COMMENTARY

WESTERN DIET AND INFLAMMATION

by John Neustadt, ND

The prevalence of chronic, degenerative diseases foods. This diet, commonly called the Paleolithic diet or
attributable wholly or in part to dietary patterns is the Hunter-Gatherer diet, had predominated for about 2 mil-
most serious threat to public health in the United States. lion years. According to AP Simopoulos, a leading
These diseases include cardiovascular disease (CVD), can- researcher into the effects of polyunsaturated fatty acids
cer, type 2 diabetes mellitus, and overweight/obesity. The on health and disease, the Paleolithic diet contained 19%
numbers are truly staggering. One third of American to 36% protein and 22% to 46% carbohydrates; daily
adults (more than 71 million people) have one or more intakes of 520 mg cholesterol, 100 to 150 g fiber, 690 mg
types of CVD, including 13.2 million cases of coronary sodium, 1500 to 2000 mg calcium, and 400 mg vitamin C;
heart disease (CHD) and 65 million cases of high blood and a polyunsaturated-to-saturated fatty acid ratio of
pressure (HBP, defined as systolic blood pressure ≥140 1.41.15,16 Additionally, this diet contained a potassium-to-
mm Hg and/or diastolic blood pressure ≥90 mm Hg).1 sodium ratio of approximately 10:1.17 The Paleolithic diet,
CVD, the number-one cause of mortality in the United of course, was devoid of all processed foods.16,18
States, accounted for 37.3% of all US deaths in 2003, and In contrast, the post-Agricultural Revolution
was “an underlying or contributing cause” for approxi- Western diet, also called the Standard American diet
mately 58% of deaths in 2002.1 (SAD), is radically different from our ancestors’ diet.
Cancer is responsible for 25% of US deaths and is the Today’s Western dietary pattern is characterized by a high
second leading cause of mortality.2 Research suggests intake of saturated fatty acids, trans fatty acids, and
that about one-third of all cancer deaths are attributable processed foods; and low intakes of mono- and poly-
to poor nutrition, physical inactivity, and overweight or unsaturated fatty acids, dietary fiber, and micronutrients.
obesity;2 and these risk factors may account for up to 80% The foods most commonly consumed in the Western
of large bowel, breast, and prostate cancers.3,4 dietary pattern are grain-fed beef, processed meat (eg, deli
Overweight (defined as body mass index [BMI] of 25- meats or hotdogs), refined-grain products, eggs, French
29.9) and obesity (BMI ≥30) are at epidemic levels, with fries, high-fat dairy products, and sweets and other
65% of US adults classified as overweight or obese.5 desserts.19,20
Nearly one-third of US children are either at risk for In contrast with the Paleolithic diet, which contained
being overweight or are already overweight or obese.5 no refined sugar, in 2000 the consumption of all refined
Obesity contributes to more than 280,000 deaths each sugars in the US was 69.1 kg, up from 55.5 kg in 1970.21 In
year in the United States,6 and in the coming decades addition, the typical Western diet has been estimated to
may erode the national gains in life expectancy.7 contain 16 to 30 times more omega-6 fat than omega-3
A common factor that may contribute to the develop- fat15,22 and has a potassium-to-sodium ratio of
ment and progression of these illnesses is chronic inflam- 1:1.25–3.75.17 The potassium, found primarily in plant
mation, which can be caused and modified by diet.8-13 In foods, is mostly in the form of potassium bicarbonate
fact, several pathologies that were once viewed as unrelat- (KHCO3), while sodium in the Western diet is in the form
ed are now grouped by some researchers and clinicians of sodium chloride (NaCl) from processed foods.
into the category of “inflammatory disease,” including ath- Therefore, the imbalance of potassium to sodium in the
erosclerosis, dementia, arthritis, vasculitis, diabetes, and Western diet is also accompanied by elevated dietary chlo-
autoimmune diseases.14 This article reviews the role diet ride consumption and decreased dietary bicarbonate con-
plays in creating inflammation in the body. sumption.17 Additionally, in the year 2000, cereal grains,
such as wheat and rye, were consumed at a rate of 200
THE WESTERN DIETARY PATTERN pounds per person per year in the United States.21
Since the Agricultural Revolution approximately Summarizing the major differences between ances-
10,000 years ago, dietary and lifestyle patterns have dra- tral diets and the Western diet, Simopoulos writes,
matically changed. Prior to the revolution, people con- “Today industrialized societies are characterized by (1) an
sumed an enormous variety of wild plants and animal increase in energy intake and decrease in energy expendi-

14 Integrative Medicine • Vol. 5, No. 4 • Aug/Sept 2006

ture; (2) an increase in saturated fat, omega-6 fatty acids response to noxious stimuli (eg, environmental factors,
and trans fatty acids, and a decrease in omega-3 fatty acid food, or microbial antigens; or vascular endothelial dam-
intake; (3) a decrease in complex carbohydrates and fiber; age) that involves leukocytes (eg, mast cells, eosinophils,
(4) an increase in cereal grains and a decrease in fruits and basophils, and neutrophils) as well as signaling molecules
vegetables; and (5) a decrease in protein, antioxidants, produced by these cells such as interleukins (eg, IL-1, IL-
and calcium intake.”15 (See Table 1.) 6), leukotrienes (eg, LTB4), and prostaglandins (eg,
PGE2). Other inflammatory molecules are produced by
FOOD AND INFLAMMATION the endothelium [eg, E-selectin, intercellular adhesion
Inflammation is a dynamic, immune-mediated molecule 1 (ICAM-1) and vascular cell adhesion molecule
1 (VCAM-1)] and the liver [eg, C-reactive protein (CRP),
TABLE 1 NUTRIENT CONTENT OF PALEOLITHIC AND fibrinogen]. Additionally, the immune system requires
WESTERN DIETS15-18, 21 reactive oxygen species (ROS) to kill pathogens, but these
free radicals can also induce inflammation. All of these, as
Dietary component Western diet Paleolithic
well as other, inflammatory mediators are relatively short
Calories (calories/d) 3,900 ↓*
lived and are part of the acute inflammatory response. In
Protein 11 19-35
(% of total calories) this response, vessel diameter and permeability are
Meat 12 (mostly conven- 45–60 (wild game)† altered, which permits plasma proteins and leukocytes to
(% of total calories) tionally raised beef ) migrate out of the blood vessel and into a lesion.
Carbohydrates (% of 50 22-46 Chronic inflammation occurs when damage contin-
total calories) ues and acute inflammatory mediators remain elevated or
Carbohydrate quality Mostly refined, Mostly complex, become elevated too often. This state is characterized by
rapidly absorbed slowly absorbed
an infiltration of mononuclear cells (lymphocytes and
Refined sugars (kg/yr) 69.1 0
monocytes), inflammatory cell–mediated tissue destruc-
Water, relative ↓ (mainly in calorie _ tion, and increased angiogenesis at the foci of active tissue
consumption containing soft
drinks) repair.23 A complete discussion of the pathology and bio-
Fat, total (% total 39 21 (mostly unrefined, chemistry of inflammation is beyond the scope of this
daily calories) plant based) paper; however, a partial list of inflammatory mediators is
Saturated fat (% total 32 ↓ provided in Table 2.
daily calories)
Polyunsaturated-to- 0.67 1.41
saturated fat ratio TABLE 2 SOME INFLAMMATORY MEDIATORS
Cholesterol (mg/day) 430 520 IL-1
trans fatty acids (g/day) 5.3 0 IL-6
Total long-chain 0.2 2.3 TNF-alpha
omega-6 + omega-3
(g/day) Fibrinogen
Ratio of omega 6:3 12 2.4 LTB4
Fiber (g/day) 24 100-150 PGE2
Fiber from vegetables 40 100 Cyclooxygenase-2 (COX-2)
and fruit (%) ICAM-1
Sodium (mg/day) 1,330 690 VCAM-1
K:Na 2.81 _ (Potassium intake CRP
was 3 to 4 times high-
er than today) Nuclear factor-_B
Riboflavin mg/d 1.34-2.08 6.49
The influence of diet on inflammation results from a
Folate mg/d 0.149-0.205 0.357
combination of food quantity and quality, and genetic
Thiamin mg/d 1.08-1.75 3.91
susceptibility. James O’Keefe, Jr, MD, of the Mid America
Carotene mg/d 2.05-2.57 5.56
Heart Institute, co-authored a review article on the effects
Vitamin A mg/d 7.02-8.48 17.2
diet has on cardiovascular disease. He concluded that it
Vitamin C mg/d 77-109 440-604
results from a diet and lifestyle “at odds with our
Vitamin E mg/d 7-10 32.8 Paleolithic genome.”16 Several features of the modern diet
*Up and down arrows are used when exact numbers are not known, have been studied extensively for their effects on inflam-
and denote relatively higher or lower amounts, respectively.
†Conventionally-raised beef has a higher fat content than wild game, mation. Specifically, excessive consumption of refined
and the fat in conventionally-raised beef has a relatively high omega-6 carbohydrates, low dietary fiber intake, and a high omega-
to omega-3 ratio compared to wild game. 6 to omega-3 ratio are strongly associated with the pro-

Integrative Medicine • Vol. 5, No. 4 • Aug/Sept 2006 15

 duction of pro-inflammatory molecules.24-26 Additionally, and levels of cholesterol than did controls. Total fruit, veg-
antioxidants decrease inflammation, and the low intake of etable, nuts, and whole grain intakes, and olive oil con-
antioxidants in the form of vitamins (eg, C and E) and sumption were also significantly higher.” Compared with
flavonoids found in fruits and vegetables contributes to a the control group, the Mediterranean diet group also had
chronic, pro-inflammatory state that initiates, maintains, significantly greater improvement in all end points after
and exacerbates disease.19,27,28 (See Table 3 for a list of the 2 years. In addition, only 40 patients in the
dietary patterns or components and their relationship to Mediterranean diet group could still be classified as hav-
inflammatory mediators.) ing metabolic syndrome at the end of the trial, compared
In a cross-sectional study of 732 women (43-69 years with 78 volunteers in the control group (P<0.001).
old, average 56 years) participating in the Nurses’ Health Among other reasons, diet can alter inflammatory
Study, researchers analyzed the correlation between markers because of the quantity of food consumed,
dietary patterns and inflammatory markers. Two dietary macronutrient and antioxidant content, glycemic load,
patterns were identified using food frequency question- and fatty acid ratio. Due to the high quantity of low-fiber
naires: the “prudent pattern” diet and the Western diet. processed foods in the Western diet, the glycemic load
The prudent pattern diet was much closer to a Paleolithic (GL) of food is higher than in the Paleolithic or
diet than the Western diet in that the prudent pattern diet Mediterranean diets. The GL indicates the relative effect a
contained larger amounts of vegetables, fruit, legumes, given quantity of food has on raising blood sugar. Unlike
whole grains, fish, and poultry. The Western diet pattern the glycemic index (GI), which denotes how rapidly a car-
in this cohort contained more red meat, processed meat, bohydrate (eg, a potato) turns into glucose, the GL takes
refined grains, sweets and other desserts, French fries, and into account how much carbohydrate might be in a given
high-fat dairy products. Inflammatory markers showed a serving of the food, and, therefore, how eating a specific
positive relation with the Western diet, including signifi- quantity of that food affects blood sugar. Thus, a high-GI
cantly greater concentrations of CRP (P<0.001), IL-6 food, such as watermelon, may have a low GL if the person
(P=0.006), E-selectin (P<0.001), sICAM-1 (P<0.001), and only eats a small serving. In diets containing refined foods
sVCAM-1 (P=0.008) in the highest quintile of those fol- low in fiber, people typically consume large amounts of
lowing the Western diet, compared with the lowest quin- high-GL foods. One result from this is blood fluctuations.
tile. In comparison, there was a modest but statistically Recently, acute postprandial fluctuations in blood glucose
significant decrease in these same inflammatory markers concentrations in patients with type 2 diabetes were
in the highest quintile of the prudent pattern diet com- shown to result in greater generation of oxidative stress
pared with the lowest quintile.29 than chronic, sustained hyperglycemia.31 It is a sobering
Similar to the prudent pattern diet, the comparison, since, in itself, hyperglycemia has such dele-
Mediterranean diet stresses exercise, whole grains, fruits, terious effects because it produces ROS that damage mito-
vegetables, legumes, and nuts.30 In a single, blind, 2-year chondria and activate nuclear factor kappa beta (NFkB), a
clinical trial, 180 volunteers (mean age approximately 44 nuclear transcription factor involved in the production of
years) diagnosed with metabolic syndrome were random- inflammatory mediators such as interleukins and TNF-
ized to follow a Mediterranean diet (n=90) or a control alpha.32,33 Consuming fructose, which is used to sweeten
diet (n=90) containing 50% to 60% carbohydrates, 15% to soft drinks, can also increase free-radical generation.34
20% proteins, and less than 30% total fat. Volunteers in the Fat quality also plays a role in inflammation because
Mediterranean diet group were given the same percent it is incorporated into cell membranes and affects cell-sig-
recommendations as in the control group, but were also naling. Fatty acids are cleaved from the cell membrane by
instructed to eat less than 10% saturated fat and less than phospholipase A2 (PLA2) and then metabolized to
300 mg/day cholesterol; to consume at least 250 to 300 prostaglandins or leukotrienes by either cyclooxygenase
g/day fruits, 125 to 150 g/day vegetables, 25 to 50 g/day or lipoxygenase enzymes. The omega-6 series of fatty
walnuts, and 400 g/day whole grains (defined in this acids, such as arachadonic acid (20:4 omega-6) are con-
study as legumes, rice, maize, and wheat); and to increase verted by these enzymes into cytokines that are part of the
olive oil consumption. End points, which included serum pro-inflammatory cascade, such as PGE2 and LTB4. In
high-sensitivity C-reactive protein (hsCRP), IL-6, IL-7, and contrast, fatty acids in the omega-3 series, such as eicos-
IL-18, were determined at baseline and after 2 years. apentaenoic acid (EPA, 20:5 omega-3), are metabolized by
The researchers reported that after 2 years on the these enzymes into cytokines that are part of the anti-
Mediterranean diet, volunteers “consumed a greater per- inflammatory cascade, such as prostaglandin I3 (PGI3)
centage of calories from complex carbohydrates and from and thromboxane (TXA3).
polyunsaturated and monounsaturated fat; had a greater The relative proportion of omega-6 and omega-3
intake of fiber; had a lower ratio of omega-6 to omega-3 fatty acids in tissues is modified by diet. High concentra-
fatty acids; and had lower calories, levels of saturated fat, tions of omega-6 fats are found in red meat and dairy

16 Integrative Medicine • Vol. 5, No. 4 • Aug/Sept 2006

products, while omega-3 fatty acids are found in the high- nicians can help decrease the overwhelming burden of
est quantities in nuts, vegetables, and fish. As already chronic degenerative diseases on our healthcare system by
noted, the Western diet is high in omega-6 and low in educating and encouraging patients to move in the direc-
omega-3 fatty acids, which contributes to a pro-inflamma- tion of better health through better diet (see Table 4).
tory state. As levels of EPA increase in macrophages, pro-
duction of TNF-alpha and IL-1_ decrease.35 TABLE 4
Trans fatty acids, which are present in fried and many HEALTHY DIET AND LIFESTYLE RECOMMENDATIONS16
processed foods, also contribute to inflammation. Using
Eat whole, natural, fresh foods.
data from the Nurses’ Health Study, Walter Willet, MD,
showed 12 years ago in 1993 that trans fatty acid con- Consume a diet high in fruits, vegetables, nuts, and berries;
sumption increases the risk of CHD.36 In a follow-up to the and low in refined grains and sugars.
Nurses’ Health Study, trans fat intake linearly correlated
with plasma concentration of CRP (P=0.009). CRP was Increase consumption of omega-3 fatty acids from fish, fish oil,
and plant sources.
73% higher among women in the highest quintile of trans
fatty acid intake (3.7 ± 0.6 g/d) compared with those in Avoid all trans fats and limit intake of saturated fats. Eliminate
the lowest quintile (1.5 ± 0.3 g/d).37 fried foods, hard margarine, commercial baked goods, and
most packaged and processed snack foods. Substitute
TABLE 3 DIETARY PATTERN OR COMPONENTS AND monounsaturated fats (eg, avocados, nuts and seeds) and
THEIR RELATIONSHIP TO INFLAMMATORY MEDIATORS polyunsaturated fats (eg, whole grains, fish—in particular her-
ring, salmon, mackerel, and halibut—and soybeans) for satu-
Diet or dietary components Effects on inflammation rated fats (eg, red meats and high-fat dairy products).
Western dietary pattern Associated with increased CRP,
IL-6, E-selectin, sICAM-1, Increase consumption of lean protein, such as skinless poultry,
sVCAM-129 fish, and game meats and lean cuts of red meat. Avoid high-fat
Prudent pattern diet Associated with decreased CRP dairy and fatty, salty processed meats, such as bacon, sausage,
and E-selectin29 and deli meats.
Mediterranean diet Decreased CRP and IL-638
Incorporate olive oil into the diet.
Trans fatty acids Associated with increased CRP37
Sugar-sweetened soft drink; Associated with increased CRP, Drink water.
refined grains; processed meat; IL-6, E-selectin, sICAM-1, and
diet soft drinks; vegetables other sVCAM-119
Participate in daily exercise through various activities (incorpo-
than green leafy vegetables, yel-
rating aerobic and strength training and stretching exercises).
low vegetables, cruciferous veg-
etables, tomatoes, and legumes Outdoor activities are ideal.
Wine, coffee, cruciferous Associated with decreased CRP,
vegetables, yellow vegetables IL-6, E-selectin, sICAM-1, and John Neustadt, ND, is the founder of Montana Integrative Medicine in
sVCAM-119 Bozeman, Mont. He is a member of the American Association of
Naturopathic Physicians’ Scientific Affairs Committee. Dr Neustadt has
Omega-3 fatty acids Decreases TXA2, PGE2, TNF-
written more than 100 published research reviews and is co-author, with
alpha, IL-1 beta.35 Associated
Jonathan Wright, MD, of Thriving through Dialysis (Auburn, Wash: Dragon
with decreased TNF-alpha
Arts Publishing; 2006).
receptor expression and CRP.25

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