C-reactive protein

By now, most clinicians and dietitians have learned to assess patient lab work with at least some new-found appreciation for those markers of inflammation.  These may range from the highly sensitive C-reactive protein (CRP-hs) to the more general erythrocyte sedimentation rate (ESR) or possibly the surrogate marker of renal inflammation, urinary micro albumin.  Each of these has its own role in detecting inflammatory-based issues and each should indicate the potential role for dietary intervention. C-reactive protein tests, both regular and highly sensitive, have become the most common measures of inflammation. CRP values greater than 3.0 are major red flags,- in fact, anything greater than 1.0 should generate some concern. CRP hs values greater than 1.0 suggest a significant amount of inflammation, most likely systemic and definitely affecting the cardiovascular system. Much of this inflammation is gut-derived: microbes metabolize particular components of a meal or diet and then generate a wide variety of substances, many of which are highly inflammatory.

As a clinician overseeing the care and nutrition of a patient, these elevated markers should produce at least a general dietary recommendation.  An anti-inflammatory diet that could reduce, at least some of, those fires were being caused or exacerbated by an individual's food choices.  This involves not only eliminating the usual suspects such as wheat and all other sources of gluten, many conventional dairy products and proteins (minimally processed and unsweetened yogurt or kefir the exception), and soy-containing foods, but also others that may not be on the care provider's radar. Meat that is browned or blackened, as well as, of course, processed meats, eggs, especially fried eggs, seed and/or vegetable oils, high glycemic foods, and baked or toasted cereal products, even if gluten-free, are all examples of foods with a high potential to elevate or ignite a metabolic fire.  This may be because of how a particular food elevates a patient's insulin, alters gut microbial activity, or disrupts omega 6 fatty acid levels.  Each food has its own mechanisms whereby it can create issues.

Clinicians who are skeptical or oblivious to the role of nutrition in treating chronic and infectious disease may state that many elevated inflammatory states are ultimately caused by infection, either systemic or localized.  These clinicians do not think of microbial populations that are unbalanced as an infection, but they should.  A very small percentage of individuals with dysbiosis, another way of describing a gut infection or imbalance, present physical symptoms.  Most of these patients would describe their digestion as good or normal.  The patient narrative would not indicate that there was a source of inflammation within the GI.  The medial focus may be on treating the blocked coronary artery or the uncontrolled diabetes, but to be sure, inflammation is at work either causing or fanning the flames

Structuring a patient's meals so that there is a longer fasting window, such as a no-food or sweetened beverage window of 13 hours, in addition to adding a small amount of unsweetened yogurt, that contains active cultures, to each meal are equally important recommendations.  Concentrating the two or three meals within an 11-hour window can generate excellent anti-inflammatory results without significant fasting or deprivation.  I know because I have seen it in clinical practice many times over years. The use of the right probiotic or yogurt can mitigate a microbial response that might otherwise add trimethyl-amine oxidase (TMAO) or lipopolysaccahrides (LPS) to systemic circulation.  In addition to causing inflammation on their own, these types of molecules also play pivotal roles in other areas such as increasing leptin and insulin levels as well as altering intestinal permeability and increasing a patient's risk for sepsis or endotoxemia.

The use of a modified elimination diet, one that is structured appropriately, in combination with addressing an individual's microbiota, is the most fundamental component of treating inflammation and inflammation-mediated disease.  An infection in the presence of a disrupted micro biome is worse than the infection alone.  Large numbers of small dense LDL particles (LDL pattern B) with inflammation are much more atherogenic than on their own. The examples are almost endless.  Vegetables and brightly colored, more sour and less sweet fruits, high quality extra virgin olive oil, small, oily, wild fish, and starchy root vegetables are the core foods for most in need of anti-inflammatory dietary guidance.  Advice on cooking with turmeric or curry, adding thyme, oregano, and other herbs can also add tremendous value to the diet. While the role of grass-fed red meat simmered in vegetable juices or certain legumes such as chick peas and lentils soaked and cooked extensively may not be for everyone, they are of far less importance than the foundation of vegetables and healthy fats.

In addition to inflammatory markers, many patients suffer from one or more areas of hypomethylation.  This is simply an issue of not converting a substance that is required to be maintained at specific levels in the body.  Narrow windows of physiologically acceptable pools make this process critical for liver, cardiovascular, and neurological health among others.  All clinicians should look closely at biomarkers such as homocysteine and mean corpuscular volume (MCV).  A homocysteine greater than 10.0 should be addressed, as should MCV values higher than 95.0.  Either indicates methylation issues or deficiency in the patient.  Many of our predispositions to chronic disease are based in our genetics.  Methylation problems may be one of the absolute best examples of this. All of these, of course, can be addressed rather rapidly with nutritional intervention.  As with inflammation, most conditions are made worse by hypomethylation. Addressing these is most definitely in the patient's best interest.

This brings me back to the most fundamental aspect of patient care: treating the whole patient.  Triage has its place in the emergency room and the battlefield.  Luckily, most office visits do not require this approach.  Addressing an individual's dietary practices and regular food choices is as important as their anthropometrics, weight and blood pressure included.  Looking at these and other valuable biomarkers can make the difference between disease advancement and reversal.

~ John Bagnulo MPH, PhD. - Director of Nutrition