Introduction to Integrative Rheumatology

Posted By SHL Librarian

Presented by Neha Shah, MD
Clinical Instructor, Medicine­­-Immunology & Rheumatology
November 9, 2017

Integrative rheumatology is a field that brings together the principles of integrative medicine with rheumatology to help people with arthritis and other rheumatic and autoimmune illness.

Integrative medicine looks at the “whole” patient—body, mind, and spirit—to use therapies appropriate to each individual person. Some of the most important components are diet, nutrition and botanicals.

Such integrative therapies have been found effective against body inflammation that occurs in rheumatic disease and autoimmune conditions, said Neha Shah, MD, in a presentation at the Stanford Health Library.

Integrative medicine “is combining the best of all worlds,” said Dr. Shah, a board-certified rheumatologist and clinical instructor in immunology and rheumatology.

New and old therapies

Dr. Shah said she embraces conventional medical research studies used to assess the effectiveness of therapies and procedures. But she also thinks integrative therapies that borrow aspects of ancient medicine–like Ayurvedic and Chinese practices—have immense value as well.

“For me, 3,000 years of experience and observation and tried-and-true remedies is also a different kind of evidence,” Dr. Shah said. “They were very scientific in their own right. They can really provide patients with a whole system of medicine that really approaches all aspects of health.”

With integrative medicine, she said, “We’re not just treating one disease, or one symptom. We’re looking at patients as a whole.”

She described the three aspects of health—body, mind, and spirit—as three legs on a stool.

“If any one of them is off balance, or shorter than the other, that stool is just not going to be very balanced,” she said. “We really need to look at the whole person.”

The leaky gut

The application of integrative medicine to rheumatology has roots in the alternative medical movement of the 1960s and 1970s, Dr. Shah said. Some chiropractors and naturopaths at the time floated the idea that the human gut had walls that were “leaky.”

Leaky walls could allow environmental allergens and toxins in the gut to spread in the body and trigger inflammation elsewhere. Conventional medical doctors at that time dismissed the idea as “hogwash,” Dr. Shah said.

Fast forward to recent years. Mainstream medical studies have discovered “intestinal permeability” in the gastrointestinal (GI) tract. If someone eats food or ingests toxins that cause an inflammatory response in the gut, that inflammation may spread to other parts of the body.

“We’ve come a long way, and conventional medicine recognizes the fact that—like the skin, like the lungs–the GI tract is a huge portal through which the environment can affect our health,” Dr. Shah said.

Some of that also happens when prescribed medicines travel through the gut or GI tract. Antibiotics—as well as toxins, food particles, and food allergens–can affect the gut in ways that spread to the body.

“Allergens don’t necessarily mean food that causes hives and tongue swelling,” Dr. Shah said. “It could be foods that trigger other forms of inflammation.”

The microbiome

The gut isn’t merely a portal. It contains its own microbiome—the community of diverse bacteria that live in the gut as well as in our respiratory tract and on our skin. This bacterial community can be influenced by how we live and what we eat. In turn, the microbiome can also influence our health, Dr. Shah said.

When the gut microbiome falls out of balance—and harmful bacteria outweigh helpful bacteria—the result is called “dysbiosis,” Dr. Shah said. “When that is off balance, it starts affecting our health.”

Events like surgery, or taking drugs like antibiotics, can throw off the balance of bacteria in the gut microbiome. So can lack of exercise. “The microbiome isn’t necessarily what it’s supposed to be in a lot of patients,” Dr. Shah said.

The food we eat can also have a big effect. “It has such a huge impact on what’s growing in our gut,” Dr. Shah said. In addition to its influence on the gut, food macro- and micro-nutrients can have a direct impact on our immune system and inflammation throughout the body.

Food as medicine

“Going back 100s of years, food was medicine,” Dr. Shah said. “There weren’t pharmaceutical companies, and pills. People used food as medicine.”

In the 1980s and 1990s, Scandinavian studies found that changes in eating habits affected inflammation in the body. Some found a gluten-free diet improved inflammation, Dr. Shah said. A few studies done in Sweden supported vegan or vegetarian diets.

According to some researchers, the dominant food habits in the U.S.—dubbed “SAD” for standard American diet—may increase the risk for rheumatoid arthritis, Dr. Shah said. SAD meals are often heavy on hamburgers and French fries, without a lot of color from vegetables or fruit.

Refined flours and meat are two suspected culprits. So is sugar: “It’s a big no-no. Sugar definitely stimulates inflammation in the body through various mechanisms,” she said.

Other studies have found benefits from eating certain cold-water fish that are high in oil with omega-3 fatty acids. People eating the most fish had the lowest risk of developing rheumatoid arthritis, Dr. Shah said.

As a result, Dr. Shah advises her patients to try to shift their food choices from SAD to a Mediterranean plant-based diet. She also recommends plenty of fish rich in omega-3 fats.

Elimination diets

Dr. Shah also guides a lot of people who want to try elimination diets—cutting out first one kind of food, then another, to see which ones aggravate their arthritis or other health conditions.

“There are many diets that are out there that propose some sort of elimination: gluten-free, dairy-free, soy-free, corn-free, meat-free, sugar-free,” she said. She acknowledged that there isn’t much strong evidence from studies yet to show that eliminating specific food antigens helps ease rheumatoid arthritis or other types of inflammation.

But she thinks it’s worth a try. “I think this is a really low-risk intervention that we can do with our patients,” Dr. Shah said. “There’s not a lot of harm in taking certain things out of the diet for 3 to 4 weeks, and then re-introducing them to see if patients have more pain.”

The Mediterranean diet is sometimes called an anti-inflammatory diet. Dr. Shah described the diet as a food pyramid:At the bottom, to be eaten in the most plentiful quantities, are green leafy vegetables like kale, cabbage, arugula, and spinach.

  • Next higher come colorful vegetables that are red, yellow, and orange like peppers, beets, sweet potatoes, and tomatoes.
  • Above that are balanced proteins, some of them plant-based, including quinoa, legumes, beans, and sprouts.
  • Still higher, in limited amounts for people with diabetes, are colorful fruits like blueberries, cherries, grapes, and raspberries.
  • Near the top is food high in omega-3 fats, including nuts and seeds.
  • At the top are “functional foods” like spices, green tea, herbs, and other foods containing phytonutrients that fight inflammation.

“Eat a rainbow of fruits and vegetables,” Dr. Shah said. “They’re colorful for a reason. They have phytonutrients.” Most of the phytonutrients in these fruits and vegetables have anti-oxidant and anti-inflammatory action, or anticarcinogen action.

She is especially enthusiastic about spices like turmeric, one of the main components of curry powder, as well as ginger, garlic, and a dozen others.

She thinks of spices as adding “an upgrade on your meal. You get added flavor, and you get added health benefits with minimal calories,” Dr. Shah said.

One more tip she often has for patients is to cut back on cooking food at high temperatures. Instead of frying or grilling, try boiling or steaming. Grilling can produce advanced glycosylated end products (AGEs), which can damage DNA and age cells faster.

Many of Dr. Shah’s patients ask her if they need vitamins or supplements even if they’re eating healthy food. “The answer often is, ‘No, you don’t,’ “ she said. “I don’t think everybody needs to be on supplements. First and foremost, food is medicine.”

But she added, “I’ll be the first to say I don’t get as much turmeric in my diet as my grandmother did. So I take a curcumin supplement.”

Beyond good nutrition, there are other aspects of integrative health that can influence arthritis, other rheumatic diseases, and autoimmune conditions: sleep and stress.


Sleep affects both the body and mind components of integrative health. Sleep can be disrupted by the pain that comes from degenerative joint disease or autoimmune inflammation.

“It’s a vicious cycle,” Dr. Shah said. Lack of sleep can in turn make people more sensitive to pain.

She recommended:

  • Set a regular bedtime. Inconsistent bedtimes may disrupt the nighttime secretion of melatonin from your pineal gland—and melatonin invites sleep.
  • Set a relaxing before-bedtime routine, like reading a book, a warm bath, or deep breathing.
  • Stop eating three hours before bedtime.
  • Avoid time in front of electronic screens, particular computers and smartphones that emit blue light. Studies have found that interferes with the melatonin secretion that invites sleep.
  • Find a comfortable position to sleep. Use lots of pillows if they help.


Modern humans have inherited a stress response from ancestors who faced animal predators and other immediate threats. That stress response enabled them to react quickly, fight or run fast and mobilize other body responses that helped them survive.

Modern stress comes from other sources that are longer term. The body’s response can turn into a chronic state of heightened hormones and chemicals linked to health risks like high blood pressure and heart disease.

People often take drugs to treat these conditions. Integrative medicine also offers alternative solutions:

  • Meditation
  • Singing in a choir or chanting often requires deep breathing from the diaphragm
  • Deep breathing from yoga
  • Laughter
  • Guided imagery

For more information:

Stanford Health Library can do the searching for you. Send us your medical questions.

Neha Shah, MD

Stanford Immunology & Rheumatology Clinic