Bone & JointHealth

Bone & Joint Health

by Susan Colebank

Joint inflammation and decreased bone density are only two of the worries attached to advancing age. Currently, 45 million Americans suffer the daily aches and pains caused by joint inflammation and/or brittle bones. With 206 bones and 230 moveable and semi-moveable joints per person, it should come as no surprise the amount of problems that befalls these areas. Some of the most common complaints include osteoarthritis, fibromyalgia, rheumatoid arthritis and osteoporosis.

Osteoarthritis (OA) breaks down cartilage, a bone-like tissue made up mainly of cells known as chondrocytes, and usually targets joints in the neck, lower back, knees, hips and fingers. Joints that were previously injured, exposed to infection or subjected to prolonged heavy lifting are also prone to OA. Research indicates a loss of glycosaminoglycans (GAGs) within the joint and surrounding tissues is the physiological reason behind this disorder. OA affects 12 percent of U.S. adults. Women generally contract OA at a younger age than men, but by age 75, virtually everyone has OA in at least one joint, according to the American College of Rheumatology (ACR).

Fibromyalgia is an arthritis-related condition linked with muscular pain and fatigue; it is often referred to as a syndrome because it is a set of signs and symptoms occurring together. It originates in muscle and soft tissue, and although many patients have no underlying disorder, there are some who develop it who already have some other form of arthritis. The cause of fibromyalgia is unknown, although it may be tied to psychological stress, immune or endocrine abnormalities, or disturbances in the central nervous system, such as skewed serotonin levels. In 1990, ACR legitimized the syndrome by creating a list of criteria for diagnosing the condition, including symptoms such as widespread pain and pain in 11 of 18 tenderpoint sites. Approximately 2 percent of Americans have the disease, and it affects more women than men.

Rheumatoid arthritis (RA) is a chronic disease that can afflict any joint. RA appears to affect mainly the hands and feet, and is accompanied by pain, stiffness, swelling and limitations in mobility. It is an autoimmune disorder characterized by a malfunctioning immune system attacking healthy joints. It typically inflames the lining of the joints (known as the synovium), in addition to internal organs. Jointwise, the synovium can invade and damage bone and cartilage, and inflammatory cells release enzymes that tend to digest bone and cartilage, according to the Arthritis Foundation. This results in the joint losing its shape and alignment.

Researchers do not know the cause of RA. It attacks 1 percent of Americans, with 75 percent of sufferers being women. The onset of RA usually occurs between the ages of 20 and 45, and peripheral problems include energy loss, low-grade fevers, and dry eyes and mouth.

Osteoporosis, on the other hand, affects the bones, which are made up of two types of cells: osteoblasts, which form bone, and osteoclasts, which dissolve bone. This condition attacks the bone, decreasing mass and strength and leading to an increased risk of bone fractures. The condition is characterized by low-energy fractures resulting from inadequate bone mass, which in turn is caused by low bone density and high bone turnover. Osteoporosis is not considered a disease and, in fact, is recognized as a natural, arguably normal, loss of bone mass.

Approximately 10 percent of Americans are affected by osteoporosis, although the number of women who have it is four times greater than that of men. The Arthritis Foundation reported women are at greater risk for osteoporosis because they are born with less bone mass. Although, the National Institutes of Health (NIH) reported 55 percent of the U.S. population ages 50 years and older has low bone mass and faces an increased risk of developing osteoporosis and related fractures.

There are pharmaceuticals that are promoted for relieving pain and improving joint function. Pain relievers include nonsteroidal anti-inflammatory drugs (NSAIDs) and intermittent corticosteroid injections. However, these medications have their downsides. For example, glucocorticoid therapy, while helping with the ravages of RA, induces osteoporosis. The bevy of natural products in the bone and joint health market have fewer side effects, which make them of great interest for sufferers of bone and joint ailments.

Vitamins & Minerals

Arthritis brings with it compromised antioxidant defenses, and what better way to fight free radical damage than with vitamins and minerals? Cases in point: Inflamed joints and impaired antioxidant systems have been implicated in rheumatoid arthritis sufferers,1 as well as in osteoporotic women.2 In addition, vitamin deficiency significantly increases the risk of development of conditions such as cardiovascular disease, obesity and osteoporosis.3

Not all vitamins were created equal in terms of bone and joint health. Vitamin A, in fact, may be a detriment to bone health. Research out of the University of Uppsala, Sweden, indicated that of 2,322 people between 49 and 51 years old, those with the highest retinol levels had the highest risk of hip fracture.4 However, researchers noted the subjects levels of serum beta-carotene, a vitamin A precursor, were not associated with the risk of fracture.

Not all news is bad news regarding vitamin A. Researchers out of Ume University, Sweden, reported plasma levels of retinol were inversely related to factors related to RA.5 And, research out of Seoul, Koreas Hanyang University, indicated RA sufferers have significantly lower levels of vitamin A and beta-carotene.6

The B vitamin family offers multiple options for bone and joint health. In a cross-sectional study of 37 patients who met the ACR criteria for RA, U.S. Department of Agriculture (USDA) researchers found markers of vitamin B6 status were inversely associated with disease activity and severity, synovial burden, and pain in patients with RA.7 According to the researchers, these findings also raised the possibility that impaired vitamin B6 status is a result of inflammation. Vitamin B12 has shown promise in osteoporosis. Researchers from Wageningen University in The Netherlands found that in an investigation of 194 free-living elderly (143 women and 51 men), osteoporosis occurred more often among women whose vitamin B12 status was considered marginal or deficient than in women with normal status.8

Image: Arthritis & Osteoporosis Treaters' Daily Use of Joint-Related Supplements

Of all of the vitamins, vitamin D is most synonymous with being an arthritic natural aid. Research indicates the reason for its large role in bone and joint health is due to the bodys vitamin D endocrine system, a factor in numerous biological activities, including immune dysfunction and metabolic bone diseases.13

Calcium and vitamin D are essential for bone maintenance and for treatment-induced bone augmentation, wrote researchers from Creighton University Medical Center in Omaha, Neb.14 Deficiencies of both nutrients are very common in the age group most afflicted by osteoporosis. Vitamin D appears to aid bone health rather early by helping bar the occurrence of osteopenia, the precursor to osteoporosis.15

According to research out of Italy, BMD is one of the main determinants in the pathogenesis of fractures.16 Researchers found that dietary and serum calcium, as well as serum 25-OH vitamin D (the form of vitamin D that circulates in the body), are the only independent determinants of BMD variations at the lumbar and femoral level, respectively. However, research out of the University of Bonn, Germany, showed the oral dose necessary to achieve adequate serum 25-OH D levels is probably much higher than the current recommendation of 5 mcg/d to 15 mcg/d.17

There is a close relationship between vitamin K and osteoporosis, reported scientists from PUMC Hospital in Beijing.22 They added vitamin K can also effectively inhibit the absorption of bone mass, not only increasing BMD in osteoporotic people, but also reducing fracture rates.

Vitamins are not the only nutrients making a scene in bone and joint healthminerals such as calcium are also making a substantial impact. According to the Washington-based National Osteoporosis Foundation, calcium is essential for many bodily functions, such as regulating heartbeat, conducting nerve impulses, stimulating hormone secretions, clotting bloodand building and maintaining the human skeleton. According to the Natural Marketing Institutes (NMI) Health & Wellness Trends Database, calcium supplements are utilized by 50.2 percent of arthritis treaters, 64.2 percent of osteoporosis treaters and 41.8 percent of the general population.

Calcium, taken at a dose of 1,200 mg/d via high-calcium skim milk, has been seen to be effective in reducing the rate of bone loss over a two-year period at clinically important lumbar spine and hip sites in postmenopausal Chinese women.23 Calcium intake also had the additional benefit of improving serum 25-hydroxy vitamin D status in subjects. Research also indicates calcium and vitamin D are good for RA patients undergoing steroid treatment, which may lead to osteoporosis.24

Coral calcium, which has been the most popular form of calcium in recent times thanks to supplier enthusiasm and effective infomercials, may be another viable form. The present data, though from relatively few study subjects, suggest that the calcium of coral origin is better absorbed from the intestine than calcium of calcium carbonate origin on the average, Japanese researchers reported.25

Although calcium is the big bone mineral, there are some studies that have shown bones benefit from other minerals as welland without a drop of calcium. Cases in point? In research out of France, findings indicated copper increased collagen in OA lab cultures, possibly by upregulating the production of chondrocytes;26 Italian researchers pointed out that the antioxidant effects of manganese protected against the degenerative response in OA;27 and zinc aided osteoporosis by improving bone mineral density in women with RA.28

Other minerals such as magnesium, phosphorus and selenium are also found to be bone-health helpers. Magnesium is the eighth most abundant element in the earths crust and the bones contain approximately two-thirds of the bodys magnesium supply, which is necessary for bone turnover.29 According to NMI, magnesium supplements are utilized by 24 percent of arthritis treaters, 34.2 percent of osteoporosis treaters and 16.1 percent of the general population.

Phosphorus combined with calcium appears to make a great impact on bone status. In a study sponsored by Cranbury, N.J.-based Rhodia Inc., nine groups of weanling male rats were fed a diet providing nine levels of varying calcium and phosphorus levels (using calcium carbonate, dicalcium phosphate or tricalcium phosphate) for 28 days.31 At equivalent levels of calcium supplementation, the two phosphorus-containing salts (both provided by Rhodia) promoted significantly greater improvement in all the bone variables measured, as well as greater body weight gain compared to animals supplemented with calcium only. These results demonstrate both the co-dependence of calcium and phosphorus in bone development and the importance of providing both minerals to support soft tissue and bone growth, the studys authors concluded.

Botanically Derived Ingredients

While many in the vitamin and mineral families are considered antioxidants, so are carotenoids, healthy pigments found in fruits and vegetables. One such carotenoid, beta-cryptoxanthin, may help with RA symptoms; low levels have been found to indicate an increased risk for the disease.34 And, researchers from the National Cancer Institute in Maryland reported those persons in the highest tertile of beta-cryptoxanthin or lutein intake were 70-percent less likely to develop OA of the knee.35 Interestingly, they also found that those in the highest tertile of trans-beta-carotene and zeaxanthin were more likely to have knee OA.

The carotenoid lycopene has a surprising amount of support behind it being a bone-health supporter. In research presented at the 2002 American Dietetic Association Food and Nutrition Conference and Exhibition, lycopene was found to hold certain preventive effects against osteoporosis.36 Researchers found lycopene stimulated parameters in cells that are important for bone formation while at the same time preventing bone resorption. And, researchers out of the University of Toronto explored the hypothesis that lycopene may inhibit mineral resorption by inhibiting osteoclast formation and the production of ROS.37 Cells from a rats femur were treated with varying doses of lycopene in the absence or presence of parathyroid hormone. Results showed that lycopene inhibited the formation of ROS-secreting osteoclasts. Research further indicates that lycopene (from LycoRed Natural Products Industries Ltd., in Beer-Sheva, Israel) may be able to prevent osteoporosis by regulating osteoblast activity.38

According to NMI, soy supplements are utilized by 5.8 percent of arthritis treaters, 8.1 percent of osteoporosis treaters and 4.1 percent of the general population.

Both soy protein and isoflavones have shown promise in this arena, such as in a recent study in which researchers reported the nutrients aided in BMD and bone mineral content (BMC).41 In particular, they noted that in later postmenopausal women, there was a dose-response relationship with increasing higher BMD values associated with increasing soy protein intake quartiles. This study demonstrated that, among women after the initial few years of postmenopause, soy protein/isoflavone intake had a modest but significant association with hip BMD as well as total body BMC, the studys authors concluded.

Research out of Oklahoma State University, Stillwater, indicated soy protein is just as good for mens bones as womens. Healthy men given 40 g/d of soy protein for three months (compared to men given 40 g/d of milk-based protein) experienced increased levels of serum insulin-like growth factor-I, which is associated with higher rates of bone formation.42 (The soy used in this study was from the St. Louis-based Solae Co.)

Researchers from the University of Utah, Salt Lake City, demonstrated in a rat model that soy protein had a beneficial effect on the preservation of BMD associated with estrogen-deficiency bone loss in aged rats.43 And, in another rat model investigating the effects of soy on reversing the earliest stage of osteoporosis, osteopenia, rats given daily soy (as Novasoy from Decatur, Ill.-based ADM) were seen to have decreased bone turnover, although they did not experience a reverse in established osteopenia.44

One isoflavone, daidzein, appears to have a possible role in preventing osteoporosis, particularly in terms of influencing osteoblasts. In a study out of the Peoples Republic of China, daidzein administered in an animal model increased the viability of osteoblasts 1.4- fold, possibly due to its influence on increasing the production of bone morphogenetic protein.45

With all the talk of osteoporosis focusing on females, it is important to remember males in this health area. The isoflavone genistein was seen to prevent bone loss in male mice, and Japanese researchers hypothesized the isoflavone may prevent bone loss by counterbalancing androgen deficiency in males.46

Soy is not the only ingredient with osteoprotective isoflavonesthere is also red clover (Cimicifuga racemosa), which appears to work on a phytoestrogen level to protect against osteoporosis.47 Also, more than one of red clovers isoflavones appears to be at work in promoting bone health. A novel red clover isoflavone preparation (in the form of Novogens Clovone in its product Rimostil), containing genistein, daidzein, formononetin and biochanin, was found to significantly increase the predominantly cortical bone of the proximal radius and ulna after six months of treatment in 46 postmenopausal women.48

Other alternatives to soy isoflavones include ipriflavones, synthetic isoflavones that have been evaluated in terms of bone density in numerous studies. Research has supported the use of this type of isoflavone for the maintenance of bone density.49 According to research collected by Missoula, Mont.-based Technical Sourcing International (TSI), manufacturers of Ostivone ipriflavone, there have been eight double blind, placebo-controlled studies that showed bone-sparing effects with ipriflavone over placebo among a total of more than 850 postmenopausal women.

One of the premier botanicals in arthritis is boswellia. More specifically, its gumguggulupossesses anti-inflammatory and anti-arthritic properties. Studies out of India reported 333 mg/d of boswellia (as WokVel, a registered trademark of Noblesville, Ind.-based Geni Herbs) decreased severity of pain and swelling in knee OA, while those not taking the herb showed an increase.50

Other protective botanicals include Siberian ginseng, ginger and Ginkgo biloba. Siberian ginseng was found to protect against experimental steroid-induced osteoporosis, which was comparable with the synthetic isoflavone-derivative ipriflavone.51 Ginger appears to be beneficial in both its Zingiber officinale and Alpinia galanga forms. In patients with OA of the knee, those taking these ginger forms had a reduction in knee pain while standing and walking.52 And, in a comparison of ginger, ibuprofen and placebo, OA patients reported less pain when taking ginger compared to those taking placebo, although ibuprofen appeared to work the best.53 And ginkgo, when combined with coenzyme Q10 (CoQ10), may help alleviate the symptoms of fibromyalgia.54

While inflammation is the bodys protective response against microorganisms, toxins and allergens, chronic inflammation can be detrimental to tissues. However, scientists believe omega-3s cause a decrease in both degradative and inflammatory aspects of chondrocyte metabolism.55 Interestingly, researchers out of England reported that supplementation with omega-3s appeared to consistently improve RA symptoms and reduce NSAID use.56 According to NMI, omega-3 supplements are utilized by 8.1 percent of arthritis treaters, 10.8 percent of osteoporosis treaters and 7.2 percent of the general population.

Inflammation is not only a factor in RA, but also in OA. The rapid rate of postmenopausal bone loss is mediated by the inflammatory cytokines interleukin-1, interleukin-6 and tumor necrosis factor alpha, wrote Debra Kettler, D.C., from the California-based Sky Park Wellness Center.57 She added that omega-3 fatty acids may blunt the increase of inflammatory bone resorbing cytokines produced in the early postmenopausal years in order to slow the rapid rate of postmenopausal bone loss.

In particular, omega-3 fatty acids contained in ingredients such as flaxseed may aid RA by suppressing the production of inflammatory mediators.58

Although omega-3s are found to be beneficial in arthritis, their cousinsthe omega-6sare usually not. It has been shown that human inflammatory cells contain high proportions of the omega-6 arachidonic acid (AA).59 Data has also suggested that a diet low in the omega-6-to-omega-3 ratio may have beneficial effects on bone mineral density.60 That said, findings from a research review have also indicated that gamma linoleic acid (GLA), an omega-6, may have potential benefits in improving pain associated with RA.61 It may work by suppressing the release of interleukin-1beta, which may protect against the chronic inflammation of RA.62

Of course, not all EFAs come from the plant kingdom. Fish oil supplements, rich in omega-3 PUFAs [polyunsaturated fatty acids] such as EPA [eicosapentaenoic acid] have been claimed as beneficial in RA, possibly by suppression of the immune system and its cytokine repertoire, wrote doctors from Epson General Hospital in England. Some other oils of marine origin (e.g., from the green-lipped mussel) and a range of vegetable oils (e.g., olive oil and evening primrose oil) have indirect anti-inflammatory actions, probably mediated via prostaglandin E1.63

Green-lipped mussel is another marine-based product that can help out with arthritic symptoms. A freeze-dried, stabilized green-lipped mussel powder (as Hong Kong-based Pharmalink International Ltd.s Lyprinol) was found to have significant anti-inflammatory activity, in both humans and animals.64 Green-lipped mussel was found to have bioactive lipids with a greater potency than plant-based oils when ameliorating the signs of inflammation.

Other Bone-and-Joint Builders

One cannot have a complete conversation about alternative remedies in bone and joint health without a discussion on sulfur compounds such as MSM (methylsulfonylmethane) and glucosamine. The benefits underlying MSM may be on par with current arthritic drug remedies. A study out of Ontario indicated aspirin (an NSAID) and MSM may work via the same mechanism of action against the inflammatory response.65 Another study indicated patients taking MSM experienced a 60-percent reduction in pain after four weeks of supplementation, and the average reduction in pain at six weeks was 82 percent.66

Glucosamine is often paired with chondroitin, which is synthesized in both chondrocytes and bone cells. Spanish and Canadian researchers concurred that 800 mg/d of chondroitin sulfate for 90 days reduced pain and met criteria for NSAIDs proposed by the Osteoarthritis Research Society International for symptomatic treatment of knee OA.69 (The chondroitin used in the study was Condrosan/Condrosulf, from Bioiberica in Barcelona.) In particular, research has indicated chondroitin, given at 400 mg/d for a year to 40 patients with osteopenia and OA, significantly improves symptomatic pain as soon as one month after treatment begins.70 (The chondroitin used in the study was Condrosorb from Bioiberica in Barcelona.) However, there were no significant effects on bone density during this treatment.

Together, glucosamine and chondroitin appear to be making a great impact on OA, as well. In a review of studies spanning 33 years, glucosamine and chondroitin sulfate were found to reduce OA symptoms.71 And in findings from a rat model, researchers from Johns Hopkins reported a combination of ingredients, including glucosamine hydrochloride and purified sodium chondroitin sulfate, decreased the severity of autoimmune arthritis.72 Interestingly, one study reported GAGswhich are linked to glucosamine and chondroitinmay promote inflammation in RA.73 Harvard researchers reported there are GAG-binding cells in inflamed synovial tissue in RA patients; these cells, in turn, may promote the inflammation of RA. And, other research has raised questions regarding the efficacy of these ingredients together. In a systematic review of randomized, placebo-controlled clinical trials published between 1980 and 1998, researchers out of the Department of Public Health in Belgium sought to assess the efficacy of glucosamine sulfate and chondroiting sulfate.74 Our study demonstrates the structural efficacy of glucosamine and indistinguishable symptomatic efficacies for both compounds, they wrote. Regarding the relatively sparse data on glucosamine and joint space narrowing and the absence of data on structural effects of chondroitin, further studies are needed to investigate the relationship among time, dose, patient baseline characteristics, and structural efficacy for an accurate, disease-modifying characterization of these two compounds.

Velvet antler also contains hyaluronic acid (HA), which is found in the synovial fluid of both humans and animals, such as chickens.

Nowadays, chicken collagen is a hot ingredient in the joint health market. In particular, Type II chicken collagen, a rope-shaped, fiber-like protein that gives cartilage its structural strength, has been something of an up-and-comer in OA.

In research out of Miami, 16 men and women with OA given naturally occurring Type II collagen, in addition to chondroitin sulfate and HA, had an improvement in symptoms over the placebo group. (The product used in the study, BioCell Collagen II, was produced by Newport Beach, Calif.-based BioCell Technology.) HA is, in large part, responsible for the viscous and elastic properties of synovial fluid, which are critical for healthy joint function. HA appears to have the same ability as chondroitin sulfate to reduce free radical production in collagen-induced arthritis, which is promising news in the lives of RA sufferers.77

Human studies have shown undenatured Type II collagen may alleviate symptoms associated with RA. Several studies have shown significant improvement in symptoms when patients were supplemented with undenatured Type II collagen (as Benicia, Calif.-based InterHealths UC-II), including improved joint mobility and flexibility, reduced joint pain, and in some patients, complete remission of symptoms.78 And, because OA is often characterized by an underlying immune disorder, this nutrient could be useful in reducing inflammation and redness associated with OA.

Another nutrient being compared to NSAIDs is SAM-e (S-adenosyl-L-methionine), a naturally occurring compound that is a methyl donor involved in more than 40 of the bodys biochemical reactions. In a government-funded review of SAM-e studies, researchers from the Agency for Healthcare Research and Quality reported this compound may decrease OA pain compared to placebo. They also reported SAM-e was not found to be better than NSAIDs against pain. However, in research out of Louisiana, SAM-e was found to relieve pain to a similar degree as NSAIDs and with fewer side effects.79 SAM-e has also been seen to benefit fibromyalgia, with the only adverse effects being mild to moderate gastrointestinal complaints.80 According to NMI, SAM-e supplements are utilized by 2.2 percent of arthritis treaters, 2 percent of osteoporosis treaters and .8 percent of the general population.

More alternatives for NSAIDs could be as easy as the nearest enzyme supplement. Papain, in doses of .33 mg/kg and .75 mg/kg, was found to exert strong anti-inflammatory activity and was comparable to butadion and indomethacin, two NSAIDs.81 In addition, the enzyme bromelain was found to reduce symptoms of both OA and RA. In a study of joint health in subjects without arthritis but experiencing mild acute knee pains, 400 mg/d significantly reduced physical symptoms and improved general well-being.82

The natural options for bone and joint health are plentiful, as is the research behind them. The science indicates many of these nutrients convey the same benefits as the medications currently taken to relieve the aches and pains of OA, RA, fibromyalgia and osteoporosis. As consumers experience the benefits of these natural products first hand, sales may one day be on par with those of arthritis medications.

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