Wednesday, February 27, 2013

Potassium Citrate Supplementation Can Improve Skeletal Health

The typical Western diet, high in sugar, processed food, red meat and cheese, and low in fruits and vegetables, is very acidic. This is not good when it comes to the health of your bones. A diet high in acidic animal protein and low in vegetable protein increases urine calcium loss and contributes to the development of osteoporosis and increases the risk of fracture. Potassium, an alkaline mineral that is plentiful in fruits and vegetables, is perfect for neutralizing acids.

Just how good is potassium at alkalinizing the body? Well, according to the March 2013 issue of the Journal of Bone and Mineral Research, supplementing with potassium citrate has the potential to substantially benefit bone health. In a study by Moseley et al., researchers looked at 52 men and women who were randomly assigned to take potassium citrate 60 mmol/day, 90 mmol/day or placebo. The researchers found that after 6 months the subjects who were taking potassium citrate had reduced 24-hour urine calcium losses and significant reduction in CTX, a biomarker for bone resorption. "Potassium citrate was well-tolerated at doses as high as 90 mmol/d with demonstrably positive effects on the calcium economy." "We show that potassium citrate positively and definitively benefits the calcium economy, relieving the skeleton of its role as a source of base reservoir."

There is often concern that potassium supplementation can lead to elevated blood potassium levels (hyperkalemia) which can cause dangerous heart arrhythmias. It is true that individuals predisposed to hyperkalemia, such as those with type 1 diabetes or kidney disease, should use extra caution when considering the use of supplements with extra potassium (i.e. it is always good to talk with your doctor). But what is amazing about this study (in addition to confirming that supplemental potassium is beneficial to bone health) is that supplementing with potassium appears to be quite safe even in high doses. The researchers report "there was only 1 study participant who became mildly hyperkalemic on a dose of potassium citrate 40 mmol/d. That result was surprising given that an extensive literature review and studies performed by our group have never before demonstrated even mild hyperkalemia with escalating doses of potassium salt administration." It is important to note that they used huge doses of potassium citrate in this study (approximately 2,300 to 3,500 mg/d of potassium)...safely. Of course, the best way to get your potassium is through diet but it's not always that easy to get 5 to 9 servings of fruits and vegetables every day. Supplemental potassium, either by way of potassium citrate and/or potassium bicarbonate, is a great way to ensure a balanced body pH.

The authors concluded that "potassium citrate administration has the potential to mitigate age-related declines in bone density and strength associated with the Western diet. Readily available, safe, and easily administered in an oral form, potassium citrate also has the potential to reduce fracture in at-risk populations."

Our Osteo-pHBalance and OsteoMineralWhey both provide healthy doses of potassium and are perfect for helping to alkalinize the body, reduce urine calcium losses and improve skeletal health. By checking the pH of your urine first thing in the morning, it is possible to get an estimate of your body's pH. If your urine pH is consistently below 6.2 to 6.4, you are more than likely acidic and losing calcium. One of my (almost daily) horrors is seeing new patients who have already been to their medical doctor for their osteoporosis and have been prescribed a thiazide diuretic because they tested high in their 24-hour urine calcium test. The maximum loss of calcium in the urine that is considered to be normal for a 24 hour period is 250 mg for women, and 300 mg in men. When losses are higher, it can be extremely detrimental to bone health and patients are commonly prescribed a thiazide diuretic which acts to limit these losses. Unfortunately, diuretics can disturb electrolyte balance, create havoc in the hemodynamics of blood flow, and cause losses of important minerals such as zinc, magnesium, and manganese. Simply supplying these individuals with with some extra potassium (I typically recommend 300 to 1,000 mg of supplemental potassium/day plus vitamin K2, magnesium and boron) can stop this loss of calcium and reduce bone loss...without any of the potential adverse side-effects of diuretics. The sad thing is that doctors don't even try this regimen before resorting to a diuretic. 

Moseley et al. 2013. Potassium citrate supplementation results in sustained improvement in calcium balance in older men and women. JBMR 28(3):497-504.

Thursday, February 21, 2013

New Finding Shows that Nitrates May Help Reduce Both Spine and Hip Fractures

This morning, as I sipped my delicious nitrate-rich homemade beetroot juice (recipe below), I read with delight the International Bone and Mineral Society’s BoneKey Report about new evidence that nitric oxide may hold true promise in the fight against osteoporosis. Researchers Celeste Hamilton and colleagues from the University of Toronto examined important evidence that supports the concept that nitric oxide (NO), the smallest signaling molecule in the body, is not only critical for bone cell function and maintaining balance in the bone remodeling process, but may hold a key role in the treatment of osteoporosis. Great endorsement for the way I start my day!

During bone remodeling, a biological process that is constantly under way in the body, old weakened bone is broken down, or resorbed, and then new bone is formed it its place. Remodeling has to stay in balance for bone to remain healthy and strong. If bone remodeling becomes unbalanced and osteoclast bone resorption becomes overly aggressive, and/or osteoblast bone formation is impaired, this sets the stage for osteoporosis. It is through a complex set of signaling molecules that bone cells communicate with each other and maintain this balance. Nitric oxide (NO) is one of those molecules that bone cells use to “talk” to each other during the bone remodeling process. When NO production dwindles, as is the case during menopause when estrogen levels recede, osteoclast bone resorption increases. When NO production increases, this sets off a chain reaction of events that lowers osteoclast bone resorbing activity.  In other words, if you have osteoporosis, increasing NO levels in the body can be of great benefit.

According to Hamilton et al., organic nitrates* such as nitroglycerin can be used on an intermittent bases to increase NO levels. The researchers found that the higher NO levels improved bone cell function and substantially increased bone mass (not just density) both in trabecular and cortical bone! What this means is that nitrates may help reduce both spine and hip fractures. Bisphosphonate medications, the current drugs of choice for treating osteoporosis, are helpful for reducing vertebral fractures but have limited benefit in the war against hip fractures.

Unfortunately, there are two major drawbacks for using organic nitrates to treat osteoporosis. First, when used continuously organic nitrates could actually be detrimental; second, they have the nasty side effect of severe headaches. There are also economic considerations. Organic nitrates are typically very inexpensive to produce and because they have been around since the early 1800’s, obtaining patents can be difficult. This is an unattractive combination for pharmaceutical industries.

The good news is there are foods with inorganic nitrates and supplements that promote nitric oxide naturally. There are two biological pathways that produce NO:

1.     Arginine supplements    L-arginine + oxygen  + cofactors  ➜  nitric oxide synthase  ➜  NO
Nitric oxide is generated by a specific enzyme (NOS) from the amino acid arginine. For years
arginine (or citrulline which can also increase arginine and NO levels) has been used by athletes
to improve physical performance (NO enhances muscle tone and endurance) and by nutrition
experts to lower blood pressure (NO is a potent vasodialator). The problem with taking
supplemental arginine is that for the body to convert it into NO requires (1) plenty of oxygen
(not always that plentiful in osteoporotic bone), (2) several important cofactors (some of which
may be reduced especially in cases of mitochondrial dysfunction and arterial disease, common
in folks with osteoporosis), and (3) a functioning NOS enzyme system (which unfortunately
is not always present due to genetic polymorphisms).

2.      Nitrate-rich foods         nitrate  (NO3)  +  (oral bacteria)  ➜   nitrite  (NO2)  ➜    NO
Vegetables, especially leafy greens, are excellent sources of nitrate but beetroot is at the top
of the list. Beetroot juice is not only rich in vitamin C, B vitamins, folate, potassium, silica and
iron but it is your best source of nitrate. Studies show beetroot juice can significantly raise
blood nitrate levels, reduce blood pressure, and improve aerobic fitness through what has
been surmised as its ability to increase NO levels in the body. Beetroot is known for its
beneficial effects to bone due to its potassium, magnesium, manganese and silica but now
we may be seeing the best reason yet for adding beetroot juice to your armamentarium
against bone loss. And (as if it couldn't get better), if you are one of those individuals with 
elevated homocysteine levels, beetroot is a rich source of the phytonutrient, glycine betaine.
Homocysteine is an inflammation biomarker commonly seen elevated in people with
osteoporosis. Blood levels above 8 micromoles/L are indicative of inflammation, and when
they rise above 15, there is a 2.5-fold increase in fracture risk. (For more on inflammatory
biomarkers and how to lower them, see my book The Whole-Body Approach to Osteoporosis.)

The clear choice for most of us is nitrate-rich foods. I often start my day with a homemade beetroot juice mix. You can purchase beetroot juice but I like it fresh and organic. You’ll need a juicer but it is well worth it. Here is one of my favorite recipes:

2 beetroots (not the green tops)
2 apples
3 large carrots and 4 stalks of celery
½ bulb fennel
5 leaves of kale (can be difficult to juice )
large handful of parsley

Note: Make sure you sip and enjoy your juice. The bacteria that naturally live in your mouth are a necessary part of converting nitrates into nitrite, a necessary step before your body can then make it into NO.

* Organic nitrates are drugs such as nitroglycerine and inorganic nitrates are from dietary sources such as beetroot and green leafy vegetables.

Hamilton CJ, et al. 2013. Organic nitrates for osteoporosis: an update. BoneKey Reports doi:10.1038/bonekey.2012.259.

Monday, February 18, 2013

The Miracle of Antioxidants for Reducing Fracture Risk

"There are two ways to live your life. One is as though nothing is a miracle. The other is as though everything is a miracle."
   --Albert Einstein

I truly do believe that everything is a miracle. I'm constantly in awe of all that I see on this earth and in the stars above. In my work as a chiropractic physician, I regularly witness the human body's spectacular complexity and, if just given the chance, its almost endless innate capacity to heal. On a personal note, it is difficult for me not to see my own recovery from osteoporosis as, well, if not a "miracle" then certainly something pretty darn special. After all, just 10 years ago my skeleton was readily breaking--actually, it was close to crumbling. Just leaning up against a wall could result in a rib fracture. Yet now, my bones are capable of withstanding anything and everything that I put them up to and I've thrown a lot at them lately. From Tough Mudders, to road races, to Ironmans, to moderately heavy weight lifting and even some light boxing, I've certainly put my bones to the test. So you can see how I might consider this improvement to be somewhat special. Recovering from osteoporosis, seeing my skeleton get stronger and my overall health get better, (even as I'm getting older) has been a gift that I will forever be grateful.

But this recovery did not just "happen" and it certainly didn't take place overnight. It took a lot of work. Work that wasn't, hard per se, but it did require total immersion and dedication to "the mission." For me, that mission was one of following a healthy, gluten-free, alkaline diet and taking some important supplements that powerfully affected my bone remodeling system. Antioxidants such as alpha lipoic acid*, N-acetyl cysteine*, green tea leaf extracts*, and taurine*, plus other compounds that have the ability to modulate osteoclast activity (bone resorption) and spur osteoblast activity (bone formation) were keys to my success. As I now look back on the ordeal, I can see that much of my improvement came from neutralizing free radicals, stopping the oxidative stress that was destroying my body, and allow it--and my bones--to recover. This is a step most people with osteoporosis will need to take if they are going to reverse their bone loss.

So if you have osteopenia or osteoporosis and your antioxidant systems are not capable of efficiently neutralizing free radicals, (check out my book, The Whole-Body Approach to Osteoporosis, for information on specific lab testing) you are forming an over-abundance of reactive oxygen species (ROS). This excess in ROS can overwhelm your body and create a condition called oxidative stress that damages cells, causes premature aging, and promotes, among other things, excessive bone loss.

Many people think only of cancer when they hear the words, free radicals. But free radicals also promote bone loss. In fact, the more free radicals there are in your body, the more oxidative stress you will have, and the more likely you are to loose bone density and fall into ill health. All chronic disease, whether it be cancer or osteoporosis, or heart disease, diabetes, or Alzheimer's, they are all fueled by oxidative stress, the major destructive force behind premature aging. Cigarette smoking, excessive alcohol intake, air and water toxins, emotional and physical stress, all promote ROS production and increase oxidative stress. Even going through menopause with its loss of estrogen, contributes to oxidative stress. In fact, Cervellati and colleagues studied 191 women and determined that "menopause-related estrogen withdrawal might contribute to make bone more vulnerable to oxidative injury thereby increasing the risk of PO [post-menopausal osteoporosis] development." What we know for sure is that the less oxidative stress, the healthier you and your bones will be. But how do you do this?

The answer is actually quite simple. In addition to stopping, or at least reducing, any destructive life-style habits, if you change your diet, add in some exercise to your weekly regime, and clear your head of major stress, it IS possible to regain skeletal health and reduce fracture risk. When I say improve your diet, I REALLY mean IMPROVE YOUR DIET! Adding a small salad at lunch to a diet high in acid-forming meat and white potatoes doesn’t cut it. Eating lots of fruits and vegetables (organic where possible, of course) is the best way to increase your intake of bone-healthy phytonutrients and antioxidants. Juicing is an easy and delicious way to get in a few more servings of vegetables. In addition to improving your diet, supplementing with bone healthy compounds is critical. Our OsteoNaturals’ OsteoStim* not only provides you with powerful antioxidants that help reduce oxidative stress, but also vitamins and naturally active compounds for balancing bone remodeling.

* OsteoStim: vitamin D3, vitamin K2 (MK4 and MK7), biotin, alpha lipoic acid, N-acetyl cysteine, berberine, green tea leaf extracts, milk basic protein, taurine, and milk thistle.

Cervellati et al. 2012. Bone mass density selectively correlates with serum markers of oxidative damage in post-menopausal women. Clin Chem Lab Med doi:10.1515/cclm-2012-0095.

Saturday, February 9, 2013

Strontium for Osteoporosis? An Update on Safety

The safety of using strontium for treating osteoporosis is a hotly debated topic. In my October 20, 2012 blog post, I voiced my concerns. In this post I would like to briefly add to this discussion.

The body absorbs and uses strontium as if it were calcium. With 99% of the body's calcium stores located in the skeleton, it's no wonder that high-dose strontium readily finds its way into bone. With it's high atomic number, strontium readily increases bone density as demonstrated on bone mineral density (DXA) exams. But calcium is important for more than just making our skeleton harder. Calcium is also necessary for nerve contractions, colon health, maintaining normal blood pressure, hormone production and enzymatic reactions. Because of this, there are concerns that replacing calcium with atoms of strontium in these key areas could have the potential to create adverse effects. For example, strontium can replace calcium at nerve synapses and retard the flow of nerve impulses. In fact, neurological disorders have been reported with strontium ranelate (Reginster et al., 2012) including memory loss (annual incidence 1.1%). Increased cancer risk is also a concern. A recent study out of China (Chen et al., 2012) found high strontium levels in premenopausal women to have a 124% increased risk of breast cancer.

Safety studies of strontium ranelate show increased risk for serious skin reactions (DRESS) and a 50% increased risk in venous thromboembolisms (VTE), including pulmonary embolisms. A new study published in France linked 199 severe adverse reactions to strontium ranelate (52% were cardiovascular related). These reports prompted safety concerns and a review by the European Medicines Agency (EMA/CHMP). Their official assessment report was issued on May 25, 2012 and concluded that "new contraindications and revised warnings should be included in the product information. Strontium ranelate should not be used in patients with VTE or those temporarily or permanently immobilized."

Reginster et al., 2012. Maintenance of antifracture efficacy over 10 years with strontium ranelate n postmenopausal osteoporosis. Osteoporosis International 23:1115-1122.

Chen et al., 2012. Urinary strontium and the risk of breast cancer: a case-control study in Guangzhou, China. Environmental Research Jan;112:212-7.

Jonville-Bera AP and Autret-Leca E. 2011. Adverse drug reactions of strontium ranelate (Protelos) in France. Presse Med Oct;40(10):e453-62.

Tuesday, February 5, 2013

Calcitonin for Osteoporosis?

Several patients have recently asked me about the medication calcitonin for the treatment of osteoporosis. Calcitonin is a hormone secreted by the thyroid gland and helps direct blood calcium into bone. Salmon calcitonin nasal sprays (Fortical, Miacalcin) were some of the first medications developed to treat osteoporosis. But do they work and are they safe? As far as its effectiveness is concerned, calcitonin does seem to have a moderate but limited benefit (it often looses its effectiveness after about 2 years) for reducing vertebral, but not hip, fractures. 

Nasal calcitonin has often been used either for patients who cannot tolerate bisphosphonate therapy or for those experiencing pain from an osteoporosis-related fracture. Several studies have shown that it can reduce back pain caused by compression fractures. In a September 24, 2010 clinical practice guideline, the American Academy of Orthopaedic Surgeons recommended "patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms suggesting an acute injury (0-5 days after identifiable event or onset of symptoms) and who are neurologically intact be treated with calcitonin for 4 weeks."

Calcitonin was always considered fairly safe until recently. In July, 2012 the European Medicines Agency's (EMA) Committee for Medicinal Products for Human Use (CHMP) concluded that after reviewing the safety/benefit of calcitonin there was evidence linking it to increased cancer risk. "Although the cancer rates reported in the studies were low, the increase in cancer rates seen with calcitonin varied between 0.7% in the studies with the oral formulation to 2.4% in the studies with the nasal formulation. Taking into account the limited benefit of calcitonin when used to treat post-menopausal osteoporosis to reduce the risk of vertebral fractures, the CHMP concluded that the benefits of calcitonin did not outweigh the risks in this condition. As the nasal spray is only used in osteoporosis, the CHMP recommended that this formulation should no longer be used." As a result of this review, both Fortical and Miacalcin were withdrawn from the market in August, 2012.

Time and time again, whether it be from the disturbing news of the 2002 Women's Health Initiative study, which determined that the risks of HRT outweighed its benefits, or the rising number of cases of osteonecrosis of the jaw and atypical femur fractures from bisphosphonate therapy, or the recent delay by Merck (citing safety concerns) to apply for early approval of their next new wonder drug, odanacatib, for the treatment of osteoporosis, one thing I have learned in my journey with osteoporosis is that diet, quality supplements and exercise--not medications--are the key to improved bone health.

Friday, February 1, 2013

Do Calcium Supplements Increase Your Risk for Heart Attack?

Recent studies (Bolland et al. 2008 and 2011; Li et al. 2012) have reported a possible association between calcium supplementation and increased risk for cardiovascular events (e.g. heart attacks). However, several researchers (Abrahamsen et al. 2011; Nordin et al. 2011) have pointed out flaws in the design of these studies and indeed questioned how the cardiovascular events themselves were determined.

It is known that large doses of supplemental calcium (such as taking 500 mg at a time) can cause spikes in blood calcium levels. This increased level of calcium in the blood stream can last for several hours and the concern is that these spikes could contribute to calcification of blood vessels and the increased risk for heart attacks and stroke. The problem with this theory is that the research that links calcium supplementation to increased cardiovascular risk includes individuals who only recently started taking supplemental calcium. In other words, the subjects in the studies who had heart attacks had only been taking supplemental calcium for short periods of time--too short in fact for there to have been any substantial contribution to calcification of blood vessels.

Calcification occurs slowly over long periods (years) of time. So the question is--could there be another explanation that would explain this link? Is there some other mechanism other than the calcification of blood vessels that could link calcium supplementation to increased cardiovascular risk? The answer to this question is important because with no physiological mechanism currently known that links supplemental calcium to heart attacks, it is impossible to determine risk and reach any final conclusion.

To maintain overall health we must keep our blood calcium levels between 9.0 and 10.1 mg/dl. Too little or too much calcium in the blood can lead to serious symptoms and even death. But can short term spikes in blood calcium cause problems? Can short term spikes lead to dangerous contractions of the heart, tightening of blood vessels, and, initiate cardiovascular events? If so, what is the physiological mechanism behind this chain of events?

In the most recent issue of the Journal of Bone and Mineral Research, researchers from Australia designed a study to determine exactly that. What, if any,  physiological mechanism could possibly explain the connection between acute rises in blood calcium and heart attacks? In this proof of concept study, Burt et al. (2013) gave 25 subjects (all over the age of 50) 1,000 mg of oral calcium citrate and then evaluated them for changes in blood markers and specific cardiovascular function parameters linked to cardiovascular risk.

The researchers "found no significant change in PWV [pulse wave analysis] following calcium citrate administration. Carotid-femoral PWV is considered the gold standard measure of arterial stiffness"...
"PWV is a consistent predictor of fatal and nonfatal cardiovascular events in a range of subject populations, independent of other cardiovascular risk factors." "The failure to find a significant change in PWV suggests an acute serum calcium-mediated increase in arterial stiffness does not explain the reported increase in cardiovascular events with calcium supplements."

"Contrary to our hypothesis, we found a reduction in median Alx [augmentation index is an indirect marker of arterial stiffness] of about 10% following calcium citrate administration"...
..."if maintained long-term, [this reduction in Alx] would be associated with about a 30% reduction in relative risk of cardiovascular events." [In other words, if this 10% reduction in Alx as a result of the calcium supplementation was continued long term, there would be a 30% reduction, not increase, in risk for heart attacks.]

The authors concluded, "It is highly unlikely that there will ever be a randomized-controlled trial of sufficient size and duration to conclusively determine the effect of calcium supplementation on cardiovascular risk. Lacking these data, assessment of the effect of calcium supplements on plausible physiologic mechanisms that could underlie an increase in cardiovascular risk will greatly enhance the final interpretation of the above studies."

"Unfortunately, our study neither confirms nor refutes the safety of calcium supplementation. However, our findings do demonstrate that the rise in serum calcium following supplement administration does not acutely exert an adverse effect on these parameters of cardiovascular function."

The take home message from all of this research is not that calcium supplementation should be avoided but rather, excessive intake should be used with caution. How many times have we heard, "all things in moderation"? In addition to the superior bioavailability of the OsteoNaturals' calcium products OsteoSustain (160 mg/tab) and OsteoMineralBoost (140 mg/tab), the amount of calcium in each tablet is substantial but not overwhelming to the body. When taking these products one or two tablets at a time and spacing them out throughout the day, they provide optimal benefit to the skeleton but without excessive spikes in blood calcium.

The other important factor to remember is that when taking calcium supplements you should also make sure you are consuming adequate amounts of bio-available magnesium (NOT magnesium oxide!), vitamin D and vitamin K (OsteoSustain and OsteoStim). This is extremely important because these nutrients help your body fully utilize calcium and deposit it where it belongs--into the skeleton--and not into soft tissues where it could cause harm.

Burt et al. 2013. Acute effect of calcium citrate on serum calcium and cardiovascular function. JBMR 28(2):412-418. 

Website design and website development by Confluent Forms LLC, Easthampton MA