# The Vicious Cycle of Obesity and Low Back Pain: A Comprehensive Review
## 7 Therapeutic Strategies Targeting the Obesity-LBP Connection  
### Addressing Obesity as a Pathway to Alleviate LBP  
Weight loss, improved dietary habits, and increased physical activity are associated with numerous health benefits [206,207]. Given the established connections between obesity, back pain, and IDD, these interventions hold promise as strategies for prevention and relief. Moreover, for LBP specifically, exercise has been shown to be therapeutic and preventative [208, 209, 210], and direct links have been made with enhanced muscle strength and reduced LBP risk [212]. The high prevalence of physical inactivity among individuals with obesity (often influenced by both physical limitations and motivational challenges) may thus further compound their risk of developing LBP [213,214]. Moreover, although speculative, by reducing mechanical stress on the spine and enhancing spinal stability, weight loss may alleviate pressure and strain on IVDs and vertebral structures [5], while also mitigating systemic and local inflammation--factors implicated in both obesity and IDD [4]. Moreover, the psychological benefits, such as improved mental well-being and self-esteem [215,216], can foster a more active lifestyle conducive to spinal health. Moreover, a poor mental state, such a depression, has been associated with the worsening of pain symptoms [217,218]. Thus, this multifaceted condition underscores a likely beneficial role of lifestyle modifications in managing back pain and promoting spinal health. Given the established link between high BMI and increased risk of LBP, it seems logical to consider body weight control as a strategy for managing or alleviating LBP. However, despite this connection, research on weight control strategies for LBP relief is limited and often lacks quality. The overall evidence supporting weight loss as a method to alleviate chronic LBP remains inconclusive. For example, the 2023 WHO guideline for non-surgical management of chronic primary LBP [43] does not specifically recommend weight loss as a therapy for LBP and even advises against pharmacological weight management, both due to very low certainty of evidence. This recommendation reflects the very weak evidence base linking weight loss to improved pain or function, despite obesity's well-established association with LBP severity. Similarly, a recent systematic review by [PERSON] et al. [219] on weight loss programmes and interventions to alleviate LBP was only able to include 11 trials spanning 689 participants. They similarly concluded \"there is only very low-quality evidence that some weight loss interventions lead to improvements in LBP and disability\" [219]. If we consider the literature, three specific methods to promote weight or fat loss can be distinguished: (1) lifestyle, i.e., changes to calorie and macro-nutrient intake as well as promoting exercise, (2) surgical, e.g., gastric bypass operations, and (3) pharmacological, e.g., Ozempic. (Table 3). Our literature review focusing on human trials that assess the alleviation of back pain or reduction in the proportion of LBP patients through weight loss primarily identified studies involving surgical interventions. (Table 3) These trials typically involved either bariatricsurgery, leading to fat loss through reduced food intake, or abdominoplasty, resulting in an immediate reduction in body weight and fat proportion. Both types of surgical interventions generally showed significant BMI changes in their follow-ups. These BMI changes were often associated with a reduced proportion of LBP patients or clinically significant improvements in LBP scores. Notably, the participants often involved severely obese individuals. Contrarily, trials that promote lifestyle changes, as in requesting participants to adhere to diets, exercise regimes, and/or counselling studies, were often unable to engender significant desirable changes in patients' weight, making assessment of back pain less valuable.