Obesity, Smoking Tied to Higher PsA Disease Activity at 1 Year

Obesity and active smoking are independently associated with higher disease activity and lower likelihood of reaching treatment targets at 1 year among patients with psoriatic arthritis (PsA), according to a large registry-based cohort study published in Arthritis Care & Research.¹

The findings, drawn from newly diagnosed patients enrolled in the Dutch South West Psoriatic Arthritis (DEPAR) registry between 2013 and 2023, reinforce growing clinical evidence that modifiable lifestyle factors—not just pharmacologic therapy—shape disease trajectories in PsA.

“Despite pharmacological advances to treat PsA, achieving optimal disease control remains challenging,” the authors explained. “Thus, integrating non-pharmacological interventions into patient care becomes imperative for better disease activity control.”

The findings are particularly relevant given PsA's roots in psoriatic skin disease, which affects patients before joint symptoms emerge. Previous research has shown that higher body mass index (BMI) and active smoking are also associated with worse biologic treatment response in patients with psoriasis, suggesting that lifestyle factors compound the disease burden across multiple dimensions of psoriatic disease.²

How Prevalent Are Lifestyle Risk Factors in PsA?

The study included 938 patients who were newly diagnosed with PsA.¹ The median age was 51 years, and half were women. At baseline, 33% were classified as obese, 38% as overweight, and only 0.4% underweight. Half (51%) of patients had abdominal obesity. Overall, the median BMI of patients was in the overweight range, and the median waist circumference was elevated. Only 3% were classified as physically inactive, though the authors noted that self-reported data may have led to underreporting of inactivity.

Current smoking was reported by 19% of participants, and of those, 40% were considered moderate-to-heavy smokers. Heavy alcohol consumption was also prevalent—while 72% reported consuming alcohol, 21% of that cohort was classified as having heavy alcohol consumption.

Compared with the general Dutch population, patients with PsA showed higher rates of obesity and heavy alcohol use, while smoking rates were similar across groups. That elevated obesity burden has clinical consequences, as obesity is associated with lower retention and response rates to DMARDs in this population, making early identification of at-risk patients a practical priority.³

To capture the cumulative burden of unhealthy behaviors, investigators developed a composite lifestyle risk score from 0 to 5, incorporating abnormal BMI, abdominal obesity, current smoking, physical inactivity, and no alcohol consumption.¹ Higher scores reflected a greater number of co-occurring risk factors.

What the DEPAR Data Revealed About Disease Activity

The study assessed PsA disease activity outcomes at 3, 6, 9, and 12 months of follow-up. In multivariable analyses, each 1-point increment in the lifestyle risk score was associated with meaningfully higher scores on both the PsA Disease Activity Score (PASDAS) and Disease Activity in Psoriatic Arthritis (DAPSA) at 1 year.

Patients with higher scores were also less likely to achieve low disease activity (LDA) by either measure and less likely to reach minimal disease activity (MDA), which is a key treat-to-target end point in PsA management. Patients with at least 3 risk factors had the highest disease activity, while patients with 1 risk factor did not show any significant differences in disease activity measures compared with patients who had no lifestyle risk factors.

When the researchers broke down individual components of the score, obesity and active smoking emerged as the primary drivers. Both general and abdominal obesity were significantly associated with higher disease activity scores and reduced odds of achieving LDA or MDA. Current moderate-to-heavy smoking showed similarly strong associations, with smokers carrying higher PASDAS and DAPSA scores and lower rates of reaching treatment targets. Notably, former smoking and light smoking did not show significant associations with disease activity, suggesting a dose-dependent relationship.

The biological mechanisms may explain the findings: obesity is linked to chronic low-grade systemic inflammation, while smoking promotes inflammatory signaling and may amplify pain perception. Both of these factors compound the underlying inflammatory burden of PsA itself, the authors explained.

In contrast, alcohol consumption and physical inactivity were not significantly associated with disease activity in adjusted analyses, though the low prevalence of inactivity in the cohort limited statistical power to detect meaningful associations.

Why This Matters for Routine PsA Care

The data carry implications beyond the rheumatology clinic. Clinical experts have emphasized that rheumatology practices are often ill-equipped to address weight management directly, representing a structural gap in care delivery for a population where obesity rates are disproportionately high, despite obesity and smoking being well-documented drivers of worse treatment response.⁴ Prior research on metabolic syndrome in PsA has similarly underscored that obesity and related comorbidities are poor prognostic indicators for achieving MDA, even with advanced DMARD therapy.⁵

The DEPAR findings suggest that baseline lifestyle assessment could serve as a practical tool for identifying patients at elevated risk of persistent disease activity. While pharmacologic therapy remains central to PsA management, the authors argued for integrating weight management support and smoking cessation into standard care—a recommendation that also appears in joint clinical guidelines from the American College of Rheumatology and the National Psoriasis Foundation, which conditionally recommend nonpharmacologic interventions, including smoking cessation and weight loss, alongside drug therapy.^1,6

“Future studies that assess lifestyle-related factors longitudinally, either through observational studies or interventions, are warranted to understand how improving these factors impacts PsA disease activity,” the authors concluded. “Evidence on the associations between lifestyle and PsA disease activity provides foundation to incorporate lifestyle modifications into PsA care.”

References

1. Hojeij B, Tchetverikov I, Kok MR, et al. Associations of lifestyle-related factors and psoriatic arthritis disease activity: the Dutch South West Psoriatic Arthritis Study. Arthritis Care Res (Hoboken). Published online May 4, 2026. doi:10.1002/acr.80080

2. Steinzor P. Smoking, age, BMI, previous exposure impact response to biologics for psoriasis. AJMC®. July 24, 2024. Accessed May 13, 2026. https://www.ajmc.com/view/smoking-age-bmi-previous-exposure-impact-biologic-response-in-patients-with-psoriasis

3. AJMC staff. Obesity more common in those with psoriasis alone compared with those with wider disease. AJMC. July 19, 2019. Accessed May 13, 2026. https://www.ajmc.com/view/obesity-more-common-in-those-with-psoriasis-alone-compared-with-those-with-wider-disease

4. Evolving approaches to care in the management of psoriatic disease. AJMC. May 31, 2020. Accessed May 13, 2026. https://www.ajmc.com/view/evolving-approaches-to-care-in-the-management-of-psoriatic-disease

5. Review: patients with psoriatic arthritis have increased rates of metabolic syndrome. AJMC. June 11, 2021. Accessed May 13, 2026. https://www.ajmc.com/view/review-patients-with-psoriatic-arthritis-have-increased-rates-of-metabolic-syndrome

6. Davio K. ACR and NPF unveil new clinical guideline for treating psoriatic arthritis. AJMC. November 8, 2017. Accessed May 13, 2026. https://www.ajmc.com/view/acr-and-npf-unveil-new-clinical-guideline-for-treating-psoriatic-arthritis