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3 Ways Nutrition Can Help with Acute Pain and Inflammation

I know it’s been awhile since I’ve posted here. One reason is I’ve been busy with the launch of FunctionalMedicineCE.com a few months ago. We are hosting our second virtual symposium in a few weeks on February 29th. Dr. Frank Bodnar, DC is one of our speakers and he wrote this great post about ways we can use nutrition in inflammation and addressing pain. I hope this is beneficial to both pharmacists and patients out there as we journey on to healing together.

Dr. Hartzler

Pharmacists play a crucial role in treating acute pain and inflammation. If patients don’t head to the emergency room or urgent care center, their local pharmacy is certainly the next destination. The advantage as a pharmacist is that managing acute conditions doesn’t have to require a lengthy consultation or a complex workup. While providing clarity on the best over-the-counter analgesic to help manage acute symptoms is crucial, the value pharmacists can provide extends well beyond the normal transaction. You observe not only the grimaces, body language and postures of different pain issues but can offer an effective nutraceutical solution that targets the same biochemical pathway as traditional pharmaceuticals that a patient would otherwise never hear about.   

It’s fair to say that most pharmacists want the best for their patients’ health and are a highly trusted player on the patient’s health care team. Offering nutritional recommendations to a patient’s self-care acute pain strategy doesn’t have to be complicated. The most common traditional treatments of acute pain and inflammation reinforce blocking inflammation as the primary strategy. Nutraceuticals also have literature that show NFkB, PLA2, 5-LOX, COX-2 and COX-1 pathway modulation and clinical efficacy with a variety of inflammatory conditions.1-5

No clinician would disagree that controlling inflammation, reducing pain and improving a patient’s function as quickly as possible are good, ethical strategies. A patient-centered pharmacist understands not only the side effects and nutrient depletions but the best long-term healing mechanisms that should be considered as well. The value is more complete healing, less future pain and a satisfied patient that will let others know about their experience and your expertise.

Acute pain and inflammation can last anywhere from 1-3 days, with cardinal signs of heat, redness, swelling, pain and loss of function lingering a bit longer. Acute inflammation is driven by the body’s immune system responding to tissue injury and plays a key role in stimulating the pain signaling from the peripheral tissue. Local chemokines and pain hormones signal the initiation of vasodilation, white blood cell infiltration and clotting factors and immunoglobulins, soon followed by tissue regenerating cells such as fibroblasts. Biochemically we see acute-phase proteins such as C-reactive protein (CRP), cytokines, growth factors, eicosanoids, adhesion molecules and matrix metalloproteinases elevated.6If inflammation and free radical damage continues tissue injury and fibrosis can occur.7

The body does a great job of stopping the damage, cleaning the injured area and quickly beginning the repair process, and we want to support these processes as much as possible rather than just focusing on their inhibition. Emerging studies are showing that blocking the inflammatory response may result in delayed healing in bone in the short-term and possibly other connective tissues over the long run, possibly resulting in tissue that is at risk for future irritation and injury.8,9 Diet and supplementation have been shown to support healing and inflammatory mechanisms10 and offer a key strategy beyond resting, icing, compressing and elevating (RICE) an injury. 

During acute pain and inflammation there are three primary nutritional recommendations that can be incorporated to enhance your patient’s outcomes.

  1. 14-Day Anti-Inflammatory Diet: even with trauma, infection and surgery implementing a diet that focuses on fresh fruits, vegetables, nuts, seeds, anti-inflammatory fats and high-quality sources of protein can enhance the acute healing process and help reduce the potential for pain and inflammation to be further perpetuated. Omega-3 fatty acids, monounsaturated fatty acids, phytonutrients that are packed with antioxidants and natural anti-inflammatory compounds and lean proteins all play pivotal roles in reducing the inflammatory response and aiding in the healing process. The Anti-Inflammatory diet template and should include high amounts of nutrient dense foods:
    1. Protein: Fish, lean meat (beef, chicken), omega-3 eggs, high-quality rice and pea protein powders
    1. Green leafy and cruciferous vegetables: kale, collard greens, spinach, red cabbage, beets, watercress, romaine lettuce, cauliflower, broccoli, artichokes and brussels sprouts
    1. Healthy fats: avocado, olive oil, coconut oil and see list of nuts and seeds
    1. Fruits (high in antioxidants and fiber): strawberries, blueberries, blackberries, raspberries, cranberries, red or purple grapes, kiwi, pineapple, grapefruit, apples, pomegranate, mango, oranges, apples, papaya and cherries
    1. Tubers and others: sweet potatoes, carrots, acorn squash and butternut squash, zucchini, beans, olives, tomatoes, peppers, onions and garlic
    1. Nuts and seeds: almonds, pistachios, walnuts, cashews, pecans, macadamia, brazil nuts, and hazelnuts 
  • Whole Turmeric Matrix Supplementation: 500 – 1,000 mg/day for 14 days

The phytochemical analysis of turmeric has revealed that there are 200-plus bioactive molecules present in the natural matrix of turmeric that contribute to its health benefits. The main constituents are the curcuminoids, which include curcumin, demethoxy curcumin and bis-demethoxy curcumin. In addition to this, the non-curcuminoid components like turmerin, turmerones, elemene, furanodiene, curdione, bisacurone, cyclocurcumin, calebin A, and germacrone11-14all showing the ability to reduce pain and inflammation separate from curcumin.15,16,19-23The broad-spectrum of bioactives mechanistically go above and beyond the primary targets traditional therapies (COX-2, 5-LOX and TNF-α). Whole turmeric root modulates NFkB and pretty much every downstream cytokine and growth factor resulting in less COX-2 activation, MAPK p38 pathway modulation and iNOS expression,12,13which for a patient means less pain, less inflammation and less swelling. Recently, scientists have discovered that the microbiome metabolizes these bioactives and they enhance the anti-inflammatory signaling capacity of turmeric’s bioactives. Studies show turmeric’s bioactives increase microbiome diversity, inhibit and protect the body from LPS-induced inflammation,17fortifying enterocyte tight junctions and increasing afferent vagus nerve signaling.18These broad mechanisms provide a range of benefits that truly match the mechanistic needs of arthritic joints beyond a wear and tear, and local inflammatory approach. 

Multiple double-blind, placebo-controlled clinical trials of osteoarthritis and rheumatoid arthritis patients have shown not only a decrease in pain, increase in joint function, and improved inflammatory and autoimmune biomarkers, but have also outperformed NSAIDs in head-to-head trials.15,19-23

  • Flavonoid and Bromelain Supplementation Recommendation: Bromelain 240 mg (576 GDU)/day, Quercetin Dihydrate 240 mg/day, and Rutin 50 mg/day for 14 days. 

Bromelain is a mixture of enzymes found in the stem of the pineapple (Ananas comosus) that exhibit proteolytic characteristics. Bromelain also supports the chondrocyte’s normal cell cycle via the p53, NFkB and Bcl-2 pathways, and balances IL-1B, IL-6, INF-y, TNF-α cytokines via PGE-2 and COX-2 activity during normal local immune responses. Locally bromelain modulates plasma kinins and fibrin/fibrinogen proteins via MMP, VEGF, bFGF, and EGF activity which all contribute to normal vascular and blood supply to connective tissue and prevent excess fibrosis.24

  • A randomized, double-blinded, placebo-controlled study done on performed on 176 boxers found that bromelain supported exercise recovery with notable improvements in bruising on the face and orbits, lips, ears, chest and arms in as little as four days compared to placebo.22
  • A 2017 randomized clinical study published in Rheumatology and Orthopedic Medicine, compared standard medical therapies to proteolytic enzyme therapy in 74 patients with acute joint pain. Patients were evaluated with joint outcome measures, VAS score, hs-CRP, ESR, and liver (ALT, AST) and kidney (creatinine) markers. The results showed that bromelain lowered hs-CRP, ESR improved joint function scores and while keeping normal liver and kidney function and showing no damage the gastric mucosa.23

Quercetin is a powerful antioxidant flavonoid in plants including oak trees, onions and tea. Cell studies show quercetin inhibits COXs and LOX enzymes which produce prostaglandins and leukotrienes; reduces inflammatory pain by inhibiting oxidative stress and cytokine production; LPS-induced TNF-a, IL-8, IL-1a release; prevents mast cell release of histamine and inhibits adhesion molecules such as VCAM-1.25Similar to turmeric quercetin has also been shown to support barrier function in the intestines,26,27modulate NFkB, MAP kinases and inhibit hyaluronidases and MMPs, which are degradatory connective tissue enzymes.25

  • A 2019 meta-analysis combined the data of six randomized controlled trials consistent improvements in the acute-phase biomarker, hs-CRP, and while other cytokines such as IL-6 and TNF-a were found to be decreased in individual studies a statistical significance wasn’t reached in the combined data. Overall the authors concluded that quercetin supplementation for pain and inflammation is a promising therapeutic.28

Rutin is a flavonol found abundantly in plants such as apples, tea, buckwheat and passionflower. Rutin supports connective tissue health by inhibiting the enzymes hyaluronidase, collagenase, LOX and COXs, which all contribute to the degradation of connective tissue, and exhibits neuroprotective, analgesic, antiarthritic, broad-spectrum anti-inflammatory support and speeds wound healing in vitro.29

  • A meta-analysis of six randomized controlled trials published in the Journal of Pain Research, compared 270 knee patients who received a combination of rutin and bromelain (OEC) to 266 standard patients who received standard medical therapy. The authors found OEC to be comparable for efficacy while tolerable and safe.30

References:

  1. Al-Okbi, S. (2012). Nutraceuticals of anti-inflammatory activity as complementary therapy for rheumatoid arthritis. Toxicology and Industrial Health30(8), 738-749. 
  2. Sevda Inan (2019). The Potential Role of Nutraceuticals in Inflammation and Oxidative Stress, Nutraceuticals – Past, Present and Future, María Chávarri Hueda, IntechOpen, DOI: 10.5772/intechopen.83797.
  3. Gupta, S., Prasad, S., & Aggarwal, B. (2016). Anti-inflammatory Nutraceuticals and Chronic Diseases(1st ed., pp. 1-25). Cham: Springer International Publishing.
  4. Al-Okbi, S. (2012). Nutraceuticals of anti-inflammatory activity as complementary therapy for rheumatoid arthritis. Toxicology and Industrial Health30(8), 738-749.
  5. Ravalli S, Szychlinska MA, Leonardi RM, Musumeci G. Recently highlighted nutraceuticals for preventive management of osteoarthritis. World J Orthop 2018; 9(11): 255-261
  6. Jain, S., Gautam, V., & Naseem, S. (2011). Acute-phase proteins: As diagnostic tool. Journal of pharmacy & bioallied sciences3(1), 118–127. doi:10.4103/0975-7406.76489
  7. Edwards, S. (2020). Pathophysiology of Inflammation – Pharmacology – Manual. Retrieved 10 Jan. 2020, from https://www.merckvetmanual.com/pharmacology/anti-inflammatory-agents/pathophysiology-of-inflammation
  8. Su, B., & O’Connor, J. (2013). NSAID therapy effects on healing of bone, tendon, and the enthesis. Journal of Applied Physiology115(6), 892-899. doi: 10.1152/japplphysiol.00053.2013 
  9. Serra, M., et al. (2017). From Inflammation to Current and Alternative Therapies Involved in Wound Healing. International Journal of Inflammation2017, 1-17. doi: 10.1155/2017/3406215
  10. Seaman, D. (2017). An Anti-inflammatory Diet for Pain Patients. Retrieved 10 February 2020, from https://www.practicalpainmanagement.com/treatments/complementary/anti-inflammatory-diet-pain-patients
  11. Suzuki, M and T Nakamura. “Elucidation of Anti-Allergic Activities of Curcumin-Related Compounds with a Special Reference to their .” Biol. Pharm(2005): 1438-1443 
  12. Panahi, Y., Darvishi, B., Ghanei, M., Jowzi, N., Beiraghdar, F., & Varnamkhasti, B. (2016). Molecular mechanisms of curcumins suppressing effects on tumorigenesis, angiogenesis and metastasis, focusing on NF-κB pathway. Cytokine & Growth Factor Reviews, 28, 21-29. 
  13. Camacho-Barquero, L., Villegas, I., Sánchez-Calvo, J., Talero, E., Sánchez-Fidalgo, S., Motilva, V., & Alarcón de la Lastra, C. (2007). Curcumin, a Curcuma longa constituent, acts on MAPK p38 pathway modulating COX-2 and iNOS expression in chronic experimental colitis. International Immunopharmacology, 7(3), 333-342. 
  14. Kumar S, Ahuja V, Sankar MJ, Kumar A, Moss AC. Curcumin for maintenance of remission in ulcerative colitis. Cochrane Database Syst Rev(2012 Oct 17;10:CD008424.
  15. Daily, J and Mini, Park, S Yang. “Efficacy of Turmeric Extracts and Curcumin for Alleviating the Symptoms of Joint Arthritis: A Systematic Review and Meta-Analysis of Randomized Clinical Trial. Journal of Medicine Food(2016): 717-729
  16. Amalraj, A, K Varma and Joby Jacob. “A Randomized, Double Blind, Placebo-Controlled, Two Dose, Three Arm, and Parallel-Group Study.” Journal of Medicinal Food(2017): 1022-1030
  17. Peterson, C., Vaughn, A., Sharma, V., Chopra, D., Mills, P., Peterson, S., & Sivamani, R. (2018). Effects of Turmeric and Curcumin Dietary Supplementation on Human Gut Microbiota: A Double-Blind, Randomized, Placebo-Controlled Pilot Study. Journal of Evidence-Based Integrative Medicine, 23, 2515690X1879072. doi: 10.1177/2515690×18790725
  18. Wang, J., Ghosh, S., & Ghosh, S. (2017). Curcumin improves intestinal barrier function: modulation of intracellular signaling, and organization of tight junctions. American Journal of Physiology-Cell Physiology, 312(4), C438-C445. 
  19. ZHAO, F., GONG, Y., HU, Y., LU, M., WANG, J., & DONG, J. et al. (2014). Curcumin and its major metabolites inhibit the inflammatory response induced by lipopolysaccharide: Translocation of nuclear factor-κB as potential target. Molecular Medicine Reports, 11(4), 3087-3093. doi: 10.3892/mmr.2014.3079
  20. Rathnavelu, V., Alitheen, N., Sohila, S., Kanagesan, S., & Ramesh, R. (2016). Potential role of bromelain in clinical and therapeutic applications. Biomedical Reports, 5(3), 283-288. 
  21. Pavan, R., Jain, S., Shraddha, & Kumar, A. (2012). Properties and Therapeutic Application of Bromelain: A Review. Biotechnology Research International, 2012, 1-6. 
  22. Blonstein JL, Practitioner, Control of swelling in boxing injuries. 01 Aug 1969, 203(214):206].
  23. LS, M., M, et al. (2017). Efficacy of a combination of fixed doses of serratiopeptidases, bromelain and methylsulfonylmethane in inflammatory joint diseases. Rheumatology And Orthopedic Medicine, 2(3).
  24. Pavan, R., Jain, S., Shraddha, & Kumar, A. (2012). Properties and Therapeutic Application of Bromelain: A Review. Biotechnology Research International, 2012, 1-6.
  25. Li, Y., Yao, J., Han, C., Yang, J., Chaudhry, M., & Wang, S. et al. (2016). Quercetin, Inflammation and Immunity. Nutrients,8(3), 167.
  26. Lee, B., Moon, K., & Kim, C. (2018). Tight Junction in the Intestinal Epithelium: Its Association with Diseases and Regulation by Phytochemicals. Journal of Immunology Research, 2018, 1-11.
  27. Amasheh M, et al. Quercetin enhances epithelial barrier function and increases claudin-4 expression in Caco-2 cells. J Nutr2008 Jun;138(6):1067-73.
  28. Ou, Q., Zheng, Z., Zhao, Y., & Lin, W. (2019). Impact of quercetin on systemic levels of inflammation: a meta-analysis of randomised controlled human trials. International Journal Of Food Sciences And Nutrition, 1-12.
  29. Ganeshpurkar, A., & Saluja, A. (2017). The Pharmacological Potential of Rutin. Saudi Pharmaceutical Journal, 25(2), 149-164.
  30. Ueberall, M., Mueller-Schwefe, G., Wigand, R., & Essner, U. (2016). Efficacy, tolerability, and safety of an oral enzyme combination vs diclofenac in osteoarthritis of the knee: results of an individual patient-level pooled reanalysis of data from six randomized controlled trials. Journal Of Pain Research, (9), 941-961.

Love Your Skin: My Top 3 Supplements for Skin Health

Valentine’s Day is approaching, and love is in the air! At this time of year, we (especially women!)  often start to look at our skin and wonder how we can help our skin be healthier.  While there are a whole host of topical products aimed at healthy skin, supporting skin cells from the inside out is equally, if not more important.  This post is going to be quick but if you have questions, don’t hesitate to reach out. I have quite the to-do list with my upcoming teaching at Cedarville, and I wanted to get this to you while it is on my mind. Also, I finally feel like my probiotic post series is at a good place and I will be starting to put out that content in the next few weeks during my busy season of the year.  I am very thankful for awesome pharmacy student researchers that have helped me prep those. The data on probiotics is massive! In the midst of my busy teaching season comes 2 work-trips and 3 birthdays in this house to celebrate in March! It’s pretty much Christmas Round 2 here! Stay warm wherever you are, in Ohio we are dreaming of spring!

Dr. Hartzler

Here we go.. My top 3 supplements for glowing skin!

  1. Collagen: Collagen peptides (CPs) are the broken down product of collagen or gelatin and they are used as important active components because of their various biological activities, good absorption, and low side effects.1
    1. One study of women aged 40-60 found 1,000 mg (1 Gram) of collagen peptides to improve hydration, elasticity and appearance of wrinkles in 12 weeks. Hydration differences were seen after just six weeks.2
    2. Another study of women aged 35-55 found 2.5 to 5 grams of collagen daily significantly improved skin elasticity compared to placebo. There was improved skin moisture and skin evaporation, however those did not reach statistical significance.3
    3. Bonus: Collagen has also been shown to improve Brittle Nails4 and shown improvement in bone building!5

My favorite Collagen Product is Vital Proteins.  There have options for marine based products as well as products from animal sources. In addition there are other various options you can find in my FullScript Store.

  1. Lyciumbarbarum (also known as Goji Berry and wolfberries): This fruit has long been recognized in traditional Chinese medicine for various therapeutic properties based on its antioxidant and immune-modulating effects. Lycium barbarum polysaccharide (LBP), the most biologically active fraction of wolfberry, possesses significant antioxidative and anti-inflammatory effects on multiple tissues.6
    1. A study on human cells showed that the antioxidant LBP could partially protect against UVB irradiation-induced photodamage through activation of specific pathways and reducing DNA damage.6
    2. In a study in mice, antioxidant activity in the skin was demonstrated by the significant protection of 5% goji juice against lipid peroxidation (AKA damage) induced by UVA radiation.
    3. Bonus: the antioxidant properties of this plant extend way beyond the skin.8

Many of you know one of my favorite places to get Wolfberries.  You can find products with this compound over at Young Living in various products.  If you haven’t started your journey with YL yet, I’d love to help you get started. My team has a host of resources to set your wellness journey up for success.

  1. Vitamin C: Last but not least is Vitamin C. Who doesn’t love Vitamin C. For one it’s cheap! Secondly, it is a powerhouse antioxidant. Normal skin contains high concentrations of vitamin C, which supports important and well-known functions, stimulating collagen synthesis and assisting in antioxidant protection against UV-induced photo damage.9
    1. Vitamin C promotes collagen formation, and we already know how good collagen is!9
    2. “Vitamin C is a potent antioxidant that can neutralize and remove oxidants, such as those found in environmental pollutants and after exposure to ultraviolet radiation. This activity appears to be of particular importance in the epidermis, where vitamin C is concentrated in the skin.”9
    3. One study with men aged 30–45 given oral supplement of 54 mg or 22 mg of vit. C, 28 mg tomato extract, 27 mg grape seed extract, 210 mg of marine complex, 4 mg zinc gluconate for 180 days showed improvement in redness, hydration, radiance, and overall appearance. The treatment group decreased intensity of general skin spots, UV spots, and brown spots, improved skin texture and appearance of pores. Biopsies showed increased collagen (43%–57%) and elastin (20%–31%). This study was a mix of antioxidants, unfortunately there haven’t been a large # of human clinical trials with vitamin C alone. So mix it in with your regimen! 10

That’s a wrap.. treat yourself to good-nutrition to support your skin this valentine’s day, I would love to help you find products that fit not only your skin needs but optimize your health and wellbeing too! If you are shopping for these or any supplements please check out my limks on the blog and know that 10% of revenue on this blog goes to support amazing ministries! You know where to find me on Facebook and Instagram if you have questions.

Also know that you are Loved by your Creator this Valentines Day.. if you want to know about this more too.. I’d love to chat over coffee or virtual coffee. 🙂

As always, the information provided on this site is intended for your general knowledge and education only and is not a substitute for professional medical advice or treatment for specific medical conditions. Head over to this page if you have further questions about that.

References

  1. Song H, Zhang S, Zhang L, Li B. Effect of Orally Administered Collagen Peptides from Bovine Bone on Skin Aging in Chronologically Aged Mice.Nutrients. 2017;9(11). doi:10.3390/nu9111209.
  2. Kim D-U, Chung H-C, Choi J, Sakai Y, Lee B-Y. Oral Intake of Low-Molecular-Weight Collagen Peptide Improves Hydration, Elasticity, and Wrinkling in Human Skin: A Randomized, Double-Blind, Placebo-Controlled Study. Nutrients. 2018;10(7). doi:10.3390/nu10070826.
  3. Proksch E, Segger D, Degwert J, Schunck M, Zague V, Oesser S. Oral supplementation of specific collagen peptides has beneficial effects on human skin physiology: a double-blind, placebo-controlled study. Skin Pharmacology And Physiology. 2014;27(1):47-55. doi:10.1159/000351376.
  4. Hexsel D, Zague V, Schunck M, Siega C, Camozzato FO, Oesser S. Oral supplementation with specific bioactive collagen peptides improves nail growth and reduces symptoms of brittle nails.Journal Of Cosmetic Dermatology. 2017;16(4):520-526. doi:10.1111/jocd.12393.
  5. König D, Oesser S, Scharla S, Zdzieblik D, Gollhofer A. Specific Collagen Peptides Improve Bone Mineral Density and Bone Markers in Postmenopausal Women-A Randomized Controlled Study.Nutrients. 2018;10(1). doi:10.3390/nu10010097.
  6. Li H, Li Z, Peng L, et al. Lycium barbarum polysaccharide protects human keratinocytes against UVB-induced photo-damage.Free Radical Research. 2017;51(2):200-210. doi:10.1080/10715762.2017.1294755.
  7. Reeve VE, Allanson M, Arun SJ, Domanski D, Painter N. Mice drinking goji berry juice (Lycium barbarum) are protected from UV radiation-induced skin damage via antioxidant pathways.Photochemical & Photobiological Sciences: Official Journal Of The European Photochemistry Association And The European Society For Photobiology. 2010;9(4):601-607. doi:10.1039/b9pp00177h.
  8. Gao Y, Wei Y, Wang Y, Gao F, Chen Z. Lycium Barbarum: A Traditional Chinese Herb and A Promising Anti-Aging Agent.Aging And Disease. 2017;8(6):778-791. doi:10.14336/AD.2017.0725.
  9. Pullar JM, Carr AC, Vissers MCM. The Roles of Vitamin C in Skin Health.Nutrients. 2017;9(8). doi:10.3390/nu9080866
  10. Costa A, Pegas Pereira ES, Assumpção EC, Calixto Dos Santos FB, Ota FS, de Oliveira Pereira M, Fidelis MC, Fávaro R, Barros Langen SS, Favaro de Arruda LH, Abildgaard EN. Clin Cosmet Investig Dermatol. 2015; 8():319-28.