85% of physiotherapists look to address a patient’s weight when deemed appropriate, usually via advice that is focused on the importance of weight loss according to (Holden et al., 2019). With experience, these potentially tricky discussions get easier, but the provision of specific guidance is variable. This challenge compounds in cases where weight loss is not the primary reason for a patient’s referral.
The hope for this blog is that physiotherapy colleagues and potentially members of the wider multidisciplinary team have access to evidence based information, provided in a non-complicated format.
It is important to recognise that we are discussing ‘medically induced weight loss’ which should always be discussed by an appropriate healthcare professional. As physiotherapists, we would always promote weight loss alongside exercise and would echo (Holden et al., 2019) sentiment that physiotherapists can play an important role in supporting weight loss whilst optimising treatment outcomes.
Williamson et al. (2015) report that a medically supervised weight loss of 5% is clinically meaningful, other guidelines recommended up to 10%. We know weight loss can have a profound impact upon a spectrum of health-related concerns outside of the MSK system, including but not limited to diabetes prevention, established type 2 diabetes, cardiovascular disease, cardiometabolic risk factors, obstructive sleep apnoea, polycystic ovarian syndrome and infertility, healthcare costs, and mortality. However, as mentioned the focus of this blog is weight loss in relation to MSK disorders, so let’s delve into things a little further.
The National Institute for Health and Care Excellence (NICE) report that the number of people in England with OA is likely to increase because of an ageing population and rising levels of obesity. NICE refers to the work of Arthritis Research UK who projected an increase of 3.8% per year in the number of people with OA between 2010 and 2020. With this information, it quickly becomes apparent the importance of addressing weight loss in those patients with excess body weight. For the purposes of this blog, knee OA will be heavily discussed. However, this information could be extrapolated and applied to other joints.
Sikaris (2004) makes a hard-hitting statement when reporting that in knee OA, every pound of excess weight exerts a four-fold burden on the knee per step. In a near perfect contrast to this (Messier et al ., 2018) found a diet and exercise intervention which obtained a 5.7% weight loss achieved a four-fold reduction in the load exerted on the knee per step, for each pound of body weight lost. Whilst both studies provide support for weight loss an argument could be made that it was exercise not diet that produced such results. Messier et al. (2004) challenged this by comparing diet and exercise to exercise alone. Compared to exercise alone exercise and diet produced significant improvements in pain and function.
Whilst the knee has primarily been used as an example, research also shows that obesity is closely associated with bilateral hip OA. In (Livenese et a l., 2002) systematic review they report evidence for a positive association between obesity and the occurrence of hip OA.
Whilst obesity is most frequently linked to OA in the larger, lower limb, weight bearing joints, we know it affects multiple other regions including the spine. Whilst not commonly associated with the smaller joints of the hand, some researchers have also reported an association between obesity and hand OA. For example, (Harra et al., 2004) reports that body mass index (BMI) is directly proportional to the prevalence of thumb carpo-metacarpal OA in both sexes.
Jordan et al. (2003) when writing for The European League Against Rheumatism recommended weight loss and exercise for obese patients with OA. Messier et al. (2005) who seems to have undertaken a lot of the research in this area reports that overweight individuals with OA can reduce pain by a massive 50% whilst significantly improving function and mobility with a 10% or more weight loss over an 18-month period. 20% or more weight loss has the added benefit of continued improvement in physical health-related quality of life along with an additional 25% reduction in pain and improvement in function. Toda (2001) suggested that if weight management was better addressed and those individuals with excess weight reduced their weight by 5 kg or until their BMI was within the normal recommended range, 24% of the surgical cases for knee OA might be avoided.
Whilst much of the research around excess weight in relation to the MSK system surrounds OA we know it can have a significant impact on other MSK related concerns, including but not limited to: poorer surgery outcomes, lower back pain, gait disturbance, numerous soft tissue complaints, osteoporosis, gout, fibromyalgia, and connective tissues disorders.
We have different pieces of research suggesting similar guidance in that 5-10% or more weight loss can have an overtly positive impact upon symptoms. This range appears to be reflective of what is suggested for non-MSK and MSK related disorders. Ultimately any weight loss is likely to achieve better health outcomes but according to the research, we must not lose sight of the fact that greater weight loss is likely to achieve even better outcomes!
The focus of this blog is not about establishing how much weight patients would benefit from losing of which there are several methods, including BMI, waist circumference, and comparison to aged matched individuals etc.
The take home message from this blog is that to establish clinically meaningful improvements from an MSK stand-point we should look to encourage any weight loss but a 5-10% or higher in certain individuals would have a greater impact on pain and function.
We have highlighted some of the potential benefits of weight loss from an MSK standpoint and highlighted the positive impact on a plethora of health-related concerns outside of the MSK system. However, it is not just physiological benefits when it comes to weight loss. There is a known graded response to weight loss achieved through lifestyle intervention and improvement in the quality of life according to (Kolotkin et al., 2001) ., 2012)) found that fewer patients developed potentially significant symptoms of depression and that weight loss may protect from it.
NICE. (2015). Osteoarthritis. Available: https://www.nice.org.uk/guidance/qs87/chapter/Introduction. Last accessed 04th May 2020.
Jordan, K.M., Arden, N.K., Doherty, M., Bannwarth, B., Bijlsma, J.W.J., Dieppe, P.,……Lohmander, S. (2003). EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Annals of the rheumatic diseases, 62(12), 1145-1155.
Williamson, D.A., Bray, G.A. & Ryan, D.H. (2015). Is 5% weight loss a satisfactory criterion to define clinically significant weight loss? Obesity, 23(12), 2319.
Sikaris, K.A. (2004). The clinical biochemistry of obesity. The Clinical Biochemist Reviews, 25(3), 165.
Messier, S.P., Gutekunst, D.J., Davis, C. & DeVita, P. (2005). Weight loss reduces knee‐joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis & Rheumatism, 52(7), 2026-2032.
Messier, S.P., Loeser, R.F., Miller, G.D., Morgan, T.M., Rejeski, W.J., Sevick, M.A., … Williamson, J.D. (2004). Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Arthritis & Rheumatism, 50(5), 1501-1510.
Messier, S.P., Resnik, A.E., Beavers, D.P., Mihalko, S.L., Miller, G.D., Nicklas, B.J., …Guermazi, A. (2018). Intentional weight loss in overweight and obese patients with knee osteoarthritis: is more better? Arthritis care & research, 70(11), 1569-1575.
Kolotkin, R.L., Crosby, R.D., Williams, G.R., Hartley, G.G. & Nicol, S. (2001). The relationship between health‐related quality of life and weight loss. Obesity Research, 9(9), 564-571.
Faulconbridge, L.F., Wadden, T.A., Rubin, R.R., Wing, R.R., Walkup, M.P., Fabricatore, A.N., …Look AHEAD Research Group. (2012). One‐year changes in symptoms of depression and weight in overweight/obese individuals with type 2 diabetes in the look AHEAD study. Obesity, 20(4), 783-793.
Holden, M.A., Waterfield, J., Whittle, R., Bennell, K., Quicke, J.G., Chesterton, L. & Mallen, C.D. (2019). How do UK physiotherapists address weight loss among individuals with hip osteoarthritis? A mixed‐methods study. Musculoskeletal care, 17(1), 133-144.
Lievense, A.M., Bierma‐Zeinstra, S.M.A., Verhagen, A.P., Van Baar, M.E., Verhaar, J.A.N. & Koes, B.W. (2002). Influence of obesity on the development of osteoarthritis of the hip: a systematic review. Rheumatology, 41(10), 1155-1162.
Haara, M.M., Heliövaara, M., Kröger, H., Arokoski, J.P., Manninen, P., Kärkkäinen, … Aromaa, A. (2004). Osteoarthritis in the carpometacarpal joint of the thumb: prevalence and associations with disability and mortality. JBJS, 86(7), 1452-1457.
Toda, Y. (2001). The effect of energy restriction, walking, and exercise on lower extremity lean body mass in obese women with osteoarthritis of the knee. Journal of Orthopaedic Science, 6(2), 148-154.