International Journal of

Environmental Research
and Public Health

Article
Effects of Diet Control and Telemedicine-Based Resistance
Exercise Intervention on Patients with Obesity and Knee
Osteoarthritis: A Randomized Control Trial
Yen-I Hsu 1,2 , Ying-Chou Chen 3 , Chia-Lun Lee 4 and Nai-Jen Chang 1,5,6,7, *

1 Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan;

[email protected]
2 Nutritional Therapy, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital,
Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
3 Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang
Gung Memorial Hospital, Chang-Gung University College of Medicine, Kaohsiung 833, Taiwan;
[email protected]
4 Center for Physical and Health Education, National Sun Yat-Sen University, Kaohsiung 804, Taiwan;
[email protected]
5 Ph.D. Program in Biomedical Engineering, College of Medicine, Kaohsiung Medical University,
Kaohsiung 807, Taiwan
6 Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University,
Kaohsiung 807, Taiwan



7 Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan


* Correspondence: [email protected]; Tel.:+886-7-312-1101 (ext. 2646); Fax: +886-7-313-8359
Citation: Hsu, Y.-I; Chen, Y.-C.; Lee,
C.-L.; Chang, N.-J. Effects of Diet Abstract: This study investigated the effects of home-based nutritional and telemedicine-based resistance
Control and Telemedicine-Based
exercise interventions on improving body composition, blood biochemistry, and lower-limb functional
Resistance Exercise Intervention on
performance. In total, 66 obese patients with mild-to-moderate knee osteoarthritis were randomly divided
Patients with Obesity and Knee
into a diet control group (D), elastic band resistance exercise group (E), and diet control plus elastic band
Osteoarthritis: A Randomized
Control Trial. Int. J. Environ. Res.
exercise group (D + E). Each group was supervised by a clinical dietitian and follow-up was conducted
Public Health 2021, 18, 7744. via telephone calls or a communication application to track the participants’ progress. After 12 weeks
https://doi.org/10.3390/ of intervention, the D (p < 0.001) and D + E (p < 0.001) groups achieved significant weight loss. The
ijerph18157744 D + E group exhibited a significant reduction in body fat relative to the D (p = 0.019) and E (p = 0.012)
groups. Compared with the D (p = 0.002) and E (p = 0.019) groups, the D + E group achieved significant
Academic Editors: Ellen Glickman improvements in the timed up-and-go test and Western Ontario and McMaster Universities Osteoarthritis
and Jonghoon Park total scale. The D + E group experienced significant improvements in total cholesterol (p = 0.001), low-
density lipoprotein cholesterol (p = 0.01), and triglyceride levels (p = 0.007) relative to other groups. In
Received: 25 June 2021
conclusion, individual diet control intervention combined with telemedicine-based resistance exercise
Accepted: 18 July 2021
intervention significantly improved the body composition, blood biochemistry, and lower-limb functional
Published: 21 July 2021
performance of the investigated population with comorbid conditions.

Publisher’s Note: MDPI stays neutral

Keywords: exercise; body composition; cartilage; telemedicine; healthcare; nutrition
with regard to jurisdictional claims in
published maps and institutional affil-
iations.

1. Introduction
Obesity is a key public health issue. It promotes the development of osteoarthritis
Copyright: © 2021 by the authors.
(OA), which causes joint stiffness, pain, and declining functional performance [1,2]. In
Licensee MDPI, Basel, Switzerland.
addition, patients with obesity usually lack access to nutritional information and do not
This article is an open access article
know how to manage their nutritional intake to implement a healthy diet [3,4]. European
distributed under the terms and guidelines for obesity management recommend weight reduction as the nonpharmaco-
conditions of the Creative Commons logical treatment for this population [5]. A previous study suggested that a 5% body
Attribution (CC BY) license (https:// weight reduction produced improved clinical symptoms including pain relief and func-
creativecommons.org/licenses/by/ tional mobility improvement [6]. However, adverse effects were observed when sedentary
4.0/). patients with obesity and knee OA were subjected to a very low-energy diet; specifically,

Int. J. Environ. Res. Public Health 2021, 18, 7744. https://doi.org/10.3390/ijerph18157744 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 7744 2 of 15

they developed notable bad breath, intolerance to cold, flatulence, and loss of lean body
mass [7].
The American College of Sports Medicine proposed the position that “exercise is
medicine”. Exercise, which includes aerobic and resistance training, is an interventional
recommendation for treating OA [8,9]. Patients with knee OA who underwent an aerobic
exercise intervention reported significantly reduced joint pain and increased joint range
of motion [10]. However, obesity increases knee joint load due to the heavy weight borne
by the knees. Therefore, patients with obesity and comorbid knee OA may experience
increased joint pain during aerobic exercise due to the compressive impact force on the
knee joints, leading to low adherence [11,12]. For strength training, resistance-band training
serves as a relatively cheaper and more convenient alternative to machine-based resistance
training for patients with knee OA [13,14] and patients with sarcopenic obesity [15]. How-
ever, the clinical benefits of these therapeutic exercise programs decline over time, which is
likely due to poor adherence [16]. Engagement in therapeutic exercise among people in
osteoarthritic populations is influenced by a complex interplay between physical, personal,
and social–environmental factors [17]. These barriers to performing therapeutic exercises
include decreased motivation (e.g., patients may only complete exercises when provided
with action coping plans and/or audio/video exercises), pain and physical limitations,
nonpositive therapeutic exercise information, and lack of professional support [18]. In
addition, the limitations of elastic-band training include difficult to load control and quan-
tify the specific an amount of resistance [19]. Therefore, increasing adherence among the
aforementioned population to therapeutic exercise which can be feasibly performed as
graded exercise at home through the provision of instruction is a key strategy [20].
Telemedicine is a promising strategy, particularly for the early stages of a home-based
therapeutic exercise program; it allows for exercise techniques to be corrected for safety, and an
exercise program can be adjusted to suit an individual’s physical ability and goals [21–23]. In
our previous study, a 12-week telemedicine-based elastic band intervention was implemented
with regular follow-up via phone calls or communication software by the clinical staff of a
medical center; the intervention led to improved muscle strength, dynamic balance, and physical
function in patients with comorbid type 2 diabetes mellitus and knee OA [24]. Collectively,
these findings indicate that telemedicine-based elastic band exercise is safe for patients with
various conditions. In addition, systematic reviews and randomized controlled trials examining
people with knee and hip OA have highlighted that e-health technologies such as telehealth
and mobile health may provide more opportunities for interactions with exercise professionals
and increase the exercise adherence of patients, particularly in the OA population [17].
Previous studies have examined patients with obesity and knee OA and compared the ef-
fects of weight loss only [6,25], exercise only [26,27], and weight loss + exercise [12,28–30]. Based
on aforementioned studies, the literature has not examined the feasibility of achieving weight
loss, improving blood biochemical values, and enhancing functional performance through the
provision of nutritional advice and elastic band resistance exercise instructions provided by a
dietitian combined with implementation of follow-up using telemedicine to track participants’
progress, particularly with respect to the aforementioned population with comorbid obesity
and knee OA. Therefore, this study investigated the effects of an individualized nutritional and
elastic band resistance exercise intervention program delivered by a dietitian who specializes
in sports medicine through telemedicine and applied to older patients with obesity and knee
OA. Regarding functional assessments, the Western Ontario and McMaster Universities Os-
teoarthritis scale (WOMAC) scale is a high intraclass correlation coefficient self-questionnaire
used to assess the health status of patients with knee OA [24,31]. The Osteoarthritis Research
Society International recommends the timed up-and-go (TUG) test to assess the dynamic bal-
ance of patients with knee or hip OA [32]. The TUG test is highly reliable for patients with
mild-to-moderate knee OA [24,33].Therefore, the primary outcome was assessed by reviewing
the patients’ body composition and WOMAC scores. The secondary outcomes were assessed
by reviewing the patients’ blood biochemical analysis and TUG test results.
Int. J. Environ. Res. Public Health 2021, 18, 7744 3 of 15

2. Materials and Methods

2.1. Study Design and Setting
This research was approved by the Institutional Review Board of the Chang Gung
Medical Foundation (Approval No. 201800607B0) and conducted in line with current legis-
lation and the Declaration of Helsinki [34]. The protocol of this study was registered with
ClinicalTrials.gov (accessed on 20 July 2021) (NCT03973463). This study was a prospective,
single-center, randomized control trial. Patients with accessible electronic medical records
from visits to Kaohsiung Chang Gung Memorial Hospital in Taiwan were enrolled. A
clinical dietitian contacted the patients who met the selection criteria. Patients who had
obesity and knee OA and met the criteria of this study were enrolled from the Division
of Endocrinology and Metabolism of Kaohsiung Chang Gung Memorial Hospital. After
explaining the study purpose to eligible patients and obtaining their written informed
consent, we randomly assigned them to either the diet control (D) group, elastic band resis-
tance exercise intervention (E) group, or combined intervention (D + E) group. Random
allocations were concealed by using opaque, sealed envelopes (A lot: D group; B lot: E; C
lot: D + E group) that were prepared by clinical staff who were not involved in the enrol-
ment process. All patients drew one lot by themselves. Patient identification was recorded
on each lot. All enrolled patients in all groups were blinded to their grouping. All outcome
measures were assessed by a single investigator from the Division of Endocrinology and
Metabolism. The outcomes were assessed before and after the 12-week intervention.

2.2. Participants
Patients who were older than 55 years and had a body mass index (BMI) of 27–35 kg/m2
were included in the study. In the present study, obesity was defined per the definition estab-
lished by the National Health Agency; knee OA was diagnosed when X-ray findings indicated
a Kellgren and Lawrence (K&L) grade ≤3 [35] and visual analog scale ≥4 out of 10 [36]. The
exclusion criteria were as follows: inability to live independently; K&L grade >3; history of
hip or knee replacement surgery; history of myocardial infarction; pregnancy or lactation;
end-stage liver disease and nephropathy; severe heart disease; lung disease; inability to undergo
physical function testing due to conditions such as unstable angina, myocardial infarction, heart
failure, severe heart rhythm disorder or second- or third-degree heart conduction block, cardiac
aneurysm or aortic aneurysm, or myocarditis or pericarditis; chronic obstructive pulmonary
disease accompanied by pulmonary heart disease, untreated or unstable asthma, severe pul-
monary hypertension, or pulmonary embolism; and malignant hypertension. Throughout
the study, all participants’ drug regimens remained unchanged. This study was conducted at
Kaohsiung Chang Gung Memorial Hospital.

2.3. Interventions
2.3.1. Diet Control Group
A clinical dietician provided support to the D group and designed an individualized
nutritional plan for each participant. These participants also received dietary advice (from
the clinical dietitian), health education, and manuals and handouts (covering weight
loss and diet) during their first visit to the medical center. Each participant was asked
by the clinical dietician to follow a balanced low-energy diet of 1200 kcal/day [7] and
update his or her diet record sheet at least three times a week (at least twice and once
on weekdays and weekends, respectively). The clinical dietitian followed up with and
advised the participants through active phone calls or a communication application (e.g.,
LINE, FaceTime) once a week for 12 weeks. While performing active calls or mobile
application, patient’s interventions were actively instructed by the clinical dietitian based
on the individual’s nutritional needs and preferences of each participant.

2.3.2. Elastic Band Resistance Exercise Group

The elastic band resistance exercise intervention was implemented with the protocol
used in our previous study [24]. Due to safety concerns, seated, open-chain exercises were
 FaceTime) once a week for 12 weeks. While performing active calls or mobile application,
patient’s interventions were actively instructed by the clinical dietitian based on the indi-
vidual’s nutritional needs and preferences of each participant.

Int. J. Environ. Res. Public Health 2021,2.3.2. Elastic

18, 7744 Band Resistance Exercise Group 4 of 15
The elastic band resistance exercise intervention was implemented with the protocol
used in our previous study [24]. Due to safety concerns, seated, open-chain exercises were
incorporated to strengthen the major muscle groups of the lower extremities. The exercise
incorporated to strengthen the major muscle groups of the lower extremities. The exer-
regime included hip joint extension/flexion, abduction/adduction, external/internal rota-
cise regime included hip joint extension/flexion, abduction/adduction, external/internal
tion, knee joint extension/flexion, and ankle joint plantarflexion/dorsiflexion movements
rotation, knee joint extension/flexion, and ankle joint plantarflexion/dorsiflexion move-
(Figure 1). Each participant performed 10 repetitions/set of five sets/day of the aforemen-
ments (Figure 1). Each participant performed 10 repetitions/set of five sets/day of the
tioned exercise movements 3 days a week for 12 weeks [24]. Exercise intensity was in-
aforementioned exercise movements 3 days a week for 12 weeks [24]. Exercise intensity
creased by applying more force to the band to provide greater resistance or by switching
was increased by applying more force to the band to provide greater resistance or by
to a thicker resistance band that created more resistance and thus increased exercise diffi-
switching to a thicker resistance band that created more resistance and thus increased
culty. A repetition maximum of 10 and rated perceived exertion (RPE) of 13 (range of 6–
exercise difficulty. A repetition maximum of 10 and rated perceived exertion (RPE) of 13
20) wereofapplied
(range as the
6–20) were standards
applied as theforstandards
the exercise
for program
the exercise[13].program
As long[13].
as participants
As long as
completed 10 RM and below an RPE of 13, they were prescribed
participants completed 10 RM and below an RPE of 13, they were prescribed increased exercise diffi-
increased
culty while clinical staff performed telemedicine-based instruction. To ensure
exercise difficulty while clinical staff performed telemedicine-based instruction. To ensure that the pa-
tients understood the resistance exercise program, each movement was
that the patients understood the resistance exercise program, each movement was taught by taught by clinical
staff at the
clinical staffmedical center center
at the medical duringduring
the patients’ first visit.
the patients’ The The
first visit. clinical staffstaff
clinical specialize
specializein
sports medicine and are well trained to prescribe an exercise program.
in sports medicine and are well trained to prescribe an exercise program. A low-resistance A low-resistance
elastic
elasticband
bandwaswasused
usedunder
undersupervision
supervisionby bytelemedicine
telemedicinefor forfamiliarization
familiarization ininthethefirst 2
first
weeks, and bands with progressively higher resistance were
2 weeks, and bands with progressively higher resistance were used in the subsequentused in the subsequent
weeks.
weeks. Thereafter,
Thereafter, participants’
participants’compliance
compliancewith withthethe exercise
exercise program
program was was tracked
tracked and and
instruction
instructionprovided
providedbybyclinical
clinicalstaff once
staff every
once week
every through
week throughactive phone
active calls or
phone a com-
calls or a
munication
communication application (e.g., (e.g.,
application LINE,LINE,
FaceTime) for 12for
FaceTime) weeks. In addition,
12 weeks. they were
In addition, pro-
they were
vided brochures
provided withwith
brochures highlighted
highlighted notes thatthat
notes served as reminders.
served as reminders.

Figure
Figure 1.
1. Elastic
Elasticband
bandresistance
resistance exercise
exercise intervention.
intervention.

2.3.3.
2.3.3.Combined
CombinedGroup
Group
Both
Boththe
thediet
dietcontrol and
control elastic
and band
elastic resistance
band program
resistance interventions
program (i.e., the
interventions afore-
(i.e., the
mentioned protocols)
aforementioned were were
protocols) applied to thistogroup.
applied this group.

2.4. Outcome Measures

The clinical staff who collected the data were properly trained in data collection pro-
cedures and the execution of follow-up through active phone calls or a communication
application (e.g., LINE). The dietitian, who specializes in sports medicine, was responsible
for assessing the primary and secondary outcomes before and after the 12-week interven-
tion. In addition, the patients’ blood parameters were monitored by the Department of
Laboratory Medicine of Kaohsiung Chang Gung Memorial Hospital.
Int. J. Environ. Res. Public Health 2021, 18, 7744 5 of 15

2.4.1. Primary Outcomes

Body composition results and WOMAC scores were the primary outcomes in the
present study. Body composition was determined by performing bioelectrical impedance
analysis (BIA) to estimate a patient’s body weight, BMI, body fat percentage, body fat
mass, soft lean mass, and lower-limb muscle mass; the analysis was performed using the
Body Composition Analyzer (Model IOI 353, Jawon Medical, Seoul, South Korea) [37].
This device has a strong linear correlation (r2 = 0.894) and strong agreement (ICC = 0.917)
compared with dual-energy X-ray absorptiometry (DXA); Bland–Altman analysis showed
that the limit of agreement (%) of this device was 89.3% [38]. Participants were prohibited
from engaging in vigorous exercise, consuming food, using a sauna, or drinking excessive
amounts of water during the 4 h prior to measurement. To ensure good conductivity,
the patients were asked to remove their socks and clean their feet and hands before
placing them on the electrode plates for collection of measurements; the related procedures
were performed as described in the manufacturer’s operations manual. Body height
was measured using automatic height-measuring equipment (HW-3070, Hocom, Taipei,
Taiwan). WOMAC items are answered on a five-point Likert scale ranging from 0 (no
disability) to 4 (extremely severe disability). A higher score indicates more severe disability.
Three subscales for pain, stiffness, and physical function were used, and their scores were
added to obtain an overall score. A minimal clinically important difference (MCID) was
recognized as a reduction (relative to the baseline score) of at least 14% for the overall
score [39], 22.9% for the pain subscale score, 14.4% for the stiffness subscale score, and 19%
for the physical function subscale score [40,41].

2.4.2. Secondary Outcomes

Blood biochemical analysis and TUG test results were the secondary outcomes in the
present study. The blood biochemical analysis comprised measurements of total cholesterol (nor-
mal range <200 mg/dL), low-density lipoprotein cholesterol (LDL; normal range <150 mg/dL),
and triglyceride (normal range <150 mg/dL) levels. All blood biochemical analyses were
performed by the Department of Laboratory Medicine of Kaohsiung Chang Gung Memorial
Hospital. The enzymatic method was used; specifically, a coloring agent was added to a quan-
titative serum that was then placed in a 37 ◦ C water bath; its absorbance was measured at a
wavelength of 505 nm, and the concentration of blood in the serum was calculated. Data were
obtained from the electronic medical record system of the medical center.
The TUG test is performed as follows: Upon hearing the “Start” command verbally
given by the investigator, the participant stands up from a seated position, walks to a target
placed 2.44 m in front of them, turns around, walks back to the chair, and sits down as
quickly as possible. The time required to complete this task was measured in seconds. An
MCID was recognized as a decrease (relative to baseline) of at least 0.8 s in the total time
required to complete the task [42].

2.5. Statistical Analyses

The power estimation indicated that a sample size of at least 20 participants in each
group was required. The estimations were based on an alpha level of 0.05 and a desired
power of 80% with an anticipated dropout rate of 15% [43].
SPSS 25.0 (SPSS, Chicago, IL, USA) was used for data analysis. Data are presented as
means and standard deviations (SD). The Shapiro–Wilk test indicated a normal distribution
(p > 0.05) and the basic data of the participants were analyzed using descriptive statistics,
chi-squared tests, and Fisher’s exact test. A paired t test was used to analyze the intragroup
differences in body composition, WOMAC scale scores, blood biochemical values, and TUG
test scores. Analysis of covariance (ANCOVA) was performed, with the covariate being
set using pretest data and the groups being independent variables. To address concerns
related to the multiple comparison test, the method for controlling type I error was applied
in each corresponding multiple comparison method [44]. Post hoc analysis was performed
using the Bonferroni method. If a group exhibited nonhomogeneity, an analysis of variance
 Int. J. Environ. Res. Public Health 2021, 18, 7744 6 of 15

(ANOVA) was performed to test the homogeneity; if the same value (p > 0.05) was obtained,
then ANCOVA was used to analyze the differences between groups; if homogeneity was
not observed (p < 0.05), the Welch test was performed to determine the changes between
groups and a pairwise comparison was performed using Dunnett’s T3 test instead. The
changes from baseline to post-intervention were analyzed using one-way ANOVA, and
post hoc testing was performed using Tukey’s range test. The effect size (Cohen’s d), which
is the difference between pretest and post-test means divided by their common SD, was
calculated and interpreted as small (d = 0.2), medium (d = 0.5), or large (d = 0.8), to show
the magnitude of the effect [45]. Statistical significance was established when p < 0.05.

3. Results
3.1. Study Flow for Participants
A total of 113 outpatient screenings occurred during the enrolment period; 47 patients did
not meet the inclusion criteria, and 66 patients were enrolled. Subsequently, the enrolled patients
were assigned randomly to the D, E, or D + E groups. This study applied an intention-to-treat
analysis. Of the 66 patients, 3 interventions were not completed due to an inability to conduct
follow-up (overseas travel, loss of contact, family refusal). Ultimately, 63 participants (i.e., 21
in each group) completed the intervention (Figure 2). The adherence rates of the participants
who completed the intervention were 83%, 90%, and 87% for the D, E, and D + E groups,
respectively. No significant differences were observed among the three groups with respect to
their baseline data (i.e., age, gender, height, weight, BMI, body fat percentage, K&L classification,
Int. J. Environ. Res. Public Health 2021, 18, x 7 of 16
and medication use; Table 1). Over the entire intervention period, no adverse events related to
the intervention were reported.

Figure
Figure2.2.Consolidated
ConsolidatedStandards
StandardsofofReporting
ReportingTrials
Trialsflow
flowdiagram.
diagram.

Table 1. Baseline characteristics of participants.

Characteristics D Group (n = 21) E Group (n = 21) D + E Group (n = 21) p
Gender
Male/female 9/12 8/13 6/15 0.779
Int. J. Environ. Res. Public Health 2021, 18, 7744 7 of 15

Table 1. Baseline characteristics of participants.

Characteristics D Group (n = 21) E Group (n = 21) D + E Group (n = 21) p

Gender
Male/female 9/12 8/13 6/15 0.779
Age (year) 66.0 (3.9) 64.2 (4.1) 65.6 (3.9) 0.308
Body height (cm) 159.32 (5.64) 159.77 (7.44) 158.93 (6.82) 0.578
Body weight (kg) 78.37 (8.50) 79.00 (10.78) 77.53 (10.17) 0.891
Body mass index
30.80 (2.58) 30.84 (2.47) 31.10 (2.60) 0.915
(kg/m2 )
Body fat (%) 35.18 (6.00) 34.64 (6.47) 36.2 (5.27) 0.690
waistline (cm) 102.12 (8.10) 102.07 (10.91) 100.35 (7.25) 0.764
Kellgren–Lawrence
1.76 (0.81) 1.62 (0.65) 1.81 (0.85) 0.528
grade
I, n (%) 10 (47.6) 11 (50) 10 (47.6)
II, n (%) 6 (28.6) 8 (38.1) 5 (23.8)
III, n (%) 5 (23.8) 2 (9.1) 6 (28.6)
Drug, n (%)
Antihyperlipidemic 15 (71.4) 13 (61.9) 12 (57.1) 0.719
Antiarthritic 12 (57.1) 12 (57.1) 10 (47.6) 0.856
VAS (baseline) 6.19(1.03) 6.62 (1.17) 6.29 (1.06) 0.399
Values are means with standard deviations (in brackets) unless indicated otherwise. D: diet control group; E: resistance exercise group; D +
E: diet control and resistance exercise group.

3.2. Primary Outcomes

3.2.1. Body Composition Analysis
Table 2 presents the postintervention changes in body composition. After the conclusion
of the interventions, significant differences in body weight were observed among the three
groups (F = 69.037, p < 0.001). In the pairwise comparison test, the D + E (p < 0.001) and D
(p < 0.001) groups exhibited significant decreases in body weight relative to their baseline
data. Furthermore, the changes in the D + E (p < 0.001) and D (p < 0.001) groups represented
significant improvements relative to the E group. Significant differences in BMI were observed
among the three groups (F = 66.788, p < 0.001). In the pairwise comparison test, the D + E
(p < 0.001) and D (p < 0.001) groups exhibited significant improvements relative to their
baseline data; however, such improvements were not observed in the E group (p = 0.161).
Furthermore, the BMI changes in the D + E (p < 0.001) and D (p < 0.001) groups represented
significant decreases relative to the E group. Significant differences in body fat percentage
were observed among the three groups (F = 6.287, p = 0.003). In the pairwise comparison
test, all groups (p < 0.001) exhibited significant improvements relative to their baseline data.
Furthermore, the changes in body fat percentage in the D + E group represented significant
improvements relative to the D (p = 0.019) and E (p = 0.012) groups. Significant differences in
soft lean mass were observed among the three groups (F = 25.996, p < 0.001). In the pairwise
comparison test, all groups exhibited significant improvements relative to their baseline
data. Furthermore, the soft lean mass changes in the D + E (p < 0.001) and D (p < 0.001)
groups represented significant improvements relative to the E group. Significant differences
in lower-limb muscle mass were observed among the three groups (F = 43.255, p < 0.001).
In the pairwise comparison test, a significant reduction and increase in lower-limb muscle
mass were observed in the D and E groups, respectively, and no significant changes were
observed in the D + E group (p = 0.178). Furthermore, the changes in the D group (p < 0.001)
represented a significant reduction relative to the D + E group, and the changes in the E group
represented a significant increase relative to the other two groups.
Int. J. Environ. Res. Public Health 2021, 18, 7744 8 of 15

Table 2. Improvements in body composition after the 12-week intervention.

Outcomes D E D+E
Body weight (kg)
Baseline 78.37 ± 8.50 78.99 ± 10.78 77.53 ± 10.17
Post-intervention 74.96 ± 8.59 78.63 ± 11.00 74.03 ± 10.11
Change −3.41 ± 0.75 $ −0.36 ± 1.16 −3.50 ± 0.97 $
Effect size 0.4 0.03 0.35
p <0.001 0.168 <0.001
Body mass index (kg/m2 )
Baseline 30.8± 2.57 30.84± 2.47 31.10± 2.60
Post-intervention 29.45± 2.59 30.69± 2.59 29.7± 2.64
Change −1.35 ± 0.33 $ −0.15± 0.46 −1.41± 0.39 $
Effect size 0.52 0.06 0.53
p <0.001 0.161 <0.001
Body fat (%)
Baseline 35.18 ± 6.01 34.64± 6.48 36.20± 5.27
Post-intervention 33.97 ± 6.47 33.48± 6.46 34.32± 5.50
Change −1.20 ± 0.81 −1.17± 0.75 −1.87± 0.78 #,$
Effect size 0.19 0.18 0.35
p <0.001 <0.001 <0.001
Soft lean mass (kg)
Baseline 46.29 ± 6.25 47.05 ± 8.41 45.64 ± 8.97
Post-intervention 45.05 ± 6.38 47.83 ± 8.53 44.46 ± 8.55
Change −1.23 ± 0.65 $ 0.78 ± 0.64 −1.18 ± 1.56 $
Effect size 0.2 0.1 0.13
p <0.001 <0.001 0.002
Lower-limb muscle mass (kg)
Baseline 17.59 ± 2.62 17.37 ± 3.2 17.34 ± 3.57
Post-intervention 16.85 ± 2.60 17.89 ± 3.37 17.17 ± 3.43
Change −0.75 ± 0.40 $ 0.52 ± 0.35 −0.17 ± 0.55 #,$
Effect size 0.28 0.16 0.05
p <0.001 <0.001 <0.001
Results are expressed as means ± standard deviations. Change was calculated by subtracting the baseline value
from the postintervention value; p: pairwise test; effect size indicates Cohen’s d; $ indicates vs. E group (p < 0.05);
# indicates vs. D group (p < 0.05); D: diet control group; E: resistance exercise group; D + E: diet control and

resistance exercise group.

3.2.2. WOMAC Analysis

Table 3 presents the postintervention changes in WOMAC scores. After the interven-
tions concluded, significant differences in overall WOMAC scores were observed among
the three groups (F =5.938, p = 0.004). In the pairwise comparison test, the D + E (p = 0.007)
and D (p =0.017) groups exhibited significant improvements relative to their baseline data.
Furthermore, the changes in the D + E group represented significant improvements relative
to the D (p = 0.002) and E (p < 0.001) groups. The overall scores of the D, E, and D + E
groups improved by 26.79%, 24.78%, and 33.52%, respectively. MCIDs were observed in all
three groups.
For the pain subscale, no significant postintervention difference was observed among
the groups (F =1.319, p = 0.275). However, all three groups (P < 0.001) exhibited significant
improvements relative to their baseline data. Furthermore, the changes in the D + E group
(p < 0.03) represented significant improvements relative to the E group. The pain scores of
the D, E, and D + E groups improved by 32.16%, 29.64%, and 39.83%, respectively. MCIDs
were observed in all three groups.
Int. J. Environ. Res. Public Health 2021, 18, 7744 9 of 15

Table 3. Improvements in WOMAC scale after the 12-week intervention.

Outcomes D E D+E
Total Score
Baseline 34.57 ± 7.69 30.24 ± 6.06 38.86 ± 7.98
Post-intervention 25.33 ± 6.55 22.62 ± 5.41 25.81 ± 6.61
Change −9.24 ± 3.59 −7.62 ± 2.64 −13.05 ± 4.09 #,$
Effect size 1.29 1.33 1.78
p <0.001 <0.001 <0.001
Pain
Baseline 6.48 ± 2.21 6.05 ± 1.99 7.43 ± 2.01
Post-intervention 4.33 ± 1.65 4.14 ± 1.46 4.48 ± 1.44
Change −2.14 ± 1.28 −1.90 ± 1.48 −2.95 ± 1.12 $
Effect size 1.1 1.09 1.69
p <0.001 <0.001 <0.001
Stiffness
Baseline 2.91 ± 1.09 1.33 ± 1.15 2.86 ± 1.59
Post-intervention 1.86 ± 0.66 0.90 ± 0.83 1.38 ± 0.97
Change −1.05 ± 0.81 −0.43 ± 0.68 −1.48 ± 1.03 $
Effect size 1.17 0.21 1.12
p <0.001 <0.001 <0.001
Physical Function
Baseline 25.19 ± 5.62 22.86 ± 4.30 28.57 ± 5.76
Post-intervention 19.43 ± 5.29 17.76 ± 3.82 19.95 ± 4.79
Change −5.76 ± 2.84 −5.10 ± 1.70 −8.62 ± 3.58 #,$
Effect size 1.06 1.25 1.63
p <0.001 <0.001 <0.001
Results are expressed as means ± standard deviations. Change is calculated by subtracting the baseline value
from the postintervention value; p, pairwise test; Effect size indicates Cohen’s d; $ indicates vs. E group (p < 0.05);
# indicates vs. D group (p < 0.05); D, diet control group; E, resistance exercise group; D + E, diet control and

resistance exercise group.

For the stiffness subscale, significant postintervention differences were observed among
the groups (F =3.764, p = 0.029). In the pairwise comparison test, all three groups (p < 0.001)
exhibited significant improvements relative to their baseline data. Furthermore, the changes
in the D + E group (p = 0.001) represented significant improvements relative to the E group.
The stiffness scores of the D, E, and D + E groups improved by 32.16%, 29.64%, and 39.83%,
respectively. MCIDs were observed in all three groups.
For the physical function subscale, significant postintervention differences were ob-
served among the groups (F =3.989, p = 0.024). In the pairwise comparison test, all three
groups (p < 0.001) exhibited significant improvements relative to their baseline data. Fur-
thermore, the changes in the D + E group represented significantly improvements relative
to the D (p < 0.001) and E (p = 0.005) groups. The physical function scores of the D, E, and D
+ E groups improved by 23.05%, 21.54%, and 29.72%, respectively. MCIDs were observed
in all three groups.

3.3. Secondary Outcomes

3.3.1. Blood Biochemical Analysis
Table 4 presents the improvements in blood biochemistry values. For total cholesterol,
significant postintervention differences were observed among the groups (F = 7.214, p = 0.002).
In the pairwise comparison test, the D + E (p < 0.001) and D (p < 0.001) groups exhibited
significant improvements relative to their baseline data; however, such improvements were not
observed in the E group (p = 0.275). Furthermore, the changes in the D + E group (p = 0.001)
represented significant improvements relative to the E group.
Int. J. Environ. Res. Public Health 2021, 18, 7744 10 of 15

Table 4. Improvements in blood biochemistry values after the 12-week intervention.

Outcomes D E D+E
Total cholesterol (mg/dL)
Baseline 177.17 ± 23.35 169.95 ± 25.06 177.48 ± 27.04
Post-intervention 160.10 ± 20.16 165.81 ± 26.89 151.52 ± 18.03
Change −17.57 ± 18.07 −4.14 ± 13.40 −25.95 ± 23.27 $
Effect size 0.78 0.16 1.13
p <0.001 0.175 <0.001
LDL (mg/dL)
Baseline 99.47 ± 24.19 94.47 ± 24.19 97.57 ± 24.10
Post-intervention 84.38 ± 18.69 91.76 ± 24.32 79.52 ± 14.27
Change −15.24 ± 15.17 $ −2.71 ± 13.94 −18.05 ± 19.78 $
Effect size 0.7 0.11 0.91
p <0.001 0.325 <0.001
Triglycerides (mg/dL)
Baseline 145.40 ± 52.95 128.81 ± 62.68 140.62 ± 54.57
Post-intervention 110.75 ± 48.77 118.05 ± 47.68 97.33 ± 35.79
Change −34.65 ± 16.17 −10.76 ± 48.92 −43.29 ± 26.37 $
Effect size 0.68 0.19 0.94
p <0.001 0.325 <0.001
Results are expressed as means ± standard deviations. Change was calculated by subtracting the baseline value
from the postintervention value; p: pairwise test; effect size indicates Cohen’s d; $ indicates vs. E group (p < 0.05);
D: diet control group; E: resistance exercise group; D + E: diet control and resistance exercise group.

For LDL, significant postintervention differences were observed among the groups
(F = 5.946, p = 0.004). In the pairwise comparison test, the D + E (p < 0.001) and D (p < 0.001)
groups exhibited significant improvements relative to their baseline data; however, such
improvements were not observed in the E group (p = 0.383). Furthermore, the changes in
the D + E (p = 0.01) and D (p = 0.044) groups represented significant improvements relative
to the E group.
For triglycerides, significant postintervention differences were observed among the
groups (F = 6.035, p = 0.004). In the pairwise comparison test, the D + E (p < 0.001) and
D (p < 0.001) groups exhibited significant improvements relative to their baseline data;
however, such improvements were not observed in the E group (p = 0.325). Furthermore,
the changes in the D + E group (p = 0.007) represented significant improvements relative to
the E group.

3.3.2. TUG Test

For the TUG test, significant postintervention differences were observed among the
groups (F = 12.508, p < 0.001) (Table 5). In the pairwise comparison test, all groups (p < 0.001)
exhibited significant improvements relative to their baseline data. MCIDs were observed in
all groups. Furthermore, the changes in the D + E group (p = 0.001) represented significant
improvements relative to the E group.

Table 5. Improvements in TUG test after the 12-week intervention.

Outcomes D E D+E
TUG(s)
Baseline 11.25 ± 2.15 10.51 ± 1.97 10.98 ± 1.98
Post-intervention 9.92 ± 1.68 9.59 ± 1.56 9.37 ± 1.61
Change −1.33 ± 0.59 −0.92 ± 0.67 −1.61 ± 0.52 $
Effect size 0.69 0.52 0.89
p <0.001 <0.001 < 0.001
Results are expressed as means ± standard deviations. Change was calculated by subtracting the baseline value
from the postintervention value; p: pairwise test; effect size indicates Cohen’s d; $ indicates vs. E group (p < 0.05);
D: diet control group; E: resistance exercise group; D + E: diet control and resistance exercise group.
Int. J. Environ. Res. Public Health 2021, 18, 7744 11 of 15

4. Discussion
To the best of our knowledge, this was the first prospective study in which patients
with obesity and knee OA received home-based nutritional consultation combined with
telemedicine-based exercise intervention. Individualized diet control interventions com-
bined with telemedicine-based resistance exercise interventions, which were supervised by
a clinical dietitian, significantly improved body composition (i.e., reduction in BMI and
body fat percentage), improved blood biochemistry values (i.e., reduction in total choles-
terol, LDL, and triglyceride levels), and enhanced lower-limb functional performance (i.e.,
improvements in WOMAC and TUG results) in the investigated population. The adherence
rates of the patients who completed the intervention were 83%, 90%, and 87% in the D, E,
and D + E groups, respectively. The high compliance can be attributed to the consistent
follow-up with the clinical dietician and the convenience of exercising at home, which
indicate that this method is feasible and effective. The adherence levels observed in all
groups were higher than those reported in previous studies [16,46].
Regarding body composition changes, most weight-loss methods for patients with
obesity and knee OA involve meal replacements. Although studies involving meal re-
placements have successfully achieved >10% body weight reductions, the rapid weight
loss has also led to reductions in participants’ lean body mass by 11%–17% of their body
weight [47–49]. In contrast, in the present study, each participant followed an individual-
ized, balanced low-energy diet of 1200 kcal/day that was developed by a clinical dietitian.
Each participant also engaged in follow-up and regularly consulted with the clinical di-
etitian through phone calls or online real-time communication once a week for 12 weeks;
therefore, we were able to regularly monitor individuals’ nutritional status and control
their energy intake such that their body weight could be reduced gradually. In addition,
the percentage of participants who lost more than 5% of their body weight was 33.3%, and
47.6% in the E and D + E groups. A previous systematic review reported that a weekly
reduction of body weight by 0.25% can improve the disability status of individuals with
overweight or obesity with knee OA [50]. Moreover, we discovered that the participants
in the D group experienced not only decreases in their body weight, body fat percentage,
BMI, and soft lean mass, but also their muscle mass (which was expected). In the D + E
group, no significant decrease in muscle mass was observed, which indicates that resistance
exercise is essential for weight loss because it can slow muscle mass loss. In other words,
implementing a weight-loss intervention that does not incorporate exercises will lead to
the loss of muscle mass in the lower limbs and, consequently, increase the risk of knee
joint impact injuries resulting from insufficient quadriceps muscle strength. Elastic band
resistance exercises help to initiate muscle anabolism and improve the protein synthesis
rate of the limb muscles. In the present study, soft lean mass and lower-limb muscle mass
increased significantly in the E group. These results were consistent with those reported in
a previous study [15]. Therefore, we recommend a combined telemedicine-based interven-
tion for patients with obesity and knee OA because this intervention allows for weight loss
without the loss of lower-limb muscle mass.
Regarding functional performance, the D + E group achieved the most significant
improvements in overall WOMAC scores (33.52%) and physical function subscale (29.72%),
and these improvements met the MCID threshold. Similarly to the present study, previous
studies have indicated that elastic band resistance exercises improved the WOMAC scores
of patients with and without obesity who have OA [13,51,52]. In addition, the D + E
group exhibited significant improvements on the TUG test relative to the E group. This
finding may have contributed to the decreased pain that was reported. The three groups
experienced significant pain relief benefits after completing their interventions. Pain
and physical activity are mutually influential [24]. A study of home-based balance and
low-resistance exercise training verified that healthy older adults in the community who
participated in a supervised exercise training program took an average of 8.7–9.91 s to
complete the TUG test [53]. In the present study, after receiving telemedicine support from
clinical staff and completing the interventions, the patients with obesity and knee OA took
Int. J. Environ. Res. Public Health 2021, 18, 7744 12 of 15

9.37–9.92 s to complete the TUG test; these results are similar to those achieved by healthy
older adults (8.4–9.1 s). This finding indicated a significant improvement that met the
MCID threshold [42].
For blood biochemistry values, the three groups exhibited decreased total cholesterol
levels. In addition, the D + E group exhibited lower LDL and triglyceride levels relative to
the E group, indicating the effectiveness of regular diet control supervised by a dietician
through telemedicine. Blood lipid level (particularly LDL level) influences a patient’s
cardiovascular risk [54]. Previous studies have indicated that resistance exercise training
aids the control of blood lipid levels [55,56]. Furthermore, a high triglyceride level increases
endogenous LDL [57]. Collectively, these findings indicate that regular diet control and
resistance exercise can greatly benefit patients at high risk of cardiovascular disease (e.g.,
those with obesity).
The primary contribution of the present study is its demonstration of the feasibility
of implementing diet control through nutritional consultation and improving functional
performance through a supervised resistance exercise program for the investigated popula-
tion; this was achieved via phone consultations provided by clinical staff over a 12-week
follow-up period after the participants’ first visit to the outpatient department. However,
the study had several limitations that can be addressed in future studies. First, we enrolled
participants from only a single medical center, and the positive outcomes could have been
achieved primarily because a clinical dietitian with a sports medicine background aided
in follow-up and tracked the health status and exercise adherence of the participants via
phone calls or a communication application; in a regional hospital or small clinic, this
protocol may be difficult to replicate. Second, other intervention-related dependent vari-
ables were not assessed. Changes in physical activity levels assessed through wearable
technology (e.g., daily walking steps, speed), performance-based measures of physical
function, and quality of life for this population were not tracked, and physical or occupa-
tional activities unrelated to the study could have introduced bias into the results. The OA
participants were also not precisely assessed for intra-articular joint condition (e.g., carti-
laginous wear) by magnetic resonance imaging [58] and biomechanics changes (e.g., gait,
joint loading) [59]. Third, a potential placebo effect was not accounted for, since there is no
sham exercise. Fourth, the severe OA participants (i.e., K&L grade >3) were excluded. The
generalizability of the results to all patients with obesity and knee OA is low. Fifth, we did
not verify whether the participants’ family members actively supervised the interventions,
which is a factor that could also have introduced bias into the results. Sixth, limitations
of BIA in morbidly obese patients may exist. Obese individuals have a relatively high
amount of extracellular water and total body water, which may lead to underestimation
of fat mass and overestimation of fat-free mass [60]. Therefore, adoption of total body
DXA scanning for the precise measurement of body composition is suggested, but the
safety of repeated measurements, the cost, and technical expertise are limiting [61]. A last,
long-term follow-up should be conducted to determine, especially after the conclusion
of interventions, whether our strategy changed the dieting and exercise behavior of the
investigated population and produced long-term effects.

5. Conclusions
Supervised by a clinical dietitian, a 12-week individualized diet control intervention
combined with a telemedicine-based elastic band resistance exercise intervention led to
significant reductions in BMI, body fat, total cholesterol, LDL, and triglyceride levels
and enhanced lower-limb functional performance in patients with obesity and mild-to-
moderate knee OA. We recommend the application of this strategy by medical centers.

Author Contributions: Y.-I.H.; N.-J.C. conceived and designed the experiments; Y.-I.H.; Y.-C.C.; N.-
J.C. performed the experiments; Y.-I.H.; Y.-C.C.; C.-L.L.; N.-J.C. interpreted the data and participated
in drafting the text and figures. All authors have read and agree to the published version of the
manuscript.
Int. J. Environ. Res. Public Health 2021, 18, 7744 13 of 15

Funding: This research was supported by the Department of Medical Research, Kaohsiung Chang
Gung Memorial Hospital (Project Number: CMRPG8H0581). This work was also in part supported
by the NSYSU-KMU joint research project [NSYSUKMU110-P004].
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki, and approved by the Institutional Review Board of the Chang Gung Medical
Foundation (Approval No. 201800607B0).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study.
Data Availability Statement: Data are contained within the article.
Acknowledgments: We would like to thank all our participants for their time and effort. We also
thank researchers for assistance with statistical analyses, from the Biostatistics Center, Kaohsiung
Chang Gung Memorial Hospital.
Conflicts of Interest: The authors declare no conflict of interest.

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