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Guide to living with rheumatoid arthritis: Part 2

August 2, 2017
People that suffer from rheumatoid arthritis need to exercise on a daily basis, eat healthy, and find ways to reduce stress in their lives

If you missed Part 1 of Guide to living with rheumatoid arthritis please follow the link.  In part 1 we covered the basics: what is rheumatoid arthritis, the cause, symptoms, diagnosis, and treatment.  In part 2, I’ll be covering how rheumatoid arthritis (RA) can affect your day-to-day living, habits that worsen RA, exercise, food, and stress reduction techniques.  Without further adieu, here is Part 2 of the Guide to living with rheumatoid arthritis.  I hope you enjoy!

How will rheumatoid arthritis affect my life?

Rheumatoid arthritis changes your life. Depression, anxiety, feeling overwhelmed, these are all emotions that are perfectly natural when you get diagnosed with rheumatoid arthritis or any chronic illness. These should improve with time as you learn more about the illness and with the help of family and friends.

The Arthritis Foundation is a national non-profit organization who’s mission is to help, “conquer everyday battles through life-changing information and resources, access to optimal care, advancements in science and community connections. Our goal is to chart a winning course, guiding families in developing personalized plans for living a full life – and making each day another stride towards a cure. We also publish Arthritis Today, the award-winning magazine that reaches 4.2 million readers”.

They definitely are a good group to check out and they have chapters across the country.

The physical aspect

Other than, psychological and emotional impact of the illness, there is also the physical part. There will be good days and bad days. It’s very important to work closely with your rheumatologist when you suffer from RA. It is of utmost importance to go into remission as quickly and safely as possible. There are many medications used to treat RA. Some may work for you and some may not. By working together, you can help your rheumatologist tailor the best possible treatment plan for you.

The goal is to get you back doing what you used to do with the least amount of limitations as possible.

Be aware, even in the best of situations, expect flares. Stress, infections, the weather, and hormonal changes can precipitate a flare. Another goal is to make flares a rare event. Not the norm.

The financial aspect

Finally, although no one likes to talk about it, another important impact that rheumatoid arthritis has on your life is its impact on your wallet. Rheumatoid arthritis is expensive.  Frequent doctor’s appointments. Not only do you need to see your rheumatologist on a regular basis, but you may also need to see other specialists such as an ophthalmologist, nephrologist, pulmonologist, etc. So many co-pays.

Medication costs can get very expensive. Even with health insurance the out-of-pocket costs can be enormous. In my clinic, this is a daily problem. In fact, I’m lucky to work in a practice that has a dedicated patient advocate that helps my patients find solutions to get access to care without breaking the bank. I call her my “health insurance whisperer”.  She kindly agreed to impart some of her knowledge in Part 3 of Guide to Living with Rheumatoid Arthritis.  It’s going to be a real treat!

Other costs

These medications tend to have a long list of potential side effects. These require routine bloodwork. Yet another co-pay.

Lost work days. The less you work, the less you make.

Time. One of the most, and arguably THE most important financial costs.

I do realize that I seem to be painting a very bleak picture, but I want to make it very clear that YOU are in control. Your experience with RA will depend on how much you let it affect you. It will change you for sure but not conquer you.

Will I be able to work?  How do I tell my boss?

I won’t lie.  Rheumatoid arthritis can lead to work disability, abseeteeism, and presenteeism (at-work productivity loss) at a high cost to you but also to your employer.  You’ve had the conversation with your family and friends but now it’s time to tell your boss.

First, you’re not legally required to disclose your RA to your employer.  However, as an employer myself, I would appreciate it if my employee would disclose this information.  What if your job requires heavy lifting or standing around for a very long time?  Maybe I can help you and re-arrange your work duties to better accommodate you?  Maybe you need a better chair or a better mouse?  Every situation is different.  Not everyone with RA has horrible disease but on the flip side not everyone’s employer is accommodating.

There’s also the situation with doctor’s appointments.  Most people with RA see their rheumatologist every 3 to 6 months for regular checkups.  Some people may need medications that only come as infusions.  These infusions are given in clinic and last between 1.5 hours to half a day.  That’s more time off work.

By informing your employer, you are entitled to certain legal rights, as outlined in the Americans with Disabilities Act and the Family and Medical Leave Act.  For more information, please click on the following link[1].

Ultimately, the choice to tell your boss or not is yours.  You are in control.

What habits worsen rheumatoid arthritis?


At this point, I hope everyone understands that smoking is a terrible habit associated with a multitude of negative health outcomes.  But did you know that smoking can also predispose people to develop antibody positive rheumatoid arthritis (seropositive)?

Costenbader et al. prospectively studied 103 818 women from 1976 to 2002.  Of those women 680 developed rheumatoid arthritis.  The researchers found that both past and current cigarette smoking was associated with a 40% increased risk of developing seropositive rheumatoid arthritis.  Here are some of the other findings:

  • Increasing duration and intensity of cigarette smoking increases the risk of RA.
  • Greater than 10 pack years of smoking increases the risk of RA in a dose-dependent way.
  • It takes about 20 years of smoking cessation for the risk to return to the “never smoker” category.[2]

What if you already have rheumatoid arthritis?

Does smoking have any impact on active rheumatoid arthritis?  Anecdotally, it’s a lot more difficult to control rheumatoid arthritis when someone smokes cigarettes.  We end up having to cycle through more medications and use more medications at high doses.  However, when you think about it, it makes logical sense.

The current paradigm of RA pathogenesis is that people with certain genetic risk factors first are exposed to environmental triggers that cause local inflammation.  These people then produce autoantibodies and with time some of these people go on to develop full-blown rheumatoid arthritis.  Cigarette smoking is thought to be one of these triggers by causing local inflammation in the lungs[3].

If someone already has RA and continues smoking, well that’s like trying to put out a fire with gasoline.  You’re trying to put out the fire with DMARDs but you’re also adding to the fire by smoking cigarettes.

Another great reason to stop smoking when diagnosed with RA, is the fact that rheumatoid arthritis is well-known to increase the risk of cardiovascular disease.[4]  Other traditional cardiovascular risk factors include high blood pressure, high cholesterol, diabetes, obesity, and physical inactivity. This brings me to my next point, “not moving”.

Not moving

Sedentary behavior is defined as any waking behavior characterized by an energy expenditure of ≤ 1.5 METs and a sitting or reclining posture.  It is associated with poor health outcomes in rheumatoid arthritis.  Although adopting a sedentary lifestyle won’t necessarily directly cause increased disease activity, this lifestyle can worsen muscle density, functional disability, bone mass, and cardiovascular risk.[5]

Everyone knows that life can get really busy sometimes, and going out to the gym sometimes is the last thing on your “to-do” list.  Believe me, I don’t have a gym membership because getting into my car, driving to the gym, changing into workout gear, hopping on a boring treadmill, changing back into my regular clothing, and driving back home is the last thing I want to do after a long day at work.

But being active doesn’t necessarily mean going to the gym.  A 30 minute walk around your neighborhood 5 days week is enough.  Does walking sound boring?  How about catching up on your reading while strolling about.  Amazon has a ton of audiobooks via Audible.  This is NOT affiliate marketing.  I simply use this service on regularly during my daily walks.  I walk at least 30 minutes a day AND read about a book a week.  Win-win!

Now if you tend to forget to get active and need a little nudge to get you going, check out these free IFTTT recipes I made to help you stay active 30 minutes a day.  You need to have a Fitbit, cell phone, and an IFTTT account (which is free) for it to work.

Periodontal disease

In recent years researchers have found a correlation between rheumatoid arthritis and periodontal disease more specifically Porhyromonas gingivalis.[6] Now the question is whether treatment of periodontal disease have any effect on rheumatoid arthritis?  The answer is yes.  A recent systematic review meta-analysis showed that there was a reduction in DAS 28 (this is a scale that we use to measure RA activity) in patients with rheumatoid arthritis after periodontal treatment.[7]  Interestingly, treatment with DMARDs does not improve periodontal disease in people with rheumatoid arthritis.[8]

To keep up with good oral health, the American Dental Association (ADA) recommends brushing your teeth twice a day for two minutes and flossing once a day.  They also recommend eating a healthy diet, limiting snacks, and of course, regular dental check-ups.[9]

Which exercises are safe with rheumatoid arthritis?

This is a very frequent question.  What exercises are “good” and which exercises are “bad”.  Personally, I don’t think that there are any good or bad exercises for rheumatoid arthritis.  What really matters is whether you are you moving.  You should try being active for about 30 minutes a day.  Choose an activity that you enjoy and stick with it.  If someone tells you swimming is excellent for RA but you really don’t like swimming, chances are you won’t stick with the program.  Be active in a way that brings you joy.  Here are some examples.

  • Walking
  • Swimming
  • Yoga
  • Tai chi
  • Jogging
  • Rowing
  • Etc

Have fun!

What types of food should I eat with rheumatoid arthritis?

This is a very common question yet there is very little quality evidence-based research about this topic. Most studies with robust quality controls focus on cardiovascular disease as opposed to rheumatoid arthritis. There is very little quality evidence to support a specific diet for RA.

What is Epigenetics?

Everyone is born with genes. Some of these genes are active and some remain dormant. Your genotype is the entire makeup of your genes. Your phenotype is the result of how your genetic material is expressed. For example, you may have the genes for blue eyes and brown eyes. If the genetic material for brown eyes is dominant, you’ll have brown eyes.

This is where it gets really interesting. Over the course of your lifetime, some of your genes are turned on and off. This is influenced by factors like aging, the environment, and lifestyle. Epigenetics is the study of how genes are turned on and off based on external influences.

Epigenetic changes can be good but can also cause harm. We think that some of these changes can result in autoimmune diseases. It’s important to remember that epigenetics is in its infancy. Researchers still are not 100% sure how this happens, let alone, how to specifically manipulate the environment to cause favorable epigenetic change.

What types of foods are good for people with rheumatoid arthritis?

First, listen to your body. If you find that your arthritis worsens when you eat nightshades, then stop eating nightshades. Look for patterns.  Journaling is helpful in finding these patterns.

Since there isn’t great data supporting a specific diet for RA, I typically recommend a diet that is good for overall health. For this I recommend adhering to the principles of the Blue Zone Project, more specifically the Power 9. The Blue Zones Project initially began as a research project funded by the National Geographic. They sought to find regions in the world where people tend to live to 100 years of age and be healthy.  They identified 5 zones:

  • Ikaria, Greece
  • Okinawa, Japan
  • Ogliastra region, Sardinia
  • Loma Linda, California
  • Nicoya Peninsula, Costa Rica

All these regions have very different cultures and geography, yet they all live by these 9 common attributes. They called them the Power 9.

Move Naturally

People that live to 100 years don’t necessarily run marathons or go the gym. They are always on the go and they move naturally. For example, they tend a garden, they walk to the market, and they use stairs instead of the elevator.


People that live in the Blue Zones live with purpose. They wake up every morning, and they know “why I wake up in the morning”. Having a clear purpose in life can add an extra 7 years of life expectancy.

Down Shift

We all know that stress can cause inflammation. I often see people in my clinic who’s rheumatoid arthritis was in perfect control until something really bad happened, like a divorce, job loss, or a death in the family. Chronic stress leads to chronic inflammation. People in the Blue Zones develop daily habits to help reduce stress.

80% Rule

The Japanese have a saying “Hara hachi bu”. This is a mantra that Okinawans say before every meal, reminding them to stop eating when they feel about 80% full. There is a delay between feeling full and actually being full. When you feel 80% full, you are actually full. So if you stop eating when you feel full, you are overeating. People living in the Blue Zones tend to eat their largest meal at breakfast and their smallest meal at dinner.

Plant Slant

Although not all regions of the Blue Zones eat meat, their diets all mainly consist of fresh veg and beans. Lot’s of beans: fava, soy, lentils, etc. They eat meat very sparingly and servings are small, “about the size of a deck of cards”.

Wine @ 5

Thank goodness for this one! People in the Blue Zones, except for Adventists, drink alcohol moderately and regularly. Typically, they drink 1-2 glasses of wine per day with friends and family at the end of the work day. They found that people who drink regularly and moderately tend to live longer than those who don’t.


Almost all people who live until 100 tend to belong to some sort of faith-based community. They found that attending a service 4 times a month can add up to 4 – 14 years of life expectancy.

Loved Ones First

People living in Blue Zones tend to live close to their families. It’s common to have children, parents, and grandparents living under the same roof. They also tend to commit to a life partner.

Right Tribe

People in the Blue Zones keep strong social networks. Not only are these social strong, but they also foster healthy behaviors. Women in Okinawa create “moais” early on in life. These are groups of 5 friends that are completely committed to each other for life.

Does stress affect rheumatoid arthritis?

Psychological stress can trigger RA flares.  A recent study looked at 274 people with RA.  They found that the most frequent reasons for joint symptoms were psychological stress/mood disorder (86.1%) followed by infection.[10] Other studies have also shown similar [11] findings and I do regularly see this in clinic.

Techniques to reduce stress

Everyone experiences stress in a different way and everyone has different stress thresholds.  When it comes to the best way to reduce stress in people with rheumatoid arthritis, well the data is very poor.  There are a many studies that look at different methods but they have poor quality standards.

The Mayo clinic has a page on their website dedicated to stress management and techniques[12].  It’s quite good.  Some techniques include:

  • Autogenic relaxation
  • Progressive muscle relaxation
  • Visualization
  • Deep breathing
  • Massage
  • Meditation
  • Tai chi
  • Yoga
  • Biofeedback therapy
  • Music and art therapy
  • Aromatherapy
  • Hydrotherapy

Try a few and see what works for you.  Remember, consistency is key.


Thus concludes Part 2 of a Guide to living with rheumatoid arthritis.  In part 3 I’ll be covering the financial aspect of rheumatoid arthritis with some help from my “health insurance whisperer”.  Since you are reading this article, there’s a good chance you just were diagnosed with rheumatoid arthritis.  Now the question that I know must be on your mind, “How am I going to pay for these expensive medications?”

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.


[1] https://www.dol.gov/general/topic/benefits-leave/fmla

[2] Costenbader KH, Feskanich D, Mandl LA, Karlson EW. Smoking intensity, duration, and cessation, and the risk of rheumatoid arthritis in women. Am J Med. 2006 Jun;119(6):503.e1-9.

[3] Sparks JA, Karlson EW. The roles of cigarette smoking and the lung in the transitions between phases of preclinical rheumatoid arthritis. Curr Rheumatol Rep. 2016 Mar;18(3):15. doi: 10.1007/s11926-016-0563-2.

[4] Balsa A, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring in clinical practice: the Spanish cohort of the COMORA study. Reumatol Clin. 2017 Jul 12. pii: S1699-258X(17)30134-1. doi: 10.1016/j.reuma.2017.06.002. [Epub ahead of print].

[5] Fenton SA, Veldhuijzen van Zanten JJ, Duda JL, Metsios GS, Kitas GD. Sedentary behaviour in rheumatoid arthritis: definition, measurement and implications for health. Rheumatology (Oxford). 2017 Apr 7. doi: 10.1093/rheumatology/kex053. [Epub ahead of print]

[6] Azzi L, et al. Periodontal microbioma and rheumatoid arthritis: The role of Porhyromonas gingivalis. J Biol Regul Homeost Agents. 2017 Apr-Jun;31(2 Suppl 1):97-103.

[7] Calderaro DC, Correa JD, Ferreira GA, Barbosa IG, Martins CC, Silva TA, Teixeira AL. Influence of periodontal treatment on rheumatoid arthritis: a systematic review and meta-analysis. Rev Bras Reumatol Engl Ed. 2017 May – Jun;57(3):238-244. doi: 10.1016/j.rbre.2016.11.011. Epub 2017 Jan 4.

[8] Ayravainen L, Leirisalo-Repo M, Kuuliala A, Ahola K, Koivuniemi R. Meurman JH, Heikkinen AM. Periodontitis in early and chronic rheumatoid arthritis: a prospective follow-up study in Finnish population. BMJ Open. 2017 Jan 31;7(1):e011916. doi: 10.1136/bmjopen-2016-011916.

[9] http://www.ada.org/en/science-research/science-in-the-news/periodontal-disease-affects-nearly-half-us-population

[10] Yilmaz V, Umay E, Gundogdu I, Karaahmet ZO, Ozturk AE. Rheumatoid arthritis: are psychological factors effective in disease flare. Eur J Rheumatol. 2017 Jun;4(2):127-132. doi: 10.5152/eurjrheum.2017.16100. Epub 2017 Jun 1.

[11] Nagano J, Sudo N, Nagaoka S. Yukioka M, Kondo M. Life events, emotional responsiveness, and the functional prognosis of patients with rheumatoid arthritis. Biopsychosoc Med. 2015 Jun 23;9:15. doi: 10.1186/s13030-015-0043-3. eCollection 2015.

[12] http://www.mayoclinic.org/healthy-lifestyle/stress-management/basics/stress-basics/hlv-20049495

Guide to living with rheumatoid arthritis: Part 2
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Guide to living with rheumatoid arthritis: Part 2
How can rheumatoid arthritis affect your day-to-day living and what are habits that worsen RA? Exercise, autoimmune foods, and stress reduction techniques?
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