Ankylosing Spondalyitis

What Is Ankylosing spondylitis?

Ankylosing spondylitis (AS) is a chronic inflammatory arthritis, thought by some to be autoimmune in origin.

It would appear that the most likely causative agent in the development of Ankylosing spondylitis is an environmental factor in the genetically susceptible, HLA-B27 positive, individuals.

What is HLA-B27?

It has been shown that more than 9 out of 10 people with Ankylosing spondylitis carry a particular gene known as human leukocyte antigen B27 (HLA-B27).

Having this gene doesn’t necessarily mean you’ll develop Ankylosing spondylitis. It’s estimated 8 in every 100 people in the general population have the HLA-B27 gene, but most don’t have Ankylosing spondylitis.

It’s thought having this gene may make you more vulnerable to developing Ankylosing spondylitis, but we need a trigger, or ‘causative agent’ – such as the bacteria klebsiella pneumoniae.

What Might Be This Environmental Factor Causing AS In Those With HLA-B27?

One of the prime candidates for being an environmental factor, according to several reports, is the bacteria ‘Klebsiella pneumoniae’ which may trigger, or perpetuate, Ankylosing spondylitis:

Extensive data from several countries support the notion that Klebsiella pneumonia bacteria are the most likely culprit in the causation of Ankylosing spondylitis. These microbes possess antigens which resemble HLA-B27 and spinal collagens

This conclusion is based on evidence obtained from several disciplines: 

  • Immunogenetic studies show that there is molecular mimicry between HLA-B27 and Klebsiella
  • Increased isolation of fecal Klebsiella has been reported in both Europe and North America
  • Antibodies to Klebsiella have been demonstrated in ankylosing spondylitis patients in England and Finland

Research has also discussed the innate immune system with genome-wide analysis has also shown the association of several innate immune-related pathways and cytokines, which act as the effective therapeutic targets in Ankylosing spondylitis. 

What Is The Mechanism Associateing Klebsiella Pneumoniae With Ankylosing Spondalytis?

Molecular mimicry, or, cross-reactivity hypothesis is suggested to be the main mechanism that can link Klebsiella with the initiation and development of Ankylosing spondylitis.

“Where a foreign antigen [such as a klebsiella] shares sequence or structural similarities with self-antigens”

Essentially what we are saying here is that klebsiella is so similar in structure to that of our own tissue, the immune system attacks the tissue thinking it is klebsiella. 

The difference between other non-specific mechanisms that initiate autoimmunity and molecular mimicry is that microbial mimics specifically direct the immune response towards a tissue and/or organ. As mentioned in the above quote, klebsiella posses antigens which resemble spinal collagens – this is why back pain and stiffness are the most common symptoms.

Does Diet Help Ankylosing Spondalytis?

The main substrate that is necessary for the growth of the microbiome includes starch and complex carbohydrates which are usually available in considerable amounts in the large intestine (they are not 100% digested in the small intestine). Increased intake of high-starch diet is directly proportional to the gut-associated bacterial load, especially in the large intestine, and among these microbial agents, Klebsiella pneumoniae is considered as one of the main constituting components. 

Therefore, increased starch consumption by genetically susceptible individuals, such as those possessing HLA-B27, could trigger the disease in Ankylosing spondylitis by enhancing the growth and perpetuation of the Klebsiella microbes in the bowel (3).

These results indicate that complex carbohydrates such as starch-containing products are necessary for the growth, replication, and persistence of many enterobacterial agents including Klebsiella microbes in the large bowel.

So it has been concluded that a low-starch diet intake alongside the currently used medical therapeutic modalities could be beneficial in the management of patients with early Ankylosing spondylitis.

It seems, therefore, that an exclusion of a diet containing complex carbohydrates such as starch, but not simple carbohydrate-containing foods such as glucose or sucrose, might inhibit the growth of Klebsiella and could ameliorate the disease process and activity in patients with AS.

There is also a well documented link between gut inflammation and Ankylosing spondylitis. Low starch diets may be helpful in lowering inflammation also. 

To provide a balanced view on the research a systematic review published in 2018 on the role of diet in Ankylosing spondylitis concluded: 

“Evidence on a possible relationship between Ankylosing spondylitis and diet is extremely limited and inconclusive due to the majority of included studies being small, single studies with moderate-to-high risk of bias, and insufficient reporting of results.”

I would argue against this conclusion, as many a client can testify! It seems clearly evident to me that there is a strong connection between the two that should be investigated in each client to see how they respond to both a low-starch diet, and/or treatment for supporting the microbiome and klebsiella pneumoniae.

Supplements To Consider:

  • Saccharomyces Boulardii
  • Other probiotics of bacterial origin
  • Vitamin A
  • Vitamin D
  • NRF2 activators for innate immunity
  • Omega 3 fatty acids – these have shown to improve symptoms such as inflammation in those with inflammatory arthritic conditions.

Research

  1. https://www.ncbi.nlm.nih.gov/pubmed/29438717
  2. https://www.ncbi.nlm.nih.gov/pubmed/25385438
  3. https://www.ncbi.nlm.nih.gov/pubmed/23781254
  4. https://www.ncbi.nlm.nih.gov/pubmed/29657875
  5. https://www.ncbi.nlm.nih.gov/pubmed/1561397
  6. https://www.ncbi.nlm.nih.gov/pubmed/29852390
  7. https://www.ncbi.nlm.nih.gov/pubmed/29277308
  8. https://www.ncbi.nlm.nih.gov/pubmed/17062435
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