Nutrition and Rheumatoid Arthritis

Nutrition and Rheumatoid Arthritis | Food & Nutrition Magazine | Volume 11, Issue 1

Rheumatoid arthritis, or RA, is an inflammatory autoimmune disease in which the body’s immune system attacks the lining of healthy joints, causing pain, inflammation, stiffness and sometimes loss of function. Over time, inflammation caused by rheumatoid arthritis can lead to deformities, chronic pain or struggles with balance. While there is no cure, interventions such as medications and lifestyle and nutrition modifications may help prevent or slow the progression of joint damage and help with symptom management.

Signs and Symptoms
Common symptoms include pain, swelling or stiffness in more than one joint, usually on both sides of the body. Stiffness is typically worse in the morning, getting better as the day progresses. Joints most impacted by rheumatoid arthritis are in the hands, wrists and knees, but other joints and organs such as the lungs, heart and eyes can be affected. Other symptoms may include weight loss, fever, weakness or fatigue.

It is common for people with RA to experience flares — times when symptoms get worse — and remission, when symptoms improve.

Risk Factors
The cause of rheumatoid arthritis is unknown. Factors that may increase risk of development include aging and genetics. According to the American College of Rheumatology, about 75% of people diagnosed with RA are women. Additional risk factors include smoking, obesity, early life exposures such as children whose mothers smoked and social determinants of health. Conversely, breastfeeding has been found to decrease risk.

Blood tests are one of many completed to determine if a person has rheumatoid arthritis and are an important factor in determining whether a person has seropositive or seronegative RA. Seropositive is the most common form; it means the person has antibodies called anti-cyclic citrullinated peptides or rheumatoid factors. These antibodies attack joints and cause inflammation. Usually, people with seropositive RA will experience more severe symptoms.

Nutrition for Prevention
Though evidence is limited, some research suggests diet may play a role in the prevention of rheumatoid arthritis. Using data from two cohort studies of nearly 170,000 women, researchers found a healthier overall dietary pattern (measured by the 2010 Alternative Healthy Eating Index) led to reduced risk in women 55 or younger. In this age-specific analysis of the study, women with the highest healthy eating index scores, indicating an overall healthier diet, showed a 33% reduction in RA risk compared to those with the lowest scores.

Authors of a 2018 review discussed the potential of the Mediterranean diet for prevention. Noting the prevalence of rheumatoid arthritis in Southern Europe is lower than Northern Europe and the United States, they argued the Mediterranean diet could be a factor since it is higher in antioxidants, unsaturated fats and foods with anti-inflammatory properties compared to the typical Western diet; however, more evidence is needed.

Other studies hint that reducing sodium and sugar-sweetened soda intake may reduce risk. A cross-sectional study of 18,555 people found high sodium consumption (an average of nearly 5,000 milligrams a day) was associated with self-reported rheumatoid arthritis, while a case-control study found a significant association only existed between high sodium consumption and risk for RA among smokers, and it was dose dependent, more than doubling their risk. Additionally, another study found women who drank one or more servings of sugar-sweetened soda a day may be at an increased risk of seropositive RA (but not seronegative).

Nutrition for Disease Management
Researchers are equally interested in the Mediterranean diet for rheumatoid arthritis management but, so far, findings are mixed. Results of a 2018 systematic review showed two prospective studies found no significant benefits of following a Mediterranean diet, while two clinical trials reported modest but favorable outcomes. One clinical trial reported improvement in pain and physical function after three months and reduced stiffness after six months following the Mediterranean diet. Participants in the other clinical trial saw swelling and inflammatory biomarker improvements after three months.

Of studies included in a 2020 systematic review on the effects of diet and dietary supplements on Disease Activity Score in 28 joints, or DAS28 which measures rheumatoid arthritis severity, one reported a significant improvement after 12 weeks of following the Mediterranean diet, while another reported benefits after 10 weeks, but those results were not statistically significant.

The same systematic review looked at three small studies of various spices (administered in high doses in capsules or tablets) on DAS28. One study had participants supplement with 1.5 grams of ginger powder daily for three months; another with 2 grams of cinnamon (Cinnamomum burmannii) powder daily for two months; and another with 100 milligrams of saffron daily for three months. All three studies reported significant improvement in DAS28 when compared to placebo.

Similar results were shown in a pilot study on curcumin. Participants who supplemented 500 milligrams twice daily for eight weeks had the highest improvement in overall DAS28 scores compared to participants who supplemented with 50 milligrams diclofenac sodium (a pain medication) alone or in combination with curcumin.

Omega-3 Fatty Acids
Evidence of supplemental omega-3 fatty acid intake on RA symptoms is limited and inconsistent. Some research suggests it may help reduce the number of swollen and tender joints, and some studies suggest omega-3 fatty acid supplements may reduce the need for medication. For example, when supplementing with 10 grams of fish oil daily (containing 1.8 grams of EPA and 1.2 grams of DHA), one study found a decreased need for non-steroidal anti-inflammatory drugs.

A 2020 systematic review found two studies that supported benefits of supplementing with probiotics containing L. casei. One study had participants supplement with a capsule of L. casei 01 (108 colony forming units) and maltodextrin daily for two months, which resulted in a lower inflammatory marker score for the intervention group compared to those who only took maltodextrin. The other had participants take capsules containing L. casei (2 × 109 colony forming units), L. Acidophilus (2 × 109 colony forming units) and B. Bifidum (2 × 109 colony forming units) daily for two months. Among the beneficial effects reported in this randomized, double-blind, placebo-controlled trial was an improvement in DAS28 compared to placebo.

The Centers for Disease Control and Prevention recommend adults with arthritis aim for at least 150 minutes of moderate physical activity each week. Research has shown physical activity can help manage pain from rheumatoid arthritis and improve quality of life for people with RA. However, for someone experiencing a flare, the American College of Rheumatology recommends prioritizing rest and opting for gentle range-of-motion exercises, such as stretching.

Several community-based, physical activity programs are recommended by the CDC; they have been proven to reduce symptoms and help participants safely increase their physical activity.

Epidemiological studies suggest smoking significantly increases risk and complications of rheumatoid arthritis; recommend to clients and patients that they quit.

RDN Takeaways
Until data is more conclusive concerning the effects of diet and dietary supplements on RA prevention and symptom management, registered dietitian nutritionists should encourage patients and clients to follow an overall balanced and healthful eating pattern consistent with the 2020-2025 Dietary Guidelines for Americans. Emphasize limiting sodium consumption and encourage patients and clients to eat foods higher in unsaturated fats and dietary fiber, as well as a variety of fruits and vegetables, whole grains, lean protein foods (especially fatty fish) and low-fat or fat-free dairy.

People with rheumatoid arthritis are at risk for malnutrition, so RDNs need to tailor nutrition interventions to address disease severity, polypharmacy and comorbidities. Referrals for occupational or physical therapy may need to be considered. Finally, educate patients and clients on the benefits of appropriate physical activity for RA management and help them find healthful ways to incorporate more movement into their daily lives.


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Esther Ellis
Esther L Ellis, MS, RDN, LDN, is an associate editor of Food & Nutrition Magazine.