Designing an Anti-Inflammatory Diet

Help your patients prevent chronic disease by reducing inflammation risk factors.

By James Gerber, MS, DC.
Reproduced from the February 2010 issue of ACA News, a publication of the American Chiropractic Association.

The pathological process of inflammation has been understood for decades, but only recently health conditions not previously associated with inflammation, such as heart disease, cancer and degenerative brain disease, have been linked with this process. As a result, there has been an expansion of interest in discovering how anti-inflammatory interventions might help in the prevention or management of many diseases.

Natural approaches to achieving anti-inflammatory effects through the diet typically include: 1) an attempt to shift dietary fatty acid intake to reduce pro-inflammatory products of fatty acid metabolism, 2) an increased intake of plant-based foods that are naturally high in antioxidants and other anti-inflammatory phytonutrients and 3) a search for potentially allergenic foods, which, when eliminated, may lower systemic immune responses that promote inflammation. Let’s consider each of these strategies, the evidence supporting their rationale and the steps needed to implement them.

The Complexity of Fatty Acids
Fatty acids, specifically certain members of the omega-6 and omega-3 polyunsaturated families, are precursors of eicosanoids such as prostaglandins that have many influences on local tissues, including the mediation of inflammatory mechanisms. One of the omega-6 family, arachidonic acid, can be converted to a variety of powerful promoters of inflammation, while conversion of gamma-linolenic acid (GLA, another omega-6 fatty acid) and eicosapentaenoic acid (EPA, a long-chain omega-3 fatty acid) does not help promote inflammation to any considerable degree.

Since these precursors compete with each other for conversion to their respective eicosanoid products, a relative anti-inflammatory balance would be achieved by minimizing arachidonic acid and/or maximizing GLA and EPA in the diet. This is the rationale for modifying fatty acid intake in the anti-inflammatory diet, as well as for the use of anti-inflammatory fatty acids, such as fish oils, as supplements.

Popular anti-inflammatory diets often oversimplify the relative contribution of different omega-6 and omega-3 fatty acids to the inflammatory response. Since arachidonic acid can be produced in the body from other omega-6 precursors, a broad recommendation is typically made to limit omega-6 intake from all sources, even though some omega-6 precursors, such as GLA, are anti-inflammatory. Similarly, since EPA can be produced from other omega-3 precursors, a broad recommendation to increase intake in general from all omega-3 sources is common, even though short-chain omega-3s are converted to EPA to a limited degree only.

Clinical studies have shown the most promise for increasing food and supplemental sources of EPA and other long-chain omega-3s, beginning at about 500 mg/day for heart disease prevention and up to 3,000 mg/day for clinical anti-inflammatory effects. Reducing dietary sources of arachidonic acid by minimizing animal fats and flesh has some support, as well. GLA has shown promise as a supplement in amounts beginning at about 1,000 mg/day, but it is not present in edible foods. Flaxseed and its oil are rich in short-chain omega-3 and have some
healthful properties, but flaxseed oil was ineffective in the only clinical trial to date that investigated effects on a chronic inflammatory disease.

Clearly, the best evidence for designing the fatty acid contribution of an anti-inflammatory diet is to increase EPA intake from marine sources such as oily fish (salmon, sardines, herring, trout, black cod) and oysters, aiming for consuming these foods several times a week, and to reduce dietary sources of arachidonic acid (meat, high-fat milk and cheese products, eggs) as much as possible. This was demonstrated well in a randomized controlled trial in rheumatoid arthritis patients that found benefits from either a diet low in arachidonic acid or supplementation with fish oils—but an even larger clinical effect when both strategies were combined.

Switching to Plants
Plant-based foods are the richest dietary sources of substances known to affect the biology of inflammation, such as antioxidants and phenolics, which include the flavonoid family. The Mediterranean diet, with its emphasis on unprocessed plant-based foods and phenolic-rich olive oil, as well as recommending seafood as a preferred source of animal protein and fat, has emerged as a healthful anti-inflammatory diet. (To view Mediterranean Diet Food Pyramid, go to www.mediterraneandiet.com/tag/new-mediterranean-pyramid/.)

This diet has not only been found helpful for the prevention of heart disease through anti-inflammatory and other mechanisms, but has even helped reduce symptoms and disease activity in patients with rheumatoid arthritis. The Mediterranean diet and probably other, similar plant-based diets are certainly legitimate models for an anti-inflammatory diet.

Reducing Allergic Response
The role of food allergy in inflammatory disease has primarily focused on disorders of joints, such as rheumatoid arthritis; of the intestine, such as Crohn’s disease; and of the skin, as in atopic dermatitis. While benefits from food allergy identification and avoidance have been frequently demonstrated in individual cases and some clinical trials, controversy persists due to lack of double-blind challenges to confirm true sensitivities in most research. Of course, most dietary interventions cannot easily be concealed from subjects in a clinical trial, so placebo effects could explain the positive results on symptoms reported in these studies. Nonetheless, at least one rheumatoid arthritis trial has demonstrated persistent benefits of a low-allergen diet for up to one year.

A Combined Approach
Clinical benefits of anti-inflammatory diets may be due to a combination of the above mechanisms. Researchers in Sweden and other countries have shown that a “vegan diet free of gluten” has positive effects on symptoms and clinical signs of inflammatory diseases in trials lasting as long as one year. Such a diet would be void of arachidonic acid; free of potentially allergenic wheat, dairy and egg products; and high in plant-based antioxidants and other potentially anti-inflammatory phytonutrients. Similarly, the Mediterranean diet will typically have a more favorable omega-3/omega-6 fatty acid balance and might significantly limit potential allergens from animal-based foods. Clearly, there is more than one way to design an anti-inflammatory diet or to explain the benefits of such an approach.

Dr. Gerber is associate professor of clinical sciences at Western States Chiropractic College (WSCC) and is the lead instructor for WSCC nutrition courses. He has authored conservative care pathway protocols for treating dyslipidemia and obesity, as well as for using specialized supplements for treating joint disorders and musculoskeletal trauma. Dr. Gerber can be reached at jgerber@wschiro.edu.

Sources
1. Adam O, Beringer C, Kless T, et al. Anti-inflammatory effects of a low arachidonic acid diet and fish oil in patients with rheumatoid arthritis. Rheumatol Int 2003 Jan;23(1):27-36.
2. Gamlin L, Brostoff J. Food sensitivity and rheumatoid arthritis. Env Toxicol Pharmacol 1997;4:43-49.
3. Harris WS, Mozaffarian D, Rimm E, et al. Omega-6 fatty acids and risk for cardiovascular disease: a science advisory from the American Heart Association Nutrition Subcommittee of the Council on Nutrition, Physical Activity, and Metabolism; Council on Cardiovascular Nursing; and Council on Epidemiology and Prevention. Circulation 2009 Feb 17;119(6):902-7.
4. Hafström I, Ringertz B, Spångberg A, et al. 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 (Oxford) 2001 Oct;40(10):1175-9.
5. Kapoor R, Huang YS. Gamma linolenic acid: an antiinflammatory omega-6 fatty acid. Curr Pharm Biotechnol 2006 Dec;7(6):531-4.
6. Pischon T, Hankinson SE, Hotamisligil GS, Rifai N, Willett WC, Rimm EB. Habitual dietary intake of n-3 and n-6 fatty acids in relation to inflammatory markers among US men and women. Circulation 2003 Jul 15;108(2):155-60.
7. Skoldstam L, Hagfors L, Johansson G. An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis. Ann Rheum Dis 2003;62:208-14.

Patients in Medicare Demonstration Project Give Chiropractors High Marks

A Press Release from the American Chiropractic Association

According to long-awaited results from a congressionally mandated pilot project testing the feasibility of expanding chiropractic services in the Medicare program, patients have a high rate of satisfaction with the care they receive from Doctors of Chiropractic.

When asked to rate their satisfaction on a 10-point scale, 87 percent of patients in the study gave their Doctor of Chiropractic a level of 8 or higher. What’s more, 56 percent of those patients rated their chiropractor with a perfect 10.

Contributing to that satisfaction was the attention given to patients’ needs and the accessibility of chiropractic care. Patients reported that doctors of chiropractic listened to them carefully and spent sufficient time with them. Some 95 percent said they had to wait no longer than one week for appointments.

“Doctors of Chiropractic everywhere should feel pride in these patient satisfaction results and in being part of a profession that still sees the great need for spending time with patients and truly listening to them,” said Dr. Rick McMichael, president of the American Chiropractic Association (ACA). “It’s clear that patients deeply value the time their chiropractic providers spend with them and the expert care that Doctors of Chiropractic offer.” ACA is the largest chiropractic organization in the United States, representing more than 15,000 Doctors of Chiropractic and students.

The pilot, known as a “demonstration project” in Congress, was conducted from April 2005 to March 2007 throughout the states of Maine and New Mexico, and also in Scott County, Iowa, 26 counties comprising the Chicago metropolitan area, and 17 counties in central Virginia.

Current chiropractic coverage under Medicare is limited to spinal manipulation. Under the demonstration project, however, chiropractic care was expanded to include diagnostic and other services, such as X-rays, examinations, physical therapy and rehabilitation services.

The final report to Congress also includes information on the costs of expanding chiropractic services in the demonstration sites. The report indicates that in all but one of the demonstration sites, patients’ health care costs were not significantly changed by expanding coverage of chiropractic services. In contrast, a cost increase was found in the Chicago metropolitan area. Further research into the reasons why the results in Chicago differ from the rest of the demonstration project sites is needed to better understand these findings.

“We already know that Medicare costs in general tend to be higher in Chicago than other similar areas of the country. We must find the underlying cause of the cost difference found in the chiropractic demonstration project and determine whether it had anything at all to do with the expansion of chiropractic services,” Dr. McMichael noted.

To further analyze the results of the demonstration project, ACA is creating a taskforce of Medicare experts and researchers who will review the report and develop a response for the Centers of Medicare and Medicaid Services.

To view the report online, visit www.acatoday.org/pdf/demo_report.pdf.

Back Pain Facts and Statistics

Although chiropractors care for more than just back pain, many patients visit chiropractors looking for relief from this pervasive condition. In fact, 31 million Americans experience low-back pain at any given time.1

A few interesting facts about back pain:
· One-half of all working Americans admit to having back pain symptoms each year.2
· Back pain is one of the most common reasons for missed work. In fact, back pain is the second most common reason for visits to the doctor’s office, outnumbered only by upper-respiratory infections.
· Most cases of back pain are mechanical or non-organic—meaning they are not caused by
serious conditions, such as inflammatory arthritis, infection, fracture or cancer.
· Americans spend at least $50 billion each year on back pain—and that’s just for the more
easily identified costs.3
· Experts estimate that as many as 80% of the population will experience a back problem at
some time in our lives.4

What Causes Back Pain?
The back is a complicated structure of bones, joints, ligaments and muscles. You can sprain ligaments, strain muscles, rupture disks, and irritate joints, all of which can lead to back pain. While sports injuries, or accidents can cause back pain, sometimes the simplest of movements—for example, picking up a pencil from the floor— can have painful results. In addition, arthritis, poor posture, obesity, and psychological stress can cause or complicate back pain. Back pain can also directly result from disease of the internal organs, such as kidney stones, kidney infections, blood clots, or bone loss.

Manipulation as a Treatment for Back Problems
Used primarily by Doctors of Chiropractic (DCs) for the last century, manipulation has been largely ignored by most others in the health care community until recently. Now, with today's growing emphasis on treatment and cost effectiveness, manipulation is receiving more widespread attention.

Chiropractic spinal manipulation is a safe and effective spine pain treatment. It reduces pain, decreases medication, rapidly advances physical therapy, and requires very few passive forms of treatment, such as bed rest.5

In fact, after an extensive study of all currently available care for low back problems, the Agency for Health Care Policy and Research—a federal government research organization—recommended that low back pain sufferers choose the most conservative care first. It recommended spinal manipulation as the only safe and effective, drugless form of initial professional treatment for acute low back problems in adults.6

The American Chiropractic Association (ACA) urges you to make an informed choice about your back care. To learn more about how chiropractic manipulation may help you, contact a Doctor of Chiropractic in your area. Dr. Brenda Rooney, a member of the American Chiropractic Association, as well as a member of the Association of New Jersey Chiropractors (ANJC) recommends the following tips for back pain prevention in accordance with the ACA.

Tips to Prevent Back Pain:
· Maintain a healthy diet and weight.
· Remain active—under the supervision of your doctor of chiropractic.
· Avoid prolonged inactivity or bed rest.
· Warm up or stretch before exercising or other physical activities, such as gardening.
· Maintain proper posture.
· Wear comfortable, low-heeled shoes.
· Sleep on a mattress of medium firmness to minimize any curve in your spine.
· Lift with your knees, keep the object close to your body, and do not twist when lifting.
· Quit smoking. Smoking impairs blood flow, resulting in oxygen and nutrient deprivation to
spinal tissues.
· Work with your doctor of chiropractic to ensure that your computer workstation is
ergonomically correct.

References:
1. Jensen M, Brant-Zawadzki M, Obuchowski N, et al. Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain. N Engl J Med 1994; 331: 69-116.
2. Vallfors B. Acute, Subacute and Chronic Low Back Pain: Clinical Symptoms, Absenteeism and Working Environment. Scan J Rehab Med Suppl 1985; 11: 1-98.
3. This total represents only the more readily identifiable costs for medical care, workers compensation payments and time lost from work. It does not include costs associated with lost personal income due to acquired physical limitation resulting from a back problem and lost employer productivity due to employee medical absence. In Project Briefs: Back Pain Patient Outcomes Assessment Team (BOAT). In MEDTEP Update, Vol. 1 Issue 1, Agency for Health Care Policy and Research, Rockville, MD, Summer 1994.
4. In Vallfors B, previously cited.
5. Time to recognize value of chiropractic care? Science and patient satisfaction surveys cite usefulness of spinal manipulation. Orthopedics Today 2003 Feb; 23(2):14-15.
6. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No.14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December, 1994.