Association of weight loss with improved disease activity in patients with rheumatoid arthritis: A retrospective analysis using electronic medical record data

Characteristics of sarcopenia in patients with rheumatoid arthritis at a central university hospital in Hanoi, Vietnam: a cross-sectional study

AIM

To determine the prevalence and factors associated with sarcopenia in rheumatoid arthritis (RA) patients at a central university hospital in Hanoi, Vietnam.

METHODS

Patients with RA aged ≥ 18 were enrolled in this cross-sectional study. Dual-energy X-ray absorptiometry was performed to measure appendicular skeletal muscle (ASM). Assessment of muscle function included hand grip strength (HGS) and gait speed (GS). Sarcopenia was defined according to Asian Working Group for Sarcopenia (AWGS) criteria 2019. RA disease activity was evaluated by disease activity score 28 CRP (DAS28-CRP). Medical history and previous medications including steroids, methotrexate, bDMARDs, clinical characteristics, and comorbidities were also documented. Multivariable adjusted regression was used to examine potential factors associated with sarcopenia in patients with RA.

RESULTS

A total of 156 patients with RA were recruited, out of which the prevalence of sarcopenia was 62.82%. Among the participants, 95.16% had a low appendicular lean mass index (ALMI), 91.67% had low hand grip strength, and 36.54% had slow gait speed. Active RA disease was significantly associated with a higher odd ratio of having sarcopenia, low muscle mass, and low hand grip strength. After adjusting for potential factors, male (aOR 6.66), RA disease activity level (aOR 3.07), and hypertension (aOR 4.06) were statistically independent factors associated with sarcopenia.

CONCLUSION

Effective RA management to achieve clinical remission is essential to mitigate sarcopenia risk. Further studies are essential to better understand sarcopenia and improve management in patients with RA. Key Points • Prevalence: Sarcopenia was present in 62.82% of patients with RA, especially in those with higher disease activity. • Risk Factors: Male gender, active disease, and hypertension were associated with sarcopenia. • Inflammation and disease activity: Active RA and elevated CRP levels were linked to reduced muscle mass and strength.

GLP-1R Agonists and Their Therapeutic Potential in Inflammatory Bowel Disease and Other Immune-Mediated Inflammatory Diseases, a Systematic Review of the Literature

Background/Objectives: GLP-1 receptor agonists (GLP-1RAs) have revolutionized weight loss and shown anti-inflammatory actions in several experimental models of colitis. There has been a wealth of recent data suggesting that GLP-1RA treatment may modify disease outcomes in inflammatory bowel disease (IBD). The aim of this systematic review is to determine if GLP-1RAs can act as a sole or adjunctive agent to induce steroid-free clinical remission in IBD patients. Methods: The PubMed/Medline, Cochrane Clinical Trial, and EMBASE databases were interrogated with a pre-defined search strategy and eligibility criteria to examine the evidence regarding GLP-1RAs' use in IBD and non-IBD immune-mediated inflammatory disease (IMID) patients. Results: While there is a wealth of pre-clinical animal data suggesting that GLP-1RAs can ameliorate experimental colitis, there is a lack of prospective clinical studies on treating active IBD with GLP-1RAs to specifically induce steroid-free clinical remission. Surrogate data on better IBD composite outcomes have been reported with the use of GLP-1RAs, including a lower risk of surgery, hospitalization, corticosteroid use, and/or the initiation of advance therapies. Data from non-IBD IMID patients are only available for the effect of these agonists on psoriatic plaques, with positive signals. Conclusions: The current evidence for the role of GLP-1RAs as a potential anti-inflammatory therapy in IBD is limited, but provides the impetus for much-needed prospective studies and RCTs that include patients with active IBD.

The impact of BMI on disease activity and growth outcomes in juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) presents with diverse phenotypes and can lead to significant morbidity. Obesity, affecting 5 to 23% of JIA patients, may exacerbate disease activity and complicate management. This study evaluates the impact of body mass index (BMI) on disease activity and the influence of joint involvement on BMI in JIA patients. Between January 2012 and June 2024, 225 JIA patients were reviewed, with 173 ultimately included based on specific inclusion and exclusion criteria. Treatments followed the American College of Rheumatology (ACR) recommendations. Data on demographics, BMI, JADAS-27 scores, joint involvement, and laboratory parameters were analyzed, with statistical significance defined as p < 0.05. Among 173 JIA patients, significant increases in weight and height SDS were observed (p < 0.05). Obese patients at baseline had higher JADAS-27 scores at 6 months (p < 0.05). A positive correlation was found between initial JADAS-27 and final BMI SDS (r = 0.170, p < 0.05). Patients with hip involvement had lower BMI at diagnosis and at the first-year follow-up (p < 0.0001, p = 0.049), while knee involvement was linked to lower height SDS at the second year (p = 0.041).

CONCLUSION

Our study revealed that baseline obesity is a significant risk factor for poorer disease control at the 6-month follow-up in JIA patients. We also observed that effective treatment led to improvements in growth, particularly in patients with hip involvement, who initially had lower BMI values. These findings underscore the importance of monitoring BMI in JIA patients to optimize disease management and long-term outcomes.

WHAT IS KNOWN

• Overweight and obesity are prevalent in children with JIA, with reported rates ranging from 5 to 23% in various studies. • The relationship between BMI and disease activity in JIA remains controversial, with previous studies reporting conflicting results on whether BMI impacts disease remission or activity.

WHAT IS NEW

• Baseline obesity in juvenile idiopathic arthritis (JIA) patients is associated with worse disease activity during follow-up, particularly evident at the 6-month visit. • Patients with hip involvement had significantly lower BMI values, indicating a potential correlation with more severe disease. • Improved linear growth was observed in JIA patients during follow-up, indicating that effective treatment positively impacts growth despite the chronic nature of the disease.

Chinese guidelines for the diagnosis and treatment of rheumatoid arthritis: 2024 update

Rheumatoid arthritis (RA) is an autoimmune disease with destructive arthritis as its main clinical manifestation, which is a major cause of disability. It is very important to formulate and update a guideline for the diagnosis and treatment of RA that adhere to international guideline development standards and can be applied to clinical practice in China. This guideline is endorsed and developed by the National Clinical Research Center for Dermatologic and Immunologic Diseases, collaborated with Rheumatologists Branch of Chinese Medical Doctor Association, Rheumatology Rehabilitation Branch of Chinese Association of Rehabilitation Medicine, Rheumatology Branch of Chinese Research Hospital Association, and Rheumatology Branch of Beijing Association of Holistic Integrative Medicine, based on grading of recommendations assessment, development and evaluation (GRADE) and reporting items for practice guidelines in healthcare (RIGHT). Evidence-based recommendation were developed for 10 clinical scenario that are most relevant to Chinese rheumatologists, aiming to improve and standardize the diagnosis and treatment of RA in China, which may finally improve the quality of life and prognosis of patients.

Weight loss affects disease activity and treatment response in inflammatory rheumatic diseases

The quantity and quality of the adipose tissue is altered in obesity: hypertrophy of adipocytes, decrease in expandability, fibrosis, production of pro-inflammatory cytokines and adipokines, inflammatory infiltration by pro-inflammatory M1 macrophages and T lymphocytes. Excess adipose tissue and obesity are associated with low-grade inflammation that can aggravate chronic inflammatory diseases, decrease treatment efficacy, contribute to the development of comorbidities, and of the disease in its preclinical phase. Obesity increases the incidence of rheumatoid arthritis (RA), psoriasis, psoriatic arthritis with a weight-dose effect. It is also a predictor of worse response to treatment, in particular TNF inhibitors. Weight loss induced by bariatric surgery decreases the risk of psoriasis and psoriatic arthritis and improves disease activity and remission in RA. A 5% weight loss through a low-calorie diet improves the response to TNF inhibitors in psoriatic arthritis, losing even more weight improves the response even more. In RA, the beneficial effect of weight loss from a low-calorie diet on disease activity has been reported in a few observational studies but has not been demonstrated in a randomized controlled trial. Screening and management of obesity are part of the dietary recommendations of the French Society for Rheumatology in patients with chronic inflammatory rheumatic diseases. Of course, this should be combined with other lifestyle modifications such as smoking cessation, higher food quality, increased physical activity and reduced sedentary behavior.

Effect of dietary interventions on nutritional status in patients with rheumatoid arthritis and spondyloarthritis - A systematic review and meta-analysis

BACKGROUND & AIM

Patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) have an increased risk of developing altered body composition, such as low muscle mass, and an increased risk of developing cardiovascular diseases (CVD). Thus, investigating how to improve body composition and CVD risk factors is a relevant topic to improve management of RA and SpA. The aim of this study was to identify dietary interventions that can improve body composition, as well as reduce CVD risk factors in RA and SpA.

METHODS

We searched the databases Medline, Embase and Cochrane. Duplicates were removed using Endnote and records were screened through Rayyan. The primary outcomes were muscle mass (kg) and fat mass (kg). Secondary outcomes were body weight (kg), body mass index (BMI: kg/m2), waist circumference (cm) and lipid profile (total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides, mmol/L).

RESULTS

A total of 4965 articles were identified, and 17 articles were included in this review, of which 15 were suitable for meta-analysis. We found a reduction in TC and LDL-C, (Mean difference, [95%CI]: -0.36, [-0.63, -0.10], I2 = 43%, and -0.20, [-0.35, -0.05], I2 = 0% respectively). Otherwise, no other significant effect was seen in either primary or secondary outcomes. The evidence was graded as moderate for TC and low for LDL-C.

CONCLUSION

Dietary interventions might reduce the levels of blood lipids, and consequently, the risk of cardiovascular diseases. However, body composition did not change significantly after a 2-4 month dietary intervention. Both short intervention period and lack of reliable methods to assess body composition are possible explanations for this finding. Further studies of longer duration are needed.

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.

The dual role of body mass index on Juvenile Idiopathic Arthritis course: a pediatric experience

Despite the well-known role of obesity as risk factor for Juvenile Idiopathic Arthritis (JIA) severity, emerging but limited evidence suggested a similar role for underweight. We investigated the role of body mass index (BMI) across its full spectrum in a cohort of children with JIA.We retrospectively studied 113 children with JIA classified according to the International League of Association for Rheumatology (ILAR) criteria attending our Rheumatology Clinic. The patients underwent a comprehensive evaluation including both clinical and biochemical assessments. According to BMI Z-score, the cohort was divided into five groups as underweight, normal weight, overweight (OW), obesity (OB), and severe OB. Disease activity was calculated by Juvenile Arthritis Disease Activity Score 10 (JADAS-10) joint reduced count and relapses were defined according to Wallace criteria.The mean age of the cohort was 7.43 ± 4.03 years. The prevalence of underweight, normal weight, OW, OB, and severe OB was 7.2%, 54.1%, 10.8%, 17.1%, and 10.8%, respectively. Significant higher ferritin levels and erythrocyte sedimentation rate values were found in patients with severe OB and underweight compared to subjects belonging to normal weight, OW, and OB groups. A greater JADAS-10 score was observed in underweight patients and in those with severe OB than other groups. The relapse rate was higher in patients with severe OB and underweight compared to other groups.          Conclusions: Both underweight and OB might negatively affect JIA course. Weight control is fundamental in children with JIA to avoid a more unfavourable course of the disease. What is Known: • Obesity represents a well-known risk factor for JIA severity. • The role of underweight in children with JIA is still poorly explored. What is New: • As observed in children with obesity, underweight young patients with JIA seem to experience a more severe JIA course. • Healthy lifestyle promotion in children with JIA is a crucial step in the management of the disease.

Impact of prior bariatric surgery on outcomes of hospitalized patients with systemic lupus erythematosus: a propensity score-matched analysis of the U.S. nationwide inpatient sample

BACKGROUND

Systemic lupus erythematosus (SLE) is an autoimmune disease that primarily affects young women, has many different manifestations, and the disease severity can wax and wane.

OBJECTIVES

This study aims to determine the association between prior bariatric surgery and SLE outcomes.

SETTING

A population-based, retrospective study using data from the U.S. Nationwide Inpatient Sample (NIS) database between 2005 and 2018.

METHODS

Data of hospitalized patients with SLE and morbid obesity were extracted. Exclusion criteria were age <18 years and missing information on mortality. Patients were separated into 2 groups: with or without prior bariatric surgery. One: 4 propensity score matching (PSM) were performed to balance the characteristics between the groups. Associations between prior bariatric surgery and inpatient outcomes were determined by logistic regressions.

RESULTS

A total of 38,286 hospitalized patients with SLE and morbid obesity were identified. After exclusions and PSM, there remained 9050 subjects in the study sample (with prior bariatric surgery: 1810; without prior bariatric surgery: 7240), representing 44,952 U.S. inpatients. After adjusting for confounders in multivariable analysis, prior bariatric surgery was significantly associated with lower odds for prolonged length of stay (LOS), unfavorable discharge, and SLE-related complications. Specifically, prior bariatric surgery was significantly associated with lower risks of acute myocardial infarction (AMI)/stroke (aOR = .44, 95% CI: .30-.65), venous thromboembolism (VTE) (aOR = .74, 95% CI: .57-.96), pneumonia (aOR = .60, 95% CI: .47-.76), sepsis (aOR = .62, 95% CI: .51-.75), acute and chronic glomerulonephritis (aOR = .53, 95% CI: .38-.76), acute kidney injury (AKI) (aOR = .64, 95% CI: .52-.77), and anemia (aOR = .77, 95% CI: .68-.87).

CONCLUSIONS

Prior bariatric surgery is associated with favorable in-hospital outcomes in hospitalized patients with SLE and decreased likelihood for several SLE-related complications.

Is the relationship between deprivation and outcomes in rheumatoid arthritis mediated by body mass index? A longitudinal cohort study

OBJECTIVES

To understand the relationships between deprivation and obesity with self-reported disability and disease activity in people with RA, and to determine whether BMI mediates the relationship between area-level deprivation and these outcomes.

METHODS

Data came from the Rheumatoid Arthritis Medication Study (RAMS), a 1-year multicentre prospective observational cohort of people with RA recruited from rheumatology centres across England commencing MTX for the first time. A total of 1529 and 1626 people were included who had a baseline and at least one follow-up measurement at 6 or 12 months of HAQ-Disability Index (HAQ-DI) and DAS in 28 joints (DAS28), respectively. Linear mixed models estimated the associations of deprivation and obesity with repeated measures HAQ-DI and DAS28. Causal mediation analyses estimated the mediating effect of BMI on the relationship between deprivation and RA outcomes.

RESULTS

Higher deprivation and obesity were associated with higher disability [adjusted regression coefficients highest vs lowest deprivation fifths 0.32 (95% CI 0.19, 0.45); obesity vs no obesity 0.13 (95% CI 0.06, 0.20)] and higher disease activity [adjusted regression coefficients highest vs lowest deprivation fifths 0.34 (95% CI 0.11, 0.58); obesity vs no obesity 0.17 (95% CI 0.04, 0.31)]. BMI mediated part of the association between higher deprivation and self-reported disability (14.24%) and DAS (17.26%).

CONCLUSIONS

People with RA living in deprived areas have a higher burden of disease, which is partly mediated through obesity. Weight-loss strategies in RA could be better targeted towards those living in deprived areas.

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.

Nutrition and its role in prevention and management of rheumatoid arthritis

Accumulating research evidence suggests that nutrition might be implicated in the risk of development and in the management of autoimmune disease, including rheumatoid arthritis (RA), characterized by immune-inflammatory response. Nutrition can have direct roles through the provision of pro- or anti-inflammatory foods, and indirect roles through management of co-morbidity management. The review updates on the evidence relating RA risk and management with focus on specific foods such as fish and diets/dietary patterns such as the Mediterranean diet, fasting and elimination diets and oral nutritional supplements including omega-3 polyunsaturated fatty acids (PUFA). Evidence on herbs and spices, beverages, Vitamin D, and probiotics is also reviewed. Diet has been shown to improve disease activity through reducing inflammation and oxidation and through its beneficial effects on the gut microbiota. Based on the existing evidence, it is recommended that as an adjunct to medical treatment, nutrition therapy for RA should be based on an anti-inflammatory Mediterranean diet (MD) supplemented with at least twice a week consumption of oily fish and/or omega-3 PUFA supplements at 2 g/day. The need for rheumatologists to work more closely with registered dietitians in the management of patients particularly in supporting a well-balanced diet according to individual needs, is highlighted.

Non-pharmacological treatment in difficult-to-treat rheumatoid arthritis

Although the management of rheumatoid arthritis (RA) has improved remarkably with new pharmacological therapies, there is still a significant part of patients not reaching treatment goals. Difficult-to-treat RA (D2TRA) is a complex entity involving several factors apart from persistent inflammation, thereafter requiring a holistic management approach. As pharmacological treatment options are often limited in D2TRA, the need for non-pharmacological treatments (NPT) is even more pronounced. The mechanism of action of non-pharmacological treatments is not well investigated, NPTs seem to have a complex, holistic effect including the immune, neural and endocrine system, which can have a significant additive benefit together with targeted pharmacotherapies in the treatment of D2TRA. In this review we summarize the current knowledge on different NPT in rheumatoid arthritis, and we propose a NPT plan to follow when managing D2TRA patients.

Impact of Bariatric Surgery on Outcomes of Patients with Rheumatoid Arthritis: a Propensity Score-Matched Analysis of US Nationwide Inpatient Sample, 2005-2018

PURPOSE

Obesity has been considered one of the risk factors with more critical disease progression and poor treatment response in rheumatoid arthritis (RA). We herein utilized an extensive, nationally representative database to examine the impact of bariatric surgery on clinical outcomes in RA patients.

MATERIALS AND METHODS

This retrospective analysis utilized nationally representative data of the Healthcare Cost and Utilization Project-National Inpatient Sample database (HCUP-NIS) from 2005 to 2018. Associations between bariatric surgery and in-hospital outcomes of RA patients were determined by the univariate and multivariate logistic regression analyses.

RESULTS

After 1:4 propensity score (PS) matching, totally 33,075 hospitalized adults with RA were included as primary cohort for subsequent analyses. Among them, 6615 patients had prior bariatric surgery and 26,460 patients had not. After adjusting for relevant confounders in the multivariate analysis, prior bariatric surgery was significantly and independently associated with reduced odds for any morbidity and in-hospital mortality (aOR: 0.41, 95% CI: 0.27-0.61, p < 0.01) as compared with no prior bariatric surgery. Adults with RA who had prior bariatric surgery also had a significantly lower odds for having unfavorable discharge and prolonged length of stay (LOS) as compared with those without bariatric surgery (aOR: 0.43, 95% CI: 0.39-0.46, p < 0.01).

CONCLUSIONS

Prior bariatric surgery is associated with better in-patient outcomes among RA, including in-hospital mortality, major morbidities, discharge destination, and LOS.

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

The Effect of Ketogenic Diet on Inflammatory Arthritis and Cardiovascular Health in Rheumatic Conditions: A Mini Review

The principle of ketogenic diet (KD) is restriction of carbohydrates to a maximum of 5-10% of the total daily caloric intake, aiming at shifting body metabolism toward ketone bodies. Different studies suggested promising results of KD to help patients to lose weight, to reduce insulin requirements in diabetes, to supplement cancer protocols, to treat neurological conditions and to optimize control of metabolic and cardiovascular diseases. However, literature about the anti-inflammatory properties of KD in rheumatic diseases is still limited. The beneficial effects of weight loss in patients with inflammatory arthritis can be explained by biomechanical and biochemical factors. Obesity is associated with macrophage activation and production of pro-inflammatory cytokines including TNF-α, IL-1b, and IL-6. The clinical effect of KD may be primarily attributed to improvement of insulin sensitivity. Insulin resistance is associated with an increase of TNF-α, IL-1α, IL-1β, IL-6, and leptin. Moreover, reduction of body's adipose tissue and weight loss account for part of the anti-inflammatory effects and for the impact of KD on cardiovascular health. In rheumatoid arthritis, fasting was shown to be effective in reducing disease symptoms, possibly through the production of β-hydroxybutyrate (BHB), the main ketone body. BHB may exert inhibitory effects also on IL-17 and intermittent fasting improved the clinical manifestations of psoriatic arthritis. In ankylosing spondylitis, current literature doesn't allow to draw conclusion about the effects of KD. Future prospective studies will be needed to elucidate the potential beneficial effects of KD on specific domains and clinical outcomes in patients with inflammatory arthritis.

Dietary Recommendations of the French Society for Rheumatology for Patients with Chronic Inflammatory Rheumatic Diseases

This article presents the 1^st set of dietary recommendations of the French Society for Rheumatology for patients suffering from chronic inflammatory rheumatic diseases (IRD) made by a working group consisting of 12 rheumatology experts, 3 physician nutrition specialists, 1 internal medicine specialist, 1 registered dietician and 3 representatives from patient associations. This group relied on a systematic literature review and on expert opinions, while taking into consideration not only the joint effects of diet in IRD but also the extra-articular ones. Eight general principles and nine recommendations were established. The general principles emphasize that nutritional advice is not a substitute for pharmacological treatment of IRD and that it is an integral part of the patients' overall care, which could help the patient actively participate in their care. The recommendations propose supporting weight loss in subjects who are overweight or obese, a Mediterranean-type diet and supplementation in polyunsaturated fatty acids, mainly omega-3. Conversely, gluten-free diets (in the absence of celiac disease), vegetarian/vegan diets, fasting and elimination of dairy products should not be proposed. Supplementation with vitamins or trace elements is not indicated for controlling chronic IRD activity, while the use of probiotics or spices is not recommended given the limited or disparate data.

Effect of significant weight loss on disease activity: reason to implement this non-pharmaceutical intervention in daily clinical practice

Obesity is very common in patients with inflammatory rheumatic diseases (IRDs), of which between 27% and 37% of patients have a body mass index ≥30 kg/m². In addition to further increasing the risk of developing cardiovascular diseases (CVDs) in this group of patients, obesity is associated with higher disease activity and a lower response to drug therapy. This case series showed that in those patients with rheumatoid arthritis or psoriatic arthritis with a substantial weight loss of >10% of body mass, median Disease Activity Score 28 joints score decreased with 0.9. This reduction in disease activity resulted in an increase in the percentage of patients achieving remission from 6% to 63%. This reduction in disease activity was obtained without intensification of medical treatment in 87% of the patients. This case series supports the current evidence that weight reduction has positive effects on the course of the disease and thus also on the CVD risk profile in these patients. Therefore, weight loss can serve as a non-pharmacological treatment option in obese patients with IRDs.

Beyond Rheumatoid Arthritis Evaluation: What are We Missing?

Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune systemic disease that preferentially affects small and large joints with a progressive course and can become deforming and disabling. In recent years, much progress has been made in the evaluation of inflammation and disease activity, however, there are other factors that have a high impact on the quality of life of these patients, such as depression, anxiety, fatigue, sleep disorders, suicidal behavior, fibromyalgia, sexual activity, sarcopenia, frailty, cachexia and obesity that are not always evaluated by rheumatologists. This review shows that the evaluation and timely detection of these aspects in patients with RA could interfere with the prognosis and improve their quality of life.

Impact of ICD10 and secular changes on electronic medical record rheumatoid arthritis algorithms

OBJECTIVE

The objective of this study was to compare the performance of an RA algorithm developed and trained in 2010 utilizing natural language processing and machine learning, using updated data containing ICD10, new RA treatments, and a new electronic medical records (EMR) system.

METHODS

We extracted data from subjects with ≥1 RA International Classification of Diseases (ICD) codes from the EMR of two large academic centres to create a data mart. Gold standard RA cases were identified from reviewing a random 200 subjects from the data mart, and a random 100 subjects who only have RA ICD10 codes. We compared the performance of the following algorithms using the original 2010 data with updated data: (i) a published 2010 RA algorithm; (ii) updated algorithm, incorporating ICD10 RA codes and new DMARDs; and (iii) published algorithm using ICD codes only, ICD RA code ≥3.

RESULTS

The gold standard RA cases had mean age 65.5 years, 78.7% female, 74.1% RF or antibodies to cyclic citrullinated peptide (anti-CCP) positive. The positive predictive value (PPV) for ≥3 RA ICD was 54%, compared with 56% in 2010. At a specificity of 95%, the PPV of the 2010 algorithm and the updated version were both 91%, compared with 94% (95% CI: 91, 96%) in 2010. In subjects with ICD10 data only, the PPV for the updated 2010 RA algorithm was 93%.

CONCLUSION

The 2010 RA algorithm validated with the updated data with similar performance characteristics as the 2010 data. While the 2010 algorithm continued to perform better than the rule-based approach, the PPV of the latter also remained stable over time.

The Relevance of Selenium Status in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune and inflammatory disease that can cause joint damage. Among the environmental risk factors, diet plays an important role because it can aggravate or attenuate inflammation. Selenium (Se) is considered an essential trace element since it is a structural component of antioxidant enzymes; however, its concentration can be affected by diet, drugs and genetic polymorphisms. Studies have reported that RA patients have a deficient diet in some food groups that is associated with parameters of disease activity. Furthermore, it has been shown that there is an alteration in serum Se levels in this population. Although some clinical trials have been conducted in the past to analyze the effect of Se supplementation in RA, no significant results were obtained. Contrastingly, experimental studies that have evaluated the effect of novel Se nanoparticles in RA-induced models have shown promising results on the restoration of antioxidant enzyme levels. In particular, glutathione peroxidase (GPx) is an important selenoprotein that could have a modulating effect on inflammation in RA. Considering that RA patients present an inflammatory and oxidative state, the aim of this review is to give an overview of the current knowledge about the relevance of Se status in RA.

Curcumagalactomannoside/Glucosamine Combination Improved Joint Health Among Osteoarthritic Subjects as Compared to Chondroitin Sulfate/Glucosamine: Double-Blinded, Randomized Controlled Study

Objective: A combination of curcumagalactomannosides (CGM) (400 mg) with glucosamine hydrochloride (GLN) (500 mg) was evaluated against a standard dietary supplement combination chondroitin sulfate (CHN) (415 mg)/GLN (500 mg) for their effectiveness in alleviating the pain and symptoms among osteoarthritic subjects. Design: Randomized, double-blinded and active-controlled study. Settings/Location: The study was conducted in a hospital-based research center in Vadodara, Gujarat, India. Subjects: Eighty subjects (38 males and 42 females), with confirmed osteoarthritis (OA) (Class I-III), were randomized into two parallel groups designated as Group I (CGM-GLN) and Group II (CHN-GLN). Interventions: All the study subjects were supplemented with their corresponding intervention capsules (ether CGM along with GLN or CHN along with GLN), as a single oral dose twice a day, once in the morning 10-15 min before breakfast and again in the evening before dinner, for 84 days. Outcome measures: A validated treadmill uphill walking protocol was used for the study, and the efficiency of supplementation was evaluated using visual analogue scale (VAS) score, Karnofsky Performance Scale (KPS) score, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire at the baseline, 28th, and 84th day following the treatment. Mechanism of action of CGM-GLN combination was analyzed by measuring the levels of serum inflammatory markers interleukin 1 beta (IL-1β), interleukin 6 (IL-6), and soluble vascular cell adhesion molecule-1 (sVCAM) at the baseline and 84th day. Results: CGM-GLN was found to offer significant beneficial effects to pain, stiffness, and physical function of OA subjects compared with CHN-GLN, which was evident from the improvement in walking performance, VAS score, KPS score, and WOMAC score. The efficiency of CGM-GLN was almost double compared with the CHN-GLN by the end of the study (84th day). A significant reduction of inflammatory serum marker levels was observed among CGM-GLN subjects compared with CHN-GLN subjects. Compared with the baseline, CGM-GLN produced 54.52%, 59.08%, and 22.03% reduction in IL-1β, IL-6, and sVCAM levels, respectively. Whereas CHN-GLN group of subjects expressed only 23.17%, 21.38%, and 6.82% reduction in IL-1β, IL-6, and sVCAM levels, respectively. Conclusions: In conclusion, the present study demonstrated the potential benefits of CGM-GLN supplements in alleviating the symptoms and function of OA subjects compared with the standard CHN-GLN treatment. The augmented efficacy of CGM-GLN combination could be attributed to the enhanced anti-inflammatory effect of CGM.

Modifiable Lifestyle Factors Associated With Response to Treatment in Early Rheumatoid Arthritis

Objective

We aimed to evaluate the associations between response to algorithm‐directed treat‐to‐target conventional synthetic disease‐modifying antirheumatic drug therapy and potentially modifiable lifestyle factors, including dietary fish oil supplementation, body mass index (BMI), and smoking history in a rheumatoid arthritis (RA) inception cohort.

Methods

Patients with RA with a duration of less than 12 months were reviewed every 3 to 6 weeks to adjust therapy according to disease response. All patients received advice to take fish oil supplements, and omega‐3 status was measured as plasma levels of eicosapentaenoic acid (EPA). Lifestyle factors and other variables potentially prognostic for 28‐joint Disease Activity Score (DAS28) remission and DAS28 low disease activity (LDA) at the 12‐month visit were included in multivariable logistic regression models.

Results

Of 300 participants, 57.7% reached DAS28 LDA, and 43.7% were in DAS28 remission at 1 year. Increase in plasma EPA was associated with an increase in the odds of being in LDA (adjusted odds ratio [OR] = 1.27; P < 0.0001) and remission (adjusted OR = 1.21; P < 0.001). There was some evidence that the effect of BMI on LDA might be modified by smoking history. An increase in BMI was associated with a decrease in the odds of being in LDA in current and former smokers but had no impact on LDA in patients who had never smoked. There were no meaningful associations between BMI or smoking history and remission.

Conclusion

Omega‐3 status, BMI, and smoking history are potential predictors of outcome in early RA. The possibility of an effect modification by smoking on the predictive value of BMI merits further investigation.

The outcomes of bariatric surgery on rheumatoid arthritis disease activity: a prospective cohort study

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that primarily affects the joints. Overweight and obesity can aggravate disease activity and clinical outcome in patients with RA. However, the role of bariatric surgery in inducing weight loss in the treatment of RA has not been confirmed. In this 12-month prospective cohort study, RA patients with obesity who were referred to our hospital were included. Thirty-two patients were classified into the bariatric surgery group according to the patient's decision after a comprehensive assessment of surgery indications, and 33 patients received only pharmacotherapy for RA. At the 12-month follow-up, the response rates of ACR20, ACR50 and ACR70 were 75.0% vs. 51.5%, 53.1% vs. 39.4% and 31.3% vs. 21.2% in the bariatric surgery and non-surgery groups, respectively (all p < 0.05); the mean DAS28-ESR, DAS28-CRP and cDAI scores were 1.5 ± 0.9 vs. 2.4 ± 1.4, 1.2 ± 0.9 vs. 2.2 ± 1.7 and 9.5 ± 6.8 vs. 15.8 ± 12.5, respectively, in surgical patients compared to non-surgical patients (all p < 0.05). Compared to baseline, after 12 months, a significant reduction was observed in the use of leflunomide, biological agents, combination treatments, and NSAIDs in both groups (p < 0.05 or p < 0.01). However, there was no difference in medication use between the 2 groups either at baseline or at the 12-month follow-up (all p > 0.05). Compared to non-surgical patients, in RA patients with obesity, weight loss after bariatric surgery was associated with lower disease activity. Medication tapering for RA in patients who underwent bariatric surgery was not superior to that in non-surgical patients.

Nutrition Interventions in Rheumatoid Arthritis: The Potential Use of Plant-Based Diets. A Review

Rheumatoid arthritis (RA), a chronic inflammatory autoimmune disease, affects roughly 1% of the world's population. RA pathogenesis remains unclear, but genetic factors account for 50–60% of the risk while the remainder might be linked to modifiable factors, such as infectious diseases, tobacco smoking, gut bacteria, and nutrition. Dietary triggers may play an inciting role in the autoimmune process, and a compromised intestinal barrier may allow food components or microorganisms to enter the blood stream, triggering inflammation. In addition, excessive body weight may affect pharmacotherapy response and the likelihood of disease remission, as well as the risk of disease mortality. Evidence suggests that changes in diet might play an important role in RA management and remission. Several studies have shown improvements in RA symptoms with diets excluding animal products. Studies have also shown that dietary fiber found in these plant-based foods can improve gut bacteria composition and increase bacterial diversity in RA patients, thus reducing their inflammation and joint pain. Although some of the trigger foods in RA patients are individualized, a vegan diet helps improve symptoms by eliminating many of these foods. This review examines the potential role of a plant-based diet in mediating RA symptoms. Further research is needed to test the effectiveness of plant-based diets on joint pain, inflammation, and quality of life in patients with RA.

The Real Happy Study: Protocol for a Prospective Assessment of the Real-World Effectiveness of the HAPIFED Program-a Healthy APproach to weIght management and Food in Eating Disorders

The prevalence of obesity with comorbid binge eating behaviour is growing at a faster rate than that seen for either obesity or eating disorders as separate conditions. Approximately 6% of the population are affected and they potentially face a lifetime of poor physical and mental health outcomes and an inability to sustain long-term weight loss. Current treatment options are inadequate in that they typically address either obesity or eating disorders exclusively, not the combination of both conditions. By treating one condition without treating the other, relapse is common, and patients are often left disappointed with their lack of weight loss. An integrated approach to treating these individuals is needed to prevent a worsening of the comorbidities associated with excess body weight and eating disorders. A new therapy has recently been developed, named HAPIFED, which addresses both overweight/obesity and comorbid binge eating behaviour with the combination of behavioural weight loss therapy and cognitive behaviour therapy-enhanced (CBT-E). The aim of this paper is to document the protocol for the Real Happy Study, which will evaluate the effectiveness of the HAPIFED program in treating overweight or obesity with comorbid binge-eating behaviour in a real-world setting.

A systematic review of the association of obesity with the outcomes of inflammatory rheumatic diseases

This was a systematic review of the literature on the association between obesity and the outcome of inflammatory rheumatic diseases. We conducted a literature search using PubMed®, Embase and PsycINFO®. Articles were classified into three categories based on the effects of obesity on the outcomes of inflammatory rheumatic diseases. The subject population, country, type of studies, number of patients, measurement of obesity and outcomes assessed were presented. Quality was appraised using Kmet et al's criteria. 4,331 articles were screened and 60 were relevant to the objective. Obesity had a negative, positive and neutral association with outcomes of inflammatory rheumatic diseases in 38 (63.3%) studies with 57,612 subjects, 11 (18.3%) studies with 3,866 subjects, and 11 (18.3%) studies with 3,834 subjects, respectively. In most studies, the disease population had been diagnosed with rheumatoid arthritis (RA). Tumour necrosis factor-α inhibitors were mostly associated with negative outcomes. More studies examining subjects outside Europe and North America and diseases other than RA are warranted.

Impact of Obesity on Disease Activity and Patient-Reported Outcomes Measurement Information System (PROMIS) in Inflammatory Bowel Diseases

INTRODUCTION

We conducted a cohort study on the impact of obesity on disease activity and Patient-Reported Outcomes Measurement Information System (PROMIS) measures in the inflammatory bowel disease (IBD) Partners cohort.

METHODS

We performed a cross-sectional and longitudinal study within IBD Partners, an internet-based cohort of >15,000 patients living with Crohn's disease (CD) and ulcerative colitis (UC). We included adult patients with IBD, with recorded body mass index (BMI), with at least 6 months of follow-up, excluding patients with BMI < 18.5 kg/m. We evaluated the independent effect of World Health Organization classes of obesity on risk of clinical relapse or persistent disease activity (using validated disease activity indexes) and PROMIS measures, using multivariate logistic regression and linear regression, respectively.

RESULTS

We included 7,296 patients with IBD (4,748 patients with CD, 19.5% obese; 2,548 patients with UC with intact colon, 20.3% obese). Obesity was independently, and in a dose-dependent fashion, associated with an increased risk of persistent disease activity or relapse in both patients with CD (class II or III obesity vs normal BMI: adjusted odds ratio, 1.86; 95% confidence interval, 1.30-2.68) and UC (adjusted odds ratio, 2.97; 95% confidence interval, 1.75-5.17). Obesity was also independently associated with higher anxiety, depression, fatigue, pain, and inferior social function scores in patients with CD and UC at baseline and with worsening depression, fatigue, pain, and social function in patients with CD on longitudinal assessment.

DISCUSSION

Obesity at baseline is independently associated with worsening disease activity and PROMIS measures in patients with IBD.