The Encyclopedia of Natural Medicine, 3rd Ed.

Osteoporosis

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• Usually without symptoms until severe backache or hip fracture occurs

• Most common in postmenopausal white women

• Spontaneous fractures of the hip and vertebrae

• Decrease in height

• Demineralization of spine and pelvis, as confirmed by bone mineral density test

Osteoporosis literally means “porous bone.” It is the most common bone disease in humans and poses a serious health threat for many postmenopausal women. It is characterized by diminished bone strength, which leads to an increased risk of fracture. Osteoporosis is now determined primarily by bone mineral density (BMD) testing and is defined by BMD scores less than or equal to a standard deviation of ∇2.5 at the total hip, femoral neck, or lumbar spine.1,2

Osteoporosis most commonly occurs in postmenopausal women, and the risk increases with age. Although the prevalence is 4% in women between 50 and 59 years of age, it rises to 52% in women age 80 and above.3Osteoporosis of the hip occurs in 13% to 18% of white American women, and another 37% to 50% have low bone mass (often called osteopenia) of the hip.4

The big consequence of osteoporosis is fractures. It is estimated that osteoporosis causes approximately 1.5 million fractures every year. Of these, 250,000 are fractures of the hip.5.6 Even with considerable advances in medical care, up to 20% of women with hip fractures still die within a year of the fracture, and an additional 25% require long-term nursing care. Approximately half the women who suffer from a hip fracture are permanently unable to walk without the assistance of a cane or walker. The hip is not the only site where fractures result in serious consequences. Fractures of the bones in the spine (the vertebrae) begin to be seen more commonly in women in their mid-70s and cause significant pain as well as loss of height and exaggerated kyphosis (hunchback). In addition to pain, restricted range of motion, changes in posture, restricted lung function, and digestive problems can all be caused by vertebral fractures. Once a vertebral fracture has occurred, there is at least a five- to sevenfold increase in the risk of additional vertebral fractures.7,8

Men are not immune to osteoporosis, though their risk is only about 25% of women’s risk. Nonetheless, hip fractures in men account for one-third of all hip fractures and have a higher mortality rate than those in women.9 In addition, men who break a hip suffer worse outcomes.

Causes

Bone is dynamic living tissue that is constantly remodeling. The breaking down and rebuilding of bone are the result of the actions of two types of bone cells, osteoclasts and osteoblasts. Osteoclasts stimulate the production of acids and enzymes that dissolve minerals and protein in bone and thus promote bone breakdown (resorption). Osteoblasts create a protein matrix, primarily of collagen, that provides the structural framework upon which mineralization can occur. Bone remodeling is normally a balance of bone resorption and bone formation. An imbalance between bone removal and bone replacement results in bone loss and the development of osteoporosis.

In childhood, bone mass rapidly increases and then slows in the late teens (around age 17 for women), but it continues to increase during the 20s. After achieving a peak bone mass around age 28, women slowly lose an average of 0.4% of bone mass in the femoral neck each year. After menopause, the rate of loss is faster, with an average 2% loss annually during the first 5 to 10 years. Bone loss continues in older women (past age 70) but at a much slower rate.

Diagnostic Considerations

Risk Factors

Major risk factors for osteoporosis in postmenopausal women are advanced age, genetics, lifestyle issues (low calcium, low vitamin D intake, and smoking), thinness, and menopausal status. The most common risk factors are as follows:

• Age (50–90 years)

• Female

• Thinness

• Small stature

• Prior fragility fracture

• Parental history of hip fracture

• Current tobacco smoker

• Long-term use of glucocorticoids

• Rheumatoid arthritis

• Other causes of secondary osteoporosis (e.g., primary hyperparathyroidism, renal calcium leak)

• More than two alcoholic drinks per day

• Low level of vitamin D

• Genetic variations of vitamin D receptors

Genetic Factors

The level of peak bone mass is greatly influenced by genetic factors.1012 Young daughters of women with osteoporotic fractures have lower bone mass compared with other children their age.13 The risk of hip fractures is almost 50% higher if there is a family history of fractures and 127% higher if a hip fracture has occurred in a parent.14 One key genetic factor now being recognized is differences (polymorphisms) of the vitamin D receptor site. Some of these differences significantly increase the need for vitamin D.

Vitamin D Deficiency

The importance of vitamin D sufficiency in bone health has been underappreciated in the past. Emerging research is showing a direct correlation between both bone density and blood levels of vitamin D3. Higher blood levels of vitamin D are associated with a lower rate of fractures of virtually all types; lower blood levels of vitamin D3 are associated with a higher rate of fractures of all types.15

It is well known that vitamin D stimulates the absorption of calcium. Since vitamin D can be produced in our bodies by the action of sunlight on 7-dehydrocholesterol (a compound the body can manufacture from cholesterol) in the skin, many experts consider it more of a hormone than a vitamin. Strictly defined, a vitamin is an essential compound the human body cannot manufacture, while a hormone is a compound that the human body manufactures and that serves to control a particular function. In the case of vitamin D, the compound serves to control calcium absorption.

Relative Activities of Vitamin D3 Forms

FORM

RELATIVE ACTIVITY LEVEL

Vitamin D3 (cholecalciferol)

1

25-(OH) vitamin D (calcidiol)

2 to 5

1,25-(OH) vitamin D (calcitriol)

10

The process of vitamin D manufacture begins when sunlight changes the 7-dehydrocholesterol in the skin into vitamin D3 (cholecalciferol). This form of vitamin D is also the most popular supplement form, so taking it in supplement form bypasses the need to manufacture it in the skin. From the bloodstream vitamin D3 is then transported to the liver and converted by an enzyme into 25-(OH) vitamin D, which is two to five times more potent than vitamin D3. The 25-(OH) vitamin D is then converted by an enzyme in the kidneys to 1,25-(OH) vitamin D, which is 10 times more potent than vitamin D3.

Disorders of the liver or kidneys result in impaired conversion of cholecalciferol to more potent vitamin D compounds. In some patients who have osteoporosis, there are high levels of calcidiol, while the level of calcitriol is quite low, signifying a problem with the kidneys. So, it may not be enough to supplement with vitamin D3, as many people with osteoporosis may not be converting it fully to calcitriol. Many theories have been proposed to account for this decreased conversion seen in some patients with osteoporosis, including lack of parathyroid hormone, lack of estrogen, magnesium deficiency, and deficiency of the trace mineral boron.

Diet and Lifestyle

As significant as genetic factors are in osteoporosis risk, there is no question that the major determinants of bone health are diet and lifestyle. Factors that influence bone health include physical activity; protein intake; acid-base homeostasis; smoking; alcohol consumption; and intake of calcium, vitamin K, and vitamin D. To achieve peak bone mass, a young woman requires adequate calories, protein, and calcium.16

Dietary Protein

Both too much protein (especially animal protein) and too little protein lead to an increased risk for osteoporosis.17 Too much animal protein promotes osteoporosis, as diets high in red meat are acid-producing, and calcium from bone may be mobilized to offset the acid and maintain the acid-base balance the body requires. (Diets high in fruits, vegetables, and plant proteins are alkaline-forming.) Too little protein leads to osteoporosis because it leads to impaired formation of the collagen matrix of bone.

Smoking

Women smokers tend to lose bone more rapidly and have a lower bone mass than those who do not smoke.18,19 Some studies show that smokers also have a higher fracture rate.20,21 In addition, smokers reach menopause up to two years earlier than nonsmokers. It may be that smoking interferes with estrogen metabolism, although the mechanism is not clearly known.

Alcohol

Consumption of seven alcoholic drinks or more per day, which is considered heavy, has been shown to increase the risk of falls and hip fractures. However, moderate alcohol consumption seems to lower the risk of hip fractures in older women. It is thought that moderate amounts of alcohol inhibit bone resorption by increasing estradiol concentrations.22,23

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Vitamin D Metabolism

Physical Activity

The benefits of physical activity for reducing the risk of osteoporosis cannot be overemphasized. The evidence is overwhelming that highly active individuals have higher bone mass24 and those who are sedentary have a lower bone mass. Individuals who require bed rest25 or who are confined to a wheelchair experience a rapid and dramatic loss of bone. Exercise functions primarily to reduce osteoporosis risk by stimulating the activity of osteoblasts, the bone-building cells.

Hormonal Factors

A woman’s hormonal status clearly influences bone mass and the rate of bone resorption. After menopause, all women lose bone, and this loss is especially accelerated in the first five years. The drop in estrogen production that comes with menopause, no matter at what age, increases the rate of bone resorption. The earlier menopause occurs before the average age of onset (51 years), the sooner the bones lose the protective effect of endogenous estrogen.

Women who have premature menopause (before age 40), who began menstruating late in adolescence (e.g., after age 15 years), who have undergone surgical menopause, and/or who have experienced periods of no menstruation due to low estrogen levels in their reproductive years are at greater risk of osteoporosis. Women who missed up to half of their expected menstrual periods because of low estrogen had 12% less vertebral bone mass than did those with normal menstrual cycles; those who missed more than half had 31% less bone mass than healthy controls.26

The concentration of calcium in the blood is strictly maintained within narrow limits. If levels start to decrease, there is an increase in the secretion of parathyroid hormone by the parathyroid glands and a decrease in the secretion of calcitonin by the thyroid and parathyroids. If calcium levels in the blood start to increase, there is a decrease in the secretion of parathyroid hormone and an increase in the secretion of calcitonin.

Parathyroid hormone increases serum calcium levels primarily by increasing the activity of the osteoclasts, although it also decreases the excretion of calcium by the kidneys and increases the absorption of calcium in the intestines. In the kidneys, parathyroid hormone increases the conversion of calcidiol to calcitriol.

Assessing Risk

The more risk factors are present, the greater the potential for lower bone mass and the higher the risk of fracture. Risk factors alone cannot adequately determine whether an individual has low bone mass; rather, they are important guides in determining osteoporosis and fracture risks, and an understanding of these risks contributes to optimal prevention strategies. In addition, various medical conditions and medications can interrupt normal bone physiology and lead to osteoporosis.

Secondary Causes of Bone Loss

• Genetic disorders

  images Hemochromatosis

  images Hypophosphatasia

  images Osteogenesis imperfecta

  images Thalassemia

• Hormonal disorders

  images Cortisol excess

  images Cushing’s syndrome

  images Gonadal insufficiency

  images Hyperthyroidism

  images Primary hyperparathyroidism

  images Type 1 diabetes

  images Hypothalamic amenorrhea

  images Premature ovarian failure

• Gastrointestinal diseases

  images Primary biliary cirrhosis

  images Celiac disease

  images Crohn’s disease

  images Total astrectomy

  images Gastric bypass

• Other conditions

  images Ankylosing spondylitis

  images Chronic renal disease

  images Lymphoma and leukemia

  images Multiple myeloma

  images Anorexia nervosa

  images Bulimia

  images Rheumatoid arthritis

• Medications

  images Aromatase inhibitors

  images Cytotoxic agents

  images Excessive thyroid dosing

  images Gonadotropin-releasing hormone agonists or analogs

  images Some long-term anticonvulsants (e.g., phenytoin)

  images Glucocorticoid use for more than three months

Bone Mineral Density Testing

While bone mineral density (BMD) testing alone may not be a good predictor of fracture risk (see the box on page 852), it is a great way to increase the awareness of and establish a diagnosis of osteoporosis. There are several techniques to measure BMD, but the gold standard is dual energy X-ray absorptiometry (DEXA). Other methods of assessing bone mass include computerized tomography (CT) scans, ultrasounds of the heel, and standard X-rays, none of which is as optimal for diagnosis and follow-up as the DEXA scan.27

In addition to providing the most reliable measurement of bone density, the DEXA test requires less radiation exposure than a conventional X-ray or CT scan. Usually the DEXA scan is used to measure both the hip and the lumbar spine densities. The hip is the preferred site for BMD testing, especially in women older than 60, because the spinal measurements can be unreliable. Although peripheral DEXA sites are accurate, they may be less useful because they may not correlate as well with fracture risk and BMD at the hip and spine. The guidelines for indications for BMD testing established by many reputable and independent organizations are as follows:

• Individuals with secondary causes of bone loss (e.g., steroid use, hyperparathyroidism)

• Individuals in whom there is X-ray evidence of osteopenia (insufficient bone mineral density)

• All women 65 years and older (not only for a diagnosis, but also as a historical reference point for comparisons in the future)

• Younger postmenopausal women with fractures due to fragile bones since menopause, low body weight, or family history of spine or hip fracture

Results of BMD tests are reported as standard deviations—either a Z-score or a T-score. A Z-score is based on the standard deviation (SD) from the mean BMD of women in the same age group. A T-score is based on standard deviation from mean peak BMD of a normal young woman. The World Health Organization’s criteria for the diagnosis of osteoporosis uses T-scores. A T-score below –2.5 is associated with osteoporosis. People with a BMD in between that of normal bone and osteoporosis are classified as having osteopenia. Keep in mind that using the T-score instead of a Z-score increases the likelihood that you will be classified as having osteopenia, even though it is normal to lose some bone mass with aging.

Bone Mineral Density Score Interpretation

STATUS

T-SCORE

INTERPRETATION

Normal

Above –1

BMD is within 1 SD of a young normal adult

Osteopenia

Between –1 and –2.5

BMD is between 1 and 2.5 SD below a young normal adult

Osteoporosis

Below –2.5

BMD is 2.5 SD or more below a young normal adult

Osteoporosis Risk Assessment and Recommendations

Choose the item in each category that best describes you, and fill in the point value for that item in the space to the right.

 

POINTS

SCORE

Frame Size (choose one)

   

Small or petite frame

10

Medium frame, very lean

5

Medium frame, average or heavy build

0

Large frame, very lean

5

Large frame, heavy build

0

Ethnic Background (choose one)

   

Caucasian

10

Asian

10

Other

0

Activity Level (how often you walk briskly, jog, engage in aerobics/sports, or perform hard physical labor for at least 30 continuous minutes; choose one)

   

Seldom

30

1–2 times per week

20

3–4 times per week

5

5 or more times per week

0

Smoking (choose one)

   

Smoke 10 or more cigarettes a day

20

Smoke fewer than 10 cigarettes a day

10

Quit smoking

5

Never smoked

0

Personal Health Factors (choose all that apply)

   

Family history of osteoporosis

20

Long-term corticosteroid use

20

Long-term anticonvulsant use

20

Drink more than three glasses of alcohol each week

20

Drink more than one cup of coffee per day

10

Seldom get outside in the sunlight

10

Personal Health: Women Only (choose only one)

   

Had ovaries removed

10

Premature menopause

10

Had no children

10

Dietary Factors (choose all that apply)

   

Consume more than 4 oz meat on a daily basis

20

Drink soft drinks regularly

20

Consume the equivalent of 3–5 servings of vegetables each day

–10

Consume at least 1 cup of green leafy vegetables each day

–10

Take 1,000 mg supplemental calcium and 1,000 IU of Vitamin D

 

Consume a vegetarian diet

–10

Total Score

 

If your score is greater than 50, you are at significant risk for osteoporosis. However, you can reduce your score significantly by taking steps to reduce or eliminate risk factors as described in this chapter. For women who are at risk of osteoporosis or who have already experienced significant bone loss, the benefits of natural hormone therapy (described below) outweigh the risks. The exception is women at high risk for breast cancer or women with a disease aggravated by estrogen, such as active liver diseases or certain cardiovascular diseases.

Laboratory Tests of Bone Metabolism

Tests for biochemical markers of bone turnover include a urine test that measures the breakdown products of bone, such as cross-linked N-telopeptide of type I collagen or deoxypyridium. These tests can be correlated with the rate of bone loss, but they are not intended to be used for the diagnosis of osteoporosis or monitoring of bone loss. Such tests may be used to monitor the success (or failure) of therapy, as they provide quicker feedback compared with DEXA, with which it can take up to two years to detect a therapeutic response. The reduction of urinary levels of these markers of bone breakdown over a 2-year period has been correlated with increases in bone density measurements.28

Therapeutic Considerations

Osteoporosis is a complex condition involving genetic, hormonal, lifestyle, nutritional, and environmental factors. A comprehensive plan that addresses all of these factors offers the greatest protection. Fortunately, osteoporosis in most cases is entirely preventable through diet, lifestyle, and proper supplementation. Rarely should medical therapy (i.e., hormones and drugs) be required if proper steps are taken. However, since drug therapy is such a major focus in the conventional prevention and treatment of osteoporosis, it is important for us to discuss it. Drug treatment focuses on the use of estrogen and progesterone, bisphosphonates, Evista (a selective estrogen receptor modulator), parathyroid hormone, and calcitonin. There are currently no prospective studies comparing the efficacy of these therapies.

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DOES BONE MINERAL DENSITY PREDICT FRACTURE RISK?

While BMD testing provides useful information on bone strength, a careful review of the literature and the results of a very large study suggest that there is no correlation between bone mineral density testing alone and ability to predict future fractures.29 It turns out that bone density is not the only risk factor that contributes to future fractures. In fact, osteoporosis accounts for only about 15 to 30% of all hip fractures in postmenopausal women; one-third of all women who experience a hip fracture have normal bone density, with the rest somewhere in between normality and osteoporosis. An important risk factor for hip fracture is an increased risk of falling due to poor balance and lack of muscle strength.30 For many people, efforts to prevent falls by changing diet and lifestyle as well as improving balance and increasing muscle strength are more important in preventing fractures than increasing bone strength.31

In addition, while current drug therapy increases BMD, it does not improve bone quality or “toughness.” As an illustration, chalk is denser than bamboo, but bamboo is tougher and less likely to break. Factors that promote improved bone quality and a healthy collagen matrix are likely to be just as critical, or perhaps even more critical, to bone quality and toughness compared with the mineral content of bone.

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Hormone Replacement Therapy

As women approach menopause and immediately after, estrogen levels decline and bone resorption outpaces bone formation. Both estrogen replacement therapy (ERT) and hormone replacement therapy (HRT, using a combination of estrogen and progesterone) reduce the rate of bone turnover and resorption, leading to reduced fracture rates in postmenopausal women. In two-year trials, the average increase in BMD after ERT or HRT was 6.8% at the lumbar spine and 4.1% at the femoral neck.32,33 However, there are significant risks with HRT (see the chapter “Menopause”). For women at high risk for osteoporosis, those who underwent surgical menopause or early menopause, and other special cases, we definitely recommend consideration of bioidentical hormone therapy (see the chapter “Menopause”).

Bisphosphonates

The most widely prescribed drugs for prevention and treatment of osteoporosis are the bisphosphonates:

• Alendronate (Fosamax, Fosamax Plus D)

• Etidronate (Didronel)

• Ibandronate (Boniva)

• Pamidronate (Aredia)

• Risedronate (Actonel, Actonel with Calcium)

• Tiludronate (Skelid)

• Zoledronic acid (Reclast, Zometa)

These drugs are a $7 billion business, yet they are of marginal benefit at best and carry significant risks.

The first bisphosphonate was Fosamax, produced by the drug company Merck. Its launch coincided with the publishing of a Merck-funded study called the Fracture Intervention Trial.34 At first glance the claims made in Merck’s advertisements for Fosamax were quite impressive. Merck claimed that Fosamax reduced the rate of hip fracture, compared with a placebo, by 50%, but at a closer look the numbers do not seem so rosy. First of all, the women in the study were high-risk women who had a history of a fracture due to osteoporosis. Next, only 2 out of 100 women in the placebo group had a hip fracture during the trial, compared with 1 out of 100 in the Fosamax group. In other words, 98 women out of 100 in the Fosamax group would have fared just the same if they had been on a placebo. While in severely high-risk individuals bisphosphonate therapy may offer some benefits, we believe that in time nondrug measures will be shown to be even more effective. In fact, clinical studies examining the effect of diet, lifestyle measures, and proper supplementation (discussed below) suggest that the natural approach may be far superior.

An important consideration is that in the Fracture Intervention Trial and many others, the women studied were at extremely high risk for a fracture. Such women are a small group. In fact, bisphosphonates are prescribed just as often for women with osteopenia (bone mineral density that is lower than normal but not low enough to be classified as osteoporosis) as they are for women with osteoporosis, even though there is no correlation between osteopenia and hip fracture risk. Neither bisphosphonates nor other drugs have shown effectiveness or are indicated in the treatment of osteopenia, despite considerable efforts by drug companies to convince doctors otherwise.35 Instead of relying on a drug to reduce the risk of osteoporosis and hip fracture, the more rational approach would be to focus on diet, lifestyle, and supplement strategies.

Most of the side effects of bisphosphonates are mild, such as minor digestive disturbances (heartburn, diarrhea, flatulence), muscle and joint pain, headaches, and allergic reactions. However, these drugs can cause severe damage to the esophagus. It is very important that anyone taking an oral bisphosphonate remain standing or seated upright for 45 to 60 minutes after taking the medication.

Bisphosphonates have also been associated with severe bone destruction (osteonecrosis) of the jaw. This side effect is most often seen in cancer patients or those undergoing dental work to eliminate potential sites of infection.

One consequence of bisphosphonate use is the development of “brittle bones” and severe fractures of the thighbone (femur). Risk for brittle bones may be associated with long-term use and is one reason the use of bisphosphonates should be limited to five years at most.

Selective Estrogen-Receptor Modulators

Selective estrogen-receptor modulators (SERMs) are compounds that modulate the effects of estrogen receptors without producing the cancer-causing effects of estrogen. Currently the only SERM approved for the treatment of osteoporosis is Evista (raloxifene). In a 20-year study, raloxifene at 60 mg per day significantly improved BMD at the lumbar spine by 1.6% and at the femoral neck by 1.2%.36 In the Multiple Outcomes of Raloxifene Evaluation trial, three years of raloxifene therapy at 60 mg per day in postmenopausal women increased BMD by 2.6% at the spine and 2.1% at the femoral neck.37 Yet these benefits are not achieved without risk.

The most serious side effect for Evista is the formation of clots that can block veins or lodge in the lungs or heart. Though these side effects occur in only about 1 out of 100 patients treated with Evista, women treated with Evista were more than twice as likely to develop clot-related disease than women taking a placebo. More common side effects of Evista include difficult, burning, or painful urination; fever; increased rate of infections; leg cramps; skin rash; swelling of hands, ankles, or feet; and vaginal itching. Less common side effects include body aches and pains, congestion in the lungs, decreased vision or other changes in vision, diarrhea, difficulty breathing, hoarseness, loss of appetite, nausea, trouble swallowing, and weakness.

Parathyroid Hormone

Parathyroid hormone is given by injection under the skin once per day. Parathyroid hormone stimulates osteoblastic bone formation and increases bone density in women with osteoporosis.3840 One parathyroid hormone medication in particular, teriparatide (Forteo), is approved for the treatment of osteoporosis in postmenopausal women. Nineteen months of teriparatide treatment (20 mcg per day) increased bone density in the spine by 8.6% and in the femoral neck by 3.5% compared with a placebo.40 In addition, the incidence of new vertebral fractures was reduced by 65% and that of nonvertebral fractures by 53%. It is interesting to note that the process of injecting a placebo increased bone density by 3.5%, a degree of improvement greater than that seen with bisphosphonates or Evista.

Calcitonin

Calcitonin is approved for postmenopausal osteoporosis treatment but not for prevention. It is available as a nasal spray and a subcutaneous injection. In the Prevent Recurrence of Osteoporotic Fractures trial,41 an intranasal spray containing calcitonin (delivering 200 IU per day) was used for five years by postmenopausal women with osteoporosis; this was found to reduce the risk of new vertebral fractures by 33% compared with a placebo. No effect was seen on hip or nonvertebral fractures. Calcitonin spray may also be helpful in women with osteoporosis in that it can reduce bone pain from vertebral compression fractures.

Lifestyle

Smoking

Smoking tends to cause more rapid bone loss and lower bone mass. Women who smoke also tend to experience menopause two years earlier than nonsmokers.4244 Postmenopausal smokers have higher fracture rates,45 and meta-analyses have suggested that hip fracture risk may be increased in current smokers.46 Such fractures may be a particular risk for women over age 60. The World Health Organization reports that a history of smoking causes a substantial risk for future fracture independent of BMD.47

Alcohol

Alcohol consumption affects bone in a dose-dependent manner. While moderate alcohol consumption is associated with an increased BMD in postmenopausal women,48,49 heavy alcohol consumption—more than seven drinks a day—is associated with an increased risk of falls and fractures.50 One drink is equal to 12 fl oz beer, 4 fl oz wine, or 1 fl oz hard liquor.51

Exercise

Exercise is the major determinant of bone density. One hour of moderate physical activity three times a week has been shown to prevent bone loss and actually increase bone mass in postmenopausal women.5257 Both weight-bearing and strength-training exercises are beneficial to the development of bone and maintenance of bone health and function.5860 In a meta-analysis of postmenopausal women, those who exercised increased their spine BMD by approximately 2%.61 That equals the benefits noted with bisphosphonate drugs. In addition to increasing BMD, muscle-strengthening and balance-enhancing exercises have been shown to reduce the risk of falls and fall-related injuries by 75% in women 75 years of age and older.62 Weight-bearing exercises can be simple, such as walking or tai chi. Strength-training exercises can also be simple, with hand weights or resistance bands that can be used at home.

Diet

Many dietary factors play a role in bone health:6365

• Low intake of calcium and/or high intake of phosphorus

• High-protein diet

• Low-protein diet

• A diet high in acid ash (high in meat and dairy products, low in fruits and vegetables)

• High salt intake

• High sugar intake

• Trace mineral deficiencies

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PREVENTING SARCOPENIA

Sarcopenia is the loss of skeletal muscle mass and strength as we age. Sarcopenia is to our muscle mass what osteoporosis is to our bones. The degree of sarcopenia as we age is a predictor of mortality and disability. Sarcopenia is linked not just to a significantly shorter life expectancy but also to decreased vitality, poor balance and gait speed, and increased falls and fractures. Just as we want to build bone while we are young to help us preserve it longer through the aging process, the same is true for muscle: we want to reach peak muscle mass while we are young. And just as it is important to engage in dietary, lifestyle, and exercise strategies to fight osteoporosis in our later years, we must do the same to fight sarcopenia. For more information on sarcopenia and what you can do about it, see the discussion in the chapter “Longevity and Life Extension.”

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A vegetarian diet (either a vegan diet or one that includes milk and eggs) is associated with a lower risk of osteoporosis.66,67 Although bone mass in vegetarians does not differ significantly from that in omnivores in the third, fourth, and fifth decades, there are significant differences in the later decades. These findings indicate that the decreased incidence of osteoporosis in vegetarians is due not to increased initial bone mass but rather to decreased bone loss.

Several factors are probably responsible for the decrease in bone loss observed in vegetarians. The most important of these is probably a lowered intake of protein coupled with an alkaline-ash diet. A high-protein diet or a diet high in phosphates is associated with increased excretion of calcium in the urine, as the calcium is used to buffer the extra acid this type of diet generates in the body. Raising daily protein intake from 47 to 142 g doubles the excretion of calcium in the urine.68 A diet this high in protein is common in the United States and may be a significant factor in the increasing number of people suffering from osteoporosis in this country.69 But perhaps more important than reducing protein intake is increasing the dietary intake of fruits and vegetables for their alkalinizing effect. When the diet induces acidosis—which is typical of a diet high in protein and salt—the body maintains pH by buffering with calcium, which is taken from the bones.70 For some additional guidance on an alkaline diet, see Appendix C, “Acid-Base Values of Selected Foods.”

Gastric Acid

It has long been believed that the absorption of calcium depends on its becoming ionized in the intestines, largely on the basis of the secretion of gastric acid, and that poor ionization of calcium is a major problem with calcium carbonate—the most widely used form of calcium for nutritional supplementation. There is still some validity to these beliefs, but the situation is a bit more complicated. The biggest detriment to calcium absorption in regard to stomach acid production may be the use of acid-blocking drugs.

Although decreased gastric acidity is seen in as many as 40% of postmenopausal women,71 a critical review of available studies indicates that the effects of increased gastric pH are apparent only when poorly soluble calcium salts (such as calcium carbonate) are taken on an empty stomach.72 In a fasting state, patients with insufficient stomach acid output can absorb only about 4% of an oral dose of calcium as calcium carbonate, whereas a person with normal stomach acid can typically absorb about 22%.72 Patients with low stomach acid secretion need a form of calcium that is already in a soluble and ionized state, such as calcium citrate, calcium lactate, or calcium gluconate, if they are going to take it on an empty stomach. About 45% of the calcium is absorbed from calcium citrate in patients with reduced stomach acid.73 However, when any form of calcium is taken with meals, there is little difference in its absorption even in elderly subjects who secrete little stomach acid or those taking acid-blocking drugs. That said, there is an association between increased risk of hip fractures and long-term use of proton-pump-inhibiting acid-blocking drugs such as these:74,75

• Omeprazole (Losec, Prilosec, Zegerid, Ocid, Lomac, Omepral, Omez)

• Lansoprazole (Prevacid, Zoton, Monolitum, Inhibitol, Levant, Lupizole)

• Dexlansoprazole (Kapidex, Dexilant)

• Esomeprazole (Nexium, Esotrex)

• Pantoprazole (Protonix, Somac, Pantoloc, Pantozol, Zurcal, Zentro, Pan, Controloc)

• Rabeprazole (Zechin, Rabecid, Nzole-D, AcipHex, Pariet, Rabeloc.

• Revaprazan (Revanex)

Sugar

Refined sugar is another dietary factor that increases the loss of calcium from the body. Following sugar intake, there is an increase in the urinary excretion of calcium.76 Considering that the average American consumes 125 g sucrose, 50 g corn syrup, and other refined simple sugars every day, it is little wonder that so many suffer from osteoporosis.

Soft Drinks

Soft drinks are a major contributor to osteoporosis for those who drink them, as they are high in phosphates (phosphoric acid) and sugar. This leads to lower calcium and higher phosphate levels in the blood. The United States ranks first among countries for soft drink consumption, with an average per capita consumption of approximately 15 oz per day.

The link between soft drink consumption and bone loss is going to be even more significant as children practically weaned on soft drinks reach adulthood. Soft drink consumption among children poses a significant risk factor for impaired calcification of growing bones. Because there is such a strong correlation between maximum BMD and the risk of osteoporosis, the rate of osteoporosis may eventually reach even greater epidemic proportions.

The severely negative effect that soft drinks have on bone formation in children was clearly demonstrated in a study that compared 57 children with low blood calcium, age 18 months to 14 years, with 171 matched controls with normal calcium levels.77 The goal of the study was to assess whether the intake of at least 1.5 quarts per week of soft drinks containing phosphates is a risk for the development of low blood calcium levels. Of the 57 children with low blood calcium levels, 38 (66.7%) drank more than four bottles (12 to 16 fl oz each) per week, but only 48 (28%) of the 171 children with normal serum calcium levels drank that many soft drinks. For all 228 children, a significant inverse correlation between serum calcium level and the amount of soft drinks consumed each week was found.78

Green Leafy Vegetables

Green leafy vegetables (kale, collard greens, parsley, lettuce, etc.) offer significant protection against osteoporosis. These foods are a rich source of a broad range of vitamins and minerals that are important to maintaining healthy bones, including calcium, vitamin K1, and boron.

Vitamin K1 (phylloquinone or phytoquinone) is the form of vitamin K that is found in plants. A function of vitamin K that is often overlooked is its role in converting inactive osteocalcin (the major noncollagen protein in bone) to its active form. Osteocalcin’s role is to anchor calcium molecules and hold them in place within the bone.79 A deficiency of vitamin K leads to impaired bone health due to inadequate osteocalcin levels. In one study, very low blood levels of vitamin K1 were found in patients who had fractures due to osteoporosis.80 The severity of fractures was strongly correlated with the level of circulating vitamin K: the lower the level of vitamin K, the greater the severity of the fracture. In the Nurses Health Study a low dietary intake of vitamin K was linked to increased hip fractures.81 Despite some studies showing that the lower the level of circulating vitamin K, the lower the bone density,82 more recent studies indicate that while low dietary vitamin K levels are linked to fractures due to osteoporosis, they do not appear to be correlated with low BMD.83

This evidence clearly indicates the importance of vitamin K in preventing fractures; it probably increases the tensile strength of bone without affecting BMD. Since vitamin K is found in green leafy vegetables, it may be one of the key protective factors against osteoporosis in a vegetarian diet. The richest sources of vitamin K1 are dark green leafy vegetables (such as broccoli, lettuce, cabbage, and spinach) and green tea. Other good sources are asparagus, oats, whole wheat, and fresh green peas.

In addition to vitamin K1, the high levels of many minerals in green leafy vegetables, such as calcium and boron, may also be responsible for this protective effect.

Boron

Boron is a trace mineral that is a protective factor against osteoporosis. In one study, supplementing the diet of postmenopausal women with 3 mg boron per day reduced urinary calcium excretion by 44% and dramatically increased levels of 17-beta-estradiol, the most biologically active estrogen.84 It appears that boron is required to activate certain hormones, including estrogen and vitamin D.85 It was mentioned previously that vitamin D is converted to its most active form (1,25-[OH] vitamin D, or calcitriol) within the kidney, and that this conversion is impaired in postmenopausal osteoporosis. Boron is apparently required for this conversion to occur. A boron deficiency may contribute greatly to osteoporosis and to menopausal symptoms.

Because fruits and vegetables are the main dietary sources of boron, diets low in these foods may be deficient in boron. The standard American diet is severely deficient in these foods. In order to guarantee adequate boron levels, supplement with 3 to 5 mg boron per day.

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PRUNES TO BUILD BONES

Prunes (dried plums) are well known for their ability to prevent and relieve constipation. Prunes may also be able to help offset women’s significantly increased risk for accelerated bone loss during the first three to five years after menopause. When 58 postmenopausal women ate about 12 prunes each day for three months, they were found to have higher blood levels of enzymes and growth factors that indicate bone formation than women who did not consume prunes. Also, none of the women suffered any adverse gastrointestinal side effects. Prunes’ beneficial effects on bone formation may be due to their high concentration of phenolic compounds that act as antioxidants and help curb bone loss. Prunes also provide a good supply of boron, a trace mineral integral to bone metabolism that is thought to play an important role in the prevention of osteoporosis. A single serving (3.5 oz) of prunes provides 2 to 3 mg boron.86

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Soy Isoflavones

Soy products contain a class of compounds called isoflavones, including genistein, daidzein, and glycitein, all of which are considered to be phytoestrogens because they share a structure similar to that of 17-beta-estradiol, the main form of estrogen produced in the body. The binding of soy isoflavones to estrogen receptors is preferential for the estrogen receptor beta and thus indicates that soy isoflavones act as selective estrogen modulators similar to Evista, but seemingly without the side effects.87 The daidzein molecule is similar in shape to the molecule of a drug called ipriflavone, which is used in Europe and Japan to treat osteoporosis (as discussed below). In the United States, ipriflavone is available as a nutritional supplement.

Soy foods or soy isoflavone supplements have the potential to favorably affect bone metabolism, yet they remain a bit controversial in the medical literature due to the inconsistencies in the studies that have been done to date.88These variations include differences in the dosage and form of soy products studied (soy protein isolate, whole soy foods, or extracted soy isoflavones), differences in the menopausal status of the women studied (perimenopausal, early postmenopausal, or late postmenopausal), differences in the duration of the various trials, and differences in the tests used to assess bone density and bone metabolism. Nonetheless, there is considerable evidence that soy has a bone-building effect, as many studies have shown that soy or soy isoflavones can slow bone turnover and increase bone density in women. Menopausal women taking 55 to 90 mg soy isoflavones for six months had an increase in mineral levels and density in the lumbar spine.8991

Several detailed analyses of the clinical trials of soy and soy isoflavones concluded that a dose of 90 mg per day of soy isoflavones is required to achieve benefits for bone health.92,93 Studies that have used lower levels of soy isoflavones have consistently failed to show any real benefit to bone health. In addition, the benefits of soy in bone health may be more apparent in postmenopausal women than in premenopausal women.94,95

A nutritional influence of soy foods that may be overlooked is the amount of calcium in some of these foods or in diets that contain soy foods. A diet that includes greater amounts of soy products can account for a meaningful amount of calcium, and some soy foods can offer at least as much calcium as a serving of dairy products.

Calcium Content of Selected Soy Products

SOY PRODUCT

SERVING SIZE

CALCIUM (MG)

Tofu, firm

1/4 block

553

Tofu, regular

1/4 block

406

Soy milk, calcium-fortified

1 cup

80–300

Soy milk

1 cup

7

Soybeans, roasted

1/4 cup

119

Soybeans, boiled

1/4 cup

88

Tempeh

1/4 cup

77

Nutritional Supplements

Calcium

Adequate calcium intake has an established role in maintaining bone health, primarily in very young women and the elderly. However, calcium alone provides very little benefit in protecting against osteoporosis; vitamin D, vitamin K, and other nutrients are required as well).96 In a detailed analysis of all controlled trials with calcium supplementation evaluating bone health up to 2002, supplementation with 500 to 2,000 mg per day of calcium had only a modest benefit for bone density in postmenopausal women: the difference in the amount of bone loss between calcium and placebos was 2.05% for the total body, 1.66% for the lumbar spine, and 1.64% for the hip.97 Closer examination of the largest study, the Women’s Health Initiative, which enrolled more than 36,000 postmenopausal women, showed a surprising result: while overall data showed that supplementation with 1,000 mg per day of calcium and 400 IU per day of vitamin D decreased the risk of hip fractures by 12% when compared with a placebo, when the analysis was restricted to women who actually took the tablets at least 80% of the time, calcium plus vitamin D decreased hip fractures by 29% compared with the placebo.98 That is significant, especially because in the study vitamin D was supplemented at levels now known to be less than ideal.

In postmenopausal women, calcium supplementation has been shown to decrease bone loss by as much as 50% at nonvertebral sites. The effects were greatest in women whose baseline calcium intake was low, in older women, and in women with established osteoporosis.99 There are other studies that have shown some effects in preventing vertebral bone loss as well.100

Here are our recommendations for calcium supplementation. First, there is no reason to take more than 1,000 mg per day as a supplement. Studies are clear that the benefits seen at 2,000 mg per day are not greater than those seen with 1,000 mg. Taking large doses of calcium can impair the absorption of magnesium and other minerals. Avoid oyster-shell calcium, dolomite, and bonemeal products because these forms tend to have higher lead levels. We prefer easily ionized forms of calcium such as calcium citrate, but the reality is that if taken with meals even calcium carbonate is effectively absorbed in most people. We also like tricalcium phosphate, for the following reasons: 101,102

• Tricalcium phosphate provides three molecules of calcium for every molecule of phosphorus, so it is a highly efficient source of both calcium and phosphorus.

• Clinical studies indicate that consuming calcium with phosphorus in the form of tricalcium phosphate is more effective at building strong bones than consuming calcium alone.

• Calcium cannot be utilized in the absence of phosphorus.

• Approximately 50% of North American women are deficient in phosphorus.

• Phosphorus is an essential component of bone, with 85% of the phosphorus in your body found in your bones.

• Clinical research indicates that calcium supplements without phosphorus may actually decrease the phosphorus available to the body for bone health, thus contributing to osteoporosis.

While too much phosphorus is not a good thing, especially when it is not accompanied by calcium (as in soft drinks and animal meats), so too is not enough, especially in regard to the absorption of calcium.

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DOES MILK CONSUMPTION PREVENT OR CAUSE OSTEOPOROSIS?

While numerous clinical studies have demonstrated that calcium and vitamin D supplementation can help prevent bone loss, the data are inconclusive in regard to any link between a high dietary calcium intake from milk and prevention of osteoporosis and bone fractures. In fact, the current available data indicate that frequent milk consumption actually increases the risk for osteoporosis. When reviewing the data from the Nurses’ Health Study, a study involving 77,761 women, researchers found that women who drank two or more glasses of milk per day had a 45% increased risk for hip fracture compared with women consuming 1 glass or less per week.103 In other words, the more milk a woman consumed, the more likely she was to experience a hip fracture. This negative effect may turn out to be due to the vitamin A added to milk (at higher levels, vitamin A, but not beta-carotene, may interfere with bone formation). Interestingly, the rate of osteoporosis is considerably higher in countries where milk intake is highest.

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Vitamin D

As discussed above under “Diagnostic Considerations,” vitamin D plays a major role in bone health. Given its importance in bone health as well for general health, vitamin D supplementation seems critical. While the results from large randomized, controlled trials have found that the combination of calcium and vitamin D produces some benefits in reducing fracture risk, virtually all of these studies used vitamin D dosages that were inadequate to raise blood levels of vitamin D3 into the effective range (45 to 90 ng/ml).104,105 Nonetheless, a detailed analysis of randomized controlled trials in elderly postmenopausal women found that even at a low dose of 700 to 800 IU per day vitamin D was associated with significant reductions in the risk of hip and nonvertebral fractures.106 Vitamin D in combination with calcium supplementation definitely reduces the rate of postmenopausal bone loss, especially in older women.107 Vitamin D has also been shown to improve muscle strength108 and balance,109 thereby reducing the risk of falling.110

So, how much vitamin D do you need? As detailed in the chapter “Supplementary Measures,” the only way to accurately know your vitamin D status is to measure it in the blood. Studies indicate that for proper health, serum vitamin D levels should be between 50 and 80 ng/ml (125 to 200 nmol/l). We definitely recommend testing to ensure that optimal levels of vitamin D levels are being achieved. While some people can achieve an optimal level with just 600 IU a day (or 20 minutes of sunlight exposure per day) others have a genetic requirement for as much 10,000 IU a day. The only way to determine your optimal dosage is by testing.

For general health we recommend a dosage of 2,000 IU per day, but for women or men with reduced bone density or osteoporosis we recommend a dosage of 5,000 IU per day. Pregnant and lactating women are likely to need more vitamin D as well. In the past, breastfeeding longer than six months was considered a cause of vitamin D deficiency in children. We now know that the problem is not breastfeeding, but rather that almost all women are deficient in vitamin D.

Magnesium

Magnesium is just as important in bone mineralization as calcium, but it does not receive nearly the same level of attention. Low magnesium status is common in women with osteoporosis, and magnesium deficiency is associated with abnormal bone mineral crystals.111 Some women with reduced BMD do not have an increased fracture rate, possibly because their bone mineral crystals are of high quality, owing in part to high levels of magnesium. In a group of postmenopausal women, supplementation with 250 to 750 mg per day of magnesium for 6 months followed by 250 mg per day for 6 to 18 months resulted in an increase in bone density in 71% of the women. This increase was noteworthy because it occurred without calcium supplementation.112

Zinc

Zinc is essential for the proper formation and function of osteoblasts and osteoclasts, and it enhances the biochemical action of vitamin D. Zinc is also is necessary for the synthesis of various proteins found in bone. Low zinc levels have been found in the serum and bone in people with osteoporosis.113

Copper

A deficiency of copper is known to produce abnormal bone development in growing children and may be a contributing cause of osteoporosis. In vitro studies have shown that copper supplementation inhibits bone resorption.114,115In a double-blind trial, supplementation with 3 mg per day of copper for two years significantly decreased bone loss in postmenopausal women.116

Manganese

A deficiency of manganese may be one of the lesser-known but more important nutritional factors related to osteoporosis. Manganese deficiency causes a reduction in calcium deposition in bone. Manganese also stimulates the production of important compounds in the collagen matrix that provides a framework for the mineralization process.117

Combinations of Minerals

In a double-blind study of postmenopausal women, the combination of zinc, copper, manganese, and calcium appeared to be more effective than calcium alone for preventing bone loss in postmenopausal women.117

Silicon

During bone growth and the early phases of bone calcification, silicon has an essential role in the formation of cross-links between collagen and proteoglycans. In animals, silicon-deficient diets have produced abnormal skull development and growth retardation,118 and supplemental silicon partially prevented bone loss in female rats that had their ovaries removed.119

A highly bioavailable form of silica (choline stabilized orthosilicic acid, sold as BioSil) showed impressive clinical results in improving bone health in a double-blind study in postmenopausal women with low bone density.120Compared with a control treatment consisting of calcium and vitamin D alone, the addition of BioSil (6 mg per day) was able to increase the collagen content of the bone by 22% and increase BMD by 2% within the first year of use. The ability to improve the collagen matrix as well as BMD indicates that BioSil produced greater bone tensile strength and flexibility, thereby greatly increasing the resistance to fractures. The recommended dosage is 6–10 mg per day.

Folic Acid, Vitamin B6, and Vitamin B12

Accelerated bone loss in menopausal women may in part be due to increased levels of homocysteine, a breakdown product of methionine that will be elevated if folic acid, vitamin B6, or vitamin B12 levels are insufficient. Homocysteine has the potential to promote osteoporosis if it is not eliminated adequately. In a prospective study, women with high homocysteine levels had almost twice as high a risk of nonvertebral osteoporotic fractures as women with low homocysteine levels.121 Since a deficiency of any of the B vitamins involved in homocysteine metabolism may be the factor in the elevated homocysteine levels, it is important to supplement all three at recommended levels. Restoration of the proper status of these B vitamins will bring elevated homocysteine levels down. Deficiencies of at least one of these nutrients are common in postmenopausal women.

Vitamin C

Vitamin C promotes the formation and cross-linking of some of the structural proteins in bone. Animal studies have shown that vitamin C deficiency can cause osteoporosis,122 and it has been known for decades that scurvy, a disease caused by vitamin C deficiency, is also associated with abnormalities of bone.

Vitamin K

Vitamin K, as discussed above, is required for the production of the bone protein osteocalcin, a key component in the matrix of bone. Various forms of vitamin K supplements have been used in human trials: vitamin K1(phylloquinone or phytoquinone), menaquinone-4 (MK4, a form of vitamin K2), and menaquinone-7 (MK7, another form of vitamin K2). Studies of the effects of vitamin K supplementation on bone health have produced mixed results. We feel it is because the variable used to assess effectiveness, BMD, is probably not the right measure. Most of the double-blind studies with vitamin K1 have shown only a modest effect or no effect on bone density, and while studies with MK4 have shown positive results in reducing bone loss and fracture rates, the dosage used (45 mg per day) was extremely high, suggesting that the positive results are probably due to a drug-like effect rather than a nutritional effect.106,123129 One double-blind study with vitamin K1 showed that taking 5 mg a day for two to four years did not protect against an age-related decline in BMD in postmenopausal women with osteopenia but did result in significantly fewer fractures.124 Because vitamin K affects osteocalcin, it is entirely possible that it has an effect on improving bone health without improving BMD.

MK7 (a longer-chain form of vitamin K2) is found in high concentrations in natto (a fermented soy food popular in Japan) and is produced by gut bacteria in small amounts from dietary vitamin K1.128 MK7 has been found in animal studies to be more potent and more bioavailable as well as to have a longer half-life than MK4. When taken as a supplement (0.22 mmol per day), MK7 is more effective than K1 in activating osteocalcin and stays in the blood circulation much longer (half-life of 8 hours for K1 and MK4 vs. 96 hours for MK7).129130 In a study of postmenopausal Japanese women, a significant inverse association was found between natto consumption and the incidence of hip fractures.131 In a study of osteoporosis after organ transplantation, one year of MK7 supplementation (180 mcg per day) resulted in increased bone mineralization compared with a placebo.132 However, a study of early menopausal women given one year of supplementation of 360 mcg per day of MK7 did not show a significant improvement in BMD despite a reduction in inactive osteocalcin.133 Again, there is no question that vitamin K is performing a vital function in bone health and appears to reduce fractures, but it is unlikely to produce a significant improvement in BMD on its own.

Strontium

Strontium is a nonradioactive earth element physically and chemically similar to calcium. Strontium ranelate is the specific strontium salt used in clinical trials for osteoporosis, but this form of strontium is not available in the United States. Strontium in large doses stimulates bone formation and reduces bone resorption. In one double-blind study, 2 g per day of oral strontium ranelate (containing 680 mg per day of elemental strontium) for three years was shown to reduce the risk of vertebral fractures and to increase BMD in 1,649 postmenopausal women with osteoporosis.134 In the first year, there was a 49% reduction in the incidence of vertebral fractures in the strontium ranelate group; and there was a 41% reduction at the end of three years. A 6.8% increase in BMD was seen at the lumbar spine after three years of strontium supplementation. There was also an 8.3% increase at the femoral neck.

In a two-year trial, 353 postmenopausal women with osteoporosis and a history of at least one vertebral fracture received a placebo or one of three different doses of strontium: 170 mg per day, 340 mg per day, or 680 mg per day.135 A small increase in lumbar BMD was seen with each dose of strontium, but the difference compared with a placebo was statistically significant only for the highest dose. The incidence of new vertebral fractures was lowest (38.8%) with the lowest dose of strontium (170 mg), vs. 54.7%, 56.7%, and 42.0% in the placebo, 340 mg, and 680 mg groups, respectively. The fact that the highest dosage increased BMD the most while the lowest dosage had the greatest effect on preventing vertebral fractures indicates that the goal with strontium supplementation may not be trying to increase BMD to the highest possible degree. In addition, since there are potential adverse effects with strontium, including rickets, bone mineralization defects, and interference with vitamin D metabolism, it makes sense to use the lowest dosage possible.

There are many questions to be answered about strontium, including whether strontium chloride (the most common form of strontium used in U.S. supplements) is equal to strontium ranelate. Strontium chloride has not been the subject of published research. Other questions relate to safety and long-term benefits. Until these questions are answered, our advice is to consider supplementation with any strontium salt only as a last resort for elderly women who are at extremely high risk for fractures or who have a significant history of fractures.

Ipriflavone

Ipriflavone is a semisynthetic isoflavonoid, similar in structure to soy isoflavones, that has been approved in Japan, Hungary, and Italy for the treatment and prevention of osteoporosis. The compound, ipriflavone, has shown impressive results in a number of clinical studies. For example, in one study, ipriflavone (200 mg three times per day) increased bone density measurements by 2% and 5.8% after 6 and 12 months, respectively, in 100 women with osteoporosis.136 In another study of women with osteoporosis, ipriflavone (600 mg per day) produced a 6% increase in bone mineral density after 12 months, while the bone density of the placebo group dropped by 0.3%.137 Longer-term studies showed equally promising results given the safety and apparent efficacy of ipriflavone.138,139 The effectiveness of ipriflavone suggests that naturally occurring soy isoflavones such as genistein and diadzein may offer similar benefits. Given the protective effect of soy isoflavones against breast cancer, the regular consumption of soy foods is encouraged. The mechanism of action appears to involve the enhancement of the effect of calcitonin on calcium metabolism (see above), as ipriflavone exerts no estrogen-like effects.140

In one study of ipriflavone published in 2001, the results were not nearly so positive.141 In this double-blind, placebo-controlled four-year study, 474 postmenopausal Caucasian women with osteoporosis were randomly assigned to receive 200 mg ipriflavone three times a day plus 500 mg calcium or a placebo plus 500 mg calcium. Bone density was measured in the spine, hip, and forearm, as were biochemical markers of bone resorption. After 36 months of treatment, the annual percentage change in bone mineral density did not differ significantly between the two groups. The biochemical markers were also similar between the groups. The number of women with new spinal fractures was the same in the two groups at all points in the 36 months. Unexpected results included decreased lymphocytes (a type of white blood cell) in the blood in 31 women treated with ipriflavone.

So why did earlier studies of early and later postmenopausal women and of women with osteoporosis show positive results with ipriflavone and not this study? The most likely explanation is that the study population could have been too osteoporotic to show any benefit. Or it could be that this ipriflavone study, the largest and best-designed to date, reveals that ipriflavone just does not have a significant role in the treatment of osteoporosis. It may be more appropriate for women with osteopenia or in the prevention of osteoporosis, but not for women whose BMD has dropped to osteoporosis. And why did ipriflavone cause a decrease in lymphocytes in this study but not in others? Subsequent studies done with ipriflavone since 2001 have demonstrated very positive results with no significant side effects.142144

Our feeling is that until the issue of the decreased lymphocyte concentrations is cleared up, we recommend using soy isoflavones instead of ipriflavone. If you choose to use ipriflavone, monitor blood lymphocyte levels on a quarterly basis to detect any adverse effect.

Botanical Medicines

Green Tea

Population-based studies as well as experimental studies have demonstrated that consumption of green tea (Camellia sinensis) may offer significant protection against osteoporosis.145 Green tea is rich not only in health-promoting polyphenols but also in vitamin K1. In order to take advantage of this protection you need to drink three to five cups per day, providing a minimum of 250 mg per day of polyphenols (also referred to as catechins); alternatively, take a green tea extract providing the same level of polyphenols. In the experimental studies, the basic mechanism of green tea polyphenols was to impair bone resorption while at the same time stimulating osteoblast activity.146148 This effect would have tremendous significance if confirmed in human clinical trials.

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QUICK REVIEW

• Osteoporosis is now determined primarily by bone mineral density testing.

• The big consequence of osteoporosis is fractures, especially in older women and men.

• Men are not immune to osteoporosis, though their risk is only about 25% that of women.

• Bone is dynamic living tissue that is constantly remodeling.

• Emerging research is showing a direct correlation between bone density and blood levels of vitamin D3.

• As significant as genetic factors are in osteoporosis risk, there is no question that the major determinants of bone health are diet and lifestyle.

• The benefits of physical activity in reducing the risk of osteoporosis cannot be overemphasized.

• Women who have experienced premature menopause (before age 40), late onset of menstruation in adolescence, surgical menopause, or periods of no menstruation due to low estrogen levels in their reproductive years are at greater risk of osteoporosis.

• While BMD testing alone may not be a good predictor of fracture risk, it is a great way to increase the awareness of osteoporosis.

• Osteoporosis in most cases is entirely preventable through diet, lifestyle, and proper supplementation.

• Bisphosphonates are a $7 billion business, yet they are of marginal benefit at best and carry significant risks.

• Smoking, alcohol consumption, and physical activity are key lifestyle factors that affect bone health.

• When any form of calcium is taken with meals, there is little difference in its absorption, even in elderly subjects who secrete little stomach acid or in those taking acid-blocking drugs.

• There is an association between long-term use of proton-pump acid-blocking drugs and an increased risk of hip fracture.

• The link between soft drink consumption and bone loss is significant.

• A deficiency of vitamin K leads to impaired bone health due to inadequate osteocalcin levels.

• Boron is a trace mineral that is also a protective factor against osteoporosis.

• Soy consumption is associated with greater bone density.

• Calcium alone has very little benefit in protecting against osteoporosis; it requires vitamin D (and possibly other nutrients as well).

• There is no reason to take more than 1,000 mg calcium per day as a supplement.

• Vitamin D in combination with calcium supplementation definitely reduces the rate of postmenopausal bone loss, especially in older women.

• Vitamin D has also been shown to improve muscle strength and balance, thereby reducing the risk of falling.

• Low magnesium status is common in women with osteoporosis, and magnesium deficiency is associated with abnormal bone mineral crystals.

• A highly bioavailable from of silica (BioSil) showed impressive clinical results in improving bone health in postmenopausal women with low bone density.

• Strontium in large doses stimulates bone formation and reduces bone resorption, but there are still many questions about its use as a dietary supplement.

• Population-based studies as well as experimental studies have demonstrated that green tea consumption may offer significant protection against osteoporosis.

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TREATMENT SUMMARY

As with most chronic health conditions, the most effective approach to osteoporosis is prevention. The risk of developing osteoporosis may be reduced by optimizing peak bone mass in the younger years and minimizing subsequent bone loss with aging. In order to maximize peak bone mass (even in the context of hereditary and other nonmodifiable risk factors), a healthful lifestyle, proper nutrition, and moderate exercise should begin during childhood and adolescence and continue into adulthood. Avoid smoking and excessive alcohol consumption.

For women (and men) who have already been diagnosed with osteoporosis, drug therapies can serve as a short-term adjunct to the recommendations in this chapter if required. But there is no question that the nutritional and lifestyle factors recommended here should serve as the primary approach to slow bone loss and decrease the risk of fractures.

Lifestyle

• Weight-bearing exercise four times a week plus strength training two or more times a week

• Fewer than seven alcoholic drinks per week; no more than two per day

• Avoidance of smoking and secondhand smoke

Diet

The guidelines discussed in the chapter “A Health-Promoting Diet” are very much indicated in helping to build strong healthy bones. A key area of attention is getting adequate protein, soy isoflavones, and green leafy vegetables each day while limiting the intake of factors that promote calcium excretion, such as salt, sugar, excessive protein, and soft drinks.

Nutritional Supplements

• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”

• Key individual nutrients:

  images Calcium: 1,000 mg per day

  images Magnesium: 350 to 500 mg per day

  images Vitamin B6: 25 to 50 mg per day

  images Folic acid: 800 mcg per day

  images Vitamin B12: 800 mcg per day

  images Vitamin K2 (MK7): 100 mcg per day

  images Vitamin D3: 5,000 IU per day (ideally, measure blood levels and adjust dosage accordingly)

• Fish oils: 1,000 mg EPA + DHA per day

• One of the following:

  images Grape seed extract (>95% procyanidolic oligomers): 100 to 300 mg per day

  images Pine bark extract (>95% procyanidolic oligomers): 100 to 300 mg per day

  images Some other flavonoid-rich extract with a similar flavonoid content, super greens formula, or another plant-based antioxidant that can provide an oxygen radical absorption capacity (ORAC) of 3,000 to 6,000 units or more per day

• Specialty supplements:

  images Soy isoflavones: 90 mg per day

  images Strontium: 170 to 680 mg per day (but read the discussion above)

  images Ipriflavone: 600 mg per day (but read the discussion above)

  images Choline-orthosilicic acid (BioSil): 6 to 10 mg per day

Botanical Medicines

• Green tea: three to five cups per day, or a green tea extract that provides 250 to 300 mg polyphenols (also referred to as catechins) per day