The impact of obesity on the musculoskeletal system

Abstract

Obesity is associated with a range of disabling musculoskeletal conditions in adults. As the prevalence of obesity increases, the societal burden of these chronic musculosketelal conditions, in terms of disability, health-related quality of life, and health-care costs, also increases. Research exploring the nature and strength of the associations between obesity and musculoskeletal conditions is accumulating, providing a better understanding of underlying mechanisms. Weight reduction is important in ameliorating some of the manifestations of musculoskeletal disease and improving function.

Introduction

Obesity represents a major public health problem and carries with it the risk of developing significant medical problems. The global burden of obesity is rising at an alarming rate. The World Health Organization estimates that more than one billion people are overweight and of these, 300 million are obese.1 In Australia, about 20% of the population is obese (approximately 2.6 million).2 In addition, the levels of extreme obesity (obesity grade 3, body mass index (BMI) 40) are also escalating.3 Recently, McTigue et al.3 reported that weight-related health risk, specifically all-cause mortality, varies with degree of excess weight with those in the obesity grade 3 range faring significantly worse than individuals of normal weight or a lower grade of obesity.3

Concurrently, in part due to the aging population, the burden of arthritis and musculoskeletal conditions as causes of pain and disability continues to increase. In Australia, these conditions have been identified as the third largest contributor to direct health expenditure (behind cardiovascular disease and neurological disorders).4 ‘Arthritis and related disorders’ were the most common cause of disability in Australia in a recent population survey,5 the second most common reason for general practitioner (GP) visits and also the cause of a large number of hospital separations.6 In an analysis of the direct costs of obesity, it was estimated that the cost of osteoarthritis (some $300 million) was second only to the cost of diabetes in obesity-associated conditions.

There is a significant positive association between musculoskeletal disorders and the level of obesity.7 The Centre for Disease Control recently reported that in the United States, more than 31% of obese adults reported a doctor diagnosis of arthritis compared to only 16% of non-obese people.8 The nature and extent of the impact of obesity on the musculoskeletal system and the spectrum of conditions implicated is not well appreciated. This is surprising considering the high prevalence of chronic musculoskeletal conditions in a rapidly aging population and the associated significant societal burden of lost productivity and direct health-care costs. In addition, the chronic pain and disability associated with musculoskeletal conditions not only significantly affect an individual's quality of life but often result in the early uptake of a sedentary lifestyle associated with various serious comorbidities.

Obesity has been implicated in the development or progression of a wide variety of musculoskeletal conditions. These are summarized in Table 1. Obesity is also associated with increased operative risks in the surgical management of some of these conditions.9 The aim of this study is to provide a comprehensive overview of the specific musculoskeletal conditions associated with obesity and present the evidence underpinning the association between obesity and these musculoskeletal conditions. The possible impact of obesity on therapy is also explored. A literature search (Medline and Pubmed) was conducted from January 1966 to December 2006. Articles assessing the effect of obesity or weight loss on musculoskeletal conditions were reviewed.

Table 1 Musculoskeletal conditions associated with obesity

Osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis and the leading cause of chronic disability among older people. Large longitudinal studies10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 have demonstrated that obesity is a significant risk factor for both the development and progression of tibio-femoral knee OA (both symptomatic and radiographic). An association, though modest, has also been demonstrated between obesity and OA at other sites such as the hip, hand and patello-femoral joint, suggesting that both mechanical and metabolic factors may be responsible for the link between OA and obesity.

Knee osteoarthritis

Prospective data from the Framingham population demonstrated that obesity predates the development of knee OA, and that obesity is an independent risk factor for incident radiographic OA. The odds ratio (OR) per 5-U BMI increase was 1.6.10 In the Chingford study of over 1000 women, obesity was classified as the upper tertile of BMI (the boundaries of the middle tertile were 23.4 and 26.4 kg m−2).24 The age-adjusted OR of unilateral and bilateral radiological knee OA comparing the high and low tertiles of BMI were 6.2 and 18, respectively, and the risk was 8.6 times higher for symptomatic disease. In the recent MOST cohort, those with highest obesity were again at highest risk of developing symptomatic and radiological knee OA at 15 months (OR 3.4).25 A recent study on ambulatory loads in overweight and obese subjects indicated that cartilage thickness at the knee joint responds to loading during gait in a similar manner to OA patients. These findings suggest the possibility that increased weight initiates a pathway of cartilage degeneration prior to the emergence of OA symptoms.26

In a controlled study with twins, Cicuttini et al.19 showed that each kilogram increase in body weight was associated with an increased risk of radiographic features of OA at the knee and carpometacarpal joint. The strong association between high BMI and knee OA was confirmed in another twin study and this association was found not likely to be mediated by shared genetic factors.27 Obese patients with knee OA have more joint space narrowing in the medial and lateral tibio-femoral compartments than non-obese patients.28

Obesity is also an important risk factor for the progression of knee OA17 and has long-term detrimental effects on the knee joint.29 Sharma et al.30 looked at the role of mechanical factors, specifically malalignment, in mediating knee OA severity or progression. In patients with knee OA, there was a relationship between BMI and radiographic severity in those with varus malalignment, but not in those with valgus malalignment. BMI correlated positively with varus malalignment. However, the partial correlation between BMI and medial joint space width was reduced from 0.24 to 0.04 after adjustment for malalignment, due to the strong positive association between medial joint space width and varus malalignment. It was found that varus malalignment may explain, in part, the uniquely strong association between BMI and OA at the knee compared to other lower extremity sites. However, given the cross-sectional nature of the study, it cannot be established whether varus malalignment is causal or consequential in the relationship between obesity and OA. Nevertheless, varus malalignment is an important mediating factor in knee OA in the obese individual. Felson et al.31 also found that the adverse effect of high BMI on knee OA progression was limited to those patients with moderate malalignment.

Although the strong association between knee OA and obesity has been demonstrated, the factors underlying the mechanism of the effect have not been entirely elucidated. Age, serum lipids, serum uric acid, blood glucose or diabetes, body fat distribution, blood pressure, smoking, chondrocalcinosis, hysterectomy or estrogen replacement therapy have not been found to affect the obesity–OA relationship.30 However, being overweight is associated with increase in cartilage turnover biomarkers. Cartilage oligomeric matrix protein and collagen type 2 degradation products were increased in those with high BMI.32, 33

Another study examined the effects of measures of body composition on the longitudinal change in tibial cartilage volume using magnetic resonance imaging (MRI).34 Eighty-six healthy adults underwent assessment of body composition using dual X-ray absorptiometry and MRI at baseline and 2 years. A strong positive association was found between muscle mass in the lower limbs, muscle mass in all limbs, and muscle mass in the total body and medial tibial cartilage volume after adjustment for confounders such as age, sex, BMI, medial tibial bone size and physical activity. Importantly, in the longitudinal analysis, increased muscle mass was also associated with a reduction in the rate of loss of both medial and lateral tibial cartilage volume. In contrast, body fat was not associated with medial or lateral tibial cartilage volumes or loss in adjusted analysis. This finding was confirmed in a recent larger study suggesting that apparent gender difference in articular cartilage volumes (men demonstrating higher cartilage volume) may be largely explained by fat-free muscle mass.35 However, another study reported that increased muscle mass may predispose to lateral patello-femoral OA progression in women,36 whereas in another, greater quadriceps strength was found to have no effect on cartilage loss at the tibio-femoral joint, even in malaligned knees.37

The association between knee structural alteration and BMI was evaluated in a cross-sectional convenience sample of 372 largely healthy subjects.38 Apart from the lateral tibio-femoral compartment, BMI was significantly associated with knee cartilage defect scores such that obese subjects had higher cartilage defect severity and prevalence. BMI was also positively associated with tibial bone area but there was no significant change in cartilage volume or thickness compared to those with normal weight. This study shows that increasing BMI may induce cartilage defects even in those with no radiographic OA. The reasons for this remain to be elucidated.

There is some evidence suggesting that knee bone size may be important in the development of knee OA. Knee bone size is under strong genetic control and is higher in the offspring of those with severe OA.38 The authors propose that a greater BMI can induce larger knee subchondral bone size or that knee subchondral bone may respond to higher loads by expansion of the joint surface area. In this study, knee bone size mediated, in part, the associations between BMI and knee cartilage defects, because these associations were attenuated after adjustment for bone size and vice versa.

Higher BMI is also associated with increased risk of degenerative meniscal lesions.39 However, it is not certain if degenerative meniscal lesions have an etiological role in the development of knee OA.

Hip osteoarthritis

The First National Health and Nutrition Examination Survey data show that obesity was more closely associated with bilateral hip OA than with unilateral hip OA.40 A systematic review found moderate evidence for a positive association between obesity and the occurrence of hip OA (OR 2).41 The associations between obesity and hip OA were stronger when the diagnosis included clinical as well as radiological criteria.

Hand osteoarthritis

The association between obesity and hand OA is less certain with some studies suggesting a link and others showing conflicting results.16, 42, 43, 44, 45, 46, 47. In a large Finnish study, BMI was found to be directly proportional to the prevalence of thumb carpo-metacarpal OA in both sexes.48 The adjusted OR was 1.29 per 5 kg m−2 increment in BMI.

In the recent Rotterdam study, overweight showed a significant association with hand OA independent of other metabolic factors (OR 1.4).49 An association between overweight and hand OA infers other underlying mechanisms apart from increased load across weight-bearing joints. In this study, no intermediate effect of metabolic factors on the association of overweight with hand OA was found. Leptin may have an important role in the metabolic influence of overweight on OA. Serum leptin, the product of the obese (ob) gene, is involved in energy regulation at the level of the hypothalamus and recent evidence suggests that leptin may act locally in joint tissues.50 Leptin has been detected in synovial fluid samples obtained from OA patients and levels of leptin have been found to correlate with BMI.51 Leptin has also been strongly overexpressed in human OA cartilage and in osteophytes.

Weight reduction

Normal weight is associated with a decreased risk incidence and progression of OA.15, 52 Both the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) recommend weight loss and exercise for obese patients with knee OA.53, 54

In the Framingham study, evaluation of 800 women showed a decrease in BMI of 2 kg m−2 in the preceding 10 years decreased the odds of developing symptomatic OA by >50%.11 It has also been suggested that if all overweight and obese people reduced their weight by 5 kg or until their BMI was within the normal recommended range, 24% of the surgical cases for knee OA might be avoided.55

Until recently, only a few nonrandomized clinical trials have examined the effect of weight loss on pain and function in knee OA, suggesting that the combination of dietary weight loss plus exercise is effective.56, 57, 58 Recently, a large clinical trial, the ADAPT study, randomized 316 overweight or obese older subjects with knee OA to exercise only (combined aerobic and strengthening), dietary weight loss only, exercise plus dietary weight loss or a healthy lifestyle control group. After 18 months, despite only modest reductions in body weight, significant improvements in pain and physical function were seen in the diet plus exercise group compared to the healthy lifestyle group, but not for the weight loss or exercise-only allocations.59

A subset of the ADAPT study cohort underwent biomechanical analysis testing over an 18-month period.60 There was a significant relationship between weight loss and reduction in compressive knee-joint loads, with a four-pound reduction in knee-joint load per step for every 1 pound weight loss. To date, there are no longitudinal studies evaluating if weight loss slows the progression of knee OA but this effect would appear to be clinically plausible. In the ADAPT study, no changes in joint space narrowing were noted between the different groups.61 However, the study was probably underpowered to detect differences in joint space narrowing over an 18-month period. MRI possibly allows a more sensitive measure of joint space loss compared with radiography, but thus far, no studies have looked at MRI outcomes in subjects undergoing weight loss.

A second recent randomized clinical trial, evaluating a rapid weight loss diet among 80 patients with knee OA, found that a weight reduction of 10% improved function by 28%. The authors found that less than four patients (95% confidence interval 2–9 patients) would need to be treated with a low-energy diet for one patient to achieve a 50% improvement in the WOMAC score (a measure of joint pain, stiffness and function) when compared to a control diet.62

The effects of weight loss and exercise interventions on serum leptin were also assessed in the ADAPT cohort.63 In the ADAPT cohort, serum leptin was significantly reduced by a long-term diet (weight loss) intervention with modest weight loss of 5–6%. Serum leptin was also related to self-reported physical function with higher leptin concentrations related to greater impairments in physical function. The authors also found that initial baseline leptin levels were a predictor for subsequent weight loss, with lower baseline levels of leptin predicting greater weight loss.

Surgery

The need for joint replacement surgery has been escalating with the increased burden of OA in the community. In Australia, orthopedic surgery had the second longest median waiting time in 2003–2004.64 With the increasing prevalence of obesity, the proportion of joint replacements performed in obese patients is likely to increase dramatically, with estimates suggesting over a third of all total hip and knee replacements are performed in the obese.65, 66, 67, 68 A frequency-matched case–control study found that very obese females (BMI >40) were more likely to face joint surgery compared with matched normal weight females in either the hips (OR=4) or knees (OR=19).69 Similarly, obese males were more likely to undergo joint replacement surgery compared with non-obese males.

A recent review discussed the decision by three primary care trusts in the United Kingdom to not entitle patients with BMI >30 to hip and knee replacement surgery, and evaluated the current evidence for outcomes in obese patients for both total knee and hip replacement surgery.9 In the midterm, outcomes of knee replacement in the obese (BMI >30) are probably comparable to the non-obese but larger, prospective studies are needed to ascertain long-term outcomes. However, there is some evidence that outcomes in the morbidly obese (BMI >40) are consistently poor.9 Similar data are not available for the effect of morbid obesity in hip replacement.

Obesity may not be a contraindication to simultaneous bilateral total knee replacement surgery.70 However, a BMI >32 predicted failure in those undergoing minimally invasive medial unicompartmental knee arthroplasty in a retrospective series.71 Obesity is a risk factor for patients undergoing high tibial osteotomy for the treatment of unicompartmental knee OA in the presence of malalignment.72 Outcomes relating to quality of life and satisfaction following arthroscopic debridement of the knee were also poorer in overweight women than the normal weight group.73

Low back pain

Low back pain from degenerative disc disease of the lumbar spine, spinal canal stenosis and zygo-apophyseal joint disease is a very common problem in the community resulting in significant morbidity.74 This has important consequences in terms of productivity at work and utilization of health services. The association between obesity and lower back pain is conflicting.75, 76, 77, 78, 79 A recent review describes the lack of a clear dose–response relationship between BMI and low back pain.80

However, compared with non-obese patients, obese patients were more likely to have radicular pain and neurologic signs.81 Obesity was a significant, independent determinant of chronicity in a prospective cohort study in workers claiming compensation for lower back pain.82 In morbidly obese subjects with lower back pain undergoing bariatric surgery, weight loss significantly improved the degree of functional disability,83 and resulted in less frequent lower back pain and the use of reduced doses of medications.84

In a population-based study of 129 middle-aged working men comprising machine drivers, construction carpenters and office workers, persistent overweight was strongly associated with decreased signal intensity of the nucleus pulposus at follow-up MRI (adjusted OR 4.3).85 However, it is not known whether these MRI findings correlate with clinical symptoms. Spinal epidural lipomatosis is also associated with obesity.86 Here, there is hypertrophy of the epidural adipose tissue, causing a narrowing of the spinal canal and compression of neural structures.

The relationship between ambulation and obesity in older individuals with and without low back pain was assessed in a retrospective study. BMI had a significant inverse relationship with ambulatory measurements in terms of distance walked, steps taken and walking velocity.87

A retrospective study assessing outcomes of sciatica found that obesity was associated with adverse 6-month outcomes.88 Being overweight and obese is also a risk factor (OR 1.83) for postoperative meralgia paraesthetica after posterior thoracolumbar surgery.89 However, outcome assessment in elderly patients undergoing lumbar spinal surgery did not find any difference in the obese group suggesting that surgery in the elderly obese with appropriate symptoms would be reasonable.90

Diffuse idiopathic skeletal hyperostosis

Diffuse idiopathic skeletal hyperostosis (DISH) or Forestier's disease, a chronic age-related condition, is characterized by new bone growth especially at the entheses. DISH affects many skeletal structures but typically affects the thoracic spine. It is associated with obesity, diabetes mellitus, hyperinsulinemia and hyperlipidemia.91, 92 In an age- and gender-matched case–control study, patients with DISH were more likely to have elevated BMI than controls without DISH.93 A study examining the role of leptin in the ossification of spinal ligaments found that serum leptin levels were significantly elevated in subjects compared to controls.94 The daughters of subjects who were severely obese also had high serum leptin levels although they had not developed the condition. Leptin may thus be genetically and indirectly associated with the pathogenesis of the ossification of spinal ligaments in female patients. The role of obesity in the pathogenesis of DISH is yet to be clearly defined and the effect of weight reduction in reversing/slowing progression of disease has not been studied.

Gait disturbance

Obesity is also associated with structural and functional limitations95 with impairment of normal gait,96 flattening of the foot arches97, 98, 99 and pronation of the ankles. In a pilot study, body composition was found to influence arch index values in overweight and obese subjects.100 Obesity increases rearfoot motion during walking and causes the forefoot to abduct significantly more than in normal weight individuals.101

Excess weight is associated with increases in the amount of force across a weight-bearing joint.30, 102 A study assessing postural instability in extremely obese individuals found these individuals had inadequate postural instability as measured by time of balance maintenance and medial-lateral sway of the trunk.103 After a 3-week body weight reduction program and specific balance training, postural stability could be improved which has the potential to reduce the propensity of overweight individuals to fall while performing everyday activities. In another study, obesity was associated with attenuated dynamic balance performance.104 Poorer balance was found to be associated with higher pain scores in t he presence of weaker knees.

Morbidly obese subjects also walk significantly slower than their obese and lean counterparts.105 BMI was one of the factors affecting the variance in walking distance. The effects of obesity on gait need to be further understood as an important part of management would include incorporating an appropriate exercise program.

Soft tissue complaints

There is a high prevalence of pain in the neck (10–19%), shoulder (18–26%), elbow (8–12%) and wrist/hand (9–17%) at any given time in the community.106 Obesity is consistently a significant risk factor associated with the occurrence of these complaints. Obesity was also found to predict those who were likely to develop upper extremity tendonitis associated with work activity in a prospective cohort study over 5 years.107 In another prospective survey of upper-limb work-related musculoskeletal disorders in repetitive work, obesity again increased the risk of ulnar entrapment at the elbow.108

A recent study assessed the point prevalence of painful musculosketelal conditions in obese subjects before and after weight loss following bariatric surgery.109 There was an increased prevalence of these conditions at baseline compared to the general population. There was a significant decrease in pain at most sites following weight loss and physical activity after 6–12 months, in particular the cervical and lumbar spine, and foot.

Carpal tunnel syndrome is a common condition in the community. In a large case–control study using the UK General Practice Database, obesity was a significant risk factor associated with carpal tunnel syndrome (OR=2.06).110 Obesity has been shown to be an independent risk factor for carpel tunnel syndrome in a number of studies.111, 112 There is also an association between obesity and shoulder repair surgery for rotator cuff and other conditions, suggesting that increasing BMI is a risk factor for rotator cuff tendonitis and related conditions.113

Plantar fasciitis is a common soft-tissue disorder of the foot. Obesity is a risk factor for developing unilateral plantar fasciitis (OR 5.6 compared to normal BMI).114 Obesity is also associated with chronic plantar heel pain.115 The link between obesity and plantar heel pain is, however, not well understood. Arch biomechanics are thought to play a role in etiology but this has not been conclusive.116 Obesity is also a risk factor for trochanteric bursitis, a frequent cause of lateral hip pain in middle-aged and elderly individuals.117

Osteoporosis

A number of studies have demonstrated that body weight is closely correlated with bone mineral density (BMD).118, 119, 120 In cross-sectional studies, a 10 kg increase in body weight is associated with approximately a 1% increase in BMD. This relationship has been demonstrated for both women and men and across cultures but the effect of weight on BMD appears to be stronger in women than in men,121, 122, 123 and more in postmenopausal than premenopausal women.124, 125

Several mechanisms have been proposed to explain the effect of weight on bone density. Firstly, it could be due to the amount of adipose tissue, which is the major site of conversion of androgens to estrogen in both elderly men and women. If estrogen has a greater role in preservation of bone mass in women than men, this may explain why the effect of weight is greater in women than men. This may also explain why shortly after menopause, obese women do not lose bone as rapidly as their non-obese counterparts.126, 127 A second mechanism relates to the increased mechanical load that heavier individuals place on weight-bearing bones. This is supported by some data suggesting that body size is a better determinant in weight bearing rather than non-weight-bearing sites.123 Although it is often considered that obese subjects are at lower risk of osteoporosis, there is evidence that changes in bone marrow fat with ageing may adversely affect skeletal strength. Visceral fat may have a protective effect on BMD128 through biochemical factors such as adiponectin. The latter is an adipocyte-derived hormone that regulates insulin sensitivity and energy homeostasis.

There is still controversy over the relative importance of fat versus lean mass in the determination of BMD. Reid129 concluded that while both fat and lean mass are related to bone measures, the effect of fat mass becomes more important in postmenopausal women and that the relationship between lean mass and bone density was substantially accounted for by body size. Only a few studies have investigated the association of bone mineral measures with body composition components adjusted for body size or their distribution (such as centrality indices).130

However, recent research suggests that obesity may accelerate bone loss.131 Deng et al. showed, in two large population samples, that the bone strengthening effects of a heavy body were not due to fat but to elevated muscle mass, which increases bone density.131 The authors report that increased fat mass is associated with decreased bone mass, when the mechanical loading effect of body weight on bone mass is adjusted for. The risk of fracture in the obese is not clear with conflicting associations being reported.132, 133

There is also evidence from longitudinal studies that weight loss is a risk factor for rapid bone loss in men and women,134, 135, 136 although methodological differences between machines in relation to measurement of BMD due to changes in fat distribution may affect results. Another study showed that overweight postmenopausal women may be more susceptible to bone loss with weight reduction. Weight loss correlated with BMD loss at the trochanter but not at the femoral neck in the group receiving normal calcium intake daily compared to high calcium intake.137 Weight loss due to caloric restriction appears to induce rapid bone loss at clinically important sites of fracture, unlike exercise-induced weight loss.138 In addition, the rapid increase in obesity has led to an escalation in the uptake of surgical techniques to control weight. Procedures that involve duodenal bypassing place individuals at risk for osteoporosis as this is the primary site for calcium absorption.139 Obesity is also a risk factor for vitamin D deficiency.140

Gout

Gout is the most common form of crystal-induced arthritis and in the United States affects more than 1% of adults.141 It results from the deposition of monosodium urate crystals. Obesity is a well-known modifiable risk factor in the pathogenesis of gout and serum uric acid is positively associated with BMI.142 The size of the visceral fat area is the strongest contributor to elevated serum uric acid concentration, decreased uric acid clearance and increased urinary uric acid/creatinine ratio.143 Weight loss is advocated in the overall management of gout but no study has assessed the effect of weight reduction on uric acid levels or attacks of gout.

Fibromyalgia

Fibromyalgia is a complex disorder resulting in pain, disturbed sleep and altered mood. A number of risk factors are associated with this condition and obesity also plays a role.144 In a pilot study of overweight and obese women with fibromyalgia, the relationship between BMI and fibromyalgia symptoms were assessed after a 20-week behavioral weight loss treatment.145 Participants lost, on average, 4.4% of their initial weight, and weight loss predicted a reduction in fibromyalgia symptoms, pain interference, body satisfaction and quality of life. In a study of obese subjects undergoing bariatric surgery, there was a significant reduction in fibromyalgia syndrome at follow-up 6–12 months later.109

Connective tissue disorders

Rheumatoid arthritis (RA) is the most common chronic inflammatory joint disease. Obesity has been identified as a risk factor for RA.146 Two population-based cohort studies have shown an association between obesity and the development of RA,147, 148 whereas one149 did not. The association appears to be a threshold effect with no relationship between BMI and the risk for RA below a BMI of 30. Paradoxically, one study in a cohort of 779 RA patients found that BMI was inversely associated with mortality independent of methotrexate use. Corticosteroid use was not tabulated. Interestingly, an interaction was found between BMI and erythrocyte sedimentation rate and BMI was protective only if the erythrocyte sedimentation rate was low.150 However, obesity was also recently found to be independently associated with impaired quality of life in patients with RA.151 A marked increase in plasma levels of adipocytokines (leptin, adiponectin and visfastin) have been noted in patients with RA suggesting a role in the modulation of the inflammatory environment in these patients.152

In systemic lupus erythematosus, obesity is a strong predictor of preeclampsia.153 Obesity is common in the lupus population, 36% prevalence in one urban university clinic.154 However, obesity was not associated with hypertension and diabetes in this cohort and contrary to expectation, overweight systemic lupus erythematosus patients appeared to register the highest quality of life on questioning.

Hypoandrogenicity in males is common in obesity and in chronic inflammatory conditions such as systemic lupus erythematosus and RA.155 Leptin, as well reflecting adipose tissue mass, is stimulated by tumor necrosis factor and is associated with hypoandrogenicity in non-inflammatory conditions. Leptin has been found to correlate negatively with adrenal androgen concentrations in patients with systemic lupus erythematosus and RA, suggesting that leptin may be an important link between chronic inflammation and the hypoandrogenic state.155

Disability/quality of life

It is increasingly being recognized that obesity impacts on health-related quality of life and disability. Obesity increases the risk of disability among people who have arthritis.156, 157, 158, 159 Obesity is also associated with disability in those without self-reported arthritis.159, 160 People who have disabilities are 2.5 times more likely to be obese than those who do not have disabilities.161 In the ADAPT cohort, exercise and dietary weight loss improved mobility-related self-efficacy and self-reported pain.162 In cross-sectional data from the 1998 Quebec Health Survey, being overweight was significantly associated with short- and long-term activity limitation related to musculoskeletal disease.163

Obesity is also consistently associated with lower limb joint pain (hip and knee)164, 165, 166 and back pain.167 Osteoarticular pain (knee and hip pain) is a major predictor of poor health-related quality of life in obese subjects168 and obesity is linked with knee pain severity and disability among older knee pain sufferers in the general population.169 Population-based surveys have confirmed J-shaped associations between BMI and health-related quality of life, with obese individuals significantly more likely to report fair or poor general health status.170, 171

Exercise capacity is decreased in obesity, both at submaximal and peak intensity, and during recovery.172 Importantly, weight reduction was found to have positive short-term effects on musculoskeletal pain, perceived disability, and observed functional limitations.173 A recent systematic review also provides category 1a evidence that weight reduction reduces pain and disability in knee OA patients.174

Obesity is also significantly associated with the frailty syndrome. Frailty indicators include weakness, slowness and low physical activity, and predisposes to loss of independence. Physical frailty is common in community-dwelling obese elderly men and women.175, 176 In home-dwelling elders, obesity was again one of the primary predictors of decreased quality of life.177

Health costs

Clearly, obesity has an important impact on health-care costs due to direct and indirect costs. Obesity cost Australians $21 billion in 2005, double the cost of Medicare in Australia. Lost tax revenue, welfare and other government payouts incurred by obesity sufferers was estimated at $358 million.178 In a Dutch case–control study among self-employed insured farmers, neck, shoulder, upper extremity and back disorders accounted for 30% of claims for sick leave of less than 1 year. Multivariate analysis assessing risk factors showed that BMI>27 was two times more likely to result in musculoskeletal disorders as a cause of sick leave.179 Obese subjects were found to have more work-restricting musculoskeletal pain than the general population in a Swedish study.180 In a large cross-sectional study of patients with spinal disease, obese patients had more comorbidities and were more likely to be receiving worker's compensation.81

Obesity also results in significantly higher primary care drug prescribing in most drug categories including musculoskeletal and joint disease as noted in a recent retrospective review in the United Kingdom.181 There is also a positive relationship between musculoskeletal disorders and the consumption of disability products.182 Moreover, there is an association between obesity and being on the disability pension. A linear relationship was identified between BMI and disabling knee OA.183 In Swedish 5 birth-year cohorts, there was a J-shaped relationship between BMI and incidence of disability pension (RR in obese subjects 2.8) and musculoskeletal disorders were one of the primary reasons.184 This is corroborated in a Finnish study.185

The increasing prevalence of obesity among patients and caregivers can also lead to more frequent and serious musculoskeletal injuries among caregivers.186 The ramifications include the need to utilize safe and appropriate equipment to cope with obese individuals which inevitably requires extra care and resources.

Conclusion

Obesity is associated with a number of musculoskeletal conditions and is responsible for significant disability and impaired quality of life. The global obesity epidemic has significant consequences for both the individual and the community in terms of direct and indirect health-care costs. Further studies prospectively evaluating these conditions in the obese population are imperative to define better the mechanisms by which obesity mediates musculoskeletal disorders, and to determine the effects of moderate to large weight loss on these conditions. This has important ramifications in both the prevention and development of appropriate treatment strategies in the ongoing management of these conditions.

References

  1. 1

    World Health Organisation. 2006, http://www.who.int/dietphysicalactivity/publications/facts/obesity/en/.

  2. 2

    Australia's Health. 2004 Australian Institute of Health and Welfare 2004. AIHW Cat.No. AUS-44.

  3. 3

    McTigue K, Larson JC, Valoski A, Burke G, Kotchen J, Lewis CE et al. Mortality and cardiac and vascular outcomes in extremely obese women. JAMA 2006; 296: 79–86.

    CAS  Google Scholar 

  4. 4

    Penm E, Dixon T, Bhatia K . Health expenditure for arthritis and musculoskeletal conditions in Australia, 2000-01. Australian Institute of Health and Welfare 2006; Bulletin no. 46 (catalogue no. AUS 83).

  5. 5

    Australian Institute of Health and Welfare. The AIHW analysis of the 2003 ABS National Survey of Disability, Ageing and Carers 2003.

  6. 6

    Australia's Health 2006. Australian Institute of Health and Welfare 2006;. AIHW Cat. No. AUS-73: 88.

  7. 7

    Kortt M, Baldry J . The association between musculoskeletal disorders and obesity. Aust Health Rev 2002; 25: 207–214.

    PubMed  Google Scholar 

  8. 8

    National Center for Chronic Disease Prevention and Health Promotion. Arthritis related statistics 2006. Division of Adult and Community Health, Health Care and Aging Studies Branch 2006.

  9. 9

    Amin AK, Sales JD, Benkel IJ . Obesity and total knee and hip replacement. Curr Ortho 2006; 20: 216–221.

    Google Scholar 

  10. 10

    Felson DT, Anderson JJ, Naimark A, Walker AM, Meenan RF . Obesity and knee osteoarthritis. The Framingham Study. Ann Intern Med 1988; 109: 18–24.

    CAS  PubMed  PubMed Central  Google Scholar 

  11. 11

    Felson DT, Zhang Y, Anthony JM, Naimark A, Anderson JJ . Weight loss reduces the risk for symptomatic knee osteoarthritis in women. The Framingham Study. Ann Intern Med 1992; 116: 535–539.

    CAS  PubMed  PubMed Central  Google Scholar 

  12. 12

    Felson DT, Zhang Y, Hannan MT, Naimark A, Weissman B, Aliabadi P et al. Risk factors for incident radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis Rheum 1997; 40: 728–733.

    CAS  PubMed  Google Scholar 

  13. 13

    Hart DJ, Doyle DV, Spector TD . Incidence and risk factors for radiographic knee osteoarthritis in middle-aged women: the Chingford Study. Arthritis Rheum 1999; 42: 17–24.

    CAS  PubMed  Google Scholar 

  14. 14

    Davis MA, Ettinger WH, Neuhaus JM . The role of metabolic factors and blood pressure in the association of obesity with osteoarthritis of the knee. J Rheumatol 1988; 15: 1827–1832.

    CAS  PubMed  Google Scholar 

  15. 15

    Hochberg MC, Lethbridge-Cejku M, Scott Jr WW, Reichle R, Plato CC, Tobin JD . The association of body weight, body fatness and body fat distribution with osteoarthritis of the knee: data from the Baltimore Longitudinal Study of Aging. J Rheumatol 1995; 22: 488–493.

    CAS  PubMed  Google Scholar 

  16. 16

    Bagge E, Bjelle A, Eden S, Svanborg A . Factors associated with radiographic osteoarthritis: results from the population study 70-year-old people in Goteborg. J Rheumatol 1991; 18: 1218–1222.

    CAS  PubMed  Google Scholar 

  17. 17

    Spector TD, Hart DJ, Doyle DV . Incidence and progression of osteoarthritis in women with unilateral knee disease in the general population: the effect of obesity. Ann Rheum Dis 1994; 53: 565–568.

    CAS  PubMed  PubMed Central  Google Scholar 

  18. 18

    Cicuttini FM, Spector T, Baker J . Risk factors for osteoarthritis in the tibiofemoral and patellofemoral joints of the knee. J Rheumatol 1997; 24: 1164–1167.

    CAS  PubMed  Google Scholar 

  19. 19

    Cicuttini FM, Baker JR, Spector TD . The association of obesity with osteoarthritis of the hand and knee in women: a twin study. J Rheumatol 1996; 23: 1221–1226.

    CAS  PubMed  Google Scholar 

  20. 20

    Anderson JJ, Felson DT . Factors associated with osteoarthritis of the knee in the first national Health and Nutrition Examination Survey (HANES I). Evidence for an association with overweight, race, and physical demands of work. Am J Epidemiol 1988; 128: 179–189.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. 21

    Schouten JS, van den Ouweland FA, Valkenburg HA . A 12 year follow up study in the general population on prognostic factors of cartilage loss in osteoarthritis of the knee. Ann Rheum Dis 1992; 51: 932–937.

    CAS  PubMed  PubMed Central  Google Scholar 

  22. 22

    Ledingham J, Regan M, Jones A, Doherty M . Factors affecting radiographic progression of knee osteoarthritis. Ann Rheum Dis 1995; 54: 53–58.

    CAS  PubMed  PubMed Central  Google Scholar 

  23. 23

    Dougados M, Gueguen A, Nguyen M, Thiesce A, Listrat V, Jacob L et al. Longitudinal radiologic evaluation of osteoarthritis of the knee. J Rheumatol 1992; 19: 378–384.

    CAS  PubMed  Google Scholar 

  24. 24

    Hart DJ, Spector TD . The relationship of obesity, fat distribution and osteoarthritis in women in the general population: the Chingford Study. J Rheumatol 1993; 20: 331–335.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. 25

    Chang MT, Lane NE, Hietpas J, Felson DT, Zhu Y, Sharma L et al. Obesity, gender, and in men, prior knee injuries are associated with incident symptomatic knee OA (SxKOA) in a high risk cohort: The Multicenter Osteoarthritis Study (MOST). ACR Annual Scientific Meeting 2006. abstract: presentation number: 116.

  26. 26

    Andriacchi TP, Mundermann A . The role of ambulatory mechanics in the initiation and progression of knee osteoarthritis. Curr Opin Rheumatol 2006; 18: 514–518.

    PubMed  Google Scholar 

  27. 27

    Manek NJ, Hart D, Spector TD, MacGregor AJ . The association of body mass index and osteoarthritis of the knee joint: an examination of genetic and environmental influences. Arthritis Rheum 2003; 48: 1024–1029.

    PubMed  PubMed Central  Google Scholar 

  28. 28

    Cimen OB, Incel NA, Yapici Y, Apaydin D, Erdogan C . Obesity related measurements and joint space width in patients with knee osteoarthritis. Ups J Med Sci 2004; 109: 159–164.

    PubMed  Google Scholar 

  29. 29

    Szoeke C, Dennerstein L, Guthrie J, Clark M, Cicuttini F . The relationship between prospectively assessed body weight and physical activity and prevalence of radiological knee osteoarthritis in postmenopausal women. J Rheumatol 2006; 33: 1835–1840.

    PubMed  Google Scholar 

  30. 30

    Sharma L, Lou C, Cahue S, Dunlop DD . The mechanism of the effect of obesity in knee osteoarthritis: the mediating role of malalignment. Arthritis Rheum 2000; 43: 568–575.

    CAS  PubMed  Google Scholar 

  31. 31

    Felson DT, Goggins J, Niu J, Zhang Y, Hunter DJ . The effect of body weight on progression of knee osteoarthritis is dependent on alignment. Arthritis Rheum 2004; 50: 3904–3909.

    PubMed  Google Scholar 

  32. 32

    Jordan JM, Luta G, Stabler T, Renner JB, Dragomir AD, Vilim V et al. Ethnic and sex differences in serum levels of cartilage oligomeric matrix protein: the Johnston County Osteoarthritis Project. Arthritis Rheum 2003; 48: 675–681.

    CAS  PubMed  Google Scholar 

  33. 33

    Mouritzen U, Christgau S, Lehmann HJ, Tanko LB, Christiansen C . Cartilage turnover assessed with a newly developed assay measuring collagen type II degradation products: influence of age, sex, menopause, hormone replacement therapy, and body mass index. Ann Rheum Dis 2003; 62: 332–336.

    CAS  PubMed  PubMed Central  Google Scholar 

  34. 34

    Cicuttini FM, Teichtahl AJ, Wluka AE, Davis S, Strauss BJ, Ebeling PR . The relationship between body composition and knee cartilage volume in healthy, middle-aged subjects. Arthritis Rheum 2005; 52: 461–467.

    PubMed  PubMed Central  Google Scholar 

  35. 35

    Wluka AE, Wang Y, Giles GG, English DR, Cicuttini FM . Muscle mass explains the gender difference in knee cartilage volume. ACR Annual Scientific Meeting 2006. abstract: presentation number: 258.

  36. 36

    Hunter DJ, Zhang Y, Niu J, Goodpaster BH, Harris TB, Kwoh K et al. Muscle mass predicts patellofemoral osteoarthritis (PF OA) progression. ACR Annual Scientific Meeting 2006. abstract: presentation number: 2090.

  37. 37

    Amin S, Baker K, Niu J, Clancy M, Goggins J, Guermazi A et al. Quadriceps strength and its relation to cartilage loss in knee osteoarthritis. ACR Annual Scientific Meeting 2006. abstract: presentation number: 2092.

  38. 38

    Ding C, Cicuttini F, Scott F, Cooley H, Jones G . Knee structural alteration and BMI: a cross-sectional study. Obes Res 2005; 13: 350–361.

    PubMed  PubMed Central  Google Scholar 

  39. 39

    Baker P, Coggon D, Reading I, Barrett D, McLaren M, Cooper C . Sports injury, occupational physical activity, joint laxity, and meniscal damage. J Rheumatol 2002; 29: 557–563.

    PubMed  Google Scholar 

  40. 40

    Tepper S, Hochberg MC . Factors associated with hip osteoarthritis: data from the First National Health and Nutrition Examination Survey (NHANES-I). Am J Epidemiol 1993; 137: 1081–1088.

    CAS  PubMed  Google Scholar 

  41. 41

    Lievense AM, Bierma-Zeinstra SM, Verhagen AP, van Baar ME, Verhaar JA, Koes BW . Influence of obesity on the development of osteoarthritis of the hip: a systematic review. Rheumatology (Oxford) 2002; 41: 1155–1162.

    CAS  Google Scholar 

  42. 42

    Carman WJ, Sowers M, Hawthorne VM, Weissfeld LA . Obesity as a risk factor for osteoarthritis of the hand and wrist: a prospective study. Am J Epidemiol 1994; 139: 119–129.

    CAS  PubMed  Google Scholar 

  43. 43

    van Saase JL, Vandenbroucke JP, van Romunde LK, Valkenburg HA . Osteoarthritis and obesity in the general population. A relationship calling for an explanation. J Rheumatol 1988; 15: 1152–1158.

    CAS  PubMed  Google Scholar 

  44. 44

    Davis MA, Neuhaus JM, Ettinger WH, Mueller WH . Body fat distribution and osteoarthritis. Am J Epidemiol 1990; 132: 701–707.

    CAS  PubMed  Google Scholar 

  45. 45

    Hochberg MC, Lethbridge-Cejku M, Plato CC, Wigley FM, Tobin JD . Factors associated with osteoarthritis of the hand in males: data from the Baltimore Longitudinal Study of Aging. Am J Epidemiol 1991; 134: 1121–1127.

    CAS  PubMed  Google Scholar 

  46. 46

    Hochberg MC, Lethbridge-Cejku M, Scott Jr WW, Plato CC, Tobin JD . Obesity and osteoarthritis of the hands in women. Osteoarthritis Cartilage 1993; 1: 129–135.

    CAS  PubMed  Google Scholar 

  47. 47

    Sayer AA, Poole J, Cox V, Kuh D, Hardy R, Wadsworth M et al. Weight from birth to 53 years: a longitudinal study of the influence on clinical hand osteoarthritis. Arthritis Rheum 2003; 48: 1030–1033.

    PubMed  Google Scholar 

  48. 48

    Haara MM, Heliovaara M, Kroger H, Arokoski JP, Manninen P, Karkkainen A et al. Osteoarthritis in the carpometacarpal joint of the thumb. Prevalence and associations with disability and mortality. J Bone Joint Surg Am 2004; 86-A: 1452–1457.

    PubMed  Google Scholar 

  49. 49

    Dahaghin S, Bierma-Zeinstra SM, Koes BW, Hazes JM, Pols HA . Do metabolic factors add to the effect of overweight on hand osteoarthritis? The Rotterdam Study. Ann Rheum Dis 2007; 66: 916–920.

    CAS  PubMed  PubMed Central  Google Scholar 

  50. 50

    Loeser RF . Systemic and local regulation of articular cartilage metabolism: where does leptin fit in the puzzle? Arthritis Rheum 2003; 48: 3009–3012.

    CAS  PubMed  Google Scholar 

  51. 51

    Dumond H, Presle N, Terlain B, Mainard D, Loeuille D, Netter P et al. Evidence for a key role of leptin in osteoarthritis. Arthritis Rheum 2003; 48: 3118–3129.

    CAS  PubMed  Google Scholar 

  52. 52

    Felson DT, Zhang Y, Hannan MT, Naimark A, Weissman BN, Aliabadi P et al. The incidence and natural history of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum 1995; 38: 1500–1505.

    CAS  PubMed  Google Scholar 

  53. 53

    Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum 2000; 43: 1905–1915.

    Google Scholar 

  54. 54

    Pendleton A, Arden N, Dougados M, Doherty M, Bannwarth B, Bijlsma JW et al. EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2000; 59: 936–944.

    CAS  PubMed  PubMed Central  Google Scholar 

  55. 55

    Coggon D, Reading I, Croft P, McLaren M, Barrett D, Cooper C . Knee osteoarthritis and obesity. Int J Obes Relat Metab Disord 2001; 25: 622–627.

    CAS  PubMed  Google Scholar 

  56. 56

    Toda Y . The effect of energy restriction, walking, and exercise on lower extremity lean body mass in obese women with osteoarthritis of the knee. J Orthop Sci 2001; 6: 148–154.

    CAS  PubMed  Google Scholar 

  57. 57

    Messier SP, Loeser RF, Mitchell MN, Valle G, Morgan TP, Rejeski WJ et al. Exercise and weight loss in obese older adults with knee osteoarthritis: a preliminary study. J Am Geriatr Soc 2000; 48: 1062–1072.

    CAS  PubMed  Google Scholar 

  58. 58

    Huang MH, Chen CH, Chen TW, Weng MC, Wang WT, Wang YL . The effects of weight reduction on the rehabilitation of patients with knee osteoarthritis and obesity. Arthritis Care Res 2000; 13: 398–405.

    CAS  PubMed  Google Scholar 

  59. 59

    Rejeski WJ, Focht BC, Messier SP, Morgan T, Pahor M, Penninx B . Obese, older adults with knee osteoarthritis: weight loss, exercise, and quality of life. Health Psychol 2002; 21: 419–426.

    PubMed  PubMed Central  Google Scholar 

  60. 60

    Messier SP, Gutekunst DJ, Davis C, DeVita P . Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum 2005; 52: 2026–2032.

    Google Scholar 

  61. 61

    Messier SP, Loeser RF, Miller GD, Morgan TM, Rejeski WJ, Sevick MA . Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Arthritis Rheum 2004; 50: 1501–1510.

    Google Scholar 

  62. 62

    Christensen R, Astrup A, Bliddal H . Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial. Osteoarthritis Cartilage 2005; 13: 20–27.

    CAS  PubMed  Google Scholar 

  63. 63

    Miller GD, Nicklas BJ, Davis CC, Ambrosius WT, Loeser RF, Messier SP . Is serum leptin related to physical function and is it modifiable through weight loss and exercise in older adults with knee osteoarthritis? Int J Obes Relat Metab Disord 2004; 28: 1383–1390.

    CAS  Google Scholar 

  64. 64

    Australia's Health 2006. Australian Institute of Health and Welfare 2006;. AIHW Cat. No. AUS-73:374-375.

  65. 65

    Spicer DD, Pomeroy DL, Badenhausen WE, Schaper Jr LA, Curry JI, Suthers KE et al. Body mass index as a predictor of outcome in total knee replacement. Int Orthop 2001; 25: 246–249.

    CAS  PubMed  PubMed Central  Google Scholar 

  66. 66

    Mont MA, Mathur SK, Krackow KA, Loewy JW, Hungerford DS . Cementless total knee arthroplasty in obese patients. A comparison with a matched control group. J Arthroplasty 1996; 11: 153–156.

    CAS  PubMed  Google Scholar 

  67. 67

    Soballe K, Christensen F, Luxhoj T . Hip replacement in obese patients. Acta Orthop Scand 1987; 58: 223–225.

    CAS  PubMed  Google Scholar 

  68. 68

    Callaghan JJ, Albright JC, Goetz DD, Olejniczak JP, Johnston RC . Charnley total hip arthroplasty with cement. Minimum twenty-five-year follow-up. J Bone Joint Surg Am 2000; 82: 487–497.

    CAS  PubMed  Google Scholar 

  69. 69

    Wendelboe AM, Hegmann KT, Biggs JJ, Cox CM, Portmann AJ, Gildea JH et al. Relationships between body mass indices and surgical replacements of knee and hip joints. Am J Prev Med 2003; 25: 290–295.

    PubMed  Google Scholar 

  70. 70

    Benjamin J, Tucker T, Ballesteros P . Is obesity a contraindication to bilateral total knee arthroplasties under one anesthetic? Clin Orthop Relat Res 2001; 392: 190–195.

    Google Scholar 

  71. 71

    Berend KR, Lombardi Jr AV, Mallory TH, Adams JB, Groseth KL . Early failure of minimally invasive unicompartmental knee arthroplasty is associated with obesity. Clin Orthop Relat Res 2005; 440: 60–66.

    PubMed  Google Scholar 

  72. 72

    Spahn G, Kirschbaum S, Kahl E . Factors that influence high tibial osteotomy results in patients with medial gonarthritis: a score to predict the results. Osteoarthritis Cartilage 2006; 14: 190–195.

    CAS  PubMed  Google Scholar 

  73. 73

    Harrison MM, Morrell J, Hopman WM . Influence of obesity on outcome after knee arthroscopy. Arthroscopy 2004; 20: 691–695.

    PubMed  Google Scholar 

  74. 74

    van Tulder M, Koes B . Chronic low back pain. Am Fam Physician 2006; 74: 1577–1579.

    PubMed  Google Scholar 

  75. 75

    Kwon MA, Shim WS, Kim MH, Gwak MS, Hahm TS, Kim GS et al. A correlation between low back pain and associated factors: a study involving 772 patients who had undergone general physical examination. J Korean Med Sci 2006; 21: 1086–1091.

    PubMed  PubMed Central  Google Scholar 

  76. 76

    Vindigni D, Walker BF, Jamison JR, Da Costa C, Parkinson L, Blunden S . Low back pain risk factors in a large rural Australian Aboriginal community. An opportunity for managing co-morbidities? Chiropr Osteopat 2005; 13: 21.

    PubMed  PubMed Central  Google Scholar 

  77. 77

    Bener A, Alwash R, Gaber T, Lovasz G . Obesity and low back pain. Coll Antropol 2003; 27: 95–104.

    PubMed  Google Scholar 

  78. 78

    Yip YB, Ho SC, Chan SG . Tall stature, overweight and the prevalence of low back pain in Chinese middle-aged women. Int J Obes Relat Metab Disord 2001; 25: 887–892.

    CAS  PubMed  Google Scholar 

  79. 79

    Han TS, Schouten JS, Lean ME, Seidell JC . The prevalence of low back pain and associations with body fatness, fat distribution and height. Int J Obes Relat Metab Disord 1997; 21: 600–607.

    CAS  PubMed  Google Scholar 

  80. 80

    Mirtz TA, Greene L . Is obesity a risk factor for low back pain? An example of using the evidence to answer a clinical question. Chiropr Osteopat 2005; 13: 2.

    PubMed  PubMed Central  Google Scholar 

  81. 81

    Fanuele JC, Abdu WA, Hanscom B, Weinstein JN . Association between obesity and functional status in patients with spine disease. Spine 2002; 27: 306–312.

    PubMed  Google Scholar 

  82. 82

    Fransen M, Woodward M, Norton R, Coggan C, Dawe M, Sheridan N . Risk factors associated with the transition from acute to chronic occupational back pain. Spine 2002; 27: 92–98.

    PubMed  Google Scholar 

  83. 83

    Melissas J, Kontakis G, Volakakis E, Tsepetis T, Alegakis A, Hadjipavlou A . The effect of surgical weight reduction on functional status in morbidly obese patients with low back pain. Obes Surg 2005; 15: 378–381.

    PubMed  Google Scholar 

  84. 84

    Melissas J, Volakakis E, Hadjipavlou A . Low-back pain in morbidly obese patients and the effect of weight loss following surgery. Obes Surg 2003; 13: 389–393.

    PubMed  Google Scholar 

  85. 85

    Liuke M, Solovieva S, Lamminen A, Luoma K, Leino-Arjas P, Luukkonen R et al. Disc degeneration of the lumbar spine in relation to overweight. Int J Obes (Lond) 2005; 29: 903–908.

    CAS  Google Scholar 

  86. 86

    Fassett DR, Schmidt MH . Spinal epidural lipomatosis: a review of its causes and recommendations for treatment. Neurosurg Focus 2004; 16: E11.

    PubMed  Google Scholar 

  87. 87

    Yamakawa K, Tsai CK, Haig AJ, Miner JA, Harris MJ . Relationship between ambulation and obesity in older persons with and without low back pain. Int J Obes Relat Metab Disord 2004; 28: 137–143.

    CAS  PubMed  Google Scholar 

  88. 88

    Bejia I, Younes M, Zrour S, Touzi M, Bergaoui N . Factors predicting outcomes of mechanical sciatica: a review of 1092 cases. Joint Bone Spine 2004; 71: 567–571.

    PubMed  Google Scholar 

  89. 89

    Yang SH, Wu CC, Chen PQ . Postoperative meralgia paresthetica after posterior spine surgery: incidence, risk factors, and clinical outcomes. Spine 2005; 30: E547–E550.

    PubMed  Google Scholar 

  90. 90

    Gepstein R, Shabat S, Arinzon ZH, Berner Y, Catz A, Folman Y . Does obesity affect the results of lumbar decompressive spinal surgery in the elderly? Clin Orthop Relat Res 2004; 426: 138–144.

    Google Scholar 

  91. 91

    Smythe HA LG . Diffuse idiopathic skeletal hyperostosis. In: Klippel JH (ed). Rheumatology. Mosby: London, 1998. pp 8.10.1–6.

    Google Scholar 

  92. 92

    Denko CW, Boja B, Moskowitz RW . Growth promoting peptides in osteoarthritis and diffuse idiopathic skeletal hyperostosis—insulin, insulin-like growth factor-I, growth hormone. J Rheumatol 1994; 21: 1725–1730.

    CAS  PubMed  Google Scholar 

  93. 93

    Mader R, Dubenski N, Lavi I . Morbidity and mortality of hospitalized patients with diffuse idiopathic skeletal hyperostosis. Rheumatol Int 2005; 26: 132–136.

    CAS  PubMed  Google Scholar 

  94. 94

    Shirakura Y, Sugiyama T, Tanaka H, Taguchi T, Kawai S . Hyperleptinemia in female patients with ossification of spinal ligaments. Biochem Biophys Res Commun 2000; 267: 752–755.

    CAS  PubMed  Google Scholar 

  95. 95

    Hills AP, Hennig EM, Byrne NM, Steele JR . The biomechanics of adiposity—structural and functional limitations of obesity and implications for movement. Obes Rev 2002; 3: 35–43.

    CAS  Google Scholar 

  96. 96

    Sharma L . Local factors in osteoarthritis. Curr Opin Rheumatol 2001; 13: 441–446.

    CAS  PubMed  Google Scholar 

  97. 97

    Van Boerum DH, Sangeorzan BJ . Biomechanics and pathophysiology of flat foot. Foot Ankle Clin 2003; 8: 419–430.

    PubMed  Google Scholar 

  98. 98

    Birtane M, Tuna H . The evaluation of plantar pressure distribution in obese and non-obese adults. Clin Biomech (Bristol, Avon) 2004; 19: 1055–1059.

    Google Scholar 

  99. 99

    Gravante G, Russo G, Pomara F, Ridola C . Comparison of ground reaction forces between obese and control young adults during quiet standing on a baropodometric platform. Clin Biomech (Bristol, Avon) 2003; 18: 780–782.

    CAS  Google Scholar 

  100. 100

    Wearing SC, Hills AP, Byrne NM, Hennig EM, McDonald M . The arch index: a measure of flat or fat feet? Foot Ankle Int 2004; 25: 575–581.

    Google Scholar 

  101. 101

    Messier SP . Osteoarthritis of the knee and associated factors of age and obesity: effects on gait. Med Sci Sports Exerc 1994; 26: 1446–1452.

    CAS  PubMed  Google Scholar 

  102. 102

    Syed IY, Davis BL . Obesity and osteoarthritis of the knee: hypotheses concerning the relationship between ground reaction forces and quadriceps fatigue in long-duration walking. Med Hypotheses 2000; 54: 182–185.

    CAS  PubMed  Google Scholar 

  103. 103

    Maffiuletti NA, Agosti F, Proietti M, Riva D, Resnik M, Lafortuna CL et al. Postural instability of extremely obese individuals improves after a body weight reduction program entailing specific balance training. J Endocrinol Invest 2005; 28: 2–7.

    CAS  Google Scholar 

  104. 104

    Jadelis K, Miller ME, Ettinger Jr WH, Messier SP . Strength, balance, and the modifying effects of obesity and knee pain: results from the Observational Arthritis Study in Seniors (oasis). J Am Geriatr Soc 2001; 49: 884–891.

    CAS  Google Scholar 

  105. 105

    Hulens M, Vansant G, Claessens AL, Lysens R, Muls E . Predictors of 6-minute walk test results in lean, obese and morbidly obese women. Scand J Med Sci Sports 2003; 13: 98–105.

    CAS  PubMed  PubMed Central  Google Scholar 

  106. 106

    Walker-Bone KE, Palmer KT, Reading I, Cooper C . Soft-tissue rheumatic disorders of the neck and upper limb: prevalence and risk factors. Semin Arthritis Rheum 2003; 33: 185–203.

    PubMed  Google Scholar 

  107. 107

    Werner RA, Franzblau A, Gell N, Ulin SS, Armstrong TJ . A longitudinal study of industrial and clerical workers: predictors of upper extremity tendonitis. J Occup Rehabil 2005; 15: 37–46.

    PubMed  Google Scholar 

  108. 108

    Descatha A, Leclerc A, Chastang JF, Roquelaure Y . Incidence of ulnar nerve entrapment at the elbow in repetitive work. Scand J Work Environ Health 2004; 30: 234–240.

    PubMed  PubMed Central  Google Scholar 

  109. 109

    Hooper MM, Stellato TA, Hallowell PT, Seitz BA, Moskowitz RW . Musculoskeletal findings in obese subjects before and after weight loss following bariatric surgery. Int J Obes (Lond) 2007; 31: 114–120.

    CAS  Google Scholar 

  110. 110

    Geoghegan JM, Clark DI, Bainbridge LC, Smith C, Hubbard R . Risk factors in carpal tunnel syndrome. J Hand Surg [Br] 2004; 29: 315–320.

    CAS  Google Scholar 

  111. 111

    Bland JD . The relationship of obesity, age, and carpal tunnel syndrome: more complex than was thought? Muscle Nerve 2005; 32: 527–532.

    PubMed  Google Scholar 

  112. 112

    Becker J, Nora DB, Gomes I, Stringari FF, Seitensus R, Panosso JS et al. An evaluation of gender, obesity, age and diabetes mellitus as risk factors for carpal tunnel syndrome. Clin Neurophysiol 2002; 113: 1429–1434.

    PubMed  Google Scholar 

  113. 113

    Wendelboe AM, Hegmann KT, Gren LH, Alder SC, White Jr GL, Lyon JL . Associations between body-mass index and surgery for rotator cuff tendinitis. J Bone Joint Surg Am 2004; 86-A: 743–747.

    PubMed  Google Scholar 

  114. 114

    Riddle DL, Pulisic M, Pidcoe P, Johnson RE . Risk factors for Plantar fasciitis: a matched case–control study. J Bone Joint Surg Am 2003; 85-A: 872–877.

    PubMed  Google Scholar 

  115. 115

    Irving DB, Cook JL, Young MA, Menz HB . Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case–control study. BMC Musculoskelet Disord 2007; 8: 41.

    PubMed  PubMed Central  Google Scholar 

  116. 116

    Messier SP, Pittala KA . Etiologic factors associated with selected running injuries. Med Sci Sports Exerc 1988; 20: 501–505.

    CAS  PubMed  Google Scholar 

  117. 117

    Cohen SP, Narvaez JC, Lebovits AH, Stojanovic MP . Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study. Br J Anaesth 2005; 94: 100–106.

    CAS  PubMed  Google Scholar 

  118. 118

    Nguyen TV, Kelly PJ, Sambrook PN, Gilbert C, Pocock NA, Eisman JA . Lifestyle factors and bone density in the elderly: implications for osteoporosis prevention. J Bone Miner Res 1994; 9: 1339–1346.

    CAS  PubMed  Google Scholar 

  119. 119

    Bauer DC, Browner WS, Cauley JA, Orwoll ES, Scott JC, Black DM et al. Factors associated with appendicular bone mass in older women. The Study of Osteoporotic Fractures Research Group. Ann Intern Med 1993; 118: 657–665.

    CAS  PubMed  Google Scholar 

  120. 120

    Kroger H, Tuppurainen M, Honkanen R, Alhava E, Saarikoski S . Bone mineral density and risk factors for osteoporosis—a population-based study of 1600 perimenopausal women. Calcif Tissue Int 1994; 55: 1–7.

    CAS  PubMed  Google Scholar 

  121. 121

    Pluijm SM, Visser M, Smit JH, Popp-Snijders C, Roos JC, Lips P . Determinants of bone mineral density in older men and women: body composition as mediator. J Bone Miner Res 2001; 16: 2142–2151.

    CAS  PubMed  Google Scholar 

  122. 122

    Felson DT, Zhang Y, Hannan MT, Anderson JJ . Effects of weight and body mass index on bone mineral density in men and women: the Framingham study. J Bone Miner Res 1993; 8: 567–573.

    CAS  PubMed  PubMed Central  Google Scholar 

  123. 123

    Edelstein SL, Barrett-Connor E . Relation between body size and bone mineral density in elderly men and women. Am J Epidemiol 1993; 138: 160–169.

    CAS  PubMed  Google Scholar 

  124. 124

    Liel Y, Edwards J, Shary J, Spicer KM, Gordon L, Bell NH . The effects of race and body habitus on bone mineral density of the radius, hip, and spine in premenopausal women. J Clin Endocrinol Metab 1988; 66: 1247–1250.

    CAS  PubMed  Google Scholar 

  125. 125

    Halioua L, Anderson JJ . Age and anthropometric determinants of radial bone mass in premenopausal Caucasian women: a cross-sectional study. Osteoporos Int 1990; 1: 50–55.

    CAS  PubMed  Google Scholar 

  126. 126

    Dawson-Hughes B, Shipp C, Sadowski L, Dallal G . Bone density of the radius, spine, and hip in relation to percent of ideal body weight in postmenopausal women. Calcif Tissue Int 1987; 40: 310–314.

    CAS  PubMed  Google Scholar 

  127. 127

    Ribot C, Tremollieres F, Pouilles JM, Louvet JP, Guiraud R . Influence of the menopause and aging on spinal density in French women. Bone Miner 1988; 5: 89–97.

    CAS  PubMed  Google Scholar 

  128. 128

    Lenchik L, Register TC, Hsu FC, Lohman K, Nicklas BJ, Freedman BI et al. Adiponectin as a novel determinant of bone mineral density and visceral fat. Bone 2003; 33: 646–651.

    CAS  PubMed  Google Scholar 

  129. 129

    Reid IR . Relationships among body mass, its components, and bone. Bone 2002; 31: 547–555.

    CAS  PubMed  PubMed Central  Google Scholar 

  130. 130

    Makovey J, Naganathan V, Sambrook P . Gender differences in relationships between body composition components, their distribution and bone mineral density: a cross-sectional opposite sex twin study. Osteoporos Int 2005; 16: 1495–1505.

    PubMed  Google Scholar 

  131. 131

    Zhao LJ, Liu YJ, Hamilton J, Recker RR, Deng HW . Interventions decreasing obesity risk tend to be beneficial for decreasing risk to osteoporosis: a challenge to the current dogma. International Osteoporosis Foundation World Congress 2006. abstract: P152SU.

  132. 132

    Kato I, Toniolo P, Zeleniuch-Jacquotte A, Shore RE, Koenig KL, Akhmedkhanov A et al. Diet, smoking and anthropometric indices and postmenopausal bone fractures: a prospective study. Int J Epidemiol 2000; 29: 85–92.

    CAS  Google Scholar 

  133. 133

    Mattila VM, Jormanainen V, Sahi T, Pihlajamaki H . An association between socioeconomic, health and health behavioural indicators and fractures in young adult males. Osteoporos Int 2007; June 13 [E-pub ahead of print].

  134. 134

    Nguyen TV, Sambrook PN, Eisman JA . Bone loss, physical activity, and weight change in elderly women: the Dubbo Osteoporosis Epidemiology Study. J Bone Miner Res 1998; 13: 1458–1467.

    CAS  PubMed  Google Scholar 

  135. 135

    Ensrud KE, Lewis CE, Lambert LC, Taylor BC, Fink HA, Barrett-Connor E et al. Endogenous sex steroids, weight change and rates of hip bone loss in older men: the MrOS study. Osteoporos Int 2006; 17: 1329–1336.

    CAS  PubMed  Google Scholar 

  136. 136

    Tothill P . Dual-energy x-ray absorptiometry measurements of total-body bone mineral during weight change. J Clin Densitom 2005; 8: 31–38.

    PubMed  Google Scholar 

  137. 137

    Riedt CS, Cifuentes M, Stahl T, Chowdhury HA, Schlussel Y, Shapses SA . Overweight postmenopausal women lose bone with moderate weight reduction and 1 g/day calcium intake. J Bone Miner Res 2005; 20: 455–463.

    CAS  PubMed  Google Scholar 

  138. 138

    Villareal DT, Fontana L, Weiss EP, Racette SB, Steger-May K, Schechtman KB et al. Bone mineral density response to caloric restriction-induced weight loss or exercise-induced weight loss: a randomized controlled trial. Arch Intern Med 2006; 166: 2502–2510.

    Google Scholar 

  139. 139

    Hogan SL . The effects of weight loss on calcium and bone. Crit Care Nurs Q 2005; 28: 269–275.

    PubMed  Google Scholar 

  140. 140

    Lips P . Vitamin D physiology. Prog Biophys Mol Biol 2006; 92: 4–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  141. 141

    Saag KG, Choi H . Epidemiology, risk factors, and lifestyle modifications for gout. Arthritis Res Ther 2006; 8 (Suppl 1): S2.

    PubMed  PubMed Central  Google Scholar 

  142. 142

    Roubenoff R, Klag MJ, Mead LA, Liang KY, Seidler AJ, Hochberg MC . Incidence and risk factors for gout in white men. JAMA 1991; 266: 3004–3007.

    CAS  PubMed  Google Scholar 

  143. 143

    Takahashi S, Yamamoto T, Tsutsumi Z, Moriwaki Y, Yamakita J, Higashino K . Close correlation between visceral fat accumulation and uric acid metabolism in healthy men. Metabolism 1997; 46: 1162–1165.

    CAS  PubMed  Google Scholar 

  144. 144

    Thompson D, Lettich L, Takeshita J . Fibromyalgia: an overview. Curr Psychiatry Rep 2003; 5: 211–217.

    PubMed  Google Scholar 

  145. 145

    Shapiro JR, Anderson DA, Danoff-Burg S . A pilot study of the effects of behavioral weight loss treatment on fibromyalgia symptoms. J Psychosom Res 2005; 59: 275–282.

    PubMed  Google Scholar 

  146. 146

    Symmons DP . Looking back: rheumatoid arthritis—aetiology, occurrence and mortality. Rheumatology (Oxford) 2005; 44 (Suppl 4): iv14–iv17.

    Google Scholar 

  147. 147

    Symmons DP, Bankhead CR, Harrison BJ, Brennan P, Barrett EM, Scott DG et al. Blood transfusion, smoking, and obesity as risk factors for the development of rheumatoid arthritis: results from a primary care-based incident case–control study in Norfolk, England. Arthritis Rheum 1997; 40: 1955–1961.

    CAS  PubMed  Google Scholar 

  148. 148

    Voigt LF, Koepsell TD, Nelson JL, Dugowson CE, Daling JR . Smoking, obesity, alcohol consumption, and the risk of rheumatoid arthritis. Epidemiology 1994; 5: 525–532.

    CAS  PubMed  Google Scholar 

  149. 149

    Cerhan JR, Saag KG, Criswell LA, Merlino LA, Mikuls TR . Blood transfusion, alcohol use, and anthropometric risk factors for rheumatoid arthritis in older women. J Rheumatol 2002; 29: 246–254.

    PubMed  Google Scholar 

  150. 150

    Escalante A, Haas RW, del R I . Paradoxical effect of body mass index on survival in rheumatoid arthritis: role of comorbidity and systemic inflammation. Arch Intern Med 2005; 165: 1624–1629.

    PubMed  Google Scholar 

  151. 151

    Garcia-Poma A, Segami MI, Terrazas HN, Ugarte MF, Rhor EA, Mora CS et al. Independent association between obesity and impaired quality of life in patients with rheumatoid arthritis. ACR Annual Scientific Meeting 2006. abstract: presentation number: 123.

  152. 152

    Otero M, Lago R, Gomez R, Lago F, Dieguez C, Gomez-Reino JJ et al. Changes in plasma levels of fat-derived hormones adiponectin, leptin, resistin and visfatin in patients with rheumatoid arthritis. Ann Rheum Dis 2006; 65: 1198–1201.

    CAS  PubMed  PubMed Central  Google Scholar 

  153. 153

    Qazi UM, Petri M . Autoantibodies, low complement and obesity predict pre-eclampsia in SLE: a case–control study. ACR Annual Scientific Meeting 2006. abstract: presentation number: 552.

  154. 154

    Utset TO, Laughlin J, Schmitz A . Obesity in systemic lupus erythematosus. ACR Annual Scientific Meeting 2006. abstract: presentation number: 593.

  155. 155

    Harle P, Pongratz G, Weidler C, Buttner R, Scholmerich J, Straub RH . Possible role of leptin in hypoandrogenicity in patients with systemic lupus erythematosus and rheumatoid arthritis. Ann Rheum Dis 2004; 63: 809–816.

    CAS  PubMed  PubMed Central  Google Scholar 

  156. 156

    Verbrugge LM, Gates DM, Ike RW . Risk factors for disability among US adults with arthritis. J Clin Epidemiol 1991; 44: 167–182.

    CAS  PubMed  Google Scholar 

  157. 157

    Felson DT, Lawrence RC, Dieppe PA, Hirsch R, Helmick CG, Jordan JM et al. Osteoarthritis: new insights. Part 1: the disease and its risk factors. Ann Intern Med 2000; 133: 635–646.

    CAS  PubMed  PubMed Central  Google Scholar 

  158. 158

    Visser M, Langlois J, Guralnik JM, Cauley JA, Kronmal RA, Robbins J et al. High body fatness, but not low fat-free mass, predicts disability in older men and women: the Cardiovascular Health Study. Am J Clin Nutr 1998; 68: 584–590.

    CAS  PubMed  Google Scholar 

  159. 159

    Okoro CA, Hootman JM, Strine TW, Balluz LS, Mokdad AH . Disability, arthritis, and body weight among adults 45 years and older. Obes Res 2004; 12: 854–861.

    PubMed  Google Scholar 

  160. 160

    Jordan JM, Luta G, Renner JB, Linder GF, Dragomir A, Hochberg MC et al. Self-reported functional status in osteoarthritis of the knee in a rural southern community: the role of sociodemographic factors, obesity, and knee pain. Arthritis Care Res 1996; 9: 273–278.

    CAS  PubMed  Google Scholar 

  161. 161

    Weil E, Wachterman M, McCarthy EP, Davis RB, O'Day B, Iezzoni LI et al. Obesity among adults with disabling conditions. JAMA 2002; 288: 1265–1268.

    PubMed  Google Scholar 

  162. 162

    Focht BC, Rejeski WJ, Ambrosius WT, Katula JA, Messier SP . Exercise, self-efficacy, and mobility performance in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum 2005; 53: 659–665.

    Google Scholar 

  163. 163

    Leroux I, Dionne CE, Bourbonnais R, Brisson C . Prevalence of musculoskeletal activity limitation and associated factors among adults in the general population in the 1998 Quebec Health Survey. J Rheumatol 2005; 32: 1794–1804.

    PubMed  Google Scholar 

  164. 164

    Adamson J, Ebrahim S, Dieppe P, Hunt K . Prevalence and risk factors for joint pain among men and women in the West of Scotland Twenty-07 study. Ann Rheum Dis 2006; 65: 520–524.

    CAS  PubMed  Google Scholar 

  165. 165

    Tsuritani I, Honda R, Noborisaka Y, Ishida M, Ishizaki M, Yamada Y . Impact of obesity on musculoskeletal pain and difficulty of daily movements in Japanese middle-aged women. Maturitas 2002; 42: 23–30.

    PubMed  Google Scholar 

  166. 166

    Aoyagi K, Ross PD, Okano K, Hayashi T, Moji K, Kusano Y et al. Association of body mass index with joint pain among community-dwelling women in Japan. Aging Clin Exp Res 2002; 14: 378–381.

    PubMed  Google Scholar 

  167. 167

    Andersen RE, Crespo CJ, Bartlett SJ, Bathon JM, Fontaine KR . Relationship between body weight gain and significant knee, hip, and back pain in older Americans. Obes Res 2003; 11: 1159–1162.

    PubMed  Google Scholar 

  168. 168

    Marchesini G, Natale S, Tiraferri F, Tartaglia A, Moscatiello S, Marchesini RL et al. The burden of obesity on everyday life: a role for osteoarticular and respiratory diseases. Diabetes Nutr Metab 2003; 16: 284–290.

    CAS  Google Scholar 

  169. 169

    Jinks C, Jordan K, Croft P . Measuring the population impact of knee pain and disability with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Pain 2002; 100: 55–64.

    PubMed  Google Scholar 

  170. 170

    Heo M, Allison DB, Faith MS, Zhu S, Fontaine KR . Obesity and quality of life: mediating effects of pain and comorbidities. Obes Res 2003; 11: 209–216.

    Google Scholar 

  171. 171

    Australia's Health 2006. Australian Institute of Health and Welfare 2006. AIHW Cat.No. AUS-73:27.

  172. 172

    Hulens M, Vansant G, Lysens R, Claessens AL, Muls E . Exercise capacity in lean versus obese women. Scand J Med Sci Sports 2001; 11: 305–309.

    CAS  PubMed  Google Scholar 

  173. 173

    Larsson UE . Influence of weight loss on pain, perceived disability and observed functional limitations in obese women. Int J Obes Relat Metab Disord 2004; 28: 269–277.

    PubMed  Google Scholar 

  174. 174

    Christensen R, Bartels EM, Astrup A, Bliddal H . The effect of weight reduction in obese patients diagnosed with knee osteoarthritis (OA): a systematic review and meta-analysis. EULAR Annual Scientific Meeting 2006. abstract: presentation number: OP0194.

  175. 175

    Blaum CS, Xue QL, Michelon E, Semba RD, Fried LP . The association between obesity and the frailty syndrome in older women: the Women's Health and Aging Studies. J Am Geriatr Soc 2005; 53: 927–934.

    PubMed  Google Scholar 

  176. 176

    Villareal DT, Banks M, Siener C, Sinacore DR, Klein S . Physical frailty and body composition in obese elderly men and women. Obes Res 2004; 12: 913–920.

    PubMed  Google Scholar 

  177. 177

    Borowiak E, Kostka T . Predictors of quality of life in older people living at home and in institutions. Aging Clin Exp Res 2004; 16: 212–220.

    PubMed  Google Scholar 

  178. 178

    The economic costs of obesity. Access Economics Australia 2006; http://www.accesseconomics.com.au/publicationsreports.

  179. 179

    Hartman E, Oude Vrielink HH, Huirne RB, Metz JH . Risk factors for sick leave due to musculoskeletal disorders among self-employed Dutch farmers: a case–control study. Am J Ind Med 2006; 49: 204–214.

    PubMed  Google Scholar 

  180. 180

    Peltonen M, Lindroos AK, Torgerson JS . Musculoskeletal pain in the obese: a comparison with a general population and long-term changes after conventional and surgical obesity treatment. Pain 2003; 104: 549–557.

    Google Scholar 

  181. 181

    Counterweight Project Team. The impact of obesity on drug prescribing in primary care. Br J Gen Pract 2005; 55: 743–749.

    PubMed Central  Google Scholar 

  182. 182

    Elimimian JU, Smith PA, Iluore A . Musculoskeletal disorders and the consumption of disability products. Health Mark Q 1999; 17: 83–98.

    CAS  PubMed  Google Scholar 

  183. 183

    Manninen P, Riihimaki H, Heliovaara M, Makela P . Overweight, gender and knee osteoarthritis. Int J Obes Relat Metab Disord 1996; 20: 595–597.

    CAS  PubMed  Google Scholar 

  184. 184

    Mansson NO, Eriksson KF, Israelsson B, Ranstam J, Melander A, Rastam L . Body mass index and disability pension in middle-aged men—non-linear relations. Int J Epidemiol 1996; 25: 80–85.

    CAS  Google Scholar 

  185. 185

    Baird IM . Obesity and insurance risk: the insurance industry's viewpoint. Pharmacoeconomics 1994; 5 (Suppl 1): 62–65.

    CAS  PubMed  Google Scholar 

  186. 186

    Gallagher S . Obesity and the aging adult: ideas for promoting patient safety and preventing caregiver injury. Clin Geriatr Med 2005; 21: 757–765.

    PubMed  Google Scholar 

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Acknowledgements

Ananthila Anandacoomarasamy holds a National Health and Medical Research Council Medical Postgraduate Research Scholarship (ID number 402901).

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Anandacoomarasamy, A., Caterson, I., Sambrook, P. et al. The impact of obesity on the musculoskeletal system. Int J Obes 32, 211–222 (2008). https://doi.org/10.1038/sj.ijo.0803715

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Keywords

  • musculoskeletal
  • arthritis
  • disability
  • function

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