Your Guide to Food Elimination for RA
Curious if certain foods trigger your RA symptoms? Here’s what to know about trying an elimination diet.
An elimination diet for rheumatoid arthritis (RA) seems simple enough: Remove suspected “trigger foods” from your meal plan and see if your symptoms improve. But the truth is, there’s a lot you need to consider before taking that step. “In some cases, elimination diets may be appropriate,” says Alicia Romano, M.S., R.D., clinical registered dietitian at the Frances Stern Nutrition Center at Tufts Medical Center in Boston. But in other cases, not so much. If you’re curious whether an elimination diet is right for you, here’s what you need to know.
What’s an Elimination Diet?
It’s a procedure used to identify foods that may be triggering an adverse reaction, says Romano—specifically for RA, we’re talking about symptom flares. Basically: You remove the foods from your diet for a while to see whether symptoms resolve. If they do, you can then reintroduce the foods, one at a time, to see if symptoms come back.
Even if you’re taking medication for your RA, it’s still common to experience flares. In some cases, an elimination diet may lead to fewer flares, says Nilanjana Bose, M.D., a rheumatologist at the Rheumatology Center of Houston. And if it works well and you show you can maintain the diet for six months to a year, you may even be able to talk to your doctor about lowering your medication dose, says Dr. Bose. So if you’re taking multiple meds, you may be able to try eliminating one of them. Or if you’re on methotrexate, say, you may be able to try taking fewer pills per week. That could be great!
Still, don’t expect to kick the meds completely, says Dr. Bose. “Most patients will need something to keep their inflammation down.”
There are lots of elimination diets out there, but here are some of the most common for RA (roughly in order of how much evidence there is to back them).
Worth a try:
Gluten-free: RA patients who are sensitive to gluten—a protein found in certain grains—may notice their symptoms get better when they don’t eat it. Gluten can hide in many products, including anything with wheat, barley, or rye (like bread, crackers, and flour).
Dairy-free: Some research suggests that dairy may increase inflammation in the body for some people. And anecdotally, some RA patients report fewer symptoms when they avoid dairy. Dairy includes animal milk and foods made from milk, such as cheese, butter, and yogurt.
Maybe, but we’re not sure:
Autoimmune Protocol: The goal of this paleo-style diet is to boost the immune system by cutting out foods that can produce an inflammatory reaction, including all grains, nuts, seeds, nightshade vegetables, eggs, and dairy, says Romano. It also restricts alcohol, tobacco, coffee, processed sugars, and certain medications. That leaves you with fresh fruit (in moderation), sweet potatoes, yams, Chinese or Jerusalem artichokes, and minimally processed meats (ideally wild, pasture-raised, or grass fed). In some cases, it may help you identify trigger foods—but with no science to back it up, it’s hard to know how much it can really help, Romano says. “We don’t really understand the risk-benefit ratio,” says Romano.
Nightshade-free: Some people report worsening RA symptoms after eating so-called nightshade vegetables (eggplants, peppers, tomatoes), though there’s no research to support the link. In fact, they’re rich in antioxidants that many people with RA should get more of, says Dr. Bose.
Keep in mind, trigger foods can be different for different people. That means, if you were to try an elimination diet, your doctor might suggest something more individualized based on your unique trigger foods.
Do Doctors Recommend It for RA?
Because there’s not enough research to back them up, elimination diets are not routinely recommended for RA, says Romano. On the other hand, certain foods—such as processed sugars, refined carbohydrates, and red and processed meats—have been linked to inflammation, says Dr. Bose. Your doctor is likely to recommend avoiding these foods first before attempting anything more extreme, like an elimination diet.
Next, think about what foods you can add rather than subtract. Are you eating plenty of plants (vegetables, fruits, whole grains, legumes) and foods rich in omega-3’s (fatty fish, nuts, seeds, olive oil)? These nutrient-dense foods can support the immune system and may help lower inflammation, Romano says. You may find these dietary adjustments make a big difference in how you feel, and that you don’t need an elimination diet after all.
So who might benefit from an elimination diet? Anyone who (after making these healthy changes) has reason to believe they might have a trigger food. If that's you, your doc might talk with you about this approach.
How to Spot a Trigger Food
If you’re like a lot of people with RA, you can probably spot a trigger food through casual observation alone. But you might find keeping a food journal helpful, Romano says.
You’ll want to track three things:
Food/beverage intake: Be sure to include the time and the amount you ate/drank. You may find that the dose matters.
Your symptoms: Rate your symptoms throughout the day on a 1-to-10 scale, Romano advises. This helps establish a baseline for what is normal for you, so you can see when symptoms are getting better or worse.
Any out-of-the-ordinary occurrences: Did you get a poor night’s sleep? Did you go on a strenuous hike? Were you under a lot of stress at work? “A lot of other factors that can play a role in the inflammatory process,” Romano says. “So we want to control for that.”
By gathering this data, you can more easily zero in on any patterns, and identify (or rule out) potential trigger foods.
Drawbacks of Elimination Diets
When you cut a food out of your diet, you need to compensate for those nutrients you’ll be missing out on, says Laura Gibofsky, M.S., a registered dietitian and nutritionist at the Hospital for Special Surgery in New York City. “If someone comes to me saying, ‘I’ve removed certain foods, and now I’m eating lemon water and carrots,’ I say, ‘Well, we have a problem because that’s not going to meet your nutrition needs.’”
Getting proper nutrition to support overall health is important when you’re living with RA, she says. Plus, if you’re on certain medications, you may already be at risk for nutritional deficiencies. For example, steroids can affect how the body uses the bone-building nutrients calcium and vitamin D. “So removing calcium from your diet without replacing it could put you at greater risk for weakened bones,” says Gibofsky.
Your dietitian can help you avoid nutritional deficiencies by advising you on what foods you’ll need to eat to replace the nutrients you’ll be cutting out.
If you’re cutting out gluten, for example, you’ll need to get your whole grains from gluten-free sources, like oats, brown rice, quinoa, amaranth, and buckwheat. If you’re giving up dairy, you’ll need to get your calcium and vitamin D from dairy-free sources, such as soy milk, yogurt and cheese alternatives, fortified orange juice, fortified breakfast cereal, canned salmon, and almonds, Romano says.
If you can’t meet your nutritional needs from food intake alone, your dietitian may recommend a supplement, Romano says.
Cutting Back vs. Cutting Out
If you cut out a food and start feeling better, you might be tempted to skip the “reintroduction” phase of the diet. And that’s your call. But consider that you may be able to tolerate the food in smaller amounts without triggering your symptoms. “It’s a phased approach,” says Romano. “The end goal is the most liberal diet possible.”
Of course, if you’ve eliminated multiple foods, the reintroduction phase is especially important to identify which of those foods is the culprit. “Say you eliminated gluten and dairy for a month, and you have symptom resolution,” says Romano. “Well, which one is it? Gluten, dairy, or both?” To find out, you might first reintroduce gluten and see if your symptoms return. Then you’d eliminate gluten again, and reintroduce dairy. “It’s a step-by-step process and something patients need guidance on,” she says. Again: Don’t try this on your own!
Results Are Not Guaranteed
Keep in mind, even after you go through all this, you may not get the results you want. While some patients do see dramatic improvement in joint pain, stiffness, and energy level from an elimination diet, plenty of others see no improvement at all, says Dr. Bose. “It can be quite revolutionary for some,” she says, “but not for everyone.”
If you’re going to go forward with an elimination diet, you should be prepared for that possible outcome.
Gluten and RA: Arthritis Foundation. (n.d.) “The Connection Between Gluten and Arthritis.” arthritis.org/health-wellness/healthy-living/nutrition/anti-inflammatory/the-connection-between-gluten-and-arthritis
Dairy and RA: Arthritis Foundation. (n.d.) “Is Dairy Arthritis-Friendly?” arthritis.org/health-wellness/healthy-living/nutrition/healthy-eating/dairy-and-inflammation