Arthritis

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• Arthritis

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Osteoarthritis Overview and Risk Factors

• Osteoarthritis (OA), also known as degenerative
  joint disease, is the most common joint disorder.
  
• Characterized by hyaline cartilage degeneration
  and subchondral bone hypertrophy within a joint.
• Unlike rheumatoid arthritis, OA usually produces
  minimal inflammation.

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OA Overview (2)

• In severe cases, the articular joint surface may
  be destroyed, with resultant pain and disability.
• OA may be idiopathic or secondary
• Secondary forms
• endocrine abnormalities (e.g., hypothyroid,
  diabetes mellitus)
• other joint diseases (RA, gout, infection)
• bone pathology (avascular necrosis, Pagets
  disease).

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Symptoms and Common Sites of OA

• People with osteoarthritis usually experience
  joint pain and stiffness.
• Most commonly affected joints are interphalangeal
  joints of fingers (Heberdens and Bouchards
  nodes), thumbs, neck, lower back, knees, and
  hips.
• OA rarely affects elbow, wrist, ankle, shoulder,
  and TMJ.

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OA Risk Factors

• Obesity
• Knee and hip joints are particularly vulnerable
  in obese individuals
• Age
• Rare in young, common in middleaged and older
  adults.
• 1/3 of people older than 65 years have
  radiographic evidence of osteoarthritis in the
  knee

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OA Risk Factors (2)

• Female gender
• Adjusted relative risk equal to 2.6 X men
• Cause unclear
• Occupation
• Hands, hips, and knees
• Genetics
• Trauma
• More likely localized OA than generalized

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OA Risk Factors (3)

• Preexisting or anatomical joint abnormality
• Poor proprioception and/or quadriceps weakness
• Knee laxity

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Healthy Knee Joint
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Arthritic Knee Joint
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Arthritis Foundation on Diet

• Diet affects overall health
• Best to follow diet low in saturated fats and
  calories and rich in fruits, vegetables and
  grains.
• No specific diet for arthritis
• Despite myths, there are some ways that diet may
  affect your arthritis

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Arthritis Foundation (2)

• Food sensitivities
• Small number of people with arthritis might be
  sensitive to certain foods that could trigger
  symptoms or cause them to worsen.
• Avoid diet high in saturated fats or vegetable
  oils
• Can increase inflammatory response, contribute to
  joint and tissue inflammation.

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Arthritis Foundation (3)

• Overall health
• Diet affects overall health and affects other
  diseases such as diabetes or heart disease.
• This, in turn, may affect how the body handles
  arthritis symptoms.
• Weight
• Diets that lead to overweight or obesity make
  arthritis more likely and/or more severe.

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Andrew Weil on Diet and Arthritis

• Decrease protein toward 10 percent of daily
  caloric intake.
• Replace animal protein as much as possible with
  plant protein.
• Eliminate milk and milk products, substituting
  other calcium sources.

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Weil on Diet and Arthritis (2)

• Eliminate polyunsaturated vegetable oils,
  margarine, vegetable shortening, all partially
  hydrogenated oils, and all foods that might
  contain trans-fatty acids (such as deep-fried
  foods).
• Use extra-virgin olive oil as your main fat.
• Increase intake of omega-3 fatty acids.
• Eat ginger and turmeric regularly, both of which
  are natural anti-inflammatories.

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Glucosamine and Chondroitin

• Glucosamine is found in high concentrations in
  joints
• Believed to stimulate the formation of cartilage
  that is essential for joint repair

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Chondroitin

• Chondroitin sulfate found in cartilage
• Draws fluid into the tissue, giving the cartilage
  resistance and elasticity.
• In vitro, chondroitin sulfate stimulates the
  formation of components for new cartilage and
  slows cartilage breakdown.

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Arthritis Foundation Advice on Glucosamine and
Chondroitin

• Chondroitin and glucosamine supplements appear to
  be more effective in patients with osteoarthritis
  than in people with inflammatory diseases such as
  rheumatoid arthritis.
• The supplements might lessen pain in 30-50 of
  patients with osteoarthritis.
• European research has shown that people with OA
  who took 1500 mg of glucosamine a day had the
  same level of pain relief as those who took
  painkilling drugs such as ibuprofen.

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AF on G C Supplements (2)

• A few studies show 1200 mg of chondroitin a day
  same level of pain relief as ibuprofen and
  diclofenac (Voltaren).
• Currently no research that shows whether greater
  relief occurs when both glucosamine and
  chondroitin are taken together.

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JAMA 2000 Meta-analysis on GC for Knee and Hip OA

• Trials of glucosamine and chondroitin for OA
  symptoms demonstrate moderate to large effects,
  but quality issues and likely publication bias
  suggest that these are exaggerated. Nevertheless,
  some degree of efficacy appears probable for
  these preparations.
• McAlindon et al. JAMA 20002831469-1475

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JAMA Meta-analysis (2)

• Effect smaller at 4 weeks
• May need longer for full effect
• Even modest efficacy would have clinical value,
  given the safety of these preparations.

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Poolsup et al Systematic Review on Glucosamine
(2005)

• The available evidence suggests that glucosamine
  sulfate may be effective and safe in delaying the
  progression and improving the symptoms of knee
  OA. Due to the sparse data on structural efficacy
  and safety, further studies are warranted.
• Annals of Pharmacotherapy 2005 Vol. 39, No. 6,
  pp. 1080-1087.

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Cochrane Review of Glucosamine

• Pooled results from studies using a non-Rotta
  preparation failed to show benefit in pain and
  WOMAC function
• WOMAC involves pain, disability and joint
  function
• Studies using Rotta glucosamine superior to
  placebo in the treatment of pain and functional
  impairment resulting from symptomatic OA.
• But WOMAC outcomes of pain, stiffness and
  function did not show a superiority of
  glucosamine over placebo for both Rotta and
  non-Rotta preparations of glucosamine.
• http//www.cochrane.org/reviews/en/ab002946.html

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Rotta Type Glucosamine

• Rotta Research Group invented and patented method
  to stabilize glucosamine sulfate, through a
  chemical process of co-precipitation with sodium
  chloride, thus obtaining Crystalline Glucosamine
  Sulfate.
• Crystalline Glucosamine Sulfate is the active
  ingredient that has been investigated in more
  than 150 pre-clinical and clinical studies, and
  to which over 90 of the scientific literature
  refers.

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Confused?

• Dr. Redwoods Glucosamine Summary
• Many people with OA are clearly helped
• Studies vary on the extent of this help
• Systematic reviews endorse efficacy of at least
  some preparations
• Glucosamine appears to be quite safe
• Common dosage is 1500 mg/day for several weeks

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Systematic Review of Other Supplements for OA

• 2006 review on all nutritional supplements except
  glucosamine and chondroitin
• Nutrition can improve the symptoms of OA.
• Role of nutrition in slowing down progression of
  the disease not yet demonstrated.

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Systematic Review (2)

• Very few RCTs used structure-modifying variables
  as primary endpoints, and these were unable to
  demonstrate a benefit.
• As a whole, nutritional research in OA is only in
  its infancy.
• Ameye and Chee. Arthritis Research Therapy
  2006, 8R127.
• Online http//arthritis-research.com/content/8/4
  /R127

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Systematic Review (3)

• Good evidence for ASU avocado soybean
  unsaponifiables
• Moderate evidence for methylsulfonylmethane (MSM)
  and SKI306X, a cocktail of plant extracts.
• Limited evidence for Chinese plant extract Duhuo
  Jisheng Wan, cetyl myristoleate
• Limited evidence for green-lipped mussels, and
  plant extracts from Harpagophytum procumbens
  (Devils claw)

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Symptoms vs. Structural Change

• Important to note that studies indicating benefit
  for arthritis from supplements other than
  glucosamine and chondroitin refer to symptom
  improvements (pain, stiffness, etc.), NOT
  structural improvement in the joint.

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NIAMS Summary of Rheumatoid Arthritis

• Causes pain, swelling, stiffness and loss of
  function in joints.
• Inflammatory, autoimmune
• Can affect any joint but is common in the wrist
  and fingers.
• Women 2-3x more than men
• Often starts between ages 25 and 55.
• Most common in old. Can afflict the young.
• May last only a short time, or may come and go.

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NIAMS on RA (2)

• The severe form can last a lifetime.
• Can affect body parts besides joints
• Eyes, mouth, lungs

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NIAMS Recommends Lifestyle Changes

• Lifestyle changes can help
• Keep a good balance between rest and exercise
• Take care of your joints
• Lower your stress
• Eat a healthy diet

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RA Etiology and Presentation

• Etiology unknown, likely involves interaction of
  genetic and environmental factors.
• The typical presentation gradual onset of
  polyarticular symmetric arthritis of the small
  joints
• Pain, morning stiffness, and joint swelling.
• Early articular sites
• Metacarpophalangeal and proximal interphalangeal
  joints
• Metacarpophalangeal and interphalangeal joints of
  the thumbs
• Wrists
• Metatarsophalangeal joints of the toes.

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RA Diagnosis

• There is no single test for the disease
• The symptoms can overlap other kinds of joint
  disease
• History, exam, x-ray (joint erosion)
• Lab
• RA factor
• Inflammatory markers ESR, CRP

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Extra-articular RA

• Dry eye syndrome
• up to 50 of patients
• Pericarditis
• Episcleritis, scleritis,
• Subcutaneous nodules
• Fatigue, mild anemia

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Medications for RANutrition vs. Side Effects

• People on long-term steroid therapy may benefit
  from calcium, vitamin D, and weight bearing
  exercise re prevention and treatment of
  osteoporosis.
• Those on methotrexate (a folate antagonist)
  should take extra folic acid

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WebMD Article on Nutrition and RA (1999)

• Ronenn Roubenoff, MD, nutritionist, Tufts
  University School of Medicine speech to American
  College of Rheumatology
• Reduced muscle mass gt need more protein plus
  resistance exercise
• www.webmd.com/news/19991119/nutrition-changes-br
  ing-relief-rheumatoid-arthritis

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Roubenoff (2)

• People with rheumatoid arthritis not only have
  increased free radicals, but reduced vitamin E,
  C, and beta carotene
• Recommends diet high in fruits and vegetables
• Supplement vitamins listed above
• Fish oil or borage oil
• Check whether nightshade vegetables are a trigger
  (1-2 of RA)

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American Dietetic Association Vegetarian
Nutrition Practice Group

• www.andrews.edu/NUFS/arthritis.html
• Triggers of RA symptoms (anecdotal) dairy
  protein, corn, wheat, citrus fruits, eggs, red
  meat, sugar, fats, salt, caffeine, and nightshade
  plants like potatoes and eggplant.
• Try elimination diet, re-introduce foods one at a
  time

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Norweigian Study(Lancet, 1991)

• Vegetable juice fast for 7-10 days
• Next vegan diet excluding gluten, refined sugar,
  citrus fruits, alcohol, coffee, tea, salt, strong
  spices and preservatives.
• After 3 to 5 months, experimental group slowly
  progressed to lacto-vegetarian diet for the
  remainder of year

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Norweigian Lancet Study (2)

• Then added back milk, other dairy foods, and
  gluten every second day.
• Control group consumed an ordinary mixed food
  diet.
• Kjeldsen-Kragh. Controlled trial of fasting and
  one-year vegetarian diet in rheumatoid arthritis.
  Lancet 1991338899-902.

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Lancet Study Results (2)

• After four weeks, significant improvements as
  measured by tender and swollen joints, pain,
  duration of morning stiffness, grip strength, and
  changes in their overall health assessment.
• Improvements maintained in experimental subjects
  throughout the the study.
• Group on the vegetarian diet had a significantly
  lower ESR and CRP.
• Improvements largely sustained at 2 yrs

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Vegan and Vegetarian Diets and RA

• Patients who follow vegan or vegetarian diets may
  experience significant improvement in rheumatoid
  arthritis symptoms.
• Improvement in laboratory values (rheumatoid
  factor, CRP) is a frequent finding on these
  diets, and correlates with a reduction in
  antibodies to food antigens

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References for Previous Slide

• McDougall J, Bruce B, Spiller G, Westerdahl J,
  McDougall M. Effects of a very lowfat, vegan
  diet in subjects with rheumatoid arthritis. J
  Altern Complement Med. 200287175.
• Hafstrom et al. A vegan diet free of gluten
  improves the signs and symptoms of rheumatoid
  arthritis the effects on arthritis correlate
  with a reduction in antibodies to food antigens.
  Rheumatology (Oxford). 20014011751179.

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Meat and RA

• Higher intakes of meat and elevated serum
  cholesterol concentrations are associated with
  increased risk of developing RA.
• Pattison et al. Dietary risk factors for the
  development of inflammatory polyarthritis
  evidence for a role of high level of red meat
  consumption. Arthritis Rheum. 20045038043812.
• Grant WB. The role of meat in the expression of
  rheumatoid arthritis. Br J Nutr. 200084589595.
• Heliovaara et al. Serum cholesterol and risk of
  rheumatoid arthritis in a cohort of 52,800 men
  and women. Br J Rheumatol. 199635255257.

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Fatty Acids and Rheumatoid Arthritis

• A diet low in arachidonic acid, an omega6 fatty
  acid found in animal products, can decrease
  inflammation in patients with RA. 
• This effect was strengthened by omega3 fatty
  acid supplementation.
• Adam et al. Antiinflammatory effects of a low
  arachidonic acid diet and fish oil in patients
  with rheumatoid arthritis. Rheumatol Int. 2003
  32736.

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Fatty Acids and RA (2)

• Lower incidence of arthritis in Mediterranean
  countries, which may be attributable to olive oil
  intake
• Possibly because this fat negates the production
  of proinflammatory chemicals that affect RA
  patients.
• Linos et al. Dietary factors in relation to
  rheumatoid arthritis a role for olive oil and
  cooked vegetables? Am J Clin Nutr.
  19997010771082.

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Fatty Acids and RA (3)

• Supplementing with gammalinolenic acid (GLA)
  found effective for reducing the symptoms of RA
• GLA present in oils of borage, evening primrose,
  black currant and hemp
• Little C, Parsons T. Herbal therapy for treating
  rheumatoid arthritis. Cochrane Database Syst Rev.
  2001CD002948.

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More on Fatty Acids

• Supplementing with GLA plus omega3s reduces
  symptoms and decreases need for NSAIDs in RA
  patients.
• Lau et al. Effects of fish oil supplementation on
  nonsteroidal antiinflammatory drug requirement
  in patients with mild rheumatoid arthritisa
  doubleblind placebo controlled study. Br J
  Rheumatol. 199332982989.
• Belch et al. Effects of altering dietary
  essential fatty acids on requirements for
  nonsteroidal antiinflammatory drugs in patients
  with rheumatoid arthritis a double blind placebo
  controlled study. Ann Rheum Dis. 19884796104.