Rebecca Manno, MD, MHS, assistant professor of medicine in the Division of Rheumatology at Johns Hopkins University, addresses some common questions and misperceptions about the role of nutrition in rheumatoid arthritis (RA).
Q: Can a specific type of diet or certain foods cause RA?
A: In terms disease onset, there are no data that definitively point to any particular food or diet that causes rheumatoid arthritis.
It is possible that certain foods could contribute to a disease flare, but there are no data to suggest that there are universal flare-provoking foods. A certain individual may notice a personal pattern of certain triggers, but this is unlikely to be universal among all patients given the nuances of the immune system and the wide range of antigen stimulation by foods.
Q: What role do nutrition and diet play in the management of RA?
A: Food choices can affect body composition for those with RA just as they can for the general population not affected by RA. There are data that show, however, that individuals with RA have less lean muscle and more fat than individuals without RA, even after controlling for certain medication, such as corticosteroids, which are notorious for causing such changes in body composition. For that reason, wise food choices may be even more important to the individual with RA to combat this predisposition to muscle loss and fat gain.
Q: What research is currently available related to nutrition and RA?
A: Unfortunately, the role of nutrition in RA is a poorly studied area. A well-done study of nutrition can be expensive and time consuming, although such rigorous science can provide important guidance for our patients.
Q: There seems to be a lot of confusion over the effectiveness of certain diets in relieving symptoms of RA—specifically, the anti-inflammatory diet and the gluten-free diet. Can you discuss?
A: Though different diets have become popular at various times, there are no data specifically related to their impact on RA. As mentioned earlier, there is no diet that can prevent the onset of RA. The possibility that diet or nutrition could be an adjunct to medical treatment is an interesting idea, but at this time it is not based in rigorous science.
Regarding the anti-inflammatory diet, this type of diet generally includes a healthy combination of unprocessed foods, natural proteins, fruits, and vegetables. This is a winning combination for overall health whether you have RA or not. I would tell my patients that this is a great way to eat regardless. It can be a huge life adjustment. But is it healthy eating? Absolutely. Can I tell you that it will make your RA better? Absolutely not. Can I tell you that you might feel better? You might. But is that because RA is being treated by it? Nobody can make that conclusion.
Regarding the gluten-free diet, there is a well-described entity of gluten sensitivity, which can have an associated arthritis, called celiac disease. In celiac, which is a completely separate disease process from RA, gluten is the antigen that stimulates the immune system and can lead to gastrointestinal (GI) symptoms (weight loss, diarrhea, and abdominal pain) and other autoimmune phenomena (arthritis and rashes). The treatment for celiac is to eliminate gluten from the diet. These patients do see a marked improvement in the arthritis, but it’s important to keep in mind that this is a unique entity compared with RA.
For people who may be gluten intolerant but do not meet diagnostic categorization for celiac, I advise that if they note an improvement in nonspecific GI symptoms or arthritis symptoms while adopting a gluten-free diet, stick with it. In general, gluten-free diets are quite healthy, as they eliminate many of the processed carbohydrates (wheat, pasta, and breads) that cause spikes in blood sugar (which leads to crashes in blood sugar and fatigue) and promote the storage of fat. There is no universal recommendation for all RA patients to adopt a gluten-free diet, as many RA patients do not have gluten sensitivity and therefore would not derive any direct benefit from this type of diet.
Q: Why do you think nutrition and diet remain such hot topics among RA patients?
A: When patients ask us about food, what they want to know is what they can do in their everyday life—outside of shots, infusions, and pills—to treat RA. When they are able to use food as treatment, they feel empowered; they feel better about making food selections than they do about injections or medications—there is the idea that it is somehow safer, better, and more natural.
Q: There are a lot of blogs and other online material that describe personal success with various diets. What should patients keep in mind as they consider these personal stories?
A: When my patients bring in blogs or other personal stories and tell me that they want to eat the same way the author does, I just remind them that they are reading about one person’s experience. It may not relate to their situation.
This is why research is important: in a research study, at least you can draw a conclusion about a population of patients—you can say, for instance, that a group of 35 patients who have positive antibodies, have four swollen joints, and are on a certain type of medicine made this specific change to their diet, and that this was the outcome. With personal experience, you don’t know any of those details, so you can’t assume that you will have that same outcome.
Rebecca Manno, MD, MHS*, is assistant professor of medicine in the Division of Rheumatology at Johns Hopkins University. Dr. Manno’s research interests are focused on the intersection of aging and rheumatic diseases. She is particularly interested in studying the new onset of rheumatic diseases among older individuals and improving the care delivery for patients aging with these diseases. Her research is based in the application of resistance exercise for older patients with inflammatory disease (rheumatoid arthritis and vasculitis) to improve body composition, strength, and function and to decrease inflammation. Dr. Manno received her bachelor of science degree from Johns Hopkins University and her medical degree from University of Maryland School of Medicine. She completed her internship and residency in internal medicine at University of Maryland School of Medicine and Baltimore Veterans Medical Center, where she was chief resident; and she completed a postdoctoral fellowship in rheumatology at Johns Hopkins University School of Medicine.*
Dietitians can help provide valuable information about nutrition after an RA diagnosis.
The role of diet in the management of RA can be a confusing topic for patients, who often have a lot of questions about how they should approach nutrition after a diagnosis. Working with a dietitian in addition to a rheumatologist can help patients understand the steps they can take to improve their overall health.
Jennifer Nelson, director of clinical dietetics/nutrition at the Mayo Clinic, says that patients she works with arrive with a lot of questions about how they can use nutrition as a tool: “Most of the questions I receive are about diet itself—what to eat and what to avoid—and about supplements.” Patients also wonder about specific diets, she says.
The role of a dietitian is to answer these questions and to work with each patient to help find nutrition solutions that are right for the patient’s specific situation. “My role is to help the individual choose a diet that meets their unique needs and to ensure that whatever supplements they take promote their health—and don’t result in further problems,” Jennifer says.
To that end, she engages in a dialogue that will help her understand the patient’s needs so that she can provide constructive insight. “I listen to each patient with concern for their problems and ask questions in a way that partners us in finding ways that nutrition can help relieve them,” she says. “If they don’t have any idea about the role of nutrition and RA, I bring them along that pathway of understanding diet and its role in inflammation and/or in relieving RA complications.” If a patient already has a good understanding of the basics of diet and nutrition, she focuses on making further progress. And if she recognizes potentially harmful assumptions or patterns, she can help move patients along a healthier path: “If they have misconceptions, we discuss them, evaluate what they are doing, and work to reduce risky choices and behaviors and substitute healthier ones.”
Though data to establish definitive connections between nutrition and RA are still lacking, patients can benefit from learning more about how their overall health can be improved by making healthy food choices. Working with a dietitian can provide valuable information and support to make these changes and can help patients feel empowered in their daily lives.