Dr. Jan Atwood, an incredibly fit 72-year-old retired exercise science professor from Penn State, knocked on my office door about a year ago. When I complimented her on looking so great, she humbly told me that her running days were over and walking was her new exercise focus despite the pain in her knees. She was hoping I could suggest a nutrition supplement or a special food that, put simply, could make the pain go away. Although I didn’t know Jan well, I knew she wouldn’t be asking for something unless the pain was real and persistent.
Since osteoarthritis (OA) can bring on such sudden pain and stiffness when joints are moved, it is not surprising that physical activity or even general mobility decreases—which can lead to further disability. The average person experiencing joint pain or stiffness eventually adapts by adopting a sedentary lifestyle. Weight gain is common and exacerbates the problem, while chronic use of anti-inflammatory medications may reduce inflammation but over time can cause gastrointestinal complications. So the question put to me was a good one. Could there possibly be something nutritional—and safe—that could ease her knee pain?
What Is OA?
Although I wanted to jump in and give Jan some good advice about her diet and a possible nutrient solution to the knee pain, I realized I didn’t have much knowledge about OA. I needed to do some research.
I discovered that OA is the most common form of arthritis and is found in more than 21 million adults in the United States. In OA, the cartilage that cushions the ends of the bones wears away, leading to debilitating joint pain and stiffness. OA accounts for more than half of the total hip replacements and 85 percent of the total knee replacements done in the United States each year, with medical costs estimated between $15.5 billion to $28.6 billion annually (Arthritis Foundation 2003).
Unlike most OA sufferers, Jan is not overweight or sedentary, two instigating factors of joint pain. Rather, in Jan’s case, aging and regular exercise routines during the course of her lifetime may have helped wear away the articular cartilage, or cushioning material at the ends of her bones, which leads to progressive change in the bones and supporting tissues.
How Does OA Occur?
Although it is easy to assume OA is inevitable with aging, recent research suggests that a genetic defect leading to abnormal production of collagen (the major building material of bone and cartilage) is the major culprit (Miller 2003). In addition, it seems that a “cascade” of events occur causing cartilage breakdown and changes in bone tissue, which instigates OA. Researchers have investigated a variety of substances made by the body—such as enzymes like metalloproteinases; growth factors; chemical messengers like cytokines; and hormones like estrogen—that may provide clues to these negative changes.
The bottom line for OA sufferers is that they hurt when they move! Most OA patients wind up taking anti-inflammatory prescription or non-prescription medications to cope with the discomfort and stiffness (Arthritis Foundation 2003; Miller 2003).
Epidemiology studies identify environmental causes for OA, such as obesity, joint injuries, occupations that require considerable bending or carrying heavy objects, and general poor conditioning. Weight loss, exercising to strengthen thigh muscles and avoiding repetitive joint stress can mitigate OA from these causes (Arthritis Foundation 2003; Miller 2003).
Nutrients and OA Prevention
While weight loss is top on the list for coping with OA, adequate intake of a few key nutrients might prevent OA from occurring in the first place. Several vitamins and minerals play significant roles in promoting optimal growth of cartilage and bone tissue during developmental stages of life (Miller 2003). To prevent OA, a healthy diet may be the best beginning. The following key nutrients optimize bone and collagen formation:
- Vitamin C. Vitamin C has long been
known to play a role in collagen
formation, one of the ingredients in
articular cartilage. Virginia Kraus, MD,
PhD, at Duke University in Durham,
North Carolina, discovered that
vitamin C increased the production of
cartilage proteins, such as collagen
and aggrecan, but only when consumed
in small doses. High doses actually
worsened OA in guinea pigs. Her
research focuses on how vitamin C
can protect cartilage (Arthritis
Foundation 2003). Supplement
enthusiasts should note that 1,000
milligrams (mg) per day is the maximum
level of vitamin C recommended for
safe consumption by adults.
- Vitamin D. Vitamin D increases the
absorption of calcium into bone tissue
and consequently is a key nutrient in
healthy bone development.
- Calcium and Phosphorus. Ninety-
nine percent of the calcium in our
body is in the form of bone and teeth.
Calcium is the mineral that helps
harden bone matrix, which is largely
made of collagen. Since calcium and
phosphorus are the predominant min-
erals in bone, both must be present in
adequate amounts to assure optimal
bone development. Bone growth stops
around age 27 to 30 years.
- Omega 3 Fatty Acids. Fish oil is a
rich source of eicosapentanoic acid
(EPA) and docosahexaenoic acid
(DHA), the omega 3 fatty acids that
can convert in the body into a benefi-
cial series of prostaglandins that
appear to offer anti-inflammatory
properties. Patients taking fish oil
supplements have reported improve-
ments in the symptoms of rheumatoid
arthritis (James & Cleland 1997).
However, there have been some concerns that fish oil supplements can act as blood thinners. How does this happen? Omega 3 fatty acids convert to prostaglandins that may have anti-coagulation effects. Many people use multiple supplements for joint discomfort and inflammation such as vitamin E, aspirin, glucosamine and chondroitin sulfate. The combination of these products may exacerbate the anti-coagulant effect and could contribute to blood thinning. In addition, fish oil supplements have been found to contain varying levels of mercury or pesticides, which, over time, could negatively impact health. To avoid these problems, simply eat more cold water (North Atlantic) fish. Tuna and salmon are excellent sources of omega 3 fatty acids; light tuna (versus albacore) has the least amount of mercury.
Flax seed oil, primarily composed of omega 3 fatty acids and lignans (a type of fiber) is another rich source. Studies have shown that a 30 gram (g) daily dose (between 1 to 3 tablespoons) ease symptoms of rheumatoid arthritis by reducing joint stiffness. Unfortunately the amount of flax seed oil needed to achieve these results comes at a caloric cost of 100 calories per tablespoon (270 calories in 30 g). This is the calorie cost of walking for about 30 minutes!
What’s Missing in Our Diets?
In the last decade, the United States Department of Agriculture (USDA) has published data on food consumption to determine what nutrients Americans may or may not be getting enough of. Data published in 1997 showed that 26 percent of those surveyed consumed less than 75 percent of the vitamin C they needed, while another 15 percent of the population consumed less than 50 percent. Calcium intakes revealed that 44.5 percent of the population surveyed consumed less than 75 percent of the required amount while another 20.7 percent consumed less than 50 percent. Intakes of phosphorus are not as strikingly low but nonetheless, 11.6 percent of the population consumed less than 75 percent and another 3.2 percent ate less than 50 percent. There is no data available for vitamin D consumption (Moskowitz 2000), but what the data on vitamin C, calcium and phosphorus reveal are that a large number of individuals underconsume foods containing vital nutrients for optimal bone growth and cartilage maintenance.
An Opportunity for
From a nutritional perspective, nutrients from food are always the first line of defense for healing or recovery from injury or disease because food contains naturally occurring phytochemicals or plant nutrients that have anti-aging properties and can protect against many chronic
diseases. However, in the case of OA, there is no solid scientific evidence suggesting that vitamins or minerals alone can reduce joint stiffness or pain. Without a doubt, a well-balanced diet offering essential nutrients is key for OA prevention, but therapeutically, more of these key nutrients may not prove beneficial.
On the other hand, dietary supplements such as collagen hydrolysate and glucosamine sulfate may have tremendous potential as therapeutic agents, when accompanied by an energy-balanced diet rich in essential nutrients (Arthritis Foundation 2003).
Currently, numerous studies show that chondrocyte metabolism—which manages the synthesis and degradation of cartilage—can be positively influenced by collagen hydrolysate (Moskowitz 2000; Deal & Moskowitz 1999). In the form of gelatin or gelatin-based products, studies have shown that a daily supplemental dosage of 10 g per day reduces pain in patients with OA of the knee and hip, and that blood levels of hydroxyproline (a marker for cartilage repair) increases. Unlike many anti-inflammatory medications used by OA patients, collagen hydrolysate does not cause gastrointestinal upset characterized by the sensation of bloating, fullness or unpleasant taste.
The Gelita Corporation, the largest manufacturer of collagen hydrolysate is a leader in funding research for the therapeutic management of OA. In studies they funded, conducted at Tufts University’s Center for Clinical and Lifestyle Research by Dr. James Rippe, collagen hydrolysate was used therapeutically in OA patients with knee pain (Rippe 2002). Study results showed improvement in isometric leg strength in the group that used Knox Nutrajoint, an odorless, taste-free powder that can be mixed with any cold or hot beverage. To date, no independent research has been conducted on this product.
Glucosamine and chondroitin sulfate are other agents that researchers believe are effective chondroprotective substances. Found in the body naturally, glucosamine is a form of amino sugar believed to play a role in cartilage formation and repair. Chondroitin sulfate, on the other hand, is a large protein molecule or proteoglycan that gives cartilage elasticity. In the form of dietary supplements, these substances are extracted from crab, lobster or shrimp shells (glucosamine), or animal cartilage such as trachea or shark cartilage (chondroitin sulfate).
Numerous studies have shown that regular use of glucosamine and chondroitin sulfate offers pain relief similar to that offered by anti-inflammatory drugs, such as ibuprofen or aspirin, but minus the gastrointestinal upset that may accompany long-term use of these medications. A daily dose of 1,200 mg has been shown to reduce joint pain in OA patients, however, positive results take 2 to 4 months (Deal & Moskowitz 1999; Towheed 1998). Currently the National Institutes of Health is conducting a long-term, in-depth clinical study on glucosamine and chondroitin sulfate (Arthritis Foundation 2003).
Hope on the Horizon
Dietary supplements are not only considered easy to use, but also are popular in the United States with men and women ages 30 years and above, according to data from USDA surveys (Wilson et al. 1997). Because of this, supplements should be considered an ideal delivery system for ingredients that appear to decrease joint pain and stiffness.
Since Jan Atwood started using a
collagen hydrolysate product, she has reported no pain in her knee. This anecdotal report comes from one client as opposed to a group, so it must be considered “great news” in a cautiously optimistic way. But, as a clinician I am excited and encouraged for all of us by the research on OA and the opportunities today and in the future for joint pain sufferers.
Arthritis Foundation Web site, www.arthritis.org; retrieved on December 2, 2003.
Deal C., & Moskowitz, R.W. 1999. Nutraceuticals as therapeutic agents in osteoarthritis: The role of glucosamine, chondroitin sulfate, and collagen hydrolysate. Rheumatology Diseases in Clinics of North. America, 25, 379-95.
Haq, I., Murphy, E., & Dacre, J. 2003. Osteoarthritis. Postgraduate Medicine Journal, 79 33, 377-83.
James, M.J., & Cleland, L.G. 1997. Dietary n-3 fatty acids and therapy for rheumatoid arthritis. Seminars in Arthritis and Rheumatism, 27, 85-97.
Miller, G.D., et al. 2003. The arthritis diet and activity promotion trial (ADAPT): Design, rationale, and baseline results. Controlled Clinical Trials, 24 4, 462-80.
Moskowitz, R.W. 2000. Role of collagen hydrolysate in bone and joint disease. Seminars in Arthritis and Rheumatism, 30 2, 87-99.
Rippe, J., et al. 2002. A randomized prospective parallel design study to assess the efficacy of Knox Nutrajoint on indices of joint health, physical activity, and quality of life in individuals with mild osteoarthritis of the knee. Unpublished paper prepared for Nabisco, Co.
Towheed, T.E. 1998. Glucosamine sulfate in osteoarthritis: A systematic review. Arthritis Rheumatism, 41, S198.
Wilson, J.W., et al. 1997. Combined results from USDA’s 1994 and 1995 continuing survey of food intakes by individuals and 1995 Diet and Health Knowledge Survey. Agricultural Research Service Food Surveys Research Group. www.usda.gov; retrieved on December 2, 2003.
Following the Food Guide Pyramid can be one of the best ways to prevent osteoarthritis. The following foods provide the body with nutrients that can keep bone and cartilage strong:
- juices: orange, grapefruit, cranberry,
- all citrus fruits such as oranges,
lemons, limes, tangerines, clemen-
tines, grapefruit, strawberries,
blueberries, raspberries (fresh or
- best vegetables: green peppers,
potatoes, tomatoes, broccoli, cabbage
- milk or yogurt
- fortified cereals, egg yolk
Calcium and Phosphorus
- milk or yogurt
- molasses (calcium)
- nuts (phosphorus)
- fortified orange juice or cereals (both)
- oysters and canned
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