Anti-inflammatory foods

Scientific evidence shows that eating mostly plant-based foods — variety of vegetables, fruits, whole grains, beans and other plant foods — plays a big role in preventing cancer and contributing to a healthier life. That’s because plant-based foods are high in the types of fiber, nutrients, minerals, vitamins and phytochemicals (natural substances) that may help to prevent cancer. Plus, plant-foods can help you manage your weight, and give you the energy you need to enjoy physical activity. A healthy diet emphasizes foods such as a variety of vegetables, fruits, whole grains, and beans that can reduce your risk for cancer and other chronic diseases. These foods are rich in fiber, vitamins, and other natural substances called phytochemicals that help keep you in good health, and protect against cancer. They are also naturally low in calories. The other most important consideration for any anti-inflammatory diet is calorie restriction ¹. Any reduction of excess calorie intake will lead to a decrease in systemic oxidative stress. Calorie restriction has been the most successful therapeutic intervention to improve healthspan (defined as longevity minus years of disability) in virtually every species studied ². Significant metabolic benefits have been achieved by calorie restriction in healthy overweight and normal-weight individuals who participated in the various CALERIE (Comprehensive Assessment of the Long-Term Effects of Reducing Intake of Energy) studies ³, ⁴.

In addition, several foods have been suggested to offer numerous health benefits ⁵, including long chain omega-3 polyunsaturated fatty acids [eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)] (chia seeds, flaxseeds, fatty fish) ⁶, ⁷, ⁸, ⁹, ¹⁰, monounsaturated fatty acids (MUFA) (avocado, sesame) ¹¹, ¹², antioxidants (N-acetylcysteine [NAC]) ¹³, phytochemicals from fruits, vegetables, and legumes ¹⁴, flavonoids ¹⁵, ¹⁶, vitamin D ¹⁷, fruits with enzymatic proteins such as papain and bromelain (papaya, mango, pineapple) ¹⁸, ¹⁹, ²⁰, ginger ²¹, turmeric ²², ²³, black pepper ²⁴, ²⁵, green tea ²⁶, ²⁷, ²⁸, and legumes ²⁴, ²⁹. However, only a few randomized double-blind placebo-controlled clinical trials have attempted to determine whether supplementation with these ingredients are beneficial in patients with rheumatoid arthritis ⁹, ¹³, ¹⁵, ¹⁶, ²¹, ³⁰. Rheumatoid arthritis (RA) is a chronic (long-lasting) autoimmune disease that mostly affects joints. Rheumatoid arthritis occurs when the immune system, which normally helps protect the body from infection and disease, attacks its own tissues. Rheumatoid arthritis causes pain, swelling, stiffness, and loss of function in joints. So far, most of the studies are pilot studies with small number of patients, studies on animal models, or test tube studies ³¹.

When it comes to anti-inflammatory foods, the goal should be to incorporate as many as you can into your overall diet. So make whole grains, vegetables, fruits and pulses (legumes) such as beans and lentils a major part of your normal diet. Get started by covering at least two-thirds (2/3) of your plate with plant foods such as whole grains, vegetables, fruit and beans. The remaining third (1/3) of your plate may be filled with animal-based protein rich foods such as seafood, poultry and dairy foods and occasionally with lean red meat.

Whole grains are healthier than refined grains because the process of refining carbohydrates results in the elimination of much of the fiber, vitamins, minerals, phytonutrients, and essential fatty acids ³². Furthermore, refined starches and sugars can rapidly alter blood glucose and insulin levels ³² and postprandial hyperglycemia can increase production of free radicals as well as proinflammatory cytokines ³³.

There is consistent evidence that consumption of whole grains is protective against incident type 2 diabetes and cardiovascular disease ³⁴, ³⁵. However, it is unclear how these protective effects are mediated. Dietary fiber intake may reduce the risk of these diseases by mediating the pro-inflammatory process ³⁶, ³⁷. Two mechanistic hypotheses have emerged. First, dietary fiber may decrease oxidation of glucose and lipids, while maintaining a healthy intestinal environment. Second, dietary fiber may prevent inflammation by altering adipocytokines in adipose tissue and increasing enterohepatic circulation of lipids and lipophilic compounds ³⁸. The link between dietary fiber intake and reduced high sensitivity serum C-reactive protein (hs-CRP) has been observed in several recent studies, including two analyses using cross-sectional data from NHANES 1999–2000 ³⁹, ⁴⁰, an analysis using a longitudinal cohort of 524 healthy adults ⁴¹ and a small clinical trial ⁴².

Various dietary components including long chain omega-3 fatty acids, antioxidant vitamins, plant flavonoids, prebiotics and probiotics have the potential to modulate predisposition to chronic inflammatory conditions. These components act through a variety of mechanisms including decreasing inflammatory mediator production through effects on cell signaling and gene expression (omega-3 fatty acids, vitamin E, plant flavonoids), reducing the production of damaging oxidants (vitamin E and other antioxidants), and promoting gut barrier function and anti-inflammatory responses (prebiotics and probiotics) ⁴³. In a large Danish study ⁴⁴ involving over 7000 men and women who were followed over 15 years (1982-1998). What that study found was that in both men and women who frequently consume wholemeal bread, vegetables, fruits, and fish, was associated with a better overall survival rate as well as better cardiovascular survival ⁴⁴.

A low-fat diet (≤30% of total calories) is still considered by many physicians to be a healthy choice for both primary and secondary prevention of cardiovascular disease (coronary heart disease) ⁴⁵. An unintended consequence of emphasizing low-fat diets may have been to promote unrestricted carbohydrate intake, which reduces high-density lipoprotein cholesterol (HDL “good” cholesterol) and raises triglyceride levels, exacerbating the metabolic manifestations of the insulin resistance syndrome, also known as the metabolic syndrome ⁴⁶.

Three dietary strategies may help prevent coronary heart disease (coronary artery disease) ⁴⁷:

1. Increase consumption of omega-3 fatty acids from fish or plant sources;
2. Substitute nonhydrogenated unsaturated fats for saturated and trans-fats; and
3. Consume a diet high in fruits, vegetables, nuts, and whole grains and low in refined grains.

The effects of diet on coronary heart disease (coronary artery disease) can be mediated through multiple biologic pathways other than serum lipids, including oxidative stress, subclinical inflammation, endothelial dysfunction, insulin sensitivity, blood pressure, and thrombotic tendency ⁴⁸.

Endothelial dysfunction is one of the mechanisms linking diet and the risk of cardiovascular disease ⁴⁹, ⁵⁰. This study ⁵¹ suggests a mechanism for the role of dietary patterns in the pathogenesis of cardiovascular disease. For example, women in the Nurses’ Health Study who ate a “American” diet (high in red and processed meats, sweets, desserts, French fries, and refined grains) had higher proinflammatory cytokines (C-reactive protein, Interleukin-6, E-selectin, soluble vascular cell adhesion molecule 1 and soluble intercellular adhesion molecule 1) than those with the “healthier” pattern, characterized by higher intakes of fruit, vegetables, legumes, fish, poultry, and whole grains ⁵¹. The levels of these mediators amplify the inflammatory response, are destructive and contribute to the clinical symptoms ⁴³.

Arachidonic acid (AA) derived (omega-6) eicosanoids (primarily from refined vegetable oils such as corn, sunflower, and safflower) increase the production of proinflammatory cytokines IL-1, TNF-α, and IL-6, operating as precursors of the proinflammatory eicosanoids of the prostaglandin (PG)2-series ⁵². In contrast, the omega-3 polyunsaturated fatty acids (PUFAs), found in fish, fish oil, walnuts, wheat germ, and some dietary supplements such as flax seed products can curb the production of arachidonic acid (AA)-derived eicosanoids ⁵³. The Omega-6 and Omega-3 polyunsaturated fatty acids (PUFAs) compete for the same metabolic pathways, and thus their balance is important ⁵⁴. Accordingly, it is not surprising that both higher levels of Omega-3 polyunsaturated fatty acids (PUFAs) as well as lower Omega-6:Omega-3 ratios are associated with lower proinflammatory cytokine production ⁵⁵.

Furthermore, in another study a healthy dietary pattern rich in fruit, vegetables and olive oil, such as the Mediterranean diet, is associated with lower levels of inflammatory markers, perhaps because of the anti-inflammatory properties of antioxidants ³².

The antioxidant properties of vegetables and fruits are thought to be one of the fundamental mechanisms underlying their anti-inflammatory dietary contributions ³². Oxidants such as superoxide radicals or hydrogen peroxide that are produced during the metabolism of food can activate the NF-κB pathway, promoting inflammation ⁵⁶. Higher fruit and vegetable intakes are associated with lower oxidative stress and inflammation ⁵⁶. In fact, some evidence suggests that the addition of antioxidants or vegetables may limit or even reverse proinflammatory responses to meals high in saturated fat ⁵⁷.

Chronic inflammatory processes contribute to the pathogenesis of many age-related diseases. In search of anti-inflammatory foods, researchers in the University of Wollongong, Australia, have systematically screened 115 variety of common dietary plants and mushrooms for their anti-inflammatory activity. Gunawardena and colleagues tested 115 commercially available plants and mushroom foods (including 115 identical samples heated with glucose) for their anti-inflammatory ability ⁵⁸. The plant and mushroom samples were prepared by methods usually employed with food preparation, involving heating (i.e. ‘cooking’) and mechanical dispersion. Samples were prepared by blending in a food processor with water before heating in a microwave for 10 minutes under control conditions or including 1% glucose, to enhance Maillard reaction products. Using using the free radical nitric oxide (NO) and tumour necrosis factor–α (TNF-α) as pro-inflammatory markers, 10 foods demonstrated significant anti-inflammatory activity (see Table 3) ⁵⁸. The activation of macrophages leads to secretion of inflammatory molecules such as the pro-inflammatory cytokine TNF-α and the free radical nitric oxide (NO), which play an important role in inflammation and nitroxidative stress in many age-related diseases, including Alzheimer’s disease ⁵⁹.

To overcome silent inflammation requires an anti-inflammatory diet (with omega-3s and polyphenols). The most important aspect of such an anti-inflammatory diet is the stabilization of insulin and reduced intake of omega-6 fatty acids. The ultimate treatment lies in reestablishing hormonal and genetic balance to generate satiety instead of constant hunger. Anti-inflammatory nutrition with caloric restriction, should be considered as a form of gene silencing technology, in particular the silencing of the genes involved in the generation of silent inflammation. To this anti-inflammatory diet foundation supplemental omega-3 fatty acids at the level of 2–3 g of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) per day should be added. Finally, a diet rich in colorful, non-starchy vegetables would contribute adequate amounts of polyphenols to help not only to inhibit nuclear factor (NF)-κB (primary molecular target of inflammation) but also activate AMP kinase ⁶⁰.

Figure 1. Foods that fight cancer

Table 1. Omega-3 Fatty Acid Foods EPA (Eicosapentaenoic acid) and DHA (Docosahexaenoic acid) – Fish and Seafood Sources

[Source ⁶¹]

Table 2. Other sources of Omega-3 Alpha-Linolenic Acid (ALA) – Non-Seafood Sources

Source of ALA	ALA content, g
Pumpkin seeds (1 tbsp)	0.051
Olive oil (1 tbsp)	0.103
Walnuts, black (1 tbsp)	0.156
Soybean oil (1 tbsp)	1.231
Rapeseed oil (1 tbsp)	1.302
Walnut oil (1 tbsp)	1.414
Flaxseeds (1 tbsp)	2.350
Walnuts, English (1 tbsp)	2.574
Flaxseed oil (1 tbsp)	7.249
Almonds (100 g)	0.4
Peanuts (100 g)	0.003
Beans, navy, sprouted (100 g)	0.3
Broccoli, raw (100 g)	0.1
Lettuce, red leaf (100 g)	0.1
Mustard (100 g)	0.1
Purslane (100 g)	0.4
Spinach (100 g)	0.1
Seaweed, spirulina, dried (100 g)	0.8
Beans, common, dry (100 g)	0.6
Chickpeas, dry (100 g)	0.1
Soybeans, dry (100 g)	1.6
Oats, germ (100 g)	1.4
Rice, bran (100 g)	0.2
Wheat, germ (100 g)	0.7
Avocados, California, raw (100 g)	0.1
Raspberries, raw (100 g)	0.1
Strawberries, raw (100 g)	0.1
Novel sources of ALA	ALA content, g
Breads and pasta (100 g)	0.1–1.6
Cereals (and granola bars) (55 g)	1.0–4.9
Eggs (50 g or 1 egg)	0.1–0.6
Processed meats (100 g)	0.5
Salad dressing (14 g – 31 g)	2.0–4.0
Margarine spreads (10 g – 100 g)	0.3–1.0
Nutrition bars (50 g)	0.1–2.2

Footnote: 1 tablespoon (tbsp) oil = 13.6 g; 1 tbsp seeds or nuts = 12.35 g.

[Source ⁶²]

Table 3. Anti-inflammatory foods

[Source ⁵⁸ ]

Seven of these food preparations, including lime zest, English breakfast tea, honey brown mushroom, button mushroom, oyster mushroom, cinnamon and cloves demonstrated potent anti-inflammatory activity with IC 50 values between 0.1 and 0.5 mg/ml. However, the most active food samples were onion, followed by oregano and red sweet potato exhibiting IC 50 values below 0.1 mg/ml. In addition, English breakfast tea leaves, oyster mushroom, onion, cinnamon and button mushroom preparations suppressed TNF-α production, exhibiting with IC 50 values below 0.5 mg/ml in RAW 264.7 macrophages ⁶³.

Secondary screen using RAW 264.7 macrophages, NO and TNF-α as pro-inflammatory markers, of the 10 products, oyster mushroom and cinnamon, demonstrated the most significant anti-inflammatory activities (with IC 50 values below 0.1 mg/ml), followed by cloves, oregano, onion, English breakfast tea leaves and lime zest (see Table 3) ⁶³. The commonly used drug for the management of inflammatory conditions are non-steroidal anti-inflammatory drugs (NSAIDs), which have several adverse effects especially gastric irritation leading to the formation of gastric ulcers ⁶⁴. Two anti-inflammatory drugs, including prednisone and the non-steroidal anti-inflammatory drug (NSAID) ibuprofen were also tested in the same study assay systems. Ibuprofen was toxic to cells at concentrations of 1.63 ± 0.44 mM, and NO and TNF-α production were down-regulated at the same concentrations (Table 4).  Prednisone inhibited LPS + IFN-γ induced NO and TNF-α production with IC 50 values of 0.25 ± 0.09 mg/ml (Table 4).

Table 4. Anti-inflammatory foods re-tested in macrophages

[Source ⁵⁸]

Onions have been shown to exhibit anti-inflammatory properties, e.g. downregulation of adipokine expression in the visceral adipose tissue of rats or attenuation of vascular inflammation and oxidative stress in fructose-fed rats ⁶⁵, ⁶⁶. Among the polyphenols in onions, quercetin was suggested to be the responsible anti-inflammatory ingredient, as evidenced by the downregulation of COX2 transcription in human lymphocytes ⁶⁷. Furthermore, the anti-inflammatory activity of the onion has been
studied also in relation to the presence of thiosulfinates and cepaenes ⁶⁸, ⁶⁹.

Anti-inflammatory properties of cinnamon has been demonstrated for Cinnamomum osmophloem kaneh ⁷⁰, ⁷¹, but less is known about the ‘true’ cinnamon of India, Cinnamomum zeylanicum. Some authors reported significant inhibitory effects of inflammatory signalling by the extracts of C. cassia ⁷². Sodium benzoate appears to be one of the active ingredients in cinnamon, since it inhibits LPS-induced expression of inducible NO synthase (iNOS), pro-inflammatory cytokines (TNF-α and IL-1 β) and surface markers for inflammatory activation such as CD11b, CD11c, and CD68 in mouse microglia ⁷³. However, E-cinnamaldehyde and o-methoxycinnamaldehyde are responsible for most of the anti-inflammatory activity of cinnamon ⁷⁴.

Clove (Syzygium aromaticum) extracts have been identified as having potent free radical (including superoxide anion) scavenging properties, and metal chelating activities, which may be due to the presence of flavonoids. Cloves contain considerable concentrations of eugenol, beta-caryophyllene, quercetin and kaempferol as well as rhamnetin and kaempferol and their glycosides ⁷⁵.

Red sweet potato (Ipomoea batatas), a species rich in β-carotene and anthocyanins ⁷⁶, has been demonstrated to have anti-inflammatory properties for the first time by this study ⁶³.

Lime (Citrus aurantifolia) rich in flavonol glycosides, especially of kaempferol-type are known for their anti-oxidant properties ⁷⁷, this study ⁶³ is also the first to report on its anti-inflammatory activities.

A handful studies have shown the anti-inflammatory properties of the various mushroom species. For example, oyster mushroom concentrate was shown to suppress LPS-induced secretion of TNF-α, IL-6 and IL-12p40 in RAW264.7 macrophages and also suppressed PGE2 and NO by down-regulation of COX-2 and iNOS expression, respectively. Oyster mushroom concentrate also inhibited LPS-dependent DNA binding activity of AP-1 and NF-κ B in RAW264.7 cells ⁷⁸. In mushrooms, water-soluble polysaccharides, especially the β-glucans, are most likely to be the substances responsible for the anti-inflammatory properties. For example, β-glucans isolated Pleurotus ostreatus were able to potentiate the anti-inflammatory effects of methotrexate in rat models of experimental arthritis or colitis ⁷⁹, ⁸⁰. A further potential anti-inflammatory compound in mushrooms could be ergothioneine, a sulfur containing amino acid that functions as an antioxidant and is present in mushrooms at a concentration of up to 2.0mg/g ⁸¹. In Acute Respiratory Distress Syndrome (ARDS), ergothioneine given intravenously 1h before or 18 h after cytokine (IL-1 and IFN-γ) insufflation, decreased lung injury and lung inflammation in cytokine insufflated rats ⁸².

The anti-inflammatory activity in these food samples survived ‘cooking’ and suggesting these foods may be useful in limiting inflammation in a variety of age-related inflammatory diseases ⁶³. Furthermore, these foods could be a source for the discovery of novel anti-inflammatory drugs ⁶³. However, validation of these foods containing anti-inflammatory properties will require further clinical trials in human subjects before any recommendation can be given for their use to treat inflammatory conditions.

Fermented plant foods

Fermented plant foods are gaining wide interest worldwide as healthy foods due to their unique sensory features and their health-promoting potentials, such as antiobesity, antidiabetic, antihypertensive, and anticarcinogenic activities ⁸³. Fermented fruits, vegetables, and grains are a rich source of nutrients and could enrich your diet with numerous live microorganisms (probiotic microbes), phytochemicals (chemical compounds produced by plants) and bioactive compounds. These compounds play a key role in the functional and health-promoting properties of fermented products. The excellent biological activities of these functional foods, such as anti-inflammatory and immunomodulatory functions, are widely attributable to their high antioxidant content and lactic acid-producing bacteria (LAB). Due to the high content of phenolic compounds with strong antioxidant activity, fermented blueberries and blackberries may protect against chronic inflammatory disorders by decreasing oxidative stress, modulating inflammatory signaling and responses, and improving immunity. Regarding fermented cabbage products, sauerkraut and kimchi, live lactic acid-producing bacteria are the key player in improving health and preventing chronic diseases through improving a healthy gut microbial balance and modulating inflammatory and immune responses. Fermented soybeans are an excellent source of isoflavones with known anti-inflammatory properties. Furthermore, probiotics found in fermented soy products contribute to the health benefits of these nutritious foods. Overall, growing evidence is strongly supporting the health benefits of fermented plant foods ⁸³.

These human digestive-tract associated microbes are referred to as the gut microbiome (the collective genomes of the micro-organisms in a particular environment). Lactic acid-producing bacteria contribute to the maintenance of a healthy gut microbiota (the community of micro-organisms themselves) composition and improvement of local and systemic immunity ⁸³. Approximately 100 trillion micro-organisms (most of them bacteria, but also viruses, fungi, and protozoa) exist in the human gastrointestinal tract ⁸⁴—the microbiome is now best thought of as a virtual organ of the body. The term “microbiota,” “microflora,” or “normal flora” is used to designate this vast host of microbes which coexist with the host ⁸⁵. The bacterial cells harbored within the human gastrointestinal tract (GIT) outnumber the host’s cells by a factor of 10 and the genes encoded by the bacteria resident within the gastrointestinal tract outnumber their host’s genes by more than 100 times ⁸⁴. The human genome consists of about 23,000 genes, whereas the microbiome encodes over three million genes producing thousands of metabolites, which replace many of the functions of the host ⁸⁶, consequently influencing the host’s fitness, phenotype, and health ⁸⁷. The human gut microbiota consists of diverse microorganisms, including archaea, bacteria, viruses, and yeasts, which maintain a symbiotic relationship with the host ⁸⁸. There is a mutual influence between gut microbiota and the immune system. Gut microbiota play a key role in the function and homeostasis of the immune system by the maturation of gut-associated lymphoid tissue and innate lymphoid cells, enhancing antimicrobial peptides, antibodies, and cytokines production, inducing immunoglobulin A (IgA)-producing B cells and T cells differentiation, and regulating T helper 17 (Th17)/regulatory T cells (Tregs) balance ⁸⁹. Gut microbiota disturbance negatively affects the immune system and leads to inflammation ⁹⁰.

The human gut microbiome and its role in both health and disease has been the subject of extensive research, establishing its involvement in human metabolism, nutrition, physiology, and immune function. Imbalance of the normal gut microbiota have been linked with gastrointestinal conditions such as inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS), and wider systemic manifestations of disease such as obesity, type 2 diabetes, and atopy ⁸⁴. Atopy is a problem with your immune system that makes you more likely to develop allergic diseases.

Besides, antioxidant compounds are involved in several functional properties of fermented plant products by neutralizing free radicals, regulating antioxidant enzyme activities, reducing oxidative stress, ameliorating inflammatory responses, and enhancing immune system performance. Therefore, these products may protect against chronic inflammatory diseases, which are known as the leading cause of mortality worldwide. The gut remains the most important organ in which fermented foods exert their beneficial effects, either by systemically modulating the immune response or positively influencing the gut microbiota ⁹¹.

The anti-inflammatory and immunomodulatory properties of plant-based fermented foods are well documented ⁹². The functional properties of fermented products are, in part, related to the probiotics content of the products ⁹¹. Numerous health-promoting benefits have been attributed to probiotics due to their anti-inflammatory and immunomodulatory activities at the gut level and beyond ⁹³. Probiotic consumption in the form of fermented foods can improve gut barrier integrity and gut immunity and maintain gut homeostasis ⁹⁴, through different mechanisms, including the inhibition of pathogen colonization, the induction of antimicrobial peptides production and mucus secretion, the increase of IgA production, the down-regulation of the Th17 and pro-inflammatory cytokines such as IL-17F, IL-23, and the upregulation of Tregs production ⁹⁵.

Moreover, fermentation will lead to the degradation of complex phytochemical molecules into smaller bioactive polyphenols. Studies have shown that polyphenolic compounds found in fermented products are beneficial in microbiota metabolism and growth ⁹⁶ and can inhibit the production of inflammatory cytokines and suppress inflammatory responses ⁹⁷. Furthermore, neutralizing free radicals, regulating antioxidant enzyme activities, reducing oxidative stress, and enhancing immune system activity are other potential mechanisms by which plant-based fermented foods and beverages exert health benefits ⁹⁸.

Different plants, such as fruits, vegetables, tea, grains, legumes, and starchy roots, are used to produce plant-based fermented foods ⁹⁷. Due to the high content of phenolic compounds with strong antioxidant activity, fermented blueberries and blackberries may protect against chronic inflammatory disorders by decreasing oxidative stress, modulating inflammatory signaling and responses, and improving immunity. Regarding fermented cabbage products, sauerkraut and kimchi, live lactic acid-producing bacteria are the key player in improving health and preventing chronic diseases through improving a healthy gut microbial balance and modulating inflammatory and immune responses. Fermented soybeans are an excellent source of isoflavones with known anti-inflammatory properties. Furthermore, probiotics found in fermented soy products contribute to the health benefits of these nutritious foods. Overall, growing evidence is strongly supporting the health benefits of fermented plant foods.  However, existing evidence has been chiefly generated from in vitro (test tube studies) and animal studies, and there exist rare clinical studies in this field. Therefore, the potential role of fermented plant products in human health remains to be determined by randomized, controlled clinical trials.

What is inflammation?

Inflammation is an evolutionarily conserved process characterized by the activation of immune and non-immune cells that protect the host from bacteria, viruses, toxins and infections by eliminating pathogens and promoting tissue repair and recovery ⁹⁹. Very generally speaking, is the body’s immune system’s response to an irritant, the irritant might be a germ, but it could also be a foreign object, such as a splinter in your finger ¹⁰⁰. Inflammation is a normal part of your body’s defense to injury or infection, and, in this way, it is beneficial. But inflammation is damaging when it occurs in healthy tissues or lasts too long. Known as chronic inflammation, it may persist for months or years ¹⁰¹. Furthermore, inflammations don’t always help the body. In some diseases the immune system fights against the body’s own cells by mistake, causing harmful inflammations. Chronic inflammatory diseases contribute to more than half of deaths worldwide ¹⁰².

When an inflammation occurs in your body, many different immune system cells may be involved. They release various substances, known as inflammatory mediators. These include the hormones bradykinin and histamine ¹⁰⁰. They cause the small blood vessels in the tissue to become wider (dilate), allowing more blood to reach the injured tissue. For this reason, inflamed areas turn red and feel hot. The increased blood flow also allows more immune system cells to be carried to the injured tissue, where they help with the healing process. What’s more, both of these hormones irritate nerves and cause pain signals to be sent to the brain. This has a protective function: If the inflammation hurts, you tend to protect the affected part of the body.

The inflammatory mediators have yet another function: They make it easier for immune system cells to pass out of the small blood vessels, so that more of them can enter the affected tissue. The immune system cells also cause more fluid to enter the inflamed tissue, which is why it often swells up. The swelling goes down again after a while, when this fluid is transported out of the tissue.

Mucous membranes also release more fluid when they are inflamed. For instance, this happens when you have a stuffy nose and the membranes lining your nose are inflamed. Then the extra fluid can help to quickly flush the viruses out of your body.

Depending on the degree and extent of the inflammatory response, including whether it is systemic or local, metabolic and neuroendocrine changes can occur to conserve metabolic energy and allocate more nutrients to the activated immune system ¹⁰¹. Specific biobehavioral effects of inflammation thus include a constellation of energy-saving behaviors commonly known as “sickness behaviors,” such as sadness, anhedonia, fatigue, reduced libido and food intake, altered sleep and social-behavioral withdrawal, as well as increased blood pressure, insulin resistance and dyslipidemia ¹⁰³. These behavioral changes can be critical for survival during times of physical injury and microbial threat ¹⁰⁴.

Inflammation is associated with diseases such as the following:

• Rheumatoid arthritis (RA), where many joints throughout the body are permanently inflamed
• Systemic lupus erythematosus (SLE): Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that causes inflammation in connective tissues, such as cartilage and the lining of blood vessels, which provide strength and flexibility to structures throughout the body.
• Multiple sclerosis (MS): Multiple sclerosis (MS) is an autoimmune disease that affects the brain and spinal cord (central nervous system) that disrupts the flow of information within the brain, and between the brain and body.
• Psoriasis – a chronic skin disease
• Inflammatory bowel diseases like Crohn’s disease or ulcerative colitis
• Cardiovascular diseases like high blood pressure and heart disease
• Lung diseases like asthma
• Mental illnesses like depression ¹⁰⁵
• Metabolic diseases like type 2 diabetes
• Neurodegenerative diseases like Parkinson’s disease
• Some types of cancer, like colon cancer ¹⁰⁶

Collectively known as chronic inflammatory diseases, these diseases can last for years or even a lifetime. Their severity and level of activity varies. Together, cardiovascular disease, cancer, and diabetes account for almost 70% of all deaths in the United States; these diseases share inflammation as a common link ³², ¹⁰⁷.

A normal inflammatory response is characterized by the temporally restricted upregulation of inflammatory activity that occurs when a threat is present and that resolves once the threat has passed ¹⁰⁸. However, the presence of certain social, psychological, environmental and biological factors has been linked to the prevention of resolution of acute inflammation and, in turn, the promotion of a state of low-grade, non-infective (that is, ‘sterile’) systemic chronic inflammation that is characterized by the activation of immune components that are often distinct from those engaged during an acute immune response ¹⁰³. The clinical consequences of systemic chronic inflammation-driven damage can be severe and include increased risk of the metabolic syndrome, which includes the triad of hypertension, hyperglycemia and dyslipidemia ¹⁰⁹; type 2 diabetes ¹¹⁰; nonalcoholic fatty liver disease (NAFLD) ¹¹¹; hypertension ¹¹²; cardiovascular disease such as atherosclerosis ¹¹³; chronic kidney disease ¹¹⁴; various types of cancer ¹⁰⁶; depression ¹⁰⁵; neurodegenerative and autoimmune diseases ¹¹⁵, ¹¹⁶; osteoporosis ¹¹⁷ and sarcopenia ¹¹⁴. Empirical evidence that inflammation plays a role in disease onset or progression is strongest for metabolic syndrome, type 2 diabetes and cardiovascular disease. Indeed, it has long been known that patients with autoimmune diseases such as rheumatoid arthritis that are characterized by systemic inflammation have insulin resistance, dyslipidemia and hypertension, and that they have higher rates of metabolic syndrome, type 2 diabetes and cardiovascular disease (particularly ischemic heart disease and stroke) ¹⁰¹, ¹¹⁸. Moreover, the inflammatory biomarker high-sensitivity C-reactive protein (hs-CRP) is a predictor of cardiovascular events in men and women ¹¹⁹. In a recent meta-analysis of data from more than 160,000 people across 54 long-term prospective studies, higher levels of circulating CRP were associated with a relative increase in risk for both coronary heart disease and cardiovascular disease mortality ¹²⁰. To assess the inflammatory potential of diets, the dietary inflammatory index (DII) was developed ¹²¹. Higher dietary inflammatory index (DII) scores indicate greater inflammatory potential of the diet and have been associated with elevated inflammatory biomarker levels interleukin 6 (IL-6), tumor necrosis factor alpha (TNF-α), and C-reactive protein (CRP) ¹²².

The most compelling evidence for an association between systemic chronic inflammation and disease risk comes from randomized controlled trials that have tested drugs or biologics that target specific pro-inflammatory cytokines, such as interleukin (IL)-1β and tumor necrosis factor (TNF)-α. In a recent meta-analysis of eight randomized controlled trials that included a total of 260 participants, anti-TNF-α inhibitor therapy was found to significantly reduce insulin resistance in patients with rheumatoid arthritis and to improve their insulin sensitivity ¹²³. The risk for developing Alzheimer’s disease was also significantly lower among patients with rheumatoid arthritis treated with the TNF-α inhibitor etanercept ¹²⁴. In addition, a recent double-blind randomized controlled trial of the IL-1β inhibitor canakinumab that assessed more than 10,000 adults with a history of myocardial infarction and elevated circulating C-reactive protein (CRP) levels showed that patients treated with canakinumab subcutaneously every 3 months had lower rates of nonfatal myocardial infarction, nonfatal stroke and cardiovascular disease death compared with those treated with a placebo, despite having no change in LDL cholesterol (low-density lipoprotein or “bad” cholesterol), which is a risk factor for cardiovascular disease. In this trial, canakinumab-treated patients also exhibited a lower likelihood of unstable angina leading to urgent revascularization ¹²⁵. Along similar lines, a recent study of more than 160,000 people from North Glasgow found that a combination of the inflammatory markers CRP (>10 mg/L), albumin (>35 mg/L) and neutrophil count predicted all-cause mortality over 8 years, in addition to mortality due to cancer, cardiovascular and cerebrovascular disease ¹²⁶.

Inflammation may result from many factors, such as:

• Environmental chemicals
• Ozone and cardiovascular disease – Exposure to ozone, even at levels lower than the current U.S. Environmental Protection Agency (EPA) air quality standard, may lead to cardiovascular disease ¹²⁷.
• Injuries like scrapes, insect stings, or a splinter in your finger
• Pathogens (germs) like bacteria, viruses, or fungi
• Radiation
• Nutrition – Diets high in refined grains, alcohol, and processed foods can alter gut microbiota and lead to intestinal and immune changes.
• Microbiome (microbiome refers to the collective genomes of the micro-organisms in a particular environment) – Studies of various microbiome imbalances and disease states show connections to inflammation.
• Social and cultural changes – Disrupted sleep patterns, psychosocial stress, artificial light, and other factors influence the immune system.
• Developmental origins – Childhood obesity, psychological stress, exposure to microbes in infancy, and prenatal conditions are linked to inflammation.
• Physical activity – When skeletal muscles contract, they release proteins that can reduce inflammation throughout the body. Skeletal muscle is an endocrine organ that produces and releases cytokines and other small proteins, called myokines, into the bloodstream. This occurs particularly during muscle contraction and can have the effect of systemically reducing inflammation ¹²⁸.

Industrialization is thought to have caused a significant overall decrease in physical activity. One study showed that, worldwide, 31% of individuals are considered physically inactive—defined as not meeting the minimum international recommendations for regular physical activity—with levels of inactivity being higher in high-income countries than in low-to-middle-income countries ¹²⁹. In the United States, these numbers are even higher, with approximately 50% of American adults being considered physically inactive ¹³⁰.

Low physical activity, therefore, has been found to be directly related to increased anabolic resistance ¹³¹ and levels of C-reactive protein (CRP) and pro-inflammatory cytokine levels in healthy individuals ¹³², as well as in breast cancer survivors ¹³³ and patients with type 2 diabetes ¹³⁴. These effects can, in turn, promote several inflammation-related pathophysiologic alterations, including insulin resistance, dyslipidemia, endothelial dysfunction, high blood pressure and loss of muscle mass (sarcopenia) ¹³⁵, that have been found to increase risk for a variety of conditions, including cardiovascular disease, type 2 diabetes, nonalcoholic fatty liver disease (NAFLD), osteoporosis, various types of cancer, depression, dementia and Alzheimer’s disease, in individuals who are chronically inactive ¹²⁸.

Consistent with these effects, there is strong evidence for an association between physical inactivity and increased risk for age-related diseases and mortality ¹⁰². A recent meta-analysis of studies with cohorts from Europe, the United States and the rest of the world that included 1,683,693 participants found that going from physically inactive to achieving the recommended 150 minutes of moderate-intensity aerobic activity per week was associated with lower risk of cardiovascular disease mortality by 23%, cardiovascular disease incidence by 17%, and type 2 diabetes incidence by 26% during an average follow-up period of 12.8 years ¹³⁶. Moreover, data from 1.44 million participants across several prospective cohort studies revealed that, as compared to individuals exhibiting high levels of leisure-time physical activity (≥90th percentile), those who were physically inactive (≤10th percentile) had a greater risk (>20%) of developing several cancers, including esophageal adenocarcinoma; liver, lung, kidney, gastric cardia and endometrial cancers; and myeloid leukemia, even after adjusting for multiple major risk factors such as adiposity and smoking status (except for lung cancer) ¹³⁷. Likewise, a meta-analysis of ten studies and 23,345 older adults (70 to 80 years old) who were followed for 3.9–31 years found that individuals meeting the minimum international physical activity recommendations had a 40% lower risk of Alzheimer’s disease as compared to their physically inactive counterparts ¹³⁸.

Moreover, physical inactivity can increase individuals’ risk for various non-communicable diseases because it is linked to obesity ¹³⁵ and, in particular, excessive visceral adipose tissue, which is a significant trigger of inflammation ¹³⁹. Visceral adipose tissue is an active endocrine, immunological and metabolic organ composed of various cells (including immune cells, such as resident macrophages) that expands mostly through adipocyte hypertrophy, which can lead to areas of hypoxia and even cell death, resulting in activation of hypoxia-inducible factor-1α, increased production of reactive oxygen species, and release of damage-associated molecular patterns (DAMPs) (for example, cell-free DNA). These events can induce the secretion of numerous pro-inflammatory molecules, including adipokines, cytokines (for example, IL-1β, IL-6, TNF-α), and chemokines (especially monocyte chemoattractant protein-1) by adipocytes, endothelial cells and resident adipose tissue immune cells (for example, macrophages) ¹⁴⁰. This in turn leads to the infiltration of various immune cells in the visceral adipose tissue, including monocytes, neutrophils, dendritic cells, B cells, T cells and natural killer (NK) lymphocytes, and a reduction in T regulatory cells, thereby amplifying inflammation, which can eventually become prolonged and systemic in some individuals ¹⁴¹.

Furthermore, tumor necrosis factor alpha (TNF-α) and other molecules can cause adipocyte insulin resistance, which increases lipolysis, with the resulting spillover of lipids into other organs, such as the pancreas and liver, where they can contribute to beta-cell dysfunction, hepatic insulin resistance and fatty liver ¹⁴². Hence, visceral obesity accelerates aging and increases risk for cardiometabolic, neurodegenerative and autoimmune diseases, as well as several types of cancer ¹⁴³. These dynamics are known to occur in adults and can promote age-related disease risk, but they first emerge during childhood ¹⁴⁴. The childhood obesity epidemic might thus be playing a key role in promoting inflammation and age-related disease risk worldwide ¹⁴⁵.

In addition to physical inactivity and diet, the industrial revolution and modern era have ushered in changes in social interactions and sleep quality ¹⁴⁶ that can promote systemic chronic inflammation ¹⁴⁷ and insulin resistance ¹⁴⁸, in turn increasing risk for obesity, type 2 diabetes, cardiovascular disease and all-cause mortality ¹⁴⁹. Moreover, psychological stressors that are persistently present in some contemporary work environments, such as those characterized by high job demand and low control, can cause physiologic changes ¹⁵⁰ that disrupt the ability for glucocorticoids to effectively down-regulate inflammatory activity due to decreased sensitivity caused by chronic elevation in cortisol, leading in turn to systemic chronic inflammation and poor health ¹⁵¹.

Another core feature of modern society that has occurred very recently in human evolutionary history is increased exposure to artificial light, especially the blue spectrum, at atypical biologic times ¹⁵². Exposure to blue light, especially after sundown, increases arousal and alertness at night and thus causes circadian rhythm disruption ¹⁵³, which in turn promotes inflammation ¹⁵⁴, and is a risk for multiple inflammation-related diseases ¹⁵⁵. As an example, night-shift work has been found to increase risk for the metabolic syndrome and is suspected of being a causal factor in obesity, type 2 diabetes and cardiovascular disease, as well as in breast, ovarian, prostate, colorectal and pancreatic cancer ¹⁵².

Despite evidence linking systemic chronic inflammation with disease risk and mortality ¹²⁶, there are presently no standard biomarkers for indicating the presence of health-damaging chronic inflammation. Studies have shown that biomarkers of acute inflammation predict morbidity and mortality in both cross-sectional and longitudinal studies and may thus be used to index age-related systemic chronic inflammation ¹⁵⁶. This approach has notable limitations, though. For example, early work by Roubenoff and colleagues showed that in monocytes from ambulatory individuals, levels of IL-6 and IL-1Ra (but not IL-1β or TNF-α) increased with age ¹⁵⁷. However, no difference in IL-1 and IL-6 expression has been found between young and older individuals when the health status of older individuals is strictly controlled ¹⁵⁸.

Shifts in the inflammatory response from short- to long-lived can cause a breakdown of immune tolerance ¹⁰⁸ and lead to major alterations in all tissues and organs, as well as normal cellular physiology. Systemic chronic inflammation can also impair normal immune function, leading to increased susceptibility to infections and tumors and a poor response to vaccines ¹⁵⁹. Furthermore, systemic chronic inflammation during pregnancy and childhood can have serious developmental consequences that include elevating the risk of non-communicable diseases over the life span ¹⁶⁰, ¹⁴⁴, ¹⁶¹, ¹⁶².

Indeed, chronic inflammatory diseases have been recognized as the most significant cause of death in the world today, with more than 50% of all deaths being attributable to inflammation-related diseases such as ischemic heart disease, stroke, cancer, diabetes mellitus, chronic kidney disease, non-alcoholic fatty liver disease (NAFLD) and autoimmune and neurodegenerative conditions5. Evidence is emerging that the risk of developing chronic inflammation can be traced back to early development, and its effects are now known to persist throughout the life span to affect adulthood health and risk of mortality ¹⁶³, ¹⁶⁰, ¹⁶².

High inflammatory foods

Dietary patterns high in refined starches, sugar, and saturated and trans-fatty acids, poor in natural antioxidants and fiber from fruits, vegetables, and whole grains, and poor in omega-3 fatty acids may cause an activation of the innate immune system, most likely by excessive production of proinflammatory cytokines associated with a reduced production of anti-inflammatory cytokines ¹⁶⁴. It has been found that a higher intake of red and processed meat and fried food and a lower intake of whole grains was associated with higher levels of inflammatory markers (interleukin 6 [IL-6], tumor necrosis factor alpha [TNF-α], and C-reactive protein [CRP]), as well as accelerated cognitive decline in older ages ¹⁶⁵. The typical American diet that has become widely adopted in many countries over the past 40 years is relatively low in fruits, vegetables and other fiber- and prebiotic-rich foods ¹⁶⁶ and high in refined grains ¹⁶⁷, alcohol ¹⁶⁸ and ultra-processed foods ¹⁶⁹, particularly those containing emulsifiers ¹⁷⁰. These dietary factors can alter the gut microbiota composition and function ¹⁷¹ and are linked to increased intestinal permeability ¹⁷² and epigenetic changes in the immune system ¹⁷³ that ultimately cause low-grade endotoxemia and systemic chronic inflammation ¹⁷⁴. The influence of diet on inflammation is not confined to these effects, though. For example, orally absorbed advanced glycation and lipoxidation end-products that are formed during the processing of foods or when foods are cooked at high temperatures and in low-humidity conditions are appetite increasing and are linked to overnutrition and hence obesity and inflammation ¹⁷⁵. Furthermore, high-glycemic-load foods, such as isolated sugars and refined grains, which are common ingredients in most ultra-processed foods, can cause increased oxidative stress that activates inflammatory genes ¹⁷⁶.

When combined with low physical activity, consuming hyperpalatable processed foods that are high in fat, sugar, salt and flavor additives ¹⁷⁷ can cause major changes in cell metabolism and lead to the increased production (and defective disposal) of dysfunctional organelles such as mitochondria, as well as to misplaced, misfolded and oxidized endogenous molecules ¹⁷⁸. These altered molecules, which increase with age ¹¹⁴, can be recognized as damage-associated molecular patterns (DAMPs) by innate immune cells, which in turn activate the inflammasome machinery, amplify the inflammatory response ¹¹² and contribute to a biological state that has been called “inflammaging,” defined as the “the long-term result of the chronic physiological stimulation of the innate immune system” that occurs in later life ¹⁷⁹. As proposed, inflammaging involves changes in numerous organ systems, such as the brain, gut, liver, kidney, adipose tissue and muscle ¹¹⁴ and it is driven by a variety of molecular-age-related mechanisms that have been called the “Seven Pillars of Aging”—namely, adaptation to stress, epigenetics, inflammation, macromolecular damage, metabolism, proteostasis and stem cells and regeneration ¹⁸⁰.

Dietary strategies clearly influence inflammation, as documented through both prospective observational studies as well as randomized controlled feeding trials in which participants agree to eat only the food provided to them ³², ¹⁸¹. Studies have shown how various dietary components can modulate key pathways to inflammation including sympathetic activity, oxidative stress, transcription factor nuclear factor kappa B (NF-κB) activation, and proinflammatory cytokine production ¹⁸². Circulating markers of inflammation, such as C-reactive protein (CRP), tumor necrosis factor (TNF)-alpha, and some interleukins (IL-6, IL-18), correlate with propensity to develop coronary heart disease and heart attacks ¹⁸³, ¹⁸⁴, ¹⁸⁵. Previous studies have also shown that depression is associated with upregulated inflammatory response, characterized by increased levels of pro-inflammatory cytokines and other acute-phase proteins ¹⁸⁶.

Other dietary components that are thought to influence inflammation include trans fatty acids ¹⁸⁷ and dietary salt. For example, salt has been shown to skew macrophages toward a pro-inflammatory phenotype characterized by the increased differentiation of naive CD4+ T cells into T helper (TH)-17 cells, which are highly inflammatory, and decreased expression and anti-inflammatory activity of T regulatory cells ¹⁸⁸. In addition, high salt intake can cause adverse changes in gut microbiota composition, as exemplified by the reduced Lactobacillus population observed in animals and humans fed high-salt diets ¹⁸⁸. This specific population is critical for health as it regulates TH17 cells and enhances the integrity of the intestinal epithelial barrier, thus reducing systemic inflammation ¹⁸⁸. Consistent with the expected health-damaging effects of consuming foods that are high in trans fats and salt, a recent cohort study of 44,551 French adults who were followed for a median of 7.1 years found that a 10% increase in the proportion of ultra-processed food consumption was associated with a 14% greater risk of all-cause mortality ¹⁸⁹.

Several other nutritional factors can also promote inflammation and potentially contribute to the development of systemic chronic inflammation. These factors include deficiencies in micronutrients, including zinc ¹⁹⁰ and magnesium ¹⁹¹, which are caused by eating processed or refined foods that are low in vitamins and minerals, and having suboptimal omega-3 levels ¹⁹², which impacts the resolution phase of inflammation. Longchain omega-3 fatty acids especially eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) modulate the expression of genes involved in metabolism and inflammation ¹⁹². More importantly, they are precursors to molecules such as resolvins, maresins and protectins that are involved in the resolution of inflammation ¹⁹³. The main contributors to the growing worldwide incidence of low omega-3 status are a low intake of fish and high intake of vegetable oils that are high in linoleic acid, which displaces omega-3 fatty acids in cell membrane phospholipids ¹⁹⁴. In turn, various randomized controlled trials have shown that omega-3 fatty acid supplementation reduces inflammation ¹⁹⁵ and may thus have health-promoting effects ¹⁹⁴.

Diets that promote inflammation are ¹⁹⁶:

• High in Refined Starches or Refined Carbs,
• High in Sugar,
• High in Saturated and Trans-fats,
• High in Salt (sodium),
• Alcohol,
• Food Additives,
• Low in omega-3 fatty acids,
• Low in natural antioxidants,
• Low in fiber from fruits,
• Low in vegetables, and
• Low in whole grains.

Dietary patterns high in refined starches, sugar, and saturated and trans-fatty acids, poor in natural antioxidants and fiber from fruits, vegetables, and whole grains, and poor in omega-3 fatty acids – aka the Average American Diet – may cause an activation of the innate immune system, most likely by an excessive production of proinflammatory cytokines associated with a reduced production of anti-inflammatory cytokines ¹⁹⁷.

An Americanization of food habits has been recognized throughout the world, characterized by a high-energy diet, with increasing consumption of industrially processed foods. These foods usually contain large amounts of salt, simple sugars, saturated and trans fats, which food industries offer in response to consumers’ demands. Consequently, the intake of complex carbohydrates, fibres, fruits and vegetables has decreased. The energy and animal proteins consumed largely exceed World Health Organization recommendations, while, generally, a smaller variety of foods is being consumed.

• Most Americans exceed the recommendations for added sugars, saturated fats, and sodium. Most people say that if there is a healthy choice on a menu they will take it. But observations and research show this is generally not the case. Instead, people tend to make choices based on how food tastes. Typically, the more sugar, salt and fat in the food, the more we will like it.
  
• About three-fourths of the population has an eating pattern that is low in vegetables, fruits, dairy, and oils.
• More than half of the population is meeting or exceeding total grain and total protein foods recommendations, but, are not meeting the recommendations for the subgroups within each of these food groups.

The typical eating patterns currently consumed by many in the United States do not align with the Healthy Dietary Guidelines. As shown in Figure 1, when compared to the healthy eating pattern:

• About three-fourths of the population has an eating pattern that is low in vegetables, fruits, dairy, and oils.
• Most Americans exceed the recommendations for added sugars, saturated fats, and sodium.

Figure 2. The Average American Diet containing foods that can cause inflammation

In addition, the eating patterns of many are too high in calories. Calorie intake over time, in comparison to calorie needs, is best evaluated by measuring body weight status. The high percentage of the population that is overweight or obese suggests that many in the United States over consume calories. More than two-thirds of all adults and nearly one-third of all children and youth in the United States are either overweight or obese.

The typical American diet is about 50% carbohydrate, 15% protein, and 35% fat. The Standard American Diet or “Western-style” dietary patterns with more red meat or processed meat, sugared drinks, sweets, refined carbohydrates, or potatoes-have been linked to obesity ¹⁹⁸, ¹⁹⁹, ²⁰⁰, ²⁰¹.  The Average American (Western-style) dietary pattern is also linked to increased risk of heart disease, diabetes, and other chronic conditions.

Meal frequency and snacking have increased over the past 30 years in the U.S. ²⁰² on average, children get 27 percent of their daily calories from snacks, primarily from desserts and sugary drinks, and increasingly from salty snacks and candy.

What Americans Eat: Top 10 sources of calories in the U.S. diet

• Grain-based desserts (cakes, cookies, donuts, pies, crisps, cobblers, and granola bars)
• Yeast breads
• Chicken and chicken-mixed dishes
• Soda, energy drinks, and sports drinks
• Pizza
• Alcoholic beverages
• Pasta and pasta dishes
• Mexican mixed dishes
• Beef and beef-mixed dishes
• Dairy desserts(Source: Report of the 2010 Dietary Guidelines Advisory Committee)

For the 20-30 year old the top sources of “Nutrition” are:

1. Regular soft drinks 8.8% of total energy
2. Pizza 5.1% of total energy
3. Beer 3.9%
4. Hamburgers and meat loaf 3.4%
5. White bread 3.3%
6. Cake, doughnuts and pastries 3.3%
7. French fries and fried potatos 3.0%
8. Potato chips, corn chips and popcorn 2.7%
9. Rice 2.6%
10. Cheese and cheese spread 2.5%

Since the above list of diets cause inflammation, therefore the main dietary strategy to reduce inflammation should include adequate omega-3 fatty acids intake, reduction of saturated and trans-fats, and consumption of a diet high in fruits, vegetables, nuts, and whole grains and low in refined grains. The whole diet approach seems particularly promising to reduce the inflammation associated with the metabolic syndrome (e.g. high “bad” triglyceride, low “good” HDL cholesterol, belly fat, high blood pressure, high blood sugar/insulin resistance). The choice of healthy sources of carbohydrate, fat, and protein, associated with regular physical activity and avoidance of smoking, is critical to fighting the war against chronic disease. Western dietary patterns warm up inflammation, while healthy dietary patterns cool it down.

Refined Starches or Refined Carbs Inflammatory Foods

The process of refining a food not only removes the fiber, but it also removes much of the food’s nutritional value, including B-complex vitamins, healthy oils and fat-soluble vitamins. Refined carbohydrates are plant-based foods that have the whole grain extracted during processing, where the fibers, starches, vitamins and minerals have been removed, leaving behind refined carbohydrates. Refined carbohydrates sources include bottled fruit juices, juice concentrates, white bread, pastries, sodas, donuts, cakes, cookies, sweets, chips and other highly processed or refined foods. These items contain easily digested carbohydrates that may contribute to weight gain, interfere with weight loss, and promote diabetes and heart disease ²⁰³.

Refined carbohydrates are composed of sugars (such as fructose and glucose) which have simple chemical structures composed of only one sugar (monosaccharides) or two sugars (disaccharides). Simple carbohydrates are easily and quickly utilized for energy by the body because of their simple chemical structure, often leading to a faster rise in blood sugar and insulin secretion from the pancreas – which can have negative health effects.

When it comes to carbohydrates, what’s most important is the type of carbohydrate you choose to eat because some sources are healthier than others. The amount of carbohydrate in the diet – high or low – is less important than the type of carbohydrate in the diet. For example, healthy, whole grains such as whole wheat bread, rye, barley and quinoa are better choices than highly refined white bread or French fries. For example, whole grain whole wheat flour.

Typically, foods with highly processed refined carbohydrates (eg, white bread) are digested at a much faster rate and have higher glycemic index (high GI) values than do more compact granules (low-starch gelatinization) and high amounts of viscose soluble fiber (eg, barley, oats, and rye) foods. These refined carbohydrates are more rapidly attacked by digestive enzymes due to grinding or milling that reduces particle size and removes most of the bran and the germ. Numerous epidemiologic studies have found that higher intake of refined carbohydrates (reflected by increased dietary Glycemic Load) is associated with greater risk of type 2 diabetes and heart disease, whereas higher consumption of whole grains protects against these conditions ²⁰⁴.

Table 5. List of refined carbs for more than 100 common foods with their glycemic index and glycemic load, per serving.

FOOD	Glycemic index (glucose = 100)	Serving size (grams)	Glycemic load per serving
BAKERY PRODUCTS AND BREADS
Banana cake, made with sugar	47	60	14
Banana cake, made without sugar	55	60	12
Sponge cake, plain	46	63	17
Vanilla cake made from packet mix with vanilla frosting (Betty Crocker)	42	111	24
Apple muffin, made with rolled oats and sugar	44	60	13
Apple muffin, made with rolled oats and without sugar	48	60	9
Waffles, Aunt Jemima®	76	35	10
Bagel, white, frozen	72	70	25
Baguette, white, plain	95	30	14
Coarse barley bread, 80% kernels	34	30	7
Hamburger bun	61	30	9
Kaiser roll	73	30	12
Pumpernickel bread	56	30	7
50% cracked wheat kernel bread	58	30	12
White wheat flour bread, average	75	30	11
Wonder® bread, average	73	30	10
Whole wheat bread, average	69	30	9
100% Whole Grain® bread (Natural Ovens)	51	30	7
Pita bread, white	68	30	10
Corn tortilla	52	50	12
Wheat tortilla	30	50	8
BEVERAGES
Coca Cola® (US formula)	63	250 mL	16
Fanta®, orange soft drink	68	250 mL	23
Lucozade®, original (sparkling glucose drink)	95	250 mL	40
Apple juice, unsweetened	41	250 mL	12
Cranberry juice cocktail (Ocean Spray®)	68	250 mL	24
Gatorade, orange flavor (US formula)	89	250 mL	13
Orange juice, unsweetened, average	50	250 mL	12
Tomato juice, canned, no sugar added	38	250 mL	4
BREAKFAST CEREALS AND RELATED PRODUCTS
All-Bran®, average	44	30	9
Coco Pops®, average	77	30	20
Cornflakes®, average	81	30	20
Cream of Wheat®	66	250	17
Cream of Wheat®, Instant	74	250	22
Grape-Nuts®	75	30	16
Muesli, average	56	30	10
Oatmeal, average	55	250	13
Instant oatmeal, average	79	250	21
Puffed wheat cereal	80	30	17
Raisin Bran®	61	30	12
Special K® (US formula)	69	30	14
GRAINS
Pearled barley, average	25	150	11
Sweet corn on the cob	48	60	14
Couscous	65	150	9
Quinoa	53	150	13
White rice, boiled, type non-specified	72	150	29
Quick cooking white basmati	63	150	26
Brown rice, steamed	50	150	16
Parboiled Converted white rice (Uncle Ben’s®)	38	150	14
Whole wheat kernels, average	45	50	15
Bulgur, average	47	150	12
COOKIES AND CRACKERS
Graham crackers	74	25	13
Vanilla wafers	77	25	14
Shortbread	64	25	10
Rice cakes, average	82	25	17
Rye crisps, average	64	25	11
Soda crackers	74	25	12
DAIRY PRODUCTS AND ALTERNATIVES
Ice cream, regular, average	62	50	8
Ice cream, premium (Sara Lee®)	38	50	3
Milk, full-fat, average	31	250 mL	4
Milk, skim, average	31	250 mL	4
Reduced-fat yogurt with fruit, average	33	200	11
FRUITS
Apple, average	36	120	5
Banana, raw, average	48	120	11
Dates, dried, average	42	60	18
Grapefruit	25	120	3
Grapes, black	59	120	11
Oranges, raw, average	45	120	5
Peach, average	42	120	5
Peach, canned in light syrup	52	120	9
Pear, raw, average	38	120	4
Pear, canned in pear juice	44	120	5
Prunes, pitted	29	60	10
Raisins	64	60	28
Watermelon	72	120	4
BEANS AND NUTS
Baked beans	40	150	6
Black-eyed peas	50	150	15
Black beans	30	150	7
Chickpeas	10	150	3
Chickpeas, canned in brine	42	150	9
Navy beans, average	39	150	12
Kidney beans, average	34	150	9
Lentils	28	150	5
Soy beans, average	15	150	1
Cashews, salted	22	50	3
Peanuts	13	50	1
PASTA and NOODLES
Fettucini	32	180	15
Macaroni, average	50	180	24
Macaroni and Cheese (Kraft®)	64	180	33
Spaghetti, white, boiled, average	46	180	22
Spaghetti, white, boiled 20 min	58	180	26
Spaghetti, whole-grain, boiled	42	180	17
SNACK FOODS
Corn chips, plain, salted	42	50	11
Fruit Roll-Ups®	99	30	24
M & M’s®, peanut	33	30	6
Microwave popcorn, plain, average	65	20	7
Potato chips, average	56	50	12
Pretzels, oven-baked	83	30	16
Snickers Bar®, average	51	60	18
VEGETABLES
Green peas	54	80	4
Carrots, average	39	80	2
Parsnips	52	80	4
Baked russet potato	111	150	33
Boiled white potato, average	82	150	21
Instant mashed potato, average	87	150	17
Sweet potato, average	70	150	22
Yam, average	54	150	20
MISCELLANEOUS
Hummus (chickpea salad dip)	6	30	0
Chicken nuggets, frozen, reheated in microwave oven 5 min	46	100	7
Pizza, plain baked dough, served with parmesan cheese and tomato sauce	80	100	22
Pizza, Super Supreme (Pizza Hut®)	36	100	9
Honey, average	61	25	12

The complete list of the glycemic index and glycemic load for more than 1,000 foods can be found in the article “International tables of glycemic index and glycemic load values: 2008” by Fiona S. Atkinson, Kaye Foster-Powell, and Jennie C. Brand-Miller in the December 2008 issue of Diabetes Care, Vol. 31, number 12, pages 2281-2283 ²⁰⁵.

List of refined carbs

Any foods that have been processed for quick consumption.

• Foods made with refined or “white” flour also contain less fiber and protein than whole-grain products.
• Snacks, such as crisps, sausage rolls, pies and pasties
• Granola bars
• Ice cream
• Donuts
• Cakes
• Twinkies
• Pastries
• Canned fruits with added sugar or syrup
• Sweets
• Fruit drinks
• Colas and carbonated sweetened beverages
• Energy drinks
• Sports drink
• Jams
• Crackers
• Dressings
• Sauces
• Cookies
• Fruit chews
• Pizzas
• Apple pies
• Anything with added sugar.

Sugar by Any Other Name

You don’t always see the word “sugar” on a food label. It sometimes goes by another name, like these:

• White sugar
• Brown sugar
• Raw sugar
• Agave nectar
• Brown rice syrup
• Corn syrup
• Corn syrup solids
• Coconut sugar
• Coconut palm sugar
• High-fructose corn syrup
• Invert sugar
• Dextrose
• Anhydrous dextrose
• Crystal dextrose
• Dextrin
• Evaporated cane juice
• Fructose sweetener
• Liquid fructose
• Glucose
• Lactose
• Honey
• Malt syrup
• Maple syrup
• Molasses
• Pancake syrup
• Sucrose
• Trehalose
• Turbinado sugar

Watch out for items that list any form of sugar in the first few ingredients.

Best anti-inflammatory diet

An example of an anti-inflammatory dietary pattern is the Mediterranean diet which is characterized by high intakes of fruit and vegetables, whole grains, nuts, legumes, fish, monounsaturated fat (olive oil); moderate intakes of dairy products and alcohol; and low intakes of meat and meat products and saturated fat ²⁰⁶. A traditional Mediterranean dietary pattern, which typically has a high ratio of monounsaturated (MUFA) and Omega-3 to Omega-6 polyunsaturated fatty acid (PUFAs) and supplies an abundance of fruits, vegetables, legumes, and grains, has been shown to have anti-inflammatory effects when compared with typical North American and Northern European dietary patterns in most observational and interventional studies ²⁰⁷.

The Mediterranean Diet is characterized by ²⁰⁸:

1. An abundance of plant food (fruit, vegetables, breads, cereals, potatoes, beans, nuts, and seeds);
2. Minimally processed, seasonally fresh, locally grown foods;
3. Desserts comprised typically of fresh fruit daily and occasional sweets containing refined sugars or honey;
4. Olive oil (high in polyunsaturated fat) as the principal source of fat;
5. Daily dairy products (mainly cheese and yogurt) in low to moderate amounts;
6. Fish and poultry in low to moderate amounts;
7. Up to four eggs weekly;
8. Red meat rarely; and
9. Wine in low to moderate amounts with meals.

Adherence to a Mediterranean-type diet has been associated with a multitude of health benefits ²⁰⁹ including lower risk of all-cause mortality ²¹⁰, cancer ²¹¹, type 2 diabetes ²¹², cardiovascular disease ²¹³ and cognitive decline ²¹⁴. The Mediterranean dietary pattern is high in anti-inflammatory micronutrients (micronutrients are vitamins and minerals needed by your body in very small amounts) and phytochemicals (chemical compounds produced by plants) such as Omega-3 fatty acids, flavonoids, carotenoids, and vitamins C and E, and higher adherence to the Mediterranean diet has been associated with lower levels of inflammatory markers ²¹⁵, ²¹⁶. Therefore, greater adherence to a Mediterranean dietary pattern may elicit health benefits through impacts on systemic inflammation ¹⁶⁴. Additionally, Mediterranean-style diets have been demonstrated to elicit cardiovascular benefits including improved endothelial function and reductions in serum cholesterol and triglycerides ²¹⁷. In a six-month randomized controlled trial, breast cancer survivors who adhered to a Mediterranean type diet had beneficial changes in body composition, cholesterol, and glucose levels compared to controls ²¹⁸.

Mediterranean Diet

The Mediterranean Diet is a way of eating rather than a formal diet plan. The Mediterranean Diet features foods eaten in more than 20 countries bordering the Mediterranean Sea including Greece, Spain, southern Italy, Portugal, Morocco, Cyprus, Croatia and France and each has their own unique culture and cuisine. In reality there is no “one” Mediterranean Diet ²¹⁹, which in 2010 was recognized by UNESCO as an intangible cultural heritage of humanity.  The “Mediterranean diet” encompasses all of them—it’s not one size fits all  ²²⁰. Despite regional variations, the traditional Mediterranean diet  is characterized by a high intake of vegetables, legumes, fruits and nuts and cereals (which in the past were largely unrefined), a high intake of olive oil, but a low intake of saturated lipids, a moderately high intake of fish (depending on the proximity of the sea), a low-to-moderate intake of dairy products (and then mostly in the form of cheese or yoghurt), a low intake of meat and poultry and a regular, but moderate intake of ethanol, primarily in the form of wine and generally during meals ²²¹.

A Mediterranean-style diet typically includes:

• plenty of fruits, vegetables, bread and other grains, potatoes, beans, nuts and seeds are eaten daily and make up the majority of food consumed;
• olive oil as a primary fat source, may account for up to 40% of daily calories; and
• small portions of cheese or yogurt are usually eaten each day, along with a serving of fish, poultry, or eggs.

Fish and poultry are more common than red meat in the Mediterranean diet. The Mediterranean diet also centers on minimally processed, plant-based foods. Wine may be consumed in low to moderate amounts, usually with meals. Fruit is a common dessert instead of sweets.

Main meals consumed daily should be a combination of three elements: cereals, vegetables and fruits, and a small quantity of legumes, beans or other (though not in every meal). Cereals in the form of bread, pasta, rice, couscous or bulgur (cracked wheat) should be consumed as one–two servings per meal, preferably using whole or partly refined grains. Vegetable consumption should amount to two or more servings per day, in raw form for at least one of the two main meals (lunch and dinner). Fruit should be considered as the primary form of dessert, with one–two servings per meal. Consuming a variety of colors of both vegetables and fruit is strongly recommended to help ensure intake of a broad range of micronutrients and phytochemicals. The less these foods are cooked, the higher the retention of vitamins and the lower use of fuel, thus minimizing environmental impact.

The Mediterranean Diet is characterized by ²⁰⁸:

1. An abundance of plant food (fruit, vegetables, breads, cereals, potatoes, beans, nuts, and seeds);
2. Minimally processed, seasonally fresh, locally grown foods;
3. Desserts comprised typically of fresh fruit daily and occasional sweets containing refined sugars or honey;
4. Olive oil (high in polyunsaturated fat) as the principal source of fat;
5. Daily dairy products (mainly cheese and yogurt) in low to moderate amounts;
6. Fish and poultry in low to moderate amounts;
7. Up to four eggs weekly;
8. Red meat rarely; and
9. Wine in low to moderate amounts with meals.

Here are some things you can do to switch from a traditional Western-style diet to a more Mediterranean way of eating.

• Dip bread in a mix of olive oil and fresh herbs instead of using butter.
• Add avocado slices to your sandwich instead of bacon.
• Have fish for lunch or dinner instead of red meat. Brush it with olive oil, and broil or grill it.
• Sprinkle your salad with seeds or nuts instead of cheese.
• Cook with olive or canola oil instead of butter or oils that are high in saturated fat.
• Choose whole-grain bread, pasta, rice, and flour instead of foods made with white flour.
• Add ground flaxseed to cereal, low-fat yogurt, and soups.
• Cut back on meat in meals. Instead of having pasta with meat sauce, try pasta tossed with olive oil and topped with pine nuts and a sprinkle of Parmesan cheese.
• Dip raw vegetables in a vinaigrette dressing or hummus instead of dips made from mayonnaise or sour cream.
• Have a piece of fruit for dessert instead of a piece of cake.
• Use herbs and spices instead of salt to add flavor to foods.

A Mediterranean-style diet can help you achieve the American Heart Association’s recommendations for a healthy dietary pattern that:

• emphasizes vegetables, fruits, whole grains, beans and legumes;
• includes low-fat or fat-free dairy products, fish, poultry, non-tropical vegetable oils and nuts; and
• limits added sugars, sugary beverages, sodium, highly processed foods, refined carbohydrates, saturated fats, and fatty or processed meats.

This style of eating can play a big role in preventing heart disease and stroke and reducing risk factors such as obesity, diabetes, high cholesterol and high blood pressure. There is some evidence that a Mediterranean diet rich in virgin olive oil may help the body remove excess cholesterol from arteries and keep blood vessels open.

The traditional Mediterranean dietary pattern is of particular interest to healthcare providers and dietary scientists, because of observations from the 1960s that populations in countries of the Mediterranean region, such as Greece and Italy, had lower mortality from cardiovascular disease compared with northern European populations or the US, probably as a result of different eating habits.

However, adherence to the Mediterranean diet dietary pattern has been rapidly decreasing in the region since 2000, particularly in Greece, Portugal and Spain – due to the wide dissemination of the fast-food culture. These observations point to a nutrition transition period that encompasses considerable changes in diet and physical activity patterns, which may be leading to an increase in the incidence of chronic and degenerative diseases in the Mediterranean region.

Traditionally characterized by vegetables, legumes, beans, fruits, nuts, seeds, olives, lots of extra virgin olive oil, high-fiber breads and whole grains and fish, this way of eating not only involves a low consumption of processed food, processed carbohydrates, sweets, chocolate and red meat. The recommended foods are rich with monounsaturated fats, fiber, and omega-3 fatty acids.

The Mediterranean Diet is associated with a lower incidence of mortality from all-causes ²²² and is also related to lower incidence of cardiovascular diseases ²²³, type 2 diabetes ²²⁴, certain types of cancer ²²⁵, and neurodegenerative diseases ²²⁶. The Mediterranean diet is now recognized as one of the most healthy food patterns in the world.

Year after year, the Mediterranean diet comes out on top in the U.S. News and World Report annual ranking of best diets. The Mediterranean diet is also touted as one of the healthiest by many health organizations and dietitians ²²⁷.

The atmosphere, the state of being and mindset are equally important: people enjoying long, relaxed meals, the warm climate and a sea breeze full of negative ions. This lifestyle also encourages daily exercise — being active. So try to get at least 2½ hours of moderate aerobic activity a week. It’s fine to do blocks of 10 minutes or more throughout your day and week.

Choose exercises that make your heart beat faster and make you breathe harder. For example, go for a swim or a brisk walk or bike ride. You can also get some aerobic activity in your daily routine. Vacuuming, housework, gardening, and yard work can all be aerobic.

The Mediterranean diet is like other heart-healthy diets in that it recommends eating plenty of fruits, vegetables, and high-fiber grains. But in the Mediterranean diet, an average of 35% to 40% of calories can come from fat. Most other heart-healthy guidelines recommend getting less than 35% of your calories from fat. The fats allowed in the Mediterranean diet are mainly from unsaturated oils such as fish oils, olive oil, and certain nut or seed oils (such as canola, soybean, or flaxseed oil) and from nuts (walnuts, hazelnuts, and almonds). These types of oils may have a protective effect on the heart.

Mediterranean Diet Food List

There’s no one “Mediterranean” diet food list because there are more than 20 countries bordering the Mediterranean Sea. Diets vary between these countries and also between regions within a country. Many differences in culture, ethnic background, religion, economy and agricultural production result in different diets. But the common Mediterranean dietary meal plan (source ²²⁸) has these characteristics:

• High consumption of fruits, vegetables, bread and other cereals, potatoes, beans, nuts and seeds
• Olive oil is an important monounsaturated fat source
• Dairy products, fish and poultry are consumed in low to moderate amounts, and little red meat is eaten
• Eggs are consumed zero to four times a week
• Wine is consumed in low to moderate amounts

Mediterranean Diet Meal Plan

• Eating a variety of fruits and vegetables each day, such as grapes, blueberries, tomatoes, broccoli, peppers, figs, olives, spinach, eggplant, beans, lentils, and chickpeas.
• Eating a variety of whole-grain foods each day, such as oats, brown rice, and whole wheat bread, pasta, and couscous.
• Choosing healthy (unsaturated) fats, such as nuts, olive oil, and certain nut or seed oils like canola, soybean, and flaxseed. About 35% to 40% of daily calories can come from fat, mainly from unsaturated fats. More than half the fat calories in a Mediterranean diet come from monounsaturated fats (mainly from olive oil). Monounsaturated fat doesn’t raise blood cholesterol levels the way saturated fat does. (source ²²⁸).
• Limiting unhealthy (saturated) fats, such as butter, palm oil, and coconut oil. And limit fats found in animal products, such as meat and dairy products made with whole milk.
• Eating mostly vegetarian meals that include whole grains, beans, lentils, and vegetables.
• Eating fish at least 2 times a week, such as tuna, salmon, mackerel, lake trout, herring, or sardines.
• Eating moderate amounts of low-fat dairy products each day or weekly, such as milk, cheese, or yogurt.
• Eating moderate amounts of poultry and eggs every 2 days or weekly.
• Limiting red meat to only a few times a month in very small amounts. For example, a serving of meat is 3 ounces. This is about the size of a deck of cards.
• Limiting sweets and desserts to only a few times a week. This includes sugar-sweetened drinks like soda.

The positive findings have been plentiful:

• A plant-based Mediterranean diet supplemented with extra virgin olive oil or mixed nuts may counteract age-related cognitive decline in older adults, according to a report published online by JAMA Internal Medicine.
• A 2010 meta-analysis published in the The American Journal of Clinical Nutrition found that the Mediterranean diet conferred a significant benefit with regard to the risk of chronic diseases, such as cardiovascular disease.
• In 2014, two meta-analyses found that adherence to a Mediterranean diet was associated with a decreased risk of type 2 diabetes
• Another 2014 systematic review and meta-analysis found that adherence to the Mediterranean diet was associated with a decreased risk of cancer mortality.
• Due to the emphasis on fish and healthy fats which are needed for prostaglandin formation, the Mediterranean diet is beneficial for decreasing inflammation in the body.
• The biggest impact of Mediterranean is on lowering incidences of  diabetes.
• The Mediterranean diet is associated with a reduced risk of cancer incidence.
• Other health benefits of Mediterranean diet are prevents heart disease, lowers the risk of a heart attack, lowers cholesterol, prevents type 2 diabetes and prevents metabolic syndrome.

A Mediterranean-style diet might help prevent:

• Stroke.
• Alzheimer’s disease and other dementia.
• Depression.
• Parkinson’s disease.

Anti-inflammatory diet for inflammatory bowel diseases

In studies involving people with chronic inflammatory bowel diseases (IBD) like Crohn’s Disease and Ulcerative Colitis, the anti-Inflammatory diet (IBD-AID) has been used as an adjunct dietary therapy for the treatment of inflammatory bowel diseases (IBD) ²²⁹. The goal of the anti-Inflammatory diet (IBD-AID) is to assist with a decreased frequency and severity of flares, obtain and maintain remission in people with inflammatory bowel diseases (IBD). Dysbiosis, or altered bacterial flora, is one of the theories behind the development of anti-Inflammatory diet (IBD-AID), in that certain carbohydrates in the lumen of the gut provide pathogenic bacteria a substrate on which to proliferate ²³⁰, ²³¹.

The anti-Inflammatory diet (IBD-AID) has five basic components:

1. The first of which is the modification of certain carbohydrates, (including lactose, and refined or processed complex carbohydrates)
2. The second places strong emphasis on the ingestion of pre- and probiotics (e.g.; soluble fiber, leeks, onions, and fermented foods) to help restore the balance of the intestinal flora ²³², ²³³, ²³⁴
3. The third distinguishes between saturated, trans, mono- and polyunsaturated fats ²³⁵, ²³⁶,
4. The fourth encourages a review of the overall dietary pattern, detection of missing nutrients, and identification of intolerances.
5. The last component modifies the textures of the foods (e.g.; blenderized, ground, or cooked) as needed (per patient symptomology) to improve absorption of nutrients and minimize intact fiber.

The phases indicated in Table 4 are examples of the modification of texture complexity, so that dietitian and patient can expand the diet as the patient’s tolerance and absorption improves. Some sensitivities common to many patients (not just those with IBD), are eased through supplementation of digestive enzymes or avoidance. A senior dietitian advised the patient and either family or spouse regarding the details of the diet during regular clinic visits. Patients taking supplements (probiotics, vitamin/minerals, omega-3 fatty acids) were advised to continue or discontinue, depending on the needs of the individual and the dietary intake ²³⁷.

The anti-Inflammatory diet (IBD-AID) consists of lean meats, poultry, fish, omega-3, eggs, particular sources of carbohydrate, select fruits and vegetables, nut and legume flours, limited aged cheeses (made with active cultures and enzymes), fresh cultured yogurt, kefir, miso and other cultured products (rich with certain probiotics) and honey. Prebiotics, in the form of soluble fiber (containing beta-glucans and inulin, such as bananas, oats, blended chicory root, and flax meal) are suggested. In addition, the patient is advised to begin at a texture phase of the diet matching with symptomology, starting with phase one if in an active flare. Many patients require foods to be softened and textures mechanically altered by pureeing the foods, and avoiding foods with stems and seeds when starting the diet (see phases 1–3 of Table 4), as intact fiber can be problematic for those with strictures and highly active mucosal inflammation. Some patients will require lifelong avoidance of intact fiber. Food irritants are not limited to intact fiber, but may include certain foods, processing agents and flavorings to which IBD patients may be reactive.

Table 6. The Anti-Inflammatory Diet (IBD-AID) Food Phase chart

Phase type	Phase I	Phase II	Phase III	Phase IV
	Soft, well-cooked or cooked then pureed foods, no seeds	Soft Textures: well-cooked or pureed foods, no seeds, choose floppy or tender foods	May still need to avoid stems, choose floppy greens or other greens depending on individual tolerance	If in remission with no strictures
Vegetables	Butternut Squash, Pumpkin, Sweet Potatoes, Onions	Carrots, Zucchini, Eggplant, Peas, Snow peas, Spaghetti squash, Green beans, Yellow beans, Microgreens (2 week old baby greens), Watercress, Arugula, Fresh flat leaf parsley and cilantro, Seaweed, Algae	Butter lettuce, Baby spinach, Peeled cucumber, Olives, Leeks Bok Choy, Bamboo shoots, Collard greens, Beet greens, Sweet peppers, Kale, Fennel bulb	Artichokes, Asparagus, Tomatoes, Lettuce, Brussels sprouts, Beets, Cabbage, Kohlrabi, Rhubarb, Pickles, Spring onions, Water chestnuts, Celery, Celeriac, Cauliflower, Broccoli, Radish, Green pepper, Hot pepper
	Pureed vegetables: Mushrooms, Phase II vegetables (pureed)	Pureed vegetables: all except cruciferous	Pureed vegetables: all from Phase IV, Kimchi
Fruits	Banana, Papaya, Avocado, Pawpaw	Watermelon (seedless), Mangoes, Honeydew, Cantaloupe, May need to be cooked: Peaches, Plums, Nectarines, Pears, (Phase III fruits are allowed if pureed and seeds are strained out)	Strawberries, Cranberries, Blueberries, Apricots, Cherries, Coconut, Lemons, Limes, Kiwi, Passion fruit, Blackberries, Raspberries, Pomegranate (May need to strain seeds from berries)	Grapes, Grapefruit, Oranges, Currants, Figs, Dates, Apples (best cooked), Pineapple, Prunes
Meats and fish	All fish (no bones), Sardines (small bones ok), Turkey and ground beef, Chicken, Eggs	Scallops	Lean cuts of Beef, Lamb, Duck, Goose	Shrimp, Prawns, Lobster
Non dairy unsweetened	Coconut milk, Almond milk, Oat milk, Soy milk
Dairy, unsweetened	Yogurt, Kefir	Farmers cheese (dry curd cottage cheese), Cheddar cheese	Aged cheeses
Nuts/Oils/Legumes/Fats	Miso (refrigerated), Tofu, Olive oil, Canola oil, Flax oil, Hemp oil, Walnut oil, Coconut oil	Almond flour, Peanut flour, Soy flour, Sesame oil, Grapeseed oil, Walnut oil, Pureed nuts, Safflower oil, Sunflower oil	Whole nuts, Soybeans, Bean flours, Nut butters, Well-cooked lentils (pureed), Bean purees (e.g. hummus)	Whole beans and lentils
Grains	Ground flax or Chia Seeds (as tolerated)	Steel cut oats (well-cooked as oatmeal)	Rolled well-cooked oats
Spices	Basil, Sage, Oregano, Salt, Nutmeg, Cumin, Cinnamon, Turmeric, Saffron, Mint, Bay leaves, Tamari (wheat free soy sauce), Fenugreek tea, Fennel tea, Vanilla	Dill, Thyme, Rosemary Tarragon, Cilantro, Basil, Parsley	Mint, Ginger, Garlic (minced), Paprika, Chives, Daikon, Mustard	Wasabi, Tamarind, Horseradish, Fenugreek, Fennel
Sweeteners	Stevia, Maple syrup, Honey (local), Unsweetened fruit juice	Lemon and lime juice
Misc.	Capsule or liquid supplements, Cocoa powder	Baking powder (no cornstarch), Baking soda, Unflavored gelatin	Ghee, Light mayonnaise, Vinegar	Ketchup (sugar free), Hot sauce (sugar free)

[Source ²²⁹]

Inflammatory bowel disease dietary guidelines

To help patients navigate their nutritional questions, the International Organization of Inflammatory Bowel Diseases recently reviewed the best current evidence to develop expert recommendations regarding dietary measures that might help to control and prevent relapse of inflammatory bowel disease ²³⁸. In particular, the International Organization of Inflammatory Bowel Diseases focused on the dietary components and additives that they felt were the most important to consider because they comprise a large proportion of the diets that inflammatory bowel disease patients may follow. Furthermore, the recent International Organization of Inflammatory Bowel Diseases guidelines are an excellent starting point for discussions between patients and their doctors about whether specific dietary changes might be helpful in reducing symptoms and risk of relapse of inflammatory bowel disease. However, all patients with inflammatory bowel disease (IBD) should work with their doctor or a nutritionist, who will conduct a nutritional assessment to check for malnutrition and provide advice to correct deficiencies if they are present.

The International Organization of Inflammatory Bowel Diseases recommendations were developed with the aim of reducing symptoms and inflammation ²³⁸. The ways in which altering the intake of particular foods may trigger or reduce inflammation are quite diverse, and the mechanisms are better understood for certain foods than others. For example, fruits and vegetables are generally higher in fiber, which is fermented by bacterial enzymes within the colon. This fermentation produces short-chain fatty acids (SCFAs) that provide beneficial effects to the cells lining the colon. Patients with active IBD have been observed to have decreased short-chain fatty acids, so increasing the intake of plant-based fiber may work, in part, by boosting the production of short-chain fatty acids. However, it is important to note disease-specific considerations that might be relevant to your particular situation. For example, about one-third of Crohn’s disease patients will develop an area of intestinal narrowing, called a stricture, within the first 10 years of diagnosis. Insoluble fiber can worsen symptoms and, in some cases, lead to intestinal blockage if a stricture is present. So, while increasing consumption of fruits and vegetable is generally beneficial for Crohn’s disease, patients with a stricture should limit their intake of insoluble fiber.

The International Organization of Inflammatory Bowel Diseases guidelines include the following recommendations:

Food	If you have Crohn’s disease	If you have ulcerative colitis
Fruits	increase intake	insufficient evidence
Vegetables	increase intake	insufficient evidence
Red/processed meat	insufficient evidence	decrease intake
Unpasteurized dairy products	best to avoid	best to avoid
Dietary fat	decrease intake of saturated fats and avoid trans fats	decrease consumption of myristic acid (palm, coconut, dairy fat), avoid trans fats, and increase intake of omega-3 (from marine fish but not dietary supplements)
Food additives	decrease intake of maltodextrin-containing foods	decrease intake of maltodextrin-containing foods
Thickeners	decrease intake of carboxymethylcellulose	decrease intake of carboxymethylcellulose
Carrageenan (a thickener extracted from seaweed)	decrease intake	decrease intake
Titanium dioxide (a food colorant and preservative)	decrease intake	decrease intake
Sulfites (flavor enhancer and preservative)	decrease intake	decrease intake

[Source ²³⁸ ]

What are specific diets for inflammatory bowel disease?

A number of specific diets have been explored for inflammatory bowel disease (IBD), including the Mediterranean diet, specific carbohydrate diet, Crohn’s disease exclusion diet, autoimmune protocol diet, and a diet low in fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs). Although the International Organization of Inflammatory Bowel Diseases group initially set out to evaluate some of these diets, they did not find enough high-quality trials that specifically studied them ²³⁸. Therefore, they limited their recommendations to individual dietary components. Stronger recommendations may be possible once additional trials of these dietary patterns become available. For the time being, patients are to monitor for correlations of specific foods to their symptoms. In some cases, patients may explore some of these specific diets to see if they help.

Summary

There is scientific evidence that dietary factors may influence both the risk of developing inflammatory bowel disease and intestinal mucosal inflammation. However, there is lack of  large prospective controlled trials to provide the dietary recommendations patients’ desire. Taken together, studies of exclusive enteral nutrition, exclusion diets, and semi-vegetarian diets suggest that minimizing exposure of the intestinal lumen to selected food items may prolong the remission state of patients with inflammatory bowel disease ²³⁹. Even less evidence exists for the efficacy of the specific carbohydrate diet, FODMAP, or Paleo diet. Furthermore, the practicality of maintaining these interventions over long periods of time is doubtful. Patient-targeted dietary recommendations focus on food restrictions and are highly conflicting. High quality dietary intervention studies are needed to facilitate creation of evidence-based dietary guidelines for patients with inflammatory bowel disease. At a practical level, adherence to defined diets may result in an unnecessary financial burden or reduction in overall caloric intake in patients who are already at risk for protein-calorie malnutrition.

Anti-inflammatory diet for arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by synovial inflammation often followed by cartilage and bone erosion ²⁴⁰. Patients with rheumatoid arthritis often ask their physician for specific dietary advice and many report that different food items improve or worsen the disease symptoms (10–12). Red meat, alcohol, and soft drinks are examples of foods reported to worsen symptoms, whereas fish and berries are reported to improve symptoms ²⁴¹, ²⁴². There are few studies investigating whole diets, but beneficial effects on disease activity have been noted in intervention studies with a Mediterranean diet ²⁴³ as well as with fasting followed by a vegetarian diet ²⁴⁴ and gluten-free vegan diet ²⁴⁵. Research on the effects of food components on inflammation and patient-perceived symptoms includes Omega–3 fatty acids, probiotics, vitamin D, and antioxidants. Omega–3 fatty acids seem to have positive effects on several outcomes such as erythrocyte sedimentation rate (ESR) and tender joint count ⁸ and a number of trials using probiotics have shown positive effects on disease activity ²⁴⁶. There seems to be potential for vitamin D as well to reduce disease activity, but very few studies have been performed ²⁴⁷. Furthermore, several antioxidants and sources of bioactive compounds with antioxidative effects have been evaluated and some studies have obtained a reduction in symptoms as well as lower disease activity with these foods and supplements ²⁴⁸, ²⁴⁹, ²⁵⁰. Many of these dietary interventions in rheumatoid arthritis had small study populations and suffered from a poor design. Nevertheless, they indicate that several foods and food components have potential to reduce rheumatoid arthritis disease activity by lowering grade of inflammation or alleviating symptoms like joint pain. Still, studies investigating the effects of a comprehensive anti-inflammatory portfolio diet are lacking for rheumatoid arthritis.

The Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA) is a diet combining foods with suggested anti-inflammatory effects and food components with promising effects on rheumatoid arthritis disease activity and symptoms ²⁵¹. Table 1 describes the foods included in detail. In brief, the main meals in the Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA) diet contained fish (mainly salmon) 3–4 times/week and vegetarian dishes with legumes 1–2 times/week. Potatoes, whole-grain cereals, vegetables, yoghurt for sauces, spices, and other flavorings were also included ²⁵¹. Snacks were composed of fruits, whereas breakfasts contained low-fat dairy, whole-grain cereals, pomegranate and blueberries, nuts, and juice shots with probiotics ²⁵¹. The probiotic shot used contained Lactobacillus plantarum 299v and was provided to the participants 5 days/week. For the meals not provided, the participants were instructed to limit their intake of meat to ≤3 times/week, to eat ≥5 portions/day of fruit, berries, and vegetables (including those provided), to use oil or margarine for cooking, and to choose low-fat dairy and whole-grain cereals ²⁵¹.

The total dietary intake during control periods was intended to correspond nutritionally to the average dietary intake in 45- to 64-year-old men and women in Sweden; 17 energy percent (E%) protein, 34 energy percent total fat, 13 energy percent saturated fatty acids, and 43 energy percent carbohydrates ²⁵². The control diet provided by the study contained meat or chicken and refined grains daily, protein bar or quark for snacks, and breakfasts based on either white bread with a butter-based spread and cheese, or a mix of quark and yoghurt with corn flakes and orange juice. Beyond this, the participants were also instructed to consume meat ≥5 times/week; ≤5 portions/day of fruit, berries, and vegetables; seafood ≤1 time/week; use butter for cooking; choose high-fat dairy; and avoid products with probiotics. Before each diet period, the participants received a binder including weekly menus and recipes, and instructions on dietary intake for the meals not provided. Three weekly menus were repeated throughout the diet periods.

One component of the Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA) portfolio diet that distinguishes it from a Mediterranean diet is the probiotics. Patients with rheumatoid arthritis seem to have a less diverse microbiota composition than healthy individuals ²⁵³ and probiotics have the ability to alter the intestinal microbiota and downregulate immune response ²⁵⁴. In clinical studies, several strains of probiotics have been used to reduce symptoms in patients with rheumatoid arthritis ²⁵⁴, ²⁵⁵, ²⁵⁶, ²⁵⁷, with conflicting results. Some studies have obtained reduced disease activity with Lactobacillus casei, alone or together with Lactobacillus acidophilus and Bifidobacterium bifidum ²⁵⁶, ²⁵⁴. However, it is not possible to compare Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA) portfolio diet with this research because the strains used differ.

The beneficial effects of omega–3 fatty acids in rheumatoid arthritis have been studied, and supplementation seems to reduce concentrations of mediators of inflammation ²⁵⁸. A recent systematic review and meta-analysis on effects of omega-3 polyunsaturated fatty acids (PUFAs) concluded significant positive effects on several outcomes in rheumatoid arthritis, although not in disease activity score using 28 joint counts (DAS28) ⁸. Some individual trials have shown positive effects of omage–3 fatty acids, but these have several limitations ²⁵⁹. As an alternative to omega–3 supplements Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA) used fish intake. The Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA) diet was intended to be viable in daily life, and therefore did not aim to reach the amounts of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) used in supplementation trials. Observational data ²⁶⁰ suggest that consuming fish at least twice per week is associated with lower disease activity score using 28 joint counts (DAS28)-CRP, which is further reduced by every additional serving. Moreover, a previous study from another research group showed significant improvements in disease activity score using 28 joint counts (DAS28)-CRP with a mussel diet (low dose of omega–3 fatty acids), comparable with the change during the intervention period in ADIRA ²⁶¹. In that study, European League Against Rheumatism (EULAR) response criteria ²⁶² differed significantly between the control and intervention periods. This was not the case in Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA), again perhaps because of the lower disease activity at baseline.

This Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA) trial indicates positive effects of a proposed anti-inflammatory diet on disease activity in patients with rheumatoid arthritis ²⁵¹. However, additional studies are required to determine if Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA) diet can cause clinically relevant improvements ²⁵¹.

Table 7. The anti-inflammatory portfolio diet in the randomized crossover ADIRA (Anti-inflammatory Diet in Rheumatoid Arthritis) trial

	Foods	Comments
Breakfast	Low-fat fermented dairy
	Granola containing nuts, seeds, and berries
	Fiber-enriched oats
	Low-fat milk
	Walnuts
	Blueberries/pomegranate
	Probiotic shot	Juice
Main meal	Salmon
	Salmon + cod	Ready-to-eat meal: patties (mixed with cream and egg) served with shellfish sauce (cream and wine), soybeans, and peas
	Beans, chickpeas, and/or lentils	Ready-to-eat meals: stew with potatoes and vegetables; stew with bulgur, coconut milk, and vegetables; or patties with vegetables
	Wheat berries
	Bulgur, whole grain
	Potatoes	Cooked or oven-baked
	Pasta, whole grain
	Yogurt (10% fat)
	Crème fraiche (13% fat)
	Vegetables (e.g., soy beans, spinach, onion, garlic, pepper)	Large amount
	Mango
	Rapeseed oil
	Rice vinegar
	Soy sauce
	Honey
	Spices
	Lime, lemon
Snack	Bananas/apples/pears	Two daily

Footnote: The participants were provided with foods corresponding to ∼50% of their daily intake, 5 days/wk. For the remaining intake, they were instructed to consume similar foods to those provided.

[Source ²⁵¹ ]

Anti-inflammatory meal plan

By following the US Department of Health food guide, called ChooseMyPlate ²⁶³, you can make healthier food choices. The new US Department of Agriculture’s food guide 2015-2020 ²⁶⁴ encourages you to eat more fruits and vegetables, whole grains, lean proteins, and low-fat dairy. Using the guide ²⁶⁴, you can learn what type of food you should eat and how much you should eat. You also learn why and how much you should exercise.

There are 5 major food groups that make up a healthy diet:

1. Grains
2. Vegetables
3. Fruits
4. Dairy
5. Protein foods

You should eat foods from each group every day. How much food you should eat from each group depends on your age, gender, and how active you are.

ChooseMyPlate ²⁶³ makes specific recommendations for each type of food group.

1) GRAINS: MAKE AT LEAST HALF OF YOUR GRAINS WHOLE GRAINS

• Whole grains contain the entire grain. Processed grains have had the bran and germ removed. Be sure to read the ingredient list label and look for whole grains first on the list.
• Foods with whole grains have more fiber and protein than food made with processed grains.
• Examples of whole grains are breads and pastas made with whole-wheat flour, oatmeal, bulgur, faro, and cornmeal.
• Examples of processed grains are white flour, white bread, and white rice.

Most children and adults should eat about 5 to 8 servings of grains a day (also called “ounce equivalents”). Children age 8 and younger need about 3 to 5 servings. At least half those servings should be whole grain. An example of one serving of grains includes:

• 1 slice of bread
• Half of a bagel
• 1 cup (30 grams)of cereal
• 1/2 cup (165 grams) cooked rice
• 5 whole-wheat crackers
• 1/2 cup (75 grams) cooked pasta

Eating whole grains can help improve your health by ²⁶⁵:

• Reducing the risk of many chronic diseases.
• Whole grains can help you lose weight. Portion size is still key. Because whole grains have more fiber and protein, they are more filling than refined grains, so you can eat less to get the same feeling of being full. But if you replace vegetables with starches, you’ll gain weight, even if you eat whole grain.
• Whole grains can help you have regular bowel movements.

Ways to eat more whole grains:

• Eat brown rice instead of white rice.
• Use whole-grain pasta instead of regular pasta.
• Replace part of white flour with wheat flour in recipes.
• Replace white bread with whole-wheat bread.
• Use oatmeal in recipes instead of bread crumbs.
• Snack on air-popped popcorn instead of chips or cookies.

2) VEGETABLES: MAKE HALF OF YOUR PLATE FRUITS AND VEGETABLES

• Vegetables can be raw, fresh, cooked, canned, frozen, dried, or dehydrated.
• Vegetables are organized into 5 subgroups based on their nutrient content. The groups are dark-green vegetables, starchy vegetables, red and orange vegetables, beans and peas, and other vegetables.
• Try to include vegetables from each group, try to make sure you aren’t only picking options from the “starchy” group.

Most children and adults should eat between 2 and 3 cups (200 to 300 grams) of vegetables a day. Children age 8 need about 1 to 1 1/2 cups (100 to 150 grams). Examples of a cup include:

• Large ear of corn
• Three 5-inch (13 centimeters) broccoli spears
• 1 cup (100 grams) cooked vegetables
• 2 cups (250 grams) of raw, leafy greens
• 2 medium carrots
• 1 cup (240 milliliters) 100% vegetable juice (carrot, tomato)

Eating vegetables can help improve your health in the following ways:

• Lowers your risk of heart disease, obesity, and type 2 diabetes
• Helps protect you against some cancers
• Helps lower blood pressure
• Reduces the risk of kidney stones
• Helps reduce bone loss

Ways to eat more vegetables:

• Keep plenty of frozen vegetables handy in your freezer.
• Buy pre-washed salad and pre-chopped veggies to cut down on prep time.
• Add veggies to soups and stews.
• Add vegetables to spaghetti sauces.
• Try veggie stir-fries.
• Eat raw carrots, broccoli, or bell pepper strips dipped in hummus or ranch dressing as a snack.

3) FRUITS: MAKE HALF OF YOUR PLATE FRUITS AND VEGETABLES

• Fruits can be fresh, canned, frozen, or dried.

Most adults need 1 1/2 to 2 cups (200 to 250 grams) of fruit a day. Children age 8 and younger need about 1 to 1 1/2 cups (120 to 200 grams). Examples of a cup include:

• 1 small piece of fruit, such as an apple or pear
• 8 large strawberries
• 1/2 cup (130 grams) dried apricots or other dried fruit
• 1 cup (240 milliliters) 100% fruit juice (orange, apple, grapefruit)
• 1 cup (100 grams) cooked or canned fruit
• 1 cup (250 grams) chopped fruit

Eating fruit can help improve your health, they may help to:

• Lower your risk of heart disease, obesity, and type 2 diabetes
• Protect you against some cancers
• Lower blood pressure
• Reduce the risk of kidney stones
• Reduce bone loss

Ways to eat more fruit:

• Put out a fruit bowl and keep it full of fruit.
• Stock up on dried, frozen, or canned fruit, so you always have it available. Choose fruit that is canned in water or juice instead of syrup.
• Buy pre-cut fruit in packages to cut down on prep time.
• Try meat dishes with fruit, such as pork with apricots, lamb with figs, or chicken with mango.
• Grill peaches, apples, or other firm fruit for a healthy, tasty dessert.
• Try a smoothie made with chopped fruit and plain yogurt for breakfast.
• Use dried fruit to add texture to trail mixes.

4) PROTEIN FOODS: CHOOSE LEAN PROTEINS

Protein foods include meat, poultry, seafood, beans and peas, eggs, processed soy products, nuts and nut butters, and seeds. Beans and peas are also part of the vegetable group.

• Choose meats that are low in saturated fat and cholesterol, such as lean cuts of beef and chicken and turkey without skin.
• Most adults need 5 to 6 1/2 servings of protein a day (also called “ounce equivalents”). Children age 8 and younger need about 2 to 4 servings.

Examples of a serving include:

• 1 oz (28 grams) lean meat; like beef, pork, or lamb
• 1 oz (28 grams) poultry; such as turkey or chicken
• 1 large egg
• 1/4 cup (50 grams) tofu
• 1/2 cup (50 grams) cooked beans or lentils
• 1 tablespoon (15 grams) peanut butter
• 1/3 cup (35 grams) nuts

Eating lean protein can help improve your health:

• Seafood high in omega-3 fats, such as salmon, sardines, or trout, can help prevent heart disease.
• Peanuts and other nuts, such as almonds, walnuts, and pistachios, when eaten as part of a healthy diet, can help lower the risk of heart disease.
• Lean meats and eggs are a good source of iron

Ways to include more lean protein in your diet:

• Choose lean cuts of beef, which include sirloin, tenderloin, round, chuck, and shoulder or arm roasts and steaks.
• Choose lean pork, which include tenderloin, loin, ham, and Canadian bacon.
• Choose lean lamb, which includes tenderloin, chops, and leg.
• Buy skinless chicken or turkey, or take the skin off.
• Grill, roast, poach, or broil meats, poultry, and seafood instead of frying.
• Trim all visible fat and drain off any fat when cooking.
• Substitute peas, beans, or soy in place of meat at least once a week. Try bean chili, pea or bean soup, stir-fried tofu, rice and beans, or veggie burgers.
• Include 8 ounces (225 grams) of cooked seafood a week

5) DAIRY: CHOOSE LOW-FAT OR FAT-FREE DAIRY FOODS

Most children and adults should get about 3 cups (720 milliliters) of dairy a day. Children age 2 to 8 need about 2 to 2 1/2 cups (480 to 600 milliliters). Examples of a cup include:

• 1 cup (240 milliliters) milk
• 1 regular container of yogurt
• 1 1/2 ounces (45 grams) hard cheese (such as cheddar, mozzarella, Swiss, Parmesan)
• 1/3 cup (40 grams) shredded cheese
• 2 cups (450 grams) cottage cheese
• 1 cup (250 grams) pudding made with milk or frozen yogurt
• 1 cup (240 milliliters) calcium-fortified soymilk

Eating dairy food can improve your health:

• Consuming dairy foods is important for improving bone health especially during childhood and adolescence, when bone mass is being built.
• Dairy foods have vital nutrients including calcium, potassium, vitamin D, and protein.
• The intake of dairy products is linked to reduced risk of cardiovascular disease, type 2 diabetes, and lower blood pressure in adults.
• Low-fat or fat-free milk products provide little or no solid fat.

Ways to include low-fat foods from the dairy group in your diet:

• Include milk or calcium-fortified soymilk (soy beverage) as a beverage at meals. Choose fat-free or low-fat milk.
• Add fat-free or low-fat milk instead of water to oatmeal and hot cereals.
• Use fat-free or low-fat milk when making condensed cream soups (such as cream of tomato).
• Top casseroles, soups, stews, or vegetables with shredded reduced-fat or low-fat cheese.
• Use lactose-free or lower lactose products if you have trouble digesting dairy products. Also, you can get more calcium from non-dairy sources such as fortified juices, canned fish, soy foods, and green leafy vegetables.

6) OILS: EAT SMALL AMOUNTS OF HEART-HEALTHY OILS

• Oils are not a food group. However, they provide important nutrients and should be part of a healthy diet.
• Fats such as butter and shortening are solid at room temperature. They contain high levels of saturated fats or trans fats. Eating a lot of these fats can increase your risk of heart disease.
• Oils are liquid at room temperature. They contain monounsaturated and polyunsaturated fats. These types of fats are generally good for your heart.
• Children and adults should get about 5 to 7 teaspoons (25 to 35 milliliters) of oil a day. Children age 8 and younger need about 3 to 4 teaspoons (15 to 20 milliliters) a day.
• Choose oils such as olive, canola, sunflower, safflower, soybean, and corn oils.
• Some foods are also high in healthy oils. They include avocados, some fish, olives, and nuts.

7) WEIGHT MANAGEMENT AND PHYSICAL ACTIVITY

ChooseMyPlate ²⁶³ also provides information about how to lose excess weight:

• You can use the online SuperTracker to learn what you currently eat and drink. By writing down what you eat and drink every day, you can see where you can make better choices.
• You can use the Daily Food Plan to learn what to eat and drink. You just enter your height, weight, and age to get a personalized eating plan.
• Use the SuperTracker to track your daily activity and food you eat, plus your weight.
• If you have any specific health concerns, such as heart disease or diabetes, be sure to discuss any dietary changes with your doctor or registered dietitian first.

You also learn how to make better choices, such as:

• Eating the right amount of calories to keep you at a healthy weight
• Not overeating and avoiding big portions
• Eating fewer foods with empty calories. These are foods high in sugar or fat with few vitamins or minerals.
• Eating a balance of healthy foods from all 5 food groups
• Making better choices when eating out at restaurants
• Cooking at home more often, where you can control what goes into the foods you eat
• Exercising 150 minutes a week
• Decreasing your screen time in front of the TV or computer
• Getting tips for increasing your activity level.

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