Healthy eating tips for people with arthritis

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Healthy eating tips for people with arthritis

Arthritis is a common condition that causes pain and inflammation in the body’s joints.

In the UK, more than 10 million people have arthritis, or other similar conditions that affect the joints. Although arthritis is more common in older people, it can affect people of all ages, including children. Arthritis can affect quality of life and make daily activities a challenge (e.g. climbing the stairs, preparing/cooking food).

It is important to have a well-balanced diet and maintain a healthy body weight when you live with arthritis. A healthy diet and lifestyle can help to manage the symptoms, and also help reduce the risk of other diseases, such as obesity, cardiovascular disease and type 2 diabetes.

Diet is a topic of interest for many people living with arthritis. No special diet or ‘miracle food’ can cure arthritis, but there is a great deal of popular advice on diet and arthritis that does not have scientific evidence to support it and may be confusing.

This article looks at some of the dietary advice, and the evidence or lack of evidence, for two of the most common types of arthritis; osteoarthritis (OA) and rheumatoid arthritis (RA).

Osteoarthritis

Osteoarthritis (OA) is the most common type of arthritis in the UK, affecting nearly 9 million people. It is a disease that damages the cartilage, the tissue that cushions joints and helps them move smoothly, making movement harder and leading to increased stiffness and pain.

Osteoarthritis can affect any joint in the body, but the most common areas affected are the knees, hips and small joints in the hands.

The management of OA focuses on symptom management. It is not possible for specific foods or nutritional supplements to cure osteoarthritis, but diet and exercise can be important to help ease symptoms.

It is widely accepted that weight reduction (if overweight) in combination with increased physical activity can improve function and symptoms such as pain and stiffness, and should form part of the treatment for OA.

 

Osteoarthritis and diet  

A healthy weight

Weight loss is recommended as a core treatment for people who are overweight and obese. Reaching or maintaining a healthy weight can relieve pain, improve function, and slow the progression of OA.

Overweight is an important factor in OA since overload to the affected joint is one of the risk factors for developing OA or worsening of the symptoms of OA. Losing weight reduces pressure on joints, particularly weight bearing joints like the hips and knees.

There is increasing interest in not only reducing weight but specifically in reducing fat (or adipose) tissue, as it is now recognised that fat tissue is active and can secrete a number of chemical factors, some of which may have inflammatory effects.

Do talk to your GP or practice nurse about weight loss – they can help.

You may also find the NHS weight loss information and plan useful https://www.nhs.uk/live-well/healthy-weight/?tabname=weight-loss-support 

You can also find some information about weight loss here.

Osteoarthritis and physical activity

Painful joints and stiffness can reduce mobility and make it more difficult to be physically active. However, physical activity can help maintain a healthy body weight and protect joints by keeping muscles strong, reduce joint loading, increasing your range of movement and reducing stiffness.

Local muscle strengthening exercises (activities such as yoga, pilates or dancing that work the major muscles) and aerobic exercise (activities such as walking, cycling or swimming that temporarily increase your heart rate and respiration) are recommended.

It is important to find the right type of activity for you. Ask your GP to refer you to a physiotherapist, who can help you work out a suitable programme.

Should I take supplements for osteoarthritis?

Many people with OA report trying various dietary supplements in an effort to relieve pain and improve function.

Glucosamine and chondroitin sulphate

Joint cartilage normally contains glucosamine and chondroitin compounds, and it’s thought that taking these as supplements, which are often available in combination, may help to improve the health of damaged cartilage. However, although these supplements are considered to be safe, evidence of clinical benefit is minimal, and prescribing of supplements such as glucosamine and chondroitin is not routinely recommended for the management of OA.

If you do decide to take glucosamine and/or chondroitin, always seek advice from your pharmacist on potential interactions with other medications you may be taking. For glucosamine doses usually indicated are between 1250 and 1500 mg per day, with a review of treatment if no benefit is noticed after 2–3 months. Note: these supplements are often made from shellfish, and so are not suitable if you have a shellfish allergy.

For chondroitin there is no established dose for OA, but manufacturers tend to recommend between 400 and 1200 mg daily.

Vitamin D

Vitamin D is important for building and maintaining overall bone health. Although some research has suggested an association between low levels of vitamin D and increased risk and progression of OA, trials do not support vitamin D supplements for easing OA pain and joint degeneration. Nonetheless people with OA should follow government advice for the general population to consider taking a daily supplement containing 10 micrograms of vitamin D during the autumn and winter months when the sun isn't strong enough for the body to make vitamin D.

Other supplements like turmeric and fish oils

There is generally very limited, conflicting and poor quality evidence on dietary supplements and complementary treatments such as MSM (Methylsulfonylmethane), rosehip and curcumin (the active ingredient in turmeric) supplements used by people living with OA for symptomatic relief. Further research is needed to understand whether any supplement may be of benefit and be safe.

In addition, there is no strong evidence as yet that fish oil supplements can confer any benefit for OA, but including oily fish in your diet is recommended (at least two portions of fish a week, including one of oily fish*, in healthy eating advice for the general population.

*Note: pregnant women should not eat more than two portions of oily fish a week

Healthy dietary patterns for osteoarthritis and more 

Some research suggests a link between high blood cholesterol and increased risk and progression of OA, although it is unclear whether lowering blood cholesterol will improve OA. In any case raised blood cholesterol is a risk factor for cardiovascular disease and it is important to try and adopt healthy dietary patterns that may help to reduce blood cholesterol and the risk of cardiovascular disease, and maintain weight – see some of our tips below. 

  • Try to include a variety of at least 5 portions of fruit and vegetables, higher fibre starchy foods (choose wholegrain or higher fibre versions with less added fat, salt and sugar), dairy and dairy alternatives (choose lower fat and lower sugar options), as well as beans, pulses, fish, eggs, lean meat and other protein sources. Avoid unhealthy habits, like smoking and drinking in excess and include regular physical activity.
  • A healthy diet includes plenty of foods containing fibre such as nuts, wholegrains, beans, pulses, fruits and vegetables. But for cholesterol lowering you may want to also try eating oats and barley, which have a special soluble fibre called beta–glucan which can help to reduce blood cholesterol levels.
  • Reduce foods high in saturated fats in your diet like sausages, butter, biscuits, cake, pies, pastries and fatty meats, and replace with those containing unsaturated fats (mono- and poly-unsaturated), like oily fish, avocados, nuts and seeds and small amounts of olive, rapeseed and sunflower oils and unsaturated spreads made from them (see image below).

Rheumatoid arthritis

Rheumatoid arthritis (RA) is a long-term inflammatory condition that causes pain, swelling and stiffness in joints. The hands, wrists and feet are typically affected, but it may affect almost any joint. It is an auto-immune condition so happens when the body’s immune system, which usually fights infection, starts to attack healthy joints instead. At times symptoms can become suddenly worse causing severe pain and making it hard to go about normal everyday life. Rheumatoid arthritis is associated with a number of complications and comorbidities (conditions that often occur together with another condition) such as an increased risk of cardiovascular disease and osteoporosis (a condition that weakens bones).

Rheumatoid arthritis is less common than osteoarthritis, but it nonetheless is estimated to affect over 400,000 adults in the UK. There is no permanent cure and it can have a significant personal impact for people with the disease and their families and carers. However, early treatment can help to control it and help people carry on active and full lives. Medical management with drug therapy aims to relieve pain and stiffness and help mobility, and to modify the progress of the disease that can limit functioning in daily activities.

Rheumatoid arthritis and diet 

Diet and inflammation

People living with RA often use dietary changes and follow a variety of special diets to try to improve symptoms. A wide range of anecdotal dietary advice is available to improve symptoms but there is a lack of scientific information to support these, and some of the claimed benefits for diets are yet to be confirmed.

The most common dietary patterns tried are those that may have anti-inflammatory benefit or increase antioxidant levels (see section on antioxidants below). Other dietary strategies focus on eliminating foods or food groups that may be perceived as the cause of symptoms. Diets often tried include vegan, Mediterranean, elemental or elimination diets. However, much clarification is still needed to understand the relationship between diet and RA. It is currently unclear from the research whether diets can improve pain, stiffness and the ability to move better. Available evidence does not establish diet as a substitute for pharmaceutical treatments.

For people living with RA it is important to be aware of the dietary advice for which there is some evidence of benefit, and where the evidence is limited, as well as awareness that some alternative diets proposed can compromise nutrient intake.

What does the research say?

Mediterranean diet

UK NICE guidelines recommend that adults with RA who wish to experiment with their diet should be informed that there is no strong evidence that their arthritis will benefit. However, they could be encouraged to follow the principles of a Mediterranean diet. The Mediterranean diet is rich in plant-based foods such as wholegrains, beans, pulses, fruit and vegetables, and with moderate amounts of fish, low to moderate amounts of dairy products, low intake of meat, and olive oil as an important fat source.

Whilst research supports the Mediterranean diet for certain conditions such as the prevention of cardiovascular disease, there is limited evidence currently to suggest that the Mediterranean diet is beneficial in the prevention and treatment of RA. Only a small number of studies have identified beneficial effects of the Mediterranean diet in reducing pain and increasing physical function, and high quality studies investigating the long term effects are required to provide more conclusive answers. However, people with RA may want to follow a Mediterranean style diet as it is a healthy, non-restrictive, balanced dietary pattern that can meet nutritional requirements, and may have benefit to other health conditions, as well as helping some patients with RA.

Rheumatoid arthritis and supplements

Antioxidants

A diet rich in antioxidants may help to reduce the risk of developing RA and possibly dampen down the inflammatory response in established disease. These nutrients can be found in a healthy, balanced diet (see table below for dietary sources). However, the benefit of antioxidant nutrient supplements like vitamin A, vitamin C, vitamin E, selenium and zinc is not supported by scientific trials in patients with RA. In addition, it is important to note that ‘mega-dosing’ (intakes in doses well above current recommendations), whether self-administered or suggested by alternative practitioners, can have adverse effects and is inadvisable.

Fish oils

There is some evidence to suggest that taking fish oil supplements may be useful as an addition to existing treatments for reducing joint pain and stiffness.

The long chain omega-3 fatty acids found in fish oils, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are reported to have anti-inflammatory properties. Reviews and meta-analyses of studies that have explored benefit of fish oil and long chain omega-3 fatty acids in RA have had inconsistent findings. Some studies indicate that long chain omega-3 fatty acids may help to reduce joint swelling and pain, morning stiffness, in addition to reducing the amounts of medication for symptom relief that patients need. Other studies have found that they do not significantly affect the clinical symptoms of RA.

Whilst the current UK NICE guidelines for management of RA do not discuss the role of fish oil supplements, their use of appears to be common among RA patients. However, the optimal dose of long chain omega-3 fatty acids that may be helpful in relieving symptoms of RA is unclear, and it has been reported that supplementation can take up to 3 months before symptom relief is experienced.

Whilst there is not enough evidence to routinely recommend omega-3 supplements eating at least one portion of oily fish is included in dietary advice for the general population. Oily fish (e.g. mackerel, sardines and salmon) are the best source of these fatty acids in our diets and contain other nutrients such as vitamin D. Therefore, fish consumption is promoted in patients with RA, in line with general healthy eating recommendations (which is to eat at least two portions of fish each week, at least one of which should be oily fish; note pregnant women should not eat more than two portions of oily fish a week).

Probiotics

More recently, scientists have suggested that the gut microbiome – the bacteria that live in our gut – may also be a factor in the development of RA but the clinical effects of probiotics (usually described as ‘good’ bacteria found in food products/supplements) in RA remain unclear.

 

Elimination diets and fasting

Eliminating foods

It is a common belief among people living with RA that certain foods or ingredients have adverse effects, and that a food allergy/intolerance may cause or make inflammation worse.

Several reviews have aimed to evaluate the effectiveness of a range of interventions that restrict certain foods for the treatment of RA and management of its side effects. These include:

  • vegan diets;
  • elemental diets (liquid diets that contain nutrients that are broken down to make digestion easier);
  • fasting and;
  • elimination diets (used to find foods that might be the cause of symptoms).

However, there is very limited research in this area and the results remain largely unclear. It is uncertain whether any of these dietary strategies can improve pain and stiffness, and the ability to move better. There may be considerable individual variation, in other words, certain individuals or subgroups may show improvement if they eliminate certain foods or ingredients, but many others do not. Furthermore, some of these diets may be difficult to stick to, and people may lose weight on these diets even though they did not need or plan to.

There is no test that currently can identify an individual RA patient that may experience benefit by a change in diet, although offending foods can be identified through an exclusion programme under the supervision of a dietitian, if appropriate.

A number of tests that claim to identify food allergies can be bought on the high street or online but are not recommended because there is little evidence that they work and they can be expensive. These include:

  • applied kinesiology (a process based on muscle testing)
  • Vega test (which involves measuring electromagnetic conductivity in the body)
  • hair analysis

Fasting

Reduction of pain and inflammation has been reported with fasting and elemental diets. It is recognised that inflammatory activity is dampened by caloric restriction or reduction in gut involvement, but the results noted after fasting and very restricted diets could also be because of weight loss. In addition, such diets are not sustainable and carry significant health risks. Fasting is an extreme and temporary way of controlling pain and inflammation in RA and is not recommended. Symptoms return on resumption of regular diets, thus the benefit may be transient and not have long-term impact on disease activity.

Authoritative bodies typically will not suggest eliminating important food groups as this can increase risk of nutritional deficiency.

 

A quick look at milk and dairy foods

There has been some suggestion that dairy foods are associated with inflammation but the evidence is conflicting, and limited to small trials.

In the past dairy may have been considered pro-inflammatory, but more recent reviews of the evidence do not support this hypothesis. Studies of milk and dairy products more typically suggest a neutral or even beneficial effect on levels of inflammatory markers and would not point to an adverse inflammatory effect.

Specific dietary guidelines are difficult to define in people living with RA as there are individual differences. However, as dairy products can play an important part of a healthy, balanced diet, based on the available data, there is no evidence to support exclusion of dairy products unless an intolerance or allergy are indicated. If you think you may have an adverse reaction to milk and dairy products talk to your GP or a healthcare professional involved in your care such as your specialist nurse.

A quick look at the nightshade plant family

Aubergines, peppers, tomatoes, potatoes and goji berries are all members of the nightshade family. Some people believe that solanine, one of the alkaloids (naturally produced compounds in various plants), contributes to inflammation and pain in arthritis. However, the connection between arthritis and nightshades is largely considered anecdotal. There is a surprising lack of any clinical human studies and so currently there is no scientific evidence that nightshade vegetables make arthritis symptoms worse. It is also worth noting that solanine is also found in blueberries, apples, cherries, okra and artichokes, none of which is in the nightshade family and not included in anecdotal reports of adverse effects.

The fruit and vegetables that contain solanine are rich in nutrients and antioxidants. However, if you think you may have an adverse reaction to vegetables like potatoes, tomatoes and peppers than talk to your GP or a healthcare professional involved in your care such as your specialist nurse.

Supplements for the side effects of medication

Certain nutrition supplements may be prescribed by your specialist team/GP because they can be useful in preventing the side effects of medications.

Folic acid

Folic acid supplements may help prevent some of the side effects of methotrexate, a conventional disease modifying anti-rheumatic drug (cDMARD), commonly used in first line management of RA.

The British Society for Rheumatology guidelines recommends a typical folic acid dose of 5 mg once weekly, not on the same day as methotrexate (also typically taken once weekly). Folic acid reduces toxic effects and improves continuation of therapy and compliance.

Calcium and vitamin D

Calcium and vitamin D are essential nutrients for bone health and supplements may be prescribed for patients with RA taking glucocorticoids (steroids), which can increase the risk of bone loss and osteoporosis.

Steroids may be offered as a short-term treatment to manage flares in people with recent onset (or established disease) to rapidly decrease inflammation, and in particular to improve symptoms while waiting for a new cDMARD to take effect (which can take 2–3 months).

You can find information on food sources of calcium and vitamin D in BNF’s Calcium Counts and Vital Vitamin D resources.

Although laboratory research has suggested that vitamin D may have anti-inflammatory effects, further studies are needed to better understand the role of vitamin D in inflammatory conditions, and currently there is no evidence that vitamin D supplements are of benefit in RA. Regardless of possible effects on inflammation, it is recommended that all adults take a daily supplement containing 10 micrograms of vitamin D during the autumn and winter months, when the sun isn’t strong enough for the body to make vitamin D.

Shopping, preparing and cooking food - some tips

Cooking at home can be an enjoyable experience and can help with eating healthily. However, when movement is restricted activities around cooking including shopping and preparation can be difficult (e.g. lifting grocery bags, opening jars, dicing and slicing and lifting pots). Some tips are listed below but many more tips can be found on Versus Arthritis, one of the UK’s largest arthritis charities. https://www.versusarthritis.org/

Shopping

  • If lifting shopping bags is difficult, consider getting heavier items delivered through online shopping. That way you can still visit the supermarket if you like to, but only purchase lighter items.
  • Making lists ahead of time can help avoid unnecessary trips and also can help you plan your route in the shop so you can limit the time spent and walked around it.
  • Use convenience foods to help you when you need to, for example, ready-prepared food such as chopped vegetables, grated cheese and roasted potatoes.
  • Frozen vegetables are another way to avoid chopping fresh vegetables. Have some pre-prepared ingredients and ready-made meals in the freezer to avoid struggling when your arthritis is particularly troublesome.

Food preparation and cooking

  • If you find peeling fruit and veg painful (e.g. potatoes, carrots) then try washing them thoroughly and keeping the skins on – this will also help to retain important nutrients such as fibre.
  • Use suitable equipment or special gadgets to help you. Always try different utensils to see how the feel. Appliances like electric can openers, microwaves and hand held blenders can make food preparation and cooking easier.
  • If you are cooking a recipe, why not make double and freeze it so meals can be readily available when you are in pain or tired. Remember to label the containers and the date they were frozen.
  • Think about how you arrange cupboards and work surfaces to make items easier to reach.

 

Key references

Last reviewed August 2019.

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