The current approach to osteoporosis illustrates two of the biggest problems in medicine today.
First is the myth that only drug therapy works, especially when faced with a serious condition. This is the Big Pharma model of medicine which often frightens people by misusing statistics and overestimating the risks of developing a serious condition. This distracts us from and trivializes the very real side effects the drug treatments may have.
The combination of for-profit medicine, constant drug advertisements on TV, fear of litigation, shorter office visits and little reimbursement for lifestyle medicine all contribute to the overuse of prescription medication. Since properly prescribed medications are one of the top 5 causes of death of Americans today, it is urgent that we use medications more selectively and only when the benefits clearly outweigh the risks. This is not the current practice when it comes to preventing bone fractures; instead, many effective non-drug treatments are ignored. Drug treatment for osteoporosis has become a reflex based on a measurement of bone density that is often misinterpreted.
Medications for osteoporosis should only be used as part of a comprehensive approach and for a very limited but specific time frame, to maximize their usefulness and minimize their risks.
Bone density is typically measured when it is at its worst, around menopause, and then compared to the bone density of young women. We then call the normal, predictable bone loss due to the loss of estrogen around menopause a new disease: osteopenia. This scares women (and doctors who do not know better) into thinking that drug treatment now will prevent a fracture later and that is very misleading. Bone density (BD) scores must be age-matched to be at all useful (called a z score) and even then, BD is not able to accurately estimate your personal risk of breaking a bone. But when statistics are misused, the decisions we make are more emotional that factual.
The second problem is that, like many chronic diseases, osteoporosis is a direct result of lifestyle and diet choices over the course of a lifetime. But as a society, we do not value or invest in prevention. We allow conventional medicine to wait until chronic illness progresses, then symptoms and their consequences are treated with expensive drugs and high tech interventions.Rather than a preventive medical model, we have a Big Pharma model and there is simply no profit to be had from a comprehensive plan for bone health that tries to minimize both bone fractures and the use of medications.
So it is up to us and there is a lot we can do. First we need to understand how our body works.
The reason we measure bone density is to try and prevent bone fractures in our senior years. But there is much more to preventing bone fractures than bone density.
Like every other part of our body, bone is dynamic living tissue made up of cells. New cells replace old cells and old bone that has been damaged or worn gets replaced with healthier young bone. This happens bit by bit, in a process called remodeling, just like in a home.
Think of bone as a savings account. During childhood and until our 20s, we make bone deposits. We need to build enough strong bone to last us our lifetimes, including as we age, when we will be making more bone withdrawals than deposits. (Women lose bone earlier in life but men lose bone too.) By our late 20s our bony house is mostly built and for the rest of our adult life, we maintain it by slowly remodeling it, removing old and damaged bone as required, and replacing it with new young healthier bone. It takes about 8 to 10 years for this process to gradually replace our entire skeleton, thus keeping our bones healthy. Osteoporosis and bone fractures can occur if not enough good bone was ever made or if more bone was lost or damaged than we could replace in time.
There are three key aspects of bone that make it healthy and resistant to fractures: its density, its quality and how the remodeling is done, called bone turnover.
The density of bone is a measure of how much bone you have, but bone density says nothing about the composition or quality of that bone. This is one reason why bone density is such a poor predictor of bone fracture except at the extremes.
The quality of your bone gives it its strength and its resilience (its ability to bend a bit and not break, like a young tree). We know what goes into good quality bone — a core of protein made hard by numerous different minerals, far beyond calcium, arranged in a very structured and organized pattern – and without the right amounts and ratios of these minerals, the quality of bone is reduced.
Bone quality is also impacted by how much bone damage has accumulated. Bone is damaged in the same way that all other tissues are damaged. Oxidative stress, the damage caused by free radicals when there aren’t enough antioxidants around, weakens bone. High homocysteine, from a lack of B vitamins, is another way bone is damaged. Environmental lead tends to accumulate in bone, causing both oxidative damage and the potential to leave weakened bone when lead is removed too aggressively during detox programs without adequate nutritional support.
The third aspect that affects bone strength is called bone turnover. Many things can affect the delicate balance of that remodeling system mentioned earlier, causing more bone to be removed then is being replaced. (Think about the coordination and timing involved in a continual remodeling of your home, replacing support beams and loadbearing walls without letting the structure weaken — that’s bone turnover.)
Nutritional deficiencies of Vitamins D and B, insufficient antioxidants or protein, mineral malabsorption, and a lack of weight-bearing exercise all hamper the rebuilding process. Excess accumulated damage from drinking soda, excess sugar and caffeine or from cigarette smoking can all contribute to weakened bones. But for most women, it is the sudden loss of estrogen before and during menopause that causes abnormally high bone turnover, with more bone being broken down then is being rebuilt.
Aside from bone density, turnover is the only other area of bone health that we are currently able to measure, at least in a crude way. A simple urine test (NTx) can show if more bone is being broken down than is normal during menopause. If this is happening despite a comprehensive bone health program, treatment with very small amounts of bioidentical topical estrogen and progesterone can slow the bone turnover and allow your body time to catch up making new bone.
Besides avoiding the bad habits mentioned above, there are also a few common medications that cause premature bone loss: steroids like Prednisone and acid-blocking drugs for reflux called proton pump inhibitors are the two most common.
In addition there is plenty we can do to support our bones and to decrease our risk for fractures. We can eat a plant-based diet, especially a modified Mediterranean diet with an abundance of colorful produce at every meal. Plant foods help keep us more on the alkaline side. This is critical in bone health as bones act as the body’s reservoir of calcium and magnesium which are leeched out when the blood needs to be buffered from too much acidity. This is the primary reason why dairy is definitely not good for bones, all the marketing and lobbyists notwithstanding. Because of the acidity of dairy, the amount of calcium consumed is offset by this buffering effect, and you lose bone minerals, ending up with very little net gain from dairy. We are much better off with the smaller amounts of calcium in plant foods because we get to keep all of it – plus plants contain other essential nutrients and antioxidants.
A blood level of vitamin D (25 hydroxy D) is the only way to know if you have enough vitamin D to make bone. A level above 40 is a minimum requirement; optimal levels are between 50 and 90. Because of the pollution in our air and our internal contamination with persistent organic pollutants, making adequate vitamin D from sun exposure is no longer a given. Most of us need to take between 2,000 and 10,000 IUs of vitamin D3 daily. Other supplements that may be needed include magnesium and trace minerals, but calcium intake should be obtained from food, not from supplements, with rare exeption. Superfoods, fresh green drinks, concentrated powdered produce, spices such as turmeric and rosemary are all safe, effective sources of micronutrients and antioxidants which are great complements to a plant-based diet.
Eating and absorbing 15-25g of protein for breakfast is critical to maintain healthy muscle mass as well as bone mass. In fact, everything that helps maintain a healthy muscle mass (in the mid 30% range) as you age will also help you maintain healthy bone mass: regular muscle resistance exercise, adequate protein, micro-nutrition and balanced hormones.
Weight-bearing and muscle strengthening exercise are critical to maintaining healthy bone mass, in fact it can’t be done without them. But it is just as critical to maintain our sense of balance throughout our lives in order to avoid fractures. The vast majority of fractures in the elderly are the result of a fall. Muscles not only protect your bones if you do fall, but core muscles and good balance are how we catch ourselves early in the stumble and prevent both the fall and fracture.
Many people start to lose their sense of balance as early as their 30s. It just takes consistent practice to get it back and keep it. Stand on 1 foot whenever you are waiting in line, make a balance challenge out of putting on your shoes and socks every day. As you get good, make it harder, with your eyes closed or while doing arm exercises.
Because they affect both core strength and balance, yoga and Thai Chi or both excellent lifelong habits for lifelong bone health.
Lastly, let’s protect the next generation by continuing to work towards better nutrition and more physical activity for all our children; this is where bone health starts.
Tamara Sachs, M.D.