This article comes to us from Julianne Taylor, PGDipSci, a Registered Nutritionist and AIP Certified Coach from New Zealand. As soon as we learned about Julianne’s postgraduate research, which centered around the effects of a Paleo diet in the management of rheumatoid arthritis symptoms, we knew we had to bring her in to share her findings on our blog. Below you’ll see a summary of her study parameters, the results, and an overview of Julianne’s plans to push this research even further in the future.
I first became aware of the Paleo diet in 2009 when I was asked to be a nutrition coach for one of Auckland’s first CrossFit gyms. I had recently completed a graduate certificate in nutrition and had been a nutrition coach for several years. Paleo was completely new to me at that point, so I delved into the work of Professor Loren Cordain to learn more about it. Suffering autoimmune joint inflammation myself, I put the Paleo diet to the test and was surprised that in just 3 weeks, inflammation in my knees and neck which I had for 30 years, completely resolved. To this day – over 10 years later – I have had no recurrence.
This led me to reading all I could on the Paleo diet and consequently the Paleo Autoimmune Protocol. When I went back to university in 2012 to start post graduate papers, I became more and more interested in the application of a Paleo diet as a treatment for autoimmune disease and decided I wanted to carry out research in this area.
My first foray into research was a qualitative study for my postgrad diploma, with a mind to use this as preliminary research for my master’s year. I heard about two New Zealand women with rheumatoid arthritis (RA) who had found a Paleo diet reduced their symptoms and disease markers significantly, and a search online alerted me to many other anecdotal success stories.
I chose to interview 10 people with RA who had successfully used any type of Paleo protocol to ameliorate their symptoms. I put notices on several Facebook groups and approached others who had written about their success in blog posts. It was surprisingly quick to find 10 people with clinically confirmed RA who had success using either Paleo or AIP.
Here is a snapshot of the study participants:
- 1 male, 9 females
- From New Zealand (2), Australia (1), and USA (7)
- Aged from 28 to 60 years, mean age 41.7
- The time on the diet: from 6 months to 5 years, mean 2.9 years
- All were currently maintaining the Paleo diet at time of interview
I carried out a 90-minute, semi-structured interview with each person where I covered the following topics:
- Factors that enabled them to transition to, and maintain, a Paleo diet
- How each person made decisions as to what to eat and what to avoid
- The foods they perceived to cause an increase in RA symptoms, and the foods they perceived to be safe to eat
Study Results and Emerging Themes
A few main themes emerged in their responses. When asked what motivated them to follow a Paleo diet, I often heard it was the recommendation of a health professional, typically not the primary doctor or rheumatologist, but from an alternative health practitioner. I also was told that the science made sense, and that anecdotal success stories from other people with autoimmune disease were a motivating factor.
When it came to implementation of a Paleo diet, the thought of changing to a restrictive eating protocol was one of the most significant barriers to overcome. Most of the group found this overwhelming. Getting mentally and physically ready to change to a restrictive diet is a really important step, and includes understanding why certain foods are removed, working out how to follow the diet, and reading about others’ experiences to get an idea of what to expect. Many chose a specific start date where they were able to focus on their new diet without distractions. Most took a “cold turkey” approach rather than a gradual approach after preparation.
Primary barriers to maintaining the diet were the attitudes of others. Some family members and conventional health practitioners were skeptical and discouraging. One of the most important factors for all the subjects was having one person who was supportive, whether a spouse, close friend, or other family member.
Ongoing challenges that had to be navigated regularly were eating out, particularly at other people’s homes, travel, and the time it took to shop and prepare food. Over time however, for most it became easier and simply a new way of life.
The primary motivation to stay on the diet was quality of life and lack of pain. All were adamant it was worth the effort.
For those that reintroduced foods to test their effect, the following caused severe reactions:
- gluten grains/wheat (4)
- dairy (2)
- corn (2)
- eggs (1)
- egg-whites (1)
- store bought eggs (1)
- rice (1)
- peanuts (1)
- beer (1)
- wine (1)
- soy (1)
- legumes (1)
- non-gluten grains (1)
- heated/rancid seed oils (1)
A number of foods were reintroduced and found not to cause problems. The most common were:
- seed spices (10)
- eggs (8)
- spirits (6)
- rice (4)
- wine (3)
- nightshade vegetables (3)
- egg yolks (1)
- potatoes (1)
- legumes (1)
It is interesting too that the foods that cause a response when eaten frequently or in large amounts are common to several cases. For example 4 found this with tree nuts, yet no one suffered a severe reaction to them.
What do other RA dietary studies show?
Along with my interviews, I also carried out a literature review of similar studies examining the impact of Paleo diets on RA symptoms. I looked at over 50 case and dietary intervention studies and was surprised so many had been done, perhaps reflecting the belief or experience that those with RA notice food appears to have an effect.
There were 12 case studies in the literature where subjects with RA removed foods and consequently were reported to achieve remission. For these folks, should the offending food be reintroduced, symptoms of pain, inflammation and fatigue reappeared. I found 18 studies where elimination/reintroduction protocols were carried out. Once again, in a percentage of people, specific foods were found to aggravate RA symptoms. Several dietary patterns have also been tested in RA: Mediterranean, gluten-free, vegan, vegetarian, and anti-inflammatory patterns, all of which showed improvement for most. Fasting has the most significant impact on RA. Either a juice or water fast results in symptoms typically reducing within a week, which then reverse when a normal diet is resumed (Müller, de Toledo, & Resch, 2001).
I was able to draw the following conclusions from previous dietary intervention studies with respect to the role of diet in the manifestation of RA symptoms. To be effective in reducing RA symptoms, a diet would need to:
- Reduce inflammatory markers. ESR and CRP. An anti-inflammatory diet is low in saturated fat and arachidonic acid, low in refined grains and sugar, high in fruit and vegetables and in seafood for omega 3s (Adam et al., 2003; Winkvist, Bärebring, Gjertsson, Ellegård, & Lindqvist, 2018).
- Reduce or eliminate exacerbating foods, which may act as possible antigens. An appropriately structured elimination/reintroduction protocol is critical to success. Certain antibody tests may show some food intolerances such as gliadin or a-lactalbumin (Hafström et al., 2001).
- Improve gut microbiome by reducing bacterial flora linked with RA, which may be acting as antigens. A diet high in plant fibre and polyphenols with the addition of fermented foods may offer the best solution (Nenonen, Helve, Rauma, & Hanninen, 1998). Changing from acellular carbohydrates such as grain starch and sugars to cellular starches found in root vegetables is theorised to provide a better substrate for gut bacteria, as well as reduce inflammation (Spreadbury, 2012).
- Improve gut epithelial integrity, reducing intestinal permeability, as this allows antigens to cross the gut barrier in intact sequences of amino acids (Sundqvist et al., 1982). This involves improving the gut microbiome as above, as well as removing foods which are shown to increase intestinal inflammation and permeability, for example gluten grains and dairy (for some). Cordain suggests all grains and legumes have certain lectins contributing to intestinal permeability and should be avoided (Loren Cordain, Toohey, Smith, & Hickey, 2000).
- Decrease red cell membrane ratio of arachidonic acid to omega 3 EPA; this reduces inflammatory eicosanoid hormones and increases anti-inflammatory ones. This is achieved by reducing dietary sources of AA such as egg yolks and fatty meat, and increasing EPA by eating seafood or adding supplemental marine omega 3 (Adam et al., 2003).
- Reduce the support of the growth of urinary bacteria proteus mirabilis linked with RA, possibly a diet high in plant foods (Kjeldsen-Kragh et al., 1995).
My Further Study on RA and AIP
As yet, no dietary study has tested a Paleo or AIP diet in people with RA. I believe AIP is important to test, as while we know anecdotally many people have benefited, anecdotes are typically only success stories, and we need clinical studies testing the diet’s effect in a large group, to find the range of possible effects. Clinicians demand to have clinical evidence preferably from a large randomised, controlled study if they are to recommend a diet to RA sufferers.
So, after a couple of years’ hiatus with respect to study, I have now finalised a proposal to carry out further research for my master’s year, this time a pilot feasibility study using the AIP diet in a group of 10 people with RA. My proposal is to carry out a mixed-methods study, quantitative followed by qualitative. The quantitative study will involve two phases: a 4-week phase of usual diet, followed by an 8-week intervention using the AIP diet. Assessment will include its effect, using patient reported outcome questionnaires on quality of life, fatigue, pain, sleep and emotional wellbeing, and a qualitative assessment of each participant’s experience on the diet. Feasibility measures will include adherence and ease of following diet instructions. I would very much like to carry out a larger randomised controlled study should I go into a PhD following this year.
All going well, I will know the results of this pilot study some time next year.
- Adam, O., Beringer, C., Kless, T., Lemmen, C., Adam, A., Wiseman, M., … Forth, W. (2003). Anti-inflammatory effects of a low arachidonic acid diet and fish oil in patients with rheumatoid arthritis. Rheumatology International, 23(1), 27–36. https://doi.org/10.1007/s00296-002-0234-7
- Cordain, L. (1999). Cereal grains: humanity’s double-edged sword. World Review of Nutrition and Dietetics, 84, 19–73.
- Cordain, Loren, Toohey, L., Smith, M. J., & Hickey, M. S. (2000). Modulation of immune function by dietary lectins in rheumatoid arthritis. British Journal of Nutrition, 83(03), 207–217. https://doi.org/10.1017/S0007114500000271
- Hafström, I., Ringertz, B., Spångberg, A., Von Zweigbergk, L., Brannemark, S., Nylander, I., … Klareskog, L. (2001). 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. Rheumatology, 40(10), 1175–1179.
- Kjeldsen-Kragh, J., Rashid, T., Dybwad, A., Sioud, M., Haugen, M., Forre, O., & Ebringer, A. (1995). Decrease in anti-Proteus mirabilis but not anti-Escherichia coli antibody levels in rheumatoid arthritis patients treated with fasting and a one year vegetarian diet. Annals of the Rheumatic Diseases, 54(3), 221–224.
- Müller, H., de Toledo, F. W., & Resch, K. L. (2001). Fasting followed by vegetarian diet in patients with rheumatoid arthritis: a systematic review. Scandinavian Journal of Rheumatology, 30(1), 1–10. https://doi.org/10.1080/030097401750065256
- Nenonen, M. T., Helve, T. A., Rauma, A. L., & Hanninen, O. O. (1998). Uncooked, lactobacilli-rich, vegan food and rheumatoid arthritis. British Journal of Rheumatology, 37(3), 274–281.
- Spreadbury, I. (2012). Comparison with ancestral diets suggests dense acellular carbohydrates promote an inflammatory microbiota, and may be the primary dietary cause of leptin resistance and obesity. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 5, 175–189.
- Sundqvist, T., Lindström, F., Magnusson, K.-E., Sköldstam, L., Stjernström, I., & Tagesson, C. (1982). Influence of fasting on intestinal permeability and disease activity in patients with rheumatoid arthritis. Scandinavian Journal of Rheumatology, 11(1), 33–38.
- Winkvist, A., Bärebring, L., Gjertsson, I., Ellegård, L., & Lindqvist, H. M. (2018). A randomized controlled cross-over trial investigating the effect of anti-inflammatory diet on disease activity and quality of life in rheumatoid arthritis: The Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA) study protocol. Nutrition Journal, 17(1), 1–8. https://doi.org/10.1186/s12937-018-0354-x
Good article for those dealing with RA! Unfortunately for me, I have not responded favorably to any diet, including AIP (started 2015) and Paleo (since 2019). Food does not seem to affect my RA one way or the other. I’ve read wonderful testimonies of people improving or going into remission, so every person suffering with RA should definitely give these diets a chance! Thanks for keeping us informed!
This study interviewed people who had success on AIP, we currently have no idea how many like you have tried it and not seen an improvement. Studies in the literature that eliminate a lot of foods in RA, show that not all have an improvement. I’m doing further research and hope to find out an answer.
Thank you for the research. I wish our health organizations would support these efforts. Drugs are not the answer to everything.
Excellent article. Julianne Taylor, thanks for your research and I hope you are able to continue it. It would be nice to have some proof to say “The AIP diet helps 70% of RA sufferers.” This could be compared to the effectiveness of Humira or other drugs. My doctor told me “People don’t want a diet, they want a pill” I went for the diet and 6 years later, I’m still a success story.
You mentioned ” It is interesting too that the foods that cause a response when eaten frequently or in large amounts are common to several cases. For example 4 found this with tree nuts, yet no one suffered a severe reaction to them.” Many grain free recipes have almond flour in them. After years of eating almonds and almond flour, I started to get inflammation from them. I haven’t had any success reintroducing them. It’s interesting to see that this has occurred with other people.
Keep up the good work!
I put my seronegative RA into remission within 6 weeks on the AIP in combination with hydroxychloroquine 200 mg twice daily. My symptoms were so severe I could not grip a steering wheel or dress myself. I ordered several lab tests for my self, all of which were negative except sky high CRP and ESR. I finally consulted my rheumatologist friend who diagnosed me within 3 minutes of physical examination.
I am now off of hydroxychloroquine for 2 months and stable. After I achieved remission I slowly added back nuts, eggs, and nightshades, and then even some fermented dairy. I remain paleo except for goat milk kefir (A2 protein) and occasional goat cheese.
Thanks for sharing your story here, Robert! Wishing you continued success and congrats on those reintroductions 🙂
Why don’t you include blood tests during your pilot to ascertain effect on inflammatory markers?
Yeah, finally an article addressing R.A. I was diagnosed with R.A. a year and a half ago. I am 67 years old. Shortly after, I implemented the AIP diet for 6 months. I have reintroduced night shades, beans, nuts, but have discovered nuts are not my friend so I have elimated them. Unfortunately, I am still on Rhemicaid. I tried extending the time between infusions and did not have a good result. My biggest issue is finding a rheumatologist that takes a holistic/ integrated approach to treatment that would be covered by insurance. I know a pipe dream.
Hey Jennifer! I’m glad you feel you’ve discovered some things that work for you in trying AIP. One thing we are always clear about here, is that it isn’t always appropriate for everyone with autoimmune disease to forgo medication. It can be tricky reading success stories, as there are certainly those who have been able to reduce or eliminate medication, but there are just as many who use AIP in combination with conventional medicine in order to live their best. I agree with you that finding a rheumy that can work with both the dietary and lifestyle approaches you are using, and guide you on medication if needed is a smart choice – and don’t give up, because they are out there! You might find this article on medication & AIP helpful: https://autoimmunewellness.com/where-medication-fits-on-a-healing-diet/
Great article. I agree with everything. I have been on a strict Paleo diet since 2010 and had achieved remission. I unfortunately reintroduced goats milk cheese to my diet about 6 months ago and suffered a severe flair. I am still working to resolve the issue now. I believe so much in the premise that diet as medicine works that I started a Paleo bakery cafe With a completely dedicated kitchen in order to help others with their journey towards healing.
Thank you or doing this research. My Mom had RA, however even with my begging her to try to change her diet it was too difficult for her. She had infusions of a chemo drug to her body about every 6-8 weeks, those infusions are what I believe led to her being diagnosed with MDS. So very sad and I only wish I lived closer to her to have prepared all her meals. I realize ultimately it is the choice of the individual to want to try diet alterations, but I am positive they do help. I have differing reasons why I do AIP. Thank you for this post once again.
It’s interesting that it’s suggested that one should eat more fish and eat less egg yolks and fatty meat. Some people have claimed to resolve major joint conditions with fatty meat. The most well known example is Mikhaila Peterson.
Also, it could be noted that, like vegans and vegetarians, pescatarians may have higher rates of bone fractures. That was according to one study. But it can’t be denied that omega-3s are anti-inflammatory.
I randomly came across this post again when looking at various web search results. I had some other thoughts to add. There have been a number of people who have pointed to the specific problem being the industrial seed oils that are oxidative, inflammatory, and mutagenic.
For the inflammatory component, more anti-inflammatory omega-3s will balance that out. And so it’s unsurprising that those getting a lot of seed oils benefit from increased omega-3s. But that isn’t to say that large amounts of omega-3s are always beneficial, specifically for those not consuming excess omega-6s.
Some argue there could be problems as well when the ratio gets out of balance too far in the opposite direction. Omega-3s make the cell membranes more fluid. That is beneficial up to a point, but there is no research to no where that point is because nearly all the omega-3s research is done on a standard American diet, not a diet low in omega-6s.
The potential problem would be the cellular equivalent of a leaky gut. A too fluid cell membrane could allow into the cell what shouldn’t be there. This would weaken the protective role of the cell membrane. Also, omega-3s like all PUFAs will oxidize, even in the body. Vastly increasing PUFA intake inevitably increases oxidative stress and so strains the endogenous antioxidant system.
We want enough omega-3s to be healthy but not too many. Total PUFA intake with iron overload might particularly be problematic, although it could be moderated by carnosine that eating beef particularly increases. The problem is we don’t know what all of this might look like on an optimal diet in terms of real foods. The point is probably that, unless we are getting excess omega-6s, we shouldn’t necessarily be supplementing omega-3s. All that is needed is eating fatty cold water fish on occasion in combination with various wild-caught and pasture-raised animal foods.
Likewise our knowledge of saturated fats and arachidonic acid is likewise confounded in nutritional studies, which at the moment is stuck in a replication crisis. What drives up arachidonic acid is omega-6s (specifically linoleic acid) and so it could be an indicator of a diet high in omega-6s — typically from seed oils, grains, seeds, and nuts. As for eggs and fatty meats, they are only high in omega-6s when factory-farmed, not when pasture-raised. Many have alleviated and improved serious health conditions with various low-carb and animal-based diets. Mikhaila Peterson reversed juvenile rheumatoid arthritis with a carnivore diet. This suggests there is much we don’t understand or entirely misunderstand.
What many of these higher-protein and/or higher-fat diets, particularly carnivore, tend to exclude are the vast amounts of industrial seed oils and other sources of omega-6s. Sometimes they’ll include more omega-3s, but not in all cases. Peterson’s carnivory was limited to entirely red meat. Part of the explanation is context.
Even feedlot animals, at least pigs and fowl, will have higher levels of omega-6s if they are fed omega-6s. Only ruminants can convert omega-6s to other fats. How much research has been done on pasture-raised and wild-caught animal foods while all seed oils are eliminated and other omega-6s kept limited? Not much, other than some studies done on hunter-gatherers.
As for saturated fats, that involves a lot of conflicting research, much of it low quality. The debate, of course, is endless. But a significant point is that most of the evidence against saturated fats is correlational, not with proven causal mechanisms. And opposite that, there is plenty of research that shows benefits to saturated fats, including odd-chain saturated fats that might reduce inflammation. It’s maybe similar to how certain omega-6s are actually anti-inflammatory.
So, it’s a bit hard to generalize. It depends on the specific fats and the specific diet, in relation to other fats, macronutrients, and confounding factors. I’d recommend looking into the work of Gary Taubes, Nina Teicholz, Paul Mason, Chris Knobbe, Catherine Shanahan, Paul Saladino, Ivor Cummins, etc; and a few others could be named.
“While it’s true that AA plays a role in inflammation, inflammation is necessary to fight off sickness and to start the healing process when we are injured. AA works together with other omega-3 (i.e. EPA) and omega-6 fatty acids to keep inflammation at a healthy and stable level. High blood levels of both AA and long chain omega-3 fatty acids are associated with low levels of inflammatory markers in the blood. (9, 10)
“The balance between omega-3 fatty acids and omega-6 fatty acids is key in keeping inflammation in control. If our food intake of omega-3 fatty acids is low (i.e. not enough cold water fatty fish or grass fed beef) in our diet, our tissue levels of AA go up. If we have high doses of omega-3 fats (i.e. too much fish oil supplements) our AA levels go down. Neither is helpful to control inflammation. (11)
“Furthermore, having higher intakes of AA show no increase in inflammatory markers. Studies have shown that adding 1,200 mg/day of AA (12 times higher than the average intake of AA in the U.S.) to the diet has no clear effect on increasing inflammation. (12, 13) As well, our Paleolithic ancestors (who were largely free chronic inflammatory disease) consumed at least twice the amount of AA that the average American does today. (14)
“There are two other important facts about red meat you should know about. First, red meat actually has a lower concentration of AA than other meats. (15, 16) Second, red meat has been shown to increase tissue concentrations of both AA and the long chain omega-3s DHA and EPA. This helps keep the omega-3 and omega-6 fat acids in a healthy balance thereby keeping inflammation under control. (17)
“Our ancestors and modern day hunters and gatherers consume red meat regularly. Not only were our ancestors largely free of chronic inflammatory diseases, but so are modern day hunters and gatherers like the Masai tribe. Their traditional diet consists almost entirely of milk, meat, and blood. (21)”
“Dairy is the only source of fat in which the majority of fat is long-chain saturated fat. Analyses of the literature have found that intake of full-fat yogurt and cheese is associated with no change in or lowered risk of cardiovascular disease risk ( Astrup A. et al. 2014; Juo J. et al. 2017).
“In fact, researchers can use particular odd-chain saturated fats as blood markers of dairy intake and have reported data suggesting an inverse association between dairy intake and heart disease. These odd-chain saturated fats have even been recently proposed, in the prestigious journal Nature, to be “essential” fats that may reduce the risk of not just cardiovascular disease but also obesity, inflammation, type 2 diabetes, fatty liver disease, and certain cancers ( Venn-Watson S. et al. 2020).
“Even dolphins can benefit! An interventional study in which dolphins were fed a diet rich in these fats found that these saturated fats improved markers of metabolic syndrome ( Venn-Watson S. et al. 2015).”
[…] adhere to a paleo diet that is not as strict as an AIP diet. I still consume some nuts and seeds, quinoa or rice on […]