Thursday, April 5, 2018

DX Severe Osteoporosis: Part XIV - The Final Chapter, Time to Move On



This is Part XIV (the final part) in a multi-part essay chronicling my personal experience with osteoporosis. In this series I have been taking readers through the diagnostic and treatment phases of my care that began over 18 years ago when I was diagnosed with severe osteoporosis. Over the years, the combination of experiencing multiple fragility fractures along with an intense immersion into the study of bone pathophysiology has given me a unique understanding of this disease. If you are just joining the series, I encourage you to skim through the previous DX Severe Osteoporosis essays on my blog www.osteonaturals.com as they provide background to this final installment. It is my hope that this series has provided you with a better understanding of osteoporosis in general, plus a few "pearls" that you may be able to incorporate into your own quest for better bone health. If you have been reading the essays all along...welcome back and I apologize for the long delay in writing this final chapter. 



First: a short disclosure: 

The reason for my delay in writing this episode of DX Severe Osteoporosis was that it evoked a bit of emotion within me. It was definitely time to bring this series to a close as there are so many other important topics concerning bone loss to write about. But my journey, from the time I was first diagnosed, through the intense tracking down of the possible causes of my severe bone loss, to finally implementing treatment (and all those sleepless nights of the "fear of the unknown" in between) was difficult to rehash and share in a public way. I tried hard not to belabor things and I left out most of the emotional toll. Being side-lined by a chronic disease is difficult for anyone who has to go through it and it often becomes a huge part of her or his life. It did in mine. In retrospect, I am glad I embarked on this series but I am also happy to bring it to a close.

As I was writing this fourteenth and final part of DX Severe Osteoporosis, I realized that I left a lot of what happened out. For example, one patient ask me last week if I ever went chasing leads down dead-end rabbit holes? OH YES!...For the better part of a year I chased osteopontine, a glycoprotein that is capable of activating integrins for a cell's attachment to bone. Osteopontine can form intermittent laminated plaques in bone and give what could be the appearance of zebra striping (remember the Zebra Striping from Part IV?!)...just like what was seen in my bone biopsy. Osteopontine also can cross-link with transglutaminase (think gut damage from gluten sensitivity...yes, I had that too) creating havoc at the area of bone mineralization where osteoclasts and osteoblasts come to repair microfractures. Many trails such as this one ended in frustration and limited understanding due to a lack of available commercial lab and/or procedure testing. 

In addition, I also failed to describe all the supplements I used over the years, the results from using them, and a list of all the labs (over 250 of them!) I performed to track the results (well over $20,000—in addition to what my insurance paid) over a five year period. Explaining all of this would have taken another fourteen chapters and I just didn't think anyone would want to sit through all of that. 

The bottom line from my five-plus years of intensive research into osteoporosis was that compounds such as alpha lipoic acid, NAC, and berberine (to name a few) are the most effective for balancing bone remodeling and improving skeletal health. By working with these compounds (plus diet changes and improved GI health) to enhance bone health, I was able to raise bone density scores, substantially reduce bone resorption markers (NTX, CTX, and DPD), reduce fracturing, and return myself and others back to "normal" life activities. For me, this included being able to return to Ironman triathlon competitions. (I always referred to it as going from being a "Fragileman" to an "Ironman.") Best of all, as I worked with patients to improve their skeletal health I happily saw them reap the benefits also. By using a combination of diet, exercise, and specific supplements, I was able to turn around my patients' declining skeletal health and substantially reduce their fracture risk. Out of this consistent success came the founding of OsteoNaturals.

And finally, people often ask "Dr. McCormick, have you reversed your osteoporosis and what is your bone density?" Eighteen years ago I was diagnosed with severe osteoporosis (-4.3 of the spine). I fought tooth and nail to climb out of that deep dark hole and I certainly don't want to go back there. Back then I would break a rib just leaning up against a wall. Now I have returned to competing in road races and triathlons and the only walls that sometimes slow me down are the ones at the end of a marathon or an Ironman (when I sometimes "hit the wall"!). As to how my skeleton is doing?...Well, you will just have to keep reading this final chapter...

My personal education into the inner workings of osteoporosis and success in treatment gave me the valuable skills I needed to help others with their bone loss. OsteoNaturals, and the formulation of products designed specifically to target bone health, was the obvious next step. I wanted to make a huge dent in the sides of osteoporosis...yes, kick it in the !#*@ and help others regain structural strength and improve their quality of life. At times, my education was a bit painful...as many of you know who have sustained fractures...but I would do it again in a heartbeat for all the thanks I have received from patients taking OsteoNaturals products. Thank you for tuning in and trusting OsteoNaturals.     Dr.M


The Final Chapter, Time to Move On

I will never forget the day my friend Greg died. We had been through a lot together over the years. From the first day I met Greg when he reached out his huge warm hand to shake mine, we became best of friends. For the next eight years we trained hard together at the Modern Pentathlon Olympic Training Center. We encouraging each other, supported each other, and fought hard against each other in competitions as we often vied for one of the few slots on World Championship and Olympic Teams. Sometimes he won...sometimes I did...sometimes we made teams together...but no matter what, we always encouraged each other, cheered each other on, and always...reached out to each other with a supporting hand.

I had just left his bedside five days before; massaged his back and feet to help him still feel some of the pleasures of life. His translucent skin—his skeleton—were all that was left to sense it. I wanted so much to whisper into his ear, "just let go." Let go so he could be finished with all this suffering. But he didn't want to give up, it wasn't in his genes to stop short. It was the fight that was worth the living, no matter how much this cancer ravaged his body or how much pain came along with it. The words just wouldn't form in my mouth, only the thought. They were so close to coming out, but they stayed twisted around my tongue. Those words would have betrayed all that we had stood for throughout our lives; to take that away, in his last moments of breath, would have been like taking down the finish line in a marathon when he was only ten feet away.

Just six hours after Greg's heart finally let him rest, I lay on the exam table. He was gone and my day of reckoning was here. The room was familiar, even the technician remembered me from 1 1/2  years before—I was "that guy," the one that made her normally sensitive heart come out with such an insensitive statement:  "Wow, your bone density is worse than a 100 year-old-woman!" she had blurted out. Now she positioned me once again on the table. I was thinking of Greg. They had probably taken his body away by now. His hands would be cold and his home would forever be different; his kind and supportive wife would struggle to make sense of his way-too-early departure from this earth. Change is relentless; we can't get away from it. If we could, there would be no precious jewels to treasure.

A bone density machine sounds like a computer matrix printer as the scanner goes back and forth across the body, searching for the pixels that spell out your substance. I couldn't hope for too great of a change...after all, I had ONLY been working on improving my bone density a little more than a year. But I HAD crammed TONS of calcium down my throat during that time so there should be SOME change, I remember hoping. I thought, "I had to at least hold steady on my bone density, but maybe, just maybe, I had gained a tenth or two."..."Wouldn't that be nice!"..."Three-tenths of a point improvement would be great...four-tenths would be incredible!" I had so many grand visions in my head.

Gaining bone mineral density is a slow process, it usually takes years for improvement even when powerful drugs such as bisphosphonates are prescribed. At that point I hadn't taken any of those osteoporosis-specific drugs...as a chiropractor and as one who wanted desperately to "fix" this problem "naturally"...I didn't want to have anything to do with drugs.

The DXA scanner hummed back and forth. It reminded me of the old television set I used to watch back in 1980 after a long day of training. Every time I turned it on there was a long droning hum, like it was thinking of what to do next. I was living in California at the time, training for the U.S. Olympic
My 1976 Olympic Coke Commercial...(not really)
Trials. It had been almost four years since my first Olympic debut; four years to get stronger, four years for the hunger to burn deeper. It had been a beautiful spring day, much like all the days seem to be on the West Coast—but a dark cloud soon moved in overhead.

I had already put in hard run and swim workouts that day, and just finished a long fencing session. There was some talk among the athletes at the salle about the President of the United States giving some kind of statement on television about the upcoming Olympics in Moscow. He was going to be talking about Afghanistan and its invasion by the Soviets. One of the athletes whispered that something bad was coming down, but he didn't know what.

The black and white screen flickered up and down with snow from an antique antenna. I could barely
make out Carter's face standing at the podium with its presidential shield. But his words came out loud and clear: "We will not go...," "We will not go..." Our USA Olympic Team would not be allowed to go to Moscow to compete in the 1980 Olympic Games. It was his way of swatting flies on Brezhnev, his way of telling the Russians they shouldn't have invaded Afghanistan—that they needed to get out.

My brain flickered worse than the TV screen. I couldn't believe it—I just stared at the light that came from it, a screen that had already gone on to other things in life; an ad for a fancy car, another for cheap hamburgers at McDonald's. But there wasn't anything else for me. How could my Olympic dream just stop because the five minute press conference was over? Just because the TV station had to get back to its "regular viewing" didn't mean that I could just switch my life to another channel. It was as if the Olympics were there one second, in all their glory and as the symbol for world unification in Olympism...a global celebration of the human body and its amazing potential...and then, in the next second, they were gone, yanked away by the words of the President.

The political situation took the Olympics away...not just from me and the thousands of other hopeful, dream-filled athletes, but from the world and all those people who held the Olympic Games as a sacred celebration of spirit and hope for world peace. The modern Olympic Games were supposed to be sacred. A gathering every four years of ALL nations, where they would come together as one, in peace and understanding and respect for each other under the setting of fair athletic competition. It is where nations can put away their political differences and maybe, just maybe, come out at the end of those two weeks with more respect for each other than when they went in. The Olympic Games are NOT to be touched or used for political gain. (Yes, I am an idealist to the bitter end.) But now, there would be no Moscow Olympics—at least for U.S. athletes—no complete international celebration of sport and peace and human athleticism...not for another four years.

There was never another "four years" for me. My life moved on to other places, to other goals that needed saddling. Greg stayed, and made the 1984 Olympic Team and almost again, four years after that. And even though our lives went separate ways, we always stayed in touch and we were always there to lend each other a supporting hand. Now, standing in this small hospital room, 1973 and my
Greg
first foray into international sports competition seemed so long ago; so long since Greg and I had first met and embarked on the Olympic journey together. It was hard to believe that Greg wouldn't be around any more, and that our unshakeable friendship was gone. The fire from his heart, extinguished, even though I could still feel his incredibly strong and always supportive grip in my hand.

And now, I was looking at the piece of paper that the DXA technician handed me. The typed print was so small but the numbers seemed so huge—so heavy that they could have ripped the paper in half and crashed to the floor. She was looking at me, the technician, quiet this time...quiet like the walls of the room...and my breath. It seemed like the last grains of slickrock just let loose from the grip of my fingers. This time there was no one there, no one to reach out a hand; no one to break the fall. It seemed like such a long way down, no hand holds, just a piece of paper that read...-4.4...-4.5...-4.3.

It was worse. My bone density T scores were worse. They had dropped by a "statistically significant" amount...not enough bone to hold anything together. I felt like a total fool, a loser that had fallen prey to his own warnings about seeing, about categorizing, and about truth. I had felt so smug, sure that I had found the answers to osteoporosis. I remembered now the warnings from another close friend of mine. Paul had said that just when you think you have found truth, that's when you lose the ability to be aware and open to the truth. That's when your mind tricks you and you start following the wrong trail. I had wanted so desperately to find the answers to curing my osteoporosis, maybe I had just been grabbing onto any morsel that I could and turning them into something that wasn't real. "Always let the tracks come to you...don't expect to see the tracks.", Paul said. "If you are arrogant about your conclusions, they will become definite and you will close your mind to further awareness of the truth."

It was as if I were holding my breath so none of the words telling of these dismal numbers would settle within me. For weeks after this 3rd bone density test in 1 1/2 years, it seemed as though my lungs were empty and my skin rigid to block out the realness of uncertainty. I wanted control, not the eroding laps of this invisible phantom called osteoporosis.

That same burning rawness that had stripped through my lungs in hard runs came racing back from the past and latched deep in my gut and wouldn't let go. I was afraid that if I breathed, I would be choked by thoughts of failure, but if I didn't, I would never even see who won the race.

I had no choice but to step back out and run again. The thoughts of failure and my need to not give up pulled me into the forest of osteoporosis research for the first time since Greg had died. My legs felt heavy and it was hard to get going again. But even with the world looking so dark, I could still taste the scent of the white pines and spring's shad-bush blossoms in the air as I headed out for a run. The pines were so tall that I had to look up to see their tops, and the shad blossoms so white they were like tiny scent-clouds trapped against the earth. But in all of their beauty, I noticed that even they were not "perfect." There were crooks where there should be straightness, voids where there should be branches; the trees were all different—individuals—uniquely special and genetically encoded with particular capabilities, tendencies, and vulnerabilities.

I was seeing life in its purest form. Right in front of me was the answer to my confusion. Some of the tree's differences, like more branches toward the side of a clearing, or more blossoms on the ones that grew in direct sunlight, were clearly from their interactions with the environment around them. Their actual individual presence was revealing the interaction of their genetically encoded patterns with the conditions in which they were growing. I could see that their particularity was an integral part of the particularity of their surroundings. And their woody bodies carried a record of their experiences with light and wind and rain, with the pulsing of ground water, and with the alternating warmth and cold of the seasons.

The trees were not perfect; there were vulnerabilities encoded in their patterns of structure and functioning. They had limits in their ability to respond to the stresses of wind, disease, drought, and cold. But it wasn't just the interaction of their encoded physical genome and the environment that formed their presence. There was something more. There was a certain counteracting of these vulnerabilities and limitations that they all seemed to posses: a persistence, an ability to fight for life. I saw trees growing up through boulders, cracking them in half and forcing them apart. There were small oak saplings that spread out huge leaves for capturing what little light shown through to the forest floor. And there were massive roots extending across rocky slabs, grabbing for any foothold possible, clinging to life. These were all evidence to me of their drive to live; a force that speaks in the innate voice common to us all. It was this drive and their genetic script that was unfolding together—life and form revealing the individual to the world.

I was seeing that the mystery of the trees' individuality was the result of an entwined interaction between their internal genetic script being read, being enunciated or dampened, by the world all around them. People too are affected by their surroundings, and their genetics are a huge part of the whole equation. Yes, my bone density had dropped over the past 18 months—a failure of treatment in anybody's eyes—but what I had forgotten to take into account was that it takes time to figure things out, time to put out the destructive fires, and more time to then build back healthy, living, new bone. This, getting healthy again with new stronger bone, had been a physiological process that I had read in medical texts to be impossible...but I wouldn't believe.

Gorging my body with mega-nutrients and expecting an immediate change in my bone density was unrealistic. Nutrients are found only in small amounts in nature and our body's ability to absorb and utilize substances such as calcium and magnesium takes time. Taking the attitude of "packing them in" was the fire in me that wouldn't succeed without the balancing energy of water's wet blanket to slow the process of excess bone resorption down, and allow for the flowing spirals of osteons and the graceful fluid curves of trabeculae to form. It was now clear, I needed to balance my constitution of fire that the acupuncturist had spoken of. This would be the most important step in my recovery, not the voracious gluttony of calcium.

Of those one and a half years, the first six months were used to gain insight into the tracks of this illusive animal and how it walked through the forest. It took another six months to quite the fires and bring the lab tests and what they indicated back to normal. All the while my bone density had still been dropping. How could I expect that in just a small part of a year the effects of this decades-old pattern of bone destruction would be erased, and the bones pixeled improvement?

And what about the "crooks" and "voids" in my structure that told of my own uniqueness in this world...those differences in each of us that we can see in our reflections? My genetics—my genome—how did this biography of DNA patterning and sequencing of small nucleotides play into all of this?

Much of the DNA within humans is remarkably similar from one person to the next. We are really not that much different from one another. In fact, only a small percentage of the DNA patterns within individuals, is unique. Of course some genetic aberrations can create severe physical defects or even death to the human embryo. There are fundamental functions, such as cell division, that must remain genetically intact for the organism to survive. But other genetic changes, ones that do not threaten life-supporting functions, can be kept within the gene pool of species. Variations within the nucleotides of the DNA that can be tolerated and evolutionarily conserved because their importance is limited—that is, they are not life-threatening—are passed on from generation to generation. These differences are called polymorphisms and are what make us the individuals that we are. For example, having red or brown hair or blue or green eyes is the result of polymorphisms written into our genetics and are unaffected by our environment.

Other human genetic differences, like many that are linked to bone density, are expressed only in response to environmental factors. For example, our genetic inheritance includes a greater or lesser ability to meet the specific demands of the environment. As human beings, we have the ability to compensate, to an extraordinary degree, for limitations both in our genetic inheritance and for the stresses we experience in the course of living.

Polymorphisms can also cause changes within the structure and function of enzymes, structural proteins, and receptors in a cell's membrane. These changes can adversely affect metabolic pathways and reduce our functional efficiency or predispose us to disease. In my case, I had several interactions between polymorphisms and environmental influences that may have contributed to my bone loss. I was homozygous positive for a polymorphism of IL-1RA, the receptor antagonist of interleukin 1. Interleukin 1 (IL-1) is a pro-inflammatory cytokine that initiates an inflammatory cascade and is a powerful stimulator of osteoclastic bone resorption. IL-1RA acts as a guardian to help limit excessive inflammatory (and osteoclastic) activation.

By itself, a polymorphism of IL-1RA may not pose any immediate health risks. But if this polymorphism is sitting in an environment of substantial environmental stress, then it may be detrimental to the individual. Prolonged states of oxidative stress (read: excess physical activity such as over-training for the Olympics or Ironman triathlons) can alter the immune environment and lead to bone loss. Gastrointestinal problems are also a form of environmental stress that can compound the adverse effects of polymorphisms. For example, microbial overgrowth can produce a whole host of toxic byproducts that interfere with hormones, enzymatic function, tissue repair, detoxification, and methylation pathways (to name just a few). All of these situations increase pro-inflammatory cytokines and impair the immune system. This physiological cascade can compound the effects of polymorphisms such as that of IL-1RA and cause bone loss due to a rise in chronic systemic inflammation.

Normally there are other measures in the body to help decrease the effects of IL-1 should it get out of control. For example, essential fatty acids (EFA) help moderate the inflammatory response. DHEA and the stabilizing effects of estrone are vital to limiting the adverse effects of pro-inflammatory cytokines such as IL-1. And it looked like this link to IL-1 may have been a contributor to my bone loss as I was low in EFAs, DHEA, and estrone.

In addition to IL-1RA, I also tested homozygous positive for a vitamin D receptor polymorphism on the 12th chromosome. My vitamin D level had been normal but with a receptor polymorphism, vitamin D's effectiveness in its role in bone formation may be impaired. Vitamin D is not just involved in improving calcium absorption from the gut but it is also responsible for stimulating the production of specific glycoproteins involved in bone remodeling. Polymorphisms of the vitamin D receptor could detrimentally affect this part of the mineralization process. With my vitamin D levels normal, there was no way to know if there was a problem with the stimulation of its receptors. Supplementing with more vitamin D in this situation may not be as helpful as in someone without this polymorphism. Taking supplemental calcium, and insuring its absorption by optimizing other substances like essential fatty acids, may on the other hand, have a substantial therapeutic effect.

There are also known polymorphisms of the genes for collagen, calcitonin receptors, parathyroid hormone receptors, tumor necrosis factor, osteoporotegerin...and just about ALL the known major (and minor) players involved in osteoporosis. These, and others that are currently being identified, are all linked to low bone density. Put in combination with environmental influences, they can all increase a person's risk of fracture. Commercial testing for polymorphisms related to osteoporosis have recently come under scrutiny and availability of testing is limited. But in the not-so-distant future, this will change, and it will change the way we approach our health care.

Genetic testing in the future will no doubt change the way we approach the course of our life. I once read that "osteoporosis is a disease of the young that is manifested in the old." To start out early in life to try to prevent disorders such as osteoporosis, or perhaps even cancer, is obviously preferable to finding yourself in a hole and trying to claw your way out. Genetic testing that alerts us to our particular, individual vulnerabilities may soon make this possible.

Like the shad bushes and every other living being in the world, I was beginning see that my skeleton was greatly influenced by the genetics and epigenetics hidden deep within every cell of my body. In  my case, the answer was not necessarily to have run fewer miles in training, but with my genetic susceptibility including polymorphisms and Gilbert's syndrome, gluten sensitivity, deficiencies in nutrients, and reduced production of hormones, the answer would have been to take better care of myself—to put out the fires before they worked so deep down into the sub-soil of my being. The answer would have been to have not allowed my bones to suffer at the hands of my passion for intense long-distance running and incessant over-training. The answer would have been to achieve better nutrition and take more time for rest and recovery.

After a certain age, perhaps the best we can do for the severe osteoporotic patient is to support his or her whole system, put out as many fires as we can through diet, supplements, exercise, and health care modalities that strengthen the body's natural ability to heal, and, at the same time, be open to the benefits of medications (at least in the short run as I had to do) which can help protect against the immediate threat of high fracture risk. (I used Forteo for 18 months and backed it up with 6 months of a bisphosphonate to stop the run-a-way landslide of fracturing that was pummeling my body.) In cases of severe osteoporosis, our best for optimal health is a combination of natural healing and medical ingenuity—staying open to both ways of healing, not being closed to the benefits of either.


In Reflection:

Over the years I have learned to manage my osteoporosis well. After that first one and a half years of frustration, I finally found many of the keys for improving bone health and my density scores steadily improved and my fracture incidence went down to zero. That's a HUGE improvement from breaking 12 bones in the 5 year period immediately following my diagnosis. The fact that I don't break any more, is SO COOL...and I thank my lucky stars EVERYDAY. My last bone density was a -3.3 which is more than one whole standard deviation better than it was 18 years ago. And my NTX bone resorption marker score now hovers around 40, not 124 which it was when I first started monitoring it 18 years ago. This indicates that I not only have better bone density but also better bone quality, and this is actually more important when speaking of fracture risk. If that isn't success, I don't know what is. I have thankfully been able to "move on" from my own quest for skeletal health and now totally concentrate on that of others. My self-mission completed, it is extremely rewarding to help others and empower them in their own quest for regaining skeletal health and reducing fracture risk.

Healing comes in many forms. For me, the most important healing did not come in the way of improved bone density and bone quality (although that helped!), but in the way of acceptance, and of seeing how a flame can come close to being extinguished and still come back as fire. We ALL have that capacity even in the most difficult of times, even when severe injury, disease, or aging has opened up deep seams into our vulnerabilities. It is during these times that it becomes most difficult to continue listening to our inner burning form—to the way of being that makes us who we are. But take even the smallest of smoldering hot coals and cup it carefully within a nest of fine fibers of downy milkweed, thistle tops, and dried fine grasses. Hold it carefully, feel the hopefulness of its warmth within your hands. Then, gently, but relentlessly, blow it into a strong and healthy flame. Your breath and your will to commit to nurturing it into fire are all that you need.

When disease or dysfunction comes into our lives, we never expect it—it takes us by surprise, and often leaves us changed forever. But no matter how compromised we may become, continue listening to your passions, breathing in your basic form. What matters is your being—holding on to, and taking care of that flame.

Thank you.


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