ASSIGNMENT DIETARY ANALYSIS 30%
Concisely summarize your information. Your assignment should be no more than 4-5 pages in length (double spaced).
You will submit your assignments via Moodle.
Assignments that are handed in late will be given a penalty of 10% per academic day. Weekends are assessed as being 1 day. For example, an assignment marked out of 10 that is due on Friday and handed in on Tuesday will achieve a maximum grade of 8 out of 10 (a 20% penalty).
Assignments will no longer be accepted once they are 5 academic days late.
Students will work in groups of 4. Please include all of the names of the individuals in your group on the assignment. Please submit only one assignment.
Students are required to create an evidence based nutritional protocol and a 7-day menu plan for a medical condition or patient population.
Protocol must include:
Dietary recommendations including brief description of the chosen therapeutic eating paradigm, menu plan, foods to avoid and foods to eat
Obstacles to compliance
The anti-inflammatory diet is a long-term eating paradigm designed to promote healthy living and register an improved overall sense of well-being. The program nearly resembles Mediterranean or DASH diets as they encourage the consumption of plant-based and whole foods as opposed to processed alternatives, including sugars, meats, oils, and fats. The anti-inflammatory diet is more focused on soothing the chronic inflammation in the body. There are two main groups of food in the paradigm, including anti-inflammatory food such as antioxidant that fights against inflammation and proinflammatory food that exacerbates the condition.
Rheumatoid arthritis is an autoimmune disorder characterized by progressive joint pain and damage. The illness occurs whenever the immune system of an individual attacks their own body resulting in severe organ damage. The disease affects the joint linings resulting in extensive inflammation. The primary symptoms of the condition include fatigue, fever, and loss of appetite, joint stiffness especially following lengthy periods of inactivity, and deformity. Over time the inflammation causes bone erosion, severely impacting the individual's mobility. There is currently no cure for the illness, with the severity of the symptoms being managed by physiotherapy and medication. However, the progression of the disease can be curtailed with an anti-inflammatory eating paradigm. There is documented evidence that certain diets can be used in the management of osteoarthritis. This article will present an extensive analysis of nutrition inflammation interaction and its implications in the use of diet in rheumatoid arthritis treatment. The interventions have also been noted to have a significant impact in preventing and healing the gut microbiome. Intestinal inflammation is commonly managed through a diet enriched with nuts, fruits, vegetables, and legumes, as well as minimal intake of animal food and increased preference for plant-based alternatives. The gut microbiome has also been noted to experience expedited healing, as will be discussed in this article.
Developed by Dr. Andrew Weil, the anti-inflammatory diet pyramid consists of 16 main sources (1) of nutrients, including:
The anti-inflammatory diet restricts the consumption of certain foods, including (2)
The intake of the following foods should also be minimized:
Chronic inflammation leads to a plethora of chronic conditions; thus, the regimen serves as a complementary therapy for multiple illnesses, including:
Rheumatoid arthritis (RA) is a chronic inflammatory condition characterized by symmetrical, peripheral polyarthritis with uncertain etiology. The disease is manifested through several extra-articular symptoms, including fatigue, joint pain and numbness, and lung and heart involvement. RA results in physical disability in the long term. The annual incidence of rheumatoid arthritis worldwide is approximately 3 cases per 10,000 population, and the prevalence rate is around 1 percent, rising with age and peaking between 35 and 50 years of age. (3)
The disease has a significant effect on the quality of life with increased morbidity and shortened life expectancy, placing a major economic burden on society. (4) Studies report a combination of environmental and genetic factors to cause full disease expression, with the pathogenesis largely remaining unclear. However, the significant risk factors for RA development are shared epitopes coded by human leukocyte antigen (HLA) alleles, non-HLA genes, epigenetic factors, and differentially glycosylated proteins. (5)
RA patients exhibit gastrointestinal problems, including dyspepsia, mucosal ulceration, and changeable bowel habits (6), which can be related to altered intestinal microbiota as one of the possible etiopathogenesis of RA (7). There is growing evidence that altered microbiota in the gut of RA patients is responsible for pathogenesis as well as disease progression, (8) it should be desirable for physicians to advocate a supplemental “diet therapy” for RA patients to restore the normal gut flora and reduce the overall inflammation.
Mechanism of Action
Inflammation is a central phenomenon in innate immunity. The process is a local response to cellular injury marked by increased blood flow, capillary dilatation, leucocyte infiltration, and the localized production of a host of chemical mediators, which serves to initiate the elimination of toxic agents and initiate the repair of damaged tissue (9).
The termination of inflammation is an active process involving cytokines and other mediators, including lipids, and constitutes the switching off of pro-inflammatory pathways (10, 11). A chronic inflammatory state is a pathological feature of a wide range of chronic conditions, such as Rheumatoid Arthritis (RA). (12,13)
Many foods, nutrients, and non-nutrient food components modulate inflammation acutely and chronically (9, 14), with some eliminating general body inflammation. Dietary studies are typically limited to measuring a small number of inflammatory blood markers, often in a fasting state, thus, aiding in the understanding of diet/nutrient–inflammation interactions. Previous research efforts have dealt extensively with the food/nutrition–inflammation interaction (14,15). For instance, flavonoids anti-inflammation mechanism includes:
a. the modulation of intracellular signaling cascades that control neuronal survival, death, and differentiation;
b. an impact on gene expression and;
c. interacting with the mitochondria (16).
Anti-inflammatory properties of food and nutrients include:
a. an inhibitory role in the release of cytokines, such as IL-1β and TNF-α, from activated microglia;
b. an inhibitory action against inducible NO synthase induction and subsequent NO production;
c. an ability to inhibit the activation of NADPH oxidase and next generation of reactive oxygen species;
d. a capacity to down-regulate the activity of pro-inflammatory transcription factors, such as NF-B.
However, almost all mechanistic studies have been carried out in vitro at rather supraphysiological concentrations, with limited research on animal models and scarce data from human RCTs. Establishing and quantifying reliable and precise diet–inflammation–health associations are reliant on the availability of approved, standardized biomarkers with normative data for use in human observation studies and RCTs. Biomarker research is a highly active area with significant advances to be expected in the coming years (16).
Over the past few decades, researchers have examined the role of inflammation in the development and progression of chronic disease and the relationship between diet and chronic inflammatory conditions. The impact of the autoimmune response in Rheumatoid Arthritis and Cardiovascular disease and inflammatory conditions, such as IBD and Cancer, has also been extensively studied. A double-blind, cross-over study in 2003 compared the role of vegetarian diet, alone and in combination with fish oil supplementation on RA patients for 8 months. The participants were evaluated with clinical examination and lab tests before, after, and regularly during the study. The result showed improvement in clinical signs of inflammation in RA patients and the beneficial effect of fish oil supplementation. (17)
To promote research into the impact of diet on health, an Inflammatory Index was designed to determine the inflammatory potential of individuals' food intake using markers such as serum high-sensitivity (hs) C-reactive protein (CRP), in nearly 600 adults for 1 y. The findings were consistent with the ability of the Inflammatory Index to estimate hs-CRP and provide further proof that diet plays a role in inflammation control. (18) Even though there is no standardized anti-inflammatory diet regimen, studies suggest that adapting a modified Mediterranean or DASH diet in addition to avoiding pre-inflammatory foods can enable patients to relieve clinical symptoms and improve their quality of life.
In 2020, an anti-inflammatory diet (ITIS) was designed based on food intake details, supplements, cooking styles, and consumption of different ingredients to assist in the management of rheumatoid arthritis. In order to develop a regimen that integrates recommended anti-inflammatory ingredients in a way that was easy for patients to follow based on their behaviors and experiences, different groups were interviewed, and their input was analyzed. The diet is being used to date to assess its anti-inflammatory effect on pain and joint swelling in RA patients. (19)
Another well-designed randomized, controlled crossover trial published in 2020 indicated the positive effects of an Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA) on disease activity in 50 RA patients. (20). Although the abovementioned study was well designed, more investigation and proof are required that patients with RA will benefit from an anti-inflammatory diet. (21)
Target patient population: Rheumatoid Arthritis
Eating paradigm: Anti-inflammatory diet based on Mediterranean Diet
Mediterranean Eating Paradigm
The Mediterranean diet includes traditional delicacies and cuisines from South Eastern European countries, including Italy and Greece. The regimen immensely focuses on plant-based foods, including spices, herbs, seeds, nuts, fruits, legumes, vegetables, and whole grains. The primary source of fat is olive oil which is only allowed in minimal servings. The diet also permits the minimum consumption of red meat, dairy, products, and poultry fish. However, there are several foods that have been completely barred in the eating paradigm, including processed red meats, sausages, lunch meats, bacon, and hot dogs. The approach also highly discourages the consumption of heavily processed foods such as refined sugars, processed cheese, candy, sugary beverages, and sodas. Mediterranean diets limit the inclusion of products made from white flour, white pasta, white bread, as well as alcohol and butter. Hydrogenated or refined oils are also not included. Plant foods form the foundation of the regimen, with fruits, vegetables, and whole grains constituting a significant portion of it. Three or four servings a day are recommended. Legumes such as peas, beans, chicken peas, and lentils and nuts should be consumed at least three times a week. Plain Greek yogurt low-fat alternatives can be taken once each day as a snack. The eating paradigm also advises two to three servings a week of fish.
How the Regimen Contributes to Nutritional Deficiencies
Despite its immense impact on the management of osteoarthritis and other inflammatory conditions, the Mediterranean eating paradigm has been faulted for potentially contributing to nutritional deficiencies. While the diet may be rich in minerals and vitamins developed from fish, olive oil, nuts, wholemeal cereals, and fruits, it presents the risk of micronutrient deficiency. Essential amino acids develop from foods such as red meat and other discouraged delicacies. Additionally, restricting or completely cutting off certain foods, as is advocated for by the diet, has significant adverse implications on the general long-term well-being of the person. Each major food category plays a critical role in the wholesome development of the individual; therefore, all-around growth may be severely impaired. Additionally, the Mediterranean eating paradigm has been demonstrated to result in weight gain, especially from regular intake of olive oil and nuts. The imbalanced nutritional qualities of the regimen result in developmental disparities, vastly predisposing the individual to adverse outcomes such as obesity.
Fermented Foods and the Gut Microbiome Support
There is extensively documented research indicating that diets high in fermented foods demonstrate an increased affinity for microbial diversity and an improved immune response. Foods that have undergone fermentation, such as kimchi, have been noted to encourage the growth of microbes, resulting in the net improvement of an individual's health. The microorganisms developed in the process eat sugars resulting in enhanced well-being of the person.
Finding a dietary pattern that most effectively addresses the population's nutritional needs is critical in the setting of nutritional guidelines for the RA patient population in the Mediterranean eating paradigm. (21) The requirement for a given nutrient may be at a lower or higher intake level, according to the specified criterion. The Mediterranean diet has adequate caloric content and is high in vitamins and minerals from vegetables and fruit, nuts, cereals, whole meal, virgin olive oil, and fish, which made the possibility of low intakes of micronutrients very rare. Insufficient intakes of the vitamin B category (B1, B2, niacin, B6, folate, or B12) are uncommon in the Mediterranean diet, with antioxidant vitamins (vitamins E and C) and carotene intakes being high.(22)
Carbohydrates are typically obtained from unrefined, fiber-rich sources such as whole wheat and beans in Mediterranean diets. The diets are rich in fruit and vegetables, pasta, seeds, and fish and contain little meat and cheese. There is a moderate amount of fat in Mediterranean diets, primarily from healthy fats like olive oil. Anti-inflammatory omega-3 fatty acids in fish and other anti-inflammatory compounds found in olive oil also have a beneficial impact on patients with RA. (23)
The conventional Mediterranean diet has continually undergone immense adverse changes, including the addition of low-nutrient-rich foods (such as sugary soft beverages, desserts, baking goods, salted snacks) or varying their methods of food production (such as flour refining) to a less balanced diet. The improvements may have led to an elevated likelihood of insufficient intakes of vitamins, in particular, folate, vitamins A and D, and minimal consumption of other related nutrients (22)
The optimal intake of protein has not been identified for RA patients and depends on the specific dietary needs of the individual. However, guidelines for developing a personalized regimen exist (24). Considering the demographic pattern in the RA population, about 1 to 1.5g/Kg of bodyweight protein and 15-20% their calorie intake to avoid losing muscle mass (25).
RA patients benefit immensely from healthy monounsaturated fats, including olive oil, which is heavily used in the regimen due to its antimicrobial, anti-inflammatory, and antioxidant properties. (25) Oleocanthal and phenolic oil also inhibit inflammatory pathways in RA patients (26).
Omega-3s have also been examined as a potential therapy for RA, based on their capacity to modulate the inflammatory response. (27) Consuming fish and fish oils presents an additional benefit of alleviating cardiovascular disease and inflammation.
An analysis of non-drug therapies, however, concluded that diets high in omega-3 fats, as well as other therapeutic diets, should not be prescribed for RA patients due to their inconsistent and modest outcomes that improve pain, stiffness, and the possibility of 'unbalanced' deficiency. (28)
There are no precise recommendations for saturated fat intake for RA patients, although inflammatory indicators such as C-reactive protein and interleukin-8 have been positively correlated with its consumption. (29)
Western diets are considered pro-inflammatory due to the high ratio of omega-6 to omega-3 fatty acids, while gamma-linolenic acid, found in black currant, borage, and evening primrose supplements, is regarded as an anti-inflammatory (30, 31).
Vitamins and Minerals
There is limited evidence supporting supplementing the RA patients thus, and they are expected to maximize their nutrient intake mainly from food and rely on the supplement in case of comorbidities. In older age women with rheumatoid arthritis, lower vitamin B6 and high homocysteine levels are related to an increase in the risk of cardiovascular events. The situation occurs due to a low intake of folate, vitamin B6, and B12, which are correlated with elevated homocysteine. Some commonly prescribed medications for RA have also been known to affect homocysteine levels. (32)
Some female patients exhibit an inadequate intake of calcium, folic acid, zinc, magnesium, iron, vitamin B6 and B12, as well as low serum levels of zinc, selenium, and vitamins A and E. (33) Folate supplementation, may be considered necessary for RA patients who are taking methotrexate. Due to the high risk of osteoporosis, vitamin D and calcium supplement should be added to RA daily intake. (34)
Fruits and Vegetables
As a majority of RA patients are old with considerable mobility limitations, they might not be able to increase fresh fruit and vegetable consumption. Some of the reasons for this include lack of financial support, limited abilities regarding shopping and preparing fresh meals, and dental issues. (34) Fruits and vegetables are rich in nutrients and antioxidants, which can be more beneficial in reduced and providing essential vitamins and minerals (35).
1. Fatty fish: Fatty fish varieties such as salmon, mackerel, sardines, and trout are high in omega-3 fatty acids and vitamin D and have exhibited potent anti-inflammatory effects. Studies have shown that fatty fish had decreased levels of specific compounds, which are related to inflammation (36). Omega-3 fatty acids reduce several inflammatory markers that are involved in osteoarthritis (37). Fatty fish are a major source of vitamin D that can help prevent its deficiency. Multiple studies have determined that rheumatoid arthritis may be associated with low levels of vitamin D, which could contribute to symptoms (38).
2. Garlic: human trials have found that garlic has anti-inflammatory effects and is associated with decreased joint inflammation, and help to reduce the symptom of arthritis and lower the risk of arthritis and oxidative stress (39). Research has shown that active components of garlic enhance the function of certain immune cells to help strengthen the immune system (40). One cohort study has found that those who ate more garlic had a reduced risk of hip osteoarthritis because of its strong anti-inflammatory properties (41). Another one showed that a specific component in garlic could decrease some of the inflammatory markers associated with arthritis (42).
3. Ginger: also helps ease the symptoms of arthritis. A case-control study determined that the effects of the ginger extract are associated with osteoarthritis of the knee; 63% of participants experienced improvements in knee pain (43). Ginger and its components blocked the production of substances that promote inflammation in the body; thus, treating rats with ginger extract decreased levels of a specific inflammatory marker involved in arthritis (44).
4. Broccoli: Broccoli is one of the healthiest foods out there; it may have some positive effects with reduced inflammation. One study of 1,005 women found that the intake of cruciferous vegetables like broccoli was associated with decreased levels of inflammatory markers (45). Broccoli also contains important components, such as sulforaphane, which can help reduce symptoms of arthritis. For example, sulforaphane is a compound found in broccoli. Test-tube studies have shown that it blocks the formation of a type of cell involved in rheumatoid arthritis development. An animal study also found that sulforaphane could reduce the production of certain inflammatory markers that contribute to rheumatoid arthritis (46). While more studies in humans are needed, these test-tube and animal study results show that the compounds in broccoli may help decrease symptoms of arthritis.
5. Walnuts are nutrient-dense and loaded with compounds that have high omega-3; research has found that the lower c-reactive protein help to reduce the inflammation associated with joint disease (47). One case-control study showed that eating walnuts was associated with a reduced process of inflammation. Walnuts are especially high in omega-3 fatty acids, which have been shown to decrease the symptoms of arthritis (47). Those who received omega-3 fatty acids experienced lower levels of pain and were able to reduce their use of arthritis medications in comparison to the olive oil group (48).
Top 5 Supplements for RA
1. Fish oil: Fish oil contains EPA) and DHA) which helps with the reduction of inflammation in joints. EPA and DHA have some negative effects of producing certain proteins; as a result, the inflammation of joints has decreased. (49) A study in 2013 has found that taking fish oil regularly helps to reduce the RA symptoms than in a control group that didn't take fish oil. (50) It also reduces morning joint stiffness and decreases the number of painful or tender joints(51). Another analysis has shown that omega-3 fatty acid supplements decreased joint pain intensity, morning stiffness, the number of painful joints, and the use of pain relievers in patients with rheumatoid arthritis. (52)
2. Curcumin: Research has shown that curcumin has anti-inflammatory curcuminoids which inhibit COX-1 and COX-2 to thwart the production of the eicosanoids prostaglandin E2 and 5-hydroxyeicosatetraenoic acid that can help with decreasing RA swelling and tenderness. (53) The curcuminoids, which are the main ingredient of curcumin, are also testified to have positive effects on osteoarthritis, type 2 diabetes, and dyslipidemia due to their antioxidant and anti-inflammatory actions (54).
3. Ginger: Ginger contains Gingerol, shogaol components, which have potential inhibitory effects of reducing prostaglandin and leukotriene synthesis, also inhibit the synthesis of pro-inflammatory cytokines, such as IL-1, TNF-α, and IL-8 (55), which can reduce prostaglandin synthesis, which is the key to inflammation (56). They established that not only gingerol but also non-gingerol compounds of Zingiber officinale had substantial effects on joint health (57).
4. Chondroitin sulfate and Glucosamine. Numerous mineral supplements that assist in the management of arthritis contain chondroitin sulfate and glucosamine. Once ingested, the substances compound in the cartilage of affected joints, thus, minimizing inflammation and the progression of the illness. Additionally, clinical study outcomes have been positive, suggesting that the intervention can be utilized for pain relief as well as the rebuilding of affected cartilages in persons suffering from arthritis. The compound's primary mechanism of action is acting as a building block for larger molecules and proteoglycans, thus, presenting them with the characteristic viscoelastic property. Glucosamine sulfate has also been determined to high rate of absorption at 4 hours after consumption and regularly stimulates the repair and regeneration of the cartilage. The molecule also has anti-inflammatory effects, which minimizes the progression of the disease (58). –
5. Vitamin D: Vitamin D promotes joint and bone health and facilitates the regulation of calcium metabolism. One study has shown that low levels of vitamin D speed up the onset and progression of RA symptoms (59). Reduced the intake of vitamin D has been directly associated with developing rheumatoid arthritis (60).
Patients with RA are susceptible to develop osteoporosis and endure the pain when the disease is flaring up. The persons for the prevention and treatment of osteoporosis as well as minimize the possible effects on disease activity (61).
RA is a chronic illness with the outlook of the disease depending on many factors, including their age, disease progression, any complications, overweight, genetic factors, and lifestyle factors (61). Prognosis of RA may be anticipated based on the presence of biomarkers and clinical and laboratory evidence of the disease population (61), early diagnosis and treatment may affect disease outcomes even of the disease progression (28). Smoking tobacco can adversely affect the progression of RA. A cohort study in 2007 found that smoking was a significant risk factor for the development of the disease because it causes inflammation on joint health, which aggravate the symptoms of RA (62). Natural remission of rheumatoid arthritis occurs in about 10% of cases. Early disease states have 20% experience of spontaneous remission (63, 64). In another study relapsing or reducing disease pattern was observed in 56% (65). In patients treated with prednisolone, remission rate was greater than those who did not take prednisolone (62). Early combination DMARDs is more effective than monotherapy and short duration of corticosteroid therapy for the treatment of RA and greater chance of early remission (62). Along with conventional treatment, many people used supplements for reducing inflammation and pain. Patients taking vitamin supplements demonstrate significantly decreased symptoms and improved quality of life (64). Anti-inflammatory diet has positive effects of disease progression of RA patient. Research has also shown that Boswellia, ginger, green tea, and turmeric has a positive effect on RA disease progression (65).Literature reviews supporting the positive impact of diet therapy to decrease the disease intensity of RA patient population and reduce the inflammation of disease and increase immunity of life have been presented(68). Early signs of RA are the improvement of the dietary interventions of anti-inflammatory diet, as the long-term benefits were reported (68).
Anti-inflammatory food significantly assists patient manage the condition including alleviating the signs and symptoms of RA. Mediterranean diets help in reducing their disease activity, delaying disease progression, and reducing joint damage, and eventually a decreased dose of drugs administered for therapeutic treatment of patients.
The development of rheumatoid arthritis (RA) is associated with numerous factor major consequences for affected individuals, causing loss of function, poor quality of life, work disability and important societal economic consequences. To achieve therapeutic goals, patient's adherence including beliefs, attitudes, subjective norms, cultural context, social supports, and emotional health challenges, and depression are critical nearly the discussion of the illness. Patient nonadherence can be a persistent risk factor for health and well-being as well as economic burden. In naturopathic treatment, more than half of patient population sustain significant risks by misunderstanding, forgetting, or ignoring healthcare advice (70) with low adherence increasing treatment costs, disease progression and disability as well as change of failure the treatment (69). Therefore, improving adherence enhances the effectiveness of naturopathic medical recommendations and reduced negative health effects and financial costs associated with RA treatment.
Breakfast (326 kcal)
Lunch (440 Kcal)
Snack (142 kcal)
Dinner (605 kcal)
Daily total intake
Souces: cronometer daily intake
Breakfast (274 Kcal)
Lunch (378 Kcal)
Snack (88 Kcal)
Dinner (478 kcal)
Evening Snack (226 kcal)
Souces: cronometer daily intake
Breakfast (214 kcal)
Lunch (333 kcal)
Snack (234 calories)
Dinner (298 kcal)
Breakfast (259 kcal)
Lunch (583 kcal)
Dinner (513 kcal)
Breakfast (479 calories)
Lunch (312 calories)
Snack (271 kcal)
Dinner (398 calories)
Breakfast (198 calories)
Lunch (595 calories)
P.M. Snack (94 calories)
Dinner (399 kcal)
Breakfast (322 calories)
Lunch (535 kcal)
Snack (61 kcal)
Dinner (511 kcal)
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