By Anna Lafian, DO, MS
I find it really exciting to be in the field of rheumatology nowadays. Over the past several years, I’ve found that people are tuning into the power of their everyday lifestyle choices to optimize their health and wellness. As a firm believer in lifestyle medicine, integrative medicine, and using complementary treatments alongside the powerful pharmaceuticals we have available now, I see the potential we have to make big strides in whole-person care. I am delighted when those who live with spondyloarthritis (SpA) realize that their health can indeed be influenced by factors that are within their day-to-day control.
My patients often ask, “What can I do to help improve my symptoms? What should I eat? Can I exercise with SpA?” Researching these topics on the internet or social media can inundate us with hundreds of different dietary tips, ads for new supplements, and wellness gadgets. It can feel overwhelming when we’re struggling with where to start.
For simplicity, immune wellness (and truly, wellness in general) can be classified into five main pillars: 1) Diet, 2) Exercise, 3) Stress management, 4) Sleep, 5) Reducing exposure to environmental toxins.
Hippocrates once said, “All disease begins in the gut.” There is no question that the gut microbiome—the bacteria, yeast, and other microbes that live in our intestines—plays a role in SpA. Studies have shown that rats with the HLA-B27 gene who were raised in a germ-free environment did not develop arthritis; however, when certain bacteria were re-introduced, inflammation emerged in the gut and joints.1,2 Over the past decade or so, with advances in genome sequencing techniques, researchers have been able to look more closely at the intestinal metagenome (the genetic material present in the gut) and have come to understand that those with SpA have a different gut microbial composition than the general population.3
Diet plays a key role in the makeup of the microbiome as it affects the kinds of microbes that can live and grow in the gut. In a 2021 study published in the journal Gut, researchers found a link between the consumption of processed and animal-derived foods, and intestinal bacteria implicated in driving inflammation. The opposite was found for plant-based foods and fish, which were positively associated with short-chain fatty acid (SCFA) production and efficient metabolism. SCFAs improve gut health in a number of ways, from maintaining the integrity of the intestinal barrier to protecting against inflammation.
Healthy diets enriched with fruits, vegetables, legumes, and nuts, that feature a higher intake of plant-based foods than animal-based foods—and that minimize alcohol and sugar—have the potential to prevent intestinal inflammatory processes.4
What constitutes “healthy” nutrition? Here are a few pointers I usually give my patients:
- Focus on eating a primarily whole-food diet. Try your best to shop in the periphery of the grocery store, where there is an abundance of fresh fruits and vegetables. Eat every color of the rainbow, daily. It is usually these fiber-rich foods that help feed those “good bacteria” in the gut and prompt them to produce anti-inflammatory byproducts (such as SCFAs).
- Avoid processed foods. A good rule is to avoid packaged food items that contain dozens of ingredients, most of which we cannot pronounce. And yes, this rule may even apply to items that are marketed as organic or gluten-free.
- Eliminate as much refined sugar as you can. Try to avoid packaged candies, cookies, donuts, etc.
- Increase your intake of omega-3 fatty acids (this can be found in fish, flax seeds or flax seed oil, chia seeds, and nuts).
- Drink at least eight to ten glasses of water per day.
A large literature review published in 2020 found that exercise significantly decreased pain scores in patients with ankylosing spondylitis (AS) as measured by a visual analogue scale, and significantly improved fatigue.5 In addition, the benefits of exercise for those with SpA include improved mobility and range of motion, better posture, higher quality sleep, reduced stiffness, enhanced muscle strength, and greater lung capacity.
Studies overwhelmingly show that regular physical activity promotes better functioning in SpA. Stretching, strengthening, cardiovascular, and balance exercises are key components in an effective movement program for SpA.6 Yoga, pilates, and Tai Chi, modified to suit individual mobility levels, are good options that cover many different categories of exercise. No matter what kind of exercise you do, consistency is key. Find something you enjoy doing, start slowly, and stick to a routine.
Talk to your doctor before starting a new exercise regimen—and if a particular exercise hurts, stop doing it. Physical therapists can help tailor an exercise routine to your abilities and needs. In patients who have a lot of pain, I encourage gentle exercises like Tai Chi and aquatherapy (physical therapy in a pool).
Since SpA may affect the ribcage over time, which can cause decreased mobility in the chest, I am a huge advocate for daily use of an incentive spirometer, a device that encourages you to breathe more deeply (you can find one on Amazon). Lung capacity has a direct impact on overall wellbeing and longevity.
You may experience the most pain and stiffness after a long stretch of inactivity (such as in the morning upon awakening, or after sitting for a long while). So here’s an actionable and easy tip you can follow during the day: Get up every hour at the 55-minute mark and take a five-minute break to walk and stretch. This is especially helpful if your job consists of sitting at a desk for eight hours a day.
Sleep is a vital component of maintaining a healthy immune system. Research has shown that sleep affects a wide variety of immune functions, including the numbers of specific leukocyte subsets in circulating blood, the cell-specific production of cytokines, and other immune cell processes.7 We also know that sleep deprivation drives inflammatory processes, as opposed to healthy sleep, which helps the body repair itself.8
Unfortunately, sleep is often disrupted for those with SpA. A number of studies have demonstrated poorer sleep quality in SpA patients. One such study found significant differences between SpA patients and the general population in terms of subjective sleep quality, sleep duration, sleep disturbances, and other factors. Those with more severe disease activity naturally experienced lower quality sleep.9
The basic rules of proper sleep hygiene are as follows:
- Aim for at least seven to nine hours of sleep nightly.
- Go to bed at the same time each night.
- Following a sleep routine helps to prepare the brain and body for bed (similar to how we prepare babies for bed).
- Use your bed for sleeping and sex only; avoid eating, phone or laptop use, and watching TV in bed.
- Avoid artificial lights emitted from cell phones, tablets, computers, or TV for at least two hours prior to bed (or use blue light-blocking glasses).
- Keep your bedroom cool and dark.
- Avoid caffeine after 2 p.m.
Stressors are all around us on a daily basis. It is inevitable that we experience some amount of stress. While acute, short-term stress is not particularly worrisome, chronic, long-term stress can wreak havoc on our health and immune system. It is well-documented that stress increases pro-inflammatory cytokines in our bodies, promoting systemic inflammation.
With that said, it is possible to mitigate life’s stressors by practicing stress management and reduction techniques. There are many options available nowadays and I hope you will find a stress management practice that speaks to you. Here are a few examples:
- Gratitude journaling: Every morning or evening, spend five minutes jotting down a few things you are grateful for.
- Grounding: This is a practice in which you directly interface with the earth. You can do this by simply stepping barefoot onto the grass for a few minutes each day. Grounding has been shown to reduce pain and also affects various cytokines related to inflammation.10
- Mindfulness (or any type of meditation): There are countless resources and apps available to guide you in meditation. I personally love the Insight Timer app.
- Yoga: This ancient practice can serve as both exercise and a stress relief technique.
- Therapy: Talk therapy with a mental health professional can be very beneficial.
- Social Support: Find a trusted companion with whom you can share your worries, thoughts, and fears. [Join an SAA support group to connect with peers going through some of the same things you are. To learn more, visit spondylitis.org/groups.]
- Acupuncture: This Chinese medicine modality has been around for hundreds of years and may have countless benefits. In one study of women with anxiety, acupuncture significantly augmented immune functioning, beginning 72 hours after a single session and persisting for one month after the end of treatment.11
- Body work: Massage, myofascial release techniques, and osteopathic manipulative medicine may also relieve stress.
Avoidance of Environmental Toxins
While this topic could be an entire article on its own, here I’ll note just a few key points I tell my patients:
- Avoid smoking/tobacco use. Smoking produces a range of harmful health effects. If you are currently a smoker, speak with your physician about your desire to quit. Together you can set a plan that will increase your chances of success.
- Try to eat organic foods, to avoid pesticide residues. The Environmental Working Group (EWG) has a list of foods that we should eat organic (“Dirty Dozen”) and a list of foods that are OK to purchase non-organic (“Clean Fifteen”).
- Filter your water rather than drinking tap water straight from the faucet.
- Consider avoiding plastic containers for food or water in general, and especially when microwaving/reheating foods, as chemicals like BPA and phthalates can leach into your food.
- If you’d like to read more on this topic, check out the work of Aly Cohen, MD, FACR, a fellow integrative rheumatologist who focuses on environmental medicine.
I hope I’ve given you the encouragement to realize there are countless ways you can modify your lifestyle to optimize your pillars of immune wellness.