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In older overweight individuals with rheumatoid arthritis (RA), a composite of metabolic biomarkers as well as disease activity measures improved substantially with a professionally directed diet and home-exercise regimen, researchers found in a randomized trial.

A control group assigned to receive counseling on healthy behaviors also saw improvement in most outcomes, although the intervention was clearly superior for measures of body composition and disease activity, according to investigators led by Brian J. Andonian, MD, MHSc, of Duke University in Durham, North Carolina.

For the primary outcome, however -- a metabolic syndrome index dubbed MMSc capturing blood lipids, fasting glucose, waist circumference, and mean arterial pressure -- there was no significant difference between the two programs, the researchers .

It's well known that RA comes with higher risk for cardiovascular events, making it imperative that patients keep their other risk factors to a minimum. They can't do anything about their age, of course, but excess weight and cholesterol are at least somewhat modifiable.

A single-arm published earlier this year had found that a 10-week exercise program improved cardiorespiratory fitness among RA patients older than 55. That led the group to postulate that a regimen that also included dietary modifications could be especially beneficial in this population.

Andonian and colleagues enrolled 20 RA patients ages 60-80, with body mass index (BMI) values of 28-40 and who reported relatively minimal levels of physical activity. Participants were randomized in equal numbers to a 16-week program of remotely supervised exercise and a low-calorie diet or to a control group who received two hour-long lifestyle counseling sessions with a dietitian and an exercise physiologist, both via video.

Those assigned to the intervention had interactive video conferences with a dietitian who developed an individualized diet aimed at reducing body weight by 1-2 pounds per week, for a total of 7% of body weight by the end of the study. There were also weekly group videoconference sessions with a nutritionist to reinforce dietary goals, as well as regular weigh-ins. Participants also kept food diaries.

The exercise component was supervised remotely by a professional, focusing on aerobic training, with weekly group sessions plus additional exercises -- shown on a special YouTube channel that the investigators set up -- that participants were to do on their own. Overall, the weekly exercise goal was 150 minutes of moderate to vigorous activity plus 6,000 daily steps. Wrist-worn exercise trackers were provided to allow Andonian and colleagues to monitor patients' heart rate. Twice-weekly resistance training sessions were also included, one of which was a remotely supervised group class.

Mean participant age was about 67, and 80% were women. Disease duration averaged 15 years, with mean body weight of 85 kg. Disease activity as assessed with the 28-joint Disease Activity Score (with C-reactive protein level, DAS28-CRP) averaged 3.0 at baseline. Just over half of patients were taking tumor necrosis factor inhibitors and most were on some type of cardiovascular drug (antihypertensive and/or statin).

Both groups saw improvement in MMSc scores over the 16-week study period: by 1.34 points in the control group and 1.67 points with the intervention; the difference was not statistically significant. But the intervention was associated with significantly greater improvement on body composition measures including total weight, BMI, fat mass, and waist circumference. For example, mean BMI in the control group declined 0.9 points versus 1.8 points in the intervention group; mean waist circumference shrank by 1.4 cm and 6.4 cm, respectively.

Little difference between the programs was seen for cardiorespiratory fitness and muscle strength (perhaps because 16 weeks was not sufficient to show clear separation), but tender joint counts and DAS28-CRP values both improved more in the intervention group:

• Tender joints: mean decline 1.0 control, 1.7 intervention

• DAS28-CRP: mean decline 0.2 control, 0.8 intervention

Patient-reported measures of overall physical health and function and mental health also showed more improvement with the intervention.

"The comprehensive [intervention] overall demonstrated the powerful ability of a remotely supervised weight loss and exercise intervention to substantially impact a multitude of health markers in older adults with RA and overweight/obesity," Andonian and colleagues concluded.

Limitations to the study included the small number of participants and the limited study duration. Patients were not followed beyond the 16-week primary period to determine whether the benefits were maintained. Also, the study was conducted during the COVID-19 pandemic, with its unique and wide-ranging impacts on people's behavior.

Andonian and colleagues noted that the improvements seen in the control group exceeded their expectations. As well, participants weren't blinded to their assignments and the intervention might have had an "enhanced placebo effect," the researchers acknowledged.

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