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Spondyloarthropathies and Food Intake

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Abstract

Spondyloarthropathies is a general term that encompasses the group of heterogenous inflammatory rheumatic diseases that cause arthritis which affects the spine, different joints, and other parts of the organs related to the specific disorders. This group consists of various diseases in which ankylosing spondylitis with some common and specific clinical manifestations considered as the critical one among other types of disorders. Recently, various studies have demonstrated a broad spectrum of different factors that influence the progression, control, and decreasing the severity of ankylosing spondylitis, including investigating the immunological changes, genetic visions of this disease, also environmental factors, and food intake as the main part of this category can induce some strong changes in patients. Today, several studies have illustrated the important role of dietary products, micro-nutrition, some critical vitamins, like vitamin D, A, E, and C, starch diet, nutritional habits, and other types of components on the immunological pathways related to progression or control the severity of patients suffering from ankylosing spondylitis. The present chapter aims to investigate the pivotal role of food intake in the clinical manifestations of spondyloarthropathies like ankylosing spondylitis by explaining the specific immunological cytokines, chemokines, and various pathways related to this disease.

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References

  1. Kolahi S, Khabbazi A, Kazemi N, Mahdavi AM. Does vitamin D deficiency contribute to higher disease activity in patients with spondyloarthritis? Immunol Lett. 2019;212:1–5.

    Article  CAS  PubMed  Google Scholar 

  2. Mitulescu T-C, Trandafir M, Dimăncescu M-G, Ciuluvică R-C, Popescu V, Predețeanu D, et al. Advances in the treatment of uveitis in patients with spondyloarthritis-is it the time for biologic therapy? Romanian J Ophthalmol. 2018;62(2):114.

    Article  Google Scholar 

  3. Gill T, Rosenbaum JT. Putative pathobionts in HLA-B27-associated spondyloarthropathy. Front Immunol. 2020;11.

    Google Scholar 

  4. Rysnik O, McHugh K, van Duivenvoorde L, van Tok M, Guggino G, Taurog J, Kollnberger S, Ciccia F, Baeten D, Bowness P. Non-conventional forms of HLA-B27 are expressed in spondyloarthritis joints and gut tissue. J Autoimmun. 2016;70:12–21.

    Google Scholar 

  5. Soleimanifar N, Amirzargar AA, Mahmoudi M, Pourfathollah AA, Azizi E, Jamshidi AR, Rezaei N, Tahoori MT, Bidad K, Nikbin B, Nicknam MH. Study of programmed cell death 1 (PDCD1) gene polymorphims in Iranian patients with ankylosing spondylitis. Inflammation. 2011;34(6):707–12.

    Google Scholar 

  6. Taurog JD, Chhabra A, Colbert RA. Ankylosing spondylitis and axial spondyloarthritis. N Engl J Med. 2016;374(26):2563–74.

    Article  PubMed  Google Scholar 

  7. Pathak H, Gaffney K. Spectrum of spondyloarthritis. Indian J Rheumatol. 2020;15(5):34.

    Article  Google Scholar 

  8. Furst DE, Louie JS. Targeting inflammatory pathways in axial spondyloarthritis. Arthritis Res Ther. 2019;21(1):135.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Ritchlin C, Adamopoulos IE. Axial spondyloarthritis: new advances in diagnosis and management. BMJ. 2021;372:m4447.

    Article  PubMed  Google Scholar 

  10. Jah N, Jobart-Malfait A, Ermoza K, Noteuil A, Chiocchia G, Breban M, et al. HLA–B27 subtypes predisposing to ankylosing spondylitis accumulate in an endoplasmic reticulum–derived compartment apart from the peptide-loading complex. Arthritis Rheumatol. 2020;72(9):1534–46.

    Article  CAS  PubMed  Google Scholar 

  11. Fragoulis GE, Liava C, Daoussis D, Akriviadis E, Garyfallos A, Dimitroulas T. Inflammatory bowel diseases and spondyloarthropathies: from pathogenesis to treatment. World J Gastroenterol. 2019;25(18):2162.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Karreman MC, Luime JJ, Hazes JM, Weel AE. The prevalence and incidence of axial and peripheral spondyloarthritis in inflammatory bowel disease: a systematic review and meta-analysis. J Crohn's Colitis. 2017;11(5):631–42.

    Google Scholar 

  13. Kelly OB, Li N, Smith M, Chan J, Inman RD, Silverberg MS. The prevalence and clinical associations of subclinical sacroiliitis in inflammatory bowel disease. Inflamm Bowel Dis. 2019;25(6):1066–71.

    Article  PubMed  Google Scholar 

  14. Jethwa H, Prince M, Bukhari M, Abraham S. The evidence for dietary manipulation in inflammatory arthritis. Int J Clin Rheumatol. 2019;14(5):190.

    Google Scholar 

  15. Arends S, Spoorenberg A, Bruyn GA, Houtman PM, Leijsma MK, Kallenberg CG, et al. The relation between bone mineral density, bone turnover markers, and vitamin D status in ankylosing spondylitis patients with active disease: a cross-sectional analysis. Osteoporos Int. 2011;22(5):1431–9.

    Article  CAS  PubMed  Google Scholar 

  16. Kocyigit BF, Akyol A. Vitamin D levels in patients with ankylosing spondylitis: Is it related to disease activity? Pakistan journal of medical sciences. 2018;34(5):1209.

    Google Scholar 

  17. Chang S-W, Lee H-C. Vitamin D and health-the missing vitamin in humans. Pediatrics Neonatol. 2019;60(3):237–44.

    Article  Google Scholar 

  18. Medrano M, Carrillo-Cruz E, Montero I, Perez-Simon JA. Vitamin D: effect on haematopoiesis and immune system and clinical applications. Int J Mol Sci. 2018;19(9):2663.

    Article  PubMed Central  CAS  Google Scholar 

  19. Khabbazi A, Rashtchizadeh N, Ghorbanihaghjo A, Hajialiloo M, Ghojazadeh M, Taei R, et al. The status of serum vitamin D in patients with active Behcet's disease compared with controls. Int J Rheum Dis. 2014;17(4):430–4.

    Article  CAS  PubMed  Google Scholar 

  20. Vanherwegen A-S, Gysemans C, Mathieu C. Regulation of immune function by vitamin D and its use in diseases of immunity. Endocrinology and Metabolism Clinics. 2017;46(4):1061-94.

    Google Scholar 

  21. Alhassan Mohammed H, Mirshafiey A, Vahedi H, Hemmasi G, Moussavi Nasl Khameneh A, Parastouei K, et al. Immunoregulation of inflammatory and inhibitory cytokines by vitamin D 3 in patients with inflammatory bowel diseases. Scandinavian journal of immunology. 2017;85(6):386-94.

    Google Scholar 

  22. Colotta F, Jansson B, Bonelli F. Modulation of inflammatory and immune responses by vitamin D. Journal of autoimmunity. 2017;85:78–97.

    Google Scholar 

  23. Sassi F, Tamone C, D’Amelio P. Vitamin D: nutrient, hormone, and immunomodulator. Nutrients. 2018;10(11):1656.

    Article  CAS  PubMed Central  Google Scholar 

  24. Guła Z, Stec M, Rutkowska-Zapała M, Lenart M, Korkosz M, Gąsowski J, et al. The absolute number of circulating nonclassical (CD14^{+} CD16^{++}) monocytes negatively correlates with DAS28 and swollen joint count in patients with peripheral spondyloarthritis. Polskie Archiwum Medycyny Wewnętrznej= Polish Arch Int Med. 2017;127(12):846–53.

    Google Scholar 

  25. Martens P-J, Gysemans C, Verstuyf A, Mathieu C. Vitamin D’s effect on immune function. Nutrients. 2020;12(5):1248.

    Article  CAS  PubMed Central  Google Scholar 

  26. Zhao S, Duffield SJ, Moots RJ, Goodson NJ. Systematic review of association between vitamin D levels and susceptibility and disease activity of ankylosing spondylitis. Rheumatology. 2014;53(9):1595–603.

    Article  CAS  PubMed  Google Scholar 

  27. Fernandes S, Etcheto A, van der Heijde D, Landewé R, van den Bosch F, Dougados M, et al. Vitamin D status in spondyloarthritis: results of the ASAS-COMOSPA international study. Clin Exp Rheumatol. 2018;36(2):210–4.

    PubMed  Google Scholar 

  28. Crotti C, Becciolini A, Biggioggero M, Favalli EG. Vitamin D and spondyloarthritis: review of the literature. Open Rheumatol J. 2018;12(1):214–25.

    Google Scholar 

  29. Erten S, Kucuksahin O, Sahin A, Altunoglu A, Akyol M, Koca C. Decreased plasma vitamin D levels in patients with undifferentiated spondyloarthritis and ankylosing spondylitis. Internal Medicine. 2013;52(3):339−44.

    Google Scholar 

  30. Zhao SZ, Thong D, Duffield S, Goodson N. Vitamin D deficiency in axial spondyloarthritis is associated with higher disease activity. Archives of rheumatology. 2017;32(3):209.

    Google Scholar 

  31. Apostu D, Lucaciu O, Mester A, Oltean-Dan D, Baciut M, Baciut G, et al. Systemic drugs with impact on osteoarthritis. Drug Metab Rev. 2019;51(4):498–523.

    Article  CAS  PubMed  Google Scholar 

  32. Lee GY, Han SN. The role of vitamin E in immunity. Nutrients. 2018;10(11):1614.

    Article  PubMed Central  CAS  Google Scholar 

  33. Carr A, Maggini S. Vitamin C and immune function. Nutrients. 2017;9(11):1211.

    Article  PubMed Central  CAS  Google Scholar 

  34. Mène-Saffrané L. Vitamin E biosynthesis and its regulation in plants. Antioxidants. 2018;7(1):2.

    Article  CAS  Google Scholar 

  35. Lewis ED, Meydani SN, Wu D. Regulatory role of vitamin E in the immune system and inflammation. IUBMB Life. 2019;71(4):487–94.

    Article  CAS  PubMed  Google Scholar 

  36. Zinder R, Cooley R, Vlad LG, Molnar JA. Vitamin a and wound healing. Nutr Clin Pract. 2019;34(6):839–49.

    Article  PubMed  Google Scholar 

  37. Molano A, Meydani SN. Vitamin E, signalosomes and gene expression in T cells. Mol Asp Med. 2012;33(1):55–62.

    Article  CAS  Google Scholar 

  38. Drabińska N, Krupa-Kozak U, Abramowicz P, Jarocka-Cyrta E. Beneficial effect of oligofructose-enriched inulin on vitamin D and E status in children with celiac disease on a long-term gluten-free diet: a preliminary randomized, placebo-controlled nutritional intervention study. Nutrients. 2018;10(11):1768.

    Article  PubMed Central  CAS  Google Scholar 

  39. Masri OA, Chalhoub JM, Sharara AI. Role of vitamins in gastrointestinal diseases. World J Gastroenterol: WJG. 2015;21(17):5191.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Wirth JP, Petry N, Tanumihardjo SA, Rogers LM, McLean E, Greig A, et al. Vitamin a supplementation programs and country-level evidence of vitamin a deficiency. Nutrients. 2017;9(3):190.

    Article  PubMed Central  CAS  Google Scholar 

  41. Hiemstra IH, Beijer MR, Veninga H, Vrijland K, Borg EG, Olivier BJ, et al. The identification and developmental requirements of colonic CD 169+ macrophages. Immunology. 2014;142(2):269–78.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Huang Z, Liu Y, Qi G, Brand D, Zheng SG. Role of vitamin a in the immune system. J Clin Med. 2018;7(9):258.

    Article  CAS  PubMed Central  Google Scholar 

  43. Pereira WF, Ribeiro-Gomes FL, Guillermo LVC, Vellozo NS, Montalvão F, DosReis GA, et al. Myeloid-derived suppressor cells help protective immunity to Leishmania major infection despite suppressed T cell responses. J Leukoc Biol. 2011;90(6):1191–7.

    Article  CAS  PubMed  Google Scholar 

  44. Vellozo NS, Pereira-Marques ST, Cabral-Piccin MP, Filardy AA, Ribeiro-Gomes FL, Rigoni TS, et al. All-trans retinoic acid promotes an M1-to M2-phenotype shift and inhibits macrophage-mediated immunity to Leishmania major. Front Immunol. 2017;8:1560.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  45. Bidad K, Salehi E, Jamshidi A, Saboor-Yaraghi AA, Oraei M, Meysamie A, Mahmoudi M, Nicknam MH. Effect of alltransretinoic acid on Th17 and T regulatory cell subsets in patients with ankylosing spondylitis. The Journal of rheumatology. 2013;40(4):476–83.

    Google Scholar 

  46. Liang Y, Yi P, Wang X, Zhang B, Jie Z, Soong L, et al. Retinoic acid modulates hyperactive T cell responses and protects vitamin A–deficient mice against persistent lymphocytic Choriomeningitis virus infection. J Immunol. 2020;204(11):2984–94.

    Article  CAS  PubMed  Google Scholar 

  47. Milani A, Basirnejad M, Shahbazi S, Bolhassani A. Carotenoids: biochemistry, pharmacology and treatment. Br J Pharmacol. 2017;174(11):1290–324.

    Article  CAS  PubMed  Google Scholar 

  48. Jakubczyk K, Dec K, Kałduńska J, Kawczuga D, Kochman J, Janda K. Reactive oxygen species-sources, functions, oxidative damage. Polski Merkur Lekarski: organ Polskiego Towarzystwa Lekarskiego. 2020;48(284):124–7.

    Google Scholar 

  49. Wójcik P, Gęgotek A, Wroński A, Jastrząb A, Żebrowska A, Skrzydlewska E. Effect of redox imbalance on protein modifications in lymphocytes of psoriatic patients. J Biochem. 2020;167(3):323–31.

    Article  PubMed  CAS  Google Scholar 

  50. Nazıroğlu M, Akkuş S, Çelik H. Levels of lipid peroxidation and antioxidant vitamins in plasma and erythrocytes of patients with ankylosing spondylitis. Clinical biochemistry. 2011;44(17-18):1412−5.

    Google Scholar 

  51. Pishgahi A, Abolhasan R, Danaii S, Amanifar B, Soltani-Zangbar MS, Zamani M, et al. Immunological and oxidative stress biomarkers in ankylosing spondylitis patients with or without metabolic syndrome. Cytokine. 2020;128:155002.

    Article  CAS  PubMed  Google Scholar 

  52. Ugan Y, Nazıroğlu M, Şahin M, Aykur M. Anti-tumor necrosis factor alpha (infliximab) attenuates apoptosis, oxidative stress, and calcium ion entry through modulation of cation channels in neutrophils of patients with ankylosing spondylitis. J Membr Biol. 2016;249(4):437–47.

    Article  CAS  PubMed  Google Scholar 

  53. Feng X, Yang Q, Wang C, Tong W, Xu W. Punicalagin exerts protective effects against ankylosing spondylitis by regulating NF-κB-TH17/JAK2/STAT3 signaling and oxidative stress. Biomed Res Int. 2020;2020:4918239.

    PubMed  PubMed Central  Google Scholar 

  54. Baykara RA, Tuzcu A, Omma A, Acet GK, Dogan E, Aydin A, et al. Evaluation of serum thiol/disulfide homeostasis in patients with ankylosing spondylitis by a novel method. Northern Clin Istanbul. 2019;6(4):348.

    Google Scholar 

  55. Rashid T, Wilson C, Ebringer A. The link between ankylosing spondylitis, Crohn’s disease, Klebsiella, and starch consumption. Clin Dev Immunol. 2013;2013:872632.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  56. Breban M, Tap J, Leboime A, Said-Nahal R, Langella P, Chiocchia G, et al. Faecal microbiota study reveals specific dysbiosis in spondyloarthritis. Ann Rheum Dis. 2017;76(9):1614–22.

    Article  CAS  PubMed  Google Scholar 

  57. Garcia-Ribera S, Amat-Bou M, Climent E, Llobet M, Chenoll E, Corripio R, et al. Specific dietary components and gut microbiota composition are associated with obesity in children and adolescents with prader–willi syndrome. Nutrients. 2020;12(4):1063.

    Article  CAS  PubMed Central  Google Scholar 

  58. Livovsky DM, Pribic T, Azpiroz F. Food, eating, and the gastrointestinal tract. Nutrients. 2020;12(4):986.

    Article  PubMed Central  Google Scholar 

  59. Simone D, Al Mossawi MH, Bowness P. Progress in our understanding of the pathogenesis of ankylosing spondylitis. Rheumatology. 2018;57(suppl_6):vi4–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  60. Zhang L, Zhang Y-J, Chen J, Huang X-L, Fang G-S, Yang L-J, et al. The association of HLA-B27 and Klebsiella pneumoniae in ankylosing spondylitis: a systematic review. Microb Pathog. 2018;117:49–54.

    Article  CAS  PubMed  Google Scholar 

  61. Gutiérrez S, Svahn SL, Johansson ME. Effects of omega-3 fatty acids on immune cells. Int J Mol Sci. 2019;20(20):5028.

    Article  PubMed Central  CAS  Google Scholar 

  62. Innes JK, Calder PC. Omega-6 fatty acids and inflammation. Prostaglandins Leukot Essent Fat Acids. 2018;132:41–8.

    Article  CAS  Google Scholar 

  63. Sundström B, Stålnacke K, Hagfors L, Johansson G. Supplementation of omega-3 fatty acids in patients with ankylosing spondylitis. Scand J Rheumatol. 2006;35(5):359–62.

    Article  PubMed  CAS  Google Scholar 

  64. Chen CH, Chen HA, Liu CH, Liao HT, Chou CT, Chen CH. Association of obesity with inflammation, disease severity and cardiovascular risk factors among patients with ankylosing spondylitis. Int J Rheum Dis. 2020;23(9):1165–74.

    Article  CAS  PubMed  Google Scholar 

  65. Ortega FB, Lavie CJ, Blair SN. Obesity and cardiovascular disease. Circ Res. 2016;118(11):1752–70.

    Article  CAS  PubMed  Google Scholar 

  66. Toy S, Ozbag D, Altay Z. The effects of pre-obesity on quality of life, disease activity, and functional status in patients with ankylosing spondylitis. Northern Clin Istanbul. 2017;4(1):52.

    Google Scholar 

  67. Daïen CI, Sellam J. Obesity and inflammatory arthritis: impact on occurrence, disease characteristics and therapeutic response. RMD Open. 2015;1(1):e000012.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Pettersen IKN, Tusubira D, Ashrafi H, Dyrstad SE, Hansen L, Liu X-Z, et al. Upregulated PDK4 expression is a sensitive marker of increased fatty acid oxidation. Mitochondrion. 2019;49:97–110.

    Article  CAS  PubMed  Google Scholar 

  69. Xie Z, Zhang J, Ma S, Huang X, Huang Y. Effect of Chinese herbal medicine treatment on plasma lipid profile and hepatic lipid metabolism in Hetian broiler. Poult Sci. 2017;96(6):1918–24.

    Article  CAS  PubMed  Google Scholar 

  70. Heine RG. Food allergy prevention and treatment by targeted nutrition. Ann Nutr Metab. 2018;72(3):33–45.

    Article  CAS  PubMed  Google Scholar 

  71. Yu W, Freeland DMH, Nadeau KC. Food allergy: immune mechanisms, diagnosis and immunotherapy. Nat Rev Immunol. 2016;16(12):751.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  72. Bastan I, Ge XN, Dileepan M, Greenberg YG, Guedes AG, Hwang SH, et al. Inhibition of soluble epoxide hydrolase attenuates eosinophil recruitment and food allergen-induced gastrointestinal inflammation. J Leukoc Biol. 2018;104(1):109–22.

    Article  CAS  PubMed  Google Scholar 

  73. Ling Z, Li Z, Liu X, Cheng Y, Luo Y, Tong X, et al. Altered fecal microbiota composition associated with food allergy in infants. Appl Environ Microbiol. 2014;80(8):2546–54.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  74. Iweala OI, Choudhary SK, Commins SP. Food allergy. Curr Gastroenterol Rep. 2018;20(5):1–6.

    Article  Google Scholar 

  75. Hua X, Goedert JJ, Pu A, Yu G, Shi J. Allergy associations with the adult fecal microbiota: analysis of the American gut project. EBioMedicine. 2016;3:172–9.

    Article  PubMed  Google Scholar 

  76. Niu Q, Wei W, Huang Z, Zhang J, Yang B, Wang L. Association between food allergy and ankylosing spondylitis: an observational study. Medicine. 2019;98(6):e14421.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  77. Hodde JP, Hiles MC, Metzger DW. Characterization of the local wound environment following treatment of chronic leg ulcers with SIS wound matrix. J Tissue Viability. 2020;29(1):42–7.

    Article  PubMed  Google Scholar 

  78. Zhang W, Zhang Y, He Y, Wang X, Fang Q. Lipopolysaccharide mediates time-dependent macrophage M1/M2 polarization through the Tim-3/Galectin-9 signalling pathway. Exp Cell Res. 2019;376(2):124–32.

    Article  CAS  PubMed  Google Scholar 

  79. Yu J, Zhu R, Yu K, Wang Y, Ding Y, Zhong Y, et al. Galectin-9: a suppressor of atherosclerosis? Front Immunol. 2020;11:604265.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  80. Soleimanifar N, Nicknam MH, Bidad K, Jamshidi AR, Mahmoudi M, Mostafaei S, Hosseini-Khah Z, Nikbin B. Effect of food intake and ambient air pollution exposure on ankylosing spondylitis disease activity. Advances in Rheumatology. 2019 Jul 29;59.

    Google Scholar 

  81. Rocha DM, Caldas AP, Oliveira LL, Bressan J, Hermsdorff HH. Saturated fatty acids trigger TLR4-mediated inflammatory response. Atherosclerosis. 2016;244:211–15.

    Google Scholar 

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  1. Molecular Immunology Research Center, Tehran University of medical sciences, Tehran, Iran

    Bahareh Mohebbi & Narjes Soleimanifar

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    Mohammad Hossein Nicknam

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Mohebbi, B., Soleimanifar, N. (2022). Spondyloarthropathies and Food Intake. In: Nicknam, M.H. (eds) Ankylosing Spondylitis - Axial Spondyloarthritis. Springer, Singapore. https://doi.org/10.1007/978-981-16-4733-8_7

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