Monday, October 30, 2017

DX Severe Osteoporosis: Part VII -- In Search of the Whole Skeleton

This is Part VII of a multi-part essay about my own personal experience with osteoporosis. I will be taking you through the diagnostic and treatment phases of my care in hopes that it provides you a better understanding of osteoporosis in general, and pearls that you can use to better your own bone health. 

The universe is made up of individual particles that "flow within a continuous energy field encompassing a wholeness much greater than the thought processes which attempt to break the particles from their sea of wholeness."
                                                                                 David Bohm

When I first opened the door into the world of osteoporosis research, it was like walking into an anatomy classroom filled with lots of skeletons. Half of them were broken, missing parts and scattered about, and there was no teacher, just a huge pile of books dumped in a corner. About the only thing I knew was that you were supposed to take calcium supplements and eat lots of dairy. But
it didn't take long, the first book or two on the pile, to make me see that popular ideas about osteoporosis were far from accurate. I had a long way to go and I knew it.

Conventional Western medicine looks for certain signs and symptoms in a patient to match with what are considered the characteristic signs and symptoms of a particular disease entity. The doctor can't consider every physical manifestation that could be a clue to what is really going on because there just isn't time. Where do they draw the line? What physical, mental, or emotional conditions in a patient are significant, and which are not? Western medicine tends to select a small number of symptoms to consider. For each general complaint--headache, back pain, insomnia--there is a brief checklist of questions and a list of diseases to match with the symptoms. In my case, the initial list at the endocrinologist's office was twenty in length. The doctor's objective was not to discover my individual pattern, but to figure out which of a few disease-categories my bones might be dropped into. Having a specific diagnosis, even if it is just called "idiopathic" (meaning "we don't have a clue as to what the cause is...") or "primary," gives us the satisfaction of labeling--satisfaction that the ills are now neatly categorized, ready to be boxed and shipped out for treatment. To categorize is simply a way to feel in control.

The problem is that once we diagnose, it's easy to stop thinking, stop observing. We stop looking for other answers, other possibilities and connections. The pressure is off; the diagnosis is there. But are we really under control...? With a diagnosis, the physician has a ticket to enter the medical superhighway with its trailer-loads of information, and thousands of other physicians and researchers traveling in the same direction. The superhighway feels safe, it's familiar and well marked; but there's lots of country that it passes right by.

I'm not saying we shouldn't diagnose. But there are shortcomings in our way of doing it. Other healing practices approach the analysis of symptoms quite differently. In traditional acupuncture, as in my own chiropractic practice, listening to the patient is extremely important. The acupuncturist relies on the patient's description of the problem that brought them in and on observing the patient--noticing how they move, how they hold themselves, the feel of their skin, their smell, their affect, their energy, even the tone of their voice. As the patient describes symptoms, they are encouraged to mention anything that strikes them as characteristic of their normal pattern, and everything they associate with their current problem.

I didn't feel we were ready to label my loss of bone density with a diagnosis yet. I had no idea what the cause of the bone loss was, but I did know that there was an imbalance spurred by something... somewhere. One of the first tests the Dr. from UConn and I had ordered was the bone resorption marker N-telopeptide (NTX) and the results had come back abnormally high. A reading of 123 nmol/BCE/mmol creatinine with a reference range of 4 to 64* showed that I was loosing bone rapidly. What could cause the osteoclasts, the cells that break down bone, to be so aggressive? Was it diet, stress, over-training, or was it hormonal? Was it toxicity from chemicals or heavy metals? After all, the bone biopsy had shown that strange "zebra striping" appearance that the pathologist had said looked similar to cases of heavy metal toxicity that he had observed before. My biopsy slides hadn't stained positive for iron, and blood and hair analysis' didn't show heavy metals...but tests can be wrong. Or, could it be that my kidneys or my intestinal tract were not functioning properly. I felt TOTALLY fine...I did not FEEL sick. How could my bones be crumbling? How could they be loosing so much density so rapidly and I not feel ANYTHING? Had my genetic makeup just written it that way?

The possibilities seemed endless. The endocrinologists wanted to stick my symptoms in the box labeled "idiopathic" with alendronate as the treatment of choice. But I didn't understand. What did they expect me to do?...take a bisphosphonate drug for the next 45 years? I was only 46 years old, and I might live to be 90 (give or take a few). That just seemed ludicrous!

I wanted a doctor who could look at me as a whole, look at both my inner and outer self as one, not just a case of low bone density. It seemed that an acupuncturist trained in the Chinese healing tradition would be a good person to start with. When I asked the acupuncturist what she thought after her initial examination, she said that of the five elements that make up the body--water, wood, fire, earth, and metal--my constitution type was "fire" and that my smell was that of being "scorched." I wasn't quite sure what to make of this information, I didn't know if it was significant in terms of my efforts to track down the cause of my disease and to make a treatment plan, but I added this information to what I had already found out. At this point in the process, it was just another clue as to how the different systems of my body were working...or, more accurately, not working.

          "The whole may actually organize the parts."
                                                                  David Bohm

* With almost 20 years now of observing the bone resorption markers of hundreds of patients, it is my opinion that this reference range is totally useless. A better reference range for NTX (urine) would be 20 to 45. If a person's NTX gets below 20, osteoclastic activity is probably too low to keep bone quality in the healthy range with minimal microfracture accumulation. If NTX gets over 45 then we run the risk of excess bone resorption and a net loss of bone density.

Sunday, October 29, 2017

How Much Calcium Should I Take?

Ninety-nine percent of calcium in the body (and that is 3 pounds of the stuff!) is in our bones. And since bone is in a constant state of being torn down and then being built back (remodeling), let's just say it goes without saying that we NEED adequate calcium for good health. Calcium is important not just for our bones but also for a whole host of other essential functions. Without calcium there would be no nerve transmission, muscle contraction, cell signaling, blood clotting, constriction and relaxation of blood vessels, or secretion of hormones. (1) Studies have consistently found that higher calcium intakes reduce the risk of hypertension, obesity, and type 2 diabetes. (2,3,4). In a 2015 study from the National Osteoporosis Foundation, Weaver, et al. found a "significant decrease in fractures with calcium and vitamin D supplements." (5)

OsteoSustain: three tablets provide 500 mg calcium

The Recommended Dietary Allowance (RDA) for calcium as endorsed by the Institute of Medicine (IOM) is 1,000 to 1,200 mg daily for adults and not to exceed 2,000 mg. (6) People should strive to meet these calcium levels using food sources to the greatest extent possible. A healthful, well-balanced diet should include dairy (especially yogurt and kefir...preferably goat), dark leafy greens, and other calcium sources like sardines, almonds and beans.

Unfortunately, some people are sensitive or allergic to dairy. In addition, although many physicians recommend dairy as a calcium source, high dairy intake may come with other undesirable effects. Besides grave concerns over the dairy industries use of rBGH (growth hormones), milk is acidifying to the body (and not necessarily good for bones as the dairy industry would like you to believe) and casein, the major protein found in milk, has neoplastic (cancer) potential. Also, D-galactose (from the lactose sugar in milk) has been shown to increase inflammation, contribute to neuro-degeneration and reduced immune function. To this point, Michaelsson, et al. observed a link between high milk intake (3 or more glasses per day) and higher rate of both mortality and fracture in women, and a higher rate of mortality in men. "There were positive associations between milk intake and concentrations of markers for oxidative stress and inflammation." The authors concluded, "A higher consumption of milk in women and men is not accompanied by a lower risk of fracture and instead may be associated with a higher rate of death." (7)

We recommend 500 to 800 mg/day of supplemental calcium depending upon your diet. If you have severe bone loss and are sensitive to dairy then a slightly higher dose per day may be indicated.

1) Linus Pauling Institute. Calcium dietary supplemental fact sheet. National Institutes of Health Office of Dietary Supplements website: Updated November 21, 2013.

2) Alender, P.S., et al. 1996. Dietary calcium and blood pressure: a meta-analysis of randomized clinical trials. Ann Intern Med 124:825-31.

3) Bucher, H.C., et al. 1996. Effects of dietary calcium supplementation on blood pressure. A meta-analysis of randomized controlled trials. JAMA 275:1016-22.

4) Villegas, R., et al. 2009. Dietary calcium and magnesium intakes and the risk of type 2 diabetes: the Shanghai Women's Health Study. Am J Clin Nutr 89:1059-67.

5)Weaver, C.M., et al. 2016. Calcium plus vitamin D supplementation and risk of fractures: an updated meta-analysis from the National Osteoporosis Foundation. Osteoporo Int 27:367-376. 

6) Institute of Medicine. 2011. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National Academies Press.

7) Michaelsson, K., et al. 2014. Milk intake and risk of mortality and fractures in women and men: cohort studies. BMJ 349:g6015. 

Monday, October 16, 2017

DX Severe Osteoporosis: Part VI -- Drug Therapy, Fixing Without Healing

This is Part VI of a multi-part essay about my own personal experience with osteoporosis. I will be taking you through the diagnostic and treatment phases of my care in hopes that it provides you a better understanding of osteoporosis in general, and pearls that you can use to better your own bone health. 

"In this country we are brought up to underestimate the power of our own capacity to heal, to be ignorant of how to support and strengthen our ability to recover from illness, and to rely on external substances to counter disease, discomfort, and inadequacies of all kinds."                                 Crucibles of Will

The first endocrinologist had given me two options: either do nothing until I began to self-destruct, or immediately start taking two drugs--thiazide, a diuretic that makes you urinate more but lose less calcium, and alendronate (Fosamax), a drug that stops bone loss, boosts your density, and lowers the risk of fracture. My new doctor from UConn disagreed about the thiazide, because while it may reduce calcium in the urine it can also inhibit calcium absorption from the gut.* The alendronate though, he was in total agreement with, and said that I should start it immediately.

Medications can be incredibly dramatic and effective gifts. But most drugs don't fix things, they just interfere with bodily systems in such a way as to get a desired therapeutic effect--like taking drugs to improve one's performance in sport. Gold medals are often won with the help of chemicals because for some athletes it is simply the color at the end of the chain that is important, not how you get it. The problem with drugs, besides being illegal in sport, is that the athlete never gets to find out who they really are, what they alone can really do. They are robbed of that special feeling of truly experiencing what it is like to give their whole self to a silence, to the unknown territory of their own potential--to an emptiness into which they bring the essence of who they are and offer it to the world. 

I have always thought that it was important to pay attention to the underlying truth of any situation, and the natural integrity of other beings and of ourselves. That's one of the reasons I went into chiropractic, a drugless profession, which tries to discover the whole truth behind a person's injury or illness, and which respects the integrity of the individual's body, including that body's power to heal. Drugs certainly have their place in health care, but I feel that we should try to help people as naturally and wholly as possible--it seems like less of an insult upon the body--more pure and in harmony with the person's whole being. Growing up, I could never understand how anyone could take a drug to make them something that they were not. So being told to take alendronate before we'd even tried natural alternatives was not only difficult for me to accept as the only answer to my health problem, but my resistance also had a practical side. Once a drug therapy is initiated there is no way of assessing the effects of a natural treatment plan. 

Using bone density as an indicator of success or failure of a treatment regime for osteoporosis is impractical because density builds so slowly. But using specific lab tests to see changes in the body's physiology, changes that would be beneficial in improving bone density, is more practical. If I could see improvement in lab values as a result of natural therapy, then I would know that my biochemical patterns were shifting in a good way, becoming more balanced. Starting the use of alendronate before more information was gathered would eliminate this important guide. 

Alendronate is in the family of drugs called bisphosphonates that work by killing off (or at least making them really sick) all the osteoclasts, the cells that eat old, worn-out, and unstable bone. Normally, after the osteoclasts have resorbed the old bone, other cells, called osteoblasts, come along behind and make new, strong bone, in its place. This remodeling process is what keeps our bones healthy and resilient, and the interaction or coupling between the two cell types is a balancing act that needs to be maintained. It is precisely this coupling that the bisphosphonates disrupt. 

I felt trapped...I knew very little about osteoporosis and even less about drugs. I was concerned, fearful actually, of breaking more bones and I didn't want to fall into what looked like a big dark hole of the unknown. I was 46 years old...what were these doctors asking me to do?...take drugs for my skeleton for the rest of my life?...another 45 to 50 years?! It didn't make sense.

All my life I had tried to respect my body, both to heal and to achieve in athletic competitions, with no help from synthetic chemicals of any kind. The only substance I ever used was what came naturally inside me. Now I was being asked to participate with the doctors in doing something to my body that destroyed part of its natural functioning. If I did this, I felt I would be betraying the body I had always tried hard to respect and improve. 

The problem with bisphosphonates, and the newer drug Prolia, is that they shut down bone resorption but do nothing to encourage osteoblasts to form bone. In fact, it's the osteoclasts that normally signal the osteoblasts to make new bone. With the osteoclasts gone from the scene, new bone just doesn't get made. The overall effect is a decrease in bone remodeling with minimal increase in bone density. The reason bisphosphonates are able to reduce fractures is not from their paltry increase in the density of bone (which, is secondary in other words it isn't primary new bone, just a secondary sprinkling of minerals onto the old weak scaffolding), but from a reduction in the number of small cuts of gouged out bone that the osteoclasts ordinarily make. Like the perforations that make it easy to tear pages from a notepad, these spots are vulnerable to fracture, even though they are a necessary part of remodeling. Where there is no remodeling, there are no temporary weak spots, and no focal areas where a little crack can get started. In normal bone these small cuts pose no problem, but if the overall density and strength of bone is low, these perforations become the ideal sites for catastrophic fractures to begin. 

Older people are typically more sedentary and place less stress on their skeleton. Leaving the old bone in place by stopping remodeling, seems to work well in reducing the risk of fracture, even though the actual quality of the patient's bone becomes arguably worse. How many years can a person go without remodeling before that old bone becomes so old that it's more fragile than new bone would be with remodeling sites? That's a big question and nobody knows the answer. For an 80-year-old it's probably a reasonable risk. For a 46-year-old, it's a question that hadn't been tested much, and I wasn't sure I wanted to volunteer to be a guinea pig. 

The UConn doctor was concerned that I was going to start getting some major fractures. Besides the two ribs from skiing and the new compression fracture from lifting the couch, I snapped two more ribs just leaning up against a horse to pick out its hooves...heard them snap, as easily as twigs on a dead pine. The literature was daunting; it referred to bone loss such as mine as irreversible. That's one really ugly word, irreversible. It's like saying some runner is
My biopsy with disconnected trabeculae there's no point in even point in even entering the race. The bone loss is considered irreversible because once the trabeculae, the small structural supports that give strength to inner bone are resorbed and become disconnected from surrounding bone, there is no way for new ones to reform. And when the new ones can't form, and old ones don't repair, the density just keeps going down and the risk of fracture keeps going up.


But everyone can be beaten; maybe not by me, but by someone. I finished back in the pack in a lot more races than I ever won, but even when it looks like you can't win, you don't know till you put yourself out there and run till you drop. It is sure a lot better to get on the starting line even if you only finish second or third, or last, than it is to just sit and think about it. With osteoporosis, it was even hard to tell who was toeing the line, what I was racing against--but I knew I wasn't going to let this "irreversible" hype make me shy away from trying. I wanted to heal my body, not just take some calcium and hope for the best, and not just take some drugs that killed off some of my cells, interfered with my body's natural processes, and made my bones old. 

I knew no one was going to be committed to this program except me. But I was ready to give it everything I had. It wasn't long before I started ordering a lot of my own lab tests and researching osteoporosis using every source I could find.

One of the first tests the doctor from UConn had ordered was N-telopeptide (NTX), a bone resorption marker that measures how much bone collagen is in your urine. When the osteoclasts tear down old microfractured bone, the shards of bone collagen go into the blood and is then flushed out of the body through the urine. If the lab results for NTX come back elevated, it means the osteoclastic activity is excessive and you are loosing bone rapidly. Rapid bone loss is a major risk factor for fracture and the higher the NTX the greater the risk of breaking something. In fact, if you take two people, both the same age, same build, same everything...and they have the same bone density...the one with the higher NTX will have a greater risk of fracture. 

My NTX test result was 123 nmol BCE/mmol creatinine. (Reference range: 4 - 64 nmol BCE/mmol creatinine)  Uh-oh!     

              "Dont' give up. It is still your turn to be in this world."
                                                                   Crucibles of Will

*  Taking a thiazide diuretic didn't seem like a good idea even way back then when I didn't know much about osteoporosis. Now, with about seventeen years of experience with this disease and working with patients with bone loss for at least ten, using thiazides to limit urine calcium loss seems like an even a worse idea. Thiazides interfere with trace mineral absorption, especially magnesium and zinc. Potassium depletion is very common with thiazides and can cause heart arrhythmias and glucose metabolism problems...not something you would want to have, especially if you are running marathons and competing in Ironman triathlons. Simply adding more vegetables to a person's diet and having them supplement with boron, potassium and vitamin K-2 MK-4 almost always lowers urine calcium losses. A much safer approach.

Friday, October 13, 2017

Supplemental Calcium for the Prevention and Treatment of Osteoporosis: New Guidelines by the EMAS

Eye opening stats:
-  Approximately 50% of women and 20% of men will become osteoporotic and suffer some type of fracture within their lifetime.
-  Spine and hip fractures can be debilitating, life changing events leading to long term pain and rehabilitation.
-  Twenty-eight percent of women and thirty-seven percent of men who sustain a hip fracture die within a year.

What can be done?:
These abysmal numbers DON'T have to be that way! Osteoporosis, for the most part, IS preventable. We do NOT have to see such large numbers of fracture rates if we could increase awareness and focus on prevention. Leading a healthy lifestyle is extremely important for reducing osteoporosis risk. This includes good nutrition, maintaining regular physical activity, and not engaging in destructive alcohol, tobacco and/or drug use. Along with eating a healthy diet high in fruits and vegetables and adequate protein, sufficient calcium intake is extremely important for bone health.

But what if a person already has osteoporosis and they are 60, 70 or 80 years old? Is there no hope for them? Is prevention the only thing we can do? NO! In fact I just spoke with an very nice 78-year-old woman tonight who has sustained multiple fractures of her spine and a hip fracture. She was distraught that there might not be anything that could be done for her...that she would simply have to live in fear of more fractures and continued pain. I have been working with patients with osteoporosis for almost 20 years now and have seen other patients with similar scores and in similar situations. And I know for a fact that there IS a lot that can be done to help. That there IS hope and PLENTY of it. But we can't be passive. We need to attack situations like hers from ALL directions. But improvement CAN be had...slow and steady, like putting
At 17,500 feet on Mt K. "Just Keep Going"...and you will get there.
one foot in front of the other. But it will happen. We just need to get up EVERY day and do things to improve. Slowly, slowly...just keep grinding away...but yes, improvement will come. Not to get too off track here but I think this is why I so love challenges like competing in Ironman triathlons or running up Mt. Washington, or Mt. Kilimanjaro. These goals are long and arduous, and rewards come from "just keeping on going".

There are lots of pieces to the complex puzzle of osteoporosis. Mineral intake is just one of those pieces. I must admit that I rarely write about supplemental calcium but a newly released clinical guide for the prevention of postmenopausal osteoporosis by the European Menopause and Andropause Society (EMAS) prompted this blog.

We all know that calcium IS necessary for strong bones but recent epidemiological studies linking excess calcium intake with "possible" cardiovascular risk has confused the waters. Many patients and doctors alike are questioning if supplemental calcium is safe and indeed if it is necessary at all. In response to these questions, the EMAS released new, updated guidelines. The following is a summary of the publication's most important points:

Insufficient calcium intake
   increases fracture risk AND an
   adequate daily intake is
   important for preventing 

-  An intake of 700 to 1200 mg of
    calcium every day is important.

-  When possible, dietary calcium
    should be the preferred choice
    over supplemental calcium.

-  If dietary calcium intake is
    insufficient, supplemental
     intake is recommended.

-  Data from the National Health and
    Nutrition Examination Survey
    (NHANES) database shows that
     less than one-third of women 
    consumes enough calcium from
    their diet.

-  Excess intake of calcium does not
    help to reduce fracture risk.

There is no conclusive evidence
    that excess calcium intake causes
    harm.  [It is our opinion at OsteoNaturals that large doses of calcium (over 500 mg)
    should not be taken at one sitting, and that total daily supplemental intake be limited
    to 600 to 1,000 mg over the course of the day (depending on how much calcium is
    obtained from the diet).]

There is no doubt, CALCIUM is VERY IMPORTANT for skeletal health and not just for the prevention of osteoporosis but also for its treatment. The problem with relying on dietary calcium is that absorption of calcium from food does not exceed 35%. For this reason alone, calcium supplementation is a good idea. Adequate calcium intake is important, not just when we reach age 50, and not just when we have been diagnosed with osteopenia or osteoporosis...but when we are young and healthy! It is difficult to obtain sufficient calcium from diet alone, so no matter how you cut it, calcium supplementation is the best way to ensure sufficient intake.

Many patients do not adhere to calcium recommendations by their doctors because supplements are often poorly tolerated. Inexpensive drugstore-brand calcium products are especially difficult to absorb. Constipation, abdominal cramping and bloating are common side effects of calcium supplements. The reason for this is that most of these products contain cheap calcium sources such as calcium carbonate, dolomite, and/or oyster shell calcium. Not only are these forms of calcium not well tolerated but their absorption is low.

Take home message...check labels before purchasing calcium calcium-rich foods...and take quality supplemental calcium. Your bones will be healthier and stronger for it.

Cano, A., et al. Calcium in the prevention of postmenopausal osteoporosis: EMAS clinical guide. Maturitas

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