Do Omega-3s Reduce Osteoarthritis Pain?

How Do Rheumatoid And Osteoarthritis Differ?

Author: Dr. Stephen Chaney 

knee painThis week I am concluding my series on recent omega-3 advances by reviewing a meta-analysis that asks whether omega-3s are beneficial for people with osteoarthritis.

This is an important question because osteoarthritis affects around 32.5 million adults in the United States, and that number is increasing each year as our population ages. Osteoarthritis causes pain and disabilities that can significantly affect quality of life.

And the costs are high. Health care costs due to osteoporosis are around $140 billion/year. And when you include lost workdays, the annual cost is around $468 billion.

There are several medications for reducing symptoms of osteoarthritis. But they each have side effects and some patients cannot tolerate them. Joint replacement surgery is the final resort. But the recovery period is long, and the surgery isn’t always effective. For both reasons many patients with osteoarthritis are looking for natural solutions.

Most of the research on omega-3s and arthritis has been done with patients who have rheumatoid arthritis. Omega-3 supplements have been shown to reduce the pain, swelling of the joints, and inflammation associated with rheumatoid arthritis for many people with the disease.

Based on several dose-response studies, the NIH says the optimal dose is around 2.7 gm/day of EPA + DHA but cautions not to go above 3 gm/day without your doctor’s OK.

The evidence is less clear for omega-3s and osteoarthritis. Some studies suggest that EPA + DHA reduce the pain and inflammation associated with osteoarthritis. But other studies have come up empty. There is no consensus as to whether omega-3s are beneficial for people with osteoarthritis.

When there is disagreement between individual studies, a meta-analysis of the studies is often helpful. By pooling the data from multiple studies, a meta-analysis can smooth out some of the differences between the studies and accumulate enough data points to discover effects that would not have been statistically significant with the smaller data sets from individual studies.

With that in mind, the authors of this manuscript (W Den et al, Journal of Orthopaedic Surgery and Research, 18: 381, 3023) performed a meta-analysis on the data obtained from 9 double-blind, placebo-controlled studies looking at the effect of omega-3s versus a placebo on both pain and joint mobility in osteoarthritis patients.

How Do Rheumatoid And Osteoarthritis Differ?

While the causes of rheumatoid arthritis and osteoarthritis are very different, there are some underlying similarities between the two diseases that suggest both might benefit from omega-3 supplementation.

Rheumatoid Arthritis: Rheumatoid arthritis is thought to be an autoimmune disease, which means that our immune system attacks our cells rather than foreign invaders. It results in chronic inflammation that attacks our joints and can affect other tissues in our body.

It initially affects the lining of our joints which can result in painful, swollen joints. As the disease progresses it can also lead to bone erosion and joint deformity.

Osteoarthritis:Osteoarthritis is generally thought of as a “wear and tear” disease. It is associated with sports injuries and accidents. It is also associated with stress to particular joints due to repeated motions associated with either sports or a job. Obesity also increases wear and tear of the joints because it increases the load on the joints.

The wear and tear causes the cartilage that cushions the junction between bones to deteriorate. Eventually, the cartilage deteriorates to the extent that bone is grinding against bone, which can lead to bone loss and deformities.

Eventually, this results in an inflammation of the joint lining which causes pain and accelerates bone loss. It also causes deterioration of the connective tissue which holds bones together and connects them to muscle.

What Do These Diseases Have In Common? Inflammation is the common factor associated with both rheumatoid and osteoarthritis, and many studies suggest that omega-3s reduce inflammation. In the simplistic description of the two diseases I shared above, it sounds like inflammation occurs much earlier in the disease process for rheumatoid arthritis than for osteoarthritis. This might suggest that omega-3s could be more effective at reducing the symptoms and progression of rheumatoid arthritis than of osteoarthritis.

However, we know that the risk of developing osteoarthritis is increased by chronic inflammation caused by obesity, diseases like diabetes, and/or an inflammatory diet.

How Was This Study Done?

clinical studyThis study was a meta-analysis of 9 double-blind, placebo-controlled clinical studies looking at the effect of omega-3 fatty acids on the pain and loss of joint mobility associated with osteoarthritis. These studies were performed in countries from around the world and included a total of 2,070 participants.

The criteria for inclusion in the meta-analysis were:

1) The articles were written in English.

2) The studies had to be double-blind, placebo-controlled studies (The gold standard for clinical studies).

3) Patients with osteoarthritis were randomly assigned to an intervention group receiving omega-3 supplementation or a placebo group receiving olive oil or another plant oil.

4) The studies measured efficacy and safety outcomes including joint pain (efficacy), joint mobility (efficacy), and treatment-related adverse events (safety).

5) Patients in both the omega-3 and placebo groups were using medications to reduce osteoarthritis symptoms when they were enrolled in the study and were advised to continue with their prescribed medicines for the duration of the study.

The characteristics of the clinical studies included in this meta-analysis were:

  • Sample size (47-1221), Average = 230.
  • Mean age (55.9-68), Average = 63.
  • % men (13.8-45.1%), Average = 31%.
  • Omega-3 (EPA + DHA) dose (350 mg/day – 2,400 mg/day), Average = 1,085 mg/day.

Do Omega-3s Reduce Osteoarthritis Pain?

Question MarkWhen the data from all 9 studies were combined in a single meta-analysis, omega-3 (EPA + DHA) supplementation:

  • Reduced joint pain by 29% compared to the placebo.
  • Increased joint mobility by 21% compared to the placebo.
  • Was not associated with any adverse effects.

The authors concluded, “The results of the meta-analysis indicate that supplementation with omega-3 fatty acids is effective to relieve pain and improve joint function in patients with osteoarthritis, without increasing the risk of treatment-related adverse events. These findings support the use on omega-3 fatty acid supplementation as an alternative treatment for osteoarthritis.”

What Are The Strengths and Limitations Of This Study?

strengths and weaknessesStrengths:

  • All the studies included in this meta-analysis were randomized, double-blind, placebo-controlled studies (the gold standard for clinical trials).
  • All the individual studies that qualified for this meta-analysis found that omega-3 supplementation reduced joint pain and improved joint mobility. This improves confidence that the conclusions of the meta-analysis are correct. The meta-analysis simply improved the statistical significance of this conclusion by combining the data from the individual studies.

Limitations:

  • The biggest limitation was that the individual studies included in this meta-analysis were not performed under the guidelines of the “Fatty Acids and Outcomes Research Consortium” that I discussed in last week’s issue of “Health Tips From the Professor”.
    • The “Fatty Acids and Outcomes Research Consortium” guidelines harmonize the designs of individual studies, which strengthens the meta-analysis.
      • In contrast, the design of the individual studies within this meta-analysis was very different, which prevented the meta-analysis from being able to determine the optimal dose of omega-3 supplements and the minimum time required for omega-3 supplementation to significantly reduce the symptoms of osteoarthritis.
    • The “Fatty Acids and Outcomes Research Consortium” guidelines would have also required these studies to measure tissue levels of omega-3s (something called Omega-3 Index) at the beginning and end of each study. This was not done in any of these studies.
      • This is important because if a patient’s tissue levels of omega-3s at the beginning of the study were already in the optimal range, you would expect little additional benefit from supplementation for that patient.
  • All the individual studies were very small. This limits the ability of these studies to provide definitive conclusions. Unfortunately, this is probably unavoidable.
    • Double blind, placebo-controlled clinical studies are expensive. Only major pharmaceutical companies have the multi-million-dollar budgets required to conduct large double blind, placebo-controlled clinical studies that would provide more definitive evidence that omega-3 supplementation reduces the symptoms of osteoarthritis – and the follow-up studies that would determine the optimal dose of omega-3 supplements and the minimum time required to show an effect of omega-3 supplementation.
  • The patients in these studies were already taking medications to reduce their osteoarthritis symptoms prior to entering the study and were instructed to continue taking those medications during the study. This means that the studies were not asking whether omega-3s alone were effective at reducing osteoarthritis symptoms. They were asking whether omega-3 supplementation provided any additional benefits for people who were already taking medications to reduce symptoms.
    • Unfortunately, this is also probably unavoidable. Current guidelines consider it unethical to withhold the medical “standard of care” from any patient in a clinical trial.

What Does This Study Mean For You?

Questioning WomanThis study, while not definitive, strengthens the evidence that omega-3 supplements containing EPA + DHA may reduce joint pain and improve joint mobility for people with osteoarthritis. It also shows that the doses required to achieve these benefits are not associated with any significant side effects.

While large scale double blind, placebo-controlled clinical studies to confirm these conclusions would be nice, they are unlikely to occur for the reasons discussed above.

The investigators said, “[This study shows that] supplementation of omega-3 fatty acids is effective to relieve pain and improve joint function in patients with osteoarthritis…These findings support the use of omega-3 fatty acid supplementation as an alternative treatment for osteoarthritis.”

This might lead you to believe that omega-3 fatty acids can potentially replace medications for reducing osteoarthritis pain and loss of joint mobility. That may be true, but that is not what the study showed.

Patients in both the omega-3 and placebo group continued their prescribed medicines for osteoarthritis. In reality, the study only shows that omega-3s provide additional benefit for people already taking osteoarthritis medications. The effect of omega-3 supplements by themselves has not been tested and, as I discussed above, is not likely to be tested in the foreseeable future.

However, the use of omega-3 supplements may allow you to reduce or eliminate the medications you are on for osteoarthritis and may delay the need for joint replacement surgery. Of course, if you wish to reduce/eliminate your medications and/or delay joint replacement surgery, I recommend consulting with your doctor first.

Finally, this study provides no information on the optimal dose of omega-3s. Some studies suggest the dose of omega-3s needed to reduce osteoarthritis symptoms may be less than that required to reduce rheumatoid arthritis symptoms, but that evidence is weak.

In the absence of good dose response data, I recommend you aim for an omega-3 index of 8%. You will find a more detailed discussion of the Omega-3 Index and how to use it in last week’s “Health Tips From the Professor” article .

The Bottom Line

A recent meta-analysis looked at the effect of omega-3 supplementation on the pain and lack of joint mobility associated with osteoarthritis.

The study showed that omega-3 (EPA + DHA) supplementation:

  • Reduced joint pain by 29% compared to the placebo.
  • Increased joint mobility by 21% compared to the placebo.
  • Was not associated with any adverse effects.

The authors concluded, “The results of the meta-analysis indicate that supplementation with omega-3 fatty acids is effective to relieve pain and improve joint function in patients with osteoarthritis, without increasing the risk of treatment-related adverse events.”

For more details about the study and what it means for you, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease. 

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My posts and “Health Tips From the Professor” articles carefully avoid claims about any brand of supplement or manufacturer of supplements. However, I am often asked by representatives of supplement companies if they can share them with their customers.

My answer is, “Yes, as long as you share only the article without any additions or alterations. In particular, you should avoid adding any mention of your company or your company’s products. If you were to do that, you could be making what the FTC and FDA consider a “misleading health claim” that could result in legal action against you and the company you represent.

For more detail about FTC regulations for health claims, see this link.

https://www.ftc.gov/business-guidance/resources/health-products-compliance-guidance

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About The Author 

Dr. Chaney has a BS in Chemistry from Duke University and a PhD in Biochemistry from UCLA. He is Professor Emeritus from the University of North Carolina where he taught biochemistry and nutrition to medical and dental students for 40 years.  Dr. Chaney won numerous teaching awards at UNC, including the Academy of Educators “Excellence in Teaching Lifetime Achievement Award”. Dr Chaney also ran an active cancer research program at UNC and published over 100 scientific articles and reviews in peer-reviewed scientific journals. In addition, he authored two chapters on nutrition in one of the leading biochemistry text books for medical students.

Since retiring from the University of North Carolina, he has been writing a weekly health blog called “Health Tips From the Professor”. He has also written two best-selling books, “Slaying the Food Myths” and “Slaying the Supplement Myths”. And most recently he has created an online lifestyle change course, “Create Your Personal Health Zone”. For more information visit https://chaneyhealth.com.

For the past 45 years Dr. Chaney and his wife Suzanne have been helping people improve their health holistically through a combination of good diet, exercise, weight control and appropriate supplementation.

Do Omega-3s Oil Your Joints?

Fish Oil And Osteoarthritis

Author: Dr. Stephen Chaney

Osteoarthritis is not just painful. It is one of the leading causes of disability in this country. And because the joint pain associated with osteoarthritis limits activity levels, it is linked to:

  • Obesity
  • The diseases associated with obesity (diabetes and heart disease).
    • Osteoarthritis increases the risk of heart disease by 50%.
  • Premature death associated with the increased prevalence of obesity, diabetes, and heart disease.
    • Osteoarthritis increases the risk of all-cause mortality by 55%.

If osteoarthritis were rare, these statistics would just be an interesting side note. But osteoarthritis is the most common form of arthritis. It affects more than 32 million Americans. And it is costly. It costs the American economy:

  • $65 billion in health care costs.
  • $17 billion in lost wages.
  • $136 billion in total costs.

Conventional therapy for osteoarthritis is treatment with anti-inflammatory drugs, but they have side effects. They may even increase the risk of premature death in some individuals.

What about natural anti-inflammatory nutrients and phytonutrients? Two that have received a lot of press in recent years are omega-3s (fish oil) and curcumin.

A recent meta-analysis (NK Senftleber et al, Nutrients, 9: 42, 2017) of 42 clinical studies on the effects of omega-3s on various types of arthritis found that:

  • There is moderate quality evidence that omega-3s reduce the pain associated with rheumatoid arthritis. Basically, this means that there is strong, but not definitive, evidence that omega-3s reduce the pain of rheumatoid arthritis. Other general conclusions with respect to rheumatoid arthritis were:
    • The best results were obtained from fish oil preparations with an EPA/DHA ratio of >1.5, suggesting that EPA is more beneficial than DHA.
    • Early studies suggested that the optimal dose of omega-3s was ≥2.6 g/day for ≥12 weeks.
  • There was low quality evidence for an effect of omega-3s on osteoarthritis. Only 5 clinical trials have been published on the topic and the results of those studies are conflicting.

The data for an effect of curcumin on osteoarthritis pain are even more limited. There is some evidence it might be beneficial, but the studies are small and are conflicting.

In this week’s issue of “Health Tips From the Professor” I discuss an exploratory study (JC Kuszewski et al, Rheumatology Advances In Practice 4: 1-9, 2020) on the effect of omega-3s and curcumin on osteoarthritis pain.

How Was The Study Done?

Clinical StudyYou are probably wondering, “What is an “exploratory study?” Let me start by providing you with a little perspective from my years of heading a cancer research laboratory at the University of North Carolina:

Clinical studies are expensive. And if you are trying to study an approach that has not already proven to be successful, the money needed to fund the study can be hard to come by. It is a “Catch 22” situation. You need to conduct an “exploratory study” to show your project is likely to succeed before the funding agency will give you money to fund your project.

But where do you get the money to fund your exploratory project? One way that investigators overcome that barrier is to use data from a previous study that was originally designed for a different purpose. The study I will describe today is an example of that approach.

The study utilized data collected from a clinical trial designed to measure the effect of omega-3s and curcumin on brain function in older adults. The study recruited 152 older adults (average age = 65) who were overweight to obese (average BMI = 31) and sedentary (˂55 min/week of physical activity) from New South Wales, New Australia.

The participants were randomly divided into 4 groups:

  • Placebo group. [Note: The fish oil placebo contained 20 mg of fish oil so it would match the odor of the fish oil supplement, and the curcumin placebo contained yellow food dye so it would match the color of the curcumin supplement.]
  • Fish oil group (2,000 mg DHA & 400 mg EPA per day).
  • Curcumin group (160 mg/day curcumin).
  • Fish oil + curcumin group.

Participants were followed for 16 weeks. At the beginning and end of the study participants filled out questionnaires assessing (among other things):

  • The severity of their chronic osteoarthritis pain.
  • Disabilities caused by osteoarthritis in the participant’s daily life (physical distress, sleep disturbances, psychological distress, loss of productivity, physical limitations, physical deconditioning due to reduction in physical activity, and financial hardship).
  • Their physical and mental wellbeing during the past 4 weeks.
  • Their mood during the past 7 days.

Do Omega-3s Oil Your Joints?

fish and fish oilThe results were as follows:

  • Omega-3 supplementation reduced chronic osteoarthritis pain by 42%.
  • Omega-3 supplementation reduced disability associated with osteoarthritis by 40%.
    • The reduction in pain and disability in participants supplemented with fish oil was greatest in those who reported the highest pain/disability at the beginning of the study.
    • The reduction in pain was associated with an improved perception of physical and mental wellbeing.
    • The reduction in pain was also associated with a decrease in depression and other mood disturbances.
  • Curcumin did not affect pain or osteoarthritis burden either alone or paired with omega-3s.

The authors concluded, “Our findings indicate potential for fish oil supplementation to reduce mild osteoarthritis pain and burden in sedentary overweight/obese older adults…,which was associated with improved wellbeing.”

What Are The Pros And Cons Of This Study?

pros and consPros:

The results for the effects of omega-3s on osteoarthritis were highly significant. In addition, the questionnaires used were well designed to capture the intensity and location of pain, mood, and feelings of wellbeing.

Cons:

This was an exploratory study using data collected from a study designed to measure the effect of omega-3s and curcumin on brain health in older adults. It was not ideally designed to measure the effect of omega-3s and curcumin on osteoarthritis.

If the original study had been intended for investigating the effect of these supplements on osteoarthritis, it would have been designed differently:

  • Participants would have been recruited into the study based on the presence and intensity of osteoarthritis pain.
  • The diagnosis of osteoarthritis would have been confirmed by X-rays.
  • Participants would have been admitted into the study only if they had moderate to severe osteoarthritis pain. Most of the participants in this study had only mild osteoarthritis pain. That may have limited the ability of this study to find an effect of curcumin on osteoarthritis pain.
  • The design of the omega-3 supplement would have been different.
    • Because the original study was designed to determine the effect of omega-3s on brain health, the omega-3 supplement chosen had more DHA than EPA.
    • Had the study been designed to determine the effect on omega-3s on an inflammatory disease like osteoarthritis, the omega-3 supplement would have had more EPA than DHA.
  • The curcumin supplement was also not ideally designed for this study. The curcumin supplement used in this study contained only 160 mg of curcumin and contained no other ingredients. Well-designed curcumin supplements usually contain around 500 mg curcumin standardized to 95% curcuminoids plus piperine to enhance the absorption of the curcumin.

In the words of the authors, “Further studies are warranted to evaluate the benefits of fish oil, alone or as an adjunct to pharmacotherapy, in patients diagnosed with osteoarthritis who suffer moderate-to-severe pain…” In other words, they now intend to use the data from this exploratory study to apply for funds to conduct a larger study specifically designed to measure the effects of omega-3s on osteoarthritis pain.

The study limitations described above, severely restricted the ability of the study to detect any beneficial effect of curcumin on osteoarthritis pain. The effect of curcumin on osteoarthritis pain is probably less than the effect of omega-3s, but it would be premature to conclude that it has no benefit. However, they obtained no data from their “exploratory study” to justify a follow-up study on the effect of curcumin on osteoarthritis pain.

Fish Oil And Osteoarthritis

omega-3 fish oil supplementThis study suggests that 2.4 grams/day of omega-3s may be equally effective at reducing osteoarthritis pain and the effects that osteoarthritis pain has on both physical health and psychological health. However, because this study has several limitations, the evidence cannot be considered definite.

If you have either rheumatoid or osteoarthritis, I recommend trying omega-3 supplementation. Based on the studies described above, you might want to aim for 2-3 g/day of omega-3s with an EPA/DHA ration of 1.5 or greater.

As with any natural approach, this will work better for some people that for others. However, don’t forget that omega-3s are also important for heart health, healthy blood pressure, brain health, and a healthy pregnancy (https://www.chaneyhealth.com/healthtips/omega-3s-during-pregnancy-are-healthy/). If they also happen to reduce your arthritis pain, that is an extra benefit.

As usual, I recommend a holistic approach. You should also:

  • Keep active.
  • Aim for a healthy weight.
  • Add antioxidant and polyphenol supplements.

These lifestyle changes should allow you to reduce or eliminate any pain medication you may be taking.

Finally, if you are on blood thinners, consult with your physician before adding omega-3 supplements to your diet. My preference is to incorporate omega-3s and reduce other medications, but that is a discussion you need to have with your doctor.

The Bottom Line

A recent meta-analysis has concluded there is moderate quality evidence that omega-3s reduce the pain associated with rheumatoid arthritis. Basically, this means that there is strong, but not definitive, evidence that omega-3s reduce the pain of rheumatoid arthritis. Other general conclusions with respect to rheumatoid arthritis were:

  • The best results were obtained from fish oil preparations with an EPA/DHA ratio of >1.5, suggesting that EPA is more beneficial than DHA.
  • Earlier studies suggested that the optimal dose of omega-3s was ≥2.6 g/day for ≥12 weeks.

However, there have been few studies on the effect of omega-3s on osteoarthritis. A new exploratory study looked at the effect of 2.4 g/day of omega-3s for 16 weeks on the pain and disability associated with osteoarthritis. It found:

  • Omega-3 supplementation reduced chronic osteoarthritis pain by 42%.
  • Omega-3 supplementation reduced disability associated with osteoarthritis by 40%.
    • The reduction in pain and disability in participants supplemented with fish oil was greatest in those who reported the highest pain/disability at the beginning of the study.
    • The reduction in pain was associated with an improved perception of physical and mental wellbeing.
    • The reduction in pain was also associated with a decrease in depression and other mood disturbances.

The authors concluded, “Our findings indicate potential for fish oil supplementation to reduce mild osteoarthritis pain and burden in sedentary overweight/obese older adults. Further studies are warranted to evaluate the benefits of fish oil, alone or as an adjunct to pharmacotherapy, in patients diagnosed with osteoarthritis who suffer moderate-to-severe pain…”

If you have either rheumatoid or osteoarthritis, I recommend trying omega-3 supplementation. Based on the studies described above, you might want to aim for 2-3 g/day of omega-3s with an EPA/DHA ration of 1.5 or greater.

As with any natural approach, this will work better for some people that for others. However, don’t forget that omega-3s are also important for heart health, healthy blood pressure, brain health, and a healthy pregnancy. If they also happen to reduce your arthritis pain, that is an extra benefit.

As usual, I recommend a holistic approach. You should also:

  • Follow an anti-inflammatory diet.
  • Keep active.
  • Aim for a healthy weight.
  • Add antioxidant and polyphenol supplements.

These lifestyle changes should allow you to reduce or eliminate any pain medication you may be taking.

Finally, if you are on blood thinners, consult with your physician before adding omega-3 supplements to your diet. My preference is to incorporate omega-3s and reduce other medications, but that is a discussion you need to have with your doctor.

For more details read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

Health Tips From The Professor