Osteoarthritis

Before You Begin Information presented here is for general educational purposes only. Each one of us is biochemically and metabolically different. If you have a specific health concern and wish my personalized nutritional recommendation, write to me by clicking here.

Arthritis refers to inflammation of the joint. There are various forms, including rheumatoid arthritis, an autoimmune disorder that affects primarily young women. Osteoarthritis (OA) is a disorder caused by the wear and tear of joint due to the natural results of aging. OA characteristically affects middle age and elderly populations. 

Over 40 million American have some form of OA, including 80% of those over 50. The disease is more common in men under age 45 and in women over age 45.

This Research Brief examines the current medical thinking on this common and debilitating disease and explores alternative strategies for alleviating osteoarthritis.


Primer on Osteoarthritis (OA)

Osteoarthritis (also known as degenerative joint disease) is the localized degeneration of joint cartilage. It affects mainly the weight-bearing joints (e.g. knee, hip, spine). OA results from the repetitive use of the joints resulting in wear and tear, and from the normal results of aging without precise etiology. This is called primary OA. Secondary OA, on the other hand, could be the result of many factors such as sports injuries, inherited abnormalities in joint structure, continuous repetitive use over a long period of time, trauma, previous inflammatory disease of joints, etc.

OA is caused by the breakdown in the cellular processes that manufacture, maintain, and repair cartilage. Cartilage covers the ends of our bones. It is present in our joints and contains chondrocytes. Chondrocytes manufacture proteins known as proteoglycans that consist of chondroitin and keratin sulfate that are strung on core proteins. The proteoglycans hold joint fluid within the joint and, in conjunction with the joint cartilage, acts as a shock absorber for the body. Repetitive stress or trauma destroys the proteoglycans and collagen matrix (known as glycosaminoglycans (GAG), and inhibit the production of these substances by chondrocytes. This is how OA starts.

OA causes achy pain in the joints, leading to limitation of movement and loss of dexterity. Over time, osteoarthritic joints enter a vicious cycle of progressive deterioration, as the afflicted person tends to use the affected joints less due to pain. Symptoms generally begin in middle age, and by age 60, most people have some degree of OA. Diagnosis is primarily through a thorough history, physical examination, and x-ray findings, although the correlation is not accurate. About 40% of people with the worst x-ray classification for OA are pain-free. There is currently no reliable predictive marker for OA.


Anti-Arthritic Drugs

Modern medicine treats OA with 3 types of drugs:

1. Pain relievers, like aspirin, that primarily act to relieve symptoms of pain.
2. Non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen (Motrinâ), which focus on the relief of symptomatic pain with anti-inflammatory action.
3. Steroidal anti-inflammatory drugs. While these work wonders to provide short to medium-term relief, steroids are not recommended for long-term use.

Side Effects of Drugs

While drugs do help to relieve symptoms of OA, they have numerous adverse side effects, from relatively minor gastric upset, dizziness, and headaches, to severe gastric bleeding and interference with platelet function.

In addition, virtually all drugs used to treat OA have destructive effects on the articular cartilage lining the bones that form the joint that the drug is supposed to help. 

Analgesics, like aspirin, inhibit enzymes involved in the early stages of chondroitin sulfate biosynthesis. NSAIDs suppress proteoglycan synthesis by the chondrocyte. The depletion of chondrocytes further weakens the joint and exposes it to a faster deterioration cycle. Experimental studies show that these drugs inhibit cartilage synthesis and accelerate cartilage destruction. Steroids are the most effective anti-inflammatory agent. However, they can also cause extensive damage to chondrocytes in long-term use. In addition, chronic use of strong steroids leads to conditions that mimic Cushing's Syndrome, with a number of adverse age-accelerating consequences. 

Simply put, most drugs appear to suppress the symptoms, but accelerate the progression, of OA.


Osteoarthritis Supplementation Protocol

Attention Because of tremendous individual variation, the use of nutritionals should therefore be personalized for your body. One person’s nutrient can be another person’s toxin. If you have a specific health concern and wish my personalized nutritional recommendation, write to me by clicking here.

1. Glucosamine
2. Chondroitin Sulfate
3. MSM
4. Bromelain
5. DLPA
6. Collagen Type I and II
7. Sea Cucumber
8. CMO
9. Essential Fatty Acid
10. SAMe
11. Antioxidants - Vitamins C and E

1. Glucosamine Sulfate (GS)

Glucosamine is a simple molecule composed of glucose and an amine. It stimulates the production of glycosaminoglycan (GAG). Without glycosaminoglycan, the collagen matrix loses its gel-like nature and its ability to act as a shock absorber. The body's intrinsic production of glucosamine decreases in some people as a natural result of aging. The inability to produce glucosamine may be a major factor leading to OA. 

Several clinical studies show glucosamine is effective in the treatment of OA. In one study, 252 patients with OA were given either 500 mg of GS or a placebo three times a day for 4 weeks. Patients given GS showed significantly less pain after only 4 weeks of use. Other studies support this finding.

It has been shown the longer the use of GS, the better its therapeutic effect. In one comparative study, GS (1500 mg/day) was compared to a common NSAID called ibuprofen (1200 mg/day). While pain scores decreased faster in the first two weeks in the ibuprofen group, by week four the group receiving GS had improved more than the ibuprofen group. Physicians rated the overall responses as "good" in 44% of the GS treated patients, compared to only 15% in the ibuprofen group. 

How about side effects? In one study of 200 subjects with OA of the knee, GS (500 mg three times a day) was compared to ibuprofen (400 mg three times a day). Consistent with previous studies, the ibuprofen group showed faster pain relief. By the end of the second week, the group taking GS experienced results as good as the group taking ibuprofen. More importantly, only 6% of the GS group suffered mild adverse side effects, whereas 35% of the ibuprofen group experienced side effects.

Long-term use of GS produces better long-term results than NSAIDs as determined in double-blind studies conducted to compare the two. While NSAIDs concentrate on symptomatic relief, GS appears to address the cause of OA. 

In those patients who are obese, or have peptic ulcers or are taking diuretics, the effectiveness of GS is reduced. For these, the amount of GS should be increased. 

The improvement noted with GS lasts for a period of 6-12 weeks after the end of treatment. GS can therefore be taken in cycles of 12 weeks on followed by a few weeks of rest. Given the safety and excellent tolerability of GS, it is also suitable for long-term use for those who need it. 

Nutritional Supplementation consideration: 500 mg - 2000 mg per day.


2. Chondroitin Sulfate (CS) 

Chondroitin Sulfate (CS) is a mucopolysaccharide that contains a mixture of intact or partially hydrolyzed glycosaminoglycans (GAGs). It is a major structural component of cartilage and provides a matrix upon which collagen, the major structural protein of ligaments and tendons, is built. Mucopolysaccharides also add elasticity and resiliency to skin and other connective tissue. Shark cartilage, bovine cartilage extracts, and sea cucumber also contain GAGs. CS is composed of repeating units of derivatives of GS with attached sugar molecules.

Studies have documented the superiority of CG for treatment of osteoarthritis of the knee compared to NSAIDs. Clinical trials using a regimen of both CS and GS together vs. NSAIDs are impressive. It appears that while GS alone is better than CS alone, taking GS and CS together offers significantly greater improvement of osteoarthritis than either used separately. This makes sense from a logical point of view, since glucosamine (a structural building block of chondroitin), plus chondroitin (which stimulates the chondrocytes), should be more effective than either one alone in speeding the regeneration and recovery of articular tissues.

One should note that despite its clinical effectiveness, the exact mechanism of action of CS taken orally is controversial and not fully understood. CS molecules are 50 to 300 times larger than GS, and their absorption in the gastrointestinal tract is only 0-13% compared to 98% for GS. Because of this, some researchers pronounced that oral administration of CS could not have produced positive results. Yet they could not explain why patients showed objective signs of improvement in OA after taking CS in various research studies. 

Nutritional Supplementation consideration: 100 - 500 mg per day.


3. Methylsulfonylmethane (MSM) 

When 70 year old Hollywood star James Coburn suffered from crippling arthritis and found that traditional treatments did not help, he turned to MSM. Within weeks, his pain subsided. Within months, he was virtually pain free. Mr. Coburn returned to an active career and was subsequently awarded an Oscar. Such stories, while sounding too good to be true, are real and cannot be discarded as hoaxes. 

What is MSM? MSM is also known as dimethyl sulfone. The sulfur compound is an element found in the natural diet of all animals. Chemically speaking, it belongs in the same family as oxygen, for in an oxygen-deprived state, sulfur often replaces oxygen as a provider of chemical energy for the sustaining of life. MSM is related to DMSO (dimethyl sulfoxide). It is part of the sulfur-cycle, providing for, and recycling, the sulfur in the world. Green vegetables such as broccoli, cauliflower, garlic, and onions are good sources of MSM.

After ingestion, MSM gives up its sulfur to form the collagen and keratin of the hair and nails and to form the essential amino acids methionine, cysteine, and serum protein.

Sulfur is a critical component in maintaining normal bodily functions. It is an essential dietary element responsible for forming disulfide bonds between certain amino acids and helping to maintain the integrity of connective tissues.

While MSM is commonly found in organic food, fast foods contain very little MSM. Borderline deficiency of MSM is common among Americans.

MSM is a pain-reducing agent. It blocks the transmission of impulses in nerve fibers that carry pain signals. It also decreases pain by altering cross-linked collagen, resulting in less scar tissue. Studies in laboratory animals show that in those whose diet included MSM, there was less degenerative change of the articular joint compared to the control group. 

Nutritional Supplement Consideration: 1000 mg - 4000 mg a day.


4. Bromelain

Bromelain refers to a group of sulfur-containing enzymes that digest protein. It comes from the pineapple plant. Bromelain was first introduced as a therapeutic agent in 1957. Different grades are available. For most indications, the recommended amounts in milk clotting units (mcu) is 1,200 to 1,800 mcu. Absorption from oral ingestion peaks at 10 hours, while detectable levels in the plasma are still apparent after 48 hours. Bromelain's use in OA arises from its anti-inflammatory properties, which include:
a. Inhibition of the biosynthesis of pro-inflammatory prostaglandins.
b. Fibrinolysis activity via the plasminogen-plasmin system. Bromelain breaks down fibrin by stimulating the production of plasmin, which breaks down fibrin, thereby preventing fibrin from producing localized swelling. Plasmin also blocks the formation of pro-inflammatory compounds. 

Bromelain's ability to reduce inflammation has been well documented in a variety of experimental models and clinical studies.

Nutritional Supplement Consideration: 100 - 400 mg. 

5. Phenylalanine (DPLA)

DPLA is an amino acid that is a primary building block for neural transmitters as well as pain control. A significant amount of research has been conducted to support the use of DLPA in relief of back pain, arthritis, aches, pains, and menstrual cramps. The DL form is especially potent in this respect. It slows the body’s break down of endorphins. As a result the body’s internal painkiller will have a longer half-life and therefore pain is reduced. DLPA is also an excellent agent for the control of inflammation and enhances the effectiveness of analgesic medication. Because a diet high in grains and polyunsaturated oil often increase the inflammation response, the use of Dlpaphenyl Alanine should be accompanied by a diet free from safflower oil, sunflower oil, sugar, refined carbohydrate, and fried foods in conjunction to enhanced the inflammatory response. DLPA is often called nature's morphine because of its pain reduction effect.

If you have a condition known as Phenyl Ketonurea then this nutrient is not for you. People with this condition also know as PKU has a genetic defect that cannot break down the DLPA. Interestingly for those people that have this problem their amino acid tyrosine may provide some relief. Because PKU affects only a very small percentage of the people, the majority of the people do not have this problem. To overcome pain depression and fatigue, take 500 to 1500 mg before mealtime can be considered.

Nutritional Supplementation Consideration :  500 to 2000 mg.

6. Collagen type I and  II

There are over 15 types of Collagen and the predominant type of collagen that is present in joints and cartilage is type II. Type II collagen is derived from chicken sternum cartilage from chicks 6-8 weeks old. It contains the greatest number of anti-inflammatory and joints supporting proteoglycan including glucosanine sulfate. Glucosanine a well-known nutrient has been used for 30 years to rebuild in the cartilage in orthopedic joints. Glucosanine sulfate also has a powerful anti-inflammatory effect and supports the joint tissue. Collagen Type II also has the advantage and that it is much more absorbable compared to just ground cartilage. Up to 70% of the type II collagen can be absorbed as compared to 8%. While most people have to take anywhere from 10-15 grams of cartilage in order to get a response Type II collagen intake can be as little as 1-3 grams. In arthritis joints there is a selective destruction of Type II collagen in the joint cartilage itself. Replenishment of this type II cartilage is important. It is also important to add type I collagen to the program because type I is found in the skin and ligaments and it works together well with type II. It also reduces the enzymes attacks on the cartilage itself. Therefore it has a rejuvenation effect as well as reduction and destructive chemistry of the joints in the arthritic process.

7. Sea Cucumber

Sea Cucumber is a marine animal indigenous to the Great Barrier Reef of the coast of Australia. They are a source of whole food of chondroitin sulfate. Sea cucumber is actually not a cucumber but are marine animals related to starfishes and sea urchins. Sea Cucumber has been used by various indigenous cultures for many centuries for treatment of many ailments, including arthritis. They have been used in China for thousands of years as treatment of arthritis and other inflammatory diseases including rheumatoid arthritis and ankylosing spondilysis. It is used in osteoarthritis and has been going on for centuries. Researchers believe the sea cucumber can improve the balance of prostaglandins. Prostaglandins are chemicals that regulate the inflammatory process. Sea Cucumbers also contain substances known as mucopolysaccharides and chondroitins. Half of these are often lacking in people with arthritis and connective tissue diseases. In addition sea cucumber provides vitamins A, B1 (thymine), B2 (Riboflavin), B3 (niacin), and C, as well as minerals such as magnesium and calcium and zinc.

Sea Cucumber significantly relieves joint pains without any side effects. In particular when it is combined with essential oils, glucosamine, sulfate and Cetyl Myristoleate. The Chinese have known of this therapeutic effect for centuries. Clinical studies have shown that supplements of this compound are excellent for arthritis pain and increase joint mobility for up to 60% of the people who take it. The amount of the relief depends on the size of the dosage. Arthritic patients can start with 300 to 400 mg and tapering the dosage once the effects are noticed. Because this is a natural compound and woks it rebuild the joint it is something to be taken slowly over time and not immediately.

8. Cetyl Myristoluate (CMO)

CMO is an all-natural oil found in fish and sperm whale oil, dairy butter, in a small gland in male beavers and circulating in the blood of certain species of research mice. It has been used in the arthritis research by the National Institute of Health in the last 25 years. CMO was discovered by Doctors Biel and May. In their studies they learned that Swiss albino mice that are completely immune to arthritis have a high level of CMO that is not common in other laboratory mice. In human studies, CMO has been proven to be just as effective if given orally. In a double blind clinical study, 431 arthritic patients was given CMO, the results show that 63% percent who took 18grams over 2 months period had improvement of the symptoms; up to 87% improvement. CMO and its related metabolites interrupt the inflammatory response in the cell wall is common, including the cell wall of joints. But the long change fatty acids become incorporated in the lipid layer of the cell walls. They make the walls more resistance against pro-inflammatory enzymes. Studies have shown that the effectiveness of CMO is actually superior to over the counter prescriptions such as a non-steroid of anti-inflammatory drugs. Because of the long chain fatty acids become part of the cell wall structure they stay in the body longer as long as the cell does which can be for years. CMO must be taken consistently for approximately 2 months for it to work well. The time will allow other companion nutrients to work. After 2 weeks some relief of symptoms are usually noticed. A total of 180 capsules is necessary (4-6 per day) containing 100 mg of CMO per capsule is required.


9. Essential Fatty Acids

Fish oil contains Omega 3 fatty acids and has been found to reduce inflammation that is associated with arthritis. Fish oils works by reducing the number of inflammatory messenger molecules made by the body’s immune system. The Arthritis Foundation recommends at least eating 2 fish meals a week – particularly in fatty fish such as salmon, mackerel, and sardines. Unfortunately most fish nowadays are polluted with mercury and extensive intake should be avoided. High quality fish oil supplements are probably the best source of getting the same Omega 3 on board, without the potential toxic metal effects.

Nutritional Supplementation Consideration:  1000 - 10,000 mg of EPA/DHA


10. S-adenolsyl-methione (SAMe)

S –Adenolsyl-Methionine also known as SAMe is a compound made from the amino acid methionine. It has been available by prescription in Europe for years but has been available over the counter in the U.S.A since 1996. It is a wonderful supplement and is a fantastic nutrient for depression and chronic fatigue syndrome, arthritis, and fibromyalgia. SAMe influences the formation of brain chemicals and helps to preserve glutathione, the body’s most important internal antioxidant. SAMe is also involved in the formation of myelin, the sheath that surrounds outer part of nerve cells. As a result of this insulation property most people, taking SAMe, notice an increase of energy, alertness and well-being. SAMe has been used in Europe to treat depression and arthritis for decades. It is a liver enhancer and it helps the liver to function at its best. While it is used for all forms of arthritis it is particularly useful in the case of osteoarthritis.

A group of researchers at the University of Maryland, state that the use of SAMe is just as effective in the relieving of pain in the arthritic joint as compared to a non steroidal inflammatory drug. Furthermore there are no side effects.

Nutritional Supplementation Consideration: 100 to 400 mg a day. SAMe is an expensive nutrient because it is difficult to produce. Alternatives to this including methionine.

11. Antioxidants - Vitamins C , E and Others

Deficiency of vitamin C is common among the elderly, resulting in altered cartilage synthesis and compromised cartilage repair. Studies show that vitamin C, as with vitamin E, protects and enhances cartilage formation. Animal studies show that cartilage erosion is much less in animals kept on high dose of vitamin C. Vitamin E is a strong antioxidant. Clinical trials using 600 IU of vitamin E to treat patients with OA demonstrated significant benefits. Vitamin C and E have synergistic effects. Together, they appear to enhance the stability of sulfated proteoglycan in the collagen matrix.

Vitamin A, Vitamin B6, Copper, and Boron:
These are necessary for the normal production and maintenance of cartilage structure. A deficiency in any one of these would allow accelerated joint degeneration. Supplementation at the appropriate level would promote cartilage repair and synthesis. Boron supplementation (6 - 9 mg a day) has been used in the treatment of OA in Germany since the mid-1970s with impressive results that include arthritis relief in 90% of patients in some studies.

Nutritional Supplement Consideration: 
Vitamin C: 1,000 - 3,000 mg per day
Vitamin E: 400 - 800 IU per day
Vitamin A (in the form of beta-carotene): 15,000 - 25,000 IU per day
Vitamin B6: 50 - 100 mg per day
Copper: 1 - 2 mg per day
Boron: 2 - 6 mg per day

Attention Because of tremendous individual variation, the use of nutritionals should therefore be personalized for your body. Since natural compounds are weak by nature in terms of potency, the right amount needs to be administered. This can often mean from 2 to 5 times or more of suggested dose. One person’s nutrient can be another person’s toxin. If you have a specific health concern and wish my personalized nutritional recommendation, write to me by clicking here.

1. Dietary Considerations: Dietary therapy primarily involves the achievement of the ideal body weight to reduce stress on the joint caused by the extra weight of obesity. Antioxidant rich fruits and vegetables contain important nutrients such as vitamin C that protect against OA. Grains shoujld be avoided.
2. Natural Alternative Supplementation: Promising natural substances include Glucosamine (500 - 2,000 mg per day), Chondroitin Sulfate (100 - 1,000 mg per day), DLPA, SAMe, Sea Cucumber, Collagen Type I and II, Fish oil, MSM (1,000 -4,000 mg per day), and Bromelain (100 - 400 mg per day). Antioxidants (Vitamin C 1,000 - 3,000 mg per day; Vitamin E 400 - 800 IU per day) are valuable adjuncts.  The key is not to take any single nutrient (as large quantity of each is required) but take a complete nutritional cocktail consisting of all of the above to take advantage of the synergistic effect  of natural compounds working together and at the same time avoiding any potential overdose.
3. Physical Therapy: such as heat and hydrotherapy as needed.
4. Drugs: can be considered as last resort if the above fails. 

Message from Dr. Lam I hope you have enjoyed reading this article. If you have areas you don’t understand, comments (good or bad), or if you have a specific health concern, feel free to write to me by clicking here.

About The Author

Michael Lam, M.D., M.P.H., A.B.A.A.M. is a specialist in Preventive and Anti-Aging Medicine. He is currently the Director of Medical Education at the Academy of Anti-Aging Research, U.S.A. He received his Bachelor of Science degree from Oregon State University, and his Doctor of Medicine degree from  Loma Linda University School of Medicine, California. He also holds a Masters of Public Health degree and  is Board Certification in Anti-aging Medicine by the American Board of Anti-Aging Medicine. Dr. Lam pioneered the formulation of the three clinical phases of aging as well as the concept of diagnosis and treatment of sub-clinical age related degenerative diseases to deter the aging process. Dr. Lam has been published extensively in this field. He is the author of The Five Proven Secrets to Longevity (available on-line). He also serves as editor of the Journal of Anti-Aging Research.

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