Diet and RA

Patient Expert

Dietary advice is abundant in the arthritis community.  Despite years of interest and research, our knowledge about the impact of dietary therapy on disease activity in RA has not changed much since the editorial “Diet therapy for the patient with rheumatoid arthritis?” appeared in the journal Rheumatology in 1999.

A number of small studies have utilized restricted diets (such as fasting followed by vegan diet, lactovegetarian diet, or vegetarian diet) or diets that eliminated specific foods (such as diary products, red meat, citrus, fruits, tomatoes, alcohol or coffee) then reintroduced individual foods to note any objective or subjective changes in RA symptoms.  Most of these studies were of short duration and too small to determine statistical significance, although a number of patients did report subjective improvements in symptoms during the restricted portion of the trials.

A more comprehensive 13-month study in 57 patients with RA found that 12 patients (44%) in the diet group responded to dietary elimination of specific foods combined with a vegetarian diet with improvement as measured by objective and subjective disease variables.  Ten patients (37%) in the diet group reported aggravation of symptoms after reintroduction of one or more food items.

A follow-up study conducted 2 years later in the same patients found that responders had continued with the diet and still had significant reduction in clinical disease variables including ESR.  In the follow-up study, 13 patients (59%) in the diet group reported an increase in disease symptoms after intake of meat, and 10 patients (45%) after intake of sugar and coffee. Of the 10 responders examined in the follow-up study, eight reported an increase in disease symptoms after intake of different kinds of meat, and six after intake of coffee, sweets and refined sugar.

This implies that a number of RA patients may be sensitive to meat, coffee, and sugar.  With that in mind and knowing that RA patients have an increased risk of cardiovascular disease, what should we eat?

A Mediterranean-type diet is rich in oily fish, fresh fruits and vegetables, nuts, beans and legumes, poultry, olive oil, wholegrain cereals and low in saturated fats.  It contains foods rich in omega-3 polyunsaturated fatty acids (n-3 PUFAs) and antioxidants.  Studies suggest that some dietetic elements of the Mediterranean-type diet (polyunsaturated fatty acids, mediterranean diet and antioxidants) have anti-inflammatory effects and decrease RA disease activity (González Cernadas, 2014).

A recent meta-analysis suggests that the use of omega-3 fatty acids at dosages >2.7 g/day for more than 3 months reduces NSAID consumption by RA patients (Lee, 2012; Park, 2013).  Natural sources of omega-3 fatty acids are oily fish such as mackerel, sardines, herring, salmon, trout and fresh tuna (not canned tuna). Eating oily fish 2 or 3 times a week provides a reasonable level of the omega-3 fatty acids EPA and DHA known to be beneficial. However, it is also important to reduce consumption of omega-6 fatty acids, commonly found in sunflower oils and margarines, which may increase inflammation.

A small pilot study found significant clinical benefits in patients who followed a modified Mediterranean diet for 3 months compared with those who followed their usual diet. They had reduced swollen and tender joints, reduced duration of morning stiffness and improved general wellbeing (McKellar, 2007). This is generally a heart-healthy way to eat and has health benefits beyond improving RA such as reducing the risk of some cancers and heart disease.

The antioxidants found in brightly colored fruits and vegetables produce an anti-inflammatory effect by reducing the damage of free radicals produced in the body.  The most common antioxidants are vitamins C, E and A, and carotenoids such as βb -carotene, b -β-cryptoxanthin, luteins and lycopenes.  The vitamins and minerals found in fruit and vegetables, in addition to antioxidants, support the immune system which is important for people with RA who commonly take immunosuppressant medications.

Fruit and vegetables are also low in calories and can help support a healthy diet and weight loss.  Excess weight is bad for joints and overall health.  As the pressure on your knee joint is 5-6 times your body weight when you walk, even small amounts of weight loss can greatly reduce stress on joints.  Obesity increases inflammatory cytokines in the blood and has been implicated in a higher risk of developing RA.  However, one study associated high BMI with less severe disease activity for RA patients who were anti-CCP positive.  The evidence is mixed with regards to the effect of obesity on RA.

Basically it is important to eat a well-balanced, heart-healthy diet rich with the vitamins, minerals, antioxidants, and protein our body needs to build and repair tissues.  For a list of healthy foods which contain many of the nutrients mentioned above, check out this list compiled by Kelly Young.

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