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Nutrition

Nutrition is the cornerstone of healthy living. Hippocrates said, “Let food be thy medicine.” While food is no substitute for proven medical treatment, it can help build the foundation of a healthy body – and a healthy body is stronger in the face of stress and illness.

There is no special diet that will cure RA; however, nutrition is still important for building a solid foundation of health. Research has consistently indicated that everyone, including individuals living with RA, can benefit from eating a nutrient-dense, whole-foods diet and avoiding processed and refined foods.

The Importance of a Healthy Diet

If you’re living with RA, nutrition is one of the many tools in your toolkit to help you live well and stay healthy. True, a healthy diet cannot cure RA; however, it can help you maintain overall health and keep other conditions, such as heart disease, at bay. Unfortunately, some research indicates that individuals living with RA have a lower quality diet compared to their healthy counterparts.1 Even the smallest changes in dietary quality can translate into better nutritional status and individuals living with RA might benefit from improving their diet.

Nutrition and RA Symptoms

Despite years of study, there is no evidence that diet plays a role in either aggravating or diminishing the symptoms of RA and there is no special “diet cure” for RA; however, some individuals find that avoiding certain foods or eating certain foods can help their RA symptoms. It is important to remember, though, that there is no one-size-fits-all diet—every person is unique and has individualized dietary requirements. So, while one person with RA may need to avoid a certain type of food, another person may thrive while eating that food.

Some research indicates that 30% to 40% of people with RA improve substantially by following an elimination diet to identify foods that are associated with symptoms and then avoiding these foods.2 Typically, these individuals respond to the elimination diet within 10-21 days and the benefits are maintained if the offending foods are avoided.

Fasting, on the other hand, produces different results. Nearly all people with RA respond well to fasting and the response occurs within 3-5 days; however, the benefits are lost as soon as a normal diet is resumed.

The relationship between food sensitivity and rheumatoid arthritis is unclear and research is ongoing to continue to examine the issue. Some researchers have speculated that gut flora may play a role, but no clear evidence has been established.

If you suspect that certain foods are helping or hurting your RA symptoms, consider keeping a food diary to identify “trigger” foods. You may wish to work with your rheumatologist, allergist, or nutritionist to implement an elimination diet in order to identify problem foods.

Nutritional Deficiencies and RA

Although no food can cure RA, nutrition is paramount for anyone living with RA because both the disease and the medications used to treat it have been linked to nutritional deficiencies.

Nutritional deficiencies abound with RA. Individuals living with the disease can become deficient as a result of weight loss and weakened health or as a result of the increased metabolic rate and protein breakdown associated with chronic inflammation.3 Further exacerbating the problem, some medications cause decreased appetite or digestive problems along with specific deficiencies. For example, methotrexate is often associated with a deficiency in folic acid. One often-overlooked cause of nutritional deficiency in RA is more simple—the pain and swelling associated with RA make food preparation difficult.

Many people living with RA suffer from low levels of vitamin C, vitamin D, vitamin B6, vitamin B12, vitamin E, folic acid, calcium, magnesium, zinc, and selenium. Food is always the optimal source of vitamins and minerals; however, some people may need to use supplements. It’s important to work with your physician to continually monitor and address nutritional deficiencies.

Vitamin D Deficiency: There is a lot of recent debate over the relationship between vitamin D and RA. Vitamin D has been shown to modulate the immune system and its deficiency has been linked to the development of some autoimmune disorders, including multiple sclerosis. RA has also been associated with vitamin D deficiency.4 Some experts have concluded that vitamin D deficiency occurs at higher rates among individuals with autoimmune disorders and supplementation might be necessary.

Furthermore, the risk of osteoporosis is higher in people with RA and some RA medications—such as prednisone—can cause bone loss. In other words, adequate vitamin D levels are vitally important in RA.

Beta Carotene Deficiency: Oxidative damage has been implicated in the development of RA and antioxidants have been shown to combat inflammation and free radicals. Beta carotene is an antioxidant found in brightly colored foods such as pumpkin, sweet potatoes, carrots, and beets. One study indicated that individuals with RA have 29% lower levels of beta carotene levels than the general population.5 The researchers concluded that low antioxidant status might be a risk factor for RA. Of course, no one knows which came first—the low beta carotene levels or the RA. Still, it may be important for individuals with RA to supplement and to be sure to eat foods rich in beta carotene.

Selenium Deficiency: Selenium is a mineral that helps to fight free radicals that cause damage to healthy tissue. Some research indicates that people with RA have lower levels of selenium in their blood.6,7 Thus far, there are no recommendations for selenium supplementation in RA patients, but those living with RA should pay attention to their diet and be sure to include selenium-rich foods such as eggs, tuna, or Brazil nuts. Just two Brazil nuts contain an adequate daily supply of selenium.

Folic Acid: Folic acid is a B vitamin found in dark leafy greens, lentils, beans, broccoli, avocado, and some nuts and seeds. Your body uses folic acid—along with iron—to manufacture red blood cells. Folic acid is especially important if you take methotrexate. By supplementing with folic acid, you may avoid some of the side effects of the medication.

Nutritional Deficiencies and Other Health Problems: Individuals with RA are more likely to develop osteoporosis, anemia, and heart disease—all of which are associated to some degree with diet.

Anemia and Iron: Approximately 30%-60% of people with RA have some form of anemia, which refers to a low level of red blood cells. The anemia may be the result of chronic inflammation or iron deficiency or both. Some RA medications have been linked to iron deficiency. As a result, some people with RA need to take iron supplements.

Osteoporosis, Calcium, and Vitamin D: Osteoporosis is a condition characterized by reduced bone mass and quality, resulting in weaker bones that are more likely to break. Individuals with RA are two to four times more likely to develop osteoporosis for a variety of reasons—the arthritis itself, medications used to treat the condition, or reduced physical activity. To treat and prevent osteoporosis, eat a diet rich in calcium, vitamin D, and magnesium and avoid alcohol and tobacco.

Heart Disease: Individuals with RA have double the risk of developing heart disease. The reasons for this are unclear, but it is likely associated with inflammation. Diet is a key factor in heart disease. Individuals with RA should eat a heart healthy diet that is low in saturated fat and high in nutrient-dense foods, such as whole grains and fruits and vegetables.

Obesity and RA

Obesity has been associated with worse outcomes in RA.8 Individuals who are obese or overweight have higher disease activity, more pain, and worse general health. Furthermore, these individuals are at higher risk for diabetes and heart disease. The research indicates that excess weight puts added strain on the weight-bearing joints and worsens the joints, making them stiffer and more painful. What’s more—being overweight can exacerbate RA flares.

Maintaining a healthy weight is important for your joints and your overall health. If you are overweight, you may want to talk to your doctor about an appropriate weight-loss program for you. Shedding those excess pounds could mean less pain and better overall health.

Nutrition That May Negatively Impact RA

No research has identified a dietary cause of RA; however, some studies have identified some foods to avoid.

Saturated Fat: Research indicates that saturated fat may increase inflammation in the body. Foods that are high in saturated fats—such as bacon, red meat, and butter—may increase the level of prostaglandins in the body. Prostaglandins are chemicals that cause inflammation, pain, swelling, and joint destruction in RA.

Meat: Meat contains high amounts of arachidonic acid, which is a fatty acid that is converted to inflammatory prostaglandins in the body. Some, but not all, people with RA benefit from a vegetarian diet.

Omega-6 Fatty Acids: Omega-6 fatty acids are found in vegetable oils that contain linoleic acid, such as corn oil, soybean oil, sunflower oil, wheat germ oil, and sesame oil. Excessive consumption of omega-6 fatty acids has been linked to cancer, cardiovascular disease, and inflammatory and autoimmune diseases, including RA. The standard western diet is heavy on omega-6 fatty acids, but research has shown that for optimal health it’s important to consume fewer omega-6 fatty acids and more omega-3 fatty acids. There may be a link between inflammation in RA and consumption of omega-6 fatty acids. People with RA may benefit from restricting their intake of omega-6 fatty acids.

Nutrition That May Positively Impact RA

No food will cure RA; however, some foods have been shown to provide benefit to those living with the disease.

Omega-3 Fatty Acids: Omega-3 fatty acids are the polyunsaturated fats found in cold-water fish and some nuts and seeds, including salmon, sardines, walnuts, flaxseeds, and chia seeds. Omega-3s are a critical component of any healthy diet and have been shown to reduce inflammation.

Omega-3 fatty acids have been widely studied in RA and there is reasonably strong evidence to show that they do provide a benefit9,10, 11, 12 They appear to reduce inflammation by decreasing the production of inflammatory chemicals. While omega-3 fatty acids may improve the symptoms of RA, they do not appear to slow progression of the disease.

Some research indicates that omega-3 fatty acids may be better absorbed from food than supplements, so those with RA may want to consider eating foods that are rich in omega-3 fatty acids.13

Fish Oil: Fish oil is high in omega-3 fatty acids and may decrease the inflammatory response in RA.14 Some people with RA experience an improvement in their symptoms and are even able to discontinue their use of non-steroidal anti-inflammatory drugs (NSAIDs) without experiencing disease flare.15 There are numerous ongoing studies to evaluate the effects of fish oil in RA. Thus far, fish oil appears to provide a benefit and some researchers note that fish oil does not carry the increased cardiovascular risk associated with NSAIDs.16 Some research even indicates that intake of oily fish was associated with a modestly decreased risk of developing rheumatoid arthritis.17

Many people report improvement in pain and joint tenderness when taking fish oil. Although it is promising, fish oil will not produce instant results. It can take weeks or even months to notice a decrease in symptoms.

It’s important not to overdo it with fish oil, as some fish oil supplements may have high levels of vitamin A or mercury. Furthermore, fish oil may cause drug interactions with some RA medications. If you plan to take fish oil, be sure to discuss it with your doctor first.

Mediterranean Diet: The Mediterranean diet is based on a pattern of eating tied to the Mediterranean region, which includes Greece and southern Italy. The diet emphasizes large amounts of fruits and vegetables, olive oil, fatty fish, and limited meat consumption. The Mediterranean diet has been widely studied and has been shown to reduce the risk of cardiovascular disease, diabetes, obesity, and cancer. Because it is high in omega-3 fatty acids, the diet is believed to have anti-inflammatory and protective properties.

Research shows that the Mediterranean diet might protect against severe RA symptoms. In fact, it has been shown to reduce disease activity and pain and stiffness in patients with RA.18 One study found that after about six weeks on a Mediterranean diet, people with RA had reduced inflammation, pain, and swelling and improved physical functioning and vitality.19 Notably, the incidence of RA is lower in Mediterranean countries.

Antioxidants: Antioxidants are vitamins, minerals, and other nutrients that protect and repair cells from damage caused by free radicals, which are harmful byproducts produced by the body. Antioxidants are found in vitamins, such as vitamin E, vitamin C, and beta carotene and minerals, such as zinc and selenium. Eating a diet rich in fruits and vegetables—and therefore antioxidants—has been shown to combat inflammation and protect the immune system. Antioxidants are found in colorful fruits and vegetables, especially those that are red, orange, yellow, purple, and blue. Some antioxidant-rich foods include carrots, pumpkin, bell peppers, tomatoes, blueberries, sweet potatoes, broccoli, and spinach—but there are many, many more foods loaded with antioxidants.

Some research indicates that antioxidants help reduce the inflammation, pain, and swelling associated with RA. One study found that RA patients who took antioxidant supplements reported a decrease in the number of swollen and painful joints and an increase in general health.20 Research is ongoing to evaluate the relationship between antioxidants and RA—but it can never hurt to eat a diet rich in antioxidants for overall health.

Gluten-Free, Vegan Diet: Some research has indicated that a gluten-free, vegan diet has anti-inflammatory effects and may be beneficial for people living with RA.21 A vegan diet is rich in fruits, vegetables, grains, and legumes—all of which are high in phytonutrients, which are chemicals that contain disease-fighting properties and immune-boosting antioxidants. A plant-based diet is also high in bioflavonoids, which are plant compounds that have anti-viral, anti-inflammatory, and anti-tumor activities.

Gluten is a protein found in wheat, barley, rye, malts, and triticale. Some people, including those with Celiac disease, are allergic to gluten, whereas many others are simply sensitive or intolerant to it. Gluten can trigger an autoimmune response in these people. Thus far, there is no data supporting a link between gluten and RA; however, some people with RA find benefit in excluding gluten from their diet.

Alcohol: Oddly enough, alcohol may have protective effects against RA. Some research has found that RA patients who drink alcohol tend to have less severe symptoms than their non-drinking counterparts—and the more often they drink, the milder their symptoms are.22 Furthermore, some research even indicates that alcohol can lower the risk of developing RA, indicating that people who do not drink are nearly four times as likely to have RA than those who consume at least one drink three or more days per week.23

Despite these studies, the jury is still out on whether alcohol is necessarily “good” for people with RA. The effects of alcohol are different for everyone and it’s important for people with RA to evaluate their alcohol consumption on an individual basis. Furthermore, alcohol can have serious consequences if combined with certain RA medications, especially methotrexate. It is imperative to avoid alcohol if you are taking methotrexate, as it can result in serious liver damage.

Diet Dos and Don’ts For RA

Again, there is no special diet that will “cure” RA, but a healthy diet goes a long way to maintaining optimal health. Based on the current available data, people with RA might benefit from the following dietary guidelines:

  • Balanced Diet: Eat a balanced, immune-supportive diet that is high in fruits, vegetables, antioxidants, and essential fatty acids and low in saturated fats and processed and refined foods.
  • Nutrients: Work with your doctor to monitor and address any nutritional deficiencies you may have as a result of the disease or the medications used to treat it.
  • Choose Healthy Fats: Pay close attention to fat consumption and choose healthy omega-3 fatty acids over saturated fat or omega-6 fatty acids.
  • Supplements: Consider supplementing with antioxidants, fish oil, and other nutrients. Work with your doctor to determine the appropriate type and dose of supplements.
  • Anti-inflammatory Foods: Add anti-inflammatory foods to your diet. It can’t hurt and it might help.
  • Limit Alcohol Consumption: Use caution with alcohol consumption. Speak with your physician regarding alcohol-medication interactions. If you are taking methotextrate, avoid alcohol entirely.
  • Maintain Healthy Weight: Maintain a healthy weight to reduce the severity of your RA symptoms.
  • Keep a Food Journal: Maintaining a food journal will help you identify and avoid any problem foods.

References:

1 Grimstvedt ME, Woolf K, Milliron BJ, Manore MM. Lower healthy eating index-2005 dietary quality scores in older women with rheumatoid arthritis v. healthy controls. Public Health Nutrition. 2010; 13(8): 1170-1177.

2 Gamlin L, Brostoff J. Food sensitivity and rheumatoid arthritis. Environmental Toxicology and Pharmacology. 1997; 4: 43-49.

3 Roubenoff R, Freeman LM, Smith DE, et al. Adjuvant arthritis as a model of inflammatory cachexia. Arthritis and Rheumatism. 1997; 40(3): 534-539.

4 Pelajo CF, Lopez-Benitez JM, Miller LC. Vitamin D and autoimmune reheumatologic disorders. Autoimmunity Reviews. 2010; 9(7): 507-510.

5 Comstocka GW, Burkea AE, Hoffmana SC, et al: Serum concentrations of α tocopherol, β carotene, and retinol preceding the diagnosis of rheumatoid arthritis and systemic lupus erythematosus. Annals of the Rheumatic Diseases. 1997; 56: 323-325.

6 Kose K, Dogan P, Kardas Y, Saraymen R. Plasma selenium levels in rheumatoid arthritis. Biological Trace Element Research. 1996; 53: 51-56.

7 Heliovaara M, Knekt P, Aho K, et al. Serum antioxidants and risk of rheumatoid arthritis. Annals of the Rheumatic Diseases. 1994; 53(1): 51-53.

8 Aieganova S, Andersson ML, Hafstrom I. Obesity is associated with worse disease severity in rheumatoid arthritis as well as with co-morbidities – a long-term follow-up from disease onset. Arthritis Care & Research. Published early online: April 18, 2012. doi: 10.1002/acr.21710

9 Remans PH, Sont JK, Wagenaar LW, et al. Nutrient supplementation with polyunsaturated fatty acids and micronutrients in rheumatoid arthritis: clinical and biochemical effects. European Journal of Clinical Nutrition. 2004; 58(6): 839-845.

10 Lee S, Gura KM, Kim S, et al. Current clinical applications of omega-6 and omega-3 fatty acids. Nutrition in Clinical Practice. 2006; 21(4): 323-341.

11 Wardhana, Surachmanto ES, Datau EA. The role of omega-3 fatty acids contained in olive oil on chronic inflammation. Acta Medica Indonesiana. 2011; 43(2): 138-143.

12 Fritsche K. Fatty acids as modulators of the immune response. Annual Review of Nutrition. 2006; 26: 45-73.

13 Elvevoll EO, Barstad H, Breimo ES, et al. Enhanced incorporation of n-3 fatty acids from fish compared with fish oils. Lipids. 2006; 41(12): 1109-1114.

14 Kolahi S, Ghorbanihaghjo A, Alizadeh S, et al. Fish oil supplementation decreases serum soluble receptor activator of nuclear factor-kappa B ligand/osteoprotegerin ratio in female patients with rheumatoid arthritis. Clinical Biochemistry. 2010; 43(6); 576-580.

15 Kremer JM, Lawrence DA, Petrillo GF, et al. Effects of high-dose fish oil on rheumatoid arthritis after stopping nonsteroidal antiinflammatory drugs. Clinical and immune correlates. Arthritis & Rheumatism. 1995; 38(8): 1107-114.

16 James M, Proudman S, Cleland L. Fish oil and rheumatoid arthritis: past, present and future. The Proceedings of the Nutrition Society. 2010; 69(3): 316-23.

17 Rosell M, Wesley AM, Rydin K, et al. Dietary fish and fish oil and the risk of rheumatoid arthritis. Epidemiology. 2009; 20(6): 896-901.

18 Sales C, Oliviero F, Spinella P. The mediterranean diet model in inflammatory rheumatic diseases. Reumatismo. 2009; 61(1): 10-4.

19 Skoldstam L, Hagfors L, Johansson G. An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis. Annals of Rheumatic Disease. 2003; 62(3): 208-214.

20 van Vugt RM, Rijken PJ, Rietveld AG, et al. Antioxidant intervention in rheumatoid arthritis: results of an open pilot study. Clinical Rheumatology. 2008; 27(6): 771-775.

21 Elkan AC, Sjoberg B, Kolsrud B, et al. Gluten-free vegan diet induces decreased LDL and oxidized LDL levels and raised atheroprotective natural antibodies against phosphorylcholine in patients with rheumatoid arthritis: a randomized study. Arthritis Research & Therapy. 2008; 10(2): R34.

22 Maxwell JR, Gowers, IR, Moore DJ, Wilson AG. Alcohol consumption is inversely associated with risk and severity of rheumatoid arthritis. Rheumatology. 2010; 49(11): 2140-2146.

23 Kallberg H, Jacobsen S, Bengtsson C, et al. Alcohol consumption is associated with decreased risk of rheumatoid arthritis: results from two Scandinavian case–control studies. Annals of the Rheumatic Diseases. 2009; 68: 222-227.

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