Weight loss interventions in rheumatology patients – diet, lifestyle, and bariatric surgery

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Diet and lifestyle interventions

Guidelines on lifestyle behaviours, including diet and exercise, to maintain healthy weight, promote physical health, and improve disease outcomes in individuals living with rheumatic and musculoskeletal diseases (RMDs) have been provided by EULAR in 2021 (1). The EULAR committee recommended a balanced diet, as well as regular aerobic and anaerobic exercise, individualised to accommodate the needs of each person living with RMD (1). Surprisingly, while many studies have investigated the effects of diet and exercise on disease activity in people living with RMDs (a nice review of relevant clinical trials in rheumatoid arthritis can be found in (2)), weight loss and control of metabolic comorbidities rarely serve as primary endpoints.

Lifestyle interventions combining exercise with dietary guidance offer promising results for improvement of physical fitness and sustained weight loss in individuals with RMDs, and have been shown to be superior to either intervention alone (3). A randomised controlled trial in older adults with rheumatoid arthritis (RA) compared a weekly, remotely supervised hypocaloric diet and exercise training program vs two 60-minute lifestyle counselling sessions followed by usual care. After 16 weeks, individuals on the supervised programme showed superior weight loss and change in metabolic profile, improvement of physical and mental health, decreased fatigue, as well as decreased disease activity (4). Importantly, another study including individuals with inflammatory arthritis, osteoarthritis or fibromyalgia, who followed an intensive counselling programme combining exercise and Mediterranean diet for 3 months, showed promising long-term effects up to 2 years on weight loss and overall improvement in quality of life (5). Unfortunately, such programs are rarely available to individuals living with RMDs. The results of the CLIP-OA trial examining the effects of exercise and dietary weight loss in patients with knee osteoarthritis, including the cost-effectiveness of this intervention, are anticipated to further support the importance and applicability of such programs (6). Finally, while many studies have compared different types of diet, such as Mediterranean, low-fat or rich in antioxidants ‘anti-inflammatory diet’, there is no strong evidence to support the superiority of any specific diet over the others. Therefore, lifestyle interventions should adopt an individualised approach leading to the best possible weight loss and sustained adherence to a healthy lifestyle (1).

Bariatric surgery

Bariatric surgery has proved an effective way to achieve significant weight loss in association with reduced disease activity in individuals with RMDs. In a study by Sparks and colleagues, people with RA and severe obesity (mean body mass index 47.8 kg/m2) were followed for 12 months after bariatric surgery (Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, or sleeve gastrectomy). Twelve months post-surgery, individuals lost a mean of 41.0 kg and 70% of excess weight, accompanied by decreased disease activity and lower systemic inflammation (7). On the other hand, a recent large cohort study including 1,931 individuals with RA who underwent bariatric surgery and matched individuals who also underwent bariatric surgery,  showed that RA patients were more prone to develop nutritional complications (8). However, individuals with RA who underwent bariatric surgery still showed better disease control and lower 5-year mortality compared to matched individuals with RA who did not undergo any weight loss intervention (8).

Conclusion

Given the better disease control provided by newer medications and closer monitoring, more people with RMDs live with excess adiposity for a progressively greater number of years. Given the considerable benefits from diverse weight loss and lifestyle interventions on quality of life, disease control and long-term morbidity and mortality, the design of robust weight loss clinical trials in individuals living with RMDs is warranted (9).

Dr. Nikolaos I. Vlachogiannis Postdoctoral researcher in Rheumatology and Internal Medicine resident. First Department of Propaedeutic Internal Medicine & Joint Academic Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece EMEUNET Country Liaison for Greece and Social Media Sub-Committee member

References

  1. Gwinnutt JM, Wieczorek M, Balanescu A, Bischoff-Ferrari HA, Boonen A, Cavalli G, de Souza S, de Thurah A, Dorner TE, Moe RH, Putrik P, Rodríguez-Carrio J, Silva-Fernández L, Stamm T, Walker-Bone K, Welling J, Zlatković-Švenda MI, Guillemin F, Verstappen SMM. 2021 EULAR recommendations regarding lifestyle behaviours and work participation to prevent progression of rheumatic and musculoskeletal diseases. Ann Rheum Dis. 2023;82:48–56. doi: 10.1136/annrheumdis-2021-222020
  2. Philippou E, Petersson SD, Rodomar C, Nikiphorou E. Rheumatoid arthritis and dietary interventions: systematic review of clinical trials. Nutr Rev. 2021;79:410–28. doi: 10.1093/nutrit/nuaa033
  3. Gwinnutt JM, Wieczorek M, Cavalli G, Balanescu A, Bischoff-Ferrari HA, Boonen A, de Souza S, de Thurah A, Dorner TE, Moe RH, Putrik P, Rodríguez-Carrio J, Silva-Fernández L, Stamm T, Walker-Bone K, Welling J, Zlatković-Švenda MI, Guillemin F, Verstappen SMM. Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs. RMD Open. 2022;8:e002168. doi: 10.1136/rmdopen-2021-00216
  4. Andonian BJ, Ross LM, Sudnick AM, Johnson JL, Pieper CF, Belski KB, Counts JD, King AP, Wallis JT, Bennett WC, Gillespie JC, Moertl KM, Richard D, Huebner JL, Connelly MA, Siegler IC, Kraus WE, Bales CW, Porter Starr KN, Huffman KM. Effect of Remotely Supervised Weight Loss and Exercise Training Versus Lifestyle Counseling on Cardiovascular Risk and Clinical Outcomes in Older Adults With Rheumatoid Arthritis: A Randomized Controlled Trial. ACR Open Rheumatol. 2024;6:124–36. doi: 10.1002/acr2.11639
  5. Van Slingerland K, Kranenburg LJC, Wilmsen N, Coles E, Dolhain RJEM, de Jong PHP. The impact of an online, lifestyle intervention programme on the lives of patients with a rheumatic and musculoskeletal disease: a pilot study. Rheumatol Oxf Engl. 2025;64:3309–18. doi: 10.1093/rheumatology/keae696
  6. Focht BC, Rejeski WJ, Hackshaw K, Ambrosius WT, Groessl E, Chaplow ZL, DeScenza VR, Bowman J, Fairman CM, Nesbit B, Dispennette K, Zhang X, Fowler M, Haynam M, Hohn S. The Collaborative Lifestyle Intervention Program in Knee Osteoarthritis Patients (CLIP-OA) trial: Design and methods. Contemp Clin Trials. 2022;115:106730. doi: 10.1016/j.cct.2022.106730
  7. Sparks JA, Halperin F, Karlson JC, Karlson EW, Bermas BL. Impact of Bariatric Surgery on Patients With Rheumatoid Arthritis. Arthritis Care Res. 2015;67:1619–26. doi: 10.1002/acr.22629
  8. Zhu X, Wang Q, Mocanu V, Kachornvitaya P, Wills MV, Strong A, Navarrete S, Barajas-Gamboa JS, Corcelles R, Kroh M, Dang J. Evaluating the long-term safety and disease-modifying potential of metabolic surgery in patients with rheumatoid arthritis: a TriNetX cohort study. Surg Obes Relat Dis. 2025;S1550-7289(25)00949-9. doi: 10.1016/j.soard.2025.10.004
  9. Sattar N, Sattar LJ, McInnes IB, Siebert S, Ferguson LD. Obesity substantially impacts rheumatic and musculoskeletal diseases: time to act. Ann Rheum Dis. 2025;84:894–8. doi: 10.1016/j.ard.2025.02.013

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