis. Rheumatology International, 23(1), 27-36. doi: 10.1007/s00296-002-0234-7
Cordain, L., Toohey, L., Smith, M. J., & Hickey, M. S. (2000). Modulation of immune function by dietary lectins in rheumatoid arthritis. British Journal of Nutrition, 83(3), 207-217.
Eleftheriou, P., Kynigopoulos, S., Giovou, A., Mazmanidi, A., Yovos, J., Skepastianos, P., … Efterpiou, M. (2014). Prevalence of Anti-Neu5Gc Antibodies in Patients with Hypothyroidism. BioMed Research International, 2014, 963230. http://doi.org/10.1155/2014/963230
Hafström, I., Ringertz, B., Spångberg, A., Von Zweigbergk, L., Brannemark, S., Nylander, I., . . . Klareskog, L. (2001). A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: The effects on arthritis correlate with a reduction in antibodies to food antigens. Rheumatology, 40(10), 1175-1179.
Kjeldsen-Kragh, J., Borchgrevink, C. F., Laerum, E., Haugen, M., Eek, M., Fo̸rre, O., . . . Hovi, K. (1991). Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis. The Lancet, 338(8772), 899-902. doi: http://dx.doi.org/10.1016/0140-6736(91)91770-U
Kjeldsen-Kragh, J., Kvaavik, E., Bottolfs, M., & Lingaas, E. (1995). Inhibition of growth of Proteus mirabilis and Escherichia coli in urine in response to fasting and vegetarian diet. Apmis, 103(11), 818-822.
Kjeldsen-Kragh, J. (1999). Rheumatoid arthritis treated with vegetarian diets. American Journal of Clinical Nutrition, 70(3), 594S-600S.
Nenonen, M. T., Helve, T. A., Rauma, A. L., & Hanninen, O. O. (1998). Uncooked, lactobacilli-rich, vegan food and rheumatoid arthritis. British Journal of Rheumatology, 37(3), 274-281.
Skoldstam, L. (1986). Fasting and Vegan Diet in Rheumatoid-Arthritis. Scandinavian Journal of Rheumatology, 15(2), 219-221.
Skoldstam, L., Hagfors, L., & Johansson, G. (2003). An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis. Annals of the Rheumatic Diseases, 62(3), 208-214. doi: 10.1136/ard.62.3.208
Skoldstam, L., Larsson, L., & Lindstrom, F. D. (1979). Effects of Fasting and Lacto-Vegetarian Diet on Rheumatoid-Arthritis. Scandinavian Journal of Rheumatology, 8(4), 249-255.
Spreadbury, I. (2012). Comparison with ancestral diets suggests dense acellular carbohydrates promote an inflammatory microbiota, and may be the primary dietary cause of leptin resistance and obesity. Diabetes Metab Syndr Obes., 5, 175-189.
Sundqvist, T., Lindstrom, F., Magnusson, K. E., Skoldstam, L., Stjernstrom, I., & Tagesson, C. (1982). Influence of Fasting on Intestinal Permeability and Disease-Activity in Patients with Rheumatoid-Arthritis. Scandinavian Journal of Rheumatology, 11(1), 33-38.

Rheumatoid arthritis and diet – what worked for 10 people

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Foods that cause reactions for 10 people with Rheumatoid Arthritis (RA)

(Please read my earlier post also – case studies where eliminating certain foods put RA into remission)

For information on how to follow an auto-immune protocol:

Last year I carried out a qualitative research project as part of my Post Grad Diploma in Human Nutrition. I interviewed 10 people who had experienced a significant reduction in their RA symptoms and improvements in clinical markers as a result of changing their diet to a paleo or auto-immune paleo protocol.

The aims of the study:

  1. To find out what motivated people to change their diet in the first place.
  2. To discover which challenges they encountered changing and maintaining the diet.
  3. To learn how they managed those challenges.
  4. To find out which foods they consumed and which presented symptoms on reintroduction.

To qualify for the study:

  • Participants had positive RA clinical markers
  • The minimum duration of their RA was 6 months
  • Participants credited the paleo diet to reducing their symptoms and clinical markers
  • They had been on a paleo diet for a minimum of 6 months.

Important Note: this group is self selected, which was the intention of this study. The fact that a paleo diet worked for these people does not mean it will work for everyone with RA, much further research needs to be done. For example there need to be interviews with people for whom AIP did not work, and interviews with people for whom other diets worked for example plant based or vegan diets. An intervention study with a control group is needed to clarify the extent to which an AIP diet works.

Please do not take this research as proof that AIP is the diet everyone with RA should be doing, or that it is going to cure you. I present this as what it is – it worked for these 10 people and this is their experience. Note also – it reduced symptoms and markers of disease, it is not a cure for RA. If the diet is not followed symptoms return. If you do wish to try it, use the resources listed above, and carefully monitor your clinical markers. If you have success and wish to reduce your medication, do so only while working with your medical specialist.

Participants

The 10 people interviewed (9 female, 1 male) were from NZ (2), USA (7) and Australia (1) aged from 28 to 60 years, mean 41.7, the time on this diet ranged from 6 months to 5 years, mean 2.9 years.

As part of the interview I asked each person specifically what they ate and what they cut out on their version of the paleo diet. I asked when and how they re-introduced foods, and what they experienced as a result; how long it took for the flare to come on, how intense it was and how long it took to go away again.

In this post I will give an overview of the diet each person ate that afforded their success, what foods were particularly problematic on re-introduction, and what foods each person found were safe.

Starting the paleo or auto-immune paleo (AIP) diet

Most people in this group spent time learning about the diet, collecting recipes, and buying and preparing food in advance. They picked a start date where there were no celebratory holidays, vacations or other distractions. Kitchens were prepared – food not on the diet was removed, and AIP compliant food stocked. Some in the group made food in bulk, others found a number of recipes and planned meals ahead.

Once prepared 8 out of 10 changed their diet completely overnight to an AIP or strict paleo diet such as Whole 30.

Adherence to the paleo diet

Adherence to the diet that worked for them was described as 85% by one person and 95 – 100% by the other 9. The primary motivation to stay on the diet was stated as lack of pain, being able to reduce or eliminate medication and greatly increased quality of life. When asked about the changes in pain levels before paleo and as a result of diet changes – most (7) described their pain as being 10 out of 10, with debilitating fatigue. As a result of diet changes all described their pain levels as 0 to 1 out of 10.

Be prepared to follow AIP for at least 3 months strictly

While many of the participants experienced improvements in the first few weeks, others did not get relief from symptoms until around the 3 month mark.

Be prepared to follow AIP strictly for 3 months in order to see results. This means being physically prepared, having food for all meals for a few days ahead. Be psychologically prepared, know that for 3 months minimum you won’t stray from a strict diet.

Challenging situations to follow AIP

Traveling, eating out, at both restaurants and friends & family’s places presented the greatest challenges to staying on AIP. Be aware that these will present a problem, for these participants friends and family often did not understand the need for the strict diet, and restaurants inadvertently put non-compliant ingredients in the meals. I’ll write more about these challenges and tips to deal with them in another post.

Problem foods are discovered by re-introduction challenge

After being on the diet for at least 3 months, some but not all the participants did careful re-introductions of food to gauge what effect it would have.

Re-introduction protocol

Each person used a slightly different protocol, however foods that were least likely to cause a problem were re-introduced first. For example egg yolks or seeds. Typically a small amount of the food was eaten and then they wait for 2 – 3 days, this is important as some people have a delayed reaction. If there is no reaction they ate a lot of the food over 1-2 days and again waited 3 days to see if there is a reaction. If no reaction at all they continued to eat that food. (Re-introduction protocol for AIP)

Reactions to foods varied between people

Some foods elicited a strong inflammatory reaction or flare, where joints would become swollen and painful in the hours after the food was eaten, whereas other foods caused a small flare and only if eaten in larger amounts.

Some foods caused a painful flare if eaten in a tiny amount.

In the chart below these are listed as “problem food in any amount”. Note that foods deemed safe in a normal paleo diet cause painful flares for some people in this group – for example eggs and nightshade group of vegetables (potatoes, tomatoes, eggplant and peppers).

Some foods were recognized as a problem through accidental re-introduction, for example one woman changed a brand of supplement and had a painful flare as a result of wheat / gluten in the food.

Participants had different reaction times.

The most common reaction time frame to eating a trigger food was 12 – 24 hours, so typically it was noticed on rising the next day – increased stiffness and pain. One had a flare within 20 minutes, others 3 – 6 hours, while a few had a flare 36 or even 48 hours later.

Normal elimination diets DO contain foods that people with RA react strongly to

It is useful to note also that foods considered safe on other elimination diets were very problematic for some in this group, of note dairy (kefir is included in GAPS diet), corn (included in many gluten free diets) and rice (considered a safe grain in many elimination diets).

A food that causes a strong flare in one person can have no effect in another

Some participants had no problems with rice, nightshades or eggs, whilst for others these caused an acute RA flare.

Some foods are a weak trigger

Certain foods only trigger a minor flare, and need to be eaten regularly or in larger amounts before a flare is noticed. These foods are listed in the last column. Eggs for some, and nuts for many fell into this group.

Some foods remain untested

You will note that the first column contains foods that are untested, i.e. they have not been re-introduced.  Once a person is well, they are reluctant to re-introduce foods they suspect cause most problems, gluten grains in particular were the least likely to be introduced. Those who discovered gluten grains caused a flare only found this our through accidental re-introduction.

Foods most likely to be re-introduced

A person is more likely to re-introduce a food they would like to eat, and a food which they think is less likely to cause a flare, for example chocolate (cocoa), nuts and seeds (including seed spices) fall into this category.

The chart below shows the individual reactions to foods with respect to RA

Participant numberDiet that gave remission
Food NOT re-introduced, effect not knownFoods removed and re-introduced – no problem in any amount

Only introduced in small amount (sm)

Problem food in any amountTime to flare

 

Reaction to food if too much or too frequent intake
01AIPSoy, legumes, nightshades, seed oilsEggs, all dairy, rice, all spices, quinoa, spirits, peanuts (sm) gluten free beer (sm)Gluten grains,6 hrsTree nuts, carbs over 100g/day, corn, sweet potato, gluten free baking
02Paleo

Other Elimination

[Feels very well no pain on strict paleo, not keen to introduce any food]Cocoa, coffee, nightshades, rice, wine (sm), nuts, eggsAll dairyNext morning within 24hrsSugar
03AIPSoy, peanuts, legumes, pseudo-grains except quinoa, gluten and non-gluten grains, dairy except gheeSeeds, coffee, cocoa, night-shades (sm), ghee, seed spices, macadamia oil,Eggs, beer,Next morningWine, tree nuts
04Paleo plus rice, no nightshadesDairy, grains except rice, nightshadesLegumes, eggs, nuts, peanuts, quinoa, rice, spirits (sm)Wine36 hrs.
05AIPPseudo-grains, seedsCocoa, coffee, seed oils, seed spices, all nightshades, tree nuts wine, real farm eggs, spirits & GF beer (sm)Soy, peanuts, Gluten

grains, Rice

12 – 24 hrs

Corn 2-3 days

Corn, dairy
06AIP no cranberries or yeastCranberries, yeast, nightshades, nuts, peanuts, all grains, legumes, soy, pseudo-grains, rice, beer, dairy except gheeSeeds, spirits, seed spices, sunflower oil, cocoa, ghee & eggs tried – not clear.Shrimp, corn, sweet potato, fermented foodsNext morningApples, dried fruit,
07AIPFood with additives, pseudo-grains except chia, corn, grains except rice, alcohol except wine, legumes except sprouted lentils, peanuts, soyNut oils, seed spices, citrus fruit, wine (sm), eggs, riceAll dairy, all nightshades, sweet potato,36 hrsTree nuts, seeds, plantains,
08PaleoAll grains, all legumes, all dairy

[Is well and pain free on strict paleo]

Vodka (sm)Not knownN/ANot known
09AIPAll legumes, some nightshades, all grains, pseudo-grains except rice, seed oilsghee, Nuts (sm), wine (sm) brandy (sm), seed spices, coffee(sm) cocoa (sm)Grains, wheat, gluten grains worst3-4 hrs.Eggs, dairy, rice, nightshades – chilli, tomato, potato
10AIPPseudo-grainsCoffee, nut oils, butter, seed spices, potatoes, non-grain spirits, fresh seeds, cold pressed fresh seed oils, egg yolksDairy, legumes, gluten grains, non-gluten grains, corn, gluten free bakery, heated or rancid seed oilsCorn 20min

Legumes 24-48hrs, Oils 1hr,  All others 12-24 hrs

Tree nuts, egg whites, white rice, tomatoes

UK doctor saves government £45K by using low carb diet to treat type 2 diabetes

2

Dr David Unwin, a general practitioner (GP) in England has recently been named ‘Innovator of the Year’ at the national NHS Leadership Recognition Awards 2016.

Photo_Low_carb_GP_with_award

Dr Unwin, who practices at the Norwood Surgery in Southport, spent three years working on a project combining the benefits of a low carb diet with psychological support to help patients with diabetes. As well as having much healthier patients, the practice now saves around £45,000 a year on diabetes drugs.

Imagine the impact on health systems if every GP instituted the same approach to our type 2 diabetics. Not only saving huge amounts of money, but also seriously impacting people’s health.

I wrote previously about Dr Unwin and the specific diet he prescribes for his patients here:

A UK doctor puts 18 patients with type 2 diabetes on a low carb diet with amazing results

Since I last wrote about Dr Unwin in 2014 he has had a further case study published in the British Medical Journal, about a patient who wanted to reduce his medication for type 2 diabetes, heart disease and high blood pressure:

A patient request for some “de-prescribing”

A 52 year old man with a history of type 2 diabetes for 14 years and hypertension for nine years presented to his general practitioner. He was a non-smoker with an alcohol intake of eight units a week. He had been experiencing bloating, abdominal pains, and erratic motions for more than a year. Because he drove about 12 000 miles a year for his job he found the loose motions “a real worry.” He wondered whether any of his problems might be caused by his drugs and asked if he could cut down on any if they weren’t all needed. He admitted to being afraid that his diabetic control might deteriorate and that he might need insulin, like some of his relatives who also had diabetes.

He was taking aspirin 75 mg once daily, metformin 500 mg three times daily, perindopril 4 mg daily, and simvastatin 40 mg at night.

On examination his weight was 108.8 kg (steady at this for 10 years), body mass index was 34.4, waist circumference was 113 cm, and his blood pressure was 130/80 mm Hg (steady at this level for some years). His abdominal examination was normal, except that he had central obesity.

Glycated haemoglobin (HbA1c) was 52 mmol/mol (reference range 0-41), bilirubin was 7 µmol/L (0-20), alanine aminotransferase (ALT) was 53 U/L (5-37), and γ-glutamyl transferase (GGT) was 59 U/L (0-50). In addition, his estimated glomerular filtration rate was 100 mL/min/1.73m2 (90-120), total cholesterol was 3.7 mmol/L (desirable ≤4.0), high density lipoprotein-cholesterol was 1.3 mmol/L (>1.0), and triglycerides were 1.3 mmol/L (<1.7).

ALT and GGT were both raised, this is a sign of a fatty liver; those with type 2 diabetes have increased amounts of fat in their liver cells, called non-alcoholic fatty liver disease (NAFLD).

The case study goes on to discuss what condition this patient has, what is most likely causing his abdominal discomfort, and why his GGT is high.

The next section is the most pertinent:

How could his request to cut down on drugs be handled?

Dr Unwin compiled this table that compared the use of diet and exercise pharmaceutical drugs and their side effects. He used data from this website to calculate risk of drugs vs non drug treatment. The Absolute CVD Risk/Benefit Calculator

unwin case study table

“Using this adapted QRISK2-2014 calculator, a person like our patient with type 2 diabetes of age 52 years, weight 108.8 kg, height 178 cm, systolic blood pressure 155 mm Hg, total cholesterol 5.0 mmol/L, high density lipoprotein 1.0 mmol/L, no family history of note or history of smoking, chronic kidney disease, atrial fibrillation, or rheumatoid arthritis would have an untreated 10 year risk of heart attacks or strokes of about 15% at baseline.

As shown in the table, physical activity is as effective as low to moderate intensity statins at reducing our patient’s risk of cardiovascular disease and outperforms aspirin. The Mediterranean diet is nearly as effective as metformin. In addition, the major lifestyle interventions mentioned (physical activity and Mediterranean diet) have a low risk of harm compared with the drugs listed and reduce the risk of comorbidities such as osteoarthritis, some cancers, and gallstones.”

The patient was put on a low carbohydrate diet – this is described in detail in my previous post

How did the patient respond?

Here is a table I put together with his results after 8 months

unwin case study correct

The patient steadily lost a total of 16 kg over seven months and successfully stopped all four prescribed drugs, thereby achieving his goal of being medication-free. This was accomplished using a low carbohydrate diet—in his words: “more a lifestyle than a diet.” The weight loss enabled him to take more exercise, join a gym, and take up yoga. He has come off sugar altogether and cut out bread (he previously consumed a lot of this), potatoes, pasta, cereals, and rice. This has led to greater consumption of green vegetables, but also eggs, full fat Greek yoghurt, and cheese.

The weight loss has been maintained for a year, so he weighs less now than at any time in his adult life. The goal of coming off all drugs was achieved in a stepwise manner as he lost weight—first metformin, then perindopril, followed by simvastatin and aspirin.

His weight loss has been matched by improvements in other parameters: HbA1c down from 52 mmol/mol to 43 mmol/mol (6.9% to 6.2%), blood pressure from 130/80 mm Hg to 117/70 mm Hg, GGT from 59 U/L to 19 U/L, and alanine aminotransferase from 53 U/L to 20 U/L. Of particular note is that—despite eating more eggs and lots of full fat Greek yoghurt, and stopping statins—his cholesterol:high density lipoprotein ratio has improved slightly from 2.8 to 2.7, and serum triglycerides have improved from 1.3 mmol/L to 1.1 mmol/L.

His bowel problems and abdominal pains ceased within days of stopping metformin, his energy returned, and he now needs an hour and a half less sleep a day.

In general he reports feeling “just much younger again.”

I’m looking forward to the day when low carbohydrate whole food diets are standard for treating type 2 diabetes.

I suggest you also read the comments section – numerous people reporting on their own success for both type 1 and type 2 diabetes plus a host of other health issues.

Menopause update: diet, exercise and supplements

23

This is a follow up from my previous post: “Menopause sucks, even on a paleo diet”

It’s just over a year on. I’ve been playing with diet and exercise and menopause supplements. Trying to get back that feeling of pre-menopausal normality and trying to ward what aging is doing to my body.

Here’s what I found works

  1. Move every day – walking, weights, and high intensity short bursts.

I go to the gym 3 – 4 times a week, I lift heavy stuff, barbells, kettlebells. You MUST and if you can imagine me raising my voice  – MUST lift heavy. You need to put a truckload of weight through your muscles and bones to keep them strong and looking good. The average person loses 250grams of muscle every year after the age of 30, about 2 kg every decade. It’s just not loss of mass – sarcopenia– which makes you look spindly and flabby but dynapenia, loss of muscle strength that you need to worry about. Loss of strength is associated with faster decline and death and being far less functional as you age. Loss of strength and muscle mass are associated with mortality from all causes.

Here is a picture from this earlier post showing what happens to your figure post menopause when you lift heavy:

155 lbs before and after

And here is an excellent talk by Jamie Scott at the Ancestral Health Symposium

jamie scott talk muscle

 

 

 

 

 

 

 

I don’t spend hours at the gym – you really don’t need to to maintain strength. I do around 4 x 1/2 hour sessions per week. I focus on big movements. Dead-lifts, barbell squats, one leg squats etc. Pull-ups (with as little assistance as I can to make them hard), push-ups, bench and shoulder press. Mostly I do 6 – 10 reps x 3 – 5 sets, just managing the last few reps. (Find what works for you – this is what I like)

High intensity – for me is it either something like jumping squats, some short bursts on the rower at the gym, kettle bell swings, or sprints in the park. I walk then run for about 30 seconds and keep doing that for about 1/2 hour.

Walks – I walk every day I’m not at the gym, around 1/2 hour, I enjoy getting a nature fix – so I go to the beach or walk in the park next to my home. (Western Springs Park in Auckland)

western springs park

Incidental activity. I’ve got a desk that I can adjust to standing or sitting. I do ‘snacktivity’ getting up for a short walk every half an hour, using the stairs at work instead of the lift etc. It adds up – 2 flights of stairs which take a minute to walk up – doing that 4 times a day is 8 flights. I don’t even notice it as exercise.

2. Diet

I’ve tried a bunch of different things to get my weight – as in tummy fat down. I’m partially successful. The most successful diet regime I’ve found for me is Metabolic Effects menopause diet.

My diet is still protein and every meal, loads of vegetables and at least 1 huge salad a day, some fruit, some root vegetable starch, 1/2 – 1 glass of wine (some days), for fats I only add monounsaturated fats – whole nuts, olives, olive oil and avocado. Saturated fats only if they are on the meat I eat. (I don’t fare well on saturated fats like coconut oil and cream – they contribute to my high LDL). What doesn’t work? Sugar, refined grains, (even gluten free) eating too much, high fat meals, more than 1 glass of wine.

Here are links to a couple of useful articles by Metabolic Effects:

Postmenopausal? Perimenopause? Menopause? 4 Tricks For Weight Loss

What Causes Menopause Weight Gain?

So – have I lot weight you are wondering? Yes a little. Dresses that were tight a year ago and comfortable now. I can’t wear my pre-menopause skinny clothes though.

3. Supplements

General supplements:

I try to get a high nutrient diet, a big range of veggies, raw nuts and seeds, organ meats, animal foods, seafood. I find despite this I feel better adding in some B vitamins every so often, (in a iron free multivitamin) high purity omega 3 (I use OmegaRx) most days. I take vitamin C with bioflavanoids, tocotrienol rich vitamin E,  extra selenium (for my hashimotos), curcumin, vitamin K2, and vitamin D in the winter. Magnesium at night.

Specific menopause supplements:

At my worst, when my memory was bad, my strength decreasing, libido non-existent, I recognised that low testosterone was affecting me. The holistic doctor I see found that my levels were undetectable and I used testosterone cream for a while. That helped so much – I felt normal again in 3 weeks. It appears that this testosterone drop was temporary. I don’t really need need it any more. This graph is interesting – it shows DHEA levels dip and then increase again – DHEA converts to testosterone (reference The relationship of circulating dehydroepiandrosterone, testosterone, and estradiol to stages of the menopausal transition and ethnicity.) 

 

Hot flushes were an annoyance. My symptoms are from low oestrogen. The best menopause supplement for me is this one. Magic! Almost no hot flushes, sleep like a baby, no more night sweats. menopause supplement

 

 

 

 

 

 

4. Stress

I’m not one to stress out in general, I’m certainly no type A personality. If I can’t fit things into my life – I let it be. My teenage son causes stress and that is hard. Being supported helps. I tend to pace myself – it took me 4 years to finish my post grad diploma. Staying up all night to finish assignments is not something I do now (I regularly did when I was young). Just having a stressful thought can bring on a hot flush. So avoiding or managing stress is a big contributor to reducing menopause symptoms to a minimum.

Well that’s it so far. As always I love to get your feedback and what works for you.

Ancestral Health Conference- talks now on YouTube

2

The New Zealand Ancestral Health Society held it’s first international conference in Queenstown in October 2015. It was a resounding success, both participants and speakers were full of praise for the quality of talks and how well organised it was. It was held in a venue with a spectacular view of the lake.

The speakers came to New Zealand from all over the world, many were leaders in their fields, such as Felice Jacka who researches the impact of food on our brains, and David Raubenheimer who is leading the way in his research of the protein leverage hypothesis.

The talks are now on YouTube.

Go take a look and listen.

I’ve listed them here with a link to each video to make it easy for you.

 

Case studies – diet changes reverse rheumatoid arthritis

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Hands

Case studies – diet changes reverse rheumatoid arthritis

This is the first of a series of posts where I will be posting results from my research project. In this post I look at documented case studies where diet changes have eliminated or reduced symptoms of RA. I’ve given a summary of the studies as well as a chart with the findings. You will note that there is a range of foods that cause exacerbation of symptoms.

Important: RA is a complex disease, these documented case studies show successes, where RA is managed and symptoms reduced or even reversed in RA. This does not  mean that RA can be cured. It does not mean that all people with RA will necessarily respond to diet. Overall the range of improvements to RA in diet studies was between 5 and 70% of participants. We also know that fasting ameliorates disease for almost all with RA. So diet matters, but finding trigger foods can be a time consuming process, and food triggers vary between participants.

Rheumatoid arthritis (RA) is the second most common form of arthritis in New Zealand estimated to affect 0.74% – 3.2% of the population or approximately 40,000 New Zealanders. It affects 3 times more women than men (Pezzullo, 2010). RA is a chronic complex systemic auto-immune disease characterised by severe inflammation of the synovial lining of the joints. This chronic inflammation causes pain, swelling, inflammation and stiffness of the joints, eventual destruction of cartilage and bone causing loss of function and joint deformity. RA severely affects mobility and quality of life. Rheumatoid arthritis also has many non-joint manifestations including inflammatory conditions in the lungs, eyes, skin, heart, brain and nerves (Scott, Wolfe, & Huizinga). RA is also associated with an increased risk of cardiovascular disease (Myasoedova & Gabriel, 2010), type 2 diabetes (Su, Chen, Young, & Lian, 2013) and osteoporosis.

Typical joint deformity seen in long term rheumatoid arthritis, this deformity is not common now with modern drug therapy

 

The Arthritis New Zealand website carries a brochure about nutrition and arthritis. Inside it states “Gout is the only type of arthritis that can be improved by changing your diet and lifestyle”. For those with RA “Do I need to avoid specific foods?” The answer is that although “Some people feel that cutting out acidic fruit such as oranges and grapefruit, and vegetables from the nightshade family, there is no scientific evidence that leaving out either of these foods does help and such diets may have he undesired effect of reducing beneficial nutrients” (NZ Arthritis, 2014)

Despite this information, many people with RA believe that diet can make an impact. In my research project I found around 45 case studies, intervention, and elimination diet studies specifically showing the impact of diet on RA.

Here is an overview of case studies of the effect of diet on RA

Twelve case studies from 1948 through to 2012 are presented. In most of these studies, problem foods were tested by eliminating and then re-introducing the to see what effect they had on symptoms.

Zeller (Zeller, 1948) presents 4 case studies. To identify potential food triggers for RA he took an extensive history of allergies, noting that “foods that were productive of other allergic symptoms often also cause arthritic symptoms.” He also notes that skin tests, both scratch and intradermal did not have value for finding trigger foods for RA, however positive tests were linked to other problems; allergic reactions like hay fever or rhinitis. Potential problem foods were identified, then excluded from the diet and tested with a challenge. He found the most effective diagnostic measure was food ingestion followed by white blood cell responses. Leukocyte counts dropped significantly over 40 minutes after problem food ingestion. Each person reacted to a specific food or foods, and once these were removed from their diets, symptoms resolved and measurements related to disease severity reduced, for example erythrocyte sedimentation rate (ESR). Zeller also noted that deformity and ankyloses reversed in two people over time. Foods identified in these four included milk (2), beef (2), eggs, pork(2), tomatoes, white potatoes, fish (2), banana, whiskey, beer, green beans, lettuce and nuts. Another observation of interest is the time to an inflammatory joint response after food ingestion. From the time food is ingested joint pain and swelling was noted as being 1 hour in case 1, 4-6 hours with maximum intensity at 16 hours in case 2, in case 3 response to milk was 45 minutes and other foods 3 hours, persisting for 24 – 36 hours. In case 4 pain, swelling and fatigue took 4 -5 hours persisting 36 hours.

Three case studies showed patients reacted strongly to a single food or food group and when the food was completely removed RA went into remission. The foods were dairy products; milk and cheese (Parke & Hughes, 1981), corn or maize starch (Williams, 1981), and cereals (Lunardi et al., 1988). Another case study identified milk as a trigger and this was confirmed with blinded testing (Panush, Stroud, & Webster, 1986). The patient went into complete remission whilst fasting or on Vivonex, an elemental liquid diet replacement. After milk ingestion it is notable that like the Zeller case studies, post ingestion symptoms began at 6 – 12 hours, peaking at 24 to 48 hours. Whilst this response time to a trigger is similar in these case studies, another case study of a 15 year old female with juvenile RA where dairy foods was confirmed as the trigger, response time was far slower, after eating dairy products daily in 4 separate challenges, she developed arthralgia, fatigue and arthritis in 10 to 23 days. Once dairy was removed symptoms resolved in 10 days to 3 weeks (Ratner, Eshel, & Vigder, 1985).

O’Banion used another method to find trigger foods in 3 case studies (O’Banion, 1982). Patients kept a food and drink diary, took their pulse hourly and recorded the severity of their arthritis pain and sleep quality. Two patients had elevated pulse rates after a number of foods. In the next phase the patients ate a diet which tested vegetables, meats and fruits one food per meal, 3 foods tested per day. Changes in pulse rate and joint responses were noted, this continued until a diet of non- reactive foods was found and patient was pain free. Food challenges continued and the most triggering foods were identified. All 3 reacted to dairy, wheat, cane sugar, corn and beef, and individually to a number of other foods.

The most recent case study (Denton, 2012) and the only one found after 1988, used a more modern elimination diet which removes common inflammatory foods. After a few days the patient’s pain reduced on this diet and food challenges began. Corn and nightshade vegetables were identified as trigger foods, once removed the patient went into remission and came off all medication.

 

Scroll down to the bottom of the page to see the chart of results for more information – I have placed it so it can be viewed without distraction of adverts at right

(If you find this useful, you might consider a donation – at right – that would be really appreciated- Julianne)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Denton, C. (2012). The elimination/challenge diet. Minnesota medicine, 95(12), 43-44.
Lunardi, C., Bambara, L. M., Biasi, D., Venturini, G., Nicolis, F., Pachor, M. L., & Desandre, G. (1988). Food Allergy and Rheumatoid-Arthritis. Clinical and Experimental Rheumatology, 6(4), 423-424.
Myasoedova, E., & Gabriel, S. E. (2010). Cardiovascular disease in rheumatoid arthritis: a step forward. Current Opinion in Rheumatology, 22(3), 342-347. doi: 10.1097/BOR.0b013e3283379b91
NZArthritis. (2014). Rheumatoid Arthritis. In A. N. Zealand (Ed.).
O’Banion, D. R. (1982). Dietary control of rheumatoid arthritis pain: Three case studies. Journal of Holistic Medicine, 4(1), 49-57.
Panush, R. S., Stroud, R. M., & Webster, E. M. (1986). Food-Induced (Allergic) Arthritis – Inflammatory Arthritis Exacerbated by Milk. Arthritis and Rheumatism, 29(2), 220-226. doi: 10.1002/art.1780290210
Parke, A. L., & Hughes, G. R. V. (1981). For Debate … Rheumatoid-Arthritis and Food – A Case-Study. British Medical Journal, 282(6281), 2027-2029.
Pezzullo, L. (2010). The economic cost of arthritis in New Zealand in 2010. [Report]. Access Economics Pty for Arthritis New Zealand.
Ratner, D., Eshel, E., & Vigder, K. (1985). Juvenile rheumatoid arthritis and milk allergy. Journal of the Royal Society of Medicine, 78(5), 410-413.
Scott, D. L., Wolfe, F., & Huizinga, T. W. J. Rheumatoid arthritis. The Lancet, 376(9746), 1094-1108. doi: 10.1016/s0140-6736(10)60826-4
Su, C.-C., Chen, I.-C., Young, F.-N., & Lian, I.-B. (2013). Risk of Diabetes in Patients with Rheumatoid Arthritis: A 12-year Retrospective Cohort Study. Journal of Rheumatology, 40(9), 1513-1518. doi: 10.3899/jrheum.121259
Williams, R. (1981). Rheumatoid-Arthritis and Food – A Case-Study. British Medical Journal, 283(6290), 563-563.
Zeller, M. (1948). Rheumatoid arthritis. Food allergy as a factor. Ann Allergy, 7((2)), 200-1949.

 

 

 

 

 

 

 

 

 

Study
Age F/M
Disease duration
Diagnostic tests if known/ symptoms
Medication
 
 
How foods that cause symptoms were diagnosed
Dietary treatment that reduced RA symptoms
Outcome of diet changes
Longer term
Food implicated as triggering RA
(Zeller, 1948) Case study 1
Female, 39
9 years
RA Joint symptoms
Fatigue
Diarrhoea
constipation
Nausea
Nasal congestion
sneezing
Coal tar products partial relief
Elimination and food challenges
Symptoms exacerbated after ingestion of foods. Milk caused diarrhoea, nausea, headache & fall in leukocyte count 7400 to 5400 cells. Onset of joint pain, swelling from 1 hour.
Chocolate and banana – headache.
Beef, banana, fish, nuts on challenge produced fatigue, joint pain and swelling. Exclusion of foods gave relief of symptoms
Exclusion of foods: milk, beef, banana, fish, nuts
Exclusion of foods produced relief of joint symptoms.
Ingestion produces reactions

 

Remains symptom free except for some finger swelling
ESR reduced from 20mm to 8mm/hour
Milk, beef, banana, fish, nuts
(Zeller, 1948) case study 2
Male, 67 25 years
RA Joint pain and swelling in hands, knees and ankles
fever
fatigue
“every therapeutic measure exhausted”
Patient observed whiskey and beer caused swelling and pain in joints.
Ingestion tests showed wheat, eggs, fish, tomatoes, pork produced joint pain and swelling and fatigue 4 – 6 hours post eating. Maximum intensity 16 hours before subsiding
Exclusion of Wheat, eggs, fish, tomatoes, pork, whiskey , beer
On exclusion of foods, symptoms decreased 80% in 3 months
Ingestion tests at 3 and 6 months again produced symptoms
2 years later some deformity and ankyloses reversed. ESR May 1946: 80mm/hr, March 1948 38mm/hr
Wheat, eggs, fish, tomatoes, pork, whiskey, beer
(Zeller, 1948)case study 3
Female 41
6 years
RA Joint symptoms, pain and swelling
Low grade fever
Abdominal distension, wind,
Cramps diarrhoea daily
Sore throat
Therapy ineffective
Salicylates, bee venom
Ingestion tests (food challenges) with most frequently eaten foods
Pork – nasal congestion, abdominal bloating 40 mins
Milk – coughing, fatigue, painful joints in 45 mins, sore throat, fever 3 hours. Diarrhoea during night.
Lettuce, white potatoes, string beans, sore throat, joint pain and swelling 3 hrs, persisting 24 – 36 hours
Exclusion of these foods resulted in remarkable improvement
Deliberate ingestion causes symptoms
Exclusion of Lettuce, white potatoes, string beans, milk, pork
Food exclusion “Remarkable improvement”
Deliberate ingestion causes symptoms
Not stated
Lettuce, white potatoes, string beans, milk, pork
(Zeller, 1948)Case study 4
Female, white, 42
20 years
RA Joint symptoms
Nasal congestion
Pruritus ani
headaches
Not stated
Ingestion tests
Exclusion diet and re-introduction
Ingestion tests: Milk: sneezing, headaches, in 20 minutes lasting 24 hours. Leukocyte count 5900 to 3900 cells in 40 mins.
Wheat: sneezing in 15min, eggs- nausea in 5 mins (also leukocyte count drops 5400 to 4400 in 40min)
Placed on exclusion diet with no reactive foods. Challenge with one food at a time, 2 days apart
Beef- join pain & swelling, fatigue 4-5hrs, persisting for 36 hrs.
Eggs, pepper, garlic – vaginal itching and eruption in 2 hours
Pork, rectal itching
Wheat, nasal symptoms
Milk, nasal congestion
Problem foods excluded.
Beef   for RA, egg, pepper, garlic, pork, wheat, milk for other health concerns
Not stated but assumed that no symptoms on exclusion diet
Deformity of hands disappeared,
Wheat was eliminated for 3 months now tolerated once day
Beef only caused arthritis
Eggs, pepper, garlic -vaginal itching and eruption in 2 hours
Pork, rectal itching
Wheat, nasal symptoms
Milk, nasal congestion
(Parke & Hughes, 1981)
38, Female
25 years
Erosive seronegative RA.
ESR 110mm/h
Fatigue
Dry eyes & mouth
Salicylates NSAIDS, (not effective) prednisolone 10mg/d failed to relieve intense synovitis and stiffness
Elimination and food challenge with milk and cheese
Inadvertent consumption of dairy, symptoms returned in 12 hours
Monitored food challenge- in 24hours pronounced deterioration of arthritis, pronounced increase in synovitis, increase in Ritchie index, morning stiffness, 5mm increase in ring size, positive RAST to dairy IgE antibodies, heat-damaged red cell clearance rates
Elimination of milk, cheese, and butter
In 3 weeks – decreased synovitis and morning stiffness. Improved Richie index, VPAS,
ESR
Prolonged improvement in previously unresponsive RA
Morning stiffness completely disappeared
Synovitis completely resolved
“Well fully mobile, minimal residual disease activity.”
Off prednisone
Milk and cheese

 

(Williams, 1981)
Female, age not known
25years
“Active RA” pulmonary involvement
Aspirin, azathioprine
Removal of maize starch- dramatic improvement in 1 week
Accidental ingestion of corn-starch thickened gravy at 6 weeks “arthritis flared badly”
Exclusion diet, elimination of corn and maize starch, including starch filler in medications
“Dramatic improvement” after 1 week of exclusion diet, off all medication. ESR fell from 75 to 31. Chest xray clear, lung function normal
Off all tablets
Looking and feeling better than ever
Chest xrays clear, lung function ‘normal’
Maize / corn starch
(O’Banion, 1982) case study 1
Female 21
7 years
RA joint symptoms
Grand and petty mal seizures, headaches, fatigue, sleeping problems, depression,
Dilantin for seizures, alcohol for pain
Diet reactions observed, followed by elimination diet and re-introduction of foods.
Phase 1: Patient recorded severity of arthritis pain 1- 10, pulse rate hourly and all food and drink consumed. Sleep quality recorded from 1 – 10 for 18 days.
Phase 2: water only, testing of fresh fruit vegetables and meat, 3 foods tested each day, 1 food eaten at a time. 4 day rotation of foods. Food from same Biological family not eaten more than every 2 days. Reactions to foods noted – physical and behavioural
When 3 pain free days, returned to normal diet to test. Day 44 normal diet resumed: result – pain returned to baseline levels within 7 to 10 days
Resumed non-reactive diet of meats, vegetables, fruits. On return to non-reactive food diet became symptom free in 11 days
Day 88 tested commercial and organic pork immediate and severe arthritis pain
Treatment diet: Vegetables, meats and fruits, “non-reactive foods”
Tolerated foods: Apples, pears, watermelon, grapes, peaches, pineapple, carrots, lettuce, celery, cabbage, tuna, eggs, green beans, salmon, crab , shrimp, walnuts, Brazil nuts, coconuts, sunflower seeds avocado, sesame seeds
Pain elimination 19 days into diet testing and elimination. She reported sleeping ‘sleeping extremely well’
Daily pulse rate decreased
Patient had remained pain-free for 1.5 years, pain free at time of report.
She consistently reacted to: peanuts, beef, pork, oranges, dairy products, poultry, wheat, honey cane sugar, potatoes, coffee, corn barley, pecans.
Glue and paint fumes triggered epilepsy.
(O’Banion, 1982) case study 2
Female 18years
8 years
RA, primarily knee pain, periodically other joints.
Also headaches, temper, crying moodiness, confusion sinus problems, allergies.
6 aspirin a day, minimal effect
Phase 1: Baseline data collected for 35 days. Diet response to food recorded eating normal diet.
Phase 2: day 36 – rotary diet fresh meats, vegetables and fruits. First symptom free day – day 9. Food testing- Irregular pulse or physical or behavioural reaction to that food noted. Reactive foods eliminated and questionable foods re-tested. Normal baseline diet resumed after 4 pain free days, result: pain returned to baseline levels
No pulse rate changes to foods
Elimination diet of meats, vegetables and fruits
testing for problem foods continued.
Food removed permanently if caused a reaction
Arthritis pain eliminated, reported sleeping well, not moody. Sinus discomfort and allergic symptoms completely eliminated.
Not stated
Wheat, beef, pork, cane sugar, milk, corn and a few other foods
(O’Banion, 1982) Case study 3
Female 36
Duration not stated
Periodic RA in several joints.
headaches, bowel disturbances frequent sleepiness, sinus problems, emotional problems, obesity.
Phase 1: 13 day baseline data on normal diet
Phase 2: Testing and elimination day 14 to 32. Foods producing irregular symptomology eliminated
Rapid decrease in pain, one test food cantaloupe marked increase in pain and pulse rate
Phase 3: Day 33 normal diet resumed – this resulted in a gradual increase in pain. Reactive foods tested several times to confirm.
Some foods consistently increased pulse by 10 – 20 beats/min which also caused physical and emotional responses
Elimination diet of meat vegetables and fruits
No pain on day 32.

 

Not stated
Wheat, corn, tomatoes, cane sugar, milk products, eggs, apples, beef, lettuce, peanuts, cantaloupe, peas
(Panush et al., 1986)
Female, 52, white
11 years
Class I stage I, active disease. MSD 30 – 60 min, 9 tender joints, 3 swollen joints, objective assessment 87% on normal diet
ESR 27 – 42mm/hr
Vivonex meal replacement and food challenges
Un-blinded challenge noted exacerbations with milk, beans, meat
Normal diet 6 days- 30 min MSD, 9 tender joints, 3 swollen joint 87% subjective assessment
Vivonex 2 days, fasting 3 days, No MS, swollen joint score 0, tender joint 1, assessments 100%
Vivonex 33 days – no symptoms
Blinded milk challenge – MSD 30 min, 14 tender joints, 4 swollen joints, objective assessment 80%, symptoms began 6 – 12 hours peaking at 24 – 48 hours. IgG and IgG4 anti-milk level increase marked.
Beef, chicken, rice challenge was possible reaction but unclear
Fasting, Vivonex Vivonex meal replacement 33 days
Fasting or Vivonex – no symptoms of RA

 

Not stated
Milk.
Shellfish – urticaria
(Lunardi et al., 1988)
Not stated
Serum positive RA ARA criteria
High IgE
ESR 120mm/h
Pleuritis, vasculitis, cutaneous ulcers

 

Methylprednisolone 24mg/die 10m
Gold salts 6mg/die
Penicillamine 200mg/die 3m
Clinical condition worsening
Positive skin prick for cereals
3 week elimination diet then Challenge test: cereals triggered arthralgia, articular tumefaction, morning stiffness, vasculitis
Removal of cereals from diet

 

Patient went into remission ESR fell to 20mm/h
Waaler Rose and Rheuma test negative (now known as Rheumatoid factor)
Total IgE became normal
1 year still in complete remission
Cereals
(Denton, 2012)
Female 65
15 years
RA, gastritis, eczema, rhinitis, dry eyes, anxiety, poor sleep
fatigue
Medication not effective, methotrexate produced side effects.
Trazadone for sleep
tramadol
Elimination and food challenge
Modified Elimination diet removing most common causes of inflammation – wheat, corn, cow’s milk dairy products, nightshade vegetables (white potatoes, tomatoes, eggplant, peppers) followed by food challenges
Improvement reported after a few days. More energy, bowels normalised, pain ‘dramatically reduced’
On re-introduction corn caused eye dryness, joint inflammation and colitis. Nightshades – burning pain in back, arms, and hands, very achy, plus bloating and nausea.
No reaction to cow’s milk or wheat
For next 5 months avoided all corn and nightshade vegetables
Completely off methotrexate, trazadone and tramadol. Able to do treadmill training
Able to go on hiking trip to Asia.
In remission
Corn,   nightshade vegetables (white potatoes, tomatoes, eggplant, peppers)