Osteoarthritis (OA) is the most common form of arthritis, affecting around 27 million in the United States. It is an inflammatory and degenerative disorder. Injury, mechanical, or biochemical stress on a joint sets a complex inflammatory process in motion that involves damage to cartilage cells (chondrocytes,) bones, synovial fluid, and all other joint tissues. This process, if left unchecked, results in crippling disability and may lead to eventual joint replacement. (Bauman, 2015)
Osteoarthritis manifests as joint pain that worsens with movement and likely will become constant as the disease progresses. Sufferers also have joint stiffness—particularly upon waking and after inactivity. Joint swelling, redness, and warmth are also factors. When joints are no longer cushioned by cartilage, they crack and crunch when moved and range of motion is limited. Muscle weakness from lack of use becomes an issue. Some form knobby growths of bone (bone spurs) near joints– causing more pain and resulting in deformities. (Bauman, 2015)
Some people are more likely to develop osteoarthritis than others. Risk factors include: (Bauman, 2015 except where noted)
- Gender (more prevalent in women)
- Accumulation of AGEs (advanced glycation end products)
- Injury to the joint or history of inflammatory joint disease
- Metabolic or hormonal disorders (like diabetes and hypothyroidism)
- Congenital bone and joint disorders
- Repetitive stressful joint use
- Nutrient-poor diet
- Chronic inflammation
- Genetic predisposition
- Low Vitamin D and sunlight levels (Giles, 2009)
Traditionally, osteoarthritis has been considered a disease of wear and tear. Treatments aim at reducing pain and inflammation, but not at modifying the disease itself. New research is suggesting that much can be done to treat the underlying cause—an unchecked inflammatory response. Research done by Stanford researchers in 2011 has caused a paradigm shift in thinking about OA. Instead of osteoarthritis being an inevitable disease of wear and tear, inflammatory processes are understood to be the drivers and addressing them can prevent, halt, or slow progression. This is a revolutionary change in thinking about OA and makes the lifestyle, nutrition, and supplement approaches to treatment not only relevant but essential. (Goldman, 2011) Epigenetics tells us that we may have a genetic predisposition to a disease process, but we can do a lot to signal to our genes whether to switch on or off that predisposition. A genetic predisposition can be considered the “gun” and inflammation the “trigger.” We can greatly decrease or increase inflammation through our actions. (Bauman, 2015) Early intervention may even prevent osteoarthritis completely. (Goldman, 2011) Inflammation is a natural response of the immune system. The modern SAD diet, poor lifestyle habits, toxins, stress, and genetic susceptibility drive inflammatory diseases. (Hyman, 2010a) Controlling inflammation and targeting nutrition, supplementation, and lifestyle factors aimed at the joints all work synergistically to treat the root cause of osteoarthritis and not just mask the symptoms.
While it is not entirely clear what the initiating event is always, joint injury is often the trigger. What is in agreement is that the degradation starts with the cartilage. The work done at Stanford in 2011 showed that an injured joint elicits an immune response from the body’s immune “complement system.” This is the same process the body would undertake to attack a bacteria or virus. This sets off a “complement cascade” and there is a complex interplay between an orchestra of inflammatory proteins that eventually leads to the formation of protein clusters called MACs (membrane attack complex.) The MACs bind with cartilage cells (chondrocytes) and cause them to secrete even more inflammatory proteins and chemicals—turning the joint itself into a weapon of self-destruction. This complement cascade begins to break down the cartilage. The disintegration of the cartilage then introduces new elements into the joint capsule. One of them, called fibromodulin, reactivates the complement system creating an ongoing siege. (Goldman, 2011)
So, we now know that osteoarthritis is immune related. It is not yet classified as an autoimmune disease, but that could change in the future. Dr. Terry Wahls, in an interview done for the documentary series Betrayal, said:
Over time, we’ve been converting many of our chronic diseases into possibly immune, probably autoimmune, and then definitely autoimmune in nature. I would predict that in another 20, 30 years the vast majority of our chronic diseases will have been reclassified as probably autoimmune in nature.” (O’Bryan, 2016)
The main conventional approaches to OA are anti-inflammatory and pain relieving medications like acetaminophen, NSAIDs (non-steroidal anti-inflammatory drugs,) and corticosteroids. These bring comfort for a time, but do nothing to treat the underlying issue and, unfortunately, have serious side effects that can even make the arthritis worse. NSAIDS cause GI injury and impair healing of skeletal tissues. (Bauman, 2015) They also raise the risk of myocardial infarction and stroke, among many other adverse effects. (Wikipedia, 2016) Acetaminophen is toxic to the liver. Corticosteroids like cortisone injections into the affected joints may provide temporary relief but depress the immune system, contribute to osteoporosis, high blood pressure, Vitamin D depletion, and cataract formation–among many other side effects. (WebMD, 2015)
Dietary approaches aim at reducing inflammation and eating a nutrient dense diet that provides what joint and skeletal tissues need to be healthy. Adopting an anti-inflammatory diet that is rich in colorful plant foods and eliminates gut damaging foods and food sensitivities is key. Fat soluble vitamins like A, D, K1, AND K2 are essential to bone health. Minerals like calcium and magnesium must be sufficient and in balance. The proper ratio of good omega fats needs to be maintained. The ideal ratio of omega 6 to omega 3 is about 4:1. (Bauman, 2015)
Specific foods to avoid include: (Bauman, 2015)
- Nightshades (to see if there is an inflammation and pain reduction) Note: Some researchers go as far to say that nightshades can be a cause of osteoarthritis and that strict elimination of them can bring on full remission. (McFarland, 2013)
- Food allergens and sensitivities (best accomplished through a thorough elimination diet like the Paleo Autoimmune Protocol)
Foods to increase in the diet: (Bauman, 2015)
- Leafy greens
- More fatty fish
- Highly pigmented vegetables and fruits
- High sulfur vegetables
- Probiotic and prebiotic foods
- Bone broths, collagen, gelatin
- Pastured eggs and ghee (if tolerated)
3 Key Nutrients for Managing Osteoarthritis
Vitamin D: Vitamin D is important in osteoarthritis because of the role it plays in bone health. Vitamin D aids in calcium absorption and promotes bone growth and repair. Since the bone under the degraded cartilage in an arthritic joint is also affected, it makes sense that adequate Vitamin D helps support the joint. What is less clear is whether Vitamin D slows the progression of OA in the entire joint. Since Vitamin D plays such a large role in immune system health and bone health, optimizing Vitamin D is vitally important. (Arthritis Foundation, 2015) Vitamin D is very anti-inflammatory and helps alleviate chronic muscle pain—both important for coping with osteoarthritis. (Hyman, 2010b)
The normal target range in lab testing for Vitamin D levels is 20 nanograms per milliliter (ng/ml) to 70 ng/ml. Many practitioners consider 31 ng/ml or above to be adequate. At that level, an individual is 4 times as likely to suffer from autoimmune problems or cancer than someone with optimal levels. Dr. Terry Wahls says 80 ng/ml is an ideal target. (Wahls, 2015) Dr. Hyman recommends a range of 40-60 ng/ml. (Hyman, 2010b)
It is all but impossible to get adequate levels of Vitamin D from food alone. 80-100% of our Vitamin D comes from sun exposure, but we are not getting enough sun. Sunblock blocks 97% of Vitamin D potential from the sun. People in northern climates and those with darker skin are at a disadvantage as well. As we age, our skin becomes less efficient at producing Vitamin D from the sun—an average 70-year-old producing just 25% of what an average 20-year-old would. Studies published in the Journal of Pediatrics recently have shown that 70% of America’s children are deficient. (Hyman, 2010b) Supplementation is vital for most people. Levels should be tested and supplementation should be supervised by a healthcare professional.
Vitamin K2: Vitamin K2 and Vitamin D work together synergistically for bone health. Vitamin D makes calcium absorbable. Vitamin K2 moves that calcium into the bones and keeps it from being laid down in soft tissues like arterial walls—causing arteriosclerosis. Besides improving osteoarthritis outcomes by strengthening bone, K2 deficiencies have been shown to occur with higher rates of osteoarthritis in knee joints and coincide with cartilage lesions. (Misra, 2013) Beyond bone health, K2 deficiency is also linked to some cancers, brain health, cardiovascular health, tooth decay, and susceptibility to infectious diseases like pneumonia. K2 is believed to be commonly deficient in the age of industrial farming. (Mercola, 2011b)
Calcium: Like Vitamin D and Vitamin K2, calcium is integral to bone health. As we have noted above, Vitamin D helps us absorb calcium from supplements and food. Vitamin K helps us move that calcium into our bones and not into arteries and other soft tissues. Magnesium is also crucial for getting calcium into bones properly. The synovial fluid of joints and cartilage naturally contain calcium. Calcifications (hard deposits of calcium) in joints can cause damage to cartilage that then triggers the complement cascade of osteoarthritic joint degradation. 60% of knee joints undergoing replacement have such calcifications. (Harvard Health, 2010) It is vitally important that Vitamins D and K2 are optimized along with calcium to reduce such calcifications and to retain ideal bone strength.
Other nutrients, herbs, and foods to consider in osteoarthritis
Bone Broth/Collagen: Long simmered broths of bones and connective tissues does a world of good. The nutrients in bones and connective tissues that can be extracted through long simmering include:
- Chondroitin sulfate
- Glucosamine sulfate
Collagen has been shown in studies to encourage new cartilage growth. A 2012 study showed that 93% of patients with osteoarthritis of the knees showed significant improvement with collagen supplementation. Note other potent fighters of arthritis are in bone broth as well—including glucosamine and chondroitin. Bone broth also benefits GI health, the immune system, and reduces inflammation (all which impact OA outcomes.) (Progressive Health, 2016)
There are no guidelines for amounts of bone broth to consume or any upper limits. It can be prepared, purchased ready-made (not the same as commercially available “stocks” or “broths”,) or even purchased as a powder and added to foods and drinks in that way. In addition, there are great sources of powdered collagen that can be added to food and drinks as well. Adding collagen and/or bone broths to your daily routine is a great idea for joint health (and much more.)
Omega 3 Fatty Acids: Omega 3 Fatty Acids, like those found in wild fatty fish, flax, pastured eggs, other pastured animal products, and fish oil supplements have been shown to reduce overall inflammation and promote bone health by helping to mineralize bones. (Bauman, 2015) The omega 3 fat DHA is found in bone marrow and enhances bone mineral content. (Mercola, 2010) Best practice is to decrease inflammatory omega-6 sources, increase dietary omega-3 fats to achieve a healthy omega 6 to omega 3 ratio. The ideal 6 to 3 ratio is 4:1. Testing can indicate whether supplementation is suggested. 1-2 grams per day is a therapeutic dose. (Bauman, 2015)
Curcumin: Curcumin, the active and pigmented part of turmeric, is very useful for OA pain control and in prevention/slowing of the disease process. It reduces pain and inflammation by impacting cell signaling and blocking inflammatory pathways. Curcumin blocks COX-2 enzymes that turn on inflammation, pain, and fever. Curcumin can be used instead of NSAIDs, Tylenol, and steroids to fight pain and stiffness. Some studies show curcumin matching or even outperforming other pain medicines. Curcumin is anti-catabolic. Supplementation has shown slowed cartilage degradation by protecting cartilage cells, called chondrocytes. In addition, OA sufferers tend to lose bone faster than it is replaced. Curcumin acts to normalize bone turnover. (Bauman, 2015)
Curcumin is more bioavailable when consumed with black pepper so look for a supplement that provides both. Try 1,500 mg daily for 4-6 weeks in divided doses to see if there is OA symptom improvement. (Bauman, 2015)
Glucosamine: Glucosamine is a naturally occurring compound in cartilage. This why it can be found in bone broth. Glucosamine can be injected into a joint or muscle but is commonly taken orally as glucosamine sulfate. For those with osteoarthritis, glucosamine sulfate has been shown to:
- Reduce pain
- Improve function in knee and hip OA
- Slow the progression of OA
- Reduce joint swelling and stiffness
- Continue to provide symptom relief up to 3 months after supplementation stops
Glucosamine may have an even larger effect on intestinal barrier function than it does on OA. It is fermented by gut bacteria and is used to strengthen the lining of the GI tract. 500 mg three times a day is a therapeutic dose. Relief will not be immediate but will take 2 to 4 months to feel the full effect. If digestive side effects are experienced, take with food. (Bauman, 2015)
For everything you ever need to know about making healing bone broth, head over to my friend the Broth Whisperer.
Type II Collagen: There are 4 types of collagen. I wrote about collagen in general above, but Type II collagen, derived from cartilage, is worth singling out. It is useful in treating all types of arthritis. In OA, it has been shown to be more than twice as effective as glucosamine and chondroitin treatment at decreasing osteoarthritic pain and improving functionality. Type II collagen products aid in reducing the destruction of collagen within the body, may provide anti-inflammatory activity, and may improve joint flexibility. (Crowley, 2009) It is found in bone broth if cartilage is used to make it, but it is worth buying as a supplement to see if it helps when taken in larger doses. 40 mg daily is a good therapeutic dose and side effects are few. (Bauman, 2015)
Bromelain: Bromelain is a proteolytic enzyme. A proteolytic enzyme (also called a protease) is a compound that breaks down proteins. Bromelain, derived from pineapple, is the most studied protease for osteoarthritis. It has significant analgesic and anti-inflammatory effects. It acts by interrupting the inflammatory cascade. (Bauman, 2015) Studies of bromelain with trypsin (another protease) and rutin (an antioxidant) showed to be about as effective as prescription painkillers. (Wong, 2014) A therapeutic dose is 500-2,000 mg per day in divided doses. (Bauman, 2015)
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