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OSTEOARTHRITIS

Updated 7/24/2013   


         Dr. Bernard Presser D.C.

5696 Magnolia Woods Drive

Memphis, TN 38134



 

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Arthritis has been called the "world's primary crippler."  Nowadays one in three families in Western industrialized societies is touched by the condition.  About 40 million Americans suffer from some form of it.

Although more than 100 different afflictions are placed under the heading of ‘arthritis' (rheumatic diseases) -- from Lyme disease to ankylosing spondylitis -- the most predominant forms are rheumatoid arthritis and osteoarthritis (OA).  About 75% of adults in the U.S. have OA by the time they are 65 years old.  Women over the age of 45 are 10 times as likely to get OA as men. i

OA is a wear-and-tear process with degeneration of articular (joint) cartilage and secondary changes in underlying bone and surrounding tissues.  The cartilage (Latin cartilago, gristle) -- dense connective tissue that covers the joint surfaces of bones -- begins to degenerate or break down.  As the cartilage is slowly destroyed, bone spurs may form (hyperplasia, excess tissue growth, develops as a compensation or defense).  Pain, restricted motion, and deformity may develop.  The more the involved joints are used, the more painful they become.

OA primarily affects weight-bearing joints such as the knees, ankles, hips, hands, and spine (called "degenerative disk disease" since the cartilagenous disks that cushion vertebrae break down).  Trauma and repetitive use of other joints seem to increase risk in some individuals such as OA in the shoulders of baseball players, or in feet and ankles of ballet dancers.

These joints are subject to a lot of mechanical stress, so doctors often attribute OA to normal aging.  "Age is certainly a factor, and genetics may also play a role.  But OA is not simply a matter of wear and tear; it's also a failure of the cartilage to repair itself.  It is a disease, not just the inevitable result of aging."

Thus, some scientists think that defective collagen (a cartilage component), obesity, poor posture, and other factors contribute to the condition.  After all, not everyone gets OA as they age and the percentage of persons affected has steadily increased over the years.  Rather than a ‘normal' eventuality, OA may be prevented, slowed, or halted in many individuals.  "If you can stop cartilage from being destroyed, and actually rebuild it, you can control osteoarthritis more effectively than simply by taking medications for pain and inflammation." ii

Inflammation occurs commonly in all types of arthritis.  This is a natural and complex process by which the body attempts to remove dead or damaged tissue cells and to lay down the matrix for new cells to replace those eliminated.  However, to accomplish such tasks, all required nutrients for immune system function, its participants (as white blood cells), and tissue regeneration must be present in adequate amounts. Also, interference in any stage(s) of inflammation and repair may sabotage these innate processes.

For example, OA is usually treated with aspirin, other non-steroidal anti-inflammatory drugs (NSAIDs), or injections of cortisone or prednisone, all of which interfere with various stages of inflammation.  Symptoms may temporarily abate, yet at great expense.  Aside from not addressing the cause of the problem, repair from the inflammatory process cannot be properly completed.  Joint degeneration will proceed since only the brain is "fooled" by the drugs.  The joint continues to be stressed, so more breakdown and pain ensue.  Also, such medications may themselves contribute to increased degeneration of the cartilage and bone, leading to more hyperplasia, more joint capsule scarring, and more pain. iii

The popular NSAIDs such as aspirin, ibuprofen (Motrin, Advil), indomethacin (Indocin), naproxen (Naprosyn, Aleve), piroxicam (Feldene) have other serious adverse effects, particularly gastrointestinal irritation, erosion, and blood loss.  Used daily by some 13 million Americans, NSAIDs result in 2600 deaths yearly and many thousands of toxic reactions.  These drugs inhibit the manufacture of prostaglandins which, among other functions (including thermo-regulation, melatonin synthesis, sleep), play an essential role in inflammation.  One group of OA researchers concluded: "NSAIDs are overvalued as symptomatic treatments, yet they continue to be prescribed in high quantities as analgesics." iv

LOOKING DEEPER

It would seem prudent, then, to examine causes and possible solutions.

Connective tissues are made up of three major molecular components: (1) Collagen, the most abundant protein in the body, consists of and requires 17 amino acids, four of which, in foods, are inactivated by the heat of cooking or pasteurization.  An interstitial (cross-linked) matrix of fibers, collagen helps produce great strength, but does not have much capacity to stretch. (2) Elastin, a yellow elastic fibrous mucoprotein (a thick, gelatinous material) stretches easily and is found in elastic structures. (3) Proteoglycans, firm gel ground substances to hold together the protein components of connective tissue, consist of mucopolysaccharides (complex carbohydrates) bound to protein chains.  They include chondroitin sulfates (sulfated complex carbohydrates). which require sulfate as derived from amino acids such as methionine and cysteine, two sulfur-bearing amino acids which are essential (must come from the diet). Chondroitin sulfates serve as lubricants and support elements in the tissues, stabilizing the supporting fibrous and cellular elements.  Connective tissue characteristics depend on the ratio between collagen and elastin.  Tendons contain more collagen than elastin, so are strong but have no capacity for stretch.  Ligaments contain more elastin and less collagen; so are quite elastic.

Joint cartilage (up to 50% collagen) is tough, smooth, resistant, and very elastic, enabling it to break the force of jolts, ease friction between the bones, act as a shock absorber, and stabilize the joint.  This allows the bones to rotate in their joints without painfully grinding against each other. Collagen, elastin, and Proteoglycans all contain and must obtain protein, minerals, trace minerals, fatty acids, and depend on vitamin complexes and other dietary nutrients.

PROTEIN

Proteins making up all the various tissues are composed of unique and specific amino acid   (arrangement, structure) characteristic to those cells.  Each special protein is essential for many functions including building new tissue and repair of injured, insulted, or degradating tissue.

The quality of dietary protein depends, not only upon the chemical presence of the amino acids, but the biological value and bioavailability of the protein.  The protein must provide all the essential (and often specific nonessential) amino acids in proper proportions and in a form which makes them available to the cells for use.  "Timing can be important.  For example, all amino acids must be supplied simultaneously to support protein synthesis.  If even one of the essential amino acids is administered at a different time than the other essential and nonessential amino acids, assimilation of all to protein is curtailed." v

Of the 20 (or 22) amino acids, those the body cannot synthesize are called essential.  Of the essential amino acids, lysine, methionine, phenylalanine, threonine, and histidine are very soluble and easily denatured.  They are heat-labile since heat, as in cooking or pasteurization, destroys the biological nature and activity of the protein.

It has been demonstrated that heat damaged amino acids render the blood proteins unacceptable to tissues for either maintenance or repair. The result is degenerative diseases including OA.  "Cooked food in general predisposes to arthritis, and every case differs by reason of the personal food pattern idiosyncrasies of each victim." vi

FOOD AND ARTHRITIS

This is why Dr. Royal Lee referred to arthritis as a "cooked food" disease.  "It is evident that the cooking of food can be very important in contributing to tissue degeneration."  Test animals could develop arthritis only by feeding them cooked food.  Experiments demonstrated that cooking foods may reduce the "digestibility" (availability) of protein up to 91% and of minerals up to 79%.  The many years and hundreds of cats in the tests of Dr. Francis M. Pottenger showed that the animals fed pasteurized milk and cooked meat lost their teeth, and developed arthritis and bone degeneration, while controls on raw foods "had no trace of such disease."

Dr. Pottenger referred to osteoporosis and arthritis as "deficiency diseases" which could be "traced back to deficiencies of fresh, vital elements found in raw foods."  Applying this to humans, he reported that, "by adding fresh and raw foods to our patients' diets, a marked improvement became noticeable" from both x-ray films and subjective reports from the patients.vii

For humans on modern diets, Dr. Lee recommended the supplemental use of raw veal bone meal for the intact biologically active protein, minerals, trace minerals, and enzymes.  The cooking of bone, he stressed, renders the minerals and amino acids "relatively useless nutritionally."  Cooked bone meal has lost its protein value, its enzymes and thus its catalysts for mineral absorption -- lost "its life-supporting qualities."  The human victim of malnutrition, Dr. Lee explained, has joint and/or back pains from "the failure of his food to restore the fibrous protein" in his/her overworked joints or intervertebral discs.  Raw veal bone, carrying the enzymes for tissue regeneration, can "stimulate" repair of bone and cartilage as well as other supportive connective tissues. viii

Bone mineral consists of very small crystalline particles, an "imperfect" or impure form of hydroxyapatite.  Pure hydroxyapatite is a calcium phosphate, while hydroxyapatite of bone also incorporates anions (as carbonate, citrate, chloride, etc.) and cations (as sodium, magnesium, potassium, etc.).  Raw bone meal, then, is a wonderful source of hydroxyapatite mineral complex with all its natural components and synergists intact.  Pure hydroxyapatite, sold in supplements, falls short of the real structural matter of bone. ix

Raw veal bone meal is about half protein and half minerals in a biologically active form.  It has a very a beneficial effect on bone and supporting muscle, cartilage, ligament, tendon, and nerve tissues.  It is very rich in elements needed to build such tissue without denaturation or alteration of its nutritive qualities.

Protein components of bone -- termed bone morphogenetic protein (BMP) -- have been shown to "initiate the process that begins with cartilage formation and ends in de novo [new] bone formation."  Interactions among these BMP proteins and other proteins and cofactors "may account" for their ability to induce cartilage formation as well as "the remarkable regenerative capacity of bone..."  All protein factors and many of the cofactors are present in raw veal bone meal. x

MORE NUTRITIONAL SUPPORT

Manganese, a trace mineral; choline, a B complex factor; vitamin E complex; and vitamin C complex have also been found to be interdependent in the maintenance of bone and connective tissue.

Deficits of manganese and/or choline weaken cartilage, tendons, ligaments and bone.  Vitamin E complex promotes proper proliferation of connective tissues.  Wheat germ is a rich source of manganese, choline, and vitamin E complex.

Vitamin C -- in its whole, complex form -- has been recognized as a collateral factor also, since one of its primary functions is building connective tissue.  It plays a role in collagen hydroxylation and promotes tissue repair.  Severe deficiency of vitamin C complex, for example, results in degeneration and separation of the periosteal membrane in the joints.  Connective tissues "can lose a great part of their strength in deficiency states; in fact the tensile strength of connective tissue is often used as a measure of vitamin C deficiency..." xi

Persons with high dietary intake of vitamin C complex had a three-fold reduction in the risk of OA progression (mostly a reduced risk of cartilage loss) as well as a reduced risk of developing knee pain.  Some reduction in the risk of OA progression was also seen for vitamin E complex and carotene intake.  Vitamin E may improve mobility and diminish pain when arthritis exists.xii

Natural foods such as raw whole sugarcane juice and beets contain B complex factors (riboflavin, niacinamide, pyridoxine, choline, inositol, etc.) and minerals (potassium, zinc, calcium, magnesium, etc.) found to aid the prevention and treatment of arthritis.  Drs. Van Wagtedonk and Wulzen identified an "anti-stiffness factor" (evidently a sterol) in sugarcane juice (whole, raw) and raw cream (pasteurization destroys this factor) which reduced the stiffness and swelling in joints.  Experimental production of a collagen necrosis (destruction) disease with abnormal calcification by means of a diet deficient in this anti-stiffness factor "suggests the possibility of a nutritional factor in the pathogenesis of some collagen diseases," including arthritis. xiii

Enzymes, such as phosphatase, from raw foods are destroyed by cooking and pasteurization. "Without phosphatase in the blood we cannot either develop the protein matrix for teeth and bone nor could we promote the deposition of the minerals where the matrix is present."  The typical modern diet does not contain much (if any) animal connective tissue such as gristle, tough tendon or ligament -- sources of needed enzymes, protein and minerals - because meats are selected purposely to avoid it.  Raw dehydrated bone is a source of the amino acids, minerals AND enzymes present in such tissues.  Phosphatase is also present in raw whole wheat and raw bran. xivTrace minerals frequently serve as enzyme activators.  For example, without sufficient manganese, the phosphatase in bone fails to promote calcium deposition.  Natural vitamin D complex and fatty acids ("vitamin F") -- especially essential fatty acids - are needed in promoting calcium absorption, assimilation, and utilization. xv

Norwegian cross-sectional study results indicate that people with musculoskeletal diseases such as arthritis "may experience less pain if they take cod liver oil," rich in omega-3 polyunsaturated fatty acids, other fatty acids, vitamin A complex, D complex, iodine, and other trace minerals. xvi

Prostaglandins, unsaturated fatty acids, have, among their reported modulating actions, influence on various functions of inflammation and repair, cell mediation, and level of pain sensitivity.  Arachidonic acid, an essential fatty acid and main precursor of prostaglandins, is incorporated into activated lymphocytes and macrophages (white blood cells capable of eliminating dead or damaged tissue cells).  Gammalinolenic acid (GLA), another prostaglandin precursor, has been used in animal experiments to demonstrate improvements in the inflammation process.  Evening primrose oil, borage oil, and black currant seed oil are all good food sources of GLA.  Conversely, NSAIDs adversely affect the synthesis of prostaglandins by inhibiting a key enzyme that catalyzes their production, diminishing their formation. xvii

Although OA is regarded primarily as a cartilage disorder, bone tissue is also involved. Research indicates that bone mineral density can influence the progression of this disease. Studies show that arthritics with low vitamin D levels are three times more likely to get worse than those with higher levels.  Vitamin D complex deficiency and its affect on calcium metabolism "could impair the body's ability to repair the damage that arthritis causes in both bone and cartilage." xviii

Robert Barefoot and Carl Reich, M.D., write that calcium deposits on the tissues and joints are "a sign of the calcium regulatory system adjusting to a severe calcium deficiency."  To reinforce diminishing skeletal structural strength from decalcification of the bones, these bony calcium deposits reduce movement and cause pain.  Diseases related to such "last resort" removal of calcium from the bones due to calcium deficits include sclerosis, osteoporosis, arthritis, rheumatism, and periodontal disease. xix

British researcher Rex E. Newnham pursued epidemiological studies around the world (13 countries) to ascertain why some nations or areas have more arthritis than others.  Regions with high arthritis levels were found to have soil boron levels far too low for maintenance of human health.  The "simplistic and imbalanced use" of synthetic fertilizers had so damaged soils that boron (and no doubt other trace mineral) uptake was compromised.  A lack of sufficient boron in food can result in joint pain and deformity.  This trace mineral plays an important role in calcium and bone metabolism.  It interacts with nitrogen, magnesium, vitamin D, copper, arginine, and methionine.  Inadequate boron reduces serum levels of ionized (free) calcium and calcitonin.  The Human Nutrition Research of the U.S. Department of Agriculture has shown this mineral is needed by the parathyroid glands and thus to calcium balance and proper bone mineralization. xx

Sulfur is a constituent of the amino acids cysteine, cystine, and methionine, and is "intimately associated with protein metabolism."  There are various forms of sulfur which also require co-factors, making deficiencies very possible and particularly affecting cartilage, muscles, joints, bones, skin, hair, and nails.  Sulfur deficiency is manifest in rheumatic disturbances such as rheumatoid and osteoarthritis.  Improving sulfur levels has been shown to bring significant benefits to arthritic patients.  Raw veal bone meal contains boron and the sulfur-bearing amino acids with natural cofactors.xxi

Researcher Carlson Wade reported that "a diet of raw foods has been helpful in easing and healing arthritic pain..."  Dorothy C. Hare, M.D., supervised a program for her arthritis patients using a good deal of raw foods.  Within only four weeks, most showed significant improvement. Almost all were eventually able to enjoy freedom from arthritic pain.

"No person who is in good nutritional health develops rheumatoid or osteoarthritis," says Robert Bingham, M.D.  He found that most arthritics show a history of poor diet including refined flours and sugars as well as altered and refined fats.  Of the benefits from a good diet, "it is important," writes Dr. Bingham, "to preserve the natural food intact, including proteins and amino acids which have not been damaged by heat; hormones and enzymes which have not been altered by cooking, drying, storage or preservation; and vitamins in the highest biological efficiency..The foods must be as fresh and ripe as possible, grown by organic methods, free of residues of poisonous pesticies and fertilizers and delivered and prepared in as natural and palatable a form as possible." xxii

CHONDROITIN SULFATE AND GLUCOSAMINE SULFATE

A major best-seller book, The Arthritis Cure, by Dr. Jason Theodosakis and two coauthors promotes "The Medical Miracle that Can Halt, Reverse, and May Even Cure Osteoarthritis." Some of the authors' advice for managing OA is standard, such as a ‘balanced' diet, weight control, and exercise.  But the popularity of the book rests primarily on Dr. Theodosakis's advice to take two supplements: glucosamine sulfate and chondroitin sulfate.  Cited are various European studies.  Promised are sure relief and sometimes a reversal of arthritis through the rebuilding of cartilage.

Anatomically, a group of structural and protective complex carbohydrates, glycosaminoglycans (GAGs), are attached to proteins to form proteoglycans.  The presence of sulfur in the polysaccharides "makes these substances effective biological lubricants."  The GAGs in the proteoglycans of cartilage are chondroitin sulfates, dermatan sulfate, and keratin sulfate. Glucosamine is an amino sugar derivative -- a component or portion - of glucose occurring in GAGs.  In the body, it is NOT a compound of glucose and glutamine, as Dr. Theodosakis claims.

Proteoglycans partially ensheath collagen fibers and, with other organic molecules, link collagen fibers with each other, with fibers of the foundation substance, and with the cells of the cartilage. "It has been suggested that the proteoglycans may act as minute compressed springs, storing energy when further compacted, then releasing it on recoil and so conferring elastic properties to the matrix."

Obviously, cartilage and its nutritional needs are much more complex than just two compounds. In fact, cartilage is one of the most complex tissues of the body.  However, glucosamine and chondroitin sulfate are essential structural substances manufactured by the body, and are involved in cartilage repair and maintenance.  Chondroitin sulfate levels have been shown to be lower than normal in arthritics. xxiii

The authors of The Arthritis Cure promote glucosamine sulfate and chondroitin sulfate as supplements -- separately or in combination.  But can the synthetic or purified versions do the same as the complex natural substances in the body?So far there is no evidence that these supplements can be absorbed if swallowed or that either or both would migrate to cartilage.  Moreover, there is a "lack of convincing evidence" that they can repair or restore cartilage.  Most of the data, primarily from some European studies, relate to pain relief only (a pharmacological rather than nutritional effect). Early studies during the 1950s and 1960s demonstrated remarkable results for arthritic and other cartilage-involving conditions by using crude extracts of cartilage, NOT isolated molecules.  In other words, whole food factors providing a complex of synergistic nutrients (as in raw bone meal) showed the greatest benefits for repair.

The Italian studies cited in The Arthritis Cure, conducted about 17 years ago, were "small, limited, and inconclusive."  None of them inferred that glucosamine supplements rebuild cartilage.  One German trial found that injected glucosamine -- a drug -- relieved OA pain of the knee about the same as aspirin.  Glucosamine and chondroitin sulfate can be purchased in Europe without a prescription, but they are not viewed as a breakthrough treatment, and no books in Europe claim the substances can halt, reverse, or cure OA as does The Arthritis Cure. xxiv

Recent clinical trials comparing the effectiveness of glucosamine sulfate with ibuprofen showed glucosamine gave better pain relief and joint mobility.  Again, the results related to symptoms rather than cause, masking rather than repairing, pharmacology rather than nutrition xxv

Glucosamine sulfate is the only form of glucosamine used in scientific investigations so far.  Yet many of the supplements are glucosamine hydrochloride or N-acetyl- glucosamine (NAG). Glucosamine sulfate and NAG, for instance, are entirely different molecules handled very differently by the body.  Neither NAG nor glucosamine hydrochloride provide sulfur -- "a critical component."

The supplemental chondroitin sulfate is composed of "repeating units of derivatives of glucosamine sulfate with attached sugar molecules."  By itself, purified glucosamine sulfate appears to have a "better" absorption rate than the larger chondroitin sulfate.  One group of researchers concluded that chondroitin sulfate supplements are not properly absorbed by the gastrointestinal tract even if altered.  They feel that any direct action on cartilage is impossible.

Many of the studies cited in The Arthritis Cure used injectible forms of chondroitin sulfate for pain relief.  No food complex is injectible; this is possible only with synthetic or highly refined isolated chemicals.  Regardless, interpreting the results of such trials to apply to oral supplementation is inappropriate.  And though glucosamine sulfate is reported to be "faster acting" and eliciting more relief in joint pain, tenderness, and swelling, one point keeps surfacing:  Any purported "benefit" from glucosamine or chondroitin sulfate "supplements" is symptomatic only.  Relief is drug-like, a masking of symptoms, possibly by interfering with some stage(s) of the natural inflammation and repair process.  The nutritional approach, on the other hand, looks to the cause, not just the result (symptoms).  The goal is reparative rather than palliative, supportive to tissue strength and integrity rather than disguising the degenerative effects. xxvi

DIET AND NUTRITION

"Instead of looking for a better Band-Aid, let's look at possible solutions.  Begin by cleaning up your diet."  Refined sugars, refined flours, and all other refined, processed, and chemicalized foods should be eliminated.  Altered and refined fats such as margarine, other hydrogenated fats, refined oils, deep-fried foods, etc., should be avoided.  Luncheon meats and other preserved, smoked meats should also be stopped, and pasteurized milk products used sparingly if at all.  "Eat real foods," including fresh and raw or lightly cooked vegetables, fresh fruits, whole grains, raw nuts and seeds, real butter, certified raw milk cheeses, unrefined oils, lean meats and sea foods. "By making these dietary changes you will be increasing your body's supply of vitamins, minerals, essential fatty acids, and amino acids -- the building blocks for good health." xxvii

Sensible dietary changes also aid in weight loss or weight control.  "The prevalence of osteoarthritis among the obese is about twice that among people of normal weight."  Excess weight places an added burden on weight-bearing joints, yet "the benefits of weight reduction are not specifically confined to these areas."  Dr. Richard P. Murray referred to obesity as "a disease of starvation" since overweight indicates nutritional depletion which, in turn, precludes one to problems such as arthritis. xxviii

Food concentrate supplements to support the physical structures -- cartilage, bone, ligaments, muscles, tendons, nerves, blood vessels -- and the biochemistry of inflammation and repair would include raw veal bone meal, vitamin C complex, vitamin A and E complexes, essential fatty acids, thymus substance, ionizable calcium, other alkaline-ash minerals, and the vitamin B complex.  It is well recognized that: "Joint pain and stiffness increase when a person is malnourished and symptoms improve when dietary intake of nutrients increases."  Simple common sense xxix

i J of American Medical Association, Vol.273, No. 23, 21 June 1995, pp.1820-1822; K. Bodmer, N. Fuchs, Women's Health Letter, Vol.V, No.8, Aug. 1996, p.1.

ii Amer Health, Vol.VII, No.7, Sept. 1993, p.20; Modern Nutrition in Health & Disease, 8th Ed., ed. M. Shils, J. Olson, M. Shike, Phila: Lea & Febiger, 1994, p.1363; Univ of CA at Berkeley Wellness Letter, Vol.13, Iss 8, May 1997, p.1; Bodmer & Fuchs, Women's Health Letter, Aug. 1996, p.1.

iii The Lancet, 6 July 1985, p.11; Solomon, Journal of Bone & Joint Surgery, Vol.55B, p.246, The Lancet, 2 Sept. 1989, p.127.

iv Arthritis & Rheumatism, March 1992; P. Dieppe, et al., The Lancet, Vol.341, No.8841, 6 Feb. 1993, pp.353-354; Health Facts, Vol.XIX, No.183, Aug. 1994, pp.1,6; P. Murphy, et al., Physiological Behavior, Vol.59, 1996, pp.133-139; M. Akil, et al., British J of Rheumatology, Vol.35, 1996, pp.76-78; Scandinavian J of Clin Lab Invest, Vol.56, 1996, pp.421-429; S. Rashad, et al., Lancet, Vol.II, No.8662, 2 Sept. 1989, pp.519-522.

v A. Lehninger, Principles of Biochemistry, NY: Worth Publishers, 1982, p.764; Harrison's Principles of Internal Medicine, 9th Ed., NY: McGraw-Hill, 1980, p.397.

vi F. M. Pottenger, Amer J of Orthodontics & Oral Surgery, Vol.32, No.8, Aug. 1946, pp.467-485; Sir R. McCarrison, Studies in Deficiency Disease,

London: G. Bell & Sons, Ltd., 1954, p.270.

vii Francis M. Pottenger, M.D., Pottenger's Cats, San Diego: PPNF, Inc., 1995, pp.59, 62-63.

viii Royal Lee, Applied Trophology, Vol.2, No.7, July 1958, pp.1-2; Pottenger, Am J Ortho & Oral Surgery, Aug. 1946, pp.467-485; Royal Lee, Lecture, American Academy of Applied Nutrition, 17 Nov. 1949, Seattle & 24 May 1953, Pasadena.

ix T. Brody, Nutritional Biochemistry, San Diego: Academic, 1994, p.425; Lehninger, Principles of Biochemistry, p,783; R. Roskoski, Biochemistry, Phila: W.B. Saunders, 1996, pp.15-16.

x John M. Wozney, et al., Science, Vol.242, 16 Dec. 1988, pp.1528-1534.

xi Roskoski, Biochemistry, p.389; Royal Lee, Lecture MA Osteopathic Socienty, Boston, Jan. 1943; Royal Lee, The Direct Effect of Malnutrition on Tissue Degeneration, 17 Nov. 1949.

xii T. McAlindon, et al, Arthritis & Rheumatism, Vol.39, No.4, April 1996, pp.648-656; Nutritional Biochemistry & Metabolism, 2nd Ed., ed., M. Linder, NY: Elseview, 1991, p.175.

xiii Royal Lee, Lecture, Naturopathic Physician f FL, June 1947; Van Wagtendonk & Wulzen, Journal of Biological Chemistry, July 1946; Ross, Van Wagtendonk, Wulzen, Annual Review of Biochemistry, Vol.20, 1951, pp.295-304.

xiv Royal Lee, Lecture, American Society of

Endodontists, Chicago, 3 Feb. 1951.

xv R. Lee, Lecture, American Academy of Applied Nutrition, Coronado, CA, 12-15 April 1951.

xvi W. Eriksen, et al., European Journal of Clinical Nutrition, Vol.50, No.10, Oct. 1996, pp. 689-693.

xvii Modern Nutrition in Health and Disease, pp.1364-1365.

xviii T. McAlindon, D. Felson, et al., Annals of Internal Medicine, Vol.125, No.5, 1 Sept. 1996,

pp.353-359; Nutrition Action Healthletter, Vol.23, No.10, Dec. 1996, p.2.

xix R. R. Barefoot, C. J. Reich, M.D., The Calcium Factor, Wickenburg: Bokar Consul., 1992, p.47.

xx Acres, U.S.A., Vol.23, No.2, 2 Feb. 1993, pp.1, 6; R. Garrison, E. Somer, The Nutrition Desk Reference, 3rd Ed., New Canaan:Keats, 1995,pp.223-224; FASEB Journal, Vol.4, 1990, p.A 1050;

D.G. Blevins, et al., Environmental Health Perspectives, Vol.7 (S), No.102, 1994, pp.31-33.

xxi L. Clark, Let's Live, July 1977; R. Lee, Let's Live, April 1963; M. Murray, American Journal of Natural Medicine, Vol.4, No.4, May 1997, pp.6-7; D. Tver, P. Russell, Nutrition & Health Encyclopedia, 2nd Ed., NY:Van Nostrand, 1989, p.507.

xxii Carlson Wade, Arthritis, Nutrition & Natural Therapy, New Canaan: Keats Publ., 1992, pp.33- 62; Gala & John Kirschmann, Nutrition Alma-nac, 4th Ed., NY: McGraw-Hill, 1996, pp.48-67.

xxiii Textbook of Biochemistry, 3rd Ed., ed., T. M. Devlin, NY:Wiley-Liss, 1992, pp.378-382; Mathews & van Holde, Biochemistry, pp.287-288, 558; Gray's Anatomy, 38th Ed., NY:Churchill Livingstone,

1995, pp.444-445; Clinical Experiments in Rheumatology, Vol.9, No.2, 1991, pp.195-199.

xxiv Univ. of CA at Berkeley Wellness Letter, Vol. 13, Iss. 8, May 1997, pp.1-3; Health News, Vol.3, No.3, 4 March 1997, p.5; D. G. Williams, Alternatives, Vol.4, No.7, Jan. 1992, pp.49-51.

xxv Dr. Christiane Northrup,Health Wisdom for Women, Vol.4, No2, Feb. 1997, p.7.

xxvi Murray, Amer J of Natural Medicine, May 1997, pp.6-8; A. Baici, et al., Rheumatology Int. J, Vol.13,

1993, pp.41-43.

xxvii Bodmer & Fuchs, Women's Health Letter, Aug. 1996, p.2.

xxviii L. Mahan, M. Arlin, Food, Nutrition & Diet Therapy, 8th Ed., Phila:W.B. Saunders Co., 1992, p.695; D. Felson, The Amer J of Clinical Nutrition, Vol.63, No.3(S), March 1996, pp.430S-432S.

xxix R. Garrison, E. Somers, The Nutrition Desk Ref., 2nd Ed., New Canaan:Keats, 1990, p.213.
Originally published as an issue of Nutrition News and Views, reproduced with permission by the author, Judith A. DeCava, CNC, LNC.