關節炎膝蓋疼痛:同時運動與節食的效果比單獨節食更佳


  【24drs.com】在一篇大型隨機試驗中,過重或肥胖的膝蓋骨關節炎(OA)成年病患,減重至少10%體重者,膝蓋疼痛減少且功能顯著增加,而同時進行節食與運動者的結果比單獨節食或單獨運動者更佳。
  
  「Intensive Diet and Exercise for Arthritis (IDEA)」研究的最終資料登載於9月25日的JAMA期刊。
  
  第一作者Stephen P. Messier博士表示,對這類病患而言,至少減重10%的體重是可行且安全的;整體而言,同時節食和運動比單獨節食或單獨運動更有效。進行節食和運動的病患比較少發炎、少疼痛、功能更好,改善健康相關生活品質、活動力更佳;僅節食組的膝關節負擔舒緩程度大於僅運動組。
  
  這些和減重程度有顯著的劑量反應關係。Wake Forest大學J.B. Snow Biomechanics實驗室主任Messier博士表示,不論哪一組,相較於減重5%-10%體重或不到5%體重者,減重至少10%體重者皆顯著減少疼痛、功能更佳、膝蓋負擔減少、減少發炎。
  
  這篇隨機單盲試驗包括了454名過重和肥胖的年長社區型成人(年紀55歲以上;身體質量指數27 - 41 kg/m2)且有疼痛和X光確認的膝蓋骨關節炎;介入方式包括減重加運動、密切節食減重、運動;節食和運動介入方式是以在醫院內進行為基礎,運動組可以選擇以家庭為基礎的計畫,88%的研究對象完成了為期18個月的追蹤。
  
  Messier博士表示,我們的高追蹤率是因為有頻繁接觸研究對象、對目標和成效有明確回饋,而使研究對象願意繼續參與;健康照護專業人士也可將這些技巧運用在他們的病患上。
  
  節食介入方式是將每天的兩餐用營養品取代,另一餐是熱量500-750卡的低脂多蔬菜餐點;代餐方式運用於最初的6個月,剩下的12個月逐漸用低熱量餐點取代,這個節食計劃是希望每日熱量攝取減少到每天800-1000卡。
  
  運動介入包括有氧散步和強度訓練,每天1小時、每週3天。
  
  在追蹤18個月時,節食加運動組(-10.6 kg;95%信心區間-14.1至-7.1 kg)和節食組(-8.9 kg;95% CI,-12.4至-5.3 kg)優於運動組(-1.8 kg;95% CI,-5.7至1.8 kg)。
  
  相較於運動組,節食加運動顯著較少膝蓋疼痛、較佳功能、步速較快、生理相關生活品質較佳;節食加運動組以及節食組的研究對象,介白素6值的降低程度也大於運動組。
  
  Messier博士表示,三組在6個月後的疼痛減緩程度都一樣,到了18個月時,節食加運動組在三組中脫穎而出,完成研究者的疼痛減少程度達50%。
  
  Farshid Guilak博士表示,雖然運動一直都是骨關節炎病患的處方之一且有諸多助益,這些研究結果顯示,單靠運動通常可能無法克服過重引起的某些影響。
  
  未參與此研究的Guilak博士表示,雖然眾所皆知減重對於過重的骨關節炎患者相當重要,這些研究結果進一步強調需要有針對減重的密切方法。目前,介白素6值降低或減輕膝蓋負擔與關節長期健康之間的直接關係則是未知,需要更多研究與長期追蹤,以釐清這些因素對於骨關節炎的影響。Guilak博士是杜克大學醫學中心骨科研究主任、骨外科副主任、Laszlo Ormandy 名譽教授,也是Journal of Biomechanics期刊的主編。
  
  丹麥Frederiksberg大學醫院、未參與此研究的Henning Bliddal醫師表示,這是篇相當有說服力的研究。所有過重/肥胖的骨關節炎患者,都應參與減重計畫及運動。唯一有爭議的是,肥胖患者是否可以立即開始運動,或者要先節食以減輕膝蓋負擔。
  
  Messier博士指出,雖然減重介入方式是成功的,他們的新體重中的瘦肉含量實際上是增加的,有進行節食的兩個組別中,瘦肉的絕對量是降低的。這類病患的後續減重研究應盡量對抗肌肉量之減少,或許在運動處方中使用更多強化訓練。
  
  資料來源: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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