Dietary and nutritional factors have been identified as playing a pivotal role in the prevention and incidence of osteoporosis and fractures.¹ Vitamin C is one of the dietary components that affect bone mineral density (BMD) via its essential role in collagen synthesis and osteoblastogenesis.² Vitamin C can prevent the loss of osteoblast differentiation markers and attenuate bone loss, as well as stimulate bone formation.³

A recent 2018 systematic review and meta-analysis of observational studies found that greater dietary vitamin C intake as a result of increased fruit, vegetable and/or supplemental vitamin C consumption was associated with a 33% lower risk of osteoporosis (p=0.022), a 29% decreased incidence of hip fracture in those aged 70 years or older (p=0.009), as well as higher BMD at femoral neck (p=0.03) and lumbar spine (p=0.001).2 For example, in a double-blind, controlled clinical trial of 90 older adults over a 12-month period, administration of 1,000 mg of ascorbic acid together with alpha-tocopherol was shown to be useful in decreasing hip BMD loss, compared to no treatment (p=0.047).

Accumulating evidence also indicates that vitamin C can exhibit analgesic properties in some clinical conditions, thus potentially mitigating suffering and improving patient quality of life.⁴ As yet, there is no consensus as to the exact analgesic mechanisms by which vitamin C could be acting, however, oxidative stress and inflammation have been implicated in many pathologies, including those relating to joint and bone health, and Vitamin C may act to protect cells and tissues via its potent antioxidant and anti-inflammatory properties.⁵

Recent epidemiological evidence has indicated an association between suboptimal vitamin C status and spinal pain, primarily neck, lower back and arthritis/rheumatism.6 Musculoskeletal pain is also a symptom of the vitamin C deficiency disease scurvy.⁷ A number of randomized controlled trials have investigated the effect of vitamin C supplementation on the incidence of complex regional pain syndrome (CRPS) in wrist and ankle surgery patients. Doses of vitamin C used in these studies ranged from 0.2 to 1.5 g/day for 45–50 days post-surgery. The studies showed a decreased incidence of CRPS in the patients receiving vitamin C, with vitamin C doses ≥0.5 g/day being the most efficacious.^8,9

A randomized placebo-controlled crossover trial carried out with 133 patients with osteoarthritis of the hip or knee joint showed reduced pain following consumption of 1 g/day calcium ascorbate for 2 weeks as determined by the visual analogue scale (P < 0.008). The observed decrease in pain was less than half that reported for non-steroidal anti-inflammatories.¹⁰

An early study in 16 patients with Paget’s disease of bone showed that oral doses of 3 g/day vitamin C for 2 weeks decreased pain in 50% of the patients and resulted in a complete elimination of pain in 20% of the patients.¹¹

While scurvy may be thought of as a historical disease, vitamin C deficiency and insufficiency persists today, and is the fourth most prevalent nutrient deficiency reported in the United States.^12,13 These findings highlight the need for practitioners to consider the beneficial role of vitamin C in supporting bone health, particularly in those patients with existing musculoskeletal disorders and/or with suboptimal dietary intake. Vitamin C is cost effective and a safe Vitamin C is cost effective and safe for the majority of the population.

Practitioners should consider the following treatment approaches:

• Recommend that patients supplement with vitamin C. Requirements have been shown to increase in those experiencing illness and whose lifestyles result in increased oxidative stress; for example, from a poor diet, chronic alcohol consumption, ongoing stress and systemic inflammation.^5,14
• To achieve therapeutic benefits, prescribe a minimum of 500 mg of vitamin C daily.
• Choose buffered forms of vitamin C are recommended for those patients who experience gastrointestinal problems. Calcium and sodium ascorbate are the two main forms of buffered vitamin C and are well absorbed and gentle on the stomach.
• Educate patients of the importance of consuming a diet rich in colourful anti-inflammatory, antioxidant and nutrient dense fruits and vegetables, including: oranges, grapefruit, kiwi fruit, strawberries, blueberries, mangoes, papaya, red capsicums, broccoli, kale, potatoes and tomatoes.
• Also consider other factors such as Vitamin K2, Calcium, Vitamin D3, and key cofactors including Magnesium, Manganese, Zinc and Boron to promote bone health where diet may be lacking.

 

References

1. Sahni, S., et al., Dietary Approaches for Bone Health: Lessons from the Framingham Osteoporosis Study. Curr Osteoporos Rep, 2015. 13(4): p. 245-55.
2. Malmir, H., S. Shab-Bidar, and K. Djafarian, Vitamin C intake in relation to bone mineral density and risk of hip fracture and osteoporosis: a systematic review and meta-analysis of observational studies. Br J Nutr, 2018. 119(8): p. 847-858.
3. Aghajanian, P., et al., The Roles and Mechanisms of Actions of Vitamin C in Bone: New Developments. J Bone Miner Res, 2015. 30(11): p. 1945-55.
4. Carr, A.C. and C. McCall, The role of vitamin C in the treatment of pain: new insights. Journal of Translational Medicine, 2017. 15: p. 77.
5. Spoelstra-de Man, A.M.E., P.W.G. Elbers, and H.M. Oudemans-Van Straaten, Vitamin C: should we supplement? Current Opinion in Critical Care, 2018. 24(4): p. 248-255.
6. Dionne, C.E., et al., Serum vitamin C and spinal pain: a nationwide study. Pain, 2016. 157(11): p. 2527-2535.
7. Fain, O., Musculoskeletal manifestations of scurvy. Joint Bone Spine, 2005. 72(2): p. 124-8.
8. Shibuya, N., et al., Efficacy and Safety of High-dose Vitamin C on Complex Regional Pain Syndrome in Extremity Trauma and Surgery&#x2014;Systematic Review and Meta-Analysis. The Journal of Foot and Ankle Surgery, 2013. 52(1): p. 62-66.
9. Aim, F., et al., Efficacy of vitamin C in preventing complex regional pain syndrome after wrist fracture: A systematic review and meta-analysis. Orthop Traumatol Surg Res, 2017. 103(3): p. 465-470.
10. Jensen, N.H., Reduced pain from osteoarthritis in hip joint or knee joint during treatment with calcium ascorbate. A randomized, placebo-controlled cross-over trial in general practice. Ugeskr Laeger, 2003. 165(25): p. 2563-6.
11. Basu, T.K., et al., Ascorbic acid therapy for the relief of bone pain in Paget's disease. Acta Vitaminol Enzymol, 1978. 32(1-4): p. 45-9.
12. Schleicher, R.L., et al., Serum vitamin C and the prevalence of vitamin C deficiency in the United States: 2003-2004 National Health and Nutrition Examination Survey (NHANES). Am J Clin Nutr, 2009. 90(5): p. 1252-63.
13. Pearson, J.F., et al., Vitamin C Status Correlates with Markers of Metabolic and Cognitive Health in 50-Year-Olds: Findings of the CHALICE Cohort Study. Nutrients, 2017. 9(8).
14. Lim, D.J., Y. Sharma, and C.H. Thompson, Vitamin C and alcohol: a call to action. BMJ Nutrition, Prevention & Health, 2018. 0: p. 1-6.