hello and welcome to this edition of joint action [Music] this podcast is dedicated to all those out there who have osteoarthritis on the show we unpack the truth and demystify the myths about the disease and its management if you have joint pain and want to know more about how to manage it from the world's best experts you've come to the right place without further ado it is time to welcome your host david hunter hello and welcome to this edition of joint action this week we have the privilege of discussing can osteoarthritis be prevented osteoarthritis is an extraordinarily prevalent and disabling disease and the prevalence appears to be increasing in large part compounded by the aging of the population but also with major contributions from demographic shifts as it relates to obesity are leading to increased numbers of people with osteoarthritis the two most important risk factors for knee osteoarthritis are obesity or overweight and joint injury they account for approximately 75 of a person's likelihood of developing osteoarthritis of the knee both are eminently modifiable but from a public health perspective we do very little if anything about modifying either we've previously had an episode on joint action from tim hewitt about the importance of joint injury and opportunities for prevention of neostatus rudder so if that's of interest focus on that episode but the focus of this episode is to shift to a larger risk factor namely overweight and obesity now this accounts for approximately 50 percent of a person's likelihood of developing the osteoarthritis and has important consequences for the hip and the hand as well now our society is becoming increasingly sedentary and consuming more calories and the number of people who are above the healthy weight is increasing as a consequence in many western countries this is now approximately two-thirds of the population there are important opportunities here to modify the leading risk factor for disease and the purpose of this episode of joint action is to examine these opportunities and look where we might go and we're joined by none other than your sronha dr eustronha is an assistant professor at the department of general practice of erasmus in the netherlands he was trained as a human movement scientist at a university in amsterdam for his phd he performed the first ever trial on the primary prevention of osteoarthritis supervised by two leaders in the musculoskeletal world professor cedar berber zinstra instrument professor koz the research direction that your aims to focus on is to improve the diagnosis and treatment of musculoskeletal disorders by general practitioners and physiotherapists and importantly to shift the treatment of musculoskeletal disorders to early phase disease yes welcome to the show thank you very much david great to have you here albeit it's a much larger distance than i would like but irrespective good to see your face and good to have a chance to chat about a really important topic now before we get into the topic of the day any conflicts or disclosures that you want to announce no no conflicts from my side now the first part of the show is me usually just probing you unnecessarily to try to get to know you a little bit better we've obviously had some opportunities in the past but haven't seen you for a little while so that things may have changed but if you had to describe yourself in five words what would they be in five words i would say i'm very positive i'm loyal i would say i'm a sporty type curious and maybe uh reliable all wonderful qualities and hopefully we'll dig a little bit more into the sporty and curious in a minute but i think as as researchers one of those qualities that really stands us in good stead is curiosity and the desire to go off and pursue questions that most other people wouldn't necessarily think are worth asking now on a day-to-day basis when you're at work and admittedly at home you're at home at the moment due to the impact of covert in the netherlands but when you're at work can you tell me a little bit more about what it is that you do yeah sure so we have a very active group of researchers at our department with a large number of pc students and research assistants focusing on musculoskeletal disorders in primary care and we do studies on the diagnosis and treatment and prognosis of many musculoskeletal disorders but we tend to have a focus on osteoarthritis also given the fact that as you mentioned hershey type burmazeinstein is our head of this research like you said we try to focus on the the early diagnosis and treatment and with early we mean in primary care we see most patients start in primary care and actually stay in primary care for their treatment so we think it's very important to have a good diagnosis and treatment and knowledge about this in primary care we have we run many trials we have access to a lot of large cohorts and we try to as a group inform each other motivate each other and really stimulate each other to come to a great research output so it sounds like a wonderful environment in which to work and i'm sure cedar is a wonderful person to be in charge of that and from your perspective i think you're obviously achieving a lot so it's it's an incredibly productive environment now when you're not at work what do you enjoy doing when i'm not at work i like to spend time with my two kids like i said i do my sports i play beach volleyball twice a week and well more recently i'm spending a lot of time in preparing to actually buy a van and build that into a camper van for the upcoming summers and that's taken a lot of time but i really enjoyed doing that sounds like hopefully a lot of adventures with family but are you a mechanic at home not really like i said i'm curious i like to prepare myself well and i found out that if i do so i am skilled enough to build some things in and around the house and this will be the next challenge actually now the netherlands doesn't necessarily strike people from australia is a place where a lot of beach volleyball would be played how did you first get into that so it's it's quite a big coincidence but very nearby there's an indoor facility for beach volleyball and actually my first introduction there was when i started human movement sciences we had a very active group of students there we did all kind of activities and one of the first activities was going to this indoor location and i fell in love with the sport so i do it now yeah like almost 20 years and luckily we have some good summers so sometimes during summer the most times it's it's actually outdoors fantastic i would imagine that's where it's meant to be meant to be played one of the highlights of going to the sydney olympics was actually having an opportunity to watch the beach volleyball where they had a court set up in the middle of bond beach in sydney and it was absolutely spectacular with the ocean as a backdrop but yeah one wonderful sport now i digress and let's get into the topic of the day and we're going to start off with just by getting a sense of the scope and magnitude of the risk associated with this but can you give me a sense as to what what is the magnitude of contribution of overweight and obesity to the development of knee osteoarthritis and i'm very happy for you to explain complicated terms in layman's terms about population attributable risk and those sorts of things but if you could just give me a broad overarching sense that would be brilliant yes sure yeah like you said in your introduction there the number of people with overweight or obesity is is rising so there are many people at risk for osteoarthritis due to their weight status and we think that about 25 so one in four of every new case of osteoarthritis is directly due to being overweight or obese i believe there are over 200 million people affected worldwide so imagine if one in four is due to overweight or obesity that's a huge number yeah and as you say the epidemiologic trends as such that it's likely to continue to increase and you know i've i obviously mentioned i think a figure of 50 in the introduction but there's a i think there's a huge variability in some of the studies out there that are quoted about what proportion of people like to develop new osteoarthritis as a result of different factors when you look at the contribution that obesity plays to the number of people who get hospitalized does it also play a role there my research really focused on the primary care so i'm not really expert in the treatment that's done in the hospitals and and what are the risk factors or complicating factors there but obviously there are a lot of people with overweight and obesity that get their joint replaced in the end state of osteoarthritis and i do think that there is actually an upper limit so i do think that people that are above a certain weight can't be operated upon because of potential complications so i'm sure that a lot of hobbies and um of what people get surgery but there are even a lot of people that don't get the surgery because they are too overweight or obese yeah and i i mean i think the main point i just wanted to make there is that about 90 of people who were in hospital for a joint replacement are above a healthy weight i mean yours as you suggested those people who might go on to get elective orthopedic surgery as a consequence of them being above a healthy weight are at much greater risk of complications and a poorer outcome now when we're talking about prevention of osteoarthritis you've led one of the only prevention studies that i'm aware of called proof which i think helped to establish some really important estimates around how much weight a person needs to lose and how long they need to lose that for in order to take in take effect do you want to just tell us i guess briefly in the first instance a little bit about proof and then from what you've found how much weight does a person need to lose in order to take an effect over what time period sure so for this study like you said we wanted to prevent osteoarthritis so obviously we included people without osteoarthritis but being at risk for osteoarthritis we know women are at increased risk for developing osteoarthritis of the knee and it usually starts around the age of 50 or 60. so we included women between 50 and 60 who were free of knee complaints but also had a bmi so a body mass index of 27 or higher so that's overweight or obese so those were three risk factors and we try to help them to lose some weight in the ones that were randomized to the intervention group and obviously we compare that to the control group and if you talk about the amount of weight they have to lose i think it's really essential for people to understand that so we aimed for five kilograms or five percent weight loss which is not huge but from the literature we know that even outside of osteoarthritis it has a very strong health effects so the risk for cardiovascular disease goes down things like diabetes all are affected already by five percent but in this age group i think on average people gain weight every year roughly about half a kilogram a year so of course we aim for weight reduction but i think that people in this age category if they will be able to remain stable with their weight they're already doing very good so i definitely want to make the point that we should not aim for large reductions and very unachievable targets staying at weight or losing like five kilograms or five percent could well be enough to have a health effect not only on osteoarthritis but also in other diseases how how long did you follow these people for in the study um and obviously how long was the more intense intervention that you were applying there so we tried to have an intervention that was really if effective would be very easy to implement in primary care so we had a fairly short intervention we focused on the first year to to try to help people to change their lifestyle and through that lose some weight in the end we follow people up to over six and a half years to really see the development of osteoarthritis because that's a very slowly developing disease so you need long follow-up times to see who is actually developing the disease but our focus of the intervention was really on the first year yeah now i recognize that the magnitude of weight loss improve potentially was not necessarily what you wanted to attain in the first instance but in the analyses that you did after the effect when you looked at the people who lost five percent of their body weight what was the magnitude of benefit in terms of the risk that you'd expect for the development of osteotomy those effects are actually quite strong if we look at those who lost five kilograms or five percent over the first year and we see that after six and a half years the number of knees that have osteoarthritis is down two-thirds so 66 percent lower incidence of osteoarthritis in the ones that actually lost five kilograms or five percent in the first year so that's we think an achievable target with strong effects on osteoarthritis actually yeah i mean i just again just to really stress that point the five percent weight loss over the first 12 months and when yours and his team looked at that at six and a half years a two-thirds reduction in the development of new osteoarthritis now do you want to tell us a little bit about your intervention and if you were to do the study again what type of intervention might you use to get people to lose weight and would it be the same yeah that's something that we thought about a lot like i said we really tried to have a easy implementable study so it wasn't very strict we try to offer people something that would match their needs but i think i would improve there so we offer people a 20-week exercise program where they were introduced to a fair amount of different studies that were available in their local neighborhood hopefully to find someone to do that with them and some activity that they could prolong after the intervention period and we also sent them to a dietitian to through motivational interviewing find where their motivation is to lose weight and help them to achieve that i think we aim to get people to do a sport and i think in a new trial i would actually try to get people physically active i think we might aimed too high taking the bike to the shop or to the work taking the stairs if you go into a building or do a walk every day i think that would be more achievable for this population and i think in the end might have a larger effect because more people can actually achieve that yeah as you say i think being pragmatic and implementable is really really important um and if someone can build this into their day-to-day life it's potentially more likely to be translatable now there's a lot of interest in other ways of achieving weight loss other than diet and exercise including the use of drugs to achieve that and bariatric surgery what are your thoughts on those two types of interventions as opposed to diet and exercise from a patient perspective or a patient from a person with overweight or obese i can see why taking a drug would be easier than changing your entire lifestyle but i personally think that the effects of taking drugs or doing surgery might be only short term if you keep your lifestyle as it was before you are very likely to gain weight after these interventions so i would really advocate the change in lifestyle with is more sustainable over time although harder to achieve but i think that that's a part where we as researchers and also um the healthcare system should do a good job in helping these people to actually achieve that yeah no i haven't looked at the study in a little while but cognizant of the fact that you did mris on these people as well did you have an upper limit for body mass index or weight in the trial itself and any comments that you want to make about limitations people may have in engaging in physical activity at higher class levels of obesity there is a strong correlation between the body weight and the amount of structural damage that we see in the knees so even in this population that we studied for this preventive trial that had no symptoms and also on a plane radiograph was free of osteoarthritis on mri we saw many what we might call early features of osteoarthritis which prevalence was definitely higher in those who had a higher body weight but the trends are equal for those with more structural features and those with with less structural damage in both groups the trends of prevention of the development of osteoarthritis are similar so although there is something going on in these knees it's it's not too late to actually do something about the body weight and with that prevents true osteoarthritis we mean the symptoms of osteoarthritis to prevent yeah let's dig into that a little bit more so obviously when you recruited these people when you looked at their x-rays by and large they were normal right but you've also done mris on these people that demonstrate early structural features that are probably consistent with osteoarthritis long-term if they were left to do that but what you're suggesting is that a lot of those structural features if a person was effective in losing weight actually showed improvements is that what you're suggesting that's what we anticipated and that's what we we thought would happen in the end we don't see many features improve over time in people that lose weight but we see that those who actually gained weight do show a larger progression over time so it seems that it's fairly stable in the ones that lose weight and it progresses in those who are gaining weight over our follow-up period so we're not curing osteoarthritis but i think and i hope that we are delaying it definitely by doing weight loss in this group and if we want to prevent these features we might even need to start earlier than doing it in people with between 50 and 60 years yeah a really important point and i think just to really stress to to people who are out there that the joint does have reparative potential if you catch it early enough there is an opportunity to reverse some of these deleterious trends now when thinking about the the weight loss that you attained why does that lead to a reduction in the incidence of osteoarthritis what's the mechanism of benefit here like you said there haven't been that many studies on the prevention in general we think that there are two mechanisms by which uh obesity leads to knee osteoarthritis which one is the biomechanic so the load the the load on the knees due to the excess body weight and if you lose that then the load on the knees is suggested to go down as well but we also see that the people with overweight and obesity have a low grade inflammation throughout the body which negatively affects the structures in their knee joint and by losing five kilograms or five percent we see uh improvements in this low grade inflammation so less inflammation and less burden on the tissues in in the knee joint so those are the two main mechanisms through which we think that this is beneficial so we've spoken a bit about osteoarthritis and obviously in in the study where you've demonstrated this you've seen in those people that lose weight they get less symptoms and and less x-ray change consistent with osteoarthritis what other benefits potentially could be attained through weight loss in these people who might have other health conditions or predisposition to other health conditions as well we know that many people with osteoarthritis also have co-morbidity so other conditions we don't know that much about which conditions comes first and which one calls the other but in general these people with overweight and obesity are at risk for many other chronic conditions like the cardiovascular disease like diabetes and weight loss has effect on all these also on the risk for certain cancers we even see it now in this pandemic that those with overweight or obese have more complications and are more likely to be hospitalized so there are many many effects of an excess body weight but also beneficial effects on after losing weight on all these conditions so and that's one thing that was one of the questions that we had with our trial there's this saying saying there's no glory in prevention so these people that were in our trial why would they change their lifestyle to prevent osteoarthritis they don't have symptoms so how do you keep these people motivated to lose their weight because they can't experience any pain relief and if it's done well they will never do so so how do you know that it's effective so i think for preventing osteoarthritis through weight loss we also need to focus on the risks for other diseases and other outcomes that people can actually experience to gain some motivation and and keep to their intended goals and and their lifestyle changes yeah and that's one of the issues that i i guess i wanted to get into is that you know you've done a six and a half year study you've got a large population of people that you're engaging over a long period of time in a group that doesn't have much of any symptoms to motivate them to continue to engage how did you encourage them to continue to remain engaged and what what barriers and challenges do you see to to the maintenance or both both the attainment of loss but also the maintenance of that loss yeah for our study we we just had very regular contacts with them we visited every patient at home every six months to have a sort of build a personal relation to to check how they are doing and also of course have the data collection for our trial but that's actually one of the main challenges in this area of research so there have been studies on weight loss in people with overweight or obesity not necessarily to prevent osteoarthritis but in general but many studies are of short-term duration so and after a year or maybe two years but we know to have a sustainable effect on health you need well maybe four years five years of follow-up to see whether after such a long period people still are at a more healthy weight and i think that's that's where we lack some knowledge how really to have this long-term adherence and long-term weight maintenance that's that's something that well in osteoarthritis it definitely hasn't been done but also outside of that that's something that worth to really focus on yeah it's uh it's incredibly hard and you know we're obviously talk sitting talking about it here and probably oversimplifying the whole the whole context and the challenges that people face and trying to trying to lose weight um and we don't we definitely don't want to seem like we're we're simplifying that it's it's a huge challenge but i think some of the cues that are yours is talking about there both both in terms of you know regular contact with a person who's going to coach and counsel you through that process some of the education around the importance of losing weight both for osteoarthritis but also for the other diseases that might be affecting that person i think are really incredible places to start now not everybody is at risk of developing osteoarthritis how does one know if they are at risk so in which part they might want to embark upon that long intervention we've just been talking about yeah so we know there there are a couple of risk factors and that's what we uh the ones that we use for our trial but i guess there there are some other aspects but that's what we also focus on in in our research is that there are actually quite some patient reported outcomes that are predictive of who has an increased risk of developing osteoarthritis so something like pain when going up the stairs or standing up from a chair or the feeling of morning stiffness or some fairly simple physical exams that a gp or a physiotherapist could do like joint line tenderness we see that these are early signs that if present put people at risk of developing osteoarthritis but i think in regular healthcare these are ignored and that's how we try to shift the focus towards early detection and early treatment is by trying to educate these clinicians by not ignoring these early signs because nowadays if someone comes at a gp with pain sometimes pain when you go up the stairs and like some mild morning stiffness normally these people are sent home and are told come back when it's more severe now we know that when we start treatment when the symptoms are severe our treatments are not very effective so i think that well we can't call them patients because they don't have the complaints but that people who are at the age age range of 40 to 60 where oa normally develops and they have these signs i think they should really be educated and treatment should already start with these early signs so i think that both the patients and the clinicians should really take these first signs very seriously yeah really important point and you know i think if if one looks at some of the the literature there around what you're talking about if we wait until a person has more constant symptoms as opposed to intermittent activity related symptoms the interventions that we have there are less likely lead to a longer-term meaningful benefit now let's work on the assumption that there's now good evidence to suggest that we get a person to lose weight and we can prevent by virtue of their five percent weight loss about two-thirds of the disease from developing most healthcare systems are pretty good at delivering mris to assess a person's joint to get joint replacements on a person that has osteoarthritis but they're not that good at public health interventions what are the barriers we have to implementing the types of changes that you're talking about in modern healthcare systems yeah that's that's a very good point like we discussed it's very complex to have people change their their lifestyle so it should be definitely a multi-disciplinary approach and that's where i think we have the largest challenges to have multiple disciplines helping these people to change their lifestyle and for every individual it will be different so of course one they would need some assistance with getting physically active while others need to change their the way uh and and the type of food they consume so it's very complex it's definitely not a one-size-fits-all and it really should be tailored to the individual but then next to that you can question whether it's the healthcare system that should take this role on and whether or not it's more a population approach that the government has to implement in the sorts of food that are offered how we challenge people to be physically active so not on the individual but truly on the population i think that's also something that really could have uh very strong effects on on the number of people that have that have overweight or obesity yeah it's a really important point and obviously you know a lot of countries rage against what we call the nanny state where governments decide a lot for people that they may not necessarily feel strongly and get concerned about losing individual freedoms in that context you know we we know that by encouraging physical activity by reducing junk food or and you know taxing unhealthy foods and by increasing healthy food alternatives and subsidizing that you can make a massive difference unfortunately many countries around the world are not necessarily brave enough to adopt those policy changes but you know i think what you've demonstrated in proof is just you know a small benefit that can be attained to health care by virtue of some important policy changes as you suggested if we leave this all to individuals to change behavior it's going to be a lot more complicated all right well i'm probably digressing into something that i know very little about but yes what are the most pressing research needs in this particular field so if we talk about this area of prevention i think for a researcher we can think of who is at risk and i think we can think of what interventions we think that might be effective in these groups but like we already discussed oa is such a slow developing disease if we keep measuring the incidence of osteoarthritis the way we do with radiographs and based on chronic pain it takes many many years for oa to develop so if we want to facilitate doing preventive studies uh i would say for a research perspective the evaluation and development of what we call surrogate outcomes so outcomes that change on a short term that actually predict the long-term osteoarthritis or short-term oa outcomes that's definitely something that would improve the the research on this early phase because it's it's undoable to have hundreds of people followed for many many years in in the study to before we have any results so that's definitely one of the main challenges in this research area i think they're prognostic markers so it's so so important now in the interest of just learning a little bit more about who you are and what makes you tick why do you do what you do what motivates you i think uh in general it's the it's a curiosity and going down such a road and really find this new knowledge is something that i really enjoy but also and that's something that is a bit harder in these times the collaboration and interaction with with smart people and interesting people not only on their own departments and my own phd students or colleagues but also internationally i really enjoy to challenge one another with new findings with with small ideas into and and to help each other to to really improve the way we uh treat people with with musculoskeletal disorders yeah we're really lucky to have the jobs that we do i think it's uh wonderful to have that intellectual stimulation but i think also as you suggested you know we have a wonderful community and i think a very collegial community that understands that this is a massive problem uh that we will hopefully interrogate and fix together now if you could have a billboard with anything on it what would it be and why well if i if i take that question into the the research and the focus of my my research and a billboard might not have enough space to explain this but i really would try to educate or inform a large audience that the human body is not a machine we tend to uh compare our body with like a car if something is broken it needs to be fixed before you can use it the human body is a lot smarter than that the it has a amazing capacities to to restore damage and being active is a very good stimulation for the body if more people understand that that might lead people to become active if they have a sore knee instead of being inactive and more like like these changes that can really help their symptoms or other diseases it's a really important message but as a classic academic you're you've just written an essay on a billboard and the hopefully people get the message now is there any one piece of advice knowledge or wisdom that you'd like to give for people with osteoarthritis and passing so you're shifting here to people with osteoarthritis i think it's it's related to the the topics that we discuss for the prevention i think also in people with the disease staying physically active and on a healthy weight is very important and of course that's one of the advantages that people without osteoarthritis that want to prevent have overdose with symptoms they don't have the symptoms so they it's probably easier to be physically active but i think also for people with symptoms it's very important to get your daily exercise of course not to overload your joints and have a severe increase of symptoms due to that but i think being physically active and trying to be at a healthy weight is very important for for for all of us and so also for people with osteoarthritis it's a great way to end and you know as you said a good segue between those topics of prevention but also treating people with osteoarthritis there's a lot of really important parallels there you'll really appreciate you uh taking the time out of your busy schedule to have a chat with me about such an important topic and bringing your wisdom and thoughts to an area that you've really contributed to a lot um i do want to wish you well because it seems like the netherlands is going into another spike but hopefully you'll stay safe through all that through all of that thank you so much thank you very much david stay safe that is all for this episode of joint action if you like what you hear and want to support us please rate us on your favorite podcast platform alternatively visit the website www. jointaction.
info to post a question donate to our research or send us some feedback between now and next time please do take care of yourself stay strong and stay active thank you so much for listening thanks for listening to joint action with david hunter if you like our show and want to know more check out www. jointaction. info if you have any questions you can email us at hello at joint action.
