Creaking knees, hips and ankles are not always normal aches and pains that come with age, they could be the signs of arthritis, especially in the 50+ population. Arthritis, coming from the Greek word "arthron," meaning a joint, is an inflammatory condition that affects the joints. In the U.S. it is estimated that nearly 10% of the population have some form of arthritis.

The most common forms of arthritis are osteoarthritis (OA) and rheumatoid arthritis (RA). OA accounts for more than half of all arthritis cases in the U.S.; an estimated 20 million Americans, mostly women over the age 45, have it. OA is a degenerative disorder in which the cartilage between the joints wears away. Cartilage is the tissue that covers the ends of bones in a joint. It allows bones to glide over one another, and absorbs energy from the shock of movements, such as walking. In those that have OA the cartilage breaks down, allowing bones to rub together, causing pain, swelling and loss of movement. It is usually age-related and most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips. OA is one of the most frequent causes of physical disability among adults.

RA (from the Latin rheumatisms catarrh) is an inflammatory autoimmune disease that affects the whole body, primarily the joints. It is believed that RA occurs when the body's immune system turns against itself and starts to damage joint tissues. RA causes inflammation and deformity of the joints. According to the Arthritis Foundation, it affects two million Americans and usually strikes in middle age (35- 50 years old). Women are three times more likely than men to develop RA and it can begin very gradually or strike without warning. The first symptoms are pain, swelling and stiffness in the joints and the most commonly involved joints include hands, feet, wrists, elbows and ankles. RA usually affects the same joint on both sides of the body. This means that if the right wrist is involved, the left wrist is also involved. In terms of conventional treatment for arthritis, most treatment options include non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, etodolac, ibuprofen and indomethacin. Topical creams containing capsaicin may also be used for local pain relief.

The treatments for arthritis are not the only options out there, however. With millions of uninsured Americans, the dietary supplement industry has an opportunity to step in and provide other alternatives, which could play a role in the prevention and amelioration of these conditions.


Dietary Supplements & Alternative Therapies
Alternative therapies include a variety of nutritional ingredients such as antioxidants, chondroitin sulfate, glucosamine sulfate, S-adenosyl-methionine (SAMe), vitamin B3 (niacinamide), methylsulfonylmethane (MSM) as well as herbs such as cayenne, nettle, willow, boswellia, autumn crocus and meadowsweet.

Antioxidants: Antioxidants may help prevent the cell damage caused by free radicals, which are highly unstable oxygen molecules that steal electrons from other molecules they encounter. Free radical reactions are probably involved in inflammation, degenerative arthritis and the aging process in general. And evidence is accumulating that antioxidants may help relieve OA and RA. Adequate levels of antioxidants such as selenium and vitamins C and E have been recommended for people with arthritis.

Essential Fatty Acids (EFAs): EFAs fight inflammation by manipulating prostaglandin levels. Gamma linolenic acid (GLA), for example, has shown promising results in some patients. In one study, GLA resulted in a significant reduction in joint tenderness for RA patients1. GLA, found in borage oil, evening primrose oil and black currant oil, is converted by the body to a hormone-like substance called prostaglandin E1, which may account for its ability to reduce inflammation.

In a double-blind trial, 56 patients with active RA received either 2.8 grams daily of GLA or sunflower seed oil (placebo) for six months. At the end of the trial, the GLA group showed progressive improvement in the symptoms of RA 2. In another double-blind, placebo-controlled study, 50 people with RA were randomly assigned to take either 40 mg/kg body weight of fish oil containing 60% omega-3 fatty acids, or placebo daily for 15 weeks. At 15 weeks, the fish oil group showed modest improvement in RA symptoms, joint stiffness and soreness 3.

B-Complex Vitamins: A recent study found that niacin (vitamin B3) might improve joint flexibility and reduce inflammation. Seventy-two patients with OA were randomized for treatment with niacinamide or placebo for 12 weeks. At the end of the study, the niacinamide group reduced their anti-inflammation medications and showed improvement in joint flexibility when compared to placebo 4. Research has also shown that low levels of pantothenic acid (vitamin B5) are inversely connected to increased joint symptoms, in particular RA.

Minerals: (a) Boron-The Rheumatoid Disease Foundation suggests that three milligrams of boron daily may be helpful in treating both OA and RA. Boron is effective in helping bones retain calcium. The herb stinging nettle contains 47 parts per million of boron. This means that a 100 gram serving of stinging nettle could contain more than the recommended amount of boron. (b) Calcium-Research has shown that many people with arthritis have severe calcium deficiencies. To prevent this, supplements that are high in calcium and magnesium, which is needed for proper absorption of calcium, are recommended. Food and herbs high in calcium include alfalfa, licorice, red clover shoots, chamomile, chives, coltsfoot, dandelion, horsetail, meadowsweet, nettle, watercress, cabbage, thyme and basil. Recently, coral calcium has been touted as the best source of providing calcium and magnesium in the desired ratio of 2:1. Vitamin D is also required for the body to utilize calcium. Vitamin D is manufactured in the body with the help of a brief dose of sunshine. A prospective observational study, known as the Framingham study, involving 500 participants (mean age 70 years) found that low intake and low serum levels of vitamin D appear to be associated with an increased risk for progression of OA of the knee5.

Enzymes: Some enzymes have shown promise in alleviating symptoms associated with OA. Bromelain and papain, which are protein-digesting enzymes from pineapple and papaya, have analgesic, anti-inflammatory and swelling-reducing properties. Phlogenzym is a mix of the enzymes bromelain (90 mg), which comes from the stem of the pineapple plant (Ananas comosus Merr.), trypsin (48 mg), which is usually taken from hog pancreas and the antioxidant rutin (100 mg), derived from citrus fruits. The efficacy of phlogenzym was compared to diclofenac in patients, aged 40-75 years, with osteoarthritis of knee joints. Patients received either phlogenzym (2-3 tablets) or diclofenac for three weeks. At the end of the study, reduction in joint tenderness was greater in the phlogenzym group as compared to the diclofenac group6.

Glucosamine and Chondroitin: Both glucosamine and chondroitin are made from animal sources. Glucosamine sulfate (GS) is derived from chitin, a tissue found in shellfish and chondroitin comes from the cartilage of sharks, cows and pigs.

The number one supplement for joint problems is still GS, which is a building block needed for the synthesis and repair of joint cartilage. Clinical studies have shown that GS produces better results than NSAIDs in relieving the pain and inflammation of OA7,8. Results of a three-year, double-blind trial indicated that 1500 mg taken once per day produced significant reduction of symptoms and halted degenerative changes seen by X-ray examination9. GS not only relieved arthritis symptoms but also helped the body repair damaged joints10.

Chondroitin sulfate (CS) is also an important component of the body's natural building blocks found in the proteoglycans of cartilage. CS is a glycosaminoglycan, a polymeric material consisting of repeating glucuronic acid and N-acetylgalactosamine units. Glucosamine on the other hand acts as the building block for the biosynthesis of glycosaminoglycans needed for the formation of proteoglycans that are important constituents of the cartilage.

Studies have shown that a significant amount of CS is absorbable in humans11, and that CS supplementation reduces pain, increases joint mobility, and promotes healing within the joints of people with OA12,13.

A 16-week double-blind study conducted by the U.S. Navy on 34 males with chronic pain and radiographic degenerative disease of the knee found that patients who took the therapeutic combination of CS (1200mg/day), glucosamine hydrochloride (1500mg/day) and manganese ascorbate (226mg/day) experienced significant relief of knee pain but no improvement in function14.

Methylsulfonylmethane (MSM): MSM is a naturally occurring sulfur compound found in a variety of foods, including fruits and vegetables, milk, meat, seafood, eggs, grains, legumes, onions, garlic, asparagus, cabbage, sprouts and broccoli. It is also found in human body fluids and tissues. MSM helps maintain the structure of proteins in the body and aids in maintaining the immune system. It is effective for RA within three or four weeks of supplementation, but takes only a day or two to relieve delayed-onset muscle soreness. In a double-blind study, Ronald Lawrence at the UCLA School of Medicine found that approximately 80% of patients with arthritis who ingested 2250 mg of MSM a day for six weeks showed improvement in their pain symptoms, while those on the placebo experienced on average an 18% improvement at six weeks. Daily dosages of 2-4 grams are recommended.

S-adenosyl-methionine (SAMe): SAMe is a chemical shown to have pain-relieving and anti-inflammatory properties similar to those found in the over-the-counter (OTC) medication ibuprofen. SAMe can be found in Brazil nuts. In a recent meta-analysis of randomized controlled trials of SAMe versus placebo or NSAIDs for the treatment of OA, SAMe was found to be as effective as NSAIDs in reducing pain and improving activity limitation in patients with OA without the adverse effects associated with NSAID therapies15. A two-year trial showed significant improvement of symptoms after two weeks of 600 mg SAMe daily, followed by 400 mg daily thereafter16.

Type II Collagen: There are several types of collagen. The main ones, however, are designated Type I, Type II and Type III. Type II collagen is found predominantly in articular cartilage and is sold in dietary supplements such as BioCell Collagen-II™ (hydrolyzed collagen type II protein) and UC-II™ (not hydrolyzed). UC-II is derived from chicken sternum cartilage and consists of undenatured (native) type II collagen. In a recent study, researchers found that 39% of 54 RA patients treated orally with undenatured (not hydrolyzed) Type II collagen demonstrated significant improvement, while only 19% of 57 RA patients taking placebo showed improvement17.

Hyaluronic acid (HA): HA is a polysaccharide composed of repeating units of N-acetyl-glucosamine and D-glucuronic acid. The main source of HA is rooster combs but another important source of HA is microorganisms grown through a fermentation process. In humans, HA is found in the soft connective tissue and the synovial joint fluid (the fluid secreted by the lining of the joint to nourish and lubricate the joint).

In OA, the concentration of HA is decreased in both the cartilage and synovial fluid. In 1997, FDA approved HA for the treatment of OA of the knee. Clinical studies have shown that intra-articular injections of HA produce rapid pain relief and improved mobility in OA18. Although the exact mechanism by which HA exerts its therapeutic effects in knee OA is not known, research studies suggeste that it may reduce the production of pro-inflammatory mediators, and may enhance proteoglycan synthesis.

Soy Isoflavones: Soy isoflavones have been found to promote healthy bones. Preliminary human studies showed that isoflavones are able to increase bone density in postmenopausal women19. Hormone replacement therapy (HRT) with estrogen or a combination of estrogen and progestins has been recommended for treating osteoporosis. In recent years, isoflavones have emerged as a natural alternative to HRT, for treating osteoporosis. Genistein is the main isoflavone present in soy that appears to bind to the estrogen receptor, and in animal studies appears to be effective in preventing bone loss caused by estrogen deficiency20.

In a recent study, 23 healthy postmenopausal women were randomly assigned to receive either 62 mg isoflavones or placebo daily for four weeks. Both excretion of bone loss markers, and total serum cholesterol and low density lipoprotein (LDL) cholesterol were reduced significantly in the isoflavones group. The study concluded that soy isoflavone supplementation has the potential to reduce the risk of postmenopausal osteoporosis and cardiovascular diseases in women21.

Avocado/Soybean Un-saponifiables (ASUs): ASUs are extracted from a mixture of avocado and soybean oil (in a ratio of either one or two parts of avocado oil to three parts soybean oil). ASUs, when used daily for several months, might help OA, especially OA of the hip and knee. In a randomized, double-blind, placebo-controlled trial researchers in France examined the effect of ASUs on OA symptoms of the hip in 163 patients. Patients were assigned to either 300 mg capsules of ASUs or placebo for two years. At the end of the study, the joint space loss in patients with advanced joint space narrowing was significantly greater in the placebo group than in the ASU group. The study suggested that ASU could have a beneficial effect in people with advanced joint space loss22.


Herbs & Botanicals
Some herbs and botanicals may reduce inflammation and boost the healing process of arthritis. For example, ginger inhibits pain-producing prostaglandins. In fact, a new extract of ginger, Zinaxin, works just like NSAIDs, but without the toxicity, by interfering with the production of a hormone called prostaglandin, which plays a major role in inflammation. Other anti-inflammatory herbs include boswellia serrata, ashwagandha, nettle, turmeric, cayenne, white willow, cat's claw and devil's claw.

Turmeric (Curcuma longa), an orange-colored spice, reduces inflammation. Boswellia serrata, an Ayurvedic herb, has shown good results in reducing inflammation and improving blood supply to the joint tissues. Boswellia contains boswellic acids, which has been shown to reduce symptoms in both OA and RA.

Cayenne pepper or red pepper (Capsicum frutescens) contains capsaicin, a pain-relieving chemical, which triggers the body to release endorphins, nature's own opiates. In one study, capsaicin cream reduced RA pain by more than half and osteoarthritis pain was reduced by about one-third.

Ashwagandha (Withania somnifera) is a small shrub, which grows prolifically in India as well as in parts of northern Africa and the Middle East. The roots and leaves of this plant are used in Ayurvedic medicine extensively to reduce the pain of arthritis23.

Autumn crocus (Colchicum autumnale) contains colchicines that may be helpful for chronic back pain caused by herniated disks. A review of research studies reports that colchicines can relieve pain and muscle spasms associated with disk disease24. Colchicine was suggested to produce dramatic improvement in about 40% of cases of disk diseases25.

Meadowsweet contains salicylates, chemicals related to aspirin, that may account for its reputed ability to relieve the pain of OA.

The use of stinging nettle (Utrica dioica) dates back to the biblical times. Stinging nettle has developed a reputation as a treatment for arthritis.

Willow bark (Salix) is known as the original herbal aspirin. It contains a chemical called salicin, which was transformed into acetylsalicylic acid to make aspirin. Willow bark tea has pain-relieving and anti-inflammatory effects similar to those of aspirin and it even has the tendency to upset the stomach. However, the addition of licorice (Glycyrrhiza glabra) might help treat gastrointestinal problems caused by the willow. NW

About the author:
Yousry Naguib is the manager of new product development for Soft Gel Technologies, Los Angeles, CA. He can be reached at 323-726-0700; E-mail: yousryn@soft-gel.com.

References