Pain and inflammation

Natural Methods of Diminishing Pain and Inflammation are being sought by patients concerned about the adverse effects of using NSAIDs, COX1 and COX2 inhibitors. One of the effective methods available involves the use of fatty acids. Another approach to be used synergistically involves the use of proteolytic enzymes.

    An Introduction to Fatty Acids

We can think of the major biologically active fatty acids as originating from three major categories or “families” based on their molecular configuration and their physiologic properties.  We can then ascribe general properties to these families and the individual members within each group.  The most clinically important fatty acids are “unsaturated”, meaning they have one or more carbon-to-carbon double bonds rather than carbon-to-carbon single bonds, the latter being “saturated” with the full number of hydrogen molecules. 

Double bonds strongly influence the biochemical and clinical effects of fatty acids, making these fatty acids more reactive and biologically active than their saturated counterparts, as well as more prone to oxidation, rancidification, and hydrogenation.

Within each family, fatty acids progress from predecessors to progeny by a series of enzymatic steps catalysed by desaturase and elongase enzymes.  The desaturase enzymes are very slow in their conversions compared to the elongase enzymes, and the clinical relevance of this difference will become apparent further on.  We also note that fatty acids never change from one family to another: e.g. an omega-3 fatty acid will always remain in the omega-3 family and will never become a member of the omega-6 or omega-9 family.  This is because the defining characteristic on a molecular level is never altered: omega-3 fatty acids have their first carbon-to-carbon double bond starting at the third carbon from the methyl group; omega-6 fatty acids have theirs at the sixth carbon from the methyl group; omega-9 fatty acids have theirs starting at the ninth carbon from the methyl group.  For the sake of efficiency and accordance with nomenclature conventions, we will abbreviate “omega” as “n” for the n-3, n-6, and n-9 fatty acids, respectively. 

N-3 fatty acid

The n-3 family of fatty acids begins with alpha-linolenic acid, commonly referred to as one of the two “essential fatty acids” because it cannot be produced within the human body and must therefore be provided by the diet.  Manifestations of n-3 fatty acid deficiencies are generally subtle when contrasted to those of the n-6 family and include behavioural and visual impairment, endocrinologic alterations, and a tendency toward the development and progression of several chronic degenerative diseases.7 

Abundant in flax oil (~57%), alpha-linolenic acid ( ALA ) is converted to stearidonic acid by delta-6-desaturase.  Stearidonic acid (SDA) is elongated to n-3 eicosatetraenoic acid, which is then converted to eicosapentaenoic acid (EPA) by delta-5-desaturase.  EPA is elongated to n-3 docosapentaenoic acid (n-3 DPA), which is then converted to docosahexaenoic acid (DHA) by delta-4-desaturase. 

N-6 fatty acids: The n-6 family of fatty acids begins with linoleic acid (LA), also referred to as an “essential fatty acid” because it cannot be synthesized de novo within the human body.  LA is abundant in most nut, seed, and vegetable oils such as canola oil (21%), safflower oil (76%), sunflower oil (71%), corn oil (57%), soybean oil (54%), and cottonseed oil (54%).8  LA is converted by delta-6-desaturase to gamma-linolenic acid (GLA), which is quickly elongated to dihomo-gamma-linolenic acid (DGLA).  DGLA is slowly converted by delta-5-desaturase to arachidonic acid (ARA), which is elongated to adrenic acid, which is finally converted to n-6 docosapentaenoic acid by delta-4-desaturase.  These substrates and conversions are illustrated in Figure 2 (modified with permission from Integrative Orthopedics4).

Note that the term “eicosatetraenoic acid” can apply to both 20:4n6 (arachidonic acid) of the omega-6 fatty acid family9 and to 20:4n3 of the omega-3 fatty acid family.10  Therefore, to avoid the confusion that would result from the use of the term “eicosatetraenoic acid” by itself, “n-6 eicosatetraenoic acid” should be used when referring to 20:4n6 (arachidonic acid) and “n-3 eicosatetraenoic acid” should be used when referring to 20:4n3.  Similarly, 22:5n3 of the omega-3 fatty acid family11,12 and 22:5n6 of the omega-6 fatty acid family13,14,15 are both referred to as “docosapentaenoic acid.” Therefore using the term “docosapentaenoic acid” will be ambiguous unless the appropriate n-3 or n-6 designation is stated.  “N-3 docosapentaenoic acid” should be used to refer to 22:5n3 and “n-6 docosapentaenoic acid” should be used for 22:5n6.

N-9 fatty acids: The primary n-9 fatty acid in the human diet is oleic acid, the predominant monounsaturated fatty acid in olive oil.  While oleic acid is certainly biologically active and therefore clinically important, due to the complexity of olive oil as the primary source of oleic acid, we are not yet able to clearly determine from epidemiological studies how much of the benefit of olive oil consumption is due to the oleic acid compared to the benefits derived from the powerful antioxidant and anti-inflammatory actions of the phenolics, the relatively high content of squalene, or other confounding variables in diet and lifestyle.16,17  These complicating factors and the clinical benefits of olive oil and oleic acid will be discussed in a future article in this series. 

Enzymatic Conversion: Chemical Flowcharts Versus the Reality of Clinical Effectiveness

If conversion of one fatty acid to the next proceeded as efficiently as depicted in biochemical flow charts, then n-3 ALA and n-6 LA could be supplemented to provide all of the downstream fatty acids and their metabolites, presumably in the proper ratios.  However, clearly this is not the case due to intrinsic as well as genotypic (inherited) and phenotypic (manifested) defects in enzyme effectiveness.  Clinicians need to understand the individual characteristics of these enzymes in order to successfully employ therapies which modulate fatty acid metabolism.  Since the conversions catalysed by elongase are quite efficient and are almost never discussed as cause for concern in the medical and nutritional literature, we will focus on the desaturase enzymes, which are noted to have significant variances in phenotypic expression and which can be adversely affected by common vitamin and mineral deficiencies.

Delta-6-desaturase: The first step in the n-3 and n-6 pathways is the action of delta-6-desaturase (D6D) in converting ALA to SDA and LA to GLA, respectively.  Enzymatic conversions by D6D are rate-limiting due to 1) its strong need for several vitamin and mineral co-factors, 2) its genotypic impairment, such as in patients with eczema18, 3) its phenotypic impairment in patients with diabetes19, and its impairment by trans-fatty acids20, stress neurotransmitters21, and other environmental and nutritional influences4. The slow conversions by D6D explain why, as Horrobin noted, “…it is impossible to produce any significant elevation of DGLA levels in humans by increasing linoleic acid intake”22.  Similarly, conversion of ALA to the downstream and clinically desirable fatty acids EPA and DHA is unreliable, with most studies showing only a modest increase in EPA and no increase in DHA following supplementation with ALA.  Cofactors required for efficient action of D6D include iron, zinc, magnesium, pyridoxine, riboflavin, and niacin; when these vitamins and minerals are deficient, D6D function will be impaired and defects in fatty acid metabolism will result.23

Delta-5-desaturase: Delta-5-desaturase (D5D) slowly converts n-3 eicosatetraenoic acid to EPA, and in the n-6 pathway, DGLA to ARA.  Supplementation with GLA has been shown to result in a slight to modest increase in ARA that may or may not be clinically significant.  Impairment of D5D is seen in patients with the blinding eye disease retinitis pigmentosa, resulting in marked reduction in retinal DHA levels 24.

Delta-4-desaturase: Delta-4-desaturase (D4D), like the other desaturase enzymes, is also very slow-acting.  While impaired conversion of adrenic acid to n-6 docosapentaenoic acid appears to be of little or no consequence, reduced bioavailability of DHA due to its slow conversion from n-3 docosapentaenoic acid has tremendous implications in the aetiology of schizophrenia, a disease associated with impaired D4D activity 25.

By understanding the biochemical efficiency of these enzymes, doctors are better able to understand how to implement clinical strategies for modulating fatty acid balance in their patients.  In the n-3 family, supplementation with ALA increases (in order of decreasing efficiency) ALA , SDA, and EPA but does not consistently elevate DHA.  Therefore, although consumption of flax oil has many important benefits and may be used to modestly increase EPA levels, it cannot be relied upon to increase DHA levels.26  Supplementation with SDA increases EPA levels, but DHA is not significantly increased due to the slow conversion by D4D 27.  Supplementation with EPA proportionately increases EPA but does not consistently increase DHA.28  DHA supplementation is the most effective and reliable means for increasing DHA levels 29.

In the n-6 family, supplementation with LA does not lead to clinically significant increases in GLA or DGLA 22. Supplementation with GLA greatly increases DGLA and leads to a modest increase in ARA 30.  Diets high in ARA lead to increased tissue levels of ARA.  Consumption of EPA lowers levels of GLA/DGLA19 and oleic acid31; likewise, consumption of GLA lowers levels of EPA 30. Overall, the implications are that when a particular fatty acid is desired for its physiologic effect and clinical benefits, it should be supplied directly from the diet or supplements.

Selected references

• 1.        “Doctors of Chiropractic are physicians who consider man as an integrated being and give special attention to the physiological and biochemical aspects including structural, spinal, musculoskeletal, neurological, vascular, nutritional, emotional and environmental relationships.” Available at http://www.amerchiro.org/media/whatis/ on March 11, 2004
• 2.        Beckman JF, Fernandez CE, Coulter ID. A systems model of health care: a proposal. J Manipulative Physiol Ther. 1996 Mar-Apr;19(3):208-15
• 3.        Orme-Johnson DW, Herron RE.  An innovative approach to reducing medical care utilization and expenditures. Am J Manag Care 1997 Jan;3(1):135-44
• 4.        Vasquez A. Integrative Orthopedics: Concepts, Algorithms, and Therapeutics.  Houston; Natural Health Consulting Corporation (www.OptimalHealthResearch.com): 2004
• 5.        Manga, Pran; Angus, Doug; Papadopoulos, Costa; Swan, William. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain. Richmond Hill , Ontario : Kenilworth Publishing, 1993
• 6.        American Chiropractic Association.  See http://www.amerchiro.org/media/research/ and http://www.amerchiro.org/media/research/more_research.shtml for citations; available on March 3, 2004
• 7.        Tapiero H, Ba GN, Couvreur P, Tew KD. Polyunsaturated fatty acids (PUFA) and eicosanoids in human health and pathologies. Biomed Pharmacother. 2002 Jul;56(5):215-22
• 8.        Morris DH.  Canola and the good news about dietary fat. Published by the Canola Council at http://www.canola-council.org/pubs/GNs.pdf available as of March 3, 2004
• 9.        Mimouni V, Christiansen EN, Blond JP, Ulmann L, Poisson JP, Bezard J. Elongation and desaturation of arachidonic and eicosapentaenoic acids in rat liver. Effect of clofibrate feeding. Biochim Biophys Acta. 1991 Nov 27;1086(3):349-53
• 10.     Erasmus U.   Fats that heal, fats that kill.  British Columbia Canada : Alive Books, 1993  Page 276
• 11.     Williard DE, Harmon SD, Kaduce TL, Preuss M, Moore SA, Robbins ME, Spector AA. Docosahexaenoic acid synthesis from n-3 polyunsaturated fatty acids in differentiated rat brain astrocytes. J Lipid Res. 2001 Sep;42(9):1368-76
• 12.     Takahashi R, Nassar BA, Huang YS, Begin ME, Horrobin DF. Effect of different ratios of dietary N-6 and N-3 fatty acids on fatty acid composition, prostaglandin formation and platelet aggregation in the rat. Thromb Res. 1987 Jul 15;47(2):135-46
• 13.     Retterstol K, Haugen TB, Christophersen BO. The pathway from arachidonic to docosapentaenoic acid (20:4n-6 to 22:5n-6) and from eicosapentaenoic to docosahexaenoic acid (20:5n-3 to 22:6n-3) studied in testicular cells from immature rats. Biochim Biophys Acta. 2000 Jan 3;1483(1):119-31
• 14.     Ahmad A, Murthy M, Greiner RS, Moriguchi T, Salem N Jr. A decrease in cell size accompanies a loss of docosahexaenoate in the rat hippocampus. Nutr Neurosci. 2002 Apr;5(2):103-13
• 15.     Mimouni V, Narce M, Huang YS, Horrobin DF, Poisson JP. Adrenic acid delta 4 desaturation and fatty acid composition in liver microsomes of spontaneously diabetic Wistar BB rats. Prostaglandins Leukot Essent Fatty Acids. 1994 Jan;50(1):43-7
• 16.     Stark AH, Madar Z. Olive oil as a functional food: epidemiology and nutritional approaches. Nutr Rev. 2002 Jun;60(6):170-6
• 17.     Newmark HL.  Is oleic acid or squalene the important preventive agent?  Am J Clin Nutr. 2000 Aug;72(2):502
• 18.     Manku MS, Horrobin DF, Morse N, Kyte V, Jenkins K, Wright S, Burton JL. Reduced levels of prostaglandin precursors in the blood of atopic patients: defective delta-6-desaturase function as a biochemical basis for atopy. Prostaglandins Leukot Med. 1982 Dec;9(6):615-28
• 19.     Horrobin DF. Fatty acid metabolism in health and disease: the role of delta-6-desaturase. Am J Clin Nutr. 1993 May;57(5 Suppl):732S-736S
• 20.     Simopoulos AP. Essential fatty acids in health and chronic disease. Am J Clin Nutr. 1999 Sep;70(3 Suppl):560S-569S
• 21.     Mamalakis G, Kafatos A, Tornaritis M, Alevizos B. Anxiety and adipose essential fatty acid precursors for prostaglandin E1 and E2. J Am Coll Nutr. 1998 Jun;17(3):239-43
• 22.     Horrobin DF.  Interactions between n-3 and n-6 essential fatty acids (EFAs) in the regulation of cardiovascular disorders and inflammation.  Prostaglandins Leukot Essent Fatty Acids. 1991 Oct;44(2):127-31
• 23.     Serfontein WJ, de Villiers LS, Ubbink J, Rapley C. Delta-6-desaturase enzyme co-factors and atherosclerosis. S Afr Med J. 1985 Jul 20;68(2):67-8
• 24.     Hoffman DR, DeMar JC, Heird WC, Birch DG, Anderson RE.  Impaired synthesis of DHA in patients with X-linked retinitis pigmentosa.  J Lipid Res. 2001 Sep;42(9):1395-401
• 25.     Mahadik SP, Shendarkar NS , Scheffer RE, Mukherjee S, Correnti EE.  Utilization of precursor essential fatty acids in culture by skin fibroblasts from schizophrenic patients and normal controls.  Prostaglandins Leukot Essent Fatty Acids. 1996 Aug;55(1-2):65-70
• 26.     Francois CA, Connor SL, Bolewicz LC, Connor WE. Supplementing lactating women with flaxseed oil does not increase docosahexaenoic acid in their milk. Am J Clin Nutr. 2003 Jan;77(1):226-33
• 27.     James MJ, Ursin VM, Cleland LG. Metabolism of stearidonic acid in human subjects: comparison with the metabolism of other n-3 fatty acids. Am J Clin Nutr. 2003 May;77(5):1140-5
• 28.     Park Y, Harris W. EPA, but not DHA, decreases mean platelet volume in normal subjects. Lipids. 2002 Oct;37(10):941-6
• 29.     Mori TA, Burke V, Puddey IB, Watts GF, O'Neal DN, Best JD, Beilin LJ. Purified eicosapentaenoic and docosahexaenoic acids have differential effects on serum lipids and lipoproteins, LDL particle size, glucose, and insulin in mildly hyperlipidemic men.  Am J Clin Nutr. 2000 May;71(5):1085-94
• 30.     Jantti J, Nikkari T, Solakivi T, Vapaatalo H, Isomaki H. Evening primrose oil in rheumatoid arthritis: changes in serum lipids and fatty acids. Ann Rheum Dis. 1989 Feb;48(2):124-7
• 31.     Haban P, Zidekova E, Klvanova J. Supplementation with long-chain n-3 fatty acids in non-insulin-dependent diabetes mellitus (NIDDM) patients leads to the lowering of oleic acid content in serum phospholipids. Eur J Nutr. 2000 Oct;39(5):201-6

Independent research

• Vasquez A.  Reducing Pain and Inflammation Naturally. Part 1: New Insights into Fatty Acid Biochemistry and the Influence of Diet.  Nutritional Perspectives 2004; October pages 5-15
• Vasquez A. Integrative Orthopedics: The Art of Creating Wellness While Managing Acute and Chronic Musculoskeletal Disorders. Houston; Natural Health Consulting Corporation.  (www.OptimalHealthResearch.com): 2004
• "Indu and Ghafoorunissa showed that while keeping the amount of dietary LA constant, 3.7 g ALA appears to have biological effects similar to those of 0.3 g long-chain n-3 PUFA with conversion of 11 g ALA to 1 g long-chain n-3 PUFA."  Simopoulos AP. Essential fatty acids in health and chronic disease. Am J Clin Nutr. 1999 Sep;70(3 Suppl):560S-569S
• Francois CA, Connor SL, Bolewicz LC, Connor WE. Supplementing lactating women with flaxseed oil does not increase docosahexaenoic acid in their milk. Am J Clin Nutr. 2003 Jan;77(1):226-33
• “Linear relationships were found between dietary alpha-LA and EPA in plasma fractions and in cellular phospholipids. … There was an inverse relationship between dietary alpha-LA and docosahexaenoic acid concentrations in the phospholipids of plasma, neutrophils, mononuclear cells, and platelets.”  Mantzioris E, James MJ, Gibson RA, Cleland LG. Differences exist in the relationships between dietary linoleic and alpha-linolenic acids and their respective long-chain metabolites.  Am J Clin Nutr. 1995 Feb;61(2):320-4
• “CONCLUSIONS: Dietary supplementation with ALA for 3 months decreases significantly CRP, SAA and IL-6 levels in dyslipidaemic patients. This anti-inflammatory effect may provide a possible additional mechanism for the beneficial effect of plant n-3 polyunsaturated fatty acids in primary and secondary prevention of coronary artery disease.” Rallidis LS, Paschos G, Liakos GK, Velissaridou AH, Anastasiadis G, Zampelas A. Dietary alpha-linolenic acid decreases C-reactive protein, serum amyloid A and interleukin-6 in dyslipidaemic patients. Atherosclerosis. 2003 Apr;167(2):237-42
• Tak PP, Firestein GS. NF-kappaB: a key role in inflammatory diseases. J Clin Invest. 2001 Jan;107(1):7-11
• “Thus, 3-month's supplementation with alpha-LNA did not prove to be beneficial in rheumatoid arthritis.” Nordstrom DC, Honkanen VE, Nasu Y, Antila E, Friman C, Konttinen YT. Alpha-linolenic acid in the treatment of rheumatoid arthritis. A double-blind, placebo-controlled and randomized study: flaxseed vs. safflower seed. Rheumatol Int. 1995;14(6):231-4
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• Hu FB, Stampfer MJ, Manson JE, Rimm EB, Wolk A, Colditz GA, Hennekens CH, Willett WC. Dietary intake of alpha-linolenic acid and risk of fatal ischemic heart disease among women. Am J Clin Nutr. 1999 May;69(5):890-7
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• Tapiero H, et al. Polyunsaturated fatty acids (PUFA) and eicosanoids in human health and pathologies. Biomed Pharmacother. 2002 Jul;56(5):215-22
• Horrobin DF.  Interactions between n-3 and n-6 essential fatty acids (EFAs) in the regulation of cardiovascular disorders and inflammation.  Prostaglandins Leukot Essent Fatty Acids. 1991 Oct;44(2):127-31
• “A dose of 1.8 g EPA/d did not result in any prolongation in bleeding time, but 4 g/d increased bleeding time and decreased platelet count with no adverse effects. In human studies, there has never been a case of clinical bleeding…” Simopoulos AP. Essential fatty acids in health and chronic disease. Am J Clin Nutr. 1999 Sep;70(3 Suppl):560S-569S
• Yasui T, Tanaka H, Fujita K, Iguchi M, Kohri K.  Effects of eicosapentaenoic acid on urinary calcium excretion in calcium stone formers. Eur Urol. 2001 May;39(5):580-5
• Duffy EM, Meenagh GK, McMillan SA, Strain JJ, Hannigan BM, Bell AL. The clinical effect of dietary supplementation with omega-3 fish oils and/or copper in systemic lupus erythematosus. J Rheumatol. 2004 Aug;31(8):1551-6
• Wigmore SJ, Barber MD, Ross JA, Tisdale MJ, Fearon KC. Effect of oral eicosapentaenoic acid on weight loss in patients with pancreatic cancer. Nutr Cancer. 2000;36(2):177-84
• Zanarini MC, Frankenburg FR. omega-3 Fatty acid treatment of women with borderline personality disorder: a double-blind, placebo-controlled pilot study. Am J Psychiatry. 2003 Jan;160(1):167-9
• Nemets B, Stahl Z, Belmaker RH. Addition of omega-3 fatty acid to maintenance medication treatment for recurrent unipolar depressive disorder. Am J Psychiatry. 2002 Mar;159(3):477-9
• Puri BK, Counsell SJ, Hamilton G, Richardson AJ, Horrobin DF.Eicosapentaenoic acid in treatment-resistant depression associated with symptom remission, structural brain changes and reduced neuronal phospholipid turnover. Int J Clin Pract. 2001 Oct;55(8):560-3
• Peet M, Horrobin DF.A dose-ranging study of the effects of ethyl-eicosapentaenoate in patients with ongoing depression despite apparently adequate treatment with standard drugs. Arch Gen Psychiatry. 2002 Oct;59(10):913-9
• Emsley R, Myburgh C, Oosthuizen P, van Rensburg SJ. Randomized, placebo-controlled study of ethyl-eicosapentaenoic acid as supplemental treatment in schizophrenia. Am J Psychiatry. 2002 Sep;159(9):1596-8
• Kruger MC, Coetzer H, de Winter R, Gericke G, van Papendorp DH. Calcium, gamma-linolenic acid and eicosapentaenoic acid supplementation in senile osteoporosis. Aging (Milano). 1998 Oct;10(5):385-94
• Hong S, Gronert K, Devchand PR, Moussignac RL, Serhan CN. Novel docosatrienes and 17S-resolvins generated from docosahexaenoic acid in murine brain, human blood, and glial cells. Autacoids in anti-inflammation. J Biol Chem. 2003 Apr 25;278(17):14677-87
• Ahmad A, Murthy M, Greiner RS, Moriguchi T, Salem N Jr. A decrease in cell size accompanies a loss of docosahexaenoate in the rat hippocampus. Nutr Neurosci. 2002 Apr;5(2):103-13
• Pawlosky RJ, Bacher J, Salem N Jr. Ethanol consumption alters electroretinograms and depletes neural tissues of docosahexaenoic acid in rhesus monkeys: nutritional consequences of a low n-3 fatty acid diet. Alcohol Clin Exp Res. 2001 Dec;25(12):1758-65
• Horrocks LA, Yeo YK. Health benefits of docosahexaenoic acid (DHA). Pharmacol Res. 1999 Sep;40(3):211-25
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• “The recent GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico)-Prevention study of 11,324 patients showed a 45% decrease in risk of sudden cardiac death and a 20% reduction in all-cause mortality in the group taking 850 mg/d of omega-3 fatty acids.”  O'Keefe JH Jr, Harris WS. From Inuit to implementation: omega-3 fatty acids come of age. Mayo Clin Proc. 2000 Jun;75(6):607-14
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• Fan YY, Chapkin RS. Importance of dietary gamma-linolenic acid in human health and nutrition. J Nutr. 1998 Sep;128(9):1411-4
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• Brzeski M, Madhok R, Capell HA. Evening primrose oil in patients with rheumatoid arthritis and side-effects of non-steroidal anti-inflammatory drugs. Br J Rheumatol. 1991 Oct;30(5):370-2
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• Pacht ER, DeMichele SJ, Nelson JL, Hart J, Wennberg AK, Gadek JE. Enteral nutrition with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants reduces alveolar inflammatory mediators and protein influx in patients with acute respiratory distress syndrome. Crit Care Med. 2003 Feb;31(2):491-500
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Proteolytic Enzymes
An outstanding and highly effective treatment for muscle soreness and discomfort due to the rigours of overexertion. Other major benefits include:

• Supports hormone processing
• Digestive support
• Immune system support
• Supports a healthy circulatory system

Intenzyme Forte™ is a broad spectrum nutritional supplement capable of exerting influence over a variety of physiological and biochemical processes. intenzyme Forte™ is unique because of its proteolytic enzyme formulation that supports the numerous pathways of protein metabolism.For over 25 years Intenzyme Forte™ has provided safe, effective and reliable results. That’s why thousands of health care professionals use Intenzyme Forte™ in their practices; because of the beneficial results they consistently see with their patients.

1. Kamenicek V, Holan P, Franek P. [Systemic enzyme therapy in the treatment and prevention of post-traumatic and postoperative swelling] [Article in Czech] Acta Chir Orthop Traumatol Cech. 2001;68(1):45-9
2. Klein G, Kullich W. [Reducing pain by oral enzyme therapy in rheumatic diseases] Wien Med Wochenschr. 1999;149(21-22):577-80
3. Blonstein JL. Control of swelling in boxing injuries. Practitioner. 1969 Aug;203(214):206

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