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BRITISH BROADCASTING CORPORATION
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Programme 6. - Arthritis
RADIO 4
TUESDAY 13/06/06 2100-2130
PRESENTER:
MARK PORTER
REPORTER: LESLEY HILTON
CONTRIBUTORS:
DAVID EISENBERG
LUCY WEDDERBURN
SUE MAYLORD
JOHN GOODACRE
LIK-KWAN SHARK
PRODUCER:
PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello. Seven million people across the UK have some form of ongoing health problem because of arthritis. Most are due to osteoarthritis which tends to be age related - the older your joints are, and the more stress or damage they are subjected to, the more likely you are to have some degree of osteoarthritis. But, as we'll be finding out, inflammatory type arthritis - which we'll be concentrating on today - can strike at almost any age, including childhood.
CLIP
In the past when I've have had bad flares I can't really remember what it was like because I was much younger. But my joints started to ache and they were just really stiff and hard to get up in the morning.
PORTER
More about arthritis in childhood a little later along with a look at why exercise, not rest, is now the favoured approach to tackling painful joints and a new machine that could one day assess the state of your knees simply by listening to them?
But first non-steroidal anti-inflammatories - drugs like ibuprofen, diclofenac and naproxen. Used to ease pain and stiffness, they form the mainstay of treatment for most people with painful joints - whatever the underlying cause. They've been in the headlines again after researchers published further evidence linking the drugs to an increased risk of heart attack and stroke. Reports that have prompted a number of you to contact us about the them. So let's start by putting some of your concerns to my guest today, he's David Eisenberg, arthritis research campaigns director of rheumatology at University College London.
David, perhaps we should start by outlining the facts behind those headlines.
EISENBERG
Well non-steroidal anti-inflammatory drugs have been available for around 40 years Mark, they've been known to be very effective at treating a wide variety of forms of arthritis and actually there are over 200 different sorts of arthritis. It's very unlikely that they would be a major cause of heart attacks and strokes, I think that would have become obvious a great deal sooner. What has been concerning is the development of some newer forms of the non-steroidal anti-inflammatory drugs, drugs known as the COX-2 drugs. The purpose behind the development of these drugs was to provide drugs which were as effective but were rather safer in terms of the irritation that these drugs can cause on the lining of the stomach.
PORTER
These are drugs like Vioxx and Celebrex, people might have heard of.
EISENBERG
These are the drugs Vioxx and Celebrex and one or two others, which have been around for five or six years now. The concern about these drugs has been around for some time and as you will know, I'm sure, Vioxx was taken off the market a few months ago when it was claimed that in a study - not of arthritis ironically but a study of colonic polyps - that there was an increased risk of heart attacks in a small number of patients, that's the reason that they actually came off the market.
PORTER
But what about linking this into more everyday anti-inflammatories, drugs like even ibuprofen, I've seen headlines that ibuprofen may double your risk of heart attack, what's your take on that?
EISENBERG
Well I was taught a great lesson by a - some patients of mine. The week after Vioxx was pulled off the market five patients of mine came into the clinic on a Friday and they all said to me that Vioxx was truly the best thing that I have ever prescribed for them. Four of them were very upset that I had to stop the drug, one of them, however, said to me - I'm 73 years old, I had a heart attack a year or so ago, given what I've just heard I feel strongly that Vioxx is not the drug for me. And I think he was right. And I think what this emphasises is the certain horses for courses element when we come to prescribing drugs like non-steroidals, I think the risk of developing any major effects taking one of these drugs, whether it's a COX-2 or one of the more conventional ones, for a short period of time is close to zero but clearly taking any drug for a very long period of time may cause a problem.
PORTER
Well let's have a look at some of the queries.
MACKAY
I'm Kirsty Mackay. I'm 29 and was diagnosed with arthritis three years ago. Celebrex is the only anti-inflammatory that works for me. Ibuprofen was too weak and diclofenac upset my stomach. My GP has taken me off the Celebrex because of the risks of heart disease and now my aches and pains are back, despite taking a range of other drugs. How do doctors balance their theoretical risk of heart disease and stroke against the very real day-to-day benefits of effective pain relief?
PORTER
David, in a worst case scenario how big is that association between a COX - Celebrex is a COX-2, it's one of the more modern types of anti-inflammatories we were talking about - how much may it increase the risk of heart attack or stroke?
EISENBERG
Well let's look at the figures. Approximately 1300 patients were given Vioxx, these were the patients with the colonic polyps, and followed for 18 months. Another 1300 were given a placebo. After one year there was no difference in the heart attack risk between the two groups, but after 18 months approximately 25 in the placebo group had developed a heart attack and 45 in the patients given Vioxx. So in other words there's an increase of 20 against the denominator of 1,300, so the risk is small and the patients had to be on these drugs for 18 months before the difference could be shown up.
PORTER
So how do you assess this risk benefit ratio, presumably in somebody - I mean Kirsty's 29, her risk of heart disease is very small?
EISENBERG
Yes, clearly there are much more important factors in terms of the development of attacks, smoking being a classic example, family history being another example, diabetes. And it gets back to this argument about horses for courses - if I was a 70-year-old diabetic, if I'd just had a heart attack, if I smoked 70 a day a COX-2 drug probably wouldn't be the one for me. But if I'm 20 years old and I require an anti-inflammatory drug for two or three months I really don't think they'll be any problem at all.
PORTER
Okay, let's go on to our next one.
STOPHER
Brian Stopher. The anti-inflammatory diclofenac damaged my colon. A lot of the media attention surrounding diclofenac and related drugs has concentrated on heart disease and stroke but they have lots of other nasty effects too. I wonder how many doctors would be prepared to take an anti-inflammatory long term?
EISENBERG
Anti-inflammatory drugs can affect the kidney, especially in patients who some degree of kidney failure, an anti-inflammatory drug can tip those patients into complete kidney failure requiring dialysis, so one has to be careful there. The risks may also occur through skin rashes, that's an occasional problem, the main concern though is the trouble - the irritation that occurs to the lining of the stomach, that's where the main problem has occurred over the years and that can be serious in a small but definite number of patients.
PORTER
I mean it's a fair number of people, I mean tens of thousands of people might be affected across the UK, I mean it's a couple of thousand deaths some people estimate or maybe more?
EISENBERG
It is a couple of thousand deaths or at least it has been but I think doctors are now much more sensible about the prescription of these anti-inflammatory drugs and if there's any hint of trouble in the previous history patients can now be co-prescribed other drugs to protect the lining of the stomach were the patients to have arthritis and to need some anti-inflammatory drug to control their arthritis.
PORTER
And of course that was one of the reasons why the COX-2 range, the more modern ones, were brought in to try and reduce that.
EISENBERG
That's correct, that's right.
PORTER
Okay, I want to come back to treatments later on David but let's get a few basics out of the way first. The term arthritis covers a number of different underlying medical problems, doesn't it, how can we categorise it?
EISENBERG
Well there are something like 200 different sorts of arthritis. The name arthritis comes from the Greek meaning inflammation of the joints, so there is unfortunately a wide selection, many different forms of arthritis. Many of them are, fortunately, rather rare, some of them are very serious and rare but some are serious and common and perhaps the most troublesome and common of these is rheumatoid arthritis.
PORTER
So what's actually going on in these people?
EISENBERG
Patients with rheumatoid arthritis have marked inflammation, which starts mainly in the small joints, so in the knuckles, the small joints of the hands but can then spread very rapidly to involve other joints, many other joints, within the body, even involving one particular joint in the neck. And unfortunately it's not a disease which confines its attention to the joints, it can sometimes involve the internal organs as well.
PORTER
And this is the immune system attacking our joints and other parts of the body but why?
EISENBERG
Well let me give you an analogy. You can think of the immune system as a defensive sort of army, it's an army which is very good - it works like a sort of radar system, it spots the invaders, the microbes, that we all face every time we eat, every time we have a glass of water millions of bacteria and viruses are pouring into our body and normally our immune system, our radar system, can spot these, distinguishes them as not part of our own body and will get rid of them. They're rather like some of the unfortunate events that happened during the two Gulf wars, where the Americans at night shot and killed some of their own troops because at night they couldn't distinguish their troops from the enemy troops. So on occasions our immune systems make terrible mistakes and begin to attack parts of our body in the mistaken belief that it's doing us a favour. If it attacks the pancreas we call it diabetes, if it attacks the joints we call it inflammatory arthritis.
PORTER
What about the typical patient who's presenting with an inflammatory arthritis, you said there were 200 different types, let's look at rheumatoid as the most common form. People arriving in your clinic are who - male, female, how old?
EISENBERG
The risk is greater in females, the ratio is about three to one. Most patients with rheumatoid arthritis develop the disease between 30 and 55, that's the common age, but you do see it, as you've heard, in children, you even see it in patients presenting for the first time in the 80s and 90s.
PORTER
And this sex bias is quite interesting because that applies right across the board of these autoimmune arthritises as well.
EISENBERG
Yes, it's a very striking feature that in virtually every disease of the immune system women are much more likely to get these diseases. In lupus it's 10 to 1, scleroderma it's about the same, myositis - an inflammatory muscle disease - it's three to one.
PORTER
And why do people get these inflammatory arthritises, is it a genetic component?
EISENBERG
Well I think the simplest way to explain it is to think of an analogy with a game of cards. Now the name of the game is health but when you look at the cards they're not marked the ace of diamonds, the two of spades, three of clubs but rather they're marked with - one card might be marked female sex, one is male sex, one is genetic factor x or y, one is high fat diet, one is exposure to a particular sort of virus. Imagine that the cards are shuffled, now if you are unlucky enough to be dealt a hand of cards which consist of the female sex card, the age 30-50 card, perhaps a high fat diet card, perhaps an exposure to Epstein Barr virus card and three or four other suitable cards I've just dealt you a rheumatoid arthritis hand. And it makes the point that nobody gets these diseases because of one thing going on in their body but because of a conspiracy which is happening, it's these factors conspiring together to cause the disease.
PORTER
Traditionally - I remember when I was working in a hospital about 20 years ago or more - people with bad rheumatoid arthritis we used to get them into hospital sometimes, put them into splints and rest them but that approach has changed now, we're much more keen on keeping people active.
EISENBERG
Yes, I think unfortunately resting a joint which is inflamed can lead to contractures of the joint - the joint gets stuck in a position of flexion, for example, and then it's very difficult to straighten that flexed joint. It's particularly true in children but it's also true in adults who get rheumatoid arthritis.
PORTER
Keeping active and doing regular exercise, as David pointed out, is particularly important in children. Around 12,000 children across the UK are currently undergoing treatment for juvenile arthritis. Thirteen-year-old Rhys is one of them - although in his case the diagnosis was far from clear when his knee started swelling just before his second birthday, much to the concern of his parents.
RHYS'S MOTHER
At our local hospital we were referred to they suspected a tumour on his knee and subsequently arranged for him to have a biopsy and followed by the removal of the tumour. So he was actually set for surgery at that point, that was their diagnosis.
RHYS'S FATHER
And so they contacted us very quickly and we were back in the hospital within a few days. Obviously slightly panicked and fearing that it could be a tumour. And rheumatoid arthritis - that one hadn't been muted at all. And when we went in on the day of the procedure for the biopsy they decided to get somebody down from paediatrics and one of the doctors there had recently been doing a rotation and training at Great Ormond Street on the rheumatoid wing, which was incredibly fortunate for us, and spotted this swelling and thought hello that looks familiar. And we were then referred to Great Ormond Street where they diagnosed arthritis. It was almost a relief as well. It was something that my grandfather had and something that wasn't life threatening. And so anything that wasn't cancer we thought well that's fine we can work with that and we can live with that and get treatment.
PORTER
Lucy Wedderburn is a rheumatologist at Great Ormond Street.
WEDDERBURN
Most people don't know that children do get arthritis but in fact about one in a thousand children gets arthritis. So if you think about it in numbers that's typically one child in every large secondary school.
PORTER
And that's presenting how?
WEDDERBURN
Usually it presents with the child having pain or swelling or just being a bit off colour, it's not always clear why. Often it's quite a young child so the child may not be able to say that they have pain in a particular joint, typically a knee or sometimes the foot ankle, sometimes the hands, wrists. And so often a parent will say oh our child has stopped walking - they might be 18 months two year, three years old.
PORTER
And what's the underlying problem, what's causing the inflammation?
WEDDERBURN
If only we knew. We think that the basic processes that the immune system for some reason has so that the parts of the body that are designed really to protect you from infection from the outside world has gone overboard, instead of just finishing a normal immune response it's actually continued the immune response but within the lining of the joints. So the joint itself has this very thin lining in normal health in both adults and children which is kind of lubricant really. But when the immune system starts to attack that part of the joint it gets very thickened and makes extra fluid and that makes it difficult to move the joint and may cause a lot of pain.
RHYS'S FATHER
Quite soon after noticing the swelling in one knee the second knee then became remarkably swollen and it went into his ankles. All within two or three months?
RHYS'S MOTHER
It was very quick.
RHYS'S FATHER
Very quick wasn't it. He did start to limp and certainly when he was in a flare it would be very sore, it was difficult to get him up in the mornings and to get him going.
PORTER
And you were using similar drugs to the ones we use in adults?
WEDDERBURN
A lot of the drugs are similar, children typically start on anti-inflammatory drugs, things like brufen and related drugs. But we have to use them at quite a lot higher doses than the normal amounts used for temperatures or aches and pains. But if that alone doesn't work then a lot of children take a medication that's called methotrexate, which has now been used for many years in children and is actually a very safe drug and in some ways has many advantages because it's only taken once a week. And that will control, at least to some extent and sometimes completely, the arthritis in 60-70% of cases, not all children however.
RHYS
In the past when I have had bad flares I can't really remember what it was like because I was much younger. But my joints started to ache and they were just really stiff and hard to get up in the morning.
PORTER
In adults with this type of arthritis or similar types of arthritis it's not a disease that's just confined to the joints of course, other parts of the body are susceptible to attack from the immune system as well. Is the same thing happening in children?
WEDDERBURN
Yes, in fact that is the case. Childhood disease has a particular problem that can happen associated with it which is inflammation in the eye and that generally doesn't cause pain, so the child can't tell anyone about it, but if it's left untreated can change and even affect the vision.
PORTER
Sue Maylord is a specialist physiotherapist at Great Ormond Street, and one of the team responsible for making sure people like Rhys do as much as they can to help themselves.
MAYLORD
What we're teaching them to do is to use their muscles which are their main thing that they've got in their body for looking after and controlling their joints and making those as effective and as efficient as possible to counteract the effects of the inflammation caused by the arthritis.
PORTER
So what sort of exercises do you get them doing?
MAYLORD
We use a progressive resisted exercise programme. So it's three exercises, usually lying on the floor or sitting on a chair, those types of exercises that they can do very easily at home, often in front of the television with very little equipment but very specific, so we look at each individual muscle. But often what the children find is the more they exercise the less their pain is, so quite quickly they learn that if they keep still and don't move then they're stiff, it's difficult to move, it's painful, if they keep exercising and they get strong then their pain gets less.
PORTER
And presumably their day to day activities are great exercise as well, the sort of things normal kids do that you don't have to follow a written down programme?
MAYLORD
That's really vital as part of normal life but what you have to be very careful with is normal activities - sport, playing - those sorts of things are very good for your general fitness and mobility, what they don't deal with is specific muscle problems and specific joint problems and that's where many people run into difficulties because the parents will say yeah but they walk to school everyday and therefore I think they're exercising. But what you do is you walk in a bad way, so if you don't have specific muscles you can walk without them but you never get them back because your body adapts and carries on using different muscles that have compensated and you'll never change that, the pain will stay continue and in fact the weaker muscles keep getting weaker and the stronger muscles get stronger and you end up with bigger muscle imbalances. So sports and those types of activities are vital as part of normal activity but a physiotherapy programme is very different and it's there so that they can do all the sporting activities they want safely and without damage to their joints.
PORTER
Physio Sue Maylord talking to me at Great Ormond Street Hospital.
David, we talked about anti-inflammatories to ease pain and stiffness in arthritis but do they actually influence the progression of the underlying disease?
EISENBERG
Certainly not, they treat the symptoms, as your question implies but they don't really get to grips with the cause of the problem.
PORTER
So what can we do to alter the course of the disease - people will have these - an inflammatory arthritis for decades?
EISENBERG
Well for some 30 or 40 years a variety of drugs which suppressed the immune system in a general sort of way have proved to be very helpful and we've heard about Rhys being on methotrexate, that's a very good example of a drug, which although it's a general immunosuppressive is very effective in quietening down the joints and reducing the inflammation.
PORTER
So it's basically sitting on these soldiers that are responsible for the friendly fire?
EISENBERG
That's correct.
PORTER
What happens when the patient has a flare up, because, we haven't mentioned, that's a characteristic of the disease, you can be - it's not slowly progressive, you often have great - you can be relatively well and then you have a really bad spell and I get patients coming to surgery who can barely walk sometimes, how should we be treating them, if for instance they're already on methotrexate?
EISENBERG
Well there are several options. You can go back to using anti-inflammatory drugs, you can try to increase the drug that the patient is taking, if it's an immunosuppressive drug and of course the role of steroids can be very helpful in patients with a flare up of their arthritis.
PORTER
That's what I was angling after really because these are the ultimate anti-inflammatory really, I mean they're miraculous drugs but we don't like using them that much.
EISENBERG
Well as your question implies they've been rather controversial since they were first introduced by - actually by an American rheumatologist, the only rheumatologist to win the Nobel prize in the late 1940s and early '50s. And the problems have been that it was some 10 years before their very serious side effects were recognised. And I think most people would accept that the best dose of steroids is the lowest possible dose for the shortest possible period of time. But having said that they can be virtually life saving in many patients.
PORTER
What about the newer agents?
EISENBERG
Well this is where the current excitement lies. We're now moving to an era where we can target the key molecules, the key molecules which cause the inflammation and these are showing tremendous promise, in fact they're beyond promise - they're delivering some very palpable results to us now.
PORTER
And these are so-called biological therapies?
EISENBERG
These are the biological therapies, the therapies which are aimed to block the effects of individual molecules which make a major contribution to the cause of arthritis and not just rheumatoid arthritis incidentally but akylosing spondylitis, psoriatic arthritis, lupus - a whole variety of different arthritic conditions.
PORTER
Now you don't meet many patients who are taking these at the moment. Their introduction is slow - I know they're incredibly expensive - but is it - are we proceeding cautiously or is it simply a matter that they're reserved only for in inverted commas "worst cases"?
EISENBERG
Well that's a rather interesting question and it rather depends on which way you look at it. In the United States it's estimated that nearly 20% of patients with rheumatoid arthritis are on these drugs, in Scandinavia it's probably over 10%, in the UK it's around 5%. It appears that the UK has put up barriers which don't seem to exist in other countries, which in many ways is a great shame because they are proving to be very effective, we know that of the three main drugs which block one of these particular inflammatory molecules that we call TNF-alpha, 70% of patients given one of these three drugs which can do this will reap great rewards to the patients, huge benefits in terms of lessening of the inflammation, greatly improved sense of wellbeing, the numbers of swollen joints go down, really a great advance.
PORTER
What about safety?
EISENBERG
Clearly nobody on the planet has been given these drugs for more than seven or eight years so we can't speak of long term safety for 10 or 15 years as we can with methotrexate which has been around for 40 or steroids which have been around for 50. But what I can tell you, from a role that I have working for the British Society of Rheumatology, I'm the chairman of the Biologics Committee we have, it does seem that in the medium term, so five or six years, there does not appear to be an increase in tumours, for example, which was one concern. There's a small increased risk of certain sorts of infections but in the main the advantages are overwhelmingly outweighing the disadvantages.
PORTER
What about disease monitoring - how do you know if the drugs that you are using in your patients are working? Are we going purely by symptoms?
EISENBERG
Well when I assess patients I try to make two important distinctions, the distinction between activity and damage. Now by activity I mean ongoing inflammation, things which you can do something about, things which you can change, which you can alter, which you can improve, damage - I mean permanent change. Now rheumatoid arthritis is a very good example of this because with rheumatoid arthritis once the inflammation begins to dig little holes in the bones, that we call erosions, that's damage, that's permanent, no drug that we could offer a patient will ever change that unfortunately. So when I assess a patient, yes, I look at the patient's hands, I look at their other joints, are those joints swollen, are they painful to the touch. So it's a combination of making that assessment of activity and damage.
PORTER
Well one unusual approach to assessing how bad arthritis may be is to listen to the joint. Not the sort of the creaks and groans that I am increasingly hearing when I bend down or sit in a chair, but high frequency noises that are inaudible to the human ear. Lesley Hilton went to Lancashire to find out more.
HILTON
Many of us have knees which make strange noises when we move. But now a form of technology more commonly used in the engineering industry to detect unsafe bridges and buildings, or problems in aeroplanes, is being tested to see if it can find out just what is happening in our noisy knees. I'm at the University of Central Lancashire with Professor John Goodacre from the School of Health and Postgraduate Medicine.
GOODACRE
The thing that we're most interested in here is the ability to show change, so I think we're interested in the idea that we will be able to measure the integrity and the function of the joint in this way. What we think it's unlikely to tell us is whether it's one type of arthritis or another. I don't think it has the potential to be able to distinguish different types of arthritis but in terms of asking whether an individual's arthritis is changing we think that that's the way in which it will prove to be the most useful.
ACTUALITY
You want a knee?
Yes I want a knee.
In what position?
That's fine, just - if you just have it normally. Basically all we do is position the sensor on a certain location that we've defined upon the knee joint. If I can just ask you to straighten your leg and then bend it again. So basically if you just keep doing that. And as you can see on the screen we're picking up certain noises from within the knee joint. This is the data that we get up on the screen ...
HILTON
James Prior, one of the PHD students involved in the project listened to my knees. But how can you hear them when the equipment doesn't make any noise? Professor Lik-Kwan Shark, Head of Research for Applied Digital Signal and Image Processing.
SHARK
It will come as a waveform and we can analyse the waveform, we can look at the [indistinct word] of the waveform, we can look at how fast the sound's being generated, whether the sound's very long or very short et cetera. So all this will give us some ideas in terms of the knees. If the knees for example are bones grinding against the bones, compared with the sound of fibre rubbing against fibre, obviously the sounds coming from the bones are much louder than the fibres.
HILTON
During movement knee joints emit sounds at frequencies that are too high to be heard by the human ear. It's thought that an arthritic knee will send out high-frequency wave patterns which will differ from those of a healthy knee and that this difference can be picked up by acoustic transmission - enabling doctors to listen in on the progress of arthritis. So could it be used for other joints too? John Goodacre.
GOODACRE
We're focusing of course upon knees and that's our start point. If we do find that the information that we get from this approach is useful clinically what we would obviously want to do is go on to ask whether we can get similar value from looking at other joints and in principle there's no reason why that shouldn't be possible.
HILTON
What about looking at hip joints in this way?
GOODACRE
Yes I mean I think in a way that would be the next level that we would want to go to, to ask whether it can tell us something about hip arthritis but also whether it could be used for example to detect problems in artificial joints either in the knee or the hip and to ask whether or not this could be used as an early detection of problems that are coming along further down the line in that respect.
HILTON
At the moment the high tech imaging techniques currently used to monitor joints are only available in hospitals. John Goodacre and Lik-Kwan Shark would like to develop a smaller more easily accessed piece of equipment.
GOODACRE
What we would envisage is that in due course we would be able to design a piece of equipment that could be located in for example GPs' surgeries or other health environments that doctors and other professionals could use very easily, it would be a portable piece of equipment, and they could actually take very frequent and regular measurements of the knee and enable them to, as I say, plot change much more objectively, much more carefully, much more readily, than is currently possible. So we would like to think that we could work towards developing a portable, readily available and very convenient piece of equipment to, as I say, fill that gap between clinical assessment and the more high tech imaging that is currently used.
PORTER
Professor John Goodacre talking to Lesley Hilton.
David, what does the future hold? We've heard about the biological therapies, they're looking very promising, what do you say to somebody now who comes to see you - aged 35, a woman - who's just been diagnosed with rheumatoid arthritis, what does the future hold for her?
EISENBERG
You have to be realistic, some patients with rheumatoid arthritis will not do as well, even with the new drugs as we would like them to do. But what I would emphasis to them is that with proper management, which is likely to involve the use of other professionals - physiotherapists, occupational therapists, orthopaedic surgeons - the outlook is truly much brighter than it was and has ever has been and is likely to continue to improve because we do have several other drugs lining up behind the TNF-alpha blockers waiting to come into common clinical practice.
PORTER
We must leave it there. Professor David Eisenberg thank you very much.
Don't forget that if you have access to the internet you can listen to the programme again via our website bbc.co.uk/radio 4.
Next week's programme will be the last in the current series and will be all about the bowel. I'll be finding out what's happened to the much vaunted national bowel cancer screening programme, and discovering how bananas could be used to develop a new dietary treatment for people with Crohn's disease.
ENDS
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