The 4 Pillars Of Joint Health
Let’s start with the bad news, there isn’t a one size fits all practice when it comes to looking after our joints. There also isn’t a golden bullet that will miraculously make our joints feel supple, youthful and pain free. In reality, our joint health is affected by a multitude of factors within our lifestyle and genetic make up.
The 4 key pillars to maintaining good joint health are:
- Diet and Supplementation
- Exercise and Activity
- Weight, Lifestyle and Genetics
- Joint Protection
The good news is this 4 part newsletter series will examine each of these pillars in turn and discuss what measures we an incorporate into our lifestyle to improve our joint health. In this newsletter we will examine Pillar 1, Diet and Supplementation.
But let us start with a bit of background science around joints.
What Are Joints?
A joint is essentially a place in the body where two bones meet, or articulate. Most of our joints are connected together by cartilage which makes the skeleton flexible. Joints allow our body to move in many different ways and allow for bones to glide together efficiently.
There are different types of joints, which are classified by their range of movement:
- Immovable, or fibrous, joints – As you may have guessed, these joints do not permit much movement. There aren’t many immovable joints throughout the body, and they usually occur when we needs stiffness and support in the skeleton. Examples include the pelvis and skull.
- Partially moveable, or cartilaginous joints – These joints have a little more movements. An example are the vertebral bones in your spine are linked together by the cartilage (discs) below and above each bone. This formation gives our spine its flexibility.
- Freely movable, or synovial joints – These joints move in lots of different planes with varying degrees of motion. The shoulder for example is the most mobile joint in the body moving in all directions, whereas the knee is a hinge joint. These joints are filled with synovial fluid which helps the joints move easily and provide lubrication.
Joints are held together by a capsule which stops the bones from moving too far, inside the capsule, there is an inner lining called the synovium. This makes a thick fluid, known as synovial fluid which protects the joint.
The ends of the bones are covered with a thin layer of slippery tissue called cartilage. This acts as a protective cushion, stopping the bones from rubbing against each other.
Your muscles are attached to tendons, which are attached to bones. When we move, our muscles pull the tendons, which then pull our bones in certain directions.
There are three kinds of freely movable joints which play a big part in our voluntary movements.
- Hinge joints – Are as you would expect and allow us to move primarily in one plane. Our knees and elbows are hinge joints because they move forwards and backwards like a hinge.
- Pivot joints – Add a pivot or rotatory element to our movements which allow us to rotate or twist, such as moving our heads from side to side.
- Ball and socket joints – These allow for the most amount of movement. These are found in your hips and shoulders, they have a type of joint which has a round end which fits into the hollow of another bone.
Did you know the elbow is both hinge and pivot joint?
This allows to rotate our forearm as well as bend/straight the elbow.
What Happens To Joints As We Get Older?
We all experience some degree of “wear and tear” in our joints as we age. Although possible, it is unreasonable to assume that our joints will remain prestine throughout our lifespan.
As part of normal life, our joints are exposed to a constant low level of damage. In most cases, our body repairs the damage itself and we do not experience any symptoms.
In osteoarthritis, the protective cartilage on the ends of our bones breaks down, causing pain, swelling and problems moving the joint. Bony growths can develop and the area can become swollen and red (redness can be harder to see on brown and black skin.) The diagram below shows the common arthritic changes that occur and an x-ray comparison of the knee joint.
Although, the exact cause is not known, several things are thought to increase your risk of developing osteoarthritis, including:
- Joint injury – overusing our joints when they have not had enough time to heal after an injury.
- Other conditions (secondary arthritis) – osteoarthritis can happen in joints severely damaged by a previous or existing condition, such as rheumatoid arthritis or gout
- Age – our risk of developing the condition increases as we get older.
- Family history – osteoarthritis may run in families, although studies have not identified a single gene responsible.
- Obesity – being overweight puts excess strain on your joints, particularly those that bear most of your weight, such as your knees and hips.
- Being a woman – osteoarthritis is more common in women than men.
Watch this useful video for more information on the structure and function of cartilage.
Diet and Supplementation
Maintaining a healthy balanced diet is an essential pillar for good joint heath. Fortunately, most of the nutrients and supplements that support joint health also aid bone, muscle and the wider skeletal system.
It is therefore useful to think about our musculoskeletal systems in their entirity rather than just focus on joints. Besides, having stronger bones and muscles can provide stability and protection for our joints.
Several nutritional supplements have shown promise for relieving pain, stiffness and other arthritis symptoms. Some of these natural remedies may offer arthritis symptom relief, especially when you use them in conjunction with traditional treatments.
A recent high level study suggested that supplements provided moderate and clinically meaningful treatment effects on pain and function in certain conditions such as hand, hip or knee osteoarthritis at short term, although the quality of evidence needs to be improved.
It is importance to stress that there is almost no evidence for any supplementation in having a regenerative effect on joints, but they can improve symptoms of joint pain and inflammation. It is more sensible to consider diet and supplementation along with the other pillars as a strategy to maintain a healthy lifestyle as well as looking after your joints.
Calcium and Phosphate
Calcium is an essential element that has numerous biological functions in the body, and one of the most important is skeletal mineralisation.
Calcium makes up the majority of the structure of bones and teeth and allows normal bodily movement by keeping tissue rigid, strong and flexible.
It also helps other tissues mediate blood vessel contraction and dilation, muscle function, blood clotting, nerve transmission and hormone secretion.
In bone, more than 99% of the calcium is bound to phosphate to form crystals (see picture below). These crystal provide the skeleton with strength and structure, also creating metabolic reservoir of calcium to maintain the calcium levels in the body. In other words, if dietary calcium levels are too low, our body does not hestitate to sacrifice our bone structure by breaking it down (known as bone resorption) releasing more calcium into our blood to maintain optimal levels.
Too little calicium in our bones can cause them to become “thin” or “less dense” and develop a condition called osteopenia or osteoporosis. If there is calcium deficiency in the growing skeleton, children may develop a condition called rickets.
Calcium is widely available in many foods, not just milk and other dairy foods. Fruits, leafy greens, beans, nuts, and some starchy vegetables are also good sources.
- Dairy (cow, goat, sheep) and fortified plant-based milks (almond, soy, rice)
- Calcium-fortified orange juice
- Winter squash
- Edamame (young green soybeans)
- Tofu, made with calcium sulfate
- Canned sardines, salmon (with bones)
- Leafy greens (collard, mustard, turnip, kale, bok choy, spinach)
It is also possible to have calcium phosphate via supplementation, but vital to make sure your are not overdosing in calcium.
LBSM Recommendations for calcium dietary intake:
Adults aged 19 to 64 need 700mg of calcium a day.
BEWARE – Taking high doses of calcium (more than 1,500mg a day) could lead to stomach pain, constipation, diarrhoea and nerve issues. Please consult you doctor if you are unsure how much calcium to take.
Vitamin D helps regulate the amount of calcium and phosphate in the body. For those people who perform regular moderate to vigorous exercise it is vital for tissue healing and regenation as well as joint health. In joint cartilage, Vitamin D plays an important part in the production of proteoglycans (a type of protein), as well as helping to maintain a healthy musculoskeletal system.
From about late March/early April to the end of September, most people should be able to make all the vitamin D they need from sunlight. However, people with darker skin do not tend to absorb as much vitamin D.
Vitamin D is also found in a small number of foods. Sources include:
- Oily fish – such as salmon, sardines, herring and mackerel
- Red meat
- Egg yolks
- Fortified foods – such as some fat spreads and breakfast cereals
In the UK, cows’ milk is generally not a good source of vitamin D because it is not fortified, as it is in some other countries.
LBSM Recommendations for vitamin D dietary intake:
Adults aged 19 to 64 need at least 10 micrograms of vitamin D, which is is equal to 400 IU as a minimum
Unlike Calcium and Phosphate, Vitamin D is relatively safe in higher quantities and difficult to overdose on. We recommend 2,000IU a day for all adults and 4,000IU a day for those patients with conditions such as bone injury and fatigue or those with darker skin.
Although water is not strictly speaking a supplement, keeping hydrated is essential to maintain joint function and health. Conversely, dehydration can cause joint pain because of the lubricating effect it has on the joints. It’s estimated that 70 – 80% of your joint cartilage consists of water store in proteins and synovial fluid (which is the lubrication fluid layer located between the joint ends). There is lots of evidence to suggest that dehydration can exacerbate joint stiffness and pain in people with arthritis.
Make sure you keep hydrated throughout the day, and adjust your fluid intake levels when exercising and in hot and humind conditions. Monitoring your wee colour and volume is the most effective way of making sure you are hydrated. Plain water is always the preferred option for maintaining hydration as it doesn’t not include any other preservatives and chemicals that may affect our health negatively.
Glucosamine and Chondroitin
Glucosamine and Chondrotin are natural compounds found in cartilage.
In supplement form, glucosamine is harvested from shells of shellfish or made in a labatory. There are several formulations of glucosamine, including;
- Glucosamine sulfate
- Glucosamine hydrochloride
- N-acetyl glucosamine (less clinical evidence promoting this formulation)
A large National Institutes of Health study in the US called the GAIT trial compared glucosamine and chondroitin, in people with knee osteoarthritis (OA). Glucosamine improved symptoms like pain and function.
LBSM Recommendations for glucosamine and chondroitin dietary intake:
Glucosamine sulfate and chondrotin might provide some pain relief for people with osteoarthritis. The supplement appears to be safe and might be a helpful option for people who can’t take nonsteroidal anti-inflammatory drugs (NSAIDs). While study results are mixed, glucosamine sulfate might be worth a try.
Glucosamine sulfate 1250-1500mg once daily
Chondroitin sulfate 800mg-1200mg, once daily
When taken in appropriate amounts, glucosamine and chondroitin sulfate appears to be safe with minimal side effects.
Recent evidence suggests that sufficient levels of vitamin K is associated with a lower risk of osteoarthritis and other negative joint features. Vitamin K is essential for developing cartilage as it helps calcium regulation. Vitamin K is a strong antioxidant (meaning it can prevent cell damage in your body by interacting with harmful molecules called free radicals which are produced within the cells). In addition, Vitamin K helps the body with blood clotting and wound healing.
Vitamin K is found in:
- Green leafy vegetables – such as broccoli and spinach
- Vegetable oils
- Cereal grains
Small amounts can also be found in meat and dairy foods.
LBSM Recommendations for Vitamin K Dietary Intake:
Adults need approximately 1 microgram a day of vitamin K for each kilogram of their body weight. For example, someone who weighs 70kg would need 70 micrograms a day of vitamin K. (Please note, a microgram is 1,000 times smaller than a milligram (mg). The word microgram is sometimes written with the Greek symbol μ followed by the letter g (μg).)
You should be able to get all the vitamin K you need by eating a varied and balanced diet. Any vitamin K your body does not need immediately is stored in the liver for future use, so you do not need it in your diet every day.
If you do decide to take a Vitamin K supplement, this should be covered in most multivitamins ensuring you do not take too much as this might be harmful.
Taking 1mg or less of vitamin K supplements a day is unlikely to cause any harm.
Curcumin and Tumeric
Curcumin is the active compound in the yellow-hued spice, turmeric, which is a staple of Indian curries. In the body, it acts as a powerful anti-inflammatory agent, blocking the same inflammation-promoting enzyme as the COX-2 inhibitor drug, celecoxib.
Recent studies provide scientific evidence that supports the use of of turmeric extract in the treatment of arthritis to improve pain and swelling of joints.
A 1,500 mg daily dose of curcumin extract was as effective as 1,200 mg a day of ibuprofen, without the gastrointestinal side effects, according to other studies.
LBSM Recommendations for curcumin and tumeric dietary intake:
As a spice
Adding more turmeric to your diet by regularly cooking with the spice is unlikely to have significant health benefits. This is because most recipes containing turmeric call for small amounts of the spice. What’s more, the natural curcumin content of turmeric is relatively low.
As a tea
An alternative to cooking with turmeric is to drink it as a tea. You can make turmeric tea by adding boiling water to freshly grated turmeric root or powder, or by using shop-bought products. The benefit of shop-bought turmeric tea is that it is often prepared specially so that it contains a particularly high concentration of curcumin.
As a supplement
Another efficient way to consume turmeric is to take it as a supplement, in capsule form. Supplements are usually prepared so that they contain high levels of curcumin. Certain supplements also contain black pepper, which is thought to help the body absorb more curcumin.
S-Adenosyl-L-methionine (also called S-adenosyl methionine, S-adenosylmethionine, SAMe, or SAM-e) is a chemical that is found naturally in the body. SAMe was discovered in the early 1950s. It’s made in the body from methionine, an amino acid found in foods. It has been found to regulate key functions in living cells.
Abnormal levels of SAMe in the body have been reported in liver diseases and depression. This prompted researchers to investigate whether SAMe might be helpful in treating these conditions. The idea that SAMe might be helpful for osteoarthritis came from studies of SAMe for depression. Some of the participants in the depression studies who also had osteoarthritis said their joint symptoms improved when they took SAMe.
The results of research on SAMe for osteoarthritis are mixed. Studies in people have compared oral SAMe with nonsteroidal anti-inflammatory drugs (NSAIDs; medicines used to relieve osteoarthritis pain) or placebos (inactive substances) in patients with osteoarthritis of the knee or hip.
- In general, studies that compared SAMe with NSAIDs showed that each had similar pain relief and improvement in joint function, with fewer side effects in the patients taking SAMe.
- The smaller number of studies that compared SAMe with placebo did not consistently show SAMe to be beneficial.
LBSM Recommendations for SAMe intake:
We would advise not taking SAMe unless clinically prescribed by a doctor due to its potential side effect risk and limited benefits.
Fish body oil and fish liver oil are rich in omega-3 essential fatty acids, which can help control your immune system and fight joint inflammation. Fish liver oil is also a rich source of vitamin A (a strong antioxidant) and vitamin D, which are both important for maintaining healthy joints as discusseda bove.
Evidence suggests that fish body oil can improve the symptoms of rheumatoid arthritis. Unconfirmed evidence also suggests a combination of fish body and liver oils might also be useful in the long term, particularly in reducing the use of non-steroidal anti-inflammatory drugs (NSAIDs).
Fish oils are rich in omega-3 essential fatty acids, which have strong anti-inflammatory properties:
- They significantly reduce the release of several elements that play a part in inflammation from your white blood cells.
- They form the building blocks for prostaglandins, which regulate your immune system and fight joint inflammation.
Omega-3 fatty acids also play a role in lowering cholesterol and triglyceride levels in your blood, so they can reduce the risk of heart disease and stroke in people with inflammatory arthritis.
LBSM Recommendations for fish oils dietary intake:
The best way of obtaining fish oils is by eating oily (fatty) fish at least twice per week, but if you don’t eat fatty fish often, you should consider taking a supplement.
Fish body oil is made from tissues of fatty fish like sardines, sprat, salmon, and mackerel. Fish liver oil is made by pressing the cooked liver of halibut, shark or, most commonly, cod. Both types are available from high-street retailers.
Though there are no conclusive recommendations, 250–500 mg per day of combined EPA and DHA of which fish oil is an excellent source is enough for most healthy people.
MSM is rich in organic sulphur, an important ‘building block’ for healthy bones and joints, and it’s very useful for your immune system.
MSM, a sulfure compound found in green fruits and vegetables and meat, is used in the body to maintain and repair connective tissue, and it may have anti-inflammatory properties. The compound used to treat diseases, MSM, is a white crystalline substance that contains 30% sulphur. It also comes in supplement forms which can be bought from the high-street.
Available evidence shows that MSM may have a moderate effect in improving joint pain and swelling as well as general functional wellbeing in people with osteoarthritis. In one trial this effect was greater when MSM was combined with glucosamine.
LBSM Recommendations for MSM dietary intake:
A daily dose of 1,500 mg per day for up to three months is safe. MSM can cause side effects, including allergic reactions.For longer term doses please consult your clinician.
Undentured type II collagen (UC-II)
Collagen is the structural protein in skin, tendons, and bones. Collagen type II is the form in the cartilage lining the joints. Undenatured type II collagen (UC-II) supplements come from the breastbone of chickens. One study showed that UC-11 improved pain, stiffness, and function in knee arthritis better than a placebo, and slightly better than glucosamine and chondroitin supplements. Additional research is needed to confirm whether this supplement is effective for joint health in general.
Pycnogenol, a bark extract of the maritime pine, is thought to have anti-inflammatory properties. A research review found that limited evidence supports trying this for OA for a few months; other studies show improvements in knee OA pain and function when taken at 50 mg two or three times daily for three months. Side effects may include stomach upset and increased symptoms of autoimmune diseases so talk to your doctor before trying it.
This plant extract has been used in Ayurvedic medicine for centuries to treat inflammatory diseases. In studies, proprietary extracts of Boswellia serrata (5-Loxin, Aflapin) temporarily reduced inflammation and pain and disability in knee OA. A systematic review found noteworthy effects in easing OA symptoms, although the quality of the evidence was weak. Minor side effects included nausea, headache, fever, diarrhea, abdominal pain and general weakness.
Willow bark comes from the same type of tree – Salix – that gives us salicylic acid, or aspirin. It’s been used for thousands of years to treat pain and inflammation. Whether willow bark works for OA hard to say, because study results have been mixed or have not shown any improvement compared to placebo. Although its side effects are minimal, willow bark can cause allergic reactions in people who are sensitive to aspirin.
Avocado/Soybean Unsaponifiables (ASUs)
Made of extracts from avocado and soybean oils, these hard-to-pronounce supplements block inflammatory substances that break down cartilage. Some studies found ASUs improved pain, stiffness and joint function in knee and hip OA, although a recent review of studies concluded that the quality of studies was weak and improvements were modest. In certain people, ASUs can trigger an allergic reaction.
Hyaluronic acid (HA) is a polysaccharide (a type of carbohydrate) that is widely distributed in body tissues and is found at high concentrations in the joint synovial fluid, vitreous humor (colorless, gel-like fluid in the eye), and skin. Since HA has a thick and sticky consistency and retains moisture, it helps our joints move smoothly and moisturises the skin.
Some factors that reduce the amount of HA in the body include aging, solar ultraviolet radiation, smoking, and air pollutants. Due to such risk factors, HA supplementation has gained popularity in the health, food, and cosmetic industries.
Hyaluronic acid is commonly injected into certain joints (such as the knee) with good clinical outcomes. Less evidence is avaiable describing it’s use as a supplement for joints.
HA supplementation by mouth was confirmed to be safe at dosages of up to 200 milligrams (mg) per day ingested for periods of up to 12 months.
Before you purchase your supplements…
There are an overwhelming amount of supplements available to purchase, in store and online. Safety must always come first. In the UK, food supplements are regulated as foods by the Food Standards Agency (the FSA) and are subject to the provisions of general food law.
Some considerations when choosing your supplement include:
- Selecting the correct dose and formulation – Be sure you are choosing the correct dose for your requirements. It isn’t always the case that the higher the dose the better and overdosing can sometimes be dangerous. The ease of application is also another factor to take into consideration. Swallowing capsules is not ideal for everyone especially those with digestive issues or insufficiencies for example, so buying supplements in oral sprays, liquids and other topical methods can be an easier option.
- All inclusive formulaes – Some supplements contain individual ingredients, while others, mutliple. Again, it comes down to dosing so be sure to check the individual doses of each ingredient. Some ingredients are best take as an all inclusive preparation (e.g., chondroitin with glucosamine, tumeric with pepper) and can reduce the numbers of supplements you need to take.
- Read the ingredients – If a supplement lists any ingredient you don’t recognise or understand, research them to ensure it’s not an unnecessary additive. Look for clean and pure products with no added sugars, colourings, additives or artificial flavourings. Keep an eye out for allergens too such as gluten, dairy and soy as these can often be used in supplements. It’s particularly important to check for this if you have allergies. Low-quality supplements can also contain additives that block your body from absorbing the active ingredient (the nutrient you want). Often, you can get an indication of the quality of a supplement by checking the ‘free from” information.
- Bioavailability – Bioavailability refers to the amount of nutrients that your body is able to absorb. There are many different forms of nutrients and some are much easier to absorb than others. For example, magnesium is available in many different forms, like magnesium chloride, sulphate, bisglycinate, taurate, or citrate. Some of these are easier to absorb but they can also have different benefits. If you are not sure what formulations are best for you, speak to a healthcare profressional.
- Genetically Modified Organisms (GMOs) – Always avoid anything that has been genetically modified, including your supplements. Not only are GMO products bad for your health, they are not good for the environment and the community. They can require heavy use of toxic pesticides and herbicides including glyphosate which has been linked to many health conditions including cancer and digestive complaints.
- Local Manufacturing – It is recommended to try and buy from local UK based companies. Occasionally, with the larger international brands their products are made abroad and sometimes result poor quality ingredients with potential harmful side effects.
- Consider the cost – Supplements can be really expensive, so look for a price that works for you and, if needed, a price you can afford long-term. There can be a trade-off between the cost and quality of the supplement, so you need to get the balance right.
- Money back guarantee – Companies that stand by their product will usually have a 60 day money back guarantee. These products usually be of better quality. It also gives you the chance to see if the supplement works for you.
So Where Do I Start?
Diet and supplementation is one of the 4 pillars and should not be considered as a one stop intervention to maintain good joint health.
If you are looking for a supplement and don’t know where to start, we would recommend starting with the following combination;
- A health, varied diet rich in Calcium
- Keeping well hydrated throughout the day
- Trying to add tumeric into you diet, or supplementation
- A high quality multivitamin
- Vitamin 2000IU/day/all year (4,000IU/day if medically advised)
- Fish oil supplement/day/all year
- Glucosamine and Chondrotin supplement/day/all year
Try this regime for 3-6 months and see how your joint symptoms feel. Remember its always best to seek professional medical advice around your joint health and supplementation prior to help guide you in the right direction.
In the next series we will look at the positive affects that exercise and physical activity has on our joint health.
See you then!