Supplements, not Substitutes
The goal is for fresh fruits and vegetables to form a major portion of the diet, to be the main course rather than a side dish.

The benefits from fruits and veggies are not derived solely from the vitamins; they can therefore not be obtained from the use of multivitamin pills as a substitute for whole foods.
Fruits and Veggies with Highest Antioxidant Value
Cranberries
Apples
Red grapes
Strawberries
Red peppers
Broccoli
Carrots
Spinach
Other Recap Issues from Nutrition 101
Eat adequate protein – ½ – ¾ gram per pound of lean body weight, depending on activity level
Avoid simple sugar and eat low glycemic index foods
Avoid artificial sweeteners and other additives
Avoid food allergens
Eat organic to the extent possible
Consider reducing or eliminating caffeine

AGE (advanced glycation end-products) and inflammation – dietary intake affects circulating AGEs
PNAS 99(24):15596-601, 2002
Low AGE diet
Animal-derived products, such as cheese, sausage and bacon speed up AGE formation.
Prepare meals under low heat, for least amount of time necessary, and with as much water as possible. Water delays reactions that lead to AGEs.
Boiling, steaming and poaching are preferred to broiling, frying, baking and other high-temperature cooking. Eat vegetables, which are low in AGEs.
Slice meat very thinly and pass it quickly in a frying pan with little oil.
Enhance flavor with spices rather than relying on cooking methods like frying to improve taste

Trans Fatty Acid Intake
Increases insulin resistance, Associated with elevated risk of new onset diabetes.
Positively associated with IL-6 and CRP concentrations in women with higher BMI.

Average consumption in industrialized countries: 4-7% of total dietary fat. (4.7% in Nurses Health Study)
Major sources: fast foods, bakery products, packaged snacks, and margarines.
TFA intake independently predicts CAD and diabetes risks.
TFA intake positively associated with markers of systemic inflammation in women (sTNF-R1and sTNF-R2).
In 19 subjects, soybean margarine diets: 6.7% vs 0.6% Cal from TFAs increased TNF production by cultured mononuclear cells. Mozaffarian D et al: Am J Clin Nutr. 2004;79:606-12

Care and Feeding of the Joints
Spondylosis
Hydrolyzed collagen – Arthred
Collagen is an unusual protein in composition; every third AA is proline.
Hydrolyzed collagen provides raw materials for repair of ligaments and tendons
The dietary equivalent is soup made from bones and gristle and boiled much of the day.
May also have some benefit for prevention of osteoporosis.

Glucosamine Sulfate:
Over 300 studies – 20 are double-blind, placebo controlled
Building block of proteoglycans that make up cartilage
Proven to:
Regenerate cartilage
Reduce cartilage-degrading enzymes
Relieve joint pain – better than LT ibuprofen
Increase joint mobility
Glucosamine Sulfate
o Dose: Up to 3,000mg for 1st 12 weeks
o Maintenance dose: 1,500mg daily of HCL or sulfate form
Side effects: Minimal effect on glycemic control

Chondroitin Sulfate
In 1998 the journal Osteoarthritis and Cartilage published 3 double-blind, placebo controlled studies that documented the effectiveness of chondroitin sulfate for treating arthritis.
In 2000 JAMA reviewed the outcomes of 37 studies on the effects of glucosamine and chondroitin. Chondroitin had a high positive outcome on OA and glucosamine a moderate outcome. (JAMA. 2000:283:1469-1475)

Dose: 400mg. 3x daily
Side effects: Rare GI disturbance
Cost – only 3% of dose may be absorbed as intact chondroitin
Studies are ongoing to establish whether combination of glucosamine and chondroitin is more effective than glucosamine alone

SAMe: S-adenosyl Methionine
Used extensively in Europe for OA and depression
Several double-blind and comparison studies showing it as effective as naproxen and piroxicam for pain relief in OA
Dose recommendation:
Recommended 400mg 3x daily for 3 weeks
Maintenance Dose: 200mg 3x daily
Tip: take with bromelain to improve oral absorption
Drawback: Expensive! May provoke mania.
Contraindications: High serum homocysteine.

Niacinamide:
1996 – niacinamide (500mg 6x daily) significantly improved severity of arthritis and joint mobility .
Increases circulation into the joint
Reduces chemicals that accelerate cartilage damage
Decreases inflammation by reducing cytokines (TNFa)
Dose: 500mg 2-6x daily

Other Dietary Supplements for OA
Foundation Nutrition: Multivitamin/ mineral/ antioxidant/phytonutrient formula
Vitamin D 400 IU per day – or even 4000 IU (watch calcium)
Vitamin E mixed tocopherols 400 IU per day
Probably:
Essential Fatty Acids: Fish oils EPA 1-3g/DHA 400-600mg daily
Calcium/Magnesium 1,000-1,200mg calcium, 400-600mg magnesium
Vitamin C: Ascorbate and/or esterified: 1-3 grams daily

Botanical Therapy – Topical
Counterirritation:
   Rubefacients
   Nettles
Capsaicin – Depletion of Substance P
Dose: 0.025% – 0.075% applied 4 times per day for 2-4 weeks to determine effect

Botanical Medicine for OA
Boswellia: Ayurvedic herb Researched in India to relieve inflammation, joint swelling, and promote joint circulation
boswellic acids in the tree resin counteract the effects of leukotrienes
Increases joint blood supply
Dose: 500mg standardized to 70% boswellic acids 3-5x daily on empty stomach
Curcumin:
Natural anti-inflammatory and anti-oxidant Potentiates cortisol’s ability to reduce inflammation.
Reduces leukotrienes.
Dose: 400mg standardized to 95% curcuminoids 3x daily on empty stomach -though there are no studies of this as a stand-alone supplement (use in combination therapy)
Side effect: dyspepsia
Combine both Boswellia and Curcumin with 1,000 mg bromelain for max. absorption; lecithin may also improve absorption
In one study, Boswellia, Turmeric (Curcumin) were combined with Withania, Zinc and 70% of subjects had a significant decrease in pain and disability

Devil’s Claw
Harpagophytum procumbens (Devil’s claw) – 60 mg harpagoside per day
Primarily analgesic, not much anti-inflammatory activity; in one study was as effective as vioxx for low back pain
Try for 4-8 weeks

Antioxidants in Tendonitis
Osgood-Schlatter: selenium 50 mcg tid, vitamin E 400 IU/d
I have used this with success in plantar fasciitis as well

Tendonitis – Enzyme Therapy
Certain digestive enzymes, when taken between meals, are absorbed systemically and decrease circulating immune complexes, decrease activated complement, etc.
Wobenzym-N has been studied in ankle tendonitis, hand flexor tendonitis, supracondylar fractures in children
We often use bromelain in this way (500 – 1000 mg three times daily between meals)

Cat’s Claw (Una de Gato)
Rainforest herb which decreases inflammation (inhibits lipoxygenase), is also an immune stimulant
Saventaro is a unique extract with higher activity (POA’s only, free of TOA’s)
Has been shown to be effective in OA in the knee and RA.

MSM – Methylsulfonylmethane
Related to DMSO, sulfur source
May act by contributing to methylation cycle and glutathione regeneration
Tiny clinical trials only, appears safe in animal trials
Dose: 3000 – 8000 mg per day
Side effects: Diarrhea

Essential Fatty Acids
Fish oil – 2-3 tsp per day of liquid cod liver oil with EPA and DHA, or 2-3 Tblsp of flax oil
GLA – 500 mg per day, only if already using fish oil
and IL1-Effect on TNF-b Production of Diets Enriched in n-3 Fatty Acids From Vegetable Oil or Fish Oil
Flaxseed oil x 4 wks reduced TNF- and IL1-b production by 30%.
andFish oil x 4 wks reduced TNF- IL1-b 74% and 80% respectively.
Inverse exponential relation between ,TNF- IL1-b production and mononuclear EPA conc.
Caughey GE et al, Am J Clin Nutr. 1996;63(1):116-22.

Depression
Omega-3 Fatty Acids
o After 5 years, switching subjects to a cholesterol-lowering diet in which fish consumption was increased, thus raising w-3 intake, was associated with reductions in measures of depression.
l Ann Intern Med. 117(10):820-3, 1992

Additional Measures For Fighting Inflammation:
Vitamin E with mixed tocopherols, including gamma (inhibits cyclooxygenase).
Vitamin C 1-2 grams per day – reduces pain and need for surgery in patients with low back pain
Possibly vitamin D at high doses: 2000 – 4000 IU per day (monitor calcium when starting this)- down-modulates NF-kappaB
Ginger – inhibits lipoxygenase and cyclooxygenase
Other herbs: grape seed extract, rosemary, green tea, cherry, etc.
Zyflamend 1 cap twice a day

Detoxification Support and Cartilage Protection
“Brief exposure to blood resulted in dose-dependent inhibition of proteoglycan synthesis.The effect was irreversible, independent of IL-1 and TNFa production, and was accompanied by chondrocyte death. These effects were partially prevented by N-acetylcysteine…Brief exposure of cartilage to blood as occurs after a single episode or a limited number of bleeding episodes, results in lasting cartilage damage in vitro, in which cytotoxic oxygen metabolites play a role.”

Roosendaal, G et al. Arthritis & Rheumatism 1999;42(5):1025-1031

Other mechanisms to inhibit inflammation
Cyclooxygenase
Modulated by EPA/AA ratio.
Inhibited by
Indomethacin, aspirin, ibuprofen, acetaminophen (weak), sulfasalazine (topical).
Ginger, tumeric (Curcumin longa), melatonin, green tea, purple grape, thyme, rosemary, cayenne, hops fractions.

Lipoxygenase
(5-LPX, 12-LPX)
Modulated by EPA/AA ratio.
Inhibited by
Sulfasalazine (topical), colchicine (LTB4)
Vitamin E, GSH, quercitin, onion (Allium cepa), garlic (Allium sativa), tumeric (Curcumin longa), Boswellia serrata.