-IBIS-1.7.6-
tx
immune system
rheumatoid arthritis
Nutrition

dietary guidelines

» eating principles:
Reduce fat intake to 20% of calories: Saturated fats, because of their arachidonic acid content, promote the production of PGE2 and pro-inflammatory mediators.
(Lucas C, Power L. Clin. Res. 1981;29(4):754A; JAMA Apr 9, 1982; Skoldstam L. Scand. J. Rheumatol. 1987;15(2):219-221.)
Vegetarian or Vegan diet:
(Nenonen M, et al. AJCN 1992;56:762; Kjeldsen-Kragh J, et al. Lancet 1991;338:899-902; Kjeldsen-Kragh J, et al. Clin Rheumatol 1994;13:475-482.)
• Low sugar
• Low fat diet of unsaturated fats
• Calorie percentages: 70% complex carbohydrates, protein 12-15%, fat 15-18%
• Short fasts (5-7 days) are recommended with 2 week intervals between them
• Vegetarian cleansing diet
• Elimination/rotation diet, rotation diet, rotation diet expanded

» important considerations:
• Treat hypothyroid
• Treat heavy metal toxicity or other environmental sensitivities
• Avoid NSAID: They increase permeability of the intestinal mucosa and can worsen the actual joint tissue. (Marz, 347, 1997.)
• Treat parasites: There have been reported cases of amoebas triggering off severe RA. Treatment involves the use of Flagyl 2 g per day on 2 consecutive days during the week. Take in divided doses with food and each week for 6 weeks (i.e., 2 days per week for 6 weeks). The 2 g dose per day is for a person weighing 150lbs and different weight people should adjust the dose accordingly. Flagyl can cause significant toxic side effects so consider recommending Silymarin 80% standardized extract 400 mg per day during the treatment protocol. Avoid alcohol or any other liver toxic substances while doing the treatment. (Marz, 347, 1997.)
• Bee venom therapy: contact the American Apitherapy Society (802)436-2708

» therapeutic foods:
• Increase omega-3 and omega-6 fatty acids: vegetable, nut, seed oils, salmon, herring, mackerel, sardines, walnuts, flaxseed oil, evening primrose oil, black currant oil
Curcumin: Curcumin has potent antiinflammatory effects especially for acute inflammation. It has been found to be equal or even more potent than cortisone and phenylbutazone in acute inflammation. It has long been used in Ayurvedic medicine both locally and internally to treat inflammation as well as in Chinese medicine in the treatment of shoulder inflammation. (Srimal R, Dhawan B. J Pharm Pharmacol 1973;25, 447-452.)
Ginger: Ginger inhibits prostaglandin and leukotriene synthesis as well as acting as an antioxidant. It also inhibits platelet aggregation and may thus enhance circulation. It contains proteases similar to bromelain which have antiinflammatory effects. (1 oz fresh ginger)
(Srivastava KC, Mustafa T. Med Hypothesis 1992;39:342-348.)
• Sesame seeds, kale, artichokes, green beans, millet, celery, barley, okra, almonds, collards, turnip greens, raw goat's milk, goat whey and black mission figs, gelatin (make a gelatin mold with cherry concentrate - no sugar), burdock root, cherries, pineapple, quince, watercress, blackberries, black currants, mustard greens, limes, lettuce, olive oil (Jensen)

» fresh juices:
• Celery and parsley (Jensen, p. 49) or tea (decoct 7-8 minutes) (Shefi)
• Cucumber, endive, and goat's whey (Jensen)
• Celery and apple (Shefi)
• Grapefruit (Walker)
• Celery (Walker)
• Carrot and celery (Walker)
• Goat milk or whey and black mission figs (Jensen, 43.)

» specific remedies:
• Soak 500 g of red cherries in 1 liter rice wine for ten days. Drink 30-60 ml of wine twice daily (Yin-fang and Cheng-jun, 91.)

» avoid:
Avoid Food sensitivities
(Panush, R. Arthritis Rheum. 1986;29(2):220-226; Hicklin, J. Clin Allergy 1980;10:463; Skoldstam, L. Scand J Rheum. 1979;8:249-255; Seignalet J. Lancet. 1992;339:68-69.)
• Animal products, cow's milk and other dairy products due to promotion of PGE2 pro-inflammatory mediators (Lucas C, Power L. Clin Res. 1981;29(4):754A; JAMA Apr 9 1982; Skoldstam L. Scand J Rheumatol. 1987;15(2):219-221.)
• Spinach, asparagus, rhubarb, vegetables from the nightshade family (tomatoes, green peppers, potatoes, pimentoes, eggplant), tobacco, coffee, caffeine, sugar, refined foods, fried foods
Nonsteroidal anti-inflammatories; aspirin causes increased urinary folate in rheumatoid patients
• High protein diet
Iron: Iron is found in elevated amounts in the synovial fluid of RA sufferers compared to normals, and was significantly reduced in serum. If an RA patient is anemic, iron supplementation is often contraindicated. However if patient has low ferritin levels and very anemic (low HCT and HgB) then certainly consider giving at least a liver extract. Remember that ferritin is usually going to be falsely elevated in a patient who has active RA. (Marz, 346, 1997)

» drug interaction:
prednisone/prednisolone: causes increased gluconeogenesis and consequently leads to protein wasting; some authors recommend a high protein diet to compensate (Trovato, et al., 1991; 44: 1651-1658.); however, this may be questionable considering that RA patients seem to do well on low protein vegan diets.

» therapeutic foods
• Cold-type arthritis:
garlic, green onions, pepper, black beans, sesame seeds, chicken, lamb, mustard greens, ginger, spicy foods, grapes, grape vine tea, parsnip (Ni, 103.)

avoid:
• cold foods, raw foods

» therapeutic foods
• Wind type arthritis:
scallions, grapes, grapevine tea, black beans, most grains, leafy vegetables (Ni, 103.)

avoid:
meats, shellfish, sugar, alcohol, smoking and stimulants

» therapeutic foods
• Damp-type arthritis:
barley, mung beans, mustard greens, red beans, millet, sweet rice wine with meals, cornsilk tea, diuretic foods and herbs (Ni, p. 104)

avoid:
cold foods, raw foods, dairy products

» therapeutic foods
• Heat-type arthritis:
fresh fruits and vegetables, dandelion, cabbage, mung beans, winter melon, soybean sprouts (Ni, pp. 104-105)

avoid:
• spicy foods, alcohol, smoking, stress, green onions


supplements

• Vitamin B5 500 mg four times per day (Practitioner, 1980, 208ff.)
• Vitamin C (Roberts, 1984, 88.)
Vitamin E 1000 IU per day Antioxidant acts as an anti-inflammatory by altering leukotriene production
• Vitamin K 5-10 mg three times daily, to stabilize synovial linings.
Copper salicylate: 64 mg twice daily, may form complexes which serve as selective antioxidants.
(Hangarter W. Med Welt. 1980;31:1625.)
• Manganese
Selenium 200-400 mcg per day. Antioxidant which acts as an anti-inflammatory by altering leukotriene production.
Zinc: 150 mg zinc sulfate or 90 mg zinc picolinate (50 mg elemental zinc): improvement in joint swelling, joint tenderness, morning stiffness.
(Svenson, 1985, 189ff; Simkin P. Lancet 1976;2:539; Marz, 345, 1997.)
Omega 3 fatty acids: 1.8 gms per day (10 caps)
(Sperling, 1986; Kremer, J. Lancet 1:184-87, 1985; Das UN. 51:207-213, 1994; Geusens P, et al. Arthritis Rheum 1994 Jun;37(6):824-829.)
EPO or Borage oil: 1gm four times per day, this treatment takes 4-12 weeks and the patient should not be on NSAID because of the effect of inhibiting PGE1 formation which acts as an anti-inflammatory.
(Hansen T. Scand J Rheum. 1983;12:85; Leventhal LJ, et al. Annal Intern Med. 1993;119:867-873.)
Bromelain
Acute flare-ups:1000mg of 2800 mcu (milk clotting units) four times per day (Marz, 345, 1997.)
Maintenance: 500 mg three times daily (Marz, 345, 1997.)
200-250 mg twice daily between meals
(Cohen, Goldman. Pennsyl Med J. 1964 June 67:27-30.)
• Catechin
Glycosaminoglycans found in Perna canaliculus (green lipped mussel extract): 350 mg three times daily
(Gibson R. Practitioner 1980 Sept; 224:955-960; Lancet 1981;1:439; El-Ghobarey A. Quart J Med. 1978;47:385.)
Pantothenic acid: 500 mg four times per day
Quercetin: 500mg three times daily before mealsinhibits leukotriene formation, effective at stabilizing cell
Sea Cucumber: 500 mg four times per day (Hazelton RA. 1988.)
• D, L phenylalanine
• L-histidine
• Tryptophan

» drug interaction:
Folate and aspirin: aspirin causes increased levels of urinary folate in patients with rheumatoid arthritis (Buist, 1984; 4 (3):114.)
Potassium and indomethacin (Indocin): as a prostaglandin inhibitor, indomethacin reduces renin and aldosterone, and consequently reduces potassium excretion and causes hyperkalemia (Goldszer, et al., 1981;141: 802-804; Tan, et al., 1979; 90:783-785; MacCarthy, et al., 1979;1:550.)
prednisone/prednisolone:
- causes Sodium retention
- causes reduced activation of Vitamin D (Travato, 1991;44:1651-1658; Tuttle, 1982;126:1161-1162); 1,25(OH)2D3 can be measured to determine if supplementation necessary, with low levels can use calcitriol
- causes increased urinary excretion of Zinc, Vitamin K and Vitamin C (Buist, 1984;4(3):114.)
Folic acid and methotrexate (Amethopterin): methotrexate interferes with activation of folate, therefore disrupting DNA replication for cells


footnotes

Cohen, Goldman. Bromelain Therapy in RA. Pennsyl Med. J. June, 1964; 67:27-30.
Abstract: 25 patients with stages 2 or 3 RA were on small maintenance doses of steroids and they received 20-40mg of bromelain 3-four times per day. It was found, after 13 weeks, that 28% had excellent results, 45% had good results, 14% had fair results, and 14% had poor results.

Das UN. Beneficial effect of EPA and DHA in the management of SLE and its relationship to the cytokine network. Prostaglandins, Leukotrienes, EFAs 1994;51:207-213.
Abstract: 10 pts with SLE received 300mg EPA/DHA for periods of 3 months to 3 years. All patients had previously been evaluated for GLA, EPA and DHA levels prior to study and were found to be low. After treatment biochemical changes showed increases in the deficiencies and marked improvement of all of their symptoms. All medications were discontinued and pts remained symptoms free for periods up to 3 years.

El-Ghobarey A. Quart J Med. 1978; 47:385.
Abstract: 28 patients on NSAIDs were supplemented with perna canaliculus 350 mg three times daily daily or placebo for 6 months with significant benefit to the experimental group as compared to controls.

Geusens P, Wouters C, Nijs J, Jiang Y, Dequeker Jv. Long-term effect of omega-3 fatty acid supplementation in active rheumatoid arthritis. A 12-month, double-blind, controlled study. Arthritis Rheum 1994 Jun;37(6):824-829.
Abstract: 90 pts with RA received either 2.6gms omega 3 oil (fish) or placebo in a double blinded study for 12 months. The fish oil resulted in significant clinical benefit both subjective and objective on pain scores.

Gibson R. Perna canaliculus in the reaction of arthritis. Practitioner Sept.. 1980; 224:955-60; also in another study in Lancet 1:439, 1981.
Abstract: Perna canaliculus (green-lipped mussel), a rich source of glycosaminoglycans, benefited in the treatment of RA. The 1980 study was a double blind study of 25 pts average age 57 years with RA who had failed to respond to NSAIDS. Pts randomly received either placebo or 1gm of Perna c. After 3 months 67% of treated pts vs 30% of placebo pts responded. Following this the placebo treated pts were then switched to the Perna c. and 60% of these people responded favorably.

Hangarter W. Copper salicylate in rheumatoid arthritis and rheumatism-like degenerative disease. Med Welt. 1980; 31:1625.
Abstract: 60mg twice daily was compared with salicylic acid and copper acetate in equal doses in patients with RA. The copper salicylate was more effective than either salicylic acid or copper acetate and produced reduction in morning stiffness, increased joint mobility, and reduced need for other drugs.

Hansen T. Treatment of Rheumatoid Arthritis with Prostaglandin E1 precursors cis-linoleic acid and GLA. Scand J Rheum. 1983;12:85.
Abstract: When combined with cofactors zinc, vitamin C, B3, B6, and EPO was as effective as conventional treatment for 20 patients switched to it from NSAID.

Hazelton RA.(senior lecturer in medicine (rheumatology, U of Queensland, Australia.. C-cure in RA: A six month placebo controlled trial, Unpublished manuscript, 1988.
Abstract: 34 pts with RA received either C-Cure (Pacif. Pharm., LTd, Australia).1 capsule 2x per day or placebo. No difference was seen in grip strength between the 2 groups. After 18-24 weeks, the articular index was significantly lower and the grip strength significantly higher in the experimental group.

Hicklin J. The effect of diet in RA. Clin. Allergy 1980;10:463.
Abstract: 22 patients, 15 of which were seronegative, followed allergen exclusion diets. 20 subjectively improved, and 19 reported that certain foods would repeatedly exacerbate arthritic symptoms. Improvement occurred an average of 10 days after the correct exclusions with a maximum of 18 days. Reactions to provocation varied from 2 hours to 2 weeks. Grains were by far the most common allergen. Symptom evoking foods were: grains (14 patients), milk (4), nuts (8), beef (4), eggs (5), and 1 each for chicken, fish, potato, onion, and liver.

Kjeldsen-Kragh J, et al.. Controlled trial of fasting and one year vegetarian diet in the treatment of rheumatoid arthritis. Lancet 1991;338:899-902.
Abstract: 27 pts with RA were put on a 7-10 partial fast in which they were allowed to consume vegetable broth various spices and teas, and juices made from potato, parsley, beets, carrots, beets and celery (There was a control group of 26 pts that ate a standard diet with no restrictions). After the partial fast the treatment group introduced one food every 2 days. If the food provoked symptoms, it was removed from the diet and then retested in 7 days. If the food again provoked symptoms, it was then not permitted in the diet. During the first 31/2 months gluten, meat, fish, eggs, dairy products, refined sugar, citrus fruit, preservatives, coffee, tea, alcohol, salt, and strong spices were avoided. Both dairy and gluten were returned to the diet after 31/2 months if they did not provoke symptoms. After 4 weeks the tx group showed a significant improvement in the number of tender joints, Ritchies articular index, number of swollen joints, pain scored, duration of morning stiffness, grip strength, SED rate, C-reactive protein, WBC count, and a health assessment questionnaire score. In the control group only the pain scored improved significantly. The improvements were still noted in the treatment group one year later.

Kjeldsen-Kragh J, et al.. Vegetarian diet for patients with RA-status 2 years after introduction of the diet. Clin Rheumatol 1994;13:475-482.
Abstract: The above study was followed up and it was found that if the people who responded to the vegetarian diet continued for another year their symptoms remained improved.

Kremer J. Effect of manipulation of dietary fatty acids on clinical manifestations of rheumatoid arthritis. Lancet 1985;1:184-187.
Abstract: 17 patients were placed on a high PUFA, low saturated fat diet and supplemented with 10 caps of Max EPA/day, while 20 controls received a typical American diet and placebo caps. After 12 weeks, the EPA group had significantly less morning stiffness compared to a worsening in the control group. Joints were also less tender and Hgb improved. A rapid deterioration with increased pain and stiffness was seen in treated patients compared to controls upon cessation of the experimental diet.

Leventhal LJ, et al. Treatment of rheumatoid arthritis with GLA. Annal Intern Med. 1993;119:867-873.
Abstract: 37 pts with RA were randomly assigned to receive 1.4gms per day of GLA from borage oil or placebo (cottonseed oil). This was a double-blind trial that lasted 24 weeks. The GLA treated group had significant reduction in signs and symptoms of disease activity whereas pts receiving the placebo showed no change in symptoms. GLA reduced the number of tender joints by 36% and tender joint score by 45%. All pts were allowed to continue with their NSAIDS during the study.

Lucas C., Power L. Dietary fat aggravates active RA. Clin Res. 1981;29(4):754A; JAMA Apr 9 1982.
Abstract: 6 patients, 2 of which were obese, were treated for RA with a low calorie, fat free weight control formula or diet. The 2 obese patients remained symptom free for 9-14 months and the other 4 patients also experienced a remission in symptoms. Within 24-72 hours of introducing vegetable oil, animal fat, cheese, safflower oil, beef, coconut oil or other foods with a high proportion of calories from fat, they experienced exacerbations of symptoms, i.e. joint swelling, morning stiffness, and tenderness.

Marz R. Medical Nutrition from Marz, 346-347, 1997. In one unpublished study in Poona, India, 18 RA patients were divided and 1/2 were given 250 mg of zinc sulfate (50 mg elemental zinc) three times daily. The zinc treated group showed significant improvement in joint swelling, joint tenderness, morning stiffness, onset of fatigue, general condition of the patient and 50 foot walking time. A similar response was observed in the placebo group when they were given zinc. Patients were able to cut back their NSAID by half.

Nenonen M, et al.. Effects of uncooked vegan food-living food- on RA, a 3 month controlled and randomized study. Am J Clin Nutr 56:762, 1992.
Abstract: 40 patients with RA were randomly assigned to receive an uncooked vegan diet or a control diet for 3 months. After this period pts on the vegan diets reported relief of stiffness, joint welling and general well being. When the vegan eating group switched back to their normal omnivorous diet most all of the symptoms became worse.

Panush R. Food-induced allergic arthritis. Arthritis Rheum. 29(2):220-226, 1986.
Abstract: 52 year old white female with an 11 year history of joint pain, tenderness, swelling and stiffness fulfilled the criteria for active RA and achieved only fair results from NSAIDs. She was placed on a baseline diet for 6 days, a 3 day mineral water fast and vanilla flavored Vivonex. There were no notable responses to 52 placebo challenges, but she responded with symptomatic deterioration and worsening of ESR and other peak responses to cows milk challenge on 4 separate occasions. While there was no elevation of IgE antibodies to foods, there was a mild elevation of IgG and large amounts of IgG4 anti-milk antibodies.

Seignalet J. Diet, fasting and rheumatoid arthritis. Lancet. 1992;339:68-69.
Abstract: 46 adults with RA were placed on a diet that consisted of raw foods, while avoiding grains and dairy products. The study lasted for between 1-3 years. 36 patients had significant improvement in painful joints, swollen joints, morning stiffness, SED rate and other parameters. Among the 36 people who had positive benefits, 17 were clearly improved and 19 were in complete remission for 1-5 years. 8 of these 19 pts stopped all medications and no relapse was noted. Improvements were noted in 32 of the 36 responders before the end of the 3rd month. Improvement was progressive and often rapid. 7 of the people that had positive results had all of their symptoms return when they abandoned their diet, but again improved when they resumed their diet.

Simkin P. Oral zinc sulfate in rheumatoid arthritis. Lancet 1976;2:539.
Abstract: 12/24 treatment resistant patients received 50mg zinc 3x daily for 12 weeks while the rest received placebo. The remaining 24 patients received zinc for 12 more weeks along with the initially supplemented group. There were significant improvements in joint swelling, morning stiffness, walking time and subjective symptoms during the first part of the study with continuing impressive improvement in the second part in both groups.

Skoldstam L. Effects of fasting and lactovegetarian diet on rheumatoid arthritis. Scand J Rheum. 1979;8:249-255.
Abstract: Of 26 patients with classical RA (all on NSAIDs), 16 were placed on a diet of fruit and vegetable juices and herbal tea for 7-10 days (1 stopped after 2 days) while the other 10 were controls. Most of the 15 experimental patients felt better by day 5-6. At the end of the first diet, 10 reported reduction in pain and stiffness. 5/15 showed objective improvement defined as a greater than 10% decrease in the SED rate with concomitant decrease in joint tenderness, while only 1 of the controls improved. A subsequent lactovegetarian diet was ineffective for all but 1 patient..

Skoldstam L. Effects of fasting andlactovegetarian diet on RA. Scand J Rheumatol. 1987;15(2):219-221.
Abstract: 20 patients were placed on a vegan diet following a 7-10 day fast. Also excluded or used sparingly were refined sugar, corn flour, salt, strong spices, alcohol, tea, and coffee. After 4 months, 12 patients reported some improvement, 5 reported no change, and 3 felt worse. Most felt less pain and were better able to function, although there were no changes in objective measures such as grip strength and joint tenderness.

Srimal R, Dhawan B. Pharmacology of diferuloyl methane (curcumin), an NSAID agent. J Pharm Pharmacol 1973;25, 447-452.

Srivastava KC, Mustafa T. Ginger in rheumatism and musculoskeletal disorders. Med Hypothesis 1992;39:342-348.
Abstract: 28 patients with RA and 18 with OA and 10 with muscular discomfort were treated with 1-4gms of powdered ginger for periods of 3months to 21/2 years. There was significant improvement in many of the patients, but especially in the patients that just had muscular pain.