The Prevention and Treatment of Crohn’s Disease with a Vegetarian Diet

We are delighted to announce that this article was published in the peer-reviewed journal, Advanced Research in Gastroenterology and Hepatology, Feb 16, 2018.

Here is the pdf of the published article

Abstract

Epidemiologic studies show that IBD is prevalent in wealthy nations where dietary westernization usually occurs. Dietary westernization is characterized by increased consumption of animal protein, animal fat, and sugar. An epidemiological study found that the risk of Crohn’s disease reduced by 70% in females and 80% in males following a vegetarian diet.

Treatment with medications, though efficacious to a degree, all have significant adverse reactions. Many of these medications will also be contraindicated in a significant number of patients.

Treatment is aimed at inducing remission. A semi-vegetarian diet has been shown to achieve a 100% remission rate at 1 year and 92% at 2 years. Plant-based diets are rich in phytochemicals that help reduce inflammation by modifying several inflammatory mechanisms.

A study of treatment with infliximab and a plant-based diet showed a remission rate of 96%, substantial reduction in CRP and CDAI and improvements in mucosa healing. This study shows that combining infliximab with a plant-based diet results in a strong clinical response.

Plant-based diets promote a more favorable gut microbial profile that is anti-inflammatory. Naturally occurring substances in plant foods, having anti-inflammatory bowel actions include phytochemicals, antioxidants, dietary fibers, and lipids. Many of these natural products exert their beneficial action by altering cytokine production.

The plant-based diet has no adverse reactions or contra-indications and is affordable, so physicians can initiate therapy with a plant-based diet immediately, and prescribe it as a prophylaxis for all patients at risk of Crohn’s disease.

 

Introduction

Crohn’s disease is difficult to treat and can be frustrating for both the patient and their physician. Safer and more efficacious treatments are needed for this disease.

The current standard treatment for Crohn’s disease involves medication to manage symptoms and induce remission, and when necessary, bowel resection. Medications used in the treatment of Crohn’s disease include the following:

  • 5-Aminosalicylic acid derivative agents (eg. mesalamine rectal, mesalamine, balsalazide)
  • Corticosteroids (eg. prednisone, methylprednisolone, budesonide)
  • Immunosuppressive agents (eg. mercaptopurine, methotrexate, tacrolimus)
  • Biologics (eg. infliximab, adalimumab, certolizumab pegol, natalizumab, vedolizumab)
  • Antibiotics (eg. metronidazole, ciprofloxacin)
  • Antidiarrheal agents (eg. loperamide, diphenoxylate-atropine)
  • Bile acid sequestrants (eg. cholestyramine, colestipol)
  • Anticholinergic agents (eg. dicyclomine, hyoscyamine, propantheline)

These medications, though efficacious to a degree, all have significant adverse reactions. Many of these medications will also be contraindicated in a significant number of patients.

Most patients with Crohn’s disease require surgical intervention during their lifetime, as it plays an integral role in controlling the symptoms and treating the complications of Crohn’s disease, but operative resection is not curative. Because of the high rate of disease recurrence after segmental bowel resection, the guiding principle of surgical management of Crohn’s disease is preservation of intestinal length and function. (1)

Mean annual costs for Crohn’s disease are about $8265. 31% of costs were attributable to hospitalization, 33% to outpatient care, and 35% to pharmaceutical claims. The annual dollar cost for Crohn’s disease in the United States is $3.6 billion. (2) It can reasonably be concluded that Crohn’s is both difficult and expensive to treat.

Symptoms of Crohn’s disease may subside with total parenteral nutrition or total enteral nutrition, but it is well known to flare up after the resumption of meals. Therefore, the food in patient’s meals are thought to be an etiologic factor in gut inflammation. (3)

While parenteral nutrition is possible, nutrition taken orally is to be preferred if it won’t cause a flare up, or even better, if it can prevent flare ups and induce remission. This is what a vegetarian diet seems to accomplish.

Prevention

The etiology of Crohn’s disease is unknown. Genetic, microbial, immunologic, environmental, dietary, vascular, and psychosocial factors have been implicated, as have smoking and the use of oral contraceptives and nonsteroidal anti-inflammatory agents (NSAIDs).

Epidemiology shows that IBD is prevalent in wealthy nations (4, 5, 6) where dietary westernization inevitably occurs (7, 8). Dietary westernization is characterized by increased consumption of animal protein, animal fat, and sugar. Diets rich in animal protein and animal fat cause a decrease in beneficial bacteria in the intestine (9, 10).

However, the risk of Crohn’s disease was found to be reduced by 70% in female and 80% in male young people following a nearly vegetarian diet. (11)

Treatment

Treatment is aimed at inducing remission.  An important and well-designed study published in 2010, using a semi-vegetarian diet, achieved a 100% remission rate at 1 year and 92% at 2 years. (12)

A more advanced study published in 2017 examined whether a substantial improvement of the relapse-free rate in Crohn’s Disease could be obtained by incorporating three recently developed concepts in medicine: biologics, a plant-based diet and window of opportunity. This was followed by maintenance of remission with a plant-based diet, rather than further use of biologics with or without immunosuppressants. (13)

Patients were treated with infliximab and a plant-based diet. The primary end point was clinical remission at week 6. Secondary end points were normalization of C-reactive protein (CRP) concentration at week 6 and mucosal healing. Crohn Disease Activity Index (CDAI) score was also evaluated. (13)

All patients in this study who completed the protocol achieved remission at week 6. Remission rates by intention-to-treat and per protocol analysis were 96% and 100%, respectively. The rates of CRP normalization at week 6 were 92% among adults with a new diagnosis, 82% among children with a new diagnosis and 67% among relapsing adults. The mean CDAI score was significantly decreased from 314 before treatment to 163 after the first week. The scores were further decreased chronologically: 115, 98, 82, 74, and 63 at weeks 2, 3, 4, 5, and 6, respectively. Mucosal healing was achieved in 46% patients. This study has shown that a plant-based diet can improve the efficacy of biologics such as infliximab. (13)

Plant-based dietary patterns may promote a more favorable gut microbial profile. Such diets are high in dietary fiber and fermentable substrate (i.e. non digestible or undigested carbohydrates), which are sources of metabolic fuel for gut microbial fermentation and, in turn, result in end products that may be used by the host (i.e. short chain fatty acids such as butyrate). These end products may have direct or indirect effects on modulating the health of their host. (14)

The naturally occurring substances in plant foods having anti-inflammatory bowel actions include phytochemicals, antioxidants, microorganisms, dietary fibers, and lipids. The literature indicates that many of these natural products exert their beneficial action by altering cytokine production. Specifically, phytochemicals such as polyphenols or flavonoids are the most abundant, naturally occurring anti-inflammatory substances. The effects of lipids are primarily related to the n-3 polyunsaturated fatty acids. The effects of phytochemicals are associated with modulating the levels of tumor necrosis factor α (TNF-α), interleukin (IL)-1, IL-6, inducible nitric oxide synthase, and myeloperoxide. The anti-IBD effects of dietary fiber are mainly mediated via peroxisome proliferator-activated receptor-γ, TNF-α, nitric oxide, and IL-2, whereas the effects of lactic acid bacteria are reported to influence interferon-γ, IL-6, IL-12, TNF-α, and nuclear factor-κ light-chain enhancer of activated B cells. These results suggest that the anti-IBD effects exhibited by natural products are mainly caused by their ability to modulate cytokine production. (15)

Studies, conducted using in vivo and in vitro models, provide evidence that pure polyphenolic compounds and natural polyphenolic plant extracts can modulate intestinal inflammation. (16)  Polyphenols may thus be considered able to prevent or delay the progression of Crohn’s disease, especially because they reach higher concentrations in the gut than in other tissues. (17)

While not perfect, of all the laboratory markers, C-Reactive Protein (CRP) is the most studied and has been shown to have the best overall performance. CRP is an objective marker of inflammation and correlates well with disease activity in Crohn’s disease. (18)  It is produced as an acute phase reactant predominantly in the liver, in response to stimulation by interleukin (IL)-6, TNF-α and IL-1β, which are produced at the site of inflammation. (19)

Adipocytes in hypertrophied mesenteric adipose tissue produce and secrete significant amounts of adiponectin, which may be involved in the regulation of intestinal inflammation associated with Crohn’s disease. Furthermore, adiponectin concentrations in hypertrophied mesenteric adipose tissues of Crohn’s disease patients correlated inversely with serum CRP levels (r = −0.51, p = 0.015) (20)  There is a good correlation between CRP and other measures of inflammation such as the Crohn’s Disease Activity Index, radioactive labelled fecal granulocyte excretion and fecal calprotectin. (21, 22, 23)

Plant-based diets have been shown to increase adiponectin in diabetics, and reduce CRP in both diabetics and patients with coronary artery disease, and may well be doing the same in Crohn’s disease patients. (24, 25, 26)  This improved profile of cytokines may be part of the therapeutic efficacy of plant-based diets in Crohn’s disease.

Discussion

To put the efficacy of a vegetarian diet into perspective one must compare it to standard treatments. Overall, despite the use of oral mesalamine treatment in the past, new evidence suggests that this approach is minimally effective as compared with a placebo, and less effective than budesonide or conventional corticosteroids.  Induction of remission was noted in 52% of Crohn’s disease patients.

Maintenance of remission was reported in 71% of Crohn’s disease patients on azathioprine over a 6-month to 2-year period. Induction and maintenance of remission was noted in 70% of Crohn’s disease patients on methotrexate over a 40-week period. Induction of remission was reported in 32%, 26%, and 20% of Crohn’s Disease patients on infliximab, adalimumab or certolizumab, respectively. Approximately one-fifth of Crohn’s disease patients treated with biologicals require intestinal resection after 2–5 years in referral-center studies. (27)  The adverse reactions of the above medications are well-known, as are the risks and complications of surgery.

The safety and efficacy of a plant-based diet to treat Crohn’s disease would seem quite advantageous. It has no contraindications and no adverse reactions. Therefore, it may be safely combined with standard treatments.

Treatment with a plant-based diet also reduces the risk of common diseases that the Crohn’s patient will face in common with all patients, such as coronary artery disease and type II diabetes mellitus.

Given the substantial advantages more study is warranted. However, given its safety the physician can institute therapy with a plant-based diet immediately.

Finally, every physician should practice prevention. The decreased risk of Crohn’s disease obtained with a plant-based diet is considerable. It is a safe prophylaxis, and should especially be prescribed for patients at risk because of family history or because of cigarette smoking.

Conflict of Interest

The authors have no conflicts of interest to disclose.

 

References

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Chiba M, Abe T, Tsuda H, Sugawara T, Tsuda S, et.al. (2010) Lifestyle-related disease in Crohn’s disease: Relapse prevention by a semi-vegetarian diet. World J Gastroenterol. 16(20):2484–2495. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2877178/

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Chiba M, Tsuji T, Nakane K, Tsuda S, Ishii H, et al. (2017) Induction with Infliximab and a plant-based diet as first-line (IPF) therapy for Crohn disease: a single-group trial. Perm J.21:17-009. https://www.ncbi.nlm.nih.gov/pubmed/29035182

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Wong J. (2014) Gut microbiota and cardiometabolic outcomes: influence of dietary patterns and their associated components. Am J Clin Nutr. 100(Suppl 1):369S-77S. https://www.ncbi.nlm.nih.gov/pubmed/24898225

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Hur SJ, Kang SH, Jung HS, Kim SC, Jeon HS, et al. (2012) Review of natural products actions on cytokines in inflammatory bowel disease. Nutr Res. 32(11):801-16. https://www.ncbi.nlm.nih.gov/pubmed/23176791

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Romier B, Schneider Y, Larondelle Y, During A. (2009) Dietary polyphenols can modulate the intestinal inflammatory response. Nutr Rev. 67(7):363-78. https://www.ncbi.nlm.nih.gov/pubmed/19566597

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Biasi F, Astegiano M, Maina M, Leonarduzzi G, Poli G. (2011) Polyphenol supplementation as a complementary medicinal approach to treating inflammatory bowel disease. Curr Med Chem. 18(31):4851-65. https://www.ncbi.nlm.nih.gov/pubmed/21919842

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Vermeire S, Van Assche G, Rutgeerts P. (2006) Laboratory markers in IBD: useful, magic, or unnecessary toys? Gut. 55(3):426-431. https://www.ncbi.nlm.nih.gov/pubmed/16474109

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Vermeire S, Van Assche G, Rutgeerts P. (2004) C-reactive protein as a marker for inflammatory bowel disease. Inflamm Bowel Dis. 10(5):661-5. https://www.ncbi.nlm.nih.gov/pubmed/15472532

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Yamamoto K, Kiyohara T, Murayama Y, Kihara S, Okamoto T, et al. (2005) Production of adiponectin, an anti-inflammatory protein, in mesenteric adipose tissue in Crohn’s disease. Gut. 54(6):789-96. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774527/

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Fagan EA, Dyck RF, Maton PN, Hodgson HJ, Chadwick VS, et al. (1982) Serum levels of C-reactive protein in Crohn’s disease and ulcerative colitis. Eur J Clin Invest. 12(4):351-9. https://www.ncbi.nlm.nih.gov/pubmed/6814926

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Saverymuttu S, Hodgson H, Chadwick V, Pepys M. (1986) Differing acute phase responses in Crohn’s disease and ulcerative colitis. Gut. 27(7):809–813. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1433572/

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Hammer H, Kvien T, Glennås A, Melby K. (1995) A longitudinal study of calprotectin as an inflammatory marker in patients with reactive arthritis. Clin Exp Rheumatol. 13(1):59-64. https://www.ncbi.nlm.nih.gov/pubmed/7774104

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Kahleova H, Matoulek M, Malinska H, Oliyarnik O, Kazdova L, et al. (2011) Vegetarian diet improves insulin resistance and oxidative stress markers more than conventional diet in subjects with Type 2 diabetes. Diabet Med. 28(5):549-59. https://www.ncbi.nlm.nih.gov/pubmed/21480966

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Chen C, Lin Y, Lin T, Lin C, Chen B, Lin C. (2008) Total cardiovascular risk profile of Taiwanese vegetarians. Eur J Clin Nutr. 62(1):138-44. https://www.ncbi.nlm.nih.gov/pubmed/17356561

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Peyrin-Biroulet L, Lémann M. (2011) Review article: remission rates achievable by current therapies for inflammatory bowel disease. Aliment Pharmacol Ther. 33(8):870-9. https://www.ncbi.nlm.nih.gov/pubmed/21323689

Rheumatoid Arthritis: Prevention and Treatment with a Plant-Based Diet

This article was published on Oct 5, 2018, in the peer-reviewed Orthopedics and Rheumatology Open Access Journal.

Abstract

Rheumatoid arthritis has no cure, so long term treatment is indicated. An individual’s dietary choices greatly influence the progression of chronic autoimmune rheumatic diseases. This review shows that the plant-based diet has good scientific evidence of safety and efficacy for both prevention and treatment of rheumatoid arthritis. Studies have shown significant improvements in specific symptoms, such as number of tender joints, Ritchie’s articular index, number of swollen joints, pain score, duration of morning stiffness, grip strength, and improved laboratory values such as sed rate (ESR), C-reactive protein, and rheumatic factor. Patients placed on a plant-based diet also have a beneficial shift in intestinal microbiota, which correlates with clinical improvement. With respect to prevention, those following a plant-based diet experience a reduction in risk of rheumatoid arthritis by about 50%.

RA patients should be advised that a plant-based diet that includes appropriate amounts of carbohydrate, especially dietary fiber, is important for maintaining the symbiosis of intestinal flora, which could be beneficial for preventing autoimmunity. As disease severity worsens, individuals with RA may experience functional decline that can impact dietary intake. New healthy plant-based convenience foods are a good choice for such patients.

 Treatment with a plant-based diet is affordable for the patient, has no adverse reactions and no contraindications, and it can be combined with any of the standard treatments. For mild cases it may suffice as a monotherapy. For moderate and severe cases, it may serve as an adjunct, allowing dosage reductions thus lessening the costs and side effects.

See Dr Chan Hwang, Physical Medicine and Rehab, talk about the treatment of Crohn’s Disease and Rheumatoid Arthritis with a plant-based diet:

 

Introduction

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease of unknown etiology. There is no cure, so long term treatment is indicated. Medication-based therapies comprise several classes of agents, including nonsteroidal anti-inflammatory drugs (NSAIDs), non-biologic and biologic disease modifying anti-rheumatic drugs (DMARDs), immunosuppressants, and corticosteroids. Other standard treatments include physical therapy and surgery.

Surveys have shown that a substantial proportion of people with RA will try complementary and alternative interventions, perhaps reflecting the lack of complete satisfaction with conventional approaches, and also a desire to help themselves. (1)  In 1989, Arthritis Care noted that more than 50% of the Arthritis Care members who were surveyed, had invested in “unorthodox medicines, substances, or treatments (including diets), during the prior six months”. (2)

Today, with increased access to health care information has come a growing demand for safe, cost-effective and easy to administer therapies. While a number of purported treatments have questionable or no research behind them, one of these so-called “unorthodox treatments” does.  An individual’s dietary choices can greatly influence the progression and manifestation of chronic autoimmune rheumatic diseases. In light of these effects, it makes sense that the search for additional therapies to attenuate such diseases would include investigations into dietary modifications. (3)

Dietary interventions have a widespread appeal for both patients as well as clinicians due to factors including affordability, accessibility, and presence of scientific evidences that demonstrate substantial benefits in reducing disease symptoms such as pain, joint stiffness, swelling, tenderness and associated disability with disease progression. (4)

Epidemiology

There have been few studies on the risk of RA in relation to vegetarian status.  However, one good-sized study showed that non-vegetarian women had a 57% increased risk of RA, and semi-vegetarians an increased risk of 16%, when compared with vegetarian women. Non-vegetarian men showed an increased risk of 50% and semi-vegetarian men an increased risk of 14%. (5) These results are especially notable considering that the non-vegetarians in this study already had a relatively low consumption of meat.

Interventional studies

Many doctors have anecdotally noted an association between the consumption of animal-derived foods, especially meat, and Rheumatoid Arthritis. (6)

A meta-study on RA looked at studies on the effects of short-term modified fasting followed subsequently with plant-based diets lasting at least three months. The pooling of these studies showed a statistically and clinically significant beneficial long-term effect. Thus available evidence suggests that fasting followed by vegetarian diets might be useful in the treatment of RA. (7)

The effect of a one-year study on RA patients of brief (7-10 day) modified fasting, followed first by a vegan diet and then by a vegetarian diet was assessed in a randomized, single blind controlled trial. After four weeks, the diet group showed a significant improvement in the number of tender joints, Ritchie’s articular index, number of swollen joints, pain score, duration of morning stiffness, grip strength, erythrocyte sedimentation rate, C reactive protein, white blood cell count, and a health assessment questionnaire score. The improvements were still present at the end of one year. A significant drop in the levels of intestinal Proteus Mirabilis was observed. (8)

In a follow-up study of the same patients two years later, pain score, duration of morning stiffness, Stanford Health Assessment Questionnaire index, number of tender joints, Ritchie’s articular index, number of swollen joints, ESR and platelet count all maintained their improvement in patients who were responders. Interestingly, most patients who were originally in the vegetarian group, but switched back to their usual diet, reported an increase in disease symptoms after intake of meat. (9)

A separate one-year study of RA patients placed on a vegetarian diet, and focusing on clinical laboratory values, showed significant improvements in leukocyte count, IgM, RF (Rheumatic Factor), and the complement components C3 and C4, along with patient symptoms. (10)

It usually takes several months for a plant-based diet to reach full effect in RA. However, one study showed improvements in pain, joint swelling, severity in morning stiffness and limitation in function in only 4 weeks. There were also non-significant trends in the reduction of C-reactive protein and Rheumatic factor. Based on the results of other studies, these might have become significant with further time. (11)

Studies have noted a link between vegan diets and protection against other autoimmune diseases. For example, an analysis of an Adventist cohort found that a vegan diet, but not a vegetarian diet, was associated with a lower risk of hypothyroid disease. (12)

Several researchers have examined the role of gut bacteria in RA disease activity. (13, 14, 15, 16, 17)  Researchers Ling and Hänninen tested subjects on both a conventional Western diet and a vegan diet for one month, in order to determine the shift in intestinal flora. They found that four fecal hydrolytic enzymes, associated with toxic and inflammatory products, diminished during consumption of the vegan diet. However, these changes in fecal urease, choloylglycine hydrolase, β-glucuronidase and β-glucosidase, disappeared within two weeks of resuming a conventional diet. The authors attribute these reductions in fecal enzymes not only to the activity of bacteria during the dietary shift, but also to the high fiber content of the vegan diet which can affect fecal weight, transit time and bacterial metabolism. (18)

RA patients have been found to have higher levels of Proteus mirabilis antibodies, when compared with healthy controls or subjects with other diseases. The subjects from the vegetarian diet study had a significantly lower mean antibody level against Proteus mirabilis, which was correlated significantly with the measured decrease in disease activity. (19) This suggests that the improvement in RA disease activity may be related to the effects of the vegan diet on the presence of gut bacteria, such as Proteus mirabilis, and the body’s response to such bacteria.

The possibility that a vegan diet can induce a rapid change in gut profile was supported by studies of rheumatoid arthritis patients, in which a one-month switch to a vegan diet was sufficient to significantly alter the fecal microflora, as determined by stool sample gas-liquid chromatography profiles of bacterial cellular fatty acids. (20, 21)

Peltonen et al. conducted a study of RA patients and found a significant change in intestinal flora after a one-year shift from a conventional diet to a vegan and then a lactovegetarian diet. They also noted a significant difference between the fecal flora of test subjects in the high improvement group and the low improvement group, suggesting a direct connection between gut profiles and levels of disease activity. (22)

To further test the role of diet-induced changes in levels of various intestinal flora on rheumatoid arthritis activity, 43 RA patients were randomly assigned to either a raw vegan diet rich in lactobacilli, or an omnivorous diet. After one month, there was a significant change in the fecal flora of the 18 subjects in the vegan diet group who completed the study; no such change was found in the omnivore control group. Importantly, the vegan diet also induced a decrease in disease activity in some of the RA patients, leading the authors to conclude that changes in the intestinal flora are associated with diet-induced changes in disease activity. (20)

Kjeldsen-Kragh et al. followed upon their work by putting rheumatoid arthritis patients on a fast followed by 3.5 months of a vegan diet, followed by a 9-month lactovegetarian diet. (23) Subjects in the vegan then vegetarian diet group improved significantly over those maintained on an omnivorous diet. Similar to other studies, the authors found that subjects’ fecal flora during times of clinical improvement differed significantly from times of no or minor improvements. Others have found that a raw vegan diet rich in lactobacilli and fiber decreased symptoms of rheumatoid arthritis, suggesting that the probiotic lactobacilli, among other components of a raw vegan diet, may be helpful to RA patients. (24, 25, 26) One way that these bacteria are helpful is that they regulate the T cell phenotype and T cell mediated immunity. (27)

Caution is warranted in interpreting bacteriologic studies on vegan diets and RA. Although diet-induced modification in intestinal flora, and an associated reduction in inflammation severity, may be a contributing factor to the improvements seen in RA patients, it is important to note that other features of a vegan diet have been credited with alleviating RA symptoms among vegan diet adherents. These include an increase in fruit, vegetable and fiber intake, a reduction in saturated fat and caloric intake, improved antioxidant levels, weight loss, and a reduction in food allergies and intolerances. (28, 29, 17)

It has been observed that vegetarians consume enough foods naturally containing salicylates to have an anti-inflammatory effect. The presence of salicylate in the blood of patients placed on a vegetarian diet was found at concentrations that are known to inhibit the transcription of COX 2, a key inflammatory enzyme in various pathologies. An emphasis on those foods highest in salicylate might enhance the therapeutic effect of a plant-based diet and warrants further investigation. (30)

The low-fat vegan diet and diets rich in unsaturated fat (such as plant-based oils) or probiotics have positive effects at alleviating pain and on inflammation markers. (31) There was much hope for the role for Omega 3 fatty acids from fish oil. However, clinical studies on supplementation of ω-3 fatty acids have not supported the expectations. (32, 33, 34, 35, 36, 37)

Reduction of risk of Coronary Artery Disease (CAD)

Patients with rheumatoid arthritis (RA) have increased cardiovascular disease and mortality. (38, 39, 40) Several recent studies indicate an increased prevalence not only of cardiovascular disease (CVD) but also of atherosclerosis as determined by ultrasound tomography of carotid arteries. (38, 41, 42) The underlying mechanisms causing this increased risk are not wholly clarified but inflammation and disease duration are suggested to be of importance. (43, 44, 45, 46)

One study investigated the effects of a vegan diet, in patients with rheumatoid arthritis (RA), on the blood lipids: oxidized low-density lipoprotein (oxLDL) and on natural atheroprotective antibodies against phosphorylcholine (anti-PCs). The study examined the effects of intervention using a gluten-free vegan diet on patients with active RA. They were randomly assigned to either a vegan diet or a well-balanced non-vegan diet for one year. The gluten-free vegan diet induced significantly lower body mass index (BMI), low density lipoprotein (LDL), ox LDL, total cholesterol, and higher anti-PC IgM than control diet. Triglycerides and high-density lipoprotein did not change, since this was not a low fat vegan diet. Therefore a vegan diet in patients with RA induces changes that are potentially atheroprotective and anti-inflammatory, including decreased LDL and oxLDL levels, and raised anti-PC IgM and IgA levels. (47)

Clinical Considerations

Rheumatoid arthritis (RA) afflicts approximately 1.5 million American adults and is a major cause of disability. As disease severity worsens, individuals with RA may experience functional decline that can impact dietary intake. The diet quality of many individuals with RA needs improvement and may be related to functional disability associated with RA. Healthcare providers should encourage individuals with RA to meet dietary guidelines and maintain a healthy diet. Moreover, healthcare providers should be aware of the potential impacts of functional disability on diet quality in individuals with RA. (48)

Patients with rheumatoid arthritis often have trouble preparing foods that require manual dexterity and strength. These patients should be counseled to purchase the new healthy plant-based convenience foods that are now widely available. These foods are usually higher in fiber and lower in sugar, fat, sodium and calories than ordinary convenience foods. (49)

RA patients should be advised that a plant-based diet that includes appropriate amounts of carbohydrate, especially dietary fiber, is important for maintaining the symbiosis of intestinal flora, which could be beneficial for preventing autoimmunity. (27)

Active participation of the patient and family in the design and implementation of the therapeutic program helps ensure compliance, as does explaining the rationale for dietary treatment.

 This treatment may be sufficient as a monotherapy in mild cases, or can be used as an adjunct to standard treatments in moderate and severe cases. Dosages may be able to be titrated down as the clinical effects of the diet manifest themselves.

 

Discussion

Optimal care of patients with rheumatoid arthritis consists of an integrated approach that includes both pharmacologic and non-pharmacologic therapies. Medications have side effects which must be managed and are costly to the patient. Some of the non-pharmacologic treatments are available for this disease include physical therapy and surgery. (50) A plant-based diet should be added to this list.

Studies show that not only is a plant-based diet safe and efficacious for the prevention and treatment of Rheumatoid Arthritis, it has several advantages in its favor. It has no adverse effects, no contraindications, and it’s very affordable for the patient.  It can be combined with any standard treatment, and is likely to synergize treatments effects with them. It is safe in the long term, and has been shown to reduce the risk of comorbidities, such as coronary artery disease, in rheumatoid arthritis patients.

Further research should focus on the most effective dietary elements within plant-based diets.

Conflict of Interest

The authors state no conflicts of interest or funding sources.

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Vegetarian and Vegan Diets during Pregnancy

Both vegetarian and vegan diets are safe and can meet nutrient requirements with the supplementation of vitamin B12.[i]  According to the Vegetarian Position statement of the Academy of Nutrition and Dietetics (formerly known as the American Dietetic Association) “Well-designed vegetarian diets, that may include fortified foods or supplements, meet current nutrient recommendations and are appropriate for all stages of the life cycle, including pregnancy, lactation, infancy, childhood, and adolescence.”[ii]

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Thermal Burn Treatment – vegetarian diet just as good as meat-centered

About 450,000 burns in the US every year require medical attention, with about 40,000 requiring hospitalization.[i] A large body of evidence demonstrates the essential role of nutrition in wound healing. Without adequate nutrition, healing may be impaired and prolonged.[ii] Wound healing is the complex process of replacing injured tissue with new tissue produced by the body, which demands an increased consumption of energy and specific nutrients, particularly protein and calories.[iii] [iv]

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Cholelithiasis – prevention through a plant-based diet

The prevalence of cholelithiasis is about 10 percent to 15 percent of the population of the U.S., or well over 25 million people. Nearly 1 million new cases of gallstone disease are diagnosed every year and approximately one quarter of these require treatment. The burden of cholelithiasis and its complications, such as cholecystitis, pancreatitis, and cholangitis, are major public health problems. A 2006 study reported that more than 700,000 cholecystectomies were performed in the United States at a cost of $6.5 billion dollars annually.[i]

Most patients are asymptomatic, but approximately 20% become symptomatic after 10 years of follow up.[ii] A study of both symptomatic and asymptomatic sonographically-confirmed cholelithiasis cases, found that the prevalence of gallstones was 1.9 time higher in non-vegetarians than in vegetarians.[iii]

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The Superiority of Vegan Diets

A recent European study confirmed the superiority of plant-based or vegan diets. This study used several different indexing systems to rate the healthfulness of a wide spectrum of diets, from vegan to vegetarian, semivegetarian, pesco-vegetarian and omnivorous and concluded that, “the use of indexing systems, estimating the overall diet quality based on different aspects of healthful dietary models  indicated consistently the vegan diet as the most healthy one.”  The study goes on to say that, “the vegan diet received the highest index values and the omnivorous the lowest. Typical aspects of a vegan diet (high fruit and vegetable intake, low sodium intake, and low intake of saturated fat) contributed substantially to the total score, independent of the indexing system used.[i]

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Diverticular Disease risk reduction through diet

By age 60, two-thirds of all Americans will have developed diverticulosis.[i]  Twenty-five percent of patients with diverticulosis will go on to develop acute diverticulitis. This imposes a significant burden on healthcare systems, resulting in greater than 300,000 admissions per year with an estimated annual cost of $3 billion.[ii]

Back in 1979, a research article in the British journal, the Lancet, reported that the prevalence of diverticular disease in vegetarians was almost one third that of meat eaters. It was noted in this study that vegetarians had a mean intake of fiber of 42gm/day vs. 21 gm/day for meat eaters.[iii]

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