This is the lay version of the 2021 EULAR recommendations for lifestyle behaviours and work participation to prevent progression of rheumatic and musculoskeletal diseases. The original publication can be downloaded from the EULAR website: www.eular.org.
Gwinnutt JM, et al. 2021 EULAR recommendations regarding lifestyle behaviours and work participation to
prevent progression of rheumatic and musculoskeletal diseases. Annals of the Rheumatic Diseases
Published Online First: 08 March 2022. doi: 10.1136/annrheumdis-2021-222020
EULAR provides advice to health professionals and patients about the best way to treat and manage
rheumatic and musculoskeletal diseases (RMDs). Doctors, other health professionals, and patients, worked together to develop these recommendations on lifestyle and work in people with RMDs. Patients in the team ensured that patients’ points of view were included.
What do we already know?
RMDs affect a lot of people, causing disability and reducing quality of life. There are pharmacological
treatments for some RMDs such as rheumatoid arthritis and gout. These treatments can reduce disease
activity and prevent disability, but for many people there is still room for improvement. Furthermore, some RMDs such as osteoarthritis do not have effective pharmacological treatment options. People, therefore, often look for ways to make lifestyle changes that might further help ease the symptoms or severity of their RMD.
All adults should aim for a healthy, balanced diet containing fruits, vegetables, nuts, and whole grains – and with limited amounts of sugar, fat, and salt. We also know that physical activity is fundamental to good health, and that obesity, smoking, and drinking too much alcohol can have negative health consequences. These are clear messages for the general population, but for people with RMDs these aspects of health have not yet been prioritized in strategies to promote musculoskeletal health.
EULAR set up a taskforce to look at the evidence regarding lifestyle and behaviour modification in seven common inflammatory and non-inflammatory RMDs: osteoarthritis, rheumatoid arthritis, axial
spondyloarthritis, psoriatic arthritis, systemic lupus erythematosus, systemic sclerosis, and gout.
What do the recommendations say?
In total, there are five overarching principles and 18 recommendations across six key categories of exercise, diet, weight, alcohol, smoking, and work participation. The principles define the importance of a healthy lifestyle, how lifestyle modifications should be implemented, and their role in relation to medical treatments.
Each recommendation is based on the best current knowledge from scientific studies and/or expert opinion. The more stars a recommendation has, the stronger the evidence is. However, recommendations with limited scientific evidence may still be important, because experts can have a strong opinion even when published evidence may be lacking.
One star (*) means it is a recommendation with limited scientific evidence.
Two stars (**) means it is a recommendation with some scientific evidence.
Three stars (***) means it is a recommendation with quite a lot of scientific evidence.
Four stars (****) means it is a recommendation supported with a lot of scientific evidence.
- Exercise is good for health outcomes, and may help reduce your RMD symptoms and
Exercise can help improve a lot of general health outcomes. If you have an RMD, your health team
should work with you to find a type of activity that is appropriate for your ability and condition.
- People with RMDs should exercise because of the benefits on pain, function, and
quality of life.****
The benefits of exercise have been shown for RMD-specific outcomes, such as pain and disability. In
general, appropriate exercise can help improve pain, function, fatigue, and health-related quality of life in people with RMDs. The evidence is stronger for short-term benefits over 6–12 months compared with long-term benefits, although long-term benefits have been shown for the general population across a range of health outcomes.
- If you have an RMD, you should avoid physical inactivity; take regular exercise according to your abilities.*
Sedentary behaviour is associated with many negative health outcomes in the general population.
These negative outcomes will also affect people with RMDs. If you have an RMD, your health care team should encourage you to avoid prolonged periods of physical inactivity.
- People with RMDs should perform both aerobic and strengthening exercises – aim for at least moderate intensity.****
There is evidence to suggest that both aerobic and strengthening exercises are beneficial for people
with RMDs, so you should include both when exercising. Aerobic exercise is also called “cardio” –
activities that increase your breathing and heart rate. People with RMDs should aim for moderate
intensity aerobic exercise (64–76% of your maximal heart rate) for at least 150 minutes every week, and strengthening exercises such as weights or resistance training twice a week.
- People with RMDs should be advised that exercise is safe and that it is never too late to start.****
Very few people have adverse events related to exercise. If you have an RMD, exercise is a safe way to improve your health condition, and it is never too late to take up exercise – even if you were not very physically active before your RMD started.
- Exercise can be performed in different settings, alone or in groups.****
There are a lot of different exercise types, and you should choose the one that suits you best. There is some evidence that group exercise might be slightly better than exercising on your own, and you might benefit from the supervision and social aspect of a class – but if you prefer to work on your own this should not discourage you.
- If you have osteoarthritis or axial spondyloarthritis, exercise is particularly beneficial.****
Studies in people with osteoarthritis or axial spondyloarthritis showed that exercise can have a strong and consistent effect on reducing pain and improving function.
- Consuming more or less of specific food types is unlikely to have large benefits for RMD outcomes.****
Some small studies have suggested that certain food components should be increased or avoided in people with certain RMDs. However, the evidence is very limited, and at present EULAR believe it is unlikely that eating specific food types will have large effects on RMD-specific outcomes. The only exception is that people with gout may benefit from avoiding sugar-sweetened drinks, heavy meals, and excessive amounts of meat and seafood.
- People with RMDs should aim for a healthy weight.*
In adults, a body mass index (BMI) of 25 or more is considered overweight, and 30 or more is classed
as obese. However, what is a “healthy weight” varies from person to person. Your goal should be based on your age and sex, as well as your underlying disease and health state. If you lose or gain weight, this can have an effect on some medications, so you should talk to the health professionals involved in your care if you are concerned about your weight.
- If you are overweight or obese, work with your health professionals to achieve controlled and
intentional weight loss through healthy diet and increased physical activity.***
If you have a BMI of 25 or more, achieving controlled weight loss could be beneficial for some RMD
outcomes. Talk to the health professionals involved in your care to learn about achieving healthy weight loss through diet and exercise.
- Your health team may want to discuss alcohol consumption with you, particularly if you are
starting a new treatment.*
There are negative health consequences of drinking too much alcohol. Health professionals may raise this with you to ensure you know what the healthy limits are – as well as to ensure you know if you cannot drink on a particular medication.
- If you have an RMD, a low level of alcohol consumption is unlikely to negatively impact your
RMD outcomes, except in certain situations.***
In general, alcohol is fine in moderation. The exception would be if you have liver disease, or if you are prescribed certain medications – for example, methotrexate or leflunomide.
- Health professionals and people with rheumatoid arthritis should be aware that moderate
alcohol consumption is associated with increased risk of flare and comorbidities.***
If you have rheumatoid arthritis, even moderate alcohol consumption can increase your risk of having a disease flare or developing other linked diseases (comorbidities). Your health care team may raise this with you to ensure you know what the healthy limits are for you – as well as to ensure you know if you cannot drink on a particular medication.
- Health professionals and people with gout should be aware that moderate alcohol consumption is associated with increased risk of gout flare.***
If you have gout, any alcohol consumption can increase your risk of having a flare. Your health care
team may raise this with you to ensure you know the risks.
- People with RMDs should be encouraged to stop smoking and be informed that smoking is
detrimental to symptoms, function, disease activity, disease progression and occurrence of
comorbidities in all RMDs.***
It is well known that smoking is bad for you. In addition to the risks for people in the general population, if you have an RMD smoking can also have a negative impact on your disease, and may worsen your symptoms. If you are interested in quitting, you should talk to your health professional to see what support and resources might be available to you.
- Smoking may affect how well your RMD medicines work.***
The response to some RMD medications can be less in people who smoke. If you are interested in
quitting, you should talk to your health professional to see what support and resources might be
available to you.
- Work participation may be beneficial for people with RMDs; this should be addressed in health
If you are able to stay in work, you may find it has a positive effect, particularly on your mental health.
What type of work you are able to do will depend on your individual circumstances, and some people
may find that physically demanding jobs worsen their RMD symptoms. Advice and support around your work participation should be given by your health care team.
Overall, these recommendations cover a range of important, modifiable lifestyle behaviours. In general, the World Health Organization recommendations for a healthy lifestyle are also applicable to people with RMDs, although recommendations for each individual with an RMD depend on factors such as age, gender, health condition, pregnancy and possible other linked health conditions. EULAR hopes these new
recommendations will be used to guide shared decision-making between people with RMDs and health
professionals when formulating and monitoring treatment plans. There should be regular discussions
between people with RMDs and health professionals regarding lifestyle behaviours and work participation..
If you have any questions or concerns about your disease or your medication, you should speak to a health professional involved in your care.
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