Dr. Torelli’s Comment:

This study supports much of what we emphasize on our Inflammation Wellness website. First, we suggest that reducing inflammation is a preventative measure with major potential health benefits to those who know how to do it. (See our plans for diet, fitness and stress management) Second, CRP is an excellent diagnostic marker for monitoring inflammation. (See our section on lab tests) I would add a third factor which is not addressed in this research paper, which is that inflammation can be lowered through natural methods rather than drugs.

The paper below shows findings that a high level of CRP indicates systemic inflammation and an increase in the risk of eventually having to have a joint replacement. Even more importantly, taking steps to reduce CRP cuts your risk in half!

 November 5, 2008

Author: Chris D. Poole, Pete Conway, Alan Reynolds and Craig J. Currie
Credits/Source: BMC Musculoskeletal Disorders 2008, 9:146

Background

Dr. Julius Torelli on Chronic Inflammation

Dale True, editor of the Inflammation Wellness website, interviewed Julius Torelli, M.D. on a broad scope of topics related to the prevention and treatment of chronic inflammation. The interview took place in Dr. Torelli’s office in the Integrative Cardiology Center in High Point, North Carolina.

DT: Why should readers of the Inflammation Wellness web site be aware of chronic inflammation, and specifically, what do they need to know?

JT: When I look at the Stedman’s Medical Dictionary definition of inflammation, I find: “a localized protective reaction of tissue to irritation, injury or infection, characterized by pain, redness or swelling”. A protective reaction!

I knew it was a protective reaction, but clearly something has happened to change the normal protective state of inflammation. While it is still protective in the case of a sore throat, pneumonia or any infection and you need that, something has gone haywire, causing this protective mechanism to become destructive.

Most chronic diseases appear to be inflammatory in nature. Inflammation can be very severe, especially in the form of autoimmune diseases, such as lupus, multiple sclerosis, rheumatoid arthritis and certain forms of cancer. These are the type of health issues that cause CRP levels go to 50 or 100 or more.

Then there are other more moderate inflammation states that are indicative of heart disease, diabetes, insulin resistance and types of cancers and arthritis. There are also some diseases that are caused by mild inflammation, such as gingivitis, skin disease (psoriasis and eczema) and allergies. 

All of these diseases and many others appear to have excessive inflammation as the root cause.

Rheumatoid arthritis, as an example, is caused by severe chronic inflammation. Your body is making antibodies that continually attack and damage the synovial membrane of the joints. Traditional allopathic medicine focuses on developing and prescribing drugs to stop the inflammation process. Aspirin, steroids and other compounds have made great progress. We now have some very powerful anti-inflammatory drugs, immunosuppressants and chemotherapy treatments for cancers.

Yet with all of the pharmaceutical agents available, we see very poor effectiveness in stopping the inflammation associated with rheumatoid arthritis. So those who have this severe chronic disease face a powerful immune response. But in allopathic medicine, we never stop to ask why this condition occurs in the first place. We just keep exploring for more drugs to treat it.

DT: Are you saying we don’t know the cause of chronic inflammation?

JT: There is very little research as to why chronic inflammation is happening. From my standpoint, you’ve got three major lifestyle issues. One is the emotional component that Western medicine never talks about. Another is the nutritional component, which we almost never talk about. There’s also an activity component—or lack of it—to which we only give lip service.

So I think it’s important to know inflammation is a root cause of chronic disease and we must address those three areas of our lives if we wish to prevent or fight excessive inflammation.

DT: In your practice, have you successfully treated patients utilizing a nutrition, exercise and stress management plan?

JT: Good question. I certainly have not compiled enough data to provide scientific evidence. I don’t have the money or the time to do that. But I can tell you that there are only two choices for people who are pre-diabetic, meaning their lab tests show signs of insulin-resistance, they are inactive physically, plus 60 pounds or so overweight and making poor food choices.

One, which is the one most people choose, is to maintain their current unhealthy lifestyle and in the future—could be six months or six years—you will be diagnosed with diabetes and require medicines that you’ll need to take the rest of your life. By the way, these medicines may only manage the disease until it eventually ends your life.

But, here’s the second choice. You can choose to alter the way you eat and increase your activity level. It’s not easy and I can’t do it for you. I struggle with this myself. I try to eat the right foods and make time for exercise, but it is a struggle in our busy and complex society.

When you educate people on the seriousness of the situation and the benefit of adopting a healthy lifestyle, they begin to take on some responsibility for their own health care. They also respond to someone working with them instead of just telling them to take these three medicines and then walk out.

DT: To what degree have you seen changes in these patients with chronic illnesses using natural methods?

JT: When people commit to the health strategies I recommend, they do get better. That is very clear to me. For example, I had one 42 year old patient who was about 60 pounds overweight, although fairly active at his job. I diagnosed him as having heart disease. His insulin level was at 137—the highest I’ve ever seen. Normal is less than 15. His CRP was also high at 8. I prefer to see CRP below 3, for sure, and ideally less than 1.

We treated the problem through changes in his normal diet and exercise. He walked daily and followed an inflammation-free diet. He also cut out sodas, which was a big deal! Three months later, when he came in for his follow-up exam, he had lost 12 pounds, which was a modest weight loss for that amount of time. We re-checked the lab tests at four months and his insulin level was 12! (Down from 137) His CRP was 1.5! (Down from 8.) I didn’t believe it and asked the lab to confirm the tests. I was shocked!

How much did this lower his risk of a heart attack or other chronic disease? That’s nearly impossible to state absolutely. But without question, the lower insulin and CRP levels suggest that this man would have much better health, if he maintained the rather simple steps he took.

So, have I successfully treated patients using natural methods?  Yes, people feel better and their critical lab data gets better, as well as their tolerance to do more physical activity. In the world of preventative medicine, this is unquestionable success. Success in traditional medicine is opening up a blocked artery to stop a heart attack. I prefer to prevent the need for open heart surgery!

DT: In your book, Beyond Cholesterol, you detailed diagnostic tests, such as CRP, that reflect inflammation levels in the body. Would you like for people to know their CRP levels regardless of their health condition?

JT: It’s a very important level to know. Why wouldn’t you ask your doctor to order a CRP test, especially once you realize the benefits of early detection of excessive inflammation in your body? 

CRP is a non-specific marker of inflammation, meaning it can tell you whether or not you have excessive inflammation, but it cannot tell you where in the body it is. Still, CRP is a much better diagnostic test than the traditional sedimentation rate, or sed rate, as it is often called.

DT: You also wrote in your book about the importance of the fasting insulin test. Why is it so vital to know our fasting insulin level?

JT: I order a lot of fasting insulin tests, although it is not a direct marker of inflammation. But it is important in detecting insulin resistance. Insulin resistance often leads to metabolic syndrome, which is linked to the development of arterial inflammation and other aspects of heart disease.

High insulin levels do not cause the inflammation that leads to diabetes, atherosclerosis or other diseases related to diabetes. But high insulin levels are an indicator that things are out of balance within the body. If this can be detected early enough, there are natural methods that can be adopted to prevent chronic disease from becoming firmly established. We know with certainty that weight loss and exercise improve insulin resistance.

DT: Increasing physical activity is a major part of your Inflammation Wellness Program. How does exercise improve our health?

JT: Maintaining enough physical activity to have a greater metabolic rate will prevent weight gain. Ironically, exercise causes a small amount of inflammation. But the body quickly recovers from normal physical activity.

When you are sitting, doing nothing, you are burning fat for energy. That’s what I call your idle speed—your basal metabolic rate. If you go walking, you will burn even more fat for energy. You have to take in oxygen to burn fat. If you can’t get enough oxygen to burn the fat that you need for that level of exertion, your body will switch from burning fat to burning sugar. The level of that switch from burning fat to burning sugar is called the anaerobic threshold.

Getting out and moving is very important. I like to think of it less as exercise and more as adopting an active lifestyle. Instead of sitting home watching TV, go out hiking or canoeing. Let’s face it; spending 45 minutes on the tread mill is not the most exciting thing in the world. It’s boring and somewhat unnatural. But hiking is really fun; most people tell me they really like that. It’s a completely different experience—you’re outside enjoying the sights. There’s a different sense of vigor and good feelings with natural activity as opposed to using exercise equipment. On a treadmill, most people only feel good when they’re finally done.

DT: Earlier you mentioned lifestyle issues as a reason we’re seeing more and more chronic inflammation in our society. How can people alter their lifestyle to achieve better health?

JT: With any of this, but especially the physical activity, there’s an optimal level and a practical level. What we would ultimately like to do is come up with a lifestyle program with recommendations for physical activity, nutrition and stress management that is practical for people to do.

The reason we don’t do these things today, for most of us, is that it is not practical—it does not fit into our lifestyle or time limitations. People eat fast food, not necessarily because it tastes good, but because dad works, mom works, they don’t get off work until 5:30 or 6:00, she’s got to go home and prepare food—clean it, cut it, cook it—clean up everything, help the kids with homework, bake cupcakes for the school bake sale—no! She stops by McDonald’s or the fried chicken place in order to cut out a big part of that time commitment.

DT: How does stress management lower inflammation?

JT: I believe that our overly-stressed lives play a major role in chronic inflammation and definitely contribute to diseases such as heart attacks, cancer, arthritis and other maladies. Many people live an “inflammatory lifestyle”. Inflammatory disease does not derive exclusively from being overweight, lack of exercise or the foods we eat. It also comes from a lack of stress management, which causes a release of harmful hormones.

How people express their emotions are important with regards to chronic inflammation. There are studies that have looked at the personalities of people with rheumatoid arthritis. It’s fascinating.

When I was in training, we had to go through different rotations. One was rheumatology rotation. I remember seeing all these patients with rheumatoid arthritis and I said, “We shouldn’t call this the rheumatoid arthritis syndrome, we should call it the ‘nice guy syndrome’.” The attending physician asked why I would say that. “Well, every time I go into a room, I come out and think to myself, “Geez, that’s a nice guy, but the rheumatoid arthritis is awful’”. I have never seen many jerks that had rheumatoid arthritis. Rheumatoid arthritis has been referred to as “anger turned inward”. Angry is also an apt description of a joint inflicted with severe rheumatoid arthritis.

A study of personality and rheumatoid arthritis indicates that 70% of those that develop this disease have the martyr syndrome, or as I call it, the nice guy syndrome. This personality type usually goes along with what everyone else wants to do and rarely do what they want. They favor conflict avoidance, preferring to not “rock the boat”, and rarely speak up if they feel wronged.

Is anger responsible in some part in the development of rheumatoid arthritis? The evidence suggests it may be.

DT: Is it possible for people to change how they react to external events?

JT: I read in the Seven Habits of Effective People that people say they are stressed by what’s going on, because they don’t want to take responsibility for their own actions.

If you go into a rage when another driver cuts you off in traffic, your body secrets fight or flight hormones, such as adrenaline, noradrenaline and others which cause your vessels to constrict, your heart rate goes up, your blood pressure goes up, your sugar level actually goes up and your cholesterol level goes up—all of these negative things flood your system when you react this way. You are allowing a perfect stranger to negatively affect your health.

Instead, act out of the role of appreciation. “Wow! That was close and he almost hit me. I’m so appreciative he didn’t hit me. Thank God he didn’t hit me.” Or “maybe he was on his way to the emergency room because his wife was taken there. I hope he gets there safely.” If you give him the benefit of the doubt, you’re not even mad at him anymore. Reacting that way causes little or no reaction in blood pressure or heart rate and you didn’t secret all those bad hormones.

So it wasn’t the situation that caused the bad physical reaction, but rather our reaction to the situation. We always have a choice to react calmly or react angrily. Repeated calm reactions lead to managed stress and help us maintain good health; repeated angry reactions lead to unmanaged stress and contribute to poor health.

Managing stress through appreciation is a learned behavior. But it becomes natural as we practice the management of stress this way.

DT: In your book, Beyond Cholesterol, you make the case that heart disease is more a function of excessive inflammation than high cholesterol. Is the medical community in agreement with your view?

JT: When comes to cardiovascular health, most doctors consider cholesterol to be the primary indicator. If you have a heart attack and your LDL is 90 (the recommendation is less than 100), most physicians will put you on a statin drug in order to lower your cholesterol further.

“But my LDL was 90, which is lower than recommended.”

“Yes, but you had a heart attack, so your LDL was too high for you.”

In a cardiologist’s mind there’s no “too low” from an LDL standpoint. If they can get it to zero, that’s what they would do.

But here’s the issue, although doctors mean well and they want to practice evidence-based medicine, the studies required to get the evidence is very expensive. The cost for these studies can run from 10 to 100 million dollars. Some of the big cholesterol mortality trials with a lot of patients cost 100 million dollars!

So doctors can say that they only pay attention to peer-reviewed studies in the journals, those that are randomized, double blind and placebo-controlled. But there is bias in these studies, because it is the pharmaceutical companies that are paying for them. More importantly, all of the really large studies are from the pharmaceutical industry. Who is going to pay for a 50 million dollar study on the effects of exercise or a low-inflammatory diet on cardiovascular health? Certainly not the pharmaceutical industry!

So when it comes to natural wellness for chronic disease, we’re left with antidotal evidence, common sense approaches, and a lot of small studies, mostly from outside the U.S. I have no problem with the foreign studies, but in this country, we seem to have a bias against studies performed in Europe or Japan. We have studies from Europe on the health benefits of fish oil dating back well over a decade, but we never paid attention to them.

DT: Still, there seems to be a lot more public interest in natural health, especially in fish oil to lower the risk of heart disease.

JT: When Lovaza, the first prescription fish oil drug, became available in the United States, suddenly lots of primary care physicians were putting their patients on fish oil. Five years ago these physicians would rarely, if ever, even mention fish oil to their patients. But the new drug put drug company reps into doctor’s offices talking about fish oil, which confirmed what I already knew—doctors receive 90 percent of their information from drug company representatives.

Now I do not have a problem with reps providing information on the drugs they sell, but it does concern me when that seems to be where physicians get the majority of their research information. This is why most physicians are either unaware of the evidence concerning how nutrition and exercise can be used to treat chronic inflammation or they have little confidence in such evidence because it’s not coming from their traditional sources.

DT: Thank you, Dr. Torelli. I hope our readers will benefit from your insight and experience in treating chronic inflammation with natural methods.

Monica Reinagel is the author of The Inflammation-Free Diet Plan, which serves as a major component of Dr. Torelli’s Inflammation Wellness Program. In her book, Monica demonstrates how eating an anti-inflammatory diet can help you lose weight, slow aging, and prevent disease. The book includes Inflammation Factor Ratings for 1500 foods, indicating the best and worst foods for fighting inflammation.

Dale True, editor of the Inflammation Wellness, interviewed Monica on the development of her Inflammation Factor Rating system, and the connection between nutrition and chronic inflammation.

DT: Was there an event or a moment that led you to explore how specific foods contribute to systematic inflammation?

MR: It was more of a dawning. I’ve been writing in this field for 12 years and I saw the beginning of interest in inflammation crop up. At first it looked like it might be the gimmick of the year. But year after year I found more and more research compiling to support the theory.

As we had more research, I saw that the theory of systemic inflammation was the single cause for a whole variety of age-related dysfunctions. Chronic inflammation appeared to be not just another piece of the puzzle, but something that drew all the pieces of the puzzle together and brought it into focus as a unifying whole.

From there, it seemed obvious that helping people control inflammation with their diet would be a very helpful therapeutic step. And I looked around to see what guidelines existed, it was clear to me that no one had ever pulled together the effects of various food components of nutrition into a unified system. Dr. Floyd Chilton had done some research which was very seminal for me in reading his book [Inflammation Nation], but it really dealt only with fatty acids. His work on the effects of foods on inflammation was confined mostly to the effect of DHA [an omega-3 oil] and arachadonic acid— a brilliant insight, but it leaves out a whole category of foods that are not included in that view.

There were other people who were focused very much on the anti-oxidant benefits of foods as a way of reducing inflammation. But again, that was limited to a single category of foods and there were whole groups of foods that didn’t fall into that view.

So there appeared to me to be a gap—not in the understanding, but in a tool that allowed people to apply in their diet what we understood. We needed a single means of evaluation that would look into several things at once. It should evaluate antioxidant capacity, glycemic impact, fatty acid balance and ratios and other factors that had been established. That evaluation need to weigh the net benefit of all those pluses and minuses.

So my challenge was devising a formula [Inflammation Factor Rating] that I felt adequately compiled all of that insight into a tool that was usable on a consumer level— and made it simple, because it’s pretty complex. But the IF Rating makes it a little bit easier for consumers to put together a diet that would have a net anti-inflammatory effect.  

DT: Is there a follow-up book or a revised edition on the horizon that would add more IF Rated foods?

MR: Yes, actually. We discussed the possibility of a follow-up book and due to the commercial nature of publishing, that’s been tabled for the time being. But the expansion of the content has continued online. Largely through a web site called NutritionData.com. Subsequently, I became involved as a nutrition editor. But initially, I became involved with them as a means to distribute IF Ratings.

DT: Have you had any reason to tweak the formula for the IF Rating?

MR: The biggest limitation in the original IF Rating formula was the fact that it relied on glycemic index data from the University of Sydney [in Australia] as a crucial part of the formula. That was a very limiting factor. There were only a few hundred foods and many of those are not common to the North American food supply. 

The new development has been my work with Ron Johnson, who was the founder of NutritionData.com. We developed a logarithm, a regression analysis, which allowed us to predict the glycemic load of foods that had not yet been tested.

This new model has exploded the possibilities. By having a fairly reliable estimation of glycemic load for any food for which we had readily available metrics for protein, fat, net-carbohydrates, fiber and calories—the raw inputs for that formula— we went from being able to calculate IF Ratings for about 500 foods to an unlimited number of foods.

DT: Your book recommends that people should not limit their food choices to only those items that have positive IF Ratings. Why is it so important to balance both positive and negative rated foods in our diet?

MR: Inflammation is a normal and healthy part of the immune response. The goal of the diet is not to eliminate inflammation from the body. The goal is to restrict inflammation to its appropriate function. Pro-Inflammatory and anti-inflammatory capacity exist in a dynamic tension, or balance, in the body. Foods are designed to support both sides of that equation.

There’s no need to eliminate every food that is not anti-inflammatory, in fact that’s not even desirable. What we are looking for is a balance of foods that feed the anti-inflammatory channels and those that support the normal immune response of the body.

There are many foods that are wholesome parts of a healthy diet, such as grains and fruits, which because of their carbohydrate content and their impact on blood sugar levels will tend to be mildly inflammatory. Although these foods have a slightly negative IF Rating, it is not at all my intention to say that these foods should be eliminated from the diet. If one were to eat a diet of nothing but apples, it would not be healthy or balanced, even though apples are a healthy food. So The Inflammation-Free Diet Plan is about restoring balance to the diet.

The problem is that most people, if they are eating a standard American diet, are consuming foods that are stacked heavily into the inflammatory side of the equation. The objective is to reduce the number of inflammatory foods and increase the number of anti-inflammatory foods until we’ve reached a balance. 

DT: In your book you describe how with meats, the cut and type of cooking will affect the IF Rating. Have you found any research that shows whether or not vine-ripened fruits and vegetables have different IF Ratings from those not vine-ripened?

MR: Certainly, I know that it does have an effect. And not only if it is vine-ripened or ethylene-ripened, but how far and how long it has traveled since it was harvested. This is a problem that pervades the entire nutrient composition field.

The U.S.D.A. Nutrition Composition Data Base is the one of the largest databases in the world and still it doesn’t come close to everything we would like to have. It isn’t able to show us the differences between a tomato one day after it was picked and another tomato two weeks after it was picked and where and how it ripened. It does not sufficiently reflect the differences in organic produce and non-organic produce.  It does not sufficiently reflect the differences between grass-fed livestock and grain-fed livestock. It’s catching up as these food sources become more and more main stream. Clearly there are nutritional differences. This is the source for nutrient information from which everybody does all their nutritional calculations.

I guess that is a long way of saying that I intuitively know that grass-fed beef is going to be less inflammatory than conventionally-raised beef, and that organically raised vegetables are going to be more anti-inflammatory than conventionally-grown vegetables. But I don’t have the data to quantify that in a concrete way with the IF Rating system.

DT: Are you encouraged by the research currently being done in the area of nutrition and inflammation wellness?

MR: Actually, I’m impressed by the continuing research on the underlying links of inflammation to disease, as a concept unifying aging and degeneration. I’m discouraged by the relative lack of coherent research going into the effect of foods on inflammation. I actually don’t see that happening.

I see a little bit of research happening on supplements, most remarkably with fish oil, but very little epidemiological research on diet. Most of what I see has to do with linking the state of inflammation with unfavorable outcomes. I don’t see a whole lot about ways to address the problem.

DT: It appears that many more people are interested in finding natural methods for fighting chronic illness. For example, a number of people have told me they would love to find an alternative to statin drugs in order to reduce high cholesterol.

MR: Oh yes, there is a great deal of interest on this, but I do not see the research coming in quite as heavy as we had hoped.

It’s much easier to research a drug. It’s even easier to research a supplement, like fish oil, than it is to research the effects of diet. Dietary research is very complex and expensive to conduct. For example, we have very little data correlating dietary interventions with reduction in CRP, virtually none. But we continue to get a lot of data correlating CRP levels with disease.

DT: And yet very few people know what their CRP level is.

MR: CRP is becoming more important as part of the standard laboratory profile along with cholesterol. But you do not need to know what your CRP level is to take steps to reduce systematic inflammation—to move from an inflammatory dietary pattern to an anti-inflammatory dietary pattern. CRP values may be motivating for some people and it may be validating to see that what they’ve done has produced a result, but ultimately I’m not sure that people not knowing their CRP level is the limiting factor.   

DT: For myself, having had high cholesterol and a family history of heart disease, knowing that my CRP level and other inflammation biomarkers were low was very comforting and allowed me to use diet and exercise to reduce my blood lipids, rather than statin drugs. Had my CRP been elevated, I may have been reluctant to try the natural approach.

MR: Right. I just read an article last week talking about how using cholesterol and CRP levels together allows researchers to sort people into more risk categories than you can with just a cholesterol value. Someone with high cholesterol and low CRP is in a much lower risk profile than somebody with high cholesterol and high CRP.   

DT: Your biography mentions that you are a trained chef. Did you pursue that as a profession at one time, or is it merely an interest of yours?

MR: Although I always enjoyed cooking, I never intended to do it professionally. As a nutritionist, I spend a lot of time talking about how to prepare food and develop recipes for my books and web sites. Being a “foodie”, I wanted to be sure that my recipes taste good and are fun to eat, as well as being healthy. So I became a chef as a form of professional enrichment to aid me in recipe development. Those technical skills help make my recipes be a culinary delight as well as healthy.

DT: Thank you so much, Monica. We appreciate your insight and contribution on the inflammation-free diet.