Weight management in osteoarthritis

Being overweight increases the risk of osteoarthritis. Osteoarthritis also increases faster in overweight people. There is overweight with a BMI of 25-30 and obesity with a BMI > 30.

Overweight and obesity not only lead to osteoarthritis because of the extra weight you have to carry. Because there is a relationship between overweight and osteoarthritis of the hand and wrist, we know that other factors also play a role. Fat tissue secretes substances (adipokine, leptin) that promote inflammation. This leads to low-grade inflammation in the body and can contribute to the breakdown of cartilage and increase osteoarthritis.

Conservative treatment

Weight reduction and exercise are the cornerstone of conservative osteoarthritis treatment worldwide. If you are overweight or obese, it is important to lose weight and then maintain a healthy weight through the combination of dietary changes and increased physical activity. The best way to lose weight is through the combination of reduced calorie intake and aerobic exercise.

Who should lose weight?

Weight loss is of added value in all phases of osteoarthritis and is recommended for patients with complaints of osteoarthritis who have a BMI above 25.

Effects of losing weight

Losing weight leads to a reduction in fat tissue and ensures that less leptin and other pro-inflammatory substances are released by the fat tissue (Hauner 2005). This leads to an improvement in pain and function in patients with osteoarthritis. In addition, weight loss reduces the load on the joint and has a positive effect on general health and the metabolic risk profile (blood pressure, cholesterol, blood sugar)

Effects of physical activity

Physical activity leads to less secretion of pro-inflammatory substances by the fat tissue. improvement of the adipokine profile of adipose tissue (Stanford 2015). The combination of weight loss and increased exercise has the best effect on pain and function and reduces the increase in radiological abnormalities. The combination of diet and exercise also reduces inflammation. Exercise programs that combine strength, flexibility and cardiovascular training have the greatest effect on pain and function (Uthman 2013). Physical exercise is also important to maintain muscle mass

How much weight to lose?

Research shows that a weight reduction of 5% in knee osteoarthritis can already lead to significant pain reduction (KNGF). The effect on pain and physical functioning is more favorable as a patient with osteoarthritis loses more weight and most guidelines (including NOV 2018) advise patients with complaints of osteoarthritis and overweight to lose at least 10% of their weight through the combination of eating less and exercising more.
It is uncertain whether weight reduction leads to less structural damage to the joint, but overweight and obesity do appear to be related to an increase in X-ray abnormalities in knee osteoarthritis and patients who manage to lose 5 kg or 5% of their body weight in a year a significantly reduced chance of developing complaints of knee osteoarthritis. In addition, weight loss also has other benefits, such as a reduced side to diabetes and cardiovascular disease.

How to lose weight?

For weight loss, the general guidelines for weight reduction apply to osteoarthritis. It is advised to reduce energy intake by approximately 500-600 kcal per day and to follow guidelines for a healthy diet (less fat and sugar, more fruit and vegetables, smaller portion size). This allows a weight loss of 0.5-1 kg per week to be achieved. If you are unable to lose weight independently, referral to a dietician may offer a solution. An approach that also pays attention to behavioral change and regular contact with a dietitian ensures that the advice is better followed. (Aaboe 2012, Messier 2013, Messier 2008). Also, exercising under supervision or in a group can sometimes yield better results than when done independently.

Healthy Food and Osteoarthritis

A healthy diet is also important for people who are not overweight. Various studies have shown that nutrition can have a beneficial effect in osteoarthritis [24–26], while an unhealthy diet can lead to an increase in complaints and joint damage.

For example, the ‘Prudent dietary pattern’ and the ‘Mediterranean dietary pattern’ reduce the progression of osteoarthritis symptoms, while the ‘Western dietary pattern’ actually increased the symptoms of osteoarthritis (Zeng, Nutr Diet 2022). A higher fiber intake reduced pain and progression of osteoarthritis. A diet with a high inflammatory potential increased the risk of new onset symptomatic osteoarthritis and there was a negative association between dietary inflammatory index (DII) and quality of life in various populations, including patients with osteoarthritis.

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The mediterranean diet

The Mediterranean diet has been on the list of the healthiest diets for years and has a positive effect on cardiovascular disease, various cancers, various chronic conditions and on cognitive functions such as memory and concentration. In addition, research shows that it can have a positive influence on osteoarthritis.

Important characteristics of a Mediterranean diet are a high intake of fruits, vegetables, legumes, nuts, seeds and grains, a high intake of fish and seafood, and a moderate intake of dairy, poultry and eggs and olive oil.

Research shows that osteoarthritis is less common in people who adhere more strictly to the Mediterranean diet. They experience less pain, physical limitations and depressive symptoms and have a better quality of life than people who do not adhere to the Mediterranean diet or adhere less strictly to it. Biomarkers of inflammation and cartilage breakdown are also lower. In particular, a higher intake of grains seems to reduce the risk of knee osteoarthritis.

Protective effects

The protective effect of the Mediterranean diet has been attributed to antioxidants, the anti-inflammatory properties of the Mediterranean diet and the prevention of obesity and metabolic syndrome.

Inflammation

Chronic low-grade inflammation seems to play an important role in the development of osteoarthritis. Inflammation of the joint capsule (synovitis) is related to the severity of the complaints, cartilage loss and abnormalities on X-ray examination. Increased inflammatory values ​​in the blood (CRP) are also predictive for the development and course of osteoarthritis. The Mediterranean diet leads to weight loss and reduction of inflammatory mediators and, due to its anti-inflammatory properties, can reduce osteoarthritis and improve quality of life in patients with osteoarthritis.

Metabolic syndrome

Metabolic syndrome is the combination of elevated cholesterol, high blood pressure and resistance to insulin. There is a clear relationship between osteoarthritis and the metabolic syndrome. Osteoarthritis occurs in 57% of people with metabolic syndrome and in 23% of the normal population. Osteoarthritis patients with metabolic syndrome have more pain and inflammation compared to other osteoarthritis patients. The Mediterranean diet can reverse metabolic syndrome and improve quality of life. Treatment of metabolic syndrome could possibly prevent progression of osteoarthritis.

Antioxidants

Free oxygen and nitrogen radicals are formed in various processes in our body. These are aggressive substances that can cause damage to cells and tissue. Antioxidants can neutralize these free radicals. Normally, the free radicals and antioxidants in our body are in balance, but in some cases, for example in osteoarthritis, the production of free radicals can be increased.

The Mediterranean diet is rich in antioxidants. There are studies that show that intake of antioxidants (Vitamins A, C and E) could possibly prevent or delay osteoarthritis (Li 2016, Chiu 2016, Grover 2016, Henrotin 2007), but there is currently too little scientific evidence to support this. to say with certainty. A healthy diet with adequate amounts of antioxidants is also important for general health.

Polyphenols

The Mediterranean diet is rich in polyphenols. Polyphenols are plant components with high anti-oxidative properties. Polyphenols are abundant in our diet and, due to their anti-oxidative and anti-inflammatory properties, may play a role in the prevention of osteoarthritis (Leong 2013).

Laboratory research into cartilage protective effects of polyphenols shows that they can have a beneficial effect on osteoarthritis, but more research is needed to demonstrate these effects in patients as well.

Fat and cholesterol

Fats

Fats are stored in and around cartilage cells and may play a role in inflammation and damage to the cartilage (Masuko 2009). Intake of saturated fats is associated with joint space narrowing, while an intake of unsaturated fatty acids is associated with a lower progression of radiological abnormalities (Lu 2017).

Both omega 6 and omega 3 fatty acids are unsaturated fatty acids and are part of a healthy diet. In addition, omega 3 fatty acids have a protective effect against osteoarthritis, while omega 6 fatty acids can increase the inflammatory process and cause cartilage damage. For example, joints with osteoarthritis contain high levels of omega-6 fatty acids, which are related to inflammation of the joint capsule, while omega-3 fatty acids have an anti-inflammatory effect and are related to less cartilage loss (Baker 2012).

Unsaturated fatty acids in the Western diet have a relatively high omega 6: omega 3 fatty acid ratio, while the Mediterranean diet actually lowers the omega 6: omega 3 fatty acid ratio. Oils high in n-6 fatty acids (linoleic acid) include sunflower oil. Oils high in n-3 fatty acids are mainly fish oil. Guidelines recommend at least one portion of oily fish per week, but many people do not achieve this.

Cholesterol

In osteoarthritis, cholesterol accumulates in cartilage cells. This leads to the release of pro-inflammatory substances and increases the fragility of cartilage cells.

Lowering cholesterol with drugs reduces inflammation, cartilage breakdown and radiological progression of osteoarthritis. Cholesterol can also be lowered by losing weight with a targeted diet. This can mainly be achieved by reducing the intake of saturated fatty acids (animal fats), but intake of fiber, soy protein (25 g / day) and nuts (30 g / day) can help lower cholesterol. However, there is still insufficient evidence that adjusting fat intake and lowering cholesterol actually has a beneficial effect on osteoarthritis.

Vitamin D

Vitamin D supplementation has a positive effect on muscle strength, which can be beneficial in osteoarthritis, where weakness of the Quadriceps is often seen (Hall 2006). There seems to be a relationship between Vit D deficiency, cartilage loss and osteoarthritis and a vitamin D deficiency could possibly slow down the progression of osteoarthritis. The aim is to have a Vit D of at least 50 nmol/l in patients with OA.

Vitamin K

Vitamin K is a fat-soluble vitamin. Vit K1 is mainly found in green leafy vegetables and oils. Vitamin K2 is mainly produced by bacteria. Vit K plays a role in the immune system and in the mineralization of bone and cartilage. Insufficient research has been done to make a statement about the effect of Vit K supplementation on osteoarthritis.

Darmflora

Intestinal flora and osteoarthritis

There is increasing evidence that low-grade inflammation plays a role in the development of osteoarthritis and that there is a relationship with gut microbiota. The intestinal flora includes more than 5000 different types of bacteria. The main species are Firmicutes and Bacteroidetes. They make up 90% of the gut microbiome.

Overweight and obesity can disrupt the intestinal flora. This can lead to increased permeability of the intestinal wall and increased excretion of endotoxins by bacteria into the bloodstream. This can lead to activation of the immune system and could possibly lead to an increase in joint inflammation. Exercise can reverse these disturbances. It has been shown in mice that influencing the intestinal flora can prevent an increase in osteoarthritis. Supplementation with probiotics reduces intestinal damage and inflammation and could potentially play a role in the treatment of osteoarthritis. The relationship between intestinal flora and osteoarthritis has not yet been demonstrated in humans. Physical exercise actually increases the diversity of intestinal flora and reduces the Firmicutes/Bacteroidetes ratio (56). In patients with osteoarthritis, physical activity also produces endocannabinoids, which in turn stimulate the intestinal flora to produce anti-inflammatory substances that reduce pain.

Algemene conclusies

Conclusies

A healthy diet and a healthy weight are important in osteoarthritis. The following advice may play a role in preventing or delaying osteoarthritis and will in any case have a beneficial effect on metabolic health:

  1. Weight reduction in osteoarthritis patients. Aiming for a 10% reduction in body weight in osteoarthritis patients with obesity. The ultimate goal is a healthy BMI (<25 kg/m2). Achievable by moderately reducing energy intake without reducing micronutrient intake. In addition, exercise should be encouraged (a combination of aerobic, strength and flexibility) tailored to the patient’s capabilities. Regular contact and monitoring are essential with attention to behavioral change.
  1. Modifying lipid intake: omega 6 fatty acids (meat) are pro-inflammatory, omega 3 fatty acids (fish oil) are anti-inflammatory. Replace N-6 fatty acids with oil rich in monounsaturated fatty acids such as rapeseed and olive oil. Increase intake of omega-3 fatty acids (EPA/DHA) by taking fatty fish oil 1-2 servings/week (as advised in the general guidelines for a healthy diet). Consider daily fish oil supplementation.
  1. Dietary guidelines for cholesterol, serum lipids, metabolic syndrome and cardiovascular disease:
    1. Advise a cholesterol-lowering diet with a total chol > 5, LDL > 3. This may also have a positive effect on osteoarthritis.
    2. 52 g/day plant stanols/sterols.
    3. Reduce saturated fatty acids to <11% of total energy intake (around 31 g/day for men and 24 g/day for women).
    4. Ensure intake of sufficient fiber (eg oats), soy protein (25 g, eg soy milk, edamame beans, tofu) and nuts (30 g).
    5. For obese/overweight patients, weight control remains of primary importance for reducing both OA symptoms and comorbidities.
  1. Antioxidants: Sufficient vit A, C and E: Vitamin A (retinol equivalent): 650-750 mg/day (Europe), 700-900 mg/day (USA [51])c Vitamin C: 95-110 mg/day ( Europe[52]); 75-90 mg (USA [51])c Vitamin E (a-tocopherol equivalent): 11-13 mg/day (Europe [53]); 15 mg/day (USA [51, 107]). In case of insufficient intake from the diet, a multivitamin can be considered, but it is preferable to take it through the diet. Smokers: extra vit C supplementation.
  1. Vit D: Vitamin D-rich food (fish oil, egg (yolk), vitamin D-enriched spreads, vit D enriched milk or degrees. In the summer months, daily exposure to sunlight 10-20 min/day without protective cream/lotion enough for adequate Vit D concentrations Otherwise consider supplementation of 15-20 mg/day. A healthy BMI lowers the risk of Vit D sequestration in adipose tissue.
  1. Vit K: increase intake by taking green vegetables (spinach, Brussels sprouts, broccoli, cale). Certain fats and lien (blended vegetable oil, olive oil, margarine) contain small amounts of Vit K and can be used for cooking.

Nutritional supplements

The most important nutritional measures for osteoarthritis are weight loss, more exercise and a healthy diet. Nevertheless, we regularly receive questions about nutritional supplements for osteoarthritis. Below we explain what is known in the literature about various nutritional supplements for osteoarthritis. Click on one of the supplements below to read more about it.

Glucosamine and chondroitine

Glucosamine en chondroitinesulfaat zijn bestandsdelen van gewrichtskraakbeen en worden vaak gebruikt bij artrose. Er is beperkt wetenschappelijk bewijs dat deze supplementen een positief effect hebben bij knieartrose. Een overzichtsartikel uit 2022 (Zhiyao Wang) liet zien dat effect van chondroitine in combinatie met glucosamine een positief effect had op pijn, zwelling en functie bij patienten met knieartrose en er werden geen vervelende bijwerkingen gezien. Er waren echter slecht 6 trials geincludeerd wat erg weinig is. Omdat er geen duidelijke nadelen zijn is er ondanks het beperkte bewijs geen bezwaar als patienten deze supplementen willen gebruiken (Hsu & Siwiecl, Statpearls 2020).

Collageen

OnJabbari (int J Rheum Dis 2022): High adverse effects of collagen supplementation and its low efficiency compared to routine treatments were reported by several included studies. Also, risk of bias assessment showed that most of the studies had poor quality. Therefore, it is not possible to definitely decide on the beneficial or detrimental effects of collagen supplementation on OA and RA patients.

Curcumin and ginger
Research 1

Mathieu (Nutrients 2022) found that Curcumin and ginger supplementation can have a positive effect on symptoms of knee osteoarthritis. More research is needed to assess the effect of omega-3 and vitamin D.

Research 2

Shokri-Mashhadi (Adv Exp Med Biol 2022) found that various components of curcuma can have a positive effect in the treatment of osteoarthritis. Components with a higher bioavailability had more positive effects.

Research 3

Paultre (BMJ Open Sport Exerc Med 2021) found in a review article that Curcum (also called Tumeric) has a positive effect on pain and function in knee osteoarthritis compared to placebo. A few studies show that the effect is comparable to NSAIDs. More research into the correct dosage, frequency and composition is needed.

Research 4

Feng 2022- Effectiveness and safety of curcumoids (CURs) in reducing pain in knee osteoarthritis. CURs were more effective than placebo in improving the VAS pain score, and the Womac scores (total/pain/function/stiffness). CURs were not inferior to NSAIDs in reducing pain and function and did not produce more side effects than placebo. CURs can therefore reduce pain and improve function in knee osteoarthritis in the short term without side effects. Insufficient quality and too great a heterogeneity of studies to recommend Curcuma in practice. More research is needed.

Research 5

Wenli Dai 2021 – Effectiveness of Curcuma longa extract versus placebo for the treatment of knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials.

Current evidence indicates that, compared with placebo, Curcuma longa extract has more benefit in pain relief and functional improvement for symptomatic knee OA. However, considering the potential heterogeneity in the included studies, more future high-quality RCTs with large sample sizes are necessary to confirm the benefits of Curcuma longa extract on knee OA.

Polyphenols

Valsamidou (Nutrients 2021): combined polyphenols may be promising for the treatment of osteoarthritis in the future, but more clinical trials with novel approaches in the identification of the in-between relationship of such constituents are needed.

EPA/DHA supplements

Fish oil intake shows reduction in pain in RA. This was not seen in OA, however quality of the studies is low and the results were very heterogeneous. A study unexpectedly showed that a low dose of fish oil was more effective than a higher dose of fish oil in improving pain and function. Although more research is needed, a low dose of fish oil (1.5g/day) may help reduce pain in OA. In addition, fish oil is good for cardiovascular disease and metabolic syndrome associated with OA.

Groenlipmossel extract

Abshirini (Inflammopharmacology 2021): review of the effect of group lip mussel extract on symptoms of osteoarthritis. Green-lipped mussel extract showed moderate but clinically significant treatment effects on osteoarthritis pain. However, the evidence is limited by the number and quality of studies.

Perna canaliculus, green-lipped mussel, is endemic to New Zealand. It is traded as greenshell™ mussel (GSM). Various therapeutic substances such as Lyprinol® are produced from GSM. Orally (powder or oil extract), GSM has been shown to reduce pain and inflammation in RA and OA without the negative side effects of NSAIDs (Cho et al. 2003; Gibson and Gibson 1998). The underlying mechanism involves the anti-inflammatory activity of biolipids in mussels including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). These lipids influence inflammatory responses by inhibiting the cyclooxygenase (COX) and lipooxygenase (LOX) cascades of arachidonic acid (AA) metabolism, leading to a decrease in the synthesis of proinflammatory prostaglandins and leukotrienes (Halpern 2000; McPhee et al. 2007).