What is the best diet for my advanced knee pain?

Ross Hauser, MD., Danielle Matias, PA-C., Marion Hauser, MS, RD

One of the more obvious ways to help a patient with degenerative knee pain and metabolic syndrome (abdominal obesity, hypertension, and diabetes) is to help them understand that a healthy lifestyle can be extraordinarily beneficial to their joint pain, especially their knees and spines. This usually does not take a lot of convincing. However, one of the hardest aspects of this understanding is not convincing a patient of is that they need to examine their food choices and lifestyle choices and make immediate and meaningful changes that may help them save their knee. Rather, it is helping with information that may provide motivation and  support system to allow them to succeed.

As you may be aware because of your own situation, often depression, anxiety and other factors get in the way. In some patients, a great deal of mobility has been lost. This of course can increase the risk of you eventually needing institutional care as you may be considered a fall risk or you simply can no longer walk without significant help.

It is very likely that if you are reading this article, you have:

Learning summary points of this article.

Every 1% weight loss was associated with a 2% reduced risk of knee replacement

Sometimes simple statements can provide the motivation necessary to find ways to lose and maintain weight loss. How about a little weight loss can reduce your need for knee replacement by a little. A lot of weight loss can reduce your risk of knee replacement by a lot.

Let’s start our article with an April 2022 study in the International journal of obesity (10). In this paper from medical university researchers in Australia, doctors described the impact of weight loss on helping people avoid a knee and hip replacement. What the researchers found was: “In people with or at risk of clinically significant knee osteoarthritis, every 1% weight loss was associated with a 2% reduced risk of knee replacement and – in those people who also had one or more persistently painful hips – a 3% reduced risk of hip replacement, regardless of (how overweight they were).”

In other words, if you are a 180 pound person and are 36 pounds overweight and you lost that 36 pounds – you would reduce your chances of needing a knee replacement by 72%. Knee replacement of course is a major operation and while many people have very successful surgeries, others do not. We do see many people with pain and complication after knee replacement. For the most part, when given information to review, most will try to avoid a knee replacement.

We do recognize however that some people are anxious to get a knee replacement. One of the motivating factors is if they get the knee replacement that their mobility will be restored and that they will be able to lose weight. While true for some, it is not true for everyone. We cover the issues of weight loss after knee replacement in our article: Knee replacement does not help many people lose weight.

Your inability to move pain-free, without frailty and instability is related to body mass index. “Locomotion Syndrome.”

There is the hope that knee replacement can help you move better. There is a hope that weight loss can help you move better. There is always hope, but if the reality is that you are aging, overweight, and losing range of motion, your adult children may be talking to you about considering assisted living one day in the future. Why? Because you may be on the verge of “Locomotion Syndrome.”

Locomotion Syndrome

Your inability to move pain-free, without frailty and instability, is called “Locomotion Syndrome.” If you can keep body mass index (weight and obesity) low, the faster you can walk.

“Locomotion Syndrome” is the loss of your own “locomotion” or ability to move. There are some obvious causes of “Locomotion Syndrome.” These include progressive degenerative disorders such as degenerative joint disease, rapidly developing hip osteoarthritis, knee osteoarthritis, degenerative diseases of the ankle and foot, and osteoporosis. Obviously disorders that would make it very difficult for someone to walk. But what if you did not have a significantly degenerated spine and joint disease and you have problems walking, or maintaining your balance, or even standing? What else could it be?

Let’s look at a November 2019 study in the medical journal Geriatrics & Gerontology International (1) that looks at aging patients to see what is causing aging patients their locomotion problems. The researchers state: The objective of the present study was to identify the factors related to onset and progression of Locomotion Syndrome in the absence of degenerative joint and spine disorders.

So they gathered and examined 1034 volunteers (444 men, 590 women, average age 63.5 years).

They divided the volunteers into two groups:

Then they grouped these people by age, sex, body mass index, muscle strength, gait ability, pain, body balance, spinal sagittal alignment, geriatric syndrome (locomotive syndrome, frailty and sarcopenia or bone loss) and Quality of Life scores.

The somewhat obvious findings were in patients without degenerative disease.

In a September 2020 follow up on this research, doctors writing in the journal BioMed research international (21) “With increasing Locomotion Syndrome risk stage, the prevalence of and VAS (0-10 pain score, 10 being worst) score for low back pain increased significantly, and back muscle strength and physical abilities decreased significantly.”

A look at Locomotive Syndrome – reduced mobility requiring nursing care

In January 2019, researchers at Nara Medical University in Japan published a study in the journal Modern Rheumatology (2). What they wanted to observe and assess was the impact of musculoskeletal diseases, depressive mental state, and hypertension on locomotive syndrome.

Learning points of this research:

In November 2018 another Japanese research team lead by Tokai University Oiso Hospital researchers looked at people with reduced muscle strength to measure the relationship with muscle frailty and metabolic syndrome leading to locomotive syndrome and required nursing care. This was published in the Journal of Orthopaedic Science.(3) They found a problem for women.

Locomotive Syndrome – A problem for women In women, body weight, body mass index, and abdominal circumference were significantly higher in the Locomotive Syndrome risk group.

 

Locomotive Syndrome - A problem for women

Locomotive Syndrome – A problem for women

Here are the leaning points of this study:

An August 2022 paper in the Japanese medical journal Modern rheumatology (22) investigated whether the locomotive syndrome severity affects future fragility fractures in osteoporosis patients. In this study,  315 women with osteoporosis (mean follow-up period, 2.8 years) were reviewed. Fragility fractures occurred in 37 of 315 participants (11.8%). This study revealed the locomotive syndrome severity to predicted fragility fractures.  The researchers suggested that the progression of locomotive syndrome associated with osteoporosis increases the fracture risk.

Another problem for women is cardiovascular disease. A December 2022 paper published in the BMJ Open (26) medical journal also found that central (belly) obesity is associated with pain severity, and further, in women with osteoarthritis, an increased risk of cardiovascular disease. The stress here is on belly fat or central fat. The researchers found that belly fat, not Body Mass Index (BMI), is more relevant to pain and cardiovascular disease in patients with osteoarthritis than BMI.

Abdominal obesity, hypertension, and diabetes accelerates knee pain and osteoarthritis and Locomotion Syndrome

In October 2018, researchers in the journal Clinical Rheumatology (4) reinforced these findings.

The goal of the study was to take patients who had metabolic syndrome (abdominal obesity, hypertension, and diabetes), and knee osteoarthritis and examine the patient’s clinical history, functional capabilities, and match that with scans and MRIs of their knees.

The obvious conclusion? You will probably walk a lot better and feel a lot better if the issues of Abdominal obesity, hypertension, and diabetes are confronted.

Why do men fail to lose weight on diets aimed to reduce knee and joint pain? Men may not associate being overweight with being unhealthy. They are not limping YET.

This is not denial, it is a line of thinking that suggests big men are healthy and successful men. We have covered ground above in the more disabled patient. But what about the patient who is not disabled or is effective in managing themselves with anti-inflammatories and just “working through it?” These can be stubborn patients.
Diet and knee osteoarthritis

More than half the men in one study were on diets, researchers examined why they keep failing to lose weight.

It is not easy for anyone, especially aging people with arthritis to lose weight. But many try. Researchers from the University of Florida and the University of West Florida examined the weight loss strategies of Baby Boomer men (born in 1946-1964).

Publishing in the Journal of Human Nutrition and Dietetics, (13) the Florida researchers aimed to identify weight-loss strategies used by the Baby Boomers to see if they worked.

In the study of 211 men, 82% were classified as being overweight or obese.

The more obese men employed the least healthier options more often.

Spouses were considered essential to their weight management success

Here is what the researchers determined:

They also noted, “Wives were considered essential to their weight management success.”

In the above studies, we clearly see that it is difficult for aging men to lose weight and they may give up very easily by justifying that “it doesn’t matter anymore,” or even acknowledging that they have a weight problem. When men do try to lose weight the bigger the problem, the more reliance on quick-fix solutions like diet pills and fasting.

Losing weight is considered a form a punishment or being deprived – doctors need to change the thinking to positive

A July 2018 paper from the University of Oxford published in the journal Applied psychology. Health and well-being noted (24) : “Some people construe deliberate weight loss as a form of deprivation and cognitively reframe (think positively) to avoid the negative emotions this creates and to prevent relapse. Reframing the dietary regimen as about healthy eating and a new way of life made weight control seem less burdensome for these participants and they felt able to maintain their efforts.”

Certainly no one is shocked that dieters feel deprived, nor should any one be surprised that a more positive outlook is needed.

In November of 2021 doctors writing in the journal The patient (25) assessed the perceptions of self-management interventions in their ability to manage chronic diseases. Part of managing chronic disease is managing diet. Two of the diseases examined was type 2 diabetes mellitus and obesity. What the researchers found was that the success of the self-management depended on the belief that the, in this case, diet would work, it was easy to manage, easy to do, and made sense for the patient. Again, we find no surprises here. These characteristics and desires of the workability of a diet are based in the positive thinking that the diet will help or that, in some cases, there is no choice, this diet must be adhered.

Let’s stop here for a second and discuss fear. Many motivations for successful dieting is based in fear that if the diet is not successful the patient’s health will further deteriorate. While fear can be a good motivator, it is still based in anxiety. Anxiety and stress can create their own problems.

If you have a big belly. Look down. You are looking at an inflammation processing plant. Your fat cells are pumping out inflammation to your joints.

Now let’s examine the role of chronic inflammation. Our daily food choices can fall into either “pro-inflammatory” or “anti-inflammatory” categories. As seen in the research of this article, links have been found between eating a pro-inflammatory (bad inflammation) diet and an increase in osteoarthritis in both men and women.

Dr. Karel Pavelka of the Czech Republic has published findings in the Fall 2017 issue of the Czech language journal Internal Medicine. (5) Here are his bullet points on metabolic syndrome (high blood pressure, high blood sugar, abdominal fat (big bellies), and high cholesterol levels.)

In other words, your fat cells are pumping out inflammation.

The message again: Your fat cells are pumping out inflammation

Your fat cells are pumping out inflammation

Your fat cells are pumping out inflammation

In other words – abdominal obesity, hypertension, and diabetes are destroying your joints as if it were a wear and tear disease.

State Medical University researchers in Russia (6) published their observations on 164 patients with osteoarthritis. Eighty-two patients were diagnosed with Metabolic Syndrome, Eighty-two were not and used as controls.

In the 82 patients with Metabolic Syndrome, clear indications of the negative impact of the disorder were seen:

Doctors in France cited these same findings in their research on factors affecting joint healing and metabolic syndrome in Current Opinion in Rheumatology: (7)

Research: Your big belly is causing your joint swelling

First we are going to start with rats’ knees and let further research demonstrate how that big puffy knee of yours is being made puffy by your belly. University researchers in Australia write in the journal PLoS One (Public Library of Science one) (8) of the established risks obesity plays in osteoarthritis. To prove the point they made rats obese by feeding them a high-carbohydrate, high-fat diet for a period of 8 and 16 weeks. The study showed that obesity-induced by this diet is associated with spontaneous and local inflammation of the synovial membranes in the rats even before the cartilage degradation.

This was followed by increased synovitis and increased macrophage infiltration (immune cells are now invading the areas causing swelling and edema) into the synovium and a predominant elevation of pro-inflammatory M1 macrophages (A specific type of immune cell).

This study demonstrates a strong association between obesity and a dynamic immune response locally within synovial tissues before cartilage degradation.

Let’s have a July 2022 paper explore both human and animal studies tie this together. In July 2022, in the journal Frontiers in immunology (27) researchers explain the evolving thinking connecting obesity to inflammation. “Obesity remains the most important risk factor for the incidence and progression of osteoarthritis. The leading cause of osteoarthritis was believed to be overloading the joints due to excess weight which in turn leads to the destruction of articular cartilage. However, recent studies have proved otherwise, various other factors like adipose deposition (body type fat, abdominal, big bell fat being worse), insulin resistance, and especially the improper coordination of innate and adaptive immune responses (an example of this is described above, the immune system is sending inflammation and creating swelling in a knee that has no cartilage damage).” All this, the researchers say, “may lead to the initiation and progression of obesity-associated osteoarthritis.”

Obesity and high fat diet stimulates chronic inflammation and eventual breakdown of cartilage.

This line of researching has lead to an understanding that fighting obesity IS an anti-inflammatory fight when it comes to degenerative joint disease.

A March 2022 paper published in the Journal of orthopaedic translation (23) looked for a way to provide drug manufacturers information on producing better anti-inflammatory medications for people with joint pain. What they found was a protein gene (ADCY7 ) that was being stimulated by obesity to help create inflammation. What the researchers did was to take synovial fluid samples from osteoarthritis patients. In some of these patients, there was a ADCY7 (gene)  expression.

The researchers write that “this may represent a currently undefined osteoarthritis subtype and explain the clinical phenomenon of more severe synovial inflammation in obese osteoarthritis patients.  . . ” Further, they confirm that the inhibition (stopping the gene expression) of ADCY7 could effectively stop high-fat diet-induced degenerative changes as well as the inflammatory (break down of lipid or fatty acids) lipolysis and fibroblast-like synoviocytes dysfunction (a dysfunction that causes chronic inflammation and eventual breakdown of cartilage) as they had observed in an animal study.

What does this suggest in simpler terms? Obesity and high fat diet stimulates chronic inflammation and eventual breakdown of cartilage.

The problems of managing insulin and inflammation

In our article What to do about knee pain being caused by your unmanaged or uncontrolled Type 2 diabetes, we describe the problems of insulin resistance and knee pain. Insulin resistance is a two fold problem. First is your inability to produce enough insulin to meet the needs of the amount of sugar in your blood. Second, the cells of our bodies that utilize insulin to breakdown and convert glucose to energy are not responding and acting upon the insulin in the blood stream. The cells became resistant to the insulin.

Chronic low-grade inflammation that is constantly eating at your knee.

Doctors writing in the journal Medical Hypotheses (9) offered evidence making a connection between insulin, inflammation, and joint pain here are the bullet points of their findings.

Reducing circulating insulin levels can be achieved in many cases with health-professional guided lifestyle and dietary changes.

Inflammation, pre-surgical inflammatory bowel disease can lead to knee replacement complication

Here is one more thing about diet. Doctors at the Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, investigated the influence of inflammatory bowel disease on complications following total knee replacement. They reported their findings in January 2023 in the journal Knee (28). Nearly 20,000 patients who underwent total knee replacement were divided into two groups, those with pre-surgery Crohn’s disease and those with pre-surgery ulcerative colitis. They compared these patients knee replacement outcomes with those knee replacement patients who did not have inflammatory bowel disease .

Results: Compared to patients without inflammatory bowel disease, patients with inflammatory bowel disease were associated with higher unadjusted 90-day odds for Clostridium difficile infection and two-year periprosthetic joint infection. The researchers suggest “providers should consider discussing these risks with patients who have a diagnosis of inflammatory bowel disease.”

What this research points out that difficult to manage inflammatory bowel disease can lead to post-surgery infections. Managing inflammatory bowel disease can help with synovial inflammation pre-surgery.

Eating foods that maximize healing

The same researching team cited above also examined the recent advances in the knowledge of osteoarthritis and its association with obesity and metabolic syndrome through systemic mechanisms.

“Type 2 diabetes has been described in two (studies) as an independent risk factor for osteoarthritis.” In these animal studies, diabetic rodents display spontaneous and more severe osteoarthritis than their non-diabetic counterparts.

The negative impact of diabetes on joints could be explained by the induction of oxidative stress and pro-inflammatory cytokines (systemic low-grade inflammation) and by joint tissues exposed to chronic high glucose concentration.

The message here is simple: Abdominal obesity, hypertension, and diabetes = knee pain and accelerated knee osteoarthritis. The choice to do something about it is yours.

What is the best diet for my knee pain? Simple tips.

What is the best diet for my knee pain?

You probably did not need all that science above to convince you that obesity can cause advanced degenerative damage in your knee. Many patients come into our office with knee pain and a bit of a belly. They tell us that they need to lose some weight but it is hard with their knee pain limiting their activities. We understand and we do not lecture patients on this. We try to offer suggestive help. So, when these people come into our clinic with significant knee pain, and they ask our clinicians about what type of diet they should be on. The answer is usually, the one that helps you to a healthy body weight.

Avoid foods that cause weight gain AND inflammation. As the research will show you below, you eat stuff that creates inflammation and weight gain, it is very likely you will have knee swelling and knee pain from your food.

The best diet is one that does not cause weight gain and does not cause inflammation independent of the degenerative inflammatory response. There is a list of “wrong foods,” that would be incredibly long. So I will simplify this list down to the following foods noted on the Dietary Inflammatory Index Scale, this is a scale that measure which foods cause the most and least inflammation and is used in making food choice recommendations for heart disease and cancer prevention.

The list is somewhat obvious in its recommendation to avoid pro-inflammatory foods:

As the research will show you below, you eat this stuff, it is very likely you will have knee swelling and knee pain from both excess weight and these foods producing their own inflammation. This is why you get a C-Reactive Protein test to screen for heart disease. The test is checking for the inflammation in your body independent of joint damage. So as the right food stimulates healing, the wrong food can cause inflammatory reactions and make your knees feel worse.

What are the right foods?

Here are our articles on this website. They list the scientific benefits of certain foods.

According to medical studies, dieting will help some people with knee pain, dieting will not help some people with knee pain.

Will it help you? That depends, according to researchers, on the type of diet you are on.

Where do we begin with all of this? With research.

At the University of Alabama at Birmingham, a research team published their findings that diet may offer a an alternative to opioids, acetaminophen, and nonsteroidal anti-inflammatory drugs.  This research appears in the journal Pain Medicine.(14)

Study learning points:

RESULTS: Over a period of 12 weeks, the low-carbohydrate diet group reduced pain intensity and unpleasantness in some functional pain tasks, as well as self-reported pain, compared with the low-fat diet group and the people acting as a control group who continued to eat as usual.

In the above study, the researchers measured the adipokine leptin or fat cells. Fat cells cause inflammation. Above in this article and in our article Is losing weight an anti-inflammatory? I showed research that obesity is more than weight load – it causes inflammation without wear and tear. I shared with the readers research from doctors at the University of Calgary who wrote in the journal Osteoarthritis and Cartilage (15) that when they examined obese laboratory animals, they found that not only does obesity cause osteoarthritis because of weight load (such as in a knee), but it also causes osteoarthritis in a “non-mechanical” way – in other words by inflammation without wear and tear.

Low Carb Diet works for some

For some patients, we would offer recommendations that they pursue a high protein, low carb diet. We do stress that it is for some patients not all. We call this the Lion Diet, a diet that typically a lion would eat in the wild. It would be about 60% protein, 25% fat and 15% carbs. This type of diet was general recommendation for people with abnormalities in both the glucose tolerance test (high insulin levels (insulin resistance) and blood pH levels pointing to being more acidic. Eating these foods regularly (every 3-4 hours, even including a snack before bed) could prevent blood sugar swings, raise blood pH, and lower insulin levels. This diet would work for many people, but not all.

Will a diet of fruits, vegetables, and fiber help my knee pain?

The different types of foods that could help knee osteoarthritis is something that we cover in many articles on this website. Let’s get to some introductory research that will help us understand the role of fruits, vegetables, and fiber.

In the April 2019 issue of the European medical journal Maturitas (16) which deals with the subject of Menopause, research led by the University of Wollongong in Australia examined the effect of dietary phytochemical intake from foods on osteoarthritis.

Quick notes:

The researchers of this study, while warning that there is not enough research to make a strong recommendation on what types of phytochemicals may be beneficial, did suggest that:

Let’s take a quick look at strawberries with a summary from my article Can strawberries help with joint pain?

Above we also discussed oxidative stress 

Research: Fruits and vegetables do help knee pain, but how?

A 2017 study from The Journal of Nutrition, Health & Aging (19) did make a positive connection between the consumption of fruits and vegetables. The question was how? The answer it may all be in your mind.

The research team hypothesized that higher fruit and vegetable consumption might be associated with the severity of knee pain lower prevalence of severe knee pain by affecting pain perception in the knee joint. So they investigated the relationship between self-reported knee pain and the consumption of fruits vegetables, carotenoids, and vitamin C and self-reported knee pain.

In this study, the patients told the doctors how much their knee(s) hurt on a standardized scoring system. Then they ate a diet rich in food and vegetables. Here are the results:

What the researchers questioned was the question, did these people knees hurt less because of the diet’s specific impact on their knees or did the people of this study, because they were eating better, simply feel better overall? To the person the diet is helping, it does not matter.

Zinc and Iron

A November 2023 paper (28) looked to provide doctor and patient guidance to better understand zinc and iron intake in subchondral sclerosis (bone thickening)  in patients with osteoarthritis. Four hundred and seventy four patients compromised the study group (216 females, 258 males, average age about 64 years old.) The study noted a significant delay in the progression of osteoarthritic subchondral sclerosis in patients who increased zinc intakes along with adequate calcium intake. This delay was especially noted in female and middle-aged patients, individuals with higher calcium and magnesium intake, and patients with more severe osteoarthritis. However, increased iron intake intensifies osteoarthritic subchondral sclerosis to a certain degree.

Will a cholesterol-lowering diet help my knee pain?

In my article My doctor says that my knee pain is being made worse by my elevated cholesterol, we looked at a study in the influential journal Scientific Reports.(20)

What is the best diet for your knee pain?

It is very likely that you have been on numerous diets and have not done as well as you would have liked, else wise you would still not be looking for help. Generally, the best diets for people are the ones that tend to show some success at the onset is not just losing weight but in overall health. Above we spoke about researchers who could not distinguish whether the diet was helping the knee pain or the idea of the diet and eating health was helping the knee pain. One thing for sure, something was helping the knee pain and this lead people to stay on the diet.

 

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This article was updated December 5, 2023

 

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