Richard G. Petty, MD

Fats, Inflammation and Depression

We have talked before about the associations between inflammation and psychiatric illnesses.

There is yet more evidence in the shape of a study just published in the journal Psychosomatic Medicine. by Janice K. Kiecolt-Glaser and her colleagues from Ohio State University College of Medicine in Columbus.

The study involved 43 older adults with a mean age of 66.67 years, and the results suggests that the imbalance of omega-6 and omega-3 fatty acids in the typical American diet could be associated with the sharp increase in heart disease and depression seen over the past century. The more omega-6 fatty acids people had in their blood compared with omega-3 fatty acid levels, the higher their levels of the inflammatory mediators tumor necrosis factor-alpha and interleukin-6, and the greater the chance that they would suffer from depression. These are the same inflammatory mediators associated with insulin resistance, type 2 diabetes and coronary artery disease, all of which are more common in depression. And depression is more common in diabetes, arthritis and coronary artery disease than expected.

Our hunter-gatherer ancestors consumed two or three times as much omega-6 as omega-3, but today the average Western diet contains 15- to 17-times more omega-6 than omega-3. There were 6 individuals in the study who had been diagnosed with major depression, and they had nearly 18 times as much omega-6 as omega-3 in their blood, compared with about 13 times as much for subjects who didn't meet the criteria for major depression.

Depressed patients also had higher levels of tumor necrosis factor alpha, interleukin-6, and other inflammatory compounds. And as levels of depressive symptoms rose, so did the omega 6 and omega 3 ratio. So it seems as if the effects of diet and depression enhance each other. People who had few depressive symptoms and/or were on a well-balanced diet had low levels of inflammation in their blood. But when they became more depressed and their diets became worse – which is very common when people are depressed – then the inflammatory mediators in the blood surged.

Omega-3 fatty acids are found in foods such as fish, flax seed oil and walnuts, while omega-6 fatty acids are found in refined vegetable oils used to make everything from margarine to baked goods and snack foods. The amount of omega-6 fatty acids in the Western diet increased sharply once refined vegetable oils became part of the average diet in the early 20th century.

Depression alone is known to increase inflammation, the researchers note in their report, while a number of studies have found omega-3 supplements prevent depression.

So this more evidence for the value of eating fatty fish like salmon, mackerel or sardines two or three times a week, but be sure to avoid fish that may contain a lot of mercury. If you add more fruits and vegetables to your diet, you will also reduce your levels of omega-6 fatty acids.

I have just finished analyzing all the new literature on using fish oils for the prevention and treatment of psychological and psychiatric problems, and I am going to post my findings in the next couple of days.

Arthritis and Sex

Today being Valentine's Day (you did remember didn't you?), Arthritis Care in the United Kingdom has taken the opportunity  to publicize its free booklet on sex, relationships, intimacy and arthritis, downloadable from its website (pdf).

Integrated Medicine is all about empowering and caring for the whole person, so I was very pleased to see this document. I spent some very happy times helping people with various types of arthritis, and I was astonished how infrequently anyone had ever asked them about the ways in which the illness impacted normal daily activities and had ever given them any advice on ways to work around problems.

Let me quote form the Arthritis Care news release:

"One of the reasons we produced the guide is to address issues people felt awkward discussing. It may be embarrassing to talk to your consultant rheumatologist, nurse or GP about emotional and sexual things, or matters of self-image and self-esteem - and they may be embarrassed to be asked. So where do you turn?' said Kate Llewelyn head of publications at Arthritis Care, who was diagnosed with rheumatoid arthritis at the age of thirteen.

The booklet provides a valuable insight for healthcare professionals and for the partners and families of people with arthritis, highlighting issues of concern to them, and suggesting practical and achievable solutions.

For people with arthritis, or other disabilities, difficulty can start before any relationship, pre-dating any date.

'Managing pain and other symptoms is exhausting, and it stops many people getting out and socializing. As a result, arthritis can be isolating, keeping you from making friends or seeing family, let alone dating and finding a partner. And maybe you are not very mobile, so can't dance, or play sport, or can't drink because of your medications. What's more, although anti-discrimination law means venues must now offer better access for disabled people, you still may find it harder to do things people without arthritis take for granted', said Kate Llewelyn.

Once a relationship has been formed, the challenges continue; the couple must work out ways of ensuring their personal and sexual relationship is sustained and developed, overcoming and working round the incurable and debilitating condition.

The report discusses a number of very practical matters: how pain and also medication can interfere with sex drive and some can cause weight gain. Many forms of arthritis are also associated with anemia and/or chronic fatigue.

It also discusses some of the psychological factors that can interfere with the sex lives of arthritis sufferers. For example, men may feel emasculated if they cannot perform their 'traditional' roles like playing sport or carrying heavy objects. Women may feel unfeminine if they put on weight with steroids, cannot do the housework or lift their children as a result of having arthritis. Others, with limited joint movement, or severe pain may be put off sex altogether, or find some of the traditional sex positions too uncomfortable.

'The book has got diagrams of lovemaking positions which people of differing physical abilities and limited movement have found useful. If you've got problems with your spine, or hips, or knees, it makes sense to experiment with positions that place least weight or strain on the rogue joints. Of course, after joint surgery or replacement, you may be advised to take a temporary break from sex, but, relationships are more than sex, and, with this guide, abstinence may make the heart grow fonder', said Kate Llewelyn.

Sex is rarely discussed with people strugglig with chronic illness, often because health care providers get embarassed about it.

It is essential for that to change, and I want to say a big thank you to Arthitis Care for having the courage to do this.

Chloroquine, Insulin and Inflammation

Your humble reporter was fascinated to read about some new research using the anti-malarial agent chloroquine as a potential treatment for the insulin resistance syndrome.

I have a personal reason for being interested. Hypoglycemia (low blood glucose) is an occasional feature of treatment with chloroquine and in 1980 a study first indicated that chloroquine might slow the break down of insulin by the liver. In the early 1980s there were a flurry of papers indicating that chloroquine did some subtle things to insulin and insulin receptors in many tissues. So we came up with the idea of measuring its effects in humans. There was a memorable occasion on which I was doing an outpatient clinic with an intravenous line in my arm. (English doctors are well known for doing experiments on themselves: I had a professor in medical school who said that you should never do to a patient what you haven’t had done to yourself. I shall leave it to you, gentle reader, to wonder if I've tried everything....).

So there I am doing my clinic when, around 11AM I begin to feel really strange: my glucose level was almost unrecordable and my insulin level was off the chart. Nothing that couldn’t be solved with a large dollop of sugar, but it made me very sympathetic to people who get hypoglycemic from their regular treatments.

Sometimes Nature does our experiments for us: we did a lot of work on diabetes because it is associated with high rates of vascular disease. So understanding the mechanisms by which diabetes does that may help illuminate some of the cellular disturbances underlying arteriosclerosis in general. We are also interested in the few illnesses in which a single disturbed gene may lead to a definable set of signs and symptoms. There is a rare illness known as ataxia telangiectasia in which sufferers have a high risk of developing some cancers particularly lymphomas and leukemia. People with the illness are very sensitive to ionizing radiation, have a specific type of immune deficiency, degeneration of parts of the brain related to muscle function and coordination and they age prematurely. More than ten years ago it was discovered that a single gene - ataxia-telangiectasia mutated (ATM) gene – was responsible for the illness. The gene is responsible for producing a protein that recognizes damage to DNA. It now seems that ATM may also be linked to metabolic and cardiovascular diseases. It does this by inhibiting a protein called JNK, a stress kinase involved in inflammation with related effects in insulin resistance and atherosclerosis. So to everyone’s surprise a gene that can cause a rare disease can also cause insulin resistance.

In the November issue of Cell Metabolism, researchers at Washington University School of Medicine in St. Louis and St. Jude Children's Research Hospital in Memphis, Tennessee report that a small dose of chloroquine eased many symptoms of metabolic syndrome in mice, reducing blood pressure, decreasing hardening and narrowing of the arteries and improving blood sugar tolerance. The results suggest we may only need very low and perhaps infrequent doses of chloroquine to achieve similar effects in humans. Both insulin and chloroquine activate the ATM gene.

This adds to the data that some of the metabolic dysfunctions triggered by obesity may be linked to the inflammatory responses that go wrong in autoimmune disorders like arthritis and systemic lupus erythematosus.

And an older treatment for rheumatoid and lupus just happens to be chloroquine.

Chloroquine itself has some side effects, but this is important information that will help us design more effective and carefully targeted holistic treatments for both metabolic disturbances and inflammatory conditions. All in all, very good news indeed.

Curing Chronic Pain: Its All Done with Mirrors

There is a fascinating new approach to treating chronic pain. 

The story goes back two years, to the publication of important research from a team at the Royal National Hospital for Rheumatic Diseases, in Bath in England. They wrote a paper in which they tried to link joint pain in neurological conditions. They wanted to see how the pain of rheumatoid arthritis, fibromyalgia and complex regional pain syndrome might relate to phantom limb pain (PLP) experienced by many amputees.

They suggested that in each condition there is reorganization in the sensory regions of the cerebral cortex. And it is this reorganization that generates pain and an altered body image. It seems to be just the same in rheumatology patients as has previously been hypothesized for amputees with PLP; that is a motor/sensory conflict. The body and the sense don’t match and it hurts. Their initial research indicated that something incredibly simple: using a mirror could help people correct of this conflict. They were able to show that a mismatch between motor output and sensory input creates sensory disturbances, including pain, in rheumatology patients and also in healthy volunteers.

In a second paper the investigators were able to show that doing a movement while looking at a distorting mirror could quickly induce uncomfortable symptoms in fit healthy people.

For over two decades, David Blake - the senior author of this research - has championed the idea that there is an important neurological component in inflammatory arthritis. It all started with a simple observation that has puzzled generations of clinicians: why is it that joint involvement in inflammatory arthritis is so often symmetrical? It isn’t surprising if both hips get arthritis: they will likely both have been subjected to a lot of wear and tear. But why should arthritis involve the second joint of the index finger in both hands? It has always looked as if this might imply some neurological contribution.

The idea is that although pain may have originated in inflamed joints, it is maintained and exacerbated by the nervous system. This fits with a fact that has been known to acupuncturists for centuries and has been replicated in pain clinics around the world. If you can interrupt what we call the pain cycle - constant chronic pain that feeds on itself and gets progressively worse – then you may often see pain relief for weeks or months, or sometimes even indefinitely. It is quite common for chronic pain to have had a clear physical precipitant, but to be maintained by key regions in the brain.

This new research strongly supports these observations, implies that the successful treatment of chronic rheumatological pain may involve a neurological approach, and offers a brand new therapeutic option.

“The speaker is only a mirror. Where you can see yourself. When you recognize yourself clearly, you can put aside the mirror.”--Jiddu Krishnamurti (Indian Spiritual Teacher, 1895-1986)

“Perception is but a mirror, not a fact. What I look on is my state of mind reflected outward.”--A Course in Miracles

Turmeric and Arthritis

I recently reported about some research from SIngapore that indicated that the spice turmeric might help with cognition.

Today there is a study form the University of Arizona in the journal Arthritis and Rheumatism suggesting that the spice may also be helpful in experimental rheumatoid arthritis. In line with most other studies of herbal supplements it is interesting that the maximal effect was obtained by using the natural form of turmeric, that contains three major "curcuminoids," the likely active ingredients. If one of the three is missing, the effect is a lot less.

The extracts appears to work by preventing the activation of a protein that controls when genes are switched on or off in the joint. Once the protein known as NF-KB is activated, it binds to genes and increases the production of inflammatory proteins, which in turn attack the joints.

This is not a surprise: In traditional Indian Ayurvedic medicine turmeric has been used for centuries as a treatment for inflammatory disorders including arthritis. Based on that, dietary supplements containing turmeric rhizome and turmeric extracts have been sold for years. However, there's been little direct evidence that they are helpful.

We are going to need more research before we can sy whether turmeric supplements can be recommended for medicinal pruposes, and eating more spices is unlikely to work.

These findings are opening up a new approach to treating not just rheumatoid arthritis, but perhaps also other inflammatory diseases such as inflammatory bowel disease, asthma and multiple sclerosis. Interestingly the turmeric extract also has another effect: it deactivates a biochemical pathway that leads to the resorption of bone. So it may help with osteoporosis.

Rheumatoid Arthritis: A Neurological Disease?

For more than a century, there’s has been a puzzle in rheumatology. Why is it that so many people with inflammatory arthritis get symmetrical involvement of their joints? It is very common for people to get exactly the same joints involved in both hands or in both feet.

Sometimes joints get affected by arthritis because they have already been subjected to a lot of wear and tear: that’s thought to be one of the reasons why gout most often affects the big toe. But the symmetrical pattern of arthritis is far more difficult to understand. There has been speculation for at least 30 years that this symmetry indicates neurological involvement in the disease, and there was a stimulating paper on the topic seventeen years ago, and it has been known for some time that artificially induced arthritis in one joint produces inflammatory changes in the same joint on the other side of the body.

Now investigators from the University of California at San Diego School of Medicine have published an important discovery. Rheumatoid arthritis drugs work better, at least in arthritic rats, when delivered into the central nervous system. Rheumatoid arthritis (RA) is a disease in which there is chronic inflammation, leading to joint pain and destruction. Pain and inflammation in the joints are constantly monitored by the central nervous system, and we have known for many years that the nervous system can regulate inflammation and immune responses. It was demonstrated in the 1960s that damage to certain regions in the hypothalamus of the brain could impair the work of the immune system. The scientists from San Diego focused on a protein called p38, which is involved in a number of cellular processes critical to the development of RA. Several substances that block the action of p38 are effective in animal models of arthritis and are currently being tested in clinical trials in patients with RA.

Pain and inflammation activate p38 in the brain and spinal cord, and blocking it by introducing medicines directly into the central nervous system reduces inflammation in joints.

This is important research, because it opens up new possibilities for treating an illness that can often be very difficult to treat. It may also help explain another observation. Some patients with rheumatoid arthritis who are treated with acupuncture get a reduction in joint symptoms and sometimes even repair of some of the damage to the cartilage in their joints. Experienced acupuncturists see this in about a third of patients whom they treat, so it was a surprise to see a review claiming that acupuncture did not help RA. If we see a disconnect between clinical observation and a research study, there are two options: either clinicians are deluding themselves or there’s something wrong with the research method. Interestingly, there’s recently been a great deal of discussion about the kind of research methodology that produced this negative result, prompted by a very interesting and challenging paper.

My conclusion? Acupuncture may indeed be a valuable adjunctive treatment for RA. But whether it will work on its own remains less certain.

And the best approach of all is to address the physical, psychological, social, subtle and spiritual dimensions of a person with RA. In other words, the new form of Integrated Medicine that I describe in Healing, Meaning and Purpose.

Chronic Widespread Pain, Fibromyalgia and Anti-inflammatory Proteins

Chronic widespread pain is a common and distressing medical condition that can be difficult to treat and is usually associated with fatigue, poor sleep and depression. One major subgroup is fibromyalgia. A connection between fibromyalgia and cytokines – small proteins that act as messengers between cells – has been suspected for some time, since some cancer patients treated with the cytokine interleukin -2 develop fibromyalgia-like symptoms. A new study from Wurzburg in Germany, published in the August 2006 issue of Arthritis and Rheumatism examined cytokine profiles in patients with chronic widespread pain and found that they had significantly lower levels of the anti-inflammatory cytokines IL-4 and IL-10.

This is an important finding: Previous research has shown that IL-10, administered as a protein or via gene transfer, reduces sensitivity to pain. Similarly, IL-4 has been shown to dull the pain response. There is also another piece to this: genetic variations in different cytokine genes are associated with distinct diseases, such as the association between IL-4 gene variations and asthma, Crohn's disease, and chronic polyarthritis.

Although low levels of anti-inflammatory cytokines could be a consequence of chronic widespread pain and its treatment, it is much more likely that these proteins actually play a role in the causation of chronic widespread pain.

This new research raises all kinds of possibilities for the physical treatment of a particularly horrible set of illnesses.

Temporomandibular Joint Dysfunction

The temporomandibular joint (TMJ) is the hinge joint that connects your mandible or lower jaw to the temporal bone at the side of the skull.

The joint can be affected by many disease processes including osteoarthritis, rheumatoid arthritis, the arthritis associated with psoriasis and infectious arthritis. There’s a whole ragbag of other illnesses and injuries that can affect the joint. But it is more commonly affected by muscular tension, problems with the bite, or tooth grinding (bruxism). I’ve been interested in TMJ problems ever since my days working in the Princess Margaret Migraine Clinic in London, where I saw a great many people with chronic headaches due to problems at the joint. A dental colleague helped many of them. Once I had been trained in acupuncture, I found that this is one condition in which I’ve always had good rates of success, both in humans and in horses.

So I was pleased to see an audit of 60 patients with TMJ dysfunction was compiled from the practices of 15 dental practitioners in the United Kingdom who were applying to become members of the thriving British Dental Acupuncture Society. Simple acupuncture was used at local points around the joint, on the neck, and on a point on the hand that is linked up with the joint, and tends to relax muscles and improve blood flow. This was a simple study, and in hindsight, it could have been improved. But the conclusions were encouraging: 85% of patients benefited, and the intensity of the pain was reduced by an average of 75%. This is remarkable since the patients were only receiving acupuncture and not any of the “extras” that I normally recommend as a matter of course.

Technorati tags: Temporomandibular joint Arthritis Acupuncture Migraine

Fibromyalgia

Fibromyalgia can be one of the most difficult of clinical problems. Sadly this illness or group of illnesses is often dismissed as no more than a series of symptoms caused by depression, and people then do not get the treatment that they need. Fortunately we are now seeing the emergence of consensus guidelines on how to diagnose the problem.

Fibromyalgia is a common syndrome of chronic pain and fatigue, but it is a great deal more than just pain. It may affect many systems of the body, and depression and cognitive symptoms are common.

One of the key difficulties in people with fibromyalgia is a disturbance in pain thresholds. There has also been a lot of interest in the idea that people with fibromyalgia are “hypervigilant,” as a result of disturbance in the serotonin pathways in the brain. Something similar happens in many people with other types of chronic pain, particularly low back pain. The problem with all of this research has always been the chicken and egg problem: how many of these abnormalities are due to having chronic pain, and how many might be the cause of the problem?

As an example, I was treating someone with fibromyalgia, and as part of the package of treatments, she was to have acupuncture. If practiced by a professional, acupuncture is usually painless. I had not seen anyone experience pain from the treatment in many years; however, this person was so sensitive that even gentle tapping was excruciatingly painful for her. I have colleagues who take this to be evidence that the whole thing is psychological. But I am sure that they are not correct. To a neurologist this is wrong on three counts:
1.    There is a lot of data indicating metabolic disturbances in people with fibromyalgia that is quite different from anything seen in anxiety or depression. These include reductions in the activity of the cellular powerhouses - the mitochondria - as well as subtle effects in blood flow.

2.    A number of other illnesses, like migraine, are associated with changes in pain threshold, indicating a disturbance in the mechanisms that control pain sensation, either in the brain stem on the thalamus.

3.    This notion that “it’s psychological rather than physical,” harks back to the kind of dualism that is not very helpful.

Recent research  indicates that although fibromyalgia is a little more common in women, the old view that it is predominantly a female illness is not correct. There are also some strong associations with other illnesses, including depression, anxiety, headache, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosus, and rheumatoid arthritis.

In the days that I treated a great many individuals myself, I always found that fibromyalgia and chronic fatigue syndrome were amongst the most difficult.

I’ve long been interested in the links between sleep disturbances and fibromyalgia as well as the modest improvement in people with a meditation program.  There is also another factor that is often not much talked about: people with chronic pain, from whatever cause can develop pain cycles: pain begins in some part of the body, but is then maintained by neurological circuits in the spinal cord and brain. Interfering with these pain cycles for even a day or two can sometimes be very helpful.

Fibromyalgia is one of the groups of conditions in which combinations are key. Trying just to use a medicine or just a diet is rarely likely to be crowned with success. The most helpful strategies that we have found have been combinations of:

1. Physical care:
   
   1. Appropriate medications to help with pain transmission and symptoms of depression
   2. Sleep hygiene, and some of the other approaches that I’ve suggested for dealing with disrupted sleep.
   3. Low intensity exercise
   4. Nutrition: this one of the clinical conditions that first persuaded  me that there are some people who have genuine food and environmental sensitivities, and, in some rare cases Candida overgrowth. There are quite a number of foods that may be very helpful, depending upon the individual’s likes and dislikes.   
   5. I’ve had colleagues who’ve had some great results with herbal remedies and supplements, but there is little published  evidence that these work.      
   6. Some people seem to have biochemical disturbances that can be  helped with some of the Schussler tissue salts.
2. Psychological support: there is some good evidence that some personality types and temperaments may be at increase risk of developing fibromyalgia, so any thing that helps build resilience and cope with negative cognitions can be very helpful. Some of the  tapping therapies can be very helpful adjunctive treatments, as can music therapy.
3. People with fibromyalgia are often very sensitive to the people around them, and their nearest and dearest often need help in understanding how best to support the person with the illness.
4. The subtle systems of the body are invariably compromised in people with fibromyalgia, and acupuncture – if people can tolerate it – as well as homeopathy can be very helpful. We have often used both together, though this is anathema to many classical homeopaths or acupuncturists. Perhaps they could not have been used in combination 50 years ago, but people have changed physically, psychologically, socially and energetically, and the rules have changed.
5. As with most people struggling with chronic illness, many people with fibromyalgia lose contact with their Source. And this is why - in my books and recordings – I spend so much time helping people  re-establish meaning and purpose in their lives, and help them use the illness not simply  as a barrier to be overcome, but as a stimulus for internal growth. I have also seen a number of indivudals in whom fibromyalgia was symptommatic of a spiritual awakening.       

One of my biggest worries with fibromyalgia, as with so many chronic illnesses, is that many desperate sufferers and their families can become victims of the unscrupulous. I have seen countless people selling advice and treatments that have no basis in fact.

Not everything that I have discussed here is evidence based: there is so little research on things like acupuncture and homeopathy. But those are treatments to be used in combination with more conventional approaches. Using all together is usually the best way forward. And everything that I’ve discussed here has been used in working with hundreds of people around the world.

Technorati tags: Fibromyalgia Chronic pain Integrated medicine Irritable bowel syndrome Sleep disturbance Candida

A New Way of Looking at – and Treating - Inflammation

Diseases of both large and small blood vessels are two of the biggest problem facing people with diabetes. Not only is it a huge clinical challenge, but also nature sometimes does our experiments for us. The high rates of coronary and peripheral vascular disease in diabetes can be seen as a kind of experiment of nature: a recognizable set of chemical abnormalities that might shed light on vascular diseases in general. It was those twin factors: a huge clinical problem, and an experiment of nature, that lead me to pick the topic of my research doctorate. 

When I was working on my research doctorate in the mid 1980s, I came across a lot of old research that seemed to show links between inflammatory and autoimmune conditions like systemic lupus erythematosus and rheumatic fever, and the eventual development of coronary artery disease. There was also a lot of old and largely forgotten research about the link between some viral infections and the development of coronary artery disease and acute coronary artery occlusions, because some infections can make blood more “sticky.” Inflammation evolved as one of the body’s defence mechanisms.

So I made the proposal – revolutionary at the time – that diabetes, coronary artery disease and a range of other illnesses might be inflammatory rather than degenerative. I soon found inflammatory markers in people with diabetes, that helped predict when someone was running into trouble with their eyes, kidneys or heart.  Even with stacks of data, I had to spend a lot of time defending that position, because it also implied that some illnesses thought to be irreversible might not be.

With the passage of time, it has tuned out that I was probably correct. Chronic inflammation, wherever it starts, mat have long-term effects on the body and on the mind. Chronic inflammation increases the risk of diseases of many blood vessels, as well as causing anemia, organic depression and cognitive impairment. Here is a partial list of common conditions in which inflammation is a prominent factor:
1.  Rheumatoid arthritis
2.  Systemic lupus erythematosus
3.  Fibromyalgia
4.  Chronic infections
5.  Insulin resistance or metabolic syndrome
6.  Arteriosclerosis
7.  Diabetes mellitus
8.  Hypertension
9.  Asthma
10. Inflammatory bowel disease
11. Psoriasis
12. Migraine
13. Peripheral neuropathy
14. Alzheimer’s disease
15. Autism
16. Gingivitis
17. Cystitis

The reason for raising the issue is not to say “told you so!”

It is instead that we need to think about inflammation a little differently. There is a mountain of information about the physical aspects of inflammation. We can stop at the simple description of inflammation as a condition in which part of the body becomes reddened, swollen, hot, and usually painful, or we can look below the surface: we can examine inflammation not only as a physical problem, but also as a psychological, social, subtle and spiritual problem. Why bother? Because the deeper approach allows us to understand and to treat and transcend inflammation as never before.

I am going to write some more about specific ways to address inflammation and what it means in future articles. I would also like to direct you to the book Healing, Meaning and Purpose, in which I talk about specific approaches in more detail.

But I would like to start with this.

In Ayurvedic and homeopathic medicine, inflammation is a sign of an imbalance in the vital forces of the body, and the traditional Chinese system agrees: here inflammation is usually a manifestation of an excess of Yang Qi, or a deficiency of Yin Qi. Most of our lives are seriously out of balance: Yang Qi is like a rampaging lion that has been stimulated by:
Acidic foods;
Environmental toxins;
Unwanted sexual stimulation:
Noise;
Discordant music:
Constant demands from others:
Toxic relationships;
Years spent in front of television sets and limitless multi-tasking.

It should be no surprise to learn that all of these inflammatory conditions are increasing rapidly throughout the Western world. Not because we are getting better at identifying them, or we are living longer, but genuinely increasing.

It is wrong to put all the blame on poor diets or inadequate exercise. The problem is more subtle and is a reflection of distorted Information being fed to our bodies, minds, relationships, subtle systems and spiritual relationships.

The great news is that this simple conceptual shift gives us a whole load of new tools for handling these problems, and for using them as catalysts to growth.

In the next few weeks, I am going to drill down and give you some specific guidance that ties into the material in Healing, Meaning and Purpose and the next two that are on the launch pad.

Fasten your seat belt!

Technorati tags: Inflammation Aging Alzheimer's disease Arteriosclerosis Neuropathy Autism Arthritis Systemic lupus erythrmatosus Fibromyalgia Inflammatory bowel disease Gingivitis 

Glucosamine and Chondroitin

A study has been published in last week’s New England Journal of Medicine that seems to show that there’s no advantage in taking the popular dietary supplements glucosamine and chondroitin. Indeed that’s what has been reported in the media . But notice that I said, “Seems to show,” for on closer examination there is more to this paper than it appears.

The investigators are to be congratulated for doing the study in the first place. What they did was to take a large group of 1583 patients who all had osteoarthritis of the knees, and divide them into five groups:

• A placebo group
• A group that took celecoxib (Celebrex) 200mg/day
• 1500mg of glucosamine/day
• 1200mg of chondroitin/day
• A combination of 1500mg of glucosamine/day and 1200mg of chondroitin/day

The study lasted 24 weeks, and the main outcome measure was pain in the knees. The study showed that although patients on Celebrex did very well compared with the placebo group, those on glucosamine and chondroitin did not do better than placebo, although the combination was better than using either supplement alone. But one of the odd things was that people with moderate to severe pain WERE helped by the combination, and in fact the combination out-performed Celebrex!

Not only does the combination seem to help people with the biggest problems with pain, but also there are some other important points:

1. The worse someone is, the bigger the room for improvement. If someone only has mild pain, you need a lot more patients to find a statistically significant improvement.

2. As in most studies, multiple measurements were done, and Celebrex was no better than placebo in 12 out of 14 of them. So if the “active comparison” failed on multiple measures, we need to be very cautious about how we interpret the study.

3. The placebo response rate in the study was 60%, while the average is 30-35%. This is a huge difference. This may be because the patients knew that they had a four in five chance of getting a treatment that might help them, so they went into the study with high expectations.

4. This is only one study, concerning one type of joint problem. There are more than 30 others that have in general been even more positive then the findings in the moderate to sever group, including a very long-term study that showed that over an eight-year period, the combination dropped the rate of knee replacement by almost 75%. It is crucially important to examine the results of any study in the context of everything else that has been known and discovered. Every type of study has to be checked, and verified.

5. The study was funded by the National Institutes of Health and is the first of two parts, with a second study of the impact of the treatments on X-rays of the knees still pending.

6. None of the groups had many side effects, but it is worth remembering that medicines of the Celebrex type are under intense scrutiny because of the possible association with cardiovascular disease.

7. Many specialists use anti-inflammatory medicines together with glucosamine/chondroitin, at least at the beginning of a course of treatment. And that makes good sense.

8. What about the dosing of the supplements? Although those are the doses used by most people, they may not always be enough. In patients who weigh more than 200 pounds, many experts recommend 2000mg of glucosamine and 1600mg of chondroitin. It is also wise to take the supplement in divided doses with food. (I have sometimes also found it very useful to add Methylsulfonylmethane (MSM), 1000mg/day to the glucosamine and chondroitin, though there is little research to support it.)

None of these treatments can be given to pregnant women or nursing mothers.

One other small caveat, if you are having surgery make sure that you tell you surgeon if you are taking these supplements. Chondroitin has minor anticoagulant activity , and so may glucosamine.

And remember that the maintenance of joint health is not just a matter of taking some supplements. It is a judicious mixture of taking the right medication when needed, together with supplements, a healthy diet containing some omega-3 fatty acids and antioxidants, exercise, management of posture, particularly of the spine, and weight management. To say nothing of ensuring that joint problems are not being compounded by psychological and relationship problems, and disturbances in the subtle systems of the body.

Technorati tags: glucosamine, chondroitin, knee pain, arthritis