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Osteoarthritis and Its Treatment:What You Need to Know

This booklet is based on a paper written for ACSH by

Gary W. Williams, M.D., Ph.D.Chairman, Department of Medicine

Scripps Clinic Medical GroupVice President for Medicine Services

and Academic Affairsthe Scripps Clinic Foundation, La Jolla, CA

January 2004

KATHLEEN MEISTER, M.S., WROTE THIS BOOKLET, BASED ON AN EARLIER PAPER

WRITTEN FOR ACSH BY GARY W. WILLIAMS, M.D., PH.D., WHICH WAS

REVIEWED BY:

ACSH accepts unrestricted grants on the condition that it is solely responsible for theconduct of its research and the dissemination of its work to the public. The organizationdoes not perform proprietary research, nor does it accept support from individual corpo-rations for specific research projects. All contributions to ACSH—a publicly fundedorganization under Section 501(c)(3) of the Internal Revenue Code—are tax deductible.

Individual copies of this report are available at a cost of $5.00. Reduced prices for 10 ormore copies are available upon request.

Copyright © 2004 by American Council on Science and Health, Inc.This book may not be reproduced in whole or in part, by mimeograph or any othermeans, without permission.

Steven Abramson, M.D.NYU School of MedicineHospital for Joint Diseases

Karl E. Anderson, M.D., FACPUniversity of Texas MedicalBranch

Peter Barland, M.D.Albert Einstein College ofMedicine

George E. Ehrlich, M.D.University of Pennsylvania/NYU/WHO

Allan Gibofsky, M.D., J.D., FACP,FCLMJoan and Sanford Weill MedicalCollege of Cornell University

Michael Kirsch, M.D., FACPHighland Heights, OH

Joseph Markenson, M.D.Joan and Sanford Weill MedicalCollege of Cornell University

Roland W. Moskowitz, M.D.Case Western Reserve UniversitySchool of Medicine

Dennis L. Sprecher, M.D.Cleveland Clinic Foundation

William B. White, M.D., FACPUniversity of Connecticut Schoolof Medicine

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Table of Contents

Osteoarthritis Basics

How Doctors Diagnose Osteoarthritis

Self-Treatment of Osteoarthritis

Forms of Treatment for Osteoarthritis

Glucosamine and Chondroitin

Future Drug Therapies for Osteoarthritis

Summary

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Arthritis and other “rheumatic” (joint-related) conditions are the leadingcause of disability in the United States. Between one sixth and one thirdof American adults — that is, somewhere between 40 and 70 millionpeople — have some type of arthritis or chronic joint problem.1 Themost common type of arthritis is osteoarthritis; more than 20 millionAmericans have this condition.2

At the present time, osteoarthritis cannot be cured. However, much canbe done to control its symptoms and maintain joint function. This reportfrom the American Council on Science and Health provides a brief sum-mary of the symptoms and causes of osteoarthritis and explains experts’current views on the best ways to treat this disease.

Osteoarthritis Basics

The word arthritis literally means joint inflammation. In practice, theword is used to refer to a group of more than 100 diseases and condi-tions3 that can cause pain, stiffness, and swelling in the joints, includingsome conditions — such as osteoarthritis — in which inflammation isnot necessarily apparent.

The word osteoarthritis refers to a group of disorders that affect the car-tilage of the joints. Cartilage is the slippery tissue that covers the endsof the bones in a joint. When cartilage is healthy, it allows bones toglide over one another easily. It works as a shock absorber, helping tocushion the joint against damage from physical movement. When carti-lage breaks down and wears away, however, as it does in osteoarthritis,the joint does not function well. The bones rub against each otherdirectly, causing pain, swelling, stiffness, and difficulty in movement.Over time, the joint may lose its normal shape, bits of bone (bone spurs)may grow on the edges of the joint, and small pieces of bone or carti-lage may break off and float inside the joint. All of these changes con-tribute to additional pain, loss of function, and joint damage.

1 CDC Press Release, “Arthritis and Chronic Joint Conditions More Common ThanPreviously Thought,” 10/24/02.

2 NIAMS fact sheet, “Handout on Health: Osteoarthritis” (referred to later as NIAMS2002).

3 Lewis, C, Arthritis: timely treatments for an ageless disease, FDA Consumer, May-June 2000 (referred to later as FDA Consumer 2000).

Osteoarthritis and Its Treatment: What You Need to Know

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Like other tissues in the body, cartilage is continually remade. Everyday, some cartilage is broken down, and some new cartilage is formed.In osteoarthritis, there is an imbalance between the formation andbreakdown of cartilage, so that the synthesis of new cartilage does notkeep up with the wearing away of old cartilage. This is why the amountof cartilage in the joint decreases and the functioning of the jointbecomes impaired.

Scientists have learned that the process by which cartilage deterioratesin osteoarthritis is very complex, involving multiple steps and theactions of many different body chemicals. Although this complexitymakes the process difficult to understand, it also offers hope for thedevelopment of more effective treatments; drugs that inhibit any stagein the destructive process might be useful in relieving symptoms orslowing the progress of joint damage.

The joints most often affected by osteoarthritis are in the hands, knees,hips, and spine.4 The problem usually develops gradually; joint pain isthe first symptom, and the pain is made worse by repetitive use of thejoint.5 Some people have osteoarthritis in only one joint; in other indi-viduals, many joints may be affected.

Older people are most at risk for osteoarthritis. The joints in the humanbody are under a great deal of stress, and cartilage has only a limitedability to repair itself. Thus, as people get older, the accumulation ofmany years of wear and tear on the joints increases the chances thatosteoarthritis will develop. Aging is also associated with decreases inmuscle mass and strength and with changes in bone, which may putadditional stress on the cartilage of the joints.

Age is not the only risk factor for osteoarthritis, however. The disease canoccur even in young people as a result of injury to a joint — generally fromrepeated trauma from recreational or other activities. Obesity is a majorcontributing factor in osteoarthritis of the knee, especially in women.Genetic factors are also believed to play a role. Osteoarthritis runs in somefamilies. In addition, some people have hereditary conditions, such ashemochromatosis (an inherited disorder in which excessive amounts of ironaccumulate in the body) that predispose them to osteoarthritis.

4 NIAMS 2002.5 FDA Consumer 2000.

How Doctors Diagnose Osteoarthritis

When patients go to a doctor because of concern about joint pain orother joint symptoms, the doctor will need to determine whether theproblem is due to osteoarthritis or to other causes. Many different con-ditions can cause joint pain; because these conditions require differenttypes of treatment, it is important to distinguish among them.

There is no specific diagnostic test for osteoarthritis, but the physiciancan usually diagnose the problem through a physical examination andmedical history (asking the patient about the symptoms and when theyoccur). X-rays are often taken. In some instances, particularly inpatients who have inflammation (swelling of or fluid in the joint, and/orredness, and/or heat) along with joint pain and stiffness, blood tests orother diagnostic tests may be needed to distinguish osteoarthritis fromother diseases such as rheumatoid arthritis. In patients with osteoarthri-tis, the results of the tests will be normal; in those with other diseases,they may not be.

Self-Treatment of Osteoarthritis

Most of the rest of this report will discuss the ways in which doctorstreat osteoarthritis. It’s important to note, though, that before patientssee a doctor, they have usually been aware of their joint problems forsome time and have taken steps to deal with the symptoms by usingnonprescription medicines, devices, and/or dietary supplements. Manypatients do not discuss their joint problems with a doctor until theyreach the point where nonprescription remedies no longer relieve theirsymptoms.

Although self-treatment can be an appropriate way to deal with minor,occasional health problems, it is important for patients to realize thatremedies available without a prescription are not necessarily risk-free.Also, people who use nonprescription products to treat joint symptomsmay be delaying obtaining a correct diagnosis and thus appropriatemedical care — joint pain may be caused by a number of illnesses otherthan arthritis — so an accurate diagnosis is important.

Those who decide to continue self-medicating should take the followingprecautions:

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Osteoarthritis and Its Treatment: What You Need to Know

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1. Always read and follow the directions on the product label.

2. If you take prescription medication or have any type of medicalproblem (even something unrelated to arthritis), consult your doctorbefore using any over-the-counter drug or dietary supplement. Someproducts sold without a prescription may not be safe for you or mayinterfere with your medications. For example, recent research indi-cates that ibuprofen (sold under many brand names including Adviland Motrin), which is commonly used to relieve mild arthritis painand is available over the counter, may interfere with the protectiveeffect of low-dose aspirin against heart attacks.

3. Be aware that, unlike over-the-counter drugs, dietary supplements donot need to be proven safe or effective before they can be sold.Many of these products have received little formal scientific scrutiny,and their risks and benefits may be uncertain. Dietary supplementsmay also be inconsistent in quality and purity.

4. If you need to treat yourself for joint symptoms frequently, it wouldbe a good idea to consult your doctor even if you are still obtainingsatisfactory results from nonprescription remedies. Your doctor maybe able to recommend or prescribe treatments that are safer or moreeffective than those that you have been using on your own.

Forms of Treatment for Osteoarthritis

The currently available forms of treatment for arthritis do not cure ormodify the course of the disease. Instead, the goal of therapy is to con-trol pain and maintain or improve joint function.

Two professional organizations, the American College ofRheumatology (the organization of U.S. physicians who specialize inarthritis care) and the American Pain Society (an organization of scien-tists and physicians specializing in research on and treatment of pain),have issued treatment guidelines for osteoarthritis. The goal of theseguidelines is to ensure that the safest treatments are used first, withforms of therapy that are most likely to produce troublesome sideeffects reserved for cases in which the preferred treatments did not pro-duce adequate relief of symptoms.

Both sets of guidelines begin by recommending non-drug therapies,

such as weight loss (particularly valuable for patients with osteoarthritisof the knee) and appropriate exercises to strengthen muscles. Theseforms of treatment are safe when performed properly, and they mayallow patients with mild or intermittent joint symptoms to avoid the useof drugs (and therefore the potential side effects of drug therapy).

Drug TherapyIf non-drug therapies don’t produce sufficient relief, the use of drugs isthe next step in osteoarthritis therapy. For patients with mild joint pain,the first drug recommended in both sets of guidelines is acetaminophen(the active ingredient in Tylenol and many other brands of non-aspirinpain reliever). The advantages of this drug include its relatively lowcost, widespread over-the-counter availability, and general safety.For patients whose arthritis pain is too severe to be relieved by aceta-minophen, the recommendations are more complex. To understand thereasoning behind them, it is helpful to take a brief look at the types ofdrugs used to treat osteoarthritis and how they work.

The drugs most commonly used to treat osteoarthritis are non-steroidalanti-inflammatory drugs (NSAIDs). These drugs work in the body byinhibiting the actions of enzymes called cyclooxygenases (COX), whichcontribute to pain and inflammation. There are at least two kinds ofCOX enzymes in the body: COX-1 and COX-2. Research indicates thatthe COX-2 enzyme is the one that’s important in causing pain andinflammation. COX-1 is more of a “housekeeping” enzyme; it playsroles in the normal functioning of several body organs and, in particular,seems to have a protective role in the digestive tract.

Traditional NSAIDs, such as ibuprofen (Advil, Motrin, etc.), naproxen(Anaprox, Aleve, Naprosyn), ketoprofen (Orudis, Oruvail), andindomethacin (Indocin), inhibit both COX-1 and COX-2. These drugsare effective against pain and inflammation, but they also tend to haveside effects in the digestive tract, especially when they’re used on a regu-lar basis, as they often are by patients with osteoarthritis. The side effectssometimes include serious problems, such as ulcers and bleeding.

Some newer drugs, called COX-2–selective agents, are also used in thetreatment of osteoarthritis. This group of drugs includes celecoxib(Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra). These drugs areNSAIDs, but they inhibit COX-2 only; they don’t affect COX-1.Research has indicated that they work as well as the traditional

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Osteoarthritis and Its Treatment: What You Need to Know

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nonselective NSAIDs do in reducing pain and inflammation. Apparent-ly, COX-2 is the important enzyme when it comes to pain; whether ornot a drug inhibits COX-1 seems to be irrelevant in terms of the drug’seffectiveness against arthritis pain.

The COX-2–selective agents have fewer gastrointestinal side effectsthan do traditional nonselective NSAIDs, suggesting that the sideeffects of the traditional drugs are due primarily to their impact onCOX-1. COX-2–selective agents are not entirely free from side effects(no drug is), but they do have a safety advantage over traditional nonse-lective NSAIDs in terms of their most common adverse effect, bleedingin the stomach and related areas. The lower risk of stomach effects isnot absolute. These drugs should also be used with caution in thosewho have had any episode of internal bleeding. Kidney and liver dam-age can also be made worse by COX-2–selective drugs.

One recently-approved COX-2–selective agent, rofecoxib, was found inone large study to have a negative effect on the risk of heart attack,especially in those using a higher dose. Thus, practitioners have beenadvised by the FDA to bear this in mind before prescribing this agent topatients with cardiovascular disease.

Because COX-2–selective agents work as well as traditional nonselec-tive NSAIDs do but produce fewer troublesome side effects, both setsof official guidelines recommend the COX-2–selective agents as thepreferred drugs for patients who need something stronger than aceta-minophen to treat their osteoarthritis. When expense is not an issue —the newer COX-2 selective agents are more expensive — traditionalnonselective NSAIDs should be used only if the newer agents are noteffective. In that instance, patients who are judged to be at risk fordigestive tract problems may need to take an additional drug to protectthe stomach and GI tract along with the traditional nonselective NSAIDto reduce the risk of these problems.

It should also be noted that those patients taking aspirin to protectthemselves against heart disease must continue to take it if they are alsoprescribed any of the NSAIDs discussed here, since none of the anti-arthritis drugs (COX-2 selective or not) offer that same protection.While taking both aspirin and a NSAID the risk of stomach or otherinternal bleeding is increased — thus, it is most important that thepatient’s doctor be informed if this is the case.

Other Drugs and Therapies

In addition to the drugs discussed above, several other forms of therapyare sometimes used in patients with osteoarthritis. These include:

• Topical agents — A few creams, rubs, or sprays that are applieddirectly to the skin may be helpful in relieving mild pain due toosteoarthritis. However, these should be discussed thoroughly withyour doctor as there are many so-called “alternative” remedies thatcome in these forms and are of no value whatsoever.

• Hyaluronates — This is a substance that can be injected into anarthritic joint. It has a lubricating effect and may have other benefi-cial effects as well. It is usually used to treat osteoarthritis of theknee, and it may work well enough to allow patients to discontinueoral medication for a period of time.

• Corticosteroids — This is another type of medication that may beinjected into an arthritic joint. Corticosteroids take effect more quick-ly and cost less than hyaluronic acid does, but there has been somecontroversy about possible harmful effects if they are used too often.

• Narcotics or a non-narcotic pain reliever called tramadol (Ultram) —These strong pain relievers may be used to relieve osteoarthritis painwhen other drugs fail, but they are considered only a last resortbecause they pose a serious risk of becoming habit-forming.6 As arule, narcotic drugs should only be used in the short period whilesurgery is being contemplated.

• Surgery — When other measures fail, joint replacement surgery isoften performed in patients with advanced osteoarthritis. Since thefirst such procedures were performed around 40 years ago, the tech-niques have improved to such a degree that the large majority ofpatients who undergo joint replacement surgery are largely relievedof pain while experiencing improved function and mobility.

Glucosamine and Chondroitin

Two dietary supplements usually used in combination, glucosamine sul-fate and chondroitin sulfate, are probably the most widely used alterna-

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6 NIAMS 2002.

Osteoarthritis and Its Treatment: What You Need to Know

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tive therapy for osteoarthritis. Glucosamine and chondroitin are impor-tant constituents of cartilage, and the basis for their use is the hope thattaking them as dietary supplements might help to replenish and restorecartilage.

The results of several scientific studies suggest that glucosamine mayindeed be helpful in relieving symptoms of osteoarthritis. This agentseems to work better than inactive placebos do, and may even produceresults as good as those seen with NSAIDs in some patients. However, itis important to remember that glucosamine is a “dietary supplement,”not an FDA-approved drug, and therefore is not subject to the stringentsafety, efficacy, and quality standards applied to drugs. Further scientificstudy of glucosamine (and chondroitin) is needed. Patients withosteoarthritis who plan to try these products should tell their doctors thatthey intend to do so. As with all drugs and dietary supplements, sideeffects and interactions with other agents are possible, so it is importantfor the physician to be aware of all substances that the patient is using.

Future Drug Therapies for Osteoarthritis

At the present time, drugs that actually modify the course ofosteoarthritis are not available. However, efforts are being made todevelop drugs of this type. It seems reasonable to assume that suchdrugs can be developed; in fact, disease-modifying drugs have longexisted for another major form of arthritis, rheumatoid arthritis. If drugsthat modify the course of osteoarthritis come onto the market, theymight drastically alter the treatment of this disease, making joint preser-vation, rather than symptom control, the principal goal of therapy.

Summary

Osteoarthritis, a type of arthritis caused by breakdown of cartilage inthe joints, is a very common medical problem, affecting more than 20million Americans. The joints most often affected are the hands, knees,hips, and spine. Older people are most at risk, but even young peoplecan develop osteoarthritis as a result of joint injury. The disease is usu-ally diagnosed on the basis of the patient’s symptoms and medical his-tory; no specific diagnostic test exists, although X-rays are often highlysuggestive, but various tests may be conducted to rule out other dis-eases of the joints.

It is common for people with mild or occasional joint symptoms to treatthemselves using nonprescription remedies. While this is not necessarilyinappropriate, ACSH urges people with persistent or frequent joint prob-lems to consult a physician. People who take prescription medication orhave any type of medical problem should consult a doctor before usingany over-the-counter drug or dietary supplement to treat joint symp-toms.

Two major professional organizations, the American College ofRheumatology and the American Pain Society, have issued treatmentguidelines for osteoarthritis. These guidelines state that:

1. Non-drug therapies such as exercise and weight loss should be triedfirst.

2. Acetaminophen is recommended as a first-choice drug for mild jointpain.

3. For moderate or severe joint pain, the COX-2–selective agents arethe first-choice drugs. The effectiveness of these drugs is comparableto that of traditional nonselective NSAIDs, but the COX-2–selectiveagents have the advantage of a lower risk of gastrointestinal sideeffects. In addition, they may also be less likely to interfere with theprotective effect of aspirin against heart attacks.

4. COX-2–selective agents are expensive, however.

5. In instances in which COX-2–selective agents do not produce suffi-cient relief of symptoms, traditional nonselective NSAIDs may beused, but patients should be evaluated for the risk of digestive tractside effects, and additional medications to reduce the risk of suchside effects may be needed.

6. Other forms of therapy that may be used in selected cases includetopical agents, hyaluronic acid joint injections, glucosamine, corti-costeroid joint injections, narcotic pain relievers, tramadol, and sur-gery.

7. The treatments currently available only relieve symptoms ofosteoarthritis without modifying the course of the disease. However,efforts are currently being made to develop disease-modifying drugs.

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Elizabeth M. Whelan, Sc.D., M.P.H.President

A C S H B O A R D O F D I R E C T O R S

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Steven Black, M.D.Kaiser-Permanente Vaccine Study Center

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Rino Cerio, M.D.Barts and The London Hospital Instituteof Pathology

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Harry G. Day, Sc.D.Indiana University

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Alfred E. Harper, Ph.D.University of Wisconsin, Madison

Terryl J. Hartman, Ph.D., M.P.H., R.D.The Pennsylvania State University

Clare M. Hasler, Ph.D.University of Illinois at Urbana-Champaign

Robert D. Havener, M.P.A.Sacramento, CA

Virgil W. Hays, Ph.D.University of Kentucky

Cheryl G. Healton, Dr.PH.Columbia University

Clark W. Heath, Jr., M.D.American Cancer Society

Dwight B. Heath, Ph.D.Brown University

Robert Heimer, Ph.D.Yale School of Public Health

Robert B. Helms, Ph.D.American Enterprise Institute

Zane R. Helsel, Ph.D.Rutgers University, Cook College

Donald A. Henderson, M.D., M.P.H.Johns Hopkins University

James D. Herbert, Ph.D.MCP Hahnemann University

Gene M. Heyman, Ph.D.McLean Hospital/Harvard Medical School

Richard M. Hoar, Ph.D.Williamstown, MA

Theodore R. Holford, Ph.D.Yale University School of Medicine

A C S H E X E C U T I V E S T A F F

Robert M. Hollingworth, Ph.D.Michigan State University

Edward S. Horton, M.D.Joslin Diabetes Center

Joseph H. Hotchkiss, Ph.D.Cornell University

Steve E. Hrudey, Ph.D.University of Alberta

Susanne L. Huttner, Ph.D.University of California, Berkeley

Robert H. Imrie, D.V.M.Seattle, WA

Lucien R. Jacobs, M.D.University of California, Los Angeles

Alejandro R. Jadad, M.D., D.Phil.,F.R.C.P.C.University of Toronto, Canada

Rudolph J. Jaeger, Ph.D.Environmental Medicine, Inc.

William T. Jarvis, Ph.D.Loma Linda University

Michael Kamrin, Ph.D.Michigan State University

John B. Kaneene,Ph.D., M.P.H., D.V.M.Michigan State University

P. Andrew Karam, Ph.D., CHPUniversity of Rochester

Philip G. Keeney, Ph.D.Pennsylvania State University

John G. Keller, Ph.D. Olney, MD

Kathryn E. Kelly, Dr.P.H.Delta Toxicology

George R. Kerr, M.D.University of Texas, Houston

George A. Keyworth II, Ph.D.Progress and Freedom Foundation

Michael Kirsch, M.D.Highland Heights, OH

John C. Kirschman, Ph.D.Emmaus, PA

Ronald E. Kleinman, M.D.Massachusetts General Hospital

Leslie M. Klevay, M.D., S.D.in Hyg.University of North Dakota School of Medicine

David M. Klurfeld, Ph.D.Wayne State University

Kathryn M. Kolasa, Ph.D., R.D.East Carolina University

James S. Koopman, M.D, M.P.H.University of Michigan

Alan R. Kristal, Dr.P.H.Fred Hutchinson Cancer Research Center

David Kritchevsky, Ph.D.The Wistar Institute

Stephen B. Kritchevsky, Ph.D.Wake Forest University Health Sciences

Mitzi R. Krockover, M.D.Humana, Inc.

Manfred Kroger, Ph.D.Pennsylvania State University

Laurence J. Kulp, Ph.D.University of Washington

Sandford F. Kuvin, M.D.University of Miami

Carolyn J. Lackey, Ph.D., R.D.North Carolina State University

Pagona Lagiou, M.D., DrMedSciUniversity of Athens Medical School

J. Clayburn LaForce, Ph.D.University of California, Los Angeles

James C. Lamb, IV, Ph.D., J.D.Blasland, Bouck & Lee

Lawrence E. Lamb, M.D.San Antonio, TX

William E. M. Lands, Ph.D.College Park, MD

Lillian Langseth, Dr.P.H.Lyda Associates, Inc.

Brian A. Larkins, Ph.D.University of Arizona

Larry Laudan, Ph.D.National Autonomous University of Mexico

Tom B. Leamon, Ph.D.Liberty Mutual Insurance Company

Jay H. Lehr, Ph.D.Environmental Education Enterprises, Inc.

Brian C. Lentle, M.D., FRCPC, DMRDUniversity of British Columbia

Floy Lilley, J.D.Amelia Island, FlF

Paul J. Lioy, Ph.D.UMDNJ-Robert Wood Johnson MedicalSchool

William M. London, Ed.D., M.P.H.Walden University

Frank C. Lu, M.D., BCFEMiami, FL

William M. Lunch, Ph.D.Oregon State University

Daryl Lund, Ph.D.University of Wisconsin

George D. Lundberg, M.D.Medscape

Howard D. Maccabee, Ph.D., M.D.Radiation Oncology Center

Janet E. Macheledt, M.D., M.S., M.P.H.Houston, TX

Roger P. Maickel, Ph.D. Purdue University

Henry G. Manne, J.S.D.George Mason University Law School

Karl Maramorosch, Ph.D.Rutgers University, Cook College

Judith A. Marlett, Ph.D., R.D.University of Wisconsin, Madison

James R. Marshall, Ph.D.Roswell Park Cancer Institute

Margaret N. Maxey, Ph.D.University of Texas at Austin

Mary H. McGrath, M.D., M.P.H.Loyola University Medical Center

Alan G. McHughen, D.Phil.University of California, Riverside

James D. McKean, D.V.M., J.D.Iowa State University

John J. McKetta, Ph.D.University of Texas at Austin

Donald J. McNamara, Ph.D.Egg Nutrition Center

Michael H. Merson, M.D.Yale University School of Medicine

Patrick J. Michaels, Ph.D.University of Virginia

Thomas H. Milby, M.D., M.P.H.Walnut Creek, CA

Joseph M. Miller, M.D., M.P.H.University of New Hampshire

William J. Miller, Ph.D.University of Georgia

Dade W. Moeller, Ph.D.Harvard University

Grace P. Monaco, J.D.Medical Care Management Corp.

Brian E. Mondell, M.D.Baltimore Headache Institute

Eric W. Mood, LL.D., M.P.H.Yale University School of Medicine

John W. Morgan, Dr.P.H.California Cancer Registry

W. K. C. Morgan, M.D.University of Western Ontario

Stephen J. Moss, D.D.S., M.S.Health Education Enterprises, Inc.

Brooke T. Mossman, Ph.D.University of Vermont College of Medicine

Allison A. Muller, Pharm.DThe Children’s Hospital of Philadelphia

Ian C. Munro, F.A.T.S., Ph.D., FRCPathCantox Health Sciences International

Kevin B. MurphyMerrill Lynch, Pierce, Fenner & Smith

Harris M. Nagler, M.D.Beth Israel Medical Center

Daniel J. Ncayiyana, M.D.University of Cape Town

Philip E. Nelson, Ph.D.Purdue University

Malden C. Nesheim, Ph.D.Cornell University

Joyce A. Nettleton, D.Sc., R.D.Aurora, Co

John S. Neuberger, Dr.P.H.University of Kansas School of Medicine

Gordon W. Newell, Ph.D., M.S.,F.-A.T.S.Palo Alto, CA

Thomas J. Nicholson, Ph.D., M.P.H.Western Kentucky University

Steven P. Novella, M.D.Yale University School of Medicine

James L. Oblinger, Ph.D.North Carolina State University

Deborah L. O’Connor, Ph.D.University of Toronto/The Hospital forSick Children

John Patrick O’Grady, M.D.Tufts University School of Medicine

James E. Oldfield, Ph.D.Oregon State University

Stanley T. Omaye, Ph.D., F.-A.T.S.,F.ACN, C.N.S.University of Nevada, Reno

Michael T. Osterholm, Ph.D., M.P.H.University of Minnesota

M. Alice Ottoboni, Ph.D.Sparks, NV

Michael W. Pariza, Ph.D.University of Wisconsin, Madison

Stuart Patton, Ph.D.University of California, San Diego

James Marc Perrin, M.D.Mass General Hospital for Children

Timothy Dukes Phillips, Ph.D.Texas A&M University

Mary Frances Picciano, Ph.D.National Institutes of Health

David R. Pike, Ph.D.University of Illinois, Urbana-Champaign

Thomas T. Poleman, Ph.D.Cornell University

Charles Poole, M.P.H., Sc.DUniversity of North Carolina School ofPublic Health

Gary P. Posner, M.D.Tampa, FL

John J. Powers, Ph.D.University of Georgia

William D. Powrie, Ph.D.University of British Columbia

C.S. Prakash, Ph.D.Tuskegee University

Kary D. PrestenU.S. Trust Co.

Marvin P. Pritts, Ph.D.Cornell University

Daniel J. Raiten, Ph.D.National Institute of Health

David W. Ramey, D.V.M.Ramey Equine Group

R.T. Ravenholt, M.D., M.P.H.Population Health Imperatives

Russel J. Reiter, Ph.D.University of Texas, San Antonio

William O. Robertson, M.D.University of Washington School of Medicine

J. D. Robinson, M.D.Georgetown University School of Medicine

Bill D. Roebuck, Ph.D., D.A.B.T.Dartmouth Medical School

David B. Roll, Ph.D.University of Utah

Dale R. Romsos, Ph.D.Michigan State University

Joseph D. Rosen, Ph.D.Cook College, Rutgers University

Steven T. Rosen, M.D.Northwestern University Medical School

Kenneth J. Rothman, Dr.P.H.Boston University

Stanley Rothman, Ph.D.Smith College

Edward C. A. Runge, Ph.D.Texas A&M University

Stephen H. Safe, D.Phil.Texas A&M University

Wallace I. Sampson, M.D.Stanford University School of Medicine

Harold H. Sandstead, M.D.University of Texas Medical Branch

Charles R. Santerre, Ph.D.Purdue University

Herbert P. Sarett, Ph.D.Sarasota, FL

Sally L. Satel, M.D.American Enterprise Institute

Lowell D. Satterlee, Ph.D.Oklahoma State University

Jeffrey Wyatt SavellTexas A&M University

Marvin J. Schissel, D.D.S.Roslyn Heights, NY

Lawrence J. Schneiderman, M.D.University of California, San Diego

Edgar J. Schoen, M.D.Kaiser Permanente Medical Center

David Schottenfeld, M.D., M.Sc.University of Michigan

Joel M. Schwartz, M.S.Reason Public Policy Institute

David E. Seidemann, Ph.D. Brooklyn College/Yale University

Patrick J. Shea, Ph.D.University of Nebraska, Lincoln

Michael B. Shermer, Ph.D.Skeptic Magazine

Sidney Shindell, M.D., LL.B.Medical College of Wisconsin

Sarah Short, Ph.D., Ed.D., R.D.Syracuse University

A. J. Siedler, Ph.D.University of Illinois, Urbana-Champaign

Lee M. Silver, Ph.D.Princeton University

Michael S. Simon, M.D., M.P.H.Wayne State University

S. Fred Singer, Ph.D.Science & Environmental Policy Project

Robert B. Sklaroff, M.D.Elkins Park, PA

Anne M. Smith, Ph.D., R.D., L.D.The Ohio State University

Gary C. Smith, Ph.D.Colorado State University

John N. Sofos, Ph.D.Colorado State University

Roy F. Spalding, Ph.D.University of Nebraska, Lincoln

Leonard T. Sperry, M.D., Ph.D.Barry University

Robert A. Squire, D.V.M., Ph.D.Johns Hopkins University

Ronald T. Stanko, M.D.University of Pittsburgh Medical Center

James H. Steele, D.V.M., M.P.H.University of Texas, Houston

Robert D. Steele, Ph.D.Pennsylvania State University

Judith S. Stern, Sc.D., R.D.University of California, Davis

Ronald D. Stewart, O.C., M.D., FRCPCDalhousie University

Martha Barnes Stone, Ph.D.Colorado State University

Jon A. Story, Ph.D.Purdue University

Michael M. Sveda, Ph.D.Gaithersburg, MD

Glenn Swogger, Jr., M.D.Topeka, KS

Sita R. Tatini, Ph.D. University of Minnesota

Steve L. Taylor, Ph.D.University of Nebraska, Lincoln

James W. Tillotson, Ph.D., M.B.A.Tufts University

Dimitrios Trichopoulos, M.D.Harvard School of Public Health

Murray M. Tuckerman, Ph.D.Winchendon, MA

Robert P. Upchurch, Ph.D.University of Arizona

Mark J. Utell, M.D.University of Rochester Medical Center

Shashi B. Verma, Ph.D.University of Nebraska, Lincoln

Willard J. Visek, M.D., Ph.D.University of Illinois College of Medicine

Donald M. Watkin, M.D., M.P.H., F.A.C.P.George Washington University

Miles Weinberger, M.D.University of Iowa Hospitals and Clinics

Lynn Waishwell, Ph.D., CHESUniversity of Medicine and Dentistry ofNew Jersey

Janet S. Weiss, M.D.University of California at San-Francisco

Simon Wessley, M.D., FRCPKing’s College London and Institute ofPsychiatry

Steven D. Wexner, M.D.Cleveland Clinic Florida

Joel Elliot White, M.D., F.A.C.R.John Muir Comprehensive Cancer Center

Carol Whitlock, Ph.D., R.D.Rochester Institute of Technology

Christopher F. Wilkinson, Ph.D.Burke, VA

Mark L. Willenbring, M.D.Veterans Affairs Medical Center

Carl K. Winter, Ph.D.University of California, Davis

Lloyd D. Witter, Ph.D.University of Illinois, Urbana-Champaign

James J. Worman, Ph.D.Rochester Institute of Technology

Russell S. Worrall, O.D.University of California, Berkeley

Panayiotis M. Zavos, Ph.D., Ed.S.University of Kentucky

Steven H. Zeisel, M.D., Ph.D.The University of North Carolina

Michael B. Zemel, Ph.D.Nutrition Institute, University of Tennessee

Ekhard E. Ziegler, M.D.University of Iowa

A C S H B O A R D O F S C I E N T I F I C A N D P O L I C Y A D V I S O R S

The opinions expressed in ACSH publications do not necessarily represent the views of all ACSH Directors and Advisors.ACSH Directors and Advisors serve without compensation.