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PREVENTING AND TREATING OSTEOPOROSIS:
CUTTING THROUGH THE HYPE AND HALF-TRUTHS

Over the last 25 years, the perception of osteoporosis has changed from a rare but serious disease that affected only some older women to a frightening condition of epidemic proportions that threatens almost half of post-menopausal women in the US. What has changed over that time?

Frankly, not much, except the hype. Similar to the constant barrage of advertising regarding the evils of high cholesterol, the publicity about osteoporosis is mostly about drug company profits, not about women’s health.

There’s a whole lot that can be done to support bone health — naturally and without drugs. Many of my patients have actually reversed osteoporosis and improve bone mineral density by fixing their nutrition, digestion and hormone function.

So let’s cut through the hype and understand the reality behind your risk of osteoporosis — and what you should be doing to promote bone health no matter your age.

Osteoporosis: countering the fears
Bone loss and fractures have always been a concern for women over 65, and rightly so. But a couple of decades ago research indicated that bone loss speeds up in the years immediately after menopause, raising concerns about osteoporosis among women in their 40’s and 50’s. Next, conventional medicine created a new condition, osteopenia, which soon was construed to be a precursor to real disease. Suddenly any woman over 40 felt she was at risk for osteoporosis.

Compounding these fears is women’s confusion over bone mineral density (BMD) tests. The BMD compares your bones to those of much younger women. But who’s to say whether your bone density is abnormal if you can’t compare it to your own baseline? Moreover, bone density itself is not a very good measure of bone strength or the risk of fracture. But women aren’t told to take their BMD results with a grain of salt.

Healthy bone function and peak bone mass
Bone loss is a natural, in fact vital process. Only bone loss (called resorption) can initiate healthy new bone formation (called deposition or formation). As with all things in nature, good bone health relies on a balance between this action and counter-action, like breathing out and breathing in.

New bone is strong and flexible with the ability to bear both compression (running, jumping) and tensile (flexing) pressure. Bones strengthen with use, just like muscle, all through your life. But at some point, bone loss gradually begins to outpace bone growth — when this begins happening is highly individual, but it can be as much as 20 years or more before menopause.

Bone health is influenced by many factors: family history, body frame size, diet, calcium intake, vitamin D levels, physical exercise, hormonal balance, stress, and lifestyle. And because bones are constantly regenerating, before and after menopause, every positive step you take to support their function will make a big difference — whenever you take them.

Bone health depends on the give-and-take process I described above, also called remodeling. During this process, bone cells called osteoclasts travel through bone tissue retrieving old bone and leaving small, jagged spaces behind. This triggers their counterparts, called osteoblasts, to come into these spaces and deposit new bone. About 5–10% of all our bone tissue is replaced — or turned over — in a year, in this way. Osteoblasts cannot work properly without sufficient osteoclast activity, and new bone is stronger and — this is key — more flexible than old bone.

Exercise and physical stress naturally build new bone and speed the remodeling process, even when you’re older. That’s why you can lift progressively heavier weights in an exercise program — it’s not just muscle you’re building.

But no matter how much bone you make, you’ll still experience bone loss with age. The bell curve looks something like this: during puberty, when our body and skeleton are growing, bone formation outpaces bone loss. Between ages 20 and 30 most women have reached peak bone mass, but the age varies depending on race and lifestyle.

The concept of peak bone mass has been oversimplified. The accepted idea is that it’s like a retirement account — the more healthy bone you’ve accumulated by your mid-20’s, the more you’ll have to draw down as you get older. But peak bone mass can vary as much as 100% in women of the same age from different cultures. And peak bone mass seems to have minimal affect on fracture risk: for instance, Asian women have a lower bone mass than Western women but a lower fracture rate.
Differences in ethnicity, diet, exercise, onset of puberty, and lifestyle make peak bone mass a very individual characteristic, hard to quantify — and not a good measure of bone health.

At some point in your mid to late 30’s, bone resorption begins to outpace formation (by about 0.5–1.0% per year). After menopause this rate may accelerate to 1.0–5.0% with the dip in reproductive hormones. Within five years after menopause, when hormonal fluctuations settle down, bone loss evens out again to a gradual and perfectly normal decline of 1.0–1.5% per year.

So what differentiates normal and abnormal bone loss — and who’s really at risk for osteoporosis?

What is osteoporosis anyway?
If you have established osteoporosis (not just the risk of getting it), bone loss may accelerate over time to absorb up to one-third of your total bone mass. Over time whatever bone is left is thin and porous — it looks like ruined honeycomb — and fractures easily doing everyday things like walking and coughing.
Before 1994, to officially have osteoporosis, you actually had to break a bone as the result of minor impact or trauma. Since then, new bone-scanning technology has cast a wider net and allowed medicine to quantify the diagnosis. Osteoporosis is now defined as having a bone mineral density (BMD) that deviates more than 2.5 points below a standard. That standard is the average for a large sample of 20 to 29-year-olds. In short, you’re being compared to young women with supposedly peak bone density.

What is osteopenia?
As recently as the 1970’s, the diagnosis of osteopenia didn’t exist. Experts chose this term in the 1980’s to fit the women who didn’t quite have osteoporosis to motivate them to pay attention to bone health.

However, there was no medical basis for choosing this number and no studies to support everyone’s immediate assumption that a diagnosis of osteopenia meant you were headed for osteoporosis. No one seemed to notice — except of course the drug companies — that by this definition almost half of all post-menopausal women now had the new medical condition called osteopenia. Because osteoporosis is progressive, the diagnosis of osteopenia can be very frightening. Many women stop lifting heavy objects or engaging in physical exercise for fear of fractures. But in reality almost all women with osteopenia should be getting more exercise, not less!

Risk factors and causes of osteoporosis
A small percentage of women will get true osteoporosis. Osteoporosis occurs earlier and more severely in white women of Northern European descent who are small-boned and thin. And despite the claims made by the calcium supplement makers, the highest rate of osteoporosis is seen in cultures that eat the most dairy.

Other risk factors for osteoporosis include:

• post-menopause, either natural or surgical
• maternal history of osteoporosis
• delayed puberty, persistent amenorrhea, low hormone levels or other endocrine disorders
• poor diet, including vitamin D, calcium, and/or magnesium deficiency
• gastrointestinal disorders that interfere with natural mineral absorption
• eating disorders
• advanced age
• heavy alcohol consumption
• smoking
• under or over-exercising
• less than 15% body fat
• elevated blood acid levels
• use of corticosteroids or other medical drugs
• thyroid or kidney disorders
• bone cancers or other malignancies

Bone density, bone strength and the risk of fracture
When most women hear the word “osteoporosis” they think with a shudder about hip fractures, broken wrists, and the loss of height and spinal deformity characterized as the “dowager’s hump.” We automatically assume, because we’ve been told, that low bone density is the first step to bone fractures.

But there is no hard evidence that bone density correlates with bone strength or flexibility — the two factors that prevent bone from fracturing under stress. In fact, bones can be dense (rich in calcium and hard) yet brittle — what matters more is the health of the collagen matrix, which keeps the mineralized bone supple and resilient.
The collagen matrix is a foundation of nutrients and minerals that allows the bone to expand, contract, and mend without breaking. Think of the difference between a living, breathing sand dollar and its ossified shell, or a slab of dried wood and a thinner piece that has been saturated in protective oils. While this is not an exact comparison, it may help you understand why a dense, hard covering can actually be more fragile than a thin but well-integrated whole — and why drugs like Fosamax and Actonel that treat only bone density do not necessarily prevent fractures.

Bone density test and osteoporosis screening
Unfortunately we can’t test bone health directly — we mostly look only at bone density. But it’s better than nothing, as long as you remember the limitations of the test.
When diagnosing osteopenia or osteoporosis, most doctors rely on a bone density test, usually dual-energy X-ray absorptiometry, or DEXA. There are other tests, including CT scans, dual photon absorptiometry (DPA) and ultrasound, but DEXA is by far the most prevalent.

Be sure when discussing your BMD results with your doctor to remember to ask what standard you were evaluated against. Often simply normalizing for your age, race, or region will give you very different results. And be sure to get a copy of the results. This is your test and you should keep your own medical file.

Bone health and fractures
While fractures are frightening and can be incapacitating, the common perception that low bone density causes fractures is misleading. The simple reality is that falls cause fractures. The average age of a women who suffers a hip fracture is 79, and over 90% of hip fractures occur after a fall (not vice versa). Most falls are due to complicating factors, and low bone density is pretty far down on the list of risks.

Why has there been so much focus on bone density as a cause of fractures if the relationship is so weak? One answer is that we actually have a test for bone density. The other is that there is a drug to sell — namely biphosphonates (such as Fosamax and Actonel).

Osteoporosis prevention and hormones
Before menopause, it’s important to promote your body’s natural hormonal balance so bone growth stays consistent. After menopause, your body has many natural mechanisms to boost estrogen levels and maintain bone health.

One is to store a little extra weight. Estrogen is made and stored in fat cells, so keeping a few more around can actually be good for your bones. This is the one instance where thin is not better!

Testosterone, a potent steroid hormone, increases muscle mass, which in turn helps build bone density. After menopause, testosterone can be one of the substances your body converts into estrogen. When you exercise, your body releases testosterone — just one of the reasons physical activity is a natural antidote to bone loss.
But what about women who don’t make enough hormones naturally?

In that case, the best option is bioidentical hormone therapy that includes the proper balance of estrogen, progesterone, and testosterone. Not only do these hormones provide symptom relief, but they are an important option for women to reduce the risk of osteoporosis. In addition to hormone balance, most women would also benefit by focusing more on natural and nutritional steps to improving bone health.

Calcium and bone health
Healthy bones store about 99% of the body’s calcium; the rest is used throughout the body for other vital functions. Bones also house about 85% of the body’s phosphorous and 50% of the body’s total sodium and magnesium. Calcium is one of the most important minerals in the body, not only for bone health but for other physiological functions, including nerve transmission, blood clotting, muscle growth and contraction, heart function, hormone function, and metabolism.

But calcium makes you work for it. It requires a lot of digestive teamwork, including the presence of stomach acid, a whole alphabet of vitamins, magnesium, other essential minerals, and a well-functioning GI tract to deliver calcium’s many benefits. If you have deficiencies anywhere along the line, it won’t matter how much calcium you eat, your body will take it (and whatever other minerals it needs) from your bones. This usually shows up first in non-vital areas like your teeth, hair, and nails.

To test how easily your calcium supplement breaks down in a healthy stomach, put it in a glass of vinegar and stir occasionally. It should dissolve completely in twelve hours.

Bones release calcium by upping the rate of resorption. Whatever doesn’t get used gets excreted through the kidneys — this is why doctors test your urine for calcium as one marker of bone loss.

But increasing calcium is not the answer: too much is as problematic as too little, causing other difficulties, like kidney stones, gallstones and hypercalcemia. Our American diets have plenty of available calcium and we still have osteoporosis — what many of us lack is the ability to successfully use the calcium we get.

If you have GI issues, including IBS or celiac disease, you can’t absorb the calcium you need from your food. Older women often lack the digestive acids necessary to break down calcium. Ironically, women are told that antacids like TUMS are good calcium supplements — but antacids oppose the very stomach acid (hydrochloric acid) needed for calcium absorption. Proton pump inhibitors, like Prilosec and Nexium, have the same problem.

Nutrition and calcium absorption
Vitamin D is crucial to moving calcium from the small intestine into the bloodstream, in conjunction with stomach acids and other vitamins. In one study, up to 30–40% of older patients with hip fractures had a vitamin D deficiency or insufficiency. Maybe the real health risk for bone fractures is vitamin D deficiency, not low bone density!
Magnesium is also important in that it increases calcium absorption from the blood into the bone. Dairy products contain little magnesium and alcohol depletes it. Ironically, too much calcium blocks the absorption of magnesium, leading to a deficiency characterized by hair loss, muscle cramps, irritability, trembling, and disorientation.

A good balance between calcium and phosphorous (about 5:1) is crucial to bone strength, but too much phosphorous depletes calcium. Soda and red meat — two staples of the American diet — are full of this mineral, so much so that now some sodas have extra calcium to counteract the deleterious effect of drinking so much phosphorous.

Trace minerals like boron, selenium, copper, silicon, manganese, and zinc are also important in supporting the healthy balance that makes bone. Good calcium digestion is dependent on a lot of other factors too, but I’ll cover only two other substances here because of their prescription use in osteoporosis treatment: calcitonin and parathyroid hormone. The former is secreted by the thyroid gland, the latter by the parathyroid gland.

Calcitonin stabilizes high levels of calcium by inhibiting osteoclast activity (the agents in bone resorption). It’s now available as a prescription nasal spray but is most effective in women who have osteoporosis as a result of corticosteroid use. It causes nasal irritation, headache and joint pain.

Parathyroid hormone (PTH) is normally triggered by high levels of phosphorous in the blood with corresponding low levels of calcium. Daily injections seem to stimulate bone formation and are being used to treat women with severe osteoporosis. High doses of the medication caused bone cancer in rats so treatment is not recommended for more than two years.

Osteoporosis and inflammation
An emerging area of study is the relationship between bone loss and blood acidity. It has been known for a while that vegetarians and women eating a low-protein diet have a lower rate of bone loss. What hasn’t been understood is why.

New studies are showing that high levels of the pro-inflammatory blood acid called homocysteine double the risk of osteoporosis-related fractures. It has also been linked to other inflammatory conditions like heart attack, stroke, and Alzheimer’s disease.

A report published recently in the New England Journal of Medicine asserted that elevated homocysteine levels inhibit new bone formation by interrupting the cross-linking of collagen fibers in bone tissue. It’s also possible that the body tries to neutralize acidic blood serum (i.e., low pH) by releasing more bone calcium. Homocysteine levels can also be stabilized by taking a vitamin supplement with folic acid, B12, and B6.

Be aware that a minority of the population can’t convert folic acid due to a genetic factor. If your homocysteine levels remain high even after a few weeks of B supplementation, you may want to ask your doctor about adding a more bioavailable form of folate called 5-methyl-tetrahydrofolate to your diet.

Other foods that cause blood acidity are refined carbohydrates and simple sugars — yet another reason to minimize these unhealthy foods in your diet.

So, if we know that all this and more go into the proper balance of bone formation and resorption — and one function can’t thrive without the other — why is mainstream medicine so skewed to the side of drugs for osteoporosis?

The benefits and risks of Fosamax and other bisphosphonates
The original use of biphosophonates — the class of drugs that includes Fosamax (alendronate), and Actonel (risedronate), was industrial: corrosion prevention, laundry soaps, and fertilizer. They were used primarily in the textile and oil industries.

Scientists only discovered that bisphosphonates inhibit bone resorption in the late 1960’s. Bone density tests proved that the drugs increased bone density as long as they were taken regularly. The FDA approved Fosamax for use in the treatment and prevention of osteoporosis in 1995 — the year after osteopenia was created as a medical condition. Sales are now in the billions of dollars a year.

There have been no studies on how these drugs affect bone health and overall health in long-term use. The longest study spanned ten years, during which time half of the test population dropped out citing difficulty in following the protocol and negative side effects. And now that we know that inhibiting bone loss also inhibits new bone growth — it’s possible that we are creating a generation of women with dense but old and brittle bone. And the alendronate in Fosamax actually remains in your bones. Who knows what the long-term effects are of that.

Merck, the parent company of Fosamax (as well as Vioxx) claims that its drug is safe if taken as directed (upon rising, with a full glass of water at least 30–60 minutes before breakfast, during which time you must stay upright to minimize the unpleasant side effects). Inflammation of the esophagus and stomach lining can occur if you lie down too soon after taking the pill. Merck asserts that long-term use of Fosamax has no ill affect.

While this may be true for some women, the side effects of Fosamax for others appear to worsen quickly — some women complain of debilitating indigestion and stomach pain in as little as three days. Other women taking Fosamax for longer periods report serious bone and joint pain and decreased mobility (perhaps a side effect of increased bone mineralization with no new bone growth?).

Other troubling effects of Fosamax are surfacing. A 1993 report discovered that a small percentage of bisphosphonate users experienced serious eye problems that could lead to vision loss; 33% of the study group complained of blurred vision. More troubling is the small group of people in a recent study who were on corticosteroids and then Fosamax-like drugs: one in 12 experienced bone death (osteonecronosis) in their jaws.

When many women are put on Fosamax, without addressing their other systemic issues, they face a steady downward spiral that begins with worsening GI issues and culminates in debilitating joint and bone pain and general metabolic/physical degeneration. In a mainstream medical practice, this domino effect will lead to more prescriptions — NSAID’s for pain, proton pump inhibitors like Nexium and Prilosec for digestive issues, and Lipitor for high cholesterol. While these medications may control symptoms in the short-term, they do nothing to treat the underlying issues.
More to the point, there is practically no long-term research being done on the safety of combining these drugs with Fosamax. According to one limited study of Fosamax and naproxen (a popular NSAID prescribed for arthritis pain), 38% of users developed stomach ulcers and 69% experienced serious side effects, leading the authors to conclude that the drugs had a synergistic effect that promoted gastric ulcers. If you understand that bone health depends on your stomach’s ability to digest protein, calcium and minerals, you can see how very detrimental this is.

The inflammatory nature of bisphosphonates makes sense when you think that this is a class of drug in the same family as cleansing powders! What’s more, most of these women are paying a hefty monthly price for this treatment. The average cost of a month’s prescription of Fosamax is $65. Multiply that by the millions of post-menopausal women who are expected to be on the medication for anywhere from 20–30 years, and you see why the drug companies are so anxious to maintain the current atmosphere of paranoia about osteoporosis.

The truth is that the two most important things you can do for your bones — eating well and daily exercise — can’t be marketed by big companies for profit: walking is free and you have to eat anyway. Even the highest medical-grade vitamin supplement costs less per month than a prescription for Fosamax and you get a lot more bang for your buck without the risks; quality supplements work from the inside out to support a host of body functions in addition to bone health.

I think it’s high time we stop being guinea pigs for the sake of drug-based medicine. We need to accept responsibility for our health and make the lifestyle changes necessary to nurture it.

What if you are already taking Fosamax?
If you’ve been taking Fosamax, don’t stop suddenly. Talk to your doctor about your concerns and discuss other forms of osteoporosis prevention. You can begin to educate yourself about your options and, most importantly, change your diet and exercise regularly.

As your bones begin to benefit from your new changes, you may find you can stop your prescription in confidence. If you have already received a diagnosis of osteoporosis, consider it a wake-up call to take action. Osteoporosis is a preventable and reversible condition, it just takes a little work. Here’s where to begin.

My approach
Your bones, including your hair, teeth and nails, are mirrors of what you put into your body and the balance in your life. In my practice, I encourage my patients to try a combination approach to preventing and treating osteoporosis that begins with optimal nutrition. In short, this means:

• Take a daily medical-grade nutritional supplement rich in the minerals and nutrients that support bone health. Your vitamin should contain calcium and magnesium, vitamins A, D, K, B6, and B12, folic acid, and essential fatty acids. A calcium supplement is only as good as its rate of absorption, so buy the best quality you can afford.
• Exercise daily; include weight-training exercises at least twice a week. Bones are kept healthy with use! The more you ask of them, the stronger they’ll become, especially if you feed them well.
• Eat a balanced diet rich in leafy green vegetables, fruits, whole grains, and seaweed products. These are much less allergenic sources of calcium than dairy products. If you consume dairy, try to buy organic.
• Have protein as part of every meal and snack, but don’t overdo it.
• Avoid refined carbohydrates and simple sugars. Eliminate sodas and limit caffeine, — both are bone weakeners.
• Include healthy fats in every meal. Bone building vitamins A, D and K are fat-soluble and a certain amount of fat is needed for proper hormone and immune function.
• Maintain hormonal balance during perimenopause and menopause. This is critical to healthy bone formation. Healthy thyroid and adrenal balance is also important. And if you get a low bone density reading, have your hormones checked, including your free and total testosterone levels.
• Maintain a healthy ratio of body fat: 20-25% body fat for women is normal.
• Get some daily sun exposure to trigger natural production of vitamin D, at least 15 minutes of unprotected sun in the early morning and late afternoon.
• Get a baseline bone density scan in your 40’s if you have any of the risk factors for osteoporosis. That way you’ll have something to compare yourself to later on. After 65, continue to get bone scans every couple of years to check your own individual progress.

Solid bones need support
In the end, osteoporosis is only as frightening as the power we give it. With some attention to your diet, a medical-grade supplement, hormonal balance and a few healthy lifestyle changes, most women can prevent, treat, even reverse bone loss without drugs and their side effects.

-written by Marcelle Pick NP and edited by Paul Navar MD

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