Rheumatoid Arthritis and the Paleo Diet – A Qualitative Study

This article comes to us from Julianne Taylor, PGDipSci, a Registered Nutritionist and AIP Certified Coach from New Zealand. As soon as we learned about Julianne’s postgraduate research, which centered around the effects of a Paleo diet in the management of rheumatoid arthritis symptoms, we knew we had to bring her in to share her findings on our blog. Below you’ll see a summary of her study parameters, the results, and an overview of Julianne’s plans to push this research even further in the future. 

I first became aware of the Paleo diet in 2009 when I was asked to be a nutrition coach for one of Auckland’s first CrossFit gyms. I had recently completed a graduate certificate in nutrition and had been a nutrition coach for several years. Paleo was completely new to me at that point, so I delved into the work of Professor Loren Cordain to learn more about it. Suffering autoimmune joint inflammation myself, I put the Paleo diet to the test and was surprised that in just 3 weeks, inflammation in my knees and neck which I had for 30 years, completely resolved. To this day – over 10 years later – I have had no recurrence.

This led me to reading all I could on the Paleo diet and consequently the Paleo Autoimmune Protocol. When I went back to university in 2012 to start post graduate papers, I became more and more interested in the application of a Paleo diet as a treatment for autoimmune disease and decided I wanted to carry out research in this area.

My first foray into research was a qualitative study for my postgrad diploma, with a mind to use this as preliminary research for my master’s year. I heard about two New Zealand women with rheumatoid arthritis (RA) who had found a Paleo diet reduced their symptoms and disease markers significantly, and a search online alerted me to many other anecdotal success stories.

Study Parameters

I chose to interview 10 people with RA who had successfully used any type of Paleo protocol to ameliorate their symptoms. I put notices on several Facebook groups and approached others who had written about their success in blog posts. It was surprisingly quick to find 10 people with clinically confirmed RA who had success using either Paleo or AIP.

Here is a snapshot of the study participants:

• 1 male, 9 females
• From New Zealand (2), Australia (1), and USA (7)
• Aged from 28 to 60 years, mean age 41.7
• The time on the diet: from 6 months to 5 years, mean 2.9 years
• All were currently maintaining the Paleo diet at time of interview

I carried out a 90-minute, semi-structured interview with each person where I covered the following topics:

• Factors that enabled them to transition to, and maintain, a Paleo diet
• How each person made decisions as to what to eat and what to avoid
• The foods they perceived to cause an increase in RA symptoms, and the foods they perceived to be safe to eat

Study Results and Emerging Themes

A few main themes emerged in their responses. When asked what motivated them to follow a Paleo diet, I often heard it was the recommendation of a health professional, typically not the primary doctor or rheumatologist, but from an alternative health practitioner. I also was told that the science made sense, and that anecdotal success stories from other people with autoimmune disease were a motivating factor.

When it came to implementation of a Paleo diet, the thought of changing to a restrictive eating protocol was one of the most significant barriers to overcome. Most of the group found this overwhelming. Getting mentally and physically ready to change to a restrictive diet is a really important step, and includes understanding why certain foods are removed, working out how to follow the diet, and reading about others’ experiences to get an idea of what to expect. Many chose a specific start date where they were able to focus on their new diet without distractions. Most took a “cold turkey” approach rather than a gradual approach after preparation.

Primary barriers to maintaining the diet were the attitudes of others. Some family members and conventional health practitioners were skeptical and discouraging. One of the most important factors for all the subjects was having one person who was supportive, whether a spouse, close friend, or other family member.

Ongoing challenges that had to be navigated regularly were eating out, particularly at other people’s homes, travel, and the time it took to shop and prepare food. Over time however, for most it became easier and simply a new way of life.

The primary motivation to stay on the diet was quality of life and lack of pain. All were adamant it was worth the effort.

For those that reintroduced foods to test their effect, the following caused severe reactions:

• gluten grains/wheat (4)
• dairy (2)
• corn (2)
• eggs (1)
• egg-whites (1)
• store bought eggs (1)
• rice (1)
• peanuts (1)
• beer (1)
• wine (1)
• soy (1)
• legumes (1)
• non-gluten grains (1)
• heated/rancid seed oils (1)

A number of foods were reintroduced and found not to cause problems. The most common were:

• seed spices (10)
• eggs (8)
• spirits (6)
• rice (4)
• wine (3)
• nightshade vegetables (3)
• egg yolks (1)
• potatoes (1)
• legumes (1)

It is interesting too that the foods that cause a response when eaten frequently or in large amounts are common to several cases. For example 4 found this with tree nuts, yet no one suffered a severe reaction to them.

What do other RA dietary studies show?

Along with my interviews, I also carried out a literature review of similar studies examining the impact of Paleo diets on RA symptoms. I looked at over 50 case and dietary intervention studies and was surprised so many had been done, perhaps reflecting the belief or experience that those with RA notice food appears to have an effect.

There were 12 case studies in the literature where subjects with RA removed foods and consequently were reported to achieve remission. For these folks, should the offending food be reintroduced, symptoms of pain, inflammation and fatigue reappeared. I found 18 studies where elimination/reintroduction protocols were carried out. Once again, in a percentage of people, specific foods were found to aggravate RA symptoms. Several dietary patterns have also been tested in RA: Mediterranean, gluten-free, vegan, vegetarian, and anti-inflammatory patterns, all of which showed improvement for most. Fasting has the most significant impact on RA. Either a juice or water fast results in symptoms typically reducing within a week, which then reverse when a normal diet is resumed (Müller, de Toledo, & Resch, 2001).

I was able to draw the following conclusions from previous dietary intervention studies with respect to the role of diet in the manifestation of RA symptoms. To be effective in reducing RA symptoms, a diet would need to:

• Reduce inflammatory markers. ESR and CRP. An anti-inflammatory diet is low in saturated fat and arachidonic acid, low in refined grains and sugar, high in fruit and vegetables and in seafood for omega 3s (Adam et al., 2003; Winkvist, Bärebring, Gjertsson, Ellegård, & Lindqvist, 2018).
• Reduce or eliminate exacerbating foods, which may act as possible antigens. An appropriately structured elimination/reintroduction protocol is critical to success. Certain antibody tests may show some food intolerances such as gliadin or a-lactalbumin (Hafström et al., 2001).
• Improve gut microbiome by reducing bacterial flora linked with RA, which may be acting as antigens. A diet high in plant fibre and polyphenols with the addition of fermented foods may offer the best solution (Nenonen, Helve, Rauma, & Hanninen, 1998). Changing from acellular carbohydrates such as grain starch and sugars to cellular starches found in root vegetables is theorised to provide a better substrate for gut bacteria, as well as reduce inflammation (Spreadbury, 2012).
• Improve gut epithelial integrity, reducing intestinal permeability, as this allows antigens to cross the gut barrier in intact sequences of amino acids (Sundqvist et al., 1982). This involves improving the gut microbiome as above, as well as removing foods which are shown to increase intestinal inflammation and permeability, for example gluten grains and dairy (for some). Cordain suggests all grains and legumes have certain lectins contributing to intestinal permeability and should be avoided (Loren Cordain, Toohey, Smith, & Hickey, 2000).
• Decrease red cell membrane ratio of arachidonic acid to omega 3 EPA; this reduces inflammatory eicosanoid hormones and increases anti-inflammatory ones. This is achieved by reducing dietary sources of AA such as egg yolks and fatty meat, and increasing EPA by eating seafood or adding supplemental marine omega 3 (Adam et al., 2003).
• Reduce the support of the growth of urinary bacteria proteus mirabilis linked with RA, possibly a diet high in plant foods (Kjeldsen-Kragh et al., 1995).

My Further Study on RA and AIP

As yet, no dietary study has tested a Paleo or AIP diet in people with RA. I believe AIP is important to test, as while we know anecdotally many people have benefited, anecdotes are typically only success stories, and we need clinical studies testing the diet’s effect in a large group, to find the range of possible effects. Clinicians demand to have clinical evidence preferably from a large randomised, controlled study if they are to recommend a diet to RA sufferers.

So, after a couple of years’ hiatus with respect to study, I have now finalised a proposal to carry out further research for my master’s year, this time a pilot feasibility study using the AIP diet in a group of 10 people with RA. My proposal is to carry out a mixed-methods study, quantitative followed by qualitative. The quantitative study will involve two phases: a 4-week phase of usual diet, followed by an 8-week intervention using the AIP diet. Assessment will include its effect, using patient reported outcome questionnaires on quality of life, fatigue, pain, sleep and emotional wellbeing, and a qualitative assessment of each participant’s experience on the diet. Feasibility measures will include adherence and ease of following diet instructions. I would very much like to carry out a larger randomised controlled study should I go into a PhD following this year.

All going well, I will know the results of this pilot study some time next year.

References

1. Adam, O., Beringer, C., Kless, T., Lemmen, C., Adam, A., Wiseman, M., … Forth, W. (2003). Anti-inflammatory effects of a low arachidonic acid diet and fish oil in patients with rheumatoid arthritis. Rheumatology International, 23(1), 27–36. https://doi.org/10.1007/s00296-002-0234-7
2. Cordain, L. (1999). Cereal grains: humanity’s double-edged sword. World Review of Nutrition and Dietetics, 84, 19–73.
3. Cordain, Loren, Toohey, L., Smith, M. J., & Hickey, M. S. (2000). Modulation of immune function by dietary lectins in rheumatoid arthritis. British Journal of Nutrition, 83(03), 207–217. https://doi.org/10.1017/S0007114500000271
4. Hafström, I., Ringertz, B., Spångberg, A., Von Zweigbergk, L., Brannemark, S., Nylander, I., … Klareskog, L. (2001). A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: The effects on arthritis correlate with a reduction in antibodies to food antigens. Rheumatology, 40(10), 1175–1179.
5. Kjeldsen-Kragh, J., Rashid, T., Dybwad, A., Sioud, M., Haugen, M., Forre, O., & Ebringer, A. (1995). Decrease in anti-Proteus mirabilis but not anti-Escherichia coli antibody levels in rheumatoid arthritis patients treated with fasting and a one year vegetarian diet. Annals of the Rheumatic Diseases, 54(3), 221–224.
6. Müller, H., de Toledo, F. W., & Resch, K. L. (2001). Fasting followed by vegetarian diet in patients with rheumatoid arthritis: a systematic review. Scandinavian Journal of Rheumatology, 30(1), 1–10. https://doi.org/10.1080/030097401750065256
7. Nenonen, M. T., Helve, T. A., Rauma, A. L., & Hanninen, O. O. (1998). Uncooked, lactobacilli-rich, vegan food and rheumatoid arthritis. British Journal of Rheumatology, 37(3), 274–281.
8. Spreadbury, I. (2012). Comparison with ancestral diets suggests dense acellular carbohydrates promote an inflammatory microbiota, and may be the primary dietary cause of leptin resistance and obesity. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 5, 175–189.
9. Sundqvist, T., Lindström, F., Magnusson, K.-E., Sköldstam, L., Stjernström, I., & Tagesson, C. (1982). Influence of fasting on intestinal permeability and disease activity in patients with rheumatoid arthritis. Scandinavian Journal of Rheumatology, 11(1), 33–38.
10. Winkvist, A., Bärebring, L., Gjertsson, I., Ellegård, L., & Lindqvist, H. M. (2018). A randomized controlled cross-over trial investigating the effect of anti-inflammatory diet on disease activity and quality of life in rheumatoid arthritis: The Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA) study protocol. Nutrition Journal, 17(1), 1–8. https://doi.org/10.1186/s12937-018-0354-x