We have talked before about the associations between inflammation and psychiatric illnesses.

There is yet more evidence in the shape of a study just published in the journal Psychosomatic Medicine. by Janice K. Kiecolt-Glaser and her colleagues from Ohio State University College of Medicine in Columbus.

The study involved 43 older adults with a mean age of 66.67 years, and the results suggests that the imbalance of omega-6 and omega-3 fatty acids in the typical American diet could be associated with the sharp increase in heart disease and depression seen over the past century. The more omega-6 fatty acids people had in their blood compared with omega-3 fatty acid levels, the higher their levels of the inflammatory mediators tumor necrosis factor-alpha and interleukin-6, and the greater the chance that they would suffer from depression. These are the same inflammatory mediators associated with insulin resistance, type 2 diabetes and coronary artery disease, all of which are more common in depression. And depression is more common in diabetes, arthritis and coronary artery disease than expected.

Our hunter-gatherer ancestors consumed two or three times as much omega-6 as omega-3, but today the average Western diet contains 15- to 17-times more omega-6 than omega-3. There were 6 individuals in the study who had been diagnosed with major depression, and they had nearly 18 times as much omega-6 as omega-3 in their blood, compared with about 13 times as much for subjects who didn’t meet the criteria for major depression.

Depressed patients also had higher levels of tumor necrosis factor alpha, interleukin-6, and other inflammatory compounds. And as levels of depressive symptoms rose, so did the omega 6 and omega 3 ratio. So it seems as if the effects of diet and depression enhance each other. People who had few depressive symptoms and/or were on a well-balanced diet had low levels of inflammation in their blood. But when they became more depressed and their diets became worse – which is very common when people are depressed – then the inflammatory mediators in the blood surged.

Omega-3 fatty acids are found in foods such as fish, flax seed oil and walnuts, while omega-6 fatty acids are found in refined vegetable oils used to make everything from margarine to baked goods and snack foods. The amount of omega-6 fatty acids in the Western diet increased sharply once refined vegetable oils became part of the average diet in the early 20th century.

Depression alone is known to increase inflammation, the researchers note in their report, while a number of studies have found omega-3 supplements prevent depression.

So this more evidence for the value of eating fatty fish like salmon, mackerel or sardines two or three times a week, but be sure to avoid fish that may contain a lot of mercury. If you add more fruits and vegetables to your diet, you will also reduce your levels of omega-6 fatty acids.

I have just finished analyzing all the new literature on using fish oils for the prevention and treatment of psychological and psychiatric problems, and I am going to post my findings in the next couple of days.

Today being Valentine’s Day (you did remember didn’t you?), Arthritis Care in the United Kingdom has taken the opportunity  to publicize its free booklet on sex, relationships, intimacy and arthritis, downloadable from its website (pdf).

Integrated Medicine is all about empowering and caring for the whole person, so I was very pleased to see this document. I spent some very happy times helping people with various types of arthritis, and I was astonished how infrequently anyone had ever asked them about the ways in which the illness impacted normal daily activities and had ever given them any advice on ways to work around problems.

Let me quote form the Arthritis Care news release:

"One of the reasons we produced the guide is to address issues people felt awkward discussing. It may be embarrassing to talk to your consultant rheumatologist, nurse or GP about emotional and sexual things, or matters of self-image and self-esteem - and they may be embarrassed to be asked. So where do you turn?’ said Kate Llewelyn head of publications at Arthritis Care, who was diagnosed with rheumatoid arthritis at the age of thirteen.

The booklet provides a valuable insight for healthcare professionals and for the partners and families of people with arthritis, highlighting issues of concern to them, and suggesting practical and achievable solutions.

For people with arthritis, or other disabilities, difficulty can start before any relationship, pre-dating any date.

‘Managing pain and other symptoms is exhausting, and it stops many people getting out and socializing. As a result, arthritis can be isolating, keeping you from making friends or seeing family, let alone dating and finding a partner. And maybe you are not very mobile, so can’t dance, or play sport, or can’t drink because of your medications. What’s more, although anti-discrimination law means venues must now offer better access for disabled people, you still may find it harder to do things people without arthritis take for granted’, said Kate Llewelyn.

Once a relationship has been formed, the challenges continue; the couple must work out ways of ensuring their personal and sexual relationship is sustained and developed, overcoming and working round the incurable and debilitating condition.

The report discusses a number of very practical matters: how pain and also medication can interfere with sex drive and some can cause weight gain. Many forms of arthritis are also associated with anemia and/or chronic fatigue.

It also discusses some of the psychological factors that can interfere with the sex lives of arthritis sufferers. For example, men may feel emasculated if they cannot perform their ‘traditional’ roles like playing sport or carrying heavy objects. Women may feel unfeminine if they put on weight with steroids, cannot do the housework or lift their children as a result of having arthritis. Others, with limited joint movement, or severe pain may be put off sex altogether, or find some of the traditional sex positions too uncomfortable.

‘The book has got diagrams of lovemaking positions which people of differing physical abilities and limited movement have found useful. If you’ve got problems with your spine, or hips, or knees, it makes sense to experiment with positions that place least weight or strain on the rogue joints. Of course, after joint surgery or replacement, you may be advised to take a temporary break from sex, but, relationships are more than sex, and, with this guide, abstinence may make the heart grow fonder’, said Kate Llewelyn.

Sex is rarely discussed with people strugglig with chronic illness, often because health care providers get embarassed about it.

It is essential for that to change, and I want to say a big thank you to Arthitis Care for having the courage to do this.

Your humble reporter was fascinated to read about some new research using the anti-malarial agent chloroquine as a potential treatment for the insulin resistance syndrome.

I have a personal reason for being interested. Hypoglycemia (low blood glucose) is an occasional feature of treatment with chloroquine and in 1980 a study first indicated that chloroquine might slow the break down of insulin by the liver. In the early 1980s there were a flurry of papers indicating that chloroquine did some subtle things to insulin and insulin receptors in many tissues. So we came up with the idea of measuring its effects in humans. There was a memorable occasion on which I was doing an outpatient clinic with an intravenous line in my arm. (English doctors are well known for doing experiments on themselves: I had a professor in medical school who said that you should never do to a patient what you haven’t had done to yourself. I shall leave it to you, gentle reader, to wonder if I’ve tried everything….).

So there I am doing my clinic when, around 11AM I begin to feel really strange: my glucose level was almost unrecordable and my insulin level was off the chart. Nothing that couldn’t be solved with a large dollop of sugar, but it made me very sympathetic to people who get hypoglycemic from their regular treatments.

Sometimes Nature does our experiments for us: we did a lot of work on diabetes because it is associated with high rates of vascular disease. So understanding the mechanisms by which diabetes does that may help illuminate some of the cellular disturbances underlying arteriosclerosis in general. We are also interested in the few illnesses in which a single disturbed gene may lead to a definable set of signs and symptoms. There is a rare illness known as ataxia telangiectasia in which sufferers have a high risk of developing some cancers particularly lymphomas and leukemia. People with the illness are very sensitive to ionizing radiation, have a specific type of immune deficiency, degeneration of parts of the brain related to muscle function and coordination and they age prematurely. More than ten years ago it was discovered that a single gene - ataxia-telangiectasia mutated (ATM) gene – was responsible for the illness. The gene is responsible for producing a protein that recognizes damage to DNA. It now seems that ATM may also be linked to metabolic and cardiovascular diseases. It does this by inhibiting a protein called JNK, a stress kinase involved in inflammation with related effects in insulin resistance and atherosclerosis. So to everyone’s surprise a gene that can cause a rare disease can also cause insulin resistance.

In the November issue of Cell Metabolism, researchers at Washington University School of Medicine in St. Louis and St. Jude Children’s Research Hospital in Memphis, Tennessee report that a small dose of chloroquine eased many symptoms of metabolic syndrome in mice, reducing blood pressure, decreasing hardening and narrowing of the arteries and improving blood sugar tolerance. The results suggest we may only need very low and perhaps infrequent doses of chloroquine to achieve similar effects in humans. Both insulin and chloroquine activate the ATM gene.

This adds to the data that some of the metabolic dysfunctions triggered by obesity may be linked to the inflammatory responses that go wrong in autoimmune disorders like arthritis and systemic lupus erythematosus.

And an older treatment for rheumatoid and lupus just happens to be chloroquine.

Chloroquine itself has some side effects, but this is important information that will help us design more effective and carefully targeted holistic treatments for both metabolic disturbances and inflammatory conditions. All in all, very good news indeed.

There is a fascinating new approach to treating chronic pain.

The story goes back two years, to the publication of important research from a team at the Royal National Hospital for Rheumatic Diseases, in Bath in England. They wrote a paper in which they tried to link joint pain in neurological conditions. They wanted to see how the pain of rheumatoid arthritis, fibromyalgia and complex regional pain syndrome might relate to phantom limb pain (PLP) experienced by many amputees.

They suggested that in each condition there is reorganization in the sensory regions of the cerebral cortex. And it is this reorganization that generates pain and an altered body image. It seems to be just the same in rheumatology patients as has previously been hypothesized for amputees with PLP; that is a motor/sensory conflict. The body and the sense don’t match and it hurts. Their initial research indicated that something incredibly simple: using a mirror could help people correct of this conflict. They were able to show that a mismatch between motor output and sensory input creates sensory disturbances, including pain, in rheumatology patients and also in healthy volunteers.

In a second paper the investigators were able to show that doing a movement while looking at a distorting mirror could quickly induce uncomfortable symptoms in fit healthy people.

For over two decades, David Blake - the senior author of this research - has championed the idea that there is an important neurological component in inflammatory arthritis. It all started with a simple observation that has puzzled generations of clinicians: why is it that joint involvement in inflammatory arthritis is so often symmetrical? It isn’t surprising if both hips get arthritis: they will likely both have been subjected to a lot of wear and tear. But why should arthritis involve the second joint of the index finger in both hands? It has always looked as if this might imply some neurological contribution.

The idea is that although pain may have originated in inflamed joints, it is maintained and exacerbated by the nervous system. This fits with a fact that has been known to acupuncturists for centuries and has been replicated in pain clinics around the world. If you can interrupt what we call the pain cycle - constant chronic pain that feeds on itself and gets progressively worse – then you may often see pain relief for weeks or months, or sometimes even indefinitely. It is quite common for chronic pain to have had a clear physical precipitant, but to be maintained by key regions in the brain.

This new research strongly supports these observations, implies that the successful treatment of chronic rheumatological pain may involve a neurological approach, and offers a brand new therapeutic option.

“The speaker is only a mirror. Where you can see yourself. When you recognize yourself clearly, you can put aside the mirror.”–Jiddu Krishnamurti (Indian Spiritual Teacher, 1895-1986)

“Perception is but a mirror, not a fact. What I look on is my state of mind reflected outward.”–A Course in Miracles

I recently reported about some research from SIngapore that indicated that the spice turmeric might help with cognition.

Today there is a study form the University of Arizona in the journal Arthritis and Rheumatism suggesting that the spice may also be helpful in experimental rheumatoid arthritis. In line with most other studies of herbal supplements it is interesting that the maximal effect was obtained by using the natural form of turmeric, that contains three major "curcuminoids," the likely active ingredients. If one of the three is missing, the effect is a lot less.

The extracts appears to work by preventing the activation of a protein that controls when genes are switched on or off in the joint. Once the protein known as NF-KB is activated, it binds to genes and increases the production of inflammatory proteins, which in turn attack the joints.

This is not a surprise: In traditional Indian Ayurvedic medicine turmeric has been used for centuries as a treatment for inflammatory disorders including arthritis. Based on that, dietary supplements containing turmeric rhizome and turmeric extracts have been sold for years. However, there’s been little direct evidence that they are helpful.

We are going to need more research before we can sy whether turmeric supplements can be recommended for medicinal pruposes, and eating more spices is unlikely to work.

These findings are opening up a new approach to treating not just rheumatoid arthritis, but perhaps also other inflammatory diseases such as inflammatory bowel disease, asthma and multiple sclerosis. Interestingly the turmeric extract also has another effect: it deactivates a biochemical pathway that leads to the resorption of bone. So it may help with osteoporosis.