Wendy Walrabenstein is a lecturer at the Amsterdam University of Applied Science on Nutrition and Dietetics. She is one of the two lead researchers on a recently completed study on the impact of a plant-based diet for rheumatoid arthritis patients called the Plants For Joints Study, conducted in the Netherlands, and today we talk with her about some very interesting findings.

We discuss in this interview:

• How disease activity in RA decreased in people doing the prescribed program
• The multidisciplinary nature of the program, including diet, physical activity and stress management
• The effects on different levels of inflammation
• Lifestyle medicine
• The choice of inflammation markers and other measurements for the study
• Dietary guidelines from the International Rheumatology Association
• Mediterranean diets and plant-based diets
• Fish and saturated fat
• Dirkjan Van Schaardenburg and his work as a rheumatologist in the Netherlands
• The Paddison Program as a stringent version of the study’s program
• Food sensitivities

Clint – What a guest we have with us today. We have Wendy Walrabenstein, she is a lecturer at the Amsterdam University of Applied Science on Nutrition and Dietetics. And she was one of the two lead researchers on a recently completed study on the impact of a plant-based diet for rheumatoid arthritis patients called the Plants For Joints Study, conducted in the Netherlands. It’s super exciting to have her with us, good day Wendy!

Wendy – Hi Clint. It’s so awesome to be here with you today. Thank you.

Clint – Wendy, you are going to share with us all of the findings from this study. You’re going to share with us how it came about, what it means for the plant-based community, what you found, how it contributes to the body of evidence with regards to diet and rheumatoid arthritis. And maybe sort of put some of these questions to rest about what we should actually be eating. We’re going to talk about how this study differs from the Paddison Program, and we’re going to talk about what’s next for you and your research team. But first of all, tell us what did the study look like and what were the results?

Wendy – Well, Clint, the most important result was that disease activity in rheumatoid arthritis decreased for people who did the program. The decrease was comparable with what we usually see in medication studies, which is a huge positive effect. We were of course so enthusiastic about this result. It’s a big step forward in the evidence which is already quite large in favor of plant-based diets. It’s also the first study in which we did not only do a diet, but we compared it. We included physical activity and stress management in this program, and it was a beautiful result. The reason we chose this multidisciplinary approach of not only diet but also physical activity and stress management, was that one of the previous studies. A study you also often mentioned the trial, which was done in Norway. People were put on a fasting diet of one week and after that were placed on a plant-based diet for almost a year. Then one of the professors in our team said, that is quite interesting. The results are impressive, it’s also worth notifying that many rheumatologists don’t know anything about that study, which is a large study published in The Lancet and it was done in the 80s. Also, it was done at the same time that there were more effective medication was introduced in the market. Thus, we have the impression that it was a little bit forgotten because of this development of effective DMARDs or disease-modifying antirheumatic drugs. However, the effect of that study was also impressive. But if you take a closer look, you see that the disease activity in that Norwegian study was quite high. People had high inflammation and a lot of pain, and of course, the situation now is different. I mean, I’m very much for lifestyle and diet, but it is also fortunate that we have drugs that can help or support us. What we see now is that the disease activity in most people with rheumatoid arthritis is in a lower range than at that time. For example, the erythrocyte sedimentation rate (a marker for inflammation) was lowered in our study, but that was not significant but this has not been published yet.

Wendy – We also have one-year data and what we did in our study. After the randomized controlled trial of four months, we followed all the participants in the study for another two years and we now have the one-year data. In the one-year data, you see that disease activity remains low, which is very nice to see. But also that the ESR, so the inflammation marker that started to decrease within the trial decreased further. If you compare one year of data with the baseline data, you see a significant decrease in inflammation, which is very nice. However, the difference between the 80s and now, decreased in disease activity and decrease in inflammation is lower because we are already on a lower level. The reason why this professor told us, why can’t you also add physical activity and stress management? The reason for that was that he said, well, those effects in a Norwegian study are perfect. However, taking into account that disease activity now is lower. Perhaps, you should do more than just diet to make sure that they come even lower. Thus, it is why we did a pre-study to see what other things can we do. Of course, we could have done a step, let’s say further into the diet which is the Paddison Program that takes diet, let’s say a step deeper. However, we chose physical activity because physical activity is already in, let’s say the general recommendation for the treatment of rheumatoid arthritis and stress. Also, that was a very personal one because one of the things that impressed me personally most all the things that I looked up before starting this study, which is my Ph.D. project. I hope to get my Ph.D. this year for this project. What I saw was actually that people who have an extreme form of stress, which is post-traumatic stress disorder, have up to twice the risk of developing rheumatoid arthritis. When I discussed this with other researchers, they also said that this is quite impressive. Then, we decided to cooperate with colleagues from the faculty of psychology also in the Netherlands. They were doing already quite some studies with people having rheumatoid arthritis. Then we said, let’s put this together also. It is because we have noticed in the general treatment of common diseases that there is a great need for evidence regarding multidisciplinary programs. Thus, it was the reason why we said let’s combine these three elements into one program. It was the basis of our study and that was also influenced by studies done by Dean Ornish. Dean Ornish is one of the founding fathers of lifestyle medicine, because he also in the 80s did the first multidisciplinary lifestyle trial for people with heart disease. As we know, people with RA have twice as high risk of developing heart disease. There we see things coming together because the program of Dean Ornish is also a whole food plant-based diet combined with physical activity and stress management. The Ornish program was so successful in lowering the risk of heart disease and reversing heart disease that all the large health insurance companies in the US now refund this quite expensive program. Let’s say previous studies influenced us to do this. Then, you yourself because Clint we had a meeting. I think it was five years ago when I was building up this protocol. I had a couple of patients that we knew from our rheumatology clinic. It is because I also work in a rheumatology clinic in Amsterdam where we have conducted this study and in our clinic. But also I came across them through social media. We had patients who were following your program and were very successful and so they inspired us as well. Your program inspired us as well to implement this in this way.

Clint – That is so wonderful to hear. I remember when we had our conversation, I was living in Florida. It was 2018 in fact, it was almost five years ago exactly about two weeks from now. It was exciting to hear about what you had planned. Then, we had a great conversation about all of the nuances of the diet. We also did talk lifestyle and it was really great. Then now five years later, here we are, and you’ve put it all together. You’ve manifested it, you made it happen, and it’s cool to now sit and talk about this publicly and share your results. Thank you for all that. Is there a way that we could almost do like imagine a comparison table in our mind of the control result and the plant for joints result? Could we say that the disease activity score is 28? Is it improved in plants for joints versus the control? I know medications were reduced in more patients who were following plants for joints. Would you be able to just rattle off a couple of comparison data like that?

Wendy – Yeah, I’ll take a peek for myself because I have them in front of me over here. First of all, regarding the setup of the study, it might be interesting to know that we had a randomized control. People who entered the study were randomized to the intervention group, which was the plan for a joint group or the control group. People who could join this study had an average to low disease activity. Also, not be too high because that would be irresponsible and not too low. It is because if people are too low, you cannot measure any improvement. It was a low to average disease activity of around 3.9. So the DAS28, which is the disease activity score based on 28 joints. It is a score that is set up of painful joints and swollen joints. Your score of, let’s say, perceived health and then this ESR or this inflammation marker. It’s in a score and people could join between 2.9 and 5.1, so the average was 3.9. Let’s say the treatment for people with RA aims to get it below 2.6. Then, within the intervention group, we started with 3.9 and then the patients went to 2.9. Thus, that’s a whole point difference which is large. As I said before, our results are comparable with drugs. Then in the control group, they started at 3.8 and remained at 3.8. Thus, in both groups, we had people with and without medication. To be able to join this study, if you had medication it had to be three months stable. It is because medication for rheumatoid arthritis can be effects can be somewhat delayed. You want people to be stable before they start. The aim was to leave the medication at baseline throughout the whole study, which was not possible for some people. Only a small group changed medication, but on average more people lowered medication because of side effects. For example, in the intervention group than in the control group. As I mentioned, in the two-year extension study that we set up, the protocol for that study was that people that we had a standardized tapering scheme to lower medication even further. Indeed, the one-year data shows show that people on the program were able to lower medication even further while remaining lower in the disease activity. Then, what we did was we had these two groups to be able to convince people to join this study. Although being part of the control group, we told them, if they join and if they are randomized to the control group, you will be our control for four months. You’ll have to undergo all kinds of measurements and we had many measurements. I feel guilty about all the measurements we did. All these great people came every time again to our clinic for scanning, and for delivering their poops. It is because we did a microbiome study as well to give blood and stuff like that. That was awesome, I really have to thank all the participants. The control group, after four months of being controlled, received the program as well. Then, it was the thank you that we gave them. Fortunately, all these people joined the two-year extension study and we have quite some people in that study. Just to give you an idea, we had 40 people in the intervention group, 37 in the control group, and so 77 people who finished the study and who did the whole program. Now, they are finishing this two-year extension study, and from whom we already have the one-year data. So that is about disease activity. Then next.

Wendy – Besides ESR as an inflammation marker, we also had CRP C-reactive protein, which is also a very known inflammation marker. Then, most rheumatologists use either ESR or CRP. We measured them both and actually, people in the intervention group started at 4.3, which I would say is a low-grade inflammation. They lowered in the control group they started at 3.4 and went up to 4.8. However, the difference was not significant. Interestingly enough, in our osteoarthritis trial, which we will discuss at a later time. However, in the osteoarthritis trial, we did see a significant decrease in CRP. It’s a little bit sometimes it hits significance and sometimes no. Thus, you can see that the tendency is that inflammation and objective inflammation markers are going down.

Clint – Yeah. I’m going to let’s just place a little footnote there to come back to this. It is because the word significance here has a very unique definition within the jargon of scientific publication. Thus, let’s come back to that. If you have a couple of other bullet points and then I’ll ask you about that.

Wendy – Yeah, that is great. I will go through some other anthropometric measurements like body composition markers. The people on average had a BMI of 26 when they started. So we know BMI body mass index should be around 20-25 to be healthy. As of 25, you’re a little bit overweight and at 30 you’re obese. However, the people who were joining this study had a relatively healthy weight. A BMI of 26 is a little bit overweight, but not too much. Of course, that went down and they lost on average. They started at a mean weight of 77 and they went down to 73, and that’s quite something. In the intervention group, they started at 72kg and remained at 72kg. Most of the weight loss was fat mass and people lost a little bit of muscle mass. However, one of the professors involved is a professor who specialized in body composition. Thus, he knows all about protein, body composition, and muscle mass. He said that the loss of lean mass was very low. When you take into account that people, ate a little bit less protein. As a result, this is an interesting thing and this is also one of the reasons why I would not include people who have a very high disease activity, without any additional attention in a program like this. It is because if you are high on inflammation or if your disease activity is very high and you’re not treated, you are converting to a plant-based diet. Then, most probably your protein intake will go down. This can affect your muscle mass because if you are in a high inflammatory state, your catabolic, so your muscle mass is going down. If you’re also decreasing protein intake, this can accelerate a little bit too much. If your disease activity is in a manageable range, you can perfectly come down with a little bit of protein and that’s not a problem at all. It is an important thing to take into account if you are doing this for a longer period. I would recommend focusing on the legumes to take your protein. Then we also measured, for example, bone mineral mass, because we did DEXA scans. We use them mainly to measure fat mass and muscle mass, but it also measures bone mineral density. Within four months, it didn’t do anything at all because that goes very slowly. I have not analyzed that yet, but what it does on a one-year duration.

Wendy – Then, we also have some metabolic markers. We are talking about glucose, cholesterol, and stuff like that. There you can see that this type of lifestyle program is effective for people with diabetes, people who have pre-diabetes, or a high risk of diabetes. Also, for people who are who have a high risk of heart disease, for example, people with high LDL. The bad cholesterol, because both glucose, as well as LDL, really went down again, significantly. Also, I forgot about body composition, what also went down was the waist circumference. Also, it is more often mentioned as an even more important marker for health than BMI. Yeah, waist circumference went down significantly.

Clint – If that checklist were the only reason to consider going on a plant-based diet, you would jump at it, wouldn’t you? It’s pretty comprehensive.

Wendy – Yeah, absolutely. It is also difficult with scientific studies. When you do a scientific study on lifestyle programs you have to take into account that in scientific studies you have to choose one primary outcome. For example, in our case, this was DAS 28 or the disease activity score, you have to choose one. Then, we come also to the significance thing. If you analyze all these data, you use statistical methods to see whether the improvements are real. It is because if you throw your dice and you say, if I do it like this, then I can throw six. Then, you also have the chance that you throw six by coincidence. It means that the odds that it was a chance finding and a coincidence is less than 5% actually for the do it’s less than 0.0001%. So we can say that the outcome regarding disease activity is the hard outcome. It is no coincidence that people improved. However, if you have several outcomes, the more outcomes you have. The more chance you will have to find a significant outcome. The more outcomes you have, let’s say the lower your strength is. This is why we only analyze the significance of that primary outcome. The difficult thing is the outcome, which is quite large in our case. However, more often the outcome is not that large, but it is positive for many outcomes. In this case, you see positive outcomes for the disease activity, weight, fat mass, glucose, and LDL. It’s a typical outcome for a lifestyle-related intervention. Whereas as you look at drugs, for example, drugs are often focused on one molecule and that lowers and has a primary outcome. However, all the other things will not improve and sometimes there will be harmful side effects. For example, the difficulty in performing a lifestyle trial.

Clint – Based on what you have researched before this study and now the results of your study, do you feel that this is conclusive? It indicates that everyone with rheumatoid arthritis should be eating a plant-based diet.

Wendy – I would not say everyone because like with drugs there are always some people who don’t react. In our study, let’s say the positive outcome was that the mean decrease in disease activity was large, and the spread was low. People on average almost all decreased in disease activity and some people remained stable. So almost nobody increased in disease activity. So that is the first thing I want to say and the second thing is that with diet. The fact that in most Western countries we have dietary guidelines and dietary guidelines, food pyramids, healthy eating plates, and stuff like that. We have them in the Netherlands and our intervention was based on that. It is because we wanted to also give doctors a sense of safety and because those dietary guidelines are often well studied and taken into account also. For example, potential nutritional deficiencies and stuff like that. If you depart from that idea, a plant-based diet can be fortunately, less and less, but still can be perceived as extreme. We discussed earlier the guidelines from the International Rheumatology Association.

Clint – We discussed those before we hit record. Can you just tell us What you’re talking about there and then continue on?

Wendy – Yeah. Rheumatologists internationally agree that we should perhaps adopt a Mediterranean diet if we have rheumatoid arthritis, which is already great. I mean, I’m already glad that they say something about diet.

Clint – That’s a new thing. Let’s step back and say this is all brand new. They’re about to release guidelines for the first time on lifestyle within the American guidelines of rheumatology. A new phase is happening within the rheumatology conventional traditional medicine world. They’re bringing forth recommendations around exercise, diet supplementation, and so on. It’s all-new and it’s coming out soon. So but what Wendy and I were discussing just before this call, is why have they chosen a Mediterranean diet. When all the evidence that I can find supports better results with a plant-based diet and that’s even before Wendy’s study? Let’s discuss this.

Wendy – First of all, as I said, let’s say many of them are based on studies involving a Mediterranean diet and are influenced by Mediterranean diets, and that is the first thing that is a safe option. That’s the first thing. Second thing is that there has been a very nice study done on the Mediterranean diet which showed also a significant decrease in disease activity. Thus, you could conclude that a Mediterranean diet is already a step forward and it is safe. Whereas plant-based diets, when develop these guidelines. Indeed, my study was not published yet, and there are two other studies. One was done in the US by Neal Barnard and the other one was done in Germany by Andreas Mikkelsen and his colleagues. These three studies of us came out after these guidelines were conceptualized. I know that some researchers, including a colleague of mine, Caroline Wagner. She is also one of the co-authors and my colleague on, on this study. They are now thinking of performing a new review and literature review based on previously done studies. Let’s say, a high level of evidence and can be used in the future to develop guidelines. It’s very important that our studies are first published and second, that they are reviewed. I’m hopeful that this is the first step. The Mediterranean diet is already a good idea for many and that we from here will take it forward also because many dietary guidelines. For example, in the Netherlands as well as in Canada, are already very clearly say a more plant-based diet is very healthy for us all. Of course there is some, let’s say, confusion about what is really a Mediterranean diet. But if you look into the study done on rheumatoid arthritis. For example, it is a Mediterranean diet like they ate it on Crete in the 50s, which was really an almost plant-based diet. It was very rich in legumes, whole foods and very little animal-based foods. I think it’s important to take that into account as well. Also, we often think that Mediterranean diets are very rich in fish, which sometimes they can be. You see a little bit more fish in Mediterranean diet. Of course the fats of fatty fish contain very healthy omega three fatty acids. However, the fish of the 50s is not any longer the fish that we consume right now. It is because unfortunately fish and especially the fats in fish are very much contaminated with heavy metals, with PCBs, with plastics and stuff like that. Also we in our rheumatology clinic, we started actually quite positive about fish because of those omega three fatty acids. We actually said to our participants, if you really want your fish, if you’re done with this study, you can include it. Actually, there was a study done, for example, in Belgium in which they concluded that fish makes up 2% of our diet. However, it is largely responsible for all the contaminate oceans. We get into our bodies through food. I think that we have to be a bit cautious wtuh fish in general. If you do eat fish, please make sure you eat very small fish. It is because those contaminants they build up in the fats of fish and in large fish relatively, you will find more of those contaminants.

Clint – Yeah. In addition to that published another study I can see on your website just last year, about the lack of association between saturated fatty acid and non-communicable diseases. This ties into a fish discussion as well, because they’re so rich in saturated fat. Whilst, I don’t want to get too much off our topic here, maybe just speak to that just really briefly about fish saturated fat and associated disease risks.

Wendy – Yeah. In general, that article you mentioned was a response to a horrifying article published by some researchers who, on the basis of very bad data, concluded that saturated fat was actually not of not so much of a problem. My colleagues and I, we could not accept this. Thus, we wrote this commentary in which we explain that saturated fat really is an issue, and especially for people with inflammatory arthritis. It is because they already have this increased risk of heart disease. They should really be very careful with building up saturated fat. I think if you look into the results of our study, we also asked our participants to keep food diaries. The fun thing about our outcomes is that. Actually, I think my participants, Clint, are not that adherent. I’m afraid that I’m less convincing than you are. It is because if I talk to your, the people in your program, I’m always surprised about how perfectly well they are following your guidelins. Whereas the people in my study very often said, sometimes I’m eating an egg and sometimes I’m eating a fish. The fun part was about that on average, the people who adhered best, we divided them in four groups. The people who did worst in adhering to the guidelines of our program and the people who did best. Actually, the third group had the best outcomes and I thought that was very funny. It is because this means that actually if you are too much, let’s say if you are going too much for perfection that might involve some stress which is not very good for you. Whereas the people, who are a little bit more relaxed and say I’m going for it, but I’m not perfect. For example, I’ll eat out and I’ll have something that is not perfectly within the guidelines of the program, but I’ll enjoy it. They also did very well and so that is first. Going back to the saturated fat part, we actually advise them to eat a whole food plant-based diet to eat as the least processed foods possible. We also advise them to abstain as much as possible from fatty acids in the form of butter, but also the plant-based variants which are palm oil and coconut oil. It is because we did find some associations between omega six fatty acids and arthritis. We said if you are using oil, don’t use too much and keep it to olive oil. It is because olive oil has omega nine fatty acids mostly, and those are associated with lower inflammation. I would really say if you have no arthritis, you should lower your intake of saturated fat fatty acids. If you have inflammatory arthritis, you should especially lower saturated fatty acids.

Clint – Okay, let’s get on to your colleague who worked on this project with you and he’s a rheumatologist. I want to learn about him, and his career. Also, has he been treating Paddison Program folks over the years. It is because there’s been whispers and discussions over many years of patients in the Netherlands, who have this fabulous rheumatologist who supports our program. It’s just never filtered clearly through to me who that is and if that is the same doctor. Also, how this all ties together, could you help us with that?

Wendy – Well, just a small story. I’m actually an economist, and I worked in banking for 15 years and only studied dietetics when I was 30. I started it when I was 39 and because I was already influenced by the idea that perhaps a more plant-based diet can help you live longer, especially live to expand your healthy longevity. This was important for me because my husband, who I love very much, is a little bit older than I am. I thought this is interesting for me because of course I want him to reach a very old age in great health. Also, it was my personal journey into dietetics lifestyle, especially this plant-based lifestyle, which is also recommended from this blue zone perspective. The blue zones are the five regions in which, let’s say the odds of becoming a centenarian are ten times higher than in the United States, and so that was my start. Then, I studied dietetics and then I started as a clinical dietitian in the university hospital, and I had my own practice. Then, a great friend of ours who has rheumatoid arthritis said, perhaps you should contact my rheumatologist because he now is telling me that I have to adopt a vegan diet as well. Then I said, I need to talk with him and so his name is Dirkjan Van Schaardenburg, and he’s the last author of our article. Actually, he’s my boss and with him together. I developed this program and I sent him an email because I noticed that he just said to people, perhaps you can try a vegan diet. Then I wrote him and I said, it is interesting and are they doing that? Then he said, perhaps you should come over and then I came over. Then he said, strangely enough, they’re not listening to me. I said, welcome to the world of behavioral change. It was so funny and because he is a person like that. If you tell him, this is more healthy and you can prove it with evidence. He is just the person who does it and I mean disciplined to the max. Actually, we were talking about this and he said, this is very interesting and perhaps we should work together. Then, we developed this idea and so that’s him. It’s Dirkjan Van Schaardenburg and he’s a professor at the Amsterdam University Medical Center, and he is one of the rheumatologists at Reade, which is a rheumatology clinic in the Netherlands. When I started together with Dirk because this clinic works very closely together with the Amsterdam University Medical Center, where I’m a Ph.D. student. They are among the best researchers and professors in the field. The one at the one hand, it was fortunate that I could work and develop this study in this highly great scientific environment. On the other hand, they made my life really difficult because the first time I wanted to do a presentation on fasting for rheumatoid arthritis. For example, there were rheumatologists who said, do I really have to listen to this nonsense? I mean, how alternative and how unscientific is this? I really had to work my ass off to convince them that there are studies proving that fasting decreases your objectively measured, inflammatory, inflammatory markers and stuff like that. It was a huge challenge and the great thing is they’re really scientific. I mean, they are the best rheumatologist we have in the Netherlands because they are I think that this study has helped them to become more holistic. There are rheumatologists who really understand the relationship between arthritis, stress, lack of sleep, physical activity, unhealthy food, and dietary habits. There are great rheumatologists everywhere. However, I think within the Netherlands this clinic is really outstanding. Nowadays, they also have a rehabilitation department and throughout the whole clinic, we now have adopted a more plant-based diet. So people are offered also when they are in the hospital, they are offered a mostly plant-based diet. In our restaurants, there are all kinds of healthy options. Our employees are having are are are stimulated to eat more healthily. It’s really a great example of how things can change within, 5 to 10 years.

Clint – Wow, isn’t that fantastic? I learned from Dr. Gregor and Dr. Caldwell Esselstyn recently when we did a conference. They were guest speakers that I interviewed in Melbourne just last month. Also, the Canadian guidelines appear to be the most progressive in terms of recommendations for plant-based diets on a national scale. But I’m picking up from you that the Netherlands might not be too far behind.

Wendy – Yeah, totally agree. Canada is very advanced in that in that sense. I think in the Netherlands we have taken a great leap as well. I’m working also in all kinds of associations for doctors and nutritionists to really implement that even further. The interesting thing is that in the end, we know that a more plant-based diet or a plant-centered diet, is the healthiest choice for everyone and also for our planet. If we take that together, we should take more courageous steps, especially also in our hospitals and in our healthcare environments. For example, in the Netherlands and I know in a lot of Western countries or it’s like health care is challenged to the max. We have way too many diseased people and approximately 60% of people in affluent countries are sick, and that is horrifying. If you look at, for example, osteoarthritis in the Netherlands, one out of ten inhabitants have osteoarthritis. It’s the fastest-growing disease in the Netherlands, and it’s the same way in many other Western countries. One of my colleagues is working on a more plant-based food environment in the Netherlands and he is an orthopedic surgeon. Then he says, I stopped because I cannot handle this anymore. He also said that he has to replace his knees and hips. All the time I’m saying to people, you have to improve your diet and you have to improve your lifestyle. He said this 1 to 1 and I cannot do any anything further. Thus, we have to upscale this and we have to convince the world that we cannot go on like this. We are killing ourselves and we are killing our planet.

Clint – Well said, I’ll be backtracking a little bit. I know I’m going to get a lot of questions. Can people in the Netherlands contact that rheumatologist? He’s going to become very sought after. Is that possible?

Wendy – He is actually retiring in May, so very sorry about that. But if you are in the Netherlands and if you are looking for a clinic that is more into the diet. Then you can certainly look up www.reade.nl which is the clinic. We have conducted this study and we have a lot of lifestyle-minded rheumatologists over there. I know there are several others because there are. For example, also studies in the Netherlands now, let’s say more pragmatic studies done on a Mediterranean diet that is more plant-based as well. These are done in several other clinics. In my opinion, if you are looking for a rheumatologist. I mean, often I know fortunately of some patients who were dismissed by their rheumatologist, some people who did your program were dismissed by the rheumatologist. So but often you will have a very long-term relationship with your rheumatologist. I would really recommend to really select one that fits your needs, needs. It doesn’t always have to be a rheumatologist that knows everything about food. I know one rheumatologist who is very positive, but he says, I’m not an expert in that field but I fully support it. However, this rheumatologist specialized in medication and other treatments. Also, his patients are very much at home with him as well because he is supportive. However, he also knows his limitation and I really appreciate that as well.

Wendy – Yeah, we actually have a growing number of dietitians in the Netherlands who are familiar with this program. Actually, if you are looking internationally for health care providers, including dietitians who support this. I really recommend you take a look at the website of the Physicians Association for Nutrition. I’m on the board of the Dutch Association and I’m also working a lot with my colleagues in the Physicians Association for Nutrition. On the international level, we’re even talking about cooperation with our program. Please go to the website of this association which is www.pan-int.org. I mean, perhaps we can put that link in your show notes. I think that is an international website where you can find some information. Actually, I wrote general information about rheumatoid arthritis and nutrition on that website which has to be updated, since we published our results now. But that gives quite some, let’s say general information.

Clint – Absolutely fantastic. You’re doing such great things and it’s great to see the parallels. We talked at the start about the differences and the overlap between Paddison Program and your study. I think we’ll just talk about this and then I only have 1 or 2 more questions for you and we’ll wrap this up. But I think one of there’s a couple of areas where the study is not as stringent as the Paddison program, which is the no oils. Obviously, there was some occasional grazing into the eggs and some other things. Also, there was no restriction on fat intake. Whilst, there’s not an overt restriction in the Paddison program, we have a guideline of reintroduction sequence that tends to be slowly increasing with calorie density, and that’s very deliberate. If there was one thing that overarched the general progression of foods, it’s that we’re starting with lots of polyphenols from fruits and spices and we’re moving to increase the fat content. Thus, that’s pretty much the general trend. Then food sensitivities, which is a big one, which is why people jump onto ridiculous diets like Carnivore and Paleo and so on. Then sometimes get relief immediately, it is because it’s not that the meat in those plans is good for them or helpful or anti-inflammatory even. It’s that they’re burning island situation that they’re on. They’re jumping off onto anything that’s an elimination diet. If it’s a processed food situation or a dairy situation, then often they can immediately see relief because they’re not triggering those food sensitivities. So what we do in our program, everyone who follows it understands this very well is we reduce the plant-based foods to become an elimination diet. Then, we slowly increase plants to increase gut bacteria diversity. Then, we slowly reintroduce foods to also then acclimatize to those foods and reduce food sensitivities. There are some things there that would be interesting to explore if there are further data. I know you’ve got some more data in there or potentially another study in the future, a collaboration. I can certainly help you recruit for that. We could look into that, but people have asked me in the past and said, why don’t you do a study? I’ve been asked that question maybe 100 to 200 times over the years. I believe the evidence is strong enough and look at the work that you’ve put in. Look at the collaboration you’ve worked with and it’s a huge amount of work. I can now just say, look what Wendy has done. I want to say maybe like an even easier version of what I’m suggesting. Also, look at the results, we don’t need another or we don’t need to go over this yet again in my view.

Wendy – Yeah. First of all, about food sensitivities. We wanted to do a program that was also easy to understand for all layers of society. We deliberately said we understand that there are some food sensitivities. We also had some participants who said, I’m reacting very much on gluten. Then, we could regard them to do this without the gluten, and that’s we adapted it sometimes on a personal level. However, not too much and we decided this already. As you said, we believe that this already does so much. Indeed, sometimes you see people who have done this and say, I want to take it a step further. I send them to you because that is one step further and that is okay. I also do believe that there is an explanation for the food sensitivities and this is very much still at a hypothetical level. All the people who joined this study and we also collected feces. Then, we put them in a freezer at -80°C and they actually were sent a couple of weeks ago to Germany. It is because in Germany we have great researchers and great colleagues. They specialized in microbiome metabolites and they are now studying our poops, our microbiomes, and the metabolites. That’s perhaps interesting to explain. You have a microbiome, so you have your gut bacteria, which is in your poop. Your gut bacteria consists of good bacteria, and bad bacteria, and the good ones actually release anti-inflammatory substances. Then, what we saw in our participants was if you look at the diet. We were able to decrease saturated fat intake significantly really was a big step lower and increase fiber intake hugely. People went from quite a low intake of fiber to a very high level of fiber, which was a challenge at first. It is because your listeners certainly will understand. This goes with some bloating and intestinal complaints, but most often these are temporary. With some adaptations or soaking legumes somewhat longer or adding some baking soda or lowering it first to increase it later. We were able to manage this all. However, in the end, the intake of fiber was increased to a very high level. Then, what we think will happen is that the microbiome is improved. I guess that is the outcome and we still have to study that. However, let’s say if our expectations come true, it’s improved and we think that also increased metabolites. Thus, it is perhaps for a part responsible for the longer-term, slowly decreasing level of inflammation. I also think that food sensitivities are related to the microbiome. We know that the microbiome of people with rheumatoid arthritis really different from people who don’t have rheumatoid arthritis. For example, I was discussing this with one of the top researchers in the microbiome field. I explained to him that some of our participants if they eat red meat, will have inflammation or a flare within 24 hours. He actually said it could be that because those people did very well in this program. He said they are most probably doing well but their microbiome is still not optimized. Thus, their microbiome as soon as they get food for the more pathogenic, for example, the worse bacteria. Then, you’ll see that their complaints increase.

Clint – Yeah, absolutely. In addition, I believe there is even when we are in a state of balance, in the early stages of gut restoration. We still have a degree of gut permeability and that gut permeability still allows the cross-pollination of the lipopolysaccharide endotoxin into the bloodstream in the presence of a high-fat environment. Thus, this is why it can happen very quickly in my view because you’ve still got the holes in the tube. If you’re running the garden hose, which still has some holes in it that can create problems. Then, those holes can migrate this endotoxin more easily in the presence of high fat, and that’s another theory.

Wendy – Well, we are not sure yet if they are able to research it, but we hope that they are able. These researchers in Germany are able to also give us some clues based on the material we send them to give us some clues about gut permeability. Yeah.

Clint – Yeah, great. To wrap this up, do you think this also can work for other autoimmune inflammatory arthritic conditions besides RA?

Wendy – Oh, absolutely. One of our inspirations was actually the Dean Ornish program, a program developed by Dean Ornish in the 80s to treat heart disease. I think we could say it has been already sufficiently proven as an effective intervention for that target group. I think the studies done by Neal Barnard on diabetes are also very convincing. I definitely recommend this program also for people with a not very advanced type two diabetes or for those who are in the early stages of diabetes. I think this is also a very interesting one as a secondary prevention for cancer that still has to be studied, but I think it has all the ingredients such as stress and physical activity. If you look at the recommendations of the World Cancer Research Fund, they have a great overview of all the studies done on cancer. They actually say to lower your intake of red meat and increase your intake of vegetables and fruits. It all comes out in the same corner. We actually have plans to transfer plans for joints to plans for health. Then, try to offer this as a broad lifestyle program that really fits the most important diseases of affluence.

Clint – Yeah, Love it. Well, thank you so much. I’m hoping we can reconvene and have another one of these interviews. When you have released your data for the osteoarthritis study that you’ve also done. Would you be kind enough to do another interview with me when those results are published?

Wendy – Well, Clint, not only do another interview, I think we have to be very much connected because we are working in the same field with the same patients. I think we can really together make sure that a lot of people can be helped to take their health a step forward.

Clint – Yeah, wonderful. Well, let’s work on those initiatives. Let’s work together on whatever ideas you might have or I might come up with because you’re absolutely right. There’s so much overlap with not just the dietary recommendations, but our mission. I’d love to explore that further and I’d love to have you back. When we talk about that study, osteoarthritis, you get that for free when you’ve got rheumatoid arthritis. All of the data around that very much applies to us as well. I can’t wait to have you back and congratulations on all that you’ve done with this study. All the work that you’ve put in is enormous and that team of people that you’ve now got around you are all working together to spread this, especially within the arthritis community. It means so much to all of us as patients of rheumatoid. Thank you.

Wendy – Thank you very much, Clint. It was awesome and thank you also for your great work.