The talk focused on "Nutritional Interventions in Autoimmune Diseases (AD)", the subject being hotly debated and fast progressions taking place. Established guidelines incorporate these findings increasingly as the topic gains prominence in disease prevention/ modification and are of interest to any healthcare professional. The presentation includes: - A brief overview of the prevalence and cost of AD, - Problems with current treatment approaches, - A short overview of the genesis of AD - The role our environment (incl. our food) plays - Finally a solution suggesting an oligoantigenic elimination diet - A "Paleo Autoimmune Protocol" is proposed and some clinical practice insights are given. Thanks very much to everybody who attended the talk. I am looking forward to receive your questions, concerns and feedback!

1. Nutritional Interventions in
Autoimmune Diseases
Academic talk, Christiaan Barnard Memorial Hospital
24th January 2013
Thursday 24 January 2013 1

2. GOOD MORNING. Who’s talking
PAST PRESENT
Universities of Helping people to get
Düsseldorf and Cape off drugs rather than
Town supplying them
2nd pharmacist in Working independently
Europe’s biggest mail in own practice -
order pharmacy: No disclosures
Docmorris
Grey Healthcare/ Not favouring any
working for particular Supplement®
Big Food and Pharma
Pfizer Animal Health
EUAfME
Christoph Lenz
Pharmacist & nutritional coach
2
Thursday 24 January 2013 2

3. DEFINITION of Autoimmune Disease
The basic definition of an autoimmune disease is a disorder caused by an
autoimmune response, i.e., an immune response directed to something in
the body of the patient. Since autoimmunity can affect any organ in the body
(including brain, skin, kidney, lungs, liver, heart, and thyroid), the clinical
expression of the disease depends upon the site affected. In our system of highly
compartmentalized medicine, patients with autoimmune disease may be cared
for by physicians in virtually any medical specialty.
The presence of an autoimmune response is signaled by the appearance of
autoantibody in the circulation, and so the demonstration of a particular
autoantibody usually constitutes the path to recognize an autoimmune
disease.
Diagnosis done by specialists
Many patients are not or mis-diagnosed
Thursday 24 January 2013 3

4. PREVALENCE of Autoimmune Diseases
According to the American Autoimmune Related
Diseases Association (AARDA), it is estimated that
50 million Americans have an autoimmune
disease. (Cancer 9 million, CVD 22 million)
Autoimmune diseases affect women 75
percent more often than men. The cause of
this sex bias is not fully known.
Most autoimmune diseases are relatively rare, and
most are not fatal. They never appear on the
public "radar screen" as a serious health
problem requiring more attention and more
funding. Taken together, however, the autoimmune
diseases occupy the third or fourth place in
the list of prevalent diseases in the US.
Thursday 24 January 2013 4

5. PROGRESS in Health Care
$100M
$10M Moore’s Law
$1M
$100k
$10k
$1k
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Cost of 1GB memory in the 80s ~ $1 000 000
.
Analysis of 1 Megabase DNA costs <10 Cents in 2012
National Human Genome Research Institute
genome.gov/sequencingcosts
Thursday 24 January 2013 5

6. COSTS of Autoimmune Diseases
NIH estimates annual direct health care costs
Runner
Autoimmune diseases > $100 billionup
Cancer $57 billion
Best
price
Heart and stroke $200 billion
AARDA, NCAPG; The Cost Burden of Autoimmune Disease; 2011
Thursday 24 January 2013 6

7. REPERCUSSIONS of AD
“... patients face a lifetime
of illness and treatment.
They often endure
debilitating symptoms,
loss of organ function,
reduced productivity at
work, and high medical
expenses.”
NIH, Autoimmune Diseases Coordinating Committee, Progress in
Autoimmune Diseases Research, Report to Congress 2005
Thursday 24 January 2013 7

8. CAUSAL Factors of Autoimmune Disease
Genetic
Pollutants/ toxins
Infectious agents
Microbiome
Environmental triggers
Food
Polyautoimmunity and familial autoimmunity are common
What is the red thread?
Thursday 24 January 2013 8

9. Autoimmune diseases
>33% already linked to “Leaky gut”
Disease Organ/ tissue involved Source
Allergies various Liu et al. Acta Paediatrica 2005, 94, 386-93
Ankyllosing Spondylitis Skeletal system Vaile JH et al. J. Rheumatol. 1999, 26, 128-35
Aphthous stomatitis Mouth Veloso FT et al. Hepatogastroenterol. 1987, 34, 36-7
Asthma Lungs Benard A et al. J. Allergy Clin. Immun. 1996, 97, 1173-8
Autism Nerve/ brain White JF. Exp. Bio. Med. 2003, 228, 639-49
Autoimmun gastritis GIT Greenwood DL et al. Eur. J. Pediatr. 2008, 167, 917-25
Autoimmune hepatitis Liver Terjung B Clin. Rev. Allergy Immunol. 2009, 36, 40-51
Morbus Behçet Small blood vessels Fresko I et al. Ann. Rheum. Dis. 2001, 60, 65-6
Celiac disease Gut Schulzke JD et al. Pediatric. Res. 1998,43, 435-41
Chronic fatigue syndrome (CFS) Multiple Maes M et al. Neuroendol. Lett. 2007, 28, 739-44
Crohn’s disease Gut Caradonna L et al. J. Endotoxin. Res. 2000, 6, 205-14
Depression Brain, gut Maes M et al. Neuroendocrinol. Lett. 2008, 29, 117-24
Morbus Duhring (dermatitis herpet.) Skin (men > women) Kieffer M et al. Br J. Dermatol. 1983, 108, 673-8
Diabetes Typ I Pancreas Sapone A et al. Diabetes 2006, 55, 1443-49
Eczema Skin Hamilton et al. Q. J. Med. 1985, 56, 559-67
Gut migraine children Gut Amery WK et al. Cephalalgia 1989, 9, 227-9
“Dietary Mechanisms of Autoimmunity”, Loren Cordain, Ph. D
Thursday 24 January 2013 9

10. Autoimmune diseases
>33% already linked to “Leaky gut”
Disease Organ/ tissue involved Source
Hashimoto’s thyroiditis Thyroid Sasso FC et al. Gut 2004, 53, 1878-80
IgG Nephropathy Kidney Rostoker G et al. Nephron. 1993, 63, 286-290.
Intrahep. cholestasis of pregn. Liver/ gallbladder/ GIT Reyes H et al. Hepatology 2006, 43, 715-22
Juvenile Arthritis Collagen/ joints Picco P et al. Clin. Exp. Rheumatol. 2000, 18, 773-8
Lupus erythematosis Multiple Apperloo HZ et al. Epidemiol. Infect. 1994, 112, 367-73
Multiple sclerosis Nerve/ brain Yacyshyn B et al. Dig. Dis. Sci. 1996, 41, 2493-98
Pemphigus-diseases Skin Kieffer M et al. Br J. Dermatol. 1983, 108, 673-8
Primary biiary cirrhosis Liver/ gallbladder/ GIT Di Leo V et al. Eur. J. Gastro. Hepatol. 2003, 15, 967-73
Psoriasis Skin Hamilton et al. Q. J. Med. 1985, 56, 559-67
Rheumatoid arthritis Joints Smith MD et al. J. Rheumatol. 1985, 12, 299-305
Rosacea Skin Kendall SN. Exp. Dermatol. 2004, 29, 297-99
Schizophrenia Brain Wood NC et al. Br. J. Psychiatry 1987, 150, 853-6
Skleroderma Connective tissue Caserta L et al. Rheumatol. Int. 2003, 23, 226-30
Sclerosing Cholangitis Liver Terjung B Clin. Rev. Allergy Immunol. 2009, 36, 40-51
Spontanous abortion Uterus Friebe A Int. J. Biochem. Cell Biol. 2008, 40, 2348-52
Ulcerative colitis Gut Caradonna L et al. J. Endotoxin Res. 2000, 6, 205-14
Urticaria Skin Buhner S et al. Allergy 2004, 59, 1118-23
Uveitis Eye Benitez JM et al. Eye 2000, 14(pt 3A), 340-3
“Dietary Mechanisms of Autoimmunity”, Loren Cordain, Ph. D
Thursday 24 January 2013 10

11. Diet shapes gut microbial
community structure and function,
Diet shapes gut microbial community
and the microbiota adapts in
structure and function, and the microbiota
adapts in ways promote nutrient
ways that that promote nutrient
processing; the ability of the
processing; the ability of the microbiota to
process a given to process athe nutrient and
microbiota diet affects given diet
energetic value nutrient andThe microbiota
affects the of that diet. energetic
value of that diet. The
and immune systems co-evolve: malnutrition
microbiota and immune
affects the innate and adaptive immune
systems as well co-evolve:
systems as the microbiota.
malnutrition affects the innate and
adaptive immune systems as well
as the microbiota.
Kau etal; Nature; 474(7351): 327–336, 2011
Thursday 24 January 2013 11

12. A disrupted microbiome has been
associated with a lengthening list of problems:
obesity and its opposite, malnutrition;
diabetes (both type-1 and type-2);
atherosclerosis and heart disease;
multiple sclerosis; asthma and eczema;
liver disease; numerous diseases of
the intestines, including bowel cancer; and
autism.
Thursday 24 January 2013 12

13. SIDE EFFECTIVE Treatments for AD
Resulting in bad compliance
Patients are often referred to as “psycho somatic”
Thursday 24 January 2013 13

14. EFFECTIVENESS of DM Drugs in MS
“The outcomes so far obtained in the prespecified primary
analysis suggest a lack of delay in disease progression for
all disease modifying treatments” Boggild M, Palace J, Barton P, Ben-Shlomo Y, Bregenzer T,
Dobson C, Gray R., Multiple sclerosis risk sharing scheme:
“Disease progression was worse than that in the untreated two year results of clinical cohort study with historical
control group” comparator. BMJ. 2009, 9 pages.
“... it took untreated persons 14.4 years with a 95%
Veugelers PJ, Fisk JD, Brown MG, Stadnyk K, Sketris IS,
Murray TJ, Bhan V., Disease progression among multiple confidence interval of 12-17.4 years whereas the treated
sclerosis patients before and during a disease-modifying patients were estimated to reach EDSS 6 at 18.6 years with
drug program: a longitudinal population-based evaluation.
Mult Scler. 2009 Nov;15(11):1286-94. a 95% confidence interval of 15.9-21.9 years.”
“... 38.6% of untreated patients (those on betaseron
for less than 10% of the time) reached EDSS 6 within
the past 16 years. This compares with 35.7% of Ebers, G, Traboulsee A, Li D, et al., Analysis of
treated patients (those on betaseron for over 80% of clinical outcomes according to original treatment
groups 16 years after the pivotal IFNB-1b trial. J
the time) reaching EDSS 6 in the same time interval.” Neurol Neurosurg Psychiatry, in press, 6 pages.
$25.000 = Disease Modifying drug therapy/a
Not taking adverse drug events into consideration
Thursday 24 January 2013 14

15. MTX Actions and REACTIONS
Mode of Action
Methotrexate is an antimetabolite that interferes with DNA synthesis,
repair, and cellular replication by inhibiting DHF reductase.
Tissues with high proliferation rate are affected: neoplasms, bone
marrow, fetal cells, buccal and intestinal mucosa, urinary bladder
Common ADE
Rash, nausea, vomiting, thrombocytopenia, dizziness
Severe ADE
Pericardial effusion, thromboembolic disorder, epidermal necrolysis, GI
hemorrhage, stomatitis, aplastic anemia, malignant lymphoma,
myelosuppression, liver cirrhosis/ fibrosis, hepatitis, liver failure,
encephalopathy, neurotoxicity, seizure, nephrotoxicity, interstitial
pneumonia, infectious diseases
Complimentary drugs are prescribed to counteract ADE
Are we really surprised if the liver fails?
Thursday 24 January 2013 15

16. Treat the PATIENT, not a Disease
- Many chronic diseases are very responsive to dietary and
lifestyle interventions
- Agents of the industry teach about drugs to persuade
doctors to use the newest and most expensive
medications - even in the absence of scientific evidence
that they are any better than older, less costly ones.
- In fact, many significantly less expensive.therapeutically
effective and
non-drug interventions are
Relman As. Your doctor’s drug problem. The New York Times, November 18, 2003
How much can we change a patients environment?
Healthcare spendings need to invest in prevention an patient education
Thursday 24 January 2013 16

17. INFLUENCE the Factors You Can
Genetics and epigenetics
Most AD “run in families”
Infections and Microbiota
i.e. Epstein Barr Virus, chlamydia
pneumoniae, measals, rubella
Geography
Risk increases with distance from the equator
Sunlight, UV, vitamin D
Dr. Terry Wahls Trauma
Operations, psychological stress,
environmental toxins, heavy metals, smoking
Vaccinations
Which adjuvants were used?
Food
Certain triggers compromise gut
integrity.
Poser C. M. Clin. Neurol. Neurosurg. 2006, 108, 227-33
Hafler D.A. et al. Nat. Rev. Immunol. 2005, 5, 83-91
Willer C. et al. Proc. natl. Acad. Sci. 2003, 100, 12877-12882
Thursday 24 January 2013 17

18. PATHOGENESIS of Autoimmune Disease
Epithelial cells are targeted
Leaky gut
One of the hottest research topics currently
Thursday 24 January 2013 18

19. Thursday 24 January 2013 19

20. 1. Miscommunication between innate and adaptive
immunity
2. Molecular mimicry or bystander effects alone don’t
entirely explain the complex events involved.
Continuous stimulation by environmental triggers is
necessary to perpetuate the process. ... the
autoimmune response can theoretically be stopped
and perhaps reversed if the interplay between genes
predisposing individuals to the development of
autoimmunity and environmental triggers is prevented
or eliminated.
3. In addition to genetic predisposition and exposure to
triggering nonself-antigens, the loss of the protective
function of mucosal barriers that interact with the
environment (mainly the gastrointestinal and lung
mucosa) is necessary for autoimmunity to develop.
Thursday 24 January 2013 20

21. Are Autoimmune Diseases HEREDITARY?
MYTH Autoimmune diseases are hereditary and a patients genetic and
metabolic makeup far outweighs the role of environmental
factors in disease
TRUTH One major environmental factor that modifies gene expression is the
individual’s nutritional status. Both macro- and micronutrients can
influence the expression of genes, the translation of the genetic message
into active protein, and that protein’s ultimate influence in controlling
metabolic function.
Desiere F. Towards a systems biology understanding of human health: interplay between genotype,
environment and nutrition. Biotechnol Annu Rev. 2004; 10:51-84
Masson LF, McNeill G, Avenell A. Genetic variations and the lipid response to dietary intervention: a
systematic review. Am J Clin Nutr. 2003;77:1098-111.
Thursday 24 January 2013 21

22. PRIMAL body
"we are the heirs of inherited characteristics accrued over
millions of years; the vast majority of our biochemistry and
physiology is tuned to life conditions that existed before the
advent of agriculture some 10,000 years ago.
Genetically our bodies are virtually the same as they were at
the end of the Paleolithic era some 20,000 years ago."
Today’s environment
Food, stress, toxins, allergens, pollution
Eaton SB, Eaton SB 3rd, Konner MJ (1997). "Paleolithic nutrition revisited: a twelve-year retrospective on its nature and implications"
European Journal of Clinical Nutrition 51 (4): 207–16
Thursday 24 January 2013 22

23. Clinical Practice
Thursday 24 January 2013 23

24. FUNCTIONAL Roles of the GUT
Digestion/ absorption
Intestinal permeability
Gut microbiota
Immune Regulation
Nervous System
“Gut Feelings “
Thursday 24 January 2013 24

25. Rx. 5R FRAMEWORK
Targeted, individualised intervention
aiming to normalise critical gut functions
–Remove
–Replace
–ReInoculate
–Repair
–Re-Balance
Thursday 24 January 2013 25

26. REMOVE...
... refers to the elimination of factors such as:
-Pathogenic microflora (e.g., bacteria, fungi, parasites)
-Foods to which an individual is sensitive, intolerant, or allergic
-Environmental stressors such as pollutants
-Stress
Clinical approaches may include:
-Oligoantigenic elimination diet - Paleo Autoimmune Protocol
-Botanical antimicrobials or bacteriostatic/bacteriocidal phytonutrients
-Antibiotics/Antifungals
-Stress management
Thursday 24 January 2013 26

27. REPLACE...
... refers to the replacement of factors that may be inadequate or lacking.
Clinical approaches may include:
-Digestive enzymes (HCL, pancreatic enzymes, ox bile)
-Intrinsic secretions
-Soluble fiber to support transit and general GI function
-Vit D, B vitamins, selenium, magnesium, zinc, antioxidants, ...
Thursday 24 January 2013 27

28. REINOCULATE...
... refers to the reintroduction of desirable GI microflora (prebiotics,
probiotics, FMT) to obtain a more desirable balance to the intestinal milieu
Clinical approaches may include:
-Bifidobacteria strains
-Lactobacillus strains
-Saccharomyces Boulardii
-Inulin or fructooligosaccharides (FOS)
-Soluble fibers
-Arabinogalactans
Thursday 24 January 2013 28

29. REPAIR...
... refers to providing nutritional support for healing of the GI mucosa
Clinical approaches may include:
-zinc, phosphatidylcholine repair: Glutamine, arginine, vitamins A D C,
Nutrients important for GI
-polysaccharides protectants: phosphatidylcholine, plantain,
Mucosal secretion
-lactoferrin, lactoperoxidase, whey immunoglobulins) function (e.g.,
Support for GALT (Gut-Associated Lymphoid Tissue)
-Antioxidants known to function in the GI (e.g. catechins)
-E, carotenoids, ...) to support healing (e.g., pantothenic acid, vitamin
Micronutrients shown
-Nutritional anti-inflammatories (e.g., curcumin, EPA and DHA)
Thursday 24 January 2013 29

30. REBALANCE...
... refers to providing support for restorative processes in a patients life
Clinical approaches may include:
-‘Scheduling’ and relaxation
-Mindful eating and better choices for ‘difficult’ situations
-Heart Rate Variability, BioFeedback
-Yoga, meditation, Tai Chi, prayer, breathing or other centering practices
-Psychotherapy, life counceling
Thursday 24 January 2013 30

31. Olive oil. Virgin coco. Unleaded. Diesel. Super.
Which type are you?
Nutrition should meat your needs ;)
Thursday 24 January 2013 31

32. ALTERNATIVE Treatments
Ozone therapy Acupuncture
Bioresonance therapy Walking
Tai Chi/ Qi Gong Low dose naltrexone
sub blabla
Thursday 24 January 2013 52

33. Further Reading
http://www.ncbi.nlm.nih.gov/pubmed/ The Autoimmune Epidemic,
by D. Jackson Nakazawa
http://www.functionalmedicine.org
Minding My Mitochondria, Terry Wahls
http://www.thepaleomom.com The Paleo Solution, by Robb Wolf
http://robbwolf.com/ Good Calories, Bad Calories, by Gary Taubes
http://whole9life.com/ Why we got fat, by Gary Taubes
Food Rules: An Eater’s Manual,
http://www.westonaprice.org by Michael Pollan
http://thinkfood.co.za/ Food, Inc. (documentary film)
The Future of Food (documentary film)
Thursday 24 January 2013 32

34. Thank you for your attention.
Any QUESTIONS?
... feedback is welcome!
Thursday 24 January 2013 33