Osteoarthritis (OA) is a prevalent joint disorder, especially among the elderly, that significantly impacts quality of life. Characterized by the deterioration of the entire joint, including articular cartilage injury, low-grade inflammation, and adjacent bone remodeling, OA commonly affects the knee and hip joints, leading to pain, stiffness, and decreased mobility. Obesity stands out as one of the primary risk factors for the onset and progression of OA. Consequently, weight loss is frequently recommended as a strategy to alleviate symptoms and manage this debilitating condition. This article explores the multifaceted effects of weight loss interventions in OA patients, including the potential risks and detriments associated with weight loss, such as weight regain, malnutrition, sarcopenia, joint instability, bone density reduction, and psychoemotional stress.
The Link Between Weight and Knee Pain
Excess weight places additional strain on the knees, leading to chronic pain and increased risk of conditions such as osteoarthritis. Studies have shown that people with obesity have a significantly higher chance of developing knee OA compared to those with a healthy weight. In fact, individuals with grade 2 obesity (BMI of 35-39.9) have a staggering 19.5% chance of developing knee OA. The pressure exerted on the knee joints due to extra weight can result in wear and tear, leading to joint degeneration and inflammation.
Benefits of Weight Loss for Knee Pain
Weight loss has been widely advocated as a strategy to manage the symptoms of knee and hip osteoarthritis. Weight reduction in individuals with OA can alleviate pain, enhance joint function, and potentially delay or prevent the need for surgical interventions.
Maintaining a healthy weight offers numerous health benefits, including:
- Reducing pressure on the knees.
- Decreasing joint inflammation.
- Lowering the risk of various diseases.
For people with overweight, each pound they lose can reduce the load on their knee joint by 4 pounds (1.81 kg). That means if you lose 10 pounds (4.54 kg), there’ll be 40 pounds (18.14 kg) less weight in each step for your knees to support. Less pressure means less wear and tear on the knees and a lower risk of osteoarthritis (OA). According to the American College of Rheumatology/Arthritis Foundation, losing 5 percent or more of your body weight can have a positive effect on both knee function and treatment outcomes.
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Multiple studies show that losing weight results in arthritis pain relief. One 2018 study found that the more weight you lose, the more pain is relieved. The study of overweight and obese older adults with pain from knee osteoarthritis found that greater weight loss resulted in better outcomes than losing a smaller amount of weight. Losing 10 to 20% of your starting body weight can improve pain, function and quality of life better than losing 5% of your body weight.
Understanding the Role of Inflammation
Inflammation plays a key role in the development and progression of OA, and obesity has been shown to contribute to the chronic low-grade inflammation associated with the condition. While osteoarthritis was traditionally considered a wear-and-tear disease, recent research suggests that inflammation may be a risk factor rather than a consequence. Obesity may increase inflammation levels in the body, which may lead to joint pain. Losing weight can reduce this inflammatory response.
Fat is an active tissue that creates and releases inflammatory chemicals into your body. By reducing fat stores in the body, your overall inflammation will decrease. Research indicates that obesity can activate and sustain low-grade inflammation throughout the body. The inflammation can amplify and aggravate painful autoimmune disorders, such as psoriatic arthritis, rheumatoid arthritis and lupus.
Metabolic Syndrome and Osteoarthritis
Obesity is closely linked to various health issues, including type 2 diabetes, cardiovascular disease, and metabolic syndrome. There’s growing evidence that OA may also be part of metabolic syndrome. Following a diet that reduces the risk, which helps slow the progression of metabolic syndrome, may also help with OA.
This includes eating fresh foods that are high in nutrients, with a focus on:
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- Fresh fruits and vegetables, which provide antioxidants and other nutrients
- Fiber-rich foods, such as whole foods and plant-based foods
- Healthy oils, such as olive oil
Foods to avoid include those that:
- Have added sugar, fat, and salt
- Are highly processed
- Contain saturated and trans fats, as these may raise cholesterol levels
The Importance of Exercise
Together with dietary choices, exercise can help you lose weight and reduce the risk of OA.
Current guidelines recommend the following activities:
- Walking
- Cycling
- Strengthening exercises
- Water-based activities
- Tai chi
- Yoga
As well as contributing to weight loss, these can improve strength and flexibility, and they may also reduce stress. Stress can contribute to inflammation, which may worsen knee pain.
Practical Steps for Weight Loss
Here are some other steps you can take to start losing weight.
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- Reduce portion sizes.
- Add one vegetable to your plate.
- Go for a walk after a meal.
- Take the stairs rather than the escalator or elevator.
- Pack your own lunch instead of eating out.
- Use a pedometer and challenge yourself to walk further.
Potential Risks and Considerations of Weight Loss
While weight loss can significantly benefit individuals with knee and hip osteoarthritis, optimising its effectiveness across individual, group, and population levels requires careful consideration of potential risks. Approaching weight reduction in osteoarthritis patients should involve close healthcare supervision to prevent unintended consequences, such as muscle and bone loss, joint instability, malnutrition, and psychoemotional stress linked to frequent weight fluctuations.
Weight Regain
Weight regain after a successful weight loss intervention is a common side effect. Studies have shown that a considerable portion of individuals who lose weight are unable to maintain their weight loss long-term and often regain much of the weight they lost. Furthermore, a recent study highlights the concept of “obesogenic memory”, rooted primarily in stable epigenetic modifications within adipocytes and potentially other cell types. These changes appear to predispose cells to pathological responses in obesogenic environments, offering a possible explanation for the challenging “yo-yo” effect frequently observed with dieting. Studies have demonstrated that sustaining weight loss after an intervention is often challenging, with OA potentially adding an additional layer of difficulty. The success rate of weight loss sustainability varies widely depending on the study and the population being studied. Rates of weight regain are notably elevated within the first year, with the majority of individuals recovering the lost weight within five years. Quality data revealed that individuals who experienced greater initial weight loss tended to regain weight more quickly.
Rapid Weight Loss
Defining the optimal pace of weight loss in individuals with knee and hip osteoarthritis can be a challenging task for patients and healthcare providers. Nevertheless, rapid weight loss can lead to joint instability, muscle weakness, and, paradoxically, increased stress on the affected joints in individuals with knee and hip osteoarthritis.
Malnutrition and Sarcopenia
Knee pain is linked to poor diet quality and malnutrition. Reducing calorie intake in older adults can further lead to suboptimal nutrient intake or even malnutrition, posing a significant risk. As calorie needs decrease with age, the requirement for certain nutrients increases, making nutrient-dense diets crucial. To slow or prevent muscle protein catabolism, protein intake should be maintained or even increased in older individuals restricting calories. However, the potential for underlying impaired function in high-protein diets can be overlooked, adding to the complexity of nutritional management. This highlights the importance of ensuring a high-quality diet through dietary education or counselling to help alleviate knee pain, along with weight management to address imbalances between caloric intake and expenditure. Weight loss also results in decreased muscle mass, which can contribute to muscle weakness and decreased stability of the affected joints. A 12-week weight reduction program resulted in a 10.5% weight reduction, a 6.1% loss of lower extremity muscle mass, and a significant decline in muscle strength. Although body weight-normalised muscle strength remained stable, with slight increases of 1.2% and 1.4%, these findings could be of clinical significance. Strong evidence however exists that individuals with lower levels of quadriceps muscle mass are at an increased risk of developing knee osteoarthritis.
Joint Instability
It is important to note that the impact of weight loss on joint stability in individuals with osteoarthritis can vary greatly depending on individual factors such as age, overall health status, and the severity of osteoarthritis.
Bone Density Reduction
Significant weight loss in older adults can potentially exacerbate bone loss, increasing the risk of osteopenia and osteoporosis, particularly in weight-bearing regions such as the hip.
Psychoemotional Stress
The failure to lose weight to manage knee or hip osteoarthritis can have a significant psychological impact on individuals. In discussing the psychoemotional stress associated with weight loss (over)promotion, it is important to recognise the concept of “slow violence”. This term refers to the gradual, often unnoticed accumulation of harm caused by repeated exposure to weight-loss content, which can have significant emotional and physical impacts. Such exposure can amplify feelings of stress, frustration, and inadequacy, especially in vulnerable individuals struggling with obesity or osteoarthritis. These subtle but persistent pressures may exacerbate mental health concerns like anxiety or depression. The pressure to lose weight can also increase stress levels and exacerbate pain and discomfort. It is important for healthcare providers to recognise and address the psychological impact of weight loss advice on individuals with knee or hip osteoarthritis. This may involve referrals to mental health professionals, support groups, and lifestyle modification programs. Providing resources and support to help individuals manage their physical and mental health can help mitigate the negative psychological consequences of weight loss advice and improve their overall quality of life.
Emerging Anti-Obesity Therapies
Advancements in anti-obesity pharmacotherapy have introduced drugs such as semaglutide, liraglutide, and tirzepatide, which have shown promising results not only in achieving significant weight loss but also in improving OA-related outcomes. A pivotal randomised controlled trial demonstrated that semaglutide led to an average weight reduction of 13.7% over 68 weeks, significantly greater than the 3.2% observed with placebo.
The advent of new anti-obesity therapies represents a paradigm shift in the management of patients with obesity and OA. These therapies not only facilitate significant and sustained weight loss but also potentially address underlying biomechanical and inflammatory pathways contributing to OA progression. Both glucagon-like peptide (GLP)-1 and dual glucose-dependent insulinotropic polypeptide and GLP-1 receptor agonists work by enhancing insulin secretion, delaying gastric emptying, and promoting satiety, which collectively lead to reduced caloric intake and weight loss. A recent meta-analysis demonstrated that these agents can reduce body weight by over 10%, with associated improvements in physical function and quality of life in patients with knee OA. Furthermore, evidence suggests these drugs may lower the risk of OA development in individuals with obesity, likely by mitigating joint overload and systemic inflammation. The long-term use of these therapies could transform the clinical approach to OA by targeting obesity as a modifiable risk factor. By integrating these medications into comprehensive treatment plans, clinicians may not only improve weight-related outcomes but also reduce OA symptoms, delay disease progression, and enhance patient adherence to long-term management strategies.
While weight loss medications offer promising avenues for addressing obesity and OA, it is essential to consider their broader implications on patient psychology and holistic treatment strategies. For instance, the potential for treatment-related adverse effects, discontinuation rates, and the psychological impact of pharmacological weight-loss efforts must be carefully evaluated.
A Holistic Approach to Weight Management
A comprehensive approach to clinical practice is crucial for preventing sarcopenia, osteopenia, osteoporosis, and related complications in elderly individuals with osteoarthritis. Encouraging a diet rich in high-quality proteins supports muscle maintenance and repair, while adequate calcium and vitamin D intake strengthens bone health and reduces fracture risk. Regular physical exercise, including resistance and balance training, improves muscle mass, and joint stability, and reduces the risk of falls. Addressing mental health is equally important, as conditions like depression can exacerbate malnutrition and inactivity. Tailored nutritional guidance to prevent weight fluctuations and mitigate malnutrition ensures that energy needs are met without overburdening compromised joints, promoting overall physical and functional well-being in this population.
A holistic approach and key pillars for balanced weight management in patients with osteoarthritis includes: food intake (ensuring adequate protein, calcium-rich foods, and vitamin D intake), physical activity (engaging in regular exercise and gradual weight loss strategies), and mental health and well-being (fostering social connections, team sports, and sun exposure).
The Importance of Medical Guidance
If you have obesity and OA, a doctor may suggest setting a goal to lose 10 percent of your weight and aiming for a BMI of 18.5-25. This may help reduce knee pain and prevent joint damage from getting worse. Losing weight can also help you manage other conditions that commonly occur as part of metabolic syndrome, such as:
- Type 2 diabetes
- High blood pressure (hypertension)
- Heart disease
Your healthcare provider can help you create a plan to lose weight.
While lifestyle modifications can effectively manage knee pain and promote weight loss, it is crucial to seek medical guidance for a comprehensive approach to pain management. Healthcare providers can help create a personalized treatment plan based on your needs and medical history. They can also provide guidance on appropriate exercises, advise on pain-relief medications, and explore other treatment options if necessary.