Research Article - (2025) Volume 20, Issue 6

Investigating The Influence Of Lifestyle Factors On The Development And Progression Of Rheumatological Conditions System

Keywords

Rheumatoid arthritis; Osteoarthritis; Ankylosing spondylitis; Lifestyle; Diet; Physical activity; Smoking; Autoimmune disease; Inflammation; Disease progression

Introduction

Rheumatological conditions, including rheumatoid arthritis (RA), osteoarthritis (OA), and ankylosing spondylitis (AS), are chronic inflammatory disorders that significantly impair quality of life and impose substantial socio-economic burdens worldwide. These diseases often share underlying pathogenic mechanisms, such as systemic inflammation and immune dysregulation. In recent years, there has been growing recognition of the impact that modifiable lifestyle factors—such as smoking, diet, physical activity, and stress—have on both the development and progression of these conditions (Schäfer & Keyßer, 2022).

Traditionally, the etiology of rheumatologically conditions has been attributed primarily to genetic predispositions and autoimmunity. However, emerging evidence suggests that environmental exposures and lifestyle-related choices can epigenetically influence gene expression, thereby playing an integral role in disease susceptibility (Musumeci et al., 2015). For instance, obesity—a modifiable lifestyle factor—has been associated with both increased mechanical stress on joints and systemic low-grade inflammation, particularly in OA.

The role of dyslipidemia in RA progression provides another compelling example of lifestyle factors interacting with pathophysiological processes. Lifestyle-induced lipid disturbances, such as those associated with poor diet or sedentary behaviour, exacerbate systemic inflammation and cardiovascular comorbidities in patients with RA (Toms & Symmons, 2010). These associations underscore the need for comprehensive disease management strategies that extend beyond pharmacological approaches.

Recent advances in disease-modifying treatments and biologics have improved clinical outcomes for many patients. Yet, these treatments do not eliminate disease activity for all patients and may not address contributing lifestyle factors. Integrating lifestyle interventions with standard care is increasingly being advocated to enhance therapeutic efficacy and improve long-term outcomes (Rehman et al., 2024).

Smoking is perhaps the most well-established lifestyle factor linked to adverse rheumatologic outcomes. In AS, for example, smoking not only increases the risk of disease but also significantly accelerates radiographic progression, particularly when combined with high disease activity (Ramiro et al., 2015). Likewise, prolonged smoking has been associated with increased risk for RA development and worse therapeutic responses.

Moreover, environmental exposures such as air pollution have been linked to increased RA incidence. Living in areas with high particulate matter pollution can increase systemic inflammatory markers, contributing to the pathogenesis of autoimmune responses (Venetsanopoulou & Alamanos, 2023). The synergistic impact of urban lifestyle and environmental stressors may therefore create a fertile ground for disease initiation.

The global burden of rheumatic diseases continues to rise, making preventive strategies increasingly vital. Understanding regional and global epidemiological trends highlights the role of socioeconomic status, access to healthcare, and cultural dietary patterns in shaping disease outcomes (Finckh et al., 2022). These findings encourage a shift from reactive to proactive approaches in managing rheumatologic conditions, emphasizing preventive care through lifestyle modifications.

Finally, a growing body of research points to the influence of gut microbiota, shaped heavily by dietary intake, in the pathogenesis of rheumatic diseases. Diets high in fiber and low in processed foods have been associated with greater microbial diversity and lower systemic inflammation, potentially reducing autoimmune activation (Romão & Fonseca, 2021). This underscores the interconnectivity between lifestyle choices, immunological health, and chronic disease progression.

Methodology

Study Design

This study employed a systematic review methodology, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines for transparent and replicable reporting. The objective was to synthesize existing empirical evidence on the influence of lifestyle factors on the development and progression of rheumatological conditions. The review focused on peer-reviewed journal articles involving human subjects and provided quantitative or qualitative insights into the role of modifiable lifestyle elements such as smoking, diet, physical activity, alcohol consumption, stress, and sleep.

Eligibility Criteria

Studies were included based on the following criteria:

• Population: Adults (≥18 years) diagnosed with rheumatological conditions, such as rheumatoid arthritis (RA), osteoarthritis (OA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE), and psoriatic arthritis (PsA).
• Interventions/Exposures: Any reported lifestyle factors including but not limited to diet, physical activity, smoking, alcohol, sleep patterns, and stress.
• Comparators: Healthy individuals or patients with different lifestyle exposures (e.g., smokers vs. non-smokers, sedentary vs. active).
• Outcomes: Disease incidence, progression (clinical or radiological), symptom severity, inflammatory markers, and quality of life.
• Study Designs: Randomized controlled trials (RCTs), cohort studies, case-control studies, and cross-sectional analyses.
• Language: Only studies published in English were considered.
• Publication Period: 2010 to 2024 to ensure contemporary relevance (Figure 1).

Figure 1. PRISMA flow diagram.

Search Strategy

A structured search was conducted using databases including PubMed, Scopus, Web of Science, Embase, and Google Scholar for grey literature. The following Boolean search terms and keywords were used in various combinations:

• (“rheumatology” OR “rheumatoid arthritis” OR “osteoarthritis” OR “ankylosing spondylitis” OR “autoimmune arthritis”)
• AND (“lifestyle” OR “diet” OR “physical activity” OR “exercise” OR “smoking” OR “alcohol” OR “stress” OR “sleep”)
• AND (“development” OR “progression” OR “flare-up” OR “severity” OR “disease activity”)

Manual searches of reference list from key review papers were also performed to identify relevant articles not captured by database searches.

Study Selection Process

After database searches, all citations were exported to Zotero, where duplicates were removed. Titles and abstracts were screened by two independent reviewers (blinded to each other’s decisions). Full texts of potentially eligible studies were retrieved and reviewed in detail for inclusion. Disagreements were resolved through discussion or consultation with a third reviewer. The final selection included 15 studies that met all eligibility criteria.

Data Extraction

A standardized data extraction form was developed and piloted. The following information was systematically extracted from each included study:

• Author(s), publication year, country
• Study design and sample size
• Population characteristics (age, gender, diagnosis)
• Lifestyle factors evaluated
• Measurement tools (e.g., food frequency questionnaires, physical activity scales)
• Main findings related to disease development or progression
• Confounders adjusted for in statistical analyses

Extraction was conducted by two reviewers and verified for accuracy by a third reviewer.

Quality Assessment

The quality and risk of bias of included studies were evaluated using appropriate tools depending on the study design:

• Newcastle-Ottawa Scale (NOS) for observational studies
• Cochrane Risk of Bias Tool for randomized controlled trials

Studies were rated as high, moderate, or low quality based on criteria such as selection bias, comparability of groups, and outcome assessment reliability.

Data Synthesis

Given the heterogeneity of included studies in terms of populations, exposures, and outcome measures, a narrative synthesis was conducted. Key themes and patterns were identified and categorized by lifestyle factor and rheumatologic condition. Where data permitted, relative risks (RR), odds ratios (OR), or hazard ratios (HR) were reported. No meta-analysis was conducted due to variability in outcome definitions and measurement tools across studies.

Ethical Considerations

As this was a secondary analysis of published data, no ethical approval or informed consent was required. However, all included studies were published in peer-reviewed journals and were assumed to have received appropriate ethical clearance.

Results

A total of 15 studies met the inclusion criteria and were analyzed to evaluate the influence of lifestyle factors on the development and progression of rheumatological diseases. These studies spanned various rheumatologic conditions, including rheumatoid arthritis (RA), osteoarthritis (OA), and ankylosing spondylitis (AS), and examined a wide range of modifiable lifestyle exposures such as smoking, diet, physical activity, sleep, obesity, and stress.

Smoking was the most consistently reported detrimental lifestyle factor across the studies. It was linked not only to an increased risk of developing RA but also to more severe disease manifestations and poorer treatment responses. For instance, Ramiro et al. (2015) demonstrated that smoking amplified radiographic spinal progression in AS patients, especially those with higher disease activity. Similarly, Karstensen et al. (2022) found that smoking was associated with more severe disease phenotypes and reduced treatment responsiveness in RA cohorts from Scandinavia.

Dietary patterns also significantly impacted disease development and management. Several studies identified that anti-inflammatory diets, particularly the Mediterranean diet, were associated with reduced disease activity and flare frequency. Gioia et al. (2020) emphasized the benefits of nutrient-dense diets rich in omega-3 fatty acids and vitamin D for RA patients. Likewise, Shekhar et al. (2023) reviewed the connection between poor dietary habits and the increased risk of developing RA, suggesting that metabolic and inflammatory pathways are influenced by nutritional intake.

The gut microbiota, heavily influenced by diet, was highlighted by Romão and Fonseca (2021) as a crucial factor in autoimmune pathogenesis. Their study described how dysbiosis might disrupt immune tolerance and promote systemic inflammation. The authors suggested that dietary modification could potentially re-balance the microbiome and reduce disease risk.

Physical activity emerged as a protective factor in several studies. Katz et al. (2017) reported that increased physical activity was associated with slower functional decline and improved joint performance in RA patients. In OA patients, Musumeci et al. (2015) observed that regular physical activity reduced stiffness, improved joint mobility, and delayed disease progression.

Obesity and elevated body mass index (BMI) were found to be major contributors to disease burden across both RA and OA populations. Overweight individuals had higher disease activity scores and were more prone to structural joint damage. Novella-Navarro and Plasencia-Rodríguez (2021) concluded that elevated BMI in undifferentiated arthritis patients predicted disease persistence and erosive progression. McAlindon et al. (2014) supported these findings, reporting that weight loss significantly improved joint symptoms and slowed OA progression.

Stress and sleep were less frequently investigated but showed notable correlations. Hu et al. (2019) conducted a meta-analysis demonstrating that poor sleep quality significantly correlated with increased inflammatory markers and RA symptom severity. Additionally, Arleevskaya et al. (2022) highlighted that chronic stress could provoke immune dysregulation, leading to flares and heightened disease activity.

In exploring early disease markers, Sparks et al. (2016) demonstrated that smoking contributed to seropositive RA development in women in a dose-dependent manner. Their longitudinal cohort study added strong epidemiological evidence to the role of environmental exposures in disease etiology.

Environmental and socioeconomic contexts were also considered. Finckh et al. (2022) analyzed global RA epidemiology and emphasized that lifestyle-related risk factors such as smoking, diet, and obesity interacted with access to healthcare, shaping disease burden across populations. Toms and Simons (2010) further elaborated on how lifestyle-driven dyslipidemia compounded cardiovascular risk in RA, a major cause of mortality in this population.

Lastly, Venetsanopoulou and Alamanos (2022) reviewed both genetic and environmental contributions to RA, underscoring that while genetic predisposition is important, lifestyle factors such as smoking, obesity, and poor diet often determine whether the disease manifests clinically.

Taken together, the studies provide strong evidence that lifestyle factors significantly influence both the onset and trajectory of rheumatological conditions. The integration of lifestyle interventions with pharmacological treatments appears essential for comprehensive disease management (Table 1).

Discussion

The findings of this systematic review confirm that modifiable lifestyle factors play a significant role in both the development and progression of rheumatological conditions such as rheumatoid arthritis (RA), osteoarthritis (OA), and ankylosing spondylitis (AS). Multiple studies have highlighted the gap between patient awareness of these influences and the extent to which they are discussed in clinical settings. For example, Schäfer and Keyßer (2022) noted that although patients with inflammatory arthritis frequently inquire about how lifestyle affects their disease, physicians often neglect these discussions during routine consultations (Schäfer & Keyßer, 2022).

One of the most consistently documented lifestyle factors affecting rheumatological conditions is smoking. It not only increases the risk of developing RA but also accelerates disease progression and diminishes treatment response. Karstensen et al. (2022) found that smoking was associated with higher disease activity and lower remission rates in Scandinavian cohorts, reinforcing its status as a key preventable risk factor (Karstensen et al., 2022). Similarly, Gerlag et al. (2012) emphasized that early immune alterations in preclinical RA stages were more likely to lead to seropositive RA among smokers (Gerlag et al., 2012).

Obesity and increased body mass index (BMI) have also emerged as significant contributors. Novella-Navarro and Plasencia-Rodríguez (2021) showed that elevated BMI was associated with a greater risk of disease persistence and erosive progression in patients presenting with undifferentiated arthritis (Novella-Navarro & Plasencia-Rodríguez, 2021). This is consistent with other evidence suggesting that adipose tissue promotes a chronic inflammatory state, which exacerbates autoimmune activation and joint degradation.

Dietary habits represent another influential modifiable domain. Diets rich in anti-inflammatory foods—such as the Mediterranean diet-have been shown to decrease systemic inflammation. Gioia et al. (2020) found that adherence to such dietary patterns correlated with reduced disease activity and flare frequency in RA patients (Gioia et al., 2020). Meanwhile, Maisha et al. (2023) proposed mechanistic pathways linking poor nutrition to mucosal immune activation and the development of RA-related autoantibodies (Maisha et al., 2023).

Another emerging area of interest is the gut microbiome. Recent evidence supports the hypothesis that diet-induced dysbiosis can modulate systemic immune responses. Gerlag, Norris, and Tak (2016) described how alterations in microbial composition might influence the breach of immune tolerance, thus paving the way for RA onset (Gerlag et al., 2016). These findings highlight the potential for dietary interventions not just as symptom management tools but as preventative strategies.

Stress and psychological health are increasingly recognized as important in modulating inflammatory responses. Arleevskaya et al. (2022) emphasized the biopsychosocial interplay in RA, suggesting that psychosocial stressors can influence disease susceptibility and progression through neuroendocrine mechanisms (Arleevskaya et al., 2022). This underscores the importance of holistic approaches that incorporate mental health support into rheumatologic care plans.

Although substantial evidence supports the role of modifiable risk factors, Oliver and Silman (2006) caution that the strength of associations varies, and some relationships (such as those between RA and specific diets or occupations) lack consistent biological plausibility (Oliver & Silman, 2006). Nevertheless, the reproducibility of findings across diverse populations and methodologies lends weight to the importance of lifestyle interventions.

Finally, the interplay between genetics and lifestyle must not be overlooked. Deane et al. (2017) argued that while genetic predisposition may create susceptibility, environmental exposures like smoking or diet ultimately determine disease manifestation and severity (Deane et al., 2017). This gene-environment interaction reinforces the value of early lifestyle modification, particularly for individuals at high genetic risk.

Conclusion

This systematic review highlights the substantial influence of modifiable lifestyle factors-such as smoking, diet, physical activity, sleep, and stress—on the development and progression of rheumatological conditions, including rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis. The evidence across 15 studies demonstrates that unhealthy behaviours like smoking, poor diet, and sedentary lifestyle significantly increase disease risk and exacerbate disease activity, while healthier behaviours contribute to reduced inflammation, slower radiographic progression, and improved functional outcomes. These findings emphasize the importance of early lifestyle interventions as part of both preventive and therapeutic strategies in rheumatology.

Despite the growing body of evidence supporting lifestyle modification, these factors remain under-addressed in clinical practice. To optimize patient outcomes, a more integrative care model is needed-one that combines pharmacological treatment with individualized lifestyle counselling. Future research should focus on longitudinal, controlled interventions to quantify the impact of lifestyle changes on clinical, radiological, and immunological outcomes. Meanwhile, clinicians should be encouraged to actively engage patients in discussions about behaviour change, empowering them as active participants in managing their condition.

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