Published: 22nd February, 2014
Authors: A. Ebringer, Clyde Wilson

This is an important paper because it documents the study of 36 ankylosing spondylitis patients following the Low Starch Diet (or “London AS Diet”).

Following on from the success of this trial the diet was used to treat over 450 patients at the AS clinic in the Middlesex Hospital in London.

Frustratingly rheumatologists and medical professionals are often completely unaware of these trials or Professor Ebringer’s work.

However, there is good news…

The University of Porto, Portugal is running a clinical trial of 150 patients following the Low Starch Diet.

It is hoped this will conclude in the latter half of 2022. More details on this can be seen here.

Summary:

“The majority of ankylosing spondylitis (AS) patients not only possess HLA-B27, but during active phases of the disease have elevated levels of total serum IgA, suggesting that a microbe from the bowel flora is acting across the gut mucosa.

Biochemical studies have revealed that Klebsiella bacteria, not only possess 2 molecules carrying sequences resembling HLA-B27 but increased quantities of such microbes are found in fecal samples obtained from AS patients and such patients have Crohn’s like lesions in the i1eo-caecal regions of the gut. Furthermore AS patients from 10 different countries have been found to have elevated levels of specific antibodies against Klebsiella bacteria.

It has been suggested that these Klebsiella microbes, found in the bowel flora, might be the trigger factors in this disease and therefore reduction in the size of the bowel flora could be of benefit in the treatment of AS patients.

Microbes from the bowel flora depend on dietary starch for their growth aud therefore a reduction in starch intake might be beneficial In AS patients.

A “low starch diet” involving a reduced intake of “bread, potatoes, cakes and pasta” has been devised and tested in healthy control subjects and AS patients.

The “low starch diet” leads to a reduction of total serum IgA in both healthy controls as well as patients, and furthermore to a decrease in inflammation and symptoms in the AS patients.

The role of a “low starch diet” in the management of AS requires further evaluation.”

Introduction:

“The discovery that the majority of patients with ankylosing spondylitis (AS) are HLA-B27 positive has led to a search of suitable biochemical models which could explain the association, the two most important being the “receptor theory” and the “molecular mimicry theory”.

Using the “molecular mimicry theory” as a model, molecules have been identified in Klebsiella microorganisms, which possess sequences resembling HLA-B27.

Furthermore AS patients from 10 different countries have been found to have elevated levels of specific antibodies against Klebsiella microorganisms and it has been suggested that these microbes are probably the causative agents of this disease.

These observations could be of relevance in the treatment and even prevention of this condition…”

Starch as the Source of the Main Bacterial Substrate in the Gut:

“Early studies in patients with AS using low doses of antibiotics such as co-trimoxazole and phthalyl-sulphathiazole did not lead to any significant improvements, although some patients admitted that the use of antibiotics decreased the dose of “nonsteroidal anti-inflammatory drugs” (NSAID’s) required to control their symptoms…”

Low Starch Diet in AD Patients

“In an initial study of 36 active AS patients (ESR > 15 mm/hr), the mean ESR dropped from 38 ± 3 mm/hr (mean± SE)to24± 2mm/hr(p<0.001), when studied over a period of 9 months, but no such difference was observed in the same group of patients when examined retrospectively for the same period of time before they went on the “low starch diet”.

A significant drop in total serum IgA was also observed in these patients over this period.

The majority of these AS patients reported that the severity of their symptoms declined and in some cases completely disappeared. Many patients noticed that their requirement of NSAID’s also decreased.

Since 1983, the “low starch diet” has been used in the treatment of over 450 AS patients attending the ”AS Clinic” at the Middlesex Hospital in London.

Over half of these patients do not require any medication and are treated by diet alone.

The remaining patients, may require low doses of NSAID’s and those with an ESR elevation above 20 mrn/ hr are treated with sulphasalazine-EN (Salazopyrin), in the dose range from 0.5 G to 3.0 G daily.

Another advantage of the “low starch diet” is that lower doses of sulphasalazine-EN are required to achieve a therapeutic effect, thereby avoiding some of the undesirable side-effects of NSAID’s.

It takes some time, usually 3 to 6 months for the patients to become familiar with the “low starch diet”. Patients are advised to consult the members of the AS Clinic, either the attending physician or specially trained nursing staff.

The AS patients are encouraged to ring the sister in charge of the AS Clinic, with any queries regarding the management of their condition and especially to discuss any problems associated with the “low starch diet”. A minority of patients find the diet difficult to adhere to and then they have to be treated with higher doses of NSAID’s.”

Case

“Mrs. B; who is HLA-B27 positive, had her first symptoms of AS in 1969, when she was 20 years old. She was first seen in the ‘AS Clinic” in 1976 and over the subsequent 7 years had almost continuous, unremitting pains affecting large peripheral joints, thoracic cage and the whole of the spinal column, eventually leading to complete ankylosis.

During this period, her ESR was rarely below 20 mm/hr and she acquired the radiological and clinical stigmata of advanced AS.

She started on the “low starch diet” in 1983 and her clinical condition improved over the subsequent months. Her ESR dropped to below 20 mm/hr and has remained normal for the last 12 years.

She was last seen in May 1995 when her ESR was 5 mm/hr and her haemoglobin was 13.2 G/dl. She takes an occasional NSAID tablet for the mechanical pains produced by her rigid spine.

Clearly the use of a “low starch diet” in the treatment of AS patients during active phases of the disease could be beneficial but these results must be evaluated by prospective, longitudinal studies.

Treatment of AS Patients and HLA-B27:

“The discovery of the association of HLA-B27 with AS has opened new approaches to the treatment of this disease which will require evaluation by many rheumatological centers in different countries.

The “molecular mimicry theory” has led to the recognition that Klebsiella micro-organisms are somehow involved in this disease.

Several independent studies have demonstrated that sulphasalazine is an effective drug in the treatment of AS and it isknown that this drug has antibiotic activity against Klebsiella microorganisms. Furthermore, Finnish studies have demonstrated that following treatment with sulphasalazine, the titre of anti Klebsielia antibodies decreases.

Another possible therapeutic approach is to restrict the growth of gut Klebsiella by a modified “low starch diet “.

Rheumatological centres can now contribute to the debate as to the role of HLA-B27 in AS, by studying the response of patients following treatment with anti-bacterial antibiotics and diet manipulation.”