Foods that affect rheumatoid arthritis

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

RA is an autoimmune disorder -- a disease in which the immune system attacks the body.

Information from the Arthritis Foundation, Arthritis Today, and the National Institutes of Health

The primary target of this inflammatory response is the synovium (the thin membrane lining the capsule that encloses a joint).

Though the cause of rheumatoid arthritis is still unknown, it is hypothesized that the abnormal immune response is triggered by antigens (foreign proteins.) These antigens may be infectious agents such as bacteria. Studies have suggested that bacteria from the gut or from periodontal disease may be responsible.

The disease is unpredictable. The frequency of episodes, the number of joints affected, and the severity of symptoms vary from person to person.

While a nutritional approach used to be controversial,the Arthritis Foundation has noted there is evidence pointing to diet as a factor contributing to symptoms.

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 option 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.

Another reason why diet would have an effect on what is essentially an autoimmune disease is that food contains many allergens that the body is contending with.

There are putative food allergies that aggravate RA including claims about wheat, corn, milk and other dairy products, and beef.

Elimination of specific foods has been shown to offer benefit to some individuals with rheumatoid arthritis. One method is the elimination diet. Eliminate all foods suspected of causing the RA, then gradually re-introduce them one at a time.

Fatty acids are important in inflammation mechanism through their ability to form prostaglandins, thromboxanes and leukotrienes. Leptins, inflammatory cytokines produced by fat cells, also play a role.

Manipulation of dietary oil intake can significantly increase or decrease inflammation, depending on the type of oil being increased.

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.

Coldwater fish such as mackerel, herring, sardines and salmon are rich sources of eicosapentaenoic acid (EPA) which have anti-inflammatory effects. 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.

Some patients with RA have benefited from fasting. It may also have an effect on the immune system.

A few 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.

This happens because fasting changes the levels of polyunsaturated fatty acids in cell membranes, according to rheumatologist, Richard I. Sperling, an assistant professor of medicine at Harvard Medical School. These fatty acids may be metabolized into substances that provoke inflammation.

Other researchers suggest that short-term fasting helps people with RA because possible allergy-provoking chemicals from digested foods are not getting into the bloodstream.

Many people with RA are convinced that eating certain foods aggravates their symptoms. 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. 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 components 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.

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 reduces inflammation. This finding offers one more reason for eating lots of omega-3-containing fish.

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.

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."

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 admitted 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. (Kjeldsen-Kragh J. Rheumatoid arthritis treated with vegetarian diets. Am J Clin Nutr 1999;70(suppl):594S–600S.) 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.

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.

Several researchers HAVE examined the role of gut bacteria in RA disease activity. In a few of these studies, RA patients have been found to have higher levels of Proteus mirabilis antibodies when compared with healthy controls or subjects with other diseases. 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 excess weight 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. Various studies have produced conflicting results.

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. One study showed a diet high in polyunsaturated fat and low in saturated fat with a daily supplement of eicosapentaenoic acid led to 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.

Some individuals with RA may wish to change to a vegetarian or vegan diet to see if it ameliorates their symptoms.

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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