Arya M. Sharma, MD

Yesterday, the Arthritis Alliance of Canada together with the Canadian Arthritis Network released The Impact of Arthritis in Canada: Today and Over the Next 30 Years, a 50-page report that provides a detailed look at the impact of arthritis in Canada and offers solutions on how to mitigate and manage the situation.

According to this report, there are currently more than 4.4 million people living with osteoarthritis (OA) in Canada. In 30 years, more than 10 million or one in four Canadians is expected to have OA. Within a generation (in 30 years), there will be a new diagnosis of OA every 60 seconds.

Currently OA drives about $10 billion in direct health care costs and about $17 billion in indirect costs (lost wages, lost taxes, etc.) - together with other forms of arthritis (especially rheumatoid arthritis) the total cost of arthritis amounts to an estimated $33 billion annually. These numbers will on only grow.

Recognising that excess weight is one of the prime (modifiable) drivers of the OA epidemic, the report suggests that targeting obesity should be a priority (along with better access to joint replacements and adequate pain management) in reducing the burden of arthritis on Canadians.

As the report points out:

If a prevention program was available to reduce obesity rates by 50% in the Canadian population over the next 10 years:

• 45,000 new cases of OA could be avoided over 10 years and over 200,000 cases of OA could be avoided over 30 years;

• 25,000 workers could avoid OA over 10 years and over 136,000 cases of OA in the labour force could be avoided over 30 years;

• $3.8 billion could be saved in cumulative direct health care costs over 10 years and $48.3 billion over 30 years (2010 dollars); and

• $14.0 billion could be saved in cumulative productivity losses over 10 years and $163.7 billion saved over 30 years (2010 dollars).

(Limitation: Costs attributable to obesity-reduction interventions were unavailable and, therefore, not considered in the model.)

While this conclusion stresses the importance of obesity as a key driver of arthritis costs, this assumption of course is rather optimistic.

To my knowledge, there is no known prevention strategy that comes even close to reducing obesity prevalence by 50% in 10 years. Indeed, for those at the highest risk of OA, namely, those who are already obese, ‘prevention’ strategies come too late - you would actually have to look at ‘treatment’ strategies.

The authors are certainly aware of this as they concede that:

“Further research is needed to improve on current strategies for preventing and treating obesity.”

Fortunately, we’re already on it.

AMS
Edmonton, Alberta

As not everyone may have a chance during the week to read every post, here’s a roundup of last week’s posts:

• Should We Outsource Obesity Treatments To Weight Watchers?
• Alberta’s Obesity Initiative: Not Just Diet and Exercise
• Is There Any Path For Approval of Anti-Obesity Drugs?
• GLP-1 Receptor Agonists, Obesity and Psoriasis
• Bariatric Surgery For Osteoarthritis of Hips and Knees?

Have a great Sunday! (or what’s left of it)

AMS
London, UK

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Osteoarthritis in hips and knees is a common progressive disease leading to joint pain and severe disability. It is a complex multifactorial condition leading to damage of cartilage, deposition of subchondral bone matrix and release of pro-inflammatory cytokines.

One of the most common risk factors for osteoarthritis is carrying around excess weight. In fact, no matter what the root cause of the problem (trauma or otherwise), weight loss has consistently been shown to reduce pain (for e.g. each lb lost takes about four pounds off each knee).

So the question arises, whether bariatric surgery should be used more commonly in obese patients with osteoarthritis in hips or knees.

In a paper authored by Richdeep Gill and other colleagues, just published in Obesity Reviews, we report our findings from a systematic review of the literature on bariatric surgery and osteorarthritis.

A comprehensive search of electronic databases using broad search terms revealed a total of 400 articles, including six studies, which met our criteria for inclusion in our qualitative analysis.

Although there was a clear trend towards improvement of hip and knee osteoarthritis in hips and knees following bariatric surgery, the data consists largely of case series.

Thus, it may well be time to conduct a large randomized controlled trial to determine whether or not bariatric surgery should perhaps be routinely considered as a means to better manage hip or knee osteoarthritis in patients with severe obesity.

AMS
Edmonton, Alberta

Gill RS, Al-Adra DP, Shi X, Sharma AM, Birch DW, & Karmali S (2011). The benefits of bariatric surgery in obese patients with hip and knee osteoarthritis: a systematic review. Obesity reviews : an official journal of the International Association for the Study of Obesity PMID: 21883871

Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network.

This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest.

CHRONIC PAIN CONDITIONS

Any condition that leads to chronic pain can contribute to obesity by increasing physiological and psychological stress. Pain also makes exercise more difficult to undertake and enjoy.

Osteoarthritis and Back Pain

Obesity is commonly associated with musculoskeletal pain and osteoarthritis, resulting in functional and motor limitations. Obese patients usually move more slowly, are less flexible and feel pain when performing tasks at floor level. There is a strong association between knee osteoarthritis and obesity. Degenerative arthritis resulting from chronic trauma associated with excess body weight develops primarily in weight-bearing joints such as the knee and ankle. However osteoarthritis can also be seen in non-weight-bearing joints, suggesting a systemic inflammatory response. Excess body weight is also closely related to lower back pain. Both static and compressive loading may damage the integrity of intervertebral discs. Increased biomechanical force can also cause muscle sprain and ligament strain.Sleep disorders are very prevalent among obese people. Obstructive sleep apnea is the most common disorder, but disturbed sleep may also be due to primary insomnia, or insomnia secondary to medications, medical or psychiatric disorders.

The presence of significant pain can promote immobility, leading to loss of muscle mass and reduced cardiopulmonary fitness. This can precipitate psychological and metabolic changes that promote further weight gain.

Patients with painful joints may benefit from water-based (non-weight-bearing) exercise and may require pain management before embarking on a weight-loss program. Obese patients requiring joint-replacement surgery are generally advised to lose weight (often in unrealistic amounts) before surgery, but this is very difficult if they are already partially immobilized by pain.

To complicate matters further, most commercial gyms are ill-equipped to handle the needs of obese clients, many of whom cannot go from lying down on the floor to standing up without assistance. Step classes and aerobics classes are in many cases ill-advised, and exercise machines and weight benches are not usually designed for obese users.

Fibromyalgia

Obesity is often associated with fibromyalgia, a common disorder characterized by fatigue, pain, stiffness in the trunk and extremities and a number of specific tender points. Fibromyalgia is more common in women than in men and is frequently accompanied by sleep disorders. Treatment of fibromyalgia may increase a patient’s ability to be physically active, and exercise has been shown to reduce the severity of fibromyalgia symptoms over time. As with severe osteoarthritis, starting with joint-sparing exercises may be prudent.

© Copyright 2010 by Dr. Arya M. Sharma and Dr. Yoni Freedhoff. All rights reserved.

The opinions in this book are those of the authors and do not represent those of the Canadian Obesity Network.

Members of the Canadian Obesity Network can download Best Weight for free.

Best Weight is also available at Amazon and Barnes & Nobles (part of the proceeds from all sales go to support the Canadian Obesity Network)

If you have already read Best Weight, please take a few minutes to leave a review on the Amazon or Barnes & Nobles website.

Osteoarthritis is one of the most disabling and painful conditions attributable (in part) to excess weight. Once established, osteoarthritis significantly reduces quality of life and mobility, often precipitating further weight gain and posing an important barrier to weight management.

A panel of experts (The Ottawa Panel) has now released a comprehensive set of evidence-based clinical practice guidelines for the management of osteoarthritis in overweight and obese patients, published in PHYSICAL THERAPY.

The recommendations are based on an extensive review of published articles with strict application of quality criteria to rate the strength of evidence (A, B, C, C+, D, D+, or D-) as well as experimental design (I for randomized controlled trials and II for nonrandomized studies).

Clinical significance was established by an improvement of ≥15% in the experimental group compared with the control group.

The panel decided on a total of 79 recommendations: 36 positive (21 grade A and 15 grade C+) - all were of clinical benefit.

Overall the data supports the recommendation that physical activity combined with (mildly restrictive) diet programs are beneficial for pain relief, functional status, strength and quality of life.

Although 5% reduction in body weight reduced pain and functional status, this degree of weight loss was insufficient to slow disease progression.

Both aquatic and land-based aerobic exercise were shown to be more effective in reducing pain than home-based strengthening exercises. On the other hand, land-based exercise performed in a gym that included strength, aerobic, stretching, and range-of-motion training was more effective in reducing pain compared with a home-based strengthening exercise program.

These benefits of exercise are independent of any changes in body weight and the authors suggest:

“The significant improvements in QoL among study participants with OA who were obese or overweight may be a reflection of mental health and social benefits associated with the participation in physical activities. Physical activity promotes psychological well-being by reducing feelings of fatigue, depression, and anxiety and improving self-esteem, confidence, concentration, and mental awareness. The social benefits of participation in physical activity include a reduction in the sense of isolation and loneliness, improved social networks and social capital, and increased community connectedness and cohesion.”

Importantly, the authors also note that:

“To the knowledge of the Ottawa Panel, there is no conclusive evidence on the most appropriate methodological scale to apply for OA and obesity research. The use of BMI, waist circumference, and body weight as valid indicators of successful weight loss in individuals with OA is debatable because these measurements do not discriminate between lean and fat body mass.”

Nevertheless, the panel recommends:

“…reducing weight prior to the implementation of weight-bearing exercise to maintain joint integrity and to avoid joint disease and dysfunction.”

How this weight loss is best achieved (and maintained) of course remains open to debate.

Importantly perhaps, the readers should also note that the review did not look at surgical studies, where patients generally experience substantially greater weight loss than with ‘diet and exercise’ alone.

I would certainly love to hear my readers’ experience of the impact of diet and exercise and/or weight loss on their osteoarthritis symptoms. What worked? What didn’t?

AMS
Edmonton, Alberta

p.s. the issue of osteoarthritis and obesity will be an important topic at the upcoming 2nd National Obesity Summit in Montreal next week.

Brosseau L, Wells GA, Tugwell P, Egan M, Dubouloz CJ, Casimiro L, Bugnariu N, Welch VA, De Angelis G, Francoeur L, Milne S, Loew L, McEwan J, Messier SP, Doucet E, Kenny GP, Prud’homme D, Lineker S, Bell M, Poitras S, Li JX, Finestone HM, Laferrière L, Haines-Wangda A, Russell-Doreleyers M, Lambert K, Marshall AD, Cartizzone M, & Teav A (2011). Ottawa Panel Evidence-Based Clinical Practice Guidelines for the Management of Osteoarthritis in Adults Who Are Obese or Overweight. Physical therapy PMID: 21493746