Sex differences in assessment of obesity in rheumatoid arthritis

Exploring complex links: inflammatory rheumatic diseases and men's health

This article examines the complex interactions between inflammatory rheumatic diseases (IRDs) and men's health. It delves into the effects of IRDs on reproductive health, erectile dysfunction, prostate involvement, male osteoporosis, body composition, physical activity, and coping mechanisms. The findings show that the prevalence of sexual dysfunction varies among different diseases, underscoring the necessity for comprehensive counseling. The link between IRDs and prostate health, with a substantial rise in benign prostatic hyperplasia among IRD patients, demonstrates the condition's importance. In contrast to popular belief, osteoporosis mostly affects women; the current study highlights the growing identification of male osteoporosis, particularly in the setting of IRDs. Male RA patients had a significant loss in bone mineral density, highlighting the importance of increasing awareness and tailored therapy to address osteoporosis in men. IRDs affect body composition, with male RA patients showing imbalances characterized by decreased lean body mass and increased fat mass. Given the dynamic nature of these conditions, coping with IRDs necessitates thorough and individualized diversified approaches. The complex link between IRDs and men's health demands continuing research, including longitudinal studies and tailored therapies. The essay promotes a patient-centered approach, recognizing the unique obstacles that males with IRDs confront.

Effect of Remotely Supervised Weight Loss and Exercise Training Versus Lifestyle Counseling on Cardiovascular Risk and Clinical Outcomes in Older Adults With Rheumatoid Arthritis: A Randomized Controlled Trial

OBJECTIVE

To compare a remotely supervised weight loss and exercise intervention to lifestyle counseling for effects on cardiovascular disease risk, disease activity, and patient-reported outcomes in older patients with rheumatoid arthritis (RA) and overweight/obesity.

METHODS

Twenty older (60-80 years), previously sedentary participants with seropositive RA and overweight/obesity were randomized to 16 weeks of either Supervised Weight loss and Exercise Training (SWET) or Counseling Health As Treatment (CHAT). The SWET group completed aerobic training (150 minutes/week moderate-to-vigorous intensity), resistance training (two days/week), and a hypocaloric diet (7% weight loss goal). The CHAT control group completed two lifestyle counseling sessions followed by monthly check-ins. The primary outcome was a composite metabolic syndrome z-score (MSSc) derived from fasting glucose, triglycerides, high density lipoprotein-cholesterol, minimal waist circumference, and mean arterial pressure. Secondary outcomes included RA disease activity and patient-reported outcomes.

RESULTS

Both groups improved MSSc (absolute change -1.67 ± 0.64 in SWET; -1.34 ± 1.30 in CHAT; P < 0.01 for both groups) with no between-group difference. Compared with CHAT, SWET significantly improved body weight, fat mass, Disease Activity Score-28 C-reactive protein, and patient-reported physical health, physical function, mental health, and fatigue (P < 0.04 for all between-group comparisons). Based on canonical correlations for fat mass, cardiorespiratory fitness, and leg strength, component-specific effects were strongest for (1) weight loss improving MSSc, physical health, and mental health; (2) aerobic training improving physical function and fatigue; and (3) resistance training improving Disease Activity Score-28 C-reactive protein.

CONCLUSION

In older patients with RA and overweight/obesity, 16 weeks of remotely supervised weight loss, aerobic training, and resistance training improve cardiometabolic health, patient-reported outcomes, and disease activity. Less intensive lifestyle counseling similarly improves cardiovascular disease risk profiles, suggesting an important role for integrative interventions in the routine clinical care of this at-risk RA population.

High fat diet reveals sex-specific fecal and liver metabolic alterations in C57BL/6J obese mice

Obesity is a major health concern that poses significant risks for many other diseases, including diabetes, cardiovascular disease, and cancer. Prevalence of these diseases varies by biological sex. This study utilizes a mouse (C57BL/6J) model of obesity to analyze liver and fecal metabolic profiles at various time points of dietary exposure: 5, 9, and 12 months in control or high fat diet (HFD)-exposed mice. Our study discovered that the female HFD group has a more discernable perturbation and set of significant changes in metabolic profiles than the male HFD group. In the female mice, HFD fecal metabolites including pyruvate, aspartate, and glutamate were lower than control diet-exposed mice after both 9th and 12th month exposure time points, while lactate and alanine were significantly downregulated only at the 12th month. Perturbations of liver metabolic profiles were observed in both male and female HFD groups, compared to controls at the 12th month. Overall, the female HFD group showed higher lactate and glutathione levels compared to controls, while the male HFD group showed higher levels of glutamine and taurine compared to controls. These metabolite-based findings in both fecal and liver samples for a diet-induced effect of obesity may help guide future pioneering discoveries relating to the analysis and prevention of obesity in people, especially for females.

Effects of Exercise on Body Composition and Physical Function in Rheumatoid Arthritis Patients: Scoping Review

Background

In rheumatoid arthritis (RA) patients, an adverse change in body composition, which usually results in muscle wasting and increased fat mass, is high, contributing to increased functional disability. There are indications that resistance and dynamic exercise interventions could improve body composition and functional capacity in RA patients and should be recommended to manage RA.

Purpose

The scoping literature review aimed to analyze available literature about the effects of exercise on body composition in RA patients. Secondly to identify the contribution of exercise to improve physical function in RA patients, thirdly to identify gaps in the literature about physical exercises and health outcomes in RA patients, and make recommendations for future research.

Methods

A scoping literature review design was employed following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. A systematic search of three databases (PubMed, CINAHL, and Scopus) for studies published from 2012 to 2022 was conducted. The words searched include "exercise intervention" AND "body fat" OR "muscle wasting" OR "lean body mass" AND "functional ability" OR "health assessments". The search strategy was limited to studies published in English on RA patients and exercise interventions.

Results

This search yielded 2693 studies, of which 11 met the inclusion criteria and were selected for review. The findings showed significant, positive effects of exercise interventions on RA patients' body composition and functional capacity, with exercise being highly beneficial. It is evident that high-intensity resistance exercise, as a stand-alone intervention, is feasible and safe for managing RA conditions.

Conclusion

Physical exercises, following scientific guidelines, should be included as an integrated approach to managing RA conditions.

Remotely Supervised Weight Loss and Exercise Training to Improve Rheumatoid Arthritis Cardiovascular Risk: Rationale and Design of the Supervised Weight Loss Plus Exercise Training-Rheumatoid Arthritis Trial

Patients with rheumatoid arthritis (RA) remain at an increased risk for cardiovascular disease (CVD) and mortality. RA CVD results from a combination of traditional risk factors and RA-related systemic inflammation. One hypothetical means of improving overall RA CVD risk is through reduction of excess body weight and increased physical activity. Together, weight loss and physical activity can improve traditional cardiometabolic health through fat mass loss, while also improving skeletal muscle health. Additionally, disease-related CVD risk may improve as both fat mass loss and exercise reduce systemic inflammation. To explore this hypothesis, 26 older persons with RA and overweight/obesity will be randomized to 16 weeks of a usual care control arm or to a remotely Supervised Weight Loss Plus Exercise Training (SWET) program. A caloric restriction diet (targeting 7% weight loss) will occur via a dietitian-led intervention, with weekly weigh-ins and group support sessions. Exercise training will consist of both aerobic training (150 minutes/week moderate-to-vigorous exercise) and resistance training (twice weekly). The SWET remote program will be delivered via a combination of video conference, the study YouTube channel, and study mobile applications. The primary cardiometabolic outcome is the metabolic syndrome Z score, calculated from blood pressure, waist circumference, high-density lipoprotein cholesterol, triglycerides, and glucose. RA-specific CVD risk will be assessed with measures of systemic inflammation, disease activity, patient-reported outcomes, and immune cell function. The SWET-RA trial will be the first to assess whether a remotely supervised, combined lifestyle intervention improves cardiometabolic health in an at-risk population of older individuals with RA and overweight/obesity.

Adipocytokines and Associations With Abnormal Body Composition in Rheumatoid Arthritis

OBJECTIVE

We determined associations between adipokines and abnormal body composition in patients with rheumatoid arthritis (RA).

METHODS

Combining data from three RA cohorts, whole-body dual-energy absorptiometry measures of appendicular lean mass and fat mass indices were converted to age-, sex-, and race- and ethnicity-specific Z scores. Lean mass relative to fat mass was determined based on prior methods. Independent associations between body composition profiles and circulating levels of adiponectin, leptin, and fibroblast growth factor (FGF)-21 were assessed using linear and logistic regression models adjusting for demographic characteristics and study cohort. We also determined the improvement in the area under the curve (AUC) for prediction of low lean mass when adipokines were added to predictive models that included clinical factors such as demographic characteristics, study, and body mass index (BMI).

RESULTS

Among 419 participants, older age was associated with higher levels of all adipokines, whereas higher C-reactive protein level was associated with lower adiponectin levels and higher FGF-21 levels. Greater fat mass was strongly associated with lower adiponectin levels and higher leptin and FGF-21 levels. Higher levels of adiponectin, leptin, and FGF-21 were independently associated with low lean mass. The addition of adiponectin and leptin levels to regression models improved prediction of low lean mass when combined with demographic characteristics, study, and BMI (AUC 0.75 vs. 0.66).

CONCLUSION

Adipokines are associated with both excess adiposity and low lean mass in patients with RA. Improvements in the prediction of body composition abnormalities suggest that laboratory screening could help identify patients with altered body composition who may be at greater risk of adverse outcomes.

The effects of resistance training with blood flow restriction on muscle strength, muscle hypertrophy and functionality in patients with osteoarthritis and rheumatoid arthritis: A systematic review with meta-analysis

Introduction

Rheumatoid arthritis(RA) and osteoarthritis(OA) patients showed systemic manifestations that may lead to a reduction in muscle strength, muscle mass and, consequently, to a reduction in functionality. On the other hand, moderate intensity resistance training(MIRT) and high intensity resistance training(HIRT) are able to improve muscle strength and muscle mass in RA and OA without affecting the disease course. However, due to the articular manifestations caused by these diseases, these patients may present intolerance to MIRT or HIRT. Thus, the low intensity resistance training combined with blood flow restriction(LIRTBFR) may be a new training strategy for these populations.

Objective

To perform a systematic review with meta-analysis to verify the effects of LIRTBFR on muscle strength, muscle mass and functionality in RA and OA patients.

Materials and methods

A systematic review with meta-analysis of randomized clinical trials(RCTs), published in English, between 1957–2021, was conducted using MEDLINE(PubMed), Embase and Cochrane Library. The methodological quality was assessed using Physiotherapy Evidence Database scale. The risk of bias was assessed using RoB2.0. Mean difference(MD) or standardized mean difference(SMD) and 95% confidence intervals(CI) were pooled using a random-effects model. A P<0.05 was considered statistically significant.

Results

Five RCTs were included. We found no significant differences in the effects between LIRTBFR, MIRT and HIRT on muscle strength, which was assessed by tests of quadriceps strength(SMD = -0.01[-0.57, 0.54], P = 0.96; I² = 58%) and functionality measured by tests with patterns similar to walking(SMD = -0.04[-0.39, 0.31], P = 0.82; I² = 0%). Compared to HIRT, muscle mass gain after LIRTBFR was reported to be similar. When comparing LIRTBFR with low intensity resistance training without blood flow restriction(LIRT), the effect LIRTBFR was reported to be higher on muscle strength, which was evaluated by the knee extension test.

Conclusion

LIRTBFR appears to be a promising strategy for gains in muscle strength, muscle mass and functionality in a predominant sample of RA and OA women.

Sarcopenic Obesity in Rheumatoid Arthritis: Prevalence and Impact on Physical Functioning

OBJECTIVE

We determined the prevalence of sarcopenic obesity in patients with rheumatoid arthritis (RA) using multiple methods and assessed associations with physical functioning.

METHODS

This study evaluated data from three RA cohorts. Whole-body dual-energy absorptiometry (DXA) measures of appendicular lean mass index (ALMI, kg/m2) and fat mass index (FMI) were converted to age, sex, and race-specific Z-Scores and categorized using a recently validated method and compared it to a widely-used existing method. The prevalence of body composition abnormalities in RA was compared with two reference populations. In the RA cohorts, associations between body composition and change in the Health Assessment Questionnaire (HAQ) and the Short Physical Performance Battery (SPPB) in follow-up were assessed using linear and logistic regression, adjusting for age, sex, race, and study.

RESULTS

The prevalence of low lean mass and sarcopenic obesity were higher in patients with RA (14.2; 12.6%, respectively) compared with the reference population cohorts (7-10%; 4-4.5%, respectively, all p< 0.05). There was only moderate agreement among methods of sarcopenic obesity categorization (Kappa 0.45). The recently validated method categorized fewer subjects as obese, and many of these were categorized as low lean mass only. Low lean mass, obesity, and sarcopenic obesity were each associated with higher HAQ and lower SPPB at baseline and numerically greater worsening.

CONCLUSION

RA patients had higher rates of low lean mass and sarcopenic obesity than the general population. The recently validated methods characterized body composition changes differently from traditional methods and were more strongly associated with physical function.

Skeletal muscle disease in rheumatoid arthritis: the center of cardiometabolic comorbidities?

PURPOSE OF REVIEW

Despite its critical roles in body movement, structure, and metabolism, skeletal muscle remains underappreciated in the context of rheumatoid arthritis. In rheumatoid arthritis, chronic inflammation, physical inactivity, and medication toxicities impair skeletal muscle. These skeletal muscle alterations contribute to continued rheumatoid arthritis disparities in physical function and cardiometabolic health.

RECENT FINDINGS

In the prebiologic disease-modifying antirheumatic drug era, rheumatoid arthritis skeletal muscle atrophy was the central feature of 'rheumatoid cachexia,' a hypermetabolic state driven by chronic systemic inflammation and muscle protein degradation. In the current era, rheumatoid arthritis muscle deficits are less visible, yet persist as a key component of 'sarcopenic obesity.' In rheumatoid arthritis sarcopenic obesity, chronic inflammation, physical inactivity, and medication toxicities contribute to muscle contractile deficits, inflammation, altered metabolism, and intramuscular adiposity, a key predictor of rheumatoid arthritis disability and insulin resistance.

SUMMARY

Rheumatoid arthritis skeletal muscle disease in the current era is defined by impaired contractile function (poor strength and endurance) and sarcopenic obesity (decreased muscle mass, increased fat mass, and intramuscular adiposity). These muscle impairments contribute to disability and cardiometabolic disease in rheumatoid arthritis. Management should focus on monitoring of rheumatoid arthritis muscle function and body composition, limiting potentially myotoxic drugs, and prescription of exercise training.

Modified Diet Use in Adults with Temporomandibular Disorders related to Rheumatoid Arthritis: A Systematic Review

Objective:

Individuals presenting with rheumatoid arthritis (RA) frequently experience temporomandibular disorders (TMDs), which can result in limited ranges of mandibular motion, pain and fatigue on jaw function, and impaired mastication. As such, individuals with RA-related TMDs may consume a texture-modified diet in order to reduce the exacerbation of jaw pain and dysfunction, and to increase the ease of oral intake. These softer food options may not contain the recommended nutrients, vitamins, and minerals, and therefore, may not be nutritionally optimal. As unintentional body composition and weight changes are common in individuals with RA, there may be elevated risks of obesity or malnutrition in this patient subgroup. However, minimal researcth has been conducted to investigate the use of modified diets in this cohort, and therefore, the true level of risk to these patients cannot not be adequately determined. The aim of this study was to determine the prevalence of diet modifications in adults presenting with RA affecting the TMJ.

Methods:

All available evidence presenting data on adults with RA who consume modified diets was systematically reviewed. A range of electronic databases were searched, including: EMBASE, PubMed, CINAHL, Web of Science, Elsevier Scopus, Science Direct, AMED, The Cochrane Database of Systematic Reviews, and ProQuest Dissertations and Theses A & I. Supplementary Google Scholar, reference list, and grey literature searches were also conducted. Independent reviewers assessed study eligibility, and methodological quality was rated using the Down’s and Black assessment.

Results:

One study was eligible for inclusion, and half (50.82%; CI: 37.7–63.86) of individuals with RA in this study consumed a modified diet. This study was rated to be of moderate quality. The primary limitation of this review was the lack of studies on this topic which were available for inclusion.

Conclusions:

Although from clinical practice, it is recognised that adults with TMD related to RA do modify their diets to cope with the functional impairment of TMD, this review confirms that minimal research has been conducted regarding the use of texture modified diets by this population. This is despite concerns regarding unintentional weight changes in this patient group. Further research investigating this area is warranted in order to improve patient outcomes and experience of care.

Sex differences in frailty and its association with low bone mineral density in rheumatoid arthritis

Objectives

Frailty in the general population is associated with poor health outcomes including low bone mass and osteoporotic fracture. The relationship between frailty and low bone mineral density (BMD) in rheumatoid arthritis (RA) is unknown. This study examined associations between frailty and BMD in RA, controlling for established osteoporosis risk factors.

Methods

We performed a cross-sectional analysis of a longitudinal RA cohort (n = 138; 117 female, 21 male). Participants fulfilled ACR RA classification criteria. Frailty was evaluated using the Fried Index, categorizing each participant as robust, pre-frail or frail. To identify independent predictors of BMD, we performed a multivariable linear regression analysis. Because risk factors for low BMD differ between sexes, we performed additional sex-stratified multivariable analyses.

Results

Mean age and disease duration were 58.0 ± 10.8 and 19 ± 10.9 years, respectively. The majority of participants were categorized as pre-frail (70%) or frail (10%). Females had higher rates of frailty than males. In the whole cohort, both pre-frail and frail had independent negative associations with BMD (β = −0.074 and −0.092 respectively, p < 0.05). In sex-stratified analyses, frailty did not have a significant association with BMD in females, but had a strong independent negative association in males (β = −0.247, p = 0.001).

Conclusion

Frailty was associated with BMD in patients with RA. Females had higher rates of frailty than males, yet frailty was independently associated with BMD in males but not in females. Frailty appears to be an important factor associated with low BMD; sex may influence this relationship in RA.

•

Frailty was independently associated with lower femoral neck BMD in RA participants.

•

Frailty was independently associated with lower BMD in males, not females.

•

Of the frailty components, weakness had the strongest negative association with BMD.

Benefits of exercise in patients with rheumatoid arthritis: a randomized controlled trial of a patient-specific exercise programme

BACKGROUND

Patients with rheumatoid arthritis (RA) tend to be more overweight, take less physical exercise, exhibit decreased cardiorespiratory fitness and demonstrate reduced muscle strength compared with age- and sex-matched controls. Impaired cognitive function in RA is an important associated factor, although it has been less well-recognized. The aim of this study was to investigate the effects of a specifically designed exercise programme on body composition, aerobic capacity, muscle strength and cognition in RA.

METHODS

Sixty-six patients with RA were randomized to a specifically designed, personalized exercise programme or standard care. Assessments included body composition, fitness, grip strength and cognitive testing, in addition to disease related measures.

RESULTS

Significant improvements in C-reactive protein (p = 0.025), fatigue scores (p = 0.047) and truncal fat (p = 0.004) were observed in the exercise group compared with controls. Median waist circumference was significantly reduced (94.0 to 91.4 cm, p < 0.0001). Improvements were also seen in aerobic capacity (23.2 to 27.6 ml/kg/min, p = 0.002) and in median right (12.0 to 13.0 kg, p = 0.025) and left grip strength (8.0 to 10 kg, p = 0.005). Cognitive function improved in the exercise group, with median Montreal Cognitive Assessment score 25.5 at 0 months compared to 28.0 at 3 months (p = 0.001).

CONCLUSION

This study demonstrates that exercise has a significant and positive impact on cognitive function in RA. Furthermore, physical activity is safe and effective in chronic inflammatory joint disease and is recommended as a vital component in the holistic management of these patients.Key Points• A dedicated physical exercise programme is feasible and safe in patients with rheumatoid arthritis (RA).• Physical exercise helps reduce fatigue scores and improves cardiovascular fitness in stable RA patients.• Physical exercise has a positive impact on cognition in patients with RA.• A structured exercise programme should be an integral part of chronic disease management protocols for patients with RA.

Interplay between obesity and smoking with regard to RA risk

Objectives

Previous studies on rheumatoid arthritis (RA) and body mass index (BMI) have yielded diverging results. We aimed to clarify the influence of BMI on the risk of developing anticitrullinated peptide antibody (ACPA)-positive and ACPA-negative RA by taking into consideration gender, smoking habits and human leukocyte antigen (HLA-DRB1) shared epitope (SE) status.

Methods

The present report is based on a Swedish population-based, case–control study with incident cases of RA (3572 cases, 5772 matched controls). Using logistic regression models, overweight/obese subjects were compared with normal weight subjects regarding risk of developing RA, by calculating ORs with 95% CIs.

Results

We observed diverging results for women and men. Among women, the risk of both ACPA-positive and ACPA-negative RA increased with increasing BMI, whereas an inverse association was observed among men for ACPA-positive RA. The results were similar regardless if RA onset before or after the age of 55 years was considered. When the analyses were stratified by smoking habits, the influence of BMI on RA risk was mainly restricted to smokers. Among women, a significant interaction was observed between smoking and overweight/obesity with regard to both subsets of RA. No interaction was observed between HLA-DRB1 SE and overweight/obesity with regard to RA risk.

Conclusions

The interaction between smoking and obesity regarding risk for RA in women warrants efforts to reduce these risk factors in those at risk for RA. The sex differences concerning the influence of obesity on RA risk merit further studies to verify these results and understand underlying mechanisms.

Assessment of nutritional status by dual X-Ray absorptiometry in women with rheumatoid arthritis: A case-control study

Rheumatoid arthritis (RA) has been related to an impairment of the nutritional status. Body mass index (BMI) has been used but questions arise about how to properly evaluate nutritional status in RA patients. Few studies have evaluated it by dual-energy X-ray absorptiometry.In women with RA, to analyze:Case-control study including 89 women with RA. The control group was composed by 100 patients affected by non-inflammatory rheumatic disorders. Study variables included age, RA duration, history, activity and disability, and in relation to nutritional status: BMI, serum albumin (ALB), whole body DXA assessment, and skeletal muscle index (SMI).Mean age of patients was 62 ± 8 years, mean duration of RA was 14 ± 9 years, mean disease activity score (DAS28) was 3.7 ± 1.4 and mean Health Assessment Questionnaire was 0.88 ± 0.77. BMI was 27.43 ± 5.16 Kg/m in patients and 27.78 ± 3.98 Kg/m in controls (P: ns). ALB was within normal range in all patients.By whole body DXA, RA patients presented a statistically significant lower lean mass in all locations and lower fat mass in limbs than controls. Patients had a redistribution of fat mass to trunk. Lean mass directly correlated with fat mass.Neither BMI nor ALB correlated with DXA parameters.BMI, appendicular lean mass and SMI correlated inversely with disease duration. Trunk lean mass correlated inversely, and fat mass directly, with RA disability parameters.RA patients fulfilled criteria of sarcopenia in 44% of cases versus 19% of controls (P <.001). In RA patients, regarding SMI, BMI showed a high specificity to detect sarcopenia (94% of the patients with low BMI had sarcopenia) but low sensitivity (47% of the patients with normal BMI or overweight had sarcopenia).RA patients have an impairment of nutritional status associated to disease duration that looks like sarcopenia and that is not predicted by BMI.

Overweight, Obesity, and the Likelihood of Achieving Sustained Remission in Early Rheumatoid Arthritis: Results From a Multicenter Prospective Cohort Study

OBJECTIVE

Obesity is implicated in rheumatoid arthritis (RA) development, severity, outcomes, and treatment response. We estimated the independent effects of overweight and obesity on ability to achieve sustained remission (sREM) in the 3 years following RA diagnosis.

METHODS

Data were from the Canadian Early Arthritis Cohort, a multicenter observational trial of early RA patients treated by rheumatologists using guideline-based care. sREM was defined as Disease Activity Score in 28 joints (DAS28) <2.6 for 2 consecutive visits. Patients were stratified by body mass index (BMI) as healthy (18.5-24.9 kg/m² ), overweight (25-29.9 kg/m² ), and obese (≥30 kg/m² ). Cox regression was used to estimate the effect of the BMI category on the probability of achieving sREM over the first 3 years, controlling for age, sex, race, education, RA duration, smoking status, comorbidities, baseline DAS28, Health Assessment Questionnaire disability index, C-reactive protein level, and initial treatment.

RESULTS

Of 982 patients, 315 (32%) had a healthy BMI, 343 (35%) were overweight, and 324 (33%) were obese; 355 (36%) achieved sREM within 3 years. Initial treatment did not differ by BMI category. Compared to healthy BMI, overweight patients (hazard ratio [HR] 0.75 [95% confidence interval (95% CI) 0.58-0.98]) and obese patients (HR 0.53 [95% CI 0.39-0.71]) were significantly less likely to achieve sREM.

CONCLUSION

Rates of overweight and obesity were high (69%) in this early RA cohort. Overweight patients were 25% less likely, and obese patients were 47% less likely, to achieve sREM in the first 3 years, despite similar initial disease-modifying antirheumatic drug treatment and subsequent biologic use. This is the largest study demonstrating the negative impact of excess weight on RA disease activity and supports a call to action to better identify and address this risk in RA patients.

Leptin as an obesity marker in rheumatoid arthritis

The determination of excess of body fat mass provides a more suitable determinant of obesity in rheumatoid arthritis patients; however, body mass index (BMI) may not be accurate for the quantification of adiposity. To identify a marker of excess adiposity in women with rheumatoid arthritis (RA) using different methods for fat mass evaluation. A cross-sectional study was conducted in adult female patients with RA. Disease activity was assessed by DAS28-ESR, and obesity was determined by waist circumference (WC), BMI and dual-energy X-ray absorptiometry (DXA). The Human Bone Metabolism kit (Merck Millipore, Darmstadt, Alemanha) was used to determine the plasma levels of leptin, TNF-α, IL-6, and IL-1β by quantification of serum proteins by technical microspheres (LUMINEX, TX, USA). Adiponectin was measured by enzyme-linked immunosorbent assay sandwich kit (R&D Systems, Minneapolis, MN, USA). Eighty-nine female patients, median age of 55.4 (± 11.6) years, and median disease duration of 16.4 (± 14.9) years were included. The frequency of obesity was 33.7% according to BMI, 89.9% with WC, and 56.1% with DXA. The median serum leptin concentration was the only marker that correlated with body fat percentage according to the three methods. This correlation was positive and not influenced by DAS28, C-reactive protein, erythrocyte sedimentation rate, or inflammatory cytokines levels (IL-6, TNF-α, IL-1β). Analysis of ROC curves determined the cut-off point of 10.3 ng/mL of leptin as an obesity marker, with a sensitivity of 96.43% and a specificity of 23.81%. Serum leptin correlates positively with fat mass and is potentially useful in excess fat mass determination in clinical practice.

Association of High Anti-Cyclic Citrullinated Peptide Seropositivity and Lean Mass Index With Low Bone Mineral Density in Rheumatoid Arthritis

OBJECTIVE

Osteoporotic fractures are associated with high morbidity and mortality. Persons with rheumatoid arthritis (RA) have twice the risk of osteoporosis-related fracture than age-matched controls, the causes for which remain unknown. We investigated contributions of RA characteristics, medication use, and body composition to low bone mineral density (BMD) in patients with RA.

METHODS

Data were from the Arthritis, Body Composition, and Disability Study (n = 138; 82 women, 56 men). Demographic, clinical, laboratory, and functional variables were collected at study visits. Body composition (fat, lean muscle, and BMD) was measured by dual x-ray absorptiometry. Linear regression analyses evaluated the association between predictors and femoral neck BMD.

RESULTS

Average disease duration was 19 years, 70% of patients were rheumatoid factor positive, and 55% were high-positive anti-cyclic citrullinated peptide (anti-CCP). Age and high anti-CCP positivity were negatively associated with BMD after controlling for other variables (β = -0.003 and -0.055, respectively, P < 0.05). Appendicular lean mass index (ALMI) was positively associated with BMD (β = 0.053, P < 0.0001). In high anti-CCP positivity participants, increasing anti-CCP levels were associated with a negative linear trend in BMD (β = -0.011, P = 0.026).

CONCLUSION

High anti-CCP positivity and ALMI were strongly associated with BMD in patients with RA. The linear relationship of anti-CCP levels with lower BMD supports the hypothesis that processes specific to RA negatively impact BMD. In contrast, ALMI was positively associated with BMD, emphasizing the importance of this potentially modifiable risk factor. Our findings highlight the complicated interplay of RA disease-specific and functional factors and their impact on bone mass.

Impact of Obesity and Adiposity on Inflammatory Markers in Patients With Rheumatoid Arthritis

OBJECTIVE

The C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) are important disease activity biomarkers in rheumatoid arthritis (RA). This study aimed to determine to what extent obesity biases these biomarkers.

METHODS

Body mass index (BMI) associations with CRP level and ESR were assessed in 2 RA cohorts: the cross-sectional Body Composition (BC) cohort (n = 451), including whole-body dual x-ray absorptiometry measures of fat mass index; and the longitudinal Veterans Affairs Rheumatoid Arthritis (VARA) registry (n = 1,652), using multivariable models stratified by sex. For comparison, associations were evaluated in the general population using the National Health and Nutrition Examination Survey.

RESULTS

Among women with RA and in the general population, greater BMI was associated with greater CRP levels, especially among women with severe obesity (P < 0.001 for BMI ≥35 kg/m2 versus 20-25 kg/m2 ). This association remained after adjustment for joint counts and patient global health scores (P < 0.001 in BC and P < 0.01 in VARA), but was attenuated after adjustment for fat mass index (P = 0.17). Positive associations between BMI and ESR in women were more modest. In men with RA, lower BMI was associated with higher CRP levels and ESR, contrasting with positive associations among men in the general population.

CONCLUSION

Obesity is associated with higher CRP levels and ESR in women with RA. This association is related to fat mass and not RA disease activity. Low BMI is associated with higher CRP levels in men with RA; this unexpected finding remains incompletely explained but likely is not a direct effect of adiposity.

Fatigue in Rheumatoid Arthritis

PURPOSE OF REVIEW

The purpose of this study was to review the current information on fatigue in rheumatoid arthritis (RA).

RECENT FINDINGS

Severe fatigue is common among individuals with RA and has a significant impact on quality of life (QOL). RA-related factors (e.g., inflammation, pain) are associated with greater fatigue, but other factors, such as obesity, physical inactivity, sleep disturbance, and depression, explain the majority of variation in fatigue. Medications targeting RA have little effect on fatigue. Instead, the most effective interventions seem to address non-RA-specific factors such as physical inactivity or use cognitive behavioral approaches. No recommendations have been made for tools to measure fatigue in RA, leading to potential difficulty comparing studies. Although fatigue has great impact on patients' QOL, effective interventions that are feasible for broad dissemination remain elusive. Additional multi-faceted research is needed to identify modifiable sources of fatigue. Such research would be enhanced by harmonization of fatigue measurement across studies.

Discordance of the Framingham cardiovascular risk score and the 2013 American College of Cardiology/American Heart Association risk score in systemic lupus erythematosus and rheumatoid arthritis

Despite the increasing use of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) cardiovascular (CV) risk score in clinical practice, few studies have compared this score to the Framingham risk score among rheumatologic patients. We calculated Framingham and 2013 ACC/AHA risk scores in subjects with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) and assessed demographic, CV, and rheumatologic characteristics associated with discordant scores (high-risk ACC/AHA scores but low-risk Framingham scores). SLE and RA subjects drawn from two population-based cohort studies were assessed during in-person study visits. We used chi-squared tests and t tests to examine the association of discordant CV risk scores with baseline characteristics. Eleven (7.0%) of 157 SLE subjects and 11 (11.5%) of 96 RA subjects had discordant CV risk scores with high ACC/AHA scores and low Framingham scores. These findings did not significantly change when a 1.5 multiplier was applied to the Framingham score. Rheumatologic disease duration, high-sensitivity CRP levels, African-American race, diabetes, current use of anti-hypertensive medication, higher age, and higher systolic blood pressure were each significantly associated with discordant risk scores. Approximately 10% of SLE and RA subjects had discordant 10-year CV risk scores. Our findings suggest that the use of the 2013 ACC/AHA risk score could result in changes to lipid-lowering therapy recommendations in a significant number of rheumatologic patients. Prospective studies are needed to compare which score better predicts CV events in rheumatologic patients, especially those with risk factors associated with discordant risk scores.

Which is the best cutoff of body mass index to identify obesity in female patients with rheumatoid arthritis? A study using dual energy X-ray absorptiometry body composition

INTRODUCTION

Standard anthropometric measures used to diagnose obesity in the general population may not have the same performance in patients with rheumatoid arthritis.

OBJECTIVE

To determine cutoff points for body mass index (BMI) and waist circumference (WC) for detecting obesity in women with rheumatoid arthritis (RA) by comparing these standard anthropometric measures to a dual-energy X-ray absorptiometry (DXA)-based obesity criterion.

PATIENTS AND METHOD

Adult female patients with more than six months of diagnosis of RA underwent clinical evaluation, with anthropometric measures and body composition with DXA.

RESULTS

Eighty two patients were included, mean age 55±10.7 years. The diagnosis of obesity in the sample was about 31.7% by BMI, 86.6% by WC and 59.8% by DXA. Considering DXA as golden standard, cutoff points were identified for anthropometric measures to better approximate DXA estimates of percent body fat: for BMI value≥25kg/m² was the best for definition of obesity in female patients with RA, with sensitivity of 80% and specificity of 60%. For WC, with 80% of sensitivity and 35% of specificity, the best value to detect obesity was 86cm.

CONCLUSION

A large percentage of patients were obese. The traditional cutoff points used for obesity were not suitable for our sample. For this female population with established RA, BMI cutoff point of 25kg/m² and WC cutoff point of 86cm were the most appropriate to detect obesity.

Assessment of muscle mass relative to fat mass and associations with physical functioning in rheumatoid arthritis

Objectives

To determine whether a novel measure of appendicular lean mass relative to fat mass is associated with physical functioning in RA.

Methods

In a cross-sectional design, three independent RA cohorts were retrospectively analysed. Whole-body DXA measures of appendicular lean mass index (ALMI, kg/m 2 ) and fat mass index (FMI, kg/m 2 ) were converted to age, sex and race-specific Z-scores using published National Health and Nutrition Examination Survey reference ranges. Adiposity-adjusted ALMI Z-scores (ALMI FMI ) were determined using a published method to adjust for normal associations between ALMI and FMI Z-scores. Associations between ALMI Z-scores, ALMI FMI Z-scores and physical functioning were assessed after adjusting for age, sex and study. Functional outcomes assessed included the HAQ, Valued Life Activities assessment and Short Physical Performance Battery. Low lean for age was defined as a Z-score of -1 or less.

Results

Our sample consisted of 442 patients with RA. The combined cohort had a mean ALMI Z-score of - 0.51 (1.08) and a mean ALMI FMI Z-score of - 0.58 (1.53), suggesting muscle mass deficits compared with a nationally representative sample. Greater ALMI FMI Z-scores demonstrated stronger associations with better functional outcomes compared with ALMI Z-scores. Associations were not attenuated with adjustment for systemic inflammation or pain. The FMI Z-score was independently associated with physical functioning, with a stronger association seen among patients with greater FMI Z-score. Adiposity-adjusted definitions of low lean mass more clearly identified those with functional impairment.

Conclusion

Estimates of appendicular lean mass that are adjusted for adiposity demonstrate stronger positive associations with functional outcomes compared with unadjusted estimates.

Causes and consequences of fatigue in rheumatoid arthritis

PURPOSE OF REVIEW

To review current information on the causes, treatments, and consequences of fatigue in rheumatoid arthritis.

RECENT FINDINGS

Disease activity (inflammation, pain, joint symptoms) is associated with greater fatigue. However, disease activity per se accounts for only a small portion of fatigue, and rheumatoid arthritis medications that reduce disease activity have small effects on fatigue. Instead, factors outside the direct effects of rheumatoid arthritis, such as obesity, physical inactivity, sleep disturbance, and depression, explain the majority of variation in fatigue. Some of these factors may be indirect effects of disease (e.g. pain can lead to sleep disturbance). Rheumatoid arthritis has significant effects on the quality of life of individuals with rheumatoid arthritis. The most effective approaches to reducing rheumatoid arthritis fatigue appear to be behavioral, such as increasing physical activity, or cognitive, such as cognitive behavioral interventions.

SUMMARY

Fatigue in rheumatoid arthritis appears to be largely because of factors outside the direct effects of the disease, such as behavioral and psychological factors. In spite of the tremendous impact of fatigue on patient health and quality of life, effective treatments remain elusive, but existing data show that behavioral and cognitive approaches may be most effective.

Frailty and reduced physical function go hand in hand in adults with rheumatoid arthritis: a US observational cohort study

Reduced physical function and health-related quality of life are common in rheumatoid arthritis (RA), and further studies are needed that examine novel determinates of reduced physical function in RA. This study examines whether frailty, a state of increased vulnerability to stressors, is associated with differences in self-reported physical function among adults with RA. Adults from a longitudinal RA cohort (n = 124) participated in the study. Using an established definition of frailty, individuals with three or more of the following physical deficits were classified as frail: (1) body mass index ≤18.5, (2) low grip strength (adjusted for sex and body mass index (BMI), measured by handheld dynamometer), (3) severe fatigue (measured by the Multidimensional Assessment of Fatigue), (4) slow 4-m walking speed (adjusted for sex and height), and (5) low physical activity (measured by the International Physical Activity Questionnaire). Individuals with one or two deficits were classified as "pre-frail" and those with no deficits as "robust." Self-reported physical function was assessed by the Health Assessment Questionnaire (HAQ) and the Valued Life Activities Difficulty scale. Regression analyses modeled associations of frailty category with HAQ and Valued Life Activities (VLA) Difficulty scores with and without controlling for age, sex, disease duration, C-reactive protein, use of oral steroids, and pain. Among adults with RA, being frail compared to being robust was associated with a 0.44 worse VLA score (p < 0.01) when the effects of covariates are held constant. Being frail, compared to being robust, is associated with clinically meaningful differences in self-reported physical function among adults with RA.

Impact of Obesity on Remission and Disease Activity in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

To summarize the relationship between obesity and remission in rheumatoid arthritis (RA); secondary objectives were to summarize other measures of treatment response and mortality in RA.

METHODS

Medline and Embase searches were performed in March 2016 using relevant MeSH and keyword terms for obesity and RA. Articles were selected if they reported estimates for achieving remission in obese subjects relative to other body mass index (BMI) categories, or changes in composite or individual disease activity measures or patient-reported outcomes during therapy, or mortality rates, in relation to BMI category or on a continuous scale. Remission outcomes were conducive to meta-analysis, and all other outcomes were summarized.

RESULTS

A total of 3,368 records were screened; we included 8 reporting remission rates, 9 reporting disease activity measures or patient-reported outcomes, and 3 examining mortality by obesity status or BMI. Obese patients attain remission less frequently than nonobese and/or normal-weight patients. In adjusted models, obese patients demonstrated lower odds of achieving remission (pooled odds ratio [OR] 0.57 [95% confidence interval (95% CI) 0.45, 0.72]) and sustained remission (pooled OR 0.49 [95% CI 0.32, 0.74]) relative to nonobese subjects. Most studies found obese patients to have worse Disease Activity Scores or Disease Activity Scores in 28 joints, tender joint counts, inflammatory markers, patient global evaluation scores, pain scores, and physical function scores during followup, but not worse swollen joint counts. Obesity was not associated with increased mortality.

CONCLUSION

Obesity decreases the odds of achieving remission in RA and negatively impacts disease activity and patient-reported outcomes during therapy. Interventions to reduce BMI should be investigated for their ability to improve disease outcomes.

Development of Novel Methods to Define Deficits in Appendicular Lean Mass Relative to Fat Mass

Background

Recent studies suggest that adjustment of measures of lean mass for adiposity improves associations with physical function. Our objective was to develop and test a method to adjust appendicular lean mass for adiposity.

Methods

Whole-body DXA data in 14,850 adults in the National Health and Nutrition Examination Survey were used to generate sex-, and race-specific standard deviation scores (Z-Scores relative to age and T-scores relative to 25 year-olds) for appendicular lean mass index (ALMI, kg/m²) and fat mass index (FMI, kg/m²). Correlations between ALMI and FMI Z- and T-Scores were assessed within demographic categories. Fat-adjusted ALMI (ALMI_FMI) scores were determined using residual methods. Sarcopenia was defined as a T-Score <-2.0 and low lean for age as a Z-Score <-1.0. Correlations with physical function were assessed in an at-risk population.

Results

Positive associations between ALMI and FMI Z- and T-Scores were significant (R >0.50; p<0.001) within all demographic categories. The impact of a unit greater FMI Z-score on ALMI Z-score was less in the elderly, men, white subjects, and among individuals with lower FMI (all tests for interaction p<0.001). There was fair agreement between ALMI and ALMI_FMI estimates of sarcopenia and low lean for age [Kappa: 0.46, 0.52, respectively (p<0.0001)]. Elderly subjects were likely to be re-classified as sarcopenic while young subjects were likely to be re-classified as normal using ALMI_FMI. ALMI_FMI T-scores resulted in approximately twice the number of subjects defined as sarcopenic, compared with ALMI T-Scores. (1299 v. 534). Among rheumatoid arthritis patients, ALMI_FMI Z-scores correlated with physical function (Health Assessment Questionnaire: rho = -0.22, p = 0.04; Short Physical Performance Battery: rho = 0.27, p = 0.01); however, the ALMI Z-Score did not.

Conclusions

Adjustment of ALMI for the confounding association with FMI impacts the definition of lean mass deficits. These methods provide a practical tool for investigators and clinicians based on population-based reference data.

The Obesity Epidemic and Consequences for Rheumatoid Arthritis Care

With the prevalence of obesity increasing dramatically worldwide over the past several decades, an increasing body of literature has examined the impact of obesity in the context of rheumatoid arthritis (RA). Epidemiologic studies suggest that obesity may be associated with a modestly increased risk for the development of RA, although these studies have shown conflicting results. Among patients with established RA, obesity has been observed to be associated with greater subjective measures of disease activity and poor treatment response, but also with a decreased risk of joint damage and lower mortality. A comprehensive evaluation of the influence of obesity on the measurement of disease, response to therapies, and long-term prognosis is critical in order to understand these observations. This review therefore focuses on recent observations, potential explanations for these findings, and implications for clinicians and investigators caring for and studying patients with RA.

Tight control of disease activity fails to improve body composition or physical function in rheumatoid arthritis patients

OBJECTIVE

RA typically features rheumatoid cachexia [loss of muscle mass (MM) and excessive total fat mass (TFM), especially trunk FM], which contributes to physical disability. Since rheumatoid cachexia is driven by inflammation, it would be anticipated that the success of tight control of disease activity, such as treat-to-target (T2T), in attenuating inflammation would benefit body composition and physical function. This aim of this cross-sectional study was to assess the impact of T2T on body composition and objectively assessed function in RA patients.

METHODS

A total of 82 RA patients exclusively treated by T2T, were compared with 85 matched sedentary healthy controls (HCs). Body composition was estimated by DXA, with appendicular lean mass the surrogate measure of total MM. Physical function was assessed by knee extensor strength, handgrip strength, 30 s sit-to-stands, 8' up and go, and 50' walk (tests which reflect the ability to perform activities of daily living).

RESULTS

Although generally well treated (mean DAS28 = 2.8, with 49% in remission), RA patients had ∼10% proportionally less appendicular lean mass and were considerably fatter (by ∼27%), particularly in the trunk (∼32%), than HCs. All measures of function were 24-34% poorer in the RA patients relative to HC.

CONCLUSIONS

Despite marked improvements in disease control (most patients achieving or approaching remission), the relative loss of MM and increased adiposity in RA patients compared with matched HCs was similar to that observed pre-T2T. Additionally, performance of objective function tests was unchanged from that reported by our group for pre-T2T RA patients. Thus T2T, even in responsive RA patients, did not attenuate rheumatoid cachexia or improve objectively assessed function.

Impact of Bariatric Surgery on Patients With Rheumatoid Arthritis

OBJECTIVE

To investigate the effect of weight loss after bariatric surgery among patients with rheumatoid arthritis (RA).

METHODS

We conducted a retrospective cohort study of RA patients who underwent bariatric surgery (Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, or sleeve gastrectomy) at 2 medical centers. We obtained information on anthropometrics, laboratory values, RA disease activity, and medication use at baseline (prior to surgery), at 6 and 12 months following surgery, and at the most recent followup visits. RA disease activity was determined by clinical or validated measures. At each postsurgical visit, characteristics were compared to baseline.

RESULTS

We identified 53 RA patients who underwent bariatric surgery. At baseline prior to surgery, mean ± SD body mass index was 47.8 ± 7.7 kg/m(2), mean ± SD weight was 128.2 ± 24.1 kg, and 57% had moderate to high RA disease activity. Twelve months following surgery, subjects lost a mean ± SD weight of 41.0 ± 17.3 kg, mean ± SD 70% ± 24% excess weight (P < 0.001). RA disease activity significantly improved at postsurgical visits (P < 0.001). At 12 months following surgery, 6% had moderate to high disease activity, compared to 57% at baseline (P < 0.001). At the most recent followup (mean ± SD 5.8 ± 3.2 years after surgery), 74% were in remission, compared to 26% at baseline (P < 0.001). Subjects had significantly lower erythrocyte sedimentation rate, C-reactive protein level, and RA-related medication use at followup visits compared to baseline (P < 0.05).

CONCLUSION

After substantial weight loss from bariatric surgery, RA patients had lower disease activity, decreased serum inflammatory markers, and less RA-related medication use. Weight loss may be an important nonpharmacologic strategy to reduce RA disease activity. However, other factors, such as improved efficacy of medications, improved physical activity, and metabolic changes, may also have contributed to these postsurgical improvements.

Role of Sleep Disturbance, Depression, Obesity, and Physical Inactivity in Fatigue in Rheumatoid Arthritis

OBJECTIVE

Fatigue is a major concern for individuals with rheumatoid arthritis (RA). However, in order to treat fatigue adequately, its sources need to be identified.

METHODS

Data were collected during a single home visit (number of participants = 158). All participants had physician-diagnosed RA. Assessments of self-reported sleep quality, depression, physical activity, RA disease activity, muscle strength, functional limitations, and body composition were made. Information on demographics, medications, and smoking was collected. The Fatigue Severity Inventory (FSI; measuring average fatigue over the past 7 days) was used as the primary outcome. Analyses were first conducted to evaluate bivariate relationships with fatigue. Correlations among risk factors were examined. Multivariate analyses identified independent predictors of fatigue.

RESULTS

The mean ± SD age was 59 ± 11 years, the mean ± SD disease duration was 21 ± 13 years, and 85% of subjects were female. The mean ± SD FSI rating was 3.8 ± 2.0 (range 0-10). In multivariate analyses, self-reported disease activity, poor sleep, depression, and obesity were independently associated with fatigue. Physical inactivity was correlated with poor sleep, depression, and obesity. Mediation analyses indicated that physical inactivity had an indirect association with fatigue, mediated by poor sleep, depression, and obesity.

CONCLUSION

This cross-sectional study suggests that fatigue may not be solely a result of RA disease activity, but may result from a constellation of factors that includes RA disease activity or pain, but also includes inactivity, depression, obesity, and poor sleep. The results suggest new avenues for interventions to improve fatigue in individuals with RA, such as increasing physical activity or addressing depression or obesity.

Biomolecular features of inflammation in obese rheumatoid arthritis patients: management considerations

Adipose tissue is an active organ playing a role not only in metabolism but also in immune and inflammatory processes, releasing several pro-inflammatory mediators. This can explain the possible association between obesity and rheumatoid arthritis (RA) and its role in the progression of the disease. Adipose and synovial tissues share common histological features of local inflammation in terms of activation of target tissues infiltrating cells (i.e. myeloid cells). Among the so-called adipocytokines, PEDF and Chemerin orchestrate the cellular cross-talk between adipose and myeloid cells, being possible biomarkers to monitor the effect of weight loss or the decrease of adipose tissue in patients with RA. Moreover, dietary intervention has been demonstrated to reduce Chemerin as well as IL-6 and MCP-1 expression. Finally, epigenetic regulators such as micro-RNAs (i.e. miR-155) are key regulators of myeloid cells activation in RA and obesity as well as in adipocytes. In this review, we will summarize the biological link between obesity/overweight state and RA focusing on pathophysiological mechanisms, consequences and management considerations.

Which is the best cutoff of body mass index to identify obesity in female patients with rheumatoid arthritis? A study using dual energy X-ray absorptiometry body composition

INTRODUCTION

Standard anthropometric measures used to diagnose obesity in the general population may not have the same performance in patients with rheumatoid arthritis.

OBJECTIVE

To determine cutoff points for body mass index (BMI) and waist circumference (WC) for detecting obesity in women with rheumatoid arthritis (RA) by comparing these standard anthropometric measures to a dual-energy x-ray absorptiometry (DXA)-based obesity criterion.

PATIENTS AND METHOD

Adult female patients with more than six months of diagnosis of RA underwent clinical evaluation, with anthropometric measures and body composition with DXA.

RESULTS

Eighty two patients were included, mean age 55±10.7 years. The diagnosis of obesity in the sample was about 31.7% by BMI, 86.6% by WC and 59.8% by DXA. Considering DXA as golden standard, Cutoff points were identified for anthropometric measures to better approximate DXA estimates of percent body fat: for BMI value ≥ 25kg/m2 was the best for definition of obesity in female patients with RA, with sensitivity of 80% and specificity of 60%. For WC, with 80% of sensitivity and 35% of specificity, the best value to detect obesity was 86cm.

CONCLUSION

A large percentage of patients were obese. The traditional cutoff points used for obesity were not suitable for our sample. For this female population with established RA, BMI cutoff point of 25kg/m2 and WC cutoff point of 86cm were the most appropriate to detect obesity.

High rates of obesity and greater associated disability among people with rheumatoid arthritis in Canada

Obesity in rheumatoid arthritis has been associated with increased risk of comorbidities, larger medical costs, decreased quality of life, higher disease activity, and reduced therapeutic responses. We assessed the burden of obesity among rheumatoid arthritis patients and its impact on patient-reported outcomes. Patients receiving care at two Canadian University Centers were included. Height and weight were measured and selected sociodemographic and rheumatoid arthritis (RA) characteristics as well as patient-reported outcomes were obtained. Patients were classified according to WHO criteria and proposed RA cut points, and results were compared with national data. Using WHO criteria, 68 (34 %) RA patients were classified as obese (vs. ~25 % of Canadians). Using RA cut points, 112 (55 %) RA patients were classified as obese. With both classification methods, obese individuals had significantly higher mean HAQ scores and a higher odds of significant disability (HAQ ≥ 1: WHO OR 2.3; 95 % CI 1.2, 4.2 and RA-specific OR 1.8; 95 % CI 1.0, 3.2). Independent of the classification method use, RA patients have significantly higher rates of obesity than national prevalence estimates. Obese RA patients had about twice the odds of reporting moderate to severe disability.

A lifetime history of alcohol use disorder increases risk for chronic medical conditions after stable remission

BACKGROUND

The long-term impact of a past alcohol use disorder (AUD) among those who are currently in stable remission has not been well-explored. This study examined whether a past history of AUD was associated with increased risk for chronic medical conditions in a large U.S. nationally representative sample of adults ≥30 years old.

METHODS

Using 25,840 participants from Wave 1 and Wave 2 surveys of the National Epidemiologic Survey on Alcohol and Related Condition (NESARC), multiple logistic regression analysis was conducted to compare the risk for reporting metabolic, cardiovascular, liver, gastrointestinal, and inflammatory conditions between those in full-remission from AUD for longer than 5 years and those without a history of AUD diagnosis.

RESULTS

Compared with a model adjusting only for age, a model adjusting for other potential psychosocial confounders revealed fewer significant associations between AUD history and chronic medical conditions, particularly for the middle-aged population and for men. For the elderly, AUD history was associated with more chronic medical conditions in fully adjusted models. AUD history was associated with severe medical conditions such as liver diseases and myocardial infarction in women. In general, longer AUD exposure and shorter remission were also associated with the risk for chronic medical conditions.

CONCLUSIONS

Our findings suggest associations between past AUD diagnosis and chronic medical conditions, particularly for the elderly individuals. Screening for past alcohol use problems and associated health risks are important for the promotion of aging and prevention of chronic medical conditions even when an individual presents no current symptoms of AUD.

Association between body composition and disease activity in rheumatoid arthritis. A systematic review

BACKGROUND

Reports regarding the association between body composition and inflammatory activity in rheumatoid arthritis (RA) have consistently yielded contradictory results.

OBJECTIVE

To perform a systematic review on the association between overweight/obesity and inflammatory activity in RA.

METHODS

FAST approach: Article search (Medline, EBSCO, Cochrane Library), followed by abstract retrieval, full text review and blinded assessment of methodological quality for final inclusion. Because of marked heterogeneity in statistical approach and RA activity assessment method, a meta-analysis could not be done. Results are presented as qualitative synthesis.

RESULTS

One hundred and nineteen reports were found, 16 of them qualified for full text review. Eleven studies (8,147 patients; n range: 37-5,161) approved the methodological quality filter and were finally included. Interobserver agreement for methodological quality score (ICC: 0.93; 95% CI: 0.82-0.98; P<.001) and inclusion/rejection decision (k 1.00, P>.001) was excellent. In all reports body composition was assessed by BMI; however a marked heterogeneity was found in the method used for RA activity assessment. A significant association between BMI and RA activity was found in 6 reports having larger mean sample size: 1,274 (range: 140-5,161). On the other hand, this association was not found in 5 studies having lower mean sample size: 100 (range: 7-150).

CONCLUSIONS

The modulation of RA clinical status by body fat mass is suggested because a significant association was found between BMI and inflammatory activity in those reports with a trend toward higher statistical power. The relationship between body composition and clinical activity in RA requires be approached with further studies with higher methodological quality.

Obesity and inflammatory arthritis: impact on occurrence, disease characteristics and therapeutic response

Overweight and obesity are increasing worldwide and now reach about one-third of the world's population. Obesity also involves patients with inflammatory arthritis. Knowing the impact of obesity on rheumatic diseases (rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis) is thus an important issue. This article first reviews the epidemiological and clinical data available on obesity in inflammatory rheumatic diseases, that is, its impact on incident disease, disease characteristics and the therapeutic response. The second part of this review gives an overview of the factors potentially involved in the specifics of inflammatory arthritis in patients with obesity, such as limitations in the clinical assessment, diet, microbiota and adipokines.

Prevention of cardiovascular disease in rheumatoid arthritis

The increased risk of cardiovascular disease (CVD) in rheumatoid arthritis (RA) has been recognized for many years. However, although the characteristics of CVD and its burden resemble those in diabetes, the focus on cardiovascular (CV) prevention in RA has lagged behind, both in the clinical and research settings. Similar to diabetes, the clinical picture of CVD in RA may be atypical, even asymptomatic. Therefore, a proactive screening for subclinical CVD in RA is warranted. Because of the lack of clinical trials, the ideal CVD prevention (CVP) in RA has not yet been defined. In this article, we focus on challenges and controversies in the CVP in RA (such as thresholds for statin therapy), and propose recommendations based on the current evidence. Due to the significant contribution of non-traditional, RA-related CV risk factors, the CV risk calculators developed for the general population underestimate the true risk in RA. Thus, there is an enormous need to develop adequate CV risk stratification tools and to identify the optimal CVP strategies in RA. While awaiting results from randomized controlled trials in RA, clinicians are largely dependent on the use of common sense, and extrapolation of data from studies on other patient populations. The CVP in RA should be based on an individualized evaluation of a broad spectrum of risk factors, and include: 1) reduction of inflammation, preferably with drugs decreasing CV risk, 2) management of factors associated with increased CV risk (e.g., smoking, hypertension, hyperglycemia, dyslipidemia, kidney disease, depression, periodontitis, hypothyroidism, vitamin D deficiency and sleep apnea), and promotion of healthy life style (smoking cessation, healthy diet, adjusted physical activity, stress management, weight control), 3) aspirin and influenza and pneumococcus vaccines according to current guidelines, and 4) limiting use of drugs that increase CV risk. Rheumatologists should take responsibility for the education of health care providers and RA patients regarding CVP in RA. It is immensely important to incorporate CV outcomes in testing of anti-rheumatic drugs.

Muscle strength, muscle mass, and physical disability in women with systemic lupus erythematosus

OBJECTIVE

Data describing relationships between muscle strength, muscle mass, and physical disability among individuals with systemic lupus erythematosus (SLE) are limited. The present study examines the relationship of muscle strength and muscle mass with physical disability among adult women with SLE.

METHODS

A total of 146 women from a longitudinal SLE cohort participated in the study. All measures were collected during an in-person research visit. Lower extremity muscle strength was assessed by peak knee torque of extension and flexion and by chair-stand time. Total lean body mass, appendicular lean mass, and fat mass (kg/m(2) ) were measured by whole-body dual x-ray absorptiometry. Self-reported physical disability was assessed using the Short Form 36 health survey (SF-36) physical functioning subscale, and the Valued Life Activities (VLA) disability scale. Spearman's rank correlation coefficients tested the correlations between muscle strength, muscle mass, and disability scores. Regression analyses modeled the effect of lower extremity muscle strength and mass on SF-36 and VLA disability scores controlling for age, SLE duration, SLE disease activity measured with the Systemic Lupus Activity Questionnaire, physical activity level, prednisone use, body composition, and depression.

RESULTS

On all measures, reduced lower extremity muscle strength was associated with poorer SF-36 and VLA disability scores. Trends persisted after adjustment for covariates. Muscle mass was moderately correlated with muscle strength, but did not contribute significantly to adjusted regression models.

CONCLUSION

Lower extremity muscle strength, but not muscle mass, was strongly associated with physical disability scores. While further studies are needed, these findings suggest that improving muscle strength may reduce physical disability among women with SLE.

Are men at greater risk of lean mass deficits in rheumatoid arthritis?

OBJECTIVE

We aimed to determine if there were sex differences in lean body mass (LBM) in patients with rheumatoid arthritis (RA) when compared with sex- and race-specific National Health and Nutrition Examination Survey (NHANES) reference data, and to investigate the impact of sex differences in risk factors for LBM deficits.

METHODS

Dual x-ray absorptiometry measures of whole body LBM and appendicular LBM (arms and legs, appendicular lean mass [ALM]) were obtained on a total of 190 subjects from 2 independent cohorts (141 from San Francisco [SF], 49 from Philadelphia [PA]), expressed as indices adjusted for height (LBM index and ALM index, kg/m(2) ), and converted to sex- and race-specific Z scores relative to age and based on NHANES data. Sarcopenia was defined using 4 different sex-specific definitions. Multivariable linear and logistic regression analyses adjusted for disease activity, disease duration, physical activity, anti-cyclic citrullinated peptide seropositivity, fat mass index, and glucocorticoid use.

RESULTS

While there were significant differences between the 2 cohorts, ALM index Z scores were significantly lower in men compared to women in both (SF: -1.43 versus -0.43, P < 0.0001; PA: -0.83 versus -0.06, P = 0.03). Observed sex differences were significant after adjustment in multivariable analyses within both cohorts. Odds of sarcopenia were 3 to 8 times greater in men in the SF cohort. Men in the PA cohort also had a higher, but nonsignificant, risk of sarcopenia.

CONCLUSION

RA is associated with significant LBM deficits, with greater deficits observed in men. Future study may help elucidate the mechanisms driving greater deficits among men.

Obesity as a risk and severity factor in rheumatic diseases (autoimmune chronic inflammatory diseases)

The growing body of evidence recognizing the adipose tissue (AT) as an active endocrine organ secreting bioactive mediators involved in metabolic and inflammatory disorders, together with the global epidemic of overweight and obesity, rise obesity as a hot topic of current research. The chronic state of low-grade inflammation present in the obese condition and the multiple pleiotropic effects of adipokines on the immune system has been implicated in the pathogenesis of several inflammatory conditions including rheumatic autoimmune and inflammatory diseases. We will discuss the main relevant evidences on the role of the AT on immune and inflammatory networks and the more recent evidences regarding the effects of obesity on the incidence and outcomes of the major autoimmune chronic inflammatory diseases.

Results from systematic screening for cardiovascular risk in outpatients with rheumatoid arthritis in accordance with the EULAR recommendations

AIM

To investigate risk factors for the development of cardiovascular disease (CVD) and estimate the risk of cardiovascular death in rheumatoid arthritis (RA) patients in accordance with EULAR recommendations.

MATERIALS AND METHODS

Outpatients with RA ≤85 years of age from a Danish hospital were invited to participate. Patients' risk of cardiovascular death was calculated according to the SCORE system, based on total cholesterol/high-density lipoprotein (HDL) ratio, smoking habits, blood pressure, age and gender. The SCORE was adjusted based on disease duration, IgM-RF/anti-CCP positivity and the presence of extra-articular manifestations. Factors such as history of CVD, hypertension or diabetes mellitus (DM), fasting glucose, exercise habits, body mass index (BMI) and waist circumference were explored.

RESULTS

836 patients participated; 71.5% women; mean (SD) age 64.3 years (12.0); 152 (19.1%) were already diagnosed with CVD and 74 (9.0%) with DM. Among the 644 patients without CVD or DM, 158 (24.5%) were smokers, 229 (35.8%) had a systolic blood pressure ≥140, 397 (65.6%) total cholesterol ≥5.0 mM/L, 326 (55.4%) low-density lipoprotein cholesterol ≥3.0 mM/L, 18 (4.0%) women and 19 (12.1%) men had a HDL-cholesterol level below 1.2/1.0 mM/L. BMI was >25 in 409 (63.8%). Waist circumference was above 80/94 cm in 297 (63.3%) of female and 111 (63.8%) of male patients, respectively, and 418 (64.9%) exercised ≤5 times a week. Among patients without DM, 14.3% had a fasting glucose ≥6.0 mmol/L. The SCORE was ≥5 in 122 (20.2%). They were referred to follow-up by their GP and community advice services.

CONCLUSIONS

Systematic screening revealed several risk factors that needed medical follow-up or support to initiate lifestyle changes.