Rheumatoid arthritis is classified as highly debilitating and has an autoimmune component (where the body’s defence systems produce antibodies against its own tissues). Rheumatoid arthritis includes juvenile rheumatoid arthritis, gout, Sjögren’s syndrome (SS), fibromyalgia or yuppy flu as it was originally called, systemic lupus erythematosus (SLE) and scleroderma.
One example of these diseases is Sjögren’s syndrome (SS), which Mahan et al (2012), describe as "a chronic autoimmune disease characterised by lymphocytic infiltration of the exocrine glands, particularly the salivary and lacrimal glands, leading to dryness of the mouth (xerostomia) and of the eyes (xerophthalmia)".
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RA is not as common as osteoarthritis, but it can be particularly invasive and crippling. Because of its autoimmune component degeneration of many body tissues can occur, namely the so-called interstitial tissue (i.e. tissue between body cells), blood vessels, cartilage, bone, tendons and ligaments. Consequently RA is capable of causing the entire body and its support system to disintegrate.
As a disease, RA is characterised by periods of remission when patients may be free of symptoms followed by exacerbations when symptoms flare up and may seriously incapacitate the sufferer (Mahan et al, 2012).
RA can also increase the patient’s risk of developing heart disease. According to Mahan et al (2012), this tendency has now become complicated by the fact that many of the medications that are used to treat RA (COX-2 selective non-steroidal anti-inflammatory drugs or NSAIDs) can cause raised homocysteine levels, high blood pressure and hyperglycaemia (raised blood sugar levels), which are all classified as risk factors for cardiovascular disease. Thus treatment of RA must strive to reduce inflammation, as well as these risk factors (Mahan et al, 2012).
Drug-food interactions play an important role in the treatment of RA. Salicylic acid preparations (aspirin) which are used to treat pain and swelling of RA, as well as cardiovascular disease, may cause damage to the lining of the digestive tract, bleeding and loss of vitamin C via the kidneys. Consequently it is advisable for patients on chronic aspirin treatment to take their medication with milk, food or an antacid to prevent gastrointestinal irritation and if tests show that there is a vitamin C deficiency, supplementation may be required (Mahan et al, 2012).
Potent antirheumatic drugs such as methotrexate, sulfasalazine, hydroxychloroquine, azathioprine and leflunomide can slow the progression of RA and are increasingly being used by more and more patients. Unfortunately such drugs can have serious side-effects, for example methotrexate antagonises folic acid which in turn increases the blood levels of the chemical homocysteine a marker associated with heart disease.
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Supplementation with folate and a balanced folate-rich diet can help patients to avoid this negative effect of RA treatment. Such folate supplementation for patients using methotrexate is essential to prevent nausea, vomiting, mouth ulcers, and neutropenia (Mahan et al, 2012).
All patients receiving active antirheumatic drug therapy for RA must be monitored for such deficiencies and receive appropriate supplements when necessary.
Diet therapy for RA
Because of the invasive nature of RA and the serious side-effects caused by the medications which are currently available to treat this autoimmune disease, all RA patients should be under the care of a registered dietitian as part of the team responsible for their long-term care.
The dietitian is required to monitor the following aspects for RA patients:
- Continuous charting of the patient’s health and weight as RA can result in serious loss of weight and muscle tissue. Mahan et al (2012) state that “weight change is an important measure of RA severity".
- Monitoring of the negative effects of RA medications on dietary intake and correction of deficiencies (e.g. folate, vitamin C, etc).
- The increase in metabolic rate during flare-ups can increase nutrient requirements considerably which must then be provided by increasing the energy or protein or other nutrient intakes.
- Assessment of the use of dietary treatments which may or may not be beneficial. Many RA patients are driven to experiment with a variety of dietary manipulations which may worsen their condition. At present researchers are still not sure if any specific dietary adjustment can successfully influence the progression of RA disease.
- The anti-inflammatory diet for osteoarthritis may be beneficial and some patients experience improvements if they use a vegan, gluten-free diet. It is important to remember that changing over to a gluten-free vegan diet can be tricky without expert assistance. So if you are contemplating such a switch, please consult your dietitian for assistance to prevent development of deficiencies which may counteract the positive effects such a diet may have.
- RA may increase the requirement for protein particularly during flare-ups so that patients may need to ingest up to 2g of protein per kg body weight (i.e. a 60 kg woman would need to eat 120 g of protein per day). Because red meat may increase inflammatory reactivity and is also implicated in cardiovascular disease, protein from sources such as milk, yoghurt, maas, cottage cheese, egg white, fish particularly oily fish, chicken and pork (white meats), should be used. Vegetarian sources of protein like soya, tofu, and other legumes (cooked or canned dry beans, peas or lentils) can also make a significant contribution to protein intake.
- RA is one condition where using a low-fat diet may not be advisable because such diets tend to lower the levels of vitamin A and E in the body. Such deficiencies can stimulate the production of inflammatory compounds which may aggravate RA. Consequently current dietary recommendations suggest that instead of reducing the fat content of the diet in RA, patients should rather change the type of fat they eat. The anti-inflammatory diet described last week for osteoarthritis, will for example, boost the intake of omega-3 fatty acids via fatty fish, and omega-3 oil supplements.
- Vitamin E is regarded as beneficial in RA and may reduce inflammation and pain. As a general recommendation, it is prudent to discuss the use of any supplement with your dietitian as excessive intakes of vitamins and other nutrients like trace elements (zinc, selenium) can be counterproductive.
- Nutrients that require attention are folic acid (see above), calcium, vitamin D, Vitamin E, zinc, selenium and vitamin B complex, particularly vitamins B6 and B12.
- If you are considering the use of one or more herbal remedies for RA, please first consult your medical team and your dietitian. In some cases such herbal products have been found to cause toxicity which could further complicate the already complicated disease process of RA.
The use of individual diet prescriptions compiled by a registered dietitian for individual patients together with moderate supervised exercise should help most RA patients to improve their quality of life and reduce the progression of their disease.
(References: Mahan LK et al (2012).Krause’s Food and the Nutrition Care Process,13th Edition. Elsevier, USA)
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