Rheumatoid arthritis and lifestyle

Source: Jeleefstijlalsmedicijn

Rheumatoid arthritis (RA) affects thousands of Dutch people annually and has a major impact on daily life through pain, stiffness, and fatigue. Treatment with rheumatoid medications is often effective in reducing inflammation, but does not always provide complete relief — only 10-20 percent of patients achieve sustained remission where medication can be completely discontinued. Many patients therefore continue to have complaints even when joint inflammation is quiet with medication. However, there is hope. Recent scientific research shows that lifestyle factors not only influence the risk of developing RA, but can also reduce symptoms and thus are a welcome addition to current pharmaceutical treatment. From nutrition and exercise to stress management and sleep — the right lifestyle choices can make a major contribution to the course of the disease.

Author: Jaap Versfelt

Medical-scientific reviewer: dr. Pascal de Jong, rheumatologist Erasmus MC

Key points from this article (16 minutes reading time)

Prevalence Rheumatoid arthritis (RA) affects 277,000 Dutch people, occurs more often in women, and has increased worldwide by 14 percent since 1990.
Causes RA develops through a combination of genetic predisposition (2-5x higher risk in first-degree relatives), immune system disturbances, and lifestyle factors.
Treatment limitations Medication is effective against inflammation but offers no cure; only 10-20 percent achieve sustained remission and many patients continue to have complaints despite medication.
Overweight Being overweight increases the risk of RA by 25 percent, reduces the effectiveness of medications, and makes remission harder to achieve.
Nutrition Healthy nutrition lowers the risk of RA by 40 percent. Omega-3 supplements have proven effects for symptom relief. The Mediterranean diet is promising and for the vegan diet, results are contradictory.
Exercise Regular physical exercise lowers risk of RA by 35 percent and for existing RA counteracts pain, fatigue, and mobility limitations.
Sunlight Little sun exposure increases risk of RA by 27 percent, presumably due to insufficient vitamin D production, but supplements show no proven effect on disease activity.
Sleep Disturbed sleep increases the risk of RA by 33-38 percent and creates a vicious cycle with pain. Improving sleep quality can relieve symptoms.
Stress Chronic stress significantly increases the risk of RA (76 percent with PTSD symptoms). Psychological interventions show a moderate to strong positive effect on pain and fatigue.
Smoking Smoking increases the risk of RA by 40 percent and explains 20-25 percent of all cases. Quitting reduces disease activity and improves medication effectiveness.
Alcohol Alcohol use has a complex relationship with RA. Moderate use reduces the risk by 14 percent, while excessive use can worsen symptoms, especially with certain medication.
Lifestyle programs The Dutch studies Leef! met Reuma and Plants for Joints show that combined lifestyle interventions lead to long-term improvements regarding pain, stiffness, and disease activity.
Effectiveness A combined approach focusing on weight, nutrition, exercise, stress, sleep, and smoking offers people with RA the opportunity to influence their disease course themselves alongside medication.

1. What is inflammatory rheumatism and how often does it occur?

In rheumatoid arthritis (RA), joint inflammation develops. It is an autoimmune disease, where the immune system turns against the body. RA usually begins in the joints of hands and feet, which become painful, swollen, and stiff. Without treatment, inflammation can lead to permanent joint damage and deformities (ReumaNederland).

RA can begin insidiously or arise suddenly. It is a chronic condition with a variable course: periods when someone has (a lot of) joint inflammation alternate with periods when there is little or no inflammation. The disease can occur at all ages, but the first symptoms usually appear at middle age (50 to 60 years). Women are affected two to three times more often than men (FMS).

Rheumatoid arthritis unfortunately occurs frequently: in 2023, there were 277,000 people with this condition in the Netherlands (Vzinfo). Worldwide, the number of people with RA is increasing (14 percent rise since 1990) and the expectation is that it will further increase (GBD 2021). ** **

2. Causes of rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune disease where the immune system accidentally attacks its own body, particularly the joints. The exact cause of RA is not yet fully known, but research shows that it is an interplay of genetic predisposition, lifestyle, and immune system disturbances.

Genetic factors People with certain genetic variants (especially the HLA-DRB1 gene) have an increased chance of RA. However, heredity plays only a small role. If the disease occurs in a family (father, mother, brother, or sister), the chance is 2 to 5 times greater that another family member will also get it (Romao, 2021), nevertheless even then the chance remains small that you get RA: 2 to 3 per thousand people (normal is 0.5 to 0.8).
Immune system disturbances In RA, the immune system becomes dysregulated and the body attacks its own joint tissue. The formation of antibodies plays an important role in this. The antibodies can often already be present in the blood years before the first symptoms.
Lifestyle In RA, lifestyle plays a major role. Overweight, an unhealthy diet, little exercise, little sunlight, disturbed sleep, stress, smoking, and excessive alcohol use are all risk factors for getting RA. More on this in paragraph 4.

3. Limitations of pharmaceutical treatments

The treatment of RA consists mainly of medication that suppresses inflammation, such as DMARDs (e.g., methotrexate, sulfasalazine) and biological agents. The pharmaceutical therapies are effective in slowing the disease, but often do not cure it. Many patients continue to have complaints.

3.1 Only 10-20 percent of patients can be cured

RA often returns as soon as medication is stopped. Only a small part of patients (about 10 to 20 percent) achieves sustained remission where all medication can be stopped. In other words, for 80 to 90 percent of people, continuous treatment is needed to keep the disease under control (Verstappen, 2020).

3.2 Many patients continue to have complaints

The therapeutic options for treating RA have expanded greatly in recent years, with the result that we can bring the disease under control much better. Despite not all patients responding equally well to the various rheumatoid suppressants, generally all joint inflammation can be treated away in virtually every RA patient. Yet many patients continue to have complaints even when there is no joint inflammation, which manifests in persistent pain, stiffness, and fatigue.

4. Lifestyle and rheumatoid arthritis

Lifestyle plays a major role in RA. An unhealthy lifestyle increases the chance of getting the condition. Additionally, changing lifestyle can help treatment and improve symptoms. We go through all known factors one by one and look at two things:

How does the lifestyle factor increase the chance of getting RA?
Does changing lifestyle help with treatment?

For the second part (treatment), we summarize the recommendations from a European task force (Eular) that listed all research on this (Gwinnutt, 2023).

4.1 Overweight — 25 percent higher risk

Chance of RA People who are overweight or obese have a 25 percent increased risk of rheumatoid arthritis (Qin, 2015). The higher the BMI (weight relative to height), and the longer someone is overweight, the greater the risk (Lu, 2014).

Treatment For people with RA, it is important to pursue a healthy weight. Overweight has a negative influence on rheumatic symptoms such as pain, inflammation, and fatigue. Research shows that weight loss can significantly reduce symptoms. Additionally, people who are overweight respond less well to certain rheumatic medications (Klaasen, 2011, Singh, 2018) and achieve sustained remission less often (Schulman, 2018).

4.2 Unhealthy nutrition — 67 percent higher risk

Chance of RA Healthy eating plays a major role in preventing rheumatism. People who eat healthy long-term, especially with fewer sugary soft drinks, less salt and less sugar, and more healthy fats such as omega-3 fatty acids (from, for example, fatty fish), have up to 40 percent less chance of getting RA. Also eating lots of vegetables, fruit, and fiber can reduce the risk of rheumatism (Romao, 2021).

Treatment The strongest evidence exists for the use of omega-3 fish oil (in high doses). The Mediterranean diet is also promising, especially as a supplement to regular treatment. For a vegan diet, results are still contradictory. Other diets and interventions such as fasting or elimination diets give variable or temporary effects, with less solid evidence (Philippou, 2021).

Nutritional intervention	Effect	Description of effect	Evidence strength
Omega-3 fish oil	Positive	Reduction in pain, morning stiffness, tender joints, physical limitations, and swelling. ESR decreased.	High; 20 RCTs, 1,288 participants (Gioxari, 2018)
Mediterranean diet	Positive	Improvements in pain, physical function, and morning stiffness.	Moderate; 2 studies, 186 participants (Hagen, 2009)
Fasting	Positive	Improvement in pain, morning stiffness, and number of painful joints.	Moderate; 2 studies, 79 participants (Hagen, 2009)
Vegan diet	Contradictory	Diet only: no effect. With lifestyle intervention: decrease in disease activity.	Moderate; 3 studies, 192 participants (Hagen, 2009, Walrabenstein, 2023)

Table 1 - overview effect of nutritional interventions

None of the studies examined the effect of a ketogenic diet, despite the known anti-inflammatory effects. Fasting has similar effects as a ketogenic diet because it creates a state of ketosis in the body (Su, 2013).

4.3 Insufficient exercise — 54 percent higher risk

Chance of RA A large study shows that people who exercise regularly (at least 20 minutes per day of walking or cycling and at least 1 hour per week of more intensive activity) have 35 percent less chance of getting RA. Active household work also appears to work positively. Conversely, physical inactivity increases the risk (Giuseppe, 2015).

Treatment Regular physical exercise reduces rheumatic complaints such as pain, fatigue, and mobility limitations. Both conditioning activities (such as walking or cycling) and muscle-strengthening exercises (strength training) are useful. The recommendation is to, according to one’s own ability, walk or cycle at least 150 minutes per week and do muscle-strengthening exercises twice a week (Metsios, 2015). Moreover, it has been proven that exercise is safe, also with rheumatism, and it is never too late to start.

4.4 Little sunlight — 27 percent higher risk

Chance of RA People who are more often in the sun have a lower risk of developing rheumatoid arthritis, probably due to exposure to UV-B radiation from sunlight (Arkema, 2012). This is presumably because sunlight ensures the production of vitamin D through the skin.

Treatment Lower vitamin D values are associated with higher disease activity (such as pain, inflammation, and elevated inflammation values such as CRP and ESR). Although these findings point to a possible beneficial effect of vitamin D, there is no evidence for disease reduction from taking vitamin D supplements.

4.5 Disturbed sleep — 33 to 38 percent higher risk

Chance of RA Chronic poor sleep quality increases the risk of RA. In a recent study, a U-shaped relationship was found between sleep duration and RA: both people with very short night rest and with extremely long sleep times had a greater chance of getting RA (Liu, 2024).

Treatment Disturbed sleep is common in people with RA and is strongly associated with pain and functional limitations. In a study, people with more pain more often reported a non-optimal sleep duration (Grabovac 2018). Pain contributes to poor sleep, and in turn that lack of sleep contributes to pain, fatigue, and limitations. Non-pharmaceutical treatments such as relaxation, sleep restriction, and meditation demonstrably improve sleep quality (Tang, 2015), and therefore deserve attention within RA treatment.

4.6 Stress — strong effect

Risk of RA Chronic stress and negative emotions are common in people with RA and can intensify their complaints such as pain, fatigue, and mobility limitations. Stress-related problems include anxiety, depressive feelings, gloominess, and a sense of helplessness (Nagy, 2023). A large study showed that women with PTSD (post-traumatic stress disorder) symptoms have 76 percent higher risk of developing RA (Lee, 2017).

Treatment It has been demonstrated that psychological interventions such as stress management, cognitive behavioral therapy (CBT), mindfulness, and group therapy can reduce complaints and improve quality of life. A recent overview of all available research concludes that such interventions have a moderate to strong positive effect on pain, fatigue, stress complaints, and general well-being in people with RA (Nagy, 2023).

4.7 Smoking — 40 percent higher risk

Chance of RA Smoking is one of the most important risk factors for RA and explains about 20 to 25 percent of all cases. In people who have ever smoked, the risk is about 40 percent higher, and in heavy smokers even higher. Quitting smoking lowers the risk again gradually; after 20 to 30 years of not smoking, the risk is again comparable to that of people who never smoked. Even passive smoking (secondhand smoke) increases the chance of RA, so smoke-free environments are also important (Romao, 2021).

Treatment People with rheumatism who quit smoking often experience less disease activity, better medication effectiveness (Saevarsdottir, 2011), and fewer associated health problems.

4.8 Excessive alcohol use — unclear effect

Chance of RA Alcohol has a complex relationship with RA. Regular but moderate alcohol consumption seems to slightly reduce the risk of RA (14 percent with one glass of beer or wine per day), while excessive use or complete avoidance of alcohol are associated with a greater risk (Romao, 2021).** **

Treatment Although moderate alcohol use for some people has no direct negative influence, regular or heavy alcohol use in people with RA can lead to more complaints, such as inflammation and pain. Especially with certain medication (such as methotrexate) or with associated conditions (such as liver problems or gout), the risk of complaints increases. \

5. Combined lifestyle interventions

In the previous paragraphs, we looked at individual lifestyle factors such as nutrition, exercise, sleep, stress, and smoking. But what happens when you combine these factors? Two Dutch studies — Leef! met Reuma and Plants for Joints — did that. What did such a combined lifestyle intervention yield? And how strong is the evidence?

5.1 Leef! met Reuma

In 2021, the lifestyle program Leef! met Reuma started, developed by Voeding Leeft and researched by Erasmus MC. The program focused on people with, among others, rheumatoid arthritis (88 participants) and included interventions in the areas of nutrition, exercise, relaxation, and sleep. The diet consisted of a Mediterranean diet, with lots of unprocessed food (Slingerland, 2024).

The program consisted of an intensive part of 3 months, followed by an aftercare period of 21 months. The lifestyle program focused on four pillars: nutrition, exercise, relaxation, and sleep. The prescribed diet was comparable to the Mediterranean diet, with emphasis on unprocessed foods (especially vegetables).
The results showed that participants with RA reported less morning stiffness and sleep problems after three months, and also showed weight loss. These positive effects persisted until the end of the follow-up (24 months), with improvements remaining in pain, morning stiffness, and sleep quality. Of these improvements, the improvement for morning stiffness exceeded the so-called MCID: the threshold for a clinically relevant improvement.

What makes this study extra interesting is that the measured improvement was still there after two years, while the participants only received three months of guidance. The program thus seems to bring about a long-term behavioral change.

However, there are also some caveats: (1) the study had no control group, which makes the evidence somewhat less strong, and (2) it did not contain a disease activity measure (such as DAS28).

5.2. Plants for joints

The Plants for Joints (PFJ) program studied a combined lifestyle intervention. The study was a randomized controlled trial (RCT) with a control group, and also looked at disease activity.

The intervention included a four-month program with group meetings and guidance in the areas of a wholesome plant-based diet, exercise, stress management, and sleep (Walrabenstein, 2023, Wagenaar, 2024).

In people with RA, the intervention led to a clinically relevant decrease in disease activity (DAS28 -0.9 compared to the control group), which was maintained one year after the intervention ended. Moreover, participants saw improvements in inflammation values.

A caveat to this study is that the decrease in disease activity (DAS28) mainly consisted of subjective improvements such as less pain and better perceived health, while the objective components — particularly the number of swollen joints and inflammation values — improved less strongly or not significantly.

6. Conclusions

Although medication remains essential in the treatment of rheumatoid arthritis, research shows that lifestyle factors play a crucial role — both in the development and in the course of the disease.

The research on lifestyle in RA shows that adopting a healthier lifestyle is effective. Programs such as Plants for Joints and Leef! met Reuma show that an approach with attention to nutrition, exercise, stress management, and sleep can lead to clinically relevant improvements in disease activity, inflammation values, and experienced symptoms.

Specifically, the following appears to help:

Pursuing a healthy weight
Using healthy nutrition (rich in omega-3, vegetables, fruit, and fiber)
Exercising regularly (150 minutes per week moderate exertion plus twice weekly strength training)
Stress reduction through relaxation techniques
Good sleep hygiene
Quitting smoking.

For people with RA, this offers perspective: alongside medication, they have influence on the disease course themselves. Through conscious lifestyle choices, they can reduce their complaints, improve their overall health, and possibly even increase the effectiveness of medication.

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Veelgestelde vragen

How can I adjust my lifestyle to improve rheumatoid arthritis?

A healthy lifestyle can reduce RA symptoms by focusing on: healthy weight, healthy nutrition, regular exercise, stress reduction, good sleep, and quitting smoking. Dutch lifestyle programs such as *Leef! met Reuma* and *Plants for Joints* show that this approach is effective in reducing pain, stiffness, and disease activity.

Which nutrition is good for rheumatoid arthritis?

For RA, a dietary pattern rich in omega-3 fatty acids (such as in fatty fish), vegetables, fruit, and fiber is most effective. Omega-3 supplements have the strongest evidence for reducing pain, morning stiffness, and inflammation. The Mediterranean diet also shows positive results. Fasting can temporarily improve symptoms, while for a vegan diet, results are contradictory.

Can rheumatoid arthritis be completely cured?

Complete cure is rare; only 10-20 percent of patients achieve sustained remission where all medication can be stopped. For 80-90 percent of people, continuous treatment remains necessary. However, lifestyle adjustments alongside medication can significantly reduce symptoms, even when joint inflammation is under control.

Does exercise help reduce rheumatoid arthritis pain?

Yes, regular exercise is proven effective in reducing pain, fatigue, and mobility limitations in rheumatoid arthritis. The recommendation is at least 150 minutes per week of walking or cycling, plus twice weekly muscle-strengthening exercises. Exercise is safe with rheumatoid arthritis and it is never too late to start. People who exercise regularly also have 35 percent less chance of developing RA.

What is the influence of stress on rheumatoid arthritis?

Stress has a strongly negative effect on rheumatoid arthritis. Chronic stress and negative emotions can intensify symptoms such as pain, fatigue, and mobility limitations. People with PTSD symptoms even have 76 percent higher risk of developing RA. Psychological interventions such as stress management, cognitive behavioral therapy, mindfulness, and group therapy can effectively reduce pain, fatigue, and stress and improve general well-being.

What is the effect of quitting smoking on rheumatoid arthritis?

Smoking is an important risk factor for RA and explains 20-25 percent of all cases. Quitting smoking reduces disease activity, improves medication effectiveness, and reduces associated health problems. The risk of RA decreases gradually after quitting; after 20-30 years of not smoking, the risk is again comparable to that of people who never smoked.

Does losing weight help with rheumatoid arthritis?

Yes, weight loss can significantly reduce symptoms such as pain, inflammation, and fatigue. People who are overweight or obese have a 25 percent increased risk of RA and respond less well to medications. They also achieve sustained remission less often. Pursuing a healthy weight is therefore an important part of treatment.

Is a Mediterranean diet good for rheumatoid arthritis?

The Mediterranean diet shows promising results for RA, especially as a supplement to regular treatment. Research points to improvements in pain, physical function, and morning stiffness. Dutch lifestyle programs such as *Leef! met Reuma* that prescribe a Mediterranean diet with emphasis on unprocessed foods (especially vegetables), show long-term positive effects on pain and stiffness.

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