Diets, dietary supplements, and nutritional therapies in rheumatic diseases

Understanding the Role and Uses of Alternative Therapies for Management of Rheumatoid Arthritis

With growing popularity of complementary and alternative medicine (CAM) among the individuals with chronic pain and muscular problems, a number of patients with rheumatoid arthritis (RA) show their interest in CAM interventions for disease improvement. Various reports published on CAM are based on animal model of RA however there is often lack of high quality clinical investigations for explaining the success stories of CAM therapies in patients with RA. CAMs having potential to be used for therapy in patients with RA have been identified, however lack of awareness and scepticism of their efficacy has made the patients reluctant to choose these drug less therapies. In this review, we have summarized the existing evidences which suggest promising efficacy of different alternative therapies in managing RA and providing both physical and mental well being to RA patients.

Effect of Boswellia Serrata Extract on Acute Inflammatory Parameters and Tumor Necrosis Factor-α in Complete Freund's Adjuvant-Induced Animal Model of Rheumatoid Arthritis

Context

The worldwide prevalence of rheumatoid arthritis (RA) is about 1%, whereas in India, it is approximately 0.75%. The current therapy for RA includes nonsteroidal anti-inflammatory drugs corticosteroids, disease-modifying anti-rheumatic drugs and some recently developed biologic agents, but all of these are associated with adverse effects. Some herbal drugs, such as Boswellia serrata, have been reported to possess anti-inflammatory activity.

Aims

The aim of this study is to evaluate the anti-arthritic activity of Boswellia serrata extract (BSE) in complete Freund's adjuvant (CFA)-induced arthritis in rats.

Materials and Methods

Thirty-six Wistar rats were divided into six equal groups. RA was induced by intradermal injection of 0.1 ml CFA in hind paw. Body weight, ankle diameter, paw volume, arthritic index, tumor necrosis factor-α (TNF-α), and histopathological examination were assessed. The experimental data were statistically assessed by one-way analysis of variance (ANOVA).

Statistical Analysis Used

The recorded data were analyzed using paired t-test and ANOVA test using SPSS. The data were analyzed and represented as mean difference. Value of P < 0.05 was considered statistically significant.

Results

BSE at dose 180 mg/kg showed statistically significant improvement in body weight and decrease in ankle diameter and arthritic index (P < 0.05); however, there was insignificant change in paw volume (P = 0.056). This improvement was comparable with Indomethacin. The level of TNF-α did not show any statistically significant change (P = 0.076). Histopathological results also exhibited a reduction in inflammatory parameters.

Conclusions

BSE might have usefulness as an adjunct to conventional therapy of RA.

The impact of nutrition and generally available products such as nicotine and alcohol on rheumatoid arthritis - review of the literature

Nutrition habits and diet may influence disease development and course. There are no specific recommendations related to rheumatic diseases for a diet that would facilitate treatment. However, some research results suggest that various nutrients may affect the health of patients, especially in the case of inflammatory rheumatic disease such as rheumatoid arthritis (RA). Scientists have been trying to find a relation between inflammatory rheumatic diseases and diet but have never come up with any firm conclusions that would help in determining the model of a diet for such patients. Nevertheless, there are some consistent results that refer to the influence of nutritional behaviours on symptoms of RA. The article presents a review of the research showing that certain nutrients may be beneficial for the course of disease among some RA patients.

Muscle wasting in rheumatoid arthritis: The role of oxidative stress

Rheumatoid arthritis (RA), the commonest inflammatory arthritis, is a debilitating disease leading to functional and social disability. In addition to the joints, RA affects several other tissues of the body including the muscle. RA patients have significantly less muscle mass compared to the general population. Several theories have been proposed to explain this. High grade inflammation, a central component in the pathophysiology of the disease, has long been proposed as the key driver of muscle wasting. More recent findings however, indicate that inflammation on its own cannot fully explain the high prevalence of muscle wasting in RA. Thus, the contribution of other potential confounders, such as nutrition and physical activity, has also been studied. Results indicate that they play a significant role in muscle wasting in RA, but again neither of these factors seems to be able to fully explain the condition. Oxidative stress is one of the major mechanisms thought to contribute to the development and progression of RA but its potential contribution to muscle wasting in these patients has received limited attention. Oxidative stress has been shown to promote muscle wasting in healthy populations and people with several chronic conditions. Moreover, all of the aforementioned potential contributors to muscle wasting in RA (i.e., inflammation, nutrition, and physical activity) may promote pro- or anti-oxidative mechanisms. This review aims to highlight the importance of oxidative stress as a driving mechanism for muscle wasting in RA and discusses potential interventions that may promote muscle regeneration via reduction in oxidative stress.

Bone mass and quality in patients with juvenile idiopathic arthritis: longitudinal evaluation of bone-mass determinants by using dual-energy x-ray absorptiometry, peripheral quantitative computed tomography, and quantitative ultrasonography

Introduction

Our objective was to evaluate longitudinally the main bone-mass and quality predictors in young juvenile idiopathic arthritis (JIA) patients by using lumbar spine dual-energy X-ray absorptiometry (DXA) scan, radius peripheral quantitative computed tomography (pQCT), and phalangeal quantitative ultrasonography (QUS) at the same time.

Methods

In total, 245 patients (172 females, 73 males; median age, 15.6 years: 148 oligoarticular, 55 polyarticular, 20 systemic, and 22 enthesitis-related-arthritis (ERA) onset) entered the study. Of these, 166 patients were evaluated longitudinally. Data were compared with two age- and sex-matched control groups.

Results

In comparison with controls, JIA patients, but not with ERA, had a reduced spine bone-mineral apparent density (BMAD) standard deviation score (P < 0.001) and musculoskeletal deficits, with significantly lower levels of trabecular bone mineral density (TrabBMD) (P < 0.0001), muscle cross-sectional area (CSA) (P < 0.005), and density-weighted polar section modulus (SSIp) (P < 0.05). In contrast, JIA showed fat CSA significantly higher than controls (P < 0.0001). Finally, JIA patients had a significant reduced amplitude-dependent speed of sound (AD-SoS) (P < 0.001), and QUS z score (P < 0.005).

Longitudinally, we did not find any difference in all JIA patients in comparison with baseline, except for the SSIp value that normalized. Analyzing the treatments, a significant negative correlation among spine BMAD values, TrabBMD, AD-SoS, and systemic and/or intraarticular corticosteroids, and a positive correlation among TNF-α-blocking agents and spine BMAD, TrabBMD, and AD-SoS were observed.

Conclusions

JIA patients have a low bone mass that, after a first increase due to the therapy, does not reach the normal condition over time. The pronounced bone deficits in JIA are greater than would be expected because of reduction in muscle cross-sectional area. Thus, bone alterations in JIA likely represent a mixed defect of bone accrual and lower muscle forces.

Cross-sectional and Longitudinal Evaluation of Bone Mass in Children and Young Adults with Juvenile Idiopathic Arthritis: The Role of Bone Mass Determinants in a Large Cohort of Patients

Objective.

To assess the prevalence of reduced spine bone mineral apparent density (BMAD), and to identify the main predictors of reduced spine BMAD in a cross-sectional and longitudinal evaluation of the same large cohort of patients with juvenile idiopathic arthritis (JIA). There are few prospective data on bone mass evaluation in a large number of patients with JIA, and with enthesitis-related arthritis onset.

Methods.

Two hundred nineteen patients with JIA (median age 8.7 yrs, range 6.1–13.1 yrs; 104 oligoarticular JIA, 61 polyarticular, 20 systemic, and 34 enthesitis-related arthritis onset) were retrospectively evaluated. A dual-energy x-ray absorptiometry (DEXA) scan at the lumbar spine was performed in all subjects. Of these, 89 consecutive patients were followed up randomly and longitudinally with a second and a third DEXA evaluation. The data obtained were compared with 80 age-matched and sex-matched healthy subjects.

Results.

At the first DEXA, patients with JIA showed a reduced spine BMAD standard deviation score (SDS) in comparison to controls (p < 0.001). These results were confirmed when the subjects were divided into JIA subtypes (p < 0.005) with the exception of enthesitis-related arthritis onset. Spine BMAD SDS significantly correlated with JIA onset type (p < 0.01), age at JIA onset (p < 0.005), and flares (p = 0.008). The longitudinal evaluation showed that spine BMAD SDS did not significantly improve at the followup in comparison to controls, in all subsets with JIA except for systemic onset (p < 0.05). Spine BMAD correlated with sex (p < 0.01), systemic corticosteroid exposure (p < 0.01), the number of intraarticular corticosteroid injections (p < 0.01), the interval from last steroid injection (p < 0.05), erythrocyte sedimentation rate (p < 0.005), and C-reactive protein levels (p < 0.005).

Conclusion.

Patients with JIA have a low bone mass and, after a first increase due to therapy, do not reach a healthy condition over time despite our current more effective drugs. These patients have a high risk of osteoporosis in early adulthood. To reduce the risk and improve the bone mass, close monitoring of bone mineral density, better control of disease activity, physical activity, and intake of calcium and vitamin D are recommended. In patients with osteoporosis, therapeutic approaches including bisphosphonates should be considered.

Racial/Ethnic Differences in the Use of Complementary and Alternative Medicine in Patients With Arthritis

OBJECTIVE

To examine use of complementary and alternative medicine (CAM) by individuals with osteoarthritis (OA) from 4 ethnic groups, differences in CAM use among groups, and correlates of CAM use.

METHODS

Data were obtained from individuals from 4 ethnic groups (African, Asian, and Hispanic Americans, and Caucasians) participating in trials assessing celecoxib efficacy. A questionnaire assessing CAMs specifically used to help arthritis was administered at screening. Use of 42 specific therapies within 7 categories-alternative medical systems, mind-body interventions, manipulation and body-based methods, energy therapies, and 3 types of biologically based therapies--was queried.

RESULTS

More than 80% of subjects reported that they used some CAM for arthritis in the past month. In contrast, 50% reported the use of prescription medicines, and 52% reported the use of over-the-counter medicines. Dietary practices were the most common type of CAM (71.5%), followed by mind-body interventions (42.4%), topical agents (38.1%), use of supplements or herbs (32.9%), and manipulation and body-based methods (21.4%). African Americans were more likely to report any CAM use than other groups (89.1% versus 83.1% [Asian], 81.1% [Hispanic], 77.7% [Caucasian]). African and Asian Americans more commonly reported the use of mind-body interventions in general, and prayer in particular. African Americans were also most likely to report the use of topical agents. Asian Americans were most likely to report use of alternative medical systems, manipulation methods, and supplements. Caucasians were least likely to report use of dietary practices.

CONCLUSION

Individuals with OA commonly use CAM. Use of these therapies varies by racial/ethnic group. Some CAMs may be effective for symptom relief, while others may interact with prescription medications, suggesting that routine queries by physicians concerning CAM use would be beneficial.

Use of herbal preparations in the treatment of oxidant-mediated inflammatory disorders

Complementary and alternative medicine (CAM) use has increased in popularity in recent years and herbal therapy alone is now a billion dollar market. For centuries herbs have been used as food and for medicinal purposes. Various herbs have been identified as possessing anti-inflammatory and antioxidative properties, and they are currently being used to treat inflammatory disorders as well as those caused by reactive oxygen species (ROS). Asthma, Alzheimer's disease, inflammatory bowel disease (IBD), rheumatoid arthritis (RA), and atherogenesis are all disorders where inflammation and ROS are involved in their pathogenesis. This review examines the pathogenesis of the above mentioned ROS-mediated inflammatory disorders, as well as discusses the antioxidant and anti-inflammatory mechanisms of various herbs and the clinical trials where herbs have been used to treat these disorders.

Complementary and Alternative Pain Therapy in the Emergency Department

One primary reason patients go to emergency departments is for pain relief. Understanding the physiologic dynamics of pain, pharmacologic methods for treatment of pain, as well CAM therapies used in treatment of pain is important to all providers in emergency care. Asking patients about self-care and treatments used outside of the emergency department is an important part of the patient history. Complementary and alternative therapies are very popular for painful conditions despite the lack of strong research supporting some of their use. Even though evidenced-based studies that are double blinded and show a high degree of interrater observer reliability do not exist, patients will likely continue to seek out CAM therapies as a means of self-treatment and a way to maintain additional life control. Regardless of absolute validity of a therapy for some patients, it is the bottom line: "it seems to help my pain." Pain management distills down to a very simple endpoint, patient relief, and comfort. Sham or science, if the patient feels better, feels comforted, feels less stressed, and more functional in life and their practices pose no health risk, then supporting their CAM therapy creates a true wholistic partnership in their health care.CAM should be relatively inexpensive and extremely safe. Such is not always the case, as some patients have discovered with the use of botanicals. It becomes an imperative that all providers be aware of CAM therapies and informed about potential interactions and side effects when helping patients manage pain and explore adding CAM strategies for pain relief. The use of regulated breathing, meditation, guided imagery, or a massage for a pain sufferer are simple but potentially beneficial inexpensive aids to care that can be easily employed in the emergency department. Some CAM therapies covered here, while not easily practiced in the emergency department, exist as possibilities for exploration of patients after they leave, and may offer an improved sense of well-being and empowerment in the face of suffering and despair. The foundations of good nutrition, exercise, stress reduction, and reengagement in life can contribute much to restoring the quality of life to a pain patient. Adding nondrug therapies of physical therapy, cognitive-behavioral therapy, TENS, hypnosis, biofeedback, psychoanalysis, and others can complete the conventional picture. Adding in simple mind/body therapies, touch therapies, acupuncture, or others may be appropriate in select cases, and depending on the circumstances, may effect and enhance a conventional pain management program. Armed with an understanding of pain dynamics and treatments, practitioners can better meet patient needs, avoid serious side effects, and improve care when addressing pain management in the emergency department.

Oxidative stress and nutritional prevention in autoimmune rheumatic diseases

The hypothesis that oxidative stress favours flogistic and immune processes inducing autoimmune rheumatic diseases (ARDs) and their complications is still under discussion. In this review we take into consideration both the aetiopathological role of the diet in such diseases and the possible efficacy of dietary supports as adjuvants for the usual specific therapies. Moreover, we shall examine the hypothetical pathophysiological role of oxidative stress on ARDs and their complications, the methods for its evaluation and the possibility of intervening on oxidative pathways by means of nutritional modulation. It is possible that in the future we will be able to control connective pathology by associating an immuno-modulating therapy ('re-educating') with natural products having an anti-oxidant activity to current immunosuppressive treatment (which has potentially toxic effects).

Nutritional management of rheumatoid arthritis: a review of the evidence

Rheumatoid arthritis (RA) is a debilitating disease and is associated with increased risk of cardiovascular disease and osteoporosis. Poor nutrient status in RA patients has been reported and some drug therapies, such as nonsteroidal anti-inflammatory drugs (NSAIDs), prescribed to alleviate RA symptoms, may increase the requirement for some nutrients and reduce their absorption. This paper reviews the scientific evidence for the role of diet and nutrient supplementation in the management of RA, by alleviating symptoms, decreasing progression of the disease or by reducing the reliance on, or combating the side-effects of, NSAIDs. Supplementation with long-chain n-3 polyunsaturated fatty acids (PUFA) consistently demonstrates an improvement in symptoms and a reduction in NSAID usage. Evidence relating to other fatty acids, antioxidants, zinc, iron, folate, other B vitamins, calcium, vitamin D and fluoride are also considered. The present evidence suggests that RA patients should consume a balanced diet rich in long-chain n-3 PUFA and antioxidants. More randomized long-term studies are needed to provide evidence for the benefits of specific nutritional supplementation and to determine optimum intake, particularly for n-3 PUFA and antioxidants.

Nutrient intake in women with primary and secondary Sjögren's syndrome

OBJECTIVE

Recently, it has been proposed that dietary factors may contribute to the etiology and progression of Sjögren's syndrome, and that nutritional intervention may modify the severity of pathological abnormalities. The objective of this study was to determine whether the nutrient intake of women with primary (1 degrees SS) or secondary (2 degrees SS; ie with systemic lupus erythematosus (2 degrees SS/SLE) or rheumatoid arthritis (2 degrees SS/RA) Sjögren's syndrome is significantly different than that of age- and gender-matched controls.

DESIGN

Women with Sjögren's syndrome were asked to complete the 97 General Purpose Semi-Quantitative Food Frequency Questionnaire, which consists of a list of 147 separate food items that represent the major sources of multiple nutrients. Nutritional data were evaluated in terms of absolute and energy-adjusted nutrient amounts and analyzed by ANOVA.

RESULTS

Our results showed: (a) greater intake of energy, glutamate, carbohydrates, lactose, phosphorus, caffeine and unsupplemental thiamin and riboflavin in 1 degrees SS, as well as supplemental calcium in 2 degrees SS/SLE, compared with controls; (b) greater nutrient intake of energy, protein, glutamate, methionine, tryptophan, carbohydrates, lactose, supplemental calcium and phosphorus, sodium, caffeine and unsupplemental calcium, riboflavin and thiamin in 2 degrees SS/RA, relative to 1 degrees SS and/or 2 degrees SS/SLE; (c) higher energy-adjusted values for supplemental calcium in 2 degrees SS/SLE, and for vitamin A and supplemental iron and zinc in 2 degrees SS/RA, compared with other groups; and (d) higher energy-adjusted intake of supplemental calcium, and a lower energy-adjusted intake of unsupplemental vitamin C, polyunsaturated fat, linoleic acid, omega-3 fatty acid, and specific other unsaturated fatty acids, in the Sjögren's syndrome group as a whole, relative to controls.

CONCLUSIONS

Our findings demonstrate that nutrient intake is altered in Sjögren's syndrome.

Elk velvet antler in rheumatoid arthritis: phase II trial

The purpose of this phase II clinical trial was to examine safety of elk velvet antler taken concurrently with rheumatoid arthritis medications and to determine efficacy by dose to enable sample size estimation and dose standardization for a larger study. Forty patients with stage II rheumatoid arthritis were randomly assigned to 1 of 4 arms of 10 patients each. One group received placebo and the other 3 groups received 2, 4, or 6 capsules (215 mg) of elk velvet antler with appropriate placebos to total 6 capsules daily. All subjects continued to take their arthritis medications. Outcome variables were reported adverse events and health status. At 1 month, there were no significant differences between groups in number of adverse events or health status. The greatest improvement was in the 6 elk velvet antler group, the least was in the placebo group. Differences were not statistically significant. It was concluded that elk velvet antler can be taken safely in conjunction with a number of rheumatoid arthritis medications and should be studied further to assess efficacy.

Pain in nursing home residents: management strategies

Pain is prevalent and undertreated in nursing home residents, despite the existing wide array of effective pharmacological and nonpharmacological treatment modalities. In order to improve the quality of life of these vulnerable individuals, practitioners require education about the correct approach to assessment and management. Assessment should be comprehensive, taking into account the basic underlying pathology (e.g. osteoarthritis, osteoporosis, peripheral neuropathy, fibromyalgia, cancer) as well as other contributory pathology (e.g. muscle spasm, myofascial pain) and modifying comorbidities (e.g. depression, anxiety, fear, sleep disturbance). Pharmacological management should be guided by a stepped-care approach, modelled after that recommended by the World Health Organization for treatment of cancer pain. Nonopioid and opioid analgesics are the cornerstone of pharmacological pain management. Tricyclic antidepressants and anticonvulsants can be very effective for the treatment of certain types of neuropathic pain. In addition to treating the pain per se, attention should be given to prevention of disease progression and exacerbation, as maintaining function is of prime importance. Nursing home residents with severe dementia challenge the practitioner's pain assessment skills; an empirical approach to treatment may sometimes be warranted. The success of treatment should be measured by improvement in pain intensity as well as physical, psychosocial and cognitive function. Effective pain management may impact any or all of these functional domains and, therefore, substantially improve the nursing home resident's quality of life.

Complementary and alternative therapies for fibromyalgia

Fibromyalgia (FM) is a syndrome of chronic widespread musculoskeletal pain that is accompanied by sleep disturbance and fatigue. Clinical treatment usually includes lifestyle modifications and pharmacologic interventions meant to relieve pain, improve sleep quality, and treat mood disorders. These therapies are often ineffective or have been shown in clinical studies to have only short-term effectiveness. Pharmacologic treatments have considerable side effects. Patients may have difficulty complying with exercise-based treatments. Thus, patients seek alternative therapeutic approaches and physicians are routinely asked for advice about these treatments. This article reviews nontraditional treatment alternatives, from use of nutritional and herbal supplements to acupuncture and mind-body therapy. Little is known about efficacy and tolerance of complementary and alternative therapies in FM and other chronic musculoskeletal pain syndromes. Most studies on these treatments have been performed for osteoarthritis, rheumatoid arthritis, or focal musculoskeletal conditions. Clinical trials are scarce; the quality of these trials is often criticized because of small study population size, lack of appropriate control interventions, poor compliance, or short duration of follow-up. However, because of widespread and growing use of alternative medicine, especially by persons with chronic illnesses, it is essential to review efficacy and adverse effects of complementary and alternative therapies.

The role of meat in the expression of rheumatoid arthritis

Rheumatoid arthritis (RA) is characterized by inflammation of the synovial tissues in the joints. A number of papers related to dietary components that are associated with this inflammation are reviewed. In addition, the ecological approach is used to study the links between diet and RA. Multi-country data for prevalence of RA for females from eight and fifteen countries were compared statistically with components of national dietary supply. Fat from meat and offal for the period 2 years before the prevalence data was found to have the highest statistical association with the prevalence of RA (r(2) 0.877, P<0.001 for eight countries). The statistical correlations for meat and offal were almost as high as those for their fat. Similar correlations were found for temporal changes in indices of effects of RA in several European countries between 1968 and 1978 as more meat was added to the national diets, although the correlations were higher for meat than for fat. It is hypothesized that meat and offal may be a major factor contributing to the inflammation in RA. In the present short review, the author examines some of the data that associate meat consumption with RA and the possible factors, e.g. fat, Fe and nitrite, which may contribute to the inflammation.