Older athletes: Don’t let age become a pain!

Andrew Hamilton looks at exciting new research on natural plant extracts that can combat inflammation, accelerate recovery and reduce stiffness

The theoretical physicist Stephen Hawking once said: “You may see a cup of tea fall off a table and break into pieces on the floor. But you will never see that cup gather itself back together and jump back on the table. The increase of disorder, or entropy, is what distinguishes the past from the future, giving a direction to time”.

This increasing disorder as time passes is also why we age. No matter how perfectly formed at birth, the physiological structures and genetic programming of the human body gradually becomes more disordered and less efficient as the years pass. For aging athletes, this manifests itself as progressively reduced strength and endurance, slower recovery and increased soreness after training. Over extended periods of time, more insidious changes can occur, leading to more chronic pain, stiffness and swelling – for example conditions such as osteo and rheumatoid arthritis.

The enemy is inflammation

A common factor in these trainingrelated manifestations of aging is an increase in inflammation. While some inflammation (for example following an acute injury) is a part of the natural healing process and a desirable thing, chronic inflammation caused by age-related degeneration is not. When inflammation becomes chronic, it can result in damage to healthy tissue, which triggers further inflammation, leading to a vicious circle.

When inflammation becomes chronic, anti-inflammatory medication in the form of non-steroidal anti-inflammatory drugs (NSAIDs) is often prescribed. However, while effective in the short term, the long-term use of NSAIDs carries considerable risk. In particular, the mechanism of NSAID action (see figure 1) can result in damage to the lining of the stomach, leading to stomach ulcers and gastric bleeding, which can be potentially very hazardous (see table 1). For this reason, the long-term use of NSAID painkillers such as Ibuprofen is not recommended. Indeed, even the short-term use of NSAIDs following acute injury may be undesirable because various studies have shown that NSAIDs can delay muscle regeneration and may reduce ligament, tendon, and cartilage healing, making re-injury or chronic injury more likely^{Sports Med. 1999;28:383–8 BMC Complement Altern Med. 2006;6:13}.

The good news for older athletes prone to training-related aches and pains is that recent scientific research suggests that a number of naturally occurring food compounds can help counter inflammation - without the undesirable side effects of medication. Indeed, some of these extracts may also enhance recovery and performance in their own right, and confer additional health benefits such as a reduced risk of degenerative diseases like coronary heart disease and cancer. In this article therefore, we’ll consider some of the natural options for older athletes seeking a more natural way to fight training-related aches and pains.

Figure 1: How NSAIDS work

Curcumin (turmeric)

One of the potential anti-inflammatory, jointhealth agents currently under intense scientific scrutiny is curcumin. Curcumin is derived from turmeric, a popular spice used in India, South Asia, and Japan, and which is the ground root and root system of the plant Curcuma longa (see figure 2). In traditional Indian medicine, turmeric is used to treat digestive disorders, wounds, and rheumatic diseases. Besides vitamins, minerals, protein, carbohydrate etc, the extract of turmeric contains 77% curcumin, 17% demethoxycurcumin, and 3% bisdemethoxycurcumin, collectively named curcuminoids, which render turmeric its distinct orangey-yellowish hue (Figure 1). Curcumin is both a powerful anti-inflammatory and antioxidant.

In fact, such is the potency of curcumin’s antioxidant and anti-inflammatory activity that scientists are currently investigating its potential to treat and prevent a wide array of degenerative and inflammationrelated diseases. Thanks to its different pharmacological actions, curcumin has been employed in different studies involving several pathologies such as cardiovascular and ophthalmic diseases, diabetes, depression, HIV, vitiligo, Alzheimer’s disease, endometriosis, osteoporosis, inflammatory bowel disease, epilepsy, Parkinson’s disease, and even cancer (see figure 3)^{Iran J Pharm Res. 2015;14:479–86 Pharmacogn Rev. 2010;4:27–31 Sci Rep. 2016;6:27539 Planta Med. 2014;80:249–54 Rev Bras Farmacognosia. 2015;25:53–60 Curr Top Med Chem. 2017;17:148–61 Eur J Pharmacol. 2016;784:192–8 Iran J Reprod Med. 2013;11:415–22 Neurochem Int. 2015;89:40–50 Nutrients. 2016 8. pii: E334 Int J Mol Med. 2016;37:329–38 Neurochem Res. 2016;41:3113–28}.

One area where curcumin is proving to be very effective is in the treatment of joint pain and arthritis (both rheumatoid and osteoarthritis). A number of studies have demonstrated that taken as supplement, curcumin can diminish joint pain and improve mobility compared to an inert placebo, and that these improvements are brought about by a reduction in joint inflammation^{Drug Design, Development and Therapy 2016:10}. Indeed, there’s good evidence that curcumin may be as effective in reducing inflammation and pain as over-the-counter Ibruprofen.

In one study, 185 osteoarthritic patients took 1,500mg of curcumin extract per day for four weeks while a further 160 patients received 1,200 mg Ibuprofen per day^{Clin Interv Aging. 2014;9:451–458}. The results showed that both groups exhibited significant and similar improvements in pain and mobility. This study is particularly important because it is the largest curcumin study on osteoarthritis to date, and it benefited from having a large sample size, proper blinding and randomisation, despite a short duration of treatment – in other words, the evidence is of very high quality.

How does curcumin exert these beneficial effects? This is an area of ongoing research, but it’s most likely due to curcumin’s ability to prevent the destruction of key cells called chondrocytes, which are involved in the formation and maintenance of joint cartilage. Its anti-inflammatory effect also helps in the process, as well as producing a pain-reduction effect in its own right.

Summing up, extensive clinical trials on the effects of curcumin in patients with joint pain and stiffness show that curcumin can reduce pain and improve functionality in as little as four weeks and its effects are comparable to standard pharmacological agents, such as NSAIDs and glucosamine. The usual dosage of standardised turmeric powder is 400– 600 mg taken three times per day.

TABLE 1 AGE RELATED RISK OF NSAIDS PROBLEMS

The chance of a gastrointestinal (GI) bleed following chronic NSAID use is high. Once a bleed occurs, there is a 1 in 6 chance of death. Even without GI bleeds, prolonged NSAID use can lead to a variety of side effects including indigestion, tummy aches, nausea, headaches and dizziness.

Figure 2: Cumcuma longa root

Figure 3: Diseases and medical conditions where curcumin may be of therapeutic value

Tart cherry extract

Cherries first hit the sports nutrition headlines back in the mid 2000s, when it was discovered that by consuming tart cherry (Montmorency) juice, athletes were able to reduce the extent of exercise-induced muscle damage following very strenuous exercise. Soon after, other studies confirmed that this reduced muscle damage might explain why tart cherry juice could also reduce post-exercise muscle soreness.

In the intervening years, further research has also suggested that cherry juice taken after an initial bout of hard exercise might help improve exercise efficiency during a second bout a few days later and that it can also help before an initial bout of exercise. For example, a study just last year looked at whether short-term supplementation of a powdered tart cherry supplement prior to and following a half marathon affected performance in runners and triathletes, along with markers of muscle damage and inflammation, and/or muscle soreness^{J Int Soc Sports Nutr. 2016 May 26;13:22}.

It turned out that when the athletes took the tart cherry supplement, they averaged 13% faster times in the half-marathon race. Even better, the tart cherry-supplemented athletes reported lower levels of post-exercise muscle soreness before the race and experienced more rapid recovery from soreness after the race. This was borne out by the levels of inflammatory chemicals in the tart cherry athletes, which were lower than in the placebo group.

The anti-inflammatory and soreness-reducing effects of tart cherry juice appear to be due to the high levels of natural phytochemical antioxidant compounds called anthocyanins (see figure 4), which are found in high concentrations in all tissues of most dark/brightly coloured fruits and plants. Research has shown that by suppressing biochemical pathways in the body leading to inflammation, these anthocyanins may actually provide a more potent anti-inflammatory effect than aspirin^{J. Nat. Prod. 1999; 62(2): 294-296 Exerc. Immunol. Rev. 2005; 11: 64-85}!

In what form and how often should tart cherry juice be consumed? The evidence seems to suggest that cherry juice is particularly effective prior to and following bouts of more intense exercise. Therefore, consuming 30-60mls of tart cherry juice concentrate twice a day during periods of high-intensity training is likely to be a useful strategy. It can of course be taken as an everyday supplement, and there’s good evidence that this can produce additional health benefits such as improved cardiovascular health^{Am J Clin Nutr. 2016 Jun;103(6):1531-9} and better sleep quality^{Eur J Nutr. 2012 Dec;51(8):909-16}. However, given the cost of a quality tart cherry concentrate, this may be prohibitive.

Figure 4: Antioxidant power of tart cherry juice

Ginger

Ginger, which is the root system of a plant called Zingiber officinale (see figure 5), has been used as a herbal drug for a long time. In traditional Chinese and Indian medicine, ginger has been used to treat a wide range of diseases including stomach ache, diarrhea, nausea, asthma, respiratory disorders, toothache, gingivitis, and arthritis. In the early 1970s, it was discovered that NSAIDs exert their therapeutic effects by inhibiting the biosynthesis of prostaglandins (PGs – see figure 1). Soon thereafter, ginger was found to contain constituents that inhibit PG synthesis too, and subsequent studies revealed that some of the constituents of ginger have pharmacological properties similar to the new class of dualacting NSAIDs, which have notably fewer side effects than conventional NSAIDs^{J Med Food. 2005;8:125–32 Food Chem Toxicol. 2008;46:409–20}. Since then, several animal studies have shown that dried ginger or ginger extract can reduce acute inflammation ^{Phytomedicine 2005;12:684–701 Phytother Res. 2006;20:764–72 Prostaglandins Leukot Essent Fatty Acids. 2007;77:129–38 Basic Clin Pharmacol Toxicol. 2009;104:262–71}. In humans, several clinical studies support the value of ginger for the treatment of osteoarthritis, and in some cases, a significant reduction in knee pain has been reported^{Osteoarthritis Cartilage. 2003;11:783–9 Osteoarthritis Cartilage. 2000;8:9–12 Arch Iran Med. 2005;8:267–71}. Some of these trials also found that ginger relieved pain and swelling to varying degrees in patients with osteoarthritis, rheumatoid arthritis, and muscular pain - without causing serious adverse effects even after long periods of use^{J Altern Complement Med. 2009;15:231–7}.

Figure 5: Ginger root

A very recent study has demonstrated the anti-inflammatory power of ginger^{Dent Res J (Isfahan). 2017 Jan-Feb; 14(1): 1–7.}. The 67 subjects were actually dental patients who had to undergo a tooth extraction. Immediately following the extraction, the patients were randomly allocated into one of the three groups:

• A 500mg capsule of ginger powder taken after surgery then at 6-hourly intervals
• A 400mg Ibuprofen capsule taken at 6-hourly intervals
• An inert placebo capsule taken 6-hourly The subsequent degree of swelling, pain and need for paracetamol (when the pain became too uncomfortable) were recorded over the following days. The results showed that both the ginger and Ibuprofen resulted in less pain and swelling, with less need for paracetamol use. Also, the ginger was equally as effective as Ibuprofen at combating pain (see figure 6).

Why is a study into dental pain relevant to athletes with joint pain or stiffness I hear you ask? Well, that’s because the dental pain model is a widely employed, validated, and highly standardised acute pain model, and has been shown to be the most appropriate model to investigate the onset of analgesic action. It is often used as the reference clinical pain model for the investigation of analgesic drugs, and in this model, compounds with anti-inflammatory properties provide better pain relief than conventional painkillers.

Figure 6: Ginger supplementation and pain^{Dent Res J (Isfahan). 2017 Jan-Feb; 14(1): 1–7.}

Omega-3 essential oils (fish oil)

The use of fish oil (in the form of cod liver oil), an omega-3 essential fatty acids (EFA)s, for the treatment of muscular and skeletal diseases, can be traced back to the late 18th century. However, because of the rapid onset of rancidity of these polyunsaturated oils when exposed to air (and hence the disconcerting odour), cod liver oil fell out of favour. But now, with improved extraction techniques such as using a protective nitrogen blanket and enhanced oxygen-free encapsulation methods, there is less chance of oxidation during the manufacturing process.

Over the past 20 years or so, research has shown that omega-3 polyunsaturated fatty acids are some of the most effective natural anti-inflammatory agents available. With the discovery that inflammation in blood vessels is the underlying cause of coronary artery disease, fish and fish oil supplements are now recommended by the American Heart Association for the prevention of this disease. The biological basis for the effectiveness of fish oil in treating arthritis has been well documented with many positive clinical studies, when compared to traditional pharmaceutical anti-inflammatory agents^{Cell Mol Life Sci. 2000;57:834–41 Drug Discov Today. 2004;9:165–72 J Bio Chem. 2000;275:721–4 Arthritis Rheum. 2002;46:1544–53}.

The active ingredients in fish oil (eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) – see figure 7) enhance the production of a substance known as prostaglandin E3. A natural anti-inflammatory agent, prostaglandin E3 competitively inhibits the effects of the arachidonic acid conversion to prostaglandin E2, a highly inflammatory substance (as shown in figure 1). Prostaglandin E3 also inhibits the synthesis of TNF-α and IL-1b, both of which are immune cells involved in the process of inflammation.

Figure 7: Omega-3 oils EPA and DHA

Furthermore, omega-3 EFA, found in fish oil, can directly reduce the levels of degenerative enzymes that are involved in the inflammation and breakdown of synovial cartilage in joints. A 2006 study of 250 patients with cervical and lumbar disc disease, who were taking NSAIDs revealed that 59% could substitute fish oil supplements as a natural anti-inflammatory agent for the NSAIDs^{Surg Neurol. 2006;65:326–31}. More recent studies provide further evidence for the value of using omega-3 EFAs to reduce pain and inflammation. In a 2012 study, researchers reviewed the data accumulated from 23 previous studies on this topic. It found that that there was a modest but fairly consistent benefit of omega-3 EFAs on joint swelling and pain, duration of morning stiffness, and discomfort^{Br J Nutr. 2012 Jun;107 Suppl 2:S171-84}.

In a brand new study published just last month, researchers carried out a metastudy (gathering the data together from previous studies) to determine the effect of omega-3 EFAs on arthritic pain^{Nutrition. 2017 Jul - Aug;39-40:57-66}. Eighteen studies published between 1985 and 2013 involving 1143 patients were included, with doses of 2.1 to 9.1 grams of EFA per day, with study durations of 12 to 52 wk. They concluded that while a minority of studies proved inconclusive, studies using doses of 3-6 grams per day of omega-3 EFAs had a therapeutic role in decreasing arthritis-associated pain.

Practical recommendations for the older athlete

Reducing inflammation in the body is an essential element of a programme to promote maximum mobility and minimum stiffness pain in older athletes. This is particularly true when training loads or intensities increase. Here then are some practical recommendations based on the research above combined with overall best practice.

GENERAL DIET

• Eat fatty fish (mackerel, herring, trout, salmon, sardines etc.) twice a week to boost your omega3EFA intake.
• Consume pumpkin seeds and walnuts as snacks and add to salads to further boost omega-3 intake.
• Use flax seed and/or extra virgin olive oil for salad dressings; both of these oils have been shown to exert an anti-inflammatory effect^{Metabolism. 2013 May;62(5):686-93}.
• Avoid the excessive use of sunflower oils and spreads. These are rich in omega-6 EFAs, which can reduce the benefits of consuming omega-3 oils. Use butter or olive oil for frying and spread butter on bread.
• Try to consume plenty of colourful fruits and vegetables such as blueberries, blackberries,
  cherries, strawberries, spinach, kale and broccoli each day. The powerful antioxidants in these foods will help fight inflammation.
• Use beans for some of your protein needs. Beans contain several antioxidant and anti-inflammatory compounds. They’re also a low-cost source of fibre, vitamins and minerals.
• Avoid processed foods such as biscuits, crisps, cakes and other snacks; these are often high in unhealthy fats, which are linked with inflammation. Opt for fresh fruit instead.
• Use alcohol sparingly as excessive alcohol consumption may increase inflammation. If you enjoy a tipple, red wine is probably your best bet as resveratrol - a compound found in red wine - is known to have anti-inflammatory effects^{Inflammation. 2007;30:1–6}.

LIFESTYLE

• Get sufficient sleep; sleep deprivation is known to enhance inflammatory processes in the body.
• Try to avoid prolonged periods of stress by using relaxation techniques if necessary. Stress raises levels of a hormone called cortisol, which in the short term, acts as a potent anti-inflammatory. However, when stress becomes chronic and cortisol remains elevated for long periods of time, cortisol dysfunction may occur, with increased levels of inflammation and pain^{Physical Therapy. 2014;94(12):1816-1825}.

SUPPLEMENTATION

• When taking curcumin, go for a standardised turmeric extract, which will contain known levels of curcumin compounds. Take around 2,000mgs (2g) per day in divided doses, with food. Allow at least four weeks to experience the full effects.
• If you want to try out cherry extract supplementation, be sure that the supplement is from tart cherries - eg Montmorency tart cherries. Ordinary sweet cherries, while delicious and healthy, don’t have the same antioxidant levels as tart cherries.
• Allow at least a week to 10 days of supplementation before expecting the full benefits of supplementation; it takes time for the compounds to accumulate and exert maximum effect.
• Choose a reputable brand of tart cherry extract with proven high levels of antioxidants. Some of the cheaper brands may contain extracts that aren’t rich in the biologically active ingredients.
• When supplementing omega-3, bear in mind that most fish oil supplements have a one to one ratio of DHA to EPA. If your goal is to dampen or prevent inflammation, a fish oil containing more EPA than DHA may be desirable.
• Ensure that your diet contains two portions per week of fatty fish in addition to any omega-3 supplement (see above).
• While many forms of ginger boast health benefits, powdered ginger in capsules is what has been used in the literature, and is recommended.
• Look for brands that use ‘super-critical extraction’, because it results in the purest ginger and will provide the greatest effect. Aim for a total daily intake to provide 10-20mg of gingerols – the active component in ginger.
• Take ginger capsules with food; although small amounts of ginger can help settle a sour stomach, concentrated doses may cause nausea.
• Although they smell wonderful, foods like gingerbread, gingersnaps and ginger tea may not contain enough ginger to have an effect.