Starting-points
Why do some doctors give dusty rebuffs to questions about diet and arthritis?
Is there anything doctors can say for sure about diet and arthritis?
Why are there are no easy shortcuts?
Could an allergy testing service help you find out if you have a 'food allergy'?
Finding out if you have a particular food intolerance/sensitivity
Research into specific diets for people with arthritis
The Darlington, Mansfield and Ramsay study of elimination diet
The Kremer study/the 'Eskimo Diet'
Research into diet and ankylosing spondylitis (AS)
Evidence-based dietary approaches you could consider exploring
1 Weight reduction
2 Fish and plant oils (Fatty acids EPAs and GLAs)
Fish oils (omega-3 fatty acids) for rheumatoid arthritis
Plant oils (GLAs) for rheumatoid arthritis
Olive oil (omega-9 fatty acids) for rheumatoid arthritis
Rapeseed oil?
Using oils and dietary therapy for other types of inflammatory arthritis
3 Elimination diets
4 Healthier eating
Interactions: arthritis, drugs, foods, and supplements
Specialists in diet and nutrition
Food composition
Summary of dietary dos and don'ts
Further information
Broccoli
Grapes
"What about diet?" is often one of the first questions that comes to mind when you're wondering what on earth you can do about your arthritis. Alas, there's no magical dietary 'cure', though some publications may give that impression. Some people do seem to benefit from looking at their diet and making changes, though 'one man's meat is another man's poison', and what works for one person might not work for someone else.
What can you do if you're wondering whether dietary changes might help you? As always, see what your doctor thinks. Do some background reading too. ARC's booklet Diet and arthritis is a good starting-point, clear and not too wordy or technical. So too is Arthritis Care's Healthy eating and arthritis.
Rheumatologist Dr Gail Darlington and biochemist/ writer Linda Gamlin's book Diet and Arthritis is long but amazingly comprehensive; lots of helpful info. The more general Nutritional Medicine and The Complete Guide to Food Allergy and Intolerance are also both written by reputably qualified medics with special knowledge of diet and health. Full details in 'Further information', at the end of this chapter, which I hope will help you find out more, from reputable, rather than 'quack' sources.
Why do some doctors give dusty rebuffs to questions about diet and arthritis?
Well — the study of nutrition still plays only a small part in a medical student's curriculum, and orthodox medicine has traditionally been suspicious of claims that diet might have a part to play in either the cause or treatment of inflammatory arthritis.
However that hasn't stopped many desperate sufferers trying out all sorts of diets, some more weird and wonderful than others. And it's left many desperate people at the mercy of unscrupulous 'quacks' whose bank accounts have benefited considerably more than their victims, thus making many caring, orthodox doctors even more suspicious, even angry, at the question " What about diet?".
Fortunately, at last, food sensitivity and dietary therapy are being studied in an orthodox manner, as carefully as any other new form of treatment (though research on diet and arthritis specifically is still at an early stage). So, instead of being at the mercy of any Tom, Dick or Harriet Quack, and instead of the dismissive rebuffs we get from some doctors to questions about diet, hopefully we should soon find a more open-minded reaction, like that of one rheumatologist:
"I have no objection to my patients having a special diet if they feel it does them good, provided it does not produce a deficiency. Some diets may do this. I do, however, provide patients with a diet sheet containing the type of diet which would benefit anyone, entitled 'Eating Your Way to Good Health'." (ARC Magazine, 1985)
Look at 'Healthier eating', later, for tips to help you plan a healthy, balanced diet. But what if you want to try a 'special diet', or to try to identify any individual problem food? You want to be sure that what you do isn't going to do any harm, or produce any dietary deficiency, even if it doesn't actually turn out to be helpful. Explain to the doctor this is where you'd welcome his or her support. S/he might even be willing to refer you to a dietitian for advice.
Is there anything doctors can say for sure about diet and arthritis?
There are three things:
Why are there are no easy shortcuts?
Nutrition in general is a tricky enough topic even before you start to bring arthritis and its eccentricities into the picture. Not suprising when you consider that in addition to carbohydrates, fats, and proteins, there are known to be some 45 nutrients (eg vitamins, minerals, others like fibre, oxygen, water) essential for human life. Too little of any particular one and deficiency symptoms result. Too much, and toxic (poisonous) symptoms occur. Even the happy medium can't be precisely defined, as many other factors have to be taken into account too, like the quality and quantity of the food we eat, the efficiency of the digestive system, plus each person's unique nutritional requirements ('one man's meat', etc) and age, growth, sex, pregnancy and breast-feeding, illness, stress, activity level, genetics, possible interactions with medicines or alcohol, smoking, etc!
Good books on nutritional medicine in general, written by reputable medical experts are few and far between. Dr Stephen Davies and Dr Alan Stewart's Nutritional Medicine (Pan, 1987), is written for professionals but isn't too technical for laypeople too. One drawback alas — though it's a paperback, it's a very thick one, unwieldy for arthritic fingers. It's the sort of book you could try (tactfully!) lending your doctor if s/he's high in sympathy but low in information. It includes items on rheumatic disorders such as RA, OA, osteoporosis, and psoriasis. The authors were founder members of the British Society for Nutritional Medicine, set up in mid-1984 as an association of orthodox doctors with a special interest in nutrition; it's since become the British Society for Ecological Medicine.
The book's a fascinating insight into just how intricate a balancing act has to be performed when designing a healthy diet for anyone even before you begin to look at special diets for special needs. Experts tend to agree that in the West we need to cut down our intake of fat, sugar and salt, and increase fibre. But too much fibre stops you absorbing calcium, crucial for good bones, and essential zinc and iron, too. (Fresh fruit and vegetables are a better source of fibre than adding lots of bran to a junk-food diet.) If you cut out citrus fruits and/or potatoes you need to substitute another source of vitamin C. If you cut out milk you will need another source of calcium. Drinking tea with meals inhibits the absorption of iron, but orange juice (or other source of vitamin C) helps iron absorption — just the opposite!
It's all a highly complicated balancing act, and certainly explains why it's not a good idea to try DIY special diets without expert advice.
Could an allergy testing service help you find out if you have a 'food allergy'?
No! Outside orthodox medicine there are a lot of dubious and unscientific 'allergy testing' services, keen to part you from your money — please don't be misled into using them. Which? magazine and Guy's Hospital put five commercial allergy testing clinics to the test. The clinics didn't reliably identify fish allergies in patients known to have them, they gave different results for the same person, and they often gave dubious and risky dietary advice (Which? report, January 1987). In 2000 an investigation of nutritional therapists by Health Which? reported that patients were given poor advice, were sold dubious dietary products, and were charged up to £85 for an initial consultation.
There's no easy shortcut like this to finding out whether you have a food 'allergy'. In any case, doctors prefer to make a distinction between the terms food allergy and 'food intolerance' (or 'sensitivity'). It's usually more correct to use the term intolerance or sensitivity rather than allergy in someone who's looking for a link between what they eat and their arthritis.
The Royal College of Physicians defines food allergy as 'an abnormal immunological reaction to the food'. True allergy is for life: once identified, the cause must be avoided rigorously and always. In true food allergy, the body produces excessive amounts of immunoglobulin E (IgE) antibodies to fight a particular food (eg peanuts) which it considers a foreign invader: symptoms may vary from wheezing and a runny nose, for example, to extremely serious life-threatening problems. Food intolerance on the other hand is usually unconnected with the immunoglobulin E system, and produces a more delayed reaction, building up over a period of time.
One form of diagnosis or testing for food intolerance is an elimination diet, one that's been scientifically evaluated. But it's no easy shortcut and you do need to plan it carefully beforehand and check it out with your doctor. More about elimination diets later.
Finding out if you have a particular food intolerance/sensitivity
A small number of people find that a particular food or drink (eg wheat, beef, milk, coffee, tea) does cause an 'allergic' reaction directly affecting their arthritis. In 1981 a report in the British Medical Journal described a woman with RA whose illness was made worse by cheese. Someone I know finds that strawberries activate her RA symptoms even before she's finished eating a bowlful! However that doesn't mean cheese or any other food is necessarily harmful to you, just that some people may have that particular food sensitivity.
Some researches on diet and RA have suggested that low-fat diets (cutting out saturated fats in red meat, full-fat milk, butter, biscuits, cakes made with butter) may help some people, in the short term, anyway. Younger person with arthritis, Julie McKechnie, found that changing to a low-fat diet suited her:
"…after only a few weeks I began to feel the benefits resulting from a complete change in my eating habits. Inflammation and swellings were reduced, aches and pains were less and tiredness down to a minimum and believe me, with a lively two year old to look after, that was an added bonus. Then, after a couple of months, with my doctor's advice, I was able to reduce my cortisone level by 1 mg. I know it doesn't sound a lot but arthritics on cortisone will know how hard it is to drop just that tiny bit." (In Contact)
Perfect food intolerance tests don't exist and it's not easy to work out whether or not your symptoms might be linked to something you eat/drink. Bear in mind too that arthritis could be activated by something totally different, such as hormonal changes after childbirth, or some sort of viral infection. However if you think your aches and pains do have a specific pattern in relation to something you eat or drink, keeping a diary, and trial and error might help you work out what suspect 'trigger' to avoid. One YPA (younger person with arthritis) wrote in In Contact:
"I decided that I'd do a small experiment, after all, I had nothing to lose. So I cut apples out of my diet for about five days, then I ate one. The effect was amazing. I had the apple in the afternoon, the next morning I was incredibly stiff. Coincidence, I thought, so I did it again, five days with no apple, waking up with only a slight stiffness and getting better every day, then I ate an apple, same response as before. I cut apples out of my diet entirely. Since then I have found that all fruit (except strawberries for some reason) affect me in the same way, though I haven't tried melons, kiwi fruit and all the more exotic fruit. Tomatoes are included in this."
She doesn't say how she makes up for the essential vitamins and minerals she isn't now getting from fruit, but it's crucial she still gets all she needs. She needs to avoid ending up with scurvy, for instance, through not getting vitamin C, to say nothing of many other possible deficiency problems.
As Dr Rose Martin stresses, in online NRAS leaflet The merits and myths of dietary intervention in rheumatoid arthritis:
"Identifying any true food intolerance requires meticulously controlled elimination and reintroduction diets under medical supervision. It is especially difficult given the unpredictable nature of RA. … Elimination by food restriction carries a real risk of malnutrition from deficiency of energy and micronutrients."
Arthritis Research Campaign's Diet and arthritis booklet agrees that:
"The only way to be sure that you have a food allergy is an elimination diet followed by 'challenge' … an elimination diet where you exclude (leave out) a certain food from your diet, for a period of 3 – 4 weeks, followed by a 'challenge', where you reintroduce the food to see if it causes a reaction."
Rheumatologist Dr Gail Darlington is a strong advocate of elimination diets for some people with RA. — More about her, her book and her methods in the next section.
Whatever you try, do stick to orthodox medicine and practitioners.
The first difficulty researchers face is that something like RA waxes and wanes so unpredictably anyway that it's difficult to say whether any improvement is due to a particular diet, or whether it might have happened anyway. A second difficulty is the placebo effect (see chapter 11) — something may seem to do you good simply because you believe it's going to do you good. Even coloured water can work this way! Thirdly, it's difficult to get people to follow a diet experiment exactly when it involves changing tastes and habits of a lifetime and avoiding all temptation to go astray.
Dr Gail Darlington is a consultant rheumatologist who has studied diet and arthritis in detail. She uses an elimination diet as part of the treatment regime at Epsom and St Helier University Hospitals Trust in Surrey, and tested it in people with rheumatoid arthritis as part of a clinical trial, published in the Lancet in 1986. She wrote in In Contact:
"Speculation about food intolerance in rheumatology dates from the early part of the [twentieth] century but it was not until 1979, when Skoldstarn and his co-workers showed improvement among rheumatoid patients partially fasted for seven to ten days, that interest was rekindled and a series of papers on the subject have been published recently."
"In 1983, Panush et al in Florida undertook a ten week, controlled, trial in 26 patients to investigate the Dong diet for rheumatoid arthritis. This is a popular diet free from additives, preservatives, fruit, red meat, herbs and dairy produce. Panush et al stated that their study failed to provide evidence of overall benefit for the diet but felt that the results were consistent with the possibility that individualised dietary changes might be beneficial for some patients with rheumatoid arthritis."
"In 1984, Kroker and his colleagues described a study in which there was improvement in 43 patients with rheumatoid arthritis who underwent a water fast lasting for one week under controlled environmental conditions."
"In January 1985, Kremer and his colleagues described their manipulation of diet in patients with rheumatoid arthritis by giving them a diet high in polyunsaturated fat with a fish oil supplement and these patients were compared with a group of patients on an ordinary, controlled diet. The results favoured the experimental group at 12 weeks and after stopping the diet the experimental group deteriorated. The coverage of Kremer's paper by the media led to the name of the 'Eskimo Diet' being given to the reduction in dairy produce and animal fat in the study and the use of a diet rich in fish and fish oil."
"In 1985, Dr Ramsay, Dr Mansfield and I completed our placebo controlled study of dietary therapy in patients with rheumatoid disease and this showed significant benefit for the patients receiving dietary therapy. There are a number of possible reasons for this improvement and it would take considerably more research before the role of dietary therapy in some patients with rheumatoid arthritis is fully explained. Nonetheless, there are a number of very interesting explanations being tested at present."
"Not all patients respond to dietary therapy but the treatment is safe when supervised and its relevance to any particular patient can be determined in about six weeks. It certainly appears to help at least a sub-group of patients with rheumatoid arthritis. It should, however, always be undertaken under medical supervision."
The Darlington, Mansfield and Ramsay study of elimination diet The results of the 1985 study (Lancet February 1st, 1986, 236, 'Placebo Controlled Blind Study of Dietary Manipulation Therapy in Rheumatoid Arthritis') were very encouraging. Out of 44 patients with rheumatoid arthritis, after dietary treatment 36 per cent described themselves as 'much better', 39 per cent rated themselves as 'better', and a quarter thought they were the same or worse. Diet came out better than placebo, and resulted in less pain, fewer inflamed joints, greater grip strength and a far shorter period of morning stiffness.
Dr Darlington continues to use the elimination diet for some of her patients at Epsom and St Helier University Hospitals Trust in Surrey. Her co-author Dr Mansfield continues to practice allergy, environmental and nutritional medicine at the Burghwood Clinic also in Surrey. More about how the diet works, in 'Elimination diets', below.
The Kremer study/the 'Eskimo Diet' was reported in the Lancet (1985, volume 1, 8422, pages 184 - 187). Fish and fish-oil were significant in the diet and scientific research has since been looking at how and why they might be beneficial. What most definitely does not happen is what many quacks suggest, ie that fish oil or olive oil is absorbed and 'acts as a lubricant in the joint'. That's impossible, as the oil is broken down in the gut before being absorbed. Instead research has shown that polyunsaturated fatty acids, especially omega-3 (n-3) fish oils, can have modest beneficial effects in some forms of inflammatory arthritis (but not gout). More about fish and other oils later.
Research into diet and ankylosing spondylitis (AS) Some scientists believe that a diet low in certain carbohydrates (especially starches and flour products) and high in protein may benefit some people with AS. This follows research by Dr Ebringer at the Middlesex Hospital in London, which explored the relationship between HLA B27 and the bacterium Klebsiella in AS.
Along with other micro-organisms, Klebsiella enters the gut with food, but is present in increased numbers in the gut during a flare-up of AS. A team of scientists in Finland agreed with Dr Ebringer's findings, though other researchers elsewhere did not! The spring/summer 1989 newsletter of NASS (National Ankylosing Spondylitis Society), included the diet guidelines, and an article on the research. For up-to-date comments on AS and diet visit NASS's AS research.
Another theory suggests that there may be a relationship between rheumatoid arthritis and the micro-organism Proteus in the gut, and that this may be a mechanism by which dietary treatment works.
Although there is, alas, no magic dietary cure for inflammatory arthritis in its many forms, research and clinical trials have highlighted some dietary approaches you could think about exploring. For detailed information look at Diet and Arthritis — a comprehensive guide to controlling arthritis through diet (Darlington and Gamlin, Vermilion), Arthritis Care's Healthy eating and arthritis booklet, and The merits and myths of dietary intervention in rheumatoid arthritis (Martin, NRAS) (full details in 'Further information', later).
It's crucial that any advice you follow is right for your particular form of diagnosed arthritis — Diet and Arthritis includes an A - Z directory of the different types of arthritis with dietary information specific to each type. Anyone pregnant, or planning to become pregnant, must check out first with their doctor any changes they're thinking about making in their treatment, including dietary changes outlined here.
Four approaches to consider exploring are:
The last is worth looking at even if you can't be bothered with the other three!
1 Weight reduction
Not to be considered if you're normal weight or underweight. And you should consult your doctor if you have RA, gout, or other form of inflammatory arthritis. To check if your weight is within a healthy range, try the Body Mass Index (BMI) chart in Arthritis Care's Healthy eating and arthritis booklet or the automatic BMI calculator on the Food Standards Agency's Eatwell website.
Being overweight puts extra pressure and strain on damaged joints. Diet and Arthritis vividly explains:
"as each foot hits the ground, the pressure felt by the knee and hip joint of that leg is equivalent to four times the body weight. So being ten pounds overweight puts forty pounds of extra pressure on each knee and hip joint … During certain actions, the load on one part of the knee is even higher; 7 - 8 times the weight of the body."
Amazing! If you are overweight, what you need though is not a quick-fix weird-and-wonderful crash diet followed by rapid weight re-gain, but instead a long-term solution to keep the excess off for ever! That means re-educating your appetite and changing your eating habits, permanently. Slower than a crash diet but more reliable in the long run.
There's helpful guidance in 'Weight-reducing diets' (Diet and Arthritis), including a calorie-counting checklist. The British Dietetic Association’s weightwise website also has useful tips on how to lose weight. Lots of helpful info too on Eatwell, the Food Standards Agency's website, including 'good' fats and 'bad' fats, facts about sugars and starches, other nutrition essentials, etc.
You might also find helpful, for checking calories, etc, the section on 'Food composition', later.
2 Fish and plant oils (Fatty acids EPAs and GLAs)
Recent studies have shown that certain food oils can produce modest benefits in some types of inflammatory arthritis, particularly rheumatoid arthritis, though more research is still needed, for example into long-term effects and the best dosage. In Diet and Arthritis Dr Darlington looks in detail at various scientific trials, their rationale and findings.
In her multi-referenced NRAS (National Rheumatoid Arthritis Society) paper, Dr Rose Martin summarises:
"Immune, inflammatory responses may be influenced by changes in the balance of fatty acids (Endres & von Shacky 1996, Grimble 1998, Calder 1998). Essential fatty acids in fish and plant oils, are converted by the body into prostaglandins and leukotrienes…"
(The merits and myths of dietary intervention in rheumatoid arthritis, online NRAS leaflet, in 'Lifestyle issues')
Prostaglandins and leukotrienes act as messengers in our bodies, carrying instructions from one part to another, for instance to do with the immune system, or the clotting of the blood. Olive oil works in a different way, but has also been shown to possess anti-inflammatory, immune modulating activity.
Don't be put off by the fact that these are 'fats' (fatty acids) — it is important to have some fat in our diet because fat helps the body absorb some vitamins, it's a good source of energy and of 'essential fatty acids' that the body can't make itself. What you're aiming to do is to decrease saturated fats in your diet and replace them with unsaturated fats, preferably mono-unsaturated. Reducing saturated fat intake also helps prevent heart disease.
If you're thinking about trying oils in your diet to control inflammation, Diet and Arthritis chapter 'Using oils in the diet to reduce inflammation' gives detailed practical guidance. Be aware that:
But caution… Check out the hazards. Using oils can actually be harmful in some types of arthritis, so make sure any advice you find is specific to your particular diagnosed type. For instance you should avoid omega-3 fish oils if you have lupus (SLE) or Raynaud's syndrome or gout. And because fish oils contain chemicals which thin the blood and make it less likely to clot, they should be avoided by people with blood disorders or bleeding problems, and people who are taking warfarin or other blood-thinning drugs, plus some herbal supplements such as gingko biloba.
There's a fuller list in Diet and Arthritis, chapter 2.2, of diseases and drugs incompatible with fish oil. You can also check out omega-3 fatty acids, fish oils and interactions in the US National Library of Medicine's Medline Plus 'Drugs, Supplements, and Herbal Information'.
Anyone pregnant, or planning to become pregnant, must check out first with their doctor any plans they have to make changes in their treatment, including trying out fish or other oils.
Fish oils (omega-3 fatty acids) for rheumatoid arthritis
Do not confuse omega-3 (n-3) fish oils with cod liver oil, which contains large amounts of vitamins A and D; it can be toxic if too much is taken, and should definitely not be taken if you are pregnant or planning a pregnancy. Stick to omega-3 fish oils instead (made from the body of the fish, not the liver). You can take these either by eating oily fish or by taking fish oil capsules; Diet and Arthritis suggests a good option might be to eat fresh or tinned fish some days, and take capsules on others.
Examples of oily fish are mackerel, herring, sardines, pilchards, salmon, whitebait, anchovies, snapper — these can all be fresh or canned — also fresh tuna but not canned tuna. The fish oil supplement used in most scientific trials is MaxEPA, sold in pharmacies. Dosage, especially if you mix fish and capsules, can be difficult to work out — Diet and Arthritis advises:
"taking 1.8 gm of EPA per day if possible (equivalent to 3 gm of total omega-3s in most supplements, but not in whole fish, where a larger intake of total omega-3s would be required to give 1.8 gm of EPA) … A smaller amount may have some lesser benefits, but there is probably no point in taking less than 0.8 gm per day." [EPA is the fatty acid eicosapentaenoic acid]
To balance polyunsaturated omega-3 fats, you need to make sure you're taking in enough Vitamin E, a natural antioxidant. It's already added to capsules of fish oil, but if you're eating fresh or tinned oily fish you'll need to add it yourself. Rather than taking it in supplement/ capsule form, it's better to take it naturally, by eating plenty of fresh fruit and vegetables, including for example hazlenuts, peanuts, sunflower seeds, or other foods with good levels of vitamin E.
(Antioxidants like vitamin E and vitamin C can help protect joints, and help reduce inflammation by neutralizing excess 'free radicals' which may cause tissue damage or disease.)
Have fun working out imaginative ways of using more oily fish in your eating. Not just sardines on toast (spread with solid olive oil — see below), but how about easy pasta sauce of onions plus garlic, tomatoes, tomato paste plus anchovies (or similar); mackerel pate or kipper pate; salade nicoise; topping a bought tomato and cheese pizza with anchovies or sardines; fishcakes; or 'cheap and easy 'seafood fritters' (mix sardines and tomato paste into a fritter batter, form into small thick pancakes, coat in flour, fry lightly till ready). Plenty of appetising ideas in Mediterranean and fish cookery books and websites! And some in Arthritis Care's Healthy eating and arthritis booklet, plus more at the end of this chapter.
Plant oils (GLA fatty acids) for rheumatoid arthritis
Clinical trials have shown that some plant oils can produce improvements in morning stiffness, pain, and joint swelling in some people with RA. The oils are evening primrose oil, blackcurrant seed oil and borage ('starflower') seed oil, which all contain the fatty acid GLA (gamma-linolenic acid). As with fish oils their effects build up very slowly. They are sold only as supplements, in capsules, cheaper than fish oil capsules. Swallow the capsules whole, never break or chew them because the oil will irritate your throat and can cause a persistent hacking cough.
Diet and Arthritis advises:
"The amount of GLA shown to be effective aganst rheumatoid arthritis in experiments is 540 mg per day, which tends to produce a small but steady easing of symptoms… None of the supplements sold in shops at present has a recommended dose giving 540 mg per day of GLA, but some can be taken at 300 mg per day … Although 300 mg per day will not have as much effect as 540 mg per day, it should be of some benefit." [Higher strength brands can be bought by post — for instance from Nature's Best, Tunbridge Wells.]
Dr Martin reports a different dose:
"Individual studies suggest benefits in terms of reduced pain, joint swelling and intake of anti-inflammatory drugs drugs during treatment with high dose GLA (1.4g /day) for at least 6 months (Little & Parsons 2001, Rothman et al 1995). However, further research is required in order to confirm initial observations and establish the optimum dose and duration of treatment." (The merits and myths of dietary intervention in rheumatoid arthritis, DR Rose Martin, online NRAS leaflet, in 'Lifestyle issues')
Olive oil (omega-9 fatty acids) for rheumatoid arthritis
Adding olive oil to your diet is cheap and simple. Researches have shown that olive oil can have some anti-inflammatory benefits, although scientists don't yet understand how and why. Dr E Kaklamani, Professor Emeritus, Medical School of the University of Athens, goes into detail in Olive Oil and Diet and Rheumatoid Arthritis (NRAS leaflet). He describe the benefits of the traditional Greek diet, where olive oil, vegetables (raw or cooked or eaten with olive oil) and fruits are consumed frequently, while meat and animal products are eaten less frequently. In dietary studies of patients with RA:
"It was found that supplementing the diet with olive oil reduced the number of painful joints, improved the grip strength and reduced the length of time that the patients had stiff joints in the mornings … there was, in addition, a reduction in the levels of C-reactive protein, a blood protein, which is an objective laboratory measure of inflammation."
Diet and Arthritis advises:
"The amount that has given the greatest benefit … in research studies is 22 ml (1.5 tablespoons) per day … A smaller daily dose of olive oil, 7.5 ml (1.5 teaspoons), also has some limited benefit in reducing pain and joint tenderness, but does not seem to improve morning stiffness … 22 ml (1.5 tablespoons) supplies 166 calories, which you can compensate for by cutting out an equivalent amount of oil or butter."
Diet and Arthritis suggests all sorts of imaginative ways to include olive oil in your diet; some examples:
One particularly canny idea: solidify your olive oil ration by putting it in a small plastic container in the freezer the night before: next day, use it like butter! Spread it on bread or toast, alone, or how about with sardines or mackerel pate on toast? Get more inspiration from recipe books focusing on Greek or French provencal or other Mediterranean cookery, or on olive oil itself (some suggestions at the end of this chapter).
Rapeseed oil?
I'm not aware of any clinical trials investigating whether rapeseed oil has any anti-inflammatory effects, but it does have impressive properties in its cold-pressed form. (Avoid the hot-pressed form, which turns omega-3 fatty acids rancid). Overseas rapeseed oil is also known as canola oil. Rapeseed oil contains high amounts of beneficial omega-3 fatty acid, unlike other vegetable oils (eg corn, sunflower seeds, safflower, cotton seeds and soy beans) which have high amounts of the not-so-good omega-6 fatty acids.
Cold-pressed rapeseed oil has half the saturated fat of olive oil, ten times more omega-3, and contains natural antioxidant vitamin E. It's also good for frying, performing better than olive oil at high temperatures, as well as ideal for salad dressings, baking, roasting or even drizzled on to bread as an alternative to butter (or solidify it like olive oil, above). You can use it instead of margarine for baking. For more info, recipes, stockists, mail-order etc, try Farrington Oils Ltd, who produce cold-pressed rapeseed oil in Hargrave, Northamptonshire.
Using oils and dietary therapy for other types of inflammatory arthritis
In Diet and Arthritis there's a detailed A - Z directory of the different types of arthritis, together with information on whether diet might help each specific type. Look too at the support group website(s) specialising in your own type of arthritis.
ankylosing spondylitis (AS) For up-to-date comments on AS and diet visit NASS's AS research. People with AS are particularly vulnerable to developing osteoporosis, so should make sure there's sufficient calcium, vitamin D and vitamin K in their diet, besides keeping up with their exercises. (And see 'osteoporosis', below)
A study was published in 1996 that suggested a low starch diet (ie not eating bread, potatoes, cakes and pasta) could help alleviate the symptoms of AS. Look back at 'Research into diet and ankylosing spondylitis', earlier.
lupus (SLE) Taking omega-3 fish oils or large amounts of oily fish is not advised; one study found that patients got worse in the months after trying fish oil. Neither olive oil nor GLA oils has been tried for lupus. Do not take alfafa in any form.
osteoarthritis (OA) Try losing weight if you're overweight. If you have some inflammation — red swollen joints — with your OA, omega-3 fish oils and/or trying an elimination diet may help.
osteoporosis The right sort of diet is so important for prevention and treatment of osteoporosis that I recommend you visit the National Osteoporosis Society (NOS) website for information, which includes their booklets Healthy Eating for Strong Bones, Calcium Rich Foods, Supplements of calcium & vitamin D.
psoriatic arthritis Evening primrose oil or omega-3 fish oils are of variable effect, but may help. Cutting down on saturated fats helps some people.
Raynaud's Evening primrose oil may be helpful, as may olive oil though it has not been so thoroughly tested. Taking omega-3 fish oils or large amounts of oily fish is not advised. Tea, coffee and cola can worsen symptoms in some people: try cutting out caffeine for a few weeks to see if that helps. The Raynauds & Scleroderma Association (RSA) website comments:
"There is as yet, no satisfactory medical evidence that diet makes any difference to Raynaud's but it is always sensible to avoid foods which upset you or to which you are allergic. Your body needs plenty of warming 'fuel'. A bowl of hot porridge or cereal with warm milk makes a good start to the day and aim to eat several small meals to maintain your energy heat levels…"
"If reflux is a problem, fatty foods, spices, tea, coffee and alcohol should be avoided as these can make it worse. It is known that occasionally some patients with Raynaud’s have weakness in the muscles of the oesophagus and this can cause swallowing problems"
Also on the RSA website is an interesting section on natural remedies: supplements and herbs which have not been thoroughly studied or monitored, scientific evidence is limited and safety and effectiveness may not be proven. However some RSA members have told the Society they have used them with some success.
Sjögren's syndrome Evening primrose oil has been tried but does not seem to be effective.
3 Elimination diets
See earlier for the very encouraging results of the Darlington, Mansfield and Ramsay 1985 elimination diet study reported in the Lancet in 1986. Dr Darlington continues to use this elimination diet with some of her patients at Epsom and St Helier University Hospitals Trust in Surrey. The main types of joint disease likely to respond are arthralgia (simple joint pain), episodic arthritis (also called palindromic rheumatism) and rheumatoid arthritis.
Diet and Arthritis describes the elimination diet in detail. It's not a dogmatic, prescriptive diet but is a form of diagnosis, a way of testing your body to see if you have a 'food intolerance', to see whether one or more foods make your joints much worse. It's not easy, needs thoughtful planning, and you should seek the agreement of your doctor beforehand, but:
"if followed carefully, [it] could help some readers a great deal … other readers will feel a moderate benefit or a few small improvements. Some may find that they need to take fewer drugs… and finally … some readers will have no change at all — but they will at least have the peace of mind of knowing that they have tried out dietary treatment in the best possible way." (Diet and Arthritis)
Diet and Arthritis gives helpful suggestions for dealing with any scepticism your doctor may express — a good place to start is Section 2.1 'Finding the right diet'; subsection 'Can diet help with rheumatoid arthritis?'. S/he may also be interested in a more-recently published book (2003) for professionals, co-edited by Dr Darlington: Diet and Human Immune Function, published by Humana Press, editors: D A Hughes, G Darlington, A Bendich (contains a chapter on Diet and Rheumatoid Arthritis), and Nutrition and Arthritis (Blackwell, 2006), details in 'Further information'.
Before and during the elimination diet you'll need to keep a 'Food and Symptoms diary', and do quite a bit of planning and preparation beforehand. The diet proper starts with the 'exclusion phase', (about seven to ten days) during which you stop eating almost everything you normally eat, and live instead on a small range of rarely eaten foods. During that time, if you are sensitive to/ intolerant of one or more particular foods, there should be some improvement (though there may at first briefly be 'withdrawal symptoms', which are actually a good sign).
Next comes the 'challenge' or 'reintroduction phase' when you test single specified foods, one by one, to see which ones (if any) cause a reaction. If there's no improvement, and no great reaction to a reintroduced food within the first three weeks, the diet is discontinued. But if one (or more) foods do cause a reaction, that indicates a 'food intolerance', and you're advised to avoid the culprit food(s) in future. The 'culprits' will be different for different individuals.
Helen Farley BVSc gave an interesting account in the British Medical Journal, 30 November 1999, of her experience of trying the elimination diet, successfully, to relieve her own very severe rheumatoid arthritis. She used the guidelines in Diet and Arthritis, and in Arthritis: Allergy, Nutrition and the Environment (HarperCollins, 1995) by Dr John Mansfield, another of the authors of the elimination diet reported in the Lancet in 1986.
Three other sources of general information about food intolerance and elimination/ exclusion diets, not specifically related to arthritis are:
4 Healthier eating
Whether or not you're interested in trying out approaches 1 - 3, above, it's still important to check that your diet is healthy and well-balanced, and especially if mobility and other problems limit what shopping and cooking you can do. For tips on overcoming problems preparing food see chapter 22. For tips on dealing with problems shopping for food, see chapter 23.
Make sure your food contains all the recommended vitamins and minerals and other essential nutrients. Arthritis Care's Healthy eating and arthritis booklet (downloadable or in print) is easy to read and full of excellent advice, with chapters on what makes up a healthy diet, how to maintain a healthy diet (includes shopping for food, cooking tips and some easy but tasty recipes), interactions between food and arthritis (includes particular foods that may help some people with arthritis), supplements, other sources of help.
The 'eatwell plate' shows in picture form how much of what you eat should come from each food group to achieve a healthy balanced diet. Generally speaking, for a healthier diet:
"This is to make sure that the body receives the important nutrients, particularly vitamins, minerals and antioxidants which it needs to maintain good health and to protect it during the stress of disease. Antioxidants can help protect joints, and help reduce inflammation by 'mopping up' some of the body chemicals which cause inflammation, and may even help prevent arthritis … The body produces its own antioxidants but it is thought that antioxidants in the diet (such as vitamin C) help destroy excess free radicals which may cause tissue damage or disease."
Besides Arthritis Care's Healthy eating and arthritis booklet, try the following for more information:
For quick up-to-date info about food items try the USDA National Nutrient Database for Standard Reference (American). You can do a SEARCH, for instance what minerals and vitamins does a banana contain — how much potassium?; which foods contain calcium? how much calcium in a large hard-boiled 50g egg?; how much saturated fat in cheddar cheese? how much in Brie? You can use the database in other ways too. The database lists over 7,290 different foods, and is run by the US Agricultural Research Service.
The whole chapter 'Healthy eating for everyone with arthritis' in Diet and Arthritis is well worth reading if you can get hold of a copy. It includes a list of 'nutrients often lacking in the diet of patients with rheumatoid arthritis or osteoarthritis'. Nuts are "a very good source of many of the vitamins and minerals most likely to be in short supply. Of the nutrients they contain, vitamin E may be especially valuable to anyone with ankylosing spondylitis, rheumatoid arthritis or another form of inflammatory arthritis because it acts as an antioxidant. Osteoarthritis with an inflammatory component (indicated by red, warm or swollen joints) may also be helped." Seeds (eg pumpkin or sunflower) or nut butters or spreads are alternative sources.
When planning dietary changes it's crucial you don't mess around with your prescribed drugs without first consulting your doctor. Your pharmacist can give helpful advice too.
Some foods and 'food supplements', especially in large amounts, may interact badly with medication or your condition. For instance grapefruit even in small quantities can interact with nifedipine (used for Raynauds and high blood pressure) and with some DMARDs (disease-modifying anti-inflammatory drugs) such as ciclosporin. Ginger and garlic can interact with warfarin. Someone with lupus (SLE) should avoid omega-3 fish oil supplements and any form of alfafa. Magnesium can make antibiotics less effective. Most vitamins are harmful if taken in excessive doses; vitamins A, D, E and K are especially dangerous in high doses.
On the other hand, some of the drugs used to treat RA and other types of inflammatory arthritis may mean you need to increase your intake of some nutrients, for instance long-term use of penicillamine and steroids can produce zinc deficiency. The BMA Guide to Medicines and Drugs includes an A to Z of vitamins and minerals, and gives dietary advice for individual drugs where appropriate, eg prolonged use of penicillamine may deplete pyridoxine (vitamin B6) and iron.
Sulphasalazine may reduce absorption of folic acid (one of the B vitamins) from the intestine, so you should eat plenty of green vegetables and drink at least 1.5 litres of fluid a day. Good sources include broccoli, brussels sprouts, asparagus, peas, chickpeas and brown rice. Other useful sources include fortified breakfast cereals, some bread and some fruit (such as bananas, blueberries, blackberries, blackcurrants, cranberries, and other berries. Methotrexate too interferes with the action of folic acid in the body but your doctor will usually prescribe a folic acid supplement and tell you exactly when to take it — the timing has to be exactly right so the folic acid doesn't decrease the effectiveness of the methotrexate.
Besides the BMA Guide to Medicines and Drugs you can find medication information (including interactions and dietary advice where appropriate) online in the electronic Medicines Compendium (eMC) of www.Medicines.org.uk or in the US National Library of Medicine's Medline Plus 'Drugs, Supplements, and Herbal Information' — though bear in mind that the latter is American and may sometimes differ from the UK.
Some food interactions can be beneficial. Iron is more easily absorbed by your body if you have it at the same time as vitamin C, for instance in fruit and vegetables or in a glass of orange juice. But the tannin in tea inhibits iron absorption so avoid drinking tea with or just after your meal. A high intake of caffeine (eg in coffee, tea, cola drinks) can be bad for the bones.
Check out with your doctor and pharmacist any supplements you're thinking of taking — they can interact with prescribed drugs, with each other and be less effective, for instance calcium supplements shouldn't be taken by people with kidney problems without medical advice, zinc interferes with the absorption of copper and iron, etc. Be aware, too, that supplements are not subject to the same rigorous safety tests and regulations as are medications. A USA government website that discusses dietary supplements and possible pitfalls is Tips for the savvy supplement user: making informed decisions and evaluating information. [This website page is no longer available.]
You can check out individual supplements and their interactions in the US National Library of Medicine's Medline Plus 'Drugs, Supplements, and Herbal Information', or in Dietary Supplement Fact Sheets on the website of the Office of Dietary Supplements (US National Institute of Health) and the American Arthritis Today's 2005 Vitamin and Mineral Guide.
For general questions (non-medical) on food and nutrition, you could try contacting the British Nutrition Foundation (BNF). Although BNF doesn't provide specific dietary advice for individuals, it does give general advice on nutrition to members of the public, schools, the media, the food industry and other organisations. It's a charity, working to promote the nutritional wellbeing of society in partnership with academic and research institutes, the food industry, educators and government.
BNF's website includes 'how to find a registered dietitian or nutritionist' plus masses of helpful info, such as nutrition basics, food labels, healthy eating — 'a whole diet approach', healthier packed lunch ideas, etc. Some fascinating facts are tucked away, for instance about canned food:
"Canned baby sweetcorn, apricots and gooseberries all provide more vitamin C than their fresh equivalents … A 100g serving of tomatoes, spinach or apricots all provide almost a quarter of the Recommended Daily Amount (RDA) for vitamin C, providing more than fresh equivalents … Canned beans and pulses are a good source of a number of vitamins and minerals … Chickpeas are a source of the antioxidant, vitamin E."
Registered dietitians, regulated by the government, are experts in diet and nutrition, and can help people make informed choices about food and lifestyle, with advice appropriate to medical conditions. You can contact a registered dietitian through your local hospital or GP surgery. Or you can find one privately through the British Dietetic Association, the professional association for dietitians.
British Society for Ecological Medicine (BSEM) members are registered medical, dental and veterinary practitioners and scientists with special interests in the areas of allergy, environmental and nutritional medicine. There's a 'find a practitioner' service on the BSEM website of members who will accept referrals from doctors; some also accept self-referrals from patients.
Nutritionists provide general information about diet, but do not provide advice specifically tailored to medical conditions. The Nutrition Society has a register of nutritionists who have received an approved level of training.
For over 60 years the standard source of information on the nutritional value of foods consumed in the UK has been McCance and Widdowson's The Composition of Foods (Royal Society of Chemistry and Food Standards Agency, 554 pages, expensive!).
However if you don't have access to McCance and Widdowson's tome, but want quick and easy answers to questions such as what vitamins and minerals are in a banana? how much potassium? how many calories? which foods contain calcium? how much calcium in a large hard-boiled 50g egg?; how much saturated fat in cheddar cheese? how much in Brie? etc, try a SEARCH on the amazing USDA National Nutrient Database for Standard Reference.
The database lists over 7,290 different foods, and is run by the United States Agricultural Research Service. Keep in mind that there may be some differences between American and UK practice. You can use the database in various ways.
There may in future be something similar in Europe. EuroFIR (European Food Information Resource Network) is compiling a web-based comprehensive database of European food composition, EuroFIR-BASIS, and there are interesting related topics on their website.
Still in print, and much cheaper than McCance and Widdowson, though not so up-to-date or comprehensive is the Manual of Nutrition (10th edition, published by TSO, The Stationery Office, ISBN 0112429912), packed with info about important nutrients, including vitamins and minerals, the foods that provide them, how different methods of cooking and processing affect them, plus a useful 'food composition' table for a range of common foods, etc.
Dietary supplements and possible pitfalls are discussed on the US government's Tips for the savvy supplement user: making informed decisions and evaluating information. [This website page is no longer available.] You can check out individual supplements (eg cod liver oil, vitamin C) in the US National Library of Medicine's Medline Plus 'Drugs, Supplements, and Herbal Information', and the Dietary Supplement Fact Sheets on the website of the Office of Dietary Supplements (US National Institute of Health) and the American Arthritis Today's 2005 Vitamin and Mineral Guide.
1 Remember we're all different. A diet that seems to work for one person may not work or could even be harmful for someone else.
2 Do talk to your doctor. With a bit of luck s/he might realise that an open-minded, supportive approach is more helpful than an attitude which sends you scuttling off in search of the nearest quack remedy. Explain that you'd like support in making sure that any diet you try is sufficiently well-balanced not to do you any harm, whether or not it helps your arthritis. If s/he's supportive but feels s/he doesn't know enough about it, try suggesting a look at the books mentioned in 'Further information' below, or ask for referral to a dietitian. Or suggest s/he contacts the British Society for Ecological Medicine (BSEM). Members are bona fide orthodox professionals — registered medical, dental and veterinary practitioners and scientists with special interests in the areas of allergy, environmental and nutritional medicine.
3 If your doctor's unhelpful do be wary of rejecting his/her trusted remedy in favour of what could be a restricted and unbalanced diet. Avoid 'miracle cures' and fad diets which claim to 'eliminate noxious acids' or 'boost lubrication', etc.
4 You don't necessarily have to embark on a complicated trial of every food under the sun! Some people, like the younger people with arthritis quoted in 'Finding out if you have a particular food intolerance/ sensitivity', earlier, find that just one or two particular types of food make their arthritis worse. If so, with your doctor's agreement, eliminate that particular bugbear from your diet.
5 Even if you don't want to be bothered with 'special' diets, do keep an eye on your eating and drinking habits. It's all too easy to put on excess weight, especially if you can't take much exercise. Aim for a sensible, well-balanced diet. And remember diet's not the only essential for good health; others include taking regular 'mental exercise' (eg reading, writing, creative arts, hobbies); having goals; cutting down on avoidable stresses; finding something to enjoy in life; not smoking (apart from causing cancers and respiratory and circulatory illnesses, did you know smoking also has a powerful anti-vitamin C effect, and inhibits the workings of the pancreas, essential to good digestion?).
6 Sometimes minor dietary changes like cutting down or cutting out caffeine-containing tea, coffee and cola drinks and chocolate may be helpful. An average cup of strong tea contains 50 mg of caffeine, coffee 100 mg, though it varies a lot. Caffeine's a stimulant and a diuretic (increases your need to pass urine), so you might find you sleep better and don't waste so much precious energy on journeys to and from the loo! Tea and coffee also inhibit the absorption of iron and zinc, and have other sometimes surprising adverse effects, listed by Davies and Stewart in Nutritional Medicine. Incidentally, cutting out caffeine may cause withdrawal symptoms at first, such as headaches, but these do pass.
Publications
Look back at 'Food composition' for several other useful publications and websites.
Some of the following books are out-of-print, but you'll find secondhand copies on the internet from sources such as www.abebooks.com or www.amazon.co.uk; or try borrowing them from your library:
Books written for professionals include:
Websites
Recipes
Some of the books and websites mentioned earlier have recipe ideas, including Arthritis Care's Healthy eating and arthritis booklet (downloadable or in print). If you like a particular product (eg sardines, olive oil, avocado) you could try asking the food manufacturer or supplier for recipe ideas or look on the internet. Here are some other ideas:
Using oil — an easy French recipe for making a thin-and-crispy pizza base, adaptable for other savoury and sweet dishes:
Mix well together: 150g flour, 3 dessertspoons water, 4 dessertspoons olive oil or rapeseed oil, 2 egg yolks, pinch of salt. Leave the dough to rest for about two hours.
Press the dough down thinly over a ready greased flat ovenproof baking tray (or similar). Cover the pastry with your chosen ingredients (eg tomatoes, tomato paste, grated cheese, onions). Bake in a medium oven (180 - 200 C) for 30 - 35 minutes.
Published in The Times, 28th August 2013
Broccoli could end misery of arthritis
written by Lucy Maddox
A compound found in broccoli could protect against arthritis, according to scientists. Sulforaphane is found in many green vegetables, and in high levels in broccoli, and appears to protect against inflammation and cartilage damage.
There is no effective treatment for arthritis, which affects more than 8.5 million people in Britain, and if confirmed in clinical trials, the findings could present a way to control the condition.
Scientists have now begun a study with 40 osteoarthritic patients to test whether eating a strain of broccoli with naturally high levels of sulforaphane, two weeks before a joint replacement operation, results in higher levels of the compound being found the joints.
Results from the preliminary patient study are expected early next year.
The study, published today in the journal Arthritis and Rheumatism, found that when mice were fed the compound for two weeks they had significantly less cartilage damage and osteoarthritis than those that were not.
Rose Davidson, a biologist at the University of East Anglia, said: "We had an inkling it would be good but we were excited to see it was so good."
How the compound works is not yet fully understood, but Dr Davidson believes that it may inhibit the body's inflammatory response, which eventually results in the break down of cartilage in arthritis.
In a second experiment, the compound was shown to reduce inflammation in human tissue cells in culture.
The latest study could explain epidemiological data showing that people who eat more fruit and vegetables are less likely to suffer from osteoarthritis.
Professor Alan Silman, the medical director of Arthritis Research UK, said that the research suggested possible health benefits from eating broccoli for people who have osteoarthritis and even the possibility of protecting people from developing the condition in the first place.
Results from the preliminary patient study are expected early next year.
[There is a reference to broccoli in the fourth paragraph under Interactions: arthritis, drugs, foods, and supplements on this page.]
Published in The Times, 13th August 2014
Grapes may reduce pain of arthritis
Eating grapes regularly can help mobility and reduce pain from arthritis, according to research.
The study showed that organic chemicals found in grapes known as polyphenols helped alleviate pain from osteoarthritis of the knee and improved joint flexibility and overall mobility.
Researchers at the Texas Woman’s University undertook a four-month clinical study into the benefits of grape consumption on inflammation and osteoarthritis.
Seventy-two men and women with knee osteoarthritis were assigned to either consume grapes in the form of a whole grape freeze-dried powder or a placebo powder.
The results showed that both men and women consuming a grape-enriched diet had a significant decrease in self-reported pain related to activity and an overall decrease in total knee symptoms.
This beneficial effect was more pronounced in women.
Those under 64 taking the grape powder showed a 70 per cent increase in being able to do very hard activity, whilst those on the placebo showed a marked decrease.
Those over 65 reported a decline in moderate to hard activity whether taking the placebo or grape powder.
Men on the grape diet showed higher levels of an important cartilage growth factor (IGF-1) than those on placebo.
This protective effect was not observed in women.
Presenting the findings at the Experimental Biology conference in San Diego, California, Dr Shanil Juma, the lead investigator, said: "These findings provide promising data that links grape consumption to two very important outcomes for those living with knee osteoarthritis: reduced pain and improvements in joint flexibility.
"More research is needed to better understand the results as well as the age and gender differences observed."
Dr Juma also shared results from a recent cell study that looked at the effects of whole grape polyphenols on cartilage cell integrity and markers of cartilage health.
Cartilage cells were first treated with various doses of whole grape polyphenols, and then stimulated with an inflammatory agent.
Cell proliferation increased significantly, in a dose-dependent manner, in the grape polyphenol-treated cells in the presence of an inflammatory agent.
Additionally, a marker for cartilage degradation was significantly lower with the three highest doses of the whole grape polyphenols when compared with control cells and cells treated with the inflammatory agent, suggesting a possible protective effect of grapes on cartilage cells.