2021 EULAR Recommendations on Lifestyle Behaviors and Work Participation Among Patients With Rheumatic and Musculoskeletal Diseases

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A EULAR taskforce developed recommendations regarding lifestyle behaviors and work participation to prevent progression of rheumatic and musculoskeletal diseases among patients.

The European Alliance of Associations for Rheumatology (EULAR) released recommendations on lifestyle behaviors and work participation to prevent the progression of rheumatic and musculoskeletal diseases (RMDs). The full report was published in Annals of the Rheumatic Diseases.

The recommendations were developed by a EULAR taskforce using an evidence-based approach. The taskforce included 19 members, including rheumatology health care professionals, geriatricians, epidemiologists, public health experts, individuals with RMDs, Emerging EULAR Network members, and exposure domain experts (nutrition, exercise, and work participation experts) from 11 European countries.

The taskforce initially convened via teleconference to develop the protocol and search strategies for systemic reviews to evaluate the association between 6 lifestyle exposures (exercise, diet, weight, alcohol, smoking, and work participation) and 7 RMDs (osteoarthritis, rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis, systemic lupus erythematosus, systemic sclerosis, and gout).

An initial systemic review was conducted between January 1, 2013, and September 18, 2018, and the results were reviewed in January 2019. Systematic reviews of original research, 1 for each of the 6 predefined exposures, were conducted from March 2019 to May 2019. The population, intervention, comparator, and outcome (PICO) format was used to develop search strategies for each review. Searches were conducted in PubMed/Medline, EMBASE, and CENTRAL databases. A total of 6 systematic reviews were performed for each exposure to gather evidence to develop the recommendations. The taskforce later reconvened in person to discuss the systemic review results.

The EULAR taskforce developed a final set of 18 specific recommendations regarding individual lifestyle factors and 5 overarching principles. All taskforce members indicated their level of agreement for each recommendation.

Overarching Principles

  • Lifestyle improvements should complement rather than replace medical treatment.
  • Lifestyle improvements should made be an important part of RMD management as they are essential to the overall health and well-being of patients.
  • The World Health Organization (WHO)’s recommendations for a healthy lifestyle are noted to be relevant and useful.
  • Several factors such as age, sex, health condition, pregnancy, and comorbidities individually influence the effectiveness of lifestyle recommendations. Therefore, health care professionals need to consider these factors while providing options for lifestyle changes.
  • Regular discussions on lifestyle factors are encouraged between health care professionals and patients with RMDs.

Exposure-Specific Recommendations


  • The taskforce noted the benefits of exercise for patients with RMDs, especially with regard to disease symptoms and progression.
  • Exercise should be encouraged among patients owing to its benefits in pain management, function, and improved quality of life.
  • Physical inactivity should be discouraged among patients with RMDs; providers can recommend regular exercise depending on individual abilities.
  • Moderate-intensity workouts, including aerobic and strengthening exercises, should be considered for patients with RMDs.
  • Health care providers should remind patients that exercise is safe and that it is never too late to begin exercising, even if patients have been physically inactive prior to the onset of their condition.
  • Patients can be encouraged to perform exercises in different settings, alone or in groups. Group exercises have shown a marginal benefit over exercises performed alone.
  • Providers should encourage exercise for patients with osteoarthritis and axial spondyloarthritis owing to its benefit in disease-related outcomes.


  • The taskforce noted the importance of a healthy and balanced diet in lifestyle improvement.
  • Patients should be made aware that only eating specific food types are unlikely to have significant benefits with regard to RMD outcomes.


  • The taskforce noted that targeting for a healthy weight is essential.
  • Health care professionals should work with patients who are considered overweight or with obesity to achieve controlled and intentional weight loss through a healthy diet and increased physical activity, as this may be beneficial for RMD outcomes.


  • Health care professionals should discuss alcohol consumption with patients before initiating new treatments.
  • Patients should be reassured that a low level of alcohol consumption is unlikely to negatively impact RMD outcomes, except in certain situations.
  • Health care professionals and patients with rheumatoid arthritis (RA) must be consider the fact that moderate alcohol consumption is associated with increased risk for RA flares and comorbidities.
  • Health care professionals and patients with gout also must consider that moderate alcohol consumption is associated with increased risk for gout flare.


  • Smoking should not be encouraged among patients with RMDs. Patients must be made aware that smoking is detrimental to symptoms, function, disease activity, disease progression, and occurrence of comorbidities.
  • Health care professionals and patients with RA must note that smoking may alter disease modifying anti-rheumatic drug (DMARD) treatment response.


  • Work participation may benefit overall health outcomes, and therefore, it should receive attention during health care consultations.

Limitations of the recommendations included the possibility of missing studies due to the large scope of the project, publication bias, potential conflict of interests in certain dietary exposures, and the existence of a large disparity in the evidence published.

The taskforce members concluded, “[W]e have developed an extensive set of recommendations that can serve as a foundation for discussion and shared decision-making regarding positive modifications to the lifestyles of people with RMDs, with the ultimate goal being improvements in symptoms, quality of life and long-term outcomes.”


Gwinnutt JM, Wieczorek M, Balanescu A, et al. 2021 EULAR recommendations regarding lifestyle behaviours and work participation to prevent progression of rheumatic and musculoskeletal diseases. Ann Rheum Dis. Published online March 8, 2022. doi:10.1136/annrheumdis-2021-222020