Q&A: No ‘one-size-fits-all’ approach to diet in rheumatoid arthritis
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KEY TAKEAWAYS
- A diet that emphasizes plant-based foods and lessens sugar intake may help patients reduce inflammation.
- The best diet for rheumatoid arthritis may be a Mediterranean or plant-based diet.
Patients with rheumatoid arthritis may be able to tame their disease progression and inflammation by adopting elements of the Mediterranean diet such as lowering sugar intake and incorporating protein in the form of fish or plant-based sources.
Studies have examined how some diets, like vegan or fiber-heavy diets, can have an impact on patients with rheumatoid arthritis, but gut microbiota-targeted diets have not yet been studied in-depth for rheumatoid arthritis management.
Healio spoke with Brian Andonian, MD, MHSc, assistant professor in the department of medicine, division of rheumatology at Duke University, about the most impactful dietary changes patients with RA can make to see positive changes in their inflammation and joint pain.
Healio: How do nutrition and dietary patterns influence the development and progression of rheumatoid arthritis?
Andonian: Nutrition and dietary patterns appear to influence both the development and progression of RA. However, the data supporting the benefits of diet for RA is mixed. The best evidence is for a Mediterranean-style diet, which per the 2022 American College of Rheumatology Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for RA, is conditionally recommended for the management of RA. This does not mean that other diets aren’t potentially impactful in RA development and progression, just that other formally defined diets have not been rigorously studied enough to support a recommendation (one way or another). Anecdotally, many of my patients have gained benefit in improving RA-associated symptoms through dietary modification.
Healio: How can diet impact inflammatory response in individuals with RA?
Andonian: There is growing evidence that diet can impact inflammatory pathways, but the exact mechanisms and specific effects in patients with RA are less well understood. For example, in pre-clinical studies, omega-3 fatty acids and certain spices — such as turmeric/curcumin and ginger — have been shown to have anti-inflammatory properties. In clinical trials, these substances appear to reduce inflammation in RA as well.
Healio: What role does the gut microbiome in relationship with dietary choices play in the modulation of rheumatoid arthritis symptoms?
Andonian: Alterations in the gut microbiome or dysbiosis are associated with RA development and RA-related inflammatory pathways. Gut microbiota-targeted diets such as diets rich in fermented foods, including fermented dairy products, fermented vegetables and fermented non-alcoholic drinks can increase microbiome diversity and subsequently decrease systemic inflammation. However, gut microbiota-targeted diets have not yet been well-studied for RA.
Healio: What evidence exists regarding the relationship between sugar intake and the severity of RA symptoms?
Andonian: RA was first described in the 1800s; one theory as to why RA become more common during that time is because of increased sugar consumption in western society leading to tooth decay, periodontal disease, and subsequent RA development. Today, we know that glucose is a key fuel for our immune cells in triggering inflammatory pathways. Also, most diets that have shown positive benefit for RA recommend minimal added sugar as a component of that diet.
Healio: What questions do you hear from patients regarding diet in relationship to RA and how do you respond to them?
Andonian: As a rheumatologist who practices lifestyle medicine, I am frequently asked about what the best diet is to help manage RA disease and symptoms. I discuss with my patients that there is not one best diet for patients with RA. Diet should be individualized for patients with rheumatoid arthritis based on their goals. Any dietary modification should start out small and be something the patient is willing to sustain long-term. I discuss that the best evidence for specific diets for RA is for a Mediterranean-style or plant-based diet. I explain that what is currently best understood as an “anti-inflammatory diet” includes a few principles, including:
- cooking with more healthy oils, such as olive oil or avocado oil, as opposed to more processed oils/processed foods
- getting protein in the diet primarily from fatty, oily fish or plant-based sources, such as beans, nuts and legumes (peas, chickpeas, lentils)
- flavoring food will with more spices and herbs with less sugar and salt
Healio: What misconceptions about diet in relationship to RA exist and how can they be addressed?
Andonian: As above, patients should know that there is not a one-size-fits-all approach to diet for RA. Many diets alleging to be the best “anti-inflammatory diet” can be very restrictive. These restrictive diets commonly do not allow any grains, sugar, dairy, animal products, the nightshade vegetables (such as tomatoes, potatoes, peppers and eggplant), and even nuts, seeds and legumes. What patients often don’t understand is that the goal of these diets is to slowly reintroduce these foods back into the diet. When a highly restrictive diet is continued long-term, this can lead to problems, such as disordered eating and nutrient deficiencies. My advice for patients is that is reasonable to try a restrictive- or elimination-type diet (as some patients with RA do get benefit), but consider only eliminating one food at a timereintroduce as many foods back into the diet as possible to maintain a healthy balance and nutritious diet.
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