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Cover of Evidence review for the benefit of weight loss for the management of osteoarthritis for people living with overweight or obesity

Evidence review for the benefit of weight loss for the management of osteoarthritis for people living with overweight or obesity

Osteoarthritis in over 16s: diagnosis and management

Evidence review D

NICE Guideline, No. 226

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-4740-9

1. Benefits of weight loss for people osteoarthritis who are overweight or obese

1.1. Review question

What is the benefit of weight loss for the management of osteoarthritis in overweight and obese people?

1.1.1. Introduction

The benefits of weight loss in overweight and obese people are widely accepted. It is believed to help reduce the risk of a variety of conditions including type 2 diabetes, heart disease, stroke, some cancers and high blood pressure. While being overweight is thought to exacerbate lower limb osteoarthritis through extra pressure being placed on the joints, the interplay between weight and osteoarthritis is more complex than this alone, as people who are overweight and obese are more likely to get osteoarthritis in non-weight bearing joints such as the hand. While all the mechanisms are not completely understood, controlling weight to a healthy BMI is consistently advocated internationally both for osteoarthritis and general wellbeing.

Current practice for people with osteoarthritis is to advise them to lose weight. While most overweight and obese people with osteoarthritis will agree that losing weight would help their quality of life, they find it difficult to lose and sustain a weight loss. Currently, weight loss can occur in through one-to-one advice or within a group setting, in some areas of the country, dedicated weight loss programmes are commissioned, in others, osteoarthritis programmes are commissioned which include weight loss. There is no standard approach to how people with osteoarthritis should be supported to lose weight. This review aims to inform patients and healthcare professionals about the amount of weight loss needed to promote improvement in their osteoarthritis symptoms and joint functioning to then decide together how this may best be achieved.

1.1.2. Summary of the protocol

Table 1. PICO characteristics of review question.

Table 1

PICO characteristics of review question.

For full details see the review protocol in Appendix A.

1.1.3. Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in Appendix A and the methods document.

were recorded according to NICE’s conflicts of interest policy.

1.1.4. Prognostic evidence

1.1.4.1. Included studies

Two prospective cohort studies were included in the review3, 55; these are summarised in below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3). These studies included people who were either obese3 or where the proportion of people who were obese or overweight is unclear55. All studies included people with knee osteoarthritis. No relevant clinical studies investigated the effects on people with osteoarthritis of different joint sites. One study accounted for all confounders within a regression analysis3, while the other accounted for some of these confounders in a regression analysis while other confounders were matched at baseline55.

See also the study selection flow chart in Appendix A, study evidence tables in Appendix D, forest plots in Appendix E and GRADE tables in Appendix F.

1.1.4.2. Excluded studies

See the excluded studies list in Appendix J.

1.1.5. Summary of studies included in the prognostic evidence

Table 2. Summary of studies included in the evidence review.

Table 2

Summary of studies included in the evidence review.

See Appendix D for full evidence tables.

1.1.6. Summary of the prognostic evidence

Table 3. Clinical evidence summary: loss of 5–10% of baseline weight compared to loss of <5% of baseline weight for people with knee osteoarthritis who are obese (BMI ≥30).

Table 3

Clinical evidence summary: loss of 5–10% of baseline weight compared to loss of <5% of baseline weight for people with knee osteoarthritis who are obese (BMI ≥30).

Table 4. Clinical evidence summary: >10% of baseline weight compared to loss of <5% of baseline weight for people with knee osteoarthritis who are obese (BMI ≥30).

Table 4

Clinical evidence summary: >10% of baseline weight compared to loss of <5% of baseline weight for people with knee osteoarthritis who are obese (BMI ≥30).

Table 5. Clinical evidence summary: >10% of baseline weight compared to loss of 5–10% of baseline weight for people with knee osteoarthritis who are obese (BMI ≥30).

Table 5

Clinical evidence summary: >10% of baseline weight compared to loss of 5–10% of baseline weight for people with knee osteoarthritis who are obese (BMI ≥30).

Table 6. Clinical evidence summary: loss of 5–10% of baseline weight compared to loss of <5% of baseline weight for people with knee osteoarthritis where their BMI classification before the study is unclear (assumed overweight [BMI 25–30] for the analysis).

Table 6

Clinical evidence summary: loss of 5–10% of baseline weight compared to loss of <5% of baseline weight for people with knee osteoarthritis where their BMI classification before the study is unclear (assumed overweight [BMI 25–30] (more...)

Table 7. Clinical evidence summary: loss of >10% of baseline weight compared to loss of <5% of baseline weight for people with knee osteoarthritis where their BMI classification before the study is unclear (assumed overweight [BMI 25–30] for the analysis).

Table 7

Clinical evidence summary: loss of >10% of baseline weight compared to loss of <5% of baseline weight for people with knee osteoarthritis where their BMI classification before the study is unclear (assumed overweight [BMI 25–30] (more...)

Table 8. Clinical evidence summary: loss of >10% of baseline weight compared to loss of 5–10% of baseline weight for people with knee osteoarthritis where their BMI classification before the study is unclear (assumed overweight [BMI 25–30] for the analysis).

Table 8

Clinical evidence summary: loss of >10% of baseline weight compared to loss of 5–10% of baseline weight for people with knee osteoarthritis where their BMI classification before the study is unclear (assumed overweight [BMI 25–30] (more...)

See Appendix F for full GRADE tables.

1.1.7. Economic evidence

1.1.7.1. Included studies

No health economic studies were included.

1.1.7.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix G.

1.1.8. Summary of included economic evidence

There was no economic evidence found

1.1.9. Economic model

This area was not prioritised for new cost-effectiveness analysis.

1.1.10. Economic evidence statements

  • No relevant economic evaluations were identified.

1.1.11. The committee’s discussion and interpretation of the evidence

1.1.11.1. The outcomes that matter most

The critical outcomes were quality of life, pain and physical function. These were considered critical due to their relevance importance to people with osteoarthritis. The Osteoarthritis Research Society International (OARSI) consider that pain and physical function were the most important outcomes for evaluating interventions. Quality of life gives a broader perspective on the person’s wellbeing, allowing for examination of the biopsychosocial impact of interventions. Psychological distress and osteoarthritis flares were included as important outcomes.

The committee considered osteoarthritis flares to be important in the lived experience and management of osteoarthritis. However, these were also considered difficult to measure with no clear consensus on their definition. The Flares in OA OMERACT working group have proposed an initial definition and domains of OA flares through a consensus exercise; “it is a transient state, different from the usual state of the condition, with a duration of a few days, characterized by onset, worsening of pain, swelling, stiffness, impact on sleep, activity, functioning, and psychological aspects that can resolve spontaneously or lead to a need to adjust therapy”. However, this has been considered to have limitations and has not been widely adopted. Therefore, the committee included the outcome accepting any reasonable definition provided by any studies discussing the event.

Mortality was included as treatment adverse events rather than as a discreet outcome and categorised as an important outcome. Osteoarthritis as a disease process is not considered to cause mortality by itself and mortality is an uncommon outcome from osteoarthritis interventions.

There was no evidence available for osteoarthritis flares and psychological distress. The committee acknowledged these as important outcomes rather than critical and agreed that they could make recommendations even though there was limited information for this outcome.

1.1.11.2. The quality of the evidence

Two studies were included in this review. The first (Atukorala 20163) included people with knee osteoarthritis who were obese and investigated the effect of losing ≤5%, 5–10% and ≥10% of their baseline weight after participating in a weight loss management program. The second (Riddle 201355) included people with knee osteoarthritis where it was unclear whether they were overweight or obese before entering the study. It also investigated the effect of losing ≤5%, 5–10% and ≥10% of their baseline weight after participating in two different weight loss management programs. These studies were not pooled for analysis as the populations were not comparable (one including only people who were obese, one comparing people who were overweight or obese) and different methods used to analyse the effect of confounders.

All outcomes were noted to be of very high risk of bias. The reasons for this included bias in study participation (as the inclusion and exclusion criteria are unclear), study attrition (as the proportion of baseline sample available for analysis was inadequate and there was insufficient information on why participants were lost to follow up) and study confounding (as not all confounding factors established in the protocol were accounted for in a multivariate analysis). No indirectness was noted in any outcomes. Imprecision was noted in four outcomes, including participants where their BMI classification before entering the study is unclear.

1.1.11.3. Clinical effects of weight loss

For people with knee osteoarthritis who were obese, the outcomes reported were quality of life, pain and physical function. For people with knee osteoarthritis where their BMI classification before the study was unclear, the outcomes reported were pain and physical function. All outcomes were reported at >3 months (18 weeks and 30 months respectively). In people who were obese, the results showed that people who have a >10% weight loss have a clinically important improvement in physical function at >3 months when compared to people with a loss of <5% of their baseline weight. Other outcomes did not show evidence of a clinically important effect using a standardised mean difference value of 0.5. However, in all outcomes participants achieved a beneficial effect to quality of life, pain and physical function at >3 months to lesser degrees (with standardised mean difference values between 0.15–0.27 for quality of life, pain and physical function for people losing 5–10% of their baseline weight compared to people with a <5% loss, and 0.42 in quality of life and pain for people losing >10% of their baseline weight compared to people with a <5% loss).

For people with knee osteoarthritis and an unclear BMI classification before the study no outcomes showed a clinically important change. The effects at >3 months with a loss of 5–10% of baseline weight had small effect sizes (for standardised mean differences where high is poor, pain = 0.03, physical function = −0.05) while the effects with a loss of >10% of baseline weight there were larger effect sizes indicating a possible benefit (pain = −0.24, physical function = −0.40). There was no evidence identified for the outcomes of osteoarthritis flares or psychological distress.

The committee acknowledged that there was a trend that increased weight loss led to better outcomes reflecting that the evidence indicated a dose-response gradient (with >10% weight loss group appearing to have a much more significant change than the <5% weight loss group). They acknowledged that the studies included achieved the higher amounts of weight loss through a formal weight loss programme, and so considered that support should be provided to people to help them to lose weight. However, the committee considered that the support required for people with osteoarthritis would be similar to from the support required for people with other conditions and so recommended to consider other relevant NICE guidance for this information (including: Weight management: lifestyle services for overweight or obese adults (PH53) and Obesity: identification, assessment and management (CG189)). Due to the observed benefits of weight loss the committee made a recommendation to advise people about weight loss and to support them to make meaningful weight loss goals. The committee noted that benefits were seen with all amounts of weight loss, with the most benefits being seen when ≥10% of their body weight was lost. To this end, they recommended that people lose as much weight as they can but wanted to encourage that losing any weight was likely to provide benefits for people with osteoarthritis who are overweight or obese.

Furthermore, the committee agreed that good practice should be used in supporting people to achieve this weight loss. This should include helping people to choose an achievable weight goal. The committee agreed that while there was limited evidence available, the evidence was sufficient to make a recommendation and therefore, no additional research was required in this area.

1.1.11.4. Cost effectiveness and resource use

No economic evaluations were identified for this question.

The clinical review showed a trend between greater weight loss and improved reported health outcomes. Conclusions could not be made regarding the cost effectiveness of structured weight loss programmes in osteoarthritis, however the committee agreed that some form of patient support should be indicated based on the clinical evidence, and motivational interviewing and health coaching techniques were suggested.

The committee acknowledged that the recommendation would require the time of a healthcare professional but did not think it would lead to a substantial resource impact since this recommendation is intended to build upon likely unstructured conversations that are already occurring.

1.1.11.5. Other factors the committee took into account

Studies did not report if weight loss was maintained over this time period. The committee acknowledged the challenges of maintaining weight loss over a long period of time and that in order to maintain the benefits, maintained weight loss would be useful. They wanted to reinforce that good practice for supporting people with weight management should be used (such as those in other relevant NICE guidance) to help people maintain any weight loss that they achieve.

Overweight and obese people with osteoarthritis are often told to lose weight before they will be considered for joint replacement. However, losing weight may require exercise (for more information about exercise for osteoarthritis see evidence review C) and people report having difficulty exercising when they have joint pain, and it is uncertain whether losing weight before a joint replacement is required. The effect of people being in different BMI categories before joint replacement surgery is considered in evidence review ‘Outcomes of joint replacement surgery dependent on body mass index’, which investigates elements of this.

1.1.12. Recommendations supported by this evidence review

This evidence review supports recommendation 1.3.5. Other evidence supporting this recommendation can be found in evidence review D.

1.1.13. References

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Appendices

Appendix B. Literature search strategies

  • What is the benefit of weight loss for the management of osteoarthritis in overweight and obese people?

The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.45

For more information, please see the Methodology review published as part of the accompanying documents for this guideline.

B.1. Clinical search literature search strategy (PDF, 134K)

B.2. Health Economics literature search strategy (PDF, 149K)

Appendix D. Prognostic evidence

Download PDF (225K)

Appendix G. Economic evidence study selection

Download PDF (117K)

Appendix H. Economic evidence tables

There were no health economic studies found in the review.

Appendix I. Health economic model

No original economic modelling was undertaken.

Appendix J. Excluded studies

Clinical studies

Download PDF (108K)

Health Economic studies

Published health economic studies that met the inclusion criteria (relevant population, comparators, economic study design, published 2005 or later and not from non-OECD country or USA) but that were excluded following appraisal of applicability and methodological quality are listed below. See the health economic protocol for more details.

None.

Final

Evidence reviews underpinning recommendation 1.3.5 in the NICE guideline

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Copyright © NICE 2022.
Bookshelf ID: NBK590292PMID: 37036916

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