Question
Could you recommend any changes in diet that would help a rheumatoid arthritis sufferer, such as my husband??  He is under the care of another doctor, but would like your opinion on how diet could also help.

Thanks

Answer
Hi Ann,

Below is what I've collected on the diet alternative and RA. The real focus should be on getting the gluten and casein out of the diet.

Adding good oils to your diet ?and eliminating bad ones ?can make a difference in how you feel. Here抯 what you should know about the best and the worst oils.

Just about anyone suffering from stiff and aching joints has wished for magical oil to make those bones move more smoothly. Some have even tried rubbing sore joints with motor oil or spraying them with WD-40.

Smearing yourself with these messy metal lubricants won抰 do a thing for your arthritis. But you may be surprised to learn that putting the right kind of oils inside your body could help with the aches and pains.

Out of all the choices, four oils rise to the top. There抯 strong evidence that fish oil supplements with omega-3 fatty acids can ease rheumatoid arthritis (RA) symptoms, help prevent Raynaud抯 syndrome spasms and possibly relieve some lupus symptoms. Both borage seed and evening primrose seed oils have been shown to ease RA inflammation, and flaxseed oil may be also helpful. Readily available, these oils appear not to have serious side effects when taken as directed.

Though these oils aren抰 mainstream medical treatment, some people have been using them for a decade or more, often along with conventional medications ?and with their doctors?blessings. Lawrence Leventhal, MD, chief of rheumatology at Graduate Hospital in Philadelphia, says many of his rheumatoid arthritis patients are taking borage seed oil supplements.

"I prefer that my rheumatoid arthritis patients be on proven prescription medication if they have severe disease," says Dr. Leventhal. "But there are people who resist taking drugs because of concerns about side effects. So I start them on borage oil. It抯 a reasonable thing to try."

Although many say oil supplements give only "modest" improvement, Leventhal says the results vary. "I抳e had some patients it doesn抰 work for," he says. "And I抳e had others who could taper down on methotrexate or steroids and do fine. A few patients use borage oil as their only medication."

Oil supplements are not a cure and, at best, appear to give relief similar to nonsteroidal anti-inflammatory drugs (NSAIDs) ?though without risky side effects. Many people with RA and similar diseases need to take disease modifying drugs for maximum protection from joint destruction, using NSAIDs or perhaps these oils as a supplemental treatment.

Moreover, rheumatic diseases have flares and remissions, so any reduction in symptoms has to be carefully examined for cause and effect. Also, Joel Kremer, MD, chief of rheumatology at Albany Medical College in New York and a leading researcher on fish oil, says that despite more than a decade of study, researchers still don抰 know the optimal dosage, or if a combination of oils might work better than one alone.

Taking oil supplements might help your symptoms, says Kremer, but you have to take a lot of capsules ?10 to 20 per day, depending on the potency of the products ?to match the amounts used in studies, and it might take up to three months before you notice any effects. Although oil supplements don抰 cost more than most prescription medications ?fish oil and flaxseed cost about $30 a month, evening primrose oil $100 or so ?they are not covered by insurance.

Supplements aren抰 the whole story on oils, though. Kremer抯 best advice, he says, is to take some supplements, but also to lower your overall fat intake, change some of the oils you eat and add oil-rich cold water fish to your diet at least twice a week. Here抯 why.

Good Fats, Bad Fats
It抯 known that saturated fats from animal products contribute to many diseases. Now researchers believe the balance of polyunsaturated fats in Western diets is out of whack and may be contributing to an increase in inflammatory and autoimmune diseases. They say we consume too many of the fats that promote inflammation and not enough of the fats that produce the chemicals to counter it.

Our diets are overwhelmed by the omega-6 fatty acids called linoleic acid, the type that抯 in most vegetable and cooking oils and is the primary oil used in processed and fast foods. In our bodies, some of this fat breaks down into arachidonic acid that fuels the agents that contribute to inflammation.

Meanwhile, we are probably getting too little of the fatty acids ?omega 3s and others ?that help reduce inflammation and improve circulation.

To get our fats back in balance, says oil experts, we need to cut down on dietary fats from linoleic acid and increase our consumption of omega 3s and other beneficial fats found in cold water fish, and some plants oils such as flaxseed, olive and canola oils.

Another type of "good" fat, called GLA, or gamma linoleic acid, is found concentrated in borage seed oil and evening primrose seed oil and is not easily found in food.

A Who抯 Who of Oils
Here抯 an overview of the oil supplements most-used for rheumatoid arthritis and other forms of inflammatory arthritis.

Fish oil is perhaps best known for its heart-saving abilities, but the same qualities help reduce RA and Raynaud抯 symptoms. In some studies, those with RA using fish oil were able to significantly reduce their use of NSAIDs, or even discontinue them without increased pain and inflammation. In a study of 32 people with Raynaud抯 who took fish oil, researchers found that the oil improved the tolerance to cold exposure among those who had primary but not secondary Raynaud抯.

How it抯 used: Fish oil comes as a liquid and in softgel capsules. The usual dose is about three grams, or 3,000 milligrams (mg), total of EPA/DHA (the key ingredient in fish oil) per day. Be sure to check the labels: the capsules may say "1,000 mg of fish oil," but will have varying percentages of EPA and DHA. If they contain 300 mg, you抣l need to take 10 capsules a day. Look for high potency capsules so you don抰 have to take so many. A month抯 supply costs about $45.

Evening primrose seed oil and borage seed oil also eased RA symptoms in studies ?some say better than fish oil in terms of relieving joint tenderness. Evening primrose oil is better known, but borage oil has a higher percentage the beneficial acid GLA. Some folklore recommends rubbing these oils on your aching joints, or on the hands for those with Raynaud抯, but there is no evidence that this helps.

How it抯 used: These oils are available as liquids but are most often taken in softgel capsules. The usual dosage for RA is about 1.8 grams (1,800 mg) of GLA a day. Again, check the ingredients on the label and see how much GLA is in each capsule, then do the math. If the capsules have 300 mg of GLA, you will need to take six a day. Evening primrose oil may contain 130 mg of GLA, so you抣l need 14 capsules per day. A month抯 supply of borage oil is about $60; evening primrose oil is about $100 a month.

Flaxseed oil is believed by some to help arthritis, but so far there aren抰 any good studies that prove this. The belief it may reduce inflammation in RA comes from its composition, and from studies that show it increases levels of the beneficial fatty acid EPA. In a study of healthy men who limited "bad" fats in the diet, researchers found flaxseed oil worked as well as fish oil. It抯 also possible flaxseed might help with lupus. In a small study of nine people with lupus nephritis (kidney inflammation), 30 grams of flaxseed a day significantly lowered cholesterol, thinned blood, reduced inflammation and improved kidney function.

How it抯 used: Flaxseed is sold as a liquid, whole seeds and a meal or flour for baking. Some sources recommend taking 1 to 3 tablespoons a day of the oil or about 30 grams (one-fourth of a cup) of the meal or flour. You can use the meal or flour, which costs about $1 a pound, in bread, pancake and waffle recipes: One quick-bread recipe uses 2 cups of flaxseed flour with 4 cups of regular flour. It has a nutty flavor and the oil, which costs about $15 for 16 ounces, is used in salad dressings.

How to Buy and Store Oils
These medicinal oils can become rancid after exposure to heat, light and oxygen. To prevent this:

Read supplement labels carefully. Buy only plant oils that are certified organic (or grown without pesticides); that are packaged in opaque plastic containers; and that have an expiration date. Look for products that have been "expeller-pressed;" expeller pressing means no heat or chemicals were used in the process of squeezing the oil out of the seeds.
Look for liquid oils displayed in a refrigerated case; store oils and capsules in the refrigerator.
Remember: The products are not pure GLA or EPA/DHA. Check to see how much of the active ingredients you are getting. Look for high dosage capsules, and be prepared to do some calculations to figure out how many you need to take. If you aren抰 sure, ask a pharmacist.
Not Ready for Prime Time?
In spite of the evidence for these oil supplements, they aren抰 routinely recommended. That may be because they are not FDA approved or covered by insurance, says Robert B. Zurier, MD, chief of rheumatology at the University of Massachusetts and a leading researcher in GLA oils.

According to Dr. Leventhal, who has also conducted research on GLA oils, "Physicians are naturally skeptical about a diet therapy."

There are also some unanswered questions: Which type of oil is better? Would it help to take more than one? And what抯 the best dosage?

"Both GLA and fish oil have been shown to help, and they might be good together," says Kremer. "But we don抰 know ?it hasn抰 been studied enough."

Until more is known, proceed with caution. "I don抰 want my patients to think this is the way to go, and give up conventional treatments," says Dr. Leventhal. "People who want to try this should talk to their doctor."

Cautions and Good Advice
If you decide to try oil supplements, tell your doctor and keep a daily diary to note any changes.

Fish oil and the GLA oils thin the blood, which means they could increase your risk of bleeding if you are also taking NSAIDs, blood thinning medication, or herbs such as ginger or turmeric that also slow clotting. Although no one has had a bleeding incident in any of the studies, it抯 best to be cautious. Check with your doctor.
If you use the old fish oil standby, cod liver oil, be sure it has been stripped of vitamins A and D: These vitamins are toxic in large doses.
Allow three months for the oil supplements to take effect. If you don抰 see any changes by then, the supplements may not be working for you.
It抯 rare, but some people may get intestinal upsets or gas when they start taking oils. Start with a one-third dosage and increase it gradually to reduce the chances of stomach upsets or gas.
Fish oil capsules are tasteless, but burping may bring up a fishy taste or odor, so take them right before meals.
Some people who take high doses of fish oil have reported that their body odor takes on a fishy smell.
Fish that Give Good Fat

Mackerel
Herring
Sardines
Anchovies
Albacore tuna
Salmon
The colder the water they live in, the more omega-3 oil in the fish: A half a pound of salmon yields 3 to 4 grams of omega-3 oil. Frozen and canned fish are fine. However, be sure the fish is wild: Farm-raised fish (such as salmon) are fed commercial products resulting in lower omega-3 levels.

Is it Time to Change Your Oil?
Consider changing the balance of oils in your diet to improve your whole health picture. Here抯 what some experts suggest.

Toss the cooking and salad oils in your house except for those high in beneficial fatty acids such as flaxseed, olive and canola oils.
Cut your meat and other animal product consumption to no more than 4 to 6 ounces per day (about the size of two decks of playing cards).
Eat cold water fish two or three times a week (see list above).
Add flaxseed products to your diet. The oil can be used in salad dressings and the flour can be cooked into muffins or pancakes for breakfast.
Watch your overall fat intake: no more than 30 percent of your daily calories should come from any kind of fat.


But there is a new paradigm in autoimmunity. It offers a profoundly morehopeful perspective than has been possible in the past. If the notion of molecular mimicry is substantiated in RA, which seems likely, given the
recent exponential increase in researchers' interest in this area. By my count, more than 80% of the research connecting RA with molecular mimicry,as reported on Medline, has been reported during the last decade.

Some researchers are looking for a protein, or partial protein (peptide), from a chronic infectious agent that might reside in the gut, and regularly be transported across a permeable intestinal wall into the circulation.
Others are searching for a specific bacterium or virus that has an amino acid sequence that would serve as a trigger for production of antibodies against that "invader". The assumption is, of course, that the antibodies in question would attack tissues with similar sequences of amino acids in their protein structures. The immune system would start out mounting an attack against a foreign substance, and wind up attacking the collagenous
tissues at the joints, as in RA.  

There is considerable interest in this area, and I believe it warrants exploration. However, I am disposed to the application of the theory of molecular mimicry, to RA, in a little different manner. Infectious agents
often come and go. Yet autoimmune diseases usually progress, either steadilly, or through cycles of remission and relapse. This may be an important flaw in the application of the theory of molecular mimicry to
infectious agents.

What foreign proteins find their way into the blood on a continuous basis?
There is clear evidence that some of the alcohol soluble proteins from farinacious grains are regularly absorbed into the blood (3). Since these grains serve as a daily staple in the diets of virtually everyone living in
the industrial world, such grains are a likely prospect for initiating and perpetuating a dynamic of molecular mimicry leading to rheumatoid arthritis.

On the strength of this evidence alone, a gluten-free diet should be given an empirical trial with every RA patient, but there is much more evidence suggesting the need for such a trial. It has been reported that celiac
disease, a disease characterized by an intestinal inflammatory response to farinacious grains, is associated with endocrine or connective tissue disorders (4) and that celiac disease is overrepresented in connective
tissue disease, including RA (5). This lends further implicit support to the notion that gluten-containing grains may be a factor in at least some
cases of RA. In fact, one group reported that 37% of their RA patients demonstrated elevated antibodies against gliadin. Although it is important to note that the presence of these antibodies are often not predictive of celiac disease the following conclusion warrants careful
reading:

"CONCLUSION. Despite the increased AGA positivity found distinctively in patients with recent-onset RA, none of the RA patients showed clear evidence of coeliac disease. AGA positivity in early RA may indicate a role
of the gut immune system in the initiation of RA."

Perhaps the most compelling evidence for a causal relationship between gluten and some cases of RA may be found in the reports that in patients where both celiac disease and RA are diagnosed, the gluten free diet is
often an effective treatment for both conditions.

Not surprisingly, this new understanding serves as something of an indictment of some current practices in the treatment of RA. Koot etal conclude their report with the following statement: "The elevated IgA antigliadin titre in the RA group might be ascribed to the use of NSAIDs, which are harmful to the gut, but the immunological trigger effect of gluten cannot be ruled out"(10). It is important to manage pain, but it is
also important to limit any self-perpetuating impact of analgesics.

The theory of molecular mimicry offers new hope to those who suffer from RA, and there is a compelling alternative to waiting for the current search
to exhaust the field of infectious agents, and begin to investigate dietary antigens as a possible trigger and perpetuating factor in RA. ELISA testing offers to identify specific dietary antigens that may be at work in RA. In a large number of cases this will likely include gluten, but may not be restricted to gluten alone. Milk protein is also relatively new to the human diet, and may also need to be excluded. Caseins, proteins found in
dairy products, are structurally similar to gluten, and are also likely candidates for inciting autoimmune dynamics through the dynamic of molecular mimicry. In other cases, perhaps additional dietary antigens will
also need to be removed from the diet.


Hpoe this helps!


Dr. Timothy Durnin
drs.chiroweb.com