Nutrition and Arthritis

Acknowledgements.

Abbreviations.

CHAPTER 1: INTRODUCTION.

1.1 The range of rheumatic diseases.

1.2 Rheumatoid arthritis (RA): description.

1.3 Osteoarthritis (OA): description.

1. 4 Incidence and prevalence.

1.5 Mortality.

1.6 Morbidity.

1.7 Economic cost of arthritis.

1.8 The aim of this book.

CHAPTER 2: CLASSIFICATION, PATHOLOGY AND MEASURES OF DISEASE ASSESSMENT.

2.1 Classification of OA.

2.2 Classification of RA.

2.3 Pathology of OA.

2.3.1 General features of OA.

2.3.3.1 Cartilage degradation.

2.3.3.2 Nitric oxide synthesis damages chondrocytes.

2.3.3.3 Sulphation pattern of GAGs in articular cartilage.

2.3.3.4 Bone changes.

2.3.3.5 Inflammation.

2.3.3.6 Angiogenesis.

2.3.3.7 Oxidative stress.

2.3.2 Structure of cartilage.

2.3.3 Pathogenesis of OA.

2.4 Pathology of RA.

2.4.1 General features of RA.

2.4.2 Immunopathogenesis and production of inflammatory mediators.

2.4.3 Autoantibodies: rheumatoid factor.

2.4.4 Glycosylation patterns of IgG and complement activation.

2.4.5 Dietary lectins, gut translocation and the shared epitope.

2.4.6 Abnormal gut microflora.

2.4.7 Reactive oxygen and nitrogen species involved in damage to the rheumatoid joint.

2.4.7.1 Phagocytosis.

2.4.7.2 Hypoxia-reperfusion injury and joint pH.

2.4.7.3 Involvement of nitric oxide and peroxynitrite.

2.4.7.4 Consequences of the production of reactive oxygen and nitrogen species in the RA joint.

2.4.8 Lipid abnormalities and cardiovascular risk in RA.

2.4.8.1 C-Reactive Protein (CRP).

2.4.8.2 Dyslipidaemia.

2.4.8.3 Endothelial dysfunction.

2.4.8.4 Oxidised-LDL in the joint and the formation of fatty streaks.

2.4.8.5 Adhesion molecules.

2.4.8.6 Haemostatic changes.

2.4.8.7 Elevated homocysteine and vitamin B6 status.

2.4.8.8 Elevated homocysteine and impaired sulphur metabolism.

2.4.8.9 Insulin resistance.

2.4.9 Angiogenesis.

2.4.10 Osteoporosis.

2.5 Assessment of severity of RA and OA.

2.5.1 Outcome measures for rheumatoid arthritis.

2.5.1.1 Patient's global assessment.

2.5.1.2 Pain.

2.5.1.3 Disability.

2.5.1.4 Swollen and tender joint counts.

2.5.1.5 Acute phase reactants.

2.5.1.6 RA Quality of Life Index.

2.5.1.7 Radiological assessment.

2.5.2 Some outcome measures for OA.

2.5.2.1 Patient global assessment.

2.5.2.2 Pain score.

2.5.2.3 New joint score.

2.5.2.4 Severity score.

2.5.2.5 Disability.

2.5.2.6 Radiological assessment.

CHAPTER 3: AETIOLOGY AND RISK FACTORS FOR RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS.

3.1 Introduction.

3.2 Genetic risk factors.

3.3 Age.

3.4 Gender.

3.5 Biomechanical factors as risk factors for OA.

3.5.1 Occupation, sport and physical activity.

3.5.2 Joint trauma and surgery.

3.5.3 Load distribution and malalignment.

3.5.4 Muscle weakness.

3.6 Obesity.

3.7 Smoking.

3.8 Dietary factors.

3.8.1 Olive oil.

3.8.2 Fish and n-3 PUFA.

3.8.3 Meat.

3.8.4 Fruit and Vegetables.

3.8.5 Antioxidants.

3.8.6 Vitamin C.

3.8.7 b-Cryptoxanthin.

3.9 Beverage consumption.

3.9.1 Coffee and tea.

3.9.2 Alcohol 3.10 Hormones, OA and RA 3.11 Medical risk factors for RA.

3.11.1 Infection and microorganisms 3.11.2 Blood transfusions.

3.11.3 Haemochromatosis.

CHAPTER 4: CURRENT MANAGEMENT OF OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS.

4. 1 Overview of current treatment.

4.2 Medication.

4.2.1.Analgesia.

4.2.2 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs).

4.2.3Disease Modifying Anti-Rheumatic Drugs (DMARDS).

4.2.4Biological agents (anti-cytokine therapy).

4.2.5Glucocorticoids4.3 Surgical management.

4.3.1 Preventative.

4.3.2 Preservative.

4.3.3 Corrective.

4.3.4 Salvage.

4.4 Physiotherapy and occupational therapy management.

4.4.1 Physiotherapy.

4.4.2 Occupational therapy.

4.5 Acupuncture.

CHAPTER 5: NUTRITIONAL STATUS AND ADEQUACY OF THE DIET IN RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS.

5.1 Introduction.

5. 2 Body mass index (BMI).

5.2.1 Low BMI and rheumatoid cachexia.

5.2.1 High BMI.

5.3 Malnutrition and malnutrition screening.

5.4 Macronutrient intake.

5.5 Micronutrient intake and deficiency in RA.

5.7 Importance of individual assessment.

5.6 Drug nutrient interactions.

CHAPTER 6: POPULAR DIETARY APPROACHES.

6.1 Introduction.

6.2 Well-known popular diets.

6.3 Food avoidance.

6. 4 Supplements.

CHAPTER 7: EXCLUSION, VEGETARIAN, VEGAN AND OTHER DIETARY APPROACHES IN RHEUMATOID ARTHRITIS.

7.1 Introduction.

7.2 Exclusion diets.

7.3 Vegan and vegetarian diets.

7.4 The Mediterranean diet.

7.5 Elemental diets.

7.6 Summary of dietary findings.

7.7 Possible mechanisms by which exclusion, elemental, vegan and vegetarian diets may exert their effects on RA.

7.7.1 Food allergy or intolerance.

7.7.2 Alteration of gastro-intestinal permeability.

7.7.3 Effect of lectins.

7.7.4 Alteration to gut flora: pre- and pro-biotic dietary components.

7.7.5 Weight reduction and associated immunosuppression.

7.7.6 Placebo effect.

7.8 Risks of undertaking dietary modifications.

CHAPTER 8: ROLE OF MICRONUTRIENTS IN THE AMELIORATION OF RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS.

8.1 Introduction.

8. 2 Antioxidants in the body.

8. 3 Vitamins A, C and E and b-carotene and their role in RA and OA.

8.3.1 Description and functions of vitamins A, C and E and b-carotene.

8.3.2 Studies of vitamins A, C and E and b-carotene in RA and OA.

8.3.3 Conclusions and recommendations from these studies.

8.4 Selenium in RA and OA.

8.4.1 Functions of selenium relevant to RA and OA.

8.4.2 Selenium status in OA and RA patients.

8.4.3 Prospective and intervention studies with selenium.

8.4.4 Recommendations for selenium intake.

8.5 Copper, zinc and RA and OA.

8.5.1 Functions of copper and zinc relevant to RA and OA.

8.5.2 Copper and zinc status in OA and RA patients.

8.5.3 Intervention studies with copper and zinc.

8.5.4 Recommendations for intake of copper and zinc in RA and OA.

8. 6 Iron in RA and OA.

8.6.1 Functions of iron relevant to RA and OA.

8.6.2 Iron status in OA and RA patients.

8.6.3 Effect of resolution of anaemia on RA symptoms and quality of life.

8.6.4 Recommendations for iron intake.

8. 7 Vitamin D in OA and RA.

8.7.1 Role of vitamin D in relation to OA and RA.

8.7.2 Studies looking at the relationship between vitamin D and arthritis.

8.7.3 Vitamin D status.

8.7.4 Recommendations for vitamin D intake.

8.8 Boron and arthritis.

8.9 Magnesium.

8.10 Potassium.

8.11 Recommendations for micronutrient use in RA and OA.

8.11.1 How should these recommendations best be achieved - dietary intake, fortification, or supplementation?.

CHAPTER 9: POLYUNSATURATED FATTY ACIDS IN THE TREATMENT OF ARTHRITIS.

9.1 Essential fatty acids and their nomenclature9.2 Role of fatty acids: relevance to arthritis.

9.3 Metabolism of polyunsaturated fatty acids.

9.3.1 Conversion to long-chain PUFAs.

9.3.2 Formation of eicosanoids from PUFA precursors.

9.4 Inflammatory potential of eicosanoids.

9.5 Eicosanoids in arthritis.

9.6 Rationale for the use of specific PUFAs in the treatment of arthritis.

9.7 Beneficial effects of GLA, DGLA and n-3 PUFAs.

9.7.1 Effects on eicosanoids.

9.7.2 Effects on cytokine production.

9.7.3 Effects of fish oils on cytokine production depend on genotype.

9.7.4 Effects on lymphocyte proliferation.

9.7.5 Effects of n-3 PUFA on cartilage integrity.

9.8 Epidemiology of n-3 PUFA and arthritis.

9.9 Interventions with GLA and DGLA in arthritic patients.

9.10 Interventions with fish oil in RA patients.

9.11 Interventions with fish oil in RA patients with reduced n-6 PUFA intake.

9.12 Limitations of human intervention studies with PUFAs.

9.13 Recommendations for PUFA intake in inflammatory arthritis.

9.14 Current intakes of PUFAs.

9.15 How to achieve an anti-inflammatory intake of PUFAs.

9.15.1 Oily fish.

9.15.2 Fish-oil supplements.

9.15.3 Animal sources of n-3 PUFAs: grass-fed meat and game.

9.15.4 Sources of short-chain n-3 PUFA.

9.15.5 Direct long-chain n-3 PUFA sources for vegetarians or non-fish eaters.

9.15.6 Practical guidelines for vegetarians.

9.16 Reducing n-6 PUFAs in the diet.

9.17 Collateral benefits of increasing the intake of long-chain n-3 PUFAs.

9.17.1 Reduced risk of cardiovascular mortality.

9.17.2 Reduced requirement for NSAIDs or other drugs.

9.18 Safety issues.

9.18.1 Contraindications for cod liver oil supplements.

9.18.2 Side effects of n-3 PUFAs.

9.18.3 Peroxidation issues related to increased n-3 PUFA intake.

9.18.4 Effects on immunity of increased n-3 PUFA.

9.18.5 Contamination with dioxins and dioxin like PCBs.

9.18.6 Fish contamination with mercury.

9.19 Ethical issues: fish stocks.

9.20 Conclusion.

CHAPTER 10: GLUCOSAMINE AND CHONDROITIN IN OSTEOARTHRITIS.

10.1 Introduction.

10. 2 What are glucosamine and chondroitin?.

10.3 Sources of glucosamine and chondroitin.

10.4 Bioavailability10.5 Postulated mechanism of action.

10. 6 Trials of glucosamine and chondroitin and their efficacy in OA.

10.6.1 Meta-analyses of glucosamine and chondroitin trials.

10.6.2 Long-term glucosamine trials.

10.6.3 Combination trials including manganese.

10.6.4 Glucosamine trials with negative findings.

10.7 Possible reasons for conflicting trial results.

10.8 Topical treatment.

10.9 Comparison with NSAIDs.

10.10 Safety issues.

10.10.1 Adverse events.

10.10.2 Contraindications.

10.10.3 Caution with usage.

10.11 Further studies.

10.12 Preliminary results from GAIT.

10.13 Conclusions and recommendations for glucosamine and chondroitin use.

10.14 Supplements of glucosamine sulphate and chondroitin available.

CHAPTER 11: OTHER FOODS OR SUPPLEMENTS MARKETED FOR ARTHRITIS RELIEF.

11.1 Introduction.

11.2 Green tea extracts.

11.3 Ginger.

11.4 New-Zealand green-lipped mussel.

11.5 Methylsulfonylmethane (MSM).

11.6 Noni Juice.

11.7 Shark Cartilage.

11.8 Herbal remedies.

11.9 Conclusion.

CHAPTER 12: ASSESSMENT OF LEVEL OF EVIDENCE FOR NUTRITIONAL RECOMMENDATIONS AND SUGGESTIONS FOR THE FUTURE.

12.1 Summary of nutritional factors that may affect risk of RA and OA.

12.2 Level of evidence for nutritional recommendations in RA and OA.

12.3 Suggestions for the future.

APPENDICES.

Appendix 1 How to interpret the statistical data on studies quoted in this book.

Appendix 2 Malnutrition Universal Screening Tool - MUST.

Appendix 3 Table of UK and USA dietary reference values for vitamins, minerals and trace elements.

Appendix 4 Elimination diet for rheumatoid arthritis.

GLOSSARY.

INDEX.