Fasting for Rheumatoid Arthritis

Fasting was a central component of many ancient medical and spiritual systems, but its modern use began in the United States with the natural and physical medicine movements of the late 19th century. Enthusiasm for the practice burgeoned until, in 1912, a practitioner in the Pacific Northwest, Linda Burfield Hazzard, was brought to trial, found guilty of manslaughter, and sent to prison after the starvation death of a wealthy young Englishwoman under her care.

Although the practice of fasting subsequently fell from favor in the United States, it experienced a resurgence in Europe in the 1950s, particularly in Germany and Scandinavia, where patients can receive the treatment at spas and clinics.

Fasting leads to neuroendocrine changes, as was seen in a study of 22 patients with chronic pain conditions who participated in a 7-day fast. These patients had significant increases in urinary levels of noradrenaline, adrenaline, and cortisol; control patients following a vegetarian diet showed no changes (Nutr. Neurosci. 2003;6:11–8).

Many patients with rheumatoid arthritis (RA) have reported benefits from dietary therapies such as fasting, and various hypotheses have been proposed to explain this. One suggestion is that alterations in gut microflora and changes in bacterial substances absorbed via the intestinal mucosa may influence inflammatory activity in the joints (Am. J. Clin. Nutr. 1999;70[suppl.]:594S-600S).

In Essen, Germany, at the department of integrative medicine, Kliniken Essen-Mitte, a large prospective outcome study found significant benefits from a 7-day fasting program among inpatients with various chronic pain conditions including rheumatoid arthritis, osteoarthritis, fibromyalgia, and migraine.

Patients typically stay at this clinic for 10–14 days and undergo a program of lifestyle modification and mind-body medicine. Treatment costs for the program are reimbursable in the German health care system.

The clinic, which was founded in 1999, expanded in 2001 and began offering medically supervised therapeutic fasts to all patients except those with eating disorders, liver or renal disease, gastric ulcers, or other comorbidities that could make it unsafe to fast.

Between 2001 and 2004, there were 2,787 patients who attended the clinic for 3 days or more. Of the 2,121 patients with complete discharge questionnaires, 952 fasted, 873 followed a normocaloric Mediterranean diet, and 296 followed other nutritional programs such as elimination diets or rice diets and were not included in the study.

Patients who elected to fast had 2 prefasting days when they consumed 800 calories from fruit, rice, or potatoes. During the 7 days of actual fasting, they were instructed to drink 2–3 L of mineral water, herbal tea, vegetable broth, and juice, for a total caloric intake of 350 kcal. In the 4 days following the fast, foods were slowly reintroduced. Enemas or laxatives were administered during the fast according to patient preference.

At the time of discharge, disease-related complaints had improved to a significantly greater degree among fasting patients, with 344 (37%) reporting that their symptoms were “much better,” compared with 209 (24%) of the nonfasting patients. Overall, 743 (78%) of fasting patients reported improvements in their health status, while 176 (18%) reported no change and 33 (3%) reported worsening of their health (J. Altern. Complement. Med. 2005;11:601–7).

No serious adverse events were reported. Two patients developed hyponatremia when they continued diuretic use against medical advice; their sodium levels normalized when the diuretics were withdrawn. A total of 23 patients stopped fasting early because of hunger or irritability, and 4 had moderate gastric pain. Discomfort during fasting most commonly occurs on day 2 or 3, when the metabolism is shifting to lipolysis.

The most common complaint during fasting was headache, reported by about 15% of patients. “This was at least partly a result of coffee withdrawal,” lead investigator Andreas Michalsen, M.D., said in discussing the study at a symposium on alternative and complementary medicine sponsored by the universities of Exeter and Plymouth held in Exeter, England.

“Patients who fasted also seemed to have better success in maintaining beneficial long-term lifestyle changes such as exercise and relaxation,” he said.

A systematic review identified 31 original reports on fasting as a treatment for RA; 4 of them were controlled and methodologically adequate. The results of these four studies “support the hypothesis that a short period of fasting followed by a vegetarian diet can cause clinically relevant long-term improvement in patients with Rheumatoid Arthritis” (Scand. J. Rheumatol. 2001;30:1–10).

The most convincing evidence, according to the authors of the systematic review, was collected in a randomized, single-blind Norwegian study. The study assigned 27 patients to 4 weeks at a health farm where they fasted initially and then followed a vegetarian diet; another 26 patients stayed at a convalescent home for 4 weeks where they followed an omnivorous diet. The groups were followed for an additional 12 months, during which significant differences were seen between the two in multiple disease-activity variables including tender joints, morning stiffness, health assessment questionnaire scores, and global assessment (Lancet 1991;338:899–902).

A subsequent analysis of this cohort also found that patients who fasted and then followed a vegetarian diet had significant decreases in leukocyte counts, rheumatoid factor, and the C3 and C4 complement components, suggesting “dietary treatment can reduce disease activity in some patients with rheumatoid arthritis” (Scand. J. Rheumatol. 1995;24:85–93).