Nutritional considerations for rheumatoid arthritis

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By Kellie Blake, RDN, LD, IFNCP

Rheumatoid arthritis (RA) can be a devastating disease. My grandfather suffered with RA for years and I remember his morning ritual of soaking his hands and feet in warm water for up to an hour before he could function for the day. His hands, wrists, and ankles were swollen and misshapen despite his use of disease-modifying antirheumatic drugs (DMARDs) and steroids. Unfortunately, he never found relief. 

RA is the most common systemic inflammatory arthritis affecting up to 1 percent of the worldwide population. Hallmark presentation includes pain and stiffness especially in the wrists and proximal interphalangeal and metacarpophalangeal joints, but other symptoms such as extreme fatigue, weight loss and low-grade fever can be present. Left untreated, RA can cause not only physical deformity, but patients can suffer cardiovascular, renal, and skin complications. Like with other autoimmune diseases, RA is more common in women. 

While each RA patient is unique, a genetic predisposition accompanied by an environmental trigger (the most common being current or past exposure to cigarette smoke), and increased intestinal permeability with an altered gut microbiome are all implicated in the development of the disease. As reported in The Open Rheumatology Journal, there is an increase in intestinal permeability and altered mucin layer, which allows the gut microbiota to inappropriately influence T helper (Th) 17 cells. The Th cells set off a cascade of events leading to inflammation in synovial tissues causing cartilage destruction and bony erosions.

Unfortunately, many of the conventional medications like non-steroidal anti-inflammatory drugs (NSAIDs), DMARDs, biologics, and steroids used in the treatment of inflammatory diseases like RA negatively affect an already altered gut microbiome, making treatment of the root cause more difficult. Despite the strong medications though, we can still use nutrition therapy to powerfully impact symptoms with the goal of reducing medication use, allowing for gut healing. An effective nutrition plan for RA should involve targeting gut function, fasting, and nutrient supplementation.

Initiating the 5-R protocol is my first objective with RA patients. I prescribe an elimination diet for a minimum of eight weeks to remove potential food allergens and inflammatory foods.  Ideally the elimination diet is tailored to the patient, but possible foods to eliminate include gluten, dairy, soy, corn, nightshades, processed grains, peanuts, shellfish, eggs, inflammatory fats, caffeine, chocolate, artificial sweeteners, sugar, alcohol, and food additives. To improve gut bacterial diversity, I encourage fermented foods like kimchi, sauerkraut, and apple cider vinegar with the mother. If needed, I add digestive enzymes or hydrochloric acid to improve digestion and nutrient absorption. In addition, I utilize gut healing nutrients like vitamin E, zinc, and l-glutamine. Finally, I educate patients on how to maintain optimal gut health with lifestyle strategies including stress management, exercise, and healthy sleep.

Once gut function has been improved, I transition RA patients to the most appropriate maintenance meal plan. Positive results have been found with both Mediterranean and plant-based meal plans. The Mediterranean diet (MD) has been researched extensively and has been shown to significantly improve disease activity scores in RA patients after 12 weeks of diet therapy as compared to controls. This meal pattern focuses on antioxidant-rich foods, limits red meat, is abundant in omega-3 fatty acids and extra-virgin olive oil, and is naturally anti-inflammatory. I tailor the maintenance meal plan and educate patients that some foods may need to be avoided indefinitely. Items like sugar, artificial sweeteners, excess salt, gluten, dairy, processed grains, inflammatory fats, sensitive foods, and alcohol are all items to consider given their known negative effects on the gut microbiome.  

In addition to the maintenance meal plan, I incorporate a fasting protocol for RA patients. Research by Valter Longo, PhD, has shown that fasting and low-calorie diets can be effective in the treatment of RA. While symptoms improve during the fast, however, they can return upon resumption of a normal diet. But when the fast is followed by a long-term vegetarian or Mediterranean meal plan, symptom reversal can last for years. Cycles of the fasting mimicking diet from one to three months followed by a Mediterranean diet or similar protocol in between cycles for RA patients can be an effective fasting protocol.

Several specific nutrients and supplements have been shown to improve RA symptoms. Omega-3 fatty acids can significantly improve RA symptoms and morning stiffness, but also reduce the need for NSAIDs. I encourage consumption of high-quality fatty fish twice weekly in addition to a high-quality omega-3 fatty acid supplement up to 4,000 milligrams per day.

Probiotics can decrease high sensitivity C-reactive protein (hsCRP) levels, as well as improve joint pain and disease activity scores when compared to controls. As reported in Therapeutic Advances in Musculoskeletal Diseases, one study showed decreased joint disease severity when a bifidobacterium probiotic supplement was used. I encourage a high-potency probiotic with a variety of strains in addition to both pre-and probiotic foods in the meal plan.

Vitamin D is another important consideration since RA patients have lower vitamin D levels when compared to healthy controls. Vitamin D deficiency does appear to be a factor in the development of RA, but can also increase disease activity in those with the disease. I help my patients achieve an optimal vitamin D level of 50 to 80ng/dL via a combination of supplementation, food sources, and sun exposure.

Extra virgin olive oil contains oleic acids and polyphenolic compounds that can provide powerful anti-inflammatory relief. I often prescribe two to four tablespoons of high-quality olive oil daily. And finally, curcumin, a bioactive compound found in the spice turmeric has been shown in animal models to decrease pro-inflammatory Th cells and increase regulatory T cells. In addition, studies have shown great improvement in disease activity scores and hsCRP levels in RA patients given 500 milligrams curcumin per day as compared to controls. Curcumin is typically well-tolerated, and I aim for at least 500 milligrams per day of active curcumin in supplement form.

Case Study

My patient struggled with worsening RA symptoms for one year prior to our visit. Her hsCRP had gone from 5 mg/L to 27 mg/L and she had a very low vitamin D level of 27.9 ng/dL. Celiac disease and thyroid dysfunction had been ruled out. She had a very stressful job, wasn’t sleeping well, and reported a 30-pound weight loss since her diagnosis. She felt very stiff in the morning, taking up to an hour to get moving upon waking. She was already trying to follow a gluten and dairy-free, plant-based meal plan, but admitted to having sweets at times, especially when she wasn’t feeling well. I suspected significant gastrointestinal dysfunction and unmanaged stress as root causes of the extreme inflammation. GI Map stool testing and salivary cortisol testing were recommended but declined due to cost.

I targeted her gastrointestinal and adrenal function with the 5-R protocol and utilized a variety of nutrients to address the inflammation and vitamin D deficiency. My initial plan included:

Stress Management and Sleep Strategies

1. Meditation: work up to 20 minutes twice per day
2. Aromatic lavender essential oil before bed
3. No blue light at least one hour prior to bedtime
4. Holy Basil or chamomile tea (two teabags) before bed
5. Magnesium glycinate 200 to 400 milligrams before bed

Inflammation and Gut Healing Strategies

1. Elimination diet for eight weeks with 1,000 milligrams buffered vitamin C daily for the first week
2. Ginger, 500 milligrams BID
3. Curcumin, 500 milligrams TID
4. Selective Kinase Response Modulator 1 cap TID
5. High quality fish oil 3,000 milligrams per day
6. Vitamin D3 5,000 international units with K2 daily for three months
7. Extra virgin olive oil two to four tablespoons per day
8. High-potency probiotic supplement and two tablespoons fermented foods each day
9. Prebiotics daily: patient was to choose from under-ripe bananas, raw dandelion greens, raw leeks, raw jicama, raw chicory root, raw garlic, raw or cooked onions, and/or raw asparagus

After four weeks, my patient had experienced some symptom improvement, but hsCRP remained quite elevated. I recommended continuing with the initial strategies and added the fasting mimicking diet protocol outlined above. My patient declined due to cost, so I recommended a 12-hour overnight fast daily and a longer 16 to 18-hour fast twice per week. My patient has incorporated the above recommendations and over the past one year, her hsCRP is down to 1 mg/L. Her symptoms are much improved, and she can move well upon waking. While she remains on a Janus kinase inhibitor, she feels the nutrition and lifestyle-related changes have been extremely helpful for symptom management. Her maintenance meal plan is a mostly plant-based, modified Mediterranean diet excluding gluten, dairy, red meat, and nightshades.

RA is a challenging disease to manage and patients can feel very frustrated with the relapsing and remitting nature. Traditional medications may be necessary, but helping patients utilize nutrition and lifestyle-related strategies can help ease the symptom burden, possibly reduce the need for medication, and improve long-term outcomes.

References:

Asteriou E, Gkoutzourelas A, Mavropoulos A, Katsiari C, Sakkas LI, & Bogdanos DP. (2018) Curcumin for the Management of Periodontitis and Early ACPA-Positive Rheumatoid Arthritis: Killing Two Birds with One Stone. Nutrients. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/30012973/

Bodkhe R, Balakrishnan B, & Taneja V. (2019). The role of microbiome in rheumatoid arthritis treatment. Ther Adv Musculoskelet Dis. Retrieved from: https://journals.sagepub.com/doi/10.1177/1759720X19844632

Fasano A. (2012). Intestinal permeability and its regulation by zonulin: diagnostic and therapeutic implications. Clin Gastroenterol Hepatol. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/22902773/

Guerreiro CS, Calado Â, Sousa J, & Fonseca JE. (2018). Diet, Microbiota, and Gut Permeability-The Unknown Triad in Rheumatoid Arthritis. Front Med (Lausanne). Retrieved from: https://www.frontiersin.org/articles/10.3389/fmed.2018.00349/full

Lee YH & Bae SC. (2016). Vitamin D level in rheumatoid arthritis and its correlation with the disease activity: a meta-analysis. Clin Exp Rheumatol. https://www.clinexprheumatol.org/abstract.asp?a=10111

Longo, V. (2018). The Longevity Diet. New York. Avery.

Sales C, Oliviero F, & Spinella P. (2009). Il modello nutrizionale mediterraneo nelle malattie reumatiche infiammatorie [The mediterranean diet model in inflammatory rheumatic diseases]. Reumatismo. Retrieved from: doi:10.4081/reumatismo.2009.10

Veselinovic M, Vasiljevic D, & Vucic V, et al. (2017). Clinical Benefits of n-3 PUFA and ɤ-Linolenic Acid in Patients with Rheumatoid Arthritis. Nutrients. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/28346333/

Wasserman AM. (2011). Diagnosis and management of rheumatoid arthritis. Am Fam Physician. Retrieved from: https://www.aafp.org/afp/2011/1201/p1245.html