Hand handicap and rheumatoid arthritis in a fish-eating society (the Faroe Islands)

Risk factor assessment of rheumatoid arthritis in North Kerala

OBJECTIVE

Rheumatoid arthritis (RA) is a multifactorial disease; it leads to disabling and painful chronic inflammatory arthritis. Its onset may be delayed or even prevented by modifying the risk factors involved. Many genetic, epigenetic, and environmental factors are implicated in the pathogenesis of RA. The objectives of this case-control study were to assess various risk factors in our population and to compare the same with age- and sex-matched controls.

METHODS

We studied 118 cases with RA diagnosed using the EULAR criteria. In total, 581 age- and sex-matched controls were selected. Each individual was administered a separate questionnaire regarding their risk factors (known risk factors were studied). The implicated dietary factors were incorporated in a food frequency questionnaire (FFQ) and administered to both cases and controls. Comparison was made between those who consume an item at a particular frequency, who consume less, and who consume nothing at all. Among those who consume, each group was re-compared. Statistical analysis was conducted using Statistical Package for Social Sciences (IBM Corp.; Armonk, NY, USA).

RESULTS

There was significant relationship for family history, periodontitis, history of chikungunya, and sun exposure (p<0.05). Association with various food items was studied using the FFQ, but the relationship was inconsistent, probably due to consumption of modified diet by the persons with RA. Also, a majority of cases were females and nonsmokers for assessing an association with smoking habits.

CONCLUSION

In our population, previous infections (e.g., chikungunya and poor oral hygiene with periodontitis) were the prominently observed risk factors. Also, smoking was less common among women, and probably contributed less, as majority of cases were females. For dietary pattern association, a prospective cohort study may be needed.

Modifiable risk factors for RA: prevention, better than cure?

OBJECTIVE

To perform a meta-synthesis of the evidence for modifiable lifestyle risk factors for inflammatory polyarthritis (IP) and RA.

METHODS

We performed a MEDLINE literature search. Case-control and cohort studies and systematic reviews published from 1948 through February 2011 and studying modifiable risk factors for RA were retrieved. The main outcome measure was diagnosis of RA according to the standard criteria.

RESULTS

Smoking contributes up to 25% of the population burden of RA. The risk is dose related, stronger in males and especially strong for anti-citrullinated peptide antibody positive (ACPA(+)) RA through an interaction with the shared epitope. After smoking cessation, there is, however, a latency of up to 20 years to return to baseline risk. Other associations are less definitive; however, prospective studies suggest that dietary antioxidants and breastfeeding may be protective and that high coffee consumption may increase RA risk. An inverse association with alcohol intake (especially in smokers) and with education/social class (especially seropositive RA) and an increased risk with obesity (seronegative RA) is also noted.

CONCLUSION

There is a need for further large-scale prospective studies with a consistent definition of RA phenotype (undifferentiated IP through to ACPA(+)/RF(+) disease). This will ultimately afford the opportunity to evaluate preventative population strategies for RA akin to the well-established programmes for cardiovascular disease and cancer, targeting common risk factors.

Prevalence of rheumatoid arthritis in the southern part of denmark

The aim of the present study was to estimate the prevalence of rheumatoid arthritis in the southern part of Denmark. Using a screening questionnaire, telephone interview, register data, and a clinical examination cases were ascertained from a random sample of 4995 individuals over the age of 15. As case definition we used the original and modified 1987 American College of Rheumatology classification criteria. The overall point prevalence was 0.26% (95% confidence interval: 0.13-0.39) in the total sample and 0.35% (95% confidence interval: 0.17-0.52) among the responders; the cumulative prevalence was 0.75% (95% confidence interval: 0.52-0.97) in the total sample and 0.92% (95% confidence interval: 0.62-1.21) among the responders.The cumulative prevalence was higher than in other studies combining the results of a survey with register data. The point prevalence was underestimated due to low participation rate in the clinical examination and remission among the participants.

Dietary fish and fish oil and the risk of rheumatoid arthritis

BACKGROUND

Intake of fish oil and oily fish has been reported to improve clinical symptoms in people who have rheumatoid arthritis. Whether the intake of oily fish and fish oil might also protect against the development of rheumatoid arthritis is not known.

OBJECTIVE

We investigated the association between intake of oily fish and fish oil supplements and the risk of rheumatoid arthritis in a population-based case-control study.

METHODS

The study comprised 1889 incident cases of rheumatoid arthritis and 2145 randomly selected controls recruited from a geographically defined area of Sweden during 1996-2005. Data on the consumption of oily fish and fish oil supplements 5 years preceding enrollment had been obtained through a questionnaire. We calculated odds ratios (ORs) for the development of rheumatoid arthritis, using logistic regression to adjust for age, residential area, body mass index, smoking, and alcohol consumption.

RESULTS

Compared with subjects who never or seldom consumed oily fish, the OR for developing rheumatoid arthritis was 0.8 (95% confidence interval = 0.6-1.0) for subjects who consumed oily fish 1-7 times a week. The results did not change notably when stratifying the cases for rheumatoid factor or for antibodies to citrullinated peptide antigens. Similar results were seen for subjects consuming oily fish 1-3 times a month. Cases and controls did not differ in their consumption of fish oil supplements.

CONCLUSION

Intake of oily fish was associated with a modestly decreased risk of developing rheumatoid arthritis.

Intravenous application of omega-3 fatty acids in patients with active rheumatoid arthritis. The ORA-1 trial. An open pilot study

The objective of this work was to assess the therapeutic efficacy and tolerability of intravenously applied n-3-PUFA in patients with active rheumatoid arthritis (RA). Thirty-four patients with active RA [identified as having a DAS28 (disease activity score including a 28 joint count) > 4.0] were enrolled into this 5-wk open pilot study (one group design). From the time of screening (visit 0, or V0), background therapy had to remain unchanged. Patients received 2 mL/kg (= 0.1-0.2 g fish oil/kg) fish oil emulsion intravenously on 7 consecutive days (Visit 1-Visit 2, or V1-V2) in addition to their background therapy. A decrease of the DAS28 > 0.6 at day 8 (Visit 2) was the primary efficacy measure. Moreover, the DAS28 at day 35 (Visit 3, or V3), the modified Health Assessment Questionnaire, the American College of Rheumatology (ACR) response criteria (V2, V3) and the Short Form-36 (V3) were assessed. Thirty-three patients completed the trial. The mean DAS28 at V1 was 5.45;at V2, 4.51 (P < .001 V1-V2) and at V3, 4.73 (P < .001 V1-V3; V2-V3, not significantly different). Of the 34 patients, 56% achieved a reduction of the DAS28 > 0.6 at V2 (mean 1.52); 27% > 1.2. At V3, 41% of the patients showed a DAS28 reduction > 0.6 (mean 1.06), and 36% > 1.2. ACR 20 and 50% responses at V2 were seen in 29 and 12% of patients, respectively; at V3, the comparable values were 18 and 9%, respectively. Overall tolerability was excellent. Intravenous application of n-3-PUFA (as an add-on therapy) was considerably well tolerated and led to improvement of the disease activity status in a reasonable number of RA patients. Future trials are warranted to answer whether the intravenous application of n-3-PUFA constitutes a therapeutic option in RA patients.

Dietary risk factors for rheumatic diseases

PURPOSE OF REVIEW

Recent scientific data illuminate the dietary link to rheumatic disorders. This review summarizes recently published articles on the dietary link to rheumatoid arthritis, gout, and osteoarthritis.

RECENT FINDINGS

A prospective study suggests that higher intakes of meat and total protein as well as lower intakes of fruit, vegetables, and vitamin C are associated with an increased risk of inflammatory polyarthritis or rheumatoid arthritis. Several studies suggest that the Mediterranean-type diet or its main components may have protective effects on the development or severity of rheumatoid arthritis. A recent prospective study investigated several purported dietary factors for gout and confirmed some of the long-standing suspicions (red meats, seafood, beer, and liquor), exonerated others (total protein, wine, and purine-rich vegetables), and also identified potentially new protective factors (dairy products). Recent double-blind, randomized, placebo-controlled studies suggest that antioxidant vitamins (vitamin E, vitamin C, beta-carotene, and retinol) do not halt the progression of symptomatic knee osteoarthritis, as was previously suggested.

SUMMARY

Because diet is an unavoidable universal exposure for people, even a small effect that can be achieved by dietary manipulation may produce a large impact on the population's health. As the evidence on the role of dietary factors in rheumatic disorders grows it becomes increasingly important for clinicians and investigators in the field of rheumatology to familiarize themselves with the relevant data and appropriately apply them to clinical and public health practice.

An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis

OBJECTIVE

To investigate the efficacy of a Mediterranean diet (MD) versus an ordinary Western diet for suppression of disease activity in patients with rheumatoid arthritis (RA).

METHODS

Patients with well controlled, although active RA of at least two years' duration, who were receiving stable pharmacological treatment, were invited to participate. All patients were randomly allocated to the MD or the control diet (CD). To achieve good compliance with prescribed diets all patients were for the first three weeks served the MD or the CD, respectively, for lunch and dinner at the outpatient clinic's canteen. Clinical examinations were performed at baseline, and again in the 3rd, 6th, and 12th week. A composite disease activity index (DAS28), a physical function index (Health Assessment Questionnaire (HAQ)), a health survey of quality of life (Short Form-36 (SF-36)), and the daily consumption of non-steroidal anti-inflammatory drugs were used as primary efficacy variables.

RESULTS

From baseline to the end of the study the patients in the MD group (n=26) showed a decrease in DAS28 of 0.56 (p<0.001), in HAQ of 0.15 (p=0.020), and in two dimensions of the SF-36 Health Survey: an increase in "vitality" of 11.3 (p=0.018) and a decrease in "compared with one year earlier" of 0.6 (p=0.016). For the control patients (n=25) no significant change was seen at the end of the study. This difference between the two treatment groups was notable only in the second half of the trial.

CONCLUSION

The results indicate that patients with RA, by adjusting to a Mediterranean diet, did obtain a reduction in inflammatory activity, an increase in physical function, and improved vitality.

Dietary factors in relation to rheumatoid arthritis: a role for olive oil and cooked vegetables?

BACKGROUND

Although several studies showed that risk of rheumatoid arthritis (RA) is inversely associated with consumption of n-3 fatty acids, the one study showing that olive oil may have a protective role has not yet been confirmed.

OBJECTIVE

We examined the relation between dietary factors and risk of RA in persons from southern Greece.

DESIGN

We studied 145 RA patients and 188 control subjects who provided information on demographic and socioeconomic variables, prior medical and family history, and present disease status. Subjects responded to an interviewer-administered, validated, food-frequency questionnaire that assessed the consumption of >100 food items. We calculated chi-square statistics for linear trend and odds ratios (ORs) for the development of RA in relation to the consumption of olive oil, fish, vegetables, and a series of food groups classified in quartiles.

RESULTS

Risk of developing RA was inversely and significantly associated only with cooked vegetables (OR: 0.39) and olive oil (OR: 0.39) by univariate analysis. A significant trend was observed with increasing olive oil (chi-square: 4.28; P = 0.03) and cooked vegetable (chi-square: 10. 48; P = 0.001) consumption. Multiple logistic regression analysis models confirmed the independent and inverse association between olive oil or cooked vegetable consumption and risk of RA (OR: 0.38 and 0.24, respectively).

CONCLUSIONS

Consumption of both cooked vegetables and olive oil was inversely and independently associated with risk of RA in this population. Further research is needed to elucidate the underlying mechanisms of this finding, which may include the antioxidant properties or the high n-9 fatty acid content of the olive oil.

The role of nutrition and diet in rheumatoid arthritis

Given the lack of understanding of the nutritional requirements in RA, plus the variability in its clinical course, it is difficult to produce specific dietary recommendations for RA. In general, sufferers should consume as varied a diet as possible, based on current Department of Health (1991) guidelines. Dietary counselling is important to help patients achieve this. Self-imposed elimination diets should be avoided and suspected food intolerance tested under strict clinical supervision. Nutrient megadosing is inadvisable, although dietary supplementation with Ca, vitamin D, folic acid or multivitamins and minerals should be recommended where necessary.

Epidemiology of rheumatoid arthritis in Finland

OBJECTIVES

To review the work pertaining to rheumatoid arthritis (RA) morbidity in Finland and to compare the data with that available from other countries.

METHODS

Extensive investigations in Finland of the epidemiology of RA, based on nationwide registers designed primarily for administrative purposes and on extensive population studies, frequently in combination.

RESULTS

According to several surveys with somewhat different study designs, the prevalence of clinically significant RA is about 0.8% of the adult Finnish population. Five national health interviews from a 30-year period have revealed figures about 50% higher, but with no clear change in prevalence. The incidence of clinically significant RA is about 40 per 100,000 of the adult population, which is in accordance with the prevalence figures. The mean age at diagnosis increased by 7.6 years from 1975 to 1990. Between 1978 and 1980, 5.8% of the severe disability in the adult Finnish population was attributable to RA. Some evidence suggests that severe disability resulting from RA diminished during the 1980s, possibly because of joint replacement surgery.

CONCLUSIONS

Monitoring sickness insurance statistics is a useful means of following the epidemiology of RA.

Efficacy of the Tibetan treatment for arthritis

Tibetans in the refugee communities in Northern India are exposed to both traditional Tibetan and Western medicine. For Tibetans suffering from arthritis (or trung-bo), the Tibetan treatment was compared with the Western treatment in an open randomized controlled trial. On a significance level of 0.0005, this trial demonstrated that for these Tibetans, their indigenous treatment worked better than the Western treatment for improved limb mobility.

Hand osteoarthritis in the elderly. Application of clinical criteria

The American College of Rheumatology (ACR) classification criteria were used to define the prevalence of clinical hand osteoarthritis (OA) in an elderly population in Iceland. The prevalence of hand OA was 3.3% for men and 6.8% for women, however, 19.6% of the men and 32.0% of the women fulfilled the ACR examination but lacked required symptoms. The prevalence of clinical signs of OA in the interphalangeal joints were similar for both sexes but were much more common in the first carpometacarpal joint of women (31.3% vs. 1.0% in men, p < 0.0001). No differences were observed between former seamen (55% of the men) and nonseamen or between the right and left hand. Intra- and interobserver agreement in diagnosis ranged from 83% to 97%, but only 70% of subjects fulfilling the symptoms criterion fulfilled the same criterion six months later. Our results suggest that the present symptoms criterion of the ACR clinical criteria restricts their use in population surveys, being both insensitive and unstable over time.

The absorption of fish oils and concentrates

Both preventive and curative therapies have created a considerable demand for eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids. The most common sources for omega 3 fatty acids are fish oil. The concentrations of EPA and DHA in commercial oils, after modest enrichment, reach about 300 mg/g; alternative technologies can produce reasonably priced fish oils containing 400 or even 500 mg/g of omega 3 acids. When the acids are liberated from the glycerides, concentrates of ethyl esters or free acids with 65 to 70% total omega 3 fatty acids (at least 50% EPA + DHA) are readily prepared. Difficulties have arisen because most clinical trials have used fish oils of unspecified composition, and some trials are now based on either ethyl esters or free acids. There are at least three different, but not mutually exclusive, absorption routes in humans, namely the preduodenal route, the lymphatic route via chylomicrons, and the route via the portal vein to the liver. This makes it difficult to compare results. The difficulty in obtaining dose-related clinical data may in part be due to the form in which the omega 3 acids are offered and due in part to the natural presence of these fatty acids in the body. The nontriglyceride forms, especially the free acids, have been advocated for standardization of trials to facilitate interlaboratory comparisons.

The effects of dietary supplementation with n-3 polyunsaturated fatty acids in patients with rheumatoid arthritis: a randomized, double blind trial

STUDY OBJECTIVE

To determine the effect of dietary supplementation with n-3 polyunsaturated fatty acids (n-3 PUFA) on disease variables in patients with rheumatoid arthritis.

DESIGN

Multicenter, randomized, placebo controlled, double blind.

SETTING

Three Danish hospital Departments of Rheumatology.

PATIENTS

Fifty-one patients with active rheumatoid arthritis.

INTERVENTION

Random allocation to 12 weeks of treatment with either six n-3 PUFA capsules (3.6 g) or six capsules with fat composition as the average Danish diet.

MAIN RESULTS

Significant improvement of morning stiffness and joint tenderness. No significant effect on the four other assessed clinical parameters. No serious side effects.

CONCLUSIONS

Dietary supplementation with n-3 PUFA in patients with rheumatoid arthritis improved two out of six patient reported disease parameters. Further studies are needed to clarify the more precise role of n-3 PUFA in the treatment of rheumatoid arthritis.

Impairment of grip function in rheumatoid arthritis--studies with a simple hand test

A new, simple and quick method for assessment of impaired grip function was evaluated in a rheumatology department, 208 of 211 patients with definite rheumatoid arthritis were unable to do the test, 48 of these patients had regarded their hands as unaffected when questioned. The impairment of grip function was closely related to clinical and functional observations but not related to the most common laboratory tests. The study confirms the hypothesis that almost all patients with RA are unable to do the hand test, even those who consider their hand function as normal.