With a growing number of conditions being grouped under the ‘umbrella’ of autoimmune disease, supporting clients who are, increasingly, presenting with various, and often multiple, autoimmune conditions, can appear complex at first glance. In this webinar, Dr Danielle Crida outlines a clinical protocol that can support most autoimmune conditions, and takes a deep dive into the role of the immune system and key inflammatory processes at play.

1. Dr Danielle Crida MBChB, Dip Nutr
Nutritionist, Igennus Healthcare Nutrition
1
Supporting clients with
autoimmune disease
in clinical practice

2. Contents
1. Overview of autoimmune disease and causal
mechanisms
2. Diet and autoimmune disease
3. Lifestyle and autoimmune disease
4. Supplements in autoimmune disease
5. Support summary

3. 1. Overview of autoimmune disease

4. Genetics
TriggerEnvironment
• Females
• Stress
• Lack of sunlight/ vitamin D
• Smoking
• Alcohol
• Obesity
• Metabolic syndrome
• Hygiene hypothesis
• Western diet
• Micronutrient deficiencies
• Infections (EBV, HS1&2, E Coli)
• Gut dysbiosis
• Increased gut permeability
• Chemicals
• Heavy metals
• Toxins
Protective: Polyunsaturated fats, fibre,
parasitic worms

5. From https://www.astasupreme.co.nz/news/understanding-managing-autoimmune-
disease.html

7. Foreign
substance/microbe
resembles the
body
Body cells are
altered e.g. by a
virus, to look
foreign
Body substance
enters the
bloodstream
B cells malfunction
and make
abnormal
antibodies
Mechanisms: Creation of an autoimmune reaction

8. The Balance of Th17 versus Treg Cells in autoimmunity
Th1 • Drives
autoimmunity
Th17
• Drives
autoimmunity and
inflammation
• Pathogen clearance
Treg • Maintain immune
homeostasis
Naive
T cell

9. Jörg S, Grohme DA, Erzler M, et al. Environmental factors in autoimmune diseases and their role in multiple
sclerosis.
Cell Mol Life Sci. 2016;73(24):4611–4622. doi:10.1007/s00018-016-2311-1

10. 2. Diet and autoimmune disease
• Gluten
• Salt
• Sugar
• Fat
• Paleo and Autoimmune Protocol
• Specific Carbohydrate Diet (SCD)
• Anti-inflammatory diet
• Wahls Protocol
• Fasting
• Vegan
• Semi-vegetarian

11. Gluten & autoimmune disease:
3 possible mechanisms
• Intestinal permeability
• Inflammation
• Molecular mimicry

12. Sodium & autoimmune
disease
• 2 ways sodium may drive autoimmune disease:
• Activation of Th17 + Th1 cells
• Activation of inflammatory monocytes, increased
proinflammatory cytokines and decreased anti-inflammatory
cytokines (Yi 2015)
• Increased disease activity in multiple sclerosis
• Salt alters gut microbiome composition, predisposing to
obesity
(Binger 2015)

13. Glucose & autoimmunity
• High glucose intake exacerbates
colitis and MS by activatingTh17
cells
• Increased mitochondrial ROS
which induce TGF-β activation
and Th17 related inflammation
(Zhang 2019)

14. Dietary fat, obesity and autoimmunity
High fat diet
Altered gut microbiome
Improved capacity for
energy harvest and storage
Increased gut permeability
and inflammation
Autoimmune and other disease risk
High calorie intake
Obesity
Leptin
T cell proliferation
Th1 response
Raised
omega-6:3
ratio
Inflammatory eicosanoids
activate Th17 response

15. Image from Paleomom.com
Paleo and Autoimmune Protocol Diet

16. The Autoimmune Protocol
• In addition to the grains, legumes, dairy
and soy avoided by standard Paleo diet,
AIP also eliminates eggs, chocolate,
coffee, nuts & seeds, nightshades and
alcohol
• Elimination phase
• Maintenance
• Reintroduction
Focus areas:
• 1. Nutrient density
• 2. Gut health
• 3. Hormone regulation
• 4. Immune system regulation

17. Trial: Efficacy of the Autoimmune
Protocol
Diet for Inflammatory Bowel Disease
• Adults with active Crohn’s disease
and ulcerative colitis (non-coeliac)
• Mean duration 19 years, active biological use 47%
• Clinical remission in 73% by week 6, maintained
through week 11
• Mean faecal calprotectin improved from 471 to 112
• This % of remission rivals most drugs for IBD
(Konijeti G 2017)

18. • Women with Hashimoto’s thyroiditis
• 6-week transition onto AIP with 4 weeks maintenance
• Significant improvement in quality of life scores
• Clinical symptom burden decreased from 92 to 29 on
MSQ
• Reductions in CRP and white cell counts
(Abbott R 2019)
Trial: Autoimmune protocol in
Hashimoto’s thyroiditis

19. Specific Carbohydrate Diet
• Used in (paediatric) inflammatory bowel disease
• Used by some people to manage IBD, cystic fibrosis
and autism
• Included: animal products without additives, certain
legumes incl. dried beans, lentils, split peas, most nuts,
certain dairy products (encouraging homemade live
yoghurt), most veg, all fruit, most nuts, most oils, tea,
coffee, honey
• Prohibited: sugar & sweeteners, grains, some legumes,
seaweed, starchy tubers (potatoes, sweet potatoes,
turnips), additives, milk & milk products high in lactose

20. • Suskind 2014: 7 children with
Crohn’s on no immunosupressants.
On diet for on average 14 months.
All children clinical remission after 3
months. Blood results
normalised/significantly improved
• Cohen 2014: 10 children with
Crohn’s, 12 weeks on SCD. Clinical
and mucosal improvement
• Suskind 2016: Survey of IBD and
SCD: 417 respondents. 33% reported
remission at 2 months, 42% at 6 &
12 months.
SCD in Crohn’s and IBD

21. An anti-inflammatory diet as
treatment for inflammatory
bowel disease
• IBD-AID 5 basic components, introduced in different phases:
1. Modification of certain carbohydrates incl lactose + refined carbohydrates.
Soluble fibre encouraged (bananas, oats, flax meal)
2. Inclusion of pre and probiotics (soluble fibre - bananas, oats, flax meal, leeks, onions, fermented foods)
3. Fats
4. Correction of missing nutrients, diagnoses of intolerances
5. Modified texture of foods (blended/ground/cooked) as per symptoms to improve nutrient absorption and
minimise intact fibre
• 33% chose not to attempt diet, others used diet for 4 weeks, at 70% or more compliance to diet
• 24/27 had good/very good response to diet
• 3/27: mixed results
• 100% able to discontinue
• 100% decreased symptoms

22. Wahls Protocol in MS
• Paleo-like diet protocol
• Study included supplements (optional fish
oil), stretching & strengthening exercises,
meditation, massage
• 1 year study, 10 subjects – 8 completed
study, 6 fully adherent
• Average adherence
to diet 90% of days,
exercise 75% or days.
Average daily meditation
13 mins, massage 7 mins
• Significant improvement
in fatigue
(Bischt 2014)
Dr Terry Wahls

24. MS and fasting
Multiple sclerosis is an autoimmune disorder of the central nervous system during which
the immune system attacks and destroys the myelin sheath around nerve axons. Most
treatments for multiple sclerosis are immunosuppressive and do not alleviate
autoimmunity or regenerate the damage already caused. New research hopes to
determine the role diet and nutrition could have on overcoming multiple sclerosis.

25. Diet mimicking fasting promotes regeneration and reduces
autoimmunity and multiple sclerosis symptoms
Choi 2016

27. Controlled fasting followed by 1-year gluten-free
vegan, then vegetarian diet in RA
• 4-week stay at health farm
• Initial 7-10 day subtotal fast
• Gluten-free, vegan diet for 3.5 months
• Gradually changed to lactovegetarian diet
• Significant improvements vs control group
(Kjeldsen-Kragh 1991)

28. Low-fat vegan diet in rheumatoid arthritis
• 4 weeks
• Very low fat – 10%
• Blinded rheumatologist
• Significant decrease in almost all measures of RA
symptomatology
• Significant decrease in weight
• Rheumatoid factor decreased by 10%
• CRP decreased 16%
(McDougall 2002)

29. Semi-vegetarian diet in
Crohn’s
• Allowing milk and eggs, fish once
per week, and other meat once
every 2 weeks
• Adults who had achieved medical
or surgical remission
• Compliance 73%
• Remission 94% after 2 yrs
vs 33% in control group
(Chiba 2010)

30. 3. Lifestyle and autoimmune disease
• Cigarette smoking
• Exercise
• Sleep
• Stress
• Mindfulness & meditation
• Cold exposure

31. Smoking and autoimmune disease
• Strongly linked to development and severity of many autoimmune
diseases
• Affects both innate and adaptive immune systems
• Increases pro-inflammatory cytokines; decreases anti-inflammatory
cytokines
• Activates macrophage and dendritic cell activity
• Stimulates production of auto-antibodies
(Arnson 2009)

32. Exercise in autoimmune disease
• Boosts energy
• Releases endorphins – natural painkiller
• Reduces inflammation
• Combats depression and anxiety
• Helps manage weight
• Moderate, low-impact exercise

33. • Elevation in Treg cells
• Decreased Th1
• Decreased
immunoglobulin
secretion
• Promotes IL-6 release
from muscle
(Sharif 2018)
Physical activity and autoimmune disease

34. Sleep
• Chronic insomnia increases risk
of autoimmune condition and vice versa
• Increased sleep disorders in autoimmune conditions
• Symptoms cause disturbed sleep
(Zielinksi 2019)
• Melatonin dysregulation involved in pathogenesis of
autoimmune conditions
• Melatonin therapy–modulates Th1/Th2 balance, and
cytokine production
(Zin 2013)

35. Stress
Stress -
trigger
Autoimmune
disease
Mental
health
issues/Stress
Up to 80% of patients reported
uncommon emotional stress
before disease onset
(Stojanovich 2010)

36. Mindfulness-based interventions
and the immune system
• Reduced NF-κB
• Reduced CRP in ulcerative colitis
• Increased IL-10 in UC
• Reduced TNF-α in ulcerative colitis
• Reduced NF-κB
• Increased telomere length
• Dosage dependent
(Black 2016)

37. Wim Hoff
method
• Breathing exercises, cold water exposure and meditation
• Proved that autonomic and innate nervous system can be
actively influenced
• Safety and anti-inflammatory effects in patients with axial
spondyloarthritis
• ESR,CRP and calprotectin declined relative to control group
(Buijze 2019)

38. 4. Supplements in autoimmune disease
• Omega-3
• Curcumin
• Vitamin D
• Astaxanthin
• Probiotics

39. • Influence amount and type of immunomodulatory eicosanoids
• Act on intracellular pathways, transcription factors and gene expression
• Decrease the high levels of IL-1 common to autoimmune diseases and CVD,
depression, ageing and cancer
(Simopoulos 2002)
Omega-3 supplementation

40. Therapeutic potential of omega-3s in
human autoimmune disease
• Rheumatoid arthritis: Many studies showing improvement in symptoms
and decreased inflammatory cytokines
• SLE: DHA supplementation preventative (Wieringa 2019). Improvement in endothelial
function, disease activity and inflammatory markers after >12 weeks of treatment
• Type 1 diabetes: Preventative (high-risk children) and therapeutic
• Multiple sclerosis: Most studies show decreased exacerbation and disability
Preventative role
(Li 2019)

41. Curcumin
• 3 studies in ulcerative colitis, 2 of which yielded significant improvement
in disease remission, outcome ~ dose used (ineffective low dose)
• 2 clinical trials on RA – 1 decreased disease activity & CRP. Other – only 2
weeks
• 1 Lupus nephritis – decreased proteinuria, hematuria and blood pressure
even at low dose 3 times daily
• 2 on MS looking at lab outcomes. Curcumin able to restore expression
pattern of dysregulated miRNA. Other study – significant decrease in Th 17
and IL-17, which may improve disease progression
• Modulation of the eicosanoid pathway towards a more anti-inflammatory
pathway
• Modulation of serum lipids towards a favourable profile
• Yang (2019) - Curcumin in Autoimmune and Rheumatic Diseases. Review
article

42. Vitamin D
• MS: risk factor, and lower blood levels of
vitamin D, especially during relapses
• Type 1 DM: Supplementation reduces risk
and protects pancreatic cells
• SLE: Risk factor, and supplementation
decreases fatigue
(Yang 2013)
• Vitamin D receptor in immune cells
• Inhibits Th1 cells and their inflammatory cytokines
• Promotes shift to Th2 response with more regulated, anti-
inflammatory response
• Suppresses Th17 response and increases Treg activity

43. Astaxanthin
• Role of antioxidants in autoimmune disease not fully
researched
• Nurses health study – no link between reported anti-
oxidant intake and development of RA or lupus
• Increased oxidative stress in autoimmune conditions
• Free radicals cause damage to cell membranes and
tissues
• Vitamins A and E can become pro-oxidant in certain
circumstances
Astaxanthin is a good choice if you want an antioxidant
• Highest ORAC value
• Never becomes pro-oxidant
• Acts intra- and extra-cellularly
• Inhibits NF-Kappa-B
• Flexible dosing
• Promise in pain in RA

44. Probiotics
• Studies using different probiotics in different
conditions have shown various amount of
success
• 1 study suggesting that L. reuteri improves
symptoms and quality of life in human MS
• VSL #3, an eight-strain probiotic which includes
lactobacilli, bifidobacilli, and Streptococcus
thermophilus, is effective in UC
(Liu, 2018)

45. Metal toxicity
• Metal toxicity is a risk factor for autoimmunity
(Stejskal J 1999)
• 71% of patients with autoimmune disease
showed improved health 6 months after
amalgam replacement (Prochazkova, 2004)

46. • Healthy weight
• Prioritise gut health
• Low sugar and refined carbs
• Avoid excessive salt
• Lower fat especially saturated fat
• Increase vegetables
• Avoid processed food
• Avoid gluten
• Consider specialised diet guided by research and client preferences
• Supplements: Omega-3, Curcumin, Vitamin D
+/- Astaxanthin, probiotics
• Stop cigarette smoking
• Optimise sleep
• Exercise – correct balance
• Stress reduction e.g. meditation
5. Support summary

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References