Diet & Nutrition Discussion for Rheumatoid arthritis
Research has demonstrated in animal trials that a diet high in fat diet increases the vulnerability to rheumatoid arthritis for those animals that had been bred to be vulnerable to autoimmune disease.1 It has been noted that patients who have rheumatoid arthritis (RA) generally have much higher fat content in their diet than those who do not.2 Studies of short duration have demonstrated that fat-free diets are very beneficial for RA patients.3 However, some fat in one's diet is essential for maintaining health. Certain essential fatty acids also have natural anti-inflammatory benefits including omega-3 fatty acids such as those found in fish oil and certain omega-6 fatty acids such as those in Black Currant Seed and Borage Oils. a high quality olive oil is highly recommended in one's diet as well for use on salads for example. Avoid all vegetable oils and any foods containing trans-fatty acids.
Pure vegetarian, low-fat diets have been reported to reduce rheumatoid arthritis symptoms.4 5 In the 1950s-70s, a naturopathic doctor named Max Warmbrand used a very low-fat diet for his RA patients. The diet was free of meat, eggs, dairy, sugar, chemicals and processed foods.6 a 10-week study using this method showed no benefit7 but the Warmbrand diet must be followed for at least 6 months to show results. One 14 week trial following a strictly vegetarian and gluten free diet, which gradually added dairy, did demonstrate reduced symptoms and improved objective measures of the disease.8
Fasting historically has been used as a treatment for RA, helping to significantly reduce symptoms. The benefits are most likely due to the elimination of toxins and other particles in the blood and tissue that activate one's inflammatory response on a chronic basis. Most symptoms do tend to return after one's standard diet resumed.11, 12 However, fasting, followed by a year on a vegetarian diet, appeared to stabilize the benefits of fasting.13 14 This combination has not been sufficiently investigated.
Undigested protein crossing the intestinal barrier is thought to cause or contribute to food allergies. Reseach has found that many rheumatoid arthritis patients have increased intestinal permeability19 which may tie RA symptoms to food sensitivities and allergies.20 Symptoms frequently do worsen when patients eat food allergens and improve when they avoid those foods.21-24 One research study found that most of the RA patients evaluated had high levels of antibodies to milk and/or wheat suggesting allergies to those foods.25 Many people also react to corn, which is in many foods we eat including corn syrup used in many processed food. Another study demonstrated that for 1/3 of RA patients, the condition may be completely controlled through avoiding allergens.26 Your health care provider can help you with identifying such allergens.
It was reported years ago that some RA patients have inadequate stomach acid84 which breaks down protein, resulting in allergies. Some feel therefore that in such cases, supplementing with betaine HCl can lessen reactions to food allergens. This might help reduce symptoms associated with RA, but research is needed to document the point. The amount used depends on meal size and amount of protein and should be supervised by a medical professional. We also recommend supplementing with digestive enzymes with each meal.
Drinking more than 4 cups of coffee daily may raise the risk of rhematoid arthritis.27
While exercise may be painful for RA patients, gentle exercise does reduce RA symptoms.28,29 Female RA patients who are on low-dose therapy with steroids can do weight-bearing exercise safely with many benefits including fitness levels, ability to function well physicaly, improved bone density, and more without aggrevating RA symptoms.30 Many healthcare providers recommend walking, stretching, yoga and swimming for their patients.
RA pain is increased by excess weight - so managing your diet and getting plenty of exercise will be helpful.
Key Nutritional Supplement Treatment Options
Vitamin D has been identified in immune system cells and research is suggesting that vitamin D plays an important role in autoimmune conditions such as RA, and may as well have properties to help regulate the immune system.105 Vitamin D deficiency is often seen in RA patients, as it is in patients with osteoporosis.106, 113, 114 Clinical research indicates that vitamin D is connected to a lower rheumatoid arthritis risk and improvement in the condition is seen with vitamin D supplementation.107 We recommend supplementing with vitamin D3 because it is most easily absorbed.
Research published in 2017 involving more than 700 patients in 10 Swedish hospitals found that supplementing with vitamin D and omega-3 fatty acids is linked to better results in anti-rheumatic treatments. This is especially true when vitamin D and omega-3 are taken in the year before prescription drug treatment begins.112
Fish Oil & Omega-3 & 6 Fatty acids
Some preliminary trials show benefit from olive oil.9 But fish oil shows more promise.
Increasingly there is excellent clinical evidence that fish oil, consumed daily, reduces inflammation51 and swollen joints.10, 108 Furthermore, RA patients are at risk for cardiovascular disease, and fish has has been demonstrated to have a protective role for that condition.109 A mega-study published in 2017, which reviewed 18 studies from 1985 to 2013, that included over 1,100 patients, reported that omega-3s were quite helpful in helpfing to reduce pain experienced by RA patients.115
A number of trials have suggested that omega-3 fatty acids DHa & EPa, which are found in fish oil, are very effective in reducing RA symptoms.45-50 Many health care providers suggest 3 grams/daily of DHa and EPa which is contained in 10 grams fish oil. It can take three months for good result to appear. Flaxseed oil is not to as effective.52
Omega-6 alone has not been found helpful for reducing RA pain.116 Here's why. We tend to have a lot of omega-6 in our diet, mostly arachidonic acid (AA) found in meat, eggs, and dairy. It is essential for a healthy nervous system and muscle growth. Another kind of omega-6 is linoleic acid (LA) from butter, nuts, seeds and vege oils. Normally LA gets converted to gama-linolenic acid (GLA) which reduces inflammation. However, if there is too much AA, then the conversion does not take place.
These are GLA-containing oils which can be helpful in RA, especially when combined with omega-3s.
- Borage oil38-40
- Black currant seed oil,41 and
- Evening primrose oil (EPO)42, 43
Greater improvement was reported testing with borage oil (which contains more GLa110) than black current seed or evening primrose oil - but the results are mixed. The best results were seeen when these oils were combined with olive oil, which, itself, may reduce inflammation. Combining EPO with fish oil was found to be very effective.44
Do not take high doses of borage oil. At least one case study reported problems taking 1500 to 3000 mg/ daily.117
There have been reports that RA patients have low levels of antioxidants suggesting that that they are more at risk for damage from free radicals.31, 32 Because Vitamin E functions as an antioxidant it may have a role in protecting joint tissue from damage from oxidation. Several double-blind trials suggested that high levels (about 1,800IU/daily) could lessen RA pain33 and that it might be as effective as some anti-inflammatory drugs34,35 but that it certainly was more effective than placebo.36, 37
Cetyle myristoleate (CMO) is a pain-reliever, reduces inflammation, and modulates the immune system and is sometimes recommended for gout, osteoarthritis and rheumatoid arthritis, bursitis, and fibromyalgia. Some double-blind research indicates that it was helpful, tested against a placebo.53 64% of the patients reported improved symptoms, 14% of the placebo patients reported improvements. More research is needed.
Dimethyl sulfoxide (DMSO) used mostly as a topical painkiller, and is recognized as having antioxidant and inflammation-reducing qualities.54 55 It seems to act as an analgesic because it inhibits pain message transmission by the nerves.56 It should be used only under the supervision of a doctor since in animal reseach low level exposures brought about brain degeneration.
Patients with rheumatoid arthritis may have vitamin B5 (pantothenic acid) deficiencies.57 One trial with placebos, reported that it reduced disability, pain and morning stiffness in RA patients over a 2 month period.58
New Zealand Green-lipped mussel
Supplementing with extracts of these mussels (Perna canaliculus) markedly improved symptoms of rheumatoid arthritis in 68% of RA patients59 and over a 3 month period65 Other studies have confirmed or disagreed with that finding.60-64 There have, however, been reports of side effects such as indigestion, rashes, and gout.
Zinc deficiencies are reported in RA patients.67 Trials have reported both reduced symptoms,68 and no change.69 70 Zinc might be helpful only for patients with deficiencies.71
Selenium deficiencies are also reported in RA patients.72 73 Trials have report both reduced symptoms74 and little change.75 More research is needed.
Copper deficiencies have sometimes been found in RA patients.76 Copper has anti-inflammatory properties and binds to superoxide dismutase (SOD) (as does zinc), an enzyme with inflammation protecting capacity for joints. Supplementing with copper has been found to raise SOD levels77 and so may be effective in treating people with RA78-80 even though it has been found to heighten inflammation in some cases.81 Some medical professionals recommend trying a trial of 1-3mg/daily for several months.
Supplementing with boron (3-9mg/daily) may be helpful, especially in young people82 but the research is inconclusive.
Likewise D-phenylalanine testing reports contradictory results for treating chronic pain symptoms in RA.83 More research is needed.
Bromelain, provided it is enteric-coated, has good capacity for reducing inflammation. Early trials of RA patients receiving bromelain reported decreased swelling and increased mobility85 but the dosages are unknown. Recent research found that a product combining three natural anti-inflammatory botanicals, Devil's claw, tumeric and bromelain were clinically relevant in 42 patients with acute or chronic degenerative spine or joint pain. The pain measure, VAS, decreased from 68.0mm-69.1mm to 37.8mm-42.1mm respectively, for chronic and acute pain.111
Propolis is the resinous material collected by bees from leaf buds and bark that is used to seal cracks in their hives in wintertime. Inflammation-reducing results have been reported in animal research86 patients with RA who received propolis topically reported improvements as compared to a placebo.87
Botanical Treatment Options
Ayurvedic medicine recommends boswellia for arthritis. It has relieved RA symptoms most reports.88, 89 the evidence is inconclusive90,91 although in some trials with negative results other use of NSaIDs was continued - which can distort findings. Boswellia and NSaIDs operate similarly in lessning inflammation. Some medical professionals recommend using 400-800mg in tablets or capsules three times daily.
Topical creams including cayenne pepper's ingredient, capsaicin, can help relieve joint pain when rubbed onto arthritic joints.92 It does so by pulling a pain-mediating neurotransmitter called substance P out of the skin. It brings about a burning feeling at first, but this reduces with each use and goes away entirely for most people in a few days. Creams with 0.025-0.075% of capsaicin used 3-5 times/daily, but under a medical professional's supervision.
This herb also reduces inflammation and pain and is a traditional remedy for arthritis. Research has yielded mixed results93 so the real benefit is unknown. Dosage is 800mg, in capsules, 3 times/daily or 4.5-10 grams of powder daily. Devil's Claw was quite effective taken with bromelain and turmeric.
Tumeric includes curcumin, which is a strong inflammation reducer that traditionally is held to be effective for arthritis and other inflammatory-related conditions. Research verifies that it reduces inflammation and fights free radicals.94, 95 The amount used is usually 400mg 3 times daily. Tumeric was quite effective taken with bromelain and devil's claw.
Ayurvedic medicine also recommends ginger for arthritis treatment. A few case studies suggest that consumption of 6-50 grams of powdered (less if fresh) daily may reduce the rheumatoid arthritis symptoms.96 Combining ginger with boswellia, turmeric, ashwagandha is slightly more effective than a placebo97 although the amounts used are unknown.
Willow acts slowly as a pain reliever but its effect may last longer than aspirin. Research has found that a combination of willow bark (100mg) and sarsaparilla (25mg), guaiac (40mg), poplar (17mg), and black cohosh (35mg), was more effective for RA pain than a placebo over a 2-month trial.99 The patients continued their regular medications. Research is needed for willow alone (which may take 1-4 weeks for results).100
Topical use of botanical oils are approved in Germany for RA symptoms..101 These are cajeput oil, eucalyptus oil, camphor oil, pine needle oil, fir needle oil, and rosemary oil and are used by rubbing a few drops severl times a day into the sore joint. These lack research however for RA treatment.
Picrorhiza, Chaparral, Yucca, Burdock, Cat's Claw, Meadowsweet
Reseach demonstrates a benefit using picrorhiza for people rheumatoid arthritis patients.102 but there is contradictory evidence.
The same is true of chaparral (which does have inflammation reducing effects in test tube research) used topically.
Yucca, a south western traditional treatment, contains soap-like saponins. Yucca tea (7-8 grams root simmered 2 cups water, 15 minutes) may be drunk for symptom relief three to five times per day. It has not been researched.
Burdock root, cat's claw and meadowsweet103 are other traditionally recommended treatments for painful joints that have not been researched.
105. Cutolo M, Otsa K, Uprus M, Paolino S, Seriolo B. (aug 2007). "Vitamin D in rheumatoid arthritis". Autoimmun Rev 7 (1): 59-64.
106. Merlino La, Curtis J, Mikuls TR, Cerhan JR, Criswell La, Saag KG; Iowa Women's Health Study. (Jan 2004). "Vitamin D intake is inversely associated with rheumatoid arthritis: results from the Iowa Women's Health Study". Arthritis Rheum. 50 (1): 72-7
107. Leventis P, Patel S (2008). "Clinical aspects of vitamin D in the management of rheumatoid arthritis". Rheumatology (Oxford) 47 (11): 1617-21
108. Dietary fish oil and olive oil supplementation in patients with rheumatoid arthritis. Clinical and immunologic effects. by Kremer JM, Lawrence Da, Jubiz W, DiGiacomo R, Rynes R, Bartholomew LE, Sherman M., arthritis Rheum. 1990 Jun;33(6):810-20.
109. The role of fish oils in the treatment of rheumatoid arthritis. by Cleland LG, James MJ, Proudman SM,, Drugs. 2003;63(9):845-53.
110. GLa is a compound that converts to the hormone-like "prostaglandin E1" which reduces inflammation.
111. A complex of three natural anti-inflammatory agents provides relief of osteoarthritis pain, Conrozier, T., et al, Alternative Therapies in Health and Medicine, Winter, 2014.
112. C. Lourdudoss, A. Wolk, et al, Are dietary vitamin D, omega-3 fatty acids and folate associated with treatment results in patients with early rheumatoid arthritis? Data from a Swedish population-based prospective study, MMJ Open, June, 2017.
113. S. Mateen, S. Moin, et al, Level of inflammatory cytokines in rheumatoid arthritis patients: Correlation with 25-hydroxy vitamin D and reactive oxygen species, PLoS One, June, 2017.
114. I. Buondonno, G. Rovera, et al, Vitamin D and immunomodulation in early rheumatoid arthritis: A randomized double-blind placebo-controlled study, PLoS One, June, 2017.
115. M. Abdulrazaq, J.K. Innes, et al, Effect of omega-3 polyunsaturated fatty acids on arthritic pain: A systematic review, Nutrition, July, 2017.
116. C. Lourdudoss, D. Di Guiseppe, et al, Dietary Intake of Polyunsaturated Fatty Acids and Pain in spite of Inflammatory Control among Methotrexate Treated Early Rheumatoid Arthritis Patients, Arthritis Care Research, March, 2017.
117. W.A. Al-Khamees, M.D. Schwartz, Status Epilepticus Associated with Borage Oil Ingestion, Journal of Medical Toxicolory, June, 2011.