When I decided to write an article about bone health, I had no idea what I was going to learn. I thought it would be straight forward and easy. That was not the case! I hope that what I uncovered will be helpful to those who are interested in natural ways to stay strong, active and healthy well into our later years.
First of all, I find it very interesting that many countries do not even identify osteoporosis as a disease to be concerned about.(6) When my mom fell a couple of years ago and had a small fracture in her pelvis, I thought a lot about bone health as she was 84 when this happened and I was 52. I noted that she has been given the diagnosis of osteopenia and even though I am a nurse, I did not know a lot about what that meant. I wondered if we should be looking into specific treatments or if we should try to figure out another way to get her to take the calcium supplements she was refusing. I also wondered about my own bones. I had taken a hard fall a few years ago and got bruised up but nothing broken. Were we doing what we needed to do to keep as healthy as we could? As an RN, herbal practitioner and holistic nutritionist, I have seen many with the diagnosis of osteoporosis. I know the dangers of taking bisphosphonates, which are drugs used to treat osteoporosis. Many people around the world, especially women, take these drugs on the advice of their doctors to keep from getting fractures they have been told they are at risk for and to keep from losing independence or even worse, death, from fracture complications.
I agree that healthy bones are important, but found that the real facts are not easy to find. Because bone health is a big business for some, there are all sorts of opinions, often inconsistent. Many factors affect fracture rates for people of all ages, especially the elderly and there is contradictory information about diagnoses, risk factors and treatments versus natural options and nutritional interventions. In Part 1 of this 4-part series, we will look at what bones are, what the diagnoses of osteoporosis and osteopenia mean, what is meant by risk factors for bone problems or fractures and risks caused by poor diet. Part 2 will look at testing and medical or pharmaceutical treatments and Parts 3 & 4 will deal with natural therapies. Through this whole process, I looked at the data and facts from solid sources, then to the viewpoint, opinion, or attitude of the writers presenting the information. I also looked to nature as God's creation. I have found that He provides and teaches us much about health and well-being through nature. I kept all this in mind as I looked for true understanding about bone health. My intent is to report the real story but please know that I may have missed some things. The resources I used are listed so you can see where I got my information. Since this is a multi-billion dollar industry, I prayed for wisdom and discernment and hope that I can help us all to answer some very important questions.
WHAT ABOUT BONES?
According to the NIH (National Institutes of Health, an agency of the U.S. Department Of Health & Human Services) website on osteoporosis, bone is a living and growing tissue, always changing and remodeling. Bones are made to be strong and flexible with a combination of calcium and collagen. Calcium phosphate is a mineral salt which provides strength and hardens our frame and collagen is the soft part of the framework.(11) There are two types of bone. Cortical bone is the outer hard shell of all bones and long bone shafts that comprises about 80% or our skeleton, while trabecular bone is like a rigid sponge and is found inside the bones housing marrow and blood vessels. Through a complex process, bone is removed by cells called osteoclasts and replaced by cells called osteoblasts and in healthy bodies, our bones are replaced every 10 or so years. They contain many different substances including water, collagen, protein and minerals. Collagen is in the connective tissue of cartilage and bone, making up around 30% of the structure. This provides the support for mineral deposits and offers resilience.(84) Calcium, phosphorus, magnesium, boron, chromium, copper, iron, sodium, citrate, potassium, zinc, fluoride, manganese, silica, strontium, and sulfur are minerals found in bones.(4) Calcium is the primary bone mineral and there is an exchange of calcium from blood to bones as needed. Calcium plays a large role in other vital mechanisms of our body including muscle contraction, nerve transmission, heart beat and fluid balance.(2) Around 1% of the calcium in the body is in the blood, whereas 99% of our calcium and about 85% of our phosphorus is in our bones.(3,11)
Something called peak bone mass is reached by our early twenties to early thirties and we form around 80% of our total bone mass before we are 18 years old with the most growth during puberty.(1) Peak bone mass means the highest our bone mass will be in our lifetime and is determined 60-80% by genetics, with the other 20-40% by lifestyle factors.(5) It seems that what we eat and what we do for activity when we are young is very important to healthy bones throughout our lives and to the lives of our children. Even our grandchildren benefit from our good health as you can see by the high genetic influence. Results of a large multi-ethnic study shows that the greatest reduction in mineral density starts in perimenopause, 1 to 2 years before menopause begins and then during the first two years after the final menstrual period. Lower rates of loss in the next 7 years then follow. Body weight also affects bone loss with the highest loss seen in women of lower weight.(9) Men's bones slowly lose density as they age and they also have risk for fracture but is noted to be lower. They have slow bone loss that starts soon after reaching peak BMD (bone mineral density) then appears to accelerate exponentially after the age of 70. Estrogen is seen to play a large role for women as the decrease during menopause leads to activation of osteoclasts and increased bone resorption or bone removal, which leads to bone loss. Peak BMD in men is higher and bones are larger so age-related bone loss is less damaging to bone strength in comparison with women. Bone loss in men is also related to their estrogen levels as they have estrogen in their bodies as well, in lower amounts.(10) Not everything is understood, but because women have a smaller skeletal size and are under the effects of higher bone loss related to significantly decreased estrogen, they are thought to be at a higher risk of fracture. Men are noted to have a higher death rate following a fracture and this is most likely due to the fact that since fractures are less common in men, if they sustain a fracture, it is a reflection of other health problems.(5)
Before we look at the definition of osteoporosis, I want to point something out. There is an ongoing balance between the osteoblasts and the osteoclasts responsible for the constant, intricate reshaping of our bones.(2) As we age, the cells that build up (osteoblasts) are found to slow down and the bones lose some density. Gradual loss occurs naturally in all males and females over their lifetime and this loss varies at different bone sites. Some bones gain density while others lose very little, so age-related density loss does not necessarily lead to fractures due to fragility.(4) Later in life we lose muscle mass, hormones decrease, many parts of our bodies change and slow or decline as well, so it would make sense that we might lose density without causing disease. These are all NORMAL processes. The fractures are what to avoid and these can happen whatever one’s bone density, as you will shortly see.
DEFINITIONS
BMD, also called bone density is the abbreviation for bone mineral density and mainstream medical experts consider this a reliable way to measure the amount of minerals within a certain volume of bone, usually the hip, spine or wrist. Bone mass is often used interchangeably with the other two terms, but actually means the totality of bone tissue, while density refers to the mineral content.(1)
Osteoporosis used to be defined primarily as a disease and now is called a condition by some sources, including the International Osteoporosis Foundation (IOF).(6,126) Unlike most medical definitions, the definition of osteoporosis varies with each source and has varied since the 1990’s when bone density testing was developed. According to one document, the IOF states it is a “disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk,” but another site headed by them states it is a disease and a “treatable condition.”(10,126) The National Institutes of Health (NIH) definition states “Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fractures of the hip, spine, and wrist.”(11) The World Health Organization (WHO) has defined osteoporosis on the basis of the bone mineral density (BMD) assessment and does not mention disease or condition. According to their criteria, “Osteoporosis has been operationally defined on the basis of bone mineral density (BMD) assessment. According to the WHO criteria, osteoporosis is defined as a BMD that lies 2.5 standard deviations or more below the average value for young healthy women. This criterion has been widely accepted and, in many Member States, provides both a diagnostic and intervention threshold. The most widely validated technique to measure BMD is dual energy X-ray absorptiometry (DXA), and diagnostic criteria based on the T-score for BMD are a recommended entry criterion for the development of pharmaceutical interventions in osteoporosis.”(12) If the BMD identifies risk, decides diagnosis of a “disease” state and shows what parameters determine when to start medication, then the drug companies and DXA scan companies really win with this definition. According to the NIH, men and women are affected by osteoporosis, a disease that can be prevented and treated. According to the NIH Osteoporosis and Related Bone Disease National Resource Center, in the United States, more than 53 million people either already have osteoporosis or are at high risk due to low bone mass.(11) This sounds ominous, but may be misleading. I will explain as we go along.
Now let’s look at osteopenia. This one is even more concerning to learn the truth about. In Dr. Lani Simpson’s book, Dr. Lani's No-Nonsense Bone Health Guide, she informs us that osteopenia is not strictly a medical condition. She states that with the new testing in the 1990s, the marketing of osteoporosis drugs and public awareness happened simultaneously with younger women being diagnosed with “osteopenia,” a condition that is most accurately recognized as “low bone density.” In 2009, on NPR, Anna Tosteson, a Dartmouth professor and osteoporosis authority, stated that experts at the WHO meeting in 1992 termed “osteopenia” to give public health researchers a clear category for their studies. She said no one imagined that “people would come to think of osteopenia as a disease in itself to be treated.” Long time osteoporosis researcher and author of The Complete Book Of Bone Health, Dr. Diane Schneider says, “Osteopenia is not a disease.”(1, 5) She also states, “Strike this word from your vocabularies” and “thin bones do not necessarily mean weak bones.”(5) Another bone disorder called osteomalacia should not be confused with either osteoporosis or osteopenia. This is caused by severe vitamin D deficiency and results in soft bones often causing widespread musculoskeletal pain, localized tenderness and fatigue. Risk of fracture is high with this and is often accompanied by other abnormal metabolic issues.(5)
In Gillian Sanson’s book, The Myth Of Osteoporosis, she writes, “Fifty years ago osteoporosis was rare. Doctors considered it an uncommon bone disease, not a women’s disease." She states that it used to be a disease where “bones fracture as a result of little impact because they have become thin, brittle and have lost tensile strength.” Today, as Sanson states, it is defined as a “condition characterized by low bone density or reduced bone quantity.” She says the disease is uncommon and even rare in those under 80 years old and over 80 there are other factors involved. It has been noted in our history, but has affected only a small portion of the population.(6) What has changed? Could it be that there are new drugs and machines to sell? Solid sources say that everyone will lose bone density as they age, but very few will fracture because of it. Starting in our thirties, bone resorption exceeds formation. This is a normal process. The actual disease state where porous bones fracture without trauma is rare and many other factors are usually involved.
But, we are told now that one in two Western women will fracture and one in three men will fracture in their lifetime(6,7) Of these, many will die within the first year after or require long term care. Dr. Lani Simpson states that it is important to know that the ones who pass away are usually frail and have other medical issues as well.(1)
RISK FACTORS FOR BONE PROBLEMS
The International Osteoporosis Foundation (IOP) states that lifestyle factors shown to increase the risk of low BMD and fractures can include alcohol abuse, smoking, low calcium intake and lack of physical activity. These factors are related because smokers tend to drink more alcohol, often have a poorer diet, are thinner and have less physical activity. Components of tobacco smoke influence enzymes involved in the metabolism of steroid hormones. Some diseases also increase the risk of osteoporosis, including hyperthyroidism, Cushing’s disease, hemochromatosis, primary biliary cirrhosis, multiple myeloma, chronic obstructive pulmonary disease (COPD), beta-thalassemia, hypogonadism and diseases of the digestive tract impairing intestinal absorption such as Crohn’s disease, chronic pancreatitis and celiac disease. Drugs that increase the risk of osteoporosis include glucocorticoids (especially from long-term oral use), thyroid hormone excess or suppressive treatment after thyroid cancer, anti-androgen treatment (surgical castration, gonadotrophin releasing hormone agonists), aromatase inhibitors, thiazolidinediones, proton pump inhibitors, loop diuretics, selective serotonin reuptake inhibitors (SSRI) and some drugs used in the treatment of AIDS (mainly tenofovir, protease inhibitors).(10) Antacids and Coumadin also can increase risk.(4) Ironically, many are put on antacids by their medical professional as a calcium supplement to prevent osteoporosis. Other risk factors cited are decreased weight and height since 25, maternal history of hip fracture, self-rating of own health as fair or poor, less than four hours on feet during the day, tall at age 25, consumption of processed dairy, previous hyperthyroidism, cystic fibrosis, decreased thigh muscle strength, folic acid (B9) deficiency, vitamin B12 and Vitamin K deficiency, poor nutrition, caffeine excess, presence of environmental hazards, fall risk, slow gait speed and hormonal issues. Hormonal issues can include estrogen, progesterone or testosterone deficiency, hypopituitarism, cortisone excess, hyperparathyroidism, Provera use, prolactinoma, and Vitamin D deficiency.(4)
RISK FOR FRACTURES
Estimated risk of a fracture related to osteoporosis after 50 years old for a woman will depend upon the information source, the country she lives in, the disease definition and the interpretation of the fracture data. This is also true for men. For women, it will range from 10 to 56 percent.(6) According to NIH, lifetime hip fracture risk at 50 years of age in the US is 15.8% for women and 6.0% for men. These numbers vary with different sources. Ethnicity and race influence epidemiology of fractures with the highest fracture rates in white women. Rates of fracture are very low in Africa, South America and most of Asia. In Cambodia, osteoporosis is unheard of.(6) Vertebral fractures can result in loss of some height but most do not have any major symptoms and may go unnoticed. They are factored into the fracture risk data but are not nearly as serious as a hip fractures, which are not as common until after 80 years old and invariably linked to factors other than osteoporosis.(6) In The Myth of Osteoporosis, Sanson states that there is no standard on criteria to measure fracture and risk statistics so they vary greatly. The Mayo clinic says 21% of postmenopausal women have osteoporosis and 16% fracture. The US National Osteoporosis Foundation says 1 in 2 women and 1 in 8 men over 50 will have an osteoporosis related fracture in their life. The International Osteoporosis Foundation says that a woman has 30-40% risk and men have a 13% risk of fracture in their lifetime related to osteoporosis. An international osteoporosis authority, Dr. Susan Ott, Associate Professor of Medicine, from the University of Washington, says that “counting the actual number of fractures related to osteoporosis is more difficult than it appears and requires strict criteria. It would be quite easy to make the figures high if you wanted.” She goes on to state that a huge number fracture due to accidents and who knows how many of those should be counted in the statistics. Another osteoporosis expert, Dr. R. P. Heaney, stated that any bone will break if pressure is applied in a particular way. He says that even young bones will fracture if struck just right and many elderly fractures are this sort.(6) The American Society for Bone and Mineral Research shows a woman with kyphosis, also known as humpback, and says, “The increasing numbers of fractures are caused by the fragile bones of osteoporosis.”(15) Vertebral fracture is the most common osteoporotic fracture. They may occur in the absence of trauma or after only minimal trauma, such as bending, lifting or turning. Some experts say that vertebral fractures have a major personal and societal impact in terms of disability and financial costs and go on to state that the clinical symptoms of vertebral fractures are back pain, limitation of spine mobility, loss of height and disability.(10) While this may be true for some, but is not the case for all vertebral fractures. According to Dr. Bruce Ettinger, Senior Investigator, Div. Of Research, Kaiser Permanente Medical Care Program, only 5-7% of 70 year old patients will show vertebral collapse, with only half of those having two involved vertebrae and possibly one-fifth or one-sixth will have any symptoms. He saw very few bent over people in his large practice.(6) The International Osteoporosis Foundation (IOF) says about two thirds of vertebral fractures do not give clinical symptoms.(10) Hip and wrist fractures are also listed in statistics as caused by osteoporosis when we are all aware that these are dependent on the age, general health condition and type of fall and not necessarily because the person has fragile bones originally. According to Gillian Sanson, after analyzing much data, a 50 yr old woman has a 15% chance of a hip fracture by 80 and only a fraction of those will have life-threatening complications. She reminds us that one can have low bone density and never fracture or can have normal or better density and still fracture. The osteoporosis that causes pain, disability and death is very rare.(6) In The Study of Osteoporotic Fractures, older women who had hip bone densities higher than the osteoporosis cut-off, accounted for more than half of the hip fractures. Many factors play a role beyond what is measurable in bone density, including bone strength.(5) There are many countries that have not identified this as a disease. The above risk factors, plus overall health, fall risk, muscle and bone strength and likely various other factors play a significant role in fracture risk.(1,5)
DIET RISK FACTORS-SUGAR
It is well known that consumption of sugar depletes overall nutrient intake. A person who consumes 20 percent of his total daily calories in sugar will have an equivalent reduction of vitamins and minerals of about 20 percent. The vitamins and minerals that are depleted include calcium, phosphorus, vitamin D, magnesium and zinc. Nutrient deficiencies can then occur with ill health following. If magnesium is depleted, the body is unable to adequately store calcium and unable to stimulate calcitonin which is a hormone that takes calcium from blood and tissues and puts it back into bones. Our body is then unable to suppress the action of bone break-down by parathyroid hormone and is unable to convert vitamin D to the active form allowing calcium absorption. We are unable to regulate calcium transport and unable to active an enzyme that helps form new bone. Sugar causes an increase in cortisol levels which in excess can cause osteoporosis. Cortisone drugs are known to cause bone loss, so anything that causes an increase in cortisol in the body, will cause bone loss and thinning of bones. Sugar causes a rapid increase in glucose levels and alters the pH making the body more acidic. In an attempt to buffer this, calcium is leached from the bones. Studies also show that eating sugar causes a significant increase in urinary excretion of calcium.(62) There is also an increase of glucose levels in our cells. This happens faster than the oxygen levels in the cells can be increased, leading to incomplete oxidation. Acids are formed which subsequently acidifies the body. Now calcium is leached from the bones to combat this.(63) It has been noted that countries having the highest calcium and sugar consumption also have the highest osteoporosis rate. Clearly, calcium alone is not going to be the solution to bone health and sugar may aggravate the problem immensely.(63) Sugar also competes with Vitamin C because insulin carries both sugar and Vitamin C into our cells. As our cells are busy taking sugar in, Vitamin C will be lost, affecting not only the bones, but the immune system.(125) Certain soft drinks, especially dark ones, contain high amounts of phosphates as well as sugar. Phosphates also cause the body to excrete calcium as they are eliminated, even if that means calcium must be removed from bones.(46)
OTHER DIET RISK FACTORS
White flour, caffeine, excessive amounts of meat, refined salt and alcohol can cause depletion of calcium from our bones and/or can slow the manufacture of calcium. Studies have shown that caffeine and alcohol intake correlate to an increase in fractures in women. Smoking and tobacco use have been shown to decrease bone mass. Also we are encouraged to use temperance with animal products like meat and eggs because they contain methionine, which transforms to homocysteine. This has been shown to increase osteoporosis risk.(7) According to Dr. Schneider, in her book, moderate amounts of caffeine, if not related to a decrease in calcium intake has conflicting data. In one study coffee was only related to bone density when the coffee was not supplemented daily with milk. She feels the solution is to make sure calcium intake is adequate along with low to moderate intake of caffeine.(5) Additionally, Dr. Simpson reminds us that inflammation can cause all sorts of issues, but also be aware of the fact that inflammation in small doses is helpful and designed to assist us to fight pathogens and to heal injuries. Too much can play a role in certain diseases, food allergies and sensitivities. Foods that can cause too much inflammation include low-nutrient, high-sugar, processed foods, alcohol and some genetically modified foods. She recommends a low-inflammation diet for all who might have osteoporosis or feel they are at risk for low bone density+.(1)
Please understand there are definitely some people at risk. There are some who have a dangerously low bone density because of genetics or lifestyle. Our nutrition and activity while we are young seems to be very important to our health and the health of the next generations. Education seems to be key here. Our young people need to be informed about how to grow and maintain good bones in their generation and those to come, as they might not be aware that what they do in their early years will affect their children and grandchildren. I was surprised how misleading and contradictory much of the information was but also pleased to see there are some doing their homework and sharing their understanding and wisdom in a clear, concise manner. I am writing this to not scare or discourage, but to empower and inform through a wide range of sources.
How much better to get wisdom than gold! To get understanding is to be chosen rather than silver. Proverbs 16:16
In OSTEOPOROSIS: Testing The Facts Part 2, we will be looking at testing for osteoporosis and the pharmaceutical treatments available based on the testing.
REFERENCES (available at the end of Part 4)
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