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Osteoporosis part two

Osteoporosis, a condition characterized by loss of bone mass and increased bone fragility, has become big news and big business. Advertising campaigns and fact sheets in doctors' waiting rooms and pharmacies continually warn women of the dangers of disappearing bone mass. The statistics from the United States show that more than 20 million people have osteoporosis and approximately 1.3 million annually suffer a bone fracture as a result of the disease. Sixteen per cent of patients who have hip fractures will die within six months, while 50 per cent will require long-term nursing care.

Women are bombarded with the message that the war on bone loss must include calcium supplements and a daily consumption of calcium-rich foods, primarily dairy products. Doctors recommend long-term use of hormones such as estrogen to the post-menopausal woman, or they prescribe bone-building drugs like Fosamax® or Boniva®.

Osteoporosis is a problem of bones, not women. Although men have half as many fractures as women, they are more likely to die as a result of the fracture than are women. Bone is living tissue that undergoes constant transformation. Old bone is constantly dissolved and new bone is laid down to replace it. Bone tissue is nourished and detoxified by nutrients from the blood in constant exchange with the rest of the body. A healthy body will ensure healthy bones.

How do we treat Osteoporosis?
As discussed in part one of this series, perhaps the most important aspect of osteoporosis treatment is reducing bone fragility, rather than solely focusing on bone density. The current emphasis on bone density in the diagnosis and treatment of osteoporosis greatly limits understanding of the importance of bone quality. Bone density alone is not an accurate predictor of fractures, or lack of bone strength. Qualities such as bone size, shape, integrity of collagen, thickness and connectedness of trabecular bone, and rate of bone turnover all effect bone strength. (1) It is becoming evident that use of bisphosphonate drug therapies (such as Fosamax®) for osteoporosis is only weakly associated with overall fracture reduction (2,3) and only slightly improves bone strength. (4) In light of this, it is prudent to expand the way we think about osteoporosis treatment.

What then are viable treatment options? The major non-genetic factors contributing to osteoporosis are lifestyle and diet. Numerous studies have demonstrated that physical fitness is the major determinant of bone density. Weight bearing exercise, including walking, aids in the normal remodeling process of bone building and strengthening. Exercise in adolescence and adulthood actually helps increase bone density and improves overall bone health. (5,6) Exercise increases anti-inflammatory cellular chemicals known as cytokines along with strengthening muscles and increasing coordination, thereby also reducing falls which remain the number one risk factor for osteoporotic fracture.(7)

Although weight-bearing exercise is very beneficial in promoting bone health, chronic high intensity excessive exercise (e.g. long distance marathon runners or iron man competitors) actually causes bone breakdown due to the created metabolic acidosis, hypoxia, excess oxidative stress and pro-inflammatory cytokines.(8)

Stress Management
Managing stress is extremely important in order to achieve optimal health for a variety of reasons. The ill-effects of stress on heart health seem to be well known, however prolonged chronic stress has deleterious effects on many other body systems and functions as well. Elevated levels of stress adversely affect digestion and absorption, which is also likely to affect calcium absorption. Cortisol is normally released in response to stress: it is one of the “fight or flight” steroid hormones. Over prolonged periods of ill-managed stress levels, cortisol levels remain chronically high, which depletes the normal stores of DHEA (dehydroepiandrosterone), a precursor to cortisol. Elevated cortisol and reduced levels of DHEA have been related to the onset of osteoporosis. The effects of chronically elevated cortisol or reduced DHEA can be similar to those of exogenous steroids. (9) Steroids, whether in drug form or created by one’s own body, inhibit osteoblast formation and sensitize existing osteoblasts to the effects of parathyroid hormone and vitamin D, which in turn increases bone resorption (loss). Steroids also depress collagen synthesis and inhibit calcium absorption in the intestine. DHEA may have an effect of inhibiting bone resorption as it can be converted into both estrogen and testosterone, both of which are protective against bone loss. (10)

The moral of this story: develop a daily practice and strategy for handling your stress. It will make you and your loved ones much healthier and happier!

It is slowly being recognized that inflammation plays an important role in development of osteoporosis. (11) Receptors for two major pro-inflammatory cytokines (cellular chemicals) are present on both the cellular precursors to osteoclasts and osteoclasts themselves. When these cytokines activate the osteoclasts, bone is broken down. Estrogen inhibits bone resorption by blocking the action of these pro-inflammatory cytokines. When these pro-inflammatory substances are present in excess we can expect a greater amount of bone resorption, therefore it makes sense to minimize the sources of these substances.

C-reactive protein is an abnormal glycoprotein produced by the liver in response to generalized inflammation. This protein may be associated with bone density loss and can easily be assessed via a blood test.
One way to reduce the ratio of these inflammatory substances is through daily ingestion of “good” fats and reducing pro-inflammatory foods, particularly elevated amounts of animal products. Consumption of omega 3 fatty acids such as fish oil, dietary fish, and flax seed oil decrease the production of these harmful substances. (12_ Alpha lipoic acid, n-acetylcysteine, taurine, and curcumin are other anti-inflammatory substances that might be considered.

The Importance of Calcium
Recall that about 30 percent of bone is made up of various proteins, while the remainder is composed of minerals. 95 percent of the make up of the mineral aspect of bone is calcium. Mineral absorption and assimilation is dependent on several factors: minerals must be broken down into an absorbable form by stomach acid in order to be absorbed in the intestine. If one is taking an “acid blocker” such as Protonix®, Nexium®, Prevacid®, or another “proton pump inhibitor” (PPI), acid production in the stomach is greatly reduced, thereby reducing the body’s ability to break down minerals. There was 44 percent increased risk of hip fractures found in women over age 50 who had been taking acid suppression therapy for more than one year. In addition, investigators found that long-term high dose use of PPIs increased risk of hip fracture by 245 percent. (13)
Calcium is very strictly regulated in the blood because increases or decreases in calcium levels can adversely affect heart function among other physiologic processes. Coffee, alcohol, and smoking all negatively affect calcium balance and are associated with a higher risk of developing osteoporosis. Sedentary lifestyles, including immobilization following fractures, can double the rate of fecal and urinary calcium excretion causing a loss of bone density.

Diets high in phosphate, protein, acid-ash and salt while low in calcium and trace mineral intake have been associated with higher risk of developing osteoporosis. Refined sugar is also associated with the loss of calcium from the body. After eating refined sugar, there is increased urinary excretion of calcium.

Foods considered to be high in acid-ash include meat, eggs, nuts and peanuts (which are really legumes), grains and grasses (breads, baked goods, cereals, rice, pasta) and dairy products (including milk, yogurt, butter and cheese). Most fruits and vegetables are considered to be alkaline and therefore a good choice for optimal bone health. Green leafy vegetables are also a rich source of a broad range of vitamins and minerals including calcium, vitamin K1, and boron. A healthy diet includes a high proportion of alkaline foods (fruits and vegetables) to acid-ash foods. Soft drinks are very high in phosphates and contain virtually no calcium, which leads to higher phosphate levels in the blood and lower calcium levels. Soft drinks also contain other additives, including the artificial sweetener aspartame in diet drinks that may have other detrimental health effects.

Calcium Supplementation at Menopause
The Women's Health Initiatives (WHI) Study that was released February 16, 2006 in the New England Journal of Medicine prompted headlines such as the New York Times’ that read, "Big Study Finds No Clear Benefit of Calcium Pills." This 7-year, 18 million dollar study funded by our federal government apparently meant to prove solely calcium with vitamin D was the ultimate cure for osteoporosis.

In the WHI study, 18,176 were given calcium (1,000 mg daily) and vitamin D (400 IU daily) in 2 divided doses per day and 18,106 got a placebo. After seven years only 59% of the women were still taking the pills regularly (80% of the time). For those women who were still taking the pills, there was a 29% decrease in hip fractures. In simple words, the study concluded taking calcium and vitamin D most of the time resulted in a third less hip fractures in an at-risk population. By most standards, a one third reduction in this population is a fairly successful treatment option. The main catch: if the calcium and vitamin D pills are not taken, they will not help!

How much Calcium is enough?
The Bantu of West Africa have the lowest rates of osteoporosis of any culture, yet they consume less than 500 mg of calcium daily. The Japanese average about 540 mg daily, but the post-menopausal fractures so common in the West are almost unheard of in Japan, even though the Japanese have one of the longest life spans of any population. Studies of populations in China, Gambia, Ceylon, Suriname, Peru and other cultures all report similar findings of low calcium intake and low osteoporosis rates. Studies in people in North and Central America failed to find a link between calcium intake and bone loss. While it is agreed that adequate calcium is absolutely necessary for development and maintenance of healthy bones, it is also obvious from these studies that high calcium intake is not necessary for healthy bones.

There is good data to suggest that calcium supplements are effective in reducing bone loss in late menopausal women (more than 5 years post menopause), particularly in those with habitually low calcium intake (less than 400 mg/day). In addition, a meta-analysis that includes 15 trials indicates that calcium supplementation at levels between 500 and 2000 mg/day reduces postmenopausal bone loss. Currently, in the United States, 1200 mg/day is considered an optimal calcium intake for women 51 years and older, with recommendations being lower in European countries (between 700 and 1000 mg/day). The findings of calcium supplementation studies in the early stages of menopause are conflicting, and this is an important area for research in this "post-WHI" (Women's Health Initiative) era, as menopausal hormone therapy use for long duration is no longer recommended.

Protein Intake and Bone Health
There has been controversy concerning the relationship between dietary protein and osteoporosis. Excess dietary protein can result in urinary calcium loss, negative calcium balance, and increased bone loss. It is very important to note, however, that protein under-nutrition is also a risk factor for bone loss, osteoporosis, and fracture, and the elderly in particular are at risk for protein under-nutrition.

Protein is in ample supply in the Western diet, and hence the focus of attention has been protein excess as opposed to protein insufficiency. The general recommendation is 1 mg of protein per kg body weight. Particular attention should be paid to this recommendation in the aging population, for whom protein insufficiency is a particular problem. A daily protein supplement (providing 20 grams of protein) may be of particular benefit to the elderly. Food fortification of protein foods should be considered.

Vitamin D
Vitamin D is one of the most important nutrients affecting bone health due to its role in stimulating intestinal absorption if calcium. Vitamin D deficiency has been found in 25 percent of elderly patients presenting with hip fractures. (14) This is due to decreased intestinal absorption, impaired hepatic and renal conversion of vitamin D to its active form, and/or insufficient exposure to sunlight. Lack of sufficient sunlight exposure—especially but not only in Northern countries during winter months—poor nutrition or low milk consumption or vegan diet, nonwhite ethnicity, urban residence, and poverty are key factors that have been cited as contributing to the low vitamin D levels.

Ipriflavone is a substance synthesized from soy and appears to hold great promise as a prevention and treatment for osteoporosis. Ipriflavone seems to have several mechanisms of action, all of which enhance bone density. It has been studied in about 60 human studies in comparison to several conventional therapies such as conventional hormone replacement therapy and bisphosphonates (like Fosamax®). It appears to inhibit bone resorption, enhance bone formation, and enhance estrogen’s effects without acting like estrogen. (15)

It is clear that osteoporosis involves much more that simply calcium intake. Simply having a reduced bone density does not mean one will suffer a fracture, and improving only bone density does not confer automatic protection against fractures. There is increasing evidence that bone quality is influenced by multiple factors.

Women should not assume that taking only calcium and vitamin D will prevent osteoporosis. Those at risk for development of osteoporosis or fractures should consider a more complete nutritional protocol, one that includes magnesium, strontium, vitamin K-2 and vitamins B6, B12, D, folic acid, and ipriflavones along with a healthy diet (as discussed above), a daily exercise program, and careful attention to stress management. Women with severe cases of osteoporosis may require hormone replacement therapy or pharmaceutical intervention such as Fosamax® or Boniva® in order to help prevent fractures. Treatment for osteoporosis will continue to evolve, along with our understanding of the pathological processes that need treatment.

1 McCormick, Keith R., “Osteoporosis: Integrating Biomarkers and other Diagnostic Correlates into the Management of Bone Fragility,” Alternative Medicine Review (2007): 113-145.
2 Chestnut CH 3rd, Rosen CJ, Bone Quality Discussion Group, “Reconsidering the effects of antiresorptive therapies in reducing osteoporotic fracture,” Journal Bone Mineral Research (2001): 16; 2163-2172.
3 Cummings SR et. al., “Improvement of spine bone density and reduction in risk of vertebral fractures during treatment with antiresorptive drugs,” American Medical Journal (2002); 112;281-289.
4 Seeman E Delmas, “Bone quality – the material and structural basis of bone strength and fragility,” New England Journal of Medicine (2006); 354; 2250-2261.
5 Welton DC et. Al., “Weight bearing activity through youth is a more important factor for peak bone mass than calcium intake,” Journal Bone Mineral Research; (1994); 9:1089-1096.
6 Cooper, C, “Childhood growth, physical activity, and peak bone mass in women,” Journal Bone Mineral Research; (1995); 10: 940-947.
7 Grisso et. al., “Risk factors for hip fractures in men: a preliminary study,” Journal Bone Mineral Research; (1991); 6: 865-868
8 Ostrowski, K et. Al., “Evidence that Interleukin 6 is produced in human skeletal muscle during prolonged running,” Journal Physiology (1998); 508:949-953.
9 McCormick, Keith R., “Osteoporosis: Integrating Biomarkers and other Diagnostic Correlates into the Management of Bone Fragility,” Alternative Medicine Review (2007): 113-145.
10 Gaby Allen, “Dehydroepiandroaterone: Biological effects and clinical significance,” Alternative Medicine Review, (1996); 1: 60-69
11 McCormick, Keith R., “Osteoporosis: Integrating Biomarkers and other Diagnostic Correlates into the Management of Bone Fragility,” Alternative Medicine Review (2007): 113-145.
12 Kettler, Debra B., “Can manipulation of the ratios of essential fatty acids slow the rapid rate of postmenopausal bone loss?,” Alternative Medicine Review (2001): 6; 61-77
13 Yang et. Al., “Long-term proton pump inhibitor therapy and risk of hip fracture,” JAMA (2006); 296: 2947-2953
14 Krane, SM and Holick, MF, “Metabolic Bone Disease: Osteoporosis. In: Isselbacher K et. al., eds. Harrison’s Textbook of Internal Medicine, New York, N.Y., McGraw Hill, Inc., (1994) 2172-2176
15 Head, Kathleen A., “Ipriflavone: An important bone-building isoflavone,” Alternative Medicine Review (1999) 4: 10-22.