Talking about bowel habits is not something we often do but if constipation is affecting your life it can be quite uncomfortable and even upsetting.  Thankfully there are plenty of ways to ease the problem without resorting to pharmaceutical laxatives.  Constipation is usually defined as a change in daily bowel patterns, particularly a decrease in the number or consistency of bowel movements, or pain or difficulty passing stools

Prebiotics and probiotics
Previously (in August) I wrote extensively about prebiotics, probiotics and synbiotics with regards IBS (irritable bowel syndrome).  Unsurprisingly these same agents work very well in the prevention and treatment of constipation.  By positively changing the bacterial makeup of the gut they help to keep the digestive system functioning efficiently.  Prebiotics also act as a source of fibre, which adds bulk to stools and absorbs water to help eliminate waste efficiently and painlessly. 

As you will probably be aware, there are many yoghurts now available on the market which contain both pre-biotics and pro-biotics.  There is evidence from recent trials (1,2) to suggest they are effective in treating constipation.  A recent study (1), published in march, found that consumption of the yoghurt was associated with increased frequency of bowel movements, a reduced perception of straining effort and a reduced perception of pain associated with defecation.

Inulin, a type of prebiotic powder supplement, has been shown to increase the number of good bacteria in the gut as well as reducing constipation better than a traditionally used lactose laxative (3).  A supplement containing both prebiotics and probiotics has also shown good results in the treatment of constipation (4).   Taking a daily symbiotic supplements, those containing prebiotics and probiotics, may well be useful for the treatment and prevention of constipation and the efficient functioning of the digestive system.  There is also emerging evidence, that I have discussed previously, which indicates that a good bacterial balance in the gut may affect the immune system of the whole body, so a daily supplement may help to keep you feeling great!

Artichoke leaf extract
As well as its usefulness in treating IBS, artichoke leaf extract seems to be helpful in alleviating constipation.  One study(5) found that 71% of constipation patients experienced improvement using artichoke leaf extract for 6 weeks.  If you are suffering from this uncomfortable condition you may wish to try an ALE supplement for a few weeks to see if it brings relief and normalises daily bowel habits.

Fibre
Previously I have mentioned how, in the UK, we tend to fall short of the daily recommendations for fibre provision.  Many of us reach only 12g/day, the recommendation is for at least 18g/day with many health professionals recommending around 25g/day.  Fruit and vegetables provide lots of fibre, as well as all the other nutrients packed within them.  We would all do well to reach a minimum of five portions daily.  Fibre provides bulk in the digestive system, this then absorbs water making stools easy to pass and preventing constipation.  A recent study(6) in children found that constipated children had significantly lower intakes of dietary fibre than non-constipated counterparts which was attributable to under-consumption of plant foods.

Regularly eating the recommended portions of a variety of fruit and vegetables may prevent the occurrence of constipation.  Increasing intakes if constipation is already present may also help to ease and clear the problem.  Two studies (7,8) have found that eating a couple of kiwi fruit a day is helpful in the treatment of constipation.

You may wish to consider a supplemental source of fibre as a short term measure for treating constipation.  One source of fibre which seems to be helpful is flaxseeds (9,10).  If you want to try this form of fibre I would recommend buying a ground flaxseed, sometimes called linseed, supplement (or grinding the seeds yourself at home), these are easier on the digestive system and the grinding will also help to release essential omega 3 fatty acids within the seeds which adds to the nutritional benefits.  A table-spoonful of ground flax (about 15-25g) a day will probably help to ease constipation within a couple of days.  A teaspoon a day (around 5g) could be useful in prevention or re-occurrence of constipation and may be particularly useful if you feel your daily fibre intake is habitually low.

Water
Drinking enough (around 1.5L) water daily is important in the prevention and treatment of constipation.  Water is absorbed by fibre in the digestive system and adds bulk to the waste making it easier to pass.  One study (11) found that including 25g of fibre from food in the daily diet was very helpful in treating constipation and that the effect was significantly enhanced by increasing fluid intake to 1.5-2.0 litres/day.  Another study (12) concluded that fluid loss (via diarrhoea and laxative use), fluid restriction, poor hydration and dehydration increased constipation. It is very important to maintain hydration to prevent constipation.

Cow’s milk
Finally I would like to suggest that if your child (up to age 10) is suffering from regular bouts of constipation it may be a good idea to ask your GP to do a test for allergy to cow’s milk.  There are studies (13,14,15) to suggest that chronic constipation occurs as a result of cows milk allergy in some children.  There is also a lot of anecdotal evidence to back this up.  It is very important that you see your GP for the allergy test, never try elimination diets at home without the involvement of a health professional.

(1)De Paula JA et al.  2008.  Effect of the ingestion of a symbiotic yoghurt on the bowel health of women with functional constipation.  Acta Gastroenterol Latinoam.  38:16-25
(2)Sairanen U et al.  2007.  Yoghurt containing galacto-oligosaccharides, prunes and linseed reduces the severity of mild constipation in elderly subjects.  Eur J Clin Nutr.  61:1423-1428
(3) Kleessen B et al.  1997.  Effects of inulin and lactose on fecal microflora, microbial activity, and bowel habit in elderly constipated persons.  Am J Clin Nutr.  65(5):1397-1402.
(4)Amenta M et al.  2006.  Diet and chronic constipation. Benefits of oral supplementation with symbiotic zir fos (Bifidobacterium longum W11 + FOS Actilight).  Acta Biomed.  77:157-162
(5) Gebhardt R.  1996.   Antidyspeptic and lipid-lowering effects of artichoke leaf extract.  Journal for General Medicine.  2
(6)Lee WT et al.  2008.  Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant foods: A community-based study.  J Paediatr Child Health.  44:170-175
(7)Chan AO et al.  2007.  Increasing dietary fiber intake in terms of kiwifruit improves constipation in Chinese patients. World J Gastroenterol.  13(35):4771-5.
(8)Rish EC et al.  2002.  Kiwifruit promotes laxation in the elderly.  Asia Pacific Journal of Clinical Nutrition.  11(2):164.
(9)Cunnane, S. C., et al.  Nutritional attributes of traditional flaxseed in healthy young adults.  American Journal of Clinical Nutrition.  61(1):62-68, 1995.
(10)Dahl, W. J., et al.  Effects of flax fiber on laxation and glycemic response in healthy volunteers.  Journal of Medicinal Food.  8(4):508-511, 2005.
(11) Anti M et al.  1998.   Water supplementation enhances the effect of high-fiber diet on stool frequency and laxative consumption in adult patients with functional constipation.  Hepatogastroenterology.  45(21):727-32
(12) Arnauld MJ.  2003.  Mild dehydration: a risk factor of constipation?  Eur J Clin Nutr.  57(Supplement 2):S88-S95.
(13)Daher S et al.  2001.  Cow's milk protein intolerance and chronic constipation in children.  Pediatr Allergy Immunol.  12(6):339-42
(14)Iacono G et al.  Intolerance of cow’s milk and chronic constipation in children.  New England Journal of Medicine.  339(16):1100-1104, 1998.
(15)Heine RG et al.  2002.  Cow's milk allergy in infancy.  Curr Opin Allergy Clin Immunol.  2(3):217-25

Written by Ani Kowal

Last week I wrote about light box therapy, and other ideas, for improving mood in SAD (seasonal affective disorder).  A more conventional approach to SAD is pharmaceutical antidepressant therapy with, for example, SSRI (selective serotonin reuptake inhibitors) type antidepressants which include fluoxetine (Prozac) and paroxetine (Paxil, Seroxat).  However, these drugs come with certain side effects (including an increased risk of suicide attempts) and their effectiveness has also been questioned.  For these reasons, many individuals seek alternative ways of dealing with low mood.  One well recognised natural agent is the herb St John’s wort (Hypericum perforatum).  Historically this plant has been used as a remedy for the treatment of depression and there is now quite a bank of medical and scientific evidence(1) confirming the effectiveness of this herb for aiding various mood disturbances.

St John’s wort is a shrubby perennial plant with bright yellow flowers, named after St John the Baptist.  Ancient Greeks and Romans believed that the herb could deter evil spirits but today it is mainly used as a natural, alternative to antidepressants.  The herbal supplements are made from the dried flowers of the plant.  The herb has been routinely used in Germany for many years where doctors and health practitioners frequently prescribe supplements for depression.

Very recently a paper was published (1) reviewing the available evidence for the use of St John’s wort in the treatment of depression.  The review included 29 high quality studies (randomised and double-blind) from a variety of countries, the studies included a total of 5489 patients and ranged from 4 weeks to 12 weeks in length.  The researchers found that, for people suffering from mild to moderate depression, St John’s wort can provide effective relief, similar to that of standard antidepressants but with fewer side effects. 

The authors note, and it is important to state, that people suffering from depressive symptoms (including a low mood, loss of interest or pleasure in life and activities) who wish to use a St John’s wort product should ALWAYS consult a doctor.  The quality of products available on the market varies widely and the herb can interact with other medications so it is always best to check with a medical practitioner before embarking on a treatment plan.

The antidepressant properties of St John’s wort are thought to be ascribed to the compounds hypericin and hyperforin that are contained within the herb.  It is not entirely known how the herb works to lift the mood but it seems to act on certain ‘feel-good’ brain chemicals (known as neurotransmitters) such as dopamine, serotonin and noradrenaline.

The typical recommended dose is 300mg of St John’s wort extract three times a day for supplements standardised to contain 0.3% hypericin.  One a day supplements containing 900mcg hypericin are also available.  ALWAYS check with a doctor before taking the herb.  It may take 4 weeks before you see any benefit.  Side effects are uncommon, however in people with fair skin it is advisable to avoid prolonged exposure to sunlight whilst taking the herb.

The herbal supplement also seems useful for the treatment of other mood disturbances such as anxiety, apathy, insomnia, stress and SAD, if you think you could benefit from taking St Johns wort I would suggest chatting with a health professional prior to undertaking a supplementation regimen.
 

(1)Linde K et al.  2008.  St John’s wort for major depression.  Cochrane Database of Systematic Reviews Issue 3. Art. No.: CD000448. DOI: 10.1002/14651858.CD000448.pub3

Written by Ani Kowal

Continuing on from from Part I here are some more ideas for SAD (seasonal affective disorder) sufferers, or for anyone wishing to lift their mood in the autumn and winter months.

Exercise
Numerous studies point toward the general mood enhancing effects of exercise.  A 30 minute walk during the day may help to lift the mood.  Studies specifically investigating SAD have found that light therapy in conjunction with daily exercise seems highly beneficial in reducing SAD symptoms (1,2,3).  There seems to be an apparent additive effect of exercise and light on mood and health-related quality of life in individuals suffering with SAD.  Trying to get out for a lunchtime walk, when the light is at its best in the winter, may really help to lift mood.  Walking with a friend can help motivation and provide time for talking which can help clear the mind.

Vitamin D
A review was published earlier this year (4) which looked at the association between vitamin D and mood disorders in women.  The researchers reviewed published study data and found that there was an association between low vitamin D levels and higher incidences of seasonal affective disorder (as well as major depressive disorder).  The authors conclude that further studies are warranted in order to asses the association in more detail.

I have previously mentioned that in the UK many of us do not get enough vitamin D.  Supplementation with vitamin D may be useful to improve mood in SAD sufferers (5,6).  It has been suggested that the seasonal symptoms of SAD may be due to changing levels of vitamin D3, the hormone of sunlight, and that supplementation with vitamin D may lead to positive changes in brain serotonin levels (a ‘feel-good’ brain chemical).  In one study subjects were given 400 IU, 800 IU, or no vitamin D3 for 5 days during late winter.  Results showed that vitamin D3 significantly enhanced positive feeling and there was some evidence of a reduction in negativity (5).  In another study, 30 days of treatment with vitamin D proved highly effective in resolving depression in a group of SAD sufferers (6).  Taking 400-800IU daily may be helpful to SAD sufferers during the winter months when sunlight is scarce.

Good diet, food cravings and blood sugar balance
Carbohydrate cravings are often reported by individuals suffering with SAD.  This could be due to the fact that carbohydrate increases the uptake of an amino acid (building blocks of protein) called tryptophan.  Tryptophan is used in the synthesis of serotonin, the good mood brain chemical.  If serotonin levels are good then appetite is often normalised and cravings are less likely occur. 

Regulating blood sugar levels with diet may also be helpful to SAD sufferers with disordered eating and cravings.  I wrote about this in more depth on the 8th and 10th of September.  Balancing blood sugar levels through eating a healthy diet that provides a slow and steady supply of energy throughout the day may help to prevent cravings and fatigue.  A diet rich in vegetables and fruits, healthy fats (especially omega 3 fatty acids from oily fish, fish oil or flax seed oil supplements) and proteins (from nuts/seeds, eggs, lean unprocessed meats, fish and pulses/beans) may help to minimise blood sugar imbalances and cravings.  Vegetables and fruits are great sources of unrefined carbohydrates as are wholegrains with a low glycaemic index (GI).  Please read my previous posts for more detail on glycaemic index and eating to minimise cravings.  If you feel that your diet is inadequate you may wish to consider taking an omega 3 fatty acid supplement (a fish oil or flaxseed oil supplement) and a good quality multivitamin-mineral supplement (I prefer ‘food state’ supplements).

Women suffering from the eating disorders bulimia or binge eating disorder may find that their conditions are more difficult to control in the winter time.  There is some indication (7) that light therapy can help minimise these symptoms in autumn/winter and aid mood and carbohydrate craving.  Investing in a light box or daylight alarm clock may prove useful.  For help and information on eating disorders please visit the BEAT website.  BEAT is a charity (the working name for the Eating Disorders Association) for people with eating disorders and their families.

Cognitive behaviour therapy / counselling
Finally, if you feel distressed and unable to cope with the depressive/mood symptoms associated with SAD you may well want to look at a form of counselling called Cognitive Behaviour Therapy to help.  There is indication (8) that this form of therapy is very useful in individuals dealing with SAD and low mood in winter.  For more information and useful links please visit the Royal College of Psychiatrists. 

Wishing you all a happy winter!

(1)Leppamaki S et al.  2004.  Drop-out and mood improvement: a randomised controlled trial with light exposure and physical exercise.  BMC Psychiatry.  4:22
(2)Partonen T et al.  1998.  Randomized trial of physical exercise alone or combined with bright light on mood and health related quality of life.  Psychol Med.  28:1359-1364
(3)Leppamaki SJ et al.  2002.  Bright light exposure combined with physical activity elevates mood.  J Affect Disord.  72:139
(4) Murphy PK&Wagner CL.  2008.  Vitamin D and mood disorders among women: an integrative review.  J Midwifery Womens Health. 53(5):440-6.
(5) Lansdowne AT et al.  1998.  Vitamin D3 enhances mood in helathy subjects during winter.  Psychopharmacology.  135(4):319-323.
(6)Gloth FM et al.  1999.  Vitamin D vs broad spectrum phototherapy in the treatment of seasonal affective disorder.  J Nutr Health Aging.  3:5-7
(7) Lam RW et al.  2001.  An open trial of light therapy for women with seasonal affective disorder and comorbid bulimia nervosa. J Clin Psychiatry.  62(3):164-8
(8)Rohan KJ et al.  2007.  A randomised controlled trial of cognitive behaviour therapy, light therapy and their combination for seasonal affective disorder.  J Consult Clin Psychol.  75:489-500

Written by Ani Kowal

Dwindling sunlight and wintry weather may leave some of us feeling a little less positive and uplifted than we would like.  This shift in mood is common, but for some individuals a real sense of depression can occur in the autumn and winter months.  In such cases Seasonal Affective Disorder, or SAD as it is commonly known, may be diagnosed. 

People with SAD frequently suffer sleep disruption, carbohydrate cravings and weight gain, depression, irritability, loss of libido, lethargy, joint pain, stomach problems and often find that their ability to cope seems to be lowered.  Treatment aims to lift mood and relieve depression.  You will be pleased to hear that there are some simple steps that can be taken to help.

Last week I mentioned The Sunlight Campaign being run by the National Osteoporosis Society which aims to highlight the importance of getting out in the sunlight in order for the body to manufacture vitamin D which is crucial for bone health (and many other health parameters!).  Today I wanted to look at the link between sunlight and mood.

The changing seasons can affect our mood and behaviour, this is a natural process that can clearly been seen in animals – and we are no exception.  Many of us will find that we want to eat a little more and sleep a little more in the winter and that the dark mornings and short days are not to our liking.  For some people these kinds of symptoms are severe enough to disrupt normal daily life and cause real distress.  These individuals are said to suffer from SAD.  SAD is characterised by episodes of depression in autumn/winter and is thought to be caused because of lack of daylight.  Our bodies have an internal 24hour clock or cycle, known as the circadian rhythm.  This cycle of day-night is affected when the daylight hours shorten in autumn/winter.  Sunlight is known to affect certain mood chemicals in the brain such as serotonin and melatonin, if there is less light then less serotonin is produced and this may lead to low mood.

Light therapy
Bright light appears to immediately have an effect on mood via the brain chemical serotonin and the pathways involved in its production (1,2,3).  There have been many studies (too many to list), which show the beneficial effects of light therapy for those suffering with SAD.  Light boxes are available to buy online and in stores and do make a real difference.  Make sure that you follow the manufacturers instructions and if you are also seeing a doctor work with them in order to gain maximum benefit.  Most people find that morning use of the light box, for between 30 minutes to an hour, is most helpful.  The light emitted from these units has a similar spectrum to daylight (it is thought hat the light needs to be at least 2,500 lux in order to be beneficial).  Daylight bulbs are also available to buy.

Bright light may actually help us all in the winter.  A study carried out in the year 2000 (4) found that bright light improved vitality and mood among people with SAD but also in healthy subjects with no SAD but who worked indoors during the winter.  This does not surprise me, if you work indoors during the winter months you are more than likely to arrive at work while it is dark, sit in the office in false light and leave when it is dark outside thus never seeing natural daylight.  Getting out for a lunchtime walk or buying a small daylight lamp unit to sit on your desk at work may make a real impact on your mood.

Dawn simulation
Some studies (5,6,7)  have now been carried out with dawn simulators for SAD.  These simulators (daylight alarm clock) are now widely available to buy and usually consist of a unit with a light that gradually increases in intensity over a 30 minute period until it is at it’s brightest when an alarm usually sounds.  The thinking behind the sunrise alarm clock is that in the winter we often wake up with a start when the alarm goes off, but it is still very dark outside.  Our bodies awake with a shock and then we turn on a bright light, we miss the normal cues to the body that occur with dawn and increasing light.  If we wake up with gradual, dawn light our circadian rhythm / natural body clock, is less disrupted.  The studies have proved very positive with some indication that the dawn simulation sunrise alarm clocks, are as good as light boxes at helping mood in SAD sufferers.

Check back later in the week for more information on SAD.

You may also wish to contact the the 'Seasonal Affective Disorder Association' a registered charity which informs the public and health professions about SAD and supports and advises sufferers of the illness.

(1)Grass F & Kasper S.  2008.  Humoral phototransduction: light transportation in the blood, and possible biological effects.  Med Hypotheses.  71:314-317
(2)Aan het Rot M et al.  2008.  Bright light exposure during acute tryptophan depletion prevents a lowering of mood in midly seasonal women.  Eur Neuropsychopharmacol.  18:14-23
(3)Hoekstra R et al.  Effect of light therapy on biopterin, neopterin and tryptophan in patients with seasonal affective disorder.  Psychiatry Res.  120:37-42
(4)Partonen T & Lonnqvist J.  2000.  Bright light improves vitality and alleviates distress in healthy people.  J Affect Disord.  57:55-61
(5)Terman M & Terman JS.  2006.  Controlled trial of naturalistic dawn simulation and negative air ionization for seasonal affective disorder.  Am J Psychiatry.  163:2126-2133
(6) Avery DH et al.  2001.  Dawn simulation and bright light in the treatment of SAD: a controlled study.  Biol Psychiatry.  50:205-216
(7)Avery DH et al.  1993.  Dawn simulation treatment of winter depression: a controlled studyAm J Psychiatry.  150:113-117

Written by Ani Kowal

On Monday I wrote generally about bone health.  Today I wanted to highlight the relatively recent research linking various B vitamins to bone health and strength. 

Scientists have been interested in preventing heart disease with the use of B vitamins for a while now.  This stems from the mounting research which suggests that elevated homocysteine levels are a risk factor for heart disease.

Homocysteine is produced when the amino acid (the building blocks of protein) methionine is broken down in the body.  Normal levels of homocysteine are important to help build and maintain body tissues, however elevated concentrations in the blood can be harmful and have been associated with an increased risk of heart disease and other disorders.  At normal levels homocystein can be converted in the body into a harmless substance called cystanthionine.  The conversion of homocysteine into this harmless substance depends upon various B vitamins  (B6, B12 and folic acid).  Having good levels of these B vitamins appears to be a very good way of preventing high homocysteine levels and low levels of B vitamins have been associated with raised homocysteine levels

Just recently research has been published (2,3) which suggests that B vitamins may also be important for the health of our bones and that elevated homocysteine levels may be implicated in bone deterioration.

In one study (2) the researchers wanted to examine the associations of blood plasma concentrations of folate, vitamin B12, vitamin B6, and homocysteine with bone loss and hip fracture risk in elderly men and women.  The study included a total of 1002 men and women with the average age of 75, their blood levels of B vitamins were measured at the start of the study and they were followed for 4 years.  Bone loss was associated with low vitamin B6 levels and low levels of vitamins B12 and B6 were associated with hip fracture risk.  The participants with high homocysteine levels also had a higher risk for hip fracture.

The study suggests that both low vitamin B status and high homocysteine levels may be a risk factor for hip fracture.  The authors of the study conclude that it is not entirely clear why or how B vitamins or homocysteine are related to bone health or fracture risk and that clinical trials with B vitamin supplements may help to provide more information. 

I find the results of the study very interesting as they highlight another area where nutrition is linked to health.  An overall healthy diet rich in a variety of unprocessed foods really does provide nutrients to all cells in the body.  Bones rely on essential nutrients as much as any other part of us!  All the cells in our body require regular, good supplies of the whole spectrum of nutrients.  A healthy diet really is important for so many reasons!

Vitamin B6 is found in foods like potatoes, bananas, beans and chickpeas, avocados, fish and poultry.  Vitamin B12 is found mainly in meat, fish and poultry.  Eggs and cheese also contain B12 as does brewer’s yeast.  Many vegetarians and vegans have very low intakes of this vital nutrient and may wish to consider a multi-B vitamin supplement.  Folic acid is found in beans, green vegetables and wholegrains.  If you decide you would like to take a vitamin B supplement I would always suggest a broad spectrum supplement that supplies adequate, but not megadose, levels of all of the B vitamins (not single nutrient supplements), these vitamins work best together as a team!

(1)The National Osteoporosis Society
(2)McLean R et al.  2008.  Plasma B Vitamins, Homocysteine, and Their Relation with Bone Loss and Hip Fracture in Elderly Men and Women.  J Clin Endocrinol Metab.  93: 2206-2212
(3)Cagnacci A et al.  2008.  Relation of folates, vitamin B12 and homocysteine to vertebral bone mineral density change in postmenopausal women. A five-year longitudinal evaluation. Bone.  42(2):314-20.

Written by Ani Kowal

World Osteoporosis Day occurs on Monday October 20th and the National Osteoporosis Society (NOS) is running a UK-wide campaign ‘Love Your Bones’ which is intended to raise awareness about the importance of healthy bones.  The goal of the National Osteoporosis Society is to improve understanding of osteoporosis, what causes it and to promote the steps people can take to keep their bones healthy and reduce their risk.

“Osteoporosis literally means ‘porous bones’. Our bones are made up of a thick outer shell and a strong inner mesh which looks like a honeycomb made up of tiny struts of bone. Osteoporosis means some of these struts become thin or break, making bones more fragile and prone to fracture. It often remains undetected until a bone is first broken, which commonly occurs in the wrists, hips and spinal bones. It is these broken bones or fractures which can lead to the pain associated with osteoporosis. Spinal fractures can also cause loss of height and curvature of the spine.”(1)

Please visit the NOS for loads more information on bone health.  They have many online and downloadable resources, including a booklet ‘Healthy Eating For Strong Bones’ and a page dedicated to the ‘Sunlight Campaign’ which highlights the fact that sunlight is one of the very best natural sources of vitamin D, a vitamin that is essential for the building of healthy bones and the prevention of osteoporosis.  The NOS point out that up to 15 % of people in the UK are estimated to have low levels of vitamin D, while 80% have levels which are considered unhealthy.  There have now been many calls for a revised vitamin D intake recommendation in the UK(2) due to extensive evidence of low levels. The NOS website provides simple tips for boosting your vitamin D levels.

Calcium and Vitamin D
A recent review paper(2) looked at the evidence surrounding the importance of calcium and vitamin D for bone health and the prevention and treatment of osteoporosis.  The paper points out that an estimated one in three women and one in twelve men aged over 55 years will suffer from osteoporosis in their lifetime.  This represents a huge cost in the UK (many millions of pounds per year).  Calcium supplements appear to be effective in reducing bone loss in women in late post menopause (after five years), particularly in those with a low daily calcium intake (less than 400 mg/d).  Supplementation with vitamin D and calcium has also been shown to reduce fracture rates in some elderly populations. Low vitamin D status is associated with an increased risk of falling and a variety of other health outcomes and is an area that requires urgent attention.

It is very important to consider bone health at an early age, this is because peak bone mass (peak bone strength) is reached before the age of 30, after this age bone gradually grows weaker.  Building up great bone strength early on in life will help reduce the risk of osteoporosis later in life.  Most studies show that calcium, supplemental or high dietary intake, is important in at a young age in order to reach a good peak bone mass (3), 600mg-1,000mg calcium daily before the age of 25 may be beneficial to reaching a good bone mass.  As mentioned above evidence regarding supplementation later in life is mixed.  However, a supplement containing vitamin D and calcium could be useful in maintaining bone mass (providing around 800mg calcium daily and 20mcg/800IU vitamin D).

Other nutrients
The role of other nutrients on bone remains to be fully defined(2), although there are promising data in the literature for links between various nutrients including: magnesium, zinc, copper, potassium, silicon, manganese, vitamin K, vitamin C, vitamin B and phytonutrients (biochemical plant compounds).  A varied, healthy diet, especially on rich in fruits and vegetables, will provide a huge array of nutrients that may positively impact bone health.  If you feel your diet is lacking you may wish to consider a high quality food-state multi-vitamin and mineral supplement.  This is NOT a substitute for good dietary habits!! 

Omega 3 fatty acids
Yes, it is the fish oils making an appearance again!  Eating a diet rich in the omega 3 fatty acids EPA and DHA, found in oily fish such as mackerel, salmon and sardines, may contribute to a reduced risk of osteoporosis by inhibiting the production of pro-inflammatory chemicals (eicosanoids) that are known to be involved in the process of bone loss.  This is a relatively new field of interest in osteoporosis.  Two recent reviews (4,5) looked at the evidence so far which does indicate a benefit, though the authors point out that further evidence is needed before firm conclusions can be drawn.  However, due to the numerous health benefits of omega 3 fatty acids (see previous blog posts) I would suggest the regular inclusion of oily fish in the diet (at least twice weekly), or taking a supplement providing around 250mg EPA and 250mg DHA a day.  For vegetarians I would suggest a daily flaxseed oil supplement to provide around 500mg alpha-linolenic acid (a shorter chain omega 3 fatty acid).

Fruits and Vegetables
A number of studies over the last decade have suggested a clear, positive link between fruit and vegetable consumption and bone health(6).  These foods provide a huge range of nutrients that are important for bone health.  In addition to the nutrients fruit and vegetables positively affect the pH balance (a measure of acid-alkali balance) in the body, by increasing the alkalinity in the body (making the body less acidic), which plays a major role in the prevention of calcium loss from bones.  Foods which are acid forming in the body include foods such as most meat and animal protein, cheddar cheese and many grain products e.g. white bread, pasta, cornflakes.  If the body is too acidic, not in pH balance, then bones can release their calcium (which increases alkalinity) into the blood to try and maintain the balance.  Obviously calcium loss is not what we want!!  Providing the body with abundant supplies of vegetables and fruits may well help to keep our bones strong as well as protecting us from many other diseases.

If you drink a lot of caffeinated tea, coffee or regularly consume fizzy drinks you may wish to reduce the amount you consume in order to protect your bones.  High intakes of these drinks can have a negative effect on bones.  The phosphoric acid they contain may cause calcium loss from bones.

Visit the National Osteoporosis Society website for more information

(1)The National Osteoporosis Society
(2) New-Lanham SA.  2008.  Importance of calcium, vitamin D and vitamin K for osteoporosis prevention and treatment.  Proc Nutr Soc.  67(2):163-76.
(3) Eastell R & Lambert H.  2002.  Strategies for skeletal health in the elderly.  Proc Nutr Soc.  61:173-180
(4)Salari P et al.  2008.  A systematic review of the impact of the impact of n-3 fatty acids in bone health and osteoporosis.  Med Sci Monit.  14:RA37-44
(5)Fernandes G et al.  2008.  Effects of n-3 fatty acids on autoimmunity and osteoporosis.  Front Biosci.  13:4015-4020
(6) New SA.  2003.  Intake of fruit and vegetables:implications for bone health.  Proc Nutr Soc.  62:889-899

Written by Ani Kowal

As I mentioned on Monday, the 12th October marks World Arthritis Day 2008.  Today I am going to cover osteoarthritis which is the most common type of arthritis.  The disease occurs due to the gradual degeneration of the cartilage which lines the joints.  This causes pain, swelling and restricted movement.  The condition most commonly affects weight bearing joints such as the hips and knees but may also attack the joints in the hands and feet.  Women are twice as likely as men to be affected and the most common form of treatment are NSAIDs, non-steroidal anti-inflammatory drugs, to relieve pain and reduce swelling/inflammation. 

For more info on osteoarthritis please visit Arthritis Care, a UK based charity for those suffering with the condition.

My intention had been to start off by reviewing some of the evidence surrounding glucosamine sulphate and chondroitin sulphate in relieving symptoms of osteoarthritis.  However the press pounced on a story earlier this week and you may have read headlines saying that dietary supplements of glucosamine and/or chondroitin fare no better than placebo in slowing the progression of knee osteoarthritis. (Oh the media do love a negative story!).  The study(1) being referred to did indeed find that neither glucosamine sulphate nor chondroitin sulphate worked to slow the loss of knee cartilage in osteoarthritis.  However, the researchers have said that some of their findings were confusing and that more study was needed before any definite conclusions could be drawn.  In addition to this it was quite a small study which can affect the statistical analysis of results, and a small sub-set group of patients (with grade 2 osteoarthritis) did appear to show a trend toward benefit from the supplements (but the benefit was not statistically/mathmatically significant) compared to placebo.  The study did not measure the effects of supplementation on pain levels, or other symptoms, in the osteoarthritis sufferers.

I am going to continue along my planned lines of mentioning glucosamine and chondroitin sulphate supplementation for osteoarthritis as there are a number of studies that do indicate that these agents may well be beneficial to sufferers of the condition.

Glucosamine sulphate is an essential building block in the manufacture of cartilage and, taken as a supplement, may reduce the pain and inflammation associated with osteoarthritis.  Several studies exist which show glucosamine to be an effective treatment for osteoarthritis(2,3,4,5). Glucosamine sulphate has also been shown to control the symptoms of osteoarthritis as well as the NSAID ibuprofen (6,7). The normal recommended dose of glucosamine sulphate is 500 mg, three times daily. Once therapeutic benefit is achieved, it is usually possible to taper down to a once or twice a day dose.

Another agent which is often used in conjunction with glucosamine sulphate is chondroitin sulphate.  Chondroitin sulphate seems to work by attracting fluid into the joint cartilage tissue. This may improve the spongy, shock-absorbing qualities of the cartilage, and may also help bring essential nutrients to the area.  Many trials have shown that supplementation with chondroitin sulphate can reduce pain, increase joint mobility and/or cause healing within the joints of osteoarthritis sufferers (8,9,10,11). The normal recommended dose of chondroitin sulphate is 400 mg, three times a day.

Glucosamine and chondroitin are very often combined together in nutritional supplements designed to enhance joint health, although it is yet uncertain whether a combination works more effectively than either agent alone.  A review(12) published this year concluded that “although the evidence is not entirely consistent, most research suggests that glucosamine sulphate can improve symptoms of pain related to osteoarthritis, as well as slow disease progression in patients with osteoarthritis of the knee. Chondroitin sulphate also appears to reduce osteoarthritis symptoms and is often combined with glucosamine, but there is no reliable evidence that the combination is more effective than either agent alone”

The evidence for other supplements aiding osteoarthritis is not strong(13) and further trials are needed however, there is indication that antioxidant vitamins such as vitamin C, E and Beta carotene, vitamins D and various B vitamins as well as omega 3 fatty acids may be involved with reducing symptoms.  To me this highlights the importance of a healthy diet rich in a variety of fruits and vegetables, to provide the body with vitamins and minerals, together with regular inclusion of oily fish to provide omega 3 fatty acids (which can act as anti-inflammatory agents in the body).

1.Sawitzke AD et al.  2008.  The Effect of Glucosamine and/or Chondroitin Sulfate on the Progression of Knee Osteoarthritis: A Report from the Glucosamine/Chondroitin Arthritis Intervention Trial. Arthritis & Rheumatism.  58:3183-3191.
2.Reginster JY et al.  2001.  Long-term effects of glucosamine sulphate on osteoarthritis progression: a randomised, placebo-controlled clinical trial.  Lancet.  357:251-256.
3.Noack W et al.  1994. Glucosamine sulphate in osteoarthritis of the knee. Osteo and Cart.  2:51-59
4.Pujalte JM et al.  1980.  Double blind clinical evaluation of oral glucosamine sulphate in the basic treatment of osteoarthrosis. Curr Med Res Opin.  2:110-114
5.Dovanti A et al.  1980.  Therapeutic activity of oral glucosamine sulphate in osteoarthritis: a placebo-controlled double-blind investigation. Clinical Therapeutics.  3(4):266-272
6.Qiu GX et al.  1998.  Efficacy and safety of glucosamine sulfate versus ibuprofen in patients with knee osteoarthritis.  Arzneimittelforschung.  48:469-474
7.Muller-Fabbender H et al.  1994.  Glucosamine sulphate compared to ibuprofen in osteoarthritis of the knee.  Osteo and Cart.  2:61-69
8.Uebelhart D et al.  1998.  Effects of oral chondroitin sulfate on the progression of knee osteoarthritis: a pilot study.  Osteoarthritis Cartilage.  6(Suppl A):39-46
9.Verbruggen G et al.  1998.  Chondroitin sulfate: S/DMOAD (structure/disease modifying anti-osteoarthritis drug) in the treatment of finger joint OA.  Osteoarthritis Cartilage.  6(Supplement A):37-38
10.Bucsi L et al.  1998.  Efficacy and tolerability of oral chondroitin sulfate as a symptomatic slow-acting drug for osteoarthritis (SYSADOA) in the treatment of knee osteoarthritis.  Osteoarthritis Cartilage.  May 6, (Supplement A):31-36.
11.Leeb BF et al.  2000.  A metaanalysis of chondroitin sulfate in the treatment of osteoarthritis.  J Rheumatol.  27(1):205-11
12. Gregory PJ et al.  2008.   Dietary supplements for osteoarthritis. Am Fam Physician. 77(2):177-84.
13.  Wang Y et al.2004.  The effect of nutritional supplements on osteoarthritis.  Altern Med Rev. 9(3):275-96.

Written by Ani Kowal

Sunday 12th October marks World Arthritis Day 2008.  The theme for the day this year is ‘Think Positive’, this acknowledges the fact that many arthritis sufferers are often emotionally affected.  The World Arthritis Day website and the UK site Arthritis Care, both provide fantastic resources which include positive and helpful information to those suffering from arthritis.  This campaign this year focuses on improvement of access to psychological forms of support and self-management courses.
 

Rheumatoid arthritis is an autoimmune disease; a disease when, for unknown reasons, the body starts to attack itself.  In Rheumatoid arthritis the attack occurs on the membranes (synovial membranes) of a joint which becomes chronically inflamed which can cause pain, swelling, morning stiffness, muscle wasting and osteoporosis.  Eventually bone and cartilage is damaged.  Rheumatoid arthritis can affect several joints and commonly occurs in people aged between 30 and 50.  The condition is three times more common in women than men and seems to run in families. Conventional treatment centres around pain relief and reduction of inflammation, most commonly with drugs called NSAIDs, Non steroidal anti-inflammatory drugs.

Healthy eating is important in order to support the body so that it may function optimally.  A balanced diet will provide all the important vitamins, minerals, amino-acids (proteins), essential fatty acids and energy necessary for health.  There is some indication that a healthy diet rich in fruits, vegetables and healthy fats , such as the omega 3 fatty acids found in oily fish and olive oil, is protective against the development of rheumatoid arthritis (e.g.1,2,3).  A study last year(4) found that this kind of Mediterranean-type diet, rich in vegetables, fruits and fish, also seems helpful in relieving some of the symptoms of rheumatoid arthritis, such as pain and early morning stiffness, in those already suffering from the disease.

If you suffer from rheumatoid arthritis you may want to consider talking to your GP/health professional about being allergy tested.  There are medical studies to show that in some individuals who suffer from rheumatoid arthritis, it is made worse when they eat foods they are allergic or sensitive to and made better when they avoid those specific foods (5,6,7,8,9,10).   Please do not attempt an elimination diet without the support of a health professional. 

With regards specific foods and/or supplements that may be helpful to rheumatoid arthritis sufferers the evidence centres mainly around the long chain omega 3 fatty acids, found in oily fish such as mackerel, salmon, trout and sardines.  (Regular readers of my blog will, no doubt, have guessed these fats would have come up somewhere in this post).  These long chain omega 3 fatty acids (EPA and DHA) decrease the production of inflammatory chemicals (such as eicosanoids, cytokines and reactive oxygen species) in the body and also give rise to a family of anti-inflammatory mediators (called resolvins).  Omega 3 fatty acids are therefore potentially very potent natural anti-inflammatory agents.  There have been many studies (11 provides a review) which report anti-inflammatory effects of supplemental fish oil in patients with rheumatoid arthritis. 

The benefits of fish oil in these trials included reduced duration of morning stiffness, reduced number of tender or swollen joints, reduced joint pain, reduced time to fatigue, increased grip strength and decreased use of NSAIDs.  The totality of current evidence really suggests that long chain omega 3 fatty acids so have clinical benefit in rheumatoid arthritis.  One paper(12) concluded that "the findings of benefit from fish oil in rheumatoid arthritis are robust," "dietary fish oil supplements in rheumatoid arthritis have treatment efficacy," and "dietary fish oil supplements should now be regarded as part of the standard therapy for rheumatoid arthritis".

If you are not a regular eater of oily fish (at least twice a week) then you may wish to consider taking a fish oil supplement.  The doses used in trials with rheumatoid arthritis sufferers have varied, you may wish to start by taking 2g of fish oil a day to provide around 500-700mg of EPA and 500-700mg DHA per day (try splitting this dose throughout the day as this will minimise any potential adverse effects on the digestive system).  

In addition to increasing oily fish intake, or taking a supplement, it may be advantageous to simultaneously reduce your consumption of a specific type of fatty acid called ‘arachidonic acid’ this is a specific omega 6 fatty acid found preformed in egg yolk, beef, liver and kidneys (it can also be manufactured in the body from precursor fatty acids found in vegetable oils).  Arachidonic acid can be used by the body to produce chemicals that have potent inflammatory activity.  One study (13) found that fish oils were more efficacious when taken simultaneously with a diet low in arachidonic acid.  In this study fish oil or placebo was given to patients who ate either their typical diet or an ‘anti-inflammatory diet’ that restricted the intake of arachidonic acid-rich foods.  Patients consuming the anti-inflammatory diet in addition to taking the fish oil supplement had significantly lowered inflammatory chemicals in their blood plasma.  The reductions in the number of swollen joints, number of tender joints and pain scores seen with fish oil supplementation were all also greater for patients consuming the anti-inflammatory diet.

For more information on rheumatoid arthritis please visit the Arthritis Care website.

Check back later in the week for information regarding osteoarthritis.

1.Cerhan JR et al.  2003.  Antioxidant micronutrients and risk of rheumatoid arthritis in a cohort of older women.  Am J Epidemiol.  157:345-354
2.Pattison DJ et al.  2004.  Does diet have a role in the aetiology of rheumatoid arthritis?  Proc Nutr Soc.  63:137-143
3. Linos A et al.  1999.  Dietary factors in relation to rheumatoid arthritis: a role for olive oil and cooked vegetables?  Am J Clinical Nutr.  70:1077-1082.
4.McKellar G et al.  2007.  A pilot study of a Mediterranean-type diet intervention in female patients with rheumatoid arthritis living in areas of social deprivation in Glasgow.  Ann Rheum Dis.  66:1239-1243
5.Darlington LG et al.  1986.  Placebo-controlled, blind study of dietary manipulation therapy in rheumatoid arthritis.  Lancet.  i:236-238
6.Darlington LG.  1991.  Dietary therapy for arthritis.  Rheum Dis Clin North Am.  17:273-285.
7.Beri, D., et al.  1988.  Effect of dietary restrictions on disease activity in rheumatoid arthritis.  Ann Rheum Dis.  47:69-72
8.Hicklin JA et al.  1980.  The effect of diet in rheumatoid arthritis. Clin Allergy.  10:463
9.Panush RS et al.  1988.  Diet therapy for rheumatoid arthritis.  Arthritis Rheum.  26:462-471
10.Taylor, M. R.  1983.  Food allergy as an etiological factor in arthropathies:  a survey.  J Internat Acad Prev Med  8:28-38
11.Calder PC.  2006.  N-3 polyunsaturated fatty acids, inflammation and inflammatory diseases.  Am J Clin Nutr.  83:1505S-1519S
12.Cleland LG & James MJ.  2000.  Fish oil and rheumatoid arthritis:anti-inflammatory and collateral health benefits.  J Rheumatol.  27:2305-2307
13.Adam O et al.  2003.  Anti-inflammatory effects of a low arachidonic acid diet and fish oil in patients with rheumatoid arthritis.  Rheumatol Int.  23:27-36

Written by Ani Kowal