Clinical trials are conducted to create evidence. Companies, researchers, physicians, etc. take data from clinical trials and publish it via research papers. Professional societies then create clinical treatment guidelines based off of the publications.

To better understand what's coming down the pipeline and what trials will be influencing future treatment guidelines, I took a look at all RA clinical trials on ClinicalTrials.gov. I narrowed the search down to look at RA studies to be completed between 2015 to 2030.

We see a disproportionate number, >50%, of clinical studies focused on drugs and biologics. And, almost 60% if we include devices. A modest 7% of clinical trials are looking at lifestyle impacts, such as exercise and diet.

Why is this? Well, funding. Large pharma players have the capital available to invest in therapies and support large scale clinical trials to influence professional societies, standard of care guidelines, and further product development. Pharma companies get reimbursed fairly well (as we saw in Kawatkar's analysis) for producing "improved outcomes" defined by ACR (as we saw in the ACR '21 Guidelines). Now, this isn't a bad thing. We need innovative, life-saving therapies.

Should these therapies be used as the first line defense? Most would say 'yes' given the research showing they improve "quality of life" and stunt disease progression...well, I hesitantly type that. Do they really improve quality of life given how severe the side effects are? Are they truly slowing progression of the disease?

Are drugs the only way to slow disease progression? We won't know until we study other interventions, therapies, tools, and ways of treating... of healing...

American College of Rheumatology (ACR) printed 2021 Guidelines for Rheumatoid Arthritis

Key Take-aways

Unsurprisingly, ACR had a heavy focus on drug interventions favoring methotrexate. I was happy to see consensus around avoiding glucocorticoids when possible. This a huge step given the distress this product has on our gut microbiome, addictive properties, and never mind increases in mortality rates. ACR also addressed a therapy taper approach for patients who have achieved remission or low disease activity - finally.

ACR noted key outcomes desired for RA patients. Again, drug and pharma heavy. Interestingly, remission is not noted. Why is that? Does research not support remission? If we don't start demanding remission, will therapies and solutions to consistently achieve remission ever arise?

For those who're interested, here a high-lights from the recommendations:

• Strong emphasis on  use of methotrexate with oral administration preferred
• Recommendation to avoid glucocorticoids whenever possible
• Recommendations to lead with methotrexate and add a biologic DMARD or targeted synthetic DMARD for methotrexate non-responders
• General lack of therapy comparative effectiveness research in rheumatology, which is a callout for more research needed in this area
• Patients who are in low disease activity or remission for at least 6 months can attempt reducing dosage or extending the interval between doses

Deep Dive

American College of Rheumatology (ACR) is an independent, professional, medical and scientific society. Through out medicine, societies, such as ACR, exist to develop guidelines for treating various diseases, among other things. These guidelines should be supported by significant evidence. Physicians, such as Rheumatologists, then treat patients based on the societies' guidelines.

"The ACR updates its clinical practice guidelines every 5 years at minimum. The 2021 guidelines for RA include a total of 44 recommendations, including 7 strong and 37 conditional items." (Healio)

7 strong recommendations:

• Methotrexate should be used over hydroxychloroquine or sulfasalazine in patients with moderate to high disease activity who are DMARD-naïve;
• Methotrexate monotherapy should be used over biologic or targeted synthetic DMARDs among patients with moderate-to-high disease activity who are DMARD-naïve;
• Methotrexate monotherapy should be used over combination therapy with methotrexate plus a non-TNF-inhibitor biologic or targeted synthetic DMARD among patients with moderate-to-high disease activity who are DMARD-naïve;
• Clinicians should start a conventional synthetic DMARD without longer-term glucocorticoids, rather than initiating such DMARDs with longer-term glucocorticoids, for DMARD-naïve patients with moderate-to-high disease activity;
• Clinicals should use a treat-to-target rather than usual care for patients who have not been previously treated with biologic or targeted synthetic DMARDs;
• Prophylactic antiviral therapy should be used, over frequent monitoring of viral load and liver enzymes alone, among patients starting rituximab (Rituxan, Genentech) who are positive for hepatitis B core antibodies, regardless of hepatitis B surface antigen status; and
• Prophylactic antiviral therapy should also be used, rather than frequent monitoring alone, for patients starting any biologic or targeted synthetic DMARD who are positive for hepatitis B core antibodies and hepatitis B surface antigen.

In addition, RCA recommends Rheumatologists focus on the following outcomes in the patient (mind you, these are most likely tied to physician compensation and how much insurance is willing to reimburse):

• Disease activity
• Function or functional activity (i.e. employment)
• Preventing joint damage
• Serious adverse events (i.e. opportunistic infections such as TB)
• Reversible side effects  that are not "serious" but impact quality of life or decision making
• Percent stopping medication because of side effects
• Drug survival
• Quality of life

Supporting References

• ACR Guidelines
• Medpage Today Perspective
• Healio Perspective
• ACR Outcomes & Guidelines

2012 Economic Review  

U.S. healthcare costs are astronomically high and one of the top healthcare expenditures globally. The Affordable Care Act, widely known as 'Obamacare', was enacted to 'curb spending' by defining and paying for quality care driven by outcomes rather than quantity of care.

In this era of understanding costs, many papers were developed to understand major cost drivers for our care system. Kawatkar et al. took a look at direct medical expenditures associated with Rheumatoid Arthritis in the U.S. population, largely from a payer perspective.

Methods: Compared RA cohort (5.8M) to control without RA (190M) using probability-weighted sample of adult respondents from the Medical Expenditure Panel Suvery (2008). Estimated annual expenditures related to pharmacy, office-based visits, emergency department visits, hospital inpatient stays, and residual. These cohorts were adjusted for sociodemographic, employment, insurance coverage, health behavior, and health status.

Results: Adjusted average annual total expenditures of RA cohort was ~$13,000 compared to control of ~$5,000. RA cohort has a significantly higher pharmacy expenditure. Summated total incremental expenditure of all RA patients in US was $22.3B ('08, USD).

Conclusion: RA patients exert considerable economic cost on US health care system primarily driven by incremental pharmacy expenditure.

Sentiment

To put this study into perspective, the total direct medical expenditure of RA was $73.4B, 0.5% of our GDP, and approximately 6.5% of our $1.14T health care spend. Incrementally, expenditure is at $22.3B on our healthcare system, about 0.16% of our GDP in 2008.

RA is a huge financial burden on our healthcare system, largely driven by expensive pharmaceutical products that aren't delivering remission and questionable improved quality of life.

As a person with RA, are your needs being met with current therapies? Are we spending almost 0.2% of our GDP on drugs that aren't meeting our expectations, increasing quality of life, or improving our overall health?

One of the many blessings RA has given me - my love for reading. I devour health and wellness books capturing information, saving delicious recipes, and connecting with authors over shared experiences. The more I read, the more empowered I feel. Empowered to make my own health decisions and empowered to heal. These are a few of my favorite autoimmune books and I hope you have a similar experience in reading them!

Brave New Medicine: A Doctor's Unconventional Path to Healing her Autoimmune Disease

by Cynthia Li

In her beautiful memoir, Cynthia makes you feel heard, part of a community. Medical doctor battling what we're going through - mysterious painful symptoms that pharma products struggle to help with.

The Elimination Diet

by Tom Malterre and Alissa Segersten

Easy to follow protocol to identify food triggering your flares and autoimmune disease. I followed Tom's protocol and found several foods leading to inflammation and pain. Alissa provides nutritious recipes to help along the way. I love her soup recipes!

The Autoimmune Pandemic

by Donna Jackson Nakazawa

Wow! Eye opener. Donna discusses everything from environmental to viral causes for autoimmune diseases. Her real-life stories and experiences bring to life the message she shares with the world.

Liver Rescue

by Anthony William

Our liver is such an important organ in our bodies. Often over-used and unappreciated. Anthony brings new perspective to healing and nourishing your liver. While it may not be the right tool for everyone, my liver loved some of his recommendations and I began to see differences in the ridges in my nails when followed. Anthony also provides a comprehensive overview of key supplements and herbs and benefits to the body relative to various diseases.  

The Autoimmune Solution

by Amy Meyers

Amy is a well-respected functional medicine doctor with years of personal and professional experience healing autoimmune diseases. While her book is dense with clinical information and explanation, she drives at key remedies for many autoimmune diseases. This book has a been a great reference over the years.

*I do not receive any monetary kick-backs from these links. My goal is to share information with you that's helping me navigate this journey.

"There is no cure".

"You will be on prednisone and immune suppressants for the rest of your life".

"This is your only option".

This is what I heard at my first rheumatology appointment. I still cringe as I replay it over. Something in my soul was disgusted by these words and purely did not believe it. How can this be true? At 25 years old, how can lifelong drugs be my only option? There has to be another option for controlling my autoimmune diseases.

A couple weeks after receiving positive lab testing, two family friends, who don't know each other, recommended a local naturopath to me on the same day. Well, this is another option, I thought, and called scheduled an appointment the following morning.

What is a Naturopath?

Naturopaths focus on healing methods in a non-invasive natural way. They promote self-healing and emphasize prevention through healthy living and natural, holistic therapies. This approach is designed from century-old knowledge and philosophy that nature is the most effective healer.

Bastyr University in California is considered the top naturopathic school in the states. Their education is quite extensive and almost mirrors medical school. The only difference - their definition of health and health care. I recommend seeking out a Naturopath trained by Bastyr University and/or one who has many referrals.

What to Expect from a Naturopath?

My naturopath, Dr. Chan, had about a 2 month waitlist for an appointment. In the meantime, she asked me fill out an extensive questionnaire, which asked questions like "what symptoms do you have" to "did you have any infections or illnesses as a child" to "what do your bowel movements look like". This questionnaire took me about 40 minutes to fill out, but provided a mapping for my entire life.

My first appointment was about 2 hours long. The waiting room had plush couches with soothing music playing in the background. Meditation and herb books scattered the coffee tables and bookshelves. A little, white dog pranced out of an office and sat at my feet as my husband, Steve, and I waited.

Dr. Chan, a petite, compassionate woman, led us into her office, a warm space, colored in mossy green with potted flowers and plants scattered throughout. An acupuncture table sat in the back of the room, where she offers treatments to her clients, and an air purifier offers a soft hum in the background.

We started our conversation with niceties, like how are you and what do you do for work, but quickly moved into more details about how my symptoms started and what my lab results are. She started many of her questions with my answers from the questionnaire, like "you answered 'yes' for asthma, when did it start and what symptoms do you experience?".

Dr. Chan, like most Naturopaths, identify and treat root causes for disease. For autoimmune diseases, root causes typically fall within a couple of categories, mainly gut health, infection, and environment. Based on my symptoms and health history, Dr. Chan ordered numerous testing, some covered by insurance, like blood tests, and others partially covered by insurance, like stool testing, to identify my root causes.

The testing we did told a story. The normal flora, normal bugs that live in our mucosal surfaces, within my gut were imbalanced and some in excess. We used anti-microbials derived from natural sources, like garlic, to rebalance my gut flora. I also started taking a probiotic, VSL #3, to replenish good bugs. By doing this, I got a total of 6 weeks pain free and I learned my gut health is super important in fighting this disease.

Food is such a huge part of my gut health! If we have a damaged gut, the food we eat cross our gut barrier and activate our immune system. I did an elimination diet to find foods my body liked and did not liked. I found nightshades, sugar, and alcohol activated flares, so I tend to stay away from these to help control inflammation within my joints and make my gut happy.

We also found that I had several infections latent within my body, like Epstein Barr virus. Viruses and bacteria can harbor in various areas throughout our bodies' and our bodies' can have a difficult time getting rid of them. We used biomagnetic therapy to clear these infections. This was truly life changing therapy and has relieved so much of my pain and inflammation.

How does Rheumatology differ from Naturopathic care?

During my initial rheumatology appointment, the doctor looked at my joints and palpated my abdomen. She asked me a couple questions like "do you have a fever with your flares" and "how do your joints feel in the morning", but never once asked about the foods I eat or my stress levels. Instead she prescribed me harsh, life long medications that would destroy my liver and gut among other things. This is purely symptom management, rather than healing our bodies.

Rheumatology and conventional medicine treat symptoms, not root causes. Naturopaths identify and treat root causes, which in turn get rid of symptoms and disease.

How to prepare for your first Naturopath appointment?

1. Do you want someone to join you? My husband, Steve, came with me to my first appointment. He colored my answers and offered timelines that I forgot. We also talked about the appointment together after and were on the same page about my care plan and health goals.
2. Collect the last couple of years of any testing you've had. If you have an online health record portal, they can be printed through there or you can call your PCP and rheumatology office and request paper copies.
3. Write down all of your symptoms and when they started. Do you have any other symptoms? How is your GI tract? How are your sleeping patterns? How would you rate your stress? How would you rate your pain and why?
4. Think about your health goals. Mine was to heal my body without pharmaceutical products. Some may be to lower their medication or come off of it. Spend some time thinking about your various options and what you would like to achieve.
5. Commit. Commit to healing. Commit to giving your body everything it needs to do so. This is a commitment of time, discipline, money and honesty. What are you willing to and can you commit? Be honest with yourself and work within your commitment.

My rheumatologist recommended prednisone and plaquenil for the rest of my life. At the time, something in the pit of my stomach was steering me far, far away. But with my logical mind and experience in medicine, I struggled to wrap around why.

People write blogs and articles of achieving remission from autoimmune diseases and all their Eastern-medicine (sometimes woo-woo) remedies. When I first read these, I half-heartedly believed them. Yeah, ok, that woman says she cured her RA with elderberries, but did that really happen? Does changing the foods we eat and the way we think really make a difference? Could infections and trauma truly be causing all of this pain and inflammation?

I'm here to tell you YES! Ok, well maybe elderberries won't cure all your symptoms, but root causes exist and addressing them will relieve your pain and symptoms.

And, I'm living proof of this. So, how did I do this?

1) Work with a Naturopathic doctor. I HIGHLY recommend finding one you connect with. Functional medicine doctors are another great option!

2) Find YOUR root cause. We are all different. My root cause is different than yours. Why is your body alarming? How can you remove the cause for the alarm? This take discipline and patience. But, your body will thank you.

3) Nourish your body with whole foods given to us by mother nature. Choose options with less artificial ingredients and more natural ingredients. No, Doritos are not whole foods as much as we may wish.

4) Listen to your body. What does it need? Is it craving sleep? How about red meat or leafy greens? Ask yourself what your body needs and give yourself what you need.

5) Heal your gut. Ah, famous advice given by many New York Times best sellers. Our gut truly is a remarkable world. We must care for it and provide it nutrients that promote balance and restoration. Invest in a good probiotic (my favorite is VSL #3). Eat fermented foods and stay away from acidic, sugary foods.

6) Rid infections. We needs bugs. Yes, we do. They actually live on and in our bodies. However, some bugs can be problematic, like Epstein-Barr virus. Find these infections and help your body clear them. Biomagnetic therapy did wonders for clearing my infections.

7) Lastly, be kind to yourself. This is tough. Really tough. Be patient with yourself. I had my fair share of cheat meals and emotional breakdowns. You will fall down, and you will pick yourself back up and keep trying. Your body will thank you.

For the past 5 years, my husband, Steve, and I rang in New Years with champagne and fireworks in a different capital city with our friends and family. Needless to say, we love to travel and take every opportunity to – like New Years, anniversaries, birthdays, graduations. In traveling, both locally and abroad, I've found tips and tricks that make it easier to travel with an autoimmune disease.

Traveling Tips & Tricks

• Stay hydrated! I always bring Superieur electrolytes with me and take them 24 hours before traveling in a plane.
• Wear comfortable walking shoes. You want a pair of shoes that will support your joints while walking around and exploring a new town or city. It doesn't have to be clunky, black sneakers, but rather a comfortable pair of shoes that you can dress up or down. My favorite shoes are Cole Haan's mesh sneakers.
• Go grocery shopping. When we first arrive in a new city or town, we always find the closest grocery store and stock up on bottled water, fruits, nuts, and any other snacks we may want. This takes some pressure off from finding a restaurant I can eat at.
• Set eating parameters for yourself before you go. What foods do you have to be diligent on? For me, I have to stay away from sugar, alcohol, and nightshades. But eating 100% organic will be challenging and ordering a salad in Rome will most likely contain gluten. To help control this, plan your meals, eat a snack before you go to a restaurant, check restaurant menus before you go, and consider staying at an airbnb with a kitchen where you can cook in for most meals.
• Bring epsom salt, especially if you plan to walk a lot. My feet ballooned after spending an entire day walking through Hyde park in London. I found a pharmacy that sold epsom salt and soaked me feet in our hotel sink. I will never forget the relief this brought. Now, I always bring some with me and usually end up soaking my feet a couple of times during our trips.  
• For ladies, bring a scarf or shall for your shoulders. I tend to run cold and wrap up in a scarf even in sunny Bermuda! I always bring a scarf to wrap around my shoulders if I get cold at a restaurant or while out site seeing. They're easy to pack and don't take up much space, but I always appreciate having one with me.
• Bring your supplements and vitamins in a weekly pill organizer. This avoids bringing all supplement and vitamin containers. I usually pack 1-2 days worth extra just in case we are delayed coming home.

1 tbsp coconut oil
1 onion (chopped)
2 cloves garlic (chopped)
3 celery stalks (chopped)
3 carrots (chopped)
1 beet (chopped)
1/2 cup pumpkin
2 1/2 cups bone broth
2 sprigs fresh oregano
5-6 leaves of fresh basil
1-2 tsp of salt
1/2 juice of a lemon
optional topping: pitted kalamata olives, cooked ground beef, goat cheese

Directions

1. Heat coconut oil in a sauce pan over medium heat and saute onions and garlic.
2. When onions are slightly translucent add chopped celery, carrots, and beets and cook over medium heat until vegetables are soft.
3. Add pumpkin puree, bone broth, and rest of ingredients, except topping. Cook for 10 minutes.
4. Using an immersion blender or transfer to a high-speed blender, pulse until in a tomato sauce texture.
5. Add pitted kalamata olives, cooked ground beef, and/or goat cheese and serve over "zoodles", gluten free pasta, or sauted vegetables.

The time leading up to diagnosis, I did not take care of myself. I did not sleep; I ate junk food; I went out drinking; I was stressed. My liver and kidneys couldn't filter through it all. They got clogged with toxins, bugs, cell debris and other things as I continued to pour bad things into my body. And, voila, autoimmune diseases arose.

RA forced me to focus on my health and well-being. This isn't a choice. My body didn't ask me, "hey, I need to rest" or "can we not run 6 miles today". On second thought, maybe it did. And, I just didn't listen. Did I know how to listen?

One way or another, my body forced me to listen. It forced me to listen by screaming red, hot pain in my joints making me so exhausted that I couldn't move for days. Body, you have my attention now. I am listening.

How do you listen to what your body needs?

Ask your body

Yes, you read that correctly. Stand in the shower and consciously say aloud, "what do you need to heal today?". Now, your body will not outwardly tell you, "give me 30 oz of water and I'll stop attacking things". But, by saying this aloud you are setting an intention to yourself. You're bringing to the forefront of your thinking that (a) your body needs something and (b) you are willing to give it what it needs.

Listen to your body

Our body's communicate with us through signs and symptoms. A cough is our body saying "hey, there is something in my lungs that I want out" where as diarrhea is our body saying "there is something in my GI that I want out". So, take inventory. What are your current aches and pains? Do you spend every morning draining the mucous from the your nose? Or do you run to the bathroom every time you eat? Then, watch for these signs and symptoms throughout the day. Do you only run to the bathroom after you eat certain foods? Observe and take note of your aches and pains, your habits, your bowel movements, your bedtime routines, stressors in your life, etc. Are there any patterns?

Give your body what it's asking for

I used to wake up every morning with a runny nose and sneezing my brains out. I realized this was an inflammatory reaction to something in my bedroom. I removed my down comforter and added an air purifier to our bedroom. Now, I don't wake up with a runny nose and sneeze attack every morning. Go through the things you've observed and start making changes. This will take experimentation until you find the right "recipe" that works for you.

Through this, I've learned more about myself in the last year than the previous 25. I've learned my body craves time to rest, so I block off time during my weekend specifically meant for resting. I've learned my body craves green leafy vegetables and fermented foods, so I make sure to include in my daily meals. I've learned my body hates sugar, as I sneeze and feel fevered every time I eat it. Find the things your body loves and hates, and it will thank you.

You can tell a lot about someone by the car they drive and shoes they wear. One of my co-workers, who wears Sperry boat shoes, pulled up in a maroon truck with an extra long bed and tinted windows. I immediately imagined him standing on a boat dock with a linen shirt and khaki shorts hauling his boat in from the water. After chatting with him for some time, I learned the picture I built in my head was not far from the truth.

Woman take pride in matching shoes with their outfits. My closet is stacked full of adorable red wedge heels, black suede stilettos, and my favorite leather boots with matching outfits hanging above them. Since being diagnosed with rheumatoid arthritis, my favorite shoes cause nothing but flares and pain. My black sneakers cause swelling in my ankles and my cute brown flats cause my right foot to flare every time. And, forget any sort of heel. I fooled myself thinking I could wear my navy, leather wedges to my cousin's wedding. Needless to say, they came off halfway to my car. Yes, I did not even make it from my apartment to my car.

It's been really challenging to find shoes that fit my changing feet. Some mornings, my feet are very swollen and can barely squeeze into any shoe, while other mornings they're so painful I don't want any fabric touching them. This has lead to a shoe shopping battle. Countless hours in and out of stores to find the perfect pair of shoes only to find they don't fit my swollen feet the next morning.

The battle completely changed when I found the holy grail of shoes – Cole Haan. The Nike soles provide cushy support on the days when the one joint in the bottom of my foots will not quit throbbing. The mesh, forgiving fabric on the top of the shoe comfortably wraps around my morning swollen feet. And, they match with every outfit – a navy dress at a wedding or a pair of leggings with a tank. Needless to say, I have more pairs than I care to admit.

The nail technician lifted my thumb and pointed to my nail. I rubbed my pointer finger over the small, horizontal ridges in the nail. Embarrassed, I said "I know. I've had it for a while now".

During my check-up with my PCP, I showed my doctor the ridges in my nails. She looked puzzled, "I haven't seen those before, but let's refer you to Dermatology to get it checked out". I shrugged my shoulders, noting that I needed to go anyway to have some freckles looked at.

Less than a month later, I met with my Naturopath for the first time. I showed her the ridges in my thumb nails and without taking a breath, she said, "Oh! In Chinese medicine that's a sign your liver is not detoxing properly. Let's put you on milk thistle to support your liver". In less than 3 months of starting milk thistle, I saw remarkable improvements in my nails.

Some people may struggle getting rid of toxins and debris in their body. This is largely due to our livers ability to function correctly. I find anecdotally from others and myself that people who develop autoimmune diseases often feel better when their liver is supported in its functions. There is come research to support this and I hope more continues to arise.

Liver & RA Stats

• Your liver filters large toxins from your blood and releases enzymes to break down these toxins into digestible compounds.
• 65% of people of RA have abnormal liver biopsies. For some, this may be due to NSAID and methotrexate treatment, RA itself, or a combination of both.  

Affects of Milk Thistle & RA

Milk thistle is an herb that has been used since the Roman empire to treat liver diseases. It has a compound called Silymarin in it, which reduces free radical production and lipid peroxidation, has antifibrotic activity, and inhibits toxins binding to liver cells. That's a lot of science words to say that it reduces liver cell damage and supports liver functions.

Like most natural remedies, the science is relatively inconclusive. Some studies site anti-inflammatory mechanisms of constituents of Milk Thistle against symptoms of RA, while others didn't find concrete evidence.

Recommendations

If you suspect your liver needs help and support detoxing, I would recommend consulting a Naturopath or functional medicine doctor about starting milk thistle. Gaia is my go-to brand for milk thistle. I pick it up at Whole Foods or through Wellevate.com. I started with 1 capsule at night and have slowly worked my way up to 3 capsules a night.

I crave Saag Paneer, but the dairy and additives from my favorite Indian restaurant flares my RA. This variation satisfies my cravings! Now, I need to find a dairy-free, night-shade free curry (but that may be too wishful!).

Ingredients:
2 tbs olive oil
1 medium onion (chopped)
4 cloves of garlic (minced)
2 tsp ginger root (grated)
1lb fresh spinach
1 tsp Garam Masala
½ tsp cumin
½ tsp coriander
½ tsp turmeric
1 tsp salt
½ cup water
1 cup coconut cream and milk (use separated coconut cream at top of coconut milk can and add coconut milk until 1 cup is reached)

Optional:
Organic basmati rice
Riced cauliflower
Cooked chicken
Tofu

Directions:

1. Finely chop spinach with a food processor or blender.
2. Heat olive oil in skillet for 1-2 minutes. Place in onions and saute for 3 minutes.
3. Add ginger, garlic and salt and saute for 2 minutes.
4. Stir in spices, spinach, water and simmer for 5-10 minutes until water is evaporated and spinach is tender.
5. Stir in coconut cream and coconut milk. Simmer for another 5 minutes.
6. Add cooked chicken or tofu if desired and serve over organic basmati rice or riced cauliflower.

Type 1 diabetes is an autoimmune disease, where the body doesn’t produce insulin, which is crucial in regulating sugar uptake by various cells. Without insulin, people with diabetes can have too much or not enough sugar throughout their bodies which causes many issues. To counteract this, people give themselves insulin in reaction to how much sugar they’ve eaten and how much glucose is in their body. For many years, this has been done by injecting insulin using a needle and syringe. However, recent medical advancements have changed this, including medical devices that automatically reads peoples’ glucose, calculates insulin dosage, and administers insulin accordingly. These devices do the work for people with diabetes, which will be a life changing product for many.

Many of people with diabetes say they want a vacation from their disease, and these devices are a leap in this direction. Yes, a leap. It’s truly incredible to have a system read, calculate, and administer in such a manner.

We never get a vacation from RA. It’s a job that never ends and follows us wherever we go. When I go to the grocery store, I grab a cart to carry eggs and apples because my arms cannot carry a basket around the store. I weigh every text message I receive, “is the pain and stiffness in my fingers tomorrow morning worth responding to this text?”. When I cook, I pick pots and pans from my cabinet based on whether I can lift them to the stove.

When I truly get a relaxing vacation to a sunny beach, like Bermuda (yes, I am on a flight there now), half my suitcase is packed with medication, supplements, comfy shoes, and food I can eat. The TSA agent was probably curious why I had 5 lemons stuffed between my bathing suit and sandals in my suitcase. Never mind, the preparation and lists. It gives me a sneak preview into packing for a newborn. Did I remember my CBD oil? What do I need for the flight in case my feet start flaring? What restaurants are we eating at and can I eat anything on the menu? Is this truly a vacation? It’s a vacation from my 9 to 5 job, but not from my 24/7.

What does a vacation from RA look like to you?

What does a vacation from RA mean to you? Does it mean you get to relax for 20 minutes without pain? Does it mean you give your hands a break from cooking dinner one night a week and take a bath instead?

For me, it's when my body feels truly restful. Every night, I go to bed about 30 minutes before I fall asleep and read. I prop my book on a couple of pillows, and let my body go limp. I rest and sometimes mediate. All joint pain seizes. This is my vacation.  

I go to acupuncture every week. My acupuncturist has me lie on her table for 40 minutes with needles poking in my feet, knees, elbows, and head. Every muscle heavily drops into the table. I think about moving my leg or lifting my arm, but my whole body stays motionless and the pain subsides. This is my vacation.

Don't get me wrong – sitting by the ocean on a humid, sunny afternoon in Bermuda is also extremely relaxing! But, I look forward to going to bed or my acupuncture appointments. It's a couple of minutes of total relief and relaxation. My body craves this. It needs this to heal.

Find your vacation. Take your vacation.

Yes, find the peaceful moments that relieve your pain. For some this is yoga or a bath or reading a book. Allow your body to fully relax, restore, and heal during this time. I challenge you to find your vacation and then go on vacation every week. Your body will thank you.

One of my RA triggers is (what I call) physical trauma. I noticed it for the first time when I was skiing with a bunch of friends. After a long day on the mountain, I took my ski boots off only to notice that some of my toes were red, hot, and swollen from my slightly too small boots. This led to a 6-week flare. 9 months later and I still had occasional redness and pain along with nerve damage.

The second time this happened was at my husband's 30th birthday party. I wore a pair of clogs that I've worn for the past 5 years. I was on my feet for about 4 hours and could feel an ache in my right foot towards the end of the night. It was really difficult to walk for the next three days. I've thrown out all my high heels and have succumb to wearing sneakers everywhere - even at work. Cole Haan has been a lifesaver! Their Nike soles with flattering style has given me a comfortable business casual shoe that I can dress up or down.

When my knees and feet first flared, I always thought, "I still have my hands. I can still type on my computer, work, do laundry, and cook". With time this has become increasingly more difficult. It's frustrating and demoralizing to not be able to text people back or only able to chop half an onion.

Everything I do has a lifelong consequence to my body. Before RA I would spend all day riding horses or in the kitchen cooking and not think twice about it. Now I think about the consequences every activity has on my body. I used to see a large staircase and think "this is great exercise". Now I ask "will I be able to walk tomorrow?".

This isn't only physically exhausting, but also mentally and emotionally. As humans, we naturally create habits and routines to decrease the number of decisions we make throughout the day. This gives us more energy to make larger, more challenging decisions, like how to handle a difficult situation at work. However, chronic illnesses require more decisions throughout the day. Can I go up these stairs and walk tomorrow? Will this food trigger a flare? Did I take my medication this morning? This requires more energy. Energy my body doesn't have.

When I first got diagnosed with rheumatoid arthritis, my Vitamin D levels were extremely low. Living in New England this didn't come as a surprise. I picked up a Vitamin D supplement at Whole Foods with two ingredients: Vitamin D and peppermint. I started by taking 10,000 IU and have since decreased to 5,000 IU. After taking it for a couple months, I learned the importance of Vitamin D and autoimmunity. This has quickly turned into one of my forever supplements.

Vitamin D & RA Statistics

• Vitamin D deficiency is highly prevalent in people with RA²
• Prevalence of RA decreases in individuals with high intake of Vitamin D
• Deficiency may be associated with disease activity
• Low Vitamin D level in RA may lead to secondary osteoporosis
• People with RA and depression have significantly lower Vitamin D levels than people with RA and without depression
• Low Vitamin D levels have increased neuropathic pain¹

Vitamin D Affects on RA

Vitamin D is a hormone produced when the skin is exposed to sunlight or absorbed through the foods we eat. It regulates 5% of the human genome and directly or indirectly regulates behavior of more than 36 different cell types¹. Most importantly Vitamin D regulates the immune system, and deficiencies can even induce autoimmune diseases, including RA.

Liver and kidney enzymes convert Vitamin D to its active form, which goes on to support many functions, including regulating the immune system. It does this through three key pathways that are pertinent to RA. First, it maintains a balance of different types of immune cells, called T cells, to suppress autoimmune response¹. Secondly, Vitamin D regulates cytokines, which are communication molecules within the immune system. One particular cytokine found to be elevated in people with RA is TNF. Studies have found that as Vitamin D increases, TNF decreases, and vice versa. Lastly, Estrogen boosts immune activity in joint tissue of people with RA, however, Vitamin D suppresses estrogen activity, thus controlling immune response³.

Vitamin D is heavily correlated with RA disease activity and anti-CCP level¹. As Vitamin D decreases both disease activity and anti-ccp increases⁵. And vice-versa, as Vitamin D increases disease activity and anti-ccp decreases.

Importantly, Vitamin D helps regulate bone mineralization by stimulating calcium and phosphate absorption in the gut and bone cell differentiation. Bone mineralization is a delicate and dynamic process to form a fibrous matrix of collagen and minerals, including calcium and phosphate, within the bone. This fibrous matrix gives bone rigidity and structure to support our bodies. It's a process that constantly takes place throughout our lives.

Corticosteroids, such as prednisone, impairs vitamin D metabolism and reduces calcium absorption. This disrupts bone mineralization, which causes weak, brittle bones. Because of this, Osteoporosis is a secondary side effect to long-term prednisone use in people with RA⁴.

Should I Take a Vitamin D Supplement?

If you have RA, you may consider getting your Vitamin D levels tested and supplement with a Vitamin D3 as needed. Humans obtain Vitamin D in two forms: vitamin D2 and vitamin D3. Vitamin D3 is the main form we use. You may also want to consider a supplement with limited additives.

In addition, we should look to eat Vitamin D rich foods, which include fatty fish (salmon and tuna), fish liver oils, and small amounts in beef liver, cheese, and egg yolks.

Sun exposure is another crucial way of getting Vitamin D and only a small amount is needed. 5 to 30 minutes between 10 a.m. and 3 p.m. at least twice a week on the face arms legs or back without sunscreen raises Vitamin D to sufficient levels⁴.

Vitamin D can be used to prevent onset of autoimmune diseases. If you have a family history of autoimmune diseases, such as lupus or rheumatoid arthritis, it may be beneficial to consider taking a Vitamin D supplement to prevent activation and diagnosis.

References:

1. Aslam, M., et al. (2019). Vitamin D as a principal factor in mediating rheumatoid arthritis-derived immune response. BioMed Research International.
2. Kostoglou-Athanassiou, I. et al. (2012). Vitamin D and Rheumatoid Arthritis. Endocrinology and Metabolism. 3(6): 181-187.
3. Harrison, S. R., Li S., Jaffrey, L. E., Raza, K., Hewison, M. (2019). Vitamin D, Autoimmune Disease and Rheumatoid Arthritis. Calcified Tissue International.
4. Vitamin D. (N.D.) National Institute of Health.
5. Wang, Y., et al. (2016). Serum Vitamin D Level is Inversely Associated With Anti-Cyclic Citrullinated Peptide Antibody Level and Disease Activity in Rheumatoid Arthritis Patients. Archives of Rheumatology. 31(1):64-70.