The Weight Loss Intervention recommendation has been downgraded one level because of inconsistent evidence.
There were 1 high (Jenkinson et.al 2009),1 moderate (Miller 2006), and 2 low strength (Focht 2005, Rejeski 2002) studies evaluating diet and exercise as weight loss interventions to treat knee osteoarthritis. Overall pain and function improved with weight loss achieved through a combination of diet and exercise.
However, when evaluating only diet vs control, 2 high (Bliddal 2011, Christensen 2015), 2 moderate (Messier 2013, Mihalko 2018) and 2 low strength (Rejeski 2002, Fochyt 2005) there was no clear clinically significant change in patient outcomes. Specifically, Christensen et al, 2015 published a high-quality study investigating the effect of weight on symptoms of knee osteoarthritis. They showed no significant difference in pain and function at 1 year. Bliddal et al, 2010 published another high quality study which investigated the effect of weight loss on symptoms of knee OA in the obese patient, showing that perceived pain (via WOMAC) was significantly lessened despite not being able to show improvement in function and quality of life at 1 year.
There were 2 moderate strength studies (Messier 2013, Mihalko 2018) which evaluated diet vs exercise, which favored exercises. To note, Messier et al 2013 published results of the IDEA trial with moderate quality study which was an attempt to determine if a 10% reduction in body weight (induced by diet, with or without exercise) would improve “clinical and mechanistic” outcomes in sedentary lifestyle patients (BMI 27 thru 41). Interestingly, in this primary study, they were unable to show an improvement in WOMAC pain but they did show improvement in the WOMAC function subscale, and also showed improvements in the 6 minute walk test.
Given the current evidence, it is at the discretion of the surgeon as to which approach is utilized to address weight loss, however a combination of diet and exercises appears to be the preferred alternative.
Benefits/Harms of Implementation
There are no known or anticipated harms associated with implementing this recommendation.
Outcome Importance
Management of obesity and overweight through weight loss may have high impact on symptoms and overall health.
Cost Effectiveness/Resource Utilization
Weight loss presents a potentially high level of cost effectiveness compared to other surgical and nonsurgical approaches; however, the cost-effectiveness of different weight loss approaches is still to be determined.
Acceptability
Currently weight loss is a commonly utilized approach in the optimization of patient who present with obesity and knee osteoarthritis, hence there should be no issues implementing this recommendation as it does not influence a major change in clinical practice. To note, patients often are reluctant or unwilling to accept referrals for weight loss as a suggestion for a path to improvement.
Feasibility
This recommendation does not interfere with other interventions or clinical practice therefore it is deemed very feasible in a subset of overweight and obese patients.
Future Research
Future research should focus on large randomized clinical trials and should focus more on function and quality of life measures since it appears obvious that pain improved through weight loss.
- Rejeski, W. J., Focht, B. C., Messier, S. P., Morgan, T., Pahor, M., Penninx, B. Obese, older adults with knee osteoarthritis: weight loss, exercise, and quality of life. Health Psychology 2002; 5: 419-26
- Rejeski, W. J., Focht, B. C., Messier, S. P., Morgan, T., Pahor, M., Penninx, B. Obese, older adults with knee osteoarthritis: weight loss, exercise, and quality of life. Health Psychology 2002; 5: 419-26
- Miller, G. D., Nicklas, B. J., Davis, C., Loeser, R. F., Lenchik, L., Messier, S. P. Intensive weight loss program improves physical function in older obese adults with knee osteoarthritis. 2006; 7: 1219-30
- Mihalko, S. L., Cox, P., Beavers, D. P., Miller, G. D., Nicklas, B. J., Lyles, M., Hunter, D. J., Eckstein, F., Guermazi, A., Loeser, R. F., DeVita, P., Messier, S. P. Effect of intensive diet and exercise on self-efficacy in overweight and obese adults with knee osteoarthritis: The IDEA randomized clinical trial. Translational Behavioral Medicine 2018; 0: 04
- Messier, S. P., Mihalko, S. L., Legault, C., Miller, G. D., Nicklas, B. J., DeVita, P., Beavers, D. P., Hunter, D. J., Lyles, M. F., Eckstein, F., Williamson, J. D., Carr, J. J., Guermazi, A., Loeser, R. F. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA 2013; 12: 1263-73
- Jenkinson C., Doherty M., Avery A., Read A., Taylor M., Sach T., Silcocks P., Muir K. Effects of dietary intervention and quadriceps strengthening exercises on pain and function in overweight people with knee pain: randomised controlled trial. BMJ 2009;339: b3170. doi:10.1136/bmj.b3170
- Focht, B. C., Rejeski, W. J., Ambrosius, W. T., Katula, J. A., Messier, S. P. Exercise, self-efficacy, and mobility performance in overweight and obese older adults with knee osteoarthritis. Arthritis & Rheumatism 2005; 5: 659-65
- Focht, B. C., Rejeski, W. J., Ambrosius, W. T., Katula, J. A., Messier, S. P. Exercise, self-efficacy, and mobility performance in overweight and obese older adults with knee osteoarthritis. Arthritis & Rheumatism 2005; 5: 659-65
- Christensen, R., Henriksen, M., Leeds, A. R., Gudbergsen, H., Christensen, P., Sorensen, T. J., Bartels, E. M., Riecke, B. F., Aaboe, J., Frederiksen, R., Boesen, M., Lohmander, L. S., Astrup, A., Bliddal, H. Effect of weight maintenance on symptoms of knee osteoarthritis in obese patients: a twelve-month randomized controlled trial. Arthritis care & research 2015; 5: 640-50
- Bliddal, H., Leeds, A. R., Stigsgaard, L., Astrup, A., Christensen, R. Weight loss as treatment for knee osteoarthritis symptoms in obese patients: 1-year results from a randomised controlled trial. Annals of the Rheumatic Diseases 2011; 10: 1798-803
- (60) Jenkinson CM, Doherty M, Avery AJ et al. Effects of dietary intervention and quadriceps strengthening exercises on pain and function in overweight people with knee pain: randomised controlled trial. BMJ 2009;339):b3170. PM:19690345