What dietary recommendations are suitable for a patient with rheumatoid arthritis (RA) to manage symptoms and support overall health?

Dietary Recommendations for Rheumatoid Arthritis

For patients with rheumatoid arthritis, adopt a Mediterranean-style diet emphasizing vegetables, fruits, whole grains, nuts, seeds, olive oil, moderate low-fat dairy and fish, while limiting added sugars, sodium, processed foods, refined carbohydrates, and saturated fats. 1

Primary Dietary Recommendation

The American College of Rheumatology (2022) conditionally recommends the Mediterranean-style diet as the only formally defined diet with evidence supporting its use in RA management. 1 This recommendation is based on low to moderate certainty evidence demonstrating improvement in pain, though no significant difference was found in physical function or disease activity. 1

Core Components to Emphasize Daily:

• Vegetables and fruits: 5 portions daily, prioritizing green leafy vegetables, berries, and citrus fruits 2
• Whole grains: 3 portions daily (preferably gluten-free options) 2
• Extra virgin olive oil: As the primary fat source 3
• Nuts and seeds: Regular daily intake 3
• Low-fat dairy: 125 ml light yogurt and 200 ml skim milk 2

Weekly Protein Sources:

• Fish: 3 portions per week, particularly oily fish rich in omega-3 fatty acids 3, 2
• White meat: 3 portions per week 2
• Legumes: 2 portions per week 2
• Eggs: 2 portions per week 2
• Red or processed meats: Maximum once weekly 2

Foods to Strictly Limit or Avoid:

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

Mechanism of Benefit

The Mediterranean diet provides anti-inflammatory and antioxidant properties that target inflammatory pathways involved in RA. 3 It also helps restore healthier gut microbiome composition, which is altered in RA patients. 3 The diet's cardiovascular benefits are particularly important given that RA patients have elevated cardiovascular risk. 1

What NOT to Recommend

The American College of Rheumatology conditionally recommends AGAINST other formally defined diets (ketogenic, paleo, gluten-free, vegetarian, vegan, intermittent fasting, elemental, elimination, raw foods) due to very low to moderate certainty evidence showing no consistent, clinically meaningful benefit for RA-specific outcomes. 1, 3 While some individual patients may report subjective improvement with alternative diets, the evidence does not support their routine recommendation. 4

Dietary Supplements

Follow a "food first" approach and conditionally recommend AGAINST routine dietary supplement use for RA management. 1 This applies to all dietary supplements and is based on very low to moderate certainty evidence showing no consistent benefit for physical function, pain, or disease activity. 1

Important Exceptions:

• Vitamin D: May be necessary for bone health, particularly important in RA patients 1
• Omega-3/fish oil: May serve a role for cardiovascular health 1
• Folic acid: Required when taking methotrexate (covered in pharmacologic guidelines) 1

The rationale against routine supplementation includes lack of FDA regulation, possibility of medication interactions and side effects, costs, and the superiority of obtaining nutrients through whole foods. 1

Weight Management

Maintaining a healthy body weight is unanimously supported for optimizing RA outcomes. 5, 3 Obesity is associated with higher disease activity, impaired physical function, and poorer treatment response in RA. 5, 3 While the ACR guideline did not vote on specific weight loss interventions, weight optimization should be a treatment goal. 1

Role of the Interprofessional Team

Involve a registered dietitian as part of the interprofessional care team for patients wishing to modify their diet. 1 The expertise of a registered dietitian is recognized as valuable for implementing dietary changes effectively. 1

Common Pitfalls to Avoid

• Do not recommend expensive or burdensome elimination diets without evidence of benefit, as these may lead to nutritional deficiencies and patient frustration 1
• Do not suggest dietary changes as a replacement for standard pharmacologic treatment—diet is complementary, not alternative therapy 6
• Avoid recommending unregulated supplements that may interact with RA medications or cause adverse effects 1
• Do not ignore patient preferences and access barriers when recommending the Mediterranean diet, as costs and cultural factors affect adherence 1

Additional Lifestyle Factors

Beyond diet, counsel patients on:

• Smoking cessation: Critical for RA outcomes 5, 3
• Regular physical activity: At least 150 minutes/week of moderate or 75 minutes/week of vigorous aerobic activity 3
• Stress management: Using cognitive behavioral therapy approaches 3