We can – and should – do more for patients with obesity than simply tell them to lose weight.
Obesity and rheumatic disease regularly keep each other’s company, both rising with the same tide. Getting a hold on the first condition could really make a dent in the second, but when it comes to solutions, rheumatologists and their patients are being left high and dry.
Obesity is a major risk factor for rheumatological disease. It worsens outcomes for patients, increasing pain and disability. It decreases the effectiveness of commonly used treatments, including biologics. The risk of needing joint replacement goes up while the results of surgery are worse. One in four Australians will develop osteoarthritis as a direct result of obesity, Arthritis Australia told the Inquiry into the Obesity Epidemic in Australia [1].
It’s no picnic for economies and health systems either. Arthritis is the second leading cause of health-related disability and early retirement in Australia, costing over a billion dollars yearly in welfare and lost tax revenue and more than $7 billion in lost GDP. Around 40% of lost productivity is down to arthritis.
Worldwide, over 600 million adults are currently classed as obese with numbers tripling since 1975. In Australia, the most recent government data shows almost one-third of adults are obese (body mass index 30 or above), and another third are overweight (BMI 25-29.9).
“Unless more is done to reduce the current growth in obesity rates both in children and adults, we can look forward to increasing prevalence, earlier onset and greater severity of arthritis in coming years,” the peak body warned in its submission.
Meanwhile clinicians face the dilemma of how to address obesity in their clinics every day.
US rheumatologist and researcher Professor Alexis Ogdie, of the University of Pennsylvania, says it’s clear that obesity affects therapy and long-term outcomes for rheumatic disease patients, particularly those with psoriatic arthritis.
“For some reason, patients with psoriasis and psoriatic arthritis tend to be significantly more obese than the general population and significantly more obese than our patients with rheumatoid arthritis,” says Professor Ogdie.
“There’s plenty of data showing that response to therapy decreases with obesity. And we’re not sure why that is, if it’s that the fat cells make inflammation that we can’t tamp down with our therapies, or that there’s a volume of distribution problem. From pharmacokinetic studies it’s not supposed to be like that. But we also know they don’t always study the full range of patients that we see,” she says.
Research also shows that weight loss helps. A 2014 Italian study [2] demonstrated that losing over 5% of body weight was a “major and independent predictor” of response to therapy at six months, regardless of the type of diet. Participants in a 2019 Swedish study [3], who were put on a very low energy diet, lost between eight and 40kg and showed significant improvement in disease activity at six months, including tender/swollen joints count, psoriasis body surface area, C-reactive protein , enthesitis, pain and fatigue.
In both studies, losing more weight resulted in better response. Some of the initial loss of function may have been due to obesity rather than rheumatic disease, Professor Ogdie noted. In fact, there are still many questions to be answered about the interaction between the two conditions.
We can barely talk about it
“Emotive”, “fraught” and “loaded” are the words Associate Professor Helen Keen uses to describe the issue of weight.
“It’s a really hard thing to even begin to discuss,” says the head of rheumatology at Perth’s Fiona Stanley Hospital. “I once had a patient who handed me a piece of paper saying, ‘Do not discuss my weight, do not weigh me’.”
“It’s filled with judgment and stigma and blame. And the reality is, once you’re obese, trying to lose weight and maintain it is almost physiologically impossible. And that’s been shown over and over and over again in studies,” she says.
Professor Ogdie says she’s not sure how best to approach a patient about the sensitive topic of weight, though she likes a suggestion she recently heard from Cleveland Clinic rheumatologist Dr Elaine Husni to ask permission to talk about it.
“I have found that, in general, patients are receptive to the information,” says Professor Ogdie. “It’s important to educate them about the fact that obesity is related, and that it will impair them from getting to their lowest disease activity, and addressing it is really important for their disease. I think that changes the outlook on it, as opposed to just thinking about it being a general problem that they have.”
The conversation about weight loss is difficult, agrees Sydney-based exercise physiologist Sarah Comensoli. Nobody wants to offend, but the alternative is withholding relevant information.
“It’s part of what patients need to make an informed decision about what treatments they want to take part in – or not,” says Ms Comensoli.
“Whether they choose to follow up is up to them. They might not be ready to make a decision that day, but to give them that information and that understanding is really important,” she says.
What do we have to offer?
Rheumatologists are seeing more of their patients affected by obesity, but they’re not seeing better solutions for them, says Professor Keen. “It impacts the development of the disease, the response to therapy, it limits the therapies we can use, and it even impacts the ability to assess the side effects of our therapies. And it’s really difficult to address in reality.”
“To be honest, I rarely raise it, and the reason is I don’t feel I have any ability to offer helpful solutions.”
People know they’re overweight, even if they’re not always aware of the extent of its impact, says Professor Keen. “But unless you can give them tools to deal with it, or to change it and modify their weight, then I feel a bit nihilistic about telling people they need to lose weight, because that’s not a useful piece of information unless you give them ways to do it.”
Allied health can give patients options, says Ms Comensoli. Managing weight with the assistance of exercise and diet specialists gives patients some control over the impact of medications, disease progression and pain.
It’s not a one-size-fits all, adds Ms Comensoli. Not everyone who is overweight will struggle to manage their condition. Intervention requires a personalised approach – individual circumstances matter a lot when it comes to figuring out diet and helping people feeling safe to exercise when they’re already tired and in pain.
But as Professor Keen points out, the public system does not facilitate those solutions. Unlike GPs, rheumatologists can’t provide a chronic health care plan to give patients access to subsidised allied health services. That means taking a more circuitous route and a limited number of sessions for public patients.
Nevertheless, rheumatologists should not feel they have to do it alone, says Ms Comensoli.
Ms Comensoli is lucky, she tells The Medical Republic, because BJC Health, a multidisciplinary Sydney practice she’s worked with for over a decade, employs rheumatologists, physiotherapists, exercise physiologists, massage therapists and dietitians to provide holistic care. But the majority of rheumatologists would need to seek out their own connections.
“It’s great to try and find [allied health practitioners] in the local area to see whether there’s anyone interested in working with our rheumatic disease patients, because it can make such a difference. It’s really worthwhile for a rheumatologist to sort of have those links,” she says.
Professor Ogdie is currently involved in a trial to see what dietary interventions will work.
“Patients don’t want to hear ‘you should lose weight’ because they’ve all tried to do it a thousand times,” says Professor Ogdie.
They don’t want to weigh themselves constantly or meticulously document every morsel of food either, they told her team. What they do want is a lifestyle change.
“We know from behavioural economics, there’s lots of little pieces that you can apply in terms of the way you frame something. If you frame it as we’re putting you on a diet, you’re going to track your food and we’re going to keep on you, that gives a negative impression. It makes it sound like a lot of work,” she explains.
Instead, participants in the trial are given information, examples of meals and specific portion sizes for individuals.
“The dietitian calls to check in and asks, ‘What are you struggling with? What are some of the barriers that you’re having? What are some things we can talk through to think about how we can motivate change, and get getting over those barriers?’”
The trial is still blinded, and so far, the participants seem happy, she tells The Medical Republic. But it’s not yet known whether that’s down to the particulars of the intervention or just the fact of being involved in one.
None of the study participants have a BMI over 40, says Professor Ogdie, because dietary interventions are less likely to be beneficial in that group.
In fact, lifestyle interventions don’t work well in most cases, according to obesity researcher Adjunct Professor John Dixon from the Baker Heart and Diabetes Institute, with perhaps one in 20 people able to keep the weight off in the long term.
“It produces a very small weight loss and it’s hard to maintain,” he said at a recent obesity expert panel discussion in Sydney.
Despite its pervasiveness, people don’t have a good understanding of the science of obesity, endocrinologist and president of the National Association of Clinical Obesity Services (NACOS) Professor Samantha Hocking told The Medical Republic.
“Obesity is driven by appetite and hunger hormones. And when you lose weight, those hormones increase, and so it becomes increasingly difficult for you to lose weight further or maintain your weight loss. And we need medications to help blunt that physiological response.”
Pharmacotherapies result in between 5% and 15% body weight reduction, depending on whether they’re used with very low energy diets.
“People need treatment for this chronic disease. And we just we really need to move forward and accept that, get the medications available and hopefully subsidise them on the Pharmaceutical Benefits Scheme,” says Professor Hocking.
Like other chronic conditions, treatment is life-long, the drugs are expensive and the condition disproportionately effects people from lower socio-economic groups.
“It really is quite unfair. We need highly effective agents that are safe, that can be used long term and at a cost that’s affordable.”
A healthy diet, reducing alcohol, not smoking, and aerobic and resistance exercise have many benefits, she says, but they won’t result in substantial weight loss.
The cycle of weight loss and regain is frustrating, she noted. “It’s really important to explain that’s not because of laziness, or not following the diet properly or giving up. This is a physiological adaptation to weight loss. Your body is driving weight re-gain.”
Medication and surgery are effective because they counter the body’s response, and offering them is “a no-brainer”, she explains. “They absolutely do help people make the lifestyle changes and stick to them.”
The recent scramble for access to semaglutide demonstrates that people do want pharmacological help. Semaglutide (Ozempic, Novo Nordisk) is indicated in Australia for type 2 diabetes in a 1mg dose. In the US, it is marketed in a 2.4mg dose for weight loss under the name Wegovy. The TGA has approved Wegovy for chronic weight management, but it’s not yet available in Australia.
“We’ve seen all the clinical trial data, which shows about 15% weight loss with a 2.4 milligram dose. People are obviously jumping the gun and already wanting to use it in Australia off label. The off-label use has been large because it is so effective, and people want access to effective medications for their weight. It’s actually sold out globally,” says Professor Hocking.
There are four weight loss medications licenced for use in Australia at present.
Phentermine (Duromine, iNova) is a powerful appetite suppressant that works on the hypothalamus and has been around for a long time. Naltrexone-bupropion (Contrave, iNova) lowers appetite and also affects the reward pathways in the brain (which can help with cravings, said Professor Hocking). Liraglutide (Saxenda, Novo Nordisk) is in the same class as semaglutide and lowers appetite and hunger. More will be available in the next 12 months.
Bariatric surgery is another option in Australia. It’s associated with 25-30% weight loss and is available to those with a BMI over 35 with obesity related complications or comorbidities, or a BMI over 40, taking into account individual aspects such as age and other risk factors.
However, the high cost of treatment in the private health system and long waiting lists in the public health system mean it may not be a feasible option for many patients.
Professor Keen says obesity is something the rheumatology community has to learn more about.
“We need to understand more about how it impacts our diseases and pathophysiology and how we can help to begin to deal with it.
“Because you see your patient in front of you and you know their weight is likely to be contributing to their poor health outcome. Is it a modifiable comorbidity or not? We don’t talk about non-modifiable conditions with our patients. We should be able to modify it.”
References
[1] https://arthritisaustralia.com.au/wordpress/wp-content/uploads/2020/01/180812-Arthritis-Australia_submission-to-Obesity-Inquiry.pdf
[2] di Minno MN, Peluso R, Iervolino S, et al. Obesity and the prediction of minimal disease activity: a prospective study in psoriatic arthritis. Arthritis Care Res (Hoboken) 2013;65(1):141–147
[3] Klingberg E, Bilberg A, Bjorkman S, et al. Weight loss improves disease activity in patients with psoriatic arthritis and obesity: an interventional study. Arthritis Res Ther. 2019;21(1):17.
