Joshua Baker, M.D.Rheumatologist and Assistant Professor of Medicine
Hospital of the University of Pennsylvania and the Veteran’s Administration Medical Center
What Is Rheumatoid Arthritis Again?
Odds are, you know someone with rheumatoid arthritis (RA). It's the second most-common type of arthritis and affects about 1.3 million people in the United States, 70% of whom are women, according to the Arthritis Foundation. RA primarily strikes at the joints but it can impact other areas of your body, too. And though it usually pops up between the ages 40 and 60, it's known to occur in children via a condition called juvenile idiopathic arthritis.
How Does Diet Impact Rheumatoid Arthritis?
There's not a heck of a lot of clinical evidence to support the idea that specific foods can help treat RA, but don't tell that to people with the disease who swear what they eat affects how they feel . In one study from Brigham and Women's Hospital, 25% of RA patients were convinced certain foods made their arthritis symptoms better or worse. (Blueberries and spinach topped the list of feel-better foods while sugary sodas and desserts took honors for the worst.)
Here are a few ways diet may impact RA:
Body weight: RA patients have a higher risk of obesity (and all the metabolic complications that go along with it), and if you're obese you're less likely respond to medical treatment compared to someone at a healthy weight. A healthy body weight also improves your odds of achieving remission and puts less pressure on your already achy joints.
Heart disease risk: "Heart smart" isn’t just a cute phrase for RA sufferers, who are twice as likely as the general population to suffer heart problems. It's not totally clear why, but it could be that the systemic inflammation due to RA causes swelling of the arteries that lead to the heart. Following a heart-healthy diet is key.
Inflammation: Medical researchers believe an excess of inflammatory molecules called prostaglandins may contribute to RA. Omega-3 fatty acids, found in fatty fish, nuts, and plant oils, have anti-inflammatory effects that may interfere with the formation of these molecules.
Immune system: A diet rich in antioxidants gives your immune system the support it needs to fight the disease and may help reduce the chance of infection.
Gut health: If you have RA, you know all about GI problems like bloating and nausea. Inflammation and impaired immunity likely play a role in your gassy gut, as do some common RA medications. In addition, certain imbalances in the gut microbiome have been linked to RA. A healthy diet is the first step to restoring order in the GI tract.
What Is the Best Diet for Rheumatoid Arthritis?
Because the research on specific foods is inconclusive, your doc will probably tell you to eat a generally healthy diet. That means go easy on the red meat and processed foods and load up on fresh fruit, leafy greens, lean proteins, and whole grains. Beyond that, some studies show that these specific types of diets can be beneficial to easing RA symptoms.
Ah, the famous Med diet, full of fish, whole grains, olive oil, fruits, vegetables, and legumes. Don't you feel better just reading about it? Seriously, this approach has been shown to help lower inflammation, likely due to the omega-3 fatty acids found in nuts, olive oil, and fatty fish. In one randomized controlled trial from Sweden, RA patients who followed a Mediterranean diet for three months had fewer symptoms and better quality of life. Bonus: The Mediterranean diet is good for your heart, too.
Vegan / Vegetarian
It's cool and trendy, and it also works: Several small studies suggest that avoiding animal products may help reduce inflammation and ease RA flares. What’s more, vegans and vegetarians are less likely to be overweight than meat eaters, and they have lower blood pressure and cholesterol levels (markers of heart health), too. On the flip side, plant-only eaters can have lower levels of vitamins B12 (key for energy), calcium, and vitamin D (vital for bone health). If you’re thinking about going vegan or vegetarian, talk with your doctor and a registered dietitian first, and keep an eye on your vitamin levels.
Also in the trend du jour camp, this approach seems to have legs: Research shows that going for multiple hours without eating may improve RA symptoms. Fasting may help "reset" the immune system by eliminating damaged cells and replacing them with new ones. Bummer though, RA patients tend to relapse upon returning to a normal eating pattern. Think of fasting as a short-term treatment, not a long-term solution.
Anti-Inflammatory Foods That Fight RA
Having just said that specific foods can't cure RA, we're now going to tell you that certain ones can ease symptoms (which is nearly as good, right?). Load up on these inflammation-reducing options.
Fatty fish: Cold-water fish—the kind high in omega-3 fats—are perhaps the most promising food in the fight against inflammation. In another Brigham and Women's Hospital study, RA patients who ate non-fried fish two or more times a week had lower disease activity than those who never ate fish. Cold-water fatty fish include salmon, tuna, sardines, herring, mackerel, and trout.
Fruits and vegetables: Antioxidant-rich produce (like blueberries and cherries) are great for stabilizing the "free radicals" that trigger inflammation. They’re also packed with polyphenols, which may help lower C-reactive protein. Cover your nutritional bases by eating a bunch of different colors every day.
Whole grains: Whole grains lower levels of C-reactive protein (a marker of inflammation) and reduce heart disease risk (elevated in people with RA). They're also rich in selenium, which you might be low in if you have RA, and fiber, which has been shown to reduce inflammation. Choose oats, whole wheat, brown rice, quinoa, or corn.
Legumes: These high-protein, low-fat foods are rich in folic acid, magnesium, iron, zinc, and potassium—all good for your heart and immune system. Black, garbanzo, and red kidney beans and black-eyed peas are good choices.
Nuts: Your favorite snack also happens to be full of heart-healthy monounsaturated fat. Walnuts are especially good because they're also high in omega-3s. Feeling adventurous? Try pine nuts, pistachios, and hazelnuts, too.
Olive oil: In addition to healthy fats, this oil contains a natural phenolic compound called oleocanthal, which acts like ibuprofen to block inflammation. (But don't use it as a substitute for pain meds—it would take a 400-calorie serving to equal one 200mg ibuprofen tablet!) Sub it in for other cooking oils and butter to make your meals healthier.
Foods to Avoid When You Have Rheumatoid Arthritis
Add some, minus others. Experts recommend cutting back on these foods, which may make your RA symptoms worse.
Red meat: That juicy burger contains omega-6 fatty acids, which in excess can contribute to inflammation. What's more, a diet high in red meat has been linked to increased heart disease risk. Your best bet: Choose lean cuts (10% fat or less) and look for "grass-fed" on the label, which may contain more omega-3’s than other types. Try to limit red meat to once a week.
Processed foods: Soft drinks, chips, and candy—the stuff of vending-machine heaven—are high in added sugars and unhealthy fats, which raise the risk of obesity and joint inflammation.
Gluten (sometimes): This one's a little on the border. We know gluten can trigger inflammation in the gut, skin, and joints if you have celiac disease, and some RA patients say eating gluten makes them feel worse. There’s no evidence to support a blanket recommendation, but if you have a sensitivity to it, skip it.
Should You Try an Elimination Diet for Rheumatoid Arthritis?
Figuring out which foods are better or worse for your symptoms may come down to trial and error. Some doctors recommend cutting out common allergy triggers like milk, meat, and processed foods, then gradually reintroducing them one by one to see if any cause a reaction.
Other experts are wary of this approach, since elimination diets can result in nutritional imbalances that may lead to anemia and make you feel worse. If you’re curious about trying an elimination diet, it's best to consult a registered dietitian first. Ask your doctor to hook you up.
Can You Drink Alcohol If You Have Rheumatoid Arthritis?
Some research suggests that people who drink are less likely to develop RA, and that RA patients who drink may have less severe symptoms. But before you load up the liquor cabinet, hear this: According to a new Arthritis Care & Research study, which looked at data from almost 17,000 RA patients, those with severe symptoms are more likely to stop drinking than those with mild symptoms. The conclusion? People who feel well are more likely to drink than those who feel sick. (After all, do you feel like drinking when you have the flu?) In other words, drinking may be the result of feeling good, not the cause.
Still, moderate alcohol consumption (a 5-ounce glass of wine or 12-ounce beer per day for women, or twice that for men) with RA is generally considered safe—unless you’re taking certain RA medications.
How Alcohol Interacts With RA Medication
Because both alcohol and certain RA medications are hard on the liver, combining the two may put you at twice the risk for liver problems. These common RA medications may become unsafe if you drink alcohol while taking them:
Azulfidine, Sulfazine (sulfasalazine)
Otrexup, Rasuvo, Trexall (methotrexate)
Some supplements may also interact with the liver and make certain medications unsafe. Because every person is different, it's important to talk to your doctor about alcohol, supplements, and any other meds you are taking, in case you are putting your liver at risk.
Diet Challenges That RA Patients Face
It's easy to see why you might not have much of an appetite when you're in chronic pain, but there's another reason people with RA are at risk for malnutrition and weight loss. That's because the production of cytokines, proteins in the cells of your immune system that act as chemical messengers, can increase your resting metabolic rate and protein breakdown. In severe cases, this can lead to a condition known as rheumatoid cachexia, the loss of muscle and strength. For these patients, a high protein diet is especially important.
Some RA meds may also contribute to nutrition challenges. Methotrexate, for example, can cause nausea, while leflunomide can cause nausea as well as weight loss. Other RA meds (like NSAIDs) may be linked to conditions like gastritis or peptic ulcer, which impact appetite.
If you experience any of these side effects, be sure to tell your doctor—there are ways to help alleviate some of the discomfort. For instance, RA patients on methotrexate almost always supplement with folic acid to help avoid side effects. (The drug interferes with your body’s metabolism of the nutrient, so an extra dose can help.) If you’re still experiencing nausea, you may be able to go to a higher dose of folic acid or switch to the activated form known as leucovorin (or folinic acid). Changing from an oral form of medication to an injection may also help.
Best Supplements for RA
We know you know this, but the best source for vitamins and minerals will always be whole food. Still, supplements can give an added boost if you're deficient in certain nutrients (a blood test to check for deficiencies can help). Some supplements that address common vitamin and mineral deficiencies in RA patients include:
Two other dietary supplements may help with RA symptoms:
Some clinical trials have shown that taking omega-3 supplements may help manage RA when taken together with standard RA treatments. In one study, patients treated with fish oil supplements in combination with DMARD therapy were twice as likely to achieve remission than those on DMARDs alone. (DMARD, FYI, stands for disease-modifying anti-rheumatic drugs, a common pharmacological treatment for RA. Click over to "medications" to learn more.) However, fish oil can also irritate your gut, and may interfere with blood clotting and increase stroke risk when taken with aspirin or other NSAIDs. So if you're thinking about trying it, talk to your doctor first.
Some evidence suggests that curcumin, a compound in the spice turmeric, can reduce inflammation and ease RA symptoms. Choose food-grade turmeric from the grocery store over a supplement pill, which may contain fillers that can potentially affect the liver. You can find the ground-up spice in most grocery stores.