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Modifying Paleo for Autoimmune Conditions (i.e., The Autoimmune Protocol)

May 10, 2012 in Featured Posts, Paleo Modifications, The Autoimmune Protocol

NOTE: This is no longer the most up-to-date version of the autoimmune protocol. You can see the most current version here.

Autoimmune conditions and a leaky gut go hand in hand. In fact, in every autoimmune condition that has been tested, a leaky gut is present and is a contributing factor to the illness (not all autoimmune conditions have been tested, but many in the paleo community assume that leaky gut is a factor in all autoimmune conditions). For individuals with suspected or diagnosed autoimmune disease, additional dietary guidelines exist to help address the disease. In many cases, autoimmune conditions can be put into full remission by following these guidelines. There is some variability to these guidelines depending on who you ask, so I have reviewed them and compiled a comprehensive list of not only dietary restrictions but also food recommendations using information from The Paleo Solution, The Paleo Answer, and various podcast and YouTube interviews with Robb Wolf, Prof. Mat Lalonde and Dr. Terry Wahls (author of Food As Medicine and Minding My Mitochondria). These are all great sources for more information.

It is vitally important to adhere to a strict paleo diet with no cheating. While other people may be able to enjoy the occasional bowl of rice, if you suffer from an autoimmune condition you are not one of these people. Grains and legumes should never be consumed. Dairy of any kind (even grass-fed ghee which can still have trace lactose and dairy proteins!) should be avoided initially (most people will not be able to successfully reintroduce dairy, although some will be okay with grass-fed butter and ghee). This may be true for the rest of your life. In addition, if you have an autoimmune condition, you should completely avoid:

Eggs
Nuts
Seeds (including cocoa, coffee and seed-based spices)
Nightshades (potatoes, tomatoes, eggplants, sweet and hot peppers and spices derived from peppers)
Potential Gluten Cross-Reactive Foods
Alcohol
NSAIDS (like aspirin or ibuprofen)

The reason is that each of these causes gut irritation and/or increased gut permeability (and in the super sensitive gut of those with autoimmune conditions, they just aren’t tolerated). There is also some evidence that hormonal birth control can contribute to hunger and digestive hormone disregulation, leading to inflammation. However, you may wish to address the other elements in this post before going off birth control, depending on your personal circumstances.

Dr. Terry Wahls lays out a very convincing argument for increased vegetable intake. Her focus is on eating vegetables from four main groups: green veggies (for the vitamin B, A, C and K content and the mineral content), colorful veggies (for the flavonoids and polyphenols; at least 3 colors per day but this includes brightly colored fruit like berries), sulfur-rich veggies (cruciferous veggies, veggies from the onion family, mushrooms and asparagus), and iodine-rich foods (seaweed). Dr. Wahls recommends eating 3 cups per day of each of green veggies, colorful veggies and sulfur-rich veggies as well as at least once serving per week of seaweed. Note: If you have Grave’s Disease or Hashimotos Thyroiditis, you must also avoid goitrogenic foods, which include raw cruciferous veggies, radishes, spinach, peaches, and strawberries (cooking reduces the goitrogens; fermentation increases them). I also recommend an extra serving of seaweed each week as well as at least three servings per week of oily cold-water fish to support thyroid function (except in the case of Hashimotos Thyroiditis as there are mixed reports of iodine taken either as a supplement or in iodine-rich foods actually worsening the disease).

Meat quality is very important as this profoundly impacts the types of fat that you consume. It is extremely important to be mindful of your omega-3 to omega-6 fatty acid intake ratio, aiming for between 1:1 and 1:3, as this is essential for regulating inflammation in your body. The best way to do this is to ensure that all of your meat, poultry and fish comes from grass-fed, pastured or wild sources. Oily cold-water fish (like salmon, mackerel, sardines, herring, kipper, anchovies, trout, fresh tuna, and carp) should be consumed at least three times per week for their high omega-3 content, easily absorbed protein, vitamin D and selenium content. Grass-fed meat also contains Conjugated Linoleic Acid (CLA), known to reduce inflammation, promote healing and even fight cancer. The nutrient profile of pastured/wild meat and fish is superior as well. My post on the importance of grass-fed meat contains some suggestions for incorporating it into your diet in a budget-conscious way. It is also extremely helpful to incorporate organ meat into your diet at least twice per week due to its high nutrition density (including some amino acids, vitamins and minerals that are not as concentrated in muscle meats). Note that the high vitamin A content of liver may be contraindicated in anyone consuming foods that they are allergic or sensitive/intolerant to as it has potential adjuvant activity (it may be better to add liver into the diet after 3-4 weeks of following this protocol). It is also more important to eat organic produce as much as possible. Whole9Life has a wonderful chart on when fruits and vegetables are in season including which fruits and vegetables are important to buy organic and which aren’t, if budget is an important concern.

Autoimmune conditions are also typically associated with disruption of normal gut microflora, often including Small Intestinal Bacterial Overgrowth (SIBO). For individuals with suspected or confirmed SIBO, avoidance of starches and sugars other than monosaccharides (like glucose and fructose) is very important (read my post Fruits and Starchy Vegetables with Small Intestinal Bacterial Overgrowth for a list of which starchy vegetables are okay and which to avoid), although this is one aspect of the autoimmune protocol which is highly individual. Some people do extremely well with the inclusion of starchy vegetables in their diet. For those with gut dysbiosis (any condition in which the type, amount or location gut bacteria are not normal), it is also important to help repopulate the gut microflora by eating raw fermented foods (like sauerkraut, coconut milk kefir, or kombucha) or taking a dairy-free probiotic supplement. Some people may need to avoid high FODMAP fruits and vegetables (which I discuss in this post) as FODMAP sensitivities are common in those with leaky guts and/or gut dysbiosis (when the lining of the gut is damaged, there tends to be fewer fructose transporters so any sugar or starch containing alot of fructose is harder to digest). Others will need to limit themselves to cooked vegetables, which are typically easier to digest.

Healing the gut becomes very important. I highly recommend consuming bone broth, organ meat (note the caution against consuming liver initially described above), oily fish, and coconut oil on a fairly routine basis as well as making sure that you are getting adequate vitamin D, whether you are taking a supplement, food sources like liver and fish, or spending lots of time outside. Note that coconut oil does not contain the phytic acid or inulin fiber (both gut irritants) that other coconut products contains (a little coconut is typically tolerated, but I urge caution). Stress management is very important and I highly recommend doing at least one of the following: go for daily walks, take up yoga or tai chi, take a class on meditation, or make time for an activity/hobby that you absolutely love. And I cannot emphasize enough the importance of getting lots of good quality sleep. Aim for 8-10 hours of sleep in a cool, pitch-black room, preferably waking up without the use of an alarm. It may help both stress hormone regulation and improve sleep quality to drastically reduce your caffeine intake. Aim for no caffeine if you can. It is also very helpful to drink plenty of water and to make sure you are consuming enough food. The body is not very efficient at healing itself when you are running a caloric deficit (you shouldn’t have to gain weight to heal, but losing weight may be a competing goal for now).

I know from experience that this is a very challenging task. I also know from experience that 90% is not good enough (and the more serious your condition, the more important compliance is). I know from experience that this increases your food budget (although perhaps this can be negated by decreasing your medical expenses). I try and focus on the delicious foods that I do get to eat. I try and focus on the fact that I have a strategy for improving my health that is far more powerful than any prescription medication (Note that in many cases you will still need to be on prescription medications although you may be able to reduce your dose. Please work with your doctor on this one!). And, compliance gets easier once you start to see improvement. Are these restrictions for ever? Some may be and others might be successfully reintroduced after you see improvement in your symptoms. What foods you can reintroduce when if highly individual and will be the topic of a future post.

Tags: ancestral, auto-immune disease, auto-immunity, Autoimmune Disease, autoimmunity, casein-free, Dairy-free, Diet, Gluten-Free, Grain-free, list, paleo, Paleolithic, primal, protocol, restrictions, why
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Modifying Paleo to Treat Psoriasis

April 19, 2012 in Sarah's Personal AI Struggles, Specific Autoimmune Diseases

In the paleo community, we are accustomed to assuming that a standard paleo diet will cure (or at least significantly improve) virtually every health problem. But, if you have psoriasis (or dermatitis or eczema), be prepared: paleo not only may fail to resolve these skin conditions, it might even make it worse. Now, don’t go running for the hills. The principles behind the paleo diet are still sound. It is still the best way to eat for your long-term health. And there are certainly some people who find complete resolution of their psoriasis symptoms with the switch to a paleo diet (for those people, the root cause of the psoriasis is typically a gluten sensitivity). For me (and for many others), switching to paleo made my psoriasis worse. This isn’t because paleo has us on the wrong track; it’s simply because out-of-the-box paleo is not actually enough.

I am a long term sufferer of lichen planus, a form of psoriasis where the inflammation occurs in the mucosal layer of the skin (and very unnerving, you can actually get lesions in the gut mucosa as well!). In fact, it was my search for a cause (and hopefully cure) for this condition that brought me to paleo in the first place! All my other health issues either completely resolved or improved substantially within weeks of switching to a paleo diet, but my lichen planus did not improve. If anything, it got worse. But since paleo was working so well for me in every other respect, my search for a solution stayed within a paleo framework.

What you might not know (and certainly I didn’t) was that psoriasis (and dermatitis and eczema) is an autoimmune disease. It’s not always listed in those lists of autoimmune diseases that can be put into full remission by a paleo diet (it is listed in The Paleo Answer, but not The Paleo Diet nor The Paleo Solution). Why is it so often left out? I guess it’s because when compared to Lupus, Multiple Sclerosis or Non-Hodgkin’s lymphoma, psoriasis is small potatoes. And let’s just take a moment to appreciate how lucky we are that, when our bodies formed antibodies against our own cells, we only ended up with psoriasis!

Psoriasis is also an indicator of a severely leaky gut (that’s how we develop the autoimmunity in the first place), with a very high likelihood of Small Intestinal Bacterial Overgrowth. It is also very commonly linked to a gut-brain connection problem with inflammation and autoimmunity targeting skin cells. I went into some details about the gut-brain connection in this post, but I also recommend listening to the explanation of the gut-brain-skin axis that Chris Kresser gives in his Revolution Health Radio podcast episode titled “Naturally Get Rid Of Acne By Fixing Your Gut”. There is a complex interplay between a leaky gut, a stressed body, loss of insulin and leptin sensitivity, mood issues, food sensitivities, and the inflammation that manifests as psoriasis. Basically, if you suffer psoriasis, chances are your gut, your immune system and your hormones are all really messed up.

So, what do you do about psoriasis? The first and most important step is to follow the paleo diet “autoimmunity protocol”. This means that in addition to all of the foods we already avoid while eating paleo, we must also avoid:

Eggs (especially the whites)
Nuts and Seeds (or at least severely restrict quantities)
Nightshades (tomatoes, eggplant, peppers of all kinds)

We are also people who Can Not Cheat. Ever. We can not tolerate any dairy, not even grass-fed butter or ghee. Food quality becomes extremely important, so the more we can eat grass-fed meat, wild-caught fish, pastured eggs and chicken, and organic vegetables, the better (I know it’s expensive and I certainly can’t afford this 100%, but I just do the best I can). And we are people who can’t tolerate very much sugar (even the sugars in fruits) or starches (even from superfoods like sweet potatoes) as they tend to feed the organisms in Small Intestinal Bacterial Overgrowth. It would be worthwhile to have a look at the GAPS diet food list as an indicator of which fruits and vegetables should be avoided (although I wouldn’t suggest starting with the GAPS diet protocol unless you really have tried everything else). And that’s not all. Because stress hormones can play a key role in the perpetuation of psoriasis, it is especially important for us to get lots and lots of high quality sleep, avoid excessive caffeine intake (or cut it out completely), severely limit alcohol consumption (or avoid it completely), get lots of low-strain exercise, manage the stress in our lives, get sun exposure and take a Vitamin D3 supplement (on the higher dose side; I take 12,000IU per day in addition to trying to get outside every day). I also suggest reading my recommendations on Repairing The Gut. In particular, I suggest incorporating organ meat into your diet at least twice per week, consuming bone broth or other collagen-rich foods (like gelatin, stew hens and heart meat) at least twice per week (every day would be even better), consuming fermented foods (like raw Sauerkraut or coconut milk kefir) every day, and consuming coconut oil every day (I like it in my coffee).

So how long until you see some results? You should start to see improvement very quickly, within a couple of days for some people up to 3-4 weeks for others. If you do not see improvement within a month, you may also have developed additional food sensitivities (your gut is leaky, after all). If doing all of the above still isn’t enough to see improvement in your symptoms, it would be worth finding a physician, naturopathic doctor, or chiropractor who will order an IgG and IgA food sensitivity blood test (you might also investigate Small Intestinal Bacterial Overgrowth, internal yeast infections and parasite infections as possible confounding factors as well). These food sensitivities are transient and once your gut has healed (and at least 6 months have passed without exposure), you should be able to reintroduce the foods. Actually, you should be able to reintroduce eggs, nuts and seeds, higher sugar fruits and vegetables and maybe even nightshades at some point in the future as well. Are you wondering how long this is going to take? I’m afraid the answer is anywhere between 2 months and 2 years, depending on exactly what the root causes are for you. But, if you could see how much my lichen planus has improved in 3½ months, you would be amazed. I know that the extra dietary restrictions are tough, but it is worth it to be able to cure such an aggravating condition without the use of steroids. And the thing to keep in mind is that once the psoriasis is gone, out-of-the-box paleo really will be enough for us.

Tags: ancestral, auto-immune disease, auto-immunity, Dairy-free, Diet, eggs, Gluten-Free, Grain-free, legume-free, lichen psoriasis, Lifestyle, nightshades, nuts, paleo, Paleolithic, primal, psoriasis
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How Do Grains, Legumes and Dairy Cause a Leaky Gut? Part 1: Lectins

March 22, 2012 in Gut Health, The WHYs Behind Paleo

(Created as a guest post for The Paleo Parents)

One of the fundamental principles of paleolithic nutrition is to protect the lining of the gut by eliminating foods that damage it. By prioritizing gut health, we are able to treat and prevent the many health issues associated with having a “leaky gut”. But how exactly do grains, legumes and dairy wreak so much havoc on the digestive tract? There are several ways in which these foods create holes in the gut lining. The best understood is the damage caused by lectins.

Grains and legumes contain lectins. Lectins are a class of proteins found in many types of seeds (like wheat, oats, barley, rice, peanuts, soy, etc.) that are part of the plant’s natural defense mechanism. A digested seed is not one that can grow a new plant. To defend itself, the seed from these plants either deter predators (like us) from eating them by making us sick or resist digestion completely or both. The grains and legumes that have become a part of the human diet since the Agricultural Revolution 10,000 years ago aren’t toxic enough to make most of us severely ill immediately after eating them (otherwise humans never would have domesticated them!). Instead, their effects are more subtle and can take years to manifest as a life-threatening disease. You may be wondering why other seeds (like the ones in berries or kiwi or bananas) are okay to eat. These come from plants with a friendlier defense strategy: we get to eat the delicious fruit encasing the seeds and then the seeds, which pass through our digestive tracts intact, get to be planted in rich manure. How do you know the difference between a harmless seed and one that contains damaging lectins? Here’s the rule: if you can eat it raw, then it’s okay to eat. If you have to cook it, it has damaging lectins.

Lectins are not broken down in the normal digestive process, both because the structure of these proteins are not compatible with our bodies’ digestive enzymes but also because the foods that contain these lectins also contain protease inhibitors (compounds that stop the enzymes from breaking down proteins; more on these in Part 2). Lectins, which remain largely intact throughout the digestive tract, can damage the gut lining in several ways. First, lectins trick the enterocytes (the cells that line the gut) into thinking they are simple sugars. The enterocytes “willingly” transport the lectins from the “inside-the-gut” side of the cell to the “outside-the-gut” side of the cell. While in transit, the lectins may cause changes inside the enterocyte that either kill the cell or render it ineffective at its job, which leads to more pathogens leaking out of the gut. Once outside the gut, these lectins activate the resident immune cells of the gut which respond by producing inflammatory cytokines (the chemical messengers that circulate in the blood and tell white blood cells to attack) and antibodies against these foreign proteins. Because at least part of this response is not specific to the lectin itself, the enterocytes (being the closest innocent bystanders) can be targeted and killed by the body’s immune cells, leading to the microscopic holes that create a leaky gut.

Gluten is both the best known example of a lectin, and also the most damaging. In many individuals (like those with diagnosed gluten sensitivity and celiac disease), gluten can weaken the connections between enterocytes, essentially creating a space in between the cells through which gut contents can leak through, adding yet another way that this particular lectin can cause a leaky gut. Once gluten has passed through the gut lining, it stimulates the resident immune cells of the gut to start producing antibodies. Gluten is especially insidious because parts of this protein closely resemble many proteins in the human body, so there’s a high likelihood that some of the antibodies produced to target it will also target human cells. One extremely commonly formed antibody is one against our enzyme transglutaminase. Transglutaminase is an essential enzyme in every cell of the body, which makes important modifications to proteins as they are produced inside the cell. It also stimulates wound healing, but if antibodies have formed against it, then when it is secreted by damaged cells in inflamed areas of the small intestine (or any other damaged tissue in the body), rather than helping to heal the surrounding tissue, it instead turns it into a target of the immune system. This is yet another way in which gluten can cause a leaky gut. Importantly, when antibodies against transglutaminase form, every cell and organ in the body becomes a potential target. Because an exaggerated sensitivity to gluten is the cause of Celiac Disease, which affects at least 1 in 133 people, its effects on the gut have been the most studied. Scientists still don’t know which of the many ways that gluten can harm the body apply to all lectins and which are specific to gluten.

Gluten sensitivity has already been linked to dozens of autoimmune diseases. Even in individuals who do not have celiac disease or gluten sensitivity, it can take up to six months for the gut to fully heal after a single gluten exposure. While other lectins may not be quite as damaging as gluten, scientists continue to discover new ways in which foods that contain lectins can contribute to a leaky gut, inflammation and autoimmune diseases.

Tags: allergy, antibodies, auto-immune disease, celiac disease, Gluten, inflammation, intestinal permeability, leaky gut, lectin, lectins, paleo, Paleo Diet, Paleolithic, primal diet, transglutaminase
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What Is A Leaky Gut? (And How Can It Cause So Many Health Issues?)

March 15, 2012 in Featured Posts, Gut Health, Paleo Philosophy, The WHYs Behind Paleo

(Created as a guest post for The Paleo Parents)

One of the fundamental principles of paleolithic nutrition is avoiding foods that damage the lining of the gut. Essentially, the gut is just a long, wrinkly tube. Inside this tube, food is digested by enzymes and friendly resident bacteria, breaking down the components of our food to their simplest forms: proteins are broken down into amino acids; carbohydrates are broken down into monosaccharaides; and, fats are broken down into fatty acids. What can’t be digested by our bodies is excreted as waste. Amazingly, a single layer of highly specialized cells (called enterocytes) is all that separates the inside of the tube from the outside. These enterocytes have two very specific jobs: 1) transport the digested nutrients from the “inside-the-gut” side of the cell to the “outside-the-gut” side of the cell; and 2) keep everything else on the inside of the tube. Immediately outside this tube are two important parts of the digestive system: 1) the resident immune cells of the gut whose job it is to protect against pathogens which might accidentally find their way through the enterocytes; and 2) a network of blood vessels and lymphatic vessels that carry the digested nutrients from our food to the tissues in our body that need them (amino acids and monosaccharaides are transported through the blood while fatty acids are transported through the lymphatic system).

A “leaky gut” occurs when either the enterocytes are damaged or the proteins that form the tight bond between these cells and hold them together as a solid layer are damaged (or altered). When this happens, it creates microscopic holes through which some of the contents of the gut can leak out into the blood stream or lymphatic system. What leaks out isn’t big chunks of food. Instead, it’s a combination of many different pathogens: incompletely digested proteins, bacteria or bacterial fragments from those friendly bacteria that are supposed to stay inside your gut, or a variety of toxic substances or waste products that would normally be excreted. When these pathogens leak out, the resident immune cells of the gut recognize them as foreign invaders and mount a response against them (when large quantities of pathogens leak out, other parts of the body, especially the liver, also contribute to the response). Exactly what leaks out, and how much, determines the precise nature of this immune response.

Some pathogenic substances (like bacterial fragments and toxins) cause generalized inflammation by triggering the release of chemicals called inflammatory cytokines (the chemical messengers that circulate in the blood and tell white blood cells to attack). This type of inflammation has no target so any cell in the body can be an innocent victim. It is the liver’s job to both control this type of inflammation and to filter out the toxins that may be triggering it. When the liver is overworked, the toxins build in the body and the inflammation spreads. This type of inflammation can be a major contributor to health issues ranging from psoriasis and asthma to ADHD and depression.

Other substances (like incompletely digested proteins) cause specific inflammation, which can take the form of an allergy or an auto-immune disease. An allergy is caused by immune cells creating IgE-type antibodies targeting a part of a protein that is specific to the food it originated from (like an antibody targeting the casein in milk resulting in a milk allergy). A very similar type of immune response is caused by immune cells creating IgA-, IgM- or IgG-type antibodies targeting a part of a protein that is specific to the food it originated from. This type of immune response is technically considered a food sensitivity (and not an allergy), and can cause both allergy-type symptoms and symptoms that you might not normally attribute to an allergy, such as: pain, fatigue, and eczema. It is also the formation of these types of antibodies that can cause auto-immune diseases. Antibodies target only a short sequence of amino acids, and not all of the amino acids that form an individual protein. In the case of food allergies and sensitivities, this short sequence of amino acids is still specific to the food it originated from. But, sometimes the antibodies that form in response to “leaked-out” proteins target a sequence of amino acids that isn’t unique to that protein, but instead is a sequence of amino acids also found in many other normal proteins in the human body. When this happens, the body attacks itself thinking its own cells are foreign invaders. For example, an antibody could form against a sequence of amino acids that is found in the insulin-secreting beta cells of the pancreas. When the body attacks those cells, it causes Type I Diabetes. An enormous range of autoimmune diseases can be caused in this way, from lupus to celiac disease to Graves’ disease (many of which include genetic susceptibility as confounding factor).

It is important to know that, for some individuals, a leaky gut can develop slowly over years or decades. Stress, sleep-deprivation and/or some infections can make matters worse very quickly (and unpredictably). Once you have a leaky gut, it is only a matter of time before related health conditions begin to crop up. Depending on the extent of the damage to the gut lining, the exact substances that leak out, and your specific genetics, the inflammation and immune reactions caused by having a leaky gut can add up to any of a huge variety of different health conditions, many of which can be life-threatening. This is why the gut-friendly, anti-inflammatory paleo diet is known to address so many different health issues: if your gut is healthy, then so are you.