Gluten and rheumatoid arthritis

RA Diet: What Foods to Eat if You Have Rheumatoid Arthritis?

Jennifer Freeman, MD

Doctor of Medicine (M.D.) in 2008 from UT Health San Antonio, Surgeon at TRACC Dallas

Oct 27, 2018 4 min read

Rheumatoid arthritis (RA) patients require a stable, healthy diet for a number of reasons. Patients may become overwhelmed by their chronic pain and inflammation, remain undernourished, or develop medical complications.

Maintaining a healthy diet is an important part of protecting your overall health, managing weight, improving energy levels, boosting your mental health and boosting your immune system. While diet alone can’t treat your symptoms, the right diet for RA can certainly go a long way in helping you feel better overall.

How Diet Affects RA

Although there is no demonstrable link between diet and RA, studies have shown that the type of inflammation experienced in RA could be modulated by certain foods. Increased inflammation has been attributed to processed foods or foods cooked at higher temperatures.

It is recommended to increase consumption of foods that are considered to be anti-inflammatory, such as fruits, veggies, and cold water fish (rich in omega-3 fatty acids). As a result, inflammatory symptoms may improve and possibly lead to fewer flare-ups.

Best RA Diets

Before starting a new diet, you should consult your doctor to ensure you are making proper choices to support your over medical health. The best diets are well-balanced as we have always been taught. A healthy diet should consist of 2/3 plant-based foods including fruits, vegetables, and whole grains. Creating a proper diet for RA is no different. You should consume plenty of fruits, vegetables, whole grains while limiting lean meats and processed foods.

Below are some of the best diets to follow for helping to reduce RA inflammation and improve overall health:

Paleo Diet

Also known as the “caveman diet”, the paleo diet is the most natural. Foods consumed include meat, fruit, and vegetables. Processed foods and cultivated grains are not eaten. Because this diet includes a lot of fruits and vegetables, it may be recommended as a diet for RA. However, it does also include red meat, which can possibly cause inflammation. If you’re interested in the paleo diet, talk to your doctor first and make any necessary modifications.

Mediterranean Diet

The Mediterranean diet uses foods that people have historically eaten in the Mediterranean region. This diet is high in some of the foods considered to be anti-inflammatory. While it consists mainly of fruits and vegetables, the Mediterranean diet also includes lots of whole grains and extra-virgin olive oil. They also opt for more fatty fish rather than red meat for protein.

Gluten Free Diet

Celiac disease is another autoimmune disorder, which causes inflammation due to consuming gluten. Gluten is a protein found in certain grains like wheat, barley, and rye and is removed from someone’s diet if they have celiac disease.

Many people with celiac disease also experience symptoms similar to RA symptoms such as sore and painful joints, fatigue, depression, and anemia. By following a gluten-free diet, many RA patients have reported a decrease in inflammation.

Because having autoimmune disorder increases the likelihood of having another, some doctors suggest being tested for celiac disease if you’ve already been diagnosed with RA.

Malnutrition in RA Patients

Patients with RA are often at a higher risk of malnutrition for multiple reasons. First of all, weight loss is a common symptom in RA patients. It’s thought to be due to the autoimmune condition itself producing inflammatory responses which cause an increase in metabolic rate. This means that the body burns through more calories than normal, which can lead to weight loss. This is not considered healthy weight loss. This type of weight loss can potentially leave the patient undernourished or malnourished.

Secondly, many patients taking the common disease-modifying antirheumatic drug (DMARD) called methotrexate, have been known to have a deficiency in certain vitamins and minerals. Many RA medications produce side effects such as stomach ulcers and other digestive concerns which can make it difficult to eat. These conditions combined with weight loss further compound the problems of malnourishment in patients. Some of the most common nutrient deficiencies in RA include a lack of the following vitamins and minerals:

  • Vitamin B6
  • Vitamin B12
  • Vitamin C
  • Vitamin D
  • Vitamin E
  • Calcium
  • Folic acid
  • Magnesium
  • Selenium

A proper diet for RA that is rich in these vitamins and minerals is important for keeping patients healthy.

Finally, many RA patients are at risk of developing osteoporosis, a weakening of the bones caused by a calcium or vitamin D deficiency. RA patients should be aware of this potential risk and ensure their diet accounts for this potential deficiency.

Supplements for RA

While it’s always best to receive nutrients through food, in some cases it may be necessary to take supplements. Certain supplements may be able to provide additional nutrition to patients who aren’t receiving enough vitamins and minerals through their diet alone.

Always speak to your doctor or rheumatologist before taking any nutritional supplements as some may interact with your current prescription medications and cause serious side effects. To reduce the risk of further symptoms or complications, your doctors will be able to advise which supplements are safe for your unique case.

Tips for RA Diet

Adhering to a specific diet like paleo, Mediterranean, or gluten-free can often be challenging and overwhelming for some patients. The most important thing in staying healthy and managing your diet for RA is to do your best at eating more of the good foods (fruits, vegetables, fish), and eliminating most of the bad foods (processed, red meats).

Here are some general tips to keep in mind for a healthy RA diet:

  • — Try to eat mostly fruits and vegetables
  • — Choose healthy, whole grains, beans, and lentils
  • — Balance your diet with regular and moderate exercise
  • — Avoid processed foods like meats or foods with chemical preservatives
  • — Reduce consumption of refined sugars
  • — Drink alcohol moderately
  • — Enjoy a healthy variety of foods

If you’re concerned about your diet or want to know more ways to improve your RA symptoms through healthy eating, consult your physician for support on making the best decisions for your condition.

Is a Gluten-Free Diet Helpful for Managing Rheumatoid Arthritis Symptoms?

Gluten is the general term for the proteins found in cereal grains, including wheatberries, durum, emmer, semolina, spelt, farina, farro, graham, kamut (Khorasan wheat), einkorn, rye, barley, and triticale (a cross between wheat and rye). Gluten is sticky and acts like glue, holding foods together and helping them retain their shape.

RELATED: 5 Foods People With Rheumatoid Arthritis Should Avoid

Understanding Gluten and Where It Is Found

Gluten is present in many types of food — some of which you would never expect. It is found in other products, too, which you would never expect (such as lipstick and lip balm).

The Controversial Popularity of the Gluten-Free Diet

The gluten-free diet has become quite popular within the last few years. I know people who are committed to it and I bet you do, too. Interestingly, some people who are committed to a gluten-free dietary approach can’t articulate why they tried it or how they benefit from it. But they adamantly claim that they “feel better.”

RELATED: Rheumatoid Arthritis and Diet: What to Know

That said, the gluten-free diet has become a bit controversial. Some sources suggest that more people have tried to reduce or eliminate gluten from their diet than ever needed to. According to a July 2015 Gallup poll, 1 in 5 Americans have tried to include gluten-free foods in their diet. Some of the people who have switched to a gluten-free diet believe it is healthier, while others believe it can help them to lose weight. Others have tried to positively impact a chronic disease by making the dietary change. This is where the questions come in:

  • Which diseases and conditions are helped by a gluten-free diet?
  • Is a gluten-free diet generally healthier?
  • Is a gluten-free diet totally harmless?

Let’s consider the evidence.

Diseases and Conditions That May Improve With a Gluten-Free Diet

Some reports have suggested that there is evidence a gluten-free diet may improve symptoms associated with rheumatoid arthritis, as well as irritable bowel syndrome, type 1 diabetes, and dermatitis herpetiformis. Claims regarding relief of headaches, depression, fatigue, and nausea are not backed by sufficient evidence.

In reality, there are three undisputed conditions that warrant avoiding gluten in your diet:

  • Allergy to wheat
  • Celiac disease
  • Non-celiac gluten sensitivity

As for how a gluten-free diet may affect the other aforementioned conditions, while widespread evidence is lacking, it is still possible that some individuals may experience beneficial effects. Does that make it worth a try? You decide.

RELATED: Cinnamon May Be a Safe Way to Help Reduce Rheumatoid Arthritis Symptoms

Gluten and Rheumatoid Arthritis: What Studies Have Concluded

Theories of the effect of gluten on rheumatoid arthritis appeared more than 50 years ago when the work of an Australian physician, Ray Shatin, was published in the Journal of the American Medical Association. Dr. Shatin believed there to be a genetic similarity between people with celiac disease and those with rheumatoid arthritis. He proposed that, in RA, there is low level inflammation that occurs with gluten consumption — not as strong a reaction as that which occurs with celiac disease, though. He tested his theory on 18 RA patients and all 18 improved on the gluten-free diet. Despite those results, little to nothing was done for decades to further test the connection, if indeed there was a connection.

RELATED: Is the Gluten-Free Option the Healthier Choice?

In 2001, according to study results published in Rheumatology, 66 people with active rheumatoid arthritis were randomly assigned either a gluten-free vegan diet or a well-balanced non-vegan diet for one year. Results revealed beneficial results in the gluten-free vegan group, which researchers associated with a reduction in antibodies to food antigens. The immunoglobulin G antibody against gliadin and beta-lactoglobulin decreased in the gluten-free vegan group but not the other group. Gliadin is one of two classes of gluten protein linked to celiac disease and gluten sensitivity.

RELATED: The 10 Most Famous Fad Diets of All Time

In another older study, published in Arthritis Research & Therapy in March 2008, a group of rheumatoid arthritis patients who ate a gluten-free vegan diet were evaluated. Researchers concluded that their diet lowered cholesterol, LDL (low-density lipoprotein) and oxLDL (oxidized LDL), and raised levels of natural antibodies that have damaging effects on the body, such as causing inflammation and symptoms associated with rheumatoid arthritis. The researchers hypothesized that the beneficial results could contribute to protecting against cardiovascular disease in RA patients, but larger studies were needed.

In 2015, we learned a bit more from a study published in a Polish journal, Wiadomosci lekarskie. After studying 121 patients with rheumatoid arthritis and 30 with primary Sjögren’s syndrome, the authors concluded that anti-gliadin antibodies are far more frequently detected in patients with RA and primary Sjögren’s syndrome compared with the general population.

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In 2017, more important facts were revealed in the journal Minerva Gastroenterologica Dietologica. To date, no biomarker has been identified for non-celiac gluten sensitivity — but it had been previously reported that 50 percent of people with non-celiac gluten sensitivity were positive for anti-gliadin antibodies. However, those antibodies are not specific to gluten sensitivity. They are also found in other conditions, including celiac disease, autoimmune liver disease, connective tissue disease, irritable bowel syndrome, as well as some healthy controls. So, while being positive for anti-gliadin is not definitive for gluten sensitivity, when it accompanies clinical symptoms of gluten sensitivity, it is considered supportive evidence.

A Side Note About Gluten Sensitivity

On a personal note, this was particularly interesting to me. I have tested negative for Celiac disease, positive for gluten sensitivity, but have no symptoms attributable to gluten sensitivity. I have not been motivated to try a gluten-free diet.

While the studies have revealed a hint of a connection between gluten and RA symptoms, we are still left with too few studies and studies that are very small in scope. There is nothing yet that confirms a widespread connection.

Is a Gluten-Free Diet Generally Considered Healthy?

If you have chosen to try a gluten-free diet, you are left focusing on gluten-free products available in a dedicated section of your local grocery store. The good news is that there are more gluten-free products available now than ever before. The bad news is that they can be quite expensive. More bad news — gluten-free products are often high in sugar and fat and low in fiber. Consequently, you may experience constipation and weight gain.

Wheat is considered a nutritious grain. Many wheat-containing products (for example, breads and cereals) are fortified with vitamins and minerals. To eliminate all wheat products creates a void in your diet. When medically necessary, that void must be compensated for. When gluten-free is just a choice, there must be an awareness of the nutritional void that is created, and it should not be ignored.

RELATED: Best Foods to Add to Your Diet to Fight Rheumatoid Arthritis

Is a Gluten-Free Diet Considered Harmless?

A gluten-free diet cannot be deemed harmless because of its potential for nutritional deficiencies. If you do not have celiac disease or evidence of gluten sensitivity, there is no reason to follow a gluten-free diet. If you have a condition like rheumatoid arthritis where testimonials exist, along with some limited scientific evidence, about the beneficial impact of a gluten-free diet, talk to your doctor about your desire to try it. Follow their advice and guidance so that you can avoid nutritional deficiency and can pay attention to your intake of additional sugar and fat, as well as the diet’s effect on your weight.

Gluten-Free Diet and Arthritis: Does It Help Improve Symptoms?

Ask people with inflammatory arthritis their thoughts on following a gluten-free diet, and you’ll hear some strong opinions.

For some, the results of following a gluten-free diet have been impressive: “I’ve given up my handicap placard and my cane. My psoriasis has gone completely as well. When I eat gluten, my pain comes back — as does my psoriasis,” Kelly G. told us on Facebook. Marjorie W. says that her hands feel much better since eliminating bread, cake, and pastries. “When I indulge, swelling, stiffness, and pain return,” she says, noting that she’s also filling her diet with ample fruits and vegetables.

While many CreakyJoints members have been pleased with a switch to a gluten-free, just as many reported that cutting out gluten hasn’t improved their arthritis symptoms. Eliminating gluten made no difference for Sue D., whose friend suggested she start a gluten-free diet. Pam E. says that going gluten-free was “the best thing I’ve ever done for myself” — but only because it decreased her GI distress; it didn’t seem to affect her joints.

Gluten has earned a reputation for promoting inflammation and causing a host of health problems. In turn, going gluten-free has been perceived by many in the chronic illness community as a panacea — particularly because it’s a “natural” approach. As such, many arthritis patients have adopted a gluten-free diet, though to mixed success.

Could eliminating gluten help improve inflammation and arthritis symptoms? The idea doesn’t come out of nowhere. “Celiac disease can cause arthritis-like symptoms, so from that standpoint, it makes sense that following a gluten-free diet could help ,” says Micah Yu, MD, a board-certified internal medicine physician and rheumatology fellow at Loma Linda University Medical Center in Loma Linda, California.

There’s also a link between celiac disease and inflammatory arthritis: Data show that people who have rheumatoid arthritis are at a greater risk for celiac, and research also suggests that those with celiac are at a higher risk of later developing RA or other autoimmune disorders. In one 2017 Italian study, 35 percent of people with celiac also had another autoimmune disease, compared to a rate of 15 percent of those without celiac (the control group).

But just because cutting out gluten appears to help some people with arthritis doesn’t necessarily mean it’s right for you. Here, we looked at the latest studies on gluten and talked to rheumatology and GI experts for their take on whether going gluten-free is beneficial to people with arthritis.

What Is Gluten?

Gluten is a protein found in certain grains such as wheat, barley, and rye. While it’s necessary for those with celiac disease — who have an autoimmune response to gluten that causes GI symptoms — to stop eating gluten, many people allege that gluten can also cause problems in people without celiac.

One argument is that gluten can cause inflammation even if you don’t have celiac disease, which can worsen symptoms for those with arthritis.

Celiac Disease vs. Non-Celiac Gluten Sensitivity

Celiac is an autoimmune disease. For those with celiac, eating gluten triggers an immune response in the body that attacks the lining of the small intestine, causing GI symptoms such as diarrhea and bloating as well as dangerous nutrient deficiencies from not absorbing vitamins and minerals from your food. Celiac disease patients are treated with a strict gluten-free diet.

On the other hand, there’s another increasingly recognized condition called non-celiac gluten sensitivity (NCGS). “These patients come in with fatigue, joint pain, swelling, muscle pain. The diagnosis is one of exclusion. The doctor runs labs for celiac; when the results are negative but the patient improves from eating a gluten-free diet, that’s what we call NCGS,” explains Dr. Yu.

It may be the case that some people who have inflammatory conditions like rheumatoid arthritis or psoriasis have non-celiac gluten sensitivity.

Does Gluten Cause Inflammation or Joint Pain?

The short answer is possibly, but no one knows for sure why this could be the case.

It’s first helpful to understand what causes inflammation in people with celiac disease when they eat gluten. The human leukocyte antigen (HLA) complex is important here. HLA is a group of genes that helps the immune system distinguish your body’s own proteins and ones made from foreign invaders, such as bacteria and viruses. If the latter happens, it triggers inflammation.

There are many different variations of HLA genes, which are involved in various immune-related diseases, including celiac, rheumatoid arthritis, psoriasis and psoriatic arthritis, ankylosing spondylitis, and others. For instance, people who carry two specific variants of HLA are at an increased risk of celiac; those who carry different HLA variants are more at risk of developing other diseases. While having a certain HLA genetic variant doesn’t guarantee you’ll get an autoimmune disease, it does increase your risk.

It’s thought that these HLA genes play a role in what happens to people with celiac when they eat gluten. During digestion, gluten breaks down into proteins called peptides, which enter the superficial layer in the small intestine, explains Gauree Konijeti, MD, a gastroenterologist with Scripps Clinic Torrey Pines in La Jolla, California explains. When people with celiac disease eat gluten, their immune system recognizes the gluten peptides as foreign and mounts an attack that causes inflammation in the intestine.

But it’s not yet clear how eating gluten could trigger an inflammation response in those without celiac, says Dr. Wu.

Arthritis and Gluten: What the Science Says

There’s not a wealth of evidence showing that following a gluten-free diet could improve arthritis symptoms. A 2001 study published in the journal Rheumatology followed about 20 patients each as they embarked on a gluten-free vegan diet or a non-vegan diet for one year. At the end of the study, more of the people in the gluten-free vegan group experienced an improvement in symptoms (nine people) compared to the non-vegan group (just one). Keep in mind that there was more going on in this study than gluten or no gluten: the group that saw the benefit was also eating a vegan diet, which also eliminates animal proteins like meat and dairy. It was also an incredibly small sample size.

A later review study published in Frontiers in Nutrition in 2017 analyzed various clinical trials (including the one mentioned above) that looked at how dietary changes may affect rheumatoid arthritis symptoms. The studies in which people followed gluten-free diets also used gluten-free vegan or vegetarian diets, which means that experts couldn’t tease out the impact of gluten alone. Based on the available research, the authors lay out an ideal anti-inflammatory diet for people with arthritis: fruits, legumes, spices, herbs, oils, yogurt, and whole grains, including those that contain gluten, like whole-wheat bread, rye, and barley.

Bottom line: In the absence of a celiac disease diagnosis, there’s not enough evidence to suggest that people with rheumatoid arthritis go gluten-free, per a review in the July 2019 issue of Digestive Diseases and Sciences.

Gluten vs. Other Potential Causes of Inflammation from Diet

Consider that going gluten-free in and of itself doesn’t guarantee you’re eating a healthy diet. “As a result of going gluten-free, you may shift your diet to a healthier pattern by eating more fruits and vegetables, but many people don’t,” says Dr. Konijeti. There’s an entire industry of highly processed gluten-free foods. In other words, gluten-free doesn’t mean nutrient-dense.

There’s also the idea that the “bad guy” gluten may not be the real or only culprit. People may feel better removing gluten-containing foods because they are eliminating something in those foods other than or in addition to gluten.

Many foods with gluten also contain other compounds known as FODMAPs, which is an acronym for different types of carbohydrates (fermentable oligosaccharides, disaccharides,
monosaccharides, and polyols) found in dairy, certain fruits and vegetables, grains, and sugars. Lactose is a FODMAP, for example. According to review published in JAMA in 2017, “the reduction of FODMAPs associated with the gluten-free diet may explain, at least in part, why some patients affected with irritable bowel symptoms may report amelioration of their symptoms after starting a gluten-free diet.”

Other components of grains, called amylase-trypsin inhibitors (ATIs), have also been implicated in promoting inflammation, says Dr. Konijeti.

The Best Diet for Arthritis

The doctors we spoke with emphasize eating an anti-inflammatory diet with their patients. “A whole food, plant-based anti-inflammatory diet is my first-line recommendation,” says Dr. Yu. He counsels patients to cut out processed foods and refined sugar, and increase their fiber intake through fruits, vegetables, and whole grains, regardless if those whole grains contain gluten or not.

Fiber is the key player here: “More fiber improves gut health, which can relieve inflammation and systematically improve arthritis symptoms,” he says.

Other doctors advocate for a similar diet. Nilanjana Bose, MD, a member of the American College of Rheumatology, who practices at the Rheumatology Center of Houston, recommends a Mediterranean diet that restricts refined carbs and sugars, as well as red meat.

The benefits pay off across the board. “People who follow a low-carb anti-inflammatory diet lose weight and see their energy, sleep, and joint symptoms improve,” she says. Like Dr. Yu, she says that much of the success with an anti-inflammatory diet comes from improving the health of the microbiome, the network of trillions of bacteria in your gut.

“There’s been a lot of interest in the gut microbiome. We feel that some of these gut organisms may be promoting inflammation and there are some good gut organisms that decrease inflammation,” Dr. Bose explains.

It’s when this balance of gut bacteria is off that GI symptoms appear — and it may be one underlying trigger of autoimmune disease, she says. “Cleaning up your diet can help the gut reset. But you can do that without going gluten-free,” Dr. Bose adds.

Considering Going Gluten-Free? Keep This in Mind

If you’re not getting any results from following an anti-inflammatory diet after two months, Dr. Yu suggests exploring a gluten-free diet on the chance that you also have an underlying gluten sensitivity as well.

Know that if you cut out gluten without notifying your health care team first, you are going on a fairly restrictive diet. In the absence of a condition that warrants a gluten-free diet, you may be doing this unnecessarily.

If you have celiac disease symptoms, ask your doctor if you should be checked for celiac. You should do this before you cut out gluten. In order for blood tests to accurately test for celiac, you need to be currently eating gluten-containing foods.

Keep in mind that any diet changes you make should be part of an overall treatment plan you develop with your rheumatologist. It’s rare that people with inflammatory arthritis can improve symptoms, stop disease progression, and prevent long-term joint damage with diet changes alone. Prescription medications are often at the core of treatment due to the strong evidence supporting their success.

Keep Reading

  • What It’s Like to Try an Elimination Diet with Arthritis
  • 6 Simple Diet Lessons from Nutritionists with Rheumatoid Arthritis
  • What Is a ‘Low-Residue’ Diet, and Can It Help Treat Crohn’s Disease?

Review
Rheumatoid arthritis–celiac disease relationship: Joints get that gut feeling☆

Rheumatoid arthritis (RA) and celiac disease (CD) belong to the autoimmune disease family. Despite being separate entities they share multiple aspects. Epidemiologically they share comparable incidence environmental influences, associated antibodies and a recent incidental surge. They differ in their HLA pre-dispositions and specific predictive and diagnostic biomarkers. At the clinical level, celiac disease exhibits extra-intestinal rheumatic manifestations and RA gastrointestinal ones. Small bowel pathology exists in rheumatic patients. A trend towards responsiveness to a gluten free diet has been observed, ameliorating celiac rheumatic manifestations, whereas dietary interventions for rheumatoid arthritis remain controversial.

Pathophysiologically, both diseases are mediated by endogenous enzymes in the target organs. The infectious, dysbiotic and increased intestinal permeability theories, as drivers of the autoimmune cascade, apply to both diseases.

Contrary to their specific HLA pre-disposition, the diseases share multiple non-HLA loci. Those genes are crucial for activation and regulation of adaptive and innate immunity. Recently, light was shed on the interaction between host genetics and microbiota composition in relation to CD and RA susceptibility, connecting bugs and us and autoimmunity.

A better understanding of the above mentioned similarities in the gut–joint inter-relationship, may elucidate additional facets in the mosaic of autoimmunity, relating CD to RA.

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