How Rheumatoid Arthritis Speeds Aging—and How to Push Back

What if rheumatoid arthritis doesn’t just cause joint pain—but quietly speeds up how fast your entire body ages? In this episode of Thriving with Arthritis, Dr. Diana Girnita sits down with Dr. Neha Bhanusali, from the University of Central Florida, with additional training in lifestyle medicine and culinary medicine, to explore the powerful and often overlooked connection between chronic inflammation, biological aging, and rheumatoid arthritis. In this conversation, we move beyond trends and misinformation to focus on what actually matters for patients living with Rheumatoid arthritis (RA) and other autoimmune diseases.

Key Chapters & Takeaways

• RA and accelerated aging (“inflammaging”): chronic inflammation can accelerate biological aging—even in relatively young patients.
• Chronological age vs biological age: Why many RA patients feel older than their peers
• Why labs don’t always match symptoms
• The truth about methylation tests and anti-aging supplements
• Medications plus lifestyle—not one or the other
• Movement when you’re in pain
• Why muscle matters in RA
• Nutrition without perfection
• Gut health, fiber, and fermented foods
• Supplements: what’s reasonable and what’s risky
• Weight, inflammation, and GLP-1 medications
• Menopause and autoimmune disease
• Chronic stress, sleep, and immune aging
• The top 3 lifestyle pillars for RA and healthy aging

Neha Bhanusali is a board-certified rheumatologist with advanced training in lifestyle and culinary medicine. She also shares practical, plant-forward education on her YouTube channel @PlantForwardMD.

https://www.youtube.com/@PlantForwardMD

If you want evidence-based guidance that helps you live better—not just treat labs, subscribe to Thriving with Arthritis.

Transcript

Dr. Diana Girnita (00:00)
What if rheumatoid arthritis doesn't affect just your joints, but quietly presses the fast forward button on how your whole body will start aging? And what if there is something that you can start doing today to slow down the process of aging? To understand what inflammation is, how rheumatoid arthritis affects your biological age, and most importantly, what can we do to stop?
Dr. Diana Girnita (00:28)
or slow down the process, I have invited Dr. Neha Banusali. She is a prestigious rheumatologist from University of Central Florida. she is the first rheumatologist that I have heard talking about this important topic. And not only that, but she has extra specialties in autoimmune disease.

lifestyle medicine, but she's also a culinary medicine faculty. Dr. Neha, welcome to THriving with Arthritis podcast.

Neha Bhanusali (01:01)
Thank you so much, Diana, for inviting me.

Dr. Diana Girnita (01:04)
It's such a pleasure to have you here. I think we met at the last American Congress of Rheumatology. And what shocked me was your lecture about the impact of rheumatoid arthritis not only on the joints, but also on our age. tell us where this interest came from.

Neha Bhanusali (01:25)
I know you must have heard this also from your patients. They're in their 30s, their 40s or 50s, and they're saying to you that I may be 45 years old, but I feel like I'm 70 years old. Why is that? Something that we commonly hear, I would say like every day when we're seeing patients. And is there a reason that our patients are feeling older? And are they actually getting older faster?

I think is something that we really haven't looked at much. The CDC has come out with recommendations for the general public, but a lot of our patients don't follow that because they have so many stresses on their body. They have all this inflammation in their joints. They don't know what they should do versus they shouldn't do to protect themselves and their joints. So this actually is where my fascination came from. And I was like, are we doing a disservice by not addressing other factors that we really should? Because we're getting better and better at medications.

I won't say we're perfect, we're far from it still. compared to when I started in training, we are definitely doing better there, but maybe not so much on some of the other things that we could be.

Dr. Diana Girnita (02:27)
That's very true. I talk to my patients all the time about other things that they could do to manage their disease better. We all talk to our patients about inflammation. Inflammation can do this, inflammation can do that, but when it comes to rheumatoid arthritis, we always tell them that inflammation is like a fire that will burn their joints. But what is inflammation and how inflammation affects other parts of the body?

Neha Bhanusali (02:52)
we know about it in terms of the joints, right? Like everybody thinks about it, okay, well, you know, my joints are inflamed and I have arthritis, it's in the name, you know, and that's what I have. But actually you could have low grade inflammation in your muscles, in your heart, in your immune system, right? Your immune system is not functioning as it really should, which is why you have this autoimmune disease. So yeah, we can see inflammation in other parts, which is confusing because people think of it as an arthritis.

Dr. Diana Girnita (03:18)
True. what is the connection between inflammation and aging?

Neha Bhanusali (03:22)
there's this new term and not so new, but yeah, coming more into practice, inflammation. We actually do want inflammation when you get a cut somewhere and we want it to heal. We want those cells to run over there, fix the area, improve that and then be done with it. That should go away. You should have acute inflammation, fix it, done, gone. So the problem is chronic inflammation, low levels of chronic inflammation.

And over time, it's contributing to aging, which is what inflammation is kind of being more talked about now. And we're looking at different ways to improve that over time. Yeah.

Dr. Diana Girnita (04:00)
What are the consequences of high markers of inflammation? If we see that patients will have high markers of inflammation, does that mean that they age faster?

Neha Bhanusali (04:13)
It's an excellent point. The problem is it's so nuanced. There's a lot of trickiness to this question because as you see, some of your patients, they will correspond immediately, right? They feel bad. They feel like their joints are inflamed. And then you look at their inflammation markers on their lab results and it all corresponds. They're high, makes sense. You give them treatment, comes down, we're good. But then what about that whole other group where they get their labs done? They feel awful, okay, but they get their labs done and they're completely normal.

Their inflammation markers are normal, but they have active disease. We can see it when we're looking at them, when we're examining them that they have, you know, inflammation in their joints. They're also having it and we can't predict it so much with those inflammation markers. So I would say it's very tricky. We don't have the evidence yet to say, what do we do with that group? I do think that if you have inflammation markers that are high and it is corresponding to disease, like it makes sense, the whole picture makes sense, then yes, absolutely.

could be aging faster with just having this consistently high inflammation markers that just won't come down. Yeah, there are studies for that nowadays.

Dr. Diana Girnita (05:19)
What is the difference between the biological and chronological age?

Neha Bhanusali (05:25)
chronological age is that age on your birth certificate, know, and we get older every year. You know, if you're born in 1984, you would be about 41 years old, right? That would be your chronological age. The problem is a lot of our patients don't feel the age that's on their birth certificate. Their biological age, their biologic age is higher oftentimes than what they're seeing on that piece of paper. They're like, why do...

Why are my friends this age and I don't feel the same as them?

Dr. Diana Girnita (05:53)
Do you feel like we have any tools to evaluate what is the biological age of our rheumatoid arthritis patients?

Neha Bhanusali (06:02)
We don't have an exact measure yet, but they have a lot of different type of research that they're doing on it. And I'll give you an example. They're using something called DNA methylation clocks to see, you know, what is that age that somebody would come out to. And for example, we, most of us, not all of us tend to gain weight over time. Certainly I weigh more now than when I first got married or when I was in medical school and gaining weight itself.

can increase that biological age. For example, if your BMI used to be 25 and now it's all of a sudden 30, because over years you've gained some weight, then that five point increase in your BMI could age you perhaps almost a year more. And then on top of that, if you look at chronic stress, because that can also age you, that's another marker, sleep deprivation, just not getting enough sleep.

know, lack of movement, all of these are different factors that are contributing to increasing your biologic age, and your methylation clock. ⁓

Dr. Diana Girnita (07:03)
Let's talk more about the methylation part because I feel like there is a huge interest from patients into all these techniques that are promoted by some people with the ability to use certain supplements to methylate better.

Neha Bhanusali (07:21)
Yeah, but the problem is that none of those have really been proven to actually do it. I would love to say take this probiotic or take the supplement and it's going to really improve your lifespan, your health span, right? Because we're not always talking just about how old you're going to be.

your chronological age, we want health span to be good, right? So if we take these supplements, is it going to improve that? Honestly, we have no studies to say that. We have little tiny studies and you also have a research background and you know that people can take any research study and kind of show what they want to show in it, right? So there's not been a consistent, large, randomized trial that says any specific one of these supplements is really going to reverse that aging clock. I would love it. That would be wonderful.

Dr. Diana Girnita (08:07)
I do see a lot of companies that do promote the testing for methylation. So looking at these companies that promote this test and then looking at the supplements that they try to sell, I feel... ⁓

Neha Bhanusali (08:20)
you

Dr. Diana Girnita (08:21)
stressed to advise my patients about doing those tests because as you know, there is not enough research to support that kind of science. Now, if you have rheumatoid arthritis, can we use the medications that we have to stop aging or what other tools can we use?

Neha Bhanusali (08:42)
I get that question a lot and I think you do too. Some people do not want to use medications and they just want to try alternative techniques to improve their rheumatoid arthritis. And I am, as much as you know, I love all the lifestyle factors and using them. I am also just as big a proponent of medication because that inflammation, it is so much when you have these conditions that you really need to dampen that down.

But I do think that if you use those different lifestyle factors, which we'll talk about in a second, the goal is not to be on zero medications. It would be amazing if you could be. But especially during new diagnosis and stuff, it's not really usually feasible. But if you could just reduce kind of pare down that regimen, I think that's a win. know, not like some people have 17 medications on their list and you spend all this time doing interaction checkers. I don't know if this new medication is going to interact.

then they go to another doctor, they may have a UTI, get an antibiotic, and that somehow interacts with something else. So the goal here, I think, is to pare down that regimen, to take that biologic if you need it. You know, your joints are active, you may need it, take it, take that DMARD, but maybe you don't need extra steroids all the time, extra anti-inflammatories. There's all those other things. You don't need maybe 16 supplements either. Are they really helping you? So I think that's where really it can make an impact.

because aside from medications, we can use lifestyle. And by that, mean, number one is movement. We are not getting enough movement. A lot of it is, you when I was in New York, when I used to, when I was there for training in the city, I didn't go to the gym. I just walked more. I just walked everywhere. I would avoid the trains if I could, unless it was long. When I would go up, I was in the eighth floor. That's where our, that was where our suite was. And I would take the stairs. So I do feel bad for everybody around me.

that would see this very sweaty and out of breath person. But that was my exercise because I didn't have the time to go to the gym. And that is something that we need to really kind of institute more of because now I live in a suburban setting where we drive everywhere. And so it is hard, right, to kind of put that in your day. So a lot of us are not getting enough. And I think we have to work on that. And that does make a difference because muscle is actually metabolically active and it produces cytokines.

You know, we have the bad ones we always talk about that we want to bring this level down so that we use this medication. But nobody talks about the fact that we get good ones too when we work out and when we move. So I think that absolutely is something that we can all do a little bit more of.

Dr. Diana Girnita (11:10)
Most of our patients will tell us that they are in pain and that's the reason they cannot exercise. So what would you recommend as a regimen for them to start?

Neha Bhanusali (11:20)
everybody's regimen is going to be different. think number one, earlier this week, I met a lovely woman and she tells me that, you know, right now it's holiday season. People are getting together, large family. She's like, I can't cook the big meals anymore. But my mom, who also has rheumatoid arthritis and myself are the dishwashers for everybody. She's like, we can't carry the big dishes, but everybody brings them to us. And soaking your hands in that hot water as you're washing dishes is actually, it feels good.

And so it's really funny, but that's what their role was. And I was like, that's really amazing. It's very creative and that's what suits them. Actually standing at the sink, you know, you don't think about it because you're not really moving, but you are using a lot of muscles. So I think that's amazing they can do that. Little things like if you can't move much, balance becomes an issue for so many people. You stick to things that you can do like chair yoga. think I'm a big fan of chair yoga, regular yoga, if you can do it.

I think you have to be careful when you have rheumatoid arthritis because of what's affected. you know, a lot of times risks are affected. If you're trying to do like downward facing dog on the floor, you may not be able to because of your wrist and that's okay. You know, you change your movements. You can talk to somebody who is maybe at that gym of what you can do instead in those exercises. Like instead of palm out, you may want to make a fist and be on your arms that way. Some people can do planks, but they can do it on here. They can't do it on their hands.

There's a lot of different movements, but it really has to be tailored to the individual. And you have to think about what you can do. I think it's easier sometimes. I live in the South. It's warmer here right now. People are willing to go for walks. It's hard right now, you know, in some places it's so cold. You don't feel like going outside. So you have to be creative. I definitely have people who go to Costco and that's where they do their laps. And that's totally okay. Yeah. It hurt your credit card a little bit because it's hard to avoid buying things sometimes.

Dr. Diana Girnita (13:03)
All

Neha Bhanusali (13:08)
but I think that that's a great way to get your exercise.

Dr. Diana Girnita (13:11)
I agree 100 % that you have to be creative. You just have to find things that will be helpful to you and will apply to you. the big cardio exercise are not for everyone. What I do encourage my patients is to go in the warm water. Many times if they find a pool, a therapeutical type of pool, go there, just move all your joints.

Many of my patients will tell me that they never even thought that they could be in a pool without swimming. And that's what I say, you don't have to swim, you just go there. It's a little bit anti-gravitational. You just have to move your joints against a resistance, which is the water. And that's also ⁓ helpful in the long-term run.

Neha Bhanusali (13:44)
Mm-hmm.

Dr. Diana Girnita (13:52)
Because you are a culinary expert, I would love to hear what kind of recipes do you recommend to your patients?

Neha Bhanusali (14:02)
So I do think there definitely can be more plant-based foods that can be added. I am not about a perfect diet. There are so many different diets out there and a lot of them have been well studied. It's hard to follow some of them. Like I had definitely had patients who were like I was on this extreme diet for the last year. I feel amazing and yet it's hard to sustain. So I think some of these are what can you do? But I do think something small

that is possible for a lot of people is to add maybe more beans, lentils, you know, into their diet because it's also giving them not just plant protein, but plant fiber, which we're often not getting enough of. You know, the recommendations are certainly not something that most Americans are meeting. So I think, you know, hitting two birds with one stone would be nice if we could do a little bit more of the beans and lentils and then add more fruits and vegetables. A lot of our patients are diabetic and they're worried about the fruits.

But you know, it's overall the fiber from the fruit can be very helpful as well. So I do think that if you can tolerate it, if your blood sugar is not going wild and it's something that you can take part in, even that can be very beneficial.

Dr. Diana Girnita (15:10)
love the fact that you mention fibers because that's the part that many doctors don't even mention to their patients. And I always encourage my patients, I tell them about how the fibers are interacting with their gut, their immune system from the gut and actually regulate some of the good bacteria that we have there to produce the short chain fatty acids that we need to bring down inflammation. People don't talk enough about the role of fiber and I think that

they just focus on the sugars or the carbs or...

Neha Bhanusali (15:42)
I know.

culinary medicine is kind of this new growing field where we're trying to teach the next generation of doctors on how to use food as medicine. And they don't know how to, right? Because we've never addressed it. I certainly didn't learn about it when I was in medical school or residency, completely brand new. But also we have all these diet studies that are now coming out, right? So we have to know more about it and empower it. And I will say, here is an example that's an issue. One of our first groups that went through of medical students.

We give them scenarios, okay, what if this patient who is 68 years old has severe constipation and this issue, blood pressure and diabetes, what would you do? They'll still focus on what pills they can give for the constipation instead of thinking about the fact that what foods can we give that's going to improve because of fiber, as we talked about,

So what foods are really going to improve that constipation as opposed to just taking more pills for another problem? And that's how we're building up to 17 pills in a list in a person's list because we're not thinking about what foods we can introduce to kind of reduce that. So yes, culinary medicine has been a lot of fun and hopefully this next generation is really going to take that into account as they practice, whether it's internal medicine, even ophthalmology. So many fields now are getting into it.

Dr. Diana Girnita (16:59)
if I look back into my training, I had no nutrition training. I mean, a few, I would say a few saying here and there about nutrition, but to talk about culinary medicine, I've never had that experience. I like to cook and I learned how to cook because I have kids.

by far I'm not the greatest cook, but I do try to ⁓ implement things that I know they are healthy. So that's why my kids from time to time will tell me, ⁓ today we are eating healthy. ⁓ but I think that patients can learn very easily to do a salad, which is not very complicated to be done, or to do a stew.

Neha Bhanusali (17:31)
Yeah. Mm-hmm.

Dr. Diana Girnita (17:41)
that

not very complicated to be done.

Neha Bhanusali (17:44)
And tastes better

maybe the next day, so batch cooking would be healthy,

Dr. Diana Girnita (17:49)
I think that's another important thing that we can talk to patients. you might have days when you don't feel good about doing anything. If you have a good day where you can cook and prepare more meals and just batch them, that will help you in the time of those days where you don't feel like doing much. Do you teach ⁓ recipes during these culinary sessions?

Neha Bhanusali (18:13)
we go through patients, examples, like different medical problems, different recipes that can help. Something new that actually is more in the culinary world now is fermented food, right, which is there generations across different countries. We don't really focus on it as much over here. We don't have as much part of the Western diet, I would say, with fermented foods.

But even that, you were talking about short chain fatty acids. We're learning more how fiber helps that, but also with fermented foods, how that can help it. And I know we don't have yet the exact probiotic that's going to help people. So we're still talking about food, but the studies with our medications, right? Some people respond better to them and some people don't. And their gut microbiome is different. So how can we improve or change people's gut microbiome? So maybe even the medications will work better.

So there's so much, so much research going on over there, which is really exciting.

Dr. Diana Girnita (19:07)
also very excited to learn more about the gut health, the gut microbiome. I think we are just starting to scratch the surface into this field, but the more we learn about how our diets or how our foods, I hate this term of diet because it's so restrictive, but I do like the fact that people will incorporate more foods. In my culture, especially in this time of the year, in the wintertime, we used to eat a lot of

fermented foods from pickles to sauerkraut. That was part of my culture. I never realized how beneficial were those type of foods for us. But I had to wait for 30 years to learn about fermented foods and how beneficial they are. However, not many people in the United States will know about the value of fermented foods. Are there any fermented foods that

you'll recommend to your patients.

Neha Bhanusali (20:04)
It's easier to start off, I think, with kimchi and sauerkraut because that is here. You can get it pretty easily at most places. But I also will say that our patients may have a tougher time introducing it with their gut and they may get a little bit more issues with bloating, reflux, you so

Dr. Diana Girnita (20:20)
Thank you.

Neha Bhanusali (20:22)
Don't just go and have a whole bunch of sauerkraut, like start from the get-go. I would suggest just introducing one teaspoon of a fermented food, whichever one they choose. I think the easiest one, honestly, is miso. It's a fermented food. But the problem is that the store-bought version is not really getting you all that fermentation that you want, so you kind of have to pay attention to what you're buying and how fresh it is and how fermented it is. But it's an easier place to start than some of the other ones.

Dr. Diana Girnita (20:33)
Mm-hmm.

Neha Bhanusali (20:48)
And when you do start it, I think just one teaspoon at a time and every week you can maybe add a little bit more to that until you're at a place where you can tolerate more without getting all those GI symptoms.

Dr. Diana Girnita (20:58)
Very, very, very true, because that's kind of the feedback that I get from my patients. And I want to make sure that you can advise patients about pickles. There are a lot of pickles on the shelves of the stores. Which one are better?

Neha Bhanusali (21:15)
don't think I have a brand in mind do think with pickles, one thing is a problem is the sodium content. I think you have to really check on that and see which one kind of fits your needs. Because if that's a problem for you, then that's a problem with, I say, fermented foods. A lot of the fermented foods have more sodium in them. So that's another reason why we have to be a little bit careful when we take them. And vinegar. Yeah.

Dr. Diana Girnita (21:33)
And vinegar, we want to

avoid those that they have vinegar because that kills the bacteria that we actually want patients to have.

I really like the fact that you said there is not a perfect diet. I'm not imposing diets to my patients. And actually in the book that I wrote about lifestyle and rheumatoid arthritis, I talk about bridging the medication, like you said, bridging the medication with a lifestyle that will help them decrease the levels of inflammation. And people that...

Neha Bhanusali (22:00)
Mm-hmm.

Dr. Diana Girnita (22:08)
will promote just diet, I don't think they understand the long-term consequences of this disease if it's not properly treated.

Neha Bhanusali (22:11)
Mm-hmm.

Yeah,

actually that's exactly what I think that's one of the reasons that I kind of got into speaking on this actually is I was seeing that I was seeing people that were just like one track. If you follow this diet or if you take the supplement, your RA will be gone. And as you said, like there is no I mean, there is multifactorial. You cannot just say one diet is going to take it away. Actually, somebody I saw yesterday was saying I was like, ask her, why did you wait so long to see me?

And that's what she said. She's like, I was trying to exercise this away. I tried very hard to make it go with exercise. And I would love to say that that makes everything go away. But you know, RA. RA is just something that is unfortunately hard to turn off that inflammation cascade once it's been turned on. But there's so many things we can do.

Dr. Diana Girnita (23:02)
I have so many patients that come to me after they tried everything, from natural things to supplements to acupuncture only. And finally, when they come to me, they say, there is nothing else that I can do. I need help. And I always tell them, you did good because you tried. You saw that there is some other needs that were unmet with the diet or just the exercises you were mentioning.

But because you brought into the picture supplements, what is your opinion on supplements and what are some supplements that you agree on or you don't agree, tell us your opinion.

Neha Bhanusali (23:46)
So fiber, I prefer in food. If you can do it, a lot of patients cannot do it and they're taking fiber supplements, which is fine. If that is what works for them better, then we're happy that they're at least getting it. So fiber in whichever form. And that's the other reason why I like the foods better because you get the fiber in the foods and you get the other nutritional benefits.

But the other thing is I do like, a fan of turmeric for the most part. ⁓ It is hard to find out. Like there are those that are contaminated. And so I absolutely suggest going to more big box brands or more well-researched places, whether it's, you know, if you're doing Amazon, that's fine too, but you want to go to the place with, you know, 6,000 reviews and not like 11 reviews, right? You want to have well-vetted places.

Dr. Diana Girnita (24:09)
Mm-hmm.

cross.

Neha Bhanusali (24:30)
with the there has though there has been cases down the literature with liver failure and turmeric so we do have to be careful even with a supplement like that so that's important for us vitamin d of course is a big one that i think is important a lot of our patients it's just tough to get i live in florida and yet so much deficiency over here as well so it's not just about whether you live in a northern state versus a southern state we just see a lot of vitamin d deficiency calcium i prefer in food as opposed to supplementation

Now, some of our patients cannot get enough supplementation and then it makes sense to maybe take it. But the recommendations of 600 twice a day is not necessary for everybody. Most people actually get a fair amount in their food. And I like when they look at calcium calculators to see if they can calculate their own amount. And if it's not enough, then maybe take one of those little fun chews. know, have you ever had those? The Viac-tive chews, caramel or whatever flavor, they're tasty, great dessert, and it's 500 milligrams right there.

So I would say those are a lot of the big ones. B12 also, I am a fan of because a lot of people are deficient in B12, especially if you follow more vegan or vegetarian diets.

but also even if you don't, at a certain age, we notice just a lot more B12 deficiency and it's such an easy supplement to do that I'm totally fine with it. And one that a lot of people miss, I think, is iron actually. Like, you know, are they having enough iron in their diet? Are they losing iron for some reason? Because we have a lot of patients that have hair loss, right? That's kind of goes along and maybe part of it is definitely our medication's fault because they can cause hair loss.

But then on top of that, they may have something else that's compounding it. And a lot of times we see iron deficiency and people do better with replacement or if sometimes you're getting IV iron, whatever they need to kind of maintain that. those would probably be my top ones.

Dr. Diana Girnita (26:18)
How about fish oil?

Neha Bhanusali (26:20)
Fish oil, I would say there is studies that say that it helps with rheumatoid arthritis. You have to take kind of the larger amounts though, you two to three grams. And so a lot of people don't think they can get that if you can and you want to try it. I think it's reasonable to try. But if it's something that usually I will suggest, you know, one to two months after that, if it's not working for you, it's expensive. All of these supplements are expensive. The American College of Rheumatology, they do acknowledge there are studies.

that are positive with fish oil. But at the same time, they're not suggesting that people go ahead and take supplements, you know, because they are preferring that they get it in their diet if they can, which is why the Mediterranean diet is being touted so often now with rheumatoid arthritis. Now with also our other conditions in rheumatology, but specifically more of the studies were done in rheumatoid arthritis. Yeah.

Dr. Diana Girnita (27:09)
Let's

talk a little bit more about the Mediterranean diet. So what is your opinion about the Mediterranean diet and how can someone in the United States can apply those principles?

Neha Bhanusali (27:12)
Okay.

So the Mediterranean diet actually is very interesting and the studies they did with rheumatoid arthritis, so there's this scale, it's the VAS, the visual analog scale, and it's zero to a hundred. And when they did these studies, and there has been quite a few actually done with diet and rheumatoid arthritis, definitely more than our other conditions, and they saw that there was about a nine point drop in when you had the Mediterranean diet.

That's not very much, Diana. I wish it was much higher. I wish it was 20 to 30. That's when we really start taking notice. But at the same time, you know, when you are having this nine point drop, kind of in the pain, the fatigue and all of that, there is something that we're all doing every single day, multiple times a day. I did it this morning. I'm sure you did as well, is eating. And so if you think about it, you know, if we're doing this and even though it's only a nine point difference, but we're doing this every single day, over weeks, over years,

Dr. Diana Girnita (28:03)
Mm-hmm.

Neha Bhanusali (28:14)
We're hoping that eventually, you know, that in adjunct, like in conjunction with medication is helping also the pain, the fatigue, the different symptoms you get with rheumatoid arthritis.

Dr. Diana Girnita (28:26)
Most of my patients, when they start to incorporate principles of the Mediterranean diet, they do notice a huge improvement in their energy level, in their pain level. And I think that part of it is by cleaning the diet, moving away from certain things that we know are causing inflammation. And I would like to point the word sugar. We eat too much sugar in the United States. Sugar is incorporated in probably

if not 90 % of the foods, probably 80 % of the foods from breads to, know, pastries to cereals to you name it. Even in the ham, it's added sugar. So just by cleaning their diet and trying to incorporate more fresh fruits, more vegetables, more legumes, more fibers, then they start to feel much better. Do you seed?

in your patients?

Neha Bhanusali (29:21)
Yeah,

no, I've definitely seen diet has helped so much, you know, and the problem is the sustainability of it and and a lot of people they get frustrated because they feel they're not perfect They're not following it perfectly which I I don't I don't like people thinking that they have to be perfect because then you're gonna fall off the you know, the eating better and I'm more of an 80 20 person like 80 percent of the time try to do your best eat the best foods you can

Your body really is your temple. You that old saying that you have to feed it good stuff. And the problem really is all these ultra processed foods that you're seeing everywhere. Right. Like people don't have time to cook, which I totally understand. Life. Life is so busy. I definitely feel compared to pre covid times. It has somehow gotten even busier now. And because of that, people don't have the time to cook and they're grabbing food wherever they can. And all of this ultra processed food is not helping in any way.

between that and microplastics. So just paying attention, even if you choose the Mediterranean diet, you are making it more clean because you're thinking about what's actually going in your mouth, right? And like you said, pastries and all of these things we think of as having sugar, but there's other things like soy sauce. If you look at your soy sauce bottle, it's got a high fructose corn syrup in there. And I was like, wow. And I went through multiple bottles to see which one didn't have that listed as their main ingredient.

So there are so many different foods that we think about that are safe, that are not necessarily so. And, you know, we haven't had this study yet in RA, but in lupus, there was a study that came out with ultra, there was actually a couple of studies that came out with ultra processed foods and women who carried a certain antibody and they ate a lot of ultra processed foods. They were at a much higher rate, likelihood rather, of getting lupus. Right. So imagine we don't have that study in RA.

I wouldn't be surprised if it was similar in RA. And of course you must have families that ask you, know, I have this condition, how can I prevent the next generation from getting it? And so if there's anything that we can do, I would say that, you know, cleaner eating, cleaner eating, nutrition, paying attention to it is really something that is not gonna hurt us, right? It's gonna help not only hopefully our rheumatoid arthritis, but also our cardiovascular health because...

People with rheumatoid arthritis, have a higher chance of having heart attacks, strokes, and if we can reduce their risk over there as well, all the better.

Dr. Diana Girnita (31:46)
I totally agree with that. Many of my patients that have rheumatoid arthritis, they will ask me, how can I educate my children on certain risk factors to modify those

to avoid the onset of rheumatoid arthritis. And like you said, we cannot change genetics. but we can change the way that we act every single day. And that will have a compounding effect

You also mentioned microplastics, and I'm very, very interested in this topic, and I actually talk about it with my patients. What do you tell your patients about microplastics?

Neha Bhanusali (32:23)
for those that are interested in kind of learning more about it, I mean, as much as we talk about clean eating, it's also the other things, all the packages, the plastic water bottles that everybody's carrying around. I think a lot of people have shifted. Fortunately, they've heard this term now and I'm seeing less of the plastic water bottles being carried around and perhaps more of their own coffee mugs, instead of like on the go.

But it's everywhere, right? So how much you can decrease is really tough. Some people get really obsessed about it. And I think it's tough to live sometimes when you keep thinking about all these things. But wherever you can kind of tune it down, in these packaged foods, I think we don't know what actually goes in there. So again, if you are reducing those, you're doing more efforts into maybe cooking your own food, batch cooking, I think can be really helpful.

Dr. Diana Girnita (33:12)
There are some studies that I have seen that microplastics were linked to an increased risk of autoimmune diseases. And I want my patients to know about that. And that's why when I have the discussion with them, especially if I see them carrying a water bottle that is from plastic, I will mention that.

Neha Bhanusali (33:20)
Thank

Dr. Diana Girnita (33:31)
in the beginning of our conversation you mentioned that an extra weight will increase the risk to age faster let's go back to that and tell me more about this topic and tell us if you know the new drugs the glp1 medication will actually be helpful to this process

Neha Bhanusali (33:38)
Mm-hmm.

Yeah, I think they will be very helpful for this process. They are reducing weight, fat is inflammatory. So if we can reduce that, I think it overall helps us. We've seen in RA studies themselves, right? Just if they localized to rheumatoid arthritis patients and having a 5 % drop in their weight or 10 % even better, you know, they did better. They had less pain in their joints. They had less swelling, less fatigue.

So absolutely we've seen it with dropping weight and improving rheumatoid arthritis. We've seen it with psoriatic arthritis as well. But how do you get there, I think is a big question because it's very tough, especially for women between menopause and just overall aging, not having the time perhaps to do what they wanna do. It becomes really tough and GLP-1 medications, they are revolutionary is the way I'm looking at it.

You know, there's certainly there's risks and it has to be fine tuned, I think, to the individual. Certainly there's also like, you know, pills versus injecting. Now the pills are out as well. And I've heard from some people that they cannot tolerate pills, but they'll be okay with injections or one injection worked and the other one didn't. And I'm looking forward to the time when it's not as heavily regulated. Like we do need to know the safety data for it, but it is so challenging for people to get right now.

anywhere unless they really hit certain criteria because as you know, like the guidelines have changed. Now, if you have fatty liver, can theoretically get a GLP-1, but is it really being allowed by the insurance? Not always. So it's been a challenge, but I am a fan of any of these or most of these medications because they have really seemed to help with inflammation.

Dr. Diana Girnita (35:34)
I'm so glad that you are on the same page as me because I have seen those changes with my patients in the clinic and that's why we decided about two years ago to add a program that will address the needs of these patients. Most of our patients, because they cannot move, because they are going through a stressful period, because of certain medications, they gain a lot of weight. And because of that, it's like a vicious cycle. They get into this vicious cycle where they have more

pain, they have more weight, more pain, their joints will suffer more. And I've noticed, and I can tell you so many stories from my patients with RA or psoriatic arthritis, when we address the weight, not only that we were able to decrease the inflammation significantly, but we were able to decrease their pain and we decrease the need for medication or more medication. Because what we do as rheumatologists when we see more inflammation in their

markers when we see that they report more pain, we increase the medication and that doesn't solve the problem. So when we started to implement this program of weight loss, obviously in certain patients with considering the risk, the benefits, we have seen a dramatic change. And I'm glad that for the first time this year at the American Congress of Rheumatology, they started to talk about the GLP-1 medication.

Neha Bhanusali (37:00)
Yeah.

Dr. Diana Girnita (37:02)
but also other types of medications like you're mentioning for weight management. And they have seen or they have reported in larger studies that patients that have achieved a decrease in their weight, they will feel better with less pain and less inflammation.

Neha Bhanusali (37:16)
Mm-hmm.

Dr. Diana Girnita (37:19)
You mentioned also about menopause, and I think

Neha Bhanusali (37:21)
you

Dr. Diana Girnita (37:22)
that's also very, very important topic for our patients. I think not even a month ago, finally, the FDA representatives, Dr. Marty Makari, Dr. Rubin, there were so many other doctors involved talking about the role of hormone replacement therapy

and removing that concern

or the huge concern that hormone replacement therapy will increase the risk for blood clots, for cancer, breast cancer in particular and other types of cancers. And I was glad because most of our ladies when they hit perimenopause or menopause, they feel so much worse. And for a long time, I couldn't pinpoint what

Neha Bhanusali (38:05)
Yeah.

Dr. Diana Girnita (38:08)
is going on? Is it the rheumatoid arthritis or is

arthritis. And I did not know. And my first reaction was to say no, because you have an autoimmune disease. But I sent back and I said,

Let me research that it and I started to find important information that actually in certain patients hormone replacement therapy was helpful. Do you have any

Neha Bhanusali (38:38)
Oh, absolutely. A couple of years ago, I remember a woman said to me that, you know, she now was in perimenopause and she went to the OBGYN and she said they have no treatment. This was just two years ago. Right. She's like, they said I have nothing. There's nothing I can do. You know, it's so terrible for a woman when you go to an OBGYN and you're pregnant. Everybody cares about you, says all these wonderful things. You feel like people are taking care of you.

There's a baby coming, life is coming and everybody's happy. But when you complain about menopause type of symptoms, it's like nobody cares at this point. Like that's it, know, just pushing you to the side. And this was just, like I said, a couple of years ago and life has really changed. I think since all of this has come out, you know, a lot of my patients are on HRT now and they do ask me and I'm generally supportive of it. And I have definitely seen changes. they will add and it's important, I think, for them to notice, right?

What are your RA symptoms? And then there are some things that seem to be from perimenopause or menopause and they take it, maybe everything won't go away, but then they'll be like, okay, well, this went away. So I think that was related to that. Now I only have this left. And at least we don't have to use as many medications maybe to improve their RA symptoms. Right now we have something else that we can use. We don't have to suppress their immune system. They feel better. Maybe some of the other symptoms, you cause not everybody gets hot flashes.

Right, so that's, think, been the challenge. If you get that, people know to identify that with menopause or perimenopause. But if you don't have the more obvious ones and you only have joint pain, it can be really tough. But at the same time, it's kind of neat that as opposed to our medications, which can take months to improve things, the HRT, the hormone replacement therapy, some of these women feel better in weeks. So I think that's wonderful. But I also want to say a caveat is that

While it's been amazing, there's also people out there that are maybe not as well trained. And you really have to do your research as to who is that person that's actually giving you that medication. Because I have seen some really crazy things. especially with our RA patients, and they're on all these other medications, I'm like, hold on, slow it down. Let's step by step. So I think it's important to know who you're actually getting the medications from.

Dr. Diana Girnita (40:28)
Correct.

I'm so glad that you mentioned that because there are so many hormone clinics around, for example, where these people will get to get treatment, but get the wrong type of treatment. And what I have done in my clinic, I brought a specialist that is menopause certified to treat our patients and other patients that are in need. When I was trying to

Neha Bhanusali (40:51)
Mm-hmm.

Dr. Diana Girnita (41:13)
patients out many times they couldn't find the right specialist or they will automatically assume that these hormone clinics will be able to help them. And when I started to look at the type of treatments that they were were prescribing, I realized that's not really what these people need. that's why we in our clinic, we brought a menopause certified

Neha Bhanusali (41:25)
Mm-hmm.

Dr. Diana Girnita (41:39)
specialist that has the knowledge and understands autoimmune diseases. She's also an internist, so she understands the needs of patients with autoimmune diseases and they are able to get what they need from someone that is trained in menopause, not someone that just heard about the treatment.

Neha Bhanusali (41:57)
Yeah.

Dr. Diana Girnita (41:59)
You also mentioned about stress and how stress is connected with ⁓ more pain or faster aging. Tell us more about the role of chronic stress in aging and, you know, flaring up rheumatoid arthritis.

Neha Bhanusali (42:10)
Yes.

So

stress to your body that's acute, right, immediate, is maybe not as bad. You know, you have to get over a situation, you have to improve things. But the chronic stress is the problem. And a lot of our patients, if you can see, they live in these situations where they have a bad boss, like they truly dread going to work, or they're in a bad marriage, you know, there's all this stuff going on behind the scenes with their spouse.

a part of the sandwich generation, they're taking care of their parents as well as their kids. So many people are leaning on them and there is a lot of stress. The problem is you can't get rid of all of the stress, right? We all are living in different forms of it, different times of it. But I would say, you know, and I've been a rheumatologist for quite some time. I have some patients I've been seeing for over a decade. And a lot of times it takes several visits to be, it's eye-opening for them when they realize this is the problem.

Working 80 hours for this person who doesn't appreciate them is a problem for their body, for their disease, not just something that they tell people that I'm overworking. No, because when you have an autoimmune disease, it is actually impacting you. There was a woman that I saw last week and she's a teacher. And she developed this crazy rash. The first time was right after a horribly stressful time.

It was a family event that happened, And the next day she had this rash that was, looks really like an immune rash. And then it went away on its own. And then it happened again recently. And I was like, well, what happened this time? And she said, there was a child in the class who kept banging on drums for two hours straight. She said, all the other little kids in the class had their ears covered. The principal could not remove the child, did not want to touch him. And the parents wouldn't come to pick him up until dismissal time.

So you don't think about it, but this was extremely stressful. And it would be if anybody's banging all these loud sounds for two hours consistently. The next day, she had fully a rash all over her legs. So these are two events all from stress. The first one was just from stress in her environment because of her family and sickness. And the second one was this child that the whole situation that was created. And you could see the consequence. And this is just some one person.

But absolutely the chronic stress and the studies that are showed showed that, I think initially I thought that when someone passes away or you have a, you know, a sudden moment like that, that's worse stress. But actually the studies are showing that it's chronic stress, that little stress that's constantly gnawing at you. That is really what can be instigating your disease. So absolutely there's so much on stress, how it's affecting you. Also as a marker for biological aging, right? Having chronic stress all the time.

also will aid you with their impact those methylation clocks as well.

Dr. Diana Girnita (44:59)
How can people mitigate that kind of stress?

Neha Bhanusali (45:02)
First of all, it's identifying it. So a lot of people, just feel overwhelmed, right? There's so many things coming at them, so many different ways. And sometimes just writing it down. My father, when he was small, the way he would deal with stress is he would write it down into the top three things that are bothering him. He would fold it up and put it underneath his pillow. that physical action of actually changing something, moving it and putting it away and saying, I will not think about that until this point tomorrow.

It can be really helpful. And that's just one technique. But a lot of people are more open to going to therapy. There's a lot of things in people's childhood traumas. I'm actually doing a study right now on adverse childhood outcomes and the risk of developing an autoimmune disease because we already have some studies that show that. And there are things that eat away at you. And so it's one thing to address them. They have new techniques now. You there's all different kinds of ways that therapists are talking to patients now.

and kind of bringing it out. It may be that you don't need just a psychiatrist, you actually need a therapist too to address this. And I think another important thing is to also remember the people that are around you. Are they supportive or are they not supportive? When you have RA, sometimes it's an invisible disease. Sometimes we see it and other times it's an invisible disease. And so when we don't see it,

is the problem, right? People don't realize why are you having these issues? Why are you having pain? Why are you not doing these activities? And I think you have to give yourself grace and say that I have this condition. I'm dealing with the best I can. I cannot do these activities today. This activity is the most important thing I need to go to today. I'm going to do that. But the other stuff, it's not important to me. You know, it's not really helping me. And I think you have to identify this first. So that's one step, I would say, identification of what the problem is. The second is to

Introduce small changes in your life, just going for a walk or sitting in a quiet room, letting your mind calm down for 10 minutes. Not long. You don't have to do it very long, but it's anything that gives you a little bit of peace and start doing it more consistently. It can be very helpful.

Dr. Diana Girnita (47:08)
not perfection, consistency.

Neha Bhanusali (47:10)
Exactly. There is no perfection.

Dr. Diana Girnita (47:12)
That's true. Now, because we are closing our conversation, I would like you to tell people with rheumatoid arthritis or other autoimmune diseases, what are those three lifestyle changes that you would teach your patients with the highest impact on their disease and to age gracefully.

Neha Bhanusali (47:32)
Okay. The three things I think are the most important are number one, movement. I think movement is extremely important. And like I said, I don't think we do enough of it, but I also think we can introduce it very gradually, slowly, and start on that as our first focus on moving more. a lot of my patients are willing to go for walks, which is great, but they're not necessarily willing to do that second step, which is more resistance training, addressing...

increasing your muscle mass, eating more protein, you just focusing on how you can optimize your body. So along with movement, I really want people to think about resistance training, small different techniques, take resistance bands with you. If you're going on a cruise, and I live in a cruise culture over here because it's Florida, we have a lot of cruise ports, and people go on cruises all the time, which is wonderful, but you take your equipment with you. Resistance bands are very light, you can take them. All right, so that's number one, movement.

Number two is going to be nutrition. It's more about introducing more of plant proteins, plant-based foods. It's not about you have to remove everything bad in your diet. You're just starting to improve things by adding maybe two to three times a week some type of plant protein, reducing your ultra-processed foods, because really that's not helping you in any way, or form. I don't think so. And number three is really dealing with that stress. And sleep is part of it. know, sleep, we don't talk about it enough.

But with sleep, if you're not getting enough and you're in a chronic state of stress, this is not helping each other. Diana, you know that we've had a lot of lectures and talks and all this research coming out on whether or not we should skip methotrexate when we are taking the flu shot, right? The flu shot, I got my vaccine this year. And ⁓ what should we do with our methotrexate or other drugs? We have all these studies. And yet nobody talks about the fact that if you do not get enough sleep when you're taking your vaccines,

you may not make that antibody response that we're trying to get, right? So what's the point of taking the vaccine if your body is not making all those antibodies? So you do need to have a good amount of sleep just so our immune system works better,

Dr. Diana Girnita (49:39)
Neha, I would like to thank you very much for these insights about rheumatoid arthritis, about lifestyle, and about how to age gracefully, or how to slow down our process of aging, because in the end we all age, but it's important how we feel as long as we live. I would love to have you in a future episode.

Neha Bhanusali (50:01)
Thank you so much, Diana, for inviting me. And I think there is so much hope. We've identified different factors that we can improve. And the goal is really, as you live with this disease, there are so many different ways we can improve it outside of just what we're doing right now.