APR-A-9
My response to a questioner sent to the American Running and Fitness Association Clinic and referred to me for a response regarding the claims for Nutraceuticals
From: Glenn Geelhoed
To: "clinic@americanrunning.org".IA4GW.Harper
Date: 4/9/01 9:58AM
Subject: Re: question from a member
Dear Barb:
I have pasted the response you had requested to a member's question in the space below, and had also added another contribution for the AMAA Quarterly on the "Antarctic Run".
I will put a hard cover response together with supporting literature and post it to you before we get together in Boston, where I will see you soon.
Thanks!
GWG
John Evans
6195 Stone Arabia Road
Cicero, NY 13039‑0396
Dear John:
You are certainly right on several counts: there is a great proliferation of "nutraceutical" supplements and an even greater proliferation of claims for their alleged efficacy, many using the kind of terms you cited "arthritis fighter" or various claims of "immune system boosters" or "anti‑cancer" nutrients. These claims get more exuberant than those typically seen for drug treatments, at least currently, since there have been constraints placed upon therapeutic claims for drugs that prevent the snake oil advertising without FDA approval through evidence based data of safety and efficacy. You are also correct that there are no biologic systems of which I am aware in which there is evidence for a sulfur or sulfonyl deficiency to produce the di‑sulfide cross linkage in collagen healing/scarring systems. There are a few micronutrients that are required for growth/repair/replacement in human metabolism, a few of these are simple minerals, like calcium, iron and iodine, and because we lack the enzymes for synthesizing other "vital amines" (contracted as "vitamins"), we need to take them in from other sources that can synthesize them, typically plant food sources. This is also true, to a much lesser extent, for a few "essential lipids." Most of these micronutrients are found in a balanced diet. If fed in much greater quantity than the RDA recommended for daily adult requirements, most supplements constitute very expensive and unnecessary calories.
Having made these conservative declarations that you expected already as common knowledge, we recognize certain conditions of stress which may have above normal requirements, already acknowledged in conditions such as pregnancy, inflammatory diseases or post‑injury healing, and endurance runners may be considered a special case, since they are rather regularly in a repair state from repeated low grade (and, sadly, some times not so low grade) injury. The micro‑tears in muscles and fascia that come from competitive running out at marathon distances are generally repaired within a few rest days in muscle and connective tissue, more or less, and as we get to the lesser end of that spectrum, in bone and joint wear and tear. Under even the best of circumstances, cartilage is nearly an end‑stage tissue that most usually heals, if at all, by scarring‑replacing articular cartilage with collagen‑based connective tissue. If there were a means of helping the healing process, in joints particularly, such treatment would be helpful.
Such agents exist, and many of the drugs and a few of the nutrients are now proven beyond statistical or clinical doubt by controlled trial. You are familiar with the anti‑inflammatory drugs, particularly the non‑steroidal agents that act in the arachadonic acid‑derived eicosanoid system of inflammatory mediators. Especially helpful now are the newer introductions of COX‑2 inhibitors of which at least three have recently come to market. But there are now good clinical trial tests of combinations of a few of the agents you had referred to, particularly glucosamine/chondroitin sulfate. Once skeptical about claims for complex glycosamines or ground substance products that I thought would most likely be broken down and absorbed as simple nutrients, I was unimpressed by anecdotal testimonials in the early claims for this combination of agents, which might be considered placebo effect given their claimed benefits which followed their high priced special administration. Several persuasive items have changed my mind, so that I, like you, have become an advocate for the use of this product. Double blind trials in veterinary practice show objective evidence of improvement in joint from and function, and animals are less subject to placebo effect than humans. Second, the product has shown proven efficacy in the treatment of human osteoarthritis, in distinct contrast to rheumatoid arthritis, so the claim for joint improvement is not universal. And, third, animal model and cell culture trials show chondroprotection and repair under treatment with both agents. The product that comes supplied as a capsule with 500 mg of glucosamine/400 mg chondroitin sulfate is adequate for most maintenance programs, although a period of loading with twice this level in the acute post‑injury phase is recommended. There is no evidence that the excessive doses, as you already have been advised, have any benefit associated with consumption at that level, except, once again, to furnish very expensive calories from a less gourmet source than bovine tracheas and crab shells.
The roles of antioxidants in the both normal nutrition and for the special needs of endurance runners in the possible prevention of many kinds of inflammation and even neoplasm is a bigger question than a brief response can adequately cover, but on the basis of the evidence to date, I would have some enthusiasm for supplementation of Vitamins C and E with a multivitamin containing selenium, but stop short of a pharmacopoeia designed to scavenge free radicals in self‑limited inflammatory conditions.
To return to what was agreed upon at the outset, a balanced diet, varied among a mixed group of fresh plant food sources, is the best nutritional advice, combined with stronger advice on a good, sustained exercise program, for retention and repair of joint cartilage and its function upon which we runners depend. Of the increasingly large variety and larger claims of many newer nutraceuticals, the evidence is limited, in supporting the claims of only a few, and that at levels within a reasonable dose range, almost within reach of the balanced diet under even stress conditions. Balance in diet and exercise is not substituted for by overdosing a variety of supplements, extracted from foods to enjoy the less stringent standards of proof for foodstuffs, while being sold as drugs with claims that could not be supported if they were classified as therapeutic agents.
My only all‑purpose aphorism as a dedicated runner continues to be: "Moderation in all things; above all, in the practice of moderation."
Glenn W. Geelhoed, MD, MA, MPH, DTMH
>>> The Clinic <clinic@americanrunning.org> 04/05/01 03:31PM >>>
Glenn,
An American Running member wrote to use asking about glucosamine/chondroitin...the letter is below. Because you'll be talking about this subject next week, I thought you might have this info fresh in your mind....can you help? :‑) ‑Barb
From: "Evans EMailbox" <ourmail@twcny.rr.com>
Good Morning
I have some questions regarding nutritional supplements for joint andcartilage
health.I have been very happy with and promoted to many others the use of Glucosamine
/ Chondroitin as reported in several of the newsletters. I wish I had been
using Glucosamine earlier as I would most likely not had one or maybe even both
of my arthroscopic surgeries on my knees. I am currently using 750 mg daily
and have used up to 1000 mg daily at one point. In conversations with flight
surgeons they have confirmed that more than 1000mg is not required in contrast
with several manufacturers suggested dosages.
And some companies are suggesting Chicken Collagen II as a natural source of
Glucosamine. Now several companies are suggesting the use of MSM (methylsulphonylmenthane)
as well. They point out that collagen can not be produced in the body to repair
cartilage unless sulfur, ie. Sulfonyl, is present in the body. As far as I
can determine there is no studies to reflect a systemic lack of sulfur in the
population today nor a study showing the positive impact of MSM intake and symptom
relief. Could you clarify?
Gero Vita Labs (www.gvi.com) has also added CMO, cetyl myristoleate,
as arthritis fighter citing that double‑blind, placebo‑controlled
clinical testing on humans yielded 65% improvements in three months. They also
add Bromelain citing its efeect of stopping bad prostaglandins while not affecting
the good ones with studies by two different doctors. And then they add Tumeric
to eliminate nitric oxide radicals as well as curumin, vitamin C and lipase
to help in absorption of collagen etc. Do you have any comments on the proliferation
of all these supplements and their claims?
Thanx
John Evans