Title: Dietary advice for newly diagnosed cases of rheumatoid arthritis
Key words: rheumatoid arthritis, RA, NSAIDs, steroids, immunotherapy, dietary therapy, dietary interventions, compliance, nutritional,exclusion diets, IgE, allergy, food intolerance, fasting, remission, vegan, lactovegetarian diets, intolerances, supplements, wheat, corn, dairy, pork, mucosal damage, vitamins, immune-mediated, dysbiosis, inflammation, inflammatory, anti-inflammatory, mineral, antioxidant, malabsorption, H. pylori, hypochlorhydria, essential fatty acids, EFA, N-3 PUFA, polyunsaturated fatty acids, eicosanoids, fish oils, zinc, selenium, testosterone, oestrogen, progesterone, menopausal, herbal, curcumin, ginger, Boswellia, Chinese, Ayurvedic,
Date: Sept 2006
Category: Specific conditions
Author: Morgan, G
Dietary advice for newly diagnosed cases of rheumatoid arthritis
Conventional treatment of RA with NSAIDs, steroids and immunotherapy continues to pose problems in terms of patient response and compliance. Much evidence has now accumulated on the potential beneficial effects of dietary therapy in the management of RA. Given the relapsing and variable course of RA and the desire of many patients to retain a greater degree of control over their disease, dietary advice at presentation is to be recommended. Advice should be informed and based on the work that has been done on exclusion diets and nutritional supplements.
Though IgE mediated allergy has not been shown to be important (Darlington 1987, Panush 1990), there is much evidence to indicate that non-classical pathways of food intolerance can play a major role in the evolution and maintenance of RA (Darlington 1986, Darlington 1991, van de Laar 1992, Kavanagh 1995). In removing these factors, fasting is able to promote remissions in active disease (Kroker 1984, Hafstrom 1988). Studies show that introduction of sensitising foods such as wheat, corn, dairy and pork, following fasting or elimination, frequently produce relapses and have been reported to be significant factors in 35-40% of cases (Kjeldsen-Kragh 1991, Darlington 2003). Vegan and lactovegetarian diets have been found to be particularly helpful in excluding these intolerances (Kjeldsen-Kragh 1991, Nenonen 1998).
Food allergies and NSAID use has been linked to mucosal damage and the ‘leaky gut’ syndrome (Bjarnason 1984). Dysbiosis, related to overgrowth of pathological bacteria including Proteus and Clostridia organisms is a frequent accompaniment in RA (Mannson 1966, Ebringer 1985) and is associated with local toxic damage to the mucosa, malabsorption and vitamin, mineral and antioxidant deficiencies. Food allergies with these deficiencies combine to exacerbate the immune-mediated inflammatory processes of RA. Modulation of these factors by an appropriate exclusion diet and avoidance of NSAIDs is therefore potentially of prime importance in the control of the disease.
Dietary advice should be preceded by exclusion of celiac disease and H. pylori infection. In one study (O’Farrelly 1988) 48% of RA cases were associated with a degree of villous atrophy secondary to gluten intolerance. H. pylori, present in over 50% of the population, is associated with hypochlorhydria. Both are associated with mucosal damage, food intolerances, malabsorption and vitamin, mineral and antioxidant deficiencies.
Much work has been done looking at the effect of essential fatty acids in RA (Sperling 1987, Kremer 1987, Belch 1988, Bregski 1991). Most have shown positive effects, effects thought to be mediated though eicosanoid pathways. N-3 PUFAs in fish oils have been found to be most effective and are thought to act by suppressing the proinflammatory LTB4 and promoting the anti- inflammatory LTB5 leukotrienes (Sperling 1987, Kremer 1987). Large doses of at least 12g of MaxEPA were used in these trials however. Cost considerations and the unknown efficacy of lower doses might counsel against recommending fish oils to patients. In addition concerns have been expressed about the long-term use of n-3 PUFAs due to their possible inhibition of antioxidant and immune function (Meydani 1991, Sanders 1992, Meydani 1993, Hughes 1995). N-6 and n-9 PUFAs appear to possess lesser anti-inflammatory action but may have a place in potentiating the effect of fish oils.
Zinc and selenium deficiency is common in RA but appears not to respond to supplementation (Honkanen 1991, Tarp 1985). Age related effects associated with malabsorption and hormonal changes lead to a progressive decline in these and other antioxidant and anti-inflammatory nutrients: women are less well protected by testosterone and by declining oestrogen and progesterone levels around the menopause than men (Wilder 2000). Given the synergistic action of such factors in inflammatory and degenerative disorders, it seems only wise to recommend vitamin and mineral supplementation in RA, especially for premenopausal women. Many herbal products have been shown to possess antioxidant and anti- inflammatory effects though these have been less well researched. Several such as Curcumin, Ginger and Boswellia have been used in traditional Chinese and Ayurvedic medicine for many years. Research has shown that they exert part of their effect through the same eicosanoid pathways as the PUFAs (Sristava 1989, Kuichi 1992, Ammon 1993). Suitable preparations are now available in the West in tablet form.
Research has now confirmed that a subset of RA patients do respond to dietary and nutritional supplement measures. Many of the pathways for these actions are now known. Newly presenting RA patients should be made aware of the drawbacks of conventional treatments and the alternatives. For those that are receptive and who are willing to forebear a degree of inconvenience and expense the above treatment strategies have much to offer.
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