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Complementary and Alternative
Therapies (CAM)
Deborah Rothman, Ph.D. , M.D.Shriners Hospital for Children
Springfield, MAJA 2011 National Conference
Arlington, VA
Why is there so much interest in CAM?
Dissatisfaction with current therapies :
• Side effects
• Possible long term adverse effects • The appeal of a “natural” remedy
How does this apply to children with arthritis?
• Is there a way to feed my child that will make her arthritis better?
• Is there a special supplement that will help?
• Do certain foods make arthritis worse?
Goals
Give you tools to help you make decisionsabout CAM with your child’s physician:
1. Is there evidence that this is effective?
2. Is there evidence that this is harmful?
3. Where I am getting this information?
How do we know something helps?
There is a great deal of information on the
Internet about alternative therapies for JIA.
The volume of information isoverwhelming.
How can you possibly evaluate all of thesuggested alternative therapies?
Reliable Sources:Tufts University Health and NutritionLetter (tuftshnltr@aol.co)
International Bibliographic Information on Dietary Supplements
(IBIDS) (http://ods.od.nih.gov/databases/ibids.html
NIH Clinical Nutrition Service(http://www.cc.gov/ccc/supplements/intro.html)
PDR for Herbal MedicinesPDR for Nonprescription Drugs and DietarySupplements
www.foodnews.org (organic vs nonorganic )
Not so Reliable Sources
• Random sites on the internet• Jenny McCarthy• Sites that end in .com• Wikipedia• Friends, relatives, total strangers• Infomercials
Warning
The information that is readilyavailable on the internet may havebeen put there by people whose motivation is primarily financial. It
iscompletely unregulated.
Suggestions
• Download anything from the internet that you want to try and send to your doctor so you can discuss it at your child’s next appointment.
• If you are using alternative therapies let your doctor know.
What is the evidence that this is effective?
Has it been studied in children and the
results published in a peer-reviewed
journal?
How do we know a therapy is effective ?
Randomized placebo-controlled trials
(RCTs) are the gold standard for evaluating
medications and therapies.
What is a RCT?
The intervention is compared to a placebo( fake drug or inactive supplement ) withneither the patient, the parent or theinvestigator knowing who is receiving theactive drug or the placebo (blinded). Thedata is then analyzed to see if there is asignificant difference between the twogroups.
Diet I• Vegetarian diet
• Fasting
• Fish oil
• Borage oil
Vegetarian Diet
• No controlled trials in children.
• Poorly controlled study in adults with RA showing slight improvement
• Vegetarian diets can be healthful for children but may be limited in iron, protein, calcium and certain vitamins.
Types of Vegetarian Diets
• Vegan : Exclude meat, poultry, fish, eggs, dairy
• Lacto-vegetarian : Exclude meat, poultry, fish, eggs, allows dairy
• Lacto-ova vegetarian : Excludes meat, poultry, fish, allows dairy and eggs
• Pesco -vegetarian: Allows fish• Pollo-vegetarian: Allows chicken• Snickers-Vegetarian
Vegetarian Diet
If you are considering a vegetarian diet for
your child ask for a referral to a Registered
Dietician who can review a safe and nutritious vegetarian diet. She can also review drug/nutrient
interactions.Example: calcium and steroids,methotrexate and folic acid.
FASTING
Short-term modified fasting in adults for7-10 days showed improvement in RAactivity. Clin Exp Rheumatol 2000:18,
357.
No studies done in children
Children with S-JIA have profound anorexia with no improvement
Fish Oil
Adult studies: Multiple RCT’s showing
improvement in RA
Pediatric studies: Several RCT’s showing modest improvement: decreased CRP, able to decrease NSAID dose
Fish Oil Caveats
Fish oil thins the blood so could increasethe risk of bleeding if also taking
NSAIDs
Challenging to get children to swallow the
supplements
Mercury
Fish Recommendations
• Good fat: mackerel, herring, sardines, anchovies, albacore tuna, salmon
• BUT for young children NO mackerel
• Up to 12 oz/week of seafood that’s low in mercury: shrimp, salmon (wild), canned light tuna (albacore has 3x more mercury)
Botanical (Plant) Oils
Borage Oil: GLA (gammalinolenic acid) → DGLA→ Prostaglandin E1 which hasantiinflammatory and
immunoregulatoryproperties. It has been shown to
reducesynovitis in adults with RA.
Borage Oil
One RCT in children with JRA showed modest but statistically significantimprovement in children treated
withborage oil compared to a placebo.
A&R 42 (Suppl): S229, 1999.
GLA suppresses acute and chronic inflammation in animal models of arthritis. It has also been shown in placebo-controlled double-blind trials to reduce synovitis in adults with rheumatoid arthritis
These promising results were the basis for this clinical trial to study borage oil for the treatment of JIA.
What does this mean?
There appears to be an effect of this oil in
animal studies. Does that translate tochildren?
There appears to be an effect in adults with
RA. Does that translate to children?
Study Design I
The study was multi-center, randomized,
double-blind, and placebo-controlled. The study duration was 12 months
withthe first 6 months on borage oil orplacebo and then cross over for the
last 6 months.
What does this mean?
The groups had to be comparable
There had to be a placebo
Study Design II
Patient selection:
All patients included in the analysisfulfilled the ACR criteria for JRA.
Study drugs:
GLA in borage oil (23%) at 40 mg/kg/day BID
Safflower oil placebo given in equal volume
Results
Outcome Variable Borage Oil
Placebo P value
Physician’s global assessment (0-4)
0.38 (1.02)
0.92 ( 1.20)
0.002
Parent’s global assessment (0-100)
10.82 (13.78)
17.46 (22.40)
0.069
Functional ability scale (0-3)
0.34 (.40 )
0.42 (.47)
0.113
Number of joints with active arthritis
4.39 ( 9.75)
5.68 ( 9.85)
0.045
Number of joints with limited range of motion
2.75 (5.37)
3.54 (4.80)
0.117
Number of swollen joints 4.25 ( 9.72)
5.46 (9.91)
0.371
Number of tender joints 0.57 (2.10)
0.25 (.84)
0.825
Changing Gears
Diet II
Nutritional Elimination Diets
1.Nightshade vegetables2.Wheat3.Milk/dairy products
Elimination: Nightshade Vegetables
Potatoes, tomatoes, peppers, eggplant
All reports from same author and from anon-scientific review article
Many hits on the internet about thisCourtesy Barbara Ostrov, M.D.
Elimination: Wheat
If your child has celiac disease then wheat
and gluten need to be eliminated fromher/his diet.1.5 -10% of JIA co-exists with celiacdisease. (Rheum 2005: 44, 517)Resolve/improve on gluten-free diet
Celiac disease is a medicaldiagnosis.
Elimination: Milk
• Fewer than 10% of those who believed they were sensitive showed consistent effect of manipulation of milk in diet in PCRCT (Ann Rheum Dis 1992:51, 298)
• True cow’s milk allergy needs to be diagnosed by an allergist
Recommendations
Restrictive diets can deprive children ofvaluable nutrients.
They can isolate children and limit their ability to socialize with their peers.
For those rare children who requirerestrictive diets, work with your physician and a registered dietician.
Safe Nutrition Interventions
• Cook with olive oil
• Eat fish 2x/week
• Vegetarian diets can be safe
• Borage oil supplements
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