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A recent article published in the APA’s magazine discussed wether physios had a place in prescribing or delivering a weight loss intervention for osteoarthritis (OA). The particular intervention looked at an education tool for physios teaching them about weight management. It claims to include information about a ‘low-calorie ketogenic’ diet and biosocial elements of obesity. The tool was developed by endocrinologists, obesity researchers, tertiary education specialists, practicing physiotherapists and dieticians with experience in weight loss interventions for OA. I argue that they are ignoring key components of the management of osteoarthritis, that this program is selective in the data they are collecting (or at least sharing), and are presuming that weight loss is a safe and effective tool for all people with OA.

One of the most profound absences was the ‘psych’ part of the biopsychosocial elements of osteoarthritis. Instead they are only focusing on the biosocial aspects. I find this an interesting choice as in the management of all other conditions we are reminded to consider ALL the ‘biopsychosocial’ components. In this program, who is looking at the psychological component? Or perhaps it is being entirely ignored, in which case we need to do better. the ‘psych’ component is within our scope and we deliver psychological interventions every time we deliver any form of pain education or motivational interviewing. Are we suggesting that the psychological component conveniently no longer matters? What is more, the inclusion of information on weight stigma is helpful and a step in a positive direction. However, you cannot peddle intentional weight loss without perpetuating weight stigma. It is just that simple.

Throughout the article we are given snippets of data that suggest a ‘positive’ result – patients that took part in the diet and exercise program lost more weight than those in the exercise component alone. But at this stage it is unclear what this actually means clinically for patients. There was no information regarding reduction of symptoms or improvement of quality of life. Given the study is so recent (unpublished) there has not been any follow up. Given what we know about weight loss, the reported loss of weight is unlikely to be sustained and may even have negative consequences.

The article also suggests that weight loss is safe and effective for people with osteoarthritis which is not always the case. Many clients may have a history of an eating disorder (or at the very least disordered eating) making weight management an inappropriate intervention. Not only this, but dieting is a huge risk factor for the development of an eating disorder and people of all ages without a prior history are still vulnerable. While this study suggests that educated physios feel comfortable delivering dietary advice, it is important to note that nutritional advice should come from a dietician who has trained specifically in this area; there is a reason that we work in multidisciplinary teams, we don’t see psychologists rehabilitating an ACL do we?

I’d also like to acknowledge that the Knee Clinical Care Standards (2017) that recommend weight loss are superseded by the more recent OARSI guidelines that state that weight loss is not required for the treatment of hip or knee OA.

In summary, there are studies that suggesting that Physios can be trained in the delivery of exercise. But the question I ask is: should we?

As the anti-diet movement has become more popular diet culture has contorted itself to fit the ‘done with dieting’ mentality. Weight watchers are no longer calling themselves a diet, Noom (definitely a diet) markets itself as ‘not a diet’ and there is the old favourite ‘it’s not a diet it’s a lifestyle change. All of this is bogus. If you are modifying your diet and exercising to lose weight, it’s a diet. Recently an account followed me and I went to check out their page as I normally do and found the following bio

“Life & Weight Loss Coaching for Mid-life Women who are Done with Dieting. I can help you lose weight, feel great and confident in your body forever’

Let’s get past the random capitalisation that makes no grammatical sense whatsoever and deconstruct what this is actually saying. First it says that they are a life and weight loss coach for middle aged women. Now, that all seems pretty clear even if it is rooted in diet culture. Then she goes on to say that it’s for people who are ‘done with dieting’ now this completely contradicts her first statement – if your goal is to help women lose weight through diet and exercise you are not ‘done with dieting’ in fact you are outwardly promoting it. Just because it doesn’t have a fancy name doesn’t mean it is not a diet. The final part is completely misleading. If your methods involve dieting and losing weight in order to ‘love your body’ you are simply going to fail. Dieting and losing weight is not a long term solution to body love or even body acceptance. So long as your self-esteem comes from losing weight or being a particular size you ultimately going to feel worse when you inevitably put the weight back on.

This brings me to my second point. Many people who are promoting these ‘lifestyle changes’ and ‘non-diets’ are ‘instagram influencers’ or ‘life coaches’ who have no qualification in health – dietetics or otherwise. So why is this important? health professionals such as dieticians, exercise physiologists or physiotherapists are regulated professions and we are obliged to practice in a way that is aligned with the professions standards and evidence. Instagram influencers are not regulated and thus can get away with saying almost anything. It’s how people like Pete Evans and Belle Gibson get away with what they do. Had either of them been a health professional regulating bodies would have cracked down on them. Instead they were able to make claims that they ‘cured cancer with healthy eating’ and that there is a light that ‘cures covid’. Instagram influencers and life coaches (both unregulated) often share misleading facts such as ‘dairy causes inflammation’ (it doesn’t – see this systematic review)or a certain food is ‘toxic’. Dr Tim Crowe, an advanced accredited practicing dietician critiqued this culture in his article ‘Broccoli is bad for you, like, really toxic bad’ where he demonstrates how ill-informed influencers, life-coaches and unfortunately some bad health practitioners may selective cite certain scientific articles, take the information out of context and labelling them as ‘toxic’ or selling them as ‘superfoods’

So lets get past the bullshit and acknowledge what these ‘lifestyle’ changes actually are and call them by their real name…diets.

Osteoarthritis (OA) is one of the most common conditions with 1 in 5 people over 45 showing arthritic changes in at least one joint. It also accounts for 19% of the burden of disease from musculoskeletal conditions. As such, there is a huge focus on effective treatment of this often very painful condition. One of the key risk factors identified in OA is body weight (Felson & Chaisson, 1997). One explanation for this is the mechanical changes including the increased load, knee varus/valgus laxity and poor knee alignment (Felson et al., 2014; Sharma et al., 2000). However, given that people with high BMIs have a higher rate of OA in non-weight bearing joints mechanical stressors cannot be the sole factor (Wang & He, 2018). Researchers have suggested that the inflammatory response that is potentially caused by obesity impacts on the development of OA. This article will discuss whether this statement is accurate or whether there is an alternative explanation.

First, I’m going to talk a bit about the pathophysiology of the inflammation pathways involved in those with a high BMI and how this may impact the development of OA. Adipose tissue is involved in the production of inflammatory cytokines, chemokines and metabolically-active mediators known as adipokines. Two of the key adipokines are adiponectin and leptin have been linked with the inflammatory response in cartilage. Additionally, macrophages (which are derived from adipocytes) produce number of inflammatory cytokines that have been found in the synovial fluid, cartilage and subchondral bone indicating their role in OA pathophysiology (Wang & He, 2018).

So how does this impact on OA? OA was once thought to be a result of ‘wear and tear’ of the joints. However, it is now understood that cartilage metabolism is involved in the pathophysiology of OA (Sowers & Karvonen-Gutierrez, 2010). Thus the presence of higher levels of inflammatory cytokines in synovial fluid, cartilage and subchondral bone suggest that the inflammatory response to a high BMI may influence the inflammatory component to OA.

Conversely, I would like you to consider the fact that inflammation is also associated with weight cycling, that is the weight loss/weight regain cycle (Bacon & Aphramor, 2011). It is known that weight loss is unsustainable for the majority of people and there is no evidence that people can maintain the lifestyle factors (Bacon & Aphramor, 2011). For example, the women’s health initiative (which is the largest and longest RCT investigating a dietary intervention) tested a low-fat diet that reduced intake by an average of 360 calories per day and significantly increased their physical activity. Their final analysis showed that there was practically no change from their starting weight and abdominal fat actually increased. Attempts to lose weight are associated with weight cycling and these attempts to lose weight are more common in people with high BMIs (Kruger et al., 2004). Thus, people who have high BMIs are likely to have inflammation caused by weight-cycling. There is, therefore, an argument to be said that it is weight cycling and not a high BMI that leads to the inflammation associated with OA.

Furthermore, even if having a high BMI is associated with with a degree of inflammation, given that weight loss attempts lead to weight-cycling which in turn leads to increased inflammation are we not exacerbating one of the contributing factors to OA?

For the above reasons it is my belief that there is a compelling argument for weight-cycling being a risk factor for osteoarthritis as opposed to high BMI alone.

References

Bacon, L., Aphramor, L. Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutr J 10, 9 (2011). https://doi.org/10.1186/1475-2891-10-9

Felson DT, Chaisson CE. Understanding the relationship between body weight and osteoarthritis. 1997; 114671-81. 10.3402/pba.v2i0.17470

Felson DT, Goggins J, Niu J, Zhang Y, Hunter DJ. The effect of body weight on progression of knee osteoarthritis is dependent on alignment. 2004; 50123904-9. 10.3402/pba.v2i0.17470

Kruger J, Galuska DA, Serdula MK, Jones DA: Attempting to lose weight: specific practices among U.S. adults. Am J Prev Med. 2004, 26: 402-406. 10.1016/j.amepre.2004.02.001

Sharma L, Lou C, Cahue S, Dunlop DD. The mechanism of the effect of obesity in knee osteoarthritis: the mediating role of malalignment. 2000; 433568-75. 10.3402/pba.v2i0.17470.

Sowers, M. R., & Karvonen-Gutierrez, C. A. (2010). The evolving role of obesity in knee osteoarthritis. Current opinion in rheumatology, 22(5), 533–537. https://doi.org/10.1097/BOR.0b013e32833b4682

Wang, T., & He, C. (2018). Pro-inflammatory cytokines: The link between obesity and osteoarthritis. Cytokine and Growth Factor Reviews, 44, 38–50. https://doi.org/10.1016/j.cytogfr.2018.10.002

My name is Holly Shuttleworth and I am a physiotherapist based in Melbourne Australia. I graduated from the University of Melbourne with a Doctor of Physiotherapy and I am a parent of two ginger cats named Emma and Isla who we recently adopted. I am passionate about social justice, equality and mental health and try to incorporate these values into my practise as a physiotherapist.

I am determined to practise physiotherapy from a place of inclusivity for all people regardless of size, gender, sexuality, disability or race. Thus, I practise from a ‘Health At Every Size’ (HAES) perspective where I encourage healthy behaviours including regular exercise. I came to this position after my own struggles with body image issues and an exercise addiction. I was introduced to HAES by my dietician who showed me a new way of practising in a holistic and compassionate way.