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Healthy eating and arthritis ARTHRITIS CARE Healthy eating devised with and for people with arthritis

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Healthyeatingand

arthritis

ARTHRITIS CARE Healthy eating

devised with and for people with arthritis

Eating a balanced diet and maintaining a healthy weight canhave a huge impact on your overall wellbeing and yourarthritis. As well as ensuring that your body has all theessential nutrients to function, eating healthily may helpreduce the symptoms of arthritis both directly and byreducing the stress on your joints through weight loss. Ifyou are underweight, a balanced diet should help youovercome exhaustion and gain healthy weight.

The aim of this booklet is to explain what makes up ahealthy diet and what particular foods, if any, might beparticularly beneficial or bad for people with arthritis.

Contents

A healthy lifestyle 1Why a healthy diet is important for people with arthritis

What makes up a healthy diet 5The essential nutrients, food groups

How to maintain a healthy diet 12Shopping for food, cooking, staying healthy

Interaction between food and arthritis 17Important nutrients, particular foods that could help, food myths

Supplements 25The facts about popular supplements

Other sources of help 33Dietitians and nutritionists, weight loss groups

All people pictured on the cover and quoted in this booklet have arthritis.

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A HEALTHY LIFESTYLE

It is important to maintain ahealthy lifestyle when you havearthritis to stay in good healthgenerally, and to help manageyour arthritis and to stop itgetting worse. By eating a varieddiet and taking enough exercise,you should be able to enjoy ahealthy lifestyle.

Why is a healthy dietimportant for peoplewith arthritis?A varied diet is essential toprovide the right balance ofnutrients our bodies need forday-to-day functions. Following ahealthy diet might also reducethe amount of arthritismedications you need to takeand their side effects.

‘I would like to loseweight to reduce thestress on my joints’There is a lot of confusing andconflicting information on dietand arthritis, and whether or notparticular foods are helpful orharmful. Although certain foodsmight have more of an effect onyour arthritis than others, the

most important thing is to have abalanced diet to ensure you getall the nutrients your bodyneeds. The basic idea is to eatless fat, less sugar, more fruit andvegetables, more oily fish andplenty of calcium and iron-richfoods.

You will probably find thateveryone wants to give youadvice on what to eat and whatnot to eat. Remember thateveryone reacts differently tospecific foods and that you haveto work out for yourself whatsuits you best.

Controlling your weightCarrying excess weight is acommon problem for peoplewith arthritis. Certain drugs,such as steroids, can lead toweight gain, and others, such asnon-steroidal anti-inflammatories(NSAIDs), can lead to stomachproblems, making dietarychoices harder. Some peoplemay find that being unable toexercise or prepare fresh foodmeans that they put on weighteasily. Others get trapped in asimilar cycle during a flare-up,but one in which they are too

tired to eat and consequentlylose weight, becoming evenmore exhausted.

Eating a balanced diet is key tomaintaining a healthy weight.Controlling your weight is oftenthe most effective thing you cando to reduce the symptoms ofarthritis. Even a small weight losscan reduce strain on the hips,back, knees and feet if you aretoo heavy. And making sure youare not underweight should helpto give your body the necessarystrength and nutrition to getthrough a flare-up and to fightdisease.

For ideas on how to getactive read ArthritisCare’s booklet onexercise.

A healthy body weightA healthy bodyweight is achievedby balancing theenergy intake inour diet withthe energywe usethroughactivity. However,every individual hasunique nutritionalrequirements,

depending on your age, gender,body size and level of activity. Aguideline daily intake is 2,000kilocalories (known as kcal) foran active woman and 2,500kilocalories for an active man.Therefore, for people witharthritis who are unable toexercise, the only way to loseweight is to eat fewer calories. Itis important to choose thecalories you do eat carefully toensure that you still have anadequate supply of vitamins andminerals in your diet.

If you need to gain weight,eating slightly larger quantities

of the healthier foods is thebest approach so that youare taking in more calories.

Rather than simply eatingmore fried foods and

chocolate (which won’thelp your overall

health in the longrun), try thingssuch as having anextra slice oftoast atbreakfast, or anextra helping ofpasta or rice.

Althoughexercise burns

calories, if you can,

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include some form of activity tokeep your bones as strong andyour muscles as toned aspossible.

‘I can’t exercise really,so the only way tocontrol my weight is toeat really healthily’Lots of foods, particularlyprocessed foods, contain hiddenfat, sugar and salt. Preparingyour own food allows you tocontrol what you are eating. Ifyou have difficulties cookingfrom scratch but need to lose

weight, choose the low fatversions of ready meals from thesupermarket, checking thecalorie and salt content on theback of the packaging. For moreideas see ‘How to maintain ahealthy diet’ further on.

Doctors use the body massindex (BMI) to tell if your weightis within a healthy range. This isyour weight (in kilograms)divided by your height squared(in metres squared). People areclassed as underweight if theyhave a BMI of 18.5 or under,overweight if their BMI is 25-30and obese if it is over 30. You

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BODY MASS INDEX CHART

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canrefer tothe chart belowto work out your BMI.

The BMI does not take yourbody composition into account –if you have well-defined muscles,but low levels of body fat, youmay appear as obese on thechart.

‘The heavier you are the worse yourarthritis is’Therefore, doctors sometimesalso use waist circumferencemeasurements to decidewhether people are of a healthyweight. People with a waistcircumference of more than80cm/32 inches (women) and 94 cm/37 inches (men) are

considered to be at increasedrisk of health problems.

You should always consultyour doctor or nurse

before starting aweight lossprogrammeas it isimportant tolose weightin thecorrect way– crash dietscan harm

your body.The British

Dietetic Association’sweight wise website has someuseful tips on how to lose weight(www.bdaweightwise.com).

It is possible to maintain ahealthy body weight and stillenjoy your food. This bookletwill tell you about some of thehealthier options, but theoccasional treat or rich mealshouldn’t hurt. It is all aboutbalance.

WHAT MAKES UP A HEALTHY DIET?

Eating a healthy diet is aboutgetting a variety of food fromdifferent food groups.

In general, a healthy diet isone that is:● high in fruit and vegetables● high in starch and fibre● low in fatty foods and salt● low in added sugars.A balanced diet contains carbo-hydrates, protein, fat, vitaminsand minerals, and fibre. Carbo-hydrates provide us with energy.Protein is essential for growthand repair of the body. Vitaminsand minerals play a major part in

the healthy functioning of ourbodies. Although it is healthy notto consume too much fat, ourbodies do need some fat. Itprovides us with energy and alsohelps us to absorb certainvitamins. Fibre helps with bowelhealth (especially important forthose who have slower bowelmovements as a result of notbeing able to exercise or takingcertain medications).

Food groupsThere are five main food groups.The diagram below shows the

Bread, cerealsand potatoes

Milk and dairy foods

Fruit and vegetables

Meat, fish andalternatives

Foods containing fat,and food and drinkscontaining sugar

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proportion of your diet theyshould make up. You do notneed to have this balance atevery meal, but you should aimto achieve this over the day orthe week.

Breads, cereals and potatoesStarchy foods should be themain part of most meals andsnacks as they are the healthiestsource of energy. These include:● bread● pasta● noodles● rice● couscous● cereals● potatoes.

‘We eat a lot of fruitand vegetables and Icook everything fromscratch’These foods also providevitamins, minerals and fibre.They are not usually high incalories unless you add sugars orfats to them. Some cerealsalready contain added salt andsugar, so check the back ofcereal packets carefully beforepurchasing.

Whenever possible, instead of

white rice, pasta and bread, usebrown (or wholemeal orwholegrain) varieties as theseprovide energy for longer, arehigher in fibre and providevitamins and minerals.

Fruits and vegetablesFruits and vegetables shouldmake up a third of our diets asthey provide a wide range ofvitamins, minerals and fibre.They are also low in fat.

Eating fruits and vegetablesalso provides us with antioxi-dants. These are substanceswhich reduce inflammation andcan help protect joints. Brightlycoloured fruits and vegetablesare highest in antioxidants andother protective substances andinclude:● apples● oranges● cherries● blueberries● spinach● beetroot● broccoli.It is recommended thateveryone eats at least fiveportions of different types offruits and vegetables a day to geta sufficient range of vitamins andminerals. Frozen vegetables

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contain similar, or higher, levelsof vitamins as fresh producebecause they are frozen shortlyafter being picked. Canned anddried vegetables and fruit juicealso count.

Potatoes, yam and cassava areconsidered starchy foods ratherthan vegetables, but there is awhole host of other excitingchoices. Eating fruits andvegetables is the ideal way to behealthy as you can eat lots moreof them than other types of foodbecause they are low in calories.

‘We don’t have readymeals or processedfood. Homemade soupsare very easy to make’As a general rule, one portion offruit or vegetables is equivalentto 80g (approximately onehandful or one medium sizedpiece of fruit or vegetable) or150ml of fruit juice. As a rough

guide, the following constitute aportion:● one apple, banana, orange,

large tomato or onion● two plums● half a grapefruit, avocado or

pepper● one slice of a large fruit such

as pineapple or melon● three heaped tablespoons of

fresh fruit salad● one glass of fruit juice● one heaped tablespoon of

dried fruit● one handful of grapes, cherries

or berries● a dessert bowl of salad● three heaped tablespoons of

vegetables, beans or pulses● two large broccoli florets.It should not be hard to includefive portions of fruit andvegetables into your daily diet.Try the following:● have a fruit juice or fruit

smoothie with your breakfast● keep a sandwich bag with

dried fruit in your bag or atyour desk

● dip carrot or celery sticks intohummus as a snack

● serve vegetables as a side dishwith your dinner

● finish your meal with a fruit salad.

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If you do not like thetaste of vegetables oryour family are fussyeaters, you could trysome of the followingideas:● blend some tomatoes,

onions, mushrooms andpeppers to make a pasta sauce

● add swede or peas to potatofor some interestinglycoloured mash

● a vegetable soup ● brightly coloured courgettes,

aubergines, red and yellowpeppers combined asvegetable kebabs

● sauté some tomatoes, onionsand peppers and fill up tortillasto make fajitas.

Meat, fish and alternativesMeat, poultry, fish, eggs, nutsand pulses (such as beans,chickpeas and lentils) are allincluded in this group, whichshould be eaten two to threetimes a day. These foods are arich source of protein, vitaminsand minerals, especially iron andzinc. Meat, however, should onlybe eaten in moderation since it isrich in harmful fats.

Vegetarians should be awarethat the iron found in meat is

moreeasily absorbed by the body thaniron from plant sources. VitaminC found in citrus fruits, tomatoesand leafy vegetables helpsimprove the absorption of ironfrom vegetables and cereals.

Fortified breakfast cereals,chickpeas, spinach, baked beansand muesli are all useful sourcesof iron (for more information,see page 19). Soya products area good source of protein forvegetarians and vegans. As wellas being a good source ofprotein, peas, beans and lentilsare also a good source of fibre.

‘We eat a lot of oilyfish, I know it’s goodfor arthritis’Oily fish, such as fresh salmon,mackerel, sardines, pilchards andanchovies contain very healthyfat which can protect against

heart disease and reduce thesymptoms of arthritis (See‘Omega-3 fats’ on page 17-18).

Milk and dairy foodsIt is recommended that we eatthree servings a day from thisgroup as it is the richest sourceof calcium in the diet and isimportant for healthy bones andstrong teeth. A pot of yoghurt, a glass of milk or a small piece of cheese counts as a serving.This group is also a good sourceof protein and vitamins B12, A and D.

Adults should try to select thelow-fat versions of theseproducts, such as semi-skimmedor skimmed milk, which containjust as much calcium, proteinand B vitamins. Children shouldhave whole milk to ensure anadequate supply of energy andfat-soluble vitamins.

Foods and drinks in this groupinclude:● milk and milkshakes● cheese (hard cheese, cottage

cheese, fromage frais)● yoghurt.

Fatty and sugary foodsThese foods provide energyalthough they contain few

nutrients and can be harmful inlarge quantities. Sugar can rotyour teeth and fat can clog yourarteries. There are twice asmany calories in fat as in proteinor carbohydrate. Foods in thisgroup include butter, chocolate,fizzy drinks and squashes.

‘A Jamaican friend ofmine taught me a greatrecipe. You cook asalmon fillet on agriddle with someginger and garlic andyou don’t even need touse oil’Saturated fats and trans fatsincrease cholesterol levels and,therefore, increase the risk ofheart disease. In addition, thereis some evidence that they mightworsen the symptoms ofarthritis. Foods containing thesefats include:● meat products and meat pies ● hard cheese● butter, lard and ghee● pastry● cakes and biscuits● cream.Oils and margarines made fromcorn or sunflower sources arerich in omega-6 polyunsaturates

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which increase inflammation inthe body (not to be confusedwith omega-3 polyunsaturates,which have a beneficial effect).Therefore, these fats should beeaten in moderation.

Omega-3 polyunsaturated fatsdo not raise cholesterol levels –in fact they can reducecholesterol and we should beeating more of these. As well asprotecting against heart disease,omega-3 fats reduce inflamma-tion. The main source of

omega-3 fats is oily fish (see‘Interaction between food andarthritis’ further on).

Monounsaturated fats can befound in olive oil and rapeseedoil, and do not increase ordecrease inflammation.

Here are some tips to helpyou reduce your intake ofharmful fats:● use olive oil, flaxseed oil or

rapeseed oil instead of butter,lard, sunflower oil or ghee

● snack on a handful of unsalted

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nuts and dried fruit instead ofbiscuits

● make mashed potato witholive oil and garlic instead ofbutter

● choose spreads high inmonounsaturates or skipcompletely in sandwiches

● buy lean cuts of meat and trimoff visible fat

● add more vegetables andbeans, and less meat to stews

● use yoghurt or fromage fraisinstead of cream in recipes.

‘Eating lots of fruitand vegetables cleansesyour system. I feelmuch better’Be aware that a lot of foodsmarketed as low fat actuallycontain very high quantities ofsugar or salt to make up theflavour. Trans fats (sometimescalled ‘hydrogenated fats’) donot have to be labelled, so don’teat lots of of cakes and pastryproducts.

WaterEnsure that your body is fullyhydrated by drinking enoughwater. You should be drinkingabout six to eight glasses (1.2

litres) of water, tea, coffee, milk or fruit juices a day.

Choose a variety of drinks toget the health benefits of each,but drink tea and coffee inmoderation because theycontain caffeine.

Remember to drink morefluids when it is hot or if you areexercising as you will lose morewater naturally through sweat.

SaltIt is important to limit yourintake of salt (also known assodium chloride) to a maximumof 6g a day. This is because ahigh salt intake can cause highblood pressure, which is hard todetect and is very serious.

Check processed foodscarefully for their salt or sodiumcontent. Don’t forget to countany salt you add to food at thetable when calculating yourintake.

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Eating healthily does notnecessarily mean more effort ormore money. In fact, it may evenwork out to be cheaper.Processed foods are usuallymore expensive than fresh fruitand vegetables.

‘I always make two orthree times the quantityof food. It makes it somuch easier if I’m notfeeling great’Preparing fresh food does nothave to mean hours in thekitchen. Some careful planning,in the shops and the kitchen, canmake the transition to ahealthier lifestyle much easier.

Organising yourselfHere are some tips to makecooking and shopping easier –and cheaper.● Plan your weekly meals in

advance so you can make sureyou have the ingredients youneed.

● If you cannot get out to theshops, you could either ask afamily member or friend to dothe occasional shop for you,

do your shopping over theinternet, or perhaps even buyhealthy ready meals from acompany that will deliver.

● Buy larger versions ofproducts (such as bread) inthe shops and freeze what youdo not want to use straightaway.

● Buy frozen vegetables – theyare cheaper, easier to use (asno chopping is involved) andquite often contain morevitamins.

● Canned fruits, vegetables andpulses can be a useful standby.

● Buy pre-chopped freshvegetables and salads, butremember that cut vegetableslose their nutrients veryquickly and that this might notbe the cheapest option.

● Get lots of cooking done inadvance, and store food in thefreezer for when you mightnot be feeling so well.

Organising your kitchenThere are many things that youcan do in the kitchen to ease thestrain on your joints, including:● using lightweight pans, mugs

and kettles

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HOW TO MAINTAIN A HEALTHY DIET

● using large handled and sharpknives

● using an electric tin opener● rearranging cupboards so the

things you use the most arewithin easy reach

● sliding items along a worksurface rather than lifting them

● fitting devices to turn the tapsmore easily

● using a perching stool to sit onwhilst you are preparing food.

You will find lots of usefulgadgets in specialist shops, orthey may be cheaper in yourlocal supermarket. You might beable to get some help adapting

your kitchen or findingequipment through an occupa-tional therapist. See ArthritisCare’s booklet on independentliving for more information andlabour-saving ideas.

‘I don’t like readymeals because they’rehigh in fat and younever really know whatgoes into them’Staying healthyBuying healthy ingredients is thefirst step. The method of

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cooking that you choose canaffect the nutritional value ofyour meals greatly.

Cooking methodsCooking methods such asgrilling, baking, poaching orsteaming are healthier thanfrying or roasting as you do notneed to add extra fat. Steamingor gently boiling vegetables withthe lid on means that morenutrients are retained.Overcooking food destroys itsvitamin and mineral content.Microwaving vegetables avoidshaving to lift heavy pans of water,but be careful not to overcook.

‘Internet shopping isan absolute boon forme. I don’t have toworry about luggingheavy shopping bagsaround’Fruit and vegetables lose theirvitamin and mineral contentquickly so it is best to eat themsoon after you buy them.

Portion sizesEating regularly helps ensure youeat a balanced diet. This mightnot always be practical, but

some of the following tips mighthelp you to control how muchyou eat.● Drink a glass of water before

eating to fill your stomach.● Put less on your plate and eat

off a smaller plate.● If you eat slowly, you will feel

full faster. ● Fill up your plate with

vegetables or salad.● Set aside leftovers in a

container to be frozen● The diagram on page 5 shows

what proportion of each foodgroup you should have onyour plate.

Eating outEating healthily when you areout and about can sometimes bea challenge as you will not alwaysknow how the food has beenprepared and what it contains.

If you are making or buying asandwich at lunchtime, choosewholemeal or brown breadinstead of white bread. Skip thebutter and mayonnaise in yoursandwich – after a while you willnot notice the difference. Leanmeats, such as ham, beef, turkey,chicken without the skin, arelow-fat sandwich fillings. Manyhard cheeses such as Cheddar

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are high in fat, whereas softercheeses such as Edam andEmmental contain less fat (notethat cheese spreads can be highin fat). Baked potatoes areanother good lunchtime choice,minus the butter. Healthy fillingsinclude baked beans or cottagecheese. Ready-mixed fillings cancontain a lot of fat because theyare often made with mayonnaise.

‘I always look at thelabels on food and findthem quite easy tounderstand’Salads can be filling and tasty ifyou include some starch, such asrice, pasta or couscous. Youcould also add some cold meat,cheese, roasted vegetables andbeans.

With some careful choices,eating out can be relativelyhealthy. If you know you will beeating out later, it makes senseto plan lighter meals throughoutthe day, but do not skip meals asyou will overeat to compensate.In general, it is healthier to avoidfried, creamy or cheesy foods inrestaurants. You could opt forgrilled foods, pastas with tomatosauces and salds without

dressing instead. However,eating richer foods occasionallyis nothing to feel guilty about.

Some recipe ideas

Orange salmon baked in foilThis dish is packed with omega-3 fats and vitamin C. Serve withsome ginger stir-fried spinach totop up your iron. Ginger isthought to have anti-inflamma-tory properties. A serving ofbrown rice will provide fibre andkeep you full for longer.● Lay a salmon fillet on some

lightly oiled kitchen foil. ● Add some orange slices,

seasoning and parsley. ● Seal the foil tightly and bake in

a hot oven for 20-40 minutesdepending on the thickness ofthe fillet.

Sweet potato and lentil pieIn this dish the lentils provideprotein, iron and fibre. A sidehelping of garlic stir-fried kalewould also provide iron andcalcium. Sweet potatoes containmore vitamin A and fibre thanregular potatoes. ● Wash, then boil brown lentils

with a vegetable stock cubefor 20-30 minutes until tender.

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● Boil four large sweet potatoes,peel and mash.

● Heat a little rapeseed oil in apan, fry some red onion,tomato and red peppers. Addthe lentils and seasoning.

● Pour the lentil mixture into adish and top with the mashedsweet potato, and bake in theoven for about 20 minutes.

‘When I go out, Ichoose drier curries, orones with tomatobased sauces instead ofcreamy ones, which Inow really enjoy’Peanut chicken and vegetable stir-fryYou can use any combination ofvegetables, meat, fish, or tofuwith this dish. Peanut buttercontains folic acid, but it isfattening, so only use sparingly.Serve with brown rice for aneven healthier meal.● To make the peanut sauce,

combine a tablespoon ofpeanut butter, a tablespoon ofsweet chilli sauce and a dashof soy sauce.

● Heat a tablespoon of olive oil in a large pan or wok. Add onion and sliced chicken

or tofu and cook for about five minutes.

● Add your choice of vegetables,(chopped up small).

● Add the peanut sauce and a little water and cook thevegetables for five minutes.

Vegetable curryVegetables are packed full ofvitamins and minerals. Turmericand chilli powder are thought tohave anti-inflammatoryproperties. Instead of freshspices you can buy a jar of currypaste and combine twotablespoons with water to makea sauce.● Fry an onion and a clove of

garlic in a little olive oil fortwo minutes before addingsome fresh chopped tomatoes(or a can of tomatoes).

● Add a teaspoon of turmericpowder, then chilli powderand black pepper.

● Add the vegetables – choosefrom boiled potatoes, greenbeans, peas, sweetcorn andcarrots – with some hotwater, and allow to cook forabout 10 minutes.

● Add some fresh coriander andserve with rice.

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Although there has been a lot ofresearch into the link betweendiet and arthritis, there is nodefinite connection betweenfood and flare-ups. However, itis thought that certain foods canhelp reduce pain and inflamma-tion, and slow the progressionof arthritis.

Most of these foods form partof a healthy, well-balanced dietand are known to reduce therisk of other diseases, such asosteoporosis and heart disease.The risk of developing theseconditions is increased in somepeople with arthritis – anotherreason to follow a balanced diet.

‘I know that grapefruitjuice can interfere withsome medication forarthritis, but I don’treally like it anyway’There is growing evidence that aMediterranean diet is good forarthritis. This means moderateconsumption of lean meat,choosing monounsaturated fatsover saturated fats (see pages 9-10), and eating plenty of fresh

fish and lots of fruits andvegetables.

It is important to consult yourdoctor or a dietitian beforemaking any major changes, suchas excluding food groups fromyour diet.

People who take steroids for a long period of time can develop osteoporosis,therefore it is important thatyou make sure there is enough calcium in your diet.People taking immunosuppres-sant drugs should avoidunpasteurised milk and cheese,and uncooked meats (forexample, in pâté) because these foods increase the risk offood poisoning.

Omega-3 fatsThere is evidence thatsubstances called essential fattyacids (EFAs) in certain oils in thediet can help some people witharthritis. There are two types ofEFAs: omega-3 fats found mainlyin oily fish and some plant seedoils and nuts, and omega-6 fatsfound in corn, soybean andsunflower oils.

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INTERACTION BETWEEN FOOD AND ARTHRITIS

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There is growing evidence tosuggest that omega-3 polyunsat-urated fatty acids can helppeople with inflammatoryarthritis. You should eat agreater amount of omega-3 fatsas too much omega-6 canincrease inflammation in thebody. Most people probablyhave enough omega-6 fats intheir diet already as these arefound in saturated fats (such asmeat products and cheese).

Omega-3 fats can be obtainedthrough your diet, but manypeople with arthritis also takesupplements as quite a largedose is needed to be effective(see ‘Supplements’). Omega-3 fats are found in:● oily fish● avocados● nuts and seeds● vegetable (rapeseed) oil.The best source in the diet is oilyfish, such as salmon, sardines,herring, mackerel and trout, orfresh tuna. You should try to eatoily fish twice a week. As oilyfish can contain low levels ofpollutants, the Food StandardsAgency recommends that girlsand women who are pregnant,planning to have a baby one dayor breastfeeding eat no more

than two portions a week.Other women and men areadvised to eat no more than fourportions each week.

If you have gout, limiting yourintake of oily fish may help asthey are rich in purines –substances which are thought toaggravate gout. Flaxseeds are agood source of omega-3 fats forvegetarians and vegans.

‘I have cut out wheat,gluten, dairy, red meatand fatty foods, andfeel a lot better’Omega-3 fats can lead to theproduction of harmfulsubstances called free radicals.To combat this, it is important toconsume these fats incombination with plenty ofantioxidants (found in brightlycoloured fruits and vegetables)and vitamin E (found in nuts,seeds, sweet potatoes andavocados).

CalciumPeople with rheumatoid arthritisare at increased risk ofdeveloping osteoporosis, soensuring an adequate calciumintake is very important.

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Foods rich in calcium include:● sardines and whitebait (the

bones contain the calcium)● milk, yoghurt and cheese● white, brown or wholemeal

bread● green leafy vegetables, such as

kale, cabbage and okra (butnot spinach)

● calcium-enriched soyaproducts

● sesame seeds.Vitamin D is also needed for thebody to absorb calcium. Themain source of vitamin D is fromsunlight on our skin, but it is alsofound in oily fish. Certain groupsof people might not be able touse sunlight as a source ofvitamin D and should considertaking a vitamin D supplement.This includes people who areunable to get outside, Asianwomen, and those who covertheir skin.

IronFatigue is a very commonsymptom of rheumatoid arthritisand can be made worse byanaemia (a deficiency of redblood cells). Anaemia candevelop as a result of inflamma-tion or because of the long-termuse of NSAIDs, which can lead

to loss of blood in the stomach.Also, some people do not getenough iron in their diet. Iron-rich foods which can help tacklethis include:● red meat ● darker coloured fish● eggs● green leafy vegetables● pulses● fortified breakfast cereals.

‘Having sought advice,I now avoid certainfoods, which has had asignificant impact onmy life’Iron is more easily absorbed byyour body if you have it at thesame time as vitamin C, so havea portion of fruit or vegetableswith your meal. However,drinking tea with or straight afteryour meal inhibits the absorptionof iron.

Particular foods thatcould help people witharthritisThis at-a-glance list of foodsmight help people with arthritisto manage their symptoms.There is evidence that thesefoods will help people with

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inflammatory arthritis ratherthan osteoarthritis. It isimportant to bear in mind thateach individual will reactdifferently to specific foods.

Apples contain magnesium,which is thought to decrease thepain of fibromyalgia.

‘People tell me not toeat tomatoes, I thinkthat’s a load of rubbish’Berries (blueberries, blackber-ries, blackcurrants, cranberries,raspberries and strawberries)contain antioxidants that canreduce inflammation. They alsocontain fibre, folic acid,magnesium, potassium andvitamin C.

People taking methotrexateare often given folic acidsupplements as methotrexateinterferes with the action of folicacid in the body. Folic acid isneeded to make new cells. Soberries will be of benefit as well.

Try making a mixed berrysmoothie – a filling and tastydrink – or add a handful ofberries to your breakfast cereal.The vitamin C content of berrieswill mean that you increase the

amount of iron you absorb fromyour cereal as well.Cherries might have a role indecreasing inflammation andpain. They contain fibre, andvitamins A and C.

Try cherries mixed with plainyoghurt for a mid-morningsnack. Citrus fruits (oranges, lemons,limes, kiwis, grapefruit) are richin vitamin C, which might helpprotect against developinginflammatory arthritis. They alsocontain fibre, folic acid,magnesium and potassium. Grapefruit (or grapefruit juice)may interfere with the action ofsome disease-modifying anti-rheumatic drugs (such asciclosporin) and some othermedications, although yourdoctor should tell you about thisrisk if it is relevant to you. Having a glass of orange juice

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with meals will help theabsorption of iron. Nuts contain omega-3 fats,which help ease stiffness andreduce inflammation. Pecans,walnuts and hazelnuts are high inantioxidants. Brazil nuts are alsohigh in selenium, which isthought to limit the damage thatoccurs in arthritis and is animmune system booster.

Carry a bag of unsalted nutswith you and snack on theseinstead of crisps and biscuits.Nuts are high in fat, so eat themin moderation.

‘What works for oneperson might not workfor another – we are alldifferent’Cruciferous vegetables (broccoli,cauliflower, cabbage and Brusselssprouts) are good for the heart.People with rheumatoid arthritisare at increased risk ofdeveloping heart disease soeating sufficient quantities ofthese vegetables is important.This group of vegetables alsocontains fibre, folic acid, andvitamins A, C and K.

Fibre is important for healthyintestines. Some arthritis

medications, such as NSAIDs andpainkillers, can cause constipa-tion. Eating more fibre will meanyou are less likely to feelconstipated.

Try serving broccoli withsalmon for a tasty and healthymeal.Leafy green vegetables (kale,mustard greens, Swiss chard andokra) are a good choice as theycontain calcium. Thesevegetables are iron rich, and arealso good for the heart.

Toss some kale in a pan with alittle rapeseed oil and garlic for acouple of minutes for an easyside dish. Milk, cheese and yoghurt arehigh in calcium, which isimportant for healthy bones.Dairy products are also high in folic acid, magnesium, andvitamins.

Choose skimmed or low-fatversions of these products toavoid eating too many saturated

fats, which could increaseinflammation.Oily fish contains oils that helpfight inflammation, joint pain andstiffness. See the section onomega-3 fats on page 10 formore information. Peas, beans and lentils are agood source of iron, which isimportant in helping to preventanaemia. These foods alsocontain fibre, folic acid and otherminerals.

Try adding beans and pulses(mixed with a little rapeseed oiland some fresh herbs) to yoursalads to make them moreinteresting. Whole grains (wholewheat andbrown rice) contain magnesium,which is important for healthybones. This group is also high infibre.

‘In the past when I ateoranges it reallyaffected my joints. Butnow I can eat them’ Claims about foodsAlthough it might be helpful toeat certain foods in moderationif you have arthritis, there arelots of myths circulating for

which there is little or noevidence. It is important not toexclude any foods completelywithout consulting your doctorfirst as you may be missing outon essential nutrients. Youshould also bear in mind thateveryone will react differently tovarious foods.

A popular myth is that cuttingout acidic fruits (oranges, lemonsand grapefruit) or nightshadevegetables (potatoes, tomatoes,peppers and aubergines) willreduce the symptoms ofarthritis, but there is no satisfac-tory medical evidence tosupport this. In fact, these foodsare nutrient rich and low incalories. Some people even goso far as to claim that eliminatingthese foods will cure arthritis.This is not true.

Another false claim thatpeople make is that dairyproducts cause arthritis. Again,there is no evidence to supportthis.

Some people believe thatcider vinegar and honey will helpor cure arthritis. There is noscientific evidence to back thisclaim.

Red meat has been linked tothe development of rheumatoid

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arthritis and heart disease.However, red meat containsiron, magnesium, potassium andprotein, so think carefully whereelse in your diet you will getthese essential nutrients beforedeciding to exclude red meat.Choosing lean versions of redmeat will limit your intake ofinflammatory saturated fats.

‘I’ve never reallyexperienced foodintolerance apart fromrhubarb. If I eat it myjoints become verypainful’If you have gout, there isevidence to suggest that alcohol,liver and kidney, tinned fish andshellfish can all worsensymptoms.

Food allergy and intoleranceSome people with inflammatoryarthritis believe that they mightbe allergic to certain foods whichcause their arthritis to flare. Thiscould be the case, but manypeople also mistake food intoler-ance for food allergy.

A food allergy is a promptreaction to food (even tiny

amounts) by the immune system.Symptoms can include swellingof the lips, mouth and tongue,and a rash over the body.

If you have a less instanta-neous reaction to food, whichmakes it harder to pin down thefood that caused the reaction,this is likely to be a food intoler-ance. Symptoms include nausea,bloating, diarrhoea, vomiting orskin rashes. The only scientificway of telling if you do have anintolerance to a food is by anelimination diet process.

Elimination and otherspecial dietsAn elimination diet involvesexcluding a certain food/foodsfrom your diet for about amonth, before re-introducingit/them to see if this causes areaction. This may work forsome people with inflammatoryarthritis but it will not be effec-tive for those with osteoarthritis.

These diets should only beundertaken after consultationwith your doctor or a dietitian asit is important to ensure that youare not missing out on essentialnutrients by excluding a particu-lar food. You will usually beasked to keep a food diary for a

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couple of weeks, and to classifyyour pain and symptoms on ascale to assess with your health-care professional whether a particular food is having an effecton your arthritis.

Most people cut out foodssuch as wheat or dairy products.It is important to ensure that youcut out the particular food completely – this is sometimesdifficult as many products contain hidden wheat or dairy(for example, sausages containwheat).

Some people with arthritis say that fasting makes them feel better. However, fasting isnot advised as, although it might make you feel better, you can only fast for a short period of time.

Others have found a vegan orvegetarian diet helpful, but if youexclude animal products fromyour diet it is important to ensureyou get enough iron, protein

and B vitaminselsewhere inyour diet.

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A healthy diet should contain allthe nutrients, vitamins, andminerals needed by the body.Supplements, as their namesuggests, should only be used tosupplement a healthy diet.

People taking supplementsshould be careful not toconsume massive doses ofvitamins, such as vitamin C(which may prove inflammatoryin doses above 1,000mg a day).Consuming vitamins andminerals through your diet doesnot carry this kind of risk.

There is not much evidencethat taking dietary supplementshas a beneficial effect on peoplewith arthritis, although theresults for fish oil supplementsare promising.

A huge range of supplementsis available. Bear in mind that alot of these remedies areexpensive and their effectivenessis unproven. You should alsoremember that vitamin andmineral supplements do nothave an instant effect – you mayneed to take them for severalweeks before seeing adifference. Find out as much asyou can about the supplements

you want to take. It is important to take

supplements properly and followthe instructions on the label(many should be taken with orafter food), or they might notwork. Remember: ● take supplements with food to

improve their uptake intoyour body

● do not take lots of differentsupplements because they caninteract with each other andbe less effective. For example,zinc interferes with howcopper and iron are absorbed.

You should also bear thefollowing in mind before takingsupplements:● check with your doctor or

pharmacist for interactionwith prescribed drugs

● tell your healthcare teamabout any supplements youare taking so that they areaware of all aspects of yourtreatment plan. Report anyside effects to your doctorimmediately

● keep a record of how you arefeeling so you can try to gaugeif the supplements are havingan effect

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SUPPLEMENTS

● buy brands from large,reputable manufacturers sothat you can be more sure ofconsistency in the product

● consider the costs: takingsupplements is a long-termcommitment and can beexpensive.

Below is an in-depth look atsome of the most popularsupplements. You do not needto take all of these supplements,or even one of them, unlessdirected by your doctor. If youare unsure, consult your doctoror a dietitian.

‘I take cod liver oil andomega-3 oils becausethey’re good for healthgenerally’The recommended dailyallowance (RDA) is the averagedaily amount of nutrientrequired to maintain goodhealth. As mentioned above,some people with certain formsof arthritis will need an extraboost (of folic acid if you aretaking methotrexate, forexample) but you should alwaysconsult a doctor before takingmore than the RDA, as it can bedangerous to overdose.

More information on some ofthese supplements can be foundin Arthritis Care’s factsheets.You can download factsheets atwww.arthritiscare.org.uk or getcopies by emailing [email protected]

Supplements taken bypeople with arthritis

Aloe veraAloe is known to soothe andreduce inflammation and iscommonly used externally as agel. It is also marketed forinternal use – usually as a drink –for some conditions such asrheumatoid arthritis. Studies onanimals into its effectiveness inreducing inflammation arepromising, but not enoughresearch has been done into its

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safety. Taking aloe internallymight alter the effects ofprescribed drugs, includingsteroids, so check with yourdoctor before taking it.

BromelainBromelain, also known as AnanasComosus, is a mixture of protein-digesting enzymes taken from thestem of pineapples. It is claimedthat it can reduce inflammationand inhibit swelling and pain.However, there is no conclusiveevidence to support this.

If you are taking antibiotics orblood-thinning medication, suchas aspirin or warfarin, you mustconsult your doctor before takingbromelain as the combinationmay cause bleeding.

CalciumCalcium, a mineral found in ourbodies, is essential for a widerange of things including theconstruction and repair of bonesand teeth. It also keeps themhard. It is found in many foods(see pages 18-19), but only abouta third of dietary calcium isabsorbed. Older people do notabsorb calcium very well andusually benefit from takingcalcium supplements enriched

with vitamin D. These may beavailable on prescription fromyour doctor. Calciumsupplements should not be takenby people with kidney problemswithout medical advice. Allpeople with arthritis should checktheir dose with their doctor.

ChilliesCapsaicin, or cayenne, is a redpepper made up from groundchillies. It is usually appliedexternally as a cream to gaintemporary relief from the pain ofosteoarthritis and rheumatoidarthritis. Chillies are thought toblock pain by interfering withpain signals. You should not apply the cream to broken orirritated skin and make sure youwash your hands after applying itas it can sting your eyes if youtouch them. It is available onprescription.

Chondroitin sulphateChondroitin sulphate existsnaturally in your body and isthought to give cartilageelasticity and to slow itsbreakdown. In supplement form,it is derived from the cartilage ofcattle or fish sources (whichmight cause a reaction if you

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have a fish allergy). It is oftentaken alongside glucosamine torelieve the symptoms ofosteoarthritis. However, there islittle evidence of its effectivenessin osteoarthritis, and noevidence that it helps inrheumatoid arthritis.

Chondroitin is a slow-actingsupplement, but if you have notseen any improvement after twomonths it probably will not helpyou. It does not help everyone –if you have severe cartilage lossyou probably will not get anybenefit. There do not appear tobe any serious side effects, butminor ones include occasionalnausea and indigestion. It couldincrease your chances ofbleeding if you are taking anyblood-thinning drugs. The long-term effects of takingchondroitin are not known.

CMOCMO (cetyl myristoleate) isadvertised as a cure for almostevery kind of arthritis. Noresearch has been published toshow that CMO is either safe oreffective. It is made from beeftallow. Celadrin is a form ofadvanced CMO for which thereis also no satisfactory evidence.

The main concerns aboutCMO stem from a sales pitchthat advises customers to stoptaking prescribed medication,including methotrexate andsteroids, as they interfere withCMO activity. Always consultyour doctor before stopping anymedication, especially steroids.

Devil’s clawDevil’s claw is derived from anAfrican desert plant of the samename. It is claimed to have anti-inflammatory effects, but it is notknown how it works. As it is arelatively new remedy to peopleoutside Africa, it should be usedwith caution. It shouldn’t betaken if you are pregnant orbreastfeeding. It has a blood-thinning effect, so you mustconsult your doctor beforetaking it if you are on blood-thinning drugs such as aspirin orwarfarin.

Evening primrose oilEvening primrose oil (EPO)contains the fatty acid gammalinolenic acid (GLA). Severalstudies have shown that GLAsupplements can relieve inflam-mation and rheumatoid arthritis.EPO needs to be taken for three

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to six months to give full benefitand the effect is lost when EPOis stopped. It may also be ofvalue when taken with fish oils.

Fish oilsFish oils (rich in omega-3 fattyacids) can produce a mildimprovement in joint pain andstiffness and have a good recordfor easing the symptoms ofosteoarthritis, rheumatoidarthritis and Raynaud’ssyndrome. Research has foundthat omega-3 fatty acids areeffective because they reducesome of the pain and inflamma-tion of arthritis. A daily dose,often in capsule form, must betaken for at least three to six

months. Any benefit is lost whenyou stop taking it.

Care should be taken not toexceed safe levels of vitamins Aand D when taking fish liver oils(note that these are different tofish oils). Pregnant women orthose planning to becomepregnant should not take theseat all because of the high vitaminA content. Always check thelabel.

You should select brands offish oils high in the essential fattyacids EPA and DHA. It isimportant not to take more of aweaker brand to make up theamount of EPAs required, as thiscould lead to an overdose ofother nutrients. If you are unsureseek advice from doctor or adietitian (see page 33).

‘I think supplementshelp me to draw morebenefits fromprescription drugs andalso to counteract someof their side effects’People taking high-dosesupplements should check withtheir doctor first, particularly ifthey are taking blood thinningmedication such as aspirin or

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warfarin. Studies need to becarried out into the possiblelong-term toxicity of taking fish oils.

Folic acidThis is also known as folate orvitamin B9. You will beprescribed folic acid by yourdoctor if you are takingmethotrexate. This is becausemethotrexate interferes with theaction of folic acid in your body.We need folic acid to make newcells.

GlucosamineGlucosamine is made in the bodyand is used to build and repaircartilage. It is popular withpeople with osteoarthritis.

Glucosamine is a naturalsubstance extracted from crab,lobster or prawn shells. It doesnot help everyone, so if you havenot seen any improvement aftertwo months it probably will nothelp you.

There are no known seriousside effects, but lesser onesinclude nausea and indigestion. Ifyou have a shellfish allergy, checkthe label and take the manufac-turer’s advice on whether it issafe to take glucosamine.

Glucosamine is often taken incombination with chondroitin(see page 27). People withdiabetes should bear in mindthat glucosamine raises bloodsugar levels.

Green-lipped mussel extractAlthough some researchsuggests that green-lippedmussel extract might be helpfulfor people with osteoarthritisand rheumatoid arthritis, theevidence is not conclusive.

IronIron levels may be low in peopletaking NSAIDs as they can leadto bleeding of the gut. However,anaemia in rheumatoid arthritisdoes not always respond to ironsupplements, so you should talkto your doctor before takingiron. A common side effect oftaking iron supplements isconstipation. You should nothave more than 17mg of ironeach day.

MagnesiumMagnesium is needed tomaintain healthy bones.Supplements of this mineral havebeen shown to significantlyimprove pain and fatigue.

Magnesium is found in nuts,grains, green leafy vegetablesand whole foods, but peoplewho eat mainly processed foodsmay not be getting enough.Check with your doctor beforetaking magnesium as it caninteract with other drugs and itcan be toxic if taken in very highdoses. Magnesium makesantibiotics less effective.

MSMMSM (methyl sulfonyl methane)is touted as a cure for arthritis.There is no scientific evidence toback this claim or any researchto show that it is safe. MSM is asulphur compound. It should notbe used with anything that thinsblood.

St John’s wortThis is a popular herbal remedy.It comes from a flower andappears to act as an antidepres-sant by raising serotonin levelswhich are low in people who aredepressed and those who havefibromyalgia. Studies show that itcan relieve mild depression.It must be taken for a number ofweeks to feel an effect. It shouldnot be taken with other anti-depressants or alcohol. This

herb can also interfere with birthcontrol, and should not be takenwhen pregnant or breastfeeding.Recent research has suggestedthat St John’s wort can reducethe effectiveness of somemedication prescribed to peoplewith arthritis, such asciclosporin. If you are takingprescribed medication youshould consult your doctorbefore taking St John’s wort.People with lupus should avoid itas it can increase sensitivity tosunlight. St John’s wort usuallycomes in tablet form.

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SeleniumSelenium is an essential mineralthat is known to be low inpeople with inflammatoryconditions such as rheumatoidarthritis. It helps limit theharmful effects of inflammation.The body does not need highlevels of selenium (if you eatmeat, fish or nuts you should beable to get all the selenium youneed from your diet) and it canbe toxic in high doses.

Three brazil nuts will providea daily dose of selenium. It isfound in a number of multivita-mins, so care should be takennot to exceed doses of 0.35 mg.

Zinc sulphateZinc levels are often low inpeople with rheumatoid arthritisand some studies have foundthat joint swelling and morningstiffness are reduced whentaking zinc.

Check with a doctor beforetaking zinc supplements as manypeople are getting enoughalready in their diet (from meat,shellfish, milk and dairyproducts). No more than 25mgshould be taken on a daily basiswithout medical supervision.

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It is important to discuss anymajor dietary changes with yourdoctor as you could end upaggravating your symptoms. Ifyou require specialist help, youcan ask to be referred to adietitian or nutritionist.

Dietitians andnutritionistsRegistered dietitians are expertsin diet and nutrition, regulatedby the Government. They can help people make informedchoices about food andlifestyle, including

giving advice in relation to theirmedical condition. You cancontact a registered dietitianthrough your local hospital orGP surgery (some of which havea dietitian on site). The BritishDietetic Association(www.bda.uk.com) can directyou to a private practice.

Nutritionists provide generalinformation about diet, but donot provide advice specificallytailored to medical conditions.The Nutrition Society(www.nutritionsociety.org/index.asp) has a register of nutritionists

OTHER SOURCES OF HELP

who have received an approvedlevel of training. Some nutrition-ists work in hospitals and thecommunity, but many work inpublic health promotion.

Visiting a dietitianYou may be referred to adietitian if you have a specificfood allergy or if there areconcerns about your weight.

During the consultation youwill be asked about what youusually eat, as well as anymedications and supplementsyou are taking.

‘The dietitian gave meadvice on what to eatand what to avoid, andhelped me to makesome positive changes’A dietitian can help yourecognise which dietary advice iswell established, and which isexperimental, so that you havean objective view of any dietarychanges you wish to try.

Weight loss groupsAs well as following advice froma doctor or dietitian, somepeople find it useful to join aslimming group. These groups

provide a supportiveenvironment in which you canlearn new weight loss strategies.

You have to pay to attend the groups and they can befound across the UK. Search for your local groups online –Weight Watchers (www.weightwatchers.co.uk),Slimming World (www.slimming-world.com) and RosemaryConley Diet (www.rosemary-conley.co.uk).

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There are many advantages tofollowing a healthy diet. As wellas experiencing an improvementin general health, many peoplewith arthritis who eat a balanceddiet find that their symptoms arereduced. Eating healthily doesnot have to be difficult – onceyou are better informed, it isoften a matter of thinking aboutfood in a new way.

It is also important to keep ahealthy perspective and notget too stressed out aboutdietary choices or theoccasional indulgence.

If you apply thehealthy optionsdescribed in thisbooklet as oftenas possible andenjoy yourfood, thenyou are onthe righttrack.

THE LAST WORD

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● arc (Arthritis Research Campaign)

Copeman House, St Mary’s Court,St Mary’s Gate, Chesterfield,Derbyshire S41 7TD. Tel: 01246 558033 www.arc.org.ukFunds medical research into arthritisand produces information.● NHS DirectTel: 0845 4647www.nhsdirect.nhs.ukInformation on conditions,treatments, support groups and local NHS services.● Food Standards AgencyAviation House,125 Kingsway,London WC2B 6NH.Helpline: 020 7276 8829(Mon-Fri: 9am-5pm)www.eatwell.gov.ukIndependent government agency,provides information onrecommended daily allowances offoods and healthy eating.● The British Dietetic

Association5th Floor, Charles House,148/9 Great Charles Street,Queensway, Birmingham B3 3HT.Tel: 0121 2008080www.bda.uk.comProfessional association for dietitians,also provides a lot of consumerfocused information on healthyeating, including a range of factsheets.

● British Heart Foundation14 Fitzhardinge Street,London W1H 6DH.Tel: 020 7935 0185Information line (can advise onhealthy eating): 08450 70 80 70(Mon, Tues, Fri: 9am-5pm. Weds, Thurs: 8am-6pm)www.bhf.org.ukInformation line provides informationand advice about healthy eating.● Eating Disorders Association103 Prince of Wales Road,Norwich NR1 1DW. Adult helpline (18yrs+) 0845 6341414 (Mon-Fri: 10.30am-8.30pm,Sat: 1pm-4.30pm)Youthline (up to and including 18years of age) 0845 6347650 (Mon-Fri: 4.30pm-8.30pm, Sat: 1pm-4.30pm)www.edauk.comProvides advice and support forpeople with various eating disorders,from binge eating to anorexia.

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USEFUL ORGANISATIONS

Arthritis Care is the UK’s largestorganisation working with and for allpeople who have arthritis.

Our booklets and magazine, website and professional helpline are tools to enable people to make positive choices. Our network of localgroups, self-management programmes andinternet forums bring people together to support each other in living life to the full. Our campaigning work promotes civil rights,better access to health and social care provision,and tackles issues important to people in theirlocal area.

Get in touch with us● Our helpline offers confidential information

and support. Call free on 0808 800 4050 (10am-4pm weekdays) or [email protected]

● Our website provides information on all aspectsof arthritis and what we are doing in your area.Visit us at www.arthritiscare.org.uk

● Call us to find out more about what we do orhow to become a member.

Arthritis Care contact numbers:

UK Head Office: 020 7380 6500South England: 020 7380 6509/10Central England: 0115 952 5522North England: 01924 882150Northern Ireland: 028 9448 1380Scotland: 0141 954 7776Wales: 01239 711883

Published by Arthritis Care, 18 Stephenson Way, London NW1 2HDPrinted October 2006 ACR013 Registered Charity No. 206563

ISBN 1-903419-42-5 ISBN 978-1-903419-42-7

HEALTHY EATING AND ARTHRITIS