NMT150 Non-Specific LBP: Food and Inflammation 2023 PDF

NON-SPECIFIC LBP: Food and Inflammation AUTHOR: DR. MARYAM YAVARI, MD, PH.D., ND NMT150 2023 LEARNING OBJECTIVES Considerations for providing nutritional guidance as it relates to this week’s case presentation: Role of diet in reducing systemic inflammation TREATMENT GOALS Addr...

NON-SPECIFIC LBP: Food and Inflammation AUTHOR: DR. MARYAM YAVARI, MD, PH.D., ND NMT150 2023 LEARNING OBJECTIVES Considerations for providing nutritional guidance as it relates to this week’s case presentation: Role of diet in reducing systemic inflammation TREATMENT GOALS Address presenting symptoms and improve patient comfort Support full and speedy recovery to return to regular activities Patient education Monitor and Prevent sequelae  Inflammatory markers and chronic disorders and LBP The Western dietary pattern has typically been linked to higher levels of inflammatory markers in the body. The Anti inflammatory diet is related to reduced inflammation levels. Higher levels of DII (from a proinflammatory diet) may play a role in the prevalence of LBP. 42% higher chances of having low back pain when comparing the group with the most proinflammatory diet to the group with the least pro-inflammatory diet. https://www.sciencedirect.com/science/article/abs/pii/S0165032722013106 https://www.rehabmedicine.pitt.edu/sites/default/files/enrico.pdf  What is an anti-inflammatory diet? Rich in vegetables, fruit, whole grains, nuts, legumes, unsaturated fats, spices and herbs A moderate intake of animal products A low intake of simple carbohydrates, processed foods, saturated fats and alcohol The Mediterranean diet, DASH diet and vegetarian dietary patterns have been described as examples of anti- inflammatory diets. Mukherjee MS, Han CY, Sukumaran S, Delaney CL, Miller MD. Effect of anti-inflammatory diets on inflammation markers in adult human populations: a systematic review of randomized controlled trials. Nutr Rev. 2022 Dec 6;81(1):55-74. doi: 10.1093/nutrit/nuac045.  The Dietary Inflammatory Index (DII) Describes the inflammatory potential of a diet. The DII has been used to examine associations of an inflammatory diet and multiple health outcomes. Shivappa N, Steck SE, Hurley TG, Hussey JR, Hébert jr. Designing and developing a literature-derived, population-based dietary inflammatory index. Public Health Nutr. 2014:17(8):1689-96. Abstract available from: https://pubmed-ncbi-nlm-nih-gov.ccnm.idm.oclc.org/23941862/ Liu FH, Liu C, Gong TT, Gao S, Sun H, Jiang YT, Zhang JY, Zhang M, Gao C, Li XY, Zhao YH, Wu QJ. Dietary Inflammatory Index and Health Outcomes: An Umbrella Review of Systematic Review and Meta-Analyses of Observational Studies. Front Nutr. 2021 May 19;8:647122. doi: 10.3389/fnut.2021.647122. PMID: 34095187; PMCID: PMC8169973. Abstract available from: https://pubmed-ncbi-nlm-nih-gov.ccnm.idm.oclc.org/34095187/  The Dietary Inflammatory Index (DII) Uses a point system to score an individual’s dietary pattern on a scale from low (anti-inflammatory) to high (pro-inflammatory). An individual’s overall dietary score is totalled, with a negative score indicating a more anti-inflammatory diet and a positive score indicating a more pro-inflammatory diet. Shivappa N, Steck SE, Hurley TG, Hussey JR, Hébert jr. Designing and developing a literature-derived, population-based dietary inflammatory index. Public Health Nutr. 2014:17(8):1689-96. Abstract available from: https://pubmed-ncbi-nlm-nih-gov.ccnm.idm.oclc.org/23941862/ Liu FH, Liu C, Gong TT, Gao S, Sun H, Jiang YT, Zhang JY, Zhang M, Gao C, Li XY, Zhao YH, Wu QJ. Dietary Inflammatory Index and Health Outcomes: An Umbrella Review of Systematic Review and Meta-Analyses of Observational Studies. Front Nutr. 2021 May 19;8:647122. doi: 10.3389/fnut.2021.647122. PMID: 34095187; PMCID: PMC8169973. Abstract available from: https://pubmed-ncbi-nlm-nih-gov.ccnm.idm.oclc.org/34095187/  Nutrient Effects on Inflammation Carbohydrates Consumption of refined, high glycemic– load carbohydrates can increase systemic inflammation. Regular consumption of high glycemic– load carbohydrates results in chronic hyperglycemia, which increases the production of free radicals and proinflammatory cytokines. GiuglianoDCerielloAEspositoK. The effects of diet on inflammation: emphasis on the metabolic syndrome. J Am Coll Cardiol. 2006; 48(4): 677– 685. EspositoKNappoFMarfellaR et al. Inflammatory cytokine concentrations are acutely increased by hyperglycemia in humans: role of oxidative stress. Circulation. 2002; 106(16): 2067– 2072. BrennerRR. Nutrition and hormonal factors influencing desaturation of essential fatty acids. Prog Lipid Res. 1982; 20: 41– 48. BrennerRR. Hormonal modulation of delta6 and delta5 desaturases: case of diabetes. Prostaglandins Leukot Essent Fatty Acids. 2003; 68(2): 151– 162.  Nutrient Effects on Inflammation Carbohydrates Insulin has an impact on the enzymes delta-6 and delta-5 desaturase, which are enzymes that regulate the conversion of linoleic acid into arachidonic acid. This results in an increase in arachidonic acid production. On the other hand, glucagon has a inhibitory effect on the desaturase enzymes, which leads to a reduction in the production of arachidonic acid. GiuglianoDCerielloAEspositoK. The effects of diet on inflammation: emphasis on the metabolic syndrome. J Am Coll Cardiol. 2006; 48(4): 677– 685. EspositoKNappoFMarfellaR et al. Inflammatory cytokine concentrations are acutely increased by hyperglycemia in humans: role of oxidative stress. Circulation. 2002; 106(16): 2067– 2072. BrennerRR. Nutrition and hormonal factors influencing desaturation of essential fatty acids. Prog Lipid Res. 1982; 20: 41– 48. BrennerRR. Hormonal modulation of delta6 and delta5 desaturases: case of diabetes. Prostaglandins Leukot Essent Fatty Acids. 2003; 68(2): 151– 162.  Nutrient Effects on Inflammation Fats The level of ω-3 and ω-6 fatty acids (FAs): ω-3 FAs are considered anti-inflammatory, while ω-6 FAs are proinflammatory. Research has demonstrated that maintaining a low ratio of omega-6 to omega-3 fatty acids, specifically below 5:1.12 can have beneficial effects on various health conditions such as cardiovascular disease, rheumatoid arthritis, and asthma. SimopoulosAP. Evolutionary aspects of the dietary omega-6:omega-3 fatty acid ratio: medical implications. World Rev Nutr Diet. 2009; 100: 1– 21. SimopoulosAP. The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomed Pharmacother. 2002; 56(8): 365– 379. SimopoulosAP. Omega-6/omega-3 essential fatty acid ratio and chronic diseases. Food Reviews International. 2004; 20(1): 77– 90. IbargurenMLopezDEscribaP. The effect of natural and synthetic fatty acids on membrane structure, microdomain organization, cellular functions and human health. Biochemica et Biophysica Acta. 2014; 1838(6): 1518– 1528. SerhanCN. Resolution phase of inflammation: novel endogenous anti-inflammatory and proresolving lipid mediators and pathways. Annu Rev Immunol. 2007; 25: 101– 137. LevyB. Resolvins and protectins: natural pharmacophores for resolution biology. Prostaglandins Leukot Essent Fatty Acids. 2010; 82(4-6): 327– 332.  Nutrient Effects on Inflammation Fats Linoleic acid, which is an omega-6 fatty acid, is a precursor for several proinflammatory eicosanoids that are produced from arachidonic acid. Consuming a diet that is high in omega-6 fatty acids can lead to an increased risk of inflammation. Omega-3 fatty acids have anti-inflammatory effects. Unlike insulin, omega-3 fatty acids inhibit the delta-6 desaturase enzyme, which reduces the production of arachidonic acid. Omega-3 fatty acids can contribute to the production of anti- inflammatory eicosanoids called resolvins, which are involved in regulating the activation and movement of white blood cells. SimopoulosAP. Evolutionary aspects of the dietary omega-6:omega-3 fatty acid ratio: medical implications. World Rev Nutr Diet. 2009; 100: 1– 21. SimopoulosAP. The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomed Pharmacother. 2002; 56(8): 365– 379. SimopoulosAP. Omega-6/omega-3 essential fatty acid ratio and chronic diseases. Food Reviews International. 2004; 20(1): 77– 90. IbargurenMLopezDEscribaP. The effect of natural and synthetic fatty acids on membrane structure, microdomain organization, cellular functions and human health. Biochemica et Biophysica Acta. 2014; 1838(6): 1518– 1528. SerhanCN. Resolution phase of inflammation: novel endogenous anti-inflammatory and proresolving lipid mediators and pathways. Annu Rev Immunol. 2007; 25: 101– 137. LevyB. Resolvins and protectins: natural pharmacophores for resolution biology. Prostaglandins Leukot Essent Fatty Acids. 2010; 82(4-6): 327– 332.  Nutrient Effects on Inflammation Fats Trans fats (TFAs) are mainly consumed through foods that contain partially hydrogenated vegetable oils, such as bakery goods. Hydrogenation converts naturally occurring cis double bonds of unsaturated fats into trans double bonds, producing a solid fat with a high melting temperature and longer shelf life. TFA consumption adversely affects serum lipids due to its impact on liver function and lipoprotein metabolism. SimopoulosAP. Evolutionary aspects of the dietary omega-6:omega-3 fatty acid ratio: medical implications. World Rev Nutr Diet. 2009; 100: 1– 21. SimopoulosAP. The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomed Pharmacother. 2002; 56(8): 365– 379. SimopoulosAP. Omega-6/omega-3 essential fatty acid ratio and chronic diseases. Food Reviews International. 2004; 20(1): 77– 90. IbargurenMLopezDEscribaP. The effect of natural and synthetic fatty acids on membrane structure, microdomain organization, cellular functions and human health. Biochemica et Biophysica Acta. 2014; 1838(6): 1518– 1528. SerhanCN. Resolution phase of inflammation: novel endogenous anti-inflammatory and proresolving lipid mediators and pathways. Annu Rev Immunol. 2007; 25: 101– 137. LevyB. Resolvins and protectins: natural pharmacophores for resolution biology. Prostaglandins Leukot Essent Fatty Acids. 2010; 82(4-6): 327– 332.  Nutrient Effects on Inflammation Fats TFA consumption is inherently proinflammatory, and clinical trials and observational studies have linked it to increased markers of systemic inflammation, including tumor necrosis factor (TNF), CRP, and interleukin 6. TFAs can interfere with the metabolism of essential fatty acids involved in inflammatory pathways. SimopoulosAP. Evolutionary aspects of the dietary omega-6:omega-3 fatty acid ratio: medical implications. World Rev Nutr Diet. 2009; 100: 1– 21. SimopoulosAP. The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomed Pharmacother. 2002; 56(8): 365– 379. SimopoulosAP. Omega-6/omega-3 essential fatty acid ratio and chronic diseases. Food Reviews International. 2004; 20(1): 77– 90. IbargurenMLopezDEscribaP. The effect of natural and synthetic fatty acids on membrane structure, microdomain organization, cellular functions and human health. Biochemica et Biophysica Acta. 2014; 1838(6): 1518– 1528. SerhanCN. Resolution phase of inflammation: novel endogenous anti-inflammatory and proresolving lipid mediators and pathways. Annu Rev Immunol. 2007; 25: 101– 137. LevyB. Resolvins and protectins: natural pharmacophores for resolution biology. Prostaglandins Leukot Essent Fatty Acids. 2010; 82(4-6): 327– 332.  Nutrient Effects on Inflammation Polyphenols Polyphenols can neutralize free radicals by conjugated double bonds with a free hydroxyl group and activate endogenous antioxidant defense through regulating Nrf2, a cellular redox transcription factor involved in detoxification. GonzalezRBallesterILopez-PosadasR et al. Effects of flavonoids and other polyphenols on inflammation. Crit Rev Food Sci Nutr. 2011; 51(4): 331– 362. SantangeloCVariRScazzocchioB et al. Polyphenols, intracellular signaling and inflammation. Ann Ist Super Sanita. 2007; 43(4): 394– 405. BiesalskiHK. Polyphenols and inflammation: basic interactions. Curr Opin Clin Nutr Metab Care. 2007; 10(6): 724– 728. ReulandDJKhademiSCastleCJ et al. Upregulation of phase II enzymes through phytochemical activation of Nrf2 protects cardiomyocytes against stress. Free Radic Biol Med. 2013; 56: 102– 111. RahmanIBiswasSKirkhamP. Regulation of inflammation and redox signaling by dietary polyphenols. Biochem Pharmacol. 2006; 72(11): 1439– 1452.  Nutrient Effects on Inflammation Polyphenols Polyphenols also inhibit inflammation by activating gene transcription factors that hinder the activation of NF-kB, a transcription factor responsible for activating inflammatory pathways. Evidence suggests that polyphenols contribute to reducing inflammation, and their deficiency in the diet may be detrimental to health. GonzalezRBallesterILopez-PosadasR et al. Effects of flavonoids and other polyphenols on inflammation. Crit Rev Food Sci Nutr. 2011; 51(4): 331– 362. SantangeloCVariRScazzocchioB et al. Polyphenols, intracellular signaling and inflammation. Ann Ist Super Sanita. 2007; 43(4): 394– 405. BiesalskiHK. Polyphenols and inflammation: basic interactions. Curr Opin Clin Nutr Metab Care. 2007; 10(6): 724– 728. ReulandDJKhademiSCastleCJ et al. Upregulation of phase II enzymes through phytochemical activation of Nrf2 protects cardiomyocytes against stress. Free Radic Biol Med. 2013; 56: 102– 111. RahmanIBiswasSKirkhamP. Regulation of inflammation and redox signaling by dietary polyphenols. Biochem Pharmacol. 2006; 72(11): 1439– 1452.  Nutrient Effects on Inflammation Caloric Intake Chronic inflammation is affected by caloric intake, particularly excess caloric intake in sedentary individuals Adipose tissue directly contributes to chronic inflammation through the release of proinflammatory cytokines such as TNF-α and interleukin 6 as adipocytes enlarge Excess adipose tissue leads to other proinflammatory alterations including increased insulin resistance and sympathetic nervous system activation RajalaMWSchererPE. Minireview: the adipocyte— at the crossroads of energy homeostasis, inflammation, and atherosclerosis. Endocrinology. 2003; 144: 3765– 3773. CancelloRHenegarCViguerieN et al. Reduction of macrophage infiltration and chemoattractant gene expression changes in white adipose tissue of morbidly obese subjects after surgery induced weight loss. Diabetes. 2005; 54: 2277– 2286. XuHYBarnesGTYangQ et al. Chronic inflammation in fat plays a crucial role in the development of obesity-related insulin resistance. J Clin Invest. 2003; 112: 1821– 1830. EngeliSNegrelRSharmaAM. Physiology and pathophysiology of the adipose tissue renin-angiotensin system. Hypertension. 2000; 35: 1270– 1277. XydakisAMCaseCCJonesPH et al. Adiponectin, inflammation, and the expression of the metabolic syndrome in obese individuals: the impact of rapid weight loss through caloric restriction. J Clin Endocrinol Metab. 2004; 89: 2697– 2703.  Nutrient Effects on Inflammation Caloric Intake Calorie restriction with adequate nutrition intake has important anti-inflammatory effects by reducing the number of adipocytes in the body and lowering the level of proinflammatory adipokines and cytokines Calorie restriction improves insulin sensitivity, reduces plasma glucose levels, and lowers the production of advanced glycation end products which dampens the activation of pathways that promote inflammation RajalaMWSchererPE. Minireview: the adipocyte— at the crossroads of energy homeostasis, inflammation, and atherosclerosis. Endocrinology. 2003; 144: 3765– 3773. CancelloRHenegarCViguerieN et al. Reduction of macrophage infiltration and chemoattractant gene expression changes in white adipose tissue of morbidly obese subjects after surgery induced weight loss. Diabetes. 2005; 54: 2277– 2286. XuHYBarnesGTYangQ et al. Chronic inflammation in fat plays a crucial role in the development of obesity-related insulin resistance. J Clin Invest. 2003; 112: 1821– 1830. EngeliSNegrelRSharmaAM. Physiology and pathophysiology of the adipose tissue renin-angiotensin system. Hypertension. 2000; 35: 1270– 1277. XydakisAMCaseCCJonesPH et al. Adiponectin, inflammation, and the expression of the metabolic syndrome in obese individuals: the impact of rapid weight loss through caloric restriction. J Clin Endocrinol Metab. 2004; 89: 2697– 2703.  Nutrient Effects on Inflammation Caloric Intake Calorie restriction enhances endogenous corticosteroid production, promoting anti-inflammatory effects in the body Calorie restriction may increase parasympathetic tone, contributing to the suppression of cytokine-mediated inflammation. RajalaMWSchererPE. Minireview: the adipocyte— at the crossroads of energy homeostasis, inflammation, and atherosclerosis. Endocrinology. 2003; 144: 3765– 3773. CancelloRHenegarCViguerieN et al. Reduction of macrophage infiltration and chemoattractant gene expression changes in white adipose tissue of morbidly obese subjects after surgery induced weight loss. Diabetes. 2005; 54: 2277– 2286. XuHYBarnesGTYangQ et al. Chronic inflammation in fat plays a crucial role in the development of obesity-related insulin resistance. J Clin Invest. 2003; 112: 1821– 1830. EngeliSNegrelRSharmaAM. Physiology and pathophysiology of the adipose tissue renin-angiotensin system. Hypertension. 2000; 35: 1270– 1277. XydakisAMCaseCCJonesPH et al. Adiponectin, inflammation, and the expression of the metabolic syndrome in obese individuals: the impact of rapid weight loss through caloric restriction. J Clin Endocrinol Metab. 2004; 89: 2697– 2703.  Diet Standard American Diet Anti-Inflammatory Diet Vegetables Fewer vegetables High consumption of vegetables: large diversity, and fruits including variety of colors to increase phytonutrients Protein Red meat Plant sources of protein: legumes, soy, nuts, and source seeds Dairy More fatty fish and some lean animal protein Carbohydra Refined carbohydrates; high- Whole grains in small amounts, high fiber, tes fructose corn syrup and added reduced refined carbohydrates sugar Fewer whole grains https://aspenjournals.onlinelibrary.wiley.com/doi/full/10.1177/0884533617700353?casa_token=qOqVaAO9uhIAAAAA% 3A JxmRGRM37F2rykfM5hYsYmcOb7JeZVh1BC9F4aSlYpzxZ8Ww9FzCoNQVSWgOtlm_RPyf8awwZ0KXSnCKJ6E  Diet Standard American Diet Anti-Inflammatory Diet Dairy High-fat dairy sources Fats Solid added fats, such as butter and Olive oil for added fat source sour cream Other Soda and added-sugar beverages Spices: turmeric, garlic, ginger, and other anti- features inflammatory herbs and spices Cultural Eating on the run, overeating Mindful eating approach; quality over quantity https://aspenjournals.onlinelibrary.wiley.com/doi/full/10.1177/0884533617700353?casa_token=qOqVaAO9uhIAAAAA% 3AJxmRGR M37F2rykfM5hYsYmcOb7JeZVh1BC9F4aSlYpzxZ8Ww9FzCoNQVSWgOtlm_RPyf8awwZ0KXSnCKJ6E  Vegetables and Fruits An anti-inflammatory diet focuses on consuming a large portion of vegetables and fruits. Vegetables and fruits are lower in caloric density and rich in beneficial nutrients, including vitamins, minerals, and phytonutrients. Vegetables and fruits should be consumed in large volumes, with every meal, and in a variety of colors and types. Polyphenols found in fruits and vegetables provide their anti- inflammatory properties. SearsB. Anti-inflammatory diets. J Am Coll of Nutr. 2015; 34(suppl 1): 14– 21.GallandL. Diet and inflammation. Nutr Clin Pract. 2010; 25(6): 634– 640.GrottoDZiedE. The standard American diet and its relationship to the health status of Americans. Nutr Clin Pract. 2010; 25(6): 603– 612.  Vegetables and Fruits Nonstarchy fruits and vegetables are high in fiber, reducing their glycemic index relative to other carbohydrates. An ideal anti-inflammatory diet should contain up to two- thirds of the total food volume in vegetables and fruits. Diets high in fruits and vegetables have been shown to correlate with lower levels of inflammatory markers in the blood. Vegetables should be prioritized over fruits due to their lower glycemic index. SearsB. Anti-inflammatory diets. J Am Coll of Nutr. 2015; 34(suppl 1): 14– 21.GallandL. Diet and inflammation. Nutr Clin Pract. 2010; 25(6): 634– 640.GrottoDZiedE. The standard American diet and its relationship to the health status of Americans. Nutr Clin Pract. 2010; 25(6): 603– 612.  Vegetables and Fruits Organic vegetables are preferred as they contain lower levels of pesticides and higher levels of antioxidants. Frozen fruits and vegetables, which are picked at peak ripeness and blanched immediately, can be a good alternative when eaten out of season. Vegetables can be easily prepared with small amounts of olive oil and anti- inflammatory spices. SearsB. Anti-inflammatory diets. J Am Coll of Nutr. 2015; 34(suppl 1): 14– 21.GallandL. Diet and inflammation. Nutr Clin Pract. 2010; 25(6): 634– 640.GrottoDZiedE. The standard American diet and its relationship to the health status of Americans. Nutr Clin Pract. 2010; 25(6): 603– 612.  Protein Sources Protein in an anti-inflammatory diet should come primarily from plant-based sources, with some fish and small amounts of lean natural meats. The type of fat in the protein source determines whether it is anti-inflammatory or pro-inflammatory. Animal protein has higher levels of pro-inflammatory ω-6 FAs, while anti- inflammatory protein sources have higher levels of ω-3 FAs. Fresh-water fatty fish, such as salmon, mackerel, halibut, sardines, and herring, are good sources of anti-inflammatory protein due to their high levels of ω-3 FAs. KozarskiMKlausAJakovljevicD et al. Antioxidants of edible mushrooms. Molecules. 2015; 20(10): 19489– 19525.GuillamonEGarcía-LafuenteALozanoM et al. Edible mushrooms: role in the prevention of cardiovascular diseases. Fitoterapia. 2010; 81(7): 715– 723.  Protein Sources Wild-caught fish and naturally grazing cattle are better sources of anti-inflammatory protein due to their lower ω-6:ω-3 ratios. Organically produced dairy and meats also contain higher levels of anti-inflammatory ω-3 FAs compared to non-organic sources. Cooking method is important, as high- temperature cooking or charring can produce pro-inflammatory compounds and increase cancer risk. KozarskiMKlausAJakovljevicD et al. Antioxidants of edible mushrooms. Molecules. 2015; 20(10): 19489– 19525.GuillamonEGarcía-LafuenteALozanoM et al. Edible mushrooms: role in the prevention of cardiovascular diseases. Fitoterapia. 2010; 81(7): 715– 723.  Protein Sources Soy legumes, non-soy-based legumes, and mushrooms are excellent sources of plant-based protein with anti-inflammatory properties. Soy has been shown to decrease inflammatory markers, while non-soy-based legumes have an inverse relation to high-sensitivity CRP. Phytoestrogens in soy, daidzein, and genistein contribute to its anti-inflammatory properties. Mushrooms contain polyphenols and other anti- inflammatory phytonutrients and should be cooked to reduce natural carcinogens and release more nutrients. KozarskiMKlausAJakovljevicD et al. Antioxidants of edible mushrooms. Molecules. 2015; 20(10): 19489– 19525.GuillamonEGarcía-LafuenteALozanoM et al. Edible mushrooms: role in the prevention of cardiovascular diseases. Fitoterapia. 2010; 81(7): 715– 723.  Carbohydrates An anti-inflammatory diet includes various types of carbohydrates, including whole grains. Whole grain carbohydrates with a low glycemic index are essential in an anti-inflammatory diet. It is important to choose whole grains that have all their original parts present, such as bran, germ, and endosperm. AjaniUAFordESMokdadAH. Dietary fiber and C-reactive protein: findings from national health and nutrition examination survey data. J Nutr. 2003; 134.5: 1181– 1185.KingDEEganBMGeeseyME. Relation of dietary fat and fiber to elevation of C-reactive protein. Am J Card. 2003; 92(11): 1335– 1339. JenkinsDJAKendallCWMarchieA et al. Type 2 diabetes and the vegetarian diet. Am J Clin Nutr. 2003; 78(3): 610S– 616S.  Carbohydrates Refined grains, which strip out much of the nutrients, should be avoided. Grains that have been processed via cracking or crushing should be limited due to their high glycemic index. Examples of whole grains include buckwheat, barley, rye, and wild rice. Whole grains are high in fiber, which has been shown to reduce inflammatory markers. AjaniUAFordESMokdadAH. Dietary fiber and C-reactive protein: findings from national health and nutrition examination survey data. J Nutr. 2003; 134.5: 1181– 1185.KingDEEganBMGeeseyME. Relation of dietary fat and fiber to elevation of C-reactive protein. Am J Card. 2003; 92(11): 1335– 1339. JenkinsDJAKendallCWMarchieA et al. Type 2 diabetes and the vegetarian diet. Am J Clin Nutr. 2003; 78(3): 610S– 616S.  Healthy Fats The anti-inflammatory diet emphasizes on anti- inflammatory fats, which can be present in fruits, vegetables, and protein or added through supplementation of ω-3 FAs. Cold-water fish like salmon, sardines, and anchovies are some of the protein sources with high levels of ω-3 FAs. Fish oil, which is a potent inhibitor of inflammation, can be added as a supplement to an anti- inflammatory diet with a recommended dosage of 1000 mg three times a day. RongYChenLZhuT et al. Egg consumption and risk of coronary heart disease and stroke: dose-response meta-analysis of prospective cohort studies. BMJ. 2013; 346: e8539. MozaffarianDPischonTHankinsonSE et al. Dietary intake of trans fatty acids and systemic inflammation in women. Am J Clin Nutr. 2004; 79.4: 606– 612. BulottaSCelanoMLeporeSMMontalciniTPujiaARussoD. Beneficial effects of the olive oil phenolic components oleuropein and hydroxytyrosol: focus on protection against cardiovascular and metabolic diseases. J Transl Med. 2014; 12: 219.  Healthy Fats Flax seeds, chia seeds, walnuts, and hemp seeds are plant sources of alpha-linolenic acid, which is a good source of ω-3 FAs. Trans fats, which are proinflammatory, should be avoided, and olive oil is the best choice when used at low temperatures for cooking, while oils like soybean, cottonseed, peanut, and corn oil should be avoided as they are proinflammatory. RongYChenLZhuT et al. Egg consumption and risk of coronary heart disease and stroke: dose-response meta-analysis of prospective cohort studies. BMJ. 2013; 346: e8539. MozaffarianDPischonTHankinsonSE et al. Dietary intake of trans fatty acids and systemic inflammation in women. Am J Clin Nutr. 2004; 79.4: 606– 612. BulottaSCelanoMLeporeSMMontalciniTPujiaARussoD. Beneficial effects of the olive oil phenolic components oleuropein and hydroxytyrosol: focus on protection against cardiovascular and metabolic diseases. J Transl Med. 2014; 12: 219. Clinical case A 35-year-old female patient with a history of low back pain presents to your clinic complaining of persistent pain despite current medication therapy. Which of the following dietary changes is most likely to have a beneficial effect on her symptoms? A) Increasing intake of processed carbohydrates with high glycemic index B) Avoiding all sources of fats, including omega-3 fatty acids C) Including more cold-water fish in the diet to increase intake of omega-3 fatty acids D) Adding trans fats from vegetable oils to the diet REFERENCES CDC: https://www.cdc.gov/ Online source Center for Disease Control and Prevention Updates 2022 Prousky J. Textbook of Integrative Clinical Nutrition. CCNM Press Inc.; 2012. Katz D. Nutrition in Clinical Practice. 2nd Edition. Lippincott Williams & Wilkins; 2008. Katsilambros N. Clinical Nutrition in Practice. WileyBlackwell; 2010. Pizzorno J and Katzinger J. Clinical Pathophysiology. Mind Publishing; 2012. Marz RB. Medical Nutrition from Marz. 2nd edition. Quiet Lion Press; 1999. Murray MT. Encyclopedia of Nutritional Supplements. Prima Health; 1996. Gropper S, Smith J. Advanced Nutrition and Human Metabolism. 7th Ed. Cengage Learning; 2018. Gaby A. Nutritional Medicine.; Perlberg Publishing 2011. Hoffer A, Prousky J. Naturopathic Nutrition: A Guide to Nutrient-Rich Food & Nutritional Supplements for Optimal Health. CCNM Press; 2006. J. Wang et al. Dietary inflammatory index and depression: a meta-analysis Public Health Nutr. (2018) Ricker MA, Haas WC. Anti-inflammatory diet in clinical practice: a review. Nutrition in Clinical Practice. 2017 Jun;32(3):318-25. Haß U, Herpich C, Norman K. Anti-inflammatory diets and fatigue. Nutrients. 2019 Sep 30;11(10):2315. Sears B. Anti-inflammatory diets. Journal of the American College of Nutrition. 2015 Sep 15;34(sup1):14-21. Wirth MD, Hébert JR, Shivappa N, Hand GA, Hurley TG, Drenowatz C, McMahon D, Shook RP, Blair SN. Anti- inflammatory Dietary Inflammatory Index scores are associated with healthier scores on other dietary indices. Nutrition research. 2016 Mar 1;36(3):214-9. MozaffarianDClarkeR. Quantitative effects on cardiovascular risk factors and coronary heart disease risk of replacing partially hydrogenated vegetable oils with other fats and oils. Eur J Clin Nutr. 2009; 63(suppl 2): S22– S33. ZapolskaDDBrykDOlejarzW. Trans fatty acids and atherosclerosis-effects on inflammation and endothelial function. J Nutr Food Sci. 2015; 5(6): 426– 432. Lopez-GarciaESchulzeMBMeigsJB et al. Consumption of trans fatty acids is related to plasma biomarkers of inflammation and endothelial dysfunction. J Nutr. 2005; 135: 562– 566. BaerDJJuddJTClevidenceBA et al. Dietary fatty acids affect plasma markers of inflammation in healthy men fed controlled diets: a randomized crossover study. Am J Clin Nutr. 2004; 79(6): 969– 973. THANK YOU!