Parade magazine is the most widely read periodical in the US, with a circulation of 32 million and a readership of 71 million (1). They get that readership by placing it, free for readers, in over 400 newspapers.
The column in question is “Ease The Aches Of Arthritis” By Dr. Vijay Vad, published 09/28/2008. Dr. Vad is a physiatrist (a rehabilitation doctor) who has published several books on arthritis for the the public.
In the article, Dr. Vad discusses ways to decrease arthritis pain. Like most popular summaries, it is without references, so I used Pubmed and Google for each of his suggestions to look for the evidence to support the advice he offers. I tried to use both narrow and broad search terms in Pubmed, but I do not doubt I missed key articles. I have confidence that the readers of the blog will show me the error of my ways.
There are many types of arthritis: there is inflammatory arthritis, like rheumatoid arthritis, and osteoarthritis, due to wear and tear. There is crystalline arthritis like gout and there is infectious arthritis, due to staphylococcus or other bacteria. Most people have osteoarthritis, or degenerative joint disease. These are different diseases, and studies that evaluate the pathophysiology and treatment of one do not necessarily apply to the others. Dr Vad does not distinguish between the different types of arthritis in his article, broadly suggesting interventions for ‘arthritis’ as if all types of arthritis are equal. It is like suggesting penicillin for ‘infection’, paying no attention to the type of infection and whether the use of penicillin is applicable.
Watch your diet. Eat foods that reduce inflammation, and avoid those that cause it. Red meat, which contains omega-6 fatty acids, and high-fructose corn syrup promote inflammation.
I cannot find a clinical trial where omega-6 fatty acids promote arthritis or increase arthritis pain. I can find no trials that show an association between increased red meat consumption and increased osteoarthritis pain. There is one epidemiologic study (2) that finds an association between high red meat consumption and developing inflammatory arthritis. Note: developing and inflammatory arthritis, not osteoarthritis. It was a mild association. Association is not causation, and as the authors say “A high level of red meat consumption may represent a novel risk factor for inflammatory arthritis or may act as a marker for a group of persons with an increased risk from other lifestyle causes.”
Double blind studies with diet are particularly difficult to perform as people tend to be able to identify what they eat. The one study I could find showed no benefit of a low meat diet and the symptoms of rheumatoid arthritis (3).
Using “high fructose corn syrup” and either arthritis or inflammation yields no clinical trials or basic science articles on a Pubmed search. Nothing. I can find no credible science to support the assertion that high fructose corn syrup promotes inflammation or increases arthritis pain directly. Use of high fructose corn syrup is associated with gout, which is a form of arthritis where uric acid crystals precipitate into the joint and it is the crystals that cause inflammation. But there is no (4) data I can find to suggest that high fructose corn syrup will make your joint pain worse or avoiding it will make your joint pain better.
Instead, to reduce inflammation, consume more foods that are rich in omega-3 fatty acids, such as deep-sea fish, flaxseed, brightly colored fruits, dark-green leafy vegetables, and olive oil.
True, but the data for the benefit of fish oils is valid only for rheumatoid arthritis. If fish oil clinical trials are available for osteoarthritis, I could not find them on Pubmed. Also there are no clinical trials that support the efficacy of flaxseed, green leafy vegetables or olive oil in improving joint pain. In the Adventist Health Study, fruit consumption was weakly associated with increased osteoarthritis, as was the consumption of red meat (9) and a few studies suggesting benefit from avocados, which, I believe, is not a leafy vegetable.
Our prehistoric ancestors, to whom arthritis was virtually unknown…
A quick Google finds reports of ancient human remains with rheumatoid arthritis and osteoarthritis, some dating back 40,000 years ago. I found the information in less than a minute. Why the editors of Parade cannot fact check with similar alacrity I do not know. I thought that’s what editors did: they edit. Prior to modern society, most people didn’t live past their mid twenties to mid thirties, hardly time enough to develop widespread evidence of degenerative arthritis. If you die young, as most people did until the last 100 years, you do not have degenerative diseases that take a long life to develop.
Recent scientific data indicate that the use of ginger, glucosamine, and chondroitin sulfate may be helpful for moderate to severe knee arthritis.
Glucosamine may have some modest effects on joint pain. The results of clinical trials with chondroitin suggests that it is not effective (this is a huge and messy literature fraught with poor studies). I have always thought, since these products are synthesized onsite by the joint, rather than imported whole, that it is a therapy like eating hair for baldness. Which I wish would work.
As to ginger, there are two studies, one shows moderate efficacy for decreasing joint symptoms (5) the other doesn’t (6). Hardly compelling trials, although there are some intriguing in vitro studies to suggest that ginger has some anti inflammatory properties; it is a long way from inhibiting sow cartilage explants (7) in a test tube to recommending routine use of the spice. Unless.
It should be mentioned that Dr. Vad has been responsible as the “leading physician researcher in arthritis” for the development of Gingerflex ™, a supplement with ginger, glucosamine, and chondroitin sulfate. I cannot find his name directly associated with the product and only discovered it from a direct inquiry to the company. The company has not responded to my inquiries as to whether he is still actively involved with Gingerflex, although he recommends the product in his books and his books are sold on the same page as the product on the gingerflex.com website. The editors of Parade do not seem to be interested that the medical advice offered in the periodical may have a conflict of interest.
BTW, Dr Vad has 13 references in low impact journals in Pubmed, a solid resume, and much better than my own resume, but hardly a “leading physician researcher in arthritis.”
Use your body. Some people with arthritis are afraid that exercise can hurt them. But it’s just the opposite.
Given the wide ranging benefits of regualr exercise, I cannot argue with this advice, although the data suggest that the benefits of exercise are short term and minimal for effects on joint symptoms and function. There is surprisingly little data to suggest exercise is of benefit for the narrow indication of relieving joint pain and increasing function in a variety of different types of arthritis, although this literature is huge. As one representative meta analysis said, “For pain assessed using the 0 to 10 visual analog scale, the average effect amounts to a mean of 3.78 for treatment subjects versus 4.33 for control subjects. Control group subjects experienced statistically significant improvements in pain and, to a lesser extent, objectively measured functional ability during study participation. CONCLUSIONS: Physical activity interventions resulted in moderate positive effects on physical activity behavior and small positive effects on pain and physical function outcomes (10)”.
Breathe properly. Proper breathing in a slow, controlled rhythm is the fastest pain reliever I know of, because it shifts the mind’s attention away from the pain.
I agree with this. All my patients who have stopped breathing have done poorly. I have to admit I do not understand this advice. Breathing is for gas exchange; there is no proper way to breath unless you have Ondine’s curse. While focusing on breathing can be distracting, so can many other activities, from TV to a good beer. To be complete, I looked for breathing and changes in arthritis symptoms or pain. I found nothing.
Try massage and acupuncture. Because mainstream medicine has not provided enough arthritis treatments short of drugs and surgery, many arthritis sufferers have turned to alternative treatments such as massage and acupuncture. Specifically, massage therapy has been shown to be beneficial for arthritis of the spine and hip, and acupuncture has yielded promising results for knee arthritis in clinical trials.
One trial I found for massage and osteoarthritis of the knee (8) demonstrated benefit, and I do not doubt that massage makes anyone feel good, although I am at a loss as to how to do a placebo trial for this type of intervention. As to acupuncture, the data for this intervention has been discussed at length in this blog. Compared to sham acupuncture, ‘real’ acupuncture is no better and in one study was worse for arthritis pain. The clinical trials do not support he use of acupuncture for any disease, much less arthritis. Acupuncture is worthless to all but the acupuncturist.
So what can you say about the advice offered in Parade for suffers of arthritis?
Much of what is said does not seem to be supported by the published medical literature or is widely extrapolated from minimal or contradictory data. No effort is made to distinguish the various kinds of arthritis so there can be appropriate application of what minimal data exists. All arthritis is treated the same.
There is a suspicion of conflict of interest in the article. I always find it ironic that while I am the pawn of big pharma, it is the promoters of nutraceuticals who sell the products on their websites and from their offices and reap the profits. I have never made dime one from any drug I have ever prescribed.
As I wrote this I ran the basic ideas by one of our rheumatologists to make sure I wasn’t missing any important information. It led to an interesting discussion of how he applies this kind of information to his patients. The practice of medicine is often messy, especially with rheumatologic illnesses. He told me it is part of the general culture of rheumatology where you discuss these interventions with patients using terms like ‘may help’ and ‘people find it useful’. Not exactly recommending them, but not discouraging them either. Red meat, high fructose corn syrup and fish oils are part of the ‘popular culture’ of the treatment of joint disease, irrespective of the data, and are casually given the same consideration as NSAID’s and prednisone, especially in patients with refractory disease. Shruggies, I suppose, but there is that feeling that we should do something, anything, but not nothing, as long as there is the whiff of a hint of a suggestion of a possibility that maybe possibly it might do something good for someone somewhere sometime. We all want to help, don’t we?
A common complaint in the skeptical literature is the poor job done by mainstream media in covering science. Here is another example. The most widely read magazine in the US apparently lacks the ability for simple fact checking and insuring that the medical advice they offer is free of potential financial conflict. Parade contains a column by Marilyn vos Savant, who holds the record for the worlds highest IQ. Perhaps they should take advantage of this prodigious intellectual power to help edit the medical columns. The editors need help from someone.
2. Arthritis Rheum. 2004;50:3804-3812
3. Scand J Rheumatol. 2000;29(5):302-7. Diet therapy for rheumatoid arthritis. A controlled double-blind study of two different dietary regimens.
4. as in zip, zilch, nil, nothing, nada, zero
5. Effects of a ginger extract on knee pain in patients with osteoarthritis. Arthritis Rheum. 2001 Nov;44(11):2531-8.
6. Osteoarthritis Cartilage. 2000 Jan;8(1):9-12. A randomized, placebo-controlled, cross-over study of ginger extracts and ibuprofen in osteoarthritis.
7. J Med Food. 2005 Summer;8(2):149-53. Comparative effects of ginger root (Zingiber officinale Rosc.) on the production of inflammatory mediators in normal and osteoarthrotic sow chondrocytes.
8. Arch Intern Med. 2006 Dec 11-25;166(22):2533-8.Massage therapy for osteoarthritis of the knee: a randomized controlled trial.
9. J Nutr Health Aging. 2006 Jan-Feb;10(1):7-14. Associations between meat consumption and the prevalence of degenerative arthritis and soft tissue disorders in the adventist health study, California U.S.A.
10. This is a huge literature, Pubmed arthritis and exercise to review the references. Semin Arthritis Rheum. 2008 Apr;37(5):307-16. Epub 2007 Sep 21 Physical activity interventions among adults with arthritis: meta-analysis of outcomes..