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
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
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
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)
Knicker's advice is worth repeating: "To diagnose adverse
reactions to foods, the clinician chiefly needs to be satisfied that the
ingestion of a food predictably and repeatedly causes disease. It is not necessary to know the precise triggering mechanism or which
mediators of inflammation are activated. Such information is difficult to
obtain, often requiring considerable laboratory investigation beyond the scope
of clinical practice."
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
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
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;
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.