Remotely Supervised Weight Loss and Exercise Training to Improve Rheumatoid Arthritis Cardiovascular Risk: Rationale and Design of the Supervised Weight Loss Plus Exercise Training-Rheumatoid Arthritis Trial

Patients with rheumatoid arthritis (RA) remain at an increased risk for cardiovascular disease (CVD) and mortality. RA CVD results from a combination of traditional risk factors and RA-related systemic inflammation. One hypothetical means of improving overall RA CVD risk is through reduction of excess body weight and increased physical activity. Together, weight loss and physical activity can improve traditional cardiometabolic health through fat mass loss, while also improving skeletal muscle health. Additionally, disease-related CVD risk may improve as both fat mass loss and exercise reduce systemic inflammation. To explore this hypothesis, 26 older persons with RA and overweight/obesity will be randomized to 16 weeks of a usual care control arm or to a remotely Supervised Weight Loss Plus Exercise Training (SWET) program. A caloric restriction diet (targeting 7% weight loss) will occur via a dietitian-led intervention, with weekly weigh-ins and group support sessions. Exercise training will consist of both aerobic training (150 minutes/week moderate-to-vigorous exercise) and resistance training (twice weekly). The SWET remote program will be delivered via a combination of video conference, the study YouTube channel, and study mobile applications. The primary cardiometabolic outcome is the metabolic syndrome Z score, calculated from blood pressure, waist circumference, high-density lipoprotein cholesterol, triglycerides, and glucose. RA-specific CVD risk will be assessed with measures of systemic inflammation, disease activity, patient-reported outcomes, and immune cell function. The SWET-RA trial will be the first to assess whether a remotely supervised, combined lifestyle intervention improves cardiometabolic health in an at-risk population of older individuals with RA and overweight/obesity.

Abstract P442: An Innovative, Remotely Delivered Weight Loss and Exercise Intervention to Improve Rheumatoid Arthritis Cardiovascular Risk

Introduction: Despite improvements in pharmacologic management of rheumatoid arthritis (RA), patients with RA continue to have an increased risk for CVD - the leading cause of death in this population. RA CVD results from a combination of traditional risk factors - such as hypertension, dyslipidemia, physical inactivity, and obesity - and RA-related systemic inflammation. Although weight loss and physical activity are promising means for improving both traditional and inflammatory risk factors, evidence is lacking for lifestyle interventions targeting these health behaviors in RA.

Hypothesis: In the SWET-RA trial, we hypothesized that, as compared to standard of care, a 16-week remotely delivered weight loss and exercise intervention would improve CVD risk factors in older persons with RA and obesity.

Methods: Twenty-four patients (age 60-80 years; BMI 28-40 kg/m 2 ) were randomized to one of two groups: 1) supervised weight loss and exercise training (SWET); or 2) counseling health as treatment (CHAT). The SWET intervention - delivered via video conference, the study YouTube channel, and mobile applications - consists of a) dietitian-led caloric restriction diet (7% weight loss goal) with weekly weigh-ins and group support sessions; and b) exercise physiologist-led aerobic (150 min moderate-to-vigorous exercise) and resistance training (twice weekly). CHAT provides initial clinical counseling on healthy diets and physical activity followed by monthly check-ins. Outcomes include body mass; body composition via Air Displacement Plethysmography; peak oxygen consumption [VO 2 (mL/kg/min)] via maximal cardiopulmonary exercise testing; and mean arterial blood pressure (MAP). Within-groups, paired t-tests assessed whether post- minus pre-intervention change scores (mean ± standard deviation) were significant (p<0.05).

Results: To date, 13 patients (61.5% White; 84.6% female) have completed the study; 8 additional patients are expected to complete the study by February 2023. Following the intervention, the CHAT group (n=5) had mean changes in body mass, fat mass, and lean mass of -2.4 ± 4.0%, -3.3 ± 4.3 kg, and 1.0 ± 1.0 kg (all p>0.05). Those randomized to SWET (n=8) had significant improvements in body mass (-5.0 ± 2.9%; p=0.002) and fat mass (-4.3 ± 2.8 kg; p=0.004), and no change in lean mass (0.4 ± 1.2 kg; p=0.36). The CHAT group had a 1.1 ± 6.7% change in peak VO 2 (p=0.81), while the SWET group exhibited a 10.6 ± 16.7% change (p=0.13). There were minimal changes in MAP for both groups (CHAT: -1.0 ± 1.0 mmHg; SWET: -0.4 ± 1.2 mmHg).

Conclusions: Preliminary findings indicate that, as compared to CHAT, the SWET intervention elicits beneficial changes in body mass, fat mass, and cardiorespiratory fitness. As the SWET-RA trial is pioneering a remotely delivered program, results from this study will help guide lifestyle intervention implementation to improve CVD risk in larger groups of patients with RA.

Effects of Amount, Intensity, and Mode of Exercise Training on Insulin Resistance and Type 2 Diabetes Risk in the STRRIDE Randomized Trials

Background

Lipoprotein Insulin Resistance Index (LP-IR) and Diabetes Risk Index are novel spectroscopic multimarkers of insulin resistance and type 2 diabetes risk. As the Studies of a Targeted Risk Reduction Intervention through Defined Exercise (STRRIDE) randomized trials have previously demonstrated the ability of exercise training to improve traditional markers of insulin action, the aim of this study was to examine the effects of exercise amount, intensity, and mode on LP-IR and the Diabetes Risk Index.

Methods

A total of 503 adults with dyslipidemia [STRRIDE I (n = 194), STRRIDE AT/RT (n = 139)] or prediabetes [STRRIDE-PD (n = 170)] were randomized to control or one of 10 exercise interventions, ranging from doses of 8–23 kcal/kg/week; intensities of 50–75% V̇O_2peak; and durations of 6–8 months. Two groups included resistance training and one included dietary intervention (7% weight loss goal). Fasting plasma samples were obtained at baseline and 16–24 h after the final exercise bout. LP-IR, the Diabetes Risk Index, and concentrations of the branched chain amino acids valine and leucine were determined using nuclear magnetic resonance spectroscopy. LP-IR and the Diabetes Risk Index scores range from 0–100 and 1–100, respectively (greater scores indicate greater risk). Paired t-tests determined significance within groups (p < 0.05).

Results

After training, six exercise groups significantly improved LP-IR (ranging from −4.4 ± 8.2 to −12.4 ± 14.1), and four exercise groups significantly improved the Diabetes Risk Index (ranging from −2.8 ± 8.2 to −8.3 ± 10.4). The most beneficial interventions for both LP-IR and the Diabetes Risk Index were low amount/moderate intensity aerobic, aerobic plus resistance, and aerobic plus diet.

Summary

Multiple exercise interventions improved LP-IR and the Diabetes Risk Index. In those with dyslipidemia, adding resistance to aerobic training elicited a synergistic effect on insulin resistance and type 2 diabetes risk. In individuals with prediabetes, combining a dietary intervention and weight loss with aerobic training resulted in the most robust type 2 diabetes risk improvement.