An inflammatory disease
Rheumatoid arthritis is a chronic disease of the synovial tissue in the joints, leading to inflammation and eventually to permanent deformation. The synovia normally produces joint fluid, which acts as a lubricant, also providing the cartilage with important nutrients. In rheumatoid arthritis, the synovia are invaded by activated white blood cells, releasing certain chemical substances into the fluid and leading to the degeneration of cartilage and subsequent inflammation of the surrounding tissue. The symptoms are pain, stiffness, reduction of joint and muscle strength and, ultimately, joint deformation.
Today's treatment of rheumatic disease is directed toward suppressing symptoms and preventing joint deformation. Medical treatment is characterized by an aggressive approach, combining non-steroidal anti-inflammatory drugs (NSAIDs) with cytostatics or other immune-suppressants. The goal of this aggressive treatment is to improve the patient's long-term outcome with respect to symptoms and function. However, the challenge is to prevent adverse effects while monitoring liver and bone marrow function.
Omega-3s have beneficial effects
Omega-3 fatty acids not only reduce symptoms and may potentially facilitate lower doses of NSAIDs, they also appear to preserve joint function. To take optimal advantage of the beneficial effects of omega-3 fatty acids, individuals must take large doses, larger quantities than what is possible to get through diet alone. This requires dietary supplements of concentrated omega-3 fatty acids – 5-6 grams per day – under the advice and care of a healthcare professional.
Curb dietary omega-6s
Diet can interfere with the clinical course of a disease since fatty acids help fine-tune the human immune system. Omega-3 fatty acids reduce immunological effects while omega-6 fatty acids tend to increase immune activity. In addition to eating a diet rich in fish containing omega-3 fatty acids and/or taking dietary supplements, individuals with rheumatism should eat a diet low in red meat and avoid using vegetable oils rich in omega-6 fatty acids, such as soy, corn and sunflower oil. Use olive oil and canola oil instead as they contain more omega-9 fatty acids, which do not overactivate the immune system.
Clinical studies show omega-3 benefits for ARTHRITIS and LUPUS
Several controlled clinical studies have shown significant symptom relief from taking high doses of omega-3 fatty acids for a period of at least 2 to 3 months. Furthermore, intake of omega-3 fatty acids reduced the need for NSAIDs, which is important to prevent adverse effects from the gastro-intestinal tract. A summary of the most important studies has been published in the Journal of Clinical Epidemiology. (1)
Results of a study in Northern Ireland suggest that taking fish oil supplements may relieve symptoms of lupus. A total of 52 patients took part in the study and were randomly assigned to take fish oil supplements alone, fish oil supplements combined with copper, copper alone, or nothing for 24 weeks. The participants who received fish oil took three capsules per day (or about the equivalent of two meals of oily fish). At the end of the trial, the fish oil group showed a significant decline in symptoms and disease activity as measured by the Systemic Lupus Activity Measure (SLAM-R). The copper supplements had no apparent effect (although positive effects had previously been seen in rat studies). Fish oil had no apparent effect on inflammation in this study, but skin rashes and neurological problems improved considerably. And in contrast to typical drug therapies used to treat lupus, none of the subjects reported any adverse side effects. (2)
Low occurrence in Japan
Rheumatoid arthritis is an auto-immune disease, affecting about 1% of the population in western countries. The mechanism underlying the development of auto-immune diseases such as rheumatoid arthritis is not completely understood. Most certainly, it involves a combination of genetic and environmental factors, but psychological factors may also be involved. The coastal population of Japan has a high incidence of a genetic configuration, which is often accompanied by rheumatic diseases (so-called HLA-D4). However, rheumatoid arthritis rarely occurs in Japan, probably due to the high intake of fish and thereby omega-3 fatty acids in the Japanese diet.
- Fortin PR et al. "Validation of a meta-analysis: the effects of fish oil in rheumatoid arthritis". J Clin Epidemiol 1995;48:1379-1390.
- "The Clinical Effect of Dietary Supplementation with Omega-3 Fish Oils and/or Copper in Systemic Lupus Erythematosus", Journal of Rheumatology, Vol. 31, No. 8, August 2004
Rheumatoid arthritis and the immune system
One person out of every hundred suffers from chronic rheumatoid arthritis. It occurs when the body’s immune defenses attack the tissue in the joints, leading to pain and degeneration of the articular cartilage. The result is a reduced quality of life, loss of working capacity and subsequent invalidity.(1) The disease or its treatment also increases mortality, and patients with rheumatoid arthritis have a shorter life expectancy than their healthy peers.(2) Drugs used to limit the symptoms have a limited effect and do not improve the long-term prognosis.(1)
Our understanding of the way in which the immune system attacks the joints has increased, leading to the development of new drugs that can have a positive effect. However, these drugs are very expensive and have not been used long enough for us to be able to assess their side effects.
The treatment of arthritis is based on medical treatment and providing advice about how to facilitate daily activities. Preventive treatment of persons who may be genetically exposed to the disease is currently not promoted. However, preventive medicine may be quite effective. Persons with a family history of rheumatoid arthritis are four times more at risk of developing the disease than others. Is there anything they can do to prevent the disease from occurring? And what about patients who already have the disease? Is there anything they themselves can do to alleviate their symptoms and prevent permanent damage to the joints?
Several studies show that a change in diet can have a positive effect on the disease.(3) Fasting, which is surely the most extreme form of dietary change, has an overtly positive effect on rheumatic symptoms. There is not much that can be done about the “congenital wrong programming” of the immune system that has caused it to attack the articular tissue.
The immune system is continuously balancing between quiescence and preparedness for activation and attack. On the one hand we want our immune system to be activated and able to defend us against attacks from bacteria, viruses and cancer cells, but on the other hand we do not want an over-stimulated immune system that attacks the tissue and produces so-called autoimmune diseases, of which rheumatoid arthritis is the most common.
The immune system affects a great number of functions, using signal substances - chemical substances that trigger processes to neutralize anything they perceive as pathological or foreign. The original material for these signal substances is fatty acids, which we acquire through our food. The polyunsaturated fatty acids from vegetable and fish fat is stored in the cell walls and released either for the direct formation of signal substances or for the long-term building up of signal substances and other structures used by the immune defense system to penetrate the tissues.
Omega-6 fatty acids from plants and from pork and beef intensify the activity of the immune system, while omega-3 fatty acids from fatty fish lower the activity level. If the immune system is to perform the work for which it is designed, we must have a balanced intake of these two types of fatty acids.(4)
Our current diet contains too much red meat, too many vegetable oils, and too little fatty fish. Sufferers of rheumatoid arthritis may be able to counteract their disease by replacing beef and pork with chicken and fish, and by a general reduction in their intake of vegetable oils. Vegetable oils containing omega-6 fatty acids are used in almost all food products, including low-fat ones. It is best to use olive or canola oil as these contain mainly omega-9 fatty acids, which do not activate the immune system.
A study from the Gråsten rheumatism hospital in Denmark showed that patients generally eat too little fish, too much meat, and too few antioxidant vitamins (C and E). An adjustment of the diet to include more fresh fish, combined with omega-3 capsules, vitamin and selenium supplements, and an overall reduction in the intake of fat diminished the patients’ symptoms substantially.(5) This demonstrates that dietary adjustments help, even with patients who are badly attacked by the disease.
It would be purely speculative to assert that a diet rich in omega-3 fatty acids and antioxidants could prevent the development of the disease in individuals with a hereditary disposition for rheumatoid arthritis. It is nevertheless quite clear that the risk of developing rheumatoid arthritis in Japan, where they have this type of diet, is considerably lower than in the West, despite the fact that the immunological conditions are present to the same degree.(6)
An increased intake of omega-3 fatty acids in the form of capsules has a well-documented effect on the symptoms of rheumatoid arthritis,(7) and constitutes an important supplement to dietary adjustment. To have any effect, the capsules need to be taken in high doses for a long time. This type of treatment may also reduce side effects and the risk of death from the serious haemorrhagic complications caused by antirheumatic drugs.
Treating the symptoms is only part of the regime for the rheumatoid arthritis patient. ”Maintenance” of articular function is equally important, but in this area there is a dearth of supporting research data on dietary adjustment and the increased intake of omega-3 fatty acids. The degeneration of articular cartilage is due to the effect of special enzymes that are activated by the immune system. Researchers in Cardiff in Wales have shown that cells from the cartilage of arthritic patients are not broken down by these enzymes if omega-3 fatty acids are added.(8) Even if this is a laboratory trial, it nevertheless supports observations of arthritic patients in Greenland, where X-rays of their joints showed that changes happen much more slowly than is normal in Scandinavian patients.(9) The diet of the Greenland people contains large quantities of omega-3 fatty acids.
Rheumatoid arthritis is a chronic disease that causes great suffering, major financial outlays, and loss of income due to functional impairment and the prospect of invalidity. Dietary adjustment offers a good opportunity to influence the disease. There is clear scientific evidence that it helps, but it requires the understanding and the will to change one’s lifestyle.
- Scott DL et al. Long-term outcome of treating rheumatoid arthritis: results after 20 years. Lancet 1987;1:1108-1111
- Incus T and Callahan LE. Taking mortality in rheumatoid arthritis seriously – predictive markers, socio-economic status and comorbidity. J Rheumatol 1986;13:841-845
- Darlington LG and Ramsey NW. Review of dietary therapy for rheumatoid arthritis. Br J Rheumatol 1993;32:507-514
- Cleland LG and James MJ. Rheumatoid arthritis and the balance of dietary n-6 and n-3 essential fatty acids. Br J Rheumatol 1997;36:513-515
- Hansen GVO et al. Nutritional status of Danish rheumatoid arthritis patients and effects of a diet adjusted in energy intake, fish-meal, and antioxidants. Scand J Rheumatol 1996;25:325-330
- Shichikawa K et al. Ryumachi. Prevalence of rheumatoid arthritis in the Japanese population 1981;21:35-43
- Fortin PR et al. The effects of fish oil in rheumatoid arthritis; validation of a meta-analysis. J Clin Epidemiol 1995;48:1379-1390
- Curtis CL et al. Pathologic indicators of degradation and inflammation in human osteoarthritis cartilage are abrogated by exposure to n-3 fatty acids. Arhtitis & Rheumatism 2002;46:1544-1553
- Bunch V. Ledlidelser i en fangerbefolkning. Månedskrift for praktisk lægegerning 2000;78:949-955
Treatment of rheumatoid arthritis
by Morten Bryhn MD, PhD
Rheumatoid arthritis (RA) is a chronic disease affecting about 1% of the population, women three times more often than men. About 80% develop the disease between the ages of 35 and 50. Family studies indicate that RA is a hereditary disease. About 79% of people with the genetic code of HLA-DR4 develop RA compared to only 28% of those with other constitutions. However, genetic risk factors cannot fully account for the incidence of RA, suggesting that dietary habits and other environmental factors also play a role in the etiology of the disease. Even if the Japanese population is genetically exposed to the same risk of getting RA as the Western population, the prevalence of the disease is much lower.(1) Dietary habits may influence the risk of acquiring the disease and may also influence the course and symptoms related to the disease.
Inhabitants of Greenland and the Faroe Islands have less rheumatic problems compared to people in the Nordic region. A cohort study in these two populations revealed that RA occurred with a prevalence similar to elsewhere in the world. But the clinical picture and the long-term outcome of the disease were quite different. Patients with an overt clinical picture of RA and with a history of 10-30 years were working full time in the fishing industry with exposure to a cold and humid environment. Even more interesting, x-ray pictures of their hands showed very little joint deformations. And they had only traces of inflammatory cytokines (IL-1 and TNF) in plasma, laboratory parameters that are constantly elevated in these patients.
The inhabitants of Greenland, the Faroe Islands and the coastal population of Japan have easy access to fish, and seafood is accepted as very healthy. In seafood and sea mammals we find the omega-3 fatty acids known to interfere with a series of inflammatory events in the human body protecting against RA and other autoimmune diseases.
The London Medical Journal published the first scientific publication on effects of fish oil against rheumatism in 1783 describing practices at the Manchester Infirmary. This report was based on positive observations in a disease with no treatment at that time. However, modern documentation on omega-3 fatty acids in rheumatic disease comprise well designed, controlled studies showing positive effects on symptoms such as pain, morning stiffness and grip strength. A meta-analysis on all these studies has been published (2) and recommendations on dose have been given (3).
The modern basis for treatment of patients with RA constitutes a combination of symptom treatment and prevention of joint deformation. Symptom relief increases quality-of-life, but even more important is the prevention of the joint destruction that inevitably leads to reduced function and invalidity. Pharmacological treatment reduces or prevents the negative effects of compounds released by the immune system that are responsible for the disease. Potent pharmaceuticals have been developed which may change the long-term outcome for RA.
However the omega-3 fatty acids from fish oil, EPA and DHA, do the same thing as the pharmaceuticals. The mode-of-action may be different and the potency lower but the effects brought about are certainly more natural compared to drugs. This may explain why treatment with omega-3 capsules is usually well tolerated with no risk of serious side effects. It has also been demonstrated that omega-3 fatty acids reduce the enzymes responsible for joint destruction.(4) This finding is very important and places omega-3 fatty acids as a natural supplement in combination with anti-rheumatic drugs.
A therapeutic effect on RA utilizing omega-3 fatty acids cannot be achieved simply by increasing the amount of fish eaten. A high-quality omega-3 concentrate in the dose of 3g or more daily should be used. Clinical response will not occur immediately but will start after 2-3 months and may even increase further with sustained use.(5) At the same time the intake of red meat (high in AA and saturates) should be restricted.(2)
Omega-3 capsules may be used concomitantly with anti-rheumatic pharmaceuticals, which may increase efficacy or even reduce the risk of gastro-intestinal discomfort, which is a regular problem for so called NSAID drugs.(6) For people with only minor or transient joint problems, omega-3 fatty acids could be the first choice for self-medication.
- Shichikawa K et al. Ryumachi. Prevalence of rheumatoid arthritis in the Japanese population 1981;21:35-43
- Fortin PR et al. Validation of a meta-analysis: The effects of fish oil in rheumatoid arthritis. J Clin Epidemiol 1995;48(11):1379-90
- James MJ and Cleland LG. Dietary n-3 fatty acids and therapy for rheumatoid arthritis. Semin Arthritis Rheum 1997;27:85-97
- Curtis CL, Hughes CE, Flannery CR, et al. n-3 fatty acids specifically modulate catabolic factors involved in articular cartilage degradation. Biol Chem 2000;275:721-724
- Geusens P et al. Long-term effect of omega-3 fatty acid supplementation in active rheumatoid arthritis. Arhtr & Rheumat 1994;37:824-829
- Lau CS et al. Effects of fish oil supplementation on non-steroidal anti-inflammatory drug requirement in patients with mild rheumatoid arthritis - a double-blind placebo controlled study. Br J Rheumatol 1993;32:982-989