Review paper Reumatologia 2023; 61, 4: 318–325

DOI: https://doi.org/10.5114/reum/170401

Obesity in rheumatological practice

Jarosław Kozakowski ID , Piotr Dudek ID , Wojciech Zgliczyński ID

Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland

Abstract
Obesity is a chronic disease that leads to the development of secondary metabolic disturbances and
diseases and strongly contributes to increased morbidity and mortality. On the other hand, musculo-
skeletal disorders are currently the main cause of disability and the second most frequent reason for
visits to the doctor. Many studies clearly show that excessive body weight adversely affects the course
of almost all musculoskeletal system diseases, from osteoarthritis, through metabolic, systemic con-
nective tissue, to rarely diagnosed diseases. The impact of increased fat mass on the musculoskeletal
system is presumably complex in nature and involves the influence of biomechanical, dietary, genetic,
inflammatory and metabolic factors.
Due to the epidemic nature of obesity and its serious health consequences, this disease requires ener-
getic treatment. It is always based on lifestyle modification enriched, if necessary, by pharmacological
and, in justified cases, surgical treatment.
Key words: obesity, osteoarthritis, osteoporosis, musculoskeletal system.

Introduction problems is difficult to establish for many conditions,

there is abundant scientific evidence on the role of
Obesity is defined as a chronic disease associated obesity in the etiology of locomotor system diseases.
with abnormal or excessive fat accumulation that leads On the other hand, it has also been proved that early
to the development of secondary serious metabolic therapeutic intervention based on lifestyle modifica-
disturbances and diseases. Excessive body weight has tion, supported with pharmacotherapy of obesity, can
become a major public health problem especially in de- make a substantial difference in most musculoskeletal
veloped and developing countries. According to a World symptoms.
Health Organization (WHO) report more than 1 billion Through this review we attempt to provide a con-
people worldwide are obese – 650 million adults, 340 cise but comprehensive resource for approaching the
million adolescents and 39 million children [1]. In Poland rheumatological aspects of obesity, and provide guid-
in 2020, 54% of inhabitants were overweight. The preva- ance on how to manage patients who are comorbid for
lence of obesity was estimated at 10% [2]. some musculoskeletal diseases and obesity.
Increased body mass index (BMI) has been identified
as a risk factor for the symptoms of musculoskeletal sys-
Method
tem disorders. These disorders may trigger pain, affect
joint mobility, lead to postural changes and contribute to We searched PubMed (Medline) for English and
physical incapacities and reduced quality of movements. Polish language articles on the associations between
Currently musculoskeletal disorders are the main causes musculoskeletal disorders and obesity, using the search
of disability and pain worldwide, especially in industrial- terms “musculoskeletal disorders”, “osteoporosis”, “os-
ized regions [3]. teoarthritis, “back pain”, “fibromyalgia”, “rheumatoid
Although a causative relationship between excess arthritis”, “systemic lupus erythematosus”, “obesity”,
body weight, particularly fat mass, and musculoskeletal and “overweight”. We tried to extract clinical and pro-

Address for correspondence:

Jarosław Kozakowski, Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, 80 Cegłowska St.,
01-809 Warsaw, Poland, e-mail: [email protected]
Submitted: 05.03.2023; Accepted: 03.08.2023

Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0)

Obesity in rheumatological practice 319

spective cohort studies of sufficient size reporting well Epidemiology

documented data. We reviewed these publications and
The WHO estimates that 1 billion people worldwide
relevant references in these papers and formulated our
are obese – 650 million adults, 340 million adolescents
conclusions.
and 39 million children. This number is still increasing.
The WHO anticipates that by 2025, approximately 167
Results million people – adults and children – will become less
Definition and diagnosis of overweight healthy because their body weight is too high [1].
and obesity In Poland in 2020 54% of inhabitants were over-
weight, more often men (64%) than women (46%).
According to the definition of the World Health Or-
The prevalence of obesity (BMI ≥ 30) was estimated at
ganization, overweight and obesity are considered as
10% (12% among men and 8% among women). Exces-
abnormal or excessive fat accumulation that presents
sive body weight among school-aged children and youth
a risk to health [1].
aged 11–16 has risen in recent years (more in boys than
Scientific societies consistently describe obesity as
a chronic disease characterized by excessive accumu- in girls) to 16.5%. During the COVID-19 pandemic period,
lation of body fat, increasing the risk of many meta- between spring and autumn 2020, 28% of Poles aged
bolic disturbances and secondary disorders, including 20 or older (28% of men 29% of women) reported an in-
cardiovascular and neoplastic diseases [4]. crease in their body weight [2].
Due to the location of excess body fat, gynoid (ilio-
gluteal) and abdominal (central, visceral) types Etiology
of obesity are distinguished. Especially the latter leads Obesity in most cases is of primary nature. It means,
to the development of insulin resistance and further that it develops under the influence of environmental
metabolic disturbances – glucose intolerance, dyslip- factors that overlap the underlying genetic background.
idemia, as well as many diseases, including T2DM, More than 400 genes that may be involved in excessive
asthma, chronic obstructive pulmonary disease, sleep accumulation of fat have been described. Among the en-
apnea syndrome, hypertension and other cardiovas- vironmental factors associated with the over-abundant
cular diseases, gastroesophageal reflux, non-alcohol- fat gain the reduction of physical activity and hyperca-
ic fatty liver, various types of cancers, hypogonadism, loric diet with meals rich in saturated fats, cholesterol,
polycystic ovary syndrome, infertility, depression, and and simple carbohydrates, but poor in polyunsaturated
musculoskeletal disorders [5]. fatty acids and fiber are considered to be the most im-
Obesity diagnosis is based on the assessment BMI, portant.
which is calculated by dividing the body weight (in kg) A major role is attributed to proper nutrition during
by the square of height (in m). The normal BMI is 18.5– fetal life. Among newborns with low birth weight, child-
24.9 kg/m2. Values from 25.0 to 29.9 kg/m2 indicate hood obesity and cardiovascular diseases later in adult-
overweight (pre-obesity state), from 30.0 to 34.9 kg/m2 hood are significantly more common [8]. Also, an associ-
obesity class I, from 35.0 to 39.9 kg/m2 obesity class II, ation between high levels of birth weight and increased
and values from 40.0 kg/m2 indicate obesity class III (se- odds of obesity among older children and adolescences
vere, morbid). was found [9].
In everyday practice additional measurement of Secondary obesity may be the result of endocrine
the abdomen circumference is highly recommended. disorders (hypercortisolemia, hypothyroidism, hypo-
For men, a waist circumference below 94 cm is “low
gonadism, growth hormone deficiency), the effects
risk”, 94–102 cm is “high risk” and more than 102 cm
of certain drugs (phenothiazine derivatives, H1-receptor
is “very high”. For women, values of low, high and very
antagonists, oral contraceptives, antidepressants, antie-
high risk are 80 cm, 80–88 cm and more than 88 cm, re-
pileptic drugs, antidiabetic drugs, glucocorticosteroids,
spectively. These are the guidelines for people of white
β-blockers) and less often other causes [10].
European, black African, Middle Eastern and mixed or-
igin [6].
Obesity and the musculoskeletal system
According to a new definition of metabolic syn-
drome proposed in 2020 by nine Polish scientific soci- Disorders and diseases of the musculoskeletal sys-
eties, waist circumference from 88 cm in women and tem that could be affected by obesity include:
104 cm in men is an essential criterion in diagnosis of • osteoarthritis,
this syndrome [7]. • back pain,
• low bone mass (osteopenia, osteoporosis),

Reumatologia 2023; 61/4

320 Jarosław Kozakowski, Piotr Dudek, Wojciech Zgliczyński

• diffuse idiopathic skeletal hyperostosis (Forestier’s Higher leptin levels both in serum [20] and synovial
disease), fluid [21] in severe osteoarthritis have been found. Also,
• postural instability, a relationship has been identified between the levels of
• soft tissue diseases (e.g. carpal tunnel syndrome, this adipokine and the severity of joint lesions, including
plantar fasciitis), cartilage damage [22]. Likewise, it has been demonstrat-
• gout, ed, that an important role is played by chronic subclin-
• fibromyalgia, ical inflammation caused by increased activity of other
• connective tissue diseases (rheumatoid arthritis, cytokines: tumor necrosis factor α (TNF-α) or interleu-
systemic lupus erythematosus and others) [11]. kin-6 (IL-6) [23]. Levels of these proteins are proportional
Osteoarthritis is the most common skeletal disease. to the severity of pain. Moreover, the higher they are,
Numerous epidemiological studies indicate that there the less effective is the analgesic treatment [24].
is a clear relationship between BMI and the severity Other cells – neutrophils, eosinophils, and dendrit-
of degenerative changes, assessed both clinically and by ic cells are also involved in the pathogenesis of osteo-
X-ray examination [12, 13]. Also studies with magnetic arthritis, although their function has not been fully re-
resonance imaging (MRI) have shown a correlation be- solved. The interplay between a variety of immune cells
tween body weight and the degree of articular cartilage and other cells that reside in the articular joints may
damage [14]. It has been calculated that the odds ratio constitute a vicious cycle, leading to pathological chang-
(OR) for the development of degenerative knees chang- es of the articular joint in obese individuals [25].
es with an increase in BMI by 5 units is 1.6 [15]. Studies Another common health problem is back pain. Ex-
of twins have shown that already an increase in body cessive body weight appears to promote greater ex-
weight by 1 kg increases the risk of radiological changes posure to radicular pain and neurological symptoms.
in the knee and metacarpal joints [16]. Particularly, chronic pain seems to be associated with
The influence of obesity on the development of os- an increase in BMI [26, 27]. Research using MRI in
teoarthritis involves the participation of many factors, a group of physically working middle-aged men showed
both of mechanical and metabolic nature. Joints, es- that overweight/obesity is associated with a decrease in
pecially weight-bearing (hip and knee) are constantly the signal from the intervertebral discs, although it has
subjected to mild damage through motions. It causes not been established to what extent this affects clinical
a state of persistent wound healing and repair process- symptomatology [28].
es. As a result, the articular cartilage and neighboring There are several potential mechanisms of the rela-
bone must continually rebuild where synthesis and deg- tionship between excess body weight and back pain.
radation are a constant process [17]. Obesity may increase the mechanical load on the spine
This mechanical effects of obesity on joints may de- by causing a higher compression on the lumbar spine
pend on the arrangement of bone structures. For exam- structures. Individuals with high body weight are more
ple, the clawed position of the femurs intensifies the ef- predisposed to injuries [29]. Moreover, systemic inflam-
fect of excessive body weight on the knee joints, while mation and pathomechanical pathways associated with
in the valgus setting, obesity is not so important [18]. obesity may play a role in etiology of back pain [30].
The element of movement should also be taken into ac- A recent systematic review of twin studies revealed
count. Under physiological conditions, the pressure on that overweight or obese individuals are more likely to
the cartilage of the knee joints during walking increases have low back pain and lumbar disc generation, but
about three times. When running or climbing stairs, this the associations were weaker after controlling for famil-
pressure increases 6–10 times. It is clear that in the case ial factors, suggesting that obesity and low back pain
of obesity, such burdens must be particularly destruc- share common genetic risk factors [31]. In obese pa-
tive [19]. tients, the possibility of adipose tissue expansion within
While the mechanical component was believed to the dura mater, which may narrow the lumen of the spi-
be the main cause of osteoarthritis recent studies have nal canal has also been found [32].
proven that other factors such as adipose deposition, Numerous observations indicate the relationship
insulin resistance, and especially the improper coordina- between BMI and bone mass. It has even been calcu-
tion of innate and adaptive immune responses may lead lated that an increase in body weight by 10 kg is asso-
to the initiation and progression of obesity-associated ciated with an increase in bone mineral density (BMD)
destruction of the joints. Multi-type inflammatory cells, by 1% [33]. This is, in part, the result of more intense
especially macrophages that produces pro-inflammato- androgen aromatization in a greater amount of adipose
ry cytokines are recruited into the synovial fluid and play tissue with a subsequent increase in levels of estrogen
important role in pathological changes in the joints. – hormones that are crucial for maintaining bone mass.

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Obesity in rheumatological practice 321

A mechanical effect – increase of the pressure forces sis are also play important role [36]. These findings are
on the bone in conditions of greater body weight also confirmed by epidemiological studies, e.g. observation
comes into play. Apoptosis of osteoblasts is then inhib- of a group of older men (Osteoporotic Fractures in Men
ited, while the proliferation and differentiation of these Study) showed that an increase in BMI did not protect
cells and of osteocytes are stimulated due to activation against bone fractures [38].
of the Wnt/β-catenin system as well as to inhibition It is also well known that patients with T2DM, usu-
of PPARγ receptor expression [34]. ally overweight or obese, are more inclined to bone frac-
Moreover, it is believed that there is a close relation- tures, despite normal or even higher BMD compared
ship between regulation of the whole body’s energy to healthy controls [39]. The higher incidence of frac-
balance and bone homeostasis in the central nervous tures also results from the enhanced tendency to falls
system (CNS). Such integration may function owing to among obese and especially elderly (> 60 years of age)
many mediators, including leptin and adiponectin of ad- persons.
ipose tissue origin. Also, proinflammatory cytokines re- There are many reasons for this effect. One of them
leased from this tissue that is altered in obesity, such is the most frequent occurrence of serious diseases,
as TNF-α, interleukin-1 (IL-1) or IL-6 are important medi- such as T2DM, cardiovascular diseases, arthritis, sleep
ators of osteoclast differentiation and bone resorption. apnea syndrome and others leading to a general dete-
The adverse effects of a high-fat diet on the absorp- rioration of health. These diseases, especially diabetes,
tion of calcium from the gastrointestinal tract should lead to further complications such as peripheral neurop-
also be taken into consideration. This is all the more athy, disruption of autonomic nervous system function
important because hypovitaminosis D is usually found or orthostatic hypotension, contributing to instability.
in obesity, what worsening the absorption of substrates Excessive body weight makes it difficult to perform ev-
necessary for bone formation from the gastrointestinal eryday activities – climbing stairs, washing, etc., which
tract. further increases the risk of falls. Finally, obesity chang-
There is evidence to suggest that the relationship es the statics of the whole body (increase in pressure
between body weight and bone mass is in fact bidirec- on the heel part of the foot), again leading to poor bal-
tional: not only does the former determine the latter, but ance [37]. A higher waist-to-hip ratio is an independent
bone mass may also be one of the factors influencing factor of instability, at least in women [40].
body weight [35]. The mechanism of this phenomenon Much less common than back pain or low bone
has not been fully resolved, but the participation of os- mass is diffuse idiopathic skeletal hyperostosis. Foresti-
teocytes is suspected. It is suggested, that these cells er’s disease is characterized by bone growth in places
may react not only in short-term mode to changes in of tendon attachments, aponeuroses, and joint capsules.
pressure on the bone in the mechanism of the mecha- The lesions are particularly strongly expressed within
nostat, but also in the long-term mode affect the ab- the thoracic vertebrae, where alleged large osteophytes
sorption of energy by the body depending on bone resembling parrot beaks, usually involving several verte-
mass [36]. brae can be seen. Changes are also found within the in-
Although obesity was previously thought to protect ner lamina of the frontal bone. Although the etiology
against osteoporosis and fractures, it is currently known of the disease is not well understood, it has been shown
that the problem is of a much more complex nature. The to be more common in people with a high BMI [41].
protective role of high body weight may be related to Leptin levels in patients with spontaneous hyperostosis
greater muscle mass rather than to gain of fat mass, are higher than in the general population [42].
which in fact is a factor accelerating the decline of BMD. The impact of obesity on the movement mechan-
Moreover, the type of obesity is important – excess fat ics is unfavorable. Excessive body weight causes flat-
in the abdominal cavity is particularly unfavorable, while tening of the natural arches of the feet. As a result,
subcutaneously located fat depots do not adversely af- excessive movement of the hindfoot is marked during
fect bone mass [37]. walking, which leads to excessive abduction of the front
In general, the bone of obese people is more prone to part of the foot. There is also an overload of the joints
fractures compared to their lean counterparts. The rea- of the foot. The whole posture changes – it becomes
sons are the increased fat mass in the bone marrow, less stable, with excessive deviations of the trunk [43].
which accumulates during bone formation, as well as Severe obesity additionally slows down movement, and
higher levels of proinflammatory cytokines released significantly shortens the distance of walking.
from fat tissue, that activate osteoclasts responsible Obesity also adversely affects the structure and
for bone resorption. FTO gene mutations and acceler- functions of soft tissues that are the part of the mus-
ated aging of osteoblasts, responsible for bone synthe- culoskeletal system. Excessive body weight has been

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322 Jarosław Kozakowski, Piotr Dudek, Wojciech Zgliczyński

shown to increase the risk of tendonitis associated with in such cases usually leads to increased mobility and to
work in the upper limbs [44]. High BMI contributes to decrease in the perception of pain by sufferers.
the development of carpal tunnel syndrome – the odds
ratio (OR) in such cases is 2.06 [45]. Also, the higher in- Management of obesity – effects on
cidence of plantar fasciitis is associated with obesity. In musculoskeletal disorders
these cases OR of unilateral inflammation increases to
The epidemic nature of obesity and the serious
5.6 compared to persons with normal BMI [46].
health consequences that it causes (only those related
Excessive body weight is one of the recognized fac-
to the musculoskeletal system are included in the study)
tors in the etiology of gout. A direct relationship between
require an concerted and multipronged approach in
serum uric acid levels and BMI has been found [47].
the management of this disease.
The clearance of uric acid in obesity is reduced.
Many publications show the beneficial effects
Fibromyalgia is a disorder characterized by wide-
of weight reduction in the musculoskeletal system, e.g.
spread musculoskeletal pain accompanied by fatigue,
loss of at least 10% of body weight, coupled with ex-
sleepiness, memory and mood issues. It is believed, that
ercise, is recognized as a keystone in the management
fibromyalgia amplifies painful sensations by affecting
the way that brain and spinal cord process painful and of obese patients with osteoarthritis, and can lead to
nonpainful signals. Although the etiology of this disease significant improvement in symptoms, pain relief, physi-
is not fully understood and probably is complex obesity cal function and health-related quality of life.
is considered as a one of the factors contributing to its Some evidence supports in these cases a low-calorie
development [48]. diet, although it should be kept in mind that such a diet,
The most common systemic connective tissue dis- especially in the elderly, must provide all the essential
ease is rheumatoid arthritis (RA). It has been evidenced, nutrients and recommended daily calcium to reduce the
that one of the risk factors of this severe disease is BMI risk of osteoporosis. In some patients, compliance with
> 30, and that excessive body weight worsens the pa- long-term life-style modification is poor and other ap-
tients quality of life. The role of obesity in RA etiology is proaches, such as pharmacotherapy or bariatric surgery,
not clear, but the elevated secretion of adipokines (leptin, may be a better way to achieve weight loss [55]. It was
visfatin, adiponectin) suggests their role in the mecha- reported recently that a weight loss > 7.5% is required to
nism of chronic inflammation, which is the crucial pro- reduce the risk of total knee replacement in adults with
cess in the course of this disease [49]. overweight or obesity [56].
A recent meta-analysis showed that people with obe- In the case of back pain it has been reported that
sity tend to have higher disease activity scores and low- pain in the cervical and lumbar spine, as well as foot
er response rates for both traditional disease-modifying pain, may disappear after significant weight reduction,
antirheumatic medications and biological drugs [50]. e.g. as a result of lifestyle modification or bariatric sur-
Obesity could also affect the course of systemic lu- gery [57]. However, there is a lack of high-quality trials
pus erythematosus (SLE). Studies have reported a high on the effect of various weight loss programs focused
predominance of obesity in SLE in the range 29–50%. on individuals with low back pain. In fact, there is very
Increase in fat mass through the release of pro-inflam- low-quality evidence on this topic, although compliance
matory cytokines could modify the severity of this dis- is an important barrier to implementation of weight loss
ease and contributes to increased cardiovascular risk. programs [58].
Actually, reports have noted that obese SLE patients Also, the limited quantity of scientific data rules out
have increased gene and protein expression of vari- drawing strong conclusions about the benefit of weight
ous pro-inflammatory cytokines such as interleukin-23 loss in obese patients with fibromyalgia. However, it
(IL-23) and TNF-α [51]. was observed that weight reduction, e.g. as a result of
In fact, obesity is a state of chronic low-grade inflam- lifestyle modification or bariatric surgery, led to reduced
mation, associated with altered immune function and pain perception, clinical improvement, and better qual-
the release of several different adipokines; e.g. elevated ity of life [48]. In another study a significant decrease in
levels of leptin have been detected in SLE patients and it median pain scores (from 9 to 3) in patients with fibro-
is believed that this adipokine could be the connection myalgia was found after bariatric surgery [59].
between obesity and SLE [52, 53]. Although obesity is very common in patients with
Obesity contributes to the progressive disability inflammatory rheumatic diseases (IRDs), of which be-
of patients with the musculoskeletal system disorders. tween 27% and 37% of patients have a body mass index
Persons with disabilities are 2.5 times more likely to be ≥ 30 kg/m2 only a few trials have evaluated the effect
obese than their healthy counterparts [54]. Weight loss of weight loss on arthritis activity.

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Obesity in rheumatological practice 323

One recently published study showed that in pa- cally relevant effects in decreasing pain in patients with
tients with rheumatoid arthritis or psoriatic arthritis knee osteoarthritis or chronic lumbago, although these
with a substantial weight loss of > 10% of body mass, findings require further confirmation in prospective con-
median Disease Activity Score 28 joints score decreased trolled trials. Also, rheumatoid arthritis outcomes appear
by 0.9. This reduction in disease activity resulted in to improve following bariatric procedures. On the other
an increase in the percentage of patients achieving hand, this method of treatment may have deleterious
remission from 6% to 63%. This reduction in disease effects on bone metabolism, and there is a considerable
activity was obtained without intensification of medi- body of evidence showing that this can lead to an in-
cal treatment in 87% of the patients. This case series crease in fracture risk, particularly in patients operated
supports the current evidence that weight reduction has on with malabsorptive techniques [61].
positive effects on the course of the disease and thus
can serve as a non-pharmacological treatment option Conclusions
in obese patients with inflammatory rheumatic diseas-
Obesity is now considered as a chronic disease
es [60].
that is the real “tsunami of the twenty-first century”.
The therapy of obesity always should be individual-
The musculoskeletal system diseases are the first cause
ized, although a reasonable goal may be reducing the
of disability and are the second most common cause
body weight by 5–15% within 6 months with its sub-
of visits to primary care physicians. As has been shown in
sequent maintenance and trying to reduce it further.
many epidemiological and observational studies, exces-
Physician efforts should not be limited to BMI control,
sive body weight is an important risk factor for the on-
but should also consider other health risk factors: blood
set and worsening of many musculoskeletal diseases.
pressure, fasting and post-meal glucose, blood lipids,
The mechanisms underlying relationships between BMI
the degree of disability and finally the quality of life. De-
and these disorders are complex and in many cases are
tailed methods of treatment are specified in the scientif-
still waiting to be fully explained.
ic societies guidelines (in our country the Polish Society
Obesity, due to its epidemic nature and the serious
for the Study on Obesity [PTBO], the Polish Society for
health problems it brings about requires energetic treat-
the Treatment of Obesity [PTLO] and others).
ment, based on lifestyle modification, supplemented,
In general, treatment includes three ways of action:
if necessary, by pharmacological, and in justified cases
1. Lifestyle modification – changing eating habits, es-
surgical treatment.
pecially reducing the amount of calories consumed daily
There is now a lot of scientific evidence on the bene-
(recommended minus 600–700/day in relation to indi-
ficial effects of weight reduction in the musculoskeletal
vidual energy needs) and increasing physical activity.
system.
2. Indications for starting on with pharmacotherapy
are: BMI exceeding 30 kg/m2 or BMI > 27 kg/m2, when
is accompanied by at least one of the complications
The authors declare no conflict of interest.
of obesity (e.g. type 2 diabetes, sleep apnea, osteoarthri-
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