A personalized approach to autoimmune conditions

Photo Cred: Denis Tuksar/Unsplash

By Kellie Blake, RDN, LD, IFNCP

Rheumatoid arthritis (RA) is just one of many autoimmune diseases on the rise today in Westernized countries. Patients with RA experience a dysregulated immune system and chronic inflammation, which leads to an increase in proinflammatory cytokines in the joint synovium resulting in progressive joint degeneration. But RA doesn’t just affect the joints. This disease wreaks havoc systemically and increases the risk of cardiometabolic, lung, and eye complications. Activities of daily living can become difficult and in the most severe expression of the disease, patients can become completely debilitated and experience premature death.

While no exact cause is known, human leukocyte antigen (HLA) polymorphisms are the most important genetic factor. This complex of genes is an important part of the immune system and is responsible for triggering immune system T cells to produce antibodies. However, as with other autoimmune diseases, genetic susceptibility alone does not lead to disease development. Rather, it’s the genetic predisposition along with environmental factors and a loss of immunological tolerance to self-antigens that elicits autoantibody development.

Standard treatment for RA often involves prescription medication and lifestyle strategies to address weight, movement, and smoking cessation, if needed. While these interventions may slow the progression of the disease and provide some relief, patients aren’t given much hope of disease reversal. However, a personalized, integrative approach addressing the same lifestyle and environmental factors that contribute to the disease can improve quality of life and disease outcomes. As reported in a 2020 retrospective study published in Plos One, patients with RA and psoriatic arthritis who received both standard of care plus a functional medicine approach experienced statistically significant improvements in physical and mental health scores as well as pain scores. 

While there are many factors to consider, one important area of RA research involves the gut microbiome. As reported in the Journal of Immunology Research, RA patients have an altered gut microbiome when compared to controls. This alteration can negatively impact the immune response and is related to the risk and severity of RA.

The inflammatory nature of the standard Western diet and its impact on the gut microbiome is well-established. Diet is a significant risk factor for gut microbiome dysbiosis, which impacts the innate immunological pathways leading to an increase in pro-inflammatory cytokines. In addition, gut microbiome imbalances lead to increased intestinal permeability allowing for an increase in inflammation to distant sites such as the joints. A personalized nutrition and lifestyle intervention to restore gut microbiome balance and a healthy intestinal barrier is an important first line of defense.

Case Study

Don received his RA diagnosis in early 2020 and was treated successfully with a non-steroidal anti-inflammatory drug (NSAID) but after 14 months he noticed an increase in his joint pain and he was transitioned to a different NSAID. His liver enzymes increased, so Don’s provider encouraged him to only take his medication three times per week if possible. Don had begun taking yoga classes and experienced some improvement in his pain, but his wood-working hobby was becoming more difficult, and he was worried about medication side effects. Don sought nutrition counseling to find a more natural solution for his RA.

Don is six foot two inches tall and initially weighed 230 pounds. His weight had been stable for one year, but he reported feeling best at 200 pounds. His food diary indicated daily intake of fast food and sweets, limited intake of water and vegetables, and he skipped breakfast most days with only coffee consumption. Don reported feeling bloated frequently. His fasting blood glucose and alanine transaminase (ALT) were both elevated at 126 mg/dL and 85 units/L respectively, but his high sensitivity C reactive protein (HsCRP) was optimal at 0.2 mg/dL. He has a history of gout and cellulitis, and both his siblings have psoriatic arthritis. Interestingly, Don was exposed to second-hand smoke as a child, which is a significant environmental trigger for RA development. Don reported restful sleep and denied excess stress and he was taking 1,000 milligrams of fish oil per day. His initial symptom score was 77 indicating severe symptoms.

The initial plan for Don included:

1. A full elimination diet or a gluten and dairy-free diet for a minimum of four weeks to address gut health, microbiome balance, and food sensitivities. I also encouraged him to eat earlier in the day and to avoid skipping breakfast to target circadian rhythm and insulin resistance.
2. Patients with autoimmune disease frequently lack adequate stomach acid, so I recommended Don complete an at-home stomach acid test, which did indicate inadequate stomach acid.
3. Nutritional supplements to include ginger 500 milligrams per day with meals TID to target inflammatory pain and gut health; turmeric 500 milligrams per day with meals TID to target inflammation and gut health; vitamin D3 2,000 international units (IUs) per day for immunomodulatory effects; vitamin C 1,000 milligrams per day due to limited dietary intake and immunomodulatory effects; magnesium glycinate 200 milligrams at night before bed due to suspected suboptimal magnesium status; digestive enzyme with betaine HCL prior to all meals to improve digestive function.
4. Suggested lab work to include fasting insulin, vitamin D, full thyroid panel including thyroid antibodies, APO B, APO A1, and lipid panel, which the patient declined.
5. Walk for 10 minutes after every meal to target insulin resistance.

Don followed up after three weeks and reported he felt better than he had in years. He was able to stop taking his NSAID and his fasting blood glucose was down to 112mg/dL and ALT had improved to 56 units/L. Instead of the full elimination diet, Don opted to start by cutting out gluten, dairy, coffee, and sugar and said he noticed quick improvement. His weight dropped to 222 pounds. He said he decided to drink a regular beer and noticed terrible bloating, so he re-committed to avoiding gluten.

After six months, Don’s weight was down to 218 pounds, and he reported much more energy and much less pain. He reported that he was still RA medication-free and took his NSAID one time on a day when he hiked in extremely wet weather. His symptom score dropped to 36 and his rheumatologist said they were considering discharging him from treatment at his next follow-up in January 2022 if he continued to do so well. Don said he could get up out of bed and jump right into his day whereas it previously took him at least an hour to get moving in the mornings. He said the meal plan was rough at first, but once he stopped focusing on what he couldn’t have and chose to focus on what he could, it got much easier. He explained that he was getting accustomed to the gluten-free diet and felt like it was his biggest inflammation trigger. He said he was trying to avoid all dairy products and limit his sugar intake and he was enjoying trying new foods. He said his wife was supportive, and they experimented with and incorporated many new foods and recipes. He also said he continued to take the magnesium, ginger, turmeric, and fish oil.

RA can be a difficult autoimmune disease to treat, but Don experienced wonderful results with the implementation of rather simple nutrition and lifestyle interventions. While I would have preferred he complete a full gut restoration program, the severity of illness and client readiness should guide the intervention.

References

Badsha H. (2018) Role of Diet in Influencing Rheumatoid Arthritis Disease Activity. The Open Rheumatology Journal. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5827298/

Droz, N. (2020) The impact of functional medicine on patient-reported outcomes in inflammatory arthritis: A retrospective study. PloS One. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7544031/

Gioia, C. (2020) Dietary Habits and Nutrition in Rheumatoid Arthritis: Can Diet Influence Disease Development and Clinical Manifestations? Nutrients. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7284442/

Horta-Baas, G. (2017) Intestinal Dysbiosis and Rheumatoid Arthritis: A Link between Gut Microbiota and the Pathogenesis of Rheumatoid Arthritis. Journal of Immunology Research. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5602494/

U.S. Centers for Disease Control and Prevention. Rheumatoid Arthrits. Retrieved from: https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html