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Food as Medicine - Bone and Joint Disorders

DK PublishingDK Publishing 2/07/2014 DKBooks

Cottage cheese on crispbread - Maintaining calcium levels is critical for arthritis sufferers, but it is important to choose low-fat dairy products to help control weight.

High-calcium lunch - This lunch of cream of broccoli soup topped with grated low-fat cheese, a salmon–watercress sandwich, dried figs, and a glass of low-fat milk provides 821mg of calcium.

Joint-friendly exercise - Exercising in water minimizes stress on any joints affected by arthritis, while helping to maintain flexibility, strengthen muscles, and control weight.

Sardines are good for rheumatoid arthritis - Containing high levels of calcium, iron, B vitamins, and omega-3 fatty acids, sardines on toast makes an easy and nutritious snack.

Low-calcium lunch - Although healthy in many respects, this lunch of tomato soup, tuna–tomato sandwich in whole-wheat bread, fresh pear, and a glass of water provides just 94mg of calcium.

Bone and Joint Disorders

Nutrition plays a vital role in the health of bones and joints.

Bones and joints make up the body’s framework, protecting our internal organs and working in conjunction with our muscles to keep us mobile. Good nutrition throughout life is essential for the formation and maintenance of strong bones, while regular exercise is an important factor in maintaining the healthy function of bones and joints.


One of the most common bone diseases, osteoporosis involves a gradual loss of bone tissue, leaving the bones less dense and more prone to fracture. Osteoporosis is a major public-health problem in North America, affecting over 45 million people. The number of affected people is likely to increase as the population ages.

Adequate calcium intake is crucial for the formation and maintenance of bones. This mineral must be replaced by dietary means because it is not manufactured by the body. If your dietary intake is inadequate, calcium is lost from the bones, making them weaker.

Vitamin D is also essential for bone health because it is needed for calcium absorption, with deficiency contributing to low bone density and disease . Researchers also believe that isoflavones from soy and other phytoestrogens may help increase calcium absorption.

Osteomalacia and rickets

A disease of adults, osteomalacia is characterized by soft bones due to a failure of bone to absorb calcium. The disorder is caused by various factors including too little vitamin D in the diet, insufficient exposure to sunlight, and malabsorption of vitamin D in the intestine due to conditions such as celiac disease or after gastrointestinal surgery. Osteomalacia can lead to pain in the legs, ribs, hips, and muscles, and to easily broken bones and impaired mobility.

In children, the same condition is known as rickets and is usually caused by a vitamin D deficiency. Babies who are breast-fed for more than a year (with no vitamin D supplements) and children deprived of sufficient sunlight are most at risk of developing rickets.

However, the incidence of rickets has been significantly reduced in North America, where most milk and other dairy foods are now fortified with vitamin D.

Arthritic conditions

There are many different types of arthritis, but in general the term refers to inflammation of one or more joints, accompanied by pain, swelling, and stiffness. Rheumatoid arthritis is the most common form of inflammatory joint disease and is found in up to one percent of North Americans. Many tissues in the body may be involved, but the joints are most severely affected.

Osteoarthritis is another common form of arthritis that affects about one in seven North Americans. The condition is characterized by a gradual loss of cartilage from the joints and, in some people, joint inflammation. It most commonly affects the joints of the hands, knees, spine, and hips.

Gout is another form of arthritis that usually affects the joint at the base of the big toe. The condition is caused by high levels of uric acid in the bloodstream—which is known as hyperuricemia—leading to the deposition of uric-acid crystals in the joint. The joint becomes red, swollen, and tender, and the attack may be accompanied by fever.

Fibromyalgia and nutrition

Fibromyalgia is a complex chronic muscle disorder that affects over 10 million North Americans. The symptoms including widespread body pain, fatigue, headache, difficulty concentrating, disturbed sleep, depression, and anxiety.

While there is little scientific support for dietary treatment, many people turn to nutritional and herbal supplements, including vitamins, magnesium, and amino acids. Studies show that the pain and tenderness of fibromyalgia may be relieved by supplements of magnesium hydroxide and malic acid (a naturally occurring substance in our bodies).

Key anatomy

Joints occur where bones meet, and enable our bodies to be flexible. The ends of bones are lined with cartilage.

Who is most at risk of bone and joint disorders?

Adult bone mass is determined by the amount of bone formed during childhood, with accumulation (known as peak bone mass) complete by age 35. Bone mass is influenced by a number of factors: up to 80 percent of bone mass is influenced by genetic factors, while about 20–40 percent is environmental.

Diet and lifestyle

A life-long diet low in calcium and vitamin D is one of the major risk factors for many bone disorders. Smoking and heavy alcohol consumption, which are often accompanied by poor nutrition and lack of physical activity, are also associated with low bone density. Gout is often associated with a rich diet and heavy alcohol consumption.


Bone and joint disorders are more common among middle-aged and older adults. The onset of rheumatoid arthritis most commonly occurs between ages 40 and 60, and osteoarthritis between ages 60 and 80. Gout most commonly develops between the ages of 40 and 50 in men and over 60 in women. Asian and Caucasian women over age 65 have a particularly high risk of developing osteoporosis. On the other hand, African–American women tend to have a higher bone mass than Caucasians and a lower risk of osteoporosis.


Osteoporosis is more common in women since they have less bone mass than men to begin with. Women who have short intervals between pregnancies or several children are at increased risk of this disease. In addition, because the levels of estrogen—necessary to retain calcium in the bones—decrease in women after menopause, their risk increases at this stage. Women have twice the risk of developing rheumatoid arthritis as men. However, gout is twenty times more common in men.

Family history

Both osteoporosis and gout are conditions in which a family history increases the risk of developing the disease. A history of a maternal hip fracture after age 50 is also considered a risk factor for osteoporosis.

Treating osteoporosis

One of the most common bone diseases, osteoporosis involves a gradual loss of bone tissue, leaving the bones less dense and more prone to fracture. Osteoporosis is very common in North America, affecting over 45 million people. It is possible to slow the progress of the condition by making changes to your diet and lifestyle:

Take adequate calcium

The body does not manufacture calcium, and it is lost from the body every day. It is therefore important to maintain adequate daily intake.

Take adequate vitamin D

This vitamin is needed for normal calcium absorption by the body, as well as playing a role in the uptake of calcium into bone . It is important that you get sufficient vitamin D from your diet as well as from exposure to the sun.

Quit smoking

Studies have shown that smokers have poorer bone density than nonsmokers. Quitting smoking, even later in life, may help limit bone loss. Research shows that while hormone replacement therapy protects women from bone fractures, this may not be the case in female smokers, as tobacco may have an antiestrogenic effect. In addition, smokers tend to drink more alcohol and exercise less.

Limit alcohol intake

Those who drink alcohol heavily are more prone to bone loss and fractures, mainly because of poor nutrition but also due to their increased risk of falling.

Exercise regularly

Regular physical activity helps increase bone mass and reduce bone loss. Weight-bearing exercises such as walking, dancing, and weightlifting are best.

Checking bone density

A DEXA scan is currently the most widely used method of measuring bone-mineral density of the spine and extremities. Scanning takes a few minutes and is a sensitive and accurate test of bone density. The report compares your values with those of a young person and with a person of your age with normal bone density (age-related bone loss is normal). You are at risk of osteoporosis if you take medication, such as steroids, that affects your bones; if you have a history of menstrual cycle cessation; if you have inflammatory bowel disease; or if you had early menopause. In such circumstances, ask your doctor about having a baseline bone scan which can be repeated over time.

Boosting your dietary calcium intake

Calcium is vital for bone formation and keeping bones strong. It is important to boost your calcium intake if you are at risk of developing, or if you already suffer from, osteoporosis.

The recommended calcium intake is 800mg per day for children aged 3–8 years; 1,300mg per day for those aged 9–18 years; and 1,000mg for adults. Anyone over 50 years old should be increasing their intake to 1200mg per day. Adequate calcium intake is critical for women going through menopause as bone mass can decrease at this time.

Calcium-rich foods

The mineral calcium is absorbed by the body better in food than as a supplement, so increase your intake of calcium-rich foods. Obvious sources of calcium are dairy products, such as milk, yogurt, and cheese, but calcium is also found in spinach, watercress, green beans, broccoli, canned sardines and salmon with bones, tofu, dried apricots, and figs.

Once you know how, it is relatively easy to transform meals into calcium-rich ones—see here for an easy lunch transformation to boost calcium intake.

Preventing and treating osteomalacia and rickets

Osteomalacia and rickets (the name given to osteomalacia when it occurs in babies and children) are caused by a deficiency of vitamin D in the body.

Increasing vitamin D

Deficiency is due to inadequate dietary intake of foods containing vitamin D, or to insufficient sunlight, which is necessary for the conversion of vitamin D in our skin to its active form (a form that the body can use). There are few dietary sources of vitamin D, but many common foods, such as margarine, dairy products, and orange juice, are fortified with the vitamin. Good natural sources of vitamin D include cod liver oil, egg yolks, butter, canned salmon and sardines (with bones), herring, green leafy vegetables, and tofu.

If you do not regularly consume dairy products and live in an area where you are not exposed to the sun for certain seasons of the year, you should consider a supplement that supplies at least the DRI for vitamin D (0.005mg per day).

Treating rheumatoid arthritis

Depending on the stage of the disease, treatment of rheumatoid arthritis varies but initial treatment is usually aimed at reducing inflammation while minimizing the side effects of such treatment. The presence of other disorders, particularly liver or kidney complaints, also affects the type of treatment. In some cases, treatment may involve surgery.

Increased nutrient intake

People with active rheumatoid arthritis may have a poor dietary intake due to loss of appetite. At the same time, some of the medications that treat rheumatoid arthritis, such as anti-inflammatory drugs, may increase the requirement for certain nutrients and reduce their absorption.

Like osteoarthritis, weight loss is recommended for overweight and obese people to reduce the stress on inflamed joints. Nutritional guidelines, therefore, focus on eating a varied diet that provides essential nutrients while helping control weight.

Sufficient intake of vitamin E is important for the health of your joints; vitamin E-rich foods include oils, fish, nuts, and seeds.

You should also choose foods that provide an adequate intake of B vitamins, vitamin D, calcium, iron, and omega-3 fatty acids.

Include adequate amounts of antioxidants in your diet.

Maintaining bone density

Rheumatoid arthritis causes bone loss, which can also lead to osteoporosis. Bone loss is more likely with an increasing level of disability, resulting from rheumatoid arthritis and the decreasing level of weight-bearing activity. The use of steroid drugs further accelerates bone loss, particularly in postmenopausal women.

Bone loss can be countered by making sure you consume adequate amounts of calcium (1,000–1,500mg per day) and vitamin D (0.01–0.02mg per day), either in the diet or by taking supplements.

Exercise and mobility

Pain and stiffness often cause people with rheumatoid arthritis to stop using their inflamed joints. However, such decrease of activity can lead to loss of joint motion and loss of muscle strength, which leads to decreased joint stability and increased fatigue. Exercise can help prevent and reverse these effects, but exercise programs should be designed by a physical therapist and tailored to the severity of your condition, the former activity level, and your body build.

Omega-3 fatty acids and rheumatoid arthritis

Studies have shown that people with rheumatoid arthritis who were treated with fish-oil supplements for between 3 and 4 months had a reduction in the number of affected joints.

It is thought that omega-3 fatty acids, which are found in oily fish and in some plant oils , might reduce inflammation and help alleviate the troublesome symptoms of rheumatoid arthritis by reducing the number of inflammatory “messenger molecules” made by the body’s immune system.

High doses of omega-3 fatty acids should be taken under the supervision of a doctor to prevent side effects or interactions with medications that you may be using to treat rheumatoid arthritis. Eating oily fish, such as tuna, salmon, and mackerel, at least twice a week should be an integral part of your diet if you suffer from rheumatoid arthritis.

Can diet cure arthritis?

Theories abound that eliminating certain foods, such as tomatoes, potatoes, and peppers, taking specific supplements, or adding honey, vinegar, or herbs to the diet will alleviate arthritis. However, with the exception of gout, which may benefit from a change of diet, there is no scientific evidence that diet can cure joint disorders.

Tests have shown that diets low in saturated fats, or that include certain omega-3 fatty acids, seem to have a mild anti-inflammatory effect, but there is insufficient evidence that these are useful in the treatment of arthritis. (You should note that cod liver oil is not a source of these oils and should not be taken in large quantities.)

Neither is there any evidence that fasting and “cleansing” diets, which are sometimes promoted as methods of treating arthritis, have any long-term benefits. On the contrary, these may lead to malnutrition and health problems.

Glucosamine supplements

There is a certain amount of evidence that glucosamine, in a dose of 1,500mg per day, may help relieve the pain of osteoarthritis, and studies are now underway to try to determine whether this supplement helps preserve or regenerate damaged cartilage. Since glucosamine may affect the action of insulin in the body and may cause digestive upsets and allergic reactions, it should be taken only under medical supervision and avoided entirely if you are pregnant or breast-feeding. The usefulness of other supplements, such as S-adenosylmethionine, chondroitin sulfate, copper, and zinc is uncertain.

Tips for arthritis

If you suspect that a certain food is aggravating your arthritis, try keeping a food diary for a month, writing down everything that you eat and drink, and then see your doctor for advice. If you eliminate a food, be sure to find an alternative source for the nutrients that this food supplies. The best advice is to maintain a healthy lifestyle and eat a balanced diet, choosing foods low in sugar and fat and including a variety of food from the five major food groups every day. Other general dietary tips for people with arthritis include:

Avoid crash dieting or fasting.

Increase dietary calcium intake.

Drink plenty of nonalcoholic fluids.

Keep within a normal weight range.

If you do drink alcohol, make sure you do so in moderation.

Short-order cook with severe foot pain

Name Michael

Age 62 years


Michael woke up in the night with uncomfortable tingling at the base of his right big toe. Over the next two hours the pain became more severe and he noticed swelling and redness on the toe. He could not sleep all night and called his doctor in the morning for an emergency appointment.


Michael is a short-order cook at a neighborhood diner. He stands on his feet for 10–12 hours a day and is very upset because this pain in his foot will prevent him from going to work. He has a history of mild high blood pressure, for which his doctor has prescribed diuretic medication. Michael is moderately overweight and he gets some exercise playing golf on weekends.

Michael’s doctor diagnosed an acute attack of gout and placed him on anti-inflammatory medication. He is advised to stay off of his foot for 5–7 days and then to make a follow-up appointment to discuss how to prevent future attacks of gout. His doctor also advised him to reduce his intake of purines.

At his follow-up visit, Michael’s doctor explained that gout has been linked to “rich” diets high in meat and wine. Michael’s doctor changed his blood-pressure medications because diuretics may make gout worse, and explained that he wanted to check his blood levels of uric acid and LDL-cholesterol. He explained that gout can be a sign of a serious condition, known as metabolic syndrome, which he may have because he is overweight and has high blood pressure .


By losing weight and limiting his intake of alcohol and foods high in purine, Michael can reduce his risk of another attack. Gout is more common in those who overeat or are overweight. Rapid weight loss can precipitate a gout attack, so a reduced-calorie diet for gradual weight loss is important. Too much alcohol can cause an attack and so should be avoided or limited. Some beers even contain purines. Plenty of water is recommended to ensure dilute urine and prevent the formation of uric-acid kidney stones.

Benefits of increasing physical activity for osteoarthritis

People who exercise regularly to control their weight and manage their arthritis typically are in less pain and function better than those who are inactive.

The benefits of exercise

Being overweight not only increases the likelihood of developing osteoarthritis, but also worsens the stress on weight-bearing joints, such as the hips, knees, and lower spine, that may already be affected by the condition. Therefore, it is important for you to increase your exercise level to control your weight if you have osteoarthritis.

Regular stretching routines and exercises will help increase flexibility and reduce stiffness by keeping your joints moving, whereas strengthening exercises, which should also be performed regularly, will help maintain or increase muscle strength, and increase bone mineral density. Having strong muscles will help keep your joints stable. Cardiovascular exercise can also help with weight loss.

Different types of exercise

When starting to exercise, build up gradually, as your joints may be stiff. Water exercises such as swimming or aquaerobics, are particularly good for arthritis sufferers, as your body weight is supported by the water. In addition, low-impact exercises such as walking or Tai Chi are gentle on the joints, and easy to incorporate into a daily routine.

Nutritional therapy for gout

A common form of arthritis, gout is a very painful condition, usually affecting the base of the big toe. The condition is due to high levels of uric acid in the blood, leading to the deposition of uric-acid crystals in joint tissue. Treatment is therefore aimed at controlling uric acid in the blood and involves weight loss, where appropriate, reduction or elimination of alcohol intake, and possibly the discontinuation of diuretic drugs or other medication.

Protein and purine foods

Because foods with high protein and purine content contribute to high uric-acid levels, eliminating such foods may be beneficial for people who suffer from gout. Beer, in particular, contains high levels of purines in addition to alcohol. Milk, eggs, and cheese are good sources of protein and do not contain high levels of purine, but if you are trying to lose weight, you should choose low-fat or fat-free varieties of dairy products.

Restrict or avoid alcohol; in particular, you should stop drinking beer.

Avoid high purine meats, such as liver, kidneys, and brains.

Cut down or avoid meat extracts, such as gravy made from meat drippings.

Eat no more than 3–4oz (85–115g) of meat at any meal.

Avoid foods that are high in fat.

Cut down or, better still, avoid shellfish and anchovies.

Do not overeat, especially on a regular basis. Control your portion sizes, and share entrées when eating out.

Take your time when eating.

Lose weight if necessary, but do it gradually and avoid going on a very low-calorie diet.

Drink plenty of nonalcoholic fluids.

Do not take vitamin C supplements.

Exercise regularly.

Take your medications if you have high blood pressure or high cholesterol.

Jargon buster


This is a product of protein breakdown that causes a high level of uric acid in the blood. Fish and meat that are naturally high in purine include herring, anchovies, mackerel, sardines, scallops, game meats, all organ meats, and meat extracts such as gravy. High purine vegetables include asparagus, spinach and cauliflower.

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