In Health: Chronic Inflammation


“Intestinal inflammation can become a catalyst for systemic inflammation.”

— Ardeschir Mehrabani, N.M.D., of Blue Oak Clinic

“I try to find the source of whatever is irritating [my patients] … and I make up individual herbal tinctures.”

— Stephanie Stark, N.M.D., of Blue Oak Clinic

“We really can make food decisions that greatly impact the milieu of our body, increasing or reducing inflammation.”

— Victoria Maizes, M.D., executive director of the UA Center for Integrative Medicinena.

Chronic Inflammation: The Road to Relief

New research and treatments may hold hope for patients
with this debilitating condition.

By Elena Acoba | Photography by James Patrick

Ardeschir Mehrabani, N.M.D., used to suffer from chronic lower back pain caused by inflammation.

“I used to deal with chronically inflamed peripheral nerves,” says Mehrabani, a doctor of naturopathic medicine. After years of trying to find lasting relief, he has overcome his chronic back pain using perineural injection therapy. He is in no pain and can play soccer and spend boisterous time with his two young children.

His experience is what guided him to natural medicine as a young man, says Dr. Mehrabani, who owns Blue Oak Clinic with his wife, Stephanie Stark, N.M.D.

His story is one of many instances when chronic inflammation may play a role in disease. Medical doctors and other health professionals have recognized for a few decades that chronic inflammation is related to many diseases. But there still is much to learn.

Current research ranges from understanding how chronic inflammation works to developing treatments. “We’re looking at the triggers of inflammation that may allow us to look at the mechanism,” says Randy Horwitz, M.D., medical director of the University of Arizona Center for Integrative Medicine. “It frequently leads to therapies, but its aim is often simply to understand the process.”

The Body Inflamed
To understand chronic inflammation, it helps to know how acute inflammation crucially works to heal the body.

When you get sick or injured, your immune system engages. The attacked part of your body becomes inflamed with redness, warmth, pain, swelling and loss of function. Dr. Horwitz calls it a “cellular yell for help.”

Specific types of cells respond by fighting the agent that caused the injury or illness. The defeated germs are swept away and inflammation disappears … but not always.

Sometimes inflammation remains when there is no longer any triggering injury or disease. Or the body issues an inflammatory response even when there is no danger. In either case, constant inflammation can cause the immune system to attack healthy cells.

We have two types of immune systems. Innate, or natural, immunity dispatches certain white blood cells to attack harmful substances in the body. When this system’s inflammatory response goes haywire, rare autoinflammatory diseases could result. The acquired immune system learns what’s dangerous by having dealt with specific illness or injury or through immunization.

Different types of white blood cells fight these learned dangers. When this system goes into overdrive and attacks normal cells, it’s called autoimmunity. An autoimmune condition can lead to chronic inflammation, such as in rheumatoid arthritis or inflammatory bowel disease. But chronic inflammation also is seen in a wide variety of other diseases, including asthma, allergy, coronary artery disease, type 2 diabetes and gum disease. Recent research also ties it to Alzheimer’s disease, some cancers and mood disorders such as depression. Milder chronic inflammation may be present in some forms of osteoarthritis.

An Underlying Cause?
Chronic inflammation occurs for many reasons. It could stem from an inherited gene, a developed genetic defect, or the environment can trigger it. Repeated episodes of acute inflammation could lead to chronic inflammation, such as when asthma attacks create scar tissue that affects airways. Changes in the microbiome (the bacteria and other microorganisms in and on the body), could have something to do with it, too.

Localized inflammation can cause certain illnesses, including diseases of the heart and lungs. “The underlying process of asthma is really inflammation,” says Monica Kraft, M.D., chair of the department of medicine at the University of Arizona College of Medicine-Tucson.

Some conditions are caused by inflammation all over the body, such as in the majority of rheumatic diseases. “Rheumatoid arthritis affects the joints and has systemic manifestations outside of the joints,” says C. Kent Kwoh, M.D., director of the UA Arthritis Center. “Many types of arthritis have systemic inflammation,” he explains.

Chronic inflammation causes surprising links between conditions. “Intestinal inflammation can become a catalyst for systemic inflammation,” notes Dr. Mehrabani. Dr. Kwoh says that people with persistent infection and inflammation in the gums have an increased risk of getting rheumatoid arthritis.

Many Steps to Diagnosis
Tests can tell you if you have chronic inflammation.

One such exam measures the erythrocyte sedimentation rate (ESR), or sed rate for short. It checks the level of chemicals associated with inflammation that are in the bloodstream.

A test measuring the amount of C-reactive protein (CRP) made by the liver also helps to understand a person’s chronic inflammatory state.
The problem with these diagnostic tools is that they can’t pinpoint where chronic inflammation is occurring or if it’s affecting the body.
“These abnormal tests may tell you that something is going on,” says Dr. Kwoh, “but they won’t tell you where or what, specifically.”
Also, normal results don’t necessarily mean you don’t have chronic inflammation.

These doctors prefer to discuss symptoms, medical histories and exam results to diagnose chronic inflammation. “Inflammation unto itself is not a diagnosis,” Dr. Horwitz says. “We try to be more specific.”

Once a diagnosis is made, doctors can use the tests to figure out how much inflammation plays a role. That helps drive treatment. For instance, someone with normal cholesterol levels can still have coronary artery disease. It’s possible that the problem instead is chronic inflammation. Studies that are underway could change the focus from medications that lower LDL cholesterol to include strategies that lower inflammation.

Treatments ... And Side Effects
Drugs. Nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen and naproxen, and corticosteroids are chemical compounds that reduce inflammation symptoms. But a host of side effects make doctors reluctant to suggest them in high doses or for long-term use unless the benefits outweigh the risks for a specific patient.

Biologic response modifiers. Biologics or BRMs such as Humira, Remicade or Enbrel work differently. They target specific molecules that cause chronic inflammation. “Corticosteroids are like the atom bomb,” Dr. Horwitz comments. “Biologics are like targeted missiles.”

Biologics have their own side effects. They suppress the immune system and may expose the body to dangerous infection. And right now they’re costly.
Supplements. Drs. Mehrabani and Stark add herbal remedies and probiotics to their treatment arsenal.

“I try to find the source of whatever is irritating them,” Dr. Stark says of her patients, “and I make up individual herbal tinctures.”
She often prescribes doses of omega-3 fish oil or turmeric.

Lymphatic therapy. Linda Frost, L.E., L.L.C.C., owner of Tucson Lymphatic Therapy, focuses on the lymphatic system. That is the part of the immune system that processes injured or dying cells from an inflamed area.

She uses a light-touch stimulating technique called lymphatic drainage to treat patients whose lymphatic systems have been compromised.
“When the lymphatic system becomes stagnant, patients are susceptible to chronic inflammation and systemic infection,” says Frost, a certified lymphatic and lymphedema specialist.
People who had lymph nodes removed in surgery can experience chronic inflammation, she says. Autoimmune diseases, trauma, dehydration, medications, alcohol, mold and bacteria also can lead to an unhealthy lymphatic system.

A Path to Prevention
There are ways to avoid or reduce chronic inflammation whether or not you’re suffering from a related disease.

Nutrition. Victoria Maizes, M.D., believes food choices can keep chronic inflammation at bay. “We control what we put in our mouths,” says Dr. Maizes, executive director of the UA Center for Integrative Medicine. “We really can make food decisions that greatly impact the milieu of our body, increasing or reducing inflammation.”

She counsels her patients to adopt what’s popularly known as the Mediterranean diet.

Avoid refined, processed and manufactured food. Dr. Stark additionally suggests avoiding sugar and flour.

Eat omega-3 fatty acids, found in salmon, sardines, herring, mackerel and sablefish. Dr. Mehrabani says meat of animals fed with grass has higher omega-3 levels than of those fed with grains.
Eat low-glycemic carbohydrates like cracked wheat berries, quinoa and whole grains.

Eat foods full of fiber like fruits and vegetables.

Eat fruits and vegetables that contain antioxidants. Several studies have shown that organic produce has more than conventionally grown food, Dr. Maizes says.
Add phytonutrients to your diet. These are found in spices like cinnamon, ginger and turmeric, as well as in garlic, red wine and Asian mushrooms.
Frost adds that drinking plenty of water also helps maintain a healthy lymphatic system.

Consider a nightly fast of 12 to 13 hours, Dr. Maizes suggests. “It seems to provide a reset on the immune system,” she says. It also helps people lose weight — a good goal for obese people, whose condition puts them in a “pro-inflammatory state,” she says.

Supplements. If you get all your nutrients from food, there’s less need for supplements, says Dr. Maizes. People with specific diseases may have increased need for some nutrients and benefit from taking supplements. Talk with your doctor about your specific needs.

Probiotics, which are live microorganisms, may also help fight chronic inflammation. Dr. Kraft and Dr. Kwoh feel there’s not enough evidence yet to recommend currently available products to their patients.

Stress. Stress causes the immune system to go on alert, turning on inflammatory processes, Dr. Maizes says. That serves our bodies well when there is an acute injury. “In today’s world, we get stressed a lot, but we don’t have injury,” she adds.

Her many suggestions for reducing stress include focused breathing, journaling, mindfulness, hypnosis, guided imagery, yoga and progressive muscle relaxation. These modalities focus on calming the body.

“You’re activating the quieting part of the nervous system,” she says, “thereby ratcheting down the hormones that affect the immune system.”

Exercise is helpful if it triggers that calming effect, she says, but it shouldn’t be so intense that it actually causes stress. Dr. Kwoh suggests that arthritis patients exercise to keep joints moving, but stick to low-impact, light-to-moderate activity to avoid further injury. Exercise also keeps the lymphatic system healthy, says Frost.

Sleep. Getting good sleep involves not taking antihistamines or looking at electronic screens close to bedtime, Dr. Maizes says. Keep alcohol drinking to moderate amounts, she says, and consume caffeine with the understanding that it can stay in the body for many hours. You want to both fall asleep and not disturb the normal sleep cycle.

On the Horizon
Many questions still exist about how chronic inflammation works. Is it that the immune cells that turn it off aren’t working? Or are the inflamed cells not listening? That could open the door to more biologic treatments.

Dr. Kraft and UA research partner Julie Ledford’s work on the effect of key proteins on the immune system could eventually lead to a cure for asthma.
Some researchers in Tucson are figuring out how bacteria and other microorganisms in the gut can cause inflammation. That might lead to new treatments.
Other local research focuses on prediction and diagnosis. Dr. Kraft says research aims to identify biomarkers that could predict low lung function. Dr. Kwoh says studies look into whether MRIs can detect early changes in osteoarthritis.

How much should we be concerned with chronic inflammation absent of any symptoms of disease? Researchers are trying to figure that out, too.
“Although the inability to mount an inflammatory reaction can be life-threatening,” says Dr. Horwitz, “the inability to terminate an inappropriate inflammatory reaction also can be deleterious.”
The bottom line? “In general, we should be paying attention to reducing inflammation in the body,” says Dr. Maizes.  TL