by Dr. C.H. Weaver M.D. updated 09/2021
Nutrition is the cornerstone of healthy living. Hippocrates said, “Let food be thy medicine.” While food is no substitute for proven medical treatment, it can help build the foundation of a healthy body – and a healthy body is stronger in the face of stress and illness.
There is no special diet that will cure any inflammatory or autoimmune condition; however, nutrition is still important for building a solid foundation of health. Research has consistently indicated that everyone, can benefit from eating a nutrient-dense, whole-foods diet and avoiding processed and refined foods.
An Italian report that studied the effect of the Mediterranean diet on inflammation associated over a 6-month period provides new evidence that this diet may help control chronic inflammatory conditions.24
The Importance of a Healthy Diet
Nutrition is one of the many tools in your toolkit to help you live well and stay healthy. True, a healthy diet cannot cure you; however, it can help you maintain overall health and keep other conditions, such as heart disease, at bay. Unfortunately, some research indicates that individuals with inflammatory and autoimmune arthritis have a lower quality diet compared to their healthy counterparts. Even the smallest changes in dietary quality can translate into better nutritional status and individuals living might benefit from improving their diet.1
Nutrition and Symptoms
Despite years of study, there is no evidence that diet plays a role in either aggravating or diminishing the symptoms of RA, AS or PsA and there is no special “diet cure”; however, some individuals find that avoiding certain foods or eating certain foods can help their symptoms. It is important to remember, though, that there is no one-size-fits-all diet—every person is unique and has individualized dietary requirements. So, while one person with may need to avoid a certain type of food, another person may thrive while eating that food.
Some research indicates that 30% to 40% of people with RA improve substantially by following an elimination diet to identify foods that are associated with symptoms and then avoiding these foods.2 Typically, these individuals respond to the elimination diet within 10-21 days and the benefits are maintained if the offending foods are avoided.
Fasting, on the other hand, produces different results. Nearly all people with RA respond well to fasting and the response occurs within 3-5 days; however, the benefits are lost as soon as a normal diet is resumed.
The relationship between food sensitivity and rheumatoid arthritis is unclear and research is ongoing to continue to examine the issue. Some researchers have speculated that gut flora may play a role, but no clear evidence has been established.
If you suspect that certain foods are helping or hurting your symptoms, consider keeping a food diary to identify “trigger” foods. You may wish to work with your rheumatologist, allergist, or nutritionist to implement an elimination diet in order to identify problem foods.
Nutrition is paramount for anyone living with an autoimmune or inflammatory condition because both the disease and the medications used to treat it have been linked to nutritional deficiencies.
Individuals living with these conditions can become deficient as a result of weight loss and weakened health or as a result of the increased metabolic rate and protein breakdown associated with chronic inflammation.3 Further exacerbating the problem, some medications cause decreased appetite or digestive problems along with specific deficiencies. For example, methotrexate is often associated with a deficiency in folic acid. One often-overlooked cause of nutritional deficiency is more simple—the pain and associated swelling can make food preparation difficult.
Many people will suffer from low levels of vitamin C, vitamin D, vitamin B6, vitamin B12, vitamin E, folic acid, calcium, magnesium, zinc, and selenium. Food is always the optimal source of vitamins and minerals; however, some people may need to use supplements. It’s important to work with your physician to continually monitor and address nutritional deficiencies.
Vitamin D Deficiency: There is a lot of recent debate over the relationship between vitamin D and RA. Vitamin D has been shown to modulate the immune system and its deficiency has been linked to the development of some autoimmune disorders, including multiple sclerosis. RA has also been associated with vitamin D deficiency.4 Some experts have concluded that vitamin D deficiency occurs at higher rates among individuals with autoimmune disorders and supplementation might be necessary.
Furthermore, the risk of osteoporosis is higher in people with RA and some RA medications—such as prednisone—can cause bone loss. In other words, adequate vitamin D levels are vitally important in RA.
Beta Carotene Deficiency: Oxidative damage has been implicated in the development of RA and antioxidants have been shown to combat inflammation and free radicals. Beta carotene is an antioxidant found in brightly colored foods such as pumpkin, sweet potatoes, carrots, and beets. One study indicated that individuals with RA have 29% lower levels of beta carotene levels than the general population.5 The researchers concluded that low antioxidant status might be a risk factor for RA. Of course, no one knows which came first—the low beta carotene levels or the RA. Still, it may be important for individuals with RA to supplement and to be sure to eat foods rich in beta carotene.
Selenium Deficiency: Selenium is a mineral that helps to fight free radicals that cause damage to healthy tissue. Some research indicates that people with RA and AS may have lower levels of selenium in their blood.6,7 Thus far, there are no recommendations for selenium supplementation, but individuals should pay attention to their diet and be sure to include selenium-rich foods such as eggs, tuna, or Brazil nuts. Just two Brazil nuts contain an adequate daily supply of selenium.
Folic Acid: Folic acid is a B vitamin found in dark leafy greens, lentils, beans, broccoli, avocado, and some nuts and seeds. Your body uses folic acid—along with iron—to manufacture red blood cells. Folic acid is especially important if you take methotrexate. By supplementing with folic acid, you may avoid some of the side effects of the medication.
Nutritional Deficiencies and Other Health Problems: Individuals are more likely to develop osteoporosis, anemia, and heart disease—all of which are associated to some degree with diet.
Anemia and Iron: Approximately 30%-60% of people with autoimmune or chronic inflammatory conditions have some form of anemia, which refers to a low level of red blood cells. The anemia may be the result of chronic inflammation or iron deficiency or both. Some medications have also been linked to iron deficiency. As a result, some people need to take iron supplements.
Osteoporosis, Calcium, and Vitamin D: Osteoporosis is a condition characterized by reduced bone mass and quality, resulting in weaker bones that are more likely to break. Individuals with arthritis are two to four times more likely to develop osteoporosis for a variety of reasons—the arthritis itself, medications used to treat the condition, or reduced physical activity. To treat and prevent osteoporosis, eat a diet rich in calcium, vitamin D, and magnesium and avoid alcohol and tobacco.
Obesity has been associated with worse outcomes in RA, AS and PsA. Individuals who are obese or overweight have higher disease activity, more pain, and worse general health. Furthermore, these individuals are at higher risk for diabetes and heart disease. The research indicates that excess weight puts added strain on the weight-bearing joints and worsens the joints, making them stiffer and more painful. What’s more—being overweight can exacerbate flares.8
Maintaining a healthy weight is important for your joints and your overall health. If you are overweight, you may want to talk to your doctor about an appropriate weight-loss program for you. Shedding those excess pounds could mean less pain and better overall health.
Nutrition That May Negatively Impact Your Symptoms
No research has identified any dietary causes; however, some studies have identified some foods to avoid.
Saturated Fat: Research indicates that saturated fat may increase inflammation in the body. Foods that are high in saturated fats—such as bacon, red meat, and butter—may increase the level of prostaglandins in the body. Prostaglandins are chemicals that cause inflammation, pain, swelling, and joint destruction.
Meat: Meat contains high amounts of arachidonic acid, which is a fatty acid that is converted to inflammatory prostaglandins in the body. Some, but not all, people benefit from a vegetarian diet.
Omega-6 Fatty Acids: Omega-6 fatty acids are found in vegetable oils that contain linoleic acid, such as corn oil, soybean oil, sunflower oil, wheat germ oil, and sesame oil. Excessive consumption of omega-6 fatty acids has been linked to cancer, cardiovascular disease, and inflammatory and autoimmune diseases. The standard western diet is heavy on omega-6 fatty acids, but research has shown that for optimal health it’s important to consume fewer omega-6 fatty acids and more omega-3 fatty acids. There may be a link between inflammation and consumption of omega-6 fatty acids. Some individuals may benefit from restricting their intake of omega-6 fatty acids.
Nutrition That May Positively Impact Your Symptoms
No food can cure an autoimmune disease or arthritis; however, some foods have been shown to provide benefit to those living with these conditions.
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Omega-3 Fatty Acids: Omega-3 fatty acids are the polyunsaturated fats found in cold-water fish and some nuts and seeds, including salmon, sardines, walnuts, flaxseeds, and chia seeds. Omega-3s are a critical component of any healthy diet and have been shown to reduce inflammation.
Omega-3 fatty acids have been widely studied and there is reasonably strong evidence to show that they do provide a benefit.9-12 They appear to reduce inflammation by decreasing the production of inflammatory chemicals. While omega-3 fatty acids may improve some symptoms, they do not appear to slow progression of the disease.
Some research indicates that omega-3 fatty acids may be better absorbed from food than supplements, so those individuals may want to consider eating foods that are rich in omega-3 fatty acids.13
Fish Oil: Fish oil is high in omega-3 fatty acids and may decrease the inflammatory response in RA.14 Some people experience an improvement in their symptoms and are even able to discontinue their use of non-steroidal anti-inflammatory drugs (NSAIDs) without experiencing disease flare.15 There are numerous ongoing studies to evaluate the effects of fish oil in RA and AS. Thus far, fish oil appears to provide a benefit and some researchers note that fish oil does not carry the increased cardiovascular risk associated with NSAIDs.16 Some research even indicates that intake of oily fish was associated with a modestly decreased risk of developing rheumatoid arthritis.17
Many people report improvement in pain and joint tenderness when taking fish oil. Although it is promising, fish oil will not produce instant results. It can take weeks or even months to notice a decrease in symptoms.
It’s important not to overdo it with fish oil, as some fish oil supplements may have high levels of vitamin A or mercury. Furthermore, fish oil may cause drug interactions with some medications. If you plan to take fish oil, be sure to discuss it with your doctor first.
Mediterranean Diet: The Mediterranean diet is based on a pattern of eating tied to the Mediterranean region, which includes Greece and southern Italy. The diet emphasizes large amounts of fruits and vegetables, olive oil, fatty fish, and limited meat consumption. The Mediterranean diet has been widely studied and has been shown to reduce the risk of cardiovascular disease, diabetes, obesity, and cancer. Because it is high in omega-3 fatty acids, the diet is believed to have anti-inflammatory and protective properties.
Research shows that the Mediterranean diet might protect against severe symptoms. In fact, it has been shown to reduce disease activity and pain and stiffness in patients with RA.18 One study found that after about six weeks on a Mediterranean diet, people with had reduced inflammation, pain, and swelling and improved physical functioning and vitality.19 Notably, the incidence of RA and AS is lower in Mediterranean countries.
Antioxidants: Antioxidants are vitamins, minerals, and other nutrients that protect and repair cells from damage caused by free radicals, which are harmful byproducts produced by the body. Antioxidants are found in vitamins, such as vitamin E, vitamin C, and beta carotene and minerals, such as zinc and selenium. Eating a diet rich in fruits and vegetables—and therefore antioxidants—has been shown to combat inflammation and protect the immune system. Antioxidants are found in colorful fruits and vegetables, especially those that are red, orange, yellow, purple, and blue. Some antioxidant-rich foods include carrots, pumpkin, bell peppers, tomatoes, blueberries, sweet potatoes, broccoli, and spinach—but there are many, many more foods loaded with antioxidants.
Some research indicates that antioxidants help reduce the inflammation, pain, and swelling associated autoimmune conditions. One study found that RA patients who took antioxidant supplements reported a decrease in the number of swollen and painful joints and an increase in general health.20 Research is ongoing to evaluate the relationship between antioxidants and RA—but it can never hurt to eat a diet rich in antioxidants for overall health.
Gluten-Free, Vegan Diet: Some research has indicated that a gluten-free, vegan diet has anti-inflammatory effects and may be beneficial.21 A vegan diet is rich in fruits, vegetables, grains, and legumes—all of which are high in phytonutrients, which are chemicals that contain disease-fighting properties and immune-boosting antioxidants. A plant-based diet is also high in bioflavonoids, which are plant compounds that have anti-viral, anti-inflammatory, and anti-tumor activities.
Gluten is a protein found in wheat, barley, rye, malts, and triticale. Some people, including those with Celiac disease, are allergic to gluten, whereas many others are simply sensitive or intolerant to it. Gluten can trigger an autoimmune response in these people. Thus far, there is no data supporting a link between gluten and RA, AS or PsA; however, some people find benefit in excluding gluten from their diet.
Diet Dos and Don’ts
Again, there is no special diet that, but a healthy diet goes a long way to maintaining optimal health. Based on the current available data, individuals might benefit from the following dietary guidelines:
- Balanced Diet: Eat a balanced, immune-supportive diet that is high in fruits, vegetables, antioxidants, and essential fatty acids and low in saturated fats and processed and refined foods.
- Nutrients: Work with your doctor to monitor and address any nutritional deficiencies you may have as a result of the disease or the medications used to treat it.
- Choose Healthy Fats: Pay close attention to fat consumption and choose healthy omega-3 fatty acids over saturated fat or omega-6 fatty acids.
- Supplements: Consider supplementing with antioxidants, fish oil, and other nutrients. Work with your doctor to determine the appropriate type and dose of supplements.
- Anti-inflammatory Foods: Add anti-inflammatory foods to your diet. It can’t hurt and it might help.
- Limit Alcohol Consumption: Use caution with alcohol consumption. Speak with your physician regarding alcohol-medication interactions. If you are taking methotextrate, avoid alcohol entirely.
- Maintain Healthy Weight: Maintain a healthy weight to reduce the severity of your RA symptoms.
- Keep a Food Journal: Maintaining a food journal will help you identify and avoid any problem foods.
Ask The Expert About Nutrition and Inflammatory Arthritis
Rebecca Manno, MD, MHS, assistant professor of medicine in the Division of Rheumatology at Johns Hopkins University, addresses some common questions and misperceptions about the role of nutrition in rheumatoid arthritis (RA).
Q: Can a specific type of diet or certain foods cause RA?
A: In terms disease onset, there are no data that definitively point to any particular food or diet that causes rheumatoid arthritis.It is possible that certain foods could contribute to a disease flare, but there are no data to suggest that there are universal flare-provoking foods. A certain individual may notice a personal pattern of certain triggers, but this is unlikely to be universal among all patients given the nuances of the immune system and the wide range of antigen stimulation by foods.
Q: What role do nutrition and diet play in the management of RA?
A: Food choices can affect body composition for those with RA just as they can for the general population not affected by RA. There are data that show, however, that individuals with RA have less lean muscle and more fat than individuals without RA, even after controlling for certain medication, such as corticosteroids, which are notorious for causing such changes in body composition. For that reason, wise food choices may be even more important to the individual with RA to combat this predisposition to muscle loss and fat gain.
Q: What research is currently available related to nutrition and RA?
A: Unfortunately, the role of nutrition in RA is a poorly studied area. A well-done study of nutrition can be expensive and time consuming, although such rigorous science can provide important guidance for our patients.
Q: There seems to be a lot of confusion over the effectiveness of certain diets in relieving symptoms of RA—specifically, the anti-inflammatory diet and the gluten-free diet. Can you discuss?
A: Though different diets have become popular at various times, there are no data specifically related to their impact on RA. As mentioned earlier, there is no diet that can prevent the onset of RA. The possibility that diet or nutrition could be an adjunct to medical treatment is an interesting idea, but at this time it is not based in rigorous science. Regarding the anti-inflammatory diet, this type of diet generally includes a healthy combination of unprocessed foods, natural proteins, fruits, and vegetables. This is a winning combination for overall health whether you have RA or not. I would tell my patients that this is a great way to eat regardless. It can be a huge life adjustment. But is it healthy eating? Absolutely. Can I tell you that it will make your RA better? Absolutely not. Can I tell you that you might feel better? You might. But is that because RA is being treated by it? Nobody can make that conclusion.
Regarding the gluten-free diet, there is a well-described entity of gluten sensitivity, which can have an associated arthritis, called celiac disease. In celiac, which is a completely separate disease process from RA, gluten is the antigen that stimulates the immune system and can lead to gastrointestinal (GI) symptoms (weight loss, diarrhea, and abdominal pain) and other autoimmune phenomena (arthritis and rashes). The treatment for celiac is to eliminate gluten from the diet. These patients do see a marked improvement in the arthritis, but it’s important to keep in mind that this is a unique entity compared with RA.For people who may be gluten intolerant but do not meet diagnostic categorization for celiac, I advise that if they note an improvement in nonspecific GI symptoms or arthritis symptoms while adopting a gluten-free diet, stick with it. In general, gluten-free diets are quite healthy, as they eliminate many of the processed carbohydrates (wheat, pasta, and breads) that cause spikes in blood sugar (which leads to crashes in blood sugar and fatigue) and promote the storage of fat. There is no universal recommendation for all RA patients to adopt a gluten-free diet, as many RA patients do not have gluten sensitivity and therefore would not derive any direct benefit from this type of diet.
Q: Why do you think nutrition and diet remain such hot topics among RA patients?
A: When patients ask us about food, what they want to know is what they can do in their everyday life—outside of shots, infusions, and pills—to treat RA. When they are able to use food as treatment, they feel empowered; they feel better about making food selections than they do about injections or medications—there is the idea that it is somehow safer, better, and more natural.
Q: There are a lot of blogs and other online material that describe personal success with various diets. What should patients keep in mind as they consider these personal stories?
A: When my patients bring in blogs or other personal stories and tell me that they want to eat the same way the author does, I just remind them that they are reading about one person’s experience. It may not relate to their situation.This is why research is important: in a research study, at least you can draw a conclusion about a population of patients—you can say, for instance, that a group of 35 patients who have positive antibodies, have four swollen joints, and are on a certain type of medicine made this specific change to their diet, and that this was the outcome. With personal experience, you don’t know any of those details, so you can’t assume that you will have that same outcome.
*Dietitians can help provide valuable information about nutrition after an RA diagnosis.*The role of diet in the management of RA can be a confusing topic for patients, who often have a lot of questions about how they should approach nutrition after a diagnosis. Working with a dietitian in addition to a rheumatologist can help patients understand the steps they can take to improve their overall health. Jennifer Nelson, director of clinical dietetics/nutrition at the Mayo Clinic, says that patients she works with arrive with a lot of questions about how they can use nutrition as a tool: “Most of the questions I receive are about diet itself—what to eat and what to avoid—and about supplements.” Patients also wonder about specific diets, she says. The role of a dietitian is to answer these questions and to work with each patient to help find nutrition solutions that are right for the patient’s specific situation. “My role is to help the individual choose a diet that meets their unique needs and to ensure that whatever supplements they take promote their health—and don’t result in further problems,” Jennifer says.To that end, she engages in a dialogue that will help her understand the patient’s needs so that she can provide constructive insight. “I listen to each patient with concern for their problems and ask questions in a way that partners us in finding ways that nutrition can help relieve them,” she says. “If they don’t have any idea about the role of nutrition and RA, I bring them along that pathway of understanding diet and its role in inflammation and/or in relieving RA complications.” If a patient already has a good understanding of the basics of diet and nutrition, she focuses on making further progress. And if she recognizes potentially harmful assumptions or patterns, she can help move patients along a healthier path: “If they have misconceptions, we discuss them, evaluate what they are doing, and work to reduce risky choices and behaviors and substitute healthier ones.”Though data to establish definitive connections between nutrition and RA are still lacking, patients can benefit from learning more about how their overall health can be improved by making healthy food choices. Working with a dietitian can provide valuable information and support to make these changes and can help patients feel empowered in their daily lives.
Rebecca Manno, MD, MHS*, is assistant professor of medicine in the Division of Rheumatology at Johns Hopkins University. Dr. Manno’s research interests are focused on the intersection of aging and rheumatic diseases. She is particularly interested in studying the new onset of rheumatic diseases among older individuals and improving the care delivery for patients aging with these diseases. Her research is based in the application of resistance exercise for older patients with inflammatory disease (rheumatoid arthritis and vasculitis) to improve body composition, strength, and function and to decrease inflammation. Dr. Manno received her bachelor of science degree from Johns Hopkins University and her medical degree from University of Maryland School of Medicine. She completed her internship and residency in internal medicine at University of Maryland School of Medicine and Baltimore Veterans Medical Center, where she was chief resident; and she completed a postdoctoral fellowship in rheumatology at Johns Hopkins University School of Medicine.
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