A healthy diet can play a key role in building and maintaining healthy bones for everyone. But if you have ankylosing spondylitis, it can be even more important to pay attention to what you eat and drink.
While there’s no specific diet for ankylosing spondylitis (for instance, a review of 16 studies published in March 2018 in European Journal of Rheumatology found that there isn’t conclusive evidence of a relationship between diet and ankylosing spondylitis), eating healthy foods, along with other interventions such as quitting smoking, exercising, and taking medications as prescribed, can help reduce inflammation and maintain bone health.
This is especially important because osteoporosis has been shown to be common in people with ankylosing spondylitis, likely due to inflammation in the body as well as decreased mobility, according to an article published in July 2015 in Rheumatic and Musculoskeletal Diseases. Because ankylosing spondylitis is a type of inflammatory arthritis that primarily affects the spine, people with this condition also have an increased risk of spinal fractures.
“With ankylosing spondylitis, it’s good as prevention to know what’s good for optimal bone health,” says Deborah McInerney, RD, clinical nutritionist at Hospital for Special Surgery in New York City. Since you know that you have an elevated risk of osteoporosis, it’s worth brushing up or learning about those risks and what you can do to minimize them, she says.
“There are a lot of medical conditions that involve inflammation and meeting recommended daily allowances for key nutrients, and ankylosing spondylitis would fall under that category,” says Patrick Scheel, clinical dietitian at University of Florida Health. “When considering bone health and inflammation, there are definitely foods that you want to avoid, and some nutrients you want to make sure you get.”
Foods to Eat
Try to incorporate these bone health-promoting foods into your daily diet:
Foods rich in calcium
We know that calcium is necessary to build and maintain bones, says Scheel, but many people don’t know that calcium also plays an important role in muscle and nerve function. The National Institute of Health’s Office of Dietary Supplements (ODS) recommends 1,000 mg of calcium a day for adults and 1,200 mg a day for women over 50 and all adults over 70.
Some calcium-rich foods include:
- Low-fat dairy such as milk, yogurt, and cheese
- Canned fish with bones
- Leafy greens
(For a list of more calcium-rich foods, check out this list from the ODS.)
According to Scheel, the ankylosing spondylitis patients he works with find it’s easy to incorporate these foods and meet their calcium requirements. (For instance, you can get about 400 mg of calcium from 1 cup of low-fat yogurt, 300 mg from 1 cup of low-fat milk, and 200 mg from a 3 oz can of salmon, according to the ODS.) Once they start adding these healthy foods up, says Scheel, a lot of people are impressed by how quickly they can reach that recommended daily allowance.
Vitamin-D rich foods
“You can’t really talk about calcium without talking about vitamin D,” notes Scheel. That’s because vitamin D helps your body absorb calcium, according to the National Osteoporosis Foundation (NOF).
Vitamin D helps keep your bones strong and supports muscles needed to avoid falls, notes the NOF. It also helps regulate immune function and plays a key role in your immune health, says Scheel.
You can get vitamin D from being outside in the sun, but you’ll probably need to get it from your diet, too. Adults need about 600 IUs of vitamin D a day; after age 70, that number goes up to 800 IUs, according to the ODS. Some good sources of vitamin D are:
- Fatty fish such as rainbow trout
- Cod liver oil
- Fortified foods such as orange juice, milk (cow’s or plant-based), and cereal
(You can find more vitamin D-rich foods listed on ODS.)
Foods to Avoid
Here are some foods you should try to limit for bone health:
Sodium is a key nutrient, but at the same time, many people in the U.S. exceed sodium recommendations, notes Scheel. “When you have too much sodium in your diet, it increases calcium excretion in the urine,” he says.
The 2015-2020 Dietary Guidelines for Americans recommend people consume less than 2,300 mg of sodium a day. But the average American consumes 3,400 mg, according to the Centers for Disease Control and Prevention. “Cutting down the sodium is definitely beneficial for bone health,” says Scheel.
Another reason to watch your sodium intake: your heart. “When you look at ankylosing spondylitis, these patients are also at increased risk for cardiovascular disease,” says Scheel. According to the American Heart Association (AHA), when you eat too much sodium, it pulls water into your blood vessels, which increases blood pressure, creating an extra burden on your heart and your blood vessels. In some people, this can lead to high blood pressure, which is linked to increased risk of heart disease or stroke.
Watch for high-sodium foods such as pizza, canned soup, and cold cuts (as well as sources of “hidden” sodium such as ketchup, mayo, and other condiments); read food labels carefully; and cook fresh foods using less salt, advises the AHA. Scheel also recommends avoiding processed foods because they tend to be loaded with sodium. And don’t forget to eat lots of fresh fruits and vegetables and drink plenty of water, he adds.
Foods high in sugar
“Refined sugar — the kind you find in cakes, cookies, and pies — increases inflammatory markers,” says Scheel. A review published in May 2018 in the journal Nutrients notes that several studies have linked sugar consumption especially from sugary beverages with chronic inflammation. People who eat a lot of sugar have more inflammatory markers such as C-reactive protein in their blood.
Another reason to cut down on sugar: People with spondyloarthritis (an umbrella term for inflammatory diseases that impact the spine, including ankylosing spondylitis) who are obese tend to have worse disease symptoms and lower quality of life and more mobility and physical ability issues than those who are not overweight, according to findings from research presented at the American College of Rheumatology/Association of Rheumatology Professionals 2017 annual meeting. “Keep your weight in a healthy range because if you are super underweight or super overweight, you have an increased risk for a fracture,” says McInerney.
Some ideas for cutting down your sugar intake: Steer clear of juice, soda, energy drinks, and other sugar-loaded beverages; satisfy your sweet tooth with whole fruits rather than cookies, cakes, and candy; and check nutrition labels to avoid foods containing high fructose corn syrup and other sweeteners.
According to Scheel, increasing soda intake, regardless of whether it contains sugar or a sugar substitute, can decrease bone density, especially in older women.
A study published in August 2014 in the American Journal of Clinical Nutrition, which followed more than 73,000 women between the ages of 30 and 55 for 30 years, found that drinking soda was linked to an increased risk of hip fracture in postmenopausal women (each additional serving of total soda per day increased risk of hip fracture by 14 percent). This elevated risk was similar for both regular and diet sodas, colas and non-colas, and sodas with or without caffeine. The researchers noted that their study hadn’t found a clear explanation for how exactly soda may contribute to bone loss, and noted that more research needs to be done.
Scheel believes that the link may have something to do with the fact that when you consume a soft drink, your body is tricked into thinking you’re getting calories. According to the Cleveland Clinic, some research has suggested that the brain reacts to artificial sweeteners the same way it reacts to sugar, and drinking diet sodas regularly may lead to an increased craving for foods that are high in calories, fat, and sugar.
Another reason to skip sodas: When you drink them, you’re missing out on key nutrients that you can get from beverages such as fortified orange juice or milk, says Scheel.
“If you can drink mostly water, do that,” says Scheel. But if you absolutely have to have a carbonated drink, go for seltzer with fresh fruit.
“Caffeine in moderate intakes doesn’t seem to pose much of a problem,” says Scheel. But, he notes, research has shown that having more than 300 mg of caffeine a day can increase bone mineral density loss, especially in postmenopausal women.
Scheel advises trying to cut down or eliminate caffeine altogether by getting enough sleep, drinking more water, and switching to caffeine-free beverages instead of your morning coffee. If you must have caffeine, be sure to limit your intake to about three cups of coffee a day, he suggests.
“There’s a lot of things alcohol does in the gastrointestinal (GI) tract to impair nutrient absorption that we definitely want to avoid,” says Scheel.
Alcohol can impact GI tract permeability, which has to do with what your GI tract is letting in and what it’s not letting in, says Scheel. “The GI tract acts as a protective barrier and has a lot of immune cell function,” he says. Alcohol can impair your GI tract’s ability to absorb nutrients and block certain things that may be harmful, and it can cause inflammation, says Scheel.
According to the ODS, alcohol can reduce the body’s ability to absorb calcium and inhibit enzymes in the liver that help convert vitamin D to a form that can be used by the body.
And a study published in October 2019 in Arthritis and Research Therapy found that drinking alcohol was significantly linked to worsening of spinal structural damage in axial spondyloarthritis.
“If you can avoid alcohol altogether, I would recommend that,” says Scheel. If you do drink, the NOF recommends limiting your intake to no more than two to three drinks a day.
General Tips for Your Diet
Diet alone can’t cure ankylosing spondylitis. But following a healthy meal plan can help you reduce inflammation and feel better overall, in addition to helping keep your bones strong. Here are some tips to keep in mind.
Make an individualized eating plan with a professional. Work with a clinical nutritionist or registered dietitian who specializes in inflammatory forms of arthritis to come up with a plan tailored specifically to your needs. “When it comes to medical nutrition therapy, diet should be individualized,” says Scheel.
Keep track of what you eat. Do a diet inventory, advises McInerney. Keep a food log for a week and evaluate what you’re eating to see if you’re hitting all the food groups and identify your gaps, she says.
Use ChooseMyPlate.gov as your guide. ChooseMyPlate.gov is a great tool that allows you to visualize what your meals should ideally be comprised of — mostly fresh fruits and vegetables with whole grains and lean protein. “It’s reminding people of all the food groups,” notes McInerney. “One of the things that is not listed on there is processed food.”
Eat fewer processed foods. Nutrition labels are useful and important sources of information (to check for sodium or sugar content, for example), but ideally, most of your foods should be fresh fruits and vegetables and other whole foods that do not have labels, says Scheel.
“If you’re getting food in its natural form, you’re getting more of the nutrients you need,” says McInerney. “With any of these conditions [such as ankylosing spondylitis], people may focus on certain foods or a group of nutrients in search of a quick solution.” But the goal should be to eat a healthy, high-quality diet, she says.
Try probiotics. These may be helpful for ankylosing spondylitis, says Scheel. People with inflammatory arthritis have been shown to have inflammation in the GI tract and are known to be at increased risk for inflammatory bowel disease such as ulcerative colitis and Crohn’s disease. Inflammation increases intestinal permeability, which allows bacteria to cross the intestinal barrier and get into the bloodstream and set off an inflammatory response. Probiotics may help decrease inflammation in the GI tract, keep the intestinal barrier strong, and reduce common biomarkers of inflammation such as C-reactive protein in the body, according to the Arthritis Foundation.
Doctors don’t yet have a clear understanding of exactly how probiotics may affect health, but the potential benefits are tantalizing. “I’d like to see more literature on probiotic use included in treatment plans for ankylosing spondylitis and see more research done on specific diets in these patients,” says Scheel.
And while the Arthritis Foundation notes that supplements are not regulated enough (which means it’s possible you may not get the beneficial probiotics a product claims it contains), you can talk to your dietitian or doctor about ways to get some probiotics into your diet through foods such as yogurt, kefir, or kombucha.
You crave what you get used to eating. Your palate has memory, says McInerney. People who eat fast food tend to want more fast food because that’s what their taste buds get used to eating.
Your dietary needs may change if your disease changes. For instance, people who are older and have had fractures or have advanced disease and some fusion might be less active and more prone to muscle waste, says McInerney. For them, the need for protein may be higher. Talk to your doctor or a registered dietitian about how your nutritional needs may change as your disease progresses.
Cut yourself some slack. “You don’t want to constantly be berating and beating yourself up,” says McInerney. Instead of always focusing on what you cannot eat or drink, she suggests, focus on the positive — on what you can do. “Realistically, everyone is drinking some caffeine and maybe some alcohol,” she says. “But the idea is moderation and variety in diet.” Bottom line: “We’re not perfect; we try to hit all the food groups as best as we can,” says McInerney.