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Obesity and Arthritis: Science and Realpolitik
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In the cover story this month, we are again fortunate to have assembled an esteemed faculty — this time to discuss the intersection of obesity and arthritis. While this is most transparent for those with involvement of weight-bearing joints, it is also important for all rheumatic disease patients.
Obesity is a comorbidity that not only affects response rates to certain biologic agents while enhancing toxicity to other therapies, but also more broadly and critically contributes to the general epidemic of poor health and chronic disease threatening the very fabric of our society. I recently heard two very smart people discuss obesity as a medical/health problem; they both were informative and sobering, but they approached this problem from radically different directions. With that in mind, I want to share a few tidbits with you about science and reality.
This past week, Martin J. Blaser, MD — the noted infectious disease specialist and now microbiome scientist at the NYU School of Medicine — gave one of the best medical grand rounds I have heard in years. As I like to say, he expertly overestimated the intelligence of the audience but underestimated their knowledge on the complexities of the microbiome so all could understand and learn.
Calabrese
His perspective, expressed in his book Missing Microbes, is about the degradation of the internal microbial ecosystems of humans as a result of modern medical practices — not only the overzealous use of antimicrobials but also the epidemic of C-section births and the modification of our diets with industrialized food. His science demonstrates clearly in mouse models that even short-term exposure to antibiotics can affect generationally the microbiomes of offspring and concomitantly the risk for obesity and metabolic diseases.
The science is exquisite, but just how much or how little to temper the use of antimicrobials, a class of drugs that have brought miraculous advances to world health, is not made clear. I guess it just goes to show us that there is no free lunch (no joke intended); clearly more translational and clinical research is needed if this is going to have an impact on the obesity epidemic.
The second person I heard recently (and many, many times before) is Michael Roizen, MD, a pioneer in wellness research and education, the chief wellness officer at the Cleveland Clinic, bestselling author and personal friend. Michael has long been writing and lecturing on the threats of chronic diseases that emanate from our behavior to our society. He often cites the figure that 84% of all health care costs and 67% of the costs from population aged less than 65 years, come from four things: tobacco, food choices, physical inactivity and unmanaged stress.
I know it sounds incredible but there are strong health economic data to support this. As a reminder, we now live in a country where seven states have populations that exceed 35% prevalence of obesity. If we remain on our current trajectory of gaining 0.37% per year, we are on the road to an economic/health crisis of epic proportions.
Michael comes at this problem from the perspective of influencing personal choices (ie, wellness behavior) any way we can. For example, at large institutions such as the Cleveland Clinic, incentivizing employees financially and making wellness resources readily available — such as work-out facilities, healthy foods, stress management — can and does pay off. Why aren’t we shocked that 50% of Americans admit they do less than 10 minutes of walking on any day of the week? More importantly, what are we as a profession doing about contributing to changing this?
In the end, as I have written before, rheumatologists must join the fight for wellness! I am now going to assert one final thing and that is we need partners — we cannot do it alone, as we lack expertise and time among other things. Yes, primary care providers need to join in and some are doing great jobs. And what about pharma? Each company that has brought us miraculous therapies claims to be “patient first” but what does that really mean? To them, I say join us in bringing not only disease control to the immune-mediated inflammatory disease population, but wellness education and resources. At this point, some are taking small steps while others are not even in the game.
If we are collectively dedicated to the health and wellbeing of the patient, then we all should be in this together. Let’s talk this up with our partners and get on board ourselves, no matter in how small a way, perhaps with the next patient. Remember the journey of 1,000 miles begins with a single step.
If you have your own experiences with tackling obesity and wellness in the rheumatology space, please share your thoughts with me by email to calabrl@ccf.org or on Twitter @LCalabreseDO.
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- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
Disclosure: Calabrese reports serving as an investigator and a consultant to Horizon Pharmaceuticals.