13. Osteoarthritis: Can nutrition play a role in managing osteoarthritis symptoms?

Nutrition Unlocked // EP13 Osteoarthritis: Can nutrition play a role in managing osteoarthritis symptoms?  

Jackie: [00:00:00]  

// INTRO - JACKIE // 

Jackie: Nutrition fuels our bodies and minds. Our strength, mobility, energy, and even mood rely on the right nutrition and scientists are continually uncovering new secrets. Welcome to Nutrition Unlocked, the podcast celebrating innovations advancing the role of nutrition and health, sponsored by Nestle Health Science. 

In each episode, we talk to experts from around the world about the latest topics in the science of nutrition. 

On today's episode, we'll be talking about the role that nutrition plays in managing the symptoms of osteoarthritis. Our host is Anna Mohl.  

// INTRO - ANNA //  

Anna: Welcome back to Nutrition Unlocked. I'm Anna Mohl and in this episode I'm looking forward to discussing an important topic that impacts many of us, especially as we age, and that is osteoarthritis. 

We are joined today by Professor David Hunter, rheumatologist, epidemiologist, Professor of Medicine in Florence, and co-chair of Rheumatology at the University of Sydney. 

In this episode, we'll be unpacking the important role [00:01:00] of nutrition in osteoarthritis. A very warm welcome, David. I am very excited to have you with us today.  

// MAIN CHAT //  

Anna: So, let's get things started. World Arthritis Day is on the 12th of October and I'm sure there are probably a few of us out there who have heard about osteoarthritis but don't really know a lot about it or how it impacts people's lives. 

So maybe you could start us off with a summary of what is osteoarthritis and how does it impact people's lives? 

David: Yeah, no, it's a great way to start. This is an incredibly common problem. So, there's about 600 million people around the world who have osteoarthritis. It's the main reason why a person might present complaining of pain and limited function in their knees, their hips, their hands, but it can affect any joint within the body and usually relates to some structural damage that's occurred to a joint and some pain then begins emanating from that joint that's primarily affected.  

And then as a consequence of that, people find it difficult to do things. So, it's an activity related pain. So, they might find it difficult to walk up or downstairs, to go and play tennis, to play golf. And it's the most common reason why a person might get a joint replaced. 

So, it's very common and it's something we can do a lot about.  

Anna: And how do most people first discover they have osteoarthritis? Is it because of what you describe they find suddenly they're limited in their ability to do things they've always been able to do, or they've always enjoyed doing? 

David: Yeah, the most common reason a person finds out about it is they start noticing activity related pain. So, for example, they start noticing pain going downstairs, or walking up a hill, or squatting down to the ground or getting in and out of a car or a chair. And often times that's quite intermittent and just specifically related to that activity, but over time it may become more frequent and potentially also occur at rest, but usually it's an activity related pain that they present with.  

Anna: And you mentioned, 600 million people is quite a large number of people, you mentioned that it affects joints and you specifically mentioned hips, knees [00:03:00] hands. Why those joints or why those body parts specifically? 

David: The most common joints that are affected are the knees and the hands. And the main reason why a person might get osteoarthritis in their knees usually relates to weight or injury to that joint. Distinct from that, for hand osteoarthritis, the most common reason a person develops that is because of genes that they're born with. Sometimes it's occupation, so certain occupations that involve a lot of hand activity can predispose a person to it. But the main reason here is a family history.  

So they're a little bit different, as to why a person may get it in the first place, but for both of them, we know that excess weight plays a really important role. 

Anna: So, you mentioned a number of different factors. Are there any other risk factors that people should be aware of and should just keep an eye on, maybe even from an earlier age than they might normally start thinking about osteoarthritis? 

David: Yeah, so the best current data would suggest those really important public health factors about not having enough physical activity, carrying excess weight. Certain nutritional factors, and they're particularly deficiencies in vitamin D and vitamin K can play an important role. Injury to the major joints and we often hear about people who play impact sports tearing their ligaments in their knee or tearing the meniscus in the knee.  

And for most of those people, they're young people and oftentimes they're going to go on and develop osteoarthritis in that joint that they've torn that ligament in within 10 to 15 years. So, it has a huge effect that way.  

So, there's lots of different reasons why a person can develop osteoarthritis and many of them, and this is hopefully the more important message I want people to take away from this is many of them are modifiable. And if we did more about, you know, our weight as a community or preventing joint injury from occurring, we'd prevent the majority of this disease from occurring in the first place. 

Anna: I think that's a very important message and we're gonna try to weave that through as we have our conversation today.  

You touched on something that I want to follow up a little bit more on, you mentioned a bit about deficiency in vitamins D and K. Maybe we can use that to pivot and talk a bit about the link between nutrition and osteoarthritis. 

How does our nutrition connect to this condition and what can we do to manage our nutrition to either avoid getting symptoms or manage them or prevent it in totality? As you mentioned, this is a condition that's modifiable and potentially preventable. 

David: Nutrition plays an incredibly important role in why a person may develop disease, but also why it might continue to get worse. 

If we look at the reason why a person may develop osteoarthritis and the structural changes that go along with that, we know that mechanics of the joints play a really important role there, and so that's both load, but also the structural integrity of the joint, and we also know that inflammation plays a really important role.  

So from a mechanical perspective, one of the main reasons why biomechanics, so the structure of the joint might become altered, is because of excess load or excess weight. [00:06:00] We also know that inflammation plays a really important role. So certain factors in the diet play a really important role in either reducing inflammation or increasing inflammation. 

And then, the joint is made up of bone, cartilage, ligaments, muscle. And so the micronutrients and ingredients that go into making up those tissues, whether that be, you know, bone, particularly vitamin D and vitamin K plays a really important role in cartilage, protein and muscle, inflammation in the joint plays a really important role. 

So there's lots of different nutritional factors that play critical roles in how a joint is made up. 

Anna: I think I take away a couple of things here.  

One is :the criticality of weight management, which we know is critical for so many health factors. And then the second one that you touched on is bone health. Which obviously is very important in this. Does muscle strength or muscle fitness play a role in this as well? 

David: Yeah, all of the above. So let's unpack the weight a little bit first, Anna, 'cause to be honest, that's the most important [00:07:00] factor here.  

And so if we talk about the community as a whole, and in many developed countries, the US, Australia, and other countries such as that, about two thirds of our population are above an ideal body weight. For a person that is at risk of developing osteoarthritis, that accounts for about 50% of the reason why they might develop osteoarthritis in the first place. 

And so, for every additional five kilograms a person might carry, it increases your risk by a third. We also know for a person that's got osteoarthritis, for every additional kilogram that they carry, there's four kilograms of load goes across the joint. And so, if we get a person's body weight down, it can make a big meaningful difference to the symptoms that they feel from their disease. 

Bone, again, is a really important constituent part of any joint. Some of the reasons why that plays a really important role is in dissipation of some of those forces that we know go across the joint. And it plays a really important role in helping us to carry ourselves around through just the way our skeleton [00:08:00] moves. 

And so we really need to pay heed to the fact that our skeleton and the physiology of our skeleton needs to have ingredients to make that up. So for us, in our diet, the two ones that we tend to pay greatest attention to are things like vitamin D and calcium. And oftentimes, in the western diet, vitamin D is often not sufficient in intake and we really require in order to metabolize and make that. 

And likewise, calcium is often insufficient. So more frequently than not, this is a disease that tends to affect women. About two women are affected, to as many men. And in addition, often after the age of menopause, when we know often times the integrity of bone becomes problematic. So we pay a great deal of attention to both vitamin D and calcium ingestion in the diet, making sure that's adequate. 

Just quickly coming back to muscle. Muscles are a really important factor here. If we look at why a joint might develop osteoarthritis, joint [00:09:00] stability plays a really important role and the main stabilizers for our joints are those muscles.  

So again, it's important from the perspective of maintaining good health in your joints, that you maintain strong muscles, you remain active because our joints will benefit from that. 

And again, protein is another really important constituent in the diet that plays a role there.  

I want to go a little deeper on the food nutrition piece and then I want to come to lifestyle and exercise. So if we talk about food and nutrition, what are the kinds of diets, what are the kinds of foods or supplements that you recommend people take? 

David: The most important factor here, is excess caloric intake or excess energy. So more often than not, the diet we're advocating for people to use is a low energy diet, in combination with increasing their physical activity. So they just increase their caloric burn. Because as much as it's a very complicated equation, if we're going to get a person's weight down, it's very much, you burn more, you take in less, you're going to lose weight. So we try and keep [00:10:00] it relatively simple. So oftentimes, we're very much focused on low energy diets in combination with physical activity.  

For a number of people, obviously they're very interested in active ingredients that might help to reduce the likelihood of developing osteoarthritis or reducing inflammation in joints. And so we spend a bit of time talking about anti-inflammatory foods and or diets to help foster that.  

So we know that the omega 3 fatty acids, for example, that you might find in fish or krill or flaxseed oil are beneficial in terms of reducing inflammation in joints. In contrast, saturated animal fats, so the omega 6 fatty acids, tend to play a disingenuous role here and increase inflammation. 

So oftentimes you're trying to reduce the saturated animal fats, the omega 6, and increase the omega 3s. So they play a really important role and we're talking about trying promote diets, such as the Mediterranean diet, to promote reduced inflammation in joints. So, you know, foods that are [00:11:00] high in omega 3 fatty acids, high in fiber to help foster changes in metabolism that will reduce inflammation in joints. So, legumes, beans, grains, those sorts of things that are beneficial both in terms of fiber and reducing inflammation.  

Anna: That's great to hear. It seems that the Mediterranean diet has a positive impact for a lot of health conditions. I think on a number of the podcasts or when I just talk to people, you read a lot about nutrition and what are the beneficial diets. The Mediterranean diet is one that often comes to the top of the list. 

I've also read that there are certain micronutrients that are important. We've already talked about calcium vitamin D, you mentioned vitamin K earlier. Are there other ones that people should keep an eye on to make sure that they have the right level of bone health? 

David: It's a good point and I don't want to necessarily make it too complicated. But there is some suggestions that certain micronutrients play an important role here in bone health. I guess I'd like to [00:12:00] point towards selenium and iron and so we know that in certain parts of the world, you know they're endemically poor in terms of their nutrition, that selenium deficiency and iron deficiency can play a really important role in predisposing to arthritis. The converse of that is also true. It's so that if you have too much iron, and particularly too much copper, that it may actually increase your osteoarthritis. 

So there's probably a sweet spot here. At least from the viewpoint of bone health, some of those factors do play an important role. It's important you get enough, but it's also important you don't get too much. 

What's your view on the, I'll call it a comparison or the choice between a more natural supplement versus a drug. People have personal views. What's your professional view? 

David: My professional view is I think most of these have a role somewhere. And it's really important to engage the person who has the osteoarthritis in an appropriate conversation so they know what the evidence actually says. So, does this [00:13:00] help? Is it likely to work long term? What are the harms? What are the costs? And they're the same conversations we have, whether this is a supplement or a drug. Obviously, drugs are much more heavily policed, if you want to call it that, by the regulatory authorities than our supplements. But all supplements also have the potential to have some side effects. It's not, you know, this is natural, therefore it's safe and it's not going to do any harm. Some of them do have harm. So it's really important that people who are out there, who are thinking this is the panacea for all of my ales, understand that they're not without harm. 

Anna: I think that's a good reminder. I think whatever you're putting in your body, you want to understand what the implications are, right? Nothing is perfect. Good to understand the pros and the cons and then always just listening to your own body, right? How are you personally reacting to something I think is another important piece.  

David: Yeah, and you know, undoubtedly, if you're going to try one of these things, do it in a sensible way. So you actually say, okay well, I'm actually going to see, does [00:14:00] this make a difference to my pain, to my function? Am I better two to three weeks after taking this, than I was before using this? And if you're not, don't continue taking it because if there's no benefit as far as your symptoms are concerned, there's no rational reason to continue to take it. 

Anna: I want to hone in on the area of pain management a bit, because that is something that you hear a lot of people talk about and that, as we've already touched on, is something that often triggers people recognizing or coming to talk to a doctor about osteoarthritis. 

So what role can nutrition play in improving pain management for osteoarthritis? 

David: Nutrition plays an incredibly important role here. So let's look at the core for osteoarthritis as they currently stand. And this is what most guidelines throughout the world would advocate for. 

The core treatments are maintaining a healthy body weight, bettering and improving the strength of the muscles around the joint. Promoting physical activity and understanding the disease. And so for all of those elements, whether we're talking about weight management, [00:15:00] getting stronger, getting more active, nutrition plays a really important role.  

Let's talk about weight management. The key elements here are those low energy diet and increasing physical activity, as I mentioned before. If you're going to get active and you're going to improve muscle strength, you need the constituent parts of those muscles to help that. So, you know, making sure that your protein intake is adequate, that similarly you're getting enough energy in your diet to undertake the physical activity and strength work that you otherwise want to be able to do and obviously to stay well hydrated. 

So there's lots of key reasons why nutrition plays a really important role. And as we touched upon before, some suggestions that reducing factors in the diet can also play a critical role here. So actually having a well balanced diet that's similar to the Mediterranean diet in terms of its constituents can also play a critical role here. 

So, if we're looking at pain management, all of those things can play a really important role and they're the core treatments well before you even need to start [00:16:00] thinking about taking any medication such as an anti inflammatory for pain. 

Anna: No, I think that's good advice. We've talked a little bit about, that osteoarthritis can often impact people as they're getting older. And one of the things I wanted to talk about is muscle loss that people will often experience just naturally through the aging process and sometimes also the increase in fat tissue. 

And I wanted to hear a little bit about how that affects osteoarthritis. I would imagine that it's linked a little bit back, as you've described before, to the diet, to weight management, to weight loss, but let's talk a little bit about the impact of muscle loss and potential fat gain during the aging process. 

David: So that if we look at the average person, and not to suggest that there is an average person with osteoarthritis, but if we look at populations of people that have osteoarthritis, we know that muscle volume, muscle quality, muscle strength, all decline with age. 

And some of the factors that are going on there as we know that fat is starting to infiltrate into these areas, that a person's not necessarily doing as much activity as they may have been doing before.  

And so, you know, I guess the corollary of that is that we see that's contributing to the development of the disease. We see that's contributing towards why the disease might continue to progress and why symptoms also get worse over time.  

And so a lot of our treatments are really targeting towards trying to improve strength, improve muscle quality, improve muscle volume. And so that might come through focused strength work. 

And generally, what we're suggesting here is a person does some strength based work. on the muscles surrounding the joint that are primary stabilizers at least three to four days a week, ideally in partnership with a physical therapist or an exercise physiologist, so that you're doing it well and you're using the appropriate technique and you're not hurting yourself. [00:18:00]  

In addition to that, there's obviously some nutritional support that might be beneficial here, both in terms of ensuring that you're getting adequate protein in your diet, but also to make sure that you're not actually getting too much inappropriate fat and/or too much carbohydrate and sugars that are likely to get converted into tissues that are unhealthy for you long term. 

So, you know, nutrition plays an important role here, and long term it's really beneficial for your joints to optimize the muscle function around the joints.  

Anna: I want to come back to something that you just said, and it's around this balance between protein, fat and carbohydrate, which sounds simple and basic, but isn't always easy. And one of the things that we know about people, particularly as they get older and their protein needs change, is it's often hard to get enough protein. How do you advise people to think about that or to go about doing that? 

David: It's a great question. I get a bit [00:19:00] spoiled here, Anna, because at least in my clinical practice I work in what's called a multidisciplinary practice. So I work alongside physical therapists, dieticians, psychologists, orthotists and nurse. So more often than not most of the people who I'm seeing get to sit in there with a dietitian for a period of time and talk about, you know, what's the optimal way to get protein in the diet. 

So more often than not, historically, the way that used to happen is people used to get a lot of red meat. And you know, we know, that that's not necessarily the best way for them to address their protein needs long term, particularly if we know that some of those saturated animal fats are likely to contribute to inflammation. 

So more often than not, what we're finding is our dieticians spending time with them talking about healthier sources of protein. Whether that be protein that can come from fish, lean sources of meat, in addition to plant based sources of protein, which we know can actually also be beneficial in this regard. 

Anna: But I think that there are two, I'll say simple, I use that term loosely, points.  

One is, get some professional advice to help [00:20:00] optimise and I'll say maximise your diet, making sure you have the right level of proteins, fats, carbohydrates and all of the macro and micronutrients needed to be able to manage both weight as well as this condition, and then the exercise piece. 

it's going to be that combination of diet and exercise which is going to be so important for that real one two punch. 

David: Exactly, and really just to reinforce that point that you were making Anna there, to get help to do this, because doing it on your own is possible, but more often than not, you're going to do a lot better if someone's coaching you through that process and encouraging you and monitoring you, making sure that you're actually obtaining your goals and that it's tailored for you. You might already be strong, you might already be active, you might already have the optimal diet, but more often than not, we'll find something that is not perfect. You know, keep working towards it and get help to attain the goals that are important for you longer term.  

Anna: And I think the interesting point that you make there is there are a lot of people who already have a good diet, or who perceive they [00:21:00] have a good diet, but there's likely maybe one or two things you can do to tweak to make it just incrementally that much better that can maybe, make that little extra difference that you need. 

I want to come back to the Mediterranean diet a little bit. I think it would be good just to remind our listeners, what are some of the foods that are part of the Mediterranean diet that people should keep top of mind?  

David: To be honest, I think a lot of people are actually doing a lot better at this than they otherwise might surmise, and oftentimes it's just a case of rebalancing certain things a little bit.  

The elements of the diet that are encouraged within the Mediterranean diet are increasing grains, nuts, legumes, trying to look for healthy sources of protein that may also be rich in omega 3. So they're thinking about sources of that, like fish that may be beneficial in that regard. But by the same token, reducing some of that saturated animal fat that might come from red meat or some of the ways we cook certain foods that are likely to [00:22:00] increase inflammation. And through all of that, whether that be the grains, legumes, trying to improve the amount of fiber that we have in the diet, because we know that also plays a really important role in reducing inflammation. 

We've talked a lot about nutrition. One of the things I wanted to hone in a little more, it may be implied in nutrition, but maybe we don't always think about it, is the importance of hydration.  

 I wanted you to maybe talk a little bit about that. How people should think about hydration. And the role that can play in the overall management of osteoarthritis.  

David: I think for anybody's general health, it's important that they stay well hydrated. And more often than not, particularly when a person's being physically active, we'll find that they're generally under hydrating. So, you know, if we want people to stay mobile, and we're particularly looking at people doing that through longer endurance type physical activities, they need to stay well hydrated in order to do that. 

Anna: I think a lot of us could benefit from drinking more water. I always think to myself, I need to drink more water, so I carry a water bottle [00:23:00] around. The trick is then to open it and drink out of it, even when it's not hot out. Ha! 

David: Very, it's a very simple solution, but as you say, often forgot!  

Anna: Exactly! Now I know you have a podcast called Joint Action. I was wondering if you could tell us a little bit about that and are there any insights or takeaways that would be useful for us to understand or learn today? 

David: Yeah, so we set this up with people with osteoarthritis at the front and center of our minds and it's really just an opportunity for us to help to inform the public with osteoarthritis about what they can do about the disease and how they can best manage it and who might be able to help them with that journey. 

Similar to today's podcast, we've had a couple that have focused very strongly on nutrition, you know, one from a good colleague and friend, Steve Messier about weight management, another from, a nutritionist called Rosie Venman about aspects of diet. We've got others on physical activity, how to get strong, what activities may be beneficial, and a whole range of different topics. 

So yeah, Joint Action. Well, at least I [00:24:00] think it's a great way for people to get better informed about the disease. And the more knowledge you have, the more empowered you'll become about how better to look after yourself long term.  

Anna: No, that's great. Thanks. I think we'll make sure that we check that out.  

Now, I know, David, there are always many new discoveries that are coming out every day in terms of how to manage osteoarthritis and your primary focus has been on clinical and translational research in osteoarthritis. And I wanted to ask you if there are any emerging pieces of research or innovations that you expect are really going to change or really transform how people can prevent or manage osteoarthritis? 

David: Yeah, I mean, I get really excited about this, because obviously where I spend most of my life. But it's a really important area.  

Primarily because, you know, obviously there's so many people that are affected by this disease and there's so many people that want us to do a hell of a lot better as far as the treatments are concerned. 

So we're spending a lot of efforts and energy in developing new treatments, developing opportunities for us [00:25:00] preventing the disease, but also hopefully educating people about wasteful opportunities here.  

So let's talk about the first of those, so developing new treatments. For us the holy grail here is a thing we call disease modification. You know, when we talk about managing osteoarthritis, we're talking about managing symptoms, and that's important, but ideally we'd manage symptoms as well as manage the disease itself structurally. So we're developing treatments that will likely be injections that you might have into the joint that help to regenerate the tissues within the joint, and by virtue of essentially reconstituting the normal makeup and structure of the joint, relieve a person's symptoms long term. 

And so there's a number of these that are in late stage development. Again, we call it disease modification. It's a really exciting area. And over the next five to 10 years, some of these will likely become commercially available treatments that will essentially revolutionize the way this disease is managed. 

David: We're also doing prevention trials because, you know, [00:26:00] if we can prevent this disease in the first place, that would be again a whole lot better than if we had to wait until a person developed symptoms and managed it that way. So we've got a trial that we're about to start relatively soon, in a population of people who are at high risk of developing disease, so that's essentially women over 50 who are carrying excess weight. And we're seeing if a combination of diet and exercise can actually prevent the development of disease in the first place.  

So prevention is really important. And then that last piece that I was just talking about is just making sure people actually understand the disease. I fully appreciate that there are lots of great treatments that are out there, but there's also a lot of potential for harm and waste here. And so, you know, if I point my finger at one or two particular treatments here for osteoarthritis, it would be, you know, opioids are harmful, they don't benefit you as far as osteoarthritis is concerned. Arthroscopy similarly, there's no benefit. There are a lot of harms, a lot of cost.  

So there's lots of treatments that do work and we've spoken about those, but there's also a lot where we're wasting a [00:27:00] lot of money and potentially contributing to a lot of harm in the community. And so, you know, for us, educating disease and how best to manage it is really, really important.  

Anna: I think that's great to hear, and those are exciting developments, I think, both on the prevention as well as on the treatment front.  

Is there anything being done in the prevention area among younger people? Because I hear your point about over the age of 55, you're coming to the at risk area, but what about even earlier in people's lives? 

David: The leading risk factor amongst young people, Anna, is that of joint injury. And so that if we look at about 20 percent of people who develop osteoarthritis of the knee do so because they've torn a cruciate ligament or they've torn a meniscus in their knee. And we can prevent about 60 percent of those from occurring through injury prevention training programs, which should be part of normal training programs for sport, but unfortunately they're not. 

So if people want to look up more about that, that's called neuromuscular training. There are great programs that are out there that are run [00:28:00] by FIFA and PEP and others. And so yeah, look up "safe sport", because it's a great way for us to prevent injuries from occurring in the first place and for young people to develop osteoarthritis from occurring.  

Anna: I think that's a great education point, because I think when you're young and fit and active and playing a lot of sport, you don't think about what the implications down the road are, so that's a great tip, thank you very much. 

So, maybe to conclude, David, I'd like to ask you if there is one thing, or maybe two, we can cheat a little bit, one or two things that you want people to take away from our conversation today, because we've covered so much ground and you've shared so many amazing insights and ideas with us, what would you want that to be? 

David: The most important message I'd like people to hear is to knowledge is power. And so the better informed you are, the better the management of your disease will be. And you know, the central tenets about staying strong, staying active and having an ideal weight have a huge influence on both your risk of developing osteoarthritis, [00:29:00] but also it getting worse. 

So just get out there, get better informed and look after yourself. Makes a huge difference. 

Anna: That's a great closing thought. Thank you.  

Well, I hope this episode of Nutrition Unlocked has left everyone with a greater understanding of osteoarthritis and how nutrition can help people prevent and manage their symptoms. 

David, I really want to thank you so much for your generosity today and sharing your expertise, your insights, your ideas, your practical tips, and giving us a better understanding of how nutrition can play a role in managing osteoarthritis. I think we have covered quite a lot today. 

David: Anna, it's been an absolute pleasure. Thank you so much for giving me an opportunity to speak to your listeners.  

// Outro //  

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We look forward to sharing more insights on the science of nutrition with you very soon. 

See [00:30:00] you next time on Nutrition Unlocked. 

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