Getting Arthritis Under Control

Hello and welcome to the Nutrition Facts podcast, I’m your host Dr. Michael Greger. 

Now, I know I’ve made a name for myself in explaining how not to do certain things – just look at my books – How NOT to Die – and my upcoming book, How NOT to Diet.  But what I want to share with you is actually quite positive: what’s the best way to live a healthy life? Here are some answers.

Today we look at the best way to get arthritis under control, how to manage the inflammation that causes it. In our first story, we learn how a quarter-to a half-teaspoon a day of powdered ginger can be as pain relieving as ibuprofen, without the risk of damage to our intestinal lining.

If ginger is so effective against migraines, and the pain of menstrual cramps, what about osteoarthritis—an all-too-common disorder that produces “chronic pain and disability?” The first major study, published in 2000, showed no benefit over placebo. But, the study only lasted three weeks.

The next, in 2001, lasted longer—six weeks—and was, by the end, indeed able to show significantly better results than placebo. But, the placebo did so well, reducing pain from like sixties on a scale of 1 to 100, down to like forties, that bringing pain down that extra little bit into the thirties was not especially clinically significant. And so, an editorial in the official journal of the American College of Rheumatology concluded that ginger “should not be recommended for treatment of arthritis because of the limited efficacy.”

But, since that time, there’s been a few other trials that showed more impressive results—such that ginger is now considered indeed “able to reduce pain and disability in osteoarthritis.”

But, how well, compared to other treatments? “Since osteoarthritis is a chronic disease,” it’s especially important to weigh the risks versus benefit of treatment, and the commonly used anti-inflammatory drugs can carry “serious cardiovascular and gastrointestinal risks.”

For example, if you stick cameras down people with osteoarthritis who were on drugs like ibuprofen, nearly half were found to have major injuries to the lining of their small intestines—seven out of sixteen. Now, you can reduce that risk by taking an additional drug to counteract the side effects of the first drug. Ibuprofen-type drugs reduce our stomach linings ability to protect itself from the stomach acid; so, by blocking acid production with another drug, one can reduce the risk.

But, ginger can actually improve stomach lining protection. So, ginger, at the kinds of doses used to treat osteoarthritis, a quarter- to a half-teaspoon a day, can be considered not just neutral on the stomach, but beneficial. So, it can be as pain-relieving as ibuprofen, but without the risk of stomach ulcers.

Okay. But, this sounded a little nutty to me—topical ginger treatment, as in externally applying a ginger-soaked cloth or patch to the affected joint. It was a controlled study—compress versus patch—both showing remarkable and lasting pain relief for osteoarthritis sufferers.

But, what’s missing? A control group—there was no placebo patch. I don’t care if “ginger has been applied externally to painful joints for a thousand years.” The placebo effect has been shown to be remarkably effective in osteoarthritis to provide pain relief. So, until there’s a controlled study on topical ginger, I’m not going to believe it. But there wasn’t such a study, until twenty men stuck ginger slices onto their scrotum.

Men with inflamed testicles applied six to ten paper-thin slices of ginger over the affected testes. And, evidently, the ginger group healed nearly three times faster. Unfortunately, the original source is in Chinese; so, I can’t get further details, as is the only other controlled study on topical ginger I could find. This evidently translates to “evaluation of point plaster therapy with ginger powder in preventing nausea and vomiting from chemotherapy.”

We know ginger powder, taken orally, can be “a miracle against chemo-induced vomiting;” what about stuffing it into your belly button? The external application of ginger powder to the so-called “point of Shenque,” which is the navel, while the control group got potato powder into their belly button. And, lo and behold, the ginger group evidently had significantly less nausea and vomiting.

Unfortunately, only the abstract is in English; so, I can’t tell how they effectively blinded the patients to the treatment. I mean, presumably, it would be easy to tell whether or not you were in the ginger or placebo group just by the smell. But, maybe they controlled for that. Until we know more, I would suggest those who want to try ginger use it in their stomach, rather than on their stomach.

In our next story we hear about a randomized controlled trial comparing the safety and efficacy of drugs versus curcumin, the yellow pigment in the spice turmeric, for the treatment of autoimmune inflammatory rheumatoid arthritis.

“According to the World Health Organization, 80% of the Earth’s inhabitants rely upon  traditional medicines for their primary health-care needs, in part due to high cost of Western pharmaceuticals. Medicines derived from plants have played a pivotal role in the health care of both ancient and modern cultures. One of the prime sources of plant-derived medicines is spices.”

Turmeric is one such spice, known around the world by different names, my favorite of which is probably zard-choobag. Turmeric is the dried powdered root stalks of the turmeric plant—a member of the ginger family—from which the orange-yellow pigment curcumin can be extracted. The spice turmeric is what makes curry powder yellow, and curcumin is what makes turmeric yellow.

In recent years, more than 5,000 articles have been published in the medical literature about curcumin. Many sport impressive-looking diagrams suggesting curcumin can benefit a multitude of conditions via a dizzying array of mechanisms.

Curcumin was first isolated more than a century ago, but out of the thousands of experiments, just a handful in the 20th century were clinical studies involving actual human participants. But, since the turn of the century, more than 50 clinical trials have been done, testing curcumin against a variety of human diseases, with 84 more clinical trials on the way. But most of the 5,000 were just in vitro lab studies, which I’ve resisted covering until they moved more out of the petri dish and into the person. But, this study got my attention.

“Rheumatoid arthritis is a chronic systemic inflammatory disorder that causes progressive destruction of the cartilage and bone” of joints. “The long-term prognosis of RA is poor with as much as 80% of patients affected becoming disabled” with a “reduction of years in life expectancy.” There’s lots of drugs one can take, but unfortunately, they’re often associated with severe side effects, including blood loss, and bone loss, and bone marrow suppression, and toxicity to the liver and eyes. There’s got to be a better way.

Well, the efficacy of curcumin was first demonstrated over thirty years ago. A double-blind crossover study; curcumin versus phenylbutazone, a powerful anti-inflammatory they use in race horses. Both drugs showed significant improvement in morning stiffness, walking time, joint swelling, with the complete absence of any side effects in the curcumin group—which is more than can be said for phenylbutazone, which was pulled from the market three years later for wiping out some people’s immune systems, and their lives.

Here’s the latest. “Forty-five patients diagnosed with rheumatoid arthritis were randomized into three groups”—curcumin, the standard of care drug, or both. The primary endpoint was a reduction in disease activity, as well as a reduction in joint tenderness and swelling. All three groups got better, but interestingly, the curcumin groups showed the highest percentage of improvement—significantly better than those in the drug group.

“The findings are significant, demonstrating that curcumin alone was not only safe and effective, but was surprisingly more effective in alleviating pain compared” to the leading drug of choice—all without any apparent adverse side effects. In fact, curcumin appeared protective, given that there were more adverse reactions in the drug group than the combined drug and curcumin group. In contrast to the nonsteroidal anti-inflammatory drugs, curcumin has no gastrointestinal side effects, and may even protect the lining of the stomach.

Finally today –we learn how rheumatoid arthritis may be triggered by autoimmune friendly fire against a urinary tract infection bacteria called Proteus mirabilis, which could help explain why sufferers randomized to a plant-based diet experienced such remarkable benefit.

Rheumatoid arthritis is a chronic systemic autoimmune disease affecting millions, characterized by persistent pain and stiffness, and progressive joint destruction—particularly in the hands and feet, leading to crippling deformities. What can we do to prevent it and treat it?

In a famous 13-month long randomized controlled trial of plant-based diets for rheumatoid arthritis, patients were put on a vegan diet for three and a half months, and then switched to an egg-free lacto-vegetarian diet for the remainder of the study. Compared to the control group, who didn’t change their diet at all, the plant-based group had a significant improvement in morning stiffness within the first month, cutting the number of hours they suffered from joint stiffness in half. Pain dropped from five out of ten down to less than three out of ten. A drop in disability; they reported subjectively feeling better, significant improvement in their grip strength in their hands, fewer tender joints, less tenderness per joint, and less swelling, with the added benefit of losing about 13 pounds and keeping most of that weight off throughout the year. They also had a drop in inflammatory markers in their blood, sed rate, C-reactive protein, and white count. The question is why. What does diet have to do with inflammatory joint disease?

Well, rheumatoid arthritis is an autoimmune disease in which your body attacks the lining of your own joints. Why would it do that? Well, there’s a different autoimmune disease called rheumatic fever, in which your body attacks your own heart. Again, why would your body do that? It appears to be a matter of friendly fire.

Rheumatic fever is caused by strep throat, which is caused by a bacteria that has a protein that looks an awful lot like a protein in our heart. So when our immune system attacks the strep bacteria, it also attacks our heart valves, triggering an autoimmune attack by “molecular mimicry.” The protein on the strep bacteria is mimicking a protein in our heart, so our body gets confused and attacks both. That’s why it’s critical to treat strep throat early to prevent our heart from getting caught in the crossfire.

So researchers thought maybe rheumatoid arthritis might be triggered by an infection as well. A clue to where to start looking was the fact that women seem to get rheumatoid arthritis three times more frequently than men. What type of infection do women get more than men? Urinary tract infections, so researchers started testing the urine of rheumatoid arthritis sufferers, and lo and behold found this bacteria called Proteus mirabilis. Not enough to cause symptoms of a UTI, but enough to trigger an immune response. And indeed, there’s a molecule in the bacteria that looks an awful lot like one of our own molecules in our joints, so anti-Proteus antibodies against the bacteria may inadvertently damage our own joint tissues, leading eventually to the joint destruction. Therefore, therapeutic interventions aimed at the removal of this bacteria from the bodies of patients, with consequent reduction of antibodies against the organism, should lead to a decrease in inflammation.

Well, as we saw before, urinary tract infections originate from the fecal flora; the bugs crawl up from the rectum into the bladder. And so, how might one change the bugs in one’s colon? By changing our diet. Some of the first studies over 20 years ago on trying to fundamentally shift people’s gut flora were done using raw vegan diets, figuring that’s about as fundamental a shift from the standard Western diet as one can get. And indeed, within days one could significantly shift someone’s gut flora. And you put rheumatoid arthritis sufferers on that kind of diet, and they experienced relief, and the greater improvements were linked to greater changes in their gut flora. But the diet was considered so intolerable that half the patients couldn’t take it and dropped out–perhaps because they were trying to feed people things like buckwheat-beetroot cutlets buttered with a spread made out of almonds and fermented coconut juice, excuse me not coconut, that may have been good, cucumber juice.

Thankfully, regular vegetarian and vegan diets work too, changing the intestinal flora and improving rheumatoid arthritis, but we didn’t specifically have confirmation that plant-based diets brought down anti-Proteus antibodies, until now. Those who responded to the plant-based diet showed a significant drop in anti-Proteus mirabilis antibodies compared to the control group. Maybe it just dropped immune responses across the board? No, antibody levels against other bugs remained the same, so the assumption is that the veg diet reduced urinary or gut levels of the bug.

A shift from an omnivorous to a vegetarian diet has a profound influence on the composition of the urine–for example, higher levels of lignans in the urine of those eating vegetarian. Up until now, it was just thought that lignans protected people eating more plant-based from getting cancer, but now we know lignans can also have antimicrobial properties as well, so may be helping to clear Proteus from the system. Either way, this suggests a new type of therapy for the management of rheumatoid arthritis. This new treatment includes anti-Proteus measures such as dietary manipulations in the forms of vegetarian diet.

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