How Lifestyle Changes Can Make a Difference in PsA
Psoriatic arthritis (PsA), a chronic inflammatory condition characterized by dactylitis, enthesitis, peripheral arthritis, skin and nail psoriasis, and spondylitis, occurs in around 10%-30% of people with psoriasis. While several pharmacological treatment strategies exist, PsA continues to significantly impact patients' pain levels, functional capacity, and mental well-being.
Along with joint and skin manifestations, PsA is associated with several comorbidities, including cardiovascular disease (CVD), central sensitization syndrome, diabetes mellitus, dyslipidemia, fatty liver disease, gout, infections, inflammatory bowel disease, kidney disease, metabolic syndrome, obesity, osteoporosis, and uveitis, all of which negatively impact quality of life (QOL). Patients with PsA are also more likely to experience psychological issues, such as anxiety and depression. Given these challenges, nonpharmacological interventions play a key role in disease management. Healthy lifestyle changes, including dietary modifications, regular exercise, and quitting smoking — along with psychological interventions — are essential to improve PsA and QOL. Here are common nonpharmacological interventions that can improve symptoms and QOL of patients with PsA.
In their treatment guideline, the American College of Rheumatology and National Psoriasis Foundation (ACR/NPF) recommend nonpharmacological interventions for PsA, including acupuncture, low-impact exercise, massage, occupational therapy, physical therapy, smoking cessation, and weight loss despite weak evidence for all except smoking cessation.
The Importance of Physical Activity in Reducing Inflammation
Physical activity and targeted exercises play an important role in reducing inflammation, disease severity, and outcomes in patients with PsA. Studies have found that exercise, particularly when combined with dietary modifications, can improve PsA symptoms. The ACR/NPF recommend low-impact exercise over high-impact exercise for managing PsA. In their guideline, the European Alliance of Associations for Rheumatology notes regular physical activity as an integral part of care for patients with PsA.
Regular exercise, including resistance training, aerobic, and flexibility exercises may improve and preserve joint function, reduce inflammation, and enhance QOL in patients with PsA. A 12-week single-blind parallel randomized controlled trial by Silva et al found functional training and resistance training similarly improved disease activity, functional capacity, functional status, general QOL, and muscle strength in patients with PsA.
The Link Between Diet and Inflammation in PsA
Dietary interventions focused on weight loss alleviate mechanical strain on the joints and reduce the risk of CVD in patients with PsA. Weight loss has also been shown to improve disease activity. Moreover, research suggests some dietary modifications, along with exercise, can improve PsA disease outcomes independent of weight loss. Diets rich in saturated fats or certain omega-6 fatty acids while anti-inflammatory diets can improve PsA symptoms and disease activity. Among various anti-inflammatory diets, the Mediterranean diet has gained the most popularity as studies have found it to be associated with lower disease activity in patients with PsA.
According to the Medical Board of the National Psoriasis Foundation, patients with PsA may consider the Mediterranean diet on a trial basis in conjunction with pharmacotherapy. The NPF medical board also emphasizes increased intake of fiber, complex carbohydrates, monosaturated fatty acids, and omega-3 fatty acids. Although other dietary interventions for improving PsA are less studied, a case report by Lewandowska et al found a whole-food vegan diet improved PsA symptoms a 40-year-old woman. Further research, however, is needed to confirm the role of vegetarian or vegan diets in modulating PsA disease activity.
Smoking: What Role Does It Play?
The association between smoking and the development of PsA remains inconclusive, with studies yielding mixed results. At the population level, smoking is positively associated with PsA. However, some studies suggest smoking increases the risk of developing PsA, while others indicate no significant association between cigarette smoking and the progression of joint damage. Beyond disease onset, smoking has been linked to poorer treatment outcomes in PsA. An observational cohort study by Højgaard et al found that patients with PsA who smoke had poor responses to treatment with tumor necrosis factor-α inhibitors and were also less likely to adhere to their treatment plan. Additionally, smoking is a risk factor for CVD and other comorbidities common in PsA. Therefore, smoking cessation is an important lifestyle intervention for patients with PsA — not only to improve treatment efficacy but also to reduce the risk of other comorbidities, thereby improving the QOL.
Integrating Weight Management in PsA Care
The relationship between PsA and obesity appears to be bidirectional: Research has shown obesity is a common risk factor for developing PsA and that joint dysfunction and reduced physical activity due to PsA itself may result in weight gain. Patients with PsA and obesity often exhibit higher disease activity and poor response to treatment. An interventional study by Klingberg et al showed weight loss treatment with a very low energy diet improved disease activity, pain, fatigue, and C-reactive protein in patients with PsA and obesity. Similarly, another study by Klingberg et al also reported improvement in PsA disease activity after 12 months of weight loss treatment.
In addition to diet and exercise, GLP-1 and glucose-dependent insulinotropic polypeptide receptor agonists and incretins associated with weight loss may benefit patients with PsA and obesity. However, research on the effect of such drugs on PsA is quite limited still and requires further investigation.
The Bidirectional Link Between Sleep and Inflammation
In addition to obesity, there also appears to be a bidirectional relationship between PsA and sleep disorders. Persistent sleep disorders in PsA may be interconnected with inflammatory disease activity, chronic pain, fatigue, and psychological distress, creating a vicious cycle where each factor intensifies the others. Prolonged and significant decline in sleep quality reduces overall QOL and increases a patient's risk of developing CVD, hypertension, and metabolic disorders, comorbid conditions associated with PsA. Prolonged deterioration of sleep quality can negatively impact the QOL of PsA patients and increase the risk of developing hypertension, CVD, and metabolic disorders.
Several lifestyle changes can help to improve sleep quality in patients with PsA. These include maintaining regular sleep-wake cycles, limiting alcohol and caffeine intake, and improving the patient's sleeping environment. Additionally, medications used to treat PsA — such as guselkumab, tumor necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), and the Janus kinase inhibitor filgotinib — have shown potential in improving sleep outcomes in patients with PsA.
The Psychological Burden of PsA
Pain, fatigue, anxiety, and depression are common psychological comorbidities of PsA that have a negative impact on QOL. The odds of being diagnosed with behavioral and mental health disorders are higher in patients with PsA compared to the general population. Even with treatment, studies have shown that PsA affects patients emotionally, socially, and occupationally, underscoring the importance of comprehensive management since targeting the inflammatory activity of PsA alone may not improve the QOL.
Cognitive behavioral therapy is a well-established psychological intervention that can improve symptoms of depression, anxiety, and sleep disturbances in patients with PsA. It can also improve sleep quality in PsA patients. Although research is limited, the effectiveness of cognitive behavioral therapy (CBT) to improve psychological distress may in turn improve overall QOL in patients with PsA. Although research on this is limited, CBT can prove to be beneficial in improving mood disorders and the overall QOL of PsA patients.
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Healthy lifestyle changes, including dietary modifications, regular exercise, and quitting smoking — along with psychological interventions — are essential to improve PsA and QOL. Here are common nonpharmacological interventions that can improve symptoms and QOL of patients with PsA. In their treatment guideline, the American College of Rheumatology and National Psoriasis Foundation (ACR/NPF) recommend nonpharmacological interventions for PsA, including acupuncture, low-impact exercise, massage, occupational therapy, physical therapy, smoking cessation, and weight loss despite weak evidence for all except smoking cessation. The Importance of Physical Activity in Reducing Inflammation Physical activity and targeted exercises play an important role in reducing inflammation, disease severity, and outcomes in patients with PsA. Studies have found that exercise, particularly when combined with dietary modifications, can improve PsA symptoms. The ACR/NPF recommend low-impact exercise over high-impact exercise for managing PsA. In their guideline, the European Alliance of Associations for Rheumatology notes regular physical activity as an integral part of care for patients with PsA. Regular exercise, including resistance training, aerobic, and flexibility exercises may improve and preserve joint function, reduce inflammation, and enhance QOL in patients with PsA. A 12-week single-blind parallel randomized controlled trial by Silva et al found functional training and resistance training similarly improved disease activity, functional capacity, functional status, general QOL, and muscle strength in patients with PsA. The Link Between Diet and Inflammation in PsA Dietary interventions focused on weight loss alleviate mechanical strain on the joints and reduce the risk of CVD in patients with PsA. Weight loss has also been shown to improve disease activity. Moreover, research suggests some dietary modifications, along with exercise, can improve PsA disease outcomes independent of weight loss. Diets rich in saturated fats or certain omega-6 fatty acids while anti-inflammatory diets can improve PsA symptoms and disease activity. Among various anti-inflammatory diets, the Mediterranean diet has gained the most popularity as studies have found it to be associated with lower disease activity in patients with PsA. According to the Medical Board of the National Psoriasis Foundation, patients with PsA may consider the Mediterranean diet on a trial basis in conjunction with pharmacotherapy. The NPF medical board also emphasizes increased intake of fiber, complex carbohydrates, monosaturated fatty acids, and omega-3 fatty acids. Although other dietary interventions for improving PsA are less studied, a case report by Lewandowska et al found a whole-food vegan diet improved PsA symptoms a 40-year-old woman. Further research, however, is needed to confirm the role of vegetarian or vegan diets in modulating PsA disease activity. Smoking: What Role Does It Play? The association between smoking and the development of PsA remains inconclusive, with studies yielding mixed results. At the population level, smoking is positively associated with PsA. However, some studies suggest smoking increases the risk of developing PsA, while others indicate no significant association between cigarette smoking and the progression of joint damage. Beyond disease onset, smoking has been linked to poorer treatment outcomes in PsA. An observational cohort study by Højgaard et al found that patients with PsA who smoke had poor responses to treatment with tumor necrosis factor-α inhibitors and were also less likely to adhere to their treatment plan. Additionally, smoking is a risk factor for CVD and other comorbidities common in PsA. Therefore, smoking cessation is an important lifestyle intervention for patients with PsA — not only to improve treatment efficacy but also to reduce the risk of other comorbidities, thereby improving the QOL. Integrating Weight Management in PsA Care The relationship between PsA and obesity appears to be bidirectional: Research has shown obesity is a common risk factor for developing PsA and that joint dysfunction and reduced physical activity due to PsA itself may result in weight gain. Patients with PsA and obesity often exhibit higher disease activity and poor response to treatment. An interventional study by Klingberg et al showed weight loss treatment with a very low energy diet improved disease activity, pain, fatigue, and C-reactive protein in patients with PsA and obesity. Similarly, another study by Klingberg et al also reported improvement in PsA disease activity after 12 months of weight loss treatment. In addition to diet and exercise, GLP-1 and glucose-dependent insulinotropic polypeptide receptor agonists and incretins associated with weight loss may benefit patients with PsA and obesity. However, research on the effect of such drugs on PsA is quite limited still and requires further investigation. The Bidirectional Link Between Sleep and Inflammation In addition to obesity, there also appears to be a bidirectional relationship between PsA and sleep disorders. Persistent sleep disorders in PsA may be interconnected with inflammatory disease activity, chronic pain, fatigue, and psychological distress, creating a vicious cycle where each factor intensifies the others. Prolonged and significant decline in sleep quality reduces overall QOL and increases a patient's risk of developing CVD, hypertension, and metabolic disorders, comorbid conditions associated with PsA. Prolonged deterioration of sleep quality can negatively impact the QOL of PsA patients and increase the risk of developing hypertension, CVD, and metabolic disorders. Several lifestyle changes can help to improve sleep quality in patients with PsA. These include maintaining regular sleep-wake cycles, limiting alcohol and caffeine intake, and improving the patient's sleeping environment. Additionally, medications used to treat PsA — such as guselkumab, tumor necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), and the Janus kinase inhibitor filgotinib — have shown potential in improving sleep outcomes in patients with PsA. The Psychological Burden of PsA Pain, fatigue, anxiety, and depression are common psychological comorbidities of PsA that have a negative impact on QOL. The odds of being diagnosed with behavioral and mental health disorders are higher in patients with PsA compared to the general population. Even with treatment, studies have shown that PsA affects patients emotionally, socially, and occupationally, underscoring the importance of comprehensive management since targeting the inflammatory activity of PsA alone may not improve the QOL. Cognitive behavioral therapy is a well-established psychological intervention that can improve symptoms of depression, anxiety, and sleep disturbances in patients with PsA. It can also improve sleep quality in PsA patients. Although research is limited, the effectiveness of cognitive behavioral therapy (CBT) to improve psychological distress may in turn improve overall QOL in patients with PsA. Although research on this is limited, CBT can prove to be beneficial in improving mood disorders and the overall QOL of PsA patients.
