We are constantly learning more about how pain manifests and what causes pain in osteoarthritis. It’s an evolving field, and research has shown that obesity does not simply make osteoarthritis pain worse due to more weight/loading on joints. Beyond that, obesity itself is inflammatory. Excess fat releases molecules that cause inflammation. It’s thought that inflammation can amplify pain signals in osteoarthritis. Research suggests that carrying excess fat results in increased sensitivity to pain signals not only at the joint, but in the brain as well. Carrying excess fat tissue is also a major risk factor for cardiovascular complications like heart attacks, strokes and blood clots, and cardiovascular disease is the leading cause of death in people living with arthritis.

Life-Changing Diagnosis: Living with a chronic condition can be very difficult. While adapting to life with arthritis, it can be hard to maintain healthy habits like grocery shopping and meal preparation. Having arthritis in the hands, for example, can make it challenging to carry groceries or cut up foods, and there can be many other competing demands to balance as well. People may turn to ready-made or processed foods, which are often more calorie-dense and less healthy.

Mental Health: Living with a new chronic disease, like arthritis, can significantly affect a person’s mental health. Conditions like depression and anxiety are seen more commonly in people with arthritis as well as in people with obesity. Emotional eating, where people eat comforting foods to help them cope with challenges, can occur in response to the difficulties of living with arthritis or obesity. The relationship between developing arthritis, weight gain, and mental health is complex, and there is a lot of overlap.

Medications: Some drugs used to treat arthritis can cause weight gain. When people are first diagnosed with a disease like rheumatoid arthritis, for example, they can be prescribed prednisone to control inflammation, and this drug can cause weight gain.

Sleep: Symptoms of arthritis can affect sleep, and getting less sleep can affect levels of various hormones, increasing appetite.

Cardiovascular Disease: People are at the highest risk for heart attacks, strokes and blood clots in the legs and lungs in the first year after an arthritis diagnosis, when inflammation is at its peak. Obesity is a risk factor for the same complications. Obesity is also a risk factor for high blood pressure and high cholesterol, which can lead to cardiovascular disease.

Metabolic Dysfunction-Associated Steatotic Liver Disease: This used to be called non-alcoholic fatty liver disease and can be a consequence of obesity. Liver inflammation can lead to liver fibrosis (excessive scar tissue) and potentially liver failure if untreated.

Type 2 Diabetes: Individuals living with arthritis and obesity are at risk for blood sugar abnormalities like type 2 diabetes, where the cells in the body don’t respond normally to insulin, leading to high blood sugar levels.

Fertility Issues: Younger people living with arthritis and obesity can experience fertility issues. Obesity can reduce fertility in women, and, with weight loss, fertility can improve. In men, it can cause hypogonadism, which is a condition whereby the body does not produce enough testosterone.

For example, some individuals use food to cope with mental health challenges that emerge from conditions like arthritis, and this can lead to further weight gain. Weight gain can also worsen arthritis symptoms and mental wellbeing, so this can become a vicious cycle. We need to consider all of these factors – biological, psychological, and social – to provide effective care.

Like other chronic conditions, obesity is treatable. There are options to help with weight loss. However, the focus should be more on general health. There are many things someone can do that don’t lead to weight loss but improve overall health.

Physical Activity: Data shows that exercise alone is not a particularly effective strategy for long-term, sustainable weight loss. However, physical activity helps with weight maintenance and has many other health benefits beyond weight loss. Exercise in arthritis improves pain, function, quality of life, and fatigue, and reduces risk of developing cardiovascular disease and diabetes. For patients with arthritis experiencing barriers to physical activity, connecting with allied health professionals like physiotherapists or kinesiologists can help.

Nutrition: The best approach is for people to find healthy, long-term nutrition strategies that work for them. The healthiest nutrition plan a person can realistically stick to while maintaining a good quality of life is that person’s best diet. In terms of specifics, prioritize whole foods, mostly plants (vegetables, legumes, etc.), and lean protein sources (plant-based sources, fish, poultry, and dairy). Minimize processed foods, allowing for the occasional treat or indulgence in moderation. The diet with the best evidence to improve health overall is a Mediterranean-style diet. While this doesn’t work for everyone or all cultures, it has been shown to reduce cardiovascular risk in large randomized controlled trials.

In terms of weight loss expectations with diet, research trials show about 3-5% weight loss long term. Some lose more; some lose less. You can see more significant weight loss with more calorically-restrictive diets upfront, but oftentimes, after a couple of years, the average sustained weight loss is 3-5%. Understanding this is helpful because people will often make positive changes to their diet or physical activity but then might see these changes as a failure if they don’t achieve the weight loss they were expecting. This is why I think it’s important to focus on overall health as opposed to just weight. There are a host of health benefits that come with adopting healthy nutrition and movement patterns that extend beyond weight loss.

Medications: There are many medication options to help with weight loss that can be used alongside healthy eating and physical activity. GLP-1 receptor agonists, like semaglutide (branded as Ozempic for diabetes and Wegovy for obesity), are popular right now. At full doses, people on average lose about 10-15% of their body weight with semaglutide. Another option, tirzepatide (branded as Mounjaro for diabetes and Zepbound for obesity), a GIP/GLP-1 receptor co-agonist, leads to even more weight loss of around 15-20%. Several other drugs to help with weight loss are actively being studied, so it’s likely there will be more choices in the coming years.

Surgery: For more severe forms of obesity, there are surgical options, like bariatric surgery, for weight loss and cardiometabolic health. Depending on the type of bariatric surgery, weight loss typically ranges from 25-40% of body weight.

I first looked at the current landscape of weight management in rheumatology by designing a survey to assess practitioner views. I wanted to understand what barriers they faced, what knowledge they had about treatment options, how confident they were at treating obesity, and related questions. The majority correctly identified that obesity is associated with worse disease activity and response to treatment in rheumatoid arthritis. Nearly all agreed it was at least partly their responsibility to help patients address excess weight. However, more than three quarters of respondents didn’t feel confident, or only felt slightly confident, in their ability to help patients lose clinically meaningful amounts of weight. Most did not routinely refer to other healthcare providers or provide educational resources. Through this work, we realized that rheumatology providers knew weight management was important but faced barriers. They didn’t have the time, training or knowledge to help their patients. We saw this as an opportunity for improvement.

Then, during my internal medicine residency, I became aware of a number of landmark randomized controlled trials on GLP-1 receptor agonists showing that they had several benefits beyond controlling blood sugar. These included weight loss (when used alongside lifestyle counselling), improved cardiovascular and kidney health (lower risk of heart attacks, strokes, and kidney failure), and longer survival, to name a few.

When I saw this research, I wanted to find out if these drugs could have a role for patients with arthritis. I did a scoping review with Dr. Diane Lacaille, Arthritis Research Canada’s Scientific Director, summarizing all studies done on these drugs in rheumatoid arthritis and psoriasis. We found that they seemed to have anti-inflammatory effects based on experiments in cells and mice, and this was not just because of weight loss. That said, there hadn’t been much clinical work done yet. This was in 2021 and 2022. I saw an opportunity to fill this gap in the literature. So, this is where I took my next steps.

I started studying the effects of GLP-1 receptor agonists in people with different types of autoimmune diseases. Several large studies showed that people who used this class of drugs saw a cardiovascular benefit, but these studies didn’t describe people with arthritis. Some of the studies excluded people on immunosuppressants, which is a number of people with arthritis. I worked with Dr. Lacaille and Dr. Antonio Aviña-Zubieta, a Senior Scientist at Arthritis Research Canada, and we used administrative health data from all residents of British Columbia to see if adults with autoimmune rheumatic diseases (and inflammatory bowel disease) derived cardiovascular benefits from this class of drugs. We compared those who started GLP-1 receptor agonists to those starting another diabetes drug class (shown not to increase or decrease cardiovascular disease risk) and found that, similar to the general population, people with autoimmune diseases had a lower risk of cardiovascular disease if they took GLP-1 receptor agonists.

We’re now wrapping up a project looking at whether GLP-1 receptor agonists reduce risk of developing autoimmune rheumatic diseases, including rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, lupus, Sjögren’s disease, scleroderma, myositis, and vasculitis. We found that when we pooled all these diseases together, GLP-1 receptor agonist use did not appear to reduce risk.

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Arthritis Research Canada review finds weight loss medications may hold wide-ranging benefits for people living with arthritis and obesity, identifying a need for further research. Read More

Patients with rheumatoid arthritis who used GLP-1 receptor agonists had less disease activity and improved cardiovascular biomarkers, a small retrospective study indicated. Read More