关节炎膝盖疼痛:同时运动与节食的效果比单独节食更佳


  【24drs.com】在一篇大型随机试验中,过重或肥胖的膝盖骨关节炎(OA)成年病患,减重至少10%体重者,膝盖疼痛减少且功能显著增加,而同时进行节食与运动者的结果比单独节食或单独运动者更佳。
  
  「Intensive Diet and Exercise for Arthritis (IDEA)」研究的最终资料登载于9月25日的JAMA期刊。
  
  第一作者Stephen P. Messier博士表示,对这类病患而言,至少减重10%的体重是可行且安全的;整体而言,同时节食和运动比单独节食或单独运动更有效。进行节食和运动的病患比较少发炎、少疼痛、功能更好,改善健康相关生活质量、活动力更佳;仅节食组的膝关节负担舒缓程度大于仅运动组。
  
  这些和减重程度有显著的剂量反应关系。Wake Forest大学J.B. Snow Biomechanics实验室主任Messier博士表示,不论哪里一组,相较于减重5%-10%体重或不到5%体重者,减重至少10%体重者皆显著减少疼痛、功能更佳、膝盖负担减少、减少发炎。
  
  这篇随机单盲试验包括了454名过重和肥胖的年长社区型成人(年纪55岁以上;身体质量指数27 - 41 kg/m2)且有疼痛和X光确认的膝盖骨关节炎;介入方式包括减重加运动、密切节食减重、运动;节食和运动介入方式是以在医院内进行为基础,运动组可以选择以家庭为基础的计画,88%的研究对象完成了为期18个月的追踪。
  
  Messier博士表示,我们的高追踪率是因为有频繁接触研究对象、对目标和成效有明确回馈,而使研究对象愿意继续参与;健康照护专业人士也可将这些技巧运用在他们的病患上。
  
  节食介入方式是将每天的两餐用营养品取代,另一餐是热量500-750卡的低脂多蔬菜餐点;代餐方式运用于最初的6个月,剩下的12个月逐渐用低热量餐点取代,这个节食计划是希望每日热量摄取减少到每天800-1000卡。
  
  运动介入包括有氧散步和强度训练,每天1小时、每周3天。
  
  在追踪18个月时,节食加运动组(-10.6 kg;95%信心区间-14.1至-7.1 kg)和节食组(-8.9 kg;95% CI,-12.4至-5.3 kg)优于运动组(-1.8 kg;95% CI,-5.7至1.8 kg)。
  
  相较于运动组,节食加运动显著较少膝盖疼痛、较佳功能、步速较快、生理相关生活质量较佳;节食加运动组以及节食组的研究对象,介白素6值的降低程度也大于运动组。
  
  Messier博士表示,三组在6个月后的疼痛减缓程度都一样,到了18个月时,节食加运动组在三组中脱颖而出,完成研究者的疼痛减少程度达50%。
  
  Farshid Guilak博士表示,虽然运动一直都是骨关节炎病患的处方之一且有诸多助益,这些研究结果显示,单靠运动通常可能无法克服过重引起的某些影响。
  
  未参与此研究的Guilak博士表示,虽然众所皆知减重对于过重的骨关节炎患者相当重要,这些研究结果进一步强调需要有针对减重的密切方法。目前,介白素6值降低或减轻膝盖负担与关节长期健康之间的直接关系则是未知,需要更多研究与长期追踪,以厘清这些因素对于骨关节炎的影响。Guilak博士是杜克大学医学中心骨科研究主任、骨外科副主任、Laszlo Ormandy 名誉教授,也是Journal of Biomechanics期刊的主编。
  
  丹麦Frederiksberg大学医院、未参与此研究的Henning Bliddal医师表示,这是篇相当有说服力的研究。所有过重/肥胖的骨关节炎患者,都应参与减重计画及运动。唯一有争议的是,肥胖患者是否可以立即开始运动,或者要先节食以减轻膝盖负担。
  
  Messier博士指出,虽然减重介入方式是成功的,他们的新体重中的瘦肉含量实际上是增加的,有进行节食的两个组别中,瘦肉的绝对量是降低的。这类病患的后续减重研究应尽量对抗肌肉量之减少,或许在运动处方中使用更多强化训练。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=7013&x_classno=0&x_chkdelpoint=Y
  

Arthritis Knee Pain: Exercise and Diet Tops Diet Alone

By Janis C. Kelly
Medscape Medical News

Knee pain decreased and function increased significantly in overweight or obese adults with knee osteoarthritis (OA) who lost at least 10% of their baseline body weight, and those who combined diet and exercise had better outcomes than those who used diet or exercise alone in a large randomized trial.

The final data from the Intensive Diet and Exercise for Arthritis (IDEA) study were published in the September 25 issue of JAMA.

"Intensive weight loss of at least 10% of body weight is possible and safe in this population," lead author Stephen P. Messier, PhD, told Medscape Medical News. "Overall, diet and exercise together were more effective than either diet or exercise alone. Patients who had diet plus exercise had less inflammation, less pain, better function, improved health-related quality of life, and better mobility. The diet-only group had greater reductions in knee joint loads than the exercise comparison group."

There was a significant dose–response effect associated with weight loss. "People, regardless of group, who lost at least 10% of body weight had significantly less pain, better function, reduced joint loads, and reduced inflammation compared to people who lost between 5% and 10% or less than 5% of their baseline body weight," said Dr. Messier, who is professor and director of the J.B. Snow Biomechanics Laboratory at Wake Forest University, Winston Salem, North Carolina.

The randomized single-blind trial included 454 overweight and obese older community-dwelling adults (age, 55 years or older; body mass index, 27 - 41 kg/m2) with pain and radiographic knee OA. The interventions consisted of intensive diet-induced weight loss plus exercise, intensive diet-induced weight loss, or exercise. The diet and exercise interventions were center-based with options for the exercise groups to transition to a home-based program. Eighty-eight percent of participants completed the 18-month follow-up.

"Our excellent adherence was due to frequent contacts, clear feedback on goals and achievements, and establishing a personal commitment to the study. These same techniques could be used by healthcare professionals with their patients," Dr. Messier said.

The diet intervention was based on replacing up to 2 meals per day with nutritional shakes, plus a 500- to 750-kcal third meal that was low in fat and high in vegetables. The meal replacements were used for the first 6 months, and participants gradually replaced them with low-calorie meals for the remaining 12 months. The diet plan was designed to produce a daily energy-intake deficit of 800 to 1000 kcal/day.

The exercise intervention combined aerobic walking and strength training for 1 hour a day, 3 days a week.

Average weight loss was greater in the diet and exercise group (?10.6 kg; 95% confidence interval, ?14.1 to ?7.1 kg) and the diet group (?8.9 kg; 95% CI, ?12.4 to ?5.3 kg) compared with the exercise group (?1.8 kg; 95% CI, ?5.7 to 1.8 kg) at the 18-month follow-up.

Compared with the exercise group, the diet and exercise group had significantly less knee pain, better function, faster walking speed, and better physical health-related quality of life. Participants in the diet and exercise and diet groups also had greater reductions in interleukin 6 levels than those in the exercise group.

"All 3 groups had the same reduction in pain after 6 months. It was not until 18 months that the diet plus exercise group separated itself from the other groups, reducing pain by about 50% in the participants who completed the study," Dr. Messier said.

Although exercise has long been prescribed as a therapy for OA and has many beneficial effects, these findings show that exercise alone often cannot overcome some of the effects of being overweight, Farshid Guilak, PhD, told Medscape Medical News.

"Although it is well known that weight loss is a critical aspect of any therapy for overweight people with [OA], these findings further emphasize the need for intensive therapies that focus on reducing weight. At this point, the direct relationships between the decreases in [interleukin 6] or joint loading and the long-term health of the joint are unknown, and additional studies and long-term follow-ups will be needed to elucidate the role of these factors in OA," said Dr. Guilak, who was not involved in the study. Dr. Guilak is the Laszlo Ormandy Professor and vice-chair of orthopaedic surgery and director of orthopaedic research at Duke University Medical Center in Durham, North Carolina, and editor-in-chief of the Journal of Biomechanics.

"This is a very convincing study. All overweight/obese patients with knee OA should join a program with weight loss and exercise. The only matter of dispute is whether obese people may start off exercising right away or should go on [a] diet first not to overload their knees," said Henning Bliddal, MD, from Frederiksberg University Hospital, Frederiksberg, Denmark, who was not involved in the study.

Dr. Messier added, "While the weight loss intervention was successful and their lean mass relative to their new body weight actually increased, the absolute amount of lean mass decreased in both diet groups. Future weight loss studies in the population should try to combat the reduction in muscle mass, perhaps with a more intense strength training component of the exercise regimen."

The study was funded by the National Institutes of Health, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institute on Aging, the National Center for Research Resources, and General Nutrition Centers. Dr. Messier has given expert testimony fees from Anspach Meeks Ellenberger. One coauthor reported receiving royalties from DonJoy. One coauthor reported receiving consulting fees from MerckSerono, Novartis, Abbott, Perceptive, and Bioclinica; speaker's fees from Synthes and Medtronic; owns stock from Chondrometrics; and received travel expenses from MerckSerono. One coauthor reported receiving consulting fees from Genzyme, Astra-Zeneca, Novartis, MerckSerono, TissueGene, and sanofi-aventis and owning stock from Boston Imaging Core The other authors, Dr. Bliddal, and Dr. Guilak have disclosed no relevant financial relationships.

JAMA. 2013;310:1263-1273.

    
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