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    MYTHS vs. FACTS MYTHS vs. FACTS Presentation Transcript

    • MYTHS and FACTS: Diets, Dietary Supplements and Nutritional Therapies for Rheumatic Diseases Barbara E. Ostrov, MD Pediatric Rheumatology and Rheumatology PennState College of Medicine
    • Nutrition in Chronic Rheumatic Diseases
      • Nutritional issues in rheumatic diseases
      • Myths about:
        • role of diet as an underlying cause
        • role of specific dietary supplements in treatment
      • Truths regarding:
        • role of diet as an underlying cause
        • role of specific dietary supplements in treatment
      • Conclusions
    • Nutritional Issues
      • Growth abnormalities
        • generalized - inadequate growth in height, weight loss/gain
          • (systemic JIA, SLE)
        • localized – uneven leg growth causing unequal lengths
          • ( oligoarticular JIA)
      • Muscle atrophy (shrinkage)
        • next to inflamed joints (poly or oligo JIA)
        • generalized (juvenile dermatomyositis [JDM]; systemic JIA)
      • Abnormal fat in body
        • weight loss (polyarticular, systemic JIA, SLE)
        • lipodystrophy (JDM)
          • odd deposits of fat in some areas and none in other areas
      • Changes in body chemistry: Ex: anemia, osteoporosis
    • Cause of Nutritional Issues
      • Inflammation
          • Effects of inflammation proteins - cytokines: ex: TNF
          • poor use of nutrients, vitamins, minerals: ex: anemia, osteoporosis
      • Disease features: kidney, heart/lung, stomach/intestinal (GI)
        • Ex: GI disease features
          • Poor muscle tone in stomach/intestines: gastroparesis, dysmotility
          • chronic diarrhea, poor absorption
          • Loss of appetite, stomach pain  poor intake
      • Medication side effects
          • Oral ulcers, gum changes (ex: methotrexate, chemotherapy; cyclosporine)
          • appetite increase (ex: corticosteroids; antidepressants)
          • appetite decrease (ex: NSAIDs: ex: ibuprofen, naproxen)
    • Why the Focus on Nutrition + Disease
        • Concern about possible dietary cause of disease
        • Lack of understanding about their disease
        • Fear about medication side effects
        • Concerns about poor diet choices of children; ex:
          • not enough vegetable or meat products
          • not enough milk products
          • too much sugar
        • Grandparent or family comments
        • Control
          • diet is the one of the aspects of the management the families, children and patients can control
    • Why Patients Choose CAHC (Complementary and Alternative Health Care)
      • Vulnerable to sales pitch
        • Lack of suspicion
          • printed, word-of-mouth
          • on computer, TV  therefore must be true
        • Belief in the “easy” answers
          • easy solution to their problem
        • Self-confident
          • Pt able to discern better method/treatment
        • Desperate
          • serious, non-curable dx  try almost anything
        • Lack of trust
          • distrust of medical profession, FDA, pharmaceutical industry
    • What are Considered Supplements?
      • Dietary Supplements
        • 1994 Dietary Health and Education Act
          • taken by mouth;
          • contains a dietary ingredient to supplement the diet
          • “ dietary ingredient” includes:
            • vits, minerals, herbs, botanicals, enzymes, amino acids, organ tissues/glands, metabolites
      • Nutra-ceuticals
        • “ functional” or “healthy” foods
          • supplement to diet
            • health promoting value
            • ex: “benefits” cartilage repair
          • no FDA approval needed
    • Problems when there is no Requirement for FDA Regulation
      • Lack of safety testing
      • Lack of proven benefit testing
      • Products may be contaminated
      • Variable medication absorption from the product
      • No consistent instructions on how to give the product
      • Chemicals added in besides “active” ingredient
      • Allow claims that the product can do more than is proven – “stretch” the truth
      • No warnings re: supplement-prescription drug interactions
    • How did CAHC evolve?
      • CAHC ideas go back 5,000 years to traditional Chinese medicine, Indian (Ayurvedic) medicine
        • Role of the doctor was to help the healing process
        • Treatments focused on the underlying cause of the disease by encouraging lifestyle changes, self-care and preventive approaches
        • Prayer was important, as was "a change of air”
        • Laxatives, bleeding and leeches.
        • Through the early 20th century, people relied on the same kind of treatments as their ancestors.
      • Our society’s attitude has come full circle over the last century
    • Use of Dietary Supplements
      • Pts use CAHC
        • whether physician knows it or not
          • 20 to 70% JIA families use CAHC
            • Complement Ther Med 2009;17:208; J Rheum 2009;36:2302
          • 70% add supplements
            • Peds 1990;85:150
          • 20-30% have special dietary practices
            • Clin Rheum, 1991; 10:401
      • Money used for CAHC: ~$27 billion/yr
        • Dietary supplements alone ~$15 billion/yr
          • vitamin products
          • “ natural” or “herbal” products
      • Even KGAT newsletter has gotten into the act….
    • Proposed Ways the CAHC Work
      • True “food intolerance causes disease”
        • Uncommon occurence
          • Br J Rheum, 1997; 36:905; Ann Rheum Dis, 1992; 51:298
      • Hypersensitivity or “allergic-type reaction to food causes disease”
        • Food challenge in pts with positive skin test to specific foods, may have disease flare
            • Rheum 2004;43:1429
        • Gut inflammation may set off total body inflammation
          • change diet = altered gut bacteria = ?? Improve disease
              • Br J Rheum1994;33:638
      • Nutrition plays a role in inflammation
          • dietary aspects influence inflammation
    • Diet Facts or Myths: Dietary Factor(s) is an Underlying Cause of Arthritis
      • Theories:
        • Something in the diet causes or flares arthritis
          • remove that part of the diet and the arthritis is better/gone
          • re-feed that part of the diet and the arthritis returns/is worse
        • Starvation suppresses inflammation
          • fasting should help or “cure” arthritis
    • Problems Evaluating Diet Therapy
      • Unpredictable nature of and hard to come up with a truly “pure” diets
      • Patients do not stick well to diet restrictions
      • Varying affect of dietary changes:
        • Placebo (“sugar pill”) response
        • Reaction that looks like a food allergy may not be
        • Tolerate food choices poorly
        • Reaction to foods might be changed by drug-food interactions
    • Diet Myth: Certain Foods =  Risk
      • Diet history - risk of future development of arthritis
        • Diet hi in fish reduce the risk of RA
        • Intake of fruit, coffee, olive oil, vitamins A, E, C, D, zinc, selenium, iron, and meat no consistent  risk of RA
            • J Rheum; 2005;32:1249
        • No evidence that RA pts have consistent  reactions to food components
            • Clin Exp Rheum1995;13:167
      • Few true research challenges of diet components
        • < 5% pts with documented arthritis flare w/ selected foods
            • J Rheum 1990;17:291
    • Diet Myth Nutrient Removal Diet
      • Example: Avoid nightshade vegetables
        • foods from genus solanaceae
        • reportedly increases inflammation in
        • animals
          • tomatoes, potatoes, peppers, eggplant
        • elimination or removal diet suggested
        • as a treatment for arthritis
        • all reports from same author and derived from one non-scientific review article (J Neuro Ortho Med Surg 1993; 12:227)
        • UNPROVEN but all over the Internet !
    • Diet Myth: Fasting Diets
      • Fasting or starvation diet therapy
        • may decrease RA activity
        • many short term trials (7-10 days) of modified fast
        • fasting changes inflammation proteins (  interleukin and  lymphocyte function)
            • Clin Rheum 1999;18:394
        • inflammation and signs of RA improve with fasting
            • Scan J Rheum1995;24:85
            • Clin Exp Rheumatol. 2000;18:357
      • Unclear role and safety of long term fasts in adults
      • NO studies in children
    • Diet Fact: Role of Diet Modification
      • Theory: Certain dietary component (parts) cause arthritis
          • eliminate the dietary component  arthritis is better
      • Elimination Diet: Celiac disease
        • gluten sensitivity, specific blood tests, specific biopsy appearance
          • 20-50 % pts have a lot of non-GI symptoms
            • 60-100 % classic GI history
              • arthritis, rash, anemia, osteoporosis
          • 1.5 - 10% of JIA can also have celiac
            • (Rheum 2005;44:517; Clin Exp Rheum 1996;14:571)
          • resolve/improve on gluten -free diet
        • reasonable to do screening blood work
          • Some have a + family history for celiac
          • seen in 10-15% people with Down’s
    • Diet Fact : Role of Diet Modification
      • Elimination Diet: Milk
        • Few case reports with rechallenge
        • Documented arthritis improves and then flares with and without milk
            • J Rheum,1990;17:291
            • A&R, 1986;29:220
        • Research with animals showed some with arthritis and inflammation on blood tests after milk exposure
            • J Rheum,1990;17:285
        • Fewer than 10% of those who believed they were sensitive showed consistent effect of removing milk from their diet during controlled study
            • Ann Rheum Dis,1992;51:298
    • Diet Facts or Myths : Role of Specific Supplements in Treatment
      • Theories
        • People with arthritis are missing certain nutrients
        • Some supplements have disease-controlling benefits
        • Supplementing the diet will help treat the arthritis
          • add the supplement and the arthritis is better/gone
          • stop the supplement and the arthritis returns/is worse
    • Diet Myths: Deficiencies are Common & Need to be Replaced
      • Vitamin and nutrient deficiencies
        • vitamin C, A and E
        • zinc, copper, selenium
          • levels low in some studies but supplementation show no consistent beneficial effects
      • Anti-oxidants: ex: vitamin E, vitamin C
        • rationale: increased intake may reduce tissue damage
        • levels may be lower than normal but supplementation showed no consistent benefit
              • Clin Exp Rheum, 2000; 18:637
    • Diet Myths: Supplements help arthritis in children
      • Supplement: Glucosamine
        • animal and some human research suggest possible benefit for osteoarthritis in adults; other studies conclude it doesn’t work - NEJM 2006;354:795
        • Only a few studies in rheumatoid arthritis
          • In one study, there was no change in labs but decreased symptoms
              • Rheumatol Int. 2006 Sep 5
        • Research animals with arthritis had decreased number of inflamed joints and better labs using glucosamine
              • Inflamm Res, 2005;54:127
        • NO data in children
    • Dietary Facts: Nutritional oils help arthritis
      • Scientific data in research animal
      • Clinical research in adults
        • Fish oil (omega-3)
          • improved arthritis
          • Able to use less of other medications
            • A&R, 1994;37:824
          • reduced RA inflammation
            • J Rheum 2006;33:1973
        • Borage oil (omega-6)
          • 60% pts improved
            • A&R,1996;39:1808
    • Dietary Facts: Supplements help arthritis in children
      • Supplementation: Anti-inflammatory oils
        • Fish oil
          • Improved inflammation proteins - cytokines - 21 children after 12 weeks of 300 mg/day omega-3 (Eur Cytokine Network, 2005; 16:194)
          • decreased CRP [inflammation test] after 16 wks supplementation in a controlled trial (Ped Med Chir; 1996;18:387)
          • One study added it to to NSAID regimen x 5 mos;
            • able to  NSAID use in 17 % (Cas Lek Cesk; 1998;137:651)
        • Plant oil in JIA
          • decreased joint pain, improved daily function
          • multicenter trial borage oil
              • A&R; 42(Suppl):S229 1999
    • Dietary Facts: Supplements help children with rheumatic disease
      • Supplementation: Calcium and vitamin D
        • calcium, vit D intake poor in child/adolescent
        • 30% JIA have low bone density even without steroid use
            • A&R, 1997;40:1967
          • increased risks: disease type, more severe inflammation and use of steroid medications
        • Vitamin D important for immune system responses
            • Exp Biol Med, 2004; 229:1136
            • J Rheum 2010;37:491
        • supplemental calcium produces benefit on bone density
            • A&R; 2006; 54:2235
        • vitamin D levels and intake may not be enough for the increased requirements in JIA patients
            • J Peds; 1994;124:910
    • Dietary Facts: Supplements help arthritis in children
      • Supplementation: Oral collagen type II
        • “ shark cartilage” supplements
          • theory of how it works: decreased tendency for autoimmune reaction to cartilage protein (collagen) found by taking collagen pills
          • JIA, +/- uveitis
            • benefit in arthritis in ~ 50%, uveitis in ~ 15%
            • Ocul Immun Inflamm 2002;10:83
          • 6/8 improved with less inflammation
            • A&R 2001;44:1775
        • product studied is a purified form
          • not available over the counter
    • Non-Dietary CAHC
      • Several approaches used in adults; less often in kids
        • Acupunctur e- some decrease in pain in RA trial
        • Relaxation techniques- decreased pain, better sleep in JIA, RA
        • Spinal manipulation – no data in JIA
        • Massage techniques – decreased pain , anxiety for child and parent (who were trained in the techniques)
      • No well done research trials to prove benefit
          • Rheum Dis Clin N Am 2011; 37:85
    • Conclusions
      • Many patients use CAHC w/ or w/o medical advice or knowledge
      • Limited research available about proven benefit of CAHC for children with rheumatic disease
        • Many studies are poorly controlled or designed
        • Makes interpretation difficult
        • Taking conclusions from adult research may not be valid
        • Kids are NOT small adults
      • Must keep an open mind and review research critically to guide safest complementary choices
      • Using CAHC together with traditional prescription medication is the best approach
      • Inform your health care providers about all treatments used
    • Reputable Sources on Dietary Supplements
      • Tufts University Health and Nutrition Letter
        • [email_address]
      • International Bibliographic Information on Dietary Supplements (IBIDS)
        • http://ods.od.nih.gov/databases/ibids.html
      • NIH Clinical Nutrition Service
        • http://www.cc.nih.gov/ccc/supplements/intro.html
      • PDR for Herbal Medicines
      • PDR for Nonprescription Drugs and Dietary Supplements