Arthritis diet

Definition

Origins

Description

Function

Benefits

Precautions

Risks

Research and general acceptance

Resources

Definition

Arthritis is the general medical term for the inflammation of a joint or a disorder characterized by suchinflammation. There are a number of different arthritides (the plural form of arthritis), and therefore there is no “arthritis diet” as such that has been proposed as a treatment for all these different joint disorders. Dietary therapies for osteoarthritis (OA) and rheumatoid arthritis (RA), the two most commonforms of arthritis, fall into three major categories: mainstream management strategies that focus on weight reduction and well-balanced diets as a way to relieve stress on damaged joints and slow the progression of arthritis; dietary supplements of various types that have been evaluated in clinical trials and have been found to benefit at least some patients; and alternative medical approaches that rely on dietary adjustments (including elimination diets ) and/or traditional herbal remedies to treat arthritis.

Osteoarthritis

The reader should be aware of the differences between OA and RA in order to understand both mainstream and alternative approaches to these disorders. Osteoarthritis (OA) is the more common of the two in the general North American population, particularly among middle-aged and older adults. It is estimated to affect about 21 million adults in the United States, and to account for $86 billion in health care costs each year. It is also the single most common condition for which people seek help from complementary and alternative medical (CAM) treatments. The rate of OA increases in older age groups; about 70% of people over 70 are found to have some evidence of OA when they are X-rayed. Only half of these elderly adults, however, are affected severely enough to develop noticeable symptoms. OA is not usually a disease that completely disables people; most patients can manage its symptoms by watching their weight, staying active, avoiding overuse of affected joints, and taking over-the-counter or prescription pain relievers. OA most commonly affects the weight-bearing joints in the hips, knees, and spine, although some people first notice its symptoms in their fingers or neck. It is often unilateral, which means that it affects the joints on only one side of the body. The symptoms of OA vary considerably in severity from one patient to another; some people are only mildly affected by the disorder.

Differences between Osteoarthritis and Rheumatoid Arthritis

(Illustration by GGS Information Services/Thomson Gale.)

OA results from progressive damage to the cartilage that cushions the joints of the long bones. As the cartilage deteriorates, fluid accumulates in the joints, bony overgrowths develop, and the muscles and tendons may weaken, leading to stiffness on arising, pain, swelling, and limitation of movement. OA is gradual in onset, often taking years to develop before the person notices pain or a limited range of motion in the joint. OA is most likely to be diagnosed in people over 45 or 50, although younger adults are occasionally affected. OA affects more men than women under age 45 while more women than men are affected in the age group over 55. As of the early 2000s, OA is thought to result from a combination of factors, including heredity (possibly related to a mutation on chromosome 12); traumatic damage to joints from accidents, type of employment, or sports injuries; and obesity. It is not, however, caused by the aging process itself. Race does not appear to be a factor in

KEY TERMS

Arthritis (plural, arthritides)— A general term for the inflammation of a joint or a condition characterized by joint inflammation.

Avocado soybean unsaponifiables (ASU)— A compound of the fractions of avocado oil and soybean oil that cannot be used in the production of soap. ASU shows promise in the treatment of OA. It is available only by prescription in France, where it was first studied, but can be purchased over the counter in the United States.

Ayurveda— The traditional system of natural medicine that originated in India around 3500 bc. Its name is Sanskrit for “science of long life.” Some people have tried Ayurvedic medicines and dietary recommendations in the treatment of arthritis.

Chondroitin sulfate— A compound found naturally in the body that is part of a large protein molecule (proteoglycan) helping cartilage to retain its elasticity. Chondroitin sulfate derived from animal or shark cartilage can be taken as a dietary supplement by people with OA.

Disease-modifying antirheumatic drugs (DMARDs)— A class of prescription medications given to patients with rheumatoid arthritis that suppress the immune system and slow the progression of RA.

Elimination diet— Adiet in which the patientexcludes a specific food (or group of foods) for a period of time in order to determine whether the food is responsible for symptoms of an allergy or other disorder. Elimination diets are also known as food challenge diets.

Glucosamine— A type of amino sugar that is thought to help in the formation and repair of cartilage. It can be extracted from crab or shrimp shells and used as a dietary supplement by people with OA.

Naturopathy— A system of disease treatment that emphasizes natural means of health care, as water, natural foods, dietary adjustments, massage and manipulation, and electrotherapy, rather than conventional drugs and surgery. Naturopaths (practitioners of naturopathy) often recommend dietary therapy in the treatment of arthritis.

Nonsteroidal anti-inflammatory drugs (NSAIDs)— A class of drugs commonly given to treat the inflammation and pain associated with both RA and OA. NSAIDs work by blocking prostaglandins, which are hormone-like compounds that cause pain, fever, muscle cramps, and inflammation. Some NSAIDs are prescription drugs while others are available in over-the-counter (OTC) formulations.

Osteoarthritis (OA)— The most common form of arthritis, characterized by erosion of the cartilage layer that lies between the bones in weight-bearing joints. OA is also known as degenerative joint disease or DJD.

Rheumatoid arthritis (RA)— An autoimmune disorder that can affect organ systems as well as the joints. It is much less common that OA but is potentially much more serious.

Rheumatologist— A physician, usually a pediatrician or internist, who has additional specialized training in the diagnosis and treatment of diseases that affect the bones, muscles, and joints.

Turmeric— A perennial herb of the ginger family used as a coloring agent as well as a spice in food preparation. It is used in some traditional Ayurvedic medicines for the relief of joint pain and inflammation.

Vegan— A vegetarian who excludes all animal products from the diet, including those that can be obtained without killing the animal. Vegans are also known as strict vegetarians. Some people believe that a vegan diet is helpful in managing arthritis.

OA, although some studies indicate that African American women have a higher risk of developing OA in the knee joints. Other risk factors for OA include osteoporosis and vitamin D deficiency.

RA, by contrast, is most likely to be diagnosed in adults between the ages of 30 and 50, two-thirds of whom are women. RA affects about 0.8% of adults worldwide, or 25 in every 100,000 men and 54 in every100,000 women. Unlike OA, which is caused by degeneration of a body tissue, RA is an autoimmune disorder—one in which the body’s immune system attacks some of its own tissues. It is often sudden in onset and may affect other organ systems, not just the joints. RA is a more serious disease than OA; 30% of patients with RA will become permanently disabled within two to three years of diagnosis if they are not treated. In addition, patients with RA have a higher risk of heart attacks and stroke. RA differs from OA, too, in the joints that it most commonly affects—often the fingers, wrists, knuckles, elbows, and shoulders. RA is typically a bilateral disorder, which means that both sides of the patient’s body are affected. In addition, patients with RA often feel sick, feverish, or generally unwell, while patients with OA usually feel normal except for the stiffness or discomfort in the affected joints.

Origins

The role of diet and nutrition in both OA and RA has been studied since the 1930s, but there is little agreement as of 2007 regarding the details of dietary therapy for these disorders. One clear finding that has emerged from seven decades of research is the importance of weight reduction or maintenance in the treatment of patients with OA, and the need for nutritional balance and healthy eating patterns in the treatment of either form of arthritis. Findings regarding the use of dietary supplements or CAM therapies will be discussed in more detail below.

Various elimination diets (diets that exclude specific foods from the diet) have been proposed since the 1960s as treatments for OA. The best-known of these is the Dong diet, introduced by Dr. Collin Dong in a book published in 1975. This diet is based on traditional Chinese beliefs about the effects of certain foods inincreasing the pain of arthritis. The Dong diet requires the patient to cut out all fruits, red meat, alcohol, dairy products, herbs, and all foods containing additives or preservatives. There is, however, no clinical evidence as of 2007 that this diet is effective.

Another type of elimination diet, still recommended by naturopaths and some vegetarians in the early 2000s, is the so-called nightshade elimination diet, which takes its name from a group of plants belonging to the family Solanaceae. There are over 1700 plants in this category, including various herbs, potatoes, tomatoes, bell peppers, and eggplant as well as nightshade itself, a poisonous plant also known as belladonna. The nightshade elimination diet began in the 1960s when a researcher in horticulture at Rutgers University noticed that his joint pains increased after eating vegetables belonging to the nightshade family. He eventually published a book recommending the elimination of vegetables and herbs in the nightshade family from the diet. There is again, however, no clinical evidence that people with OA will benefit from avoiding these foods.

Description

Osteoarthritis

WEIGHT REDUCTION. The major dietary recom-mendation approved by mainstream physicians for patients with OA is keeping one’s weight at a healthy level. The reason is that OA primarily affects the weight-bearing joints of the body, and even a few pounds of extra weight can increase the pressure on damaged joints when the person moves or uses the joint. It is estimated that that a force of three to six times the weight of the body is exerted across the knee joint when a person walks or runs; thus being only 10 pounds overweight increases the forces on the knee by 30 to 60 pounds with each step. Conversely, even a modest amount of weight reduction lowers the pain level in persons with OA affecting the knee or foot joints. Obesity is a definite risk factor for developing OA; data from the National Institutes of Health (NIH) indicate that obese women are 4 times as likely to develop OA as non-obese women, while for obese men the risk is 5 times as great.

Although some doctors recommend trying a vegetarian or vegan diet as a safe approach to weight loss for patients with OA, most will approve any nutritionally sound calorie-reduction diet that works well for the individual patient

DIETARY SUPPLEMENTS. Dietary supplements are.

commonly recommended for managing the discomfort of OA and/or slowing the rate of cartilage deterioration:

• Chondroitin sulfate. Chondroitin sulfate is a compound found naturally in the body that is part of a large protein molecule called a proteoglycan, which imparts elasticity to cartilage. The supplemental form is derived from animal or shark cartilage. Recommended daily dose is 1200 mg.
• Glucosamine. Glucosamine is a form of amino sugar that is thought to support the formation and repair of cartilage. It can be extracted from crab, shrimp, or lobster shells. The recommended daily dose is 1500 mg. Dietary supplements that combine chondroitin sulfate and glucosamine can be obtained over the counter in most pharmacies or health food stores.
• Botanical preparations: Some naturopaths recommend extracts of yucca, devil’s claw, hawthorn berries, blueberries, and cherries. These extracts are thought to reduce inflammation in the joints and enhance the formation of cartilage. Powdered ginger has also been used to treat joint pain associated with OA.
• Vitamin therapy. Some doctors recommend increasing one’s daily intake of vitamins C, E, A, and B⁶, which are required to maintain cartilage structure.
• Avocado soybean unsaponifiables (ASU). ASU is a compound of the fractions of avocado oil and soybean oil that are left over from the process of making soap. It contains one part avocado oil to two parts soybean oil. ASU was first developed in France, where it is available by prescription only under the name Piascle´dine, and used as a treatment for OA in the 1990s. It appears to work by reducing inflammation and helping cartilage to repair itself. ASU can be purchased in the United States as an over-the-counter dietary supplement. The recommended daily dose is 300 mg.

CAM DIETARY THERAPIES. Two traditional alternative medical systems have been recommended in the treatment of OA. The first is Ayurveda, the traditional medical system of India. Practitioners of Ayurveda regard OA as caused by an imbalance among the three doshas, or subtle energies, in the human body. This imbalance produces toxic byproducts during digestion, known as ama, which lodges in the joints of the body instead of being eliminated through the colon. To remove these toxins from the joints, the digestive fire, or agni, must be increased. The Ayurvedic practitioner typically recommends adding such spices as turmeric, cayenne pepper, and ginger to food, and undergoing a three-to five-day detoxification diet followed by a cleansing enema to purify the body.

Traditional Chinese medicine (TCM) treats OA with various compounds containing ephedra , cinnamon, aconite, and coix. A combination herbal medicine that has been used for at least 1200 years in TCM is known as Du Huo Ji Sheng Wan, or Joint Strength. Most Westerners who try TCM for relief of OA, however, seem to find acupuncture more helpful as an alternative therapy than Chinese herbal medicines.

Rheumatoid arthritis

DIETARY ALTERATIONS. There is some indication that patients with RA benefit from cutting back on meat consumption or switching entirely to a vegetarian or vegan diet. One follow-up study of RA patients on a vegetarian diet showed that improvement continued after one and two years on the diet.

Another dietary adjustment that appears to benefit some people with RA is switching from cooking oils that are high in omega-6 fatty acids (which increase inflammation) to oils that are high in omega-3 fatty acids (which reduce inflammation. This second group includes olive oil, canola oil, and flaxseed oil.

DIETARY SUPPLEMENTS. The most common dietary supplements recommended for patients with RA are as follows:

• Fish oil. The oils from cold-water fish have been reported to reduce inflammation and relieve joint pain in some patients with RA. The recommended daily dose is 1 to 2 teaspoons.
• Plant oils that are high in gamma-linoleic acid (GLA), which reduces inflammation in the joints. These plant oils include evening primrose oil, borage oil, and black current oil. The recommended daily dose is 200 to 300 mg.
• Green tea. Drinking 3 to 4 cups of green tea per day is thought to benefit RA patients by reducing inflammation in the joints.

CAM DIETARY THERAPIES. Ayurvedic medicine recommends a compound of ginger, turmeric, boswellia, and ashwaganda to relieve the pain and fever associated with RA.

Traditional Chinese medicine (TCM) uses such plants as hare’s ear (Bupleurum falcatum) and thunder god vine (Tripterygium wilfordii) to reduce fever and joint pain in patients with RA.

Function

Osteoarthritis

The function of dietary treatment for OA is to lower (or maintain) the patient’s weight to a healthy level in order to minimize stress on damaged weight-bearing joints; to maintain the structure and composition of the cartilage in the joints; to protect the general health of tissues by including bioflavonoids and antioxidants in the diet; and by conducting food challenges when appropriate to determine whether specific foods are affecting the patient’s symptoms.

Rheumatoid arthritis

Dietary treatment of RA is primarily adjunctive, as the disease cannot be managed by nutritional changes alone. Patients with RA must take a combination of medications, usually a combination of disease-modifying anti-rheumatic drugs (DMARDs) and nonsteroidal anti-inflammatory drugs (NSAIDs), to control pain, inflammation, and slow the progression of the disease. A well-balanced and healthful diet, however, can help to offset the emotional depression that often accompanies RA and to enable patients to maintain a normal schedule of activities. It also helps to prevent nutritional deficiencies in these patients that may be caused by the use of prescription drugs to control the disease.

Benefits

Osteoarthritis

The benefits of weight reduction in overweight patients with OA are a noticeable reduction in discomfort and improved range of motion in the affected joints. The benefits of dietary supplements vary from patient to patient depending on the specific joints affected and the degree of erosion of the joint cartilage.

Rheumatoid arthritis

The benefits of dietary adjustments or dietary supplements for RA vary considerably from patient to patient. Maintenance of a balanced diet, however, is valuable in preventing the nutritional deficiencies that sometimes occur in patients with RA as side effects of high dosages of DMARDs and NSAIDs.

Precautions

Some general precautions for all persons with arthritis:

• Before beginning any form of dietary treatment for joint pain, consult a physician to obtain an accurate diagnosis of the type of arthritis that is causing the pain. When RA is suspected, it is vital to get systemic treatment as soon as possible to minimize long-term damage to health.
• Consult a physician before taking any dietary supplements, as certain OTCs and prescription medications can interact with these compounds. Chondroitin sulfate, for example, may increase bleeding time in some people, particularly if it is taken together with aspirin.
• Purchase dietary supplements only from well-established companies that can be held accountable for the quality of their products.
• Do not stop taking any medications currently prescribed by a doctor without consulting him or her.
• If maintaining a primarily vegetarian diet, be aware of the potential for iron deficiency.

People with either form of arthritis who are more than 30 pounds overweight; are pregnant, nursing, or under the age of 18; or diagnosed with type 2 diabetes, kidney disorders, or liver disorders should consult a physician before attempting a weight-reduction program.

Osteoarthritis

People with diabetes should monitor blood sugar levels more frequently if they are taking glucosamine , because it is an amino sugar. Similarly, persons who are taking blood thinners should have their blood clotting time checked periodically if they are taking chondroitin sulfate. ASU has not been reported tocause drug interactions as of 2007.

Rheumatoid arthritis

Plant oils containing GLA have been reported to cause intestinal gas, bloating, diarrhea, and nausea in some persons. In addition, these oils may interact with other prescription medications, particularly blood thinners. Some borage seed oil preparations contain ingredients known pyrrolizidine alkaloids, or PAs, that can harm the liver or worsen liver disease. Only forms of borage oil that are certified to be PA-free should be used. Last, evening primrose oil may interact with a group of tranquilizers used in the treatment of schizophrenia known as phenothiazines. This group of drugs includes chlorpromazine and prochlorperazine.

Fish oil may affect the rate of blood clotting and cause nausea or a fishy odor to the breath in some persons. Some fish oil supplements may also contain overly high levels of vitamin A or mercury. In addition, patients who take fish oil supplements must usually take them for several months before they experienceany benefits.

Risks

Osteoarthritis

Most dietary supplements for OA appear to be safe when purchased from reputable manufacturers and used as directed. Glucosamine and chondroitin sulfate have been reported to cause intestinal gas or mild diarrhea in some people. ASU causes nausea and skin rashes in some people.

Cost may be a consideration for some people, as these supplements cost between $1.50 and $3 per day, and are not usually covered by health insurance.

Rheumatoid arthritis

Chinese thunder god vine is reported to weaken bone structure and increase the risk of osteoporosis in patients with RA. Fish oils with high levels of vitamin A have been reported to cause vitamin A toxicity in some people.

Research and general acceptance

Osteoarthritis

No mainstream clinical studies have found that patients with OA benefit from elimination diets. With regard to dietary supplements, findings are mixed. A major 4-year study of glucosamine and chondroitin sulfate supplements, the Glucosamine/chrondoitin

QUESTIONS TO ASK YOUR DOCTOR

• Would you recommend glucosamine and chondroitin supplements for mild OA?
• Have any of your other patients benefited from taking ASU or other dietary supplements for arthritis?
• What is your opinion of elimination diets as treatment for arthritis?
• Would you recommend a vegetarian diet for patients with OA as well as patients with RA?

Arthritis Intervention Trial (GAIT), reported in 2006 that these supplements appear to be more beneficial to a small subgroup of patients with severe pain from OA than to a larger group with only mild to moderate levels of discomfort. There is better evidence that ASU is beneficial, but only limited evidence for the usefulness of Du Huo Ji Sheng Wan. Some clinical studies carried out in India report that an Ayurvedic compound that combines ginger, turmeric, and zinc reduced pain in patients with OA of the knees even when other aspects of Ayurvedic practice were not followed.

Rheumatoid arthritis

The National Center for Complementary and Alternative Medicine (NCCAM) has noted in a recent review of alternative treatments of RA that few high-quality studies of these treatments have been published as of 2006. Several studies indicate that vegetarian or vegan diets and the Mediterranean diet do in fact benefit patients with RA. Fish oil has been reported to reduce the risk of heart attacks in patients with RA as well as reduce joint pain and inflammation. Green tea has been tested on mice with RA but has not yet been tested on human subjects. A study conducted at the University of Arizona reported in 2006 that turmeric by itself inhibits the destruction of joint tissue in rats with RA as well as reducing joint inflammation; but as with green tea, turmeric supplements have not yet been used in clinical trials with human subjects with RA.

Resources

BOOKS

Childers, Norman Franklin. A Diet to Stop Arthritis: The Nightshades and Ill Health, 2nd ed. New Brunswick, NJ: Somerset Press, 1981.

Dong, Collin H., MD, and Jane Banks. New Hope for the Arthritic New York: Crowell, 1975.

Kandel, Joseph, and David B. Sudderth. The Anti-Arthritis Diet: Increase Mobility and Reduce Pain with This 28-Day Life-Changing Program Rocklin, CA: Prima Publishing, 1998. In spite of its title, this book focuses primarily on weight reduction in general as an important aspect of managing OA.

Murray, Michael, ND, and Joseph Pizzorno, ND. Encyclopedia of Natural Medicine, 2nd ed. Rocklin, CA: Prima Publishing, 1998. Includes a list of dietary supplements recommended by naturopaths to treat arthritis.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, “CAM Therapies for Specific Conditions: Arthritis.” New York: Fireside Books, 2002. A useful summary of the various dietary therapies that have been tried in the management of osteoarthritis and rheumatoid arthritis.

Theodosakis, Jason, MD, and Sheila Buff. The Arthritis Cure, rev. ed. New York: St. Martin’s Press, 2004.

COOKBOOKS

Adderly, Brenda, and Lissa DeAngelis. The Arthritis Cure Cookbook. Washington, DC: LifeLine Press, 1998.

Flynn, John A., MD, and Lora Brown Wilder. Recipes for Arthritis Health New York: Rebus, 2003.

Haupt, Prentiss Carl, and James McKoy. The Executive Chef’s Arthritis Cookbook and Health Guide. Pukalani, HI: Arthritis Cookbook Corporation, 2001.

PERIODICALS

Ameye, L. G., and W. S. Chee. “Osteoarthritis and Nutrition. From Nutraceuticals to Functional Foods: A Systematic Review of the Scientific Evidence.” Arthritis Research and Therapy 8 (2006): R127.

Berkow, S. E., and N. Barnard. “Vegetarian Diets and Weight Status.” Nutrition Reviews 64 (April 2006): 175–188.

Chopra, A., P. Lavin, B. Patwardhan, and D. Chitre. “A 32-Week Randomized, Placebo-Controlled Clinical Evaluation of RA-11, an Ayurvedic Drug, on Osteoarthritis of the Knees.” Journal of Clinical Rheumatology 10 (October 2004): 236–245.

Clark, K. L. “Nutritional Considerations in Joint Health.” Clinics in Sports Medicine 26 (January 2007): 101–118.

Clegg, D. O., D. J. Reda, C. L. Harris, et al. “Glucosamine, Chondroitin Sulfate, and the Two in Combination for Painful Knee Osteoarthritis.” New England Journal of Medicine 354 (February 23, 2006): 795–808.

Cleland, L. G., G. E. Caughey, M. J. James, and S. M. Proudman. “Reduction of Cardiovascular Risk Factors with Longterm Fish Oil Treatment in Early Rheumatoid Arthritis.” Journal of Rheumatology 33 (October 2006): 1973–1979.

Funk, J. L., J. B. Frye, J. N. Oyarzo, et al. “Efficacy and Mechanism of Action of Turmeric Supplements in the Treatment of Experimental Arthritis.” Arthritis and Rheumatism 54 (November 2006): 3452–3464.

Lee, S., K. M. Gura, S. Kim, et al. “Current Clinical Applications of Omega-6 and Omega-3 Fatty Acids.” Nutrition in Clinical Practice 21 (August 2006): 323–341.

Morelli, Vincent, MD, Christopher Naquin, MD, and Victor Weaver, MD. “Alternative Therapies for Traditional Disease States: Osteoarthritis.” American Family Physician 67 (January 15, 2003): 339–344.

Rindfleisch, J. Adam, MD, and Daniel Muller, MD, PhD. “Diagnosis and Management of Rheumatoid Arthritis.” American Family Physician 72 (September 15, 2005): 1037–1047.

OTHER

American College of Rheumatology Fact Sheet. Herbal and Natural Remedies. Atlanta, GA: ACR, 2005. Available online at http://www.rheumatology.org/public/factsheets/herbal.asp (accessed March 20, 2007).

Arthritis Research Campaign (ARC). Diet and Arthritis: An Information Booklet. ARC, 2006. A helpful 38-page summary of diet in the management of arthritis. Available online in PDF format at http://www.arc.org.uk/about_arth/booklets/6010/6010.html.

Bartlett, Susan, PhD. Osteoarthritis: Weight Management. Baltimore, MD: Johns Hopkins Arthritis Center, 2007. Available online at http://www.hopkins-arthritis.org/arthritis-info/osteoarthritis/weight-management.html (accessed March 18, 2007).

Klaper, Michael, MD. Nutritional Strategies for Inflamed Joints and Other Conditions. Manhattan Beach, CA: Institute of Nutrition Education and Research, 2005. Recommends the nightshade elimination diet. Dr. Klaper is a vegan who conducts research on the health benefits of veganism. Available online at http://www.vegsource.com/klaper/nutrition.htm.

Koch, Cheryl, CSND. Nutrition and Rheumatoid Arthritis Baltimore, MD: Johns Hopkins Arthritis Center, 2007. Available online at http://www.hopkins-arthritis.org/mngmnt/nutinra.html (accessed March 18, 2007).

National Center for Complementary and Alternative Medicine (NCCAM). Research Report: Rheumatoid Arthritis and Complementary and Alternative Medicine. Bethesda, MD: NCCAM, 2006. Available online at http://nccam.nih.gov/health/RA/ndash5.

ORGANIZATIONS

American Association of Naturopathic Physicians (AANP). 4435 Wisconsin Avenue NW, Suite 403, Washington, DC 20016. Telephone: (866) 538-2267 or (202) 237-8150. Website: http://www.naturopathic.org.

American College of Rheumatology (ACR). 1800 Century Place, Suite 250, Atlanta, GA 30345-4300. Telephone:(404) 633-3777. Website: http://www.rheumatology.org.

American Vegan Society (AVS). 56 Dinshah Lane, P. O. Box 369, Malaga, NJ 08328. Telephone: (856) 694-2887. Website: http://www.americanvegan.org/index.htm.

Arthritis Foundation. P.O. Box 7669, Atlanta, GA 30357-0669. Telephone: (404) 872-7100 or (800) 568-4045. Website: http://www.arthritis.org.

Arthritis Research Campaign (ARC). Copeman House, St. Mary’s Court, St. Mary’s Gate, Chesterfield, Derbyshire S41 7TD United Kingdom. Telephone: +44 (0) 1246 558007. Website: http://www.arc.org.uk.

National Center for Complementary and Alternative Medicine (NCCAM). 9000 Rockville Pike, Bethesda, MD 20892. Telephone: (888) 644-6226. Website: http://nccam.nih.gov.

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Information Clearinghouse. National Institutes of Health, 1 AMS Circle, Bethesda, MD 20892-3675. Telephone: (877) 22-NIAMS or (301) 495-4484. Website: http://www.niams.nih.gov.

National Institute of Ayurvedic Medicine (NIAM). 584 Milltown Road, Brewster, NY 10509. Telephone: (845) 278-8700. Website: http://niam.com

Rebecca J. Frey, Ph.D.