Living with rheumatoid arthritis (RA) can make it hard to maintain a healthy weight. Some medications for RA can cause weight gain, and the pain of RA can make it hard to exercise and prepare meals. At the same time, RA can sometimes lead to too much weight loss.

To learn more about the role of weight in RA, myRAteam talked with Dr. Iris Navarro-Millán, a rheumatologist at Weill Cornell Medicine and the Hospital for Special Surgery in New York City. She is a member of the American College of Rheumatology.

The Benefits of Weight Management for RA

Extra weight can aggravate existing RA symptoms. In a study of more than 23,000 people with RA, those who were severely obese — with a body mass index (BMI) of 35 or above — were at greater risk of becoming progressively disabled than those who were overweight (a BMI of 25 to 29).

Dr. Navarro-Millán pointed out that excess weight increases pressure on the joints and escalates joint pain. Previously inflamed joints must deal with extra work. In addition, if you have RA, your joint tissues produce proteins called cytokines, which cause inflammation. Excess fat also produces cytokines, so the more extra weight you have, the more inflammation you might experience on top of what RA already causes.

Maintaining a healthy weight — or even just losing some excess weight — can ease RA symptoms. One study of 174 people with RA found that those who were overweight or obese (a BMI of 25 or above) at the beginning of the study but lost at least 5 kilograms (about 11 pounds) showed improvement in their RA symptoms.

Some myRAteam members agree that intentionally losing weight has helped their RA symptoms. “I wasn’t terribly overweight, but my hips felt like they were giving out on me. I thought losing weight might help,” one member said. “It wasn't easy, especially at my age (67) with RA. However, I persevered with going to the gym and a diet high in vegetables and lean protein. I have lost 25 pounds and I do believe this has helped, especially in my hips and feet.”

Dr. Navarro-Millán notes that some treatments for RA can also lead to weight loss. For example, people who are taking the disease-modifying antirheumatic drug Arava (Leflunomide) often lose weight. The reasons for this are not fully understood, she said.

RA and the Obesity Paradox

Weight loss alone doesn’t necessarily lead to only positive outcomes for people with RA. In fact, several studies have shown that people with RA who have a BMI of 30 or above actually have a lower mortality risk than those with a BMI under 30. In other words, people with RA who are obese seem to live longer than those who are at a normal weight. This puzzling finding is called the obesity paradox.

The solution to the obesity paradox may be found in the progress of RA — specifically, the development of a condition called rheumatoid sarcopenia. In rheumatoid sarcopenia, chronic inflammation causes metabolic hyperactivity, which causes the body to shed muscle mass (the condition is often associated with visible signs of muscle wasting). Meanwhile, the amount of body fat stays stable or even increases.

Some people in this situation don’t see any weight change because the extra fat they gain balances out the lost muscle. However, Dr. Navarro-Millán noted, “Some people with RA are not doing any intentional weight loss program but find that they’re losing weight.” This weight loss can be a sign of metabolic hyperactivity.

Therefore, the “obesity paradox” revealed in studies may actually be caused by formerly overweight or obese people with RA who suddenly dropped to a normal BMI level because of other factors that cause weight loss — and also trigger severe health events. Doctors suggest that BMI may be a poor measurement of overall health risk, since it does not indicate body fat percentage or where fat is located on the body. Different fat locations, such as the belly versus the hips, can have varying effects on health.

It’s important to remember that gradual, intentional weight loss is not linked to the same prognosis as sudden weight loss caused by rheumatoid cachexia (loss of muscle mass and strength). The sudden weight loss and associated symptoms associated with rheumatoid cachexia can be eased through the use of tumor necrosis factor (TNF)-inhibiting medication, which reduces inflammation, and high-intensity strength training, which improves muscle strength and physical functioning.

The Best Diets for Managing Weight With RA

Dr. Navarro-Millán had several suggestions for regulating weight while simultaneously managing RA. In terms of diet, she said, “Start small and work your way towards healthier change. I tell my patients to start with cutting out hamburgers and french fries.”

Once you’ve eliminated unhealthier foods, you can begin to introduce healthier choices. “There is strong evidence coming from Spain regarding the benefits of the Mediterranean diet,” Dr. Navarro-Millán said. “This diet is low in red meat. It has almost no processed meat, bacon, sausages, or hamburgers.”

Dr. Navarro-Millán noted that studies of people with RA found that those who ate at least two portions of about 3.5 ounces of fish per week, predominantly salmon, had lower disease activity from RA than those who did not consume the same amount. These fish contain good fats — monounsaturated and polyunsaturated fats — which lower disease risk in general.

Dr. Navarro-Millán also suggested introducing other foods high in good fats into your diet. “Olive oil is frequently used in the meals of this diet. Remember, these oils should not be heated because heating them can lead to the production of unhealthy cholesterol,” she said. She also recommended legumes. “Legumes include beans and chickpeas. Nuts also contain a lot of healthy fat, and avocado is fantastic in terms of decreasing bad cholesterol and also is good for decreasing belly fat.”

“The strongest data about the Mediterranean diet is that it reduces your risk for heart attack and stroke,” Dr. Navarro-Millán said. People with RA are more likely than the general population to have cardiovascular problems like heart disease, heart attack, and stroke. “The data is more limited for the diet’s direct effect on RA, but people who follow it tend to have better function, less pain, and less inflammation,” she said.

Exercising To Manage Weight With RA

Physical activity is another great way to manage weight. “I would say it's the same for exercise as for diet, start small,” Dr. Navarro-Millán said. “This could mean water therapy, because water therapy is low-impact on your joints. If water therapy is available to you, it’s a good start. You can walk yourself from the pool back to the ground, because you're getting cardiovascular fitness that will also help you with exercises done out of the pool.”

Dr. Navarro-Millán also recommended using a stationary bicycle. “You don't want to use the stationary bike without some level of resistance, because not using resistance can be stressful on the knees,” she said. Once you’ve practiced with water therapy or stationary cycling, you can proceed to walking, although Dr. Navarro-Millán does not recommend running.

She also suggested resistance exercises to build the muscles. “Everybody is different. Some people can exercise with resistance bands, and some people with RA can still lift weights. Listen to your body.”

If you’re wondering where to start with an exercise program that’s right for you and your level of RA, Dr. Navarro-Millán suggested asking your rheumatologist for a referral to physical therapy. “With a physical therapist, you can get an exercise program that you can do at home. You even can do some of these exercises during the commercials while you're watching TV. These exercises are simple and can help with your arthritis without necessarily causing a flare-up.”

Dr. Navarro-Millán noted that some studies have shown that with the right programs, many people with RA do not experience flare-ups from exercising. “The worst exercise is the one that is not done,” she said.

Finding Support for RA

On myRAteam, the social network and online support group for those living with rheumatoid arthritis, members talk about a range of personal experiences and struggles. Weight management is one of the most discussed topics.

Have you explored diet or exercise as a way to balance your weight with RA? Do you have any suggestions for other members on ways to stay healthy? Have another topic you'd like to discuss or explore? Go to myRAteam today and start the conversation. You'll be surprised just how many others may share similar stories.