Wednesday, October 31, 2012

Winning Life Through Pain -- BlogTalk Radio Show

I was a guest (talking about osteoporosis of course) on the BlogTalk radio show Winning Life Through Pain co-hosted by Marla Martindale and Chris Tatevosian. Marla lives in Texas and is an RSD Coach helping individuals cope with the challenges of reflex sympathetic dystrophy. Chris wrote Life Interupted, It's Not All About Me a book to help others work through the challenges of living with chronic illness or disability. Chris was diagnosed with multiple sclerosis in 1980 and lives in Massachusetts.

Thursday, October 25, 2012

Supplemental Boron for Osteoporosis

Boron is an essential trace mineral that encourages cell growth, improves glucose utilization, and stimulates bone formation. The bone building attributes of boron stem from its ability to enhance the actions of vitamin D and estrogen. Boron helps strengthen collagen, increase calcium, phosphorus and magnesium concentrations in bone, and stimulates osteogenic cell activity in the bone marrow. The end effect is a dramatic improvement in bone stiffness and strength.

Unfortunately, most people don't get enough boron in their diets. This makes supplementing with boron necessary if you are to achieve optimal bone health and especially if your bone density is low. A typical daily diet provides only about 1 mg of boron. This is not enough for optimal bone health. You need at least 3 to 5 mg/day but intakes of 10 mg and more don't seem to provide any additional benefit. The body has tight homeostatic control over the blood plasma levels of this element and when blood reaches a certain level of saturation (typically achieved with intakes of less than 10 mg/day), the body simply excretes the rest through the urine. Prolonged excessive intake of boron can be toxic.

Many nutritional supplements for bone health (including our own OsteoSustain) contain 3 mg of boron. I recommend combining OsteoSustain with bone-healthy foods (such as dried plums) that are naturally rich in boron. This will bring your daily intake to an optimal level of 6 to 8 mg/day. Any more than 10 mg/day of boron is not helpful and excessive intake is detrimental.

Wednesday, October 24, 2012

Lactation Associated with Greater Bone Strength Later in Life

In a retrospective study published in Osteoporosis International, researchers found that mothers who breastfed in total more than 33 months had greater bone strength than mothers who had breastfed less than 12 months. This improved strength was not attributed to a greater bone density later in life but to a larger bone size.

Bone remodeling activity increases during pregnancy and results in a lowering of the mothers bone density by approximately 5%. This loss of bone density is typically regained after weaning and does not affect bone density later in life. What is fascinating is that lactation actually causes bones to grow wider. Estrogen levels drop during lactation similar to those seen in women when they go through menopause. This drop in estrogen promotes outer cortical bone growth leading to an enlargement in bone diameter. Add diameter to bone and you get greater strength.

To illustrate this concept we can look at bicycle frames and to see why size is correlated with strength. In order to reduce frame weights, bicycle manufacturers have enlarged the tubes of bikes allowing them to make the tubes thinner and lighter. The larger the tube the better the tube is at resisting bending and breaking. The same is true when bone enlarges, it becomes stronger. This is exactly what happens during lactation and breastfeeding.

The authors of this Finish study concluded that lactation-associated estrogen deficiency causes bone enlargement and that the duration of breastfeeding impacts both size and strength of a mother's bones later in life.

Wiklund, et al. 2012. Lactation is associated with greater maternal bone size and bone strength later in life. Osteoporosis International 23:1939-1945.

Saturday, October 20, 2012

Strontium for Osteoporosis?

Is it advisable to take high doses of strontium?...This is a complex question.
There has been quite a lot of research showing that strontium increases bone density and reduces fractures both in the spine (up to 40%) and the hip while continuing to preserve bone quality. At least this is what we are seeing with the osteoporosis medication, strontium ranelate (Protelos or Protos). Protelos is available in over 70 countries around the world, but the FDA has not approved it for sale in the United States. Nonetheless, interest in strontium (other than in prescription ranelate) remains high. I've had many patients ask me what I think about taking supplemental strontium salts (which contain significantly higher amounts of strontium than are found in our supplements (OsteoMineralBoost and OsteoMineralWhey). Below are my thoughts on this topic.

Strontium is quite an interesting metalic element. It is a trace mineral found naturally in foods such as shellfish, whole grains, lettuce, spinach, kale, root vegetables, Brazil nuts, and dairy. Other than radioactive strontium and strontium chromate, strontium is not toxic and there are no major adverse effects linked to taking any of the readily available supplemental forms of strontium salts such as citrate, gluconate, lactate, or carbonate.

Strontium is silver-white in color and very chemically reactive. When exposed to air it turns yellow and if you grind it up into a powder it will ignite spontaneously, bursting into bright red flames--thus its use in fireworks. Because strontium is so reactive in air and water, it is only found in nature bound to other elements.

Strontium's biological role in the body remains somewhat of a mystery. Chemically similar to calcium, strontium is able to replace calcium in certain biological settings. For example, in neural synaptic clefts strontium can be involved in conduction pathways just as calcium is. And, in the mineralization phase of bone remodeling, strontium can replace calcium in the formation of new hydroxyapatite crystals. Where else in the body, and to what extent, strontium replaces calcium atoms is not known.

Strontium Ranelate:
Strontium effects bones in two ways: it stimulates osteoblasts to form bone and it inhibits osteoclasts from resorbing bone. The result is an increase both in density and in actual bone tissue (i.e. not just harder bone but more of it). This unique dual action has driven great interest in the use of strontium for the treatment of osteoporosis. But there are two major problems, at least with strontium ranelate. The first is that 50% of the improvement seen in DXA T-scores after using strontium ranelate is not "real." Because the strontium atom is almost twice as heavy (38 on the atomic chart) as calcium (20
on the atomic chart), when strontium is deposited into bone it just "looks" more dense than calcium on DXA exams. The second problem is that the FDA has not approved strontium ranelate. The adverse effects of this medication include VTEs (vein thromboembolisms) and the rare but serious and sometimes life-threatening drug reaction/rash with eosinophilia systemic syndrome (DRESS).

Strontium Salts:
It is important to understand that the adverse effects noted above are NOT connected with strontium salts. In addition, any ability of strontium ranelate to reduce fractures cannot simply be transferred to strontium salts. We just do not know for sure if strontium salts help to reduce fractures; there has been very little research using these forms of strontium. They may improve bone density, but like strontium ranelate, 50% of this may be "artifact" and the other 50% may or may not actually help reduce fractures.

Another difficulty I have with high dose strontium salts is that I can't wrap my brain around flooding the body with a trace mineral especially when we don't actually know what this mineral does. There are only about 0.3 grams of strontium in the body whereas there are over 1,000 grams of calcium. (The highest concentration of both of these minerals occurs in bone and the teeth.) With strontium being able to step into the biological shoes of calcium and with its action appearing to be anabolic in bone (similar to Forteo), we need to approach its use with some reserve.

The Case for Bisphosphonates:
In general, when patients are at high risk for fracture they should consider using a bisphosphonate medication or teriperitide (Forteo), not high doses of strontium salts. Not only are the resulting increases in bone density true reflections of change, there have been bucket loads of research to confirm that they reduce fractures. (Note: My position on bisphosphonates is that they should only be prescribed in the short term and only when necessary to reduce immediate fracture risk.) Using short courses of these medications can be absolutely vital to patients who are fracturing and, if tolerated, they should certainly be chosen over strontium salts. Even doctors in Europe and Canada typically only prescribe strontium ranelate as a second choice to bisphosphonates which are intolerable to some patients.

The Research Continues:
Research continues to mount for the benefits of strontium for reducing fracture risk. Unfortunately, research on strontium salts will always lag behind that of strontium ranelate due to the inability to patent salts. I found the following three abstracts from the recent American Society of Bone and Mineral Research 2012 Annual Meeting quite interesting:
  • In the first abstract, researchers from China studied a special group of goats found in a village in the Yunnan Province. These goats have bright red bones and teeth and are therefore named "red-boned goats." The researchers found these goats to have 3 times the normal content of strontium in their bones and significantly lower amounts of calcium. They also found twice the level of two enzymes related to osteoblastic bone formation. Analysis of the soil where the goats grazed showed 2-4 fold higher levels of strontium and calcium concentration. The researchers concluded "Environmental strontium consumption could alter bone metabolism significantly. Higher Sr+ [strontium] consumption had an anabolic action on bone."1
  • In the second abstract, researchers from Italy analyzed the reaction of osteoblasts and calcified nodules (from the fat-derived stem cells of a 45 year old female). They found that at low doses the strontium increased mineralization and at higher doses it increased osteoblast activity. They concluded that strontium "could play a role in the therapy of bone disorders also promoting osteogenic cells proliferation and differentiation."2
  • In the third abstract, researchers from China and the University of California, Davis, again studied the red-boned goats. What they found was that strontium reduced bone resorption by reducing RANKL, a molecule that signals osteoclastic activity.3

It is clear that strontium has an anabolic effect on bone. This can be beneficial, but to what extent does this become a risk? When something interferes with bone's normal uptake of calcium and has an anabolic effect similar to Forteo,  I get concerned. For now, I will continue to recommend strontium as trace minerals to everyone. Strontium is absolutely necessary for normal bone formation and for health in general and our OsteoMineralBoost and OsteoMineralWhey are both excellent sources of trace strontium.  I recommend them highly. As for higher doses of strontium salts, I consider their use on an individual basis.

1. SA0285. Xu Z., et al. Higher strontium consumption is anabolic in goats.

2. MO0227. Ciuffi S., et al. Effect of strontium ion on in-vitro proliferation and osteogenic differentiation of PA20-h5, a clonal mesenchymal stem cell line derived from subcutaneous adipose tissue.

3. MO0243. Lin Q., et al. Comparative analysis of osetoclast differentiation from red-boned and common goats.

Monday, October 15, 2012

Radio: Your Golden Years with Dr. Mara Karpel

Good morning! I was talking with Dr. Mara Karpel on her radio (Talk 96.3 FM and 1370 AM) show last's the link. Dr. Mara is a clinical psychologist in Austin, Texas. Her show, Your Golden Years, is a bit like a rah rah motivational talk-show especially dedicated to energizing those of the geriatric community. Her goal is to encourage "the glass is half-full" mentality and also to provide her listeners with vital information that they can use to navigate the challenges of aging. It was a pleasure to talk with Dr. Mara about osteoporosis.

Saturday, October 13, 2012

Odanacatib Trial Update

Just a quick update on Odanacatib, the osteoporosis medication currently in phase III trials. Odanacatib works by blocking the bone-degrading enzyme cathepsin K. Merck has just announced that they are mid-stage in their 24-month trial which includes 243 women with osteoporosis. All of the participants in the study have previously been treated with alendronate. Results at this point show the following improvements in bone mineral density:  total hip increase of 0.83%, lumbar spine increase of 2.28%, no increase is noted thus far in the forearm.

Thursday, October 11, 2012

World Osteoporosis Day

Today is officially, World Osteoporosis Day for 2012. Each year the International Osteoporosis Foundation  dedicates this day to raising global awareness to the prevention, diagnosis and treatment of osteoporosis. Activities are planned in over 90 countries.

This year's World Osteoporosis Day theme for raising awareness of fracture prevention is "Stop at One. Make your first break your last." The theme includes 3 major messages: 1) Fragility fractures are no accident. The underlying cause of many fractures is osteoporosis, 2) Fractures are warning signs: one fracture leads to another, and 3) Over 50 and had a fracture? Get tested -- get treated.

Check them out on Facebook and see people from all over the world join in an "unbreakable embrace." OsteoNaturals solutes World Osteoporosis Day.

Tuesday, October 9, 2012

Osteoporosis: A Challenge Physically and Emotionally

"Today's unthinkables are tomorrow's realities." Those are the words of Scott Rigsby. Scott lost his legs at the age of 18 when an 18-wheeler slammed into his truck, launching him underneath the attached trailer and dragging him over 300 feet. While we all experience life challenges, some like this one can be so difficult that it is hard to comprehend. But Scott found a way to fully embrace the unthinkable, use his challenge to redefine himself, and reach unbelievable physical and mental accomplishments. He now runs marathons on carbon-fiber legs. He has even finished the Hawaii Ironman Triathlon, one of the most difficult races in the world.

On a figurative basis, an unexpected diagnosis of severe osteoporosis can feel like being hit by a truck. Multiple bone fractures and the constant fear of breaking are physically and emotionally overwhelming. I'm not saying that what I went through was anything even close to Scott Rigsby's ordeal, but like Scott I was determined NOT to be defined by this challenge. When I finally began to see improvement in my bone density scores and in my lab tests after 5 years of studying osteoporosis and finally figuring out how to overcome it, I was thrilled. the fact that I was no longer breaking bones was no less than amazing to me. But even seeing the numbers improve and the fractures disappear wasn't enough to bring back my self-confidence.

Like Scott, I needed to do something that really challenged me both physically and emotionally. I needed to find some activity that pushed me to my limits so that I could find myself. Completing an Ironman--swimming 2.4 miles, biking 112 miles, and running 26.2 miles--was just the ticket. Physically, I knew I had recovered, but emotionally I needed that Ironman finish to tell me I was "back" as the person I wanted to be, strong, capable, confident. When I crossed the finish line at the Florida Ironman, qualifying for the Ironman World Championships in Hawaii, my emotions flowed. Completing that race signified my success in overcoming osteoporosis. Crossing that white line wasn't really the finish of anything, it was the start.

We all need encouragement, inspiration, and support in fighting the battles of life. No matter what the challenge, the most important thing to remember is "never give in," "never quit."

If you have osteoporosis or are at risk for this disease, I know from first-hand experience that you CAN improve your bone health and you CAN reduce your risk for future fractures. Set goals for yourself. They don't have to be wild and crazy like an Ironman, but benchmarks are very effective at keeping you motivated. Also, look to others for support. It can be difficult to manage the emotional stresses brought by the constant fear of breaking and the pain of existing fractures. Don't go it alone. Talk to your friends; make sure your spouse or partner understands what you are going through. Look for support groups. The National Osteoporosis Foundation is a good resource. It also has its own online-support community called Inspire. And, of course, continue reading my blog. It is my hope that here at OsteoNaturals we provide not just great supplements but also important information about osteoporosis. The more you know about this disease process, the more powerful you become!


Friday, October 5, 2012

Bones, Energy Metabolism, and Vitamin K

Skeletal physiology and that of the rest of the body is intricately and inseparably intertwined. We have talked about the need to address the health of the whole body if we are going to achieve long term bone health improvement. In a 2011 perspective  in the Journal of Bone and Mineral Research, Clemens and Karsenty explain how the whole-body approach has brought new insights to the complexity of bone. Researchers have discovered that bone acts as an endocrine organ by releasing the hormone osteocalcin. Insulin, secreted by the pancreas, has long been viewed as the most important hormone for blood glucose regulation, but we now find that osteocalcin, made by the bone-forming osteoblast cells, is also a key player in energy metabolism.

Clemens and Karsenty explain that the skeleton's involvement in energy regulation may have evolved in the Devonian Period (400 million years ago) when the first amphibians crawled out of the calcium rich seas and on to terra firma. Compared to mineral rich ocean water, the terrestrial environment was scarce in calcium necessitating biological adaptation if these animals were to survive. Evolutionary change, through the development of parathyroid glands, helped control blood calcium levels. Today, all land loving animals, including humans, are able to survive and grow strong, mineral-dense bones because the parathyroid glands help control calcium levels through their hormonal influence on osteoclastic bone remodeling activity, as well as promoting calcium absorption from the gut and limiting calcium losses in the urine. In addition to the necessity to conserve calcium, Clemens and Karsenty explain that these "early land dwellers also needed a way to manage fuel production and expenditure more efficiently to survive in their less abundant terrestrial environment. For this job, skeletal muscle and fat evolved into robust factories for acquiring, burning, and storing fuel, as did elaborate endocrine networks that could inventory and report the fuel status accurately among these tissues. It seems logical, therefore, that the osteoblast [bone building cells], whose cellular ancestry is common to fat and muscle, also evolved mechanisms for partnering in the fuel production and maintenance business."

A series of mouse experiments have helped researchers understand bone's relationship to energy metabolism. We know that osteoblasts secrete osteocalcin which is important for bone formation and specifically for the formation of the hydroxyapatite crystal. Before osteocalcin is able to form bone crystals it must first be activated (a process called carboxylation) by vitamin K. This is why vitamin K is so important to bone health. Without vitamin K, osteocalcin would not be carboxylated, bone crystals would not form, and the collagen matrix produced by the osteoblasts would not be mineralized. Osteocalcin is therefore vital to bone health, but now we are seeing that this hormone has a second job outside of the bone.

When carboxylated (activated) osteocalcin is secreted by osteoblasts into a resorption pit that has been newly excavated by osteoclasts it forms bone crystals. But a percentage of this carboxylated osteocalcin becomes uncarboxylated (it returns to its inactive, but still obviously important, biological state). This deactivated osteocalcin then makes it's way into the blood stream and stimulates pancreatic insulin production.

Understanding the importance of osteocalcin for glucose regulation is important. It is also important to question extremely high doses of vitamin K therapy for osteoporosis. Could it be that taking 45 mg of vitamin K2 (which has been studied in Japan as being beneficial for patients with osteoporosis) is too much? Could this high amount of vitamin K sway the ratio of carboxylated to uncarboxylated osteocalcin too far in the direction of the carboxylated form and cause a disruption in insulin/glucose regulation? In our supplements at OsteoNaturals we have tried to strike a balance, providing effective, but not what could be excessive dosages of ingredients. Concern about excessive intake of vitamin K is a case in point. Our products, OsteoSustain and OsteoStim, have what we feel are effective, but not excessive, dosages of vitamin K. 

Bones are clearly not functionally nor metabolically separate from the rest of our body. Glucose regulation is just one more aspect of bone biology that we need to keep in mind when we are working with osteoporosis.

Thursday, October 4, 2012

Bones Provide More Than Structural Support

In my book, The Whole-Body Approach to Osteoporosis, I outline a sophisticated method for using signs, symptoms and laboratory biomarkers to help understand the causes of bone loss and to manage an individual's therapy. The biomarkers I advocate are a combination of bone-specific (such as N-telopeptide) and non-specific (hsCRP, homocysteine, etc.) tests. Why the non-specific tests? Higher bone density scores tell us only one thing: that an individual's bones are harder. They are not necessarily healthier. Improving bone density with medications such as bisphosphonates may temporarily reduce fracture risk (which may be of utmost importance in certain high risk individuals) but they are not doing anything to improve bone or overall health. It is my contention that what goes on biologically in the skeleton is not separate from the physiology of the rest of the body. Far from it! Factors such as body pH, level of inflammation, gut health, vitamin and mineral status, and hormone levels are all important. By simply taking a few steps back and observing the physiology of the whole body, we will reap greater returns in improved health.

Over the past several years scientists have thankfully begun to take a more comprehensive view of the skeleton's role in maintaining body function (even if doctors tend to lag behind this trend). Bones, they realize, are not static entities. They are vitally important to our overall health. No longer are bones seen simply as anchors for muscles, support for posture, and depots for mineral reserves. Researchers are now exploring bone biology through a whole-body approach and it is paying rich dividends. For example, we now know that our bones actually act as endocrine organs by releasing a hormone that helps insulin from the pancreas regulate energy and blood glucose levels.

A whole-body approach to the diagnosis and treatment of osteoporosis is the only way to improve bone health. As I say in my book, "Osteoporosis is not just the weakening of bones; it is a weakening of the body's entire physiology." "When you have a chronic disease, you have to treat your whole body."

Tuesday, October 2, 2012

Detecting Osteoporosis Through Plain X-Rays

Now if this will be GREAT! An article in the International Journal of Biomedical Engineering and Technology, describes the development of a computerized digitization technique whereby X-rays can be evaluated for osteoporosis. This new technique, by the Central Scientific Instruments Organization in India, requires only the addition of a reference index to an X-ray image and can be used in existing health care facilities without the addition of expensive equipment.

Currently, the only method for assessing bone mineral density is through dual X-ray absorptiometry (DXA). This procedure provides important information about bone density but insurance reimbursement requires special approval. If an individual has one or more risk factors for osteoporosis, a DXA scan will likely be paid for. But if he or she has not sustained a fragility fracture, or are not postmenopausal, but they ARE one of the 37% of individuals out there with NO risk factors for osteoporosis AND unknowingly HAVE osteoporosis...then they are out of luck! His or her low bone density will just continue to get worse and worse until its "silence" is shattered by a catastrophic fracture.

What if that individual's low bone density had been detected early on as a secondary finding during routine X-ray evaluations during their 30s and 40s? Identifying low bone density early, BEFORE it becomes critical gives that individual valuable time. Early detection is one of the most important ingredients when working with bone loss. It is easier to prevent further bone loss than to regain it.

This technique has great potential (if applied properly) to help in the prevention of osteoporotic fractures. Let's hope it is brought to market and is a success.

Kumar, N, et al. 2012. International Journal of Biomedical Engineering and Technology 9:316-324.
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