Weight loss can protect you from the need for a knee replacement. This should not be news to you. People who are overweight understand that their arthritis related knee problems can be made worse because of their weight. The news you are probably looking for is a way to lose that weight. In the end we can recommend a low carb / hi lean protein diet for you, but while that may be a great diet plan for you, it is still your ability to motivate yourself to lose the weight that will make it happen.

I know that what many of you do not need is another doctor or article that lectures you about being overweight. What you may need is some motivation by way of knowledge. Understanding what weight does to your knee and understanding what weight loss does in helping your knee may be the path to your motivation.

This is from a recent study published by doctors at the University of Oxford: What this study shows is the reaction of overweight men to advice from health care professionals that they lose weight. When the English doctors suggested to their patients that they consider going on a diet for their knee pain, the men reacted by suggesting that they did not need to go one a “bloody diet.” Which happens to be the title of their research paper on this subject: Do I really want to be going on a bloody diet? Gendered narratives in older men with painful knee osteoarthritis.

Small reductions in body weight can decrease osteoarthritic knee pain and thus should provide a strong incentive for weight-loss

The doctors of this study noted that Small reductions in body weight can decrease osteoarthritic knee pain and thus should provide a strong incentive for weight-loss. (The motivation). However many people undergoing knee joint replacement are obese, so clearly there was no motivation to lose weight.

Why didn’t the men lose weight to save their knees?

In interviewing obese men after their total knee replacement, the men said that they did not need to go on diet because:

1. Weight was not a concern to them: “I am big and healthy and don’t need to lose weight”
2. Losing weight is not something men need to worry about.
3. I have worked hard all my life, (Being overweight was a reward);
4. What is the point in trying anyway? (I never can lose the weight).
   
5. The reason I am overweight is not because of overeating, it is because I am not as active as I used to be.

• Once they got over the denial and dismissiveness, the men did acknowledge that “being this size isn’t good for me.”

The English doctors then fought back saying doctors need to educate these men because:

• Men may not associate being overweight with being unhealthy.
• Men may take pride in being in good shape and may respond better to weight loss strategies that focus on fitness not body size.
• Health care professionals should challenge the assumption that weight loss will be a net gain of knee replacement surgery. (1)

On that last note: Many people believe that once they get a knee replacement that they will be active enough again to lose weight. Weight loss following knee replacement has been shown to be just as difficult as weight loss before knee surgery. I cover this at length in my article I am getting a knee replacement so I can lose weight. Research: Knee replacements do not help you lose weight.

If you lost weight you could avoid the knee replacement

In Spain, doctors documented that patients who lost weight and were able to increase their physical activity had less knee pain and less need for knee replacement. It is worth the doctor’s efforts to incorporate strategies into their consultation for weight loss and exercise.(2)

Your knees hurt because of pressure

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Every one pound of weight equals 4 pounds of degenerative force on your knees

In 2005, research from Wake Forest University lead by Stephen P. Messier came up with some significant findings including the 1:4 ratio. In this study, the research team found that load reduction was far greater than the actual weight loss, a ratio of 1 pound to 4.

“The significant relationship between weight loss and reduction in compressive knee-joint loads indicates that the force reduction was larger than the actual weight reduction. The 1:4 ratio of weight loss to load reduction indicates that, for every 1 pound of weight loss, there is a 4-pound reduction in knee-joint load per step.

The accumulated reduction in knee load for a 1-pound loss in weight would be more than 4,800 pounds per 1 mile walked (assuming 1,200 strides/mile).

For people losing 10 pounds, each knee would be subjected to 48,000 pounds less in compressive load per mile walked. . . a reduction of this magnitude would appear to be clinically relevant.” (3)

Numerous studies have suggested that the magnitude would be a significant reduction in osteoarthritis risk and knee pain.

Weight loss saves a meniscus

A recent 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.(4)

“The most exciting finding of our research was that not only did we see slower degeneration in the articular cartilage, we saw that the menisci (meniscus) degenerated a lot slower in overweight and obese individuals who lost more than 5 percent of their body weight, and that the effects were strongest in overweight individuals and in individuals with substantial weight loss,” Dr. Gersing said.

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.”(5)

The role of obesity in degenerative joint disease cannot be overstated. In a study in the journal Molecular and cellular biochemistry a research team from the Creighton University School of Medicine wrote of why there are more incidents of knee osteoarthritis than hip osteoarthritis. In the study the research team wrote:

• The greatest risk factors for the development of osteoarthritis include age and obesity.
• Damage-associated molecular patterns (DAMPs), are released in the joint in response to stress-mediated chondrocyte (cartilage building blocks) and cartilage damage.
• DAMPs increases cartilage degradation and inflammation in the joint.

In this study, a comparison between knee and hip osteoarthritis found a significant difference in the levels of DAMPs expressed in the knee joint compared to the hip joint suggesting that knee osteoarthritis begins with inflammation as opposed to wear and tear in the hip.(6)

DAMPs are simply the molecules that initiate inflammation and are linked to obesity and aging.

Let’s move to study from Scotland where doctors outlined the common characteristics of a patient suffering from knee osteoarthritis.

1. The patient has high levels of inflammatory biomarkers, such as DAMPs
   
2. The patient has Metabolic syndrome (high prevalence of obesity, diabetes and other metabolic disturbances);
3. The patient has an altered bone and cartilage metabolism – the body is not repairing itself;
4. The patient’s knee cannot handle the mechanical overload characterised primarily by varus malalignment and medial compartment disease; (joint deformities caused by joint instability) and;
5. The patient has a heightened sense of pain that alters his/her nervous system to be in a constant state of “pain awareness.”(7)

Clearly we can see the dominating role that problems typical of obesity play in knee pain: diabetes, high levels of inflammation, and weight load.

Obesity does lead to inflammation and knee cartilage destruction

This was confirmed by an international study from the University of Western Ontario and Paracelsus Medical University Salzburg & Nuremberg.

• The more obese the patient, measured through Body Mass Index, the greater the loss of knee cartilage and knee instability.(8)

And by supportive research:

• Knee osteoarthritis is strongly linked to metabolic syndrome. In addition to weight reduction, adequate care and strict monitoring of metabolic syndrome should be encouraged.(9)
• “(Doctors) should take possible weight reduction into account for the treatment of knee osteoarthritis whenever a patient is significantly overweight.”(10)
• An obesity causing high fat, high sucrose (HFS) diet attacks synovial fluid in joints.(11)

A combined team of European researchers examined not only the relationship between being overweight and the weight load burden on osteoarthritic symptoms and severity, but also the possibility that fat accumulation (belly fat) causes osteoarthritis in NON-WEIGHT BEARING joints through inflammation. Here are some of the observations from their study:

• Overweight people are more inclined to development osteoarthritis than normal-weight people.
• Researchers have shown that fat accumulation in the joints creates inflammation.
• In fact, the researchers observed, the onset of osteoarthritis and its symptoms may be prevented more by the loss of body fat than by weight loss.(12)

This may be borne out by research suggesting that adding calories to your diet, those coming from proteins and the subsequent shift from fat to muscle in the body type can alleviate osteoarthritis symptoms.

A sensible high protein diet

Research published in the Journal of the American Medical Association looked at three groups of test subjects who were divided into “low” protein, “middle” protein, and “high” protein diets. All the participants were given 1,000 MORE calories than they burned each day with the intention of measuring weight gain in these subjects. Remember this study sought to intentionally add weight to the test subjects.

Here are the highlights:

1. In the low-protein diet test subjects, 90 percent of those extra calories turned into body fat. That extra body fat helped REMOVE 1.5 pounds of muscle.

2. In the middle and higher protein diet group, only 50 percent of the extra calories turned into body fat. The remainder helped account for ADDING almost upwards of 7 pounds of lean body mass (muscle).

• In other words, less protein – more accumulated fat — more protein, less accumulated fat, more muscle.

Further, the higher protein diets burned more calories at rest than the low protein diets.(13)

It should be clear that excessive weight represents a challenge in the healing knee pain, not only from mechanical stress but by the problems it causes by way of chronic inflammation found in Metabolic Syndrome.

Do you have questions? Ask Dr. Darrow

 

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1 Toye F, Room J, Barker KL. Do I really want to be going on a bloody diet? Gendered narratives in older men with painful knee osteoarthritis. Disability and rehabilitation. 2018 Jul 31;40(16):1914-20.
2 Carmona-Terés V, Lumillo-Gutiérrez I, Jodar-Fernández L, et al. Effectiveness and cost-effectiveness of a health coaching intervention to improve the lifestyle of patients with knee osteoarthritis: cluster randomized clinical trial. BMC Musculoskelet Disord. 2015 Feb 25;16:38. doi: 10.1186/s12891-015-0501-x.
3. Messier SP, Gutekunst DJ, Davis C, DeVita P. Weight loss reduces knee‐joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis & Rheumatology. 2005 Jul 1;52(7):2026-32.
4 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.
5 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.
6 Rosenberg JH, Rai V, Dilisio MF, Sekundiak TD, Agrawal DK. Increased expression of damage-associated molecular patterns (DAMPs) in osteoarthritis of human knee joint compared to hip joint. Molecular and Cellular Biochemistry. 2017 Jun 1:1-1.
7 Dell’Isola A, Allan R, Smith SL, Marreiros SS, Steultjens M. Identification of clinical phenotypes in knee osteoarthritis: a systematic review of the literature. BMC Musculoskelet Disord. 2016 Oct 12;17(1):425.
8 Moyer R, Wirth W, Eckstein F. Longitudinal changes in MRI-based measures of femorotibial cartilage thickness as a function of alignment and obesity Data from the OAI. Arthritis Care Res (Hoboken). 2016 Oct 1.
9: Haj Hamad W, Maraoui M, Sghir M, Guedria M, Said W, Jerbi S, Kessomtini W. Knee osteoarthritis and metabolic syndrome. Ann Phys Rehabil Med. 2016
10. Zheng H, Chen C. Body mass index and risk of knee osteoarthritis: systematic review and meta-analysis of prospective studies. BMJ Open. 2015 Dec 11;5(12):e007568. doi: 10.1136/bmjopen-2014-007568.
11. Collins KH, Hart DA,, Reimer RA, Seerattan RA, Herzog W. Response to diet-induced obesity produces time-dependent induction and progression of metabolic osteoarthritis in rat knees. J Orthop Res. 2015 Nov 17. doi: 10.1002/jor.23103. [Epub ahead of print]
12. Giuseppe Musumeci et al. Osteoarthritis in the XXIst Century: Risk Factors and Behaviours that Influence Disease Onset and Progression. Int J Mol Sci. 2015 Mar; 16(3): 6093–6112.
13. Bray GA,Smith SR, de Jonge L, et al. Effect of Dietary Protein Content on Weight Gain, Energy Expenditure, and Body Composition During Overeating: A Randomized Controlled Trial JAMA 2012;307(1):47-55. doi: 10.1001/jama.2011.1918 — 2316