**Background:** Patients with rheumatoid arthritis (RA) have substantially increased cardiovascular disease (CVD) risk and mortality compared with the general population, with over double the risk of CVD hospitalization. Approximately 50% of RA CVD risk is attributable to traditional risk factors (smoking, hypertension, dyslipidemia, impaired glucose handling, overweight/obesity), while the remainder is driven by RA-related systemic inflammation. Although disease-modifying antirheumatic drugs (DMARDs) target inflammation, they carry risks of immune suppression and infection, and CVD persists despite biologic therapy. Overweight/obesity and physical inactivity are highly prevalent in RA and worsen both traditional and inflammatory CVD risk, yet few interventions specifically target these modifiable factors. In non-RA populations, combined weight loss and exercise training produces greater cardiometabolic improvements than either intervention alone, but evidence in RA is lacking.
**Methods:** The SWET-RA trial is a single-blind, randomized controlled trial enrolling 26 adults aged 60-80 years with seropositive (or erosive) RA, BMI 28-40 kg/m², who are not meeting the 2018 Physical Activity Guidelines for Americans and have no absolute contraindications to exercise. Participants are randomized 1:1 to either the SWET intervention or a counseling health as treatment (CHAT) control arm. The SWET intervention is 16 weeks and delivered entirely remotely via video conference (Zoom), a study YouTube channel, and mobile apps (Pattern Health, MyFitnessPal). The weight loss component involves an individualized caloric restriction prescription (500-1000 kcal/day deficit below total energy expenditure) targeting 7% weight loss, with a macronutrient distribution of 40% carbohydrate, 30% fat, and 30% protein. Weekly live group nutrition sessions are led by a registered dietitian. The aerobic training component prescribes 150 minutes/week of moderate-to-vigorous exercise (at 45%-65% VO₂ reserve) plus ≥6000 steps/day, with one weekly live supervised class and one independent session. The resistance training component prescribes two weekly sessions (10-11 exercises targeting major muscle groups, 1-3 sets of 8-15 repetitions) using resistance bands, with one live supervised class and one independent session. The CHAT control receives one-time virtual counseling on healthy diet and physical activity per public health guidelines, with monthly check-in calls. The primary outcome is change in the metabolic syndrome Z score (MSSc), a continuous weighted score of five components: fasting HDL cholesterol, triglycerides, glucose, waist circumference, and mean blood pressure. Secondary outcomes include disease activity (DAS28-ESR/CRP), inflammatory markers (ESR, hs-CRP), immune cell function, body composition (air displacement plethysmography), cardiorespiratory fitness (peak VO₂ by cardiopulmonary exercise test), muscle strength and oxidative capacity, pulmonary function, and patient-reported outcomes (PROMIS measures). Sample size calculations are based on the STRRIDE studies: to detect a between-group MSSc difference of -2.5 (SD 2.1), 20 completers (10 per group) provide 82% power at one-tailed α=0.05. Accounting for 20%-25% attrition, 26 participants will be enrolled.
**Key Results:** This is a study design paper; no results are reported. The trial is ongoing and will assess pre-to-post intervention changes in the primary and secondary outcomes using regression models controlling for baseline MSSc, with intention-to-treat analysis.
**Clinical Implications:** The SWET-RA trial addresses a critical gap by testing whether a remotely delivered, combined lifestyle intervention can improve cardiometabolic health in older adults with RA and overweight/obesity—a population at high CVD risk for whom pharmacologic management alone is insufficient. If effective, the remote delivery model offers scalability and accessibility advantages over in-person programs, potentially enabling broader implementation in rheumatology clinical practice. The findings will provide evidence on whether public health physical activity recommendations (150 min/week aerobic exercise plus resistance training) are appropriate for older RA patients, and whether adding caloric restriction-induced weight loss enhances CVD risk reduction beyond exercise alone. Results could support lifestyle medicine as an adjunctive strategy to DMARD therapy for managing both traditional and inflammatory CVD risk in RA.