It is no secret that there is a growing epidemic of opioid drugs related deaths in the USA.[1] The most common type of chronic pain leading to the use of prescription pain medications is arthritis with osteoarthritis (OA) being by far the most common for that develops in a large percentage of older Americans.

Obesity has long been linked to a markedly increased risk of joint damage that leads to OA.[2] So given the aging US population coupled with the fact that more than 70% are overweight or obese it is easy to understand why OA is such a growing problem. Medical treatments have proven of little benefit and often in the case of pain medications associated with serious side effects. Surgical treatments, such as arthroscopic surgery for OA knees, have proven to be no more effective than a sham surgery.[3] It is becoming increasingly clear that waiting for OA and chronic pain associated with it to develop and then treating that pain with potent opioids drugs has contributed to the opioid drug epidemic. Perhaps addressing the cause of OA rather than dealing with it with surgery and drugs cannot be justified in terms of risk/benefit or cost benefit. At best medical interventions treat the symptoms of OA with dangerous drugs and/or expensive surgeries to replace or repair damaged and painful arthritic joints.

Lifestyle Therapy For OA Shows Real Promise

OA is the most common cause of disability in the USA. An intensive diet and exercise program significantly reduced OA pain at least in part by reducing chronic inflammation due to reducing inflammatory substances such as IL-6 in the blood.[4] A recent review emphasized the importance of exercise in the management of chronic pain among obese individuals.[5] Adopting a healthier diet containing more anti-inflammatory foods is another alternative way to prevent and treat diseases that lead to chronic OA pain. A recent study by Dr. Charles Emery at Ohio State University led him to conclude: "These data suggest that dietary intake may be another relevant behavior to address in the context of evaluating and treating pain symptoms, especially among overweight and obese individuals."[6]

More Fiber Reduces OA Pain Progression

About 54 million Americans now suffer from some form of arthritis and more than 40% of them are limited in their usual activity primarily due to joint dysfunction and/or pain. OA is the most common form of arthritis seen in middle-aged and older Americans. Standard medical treatment of OA patients typically starts with the use of nonsteroidal anti-inflammatory drugs (NSAIDs). While NASAIDs are certainly not as addicting and likely less dangerous than prescription opioid drugs, there is no question NSAIDs also can have serious side effects including GI tract bleeding and an elevated risk of heart attacks and stroke, especially when used to treat the chronic pain associated with OA in older people. A recent meta-analysis found all NSAIDs appear to increase the risk of a heart attack by about 50 to 100% and this increased risk appears to start the first week the drug is started and remains at this elevated risk level as long as the NSAID use continues. The risk is also greater with higher doses than lower doses.[7] A recent study by Dr. Zhadi Dai and colleagues examined the impact of dietary fiber intake on the pain associated with knee OA. Dr. Dai utilized data from two ongoing studies. One group of subjects consisted of a multicenter study of 4796 older individuals (mean age 61y) at risk of OA who were part of the OA Initiative. Of those 4079 subjects were followed for 4 years. The second cohort consisted a community-based population study of 1268 Framingham Offspring with an average age of 54y. From this group 971 subjects were followed for an average of 9.5 years. Dietary intake of fiber was estimated at baseline from food frequency questionnaires for both groups of subjects. In both groups new OA knee pain and worsening knee pain were found to worsen more over time in those whose diets initially contained the least dietary fiber compared with the 25% who were consuming the most dietary fiber.[8] Increasing dietary fiber likely reduces OA via multiple mechanisms such as by promoting weight loss, which reduces inflammation but also by altering the gut microbiome in ways that also increasingly are being linked to a reduction in inflammation and pain.

Do Food Supplements Reduce OA Pain?

A recent randomized controlled clinical trial compared the use of pharmaceutical-grade chondroitin sulfate (CS) supplement to celecoxib (a popular NSAID) and a placebo in subjects with knee OA. They found that both CS and celecoxib were superior to a placebo for treating symptomatic knee OA. They concluded: "A 800?mg/day pharmaceutical-grade CS is superior to placebo and similar to celecoxib in reducing pain and improving function over 6 months in symptomatic knee osteoarthritis (OA) patients. This formulation of CS should be considered a first-line treatment in the medical management of knee OA."[9] Other food supplements that have performed about as well as NSAIDS in controlled clinical trials include SAMe, omega-3 PUFA, and glucosamine sulfate. While some of these food supplements may be contraindicated in some patients they are probably safer and about as effective as NSAIDS for most people with OA pain. For more information on food supplements and OA see https://www.consumerlab.com/tnp.asp?chunkiid=21505.

Bottom Line:

Current medical options for treating OA leave much to be desired in terms of cost, efficacy, and safety. None appear to be effective for slowing the progression of OA. A safer and often more effective approach to reducing OA pain and likely also slowing the progression of OA would be a healthy diet consisting largely of minimally processed whole plant foods coupled with regular exercise, especially if this leads to the reduction of excessive body fat stores. The addition food supplements such as CS, glucosamine, SAMe, and omega-3s may also be considered although some of these may be contraindicated in patients taking certain medications. Relying on prescription opioid drugs and/or NASAIDs should be considered only after diet and lifestyle changes have failed because such drugs carry the risk of serious and life-threatening side effects. By contrast, a healthier diet and exercise program not only is more effective than drugs and/or arthroscopic surgery for most patients with OA but a healthy diet and exercise program can markedly reduce chronic inflammation, the risk of CVD events, and numerous other serious diseases, especially if some excess body weight is lost and kept off. Of course, a healthy diet & exercise program can prevent people from becoming overweight in the first place and that would certainly markedly reduce the number of older Americans developing clinical significant OA and markedly reduce the need for all those knee and hip replacement surgeries that also come with their own set of risks and very large medical costs.---By James J. Kenney PhD, FACN

References:

[1] https://en.wikipedia.org/wiki/Opioid_epidemic[2] Weiss E. Knee osteoarthritis, body mass index and pain: data from the Osteoarthritis Initiative. Rheumatology 2014;53:2095-99[3] Moseley JB, et. al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:81-8[4] doi:10.1001/jama.2013.277669[5] Paley CA, Johnson MI. Physical activity to reduce systemic inflammation associated with chronic pain and obesity: a narrative review. Clin J Pain 2016;32:365–70[6] Emery CF, et. al. Dietary intake mediates the relationship of body fat to pain. Pain J Feb 2017; www.painjournalonline.com or http://dx.doi.org/10.1097/j.pain.0000000000000754[7] http://www.medscape.com/viewarticle/880038?nlid=115489_1521&src=WNL_mdplsfeat_170606_mscpedit_wir&uac=91665FG&spon=17&impID=1362583&faf=1[8] Dai Z, et al. Dietary intake of fibre and risk of knee osteoarthritis in two US prospective cohorts. Ann Rheum Dis. May 2017 or https://www.ncbi.nlm.nih.gov/pubmed/?term=dai+z+niu+j+felson+d+dietary+intake+risk+knee+cohorts[9] http://ard.bmj.com/content/early/2017/04/29/annrheumdis-2016-210860Download word file: Nutritional Therapy for Osteoarthritis Kenney