Rheumatoid arthritis (RA) is an autoimmune disease affecting nearly 54.4 million civilians in the United States. 
In this disease, the healthy cells of the body are attacked by the immune system resulting in inflammation.
The parts of the body most affected by this are the joints. Long-term tissue damage can lead to persistent pain, deformation and loss of balance. 
Tenderness, swelling, and stiffness of the joints are some common symptoms of the disease. The specific causes of RA still remains a mystery but it has been linked to genetic factors, obesity, and smoking. 
Women are more likely to be affected by this disease. Treatment often includes medication and special diets. 
There has been increasing awareness regarding the use of special diets for the management of RA and one such diet has been a gluten-free diet. 
The scientists with the discovery of celiac disease made this association.
The protein gluten is commonly found in wheat, barley, and rye.
It triggers the immune system, which consequently attacks and damages the small intestine. 
Since rheumatoid arthritis is an autoimmune disease, in which the immune system is triggered, scientists speculated that a gluten-free diet might be helpful in alleviating the symptoms of rheumatoid arthritis.
Also, patients with RA are found to have abnormal intestinal lining and issues related to the absorption of nutrients. 
What is a Gluten Free Diet?
A gluten-free diet is a diet that lacks protein gluten. It has been the only and most beneficial therapy for people suffering from celiac disease and non-celiac gluten sensitivity.
Gluten can trigger the immune system and damage the intestinal villi in the patients with what is called the celiac disease.
Wheat, barley, rye, farina, maida, sooji, and triticale among other things are completely cut out from the diet while other grains and starches such as sorghum, rice, millet, quinoa, flax, buckwheat, arrowroot, pigweed, etc. can be consumed. 
Certain supplements and medications can also contain gluten and the ingredients should be evaluated before consumption.
Beer, bread, pasta, and other things generally derived from wheat/barley/rye should be avoided unless labeled as gluten-free. 
Benefits of a Gluten-Free Diet in Rheumatoid Arthritis
Studies and research prove that excluding gluten from the diet can prevent inflammatory flare-ups in the patients, which indirectly helps with the symptoms of rheumatoid arthritis-like chronic pain and fatigue.
Scientists have long speculated the influence of dietary restrictions on rheumatoid arthritis. Large numbers of studies have been conducted to access the effect of various kinds of diets in alleviating the signs and symptoms of the disease.
1. Gluten-free diet prevents inflammation caused by gluten sensitivity
Gluten sensitivity causes intestinal and joint inflammation resembling the symptoms of RA and consequently, scientists have studied it as a possible therapeutic regime.
People with celiac disease also have higher chances of developing other autoimmune diseases like rheumatoid arthritis and therefore diet with no gluten might indirectly help with the symptoms of the same.
In a study conducted with sixty-six patients with active rheumatoid arthritis (on medication) , scientists found that a vegan gluten-free diet improved the signs and symptoms of the disease.
Thirty-eight patients were instructed to follow a vegan gluten-free diet while twenty-eight patients were instructed to follow a non-vegan diet for one year.
On following up by conducting antibody assays and radiography of joints, it was found that 40.5% of the patients in the vegan gluten-free group showed improvement while only 4% in the non-vegan group showed such improvement. 
Significant reduction in levels of antibodies that are responsible for the damage and inflammation was observed in the vegan gluten-free group. No such reduction was observed in the other group.
What does this mean? Gluten-free diet brings down the levels of serum antibodies responsible for causing inflammation.
2. A gluten-free diet helps with pain reduction
Patients with rheumatoid arthritis suffer from chronic joint pain and sensitivity to gluten is known to trigger such joint pains. 
In the study conducted by Kragh et al, 27 patients were put on individually adjusted vegan gluten-free diet for 3-5 months and it resulted in a great deal of improvement in the movement of joints, pain score, and grip strength, etc.
The improvement could still be observed after a year thus proving that this dietary regime could be an effective addition to the lifestyle of the patients. 
This can be attributed to the fact that limiting nutrients by putting dietary restrictions results in suppression of some aspects of the immune system. This suppression can, therefore, result in decreased inflammation and pain.
What does this mean? Due to a limited number of nutrients present in a gluten-free diet, immune system undergoes slight suppression thus preventing pain caused due to its attack on the body cells.
3. The gluten-free diet lacks fatty acid that acts as precursors to inflammatory chemicals
Fatty acids found in non-vegan gluten-containing diets are considerably different from the ones found in the vegan gluten-free diet.
What does this mean? Gluten-free diet prevents inflammation caused due to certain fatty acids present in the diet. This helps with overall pain and fatigue.
4. Gluten-free diet keeps the absorption of harmful substances under check
Gluten causes damage to the small intestine by triggering the immune system.
When the intestinal layer is damaged, considerable change is observed in the type of substances absorbed by it.
Absorption of certain bacterial substances by the damaged lining of the intestine can set off an inflammatory process in the joint. 
Naturally, excluding gluten from a diet can therefore indirectly prevent the damage to the lining, which in turn can prevent the absorption of harmful chemicals and microbes.
What does this mean? Gluten-free diet does not cause corrosion of the intestine that is usually caused by gluten-containing diet and therefore prevents additional absorption of inflammation-causing substances.
5. Gluten-free diet pairs well with anti-inflammatory drugs
Most of the patients with rheumatoid arthritis are prescribed anti-inflammatory drugs.
Many anti-inflammatory drugs are shown to disrupt intestinal lining and cause inflammation of the intestinal wall. 
This coupled with gluten can prove to be very damaging to the intestine and trigger the immune system as well.
Therefore going gluten-free can help the patients who are on anti-inflammatory drugs by preventing further damage to the intestine.
What does this mean? The intestinal wall undergoes some degree of inflammation due to the regular consumption of medication in RA. Gluten free diet ensures that the wall is not further damaged due to the presence of gluten in food.
6. A gluten-free diet is anti-atherogenic
Patients with rheumatoid arthritis are also at higher risks of developing cardiovascular ailments and atherosclerosis due to changes in the lipid profile.
They have low levels of high-density lipoprotein and high levels of triglycerides in the serum.
Consumption of gluten-free diet is known to help decrease total cholesterol and low-density lipoprotein.
Low-density lipoproteins are atherogenic and their decreased level can have anti-atherogenic effects in the patients. 
What does this mean? Gluten-free diet acts as an anti-atherogenic agent by decreasing the level of bad cholesterol in the body.
What to Eat/Avoid on a Gluten-Free Diet?
Following items are gluten-free and can be consumed while on a gluten-free diet :
- Dairy products like milk, butter, real cheese, plain yoghurt, fresh cream
- Plain fruits and vegetables
- Seafood, bacon, chicken, unprocessed meat and eggs
- Flours made with a gluten-free grain like chickpea, teff, pea, buckwheat, millet, brown rice, amaranth, coconut, almond flour, quinoa etc.
- Rice and corn in all forms
- Vegetable oil
- Soybean, tapioca, root crops
- Nuts and legumes
- Tea, coffee, wine
Following items should be completely avoided while on a gluten-free diet :
- Wheat, barley, and rye in all forms
- Malt (made from barley) including malt syrup and extract
- Soy, teriyaki and other sauces containing gluten
- Licorice and other confectionery made from wheat
- Bread, pasta, pizza, cakes, cereals, pretzels, etc. that are mostly made from wheat
- Condiments like malt vinegar, some pickles, and mustard
- Meat products prepared with breadcrumbs like sausages
Following items should be consumed only if labeled as gluten-free :
- Processed cheese
- Seasonings and flavourings
- Alcohol like beer, ale
- Herbal and nutritional supplements
- Oats (cross contamination) and energy bars
Following a gluten-free diet can be a very demanding task as it deprives your body of many important nutrients and therefore it should never be loosely thrown around as an adjuvant therapy without proper analysis of the patients and their symptoms.
If you are thinking of taking up the gluten-free diet to supplement your medication, you have to keep a lot of things in mind.
One should make sure that they are taking enough vitamins, fibres and other nutrients as supplements as a GFD deprives you of many of them.
The patients also face a deficiency of various vitamins, folic acid, calcium, iron, etc. which can be easily supplemented.
Patients should always speak to their doctor/rheumatologist before starting any supplements. 
They should also focus on consuming a lot more fruits and vegetables to get the required nutrients.
One should maintain proper medical and dietetic follow-up. Once the GFD is started, it is important to analyze your symptoms and look for improvement. 
Sometimes the diet might not be as useful in ameliorating the symptoms as expected in which case only the doctor would be able to suggest a solution.
Implication on social life
Following a gluten-free diet may have a negative impact on the social life of the people as it limits the kind of food one can consume. This might prevent people from eating out with friends and family and most of the food materials in restaurants have gluten.
Stringency in terms of what can be consumed and what cannot be done cause a lot of worry in people. 
Sticking to such a diet can be tough but with the help from doctors, family and friends it can be made possible.
Poor nutritional status
Having an active autoimmune disease like RA as it leaves the person with a poor nutritional status due to pain and other psychological aspects.
The patients also end up spending more energy as the body is constantly at war with itself through inflammation.
Following a gluten-free diet comes the risk of compromising the nutrient intake of the patients and might leave them malnourished. 
Diet should be carefully planned to keep in mind individual needs and body type.
Most of the patients with rheumatoid arthritis suffer from weight loss due to high metabolic rate as energy is spent on producing inflammatory chemicals from their precursors.
Therefore a well-balanced diet is essential to prevent damage to the body. 
There is some evidence that a gluten-free diet might be helpful in curbing the signs and symptoms of rheumatoid arthritis.
Excluding gluten from the diet can prevent inflammatory flare-ups in the patients, which indirectly helps with the symptoms of rheumatoid arthritis-like chronic pain and fatigue.
Consultation with a rheumatologist and registered dietician is a must before starting this diet, as they will be able to evaluate the patient’s situation and suggest changes to better fit the diet in their lifestyle. 
Gluten can be avoided by patients with arthritis but the completely gluten-free diet should not be taken up unless gluten intolerance is present which can be diagnosed through ‘exclusion and challenge’ or blood tests.
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