Dieta Antiinflamatoria

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Rakel: Integrative Medicine, 2nd ed.

Copyright 2007 Saunders, An Imprint of Elsevier
chapter 88 The Anti-Inflammatory Diet

David Rakel, MD J. Adam Rindfleisch, MD, MPhil Measuring Inflammation 961 How Do Foods Cause (or Inhibit) Inflammation? 962 Essential Fatty Acids and Inflammation 962 Why Are Fatty Acids Essential? 962 How Are Fats Classified? 962 What Does Saturation Have to Do with How They Are Classified? 962 What Does Omega Mean in the Naming of Fatty Acids? 963 What Are Partially Hydrogenated Oils and How Are They Related to Trans-Fatty Acids? 963 How Does Partial Hydrogenation Promote Inflammation? 964 What Are Other Sources of Arachidonic Acid, and What Medicines Are Used to Inhibit its Influence? 964 What Is Gamma-Linoleic Acid? 964 What Is Delta-6 Desaturase and What Is Its Significance? 965 What Are Good Sources of Omega-3 Fatty Acids? 966 What Guidelines Should Be Followed for Buying Fish or Fish Oil? 966 How Long Will It Take for an Anti-Inflammatory Diet to Make a Change in the Body? 966 Does the Anti-Inflammatory Diet Have Any Adverse Effects? 966 How Are Omega-3 Supplements Dosed? 966 Diet and Inflammation: The Evidence 967 Conclusion 967 Chronic diseases affect more than 90 million Americans, accounting for 70% of all deaths and more than 75% of the nation's medical care costs. [1] Inflammation is at the root of many of these health problems, including cardiovascular disease, cancer, stroke, and Alzheimer's disease, all of which are among the top 10 causes of death in the United States. [2] It is true that the complex biochemical processes that cause inflammation evolved as part of the body's natural defenses, but in some instances, these processes ramp up to the point of excess, causing disease rather than promoting healing. In allopathic medicine, treating inflammation often involves prescribing anti-inflammatory medications or suppressing the symptoms caused by the inflammation, such as antipyretics for fever control or narcotics or nonsteroidal anti-inflammatory agents for pain. Other approaches are also potentially effective, however, with fewer potential adverse effects. This chapter focuses on how modifying the diet to reduce inflammation can have a major impact on the prevention and treatment of many common illnesses.
Measuring Inflammation
Inflammation encompasses hundreds of biochemical reactions within the body, and new inflammatory mediators are being discovered all the time. Researchers often evaluate the inflammatory effects of foods by exploring correlations between diet patterns and blood levels of various compounds. A study may be population-based or may use a specific dietary intervention as part of a prospective or randomized controlled
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trial. Some of the more commonly studied inflammatory mediators include the following: Now known to be an independent risk factor for cardiovascular disease, [3] the acute-phase Creactive protein (CRP) seems to be influenced by a number of dietary factors, including intake of trans-fats, [4] fiber consumption, [5] and diets that score highly (i.e., are more healthy) according to specific measurement instruments. [6] The serum value of interleukin-6 (IL-6) is often used as a proxy for overall level of inflammation. Its values are affected, for example, by the fatty acids one eats. [6] Levels of tumor necrosis factors (TNFs), especially the alpha subtypes, also vary with the types of essential fatty acids eaten. [6]
Other, less commonly measured values are levels of adhesion molecules such as selectins, components of complement C3, fibrinogen, and adiponectin.
How Do Foods Cause (or Inhibit) Inflammation?

Several mechanisms by which foods influence inflammation have been proposed; they are summarized in the following list: Pro-oxidant and antioxidant effects: Some foods lead to the production of highly reactive compounds that, although they help prevent infection, can also lead to significant inflammation and tissue damage. For example, increased overall antioxidant capacity in the diet correlates with increased CRP levels. [7] The use of high levels of individual antioxidant supplements in people with certain chronic diseases has been called into question by later studies, [8] but a diet with a varied mix of antioxidant-rich foods can potentially protect against damage induced by free radicals. For example, it has been found that higher dietary intake of two antioxidant carotenoids correlated well with a lower incidence of joint inflammation. Researchers concluded that a modest increase in betacryptoxanthin intake, equivalent to one glass of freshly squeezed orange juice per day, is associated with a reduced risk of developing inflammatory disorders. [9] Effects on insulin and glucose levels: Levels of insulin can be dramatically altered by the foods a person consumes. Certain foods, particularly products made of highly processed grains, can lead to a much higher spike in insulin levels than other, less processed foods. Liu and colleagues [10] found a strong link between high dietary glycemic load and elevated CRP concentrations in middle-aged women. Type 2 diabetes mellitus seems to be preceded by elevations in inflammatory markers. [11] There is also a connection between levels of glycation end products, which are higher in diabetic persons, and rises in levels of inflammatory markers. [12] Other mechanisms have also been proposed. [13] For additional information on managing the glycemic index, see Chapter 87 , Glycemic Index and Glycemic Load. Presence of specific compounds that directly alter inflammatory chemical reactions: Certain foods and dietary supplements contain compounds that, like medications, inhibit inflammation by acting on specific chemical pathways in the body. For example, turmeric contains compounds that suppress expression of cyclooxygenase-2, and animal studies have shown that myristicin in nutmeg inhibits release of TNF-alpha. [14] Of all the compounds that alter inflammation-related reactions, essential fatty acids have been the most thoroughly evaluated.
Essential Fatty Acids and Inflammation

Essential fatty acids are fats that the human body is unable to make on its own. They must be obtained by eating certain plants or the animals that eat those plants. Unlike humans, plants are able to make essential fatty acids from triglycerides.
Why Are Fatty Acids Essential?
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Fatty acids are needed to maintain cell membrane integrity and chemical transport. They are involved in proper development of the central nervous system, energy production, oxygen transport, and the regulation of inflammation.
How Are Fats Classified?

There are three types of fats: Saturated, such as beef fat and the fats in dairy products. Monounsaturated (omega-9 family) fats, such as olive oil and canola oil. Polyunsaturated fats (essential fatty acids, consisting of the omega-6 and omega-3 families), which have many different sources.
Examples of omega-6 fatty acids are linoleic acid (LA), gamma-linolenic acid (GLA), and arachidonic acid (AA). Examples of omega-3 fatty acids are alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). Fat sources are generally a combination of the three types, but some foods have a higher amount of one type of fat than another.
What Does Saturation Have to Do with How They Are Classified?

A fat is a chain of carbon atoms with a methyl group (CH3) on one end and a carboxyl group (COOH) on the other ( Fig. 88-1 ). Saturation describes how many hydrogen (H) atoms are connected to the carbon atom. If the fat is completely saturated with hydrogen, it will have no double bonds and will be called a saturated fat. If there is only one double bond (one carbon unsaturated with hydrogen), the fat is called a monounsaturated fat. The essential fatty acids are polyunsaturated and have multiple double bonds (many carbon atoms unsaturated with hydrogen).
FIGURE 88-1 Atomic makeup of a fat: a chain of carbon atoms with a methyl group on one end and a carboxyl group on the other.
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The more saturated the fat, the more stable it will be at room temperature. If we take samples of each fat (bacon grease, olive oil, and flaxseed oil) and put them in the refrigerator, we can see how their saturation can affect their physical state. The saturated fat turns to a more stable solid quickly, and the olive oil also turns solid but may need a colder temperature than the bacon fat. But the flaxseed oil stays liquid despite the cold temperature. The fact that polyunsaturated fats stay liquid at more extreme temperatures helps explain why cold-water fish are a good source of omega-3 fatty acids. Their high percentage of polyunsaturated omega-3 fatty acids helps keep their cell membranes functioning in cold waters. They incorporate this into their system by eating omega-3 rich foods such as algae. Unfortunately, the instability of these polyunsaturated fats also means that they will spoil quickly if left at room temperature for extended periods of time.
What Does Omega Mean in the Naming of Fatty Acids?

Omega describes where the first double bond is located. As shown in Figure 88-1 , in omega-3 fatty acids, the first double bond is after the third carbon, and in omega-6 fatty acids, it is after the sixth.
What Are Partially Hydrogenated Oils and How Are They Related to Trans-Fatty Acids?
Back in the 1950s, with the realization that saturated fats were harmful, scientists began to think of ways to use less dangerous fats in cooking (i.e., polyunsaturated). The danger was that polyunsaturated fats were unstable at room temperatures and if they were used to make crackers or chips, they would spoil quickly. The challenge was to manipulate these fats so that they would be more stable at room temperature. This manipulation is done through the process of hydrogenation. A large amount of a polyunsaturated fat, such as vegetable oil, is placed in a large metal vat that is connected to a source of hydrogen and then heated. Heating the oil does two things. It changes the fat from its natural cis form ( Fig. 88-2 ) to a more stable trans form, in which the methyl and carboxyl groups are on opposite sides of the carbon chain. Heating also breaks double bonds in the carbon chain, allowing the hydrogen gas to partially hydrogenate the oil.
FIGURE 88-2 Hydrogenation of polyunsaturated fat.
Partially hydrogenating (saturating) the oil and creating a trans-fatty acid allowed the oils to maintain freshness when used in foods such as Twinkies, which now could be preserved on shelves for prolonged periods. Partially hydrogenated vegetable oils became the main oil used in cooking, and margarines replaced butter. This change dramatically increased the intake of these fats in industrialized countries.
How Does Partial Hydrogenation Promote Inflammation?
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Partially hydrogenated oils are a major source of omega-6 fatty acids, subunits of the body's main inflammatory precursor, arachidonic acid (AA). Arachidonic acid leads to the production of the main proponents of the inflammatory cascade, prostaglandins of the two family (prostaglandin E2 [PGE2]) and leukotrienes ( Fig. 88-3 ). In contrast, omega-3 fatty acids have a more beneficial influence on inflammation. Omega-3 fatty acids lead to the production of less inflammatory prostaglandins of the one and three families (PGE1 and PGE3) and less inflammatory leukotrienes. The more omega-6 fatty acids in the body, the less the body is able to utilize the beneficial influences of the omega-3 fatty acids. In Paleolithic times, the ratio of omega-6 to omega-3 fatty acids in the diet was 1:1 to 2:1. [2] In the early 1900s the ratio in the Western diet was 4:1. This ratio dramatically increased to more than 25:1 by the end of the 20th century. One of the main goals in changing the diet is to try to reduce this ratio back to near 4:1. The change from an unprocessed diet in the early 20th century to one of more saturated fats and processed foods may play a role in the high incidence of chronic inflammatory conditions occurring in the 21st century.
FIGURE 88-3 Influence of omega-6 fatty acids and omega-3 fatty acids on inflammation.
Omega-6 fatty acids increase, while omega-3 fatty acids decrease, inflammation and platelet aggregation. Because of their stable configuration, trans-fatty acids require more energy for the body to metabolize as a source of energy. This results in greater production of free radicals, which increases the mobilization of arachidonic acid from the cell membrane. High levels of trans-fatty acids not only raise harmful low-density lipoprotein (LDL) cholesterol levels and lower beneficial high-density-lipoprotein (HDL) cholesterol levels, but also play a role in worsening inflammation. [15] [16]
What Are Other Sources of Arachidonic Acid, and What Medicines Are Used to Inhibit Its Influence?
Besides partially hydrogenated oils, animal products such as meat and dairy products are major sources of arachidonic acid. Research has shown that people with chronic inflammatory diseases such as rheumatoid arthritis are less symptomatic when they consume a vegetarian diet. The pharmaceutical industry has spent great amounts of money developing beneficial drugs that inhibit the influence of arachidonic acid in diseases such as arthritis, asthma, and inflammatory bowel disease ( Fig. 88-4 ). Such agents should not, however, be taken without the conscious effort to change the diet to reduce the load of arachidonic acid in the first place, instead of simply blocking its effects. Changing to a less inflammatory diet may help decrease the dependence on these medications. Figure 88-5 illustrates how certain foods, like medications, can influence
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the arachidonic acid pathway at different points.
FIGURE 88-4 Pharmaceutical inhibitors of arachidonic acid. AA, arachidonic acid; COX, cyclooxygenase; NSAIDs, nonsteroidal anti-inflammatory drugs.
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FIGURE 88-5 Food inhibitors of arachidonic acid. AA, arachidonic acid.
What Is Gamma-Linoleic Acid?

Gamma-linoleic acid (GLA) is an omega-6 fatty acid that is found in evening primrose oil, black currant oil, and borage oil. These oils are often used for treatment of dermatologic and gynecologic inflammatory conditions. Their benefit is thought in part to be due to GLA's ability to stimulate the production of less inflammatory PGE1 (see Fig. 88-3 ). Unfortunately, GLA has a greater influence on the stimulation of the more inflammatory arachidonic acid than omega-3 fatty acids do. Because the goal is to improve the ratio of omega-6 to omega-3 fatty acids, it would be best to use GLA-containing oils therapeutically only for the short term until more is known about their mechanism of action. Increasing consumption of omega-3 sources of fatty acids will have more beneficial long-term effects.
What Is Delta-6 Desaturase and What Is Its Significance?

Delta-6 desaturase is the main enzyme that both omega-6 and omega-3 fatty acids use in the cascade of events that leads to the production of prostaglandins and leukotrienes (see Fig. 88-3 ). Certain situations influence this enzyme to catalyze reactions along the omega-6 pathway, resulting in larger numbers of
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inflammatory mediators. [17] This shift can be caused by excessive alcohol consumption, diabetes, stress, and a high ratio of omega-6 to omega-3 fatty acids. This finding may help explain why these conditions are associated with a high risk for inflammatory complications.
What Are Good Sources of Omega-3 Fatty Acids?

Research on the health effects of essential fatty acids was initially triggered by an epidemiologic study of the Greenland Inuit Eskimos, who were found to have a significantly lower rate of heart attacks than Western controls. [18] This difference was thought to be related to the high amount of fish products the Inuit Eskimos consumed. Cold-water fish, including salmon, mackerel, sardines, herring, and albacore tuna, are excellent sources of omega-3 fatty acids. Fish oils are sources of both EPA and DHA, both of which have antiinflammatory effects that do not require the use of delta-6 desaturase. Unlike other omega-3 sources (flaxseed) that require enzymes to have beneficial effects on inflammation, fish oil has a more direct effect. This difference may partly explain its positive effects in heart disease and other chronic illnesses with an inflammatory component. One of the richest sources of omega-3 fatty acids is flaxseed. Flax can be used in different ways. It can be ground in a coffee grinder and sprinkled on cereals and salads. Its oil can be used alone or on foods. The best way to store flax is in the seed form. Once it is ground or oil is made, the product can break down when heated, so it should be kept refrigerated and used promptly. Other sources of omega-3 fatty acids are nuts (particularly walnuts), dark green leafy vegetables, soybeans, algae, and hemp seeds.
What Guidelines Should Be Followed for Buying Fish or Fish Oil?

Not all fish products are the same. If available, wild fish from northern waters are better sources of omega-3 fatty acids. Eating of farm-raised fish should be avoided. The problem with most farm-raised fish is that they are fed foods such as cornmeal, which have low amounts of omega-3 fatty acids. Wild fish eat a lot of algae, a rich source of omega-3 fatty acids.
How Long Will It Take for an Anti-Inflammatory Diet to Make a Change in the Body?
It can take from 6 weeks to 6 months for this type of diet to change the ratio of omega-6 to omega-3 fatty acids and have a noticeable clinical effect. This change should be viewed as a positive one that is not simply used for a short period but is incorporated into one's normal lifestyle.
Does the Anti-Inflammatory Diet Have Any Adverse Effects?

Omega-3 fatty acids have minimal associated adverse effects. [19] Fish oil supplements may cause a fishy aftertaste or mild dyspepsia, and occasional patients have nausea and loose stools. Freezing the supplements, taking them in divided doses, and taking them with food can often prove helpful. There is an increased risk for vitamin A toxicity with the use of cod liver oil. Although there is some evidence that fish oils may inhibit platelet aggregation and cause bleeding at doses greater than 3 gm/day, these effects have not been noted in studies using higher doses. Nonetheless, the clinician should keep this possibility in mind when prescribing omega-3 supplements to patients who are also taking anticoagulant medications. Studies of various fish oil products indicate that most widely distributed brands are much less likely than fish itself to be contaminated by mercury, polychlorinated biphenyls, and other toxic compounds because of the purification that is completed with processing. Fish oil capsules may be preferable to fish as an omega-3 fatty acid source for pregnant women and children. Studies including children have used a dose of 17 to 27 mg per kg of EPA and approximately 7 to 11 mg per kg of DHA. [19]
How Are Omega-3 Supplements Dosed?

For treatment of an active inflammatory process, 2 to 4 gm/day of total fish oil is recommended. For prevention of heart disease and other inflammatory conditions, 1 gm/day is sufficient. Sources include fish
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oils (EPA/DHA) and flaxseed oil. It is important to remember that more is not better and that taking an excess amount of omega-3 fatty acids can worsen inflammation. When the body metabolizes fat to make energy, free radicals are produced that are usually handled by the body without trouble. But if excessive amounts of fatty acids are used, a large amount of free radicals overwhelm the body's antioxidants and increase the mobilization of arachidonic acid, thereby worsening inflammation. For this reason, those using high doses of omega-3 fatty acids for prolonged periods should also take antioxidants. A recommended regimen would include vitamin E 400 IU, vitamin C 200 mg, and selenium 200 g daily. OMACOR (Reliant Pharmaceuticals, www.reliantrx.com ), a fish oil product approved by the U.S. Food
and Drug Administration, is prescribed at 4 gm daily as either a single dose or two divided doses. It should be kept in mind that fish oil dosing and actual dose of omega-3 fatty acids are not the same. Typically, 1 gm of fish oil contains approximately 180 mg of EPA and 120 mg of DHA. A 1.5:1 ratio of EPA to DHA is common in many supplements. Fish oils average 300 mg of omega-3 fatty acids per gram, whereas flaxseed oil has 700 mg per gram. Cod liver oil has 200 mg of omega-3 fatty acids per gram. Other sources, such as soy, canola, and walnut oils, average about 100 mg of omega-3 fatty acids per gram.
Diet and Inflammation: The Evidence

The challenge with describing a specific anti-inflammatory diet is that there is wide variation in how studies linking diet and inflammation are conducted. Some studies evaluate the effects of specific foods or overall diet habits on various laboratory markers. For such studies, it is important to ask how closely those markers correlate with the development of specific chronic diseases. Table 88-1 provides a summary of some key studies of this type. TABLE 88-1 -- Links Between Diet and Inflammation DIET OR SPECIFIC TYPE OF FOOD STUDIED Prudent diet (relatively higher intake of fruits, vegetables, legumes, fish, poultry, and whole grains) Diets scoring well on the Healthy Eating Index (HEI; a score that accounts for a number of components of healthy diet) Mediterranean diet Diets scoring well on various diet quality measurement instruments Fruit and vegetable consumption
EFFECTS ON INFLAMMATION
Nurses' Health Study cohort showed significantly lower levels of CRP and other markers than group eating more red meat, sweets, desserts, refined grains, and French fries. [22] Based on NHANES III. A good overall diet is linked to a lower overall CRP value. [23]
Much lower levels of various inflammatory markers in Mediterranean versus westernized Greek diet.24 HEI and alternate Mediterranean Diet Index scores for Nurses' Health Study participants showed correlations with healthy overall diets and inflammatory markers. Two other scales did not correlate well. [25] No correlation after 6 weeks with CRP levels in one study, [26] but a positive correlation after 4 weeks in another of healthy nonsmoking men. Other immune markers did not change. High long-term consumption of fruits and vegetables was tied to low CRP values in a population-based study. [27] Fiber intake (usually in doses approaching 30 gm/day) led to decreases in markers of inflammation in several studies. [5] [28] Documented effects in human studies on levels of leukotriene B4s, prostaglandins E2 and E2", and other pro-inflammatory compounds. [2] [29] [30] In one study, omega-3 levels correlated with lower TNF levels, and it was noted that it was the ratio of omega-3 to omega-6 fats that seemed to have the largest impact. [6]
Fiber consumption Foods high in omega-3 fatty acids
Foods containing magnesium (e.g., Magnesium intake at recommended amounts was linked to lower CRP
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green leafy vegetables, legumes, whole grains, molasses, nuts, seeds, and chocolate) values in the Women's Health Study [31] and NHANES. [32] (A general rule for dosage is 6 mg per kg body weight.)
CRP, C-reactive protein; NHANES, National Health and Nutrition Examination Survey; TNF, tumor necrosis factor. Other research focuses on the effects of diet on specific medical conditions. Symptom scores or quality-of-life measures are used to monitor disease activity. Table 88-2 provides a summary of some of the main conditions for which anti-inflammatory diet modifications have shown or are likely to show promise. It should be remembered that much research remains to be done in the area of diet and inflammation, and theoretically, any condition that has an inflammatory component may respond to dietary modifications. The overall risk of harm from using such approaches tends to be minimal. TABLE 88-2 -- Medical Conditions That May Improve with the Anti-Inflammatory Diet [*] CONDITION COMMENTS Coronary heart disease A 2002 review concluded that diets using nonhydrogenated unsaturated fats as the predominant form of dietary fat, whole grains as the main form of carbohydrates, an abundance of fruits and vegetables, and adequate omega3 fatty acids can offer significant protections against CHD. [33] The American Heart Association recommends the use of omega3 fatty acids for cardiac risk reduction. [34] The GISSI study found that people taking 850 mg/day of an omega3rich oil had 15% fewer cardiac events, a 20% lower mortality, and a 45% decrease in incidence of sudden cardiac death in comparison with controls. [35]
Type 2 diabetes Type 2 DM is preceded by and correlates with high levels of inflammatory markers. [10] [11] mellitus Dietary patterns that correlate with type 2 DM simultaneously correlate with higher levels of inflammation. [36] Insulin resistance is closely associated with plasma fatty acid patterns. [37] Rheumatoid arthritis Vegetarian diets and intake of fish oil decrease numbers of tender and swollen joints. [38] A 1999 review noted average symptom scores to be decreased by roughly a third. [39] A group of patients with rheumatoid arthritis who consumed 1.8 gm/day of EPA were found to have a decrease in the amount of morning stiffness and tender joints compared to controls. [40] There is a strong link between COPD and chronic systemic inflammation. lower inflammatory cytokines in COPD patients. [43]
[41] [42]
Chronic obstructive pulmonary disease Alzheimer's disease
Omega3#s
Antioxidant intake linked to decreased risk. [44] Consumption of fish, monounsaturated fats, cereal, and wine seems to protect against cognitive decline. [45] Highcarbohydrate diets may correlate with increased Alzheimer's risk. [46] A 2005 review concluded that a link between omega3 fats and cognitive function remains to be fully established. [47] Study results vary, but a 2000 overview stated that there was a potential effectiveness for omega3 fatty acids to treat IBD. [48] A supplement rich in vitamin E, C, and selenium, fructo oligosaccharides and omega3s improved clinical response and decreased steroid needs. [49] 8 months of omega3 supplementation found to decrease inflammation in CF. [50] A 2004 review concluded that results are promising but more trials are needed. [51] Lowers risk of premature birth, promotes fetal growth. May help to prevent preeclampsia and postpartum depression. [52] A suspected link exists between lower levels of omega3 fatty acids and atopic disease. [53] Hempseed oil, with high omega3 content, decreases atopic dermatitis symptoms. [54] One study of patients with seasonal allergies did not find a link with ratio of omega6 to omega3 fatty acids, [55] but another did find a link with the ratio and also with margarine consumption in men. In women, high consumption of fats, including monounsaturates, raised allergy risk. [56]
Inflammatory bowel disease Cystic fibrosis Prevention of pregnancy complications Atopic disease
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Supplementation in pregnancy and early postnatal period may prevent atopy in infants. [57] Asthma Hamburger consumption has a dosedependent relationship with asthma symptoms. [58] Fish oil supplements decrease symptoms, inflammation, and medication use in exerciseinduced asthma. [59] There is promising epidemiologic evidence for an omega3 benefit, but study results have been equivocal. [60] A diet high in polyunsaturated fats doubled preschool children's risk for development of asthma. [61] A small trial showed that a mostly raw vegetarian diet diminished fibromyalgia symptoms significantly. [62] A small study showed that a vegan diet (no milk, meat, or eggs) improved symptoms. [63] Omega3 fats have been linked in preclinical studies to (1) decreases in inflammatory mediators involved in cancer cell growth, (2) drops in mitosis rates, (3) less activation by arachidonic acid of oncogenic transcription factors, (4) increased differentiation in certain types of cancer cells, which reduces their chances of multiplying, and (5) inhibition of angiogenesis. [64] High intake of meat and dairy products is tied to higher risk of prostate cancer, and high intake of tomato and fish consumption to a lower risk. [65] Higher levels of fruit and vegetable consumption decrease bladder cancer risk in smokers. [66] There may be a correlation between higherglycemicindex diets and risk of breast cancer [67] and colon cancer, at least in men. [68]
Fibromyalgia
Cancer
CF, cystic fibrosis; CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; EPA, eicosapentaenoic acid; GISSI, Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico; IBD, inflammatory bowel disease.
* Other studies indicate that an antiinflammatory diet may also be helpful for seborrheic dermatitis, [69] ultravioletinduced skin
damage, [70] chronic neuropathy, [71] macular degeneration, [72] depression, and multiple sclerosis and schizophrenia. [73] Animal studies indicate the possibility that, when given to pregnant females, omega3 fats may prevent chronic diseases such as hypertension in their adult offspring. 74 While further research is needed, it is reasonable to believe that diets which lower inflammation will also decrease chronic pain symptoms.
Low-carbohydrate diets, such as the Atkins and Zone diets, help people lose weight when used for short periods. [20] Unfortunately, however, these diets are very high in foods rich in arachidonic acid, such as animal products. Following such diets for extended periods would not be wise, particularly for persons with active inflammatory conditions. Eating plans such as those set out by Weight Watchers and the Ornish Diet may be less inflammatory when used in the long term. O'Keefe and Harris have conducted a good review of more than 4500 of the earliest studies related to omega-3 fatty acids. [18]
Conclusion
Seaman, [21] in a review of the diet-induced proinflammatory state, concluded, We can no longer view different diseases as distinct biochemical entities. Nearly all degenerative diseases have the same underlying biochemical etiology, that is, a diet-induced proinflammatory state. Although specific diseases may require specific treatments the treatment program must also include nutritional protocols to reduce the proinflammatory state. A great deal of research remains to be done on the links between inflammation and various disease states, not to mention the efficacy of the anti-inflammatory diet for various disorders. However, the current body of available evidence supports the use of the dietary approaches described in this chapter as part of an integrative approach to dealing with a number of chronic illnesses.
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42. Matsuyama W, Mitsuyama H, Watanabe M: Effects of omega-3 polyunsaturated fatty acids on inflammatory markers in COPD. Chest 2005; 128:3817-3827.
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43. Barranco-Quintana JL, Allam MF, Del Castillo AS, et al: Risk factors for Alzheimer's disease. Rev Neurol 2005; 40:613-618. 44. Panza F, Solfrizzi V, Colacicco AM, et al: Mediterranean diet and cognitive decline. Public Health Nutr 2004; 7:959-963. 45. Henderson ST: High carbohydrate diets and Alzheimer's disease. Med Hypotheses 2004; 62:689-700. 46. Maclean CH, Issa AM, Newberry SJ: Effects of omega-3 fatty acids on cognitive function with aging, dementia, and neurological diseases. Evid Rep Technol Assess (Summ) 2005; 114:1-3. 47. Belluzzi A, Boschi S, Brignola C: Polyunsaturated fatty acids and inflammatory bowel disease. Am J Clin Nutr 2000; 71(Suppl):339S-3342S. 48. Seidner DL, Lashner BA, Brzezinski A, et al: An oral supplement enriched with fish oil, soluble fiber and antioxidants for corticosteroid sparing in ulcerative colitis: A randomized, controlled trial. Clin Gastroenterol Hepatol 2005; 3:358-369. 49. De Vizia B, Raia V, Spano C, et al: Effect of an 8-month treatment with omega-3 fatty acids (eicosapentaenoic and docosahexaenoic) in patients with cystic fibrosis. J Parenter Enteral Nutr 2003; 27:52-57. 50. Cawood AL, Carroll MP, Wootton SA, et al: Is there a case for w-3 fatty acid supplementation in cystic fibrosis?. Curr Opin Clin Nutr Metab Care 2005; 8:153-159. 51. Saldeen P, Saldeen T: Women and omega-3 fatty acids. Obstet Gynecol Surv 2004; 59:722-730. 52. Duchen K, Bjorksten B: Polyunsaturated w-3 fatty acids and the development of atopic disease. Lipids 2001; 36:1033-1042. 53. Callaway J, Schwab U, Harvima I: Efficacy of dietary hempseed oil in patients with atopic dermatitis. J Dermatolog Treat 2005; 16:87-94. 54. Kompauer I, Demmelmair H, Koletzko B: Biologically plausible, but not confirmed. w6/w3 hypothesis and allergies. Eur J Med Res 2004; 9:378-382. 55. Trak-Fellermeier MA, Brasche S, Winkler G, et al: Food an fatty acid intake and atopic disease in adults. Eur Respir J 2004; 23:575-582. 56. Prescott SL, Calder PC: w-3 polyunsaturated fatty acids and allergic disease. Curr Opin Clin Nutr Metab Care 2004; 7:123-129. 57. Wickens K, Barry D, Friezema A, et al: Fast foods are they a risk factor for asthma?. Allergy 2005; 60:15371541. 58. Mickelborough TD, Rundell KW: Dietary polyunsaturated fatty acids in asthma- and exercise-induced bronchoconstriction. Eur J Clin Nutr 2005; 59:1335-1346. 59. Wong KW: Clinical efficacy of w-3 fatty acid supplementation in patients with asthma. J Am Diet Assoc 2005; 105:98-105. 60. Haby MM, Peat JK, Marks GB, et al: Asthma in preschool children: Prevalence and risk factors. Thorax 2001; 56:589-595. 61. Donaldson MS, Speight N, Loomis S: Fibromyalgia syndrome improved using a mostly raw vegetarian diet: An observational study. BMC Complement Altern Med 2001; 1:7. 62. Kaartinen K, Lammi K, Hypen M: Vegan diet alleviates fibromyalgia symptoms. Scand J Rheumatol 2000; 29:308-313.
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Patient Handout
The Anti-Inflammatory Diet
Inflammation is one of the body's natural ways of protecting itself. Inflammation comprises the many chemical reactions in the body that help fight off infections, increase blood flow to places that need healing, or generate pain to signal that something is wrong with the body. Unfortunately, like any process in the body, it is possible to have too much of a good thing. A number of medical conditions are linked to too much inflammation in the body. Some of them are as follows: Heart disease Stroke Cancer Chronic obstructive lung diseases (emphysema and bronchitis) Asthma Chronic pain Type 2 diabetes mellitus Inflammatory bowel disease (Crohn's disease, ulcerative colitis) Alzheimer's disease
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Diseases in which the immune system attacks the body, such as rheumatoid arthritis, systemic lupus erythematosus, and scleroderma
Often, people take medications to decrease inflammation. These medicines can change the body's chemical reactions. More and more research is showing that other things can change them too. The things we have control over, such as our stress level, how much exercise we get, and the types of food we eat, influence how much inflammation we have in our bodies. It is possible to eat in ways that decrease inflammation and, thereby, the pain and other symptoms of disease. Many studies have shown that people who eat certain type foods are less likely to have the health problems just listed. Some important guidelines for people who want to eat an anti-inflammatory diet are given here.
1: Replace Saturated and Trans-Fatty Acids with Olive Oil and Omega-3 Fatty Acids
Avoid unhealthy fats. Trans-fats and fats that are high in omega-6 fatty acids cause inflammation. These fats are found in many animal products and in any food designed to have a long shelf-life. Mono-unsaturated fats, like olive oil, are better choices. Omega-3 fats, such as fish oil and flaxseed oil, are especially good for decreasing inflammation.
2: Eat Plenty of Fruits and Vegetables

Eat fruits and vegetables. Many studies are showing that a diet high in fruits and vegetables is good for decreasing inflammation. The more servings eaten, the better; 8 to 10 servings is a good goal.
3: Eat Fiber
Diets high in fiber are shown to help to decrease inflammation. A good goal is about 30 grams a day, ideally from a diet of whole grains, fruits, and vegetables. The following list shows the foods to eat or avoid to control inflammation.
Information in this chart compiled from Rakel D, Rindfleisch A: Inflammation: Nutritional, botanical, and mindbody influences. South Med J 98:302-310, 2005.
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Dieta Antiinflamatoria

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chapter 88 - The Anti-Inflammatory Diet from Rakel: Integrative Medicine on MD Con...

Rakel: Integrative Medicine, 2nd ed.

chapter 88 The Anti-Inflammatory Diet

How Do Foods Cause (or Inhibit) Inflammation?

Essential Fatty Acids and Inflammation

Why Are Fatty Acids Essential?

How Are Fats Classified?

What Does Saturation Have to Do with How They Are Classified?

What Does Omega Mean in the Naming of Fatty Acids?

FIGURE 88-2 Hydrogenation of polyunsaturated fat.

How Does Partial Hydrogenation Promote Inflammation?

FIGURE 88-5 Food inhibitors of arachidonic acid. AA, arachidonic acid.

What Is Gamma-Linoleic Acid?

What Is Delta-6 Desaturase and What Is Its Significance?

What Are Good Sources of Omega-3 Fatty Acids?

What Guidelines Should Be Followed for Buying Fish or Fish Oil?

Does the Anti-Inflammatory Diet Have Any Adverse Effects?

How Are Omega-3 Supplements Dosed?

Diet and Inflammation: The Evidence

Fiber consumption Foods high in omega-3 fatty acids

Chronic obstructive pulmonary disease Alzheimer's disease

2: Eat Plenty of Fruits and Vegetables

Copyright 2010 Elsevier Inc. All rights reserved. - www.mdconsult.com

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