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201Fasting mimicking diets: A literature review of their impact on inflammatory arthritis
Aliki I. Venetsanopoulou, Paraskevi V. Voulgari, Alexandros A. Drosos
Mediterr J Rheumatol 2019;30(4):201-6
bmws an edition of greek rheumatology society and professional association of rheumatologists
^smy e-ISSN: 2529-198X
MEDITERRANEAN JOURNAL
OF RHEUMATOLOGY
MR
December 2019 Volume 30
| Issue 4
E-ISSN: 2529-198X
mediterranean journal of rheumatology December 2019 | Volume 30 | Issue 4
©Venetsanopoulou AI, Voulgari PV, Drosos AA.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
©cd®
REVIEW
Fasting mimicking diets: A literature review of their impact on inflammatory arthritis
Aliki I. Venetsanopoulou, Paraskevi V. Voulgari, Alexandros A. Drosos
Rheumatology Clinic, Department of Internal Medicine, Medical School, University of loannina, loannina, Greece
ABSTRACT
Fasting is an act of restricting, for a certain length of time, food intake or intake of particular foods, and has been part of religious rituals for centuries. Religions such as Christianity and Islam use this practice as a form of sacrifice, self-discipline, and gratitude. However, in the past decade, fasting has penetrated the mainstream as a diet trend. There are several ways of fasting; existing fast mimicking eating methods promise accelerated weight loss, and many more benefits: lower cholesterol, prevention of type 2 diabetes and a longer lifespan. Even more, it has been proposed that fasting can downregulate the inflammatory process and potentially be used as a treatment regimen for several diseases. Here, we review the effects of fasting on immune and inflammatory pathways. Also, we present current knowledge about the role of fasting in the activity of inflammatory arthritides with a focus on rheumatoid arthritis.
Mediterr J Rheumatol 2019;30(4):201-6 https://doi.org/10.31138/mjr.30.4.201
Article Submitted: 03 Oct 2019; Article Accepted: 10 Oct 2019
Keywords: Fasting, metabolism, immunity, inflammation, rheumatoid arthritis
ABBREVIATIONS
AAs: Amino acids CR: Calorie restriction
Glutl: Glucose transporter 1 IF: Intermittent fasting IL-10: Interleukin 1 beta
IL-6: Interleukin 6 INF-y: Interferon-gam-ma
MS: Multiple sclerosis mTORCI: Mechanistic target of rapamycin complex 1
omega-3 PUFAs: Omega-3 polyunsaturated fatty acids NADPH: Nicotinamide adenine dinucleotide phosphate NSAIDs: Nonsteroidal anti-inflammatory drugs PASI: Psoriasis Area Severity Index PFKFB3: 6-phosphofructo-2-kinase/fructose-2,6-bis-phosphatase 3
PI(3)K: Phosphoinositol-3 kinase
PsA: Psoriatic arthritis
RA: Rheumatoid arthritis
ROS: Reactive oxygen species
TCA: Tricarboxylic acid
TCR: T-cell receptor
TNF-a: Tumour necrosis factor-alpha
INTRODUCTION
Fasting methods
Fasting, throughout history and in almost all religions of the world, has long been promoted as a spiritual means that brings great mental and emotional health. However, nowadays, it is becoming an increasingly popular eating
CRP: C-reactive protein FAs: Fat acids FAT: Fat acids translocase FMD: Fast mimicking diet
Corresponding Author:
Aliki I. Venetsanopoulou Academic Fellow Rheumatology Clinic, Department of Internal Medicine Medical School, University of loannina 45500 loaninna, Greece Tel.: +30 26510 79270 E-mail: [email protected]
Cite this article as: Venetsanopoulou AI, Voulgari PV, Drosos AA. Fasting mimicking diets: A literature review of their impact on inflammatory 201 arthritis. Mediterr J Rheumatol 2019;30(4):201-6.
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pattern, applied through well-known diet plans that mimic the fasting process with the aim of quick weight loss. There are many different methods used, such as intermittent fasting (IF) and fast mimicking diet (FMD), where fasting lasts from 12 hours to up to weeks at a time (Table l). Fasting should not be confused to calorie restriction (CR), which is a whole different eating pattern. CR includes a consistent reduction on average daily caloric intake below to what is typical or habitual, without deprivation of essential nutrients. Many experiments have shown that CR feeding delays the onset of age-related disorders and may correlate to lifespan extension.1'2,3 Nevertheless, some studies have conflicting results4 that may be due to differences in dietary composition, and further investigation is needed.
Fasting and health benefits
Studies have shown that fasting for short periods can increase metabolism.5 IF is assumed to influence the metabolic regulation via effects on (1) circadian biology, (2) the gastrointestinal microbiota, and (3) modifiable lifestyle behaviours.5,6 This hypothesis has driven research on animal and human subjects for decades, and has given significant evidence for the potential role of fasting on weight loss and even more on improved metabolism.7 A study by Dr. Longo et al.8 linked FMD to fat loss, as people in the fasting group, when completed
three months of FMD, lost an average of 2.7 kg and experienced notable reductions in belly fat, blood sugar, and cholesterol levels. Also, IF optimizes autophagy, a process of self-repair through cellular regeneration, and thus may protect against mental decline and slow cellular aging. A study in mice found that short-term food restriction leads to a dramatic increase of autophagy in nerve cells,9 while animal models of vascular dementia that underwent alternate-day food deprivation for 12 weeks showed a significant reduction in oxidative damage to brain tissue and improved mental sufficiency.10 Furthermore, intermittent fasting purges precancerous or cancerous cells6 and recently a combination of FMDs with chemotherapy, immunotherapy or other treatments is proposed as a potentially promising strategy to improve the effects of cancer therapies.11 Given these results, in animals and clinical trials, researchers are now studying if and how FMDs affect lifespan, not only in obese, but also in non-obese people.
Metabolism, immunity, and fasting Metabolism and immune response present a tight interdependency, and today's research has shown that glucose, amino acids (AAs), and fat acids (FAs) metabolism regulate leukocyte activation, subset differentiation, and function.12 Particularly, T cells during activation use mainly aerobic glycolysis converting glucose to lactate.
Table 1. Most popular fasting methods.
Types Fasting methods Duration
IF* • cycling through periods of drastically cutting food intake with periods of healthy eating • 16/8 fasting diet • 5:2 fasting diet • Alternate day fasting • Warrior Diet • One meal a day (OMAD) • Healthy eating limited to a single 8-hour window every day • Healthy eating for 5 days per week, and limiting calories to between 500 and 600 for 2 days a week • Fasting every other day, and healthy eating during non-fasting days • Fasting over a 20-hour window and then eating one large meal during a 4-hour evening window • Fasting for 23 hours and eating daily calories during a 1-hour window
FMD** • cycling through periods of limiting calories intake, while providing essential nutrients such as vitamins and minerals • Fasting 2-7 days every 15-365 days
*IF: Intermittent Fasting, ** FMD: Fast Mimicking Diet
Fatty acids
Figure 1. Cellular metabolism during T cells activation. During activation T cells convert glucose to lactate. This process is managed by the expression of glucose transporter 1 (Glutl). T-cell receptor (TCR) and CD28 increase the production of Glut 1 and through PI3K-Akt pathway Glut1 moves to T cell surface. Also, AAs enter leukocytes through glutamine transporters, and intracellular activate mTORC1 leading to the regulation of T cells. Finally, FAs diffuse across the plasma membrane or transport by FAT or CD36 receptors into the cytosol and inside the cell they ender TCA cycle.
This process is managed through increased glucose transporter 1 (Glut1) expression and surface localization (Figure 1). T-cell receptor (TCR) and CD28 co-stimulate and induce Glut1 upregulation, while the phosphoinosi-tol-3 kinase (PI3K)-Akt pathway provokes the translocation of Glut1 from the cytoplasm to T cell surface. AAs are an essential fuel for activated T cells due to increased demands for protein synthesis and metabolites that enter into metabolic processes, such as the tricarboxylic acid (TCA) cycle. Upon activation, leukocytes increase the expression of many AAs transporters, including the leucine and glutamine transporters. Intracellular, AAs activate mechanistic target of rapamycin complex 1 (mTORC1), leading to the regulation of CD4T cell differentiation (Th1 and Th17) and CD8+ T cell response. Moreover, several studies indicate that de novo FAs synthesis is important for activation, proliferation, and differentiation of effector T cells. Development of CD8+T memory cells, as well as differentiation of CD4+ T regulatory (Treg) cells, is linked to FAs catabolism via transport of free-FAs into the cytosol and the mitochondria b-oxidation. Specific FAs
diffuse across the plasma membrane into the cytosol, but most require transport by surface receptors such as FAs translocase (FAT) or CD36, and inside the cell they enter TCA cycle (Figure 1).13
Dysregulation of cell metabolism is implicated in the pathogenesis of autoimmune diseases.14 Systematic diseases like lupus, multiple sclerosis (MS), and inflammatory arthritis often present pathologic metabolic regulatory pathways leading to dysfunctional lymphocytes and disease progression. It is remarkable that, in rheumatoid arthritis (RA), a recent study showed that in contrast to healthy T cells, RA CD4 T cells fail to produce as much ATP and lactate due to the insufficient induction of 6-phosphofructo-2-kinase/fructose-2,6-bisphospha-tase 3 (PFKFB3), a rate-limiting enzyme in the glycolytic pathway.15 Deficient activity of PFKFB3 shunts glucose towards the pentose phosphate pathway and generates increased levels of nicotinamide adenine dinucleotide phosphate (NADPH), which in turn eventually reduces intracellular reactive oxygen species (ROS). Reduced ROS production is associated with increased severity of joint inflammation.16 PFKFB3 also diminishes the activity of autophagy, but the RA T cells are unable to upregulate the autophagic process and are forced into apoptosis. Furthermore, studies have shown that T cells in RA patients present an accelerated aging phenotype due shortening of telomeres, loss of CD28, and reduced efficiency of DNA repair mechanisms.17 Although we are unable to distinguish whether glycolytic insufficiency precedes or follows the process of T-cell aging, it is inevitable that the lower ability of T cells to generate ATP makes them more sensitive to apoptosis and thus, cause a turnover toward a more lymphopenic host.
Fasting alters cellular metabolic pathways and affects immune function, through its impact on cell trafficking and proinflammatory cytokine expression. Studies indicate that IF during Ramadan attenuates inflammatory status of the body by decreasing markers of inflammation like C-reactive protein (CRP), tumour necrosis factor-alpha (TNF-a), interferon-gamma (INF-y), leptin, interleukin 1 beta (IL-1P), and interleukin 6 (IL-6), but these alterations seem to be transient, returning to basal pre-Ramadan status shortly afterward fasting interruption.1819 Furthermore, studies show that fasting modulates the IL-12/ IL-10 cytokine balance20 and promotes the expression of endogenous IL-1 antagonists inducing IL-1 resistance.21 An animal study, using a murine model of MS, found that FMD cycles may be indeed effective in the reduction of specific inflammatory markers (INF-y, IL-17, and TNF-a), and Th1 and Th17 cells.22 Moreover, previous findings indicate that FMD provokes apoptosis of the autoreactive T cells, leading to an increase of naive T cells and Treg cells.23 Based on these results, a hypothetical simplified model of the effect of fasting, through FMD cycles, on the autoimmune response includes augmentation of
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Figure 2. Alteration of autoimmune response through periodic FMD.
Fasting through FMD causes apoptosis of the autoreactive T cells and leads to an increase of naive T cells and Treg cells. In the lesion area, FMD promotes tissue repair as it stimulates precursor cells.
Treg cells number, with simultaneous blockage of T-cell activation and promotion of T-cell death via apoptosis. In the lesion area, FMD may stimulate precursor cells and thus promote tissue repair (Figure 2).
Fasting, rheumatoid arthritis, and other inflammatory arthritides
RA is an inflammatory-destructive joint disease. The development of RA is based on both genetic and environmental factors that affect the innate immune system leading to chronic inflammatory activity in the body.24 An interaction with a dysbiotic microbiome of the intestine, characterized by the loss of beneficial bacteria and concomitant increase in potentially pathogenic microbes, is associated with chronic inflammation in RA patients.25 Among other factors, overweight and obesity seem to have an adverse effect on the onset, progress, and disease disability.26
In recent years, numerous new therapeutic concepts have been developed. Still, response to treatment varies, and so far, obese RA patients show a higher degree of synovitis not only at disease onset but also after remission achievement, which affects the overall response to treatment.27 Thus, many patients often seek healing through alternative methods of which diet is an essential component. Interestingly, 20 to 50% of RA patients have
tried dietary manipulation in an attempt to relieve their suffering.28,29
Current knowledge suggests that healthier nutrition by adjusting to a Mediterranean diet30 and a higher intake of fish31 is associated with a reduction in inflammatory activity, an increase in physical function, and improvement in RA patients' vitality. Even more, supplementation with omega-3 polyunsaturated fatty acids (omega-3 PUFAs) reduces patients' morning stiffness, painful joints, and Nonsteroidal anti-inflammatory drugs (NSAIDs) con-sumption.32
The role of fasting on RA disease activity has been studied thoroughly.33 Fraser et al. showed that patients who underwent 7-day subtotal fasting, with a limited amount of vitamin, mineral and carbohydrate supplementation, decreased CD4+ lymphocyte number and function, demonstrating a rapid immune suppression. Some clinical studies have linked fasting to the improvement of specific inflammatory markers such as IL-6, CRP, and erythrocyte sedimentation rate (ESR). At the same time, these patients present pain relief and reduction in Disease Activity Score 28 (DAS-28).353637 No correlation between better disease outcome and intestinal flora alterations has been found in RA patients who follow a fasting diet plan, and further investigation is needed.38,39,40 However, inflammation returns when food is reintro-duced, and symptoms flare up. Thus, fasting seems to have limited therapeutic value unless it is combined with other diet modifications, such a vegetarian diet.41,42 This approach has been studied by Kjeldsen-Kragh et al.43 in a single-blind controlled trial, where 53 patients with RA were randomly assigned to fasting or a control group. Patients of the diet group fasted for seven up to 10 days and afterward followed a vegetarian eating plan for 3.5 months. After 4 weeks, the diet group presented a significant improvement of the number of tender and swollen joints, pain score, and morning stiffness along with ESR, CRP, and other parameters. The beneficial effects were still present after two years of diet.44 Other trials have less convincing results, showing no significant impact of fasting followed by a Lacto-vegetarian diet.45 Yet, most of the existing trials indicate that commitment in a short fasting program followed by a modified diet provokes RA patients' advantageous outcomes.41,42,43,44,46 Studies on the role of fasting in inflammatory arthritides, other than RA, are limited. Psoriatic arthritis (PsA), a T lymphocytes-mediated inflammatory disease that presents mainly with skin psoriasis and inflammation of the joints, and entheses, has been strongly linked to obesity.47 Weight reduction in obese patients may reduce the severe comorbidities associated with PsA and lead to a better overall outcome of the disease.48 A study by Damiani et al.49 showed that IF during Ramadan has beneficial effects on the activity of psoriasis disease expressed in the Psoriasis Area Severity Index
(PASI). Finally, a recent report demonstrated a positive impact of IF on PsA patients, expressed by improvement in PsA disease activity scores, enthesitis, and dactylitis, regardless of the change in the patients' weight.50 These findings support our current understanding over the role of fasting on immune pathways in inflammatory arthritides and promote interest for future investigation.
CONCLUSIONS
Emerging research suggests that FMDs may lead to a healthier life and even aid cancer treatment. However, these claims remain controversial, and studies are primarily conducted in animal models. Fasting acts on cellular mechanisms and regulates the metabolism of immune cells. Thus, commitment to an eating pattern that includes a fasting component could suppress the inflammatory process. So far, most of the reported dietary interventions show beneficial effects on symptoms and disease progression in RA and PsA patients. Still, there is much to learn about fasting and the impact of different fasting patterns on non-obese and older patients, and more evidence is required before recommending any such eating regimens as supplemental "diet therapy'' to patients with inflammatory arthritides.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
REFERENCES
1. Martin CK, Bhapkar M, Pittas AG, Pieper CF, Das SK, Williamson DA, et al. Effect of Calorie Restriction on Mood, Quality of Life, Sleep, and Sexual Function in Healthy Nonobese Adults: The CALERIE 2 Randomized Clinical Trial. JAMA Intern Med 2016 Jun 1;176(6):743-52. [https://doi.org/10.1001/jamaint-ernmed.2016.1189] [PMID: 27136347] [PMCID: PMC4905696]
2. Lane MA, Ingram DK, Roth GS. Calorie restriction in non-human primates: Effects on diabetes and cardiovascular disease risk. Toxicol Sci 1999;52(2 Suppl):41-8. [https://doi.org/10.1093/ toxsci/52.2.41] [PMID: 10630589]
3. Maswood NY, Young J, Tilmont E, Zhang Z, Gash DM, Gerhardt GA, et al. Caloric restriction increases neurotrophic factor level and attenuates neurochemical and behavioral deficits in a primate model of Parkinson's disease. Proc Natl Acad Sci USA 2004;101 (52):18171 -6. [https://doi.org/10.1073/ pnas.0405831102] [PMCID: 539733]
4. Fontana L, Villareal DT, Das SK, Smith SR, Meydani SN, Pittas AG, et al. CALERIE Study Group. Effects of 2-year calorie restriction on circulating levels of IGF-1, IGF-binding proteins, and cortisol in nonobese men and women: a randomized clinical trial. Aging Cell 2016 Feb;15(1):22-7. [https://doi.org/10.1111/acel.12400] [PMID: 26443692] [PMCID: PMC4717266]
5. Patterson RE, Laughlin GA, LaCroix AZ, Hartman SJ, Natarajan L, Senger CM, et al. Intermittent Fasting and Human Metabolic Health. J AcadNutr Diet 2015 Aug;115(8):1203-12. [https://doi. org/10.1016/j.jand.2015.02.018] [PMID: 25857868] [PMCID: PMC4516560]
6. Longo VD, Mattson MP. Fasting: molecular mechanisms and clinical applications. Cell Metab 2014; 19:181-92. [https://doi. org/10.1016/j.cmet.2013.12.008] [PMID: 24440038] [PMCID: PMC3946160]
7. Wei M, Brandhorst S, Shelehchi M, Mirzaei H, Cheng CW, Bud-niak J, et al. Fasting-mimicking diet and markers/risk factors for aging, diabetes, cancer, and cardiovascular disease. Sci Transl Med 2017 Feb 15;9(377). pii: eaai8700. [https://doi.org/10.1126/ scitranslmed.aai8700] [PMID: 28202779] [PMCID: PMC6816332]
8. Brandhorst S, Choi IY, Wei M, Cheng CW, Sedrakyan S, Navarrete G, et al. A Periodic Diet that Mimics Fasting Promotes Multi-System Regeneration, Enhanced Cognitive Performance, and Healthspan. Cell Metab 2015 Jul 7;22(1):86-99 [https://doi.org/10.1016/j. cmet.2015.05.012] [PMID: 26094889] [PMCID: PMC4509734]
9. Alirezaei M, Kemball CC, Flynn CT, Wood MR, Whitton JL, Kiosses WB. Short-term fasting induces profound neuronal autophagy. Autophagy 2010 Aug 16;6(6):702-10. [https://doi.org/10.4161/ auto.6.6.12376] [PMID: 20534972] [PMCID: PMC3106288]
10. Hu Y, Yang Y, Zhang M, Deng M, Zhang JJ. Intermittent Fasting Pretreatment Prevents Cognitive Impairment in a Rat Model of Chronic Cerebral Hypoperfusion. J Nutr 2017 Jul;147(7):1437-45. [https://doi.org/10.3945/jn.116.245613] [PMID: 28515159]
11. Nencioni A, Caffa I, Cortellino S, Longo VD. Fasting and cancer: molecular mechanisms and clinical application. Nat Rev Cancer 2018 Nov;18(11):707-19. [https://doi.org/10.1038/s41568-018-0061-0] [PMID: 30327499]
12. Almeida L, Lochner M, Berod L, Sparwasser T. Metabolic pathways in T cell activation and lineage differentiation. Semin Immunol 2016 Oct;28(5):514-24. [https://doi.org/10.1016/j.smim.2016.10.009] [PMID: 27825556]
13. Lochner M, Berod L, Sparwasser T. Fatty acid metabolism in the regulation of T cell function. Trends Immunol 2015 Feb;36(2):81-91. [https://doi.org/10.1016/j.it.2014.12.005] [PMID: 25592731]
14. Yang Z, Matteson EL, Goronzy JJ, Weyand CM. T-cell metabolism in autoimmune disease. Arthritis Res Ther 2015 Feb 11 ;17:29. [https://doi.org/10.1186/s13075-015-0542-4] [PMID: 25890351] [PMCID: PMC4324046]
15. Yang Z, Fujii H, Mohan SV, Goronzy JJ, Weyand CM. Phosphof-ructokinase deficiency impairs ATP generation, autophagy, and redox balance in rheumatoid arthritis T cells. J Exp Med 2013 Sep 23;210(10):2119-34. [https://doi.org/10.1084/jem.20130252] [PMID: 24043759] [PMCID: PMC3782046]
16. Gelderman KA, Hultqvist M, Olsson LM, Bauer K, Pizzolla A, Olofsson P, et al. Rheumatoid arthritis: the role of reactive oxygen species in disease development and therapeutic strategies. Antioxid Redox Signal 2007;9:1541-67. [https://doi.org/10.1089/ ars.2007.1569] [PMID: 17678439]
17. Weyand CM, Yang Z, Goronzy JJ.T-cell aging in rheumatoid arthritis. Curr Opin Rheumatol 2014 Jan;26(1):93-100. [https:// doi.org/10.1097/B0R.0000000000000011] [PMID: 24296720] [PMCID: PMC3984035]
18. Faris MA, Kacimi S, Al-Kurd RA, Fararjeh MA, Bustanji YK, Mohammad MK, Salem ML. Intermittent fasting during Ramadan attenuates proinflammatory cytokines and immune cells in healthy subjects. Nutr Res 2012 Dec;32(12):947-55. [https://doi. org/10.1016/j.nutres.2012.06.021] [PMID: 23244540]
19. Adawi M, Watad A, Brown S, Aazza K, Aazza H, Zouhir M, et al. Ramadan Fasting Exerts Immunomodulatory Effects: Insights from a Systematic Review. Front Immunol 2017;8:1144. [https:// doi.org/10.3389/fimmu.2017.01144] [PMID: 29230208] [PMCID: PMC5712070]
20. Kovarik JJ, Kernbauer E, Hölzl MA, Hofer J, Gualdoni GA, Schmetterer KG, et al. Fasting metabolism modulates the interleukin-12/interleukin-10 cytokine axis. PLoS One 2017 Jul 24; 12(7):e0180900. [https://doi.org/10.1371/journal. pone.0180900] [PMID: 28742108] [PMCID: PMC5524343]
21. Joesting JJ, Moon ML, Gainey SJ, Tisza BL, Blevins NA, Freund GG. Fasting Induces IL-1 Resistance and Free-Fatty Acid-Mediated Up-Regulation of IL-1R2 and IL-1RA. Front Immunol 2014;5:315. [https://doi.org/10.3389/fimmu.2014.00315] [PMID: 25071776] [PMCID: PMC4089087]
22. Choi IY, Piccio L, Childress P, Bollman B, Ghosh A, Brandhorst S, et al. Diet mimicking fasting promotes regeneration and reduces
mediterranean journal 30
of RHEUMATOLOGY 4 2019
autoimmunity and multiple sclerosis symptoms. Cell Rep 2016 Jun 7;15(10):2136-46. [https://doi.org/10.1016/j.celrep.2016.05.009] [PMID: 27239035] [PMCID: PMC4899145]
23. Cheng CW, Adams GB, Perin L, Wei M, Zhou X, Lam BS, et al. Prolonged Fasting reduces IGF-1/PKA to promote hematopoietic stem cell-based regeneration and reverse immunosuppression. Cell Stem Cell 2014 Jun 5;14(6):810-23. [https://doi.org/10.1016/j. stem.2014.04.014] [PMID: 24905167] [PMCID: PMC4102383]
24. Alamanos Y, Drosos AA. Epidemiology of adult rheumatoid arthritis. Autoimmun Rev 2005 Mar;4(3):130-6. [https://doi.org/10.1016/j. autrev.2004.09.002] [PMID: 15823498]
25. Vaahtovuo J, Munukka E, Korkeamaki M, Luukkainen R, Toivanen P. Fecal microbiota in early rheumatoid arthritis. J Rheumatol 2008;35(8):1500-5. [PMID: 18528968]
26. Liu Y, Hazlewood GS, Kaplan GG, Eksteen B, Barnabe C. Impact of obesity on Remission and Disease Activity in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis. Arthritis Care Res (Hoboken) 2017 Feb;69(2):157-65. [https://doi.org/10.1002/ acr.22932] [PMID: 27159376]
27. Alivernini S, Tolusso B, Gigante MR, Petricca L, Bui L, Fedele AL, Di Mario C, et al. Overweight/obesity affects histological features and inflammatory gene signature of synovial membrane of Rheumatoid Arthritis. Sci Rep 2019 Jul 18;9(1):10420. [https://doi.org/10.1038/ s41598-019-46927-w] [PMID: 31320744] [PMCID: PMC6639364]
28. Martin RH. The role of nutrition and diet in rheumatoid arthritis. Proc Nutr Soc 1998;57:231-4. [https://doi.org/10.1079/pns19980036] [PMID: 9656325]
29. Salminen E, Heikkila S, Poussa T, Lagstrom H, Saario R, Salminen S. Female patients tend to alter their diet following the diagnosis of rheumatoid arthritis and breast cancer. Prev Med 2002;34:529-35. [https://doi.org/10.1006/pmed.2002.1015] [PMID: 11969354]
30. Skoldstam L, Hagfors L, Johansson G. An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis. Ann Rheum Dis 2003 Mar;62(3):208-14. [https://doi.org/10.1136/ ard.62.3.208] [PMID: 12594104] [PMCID: PMC1754463]
31. Tedeschi SK, Bathon JM, Giles JT, Lin TC, Yoshida K, Solomon DH. Relationship Between Fish Consumption and Disease Activity in Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2018 Mar;70(3):327-32. [https://doi.org/10.1002/acr.23295] [PMID: 28635117] [PMCID: PMC5740014]
32. Goldberg RJ, Katz J. A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain 2007 May;129(1-2):210-23. [https://doi. org/10.1016/j.pain.2007.01.020] [PMID: 17335973]
33. Khanna S, Jaiswal KS, Gupta B. Managing Rheumatoid Arthritis with Dietary Interventions. Front Nutr 2017;4:52. [https://doi. org/10.3389/fnut.2017.00052] [PMID: 29167795] [PMCID: PMC5682732]
34. Fraser D, Thoen J, Reseland J, Forre O, Kjeldsen-Kragh J. Decreased CD4+ lymphocyte activation and increased interleukin-4 production in peripheral blood of rheumatoid arthritis patients after acute starvation. Clin Rheumatol 1999;18(5):394-401. [https://doi. org/10.1007/s100670050125] [PMID: 10524554]
35. Fraser D, Thoen J, Dioseland O, Forre O, Kjeldsen-Kragh J. Serum levels of interleukin-6 and dehydroepiandrosterone sulphate in response to either fasting or a ketogenic diet in rheumatoid arthritis patients. Clin Exp Rheumatol 2000;18(3):357-62. [PMID: 10895373]
36. Ud6n AM, Trang L, Venizelos N, Palmblad J. Neutrophil functions and clinical performance after total fasting in patients with rheumatoid arthritis. Ann Rheum Dis 1983 Feb;42(1):45-51. [https://doi.org/10.1136/ard.42.1.45] [PMID: 6338840] [PMCID: PMC1001058]
37. Hafstrom I, Ringertz B, Gyllenhammer H, Palmblad J, Harms-Ring-dahl M. Effects of fasting in disease activity, neutrophil function, fatty acid composition, and leukotriene biosynthesis in patients with rheumatoid arthritis. Arthritis Rheum 1988;31:585-92. [https://doi. org/10.1002/art.1780310502] [PMID: 2837251]
38. Peltonen R, Kjeldsen-Kragh J, Haugen M, Tuominen J, Toivanen P, Forre O, et al. Changes of faecal flora in rheumatoid arthritis during fasting and one-year vegetarian diet. Br J Rheumatol 1994 Jul;33(7):638-43. [https://doi.org/10.1093/rheumatolo-gy/33.7.638] [PMID: 8019792]
39. Michalsen A, Riegert M, Lüdtke R, Bäcker M, Langhorst J, Schwickert M. Mediterranean diet or extended fasting's influence on changing the intestinal microflora, immunoglobulin A secretion and clinical outcome in patients with rheumatoid arthritis and fibromyalgia: an observational study. BMC Complement Altern Med 2005;5(1):22. [https://doi.org/10.1186/1472-6882-5-22] [PMID: 16372904] [PMCID: PMC1352378]
40. Abendroth A, Michalsen A, Lüdtke R, Rüffer A, Musial F, Dobos GJ, Langhorst J. Changes of Intestinal Microflora in Patients with Rheumatoid Arthritis during Fasting or a Mediterranean Diet. Forsch Komplementmed 2010;17(6):307-13. [https://doi. org/10.1159/000322313] [PMID: 21196744]
41. Sköldstam L, Larsson L, Lindström FD. Effects of fasting and lactovegetarian diet on rheumatoid arthritis. Scand J Rheumatol 1979;8(4):249-55. [https://doi.org/10.3109/03009747909114631] [PMID: 534318]
42. Müller H, de Toledo FW, Resch KL. Fasting followed by vegetarian diet in patients with rheumatoid arthritis: a systematic review. Scand J Rheumatol 2001 ;30(1):1 -10. [https://doi. org/10.1080/030097401750065256] [PMID: 11252685]
43. Kjeldsen-Kragh J, Borchgrevink C, Laerum E, Haugen M, Eek M, Forre O. Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis. Lancet 1991;338(8772):899-902.
44. Kjeldsen-Kragh J, Mellbye OJ, Haugen M, Mollnes TE, Hammer HB, Sioud M, Forre O. Changes in laboratory variables in rheumatoid arthritis patients during a trial of fasting and one-year vegetarian diet. Scand J Rheumatol. 1995; 24(2):85-93. [https:// doi.org/10.1016/0140-6736(91)91770-u] [PMID: 1681264]
45. Sköldstam L. Fasting and vegan diet in rheumatoid arthritis. Scand J Rheumatol 1986;15(2):219-21. [https://doi. org/10.3109/03009748609102091] [PMID: 3749829]
46. Lindberg E. [Can nutritional factors modify chronic polyarthritis?] Z Physiother 1973 Mar-Apr;25(2):119-29. [PMID: 4578621]
47. Jon Love T, Zhu Y, Zhang Y, Wall-Burns L, Ogdie A, Gelfand JM, et al. Obesity and the risk of psoriatic arthritis: A population-based study. Ann Rheum Dis 2012;71:1273. [https://doi.org/10.1136/ annrheumdis-2012-201299] [PMID: 22586165] [PMCID: PMC3645859]
48. Cañete JD, Mease P. The link between obesity and psoriatic arthritis. Ann Rheum Dis 2012;71:1265. [https://doi.org/10.1136/ annrheumdis-2012-201632] [PMID: 22798633]
49. Damiani G, Watad A, Bridgewood C, Pigatto PDM, Pacifico A, Malagoli P, et al. The Impact of Ramadan Fasting on the Reduction of PASI Score, in Moderate-To-Severe Psoriatic Patients: A Real-Life Multicenter Study. Nutrients 2019 Jan 27;11(2). pii: E277. [https://doi.org/10.3390/nu11020277] [PMID: 30691245] [PMCID: PMC6412911]
50. Adawi M, Damiani G, Bragazzi NL, Bridgewood C, Pacifico A, Conic RRZ, et al. The Impact of Intermittent Fasting (Ramadan Fasting) on Psoriatic Arthritis Disease Activity, Enthesitis, and Dac-tylitis: A Multicentre Study. Nutrients 2019 Mar 12;11(3). pii: E601. [https://doi.org/10.3390/nu11030601] [PMID: 30871045] [PMCID: PMC6471071]
