Effects of a Weight and Pain Management Programin Patients With Rheumatoid Arthritis With Obesity

A Randomized Controlled Pilot Investigation

Tamara J. Somers, PhD; James A. Blumenthal, PhD; Caroline S. Dorfman, PhD; Kim M. Huffman, MD, PhD; Sara N. Edmond, PhD; Shannon N. Miller, BPH; Anava A. Wren, PhD; David Caldwell, MD; Francis J. Keefe, PhD

Disclosures

J Clin Rheumatol. 2022;28(1):7-13. 

In This Article

Discussion

Obesity is associated with poor outcomes for RA patients; however, pain may challenge patients' abilities to engage in important weight loss behaviors (i.e., healthy eating, physical activity). In this investigation, we piloted a 12-session intervention, which combined a lifestyle behavioral weight management intervention with a PCST program for RA patients. Participants also completed in-person exercise sessions (3 times per week). We examined feasibility by examining accrual, attrition, and intervention adherence as well as change in outcomes from baseline to follow-up for patients who received the intervention and those who did not.

Attrition in this study should inform future trials. Six randomized participants did not initiate treatment, suggesting the need to increase engagement early in recruitment. In addition, the intervention asked participants to participate in 12 in-person group sessions, each 90 minutes in length, as well as in-person exercise sessions (3 times per week). The in-person time commitment required of participants may have been a barrier to treatment initiation and completion of intervention and exercise sessions. Alternative intervention delivery strategies (e.g., remote delivery, hybrid in-person/remote delivery), including the use of mobile health technology, may help to reduce barriers to participation and should be evaluate in future studies.

Seven participants in the control group were lost to follow up. Exploratory analyses were conducted to examine baseline differences between control group participants who completed study assessments and those lost to follow-up. Trends suggested that individuals lost to follow-up tended to be younger and employed (vs. unemployed) and have higher weight and waist circumference, and greater self-efficacy for weight control and arthritis when compared with completers. Steps to increase adherence to assessments among younger individuals with competing demands (e.g., work) may be necessary, including the use of remote assessment procedures (e.g., REDCap surveys) and pairing assessments with scheduled clinic visits. As this was a relatively small pilot feasibility trial, we were unable to include a sham intervention. A wait-list control or an active treatment condition might be necessary to increase study engagement among the control group, given participants' weight control needs and overall symptom burden.

Reductions were found in weight and pain for the intervention group. The intervention group also evidenced improvements in waist circumference, physical functioning assessed through physician report, self-report, and an objective 6MWT, eating behaviors, and self-efficacy for weight control. Results suggest that this combined intervention was associated with not only improvements in variables traditionally associated with behavioral weight management interventions but also improvements in pain and physical functioning, 2 important outcomes for patients with RA.

Several trials involving RA patients have demonstrated that psychological self-management interventions such as PCST can produce significant reductions in pain behavior and disease activity.[12] This initial pilot trial uniquely shows that an intervention combining lifestyle behavioral weight management strategies and PCST for RA patients may not only result in decreased weight, but also lead to improvements in physical functioning and pain. In a large randomized controlled trial involving OA patients, benefits were found when the study team simultaneously combined a psychological self-management program (PCST) with a lifestyle behavioral weight management program.[21] To our knowledge, the present study is the first to examine the effect of combining psychological self-management with lifestyle behavioral weight management in the treatment of pain and physical disability in RA patients.

While the outcomes of this study are promising, we recognize limitations, including that this was intended as a pilot study with a total recruitment of 50 subjects, and the sample was primarily female. Thus, the results of this study may not generalize to other samples of RA patients and provide limited information about the impact of gender on intervention effects. In addition, of the 4 males recruited to participate in this study, 3 dropped out, suggesting that additional steps should be taken to better engage male participants in the intervention. A larger sample is also needed to provide adequate power for testing group differences in study outcomes and to statistically evaluate potential mechanisms of action of the intervention. Finally, we did not conduct a psychiatric evaluation/assessment of study participants, and the type of RA pain (i.e., centralized pain, peripheral pain) endorsed by participants was not assessed upon study initiation. The presence and impact of psychiatric conditions and pain location will be considered in future work.

Nonetheless, these findings support the potential benefit of combining lifestyle and psychological approaches to managing chronic diseases such as RA. The results point to improved weight and waist circumference, physical functioning, eating behavior, pain, and self-efficacy for weight control for individuals participating in an intervention combining lifestyle behavioral weight management strategies and PCST. While intervention arm participants evidenced specific improvements in the aforementioned areas, interventions combining multiple approaches and including more than 1 treatment target may also result in more global benefits.

For example, strategies used to promote pain self-management may result in improvements in lifestyle behavior variables such as exercise and weight management, which can have a downstream positive effect on cardiovascular health and mortality. Additional studies recruiting larger samples and participants are necessary to confirm the results of the present study.

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