Arthritis and diet
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
Click here: Second Opinion Arthritis Treatment Kit
Seventy million Americans, nearly one in four suffers from one of the more than 100 types of arthritis.
Information from the Arthritis Foundation...
Osteoarthritis, the most common form of the disease, affects more than 21 million Americans. Rheumatoid arthritis attacks about 2 million more.
Inflammation—heat, swelling, pain, redness and/or loss of motion—is the common link. Scientists are just beginning to understand the inflammatory process. They know that it begins with a trigger such as an infection or tissue damage. In response to this trigger, white blood cells rush to the affected area and release chemicals to aid in the repair process. Among them are prostaglandins —which can both reduce and promote swelling, and leukotrienes—which intensify inflammation. In addition, cytokines- chemical messengers that perpetuate inflammation and destruction- are also produced.
The white blood cells also release digestive enzymes to remove bacteria and other foreign particles. The white cells recognize these invaders as foreign proteins or antigens and focus their attack. However, the enzymes the white cells release have potential side effects since they can also digest normal tissue such as cartilage, bone, ligaments, muscle, and other tissues. In inflammatory rheumatic diseases like arthritis, this process becomes chronic.
So what is the role of diet in this process? Some scientists feel the trouble may start in the intestines, where foreign antigens can slip through the lining of the intestinal wall, enter the bloodstream, and travel to a joint. The presence of antigens there attracts white blood cells and a subsequent inflammatory process.
If these invading antigens are byproducts of a particular food that a person is allergic or sensitive to, eliminating it from the diet could possibly reduce swelling in the joint and cut down on arthritis pain. However, very few people have a true food allergy.
Another explanation offered is the presence of lectins, food molecules that can act like antigens. Recent studies in both the British Journal of Rheumatology, and the British Journal of Nutrition point out that many foods commonly mentioned in discussions of food allergy, such as peanuts, beans, peas, lentils, barley, rye, oats, corn, and wheat, are particularly rich in lectins. Lectins are known to cause changes in the wall of the digestive tract that can permit antigens to leak into the system and trigger autoimmune reactions that could lead to rheumatoid arthritis. Undoubtedly, more research on the effects of lectin-rich vs. lectin-free diets is needed before any definitive conclusions can be drawn.
Researchers also suggest that arthritis patients may experience a greater transfer of antigens through the intestinal wall because of damage to the intestinal lining from prescription medications such as non-steroidal anti-inflammatory drugs that many arthritis patients take. They say that dietary manipulation, including fasting for short periods of time, could reduce the number of antigens available to pass through the intestinal lining.
Some specialists hypothesize that one reason arthritis may improve when food is restricted is that there is a modification of the immune system that for a time prevents and slows down the inflammatory attack on the body's tissues.
Arthritis, because it causes chronic pain, often prompts people to try unproven remedies. Although it is a chronic disease, its symptoms wax and wane making it difficult to tell whether a period of relief is due to a new remedy or merely to coincidence. Worse yet, even the most effective remedies tend to have a variable effect. Treatments affect each type of arthritis differently, they work differently from one person to the next, and their effects change as the disease progresses.
Doctors often have to search for the combination of therapies that works best for a particular patient. This is an arduous task. It's easy to become discouraged and look for answers in other areas.
There are a multiplicity of books on special diets, foods, and supplements that supposedly relieve arthritis. These works usually lack any solid scientific basis. They often contradict each other. Yet their attraction to arthritis sufferers is understandable.
Since arthritis is generally not life threatening and because it doesn't have the cachet, say, of cancer or heart disease, it is like Rodney Dangerfield. It gets "no respect." People operate under the illusion that arthritis is “ just getting old... that you just have to live with it.”
In a nationwide survey of 1,051 people with osteoarthritis or RA, nearly half of the respondents admitted to changing their diet to see if it would help their condition, even if their physicians advised against it. Some respondents simply started eating healthier foods, avoiding fats, and increasing their intake of vegetables. Others tried systematically eliminating foods from their diet and discovered some they thought they could associate with flare-ups of their arthritis. Still others added vitamins, minerals, and other supplements like fish oil to their diets.
Elimination diets are a way of identifying a hypersensitivity to a particular kind of food. A specific food or food group suspected of causing a reaction (such as milk, meat, or processed foods) is removed from the diet. Then the suspect foods are reintroduced one at a time to see whether any are harmful.
Some laboratories offer evaluation of blood for food allergens. This type of testing may be beneficial in selecting the proper elimination diet you need.
Researchers have found that in some rheumatoid arthritis patients, specific foods do make symptoms worse. However, avoiding these foods or food groups has been shown, for the most part, to have only limited, short-term benefits. One interesting study in England found that 10 out of 17 people benefited from any diet recommended by their doctors, pointing to a placebo effect.
Nevertheless, fad diets based on elimination of various "trigger" foods are common for arthritis sufferers to try, especially rheumatoid arthritis. There are claims that foods from the nightshade family—tomatoes, potatoes, green peppers, and eggplant—can make arthritis worse.
Researchers have uncovered other patterns while investigating the effects of diet. One study found that simply eating too many calories appeared to aggravate rheumatoid arthritis. There is an association of obesity with rheumatoid arthritis. A few other studies have shown that some people, especially vegetarians who eat no dairy or animal products, report less pain than those with high meat consumption. (About 5 percent of people with rheumatoid arthritis experience a flare-up of symptoms after drinking milk.) In these 1991 studies, when patients were fasting or on a severely restricted diet, their symptoms improved significantly. And when dairy or animal products were reintroduced, episodes of pain, swelling, and stiffness increased.
The strict vegetarian diet underwent further testing in 1998, when Finnish researchers put a group of rheumatoid arthritis sufferers on a regimen that consisted of raw fruits and vegetables supplemented with lactobacillus, one of the healthy bacteria found in many yogurts. The findings were basically positive. Patients reported improvement in their symptoms during the study, with flare-ups when they went back to their regular diet. However, the regimen is clearly not for everyone: About half the volunteers suffered nausea or diarrhea and dropped out of the experiment.
Still, the notion that lactobacillus may have a place in the treatment of arthritic diseases may prove valid. Animal experiments tend to support the idea. Mice given lactobacillus in one recent study proved less likely to develop arthritis, and their immune system was better at handling the disease.
Recent human trials suggest that a vegetarian diet—sometimes following a fast—may help relieve rheumatoid arthritis, at least in some patients. However, it's worth remembering that protein is lost during the inflammatory process, and one study has suggested that high amounts of protein could be protective. If one eliminates meat and dairy products from their diet, they should replace them with fish or vegetable proteins, such as soy products.
If you suspect that something in your diet may worsen your arthritis, you need to be use a system to prove it:
•Keep a diary of everything you eat, and a diary of pain and other arthritis symptoms. When you compare the two, you may see some correlation.
•Once you suspect a certain food is the culprit, stop eating it for at least six weeks so you can be sure it is completely out of your system. Then add that food back into your diet and see what happens. Most researchers studying the correlation between food and arthritis say six weeks is the minimum time needed to reliably and accurately test any correlation.
•Carefully consider the food group you are considering removing from your diet. Dairy products may aggravate arthritis symptoms, for example, but they also provide essential nutrients. Make sure you can get those nutrients from other foods.
A 1987 study of 48 rheumatoid arthritis patients tried to pinpoint particularly troublesome foods. After six weeks of dietary elimination, 41 were able to identify foods that had caused a flare in their symptoms. Cereal foods like corn and wheat were considered a problem by more than half of the study participants. Here is a list of foods the patients found troublesome and the percentage of symptomatic patients affected by the food:
Lamb 17%Soy 17%
Participants in the national survey on arthritis also reported cutting out some foods. Of the 1,051 people who were sent detailed questionnaires in the mail, 10 percent reported being sensitive or intolerant to certain foods. Red meat turned out to be the culprit often associated with a flare-up of arthritis pain for this group. In addition, survey respondents mentioned as triggers sugar (and sweets in general), fat and fried foods, salt, caffeine, dairy products, nightshade vegetables (tomatoes, white potatoes, eggplant, and bell peppers), pork and smoked or processed meats, alcohol, junk food, starches, additives and preservatives, acidic foods, and chocolate.
Gout is the only form of arthritis that is unquestionably linked to diet, although the number of people whose gout can be blamed entirely on what they eat is small. For a victim of gout, foods high in substances called purines, such as liver, kidney, fish roe, mussels, anchovies, peas, beans, pancreas and brain, add to the existing problem of elevated levels of uric acid in the blood. Drinking too much alcohol and crash dieting can also raise the level of this acid. The uric acid that the body either overproduces or can't get rid of forms into tiny crystals like shards of glass which float in the joint space. When the immune system attacks these crystals, inflammation occurs.
People with arthritis often have vitamin and mineral deficiencies, but these deficiencies are thought to be a result of the disease rather than its cause. An example is vitamin D deficiency in rheumatoid arthritis. Such problems are associated with other immune system diseases as well. Studies involving vitamin and mineral supplements have shown conflicting results with few hard conclusions.
The Arthritis Foundation compiled this list of 10 practices typical of promotions for unproven remedies. The Foundation warns that even a doctor's testimonial doesn't always make a claim legitimate. You should be alert for these signs:
1.A cure is offered. (There is no known cure yet for any form of chronic rheumatic disease. All current treatments merely reduce the symptoms and slow the progress. When genuine cures are found, there won't be any question about it; the whole world will know.)
2.The cure or remedy is described as a "secret" formula or device—as "exclusive," or "special." (Legitimate scientists don't keep their discoveries secret or exclusive.)
3.Testimonials and case histories of people who have supposedly been helped by the remedy are offered as "proof" of its effectiveness. (A few successes— if true—still don't prove the remedy will work for everyone.)
4.The remedy or treatment is described in sensational articles in tabloids and special health-interest publications, or advertised in magazines and through mail order promotions. (The tabloids are fun; but you should never take them seriously.)
5.Quick, simple relief of pain is promised or implied. (There is nothing simple about arthritis.)
6.The treatment is promoted as "cleansing" the body of poisons or "toxins" to allow the body's "natural" curative powers to clear up the disease. (They won't.)
7.Drugs and surgery are condemned as damaging, dangerous, and unnecessary and you are advised to try a non-drug treatment. (Standard treatments can be dangerous for some people, but that doesn't mean a non-drug treatment will work.)
8.No reliable evidence or scientific proof is offered to back up claims that the advertised remedy is safe and effective. (The promoter has not had the method properly tested in clinical trials.)
9.A special diet or nutrition treatment program is promoted as the answer. (Research scientists have not found any foods or nutrients that, by themselves, cause any rheumatic disease, or can be relied on to make any of these diseases better or worse [except modestly in gout]).
10.The "medical establishment" is accused of conspiracy to thwart progress by refusing to "recognize" or "approve" the remedy being promoted. (Doctors are conservative; but they have no reason to deliberately block progress.)
The latest supplement to bring hope to arthritis patients is fish oil. This oil contains what scientists refer to as omega-3 fatty acids, a kind of polyunsaturated fat. Research is showing that, unlike saturated animal fat, omega-3 fatty acids may reduce cholesterol buildup, lower blood pressure, prevent blood clots, and even cut the risk of some types of cancer. A number of recent studies also suggest that altering the types of fat in the diet can affect the immune system's inflammatory response, and that fish oil in particular may aid in the treatment of arthritis. Two of the acids contained in the oil—eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)—reduce production of the prostaglandins and leukotrienes that promote inflammation.
The beneficial effect of fish oils on arthritis was seen as early as 1959, when arthritis patients taking cod liver oil showed clinical improvement in their symptoms. After several other small studies, a formal trial was launched in which some patients received fish oil capsules and others received olive oil capsules. Olive oil currently has no known role in arthritis treatment; it was used as a placebo against which to measure the effect of the fish oil. The researchers carrying out the study noted that after 14 weeks of treatment the patients taking fish oil reported significantly fewer tender joints and a delay in the onset of fatigue. A similar trial, also using olive oil as a placebo, found that patients taking fish oil supplements had fewer painful joints and increased grip strength after 12 weeks. Morning stiffness and overall pain relief improved in both groups of patients, but curiously, more so in the group receiving olive oil.
So far, only high doses of fish oil in capsule form have been studied. A number of studies have demonstrated efficacy in rheumatoid arthritis. High dose fish oil concentrates are available only by prescription and can be expensive. Low dose capsules are available over-the-counter in health food stores, supermarkets, and pharmacies. They have been known to cause side effects such as upset stomach, gas, and a fishy aftertaste in the mouth. Fish oil also thins the blood, which is why it is being studied in heart disease patients.
A better way to increase the amount of omega-3's in your diet may be to eat more cold-water ocean fish. Here is a list of fish (6 ounce servings) with high omega-3 content (in grams):
Mackerel, king 3.7
Herring, Pacific 3.1
Herring, Atlantic 2.9
Tuna, bluefin 2.7
Salmon, chinook 2.6
Sturgeon, Atlantic 2.6
Tuna, albacore 2.6
Whitefish, lake 2.6
Anchovies, European 2.4
Salmon, Atlantic 2.4
Salmon, sockeye 2.2
Salmon, coho 1.7
Salmon, pink 1.7
Other oils produce similar effects for arthritis sufferers, and for similar reasons. Evening primrose oil, for example, which is high in gamma-linolenic acid (GLA), has been shown to inhibit the formation of leukotrienes. Research suggests that borage seed oil, also rich in GLA, suppresses inflammation and appears to give pain relief similar to that of NSAIDs in arthritis suffers. Blackcurrant seed oil and flax seed oil, which are high in linolenic acid, can reduce the body's level of inflammation-inducing prostaglandins. All of these oils, however, need more study before we can be certain of their value in arthritis treatment.
Remember, too, that both fish oils and oils high in GLA can thin the blood, which could become a problem for people who take NSAIDs, since these drugs also suppress blood clotting. Be sure to check with your doctor before trying any of the oils as a treatment for arthritis.
Research with animals has shown that vitamins A, B, C, D, and E are all related to immune system functions, either by supporting immune response or otherwise regulating the system. Iron deficiency can seriously impair the immune system, reducing its ability to digest bacteria and produce enough of the T cells that direct immune response and attack infection. Zinc, copper, magnesium, and selenium also play a role in immune response.
Vitamin B. Studies have shown that some people with arthritis are deficient in the B vitamins, including B6, thiamin (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), cobalamin (B12), folic acid, pantothenic acid, and biotin. In 1983, a group of researchers studied the diets of 24 patients with rheumatoid arthritis and 12 with osteoarthritis and found that most were consuming far less B vitamins than they should. In 1987, the diets of 52 people with rheumatoid arthritis (RA) were also found to be vitamin B-deficient. Some foods rich in B vitamins, like liver and kidney, are off limits to arthritis sufferers because of the high levels of purines they contain. Other foods containing vitamin B, such as whole-grain cereals, fish, and green leafy vegetables, are recommended for arthritis sufferers. One reason why arthritis patients may be deficient in B vitamins is that the drugs they use, including aspirin, can actually deplete the body of B vitamins.
Vitamin C. Along with vitamins E and beta-carotene, vitamin C is a leading antioxidant. In the body, antioxidants help to neutralize certain oxygen-reactive molecules called free radicals that are thought to contribute to disease and tissue damage. Laboratory studies show that cells from osteoarthritic knee cartilage can release excessive amounts of these free radicals. And studies in 1988 and 1989 found that osteoarthritis patients with the most antioxidants in their diets had significantly lower chances of disease progression. Those who had a high vitamin C level, for instance, enjoyed a two-thirds reduction in the risk of further osteoarthritic damage to their knees.
The body's stores of vitamin C and other antioxidants are often depleted by inflammation. Taking 500 milligrams a day of this water-soluble vitamin has been known to improve the spontaneous bruises which often accompany RA, and it may also improve the effectiveness of aspirin in the body. You can get vitamin C naturally by increasing your dietary intake of citrus fruits, melons, green leafy vegetables, tomatoes, and green peppers.
Vitamin D. Osteoarthritis can cause thinning of the bones, so patients with this disease may need additional vitamin D and calcium. In addition, steroid medications, like prednisone, which are often given to arthritis sufferers because they are powerful anti- inflammatories, can cause bone deterioration. In 1974, some British scientists published information about 17 elderly women with RA. Five of the women had suffered fractures in their leg bones, while the other 12 had not. Upon interviewing the study subjects, the researchers found that the women with the fractured bones all had diets deficient in vitamin D. These five women were also housebound and therefore unable to spend time in the sunshine, which produces vitamin D.
In the same study that examined the effect of antioxidants on osteoarthritis of the knee, researchers also evaluated the effects of vitamin D. They found that patients taking vitamin D or eating a diet high in the vitamin could expect a three-fourths reduction in the risk of disease progression. Greater blood levels of the vitamin were also associated with lower risk of progression.
Current guidelines recommend 400 IU of vitamin D per day and 600 IU per day above age 61. Lack of sunlight and unhealthy diets contribute to deficiencies in vitamin D. Good dietary sources include fortified milk, sardines, herring, salmon, tuna, liver, dairy products, and egg yolks. Although supplements are often necessary, vitamin D can be toxic in high doses, and no one should take more than 1,200 IU per day.
Vitamin E. Because vitamin E is an antioxidant, it may work similarly to vitamin C. In the study of the antioxidants' effects on osteoarthritis of the knee, patients with higher levels of vitamin E had a one-third reduction in the risk of disease progression. In a few small studies from Germany, vitamin E has also been shown to relieve arthritis pain. Corn oil, sunflower seeds, wheat germ, nuts, whole grains, and legumes are sources of vitamin E.
Calcium. If you're worried about your bone density, you should increase your intake of calcium along with vitamin D. In addition to natural aging, drugs often given to arthritis patients can reduce calcium levels. Supplements can help fight osteoarthritis, but they shouldn't take the place of foods high in calcium. Make sure you add some of these calcium-rich foods to your diet: low-fat milk, yogurt; calcium-fortified juice; sardines, salmon and mackerel (canned with bones); tofu (with calcium sulfate); cheese (cheddar, Muenster, American, part-skim mozzarella).
Copper. The ancient Greeks believed copper had mysterious powers to heal aches and pains. Some arthritis sufferers wear copper bracelets as a folk remedy; and small traces are actually absorbed into the body. But those with RA usually have higher than average levels of copper in their blood, not lower. This is important because high levels of copper can make you feel sick. Most experts believe that copper has no place in causing or treating the disease.
Selenium. Patients with RA seem to have lower levels of the trace mineral selenium than people without it. Selenium deficiency does cause a type of arthritis known as Kashin-Bek disease, which is more common in areas where the soil is particularly low in the mineral. Generally though, studies of selenium supplementation have been contradictory. If you choose to enrich your diet with selenium, eat more fish, organ meats, whole grains, beans, and nuts.
Zinc. Too much copper in the body can lead to zinc deficiency because the two minerals balance each other. In some studies patients taking zinc supplements have seen improvement. Half of the 24 people involved in a study conducted in the 1970s took 220 milligrams of zinc 3 times a day and found they experienced less morning stiffness, less swelling, and felt better overall, compared to the other half of the patients who were given placebos. Unfortunately, other studies conducted since then have had conflicting results. If you choose to increase zinc in your diet, good sources include oysters, ground beef, veal, pork, fish, soybeans, granola, cheddar cheese and tofu.
The Arthritis Foundation suggests following these seven rules to maintain a healthy diet.
•Eat a variety of foods
•Maintain ideal weight
•Avoid too much fat and cholesterol
•Avoid too much sugar
•Eat foods with enough starch and fiber
•Avoid too much sodium
•Drink alcohol in moderation
Recently, supplements of glucosamine and chondroitin have gained popularity with consumers in the U.S. because of a new book called The Arthritis Cure by Jason Theodosakis, MD, an Assistant Clinical Professor at the University of Arizona College of Medicine. Glucosamine and chondroitin are substances produced by the body to repair and maintain joint cartilage. Although scientists don't yet know exactly how they work, European and Asian studies suggest that synthetic forms of these substances are indeed capable of relieving arthritis symptoms, and may possibly slow the breakdown of cartilage in the joints. Further research by the National Institutes of Health is being conducted to confirm these findings and determine the effects of long-term use. Glucosamine and chondroitin are not found in food, and therefore must be taken in supplement form. Checking the purity of ingredients is advised when considering a supplement.
Another promising line of research indicates that the polyphenolic compounds in green tea may be effective in treating and preventing rheumatoid arthritis. Studies funded by the Arthritis Foundation showed a significant decrease in the incidence of RA and a reduction in the severity of the disease when these compounds, which have antioxidant properties, were given to mice in their water. Scientists have yet to confirm similar results in humans, but if you want to try out the remedy for yourself, three to four cups of green tea a day will supply an amount roughly equivalent to that given the mice.
Some studies have suggested that an unbalanced diet could be one of the triggers for the development of rheumatic diseases such as RA. Although we don't know this for sure, we do know that a balanced diet provides nutrients essential to your well being. Naturally, it's important for everyone to eat properly, but it's especially important if you have arthritis because of the many barriers to good nutrition that you may face.
Your medications can also interfere with a good diet. Some drugs can upset the stomach, causing nausea, diarrhea, and other reactions that result in either a lack of appetite or an inability to digest food properly. In addition, some medications can rob your body of essential vitamins and minerals. For example, steroid medications cause the body to lose potassium and retain sodium; if you have gout and are taking colchicine, it affects how well your body absorbs vitamin B12; and penicillamine, rarely given to people with RA, lowers the body's levels of copper.
One of the most important things you can do is to avoid foods high in saturated fats. Such foods are high in calories that would be better coming from a wider variety of nutritious foods. Scientists in Russia recently showed that an overall healthy diet, with only small quantities of saturated fats (but with higher levels of polyunsaturated fatty acids than many of the people in the study usually consumed), brought about improvement in many arthritis patients. Within the first two weeks of the study, more than two-thirds (67.6 percent) saw a marked decrease in painful joints, and 82 percent saw an improvement in morning stiffness. Nearly one quarter (24 percent) of the patients were able to reduce their dosage of antirheumatic drugs; for example, they lowered their intake of ibuprofen by 400 to 600 milligrams per day, and lowered their intake of prednisolone by 1.25 to 2.5 milligrams daily.
The authors of the study contend that the whole nutrient mix in the test diet, which restricted saturated fats while increasing the amount of polyunsaturated fats (including omega-3's) was responsible for the improvement in the subjects' arthritis symptoms. They believe it was also responsible for lowered blood pressure in patients who were mildly hypertensive, and contributed to weight loss in patients who were obese. Here is the nutrient content of the daily diet they followed:
total protein: 90 grams(including 50 grams animal protein)
total fats: 70 grams(including 30 grams vegetable fat)
carbohydrates: 350 grams(including 15 grams refined carbohydrates)
fiber: 25 grams
cholesterol: 0.27 grams
polyunsaturatedfatty acids: 17.9 grams
calcium: 1.1 grams
phosphorus: 1.9 grams
iron: 0.27 gram
zinc: 0.016 gram
vitamin C: 0.16 gram
vitamin E: 0.03 gram
total calories: 2390
Prepared vegetables—raw carrots, cabbage, lettuce, cucumbers, and squash—are available already sliced, diced, and peeled in the produce sections of many supermarkets. Frozen vegetables are almost as good as fresh ones and can be much simpler to prepare. Use canned vegetables only if fresh or frozen produce is unavailable, because canned foods often contain unwanted sodium and preservatives.
You can now select your groceries, household items, and prescription medications from your home computer, and have them delivered directly to you. You can learn other labor-saving cooking techniques from an occupational therapist. Ask your doctor to recommend someone for you.
Obese people are more susceptible to certain kinds of arthritis. As with almost all the other aspects of this disease, however, more studies are needed to explain and verify this theory. Still, there are many benefits to losing a few pounds if you are overweight and troubled by arthritis pain.
A healthy diet can help you shed some of those extra pounds. In addition, check with your doctor about starting an exercise program that will be right for you. For example, jogging may not be a good idea, but walking every day might be perfect. If walking is too uncomfortable, hydrorobics, a type of aerobics that uses gentle water exercises, might be the answer. Most health clubs and spas offer these aquatic programs, and local chapters of the Arthritis Foundation often set them up at swimming pools operated by the YMCA.
Another aspect of this relationship is food allergies. In our clinic we sometimes test our patients for food allergies that might aggravate their arthritis. This is done using a simple blood test. Frequently, arthritis symptoms improve when a diet eliminating food allergens is used.
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