This document discusses various integrative medicine approaches for rheumatology patients, including diet, exercise, and lifestyle factors. It recommends adopting a Mediterranean diet rich in plants, fish, and olive oil while limiting red meat and sugar. Regular physical activity and weight management are also emphasized to reduce inflammation and cardiovascular risk. Additional lifestyle approaches discussed include stress management techniques like mindfulness meditation, adequate sleep, quitting smoking, and supplements like turmeric and fish oil which may provide benefits when used alongside medical treatments.

1. Integrative Medicine in
Rheumatology

2. DIET?
EXERCISE?
PAIN Management?
FATIGUE Management?
SLEEP ?
RELAXATION TECHNIQUES?
Patient Questions

3. THIS DISCUSSION IS NOT INTENDED TO
REPLACE YOUR MEDICAL THERAPY,
BUT RATHER TO COMPLEMENT IT!
DISCLAIMER

4. Mediterranean Diet

5. DRINK MORE WATER 2.5 LITERS/day

6. Based on plant foods, legumes, fruits, grain, cereals
and nuts, and fish (PUFAs)
Limited meat consumption
Main source of fat is olive oil (oleic acid)
Moderate amounts of dairy products and eggs.
Mediterranean Diet

7. Decreases inflammation!
Improves intestinal health
Promotes metabolic health
Modifies how our genes work
Mediterranean Diet: How it works
Oliviero F, Spinella P, Fiocco U, Ramonda R, Sfriso P, Punzi L. How the Mediterranean diet and some of its
components modulate inflammatory pathways in arthritis. Swiss Med Wkly. 2015;145:w14190. Published 2015
Nov 2. doi:10.4414/smw.2015.14190

8. Patients with RA, psoriatic arthritis, gout, lupus, and
other inflammatory diseases have a higher risk of CV
disease that the general population.
Cardiovascular Health

9. Reduces the risk of:
 Cardiovascular diseases
 Cancer
 Diabetes
 Obesity
 Arthritis
Mediterranean Diet Benefits

10. Mediterranean Diet and Arthritis
Oliviero F, Spinella P, Fiocco U, Ramonda R, Sfriso P, Punzi L. How the Mediterranean diet and some of its
components modulate inflammatory pathways in arthritis. Swiss Med Wkly. 2015;145:w14190. Published 2015
Nov 2. doi:10.4414/smw.2015.14190
Can help decrease pain and joint swelling
Improves physical function
Forsyth C, Kouvari M, D'Cunha NM, et al. The effects of the Mediterranean diet on rheumatoid arthritis
prevention and treatment: a systematic review of human prospective studies. Rheumatol Int. 2018;38(5):737-
747. doi:10.1007/s00296-017-3912-1

12. Reduces RA symptoms
Decreases level of inflammation
Vegan Diet
Badsha H. Role of Diet in Influencing Rheumatoid Arthritis Disease Activity. Open Rheumatol J.
2018;12:19-28. Published 2018 Feb 8. doi:10.2174/1874312901812010019

13. INTERMITTENT FASTING (18 hours)

14. Psoriatic arthritis
 Decrease swelling of fingers and toes
 Decrease swelling of the tendons and ligaments
 Decrease in levels of inflammation
Rheumatoid arthritis
 Decrease swelling and pain of joints
 Decrease in levels of inflammation
Intermittent Fasting
Ben Nessib D, Maatallah K, Ferjani H, Kaffel D, Hamdi W. Impact of Ramadan diurnal intermittent fasting on
rheumatic diseases. Clin Rheumatol. 2020;10.1007/s10067-020-05007-5

15. Rheumatoid arthritis
 Decrease in joint pain and swelling
 Decrease in levels of inflammation
Intermittent Fasting followed by
Vegetarian Diet
Kjeldsen-Kragh J, Haugen M, Borchgrevink CF, et al. Controlled trial of fasting and one-year vegetarian diet
in rheumatoid arthritis. Lancet. 1991;338(8772):899-902. doi:10.1016/0140-6736(91)91770-u

16. SUGAR
 Sugar will cause inflammation and
severely damage health.
there is ADDED sugar
in
soft drinks, fruit drinks, yogurts,
cereals, cookies, cakes, candy, most
processed foods, soups, bread, cured
meats, and even ketchup?
 Stop eating or adding sugar to your
food or drinks

17. SPICES
TURMERIC
GARLIC
GINGER
BASIL
BLACK PEPPER
OREGANO
CHIVES
CILANTRO
OREGANO
PARSLEY
OREGANO
ROSEMERY

18. TURMERIC

19. The benefit of nuts
Lower cholesterol
level, the risk of heart
disease
One handful nuts/ day
Walnuts, almonds and
pecans are the best!

20.  Fish oil
 Algae oil
 Vitamin D
 Boswellia
 Ginger
WARNING !!! YOU NEED a discussion with your DOCTOR
as many can interact with blood thinners, pregnancy,
breastfeeding
SUPLEMENTS

21.  Fatty fish like salmon,
mackerel, sardines
 Flaxseeds
 Chia seeds
 Walnuts
 Pumpkin seeds
OMEGA -3 Fatty
acids

22. MANAGEMENT

23. Handout with guide to pain management in inflammatory arthritis and osteoarthritis.
Rinie Geenen et al. Ann Rheum Dis 2018;77:797-807
©2018 by BMJ Publishing Group Ltd and European League Against Rheumatism

24. PAIN
Physical activity
Sleep
management
Weight
management
Orthotics
Medications
Psychological/social
intervention

25. Vicious cycle
Pain
Flare-ups/ chronic
disease
Physical Activity
EatingWeight
Stiffness

26. Weight management

27. Leptin- link neuroendocrine and
inflammation
Abella V, Scotece M, Conde J, et al. Leptin in the interplay of inflammation,
metabolism and immune system disorders. Nat Rev Rheumatol. 2017;13(2):100-
109.

28. Physical activity (PA)

29. PUBLIC Recommendations for HEALTHY ADULTS
 All healthy adults 18-65 yo should participate in moderate PA minimum 30 min 5
days/ week or 20 min vigorous aerobic activity 20 min 3x/ week
 Combinations of moderate and vigorous intensity exercise
 Moderate intensity aerobic activity can be accumulated to total the 30 min minimum
by performing bouts each lasting ≥10 min.
 Every adult should perform activities that maintain or increase muscular strength
and endurance for a minimum of 2 days/week.
 Individuals who wish further improve their fitness, reduce their risk of chronic
diseases and disabilities and/ or prevent unhealthy weight gain my benefit by
exceeding the minimum recommendations
Rausch Osthoff A-K, et al. Ann Rheum Dis 2018;77:1251–1260.

30. Physical activity (PA) in arthritis
Recommendations for PA and exercise in people with inflammatory
arthritis and OA
 PA is part of a general concept to optimise health related quality of life.
 PA has health benefits for people with RA/SpA/HOA/KOA.
 General PA recommendations, including the four domains (cardiorespiratory
fitness, muscle strength, flexibility and neuromotor performance) are applicable
(feasible and safe) to people with RA/OA/SpA.
 The planning of PA requires a shared decision between healthcare providers and
people with RA/SpA/HOA/KOA, which takes people’s preferences, capabilities
and resources into account.
Rausch Osthoff A-K, et al. Ann Rheum Dis 2018;77:1251–1260.

31.  Gradual, 5x/ week at least 30
minutes or 3x/week vigorous
exercise 20 min
 Aquatics
 Salt water pools
 YOGA
EXERCISE

32. YOGA
2013 Jon Kabat-Zinn, Full Catastrophe Living, 2nd edition, Random House, NY

33. YOGA
2013 Jon Kabat-Zinn, Full Catastrophe Living, 2nd edition, Random House, NY

34. Benefits of physical activity
Build endurance and strength
Preserve muscle and normal joint motion
Minimize bone loss
Improve pain control
Improve mood

35. SLEEP

36. SLEEP
2018 survey Ireland – 60% of patients with inflammatory
arthritis report sleeping aprox 5.7h/ nigh, poor quality of
sleep
30% taking sleep aid medication at least 1x/ week
50% of health professionals discuss sleep with patients
McKenna S et al. Sleep and physical activity: a survey of people with inflammatory arthritis and their
engagement by health professionals in rheumatology in Ireland.
Disabil Rehabil. 2018;40(19):2260-2266.

37. Poor
sleep
Inflamm
arthritis
OA
Fibromyalgia
Westhovens R et al.Sleep problems in patients with rheumatoid arthritis. J Rheumatol. 2014;41(1):31-40.
Hammam N et al.Fatigue in Rheumatoid Arthritis Patients: Association With Sleep Quality, Mood Status, and Disease
Activity Reumatol Clin 2018;S1699-258X(18)30169-4. doi:10.1016/j.reuma.2018.07.010; Ulus Y et al.Exp Rheumatol. 2011
Nov-Dec;29(6 Suppl 69):S92-6
PAIN

38. SLEEP
PAIN
DEPRESSION
ANXIETY
FATIGUE The cumulative long term effect of sleep deprivation,
increased risk for diabetes, heart disease, obesity
S
L
E
E
P

39. Aprox 20,000 Sweden patients, published in 2020
Before and after treatment for RA/PsA/AS with
TNFinbitors/ other non-biologics vs controls
Decreased rates of drug use after treatment
The use of antidepressants/
antihypnotics
Brenner P, Citarella A, Wingård L, Sundström A. Use of antidepressants and benzodiazepine-related hypnotics before and
after initiation of TNF-α inhibitors or non-biological systemic treatment in patients with rheumatoid arthritis, psoriatic arthritis or
ankylosing spondylitis. BMC Rheumatol. 2020

40.  Set the same time for
bedtime (9h of
sleep/night)
 Warm bath
 Book reading
 Avoid exercise or eating
3 hours before bedtime
 Avoid screentime
 Melatonin, chamomile
tea, valerian
IMPROVE YOUR SLEEP

41. STOP SMOKING
Smoking is linked with
• Onset of RA
• Worse outcome
• Aggressive disease
• Poor response to
treatment
• Increased CV risk

42. Heart disease
Inflammation/
Autoimmunity
Cancers
STRESS

44. Practicing Mindfulness
If your attention
wanders a hundred
times, simply bring it
back a hundred times.
Observe
wandering
begin again
Attention
Wanders
Mind on chosen
target

45. Mindfulness=tool to
create awareness of pain
 1985 Jon Kabat-Zinn,:90 chronic pain patients were trained
in Mindfulness-Based Stress Reduction (MBSR)
 reductions in measures of present-moment pain, negative
body image, inhibition of activity by pain, mood
disturbance, and psychological symptomatology, including
anxiety and depression
 reduced pain-related drug utilization

46. Brain changes
Zeidan F, Vago DR. Mindfulness meditation-based pain relief: a mechanistic
account. Ann N Y Acad Sci. 2016;1373(1):114-127.

47. Mindfulness & Neuroplasticity
Hölzel BK, Carmody J, Vangel M, et al. Mindfulness practice leads to
increases in regional brain gray matter density. Psychiatry Res. 2011;
191(1):36-43.
Increased gray matter in hippocampus, temporoparietal junction leading
to compassion
Decrease gray matter in amygdala – decrease the fight and flight
Increase parasympathetic system
Increased serotonin, melatonin, decreased norepinephrins and cortisol

49.  https://www.umassmemorialhealthcare.org/umass-
memorial-medical-center/services-treatments/center-
for-mindfulness/mindfulness-classes
MBSR course UMass

50. Mindfulness APPS
Insight timer

51. A three-component lifestyle modification program
1. Low-fat low-sodium Mediterranean diet rich in fruits, vegetables,
whole grains and nuts and poor in sugar-sweetened beverages, red
and processed meat and trans fats, and the supplementation with
omega-3 fatty acids, non-essential amino acids and probiotics
2. Appropriate physical activity program based on an active daily
lifestyle, aerobic exercise and resistance training
3. Adequate sleep hygiene and smoking reduction/cessation
Seems to have positive effects in terms of disease progression and
related outcomes.
Chehade L, Jaafar ZA, El Masri D, et al. Lifestyle Modification in Rheumatoid
Arthritis: Dietary and Physical Activity Recommendations Based on
Evidence. Curr Rheumatol Rev. 2019

52. THANK YOU!
Diana Girnita MD, PhD
Founder Rheumatologist Oncall
Facebook page: Rheumatologist Oncall
Office phone: 6502521690
Fax: 6502521696
Dianagirnitamd@gmail.com
DrG@rheumatologistoncall.com