April 19, 2018

Wellness Research and Education Now Center Stage for Patients with Autoimmune Diseases

Rapid advances in science call for clinical integration

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By Leonard Calabrese, DO

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A decade ago, the topic of wellness was viewed among practicing physicians who care for IMIDs (immune-mediated inflammatory diseases) as nonscientific and the domain of a wellness community more enthusiastic than evidence based. Now, growing evidence compels us to work with our patients to achieve both disease control and wellness. Wellness in this context refers to physical, mental and spiritual aspects of health that allow us to live life well.

Advances in the science of wellness

The science of wellness has rapidly advanced, and now high-quality data suggest that the doctor’s role may account for as little as 10 percent in the overall health of patients whereas social structure and context and personal behaviors may account for 40 percent. In the age of epigenetics we are learning that Mendelian genetics play a rather limited role in a minority of diseases, and that environmental variables and our own behaviors are potent influences of our immune and metabolic functions, our microbiome and our gene expression. Such data have energized the science and have mainstreamed wellness education into the clinic.

The results of the Nurses’ Health study demonstrate the influence of wellness factors on the incidence of new-onset IMIDs, including rheumatoid arthritis (RA) and inflammatory bowel disease (IBD). Analyses from this high-quality, large longitudinal study found that young women who ate the Standard Western Diet were statistically predisposed to incident disease, whereas those who ate the Prudent Diet, enriched for omega-three fatty acids, were protected. My colleague M. Elaine Husni, MD, recently named Endowed Chair of Translational Functional Medicine Research, is currently studying the role food and wellness play in rheumatic disease progression. Dr. Husni has joined our colleagues in Cleveland Clinic’s Center for Functional Medicine to take a closer look at the utility and safety of functional medicine interventions (which focus on food and lifestyle) on health outcomes for those with musculoskeletal and rheumatic diseases.

Recent basic science observations demonstrate the powerful effects of exercise on immunologic function at the level of metabolomic and genomic signatures and support the idea of a potent exercise-immune axis. Sleep is now a physiologic state recognized to have potent immunomodulatory potential, given the perturbations of both innate and adaptive immunity in those with inadequate or disturbed sleep, and the strong correlation of adequate sleep and vaccine response. Perhaps most exciting is the growing research demonstrating the capacity of mindfulness, meditation and mind-body exercise to reduce both stress and inflammation at the immunophenotypic and genomic levels.

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I share in greater detail how personal behavior affects IMIDs in a recent grand rounds given in collaboration with the Institute for Functional Medicine and Cleveland Clinic’s Center for Functional Medicine.

Incorporating advances in wellness into patient care and education

We must now devise better ways to incorporate wellness behavioral change into our care spectrum. We must overcome provider barriers like lack of declarative and procedural knowledge in the field and patient barriers like lack of personal empowerment to achieve lasting change. The R.J. Fasenmyer Center for Clinical Immunology is taking a leading role in bringing up-to-date education to physicians interested in incorporating wellness education into their clinics. Our 6th Annual Basic and Clinical Immunology Course for the Busy Clinician in March saw over 120 participants engaged in both basic and clinical immunology education and the latest data on how behavior influences immunity, quality of life and perhaps the course of IMIDs. Mind-body exercise and mindfulness meditation were part of the course.

In the Fasenmyer Center, an educational video has welcomed patients for years; it covers a variety of immunologic wellness topics including diet, exercise, stress and sleep and reminds them to discuss their concerns and needs with their providers. Each patient also receives a monograph, “Train and Maintain your Immune System,” that I wrote and keep updated with Elizabeth Kirchner, MSN, NP.

To enhance the delivery and increase the scale of these efforts, we are now incorporating online training and coaching and mobile monitoring of personal behaviors. We are building a comprehensive online program called Immune Strength, based on Cleveland Clinic Stress Free Now, which is highly effective at reducing stress with as few as four 15-minute sessions per week. Immune Strength offers patients with IMIDs 10 weeks of education on how personal behavior influences immune function and diseases and is designed to empower patients to make change. The program incorporates e-coaching and courses on mindfulness meditation, graded exercise, healthy eating and sleep hygiene. Patients will track their health progress using self-administered PROMIS® scales developed by the NIH. We are preparing to launch Immune Strength in late 2018.

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Dr. Calabrese directs the R.J. Fasenmyer Center for Clinical Immunology.

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