Plants for Joints: Multidisciplinary Lifestyle Intervention Shows Long-Term Benefit for RA

A multidisciplinary lifestyle intervention based on a whole-food plant-based diet, physical activity, and stress management may be an effective long-term approach for improving disease activity in patients with rheumatoid arthritis (RA).¹

Findings from an extension of the Plants for Joints randomized controlled trial showed reductions in 28-joint Disease Activity Score (DAS28) were sustained through 2 years after the initial 16-week intervention, suggesting intensive lifestyle modifications can be an effective approach for RA in the long-term.¹

“Reversing and preventing adverse lifestyle factors could potentially reduce the incidence and burden of RA, as well as alleviate its comorbidities,” Wendy Walrabenstein, PhD, researcher at Reade Center for Rheumatology and Rehabilitation, and colleagues wrote.² “Specifically, beneficial effects have been found in interventions directed at single lifestyle factors, such as dietary interventions with plant-based or Mediterranean diets, physical exercise programs, or stress reduction techniques.”

Based on the known benefits of a multidisciplinary program including a whole-food plant-based diet, increased physical activity, stress reduction, and social support in patients with coronary artery disease and low-grade prostate cancer, investigators sought to explore the impact of nonpharmacologic therapies in a single integrated intervention versus usual care in patients with moderately active RA. The 16-week observer-blind and open-label RCT with parallel design was conducted between May 2019 and September 2021 at the Reade outpatient clinic for rheumatology and rehabilitation in Amsterdam, The Netherlands.²

Patients with an RA diagnosis according to the ACR/EULAR 2010 criteria, low to moderate disease activity (DAS28 2.6 ≥ and ≤ 5.1), and who were on stable treatment with Disease-modifying antirheumatic drugs (DMARDs) or off DMARD treatment for at least 3 months were randomly assigned in a 1:1 ratio with a variable block randomization in block sizes of 2 and 4 to receive the intervention in addition to usual care or usual care alone. After the 16-week period, the control group also received the intervention.^1,2

In total, 77 patients completed the 16-week portion of the study. Participants were 92% female with a mean age of 55 (Standard deviation [SD], 12) years, BMI of 26 (SD, 4) kg/m2, and mean DAS28 of 3.8 (SD, 0.7). After 16 weeks, the intervention group had a mean 0.9-point greater improvement of DAS28 compared to the control group (95% CI, 0.4 to 1.3; P <.0001). The intervention also led to greater decreases in body weight (–3.9 kg), fat mass (–2.8 kg), waist circumference (–3 cm), HbA1c (–1.3 mmol/mol), and low-density lipoprotein (–0.32 mmol/l).²

After completion of the intervention, participants were followed up for 2 years with biannual visits and 6 adherence-promoting webinars per year. Changes in medication intensity between trial initiation and the end of the extension study were classified as “increase”, “stable”, or “decrease” by an independent committee. Secondary outcomes included anthropometric and metabolic markers.^1,2

In total, 48 (62%) of the 77 participants who completed the original trial also completed the 2-year follow-up. Investigators noted participants who discontinued the extension study measurements most often indicated they were too busy, unreachable, or did not give permission for the second year of the extension study.¹

Overall, 92% of participants were female with a mean age of 55 (SD, 12) years and a baseline body mass index of 26 (4) kg/m2. Two years after completing the PFJ intervention, improvement in DAS28 after the intervention was maintained, and DAS28 was significantly lower compared to baseline (mean, –0.9; 95% CI, –1.2 to –0.6; P <.0001). Tender joint count and general health components of the DAS28 improved significantly, while there was no significant difference in the erythrocyte sedimentation rate and swollen joint count compared to baseline.¹

Results were similar in participants completing the 2-year extension study versus those who discontinued prematurely (completer mean DAS28 change, –0.9 vs dropout mean DAS28 change, –0.6; P = 0.4; completer mean change up to first-year extension study, –1.0 vs dropout mean change up to first-year extension study, –0.9; P = 0.9). Of the 39 participants who completed the follow-up and used DMARDs, 44% decreased or stopped, 26% were on a stable dose, and 31% increased medication. Of note, 65% of participants had improved DAS28 scores with stable or less medication compared to baseline.¹

After the 2-year follow-up period, high-density lipoprotein cholesterol was increased and C-reactive protein remained significantly lower compared to baseline values, although there was no longer a significant difference in weight, waist circumference, low-density lipoprotein cholesterol, or HbA1c.¹

“Significant improvements in disease activity observed after the PFJ intervention were maintained up to two years, while, on average, medication was slightly reduced,” investigators concluded.¹ “These findings indicate that intensive lifestyle modifications can be effective in the long term.”

References:

1. ^{Wagenaar C, Walrabenstein W, Van der Leeden M, et al. LONG-TERM EFFECTIVENESS OF A LIFESTYLE INTERVENTION FOR RHEUMATOID ARTHRITIS: TWO-YEAR FOLLOW-UP AFTER THE “PLANTS FOR JOINTS” RANDOMIZED CLINICAL TRIAL. EULAR. doi:10.1136/annrheumdis-2024-eular.885}
2. ^{Walrabenstein W, Wagenaar CA, van der Leeden M, et al. A multidisciplinary lifestyle program for rheumatoid arthritis: the 'Plants for Joints' randomized controlled trial. Rheumatology (Oxford). 2023;62(8):2683-2691. doi:10.1093/rheumatology/keac693}