BOARD CERTIFIED IN FAMILY MEDICINE EDITOR IN CHIEF, ALTERNATIVE THERAPIES IN HEALTH AND MEDICINE

MARK HYMAN, MD
www.drhyman.com

Getting to the Cause of Osteoarthritis

Experiencing joint pain, stiffness, swelling, crackling noises, bony growths, and other painful and movement limiting symptoms, more than 20 million people in the United States have osteoarthritis (OA), the most common form of arthritis. Symptoms typically appear in the fifth and sixth decades of life. A disease involving the breakdown of cartilage in the joint, osteoarthritis most commonly occurs in the hands, hips, knees and spine. With the loss of cartilage, the bones of any effected joints will lose their cushioning, so that in movement, bone moves against bone, which causes discomfort and limits range of motion. In the past, people assumed that arthritis came about from the wear and tear, and breakdown of these physical structures due to use. However, now doctors have begun to recognize this disease as an inflammatory disorder, often with significant systemic causes that can and should be addressed. In my medical practice, Ive often found that food allergies, particularly to gluten, play a part. In one study, 11% of patients with osteoarthritis were found to have gluten antibodies in their joints. This indicates a systemic inflammatory reaction from eating gluten found in wheat, barley, rye, spelt, kamut and oatsa far more widespread problem than many people realize. Lyme disease or other chronic infections can also be a factor. Often the gut is a major source of generalized systemic inflammation due to imbalances in the digestive tract. That is because 60% of our immune system resides in our intestinal tract. Irritable bowel syndrome and inflammatory bowel disease can both lead to arthritis and arthritis-like symptoms because of how the gut and the rest of the body is connected through the immune system.

Diet contributes to chronic inflammation via such foods as meat, alcohol, sugar, processed and refined foods. Whats more, nutritional deficiencies such as low levels of omega 3 fatty acids or antioxidants can lead to joint inflammation. Fortunately, all of these contributors can be identified and addressed. Testing for the Factors Contributing to Arthritis Since we are all biochemically unique and each of us is an individual, different people may be troubled by a disease, like arthritis, due to different reasons. Thats why, for my arthritis patients, I undertake specific tests, which I have found most helpful in pinpointing the exact cause for that person. Most helpful are the following: The C-reactive protein test: This can identify generalized inflammation that may arise from many possible causes. Once this is identified the specific cause must be found. However some people who have a normal C-reactive protein test DO have inflammation, but it shows up in a different way. If only medicine were black and white! The IGG food allergy or sensitivity test: This test reveals low-grade food reactions and sensitivities that can also cause joint pains. Most people dont realize that they dont need to have a full blown allergic reaction to be impacted by food sensitivities. While allergic reactions are more rare, sensitivities that produce symptoms are common. The ones I see in my patients most are those to dairy, eggs, gluten, yeast, soy, peanuts, and occasionally nightshades and corn. Comprehensive Stool Analysis: The gut plays a big role in the inflammatory process. Imbalances in the gut flora, (due to the overgrowth of yeast, parasites or bacteria), can be ascertained. Urinary Organic acids: This specialized test can identify by-products and chemicals produced by abnormal bacteria in the gut that are absorbed into the body, then excreted in the urine. These organic acids can be helpful in looking at gut imbalances particularly small bowel overgrowth of bacteria, and yeast, which often trigger generalized inflammation in the body and arthritis.

3 Testing for Lyme Disease and Other Infections: Hidden infections, like Lyme disease, can trigger arthritis-like symptoms. Testing for Autoimmune Markers: Rheumatoid arthritis arises from an underlying autoimmune condition. This should be ruled out through testing to identify rheumatoid factor, anti-nuclear antibodies as well as other more complex markers for autoimmune disease. Uric Acid Levels: When elevated, uric acid, can signify gout, with symptoms similar to arthritis. Insulin resistance, or pre-diabetes most often causes this. Vitamin D Status: A vitamin D deficiency is a major cause of osteoporosis, leading to chronic bone weakening and loss, a key contributor to arthritis and as well as generalized muscle and joint pains. Many people have low vitamin D levels due to reduced sun exposure from our indoor lifestyles, as well as our lower intake of fatty fish like mackerel, herring and sardines, which are good sources of vitamin D. As a result, most people need vitamin D supplementation, and the best type is vitamin D3.

Are You Gluten Sensitive? IgG and IgA anti-gliadin antibodies and tissue transglutaminase antibodies tests: These tests can help identify gluten sensitivity, which can also trigger arthritis. Full blown celiac disease affects 1% of the population or 3 million people, but up to 30% of the population has the gene that predisposes them to some gluten sensitivity which can lead to a generalized inflammation. Gene specific tests including HLA-DQ8 and HLA-DQ2 are also helpful to diagnose cases where the antibody levels are not clear. Stool testing can identify gluten antibodies when the blood antibodies are negative because that is the first site that gluten comes into contact with the immune system and can show early changes.

Nutrition for Arthritis Sufferers To improve arthritis, first of all avoid common food allergens such as dairy, eggs, corn, soy, yeast (found in bread, wine and beer), nuts, nightshades (like tomatoes and eggplant) and

4 gluten for at least one month. I recommend that you eliminate gluten (found in wheat, oats, rye, and barley) for at least three months to see if you experience less joint discomfort. In addition, I encourage people to get rid of all processed foods, high processed corn syrup, and trans fatty acids, all of which trigger inflammation. Instead enjoy whole foods, like colorful fruits and vegetables, rich in phytonutrients and antioxidants. I encourage the intake of omega 3 fats from supplements or fatty fish such as wild salmon, sardines and herring. These smaller fish do not store heavy metals, as do larger fish like tuna. Certain foods like cherries contain both anti-inflammatory properties. Increase your fiber intake from beans, nuts, seed, vegetables and fruit to normalize the gut function, which is helpful for arthritis. Exercise Exercise helps reduce arthritis pain and swelling. In fact in several studies they have found that people with arthritis who did home exercise programs had a 23% reduction in pain compared to only 6% reduction in people who do not exercise. Unfortunately, people with arthritis may avoid the very exercise that helps lower overall pain by reducing inflammation. Try walking or using low impact machines like the elliptical trainer, or swimming. Yoga and stretching can also help reduce pain and stiffness. Integrative Therapies Studies show that acupuncture is affective with arthritis. Yoga can increase joint flexibility and decrease pain. Supplements and Herbs A number of supplements and herbs can help, including the following: Glucosamine and chondroitin: (1500 mg of glucosamine sulfate and 1000-1500 mg of chondroitin sulfate a day) work together to help improve joint function and mobility. In

5 numerous studies they have helped actually increase the health of the joints by building up the cartilage and reducing the destruction of the joints, which drugs cant do. Omega-3 fatty acids: Found in fish oil, as EPA and DHA (1000-2000 gm a day), arthritis sufferers benefit from these fats to control inflammation. Food extracts: avocado and soy derivatives, which may help stimulate the growth of collagen. In a study of 164 people with osteoarthritis, people who took avocado and soy bean extracts for six months experienced less pain, increasing mobility and reduced medication without side effects. Anti-inflammatory herbs: Ginger, turmeric, which is the yellow spice in curry, cherry extract, Boswellia or frankincense, and willow are available as supplements. Capsaicin (used topically) is the main component in hot chili peppers. Effects are felt three to six or seven days after applying the capsaicin cream to the skin. Probiotics, such as acidopholous help normalize gut flora at a dose of 5-25 billion live organisms a day. SAM-e (1200 mg a day) has been shown to improve joint pain in 12 weeks or more. Vitamin D3 (2000 units a day) prevents cartilage breakdown of cartilage and promotes bone health. Periodically check your vitamin D levels to keep them between 50 and 75. Proteolytic enzymes like Wobenzyme or bromelain can help break down inflammatory proteins and reduce inflammation and pain. Niacinamide (1500 mg) is a form of B3. In a preliminary study, arthritis sufferers who took this dose had a 30% improvement in symptoms. Multi-vitamin and mineral: a high potency vitamin and mineral supplement provides many of the nutrients needed for proper joint repair and healing as well as antioxidants. Antioxidants: many additional antioxidants are available including plant compounds such as resveratrol, green tea, cocoa polyphenols, bioflavoinoids and many others, which have powerful anti-inflammatory effects as well. Other powerful anti-oxidants can be helpful such as lipoic acid, n-acetylcysteine and others to help reduce the oxidative damage to the joints. Medications and Surgery

6 Though helpful for relief of pain short term, medications like aspirin and the non-steroidal inflammatories, like Ibuprofen and Naprosyn, have significant downsides. Long term they actually increased joint destruction and damage the intestinal lining leading to increased risk of intestinal hemorrhage. The new COX inhibitors such as celecoxcib or Celebrex may help reduce pain but can have other side effects perhaps including increased risk of heart attack. Tylenol may be helpful although this can cause liver stress and deplete liver reserves for detoxification. Other treatments include steroid injections or oral steroids, which can provide only short-term relief and often lead to other complications. Hyaluronic acid is another treatment that has been available. It can be injected into joints once per week for three to five weeks and the effects may last up to a year and can be helpful. Until arthritis is fairly advanced, surgery has only limited benefits. A recent study, comparing arthroscopic surgery with the placebo (no treatment) showed no significant difference in the debridement or cleaning out of joints. In cases of advanced arthritis, of the hips and knees, joint replacement can lead to dramatic increase in activity and reduction of pain. Usually this joint replacement is reserved for older people because the joints last only 20 years. Perhaps new joints may be developed to last longer. Summary Arthritis has many causes including diet, lifestyle, food allergies, nutritional deficiencies and possible infections. I recommend specific testing to identify the causes that affect you specifically so that your treatment can be targeted. Since diet plays a huge role in regulating the inflammatory system in the body, an anti-inflammatory diet is the first step. Elimination diets to reduce inflammation or avoid allergic foods are also helpful. Many supplements can help rebuild joint cartilage or reduce inflammation naturally without side effects. Acupuncture and exercise can also reduce pain and inflammation. Medication and surgery should be reserved as a last resort treatment, only if you are unsuccessful with the often more effective lifestyle and supplement and herbal therapies. A comprehensive

7 approach to diagnosis and treatment by getting rid of the underlying causes is essential to success. Mark Hyman, M.D.