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Eating for Rheumatoid Arthritis

The majority of practicing rheumatologists at RheumNow Live were unaware of the new ACR guidelines issued in 2022 regarding dietary and lifestyle recommendations for patients with Rheumatoid Arthritis (RA) (1).  Dr. Monica Guma reviewed these guidelines during her lecture on the impact of diet on disease activity and therapeutic response. She noted mounting evidence that intestinal bacteria interact with the immune system and affect autoimmune diseases.  

The gut microbiome is dynamic; patients with active inflammatory disease have different bacteria and proportions compared to healthy individuals. A 2022 systematic review and metaanalysis compiled evidence “gut microbiota dysbiosis were associated with a shared alteration with a depletion of anti-inflammatory butyrate-producing microbes (i.e., Faecalibacterium) and an enrichment of pro-inflammatory microbes (i.e., Streptococcus) in rheumatic diseases” (2).   Dr. Guma noted the changes in the gut microbiota will influence disease activity in addition to patients’ responses to their medications.  It is possible the DMARD did not fail, but rather the absorption or metabolism of the medicine may be altered by the intestinal bacteria. 

The ACR guidelines recommended The Mediterranean diet, citing it is the only one with sufficient evidence to support its benefits compared to the vegan, anti-inflammatory diet, or elimination diets.  Dr. Guma commented the Mediterranean diet may help with promoting healthy microbiota, enhancing production of anti-inflammatory metabolites, and maintaining intestinal barrier integrity.  The diet emphasizes consuming fish, vegetables, fruits, whole grains, nuts, beans and extra virgin olive oil while moderating alcohol and minimizing highly processed foods, added sugars, sodium, refined carbohydrates, and saturated fats (1). She recommended The Arthritis Foundation’s website as a helpful resource for patients to guide them on this diet, but also advocated for referring patients to a registered dietician as part of the RA management plan.  While some patients believe taking a supplement will be sufficient to get all the nutrients they need, the ACR Voting Panel debated dietary supplements and concluded there is not enough evidence to recommend their use in RA management; the Panel emphasized the “Food First” approach to obtain necessary nutrients. 

Dr. Guma prompted the focus should not be on loosing weight when counseling patients about diet, but rather promote a healthier lifestyle. When patients eat healthier foods combined with exercise, they will lose weight naturally.  She suggested, “Patients often are stressed knowing they need to lose weight. Just telling them to lose weight is not helpful. It is better to tell patients to focus on making slow positive changes to their diet and lifestyle.”   She affirmed patients often feel helpless when it comes to their disease; many want to know what they can do to help impact the disease. Educating them about healthy food choices will empower patients and make them partners in their care. 

Author's note: We acknowledge some patients may live in places that are food deserts or are socioeconomically disadvantaged where access to fresh fruits/vegetables or any food is difficult. Greater awareness and increased funding are needed to help to reduce these disparities.  


  1. England BR et al.2022 American College of Rheumatology Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2023 Aug;75(8):1603-1615. doi: 10.1002/acr.25117. Epub 2023 May 25. PMID: 37227116.
  2. Wang Y et al. Gut dysbiosis in rheumatic diseases: A systematic review and meta-analysis of 92 observational studies. eBioMedicine. 2022;80:104055. doi: 10.1016/j.ebiom.2022.104055.


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