Transcript Diet and AS – Martin Lau

Is there a therapeutic diet for
ankylosing spondylitis (AS)?
Martin Lau
Registered Dietitian
[email protected]
The use of diet to help control pain and symptoms
of disease in musculoskeletal (MSK) conditions is
of great interest to patients because it is one way
in which they can do something to help
themselves.
Rayman & Pattison (2008) 22(3): 535-561
Is there a specific
diet for ankylosing
spondylitis (AS)?
Martin Lau
Registered Dietitian
• Dietary modifications are the most common type of
complementary and alternative medicine (CAM) used
(Ernst 2000)
• Chatfield et al (2009) examined 75 AS patients for their
use of CAM:
 72.1% used dietary modifications
o 56.4% found a slight or of no benefit
 Mainly female
 Despite poor benefits, the use of dietary CAM is
common
Key studies
• Dietary elimination of possible sources of Klebsiella
(Shinebaum 1984)
• Exclusion of milk and milk products (Appelboom & Durez 1994)
• Low starch diet (Ebringer & Wilson 1996)
• Vegan diet (Huber et al 2001)
• High dose of Omega 3 fatty acids
(Sundström et al 2011)
disease activity (ESR)
• Anti-inflammatory diet (Mediterranean diet) as a
supplementary therapy of AS (Adam 2008, Zhang & Huang
2014)
So, there you go - therapeutic diets for AS!
Hang on!!
• 2 Case studies, 2 reviews & a letter to the journal
editor
• 2 original researches
• No RCT to date
Sundström et al (2011) investigate the relationship between diet
and disease activity, plus gastrointestinal symptoms in relationship
to diet in AS
• 165 subjects with AS
• Self-administered postal questionnaire
• BASDAI and BASFI
• No significant correlation between diet and disease activity
• Higher consumption of vegetables correlates to GI pain
NASS has funded a study looking at the relationship on diet and AS
conducted by the University of Aberdeen
The Low Starch Diet
• Low carbohydrate, high protein diet
• Limit/avoid bread, potatoes, cakes, pasta and rice
• Mainly consuming protein and vegetables
• Several case studies in his book (Ebringer 2013)
• The idea behind the low starch diet is to ‘starve’ the
Klebsiella
 This Enterobacteriaceae uses dietary starch for growth
• Previous attempt by Shinebaum (1984) by avoiding salads,
cold meat and all ready prepared cold foods failed
• ‘It’s good to lose weight’ (personal communication with
Professor Ebringer)
Being overweight or obese on AS
• High BMI with AS is associated with increased functional
impairment (BASFI, BASDAI and HAQ) (Duncan et al 2012)
• Significant correlation between the amount of visceral fat and
BASDAI (Aydin et al 2014)
• Lower therapeutic response (infliximab) at 6 months (Ottaviani
et al 2012)
• Only 54% for overweight and 30% for obese subjects achieving
BASDAI50 at 1 year (Gremese et al 2014)
A high protein diet with minimal CHO induces weight loss
Shai et al NEJM 2003 359:229-41
BJN 2016 115:3 466-79
Is Klebsiella the main culprit in the disease activity of AS?
• Faecal Klebsiella is not significantly related to spinal disease activity
(Eastmond et al 1980)
• ‘On close observation none are attractive either on pragmatic or on
intuitive grounds.’ (Russell & Almazor 1992)
• The number of IgA positive sera against Yersinia, Salmomonella,
Shigella, Campylobacter and Klebsiella did not differ between HLAB27 positive patients and controls (Sprenkels et al 1998 + Stebbings
et al 2002)
• Comparison of AS affected and unaffected families, Klebsiella did
not exhibit a predominant immune response in affected subjects
(Stone et al 2003)
• Costello et al (2015) have identified the ‘microbial signature’
 Klebsiella: no difference between patients & controls
• The role of low starch diet??
The Low FODMAP Diet???
Conclusions
• Lack strong evidence to support a particular ‘therapeutic’ diet
• Healthy eating (balance, variety and maintain normal weight) is the
foundation
• Key to self-manage is to see what works for you
 Could explore the use of low starch diet?
 Under the guidance/support by rheumatologist and dietitian
 Rapid weight loss can be achieved by low starch diet.
 Cautions:
 Raises LDL
 Not recommend to those with low BMI
 Weight lost is of lean mass (muscle tissue)
• In managing MSK conditions: Knowledge + sensible eating regime +
normal weight + exercise is the equation of success!
Thank you for listening