ACR integrative guidelines for RA make sense of ‘messy’ data on diet, wellness

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DESTIN, Fla. — The 2022 American College of Rheumatology recommendations on integrative therapy in rheumatoid arthritis can help make sense of “messy” data on diet and other wellness behaviors, according to a speaker.

“For a while we could be monocentric about RA treatment guidelines,” Bryant England, MD, PhD, an associate professor in the division of rheumatology and immunology at the University of Nebraska Medical Center, told attendees at the Congress of Clinical Rheumatology East annual meeting. “That has changed over the last couple of years.”


“The diet literature is very messy,” Bryant England, MD, PhD, told attendees. Image: Justin Cooper | Healio

One of the biggest changes was the publication of the ACR’s integrative therapy recommendations, which provide information on the data supporting exercise, diet and other wellness approaches to RA management, according to England. The intention of the document was to offer a complement to the traditional, pharmacotherapeutic guidelines.

“The idea behind this guideline was that patients really, really want answers in this space,” England said. “The literature is messy in this space.”

One complication for rheumatologists is that there are at least eight guidelines that deal directly or indirectly with managing patients with RA. Making sense of the pharmacotherapeutic options is challenging enough, which is part of the reason ACR decided to supplement them with the integrative guideline, England said.

“It is not replacing the pharmacotherapeutic guideline,” he said. “It is to be used alongside, or with.”

The four main topics in the integrative medicine guidelines are exercise, rehabilitation, dietary approaches and additional interventions. Unlike the ACR’s pharmacotherapeutic guideline for RA, which includes 41 recommendations, of which seven are strong recommendations, the integrative document includes 28 recommendations, just one of which is strong.

The only strong recommendation is for consistent exercise.

“Let’s address the elephant in the room,” England said. “Let us break the myth that exercise will damage your joints. Do not stop moving.”

Despite the strong recommendation for exercise overall, when specific types of exercise were studied individually, the guideline development team was not able to allocate more than a conditional recommendation for aerobic, aquatic, resistance or mind-body approaches.

Bryant England

“The evidence was not as strong when we separated them all out,” England said.

Regarding diet, the guideline authors approved a conditional recommendation in favor of a Mediterranean food plan.

“The diet literature is very messy,” England said. “It is hard to do a diet study well.”

Beyond diet and exercise, both occupational and physical therapy are conditionally recommended.

“You need to find ones who are really interested in taking care of RA patients,” England said.

Additional self-management strategies also received conditional recommendations, including cognitive behavioral therapy, acupuncture, massage and thermal modalities. The document also contains conditional recommendations against electrotherapy and chiropractic therapy, the latter of which was decided due to the lack of available data on the topic.

For rheumatologists who may be unfamiliar with many of these approaches, or who may feel that this is too much information for a standard office visit, England stressed patience. “You do not have to do it all at once,” he said.

Setting achievable goals for diet or a simple exercise regimen is a good place to start.

“Give them a menu,” England added. “We have many things we can do.”

Managing expectations is also useful.

“Massage might be helpful, but it will not reduce swollen joint counts without medication,” England said.

Educational handouts and questionnaires can also help patients set their own goals and limits.

“We just have to be careful about adding too much to our patients,” England said. “They have a chronic disease. They are taking medications. Do not just dump all of this on them.”

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