Dairy and rheumatoid arthritis

Mayo Clinic Minute: Fighting arthritis with food

Millions of Americans suffer from symptoms of arthritis that are often debilitating. The most common form is degenerative arthritis, also known as osteoarthritis, followed by inflammatory or rheumatoid arthritis. Dr. John Davis III, a Mayo Clinic rheumatologist, says what you eat may help with some of the inflammation associated with arthritis.

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Can avoiding foods like potato chips and pizza help ease your arthritis pain? Maybe.

“Some foods can increase inflammation levels and contribute to symptoms of arthritis, especially really fatty foods –– simple sugars or carbohydrates, lots of salt, or salty food,” says Dr. Davis.

Symptoms may include swollen and achy joints, discomfort and pain.

“Arthritis relates to a diverse set of disorders where there is inflammation that occurs in joints,” says Dr. Davis.

He says that while medication may help joint pain, exercise, maintaining a healthy weight and paying attention to the food you eat play important roles.

“Small amounts of weight loss can lead to reductions of just overall inflammation in the body, which can have overall benefits,” says Dr. Davis.

Add more fruits and vegetables, healthy fats like olive oil and nuts, whole grains and fish. These foods are thought to reduce inflammation and help with pain.

“The Mediterranean diet — or anti-inflammatory diet — are concepts to consider to bring into your own diet if you are suffering from symptoms of arthritis,” says Dr. Davis.

Current Treatment Strategies for Rheumatoid Arthritis

Nonsteroidal anti-inflammatory drugs reduce inflammation and help relieve pain but seldom completely eliminate signs and symptoms of active arthritis. They inhibit 1 or both types of cyclooxygenase (COX). Cyclooxygenase-1 is constitutively expressed in the GI mucosa, kidneys, platelets, and vascular endothelium. Cyclooxygenase-2 is functionally expressed and promotes the elaboration of prostaglandins in inflamed tissues.

Selective blockage of COX-2 may lead to an improved safety profile for these agents. Celecoxib and rofecoxib are the first such agents available in the United States that selectively block COX-2. Of importance, the efficacy of these COX-2 inhibitors does not differ substantially from that of conventional NSAIDs. Their putative advantage is principally because of a reduced rate of adverse events, especially upper GI bleeding.5x5Wolf, MM, Lichtenstein, DR, and Singh, G. Gastrointestinal loxicrty of nonstcroidal antiinflammatory drugs. N Engl J Med. 1999; 340: 1888–1899
Crossref | PubMed | Scopus (1790) | Google ScholarSee all References Cyclooxygenase-2 inhibitors should be considered in patients at high risk of GI bleeding, including those older than 65 years and those with a previous history of GI bleeding. Despite advantages, these drugs may be associated with important adverse reactions, including allergy and fluid retention, and like other NSAIDs should be used with caution in patients with renal insufficiency.

Glucocorticoids are the most potent suppressors of inflammation and may be needed to control severe polyarticular disease until disease-modifying antirheumatic drugs (DMARDs) have been added and become effective. At that point, the glucocorticoids should be tapered and discontinued. Glucocorticoids should not be used alone in the management of RA. Oral prednisone or an equivalent is given in dosages typically ranging between 2 and 15 mg/d, often in divided doses (eg, 2 mg twice a day). A splitdosing regimen is frequently necessary because the antiinflammatory effect is relatively short. It is preferable, but often not possible, to avoid long-term glucocorticoid therapy in patients with RA because of the well-appreciated adverse effects of these drugs. Systemic extra-articular manifestations such as rheumatoid vasculitis may require treatment with initial prednisone dosages of 40 to 60 mg/d, tapering according to response.6x6Malleson, EL and Conn, DL. Exiraarticular manifestations of rheumaloid arthritis. in: MH Weisman, ME Weinblatl (Eds.) Treatment of the Rheumatic Diseases. WB Saundcrs Co, Philadelphia, Pa; 1995: 52–67
Google ScholarSee all References Intra-articular injection of glucocorticoids is an effective means for reducing pain and inflammation in individual recalcitrant joints.

Disease-modifying antirheumatic drug therapy is associated with reduced morbidity and mortality in patients with RA.7x7Fries, JF, Williams, CA, Morfeld, D, Singh, G, and Sibley, J. Reduction in long-term disability in patients with rheumatoid arthritis by disease-modifying antirheumatic drug-based treatment strategies. Arthritis Rheum. 1996; 39: 616–622
Crossref | PubMed | Scopus (223) | Google ScholarSee all References It should be used when the diagnosis of RA has been established and before erosive change appears. Disease-modifying antirheumatic drugs are usually given with NSAIDs and glucocorticoids, if needed. The DMARDs currently in use are listed in Table 1Table 1. The mechanism of action of most of these agents is diverse and to a variable extent overlapping. For many of the agents, the mechanism of action is defined incompletely, whereas for some, including the new class of tumor necrosis factor (TNF) blockers, it is better understood.

Table 1DMARD Therapy for Rheumatoid Arthritis*

Drugs Dosage Toxic effects requiring follow-up Monitoring studies††
Azathioprine 50-150 mg/d in 1-3 doses, based on body weight; take with food Myelosuppression, hepatotox-icity, lymphoproliferative disorders CBC and platelet count every 1-2 wk with changes in dosage, every 1-3 mo thereafter‡‡
Chlorambucil§ 0.05-0.10 mg/kg/d; maintenance dosage generally 4-6 mg/d in 1-2 doses Myelosuppression, myelopro-liferative disorders, malignancy CBC and platelet count every 1-2 wk with changes in dosage, every 1-3 mo thereafter‡‡
Corticosteroids (oral prednisone, others) For synovial disease, 2-15 mg/d in 1-4 doses; for extra-articular disease (vasculitis), 20-60 mg/d according to response Hypertension, hyperglycemia, osteoporosis Baseline blood pressure, chemistry panel, lipid profile, bone densitometry in high-risk patients; follow-up tests including glucose and lipids as indicated
Cyclophosphamide§‖‖ 50-150 mg/d orally in a single morning dose Myelosuppression, myelopro-liferative disorders, malignancy, hemorrhagic cystitis CBC and platelet count every 1-2 wk with changes in dosage, every 1-3 mo thereafter; urinalysis and urine cytology every 6-12 mo after cessation of drug‡‡
Cyclosporine 2.5-5 mg/kg/d in 1 or 2 doses Renal insufficiency, anemia, hypertension, hirsutism Creatinine every 2 wk until dose is stable, then monthly; then periodic CBC, potassium, liver function tests‡‡
Penicillamine¶ 125-250 mg/d in a single initial dose, increased to not more than 1500 mg/d in 3 doses; take on an empty stomach Myelosuppression, proteinuria CBC and urine dipstick for protein every 2 wk until dosage is stable, then every 1-2 mo
Etanercept 25 mg subcutaneously 2 times a week Reactions at injection site, influenza-like symptoms Not defined
Gold# (intramuscularly) 10 mg in a single dose the first week, 25 mg the following week, then 25-50 mg/wk thereafter; frequency may be reduced after total dose of 1 g administered Myelosuppression, proteinuria CBC, platelet count, urine dipstick every 1-2 wk for first 20 wk, then at the time of each (or every other) injection
Gold (oral) 3-9 mg/d in 1-3 doses Myelosuppression, proteinuria CBC, platelet count, urine dipstick for protein every 4-12 wk
Hydroxychloroquine 200-600 mg/d in 1 or 2 doses; take with food Macular damage Yearly ophthalmologic examination
Infliximab 3 mg/kg intravenously every 8 wk Influenza-like symptoms, development of autoanti-bodies Not defined
Leflunomide 100 mg/d for 3 days, then 10-20 mg/d Thrombocytopenia, hepato-toxicity, diarrhea CBC and AST every 4-8 wk
Methotrexate Single dose of 7.5-25 mg orally, subcutaneously, or intramuscularly per week Myelosuppression, hepatic fibrosis, cirrhosis, pulmonary infiltrates or fibrosis CBC, platelet count, AST, albumin every 4-8 wk‡‡
Minocycline 200 mg/d in 2 doses; take on an empty stomach Photosensitivity, skin discoloration, gastrointestinal upset, drug-induced hepatitis, dizziness Not defined
Sulfasalazine 2-3 g/d in 2-4 doses Myelosuppression CBC, AST, creatinine every 2-4 wk for first 3 mo, then every 3 mo**

View Table in HTML AST = aspartate aminotransferase; CBC = complete blood cell count; DMARD = disease-modifying antirheumatic drug. †Suggested laboratory studies; complete guidelines have been previously published.8x8American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Guidelines for monitoring drug therapy in rheumatoid arthritis. Arthritis Rheum. 1996; 39: 723–731
Crossref | PubMed | Scopus (252) | Google ScholarSee all References ‡When chemotherapeutic agents are initiated, obtain a baseline chest radiograph (current within 6-12 mo), hepatitis B and C, CBC, platelet count, creatinine, and AST value. §Chlorambucil and cyclophosphamide are not generally very effective for the treatment of synovitis, although they can be useful in treating extra-articular disease, specifically rheumatoid vasculitis. ‖Fluid intake should be 2-3 L/d, and bladder should be emptied before bedtime. ¶Although this drug is considered a DMARD, I do not use it in patients with rheumatoid arthritis because of its limited therapeutic benefit and its high incidence of adverse effects. 1 rarely use gold in the treatment of rheumatoid arthritis; however, I continue to prescribe it to a few patients who have taken it for years and have done well. In my opinion, the therapeutic benefit-toxicity ratio of gold is poor. Baseline glucose-6-phosphate dehydrogenase in susceptible population.

For patients with mild disease, hydroxychloroquine is often the first drug of choice because of ease of use and its favorable toxicity profile. Retinopathy due to hydroxychloroquine rarely develops when appropriate dosages are used. The onset of antirheumatic disease activity occurs in about 3 to 4 months in almost 50% of patients, although 6 months may be needed for the full benefit to be realized. For patients with moderately active or severe newly diagnosed disease, methotrexate or sometimes sulfasalazine is a preferred initial choice. In patients with continuing active established disease, methotrexate may be used in combination with other agents including hydroxychloroquine, sulfasalazine, or both or cyclosporine, azathioprine, and the more recently available DMARDs.9x9Borigini, MJ and Paulus, HE. Rheumatoid arthritis. in: MH Weisman, ME Weinblatl (Eds.) Treatment of the Rheumatic Diseases. WB Saunders Co, Philadelphia, Pa; 1995: 31–35
Google ScholarSee all References For patients with acute and severe disease, a combination of DMARDs, prednisone, and an NSAID may be initiated; the dose of prednisone should be tapered during the ensuing weeks to months as disease control improves.

Because of its favorable efficacy and toxicity profile, methotrexate is regarded by many rheumatologists as the anchor therapy for RA. The initial dosage is usually 7.5 to 10.0 mg/wk, titrated upward to an average dosage of 12.5 to 15.0 mg/wk, although dosages of 20 to 30 mg/wk (if tolerated) may be necessary to realize this drug’s therapeutic potential before the response is deemed “inadequate.” Methotrexate may be given in tablet or liquid form; the liquid form is substantially less expensive than tablets, and injection may be associated with less stomatitis and GI upset. Appropriately managed, methotrexate can be used effectively for long periods to control RA. Although generally well tolerated, methotrexate can cause GI upset and hepatotoxicity including liver fibrosis and cirrhosis. Concomitant alcohol use is an important risk factor for methotrexate-related hepatotoxicity, and thus alcohol should not be used by patients taking this drug. Methotrexate can also cause a syndrome of pulmonary hypersensitivity manifested by dyspnea, cough, and fever and should not be used in patients with hepatic or renal insufficiency or severe lung disease. Supplemental folate (usually 1 mg/d) seems to reduce the occurrence of other adverse effects, including stomatitis, hair thinning, and bone marrow suppression. In patients taking methotrexate, physicians should avoid prescribing antifolate drugs such as sulfamethoxazole for sinusitis or cystitis, which may precipitate pancytopenia.

Use of DMARDs has substantially improved disease control and the long-term outlook for patients with RA. Their use may be associated with a lower incidence of extra-articular disease manifestations such as systemic vasculitis. In a series of more than 3000 patients monitored for up to 20 years, patients who had received DMARD therapy had a 30% reduction in long-term disability and improvement in survival compared with patients who had received NSAIDs alone.7x7Fries, JF, Williams, CA, Morfeld, D, Singh, G, and Sibley, J. Reduction in long-term disability in patients with rheumatoid arthritis by disease-modifying antirheumatic drug-based treatment strategies. Arthritis Rheum. 1996; 39: 616–622
Crossref | PubMed | Scopus (223) | Google ScholarSee all References Despite these successes, major challenges exist. For example, DMARDs are becoming more accepted among practicing physicians and their patients10x10Ward, MM and Fries, JF. Trends in antirheumatic medication used among patients with rheumatoid arthritis, 1981-1996. J Rheumatal. 1998; 25: 408–416
PubMed | Google ScholarSee all References; however, adverse effects or failure of the drug to produce long-term disease control often leads to a change in DMARD therapy.

To improve disease control, therapies that contain combinations of DMARDs are often used. About 50% of patients with RA treated by rheumatologists are prescribed combination therapies with either 2 or 3 DMARDs. The combination of methotrexate, hydroxychloroquine, and sulfasalazine is among the most popular regimens. Methotrexate is often combined with other DMARDs including cyclosporine, but many other combinations of DMARDs have also been used.

In addition to hydroxychloroquine and methotrexate, other traditional DMARDs include penicillamine, gold, and sulfasalazine. Sulfasalazine was among the first drugs to be developed for the treatment of RA and may be chosen as the initial DMARD for patients with no allergy to sulfa, rather than hydroxychloroquine or methotrexate. I seldom recommend gold or penicillamine because of the limited efficacy and the pronounced incidence of adverse effects associated with these drugs.

Three to 6 months may be needed before agents such as gold, hydroxychloroquine, and even sulfasalazine are effective. If the response is inadequate after 6 months of treatment, a second DMARD should be added or the DMARD regimen should be changed.

In the past year, 3 new DMARDs, etanercept, infliximab, and leflunomide, have been approved for the treatment of patients with RA.11x11Weinblatl, ME, Kremer, JM, Bankhurst, AD et al. A trial of etancrcept, a recombinanl tumor necrosis factor receptor: Fc fusion protein, in patients with rheumatoid arthritis receiving metho-trexate. N Engl J Med. 1999; 340: 253–259
Crossref | PubMed | Scopus (1832) | Google ScholarSee all References, 12x12Moreland, LW, Baumgartner, SW, Schiff, MH et al. Treatment of rheumatoid arthritis with a recombinanl human lumor necrosis factor receptor (p75)-Fc fusion protein. N EnglJ Med. 1997; 337: 141–147
Crossref | PubMed | Scopus (1437) | Google ScholarSee all References Etanercept and infliximab are TNF-α antagonists that have powerful anti-inflammatory effects in patients with RA. Tumor necrosis factor is a potent inflammatory cytokine expressed in increased amounts in the serum and synovial fluid of patients with RA. It promotes the release of other proinflammatory cytokines, particularly interleukin (IL) 1, IL-6, and IL-8 and stimulates protease production. Etanercept consists of fusion monoclonal antibody composed of 2 identical chains of recombinant human TNF-α receptor fused with the Fc portion of human IgG1. In vitro it binds to soluble TNF. About 70% of patients receiving subcutaneous etanercept at dosages of 25 mg twice a week have substantial improvement in the extent of joint inflammation; often within 1 to 2 weeks after initiation of therapy. This improvement can be enhanced by combination with methotrexate. Adverse effects of etanercept are influenza-like symptoms and reactions at the injection site, which usually abate after the first few injections. The efficacy of infliximab, a recombinant TNF receptor fusion protein, seems to be roughly equivalent to that of etanercept. Infliximab is given intravenously once every 8 weeks, a regimen that may be more convenient for some patients. Potential long-term risks of these TNF-α antagonists have not been established. Infliximab may be associated with development of autoantibodies such as antinuclear antibodies. To date, neither drug has an increased risk of malignancy, autoimmune disease, or infection, issues that are the subject of ongoing postmarketing surveillance. The cost of these drugs is about $10,000 to $12,000 a year, generally higher for etanercept than infliximab. The available TNF-α antagonists should be considered in patients with recalcitrant disease not controlled by methotrexate.

Leflunomide is a pyrimidine synthesis inhibitor with clinical efficacy generally equivalent to methotrexate.13x13Mladenovic, V, Domljan, Z, Rozman, D et al. Safety and effectiveness ofteflunomide in the treatment of patients with active rheumatoid arthritis. Arthritis Rheum. 1995; 38: 1595–1603
Crossref | PubMed | Scopus (266) | Google ScholarSee all References Adverse effects reported include rash, alopecia, allergy, weight loss, thrombocytopenia, and diarrhea. Diarrhea often occurs early in the course of treatment and may abate, but discontinuation of the drug is necessary when the diarrhea cannot be ameliorated with dose reduction or concomitant use of antidiarrheal agents.

Serious extra-articular disease manifestations including vasculitis, scleritis, and recalcitrant serositis generally require systemic glucocorticoids and may necessitate the use of immunosuppressive agents such as cyclophosphamide. In my opinion, the only indication for cyclophosphamide in the treatment of RA is severe extra-articular disease, especially vasculitis.

Of importance, the decision about the use and aggressiveness of DMARD therapy should not be based solely on the presence or absence of the rheumatoid factor. Early in the course of RA, the rheumatoid factor may be absent, whereas in patients with established polyarticular arthritis, absence of the rheumatoid factor is not invariably associated with mild disease and good disease outcome. Treatment must be tailored to the disease manifestations and needs of the individual patient. Consultation with a rheumatologist is helpful for patients who are pregnant or considering pregnancy because many antirheumatic drugs have severe fetal toxic effects including teratogenicity. Management suggestions for several clinical scenarios involving patients with RA are listed in Table 2Table 2.

Table 2Scenarios Illustrating the Practical Application of Therapeutic Strategies for RA*

Scenario Therapeutic strategy
  • 1.

    Newly diagnosed RA in a young patient with presence of rheumatoid factor and mild disease (few joints involved and sedimentation rate <30 mm/h)

  • 1.

    Hydroxychloroquine, 400 mg/d, with or without an NSAID, and prednisone, 3-5 mg/d over a 1-to 3-mo period; sulfasalazine, up to 3 g/d in 2 divided doses, is an acceptable alternative

  • 2.

    Patient with new-onset RA with pronounced symptoms including fatigue, low-grade fever, weight loss, and polyarticular disease††

  • 2.

    Methotrexate, with an NSAID, and prednisone, 5-15 mg/d; taper prednisone over a 3-or 4-mo period if possible. If adequate control cannot be achieved after the initial 6-8 wk of therapy, consider adding hydroxychloroquine, sulfasalazine, or both to this regimen; a frequent cause of ”methotrexate failure“ is an inadequate dose of methotrexate (providing that the patient is able to tolerate the higher doses)

  • 3.

    Patient with established mild disease

  • 3.

    Hydroxychloroquine, 400 mg/d, with or without an NSAID, and prednisone, 3-5 mg/d over a 1-to 3-mo period; sulfasalazine, up to 3 g/d in 2 divided doses is an acceptable alternative

  • 4.

    Patient with established RA in whom optimal dose of methotrexate is partially effective!

    • a.

      Initiate combination therapy

    • b.

      Combination therapy with hydroxychloroquine, sulfasalazine, or both is ineffective

    • c.

      Combination therapy with methotrexate and cyclosporine, leflunomide, or azathioprine is poorly tolerated or ineffective (many rheumatologists may not use any of these combinations but would add a tumor necrosis factor a antagonist)

  • 4.

    NS AIDs if they add measurably to symptom control; prednisone, 5-15 mg/d

    • a.

      Add hydroxychloroquine, sulfasalazine, or both

    • b.

      Discontinue hydroxychloroquine and sulfasalazine; add leflunomide, azathioprine, cyclosporine, or possibly gold

    • c.

      Continue methotrexate but discontinue the combination drug and add etanercept or infliximab. TNF-α antagonists should be avoided in patients with chronic infections, draining nodules, or history of TB or TB exposure: I suggest discontinuation of these agents 7-10 d before and after major surgery

  • 5.

    Patient with established RA in whom methotrexate is ineffective, not tolerated, or contraindicatedf

  • 5.

    Mild disease: leflunomide, sulfasalazine, and azathioprine. Severe disease: cyclosporine and combinations of DMARDs such as sulfasalazine, hydroxychloroquine, and others, or etanercept or infliximab; gold may be considered, particularly in combination with any of these therapies, although in my experience it is rarely tolerated or useful

  • 6.

    Patient with established seronegative RA

  • 6.

    Of importance, decision about use and aggressiveness of DMARD therapy should not be based solely on the presence or absence of the rheumatoid factor. Early in RA, rheumatoid factor may be absent, whereas in established polyarticular arthritis, absence of rheumatoid factor is not invariably associated with mild disease and good disease outcome; treatment must be tailored to the disease manifestations in the individual patient

View Table in HTML DMARD = disease-modifying antirheumatic drug; NSAID = nonsteroidal anti-inflammatory drug; RA = rheumatoid arthritis; TB = tuberculosis; TNF-α = tumor necrosis factor α. †The role of the TNF-a antagonists is evolving; some rheumatologists may institute therapy with these agents in several of these scenarios.

When the symptoms of RA are well controlled, the glucocorticoids should be tapered, and the NSAIDs may also be tapered or used as needed. As a generalization, DMARD therapy should be continued indefinitely; however, if the patient does well and has no signs of active disease for at least 1 year, DMARD therapy could be carefully tapered. With combination DMARD therapy, one of the DMARDs could be tapered if the patient has been in remission for at least 6 months. I consider methotrexate an “anchor” therapy and generally continue this drug for the longest period. Of note, less than 5% of patients with bona fide seropositive RA remain in long-term disease-free remission.

Rheumatoid arthritis is a serious disease. Follow-up early in the course of disease and in patients with poorly controlled disease should be every 2 to 6 weeks. Patients with well-controlled disease may be seen every 3 to 6 months. The primary care physician has an important role in the management of RA and can effectively guide and monitor routine therapy, with periodic consultation by a rheumatologist as needed. Assessment of disease activity and treatment efficacy is enhanced substantially with serial use of standard outcome measures, including duration of morning stiffness, severity of fatigue, presence and degree of joint pain and stiffness including joint counts, global and disease-specific health assessment instruments such as the modified Health Assessment Questionnaire, erythrocyte sedimentation rate, and radiographs of involved joints.

Appropriate medical care for patients with RA includes immunization and prompt treatment of infections. Patients with RA have a high risk of infections even if they are not taking DMARDs but particularly when they are taking immunosuppressive drugs. Several medications used to manage RA, including NSAIDs, cyclosporine, and glucocorticoids, may cause or exacerbate hypertension. Rheumatoid arthritis is associated with an increased incidence of pulmonary disease, and patients who smoke have an especially high rate of lung disease. In patients at high risk of GI bleeding, including elderly women and those with a previous history of GI bleeding, prophylaxis is achieved with agents such as proton pump inhibitors and misoprostol. As a general principle, use of NSAIDs should be avoided when possible and certainly discontinued when symptoms diminish. Virtually all patients with RA have or develop osteoporosis as a complication of the disease or its treatment. Adequate intake of calcium (1200–1500 mg/d) and vitamin D (400 IU/d) is important. In all patients receiving long-term corticosteroid therapy, including men, an antiresportive agent such as bisphosphonates or calcitonin should be considered. In postmenopausal women, estrogen replacement therapy or agents such as raloxifene may be considered. Finally, mouth and eye moisturization is necessarv for patients with sicca complex symptoms.

Understanding the relationship of disease susceptibility and severity with genetic factors may provide an avenue for individualized treatment of patients with RA in the future. It may be possible to treat patients lacking genetic markers of severe disease with milder agents, while those with markers of severe disease may be treated more aggressively. More than 80 drugs are currently being developed for treatment of RA; thus, further advances in the management of the disease are forthcoming.

5 Foods People With RA Should Avoid in Their Diet

It’s time to kick that morning doughnut-and-coffee habit. Research shows that eating certain foods — like sugary snacks and desserts and certain caffeinated beverages — may worsen rheumatoid arthritis symptoms.

According to the American College of Rheumatology (ACR), rheumatoid arthritis (RA) is the most common type of autoimmune arthritis, affecting more than 1.3 million Americans. It is caused when the immune system (the body’s defense system) is not working properly.

Symptoms for rheumatoid arthritis may include:

  • Fatigue, fever, and weight loss
  • Joint stiffness that is usually worse in the mornings and after inactivity
  • Tender, warm, swollen joints

Early rheumatoid arthritis typically affects smaller joints first — including the joints that attach your fingers to your hands and your toes to your feet.

Over time, rheumatoid arthritis symptoms may spread to the following joints and occur on both sides of your body:

  • Ankles
  • Elbows
  • Hips
  • Knees
  • Shoulders
  • Wrists

There are many new drugs, even surgery, to treat rheumatoid arthritis, but don’t ignore the simpler ways of reducing RA pain, like lifestyle measures (rest and exercise) and a healthy diet. Though the scientific research surrounding an RA diet and rheumatoid arthritis is still inconclusive, many highly trained doctors recommend avoiding certain foods to see if this helps your joint inflammation and pain.

For example, a diet rich in fruits and vegetables and low in saturated fats may help some with their rheumatoid arthritis symptoms. Because the fats in meat are more easily metabolized into pro-inflammatory chemicals in the body, some RA patients find that changing to a plant-based diet, including soy, helps to ease symptoms.

Does coffee cause inflammation with RA? As mentioned, coffee may increase inflammation, so stopping coffee on an RA diet may be helpful in managing inflammation and joint pain.

A study published in October 2017 in the journal Lipids in Health and Disease concluded that supplementation with polyunsaturated fatty acids may represent a promising option to improve RA symptoms, including:

  • Duration of morning stiffness
  • Pain symptoms
  • Tender joint count

Polyunsaturated fats (PUFAs) are essential fatty acids your body needs for cell growth and brain function. Foods high in PUFAs include:

  • Corn oil
  • Fish, such as salmon, mackerel, herring, albacore tuna, and trout
  • Flaxseeds or flax oil
  • Safflower oil
  • Soybean oil
  • Sunflower seeds
  • Walnuts

“As of now, there is no agreed-upon diet for rheumatoid arthritis, but there are some people who do seem to have food sensitivities,” says Clement Michet Jr., MD, a rheumatologist and professor at Mayo Clinic in Rochester, Minnesota. Patients may have different tolerances for various foods, so it’s not possible to recommend a single diet across the board. But here are five foods commonly reported to aggravate arthritis symptoms.

Citrus Fruits

Oranges, grapefruits, and limes are great sources of vitamin C, which leads to a strong immune system that can help hold off inflammatory diseases like RA.


Salmon, herring, sardines, and anchovies are great sources of omega-3s. Salmon has the most, with up to 2 grams per 3-ounce serving. Don’t overcook it, because that can destroy more than half of the omega-3s. Bake or grill fish instead of frying it to preserve healthful fat. Try to eat it twice a week.


Don’t like fish? Walnuts, canola oil, and soybeans are rich in a different type of omega-3 fatty acid. Or ask your doctor about supplements.


Gingerol compounds, which give this root its flavor, also seem to be an anti-inflammatory. Studies in animals look promising, but scientists need to do more work on people before we’re sure.

Green Tea

This tasty drink offers polyphenols, which are antioxidants that may lower inflammation and slow down cartilage destruction. It also has epigallocatechin-3 (EGCG), which stops production of molecules that lead to RA joint damage.

Olive Oil

A natural chemical in olive oil stops the production of the chemicals that cause inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) like and lower inflammation by curbing the production of these same chemicals. Choose extra-virgin olive oil. Extra-virgin olive oil comes from the first pressing of the olive and has the highest content of good-for-you nutrients.


It’s a source of omega-3 fatty acids that doesn’t taste fishy. Soybeans — think tofu or edamame — are a good option. They’re also packed with fiber and protein.


This yellow spice is a star ingredient in many Indian dishes. Curcumin is the compound in it that holds promise as an anti-inflammatory. It may work better to prevent swelling and pain than to treat it once it happens. But more work needs to be done to figure out just how much it helps.

Whole Grains

When you eat more whole grains instead of processed ones (think brown rice instead of white), you may lower CRP levels. Whole wheat pasta and breads also have , an antioxidant. Some people with rheumatoid arthritis have lower levels of selenium in their blood.Continue Reading Below Another advantage of eating whole grains is that their fiber fills you up, which makes it easier to manage your appetite. That can help you stay at a healthy weight so you don’t have extra pressure on your joints.

Naser added, “understanding the role of MAP in rheumatoid arthritis means the disease could be treated more effectively.”

Rheumatologist Shazia Beg, who was also involved in the conduction of the study, said, “we don’t know the cause of rheumatoid arthritis, so we’re excited that we have found this association.”

Animal Products and Disease

The University of Florida study isn’t alone in linking animal product consumption and increased risk of disease. Some research has suggested that dairy products could increase the risk of developing Parkinson’s disease, as well as heart disease and some forms of cancer.

Breast cancer surgeon Dr. Kristi Funk advises her patients to ditch animal products altogether. She told LIVEKINDLY, “the body’s cellular response to consuming animal protein and animal fat is everything feeds and fuels illness while chocking health to death.”

Fears around dairy consumption, in particular, are growing the vegan milk market. Nearly half of American consumers now regularly purchase nondairy products such as coconut, oat, and almond milk.

Summary Article Name Eating Meat and Dairy Linked to Rheumatoid Arthritis Description A study shows that consuming a diet high in meat and dairy could trigger rheumatoid arthritis. Health risks are causing more people to choose vegan foods. Author Charlotte Pointing Publisher Name LIVEKINDLY Publisher Logo

RA Inflammatory Foods: What Foods Should I Avoid?

Hugh Duckworth MD

Doctor of Medicine (M.D.) in 1984 from University of Tennessee School of Medicine

Oct 7, 2018 4 min read

For rheumatoid arthritis patients, controlling inflammation is critical in being able to live a better quality of life and improve overall health. An important way to help control inflammation is by adhering to the right diet and choosing healthy foods. Just as there are certain foods to seek out in your diet, there are also foods that should be avoided or eliminated altogether. These foods stimulate the immune system and the inflammatory process, worsening the pain, stiffness and other health complications associated with rheumatoid arthritis.

Inflammatory Foods for Rheumatoid Arthritis

In addition to medication treatment plans that include non-steroidal anti-inflammatory medications (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs), limiting or eliminating altogether certain foods from your diet can help you to feel better as well.

Inflammatory foods are foods that can produce or trigger inflammatory symptoms in joints and in the digestive system. These are foods that are generally processed, cooked at high temperatures, or contain lots of chemical preservatives and unnatural ingredients. Be sure to check all foods labels carefully for any of the below ingredients.

Fats and Oils

Fats and oils are very common ingredients in the average North American diet. These foods are processed and chemically altered, with various ingredients added. These foods increase the body’s inflammatory response and worsening the effects of RA.

Hydrogenated Oils

Certain cooking oils like canola oil and vegetable oils are put through a process known as hydrogenation. This occurs when oils are produced by adding hydrogen atoms and effectively altering their natural state by turning them into a solid.

Many hydrogenated oils also contain a natural ingredient called omega-6 fatty acids. Omega-6 fatty acids are important for a balanced diet but too much of them, and not enough omega-3 fatty acids leads to an unbalanced diet.

Saturated Fats

Saturated fats are often referred to as unhealthy fats and they are found in processed meats and some dairy products. When saturated fats are digested they can trigger adipose or fat tissue inflammation. Try to replace foods that contain a lot of saturated fats with whole unprocessed foods.

Trans Fats

Another harmful ingredient found in processed foods is trans fats. Trans fats help to stimulate systemic inflammation. A diet high in trans fats can potentially worsen the symptoms of rheumatoid arthritis. Any foods that are highly processed or cooked with hydrogenated oils likely contain trans fats.

Red and Processed Meats

Many meat products are produced by adding preservatives, artificial ingredients, hormones, and other additives. These are chemical ingredients that are foreign to the human body and can cause adverse and systemic inflammatory reactions in some people and in particular those people with RA.

Avoid processed meats like deli meats, bacon, and pepperoni which have been altered and cooked with hydrogenated oils and contain saturated or trans fats. Instead, choose lean cuts of meat that are labeled organic and grass-fed as opposed to grain-fed. Try to reduce your intake of red meat by swapping it for fish instead.

Dairy Products

Many people can’t digest milk products due to an ingredient called casein. Look for products that include whey protein ingredients which often indicate the presence of casein. Milk is also used as an added ingredient in many baked goods like cookies, cake, crackers, bread and more.

To keep dairy products in your diet, look for low-fat options which contain less saturated fats than whole milk products and can potentially help reduce inflammation.


Sugar is an ingredient that comes in many processed forms. Sugars called fructose and glucose are refined sugar-based ingredients that can trigger inflammation when digested. Refined sugars send out inflammatory messengers in the body called cytokines. Avoid foods like white bread, French fries, and soda.

Refined Carbohydrates

Foods like white bread, white rice, pasta, and cereals are made with white flour. White flour is a refined carbohydrate that is a staple in the North American diet. It is also a leading cause of obesity and chronic disease. Refined carbohydrates like white flour also stimulate inflammatory responses and should be avoided in a rheumatoid arthritis diet. Switch to better alternatives like corn and brown rice flour.

Artificial Sugar

When products are advertised as sugar-free, they usually contain an artificial sweetener to improve the taste. However, artificial sweeteners use an ingredient called aspartame. Aspartame is a toxic chemical that cannot be naturally processed and thus triggers an inflammatory attack response when digested.


Ingredients like wheat, barley, and rye contain a complex of proteins known as gluten which for certain people causes an allergic and inflammatory reaction when digested. Many patients with rheumatoid arthritis also develop adverse inflammatory symptoms after consuming gluten. Gluten is found in bread, pasta and many preserved or processed foods.

MSG (Mono-sodium Glutamate)

Mono-sodium glutamate (MSG) is a flavor enhancer and preservative found in many processed foods. While there is no clear link between MSG and inflammation, it is still a chemical that isn’t naturally digested by the human body. Chemical-based foods can send certain people’s bodies into “attack” mode which is what causes inflammatory symptoms.

Tips for Eliminating Inflammatory Foods for Rheumatoid Arthritis

Maintaining a healthy diet can be done by simply eliminating or reducing inflammatory foods for rheumatoid arthritis. Here are some tips to help you to better avoid these kinds of foods:

  • Always read ingredient labels and look for indicated levels of saturated and trans fats
  • Compare different product brands to see which ones have lower levels of unhealthy fats and sugars
  • Switch to natural cooking oils like olive or avocado oil
  • Avoid deep fried foods or ones that have been cooked at high temperatures
  • Choose more low fat and trans-fat-free options when buying packaged foods
  • Add more omega-3 fatty acids (fish) and reduce omega-6 fatty acids (cooking oil products)
  • Eat as close to nature as possible by consuming less prepackaged and processed foods

If you’re concerned about how inflammatory foods for rheumatoid arthritis are affecting your symptoms, talk to your doctor about dietary solutions. Remember to stick to as many fruits, vegetables and whole grains as possible to help lower your inflammation levels.

Rheumatoid Arthritis Diet

An Anti-inflammatory Diet to Relieve RA Symptoms

You really are what you eat, especially when it comes to rheumatoid arthritis. The foods you eat can have a direct impact on rheumatoid arthritis (RA) symptoms. Although there’s really no such thing as a rheumatoid arthritis diet, there is something called an anti-inflammatory diet.

Eating certain foods—while limiting others—may actually help reduce RA symptoms. Some foods have an anti-inflammatory effect, which means that they can help decrease inflammation levels in your body. You may notice that some foods help decrease your RA symptoms, while others trigger rheumatoid arthritis flare-ups.

However, it’s important to note that there’s no single diet for coping with rheumatoid arthritis, so talk to your doctor and/or registered dietitian who can customize a meal plan for you—one that incorporates several of the anti-inflammatory foods below—so you can thrive with RA.

In-depth Articles on Other Rheumatoid Arthritis Treatments

  • Alternative treatments to help ease rheumatoid arthritis
  • Exercise
  • Lifestyle changes that can make living with RA easier
  • Medications
  • Physical therapy

Foods to Eat with Rheumatoid Arthritis
Adding the foods below to your diet can help you manage RA symptoms.

Beans, such as black beans and kidney beans may help fight inflammation in the body.

Fruits and vegetables should make up the foundation of an anti-inflammatory diet. They contain vitamins, minerals, and phytochemicals—natural chemicals that are found in some plant foods—to help you fight joint pain and inflammation. Cherries, grapes, and peppers are some fruits and veggies that may have anti-inflammatory effects.

Herbs and spices add a lot of flavor and have anti-inflammatory benefits without adding calories. Try seasoning your food with flare—use spices such as curry, ginger, and turmeric.

Lean protein is essential at every meal because it gives you energy to fuel your day. Examples of lean protein are boneless, skinless grilled chicken, fish, and nuts. Since fatigue is a common rheumatoid arthritis symptom, adding more protein to your diet is essential.

Omega-3 fatty acids—essential fatty acids that can help reduce inflammation and RA-related pain—are naturally found in salmon, flaxseed, walnuts, and olive oil. If you don’t like these foods, you may want to consider taking a supplement that contains omega-3s. Most people eat too many foods that contain omega-6 fatty acids, which promotes inflammation and are found in highly processed foods, full-fat dairy foods, and red meat.

To support the idea that omega-3s decrease RA symptoms and omega-6s aggravate them, a 2003 study looked at the anti-inflammatory effects of a low arachidonic acid diet (a diet low in omega-6 fatty acids), as well as fish oil in patients with RA. Researchers found that a diet low in arachidonic acid reduces inflammation in patients with RA. Patients who ate an anti-inflammatory diet, which included taking fish oil, had a major decrease in tender, swollen joints.1

Vitamin D may help reduce RA-related pain. Get more vitamin D in your diet by eating salmon, eggs, and mushrooms. Many brands of milk, yogurt, orange juice, and breakfast cereals are also fortified with vitamin D. Talk to your doctor about taking a vitamin D supplement if you’re not getting enough D in your diet.

Whole grains, such as brown rice, whole grain pasta, and whole grain bread, give you the energy you need to get through your day. Try replacing white rice, pasta, and bread with the whole grains versions.

Foods to Limit with Rheumatoid Arthritis
The foods below may exacerbate pain and other rheumatoid arthritis symptoms. Pay attention to how your body reacts to these foods: You may need to limit them in your diet to help you cope with RA.

Foods that contain aspartame: Chemicals found in this man-made sweetener can trigger the neurons in your brain and your increase pain perception. Aspartame is found in some diet soft drinks, ice cream, and even gum and mints.

Highly processed foods, such as fast foods and foods that contain monosodium glutamate (MSG) or nitrates (both are chemicals used as flavor enhancers) can aggravate RA symptoms. Some frozen dinners and Asian foods contain MSG, while lunch meats and hot dogs can contain nitrates.

“Nightshade” vegetables include eggplant, potatoes, and tomatoes. These vegetables are very nutritious, but they can trigger rheumatoid arthritis flare-ups.

Eating Well with Rheumatoid Arthritis
Sticking with an anti-inflammatory diet for rheumatoid arthritis is important to decrease inflammation and other RA symptoms, but you might not notice the effects right away. You may find that keeping a food diary helps. Jot down what you eat throughout the day to see what foods might be triggering your rheumatoid arthritis flare-ups.

Instead of adhering to a strict anti-inflammatory diet for rheumatoid arthritis, stick to a well-balanced diet that supports a healthy lifestyle. Also, maintain a healthy weight when you have rheumatoid arthritis because being overweight can also increase inflammation levels in the body.

Updated on: 01/09/20 View Sources



People living with rheumatoid arthritis (RA) experience ups and downs with respect to their symptoms. As noted by the Arthritis Foundation: “One day, your joints feel pretty good. The next, swelling and pain ratchet up and you can barely get out of bed. These symptom episodes – called flares – can be unpredictable and debilitating. Because symptoms differ from person to person, doctors have had trouble agreeing on a standard definition to guide them in treating flares.”

That said, here are a list of factors that may contribute to aggravating RA and increasing the risk of flare-up episodes:

Nonadherence to Therapy

To ensure optimal control of your RA, it’s imperative that you stick to the treatment regimen your physician puts you on. Failure to adhere to said regimen may include not filling your prescription, not taking your medications as directed, as well as foregoing exercise, and skipping appointments. This nonadherence, whether unintentional or not, can cause a flare in your RA symptoms. If you’re a patient who’s having difficulty sticking to your prescribed treatment regiment, it’s incumbent upon you to communicate with your physician, who can work with you to devise a regimen that works for you.


To mitigate RA symptoms, it’s always best practice to eat the right foods, as and avoid foods that are high on sugar, saturated fats, trans fats, omega-6 fatty acids, MS, gluten, aspartame, and alcohol can trigger inflammation. Instead, try to focus on anti-inflammatory foods and drinks such as red wine, tea, health herbs and spices (i.e., turmeric, curry powder, ginger and garlic), and proteins like fish (i.e. salmon, herring, and black cod), as well as healthy fats such as walnuts, and avocados.

Sedentary Lifestyle

RA patients should avoid living a sedentary lifestyle, while exercising to manage their symptoms, as physical activity improves muscle strength, as well as joint and bone functionality. In addition, rest is also crucial and goes along way toward restoring the body following episodes of pain or fatigue. Living a sedentary lifestyle counteracts the benefits of exercise and rest, and can increase episodes of inflammation, and extreme fatigue. However, while staying active is beneficial for RA patients, it’s important not to overexert yourself, and to respect your pain signals. In time, RA patients should come to recognize their limits and know when to stop before pushing those limits result in flare-ups.


The findings of a previous study suggest possible link between stress and RA symptoms, and many RA patients can actually recall a stressful or traumatic life event prior to the onset of their disease and can draw a correlation between stressful occurrences and RA flare-ups. Suffice it to say, mitigating stress is a good strategy for keeping RA symptoms in check.


As we all know, smoking is bad on all levels, and has no positive affect on any disease – and its effects on RA are no different. RA patients who smoke have worse symptoms and incur greater odds of severe joint damage than non-smokers. Patients with RA are encouraged to quit smoking, or they risk worsening and progressing their illness.


Neglecting to protect your joints, such as not using assisted devices like splints, and braces, not exercising (as discussed), and not executing proper body mechanics and pacing through activities can all cause symptoms to flare. Moreover, it’s also important not to neglect oral hygiene – as result indicates a connection between periodontal disease and RA. Also, neglect can come in the form of ignoring some of the initial warning signs of RA. An early diagnosis and treatment plan are crucial to ensure that RA doesn’t progress and cause joint deformity. Pay attention to all the signs and consult with your physician when something doesn’t feel right.

“Oh, my rheumatism!” You’ve probably heard this phrase from time to time. It’s quite an old saying, with the word rheuma first recorded in the first century A.D. in Greece. Many centuries ago, people believed that flowing substances in the body, like phlegm, were the culprit of most body ailments and pains.

Modern understanding has changed over several thousands of years. Today’s rheumatology practice diagnoses and manages autoimmune and inflammatory diseases. Some examples include rheumatoid arthritis, lupus, gout, psoriatic arthritis, polymyalgia rheumatica and ankylosing spondylitis. Medical professionals have also since discovered it’s our immune system and not flowing substances that is the source of rheumatic disease.

Under normal conditions, the immune system recognizes foreign invaders, like bacteria and viruses, and sweeps them away. However, when the immune system gets confused, it can attack normal body tissues, producing pain and swelling known as inflammation.

Often, these inflammatory effects are first felt in the joints and are referred to as arthritis. A deeper understanding made by practitioners has found that inflammation from a confused immune system can go beyond the joints and also attack the connective tissues, muscles, blood vessels and organs in the body. In some cases, inflammation may even be life-threatening.

Osteoarthritis or rheumatoid arthritis

We need to be careful with the term arthritis, because like the word rheuma, it’s an old, very general word. Interestingly, there are more than 100 types of arthritis, and they’re all treated quite differently. Many people are only familiar with one type of arthritis: osteoarthritis. Osteoarthritis, often described as wear-and-tear arthritis, is the most common form of arthritis, affecting 27 million people in the United States. However, osteoarthritis is not an autoimmune inflammatory disease, and it’s not the type of arthritis usually managed in a rheumatology practice.

Rather, an inflammatory arthritis like rheumatoid arthritis has these types of features:

  1. Severe pain in the joints, muscles or bones that lasts more than three to four days. Commonly, walking or lifting a spoon to eat is difficult during a flare.
  2. Stiffness in the joints lasting more than an hour in the early morning.
  3. Swelling and redness in one or more joints.

Who can develop an autoimmune condition?

While no one knows exactly what triggers the immune system to make the mistake of attacking healthy tissue, some studies indicate a genetic component, combined with environment, may increase the risk for certain arthritis. This explains why people who experience symptoms associated with inflammatory arthritis usually have a relative who also has some form of autoimmune disease. Smoking tobacco can also be a trigger and should be avoided for numerous reasons.

An inflammatory autoimmune condition can occur at any age. Right now in the United States, there are 300,000 children with inflammatory juvenile arthritis. In fact, rheumatic disease often strikes at the prime of life, with two-thirds of patients under age 65.

In many cases, the diseases are dramatic and debilitating at the time of onset. These are chronic conditions that cannot be cured. As a result, a diagnosis of an autoimmune or inflammatory disease can be stressful for the patient and his or her family.

Steps to take

If you or someone you know is experiencing signs or symptoms of an autoimmune or inflammatory condition, your primary care provider can refer you to Rheumatology for a detailed history and examination. In addition, laboratory tests on blood and urine, X-rays and sometimes samples of joint fluid are used to reach a diagnosis. Rheumatologic conditions can be challenging to diagnose and, in most, cases take several visits.

Many times, rheumatic diseases are treated with medications, which have an effect on the immune system. Additionally, exercise, physical therapy, dietary modifications, adequate sleep, stress reduction and avoiding tobacco all play critical roles in successful treatment plans.

While rheumatic autoimmune and inflammatory conditions cannot be cured, current treatment aims to limit the symptoms of the diseases. Many people with rheumatic disease lead productive, happy, satisfying lives. Your local rheumatology department is here to help.

Sarah Davis is a Mayo Clinic Health System in Mankato rheumatology nurse practitioner.

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