As I am beginning to incorporate more exercise back into my life after our move and travels the past year, I am reminded of the diagnosis of osteoarthritis in my lower back. I want to share this report I wrote during my certification program as a timely reminder for me as to how to best support this degenerative condition. I hope this can also assist you and those you love as well!
Introduction:
Arthritis is a debilitating condition causing chronic pain and difficulty in mobility in millions of Americans. There are many forms of arthritis. Osteoarthritis (OA) and Rheumatoid Arthritis (RA) are the more common, but included in this condition are also gout, Lyme disease, lupus, psoriatic arthritis, ankylosing spondylitis, Reiter’s syndrome, and Sjogren’s syndrome. Although they all have different characteristics, they all cause pain and inflammation in the joints (where bones connect). (Gottlieb, 2000; Lipsky, 2013)
To understand how arthritis degenerates joints and creates pain, let’s look at the make-up of a healthy joint: (Bauman-a, 2015; Pundak, 2014)
Cartilage is the tough, flexible connective tissue which lines the ends of our bones, enabling them to withstand compression from any angle. It is made up of 65 - 80% water, 10 - 15% collagen fibers, 5 - 10% proteoglycans.
Collagen gives cartilage it’s tensile strength.
Proteoglycans are a combination of protein and sugar molecules that help to trap fluid in the matrix of the cartilage to enable shock absorption.
Chondrocytes are the cells that produce collagen and glucosaminoglycans.
Glucosaminoglycans (aka GAGS) are sulphated, glycosylated proteins (protein and sugar molecules), which keep cartilage and collagen hydrated. Examples are glucosamine, chondroitin, hyaluronic acid, heparins. GAGS prevent crystallization from forming in the joint fluid.
Synovial fluid lubricates the cartilage in the joints to ensure smooth movement, allowing nutrients to move into the joint, and the wastes to move out.
Our skeletal systems are in a constant state of remodeling with cells called osteoclasts which break down bone tissue, and osteoblasts which rebuild the bone cells. Osteocytes are created from osteoblasts, and they are cells that keep track of the state of the skeleton in order to promote osteoclasts for constant improvement in bone structure. (Bauman-a, 2015; Pundak, 2014) When working correctly, movement of the joints provides oxygen and glucose (sugars for energy) into the cartilage, and also increases the production of synovial fluid. Movement also supplies nutrients to the cartilage and removes waste products (specifically carbon dioxide) that build up in the joint. (Pundak, 2014)
Arthritis usually comes on very gradually unless an injury is incurred that damages the joint. The two primary indicators for arthritis are 1) progressive damage of bone cartilage and 2) inflammation within the bone-joint cavity. The process begins with the death of chondrocytes, decreasing the ability to form new collagen as cartilage degrades. When joints begin to break down, osteoblasts try to build more bone, and sharp points on the bones may grow called bone spurs, or osteophytes. Once the cartilage is broken down, there is nothing protecting bone from rubbing against bone which is what causes the excruciating pain of arthritis. It mostly occurs in the hands, wrists, neck, lower back, knees, and hips. (Gottlieb, 2000, Pundak, 2014)
Symptoms:
All types of arthritis cause pain, primarily in the joints. It is usually a gradual degeneration, symptomized by stiffness after rest (especially overnight), pain that worsens on use, and loss of function. As time goes on, symptoms increase and may include: (Lipsky, 2013, Pundak, 2014)
Creaking and cracking joints when moved Warmth
Swelling Inability to grasp
Stiffness Infection
Restricted mobility, loss of flexibility Inflammation
Loss of muscle mass and strength Bone spurs
Causes:
Although some common knowledge believes that arthritis is a normal part of the aging process, nutritionally-oriented physicians are finding there to be a larger nutrition aspect to it than previously thought. Other probable contributing causes are: (Lipsky, 2013, Pundak, 2014)
Genetics Infections Physical Injury
Trauma Surgery Nutritional Deficiencies
Allergies Food Intolerance pH Imbalance
Obesity Chronic Inflammation
Chronic inflammation is now considered a primary cause of many, if not most, chronic illness. In addition to eating too much processed foods and not enough real, clean, whole foods, inflammation is believed to be caused by environmental toxins, stress, persistent infections, and allergens and food sensitivities. All that said, it is mostly believed to be caused by cytokines (cell signalling molecules from the immune system that stimulate the movement of cells towards sites of inflammation, infection and trauma) released in fat cells due to obesity. Chronic inflammation has the ability to damage and destroy DNA and promote oxidation and free radicals. Free radicals will destroy joint cartilage by damaging the joint lining, allowing the protective synovial fluid in the joint to leak out. (Bauman-a, 2015, Pundak, 2013; What are Cytokines, 2016)
Ways to Mitigate - Allopathic Approaches
Many, if not most people experiencing the pain of arthritis turn to over-the-counter and prescription NSAIDs (non-steroidal anti-inflammatory drugs) such as aspirin, ibuprofen, and naproxen, which do help with the pain but that also have serious side effects. According to several sources, thousands of hospital visits and deaths are contributed to NSAIDs each year.
One report from the FDA cited a study done in 2000 (Singh) that stated an estimated 103,000 individuals were hospitalized annually in the United States for NSAID-related gastrointestinal complications, and as many as 16,500 NSAID-related deaths occurred each year in the United States among patients with rheumatoid arthritis and osteoarthritis alone. (Assessment of Safety of Aspirin and Other Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), n.d.)
Ironically, although NSAIDs are the most used drug of choice to treat arthritis, they actually make the arthritis worse over time by accelerating the destruction of cartilage tissue. (Gottlieb, 2000) They also block the prostaglandins required to keep the digestive system lining intact, leading to increased intestinal permeability (also known as Leaky Gut). Problems with prostaglandins can limit the healing process, cause increased inflammation and pain, and impact your overall health. This all leads to a vicious cycle, as Leaky Gut will cause malnutrition, a hyper immune system, and increase the amount of pain that arthritis can cause. (Lipsky, 2013)
Non-NSAID painkillers called analgesics are also used for pain management of arthritis. Paracetamol and opioids such codeine, morphine, and tramadol can only be used for short-term relief as their side effects are also very dangerous including liver toxicity, stomach bleeding, nausea, vomiting, constipation, and a risk of dependency. (Pundak, 2014)
In extreme cases of OA, corticosteroids will be injected directly into the painful joint, offering some relief from the pain, but not providing improvement in the condition. Steroid injection cannot be overdone as their long-term side effects include joint damage, degeneration, weight gain, osteoporosis, stress fractures, and adrenal failure. (Pundak, 2014)
Ways to Mitigate - Functional Approaches
Since osteoarthritis is primarily a condition of inflammation and free radicals, there are many foods and supplements available that support the condition without increasing risk to the health of the arthritis sufferers. Several types of arthritis respond well to improvement in digestive function and osteoarthritis is known to respond well to dietary strategies. (Lipsky, 2013)
It is important in planning any diet for a particular condition to understand the way that nutrition builds and supports the different tissues and functions in the body. In order for your body to build any tissue or regenerate healthy cells, it must be given the appropriate building blocks to do so. This is accomplished through the process of eating the correct healthy and healing foods, living a clean lifestyle, managing your stress and your body weight, and supplementing with appropriate amounts of herbs, vitamins, minerals and other supplements deemed therapeutic for the condition through scientific studies. (Pundak, 2014)
The primary “natural” means to prevent, mitigate, and support OA are to reduce foods that promote inflammation, and to ensure anti-inflammatory and antioxidant foods are a primary part of your diet, add herbs and supplements that reduce inflammation, support cartilage, and manage blood sugar levels. (Pundak, 2014)
Dietary Support for Osteoarthritis:
Although osteoarthritis is not curable, it is manageable through positive diet and lifestyle practices. Probably the most important behavior and dietary change to support osteoarthritis is to avoid “foods” that cause inflammation! (Pizzorno, Murray, & Joiner-Bey, 2008; Pundak, 2014)
Refined carbohydrates as are found in flour and sugar products such as baked goods, breads, pastas, cereals, as well as corn syrup, soft drinks, and low-fat products have had the nutrients and natural fiber stripped from them, giving them a high glycemic load which causes a blood sugar spike (energy rush, then energy crash) with low nutrient content. This are the first and most important food products to avoid, or reduce as much as possible. (Pundak, 2014)
Trans fats are fats that have had hydrogen molecules forced into them to enable the molecules to be more stable at room temperature, allowing for longer shelf life. Unfortunately, there is nothing your body can use these for and they immediately get stored as fats and create free radicals in the body. They are found in products such as margarine, shortening, baked goods, peanut butter, many processed foods, and chips and crackers. Look for “hydrogenated” or “partially hydrogenated” in the ingredient list to identify them. As omega-6 perpetrators, they also stack the odds in the unhealthy, inflammatory omega-6 to omega-3 ratio in our bodies. Be very serious in avoiding these. (Bauman-b, 2015, Pundak, 2014)
Vegetable oils such as corn, soy, canola (rapeseed), safflower, and sunflower, oils should also be avoided. These are the primary sources of inflammatory omega-6 fatty acids. They are often genetically modified, and produced at high heat which cause them to lose their integrity, overdo the omega-6 fatty acids, and can contain toxic chemicals, all of which promote free radicals in the body. Watch for these ingredients in salad dressings and other condiments and fried foods. (Bauman-b, 2015; Pundak, 2014)
Commercial animal products such as beef, dairy, poultry, and farm-raised fish are often grown with unnatural diets, medications, and hormones to keep them healthy (due to their unnatural conditions). These are best avoided as what they consume ends up in your body when you consume them. Look instead for beef that has been grass fed and finished, lamb, bison and wild game, free range organic poultry and eggs, and wild-caught fish. For people suffering from osteoarthritis, it is recommended to limit red meat and all processed meats such as lunchmeat, bacon and sausage. (Bauman-b, 2015; Pundak, 2014)
Limit acidic drinks such as coffee, black tea, soft drinks, high-sugar juices, and alcohol. For different reasons, these all cause bone weakness and loss of bone integrity. (Pundak, 2014)
Preservatives, additives, dyes, colors, and artificial sweeteners (basically all “man-made” foods) are best avoided due to their unnatural nature and our body’s lack of ability to metabolize them into something useful for our cells. (Bauman-b, 2015; Pundak, 2014)
Some people are sensitive to vegetables in the nightshade family. These include tomatoes, white and red potatoes, eggplant, sweet peppers, hot chilis and black pepper. If you are avoiding everything as mentioned above and are still experiencing joint pain from your OA, you should remove these from your diet as well. You may need to eliminate these foods for 4 - 6 weeks before a benefit is noticeable. (Pundak, 2014; Pizzorno, et. al., 2008)
Eating an alkalizing diet is highly recommended to address myriad arthritis conditions. To manage blood pH, minerals are drawn from areas in the body where they can be found. So it stands to reason that when minerals are needed for autonomic essential body functions, they will be taken from places that they are located, namely from the bones and muscles. Some tips to help provide you with an alkalizing diet are: (Lipsky, 2013)
Use quinoa, oats, and wild rice as your primary grains
Use sucanat, molasses, and rice syrup as your primary sweeteners
Steamed greens and daikon radish daily are recommended
Include lentils, miso soup, and yams regularly
Use lemon, lime, and vinegar to flavor your foods
Drink fresh vegetable juices
Antioxidants as found in flavonoids, carotenoids, vitamins A, C, E, zinc and selenium are essential components of an anti-inflammatory diet such as required by those who suffer with OA. This is due to their ability to combat free radicals in the body, providing them with that lone molecule that they need to become well and whole. It’s recommended to get antioxidants from food as much as possible so that your body recognizes them, digests them, and assimilates them the way it is built to do. (Bauman-a, 2015, Pundak, 2014)
Primary Nutrition Support 1:
Omega-3 (ALA/EPA/DHA) fatty acids have been shown to be one of the best nutrients against any type of inflammation, and arthritis is no exception. Alpha-linolenic acid (ALA) as found in flax, chia, hemp, seeds, and walnuts is the precursor to eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Our bodies become less efficient at the conversion as we age, so in addition to eating these foods, I recommend eating fatty cold-water fish such as salmon, sardines, herring, mackerel, halibut, cod, and tuna which provide EPA and DHA directly. (Bauman, 2015) The key is to balance our omega-3 intake with omega-6 fatty acids as listed in the foods to avoid above.
When omega6 and omega3 fatty acids are balanced, it is easier to avoid inflammation, as well as the pain of arthritis. A therapeutic dose of fish oils for osteoarthritis is 1080mg - 1400mg of EPA and 720mg - 1000mg of DHA. It would be very difficult to consume this amount in your diet daily, so supplementation is recommended. The best form of supplements for OA are marine lipids in soft gel form. Look for EPA and DHA amounts specifically (vs. going by the overall fatty acid amount on the label). (Gottlieb, 2000, Pundak, 2014)
Primary Nutrition Support 2:
Vitamin C is considered a primary nutrient for OA. It is a major antioxidant, important for the reconstruction of cartilage and collagen, as well as supporting the immune system. It inhibits the formation of inflammatory prostaglandins which cause pain, inflammation, and swelling. Its antioxidant properties have also been specifically noted as anti-arthritic. For this condition, it is recommended to take 1 to 3 grams daily in ascorbate or ester form. Lipsky also recommends a vitamin C “flush” weekly for four weeks. (Lipsky, 2013)
There are also trace amounts of vitamin C found in sauerkraut (4.8mg), pears (3.8mg), blueberries (3.6mg), flaxseed pancakes (3.0mg), onion (1.3mg), celery (1.2mg), radishes (0.3mg), romaine (0.2mg), and spirulina (0.1mg). (NutritionCalc Plus, 2016)
It is very difficult to receive the therapeutic amounts of vitamin C for OA in your diet, so supplementation as recommended above would be necessary for this condition.
Primary Nutrition Support 3:
Vitamin A found in colorful vegetables is key to an anti-inflammatory and alkalizing diet. It is a powerful antioxidant that helps promote the development of healthy bone and helps reduce the risk of developing OA. (Pundak, 2014) Plant sources provide the precursor to Vitamin A in alpha and beta-carotenes. These sources are generally orange, red, or yellow in color including cantaloupe, carrots, sweet potatoes, bell and chili peppers, apricots and watermelon. Leafy greens, broccoli, and sea greens are good sources as well. Animal sources contain pre-formed vitamin A called retinol, found especially in chicken and beef liver, dairy foods, eggs, and fish liver oils.
The optimal daily allowance of vitamin A for both genders of adults is 6600 IUs retinol, or ~2mg. (1 IU is the biological equivalent of 0.3 mcg retinol, or of 0.6 mcg beta-carotene, but this can vary according to different sources.) (Murray, 2005; How to convert International units (IU) to mcg or mg (n.d.); Bauman-b, 2015)
Additional macro, micro, and phytonutrients that protect from and support Osteoarthritis:
Another antioxidant powerhouse providing cartilage protection, Vitamin E has been shown in many studies to improve osteoarthritis symptoms, including pain relief if taken within a specific amount. Although vitamin E can be found in common foods such as almonds, sunflower seeds, spinach, avocado, peanuts, and asparagus, it is also found in good supply in greens such as chard, turnip, beet, and mustard. Vitamin E can also be found in the omega-3-rich fatty fish! The therapeutic dose of vitamin E for osteoarthritis is up to 800 IUs of the d-alpha form of mixed tocopherols, preferably with high levels of gamma-tocopherols. (Lipsky, 2013; Vitamin E, 2016; Pundak, 2014)
The antioxidant selenium is recommended for the prevention as well as treatment of OA as it blocks free radicals, and it seems to work best with vitamin E. Selenium can be found in Brazil nuts, and almost all meats, poultry, and fish. Just one to three Brazil nuts per day will give you the daily recommended allowance of at least 200mcg of selenium. (Pundak, 2014; Selenium, 2016)
Quercetin is an anti-inflammatory agent found in brightly colored fruits such as berries and cherries as well as in apples, onions and garlic, and brassica vegetables. Several studies have shown that tart cherries and juice assist in the relief of pain due to osteoarthritis. (Pundak, 2014) Quercetin has also been shown to have powerful bone health-promoting effects by actually promoting bone building vs. just slowing bone degradation. According to an article in Life Extension Magazine from September, 2014, “In the management of arthritis, quercetin has demonstrated superior anti-inflammatory properties. When a group of flavonoids was studied, quercetin showed the strongest specific inhibitory effects on the pro-inflammatory enzymes COX-1 and 5-LOX, both of which produce powerful pro-inflammatory signaling molecules in arthritis.” The therapeutic dose of 45mg/day of quercetin for 12 - 16 weeks is suggested to improve pain and function as well as assist in new collagen formation. (Quercetin’s Unique Protective Mechanisms, 2014)
Vitamin D deficiency has been linked to loss of cartilage and osteophyte growth and increased risk of OA of the knee and hip. Vitamin D has been shown to prevent the breakdown of cartilage. Therapeutic approaches are based on lack of overall vitamin D deficiency in the general population, which tends to degrade through the winter months as the angle of the sun becomes so limited that ample D is not available to be made by the body. 1,000 to 2,000 IUs of D can maintain serum D levels, and 4,000 - 5,000 per day can increase them over the course of 2 - 3 months. (Pizorrno, et. al., 2008; Bauman-a, 2015)
B3 (Niacin, Niaciamide) has been found in several studies to assist in joint movement, and reduce inflammation, making it a good vitamin for the relief of OA. Shiitake mushrooms, tuna, salmon, chicken, asparagus, halibut, and venison are all good to excellent food sources of B3. (Pundak, 2014) A 1996 study showed that 500mg 6x/day experienced a 29% improvement in OA symptoms as compared to 10% worsening in the placebo group. Note that the vitamin must be used for at least 3 weeks to enable benefit, and that long-term use may actually slow the progression of the disease. That said, this is a therapeutically high dose of B3, and should be monitored by a doctor as high levels of this vitamin have been shown to cause liver problems in some people. (Bauman-a, 2015)
S-adenosylmethionine (SAMe) is a naturally occurring compound in the body which helps to reduce joint pain, stiffness and swelling while improving mobility and rebuilding cartilage, as well as relieving pain. It has been shown to assist in pain management as effectively as NSAIDs over time. (Bauman-a, 2015) A therapeutic dose of SAMe for OA is 400 - 1200mg/day, and needs to be taken in supplement form. Generally if SAMe is going to work for you, you will see results with a week of taking it, however, it is suggested that you allow for at least 3 months to allow for benefit, as SAMe is also used for the methylation detox pathway for the liver, and if needed for that function, that will take priority of SAMe supplementation before it may assist with pain relief for OA. SAMe is contra-indicated (not recommended) in people suffering from depression, bipolar disorder and Parkinson’s disease. (Pundak, 2014)
Glucosamine and chondroitin are often used together for the relief and prevention of further damage from osteoarthritis. Glucosamine will rebuild cartilage and chondroitin is used to help lubricate cartilage to prevent further breakdown. Studies are mixed for taking these together, with glucosamine alone having a more effective response compared to placebo in most studies, where the addition of chondroitin has had more mixed reviews due to the much larger size of the molecule. Most improvement has been shown with these together for OA of the knee and hand, but over a period of years. Best results for protection against degeneration have been seen with 1,200mg of glucosamine sulfate and (if included) 800mg of chondroitin sulfate daily. (Product Review: Glucosamine, Chondroitin, MSM and Boswellia Supplements for Joint Health, 2016, Bauman-a, 2015)
Studies have indicated that arthritic joints have a lower sulphur content, and Methylsufonylmethane (MSM) is an organic sulfur compound that can be used to remedy this. MSM reduces pain and inflammation by reducing nerve impulses that transmit pain to the brain. MSM studies have shown that 500mg doses 3x/day, increasing to as much as 2 - 4g/day safely reduced inflammation and pain intensity associated with arthritis without side effects for most people. (Pundak, 2014; MSM Supplement Improves Joints, Allergies, and Gut Health, n.d.; Bauman-a, 2015)
Sulphorophane found in the brassica vegetables (broccoli, cauliflower, cabbage, brussels sprouts, kale, and mustard greens) could prevent cartilage from breaking down by blocking the action of cartilage-degrading enzymes. This study is on-going and a therapeutic dose has not yet been determined, however it is thought that perhaps eating one or more of these vegetables every day should assist in providing relief from OA discomfort and provide the necessary minerals and other nutrients such as vitamin C to assist in the rebuilding of cartilage. (Pundak, 2014)
Curcumin, the active ingredient in the spice turmeric is a powerful antioxidant, and can lower two enzymes that cause inflammation. Curcumin is known to break down too easily in the stomach and liver, and has been found to be more bioavailable when consumed with black pepper. (Any recipes with curcumin/turmeric should include black pepper as well.) Curcumin is also known to support the chondrocytes that trigger bone remodeling (Pundak, 2014) Therapeutic doses for curcumin for osteoarthritis are 200 - 500mg 4x/day. (Bauman-b, 2015)
Lifestyle Support for Osteoarthritis:
Proper amounts of exercise for arthritis management cannot be overemphasized as movement is essential to
Keep the synovial fluid moving through the cartilage providing nutrients and removing waste
Prevent falls (and broken bones) by improving balance
Build strength by building muscle, especially with weight resistance training
Stimulate osteocytes which then trigger bone remodeling
Assist with stress management
Some of the best exercises for the skeletal system are weight/resistance training, stretching and weight bearing exercises such as walking and running which have been shown to support the osteoblast process of bone regeneration. Swimming can be beneficial when there is already knee and back pain from this disease to enable less painful movement in those joints. (Pundak, 2014; Bauman-a, 2015)
Hydration is an essential element and simple lifestyle change to protect our joints, as water is the primary element of both synovial fluid and cartilage. It has been found that people with arthritis are often severely dehydrated! You should aim to drink at least half of your weight in pounds in ounces of clean, fresh fluids including water, pure juices, and herbal teas and broths. (Bauman-a, 2015)
Topical treatments such as capsicum (capsaicin) from cayenne pepper, or arnica can be relieving for the arthritis sufferer. Different creams provide different levels of therapy, so you need to follow instructions on the bottle for dosage information. A product containing at least 0.025% to 0.07% capsaicin and applied 3 - 4 times per day has been shown to be of the most benefit. Also, generally speaking, you need to apply this to the joint for 3 - 7 days before experiencing a noticeable result. It is normal to experience a burning sensation on the skin where applied, which usually subsides. (Lipsky, 2013; Bauman-a, 2015)
Alternative approaches to body pain management such as massage and Rolfing, physical therapy, chiropractic and acupuncture are also excellent tools to consider if arthritis does strike. In their own ways, these approaches can really narrow in on areas of concern and pain to offer great relief. (Bauman-a, 2015)
Conclusion:
Osteoarthritis is a degenerative condition that, like many other common chronic conditions related to chronic inflammation can be improved or even prevented by focusing on and making a commitment to practicing corrective nutritive and lifestyle behaviors. When we provide our bodies the building blocks they require to continuously and healthfully remodel our skeletal system, we will do our best to support our structure throughout our lifetime.
A Holistic Nutrition Consultant (NC) can assist you in identifying foods and lifestyles that may be exacerbating your arthritic condition, and will work with you to create healthy anti-inflammatory meals and behaviors to manage your condition.
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