Obesity & Rheumatic Disease

Obesity and its impact on patients with rheumatic diseases was a hot-button topic at this past summer’s 9th Rheumatology Nurses Society Annual Conference. And, according to two rheumatologists who have spoken on the topic, the more attention rheumatologists pay to obesity, the better.

“Obesity is an inflammatory state, so it is in the landscape of the rheumatologist,” says Christopher Ritchlin, MD, MPH, of the University of Rochester (N.Y.) Medical Center (URMC). “Unfortunately, though, the events that lead to obesity are very complex and include genetics, environmental cues, microbiome changes and the Western diet. Nonetheless, it is important to stress to patients that weight loss may not only make them feel better, but it will likely decrease their overall inflammatory burden and decrease the stress on joints and the low back.”

Eric Matteson, MD, MPH, chair of the rheumatology department at the Mayo Clinic in Rochester, Minn., says that joints take needlessly additional pressure in obese patients.

“Excess body weight is a major contributor to joint damage of lower extremity joints because of additional loading, which contributes to progression of joint disease,” he adds. “This is especially important in patients who already have joint disease because of rheumatoid arthritis, for example.”

Prevalence & Risk Factor for Rheumatic Illnesses
Obesity has risen to record highs, according to the Centers for Disease Control and Prevention. Some 37.7% of adults were obese as of 2013–14, and 17.2% of youth ages 9–12 were classified obese.¹ The condition has been established as a risk factor for psoriasis and psoriatic arthritis, Dr. Ritchlin says.

It compounds morbidities, such as heart disease, diabetes and gout, and adipocytes are also generators of inflammatory cytokines, Dr. Matteson adds.

“This may contribute to predisposition to some forms of inflammatory arthritis and has been cited as a risk factor for rheumatoid arthritis,” he says.

Treatment Complications
Treatment for RA has advanced in the past few decades and is currently moving forward with the advent of biologics, but many treatments are less effective for obese patients.

“Many medications, including biologics, do not seem to work as well in obese patients, possibly also related to adipocyte activity,” Dr. Matteson says.

Weight Loss as a Care Goal
The diminished effectiveness of treatment is not the only hurdle. Obesity is a social and cultural phenomenon driven by a variety of factors, including people’s higher caloric intake than previous generations, the relative lack of physical activity with more modern office workplaces and the rise of a “fast food culture,” Dr. Matteson says.

“The treatment of obesity is particularly challenging,” Dr. Ritchlin adds. “The most important strategy is to cut down on caloric intake, a goal that is difficult to achieve and maintain. Additional approaches include medications and bariatric surgery.”

Dr. Ritchlin says he works with nutritionists in URMC’s Endocrinology Division to work with patients on weight loss and to emphasize to obese patients that they “play an active role in the treatment of their disease by losing weight.”

Both Drs. Matteson and Ritchlin agree that a multi-disciplinary approach to obesity is key for rheumatologists.

“I don’t think there can be too many cooks in the kitchen,” Dr. Matteson says. “Attention to obesity and its health and social consequences is the responsibility of the entire society, and certainly of all caregivers, including primary care providers (PCPs) and rheumatologists.”

With so many proverbial cooks in the kitchen, it can be difficult for rheumatologists to know who should take the lead with a patient. Dr. Matteson says that should be handled on a case-by-case basis.

“I think it depends on the relationship the patient has with their physician,” he says. “In some cases, it is the rheumatologist who is quarterbacking the coordination of healthcare for their patients, and in others, the PCP takes the primary role. In either case, the engagement of all specialties with the patient is crucial.”

The rheumatologist also has to handle the topic of obesity delicately. The personal responsibility of an obese patient’s response to their condition must be emphasized, but delivered professionally. Discussions should focus on weight control and rheumatic disease activity control, highlighting the importance of physical activity for both conditions and keeping weight control “in the forefront of the patient’s health goals,” Dr. Matteson says.

“It is important to monitor weight change at serial visits, acknowledge any weight loss and help patients work through the various treatment options without being paternalistic or denigrating,” Dr. Ritchlin adds. “Working with a team as described above is the best approach so the patient does not feel isolated or frustrated.”

Preaching at patients would only frustrate them and, potentially, reduce the positive impact of education, follow-up and encouragement, Dr. Matteson says.

“We can’t just tell our patients what to do. We need to show them what the benefits of optimal body weight and physical activity are, and provide the resources for them to link to healthy living programs and activities.”

Richard Quinn is a freelance writer in New Jersey.

Reference

1. U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Health people 2020: Nutrition, physical activity and obesity—latest data. 2016.