Strategic Nutrition for Bone and Joint Health - Fortitech

PAGE 2Global PerspectiveAging and obesity are important factors contributing to bone and joint disorders. Given therising numbers of older and obese people in both economically developed and less developedcountries, bone and joint health is a global concern. The burden of bone and jointdisease is so weighty, that governments, NGO’s, patient advocacy groups and health organizationsaround the world started a collaborative initiative dedicating 2000-2012 as theBone and Joint Decade (BJD).According to the BJD, 50% of chronic disease in the elderly isrepresented by joint diseases and 40% of women over theage of 50 are expected to suffer a minimum of one osteoporoticfracture within their lifetime. According to the WorldHealth Organization (WHO), osteoporosis ranks second tocardiovascular disease in terms of its global healthcare burden.Nutritional needschange as we age.“Ask the Experts” formore info on this byvisiting fortitech.comWorldwide, the US has the most developed bone and jointhealth market, which is expected to approach $4 billion by2013. The functional ingredients market that supports boneand joint health is also a billion dollar industry in China andJapan. In Japan, 10 million patients have osteoarthritis, withover 30% of Japanese aged 70 plus, suffering from osteoarthritis, which continues to advancewith age. Aging populations worldwide and the long-term consequences of obesitymean an increasing incidence of bone and joint conditions for many years to come.Target MarketsHistorically, women and adults age 60 plus have been the focus of bone and joint products.The market is growing, as a rising number of men and younger adults are being diagnosedwith osteoporosis or are at high risk due to low bone mass – according to the National Instituteof Aging, two million men in the United States have osteoporosis. A body of informationexists supporting that most people around the world do not get enough calcium orvitamin D, and recent research indicates that there is a high percentage of vitamin D deficiencyin children under 11, particularly noting deficiency in African American and Hispanicchildren in the United States. The wide spectrum of deficient populations, in turn, increasesthe necessity for product innovation and demographic appropriate product development.In some people, evidence of osteoarthritic changes may exist by the second or third decadeof life (usually without associated symptoms). By age 40, almost everyone has some osteoarthriticchanges in weight-bearing joints (e.g., hip and knee joints) and, by age 75, virtuallyeveryone has changes in at least one joint. Since osteoarthritis is a chronic degenerativedisease, this information suggests that even young adults need to consider protectingtheir joints against chronic wear-and-tear by optimizing their nutrient intakes.Consumer PreferencesIn the US, consumers are increasingly seeking supplements and functional foods and beveragesthat promote wellness and have scientific validation. Consumer preference is nowturning to foods — up 29%— and beverages — up 11% — fortified with joint-health ingredients,according to Nielsen data. According to market analysis by Frost and Sullivan, the“prominent competitive factors in the US bone and joint health ingredients market includeSTRATEGIC NUTRITION FOR BONE & JOINT HEALTHTECHNICAL PAPER—JAN, 2010PAGE 3

PAGE 2price, quality, distribution efficiency, ability to provide a point of differentiation throughnovel ingredient combinations, and value-added services that include assistance in productformulation and regulatory support.” Similar analysis abroad shows heightened interest inhealth promoting foods across much of Europe, in particular.Strategic Ingredients for Bone and Joint HealthThere is no one-sizefits-allapproach toproduct formulationfor bone and jointhealth. Nutrients andmarket forms areunique to eachapplicationWhile calcium was, for years, the most often referenced antidote for bone weakness, inrecent years, vitamin D has come to the fore for its own role in promoting musculoskeletalhealth, as well as for its significant supporting role to calcium in bone health. While productsmay boast about added calcium on packaging, it needs to be better recognized thatcalcium works in combination with vitamin D to promote optimal bone health. A significantportion of people worldwide currently do not get an adequate dose of vitamin D throughexposure to sunlight and do not take in enough through diet to compensate. Additionally,other nutrients may be minimal or absent from day-to-day diets that may also play a role inachieving optimal musculoskeletal health. Hence, the need exists for a more sweeping nutrientstrategy for promoting both healthy bones and joints. In particular, more consumerattention needs to be focused on joint health, and there is a great need to develop newproducts that target this condition. These products need to provide novel ingredient combinationsthat promote the maintenance of healthy bones and joints. Below we considersome important ingredients that have been shown to be efficacious in promoting bone andjoint health in people.Bone NutrientsBy far, calcium and vitamin D have been the mainstay ingredients in bone health-promotingproducts and the subject of considerable scientific research. However, there is growingconsumer interest in other ingredients that could promote optimal bone health. These ingredientsshown in Figure 2 include magnesium, vitamin K1 and vitamin K2, vitamin C, andpossibly some botanical compounds, such as those found in tea or soy.Figure 2.Bone Health IngredientsSTRATEGIC NUTRITION FOR BONE & JOINT HEALTHTECHNICAL PAPER—JAN, 2010PAGE 4

PAGE 2CalciumCalcium is an important constituent of bone, but is also needed in the body for proper functioningof the heart, muscles, nerves, and in blood clotting. A low intake of calcium, whichis common with most people, contributes to bone loss and the development of low bonemass and osteoporosis – a skeletal condition affecting 44 million people in the US alone –that results in an increased risk of bone fractures, especially of the hip, spine and wrist.Bone loss also contributes to loss of teeth due to erosion of the underlying boney anchor ofthe tooth’s root. Tooth loss affects about one-third of adults age 65 and older. Currentrecommended intakes of calcium are between 1,000-1,300 mg/day depending on age,which is about twice the level of usual calcium intakes.Explore related newsand research on boneand joint health onour TweetDeck atwww.twitter.com/fortitechVitamin DVitamin D is needed by the body to facilitate the intestinal absorptionof calcium, as well as for other important body functions.Unfortunately, vitamin D deficiency is common throughout theworld, and contributes to poor bone health, especially when dietarycalcium intakes are low. It is estimated that one in five children,aged one to 11 years old don’t get enough vitamin D.Prevalence rates for vitamin D insufficiency in black and Hispanicchildren are, alarmingly, much higher. The current recommendeddietary vitamin D intake is 5µg to 15µg (200-600 IU) per day.However, considerable disagreement over the adequacy of thisrecommendation has ensued in light of recent research findings,and some prominent vitamin D researchers are suggesting that 50µg (2,000 IU) per daymay be a more reasonable level of vitamin D intake to promote optimal bone health. Productsdesigned to deliver calcium should also provide vitamin D because these two nutrientswork together in order to provide the best opportunity for calcium to be absorbed into thebody.Vitamin KVitamin K is well known for its important role in blood clotting. However, research in recentyears has suggested that vitamin K may play an important role in maintaining bone healthand reducing the risk of osteoporotic bone fracture in the elderly. Natural vitamin K in thefood supply is found in two forms, vitamin K 1 (phylloquinone) in plant foods and vitamin K 2(menaquinone) in animal foods or produced by bacteria, with vitamin K 1 being slightly moreactive biologically than vitamin K 2 . The recommended intakes of vitamin K is 120µg/day inmen, and slightly lower in women, with intakes as high as 400-500µg/day being suggestedto influence bone metabolism. However, some very recent clinical trials of vitamin K supplementationin elderly postmenopausal women have found no effect of additional vitaminK on rates of bone loss during a three-year trial. These findings are difficult to interpret,however, because subjects were generally healthy and not selected on the basis of preexistinglow vitamin K status. Given the strong epidemiologic evidence that high vitamin Kintake is associated with reduced risk of osteoporotic fracture, it would be prudent to includevitamin K as an important nutrient in any bone-protecting fortified product.Vitamin CHigher intakes of fruits and vegetables have been associated with higher bone mineral densityin cross-sectional population studies. Investigators in the United Kingdom found thathigher vitamin C intake in adolescent boys and girls, young women, and older men andwomen are associated with bone mineral content. Research in the US found in the PostmenopausalEstrogen/Progestin Intervention Trial (PEPI Study) that higher vitamin C intakeSTRATEGIC NUTRITION FOR BONE & JOINT HEALTHTECHNICAL PAPER—JAN, 2010PAGE 5

PAGE 2was associated with higher bone mineral density only in women with calcium intakesgreater than 500 mg/day.MagnesiumMagnesium is a mineral constituent in bone and is important for a variety of other bodilyfunctions, including energy metabolism and proper nerve function. There is scant evidencethat adding additional magnesium to the diet will have a positive effect on bone metabolismand no direct evidence that magnesium supplementation will enhance bone mineral densityor reduce the risk of osteoporosis. Nevertheless, an intriguing, well-conducted study ineight-14 year old girls found that supplementation with 300 mg magnesium (as magnesiumoxide) per day for 12 months resulted in a significant increase in hip bone mineral contentcompared to a placebo group. An important element of this study was the selection of girlsthat had relatively low magnesium intakes, less than the RDA of 240 mg/d for this agegroup. Thus, at least in children, the provision of additional magnesium in the diet couldhave beneficial effects on bone.Quality is the singlemost importantfactor in the successof a product. Visitwww.fortitech.com/quality to learn moreOther Potential Bone Bioactive IngredientsTeaHabitual tea drinking has been associated with higherbone mineral density in the Women’s Health Initiative ObservationalStudy of a large number of older women (50-75 years of age) in the US. Additionally, investigators inAustralia found that elderly women tea drinkers hadhigher bone mineral density than non-tea drinkers, andhad lower rates of bone loss from the hip. Animal studieshave supported the possible role of green tea extracts inbone metabolism, but no human studies have been reportedto date.PhytoestrogensReduction in ovarian function in postmenopausal womenleads to an increase in bone resorption and greater ratesof bone loss. Isoflavones found in soy act as phytoestrogensand have been reported to protect bone from estrogen deficiency. In a paper publishedthis year, investigators at Purdue University in Indiana found that soy isoflavonescould reduce bone resorption in postmenopausal women during a 50-day study. This confirmsan early report in which bone turnover was measured in postmenopausal women receiving110 mg/day soy isoflavone supplement for six months. Positive effects of soy isoflavoneson bone resorption only occur in postmenopausal women not taking hormone replacementtherapy.DHEADHEA (dehydroepiandrosterone) concentrations in blood decrease as we age. A new studyhas assessed the effect of DHEA supplementation (50 mg/day) on bone mineral density inolder adults from Missouri that were given calcium and vitamin D supplements during a two-year study. No change in bone mineral density (BMD) was found in older men, but therewas a significant increase in BMD in women taking DHEA.STRATEGIC NUTRITION FOR BONE & JOINT HEALTHTECHNICAL PAPER—JAN, 2010PAGE 6

PAGE 2Joint NutrientsInformation about the role of nutrients and bioactive ingredients in joint health is generallymuch less developed than that of bone health. Nevertheless, a number of potentially usefulingredients as shown in Figure 3 stand out; in particular, those that are constituents of cartilage,such as chondroitin sulfate and glucosamine, or play a role in controlling inflammation,such as omega-3 fatty acids.Fortitech is theexpert when it comesto blending multiplenutrients to create anaward winning endproductFigure 3.Joint Health IngredientsChondroitin SulfateChondroitin sulfate is an important structural component of cartilage. The Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), a large randomized, double-blind, placebocontrolled intervention study in patients with knee osteoarthritis, recently reported that patientstaking 400 mg chondroitin sulfate three times per day had a significant improvementin knee joint swelling. This treatment seemed particularly effective in patients with milderlevels of pain and symptoms.GlucosamineGlucosamine is a chemical precursor of glycosaminoglycan, a major component of joint cartilagehas been the subject of much research as a potential beneficial aid in the managementof osteoarthritis. In a three-year, randomized, placebocontrolled,double-blind study of the effects of 1,500 mg of glucosaminesulfate in patients with knee osteoarthritis, Czech investigatorsfound that glucosamine sulfate slowed the progression of kneeosteoarthritis. A similar study in Belgium also found that glucosaminesulfate prevented joint space narrowing in postmenopausalwomen with knee osteoarthritis. In a follow up study, these investigatorsfound that patients who had received glucosamine sulfatefor one to three years were significantly less likely to require totaljoint replacement surgery during the subsequent five-year period.Omega-3 Fatty Acids/Fish OilBesides osteoarthritis, another important category of arthritic diseaseis rheumatoid arthritis, characterized by a systemic inflamma-STRATEGIC NUTRITION FOR BONE & JOINT HEALTHTECHNICAL PAPER—JAN, 2010PAGE 7

PAGE 2Yogurt (Bone Health)Nutrient%DV/ServingVitamin A 20Vitamin D3 25Vitamin E 30Pantothenic Acid 20Vitamin B12 20Vitamin B6 25Vitamin C 20Vitamin K1 30Calcium 6Phosphorous 4Zinc 10Magnesium 6Request a freepremix samplethroughfortitech.comBeverage (Joint Health)Nutrient%DV/ServingVitamin A 20Vitamin D3 30Niacin 25Pantothenic Acid 25Vitamin B1 20Vitamin B12 25Vitamin B2 20Vitamin B6 25Vitamin C 30Zinc 25Glucosamine 150 mgChondroitin Sulfate 150 mgCollagen Type II Undenatured 10 mgLycopene5 mgBar (Joint Health)NutrientPer ServingChondroitin Sulfate 100 mgGlucosamine Sulfate 100 mgMethyl Sulfonyl Methane 100 mgOmega-350 mgVitamin K120 mcgThe nutrients specified above can be used in any type of snack food/grain-based productwith a combination of functional food ingredients.Fortification ChallengesWhile all of the aforementioned nutrients can aid in bone and joint health, calcium is theone particular ingredient that consumers seek out when looking for products that addressthis issue. A number of market forms of calcium are available to boost a product’s calciumcontent. Food products, such as fruit juice, infant food, health food and sports beveragesare most often fortified with calcium and other minerals.STRATEGIC NUTRITION FOR BONE & JOINT HEALTHTECHNICAL PAPER—JAN, 2010PAGE 9

PAGE 2The challenge for formulators is to select an appropriate form of calcium that delivers thedesired level of the mineral without affecting flavor, solubility, bioavailability, sensory propertiesand the mouthfeel of the finished product. Calcium carbonate is perhaps the mostcost-effective source of calcium, however, it has a tendency to provide a chalkiness tasteand have a gritty mouthfeel, as does dicalcium phosphate.Fortitech’s technicalpersonnel can assistyou in overcomingformulation issuesSome of these processing issues can be prevented if a blend of calcium sources are usedinstead of a single source. In addition, these calciumsalts are not very soluble; therefore, it is desirable toadd calcium citrate or organic acid to improve solubility.In order to get the most out of these salts, amanufacturer has to decrease the pH to solubilize,which causes absorption to increase. In general, inorder to have more absorption, it is necessary tohave soluble calcium salts, but there are advantagesand disadvantages to either soluble or insolubleforms. For example, calcium gluconate is soluble butmay interact with other ingredients in the productand impact flavor.Large doses of calcium are efficiently excreted by the body and do not usually produce toxiceffects unless the individual has a history of kidney stones. While suggested dietary intakesvary with different age groups and between men and women, it is commonly recommendedthat adults consume 1,000 mg of calcium per day.Food manufacturers must work closely with their suppliers to address product developmentissues that could dramatically impact nutrient delivery or alter the end product. The suppliercan suggest appropriate market forms, interactions to avoid, and processing effectsthat will improve the chance of success.Questions to address prior to fortifying a product with ingredients aimed at improving boneand joint health include:• type of product to be fortified• amount of various nutrients to be added, particularly if a manufacturer is trying to meetlabel claims• whether additional ingredients should be added to enhance performance• processing conditions, such as time and temperature• pH of the finished product• shelf life and other components of the finished productWhile fortified beverages have become a medium of choice for delivering healthy and functionalnutrients, those in the industry know that formulating beverages can be complex,particularly when multiple ingredients are being added. There is a host of complicationsthat can occur in beverage formulation such as sedimentation, poor taste cloudiness, orlack of uniformity of ingredient incorporation among other challenges.STRATEGIC NUTRITION FOR BONE & JOINT HEALTHTECHNICAL PAPER—JAN, 2010PAGE 10

PAGE 2Adding multiple ingredients to food products and supplements can promote improved boneand joint health, as well as manage other health conditions. Good practice calls for highquality nutritional blends that address these issues, which in turn will gain consumer confidencein the product and in the role that it can play in improving their bone and jointhealth, as well as their overall wellness.Fortitech is yourpartner in productdevelopment.Contact us viainfo@fortitech.comto get startedSTRATEGIC NUTRITION FOR BONE & JOINT HEALTHTECHNICAL PAPER—JAN, 2010PAGE 11