Osteoporosis Prevention and Treatment Strategies
Osteoporosis affects 8 million American women, and 2 million men, causing 1 1/2 million fractures each year. As many as 18 million more Americans may have low bone density (osteopenia), a precursor to osteoporosis. As women age, many develop collapse of their lumbar vertebrae resulting in pain and disability. Even after screening and diagnosis most women are offered drugs and calcium, without addressing all the additional causes of osteoporosis, which are discussed below.
First, check your Vitamin D status.
I have routinely drawn Vitamin D (25 hydroxy) on patients over the years and found a surprisingly high percentage of people with Vitamin D deficiency. Vitamin D deficiency is a leading cause of osteoporosis, and I routinely find women taking calcium and drugs, such as Fosomax, who remain Vitamin D deficient.
The high prevalence of Vitamin D deficiency is in spite of the fact that the majority of these individuals were already taking a multivitamin with the standard 400 IU of Vitamin D. People everywhere are trying to avoid the sun because of the skin cancer risks and aging of the skin. Therefore I recommend that a Vitamin D level be checked occasionally at routine physician visit to assure an adequate level. Often Vitamin D supplementation is indicated, especially in the more northern latitudes.
Second, do not take vitamin A in a supplement or multi-vitamin.
Now it's been known for some time that Vitamin A in high doses can be associated with birth defects such as cleft palate and heart abnormalities, but current research suggests the dose at which you're at risk is lower than previously thought. After studying the dietary habits of almost 23,000 pregnant women researchers were surprised that even the doses found in standard vitamin pills resulted in a quadrupling of birth defects. Do you think Vitamin A is only toxic when we are pregnant and good for us when we are not? Of course not, researchers also find even relatively low doses of Vitamin A is also linked to calcium loss in the urine and osteoporosis. Taking any Vitamin A is unnatural and unwise, we make all the Vitamin A we need from the caratonoids in fresh produce.
Third, do not exceed 1500 mg of sodium daily.
All the excess salt Americans consume, that leads to high blood pressure and other medical problems, also contributes to calcium loss in the urine and osteoporosis. The excess sodium we must work to excrete every day washes away and wastes our calcium stores in the process.
Fourth, do back exercises at least three times weekly.
Remember, bone strength is directly proportional to muscle strength and maintain bone health also involves a lifetime commitment to regular exercise and physical activity. Inactivity or bed rest can be disasterous to the bones. Go to the gym, walk, wear a weighted vest, do back exercises, work in the garden and stay involved with sports or fitness pursuits appropriate to your ability and health. It is clear that taking supplements is merely an adjunct to other critical lifestyle factors to reduce risk, but hip fractures are something we all must work to avoid.
The bones are living, dynamic organs. Our bones are continually dissolving old bone tissue and rebuilding new bone. One's bone strength is directly proportional to one's muscle strength. Bones, like muscles, respond to stress by becoming bigger and stronger, and like muscles, bones weaken and literally shrink if not used. Furthermore most women are instructed to do weight-bearing exercises, such as walking and doing stairs however these exercises which may be helpful for the hip, do not protect the spine from this disease. It is essential to exercise the back too.
Studies have found that a back-strengthening exercise program can provide significant long-lasting protection against spinal fractures in women at risk for osteoporosis. One such study showed involved postmenopausal women, ages 58-75. Half performed back-strengthening exercises for two years, while the other half served as the control group. Members of the control group suffered from almost all the vertebral compression fractures at the end of 10 years. The exercise group retained a significant advantage in back strength, even eight years after the exercise program ended, and its members had significantly higher bone density than those in the control group (For more information, see this study: Sinaki M. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone, 2002;30:6:836-841).
Here are my favorite six exercises for your spine to prevent osteoperosis:
1. Seated Cable Row With knees slightly bent lean forward and then pull the handles back to your chest with elbows wide as your back comes to vertical.
2. Wide Cable or Pull Downs with Stretch Bands
Pull down the cable to your chest with elbows wide as you lean back to a 60 degree angle.
3. Back Extensions Lean over exercise ball, and arch your back up like a reverse sit up or use a back extention chair made for this exercise.
4. Superman While lying on your stomach, lift trunk and legs up off ground like a bow.
5. The Alternate Superman Use alternate arm and leg to perform the superman.
6. Wear a weighted back pack or a weighted vest for a few hours a week. Normal activities of moving around and getting up and down with a weighted back pack on or weighted vest strengthens the back.
The top three recommended exercises involve gym equipment or stretch bands that can be used at home. Never attempt to lift heavy weights with your back. Perform a smooth movement with a weight that you can comfortable do at least twenty repetitions with.
(At DrFuhrman.com we sell a comfortable, weighted vest specifically designed for women to prevent and treat osteoporosis.)
Prevention of Falls in the Elderly
Between 30 and 40 percent of those over age 65 fall each year. Most falls have multiple causes but muscular weakness, and us of multiple prescription medications are key contributors. Cardiac drugs such as antiarrthymics, digoxin, diuretics and sleep medication are key common offenders. Since our objective is to reduce the risks of hip fractures, which could be life-threatening or result in permanent nursing home placement, reducing the risk of falls cannot be accomplished by addressing nutritional factors in a vacuum.
Lower extremity muscle weakness is the most significant risk factor for falls and has been shown to increase ones risk of falling four fold. The most effective preventive strategies involve muscle strengthening and balance exercises for the elderly as well as addressing cardiovascular risk factors with nutritional and dietary modifications to avoid heavy reliance on drugs with their risky side effects. Nutritional excellence does not just strengthen your bones, it also enables you to avoid other medical problems and medication use that could further increase your risk of a hip fracture.
Acid Suppression Raises Hip Fracture Risk
A good example of doctor-induced (iatrogenic) hip fracture is medications that suppress stomach acid production used to treat our epidemic of indigestion, esophagitis, and gastritis that results from inadequate nutrition. Doctors are generally blind to the positive health effects of nutritional excellence. They are typically unaware that the these diseases are caused by poor nutrition and unaware that high cruciferous vegetable consumption prevent Helicobacter Pylori from setting up housekeeping in your stomach. Most doctors, only know one option; acid-suppression drugs.
Long-term use of acid suppression therapy with medications (H2 blockers or proton-pump inhibitors) increases the risk of hip fractures according to a recent study. These medications interfere with calcium absorption leading to osteoporosis and increased fracture risk. The study followed over 500,000 adults over the age of forty for fifteen years and found in general those on chronic therapy with these medications had about double the risk of hip fractures. Interestingly the risk of hip fractures associated with these medications was even higher for men than for women.
High Dose Calcium Supplementation Should be Avoided
Americans are constantly being urged to consume more calcium in an effort to reduce our epidemic of osteoporosis. It is hoped that increasing calcium consumption will maintain bone density and reduce the high rate of hip fractures and spinal compression fractures in the elderly. An adult woman with a life expectancy of 80 years has a 16 percent lifetime risk of sustaining a hip fracture. The death rate in the first year after a hip fracture is 15 to 20 percent. So this really is a serious problem and the risk of a hip fracture does correlate well with bone density. Studies show that women with the lowest bone density have a much greater risk of severe injury in a fall.
Because most hip fractures result from falls, the ability to identify women at higher risk of falling with aging is important and special care should be taken in those who have low bone density.
But the controversy here is whether or not women be taking 1000 to 2000 mg of calcium in the form of dairy products or supplements as is recommended by most health authorities. I suggest this is not the ideal approach. I advise getting most of our calcium from vegetables (which are an excellent source of calcium) and that additional calcium supplementation should not be excessive. When you get calcium from greens, you get a symphony of nutrients for optimal health, including folate, phosphorus, Vitamin K, and phytonutrients which all have positive effects on bone health.
When advising whether calcium supplementation is necessary at all and if so, which dose should be recommended, different scientific approaches have yielded different estimates and there is significant disagreement here among authorities.
Government advisory panels reviewed many calcium balance studies, which examine the point at which the amount of calcium consumed equals the amount of calcium excreted - suggest that a reasonable or adequate intake of calcium is about 550 mg/day. To ensure that 95 percent of the population gets this much calcium, the National Academy of Science recommended:
-1,000 mg/day for those age 19-50
-1,200 mg/day for those age 50 or over
-1,000 mg/day for pregnant or lactating adult women
What most people and supplement manufacturers have done is assumed that the person taking the supplement consumes no calcium in their diet and the supplements typically supply 800 to 1200 of calcium daily. Plus most balance studies are short-term and therefore have important limitations. To detect how the body adapts to different calcium intakes over a long period of time requires studies of longer duration. The results from such long-term studies may be surprising to some. While they do not question the importance of calcium in maximizing bone strength, they cast doubt on the value of consuming such large amounts of calcium as currently recommended for adults.
These long-term studies suggest that increasing the calcium dose over 800 mg per day doesn't lower a person's risk for osteoporosis. For example, in the large Harvard studies of male health professionals and female nurses, individuals who drank one glass of milk (or less) per week were at no greater risk of breaking a hip or forearm than were those who drank two or more glasses per week. Other studies have found similar results.
However, examining milk consumption is still a confusing because milk is usually fortified with both Vitamin A and Vitamin D, and Vitamin A has a powerful negative effect on bone health. It is possible that these studied showed milk hurt, not helped, women's bones was because of the exposure to bone damaging levels of Vitamin A as a result of the extra milk.
Additional evidence also supports the idea that American adults may not need as much calcium as is currently recommended. For example, in countries such as India, rural China, and Japan where average daily calcium intake is as about 300-400 mg/day the incidence of hip fractures is comparatively very low. Of course, these countries differ in other important factors as well - such as level of physical activity and amount of sunlight - which could account for their low fracture rates. Around the world health authorities recommend varying amounts of calcium varying from 500 to 1000 mg. In 1998, the expert committee of the European Community in the Report on Osteoporosis-Action on prevention, has given the recommended daily dietary allowances (RDA) for calcium for the elderly population, above age 65 as 700-800 mg/day. The British medical authorities agreed.
Despite the debate surrounding milk and osteoporosis and how much calcium is ideal, one thing is clear: adequate calcium is important for reducing the risk of osteoporosis and the combination supplement with both 800 of Vitamin D with calcium has been shown to significantly reduce both bone loss and hip fractures. However, one long-term 18-year analysis showed that 600 mg of calcium was as effective as 1200 mg in preventing osteoporosis as long as adequate Vitamin D was present. Low serum Vitamin D levels correlated best with fracture risk.
I recommend calcium should not be used in excessive doses and supplemental calcium when used should be in the 400 - 600 range, not the 1000 - 2000 range. Excessive ingestion of calcium could interact with minerals such as iron, zinc, magnesium, and phosphorus and creates a potential for risk of mineral depletion in vulnerable people. A 1998 report from the National Academy of Sciences on Establishing Upper Intake Levels for Nutrients stated, "Like all chemical agents, nutrients (e.g., calcium) can produce adverse health effects if intakes from any combination of food, water, nutrient supplements, and pharmacologic agents is excessive.
Iron absorption can be decreased by as much as 50 percent by many common forms of calcium and by milk ingestion when consumed at the same time as iron containing foods. Calcium citrate, calcium ascorbate or calcium chelates do not decrease iron absorption. But it is possible that increased intakes of specific sources of calcium might induce iron deficiency in individuals with marginal iron status.
In conclusion, a modest increase in calcium via supplementation is safe but real food should supply the majority of calcium intake to achieve the right balance of supportive nutrients to maximize bone health. Practices that might encourage total calcium intake(food plus supplements) to approach or exceed 2,000 mg/day seem more likely to produce adverse effects and should be avoided. The focus on calcium intake instead of the more critical factors, such as use of drugs, Vitamin A (excess) and Vitamin D (lack), high animal protein and salt intake and lack of weight-bearing exercises will guarantee osteoporosis remain a significant and dangerous problem in our population.
The information in this article was compiled from Dr. Fuhrman's newsletter, Healthy Times, which is available by becoming a member of DrFuhrman.com.
1Optimal Calcium Intake. NIH Consensus Statement Online 1994 June 6-8; 12(4):1-31
2Owusu W, Willett WC, Feskanich D, Ascherio A, Spiegelman D, Colditz GA. Calcium intake and the incidence of forearm and hip fractures among men. J Nutr 1997; 127:1782-7. Feskanich D, Willett WC, Stampfer MJ, Colditz GA. Milk, dietary calcium, and bone fractures in women: a 12-year prospective study. Am J Public Health 1997; 87:992-7.
3Feskanich D; Willett WC; Colditz GA. Calcium, vitamin D, milk consumption, and hip fractures: a prospective study among postmenopausal women. Am J Clin Nutr 2003 Feb;77(2):504-11.
4Whiting SJ The inhibitory effect of dietary calcium on iron bioavailability: a cause for concern? Nutr Rev 1995 Mar;53(3):77-80