Rheumatoid arthritis- case studies show diet success

Twelve case studies show diet eliminated or improved rheumatoid arthritis symptoms.

Feedback from Rheumatoid Arthritis (RA) sufferers in my study found that it is often assumed by rheumatologists that diet changes will make little difference to the disease process for those with  RA.

In this post I look at documented case studies where diet changes have eliminated or reduced symptoms of RA. I’ve given a summary of the studies as well as a chart with the findings. You will note that there is a range of foods that cause exacerbation of symptoms, and that these may be different for each person.

Important: RA is a complex disease, these documented case studies show successes, where RA is managed and symptoms reduced or even reversed in RA. This does not  mean that RA can be cured. It does not mean that all people with RA will necessarily respond to diet. Overall the range of improvements to RA in diet studies was between 5 and 70% of participants. We also know that fasting ameliorates disease for almost all with RA. So diet matters, but finding trigger foods can be a time consuming process, and food triggers vary between participants.

Rheumatoid arthritis (RA) is the second most common form of arthritis in New Zealand estimated to affect 0.74% – 3.2% of the population or approximately 40,000 New Zealanders. It affects 3 times more women than men (Pezzullo, 2010). RA is a chronic complex systemic auto-immune disease characterised by severe inflammation of the synovial lining of the joints. This chronic inflammation causes pain, swelling, inflammation and stiffness of the joints, eventual destruction of cartilage and bone causing loss of function and joint deformity. RA severely affects mobility and quality of life. Rheumatoid arthritis also has many non-joint manifestations including inflammatory conditions in the lungs, eyes, skin, heart, brain and nerves (Scott, Wolfe, & Huizinga). RA is also associated with an increased risk of cardiovascular disease (Myasoedova & Gabriel, 2010), type 2 diabetes (Su, Chen, Young, & Lian, 2013) and osteoporosis.

Joints typically affected in RA (source)

RA systemic

The Arthritis New Zealand website carries a brochure about nutrition and arthritis. Inside it states “Gout is the only type of arthritis that can be improved by changing your diet and lifestyle”. For those with RA “Do I need to avoid specific foods?” The answer is that although “Some people feel that cutting out acidic fruit such as oranges and grapefruit, and vegetables from the nightshade family, there is no scientific evidence that leaving out either of these foods does help and such diets may have he undesired effect of reducing beneficial nutrients” (NZ Arthritis, 2014)

Despite this information, many people with RA believe that diet can make an impact. In my research project I found around 45 case studies, intervention, and elimination diet studies specifically showing the impact of diet on RA.

Here is an overview of case studies of the effect of diet on RA

Twelve case studies from 1948 through to 2012 are presented. In most of these studies, problem foods were tested by eliminating and then re-introducing the to see what effect they had on symptoms.

Zeller (Zeller, 1948) presents 4 case studies. To identify potential food triggers for RA he took an extensive history of allergies, noting that “foods that were productive of other allergic symptoms often also cause arthritic symptoms.” He also notes that skin tests, both scratch and intradermal did not have value for finding trigger foods for RA, however positive tests were linked to other problems; allergic reactions like hay fever or rhinitis. Potential problem foods were identified, then excluded from the diet and tested with a challenge. He found the most effective diagnostic measure was food ingestion followed by white blood cell responses. Leukocyte counts dropped significantly over 40 minutes after problem food ingestion. Each person reacted to a specific food or foods, and once these were removed from their diets, symptoms resolved and measurements related to disease severity reduced, for example erythrocyte sedimentation rate (ESR). Zeller also noted that deformity and ankyloses reversed in two people over time. Foods identified in these four included milk (2), beef (2), eggs, pork(2), tomatoes, white potatoes, fish (2), banana, whiskey, beer, green beans, lettuce and nuts. Another observation of interest is the time to an inflammatory joint response after food ingestion. From the time food is ingested joint pain and swelling was noted as being 1 hour in case 1, 4-6 hours with maximum intensity at 16 hours in case 2, in case 3 response to milk was 45 minutes and other foods 3 hours, persisting for 24 – 36 hours. In case 4 pain, swelling and fatigue took 4 -5 hours persisting 36 hours.

Three case studies showed patients reacted strongly to a single food or food group and when the food was completely removed RA went into remission. The foods were dairy products; milk and cheese (Parke & Hughes, 1981), corn or maize starch (Williams, 1981), and cereals (Lunardi et al., 1988). Another case study identified milk as a trigger and this was confirmed with blinded testing (Panush, Stroud, & Webster, 1986). The patient went into complete remission whilst fasting or on Vivonex, an elemental liquid diet replacement. After milk ingestion it is notable that like the Zeller case studies, post ingestion symptoms began at 6 – 12 hours, peaking at 24 to 48 hours. Whilst this response time to a trigger is similar in these case studies, another case study of a 15 year old female with juvenile RA where dairy foods was confirmed as the trigger, response time was far slower, after eating dairy products daily in 4 separate challenges, she developed arthralgia, fatigue and arthritis in 10 to 23 days. Once dairy was removed symptoms resolved in 10 days to 3 weeks (Ratner, Eshel, & Vigder, 1985).

O’Banion used another method to find trigger foods in 3 case studies (O’Banion, 1982). Patients kept a food and drink diary, took their pulse hourly and recorded the severity of their arthritis pain and sleep quality. Two patients had elevated pulse rates after a number of foods. In the next phase the patients ate a diet which tested vegetables, meats and fruits one food per meal, 3 foods tested per day. Changes in pulse rate and joint responses were noted, this continued until a diet of non- reactive foods was found and patient was pain free. Food challenges continued and the most triggering foods were identified. All 3 reacted to dairy, wheat, cane sugar, corn and beef, and individually to a number of other foods.

The most recent case study (Denton, 2012) and the only one found after 1988, used a more modern elimination diet which removes common inflammatory foods. After a few days the patient’s pain reduced on this diet and food challenges began. Corn and nightshade vegetables were identified as trigger foods, once removed the patient went into remission and came off all medication.

Study Age F/M

Disease duration

Diagnostic tests if known

/ symptoms

Medication

used

How foods that cause symptoms were diagnosed Dietary treatment that reduced RA symptoms Outcome of diet changes Longer term Food implicated as triggering RA
(Zeller, 1948) Case study 1 Female, 39

9 years

RA Joint symptoms

Fatigue

Diarrhoea

constipation

Nausea

Nasal congestion

sneezing

 

Coal tar products partial relief Elimination and food challenges

Symptoms exacerbated after ingestion of foods. Milk caused diarrhoea, nausea, headache & fall in leukocyte count 7400 to 5400 cells. Onset of joint pain, swelling from 1 hour.

Chocolate and banana – headache.

Beef, banana, fish, nuts on challenge produced fatigue, joint pain and swelling. Exclusion of foods gave relief of symptoms

Exclusion of foods: milk, beef, banana, fish, nuts Exclusion of foods produced relief of joint symptoms.

Ingestion produces reactions

 

 

Remains symptom free except for some finger swelling

 

ESR reduced from  20mm to 8mm/hour

Milk, beef, banana, fish, nuts
(Zeller, 1948) case study 2 Male, 67 25 years RA Joint pain and swelling in hands, knees and ankles

fever

fatigue

“every therapeutic measure exhausted” Patient observed whiskey and beer caused swelling and pain in joints.

Ingestion tests showed wheat, eggs, fish, tomatoes, pork produced joint pain and swelling and fatigue  4 – 6 hours post eating. Maximum intensity 16 hours before subsiding

Exclusion of Wheat, eggs, fish, tomatoes, pork, whiskey , beer On exclusion of foods, symptoms decreased 80% in 3 months

Ingestion tests at 3 and 6 months again produced symptoms

2 years later some deformity and ankyloses reversed. ESR May 1946: 80mm/hr, March 1948 38mm/hr Wheat, eggs, fish, tomatoes, pork, whiskey, beer
(Zeller, 1948)case study 3 Female 41

6 years

RA Joint symptoms, pain and swelling

Low grade fever

Abdominal distension, wind,

Cramps diarrhoea daily

Sore throat

Therapy ineffective

Salicylates, bee venom

Ingestion tests (food challenges) with most frequently eaten foods

Pork – nasal congestion, abdominal bloating 40 mins

Milk – coughing, fatigue, painful joints in 45 mins, sore throat, fever 3 hours. Diarrhoea during night.

Lettuce, white potatoes, string beans, sore throat, joint pain and swelling 3 hrs, persisting 24 – 36 hours

Exclusion of these foods resulted in remarkable improvement

Deliberate ingestion causes symptoms

Exclusion of Lettuce, white potatoes, string beans, milk, pork Food exclusion “Remarkable improvement”

 

Deliberate ingestion causes symptoms

Not known Lettuce, white potatoes, string beans, milk, pork
(Zeller, 1948)Case study 4 Female, white, 42

20 years

RA Joint symptoms

Nasal congestion

Pruritus ani

headaches

Not stated Ingestion tests

Exclusion diet and re-introduction

Ingestion tests: Milk: sneezing, headaches, in 20 minutes lasting 24 hours. Leukocyte count 5900 to 3900 cells in 40 mins.

Wheat: sneezing in 15min, eggs- nausea in 5 mins (also leukocyte count drops 5400 to 4400 in 40min)

Placed on exclusion diet with no reactive foods. Challenge with one food at a time, 2 days apart

Beef- join pain & swelling, fatigue 4-5hrs, persisting for 36 hrs.

Eggs, pepper, garlic – vaginal itching and eruption in 2 hours

Pork, rectal itching

Wheat, nasal symptoms

Milk, nasal congestion

Problem foods excluded.

Beef  for RA,  egg, pepper, garlic, pork, wheat, milk for other health concerns

Not stated but assumed that no symptoms on exclusion diet Deformity of hands disappeared,

 

Wheat was eliminated for 3 months now tolerated once day

Beef only caused arthritis

Eggs, pepper, garlic -vaginal itching and eruption in 2 hours

Pork, rectal itching

Wheat, nasal symptoms

Milk, nasal congestion

(Parke & Hughes, 1981) 38, Female

25 years

Erosive seronegative RA.

ESR 110mm/h

Fatigue

Dry eyes & mouth

Salicylates NSAIDS, (not effective) prednisolone 10mg/d failed to relieve intense synovitis and stiffness Elimination and

food challenge with milk and cheese

 

Inadvertent consumption of dairy,  symptoms returned in 12 hours

Monitored food challenge- in 24hours pronounced deterioration of arthritis, pronounced increase in synovitis,  increase in Ritchie index, morning stiffness, 5mm increase in ring size, positive RAST to dairy IgE antibodies, heat-damaged red cell clearance rates

Elimination of milk, cheese, and butter In 3 weeks – decreased synovitis and morning stiffness. Improved Richie index, VPAS,

ESR

Prolonged improvement in previously unresponsive RA

Morning stiffness completely disappeared

Synovitis completely resolved

“Well fully mobile, minimal residual disease activity.”

Off prednisone

Milk and cheese

 

(Williams, 1981) Female, age not known

25years

“Active RA” pulmonary involvement Aspirin, azathioprine Removal of maize starch- dramatic improvement in 1 week

Accidental ingestion of corn-starch thickened gravy at 6 weeks  “arthritis flared badly”

Exclusion diet, elimination of corn and maize starch, including starch filler in medications “Dramatic improvement” after 1 week of exclusion diet, off all medication. ESR fell from 75 to 31. Chest xray clear, lung function normal Off all tablets

Looking and feeling better than ever

Chest xrays clear, lung function ‘normal’

Maize / corn starch
(O’Banion, 1982) case study 1 Female 21

7 years

RA joint symptoms

Grand and petty mal seizures, headaches, fatigue, sleeping problems, depression,

Dilantin for seizures, alcohol for pain Diet reactions observed, followed by elimination diet and re-introduction of foods.

Phase 1: Patient recorded severity of arthritis pain 1- 10, pulse rate hourly and all food and drink consumed. Sleep quality recorded from 1 – 10 for 18 days.

Phase 2: water only, testing of fresh fruit vegetables and meat, 3 foods tested each day, 1 food eaten at a time. 4 day rotation of foods. Food from same Biological family not eaten more than every 2 days. Reactions to foods noted – physical and behavioural

When 3 pain free days, returned to normal diet to test. Day 44 normal diet resumed: result – pain returned to baseline levels within 7 to 10 days

Resumed non-reactive diet of meats, vegetables, fruits. On return to non-reactive food diet became symptom free in 11 days

Day 88 tested commercial  and organic pork immediate and severe arthritis pain

Treatment diet: Vegetables, meats and fruits, “non-reactive foods”

Tolerated foods:

Apples, pears, watermelon, grapes, peaches, pineapple, carrots, lettuce, celery, cabbage, tune, eggs, green beans, salmon, crab , shrimp, walnuts, brazil nuts, coconuts, sunflower seeds avocado, sesame seeds

Pain elimination 19 days into diet testing and elimination. She reported sleeping ‘sleeping extremely well’

Daily pulse rate decreased

Patient had remained pain-free for 1.5 years, pain free at time of report. She consistently reacted to: peanuts, beef, pork, oranges, dairy products, poultry, wheat, honey cane sugar, potatoes, coffee, corn barley, pecans.

 

Glue and paint fumes triggered epilepsy.

(O’Banion, 1982) case study 2 Female 18years

8 years

RA, primarily knee pain, periodically other joints.

Also headaches, temper, crying moodiness, confusion sinus problems, allergies.

6 aspirin a day, minimal effect Phase 1: Baseline data collected for 35 days. Diet response to food recorded eating normal diet.

Phase 2: day 36 – rotary diet fresh meats, vegetables and fruits. First symptom free day – day 9. Food testing-  Irregular pulse or physical or behavioural reaction to that food noted. Reactive foods eliminated and questionable foods re-tested. Normal baseline diet resumed after 4 pain free days, result: pain returned to baseline levels

No pulse rate changes to foods

Elimination diet of meats, vegetables and fruits

testing for problem foods continued.

Food removed permanently if caused a reaction

Arthritis pain eliminated, reported sleeping well, not moody. Sinus discomfort and allergic symptoms completely eliminated. Not stated Wheat, beef, pork, cane sugar, milk, corn and a few other foods
(O’Banion, 1982) Case study 3 Female 36

Duration not stated

Periodic RA in several joints.

headaches, bowel disturbances frequent sleepiness, sinus problems, emotional problems, obesity.

Phase 1: 13 day baseline data on normal diet

Phase 2: Testing and elimination day 14 to 32. Foods producing irregular symptomology eliminated

Rapid decrease in pain, one test food cantaloupe marked increase in pain and pulse rate

Phase 3: Day 33 normal diet resumed – this resulted in a gradual increase in pain. Reactive foods tested several times to confirm.

Some foods consistently increased pulse by 10 – 20 beats/min which also caused physical and emotional responses

Elimination diet of meat vegetables and fruits No pain on day 32.

 

Not stated Wheat, corn, tomatoes, cane sugar, milk products, eggs, apples, beef, lettuce, peanuts, cantaloupe, peas
(Panush et al., 1986) Female, 52, white

11 years

Class I stage I, active disease. MSD 30 – 60 min, 9 tender joints, 3 swollen joints, objective assessment 87% on normal diet

ESR 27 – 42mm/hr

Vivonex meal replacement and food challenges

Un-blinded challenge noted exacerbations with milk, beans, meat

Normal diet 6 days- 30 min MSD, 9 tender joints, 3 swollen  joint 87% subjective assessment

Vivonex 2 days, fasting 3 days, No MS, swollen joint score 0, tender joint 1, assessments 100%

Vivonex 33 days – no symptoms

Blinded milk challenge – MSD 30 min, 14 tender joints, 4 swollen joints, objective assessment 80%, symptoms began 6 – 12 hours peaking at 24 – 48 hours. IgG and IgG4 anti-milk level increase marked.

Beef, chicken, rice challenge was possible reaction  but  unclear

Fasting, Vivonex Vivonex meal replacement 33 days Fasting or Vivonex – no symptoms of RA

 

Not stated Milk.

Shellfish – urticaria

(Lunardi et al., 1988) Not stated Serum positive RA ARA criteria

High IgE

ESR 120mm/h

Pleuritis, vasculitis, cutaneous ulcers

 

Methylprednisolone 24mg/die 10m

Gold salts 6mg/die

Penicillamine 200mg/die 3m

Clinical condition worsening

Positive skin prick for cereals

3 week elimination diet then Challenge test: cereals triggered arthralgia, articular tumefaction, morning stiffness, vasculitis

(Pachor et al., 1986)

Removal of cereals from diet

 

Patient went into remission ESR fell to 20mm/h

Waaler Rose and Rheuma test negative (now known as Rheumatoid factor)

Total IgE became normal

1 year still in complete remission Cereals
(Denton, 2012) Female 65

15 years

RA, gastritis, eczema, rhinitis, dry eyes, anxiety, poor sleep

fatigue

Medication not effective, methotrexate produced side effects.

Trazadone for sleep

tramadol

Elimination and food challenge

Modified Elimination diet removing most common causes of inflammation – wheat, corn, cow’s milk dairy products, nightshade vegetables (white potatoes, tomatoes, eggplant, peppers) followed by food challenges

Improvement reported after a few days. More energy, bowels normalised, pain ‘dramatically reduced’

On re-introduction corn caused eye dryness, joint inflammation and colitis. Nightshades – burning pain in back, arms, and hands, very achy, plus bloating and nausea.

No reaction to cow’s milk or wheat

For next 5 months avoided all corn and nightshade vegetables Completely off methotrexate, trazadone and tramadol. Able to do treadmill training Able to go on hiking trip to Asia. Corn,  nightshade vegetables (white potatoes, tomatoes, eggplant, peppers)
Denton, C. (2012). The elimination/challenge diet. Minnesota medicine, 95(12), 43-44.
Lunardi, C., Bambara, L. M., Biasi, D., Venturini, G., Nicolis, F., Pachor, M. L., & Desandre, G. (1988). Food Allergy and Rheumatoid-Arthritis. Clinical and Experimental Rheumatology, 6(4), 423-424.
Myasoedova, E., & Gabriel, S. E. (2010). Cardiovascular disease in rheumatoid arthritis: a step forward. Current Opinion in Rheumatology, 22(3), 342-347. doi: 10.1097/BOR.0b013e3283379b91
NZArthritis. (2014). Rheumatoid Arthritis. In A. N. Zealand (Ed.).
O’Banion, D. R. (1982). Dietary control of rheumatoid arthritis pain: Three case studies. Journal of Holistic Medicine, 4(1), 49-57.
Panush, R. S., Stroud, R. M., & Webster, E. M. (1986). Food-Induced (Allergic) Arthritis – Inflammatory Arthritis Exacerbated by Milk. Arthritis and Rheumatism, 29(2), 220-226. doi: 10.1002/art.1780290210
Parke, A. L., & Hughes, G. R. V. (1981). For Debate … Rheumatoid-Arthritis and Food – A Case-Study. British Medical Journal, 282(6281), 2027-2029.
Pezzullo, L. (2010). The economic cost of arthritis in New Zealand in 2010. [Report]. Access Economics Pty for Arthritis New Zealand.
Ratner, D., Eshel, E., & Vigder, K. (1985). Juvenile rheumatoid arthritis and milk allergy. Journal of the Royal Society of Medicine, 78(5), 410-413.
Scott, D. L., Wolfe, F., & Huizinga, T. W. J. Rheumatoid arthritis. The Lancet, 376(9746), 1094-1108. doi: 10.1016/s0140-6736(10)60826-4
Su, C.-C., Chen, I.-C., Young, F.-N., & Lian, I.-B. (2013). Risk of Diabetes in Patients with Rheumatoid Arthritis: A 12-year Retrospective Cohort Study. Journal of Rheumatology, 40(9), 1513-1518. doi: 10.3899/jrheum.121259
Williams, R. (1981). Rheumatoid-Arthritis and Food – A Case-Study. British Medical Journal, 283(6290), 563-563.
Zeller, M. (1948). Rheumatoid arthritis. Food allergy as a factor. Ann Allergy, 7((2)), 200-1949.

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