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Dr. Bernard Presser D.C.
5696 Magnolia Woods Drive
Memphis, TN 38134
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Arthritis is the leading cause of disability in the U.S. with one in three adults suffering from some form of arthritis or other chronic joint problem. Between 1% and 3% of the population suffers with rheumatoid arthritis (RA), and women are more likely to have it than men.
Rheumatic diseases usually affect synovial membranes lining joint surfaces, in addition to cartilage, bone, tendons, ligaments, interstitial tissues, and blood vessels. Many joints may be inflamed, particularly small joints of the hands, wrists, and feet, often spreading to the knees and hips. Affected joints (usually bilateral) are swollen, painful, warm, red, and stiff on awakening or after prolonged immobility. Nodules develop and eventually crippling deformities may occur with progressive joint destruction. Other symptoms include depression, weight loss, weakness, fatigue, and low-grade fever. Typically, there are periods when symptoms lessen in severity or disappear and periods when symptoms increase in severity or new ones appear. Symptoms mimic other illnesses or other forms of arthritis, so diagnosis may be challenging in beginning stages. Blood markers, so-called rheumatoid factors, are found in people with conditions other than RA such as lupus and endocarditis. Thus, a diagnosis of RA may not be made until the disease flourishes and causes joint damage. Though viewed as a joint disease, RA can have widespread effects. For example, osteoporosis can develop. RA does not originate in the joints, but in other bodily systems which affect the joints.
An inflamed synovium is central to RA. The synovial membrane is a thin, soft, pliable layer of connective tissue that lines the capsule of a joint (but not the joint cartilage). Along with the cartilage, it completely encloses the joint cavity. It secretes a thick, sticky, gelatinous lubricating gel: synovial fluid. In RA the synovial membrane becomes swollen, fills with white blood cells and plasma, and becomes thicker. With increased size and thickness, granulation tissue (or pannus, an outgrowth of new capillaries and eventually fibrous scar tissue) is formed. There is an accumulation of fluid or pus, which is waste from the inflammation process. Many cells, proteins, enzymes, mediators and other substances involved in immune and inflammation responses are found in the joint areas. Some are required for "remodeling" - the breakdown of dead or dying cells to make room for new tissue.
RA is usually considered an "autoimmune disease" - a reaction wherein the body destroys some of its own tissues. What triggers such an autoimmune reaction, how and why this occurs, remains a medical mystery. There are only theories. i
RA is a progressive inflammatory condition affecting mostly (but not completely) the joints, leading to acute and chronic pain, destruction of cartilage, bone erosion, and chronic deformity and crippling. Called an "autoimmune disease," the theory is that, for some unknown reason, the body attacks itself. Antibodies "somehow" orchestrate the collapse of joint linings, immune cells such as T cells and B cells are thought to cause damage, antigens are sought and fingered as likely targets, many micro-organisms have been scrutinized as causal candidates, chemical messengers (such as cytokines) are watched for signal goofs. But the culprits have not been scientifically flushed out and the conclusion is that there are diverse causes.
The dogma that joint damage is the consequence of inflammation rather than a parallel process has recently been "called into question." The resistance may have to do with "incorrect assumptions and paradigms that are currently driving investigation." Now many doctors are questioning the belief in autoimmune disease. The body is designed to balance and protect itself, not to spontaneously attack itself. However, the immune system can be overtaxed and rendered incapable of completely or satisfactorily handling insult or injury. There may be disruptions or dysfunctions that affect immune function or certain tissues and organs. Inflammation is the process the body uses to attempt repair, not self-destruct. This includes engulfment and removal of dead or dying cells as well as laying a matrix for building new replacement tissues. But in RA, either inflammation cannot keep up with the damage occurring, or there is some interference or incapacitation affecting the process.
Since women are diagnosed with RA three times more frequently than men, hormones and obstetric history have been examined. Among premenopausal women, the risk is greatest among those who never gave birth. Pregnancy appears to have an ameliorating effect, remission occurring around the third month and flare-ups returning around the third month of nursing. Fluctuations in estrogen, progesterone, and prolactin occur in pregnancy, and the adrenal glands play an essential role.
The gastrointestinal (GI) tract may be involved in rheumatic disorders. Numerous studies link unhealthy GI conditions including abnormal bacteria and insufficient hydrochloric acid or digestive enzymes to RA. Patients frequently have high blood sugar and impaired glucose tolerance which can occur with chronically excessive cortisone levels (due to, for example, excessive prolonged stress) or liver toxicity or imbalance. DHEA, an adrenal hormone, is often low. A reduction of adrenal "output" (adrenal fatigue) or chronically high adrenal hormone levels (leading to adrenal fatigue) can cause arthritic symptoms, compromise immune function, and affect digestion. RA symptoms have been relieved with physiological doses of balanced adrenal hormones. People with RA often suffer with a form of depression that includes foul moods, lack of energy, and excessive sleep indicating "a weak hypothalamic/ pituitary/ adrenal axis response" resulting in inadequate adrenal function. The liver plays a major role in blood sugar metabolism, detoxification, digestion, food intolerances or allergies, protein processing, fat metabolism, removal of bacteria and foreign particulates and toxins, storage of fat-soluble vitamins, supplying raw materials for hormone production, regulation of blood volume, and more. Anemia in RA may be related to GI blood loss associated with the use of certain drugs. But in 60% of the cases, it is due to chronic disease -- "a reticuloendothelial iron-replete" anemia from an overtaxed immune response.
Dr. Royal Lee believed RA was linked to adrenal and liver dysfunction. There is evidence to support this, though there is probably more involved, including genetic tendencies. Other contributors may include irradiated foods, genetically-modified foods, radiation, toxic chemical stressors, sodium fluoride, nutritional deficiencies, food intolerances or allergies, food additives, and other things that can compromise the immune system and tissue health. Several studies show that patients' personal psychology and attitude play a role. Simply sharing or writing about stressful life experiences or feelings result in clinically relevant gains in health status (including hormonal and immunologic RA markers). ii
One reason medications are prescribed to RA patients is to relieve symptoms. The other reason projects a war paradigm. The immune system is viewed as the enemy, so it is attacked with the belief this will solve the problem. But it has never worked out that way. While some drugs alleviate symptoms, none have ever been shown to alter the course of the disease. So the current medical tactic involves "attacking more aggressively" in the early stages, hoping to simply delay joint damage and slow disease progression, but not cure or prevent the problem. The arsenal includes several classes of drugs.
NSAIDs or non-steroidal anti-inflammatory drugs (such as aspirin, ibuprofen, etc.) reduce pain, fever, and inflammation by interfering with some stage(s) of the inflammatory process. Possible side effects include stomach irritation, bleeding and ulceration; decreased kidney function; elevated blood pressure and accelerated cartilage destruction. New NSAIDs include Cox-2 (cyclooxygenase, pronounced cyclo-oxygen-ase) inhibitors (Celebrex, Vioxx, etc.) which relieve pain by blocking an enzyme that increases formation of inflammatory prostaglandins. Theoretically, they prevent GI bleeding and ulceration. In reality, they do little to reduce GI complications are not superior in relieving pain. They are hard on the kidneys and may increase risk for cardiovascular problems.
Steroids such as prednisone reduce inflammation but have many side effects such as high blood pressure, weight gain, diabetes, bone loss, susceptibility to infection, and mood changes.
DMARDs (disease-modifying anti-rheumatic drugs) include a variety of drugs that seem to better reduce pain, disability, and progression of joint damage during the first year. However, they are more likely to cause serious side effects. They include chelating agents, antimalarial drugs, chemotherapy drugs, anti-inflammatory drugs, immuno-suppressive drugs, and immuno-modulating drugs. Biologic agents have recently been introduced to this category, purportedly being superior in delaying or preventing deformity and disability, but again, neither curing nor preventing the disease. Yet safety remains a concern. DMARDs lessen symptoms rather than eliminate them - most patients "do not get enough relief." These drugs suppress or attack the immune system. For example, methotrexate, a form of chemotherapy also used in cancer treatment, can cause severe fatigue, nausea, bone marrow or liver toxicity, and hair loss; it essentially poisons the immune system. Among the new biologic agents is leflunomide (Arava) which slows down growth and proliferation of white blood cells and can cause severe liver toxicity, failure of bone marrow to produce certain types of blood cells important to immune responses, and nerve damage. Enbrel blocks inflammation by binding to tumor necrosis factor. It leads to rapid and dramatic decreases in pain and joint swelling, but increases chances of serious infections with some fatalities, as well as headaches, nausea, malignancies, heart failure, GI bleeding, high blood pressure, and many other side effects. Since these drugs suppress the immune system, they have the potential to cause people to be more susceptible to inflammation and infection. There is increased risk for tuberculosis, pneumonia, listeria, upper respiratory tract infections, fungal infections, and more. Increased incidence of a demyelinating disease similar to multiple sclerosis, a lupus-like syndrome, and worsening of congestive heart failure have occurred. Potential for lymphoma and other malignancies exists. Symptoms may improve temporarily, but slow progression of irreversible joint destruction nevertheless occurs. Add this to the possibility of long-term, often irreversible side effects.
Some people get better without treatment or with alternative treatments that support and assist - rather than attack -- the immune system, liver, adrenals, and other areas. iii
Individuals with RA are often highly malnourished and usually are deficient in a wide array of nutrients. Insufficient intakes of, deficiencies in, and/or benefits derived from increased intakes of the following nutrients have been found to be very helpful: calcium; magnesium; vitamin E complex; selenium; niacinamide; vitamin B6; vitamin B12; folic acid; pantothenic acid and other nutrients associated with vitamin B complex; copper; zinc; manganese; vitamin A complex; vitamin D complex; various fatty acids including those in fish oil (such as cod liver oil, a good source of omega-3 fatty acids, vitamin complexes A and D); olive oil (rich in vitamin E complex); evening primrose oil (for GLA); carotenoids; vitamin C complex; flavonoids; iron; potassium; boron; NADPH; glutathione peroxidase; sulfur-containing amino acids; coenzyme Q; and many more. Low levels of nutrients probably occur years prior to diagnosis.
Most people have heard of copper bracelets as a remedy for RA joint pain. Copper in its organic or food form appears as tyrosinase, an enzyme that occurs with vitamin C complex in foods. The adrenal glands require copper with vitamin C complex for proper function. Also the adrenals need pantothenic acid and other components of the B complex. RA patients consume excessive sodium. Adrenal fatigue often brings a craving for salt, and many highly-processed, depleted foods contain a lot of salt. Low levels of fat-soluble vitamins (carotenoids, A, D, E), fatty acids (omega-3s, gamma-linolenic acid), B complex, some trace minerals, and glutathione perioxidase may reflect an overstressed or over toxic liver. Toxic drugs add to the burden.
People with RA generally have lower than normal levels of sulfur-containing amino acids. These amino acids are needed for proteins that build bones, connective tissue, and other tissues. Methionine, for example, is essential to synovial fluid and is destroyed by cooking. The protein of synovial fluid is composed of 17 amino acids, six of which are denatured by heat. Administration of sulfur significantly decreases pain and swelling. Vegetables of the cruciferous family (cabbage, broccoli, cauliflower, kale, Brussels sprouts) and allium family (onions, garlic, leeks, etc.) are good sources of sulfur as are organic eggs. Sulfur is part of the vitamin B complex.
For over a decade, trials using chicken type II collagen have demonstrated that this "structural glue" that holds cartilage together (the gelatin that congeals when chicken or beef gristle [cartilage] is cooked) has a beneficial effect against the pain and swelling of RA. Traditional peoples added bones and cartilage to soups or just chewed on them when eating meat. The medical theory is that the collagen some how "tricks" the immune system so that it attacks the chicken collagen rather than the body's collagen. But could it possibly be that the collagen is actually supplying nutrients the body "recognizes" for joint repair and health? Significant improvement has actually occurred in morning stiffness, joint tenderness, joint swelling, and erythrocyte sedimentation rate (a blood marker of inflammatory flare ups). The collagen is purified to make it soluble, but it must be undenatured. Collagen in supplements is usually not type II collagen, is insoluble, and is denatured by manufacturing procedures. A biologically-active source, such as properly processed bone meal, trachea or other cartilage source, would probably have a superior effect, being present in whole raw food form with natural synergists intact. It provides factors that help repair, maintain, protect, and build healthy structural tissues.
Polyphenols in foods and herbs such as tart cherries and green tea have been shown to protect cartilage in animal studies. However, "cooking destroys much of the [inflammation-helping] stuff" so a slice of cherry pie will not substitute. Several herbs have induced benefits such as reduced pain, reduced swelling, and improved motility. They include stinging nettles, turmeric (or its component, curcumin), Boswellia, willow bark, ginger, celery root, yucca, cayenne pepper, and the Chinese "thunder god vine" (Tripterygium wilfordii). The enzyme bromelain (from pineapple) has demonstrated its value. Years ago, research discovered an "anti-stiffness factor" in raw cream and butter (that is destroyed by pasteurization) and in raw cane juice that showed clinical benefits in patients with RA.
Very often, people with RA have poor digestion and may need assistance with hydrochloric acid, pepsin, pancreatic enzymes, or bile salts. However, hydrochloric acid should never be used at the same time as aspirin, ibuprofen, cox-2 inhibitors, prednisone, or any other anti-inflammatory drug except under the careful supervision of a physician.
Most important is a healthful diet of whole, unprocessed foods. Refined sugars; refined flours; artificial sweeteners; chemical additives, preservatives, flavorings, and colorings; most alcohol; altered fats; and processed foods should be avoided. Raw foods should be encouraged. Real food supplements can improve the nutrient status and aid digestion, immune function, tissue health, endocrine and liver activity. The wide spectrum of natural components in whole, unprocessed, unaltered, unadulterated foods work synergistically. For example, experts stress the need for antioxidants, yet the majority of studies investigating the therapeutic use of isolated, often synthetic, antioxidant supplements have shown no real benefits for RA symptoms. But whole foods rich in antioxidants along with the other natural concurrent constituents of nutrient complexes "consistently demonstrate significant clinical benefit." iv
FATS, ALLERGIES, AND DIETS
A number of studies have reported significant benefits to people with RA from fish oil and a diet low in arachidonic acid. Among the improvements are: reduction in pain and the number of tender and swollen joints; reduction in morning stiffness; increase in grip strength and reduction in global disease activity; reduction in NSAID usage and sometimes complete elimination of NSAID treatment. Certain fish and fish oils are rich in omega-3 fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).
Reducing arachidonic acid (an omega-6 fatty acid), increasing omega-3 fatty acids, and increasing food sources of antioxidants appear to elicit a synergistic response in symptom improvement. Animal foods (meats, eggs and milk products) are the primary sources of arachidonic acid (AA) in Western diets. While intake of omega-3 fatty acids is low in this country, the "excessive" intake of AA may not be "the" problem. Traditional peoples historically consumed diets high in animal foods rich in AA without high incidence of RA. Such peoples ate meats, eggs, and milk products from healthy animals consuming their natural (omega-3 rich) diets of whole, pesticide-free foods; were not given growth hormones or antibiotics or other drugs; and were not raised in crowded, artificial, distressing environments. Most meats, eggs, and milk products in the modern supermarket contain pesticide, hormone, and drug residues among other toxins; contain imbalanced fatty acids; have depleted nutritional value; and come from animals that are essentially unhealthy. Animal foods contain higher concentrations of toxins than plant-based foods. Overcooked, over-processed (with nitrites, nitrates, artificial smoke, etc., added), and pasteurized animal products present more problems, placing more stress on the liver and immune system.
Gamma-linolenic acid (GLA), an omega-6 fatty-acid found in considerable amounts in borage oil, evening primrose oil, and black currant seed oil, is another "effective treatment" for RA. Up to a 45% improvement is reported with less disease activity, less tenderness and swelling.
For decades, medical doctors have been reluctant to accept that there is any relation between diet and arthritis. But evidence of such a connection is accumulating. "There are sound scientific bases for the notion that diet might affect RA," primarily because nutrients can influence inflammation and repair processes, and food intolerances or allergies can lead to disease symptoms.
A reduced risk for developing RA or a reduction in symptoms of existing RA have been noted with: Eating more than one serving of fish per week (better than intake of omega-3 fatty acids alone), a vegetarian diet, a low-fat vegan diet, a gluten-free vegan diet, an uncooked vegan diet of "living food." These vegan, gluten-free, and vegetarian diets eliminate many toxins and imbalanced fats present in commercially-raised or processed animal foods. They also eliminate many foods that cause allergic reactions or hypersensitivities. This particularly applies to people with a stressed liver and/or increased intestinal permeability ("leaky gut"). Vegetarian diets facilitate detoxification, promote consumption of fruits and vegetables rich in needed nutrients, and increase consumption of raw foods. But vegan diets usually are inadequate for some nutrients. And, in many cases, the diets did not reverse joint destruction. Dietary stress was reduced, but sufficient quantities of nutrients needed for disease abatement and repair were not provided.
From 40% to 75% of individuals with RA are malnourished. This malnutrition is believed to be due primarily to an abnormal metabolism or abnormal absorption of nutrients rather than inadequate intake. However, food habits are often poor. With flare-ups, nutritional status can suffer because more nutrients are required and used. Fasting produces almost immediate relief from RA symptoms. But benefits do not last after a return to "normal" eating habits. Patients have a high incidence of gut mucosal lesions and excessive permeability of the intestinal wall ("leaky gut"). Prolonged treatment with NSAIDs or Cox-2 inhibitors can increase intestinal permeability and food "antigen" absorption. Fasting and low-stress diets can decrease intestinal permeability and joint inflammation. A meat-based diet gives rise to a different set of flora and by-products than a vegetable-based diet and it leads to larger pores in the intestinal walls, permitting larger particles to enter the blood stream from the intestines.
It has been estimated that 20% to 60% of people with arthritis may be affected by food sensitivities or intolerances. Various food elimination diets have been used with some success. For example, one-third of a group of 100 RA patients were still well with symptoms "controlled" on diet alone without any medication up to 7½ years after starting their dietary regimen. Epidemiological studies show that people with RA have statistically significant higher antigen levels for gliadin (a protein in gluten-containing grains like wheat) and other proteins. Yet clinical studies indicate that increased antigen levels do not always correlate with food sensitivity in patients with RA. There is often no elevation on RAST testing for IgE-mediated allergy. Yet reports from patients of arthritic flare-ups after ingestion of certain foods are common. Apparently, food sensitivity is a factor for many people with RA whether or not blood tests verify it.
After an elimination diet, a challenge with an "offending food" can result in a flare-up of arthritis usually within 32 hours after ingestion. Exclusion of such a food from the diet can lessen the number of flare-ups. Although dietary manipulation may reduce symptoms of RA, it does not always cure it. There is "something in addition" that gives rise to RA, perhaps nutritional deficits as well as an overstressed immune system, liver, and/or adrenal glands.
Scientific reviews have implicated reactions to the following foods or ingredients: citrus fruits, chocolate, alcohol, red meats, wheat (flour, cereal, gluten), refined sugar, caffeine, some spices, carbonated drinks, corn, milk and dairy products, tartrazine, azo dyes, and various chemical flavorings, colorings, and preservatives. Elimination of the nightshade family of foods (potatoes, tomatoes, peppers [bell, jalapeno, chili, etc.], tobacco, eggplant, vodka, cayenne and paprika) helps many become pain-free and medication free. Research studies "have clearly shown that certain foods do, in fact, trigger symptoms for a great many people," and that other foods or nutrient complexes can ease symptoms and assist repair.
The pattern of response to an elimination diet is different from the response to a fast, in which almost all patients respond well within 3 to 5 days but then lose the benefits when a ‘normal' diet is resumed. The pattern of response to an elimination diet (in 30% to 40% of patients) may require 10 to 21 days and the benefits are maintained if the offending foods are avoided. Interestingly, the composition of the gut flora changes when offending foods are avoided.
Some clinical ecologists believe that RA is primarily an allergy, either to certain foods or to certain environmental chemicals (such as tobacco smoke, pesticides, cleaning agents, perfumes, hair spray, etc.) or to both. Studies suggest that smoking is a risk factor as is overweight. Coffee consumption has been indicted as a risk factor, yet perhaps not due to caffeine - individuals drinking four or more cups of decaffeinated coffee a day were more than twice as likely to develop RA as those who did not drink decaf. Exercise (aerobics, strength training, yoga, Tai-Chi, etc.), even when intensive or aggressive, brings improved strength, flexibility, functional ability, stress relief, and physical capacity. Physical activities do not worsen disease activity or significantly worsen symptoms. v
1. If feasible, for 5 to 7 days, "fast" on only freshly made (not bottled or canned) juices and all the fresh fruits and vegetables desired, organic is best. But avoid corn, all members of the nightshade and citrus families. Then:
2. Gradually reintroduce other foods. At first, include only whole, natural, unrefined, and minimally-produced items such as whole grains (try millet, quinoa, buckwheat, and amaranth too!), legumes (avoid peanut butter until later), nuts and seeds, seafood, poultry, meats, milk and milk products (certified Grade A raw milk, organic raw milk cheeses, organic butter, yogurt and cottage cheese with active cultures), sweeteners (raw honey, real maple syrup, Rapadura evaporated cane juice), herb teas. Try nightshade and citrus foods. If there are obvious reactions, eliminate the food(s) from the diet. If desired, continue the challenges with refined flours, refined sugars, over-processed items; products containing artificial or chemical colors, flavors, preservatives, and other additives. Wine can be tested, though other alcohol should probably be avoided.
3. Once any and all food sensitivities are identified and eliminated from the diet - and any reactions have abated you may now use the excellent nutritional protocols for Rheumatoid Arthritis which are available in conjunction with the Symptom Survey. Take the Symptom Survey to discover specifically what nutrition you need for your individual health problems (eliminate any supplement containing a food or foods which produced your reactions).
4. Engage in regular physical activities.
5. Include psychological and spiritual adjuncts as indicated and desired.
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Originally published as an issue of Nutrition News and Views, reproduced with permission by the author, Judith A. DeCava, CNC, LNC.