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