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Does fish oil stand up to doubters?

You should be recommending fish oil for joint health

Movement is paramount to joint health, and as a DC, joint health and movement preservation is a primary focus for many of us.

One of the primary issues that limit movement is pain. The data on joint pain say it’s just a matter of time before a patient encounters joint pain, whether they move a lot or a little.

Despite the joint pain stats, maintaining mobility requires recommendations to most patients with joint pain to try to keep moving as much as possible. Our joints are sensitive to the load that is applied to it and need mechanical loading for joint maintenance.

Moderate mechanical loading maintains the integrity of the cartilage; however, both disuse and overuse can result in cartilage degradation.1

Most of our patients will reach for the medicine cabinet to alleviate the annoying ache that slows down a workout or daily activity. Some will reach for fish oil instead, and have found it to be a good alternative to over-the-counter medications. Despite the confusion and conflicting information floating around the Internet, there is a good amount of evidence that supports the use of fish oil for joint health.

Fish oil provides eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), both omega-3 polyunsaturated fatty acids which have been studied in petri dishes and placebo-controlled, double-blind studies.

What the results have shown is that fish oil can provide benefits to our joints and may even help slow the breakdown and progression of inflammatory joint diseases.

Here are some well-established benefits of fish oil for joint health:

1. Decreased inflammation

Inflammation is a process largely used by our immune system to protect us from foreign invaders and heal damaged tissue. As you’ve heard before, too much of a good thing can be a bad thing, and chronic inflammation is a bad thing. Chronic inflammation occurs when white blood cells overstay their welcome and release chemicals that begin to destroy surrounding tissue instead of saving it.

There is evidence that EPA and DHA suppress inflammatory cytokines such as IL-2, IL-6, TNF-α, and this can be objectively measured via the inflammatory marker C-reactive protein (CRP) in the blood following fish oil supplementation. The suppression of cytokines tells white blood cells to stop recruiting more of their friends to come help out and halt the production of more WBC’s for further inflammatory support.4

Fish oil is also being studied as an alternative to medications for pain relief and inflammation. DHA and EPA are essential to the body producing resolvins. Experiments have shown that resolvins reduce cellular inflammation by blocking the COX-2 DHA was also recently found to produce maresins which work as a switch for WBC’s that essentially turns off inflammation.6,7

2. Decreased pain

Pain is the alarm that our body uses to make us aware that something is not working correctly, and in most cases keeps us from further injuring ourselves. Intense exercise will break down muscle and cause delayed-onset muscle soreness (DOMS) along with general aches and pains. Most people would prefer to workout with less joint pain, especially if we’re performing multi-joint movements. EPA and DHA have both been shown to decrease pain.

What is the mechanism behind fish oil’s pain relieving effects? EPA and DHA both help block pain signaling. DHA is more potent than EPA in comparison. The cascade is complex, but here’s the over simplified version: Compounds in these two omega-3 fatty acids (RvE1 and RvE2) prevent an inflammatory cytokine (TNF-α) from interacting with a nerve receptor and block the release of the stimulatory neurotransmitter, glutamate. Preventing the release of glutamate stops the pain signal from being transmitted.2,3

Scientists have found was that there was a high correlation of decreased pain in those who had higher amounts of omega-3’s in their blood and synovial fluid. In a double-blind, placebo controlled, prospective study, patients with rheumatoid arthritis (autoimmune arthritic disease) found a decrease in tender joints and also found the physician’s pain score to be significantly lower as well. Some patients who continued to take fish oil were able to discontinue NSAIDs without experiencing a disease flare.4

In another study, 36 patients with rheumatoid arthritis and swelling who were taking fish oil examined the level of DHA and EPA in the blood and in the joint fluid. What they found was that there was a high correlation of decreased pain in those who had higher amounts of omega-3’s in their blood and synovial fluid. Fish oil supplementation also was shown to provide relief from general musculoskeletal pain, neck, and back pain, and pain from the discs in the back.

3. Decreased cartilage breakdown

Fish oil can be helpful in reducing the impact of enzymes and chemicals that destroy cartilage. Cartilage is a connective tissue composed of chondrocytes that produce materials that give cartilage its elastic, flexible, yet durable and rigid structure. Cartilage has no blood vessels or nerves, so getting nutrients into the tissue requires a mechanical method.

Chondrocytes get nutrients by motion, specifically compression and bending. Physical motion creates a pump that diffuses nutrients into the cells. Because of the lack of blood supply to cartilage, the healing, and repair process is slowed down significantly compared to other tissues. Pain signals are also decreased due to the lack of nerve supply and may not be felt until a joint is severely degenerated. This is all the more reason to try and maintain your cartilage as long as possible.

Fish oil can be helpful in reducing the impact of enzymes and chemicals that destroy cartilage. In one study scientists injected EPA into joints with osteoarthritis (OA) and found that it prevented further progression of OA. EPA was found to preserve the chondrocytes by decreasing oxidative stress-induced damage and preventing the expression of enzymes (MMP’s) that degrade cartilage in the presence of too much inflammation. 8

In another study scientists used cow cartilage cells (bovine chondrocytes) and exposed the cells to IL-1. The cells expressed all the hallmark inflammatory markers and destructive enzymes as seen in human OA. They then treated the cells with EPA, DHA, ALA, and AA (different types of omega fatty acids to get a comparison). The results showed that EPA had the greatest effect at stopping the cells from making the destructive enzymes and found the inflammatory markers were decreased as well.

The next most potent fatty acid was DHA. Scientists concluded that supplementing with fish oil for OA “may be especially useful.” 9

Other studies have also found similar results and shown fish oil (EPA and DHA) to stop cells from making inflammatory chemicals (cytokines) and cartilage destroying enzymes (MMP’s). Scientists were particularly excited about EPA’s potential to “prevent cartilage degradation associated with chronic inflammatory joint disease”.

4. Increased bone health

While bone is largely made up of minerals, protein, and vitamins, essential fatty acids have also been shown to play an important role in our bones’ overall health. Bone has its own blood vessels and living cells and can grow and repair itself. Bone also has nerve supply which allows us to feel pain.

Our shins remind of us this when we miss a box jump, and when our cartilage wears out and have bone contacting bone. While bone is largely made up of minerals, essential fatty acids have also been shown to play an important role in our bones’ overall health. Omega 3s have been studied for their effect on osteoporosis and decreasing bone loss in astronauts.

Omega 3s have been shown to alter calcium loss, increase bone building cells (osteoblasts) and decrease cells that breakdown bone (osteoclasts). Recent research is even using mice to explore the potential role omega 3s play in the developing skeleton of infants and children. 10

Fish oil is also being studied for its potential benefits for osteoporosis and bone loss prevention. One randomized, double-blind, placebo-controlled study of 126 postmenopausal women found that bone turnover decreased with omega 3 supplementation.

Even on a short-term basis high-dose fish oil was found to inhibit bone resorption. The potential to reduce osteoporotic fractures was also evaluated and results suggest that there may be an association between higher omega-3 concentrations in the body and a decreased risk of osteoporotic fractures. Astronauts have also been studied, as spaceflight and weightlessness leads to bone resorption.

NF-kB (the master switch that increase the production of inflammatory cytokines) was elevated in astronauts following a short spaceflight, and the higher amounts of fish (a rich source of omega-3 fatty acids) they consumed was associated with reduced loss of bone mineral density after flight. Scientists also studied cells in a pitri dish that where supporting the cell study findings, a higher intake of omega-3 fatty acids was associated with less N-telopeptide (a marker of bone mineral loss) excretion during bed rest. This study showed potential benefit of fish oil preventing bone loss in the astronauts as well as in the cells that were studied.11

The benefits are clear, but recommendations for fish oil will vary depending on the specifics of the patient. Considerations to take into account are the size of the patient, medications, type of joint health challenge, and current diet. Always start with a high-quality, efficacious supplement. Recommendations to start with for lupus and psoriasis, 2 g EPA/DHA three times a day.

For Raynaud’s phenomenon, 1 g four times a day. For RA and OA, up to 2.6 g, twice a day. More than 3000 mg (3 grams) a day may increase the bleeding risk in certain individuals; avoid taking with blood thinners such as warfarin (Coumadin). Some brands may also contain toxic polychlorinated biphenyls (PCBs) or mercury. Look for brands that follow good manufacturing practices and maintain rigorous testing to ensure the highest levels of quality.12

Frank Bodnar is 2010 graduate of Palmer College of Chiropractic with a M.S. degree in Human Nutrition from the University of Bridgeport and is certified in sports nutrition through the International Society of Sports Nutrition (CISSN). He practices in Racine, WI where he lives with his wife and two children. He is passionate about using nutrition to improve patient outcomes, and enhance lifestyle changes through counseling and education. He can contacted through frank.bodnar.dc@gmail.com, 262-930-2188, follow him on twitter @drfrankbodnar or connect on LinkedIn.

 

References:

  1. Sun, HB. Mechanical loading, cartilage degradation and arthritis.2010 Nov;1211:37-50. doi: 10.1111/j.1749-6632.2010.05808.x. ncbi.nlm.nih.gov/pubmed/21062294
  2. Xu, ZZ. Resolvins RvE1 and RvD1 attenuate inflammatory pain via central and peripheral actions.2010 May;16(5):592-7, 1p following 597. doi: 10.1038/nm.2123. Epub 2010 Apr 11. ncbi.nlm.nih.gov/pubmed/20383154
  3. Fish Oil. Examine.com. examine.com/supplements/fish-oil
  4. Kremer, Joek. Effects of high-dose fish oil on rheumatoid arthritis after stopping nonsteroidal antiinflammatory drugs clinical and immune correlates. August 1995. onlinelibrary.wiley.com/doi/10.1002/art.1780380813/abstract
  5. Moghaddami, M. Synovial fluid and plasma n3 long chain polyunsaturated fatty acids in patients with inflammatory arthritis.2015 Jun;97:7-12. doi: 10.1016/j.plefa.2015.02.005. Epub 2015 Mar 16. ncbi.nlm.nih.gov/pubmed/25817850
  6. Maroon, JC. Omega-3 fatty acids (fish oil) as an anti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain.Surg Neurol. 2006 Apr;65(4):326-31. ncbi.nlm.nih.gov/pubmed/16531187
  7. Federation of American Societies for Experimental Biology. Harvard and USC scientists show how DHA resolves inflammation. July 2013. eurekalert.org/pub_releases/2013-07/foas-hau070113.php
  8. Sakata, S. Oxidative stress-induced apoptosis and matrix loss of chondrocytes is inhibited by eicosapentaenoic acid.J Orthop Res. 2015 Mar;33(3):359-65. doi: 10.1002/jor.22767. Epub 2014 Dec 2.. ncbi.nlm.nih.gov/pubmed/25469820
  9. Zainal, Z. Relative efficacies of omega-3 polyunsaturated fatty acids in reducing expression of key proteins in a model system for studying osteoarthritis.Osteoarthritis Cartilage. 2009 Jul;17(7):896-905. doi: 10.1016/j.joca.2008.12.009. Epub 2009 Jan 13. ncbi.nlm.nih.gov/pubmed/19217322
  10. Koren, N. Exposure to omega-3 fatty acids at early age accelerate bone growth and improve bone quality.J Nutr Biochem. 2014 Jun;25(6):623-33. doi: 10.1016/j.jnutbio.2014.01.012. Epub 2014 Mar 12. ncbi.nlm.nih.gov/pubmed/24746838
  11. Zwart, SR. Capacity of omega-3 fatty acids or eicosapentaenoic acid to counteract weightlessness-induced bone loss by inhibiting NF-kappaB activation: from cells to bed rest to astronauts.J Bone Miner Res. 2010 May;25(5):1049-57. doi: 10.1359/jbmr.091041. ncbi.nlm.nih.gov/pubmed/19874203
  12. Fish Oil. Arthritis Foundation. arthritis.org/living-with-arthritis/treatments/natural/supplements-herbs/guide/fish-oil.php

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