Lifestyle Medicine Interventions Can Benefit Patients with Rheumatic Disease

SAN DIEGO—Lifestyle interventions, such as diet, exercise and mindfulness, can benefit patients with rheumatic disease. Although the benefits of lifestyle medicine have been shown in many studies, how best to put these strategies to use for rheumatology patients is still far from being fully explored, an expert said during a session at ACR Convergence 2023.

“The application of lifestyle medicine in the rheumatic diseases is critically important to people who are living with these conditions,” said Sarah Patterson, MD, assistant professor of medicine at the University of California, San Francisco (UCSF), and integrative rheumatologist at UCSF’s Osher Center for Integrative Health.

Dr. Patterson

These interventions can make a difference for patients when conventional therapies are not completely effective or are poorly tolerated. Lifestyle medicine can help ease persistent symptoms, while offering additional benefits, such as lowering cardiovascular disease risk.

Diet

Studies dating back to the 2000s demonstrated the benefit of the Mediterranean diet in patients with active rheumatoid arthritis (RA) compared with control. The diet consists of vegetables, nuts, fish and has very limited red meat, added sugar and processed food. In the study, these patients experienced improvements from baseline in pain and function when simply taking Mediterranean-diet cooking classes. A 2022 study comparing a Mediterranean diet with a low-fat diet and a regular diet among obese and overweight patients with RA found the greatest improvements were seen in patients using the Mediterranean diet.¹

In a recent study, 20 patients with active RA who were put on an anti-inflammatory diet—known as the ITIS diet—had significant improvement in pain after the intervention compared with baseline. Also, the fecal microbiome and metabolome were different in patients with at least 50% pain improvement compared with those who had a lesser response.²

In patients with lupus, in which diet has been studied less, researchers found that most patients who made dietary changes after diagnosis perceived a benefit from that change.³ Other research has found an independent association between sugar intake and disease activity.⁴

Studies have also demonstrated the benefits for omega-3 supplementation in patients with RA and lupus.^5,6 Dr. Patterson pointed the audience to a UCSF Web site (http://tiny.ucsf.edu/rheumnutrition) with evidence-based information on diet and people with rheumatic conditions.

Movement

Physical activity has been repeatedly found to improve with patient-reported outcomes in RA, Dr. Patterson said. In a study, a 10-week, high-intensity walking program significantly improved disease activity and immune function among previously physically inactive patients.⁷

In patients with lupus, physical activity has been found to improve fatigue and sleep, but the research has painted a mixed picture in terms of the effects on disease activity, she said.⁸

In her own research, Dr. Patterson has found that patients with RA who spent more time doing moderately intense physical activity had downregulation of that innate and adaptive immune-signaling genes that are implicated in the pathogenesis of RA. She and her colleagues also found a dose response: The more physical activity, the lower the pro-inflammatory gene expression.⁹

In a similar study on lupus, UCSF researchers found that being physically inactive was associated with an increased inflammatory signaling in CD4+ and CD8+ T cells.¹⁰

Mindfulness

Dr. Patterson and colleagues have also looked at the effects of stress in patients with lupus, finding that those who experienced an increase in stress had worse disease activity in follow-up visits.¹¹

Mindfulness-based stress reduction (MBSR) may potentially reduce stress, but the literature is mixed regarding its effect on disease activity in patients with RA, Dr. Patterson said. In patients with lupus, a study from 2021 found that those randomized to MBSR had improvements in quality of life, disease-related shame and ability to manage pain, than controls.¹²

Q&A

In the discussion portion of the session, Dr. Patterson addressed the potential value of clinical trials that give patients the power to choose their diet, given the high dropout rate seen in clinical trials with strict dietary rules and the need to determine what works on an individual level. An example of an individualized diet is an elimination diet, in which the patient would work with a healthcare professional, such as a registered dietician, to decide which foods to exclude based on associated symptoms.

“I think it’s a promising approach, and the challenge is just having a system in place, which I think really requires working closely with a registered dietician who can help the patient embark on that journey—which is labor intensive. The patient has to be really motivated,” Dr. Patterson said. “But I think in select people, it does work well, and it’s something that I’ve tried with some of my patients.”

Thomas Collins is a freelance medical writer based in Florida.

References

1. Sadeghi A, Tabatabaiee M, Mousavi MA, et al. Dietary pattern or weight loss: Which one is more important to reduce disease activity score in patients with rheumatoid arthritis? A randomized feeding trial. Int J Clin Pract. 2022 Apr 29;2022:6004916.
2. Coras R. Martino C, Gauglitz JM, et al. Baseline microbiome and metabolome are associated with response to ITIS diet in an exploratory trial in patients with rheumatoid arthritis. Clin Transl Med. 2022 Jul; 12(7):e959.
3. Knippenberg A, Robinson GA, Wincup C, et al. Plant-based dietary changes may improve symptoms in patients with systemic lupus erythematosus. Lupus. 2022 Jan;31(1):65–76.
4. Correa-Rodriguez M, Pocovi-Gerardino G, Callejas-Rubio J-L, et al. Dietary intake of free sugars is associated with disease activity and dyslipidemia in systemic lupus erythematosus patients. Nutrients. 2020 Apr 15;12(4):1094.
5. Tedeschi SK, Costenbader KH. Is there a role for diet in the therapy of rheumatoid arthritis? Curr Rheumatol Rep. 2016 May;18(5):23.
6. Ramessar N, Borad A, Schlesinger N, et al. The effect of omega-3 fatty acid supplementation in systemic lupus erythematosus patients: A systematic review. Lupus. 2022 Mar;31(3):287–296.
7. Bartlett DB, Willis LH, Slentz CA, et al. Ten weeks of high-intensity interval walk training is associated with reduced disease activity and improved innate immune function in older adults with rheumatoid arthritis: A pilot study. Arthritis Res Ther. 2018 Jun 14;20(1):127.
8. Gavilan-Carrera B, Vargas-Hitos JA, Morillas-de-Laguno P, et al. Effects of 12-week aerobic exercise on patient-reported outcomes in women with systemic lupus erythematosus. Disabil Rehabil. 2022 May;44(10):1863–1871.
9. Patterson SL, Sun S, Rychkov D, et al. Physical activity associates with lower systemic inflammatory gene expression in rheumatoid arthritis. J Rheumatol. 2022 Dec;49(12):1320–1327.
10. Perez RK, Gordon MG, Subramaniam M, et al. Single-cell RNA-seq reveals cell type-specific molecular and genetic associations to lupus. Science. 2022 Apr 8;376(6589):eabf1970.
11. Patterson S, Trupin L, Hartogensis W, et al. Perceived stress and prediction of worse disease activity and symptoms in a multiracial, multiethnic systemic lupus erythematosus cohort. Arthritis Care Res (Hoboken). 2023 Aug;75(8):1681–1689.
12. Taub R, Horesh D, Rubin N, et al. Mindfulness-based stress reduction for systemic lupus erythematosus: A mixed-methods pilot randomized controlled trial of an adapted protocol. J Clin Med. 2021 Sep 28;10(19):4450.