How to Choose the Best Rheumatoid Arthritis Diet for You

Rheumatoid Arthritis, Chronic Inflammation, and Diet

• What We Know about Rheumatoid Arthritis|
• Rheumatoid Arthritis Diet|
• Probiotics for Rheumatoid Arthritis|
• The Bottom Line|

One of the most important components of a rheumatoid arthritis treatment plan is finding the right diet for you. Diet plays a huge role in both systemic inflammation and autoimmunity, with the foods we eat having the power to either reduce or promote inflammation, and to improve or exacerbate symptoms. So what’s the best rheumatoid arthritis diet? 

As with most conditions, there’s no perfect diet for everyone with rheumatoid arthritis. But there are a few foundational principles that apply when it comes to optimizing your diet to reduce inflammation and improve RA symptoms. 

The key is to choose a diet that is anti-inflammatory. The specifics may vary depending on your individual sensitivities, gut microbiome balance, and more. The Mediterranean diet has been the most studied, but other options like the Paleo diet or, in some cases, the more restrictive Autoimmune Paleo diet (AIP) may suit you better (more on this below). 

For stubborn rheumatoid arthritis symptoms, a short-term elemental diet may also be helpful, with one small study finding this treatment to be just as effective as corticosteroids for pain relief. 

Let’s look more closely at what we know about rheumatoid arthritis, the quality of evidence that’s available to support certain dietary interventions, how to find the right rheumatoid arthritis diet for you, and the steps you can take to help improve your symptoms.

Rheumatoid Arthritis Diets: A Snapshot

• The Role of Chronic Inflammation in Autoimmunity
  • Gut inflammation creates a damaging inflammatory response.
  • Chronic inflammation can lead to autoimmunity and other chronic diseases.
  • Clearing inflammation through diet can help relieve symptoms of rheumatoid arthritis.
• Start With an Elimination Diet 
  • This can reduce inflammation and help determine food sensitivities.
• Anti-Inflammatory Diet Frameworks That May Help 
  • Paleo diet 
  • Mediterranean diet 
  • Autoimmune Paleo Diet 
  • Low FODMAP diet 
  • Elemental diets 

What We Know About Rheumatoid Arthritis 

Rheumatoid arthritis (RA) is an inflammatory autoimmune disorder that causes arthritis symptoms in the joints. Autoimmunity is when your immune system becomes overactive and attacks healthy tissue in your body. 

RA typically affects multiple joints of both hands and often involves morning stiffness lasting more than an hour. RA can affect nearly every organ in the body and create lasting health issues [1]. Only a small percentage of the developed world’s population is affected (less than 1% in North America and Europe), and it affects women 2 to 3 times more often than men [1]. 

The primary symptom of RA is arthritic joint pain (inflammation, swelling, and stiffness), but about 80% of patients also experience fatigue. If it goes untreated for a long period, joint deformities can also develop [1, 2].

Although the cause of RA is still unknown, there does seem to be a genetic component that can be “turned on” by environmental factors such as smoking, an overload of stress, respiratory disease, cancer, and cardiovascular disease [1, 3]. This phenomenon of environmental factors turning on genes is called epigenetics.

Gut microbiome composition has also been shown to be altered among patients with RA [1].

About half of RA patients test positive for anti-citrullinated protein antibodies (ACPA), which attack healthy proteins in the body, while the other half experience symptoms but test negative for this antibody [1].

The Role of Chronic Inflammation

Chronic inflammation plays a role in just about every chronic disease we treat. This includes metabolic diseases, autoimmunity (RA, celiac disease, lupus, etc), asthma, heart disease, chronic pain, chronic digestive issues, dementia and other neurodegenerative conditions, mood disorders, skin problems, allergies, and even some cancers [4]. And rheumatoid arthritis falls squarely in that mix (arthritis literally means “joint inflammation”). 

To that end, it would follow that reducing inflammation, especially through diet, could help reduce RA symptoms. 

Acute inflammation is a healthy part of the immune response — it helps you heal a wound, it alerts you to a problem in your body, it can create a fever to kill off a microbial invader. But when your immune response stays engaged for too long or begins to mistake healthy tissue for a threat, inflammation becomes a chronic problem.

For RA, specifically, a chronically overactive immune system attacks joints and connective tissue. By reducing inflammatory foods in your diet, you can reduce your overall exposure, give your digestive system a chance to heal, and calm down your immune response in the process. Foods that can irritate and create systemic inflammation include saturated fat, trans-fats, fried foods, and refined sugar and carbohydrates, as well as foods you as an individual may be particularly sensitive to [5].

Other environmental factors can also play a role in the inflammatory response. Exposure to chemicals, air pollution, and smoking all increase inflammation. Chronic stress and sleep disorders van also lead to an increased production of inflammatory cytokines [5].

I’m focusing on a rheumatoid arthritis diet in this post, but all of these factors are worth mentioning, as are adjunct lifestyle interventions to help combat some of these potential risk factors.

The Best Rheumatoid Arthritis Diet Is Anti-Inflammatory

Diet is one of the best ways to reduce chronic inflammation, making it a crucial piece of rheumatoid arthritis treatment. Anti-inflammatory diets are an effective way to reduce overall inflammation in your body, allowing your body’s tissues to heal and potentially resume healthy function. Following an anti-inflammatory diet can also lead to additional health benefits like getting to a healthy weight, lowered blood pressure and cholesterol, and reducing your risk of other chronic diseases. 

But what does an anti-inflammatory rheumatoid arthritis diet look like? 

In practice, an anti-inflammatory diet is both general and specific. Certain food ingredients (like sugar, processed carbs, trans-fats, and red meat) are pro-inflammatory foods for just about everyone. 

However, many other foods could be particularly triggering for you, specifically, even if they aren’t on that short list I just enumerated. This could be because you have a particular allergy or sensitivity, a second autoimmune disease like celiac disease, or other sensitivities due to leaky gut syndrome that are causing your immune system to fire off repeatedly. 

The list of potentially inflammatory foods can get long once you take all of that into account. That’s why a good first step is to consider an elimination diet (so that you can determine which foods are contributing to inflammation in your body, and which are not). 

Start With an Elimination Diet

An elimination diet starts with the elimination of specific foods and then systematically adds different foods back into your diet one at a time so that you and your dietitian or health care provider can determine which foods you react to and which foods are safe to keep eating. 

To simplify this process, start with the framework of an already-established diet. One of these could be your rheumatoid arthritis diet. Three of the most common diets to consider for their anti-inflammatory properties are:

• Paleo Diet
• Autoimmune Protocol (AIP, also called Autoimmune Paleo Diet)
• Low FODMAP Diet

While these diets have been shown to help reduce inflammation, not a lot of research has focused specifically on these diets for RA. That being said, a good body of evidence indicates that changes in diet can positively impact symptoms across many autoimmune diseases, so it’s worth giving one or some of these a try [6, 7]. You might find that combining principles across multiple categories will help you define the rheumatoid arthritis diet that works best for you and your symptoms.

Paleo Diet

The Paleo diet (short for Paleolithic diet) is inspired by our prehistoric ancestors. In this diet, you eat foods that are most similar to those that hunters and gatherers ate and avoid processed foods in packages or foods that emerged as a result of agriculture. 

To that end, this diet is grain- and gluten-free, legume-free, dairy-free, refined-sugar-free, and processed-food-free. What’s left on the list are healthy fats, colorful veggies (which are rich in antioxidants), fermented foods, and wild meat, fish, and fowl. 

These are gut-supporting foods, as long as you eat enough fibrous veggies to feed your gut bacteria. Gut health and inflammation are in a helpful feedback loop, meaning that healthy gut bacteria can help your body quell inflammation. And, conversely, anti-inflammatory foods can help support healthy gut bacteria [8, 9, 10, 11]. Plus, diets like this one can lead to the reduction of c-reactive protein, an important inflammatory disease marker [12, 13, 14, 15, 16].

In phase one of this diet, you’ll eat only the allowable foods for 2-3 weeks. From there, if you’re feeling great, you’ll start phase two, where you’ll reintroduce one food at a time, paying attention to how your body reacts. Give yourself a few days between each food so that you can keep track of your symptoms. It’ll be helpful to keep a journal to help you remember which foods you add in and how your body feels.

Autoimmune Paleo Diet (AIP)

Try this one if standard Paleo doesn’t help you. Rooted in the principles of the Paleo diet, AIP is a healthy diet of nutrient-dense, gut-supporting foods. The idea with this diet is to restrict in the initial phase beyond standard Paleo. That way, you can better understand which foods could be making your inflammatory response worse. 

The AIP diet allows food such as: 

• Wild meat, fish (like omega-3-rich sardines, mackerel, trout and Alaskan salmon), and fowl (including organ meats and bone broth)
• Healthy fats like olive oil, avocados and avocado oil (monounsaturated fat), fish oil supplements (omega 3 fatty acids), coconut oil, and coconut milk
• A rainbow of colorful fresh fruits and vegetables
• Fermented foods rich in probiotics (excluding yogurt and other dairy for now)
• Herbs and spices like cinnamon, turmeric, and leafy herbs (avoiding anything from seeds like mustard, fennel, anise, etc)
• Limited natural sweeteners like maple syrup or stevia (avoiding sugar alcohols and artificial sweeteners that could cause digestive distress)

This diet is grain-free, alcohol-free, coffee-free (small amounts of black and green tea are ok), egg-free, dairy-free, nut and seed-free, and nightshade-free. Nightshades include tomatoes, white potatoes, eggplant, and bell peppers. So far, only low-quality evidence seems to support the idea that these foods exacerbate joint pain, but the idea persists in certain circles [17, 18, 19, 20].

Keep in mind as well that in spite of its name, the Autoimmune Paleo diet is not recommended as a first choice for everyone who has an autoimmune condition. Many people find success with a less restrictive diet, especially over the longer term. 

Just like with the Paleo diet, you’ll spend 2-3 weeks eating only the allowable foods. If you’re feeling great after that time frame, you’ll start phase two. In this phase, you’ll begin reintroducing some of the foods you’ve eliminated in phase one. You’ll do this one food at a time and pay attention to how your body reacts. Again, give yourself a few days between each food so that you can note whether or not symptoms return before trying a new food, and keep a journal.

While more clinical trials need to be done to look at AIP for its anti-inflammatory effects in rheumatoid arthritis patients, a number of studies show improvement for other autoimmune diseases, such as IBD (inflammatory bowel disease) and Hashimoto’s thyroiditis in addition to showing that a diet like this one (and the Paleo diet) can lead to the reduction of c-reactive protein, an important inflammatory disease marker [12, 13, 14, 15, 16].

Low FODMAP Diet

If other diets haven’t worked for you, you have notatable digestive distress, and/or you have (or suspect you may have) a bacterial overgrowth like SIBO, you may want to try a low FODMAP diet. 

Like the AIP diet, the FODMAP diet is on the more restrictive side, and is usually not recommended as the first option. It restricts foods that can potentially feed harmful and/or overgrown bacteria living in your small intestine. These bacteria often cause inflammation in the gut, pushing out beneficial bacteria or yeasts and damaging the gut lining. 

A damaged gut lining can leak, allowing potential pathogens and partially digested foods into the bloodstream and further exacerbate inflammation and an immune response. SIBO (small intestinal bacterial overgrowth) is a common problem among RA patients, so treating it with a diet like this may help alleviate symptoms.

FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols. These foods aren’t inherently harmful or inflammatory in a healthy digestive system but can be exceedingly damaging for a highly inflamed system that’s out of balance. 

The list of foods that falls under this list is quite specific and limiting, and there’s no research to suggest that a low FODMAP diet could benefit RA patients specifically. That being said, many RA patients can solve their chronic gut issues, thus relieving some symptoms [21]. And once your gut health has improved, you will likely find that you can tolerate healthy, higher FODMAP foods again. A literature review studying the effects of a low FODMAP diet showed that it does reduce gut inflammation, leaky gut, and other digestive symptoms [22, 23].

Mediterranean Diet

The Mediterranean diet, much like the Paleo diet, focuses on whole foods, healthy fats, high-quality seafood and fish. This diet is less restrictive than the above three diets, and it allows for nutritious whole grains such as quinoa, whole wheat, and brown rice, and it allows for legumes. However, it recommends only occasional red meat consumption. 

A 2021 systematic review of 70 studies concluded that the Mediterranean diet can help to reduce some disease activity for those with RA [24]. However, another systematic review and meta-analysis concluded that there was no discernable benefit to following this diet for those with RA [25]. Again, dietary responses are highly individualized, and there’s no one perfect diet for everyone. If the Mediterranean diet works well for you, that’s great! And if not, you can try another option, and figure out what’s best for your body.

Keep in mind that part of the reason this diet is recommended for RA patients so often is because it’s the most studied. More work needs to be done to study other anti-inflammatory diets as they compare to this one.

Elemental Diet

The elemental diet is a hypoallergenic liquid of predigested nutrients that serve as a meal replacement to help repair your gut. The liquid contains no fiber, no prebiotics, no allergens, and is anti-inflammatory. The carbohydrates found in this liquid are fully digested, and the proteins are broken down into amino acids or partially hydrolyzed for maximum nutrient absorption. 

While long term replacement of all meals with an elemental diet is not recommended, a few days to a couple of weeks on an elemental diet can make a significant difference when it comes to repairing and resetting your gut health, and reducing inflammation. Elemental diets can also be used as occasional meal replacements (i.e. one meal per week) to help maintain symptom remission. 

Most of the research on elemental diets is for use with IBD patients, but it’s also been shown to be helpful in IBS, SIBO, celiac disease, and rheumatoid arthritis [26, 27, 28]. In fact, one study even showed that an elemental diet was equally effective as corticosteroids in reducing pain in RA patients [29].

Probiotics for Rheumatoid Arthritis

Probiotics provide benefits to gut health that can directly affect the inflammatory cascade that can lead to autoimmunity. 

Supplementing with high-quality probiotics may be helpful for RA patients. Category 1 probiotics (Lacto-bifido probiotic blends) seem to be the most beneficial, with a number of studies of moderate- to high-quality supporting use for RA. In all cases, probiotics were found to be helpful in combating inflammation, while at least four studies showed that they also helped reduce disease activity, pain, and improve quality of life [24, 30, 31, 32, 33].

As the study of probiotic use in therapeutic treatment evolves, I continue to see improvement with the use of the three-part treatment in my clinic. I’d recommend experimenting with all three categories of probiotic (Lacto-bifido probiotic blend, Saccharomyces Boulardi, and soil-based probiotics) to see how symptoms improve over time. 

Conventional Treatment for Rheumatoid Arthritis

Rheumatoid arthritis is generally managed with disease-modifying antirheumatic drugs (DMARDs). Especially with early intervention, these medications can slow the disease and even send it into remission [34]. These drugs include methotrexate, leflunomide, sulfasalazine, and hydroxychloroquine, in addition to biologic DMARDs and immunosuppressants [1]. Each of these has its own list of side effects, so taking them might feel like an additional burden to RA patients.

For short-term pain management that doesn’t impact the progression of the disease, many rheumatologists recommend NSAIDs (non-steroidal anti-inflammatories like naproxen (Aleve) or ibuprofen (Advil) or acetaminophen (Tylenol). Long-term use of these drugs also have potential side effects, including digestive ones, which can exacerbate the progression of RA. 

The Bottom Line

Lifestyle changes, specifically the use of an anti-inflammatory diet that can help reduce symptoms and (hopefully) lead to weight loss for overweight patients, a reduction in toxic exposures, better sleep, and stress reduction, are all useful ways to approach rheumatoid arthritis. 

Start with the least restrictive rheumatoid arthritis diet (Paleo or Mediterranean diet) to see how your body reacts, and go from there to build nutrition into your diet and reduce inflammation. If you need help to get started, reach out to our clinic to set up a consultation.

The Ruscio Institute has developed a range of high quality formulations, including an elemental diet formula, to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.