Anabolic Laboratories : Anti-Inflammatory Diet

DIET AND INFLAMMATION

Topics:
1. Introduction
2. Current American diet – a source of chronic inflammation
3. Calories from alcohol, dairy, whole grains & refined grains, and sugar & oil
4. Calories from vegetables & fruit
5. Calories from meat, legumes, nuts, and eggs
6. Summary & recommendations
7. Grains and the inflammation connection

1. Introduction

Historically, the use of anti-inflammatory drugs has been for treating pains and chronic conditions such as arthritis. However, astute clinicians and researchers recognized that patients regularly taking NSAIDs for arthritis were less likely to develop other conditions that were also beginning to be viewed as inflammatory, such as Alzheimer’s disease (25). Although the relationship between inflammation and chronic disease expression was becoming more appreciated in the 1990s, little attention was given to the reason for the increased inflammation, save for the emerging focus on the pro-inflammatory nature of omega-6 fatty acid and the anti-inflammatory nature of omega-3s (36).

In the early 1990s, there was very little written about the link between the overall dietary pattern, a chronic inflammatory state, and disease expression. We were directed to look closely at diet in 1991 when Kjeldsen-Kragh et al. demonstrated that a vegetable-based diet could reduce the expression of rheumatoid arthritis in those suffering with this painful inflammatory condition (22). But it was not until some ten years later when the diet-inflammation connection truly became a research focus. In fact, since 2000 there has been an explosion of research and we now know that dietary choices profoundly influence the expression of the chronic inflammatory state, which leads to the subsequent expression of most chronic diseases including chronic pain (1,8,9,20,23,27,28,34).

This research allows clinicians to specifically focus their patients’ nutritional goal toward reducing the chronic pro-inflammatory state, but allows for a broad and diverse clinical effect because chronic inflammation lies behind most conditions. Such a straightforward focus is beneficial for both health care providers and their patients. In other words, clinicians do not need to search for unique diets for various conditions, as most are caused by a chronic inflammatory state. Table 1 lists some of the diseases associated with a chronic pro-inflammatory state.

Table 1 – Examples of diseases promoted by a chronic pro-inflammatory state (1,35,37,40,42)

Alzheimer’s disease	Cardiovascular disease	Hypertension	Pain
Unhealthy aging	Cognitive decline	Kidney stones	Parkinson’s disease
Acne	Crohn’s disease	Macular degeneration	Psoriasis
Allergies	Depression & anxiety	Malaise/fatigue	Renal insufficiency
Arthritis	Dry eye syndrome	Migraine headaches	Skin cancer
Asthma	Eczema	Multiple sclerosis	Stroke
Cancer	Dysmenorrhea	Osteoporosis	Ulcerative colitis

2. Current American diet – a source of chronic inflammation

A substantial percentage of the population likes to eat sugary dessert foods and snacks, as well as fatty animal products, of which fast foods are the epitome. While these foods are not likely a problem when consumed occasionally, their daily habitual consumption as dietary staples leads to the ongoing expression of inflammation. Consider the following statement from O’Keefe et al. as written in a 2008 issue of the Journal of the American College of Cardiology (28):

“The highly processed, calorie-dense, nutrient-depleted diet favored in the current American culture frequently leads to exaggerated supraphysiological post-prandial spikes in blood glucose and lipids. This state, called post-prandial dysmetabolism, induces immediate oxidant stress, which increases in direct proportion to the increases in glucose and triglycerides after a meal. The transient increase in free radicals acutely triggers atherogenic changes including inflammation, endothelial dysfunction, hypercoagulability, and sympathetic hyperactivity.

Post-prandial dysmetabolism is an independent predictor of future cardiovascular events even in nondiabetic individuals. Improvements in diet exert profound and immediate favorable changes in the post-prandial dysmetabolism. Specifically, a diet high in minimally processed, high-fiber, plant-based foods such as vegetables and fruits, whole grains, legumes, and nuts will markedly blunt the post-meal increase in glucose, triglycerides, and inflammation. Additionally, lean protein, vinegar, fish oil, tea, cinnamon, calorie restriction, weight loss, exercise, and low-dose to moderate-dose alcohol each positively impact post-prandial dysmetabolism.”

Table 2 lists the percentage of calories in the current average American diet from alcohol, dairy, whole grains, and refined grains/flours, sugars, and omega-6 oils. Almost 70% of calories come from refined grains/flours, refined sugars, refined omega-6 oils, and dairy.

Table 2. Source of 72% of calories in the average American diet (1).

1-2 % - alcohol

10-11 % - dairy products (milk, cheese, butter)

3.5 % - whole grains

20.4 % - refined grains (various flour products [bread, pasta, etc.]; cereals)

18.6 % - refined sugars (sucrose, high fructose corn syrup, glucose, etc.)

17.6 % - refined omega-6 oils (salad/cooking oils, shortening, margarine)

3. Calories from alcohol, dairy, whole grains and refined grains, sugar, & oils

Only 1-2% of calories come from alcohol, and we know that modest alcohol intake is anti-inflammatory (28). The best alcohol choices appear to be red wine and stout beer.

While many decry dairy as an unhealthy food, it should be appreciated that only about 10% of total calories in the American diet come from dairy foods. Historically, dairy has been accused of creating mucus and respiratory diseases such as asthma; however, it turns out that dairy does not create mucus and/or promote asthma. We now know that fast/refined foods are associated with asthma expression while dairy, whole grains, vegetation, and fish are protective (15,26,38,41). The 10% of calories from dairy should not be viewed as a problem for individuals without a dairy intolerance or allergy.

Whole grains represent only 3.5% of calories consumed by Americans. Whole grains have a low glycemic index, which is anti-inflammatory. Accordingly, the recommendation to consume whole grains over refined grains is appropriate. However, whole grains possess pro-inflammatory components that are not well known, which deserve attention and further discussion [see section below].

The major sources of pro-inflammatory calories in the American diet come from refined grains, sugars, and omega-6 and trans fatty acids. A massive 56.6% of calories are derived from these sources collectively, which leads to the immediate expression of inflammation upon consumption (28).

The remaining 28% of calories not listed in Table 1 would come from vegetables, fruit, animal products, nuts, and legumes.

4. Calories from vegetables and fruit

Very few Americans eat adequate anti-inflammatory vegetable and fruit servings. For example, only 10% of people reach their individualized MyPyramid recommendations for vegetable and fruit consumption (21). This behavior is highly pro-inflammatory as we know that vegetables and fruit offer substantial anti-inflammatory and disease preventing benefits.

It should be emphasized that a “serving” for most vegetables and fruit is ½ cup. Translated into calories, this means that 5 servings (1/2 cup of broccoli [22 cal], carrots [28 cal], corn [83 cal], grapes [31 cal], and orange [38 cal]) would provide only 202 calories (13), which represents 10% of total calories in a 2000 calorie diet, or 6.7% of total calories in a 3000 calorie diet. Clearly, a mere 200 calories of anti-inflammatory vegetation is far from adequate, which means that the current recommendation of 3 vegetable and 2 fruit servings per day is far too low.

In addition to providing only 200 calories, 5 servings of vegetables/fruit provide a mere 8.8 grams of fiber, which is far less than the traditional recommendation of 25-30 grams, which is still less than the 40 grams or more that is likely ideal (1). The average American consumes about 15 grams of fiber per day, a level that is pro-inflammatory and associated with constipation, appendicitis, hemorrhoids, deep vein thrombosis, varicose veins, diverticulitis, hiatal hernia, and gastroesophageal reflux (1).

Despite the fact that 200 calories of vegetation is a small amount, we know that only about 40% of Americans achieve this goal (11). Thus, for the majority of Americans, we can estimate that vegetable and fruit consumption represents between 1-9% of total calories consumed, which is a generator of chronic inflammation.

Of issue is that potatoes are a common vegetable consumed in the United States and this should raise concern as approximately 50% are in the form of refined oil-laden French fries. Potatoes have a high glycemic index relative to other vegetables and their consumption has been shown to modestly increase the expression of type II diabetes in women (12).

In summary, our lack of anti-inflammatory vegetable and fruit consumption should be viewed as highly pro-inflammatory, disease promoting, and in need of immediate correction.

5. Calories from meat, legumes, nuts, and eggs

According to USDA statistics for the year 2000 (29), the per capita consumption was as follows: 195 pounds of meat, poultry, and fish, 8.6 pounds of legumes (beans, peas, lentils), and 8.9 pounds of nuts, most of which were actually from peanuts [a legume that is characterized as a nut]. Approximately 250 eggs are consumed per person each year. These numbers represent food supply trends and not actual consumption; however, we can see that animal products represent the majority of the 28% of calories not listed in Table 2.

Most of the animal products consumed in America are cold cuts and fatty cuts of meat. These meats are derived from grain-fed domestic feedlot cattle that are sedentary, overfed, and “obese,” containing excessive omega-6 and saturated fatty acids, which are pro-inflammatory compared to lean meat and wild game (1,3,16). The feedlot pork we consume is derived from pigs that are fed a cereal-based diet, which causes the pigs to become overweight, hyperinsulinemic, hypertense, and inflamed (19). The chicken we consume is often deep fried, which turns a lean protein chicken breast into an inflammatory high fat food. Regarding fish, a recent study determined that omega-6 fatty acid levels in farm-raised tilapia and catfish were excessive and pro-inflammatory (39).

6. Summary and recommendations

Approximately 70-90% or more of the calories in the average American diet comes from refined flour, refined sugar, refined oils, obese meat and other inflammatory animal products. It should be appreciated that these food sources acutely promote inflammation due to postprandial hyperglycemia and hyperlipemia (28). Over time, these foods lead to the generation of the chronic pro-inflammatory state, which manifests as reduced mitochondrial function, reduced ATP synthesis, free radical generation, and increased release of pro-inflammatory mediators such as cytokines and eicosanoids.

Patients need to understand that medications and nutritional supplements by themselves cannot counteract the diet-induced pro-inflammatory state. The best approach is to embrace an anti-inflammatory diet that is supported by key nutritional supplements, which is outlined in the Anabolic Laboratories’ Nutritional Foundation Program educational materials for patients. See the Nutritional Foundation Booklet and CDs.

The focus of the anti-inflammatory diet has been outlined by several authors, and is nicely encapsulated in a modified polymeal format found in Table 3 (1,8,27,28,40). While whole grains and legumes are not listed in Table 3, it does not mean they are forbidden foods; rather the foods listed in Table 3 should be viewed as the most anti-inflammatory foods that are available to us.

Table 3. Polymeal

Polymeal Foods (8)	Modified Polymeal Foods
Wine	Red wine & stout beer
Fish	Fish, lean protein & wild game
Dark chocolate	Dark Chocolate
Fruits & vegetables	Fruits and vegetables & modest potato intake
Garlic	Garlic, ginger, turmeric, rosemary, and other spices
Almonds	All nuts [best if raw]

Additional components viewed as add-ons include olive oil, teas, whole grains and legumes. The authors did us a favor by considering grains and legumes as additional options. This is because whole grains and legumes are typically a major focus of dietary change, when, in fact, they should be viewed as foods to be consumed in condiment-sized portions, and the reason is that grains/legumes have certain pro-inflammatory aspects that are rarely considered.

7. Grains and the inflammation connection

Advancing the proposition that grains are inflammatory raises the ire of many doctors and patients. In this regard, a common concern for patients is that they will not get adequate fiber without whole grains. Table 4 compares various grain products to fruits and vegetables. As you can see, on a calorie-to-calorie basis, vegetables and fruit have significantly more fiber per calorie than grains.

Table 4. Fiber and potassium in common foods (13)

Food	Calories	Fiber (g)	K (mg)
1 cup millet	280	3.2	150
2 cups oatmeal	290	8.0	262
3 pc white bread	240	2.1	108
4 pc whole wheat	280	7.6	284
1.5 cups corn	250	6.3	600
Bkd sweet potato	206	6.0	700
4 Gold delic apples	240	10.0	400
3 navel oranges	240	12.0	900
6 cups broccoli	264	27.6	3036
35 cups romaine	280	35.0	5670

Of additional importance to note is the substantial amount of potassium we derive from green vegetables in particular. Americans currently consume about 2500 mg of potassium per day and the best evidence suggests we need approximately 7000-10,000 mg per day (1,5,14). Reduced potassium in the diet is known to be pro-inflammatory, being expressed as increased free radical generation, vasomotor dysfunction, stroke, hypertension, and reduced insulin sensitivity (1,5,14,24). Of importance to note is that potassium repletion must come from vegetables and fruit. Supplementation with potassium is inappropriate as it can lead to deleterious cardiovascular effects.

As made evident in Table 4, vegetables and fruit provide substantially more fiber and potassium compared with whole grains. Clearly, it is inappropriate to strongly advance the notion that whole grains are a healthy food on par with vegetables and fruit. With a message like this, it is easy for people to opt for a “whole grain cereal” or “bran muffin” instead 3 pieces of fruit or 6 cups of broccoli.

Doctors and dieticians need to modify their message about whole grains and state that, “whole grains are a healthier choice compared with refined grains;” however, “green vegetables followed by fruit are the most important sources of fiber, micronutrients, phytonutrients, and potassium.” Without this message from clinicians, patients can be misled by inappropriate anti-inflammatory characterizations of whole grains.

For example, studies do show that whole grain consumption is associated with less inflammation and chronic disease expression (18), which appears to be due to the fiber and low glycemic index of whole grains (6). Consider for example this conclusion from a study published in Diabetes Care (30):

“Our data indicate that whole grains and a low-glycemic index diet may reduce systemic inflammation among women with type 2 diabetes.”

If you were to read this paper and similar ones that came to this conclusion, you might be swayed into thinking that whole grains are an integral part of an anti-inflammatory diet; however, a close look at the data demonstrates that we should reconsider this notion. The researchers divided diabetic subjects into quintiles of whole grain consumption. The lowest quintile of whole grain consumption had an average C-reactive protein level of 6.60 mg/l, while the highest quintile averaged 5.52 mg/l (30).

In other words, individuals with even the highest quintile of grain consumption were still substantially inflamed and at high risk for cardiovascular disease. Indeed, CRP values above 3 mg/l suggest a high risk for cardiovascular disease (31). Clearly, arguments for the anti-inflammatory effect of whole grains need to be put into perspective.

Another consideration - we know that high calorie diets rich in refined foods leads to inflammation expression (28). What would happen if we ate a low/appropriate calorie diet and included whole grains? We would likely reduce/maintain markers of inflammation in the normal range. So, how then can one argue that grains are pro-inflammatory? In short, inflammation is more complex than we have been taught, particularly when it comes to grains.

For example, gluten, which is found in wheat, rye, and barley is overtly inflammatory for people with gluten intolerance and causes of celiac disease. The mistake made by many is the failure to consider the possible extent of atypical celiac disease and instead, limit gluten intolerance to only the expression of celiac disease.

Atypical celiac disease is an unknown condition by many; however, the symptoms it creates are substantially encumbering for the sufferers and are very common presentations in clinical practice. Table 5 contains the symptoms of atypical celiac disease that commonly exist without overt gastrointestinal symptoms.

Table 5. Non-gastrointestinal symptoms caused by gluten intolerance (7,10,17,33)

Anemia	Dyspepsia	Infertility	Neurological symptoms
Autoimmune symptoms	Esophageal reflux	Irritable bowel syndrome	Peripheral neuropathies
Arthralgia	Fatigue	Learning disabilities	Central neuropathies (ataxia)
Arthritis	Guillain-Barre-like syndrome	Malaise	Psychological symptoms
Depression	Headaches	Myalgia	Reduced bone density
Dermatitis herpetiformis	Hypothyroidism	Myopathy	Thyroiditis

Interestingly, one study demonstrated that the expression of celiac disease was most common among individuals aged 30-70 (32), which is the precise age that symptoms of other chronic diseases often manifest and so atypical celiac disease should be a consideration. The diversity of atypical celiac disease has led celiac specialists to state (17): “although these symptoms are common in primary care, we suggest that clinicians should test patients if symptoms are persistent or recurrent, if multiple symptoms are present, or if secondary care referral is being considered.”

Grains contain additional pro-inflammatory factors such as lectins and an acidic pH. For more details on the inflammatory potential of grains and legumes, you can link to 2 full text documents:

· Cordain L. Cereal grains: humanity’s double-edged sword. World Rev Nutr Diet. 1999;84:19-73.

http://www.thepaleodiet.com/articles/Cereal%20article.pdf

· Cordain L, Toohey L, Smith MJ, Hickey MS. Modulation of immune function by dietary lectins in rheumatoid arthritis. Brit J Nutr. 2000;83:207-17.

http://www.thepaleodiet.com/articles/Arthritis%20PDF.pdf

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