Having lived with both rheumatoid and osteoarthritis for over 30 years, I literally can say, “I feel your pain” when I meet with clients with similar conditions. Through trial and error, my disease has waxed and waned with the need for medication being less and less. A nutritious diet plays a big part in pain management.

A recent intervention study which included a plant-based diet, exercise, sleep, and stress reduction improved pain, stiffness and physicial function in people with knee and/or hip osteoarthritis (OA) and metabolic syndrome. In patients with rheumatoid arthritis (RA), medication use was reduced along with improvement in disease activity.

The study was recently presented at the European Alliance of Associations for Rheumatology (EULAR) 2024 Annual Meeting. Principle investigator Carlijn Wagenaar, MD, a PhD candidate in Clinical Immunology and Rheumatology at Amsterdam University Medical Center, Amsterdam, the Netherlands, presented 2-year extension study results for OA and RA and an overview of the possible biological mechanisms underpinning the plant-based intervention in RA.

Wagner noted, "At 2 years, RA patients on the PFJ [Plants for Joints] intervention resulted in a significant improvement in disease activity of RA, and these outcomes were maintained 2 years after program end".

"She continued, some initial improvements in body composition and metabolic outcomes were also maintained at the end of the 2-year extension phase, and there was a net decrease in antirheumatic medication use.”

Wagenaar noted that in patients with OA, the PFJ diet reduced pain, and stiffness, and improved physical function in those with knee and/or hip OA and metabolic syndrome. The impact was maintained in the 2-year extension study, and body composition changes persisted with a decrease in cholesterol-reducing medication. Acceptability of the program was also high with long-term maintenance and clinically relevant effects.

Significant Improvements in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Score Seen with Intervention

The OA randomized control trial included 64 subjects with hip and/or knee OA and metabolic syndrome. They were randomized to the PFJ intervention or usual care. The long-term effectiveness study included 62 subjects (including those in the previous control group). Of these, 44 had 2 years of follow-up data for evaluation. Twenty subjects dropped out.

"The PFJ program is a theoretical and practical program where people learn about and follow a whole food, plant-based diet, and receive advice on sleep and stress management and exercise," said Wagenaar.

The program ran for 16 weeks. Group sessions included 6 to 12 participants. A plant-based version of the Dutch dietary guidelines was used with a focus on unprocessed food. The plan did not have a calorie restriction and included whole grains, legumes, nuts, seeds, fruit, and vegetables. Participants were able to work with a dietitian one one-on-one. The Dutch exercise guidelines were utilized and are similar to those in the US with 150 minutes of moderate to intense exercise weekly and strength training twice per week being advised.

Twice-yearly visits and six adherence-promoting webinars were used per year in the 2-year follow-up study along with monthly newsletters. Changes in medication frequency were monitored between the start of the PFJ intervention and the stop of the 2-year extension study. These were grouped into medications for pain, and metabolic conditions including blood pressure, glucose, and cholesterol.

Subjects were advised not to make medication changes during the intervention phase but were allowed during the 2-year extension study, according to Wagenaar.

In the 16-week trial, subjects were an average age of 64 years, with 84% women, with a mean body mass index (BMI) of 33 kg/m2. Of them, 73% had knee OA, 78% had hip OA, and their mean WOMAC score was 38.2, suggesting moderate to severe OA.

In those who finished the 2-year extension study, the main outcome (WOMAC score for mean stiffness and physical function) showed a significant improvement compared with the start of the PFJ intervention.

"Looking at individual components of the WOMAC score — pain, stiffness, and physical function — we found these also all significantly improved at the end of the 2-year extension phase," reported Wagenaar.

Significant improvements in weight loss (from 94.9 to 92.1 kg), BMI (from 33.3 to 32 kg/m2), and waist circumference (from 110 to 106.7 cm) were also seen.

At the end of the trial and 1 year of the extension study, there were significant improvements seen in A1C, fasting blood glucose, and LDL cholesterol. At 2 years, these were no longer significant.

With medication use, Wagenaar reported that there was no net change in usage of pain, glucose-lowering, or blood pressure medications, but 44% of patients using cholesterol-lowering medications were able to reduce their dose or discontinue them.

For individuals with OA, the following may be helpful:

·         Start with Meatless Monday! Swap out traditional burgers with bean burgers or use lentils in place of beef in Bolognese sauce.

·         Use unprocessed red meat over processed meat. Unprocessed meat is a source of glutamine, which may have anti-inflammatory properties. 2

·         Reduce sugary beverages to cut calories and aid in weight reduction.

·         Cut back on high-fat desserts, fast food, and ultra-processed food, which has been linked with OA of the knee. 3

·         Include plenty of fruits and vegetables at meals and snacks for antioxidants, which may reduce inflammation. 4

·         Include whole grains over refined grains for more fiber, which aids in weight loss and blood sugar management.

·         Provide individual diet and exercise counseling to patients with OA to aid with weight loss and mobility. 5

·         Pay attention to hunger over habit when trying to manage calorie intake for weight loss.

·         Find an exercise you enjoy to keep your joints happy. Water classes at a local recreation center may be available and affordable.

Lisa Andrews, MEd, RD, LD

References:

1.   https://ard.bmj.com/content/83/Suppl_1/118

2.   Wood AC, Graca G, Gadgil M, Senn MK, Allison MA, Tzoulaki I, Greenland P, Ebbels T, Elliott P, Goodarzi MO, Tracy R, Rotter JI, Herrington D. Untargeted metabolomic analysis investigating links between unprocessed red meat intake and markers of inflammation. Am J Clin Nutr. 2023 Nov;118(5):989-999. doi: 10.1016/j.ajcnut.2023.08.018. Epub 2023 Sep 1. PMID: 37660929; PMCID: PMC10797554.

3.   Wei Y, Zhang T, Liu Y, Liu H, Zhou Y, Su J, Chen L, Bai L, Xia Y. Ultra-processed food consumption, genetic susceptibility, and the risk of hip/knee osteoarthritis. Clin Nutr. 2024 Jun;43(6):1363-1371. doi: 10.1016/j.clnu.2024.04.030. Epub 2024 Apr 22. PMID: 38678821.

4.   Wei N, Dai Z. The Role of Nutrition in Osteoarthritis: A Literature Review. Clin Geriatr Med. 2022 May;38(2):303-322. doi: 10.1016/j.cger.2021.11.006. PMID: 35410682.

5.   Marriott KA, Birmingham TB. Fundamentals of osteoarthritis. Rehabilitation: Exercise, diet, biomechanics, and physical therapist-delivered interventions. Osteoarthritis Cartilage. 2023 Oct;31(10):1312-1326. doi: 10.1016/j.joca.2023.06.011. Epub 2023 Jul 7. PMID: 37423596.