Will a vegetarian diet and exercise actually help RA disease activity? Save

In research that surprised many at ACR Convergence 2022, a Dutch program targeting a whole food plant-based diet, physical activity, and stress management has shown benefit in DAS28 rheumatoid arthritis disease activity measures, just as ACR guidelines regarding exercise, diet and other integrative interventions for RA were released at the same meeting.

The exact role of diet, physical activity, and stress management in the management of RA has long been debated. While reasonable evidence has supported the importance of physical activity in patients with RA, its capacity to reduce disease activity via conventional measures such as DAS28 was less well delineated.

At ACR Convergence 2022, the ACR released a new guideline for ‘Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis’, but the development of this guideline proved challenging given the limited evidence for most areas addressed. It provisionally recommended a number of measures for RA patients, a Mediterranean-style diet, as well as cognitive behavioral therapy and/or mind-body approaches, reflecting uncertainty in the existing supportive evidence.

The only strong recommendation in this guideline was for ‘consistent engagement in exercise’, but even with this the immediate impact on RA disease activity has been unclear. Such uncertainty is likely to have underpinned poor broader implementation for patients with a cornerstone disease within rheumatology, despite often substantial interest from patients themselves. In the absence of evidence-guided programs, patients may well pursue expensive alternative programs with unclear clinical value, for both RA-specific and general health.

It was therefore with great interest that researchers from the Reade (within the Amsterdam University Medical Centers) in the Netherlands presented work on the Plants for Joints program, tested in patients with active RA in a randomized controlled trial. These researchers, led by Dr. Wendy Walrabenstein, an academic dietitian, examined 77 patients with low-moderate RA disease activity, as assessed by DAS28, but on stable therapy for three months before the trial. The interventional arm underwent a 16 week community-based structured program, involving a whole-food plant-based diet, sleep and stress management, and an exercise program, in addition to usual care. (Abstract 1998)

In this study, reductions in disease activity as measured by DAS28 were noted at 8 weeks, and were sustained at 16 weeks. Compared to patients in the control group of usual care, patients in the Plants for Joints program had a mean DAS28 0.9 points lower, and lost a mean of 3.9kg more. In addition, other measures including fat mass and metabolic biochemical measures were also noted to be improved with the Plants for Joints intervention.

While this presentation did not make clear which components of the DAS28 contributed most to the reduction in DAS28 disease activity, improvement in any of those in a short period of time from a non-pharmacological intervention would be of substantive value in clinical practice, especially if such a program was able to be readily replicated on scale. While the value of individual components of this program is also yet to be determined, operationalizing therapeutic interventions in this area with real impact for RA disease activity represents an exciting development in an area without enough good evidence.

13S161. ACR Guideline for Physical, Psychosocial, Mind-body, and Nutritional Interventions for Rheumatoid Arthritis: An Integrative Approach to Treatment: https://meet.acrconvergence2022.org/meetings/virtual/eH5jgLqPM7uPpGJg5

Trial protocol: https://trialsjournal.biomedcentral.com/articles/10.1186/s1