Nutrition In Rheumatoid Arthritis

(Role of Nutrition In The Management of RA)

Submitted by: Mina Magdy Fahmy,

BPharm, PgD(CP), PgD(PV)

Supervised by: Dr.Maheera H. Safwat,

BPharm, MSc, PhD
Lecturer
Department of Biochemistry
Faculty of Pharmacy
Cairo University

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Subject Page
no.
Abstract …………………………………………………………………. 3
Introduction …………………………………………………………………. 4
Pathogenesis of rheumatoid …………………………………………………………………. 4
arthritis
Triggering stage ……………………………………………………….................. 5
Maturation stage ………………………………………………………………….. 6
Targeting stage ………………………………………………………………….. 6
Fulminant stage …………………………………………………………………. 7
Hyperplastic synovium …………………………………………………………………. 7
Cartilage damage …………………………………………………………………. 7
Bone erosion ………………………………………………………………… 8
Systemic consequences …………………………………………………………………. 9
Signs and symptoms of ………………………………………………………………… 10
rheumatoid arthritis
Dietary Habits as risk of RA ………………………………………………………………… 10
Development
Treatment ………………………………………………………………….. 10
Managing rheumatoid arthritis ………………………………………………………………….. 10
with dietary interventions
Weight loss …………………………………………………………………. 11
vegan diet ………………………………………………………………….. 12
Mediterranean diet ………………………………………………………………….. 12
Elemental diet ………………………………………………………………….. 13
Elimination diet ………………………………………………………………….. 13
Vitamin D ………………………………………………………………….. 13
Essential fatty acids ………………………………………………………………….. 14
Green tea ………………………………………………………………….. 14
Probiotics ………………………………………………………………….. 14
Spices …………………………………………………………………. 14
Alcohol Consumption …………………………………………………………………. 15
Herbs …………………………………………………………………. 15
Dietary fibers and whole Grains …………………………………………………………………. 15

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Antioxidants …………………………………………………………………. 16
Flavonoids …………………………………………………………………. 16
Gluten …………………………………………………………………. 16,17
Dietary recommendation for RA …………………………………………………………………. 18
patients
Conclusion …………………………………………………………………. 18
References …………………………………………………………………. 19,23

Abstract
Clinical nutrition has been playing an important role in managing a
number of diseases recently. Self-help through means of dietary
interventions can help in treatment of many serious disorders including
rheumatoid arthritis (RA).
(RA) is considered the most common type of autoimmune arthritis
causes significant morbidity and mortality. It is a chronic systemic,
autoimmune disease with genetic and environmental factor. Its hallmark
feature is a persistent symmetric polyarthritis (synovitis) that affects the
hands and feet and can affect any joint lined by a synovial membrane. it can
cause pain and swelling in the small joints of the hand and feet.
The goal of treatment of RA is to stop joint pain and swelling and prevent
joint damage.
fortunately, it's found that Early treatment give better long-term results.
recently, a large number of studies proved that diet has a central role in
disease progression.
Nutrients which have anti-inflammatory and antioxidant properties such
as polyunsaturated fatty acids can play a protective role for RA
development, while others can have a harmful effect such as red meat and
salt.
Some dietary patterns and supplements can have protective effect such as
the Mediterranean Diet (MD), vitamin D and probiotics. So, it could be a
possible future adjunctive therapy beside the standard RA treatment.
Therefore, a healthy diet and lifestyle have a very important role in RA
treatment which must be considered in every RA patient's plan of treatment.
Aim of work
The aim of this review is to address the role of nutrition in managing and
preventing chronic diseases such as rheumatoid arthritis and its
complications.

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Introduction
Rheumatoid arthritis (RA) is a systemic, chronic inflammatory autoimmune
disorder affecting approximately 1% of the world population. The disease
severely impacts quality of life and causes significant morbidity and mortality.
With the rapidly expanding population with RA, the disease has cost the
society a lot of economic burden. (Khanna et al., 2017).
(RA) is characterized by a systemic immune-inflammatory response leading
to Joint pain and fatigue associated with the inflammatory process, deformities
that hinder the performance of
daily activities result in work disability, early retirement leading to economic
losses (Zarpellon et al., 2022).
One of the causes of increased mortality in these patients is the accelerated
atherosclerosis by the chronic inflammatory process which lead to many
cardiovascular problems. It is estimated that a RA patient is 1.5 to 2 times more
likely to develop myocardial infarction than the general people. This risk is
compared to that of a patient with diabetes mellitus type 2 and can be increased
by the other risk factors such as obesity (Pereira et al., 2012).
RA mainly attacks the joints. It has the ability to attack many joints at once.
It commonly affects joints in the hands, wrists, and knees. In a joint affected
with RA, the lining of the joint becomes inflamed leading to damage in joint
tissue. This tissue damage can cause chronic pain, lack of balance and
deformity (misshapenness) ("Rheumatoid Arthritis (RA) | Arthritis | CDC",
2022).

RA can also affect other tissues throughout the body and may affect several
organs, such as the lungs, eyes, and blood vessels.

Pathogenesis of RA
RA is divided into two subtypes according to the presence or absence of
anti-citrullinated protein antibodies (ACPAs). Citrullination is catalyzed by the
calcium-dependent enzyme peptidyl-arginine-deiminase (PAD) which can

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change a positively charged arginine to a polar but neutral citrulline as the
result of a post-translational modification. ACPAs serve as a useful diagnostic
reference for patients with undifferentiated arthritis and provide an indication
of disease progression (Bizarre N, et al.,2013).
The ACPA-positive subset of RA is more aggressive clinical phenotype
than ACPA-negative subset. It is proved that ACPA-negative RA has different
genetic patterns and differential responses of immune cells to citrullinated
antigens from those of ACPA-positive subset. less effective treatment response
of methotrexate (MTX) or rituximab was observed in ACPA-negative subset
(Malmström et al., 2016).

Triggering stage
ACPA appearance is now widely used to diagnose and predict RA due to its
high specificity (>97%) in clinical practice. ACPA occurs as a result of an
abnormal antibody response to citrullinated proteins, including fibrin, vimentin,
fibronectin, Epstein-Barr Nuclear Antigen 1 (EBNA-1), α-enolase, type II
collagen, and histones, all of them are distributed throughout the whole body.
ACPA production has been associated with genetic lifestyle, and environmental
factors.

Gene–environment interaction influences the reactivity of autoantibodies to

citrullinated antigens in RA patients (Abbasifard et al., 2020).

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 Figure 1: Triggering stage of RA

RA can be triggered in the potential trigger sites through the interaction

between the genes and environmental factors resulting in the production of
autoantibodies against citrullinated peptides as illustrated in figure 1. In RA,
PAD can be secreted by the granulocyte and macrophage. Many Citrullination
neoantigens would activate MHC class II-dependent T cells that in turn would
help B cells produce more ACPA (Guo et al., 2018).

Maturation stage
This stage is beginning at the site of secondary lymphoid tissues or bone
marrow. It refers to the development of immune responses to endogenous
epitopes resulting from the release of self-antigens. The immune response to
autoantigens may exist outside the joints and take many years before disease
onset. In this stage, epitope spreading and a gradually increased titer of ACPA
can last several years before appearance of disease symptoms (Alpizar-
Rodriguez et al., 2017).
ACCP has a great importance in predicting the interval time to disease
onset. The production of ACPA reflects break of immunological tolerance. As
a result, many Citrullination neoantigens would activate MHC class II-
dependent T cells that in turn would help B cells produce more ACPA resulting
in pain, bone loss, and inflammation in RA (Krishnamurthy et al., 2019),
(Wigerblad et al., 2015).

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Targeting stage
RA in joints usually has synovitis occurring in symmetrical small joints.
After immune activation, Joint swelling occurs as a reflection of synovial
membrane inflammation. The synovial compartment is filled with leukocytes
and pro-inflammatory mediators that interact to produce an inflammatory
cascade, which is characterized by the interactions of fibroblast-like
synoviocytes (FLSs) with the cells of the immune system, including
monocytes, macrophages and mast cells as well as cells of adaptive immune
system such as T lymphocytes (cell-mediated immunity) and B cells (humoral
immunity). The two immune systems and their interactions are involved in the
development of ACPA-positive RA, which results in inflammation (chronic
synovitis) (Cutolo et al., 2021).

ACPA can enhance NF-kB activity and TNF-α production via binding to
surface-expressed citrullinated Grp78 enhancing the production of pro-
inflammatory mediators. The imbalances between pro-inflammatory M1
macrophage and anti-inflammatory M2 macrophage can also cause
inflammatory RA (Bae et al., 2012).

Figure 2: Targeting stage of RA

Fulminant stage

Hyperplastic synovium

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 Synovium is characterized by a mixture of macrophages and specialized
FLSs. Synovial cells secrete hyaluronic acid and lubricant for joint lubrication
and function and processing waste products. In RA, the dysfunction of FLS
leads to hyperplastic synovium (Sergijenko et al., 2016).

Cartilage damage
Cartilage is a key component of synovial joints. It consists of chondrocytes
and highly organized extracellular matrix (ECM) and contains type II collagen
and glycosaminoglycan (GAGs). The hyperplastic synovium can cause major
damage to the cartilage in RA patients. The inflammatory signals which
released from the ECM, can further stimulate FLS activity. FLS synthesize
MMPs which is considered the predominant proteinase that degrades the
collagenous cartilage matrix which results in cartilage degradation (Pap &
Korb-Pap, 2015).

Bone erosion
Bone loss is an important pathological feature of RA which appears as
localized, per articular and systemic bone loss. Bone loss is due to the increase
of osteoclasts and the suppression of osteoblasts. The responsible mechanism is
unknown. It remains unknown whether inflammation or autoimmunity is the
cause of bone damage (Okamoto et al., 2017).

Evidence for the traditional inflammatory theory is through tumor necrosis

factor alpha (TNF-α), IL-6, IL-1β, IL-17, and other inflammatory cytokines
involved in RA which can exert pro-osteoclast genic effects and suppress bone
formation. The second possible pathway for bone loss in RA involves two
mechanisms for autoimmunity that can be responsible for structural bone
damage. The first mechanism is the formation of immune complex and Fc-
receptor-mediated osteoclast differentiation. The second is the formation of
anti-citrullinated antibodies against the most citrullinated protein, making
osteoclasts the ideal antigenic targets for anti-citrullinated protein antibodies
(ACPA) (Harre et al., 2012).

Systemic consequences
RA patients have elevated risk of cardiovascular problems. The main
mechanism is that cytokines increase endothelial activation and make
atheromatous plaques unstable. RA patients have reduced total cholesterol,
low-density and high-density cholesterol.

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 RA can also affect the brain by causing fatigue and reduced cognitive
function; the lungs by causing inflammatory and fibrotic disease; the exocrine
glands by causing secondary Sjogren’s syndrome; the skeletal muscles by
causing sarcopenia; and the bones by causing osteoporosis. Finally, RA
patients are at high risk of cancer, especially hematologic and kidney cancers
(Wu et al., 2014).

signs and symptoms of RA

It often begins with fever, malaise, arthralgia’s, and weakness before
progressing to joint inflammation and swelling. when symptoms get worse, it's
known as flares, and times when symptoms get better it's known as remission
("Rheumatoid Arthritis (RA) | Arthritis | CDC", 2022).

Signs and symptoms of RA may include the following: Persistent symmetric

polyarthritis of hands and feet (the hallmark feature), pain and stiffness in more
than one joint, progressive articular deterioration, tenderness and swelling in
more than one joint, weakness and fatigue ("Rheumatoid Arthritis (RA):
Practice Essentials, Background, Pathophysiology", 2022).

Figure 3: RA symptoms (Weinhouse & Weinhouse, 2022)

Dietary Habits as risk of RA Development

Excessive consumption of red meat and or high total protein intake have been
associated with an increased risk of inflammatory diseases. Meat fats and
nitrites have a role in increasing inflammations in the body in addition to an

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increased synovial involvement secondary to the excessive oral iron load
(Chiara et al.,2020).
Patients taking low amounts of fish, potatoes, mushrooms, organ meats,
citrus fruits and dairy products showed a protective effect against RA (He et
al.,2016).
A high dietary sodium (salt) intake has been linked to an increased risk of
RA. Its high levels may potentiate the effect of other environmental factors
such as smoking resulting in high serum glucocorticoid kinase-1 (SGK-1)
expression, with an increased Th17 lymphocyte differentiation and enhanced
autoimmunity. High sodium intake in smokers increases indeed the risk of anti-
citrullinated protein antibodies (ACPA) positivity (Jiang et al.,2016).
Vegetables are rich in antioxidants and could provide anti-inflammatory
effects but some of them such as potatoes, tomatoes and eggplants have been
linked to an increased RA risk. Some studies explained that solanine, a
glycoalkaloid contained in these foods has the ability to increase intestinal
permeability with a potential harmful effect on RA development (Bustamante
et al.,2020).
High intake of sugary drinks, sugar-sweetened soda and high-fructose
sweetened soft drinks could enhance arthritis development by inducing an
excessive accumulation of glycation products that increases inflammation (DE
Christophe et al.,2016).

Treatment
RA treatment depends on medication and life style modifications. Treatment
for RA can be done through the use of medications that slow disease and
prevent joint deformity, called disease-modifying ant rheumatic drugs
(DMARDs). The second-line treatment is biological response modifiers
(biologicals). In addition to medications, people can manage their RA with
self-management strategies proven to reduce pain
and disability ("Rheumatoid Arthritis (RA) | Arthritis | CDC", 2022).

Managing Rheumatoid Arthritis with Dietary interventions

weight loss
There are many studies showing that most patients with RA are above
normal weight. Most RA patients have an increased body fat and a decreased
muscle mass. The causes behind that is the inactivity imposed by a painful and
crippling joint disease. The inactivity reduces energy expenditure and can lead
to muscle atrophy. Another contributing factor is the use of medications such

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 as glucocorticoids which results in increased appetite and fat accumulation.
Their increased body weight has important implications for these patients.
One of them is the mechanical burden imposed on the joints, especially those
of the lower limbs, which are already weakened by chronic inflammation.
They will suffer structural damage more easily than normal people leading to
secondary osteoarthritis. It became very important to RA patients to follow a
healthy diet in order to be in their ideal weight (Zarpellon et al., 2014).

vegan Diet
It is a diet including intake of only fruits and vegetables with eliminating
any animal product it is reported to be clinically beneficial for disease
remission in RA patients. Studies showed that this diet could improve the
disease activity by reducing the immune- reactivity to some food antigens that
were eliminated by changing the diet. The improvement was shown as decrease
in duration of morning stiffness, articular index, concentrations of acute-phase
reactants such as orosomucoid, C3 and haptoglobin. Moreover, the release of
lysozyme which are known to cause inflammation and destruction of joints was
decreased in RA patients following this diet.
Leukotriene B4 (LTB4) which is a pro-inflammatory mediator, involved in
activation of neutrophils, eosinophils, and monocytes, production of
proinflammatory cytokines, leading to tissue inflammation and neutrophil-
mediated tissue damage was also decreased by the end of the fasting week.
Furthermore, it has been reported that during starvation, ketone bodies,
including β-hydroxybutyrate (BHB), increase and serve as an alternate source
of ATP in these patients (Newman & Verdin, 2014). Other studies reported
inhibition of activation of NLRP3 inflammasomes by BHB in response to
various NLRP3 activators which reduced NLRP3-mediated release of IL-1β
and IL-18 from human monocytes which is playing an important anti-
inflammatory role (Youm et al., 2015).

Mediterranean Diet
Mediterranean diet is a diet that depends on high consumption of olive oil,
cereals, fruits, vegetables, fish, and legumes, less red meat and inclusion of
moderate amount of red wine in diet as showed in figure 4. studies showed that
RA inflammation was reduced, vitality and physical functions were improved
in patients following Mediterranean diet. MD depends mainly on olive oil
which has antioxidant properties and rich in oleic acid (18:1n-9) which is
metabolized to form eicosatrienoic acid (20:3n-9) and has strong anti-
inflammatory effects. olive oil also can suppress phosphorylation of STAT-3
and thus repressing IL-17 production in order to decrease inflammation
(Khanna et al., 2017). It can also reduce translocation of p65 to nucleus thus

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reducing NF-κβ mediated activation of various pro-inflammatory genes
including TNF-α, IL-17, IL-6, and IL-1β within arthritic joint which will
influence osteoclast differentiation thus promoting joint destruction. Moreover,
reduction in NF-κβ mediated activation of pro-inflammatory cytokines will
minimize joint destruction in RA patients. A study proved that mice fed with
olive oil had reduced cartilage destruction and joint edema, thus, olive oil may
be beneficial for RA patients (Rosillo et al., 2015).

Figure 4 Mediterranean diet pyramid (Chiara et al.,2020)

Elemental Diet
Elemental diet depends mainly on glucose, vitamins, trace elements, and
essential amino acids so it is hypoallergenic diet contains all nutrients for daily
requirements but it is less immunogenic. In a clinical trial, RA patients were
given an elemental diet (E028) providing 86 kcal and 2.5 g protein/100 ml
liquid elemental diet for 2 weeks. 72%of patients taking this elemental diet had
more than 20% improvement in early morning stiffness, and the Ritchie
articular index (RAI). The study concluded that this diet has the same effect as
15 mg/day of oral prednisolone (Khanna et al., 2017).

Elimination Diet
The aim of this diet is to eliminate the food related antigens that may
possibly aggravate the disease symptoms. Many studies concluded that food
allergens are potential triggers of the immune system leading to inflammation
by the activation of macrophage and other inflammatory mediators. Treatment
of RA includes inhibition of TNF-α and IL-1, and these inflammatory
mediators are observed to be increased with the intake of allergenic food so

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excluding some of these food from RA patient’s diet will help them to improve
their disease condition and reduce their requirement of medications such as:
recombinant human IL-1 receptor antagonist and anti-TNF-α antibodies (Berin
& Sampson, 2013).

Seven days fasting followed by vegan diet

Some important studies showed that 7 to 10 days fasting cause a transient
immunosuppression, thereby suppressing RA through decreasing T cell
activation. these studies showed remarkable decrease in swollen and tender
joints, pain, erythrocyte sedimentation rate (ESR), and C-reactive
protein (CRP) (Tripathy et al., 2017).

Vitamin D
Several data showed that decreased vitamin D level is associated with RA
disease progression. RA disease severity can also restrict patient mobility
resulting in limiting access to ultraviolet (UV) light and diminishing epidermal
synthesis of vitamin D. Several studies showed an inverse association between
serum 25(OH)D concentrations and RA disease severity. Among patients with
RA, patients taking vitamin D supplementation showed a decreased rate of
disease flares, pain levels and Disease Activity Score 28 (DAS-28) (Di Franco
et al.,2015).

Essential Fatty Acids

Omega-3 or omega-6 fatty acids have a great role as immunosuppressants
and anti-inflammatory agents. Borage seed oil contains high amount of omega-
6 fatty acid or gamma-linolenic acid (GLA). A study showed that GLA had
significantly reduced tenderness and swallowing of joints in a group of RA
patients were taking it regularly (Tasset-Cuevas et al., 2013).
Fish oils contain high amount of omega-3 fatty acids which have a great
efficacy to treat RA. The group of RA patients which received fish oil had
reduced morning stiffness. Eicosapentaenoic and docosahexaenoic acids are
ethyl ester derivatives of omega-3 fatty acids, have the ability to reduce
severity of RA. When RA patients consumed these derivatives in an amount of
130 mg/kg body weight/day for 26–30 weeks, a significant decrease in pain,
morning stiffness and tenderness of joints was observed (Khanna et al., 2017).

Seven days fasting followed by vegan diet some important studies showed that
7 to 10 days fasting cause a transient immunosuppression, thereby suppressing
RA through decreasing T cell activation. these studies showed remarkable

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decrease in swollen and tender joints, pain, erythrocyte sedimentation rate
(ESR), and C-reactive protein (CRP) (Tripathy et al., 2017).

Green tea
The main phytochemical in green tea is Epigallocatechin-3-gallate (EGCG).
EGCG has shown its ability to downregulate Mcl-1 in synovial fibroblasts and
increases the susceptibility toward apoptosis. Moreover, EGCG can suppress
the production of MMP-1, MMP-2, and MMP-3 in synovial fibroblasts and
prevents bone and cartilage destruction. It can also inhibit IL-1β induced IL-6
production by synovial fibroblast which in turn suppresses IL-6 trans signaling
resulting in reduction in inflammation caused by RA (Drago’s et al., 2017).

Probiotics
Probiotics have been shown to lower the proinflammatory cytokine IL-6 in
RA patients but the main mechanism remains unclear. The expected
mechanism is that Probiotics contain living healthy bacteria such as Bifid
bacteria, Bacteroides-Porphyromonas-Prevotella, Bacteroides fragilis and the
Eubacterium Rectal-Clostridium coccids species which lead to a healthier gut
microbiota leading to less active immune system and inflammatory reactions in
the gut and finally leading to less inflammation systemically (Catrina et al.,
2014).

Spices
In a study, a mixture of blended ginger and turmeric were given to the
adjuvant-induced arthritic rats showed a great effect against extra-articular
complications of RA (Ramadan & El-Menshawy, 2013).
Curcumin is a potent anti-inflammatory spice through blocking the
expression of IL-1 and IL-6(Kloesch,et al.,2013).
Bark of Cinnamomum zeylanicum (Cinnamon bark) showed a great
inhibitory effects on secretion of cytokines IL-2, IL-4, and IFN-γ and reduction
in levels of TNF-α resulting in reducing the inflammation caused by RA (Rathi
et al., 2013).

Alcohol Consumption
The link between alcohol consumption and pathogenesis of RA is still under
debate. Some studies explain that alcohol consumption increase the progression
of RA, while others have showed that no relationship exists. In a recent study,
it was shown that alcohol consumption led to decrease in RA risk in a dose-
dependent manner when alcohol drinkers were compared with non-drinkers
despite of their gender and age (Khanna et al.,2017).

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 Another study linked the effect of alcohol to its frequency of consumption
not the amount frequency of alcohol uptake (Tedeschi et al.,2016).

Herbs
Herbs have a long history of being used as medicine to cure some diseases.
Sallaki (Boswellia serrata) is widely used as an anti-inflammatory herb. It
contains a phytochemical called boswellic acid which belongs to pent acyclic
triterpene family. It has the ability to inhibit the expression of lipoxygenase-5
and eventually lowering down leukotriene synthesis and its role in
inflammation process. These have also proved their potency to block NF-κβ
activation and brought down the level of pro-inflammatory cytokines like TNF-
α, IL-1, IL-2, IL-4, IL-6, and IFN-γ (Wang et al.,2014).
Ashwagandha (Withania somnifera) is one of the potent anti-inflammatory
plant. It is rich in Withaferin A, a steroidal phytochemical which can prevent
proceeding of NF-κβ signaling pathway. studies showed the ability of
ashwagandha extract to suppress release of pro-inflammatory cytokines as
TNF-α, IL-12, and IL-1β from synoviocytes of RA patients but it cannot stop
synthesis and release of IL-6. Moreover, its aqueous extract can significantly
reduce stiffness and disability to move knee and joints (Ramakanth et
al.,2016).

Dietary Fibers and whole Grains

Dietary fibers are remnants of food not digested in small intestine, which
then moves to large intestine and gets fermented by the microflora and could
induce several health promoting effects. There are two types of fibers;
Insoluble fibers such as cellulose and lignin are found in fruits, vegetables, and
whole grains and Soluble fibers including pectin, guar gum, and mucilage.
Studies have shown an inverse relationship between dietary fiber intake and
inflammatory biomarkers such as plasma fibrinogen, CRP, TNF-α, IL-6 levels
which considered as indicators of RA (Slavin et al.,2013).
Whole grains including wheat, whole rice, oats, corn, rye, barley, millets,
sorghum, canary seed, and wild rice. It provides high amounts of antioxidants,
phytic acid, vitamin E and selenium which are known to be involved in anti-
inflammatory processes (Khanna et al.,2014)

Antioxidants
The main function of antioxidants is to act as scavengers of free radicals,
inhibit tumor cells proliferation and cholesterol absorption, anti-inflammatory
effect, and modulate many redox reactions. It can also prevent and delay
atherosclerosis development. It can also cause reduction of low-density

15
lipoproteins oxidation, oxidative stress and inflammation which result in
decreased incidence of RA (De Lorenzo et al.,2017).

Flavonoids
Flavonoids are phenolic compounds present in plants and fungi. They have
antioxidant, antimicrobial and anti-inflammatory effects. Genistein, the major
active compound found in soybean, has anti-inflammatory, anti-angiogenesis,
immunomodulatory, analgesic and chondroprotective effects. Studies showed
the ability of genistein to inhibit IL-1B, TNF-α, EGF-induced proliferation and
MMP-9 expression in fibroblast-like synoviocytes of RA (Li et al.,2013).

Gluten
It is a complex mixture of several proteins present in wheat grains, mainly
gliadin and glutenin. It can trigger immunological response in some diseases
including RA. A study showed that a 1 year of gluten-free diet followed was
associated with a significant decrease of anti-beta-lacto globulin and anti-
gliadin antibodies levels resulting in low disease activity (Warjri et al.,2015)

Dietary Recommendation for RA Patients

Some healthy dietary habits are considered as useful tools in reducing the
risk of RA, related comorbidities, and RA progression and disease activity.
Red meat intake should be limited to (1-2/month), olive oil consumption
should be daily in addition to 1–2/week consumption of fatty fish, weekly
consumption of other types of fish and poultry, high consumption of
wholegrains, legumes and taking more than 5 fruits and vegetables per day.
Sugar-sweetened drinks, salt, alcohol and coffee should be restricted or only
mildly consumed. Physical activity and a healthy lifestyle should be
encouraged with dietary patterns to reach an ideal body weight (Chiara et
al.,2020).

Conclusion
RA is a very common disease which need great attention to discover new
treatment strategies. With the growing evidences supporting the positive impact
of diet strategies in decreasing disease activity in RA patients, with increasing
understanding of the beneficial effects of nutrients on inflammation and
immunity, our interest in dietary interventions is increasing.
Patients are always interested in alternative treatments to relieve their
condition so We should give great attention to diet therapy for RA patients. In
addition to the regular medications, RA patients should be encouraged to
change their eating habits. They should be aware with the benefits of eating

16
more vegetarian/vegan diets, eliminate potentially allergic food components,
and take more poly unsaturated fatty acid/oleic acid/symbiotic in their diet
plans. These dietary interventions can delay the early signs of RA which
relieve RA patients. These foods are not expensive but have a great impact on
these patients so they can take it regularly.
The ideal meal for RA patient should include raw or moderately cooked
vegetables with addition of spices, seasonal fruits and probiotic yogurt; all of
which will give them natural antioxidants and have anti-inflammatory effects.
The patient should avoid any processed food, high salt, oils, butter, sugar, and
animal products. Dietary supplements like vitamin D, cod liver oil, and
multivitamins can also help in managing RA. This diet therapy may help
patients to reduce their disease activity, delay their disease progression, and
reduce joint damage.

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