Medical Compass: Managing osteoarthritis pain without drugs
By David Dunaief, MD
If you are one of the 32.5 million in the U.S. who suffers from osteoarthritis, you know it can make it painful to perform daily tasks. Osteoarthritis (OA) most often affects the knees, hips and hands and can affect sleep quality and mood, in addition to mobility.
Common first-line medications for arthritis pain are acetaminophen and nonsteroidal anti-inflammatory drugs, such as ibuprofen. Unfortunately, while medications treat the immediate symptoms of pain and inflammation, they don’t slow osteoarthritis’ progression, and they do have side effects, especially with long-term use.
Here, we’ll focus on approaches you can use to ease pain without reaching for the medicine cabinet. Some may slow worsening — or even reverse symptoms — of your osteoarthritis.
Does dairy help or hurt?
With dairy, specifically milk, there is conflicting information. Some studies show benefits, while others show that it may contribute to the inflammation that makes osteoarthritis pain feel worse.
In the Osteoarthritis Initiative study, researchers looked specifically at joint space narrowing that occurs in those with affected knee joints (1). Results showed that low-fat (1 percent) and nonfat milk may slow the progression of osteoarthritis in women. Compared to those who did not drink milk, patients who did saw significantly less narrowing of knee joint space over a 48-month period.
The result curve was interesting, however. For those who drank from fewer than three glasses a week up to 10 glasses a week, the progression of joint space narrowing was slowed. However, for those who drank more than 10 glasses per week, there was less beneficial effect. There was no benefit seen in men or with the consumption of higher fat products, such as cheese or yogurt.
However, the study was observational and had significant flaws. First, the 2100 patients were only asked about their milk intake at the study’s start. Second, patients were asked to recall their weekly milk consumption for the previous 12 months before the study began — a challenging task.
On the flip side, a study of almost 39,000 participants from the Melbourne Collaborative Cohort Study found that increases in dairy consumption were associated with increased risk of total hip replacements for men with osteoarthritis (2).
Getting more specific, a published analysis of the Framingham Offspring Study found that those who consumed yogurt had statistically significant lower levels of interleukin-6 (IL-6), a marker for inflammation, than those who didn’t eat yogurt, but that this was not true with milk or cheese consumption (3).
We are left with more questions than answers. Would I recommend consuming low-fat or nonfat milk or yogurt? Not necessarily, but I may not dissuade osteoarthritis patients from yogurt.
Does vitamin D help?
Over the last decade, the medical community has gone from believing that vitamin D was potentially the solution to many diseases to wondering whether, in some cases, low levels were indicative of disease, but repletion was not a change-maker. Well, in a randomized controlled trial (RCT), the gold standard of studies, vitamin D had no beneficial symptom relief, nor any disease-modifying effects (4). This two-year study of almost 150 men and women raised blood levels of vitamin D on average to 36 ng/ml, which is considered respectable. Researchers used MRI and X-rays to track their results.
The role of weight
Weight management is a crucial component of any OA pain management strategy. In a study involving 112 obese patients, those who lost weight reported a reduction of knee symptoms. Even more exciting, there was also disease modification, with reduction in the loss of cartilage volume around the medial tibia (5).
On the other hand, those who gained weight saw the inverse effect. A reduction of tibial cartilage is potentially associated with the need for knee replacement. The relationship was almost one-to-one; for every 1 percent of weight lost, there was a 1.2 mm3 preservation of medial tibial cartilage volume, while the exact opposite was true with weight gain.
Exercise and diet for the win!
Diet and exercise trumped the effects of diet or exercise alone in a well-designed study (6). Patients with osteoarthritis of the knee who lost at least 10 percent of their body weight experienced significant improvements in function and a 50 percent reduction in pain, as well as reduction in inflammation, compared to those who lost 5 to 10 percent and those who lost less than 5 percent. This study was a randomized controlled single-blinded study with a duration of 18 months.
Researchers used biomarker IL6 to measure inflammation. The diet and exercise group and the diet-only group lost significantly more weight than the exercise-only group, 23.3 pounds and 19.6 pounds versus 4 pounds. The diet portion consisted of a meal replacement shake for breakfast and lunch and then a vegetable-rich, low-fat dinner. Low-calorie meals replaced the shakes after six months. The exercise regimen included one hour of a combination of weight training and walking with alacrity three times a week.
Therefore, concentrate on lifestyle modifications to reduce pain and potentially disease-modifying effects. The best effects shown are with weight loss and with a vegetable-rich diet. In terms of low-fat or nonfat milk, the results are controversial at best. For yogurt, the results suggest it may be beneficial for osteoarthritis, but stay on the low end of consumption, since dairy can increase inflammation.
References:
(1) Arthritis Care Res online. 2014 April 6. (2) J Rheumatol. 2017 Jul;44(7):1066-1070. (3) Nutrients. 2021 Feb 4;13(2):506. (4) JAMA. 2013;309:155-162. (5) Ann Rheum Dis. 2015 Jun;74(6):1024-9. (6) JAMA. 2013;310:1263-1273.
Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.
