Autoimmunity, the exposome and the rise of integrative rheumatology
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In this issue of Healio Rheumatology, we have a provocative roundtable on why there is a rise in both autoimmune laboratory phenomenon, as well as an increase in certain autoimmune diseases over the past century.
I want to thank our outstanding panelists, including Anca D. Askanase, MD, MPH, Cassandra Calabrese, DO, Frederick W. Miller, MD, PhD, and Andrew Wang, MD, PhD, for their work and perspectives on a topic that, in many ways, offers more questions than answers.
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Indeed, there is incontrovertible evidence that there is a rise in the prevalence of autoimmune laboratory phenomenon not explained merely by ascertainment bias. On the other hand, it is not entirely clear that these increases in ANA positivity have correlated with a rise in signature autoimmune diseases. This fact is not lost on any rheumatologist who is aware of the futility of most positive ANA consults in a daily rheumatology practice. However, for some decades there has been a documented increase in the incidence of a number of autoimmune conditions, leaving all of us to ask: Why?
The term “exposome” is a neologism that applies to all factors external to our genetic makeup — but not our epigenetic makeup — that can influence our biologic function. Perhaps the greatest impact of such biologic phenomenon is seen in the effects of how our personal behaviors — ie, how we eat, how we sleep, our level of physical activity and how we handle stress — influence our state of basal inflammation.
It has been asserted that chronic low-grade inflammation accounts for the majority of global deaths from diseases such as diabetes, cardiometabolic disorders, fatty liver, chronic renal and cardiovascular diseases, neurodegenerative diseases and immunodysregulatory diseases. Indeed, much of this pandemic can be attributed to our changing societal behaviors, such as unhealthy eating, obesity, and poor exercise and sleep habits, as well as chronic stress, loneliness and depression.
These behaviors may contribute to immune perturbations further influenced by the use of tobacco, drugs, excess alcohol, the quality of our food — ie, chemicals, processed, etc. — pollution, infections and global warming to name a few. I believe the study referenced below is one of the most influential papers I have read in the past 5 years, and urge all of you who have not read it and studied it to do so.
Finally, although I raise serious and complex issues that may seem far astray from the practice of rheumatology, I will assert that they are in fact now closely entwined. Our national and international societies are working hard on guidelines addressing diet, exercise and mental health among other modifiable lifestyle factors, yet we do not emphasize them in our practice or training programs often enough. Unfortunately, and reflexively, they are still too often labeled as “alternative” therapies. I believe in, and now practice, a brand of integrative rheumatology that assesses and explores the lifestyle of each of my patients, and offers resources to modify their lifestyle in healthy ways.
Indeed, some therapeutics advocated in this area lack robust data to support widespread use, but how about eating more plants and less calories (shoutout to author Michael Pollan), moderate exercise, cognitive behavioral sleep resources for those in need, and mind or mind-body practices for stress reduction treatment of nociplastic pain and fatigue?
Finally, I will shout out to my friends and colleagues, including Olga Kromo, MD, and George Muñoz, MD, who along with others have recently founded the Society for Integrative Rheumatology, which aspires to promote networking among rheumatologists with shared interest, and to critically appraise the evidence emerging from the study of such modalities and, importantly, provide a forum to discuss their shared experience in practice.
Integrative rheumatology is a field in evolution and I eagerly await more data as to its effects on health and disease, and will conclude as always by saying the data will be the data, but with a caveat. That caveat is that the time is now for wellness training and advocacy in the practice of rheumatology. For those interested in our monograph detailing the impacts of behavior on immunologic health, designed for patients with immune mediated diseases, it is free and available online (see the first reference), so please download it and use as desired.
That’s my take on immune health as of now. What’s yours? Please share your thoughts with me at calabrl@ccf.org or at rheumatology@healio.com.
- References:
- Cleveland Clinic Maintaining A Healthy Immune System monograph: https://www.clevelandclinicmeded.com/specialties/rheumatology.aspx?txtId=34.
- Furman D, et al. Nat Med. 2019; doi:10.1038/s41591-019-0675-0.
- For more information:
- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
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