Disease information

by

In: Blog, Disease information, Rheumatology, Videos

Comments Off on Diet, supplements and dietary fads in arthritis

One of the questions I’m most frequently asked by patients is whether diet plays any role in the management of arthritis.

If one were to believe what they read in the papers about dietary remedies, or in the number of books promoting diets or supplements claiming to cure arthritis, one would be forgiven for wondering whether they need to take medical treatment at all.

The idea that a simple change to diet might cure, or lessen the symptoms of a disease as potentially devastating as arthritis, is attractive. It it were only that simple….

What I have done is prepare a number of videos which addresses the available evidence for the effectiveness (or otherwise) of commonly used diets and dietary supplements. I hope you find them useful.

 

A word of caution. You should be aware that most of the claims that are made for dietary manipulation in the treatment of arthritis are based, at best, on poor quality research. Claims for the effectiveness of diet are often made in the face of weak (or absent) scientific evidence, or even worse, in the face of scientific information to the contrary.

Any of the scientific evidence that exists for benefits of diet in arthritis relates primarily to symptom improvement. The is no evidence from any of the scientific studies carried out to date, (other than perhaps weight loss diets as a treatment for osteoarthritis of the knee) that diet can slow the damage or other reduced the negative health consequences of a disease like rheumatoid arthritis. Medical treatment will usually still be required.

Where there is evidence for the effectiveness of any given diet, it may not apply to all forms of arthritis. I have done my best to address this where I can.

 

 

My patient is a middle aged professional, with no symptoms what so ever.

He is fit and healthy, a non smoker, has good teeth, eats well and has no family history of arthritis or autoimmune disease. So why is he seeing a rheumatologist?

He’s concerned about some results he has received from a genetic screening test. The test results suggest that his risk of developing two autoimmune diseases – rheumatoid arthritis and Scleroderma, conditions I frequently treat, is increased.

I’m at a slight disadvantage as this is the first time I’ve had has to counsel a patient in this situation.

There’s an additional complicating factor. The patient is me.

Eric Topol, in his book, The Creative Destruction of Medicine, describes how genetic health screening will be one of the key drivers of a shift towards personalised medicine. So, a few months back, I signed up to a service provided by the genetic screening company 23andMe, which offered a personalised screening test for $178 (On the request of the FDA, 23andMe no longer offer a health screening service).

Shortly afterwards, a courier collected a small vial of my saliva and then delivered it to a US based lab. 6 weeks later an email arrived with the results.

In arranging for the test to be performed, I broke two of my usual rules as a doctor; don’t try and practice medicine on yourself (I usually outsource my personal medical care to my excellent GP) and don’t request a test where you don’t know what to do with the answer.

I went to medical school and learnt about DNA, RNA and Mendelian inheritance. Through osmosis at medical conferences and by reading the background literature, I have acquired enough genetics knowledge to bluff at a dinner party of non geneticists. But with the exception of ‘need to know’ knowledge (specific to a fairly small number of diseases) my genetics knowledge is fairly limited.

Unfortunately these tests have not yet been validated in a clinical setting so there’s no real guidance for physicians like me trying to interpret these tests; What are the pitfalls and likelihood of a false positive or a false negative test? What is predictive value of a positive test? How reassuring is a negative test and how do these genetic risk factors interact with environmental factors to increase the risk of developing a specific disease like RA or scleroderma?

If I struggle as a doctor to put this information in context, how can I counsel and guide my patient? Until I have some I’m inclined to avoid answering. I’m going to get my patient to come back and see me in a few years’ time.

Further reading
NEJM series on Genomic Medicine
Dr. Robert West’s personalised medicine blog

‘I just can’t do it anymore doctor. I’m a wreck’.

Mary is a widowed 72 year old lady who has a bad back, sore wrists and shoulders and as a result, has difficulty sleeping and sometimes even dressing herself can be a struggle. These symptoms make her own life difficult but her main concern is not for herself. She’s afraid she’ll no longer be able to care for her 2 preschool grandsons.

She’s helping out her daughter who has had to return to work to help make ends meet now that her husband’s salary has been cut. Her daughter drops the two boys round on her way to work, 5 days a week, and picks them up on her return. 

Its a long day, but Mary is glad to be able to help out. She loves the kids and enjoys spending time with them but the physical and emotional demands of feeding, changing, cleaning up and entertaining them is taking its toll. She feels that her arthritis pains are worse, finds it difficult to make time to visit her friends, exercise or to attend her hospital clinic appointments.

She’s not alone. As the financial pressure mounts on cash strapped families in this recession,  grandparents are more frequently being asked to give a hand with childcare. Even during the financial boom, unpaid relatives were the main source of non-parental childcare in 11.5% of preschool children. There’s an increasing proportion of single parent families of whom 1/3 will avail of the services of an unpaid relative to help with childcare.  For many Irish grandparents, there’s no escape either. In Ireland, 20% of grandparents live in the same house as their grandchildren and up to about a third live within 25 Kilometres.

Looking after small kids is hard work. I frequently see young mums (more so than young dads…) overburdened with the physical and emotional demands of raising small children in my practice. Perhaps its not surprising that older people, particularly those with a pre-existing condition such as arthritis might struggle in the same situation.

However, a 2007 study found no evidence that ‘caring for grandchildren has dramatic and widespread negative effects on grandparents’ health’. It did suggest however that likelihood of negative impact of grandparent health  might be determined by the particular circumstances and ‘workload’ circumstances of the carer. For example, there might be a positive health advantage to those doing a little babysitting, but potential for problems where the grandparent is helping out in ‘skipped generation’ families (where the parents are, for whatever reason, absent), or those who provide ‘live-in’ care. It clearly depends on the circumstances.

Although there are no hard and fast rules to how to manage requests for looking after grandchildren, and I’m always cautious about offering life advice to my elders, here’s some of the advice.

1. If you enjoy looking after your grandchildren and feel up to it, keep on going! You are unlikely to do harm to your health and you are providing a great service to your children and your grandchildren.

2. In order to care effectively for grandchildren you need to look after yourself. This means making time to exercise, socialise with your friends and (if necessary) see your doctor. If you don’t have a hobby or outlet, get one. Its easier to say no when you’ve got an Art class to go to.

3. If you feel the need to set limits on your commitment, its better to do it early. Before the baby is born is ideal or at the very least, very soon after. It gives your family time to set realistic expectations and time to make alternative arrangements.

4. Don’t move in if you can help it. There’s evidence that grandparents who co-habit fare worse with their overall than those who live independently  As nice as it is to spend time with your grandchildren, its nicer doing so knowing that you can give them back.

5. If you find that you are not coping physically or emotionally and don’t feel comfortable or guilty bringing it up with your own children, it can be helpful to involve your doctor. I have, for example, written letters to my patients to ‘recap’ on advice given at clinic regarding the need to pull back form childcare which they can in turn, show to a relative.

Here’s a little bit of extra advice from Ile Nastase, the veteran tennis star on the benefits of exercise and of having small children around. 

YouTube Preview Image

1. Ankylosing Spondylitis (AS) was first described by an Irish man

Kerry physician, Bernard Connor first described the condition in 1693 in a skeleton  from a church graveyard. If you look carefully at the above illustration from that skeleton you can see how the spine is fused.

2. It takes an average of 8 years to diagnose it.

Many patients will attend a large number of doctors, physical therapists and other healthcare professionals before getting a diagnosis (for reasons why, see below).

3. Blood tests can be normal

The blood tests which are traditionally used in the diagnosis of other forms of inflammatory arthritis, the ESR and CRP tests, are normal in up to 50% of patients.

The HLA B-27 genetic test can be positive in up to 90% of patients. Sound good? Unfortunately 8% of healthy adults (without AS) have a positive test as well. This means if you test 100 people with low back pain unrelated to AS, at least 8 of them would have a positive test. The test needs to be used carefully and interpreted in the light of other features of the disease.

4. MRI scans can miss it too.

Left Sided Sacroillitis on MRI

Although MRI is probably the most reliable test for making a diagnosis, its important to scan the correct body part. An MRI of the sacroiliac joints (the joints where the spine jomeets the pelvis) is abnormal in 70% of patients with established AS. MRI of the rest of the spine scan can show signs of AS in the 25-30% of patients with AS who have normal MRI’s of their sacroiliac joints. The sensitivity of the test is  improved where the scans are looked at by a radiologist who has an interest in arthritis related conditions.

 5. Can cause chest pain

In addition to causing inflammation of the spine itself, AS can cause inflammation of lots of other structures e.g. the ribs and their attachments (aka ‘costochondritis’)

6. Can cause sore heels

In addition to causing spinal inflammation, AS causes ‘enthesitis’. Enthesitis is a form of inflammation of where ligaments and tendons attach to bone. It can cause inflammation at the attachment of the plantar fascia (a ligament in the sole of the foot) – plantar fasciitis. It can also cause inflammation of the achilles tendon  – Achilles tendonitis.

7. Can cause sore eyes

AS can be associated with an acute inflammation of the eye (uveitis) in up to 25% of patients. This will typically cause an eye that is red AND painful and needs to be treated urgently. If you have AS and an acutely painful red eye, you should be assessed by an ophthalmologist.

 8. It is very treatable

For some patients with years of chronic low back pain it can be a relief to get a diagnosis of a condition like AS which is very treatable. Until about 10 years ago, the treatment of AS revolved around anti-inflammatory medications and physiotherapy (this still sufficient for some patients). In the last few years the development of biologic therapies (Enbrel, Humira, Remicade, Simponi) has resulted in dramatic relief from the symptoms of Ankylosing spondylitis for many patients. There are subtle differences between the drugs (not every drug works for every patient) but as whole they tend to be very effective.

 

What is Gout?

May 03

YouTube Preview Image

What is it like to Have Gout?

Gout, for anyone has experienced it, is one of the most painful joint conditions that you can get. It typically causes intense pain, swelling, and redness in joints – usually lasting a few days at a time.  This is often in the big toe but also can affect the in-step, the ankle and the knee (its more common in the lower limbs) but it can also affect fingers, wrists and elbows. In its early stages, it can be difficult to diagnose and sufferers sometimes think they have sprained an ankle or they have done themselves some sort of injury.

 

What Triggers attacks of Gout?

Typical triggers include alcohol binges, dehydration, acute infections, joint injury and for some people, certain kinds of foods. There is no hard and fast rule regarding which foods trigger attacks (it varies from person to person) but some meals very rich in protein (including meat and shellfish) can trigger attacks in certain people. There is no evidence though that ‘purine rich’ vegetables such as peas, beans, mushrooms, cauliflower spinach increase the risk of attacks.

Later in the course of the disease, attacks can come on spontaneously.

What Causes Gout?

Gout itself is due to the accumulation of very, very small needle shape crystals within joints called Uric acid crystals. Everybody makes uric acid themselves but normally excrete the uric acid in the urine.  Most people who have Gout tend to excrete uric acid less efficiently so it tends to accumulate and, when its reaches a certain concentration, it forms crystals.

Over time, uric acid can build in the joints and form hard lumps under the skin called tophi (around the elbows for example).

In addition to being associated with obesity, Gout occurs more frequently in patients with Diabetes certain types of lipid problems, kidney failure and with certain medications (diuretics and low dose aspirin can cause problems for some patients). All those who develop gout should be screened for these conditions.

How Gout is treated 

YouTube Preview Image

Treatments for Gout are broken down into two broad categories.  The first is what we use for in acute attacks and the second group is really what we use to prevent attacks coming up.  

Treating Acute Gout

Most patients who have Gout in it’s early stages get attacks once in a while (for example affecting a big toe or an instep) and the trick is to prescribe an anti-inflammatory medication (for example Diclofenac or Naproxen) as early as possible to settle down an acute attack.  These usually lasts for a few days, so five to seven days of anti-inflammatory is enough for most people.

Most patients with Gout in it’s early stages will get an attack maybe once a year or once every two years.  But in some patients it can become more frequent than that. 

Some patients can’t take anti-inflammatory medications as they can upset their stomach (they also need to be avoided in patients with kidney failure or those on warfarin).  An alternative is a drug called Colchicine and doctors sometimes use steroids (which are particularly effective). These can be given as tablets, intramuscular injection occasionally by injection directly into a painful joint (not as painful as it sounds). 

Keeping a stash of anti-inflammatories in the bathroom cabinet

I tend to give patients back up prescriptions for anti-inflammatories to keep in their bathroom cabinet as attacks sometimes come on at night.   

 

Most patients who have experienced Gout get very good at sensing attacks in their early stages and take their anti-inflammatory quickly to abort an attack.  There is also some evidence that if you drink lots of water that you can abort an attack in about 20% of the time (but most patients, in my experience, need some medications to help)

Preventing Gout 

For patients who are getting very frequent attacks, we tend to use preventative treatments. There is no hard an fast rule for when to start these except to say, that most people who have more than a couple of attacks a year, or where attacks drag on for weeks at a time, will be keen to consider prevention.  And this effectively means taking something everyday for the rest of your life to prevent these attacks.

 Typically we use a drug called Allopurinol which is designed to reduce the amount of uric acid in a blood strain and in turn the amount of uric acid which is in your joints, which in turn causes the Gout.  It reduces the amount of uric acid that your own body makes and tends to do so fairly effectively depending on the dosage that is used.  And where Allopurinol doesn’t work, it’s quite often because the dosage that’s used isn’t high enough. 

Gout may initially get worse with treatment

A word of warning, when we start patients off on a drug like Allopurinol the joints can get a little bit worse initially and we would normally try prevent this happening by prescribing along with the Allopurinol an anti-inflammatory or possibly a drug called Corticosteroids for the first month to six weeks. But it is important though when you start Allopurinol and if you do get an attack within those first few weeks that you stick with the Allopurinol and rheumatologist or family doctor to treat the acute attack of Gout. 

 The Allopurinol can be very effective use in the correct tools, what we tend to do is increase the dosage until we get your uric acid to low level where the uric acid is unlikely to crystallize in your joints and this can take a few months.  For patients who are in tolerant of Allopurinol for example very, very occasionally we see patients who have allergies to it, we can use a drug called Febuxostat which can be very effective as well.

 

 

This is a brief video I have prepared which may be of use to patients who have rheumatoid arthritis or psoriatic arthritis (or other arthritis illnesses) considering taking Methotrexate as an arthritis treatment.

It outlines some of the important side effects of methotrexate but also puts them in perspective based on my many years using the drug as a rheumatologist.

This is my first attempt at providing medical information using youtube.

I’d be interested in what people genuinely think of the information posted.

Is it too detailed?

Isn’t it detailed enough?

Are there other topics you’d like to see covered? Please let me know.

YouTube Preview Image

Woody Allen’s 1970 movie ‘Sleeper’ introduced its audience to a fictional, futuristic device called the Orgasmatron. This remarkeable invention was capable of inducing physiological changes (of a pleasurable kind) in those placed within it. I sometimes wonder how much Woody Allen’s contraption was influenced by a device with a similar name from the early 1960’s in which the earliest scientific experiments on the effects of weather on arthritis symptoms were performed.

The Orgasmatron in action

The Climatron, as it was referred to in media reports of the time, was used by Professor Joseph Hollander, a Philadelphia based rheumatologist to determine the effects of the weather elements on the symptoms of arthritis patients. The device was basically a hotel room sized chamber (with room service) which was designed to comfortably house two patients for periods of two to four weeks. Using a system of valves and dials, it was possible to adjust the temperature, humidity, rate of air flow, barometric pressure within the chamber.

The Climatron in action (with Prof Hollander)

In his experiments, a small group of largely ‘weather sensitive’ arthritis patients, were recruited to come and stay in the Climatron. A number of times a day they completed a diary documenting various aspects of their health including assessments relating to their joint symptoms. They were also examined by a doctor and had their joints assessed. None of the subjects were aware that the main focus of the research was their joint symptoms and were not informed about changes being made to the weather variables within the chamber.

When individual weather variables were adjusted in the Climatron, none of the subjects  noted any difference in their joint symptoms. However when an attempt to reproduce the weather conditions of imminent stormy weather (simultaneous increase of humidity and reduction in atmospheric pressure) the effect on symptom worsening was significant in 7/8 of the rheumatoid patients and in 4/4 of the osteoarthritis patients. When this experiment was completed a number of times, those who noted a worsening did so about 3/4 of the time.

This was one of the first scientific attempts to correlate arthritis symptoms and the weather. Whereas the results are tantalizing, its hard, in view of the small numbers of patients studied, to draw any firm conclusions.

Arguments for there being a link

The strongest suggestion that arthritis symptoms are affected by weather is from patient surveys. About 2/3 patients in some studies state that their pain is worsened by certain weather changes. Some report how their joints help them predict the imminent arrival of wet weather, some note a dramatic improvement in their pain while on holidays in the sun (only to deteriorate on their arrival home ) and some even notice a worsening of their symptoms during heat waves. Whereas surveys are interesting, they don’t necessarily prove the link.

However, there are also some semi-plausable mechanisms as to how weather might affect joint symptoms; We know that joints  contain pressure receptors (baro-receptors) for example. Couldn’t changes in atmospheric pressure therefore be detected within joints ? The problem is that the sorts of barometric pressure changes seen with weather fluctuations are small and only of the sort of magnitude that might be experienced going up and down in a lift or on an airplane journey. It is also true that the physical properties of  tendons and cartilage can be altered by temperature changes but again, this has only been shown in laboratory experiments using extremes of temperature not usually seen in the environment . There’s even some evidence that levels of inflammatory proteins (cytokines) have been shown to decrease in patients undergoing hot spa therapy with inflammatory arthritis and of course heat (or cold) applied directly to joints also seems to help some patients too.

Some patients feel can predict weather changes in their joints

What’s surprising therefore is how prospective scientific studies over the years have failed to show a consistent relationship between various weather variables and arthritis symptoms.

This is at least partly due to the fact that these studies are difficult to do. If the weather were a new drug and researchers were trying to determine its effectiveness in the treatment of arthritis, we would be obliged to ‘blind’ both the patients AND their assessors to their weather treatment (a wet day, dry day etc). Its hard to be ‘blind’ to the weather. Unless you spend all of your time indoors – but then you are not being exposed to the weather changes (other than barometric pressure) either. People also wear clothes most of the time, which alter the humidity and temperature around joints and which could ‘blunt’ any effect that external factors might have.

Other investigators point to the difficult confounding role of psychological factors. Where someone with arthritis holds a belief, for example, that damp cold weather worsens their symptoms, they are psychologically more likely to place emphasis on information that reinforces this idea. They might be more likely therefore to remember those days where their joints were bad AND where the weather was damp and cold but not place emphasis on days where the weather was damp and cold and their joints were good. It has also been suggested that bad weather causes patients to feel depressed or to become inactive – both factors which have been shown to worsen pain.

What’s the bottom line:

Although the data is confusing, I tend to believe my patients when they tell me there joints are effected by the weather. This is true for some patients but not for all.

In my opinion, and despite and firm to data to back it up, I believe the following;

1. That arthritis is not caused by cold or damp weather. There is no evidence whatsoever that this is the case.

2. Where weather has an effect on arthritis,  it is solely on the symptoms of the disease and has no effect on disease progression or structural damage.

3. The effect of weather on arthritis symptoms varies from patient; as a rule I would have said that most patients prefer dry warm weather to cold damp weather. Patients with poorly controlled rheumatoid arthritis can occasionally flare when its very hot.

4. The better controlled a patients disease, the less they will notice fluctuations with weather changes. This is particularly true of patients with inflammatory arthritis (eg rheumatoid arthritis, psoriatic arthritis).

5. Emigrating for a better life with your arthritis is probably not a good idea. If an improvement is noted on moving to another country it is quite often temporary. Uprooting yourself from the support network of your family and friends isn’t a good idea and then there’s the stress of moving to another culture, negotiating another health system etc.

6. As with all things that you can’t control its probably better not to stress about it too much. You can’t control the weather…

Sun going down on Galway bay.