A Weight and Pain Management Program for RA With Obesity

Abstract and Introduction

Abstract

Background: Obesity is associated with poor outcomes for patients with rheumatoid arthritis (RA). Effective weight management is imperative. Although traditional lifestyle behavioral weight loss programs have demonstrated efficacy for reducing weight, these interventions do not meet the pain-related weight loss challenges of RA patients with obesity.

Objective: A 12-session group program (90 minutes per session) was developed integrating pain coping skills training into a lifestyle behavioral weight loss intervention. In addition to the weekly group sessions, participants engaged in supervised exercise sessions 3 times per week.

Methods: Through a small, pilot randomized trial, 50 participants were randomized to receive the intervention (n = 29) or standard care of RA (n = 21). Feasibility data (i.e., accrual, attrition, adherence) was examined using descriptive statistics (e.g., percent). We examined patterns of change in study outcomes from baseline to follow-up separately for the intervention and standard care arms using descriptive statistics and paired t tests. Effect sizes are also presented.

Results: Of those randomized to the intervention group,79.3% initiated treatment, with participants attending 74.3% of group skills sessions and 64.2% of exercise sessions. Intervention participants evidenced reductions in weight (mean, −2.28 kg) and waist circumference (mean, −4.76 cm) and improvements in physical functioning, eating behaviors, pain, and self-efficacy for weight control.

Conclusions: Findings suggest that incorporating a combined pain coping skills training and behavioral weight loss intervention into medical management of RA may improve outcomes. Study accrual and attrition, as well as intervention adherence, will inform future, larger randomized efficacy trials of the intervention.

Retrospectively Registered: January 29, 2020, NCT04246827

Introduction

Obesity has become increasingly pervasive in patients with rheumatoid arthritis (RA), with estimates suggesting that more than 30% of RA patients are obese.^[1] Body composition assessments in patients with RA have demonstrated adipose tissue excess and skeletal muscle paucity or "sarcopenic obesity."^[2] Obesity has been linked to negative outcomes for RA patients, including a poorer response to medical treatments and decreased rates of remission as well as greater pain, disability, and disease activity.^[1,3–6] There may be a reciprocal relationship between pain, pain-related disability, and obesity such that pain may result in inactivity, which may impact successful weight management and result in an exacerbation of pain and pain-related disability.^[7,8]

Weight management for chronic pain patients, including those with RA, is imperative.^[8] In 1 study, bariatric surgery was associated with 12-month postsurgical reductions in RA disease activity and RA medication usage, although it is unclear if these benefits were a direct result of weight loss.^[9] Research testing weight loss interventions with patients with other chronic pain conditions (e.g., fibromyalgia) suggests that weight reduction may lead to improvements in pain-related outcomes.^[10] Interestingly, a paradoxical relationship has been found between weight loss and increased disability for patients with RA; however, for these patients, weight loss may result from greater disease severity and may be naturally occurring and unintentional rather than intentional.^[11] To our knowledge, there have been no studies testing the impact of a behavioral weight management intervention in RA patients with obesity,^[12] although a recent retrospective study suggests that weight loss may result in improved RA disease activity.^[13]

The impact of behavioral weight management programs on pain for RA patients with obesity is currently unknown. Behavioral weight management programs emphasize gradual weight loss by addressing behavioral and psychosocial lifestyle factors. Although traditional behavioral weight loss programs have demonstrated efficacy for reducing weight in individuals with overweight and obesity in general,^[14,15] by themselves, these interventions fail to adequately meet the pain-related weight loss challenges of RA patients with obesity. Patients with RA with obesity may experience pain that significantly limits physical activity and engagement in exercise programs.^[12] In addition, people in pain often experience acute pain relief (and mood relief) from eating high-calorie foods.^[16] This maladaptive coping mechanism can lead to more weight gain, which may exacerbate pain.^{[1,4,5,17,18]}

An enhanced lifestyle behavioral weight management program integrating pain coping strategies with a traditional lifestyle behavioral weight loss intervention may enhance the abilities of RA patients with obesities to cope with pain-related weight challenges and lead to improved outcomes.^[12] Pain coping skills training (PCST) emphasizes pain as a biopsychosocial experience, using cognitive and behavioral techniques to improve pain coping.^[19,20] Skills learned during PCST may also serve as an alternative to eating for pain or mood relief. Work testing the efficacy of a combined PCST and lifestyle behavioral weight management intervention designed for patients with knee osteoarthritis (OA) resulted in greater reductions in both body mass index (BMI) and physical disability when compared with patients who received PCST alone, lifestyle behavioral weight management alone, or standard care.^[21] However, it is not known whether such an intervention would benefit patients with RA as their disease can be more debilitating and pervasive than knee OA. In addition, it is unknown whether including strategies for pain management in a behavioral weight management intervention will assist with promoting successful weight loss and management in individuals with RA.

The present study examined the feasibility of an enhanced lifestyle behavioral weight management protocol in a sample of RA patients with obesity. This protocol integrated training in pain coping skills into a lifestyle behavioral weight loss intervention to increase self-efficacy for arthritis and weight management and decrease the impact of RA pain on behavioral (e.g., activity, eating) and psychosocial (e.g., mood, relationships) weight loss factors. The primary aim was to examine feasibility, including study accrual, intervention adherence, and attrition. In addition, this study examined patterns of change in weight and pain for patients who participated in the treatment and those in the standard care condition. A secondary aim was to examine changes in physical function (i.e., physician rated, self-report, and 6-minute walk test [6MWT]), eating behavior, and self-efficacy (i.e., weight control, arthritis).