4 Questions About a Balanced Diet in Ankylosing Spondylitis

Chronic inflammation of the spine and the sacroiliac joints are common in ankylosing spondylitis (AS). Previous studies have assessed whether diet can impact manifestations of AS and reduce inflammation. However, whether a specific diet improves symptoms has not been well established due to the lack of research performed and completed.

Rheumatology Consultant caught up with Dana DiRenzo, MD, third year fellow in the division of rheumatology at Johns Hopkins Medicine, who discusses the role of a healthy diet in managing AS, which diet is most beneficial for patients, and more.

Rheumatology Consultant: What role does diet play in the management of rheumatic diseases?

Dana DiRenzo: The microbiome—the total collection of microorganisms, including bacteria, that inhabit the human body—has been recognized as a potential factor in the development of autoimmune disease.¹ Because of this, there is great interest in understanding whether the food we eat, which may affect the gut microbiome, can change the course of inflammatory diseases. While we do not know definitely what foods may be best for patient with AS, we do know that there is a general increased risk of cardiovascular disease. Therefore, a balanced heart-healthy diet is key.²

RHEUM CON: Are there any diets that are beneficial for the prevention of AS?

DD: A systematic review has recently been published ³ that assessed the relationship between diet and AS. Unfortunately, there was insufficient data and the studies were too mixed to make conclusions. However, we recommend a balanced diet with plenty of fruits and vegetables to our patients. Eating foods low in processed ingredients is also helpful. One such healthy diet is the Mediterranean diet which is rich in omega-3 fatty acids and has a small amount of evidence for benefit in those with rheumatoid arthritis.⁴ The Mediterranean diet entails high consumption of olive oil, cereals, fruits, vegetables, fish, and legumes. The diet has a minimal amount of red meats.

RHEUM CON: It has been suggested that a low starch diet can lead to lower AS disease activity. What role does diet play in the progression of AS? Are there any specific dietary interventions you would recommend to a patient to improve AS symptoms?

DD: There is inconclusive evidence that a low starch diet is associated with lower AS disease activity. The systematic review also noted that there was little evidence for eliminating dairy products or consuming fish/fish oil/or probiotics as ways to reduce susceptibility of AS or AS symptoms. In terms of the starch question, there were very few studies included—only 6—of which none of them were randomized controlled trials. The largest study was from 1998 and was a case series of 293 patients which looked at the consumption of food high in starch; foods high in starch include bread, pasta, rice, potatoes, beans, peas, pizza, quiches, and others.⁵ Their outcome measure of interest was the Bath Ankylosing Spondylitis Disease Activity Index and they found no association between the consumption of starch and disease activity.

So, the diet question comes up all the time. It is a great question but unfortunately, there have not been many rigorous studies completed to answer the question. Generally, maintaining a normal weight through diet and exercise is the most important thing you can recommend to a patient. Avoiding excess alcohol and smoking are also important.

RHEUM CON: What is the key takeaway for rheumatologists to know about diet in the management of AS?

DD: There is not one specific diet that a rheumatologist should be recommending to patients with AS. It is important for patients to maintain a balanced diet with limited processed ingredients, if possible. Eating plenty of fruits and vegetables is key.

References:

1. Manasson J and Scher JU. Spondyloarthritis and the microbiome: New insights from an ancient hypothesis. Curr. Rheumatol. Rep. 17:10 (2015). https://link.springer.com/article/10.1007%2Fs11926-014-0487-7.
2. Walsh JA, Song X, Kim G, Park Y. Evaluation of the comorbidity burden in patients with ankylosing spondylitis using a large US administrative claims data set. Clin. Rheumatol. 37:1869–1878 (2018). https://link.springer.com/article/10.1007%2Fs10067-018-4086-2.
3. Macfarlane TV, Abbood HM, Pathan E, Gordon K, et al. Relationship between diet and ankylosing spondylitis: A systematic review. Eur. J. Rheumatol. 5:45–52 (2018). https://www.eurjrheumatol.org/eng/makale/3069/213/Full-Text.
4. Tedeschi SK and Costenbader KH. Is there a role for diet in the therapy of rheumatoid arthritis? Curr. Rheumatol. Rep. 18:23 (2016). https://link.springer.com/article/10.1007%2Fs11926-016-0575-y.
5. Claudepierre P, Sibilia J, Roudot-Thoraval F, Filipo RM, et al. Factors linked to disease activity in a French cohort of patients with spondyloarthropathy. J. Rheumatol. 25:1927–31;(1998).