How a Functional Medicine approach to rheumatoid arthritis changed my life, and how it can change yours
Rheumatoid arthritis (RA) is a debilitating chronic autoimmune disorder that can significantly compromise your quality of life by causing inflammation of the joints and surrounding tissues.
I’m Lulu Ross-Brown, a Coho Health practitioner, and I know only too well the frustration and fear of being diagnosed with rheumatoid arthritis at only 30 years of age, long before I became a Nutritional Therapist and Functional Medicine practitioner.
It was a disease I thought I would never be able to cope with.
But through a Functional Medicine approach to rheumatoid arthritis, I am feeling well, have a very active lifestyle and I am pain-free.
I am in remission, and I want to help you to understand this approach, so you too can take back control of your health.
Table of Contents
I have helped many people with rheumatoid arthritis, both in clinic and through my work with National Rheumatoid Arthritis Society (NRAS charity).
What is rheumatoid arthritis?
Rheumatoid arthritis is an autoimmune disease that is caused by dysfunction of the body’s immune system, which in turn starts to attack ‘self tissues’, namely the synovial membranes.
Rheumatoid arthritis predominantly affects the joints, but it also causes systemic inflammation.
It affects approximately 1% of the population in the UK, so more than 400,000 people are struggling with ongoing pain and physical restriction (1), and these numbers are increasing.
Autoimmunity (as the name suggests) is a disease of the immune system.
If we have one autoimmune condition, unless we address this immune dysfunction, we are more likely to go on and develop further autoimmune conditions (2).
This could be for example:
- Rheumatoid arthritis and Lupus (called 'Rhupus')
- Rheumatoid arthritis and Hashimoto's
- Rheumatoid arthritis and coeliac disease
- Rheumatoid arthritis and psoriatic arthritis
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In rheumatoid arthritis, antibodies attack the synovium, a thin layer around the joint responsible for secreting synovial fluid to protect the joint.
This then becomes inflamed and releases more immune cells which damages the structure of the joint – the bones, cartilage, tendons and ligaments.
What are the symptoms of rheumatoid arthritis?
There can be many symptoms of rheumatoid arthritis.
You may experience only one or two, or many of them simultaneously.
The symptoms of rheumatoid arthritis can include:
- Inflammation
- Joint or muscle pain
- Stiffness
- Swelling of the joints
- Joint restriction
- Fatigue
- Depression
- Loss of appetite
- Weight fluctuations
In addition to treating these symptoms of RA, in a Functional Medicine approach to rheumatoid arthritis, we aim to identify and address the many possible root causes.
This includes genetics and environmental factors, as well as restoring balance in general so you can take back control of your health and live the life you want.
Who gets rheumatoid arthritis?
Rheumatoid arthritis tends to affect women more than men, with approximately three times more prevalence in women than men (3).
Many reasons have been proposed as to why this is the case:
- Female sex hormones and their cues affecting both innate and adaptive immune systems via specific receptors on cells (4)
- The number of X chromosomes impacting immune system differently (5)
- Testosterone having a blunting effect on the immune system, particularly B cells (6)
- as well gender roles and behaviour differences
Rheumatoid arthritis can occur at any age, but the average age of onset is often between 40-60 years of age (7).
You may have had symptoms for many years before getting a diagnosis.
It has been suggested that age at disease onset has an influence on disease activity.
Some research suggests that the later the onset of rheumatoid arthritis, the greater the disease activity (8).
Other research suggests that early age onset results in more clinical joint erosion and higher disease activity (9).
Rheumatoid arthritis in children is called Juvenile Idiopathic Arthritis, which is diagnosed depending on how many joints are affected in the first 6 months of their disease, and the presence of rheumatoid factor (RF) (10).
People of some races and ethnicities are more likely than others to develop rheumatoid arthritis, or to experience more severe RA and less remission.
This may be due to genetics, environmental factors, or the speed and type of treatment we are able to receive (11).
For example, poverty can be linked to stress and malnutrition, both compounding factors to the development and progression of chronic diseases like RA.
How do I know if my arthritis is rheumatoid arthritis?
There are over 100 different types of arthritis, including:
- Polymyalgia Rheumatica
- Fibromyalgia
- Psoriatic arthritis
- Osteoarthritis
- Ankylosing Spondylitis
- Gout
…to name a few, and your GP or Rheumatologist will try to determine which type of arthritis you have.
However, there are some subtle differences that you can perhaps start to look out for yourself.
Examples: osteoarthritis (OA) and rheumatoid arthritis (RA)
The main difference between osteoarthritis and rheumatoid arthritis is the cause behind the joint symptoms.
As you know, rheumatoid arthritis is an autoimmune disease where your own immune system attacks your joints, whereas osteoarthritis is caused by mechanical wear and tear of the joints.
The below table lists the common differences between OA and RA.
| Rheumatoid arthritis | Osteoarthritis |
|---|---|
|
Autoimmune response that causes inflammatory synovitis |
Degenerative disease that causes articular cartilage loss and joint space narrowing |
|
Causes pain, swelling and stiffness in joints, but also fatigue and flu like symptoms |
Causes pain and stiffness but not the systemic feelings of fatigue |
|
Tends to cause widespread morning stiffness lasting more than one hour |
Morning stiffness, if present, lasts less than one hour but reoccurs after activity or by the end of the day |
|
Can affect any joints but common in hands, feet, elbows, knees, jaw |
Tends to affect weight bearing joints (knees, hips) or ones we use a lot and that can wear i.e. fingers and thumbs |
|
Can affect other parts of the body i.e. heart, eyes, lungs |
Only affects joints |
|
Can occur at any age |
Tends to occur later in life |
|
Symmetrical pattern Tends to be both sides of the body |
Asymmetrical pattern Odd, isolated joints |
|
Can end up causing osteoarthritis in joints with repeated bouts of flare and inflammation |
Doesn’t lead to rheumatoid arthritis |
|
Swelling tends to be red and hot in synovial membranes and tendons e.g. nodules |
Swelling ends up as harder bony swellings, e.g. osteophytes |
|
Laboratory finding may be positive for rheumatoid factor, anti-CCP antibodies, elevated CRP, ESR |
Normal labs but may have raised inflammatory markers like CRP, ESR |
The below image illustrates the changes in a joint, in osteoarthritis and rheumatoid arthritis.
What are the triggers and root causes of rheumatoid arthritis?
We don’t know specifically why an individual might develop rheumatoid arthritis.
But by understanding our unique circumstances; our bodies, where we are from, our environment and health history, we can better understand the individual triggers and drivers of RA in each individual case.
Factors that can help to understand the causes of RA:
- Gender
- Age
- Race
- Genetics and family history
- General health status
- Medical history, including prior medications
- Infections or stressors
- Current and past environment
- How the initial onset of RA symptoms presented
Knowing the pathogenesis (how the disease has developed) helps us to formulate a Functional Medicine approach to rheumatoid arthritis for each individual, unique case, that specifically supports you and your symptoms.
You can reduce your flare, you can be in less pain and you can achieve remission.
And as a practitioner, it’s my job to help you dig deeper to find your root cause – your personal ‘why’.
Was the trigger a previous infection like Epstein Barr virus, travellers tummy while on a trip abroad, or candida overgrowth?
Or was it imbalanced hormones after having a baby, or during the menopause, or during high stress – or perhaps ALL of the above!
We know there needs to be a genetic predisposition to rheumatoid arthritis, but there also needs to be something that then triggers the development of RA.
As rheumatoid arthritis is an autoimmune condition, we know you have immune dysregulation, but the question is why?
Genetic and environmental factors play a role in the development and the progression of rheumatoid arthritis. Additionally, there has been considerable research in recent years on the connection between increased intestinal permeability (leaky gut) and autoimmune diseases.
Dr. Fasano, a leading specialist in this area, believes you can’t have one without the other.
This means that you can’t have an autoimmune condition unless you have an overly permeable intestinal tract (‘leaky gut’), and that autoimmunity can also contribute to intestinal permeability (12).
In our opinion, there are a main triad of factors involved in rheumatoid arthritis:
- Genetic link: Perhaps a family member that has ANY autoimmune condition (not just rheumatoid arthritis)
- Environmental factors: such as chronic infections, toxin exposures, hormonal changes, periods of high stress, poor sleep, or nutrient deficiencies
- Loss of barrier integrity in the gut (increased intestinal permeability or ‘leaky gut’): increased permeability leads to immune dysregulation. Increased permeability can also affect other areas of the body, besides the gut lining - it could also affect the blood brain barrier, the gums and blood vessels.
As we’ve mentioned there are also many environmental factors that can cause and then continue to drive your RA.
These are known as drivers and can be any of the following factors:
- Intestinal permeability
- Dysbiosis in your microbiome
- Hormonal dysfunction (sex hormones and thyroid hormones)
- Ongoing stress and Hypothalamus-Pituitary-Adrenal axis (HPA axis) dysfunction
- Exposure to toxins (plastics and other persistent organic pollutants (POPs), heavy metals, mold, pesticides, industrial chemicals, recreational drugs, etc)
- Food and drink reactions: allergies, intolerances and sensitivities
- Infections - either latent infections that can be reactivated such as Herpes or Epstein Barr virus, or chronic infections such as bacterial infections in the digestive system and oral cavity, or parasitic infections or an overgrowth of yeast in the gut
- Poor sleep
- Nutrient deficiencies
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We explore all possible drivers through obtaining a very detailed personal history.
This means that we have your unique ‘health timeline’ and clearly understand your current symptoms, as well as understanding potential historical factors and triggers.
We then begin to work on drivers that seem to be affecting you the most.
Common drivers in rheumatoid arthritis, that are relatively easy to optimise, are oral hygiene, nutrition and sleep.
Increased intestinal permeability and the gut microbiome play such a crucial role in immune regulation, and therefore a lot of focus may be placed on improving your gut health.
Comprehensive stool testing helps to pinpoint imbalances in the gut. Some of our ‘go-to’ stool testing options include the Genova Diagnostics’ GI Effects stool test, Invivo Clinicals’ GI Ecologix and Diagnostic Solutions GI-MAP stool test.
Several specific pathogens have been implicated in rheumatoid arthritis.
For example, the Proteus Mirabilis bacteria is believed to be a contributing factor in some RA development, and can be found in the gut and urinary tract.
How does conventional medicine diagnose rheumatoid arthritis?
There is no individual test to diagnose rheumatoid arthritis.
It may well be that your GP refers you to a Rheumatologist who specialises in autoimmune conditions like RA, and who will perform some tests and an examination.
Sometimes diagnosis involves ruling out other possible causes for symptoms, like the other types of arthritis mentioned earlier, as there is no single conclusive test.
Conventional medicine has several ways to reach a diagnosis:
- The DAS28 score, which is based on your symptom pattern in 28 specific joints (the number of joints affected by either pain or local inflammation)
- Your pain score
- Effect on your ADL (Activities of Daily Living)
- Blood tests to identify autoimmune antibodies, for example Rheumatoid factor, anti-nuclear antibodies (ANA), anti-CCP, and markers of inflammation (e.g. Erthyocyte Sedimentation Rate (ESR) and C- reactive protein (CRP))
Your hands and feet may be X-rayed, but often these don’t show evidence of disease activity, only of damage to the joints from ongoing inflammation.
Active disease is diagnosed by checking for synovitis using an ultrasound.
Early diagnosis or referral is important as joint damage occurs most rapidly in the early stages of the disease, and often the treatment drugs or the intervention of a Functional Medicine practitioner can take several months to take effect.
The conventional medicine approach to rheumatoid arthritis
In rheumatoid arthritis, it is really important to reduce inflammation quickly in order to prevent long term joint damage.
Because of this, your Rheumatologist may start you immediately on Disease Modifying Drugs or non-steroidal anti-inflammatory drugs (NSAIDs or COX 2 drugs).
Possibly with a proton-pump inhibitor drug to protect the stomach lining.
Sometimes a steroid injection (for example Kenalog) and other analgesic drugs may also be needed (e.g., paracetamol, co-codamol, tramadol, etc.).
While these drugs are effective at suppressing symptoms, they can also have significant side effects.
If you are getting symptoms such as joint pain AND have a family member with an autoimmune condition, then do let your GP know this, as there is a genetic, hereditary, link in rheumatoid arthritis.
However, as with most autoimmune conditions, the genes only get ‘switched on’ by environmental triggers.
This is where the Functional Medicine approach to rheumatoid arthritis differs from conventional medicine, as you’ll see as we start our investigative work in exploring these unique triggers, and drivers of the disease.
The Functional Medicine approach to rheumatoid arthritis
In conventional medicine, once you have a diagnosis, the reason why you developed rheumatoid arthritis isn’t explored further.
However, in a Functional Medicine approach to rheumatoid arthritis, understanding why you developed RA is a critical factor and enables us to understand how we are going to help you, and this is where our journey really begins.
We start with these questions in order to understand your specific trigger and help you to remove it or reduce it.
In a Functional Medicine approach to rheumatoid arthritis, as well as identifying your specific triggers and drivers for the condition, we would also assess:
- Gastrointestinal health
- Food sensitivities
- Hormonal health
- Stress
- Toxins
- Heavy metals
- Energy metabolism
- Detoxification capacity
- The oral microbiome
and many more functions or systems. We would also work closely with you to optimise your nutrition, sleep, relaxation, exercise, movement, and stress.
By Identifying your specific imbalances, and working to correct these imbalances, we can help to promote optimal immune function and support repair processes.
In our clinical experience, this approach improves rheumatoid arthritis symptoms, the duration of a flare and the frequency of flares.
Also, as it is proven that once you have one autoimmune disease you are more likely to develop another, unless we can discover your root cause and stop the immune system attacking your tissues, you may be at risk of other autoimmune conditions in the future.
Even when pursuing a Functional Medicine approach to rheumatoid arthritis, we work alongside your GP and Rheumatologist, not instead of them.
There is communication throughout regarding medications and interventions you may be receiving and regarding an integrated approach so that we can best support you.
We may also ask your GP to do some baseline blood testing for us, alongside the ones you may need monthly to check your general health, inflammatory markers, liver function tests, etc.
Oral Hygiene in rheumatoid arthritis
Research is developing on the link between the health of our gums and oral hygiene, and rheumatoid arthritis (13).
As highlighted, our gut microbiome is intrinsically linked with the health of the immune system, and the same is also true for the oral microbiome.
Pathogenic bacteria, which can not only drive our RA, is now thought to be a possible cause of RA.
What may start as bleeding gums can end up becoming a more widespread inflammatory issue.
Studies have explored how specific bacterial infections such as Porphyromonas gingivalis, can damage the joints in people with RA. The damage initiated by the bacteria, is thought be due to Citrullination and Th17 pro- inflammatory responses leading to bone damage and systemic inflammation (14).
What is remarkable to us as practitioners, and hopefully to you, as someone this can massively help, is that we can now test our oral microbiome.
Invivo Clinicals’ Oral Ecologix test is a fabulous tool to help understand the bacterial environment in the oral cavity, and knowing what is (or isn’t there) can lead us to develop effective protocols to help you.
The test requires a simple mouth swab, however even without testing, what is encouraging is that we can put steps in place to reduce local inflammation, protect your gums and thereby reduce systemic inflammation.
We can then support this with specific oral hygiene advice including botanicals, herbs, oral probiotics and nutrients, to optimise the oral microbiome.
Nutrient deficiencies and rheumatoid arthritis
Nutrient deficiencies, and certainly insufficiencies, are widespread.
However, in chronic inflammatory conditions such as RA, we need to ensure optimal nutrient status to help drive down inflammation and module the immune system.
Nutrient deficiencies can result from:
- Dietary choices
- Poor digestion and poor absorption (remember coeliac disease is also an autoimmune disease and you may have this without being aware – this results in multiple nutrient deficiencies due to malabsorption)
- Small Intestinal Bacterial Overgrowth (SIBO) frequently causes malabsorption of iron and vitamin B12
- And if you’re on Methotrexate, then this can cause a folate deficiency, which is why your Rheumatologist may ask you to supplement with folic acid
Folic acid supplementation is always a hot topic with clients we see.
Common questions are about whether folic acid, folinic acid, folate or methylfolate is the best form, or whether having an MTHFR SNP really makes a difference.
Vitamin D in rheumatoid arthritis
We definitely see in our clinics that more people are now aware of the importance of Vitamin D and the immunomodulating effects it has by promoting healthy T regulatory cell function.
Many people with rheumatoid arthritis (or any autoimmune disease) are found to be deficient in vitamin D (15), surprisingly even in countries where there is more sunlight.
In the UK, vitamin D deficiency is so widespread that often GPs will not test, but instead advise to take a vitamin D supplement over the winter months.
However, it is so important to test and not guess.
As many factors can affect how we absorb and use vitamin D, the amount we require may be different, especially if you suffer with RA.
Additionally, we can have genetic differences that effect how our vitamin D receptors function. (16)
Vitamin D has a sweet spot in terms of both supplementation, and levels in your body.
Too little or too much is not good, but in the case of autoimmune disease, we like to see values in the optimal range, and in fact slightly to the higher end of the optimal range.
Case study: gastrointestinal system imbalance in rheumatoid arthritis - low hydrochloric acid
It is so important to have adequate amounts of Hydrochloric acid (HCl) which is produced by the cells of the stomach lining.
HCl helps to:
- Act as a gate keeper to help prevent a bacterial infection in the stomach or small intestines
- Assist with protein breakdown and absorption of B12
- Support flow of bile and pancreatic enzymes
HCl helps to prevent the bacteria, Helicobacter Pylori and Porphyromonas Gingivalis from thriving in the stomach.
The latter is of particular importance in RA due to a correlation with symptoms.
Porphyromonas Gingivalis is a bacteria commonly found in the mouth in those with gum disease.
The bacteria can, however, be swallowed and enter the stomach, where in optimal conditions, the HCl would step in and kill the bacteria.
If there is insufficient acid to irradicate the bacteria in the stomach, then the bacteria can continue further down into our digestive tract and affect our microbiome and cause inflammation (more on oral health later).
If protein isn’t digested, then two things can happen:
the meat putrefies and releases chemicals which can promote inflammation
- as the protein isn’t broken down into single amino acids, if there is increased intestinal permeability, then the partially digested protein enters the blood stream and provokes an immune response (the immune system is expecting single amino acids, or small amino acid chains with 2 or 3 amino acids, anything bigger isn’t recognised by the immune system as food, so instead the partially digested protein molecule is viewed as a threat)
While it is common for the HCl levels to decline with age, this trend seems to be even more pronounced in rheumatoid arthritis.
Additionally, due to the side effects of RA medications, patients often also need to take a stomach protector such as Proton Pump Inhibitors (PPIs like Omeprazole or Lansoprazole), which unfortunately, further reduce stomach acid.
Working together, we can find ways either to enable you to come off medications that lower stomach acid, for example if your doctor is happy to consider this and there is no pathology that indicates you need to stay on PPIs (for example stomach ulcers).
Alternatively, we can support you while you are on the medication in other ways so as to ensure optimal digestion and gastrointestinal function.
Whether you’re on PPIs for reflux, a hiatus hernia, heartburn, or GERD we would support you accordingly.
Despite understanding that PPIs have side effects that can affect digestion, absorption and inflammation, please do not stop a prescribed PPI without speaking with your doctor, as in some cases they are absolutely necessary to prevent serious consequences.
Gastrointestinal testing can be important in rheumatoid arthritis.
Advanced comprehensive stool testing doesn’t just give us an insight into your microbiome and any infections you have, but also into how you are digesting your protein (and fats and fibres) and how well you are producing digestive enzymes.
The test results below show a section of a comprehensive stool test, with results specific to digestion and absorption.
The pancreatic elastase, at a level of 55, is significantly low (optimal levels being over 500). This indicates low pancreatic digestive enzyme production. The aim here would be to support HCl and pancreatic enzyme levels.
Faecal fats are low, indicating a need for better dietary fat digestion and absorption.
The Functional Medicine approach to rheumatoid arthritis: complications associated with RA
If you are on many medications and your aim is to reduce these, or perhaps you want to manage some of the side effects associated with them, then we can support you in the following ways:
- Help to reduce medication side effects
- Help to correct any nutrient deficiencies caused by the medication, such as by DMARDS or Biologics
- Help to support body weight (there may be weight loss as a side effect of the medication)
- Help to restore muscle mass (if you are experiencing rheumatoid cachexia)
- Support you to optimise your fertility
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The wrap...
Having suffered personally with rheumatoid arthritis, I understand just how much it can impact your life.
I achieved remission through a Functional Medicine approach to rheumatoid arthritis, and I want the same for you.
Hopefully this article has shown some of the considerations that go into exploring RA, and how individual the journey is for each person.
If I can help you on your journey to rheumatoid arthritis remission, you can use the contact form below to get in touch now.
To your optimised, healthy future,
Lulu & the Coho Health team
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