Can what you eat (or don’t eat) make a difference?
Rheumatoid Arthritis (RA) is an autoimmune disease that attacks the immune system of the joints and cartilage, which results in extreme pain, swelling and stiffness and permanent deformities.
RA most commonly affects the hands and feet but can progress to hips, knees and shoulders, and in some cases internal organs (heart, eyes, nerves). The progression and severity is very individualized but RA is typically chronic (ongoing) with intermittent worsening of symptoms, and complete remission is rare. This disease can occur at any age but is most commonly diagnosed in 40-60 year-olds. According to the Arthritis Society of Canada, 300,000 Canadians have RA—affecting two to three times more women than men.
There is no cure for RA but medication can help manage the symptoms and slow the progression. From a nutrition standpoint, emerging research is showing some promising results, but to date there is no specific diet, no nutrients or nutritional supplement proven to prevent, manage or that worsens RA symptoms. However, there are certain deficiencies and diseases more common in RA that can be better managed with good nutrition.
The overall nutrition guidelines for RA are the same as for the general population, with emphasis on balance and variety of healthy foods. Like most areas of nutrition information, it’s important to decipher between fact and fiction.
The weight on RA
Low body weight can be common among individuals with RA. The disease itself can increase metabolism requiring more calories to prevent weight loss. In addition to physiological barriers, inadequate intake may be due to the individual being unable to work and therefore unable to afford appropriate foods. Deformities and pain can make it challenging to grocery shop and prepare meals. A loss of appetite can occur due to feeling unwell. With weight loss comes diminished fat mass, reducing a protective barrier for joints. A low body weight increases risk of disease including osteoporosis and heart disease, which is already more prominent in RA. An inadequate diet can also lead to nutrient deficiencies.
On the other hand, carrying excessive weight puts extra strain on joints and worsens symptoms. Every 10 pounds lost is equivalent to 40 pounds less stress on knees, and the higher the excess body weight, the higher the potential for benefit with weight loss. Balanced reduction in calories is key to prevent nutrient deficiencies and minimize undesired muscle loss. Consult with a dietitian prior to any weight loss attempts. Above all, it’s important that weight loss goals are approached confidently and with long-term success in mind.
Osteoporosis’s perfect storm
Steroids such as prednisone and/or menopause increase one’s risk of osteoporosis (increased risk for bone fractures). These, combined with the deterioration of protective cartilage around bones, and inflammation, may further increase risk. Weight-bearing exercises (i.e. brisk walking, climbing stairs, yard work, lifting weights, lifting your own weight, low impact aerobics) strengthen bone and muscle. Exercise is beneficial for RA but it needs to be approached in a safe manner to minimize injury, and as symptoms allow.
Adequate intake of calcium and vitamin D also plays an important role. Aim for three servings of dairy products a day (1 serving = 1cup milk or milk alternative, 3/4 cup yogurt, or 1.5oz cheese). It’s difficult for the average Canadian to obtain adequate vitamin D (the sunshine vitamin) and most people benefit from a daily 1000IU supplement. Talk to your health care provider prior to taking any calcium and vitamin D supplements.
Studies have shown that correcting a vitamin D deficiency with supplements can slow down the progression of RA and may also play a preventative role by boosting immune function and preventing RA in older women.
Protect your heart
Those with RA are at higher risk for elevated cholesterol, leading to cardiovascular disease. The association is not entirely clear, but it’s potentially due to a side effect of RA medications, as well as the inflammation in RA contributing to increased inflammation with heart disease. Heart-healthy eating focuses on mostly fruits and vegetables, whole grains, incorporating healthy fats, and reduced meat consumption while limiting saturated and trans fats and added sugar. Many of the nutrition recommendations for heart health may provide a double benefit for RA.
Vitamins and minerals
Several vitamin and mineral deficiencies are more common in RA. These can often be corrected through diet while other times a supplement may be needed. Getting an overabundance in pill form will not provide a super benefit; in fact, this may cause harm. Prior to taking supplements, it’s best to discuss with your doctor to avoid drug interactions and potential toxicity.
Folic acid/folate deficiency is common in individuals taking methotrexate (an RA medication with potential side effects). Foods rich in folic acid include dark green vegetables, legumes (chickpeas and beans), liver, enriched flours, cereals and pastas. Other commonly-observed deficiencies include vitamins C, D and calcium, vitamins B6, B12, E, magnesium, zinc, and selenium. Vitamin E and selenium in particular may play a role in reducing swelling and pain. Food sources for vitamin E include nuts, nut butter, vegetable oil, and wheat germ. Several foods contain selenium, but this can vary depending on levels in the soil (very low in Atlantic Canada). The best source is Brazil nuts.
Fruits and vegetables contain an abundance of vitamins and minerals and antioxidants. Antioxidants are disease-fighting components thought to prevent, slow down and reverse the nasty damage caused by diseases including inflammation. One study showed participants with RA who followed a high-antioxidant diet for 10 weeks had an improvement in stiffness and pain.
Although a study has suggested cherries may play a role in decreasing RA symptoms, just aim for seven servings a day of fruits and vegetables from a variety of sources. This will ensure you get a variety of vitamins, minerals and antioxidants. If seven servings is a struggle, just aim to eat more fruits and veggies by gradually increasing.
There is no evidence to support claims that eliminating nightshade vegetables (potatoes, eggplant, tomatoes, and peppers) will improve RA.
Unsaturated (healthy) fats such as extra virgin olive oil and omega-3 have anti-inflammatory properties. When it comes to RA, olive oil has shown some promising results for potentially reducing stiffness and pain. It also provides other benefits such as increasing HDL (good) cholesterol. Although it may not improve your arthritis, it’s a healthy choice. Try replacing your oils and spreads with olive oil and aim to get a little every day. Just keep in mind, 1 tbsp contains 120 calories and 12g fat.
Omega-3 is found in fatty fishes such as mackerel, herring, trout, tuna, salmon, and sardines. Studies have found some individuals experienced decreased joint tenderness and morning stiffness after taking omega-3 for several weeks to months. Overall, there is not enough evidence to recommend omega-3 supplements. Aim for two servings of fatty fish per week; it’ll benefit your heart health, too. If you’re considering a supplement, always speak with your physician, as it can interfere with medications such as blood thinners.
Too much saturated and trans (not-so-healthy) fats found in fatty animal meat, dairy products and coconut oil, as well as deep fried and processed foods, are pro-inflammatory. To date, it’s unknown whether this worsens RA symptoms but these fats are associated with increasing LDL (lousy) cholesterol.
The Mediterranean diet is an eating pattern known for its anti-inflammatory properties and encompasses many of the components discussed above. Studies have shown that individuals who followed this diet over three months had a reduction in RA symptoms. The diet focuses on fruits and vegetables, whole grains, fish, beans, nuts and seeds while minimizing intake of high saturated fat and added sugar. Unlike many diets, this is regarded as a lifestyle that promotes a variety of tasty foods.
Elimination diets to fasting
Many individuals with RA claim that certain foods trigger symptoms despite the lack of evidence. Food allergies and intolerances are a challenging area to research, as they tend to be very individual. Some studies have suggested trigger foods include wheat, cornmeal, rice, eggs, milk, acidic fruits, coffee, refined sugars, and dried fruits. If allergies/intolerances are suspected, consult with a dietitian who will provide guidance in eliminating and reintroducing foods while also tracking your intake and symptoms.
Some studies have shown that fasting results in a significant improvement in symptoms. This is not recommended, as it is temporary and potentially dangerous. Once participants reintroduced foods, the symptoms simply returned.
Management of symptoms is just a piece of the equation when living with RA.
Living with a chronic disease can negatively impact your economic, mental, social and physical wellbeing. It’s important to acknowledge these barriers and seek help from multiple professionals including physicians, psychologists, occupational therapists, physiotherapists, social workers and dietitians. This will help you enjoy the best health possible.
Maureen Tilley is a registered dietitian & author of Hold the Salt! and Hold that Hidden Salt!