 And I would like to welcome them, Lelana, School of Public Health University of Toronto. So it's also a scientist in the Division of Healthcare and Outcomes Research and the Arthritis Program Research Institute and Assistant Professor at the Dalai Lama School. They share research interests in understanding the personal and population impact of muscle skeletal disorders, particularly osteoarthritis to the analysis of population based as well as clinical data. So I'd like to welcome our distinguished speakers. I will go ahead and turn it over to begin the webinar. Hello, thank you and welcome all of you. This is Badly speaking. If you're here for me, so Lisa, that's my alternative name. So don't be confused, there's not three of us here. There's just two of us and I'm sitting here with Anthony. I'm going to start and then I'm going to hand over to Anthony and then we will come back to me again. Okay, and I just got to work out how to change this slide. Okay, so our general objective in this webinar is to present some preliminary findings of our work in progress and perhaps indicate a little bit where we're going next. And also to suggest areas where further development of the CLSA questionnaires are required. These are sort of areas where we've sort of said, well, I wish they'd done that. So we will be moving on in that area. And but first of all, we're going to be using data from the baseline CLSA data. And just to remind you, it's a population aged 45 to 85. And we're using questionnaire data, the self-report questionnaire data from the tracking sample and the comprehensive sample and wherever possible, you'll see that we've combined the two. So first of all, arthritis. So what is arthritis? Technically, arthritis means inflammation of the joint. But this term is generally used for a family related conditions which affect the joints, such as components of the joints, sort of like the synovium and cartilage, and associated structures, such as ligaments, tendons, and underlying bones. What these family conditions have in common is that they cause pain, swelling, and stiffness in the joints. And one complication of studying arthritis is there's over 100 different conditions. So this slide lists some of the major types of arthritis. The most common type of arthritis by far is osteoarthritis, which has a population prevalence of at least 14% and probably a lot higher. Gout is another form of arthritis. Ex-mainly men with a prevalence of about 4%. The types of arthritis we perhaps hear most about, things like rheumatoid arthritis, belong in the category of inflammatory arthritis, which has a whole bunch of conditions, inflammatory rheumatoid, reactive arthritis, anchors, and spondylitis, and taken together, these have a prevalence of about 1% to 2%. But tend to be some more seriously disabling. And then there are connected tissue diseases, such as systemic lupus, erythematosis, which have a prevalence of about 1.01%, 1 in 1,000. We're going to be talking mainly about osteoarthritis in this talk. So osteoarthritis is characterised by deterioration in the cartilage and other structures in one or more joints. And this deterioration and the problem with other joints, including some inflammation, needs to joint damage, to pain and stiffness in the joint. And osteoarthritis typically affects the knees, spine, hands, hips, and feet. Osteoarthritis is important not because, not only because of its high frequency in the population, it's often written off as fairly minor complaints, but it is a major cause in the population of pain and disability, and through the pain and disability affecting the life of self-care, mobility, employment. And through this, it has an impact on quality of life. It has substantial impact on healthcare utilisation. It's one of the most common conditions consulted for in primary care, and is an important cause of hospitalisation, particularly the surgery for hip and knee joint replacements. And taken together, these create an economic burden to society where actually most of the burden is in indirect cost due to lost productivity and cost to the individual. It's often those of us relatively benign and not associated with mortality, but recent research is showing that osteoarthritis is associated with an increased risk of mortality, particularly from heart disease. And in a way, we're almost beginning to think of it as a sort of separate risk factor for heart disease, a neglected one. So it is an important condition. And I'm going to hand over now to Antoni to talk about the etiology. Good afternoon, everyone. So when we look at the etiology of osteoarthritis, it's been traditionally characterised as a wear and tear condition with joint damage predominantly caused by mechanical factors. So overloading of the joints in quotes, overuse of joints. So the typical diagram of the etiology of osteoarthritis has looked something like this. So recognising that older age and female sex is associated with osteoarthritis. Studies and genetics have really been inconsistent. But a focus on the local environment and mechanical factors, so such as obesity leading to overloaded joints, this leading then to altered joint loading and a cascade down to osteoarthritis in the joint. With that said, however, we know that OA is associated with obesity, particularly the knee, which is a load bearing joint. But we also know that obesity is associated with hand OA, so a non-load bearing joint. We also know from epidemiological studies that it appears that individuals with OA have a higher prevalence of specific conditions compared to non-OA populations. And these include hypertension, heart disease and diabetes. In addition, we know that many people with osteoarthritis have OA in more than one joint, load bearing and non-load bearing joints. And so recognising this, the characterization of OA has changed so that it is now viewed as a heterogeneous condition. That in addition to mechanical etiology also has a metabolic or a systemic etiology. So the diagram now looks something like this with the inclusion of systemic factors in there and in particular inflammation and obesity. So the common pathology that we see in the middle of this diagram can have different ideological pathways. So once you transition to osteoarthritis in the population and some of the challenges that we have had, Lisa has already mentioned that there are many different types of arthritis, with OA being the most common. But the problem is that the most population-based health surveys focus on arthritis in general. And this has made it somewhat difficult to be able to distinguish between individuals with different ideological profiles. As well, I've said that individuals with OA can have OA in multiple joints. However, most of the epidemiological research in OA has focused on individual joints. And most commonly this has been the knee. So the special feature of the CLSA study is that it asks about OA specifically in individual joints. And in this case, the knee, the hip, and the hand. And in addition, questions are asked about joint-specific symptoms. So we believe that the CLSA offers the potential for us to look at some unique insights into OA that has not been possible with other health surveys in Canada. So against the backdrop that osteoarthritis is often perceived as an inevitable condition of aging, our goal was to understand the impact of osteoarthritis across the AIDS ranges in the CLSA. And with this in mind, our objectives were to document the prevalence of osteoarthritis, to investigate the relationship between OA, obesity, and what we are calling here metabolic comorbidities, and to document the prevalence of pain and disability in OA of the knee, hip, and hand. So the CLSA, sorry, asked participants whether a doctor had ever told them that they had osteoarthritis in the knee, in the hip, or in the hand, whether they had rheumatoid arthritis, or any other type of arthritis. For this presentation, when we talk about individuals with osteoarthritis, we're referring to individuals that responded yes to any of the knee, hip, or hand OA questions. As well, whether or not individuals reported having arthritis, they were also asked about joint symptoms during the past four weeks. So for the knee and the hip, individuals were asked about pain on most days and pain on activity, in addition to as much swelling in the knee for those individuals. For the hand, individuals were asked during the past four weeks whether they had pain in the smaller joints, the tips of the fingers, and in the base of the thumb, which we know is always quite common. There were two separate questions asked of individuals who reported, or sorry, I have to report about hand symptoms, number three and number four. Three and four for the hand were not included for what we later call symptomatic OA. So symptomatic OA here was based on all of the questions for the knee and the hip, and number one and two for the hand. So some of our findings. Osteoarthritis was certainly one of the more common conditions in this population. 26% of the CLSA respondents reported having osteoarthritis. So more than three and a half million Canadians reporting have osteoarthritis in the 45 to 85 year age group. We know that this isn't underestimates. The questions here were specific to the knee, the hip, and the hand. There were no questions about back osteoarthritis, shoulder osteoarthritis, or any other joint. For that matter, foot OA, which we know can be quite common in women. So certainly an underestimate. The prevalence of osteoarthritis is higher in women than in men, and this is common across age groups. The prevalence increases with age, and it has been this increase that has really led to that perception that osteoarthritis is a disease of older age. But what we have included here in these graphs is green line that shows the number of people with osteoarthritis. The majority of individuals reporting a diagnosis of osteoarthritis are in fact below the age of 65. And so I think that you can appreciate the implications of these individuals living 20, 30, 40 years with this painful and disabling condition. We have included here similar graphs, one based on the comprehensive sample, the other on the tracking sample. The point here was simply to show how very similar the findings were from an OA perspective. And so for the most part, the rest of the presentation looks at the pooled sample. I indicated that individuals with osteoarthritis can have OA in multiple joint sites. We see this in the CLSA as well. One third of individuals reporting osteoarthritis had it in more than one joint. The reporting of multi-site OA was common across age groups. You'll see even within the youngest age group that one fifth of individuals with osteoarthritis indeed had OA in multiple sites. If we break this down further by OA duration, we still see that irrespective of age, multi-site OA is common and irrespective of duration so that even in those individuals with a recent diagnosis and in the younger age groups, multi-site OA is common. So I introduced the OA obesity and metabolic triad, if you will, and the speculation that OA may have a systemic etiology. And if so, we hypothesized that the relationship between obesity and osteoarthritis would be stronger for those individuals with multi-joint versus single-site OA, that a higher proportion of those with multi-joint osteoarthritis would have what we are calling here metabolic syndrome-associated comorbidities, so hypertension, heart disease and diabetes. And that respondents with osteoarthritis would have a greater likelihood of having these metabolic-associated comorbidities compared to individuals who do not report a diagnosis of OA. Looking at the prevalence of obesity, the prevalence certainly higher in those individuals reporting multi-site compared to single-site osteoarthritis. Again, you'll see that this is the case across age ranges. When we look at the prevalence of these conditions that we are sort of labeling metabolic conditions, higher prevalence in those individuals reporting multi-site OA versus single-site OA. And what we've included as well here is the prevalence of these three conditions in the non-OA population. And so you'll certainly see that the prevalence is higher in those individuals with osteoarthritis. We recognize that there are going to be age distribution differences and obesity distribution differences between these groups. So what we did is we looked at using a Poisson regression analysis, looking at the outcome here is reporting a diagnosis of osteoarthritis versus not, looking at a number of factors that have been identified or have been postulated to be associated with osteoarthritis. The regression here adjusts for education, household income, smoking status, and alcohol consumption, but these are not shown here. So rather women, more likely than men to report a diagnosis of OA, increasing age, more likely to report a diagnosis of OA as we expected. Individuals who are overweight and obese, more likely to report a diagnosis of osteoarthritis. Looking at those metabolic conditions that we were interested in, the more of these metabolic conditions that were reported, the more likely an individual reported a diagnosis of osteoarthritis. And in addition, the reporting of other chronic conditions, also associated with an increased likelihood of reporting a diagnosis of OA. When we looked at the sub-sample of individuals with osteoarthritis, in the CLSA, with an interest in looking at multiple versus single site OA, women, more likely than men to report multi-site versus single site disease. For the age groups, compared to the youngest age group, older individuals are more likely to report multi-site OA. But notice here that the estimates are, in fact, quite stable across the age groups. So there wasn't very much a difference between age groups in the likelihood of reporting multiple versus single site OA. Individuals who are obese, more likely to report multiple versus single site OA. We did not find a statistically significant difference for the metabolic conditions and multi-site OA, although we certainly saw the increasing trend with increasing metabolic conditions. I wanna point out here that the sample size has been reduced compared to the previous slide that we showed you. So that, for instance, the metabolic conditions here, that three category, only 3% of individuals with OA reside in that category. So I mean, it was not unexpected that we would not find something statistically significant with the caveat as well that this is a sort of a crude representation of metabolic syndrome. And this certainly is something that would need to be refined and I know Lisa is gonna touch on this a bit in the later slide. And again, individuals with more chronic conditions were more likely to report multiple site OA versus single site. And I apologize for that to mention that these were also adjusted by SCS status and smoking and alcohol. So at this point, I'll turn this in back to Lisa to talk about the impact of OA. Okay, well, we, as Anthony, well, there's a question on symptomatic OA in the past four weeks. These are people with any size of OA who report symptoms in the joints in the last four weeks. And overall, 70% of respondents had symptoms in the last four weeks. And as perhaps might be expected, respondents with more than one joint site were more likely to have symptomatic OA. But the thing I really want to point out is this does not differ by age. For both one site and multi site OA, the proportion report of symptomatic OA is similar. So it doesn't look like that you get away as a young person and it's fairly trivial. And if you get older, it gets worse. If you have OA, you have OA. And it doesn't really matter how old you are. If you're in that 45 to 54 age group, you'll have OA. You're on average going to be as likely to be symptomatic as somebody who's 85 to 85. The other thing I want to point out because it will become important later is in that more than one site, 90% of the population have symptomatic OA. So it seems that having a way is an indicator of sort of more general severity which would sort of kind of fit in with the metabolic hypothesis. As well as asking questions about symptomatic OA, the CLSA asking general paying questions to all respondents. And these are the same questions that we're asking the Canadian Community Health Survey. So the STEM question is, are you usually free of pain or discomfort? And for those people who said no, pain severity was asked in a supplementary question. How would you describe the usual intensity of your pain or discomfort? Would you say it's more or more severe? And then limitation in activities if pain was assessed by asking whether pain or discomfort limited a non a few or some or most activities. So looking now at the impact, the answers to these questions in our OA population, we find as we joint sentence, pain has little experience in the influence of pain and the experience of pain in people with OA. And these slides that I'm showing you now are looking at pain only in people with OA, not with other conditions. Overall, 60% of the population have at least some pain, some general pain. This is not attributed to OA and arguably most of it might be OA, but we don't know. I also want to point out that the overall presence of pain in the overall population was 70%. So it's a little bit lower. So people with OA who have pain in their joints are not necessarily reporting general pain, which is something we found actually in other studies. When we look at symptomatic or non-symptomatic OA, people with symptomatic OA are lightened and higher prevalence can report pain, but even in people with non-symptomatic OA, about 40% are reporting pain. It could be due to other conditions, but likely some of it is to be brought to OA. When we look at the prevalence, respondents reporting pain by side of OA, we find that more than one site more likely to report pain. And I just want to point out here, 90% of the group with more than one site OA had symptomatic OA, and we're finding 80% or less of the population in this particular group report report any kind of general pain. So there's a bit of a discordance here. Once again, there's no age gradient. So it's not that OA gets more severe over time as you get older. If you have OA, you have pain for joints. As I indicated, there was a companion question asking about limitation in carrying out activities due to pain. This is a proportion just under 60% to report any kind of limitation on carrying out activities due to pain. I think it's actually more than a few limitations. It's once again flat with age. And when we actually look at multi-site OA and symptomatic OA, we see the same kind of patterns as we found for severity of pain. So I will not go to those in detail. So turning now to difficulty with activities. Participants in the tracking sample and in the tracking sample only were asked about the difficulties in 14 basic activities. They also said that they couldn't do these activities or the doctor had ordered them not to do them. This is only a minority and for the purposes of these slides, we've coded these people as having difficulty. So these are the top 10 of the 14 activities which people report difficulty with. The most frequent one was stooping, crouting or kneeling downward where more than half of respondents with OA reported difficulty. If you think this is something you perhaps don't do very often, let me just think about putting your socks on, feeding your pet, thinking something off the floor. We probably do this far more than we ever think we do. And the second most common activity was standing up after sitting in the chair and I presume most of you were sitting down and in a few minutes you will be standing up. And so if you have OA more than, almost half of you would have, well, 40% of you would have had some difficulty in doing this. Other activities were standing for long periods. For example, activities using the upper limb and you're using the hand arm or something to do things like grip or whole things seems to involve forces of the joints and walking up and down stairs or some problem as well as walking and mobility in general. And overall 76, three quarters of the population with OA reported having a difficulty with at least one of these and over half had more than two difficulties. And when we look by age, we see that the proportion, once again similar, paralleling the results to pain who have more than two difficulties is similar for each age group and people with one site OA have a slightly less likely to report difficulty than people having OA and more than one site. Activities in daily living were asked about in both the tracking sample and comprehension sample and we're combining majorly when people were asked about activities of daily living and instrumental activities of daily living that they could carry out without help with help or not at all. And this is, this fraternel is actually the mostly older American resources and service multi-dimensional functional assessment. And I will point out that it is being used for people who are 45 to 65. So not all this population is not by no means older population. These are some of the items in the questionnaire. The response options were help except for one item shown at the bottom of the slide which is trouble getting to the bathroom on time. And this was just a yes-no question. Do you have a trouble getting to the bathroom on time? And in fact, this was the activity that was reported most often where almost a fifth of the people with OA reported trouble getting to the bathroom on time. And trouble is more like the question on difficulty. So what we did was take this question out and insert it into the questions that we've already seen about difficulties with daily activities. And you can see on the slide shown by the pink arrows in the dark bar. This is where this activity fits in the people who have difficulty. So it would be in the top 10 of difficulties of people with OA. And it's something, in fact, when we think about mobility difficulties, it's something we often don't actually think about one of the most crucial reasons we might have for mobility is perhaps to get to bathroom on time. And this is substantial problem in people with OA. So this shows the, the next slide here shows the propulsion with all the difficulty in all these activities. You can see getting to the bathroom on time, the FNL question about trouble stands out. So what I've done in the next, I've gone to it out so we can look at the questions which report needing help. And the most frequent activity where people report needing help is doing housework. But we should also remember in fact that this is one of the activities for which it's perhaps most culturally or acceptable to ask for help or have somebody to do help. And I imagine that many people, many of you now here, actually probably pay somebody to do your housework for you. I certainly do as I was answering. So sometimes getting help in housework is a survival activity for people. So doing housework was the most frequently reported and all the other activities were reported by less than 5% of the population in terms of needing help. And if you would, can you contrast in this in your mind with the high proportion of people who had difficulty doing activities, including difficulties like that wouldn't be involved in things like walking and shopping and taking a bath? And also the high proportion of the population who reported pain because of their astro-modernity. And I'll return back to this later. So 14% overall, 14% of the population reported needing help or being able to do one of these activities. And if we exclude housework, it's 8%. So any of minority. Well, let me actually look at how this relates to the, if you like, severity of OA in terms of whether they have one site or multiple site OA. We see that those people with multiple site OA are given more severe OA or more likely to need help. And excluding the oldest age group where we slightly have a lot of comorbidity and frailty and things. Once again, there was no very little age gradient. And even these 40, and with the 45 to 64 age group to being just as likely to need help with at least one ADL as people in the older age groups. So in summary, in the population, the majority of people with OA are below the age of 65. So we can't discount this as being purely a disease of the elderly, a normal part of getting old and something that you just have to put up with an old age because that's what you get in old age. They are a substantial portion of people here who are 45 to 64. There is some evidence for a metabolic systemic component to OA. However, how we conceptualize metabolic syndrome here is very proved. We just looked at obesity in three particular conditions. We're aware that the comprehensive sample has some biologic measures and one of our future plans is to add to our results here by including the biologic measures, particularly looking at waist-to-hip ratio as well as obesity. And I can tell you that the results are pretty much the same. And also actually looking at some of the blood values, looking at cholesterol and glyphids, blood glucose, which are all part of metabolic syndrome. You've probably got tired of me telling you already that there's a little difference by age in the proportion of people with symptomatic OA, severity of pain, difficulty with activities or needing help. But this raises questions for us about the implications for aging with OA, including the implications of living for many years with pain and disability and multi-morbidity. And this perhaps is something that we need to think about when we're looking at subsequent waves of the CLSA. And secondly, and lastly, generally people with multi-joined OA would normally water soft, which has major implications both from the CLSA, but also for epidemiological studies in general. We really don't need to pay more attention to OA as a multi-joint condition, not looking separately as OA as an allost of the knee or osteoarthritis of the hand. It needs to join rheumatoid arthritis and some of the other kinds of arthritis has been recognized as something that affects many joints as you can imagine. I mean, the more joints affected, the more problems you're likely to have. In doing this, we were limited by the questions asked in the CLSA. And we had a number of things where we said, if only they had or wished they had or please could be. So first of all, a more practical question. I can understand why the CLSA asked about three joints. These are the perhaps the three most common joints or the three most talked about joints in OA. But it misses, as Anson has already pointed out, osteoarthritis in other joints. So I suggest we need to ask questions about osteoarthritis in other joints, including about osteoarthritis in the back, which is probably much neglected. I mean, in primary care, no, but in populations that is certainly yes. And another suggestion would be to do a harmonculus or a list asking about symptoms in all major joints. I mean, this has been used in the studies of living with chronic diseases as an adjunct to the SOC, or the SOC you see adjunct to the CCHS on arthritis. And it's perfectly feasible to do in this world. Anson, just the list. And this would actually enable us to look at patterns associated with multi-joint OA and actually multi-joint other arthritis. The CLSA only asked about difficulty with some basic activities to the sample and the tracking sample. The questions about ADL specific, and the questions of the tracking sample sort of general things like sort of standing stairs and things like this. The specific ADL questions, the actions of daily living questions like dressing and looking after yourself and the IADL questions like shopping and household activities were only asked about using the OZ and it was only focused on needing help. So we need to ask about difficulty with ADL and IADL. Particularly bearing in mind, the high proportion of difficulty with these basic activities, I would anticipate a high proportion of people with OA have difficulty with ADL and IADL. And particularly, I think when we actually asked about difficulty, we probably get the truer measures than we do when asking about needing help because I've already indicated needing help is partly cultural need determined and much more likely to ask for help with my housework than I am to ask for help dressing or going to an accident. So I suggest that the CLSA ask ADL, IADL difficulty questions, both as a tracking and comprehensive sample, so that we can study the evolution of dependence and frailty if you want to look at it that way and relate the statistical measures. And one possibility would be to modify the OZ questions to add a difficulty response option to be done relatively easily. And then finally, I think more generally, we need better claim measures in the CLSA because pain is relevant to many conditions and it's certainly relevant to aging and one of the major complaints in ADL. Discomfort is not the same as pain. And as I've already indicated, people may respond differently to general questions like, do you usually have pain? Is it very different from questions about do you have pain in a particular site or do you always have pain? Or do you have severe pain or do you have pain that comes and goes? So I think one of the issues, I would suggest one of the issues is to consider including a more complex pain question and including possibly the site of the pain, the quality of the pain, the temporality of the pain, temporality of the pain, whether it comes and goes, whether it's pain at rest or pain on movements and so on. So no, and I already said, I've already indicated we're going to debate more on metabolic syndrome. Our major preoccupation at the moment is our CIHR, separately analysis grants a bio-psychological social approach to understanding the impact of osteoarthritis on social participation. In doing this work or using the conceptual framework of the WHO international classification of functioning disability and health, the ICF. And our goal is to try and deconstruct the relationship between OA and social participation considering several domains. So the site of joints involved in OA, pain, activity and mobility restrictions and so on. So we expect a kind of a sequence here where osteoarthritis in the joints will lead to pain which will be associated with difficulty in general activities, which will lead to problems, for example, with mobility. And then we want to see the extent to which contextual, personal factors that's age in general and environmental factors such as social support modify these relationships. And the major issue we're grappling with is how to operationalize participation. I was going to, in the fair, we said we'd talk about our work on giving and receiving help and sort of kind of taste it for what we're doing. Unfortunately, when we put all these together, we finally just didn't have time until we got to talk about that on another occasion. So finally, in acknowledgement, we acknowledge funding from our CHR friends and also from the arthritis society who through a service contract gave us funding to help document the impact of our privacy population. And in particular, thanks for going to our Research Associates Stone Mill Standard Shop in Zip. Yep, for carrying out a lot of these analyses for us and continuing to work with us on these questions. So I turn now, I'm going to you for your questions. Thank you. Do we have to do anything now? No, just stand by for one second. Okay. Carol, it seems that you're muted. Sorry about that. Thank you very much for your excellent presentation. I really enjoyed it. We now open the session up for questions. A reminder that everybody's mute remains on, but you can enter your question into the chat box from the bottom right corner of the Webex window and we'll address your question that way. If you want to be identified, go ahead and there as well. Or your affiliate, I guess the question is... Yes, of course. Which section is gone there? Yeah, so we're confident that it's in underestimates by only focusing on the hand, hip and knee. The literature sort of suggests that the prevalence of back OA probably rivals that of knee OA. They're sort of jockeying for position between the most prevalent and it's always been between the knee and the back. So I mean, it's a prevalence sort of half more than what we see there because the back has been excluded. Foot OA and particularly amongst women is a big problem but it's been missed here. So from the perspective of trying to understand the impact of the disease at a population level and how it may relate to some of those outcomes that Lisa had presented, but also to understand the systemic components to OA, we really need to know how many joints are involved. And again, our hypothesis is that if the systemic etiology is one of the pathways, it is more likely that there will be multi-joint OA. But if we don't ask about OA in all the joints, then it's a bit tough to answer that question. So this is why one of our sort of suggestions for future CLSA surveys would be that it's asked of in every joint. The second question here is about the Western Ontario McMaster's University Osserecthoritis Index, WOMAC. Are you familiar with that? And it's not through the CLSA. No, it doesn't appear in the CLSA. So for those who don't know, so the WOMAC is a joint specific and OA specific measure of lower extremity pain and sorry, when I say lower extremity, I should say just hip and knee so it does not include anything else. So pain and physical function measure in OA. So no, it does not appear in the CLSA. Although that would have been quite nice, but no. Yeah, it's a physical function. One asks about pain and on things like getting out of the chair and climbing stairs. It was developed specifically for OA but actually could be relevant to other conditions. So it kind of gets at that. You're concerned about asking about the difficulties with activities, not just the needing help for. Correct. And in terms of the moment, it seems to be the industry standard, the WOMAC, in terms of studies of OA in the population, particularly around joint location. So that's kind of where you would be heading if you could guide more information for asking about difficulties with the activities that type of thing? Not necessarily the WOMAC, but a question that I asked about difficulty in sort of the important ADL and IADL and there are several of those. I mean, it's not just the WOMAC because I think I'm aware that the CLSA covers all conditions and it's also becoming more aware of the time of the importance of comorbidities. Correct. Because people get older, they acquire more and more comorbidities. So it's not like we're looking at joint replacement population where by large people may have other conditions but you're focusing just on the arthritis. I mean, one of the big challenges I think is to look at where osteoarthritis fits within the whole package of comorbidities that people have. And it's often one that tends to get neglected because some of the other conditions, for example, I mean, arguably things like diabetes, are much more salient to individuals. We talk about them a lot more, but when we actually look at the, what's the cause of the difficulty that people have in daily life? It's not the case, but the fact that you have heart disease, you have diabetes and OA could well contribute to making a lot of conditions worse. But we just don't understand this because we haven't heard of it. That's what the next few moments will be. I'm sorry, it seems like you're kind of fading in and out. So hopefully we'll keep you here for the rest of the QA session, but we are having a little bit of problems hearing you, I think. So I think maybe that leads kind of future directions particularly if you get the longitudinal nature of the data, which is kind of what happened, particularly for these younger adults, older adults, 45-year-olds who have young, long-term projects right at home. And what kind of... Sorry, you're broken up. We can't hear what's being said. I can hear you. Sorry about the difficulties. I wonder if there's an issue with the WebEx function. Carol, would you mind repeating the question one more time? Sure. Can the speakers hear me? We're very, very patchy trying to talk to our presenters. So one of the things that we can do as an alternative if it's helpful is that we can moderate the questions through the chat function. So for Lisa and Anthony, one of the things that we'll do is send you the questions via the chat function. And if you're comfortable typing the answers or typing a shortened version of the answers, we can do that. But let's try periodically to test the audio and see if we can get it back up and running. And to the attendees, I apologize for the difficulties that we're having. Hopefully, it'll get sorted out quickly. Can you hear us? Hello. There you go. That sounds very good now. Sounds like you're back, so. Can you hear us? Okay. Can you hear us? We can hear you. Causing mechanical damage, or do you think that there are other pathways? So I think part of the issue with metabolic syndrome can be, yes, the excess weight and the excess load-in. The other is that metabolic syndrome has been associated with low-grade systemic. I apologize, Anthony. It seems as though you've cut out again. Well, we'll thank our presenters. And maybe plan to take some questions. We're welcoming Dr. Christina Wolfen from McGill University.