Weight management: A key strategy for arthritis relief and better joint health

From msn.com/en-in

By Dr. Rajiv Ranjan Kumar

Having arthritis may be problematic, particularly if joint pain, stiffness, and inflammation disrupt daily life. Osteoarthritis is an incapacitating whole joint disease leading to severe pain and disability with huge healthcare burden. There are no disease-modifying osteoarthritis drugs that have been approved, and therefore much of the attention is geared toward addressing modifiable risk factors to reduce symptoms and slow progression of the disease. Obesity is one of the most important risk factors for osteoarthritis symptoms and progression of disease, particularly for knee involvement.

Why weight matters

Having excess weight doesn't just put a strain on joints, it also leads to systemic inflammation, which further exacerbates the symptoms of arthritis. Weight reduction is one of the most popular interventions for managing obesity. Some recent research has demonstrated that weight loss of 5–10% total body weight affects pain improvement in knee osteoarthritis modestly, with, however, no substantial effect on structural outcome in osteoarthritis management. According to research, improvement by 20% from baseline pain is needed to achieve a clinically significant improvement in function and pain and requires a 10% weight loss; and for a patient with osteoarthritis to feel a reduction of 50% in pain, up to 25% weight loss is required.

Advantages of weight loss in arthritis

For individuals with arthritis, healthy weight maintenance can:

• Decrease joint pain and stiffness
• Enhance mobility and balance
• Decrease inflammation in the body
• Make arthritis drugs work more effectively
• Decrease joint replacement surgery needs

Exercise that favours Joint health

Activity is necessary, but it must be arthritis friendly. These exercises need to be focused on:

• Engage in moderate physical activity, moving to 30 minutes or more on most or ideally all days of the week
• Reduce both dietary fat and total calories. Although decreasing dietary fat will lower calories and is good for the heart, this technique alone, without calorie reduction, will fail to achieve weight loss
• Prioritize weight-maintenance after 6 months of weight-loss treatment

Seek professional support

Weight control is affected by numerous factors genetics, hormones, drugs, and emotional well-being. If you're having trouble, think about consulting a registered dietitian or healthcare professional. They will assist you in creating achievable goals, learning your nutrient requirements, and establishing a program that is compatible with your lifestyle and medical status.

For Osteoarthritis treatment, addressing obesity is key. Exercise and weight management are the best measures for Osteoarthritis symptom control and associated health outcomes. While individually modestly effective, exercise combined with weight loss brings the most benefits to the symptoms, particularly in adults with obesity. A range of evidence-based programs in clinical and community environments are available to encourage adults to be physically active and control weight, but these interventions are not being used adequately.

https://www.msn.com/en-in/health/other/weight-management-a-key-strategy-for-arthritis-relief-and-better-joint-health/ar-AA1OOlar

 

Science Reveals 3 New Ways to Relieve Knee Arthritis Pain

From webmd.com

Although joint damage is permanent, new research suggests promising ways to ease knee arthritis pain and possibly slow its progression 

If knee arthritis were a growth stock, you’d want to own a few shares.

Fifty percent of adults in the U.S. will develop knee osteoarthritis, which happens when the cartilage in the joint wears away and the bones rub more closely against one another. Once you have it, you can expect to live with it for 26 years, on average. 

While the damage can’t be reversed, new research offers promising ways to mitigate the pain and perhaps even slow the disease’s progress by targeting what drives it — things like body weight and mechanical load. 

Three recent studies exemplify the trend. 

1. Consider Weight Loss Drugs

Excess body weight has long been linked with increased knee arthritis risk. People with obesity have higher rates of knee arthritis, get diagnosed younger, and experience more pain and physical limitations. 

“Just telling people ‘go lose weight’ is not going to work,” said Elena Losina, PhD, a biostatistician and professor of orthopaedic surgery at Harvard Medical School.  

In a recent study, Losina’s research team created a model to project the cost effectiveness of five weight loss treatments for people with both obesity and knee arthritis: 

• Diet and exercise
• Tirzepatide (Mounjaro, Zepbound), a type of weight loss drug called a GLP-1 agonist
• Semaglutide (Ozempic, Wegovy), another GLP-1 medication
• Gastric sleeve surgery
• Gastric bypass surgery

The model, which was based on a method called a Monte Carlo simulation, weighed each treatment’s price tag against its projected long-term impact on quality of life. For example, the more weight someone loses, the more pain relief they should experience, along with fewer movement limitations and a lower risk of health problems like type 2 diabetes and heart disease. 

Myths and Facts: Using a GLP-1 for Weight Loss

The study found that tirzepatide gave people more years of healthier life than semaglutide, diet and exercise alone, or the “usual care” for obesity and arthritis (which may mean no treatment beyond monitoring symptoms). Semaglutide could still be cost-effective for some patients, the study found, but tirzepatide was rated as the best nonsurgical option overall. 

For people with a BMI of 35 or above, gastric bypass surgery scored highest. It produced the best results and cost less over a person’s lifetime than either of the medications, partly because surgery is a one-time cost rather than an ongoing expense.

“Bariatric surgery has very high efficacy in terms of weight loss for a very long time,” Losina said. But it’s a drastic procedure, with all the risks that entails. That’s why most people who have the choice opt for medication over surgery.

Since the study came out, the U.S. government announced an initiative to reduce the cost of GLP-1 medications — “an exciting development,” Losina said. 

Still, exercise remains the cheapest treatment option, and a second new study may help make it less painful.  

2. Change the Way You Walk 

Exercise is the most commonly recommended treatment for knee arthritis, and walking is the most commonly recommended type of exercise. 

But the repetitive stress of walking — never mind running, basketball, or tennis — can sometimes worsen knee pain.

Arthritis typically begins in the medial compartment of the knee — the part closest to the other knee. 

Medial arthritis is three times more common than lateral arthritis, on the outer part of the knee. That’s because, when you walk, 70% of the compressive force lands on the medial compartment. 

The way you walk can make the problem worse by shifting even more of that stress to the inside of the knee.  

But a recent experiment from researchers at Stanford and the University of Utah showed that gait changes could help patients with medial compartment arthritis shift some of that force to the outside of the knee, reducing pain and making exercise a more viable option.

Participants took a gait retraining program where they learned to turn their toe in or out when landing and pushing off, whichever put less pressure on the medial compartment. 

Most of them (82%) were trained to turn their toes in slightly — by 5 or 10 degrees — when they walked. The rest were trained to turn their toes out. 

After six weeks, all of them reported mild to moderate reductions in walking-related pain. After a year of maintaining the modified gait, their pain had improved even more. 

The Stanford protocol relies on experts and special equipment, so it can’t be replicated at home. But you can talk to your health care provider about making small changes to the way you walk. A physical therapist may be able to assess your gait to reduce pressure on your knee. 

Fortunately, there is an exercise program that requires only internet access and a little floor space.

3. Try a Free Tai Chi Program  

Physical therapist Kim Bennell, PhD, has been studying musculoskeletal injuries for three decades. 

In recent years, she and her research team at the University of Melbourne in Australia have increasingly focused on exercise, as it’s the most effective nonpharmaceutical, nonsurgical arthritis treatment.

One continual challenge: too many barriers to exercise for the people they were trying to help. 

Some live in remote areas without access to facilities or coaching. And some who live in cities and suburbs either don’t have transportation, aren’t mobile enough to get to a facility, or can’t afford to join a gym or pay a trainer.

“So we decided to design and test unsupervised programs that we could offer free,” said Bennell, a professor at the university’s Centre for Health, Exercise, and Sports.

Her team’s most recent study featured an online tai chi program designed for adults with knee arthritis. Participants were given access to a series of 45-minute tai chi videos, led by one of the study’s co-authors, and instructed to do three 45-minute sessions per week. 

After 12 weeks, 73% of the participants reported a clinically meaningful reduction in knee pain while walking, along with improvements in physical and mental well-being. 

This is the third online exercise program Bennell’s team has created for knee arthritis patients. The first was a six-month strength program, published in 2021. That was followed by a three-month yoga program in 2022. 

All three are free to access for anyone who wants to try them. So far, Bennell said, they’ve had 60,000 users from 120 countries.

“The tai chi program seemed to give better results for pain, compared with the yoga program,” Bennell said. Research shows tai chi can improve strength, mobility, balance, and endurance, which may lead to more controlled movement patterns, with better joint stability. The strength program was similar to tai chi in terms of pain reduction. 

Arguably the most important factor for the program’s success: “Participants did report high satisfaction with all three programs and were highly likely to recommend them to others,” Bennell said. 

https://www.webmd.com/pain-management/knee-pain/news/20251119/science-reveals-3-new-ways-relieve-arthritis-knee-pain

Understanding the weight-arthritis connection: how losing excess weight can alleviate pain

From iol.co.za

Arthritis is a pervasive challenge that affects millions globally, significantly impacting livelihoods through pain and disability. With over 100 types of this condition, including osteoarthritis, rheumatoid arthritis, and gout, the struggle is both physical and emotional. As millions grapple with the realities of arthritis symptoms, the connection between excess weight and the severity of these symptoms is becoming increasingly clear.

Murray Hewlett, CEO of Affinity Health, sheds light on this connection, stating, “Arthritis already places a tremendous burden on the body, and carrying extra weight adds even more strain to joints. The good news is that even modest weight loss can significantly reduce pain, improve mobility, and enhance quality of life for those living with arthritis.”

Understanding Arthritis

Arthritis encompasses various conditions, primarily characterised by joint inflammation and persistent pain. The most common forms — osteoarthritis, where cartilage wears down over time; rheumatoid arthritis, an autoimmune disorder; and gout, caused by uric acid build-up — all lead to debilitating symptoms such as stiffness, swelling, tenderness, and limited range of motion. This not only hampers daily functions, but also takes a toll on overall well-being.

The weight-arthritis connection

Research consistently demonstrates that carrying excess body weight amplifies arthritis symptoms. Here’s how:

• Increased Joint Pressure: Extra weight places undue pressure on weight-bearing joints such as the knees, hips, and ankles. For instance, every kilogram of body weight adds approximately four kilograms of pressure on the knees during walks.
• Faster Cartilage Breakdown: The additional load can expedite cartilage wear, leading to faster degeneration in osteoarthritis patients.
• Worsened Inflammation: Fat tissue releases inflammatory chemicals that heighten arthritis symptoms, affecting not just weight-bearing joints but also hands, wrists, and other areas.
• Reduced Mobility: Excess weight may lead to inactivity, creating a cycle of declined muscle strength and intensified joint pain.
• Increased Risk of Other Conditions: Obesity is linked to diabetes, heart disease, and metabolic syndrome, complicating both arthritis treatment and general health management.

What you can do

Taking proactive steps towards managing weight can yield significant benefits for arthritis management. Here are some recommendations:

• Focus on Healthy Weight Loss: Even modest weight reductions of 5-10% can lead to noticeable improvements in pain and function. Aim for sustainable, gradual changes over aggressive dieting.
• Adopt a Joint-Friendly Diet: Consuming a diet rich in anti-inflammatory foods can aid in weight management while alleviating arthritis symptoms. Focus on fruits, vegetables, whole grains, lean proteins, and healthy fats, while minimising processed foods and sugars.
• Stay Active: Physical activity, particularly low-impact exercises like swimming, walking, and yoga, can alleviate pain and enhance flexibility. Always consult a healthcare professional before starting any new exercise programme.
• Strengthen Supporting Muscles: Building muscle around affected joints helps reduce stress and bolster stability. Consider physical therapy or guided strength training.
• Manage Pain and Inflammation: Use over-the-counter pain relief or prescribed medications and explore complementary therapies, such as massages or acupuncture, for flare-up relief.
• Seek Professional Support: Working with healthcare providers, such as doctors, dietitians, and physiotherapists, can yield tailored management plans.

Emotional Health

The physical struggle of living with arthritis can take an emotional toll. Anxiety, frustration, and even depression are all too common. Engaging with friends and loved ones, joining support groups, or consulting a professional can help maintain a positive outlook during challenging times.

While managing arthritis alongside excess weight may seem daunting, embracing small, consistent lifestyle changes can lead to significant improvements, says Hewlett. A balanced diet, regular low-impact exercise, and professional support not only ease symptoms but also enhance mobility, ultimately promoting a healthier, more confident life. 

IOS

https://iol.co.za/ios/news/2025-11-19-understanding-the-weight-arthritis-connection-how-losing-excess-weight-can-alleviate-pain/

How to Manage the Heart Disease Risk of Psoriatic Arthritis

From everydayhealth.com

If you live with psoriatic arthritis (PsA), you’re well aware of its impact on your joints, including symptoms like stiffness and swelling, as well as the persistent fatigue it can cause. 

But PsA can also affect your heart, and while it may not cause any noticeable symptoms, the condition comes with an increased risk of heart disease and stroke.

That’s because psoriatic arthritis isn’t just a joint problem: It’s a systemic inflammatory condition, meaning that inflammation affects the entire body. And inflammation plays a major role in the development of atherosclerosis (hardening and narrowing of the arteries), the root cause of most heart disease.

But there are steps you can take to improve your heart health — and the good news is that many of them include some of the same things you’re doing to manage your PsA.

Keep reading to better understand the connection between psoriatic arthritis and heart health and get expert advice on how to reduce the likelihood of heart disease, including heart attack and stroke.

The Link Between Psoriatic Arthritis and Heart Disease

Psoriatic arthritis belongs to a family of conditions called psoriatic disease, which also includes psoriasis, a chronic skin condition. Both involve an overactive immune system that causes widespread inflammation.

“This inflammation doesn’t just affect the joints or skin,” says Michael Garshick, MD, a cardio-rheumatologist at NYU Langone Health in New York City. A lot of the same immune cells and pro-inflammatory proteins that are upregulated in psoriatic disease are also involved in the development of atherosclerosis,” he says. 

“In general, psoriasis and PsA are put together when we discuss heart disease risk. That’s mostly because there are many more patients with psoriasis compared to psoriatic arthritis, and the studies on heart disease and PsA haven't been as robust,” says Dr. Garshick. It’s estimated that about 1 in 4 people with psoriasis also have PsA.

In general, people with psoriatic disease have a cardiovascular risk similar to those with moderate to severe psoriasis, says Garshick. “So if you have really only mild psoriasis, but you have psoriatic arthritis, that upgrades the risk of a higher risk of cardiovascular disease than if you didn't have psoriatic arthritis,” he says.

Whether it's psoriasis or psoriatic arthritis, it’s believed the combination of inflammation caused by the conditions and the fact that most patients with psoriatic disease have a higher risk of the traditional cardiometabolic risk factors — like hypertension, hyperlipidemia (high cholesterol), type 2 diabetes, obesity, and smoking — promotes cardiovascular disease, says Garshick.

PsA Inflammation Impacts Heart

Experts believe that heart disease and psoriasis and PsA may share inflammatory pathways that drive the progression of both diseases.

“Although psoriasis plaques are different from plaques in the arteries, the inflammation that makes the skin red and flaky is similar to the kind of inflammation that causes blockages in the arteries,” says Joel Gelfand, MD, the director of the psoriasis and phototherapy treatment centre at Penn Medicine in Philadelphia.

In fact, a lot of the same immune cells and pro-inflammatory cytokines that are upregulated in psoriasis or psoriatic disease are also part of the disease process in atherosclerosis, specifically cytokines or proteins such as TNF-alpha, says Garshick.

Atherosclerosis is the build-up of fats and cholesterol in and on the artery walls, called plaque. The build-up limits blood flow and can eventually lead to heart attack or stroke.

There’s a really big overlap between the disease processes driving psoriasis and atherosclerosis, says Garshick. “There's even evidence from genetic studies suggesting that in patients who have atherosclerosis, that may promote worsening psoriatic disease, so we think it’s a bidirectional relationship,” he says.

Higher Risk of Traditional Heart Disease Risk Factors

People with PsA are more likely to also have traditional heart disease risk factors, including high blood pressure, type 2 diabetes, obesity, and smoking.

“It’s really a synergy,” says Dr. Garshick. “It’s the combination of systemic inflammation and the higher rates of these common risk factors that increases the overall cardiovascular risk.”

Indeed, the PsA inflammation could contribute to or worsen cardiovascular disease risk factors, including the following: 

• Insulin Resistance Inflammatory chemicals interfere with how the body uses insulin, leading to higher blood sugar and an increased risk of type 2 diabetes, a major heart disease risk factor. 
• High Cholesterol Inflammation disrupts normal fat metabolism, raising triglycerides and lowering “good” HDL cholesterol, contributing to clogged arteries.
• Hormone Imbalance From Fat Tissue (Adipokines) The hormones leptin and resistin are elevated in PsA and promote more inflammation and artery damage.

“In general, the higher prevalence of atherosclerosis in the psoriatic patient population is a contribution from both underlying systemic inflammation and traditional cardiovascular risk factors,” says Garshick.

How to Manage Heart Disease Risk

“Unfortunately, there’s good evidence to suggest that cardiovascular risk factors are both underrecognized and undertreated in people with PsA,” says Garshick.

According to the most up-to-date recommendations, more aggressive heart disease risk management is needed in PsA to reduce morbidity and early death, he says.

Identify Controllable Risk Factors

People should have a cardiovascular disease assessment when they are first diagnosed with PsA, per the new recommendations by the Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network (PPACMAN).

“For patients with psoriatic disease, that would include checking lipids, blood pressure, and blood sugar levels, and, if they’re elevated, to either treat, or refer to their primary care doctor or a preventive cardiologist office,” says Garshick.

A preventive cardiologist may be especially helpful if you are reluctant to start medication, have trouble tolerating drugs like statins, or when you want more personalization, he adds.

Many people assume that because they’re regularly seeing a rheumatologist or dermatologist, their heart health is also being monitored, but that’s not always the case. 

Garshick recommends taking a proactive approach and making sure you know your numbers for cholesterol and blood pressure.

Discuss Drug Choices for Psoriatic Arthritis

Effective treatment of inflammation is key to improving PsA symptoms and slowing the disease process, but does that help reduce the risk of heart disease?

“There’s observational data suggesting that treating psoriatic disease may reduce cardiovascular risk, but randomized controlled trials haven’t definitively proven that yet,” says Garshick.

There has been concern that some drugs used to manage PsA may actually increase heart-related risks, says Garshick.

There were concerns about a couple of biologics used for PsA, including TNF-alpha inhibitors, which include adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade), and IL-23 inhibitors, which include guselkumab (Tremfya) and risankizumab (Skyrizi), but recent evidence shows they are generally safe, he says. 

On the other hand, Janus kinase (JAK) inhibitors, a new kind of disease-modifying drug (DMARD), do come with heart risks. The JAK inhibitors approved to treat PsA include tofacitinib (Xeljanz) and upadacitinib (Rinvoq).

“These medications come with a black box warning from the FDA for cardiovascular and clotting events. They also tend to raise LDL, or ‘bad,’ cholesterol, but that doesn’t fully explain the risk,” he says.

Because of this, the preventive cardiologist and the rheumatologist need to have a conversation before a patient is started on a JAK inhibitor, to make sure it’s the best choice and that cardiovascular risks are managed appropriately, says Garshick.

Maintain a Heart-Healthy Lifestyle

The experts in the Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network recommend the following lifestyle changes to manage your heart disease risk if you have psoriatic arthritis. 

• Be physically active. Aim for regular moderate to vigorous exercise to boost both your physical and mental health. Exercise can reduce psoriasis and joint symptoms, improve your mood, and help you sleep better. If skin discomfort, joint pain, or fatigue makes it hard to exercise, start small and talk to your doctor about ways to stay active comfortably.
• Eat a healthy, balanced diet. Choose nutrient-rich foods like vegetables, fruits, lean proteins, and whole grains. Avoid high-sugar, high-fat, and processed foods that can increase inflammation.
• Aim for a healthy weight. Any loss of excess weight — even a small amount — can reduce joint pain, lower inflammation, and improve your response to psoriasis treatments. If diet and exercise aren’t enough, weight loss medications like GLP-1 agonists may be an option.
• Quit smoking. Smoking increases your risk of developing psoriasis and can make symptoms worse. It may also make treatments less effective and raise your risk of heart disease. One of the best things you can do for your skin, joints, and overall health is to stop smoking.

The Takeaway

• Psoriatic arthritis increases your risk of heart disease caused by widespread inflammation and related conditions like high blood pressure, diabetes, and obesity.
• Regular screening for heart disease risk factors is essential and should begin at diagnosis.
• Management of PsA with the appropriate medications may reduce cardiovascular risk, but some medications may increase it. Discuss your treatment options with your doctor.
• A heart-healthy lifestyle, including exercise, a balanced diet, weight management, and smoking cessation, can significantly improve both joint health and heart health.
• 
  
• https://www.everydayhealth.com/rheumatic-conditions/how-to-manage-heart-disease-risk-in-psoriatic-arthritis/

PODCAST: How To Lose Weight for Arthritis

From arthritis.org/liveyes

Losing excess weight is especially important when you have arthritis, and there are more tools now than ever to help. In this episode, a rheumatologist (who is also a fitness trainer) talks about why weight management is important for all forms of arthritis. He also discusses the pros and cons of GLP-1 agonist drugs and bariatric surgery for weight loss, and he offers some real-world tips for lifestyle changes, including diet and exercise, to lose extra fat 

PODCAST OPEN: Thank you for tuning in to the Live Yes! With Arthritis podcast, produced as a public service by the Arthritis Foundation. You may have arthritis, but arthritis doesn’t have you. Here, you’ll get information, insights and tips you can trust — featuring volunteer hosts and guest experts who live with arthritis every day and have experience with the challenges it can bring. Their unique perspectives may help you — wherever you are in your arthritis journey. The Arthritis Foundation is committed to helping you live your best life through our wide-ranging programs, resources and services. Our podcast is made possible in part by the generous financial contributions of people like you. Now, let’s listen in.

Jamie Nicole: Hi everyone, I am Jamie Nicole, and welcome to this episode of the Live Yes! With Arthritis podcast, where we will be discussing weight management for arthritis. As someone myself navigating both osteoarthritis and rheumatoid arthritis, I know first-hand that the conversation around weight can be complex and, honestly, sometimes exhausting. You've likely been told that losing weight can help ease joint pain. But rarely is there enough discussion about how hard that is when you're also dealing with fatigue, inflammation, mobility limitations and the emotional weight of chronic illness. 

The good news is: Even small shifts in weight can lead to meaningful improvements in arthritis symptoms. And today there are more tools than ever to support people in making those shifts in a way that's realistic and sustainable. Joining me today is Dr. Brian Andonian, a rheumatologist and researcher at Duke University School of Medicine. We'll talk about the role of medications, like GLP-1s, and lifestyle strategies. Dr. Andonian, I'm glad that you're here and thank you for joining us. 

Dr. Brian Andonian: Thanks so much for having me. 

Jamie Nicole: So, we're going to hop right into it, and first I want you to just kind of give the audience a little bit more about yourself and your focus at Duke. 

Dr. Brian Andonian: Sure. I'm a rheumatologist at Duke, so I treat, broadly, patients with different kinds of autoimmune and inflammatory conditions, as well as arthritis of all kinds, including osteoarthritis, rheumatoid arthritis, spondyloarthritis. I'm also an athletic trainer, and I have a background in exercise science. And so, I really try to apply my background in lifestyle medicine, and that includes nutrition, physical activity, stress management, restorative sleep, social connection, really to the care of my patients. I'm also a clinician scientist. And that means I do research on top of my clinical work, and I study really the effects of lifestyle, especially diet and exercise, for improving the health for my patients with arthritis and autoimmune disease.

Jamie Nicole: That is wonderful. I'm excited for this conversation. How does excess weight impact people living with arthritis — and not just osteoarthritis, but the inflammatory types as well?

Dr. Brian Andonian: Excess weight can affect arthritis in multiple ways. For one, it can impact the development of arthritis. As you mentioned, not just osteoarthritis, but also inflammatory types of arthritis, including rheumatoid arthritis. And we also know that it affects arthritis management. We know that patients who are overweight or obese don't respond to our medications as well, and that's particularly true of rheumatoid arthritis and other inflammatory diseases.

I think there's a few reasons for this. One, people commonly think about stress on the joints related to added weight, but there's also other factors related to having overweight or obesity, and that's inflammation. There's inflammation contributions to arthritis both from osteoarthritis and from an inflammatory arthritis standpoint as well.

Jamie Nicole: There are certain people, due to age, gender, hormone changes or other factors — how are they affected differently?

Dr. Brian Andonian: Women in particular have higher risk for arthritis, first mention that. That includes osteoarthritis and other inflammatory types of arthritis like rheumatoid arthritis. And around age 50 is where we start to see an inflection point in terms of arthritis onset and when patients start to develop arthritis. And so, we think that there could be a connection with hormonal changes in perimenopause in women.

But there's also… Men tend to get arthritis more around age 50. So, there's multiple factors that are contributing here. Age is certainly a large factor in arthritis. And potential reasons for this are multiple. Things that I think about, in particular, are loss of muscle as we age. Unfortunately, we all lose muscle mass; it's just part of the aging process. And that can contribute to arthritis in and of itself, with or without having excess adipose or fat mass as well.

We know that our patients with arthritis, and particularly rheumatoid arthritis, can have low muscle mass, a normal BMI, but still have a lot of problems related to the adipose tissue contributing to arthritis and overall health risks.

Jamie Nicole: So, if you're a woman close to 50 going through perimenopause, you're just going to get hit from all angles and should really be paying attention to making sure, if I heard you correct, maintaining the muscle that we have.

Dr. Brian Andonian: Yeah, I agree. I think the more we can try to maintain muscle and build muscle… I'm not saying you can't build muscle as you get older. It's that if you don't do anything to combat it, you will lose muscle.

Jamie Nicole: That kind of leads into the next set of questions that I have is: understanding the challenges. Why is weight management so much more difficult when you're dealing with arthritis, especially losing weight and then also keeping it off?

Dr. Brian Andonian: Well, it's more complicated than just calories in, calories out, the calories we burn off. Metabolism is really affected within patients with obesity or who are overweight. And at the cellular level, there's multiple things that prevent us from losing weight. For example, our fat cells have memory, things that occur, called epigenetic changes, or changes to the way our DNA is programmed that affect the way that we are able to maintain our weight over time.

There are multiple systems, including our brain and our nervous system, that connect with our gut and hormones throughout our body that really want us to maintain the amount of adipose tissue or fat over time. This was likely beneficial when, during our ancestral past, when we had to hold on to store calories when it wasn't clear when our next meal would be, but much less helpful now. And I think arthritis just compounds the problem even more. It's really not as simple as you just need to eat less.

Jamie Nicole: I'm so glad that you said that, but because before I was diagnosed, I was living on the theory that we oftentimes hear, you know, number one: no pain, no gain. And what you said, calories in versus calories out. And I was working out multiple times a week. I knew that my calories in was less than my calories out, and I ended up making myself worse with inflammation by overdoing it at the gym.

But it wasn't until I started focusing on some of the other factors that you mentioned, like gut health and inflammation, where I can start eating more and working out less. And I actually lost 70 pounds that way. And it wasn't calories in or calories out. There has been a lot of buzz about GLP-1 drugs like Wegovy and Ozempic. Can you break down what they are and how they work?

Dr. Brian Andonian: I'll do my best. The glucagon-like peptide, or GLP-1 receptor agonist, we can say GLP-1 for simplicity: These are injections under the skin that were originally studied for management of diabetes and to help lower blood sugar through control of insulin secretion and limiting glucagon. But we really learned over time, from the studies that were looking at diabetes care, that patients lost a lot of weight, and that seemed to be different from the mechanisms that were affecting blood sugar.

It seems these medications have direct effects on reducing appetite. And there's likely impacts both in the gut and in the brain and nervous system that really help give a signal of fullness and prevent cravings and prevent people from overeating. So, we're still learning more actually about how exactly the medications work, and there are a lot of other medications similarly in the pipeline. I think patients should stay tuned to other options that’ll actually be available hopefully in the next few years.

Jamie Nicole: I've seen some people saying that it helps with inflammation. Is there really an impact on inflammation, and that's what's causing them to be more successful at weight loss? And then what are the pros and cons and other things we should be considering when we consider GLP-1s?

Dr. Brian Andonian: Yeah, great question, and ongoing area of study. It does seem that patients do reduce inflammation. The question is a little bit: How? Is it related to weight loss itself? I already mentioned that just having more adipose tissue, or being obese, can contribute to inflammation in the body. So, we're really trying to understand if there are other mechanisms, because that'd be really fascinating. If independent of how much weight you lost, we still could make an impact on inflammation. So, there are a lot of pros and cons. One, for arthritis, we're seeing a lot of signals that this can help arthritis directly. In particular, there's a large study looking at improvements in knee osteoarthritis after using these medications.

And anecdotally I can say that other patients with, say, rheumatoid arthritis and other types of arthritis also have had benefit, but it hasn't been studied as rigorously yet. I think to be determined. We do know that these medicines can really help with weight loss. We've seen that in multiple studies, and they also seem to have other effects, too, that are important to our patients with arthritis, including improving cardiometabolic disease. So, improving cardiovascular risk, improving diabetes and other things, as well as improving addiction that can help with kidney disease.

There are some downsides potentially. Some patients do have side effects. Most of these are GI-related, so having nausea or vomiting or changes in the way your gut moves food through, which can cause more symptoms. I think the biggest question with these medications is the long-term impact and whether you need to be on them for forever, basically, to get the benefit. Or can you just be on it for a certain amount of time and get really the benefits you need and not have to stay on the medication? So, there's a lot of interest in how long we prescribe them and how we really utilize them in the long term.

The other thing I should mention is another question. Is it… What kind of weight are patients losing? Is it just fat or adipose tissue (which would be ideal)? Or is it also muscle loss? Because we already mentioned that muscle can be really important. One question is: If we lose a lot of muscle with these medications, can that have negative effects down the road?

Jamie Nicole: Bariatric surgery… Is this still a good option for people with arthritis?

Dr. Brian Andonian: It's definitely still an option. There's plenty of evidence showing that it can help patients lose weight but also improve that cardiometabolic risk. So, decreasing risk for cardiovascular disease, improving diabetes. Also, studies suggesting it can help with arthritis symptoms, including osteoarthritis, pain and function, as well as rheumatoid arthritis disease activity.

There are some potential issues. One is this access to surgeon; there's complications from surgery potentially. With the older surgeries there was some potential for having malnutrition and not getting the nutrients absorbed appropriately, which is less of an issue now. So again, it is an option. There are some potential downsides, but for weight loss it can be very effective, and that could have downstream effects to arthritis.

Jamie Nicole: How do these medications, the GLP-1s that we just talked about, compare to bariatric surgery in terms of risk, access and results?

Dr. Brian Andonian: Both potentially have access-related issues in terms of costs and getting approvals, and there's a lot of factors that go into which patients right now qualify for surgery or the medications. So that's a big issue, I think, for both. Surgery is obviously going to have the risks inherent to any surgery, and there's just more that's involved in terms of anaesthesia and the risks there. And it's harder to reverse the effects of surgery.

There was a thought that potentially you'd lost more weight with surgery. But what we're seeing for some of these drugs is that potentially patients are losing as much weight, if not more, in some cases. So, it's not for sure that surgery is better in terms of weight loss. And you mentioned a really important point: that there's not necessarily one that's better than the other. It really should be personalized, based on discussions with your providers, dieticians, family and support groups.

Jamie Nicole: We have a question about both from Alicia Cunningham. And from the question, it seems as though those factors that you mentioned earlier — being over 50, being a woman and being in a hormonal transition — is related to her question. She says, " Does bariatric surgery and GLP-1s cause and/or affect osteoarthritis post-menopause?" Can you speak to that?

Dr. Brian Andonian: Yeah, it's a great question, Alicia. And I mentioned that hormonal factors certainly play a role in arthritis development. And they also can play a role in our metabolism and obesity and weight loss. But it's unclear if surgery or medications, for example, can really prevent arthritis in the first place. That's an ongoing question. For example, if you lose weight at some point in your life, even around the perimenopausal phase, will that prevent you from getting arthritis? That's an interesting question.

Going back to that question about muscle loss: Is there an issue with losing a lot of weight during that time in your life, that if it's mostly muscle: Does that have a potential negative effect on arthritis development? I think more needs to be learned here, but we do know that that's a very sensitive time in terms of women developing arthritis in the perimenopausal phase.

Jamie Nicole: I wanted to ask you about supplements. Are there any that truly help with weight loss and/or inflammation?

Dr. Brian Andonian: I generally counsel patients against taking weight loss supplements. I think for the most part the risks outweigh the potential benefits, and that's especially true of some of the older supplements that were tried for weight loss. I think of Ephedra and other stimulant-type supplements. There's not a lot of evidence supporting supplements specifically for weight loss.

Inflammation, I think, is a different conversation. There is, I think, growing and a good amount of evidence supporting a few supplements for inflammation and arthritis management. Two of them would be turmeric and ginger; they are two related roots that I think can have anti-inflammatory benefit. The other is omega-3 supplement. They've been all studied and potentially have benefit for arthritis. And the point also should be that, just because it's a supplement doesn't mean that it's safe. Supplements aren't necessarily regulated the same way as medications.

And even ginger and turmeric, things that we include in our diet, when taken at high doses still can have negative effects. And that's especially true of patients who are on blood thinners. They can actually contribute to thinning the blood and cause bleeding, and it can rarely cause liver injury. So, there's just things you have to think about; that it's not all benign. But for the most part, either incorporating ginger or turmeric, or taking those as supplements, can be helpful for arthritis.

Jamie Nicole: On to the next section — we talk about lifestyle changes, diet and movement, one of my favourite topics. Diet and exercise are usually the first tools that are mentioned. What does the research say about how effective they are for arthritis?

Dr. Brian Andonian: One of my favourite topics as well. In my opinion, diet and exercise really should be a cornerstone for weight loss programs, as well as just arthritis care and maintaining health in general. And that's including those who are considering trying medications and surgery. I think this is the base for any program that we're considering.

And there's data from observational studies all the way through randomized control trials. High levels of evidence supporting diet and exercise, for both weight loss and arthritis. For example, our team at Duke has studied the effects of an intensive supervised weight loss diet and exercise training program we called SWEAT for patients with rheumatoid arthritis. And we found benefits for patients with RA across multiple aspects of health. And this includes inflammation, disease activity, their cardiometabolic health, as well as physical function. And even mental health and fatigue improve, so not just one aspect; we're really hitting multiple different areas.

Hopefully, we can figure out how to individualize these, like what factors about an individual can actually benefit from certain programs and certain diets. I think that's the holy grail in lifestyle medicine research. But we are getting closer. So, I would say stay tuned. And hopefully we'll have more answers for you guys soon enough.

Jamie Nicole: Instead of thinking about diet and exercise versus medication — and we've talked about this a little already — can you talk a little bit more about how these approaches work together?

Dr. Brian Andonian: As I mentioned, I think diet and exercise really should be the base that's always there and always an ongoing process, and then the medications would be an add-on. But when you're looking at each alone, like comparing lifestyle versus medications, it seems clear that the medications can potentially contribute to more weight loss, if we're just looking at what the evidence would show us. Like, for the medications losing 15 to even 25% of body weight versus maybe five to 10% of body weight with diet and exercise programs.

The question is still about sustainability. Do you need to take a medicine for the rest of your life, versus a diet and exercise program. If you try to have a program that you don't like to do, for example, a diet that you don't like to eat or exercise that you don't like to do, it's unlikely to be sustainable. So, you have to think about things that you really can do in the long run.

Jamie Nicole: So, if someone had to focus on just one, diet or exercise, and I know you're going say that both are important, which one tends to be the most impactful in your opinion?

Dr. Brian Andonian: Yeah, it's a bit of a trick question. The answer is certainly combining the two. But when you're really comparing them head to head, I think diet wins out, strictly from a weight loss standpoint. Exercise alone, I often tell patients, is not necessarily the right way to lose weight. You really just can't exercise and assume that alone is going to contribute to weight loss. But there's so many other benefits to exercise, and in combination with diet, it really can contribute to weight loss. So don't just discount exercise, because it alone doesn't work as well.

We already talked about the potential benefit of increasing muscle mass, which you really need exercise, and particularly resistance or strengthening-type exercise, to get there. So, don't sleep on exercise, it's something you need to keep doing. But if you're thinking about weight loss alone, there has to be some diet component. 

Jamie Nicole: Is there a particular diet that shows promise for people with arthritis? Things like intermittent fasting or keto or any anti-inflammatory plans? 

Dr. Brian Andonian: Another tough question. The answer really might depend on who you ask and also depends on the individual. But if you're trying to compare — Is it a low-fat diet? Is it a low-carb diet? Is it a keto diet, a high protein diet, a well-balanced but plant-based diet, Mediterranean style diet? — I think all have had evidence for some potential benefit. 

But we're talking about weight loss. One thing that's always true of these diets is there has to be some form of calorie restriction, meaning you're cutting back on how much you're eating to a certain extent. And this ranges from very low-calorie diets, where you're really only eating, you know, 200 to 500, 800 calories a day, which can lead to rapid weight loss but are really not sustainable in the long term. And I tend to not recommend really substantial or drastic cuts in calories.

Most evidence would point towards a more modest reduction in calories, maybe five to 10%, or reducing calories by maybe 300 to 500 max calories per day, which will lead to weight loss slowly. But again, I think sustainability is probably one of the most important things. And regardless of diet, I think diet quality has to be there. It's not just reducing the calories; it has to be some thought into improving the nutrition that you're getting from the program. And there's a lot of questions about what an anti-inflammatory diet is. And honestly, the best evidence overall would point to either the Mediterranean-style diet or more of a plant-based diet as having best benefit for improving inflammation.

 Intermittent fasting is a hot topic, and there's a lot of consideration and study ongoing for what intermittent fasting can do. We know there's a lot of health benefits from fasting periodically, and that can include kind of improvements in cardiometabolic health, improving diabetes, cardiovascular risk. But it hasn't necessarily been shown in and of itself to be better at weight loss than other diets. But potentially, because of the other benefits, intermittent fasting is something that can be helpful.

And we're learning more about how it can be useful for improving inflammation. I think we need to study it better, but anecdotally, and in some observational studies, intermittent fasting, for example, studying patients during Ramadan, where they fast as part of that period of the year, really can get benefit in terms of arthritis inflammation. Another area we need to learn more about.

Jamie Nicole: You often hear what you have to take out of your diet, but no one focuses on what you need to put into your diet as far as nutrients and nutrient density. Making sure that you are looking at the nutrients and your nutrient intake is just as important as those things that you're removing from your diet.

Dr. Brian Andonian: Yeah. And I would add that if you research anti-inflammatory diet, there's a lot of thoughts about things that you can take out, or elimination-type diets. And while those can be helpful, the goal of all those diets is try to reintroduce as many foods back into it as possible.

So, when I see patients getting into trouble is that they take out all these things from their diet, they actually don't know what was the trouble point and then they just continue on that way. And that can lead to nutritional problems and more issues down the road. If you're considering taking something out, really try to do one thing at a time, and really make sure that actually was giving you the problem. And then, if it really wasn't, try to add it back in. Trying to add more good foods is really the way to go, as you said, Jamie.

Jamie Nicole: I'm an autoimmune protocol coach, and that's one of the things that we have issues with, with people, is they want to take everything out, and they feel good, not understanding it's just supposed to be defined what your trigger is. So, moving on to the next question: What types of movement help with weight loss without flaring symptoms? And then, are there any favourites that you may recommend to your patients?

Dr. Brian Andonian: I love the question, that’s great. There is some misconception that just exercise is going to cause my joints to flare, like hard stop. I think there's a lot of considerations in terms of exercise and types of movements you should do. But for any type of movement program, the recommendation is always to start slow. We have guidelines that would suggest that we should be getting 150 minutes of moderate intensity aerobic activities, or two days a week of muscle strengthening exercise. For someone who's really not doing a lot to begin with, especially our patients with arthritis, that can be a lot. 

But as long as you're progressing slowly and not really pushing through pain, you know, usually... You should use pain as your guide and not go too hard through it. You’ve really got to listen to your body. Because we know that both aerobic exercise —that includes biking, walking, swimming, aerobics classes; and resistance-type exercise, which includes weight training, using resistance bands —that both of those are really helpful and important. 

In my opinion, I think resistance or muscle strengthening exercise is the one thing that's really missed. Using weights or machines, or even just how to use your body, using body weight to do resistance-type exercise, requires a little bit more learning, but perhaps is the most important in terms of building muscle, versus, say, aerobic-type exercise. So, I'll keep going back to muscle being important, maybe just as important as losing fat weight. So, I think we really need to consider resistance training exercise. 

Jamie Nicole: These lifestyle changes that you have mentioned can be hard to some that are not familiar with them or who are just easing into them, especially when you're managing chronic pain. What strategies help people actually stick with it for the long term? 

Dr. Brian Andonian: Yeah, as mentioned, every program has to be individualized. I think people have this idea about what they really want to do in their mind, in terms of the perfect diet or the perfect exercise program. And often those are really not attainable right away, depending on a lot of things, just our day-to-day life and trying to get through the day. So, my first recommendation is just starting slow and then really setting small, attainable goals. For diet, that should be something relatively easy to do. 

One of the simplest things we talk about is just, you know, consider reducing sugary beverages that you have during the given week, as opposed to patients, "Well, give me a goal of I'm going to eliminate all sugar from my diet." And I say, "Well, that's potentially a good goal, but it's not necessarily realistic to cut out sugar completely." So, I think starting with kind of baby steps is the way to go. 

For exercise, it would also be just increasing your activity any amount that's more than you're doing, and that can just be two or three minutes at a time. We know that even getting two to five minutes of exercise in a given day can have a lot of health benefits. And so, if you do that, you can feel good about it, and you've achieved that goal. Let's keep building towards doing more as your body allows. 

Jamie Nicole: What about combining tools, like using medication or surgery to drop weight, and then using that momentum to start exercising? Is that effective? 

Dr. Brian Andonian: Consider medications to help us get going first. And I think there is some thought that that could be helpful. But the idea, as I said, I think every person, for example, can exercise. It's just a matter of what that kind of exercise looks like. Even my patients who have, say, significant physical disabilities, or have really severe arthritis, I get creative with the things that they can do in terms of increasing physical activities, and that can be using like a foot pedal bike at home, just to get their legs moving a little bit, doing minor exercises while they're sitting in a chair, or even in bed using resistance bands. 

But I do think that combining different tools — including surgery, including medications, with the lifestyle things that are potentially beneficial — I think we need to think about combined strategies. And there's a lot of, I think, studies coming on looking at even combining medications, for example, for those really struggling to lose weight.

Jamie Nicole: Are there any lesser known tools, like apps or coaching or community support, that you've seen help people sustain these changes for the long term?

Dr. Brian Andonian: Well, first I think that working with a dedicated professional can be very helpful, and that can be a registered dietician, a health coach, exercise physiologist, someone to really help guide you through the process. I think it's really beneficial. There's a lot of options within a given community. I found that there's a lot of apps and programs that can be helpful for patients in sustaining lifestyle change, but I can't necessarily recommend one. I have some patients who swear by certain tools and apps and others that didn't really care for it. So, the point there is to explore. See what options there are, see what might work with you, and something might really fit well with you, even if it didn't work for someone else.

The other thing I really want to stress is that there are other lifestyle factors that play a role in weight loss and just overall health. And one would be stress management, and then restorative sleep. I think patients don't necessarily connect that if we're really sleeping poorly and really stressed out, that really can cause biologic changes that prevent us from losing weight and can prevent us from even being active and cause more pain, more fatigue. So, if we're struggling with, say, the diet and exercise piece, let's look at the other things. And usually I go to stress management and sleep as the first places to go.

The other point I'll make is thinking about medications. A lot of our patients with arthritis are on multiple medications, and some medications can contribute to weight gain or actually make it harder to lose weight. For example, we use steroids like prednisone for the management of arthritis, but we've long known that those can cause weight gain. And they reduce muscle mass. So, there's two bad problems from using steroids right there. Actually, some of the biologic medications we use for, say, rheumatoid arthritis, like the TNF inhibitors, for example, adalimumab or etanercept, some patients can gain weight on those and actually can have difficulties with losing weight while they're on those medications. So, let's think about other things that could be contributing and not just to say that “this program isn’t working for me. There might be other factors that are relatively easy, just with changing medications or thinking about some other lifestyle change that could help.

Jamie Nicole: As we wrap up, I wanted to go over some answers from the question that we asked our social media followers. And that question was: If you're losing weight to help your arthritis, what's working for you? And so, we have a couple of responses that I want to share with you. The first one is from Chrissy Livergood. She says, “Planning and tracking, and frankly,” she says, “being honest about how much I eat, what I eat and how much I move," et cetera… That's what really has helped her. 

And I'll read one more and let you respond. Rose Cramer, she mentioned — and these are things that you've mentioned throughout the podcast as well — making sure that she eats enough protein, veggies and fruits. She adds in a protein shake if she's too low for the day. And so far, she has been... She's 31 pounds down since January, so she emphasizes tracking her calories, and she says no sugar and no soda. 

Dr. Brian Andonian: Well, I appreciate those thoughts and congratulate them on their success. It’s not an easy thing to do. I think one of the things I hear is it's more about quality and not the quantity. Although you have to potentially reduce calories, you’ve really got to think about what you’re eating as maybe the most important thing. 

Jamie Nicole: And then I believe it’s Charla Ather, she is on Wegovy and has lost 60 pounds. She says, “I’m one of the lucky ones. My health insurance paid the bill. I can move around better…” with the extra weight off of her joints.

Dr. Brian Andonian: Yeah, there's multiple ways to do it. 

Jamie Nicole: Yeah, absolutely. So, based on everything that we've covered today, is there any final insight or reminder you'd like to leave our listeners with? 

Dr. Brian Andonian: Sure. I always go back to the point that weight is only a number and that our weight is made up of multiple things, including fat and muscle. And perhaps just focusing on the scale and the number on the scale is not the way to go. And trying to focus on the process. Meaning, you're making healthy lifestyle changes, you're trying new things to really help your health and potentially lose weight, even if you're not yet. But then focusing on symptoms and how you feel and your overall just well-being, maybe those are more important than is the number on the scale. 

And then the other thing is, again: Everyone is going to respond differently. It's tough when maybe you're doing a program with a friend, for example, and they're getting all the success and you're not. But there's so many factors that have to do with our biology, genetics, among other things, that really can make one person do well and another do well with another program. So, it's easy to give up hope when you see that you're not responding as maybe you'd like. It just means that we need to try different things. Hopefully one day we'll be able to assess: This one person will benefit from that program. But we're not quite there yet. Unfortunately, it's a little bit of a trial and error, and so I encourage people just to continue trying. 

Jamie Nicole: And what came to mind is not to let the perfect be the enemy of the good. For me, that was something that hindered me at the beginning of this journey. I thought that my journey should look similar to others. But I soon found out that there were other factors, as you mentioned. It wasn't all about calories in versus calories out, and that I really did have to learn about my body. If you want to learn more about weight management, the Arthritis Foundation has lots of good information on their website, where you'll find additional resources, insights and stories from others on a similar journey like you. Dr. Andonian, thank you again for joining us. 

Dr. Brian Andonian: Thanks so much for having me. I really enjoyed our conversation.

https://www.arthritis.org/liveyes/podcast/episodes/how-to-lose-weight-for-arthritis