Diet and Your Arthritis

Diet and Your Arthritis A LOOK AT THE RESEARCH Can the foods you eat cause or affect your arthritis? That s one of the most common questions people with arthritis ask. Because symptoms of arthritis can vary from day to day, it is natural to think that what you ate yesterday caused or reduced the pain you feel today. Researchers have looked at the roles diet may play in arthritis. There are some scientific reasons to think that the foods you eat could affect certain kinds of arthritis. Evidence shows that excessive weight and the type of diet you follow may influence symptoms of certain types of arthritis and related conditions. However, all persons with arthritis, young and old, can benefit from eating a healthy, well-balanced diet. This includes a variety of foods; plenty of vegetables, fruits and whole-grain products; and sugar, salt and fat (especially saturated fat found in animal products) in moderation. Taking the recommended daily amounts of vitamins and minerals also is an important part of a healthful diet. A good diet promotes overall health and helps to control weight. What We Already Know Research has shown several connections between food, nutritional supplements (vitamins, minerals and omega-3 fatty acids) and certain forms of arthritis or related conditions, such as gout (GOWT), osteoporosis (ah-stee-oh-po- RO-sis), osteoarthritis (ah-stee-oh-ar-thrytis), rheumatoid arthritis (ROO-ma-toyd ar- THRY-tis), or RA, and reactive arthritis. PURINES AND GOUT Gout, which is caused by deposits of uric acid crystals in the body, is the most familiar example of an arthritis-related disease that has a link with diet. Uric acid normally forms when the body breaks down waste products called purines (PURE-eens). The uric acid usually dissolves in the blood and passes through the kidneys into the urine. In people with gout, the blood s uric acid level is elevated so that crystals form and are deposited in joints and other tissues. This causes inflammation (swelling) in the joint, often in the big toe. Alcohol and foods, such as organ Page 1 of 10

meats, legumes, sardines and anchovies, and broths and gravies can contribute to high levels of purines. When you have gout, your body either has trouble using or getting rid of uric acid or your body produces too much uric acid. Alcohol consumption may elevate uric acid levels in your body. Fortunately, medications combined with a low-purine diet are effective in minimizing uric acid levels and may help in controlling weight. CALCIUM, VITAMIN D, ALCOHOL AND OSTEOPOROSIS Both calcium and alcohol affect the strength of your bones, but in different ways. Diets low in calcium, vitamin D or both, and excessive alcohol consumption may increase your chances for developing osteoporosis, a condition in which bones become so weak that they break easily. Osteoporosis is most common in older, post-menopausal women, but the disease also occurs in men and children, as well as younger adults. Prevention should begin in early childhood to prevent weak bones. If you have a type of inflammatory arthritis or connective tissue disease, such as RA, juvenile rheumatoid arthritis or lupus (LOO-pus), or if you take glucocorticoid medications, you are at risk for developing osteoporosis. Following a diet with the right amounts of calcium and vitamin D will help reduce the risk for developing osteoporosis. Calcium, which is found in dairy products, foods such as green, leafy vegetables, shellfish and calcium-fortified foods (some dairy products, orange juice, breads and cereals), is one of the main building blocks of bone. Between the ages of approximately 10 and 25, the calcium you get from food helps bone rebuild faster than it breaks down. To help this process and to prevent osteoporosis, you need 1,000 to 1,500 milligrams (mg) of calcium a day, especially if you are a woman under 30. If you are taking glucocorticoids, you should take 1,500 mg of calcium per day. Talk to your doctor. Although calcium alone won t stop osteoporosis once you have it, calcium may slow bone loss or reduce the effects of the disease. Many doctors advise their patients, particularly female patients, to take calcium supplements in addition to including dairy products in their diets. Vitamin D also is important in building and maintaining strong bones because it helps your body to absorb calcium from food. Vitamin D comes from sunlight as well as food like fortified dairy products, such as milk. The recommended daily intake of vitamin D is 400 international units (IU) per day. After age 55, the recommended daily intake is 800 IU per day. Alcohol intake can weaken bones. Consuming more than two alcoholic drinks a day increases your chances for thinning bones, leading to osteoporosis. One alcoholic drink is equal to 12 ounces of beer, five ounces of wine or one-anda-half ounces of liquor. GASTROINTESTINAL INFECTIONS (FOOD POISONING) AND REACTIVE ARTHRITIS Food or water contaminated by Salmonella or other specific types of bacteria can lead to a form of arthritis called reactive arthritis. People who develop this form of arthritis seem to have an abnormal response to certain infections. In the process of fighting off the infection, their immune system attacks their joints. This reaction can lead to swelling and pain in the affected joints, as well as complications in other organs such as the eyes, skin and heart. Page 2 of 10

Almost half of the people with reactive arthritis will not have a second episode. Statistics are similar after the second episode. But with later episodes, it is more likely that the disease will become chronic. WEIGHT AND OSTEOARTHRITIS Pain and stiffness in certain joints characterize osteoarthritis, a disease that causes the cartilage (CAR-ti-lij) that cushions the bones in joints to break down. Osteoarthritis is more common in people who are overweight. If you are overweight you are at greater risk for developing osteoarthritis in the weight-bearing joints, such as the knees and hips. Therefore, it is especially important to maintain your recommended weight by eating a healthy diet and exercising regularly. What if you re already overweight? Research shows that middle-aged and older women of average height who lose 11 pounds or more over a period of 10 years cut their risk in half for developing osteoarthritis of the knee. An 11-pound weight loss can reduce the pain of knee OA. It also can decrease blood pressure and lower your blood sugar if you have high blood pressure or diabetes. Evidence suggests that low levels of vitamins C and D may put you at risk for OA of the knee and hip. These low levels also may make the damage from OA progress more quickly. Talk to your physician about ways to enhance vitamins C and D intake and to maintain proper weight. FOOD ALLERGIES AND REACTIONS Allergic reactions to certain foods may bring about or worsen arthritis symptoms, such as joint pain or inflammation. But these instances are not common. For most types of arthritis, there are no proven, consistent connections between a specific kind of food and a specific symptom of arthritis. FASTING OR LOW-CALORIE/LOW-FAT DIETS Other factors in the diet, however, may actually have positive effects on the body s immune system. For example, several researchers have observed that short periods of fasting, as well as following a diet low in calories, fat and protein, may reduce some symptoms of RA in humans, or lupus in animals. Both RA and lupus are autoimmune diseases brought about by an overzealous immune response. This inappropriate response may be inhibited during fasting; however, prolonged fasting to minimize disease symptoms is not recommended. But the dangers of fasting far outweigh its benefits. Fasting without medical supervision is dangerous for anyone, but especially for people with arthritis. Fasting can cause a loss of muscle. Since people with inflammatory diseases like RA often have low muscle mass to begin with, fasting may be especially dangerous. A vegetarian diet that incorporates sufficient nutrients from the fruit and vegetable, dairy and meat food groups (see illustration of the Food Guide Pyramid on page 8) can be healthy for anyone. Check with your physician and a dietitian before you begin a strict vegetarian diet to make sure you are not missing out on any of the essential nutrients. FISH OILS/PLANT OILS Studies have shown that people with RA have had improvement in pain or joint tenderness after taking fish oil rich in omega-3 fatty acids. These fatty acids, including oils from some cold-water fish like salmon, mackerel and herring, modify the inflammation associated with RA. Studies show that some plant oils, such as Page 3 of 10

borage oil and evening primrose oil, also may ease RA symptoms. Talk with your doctor before attempting to treat your arthritis by supplementing your diet with fish oils or plant oils. As you can see, researchers have examined many types of diets. Because there are no special diets that have been consistently beneficial for people with arthritis, doctors generally advise their patients against experimenting with diet. Instead, doctors encourage people with arthritis to follow healthy nutritional practices. How Researchers Test Diets To determine the effects of a particular diet on arthritis, researchers divide people who have arthritis into two groups at random. One group follows a diet containing the food or foods being studied; the other group follows a diet without those kinds of foods. Neither group of participants is told which food is being tested. Both groups follow their diets for a number of weeks while adhering to their regular medical treatment programs throughout the study. Researchers measure the changes, such as decreased swelling in joints, in each study participant and compare the total changes between the two groups to determine if the tested diet made a difference. The study is then repeated three or four times with other groups of people to see if the results are similar. Only after such a series of tests do the researchers consider the test results conclusive and the diet treatments effective. Unproven Diet Claims Today, there are many claims that special diets, foods or supplements can cause or cure arthritis. Many of these claims generate a lot of publicity. The idea that there are simple answers to complicated autoimmune diseases is very appealing. Unfortunately, most claims for cure-all diets or nutritional supplements have not been scientifically tested to determine if they work and if they are safe. The scientific studies associated with these claims are often incomplete and may be harmful instead of beneficial. Some diets and supplements promoted as arthritis cures are outright frauds; others simply haven t been sufficiently tested. Some of the specific diets that are known to have harmful side effects include those that rely on large doses of alfalfa, copper salts or zinc, or the socalled immune power diet or the lowcalorie/low-fat/ low-protein diet. QUESTIONS ABOUT DIET CLAIMS When you hear diet claims in the treatment of arthritis, ask the following questions: Does the diet eliminate any complete group of foods from the Food Guide Pyramid? (See page 8) Does the diet stress only a few foods or eliminate others? Does following the diet have any potentially harmful effects? Does the diet have only personal testimonies, rather than scientific evidence, to support it? If you can answer yes to any of these questions, it is probably an unproven diet. TRYING A CHANGE IN DIET You should be suspicious of any diet that claims to treat or cure arthritis. If such a diet existed, you can be sure your doctor would know about it and recommend the diet to you. Still, many people believe their arthritis is linked to what they eat, and they are tempted to try various kinds of diets and supplements. If you Page 4 of 10

think something in your diet makes your arthritis better or worse, talk to your doctor and a dietitian. Continue your regular medical care for arthritis even if you decide to try a diet change. GUIDE TO A HEALTHY DIET Because there are more than 100 types of arthritis and related diseases, no single diet will help everyone. However, doctors strongly recommend that people with arthritis or related conditions follow a diet based on variety, balance and moderation. A balanced diet can help you feel better and stay healthy; prevent chronic diseases, such as cancer and cardiovascular disease; and be a positive step toward managing your arthritis. Good nutrition can be a challenge. People with certain kinds of arthritis may have difficulty preparing foods because of joint pain, swelling, limited mobility and fatigue. Some arthritis medications may lessen appetite and cause stomach upset. Pain and the depression that can accompany chronic illness also can affect a person s appetite or eating habits. Certain kinds of arthritis and some of the medications doctors prescribe also can affect how well your body uses what you eat. For example, glucocorticoids used to treat rheumatoid arthritis can cause your body to lose potassium and retain sodium. Some antacids, which may be taken to reduce stomach irritation, also contain high levels of sodium, calcium and magnesium. It is important to know this if you have kidney problems, which can make it harder for your body to regulate these important minerals. Methotrexate, used for RA, myositis (my-o- SY-tis) and psoriatic arthritis (sore-ee-aahtick ar-thry-tis), can lower levels of folic acid. Having a folic acid deficiency may predispose you to methotrexate toxicity. Talk to your physician about how the medications you take affect your nutritional status and whether a vitamin supplement may be useful for you. What Is a Good Diet? Experts recommend seven basic guidelines for a balanced, healthy diet. You can use these guidelines in planning meals every day. The following sections explain how each of the guidelines is helpful to people with arthritis or a related condition. Guidelines for a Healthy Diet Eat a variety of foods, and avoid those that can interact with your medications. Maintain a healthy weight. Use fat and cholesterol in moderation. Eat plenty of vegetables, fruits and wholegrain products. Use sugar and salt in moderation. Drink alcohol in moderation. Take in the daily requirements of vitamins and minerals, including calcium. EAT A VARIETY OF FOODS Most Americans don t eat enough whole grains, fruits and vegetables. A good diet includes choices from each of five different groups of foods: breads and grains; fruits; vegetables; dairy products; and meats. This variety ensures that you get the 40 or more nutrients your body needs to grow and function. Arthritis can make it difficult to eat a proper variety of foods, especially when pain, fatigue or depression lowers the appetite or when painful joints and loss of mobility cause people to avoid foods that require time or effort to pre- Page 5 of 10

pare. Follow the tips below to simplify food preparation. Health professionals can refer you to dietitians or occupational therapists that can give you advice on making food preparation easier. Make Meal Preparation Easier Plan rest breaks during meal preparation time. Use good posture to avoid fatigue or strain while performing kitchen tasks. Arrange your kitchen for maximum convenience; keep the utensils you use most where they are easy to reach. Use labor-saving kitchen gadgets and appliances, such as electric can openers and microwave ovens, to make cooking tasks easier. Be on the lookout for healthy convenience foods at the grocery store, such as pre-sliced or chopped vegetables. Add fresh fruit and whole-grain bread to a frozen dinner to make a complete, satisfying meal. MAINTAIN A HEALTHY WEIGHT People who are overweight are at greater risk for and have greater difficulty with osteoarthritis. If you are overweight, work with a registered dietitian and your doctor to find a lifelong weight-management plan that is right for you. A good plan will include balance, variety and moderation in your diet, as well as regular exercise. It is important to limit foods high in fats and foods and beverages high in sugar, such as soda and fruit juice. A daily walk or swim can allow you to get the exercise you need without placing too much stress on your joints. USE FAT AND CHOLESTEROL IN MODERATION Many adults with arthritis also have high blood pressure or heart disease. Reducing fats and cholesterol in your diet will help control or prevent these diseases. Because fat is a source of concentrated calories, eating less fat may help you maintain or lose weight. To follow a diet low in saturated fat and cholesterol, choose low-fat cuts of meat, such as poultry or flank steak; use nonfat or low-fat dairy products; and limit amounts of fats, oils, salad dressings, sweets and alcohol in your diet. A daily serving of meat or fish the size of a deck of playing cards, or about 3 to 4 ounces, is adequate for most adults. EAT PLENTY OF FRUITS, VEGETABLES AND WHOLE-GRAIN PRODUCTS Fruits, vegetables and whole-grain products help give you vitamins and can keep your bowels regular. Most of these foods also are low in fat and high in fiber, and in increased amounts, can help you lose weight. Foods high in complex carbohydrates are useful in weight control because they give you a feeling of fullness. Fruits, vegetables and whole-grain products also are excellent sources of fiber and can help you avoid constipation. Fiber comes from the parts of plants your body cannot digest. Some fibers, such as oat bran, help lower cholesterol levels. It is better to get fiber naturally from foods instead of taking supplements. USE SUGAR AND SALT IN MODERATION Sugars provide sweetness to your food, but they also add calories and promote weight gain and tooth decay. You should check the sugar content of the foods you eat. To do so, look for the words dextrose, sucrose, fructose, honey, Page 6 of 10

Lima Beans Potatoes Whole-Grain Breads Popcorn Beans Corn Peas Pasta Breads Rice Vegetables Fruits Cereals Pasta Examples of starch foods Examples of high-fiber foods corn syrup solids, dextrine and maltadextrine to determine whether there is added sugar. Adults with arthritis who also have high blood pressure have to be careful not to eat too much salt (sodium). It s not just a matter of how much salt you add at the table: A lot of processed food such as canned soups, packaged sauces and gravies, pickles, prepared frozen dinners, restaurant fast foods and tomato products are high in salt. Some arthritis drugs, such as glucocorticoids (prednisone), also may cause the body to retain too much sodium. Sodium causes your body to retain water, which can affect your blood pressure. Your doctor may recommend a low-sodium diet to help with this problem. Many foods now come in low- or no-salt-added forms. This makes it easier to maintain a low-sodium diet. Another way to cut down on sodium is to remove the salt shaker from your table. You also may want to talk with your doctor or dietitian about whether a salt substitute would be useful for you. Drink Alcohol Only in Moderation Alcohol can have many adverse effects on your health. Excessive alcohol use can weaken your bones, which can lead to osteoporosis. Alcohol also adds unwanted pounds because it adds extra calories to your diet. Alcohol does not mix well with certain arthritis medications. For instance, stomach problems are more likely if you combine alcohol with aspirin or other nonsteroidal antiinflammatory drugs (NSAIDs). Large amounts of alcohol combined with acetaminophen or methotrexate can cause liver damage. Alcohol also can increase uric acid in the blood and aggravate gout. If you are taking any medications for arthritis you should check with your doctor about drinking alcohol, even in moderation. The Food Guide Pyramid The Food Guide Pyramid developed by the U.S. Departments of Agriculture and Health and Human Services illustrates how to follow Page 7 of 10

Fats, oils & sweets Meats, eggs, poultry, fish, nuts & dry beans Dairy Vegetables Fruits Breads & grains Following the Food Guide Pyramid can help you eat a well-balanced diet that consists primarily of grains, fruits and vegetables. dietary guidelines and make wise food choices. Select most foods from the bottom two levels of the pyramid (whole grains/cereals, fruits and vegetables) and fewer foods from the top (fats, oils and sweets), based on the recommended number of servings. Eat a variety of foods from the five major food groups to help provide all the nutrients your body needs each day. Following the Food Guide Pyramid will help you eat a balanced diet that consists primarily of whole grains, fruits and vegetables, with moderate amounts of sugar, sodium and saturated fat. It also will help you get the right amount of calories to maintain a healthy weight. The Food Labeling Act Since 1994, a comprehensive nutrition label has been required for most food products. Although some packages did list ingredients in the past, there were no standards for comparing one food with another. The current label required by the Food Labeling Act helps you make smart choices for a healthier diet. The required food label makes it easier to compare food choices so you know what you re eating. The Food Labeling Act also set new guidelines for health claims a food manufacturer can make. Claims like fat-free, cholesterol-free, low-sodium and others are now defined by government standards. The list on the next page defines these and other claims: Fat-free: A food that has less than 0.5 grams of fat per serving, with no added fat or oil Low-fat: 3 grams of fat per serving Less fat: 25 percent or less fat than the comparison food Saturated fat-free: Less than 0.5 grams of saturated fat and 0.5 grams of trans-fatty acids per serving Page 8 of 10

Cholesterol-free: Less than 2 mg cholesterol per serving, and 2 grams or less saturated fat per serving Low cholesterol: 20 mg or less cholesterol per serving and 2 grams or less saturated fat per serving High-fiber: 5 grams or more fiber per serving Sodium-free or salt-free: Less than 5 mg of sodium per serving Low sodium: 140 mg or less per serving Sugar-free: Less than 0.5 grams of sugar per serving Healthy: A food low in fat, saturated fat, cholesterol and sodium, and contains at least 10 percent of the daily values for vitamin A, vitamin C, iron, calcium, protein or fiber Nutrition on the Net The Internet is a valuable resource for finding additional nutrition information. These Web sites are a good starting point. United States Department of Agriculture: www.usda.gov American Dietetic Association: www.eatright.org The Food and Agriculture Organization: www.fao.org To learn more about dietary guidelines: www.nal.usda.gov/fnic/dga/dguide95.html To view the Food Guide Pyramid: www.nal.usda.gov/fnic/fpyr/pyramid.html IN SUMMARY Researchers continue to look with increased interest at several roles diet may play in arthritis and stress the importance of a healthy diet for people with arthritis. There are two major ways to change to a healthier diet: Add variety to your diet and eat more foods with fiber and starch; and reduce your intake of salt, fat, cholesterol, sugar and alcohol. Making these changes will help you maintain or achieve a healthy weight, the foundation for improved quality of life for many people with arthritis. FOR MORE INFORMATION There are many sources for answers to your questions about diet. A good place to start is with your doctor. Your doctor can refer you to experts in diet and nutrition for help with applying diet guidelines, planning a weight-loss program, and answering any of your questions. THE ARTHRITIS FOUNDATION The mission of the Arthritis Foundation is to improve lives through leadership in the prevention, control and cure of arthritis and related diseases. The Arthritis Foundation supports research with the greatest potential for advances and has invested more than $320 million in these efforts since its inception in 1948. Additionally, the Arthritis Foundation supports key public policy and advocacy efforts at a local and national level in order to make a difference on behalf of 70 million people living with arthritis. As your partner in taking greater control of arthritis, the Arthritis Foundation also offers a large number of programs and services nationwide to make life with arthritis easier and less painful and to help you become an active partner in your own health care. Contact us at (800) 283-7800 or visit us on the Web at to become an Page 9 of 10

Arthritis Advocate or to find out how you can become involved. The Arthritis Foundation acknowledges with appreciation Carol Henderson, PhD, RD, LD, Georgia State University, Atlanta; Richard Panush, MD, St. Barnabas Medical Center, Livingston, N.J.; and Laura Robbins, DSW, Hospital for Special Surgery, New York, for their assistance with this booklet. For more information: The Arthritis Foundation offers a wide variety of books, brochures and videos about different forms of arthritis, treatment and self-management techniques to help you take control of your arthritis. To order any of these products, become an Arthritis Foundation member or to subscribe to the Arthritis Foundation's award-winning consumer health magazine, Arthritis Today, call (800) 283-7800. Call or visit our Web site () to find out how you can take control of your arthritis and start living better today! This brochure has been reviewed by the AMERICAN COLLEGE OF RHEUMATOLOGY. MISSION STATEMENT: The mission of the Arthritis Foundation is to improve lives through leadership in the prevention, control and cure of arthritis and related diseases. Page 10 of 10