Brief case reports of medically supervised, water-only fasting associated with remission of autoimmune disease.pdf

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112 ALTERN ATI VE TH ERAPI ES, Ju l y / Au g 2002, VOL. 8, N O. 4 Fasting in Remission of Autoimmune Disease Joel Fuhrman is a board-certified family physician affiliated with Hunterdon Medical Center in Flemington, NJ. Barbara Sarter is an associate professor in the Department of Nursing at the University of Southern California in Los Angeles. David J. Calabro is a chiropractor in private prac- tice in Linwood, NJ. M edically supervised, water-only fasting is known to be an effective
  112ALTERNATIVE THERAPIES, July/Aug 2002, VOL. 8, NO. 4 Fasting in Remission of Autoimmune Disease  Joel Fuhrman is a board-certified family physician affiliatedwith Hunterdon Medical Center in Flemington, NJ. BarbaraSarter is an associate professor in the Department of Nursing at the University of Southern California in LosAngeles. David J. Calabro is a chiropractor in private prac-tice in Linwood, NJ. M edically supervised, water-only fasting isknown to be an effective means of lessen-ing the symptoms of autoimmune illnesses;in many cases, remission of the diseaseoccurs. 1 The challenge, however, is to main-tain the benefits of the fast after reintroduction of foods.Those studies that have shown no long-term benefit to fastinghave allowed unrestricted food intake after the fasting peri-od. 2-4 A few studies, however, have demonstrated long-termbenefit from adherence to a vegan or lacto-vegan diet afterfasting. 5-8 In our practice, we admit motivated patients suffer-ing from autoimmune diseases to a facility where they areoffered intensive education and support in vegan eating dur-ing a medically supervised, water-only fast that varies inlength from 1 to 3 weeks. Patients then maintain the vegandiet after the fast. We describe 6 representative cases below.A recent meta-analysis 9 of 31 scientific reports on fastingfollowed by vegetarian diet in patients with rheumatoid arthri-tis concluded that this regimen may be useful in the treatmentof rheumatoid arthritis. Of the 31 studies identified, only 4 10-13 were found to be controlled clinical trials that reported follow-up data for at least 3 months after initiation of treatment. Theresults of these 4 studies were pooled, and an effect size (d) andits standard deviation for each study was calculated, demon-strating a significant beneficial effect of fasting followed by veg-etarian diet (  P  <.001, r  =.38, d=.83). A separate pooling of the 2randomized, controlled studies showed a significant improve-ment in the treatment groups (  P  <.01, r  =.28, d=.58). For mostof the studies analyzed, the criterion for clinical improvementwas a visual analog pain scale. CASE REPORTS We report here 6 cases in which medically supervised,water-only fasting followed by a vegan diet resulted in reductionin pain and inflammatory markers in patients with autoimmuneillnesses. These cases indicate the therapeutic potential of thisapproach and a need for further clinical research. Materials and Methods All patients were given a carefully designed vegan dietbefore they came to a treatment facility to fast. This was ahigh-nutrient–density diet consisting of fresh fruits, vegeta-bles, beans, and nuts. All antirheumatic medications weretapered and discontinued before the fast. Baseline serologicalstudies included a basic chemistry panel to assure adequaterenal and hepatic function before fasting.Patients were admitted to a medically supervised site forthe fasting period. Informed consent was obtained, and patientsunderstood that they could stop the fast at any time. Patientswere instructed to drink at least 1 quart of distilled spring waterper day and to minimize physical or mental exertion. Daily vitalsigns were recorded including weight. A chemistry panel wasobtained once per week and more often as needed.Patients fasted from 1 to 3 weeks. However, fasts werebroken earlier if there were indications of electrolyte deficien-cy either from results of laboratory work or from symptoms.Fasts were broken by a vegetable and fruit diet. The first day of refeeding consisted of small portions of light fruits and vegeta-bles every 2 hours. The diet was then advanced gradually toinclude other fruits and vegetables, then to a normal caloricintake of a natural food diet as described above. All patientswere discharged after a minimum of 4 days of refeeding. They BRIEF CASE REPORTS OF MEDICALLY SUPERVISED,WATER-ONLY FASTING ASSOCIATED WITHREMISSION OF AUTOIMMUNE DISEASE  Joel Fuhrman, MD , Barbara Sarter, P h D , RN , FNP , and David J. Calabro, DC  Reprint requests: InnoVision Communications, 169 Saxony Road, Suite 104, Encinitas, CA 92024; phone, (866) 828-2962 or (760) 633-3910; e-mail, Case Reports  is a regularly featured column meant to highlight the clinical applications of alternative or integrative therapies as they are implemented in patient care. Preference will be given to cases in which diagnosis, treatment, and outcomes are clearly defined. Continued on page 140 case reports  were followed with an outpatient visit 2 weeks later and thenwith visits at bimonthly intervals. Case 1: Rheumatoid Arthritis A 61-year-old man was diagnosed with rheumatoid arthri-tis in 1990. At his first consultation, he reported pain and stiff-ness in all extremities, fatigue, and headaches. He alsoexperienced episodes of autoimmune hemorrhagic conjunc-tivitis. Medications included 100 mg cyclosporin and 5 mgprednisone daily with only mild improvement of symptoms.One month after stopping his medications, he began to fast.His initial weight was 71.8 kg and his blood pressure was 110/60mm Hg. Within 2 days of fasting, his joint symptoms began tosubside. After a week of fasting, he was without pain and hismobility had returned. On the eighth day, he experienced a brief recurrence of conjunctivitis. He fasted for 17 days. Renal andhepatic function as well as electrolytes were stable throughoutthe fast, and his erythrocyte sedimentation rate returned to nor-mal. After the fast, he had no residual symptoms. His weight was63.4 kg and blood pressure was 90/60 mm Hg. He continued todo well and was free of symptoms at follow-up visits. CASE REPORTS Continued from page 112 Case 2: Mixed Connective-Tissue Disease A 38-year-old woman was diagnosed in 1996 with mixedconnective-tissue disease. Her signs and symptoms includedsevere joint pains, facial edema, weakness and fatigue, tachy-cardia, chills, myalgia, and photosensitivity. She was takinghydroxychloroquine, tramadol, levothyroxine, cetirizine, andprednisone.Before fasting, she was weaned off all medications excepther thyroid replacement, which was reduced during the fast,then raised to her normal dose after the fast. Her weight was68.1 kg and her blood pressure was 115/80 mm Hg at thestart of the fast. At the onset of her fast, she had increased hippain and discomfort as well as muscle weakness. She also hadan overall ill feeling during the first week of fasting. By thetenth day she was feeling better, and after 21 days of fastingshe had no further complaints. Her weight was down to 58.8kg and her blood pressure was 80/60 mm Hg. Renal andhepatic function as well as electrolytes were stable through-out the fast. At follow-up, she remained free of medicationwith minimal symptoms. Case 3: Fibromyalgia A 46-year-old woman diagnosed with fibromyalgia pre-sented with a history of poor sleep and pain, especially in herright arm, back and neck, and both legs. She could not sus-tain any activity for more than 1 hour. Medications includednefazodone, nortriptyline, propoxyphene, ibuprofen, andlevothyroxine.Her weight at the onset of the fast was 67.2 kg and bloodpressure was 120/80 mm Hg. Her fast lasted 24 days, at theend of which she was symptom free. At discharge, her weightwas 57.9 kg and blood pressure was 115/85 mm Hg. Renaland hepatic function as well as electrolytes were stablethroughout the fast. At the follow-up visit 1 month later, shewas still free of symptoms. Case 4: Systemic Lupus Erythematosis A 45-year-old woman presented with a history of lupus.Her symptoms included joint pain and skin rash. She wastaking 25 mg of prednisone and 5 mg of hydroxychloro-quine daily without adequate resolution of her chest pain.She was weaned off her medications over a 2-month periodand was medication free 2 weeks before the fast. Her weightat the start of the fast was 58.8 kg and blood pressure was120/75 mm Hg. Through the first 3 days of the fast, sheexperienced mild discomfort, poor sleep, and nausea. By thefourth day, the patient was feeling significantly better, withno complaints and no joint pains. The fast was broken onher seventh day because of increased weakness and mildtachycardia. Her weight was down to 55 kg and blood pres-sure was 110/80 mm Hg. Adrenal suppression was a concerndue to the prolonged use of prednisone. Electrolytesremained normal. She remained symptom free for 1 year,  when her symptoms began to recur. She underwent a second7-day fast, after which she had no symptoms. She is present-ly in remission. Case 5: Rheumatoid Arthritis A 40-year-old woman was diagnosed with rheumatoidarthritis in March 1999. After 2 weeks of prednisone therapy,she decided to undergo a medically supervised, water-only fast.On her initial consultation, she complained of pain in all joints,especially her knees.The patient’s weight at the start of the fast was 71.8 kg,and her blood pressure was 125/100 mm Hg. In the first fewdays of her fast, she experienced a noticeable increase in painin her spine, shoulders, and neck. Her pain decreased as shefasted, and by day 10, there was no further joint pain. Thepatient fasted for 12 days. Renal and hepatic function as wellas electrolytes were stable throughout the fast. Her weightwent down to 65 kg and her blood pressure to 110/70 mm Hg.Her symptoms have not recurred. Case 6: Rheumatoid Arthritis A 46-year-old woman diagnosed with rheumatoid arthri-tis consulted us for a nutritional approach to treatment. Shereported pain in her fingers, wrists, shoulders, and knees. Shehad no joint deformities. She was being treated with irbesar-tan and amlodipine for hypertension, and celecoxib and rofe-coxib for the arthritis. Her blood pressure was 170/80 mm Hgon the above medications, and her weight was 106.6 kg at ini-tial presentation.The woman was weaned off all medication and lost 9.1kg during 8 weeks of dietary intervention before beginningthe fast. At the start of the fast, her weight was 94.5 kg, andher blood pressure without medication was 130/78 mm Hg.Within 4 days of the fast, her joint pain decreased. Hersymptoms continued to decrease throughout the fast. Herblood pressure also slowly continued to decrease. Her elec-trolytes were stable throughout the fast, except for potassi-um, which dropped to 3.4 mmol/L. On day 17 she began oralpotassium gluoconate (500 mg) and continued taking it for 3days, after which her potassium level was within the normalrange at 4.2 mmol/L.She fasted for 24 days and had no residual symptoms. Herweight dropped to 84.3 kg. As a secondary benefit, her bloodpressure normalized to 110/80 mm Hg and she stopped takingher blood pressure medication. She remains in remission. COMMENT Dietary modification alone sometimes reduces symptomsin patients with autoimmune diseases, but in most cases, as rep-resented by those described above, dietary changes alone are notsufficient to completely resolve symptoms. After fasting from 7to 24 days, these patients were free of symptoms, and theirsymptoms did not recur when they resumed eating a carefully Fasting in Remission of Autoimmune Disease ALTERNATIVE THERAPIES, July/Aug 2002, VOL. 8, NO. 4 111 designed vegan diet. Remission was confirmed at subsequentcontacts months and sometimes years later.We do not feel that commonly proposed mechanisms,such as changes in gut permeability and intestinal flora,adequately explain the clinical course of remission punctu-ated by brief exacerbations that we routinely observe duringwater-only fasting. We believe additional, poorly studiedmechanisms account for fasting’s effectiveness in improvingsymptoms and inducing remissions. These mechanismsinclude a reduction in excessive lymphocyte activity and themobilization and elimination of noxious stimuli from fatand tissue stores. Retained antibody-antigen complexes mayalso be involved. Though fibromyalgia is not classified as anautoimmune disease, it was included in these case reportsbecause it demonstrated the same positive response to fast-ing as did rheumatoid arthritis, lupus, and mixed connec-tive-tissue disease. Maintaining a nutrient-dense, vegan dietof unrefined plant foods appears to be necessary after thefast to prevent the recurrence of symptoms and inflammato-ry activity. CONCLUSION These cases demonstrate the need for further research inthe benefits of fasting. Under medical supervision, this therapyis safe and results in only transient side effects. Eating a vegandiet before fasting often resulted in partial improvement of symptoms, enabling patients to reduce their medicationsbefore the fast. Additional studies of fasting may explain howthis treatment induces remission and may clarify our under-standing of the pathophysiology of rheumatoid arthritis andother autoimmune illnesses. References 1.Palmblad J, Hafstrom I, Ringertz B. Antirheumatic effects of fasting.  Rheum Dis Clin North Am . 1991;17(2):351-362.2.Lithell H, Bruce A, Gustafsson IB, et al. A fasting and vegetarian diet treatment trialon chronic inflammatory disorders.  Acta Derm Venereol  (Stockh). 1983;63:397-403.3.Skoldstam L, Magnusson KE. Fasting, intestinal permeability, and rheumatoidarthritis.  Rheum Dis Clin North Am . 1991;17(2):363-371.4.Sundqvist T, Lindstrom F, Magnusson KE, Skoldstam L, Stjernstrom I, Tagesson C.Influence of fasting on intestinal permeability and disease activity in patients withrheumatoid arthritis. Scand J Rheumatol  . 1982;11(1):33-38.5.Peltonen R, Kjeldsen-Kragh J, Haugen M, et al. Changes of faecal flora in rheuma-toid arthritis during fasting and one-year vegetarian diet.  Br J Rheumatol  .1994;33(7):638-643.6.Nenonen MT, Helve TA, Rauma AL, Hanninen O. Uncooked, lactobacilli-rich,vegan food and rheumatoid arthritis.  Br J Rheumatol  . 1998;37(3):274-281.7.Jajic Z, Vuksic D, Jajic I. Effect of nutrition on the clinical picture of rheumatoidarthritis.  Reumatizam . 1998;46(1):27-30.8.Haugen MA, Kjeldsen-Kragh J, Bjerve KS, et al. Changes in plasma phospholipidfatty acids and their relationship to disease activity in rheumatoid arthritis patientstreated with a vegetarian diet.  Br J Nutr  . 1994;72(4):555-566.9.Muller H, de Toledo FW, Resch K-L. Fasting followed by vegetarian diet in patientswith rheumatoid arthritis: a systematic review. Scand J Rheumatol  . 2001;30(1):1-10.10.Kjeldsen-Kragh J. Rheumatoid arthritis treated with vegetarian diets.  Am J Clin Nutr  . 1999;70(suppl 3):594S-600S.11.Skoldstam L, Larsson L, Lindstrom FD. Effect of fasting and lactovegetarian diet onrheumatoid arthritis. Scand J Rheumatol  . 1979;8:249-255.12.Skoldstam L. Fasting and vegan diet in rheumatoid arthritis. Scand J Rheumatol  .1986;15:219-221.13.Lindberg E. Konnen Ermahrungsfaktoren die chronische polyarthritis beein-flussen?  Z Physiother  . 1973;25:119-129.


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