Complementary Medicine Meets Rheumatology: New Ways to Reduce Inflammation

CHICAGO—At a session of ACR Convergence 2025, attendees explored several topics from the vantage of complementary and alternative medicine, many of which could easily be incorporated into a more traditional medical approach.

Putting Out the Fire of Inflammation

The speaker, Nisha Manek, MD, FACP, FRCP, is a telemedicine integrative rheumatologist with Avel eCare and is based in Yorba Linda, Calif. She has added to her conventional rheumatology expertise with various kinds of training in complementary medicine, such as through the University of Arizona’s Fellowship in Integrative Medicine.

Dr. Manek urged her colleagues to pursue alternative avenues to “fight the fire” of their patients’ inflammation. She advocated for finding ways to address inflammation at its origin and not just through standard therapies.

Diet

Dr. Manek shared stories of some patients whose symptoms remarkably improved after radically changing their diet. However, she noted that making big changes can be challenging for patients. She said, “They’re surrounded by processed foods. That’s what’s easy and accessible.”

Questions about diet are not a standard part of the medical history, Dr. Manek pointed out, and taking time to ask such questions may not be billable. “But it is concrete and modifiable. Find out what your patients are eating,” she urged.

Mediterranean Diet & Ultra-Processed Foods

Dr. Manek noted that the ACR recommends a Mediterranean diet, which emphasizes intake of vegetables, fruits, whole grains, nuts, seeds and olive oil, with moderate portions of dairy, fish, poultry, eggs and beans. Importantly, the diet also limits added sugars, refined carbohydrates and highly processed foods.¹

Zoning in on this latter category, Dr. Manek especially warned that these foods can contain many additives not optimal for health. Such foods are also often high in sugar, fat and salt.

Generally speaking, the rheumatology community agrees that large amounts of highly processed “junk foods” can worsen patients’ health. For example, two recent studies found that ultra-processed foods may increase the risk of rheumatoid arthritis (RA).^2,3

Dr. Manek also recommended limiting the use of seed oils, such as soybean, corn, cottonseed, canola, grapeseed, sunflower, safflower and generic vegetable oil, usually some blend of these. This is consistent with current health trends positing their role in inflammation, perhaps due to the way these oils are processed or their omega-6 content. Although this is not in line with much of the current expert opinion on the subject, such oils are quite common in ultra-processed foods, so limiting them in that setting may be beneficial.^4,5

Whole foods, such as fruits and vegetables, are also rich in prebiotic components that help promote a healthy microbiome, a key emerging topic in overall rheumatology patient health. In contrast, ultra-processed foods may have a detrimental effect on overall gut microbiome health.⁶ To follow emerging scientific information on this topic, Dr. Manek recommended the International Scientific Association for Prebiotics and Probiotics.⁷

Food Avoidance Trials

Some patients may also benefit from cutting out other specific types of foods, like those containing gluten, Dr. Manek argued, as they may have an inflammatory effect. This science is not settled, with many experts claiming a lack of convincing evidence on this point, at least for patients without celiac disease or a clear gluten intolerance.^8,9 For some, a gluten free diet may entail eating fewer ultra-processed foods, which can complicate interpretation.

If patients do want to try a dietary change, such as going gluten-free, Dr. Manek recommends a 12-week trial, carefully comparing symptoms before and after the change.

Supplements

Although a huge part of the commercial health industry, supplements raise concerns about drug interactions, product quality and efficacy.

Especially for complex patients on multiple medications, it’s important to assess safety and potential drug interactions. Dr. Manek noted that Natural Medicine’s Database for Healthcare Professions, a subscription-based service, is a helpful resource for clinicians in this respect.¹⁰

Dr. Manek recommends consumerlab.com as a subscription-based patient resource for supplements. They perform third party testing of popular brands of supplements, both assessing quality and giving price comparisons.

Vitamin D

Vitamin D plays an important role in immunomodulation, and many patients do not obtain sufficient levels through sunlight and diet alone. Multiple studies have shown associations between low levels of vitamin D and the presence and severity of rheumatic diseases.¹¹

The optimal level of serum vitamin D is a matter of debate. Although a level greater than 30 ng/mL may prevent osteomalacia and secondary osteoporosis, higher levels might be needed for overall immune and general health.¹¹

Dr. Manek tests many of her patients for vitamin D and very frequently finds low levels. She has found that many such patients improve with vitamin D supplementation, and she aims for 50 to 80 ng/mL.

Turmeric

Turmeric, a traditional herb, contains the active ingredient curcumin, which may have anti-inflammatory effects via the nuclear factor kappa B pathway. Some data have shown potential effectiveness in RA, for example, although consumers take the popular supplement for a variety of concerns.¹²

As a supplement, turmeric is often sold with piperine, the active component of black pepper. Although this might enhance absorption, the science on this isn’t clear. Piperine may cause gastrointestinal upset in some patients, so some may prefer versions without this added ingredient.

Fish Oil

Years of research show that fish oil may help decrease symptoms of such inflammatory diseases as RA, but supplement quality and quantity may be key.¹³ For example, Dr. Manek has concerns about many products containing multiple questionable additives.

For patients who want to try it, Dr. Manek recommends a trial of three months, with a dose of at least 2.6 grams total of eicosapentaenoic acid and docosahexaenoic acid. Patients should also cut open the capsule and smell to make sure it is not rancid, as this is a very common issue; such supplements are too oxidized to exert any positive health effects.¹⁴

Stress Management

In addition to the key role of sleep, Dr. Manek emphasized the importance of stress management for controlling inflammation. “The medications for inflammatory arthritis and connective tissue diseases do not address the stress pathways that are so fundamental to these conditions,” she said.

The nervous system and immune system are in close communication, in real time, through multiple pathways.¹⁵ Comparatively lower vagal tone (e.g., decreased parasympathetic activation) has been found in many immune-mediated inflammatory disorders. This has generated interest in vagal nerve stimulation as a potential anti-inflammatory intervention, with some promising early data.¹⁶

Dr. Manek shared results from an interesting exploratory study in RA and psoriatic arthritis that analyzed various parasympathetic and sympathetic measures, including heart rate variability. Patients who responded poorly to anti-tumor necrosis factor therapy initially had lower parasympathetic tone and higher sympathetic activation compared with responders. This underscores a potential role for autonomic effects in inflammatory autoimmune disease.¹⁷

Of course, addressing patients’ stress can be challenging on a practical level, but just communicating with patients about this factor may be beneficial. Dr. Manek also shared a popular breathing technique: breathing in for four seconds, holding the breath for seven, then exhaling for eight seconds. It doesn’t take long to share with patients, said Dr. Manek, and they quickly notice a calming effect as the parasympathetic nervous system is stimulated.

Dr. Manek also discussed strong results from a study of tai chi in fibromyalgia. She noted that such mindful, slow exercises can be accessible and reinvigorating for even some of the most debilitated patients.¹⁸ This is in alignment with current ACR positive recommendations for mind-body exercises, such as tai chi, yoga and qi gong in appropriate patients.¹

Dr. Manek also urged rheumatologists not to be dismissive when patients come to them with interventions that seem to have improved their health, even if the scientific basis isn’t clear.

“When your patients are asking and telling you things, listen, because they’re onto something,” she said.

Ruth Jessen Hickman, MD, a graduate of the Indiana University School of Medicine, is a medical and science writer in Bloomington, Ind.

References

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