How Can Clinicians Help Patients With Rheumatic Diseases Make Lifestyle Changes?

The association between lifestyle habits and health has been well established in the literature. Recommendations have been developed for the general population for physical activity¹, healthy eating², smoking³, and alcohol use.⁴

Many studies have shown that lifestyle factors play an important role in the health of patients with rheumatic diseases. For example, a recent study explored physical activity levels in older adults with rheumatoid arthritis (RA),⁵ in which the researchers found that lower physical activity was associated with higher rates of depression and worse patient-reported outcome scores related to pain, fatigue, and sleep disturbances.

Following extensive literature reviews of the effects of lifestyle factors on disease-specific outcomes across 7 rheumatic diseases,^6-8 the European Alliance of Associations for Rheumatology (EULAR) developed lifestyle behavior recommendations to prevent the progression of rheumatic and musculoskeletal diseases.⁹

The recommendations emphasized the importance of the following factors:

• Regular aerobic and strengthening exercises, which significantly improve disease-specific outcomes, especially for patients with osteoarthritis and axial spondyloarthritis.
• A healthy, balanced diet and the lack of evidence supporting the benefits of specific nutrients (eg, vitamin D and omega 3).
• A healthy weight and, for people with overweight or obesity, the benefits of weight loss through a healthy diet and exercise.
• A low level of alcohol consumption and the risk for disease flares with moderate alcohol use in patients with RA and gout.
• Quitting smoking, due to the negative effects of smoking on symptoms, function, disease activity, and disease progression, and the occurrence of comorbidities.

The EULAR taskforce noted that the implementation of these recommendations should be a multidisciplinary effort.

The Role of the Clinician in Helping Patients Make Lifestyle Changes

Patients with rheumatic diseases face barriers in the adoption and practice of making lifestyle changes. Katz et al¹⁰ reviewed the barriers among patients with RA in engaging in physical activity. Joint damage, current RA symptoms, and being unaware that physical activity can improve symptoms were all found to affect exercise levels. However, the researchers noted that the greatest barrier was the lack of direction from health care providers.

Patients with rheumatic diseases are seeking information about how lifestyle changes, along with more effective disease management, can prevent disease progression.⁹ Researchers noted that the educational needs of patients with rheumatic diseases, understanding disease processes, treatments, and self-management strategies were the most important to patients who wish to make lifestyle changes.¹¹

Promoting Self-Management Among Patients

Self-management among patients with rheumatic diseases can improve outcomes and overall well-being.¹² The 2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis (IA)¹³ clearly emphasized the importance of providers in certain areas:

• Encouraging patients to be active partners of their care team
• Providing patient education, which is the foundation for self-management
• Promoting physical activity and evidence-based healthy lifestyle changes
• Assessing mental health, which can affect patients’ ability to self-manage their condition

The recommendations also  health care providers to be aware of relevant resources for patients, including those involving digital technologies.

Connecting Patients With the Right Educational Resources

There are several programs to help people quit smoking, exercise more, eat a healthy diet, and lose weight. For patients with specific conditions, self-management education workshops are also available, such as the Chronic Disease Self-Management Program and Arthritis Self-Management Program.¹⁴

When recommending self-management interventions, providers should lean toward programs that include problem solving, goal setting, and cognitive behavioral therapy, when appropriate, as compared with didactic education-only programs.¹³

The EULAR recommendations¹⁵ emphasize the importance of interactive learning to help patients manage their IA. The interactive learning process, as defined by the EULAR, includes many types of interventions, including cognitive behavioral therapy, counselling, didactic education, individual consultations with health care providers, mindfulness, and motivational discussions.

A randomized controlled trial by Shao et al¹⁶ highlighted the effectiveness of a multimodal approach for a self-management joint protection program in patients with RA. The intervention group participated in an 8-week program and physical activity with nursing support. Compared with the control group receiving standard care, the intervention group demonstrated significant improvement in physical functioning, pain self-efficacy, and self-management behaviors.

Harnessing Digital Technologies

With the evolution of technology, researchers are also finding new ways to help people make lifestyle changes. A review by Davergne et al¹⁷ concluded that activity trackers can encourage physical activity in patients with rheumatic diseases. The researchers also suggested strategies to enhance the effectiveness of activity trackers, including the use of more advanced devices for longer periods of time (at least 12 weeks) and incorporation of text messages and personalization features.

Apps can also be used in the delivery of rheumatic disease interventions. For example, CareHand is a smartphone app for patients with RA of the hands, which features a tailored exercise program, education, and self-management recommendations. A randomized controlled trial found that CareHand significantly improved hand function, work performance, pain, and satisfaction.¹⁸

Factors Influencing Lifestyle Changes

Health of individuals is informed by factors, or determinants, that operate at the individual (income, education), environmental (neighborhoods, workplaces, families), and societal (systems, policies) levels.¹⁹ Some determinants of health, such as discrimination and stress, operate at all levels. The social determinants of health model incorporates multilevel factors that have been widely used to explain health disparities.

The incidence and outcomes of many chronic diseases, including rheumatic diseases, often vary by socioeconomic status, race, ethnicity, and sex. In rheumatic diseases, health disparities are most evident in systemic lupus erythematosus (SLE).²⁰ Women and racial/ethnic minorities (especially Black women), and people who have a low socioeconomic status, are uninsured, and have low education are at higher risk of developing SLE and experiencing poorer outcomes.²⁰

Health behaviors, such as smoking, alcohol use, diet, and exercise, are important drivers of health outcomes and are affected by the various social determinants of health. For example, the decision to exercise is often a function of many factors, including knowledge/education, neighborhood, income, time resources, and support systems.

In the context of the external factors that affect health behaviors, counseling patients to adopt healthy lifestyle habits can be challenging for health care providers. A qualitative study by Loignon et al identified several strategies for delivering effective care to vulnerable populations.²¹

• Building a personal connection to reduce social distance: Physicians should inquire about patients’ financial or social conditions.
• Aligning expectations with social vulnerability: Physicians can implement small changes by focusing on strengths and accepting that some patients may only achieve minimal gain.
• Collaborating with other professionals: Teamwork is a fundamental strategy in chronic care management. The inclusion of nurses, social workers, and other professionals improves patient access to services and continuity of care.

Addressing health literacy may also be important in reducing health disparities. A review by Stormacq et al found that health literacy plays a mediating role between   socioeconomic status and health status, quality of life, specific health-related outcomes, and health behaviors.²² To promote health literacy, providers should focus on clear and concise verbal and written communication, using visual aids, encouraging patient self-management, and enabling supportive systems, such as providing links to nonmedical support and community resources.²³

The Importance of Shared Decision-Making

Shared decision-making emphasizes the importance of collaboration between patients and providers when making health care decisions. In rheumatology, shared decision-making is a standard approach for implementing various treatment and management recommendations. For example, the EULAR recommendations for lifestyle behaviors to prevent the progression of rheumatic and musculoskeletal diseases were developed as the foundation for patient-provider discussions and share decision-making.⁹

According to the Agency for Healthcare Research and Quality (AHRQ),²⁴ shared decision-making is most effective when it incorporates evidence-based information about available options, provider knowledge and experience, and patient values and preferences. AHRQ designed a 5-step process (SHARE) to help patients make decisions about their medical care.

1. Seeking participation by letting patients know that they have options and can be a part of the decision-making process.
2. Helping patients explore and compare treatment options by discussing the benefits and risks.
3. Assessing patient values by talking to them about their preferences.
4. Reaching a decision with the patient.
5. Evaluating patients’ decision, after an appropriate period, to identify barriers to implementing the decision, revisit the decision, or determine if other decisions need to be made.

Incorporating shared decision-making into clinical practice may require some adjustment in clinical workflows. However, the benefits of more engaged patients who develop better self-management skills and realize improved disease outcomes seem to merit the effort.