Nutrition and Arthritis

282 Pages·2008·1.34 MB·English

Nutrition and Arthritis
Margaret Rayman
BSc, DPhil (Oxon), RPHNutr
Division of Nutrition, Dietetics and Food Science
School of Biomedical and Molecular Sciences
University of Surrey, Guildford, UK
Alison Callaghan
BSc, SRD
Senior Dietitian
Queen Elizabeth The Queen Mother Hospital, Kent, UK

Nutrition and Arthritis
Margaret Rayman
BSc, DPhil (Oxon), RPHNutr
Division of Nutrition, Dietetics and Food Science
School of Biomedical and Molecular Sciences
University of Surrey, Guildford, UK
Alison Callaghan
BSc, SRD
Senior Dietitian
Queen Elizabeth The Queen Mother Hospital, Kent, UK
© 2006 Margaret Rayman and Alison Callaghan
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First published 2006 by Blackwell Publishing Ltd
ISBN-10: 1-4051-2418-0
ISBN-13: 978-1-4051-2418-8
Library of Congress Cataloging-in-Publication Data
Rayman, Margaret.
Nutrition and arthritis / Margaret Rayman, Alison Callaghan.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-4051-2418-8 (pbk. : alk. paper)
ISBN-10: 1-4051-2418-0 (pbk. : alk. paper)
1. Arthritis—Nutritional aspects. 2. Arthritis—Diet therapy.
[DNLM: 1. Arthritis—diet therapy. 2. Nutrition Therapy. WE 344 R267n 2006]
I. Callaghan, Alison. II. Title.
RC933.R332 2006
616.7′220654—dc22
2005035552
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‘Leave your drugs in the chemist’s pot if
you can heal the patient with food.’
Hippocrates, the Father of Medicine

Contents
Acknowledgements xiii
Abbreviations xiv
1 Introduction 1
1.1 The range of rheumatic diseases 1
1.2 Rheumatoid arthritis (RA): description 2
1.3 Osteoarthritis (OA): description 2
1.4 Incidence and prevalence 3
1.5 Mortality 5
1.6 Morbidity 6
1.7 Economic cost of arthritis 7
1.8 The aim of this book 8
2 Classification, pathology and measures of disease assessment 11
2.1 Classification of OA 11
2.2 Classification of RA 11
2.3 Pathology of OA 13
2.3.1 General features of OA 13
2.3.2 Structure of cartilage 14
2.3.3 Pathogenesis of OA 15
2.3.3.1 Cartilage degradation 15
2.3.3.2 Nitric oxide synthesis damages chondrocytes 17
2.3.3.3 Sulphation pattern of GAGs in articular cartilage 17
2.3.3.4 Bone changes 17
2.3.3.5 Inflammation 18
2.3.3.6 Angiogenesis 18
2.3.3.7 Oxidative stress 18
2.4 Pathology of RA 19
2.4.1 General features of RA 19
2.4.2 Immunopathogenesis and production of inflammatory
mediators 20
2.4.3 Autoantibodies: rheumatoid factor 21
2.4.4 Glycosylation patterns of immunoglobulins and
complement activation 22
2.4.5 Dietary lectins, gut translocation and the shared epitope 23
2.4.6 Abnormal gut microflora 24
2.4.7 Reactive oxygen and nitrogen species involved in damage to
the rheumatoid joint 24
2.4.7.1 Phagocytosis 25
2.4.7.2 Hypoxia reperfusion injury and joint pH 25
vi Contents
2.4.7.3 Involvement of nitric oxide and peroxynitrite 25
2.4.7.4 Consequences of the production of reactive oxygen
and nitrogen species in the RA joint 26
2.4.8 Lipid abnormalities and cardiovascular risk in RA 26
2.4.8.1 C-Reactive Protein (CRP) 27
2.4.8.2 Dyslipidaemia 27
2.4.8.3 Endothelial dysfunction 27
2.4.8.4 Oxidised LDL in the joint and the formation of
fatty streaks 27
2.4.8.5 Adhesion molecules 27
2.4.8.6 Haemostatic changes 27
2.4.8.7 Elevated homocysteine and low vitamin B status 28
6
2.4.8.8 Elevated homocysteine and impaired sulphur
metabolism 28
2.4.8.9 Insulin resistance 30
2.4.9 Angiogenesis 30
2.4.10 Osteoporosis 31
2.5 Assessment of severity of RA and OA 31
2.5.1 Outcome measures for RA 31
2.5.1.1 Patient’s global assessment 31
2.5.1.2 Pain 32
2.5.1.3 Disability 32
2.5.1.4 Swollen and tender joint counts 32
2.5.1.5 Acute phase reactants 33
2.5.1.6 RA quality of life index 33
2.5.1.7 Radiological assessment 33
2.5.2 Some outcome measures for OA 34
2.5.2.1 Patient global assessment 34
2.5.2.2 Pain score 34
2.5.2.3 New joint score 34
2.5.2.4 Severity score 34
2.5.2.5 Disability 34
2.5.2.6 Radiological assessment 35
3 Aetiology and risk factors for osteoarthritis and rheumatoid arthritis 40
3.1 Introduction 40
3.2 Genetic risk factors 40
3.3 Age 42
3.4 Gender 44
3.5 Biomechanical factors as risk factors for OA 45
3.5.1 Occupation, sport and physical activity 45
3.5.2 Joint trauma and surgery 45
3.5.3 Load distribution and malalignment 46
3.5.4 Muscle weakness 46
3.6 Obesity 46
3.7 Smoking 48
3.8 Dietary factors 49
3.8.1 Olive oil 50
3.8.2 Fish and n-3 polyunsaturated fatty acid (PUFA) 50
3.8.3 Meat 50
Contents vii
3.8.4 Fruit and vegetables 51
3.8.5 Antioxidants 51
3.8.6 Vitamin C 51
3.8.7 β-Cryptoxanthin 52
3.9 Vitamin D 52
3.10 Beverage consumption 53
3.10.1 Coffee and tea 53
3.10.2 Alcohol 54
3.11 Hormones, OA and RA 55
3.12 Medical risk factors for RA 56
3.12.1 Infection and micro-organisms 56
3.12.2 Blood transfusions 56
3.12.3 Haemochromatosis 57
4 Current management of osteoarthritis and rheumatoid arthritis 61
4.1 Overview of current treatment 61
4.2 Medication 62
4.2.1 Analgesia 62
4.2.2 Non-steroidal anti-inflammatory drugs (NSAIDs) 63
4.2.3 Disease-modifying antirheumatic drugs (DMARDs) 65
4.2.4 Biological agents 68
4.2.5 Glucocorticoids 68
4.2.6 Side effects of arthritis medication likely to affect
nutritional status 69
4.3 Surgical management 69
4.3.1 Preventative 69
4.3.2 Preservative 71
4.3.3 Corrective 71
4.3.4 Salvage 72
4.4 Physiotherapy and occupational therapy management 72
4.4.1 Physiotherapy 72
4.4.2 Occupational therapy 74
4.5 Acupuncture 74
5 Nutritional status and adequacy of the diet in rheumatoid arthritis
and osteoarthritis 78
5.1 Introduction 78
5.2 Body mass index (BMI) 78
5.2.1 Low BMI and rheumatoid cachexia 78
5.2.2 High BMI 80
5.3 Malnutrition and malnutrition screening 81
5.4 Macronutrient intake 82
5.5 Micronutrient intake and deficiency in RA 82
5.6 Drug–nutrient interactions 85
5.7 Importance of individual assessment 86
6 Popular dietary approaches 88
6.1 Introduction 88
6.2 Well known popular diets 88
viii Contents
6.3 Food avoidance 90
6.4 Supplements 90
7 Exclusion, vegetarian, vegan and other dietary approaches in
rheumatoid arthritis 92
7.1 Introduction 92
7.2 Exclusion diets 92
7.3 Vegan and vegetarian diets 95
7.4 The Mediterranean diet 97
7.5 Elemental diets 98
7.6 Summary of dietary findings 100
7.7 Possible mechanisms by which exclusion, elemental, vegan and
vegetarian diets may exert their effects on RA 101
7.7.1 Food allergy or intolerance 102
7.7.2 Alteration of gastrointestinal permeability 103
7.7.3 Effect of lectins 103
7.7.4 Alteration to gut flora: pre- and probiotic dietary components 105
7.7.5 Weight reduction and associated immunosuppression 107
7.7.6 Placebo effect 108
7.8 Risks of undertaking dietary modifications 108
8 Role of micronutrients in the amelioration of rheumatoid arthritis and
osteoarthritis 112
8.1 Introduction 112
8.2 Antioxidants in the body 112
8.3 Vitamins A, C and E and β-carotene and their role in RA and OA 113
8.3.1 Description and functions of vitamins A, C and E and
β-carotene 113
8.3.2 Studies of vitamins A, C and E and β-carotene in
RA and OA 114
8.3.3 Conclusions and recommendations from these studies 116
8.4 Selenium in RA and OA 117
8.4.1 Functions of selenium relevant to RA and OA 117
8.4.2 Selenium status in OA and RA patients 119
8.4.3 Prospective and intervention studies with selenium 120
8.4.4 Recommendations for selenium intake 122
8.5 Copper, zinc and RA and OA 124
8.5.1 Functions of copper and zinc relevant to RA and OA 124
8.5.2 Copper and zinc status in OA and RA patients 124
8.5.3 Intervention studies with copper and zinc 125
8.5.4 Recommendations for intake of copper and zinc in
RA and OA 126
8.6 Iron in RA and OA 126
8.6.1 Functions of iron relevant to RA and OA 126
8.6.2 Iron status in OA and RA patients 127
8.6.3 Effect of resolution of anaemia on RA symptoms and
quality of life 129
8.6.4 Recommendations for iron intake 129
8.7 Vitamin D in OA and RA 129
8.7.1 Role of vitamin D in relation to OA and RA 129