Cate Boyle

Sci Writing T/Th 3:05-4:20

19 April 2012

A review of literature on the effects of diet manipulation and supplementation on those

living with arthritis.

Key Words: "arthritis," "inflammation," "joint pain," "diet," "supplements," "Mediterranean

Diet," "Alkaline Diet," "fish oil," "glucosamine," and "diet manipulation," in any and all

combinations.

Abstract

The human race as a whole has always seemed to instinctually know that it needs nutrition in

varying amounts and styles, in order to survive. Somewhere along the path of human

advancement, we have replaced this instinct with an unhealthy relationship between food and us.

In response, our bodies have developed ailments and diseases. Arthritis lies among these

debilitating diseases. In the search for a cure, researchers have performed dozens of studies

looking at the effect of different diets and supplementations on the swellings, mobility-stunting,

and multiple other aches and pains of arthritis. The overall conclusion in such studies was that,

by changing one’s diet, and possibly supplementing the diet with essential vitamins and

minerals, the symptoms of arthritis, and possibly the prevention of arthritis, is possible. In light

of the growing popularity in the world of health, it makes sense to raise the question: do changes

in diet and supplementation help to ease the pain, swelling, and stiffness of arthritis? Through the

use of scientific databases, limited to research articles found in peer-reviewed journals, this

literature review offers evidence to either prove or disprove such claims. The conclusion being

an overwhelmingly positive nutritionally spurred effect on the common symptoms of arthritis.

Introduction and Background

Arthritis is a rheumatic disease that causes the inflammation of joints and connective tissues,

leading to pain, swelling, and in severe cases, the complete loss of mobility in a person’s joints.

The exact cause of this detrimental disease, that affects over 50 million people in the US alone, is

still of great debate among scientists and medical professionals alike. It is known that the disease

is an autoimmune disorder that can be due to infectious, metabolic, or constitutional causes, but

is it possible to re-set, so-to-speak? Is it possible to fight back against these baseline causes and

recover from such a fate? Many scientists, doctors, and researchers agree that there could be a

link lying right in front of us on our dinner plates.

As stated by Selmi and Tsuneyama, nutrition and immunity have been linked to each other for

centuries, though their specific connection between dietary factors and autoimmunity onset

(otherwise known as Rheumatoid Arthritis/RA) is a much more recent acquisition. This leads us

to the obvious; interactions between one’s nutrition and one’s immune system have clinical,

practical, and public health implications. This is cause for further research into the benefit of

reassessing a patient with RA’s food and diet habits/conditions1.

Prior to such an acquisition, patients suffering from arthritis were handed prescriptions to various

drugs, hoping for a cure-all. Such a thing does not exist though, and according to Smedslund et

al, while new drugs have shown promising effects from the unfortunate pains of arthritis, they

are also associated with significant side effects. Instead, these researchers looked into the

following diets: Vegan and Gluten-free, Mediterranean (in particular the Cretan Mediterranean)

and the Elimination Diet2. These diets came out on top in a number of studies compiled by

researchers across the board, and are therefore worth taking a deeper look at.

Another well-studied, nutritionally based remedy came in the form of supplementation. Selmi

and Tsuneyama found a significant benefit to the use of omega-3 fatty acids, obtained from fish

oil. Through their research, they found that, due to these omega-3 fatty acids, there was a

lowered need for the use of anti-inflammatory drugs, a decreased amount of pain and stiffness,

and, in some cases, proved to be a preventative agent1.

These facts are all strong indicators that there needs to be a concise review of the findings of

numerous researchers, all seeking to answer the question: will changing one’s diet, with or

without supplementation, have a positive effect on the symptoms of joint inflammation?

Methods

While there are dozens of research methods that can be used to help answer these questions, for

this particular report, only those found in peer-reviewed journals and written in English were

used. These articles also had to include living, human patients suffering from arthritis; no animal

research/studies were looked into.

From here, the methods vary greatly, but all revolve around the effects diet and supplementations

have on joint pain. For instance, Selmi and Tsuneyama compiled numerous articles and then

assessed, compared, and contrasted the findings in each to determine the omega-3 fatty acid

effect on arthritis1.

Smedslund et al conducted a similar research plan by selecting exact and precise articles that

were randomized controlled trials of dietary interventions performed on patients with arthritis.

They made sure that each study had an “intervention” group and a “comparison” group, as well2.

In order to expand upon this new wealth of knowledge, a great number of articles that were first-

hand trials conducted on patients with arthritis (as approved by the American College of

Rheumatology) were used for this report. These trials included the previously mentioned

“intervention” versus “comparison” group categories, as well as an active approach taken by the

researchers to give their patients the proper aid and support to stimulate positive results2. In such

studies, including Bahadori et al, Li and Micheletti, Karatay et al, Benito-Garcia et al, Elkan et

al, McKellar et al, and Jouris et al (for reference points) not only was the rate of inflammation

tested throughout the trials, but the patients’ ages, Body Mass Indexes, length of arthritis

complications, blood pressure and levels of cholesterol (both HDL “good” and LDL “bad”) were

measured as well.

Results

After scouring the aforementioned databases, 16 articles were chosen for review, 14 of which

were included in the following results data. There was an overwhelming amount of positivity as

well as a new wealth of knowledge introduced for the use of sufferers of arthritis.

Smedslund et al discovered a number of diets that served an important role in the reduction of

inflammation. In vegan diets, they found that a higher antioxidant intake could be a casual factor

in reducing pain and stiffness. Likewise, the Mediterranean diet with low saturated fat and high

antioxidant levels could play a role in relief of pain and stiffness. Mediterranean diets-especially

Cretan style eating plans-showed a significant difference in pain and physical function. The

elimination diet, that eliminates certain foods from the diet for a certain amount of time before

reintroducing them to the patient’s system, offered a possible difference in pain but no

significant differences in physical function or morning stiffness2.

The Mediterranean diet had numerous supporters as well as the most positive results in the study

done by Smedslund et al. This led to further research of the ever-growing diet plan and a

procession of positive findings were collected.

A randomized study performed by Skoldstam et al which found that in a 12 week, 56 patient

clinical trial, using the Cretan Mediterranean Diet (where Olive Oil is the principal fat as well as

moderate wine consumption, with an ordinary diet) proved to be an aid in the significant

decrease in pain seen in many arthritic patients3. This evidence was further cited in 28 other peer-

reviewed articles including a compilation study done by Li and Micheletti. These researchers

gave a condensed definition of the typical Mediterranean diet plan: high in plant foods (fruits,

vegetables, cereals, beans, nuts, and seeds), fish, and olive oil, and low in red meat4.

Serra-Majem et al should be included among these significant studies of the Mediterranean diet.

This team noted the rapidly increasing number of original articles addressing the diet, as well as

an increase in progress on the positive effects of such a diet, since 1999. Their studies showed

that, after participating in the diet plan, the patients’ analysis of arthritis functionality and pain

had a significant reduction, adding to previously found results in the same field5.

Schwarzenfeld et al were inspired by the fact that common Western diets comprise in an

outbalanced ratio of 15-16:1, omega-6:omega-3 fatty acids. Results indicate that these diets are

poor in omega-3 and excessively high in omega-6 (omega-6 fatty acids are those obtained

through vegetable oils such as soybean, safflower, or corn oils, and are therefore used in a

number of Western food products). This is contrary to the way in which human beings evolved,

which was with approximately equal amounts of omega-6 and omega-3’s. Reducing the supply

of omega-6 and increasing the supply of omega-3 will create a ratio of 2-3:1 within the body and

will suppress joint inflammation. Fish (a prime source of omega-3) intake on a regular basis can

prevent patients with arthritis from suffering from flare ups, and even prevent the disease from

occurring in people who might be considered at risk6.

As for supplementing one’s diet, it has been found that the impact of nutrients, minerals and

vitamins is quite influential on the function of the human immune system. Supplementation,

meaning the oral consumption of pills to enhance the diet, has been focused on in a number of

studies, many of which found an importance in omega-3 fatty acid supplementation for arthritic

patients.

The many supplements (omega-3 fatty acids were focused on in this report, but there have been

links to a great many other supplements including, but not limited to, glucosamine, MSM,

Resveratrol, flaxseed, ginger, curcumin, etc.) known to fight against inflammation have no real

or leading side effects on the human body, and for that reason, many people look to them as

homeopathic cures. They do so in hopes to find a more natural replacement for chemically made,

prescription drugs that have side effects, among which lies the very real and very detrimental risk

of cardiovascular complications. By taking supplements (most effect when paired with a strong,

healthy diet) arthritis patients may also be able to cut down the amount of these prescription

drugs they are taking, thereby reducing their risk to suffer from an even greater number of bodily

dysfunctions. The following results help to prove the effectiveness of supplementing one’s diet

to relieve and prevent arthritis.

First, what exactly does the term “omega-3 fatty acid” mean? Wall et al describe omega-3 fatty

acids as an essential part of the human diet, these acids being found in leafy greens, flaxseed, and

rapeseed oils, but, unfortunately not commonly found in the Westerner diet. Instead, Western

diets consist highly of omega-6 fatty acids. While omega-6 is essential and needed by the human

body, they are extremely easy to “overdose” on7.

This concept is illustrated nicely by Selmi and Tsuneyama who found that omega-3

polyunsaturated fatty acids-particularly fish oil-manifest significant immuno-modulatory

activities, and animal and clinical studies support the hypothesis that they have anti-

inflammatory properties and therefore might be useful in the management of inflammation and

autoimmune disorders. Studies this team found and analyzed showed a slight reduction in the

risk of developing RA in subjects who consumed fish oil between one to seven times per week

compared to subjects who never did so during the previous year. They also found that data in

certain studies suggested significant benefits including decreased disease activity and a lowered

use of anti-inflammatory drugs in patients who took fish oil1.

Schwarzenfeld et al found that, interestingly enough, intravenous rather than oral consumption of

omega-3 supplementation had a less invasive effect on the patients. Normal side effects of taking

the pill-form of omega-3, which is typically comprised of fish oil, include a fishy taste, secreting

a fishy smell, and at times an upset stomach. But when taken intravenously, these side effects

were not seen. Both sources boast the same beneficial effects, including the alleviation of the

number of tender joints, the duration of morning stiffness, and the patients’ evaluations of global

arthritis activity. Their concluding recommendation was that patients should consume dietary

supplements containing 3-6 grams of omega 3 fatty acids daily6.

Jouris et al, performed a study on the amount of inflammation in patients who either took or did

not take omega-3 supplements, before and after a specific exercise. They found that the omega-3

group saw a decrease in muscle soreness after the exercise, as compared the control group. They

concluded that 3000 mg of DHA/EPA omega-3 supplements decreases the severe localized

soreness (a sign of inflammation) after exercise. Proving supplementation could be beneficial to

arthritis8.

The only negative findings due to diet can be noted by Benito-Garcia et al who found no

significant association between protein or iron intakes and the risk for RA existed, including

specific analysis of animal and vegetable proteins, heme iron, and iron from foods and

supplements. They also noted no association found between the primary food sources of the

nutrients protein and iron (namely red meat, poultry and fish) and the development of arthritis.

However, further research needs to be completed to prove such results9.

Karatay et al found that using the elimination diet and skin prick test, patients observed

important disease aggravation by food challenges, whose exacerbations disappeared in only by

re-elimination of the allergen. However, they were sure to include that many outliers could have

played a role in their findings10. To expand on their fear of outliers, it should also be noted that

one study, found by Gossec et al, believed that the elimination diet was in need of further study

and observation. They found that, particularly in restriction diets involving dairy-limitation,

patients with RA did not respond positively11.

Secondary Results

While the depth of knowledge about diet and arthritis was clearly widened by this review,

there were also a number of positive side effects not directly related to arthritis, but still along the

lines of health care and well-being. Elkan et al conducted a study on the effects of a gluten-free,

vegan diet on those with arthritis. Their patients, (separated into two study groups: Gluten-Free,

Vegan and Control, No Diet) at baseline, were well balanced in regard to patient characteristics

and disease activity, and there was no difference between the groups as far as metabolic and lipid

variables are concerned. Yet, at the end of the study, the vegan, non gluten dieters decreased

their weights from 66.4kg to 62.2kg, and decreased their Body Mass Indexes (BMIs) from 24.1

to 22.7, collectively12. Not only were waistlines and BMIs directly effected, but, as seen in the

study by Serra-Majem et al, found a decrease in overall cholesterol as well as a rise in HDL

“good” cholesterol, and a drop in LDL “bad” cholesterol. They also concluded that while some

studies showed no effects on insulin or glucose levels, their patients saw that endothelial function

improved overall, and insulin resistance and metabolic syndrome were reduced while on the

diet5.

While these are extremely beneficial side effects to the patients, it should be noted that there was

a common thread of patients who were incapable of making it to the end of the studies and/or

maintaining a new diet after the study’s completion. This could be related to a number of gaps

left unanswered by the studies such as, personal motivation and effort, financial strains, lack of

support of loved ones, the vast quantity of temptations in the form of fast food restaurants

and so on.

However, a study conducted by McKellar et al, came to the alternate conclusion that such diet

interventions can have a positive mental effect on the patient as well. The researchers found that

by increasing the knowledge and confidence of the patients in the intervention group, they were

able to make real and positive changes to their lifestyles and body healthfulness13. This speaks

volumes to the effect that diet can have on a being’s body and mind. It is a much more “Eastern”

process of thought, but when the cold data is looked at, one can clearly see how those influenced

by the “Western” mindset, are also suffering from a greater number of diseases, including

arthritis.

McKellar et al’s intervention was found to be achievable and well received as well as

straightforward and affordable to their patients even though they lived in a lower income bracket

(just three patients stated they were unable to purchase the necessary ingredients on their own)13.

This, again, illustrates how doable a lifestyle change is, even when under the constraints of a

tight wallet. A positive mental attitude, could lead to positive physical results within one’s body.

Conclusion

In this multiple case study, I sought to assess whether one could modify one’s lifestyle by way of

diet and supplementation, with the end goal of reducing the stresses, strains, stiffness, and pains

of arthritis found in many people today. Bahadori et al refer to arthritis as a condition in need of

lifelong treatment, noting that 60% of all those diagnosed are incapable of performing their jobs

after 10 years of living with the disease14.

Given that it is indeed a lifelong disease, lifelong changes must be considered to combat it. It

seems that the two most user-friendly and easily managed nonpharmaceutical approaches to take

include the Mediterranean diet or lifestyle, and supplementing one’s diet with omega-3 fatty

acids, while managing the consumption of omega-6 fatty acids. Because there are dozens of

other seemingly effective diets and supplements, it should be stated that by adding in more key

words that include other popular diets and supplements, the results could have been different and

possibly more varied. However, my current findings show that these two in particular were the

most readily utilized.

Some might think that both of these options are too difficult or financially burdensome, however,

McKellar et al ran a pilot study of the effects of the Mediterranean diet on females suffering

from arthritis, and obtained not only great results, but also the most convincing argument

towards a lifestyle shift cure as well. The women they focused their study around were of similar

age, disease duration, and BMI (in both intervention and control groups) at the beginning of the

study. They also lived in areas of social deprivation; the common excuse for many unhealthy

lifestyles revolves around a lack of finances to buy healthier foods, gain access to nutritionists,

trainers, or psychologists, obtain knowledge about what they are eating or how in effects their

bodies, etc. However, these researchers were still able to provide recipes, support, resources, and

a healthy life, all on a low budget. By the three-month mark, consumption of fruit, vegetables,

and legumes, as well as the ratio of monounsaturated/saturated fats consumed, improved in the

intervention group. They even showed a significant drop in systolic blood pressure, all while the

control group showed no change in any of these factors13.

Due to the present findings collected throughout this review, I am confident that, while there are

still certain questions to be further studied, the incorporation of healthy diet plans and nutritional

supplements should be more strongly encouraged and suggested to all patients suffering from

arthritis.

References

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Reviews. 2010;9(5):A267-A270.

2. Smedslund G, Gjeitung M, Byfuglien, Olsen SU, Hagen KB. Effectiveness and Safety of

Dietary Interventions for Rheumatoid Arthritis: A Systematic Review of Randomized

Controlled Trials. Journal of the American Dietetic Association 2010;110(5):728-735.

3. Skoldstam L, Hagfors L, Johansson G. An experimental study of a Mediterranean diet

intervention for patients with rheumatoid arthritis. Annals of the Rheumatic Diseases

2003;62(3):208-214.

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