Rheumatoid arthritis and 'Plants for Joints'An effective lifestyle program for rheumatoid arthritis
What is rheumatoid arthritis?
Rheumatoid arthritis is a chronic condition without a cure. If you would have walked into a rheumatologist’s waiting room around 30 years ago, you would have seen many people with deformed joints, because that is what rheumatism does; it affects your joints due to inflammation caused by the immune system. Rheumatoid arthritis, or RA is is an autoimmune disease.
In recent years, fortunately, effective medical treatment for RA has improved significantly. By inhibiting or suppressing inflammation, these drugs affect the immune system. This results in less pain and less damage to the joints. Yet these medications do not solve everything. Many people with RA continue to suffer from pain and fatigue. In some people, the drugs are not effective enough and then there is a group for whom the drugs do work, but the side effects are actually worse than the disease.
There are more than 150 different rheumatic conditions. The three largest are osteoarthritis, gout and rheumatoid arthritis (RA), which differ greatly from one another.
Rheumatoid arthritis is an autoimmune disease that leads to inflammation in various joints.
Osteoarthritis is a disease in which cartilage is affected and the underlying bone thickens. It occurs everywhere, but especially in hands, hips and knees. The affected joints are sometimes also (somewhat) inflamed.
Gout is a more metabolic disease, in which uric acid (a breakdown product in the body) accumulates in the body as crystals. Inflammation can occur at these accumulation sites, most commonly at the big toe.
Fasting is effective for Rheumatoid arthritis
Before the development of ‘disease modifying anti-rheumatic drugs’ (DMARDs), people with RA tried everything. It was already known that when you stopped eating, the pain and inflammation decreased. This was also confirmed by severall studies. But of course, you can’t fast for the rest of your life! So a group of Norwegian researchers figured out that perhaps a plant-based diet after fasting could maintain the decreased disease activity. Plant-based foods, they figured, might be less inflammatory. The results of the study they subsequently conducted were impressive and were published in the Lancet.
The Norwegian researchers randomly divided 53 people with RA into an intervention and a control group. Both groups were admitted to a clinic for 4 weeks. The intervention group started with a week of fasting, after which they followed a plant-based diet. They adhered to the diet to the best of their abilities for up to a year. The control group followed a normal non-vegetarian diet during the same period. In the graph below you can see the differences between the groups. On all important outcomes such as pain, stiffness, swollen joints, but also objective blood markers for inflammation (e.g. ESR and C-reactive protein) the intervention group did significantly better.
The figures show the outcomes of the Norwegian study. The solid line is from the intervention group (fasting and then plant-based eating), the dashed line from the control group (average diet).
A plant-based diet is effective for rheumatoid arthritis
Why was nothing done with the results of this study? Why is it that most rheumatologists know nothing at all about this research? I think it is because of the power of the pharmaceutical industry. The pharmaceutical companies developed effective drugs and have a lot of financial power for drug development and marketing. Nutrition turned out to be not competitive enough.
Prof. Dr. Dirkjan van Schaardenburg thankfully dusted off the Norwegian research. Together we developed a new study: a randomized and controlled trial (a so-called RCT, see below) with which we wanted to test the effect of the Plants for Joints lifestyle program on disease activity in people with rheumatoid arthritis.
What is an RCT?
A randomized controlled trial (RCT) is a scientific study in which you randomly (i.e. based on chance) divide people into an intervention group and a control group. The subjects meet certain criteria, such as adult people with rheumatoid arthritis.
In an RCT, you test a hypothesis that often has to do with the effectiveness of a treatment. The evidence of an RCT valued more than that of a study without a control group.
A plant-based diet, physical activity and stress management for rheumatoid arthritis
We studied the effectiveness of the Plants for Joints lifestyle program in a group of 77 people with RA and 64 people with osteoarthritis combined with metabolic syndrome. Since these two groups are very different, we publish the results in two different scientific articles. The first article has now been published and can be found here. As soon as the second article on osteoarthritis is published, I will of course dedicate a new blog to it.
All 77 participants with RA received a normal treatment from their rheumatologist. This means that some people were on medication and some people were not. During the 4-month study, medication use was not changed. In the study, 40 people participated in the Plants for Joints program, while the remaining 37 participants in the controle group only received their regular treatment.
The Plants for Joints program
Plants for Joints is about:
- Healthy, unprocessed, plant-based foods and above all: tasty food (because otherwise it’s not sustainable).
- Sitting less and moving more.
- Sleep and rest better.
- Stress reduction and stress management.
The program starts with a cooking class and is followed by 9 more meetings, spread over 4 months, in groups of 6 to 12 participants. During the meetings the groups actively work on all lifestyle components.
The groups were guided by dieticians, exercise coaches and relaxation coaches. Where necessary, additional individual guidance was also provided.
In the first video you see some participants of the study. The other video features my colleague Carlijn Wagenaar (physician-researcher) and our supervisor Dirkjan van Schaardenburg, professor of rheumatology.
Participants (English subtitles)
Researchers (English subtitles)
Results Plants for Joints in rheumatoid arthritis
To measure the effect of Plants for Joints, the Disease Activity Score based on 28 joints (the DAS28) was used. This score is calculated from the number of painful and swollen joints, among other factors, and is the most commonly used measure world wide of disease activity in rheumatoid arthritis.
At baseline, the participants had a score of 3.8, which means that the arthritis was not very severe, but there were clearly severall symptoms. In fact, the objective of the treatment for RA is to get the score below 2.6, the treshold for ‘low disease activity’ or remission.
In the figure you can see that the intervention group, following the Plants for Joints program, very quickly showed a strong improvement, while the control group remained stable.
An additional benefit of a healthy lifestyle are the pleasant side effects. In fact, the participants who followed the Plants for Joints program also lost weight, which was mostly fat mass and especially abdominal fat. Furthermore, the ‘bad’ cholesterol (LDL) decreased and the HbA1c value, which is indicative for blood sugar levels over the past 3 months, also decreased.
The Plants for Joints lifestyle program is beneficial for people with rheumatoid arthritis. Together with my colleagues, we are therefore working on a plan to implement this lifestyle program in healthcare. First in The Netherlands, but of course we prefer to offer it to anyone with arthritis!
Do you want to start right now?
At this time, we are not yet able to offer the Plants for Joints program.
Do you have rheumatoid arthritis or osteoarthritis yourself and still want to make a move? Then I have a few tips below to get started today.
- Realize that every step is positive and that it doesn’t have to be perfect. In fact, one of the conclusions of our study was that even people who did not follow the lifestyle program perfectly really improved. The people who followed the program the best did not necessarily do better.
- Are you able to read Dutch? Then you can use my book Food Body Mind. I wrote this book in anticipation of the Plants for Joints study.
- For plant-based nutrition advice, check out the (Dutch) website ‘De Schijf for Life’ to which I also contributed.
- Do you prefer personal counseling? That’s possible! My waiting list is a bit long for now, this will hopefully change soon. However, you can also contact one of the dieticians who have collaborated on Plants for Joints, such as De Eetmevrouw or Diëtistenpraktijk Roots (they all speak English and are available for online consultations). And of course you can send me a message if you don’t mind waiting a while :-)
- Are you a health care provider yourself and want to do something with Plants for Joints? Then go to Plants for Health or become a member of the Physicians Association for Nutrition.
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- Walrabenstein W, van der Leeden M, Weijs P, et al. The effect of a multidisciplinary lifestyle program for patients with rheumatoid arthritis, an increased risk for rheumatoid arthritis or with metabolic syndrome-associated osteoarthritis: the “Plants for Joints” randomized controlled trial protocol. 2021;22(1):715. doi: 10.1186/s13063-021-05682-y.
- Kjeldsen-Kragh. Rheumatoid arthritis treated with vegetarian diets. Am J Clin Nutr. 1999;70:594S-600S. doi: 1093/ajcn/70.3.594s
- Walrabenstein W, Wagenaar CA, van der Leeden M, et al. A multidisciplinary lifestyle program for rheumatoid arthritis: the “Plants for Joints” randomized controlled trial. Rheumatology (Oxford). 2023; doi: 10.1093/rheumatology/keac693.