The Effect of the Vegan Diet on Rheumatoid Arthritis

Heidi Agustin Joseph Azevedo Fall 2013 October 22, 2013

! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! A mock counseling session addressing an alternative nutrition topic was conducted by a health care professional to improve the quality of diet, thus, the lifestyle

of a client. A case study on the effect of the vegan diet on Rheumatoid Arthritis was created and knowledge of counseling theories and skills were applied using evidencebased resources to guide the appropriate intervention. A short script was created and reenacted to highlight important aspects of the intervention using the chosen counseling theory and interviewing skills. The following case study will describe the background and introduction to the scenario, evidence-based research to support the appropriate counseling theory, information regarding the case study, and the summary, reflection, conclusion of the interview, followed by appendices of the ADIME documentation of the client and the script. About 1.2 million Americans suffer from Rheumatoid Arthritis (RA), an unknown onset of an autoimmune disease that destroys destructs the bodys joint tissues, which result in chronic pain, mobile disability, and emotional distress. The cure for RA is also unknown and medications have shown side effects as well as adverse effects with longterm use, causing more difficulty for patients to cope with the disease. This has led some patients to turn to alternative therapy, which includes complementary and alternative medicine (CAM) (Astin, J. A., 2002). The following study done at the Bastyr Center for Natural Health assigned thirtyeight people with RA the vegan diet. Twenty-eight more people with RA were assigned to eat a more typical diet, including meat (control group). Only 22 of the 38 people assigned to eat the vegan diet completed at least nine months of the dietary intervention. Of those, 40% (nine people) experienced improvement in the symptoms of RA compared with only 4% (one person) in the group eating the standard diet (Vegan Diet Improves Rheumatoid Arthritis Symptoms, n.d). There are many possible

explanations for the improvements seen in the study done at the Bastyr Center. Meat is high in a specific fatty acid that is believed to promote inflammation in the body. Because vegan diets contain less of this fatty acid than omnivorous diets, consuming a vegan diet might produce an anti-inflammatory effect. The following case study is of a known individual that has been diagnosed with RA in the past 2 years who also suffers from high blood pressure. Prescription information of the medication used for treatment reveals being used congruently to treat patients suffering from cancer. Treatment is also followed by routine check-ups of the liver and kidneys, making liver and kidney damage a potential side effect. Awareness of side effects and adverse effects of medications have led to looking into the vegan diet as a form of CAM for this case study. The scenario is to provide education on the vegan diet and its effect on RA, while lowering the clients blood pressure and meeting the clients needs. The average age of persons with RA is 67 and affects 2.5 more women than men (Arthritis Foundation, 2008). People in this age group typically have adapted to their desired lifestyle and habits and are usually resistant to change, including diet. Thus, Cognitive-Behavioral Therapy (CBT) is best used for counseling clients in this age group and Motivational Interviewing (MI) is supplemented to assess the efficacy in the clients willingness to make changes and coming up with solutions (Holli, B.B., Beto, J.A., 2014). Supporting evidence includes a randomized, control trial (RCT) specifically for patients with an early onset of RA (less than 8 years). The trial measured the effectiveness of CBT when treatment was tailored based on the patients preferred

priority. Priorities were individualized to two out of four tailor-made treatment modules that addressed problems most frequently experienced in RA patients, which consisted of fatigue, negative mood, social relationships, and functional disability (Evers, A., W., M., Kraaimaat, F. W., Van Riel, P., L., C., M., De Jong, A., J., L., 2002) In the clients case, negative mood, which includes anxiety, matched the problem that was most experienced. Anxiety was brought upon from the side effects of the multiple medications prescribed (see Appendix C). The negative mood module was one of the first choices in two-thirds of the patients, where negative mood decreased in posttreatment and follow-up assessment, making CBT effective for treatment (Evers, A., W., M., Kraaimaat, F. W., Van Riel, P., L., C., M., De Jong, A., J., L., 2002). The scenario is a real case study of a 61-year-old female that has been diagnosed with RA for the past 2 years and suffers from high blood pressure. She has been concerned about the medication and additional medication she has to take to treat and alleviate the symptoms. Research has shown that the vegan diet can help alleviate symptoms of RA (Vegan Diet Improves Rheumatoid Arthritis Symptoms (n.d)), which guided the counseling session to be created for the client to seek a dietitian in making dietary changes as an alternative form of therapy. Her history reveals her mother had suffered from arthritis, that she had been maintaining her weight, and does routine walking. During the counseling session, the client expressed her concern about liver and kidney damage due to the medication prescribed used to treat RA. She was also concerned about the side effects that may occur from this medication along with the

dose of pain medication as well as blood pressure medication. This has led the client to seek an alternative to taking medication by looking into the vegan diet. As previously mentioned, CBT and MI were the interventions recommended for treatment in those reluctant to making changes. The RTC mentioned that CTB that is individualized to the patient would be most effective in the treatment of RA. Intervention would include having the client seek the barriers to her concern, guiding the client in finding an appropriate solution based on her needs, and setting up goals supplemented with MI. In this counseling session, education of the vegan diet and its effect on RA are discussed and alternative meat and milk products and the food model, MyPlate are introduced as options to incorporate into the diet. Handouts on details of this information are provided throughout the session for self-guidance to the client for post-treatment. During the interview, the client expressed difficulty in adapting to the vegan diet due to having to exclude animal products, which was emphasized as being a main part of her diet. The dietitian emphasized this concern with the client but also addressed her main concern of the side effects of the medication to treat RA. This had led to an individualized treatment approach of CBT by referring to the vegetarian diet, an alternative diet in treating RA (Jens., Kieldsen-Kragh, 1999), which allowed the client to continue have milk and eggs in her diet. The clients diet history was reviewed to find alternatives and a desired meal plan. These included alternatives to milk as an option to further maximize treatment, which is part of the vegan diet. Education on incorporating vegetables in the diet from antioxidants to help alleviate symptoms of RA were mentioned (Jaswal S., Mehta H. C. , Sood A. K., Kaur J, 2003) and MyPlate was introduced as a suggestion on how to include more vegetables in the diet. Fluid intake

was noted and education on the effect of fluid intake with RA was also mentioned (Arthritis Treatment, n.d.), and the clients desire for fruit drinks allowed her to include more water in her diet by her own suggestion of diluting her drinks. In reflection of the interview, CBT and MI were used to guide the client in coming up with solutions to her concern of her current treatment with RA. An alternative diet as a form of therapy to alleviate symptoms for RA and side effects of medication was desired for the client. An individualized approach of CBT was used to cater to the clients usual eating habits by incorporating the vegetarian diet into the vegan diet. In guiding this intervention, the reflective listening statement of What is it about soy products that dont look appetizing, opened the conversation to allow the client to express her feelings towards making a dietary change and for the dietitian to help come up with a solution to this barrier. This was followed by the emphasizing statement, it seems like it would be difficult for you to change your usual diet. The dietitian then took a directive guidance approach by using a double side reflection statement, you also mentioned that changing your diet can help with your arthritis and help lower your blood pressure and the amount of medication you have to take. The MI question in including soy products into the clients diet that was asked prior to this statement allowed the client to evaluate her willingness to make changes. The dietitians understanding in the difficulty to make drastic changes for clients in this age group allowed her to come up with an alternative to the vegan diet by mentioning the vegetarian diet: If you would like, we can look into other diets that might help with your arthritis! research has shown that the vegetarian diet can help with symptoms of arthritis and the vegetarian diet includes eggs and milk (Jens., Kieldsen-Kragh, 1999). These statements using the

evidence-based approach of CBT and individualized treatment through multiple diet alternatives along with MI was effective and the best treatment for the client. The final suggestion of the vegetarian diet provided ease to the client in allowing her to keep eating the foods she has been accustomed to while still providing a diet alternative towards her goal in making dietary changes as a form of alternative therapy for RA (see Appendix C for the script). In summary of the client intervention, an individualized alternative diet incorporating the vegetarian diet to the vegan diet allowed foods enjoyed by the client to help alleviate symptoms of RA and the possibility of lowering medication use including blood pressure. Examples of soy products and milk alternatives were mentioned and encouraged using MI. Education on the effects of the vegan/vegetarian diet on RA and incorporating more vegetables as well water intake in the diet was provided, followed by the tool, MyPlate for guidance. Additional information through handouts and a pamphlet were also provided, which included treatment for blood pressure, were self-guidance tools to the client for post treatment. The ease in the client having an individualized diet allowed her to make an attempt in making dietary changes and a satisfying counseling session to schedule a follow up appointment.

References

Astin, J. A., Beckner, W., Soeken, K. Hockberg, M. C., Berman, B (2002). Psychological interventions for rheumatoid arthritis: A meta-analysis of randomized controlled trials (2002). Arthritis Care & Research, 47, (3), 291-302, June 15, 2002. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/art.10416/full on October 18, 2013. Arthritis Foundation (2002). Rheumatoid Arthritis Fact Sheet. Retrieved from ! http://www.arthritis.org/files/images/newsroom/mediakits/Rheumatoid_Arthritis_Fact_Sheet.pdf on October 20, 2013. Arthritis Treatment (n.d). Natural Arthritis Treatment. Retrieved from http://arthritistreatmenthq.org on October 20, 2013. Evers, A., W., M., Kraaimaat, F. W., Van Riel, P., L., C., M., De Jong, A., J., L., (2002). Pain, 100 (1), 141-153, November 2002. Retrieved from http://www.sciencedirect.com/science/article/pii/S0304395902002749 on October 18, 2013. Holli, B.B., Beto, J.A. (2014). Nutrition Counseling and Education Skills for Dietetics Professionals (6 ed.). Baltimore, MD/Philadelphia, PA: Lippincott Williams & Wilkins.
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Jens, Kjeldsen-Kragh (1999) Rheumatoid arthritis treated with the vegetarian diet. The Department of Immunology and Transfusion Medicine, Ullevaal University Hospital, Oslo. Jaswal S., Mehta H. C. , Sood A. K., Kaur J. (2003). Antioxidant status in rheumatoid arthritis and role of antioxidant therapy. Clin Chim Acta. 2003 338, (1-2), 123-9, December 2003. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14637276 on October 17, 2013. Vegan Diet Improves Rheumatoid Arthritis Symptoms (n.d), Retrieved from http://www.bastyrcenter.org/content/view/358/ on October 21, 2013.

Appendix A

ADIME: Name: Heidi Age: 61 Sex: F Height: 52 Weight: 120 BMI: 22 Labs: 140/80 Medication: Methotrexate: 25mg 2x/d (Rheumatoid Arthritis) Metroprolol: 2.5mg 1/wk (blood pressure) Folic Acid: 1mg daily Nabumetone: 500 mg as needed (about 1x/wk) (pain) Tylenol: over the counter, as needed (about 2x/mo) (headache) Weight History: Has maintained normal weight. Medical History: Diagnosed with high blood pressure 10 years ago. Diagnosed with Rheumatoid Arthritis in 2011. Mother had Arthritis. Diet Recall: See Appendix C Physical Activity History: Walk outdoors 30 mins 2 hours 3-4 times a week, 30 45 minutes on treadmill if not outdoors. PES Statement before the interview: decreased water intake due to personal choice, as evidenced by diet recall of 1 cup of water and three cups of fruit juice. Intervention -Planned goals for session: Find food alternatives to help alleviate symptoms of RA, help lower blood pressure through diet, eat balanced meals. -Planned goals as actual team: 1) Eat soy-based products three times a week. 2) Drink 6-8 cups of water.

PES Statement after interview: decreased water and vegetable intake due to personal choice, as evidenced by diet recall (see diet recall) Monitoring & Evaluation: Follow up appointment in 2 weeks. Check with client on degree of pain from RA. Check blood pressure. Signature: Joseph Azevedo Date: October 21, 2013

YouTube Link: http://www.youtube.com/watch?v=6jsz48Lz8mU&list=PLEGueCKLZmr2bXArKAJRc4VglqQCXWJ3&index=25

Appendix B

Usual Intake: Breakfast: Toast with peanut butter and jelly, coffee with milk and sugar Lunch: Chicken (2-3 drumsticks) in soy-based sauce, 1-2 cups of rice Dinner: 2 cups spaghetti with ground meat and tomato sauce Drinks: 1 cup water, 4 cups fruit juice (orange, minute maid juices) Snacks: 2 fruits Other: Fast food 2x/wk

Appendix C

Script: Opening Statement: Heidi is a 61-year-old female that has been diagnosed with Rheumatoid Arthritis for the past 2 years and suffers from high blood pressure. She has been concerned about the medication and additional medication she has to take to treat and alleviate the symptoms. She has read that the vegan diet can help with her arthritis and has come in to see a dietitian on how she can make that possible. We will be using Cognitive Behavioral Therapy and Motivational Interviewing. Heidis blood pressure is 140/90, is 52, and 120 pounds. Script: J: Hi, Im Joseph. What brings you in today? H: Im here because I have Rheumatoid Arthritis (RA) and also have high blood pressure and I am concerned about the medication I have to take to treat it. One of the medications I am taking is used to treat cancer and I have to constantly get my liver and kidneys checked to make sure they are OK. I dont want to ruin them because of my medication. J: So you are saying you have Rheumatoid Arthritis and high blood pressure, and are concerned about the medications you have to take ruining your liver and kidneys, correct? H: Yes, and also my arthritis gets really painful and I have to take a really strong dose for it. I also take Tylenol for when I get headaches. I think I am taking too much medicine and I dont want to worry about all the side effects from them. I read on the Internet that going on the Vegan diet can help with my arthritis and that I dont have to take as much medication.

J: Yes, that is true. Have you thought about trying the Vegan diet? H: Not really, what is the Vegan diet exactly? J: Veganism is the practice of abstaining from the use of animal products, particularly in diet. A follower of veganism is known as a vegan. H: So how will that help with my arthritis? J: Well, a Vegan diet will help with your inflammation. Inflammation is your body's attempt at self-protection; inflammatory forms of arthritis usually involve many joints throughout the body at the same time. H: Oh OK. So you are saying eliminating meat, including fish would help with my arthritis. When you say animal products, does that mean eggs and milk too? J: Yes, animal products meaning anything made by the animal, such as eggs and milk and things produced from them such as cheese. H: Wow, thats a really strict diet. Meat is a big part of my diet and in a lot of the food I eat including eggs and milk. J: I understand how it might be hard in making changes to the food you usually eat. Choose a number from 1-10. How hard would it be for you to adapt to the Vegan diet? H: I feel like a 7. It would be really hard for me to completely cut off eggs, and milk, let alone meat. J: Why a 7 and not.. Lets say a 4? H: I dont know what else I would be able to eat besides fruits and vegetables if I cant have any meat, eggs, or milk. J: You can include soy-based products into your diet. Do you mind if I explain to you what that is?

H: No, what are those? J: Soy-based products are foods like tofu and tempeh can be an alternative meat. There are tofu replacements for burgers, hotdogs, even whole turkeys. How do you feel about including more soy-based products into your diet? H: Ive seen them in the store but they never looked appetizing so Im not sure if Ill like them. J: What is it about soy products that don't look appetizing? What is your willingness to try? Choose a number from 1-10. H: I think a 4. They dont look like and dont seem as satisfying as the real thing. J: It seems like it would be difficult for you to change your usual diet. You also mentioned that changing your diet can help with your arthritis and lower the amount of medication you have to take. H: Thats true. It would be such a drastic change to cut all of those things out of my diet, especially when Ive been eating those things all my life. J: I understand. If you would like, we can look into other diets that might help with your arthritis. Would you be interested? H: Oh, there are other diets besides the Vegan diet that can help? J: Absolutely. Research has shown that the Vegetarian diet can help with symptoms of arthritis and the Vegetarian diet includes eggs and milk. How do you feel about that? H: That sounds good, as long as I have my milk and eggs, then maybe I can try the soy products.

J: Its great that you are more willing to try some soy products. How about we go over your diet recall to see how we can add these foods into your diet. How do you feel about trying a tofu burger or soymilk? H: A tofu burger actually sounds good and Ive never tried soymilk but I think I can try it. J: When you are thinking of a protein to have for your meals how do you feel about including soy-based products three times a week? If you would like, I have a brochure with different soy products available for you. H: Three times a week doesnt seem hard. Yes, I would like to have the brochure. J: Its great that you include fruits as snacks but Ive noticed that vegetables are lacking in your diet recall. Fruits and vegetables contain antioxidants, which can also help with inflammation. How do you feel about that? H: I could include more vegetables in my diet if thats going to help with my arthritis. J: There is a strategy that can help you called MyPlate, which is a food model. You mainly work towards having half your plate being fruits and vegetables and the other half proteins and grains. What do you think about myplate? H: That sounds like something I can do too. J: Ive noticed your water intake is low. Why do you think that? H: Yes, Im not much of a water drinker so I drink the fruit juices that my daughter has at home. J: Having adequate water can help alleviate pain with arthritis. Keeping hydrated can help your joints stay lubricated. How about trying to drink 6-8 cups of water a day? H: Wow, thats a lot of water. Can I dilute my fruit drinks?

J: Yes, you can definitely do that. Is it okay if we shoot for the goal of trying a soy-based product 3 times a week and to drink 6-8 cups of water per day? H: Yes, will any of this help with my blood pressure too? J: Yes of course, I can give you some material on how these dietary changes will help with your blood pressure if you would like. Also, are there any other concerns you have for me? H: Yes, I would like to have more of this information. J: How about I schedule an appointment to see you again in two weeks to see your progress. How does that sound? H: Yes, that sounds great. J: Here is my business card call or email me if you have any other questions, and I will see you in two weeks. H: Thank you Joseph, I will try my best to do these things and I will let you know about them. J: See you soon.

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