Obesity and low back pain: a retrospective cohort study of Japanese males

Management and Nursing Approaches to Low Back Pain: Investigating the Causal Association with Lifestyle-Related Risk Factors

BACKGROUND

Notwithstanding a plethora of observational studies, the causal implications of obesity, encompassing both body mass index (BMI) and waist circumference (WC), as well as type 2 diabetes (T2D), and lifestyle factors, in relation to the vulnerability to low back pain (LBP), remain enigmatic.

AIMS

This study was designed to investigate the related causal associations DESIGN: A two-sample Mendelian randomization (MR) analysis.

SETTINGS

By utilizing genetic variants associated with pertinent factors gleaned from genome-wide association studies (GWASs), We extracted independent genetic variants about exposures such as BMI, WC, T2D, smoking, alcohol consumption, and coffee intake from published GWASs, ensuring their genome-wide significance.

PARTICIPANTS/SUBJECTS

The GWASs were selected from the most up-to-date and largest publicly accessible databases.

METHODS

The summary data concerning LBP emanated from a GWAS of European cases and controls, which was based on the esteemed MRC-IEU (Medical Research Council Integrative Epidemiology Unit) consortium.

RESULTS

Heightened body mass index and waist circumference exhibited odds ratios of 1.003 (95% confidence interval [CI] = 1.002-1.004, p < 0.001) and 1.003 (95% CI = 1.002-1.004, p < 0.001) for LBP, respectively, per each standard deviation (SD) increase. As for smoking initiation and every SD increase in the frequency of alcohol intake, the odds ratios were 1.002 (95% CI = 1.001-1.003, p = 0.003) and 1.002 (95% CI = 1.000-1.003, p = 0.011), respectively, for LBP. Conversely, an increased log odds ratio for T2D, and prevalence of coffee intake, divulged no discernible causal effects on the risk of LBP.

CONCLUSION

This study provides suggestive evidence to support the causal involvement of obesity, smoking, and the frequency of alcohol intake in the development of LBP, which suggests that implementing measures to mitigate these risk factors may aid in preventing LBP.

Causations between obesity, diabetes, lifestyle factors and the risk of low back pain

BACKGROUND

Despite numerous observational studies, the causal relationship between obesity-measured by body mass index (BMI) and waist circumference (WC)-as well as type 2 diabetes (T2D), lifestyle habits, and susceptibility to low back pain (LBP) remains obscure.

METHODS

This investigation employed two-sample Mendelian randomization (MR) analysis to explore causality, using genetic variants linked to relevant factors from genome-wide association studies (GWASs). Specifically, we selected independent genetic variants related to BMI, WC, T2D, smoking, alcohol consumption, and coffee intake from established GWASs, all of which demonstrated genome-wide significance. The comparative data for LBP were derived from a GWAS involving European subjects, under the auspices of the renowned MRC-IEU (Medical Research Council Integrative Epidemiology Unit) consortium.

RESULTS

Elevated BMI and WC were associated with odds ratios of 1.002 (95% confidence interval [CI] = 1.001-1.004, p < 0.001) and 1.003 (95% CI = 1.002-1.004, p < 0.001) for LBP per standard deviation (SD) increase, respectively. Regarding smoking initiation and coffee consumption, the odds ratios stood at 1.002 (95% CI = 1.001-1.004, p = 0.001) and 1.004 (95% CI = 1.001-1.008, p = 0.034) for LBP, respectively. However, an augmented log odds ratio for T2D and each SD rise in alcohol consumption frequency revealed no significant causal impact on LBP risk.

CONCLUSION

Our findings indicate a potential causal link between obesity, smoking, and coffee intake in the genesis of LBP, suggesting that mitigating these factors could contribute to LBP prevention.

Association Between Body Mass Index and Nonspecific Recurrent Low Back Pain in Over 600,000 Healthy Young Adults

An association between body mass index (BMI; weight (kg)/height (m)2) and low back pain (LBP) has long been debated, but inconsistent measurements of BMI and varying definitions of LBP have produced conflicting findings. We explored this association using measured BMI and physician documentation of recurrent LBP among healthy young adults. Data were extracted from the Israel Defense Forces electronic medical record system. All Israeli citizens with compulsory military service during January 2008-March 2019 were included (n = 705,840). Exclusion criteria were spine deformities, disc pathologies, spinal surgeries, arthropathies, connective tissue diseases, pain syndromes, low bone density disorders, cancers, and psychiatric illnesses. LBP was defined as electronic medical record system documentation of 1) 2 medical visits at least 6 weeks apart with a diagnosis of LBP or "LBP with radiation" or 2) 1 medical visit resulting in referral to an orthopedic surgeon. Logistic regression models were used to explore the association between BMI category and LBP; 619,969 (87.8%) individuals (mean age = 18.9 (standard deviation, 0.97) years; 56.9% male) were included. LBP prevalence was 9.2% (n = 56,918) and higher among males (9.7%) than females (8.5%). Overweight (odds ratio = 1.123, 95% confidence interval: 1.096, 1.151) and obesity (odds ratio = 1.137, 95% confidence interval: 1.096, 1.179) were associated with LBP. The association remained significant after accounting for various sociodemographic factors. Maintaining a healthy BMI may aid in the prevention of LBP in young adults.

Prevalence and Risk Factors of Low Back Pain in Malaysia: A Scoping Review

Data on the prevalence and risk factors of low back pain (LBP) in Malaysia remain unclear as they are currently limited to specific settings and occupational groups. Therefore, this study aims to determine the prevalence and risk factors of low back pain in Malaysia. In this scoping review, we had systematically searched PubMed, Scopus, ScienceDirect and Google Scholar from January 2016 to April 2020. In addition, we had included cross-sectional studies on LBP in Malaysia. Studies without data on the prevalence and risk factors were excluded. The settings, population, design, sample size, evaluation methods, prevalence and risk factors of the studies were summarised. The literature search identified 435 potentially eligible studies; of these, 21 had met the inclusion criteria. The prevalence of LBP in Malaysia among various types of the population had ranged from 12.4% to 84.6%. Among the various types of occupation, the prevalence of LBP was the highest among nurses (67.9%), followed by drivers (65.7%). In addition, age, gender, body mass index (BMI), lifting heavy objects, working posture, lifestyle, working hours and mental health were identified as the risk factors of LBP in Malaysia. The current evidence suggests that LBP is a serious health problem among several occupational groups in Malaysia. Therefore, it is crucial to implement the correct interventions for the prevention of LBP among these groups.

Physiological Changes and Pathological Pain Associated with Sedentary Lifestyle-Induced Body Systems Fat Accumulation and Their Modulation by Physical Exercise

A sedentary lifestyle is associated with overweight/obesity, which involves excessive fat body accumulation, triggering structural and functional changes in tissues, organs, and body systems. Research shows that this fat accumulation is responsible for several comorbidities, including cardiovascular, gastrointestinal, and metabolic dysfunctions, as well as pathological pain behaviors. These health concerns are related to the crosstalk between adipose tissue and body systems, leading to pathophysiological changes to the latter. To deal with these health issues, it has been suggested that physical exercise may reverse part of these obesity-related pathologies by modulating the cross talk between the adipose tissue and body systems. In this context, this review was carried out to provide knowledge about (i) the structural and functional changes in tissues, organs, and body systems from accumulation of fat in obesity, emphasizing the crosstalk between fat and body tissues; (ii) the crosstalk between fat and body tissues triggering pain; and (iii) the effects of physical exercise on body tissues and organs in obese and non-obese subjects, and their impact on pathological pain. This information may help one to better understand this crosstalk and the factors involved, and it could be useful in designing more specific training interventions (according to the nature of the comorbidity).

Waist circumference, waist-hip ratio, body fat rate, total body fat mass and risk of low back pain: a systematic review and meta-analysis

PURPOSE

To identify the associations between waist circumference (WC), waist-hip ratio (WHR), body fat rate (BFR), total body fat mass (BFM), and the risk of low back pain (LBP).

METHODS

We have searched PubMed through October 2020 for observational studies investigating the associations between WC, WHR, BFR, or total BFM and the risk of LBP. Random-effect models were used to calculate the summary risk estimates and corresponding 95% confidence intervals (95% CIs).

RESULTS

A total of fifteen studies with 92,936 participants were included, of which ten were related to WC, five were related to WHR, four were related to BFR, and four were related to total BFM. Pooled results indicated that high WC (odds ratio (OR) = 1.30, 95% CI 1.10-1.54) and WHR (OR = 1.33, 95% CI 1.00-1.76) were associated with an increased risk of chronic low back pain (c-LBP). High WC (OR = 1.18, 95% CI 1.03-1.34) was also associated with an increased risk of non-c-LBP. The risk of non-c-LBP increased by 23% (OR = 1.23, 95% CI 1.01-1.50) for every 10% increase in BFR, and for every 10 kg increase in total BFM, the risk of non-c-LBP increased by 24% (OR = 1.24, 95% CI 1.10-1.39).

CONCLUSION

Observational epidemiological evidence suggested that individuals with increased WC, WHR, BFR, or total BFM tended to have an increased risk of LBP, regardless of whether their body mass indexes were normal. Excessive fat mass was the essence of the process.

Prevalence and Related Factors of Low Back Pain in the General Elderly Population: A Japanese Cross-Sectional Study Randomly Sampled from a Basic Resident Registry

Low back pain (LBP) is one of the main etiologies of disability in daily life. In the face of LBP increases in super-aged societies, there are serious concerns of escalating medical costs and deteriorations in the social economy. It is therefore important to identify the factors associated with LBP for prompt preventative and therapeutic measures. This study investigated the prevalence of LBP and the impact of subject-specific factors on LBP development in Japanese community-dwelling older adults. We established eight groups based on age (50's, 60's, 70's, and 80's) and gender after random sampling from a resident registry. A total of 411 participants (201 male and 210 female) were enrolled for a whole-spine lateral radiographic examination and dual-energy X-ray absorptiometry. All subjects were evaluated for the presence and degree of LBP. We analyzed the impact of clinical factors on LBP using multivariate analysis. Fifty-three (12.9%) participants (23 (11.4%) male and 30 (14.3%) female) were found to have LBP. The prevalence of LBP tended to increase with age, and similar results were found between genders. In univariate analysis, the subject-related factors of the sagittal vertebral axis, pelvic incidence minus lumbar lordosis (PI-LL) mismatch, and aging had significant associations with LBP. PI-LL mismatch was a significant independent factor in multivariate analysis. In conclusion, this study identified LBP prevalence and subject-specific factors on a general population basis. Multivariate analysis revealed PI-LL mismatch as an independent factor associated with LBP in the healthy community-dwelling elderly.

Is adiposity associated with back and lower limb pain? A systematic review

BACKGROUND

Back and lower limb pain have a major impact on physical function and quality of life. While obesity is a modifiable risk factor for musculoskeletal pain, the role of adiposity is less clear. This systematic review aimed to examine the relationship between both adiposity and its distribution and back and lower limb pain.

METHODS

A systematic search of electronic databases was conducted to identify studies that examined the association between anthropometric and/or direct measures of adiposity and site specific musculoskeletal pain. Risk of bias was assessed and a best evidence synthesis was performed.

RESULTS

A total of 56 studies were identified which examined 4 pain regions, including the lower back (36 studies), hip (two studies), knee (13 studies) and foot (eight studies). 31(55%) studies were assessed as having low to moderate risk of bias. 17(30%) studies were cohort in design. The best evidence synthesis provided evidence of a relationship between central adiposity and low back and knee pain, but not hip or foot pain. There was also evidence of a longitudinal relationship between adiposity and the presence of back, knee and foot pain, as well as incident and increasing foot pain.

CONCLUSIONS

This systematic review provides evidence of an association between both body fat and its central distribution and low back and knee pain, and a longitudinal relationship between adiposity and back, knee and foot pain. These results highlight the potential for targeting adiposity in the development of novel treatments at these sites.

Drp1-mediated mitochondrial fission is involved in oxidized low-density lipoprotein-induced AF cella poptosis

This study aimed to assess the negative effect of oxidized low-density lipoprotein (oxLDL) on annulus fibrosus (AF) cells and decipher the mechanism of action of the process. After treating AF cells with various concentrations (0, 25, 50, 100, and 200 μg/mL) of oxLDL for 24 and 48 hours, their viability was evaluated using cell counting kit-8 and live/dead staining. The percentage of AF cell death was determined with Annexin V/propidium iodide apoptosis staining. The expression of proteins related to the mitochondrial apoptosis pathway was determined using Western blot. Additionally, mitochondrial membrane potential (MMP) and intracellular reactive oxygen species (ROS) were assessed with JC-1 staining and dichlorodihydrofluorescein diacetate ormitoSOX probes, respectively. Mitochondrial morphology was observed with a transmission electron microscope. After treatment with oxLDL, AF cell viability decreased, pro-apoptosis proteins (such as Bax, cleaved caspase-9, and cleaved caspase-3) increased, and anti-apoptosis proteins (Bcl-2) declined. Excessive ROS and diminished MMP were also detected during this process, as were enhanced mitochondrial fission and augmented Drp1 expression. Furthermore, knocking down the expression of Drp1 rescued oxLDL-induced AF cell death. Collectively, these results suggest that oxLDL induces AF cell death through a mitochondria-related pathway. Enhanced mitochondrial fission was involved in oxLDL-induced AF cell death. Targeting Drp1, a target for regulating the process of mitochondrial fission, may be a feasible strategy for preventing intervertebral disc degeneration in hyperlipidemia.

Study on the Associations of Individual and Work-Related Factors with Low Back Pain among Manufacturing Workers Based on Logistic Regression and Structural Equation Model

Work-related musculoskeletal injuries are one of the major occupational health issues of the workers, especially low back pain (LBP). The aim of this study was to survey the prevalence of LBP among manufacturing workers and to identify associations of individual and work-related factors with LBP. A cross-sectional questionnaire study was performed with 1173 participating manufacturing workers. The questionnaire included individual factors, psychosocial and physical exposures, and musculoskeletal discomfort. It was analyzed by logistic regression and structural equation modeling (SEM). The 1-year prevalence of LBP among Chinese manufacturing workers was 33.6%. Logistic regression analysis showed that job tenure, awkward postures, vibration and job demand were positively—while social support and job control were negatively associated with LBP (p < 0.05). The SEM results indicated that, as shown in other studies, job types, job tenure, postural load, high job demand, low job control and vibration were directly associated with LBP, but also that job types, high job demand, low social support and vibration may have indirect effects on LBP—mediated by postural load.

High prevalence of musculoskeletal pain in individuals with severe obesity: sites, intensity, and associated factors

Background

Musculoskeletal pain is associated with obesity; however, information on factors associated with pain in adults with obesity and severe obesity is limited. The purpose of this study was to assess the prevalence of musculoskeletal pain by site and intensity of pain and associated factors in individuals with severe obesity (body mass index ≥ 35.0 kg/m²).

Methods

Baseline data from the DieTBra Trial study evaluating pain symptoms in nine body regions over the last seven days using the Nordic Questionnaire on Musculoskeletal Symptoms and Numerical Pain Scale. The variables analyzed using multiple Poisson regression with hierarchical analysis were: sociodemographic, lifestyle, food consumption, clinical, and anthropometric, and the outcome was moderate and intense pain.

Results

In 150 participants, there was a high prevalence of ankle and foot pain (68.7%), lower back pain (62.7%), pain in the knees (53.3%) and upper back pain (52.0%), with a predominance of intense pain. Factors associated with pain according to specific sites were: type 2 diabetes with hand/wrist pain; sedentary time with hip pain; insomnia with pain in the hip and knee; edema in the lower limbs with pain in the lower back and ankles/feet; degree of obesity with ankle/foot pain; and percentage of total fat with ankle/foot pain.

Conclusions

There was a high prevalence of pain and intense pain in individuals with severe obesity and an association with clinical variables, the degree of obesity, and sedentary lifestyle.

BMI and Medically Certified Long-Term Sickness Absence Among Japanese Employees

OBJECTIVE

In contrast to the association between excess weight and sickness absence (SA), the association in relation to underweight has been under-researched. This study aimed to examine the effects of BMI at both extremes of its distribution on SA.

METHODS

Data came from the Japan Epidemiology Collaboration on Occupational Health study of 77,760 workers aged 20 to 59 years (66,166 males, 11,594 females). Information was collected on medically certified long-term SA (LTSA) (i.e., SA lasting ≥ 30 consecutive days) from April 2012 to March 2017. A sex-specific Cox proportional hazards model was used to investigate the associations.

RESULTS

Among males, both obesity (hazard ratio [HR] = 1.81, 95% CI: 1.50-2.17) and underweight (HR = 1.56, 95% CI: 1.23-1.96) were significantly associated with LTSA compared with normal weight. This U-shaped association between BMI categories and LTSA was observed both for mental and physical disorders. Among females, an elevated risk was observed among those with overweight (HR = 1.54, 95% CI: 1.16-2.05).

CONCLUSIONS

In a cohort of the Japanese working-age population, both obesity and underweight were associated with a greater risk of LTSA in males. Future research should not overlook the excess risk of LTSA associated with underweight.

Risk and Prognostic Factors of Low Back Pain: Repeated Population-based Cohort Study in Sweden

STUDY DESIGN

Prospective longitudinal cohort study.

OBJECTIVE

To determine the associations for workload and health-related factors with incident and recurrent low back pain (LBP), and to determine the mediating role of health-related factors in associations between physical workload factors and incident LBP.

SUMMARY OF BACKGROUND DATA

It is not known whether the risk factors for the development of LBP are also prognostic factors for recurrence of LBP and whether the associations between physical workload and incident LBP are mediated by health-related factors. We used data from the Swedish Longitudinal Occupational Survey of Health study. Those responding to any two subsequent surveys in 2010 to 2016 were included for the main analyses (N = 17,962). Information on occupational lifting, working in twisted positions, weight/height, smoking, physical activity, depressive symptoms, and sleep problems were self-reported. Incident LBP was defined as pain limiting daily activities in the preceding three months in participants free from LBP at baseline. Recurrent LBP was defined as having LBP both at baseline and follow-up. For the mediation analyses, those responding to three subsequent surveys were included (N = 3516).

METHODS

Main associations were determined using generalized estimating equation models for repeated measures data. Mediation was examined with counterfactual mediation analysis.

RESULTS

All risk factors at baseline but smoking and physical activity were associated with incident LBP after adjustment for confounders. The strongest associations were observed for working in twisted positions (risk ratio  = 1.52, 95% CI 1.37, 1.70) and occupational lifting (risk ratio  = 1.52, 95% CI 1.32, 1.74). These associations were not mediated by health-related factors. The studied factors did not have meaningful effects on recurrent LBP.

CONCLUSION

The findings suggest that workload and health-related factors have stronger effects on the development than on the recurrence or progression of LBP, and that health-related factors do not mediate associations between workload factors and incident LBP.

LEVEL OF EVIDENCE

3.

High baseline fat mass, but not lean tissue mass, is associated with high intensity low back pain and disability in community-based adults

Objectives

Low back pain is the largest contributor to disability worldwide. The role of body composition as a risk factor for back pain remains unclear. Our aim was to examine the relationship between fat mass and fat distribution on back pain intensity and disability using validated tools over 3 years.

Methods

Participants (aged 25–60 years) were assessed at baseline using dual-energy X-ray absorptiometry (DXA) to measure body composition. All participants completed the Chronic Pain Grade Scale at baseline and 3-year follow-up. Of the 150 participants, 123 (82%) completed the follow-up.

Results

Higher baseline body mass index (BMI) and fat mass (total, trunk, upper limb, lower limb, android, and gynoid) were all associated with high intensity back pain at either baseline and/or follow-up (total fat mass: multivariable OR 1.05, 95% CI 1.01–1.09, p < 0.001). There were similar findings for all fat mass measures and high levels of back disability. A higher android to gynoid ratio was associated with high intensity back pain (multivariable OR 1.04, 95% CI 1.01–1.08, p = 0.009). There were no associations between lean mass and back pain.

Conclusions

This cohort study provides evidence for the important role of fat mass, specifically android fat relative to gynoid fat, on back pain and disability.

[Bilateral breast reduction and obesity: What is the ideal resection enabling significant improvement in back pain according to the body mass index?]

INTRODUCTION

Dorsal pain is the first symptoms about which patients with macromasty complain. Health insurance reimbursement takes place if the resection weight is at least 300grams per breast. However, this weight is not correlated with the body mass index (BMI). In this context, we sought to determine the ideal resection weight leading to significant BMI-based improvement.

MATERIALS AND METHODS

This is a multicentre prospective study of patients operated between November 2016 and July 2017. In the year following the surgical procedure, we studied overall improvement using the INDIC questionnaire. Any INDIC improvement of at least 50% was considered positive. These data were then compared to tissue resection weights and BMI. In order to refine our results, age, bra size, comorbidities and complications were also identified.

RESULTS

Forty-one patients were included in our study. Average age was 41.5±11.4years. Average BMI was 27.9±4.1kg/m². The bra cap chosen after the procedure were C. Average resection weight was 663±352g per breast. The preoperative and postoperative INDIC scores were 734.9±226.6 points and 225.3±319.1 points, respectively (P=0.001). Significant improvement was achieved at 12months in 71.8% of patients. A correlation of 38.7g/kg/m² was found between breast resection weight and BMI.

CONCLUSION

This study clarifies the correlation between the breast resection weight required to relieve optimal back pain and BMI. It defines three categories of patients: patients with standard weights (18<BMI<25), overweight (25<BMI<30) and obese (BMI>30). Overweight and obese patients require greater tissue excretion to be relieved optimally. These findings underline a need to adjust the health insurance threshold for these types of patients.

Examining Risk for Persistent Pain among Adults with Overweight Status

Aims of Investigation: Obesity and persistent pain are public health concerns with associated high costs. Evidence supports an increased risk for reports of persistent pain among adults who are above the recommended body mass index level. However, data have not been clearly synthesized to report the risk for the two co-occurring conditions. Even less is known about how overweight status that does not reach the level of obesity is related to pain. Thus, the aim driving this review was to calculate the risk and odds ratios of chronic pain among adults with an overweight body mass index.

METHODS

A literature review was completed using CINAHL and PubMed databases. Key words were entered using combinations of several MeSH headers.

RESULTS

Risk and odds ratios were calculated to determine overweight status among adults with chronic pain. Risk and odds ratios were calculated from nine studies. Overweight adults were between 14% and 71% more likely to report chronic pain than normal-weight adults.

IMPLICATIONS FOR PRACTICE

Pain management nurses should educate adults about the importance of weight management to reduce risk for persistent pain. Nurses need to be informed about current national physical activity and diet recommendations to ensure proper health information is relayed to patients.

CONCLUSIONS

There is an elevated risk for persistent pain among adults who are overweight compared with those who are recommended weight status. Future longitudinal research focused on causality can help determine which condition contributes to the other. Weight management may be implied for clinical risk reduction of pain conditions among adults who are above recommended body mass index levels.

The association between body fat and musculoskeletal pain: a systematic review and meta-analysis

BACKGROUND

Obesity and musculoskeletal pain are strongly related, but there is emerging evidence that body fat, not body weight, may be a better indicator of risk. There is, therefore, a need to determine if body fat is associated with musculoskeletal pain as it may improve management strategies. The aim of this systematic review was to investigate the association between body fat and musculoskeletal pain.

METHODS

Seven electronic databases were searched from inception to 8th January 2018. Cross-sectional and longitudinal studies investigating the association between measures of body fat and musculoskeletal pain were included. All included articles were assessed for methodological rigour using the Epidemiology Appraisal Instrument. Standardised mean differences (SMDs) and effect estimates were pooled for meta-analysis.

RESULTS

A total of 10,221 citations were identified through the database searching, which after abstract and full-text review, yielded 28 unique articles. Fourteen studies were included in the meta-analyses, which found significant cross-sectional associations between total body fat mass and widespread pain (SMD 0.49, 95% CI 0.37-0.61, p < 0.001). Individuals with low-back pain and knee pain had a higher body fat percentage than asymptomatic controls (SMD 0.34, 95% CI 0.17-0.52, p < 0.001 and SMD 0.18, 95% CI 0.05-0.32, p = 0.009, respectively). Fat mass index was significantly, albeit weakly, associated with foot pain (SMD 0.05, 95% CI 0.03-0.06, p < 0.001). Longitudinal studies (n = 8) were unsuitable for meta-analysis, but were largely indicative of elevated body fat increasing the risk of incident and worsening joint pain. There was conflicting evidence for an association between body fat percentage and incident low-back pain (3 studies, follow-up 4-20 years). Increasing knee pain (1 study) and incident foot pain (2 studies) were positively associated with body fat percentage and fat mass index. The percentage of items in the EAI graded as 'yes' for each study ranged from 23 to 85%, indicating variable methodological quality of the included studies.

CONCLUSIONS

This systematic review and meta-analysis identified positive cross-sectional associations between increased body fat and widespread and single-site joint pain in the low-back, knee and foot. Longitudinal studies suggest elevated body fat may infer increased risk of incident and worsening joint pain, although further high-quality studies are required.