Inflammatory Arthritis

Some Topics

Food & Arthritis Benefits of Diet Revision

Several diet revision studies have shown benefit for patients with rheumatoid arthritis. These studies support the more common and persistent claims in the community that diet revision has benefits. The occurrence of transient inflammatory arthritis after eating reactive foods with improvement between attacks is one pattern of food allergy. The food connection to more chronic and progressive inflammatory disease is difficult to recognize because the reactions are delayed and there may be little or no improvement between attacks.

Carinini and Brostoff reviewed the concepts of and evidence for food-induced arthritis. They stated: "Despite an increasing interest in food allergy and the conviction of innumerable patients with joint disease that certain foods exacerbate their symptoms, relatively little scientific attention has been paid to this relationship. Abnormalities of the gastrointestinal tract are commonly found in rheumatic disease...Support for an intestinal origin of antigens comes from studies of patients whose joint symptoms have improved on the avoidance of certain foods antigens, and become worse on consuming them. These have included patients with both intermittent symptoms, palindromic rheumatism and more chronic disease."

In one study of diet revision, 33 of 45 patients with rheumatoid arthritis improved significantly on a hypoallergenic diet. The authors concluded: "Increasing numbers of scientific studies suggest that dietary manipulation may help at least some rheumatoid patients and perhaps the greatest need now is for more careful and well-designed research so that preconceptions may be put aside and role of diet, as a specific or even a non-specific adjunctive therapy, may be determined."

In a review article, Darlington and Ramsey suggest that there are now enough good studies that show that diet therapy in some cases may improve symptoms and possibly halt the progression of arthritis. They review both supplementation and food elimination approaches. They suggested that diet therapy should begin with elimination of all foods which might be causing symptoms, followed by single food re-introductions to discover which foods reproduce symptoms. They list corn, wheat, cow's milk, pork, oranges, oats, rye, eggs, beef, coffee, malt, cheese, grapefruit, lemon, tomato, peanuts, and soya as the foods most likely to cause arthritis.

Appelboom et al reported benefit from the exclusion of dairy products in patients with ankylosing spondylitis and related spondyloarthropathies; 18 of 25 patients complied with 6 weeks of dairy exclusion - 13 had major improvement and 8 of these discontinued NSAID use; another 4 had moderate improvement.

Hafstrom et al reported that a vegan diet free of gluten and cow’s milk products improves rheumatoid arthritis and that the benefits correlate with a reduction in antibodies to food antigens. (Hafstrom I; Ringertz B; Spangberg A; von Zweigbergk L; Brannemark S; Nylander I; Ronnelid J; Laasonen L; Klareskog L. Vegan diet free of gluten improves rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food antigens. Rheumatology 2001 Oct;40(10):1175-9)

Food Proteins Cause Arthritis

Sr. Wm. Osler had first suggested that dietary proteins were important in the pathogenesis of Henoch-Schonlein purpura and arthritis. The term "palindromic arthritis" was used to describe transient synovitis in food-sensitive patients. The occurrence of transient episodes of inflammatory arthritis with the complete absence of signs and symptoms between attacks is typical of one pattern of food allergy, but the connection to more chronic and progressive disease has been more difficult to recognize.

The frequent occurrence of arthritis in patients with digestive tract disease is a major clue. About 20% of patients with regional enteritis and 10% with ulcerative colitis develop inflammatory arthritis. Intestinal bypass for obesity leads to polyarthritis in 20 % of patients and is associated with other features of "autoimmune" disease. Another clue is that people with celiac disease who continue to eat gluten-containing foods such as bread, pasta, cakes and cookies develop rheumatoid arthritis.  Another clue is an animal model of rheumatoid arthritis in rabbits who develop typical joint lesions when they are fed cow's milk.

A wheat gluten mechanism has been studied in rheumatoid arthritis patients. Careful observation revealed that wheat ingestion is followed within hours by increased joint swelling and pain. Little and his colleagues studied the mechanism, as it developed sequentially following gluten ingestion. Parke et al concurred with this explanation of the gut-arthritis link in their report of three patients with celiac disease and rheumatoid arthritis. The mechanism they postulated involves several stages:

The digestive tract must be permeable to antigenic proteins or peptide fragments, derived from digested food. The food antigens appear in the blood stream and are bound by a specific antibody (probably of IgA or IgG, not IgE class), forming an antigen-antibody complex, a circulating immune complex (CIC).  The antigen-antibody complexes activate the rest of the immune response, beginning with the release of mediators - serotonin is released from the blood platelets. Serotonin release causes "symptoms" as it circulates in the blood stream and enhances the deposition of CICs in joint tissues.

Once in the joint, the immune complexes activate complement, which in turn damages cells and activates inflammation. Inflammation causes pain, swelling, stiffness, and loss of mobility.

Some Example References

Abstracts

Joint complaints and food allergic disorders.

Author Denman AM; Mitchell B; Ansell BM

Source Ann Allergy, 1983 Aug, 51:2 Pt 2, 260-3

An important problem in investigating food allergic diseases is to adduce evidence that specific diseases of unknown cause may be attributable to food allergy. Polyarthritis is a good example of the difficulties involved in such studies because it is a very heterogeneous disorder and generalizations about aetiology are unlikely to prove correct. We have observed transient synovitis in both children and adults which is caused by food allergy. On the other hand we have not been able to show that food allergy demonstrably contributes to juvenile chronic arthritis or to rheumatoid arthritis in adults. The arthritis associated with inflammatory bowel disease undoubtedly responds to elemental diets and the mechanism of this remission warrants further investigation.

Prevalence and severity of food allergy--need for control.

Food Allergy to Wheat

Identification of immunogloglin E and immunoglobulin G-binding proteins with sequential extracts and purified proteins from wheat flour. Clin Exp Allergy.  2003; 33(7):962-70 (ISSN: 0954-7894)

Battais F; Pineau F; Popineau Y; Aparicio C; Kanny G; Guerin L; Moneret-Vautrin DA; Denery-Papini S

BACKGROUND: Cereal-associated allergy is particularly considered a serious problem, because cereals are essential in our daily diet. Wheat proteins are classified into albumins, globulins and prolamins (insoluble gliadins and glutenins). OBJECTIVES: Our objectives were to study the involvement in food allergy to wheat of these different protein types by using purified fractions and to identify those binding IgE and IgG antibodies. METHODS: Sera were obtained from 28 patients with food allergy to wheat. Albumins/globulins, gliadins and glutenins were obtained by sequential extraction based on differential solubility; alpha-, beta-, gamma- and omega-gliadins and low molecular weight (LMW) and high molecular weight (HMW) glutenin subunits were purified by chromatography. IgE binding to these extracts and fractions were analysed by radioallergosorbent test (RAST), and immunoblotting; IgG binding was detected by enzyme-linked immunosorbent assay (ELISA). RESULTS: In RAST, 60% of sera were shown to have specific IgE antibodies against alpha-, beta-gliadins and LMW glutenin subunits, 55% to gamma-gliadins, 48% to omega-gliadins and 26% to HMW glutenins. Immunoblotting analysis confirmed results obtained in RAST concerning LMW and HMW glutenin subunits and showed that 67% of patients have IgE antibodies to the albumin/globulin fraction. CONCLUSION: Results obtained in the different tests showed common features and in agreement with other studies indicated the presence of numerous allergens in food allergy to wheat; alpha-, beta-, gamma- and omega-gliadins, LMW glutenin subunits and some water/salt-soluble proteins appeared as major IgE binding allergens, whereas HMW glutenins were only minor allergens. The same type of antigenic profile against gliadins and glutenins was observed with IgG antibodies. Important sequence or structural homologies between the various gliadins and LMW glutenin subunits could certainly explain similarity of IgE binding to these proteins.

Diet free of gluten improves rheumatoid arthritis

The effects on arthritis correlate with a reduction in antibodies to food antigens.

Hafstrom I; Ringertz B; Spangberg A; von Zweigbergk L; Brannemark S; Nylander I; Ronnelid J; Laasonen L; Klareskog L

Rheumatology (Oxford) 2001 Oct;40(10):1175-9    (ISSN: 1462-0324)

OBJECTIVE: Whether food intake can modify the course of rheumatoid arthritis (RA) is an issue of continued scientific and public interest. However, data from controlled clinical trials are sparse. We thus decided to study the clinical effects of a vegan diet free of gluten in RA and to quantify the levels of antibodies to key food antigens not present in the vegan diet. METHODS: Sixty-six patients with active RA were randomized to either a vegan diet free of gluten (38 patients) or a well-balanced non-vegan diet (28 patients) for 1 yr. All patients were instructed and followed-up in the same manner. They were analysed at baseline and after 3, 6 and 12 months, according to the response criteria of the American College of Rheumatology (ACR). Furthermore, levels of antibodies against gliadin and beta-lactoglobulin were assessed and radiographs of the hands and feet were performed. RESULTS: Twenty-two patients in the vegan group and 25 patients in the non-vegan diet group completed 9 months or more on the diet regimens. Of these diet completers, 40.5% (nine patients) in the vegan group fulfilled the ACR20 improvement criteria compared with 4% (one patient) in the non-vegan group. Corresponding figures for the intention to treat populations were 34.3 and 3.8%, respectively. The immunoglobulin G (IgG) antibody levels against gliadin and beta-lactoglobulin decreased in the responder subgroup in the vegan diet-treated patients, but not in the other analysed groups. No retardation of radiological destruction was apparent in any of the groups. CONCLUSION: The data provide evidence that dietary modification may be of benefit for certain RA patients, and that this benefit may be related to a reduction in immunoreactivity to food antigens eliminated by the change in diet. 

Fasting & vegetarian diet in arthritis

Muller H; de Toledo FW; Resch KL. Scand J Rheumatol 2001;30(1):1-10 (ISSN: 0300-9742)

Clinical experience suggests that fasting followed by vegetarian diet may help patients with rheumatoid arthritis (RA). We reviewed the available scientific evidence, because patients frequently ask for dietary advice, and exclusive pharmacological treatment of RA is often not satisfying. Fasting studies in RA were searched in MEDLINE and by checking references in relevant reports. The results of the controlled studies which reported follow-up data for at least three months after fasting were quantitatively pooled. Thirty-one reports of fasting studies in patients with RA were found. Only four controlled studies investigated the effects of fasting and subsequent diets for at least three months. The pooling of these studies showed a statistically and clinically significant beneficial long-term effect. Thus, available evidence suggests that fasting followed by vegetarian diets might be useful in the treatment of RA.

Polyarthritis  & celiac disease.

 Rheumatol Int 2000 Dec;20(1):29-30    (ISSN: 0172-8172) Bagnato GF; Quattrocchi E; Gulli S; Giacobbe O; Chirico G; Romano C; Purello D'Ambrosio F

This report describes a patient who presented with an unusual polyarthritis accompanied by myalgia, fever and anxiety. After extensive clinical and serological evaluation, duodenal biopsy and serological tests provided evidence for the diagnosis of coeliac disease (CD). The patient was promptly put on a gluten-free diet, which led to an improvement in the clinical abnormalities.

Palindromic rheumatism: dietary manipulation.

Clin Exp Rheumatol 2000 May-Jun;18(3):375-8    (ISSN: 0392-856X)

Nesher G; Mates M

OBJECTIVE: Evaluation of the contribution of dietary components in triggering the attacks of palindromic rheumatism (PR), and the effect of dietary manipulation on the frequency and severity of PR attacks. METHODS: Sixteen patients (10 males, 6 females) were diagnosed as having PR during 1994-8 in one center. Their mean age was 45 +/- 6, duration of symptoms prior to diagnosis was 4 +/- 1.4 years, and frequency of PR attacks were 3.1 +/- 1.8/month. All patients were instructed to make a list of the food that was consumed daily and to specify the dates of PR episodes. Data were evaluated after a period of 2-4 months in each patient. RESULTS: In 5 patients (31%) there was an association between episodes of PR and certain foods that were consumed within 36 hours prior to PR episodes. These were fish (2 patients), eggs, canned vegetables and processed cheese (each in one case). Elimination of the relevant food from each patient's diet resulted in complete cessation of the PR attacks in two of the cases, while the other three had milder, infrequent attacks. Four patients were rechallenged with the offending food. In all cases it resulted in recurrence of the PR attacks. No association between PR episodes and prior consumption of certain foods could be documented in the other 11 patients. CONCLUSIONS: In some PR patients ingestion of certain foods, specific for each case, can trigger the typical attack.

 Modulation of immune function by dietary lectins

Br J Nutr 2000 Mar;83(3):207-17    (ISSN: 0007-1145)

Cordain L; Toohey L; Smith MJ; Hickey MS

Despite the almost universal clinical observation that inflammation of the gut is frequently associated with inflammation of the joints and vice versa, the nature of this relationship remains elusive. In the present review, we provide evidence for how the interaction of dietary lectins with enterocytes and lymphocytes may facilitate the translocation of both dietary and gut-derived pathogenic antigens to peripheral tissues, which in turn causes persistent peripheral antigenic stimulation. In genetically susceptible individuals, this antigenic stimulation may ultimately result in the expression of overt rheumatoid arthritis (RA) via molecular mimicry, a process whereby foreign peptides, similar in structure to endogenous peptides, may cause antibodies or T-lymphocytes to cross-react with both foreign and endogenous peptides and thereby break immunological tolerance. By eliminating dietary elements, particularly lectins, which adversely influence both enterocyte and lymphocyte structure and function, it is proposed that the peripheral antigenic stimulus (both pathogenic and dietary) will be reduced.  

Calorie restricted diet in rheumatoid arthritis.

 J Physiol Anthropol Appl Human Sci 2004 Jan;23(1):19-24    (ISSN: 1345-3475) Iwashige K; Kouda K; Kouda M; Horiuchi K; Takahashi M; Nagano A; Tanaka T; Takeuchi H

Low-energy diets and fasting have suppressive effects on rheumatoid arthritis. It was reported recently that urine levels of pentosidine (i.e., an advanced glycation end product formed by glycosylation) is associated with the activity of rheumatoid arthritis.

We conducted a regimen of caloric restriction combined with fasting in patients with rheumatoid arthritis, and then evaluated urinary pentosidine levels. Ten patients with rheumatoid arthritis underwent a 54-day caloric restriction program. Urinary pentosidine levels were measured and the Lansbury Index were determined by examining the clinical features, blood biochemistry and the inflammation activity of rheumatoid arthritis on days 0, 25 and 54. On day 0, the mean urinary pentosidine level of patients with rheumatoid arthritis was significantly higher than that of the control subjects. On day 54, the mean body weight had reduced due to caloric restriction. The mean values of the erythrocyte sedimentation rate and the Lansbury Index of patients both significantly decreased during the study. In addition, although the urinary pentosidine levels showed no significant difference between day 0 and 25, it was significantly decreased at the end of the study (day 54).

The study showed that under a low energy diet a reduction of disease activity in rheumatoid arthritis was accompanied with a reduction of the urinary pentosidine. 

Mediterranean diet… rheumatoid arthritis

 

Ann Rheum Dis 2003 Mar;62(3):208-14 Skoldstam L; Hagfors L; Johansson G

 OBJECTIVE: To investigate the efficacy of a Mediterranean diet (MD) versus an ordinary Western diet for suppression of disease activity in patients with rheumatoid arthritis (RA). Patients with well controlled, although active RA of at least two years' duration, who were receiving stable pharmacological treatment, were invited to participate. All patients were randomly allocated to the MD or the control diet (CD). To achieve good compliance with prescribed diets all patients were for the first three weeks served the MD or the CD, respectively, for lunch and dinner at the outpatient clinic's canteen. Clinical examinations were performed at baseline, and again in the 3rd, 6th, and 12th week. A composite disease activity index, a physical function index, a health survey of quality of life, and the daily consumption of non-steroidal anti-inflammatory drugs were used as efficacy variables. From baseline to the end of the study the patients in the MD group (n=26) showed a decrease in DAS28 of 0.56 (p<0.001), in HAQ of 0.15 (p=0.020), and in two dimensions of the SF-36 Health Survey: an increase in "vitality" of 11.3 (p=0.018) and a decrease in "compared with one year earlier" of 0.6 (p=0.016). For the control patients, no significant change was seen at the end of the study. This difference between the two treatment groups was notable only in the second half of the trial. The results indicate that patients with RA, by adopting a Mediterranean diet, did obtain a reduction in inflammatory activity, an increase in physical function, and improved vitality.

 


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