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The Mediterranean diet, and not dietary inflammatory index, is associated with rheumatoid arthritis disease activity, the impact of disease and functional disability



To assess the relationship between adherence to the Mediterranean Diet (MD) /individual Dietary Inflammatory Index (DII) and disease activity, disease impact, and functional status in Rheumatoid Arthritis (RA) patients.


RA patients followed at a hospital in Lisbon, Portugal, were recruited. DII was calculated using dietary intake data collected with a food frequency questionnaire (FFQ). Adherence to the MD was obtained using the 14-item Mediterranean Diet assessment tool. Disease Activity Score of 28 Joints (DAS28) and the DAS28 calculated with C-Reactive Protein (DAS28-CRP) were used to assess disease activity. Impact of disease and functional status were evaluated using the Rheumatoid Arthritis Impact of Disease (RAID) questionnaire and the Health Assessment Questionnaire (HAQ), respectively.


120 patients (73.3% female, 61.8 ± 10.1 years of age) were included. Patients with higher adherence to the MD had significantly lower DAS28-CRP (median 3.27(2.37) vs 2.77(1.49), p = 0.030), RAID (median 5.65(2.38) vs 3.51(4.51), p = 0.032) and HAQ (median 1.00(0.56) vs 0.56(1.03), p = 0.013) scores. Higher adherence to the MD reduced the odds of having a higher DAS28 by 70% (OR = 0.303, 95%CI = (0.261, 0.347), p = 0.003). Lower adherence to MD was associated with higher DAS28-CRP (β = − 0.164, p = 0.001), higher RAID (β = − 0.311, p < 0.0001), and higher HAQ scores (β = − 0.089, p = 0.001), irrespective of age, gender, BMI and pharmacological therapy. Mean DII of our cohort was not significantly different from the Portuguese population (0.00 ± 0.17 vs − 0.10 ± 1.46, p = 0.578). No associations between macronutrient intake or DII and RA outcomes were found.


Higher adherence to the MD was associated with lower disease activity, lower impact of disease, and lower functional disability in RA patients.

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Fig. 1

Data availability

All data supporting the findings of this study is available within the paper. Further inquiries can be directed to the corresponding author.



American college of rheumatology


Biological disease-modifying antirheumatic drugs


Body mass index


C-reactive protein


Disease activity score in 28 joints


Disease activity score in 28 joints calculated with C-reactive protein


Dietary inflammatory index


Disease-modifying antirheumatic drugs


European league against rheumatism


Erythrocyte sedimentation rate


Food frequency questionnaire


Health assessment questionnaire


High-sensitivity C-reactive protein


Mediterranean diet


Prevención con dieta Mediterránea


Rheumatoid arthritis


Rheumatoid arthritis impact of disease


Randomised clinical trial


Rheumatoid factor


Standard deviation


Short-chain fatty acids


Swollen joint count


Tender joint count


Visual analogue scale


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The authors wish to express their gratitude to all professionals of the Rheumatology Department of Centro Hospitalar Universitário Lisboa Norte, particularly Drs. Cristina Ponte, Joaquim Pereira, Maria João Saavedra and Rita Barros, for supporting the study.


No funding was received for conducting this study.

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Authors and Affiliations



SC: investigation, visualization, roles/writing—original draft. MF: investigation, visualization, roles/writing—original draft. JV: data curation, writing—review & editing. EC: formal analysis, writing—review & editing. JM-M: resources, writing—review & editing. AMD-M: resources. ED: resources, writing—review & editing. JEF: conceptualisation, methodology, resources, supervision, validation, project administration, writing—review & editing. CSG: conceptualisation, methodology, resources, supervision, validation, project administration, writing—review & editing.

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Correspondence to Eduardo Dourado.

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This study was conducted in accordance with the Declaration of Helsinki and its later amendments or comparable ethical standards, with the approval of the Lisbon Academic Medical Center Ethical Committee (Ref. Nº 262/19). All participants gave their informed consent prior to their inclusion in the study.

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Charneca, S., Ferro, M., Vasques, J. et al. The Mediterranean diet, and not dietary inflammatory index, is associated with rheumatoid arthritis disease activity, the impact of disease and functional disability. Eur J Nutr 62, 2827–2839 (2023).

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