Nutrition can be a difficult topic to navigate when living with a rheumatic disease. So much misinformation is out there and pressure on rheumatic disease patients to eat healthy, however guidance is needed to navigate the misinformation and build healthy eating habits.
What is the impact of diet on rheumatic diseases?
Cristina Montoya – Registered Dietitian and Person Living With a Rheumatic Disease: Research is continuously shedding light on the importance of nutrition in managing arthritis symptoms. The 2023 ACR guidelines for exercise, rehabilitation, diet and additional integrative interventions for RA recommended the Mediterranean diet due to the low-moderate evidence for improvement in pain and vitality. The MedDiet is mostly a plant-based dietary pattern rich in fruits, vegetables, whole grains, legumes, nuts, seeds, fermented dairy products, fish, olive oil, herbs and spices, with moderate consumption of eggs and poultry and the occasional intake of red meats. Other studies have revealed that high-fibre diets are associated with lower CRP levels.
Can everyone afford or implement this dietary pattern? Dr. Thompson and her colleagues assessed adherence and barriers to adopting the Mediterranean Diet (MedDiet) among a diverse U.S. population. Their research revealed low adherence due to food insecurity, educational and income disparities, and racial factors. Only 27% of the 1,385 participants had heard of the diet. While many were open to trying it, challenges included food aversions and insufficient dietary information from healthcare providers. I look forward to hearing from Dr. Thompson tomorrow.
What dietary interventions are recommended for rheumatic diseases?
Cristina Montoya – Registered Dietitian and Person Living With a Rheumatic Disease: I emphasize to my clients that they should stop fixating on a specific food, nutrient, or meal and instead focus on their overall eating pattern. It’s not just about what you eat but also what you don’t eat. I prefer using the term ‘eating pattern’ rather than ‘diet’ to promote more sustainable changes.
Start with foods they can add to their meals and snacks:
- Whole grains or resistant starches: oats, barley, rice, quinoa, cooked/cooled rice, pasta, and potatoes. If they feel adventurous, try grains or pseudo-grains like teff, amaranth, millet, farro.
- Nuts and seeds
- Optimize intake of Omega-3 Fatty Acids: Found in fatty fish like salmon, sardines, herrings and plant-based foods like flaxseeds, chia seeds and walnuts.
- Low glycemic index foods: eggplant, artichokes, raw carrots, sweet potatoes, cassava, cabbage, green bananas, spinach, mushrooms, apple, pears, oranges, legumes, certain whole grains, legumes.
Eat a variety of legumes like chickpeas, beans, lentils, soy or soy products.
Experiment with different herbs and spices. Try a new food or recipe every week.
Stay hydrated throughout the day, mostly with water, green tea and decaffeinated herbal teas.
Walk it off: gentle movement or walking for 10 minutes after each meal to improve gastric motility.
Limit or avoid: emphasize nutrition label reading.
Ultra-processed foods, such as baked goods and prepackaged meals or snacks, often contain trans fats and saturated fats. Trans fats can trigger systemic inflammation. Additionally, heating olive oil beyond its smoke point reduces antioxidants, vitamin E, and oleocanthal—compounds known for their anti-inflammatory properties.
Excessive intake of Omega-6 fatty acids: high intake of corn, peanut and soy oils, and most meats, especially red meats, can trigger the body to produce pro-inflammatory chemicals such as arachidonic acid.
Refined sugars: pastries, chocolate bars, candy, soda beverages, energy drinks and fruit juices trigger the release of cytokines. Increases abdominal adipose stores, which are metabolically active and pro-inflammatory. Look out for dextrose, fructose, maltose, corn syrup in the nutrition labels, as they are hidden sources of sugar.
Sugar alternatives: aspartame and sucralose contained in diet sodas, gum or reduced-fat products, can cause an inflammatory response in the body because our bodies cannot process these substances well.
Red meat is high in saturated fats and contains high levels of advanced glycation end products that stimulate inflammation, especially when grilled, roasted, fried, or broiled. A few animal studies showed that saturated animal fat could increase intestinal permeability.
Red meat is also enriched in N-glycolylneuraminic acid (Neu5Gc) that humans cannot fully synthesize. A diet high in Neu5Gc induces changes in the gut microbiome.
Sodium: Studies have shown that high salt diets may elevate the expression of inflammatory biomarkers. If patients are taking corticosteroids, sodium poses risk of edema and rise of blood pressure.
As a Dietitian, it is important to include in the assessment and nutritional plan any diet modifications pertinent to managing side effects from medications like constipation, GERD, increased or low appetite, weight loss, or weight gain.
What are some common misconceptions about diet and arthritis?
Cristina Montoya – Registered Dietitian and Person Living With a Rheumatic Disease: A carnivore diet cures autoimmune diseases. It eliminates all plant-based foods including grains, legumes, nuts and seeds, which contradicts the benefits of a plant-based diet. This diet is high in saturated fats and low in fiber and antioxidants, which impacts gut microbiota balance. It is an unsustainable and unpalatable dietary pattern.
Gluten-free diets for all. It’s clear that a gluten-free diet is the only treatment for individuals with Celiac Disease. After that, we need to assess each individual on a case-by-case basis. A review of case reports from Spain suggested that individuals with fibromyalgia and spondyloarthritis who have unexplained fatigue, oral candidiasis (yeast), GI symptoms, iron-deficiency anemia, and a relative with CD might benefit from a gluten-free diet. Patients with Sjogren’s Disease have a higher prevalence of non-celiac gluten/wheat sensitivity and celiac disease compared to the general population.
“A Dietitian is only for fat people,” that’s what a doctor told a Sjogren’s patient who asked for a referral to see a dietitian related to their gastrointestinal symptoms. For example, Sjogren’s can affect the entire GI tract and a Dietitian can help by providing guidance on diet modifications to ease discomfort related to dry mouth, chewing and swallowing difficulties, GERD, gastroparesis, chronic constipation or diarrhea; develop strategies to prevent unexplained weight loss or nutritional deficiencies, and collaborate with the circle of care to enhance clinical outcomes and symptom management.
Cheryl Crow – Occupational Therapist and Person Living With a Rheumatic Disease: As a patient and occupational therapist, I’ve seen a lot of people fall prey to the “appeal to nature” fallacy, or the idea that dietary interventions are going to be safer and more effective than medications. There are many social pressures from others to “just change your diet and you’ll feel better” and trying medication is seen as a failure to “control it naturally.” I have helped my clients understand the impacts of internalized ableism, and accept that it’s possible to take whatever treatments are necessary for your disease control (most often medication) without shame.
How does your profession address diet and nutrition:
Cheryl Crow – Occupational Therapist and Person Living With a Rheumatic Disease: Occupational therapists can help assess the kitchen set up and suggest ways for people to conserve energy (such as a stool in the kitchen) and minimize joint pain during meal prep (by using good ergonomics and assistive devices).
When it comes to suggesting the actual foods to consume, that is a bit of a gray area in our scope of practice and we typically refer to registered dietitians as that is their area of expertise. However we can educate patients on the evidence around dietary interventions and their condition, and help correct misconceptions (such as that RA is going to be “cured” by diet).
Nutrition is crucial for managing rheumatic diseases, with certain diets helping reduce inflammation and improve symptoms. However, misinformation often leads to patient confusion. Relying on trusted, evidence-based resources helps individuals make informed nutritional decisions supporting their health.
