Inflammation is a huge factor in the disease processes of cystic fibrosis. Some studies have shown that faulty CFTR mutations may directly result in inadequate quenching of radical oxygen species (ROS) or excessive release of other inflammatory compounds like cytokines [1,2]. In addition, our burden of chronic infection and gastrointestinal complications contribute secondary sources of inflammation. Chronic inflammation can lead to both localized and systemic issues. Localized inflammation in the lungs can lead to deficient and/or over-reactive immune responses, bronchitis, scarification and airway remodeling, allergies/asthma/hyper-reactive airway diseases, hemoptysis, pleurisy (inflammation of the pleura), and worsened infection. Localized inflammation in the gut can lead to reflux/GERD, esophagitis, gastritis, pancreatitis, gallbladder issues, liver issues, food sensitivities, malabsorption, autoimmune issues of the intestines, gut infections, general indigestion, and excessive mucus production in both the guts and the lungs (by vagal reflex). Systemic inflammation can cause insulin resistance, body pain, arthritis, achey joints and muscles, fever, fatigue, increased risk for autoimmunity, and increased risk for cardiovascular disease.
So given that CF causes a higher than normal inflammatory burden, what do we do about it? There are four things in general that I suggest: 1) reduce inflammatory substances in your daily life, both in the diet and in the environment; 2) eat lots of anti-inflammatory foods, including probiotics; 3) take anti-inflammatory herbs; and 4) have a regular routine of moderate exercise.
Reduce Inflammatory Substances
I have discussed this at length in many other parts of this website, but reducing things in the diet that cause inflammation is a really big step to reducing one's inflammatory load. By far the most inflammatory culprit in the diet of most Americans is sugar. So sodas and sugar-sweetened foods and beverages should be completely eliminated. The only sugar-sweetened food I allow myself to eat (in moderation) is dark chocolate (at least 70% cocoa) because it is so high in antioxidants, though I do choose stevia- or honey-sweetened chocolate when possible. In addition, refined carbohydrates, like those contained in bread, pasta, white flour, breakfast cereals, and many junk foods are highly inflammatory. Rancid polyunsaturated vegetable oils like corn, soy, canola, grapeseed, safflower, or general "vegetable oil" are oxidative and cause inflammation. Also watch out for low-quality olive oils that may be labeled as olive oil but may actually contain soy, canola, or other rancid oil. I usually avoid buying olive oil altogether because I cannot verify the source, although sometimes I buy from stores that specialize in artisanal olive oil. Instead, I use unrefined coconut oil, bacon fat (from local humanely raised and pastured pigs), and unrefined cold-pressed sesame oil (though I don't cook with it). Grassfed butter or ghee is also acceptable, as long as there is no dairy sensitivity.
Also eliminate foods that the individual has a particular sensitivity to. The most common food sensitivities are gluten (especially in wheat), dairy, and eggs. An elimination diet is the best way to find out one's food sensitivities, as tests are not always very accurate and sometimes expensive.
Also examine one's environment for potential allergens, toxic chemicals, and pollutants. Assess whether or not the individual is allergic to common allergens such as pet dander, pollens, household mold, and dust. Sometimes air filters can be helpful in reducing allergen loads in the house. Also, antihistaminic and anti-allergic herbs can help alleviate many allergy symptoms and help control over-reactions of the immune system. These herbs include nettles, goldenrod, plantain, and reishi mushroom. Pollution can play a significant inflammatory role, so reducing exposure to air pollution and increasing exposure to healthy air environments such as forests and the ocean is important. Having indoor house plants can also play a big role in reducing indoor air pollution . The types of chemicals we use in the house can also cause inflammation. Avoid toxic chemicals when cleaning and instead use natural substances that work just as well, such as vinegar, baking soda, borax, and a variety of plant-based cleaners, soaps, and detergents.
Alcohol consumption and smoking are also extremely inflammatory, so I recommend CFers avoid those substances completely (except for herbal extracts using alcohol).
Eat Anti-Inflammatory Foods
In my eBook on nutrition for CF I discuss healing foods in more depth, but in general, those foods that are the most anti-inflammtory are vegetables (especially wild vegetables), low-sugar fruits (like berries and sour apples), and wild or grass-fed animal foods. Eat as much green leafy vegetables as possible, especially bitter greens like arugula, dandelion greens, radicchio, mustard greens, spinach or chard (if there's no issue with kidney stones), kale, collard greens, and much more. These greens are high in bioflavonoids and other anti-inflammatory compounds that directly quench ROS. They also upregulate liver metabolism to reduce the amount of inflammatory metabolites circulating throughout the body. Members of the crucifer/brassica and allium families such as broccoli, cauliflower, cabbage, collard greens, mustard greens, horseradish, and garlic contain isothiocyanates, a plant constituent with potent antioxidant power. Berries are high in antioxidants, low in sugar, and high in fiber, making them a tasty way to increase antioxidants in the diet. Wild blueberries are especially high in bioflavonoids called anthocyanidins. As with most plants, wild sources are higher in antioxidants than cultivated sources. For example, my sister makes a medicinal pesto made with lamb's quarters (a common weed), fresh basil, and garlic scapes that will knock your socks off!
Grass-fed, pastured, or wild meats, fish, and dairy are high in antioxidants and vitamin A that those animals extracted directly from the plants that they ate while living and grazing in a natural environment. Grass-fed meats are much higher in anti-inflammatory omega-3 fatty acids compared to meats from grain-fed animals kept in factory farms, which are higher in inflammatory omega-6 fatty acids. So whenever possible, choose organic and grass-fed meats and dairy. Wild, sustainable fish is also a healthy choice, but only if those species are not over-harvested. Check Seafood Watch to make smarter choices about sustainable fish purchases.
Also eat plenty of foods that are probiotic, like lactofermented vegetables, yogurt, or kombucha. Fermented foods are high in beneficial bacteria that release anti-inflammatory compounds and help regulate the immune system. Also consider taking a daily probiotic supplement if necessary (for most CFers on and off antibiotics, a probiotic supplement is necessary). A brand that is pretty widely available in health food stores that is relatively affordable is the Garden of Life brand, although there are some other good brands out there (and also a lot of bad ones). I recommend people avoid buying probiotics from drug stores, the Vitamin Shop, GNC, or similar conventional sources as they often sell cheap brands that are totally worthless.
Almost all herbs, being wild plants, are anti-inflammatory. That said, some are extra special in their anti-inflammatory powers. One of those is turmeric, which has gotten a lot of press and a lot of good research in the last few years. It is an excellent herb for reducing systemic inflammatory load, and when combined with other herbs (like in Indeptra) can even modulate CFTR function. There is one drawback to turmeric though: in high doses it can thin the blood and reduce clotting ability, which is a bad thing for people with a history of hemoptysis. So if you have hemoptysis sometimes, it's probably a good idea to avoid turmeric, or just take it in small doses or cook with it.
My favorite anti-inflammatory herb is baikal skullcap, also called Chinese Skullcap (Scutellaria baicalensis). It comes to us from Traditional Chinese Medicine, and is considered cold, anti-inflammatory, liver protective, immunomodulant, febrifuge (can cut fevers), and even nervine (calmative to the nervous system). In terms of high inflammatory burdens caused by infection, I believe baikal skullcap to be particularly well suited to CF. The only drawback is that for people who are already very cold (get chilled easily, poor circulation, etc.) it may exacerbate coldness over a long period of time. But the solution to that is to take it with a warming anti-inflammatory herb, like garlic or ginger.
In terms of gut inflammation, there are many herbs that work fantastically in ways that pharmaceuticals can't. Ginger is an excellent anti-inflammatory herb, both locally in the gut and systemically in the body. It is warming and works especially well for reducing nausea, stomach aches, gassiness, and post-meal indigestion. The great thing about ginger is that you can find it essentially anywhere and can take it in a variety of forms including in tea, capsule, tincture, powder, in food, fresh or dried, candied, pickled, etc. Chamomile and peppermint work similarly, although these herbs are cooling and are generally just used in tea. Meadowsweet is my go-to anti-inflammatory herb for the gut. It contains methylsalicylates, the plant form of salicylic acid which is contained in aspirin (originally extracted from willow). These constituents are highly anti-inflammatory to the gut mucous membrane and meadowsweet also contains a bit of tannins to help tone the gut tissue, especially if there is some leaky gut going on. Plus it tastes great in tea.
There are so many anti-inflammatory herbs that I can't possibly name them all. And each one is particularly good at something that none of the others are, or has a special affinity for an organ system. For instance, cinnamon is anti-inflammatory and has a special affinity for the circulatory system, plus it is excellent at helping to modulate blood sugar (it's one I use daily). Milk thistle seed is my go-to herb for liver inflammation, especially if liver enzymes are high, or if there is exposure to pharmaceuticals, alcohol, or other substances that are harmful to the liver. Reishi mushroom is my favorite herb for helping to rebalance and re-educate a hyper-reactive immune system, especially in the case of allergies or autoimmunity. It is one of the most revered herbs in Chinese medicine, and there is a lot of really good clinical research on it.
A good way to monitor your level of systemic inflammation is a simple blood test called a C-reactive protein (CRP). I get mine checked regularly to see how it changes over time. Again, there are so many anti-inflammatory herbs out there that the best way to find out which ones may be helpful for you is to study herbalism yourself, or consult an herbalist.
The human body evolved to operate best with daily moderate exercise (like walking) interspersed with short periods of intense exercise (like running, lifting heavy things, or climbing stuff). Having a daily exercise routine helps the body produce its own endogenous antioxidants, which help quench ROS and improve the body's resilience to stress. Personally, I walk and bike daily and rock climb several times a week. Since exercising regularly, I found that my energy levels have drastically improved, my cardiovascular capacity is much greater, I have more focus and my memory is better, my mood is better, my digestion is better, and I recover more quickly from infections. If I go several days without exercise, I really notice the difference, especially in my mood and my digestion.
When it comes to inflammation, conventional medicine has very few tools. What conventional doctors can offer is essentially two things: NSAIDs (non-steroidal anti-inflammatory drugs), and immunosuppressing drugs like steroids and methotrexate. These drugs have significant side effects that can be life-threatening if dosed incorrectly or if taken for too long. NSAIDs like aspirin and ibuprofen thin the blood, which can lead to excessive bleeding and so is not a good idea for people with hemoptysis. Furthermore, because they are COX-inhibitors they suppress the body's production of prostaglandins that protect the mucosal lining of the gastrointestinal tract. This means that taking NSAIDs for too long, even at normal doses, can cause stomach and intestinal ulcers. In the last 10 years CF docs have studied using high-dose ibuprofen on children, and while results have shown inflammation to be reduced, these children cannot continue using ibuprofen into adulthood without significant mucosal damage to the GI tract. If mucosal damage from NSAIDs is suspected, taking licorice can help restore the GI mucosa to normal. Steroids and other immunosuppressing drugs are also dangerous if taken for too long as they totally shut down the immune system and can make us more susceptible to catching infections of all kinds. They also increase the risk of developing cancer, as the immune system is responsible for constantly detecting and destroying cancer cells as they crop up. Furthermore, steroids like prednisone cause fluid retention, insulin resistance, and shut down our endogenous production of cortisol so that the adrenal glands sometimes have a hard time restarting production of cortisol on their own after stopping the drug, which can lead to adrenal fatigue (extreme fatigue, poor resilience to stress, poor immunity, etc.). When appropriately used at the appropriate doses for short spans of time, these drugs can be very beneficial and even life saving. But they can also be over-prescribed or misused, and so anti-inflammatory herbs can be used instead, when appropriate.
I hope I've outlined some helpful information for using natural means to tackle inflammation. Reducing the burden of inflammation in CF can help us in many different ways including aiding recovery from illness, infection, improving immune responses, reducing pain and discomfort, and improving mood. Try it out and let me know if you find anything else to be helpful.
Mica McDonald (they/he) is a clinical herbalist, nutritionist, ecologist, and writer living in Abenaki territory (Vermont).