Foods that affect rheumatoid arthritis

RA is an autoimmune disorder -- a disease in which the immune system attacks the body's own tissues. The main target of this inflammatory response is the synovium (the membrane lining the fibrous capsule that encloses a joint).

Though the cause of rheumatoid arthritis has yet to be precisely identified, there's evidence that it's related to a defect of the autoimmune system, or, more precisely, a case of an immune system that's fighting the body it's supposed to protect. What stimulates the immune system to do this? There's increasing evidence that individuals with rheumatoid arthritis have intestines that are more permeable to certain antigens, allowing these antigens to invade the body, stimulating the symptoms.

Any research that sheds light on RA is welcomed by the more than two million Americans who suffer from this condition -- which has an unknown cause and no cure. RA can strike at any time, although most people first have symptoms between the ages of 35 and 50. Women are affected two to three times more often than men.

The disease is unpredictable: the frequency of episodes, the number of joints affected, and the severity of symptoms vary considerably from person to person. Most people with RA have painfully tender joints: their fingers, wrists, knees, or feet may be stiff in the morning or after long periods of inactivity. Some patients find that they tire easily and feel vaguely ill.

In about 15% of people with RA, the disease disappears after a short time without causing lasting damage or disfigurement. But in severe cases joints are ravaged as inflammation destroys cartilage and bone; they become nodular, deformed, and stiff over time.

While a nutritional approach used to be controversial--the Arthritis Foundation still insists that there is no connection between diet and arthritis--now there's evidence pointing to diet as a major factor contributing to the development of symptoms.

Although most experts are not ready to endorse major changes in diet, they are cautiously acknowledging that certain foods may affect painful joint inflammation, the hallmark of this chronic and sometimes crippling disease.

Drug therapies for RA include high doses of aspirin or other nonsteroidal anti-inflammatory drugs, which help to reduce inflammation and ease joint pain. Patients whose symptoms fail to respond sufficiently to these medications may be switched to more-powerful agents. But these drugs all have side effects, which makes the notion of using diet to reduce RA's discomforts all the more appealing.

There are two plausible ideas about how a person's diet might trigger or worsen symptoms, according to rheumatologist Richard S. Panush, professor and chairman, Department of Medicine, Saint Barnabas Medical Center, Livingston, New Jersey. One scenario is that specific foods may provoke an allergic response that causes or worsens symptoms. A second possibility is that dietary factors act indirectly by influencing the immune system and altering the inflammatory process. Scientists are exploring both prospects in the hope of someday preventing the disease or blunting its effects.

Another reason why diet would have an effect on what is essentially an autoimmune disease is that food makes the greatest demand on the immune system. Foods contain countless allergens that the body is constantly trying to fight or adapt to. Some of these allergens are natural; others come from additives.

There are many food allergies that can aggravate RA symptoms. Among the most common foods are wheat, corn, milk and other dairy products, and beef. If you had allergies as a child, if there's a history of allergies in your family, if you developed sensitivities in recent years, food allergies could be stimulating your RA symptoms. In order to discover exactly what foods are affecting you, the best approach is an allergy-elimination diet.

Diet has been strongly implicated in many forms of arthritis. Food can cause arthritis; it can also help in the cure. Several special "arthritis diets" exist. Many of these special diets originated from the observation that RA is not found in societies that eat a more 'primitive' diet. It is predominantly found in societies consuming the so-called western diet. You can manage RA by eating a healthy diet rich in whole foods, vegetables and fiber and low in sugar, meat, refined carbohydrate and saturated fat. This diet is helpful both in the prevention as well as in the treatment of RA. Food also influences RA because of the connection between RA and food allergy.

Elimination of allergic foods has been shown to offer significant benefit to some individuals with rheumatoid arthritis. Eliminate all foods you suspect may be the cause of the RA. Then gradually introduce them 1 at a time. This way you can determine which food you are allergic to. Once determined, do not eat those foods that you are allergic to. Virtually any food can result in aggravating RA, but the most common offending foods are wheat, corn, milk and other dairy products, beef and nightshade family foods (tomato, potato, eggplants, peppers and tobacco).

Fatty acids are important in inflammation mechanism through their ability to form prostaglandins, thromboxanes and leukotrienes. Manipulation of dietary oil intake can significantly increase or decrease inflammation, depending on the type of oil being increased.

Avoid foods that contribute arachidonic acid. Arachidonic acid is a fatty acid that is derived almost entirely from animal sources (meat, dairy products, etc.) It is converted to inflammatory prostaglandins and leukotrienes that contribute significantly to the inflammation.

Consume coldwater fish such as mackerel, herring, sardines and salmon. These fish are rich sources of eicosapentaenoic acid (EPA) which competes with arachidonic acid for prostaglandin and leukotriene production. The net effect of consumption of these fish is a significantly reduced inflammatory/allergic response. Several clinical studies have attested to the beneficial effect of EPA. Studies have also shown that cod liver oil also has beneficial effects when in comes to inflammation and RA. Cod liver oil is an inexpensive way of providing the body with its required EPA.

Patients with RA have benefited from fasting. Fasting decreases the absorption of allergenic food components. It may also have an effect on the immune system.

Research on the connection between diet and RA was inspired in part by the observation that patients who temporarily stopped eating felt better. Studies have shown that after fasting for a few days, people with RA have substantially less joint pain, stiffness, and swelling; they require less medication as well.

Some scientists believe that this happens because fasting changes levels of polyunsaturated fatty acids in cell membranes, said rheumatologist Richard I. Sperling, an assistant professor of medicine at Harvard Medical School. These fatty acids influence the behavior of cells and may be metabolized into substances involved in inflammation.

Other researchers hold that short-term fasting helps people with RA because possible allergy-provoking chemicals from digested foods are not getting into the bloodstream. Whatever the reasons for fasting's apparent benefits, studies consistently show that the effects disappear when people start eating again.

Some scientists have suggested that particular foods are the culprits- not food in general. Affected people are variously said to have "allergic arthritis" or a food sensitivity or intolerance.

Many people with RA are convinced that eating certain foods aggravates their symptoms. But in the vast majority of them, the connection evaporates when it is tested under carefully controlled conditions. For a very few individuals, however, studies do indicate a genuine link between specific foods and worsened symptoms.

For example, in 1990 Dr. Panush published a study of 16 RA patients who claimed to have food sensitivity. At various times he gave them capsules filled with an inactive placebo or with freeze-dried samples of a supposedly troublesome substance such as shrimp, milk, or nitrates. Three patients showed a marked increase in symptoms- including morning stiffness and joint tenderness -- only when they took capsules containing a particular food.

In another study Dutch researchers observed inflammation-related changes in the tissues of a few RA patients who said they were allergic to certain foods. The investigators compared samples of joint and intestinal tissue taken from three participants whose symptoms improved when they ate a hypoallergenic diet but worsened when they were given their trigger foods in a disguised form. On the allergen-free diet, two of the patients showed a marked reduction in the number of mast cells (important players in allergic and inflammatory reactions).

Both Dr. Panush and the Dutch researchers emphasized that less than 5% of RA patients have true food sensitivities -- far fewer than the number who believe that they react to certain foods. Unfortunately, identifying these unusual individuals is difficult because testing is labor-intensive and costly. Nevertheless, people who have reason to believe that a particular food improves or worsens their symptoms should bring this to a physician's attention.

Research on how different dietary fats affect inflammation is expected to have far greater impact on most people with RA than investigations that focus on food allergies. Studies indicate that omega-3 polyunsaturated fatty acids (found primarily in cold-water fish -- for example, trout, salmon, mackerel, herring, and sardines) can bring about a modest reduction in symptoms for most people with RA. Such research suggests that this may be due to the capacity of omega-3 fatty acids to dampen the body's inflammatory and immune responses.

In a 1990 study, rheumatologist Joel M. Kremer and colleagues at Albany Medical College in New York found that RA patients who took omega-3 supplements for 24 weeks had less joint tenderness and swelling. They also showed decreases in certain circulating chemicals that typically rise during an inflammatory reaction.

When it comes to fatty acids, you are what you eat," Dr. Kremer said. Substituting omega-3 fatty acids for the omega-6 fatty acids that are more abundant in the typical American diet seems to create a cellular environment that discourages inflammation. This finding offers one more reason for eating lots of omega-3-containing fish- a dietary pattern already shown to help reduce the risk for cardiovascular disease.

Other researchers hypothesize that a vegetarian diet also might alter the balance of fatty acids in a manner that reduces inflammation. In 1991 a team of Norwegian researchers found that RA patients who fasted for a week, then ate individually tailored vegetarian diets for a year, reported a decrease in symptoms. The researchers attributed this to a shift in the patients' fatty-acid "profiles" but did not substantiate their claim. Experts find these results interesting but say that they can't be taken seriously until they are confirmed under rigorous experimental conditions.

Arthritis specialists generally agree that the link between food and arthritis isn't yet strong enough to support making dramatic dietary changes. Few would urge patients to become vegetarians or to eat sardines at every meal. In fact, Dr. Kremer observed, some people with severe RA are malnourished-perhaps because chronic inflammation increases the need for certain nutrients. Most people with RA would probably do well to stick with advice from the American College of Rheumatology: "Until more data are available, patients should continue to follow balanced and healthy diets."

People with RA have given anecdotal accounts of the alleviation of symptoms through dietary change. The most commonly reported triggers of symptoms are dairy protein, corn, wheat, citrus fruits, eggs, red meat, sugar, fats, salt, caffeine, and nightshade plants like potatoes and eggplant. In order to test if foods triggered symptoms a food elimination protocol was followed in a blind, placebo-controlled study that resulted in significant improvement in RA symptoms, including shorter duration of morning stiffness and fewer painful joints. Subjects initially consumed a very limited diet. New foods were introduced one at a time, with close monitoring of symptoms. Grains were noted to be a food that often caused intolerance. In 1993, Richard Panush noted that the traditional view of a simple balanced diet being the best recommendation for a RA patient was changing, and conceded that certain patients may be able to link food sensitivity with their symptoms. Diet protocols in RA studies often involve an initial period of fasting before the test diet is introduced. These 200 kcal/day fasts consisting of fruit and vegetable juices showed some short-term improvement in symptoms.

Probably the most intensive study to look at the effects of diet on RA was conducted in Norway. Subjects in the experimental group (n=27) underwent a vegetable juice fast providing 200-300 kcal/day for seven to ten days followed by a vegan diet that excluded gluten, refined sugar, citrus fruits, alcohol, coffee, tea, salt, strong spices and preservatives. After 3 to 5 months, the experimental group slowly progressed to a lacto-vegetarian diet for the remainder of the year-long study period. They added back milk, other dairy foods, and gluten every second day. The control subjects (n=26) consumed an ordinary mixed food diet. The changes in RA disease activity were measured through a global assessment by both the subject and physician. After four weeks, there were significant improvements as measured by tender and swollen joints, pain, duration of morning stiffness, grip strength, and changes in their overall health assessment. These significant improvements were maintained in experimental subjects throughout the length of the study. The group on the vegetarian diet had a significantly lower erythrocyte sedimentation rate and lower level of C-reactive protein. This suggests that the vegetarian diet positively influenced measures of inflammation and disease activity.

Forty-five of the original 53 subjects were re-examined and comparisons were made between diet responders, non-responders and omnivorous controls at baseline and 2 years following introduction of the vegetarian diet. At follow-up, all diet responders and 50% of the non-responders were on some type of modified diet, described as either the original lacto-vegetarian study diet, or an omnivorous diet excluding foods identified by subjects as exacerbating their symptoms. Refined sugar, coffee, white flour and milk were most commonly excluded. There was significant improvement in disease symptoms in the diet responders compared to both non-responders and omnivore controls. There was also some improvement in non-responders on the vegetarian diet compared to the controls. Researchers concluded that patients with RA benefit from dietary manipulation with improvement lasting at least 2 years.

This research has been criticized for a number of reasons. It appears that the subjects were not randomly selected, since a large number of the subjects had a number of food allergies and the female-to-male sex ratio was 45 to 8. In addition, gastrointestinal abnormalities in the test subjects may have affected food tolerance.

Several researchers examined the role of gut bacteria in RA disease activity. RA patients have been found to have higher levels of Proteus mirabilis antibodies when compared with healthy controls or subjects with other diseases. The subjects from the vegetarian diet study had a significantly lower mean antibody level against Proteus mirabilis which was correlated significantly with the measured decrease in disease activity. This suggests that the improvement in RA disease activity may be related to the effects of the vegan diet on the presence of gut bacteria such as Proteus mirabilis and the body's response to such bacteria.

Since overweight produces stress on the joints, weight loss due to dietary manipulation has been suggested as one possible explanation for the clinical improvement found in the above studies. Improvement in RA symptoms was associated in Sköldstam's studies with a substantial weight loss of about 6-13 pounds. However, in another study of RA patients, changes in body mass index over time did not correlate with changes in disease activity.

Many reports conclude that dietary manipulation of fatty acids beneficially affects inflammatory disease. Specifically, the types and amounts of fatty acids in the diet affect prostaglandin metabolism and a change in prostaglandin concentrations can affect the body's immune responses. A diet high in polyunsaturated fat and low in saturated fat with a daily supplement of eicosapentaenoic acid allowed for decreased morning stiffness and fewer tender joints, with symptoms returning after discontinuation of the diet. Daily supplementation with 18 g of fish oil has also led to an improvement in tender joint score and grip strength when compared to an olive oil supplement. Vegetarians can improve their omega-3 intake with the use of flax seed and other plant foods.

Several researchers have reported that people with RA exhibit deficient vitamin levels and poor nutrient intake patterns. It is common for people with RA to have difficulty in cooking and eating due to pain in the joints of their hands. A lack of mobility and obesity are also problems. Therefore dietetics professionals can assist people with RA by providing advice on good nutrition, food preparation, and weight control techniques.

There is also increased cardiovascular mortality in people with RA. Researchers at Tufts reported that an elevated homocysteine level accompanies RA. This was seen even in those who were not taking the anti-arthritis drug methotrexate, which is known to affect folate status. Since a vegetarian diet has been reported to lead to lower incidence of CVD, it may assist people with RA. Certainly, a diet rich in plant foods that are high in folate would be prudent for people with elevated homocysteine levels.

Some individuals with RA may wish to change to a vegetarian or vegan diet to see if it ameliorates their symptoms. Outpatient visits with a registered dietitian would help ensure adequate nutrient intake and provide suggestions for acceptable menus and cooking techniques. Similarly, dietetics professionals are indispensable for a patient embarking on a carefully planned elimination diet. Finally, following a vegetarian diet appears to have so many health benefits that people with RA who adopt it may gain far more than symptomatic relief from doing so.

While research remains inconclusive, at our center we do food allergy testing because we have found that many patients with rheumatoid arthritis will do better with elimination diets. Following these diets enabled us to reduce the amount of medications any patients are on. The assay we use is done by an extremely reputable company that guarantees their results.

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