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activities that may be beneficial or harmful for individuals with osteoarthritis and obesity54 . Khoja et al61 compared randomized controlled trials that investigated aerobic, resistance and combination physical activity interventions for osteoarthritis in patients with overweight and obesity. Both aerobic and resistance activity appear to be independently beneficial for reducing pain and improving function61 . Walking may be less tolerable for individuals with joint pain and obesity, and nonweight bearing activities such as cycling, aquatic walking or arm ergometers may be preferable61. While resistance exercise can improve pain and function, clarity is needed on the specific dose and types of exercises61 . The evidence is limited by the low number of studies, inclusion of individuals without obesity, and only including participants without obesity-related 11 Bone and Joint Health Strategic Clinical Network chronic diseases and mild to moderate osteoarthritis. The relevance and effectiveness of physical activity interventions in patients with comorbid conditions, higher BMIs, and more severe osteoarthritis is not known61 . Weight loss Adults with osteoarthritis and a BMI greater than 30 kg/m2 are recommended to lose weight to reduce joint stress, delay further osteoarthritis progression, and improve physical function54,62– 64, with a goal of a loss of 10% or more of body weight. However, weight loss is difficult through diet and exercise alone10, especially for those with joint pain and mobility limitations6,39,52,58,65,66 . Plow et al58 reviewed mean weight loss in patients with mobility limitations in 23 intervention studies. Although limited, results show a mean weight loss of 4.11 kg with targeted intervention. Patients attempting weight loss on their own may have less success, and are likely to regain weight once the intervention ceases6,58 . Treating obesity is difficult, and individuals must battle strong biological and environmental influences that promote weight gain6 . Rather than focusing on weight loss, the focus should be on healthy lifestyle changes (with diet and physical activity) to assist in reducing pain and improving quality of life and function65 . As health care professionals play an important role with patients52, they need to be educated on appropriate obesity treatment recommendations and health behaviour change strategies that promote patient self-management and engagement in change54 . It is ineffective to simply tell a patient to lose weight or increase physical activity60 . Non-surgical weight loss in adults requires long term behavioural support to assist with lifestyle changes and prevention of weight regain67. Referral to weight management services may be recommended54 . Long term weight loss in older adults (over 65 years old) with osteoarthritis should consider that changes in body composition as a result of weight loss can negatively impact function and health, such as loss of muscle or bone mass, or decreased muscle strength6,11,57. This patient group is also susceptible to sarcopenia58, a condition of low muscle mass and/or muscle function. Measuring changes in body composition may be more appropriate than focusing on a change in BMI after treatment interventions39,58 . Physical activity versus diet Treatment interventions that combine physical activity and diet are strongly recommended39,42,59–61. Although this combined intervention may not result in significant weight loss (defined as equal to or greater than 5% of body weight), the results are clinically effective to reduce pain, increase strength, and improve physical function and quality of life compared to either intervention alone39 . Bariatric surgery for reducing osteoarthritis related pain and disability Two systematic reviews examined the benefit of bariatric surgery for osteoarthritis-related knee and hip pain50,68 . While both reviews conclude that bariatric surgery is likely to reduce 12 Bone and Joint Health Strategic Clinical Network osteoarthritis-related pain, there was no determination of clinically important differences, and the low quality of evidence prevented clear conclusions50,68 . Surgical osteoarthritis treatment in adults with obesity General surgical considerations Choosing an appropriate surgical procedure is important for individuals with OA and obesity. Obesity has been associated with greater failure rates in high tibial osteotomy (a procedure that reshapes the tibia bone when osteoarthritis affects only one side of the joint) and poorer outcomes in uni-compartmental knee replacement (a partial knee replacement procedure when damage is limited to one area of the knee)69 . Other surgical recommendations include the use of specialized surgical instruments such as leg holders66,70, use of thromboembolic prophylaxis to reduce the risk of blood clots, and positioning of the patient to avoid ventilator concerns70 . Management of sleep apnea and hyperglycemia before surgery is essential, as they may be the most relevant factors related to surgical risk in patients with morbid obesity66 . Patients with greater limb adiposity may require larger incisions and longer operating time71 , which may result in increased infection rates due to increased surgical exposure, greater wound tension and metabolic factors that influence wound healing45,66,72 . Particular attention to wound closure in patients with obesity may assist in preventing infections72 . Reported surgical
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