Managing Inflammatory Rheumatism With Diet and Nutrition

PARIS — Patients with chronic inflammatory rheumatic diseases (IRDs) regularly make changes to their diets and the foods they eat. For example, 1 of 4 rheumatoid arthritis (RA) patients come up with an elimination diet plan.

Claire Daien, MD, PhD, is a rheumatologist at the Regional University Hospital of Montpellier, France, and a professor at the university there. At the Benjamin Delessert Institute’s Annual Day of Conferences, she gave an overview of the science of diet and nutrition and of individual beliefs about diet and nutrition. Daien was also a member of the multidisciplinary working group that established the French Society for Rheumatology’s (SFR’s) first set of dietary recommendations for patients with chronic IRDs. These recommendations were presented in an article published in 2022.

Miracle Diets?

Approximately 600,000 people in France suffer from one of the main chronic IRDs: RA, spondyloarthritis (SpA), and psoriatic arthritis (PsA). RA is the most common, occurring in 0.5% of the general population. The condition predominantly affects women; the peak incidence occurs at perimenopause. SpA, seen in 0.3% of the general population, mostly strikes people younger than 35 years. Unlike RA, this condition is more prevalent in men. The least common of the three — 0.1% of the general population — is PsA. Men and women are affected equally. It usually starts between the ages of 30 and 55 years. The SFR’s dietary recommendations pertain primarily to these three chronic IRDs.

“We now have over 15 disease-modifying drugs to treat these conditions,” said Daien. “Even so, some symptoms — joint pain and stiffness, fatigue — may persist despite efforts to try different treatments. And sometimes these treatments also give rise to side effects.

“Moreover,” she continued, “because these are chronic conditions, patients often want to address their symptoms on their own and ‘naturally,’ looking beyond medications. So, it’s quite common to see them focus on food. Indeed, 25% say that what they eat affects their symptoms: some things make them better, others make them worse. As a result, these individuals seek out ways to take control of their symptoms. Usually, this involves trying elimination diets or avoiding particular foods. In some cases, there’s a danger that they’ll stop taking their medication. In this race for a miracle diet, those who promote elimination diets or dietary supplements are not to be outdone, spreading false hope, even aggravating some comorbidities, such as osteoporosis and cardiovascular diseases — which, as it is, are already more common among patients with chronic IRDs.”

Food and Immunity

As Daien explained, “Seventy percent of immune cells are located in the gut. This is why the quality of the food one eats is so important. Food can play a role, whether directly — based on the fact that the receptors for certain nutrients and trace elements are present in some immune cells — or indirectly — by modulating the gut flora (intestinal permeability, exposure to antigens, bacterial metabolites, et cetera), as well as the energy metabolism.”

Gut microbial dysbiosis is associated with the development of autoimmune disease, but the mechanisms by which microbial dysbiosis affects the transition from asymptomatic autoimmunity to inflammatory disease are incompletely characterized. In an article published in 2020, researchers identified intestinal barrier integrity as an important checkpoint in translating autoimmunity to inflammation. Zonulin family peptide (zonulin), a potent regulator for intestinal tight junctions, is highly expressed in autoimmune mice and humans and can be used to predict transition from autoimmunity to inflammatory arthritis. Increased serum zonulin levels are accompanied by a leaky intestinal barrier, dysbiosis, and inflammation. Restoration of the intestinal barrier in the pre-phase of arthritis using butyrate or a cannabinoid type 1 receptor agonist inhibits the development of arthritis. Moreover, treatment with the zonulin antagonist larazotide acetate, which specifically increases intestinal barrier integrity, effectively reduces arthritis onset. The data presented in the article identify a preventive approach for the onset of autoimmune disease by specifically targeting impaired intestinal barrier function.

Diet After Diagnosis

Researchers surveyed 300 adult patients who had an immune-mediated inflammatory disease (IMID), including RA, PsA, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, and psoriasis. The results? After diagnosis, 44% changed their eating habits. Of these patients, 69% made the change on their own initiative (27% adopting a lactose-free diet, 18% a gluten-free diet, 17% a balanced diet, 13% a low-sugar diet), and 13% did so on the basis of the recommendation of a healthcare professional (HCP).

Among the patients who did not change their eating habits, 69% stated they did not receive nutritional advice from their HCP. Two thirds of the patients (66%) who had modified their diet experienced a change. In some cases, the consequences were positive — weight loss (27%) and better physical fitness (27%) — and in others, negative — increased fatigue (21%) and disturbed sleep (15%).

In another study, researchers examined a sample of 217 patients with RA in an RA registry and found that nearly one quarter of persons with RA and longstanding disease reported that foods affected their RA symptoms. Patients who reported eating the specific foods listed in the survey noted that some worsened RA symptoms (eg, red meat, soda with sugar, desserts) and others improved symptoms (eg, fish, spinach, strawberries). Additionally, 24.3% of all participants reported avoiding foods (16.2% sometimes, 8.1% often) because they worsen their RA.

This article was translated from the Medscape French Edition.

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