The Keystone Approach

Healing Arthritis and Psoriasis by restoring the Microbiome

By Rebecca Fett

If you are considering going on The Whole 30 Diet, the Autoimmune Paleo Diet or any other diet meant to address the microbiome or an autoimmune disease, you should read this book. The Keystone Approach is slightly different.

This book will help you better understand your microbiome, the autoimmune inflammatory cascade that takes place in our bodies and how we can impact that process with food and supplements.

The author has a degree in biochemistry and molecular biology and used her law degree as a patent litigation attorney for biotechnology companies (specifically the biologics used to treat autoimmune diseases).

When I’m closely quoting from the book I will cite page numbers.

She separates recommendations that are good for EVERYONE from the recommendations that she encourages us to test out INDIVIDUALLY. My Medication Diary, Elimination Protocol, Gut Microbiome Adventure, and Psoriatic Arthritis Diet all incorporate recommendations from this book.

The New Science of Autoimmunity, Chapter 2

If you don’t understand the autoimmune process, she summarizes it in 2 pages (pages 15-16) and clearly identifies the various steps in the process where we can influence our health.

She walks us through the history of the gut connection to arthritis. Since the 1950’s there have been medical studies connecting Crohn’s disease and arthritis and by the 1960’s they linked arthritis and ulcerative colitis. By the 1980’s, Herman Mielants showed that half of the people they tested with psoriasis, psoriatic arthritis, and ankylosing spondylitis had signs of intestinal inflammation that resembled Crohn’s (page 17). Recent research can link the degree of gut inflammation with the degree of joint inflammation.

Identification of the cells associated with the different autoimmune disease is getting more refined. In Rheumatoid Arthritis, mast cells can be activated by a wide variety of triggers. In Psoriasis & Arthritis, it appears T cells and self-reactive antibodies switch on the mast cells, which begins a cascade of the inflammatory process. Mast cells can also be activated by intestinal permeability. NSAIDs (ibuprofen, naproxen) can increase intestinal permeability. Gut bacteria can affect this process too!

Beneficial bacteria do 4 things for our gut.

They are necessary for our gut to make additional “tight junctions” in the intestine wall.
They build up the protective mucous layer.
They suppress the growth of harmful bacteria
They directly calm the immune system.

Clostridium directly regulates the immune system by boosting regulatory immune cells (page 23). Vendanta Biosciences is currently developing a drug with 17 bacterial species from the Clostridia clusters shown to increase regulatory T cells. But we can shift our own microbiome back to a balanced state without this drug.

Certain bacteria prompt the immune system to make more regulatory T cells by producing the short-chain fatty acid called butyrate.

Bacteria that is good at producing butyrate: Clostridia clusters IV & XIVa.
Butyrate is the main energy source for the cells lining the intestine.
Butyrate helps with repair & regeneration of cell layer & tight junctions.
Butyrate increases production of the protective mucous layer.

Higher levels of harmful bacteria are present in some inflammatory diseases.

Coli, “adherent-invasive E. coli (spondyloarthritis)
Salmonella
Prevotella (Rheumatoid)
Collinsella (Rheumatoid)
Klebsiella (Ankylosing spondylitis)

A side note on E. Coli. It sticks to the intestinal wall & invades the mucous layer. So anything you can do to disrupt the mucous layer while also killing the bad bacteria & encouraging the growth of good bacteria would be a good thing.

Rebalancing the Microbiome, Chapter 3

Avoid antibiotics as they wipe out the good bacteria with the bad. If you must take them, take a probiotic at the same time.

Eat mostly fruits & vegetables. Butyrate-producing bacteria do best with the fiber that comes from vegetables & fruit rather than the fiber from grains & legumes. The best vegetables are the cruciferous ones (broccoli, cabbage, cauliflower & kale) and those containing fructans (artichokes, asparagus, leeks, onions). Aim for 6 cups/day!

Polyphenols in certain fruits enhance the growth of Akkermansia muciniphila, a beneficial bacterium depleted in those with psoriatic arthritis & other autoimmune conditions (p 33). Slightly different polyphenols are found in cranberries & concord grapes & both are effective, so it is possible other darkly pigmented fruits would be similar.

Probiotics alone can’t rebalance our microbiome, but it can help replenish the good bacteria, which can shift the overall balance of the microbiome. She goes into significant detail on various probiotics. I’ve incorporated some of what I’ve learned from her in my list of Bacteria that I will link from here.

But in general, the best at feeding the butyrate-producing bacteria Clostridia are Bifidobacteria. Look for probiotics with B. xxx in them. B. longum, B. breve, B. infantis & B. bifidum.

She recommends several probiotics with the Bifidobacteria strains.

Jarrow Formulas’ Bifidus Balance-available on Amazon as a 3 pack cold shipped but I have not been able to find at my local Whole Foods, GNC or Cost Plus Nutrition, but I will keep looking.
GutPro Infant Powder-no dairy, starch or fillers, but expensive.
Seeking Health Probiotia Bifido
Align-which is available almost everywhere

She cautions against fermented foods, which are heavily promoted in Brainmaker by Dr. Perlmutter and in The Whole 30.

The bacterial strains are chosen for purposes of food production rather than health
They contain histamine-producing bacteria.
They contain yeasts.
The bacteria & yeasts could have an unpredictable effect on your microbiome.

However, if you eat fermented foods and are confident they are not your problem then you obviously can continue.

Another exception would be the process recommended in the Specific Carbohydrate Diet where you make your own yogurt, kefir, kombucha, etc. My mother and daughter in law had good luck making their own yogurt. The key is 24-hour fermentation which I believe allows for the complete breakdown of the lactose in the yogurt as well as higher & fresher probiotics. Link to Breaking the Vicious Cycle on SCD Yogurt.

Prebiotics are more complex and less of a sure thing for those with arthritis. She discusses thoroughly on pages 39-43 and if you are interested in trying a prebiotic I would read this first. Some prebiotics can feed the bacteria that are problematic

SIBO is the overgrowth of bacteria in the small intestine and so probiotics might seem like a bad idea, but she points to evidence that supports the need to balance the gut bacteria and I can personally speak to this as I was diagnosed with bacterial overgrowth in 2011. Antibiotics were the first course of treatment back then, and they did have an immediate effect on diarrhea, but clearly, they did not rebalance my microbiome. She suggests strictly limiting starch & sugar (not everyone agrees on this) and I can personally support that eliminating sugar & starch from my diet for most of the last 18 months has had the most tremendous impact on my gut health. More than anything else!

A low FODMAP diet is not recommended long-term. She recommends trying to identify which FODMAP causes problems, removing starch & sugar and then gradually reintroducing FODMAP vegetables one at a time because they are such important foods for our good bacteria.

Why Mediterranean? Chapter 4

Fish oil & olive oil appear to work best together. The type of Omega 3 is important. DHA & EPA, found in fish, are best at fighting inflammation. The type of Omega 3 found in plant sources (flaxseed) are not as anti-inflammatory & our bodies can’t convert them to EPA or DHA very well.

She provides a great resource for the best fish that are highest in EPA/DHA & low in mercury and makes it available online at The Keystone Approach website.

She does an excellent job explaining fish oil supplements & recommends 2-4 grams/day. She discusses how they oxidize, the consequences of oxidized oil, the manufacturing process, and what we can do as consumers to make the best choices.

Buy in dark or opaque bottles, keep out of light.
Soft gels oxidize less than bulk oil.
Triglyceride forms are better absorbed than other forms.
If in doubt, cut open & smell, it should not smell rancid.
Look for high concentrations, at least 1000mg/capsule.

Recommended sources

Olive oil is also prone to oxidation. She recommends 2 brands that met US & international standards for “extra virgin” status.

California Olive Ranch
Kirkland Signature (Costco brand)
Look for Australian & Californian certifications as well as the harvest date printed on the bottle.
Use within 15 months of harvest date.

Avocado oil is considered an anti-inflammatory fat, mostly monounsaturated oleic acid.

Oils to avoid: saturated fat and refined seed oils.

Long chain saturated fats (palm, ghee, beef tallow, duck & lard) seem to be more inflammatory than medium-chain fats (coconut). Although she cautions against coconut oil for another reason. Coconut oil can cause endotoxin (lipopolysaccharide) to trigger systemic inflammation by activating pattern recognition receptors on mast cells and other immune cells (p. 63). In a referenced study, fish oil decreased the level of endotoxin while coconut oil increased it.

Refined seed oils (sunflower, safflower, canola, corn & soybean) are high in omega 6 and are easily oxidized. And some of them can contain trans fats from the industrial refining process. Even more trans fats are formed when these oils are heated for long periods (restaurant fryers). We now know that trans fats are so harmful that just a 2% increase in trans fat consumption increases heart attack risk by 30% (page 65). If you are at risk for a heart attack, you must read this! The study she cites was titled “Health effects of trans-fatty acids: experimental and observational evidence.” Published in the European journal of clinical nutrition in 2009.

The discussion around Omega 6 is more complex and less certain. (pages 65-70).

The Complete Mediterranean Framework, Chapter 5

Antioxidants are essential to those with psoriasis, ankylosing spondylitis, and arthritis because we have extensive oxidative damage. Look for deeply pigmented fruits & vegetables. Barely cook them by steam, sauté or microwave rather than boiling.

Kale
Spinach
Brussel sprouts
Broccoli
Beets
Red bell pepper
Onion
Cauliflower (color exception)
Carrots (exception: more readily absorbed after cooking)
Blueberries
Blackberries
Cranberries
Strawberries
Pomegranates
Raspberries
Plums
Oranges
Grapes
Cherries
Kiwifruit

Oxalates can be a problem for some people with poor gut health. They bind with minerals such as calcium & form small crystals that deposit in the kidneys & sometimes the joints. Oxalates are usually broken down by gut bacteria & excreted. If you suspect Oxalates, she addresses them on page 75.

Our society’s tendency to blindly jump on diet bandwagons made me initially reject the gluten-free movement as a fussy fad. However, when I decided to cut starch & sugar from my diet, I noticed immediate health benefits. Research now shows that consuming gluten increases intestinal permeability in everyone.

She does an excellent job of explaining the two main groups of proteins (lectins & saponins) in grains, seeds, and legumes, that evolved to protect their embryo from other animals and fungi, but that are potentially damaging to us. (page 79-83). I suspect this will be an area of unfolding research over the coming years. But even if you are not worried about lectins & saponins, she points out that the biggest problem with grains and legumes is their high starch content to low nutrient density. A large portion of the starch we consume is not absorbed but is food for our gut bacteria and it is hypothesized that high starch feeds harmful gut bacteria which contributes to inflammation. I personally find this fascinating as starch is the focus of the Specific Carbohydrate Diet that has been around since the 1970’s.

She states that it is also difficult to meet daily vitamin and mineral needs with a grain & processed-food diet and points to a study that identifies 40% of the US population as deficient in vitamins A, C, E & Magnesium (p. 83). She points to 7 studies that associated magnesium deficiency with inflammation! I’ve just read another book The Magnesium Miracle by Carolyn Dean that I will write about soon.

She points to the importance of the amino acids glycine, glutamic acid, leucine & lysine for collagen building, especially for those of us with collagen constantly being damaged by our immune system!

Be careful with bone broth as cooking the bones too long can result in high histamine levels (I’ve already done this!)

The Autoimmune Mediterranean Framework at a glance

Eat more fish (2-3 servings/week) & take fish oil
Use Olive oil instead of inflammatory seed or saturated fat oils
Eat more vegetables
Eliminate grains & legumes

How to Find your Own Trigger Foods, Chapter 6

She is good at recognizing this is an individual journey with the science still unfolding, and so she is careful to only recommend as absolute those things that we have science to support. Beyond that, we need to do some individual trial & error work.

Three elimination categories:

Starch & sugar (chapter 7). If you have not yet tried eliminating these 2 things, you must try it immediately. I personally eliminated both for about 5 weeks. Then I only added alcohol for about a month. After that, I occasionally ate a dessert at a fancy restaurant without major digestive distress or an arthritis flare. She discusses the research supporting this approach that goes back to the 1920’s. We know this works! Since doing this work I have been able to eat foods that previously caused me problems, like onions! I occasionally have a bad week (or month in the summer) but it is much easier to get back to eating this way & my gut corrects itself in a few days. You can try a mini fast to jump-start the correction too.
Common Allergens (wheat, dairy, nuts, eggs, soy, corn), Chapter 8. I find the elimination of all allergens particularly difficult and have not yet attempted this.
Nightshades (tomatoes, peppers & potatoes), Chapter 9. She does a great job of explaining what it is about nightshades that makes them potentially problematic.

She compares the Keystone Diet to other elimination diets such as the Autoimmune Paleo diet and the Specific Carbohydrate Diet. I have been working on a table of diet comparison for a while now that I will post soon. Essential differences: she does not encourage saturated fat, coconut oil, fermented foods, or organ meats. She does overlap with some of these other diets in that she recommends eliminating grains, refined oil, allergens, nightshades, and starches such as sweet potatoes & plantains.

You’ll have to get the book to get her step by step process of incorporating the diet into your lifestyle and eliminating and reintroducing potential allergens.

Food Chemical Sensitivity, Chapter 10

It is not yet clear whether sensitivity to amines and salicylates has any effect on arthritis or psoriasis so this is a lower priority unless you have noticed symptoms associated with foods high in amines or salicylates.

Anti-inflammatory Supplements, Chapter 11

Vitamin D-research supports. I take Vitamin D3 with K2 but need to watch your levels as mine got too high so I now take it every other day.
Glucosamine supported by research but not Chondroitin.
GLA as Borage or Evening Primrose Oil—research is not clear-cut, but she recommends taking. I have seen these supplements mentioned in other books but not as highly recommended so I will be watching out for these more.
Vitamin E-best if consumed in food because it is 8 similar compounds and pill form is generally only alpha-tocopherol.
Tumeric-not much evidence to support use for psoriasis or autoimmune arthritis.

The Science of Low-Dose Naltrexone, Chapter 12

Naltrexone has been used to treat opioid addictions for years, but current research shows it can be effective at regulating the immune system and reducing pain. If you want to explore this for yourself, tell your doctor about this book as she cites the research supporting this approach in chapter 12.

My key life adjustments after reading this book?

Stopped Coconut oil & will use bacon & butter with caution.
Purchased a Collagen Peptide Powder that I’m adding to my smoothies
I purchased Borage Seed Oil for my psoriasis (this was primarily because I had to stop my Humira for about 6 weeks due to surgery & then a cold). I applied the Borage Oil directly to my skin and it did calm the psoriasis enough to get me through the 6 weeks prior to restarting my Humira.
Will try Jarrow Bifidus Balance.
Will switch to Nordic Naturals Ultimate Omega 2.
I may try Glucosamine again. I have tried various Glucosamine/chondroitin in the past & usually don’t notice a difference.