Fatigue in MS – and what to do about it

Fatigue – that horrible overwhelming inability to do another thing, sometimes even to think straight, is one of the most disabling invisible problems of MS. When I took a poll of the top symptoms that people wanted to troubleshoot in a holistic way, Fatigue was top. So here goes:
fatiguedWhy do people with MS experience fatigue?

Fatigue in MS is  of 2 types. Motor fatigue, or ‘short-circuiting’ fatigue, is when the difficulty of transmitting the electrical nerve signal down demyelinated, or damaged nerves, overwhelm the body’s ability to produce  ATP ( the energy molecule). Fatigued muscles just have to stop; you feel as if you’ve run a marathon, it’s like hitting ‘the wall’ for an athlete, and you have to sit down. After a short while, energy is replenished, and you can go again.

The second type of fatigue is more of a  widespread, overwhelming all-over fatigue, described here by MS campaigner, Shoshana Pezaro in 2015:

“It’s an absolutely crushing physical and mental symptom that cannot be overcome through will-power. When fatigue hits, I feel like my plug has been pulled out. Physically my body suffers extreme weakness and heaviness and every tiny movement, even raising my hand, is like fighting through thick treacle. But the mental effects are worse. The world separates from my consciousness. My brain is shrouded in a deep fog. It is a dreamlike state where I can hear people and see people, but I somehow I cannot connect. Fatigue cannot be fought, only managed through rest and care.”

Lots of research and debate has been carried out about what causes this type of fatigue; an interesting study reported at this year’s ECTRIMS conference investigated whether fatigue was more strongly linked to lesions in the brain, or to inflammation. They found a strong correlation to inflammation as the driver of this type of fatigue.

So to address Fatigue, we need to address the MS itself, and take both a short and a long view. The good thing is, there is a lot you can do to address both MS itself, and the problem of fatigue.

Starting with the most simple, here’s my list:

  •  Obviously read all the MS Society  ( you can download here)

http://www.mssociety.org.uk/ms-resources/fatigue-ms-essentials-14  and

pace yourself, budget your energy, and:

  • Get your groceries delivered online
  • Call a family meeting, explain that fatigue is a physical problem in MS, and give the family information about it, set rules and boundaries and share out the chores!
  • Save your energy for the stuff that counts – if you can get a cleaner, do so!
  • Fluids – ensure you drink plenty of water
  • The drug  Amantadine can be tried for fatigue in MS but it only seems to help about 20% of people, and sometimes causes unpleasant side-effects

Sleep

Baby smiling in bed with eyes closed and arms out.

It seems obvious, but if your sleep is poor, you will have fatigue!

Sleep problems:

  • No caffeine drinks after 6pm
  • Consider having something to eat before bed to prevent low blood sugar
  • Try to get outside as early as possible (once the sun is up) in the day, and making sure you are outside for at least ½ an hour a day; this helps to set your body’s circadian rythm( wake-sleep cycle)
  • Address causes of waking if possible – eg bladder, worrying, spasm, pain
  • Consider natural sleep aids like ‘Nightall’ etc which are made from hops and valerian – check that its ok to take these with any medication you are on
  • Use the HeartMath technique, for 10 minutes every morning, plus whenever you experience negative or worrying thoughts, or mind is free, and when you’re going to sleep at night.

heartmath-pic

  • Lock into a positive emotion

  • Focus on heart area

  • Breathe in for 5 seconds and out for 5 seconds in one long continuous cycle

  • imagine blowing up a balloon in your belly as you breathe in – your abdomen should rise first, then abdomen squeezes in as you expel the last bits of air out.

HeartMath is wonderful – I can’t find a good website to make it simple; you can buy all kinds of gadgets to allow yourself to see how you’re doing and coach yourself further, but the basic technique is this simple, and it has powerful and far-reaching effects on your resilience to stress, amongst other things.

Additional extras to consider.

mitochondria-2

Energy is created in our bodies by mitochondria, the ‘powerhouse’ of the cell. Each cell contains up to a thousand mitochondria. Mitochondria take fuel from the food we eat, and transform it into energy. They generate a chemical called ATP, which transports the energy for use by the body.

In order to function properly, mitochondria need the fuel of excellent nutrition and oxygen.

Dietary factors

  • Everything that we put in our mouths can either be pro-inflammatory or anti-inflammatory; what we eat has an impact on inflammation.
  • A study published in July 2016 showed improvements in fatigue over the course of one year,  in people with MS who adopted a low fat, plant-based diet

plant-based-diet

  • See www.overcomingmulstiplesclerosis.org  for this type of diet, which could be expected to reduce inflammation, www.fatfreevegan.com for recipes.
  • Also  have a look at the work of Terry Wahls, a medical doctor who reversed her own secondary progressive MS with advanced nutrition,  online. I prefer the overcomingms diet as above, but Terry’s extras like green smoothies and intense nutrition make sense to add in.
  • Be aware of food intolerances. More people with MS have full blown celiac disease than in the general population, but you can also have a milder food intolerance that is not picked up by clinical allergy testing. Experiment to find out if some foods worsen your fatigue, by excluding them for 3 weeks and then bringing them in and noticing. Common irritating foods are bread, cheese, dairy products, gluten grains, sugar, and sometimes beans, but many people have individual things that they don’t tolerate.
  • Vitamin D3 at least 5000 IU daily & consider minimal erythmal dose sunbed. Some people may need more to get into the optimal range of 150-200nmol per litre; you can get your blood checked at http://www.vitamindbloodtest.org.uk
  • A study published this year found a significant reduction in fatigue in people with MS who took 500mg of Co-enzyme Q10 daily.
  • Omega 3 fatty acids are found in oily fish, nuts, seeds and whole grains, and help to calm down and prevent inflammation, aswell as helping to store and retain energy. 20g daily can be supplied by 2 dessert spoons of cold pressed flax seed oil used cold, and make sure it’s fresh; one example; www.flaxfarm.co.uk
  • B vitamins – some people are deficient in these, which can mimic symptoms of MS; some people report these help with fatigue; probably when there has been some deficiency present.
  • Probiotics & fermented foods– very important to restore health of gut, especially after antibiotics, which contributes to health/ energy

Exercise  &  Oxygenation hyperbaric-chamber-10-person

  • Many people report that hyperbaric oxygen improves MS fatigue; if this isn’t possible, at least do deep breathing!
  • Just had great comment in response to this post by Frank:
  • “The very best thing for me has been taking Oxygen Therapy at the MS Centre. There are 56 centres to choose from so there’s almost bound to be one near you – unless you live in Northumberland or Cumbria. 
    With Oxygen Therapy and MS, lots of us find there there is an optimum pressure. The ascending protocol suggests that people should start at 1.5 ATA, move to 1.75 ATA and then try 2 ATA. After each session note down how you feel immediately afterwards and then again about 24 hours later. Once you’ve tried all three pressures you should know the one that suits you best.
    As you say, Miranda, it does not work for everyone, but then neither do any of the drug or dietary therapies – we are all different – however, I’ve found it great for reducing my fatigue and if I miss my weekly session, I certainly feel the impact. Some of my colleagues find they are really tired after the Oxygen Therapy but then feel full of energy the next day, others, like myself, feel the benefit within a few hours. Whatever your views, it’s definitely worth giving it a go.”
  • Regular cardiovascular exercise can help to raise oxygen and energy levels, in your own zone of tolerance. Exercise has been shown to be strongly anti-inflammatory – make it part of your daily routine in one form or another.
  • Some people with fatigue have reported improvement to fatigue by raising the head of their bed by 6 inches. Called ITB or inclined bed therapy – See New Pathways issue 62

APS Therapy

At the MS Therapy Centre where I work we have now had many cases of people’s MS fatigue, including post relapse, responding very well to APS Therapy. This makes sense as the treatment stimulates production of ATP, and is a replica of the wave-form of action potentials ( the electrical nerve signal.)active-nerve-cells-29027134 It hasn’t worked for everyone that’s tried it; it seems to be more effecitve for fatigue in relapsing remitting, rather than progressive MS, and we are still collecting data about this, but the therapy is available privately ( see ‘my other work’ button)  and at 7 MS Therapy Centres:

Bedford, Portsmouth, Kent, Sutton & Croydon, Leicester, Berkshire and Hertfordshire and MS-UK’s Wellbeing centre, Joseph’s Court in Colchester.

Therapies

Lots of therapies, including Shiatsu, Reflexology, Yoga and ‘EFT’ tapping are found by people to improve wellbeing, energy and sleep which may then help with fatigue.

Remember that Disease Modifying Therapies (DMTs) all aim to reduce inflammation and relapses, and by doing so, can have a marked impact on reducing fatigue and improving how you feel. If you are eligible, but not on a DMT, review and reconsider the situation. If you’re on a DMT but still having relapses, request a review, as per the the MS Brain Health Campaign. And when choosing a DMT, ask about the common side-effects, explore how other people have responded, and choose one that fits best with your needs and aims.

happy

In summary, with both long and short term strategies, there are lots of things you can do to beat fatigue and enhance your energy. Some of the long term strategies take longer to bear fruit – but keep going; many people with MS can remember a time when they were so much more fatigued than they are now.

All the best

Miranda

 

Functional medicine to heal auto-immune diseases

It’s another ‘lazy’ blog, re-blogging a great piece called ‘How to stop attacking yourself. 9 steps to heal automimmune disease’ by Dr. Mark Hyman. Brings together a lot of familiar themes; the gut, leaky gut and how to heal it, food intolerances, and calming inflammation.

http://drhyman.com/blog/2010/07/30/how-to-stop-attacking-yourself-9-steps-to-heal-autoimmune-disease/#close

When he talks about infectious agents, I agree, but I tend to use SOS-Advance as it blitzes most things without destroying your natural gut flora.

I hope that soon I’ll get a chance to write something fresh – I’ve been photographing my cooking, so expect a recipe section soon!

All the best

Miranda

MS, Auto immune disease and gut health research

I know I keep going on about guts, healthy, leaky, gut bacteria, diet, etc etc, but I just keep bumping into research that seems to show just how important it is in auto-immune disease. Here’s the latest thing I found:

http://www.med.lu.se/english/news_archive/040908_ms

So. Anyone remember Judy Blume? “I must, I must, I must, I must increase my bust”?!

Change that to “I must I must I must, I must look after my guts!”

Nourish the gut wall, as described in the 2 previous posts, identify any food intolerances that have been caused by previous/existing gut wall problems and avoid, add anti-inflammatory flax seed oil & vitamin D, and keep building up the health of the intestines and digestion with great dietary fibre, less sugar, probiotics and prebiotics.

Just found out that through MS-UK, people with MS can get a massive discount on food intolerance testing. Email info@ms-uk.org to find out about this. 🙂

Gut health and probiotics for MS

Bacteria and Digestion

I quite often get asked about bloating. But did you know that you don’t have to have digestive symptoms to be suffering from ‘dysbiosis’ or wrong bacteria in the gut? It might be easy to think of this as something that’s just a minor inconvenience. However – gut problems are not just miserable & uncomfortable, they can also possibly play a role in  auto-immune diseases like MS. In fact  Hippocrates, the ‘Father of modern medicine’ is quoted as saying that ‘all disease begins in the gut’.

If the health of the gut breaks down, undigested food molecules can pass into the bloodstream. This is known as ‘leaky gut’. These undigested food molecules can be interpreted by the body as ‘bad guys’, and activate an immune reaction, causing a food intolerance. According to the theory of ‘molecular mimicry’, the confused immune system can then mistake other molecules, of the body’s own tissues, which are similar to these undigested food molecules, to also be ‘bad guys’ or pathogens, and launch an immune response to its own tissues, setting up an auto-immune disease.

So let’s take a look at this one aspect of gut health; bacteria,  & how it affects us. The gut is basically a long tube, that travels from the mouth to the anus, with many shapes & sizes along the way, to accommodate the different stages of digestion! I’ve discussed constipation, diet and stool health, and the link between auto-immune disease and food intolerances before in this blog , but today I’m thinking about the tiny beings who live with us, lovingly help to keep us healthy but also depend on us too for their existence  – Bacteria! bacteria

From the 1600s, and the invention of the first microscope, we have known about the existence of our internal bacteria, but up until quite recently, the focus for medicine has been more about the ‘war on germs’, and the eradication of infectious disease. We now understand that our gut is home to approximately 100 trillion micro-organisms. Did you know that: Bacterial cells outnumber our human cells to the extent that you could say that we are actually only 10% human, and 90% bacterial? Or that three pounds of your body weight is bacteria?

75% of our immune system is comprised of intestinal bacteria –  and it also helps to regulate metabolism, digestion and the absorption of nutrients from food. The health of our gut depends on this intestinal ‘flora’ being in balance, and gut health is critical to overall health, with poor gut health implicated in a wide range of diseases including diabetes, obesity, rheumatoid arthritis and other auto-immune diseases, autism spectrum disorder and even depression. So what can disrupt the healthy bacteria in the gut?  Top of the list is

  • Antibiotics – life saving but also seriously disrupt the ‘biome’

Amongst others,

  • Steroids and other medications like birth control and non- steroidal anti-inflammatories
  • Diets high in refined carbohydrates, sugar and processed foods
  • Diets low in ‘fermentable fibres’ – food for the good bacteria
  • Chronic stress          &          Chronic infections

What can we do to help repopulate the gut with healthy bacteria? And what to do if suffering from ‘digestive discomfort!’?

  • Eat plenty of fermentable fibers (sweet potato, Jerusalem artichoke, yams, dandelion greens, leeks, onion, garlic, or bananas) or take a pro-biotic ( good bacteria) capsule that includes Pre-biotics ( food for the good bacteria)
  • Eat fermented foods like kefir, live yogurt,( be aware these 2 are dairy based), kombucha, sauerkraut, kim chi, – traditionally most societies do, but we’ve forgotten to!
  • and/or take a high-quality, MULTI-STRAIN PRO-BIOTIC ( good bacteria) capsule daily – Bio-Kult is a good one, many others too
  • Keep your diet as close to whole foods as possible
  • Learn how to manage stress healthily

Taking regular probiotics  helps to re-establish the strength of our gut and digestion, reducing the incidence of food intolerances, and allowing the body to free up more of its energy for healing painful conditions. It  has also been found to help prevent recurrent infections like urine infections, and increase our ability to fight off the bad bacteria. The cheapest dairy-free way to get good bacteria into your diet is by making your own sauerkraut – It’s super easy to make – just get a head of organic cabbage, chop it up, punch it in a bowl, sprinkle salt on it, let it sit for half an hour, then put it in jars with a bit of salt water and let it sit on your kichen top for a week. There’s loads of instructions on the internet, but that’s about the size of it. Then use it like pickle.  Til next time :)

What I’d do if I got diagnosed with MS

to-do-list DOING NOTHING IS NOT AN OPTION!! MS can have a very serious impact on your future quality of life. All measures you can take to stay well, have the most impact when they are done early on, and stuck to consistently. Nobody knows what causes MS. As far as the disease process goes, It’s widely believed that the early inflammation causes damage, which causes later degeneration, but we now know that degeneration is also a factor right from the start. However, there is a lot you can do to combat both inflammation and degeneration, both with medical treatment and your lifestyle & nutrition. Having worked as an MS specialist nurse for about 13 years now, here’s what I’d do if I got a diagnosis of MS:

1) ADRESS INFLAMMATION & DEGENERATION WITH DIET &LIFESTYLE. Get George Jelinek’s book ,’Overcoming MS’ and follow all the dietary and lifestyle recommendations to the letter. I consider this to be a rock solid foundation for good health, whether you have MS or not, and essential for people with MS. It’s also so great to keep hearing individuals stories of improvement, even with long-standing and progressive MS, following this approach, and both Jelinek’s, and more and more research on diet and disease backs up this evidence based approach. See www.overcomingms.org

2) Some – not all – but some, people with otherwise unexplained medical conditions, have an underlying food intolerance, and you can be completely unaware of the problem. If you do have an intolerance, for example, to gluten, then every time you eat that food, you set up a chain of inflammation in the body, which can certainly exacerbate any auto immune condition.  For that reason, I, personally, would also want to identify food intolerances. Finger prick blood tests are available online from companies like York labs and Lorisian. However, there’s a lot of controversy about them, and they have been found sometimes to be unreliable, with a tendency to just show up with whatever you’ve eaten recently. A more reliable way is to spend some weeks doing s ‘exclusion diet’, to see if you can find any cuplprits. Here’s one example: https://avivaromm.com/elimination-diet/ . We know that MS is a conditions with ups and downs anyway, and an exclusion diet is an effort, so both approaches have their pros and cons, but in my experience, when people who have a food intolerance identify and avoid that food, they get a lot better all round, so its worth doing.

If you do identify food intolerance, you need to also learn about gut health, and start building yours up by using a plant based diet and things like probiotics, more on that another time, then, hopefully, your exclusions don’t have to be forever.

3) Find out about your options re drugs. I am not going to be talking about diseases modifying treatment (‘DMT’) choices here, only broad concepts.

MS drugs aim to stop or reduce  inflammation, manifested as relapses, in the hope that this will prevent the degeneration. See the infographic in my Alemtuzimab about the relationship between safety and efficiency of the various treatments available.

An important point to consider is that some of these more effective drugs are ‘second line’ treatments, which means they are only available to you on the NHS if you have already tried the standard drugs. There are also sometimes drug trials recruiting, where you can access a drug as part of an experimental trial. (see other posts) There is a link on the MS Society website to find out what trials are ongoing and how to get involved in a trial.

MS drug treatment is a fast changing topic and you need to have a serious discussion  with your MS Nurse and/or neurologist to find out what you are eligible for, and then read round the subject and discuss to make an informed choice.

Make sure the information you use to make your decision is as objective as possible, and not coming directly from the companies making the drug. www.msdecisions.org is a decision making tool that’s been put together by the MS Trust, the MS Society, the UK MS Specialist Nurses Association and the Department of Health, so its’ as objective as you are likely to find.

Last important point: The earlier in the disease process that a drug is used, the more effective it is likely to be.

4) Consider a clear out. Environmental factors combining with genetic susceptibility is what is thought to trigger MS , and as we are still unsure exactly what those environmental factors are,  there is still a lot of interest and research going on into the role of viruses etc in MS. Even if this turns out to have nothing to do with the cause of MS, any inflammatory condition will be worsened by an overload of any organisms that should not be there, whether they are yeasts, bacteria, virus, or parasites. People who are concerned that they may have an overgrowth of yeast, wrong gut bacteria, etc may want have a ‘clear out’ by doing a  3 month ‘detox’ with a strong natural detox agent. I like something called SOS-Advance, which is a colloidal suspension of strong anti bacterial, anti viral, anti parasitic plant oils like oregano, neem etc, but there are plenty of other herbal ‘de-tox’ products. Be aware, before starting any detox product, that it’s possible to feel really grotty for up to a week at first, if you have a ‘die-off’ reaction. If this happens, drink more water, rest, make your diet light and fresh, treat any constipation, and shower/bathe frequently.

5) Eat Really good Food – it’s not all about avoiding stuff-  food has so much power to affect the cells of our bodies for brain and nervous system health, so read up on a wholesome plant based diet, and ‘eat the rainbow’, especially dark green leafy veg.

6) Becoming more resilient to stress. Super important. We know that unmanaged stress causes and inflammatory cascade in the body, and there’s enough research to identify it, along with infection, as a trigger for MS relapses. There’s load of research now on the power of meditation, mindfulness, and relaxation. Personally, and especially if you struggle to fit meditation or deep relaxation into your day, I like the HeartMath technique, where you learn to synchronise your heart rate variability, and get feedback as to how you’re doing. In my clinics, I use the desktop teaching program, and send people away with the simple technique to do regularly, but you can now purchase an app version, available from itunes: https://store.heartmath.com/innerbalance

7)Read up on intermittent fasting, even if it’s just to use if and when you’re aware that you have inflammation or relapse going on.

So, TO SUMMARISE, and adding the Jelinek/Overcomingms recommendations:

AVOID:

  • saturated fat ( meat & dairy, coconut & palm oil)
  • other fats in processed food
  • unmanaged stress
  • physical inacitivty (as much as possible)
  • foods which you test intolerant to
  • smoking
  • eating too many calories for your needs

TAKE:

  • a plant-based, whole food diet
  • eating a ‘rainbow’ with special focus on dark green!
  • high dose vitamin D3, keeping blood levels around 150nmol/litre
  • 20g omega 3 – 2 dessert spoons of cold pressed flax seed/linseed oil fulfils this
  • probiotics
  • Any appropriate MS treatment drug
  • meditation/deep relaxation 30 mins daily to improve resilience to stress, or regular Heartmath technique.
  • as vigorous as possible exercise 30 mins, at least 3-4 x a week, outside if poss
  • the sun – as close to all over as poss, 10-15 minutes when possible
  • Lipoic acid 1,200mg – see this post

and take courage – many people with MS go on to live healthy lives well into old age. I would encourage you to do these actions to help you to be one of these. 🙂

Invitation to free online event ‘Gluten summit’

This looks interesting, and I will be looking in on it as much as I can! ( Maybe whilst cooking tea… pasta with baguettes and doughballs – jokes!)

THE WORLD’S FIRST GLUTEN SUMMIT
COULD CHANGE YOUR LIFE!

Dr. Tom O’Bryan of theDr.com has gathered 29 of the world’s experts and opinion leaders on the topics of gluten-related disorders, nutrition and healthy living for a series of online interviews taking place for FREE from November 11-17, 2013.


During the summit, you will:

  • Learn about the latest research on gluten-related disorders;
  • Understand why we MUST call more attention to them;
  • Gain improved knowledge of proper diagnosis/treatment methods;
  • More frequently ask, “Could this health issue be due to gluten?”

The goal of The Gluten Summit is to shift the scientific discussion and clinical recognition of gluten-related disorders forward by five years. Meaning, we want the conversation between patients and doctors that will be happening five years from now to happen now.

REGISTER

And Join Us For FREE Now!

Tom O’Bryan, DC, CCN, DACBN

Host, The Gluten Summit; Educator/Physician, theDr.com

THE WORLD’S FIRST GLUTEN SUMMIT COULD CHANGE YOUR LIFE! Dr. Tom O’Bryan of theDr.com has gathered 29 of the world’s experts and opinion leaders on the topics of gluten-related disorders, nutrition and healthy living for a series of online interviews taking place for FREE from November 11-17, 2013.

Diet in Auto-immune disease

11.coverHow come other auto-immune diseases get articles like this in medical journals??

Even though this is about rheumatoid arthritis, it’s well worth reading if you have MS.

It confirms many things I’ve said here before. It is technical, and hard going but – scan it, and get the gist. For me, the low sat. fat diet is a cornerstone in MS, as per http://www.overcomingms.org. but I’m getting to think that individual intolerances can be wreaking havoc in some people, too. You read a lot of good discussions like this in natural health experts, but never in the medical literature for MS.

enjoy!  Reproduced from:

http://rheumatology.oxfordjournals.org/Diet therapy for the patient with rheumatoid arthritis?

In spite of the great advances that have been made in the development of new drugs for the treatment of rheumatoid arthritis (RA), many patients are interested in alternative treatments like dietary therapy. Although relatively few studies have been carried out on the possible impact of dietary therapy on disease activity in RA, interest in this matter is growing as our understanding of disease pathology and the effect of nutrients on immunity and inflammation increases.

Most clinical dietary therapy studies undertaken so far have focused on some form of dietary elimination. Scandinavian health farms have long promoted fasting and vegetarian diets for patients with rheumatic diseases.

In 1979 and 1983, Sköldstam et al. [12] carried out two studies to verify whether diet therapy could alleviate disease activity and symptoms in patients with RA. In one study, 16 RA patients fasted for 7–10 days and followed a lactovegetarian diet for the subsequent 9 weeks. There was a significant improvement in both objective and subjective disease symptoms during the fasting period, followed by rapid deterioration when the patients began on the lactovegetarian diet.

In the second study, 20 patients with RA completed a 7- to 10-day fast, followed by 3 months on a vegan diet (a diet without meat, fish or dairy products). Physician’s general assessment revealed that 11 patients had undergone subjective improvement, seven were unchanged and two were worse after the study period than before. Nineteen patients had lost weight and no improvement was seen in objective variables like erythrocyte sedimentation rate (ESR) and C-reactive protein during the dietary period. However, 5 (25%) of the patients showed both objective and subjective improvement. Several patients complained about the diet and only two patients had continued with a strict vegetarian diet after the study period. This confirms that many patients experience difficulty in implementing strict dietary changes.

In 1983, Panush et al. [3] conducted a study of the then popular Dong diet (which eliminated dairy products, red meat, citrus fruits, tomatoes, alcohol and coffee). This was an elegantly performed clinical dietary study with a double-blind, placebo-controlled design. Twenty-six patients took part, 11 on the experimental diet and 15 on a control diet. Although there was no statistical difference between the experimental and placebo diet groups, two patients in the experimental group improved noticeably. One patient experienced disease exacerbation after eating dairy products and the other after eating meat, spices and alcoholic beverages.

In 1986, Darlington et al. [4] published the results of a single-blinded, placebo-controlled study of 6 weeks of dietary manipulation in 53 patients with RA. During the first week, the patients were only allowed to eat foods they were unlikely to be intolerant to. In the article, it is not stated which food items these were. Other food items were then reintroduced one at a time to see whether any symptoms were elicited by the dietary challenge. Foods producing symptoms were then excluded from the diet. Both objective and subjective variables improved significantly, and a subgroup of 33 patients were graded as good responders. However, the patients were only observed for 6 weeks, which is a weakness in a study undertaken on patients with a chronic disease.

In 1991, we published the results of a single-blinded controlled clinical trial testing the effect on disease activity in patients with RA of dietary elimination combined with the vegetarian diet traditionally practised on Scandinavian health farms [5]. Fifty-seven patients took part in the study, 27 in the diet group and 26 in the control group. The patients were followed for 13 months, making this by far the most comprehensive study undertaken with regard to dietary therapy in RA.

We found statistically significant improvement in both objective and subjective disease variables in the diet group compared with the control group. Twelve patients (44%) in the diet group were responders, according to the Paulus criteria, compared with 2 (8%) in the control group [6]. Ten patients (37%) in the diet group reported aggravation of symptoms after reintake of one or more food items. Eight of these belonged to the responder group.

After 2 yr, we conducted a follow-up study on the same patients and found that the responders had continued with the diet and still had a significant reduction in all clinical disease variables and ESR [7]. In this study, 13 patients (59%) in the diet group reported an increase in disease symptoms after intake of meat, and 10 patients (45%) after intake of sugar and coffee. Of the 10 responders examined in the follow-up study, eight reported an increase in disease symptoms after intake of different kinds of meat, and six after intake of coffee, sweets and refined sugar.

Fasting has been documented to have beneficial effects on both clinical and laboratory variables reflecting disease activity in RA [158]. It thus serves as a useful model for studying the biological changes associated with simultaneous improvement in disease activity. Previous studies in healthy subjects have revealed that fasting decreases mitogen- and antigen-induced lymphocyte proliferative responses [9], and suppresses interleukin-2 (IL-2) production [10]. We have recently shown that a 7 day fast in RA patients also decreases CD4+ lymphocyte activation and numbers, suggesting transient immunosuppression [11]. We also found an increase in IL-4 production from mitogen-stimulated peripheral blood cells. Thus, further studies should be carried out to clarify the immunomodulatory mechanism behind fasting.

Evidence suggesting that food allergy, defined as an immunological response to food antigens or to intestinal bacterial flora, might be involved in disease pathology in most patients with RA is weak. However, it is possible that an exogenous agent like a food antigen can initiate a pathological immune process in a genetically susceptible individual [12].

Food antigens, food antibodies and their complexes have been detected in the systemic circulation of healthy subjects [1314]. Animal models indicate that the gut is an important trigger of and pathway for the immune response. Encounters with complex proteins, like gluten and milk proteins, lead to either oral tolerance or sensitization and possible loss of self-tolerance to cross-reacting epitopes [15].

An association between a special food item and disease activity has been reported by patients with a variety of rheumatic diseases, such as palindromic rheumatism [1617], systemic lupus erythematosus [1819], Sjögren’s syndrome [20] and juvenile RA (JRA) [2122]. Case reports describing an association between diet and disease activity in RA include both seropositive and seronegative disease [2325]. Although the extent of food allergy involvement is still not known, it has been suggested that between 5 and 30% of patients with RA may be affected [2627].

We found an increase in humoral response in all patients with RA, with a general increase in IgG, IgA and IgM antibodies to various food antigens, like gluten and milk proteins. However, the elevated concentrations of specific immunoglobolins could not be used to predict which food items would aggravate the disease symptoms [28].

Wheat and other rough grain products can elicit an allergic T-cell response through their lectin structures. Lectins are glycoprotein molecules that bind to carbohydrate-specific receptors on lymphocytes with high affinity and thus elicit a significant immune response. Lentils and grain products have a particularly high lectin content. Lectins are fairly heat resistant; for example, lentils have to be cooked for a long time to inactivate the lectins.

While the results of a questionnaire-based survey revealed that 37–43% of patients with rheumatic diseases experienced an increase in disease symptoms after intake of certain food items, no difference could be found between the various diseases [29]. This suggests that diet may influence the inflammatory process in general and is not a specific feature of RA.

One of the mechanisms involved may be the release or secretion of vasoactive amines (bioactive amines) like histamine and serotonin [30]. Several of the food items reported to cause disease aggravation have a high histamine content, like pork and beef sausage, meat, tomato and spinach. Since no immunological response to pork and other meat has been demonstrated, a pharmacological response would explain the often reported increase in symptoms resulting from these foods [31]. Other foods like shellfish, strawberries, chocolate and fish can cause a release of histamine.

Citrus fruits, which contain other vasoactive amines (octopamine and phenylephrine), are often said to aggravate symptoms [30]. Consumption of both coffee and alcohol has been shown to liberate adrenaline and/or noradrenaline, which suggests that they have a pharmacological effect [3032]. Consumption of alcohol can also result in the release of histamine, and certain red wines have in addition a high concentration of histamine, which may explain the frequently reported intolerance.

A pharmacological reaction would also explain why the patients reported immediate reactions to these food items, as opposed to the more delayed reactions to dairy products and gluten. This may mean that a different mechanism is involved in symptom aggravation. The reported aggravation of symptoms after intake of refined sugar and sweets in patients with RA may have a metabolic explanation, such as an increased concentration of blood glucose due to impaired glucose handling [3335].

Gut involvement in the pathogenesis of rheumatic diseases was proposed by Rea Smith [36], who reported that surgical removal of intestinal segments with focal infection had a beneficial effect on disease activity. Monroe and Hall [37] reported differences in the stools of 142 patients with chronic arthritis as compared with controls. Månsson and Olhagen [38] found not only an abnormal faecal flora, with an increase inClostridium perfringens in patients with RA, systemic lupus erythematosus and psoriatic arthropathies compared with healthy controls, but also a higher level of alpha-antitoxin in the serum of these patients. Alpha-toxin (phospholipase-C) is produced by a special strain of C. perfringens often found in RA patients. Månsson and Olhagen [38] found a rise in alpha-antitoxin titre in 75% of the patients with RA in the study, but in none of the controls.

A significantly higher carriage rate of C. perfringens in patients with RA than in healthy controls has also been documented by Shinebaum et al.[39]. An altered intestinal bacterial flora has been reported in patients with seropositive erosive RA compared with patients with seronegative RA and controls [40]. An increased concentration of antibodies to Proteus has been described in patients with active RA [4142] and to Klebsiella in patients with ankylosing spondylitis [43]. Several of these reports have suggested that RA and ankylosing spondylitis could be mediated by cross-reactivity between self and bacterial antigens.

The intestinal bacterial flora is known to be affected by diet [4446], and it has been suggested that a diet which could alter the intestinal flora might have an effect on disease activity. This theory was supported by the finding that changes in disease activity correlated with alterations in the intestinal flora measured in patients who switched from an omnivorous to a vegetarian diet [47]. The effects of the intake of functional foods (i.e. food as medicine; in this case, food which promotes the growth of health-promoting bacteria in the intestine or food items that contain natural healthy intestinal bacteria) should be an interesting field for further research.

Much interest has been taken in recent years in the immunomodulatory effects of polyunsaturated fatty acids (PUFAs) and their therapeutic potential as anti-inflammatory agents [48]. Both clinical and in vitrostudies have established that long-chain n-3 and n-6 fatty acids inhibit T-lymphocyte function [4952].

Research suggests that manipulating the balance of dietary fatty acids in favour of increased n-3 fatty acids and decreased n-6 fatty acids may have a beneficial effect on disease activity in RA [495356]. These studies have shown that long-chain n-3 fatty acids can diminish peripheral blood mononuclear cell proliferation and reduce the production of IL-1, IL-2, IL-6, tumour necrosis factor alpha (TNF-α) and interferon gamma (IFN-γ). However, clinical studies on supplementation of ω-3 fatty acids have not supported the expectations raised by the laboratory findings [5357].

The balance between unsaturated and saturated fatty acids may also affect lymphocyte proliferation (in vitro) [58]. The practical implications of these observations for the in vivo situation are currently unclear, but suggest that a diet which is high in unsaturated fatty acids and very low in saturated fatty acids may have a stronger immunosuppressive effect than that obtained by only n-3 fatty acid supplementation.

In this respect, the Mediterranean diet, with a low content of red meat and a high content of olive oil, is of interest. Olive oil has been shown to reduce lymphocyte proliferation, natural killer cell activity, adhesion molecule expression on lymphocytes and the production of pro-inflammatory cytokines in animal models [59]. In an intervention study in which dietary saturated fatty acids were partly replaced by olive oil, mononuclear cell expression of ICAM-1 was found to be significantly reduced [60].

It has also been reported that a very low intake of saturated fats is beneficial in multiple sclerosis, where, as in RA, CD4+ lymphocytes are thought to play a pathogenic role [61]. It is thus worth investigating whether a diet low in saturated fats, with a high content of olive oil and with n-3 supplementation, could have immunosuppressive effects in vivoand could thus be of benefit in the treatment of RA.

The pathological hallmark of RA is persistent destructive inflammation in the synovial membranes of joints, which leads to a gradual destruction of the supporting structures of the joints, such as bone and cartilage. Although the aetiology is still unknown, the inflammation resulting from the immunological reaction is quite well described. It is known that neutrophil granulocytes, macrophages and lymphocytes are activated, and that oxygen free radicals are produced [62]. Hence, a low concentration of antioxidants may perpetuate tissue destruction in RA. Free oxygen radicals and oxidative stress may also be of importance for the aetiology and chronicity of the inflammatory rheumatic diseases [6364]. Two epidemiological studies have recently suggested that antioxidants may play a protective role [6566].

The most important antioxidants known today are vitamin A, vitamin E, vitamin C, beta-carotene, the bioflavonoids, zinc and selenium. The antioxidant properties of vitamin A and vitamin E lead to a reduction in the oxidation catalysed by free radicals [67]. Vitamin E functions as a physiological antioxidant for the cell membrane and is the most important fat-soluble antioxidant in the cell membrane lipids [6468]. Zinc plays a significant role in antioxidant protection and immunity because it is a constituent of the cytoplasmic enzyme superoxide dismutase [69]. Selenium, on the other hand, is part of the glutathione peroxidase enzyme, which can react with peroxides formed during inflammation. Beta-carotene is a fat-soluble, chain-breaking antioxidant and a quencher of singlet oxygen, and is known, along with alpha-tocopherol, to be the most important element of the non-enzymatic antioxidant defence in biological systems [7071].

Low serum concentrations of selenium and zinc in RA patients were reported as early as 1978 [72] and were further investigated by Tarp et al.[7375]. Mezes and Bartosiewicz [63] found reduced plasma vitamin A content in patients with RA. Honkanen et al. [76] found lower serum levels of vitamin A and E in patients than in healthy controls. Sklodowska et al.[64] found lower vitamin E concentrations in plasma in children with JRA than in controls. Studies have also shown reduced concentrations of zinc and selenium in children with JRA [7778].

The reduced serum concentrations of antioxidants found in patients with inflammatory rheumatic diseases do not appear to be a consequence of reduced dietary intake in these patient groups compared with healthy controls [7880]. They may, therefore, indicate a high turnover of antioxidants and an increased antioxidant requirement in these patients which is necessary in order to balance the higher production of free radicals.

Although studies of supplementation with a single antioxidant have not shown disease reduction in RA patients, it is still possible that patients with an inflammatory rheumatic disease will benefit from supplementation with a combination of several antioxidants or from a dietary intake that exceeds the recommended dietary allowances.

Studies of immunomodulation have revealed that nutrients other than food proteins and fats also have an impact. The effects of fatty acids, antioxidants and food proteins on immunomodulation need to be investigated further, and so should the question of the involvement of the gut in the aetiology and pathology of rheumatic diseases. More knowledge on the effects of dietary components upon immunological function is necessary if the potential use of dietary therapy as a tool in the treatment of RA is to be adequately assessed.

  1. 1.     M. Haugen
  2. 2.     D. Fraser and 
  3. 3.     Ø. Førre