Key study question: Immune modulation of the gut microbiota through dietary components like fiber could be used to obtain beneficial outcomes in patients with multiple sclerosis 

Key study finding: This was a pilot study involving two groups of clinically similar relapsing-remitting (RR) MS patients who had undergone either a high-vegetable/low-protein diet (HV/LP diet group; N = 10) or a “Western Diet” (WD group; N = 10) for at least 12 months. 

Gut microbiota analysed after 12 months of diet showed that in the HV/LP diet group (1) Lachnospiraceae family was significantly more abundant; (2) IL-17-producing T CD4+ lymphocytes (p = 0.04) and PD-1 expressing T CD4+ lymphocytes (p = 0.0004) were significantly decreased; and (3) PD-L1 expressing monocytes (p = 0.009) were significantly increased. Lachnospiraceae was observed to favor Treg differentiation as well as TGFβ and IL-10 production.

The relapse rate during the 12 months follow-up period and the Expanded Disability Status Scale score at the end of the study period were significantly reduced in those with HV/LP diet. A high vegetable diet, rich in fiber may be beneficial in reducing relapses by improving the gut microbiota and, in turn promoting an anti-inflammatory state. 

Before discussing the paper this week, I wanted to mention that in our weekly reading paper “Pathogenesis and epidemiology of multiple sclerosis” it was mentioned that patients with inflammatory bowel diseases have an increased risk for demyelinating diseases, including MS. In the paper I chose for my Weekly Wall last week, it was indicated that inflammatory bowel diseases open the blood-brain barrier. Since it is speculated that T-cells cross the blood-brain barrier and activate an immune response that leads to demyelination, one could hypothesize that inflammatory bowel diseases allow the BBB to open enough for T-cells to begin crossing into the brain. 

This study is relevant to the above information because it reviewed how different situations could lead to the BBB opening and thus play a part in MS and how potentially treating these different targets could become effective therapeutic strategies. Specifically, I want to focus on their review of how MMPs (proteolytic enzymes involved in extracellular matrix remodeling) play a role in disease progression. The study discusses how MMPs cause degradation of the basement membrane and opens the BBB. Among MS patients there is an increased expression of certain MMPs found in CNS lesions. It has also been discovered that in patients with IBD, MMP expression is also upregulated (link below) which could explain why IBD patients have an increased risk for MS.

These findings could have important clinical implications. For example, the review discusses how minocycline can reduce MMP-9 activity and this has shown to significantly reduce the number of MRI-enhancing lesions in MS patients. It also has implications that having patients follow the general diet recommendations for IBD can lower their risk of developing MS.

https://www.hindawi.com/journals/mi/2015/964131/

This study is important because it brings to light that patients with Systemic Lupus Erythematosus (SLE) have a higher risk of developing cardiovascular disease than the general population.   The authors of this study point out that currently, cardiovascular disease is the leading cause of death in patients with SLE. As practitioners it is important not to forget that although nutrient deficiencies such as Vitamin D and protein may exist and anemia is a common challenge of patients with lupus that practitioners should address the benefits of a cardioprotective lifestyle (which includes anti-inflammatory dietary pattern) for patients with lupus. 

A pro-inflammatory diet is associated with less than favorable serum lipid profiles in patients with SLE.  

The study included 105 women with SLE and attempted to investigate the relationship between a proinflammatory diet and cardiovascular disease risk.  Patients with SLE are at a high risk for cardiovascular disease and the authors of this study suggest that an anti-inflammatory dietary pattern may play a role in cardiovascular disease management in patients with SLE.  On a personal note, I was very glad to have read this research article because I was not aware that patients with SLE were at higher risk for developing cardiovascular disease and therefore a cardio-protective dietary pattern and lifestyle modification strategies should be included as part of the disease management process for patients with SLE.    

This study evaluates the relationship between major identified dietary patterns and RA, in a specific population.  Due to the lack of studies assessing dietary patterns and RA in Middle Eastern populations, this study specifically looks at dietary patterns of Iranian adults.  The authors noted that many past studies have focussed on the effect of individual foods or specific nutrients, but not on identifying major dietary patterns in this population. 

The study is important for two reasons:  1) it studies a broader dietary food pattern in RA, important to better understanding dietary choices and influences that may contribute to RA risk factors, and 2) the study focusses on a specific geographic population, important to isolating how diet might impact disease in different parts geographic regions.

A 168-item questionnaire was used to collect dietary data which resulted in the identification of two primary dietary patterns that researchers labeled as Healthy and Western. The Healthy dietary pattern is more closely related to a Mediterranean diet (fish, egg, poultry, low-fat dairy, fruit) and the Western dietary pattern included processed food selections, red meat etc.  

The study results showed that lower adherence to the Healthy dietary pattern was associated with an increased risk of RA, even after taking other potential factors into account such as age, BMI and sex.  The results also demonstrated a significant association between adherence to a Western diet as defined in this study, and RA.

While the study indicated that additional research continues to be necessary to conclude that the Western diet as defined, has a causal effect on RA, the clinical implications continue to support that a Mediterranean (Healthy) dietary pattern may be supportive in preventing RA presentation, perhaps by altering systemic inflammatory responses.  As noted earlier, it is also important that this research is conducted in different study populations to find or eliminate additional variables that my impact the dietary pattern conclusions and global treatment recommendations.

One key finding from this study was that the incorporation of probiotics was a key factor in decreasing disease presentation. An ineffective microbiome is often seen in patients with RA. Probiotics are a great way to generate a healthy gut flora which help to modulate inflammation.

The clinical implications of this study is that providers should strive to address the importance of adherence to an anti-inflammatory diet to help manage disease presentation. The diet should emphasize poly-unsaturated fatty acids and probiotics. This in combination with other lifestyle modifications will help the patient achieve a greater quality of life. I think it is important to consider the quantity and quality of anti-inflammatory foods that must be consumed in order to see effects at the clinical level. Is this quantity feasible for the patient to afford and incorporate on a daily basis?

                           

Dey, M., Cutolo, M., & Nikiphorou, E. (2020, October 15). Beverages in rheumatoid arthritis: What to prefer or to avoid. Retrieved February 08, 2021, from https://www.mdpi.com/2072-6643/12/10/3155/htm

This study is important because it analyzes how different beverage consumptions can impact outcomes in RA patients. Different habitually consumed beverages were monitored. Key findings in this study show that high sugar diets increase the symptoms associated with CVD and RA. Amongst other findings, evidence was found that many drinks such as teas, fruit juices, and red wine, correlated with beneficial epigenetic, molecular, and clinical outcomes. 

In a clinical setting it would be very useful to give dietary counseling to those with RA. This has the ability to highlight the different impacts that the correct variety of different fluid intakes. A variety of beverages with diverse nutrient contents can be helpful on a case by case basis in order to control various symptoms that are indicated in RA.

 

Rheumatoid arthritis is a long-term, autoimmune inflammatory condition affecting around 0.25% of the global population. There are several genetic and environmental factors such as diet, tobacco and smoking, that make someone more susceptible to rheumatoid arthritis. There is evidence that suggests that there are dietary factors that might act as environmental triggers in genetically susceptible individuals leading to the development of rheumatoid arthritis with an immune-inflammatory response. The inflammatory response includes the production of soluble immune mediators such as cytokines and chemokines by joint tissue cells such as synovial fibroblasts, synovial macrophages and chondrocytes which leads to joint damage. Diet consisting on excessive red meat, salt, or increased in food intake has been categorized as trigger foods while fatty fish, fruits, and vegetables have been shown to reduce inflammation. A “Western” diet which can be characterized as an increased consumption of saturated fats, trans fats, low ratio of omega 3 and 6 fatty acids, as well as an increased consumption of refined carbohydrates and sugar-sweetened beverages is directly related to the increase in inflammation and increase insulin resistance. Obesity represents a rising comorbidity in the presence of rheumatoid arthritis because of the increase in inflammation and insulin resistance. Diet can play an important role in the reduced risk of rheumatoid arthritis. Evidence suggests eating lean meats such as fish that have long chain omega-3 polyunsaturated fatty acids is associated with reducing the risk in females by 35%. Consuming foods that have strong anti-inflammatory properties is found to be important factors for reducing rheumatoid arthritis.  Promoting a healthy diet and lifestyle change can determine the future for many individuals that are more susceptible to certain diseases. I believe this study proves that an overall healthy diet and lifestyle can change the course for any disease onset. 

Although genetics is a factor of Rheumatoid Arthritis, the environmental trigger is the key to genetically predisposed people.  Healthy lifestyle can be helpful to prevent onset or development of RA.  According to this study, RA patients often ask their rheumatologist for self-management strategies such as dietary habit and what to eat/avoid, resulting in more attention among the practitioners to utilize dietary advice to improve efficiency of pharmacological treatment.  This study is important to see evidence-based observation of Mediterranean diet, vitamin D, alcohol, tea, omega-3, caloric restriction, gluten, fasting, vegan diet, probiotics and more.  

This study report that, although there is no firm evidence in vitamin D to prevent RA, Mediterranean diets is a “protective dietary style” and effective suggestion of what to eat as well as weight control which affects on a remission stage and effectiveness of treatment.

This clinical implication is that, since RA is a long-term disease, the dietary manipulation and healthy lifestyle could be helpful to RA patients for less symptoms, slower progress, and less  pharmaceutical drug.

The main study finding was that after a 6-month period of patient-centered nutrition counseling, the SLE patients improved their food choices and intake, reduced their sodium and saturated fat intake, and increased their fruits and vegetable intake. Consequently, the risk of developing cardiovascular diseases can be decreased in those patients. However, due to a short intervention period, six months, there was not a significant improvement in lipid profile. 

The study’s clinical implication is that patient-centered nutrition counseling would be aided in reducing the risk of developing cardiovascular disease in SLE patients. Therefore, RDs are advised to use a patient-centered nutrition counseling strategy with those patients. 

One key finding is sodium regulation of the immune system. Sodium would control the positive correlation cytokines. Suppose the scientists discover how much salt intake results in inflammatory in the patients' bodies. The nutritionists advise that the patients manage their salt intake so that the patients may decrease their incidence. Besides, the mechanism will advance the therapy for autoimmune disease.

The study collects the patients' questionnaire, and distinguish in different autoimmune disease. The researchers can analyze which cytokinesis results from sodium and target regulation of elements. It will help treatment for the patients.

 

Citation: Pocovi-Gerardino G, Correa-Rodríguez M, Callejas-Rubio JL, et al. Beneficial effect of Mediterranean diet on disease activity and cardiovascular risk in systemic lupus erythematosus patients: a cross-sectional study. Rheumatology (Oxford). 2021;60(1):160-169. doi:10.1093/rheumatology/keaa210

                                        

Question 1:   Why is this study important?

Numerous studies have shown the benefits of adhering to a high-quality Mediterranean diet with a lower incidence of cardiovascular disease, metabolic syndrome, obesity, diabetes and recently on autoimmune diseases also.  Significant effect of this diet on the disease mechanisms and outcomes have been noted with rheumatoid arthritis and multiple sclerosis.  SLE remains one of the common autoimmune diseases and this patient's diarrhea very high risk of developing cardiovascular disease.  The study tries to analyze the influence of Mediterranean diet on SLE disease activity and cardiovascular disease risk markers.

Identify one key finding of this study and describe how it relates to nutritional sciences

This was a cross-sectional study which was performed on 280 patients with SLE under assessment of Mediterranean diet adherence was correlated.  Key findings from the study are:

1)     greater adherence to the Mediterranean diet was significantly associated with low disease activity which was calculated by the scoring systems, has improved inflammatory markers, and also had less active or inactive SLE disease

2)     significant correlation was also found between good Mediterranean diet adherence and low cardiovascular risk markers

3)     more interestingly the beneficial effect of midodrine rate was also seen in improvement of heart trouble metric data profiles like lower BMI and lower fat mass percentage

What are the clinical implications of this study? 

This is the first study to assess the correlation of Mediterranean diet on the SLE disease activity.  This effect might be secondary to the changes in the immune system, inflammatory markers and other cardiovascular disease risk factors which eventually affect the course and prognosis of these patients.  Specifically, in patients who have additional comorbidities like obesity, metabolic syndrome along with the SLE, having a single dietary plan that includes Mediterranean diet would improve adherence and address multiple comorbidities at the same time