The revolution in osteoarthritis care for the 2020s

Posted On: 13th September 2019

World Osteoarthritis Day (14th-15th September) is marked annually and this year people will gather in Brussels to hear talks from experts about progress in the care of people affected by osteoarthritis (OA).  TDMR Europe is pleased to be a partner in this event, which aims to raise awareness and showcase innovations and new advances in treatments around the condition.

To mark the occasion our chairman, Anthony Leeds, who works in the Parker (arthritis) Institute at Frederiksberg Hospital in Copenhagen has written this technical summary of the evidence for TDR in helping people with knee osteoarthritis.

With ageing populations that are heavier than in the past, the prevalence of osteoarthritis is increasing. There is currently no medication or other intervention proven to slow the disease process. Treatment is palliative until surgical joint replacement, total or partial, becomes necessary. Weight reduction is a core feature of osteoarthritis guidelines but is difficult to achieve in those with limited mobility and who may have disturbed sleep (due to pain) and depression.

Formula liquid diets are composed of nutritionally complete soups and shakes formulated to provide all needed vitamins, minerals, essential fats and protein. They are always offered with a behavioural component and physical activity guidance. When used exclusively they are defined as Total Diet Replacements (TDR) and are either classified as a very low-calorie diet (VLCD) (<800kcal/d) or a low calorie diet (LCD) (800-1200kcal/d). TDR facilitates 1–2kg weight loss weekly with metabolic improvement in glucose, insulin, blood lipids and blood pressure in people with pre-diabetes, early diabetes, advanced diabetes, osteoarthritis, psoriasis, obstructive sleep apnoea, and heart disease. The first thorough study on the proteomics of weight loss with TDR has shown sustained improvements in proteins that are associated with inflammation and insulin-resistance (Geyer P et al 2016).

The Cartilage and Osteoarthritis weight loss trial (CarOT) undertaken in Copenhagen, recruited obese people with knee osteoarthritis (KOA) for weight reduction with TDR followed by four years of weight maintenance in two phases (one year followed by three years). Average weight loss at the end of 8 weeks TDR, either a VLCDor an 810kcal/d LCDfollowed by food reintroduction lasting 8 weeks  was about 12 kg (Christensen P et al 2011). After one year of the maintenance intervention, the diet group (1 meal replacement each day) maintained 11 kg weight loss (Christensen R et al 2014). Osteoarthritis symptom scores (recorded on a 100 mm Visual Analogue Scale) were significantly improved (less pain) after the initial weight loss and after one-year maintenance (no difference between the groups). Biomechanics studies showed that each 1 kg weight reduction reduced the peak knee load by 2.2 kg (Aaboe et al. 2011). Following the one year maintenance trial all participants were invited to join the LIGHT study (long-term intervention with weight loss in patients with concomitant obesity and KOA) a  3-year maintenance study comparing usual food with one MRP substituted for one meal daily with 5 weeks of an 800kcal/d TDR every four months.  Maintenance of the initial weight loss of 10% was achieved in 108 out of 153 participants who managed to complete the full programme, with no significant differences between the treatment groups (Christensen P et al. 2017). Furthermore, reduction of symptom scores and reduced blood pressure were maintained, demonstrating the effectiveness of such a programme on other co-morbidities associated with KOA. Imaging studies on subsets of these participants in the CarOT and LIGHT study showed that inflammation in the fat pad under the knee-cap (Ballegaard et al. 2014) and membrane around the joint (Riis et al. 2016) was related to the severity of knee pain, suggesting that reduction of inflammation associated with weight loss is the mechanism that results in pain reduction. A further recent proteomics study has shown that body mass is a major determinant of systemic low-grade inflammation levels and that weight loss, however it is achieved, reduces inflammatory drive (Wewer Albrechtsen et al. 2018)

Formula diet TDR programmes can deliver in a short period of time the amounts of weight loss needed to achieve major improvement in osteoarthritis with an increasing body of evidence for successful weight maintenance afterwards, and as such offer the overweight person with knee osteoarthritis an opportunity to have an improved quality of life.

Hear Professor of Rheumatology, Henning Bliddal, speak about the Copenhagen weight loss in osteoarthritis trials: