What diet is best for osteoarthritis? In this study we learn how the results of a plant-based diet can impact osteoarthritis joint pain.

We discuss in this interview:

• The results of Wendy’s study, that show how the participants reported a significant decrease in pain and stiffness, and improved physical function
• Other effects on metabolic markers and weight
• C-Reactive protein and osteoarthritis
• Lifestyle factors and low-grade inflammation
• How the study was structured
• Practical advice to reduce symptoms
• Diet choices
• The importance of peers
• The Plants for Health social enterprise

Clint – Today we’re going to talk about osteoarthritis and the things that we can do with our lifestyle to reduce symptoms. Today’s guest is a researcher, and she has recently published with her team a journal paper that is called A Multidisciplinary Lifestyle Program For Metabolic Syndrome Associated Osteoarthritis. The Plants For Joints Randomized Controlled Trial. I have with me, Wendy Walrabenstein, and I hope I pronounced that correctly. She’s all the way from the Netherlands.

Wendy – Almost.

Clint – Why don’t you correct me?

Wendy – Walrabenstein

Clint – Think I did better the first time around?

Wendy – You did.

Clint – I did, I’ve gone backward in my knowledge and skills. Wendy, you were on this podcast several months ago where we talked about somewhat of a similar study, but for rheumatoid arthritis. For those watching on YouTube, I’ll put the link to that right now on the screen, if you want to go back and watch what we talked about with the results of that study with rheumatoid arthritis, which was outstanding. Today we’re going to talk about the follow up publication, and this was published in the Journal of Osteoarthritis and Cartilage. So let’s kick off with the most important thing which is the outcome. What we are looking for, what did you find, and let’s hear what was achieved in this study?

Wendy – Yeah. Thank you Clint. Thank you for having me again. Well what did we achieved in this osteoarthritis trial was that people who had quite a severe form of osteoarthritis in their knees or in their hips, or both experienced a clinical relevant, and also statistically significant decrease in pain, in stiffness, and they improved physical function. In addition, they also improved their metabolic markers like LDL cholesterol, blood glucose, and HBA1C they lost quite some body weight, fat mass, and also CRP, which is an important marker for inflammation decreased significantly.

Clint – To what extent do we feel that C-reactive protein contributes to osteoarthritis? Because the message that I’ve put forward for many years is that there is a small amount of inflammation going on in osteoarthritis, and this contributes to the progression of the disease. Is this also what your research has uncovered, and how significant do you think C-reactive protein is in the progression?

Wendy – Yeah, that’s a great question, Clint, because indeed you could say that there are some phenotypes of osteoarthritis. Let’s say trauma-induced osteoarthritis for example, when you have an accident or you are hurt while doing exercise or something, that is a very specific form of osteoarthritis. But most people suffer from this metabolic syndrome associated osteoarthritis, and that is specifically what we studied. And what you see there is that people who have metabolic syndrome and I will explain metabolic syndrome. Metabolic syndrome is a group of risk factors like increased body weight, increased LDL cholesterol, increased triglyceride, blood glucose, and increased blood pressure. So, you know, all these things that increase our risk of developing heart disease, but also diabetes type two. And actually, people who score high on these markers for metabolic syndrome have actually an increased risk of osteoarthritis. In the past it was believed that this had to do with the body weight. So it was thought that the weight on hips and knees caused this osteoarthritis, this wear and tear of cartilage. But actually, it has been proven that that is not the case because people who have metabolic syndrome or who are obese also have an increased risk of osteoarthritis in their hands. And of course, there we don’t see this load on the joints. What we also see is that this group of people also seems to have an increased risk of inflammation, which is in itself also associated with an increased risk of metabolic syndrome.

Wendy – To summarize this, you could say that we have a couple of lifestyle factors such as diet, lack of exercise, stress, and lack of sleep. Those stimulate this low-grade inflammation. And this low-grade inflammation could also be seen as a kind of irritation of the body. That in itself causes a lot of yeah, diseases of affluence like cardiovascular disease and diabetes, but also neurodegenerative diseases and, and things like depression, for example, but also autoimmune diseases like rheumatoid arthritis. And also a thing that is called senescence. And senescence stands for, let’s say a kind of accelerated aging. And that is also what we see in osteoarthritis. Because if you look, for example, at someone 90 years old, of course, there is a kind of wear and tear in the joints because as we grow older this is quite normal. But what we actually see is that it starts earlier and earlier, especially when you have these metabolic risk factors. And so all these lifestyle factors cause low-grade inflammation which can be measured with C-reactive protein. Actually what we have proven in our study is that improving these lifestyle factors. So eating better, exercising more and doing more relaxation exercises are actually causing the CRP to decrease. So yeah, I think it this is again evidence that there is such a thing as low-grade inflammation and that also in osteoarthritis, this plays a huge role.

Clint – Okay. Wonderful. Now, what exactly did you have the group do, and how many participants did you have in the study and how long was it for? So let’s talk about those things.

Wendy – Yeah. So in the osteoarthritis trial, we included people with this metabolic syndrome. We had 64 patients and they were randomized in two groups of 32 in the intervention group, 32 in the control group, and all 64 got usual care. So painkillers and some of them had some exercise therapy, and we advised them to continue as they did. The intervention group in addition, received this lifestyle program, which is a four-month lifestyle program, and it was composed of ten group meetings. It started with a great cooking class given by a specialized vegan chef who was specialized in plant based cooking for health. This cooking class was specifically aimed at trying all these new delicious plates. Because of course, cooking different is very important, but it is also about developing your taste. And to be clear for yourself about what you like. Do you like Middle Eastern-style cooking? Do you like Asian-style cooking and stuff like that? So we were very much involved together in this tasting and liking, et cetera. So that was the first meeting, and then we had nine other meetings spread over these four months. In these meetings we got together and spoke about how we did and what kind of difficult situations we encountered, for example, eating out, or eating with friends. We did a lot of education, so we are very much convinced that, like you do, Clint, explaining people how the body works is such an important part of improving your lifestyle. Because if you know how it works, then you are so much more motivated to do the things that really help your body. So we did that. And of course it was also about experience. Like with the tasting at the start, we experienced different styles of exercise. So all kinds of exercise from yoga to strength training. It was all about encountering the pain because of course, if you have any form of arthritis and you start to exercise, then you are confronted with, for example, a pain in your wrist, and then you have to adapt your exercise, so we worked on that. Also experiencing relaxation exercises. And with the relaxation, it was very much focused on doing all sorts of exercises and choosing what works for you. For example, a body scan or just a relaxed meditation or very slow walking in nature. We tried out everything and we really motivated people and stimulated people to choose what fit their needs. And it was also about. Um, planning your day carefully because sometimes we saw, for example, we had one participant who said, well, I’m walking ten kilometers, and then the day after I can’t do anything.

Wendy – So with situations like that, we worked on planning your week better and for example, not walking ten kilometers, but perhaps five, but do it daily. So you don’t experience so much pain the day after. Well, all kinds of stuff. We did a potluck and well, after the 10th meeting, we of course had a measurement which was confronted with the baseline measurements, and we did a measurement in between. And during those measurements, people also had the opportunity to talk all things over with a specialized dietician or a physiotherapist. So there was also a bit of individual counseling integrated in the full program. We were doing this during the Covid 19 measures, so we started out as a complete life, getting together in our clinic in Amsterdam. But we had to move very swiftly into a full online version, and then in the end, most people experienced the whole program more or less hybrid. So part of it, most of it online and a couple of live meetings, especially the cooking class, of course, that one, although we did that one also once or twice online, but most of them followed it live. So that was the program and actually, I recall that before I started this, we had a chat about the program, and we also involved a couple of people who actually followed your program in, in the first setup of this program.

Wendy – So we made the program. We invited the, let’s say, the experienced people with arthritis who already had changed their lifestyle and asked them to critically review our program, and so they gave us some advice. For example, there was an optional fasting period in this program, which was very much on request of people who had this great experience. Not that much people followed it, especially not in the osteoarthritis group. A lot of people in the rheumatoid arthritis group did do a couple of days of fasting. But what they also very much emphasized was to include also a session on sleep. So we have an occupational therapist at our clinic who specializes in sleep, and she actually did a very well received training of the participants on sleep. So yeah, that was more or less the program 4 months, as I said, with three measurements. And actually, the groups were 6 to 12 people and they were mixed. So it were osteoarthritis patients, but also rheumatoid arthritis patients all together in one group. But all the analyses were split up in randomized controlled trials.

Clint – I see nice. So that you utilized the same experts just once across both groups so that you’re able to leverage their time appropriately. Yeah. Now was there a good adherence to the plan? Because there’s quite a lot of changes that you’ve mentioned there. And I know that osteoarthritis is a debilitating condition. We mostly on this channel talk about rheumatoid, but osteoarthritis can really bring people into a state of despair. So was that adequate for them to be very compliant or did you get some people who dropped out?

Wendy – Yeah. Well, actually, in the four-month trial, both in rheumatoid arthritis and in osteoarthritis group, we had a, I believe in in the osteoarthritis, I have to check, but I think only 1 or 2 people dropped out. So the dropouts during the trial were extremely low. I mean that is unprecedented. So that’s for first. Then we follow these people, so all the participants for two years after the trial, and we recently analyzed the one-year data, and we will actually publish also an article about that. There we combined all the people together. And of course, in this article we also show the adherence for rheumatoid arthritis and osteoarthritis separately. But all together we can say the following. Frst adherence was good. In general we also did a process evaluation. So we interviewed people, we did focus groups and stuff like that. On average, you could say that people after one year say I follow this program still for about 80%. And if you dig into how and what they really follow, you can actually see that what we focus on is, first of all, and as of the start, we emphasize that perfection is not sustainable. So you will make mistakes, but don’t be too hard on yourself. Just go on, accept the fact that you’re not perfect and do the best you can so that is first.

Wendy – Second, we’re all different and one person can really miss the fish once a week forr example. The other person says, oh my egg on Sunday morning or now, and then a little bit of parmesan on my pasta, whatever. And what we focus on to really be conscious of this. I always call them delicacies and, and just add 1 or 2 of those delicacies in your daily program but to be mindful of it. Not and to emphasize that you should stop the mindless eating and enjoy mindfully now and then, this really nice treat for yourself. And the funny thing is that if you ask people after one year, so what is your treat? Then one person will say, oh, you won’t believe it, I eat some kind of terrible junk food, which is typically Dutch. I can’t can’t translate it into English. But really terrible thing that some participant ate once every month. So that’s one. Another person says no, I do eat fish once a week, but for the rest I follow the program, et cetera. So you see, they’re very personalized adherence. So that’s the second thing. What we also saw is that, of course, the better the adherence, the better the outcome. And that is important to emphasize, although this relationship was not statistically significant. But this has to do with, of course, the small number in each group of adherence. I mean, if you only have 64 people, then it’s quite hard to have large group in, for example, three groups of adherence high, middle and low. But what we did see that even people who had a low adherence improved significantly. So I think that is very important to emphasize that you don’t have to do it perfectly to have some benefit. But if you do it good, then yeah, the impact is larger.

Wendy – What we did see, however, and that is very interesting to my opinion, is that in the rheumatoid arthritis group, the improvements continue to improve one year later. And with osteoarthritis, we saw a little bit that people bounced back still enough to have a significant improvement in comparison to start. But the important thing here is that, and I know you you can recognize this. People with rheumatoid arthritis tend to have this very short feedback loop where they encounter, for example, increased pain, even swelling in joints within 24 hours after they have, for example, eaten red meat. And that was very interesting also from the perspective of one of our most skeptical participants. She said, well, I couldn’t believe my eyes, but 24 hours after I ate red meat, my fingers were swollen. And that was really because of that red meat that I ate. With osteoarthritis, you don’t have that very fast feedback loop. And there you see that the fact that the pain gradually increases again tends to decrease the motivation a bit. But still they they have improved outcomes. So it depends a bit on the person.

Clint – Yeah very interesting. I did a social media post just recently about the feedback that you get within 24 hours with rheumatoid and my hook for that social media post was the only thing I love about this disease, which is that you get the feedback. You’ve got a built-in alarm system that goes off, but if you’ve got a long-term, chronic low-grade condition like osteo or like high blood pressure or, diabetes or something, you might not quickly get that feedback. What is the message here? So if someone’s listening to this and they’re like, okay, Wendy, look, this sounds like you’ve put together an amazing study here, but specifically, what should I now do if I have osteoarthritis and it hurts and I’m willing to do whatever you tell me, but I don’t really want to go and read this osteoarthritis and cartilage like published paper here because it sounds very complicated. Specifically, what would you suggest to somebody?

Wendy – Yeah, it depends your point of departure and how far you want to go. So first of all, if you have a let’s say and people know it from themselves, if you have a very unhealthy lifestyle, then first of all, don’t be too hard on yourself. Our environments are really luring us into this unhealthy lifestyle. So if you have a very unhealthy lifestyle, go and have a look at your dietary guidelines. Visit a dietitian, take the first steps towards eating more vegetables, more fruits, more whole grains, and stuff like that, that is the first step. If you want to go all the way and you have the real motivation to do everything you can. Then I would say go for your program, because I think your program is really a good example of doing it, doing all things right. But you have to have good motivation and some time to really invest in it, so I would recommend that. We obviously chose the the middle way, the good for 80% way where you say, okay, this is achievable for a lot of people and it’s acceptable for a lot of people and you will gain quite some benefit from it. We are now working on establishing a lifestyle program online in the Netherlands, which is called Plants For Health. But we also are planning to do it internationally, especially in Europe. So you can find more information on plants for health, on our website. But if you want to go all the way, I think your program is a very, very good way to start. But you have to take into account that it’s really a big leap for someone who has a very unhealthy lifestyle now.

Wendy – I think if you are already having quite a healthy lifestyle and you suffer from pain in your knees, then I suggest that, for example, eating more vegetables and fruits. I just came across a study that actually says 800g of fruits and vegetables a day as a large group gives the highest benefit, so try to achieve that. That is also a great start. More and more dietary guidelines actually in because you have of course, people who are watching this from many countries, so look up your local dietary guidelines. You can very often you can translate them into a mostly plant-based or a fully plant-based version. For example, if you look at dairy products, you can easily use soy-based dairy products instead of normal dairy products. And if you throw away all the meat and you take, for example, legumes instead of them, then you are already there. I mean, that’s the largest part of the change. So it depends a bit on your ambition. So if you’re if you really have the ambition, go for Clint Paddison. If your ambition right now is low, if you are in a lot of pain, then discuss it also with your rheumatologist or your general practitioner. If you have osteoarthritis, most osteoarthritis patients are guided by their general practitioner. And of course, many doctors are reluctant to acknowledge that lifestyle and especially diet, can do a lot. But if you can be lucky, I mean, there are people like Gemma Newman, for example, in the UK and a lot and a growing number of rheumatologists actually out there who really recognize this. And they often also have quite a good network of, for example, dietitians who can help you further.

Wendy – So I would say, don’t do this by yourself because it really helps, and actually what I like about your program, Clint, is also the group part of it, because that was what we received back from our patients in the process evaluation. Was that often people said, don’t underestimate the effect of peers on your ability to really do this. I mean, a lot of people say, no, no, no, I don’t want to be in a group, I want to do this all by myself. But for example, you and I are of course, for some people we are health freaks. Whereas if you have a peer who says to you, no, it’s really easy if you do this overnight oat, if you take this yogurt with a lot of a little bit of muesli, then you have a great breakfast, for example. Then it’s much more acceptable than if you are when you are or I am telling them, you know what you should do, you should do, you should drink green smoothies every morning. You know it’s different.

Clint – Um, that is very insightful, and yes, we see that a lot. Sometimes the very best insight that someone needs is not from someone who’s been doing it for ten years, but it’s from someone who just did it last week. So that’s really good. And I wanted to also pick up on how you talk about the medical professionals. And so that was going to be my next question is, um, someone may have an appointment over the coming weeks with their specialist or their general practitioner, mention this conversation, maybe even take this study along that they could print out and then show the doctor and the doctor say, look, the evidence is not there. It doesn’t matter what you eat, it’s just wear and tear arthritis. To what extent do you believe that we can now definitively say that that is wrong?

Wendy – It depends on your situation. Because if your osteoarthritis is really, let’s say at a point where you need a joint replacing surgery, this won’t help you. I mean, let’s be clear on that. If your cartilage is totally gone, I mean, we have to be clear on that, that’s one thing. But for most people, that is not the case. And for people who are still in, let’s say, in the area where they don’t need joint replacement surgery, I think it’s very interesting to underline that the pain they are suffering from because of osteoarthritis, the only thing you want to get rid of is your pain. And actually what we see is that the people who are in the highest category of pain don’t have the largest loss of cartilage. So there is this if you want to work on your pain and your specialist says to you, listen, your cartilage is still there, it’s just damaged, then I would say this is something your medical specialist cannot deny that healthier diet, exercise and stress management will help you. I mean, it will help you in any way. No one in our group worsened during. I mean, so it’s always an improvement of your health, and if it doesn’t lower your pain, then it will lower your LDL cholesterol, which is a good side effect as well. So I think it is wrong thing that doctors discourage people from changing or improving, especially their diet, because we all know by now that diet is the first and foremost risk factor of not only mortality, but also quality of life. And that is I think that’s quite clear now.

Clint – I love it. Um, what next for you, Wendy? You’ve done these tremendous studies for rheumatoid arthritis, and osteoarthritis. You’re really sort of waving the flag and doing some excellent work for the plant-based community. What personally are you currently working on that might be of interest to our audience?

Wendy – Well, first, the studies that we are doing. So we are now in the process of publishing the one-year data. So that will come, that will be done by my fabulous colleague, a medical doctor and researcher, Caroline Wagner. And she is also now actually in Germany, working on all the poops that are participants donated, because she’s actually doing now the microbiome research of the plants for joint trial, both for rheumatoid arthritis and for osteoarthritis. I’m so excited to see how the microbiome of both groups has been changed. And what it also did to some important metabolites in the blood, because we all know that if your microbiome improves, then this will also lead to an increase in inflammation lowering metabolites in your blood. So she is working on that right now, very very interesting. So those are the most important studies that we do. We are actually in the process of establishing this social enterprise, which is called plants for health, starting in the Netherlands, but also through, among others, the Physicians Association for Nutrition, of which I’m in the board. That’s a fabulous association for doctors, for dietitians. So if you’re a doctor or a dietitian or another health professional, please take a look at the Physicians Association for Nutrition in Australia. Of course, doctors for nutrition is a comparable association. And so Plants for Health is actually working on offering this multidisciplinary lifestyle program. And we will start with arthritis, but we have the plan to extend to heart disease and to other diseases as well. For example, secondary prevention in cancer. So people who have had cancer but are willing to improve their lifestyle as to prevent them from having cancer again. So we are working on that.

Wendy – And the important thing about Plants for Health is that we will offer these lifestyle programs, at the same time, we will do research. So every participant will be invited to join new research to see how people improve. And third, we will be a great employer of, let’s say, a new kind of Health Organization. So which is far more based on health and instead of disease so large plants. And I’m actually working also more in the field of neurodegenerative diseases, and actually you were talking about how health professionals can be somewhat reluctant to acknowledge the power of nutrition and lifestyle. When I started this study with rheumatologists, they were very to say very nicely critical, and skeptical. In truth, there was one meeting where one of them wanted to send me out of the room. So and now all these rheumatologists that I’ve worked with are now actually sending all their patients to dieticians and motivating them to improve their lifestyle, so a lot of things can change. Right now I’m working with neurodegenerative diseases, and I noticed that I have to start all over again, because also there I see the skepticism, although somewhat less than when I started with rheumatology. But you see that still that in the education of the medical profession, we really do need a change. And that’s why it’s so important that doctors for nutrition and the Physicians Association for Nutrition are there to really work on that.

Clint – Mm. Wonderful. Well, you’ve painted a really bright future, so that’s really exciting and well done with all the outcomes that you’ve gotten and all the work that you’re doing. Well, now, Wendy you and I are going to be presenting a webinar together as part of Doctors for Nutrition webinar series, and that is going to be on the 6th of December. So if you’ve found this conversation interesting, if you’ve got rheumatoid arthritis, then on the 6th of December, Wendy and I are going to be presenting to a medical audience, but it’s open to the public and you can come and watch Wendy go into all of the hard core science behind her rheumatoid version of the plants for joints results, and then I’ll be putting that into the broader picture of all of the lifestyle changes that have been shown to be effective for rheumatoid arthritis from the spectrum of diet and stress reduction, even some supplements, but certainly exercise. So make sure you join Wendy and I for that if you’re interested. Wendy. That’s going to be a very, very punchy session together. We only get 25 minutes each, but then a bunch of Q and A, so it should be interesting.

Wendy: Yeah. Yeah, absolutely. Looking so much forward to it and will indeed tell all about the research and some additional and more technical information. So looking very much forward to that.

Clint: And thank you for coming on again and sharing once more, this time all about osteoarthritis. So we’ve now covered the two. For those folks who haven’t watched the rheumatoid, one who may have more invested interest into rheumatoid, go check that out, that episode is very interesting. Why don’t we get you back again when we talk about the follow-up after the 12 months? That would be that would be great to have that update as well, because I’m sure people are interested in, these progressive updates of this, of this study.

Wendy – Great. Thank you. And definitely, we’ll come back. Thank you, Clint.

Clint – Thank you, Wendy.

Wendy – Bye.