Cooking up arthritis treatments

One of the things about the complimentary and alternative medicine industry I like least is spurious claims to be able to treat arthritis.  Several of my nearest and dearest are severely afflicted with rheumatoid arthritis (RA).  I have seen them exasperated by people who, usually with the best of intentions, tell them that their problems would be a thing of the past if only they would take Comfrey (or some other herb) or wear a copper bracelet. 

It’s not so much the intrusion that’s annoying: it’s the often not-so-subtle sub-text.  The implication is usually that they have access to some wisdom that is beyond the ken of the humble local GP or consultant rheumatologist.  You see, for all their years of training, medics have somehow managed to remain ignorant of herbal cures and magic jewellery.  In more extreme cases there is the distinct implication that such powerful, natural and kindly measures are being deliberately withheld by evil medical professionals in thrall to the robber barons of ‘Big Pharma’. 

Then there is the implication that the NSAIDS, steroids, methotrexate^*, anti-TNF drugs and even surgery have been unnecessary.  It must be somewhat galling if you have laboured to carefully weigh the risks against the benefits, endured the pain of surgery and occasional bouts of methotrexate poisoning; when people imply that all you needed to do was drink a herbal brew, take the right supplements, eat the right food and wear a bracelet that vibrates with the right energy! 

So, it’s clear I have some pushable buttons when it comes to peddling nonsense about arthritis.  Then I had the misfortune to stumble across Naturopath Annelie Whitfield‘s “The Kitchen Pharmacy” episode on arthritis. 

This series of short programmes is sponsored by the infamous Neals Yard, for whom Whitfield works.  So an agenda that supports their commercial objectives is inevitable. 

Whitfield certainly seems sincere – which is perhaps one of the biggest problems with her commentary on herbal cures for arthritis.  She shows not a whit of uncertainty.  The various ingredients are “important” and “wonderful”; one of her cures is, “a perfect daily medicine for arthritis”.  If things were really this good then it would be a sorry indictment of the medical profession indeed. 

Now, don’t get me wrong: I have nothing against herbs.  I grow them in my garden and use them liberally in cooking.  In fact, I watch (more) than my fair share of cooking shows and this made watching the Kitchen Pharmacy even more surreal.  At times I wondered: is this a medicine or a cooking show? 

Equally, I am sure that herbs contain many interesting compounds; some of which may turn out to be therapeutically useful.  My main complaint with herbalism is the broad claims made for uncontrolled doses of chemical cocktails in the absence of decent evidence. 

On this score, Whitfield, sadly, does not disappoint.  Her first concoction is a multi-mint arthritis tea.  This is her, “perfect daily medicine for arthritis”. 

The Magnificent Seven

The recipe comprises seven herbs, five fresh (Mint, Rosemary, Sage, Thyme, Basil) and two dried (Oregano and Marjoram).  The infusion was assembled by taking various “loose handful[s]”, “little bit[s]” and “pinch[es]”.  This was steeped in hot water, and honey added for taste, though this came with a warning: never put honey into boiling tea as it can destroy some of the active ingredients. 

So why prescribe this very pleasant sounding herbal tea for arthritis sufferers?  Why so many herbs from “the mint family”?  They contain antioxidants and antioxidants are, ” really, really important for inflammation.” 

Now, it is true that rheumatoid arthritis is an inflammatory condition: 

“Also known as inflammatory arthritis, rheumatoid arthritis […] The body’s immune system attacks and destroys the joint, causing pain and swelling. It can lead to reduction of movement, and the breakdown of bone and cartilage […]”

Whereas the more common osteoarthritis occurs when: 

“Cartilage (connective tissue) between the bones gradually wastes away (degenerates), and this can lead to painful rubbing of bone on bone in the joints. It may also cause joints to fall out of their natural positions (misalignment). The most frequently affected joints are in the hands, spine, knees and hips.”

 So, I will assume that Whitfield is talking about the former, rather than the latter.

But wait, a review (Canter et al., 2007) concluded that, “There is no robust evidence that antioxidant vitamins are effective in any type of arthritis.”

Add to this a Cochrane Review (Little and Parsons, 2000) that concluded:

 “The current available evidence for herbal treatment of RA is generally sparse and reliant on small sample sizes and is therefore insufficient for reliable assessment of benefits. Studies of gamma-linolenic acid [GLA] in the treatment of RA, however, are promising and suggest that this herbal intervention may provide supplementary or alternative treatment to NSAIDs for some patients.”

 Oddly, Whitfield did not mention GLA at all in this piece.  In any event, the reviewers found insufficient data to make a reliable assessment of benefits.  GLA may be a promising therapeutic agent – but the case is far from made.

 For all the fuss on the internet about antioxidants and arthritis, the credible medical literature shows that there is little reliable evidence to say that they might help.  The same is true of herbal treatment generally.  The general evidence just does not support Whitfield’s confident pronouncements.

Searching PubMed for each of the suggested herbs as arthritis treatments also, predictably, did not turn up anything to support the use of these plants to treat arthritis.

 A general review focussed on the use of patented products made form chemicals derived from these plants, rather than the plants themselves (Darshan and Doreswamy, 2004)

 Rosemary was mentioned by Lukaczer et al. (2005) who did a trial of, “a proprietary, standardized combination of reduced iso-alpha-acids from hops, rosemary extract and oleanolic acid […] on pain in patients with rheumatic disease.”  The patients were given 440 mg three times a day for 4 weeks.  Unfortunately this was an uncontrolled open-label trial and pain is susceptible to the placebo effect, so it is unconvincing that it reported a statistically significant reduction in patient scores for pain.  Interestingly, the one objective measure, C-reactive protein (a marker for inflammation), did not show statistically significant reductions.  Again, this was not using plant to make a tea – it was using high doses of refined extracts.

 This underlines an important point: even if these plants contained chemicals that helped alleviate arthritis then the dose provided by Whitfield’s tea is likely to be much too low.

Finally, Singh et al. (2007) provided an overview of the effect of Holy Basil^** on a range of inflammatory conditions in animals.  Again, it’s about the use of the extracted oil – not the plant.  Wrong plant, wrong dose and not involving people!  Not close to evidence.

Still, Whitfield has the wisdom of the ancients to draw on; stating that mint packs were a common remedy used to treat joint pain in the Middle Ages.  I guess that the Middle Ages were a golden age for arthritis sufferers then?

As the piece moves on we are helpfully told by superimposed text caption, “in ancient Egypt rosemary was used in mummifications.”  I struggle to see the relevance of this claim.

As this segment winds down, Whitfield tells the audience that, “Rosemary and Oregano contain the most potent form of this anti-oxidant” and that the tea could be made with these alone.  This rather undermines the notion that the combination of herbs is important.  Why wibble on about seven, if two will do?

Whitfield also opines that this brew is quite a good “digestive tea” as well.

Reviewing the paucity of evidence, her authoritative statement that this multi-mint tea is, “a perfect daily medicine for arthritis” is obviously wrong.  Calling it a medicine is an insult.

The piece ends with a warning to pregnant women not to drink the tea.  It seems a bit excessive given that this is just a mix of common culinary herbs infused in hot water. Still, I’m not a doctor.

Oil Those Joints

Next we are told in Whitfield’s authoritative way that a Castor Oil compress is ideal for sore or inflamed joints.  This is just a topical application of warm castor oil.  According to the Naturopath the active ingredient – ricinoleic acid, “helps to move and stimulate the lymph and reduce information.”  Apparently, the heat helps to, “activate the castor oil, starting the healing process”.

Ricinoleic acid does, apparently, have anti-inflammatory properties.  These have been commented on in several publications (see, for example, Vieira et al., 2000; Vieira et al., 2001) examining animal models.  Interesting for the rats, mice and guinea pigs watching the show, but not so much for the people.

What Whitfield is asking the audience to believe is that ricinoleic acid works to reduce inflammation in RA, that Castor Oil contains enough of it and that it can penetrate the skin in sufficient quantity to do its stuff.  This is a very log shot – not the therapeutic certainty that Whitfield claims.

It seems to me to be a restating of a common fallacy – let’s call it the lubrication fallacy: My joints are stiff so some oil will free them up.

Gruelling

Next there is a “mineral rich” herbal broth: “One of the easiest and cheapest dietary ways to improve arthritis.”

This thin herbal gruel (I’d suggest adding some belly pork and noodles) contains some lovely ingredients: olive oil (2 table spoons), garlic (2 cloves) and (one thumb-sized piece of) ginger.  These are claimed to be, “very strong anti-inflammatories.”  So what evidence is available?  Not much.  Wigler et al. (2003) tested a ginger extract (250 mg of dried ginger root per capsule) on twenty-nine patients with gonarthritis.  They reported that it, “was as effective as placebo during the first 3 months of the study, but at the end of 6 months, 3 months after crossover, the ginger extract group showed a significant superiority over the placebo group.”  This study is to be viewed with caution: it’s very small and only 20 of the participants completed the trial – a 31% drop-out rate.

 The other papers that I have found refer to osteoarthritis.  Altman and Marcussen (2001) used a standardized, highly concentrated and purified ginger extract that, “[…] had a statistically significant effect on reducing symptoms of OA of the knee.”  However, “This effect was moderate […]”

In contrast, Bliddal et al. (2000) reported a trial that, “[…] In the cross-over study, no significant difference between placebo and ginger extract could be demonstrated […] In the present study a statistically significant effect of ginger extract could only be demonstrated by explorative statistical methods in the first period of treatment before cross-over, while a significant difference was not observed in the study as a whole […]”

So, for ginger, the evidence is about as thin as Whitfield’s herbal gruel.  If it is effective then high doses are required, not a few shavings of garnish.

The evidence for garlic is even thinner.  For example, Denisov et al. (1999) reported (in Russian) an, “open controlled trial of alisate [a Russian garlic preparation]” with thirty patients with rheumatoid arthritis (RA).  Half received, “alisate in a dose 300 mg (1 tablet) twice a day for 4-6 weeks.”  The remainder “received conventional antirheumatic therapy.”  The English abstract claims that, “[t]he alisate group achieved a good and partial response in 86.5% of cases. The drug was well tolerated and had no side effects. In control group, some parameters changed for the worse.”  It’s never satisfactory to have to rely on an abstract, but a small un-blinded trial is hardly impressive.  Neither is it relevant to the use of raw garlic in cooking.

There are a few, small studies that report some benefits from supplementation with olive oil (Berbert et al., 2005).  But there is no substantial evidence.

Whitfield continues, telling her audience about other ingredients.  She adds Fennel and white mustard seeds, claiming that they are, “great at lowering cholesterol actually” and good for digestive system.  There are, predictably, no credible published studies to support these claims.  In any event, the amounts used in the broth are tiny.

The naturopathic cook then adds a small spoon of turmeric (the putative active ingredient is curcumin), saying as she does that it, “works really well with onion”, having similar anti-inflammatory chemical compounds.

Khanna et al. (2007) claim that, “several preclinical and clinical studies suggest” that curcumin extracts, “have potential for arthritis treatment”.  Whilst Hsu and Cheng (2007) commented on the low bio-availabilty of curcumin, but stated that, “the preliminary results did support the efficacy of curcumin [but] the data to date are all preliminary and not conclusive. It is imperative that well-designed clinical trials, supported by better formulations of curcumin or novel routes of administration.”  In a similar vein Anand et al. (2007) stated:

“Curcumin, [,,,] possesses diverse pharmacologic effects including anti-inflammatory, antioxidant, antiproliferative and antiangiogenic activities. […] but exhibit poor bioavailability. Major reasons contributing to the low plasma and tissue levels of curcumin appear to be due to poor absorption, rapid metabolism, and rapid systemic elimination. […] Despite the lower bioavailability, therapeutic efficacy of curcumin against various human diseases, including […] arthritis […] has been documented.”

It looks to me like the evidence to support the therapeutic value of turmeric is limited.  Given the amount used (1 teaspoon) in this recipe and the bio-availability issue, its presence in this broth is clinically irrelevant.

Khanna et al. (2007) did observe that compounds such as curcumin “[…] constitute ‘goldmines’ for the treatment of arthritis”.  I think I agree; but probably not in the way envisaged by the authors.

Helpfully a subtitles inform us that, “Turmeric has been used in India for at least 2500 years both in cuisine and medicine”: an example of the common argument from antiquity fallacy.

Next, vegetables are added.  Carrots – are full of minerals and vitamins that “help to alkalise the body”. Celery is, “high in organic sodium [80 mg / 100g^***] and calcium [40 mg /100g]” and helps to clear away any dead wastes that clog up in the tissues.

The basic descriptions of the composition of these ingredients are – as far as I can tell – fair enough.  The claimed effects are clearly nonsense.  The acid-disease myth rears its ugly head as Whitfield ignores the body’s homeostatic mechanisms.  If the pH (acid/alkali) balance of our bodies were so easily changed then life would be precarious indeed^****.  The “dead wastes” assertion is meaningless.

Aubegine may be “high in anti-oxidants” but, as we have seen, this is unlikely to help.  It tastes nice though.  I do enjoy, “chopped white cabbage”, but is this really, “a wonderful cleanser of mucus membranes” that is, “rich in sulphur – which helps rebuild connective tissue”?  No, yes and in these quantities No.

Spinach may be, “rich in iron” but it is not, “very, very cleansing” as Whitfield wibbles on.  The cleansing claims are nonsense.  The body has very effective cleansing systems:  the liver, kidneys and colon. Neither Spinach, nor anything else we eat can improve how they work.

Whitfield appears confused about sodium.  Stock cubes are, “very high is sodium … that’s not ideal for arthritis sufferers”.  But wasn’t celery praised for its high sodium content?  Whitfield also proclaims that, “we are getting lots of organic sodium … key in arthritis sufferers.”  She also adds sea salt at the end.  Doesn’t that contain sodium?

Parsley is introduced, “rich in zinc, excellent source of fluorine really good for strengthening the bones”.  Is a handful going to make much difference?  Parsley seems to contain between 1.5 mg / 100g and 0.46 mg / 100g of zinc.  The NIH recommends either 11 mg (male) or 8 mg (female) per day for adults.  That’s a lot of parsley, whereas a decent ribeye steak, for example, will provide around half of an adults daily requirement.

I am not sure what Whitfield means by “fluorine” but as far as I can see, it doesn’t contain much or any Fluoride.

We have seen that this broth is not “perfect for arthritis”.  It’s certainly not medicine.  Whitfield is just peddling speculation and myth in equal quantities; without any thought as to the actual dose of the putative therapeutic compounds.  For someone with a science degree, this should be embarrassing – although it is a degree in Naturopathy.  Perhaps, we could see this as an eloquent testimony to the worthlessness of such quackademic qualifications.

The contention that, for people with arthritis, it is, “Important to eat the right foods” is spurious.  (aside from general healh and weight control, of course)

Panush et al. (1983) completed a, “10-week, controlled, double-blind, randomized trial of patients with active rheumatoid arthritis (RA).  Twenty-six patients completed the study; 11 were on an experimental diet (a specific popular diet free of additives, preservatives, fruit, red meat, herbs, and dairy products) and 15 were on a “placebo” diet. Of 183 variables analyzed, there were no clinically important differences among rheumatologic, laboratory, immunologic, radiologic, or nutritional findings between patients on experimental and placebo diets.”

A review by Pattison et al. (2004) concluded that whilst, “Evidence exists that diet may play a role in the etiology of RA, […] it is inconclusive due to the small number of studies available and variation in study design.”

More recently, and less optimistically a Cochrane Review by Hagen et al. (2009) concluded “It is uncertain whether diets improve pain, stiffness and the ability to move better […] instead, diets may be difficult to stick to, and people may lose weight on these diets even though they did not plan to.” 

Whitfield then foes on to recommend wheat grass as it contains superoxide dismutase which has a, “proven therapeutic effect as it reduces inflammation.”  To be fair, there is some published information on the use of SOD in treating RA.  However, it is sparse and is a long way from proof.

For instance, a review by Flohé (1988) concluded that “Systemic treatment of rheumatoid arthritis by [bovine] SOD at the dosages indicated yielded disappointing results.”

A more recent trial by Zuo et al. (1995) investigated, “The effects of Cu.Zn-SOD on rheumatoid arthritis” using a:

“[…] double blind, placebo controlled clinical study. Thirty-nine patients with definite rheumatoid arthritis were randomly divided into two groups: SOD group (n = 29) was injected with Cu.Zn-SOD 80000 unit, q.o.d., intramuscularly for four weeks and placebo was used as control (n = 10). After treatment the results showed increased grip strength, shortened duration of morning stiffness, less tender joint and swollen joints as well as lower erythrocyte sedimentation rate. In the Cu.Zn-SOD group the number of swollen joints was less (P < 0.05), and the effective rate was higher significantly (P < 0.01) than that in the placebo control group.

Given that this is a small study and trials originating in China appear to have endemic quality issues (Wise, 2009), the older negative review is probably more reliable.  In any event, Zuo et al. (1995) did not use wheat grass shots – they injected the SOD.

Whitfield still has more to say:  sulphur rich foods, the onions and garlic repair connective tissues.

Predictably Whitfield espouses a kill-joy diet, “avoid acidic forming foods like red meat, spicy food and alcohol”.  A piece of nonsense: the body maintains its own pH balance very effectively – it’s not a hostage to our dietary choices – in any event our stomachs digestive system relies on acid!

This short piece ends with a, “Take Away Tip”, not that her diet allows for many Take Aways!  Anyway her tip  is to take one tea spoon of apple cider vinegar before you eat – the organic, unpasturised and unfiltered version of course.  Why? Because it’s “good at metabolising proteins and contains mallic acid which has the potential to clear crystal deposits from the muscle tissue which is key in treating arthritis.”  

It is hard to know where to start with this nonsense.  The apple cider vinegar will be broken down in the stomach anyway.  Our digestive systems are pretty good at breaking down food anyway -it’s what it is for!  Mallic acid will not clear crystal deposits from any muscles because they are fictitious.  Perhaps Whitfield is talking about gout?  It can be classed as a form of arthritis.  However, the problematic crystal deposits are in the joints not the muscles. 

Her job done, Whitfield then leaves a Neal’s Yard shop – which is the final nail in the coffin for the credibility of this programme^†.

It is a truly amazing piece of work.  In ten short minutes this BSc Naturopath makes, with great authority, a range of claims based, as far as I can tell, on: extrapolating from clinical trials that used refined plant extracts, ignoring the dosage issue, and misconceptions about arthritis and the functioning of the human body.  This is topped off with things that appear to be fictional. 

Hagen et al. (2009) usefully point out: 

“There is no cure for RA at present, so treatments aim to relieve pain and stiffness, and improve the ability to move.” 

It is also fair to say that current treatments are far from ideal.  Pain relief is not always reliable; the drugs can have serious side effects and there is no cure.  This does make arthritis sufferers both vulnerable to and targets for pedlars of Complimentary and Alternative Nonsense. 

However, getting access to good quality medical management is important in limiting some of the more extreme consequences of the disease.  Anything that encourages people to think that ineffective treatments are can work for them may cause them to delay getting the treatment they need.  This can have serious consequences for their future quality of life.  I have seen first hand the effect of delayed treatment in serious RA; it’s not pleasant. 

Finally, critics of conventional medicine sometimes complain that it is authoritarian and fails to acknowledge its own limitations.  That seems to be a perfect description of Whitfield’s version of naturopathy. 

Disclaimer 

I am not a doctor.  This is not medical advice.  If you need that please consult a properly qualified and registered medical doctor.  

Equally, if you think I have got anything wrong in this piece, please let me know.  I try to be careful, but anyone can be mistaken.  If you are right I will happily correct what I have written. 

Notes

*See Suarez-Almazor et al. (1998)

** Not the European culinary variant used by Whitfield.

*** See the USDA National Nutrient Database for Standard Reference.

**** See Orac, HolfordWatch and Dr Aust‘s explanations.

†See the Thinking is Dangerous and HolfordWatch blogs for coverage of the Neil’s Yard approach to evidence, criticism and engagement with the public. 

References

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