We see a lot of people who have knee pain, limited mobility, accelerated weight gain, and diminishing health. When these people come into our office looking for alternatives to a recommended knee replacement, we may suggest to them that weight loss would be extremely beneficial in helping to repair their knee. Sometimes the patient will say to us, “my surgeon said we should replace the knee first and then I will be able to lose weight.” For some people that argument makes sense. When you get a knee replacement you should be able to resume normal activities and thereby lose weight. But is that what really happens? There is a debate going on between doctors, surgeons, and health care providers as to the role of weight loss in managing knee pain BEFORE knee replacement and AFTER knee replacement. Some say let the treatment fix the knee first and then lose weight, other say – lose weight and reduce inflammation now so the repair will be better. In our practice we fall into the second group – reduce weight and inflammation now.
Diet and exercise in knee replacement avoidance
Many people say to us that they go on weight loss plans but their knee does not allow them to exercise or that they wind up gaining the weight back. Yet we also hear from many people that have had success keeping their weight off and that they were successful in doing it long-term.
You don’t have to yo-yo
An August 2021 study (1) set out to determine whether long-term diet and exercise interventions, alone or in combination, have beneficial effects for older adults with knee osteoarthritis three and a half years after the person ended a formal diet and exercise program. This was a group of patients over the age of 55. What the study found was “Older adults with knee osteoarthritis who completed 1.5-year diet or diet plus exercise interventions experienced partial weight regain 3.5 years later, yet relative to baseline, they preserved statistically significant changes in weight loss and reductions in knee pain.” In other words. Get on a diet program that teaches you lifestyle choices and continue to exercise, you can be retrained to keep weight off long-term.
Lose weight then knee replacement? Knee replacement then lose weight? Doctors present conflicting opinions
Many people tell us that the reason they are considering knee replacement is the belief that if they have knee replacement, they then will have better mobility and better mobility means they can be active again. This is not always true. In fact in some people the opposite occurs.
In July 2018, a study from the United Kingdom in the European Journal of orthopaedic surgery & traumatology (2) found surgeons at odds with each other over the matter of weight management before knee replacement. Research investigators sent a survey to surgeon members of the British Association for Surgery of the Knee. The purpose was to explore knee surgeons’ opinions and practices regarding the management of painful knees in obese patients. The survey showed considerable practice variation and divided opinion on the scientific evidence.
The slight majority of surgeons stated that weight loss should be the first-line treatment, 53% and this should ideally be managed by a specialist multidisciplinary service. However, only 24% of the surgeons would be interested in being the orthopedic surgeon in such a multidisciplinary service.
Half of surgeons in this study think people should lose weight. One in 4 want to be part of a program.
Approximately 72% of obese patients and non-obese patients have post surgery improvement in activity level – 28% do not
A February 2020 study in the Journal of clinical orthopaedics and trauma (3) suggested that obese patients and non-obese patients have pretty much the same complication level following surgery and that approximately 72% of obese patients and non-obese patients have post surgery improvement in activity level. They also equally suffer from similar complications including: “patello-femoral pain, superficial wound infections, deep vein thrombosis and delayed wound healing.”
For 72% there is some post surgery improvement in activity level, for 28% none. About three in 10 knee replacement patients do not have improvement.
Reducing Body Mass Index can reduce pain and inflammation related to knee osteoarthritis
The above research is a simple sampling of the debate in the medical community as to the benefit of losing weight before knee replacement. In our practice we want to help people avoid knee replacement through our various regenerative injection techniques and whole body wellness. This includes diet for weight loss and inflammation reduction.
The management of inflammation is a very important part of our practice. Not just knee inflammation, but chronic body wide inflammation.
Here is a December 2018 study (4) which suggests that knee osteoarthritis patients should reduce their Body Mass Index (BMI) with a high fiber diet and thereby reduce C-protein inflammatory markers. This come from researchers at Boston University School of Medicine.
In this study, the researchers wanted to examine the extent to which BMI and dietary fiber influenced the relationship between inflammation and symptomatic knee osteoarthritis.
Who was in the study?
Men and women (average age 61 years old) with or at risk of knee osteoarthritis
Two groups: Persons whose fiber intake was more than 21 grams daily were compared with those with intakes were less than 21 grams daily for the overall association with symptomatic knee osteoarthritis.
The researchers found that dietary fiber or more than 21 grams daily helped reduce body weight and helped reduce inflammation as measured by C-reactive protein declines.
The conclusion? Reducing Body Mass Index can reduce pain and inflammation related to knee osteoarthritis
One diet versus another. There are results
A June 2021 paper (5) examined worsening knee osteoarthritis outcomes in the association between dietary factors and risk of knee osteoarthritis. Here 2,842 participants with at least one knee free from radiographic knee osteoarthritis (one good knee) at baseline for up to 72 months was observed to determine if any knee osteoarthritis developed that could be at least in part be attributed to weight and obesity.
Results: Among study participants, 385 (418 knees) developed knee osteoarthritis within 72 months. Following a Western dietary pattern (high processed food, carbs, sugars, etc) was associated with an increased risk of knee osteoarthritis, while adherence to the prudent pattern (a more healthy lifestyle diet) was associated with a reduced risk of knee osteoarthritis
Conclusion: Following a Western diet was associated with increased risk of knee osteoarthritis, whereas following a prudent pattern was associated with a reduced risk of knee osteoarthritis. The associations were partially mediated through BMI. (weight gain).
If you manage blood sugar and manage the inflammation you can manage knee pain and help repair degenerative knee disease
A research team lead by Tufts University and Temple University School of Medicine also found that weight loss could reduce inflammation in older patients suffering with degenerative knee problems. The 2018 study published in BioMed Central musculoskeletal disorders (5) said simply: older and overweight individuals may be more susceptible to osteoarthritis because being older and being overweight alter tissue turnover in the meniscus, articular cartilage, and bone via altered glucose homeostasis (blood sugar regulation) and inflammation. If you manage the blood sugar and you manage the inflammation you can manage knee pain and help repair degenerative knee disease.
How much of quality life is lost to patients with knee pain? To obesity? To a combination of knee pain and obesity?
Researchers writing in the Annals of Internal Medicine (6) sought to answer these questions. They looked at subjects between the ages of 50 and 84 and sought to estimate quality-adjusted life-years lost due to obesity and knee osteoarthritis and health benefits of reducing obesity prevalence to levels observed in the 1990’s when obesity was much less prevalent.
Here is what they found:
Non-obese patients with knee pain from osteoarthritis – almost 1.9 years quality life-years lost.
For patients with both osteoarthritis knee pain and obesity 3.5 years of quality life lost.
Despite the obvious benefits, weight loss is difficult to achieve.
A May 2017 study lead by Alexandra Gersing, MD of the Department of Radiology and Biomedical Imaging at the University of California, San Francisco concluded that overweight and obese people who lost a substantial amount of weight over a 48-month period showed significantly lower degeneration of their knee cartilage. The research was published in the medical journal Radiology.(7)
This study was a continuation of Dr. Gersing’s work on the subject. In 2016 she lead a team of researchers who were able to suggest from findings that: “weight loss has a protective effect on cartilage, which is detected in all (knee) compartments, and that a larger amount of weight loss is more beneficial in obese and overweight subjects in order to slow progression of cartilage matrix deterioration and worsening of clinical symptoms.”(8)
Our treatment philosophy
At the Magaziner Center for Wellness, we take a holistic view of the body, even from an orthopaedic standpoint. We bring a comprehensive understanding of thyroid, hormonal, metabolic and nutritional medicine to our treatment of our patients. Since regular exercise and a healthy diet are crucial when it comes to controlling weight, we speak to each patient about his or her lifestyle habits, as well as his or her biochemistry, in order to create a customized treatment plan.
For the long run, we help our patients understand food choices and their impact on the body. Our goal is to help our patients maintain their weight loss for a lifetime, by educating them on proper nutrition and changing body chemistry to reduce cravings and maintain proper and healthy weight.
If you would like to explore more information, please contact our office so we can start a conversation with you.
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References
1 Messier SP, Newman JJ, Scarlett MJ, Mihalko SL, Miller GD, Nicklas BJ, DeVita P, Hunter DJ, Lyles MF, Eckstein F, Guermazi A, Loeser RF, Beavers DP. Changes in body weight and knee pain in adults with knee osteoarthritis 3.5 years after completing diet and exercise interventions. Arthritis Care Res (Hoboken). 2021 Aug 9. doi: 10.1002/acr.24765. Epub ahead of print. PMID: 34369105.
2 Hill DS, Freudmann M, Sergeant JC, Board T. Management of symptomatic knee osteoarthritis in obesity: a survey of orthopaedic surgeons’ opinions and practice. European Journal of Orthopaedic Surgery & Traumatology. 2018 Jul 1;28(5):967-74.
3 Agarwala S, Jadia C, Vijayvargiya M. Is obesity A contra-indication for a successful total knee arthroplasty?. Journal of Clinical Orthopaedics and Trauma. 2018 Nov 30.
4 Dai Z, Jafarzadeh SR, Niu J, Felson DT, Jacques PF, Li S, Zhang Y. Body Mass Index Mediates the Association between Dietary Fiber and Symptomatic Knee Osteoarthritis in the Osteoarthritis Initiative and the Framingham Osteoarthritis Study. The Journal of nutrition. 2018 Dec 1;148(12):1961-7.
5 Xu C, Liu T, Driban JB, McAlindon T, Eaton CB, Lu B. Dietary patterns and risk of developing knee osteoarthritis: data from the osteoarthritis initiative. Osteoarthritis and Cartilage. 2021 Jun 1;29(6):834-40.
6 Stout AC, Barbe MF, Eaton CB, et al. Inflammation and glucose homeostasis are associated with specific structural features among adults without knee osteoarthritis: a cross-sectional study from the osteoarthritis initiative. BMC Musculoskelet Disord. 2018;19(1):1. Published 2018 Jan 5. doi:10.1186/s12891-017-1921-6
7 Losina E, Walensky RP, Reichmann WM. Impact of obesity and knee osteoarthritis on morbidity and mortality in older Americans. Ann Intern Med. 2011 Feb 15;154(4):217-26.
8 Gersing AS, Schwaiger BJ, Nevitt MC, Joseph GB, Chanchek N, Guimaraes JB, Mbapte Wamba J, Facchetti L, McCulloch CE, Link TM. Is weight loss associated with less progression of changes in knee articular cartilage among obese and overweight patients as assessed with MR imaging over 48 months? Data from the Osteoarthritis Initiative. Radiology. 2017 May 2;284(2):508-20.
9 Gersing AS, Solka M, Joseph GB, et al. Progression of Cartilage Degeneration and Clinical Symptoms in Obese and Overweight Individuals is Dependent on the Amount of Weight Loss: 48-Month Data from the Osteoarthritis Initiative. Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society. 2016;24(7):1126-1134. doi:10.1016/j.joca.2016.01.984.
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