Obesity and Osteoarthritis: Disease Genesis and Nonpharmacologic Weight Management

https://doi.org/10.1016/j.rdc.2008.04.007Get rights and content

The mechanisms by which obesity affects osteoarthritis (OA) are of great concern to osteoarthritis researchers and clinicians who manage this disease. Inflammation and joint loads are pathways commonly believed to cause or to exacerbate the disease process. This article reviews the physiologic and mechanical consequences of obesity in older adults who have knee OA, the effects of long-term exercise and weight-loss interventions, the most effective nonpharmacologic treatments for obesity, and the usefulness and feasibility of translating these results to clinical practice.

Section snippets

Obesity and risk for osteoarthritis development

First documented in 1945 [1], the strong association between obesity and knee osteoarthritis (OA) has been widely verified. Leach and colleagues [2] found that 83% of their female subjects who had knee OA were obese compared with 42% of the control group. In a case-controlled study of 675 matched pairs, Coggon and colleagues [3] determined that the risk for knee OA in people who had a body mass index (BMI) of 30 kg/m2 or greater was 6.8 times that of normal-weight controls. Felson and

Impact of obesity on function and gait

The National Health and Nutrition Examination Survey I and Epidemiologic Follow-up studies revealed that obesity at baseline increased upper and lower body disability across 20 years [5], [9]. More recently, Jenkins [10] found that functional impairment in older adults increased with BMI. In the Cardiovascular Health Study, an adjusted odds ratio of 2.94 for self-reported mobility-related disability was found for those in the highest versus the lowest quintile of fat mass [11].

As body weight

Obesity and inflammation

Obesity is typified by nutrient excess and insulin resistance, which are closely related to the excessive proinflammatory cytokine production seen in chronic inflammation [39]. Nutrient excess produces reactive oxygen species, resulting in oxidative stress that damages cells and triggers an inflammatory response. The increased inflammation blocks the protective action of insulin, which normally stimulates target cells to take up nutrients. Unfortunately, as excessive nutrients are consumed,

Inflammation and osteoarthritis

Because obese individuals have higher concentrations of inflammatory markers, inflammation may contribute to functional limitation and disease progression in those who have OA. Besides direct effects on the joint, inflammatory mediators can affect muscle function and lower the pain threshold. Recent studies confirm that low-grade inflammation plays a pathophysiologic role in OA. One of our earlier studies showed that the inflammatory cytokine interleukin-1 beta, believed to mediate joint

Managing body weight

Given the important influence obesity has in OA pathogenesis, intervening on this modifiable risk is a critically important public health goal. Wadden and colleagues [55], [56] noted that obese individuals have difficulty achieving permanent weight loss. Successful weight loss and maintenance programs involve attention to several factors, including behavioral change strategies, extended treatment, increased hours of intervention contact, adherence to a rigorous diet, exercise, and inclusion of

Exercise interventions

Although patients who have OA commonly avoid activity, physical exercise is an effective nonpharmacologic treatment. Several studies have shown that pain, physical function, and walking distance improve an average of 26%, 31%, and 15%, respectively, with short-term exercise [80], [81]. Furthermore, long-term walking and resistance training programs have made significant, if modest, improvements in self-reported function (1%–11%), slowing the decline in physical function commonly seen in this

Conceptual basis and delivery of the lifestyle intervention

The reciprocal interaction of personal factors (eg, beliefs and values), social influence (eg, support and strain), and physical environment (eg, structure and access to resources) can improve weight loss and fitness by modifying eating and physical activity behaviors [85]. Our clinical trial protocols (FAST, ADAPT, and, currently, Intensive Diet and Exercise for Arthritis [IDEA]) evolved from social cognitive theory, group dynamics literature, and more than 15 years' experience in clinical

The future of behavioral weight-loss interventions

Osteoarthritis Research Society International (OARSI) guidelines recommend a combination of nonpharmacologic and pharmacologic interventions for the treatment of knee OA [91]. In addition to the challenges presented by any weight-loss intervention, the knee OA population's typical age and chronic pain create barriers. Dietary weight-loss trials nevertheless demonstrate significant improvements in pain and function with only a 5% loss, especially if exercise is included as part of the

Translating trial results to clinical practice

The National Institutes of Health (NIH) have identified research on intervention approaches that incorporate primary care practice as a high priority [92]. Patients generally believe that their primary care physician should have a role in weight management [93]. A recent study found that only 42% of obese adults who had visited their health care professional during a 12-month span were advised to lose weight [94]. More disturbing, when either diet or exercise was discussed, a median of 0.7

Summary

Obesity plays an important role through mechanical forces and inflammation in predisposing to OA development. Interventions designed to promote dietary weight loss and exercise in obese people who have OA have demonstrated clinically significant improvements in symptoms and disease risk factors. Dissemination of these pivotal research findings into clinical practice is facing several obstacles that health care practitioners can become more involved in removing to facilitate addressing this

Acknowledgments

The assistance of my colleague Dr. Shannon Mihalko in completing the section entitled Conceptual Basis and Delivery of the Lifestyle Intervention is gratefully acknowledged.

References (97)

  • M.D. Van Loan et al.

    Effect of weight loss on bone mineral content and bone mineral density in obese women

    Am J Clin Nutr

    (1998)
  • I.G. Otterness et al.

    An analysis of 14 molecular markers for monitoring osteoarthritis. Relationship of the markers to clinical end-points

    Osteoarthr Cartil

    (2001)
  • A.J. Hartz et al.

    The association of obesity with joint pain and osteoarthritis in the HANES data

    J Chronic Dis

    (1986)
  • S. Kayman et al.

    Maintenance and relapse after weight loss in women: behavioral aspects

    Am J Clin Nutr

    (1990)
  • R. Christensen et al.

    Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial

    Osteoarthr Cartil

    (2005)
  • R.E. Andersen et al.

    Changes in bone mineral content in obese dieting women

    Metabolism

    (1997)
  • R.E. Andersen et al.

    Relation of weight loss to changes in serum lipids and lipoproteins in obese women

    Am J Clin Nutr

    (1995)
  • W. Zhang et al.

    OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines

    Osteoarthr Cartil

    (2008)
  • S.A. Flocke et al.

    Direct observation and patient recall of health behavior advice

    Prev Med

    (2004)
  • E. Fletcher et al.

    Chronic rheumatic diseases: statistical study of 1000 cases of chronic rheumatism

    Postgrad Med J

    (1945)
  • R.E. Leach et al.

    Obesity: its relationship to osteoarthritis of the knee

    Clin Orthop

    (1973)
  • D. Coggon et al.

    Knee osteoarthritis and obesity

    Int J Obes Relat Metab Disord

    (2001)
  • D.T. Felson et al.

    Weight loss reduces the risk for symptomatic knee osteoarthritis in women. The Framingham Study

    Ann Intern Med

    (1992)
  • J.P. Raynauld et al.

    Long term evaluation of disease progression through the quantitative magnetic resonance imaging of symptomatic knee osteoarthritis patients: correlation with clinical symptoms and radiographic changes

    Arthritis Res Ther

    (2006)
  • L. Kalichman et al.

    Age, body composition, and reproductive indices as predictors of radiographic hand osteoarthritis in Chuvashian women

    Scand J Rheumatol

    (2007)
  • K.R. Jenkins

    Obesity's effects on the onset of functional impairment among older adults

    Gerontologist

    (2004)
  • W.H. Ettinger et al.

    Self-reported causes of physical disability in older people: the Cardiovascular Health Study. CHS Collaborative Research Group

    J Am Geriatr Soc

    (1994)
  • A. Sartorio et al.

    Influence of gender, age and BMI on lower limb muscular power output in a large population of obese men and women

    Int J Obes Relat Metab Disord

    (2004)
  • L.Z. Rubenstein

    Falls in older people: epidemiology, risk factors and strategies for prevention

    Age Ageing

    (2006)
  • Center for disease control and prevention

    State-specific prevalence of obesity among adults—Unites States, 2005

    MMWR Morb Mortal Wkly Rep

    (2006)
  • K. Jadelis et al.

    Strength, balance, and the modifying effects of obesity and knee pain: results from the Observational Arthritis Study in Seniors (OASIS)

    J Am Geriatr Soc

    (2001)
  • N. Austin et al.

    Fear of falling in older women: a longitudinal study of incidence, persistence, and predictors

    J Am Geriatr Soc

    (2007)
  • E.A. Finkelstein et al.

    The relationship between obesity and injuries among U.S. adults

    Am J Health Promot

    (2007)
  • S.P. Messier et al.

    Obesity: effects on gait in an osteoarthritic population

    J Appl Biomech

    (1996)
  • R.C. Browning et al.

    Effects of obesity on the biomechanics of walking at different speeds

    Med Sci Sports Exerc

    (2007)
  • S.P. Messier et al.

    Severe obesity: effects on foot mechanics during walking

    Foot Ankle Int

    (1994)
  • J.D. Chodera et al.

    Footprint patterns during walking

  • D.L. Riddle et al.

    Risk factors for plantar fasciitis: a matched case-control study

    J Bone Joint Surg Am

    (2003)
  • A.P. Hills et al.

    The biomechanics of adiposity—structural and functional limitations of obesity and implications for movement

    Obes Rev

    (2002)
  • A.P. Hills et al.

    Plantar pressure differences between obese and non-obese adults: a biomechanical analysis

    Int J Obes Relat Metab Disord

    (2001)
  • S.C. Wearing et al.

    Musculoskeletal disorders associated with obesity: a biomechanical perspective

    Obes Rev

    (2006)
  • S.C. Wearing et al.

    The biomechanics of restricted movement in adult obesity

    Obes Rev

    (2006)
  • S.C. Wearing et al.

    The impact of childhood obesity on musculoskeletal form

    Obes Rev

    (2006)
  • X.L. Lu et al.

    Biomechanics of articular cartilage and determination of material properties

    Med Sci Sports Exerc

    (2008)
  • I. Kiviranta et al.

    Moderate running exercise augments glycosaminoglycans and thickness of articular cartilage in the knee joint of young beagle dogs

    J Orthop Res

    (1988)
  • M.J. Palmoski et al.

    Joint motion in the absence of normal loading does not maintain normal articular cartilage

    Arthritis Rheum

    (1980)
  • B.M. Nigg

    Biomechanical aspects of running

  • J.G. Paty

    Running injuries

    Curr Opin Rheumatol

    (1994)

    • Cited by (66)

    • The Role of Nutrition in Osteoarthritis: A Literature Review

      2022, Clinics in Geriatric Medicine
      Citation Excerpt :

      The Intensive Diet and Exercise for Arthritis (IDEA) trial has shown that a combined intervention of intensive diet plus exercise had the most significant benefit on improving joint function, relieving pain, reducing knee compressive forces, and alleviating inflammation compared with either diet or exercise alone.51 In clinical practice, successful weight loss and maintenance programs also depend on a series of factors, including behavior change strategies, extended treatment, and increased intervention exposure time, which will enhance long-term adherence to the programs.52 Weight management is one of the key nonpharmacological recommendations in preventing and managing knee or hip OA in several clinical guidelines.53,54

    • The future of deep phenotyping in osteoarthritis: How can high throughput omics technologies advance our understanding of the cellular and molecular taxonomy of the disease?

      2021, Osteoarthritis and Cartilage Open

    • Fibromyalgia and obesity: A comprehensive systematic review and meta-analysis

      2021, Seminars in Arthritis and Rheumatism
      Citation Excerpt :

      The association between excessive body weight and rheumatic diseases has been extensively investigated. Obesity is a major susceptibility factor for knee osteoarthritis (OA) with a risk ratio (RR) of 4.55 (95% confidence interval [CI]: 2.90 – 7.13) [9] and impacts negatively disease progression [10]; furthermore, obesity is associated with a higher risk of developing psoriatic arthritis (PsA) [11] and, to a lesser extent, rheumatoid arthritis (RA) [12] and negatively affect disease activity [13]. Fibromyalgia (FM) is the prototypic painful rheumatic disorder, characterized mainly by chronic widespread musculoskeletal pain, tenderness, sleep disorders, fatigue and cognitive disturbances [14,15].

    • The Role of Bariatric Surgery in the Obese Total Joint Arthroplasty Patient

      2018, Orthopedic Clinics of North America
      Citation Excerpt :

      Obesity has been identified as an independent risk factor for the development of osteoarthritis; excess body weight increases loads at the hips and knees, accelerating cartilage degeneration.12,13 The excess adipose tissue in obese patients acts like an endocrine organ, generating and releasing proinflammatory mediators that may further contribute to articular cartilage damage.14–16 Obese patients are often younger when they are considered for total joint arthroplasty (TJA), and are at increased risk for perioperative complications and readmissions.17–22

    • Treatment of obesity with bariatric surgery

      2018, Encyclopedia of Endocrine Diseases

    • Reductions in knee joint forces with weight loss are attenuated by gait adaptations in class III obesity

      2016, Gait and Posture
      Citation Excerpt :

      Obesity is a primary risk factor for numerous pathologies including knee osteoarthritis (OA) [1–3].

    View all citing articles on Scopus

    Supported by NIH grants 1R01AR052528-01 and M01-RR-0021.

    View full text
    Copyright © 2008 Elsevier Inc. All rights reserved.