What diet is recommended for an adult patient with rheumatoid arthritis?

Dietary Recommendations for Rheumatoid Arthritis

Patients with rheumatoid arthritis should follow a Mediterranean-style diet, which is the only dietary pattern with sufficient evidence to conditionally recommend for RA management. 1

Core Mediterranean Diet Components

The Mediterranean-style diet should include the following daily and weekly components 1, 2:

Daily intake:

• 3 portions of whole grains (preferably gluten-free) 3
• 5 portions of fruits and vegetables, emphasizing berries, citrus fruits, and green leafy vegetables 3
• Extra virgin olive oil as the primary fat source 1
• Nuts and seeds 1
• 125 ml light yogurt and 200 ml skim milk 3
• One glass (125 ml) of wine if desired 3

Weekly intake:

• Fish: 3 portions (particularly oily fish rich in omega-3 fatty acids) 1
• White meat: 3 portions 3
• Legumes: 2 portions 1
• Eggs: 2 portions 3
• Seasoned cheeses: 2 portions 3
• Red or processed meat: maximum once weekly 3

Strictly limit or avoid:

• Added sugars and sugar-sweetened beverages 1
• Sodium/salt 1, 3
• Highly processed foods 1
• Refined carbohydrates 1
• Saturated fats and trans fats 1

Evidence Supporting Mediterranean Diet

The Mediterranean diet has demonstrated low to moderate certainty evidence for improvement in pain symptoms in RA patients 1. While it shows no significant difference in physical function or disease activity scores specific to RA, the American College of Rheumatology recognizes its potential benefits for long-term health outcomes including cardiovascular disease prevention and longevity—outcomes that are critically affected by RA disease activity 1. The anti-inflammatory properties of this dietary pattern may help reduce systemic inflammation 2, 4.

Recommendations Against Other Diets

All other formally defined diets—including vegan, vegetarian, paleo, ketogenic, gluten-free, intermittent fasting, elemental, elimination, and raw food diets—are conditionally recommended against due to very low to moderate certainty evidence showing no consistent, clinically meaningful benefit for physical function, pain, or disease activity specific to RA 1, 5. The burden, costs, and potential nutritional risks of these restrictive diets outweigh any unproven benefits 1.

Dietary Supplements

Follow a "food first" approach without adding dietary supplements for RA symptom management 1, 2. The American College of Rheumatology conditionally recommends against dietary supplements (including probiotics, fish oil, omega-3 fatty acids, antioxidants like selenium and zinc) based on very low to moderate certainty evidence demonstrating no consistent, clinically meaningful benefit for RA-specific outcomes 1.

Exceptions requiring supplementation:

• Vitamin D and calcium for bone health in RA patients 6
• Folic acid when taking methotrexate 6
• Correction of documented nutritional deficiencies that cannot be achieved through diet alone 1

Weight Management

Maintain a healthy body weight, as obesity is associated with higher disease activity, impaired physical function, and poorer treatment response in RA 2, 5, 6. Achieving and maintaining optimal weight should be a collaborative effort between patients and healthcare professionals 1.

Role of Registered Dietitian

Involve a registered dietitian as part of the interprofessional care team to assist patients who wish to modify their diet 1, 2, 5. Early referral ensures personalized eating plans that address both nutritional adequacy and RA management goals 6.

Additional Lifestyle Factors

Support smoking cessation for all RA patients who use tobacco, as this improves disease outcomes 1, 2, 6. Alcohol consumption should be moderate, though patients with RA may be at risk of disease flares after moderate alcohol intake 1.

Critical Pitfalls to Avoid

• Do not delay or replace pharmacological DMARD therapy with dietary interventions alone—diet is complementary to, not a replacement for, standard medical treatment 5, 6
• Avoid unsupervised elimination diets or highly restrictive diets that risk malnutrition without proven RA benefit 6
• Do not recommend nutrient megadosing or unregulated supplements that lack evidence and may cause drug interactions 6
• Recognize that patient-reported food triggers are highly individualized—while 24% of RA patients report foods affect their symptoms (with blueberries and spinach most often improving symptoms, and sugar-sweetened soda and desserts most often worsening them), these associations lack rigorous evidence and should not drive blanket dietary restrictions 7