Unfortunately, many rheumatologists do not learn about dietary causes of rheumatoid arthritis (RA) in school. Nonetheless, the scientific literature clearly describes remission of the disease when triggering foods are eliminated. For some RA patients, the condition can be reversed through diet (!). Of course, triggering foods must be avoided for drug-free remission to continue.

The science

For a scientific overview of diet-based treatments for rheumatoid arthritis, a good starting point would be L. Gail Darlington and N. W. Ramsey’s 1993 review, particularly the section on Dietary Elimination Therapy (page 3 in the PDF / pg 509). To summarize what we know:

Elimination diets work for some people . According to Gail Darlington, her elimination diet protocol works in about 35-40% of RA patients. (Source: the second page of her chapter on RA in Diet and Human Immune Function.) Other diet studies show anywhere from similar remissions levels to no remission at all.

. According to Gail Darlington, her elimination diet protocol works in about of RA patients. (Source: the second page of her chapter on RA in Diet and Human Immune Function.) Other diet studies show anywhere from similar remissions levels to no remission at all. The more eliminating diets tend to have higher remission rates . Various diets have been studied: elimination diets, vegan, raw vegan, starch-based vegan, vegetarian, elemental diets (engineered meal replacements), and the Mediterranean diet. Elimination diets have shown the highest remission rates. The science suggests that the strongest dietary factor is the elimination of problematic foods.

. Various diets have been studied: elimination diets, vegan, raw vegan, starch-based vegan, vegetarian, elemental diets (engineered meal replacements), and the Mediterranean diet. Elimination diets have shown the highest remission rates. The science suggests that the strongest dietary factor is the elimination of problematic foods. Every patient is different. In the elimination diet approach, problematic foods differ from patient to patient.

Some of the key randomized controlled trials demonstrating the effectiveness of elimination diets are:

Placebo-controlled, blind study of dietary manipulation therapy in rheumatoid arthritis. (Abstract, full paper.)

This study by L. Gail Darlington (the same Gail Darlington discussed earlier), N. W. Ramsey, J. R. Mansfield was published in The Lancet, one of the world’s most prestigious medical journals. It found a significantly greater benefit from the elimination diet versus placebo. Among the 48 test subjects, 85% identified foods that made their symptoms worse.

This study by L. Gail Darlington (the same Gail Darlington discussed earlier), N. W. Ramsey, J. R. Mansfield was published in The Lancet, one of the world’s most prestigious medical journals. It found a significantly greater benefit from the elimination diet versus placebo. Among the 48 test subjects, 85% identified foods that made their symptoms worse. Hicklin JA, McEwen LM, Morgan JE. The effect of diet in rheumatoid arthritis. Clin Allergy 1980;10:463.

This exclusion diet improved outcomes for 24 of 72 RA patients (33%).

For a longer list of various trials on diet and RA, see Appendix C at the end of this post.

Why the science is obscure

You may find it difficult to believe that the scientific literature describes a drug-free way to reverse rheumatoid arthritis (for some patients) while rheumatologists claim that there is no cure. Nonetheless, most of these studies are available online for free and you can read them for yourself.

Perhaps the situation may make more sense if you understand the economics of treating RA. Pharmaceutical drugs for treating the disease are a multi-billion dollar industry. Humira treats various diseases including RA and was the world’s best-selling drug last year, generating revenues of $18,427 million in 2017 (source: Abbvie’s annual report page 33). Enbrel, another drug that treats various autoimmune conditions including RA, was the world’s third best selling drug in 2017.

When RA is framed as a “chronic” disease that requires lifelong medication, doctors and pharmaceutical companies make more money as patients “require” a lifetime of expensive treatment. Patient advocacy organizations often turn into pharmaceutical advocacy organizations when the majority of their funds come from pharma companies. For example, pharma companies such as Abbvie, Amgen, and Eli Lily top the list of the Arthritis Foundation’s donors according to page 13 of their annual report. It’s not in their interest to bite the hand that feeds them.

Medical students tend to learn very little about the elimination diet research that has been done. (Or they learn that elimination diets are something to be avoided and should not be taken seriously as treatment options.) While a rheumatologist will likely recognize The Lancet as a top journal, they may be unfamiliar with RA studies published in it as it was not a part of their education.

This is why this blog exists. I feel that it’s important for patients to know when the mainstream medical community has forgotten about effective treatment options. This dubious ignorance causes unnecessary harm to those suffering from RA.

Implementing an elimination diet

Information on implementing Gail Darlington’s elimination diet can be found in this document (Nutrition and Arthritis, pp.237-244). To briefly summarize the approach:

The first stage involves eating the ‘safest’ foods: trout / salmon / cod, fresh pears, carrots (fresh or frozen), mineral water (tap water will be tested later), and sea salt.

No smoking.

No coffee, tea, etc.

No cheat days.

More foods are slowly introduced to see if they lead to increased symptoms.

If you’re interested in trying out the elimination diet, you may find these resources to be of interest:

However, there’s one aspect of Darlington’s protocol that we haven’t figured out yet: why isn’t it as effective as fasting (not eating)?

Is diet the cause of most RA?

There are hints that diet may be the cause of RA in the majority of patients. In a Swedish study, 14 patients underwent a 1-week water fast and all 14 patients saw improvements in their RA symptoms:

We don’t fully understand why so many RA sufferers respond to fasting while the success of Darlington’s elimination diet is “only” in the 35-40% range. Here are some possibilities:

Cross contamination . I could not find information on whether or not researchers gave patients advice on how to avoid accidentally eating trace amounts of gluten or other contaminants.

. I could not find information on whether or not researchers gave patients advice on how to avoid accidentally eating trace amounts of gluten or other contaminants. Traces of food proteins in medications . Medications often contain trace amounts of proteins from milk, corn, and wheat. In rare cases, these traces can trigger allergic reactions (see the Medications section on page 3 of this article). I could not find any literature on whether or not traces of proteins in medications can trigger RA.

. Medications often contain trace amounts of proteins from milk, corn, and wheat. In rare cases, these traces can trigger allergic reactions (see the Medications section on page 3 of this article). I could not find any literature on whether or not traces of proteins in medications can trigger RA. Not enough foods are eliminated . There is mostly anecdotal evidence that some people such as Mikhaila Peterson react to almost everything except meat. More on her later.

. There is mostly anecdotal evidence that some people such as Mikhaila Peterson react to almost everything except meat. More on her later. Fasting causes your body to produce ketones. One theory is that ketones produced during fasting lead to symptom improvements. Ketones are produced when your body is forced to use fat as an energy source (e.g. from fat stored in the body) rather than carbohydrates. However, one experiment that tested a ketogenic diet (a carbohydrate-free diet that induces the production of ketones) seems to debunk this theory as the ketogenic diet was not very effective.

Unfortunately, we currently don’t understand why there is an efficacy gap between fasting and Darlington’s elimination diet. That research simply hasn’t been funded and performed. However, there is another elimination diet that could potentially narrow that gap.

The meat-only elimination diet

This may sound crazy, but it turns out that eating only meat is an option. The Inuit have done it for generations and people of other races have also lived on an all-meat diet. The elimination of fruits and vegetables may potentially be helpful in treating RA.

Advocates of this approach include:

Mikhaila Peterson (daughter of Jordan Peterson). She has had 2 joint replacements because of her rheumatoid arthritis and was the first child in Canada to receive Enbrel. As doctors couldn’t cure her, she looked outside of mainstream medicine. Her RA went away after she switched to a beef-only diet. She has also figured out that she doesn’t tolerate vegetables or pepper. She runs a blog and her interviews can be found on Youtube; her most viewed interview is with Joe Rogan.

(daughter of Jordan Peterson). She has had 2 joint replacements because of her rheumatoid arthritis and was the first child in Canada to receive Enbrel. As doctors couldn’t cure her, she looked outside of mainstream medicine. Her RA went away after she switched to a beef-only diet. She has also figured out that she doesn’t tolerate vegetables or pepper. She runs a blog and her interviews can be found on Youtube; her most viewed interview is with Joe Rogan. Paleomedicina is a clinic in Hungary that treats various autoimmune conditions with their ‘paleo ketogenic’ diet. Their Youtube channel has an interview with a successful RA patient; turn on English subtitles by clicking the CC icon in the bottom right of the Youtube player.

Please note that there are no scientific papers on all-meat diets in the context of RA. The only scientific papers about meat-only diets are from the Bellevue study, where two men ate only meat for a year so that scientists could study them. The study results can be found in these two papers:

The Bellevue study did not find any nutritional deficiencies from the diet and noted that the gingivitis of one participant went away (page 12 of the PDF):

No clinical evidence of vitamin deficiency was noted. The mild gingivitis which V. S. [Vilhjalmur Stefansson] had at the beginning cleared up entirely, after the meat diet was taken.

A meat-only diet has some theoretical advantages over Darlington’s protocol. Paleomedicina has discovered through clinical experience that a more balanced diet with fruits and vegetables leads to higher (worse) intestinal permeability than meat alone. The theory is this: a ‘leaky gut’ allows foreign proteins in the body, which leads to the immune system targeting the antigens on those proteins. Something goes wrong as the immune system does not properly differentiate between foreign and self antigens, leading it to attack the body’s own cells and cause RA.

Here is some more detail on Paleomedicina’s claims about fruits and vegetables impairing intestinal permeability:

Zsofia Clemens’ presentation (available on Youtube) provides some data (glucose levels in a diabetic patient) on the superiority of a meat-only diet over the less restrictive version of Paleomedicina’s diet that allows fruits and vegetables.

Higher-quality images of the glucose level measurements can be found from the presentation slides (page 9).



In diabetes, better glucose control (less fluctuation in blood sugar levels, as shown on the left) was achieved with the meat-only diet.

In diabetes, better glucose control (less fluctuation in blood sugar levels, as shown on the left) was achieved with the meat-only diet. Later slides in the same presentation contain examples of intestinal permeability measurements. Their experience has been that removing fruits and vegetables improves intestinal permeability.

Many RA researchers such as Gail Darlington have noted that intestinal permeability may be the cause of RA. Darlington and Ramsey’s 1993 review discusses intestinal permeability (alongside other possibilities) under the section “Possible reasons for improvements on diets”. More recent research such as Alessio Fasano’s work on zonulin suggest that intestinal permeability is the cause of RA (see section IV. INTESTINAL PERMEABILITY AND DISEASE in his paper). However, I would point out that the intestinal permeability theory has yet to be fully proven; as well, there have not been any human trials looking at all-meat diets as a treatment for RA.

Nonetheless, an all-meat diet may be an option worth exploring as it operates on the same principle (elimination) as Darlington’s diet protocol and is theoretically superior in some ways. Intestinal permeability may (or may not) explain much of the effectiveness gap between fasting and Darlington’s elimination diet. See my primer on all-meat diets for more information on their pros and cons.

Veg*ns

If you are vegan or vegetarian, the thought of an all-meat diet likely horrifies you. Please see the additional information in Appendix A regarding veg*n diets and RA.

How to avoid cross contamination

If you are trying an elimination diet, here are some tips:

Cook your own food . All of it . Eating out and buying prepared food is risky and should be avoided. Some restaurants even intentionally serve gluten to glutenfree customers. I’m sorry about how inconvenient this is. It’s also socially awkward. However, I would point out that this is what humanity did before restaurants and microwave dinners existed. It is very doable.

. . Eating out and buying prepared food is risky and should be avoided. Some restaurants even intentionally serve gluten to glutenfree customers. I’m sorry about how inconvenient this is. It’s also socially awkward. However, I would point out that this is what humanity did before restaurants and microwave dinners existed. It is very doable. Bake your food initially. Non-stick pans that have been used to cook other foods can be a source of cross-contamination. I suggest baking your food as you can use a fresh sheet of aluminium foil every time. (Glass, ceramic, and metal containers are also fine and don’t need foil if they are clean.) Later on you can buy a new pan once you know what foods you need to avoid.

initially. Non-stick pans that have been used to cook other foods can be a source of cross-contamination. I suggest baking your food as you can use a fresh sheet of aluminium foil every time. (Glass, ceramic, and metal containers are also fine and don’t need foil if they are clean.) Later on you can buy a new pan once you know what foods you need to avoid. Use metal utensils, not plastic or wood . Non-metal utensils may be a source of cross-contamination as they have crevices where problematic food can get stuck. You can buy metal tongs, forks, knives, etc. Wooden handles on utensils and knives should be fine.

. Non-metal utensils may be a source of cross-contamination as they have crevices where problematic food can get stuck. You can buy metal tongs, forks, knives, etc. Wooden handles on utensils and knives should be fine. ?Pills may cause intolerance? As mentioned previously, the binders in many pills, supplements, and medications may contain traces of proteins from wheat, corn, and dairy. The literature on food allergies notes these traces are a problem in rare cases (see the Medications section on pg 3 of this paper). This topic doesn’t seem to have been studied for RA.

Taking the same precautions as celiacs (the highly sensitive ones) may seem quite extreme. However, as discussed previously, both celiac disease and RA are autoimmune diseases that may share a common cause. If the intestinal permeability theory is true, then even trace amounts of offending foods must be avoided as these traces are known to impair intestinal permeability (which leads to disease).

Talk to your doctor before stopping medication

Some drugs used to treat RA have withdrawal symptoms. Prednisolone withdrawal can lead to life-threatening adrenal insufficiency (e.g. see prednisolone’s product monograph). Please do not discontinue prednisolone (Pediapred) suddenly.

Your doctor should be able to inform you about what drugs do and don’t have withdrawal symptoms. You should probably talk to your doctor first before discontinuing medication.

Elemental diets

Elemental diets (e.g. E028, Vivonex) are meal replacements engineered to be non-allergenic. If food does not contain complete proteins, the immune system will not have foreign antigens to attack. While elemental diets are effective in some cases, they don’t seem to be as effective as Gail Darlington’s elimination diet. There isn’t much research as to why they aren’t as effective as they ‘ought’ to be. Do the elemental diets contain trace amounts of complete proteins? I don’t know.

Search Appendix C for the word ‘elemental’ to find some elemental diet studies.

Closing thoughts

It is pretty disappointing that mainstream medicine isn’t setup to inform RA patients about dietary treatment options and to help them implement them where appropriate. However, the good news is that the diet option exists and has been scientifically studied.

If you’ve done your research and think that an elimination diet may be right for you, here are some additional pointers:

If you are looking for nutritional advice and would like a medical professional who is part of a regulated system, look for a registered dietitian rather than a nutritionist. Nutritionist isn’t always a protected title so anybody can say that they are a nutritionist. Registered dietitians however are regulated.

I wish I could tell you where to easily find medical professionals with expertise in dietary treatments for RA. Such professionals are quite rare as medical students do not learn this skillset in school. Paleomedicina offers consultations over the Internet; I’m not aware of others offering similar services. Gail Darlington looks like she is practicing out of Surrey, United Kingdom; see her website for contact details.

While you can go on social media (e.g. Reddit, Facebook) and find information about all-meat diets, be careful about the ideologies that come from diet-based communities. Many of them argue that humans have been ‘evolved’ to eat the diet that they advocate; it is not possible for all of these different dietary groups (e.g. fruitarians, paleo, carnivore/zerocarb, LCHF, WFPB) to be correct. For all-meat diets, I would be highly skeptical of the idea that most initial adaptation problems are caused by “keto flu” and can be treated by ingesting some unspecified combination of electrolytes. If you feel like you are about to faint, you may have low blood sugar (which is treated by eating some carbs).

Similarly, be skeptical about the ideologies in mainstream nutrition. The RA studies on elimination diets indicate that a “balanced diet” filled with variety is extremely risky. If you eat fish or meat, don’t be afraid about eating pieces of fat (e.g. fish skin, belly, fatty cuts) as there is no evidence that fat or saturated fat is unhealthy. I’m sorry to tell you that many areas of mainstream medicine aren’t based on solid evidence. Evidence-based medicine has done wonders for cholera, dysentery, infant mortality, and other conditions that you only read about in history textbooks. Hopefully there will come a day when evidence-based medicine becomes more mainstream and does the same for RA.

I wish you the best of luck in your health journey.

Appendix A: Veg*n diets

There have been multiple studies of vegetarian and vegan diets, with less success than the diet tested by Gail Darlington and her colleagues.

I could not find any veg*n diet studies that describe remission in their test subjects. The McDougall starch-based vegan diet study states that the diet can lead to remission, but suspiciously does not provide remission statistics for the study’s patients. The scientific literature does not paint a rosy picture regarding vegan diets versus more omnivorous diets when it comes to RA.

Perhaps the sanest approach is to simply modify Gail Darlington’s protocol for a vegan or vegetarian diet. Or consider a ‘seagan’ diet (veganism with fish) or pescatarian diet; the first stage of Darlington’s protocol is literally a seagan diet.

Here is a list of various veg*n diets that have been studied:

Raw vegan : In one study, Faecal microbial flora and disease activity in rheumatoid arthritis during a vegan diet (full paper), 5 out of 19 patients in the raw vegan group saw mild improvement in RA, while none of the 18 patients in the control group saw improvement. 3 of the 22 patients who started the raw vegan diet refused to continue with the diet.

A different study of a “living food” diet found little difference in objective measures of RA symptoms, although the authors argue that subjective measures improved. See

Uncooked, lactobacilli-rich, vegan food and rheumatoid arthritis (full paper).

: In one study, Faecal microbial flora and disease activity in rheumatoid arthritis during a vegan diet (full paper), patients in the raw vegan group saw mild improvement in RA, while in the control group saw improvement. 3 of the 22 patients who started the raw vegan diet refused to continue with the diet. A different study of a “living food” diet found little difference in objective measures of RA symptoms, although the authors argue that subjective measures improved. See Uncooked, lactobacilli-rich, vegan food and rheumatoid arthritis (full paper). Lactovegetarian : A Norwegian study looked at fasting, followed by a gluten-free vegan diet, followed by a lactovegetarian diet by patients. See Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis (abstract) and the follow-up article Rheumatoid arthritis treated with vegetarian diets (full paper). 12 out of 27 patients in the diet group showed ‘significant’ clinical improvement while 2 out of 26 patients in the control group also showed significant improvement.

: A Norwegian study looked at fasting, followed by a gluten-free vegan diet, followed by a lactovegetarian diet by patients. See Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis (abstract) and the follow-up article Rheumatoid arthritis treated with vegetarian diets (full paper). 12 out of 27 patients in the diet group showed ‘significant’ clinical improvement while 2 out of 26 patients in the control group also showed significant improvement. Gluten-free vegan : Hafström et al. found that 9 out of 38 (24%) patients in the gluten-free vegan group showed modest improvement while 1 out of 28 (4%) patients in the control group also showed improvement (fulfilled ACR20 improvement criteria, which corresponds to a small drop in symptoms). See A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food antigens (full paper).

Elkin et al. found somewhat similar results. 11 out 30 (37%) patients in the gluten-free vegan diet group and 1 out of 28 patients in the control group showed an ACR 20% response.

: Hafström et al. found that patients in the gluten-free vegan group showed modest improvement while patients in the control group also showed improvement (fulfilled ACR20 improvement criteria, which corresponds to a small drop in symptoms). See A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food antigens (full paper). Elkin et al. found somewhat similar results. patients in the gluten-free vegan diet group and patients in the control group showed an ACR 20% response. Starch-based : John McDougall is known for advocating a starch-based vegan diet. The results of a study on his diet were published in Effects of a very low-fat, vegan diet in subjects with rheumatoid arthritis . (Full paper.) There were statistically significant improvements in all RA symptoms except for duration of morning stiffness. While the investigators were aware that cereals are common RA triggers, the diet included cereals anyways. Because the study lacked a controlled design, the investigators acknowledge that the results weren’t controlled for the placebo effect or cyclic changes in disease activity (flares).

: John McDougall is known for advocating a starch-based vegan diet. The results of a study on his diet were published in . (Full paper.) There were statistically significant improvements in all RA symptoms except for duration of morning stiffness. While the investigators were aware that cereals are common RA triggers, the diet included cereals anyways. Because the study lacked a controlled design, the investigators acknowledge that the results weren’t controlled for the placebo effect or cyclic changes in disease activity (flares). Lactovegetarian and vegan: One study compared a lacto-vegetarian, vegan, and Mediterrean diet. Results were mixed. See Weight reduction is not a major reason for improvement in rheumatoid arthritis from lacto-vegetarian, vegan or Mediterranean diets (full paper).

If you have never tried a vegan diet before, you need to do your research beforehand:

You need to eat enough nutrients/calories to avoid feeling extremely hungry. Research the diet beforehand to determine the staple foods in the diet (e.g. fruit, potatoes, grains, nuts, oils, etc.). If you have been eating vegan for more than a few weeks, you should ensure that you are not nutritionally deficient. Denise Minger has a useful webpage on succeeding as a vegan such as getting enough vitamin B12, vitamin D, etc. Note however that it is unclear if supplements may cause problems as the binders in many pills are derived from wheat, corn, or milk.

Overall, the scientific literature suggests that veg*n diets are not particularly effective in general. However, every patient with RA is different and the triggers vary widely. For example, there is a case study of a RA patient with a specific intolerance to dairy. The evidence that suggest that some people with RA may be able to find a viable veg*n diet that works for their particular immune system. At the very least, the literature does indicate that many patients could see a lessening of their symptoms by changing their veg*n diet.

Appendix B: Common food intolerances

The table below was adapted from the following two sources:

Table I in “Review of Dietary Therapy for Rheumatoid Arthritis” by Darlington et al. (Full paper.)

Page 5 from Clint Paddison’s book on Hicklin JA, McEwen LM, Morgan JE. The effect of diet in rheumatoid arthritis. Clin Allergy 1980;10:463.

Corn and wheat top the list.

FOODS MOST LIKELY TO CAUSE INTOLERANCE IN RHEUMATOID PATIENTS Darlington et al Hicklin et al Food Symptomatic patients affected by food(%) Corn 57 58 Grains Wheat 54 58 Grains Bacon/pork 39 Oranges 39 Milk 37 17 Milk Oats 37 Rye 34 Eggs 32 Beef 32 17 Beef Coffee 32 Malt 27 Cheese 24 29 Cheese Grapefruit 24 Tomato 22 Peanuts 20 33 Nuts Sugar(cane) 20 Butter 17 Lamb 17 Lemons 17 Soya 17 4 Chicken 4 Fish 4 Potato 4 Liver

Appendix C: Diet studies

Placebo-controlled, blind study of dietary manipulation therapy in rheumatoid arthritis. (Abstract.)

This is Gail Darlington’s study (along with N.W. Ramsey and J.R. Mansfield), published in The Lancet.

Darlington LG, Ramsey NW. Dietary manipulation therapy in rheumatoid arthritis. In: Machtey I. ed. Progress in rheumatology III. Petah-Tiqva, Israel: Rheumatology Service, Golda Medical Center, 1987;128-32.

Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis. (Abstract.)

Results of this trial can be found in the follow-up article Rheumatoid arthritis treated with vegetarian diets. (Full paper.) 12 out of 27 patients in the diet group showed ‘significant’ clinical improvement while 2 out of 26 patients in the control group also showed significant improvement.

The effect of individualized diet challenges consisting of allergenic foods on TNF-α and IL-1β levels in patients with rheumatoid arthritis. (Full paper.)

Skin-prick tests were used to try to identify food intolerances. (Note: these tests aren’t a reliable way of determining allergies and likely are not reliable for determining food intolerances.) 13 out of 18 (72%) patients in the intervention group saw an increase in symptoms with food rechallenge while 3 out of 19? (16%) of the patients in the control group saw an increase in symptoms.

Vegetarian diet for patients with rheumatoid arthritis – status: two years after introduction of the diet. (Abstract.)

Effects of fasting and lactovegetarian diet on rheumatoid arthritis. (Abstract.)

At the conclusion of the lactovegetarian diet period only one diet patient (out of 15) showed objective improvement.

A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food antigens. (Full paper.)

This study found that 9 out of 38 patients in the gluten-free vegan group showed modest improvement while 1 out of 28 patients in the control group also showed improvement (fulfilled ACR20 improvement criteria).

Uncooked, lactobacilli-rich, vegan food and rheumatoid arthritis. (Full paper.)

This studied a raw vegan “living foods” diet.

An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis. (Full paper.)

A pilot study of a Mediterranean-type diet intervention in female patients with rheumatoid arthritis living in areas of social deprivation in Glasgow. (Full paper.)

Hicklin JA, McEwen LM, Morgan JE. The effect of diet in rheumatoid arthritis. Clin Allergy 1980;10:463.

This is a study that also tested an elimination diet.

Effects of fasting and lactovegetarian diet on rheumatoid arthritis. (Abstract.)

Diet therapy for rheumatoid arthritis. (Full paper.)

This study looked at a “specific popular diet free of additives, preservatives, fruit, red meat, herbs, and dairy products”. 2 of 11 patients on the experimental diet improved noticeably.

Food intolerance in rheumatoid arthritis. I. A double blind, controlled trial of the clinical effects of elimination of milk allergens and azo dyes. (Full paper.)

9 out of 94 patients showed favorable responses and worsening arthritis when rechallenged.

The effects of elemental diet and subsequent food reintroduction on rheumatoid-arthritis. (Abstract.)

This study had mixed/inconclusive results.

Treatment of rheumatoid arthritis with a peptide diet: a randomized, controlled trial. (Abstract.)

Only 1 out of 15 patients on the elemental diet experienced a clear remission.

Is rheumatoid arthritis a disease that starts in the intestine? A pilot study comparing an elemental diet with oral prednisolone. (Full paper.)

The flavoured elemental diet (E028) was almost as effective as oral prednisolone.

A pilot study of the effect of an elemental diet in the management of rheumatoid arthritis. PMID:8070160 (Abstract.)

3 out of 10 patients on the elemental diet and 2 out of 7 patients on the soup diet (control group) improved on all measured disease variables. The researchers argue: “These results suggest that some RA patients may respond to the elimination of offending food items. However, the results do not encourage treatment with an elemental diet in unselected RA patients.”

Nutritional status of Danish rheumatoid arthritis patients and effects of a diet adjusted in energy intake, fish-meal, and antioxidants. (Abstract.)

This study found that increased intake of fish and antioxidants improved some but not all disease outcomes.

Diet therapy for rheumatoid arthritis. A controlled double-blind study of two different dietary regimens. (Abstract.)

This study did not find a dramatic clinical difference when patients were given a hypoallergenic diet with reduced saturated fat.

Faecal microbial flora and disease activity in rheumatoid arthritis during a vegan diet. (Full paper.)

These researchers studied the effect of a raw/uncooked vegan diet on RA and the microbial flora. 5 out of 19 patients in the raw vegan group saw mild improvement in RA, while none of the 18 patients in the control group saw improvement. 3 of the 22 patients who started the raw vegan diet refused to continue with the diet.

Effects of a very low-fat, vegan diet in subjects with rheumatoid arthritis. (Full paper.) The starch-based vegan diet promoted by John Mcdougall was tested. There were statistically significant improvements in all RA symptoms except for duration of morning stiffness.

Gluten-free vegan diet induces decreased LDL and oxidized LDL levels and raised atheroprotective natural antibodies against phosphorylcholine in patients with rheumatoid arthritis: a randomized study. (Full paper.)

A vegan diet was tested. 37% of the patients in the vegan group had an ACR improvement of at least 20% while only 4% of the control group had an ACR 20% response.

Weight reduction is not a major reason for improvement in rheumatoid arthritis from lacto-vegetarian, vegan or Mediterranean diets. (Full paper.)

This study looked at lacto-vegetarian, vegan and Mediterranean diets. Results were mixed.

Serum levels of interleukin-6 and dehydroepiandrosterone sulphate in response to either fasting or a ketogenic diet in rheumatoid arthritis patients. (Full paper.)

It was found that only fasting (and not the ketogenic diet) improved disease activity.

Influence of fasting on intestinal permeability and disease activity in patients with rheumatoid arthritis. (Abstract.)

Intestinal permeability (which correlates with RA symptoms and is thought by some to be a cause of RA) improved when the patients fasted but got worse when patients started eating a lactovegetarian diet.

Antioxidants in vegan diet and rheumatic disorders. (Full paper.)

Case studies

Rheumatoid arthritis and food: a case study. (Full paper.)

One patient had a specific intolerance towards dairy. Without dairy, the patient experienced “a considerable improvement in her previously aggressive disease”.

DOES FOOD INTOLERANCE PLAY A ROLE IN JUVENILE CHRONIC ARTHRITIS? (Full paper.)

Out of 60 children, food intolerances were identified in 3 children.

Meat-Induced Joint Attacks or Meat Attacks The Joint: Rheumatism Versus Allergy (Full letter.)

This letter to the editor claims that a patient’s symptoms were related to red meat consumption. The authors do not seem to have attempted a double-blinded food challenge. Strangely, they do not make any distinction between animal products as an intolerance for one animal product doesn’t necessarily mean an intolerance for other animal products; see Appendix B in this post. The grouping of milk, dairy, and “meat” (beef, chicken, pork, etc.?) as a single category seems overly reductionist.

Appendix D: Fasting studies

Effects Of Fasting and Lactovegetarian Diet on Rheumatoid Arthritis. (Abstract.) After fasting, 5 of 15 patients showed objective signs of improvement, compared with only one of the controls. When the fasting patients were put onto the lactovegetarian diet, only one of those 15 patients showed objective improvement.

Fasting and Vegan Diet in Rheumatoid Arthritis. (First page.)

Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis. (Abstract.)

Results of this trial can be found in the follow-up article Rheumatoid arthritis treated with vegetarian diets. (Full paper.) 12 out of 27 patients in the diet group showed ‘significant’ clinical improvement while 2 out of 26 patients in the control group also showed significant improvement.

Effects of Fasting on Disease Activity, Neutrophil Function, Fatty Acid Composition, and Leukotriene biosynthesis in patients with Rheumatoid Arthritis. (Full paper.)

Kroker GP, Stroud RM, Marshall RT et al. Fasting and rheumatoid arthritis: A multi-center study. Clin Ecol 1984;2:137-44.

Calorie Restricted Diet and Urinary Pentosidine in Patients with Rheumatoid Arthritis. (Full paper.)

This Japanese study looked at the effect of calorie restriction combined with fasting (with fresh vegetable juice during the fast). On average, patients saw a mild drop in RA symptoms as measured by the Lansbury Index (see Figure 2). The results on urinary pentosidine were mixed.

Appendix E: Reviews

Managing Rheumatoid Arthritis with Dietary Interventions. (Full paper.)

Table I in this review has a summary of many different RA studies.

Review of Dietary Therapy for Rheumatoid Arthritis. (Full paper.)

1993 review by Gail Darlington.

Does food intolerance have any role in the aetiology and management of rheumatoid disease? (Full paper.) 1985.

Note that Gail Darlington would later do her own study of the effect of her elimination diet on arthritis.

Chapter 9 – Arthritis at Your Age? Late teens to early 50s: a friendly handbook for young and youngish adults with a rheumatic disorder (The book.)

Alternative Treatments for Rheumatoid Arthritis. (Full paper.)

This provides a review of the scientific evidence on various alternative therapies. This includes copper chelates of NSAIDs, wearing copper bracelets, and other treatments that may be considered wacky by mainstream practitioners. The author (Alan R. Gaby) is a past president of the American Holistic Medical Association and may have a bias in favour of alternative/functional/holistic medicine and supplements.

Effectiveness and safety of dietary interventions for rheumatoid arthritis: a systematic review of randomized controlled trials. (Abstract.)

Dietary recommendations for patients with rheumatoid arthritis: a review. Nutrition and Dietary Supplements. (Full paper on ResearchGate.)

Dietary manipulation in musculoskeletal conditions. (Full paper.)

Fasting followed by vegetarian diet in patients with rheumatoid arthritis: a systematic review. (Full article.)

Does diet have a role in the aetiology of rheumatoid arthritis? (Full paper.)

The role of diet in susceptibility to rheumatoid arthritis: a systematic review. (Abstract.) This 2004 paper is not particularly interesting as it doesn’t look at a lot of evidence and ignores fasting studies.

Joint complaints and food allergic disorders. (Abstract.) 1983.

Food sensitivity and rheumatoid arthritis. (Abstract.)

This paper notes that 30–40% of RA patients respond well to elimination diets while almost all RA patients respond well to fasting.

Role of Nutrition in Rheumatoid Arthrtis Management. (Webpage.)

This webpage (irresponsibly?) encourages patients to “eat a variety of foods” while downplaying the scientific evidence on elimination diets.

Appendix F: Fish oil supplements

Gail Darlington has written about fish oil supplements and their possible role in relieving RA symptoms- see her 1993 review co-authored with her colleagues. Here are some related studies:

Effects of high-dose fish oil on rheumatoid arthritis after stopping nonsteroidal antiinflammatory drugs. Clinical and immune correlates. (Full paper.)

The study found that patients taking fish oil supplements exhibited improvements in disease activity from baseline.

Cod liver oil (n-3 fatty acids) as an non-steroidal anti-inflammatory drug sparing agent in rheumatoid arthritis. (Full paper.)

The patients in the cod liver oil group were able to reduce their NSAIDs at a higher rate than the placebo group (39% versus 10%).

Incorporation of n-3 PUFA and γ-linolenic acid in blood lipids and red blood cell lipids together with their influence on disease activity in patients with chronic inflammatory arthritis – a randomized controlled human intervention trial. (Full paper.)

This study didn’t seem to generate meaningful clinical outcomes.

Fish oil supplementation increases the cyclooxygenase inhibitory activity of paracetamol in rheumatoid arthritis patients. (Full paper.)

This study didn’t seem to generate meaningful clinical outcomes.

Effects of n-3 fatty acids on serum interleukin-6, tumour necrosis factor-alpha and soluble tumour necrosis factor receptor p55 in active rheumatoid arthritis. (Full paper.)

There were three groups: normal diet, a diet low in omega-6 fatty acids, and the same low-omega-6 fatty acid diet supplemented with fish oil. There were no significant clinical differences between the groups.

Role of omega-3 fatty acid supplementation with indomethacin in suppression of disease activity in rheumatoid arthritis. (Full paper.)

The design of this study strikes me as bizarre, since both the control and experimental omega-3 supplement group were given a NSAID (indomethacin). The effect of the NSAID dwarfed the small differences between the supplement and control group. Also, it’s unclear if the researchers tried to reduce the placebo effect by giving the control group a placebo pill.

Long-term moderate intervention with n-3 long-chain PUFA-supplemented dairy products: effects on pathophysiological biomarkers in patients with rheumatoid arthritis. (Full paper.)

There were no measured clinical improvements in the experimental group given omega-3 supplemented dairy products. However, the authors argue that the experimental group will be theoretically healthier.

Supplementation of fish oil and olive oil in patients with rheumatoid arthritis. (Full paper.)

There were 3 groups: soy oil, fish oil, and fish+olive oil. In this unblinded study, the results seemed inconclusive to me. However, the authors have data mined the results to find improvements in the supplemented groups.

Anti-inflammatory effects of a low arachidonic acid diet and fish oil in patients with rheumatoid arthritis. (Abstract.)

One group ate a normal Western diet while the experimental group ate an anti-inflammatory diet (AID) low in omega-6 arachidonic acid. Both groups were also given placebo or fish oil capsultes in a double-blind crossover design. The AID diet and fish oil supplementation led to modest decreases in some arthritis outcomes in some patients.

Appendix G: Probiotics

Probiotics don’t seem to be helpful.

A randomized, double-blinded, placebo-controlled pilot study of probiotics in active rheumatoid arthritis. (Full paper.) It did not find that probiotics clinically improved RA as measured by ACR20.

Bacillus coagulans: a viable adjunct therapy for relieving symptoms of rheumatoid arthritis according to a randomized, controlled trial. (Full paper.) This study found that the bacteria probiotic reduced patient pain, but had no effect on other disease measurements.