I'm sure you've heard it all before..."you've got arthritis, you need to lose weight." Often this comes from your doctor or health professional following a diagnosis of Osteoarthritis aka OA (or one of many other health problems) and can be understandably met with feelings of defensiveness, shame, self-blame or anger. When it comes down to it though, it's not that easy. Losing weight can be hard, made even harder when your joints hurt, and harder again if you've been through multiple cycles of dieting in your life, and why does weight matter anyway?
Then the next thing you're told, or you assume based on the above comment, is that the reason weight is such an issue is because it puts too much load on your joints and while this holds some truth, it's not that simple. Cue everyone then thinking that loading joints is bad and they need to stop moving their joints because they are 'loading' their joints too much and 'wearing them away' even more. Again, this is understandable and arguably a logical thought...but, there is a BUT! This isn't correct and contrary to popular belief, OA isn't 'wear and tear'. Often not enough time is spent explaining the following:
A) It's not just about the load.
B) Loading / Exercise is a good thing, it's abnormal / extreme overload that isn't.
C) Chronic under-loading can lead to more pain and possible quicker advancement of OA.
Let me explain as I understand it.
A) It's not just about the load.
The general focus of my work in osteoarthritis are the weight-bearing joints of the hip and knee, basically because these are two of the most common joints in which people get OA, therefore this is what I see on a daily basis. Also, where I've worked for the past six years has a separate hand therapy department, so I personally see hand/thumb OA much less frequently, although again, it's very common. However, why is it that people with hand/thumb OA also get these flare ups and pain when they're not bearing the weight of the body like the hips and knees (unless you do handstands of course)? There are several reasons, and we still don't know all there is to know about OA, but one factor is chronic low-level inflammation, or 'metaflammation', which is contributed to by the fat cells (adipocytes).
In people who are overweight or obese there is an increase in fat cell size, which produce and release cytokines, and this can then lead to metaflammation. Leptin is an adipokine (a type of cytokine) and also a hormone, and is found in elevated levels in obese people. In it's role as a cytokine it contributes to the low-grade inflammation in the body and may contribute to the degradation of cartilage in joints as it can diffuse in to the synovial fluid (the fluid that bathes the joints). Weight loss can reduce adiposity and therefore reduce chronic low grade inflammation in the body.
Also, it's not all just about the weight or the number on the scale, it's also about the food. Whether you are obese, overweight or a 'normal' weight, a diet high in processed foods, high in sugar, high in saturated fat and low in fibre can have a negative effect on the body, and by no means just for those with OA....for anybody! This is another source of low level inflammation, and combined with increased weight (high BMI), low activity levels and poor lifestyle choices, it can all contribute to OA pain, flare-ups and OA progression.
B) Loading / Exercise is a good thing.
Yes, this is true. Don't get me wrong, 'abnormal' or 'extreme' load can be detrimental, e.g. if you have an injury to the joint, especially causing an ACL tear or meniscal damage, or if you do a job that requires frequent knee bending (for those with knee OA), this can then lead to increased susceptibility to OA. However, loading and using joints is actually necessary for normal joint development and maintenance. Loading promotes your joint tissues and surrounding muscles to adapt to the stress resulting in healthier joints, whereas doing nothing (see point C below) can be detrimental.
Sometimes for some people it's helpful to start off with lower impact exercises such as cycling/static bike, swimming, aqua aerobics etc before venturing out on longer walks or doing exercises with more impact, especially if you've not been doing much on your feet for a while, or you're joint is very irritable, but getting moving in some way is key. Increased physical activity can also help with weight loss, and you will likely find that as your weight reduces, doing exercise becomes more comfortable.
Strengthening exercises in combination with regular physical activity are also very important, and there are so many different ways in which you can work muscles to make them stronger.
Some people like to start with seated exercises like seated Tai Chi, seated Yoga, general seated strengthening exercises with elasticated bands, all of which can be a great way in. I normally start with some exercises to acclimatise the joint to the exercise and then increase the load to make sure that the muscles are working enough to actually get stronger and therefore support and protect the joint more. This is where getting the advice and guidance of a physiotherapist / physical therapist / appropriately trained personal trainer can be really beneficial. The thing to remember is, there is no 'best' exercise, but it is important you choose something you will enjoy and can realistically build in to your daily/weekly routine. The only good exercise is the one you will do.
Pacing (managing activity and pain levels effectively) is also another key component, and you may find my article on pacing in the Health Hub helpful.
C) Chronic under-loading / physical inactivity is a bad thing.
Going back to what I was saying at the beginning, and how confusion due to lack of explanation and education can cause problems, stopping exercising and activity due to worry about wearing the joint away is counterproductive. Having a look at exactly what you're doing and maybe modifying it somewhat may help (what we call activity modification); doing nothing will end up with reduced muscle strength, possible reduced joint movement and poorer overall health.
The weaker your muscles become through inactivity the less stability and support your joints have from the surrounding muscles, leaving them more susceptible to damage and deterioration. It really is a 'use it, or lose it' scenario. Of particular note is the association of reduced quadriceps (thigh muscle) strength and knee OA, so by doing nothing and letting the muscles waste away, you are sadly doing yourself a huge disservice.
As an aside, strengthening is important throughout one's life, regardless of age. Even after the age of 30 we can lose 5-8% of our muscle mass every decade if we live relatively sedentary lives and don't do anything to help keep our muscles strong and healthy. Therefore, regardless of OA or any other health condition, strengthening and physical activity is really important.
A final few thoughts
OA is complex and multifactorial. When it comes down to it, and you look at the evidence, weight loss, exercise, a healthy diet, and healthy lifestyle are key components of OA management, which is why they are featured in guidelines (e.g. N.I.C.E. Guidelines) and talked about in most associations (e.g. Versus Arthritis), but sometimes when you only have five minutes to spend with your GP/MD this is not explained properly and can lead to so much confusion and catastrophizing.
Confusion/Stress/Anxiety/Catastrophizing = increased pain!
Saying that, by no means have I covered all of the factors and components in this article; if I had it would be pages and pages long! This is just a basic overview of some of the points.
Another thing to remember is that not everyone will need a joint replacement, in fact the number is quite low (approximately only 10% of those with knee OA), with many people with OA on Xray either not having pain/symptoms or being able to reduce and manage it well. It's been suggested that if an obese person loses 10%+ of their body weight, cartilage loss can be slowed, and pain can reduce significantly. However, if you do end up needing joint replacement and you've put the work in beforehand, then the outcome after joint surgery is much more likely to be a positive one, so it's not time and effort wasted.
Also, what most people never stop to think about or understand is that obesity is usually down to much more than just eating too much or being 'lazy', and more often than not stemming from other, much deeper issues; although this is not the scope of this article but something that may be worth thinking about and need addressing on your journey to better health.
Some other things to consider if you struggle with pain and losing weight:
- Sleeping habits.
- Stress Levels.
- Relaxation / "Me" Time.
- Vegetable & Fibre Intake.
- Processed Foods Consumption.
Keep an eye out for my Managing Flare-Up's article which will be out soon!
References
Berenbaum F., Wallace I.J., Lieberman D.E. & Felson D.T. 2018. Modern-day environmental factors in the pathogenesis of osteoarthritis. Nature Reviews / Rheumatology, 14: 674-681.
Caneiro J.P., O'Sullivan, P.B., Roos E.M., Smith A.J., Choong P., Dowsey M., Hunter D.J., Kemp J., Rodriguez J., Lohmander S., Bunzli S. & Barton C.J. 2020. Three steps to changing the narrative about knee osteoarthritis care: a call to action. British Journal of Sports Medicine, 54(5): 256-258.
Either A., Hofmann G.O., & Schaible H-G. 2017. Mechanisms of Osteoarthritic Pain. Studies in Humans and Experimental Models. Frontiers in Molecular Neuroscience, Vol 10, Article 349: 1-22.
Anthony Teoli: Course: Knee Osteoarthritis Assessment & Treatment
Please note: This article is intended to be for educational purposes only, and does not constitute medical advice or replace professional assessment or personalised advice.
I do not hold responsibility for the information on any links to external websites within this article and information within these links/websites may change at any time or no longer be accessible. Any website pages/links added are also for education purposes only.
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