Weight loss associated with improvement in psoriatic arthritis
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Patients with psoriatic arthritis and obesity had lower disease activity with a very low energy liquid diet, according to a study published in Arthritis Research & Therapy.
“Obesity, diabetes, hypertension, hyperlipidemia and the metabolic syndrome are overrepresented in both psoriasis and PsA, and the patients are at increased risk of cardiovascular morbidity,” Eva Klingberg, MD, and colleagues wrote.
At baseline, 46 patients with PsA and 52 control subjects started the very low energy liquid diet (VLED).
“The VLED provides a mixture of carbohydrates, proteins and fats, with added recommended doses of vitamins, minerals, trace elements and essential fatty acids, in powder formulas that require mixing with hot or cold water before consumption as shakes or soups,” the authors wrote.
Participants took the VLED four times per day, for a daily intake of 640 kcal. Food was reintroduced gradually over 12 weeks, with subjects receiving individual dietary advice for weight stability.
Median weight loss at 12 months from baseline was 16.1% in 39 patients with PsA, and at 24 months from baseline, 7.4% in 35 patients.
Patients with minimal disease activity increased from 28.2% at baseline to 38.5% at 12 months and 45.7% at 24 months, showing a significant association with weight loss.
In addition, blood pressure, HbA1c and serum levels of total cholesterol, low-density lipoprotein, triglycerides and glucose were reduced significantly, with high-density lipoprotein increasing significantly, at the 6-month follow-up. HbA1c, triglycerides and glucose were still reduced at 12 months with higher high-density lipoprotein, and at 24 months, triglycerides were reduced with higher high-density lipoprotein.
“Weight loss treatment with VLED in patients with PsA and obesity was associated with sustained lowered disease activity after 12 months and 24 months of follow-up, with concurrent improvements in cardiovascular risk factors and lowered serum urate,” the authors wrote. “The results of the study provide support to the hypothesis of obesity as a promotor of disease activity in PsA and shows what can be achieved by 5% to 15% weight loss in patients with PsA and obesity.”
Perspective
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George Martin, MD
In psoriatic arthritis and psoriasis, obesity is associated with increased disease activity and decreased response to treatment. Obesity has been described as a pro-inflammatory state in which cytokines such as TNF alpha, IL-1, IL-6, IL-17 and IL-23, major drivers in psoriasis and PsA, are produced in adipose tissue by infiltrating macrophages, T cells and B cells. This is in addition to pro-inflammatory adipokines (leptin, resistin, fetuin-A and chemerin) produced by adipocytes. However, studies evaluating the effect of weight loss on disease activity in PsA are difficult to find largely because of issues controlling the many variables that can affect outcomes. The authors of this study previously identified the benefits of weight loss in obesity on improving disease activity in PsA in 41 patients who achieved a median weight loss of 18.6% during a 6-month study. This 24-month prospective controlled study evaluated the effect of weight loss on PsA disease activity, metabolic syndrome and cardiovascular risk factors.
The weight loss treatment program used a very low energy liquid diet for 12 to 16 weeks followed by reintroduction of food over 12 weeks. Sustained lowered disease activity was achieved in 39 patients with a 16% weight loss after 12 months and in 35 patients with an average weight loss of 7.4% after 24 months of follow-up. Improvements in cardiovascular risk factors and lowered serum urate were noted.
While the study was small, did not have a randomized control group with PsA or a threshold for disease activity as inclusion criteria, and allowed for conventional synthetic/biologic disease modifying antirheumatic drug treatment variations after 6 months, the data are still compelling. Thus, as little as 7% to 16% sustained weight loss improves disease outcome measures, lending further support for our mantra of “diet and exercise” in patients with obesity and PsA in order to reduce disease activity.
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