Skip to main content
Download PDF

Health-related quality of life significantly improved in obese patients with psoriatic arthritis one year after a structured weight loss intervention

Advances in Rheumatology volume 65, Article number: 13 (2025) Cite this article

Abstract

Objective

In this interventional weight loss study, health-related quality of life (HRQoL), anxiety, depression and fatigue were compared at baseline (BL) and at 12 months (M12) in patients with psoriatic arthritis (PsA) and controls.

Methods

PsA patients (n = 39) between 25 and 75 years of age, with body mass index (BMI) ≥ 33 kg/m2 were included in a weight loss intervention with very low energy diet (VLED) for 12 or 16 weeks depending on BL BMI < 40 or ≥ 40 kg/m2. The 36-item short-form health survey (SF-36) was used to assess HRQoL. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale. Assessments were done at BL, M3, M6 and M12. As controls (n = 39), obese individuals, already planned for VLED treatment were recruited and matched for sex, age and weight to the PsA patients.

Results

In PsA patients, physical HRQoL, as demonstrated by the physical component summary (PCS) of SF-36, improved from median (IQR) 34 (25–45) at BL to 43 (34–50) at M12, p = 0.009. No significant effect on mental HRQoL, demonstrated by the mental component summary (MCS) score, was seen. Similarly in controls, PCS significantly improved (median IQR, 44 (36–50) at BL to 52 (44–55) at M12, p < 0.001), whereas no significant improvement was seen in MCS. Anxiety and depression decreased significantly in both PsA patients and controls.

Conclusions

The weight loss intervention was associated with significant improvements in physical HRQoL, as well as anxiety and depression, in PsA patients and controls.

Trial registration

ClinicalTrials.gov identifier: NCT02917434, registered on September 21, 2016, retrospectively registered.

Key message

• Improved physical HRQoL and reductions in anxiety, and depression were seen in both PsA patients and controls after a weight loss intervention.

Background

Psoriatic arthritis (PsA) is a heterogenous disease characterized by arthritis, dactylitis, enthesitis and in a minority axial disease [1]. PsA is associated with reduced health-related quality of life (HRQoL), depression and anxiety compared with the general population [2, 3]. Obesity is common in PsA and adversely affects HRQoL, anxiety and depression [4,5,6]. Weight loss in obese patients with psoriasis (PsO) has been demonstrated to improve HRQoL [7, 8]. However the effect of weight loss on HRQoL in PsA is to our knowledge largely unexplored, although we have previously reported on positive effects on disease activity in the rheumatic disease and on summary physical aspects of HRQoL and on the health assessment questionnaire (HAQ) twelve months after a structured weight loss intervention with very low energy diet (VLED) in patients with PsA and obesity and matched controls [9]. In this post-hoc analysis we aimed to assess the effect on physical as well as mental HRQoL, anxiety and depression in the same weight loss study.

Methods

Study design and setting

In this secondary analysis of an open prospective interventional weight loss study, obese PsA patients and matched controls were followed up to twelve months. A more detailed description of the method has previously been published [10].

PsA patients

PsA patients were recruited from three hospitals in Western Sweden: the Department of Rheumatology at Sahlgrenska University Hospital, rheumatology units at Alingsås and Borås hospitals. Patients were 25 to 75 years of age, had BMI ≥ 33 kg/m2, and fulfilled the Classification criteria for Psoriatic Arthritis (CASPAR) criteria [11]. Exclusion criteria (patients and controls) were pregnancy, type 1 diabetes, heart disease, epilepsy, porphyria, type 1 diabetes, catabolic disease, severe kidney disease, binge eating disorder, current treatment with lithium/warfarin/phenytoin, or having mental imbalance affecting participation or previous stroke, myocardial infarction or major surgery/trauma the last three months, or having been treated for cancer during the last five years. Treatment with conventional synthetic or biologic disease-modifying anti-rheumatic drugs were held constant from three months before BL to M6.

Controls

Recruitment was done from the Regional Obesity Center at Sahlgrenska University Hospital. Obese individuals that were already planned to receive treatment with VLED, were matched for sex, age and weight to PsA patients. In addition to the exclusion criteria previously mentioned, those having a diagnosis of PsA, PsO, or any inflammatory rheumatic disease were not eligible for the study.

Dietary intervention

Patients and controls were given VLED (containing 640 kcal/day) (Cambridge Weight Plan Limited, Corby, UK) during 12 (if BMI < 40 kg/m2) or 16 (if BMI ≥ 40 kg/m2) weeks. Thereafter, solid foods were gradually reintroduced during 12 weeks. Participants were given personalised energy-restricted dietary advice by dietitians and brief support for physical activity. In agreement with the routines for structured weight loss treatment, all participants were followed at the Regional Obesity Center for 12 months.

Survey and physical assessments

PsA patients were followed at the Rheumatology unit at Sahlgrenska University Hospital at BL, after three, six, and twelve months. The controls were followed using a similar protocol. Body height and weight were measured, and BMI was calculated. In PsA patients, joints (66/68 swollen/tender joints count) were assessed and the DAPSA score was calculated [12]. Activity limitations (Health Assessment Questionnaire (HAQ)) [13] were assessed. The patients’ disease activity was assessed with visual analogue scales (VAS) for global disease activity, pain and fatigue. The 36-item short-form health survey (SF-36) was used to assess HRQoL [14]. The SF-36 contains 36 items, separated in eight domains: physical functioning, role physical, social functioning, role emotional, mental health, vitality, bodily pain, and general health. The different domains and the component summary scores range from 0 to 100, with higher scores indicating a better health status. The physical and mental component summary (PCS and MCS) scores are frequently used as summary measures. Higher scores on PCS and MCS represent better health and normal values, standardized to the Swedish SF-36 normative population, for PCS and MCS are (mean ± sd) 50 ± 10, where a value below 50 represents worse health status than the general population. The SF-36 has been validated for use in PsA [15]. The Hospital Anxiety and Depression Scale (HADS), consisting of 14 assumptions, seven relating to anxiety and seven relating to depression [16], was used to assess anxiety and depression. Answers are given on a scale from 0 to 3 for each assumption. A score of ≧ 8 points for anxiety or depression are considered clinically relevant.

Statistical analyses

Descriptive statistics were reported as numbers (%), median and interquartile range (IQR). The Mann-Whitney U test was used for between group comparisons of continuous variables. For categorical variables, the chi-square test was used. Wilcoxon Signed Rank Test was used for comparing continuously related samples. Two-tailed tests were used. A p-value ≤ 0.05 was considered statistically significant. Statistical analyses were done using SPSS Statistics version 29 (IBM, Chicago, USA).

Ethics

All participants provided written informed consent. The Regional Ethics Committee in Gothenburg (approval number 901‐15) approved the study. ClinicalTrials.gov identifier: NCT02917434, registered on September 21, 2016, retrospectively registered.

Results

Baseline

In total, 39 PsA patients (median age 55 (IQR 48–62) years; 64% women) and 39 controls (median age 56 (IQR 48–60) years; 74% women) were followed up until M12. There were no significant differences in height or weight comparing PsA patients and controls (Table 1). BMI was however lower in the PsA patients, 35.2 (IQR 33.9–37.9) kg/m2 compared with the controls, 38.5 (37.0-41.7) kg/m2, p < 0.001. In PsA patients the median DAPSA score at BL was 15.3 (6.6–29.1) indicating moderate disease activity, and the majority (35/41, 85%) of PsA patients had peripheral disease. Sixteen (41%) reported use of biologic-DMARDs and approximately half (17/39, 43.6%) reported use of conventional synthetic DMARDs with no biologic DMARD. SF-36 PCS scores were significantly better in controls compared to PsA patients, whereas no differences in MCS, HADS anxiety and HADS depression were observed.

Table 1 Baseline characteristics of PsA patients and controls
Full size table

BL to M12 in PsA patients

In PsA patients, BMI was reduced from 35.2 (IQR 34.3–37.9) at BL to 30.5 (28.0-32.9) at M12. HAQ, VAS scales (global disease activity and fatigue) and DAPSA improved significantly comparing BL and M12 (Table 2). For SF-36 scales, significant improvements were noted in physical domains and consequently PCS (34 (25–45) at BL to 43 (34–50)) at M12, p = 0.009), whereas mental domains and MCS were numerically although not significantly improved comparing BL and M12 (Table 2; Fig. 1). HADS was reduced from already low levels at BL, median (IQR) (3 (1-7) for anxiety and 2 (1-7) for depression to 2 (1-7.5), p = 0.045 and 1 (1-4), p = 0.045, respectively.

Table 2 Baseline and M12 comparisons in PsA patients and controls
Full size table
Fig. 1
figure 1

Summary scores (median) for SF-36 at baseline (BL) and month 12 (M12) in PsA patients and controls. PsA patients are marked in blue. Controls are marked in dark red. MCS, Mental component summary, PCS, Physical components summary

Full size image

BL to M12 in controls

In controls, BMI was reduced from 38.5 (36.8–41.7) at BL to 32.6 (30.3–34.8, p < 0.001) at M12 (Table 2). In parallel to PsA patients, significant improvements in SF-36 physical subscales (except for bodily pain) and consequently PCS, median (IQR) 44 (36–50) to 52 (47–56), p < 0.001, were seen at M12, whereas non-significant improvements were seen in mental subscales and MCS at M12 (Table 2; Fig. 1). Similarly, as in PsA patients, HADS was reduced from low levels at BL to M12. Median (IQR) for anxiety: 5 (2-8) at BL to 2 (1-5) at M12, p = 0.002. Corresponding numbers for depression were: 3 (1.3–5.8) at BL to 2 (0.3–3.8) at M12, p = 0.002.

Discussion

In this study, we show positive effects of weight loss on physical HRQoL, anxiety, depression, and fatigue in patients with PsA and obesity and matched controls. Similarly, others have reported positive effects on HRQoL in a smaller study of ten patients with PsO and obesity following weight loss through bariatric surgery [7] and in a study with 60 men with PsO and obesity following a low-energy diet for 12 weeks [8]. Obesity in PsA is associated with increased disease activity [17], which in turn is associated with increased levels of depression, anxiety and worse HRQoL [18, 19]. The improvements in physical but not mental HRQoL is in line with what has previously been reported in a systematic review and meta-analysis, although not specifically assessing PsO or PsA patients [20]. In our study, patients and controls reported no clinically significant signs of anxiety or depression (HADS below the cut-off score of eight) at BL. The small improvement that was reported at the M12 follow-up for PsA patients and controls may be of limited clinical significance, although anxiety and depression is common in PsA. While limited by a small sample size, this study shows the positive effects on HRQoL that can be achieved by weight loss and support for physical activity in obese PsA patients.

Data availability

Data is available upon reasonable request.

Abbreviations

BMI:

Body mass index

DAPSA:

Disease activity in psoriatic arthritis

DMARD:

Disease modifying anti rheumatic drug

HADS:

Hospital anxiety and depression scale

HAQ:

Health assessment questionnaire

M:

Month

PsA:

Psoriatic arthritis

PsO:

Psoriasis

SF-36:

Medical outcomes study 36-item short-form health survey

VAS:

Visual analogue scale

References

  1. Ritchlin CT, Colbert RA, Gladman DD. Psoriatic arthritis. N Engl J Med. 2017;376(10):957–70.

    Article  PubMed  Google Scholar 

  2. Salaffi F, Carotti M, Gasparini S, Intorcia M, Grassi W. The health-related quality of life in rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis: a comparison with a selected sample of healthy people. Health Qual Life Outcomes. 2009;7:25.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Geijer M, Alenius GM, André L, Husmark T, Larsson PT, Lindqvist U, et al. Health-related quality of life in early psoriatic arthritis compared with early rheumatoid arthritis and a general population. Semin Arthritis Rheum. 2021;51(1):246–52.

    Article  PubMed  Google Scholar 

  4. Husted JA, Thavaneswaran A, Chandran V, Gladman DD. Incremental effects of comorbidity on quality of life in patients with psoriatic arthritis. J Rheumatol. 2013;40(8):1349–56.

    Article  PubMed  Google Scholar 

  5. Gok K, Nas K, Tekeoglu I, Sunar I, Keskin Y, Kilic E, et al. Impact of obesity on quality of life, psychological status, and disease activity in psoriatic arthritis: a multi–center study. Rheumatol Int. 2022;42(4):659–68.

    Article  CAS  PubMed  Google Scholar 

  6. Freites Nuñez D, Madrid-García A, Leon L, Candelas G, Núñez M, Bello N, et al. Factors associated with Health-Related quality of life in psoriatic arthritis patients: A longitudinal analysis. Rheumatol Therapy. 2021;8(3):1341–54.

    Article  Google Scholar 

  7. Farias MM, Achurra P, Boza C, Vega A, de la Cruz C. Psoriasis following bariatric surgery: clinical evolution and impact on quality of life on 10 patients. Obes Surg. 2012;22(6):877–80.

    Article  CAS  PubMed  Google Scholar 

  8. Ismail AMA, Saad AE, Draz RS. Effect of low-calorie diet on psoriasis severity index, triglycerides, liver enzymes, and quality of life in psoriatic patients with non-alcoholic fatty liver disease. Reumatologia. 2023;61(2):116–22.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Bilberg A, Larsson I, Björkman S, Eliasson B, Klingberg E. The impact of a structured weight-loss treatment on physical fitness in patients with psoriatic arthritis and obesity compared to matched controls: a prospective interventional study. Clin Rheumatol. 2022;41(9):2745–54.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Klingberg E, Björkman S, Eliasson B, Larsson I, Bilberg A. Weight loss is associated with sustained improvement of disease activity and cardiovascular risk factors in patients with psoriatic arthritis and obesity: a prospective intervention study with two years of follow-up. Arthritis Res Ther. 2020;22(1):254.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006;54(8):2665–73.

    Article  PubMed  Google Scholar 

  12. Schoels M, Aletaha D, Funovits J, Kavanaugh A, Baker D, Smolen JS. Application of the DAREA/DAPSA score for assessment of disease activity in psoriatic arthritis. Ann Rheum Dis. 2010;69(8):1441–7.

    Article  PubMed  Google Scholar 

  13. Fries JF, Spitz P, Kraines RG, Holman HR. Measurement of patient outcome in arthritis. Arthritis Rheum. 1980;23(2):137–45.

    Article  CAS  PubMed  Google Scholar 

  14. Ware JE Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473–83.

    Article  PubMed  Google Scholar 

  15. Husted JA, Gladman DD, Farewell VT, Long JA, Cook RJ. Validating the SF-36 health survey questionnaire in patients with psoriatic arthritis. J Rheumatol. 1997;24(3):511–7.

    CAS  PubMed  Google Scholar 

  16. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–70.

    Article  CAS  PubMed  Google Scholar 

  17. Højgaard P, Glintborg B, Kristensen LE, Gudbjornsson B, Love TJ, Dreyer L. The influence of obesity on response to tumour necrosis factor-α inhibitors in psoriatic arthritis: results from the DANBIO and ICEBIO registries. Rheumatology (Oxford). 2016;55(12):2191–9.

    Article  PubMed  Google Scholar 

  18. McDonough E, Ayearst R, Eder L, Chandran V, Rosen CF, Thavaneswaran A, et al. Depression and anxiety in psoriatic disease: prevalence and associated factors. J Rheumatol. 2014;41(5):887–96.

    Article  PubMed  Google Scholar 

  19. Wervers K, Luime JJ, Tchetverikov I, Gerards AH, Kok MR, Appels CWY, et al. Influence of disease manifestations on Health-related quality of life in early psoriatic arthritis. J Rheumatol. 2018;45(11):1526–31.

    Article  PubMed  Google Scholar 

  20. Warkentin LM, Das D, Majumdar SR, Johnson JA, Padwal RS. The effect of weight loss on health-related quality of life: systematic review and meta-analysis of randomized trials. Obes Rev. 2014;15(3):169–82.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

N/A.

Funding

The study was financed by grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement (ALFGBG-970322 and ALFGBG-966169), the Gothenburg Society of Medicine, Inger Bendix foundation for medical research, Rune and Ulla Amlövs foundation for Rheumatology Research, Stiftelsen Psoriasisfonden, the Swedish Rheumatology Association research grant in collaboration with Roche, the Swedish Rheumatology Association research grant in collaboration with Galapagos/Biopharma, Research and Development Centre Gothenburg and Södra Bohuslän. The sponsors of the study had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; or preparation, review or approval of the manuscript.

Author information

Authors and Affiliations

  1. Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

    Anton J. Landgren, Linda Torres, Mats Dehlin, Lennart T. H. Jacobsson & Eva Klingberg

  2. Region Västra Götaland, Research and Development Primary Health Care, Gothenburg, Södra Bohuslän, Sweden

    Anton J. Landgren

  3. Institute of Neuroscience and Physiology, Section of Health and Rehabilitation, Physiotherapy, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

    Annelie Bilberg

  4. Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden

    Björn Eliasson & Ingrid Larsson

  5. Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

    Ingrid Larsson

  6. Department of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden

    Annelie Bilberg, Linda Torres, Mats Dehlin & Eva Klingberg

Authors
  1. Anton J. Landgren
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Annelie Bilberg
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Björn Eliasson
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Linda Torres
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Mats Dehlin
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Lennart T. H. Jacobsson
    View author publications

    You can also search for this author inPubMed Google Scholar

  7. Ingrid Larsson
    View author publications

    You can also search for this author inPubMed Google Scholar

  8. Eva Klingberg
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

AJL participated in interpretation of data and was responsible for statistical analyses and drafting of the article. AB participated in the study design, recruitment and examination of patients, collection, analysis and interpretation of data. BE participated in the study design, recruitment and examination of patients, collection and interpretation of data and was responsible for the weight loss treatment and follow-up. LT participated in interpretation of data and drafting of the article. MD participated in interpretation of data and drafting of the article. LTHJ participated in interpretation of data and drafting of the article. IL participated in the study design, recruitment and examination of patients, collection and interpretation of data and was responsible for the weight loss treatment and follow-up. EK was responsible for the study design, recruitment of patients, rheumatologic evaluations, data collection, interpretation of data and participated in drafting of the article. All authors have critically reviewed the manuscript, approved the final version to be published and agreed to be accountable for all aspects of the work.

Corresponding author

Correspondence to Anton J. Landgren.

Ethics declarations

Ethics approval and consent to participate

All participants gave written informed consent. The Regional Ethics Committee in Gothenburg (approval number 901‐15) approved the study.

Consent for publication

Yes.

Clinical trial number

ClinicalTrials.gov identifier: NCT02917434, registered on September 21, 2016, retrospectively registered.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Landgren, A.J., Bilberg, A., Eliasson, B. et al. Health-related quality of life significantly improved in obese patients with psoriatic arthritis one year after a structured weight loss intervention. Adv Rheumatol 65, 13 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s42358-025-00444-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s42358-025-00444-9

Keywords

Advances in Rheumatology

ISSN: 2523-3106