Five years ago, I met a patient that changed my view on practicing traditional medicine, especially when it comes to rheumatology. For years, I was proud to be in a booming field that provided patients with a new therapy every few years. As a physician and scientist, I believe that targeted therapy offers tools to treat patients like never before, but I have noticed that results vary over time.
Daniel was a 44-year-old gentleman who went from being healthy to developing severe swelling and pain in multiple joints in a matter of weeks. Despite the best efforts of his primary care, his symptoms were rapidly worsening, so much so that he could not perform his daily activities.
Daniel was diagnosed with rheumatoid arthritis. We started treatment, switching through a few medications for 12 months. Despite following all my medical recommendations, he failed to improve by more than 60 to 70 percent.
I could not help but wonder why. Daniel had the same idea and asked me: “Dr. G, what are we missing? Why are these medications not working in my case? Is it my gut microbiome or my diet?”
I was ashamed that I did not really know.
While I was aware of the impact of nutrition on chronic diseases like diabetes, obesity, and cardiovascular diseases, I had learned much less about its implications on autoimmune disease.
My training, spanning over 20 years, did not prepare me for this, as it did not incorporate more than four hours of nutrition, let alone stress reduction techniques, exercises for easing pain, or the importance of sleep. This conversation inspired me to look outside of my comfort zone.
When I got home, I opened my laptop and opened PubMed. There, I dove into articles and studies about nutrition and nutritional supplements and their relationship with autoimmune diseases. That is when I remembered that in 2013, the New England Journal of Medicine published a multicenter, randomized, controlled trial consisting of more than 7,000 patients with a high cardiovascular risk but no disease at the time of enrollment. The results suggested that patients adhering to a Mediterranean diet versus a fat-reduced diet had a 30 percent reduction in their risk of developing cardiovascular disease.
The numbers seemed too good to be true, so the study was heavily criticized and eventually withdrawn. However, in 2018, the same authors republished the study showing that the people on a Mediterranean diet supplemented with extra-virgin olive oil or nuts showed the same 30 percent reduction in their cardiovascular risk. I wondered: what would the evidence show in patients with inflammatory arthritis? What would happen if they switched to a Mediterranean diet?
For the next two years, I dedicated time to developing my knowledge. My efforts included taking a Nutrition Science course at Stanford University. The results were incredible.
The gut microbiome: the power of tuning the immune system
Initially, I learned that our gut microbiome dramatically impacts our health, from influencing the risk of obesity to modulating mood and even tuning our immune system. How many of you know that inflammatory arthritis patients have changes in their gut microbiome that might be responsible for their inflammatory disease? How many of you recognize that patients with a positive HLA-B27 differ in the species of bacteria that they have in their gut?
I learned about the impact of short-chain fatty acids (microbiota metabolites), probiotics, and prebiotics in decreasing colonic inflammation. This is especially important as two-thirds of ankylosing spondylitis patients have gastrointestinal inflammation.
So, how can we improve our gut microbiome? Nutrition is the key.
Nutrition: “We are what we eat”
We have all heard the saying that “we are what we eat,” which is true. Many factors involving our health and state of well-being are dependent on the foods we consume. Here is a list of a few international studies involving a change in diet and the effect on patients suffering from inflammatory diseases:
A Norwegian study published in 1999 reported that patients with Rheumatoid arthritis that fasted for 7-10 days and followed a vegetarian diet showed improved disease activity. Their fecal flora also showed changes compared to the patients that did not adhere to these diets. In patients with Psoriatic arthritis, intermittent fasting reduced markers of inflammation such as C-reactive, disease activity, and enthesitis improved.
Including reduced disease activity, inflammatory markers, and even pain level.
In 2018, a Swedish group showed that high adherence to the Mediterranean diet decreases the likelihood of developing RA by 21 percent.
Supplements: the scientific evidence of fish oil or omega-3 supplementation
Most of my patients will ask me what supplements benefit their disease. Let’s talk about a commonly used supplement. Fish oil is a major source of Omega-3 polyunsaturated fatty acids that have powerful anti-inflammatory properties.
In 2015, a randomized controlled trial involving 139 patients with recent-onset rheumatoid arthritis proved that adding a high dose of fish oil (5.5g per day) to the triple therapy (methotrexate, sulfasalazine, and hydroxychloroquine) significantly increased the number of patients getting into remission and lowered their disease activity.
Other studies also showed the beneficial impact of Omega-3 polyunsaturated fatty acids on patient-assessed pain, duration of morning stiffness, and the number of painful or tender joints. Omega-3 supplementation also reduces non-steroidal anti-inflammatory drug use. Even in patients with non-surgical back pain, four months of fish oil supplementation (1.2 or 2.4 g per day) led to impressive results. Approximately 60 percent of patients discontinued taking their prescription NSAID medications for pain, and their joint pain and overall pain improved. It is also essential to note that no significant side effects were reported.
Obesity, leptin, and the increased risk of inflammation
Most of us know that obesity is linked to an increased risk of inflammation. Obesity, through leptin, the most abundant adipocyte-derived hormone that acts as a proinflammatory molecule, directly influences and is influenced by TNF-Alpha and IL-1 and appears to regulate Treg cells and possibly increase the risk of autoimmunity. Encouraging obese patients to decrease their weight will decrease inflammation, the degenerative joint disease and lower the risk of developing autoimmune diseases.
As I have said time and time again, targeted therapy is like treating one tree from a suffering forest and expecting the whole forest to flourish and become healthy. Investing the time in educating myself made me believe in treating the patient as a whole person, not just their disease. Medication helps control a patient’s inflammation but seeing deeper and stronger results lies in studying the patient’s genetics and making certain lifestyle changes. Many patients will testify that after making small changes in their diets, such as just reducing sugar or processed food intake, they feel energized, have less brain fog, and have less pain.
Remembering Daniel’s story, he embarked on a journey that changed his life. As a result of many of these studies and more, he changed his lifestyle completely, including embracing a Mediterranean diet. This intervention helped Daniel get into remission.
Thus, I strongly recommend to all my colleagues in rheumatology to at least open the discussion with patients about integrative approaches to medicine with their patients, including the role of nutrition. Simple nutrition changes will improve the lives of millions of people with arthritis or autoimmune diseases. The impacts are enormous, and it all begins by changing our approach from treating one tree to treating the forest. Today, in my practice, I treat patients like who they are: whole people, not diseases.
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