Clues to the Cause of Degenerative Joint Disease

Reviews of the degenerative diseases, spinal disc herniation and osteoarthritis, show some interesting correlations. Those often cited are obesity, genetics, prior injury, overuse and certain drugs. But there are other clues that something else is going on.

Patients with these conditions often have high blood sugar; high CRP (C-reactive protein, a marker for chronic inflammation); a low carotenoid index (measure of amount of healthy whole fruits and vegetables eaten.) MRI of joints in these patients show inflammatory changes in metaphysical bone (the bone adjacent to joints.) Anthropological studies show little evidence of these diseases in people from prior times, but few lived into old age. Studies of current primitive societies and third world populations show little chronic joint disease even in older people.

Those with sciatica or spinal disc disease typically have much higher rates of vascular disease and high cholesterol. Discs and spinal nerves are very sensitive to poor blood supply and chronic inflammation. Blocked spinal arteries lead to degeneration, disc rupture and pain. In western societies this vascular disease now starts in childhood as does early disc degeneration.

Patients with joint pain who have an MRI are typically shown to have cartilage loss and irregularity, sometimes a torn meniscus. An obvious approach has been arthroscopic repair of a meniscus or cartilage irregularity. Some improved but results were disappointing. Then science intervened after  hundreds of thousands of these procedures. A group of patients with these MRI diagnoses were randomized to arthroscopic repair or a sham procedure where the patient had an incision and some probing but no repair. Surprise-- no difference in results. The patients' pain was not due to an arthroscopically correctable cause of joint disease. In spite of this surgeons continue to perform these procedures often citing personal experience to justify an expensive procedure which has been proven to be ineffective. The apparent answer then is analgesics, anti-inflammatory drugs, don't use the joint, or "suck it up and live with it" until you have the joint replaced. But that's wrong!

            Chronic Bone and Joint Disease

In past blogs I have discussed auto-immune diseases including some of the arthritides like rheumatoid and psoriatic, but the large bulk of chronic skeletal disease is the so-called degenerative variety including osteoarthritis and spinal disc disease. This group of diseases is a major cause of disability, surgery and medical expenses, currently at 20% of medical costs but increasing rapidly in our aging population. Projections of need for hip and knee replacement are staggering, and these procedures are expensive, typically a total cost of $50,000.

Joint replacement has a high success rate but many do need modification or even repeat replacement. Spine surgery for disc disease has a very high failure rate. In fact, a leading cause of spine surgery is prior spine surgery. Altered biomechanics after surgery leads to failure of adjacent discs and need for more surgery.

Reasons cited for this explosion of degenerative joint diseases are: more older people; more inactivity; more obesity. All are true but there's much more, and it's something amenable to remedial action as I'll discuss in a future blog.

                                    Miracles

The press loves medical “miracles,” often due to a new drug or elaborate new procedure which trumpets the power of modern medical science. Sometimes these are wonderful advances; more often they affect a few people at great expense, frequently with devastating side effects.

In recent years I’ve seen hundreds of medical miracles which would have been described by the press in glowing detail were they due to a new drug or procedure, not because of a simple, cost free change of diet. Unlike miracle drug cures of chronic disease, effective response to diet is the rule, almost without fail, for many life threatening or disabling diseases. While working my whole career in  university medical centers I had never seen these miracles, or even been aware that they were common in the field of lifestyle medicine.

                        Medical Education

Our society is greatly influenced by physician advice and behavior. Only when hospitals banned smoking in the early 1990's did smoking rates start to plummet nationally. The medical profession has to lead in health matters.

Our medical education model is over 100 years old and many commentators have declared it outmoded and sub-optimal. We concentrate on curing disease, not producing health, and the drug industry provides most of the funding med school professors use for their research and career advancement. In recent years big pharma has increased their dominance of medical education by designing a system which enriches researchers and academic leaders. The recent exposure of pay-offs to the top people at Sloan-Kettering in New York (one of the leading cancer research, training and patient care hospitals in the world) is just the tip of the iceberg. The same is true at virtually every research and  training institution in the United States. Since over 80% of health care dollars go to treatment of chronic disease a medical system which prevents and treats these diseases through lifestyle is totally unacceptable to big pharma and the leading academic physicians. The Hippocratic oath's "prevention is preferable to cure" is totally ignored.

The result is medical training where:

          71% of incoming medical students think nutrition is important but only 46% of those graduating do.

          Cardiology training requires no education in nutrition even though the only proven way to prevent and cure atherosclerosis, the cause of heart attacks, is with diet.

          Medical licensure exams have no questions on nutrition.

          Most medical schools ignore the minimal requirement of 25 hours of nutrition training; those that do offer nutrition usually offer irrelevant material.

          94% of practicing physicians now (at last) believe nutrition is important for health but only 14% feel they have any ability to help patients in this regard.

What a mess!  If patients seek out practitioners of lifestyle medicine our model will change. Supply and demand works in our system even if the monied interests of drug and other businesses are paying off institutional leaders.

                         Multiple Sclerosis

Saray Stancic is an MD internist who had to learn about treating chronic disease the hard way. While a senior resident, age 28, she was diagnosed as having multiple sclerosis with severe symptoms. The top doctors at her university medical center took over her care, treating her with multiple drugs which were very expensive and had terrible side effects. After eight years her disease was progressive so that she needed crutches to get around in spite of her ten medications which were tormenting her with side effects. She came across an article in a little read medical journal which reported a group of MS patients who felt much better if they ate blueberries daily. Desperate, she searched the medical literature for connections between diet and her disease. She was shocked to find quite a few, including research published decades earlier in a top journal, The New England Journal of Medicine, which showed a strong correlation between diet and MS (the work of Dr. Roy Swank which I have reviewed in an earlier blog.) Her literature search discovered other work confirming this strong relationship between lifestyle, especially diet, and development and progression of MS. Armed with this, she went to her kindly, paternal neurologist who told her that MS was genetic and she was wasting her time searching for miracles. Dr. Stancic returned to research done on MS to find that only 14-33% of monozygotic (identical) twins got MS if the other twin had it despite identical genes.

What's happening? As with all genetically caused chronic disease including cancer, epigenetics, the environment the genes are bathed in, determines if the genes are expressed and the disease actually occurs, progresses or improves.

Dr. Stancic stopped all her medications, changed to a totally whole food plant based diet, stopped working extra long hours, and slowly added exercise (she had been told not to exercise) as she could tolerate it. Very gradually she got better and was able to run a marathon seven years later. She changed her specialty from infectious disease to lifestyle medicine and was one of the first physicians board certified in this new field. She continues symptom free and healthy treating patients and teaching at her local medical school. Proper treatment of their own chronic disease is difficult for physicians since, even more than most Americans, they have been taught that all disease, chronic or acute, is best treated by pills and surgery.

        Individual Approach to Medical Care

Most American adults choose the medical care they and their family receive based on finances, availability, past experience and personal preference.

For the more educated upper middle class this is usually care predominately provided by a physician (MD or DO) and that physician's support system such as physician assistants, nurse practitioners and other nurses. A physician associated with a medical training facility may also use students, residents and fellows.

Some choose to rely mainly on other credentialed health care providers like chiropractors (DC), naturopaths (ND), those trained in some form of oriental medicine. Some of this care is excellent.

Uncredentialed practitioners offer a wide variety of approaches and treatments. Some of this care is also excellent but there is a high probability of ending up using ineffective or dangerous remedies.

Another large group uses little or no medical provider: cost, fear and mistrust are common reasons for this.

Many try a combination of some or all of these approaches depending on past experience and an increasing reliance on the internet for information. With some caveats I believe this is the optimal way to decide on health care. Acute disease like serious trauma and major infection is almost always best treated by the physician model. Emergency rooms and walk-in clinics do an excellent job. Modern surgical orthopedic care often works wonders with joint replacements. Acute heart attacks, strokes and abdominal crises also need quick attention by a hospital. 

Unless you can find a physician well trained in lifestyle medicine (there is now board certification in this specialty) you are likely to get poor care in the prevention and treatment of chronic disease. Unfortunately there is a huge amount of misinformation about chronic disease and good lifestyle, particularly diet. Indiscriminate internet searches are likely to find false or misleading advice for many reasons including financial gain for the advice giver. Many of us, including other physicians, spend a lot of effort discovering the best care for themselves and family because current medical care care options deal so poorly with chronic disease.

                       Coffee and Coffee Drinks

As I take my long morning walks with Charlie dog, the second love of my life, I often pass close to a Starbucks and see a parade of people with drinks in hand, usually some variety of a coffee extravaganza.

As a young man I started drinking coffee in company with most of my friends and physician colleagues. Cream or milk and sugar allowed me to enjoy a milkshake-like beverage, and I love milkshakes! Then living in St. Louis, I read an interview with Stan Musial, the great Cardinal baseball player, whose son was a college classmate of mine. Stan said it was okay to have milk or sugar in coffee but not both. So I tried skipping one or the other and discovered that I still enjoyed my hot morning beverage, since by now my palate had come to appreciate the coffee itself. After a while it seemed reasonable to try skipping both cream and sugar. I still liked my coffee and have drunk it that way ever since, now preferring it black. Food preferences are not usually difficult to change.

Long term tea and coffee consumption have been extensively studied. Tea has always shown significant benefits but coffee was questioned, probably due to higher caffeine content. Most recent evaluations now conclude that coffee has long term health benefits if you are not sensitive to caffeine. Darker roasted coffees are much less healthy because valuable coffee phytonutrients are destroyed with more roasting. BUT no-one even suggests that any dairy or sweetener in the coffee is healthy. In fact, dairy, but not soy milk, greatly reduces the nutritional value of coffee by binding healthy coffee chemicals with dairy protein. Take Stan the Man's advice one step further and learn to skip both milk(except plant-based milks) and sugar in your coffee.

                   Dietary Fat and Weight

In past blogs I've commented that high fat diets have several major health consequences:

     

   Serum cholesterol is raised leading to plaque development with subsequent arterial blockage from rupture with acute thrombosis, the usual cause of a heart attack, or narrowing due long term accumulation of cholesterol in the arterial wall.

   High fat in the blood blocks normal vascular ability to dilate in response to increased demand.

   Insulin is prevented from entering cells; in the long term, type 2 diabetes ensues.

A recent study by Sumei Hu and associates published in the journal Cell Metabolism looked at weight effects of 29 different diets in several strains of lab mice. Portions were not restricted nor was activity. All mice had the same weight response to different food compositions which ranged from 10-80% carbohydrates; 5-30% pure sucrose(sugar); 5-30% protein; 8-80% fat. Only very high fat diets caused the mice to overeat and become obese. Paradoxically, this did not occur when the diet was extremely high in fat (60-80%) presumably because this food was so unpalatable. High fat diets led to genetic change in brain areas evoking a happy feeling and driving too much calorie consumption, but no other dietary combination did this.

                    Schizophrenia

Schizophrenia is one of the most devastating and poorly understood mental illnesses. Over 50 years ago drugs like thorazine started to allow some schizophrenics to function, but at the price of sedation which made the whole world gray and uninteresting plus other series side effects. Because of this schizophrenics often stopped their medications and relapsed- the drugs were too unpleasant to tolerate.

Many hypotheses about the cause of schizophrenia have been suggested. Genetics is important, but it is certainly not the only factor, or even, perhaps, the most important one. Carefully studied patients with schizophrenia have shown that auto-immunity and inflammation can play important roles. Two severe schizophrenics were treated with minocycline, an older antibiotic most often used for acne. Both were totally cured but relapsed when the drug was discontinued. Long term, low dose minocycline allowed both to be discharged. Subsequent larger trials have confirmed benefit in many schizophrenics. Treatment with probiotics has shown a similar effect. The hypothesis is that improving the gut microbiome, thereby reducing systemic inflammation, helps brain chemistry and improves schizophrenia. Modern medicine loves chemical interventions like antipsychotic drugs, antibiotics and probiotics, usually ignoring the well documented fact that a whole food plant based diet is by far the best way to create and maintain a healthy gut microbiome and lower systemic chronic inflammation.