Sunday, December 24, 2017

DX Severe Osteoporosis: Part X - Impacting Skeletal Health

This is Part X of 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 as they provide background to each new installment. It is my hope that this series will provide 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.    Dr.M

                                "It's a good idea to keep at least a vague idea of
                                  where you are, no matter how much you are used to 

Now, with this inflammatory reaction to gluten being such an obvious concern, I began to look at this strand of the web through every lens I could. It didn't take long to find a few more important connections. Glutamine, an amino acid energy source for cells that line the intestinal wall, is often found deficient in professional athletes that train hard every day and I certainly fit into that category. Cells of the digestive tract need glutamine for sustenance, growth, and energy production. In an exhausted body that isn't being properly replenished, glutamine levels drop and cells of the gut suffer, with poor absorption of nutrients the unfortunate result.

Even if absorption is normal, a hard-working athlete piles on both oxidative and adrenal stress producing copious amounts of free radicals and high blood titers of the catabolic, destructive hormone, cortisol. Excessive free radical and cortisol levels places high demand on essential fatty acid supplies. An athlete's body extracts aerobic energy from molecules reacting with oxygen. In this process, the oxygen molecule looses an electron and becomes an unstable scavenger called a "radical." These free radicals are insatiable, stealing electrons from their closest molecular neighbors, which results in cellular damage. It's the phospholipids (made from fatty acids) in a cell's membrane, that often get damaged...and a cell's membrane, as I would find soon find out, is vital for more than just defining the cell's boundary.

Fatty acids and phospholipids are vital for optimal cell membrane function including the transference of signals from one cell to another. If omega 3 fatty acid intake is deficient, cell membranes (and their ability to transfer signals) suffer. Athletes are particularly demanding of omega 3 fatty acids and optimal intake is necessary to achieve high level performance. Without omega 3s, cell membranes loose some of their functional capacity. This loss of function not only alters the normal signaling of important information but it also increases the signaling for a heightened inflammatory response!

Over the next few months, I discovered more strands in this elusive web. Amazingly, there was no paucity of evidence in the literature showing that the cells and substances that the body releases in response to inflammation were also the cells involved in the destruction of bone. As the bone in our body ages, it becomes less resilient and develops microfractures. This old weakened bone must be replaced with new bone. Both bone resorption, the dissolving of the old, microfractured bone, and inflammation in response to injury, are crucial to overall health. But when the body fails to limit these processes, the immune system gets out of balance and the skeleton goes into a spiral of disrepair.

In my case, the inflammation in my hip began as a response to the stress fractures but then something went wrong—the injured tissues didn't heal, and the inflammation became chronic. And the Gilbert's* syndrome...?...The condition where bilirubin (a breakdown product of blood) increases due to a specific genetic enzyme deficiency? Where did that fit in? This "harmless," hereditary liver disorder, I found, interferes with fatty acid absorption from the gut. (Yes, the same fatty acids that are often found to be depleted in athletes.) With 5 to 7 percent of the population having this disorder, it seemed to me that it should be taken more seriously by the medical community, especially when dealing with people with an ongoing disease process...such as osteoporosis. An athlete with Gilbert's is under double the physiological stress and at a higher risk for inflammatory related disorders, including osteoporosis. Combine this with a sensitivity to gluten and we have a condition ripe for severe bone loss.

The doctors had assured me that there was "no connection" between Gilbert's and my hip pain or my osteoporosis. But that was NOT what I was seeing. What I was beginning to see was that in medicine, the term "no connection" really meant "we have not yet made that connection" or "we don't have the time or money to research it right now." In their eyes, if it hasn't been researched, it isn't worth thinking about. (And if pharmaceutical companies don't see a way to make money on it, it won't be researched.)

Of course, it is not only the essential fatty acids that can become deficient as a result of the athlete's frequency and intensity of exercise. Vitamin and mineral deficiencies are common, as are deficiencies in amino acids. Glutamine and methionine are often in short supply in both the athlete and in people with Gilbert's syndrome. Not a good thing considering the almost endless biological functions that these two amino acids are involved in: energy production, muscle building, fuel for cells of the immune and gastrointestinal systems, collagen synthesis for both joint and bone, the production of glutathione (the body's most important antioxidant), etc... These two amino acids are needed for just about everything. I immediately began supplementing my diet with glutamine and methionine, and whey protein which is a balanced source of essential amino acids. I also began to take milk thistle (sylymarin). If Gilbert's was involved in the liver's ability to function, I wanted to cleans and optimize the function of my liver as much as possible. With my chiropractic training and interest in nutrition, I knew that consuming lots of fresh green vegetables and supplementing with milk thistle could help. Milk thistle is known for its ability to fortify the liver and, as I found out, prevent the depletion of glutathione and limit free radical damage. It finally felt like I was not only starting to see patterns in this complex web, but that I was also finally starting to understand enough that I was able to do things to positively impact my skeletal health.

...Stay tuned for Part XI of DX Severe Osteoporosis

Saturday, December 9, 2017

DX Severe Osteoporosis: Part IX - Seeing Specific Threads of the Web

This is Part IX 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.

                        "We all see mountains. It is how we climb them that is different."

                                                                                Crucibles of Will

When the body is injured, the immune system's inflammatory response infiltrates the area cleansing it with blood and scavenging, destroying invading organisms. In situations of injury, inflammation can be the magic to survival, but in chronic disease, it is the destroyer of life as we once knew it. Chronic systemic inflammation, in fact, is the major cause of osteoporosis.

To initiate the inflammatory response, the body's first step toward protecting and healing damaged tissue is to put out a call for prostaglandins. These are naturally occurring chemicals that relax smooth muscle and cause peripheral vasodilation to facilitate blood flow. The body produces a specific prostaglandin called PGE2 from fatty acids found in abundance in red meat and dairy products. In addition to vasodilation, PGE2 is responsible for the fever we get when we are sick. It can also be responsible for muscle and joint pains, and, even skin sensitivity—one of my symptoms. These sensations can happen when there is an imbalance in dietary fatty acids, such as an excessive intake of omega 6 fatty acids, even when we aren't sick. It sure was looking like my discovery that I was low in omega 3 fatty acids, coupled with Gilbert's syndrome, may not only connect the dots to my symptoms, but also to my elevated bone resorption markers...and to my osteoporosis.

There are other prostaglandins not directly involved in the inflammatory response but which help prevent excessive inflammation. These prostaglandins are derived from the omega 3 fatty acids, ones found in oils from flaxseed, algae, and in cold-water fish. The sources of these fatty acids happen to be less prevalent in the typical American diet, and this is part of the reason why deficiency is common. That is, deficiency from terrible diets, which I was now beginning to see, was mine.

I felt like I was on to something important, or at least my forever positive attitude was grasping for something—anything—to shed some light on this thing. I dug deeper into the research about prostaglandins and as it turned out they weren't just important for the inflammatory response, but they were involved in bone metabolism! Prostaglandins are made by osteoblasts and can stimulate both the formation and resorption of bone. This was certainly another huge clue. Here was something that seemed to link my vague symptoms (skin sensitivity, irritability, and intermittent feelings of weakness) to two different body systems: the immune's inflammatory response AND bone biology. In addition, it was my first indication that the chronic hip inflammation and the bone loss could be linked after all. I kept remembering what an endocrinologist from the Mayo Clinic and the one from California had said, that there was "NO connection" between my persistent hip pain and the osteoporosis. They acknowledged the connection between the hip stress fractures and the osteoporosis but not the persistent hip inflammation. I didn't understand how they could be so sure about something like that.

But why was I deficient in fatty acids? The endocrinologist had told me that he had tested for diseases that could interfere with absorption, but that these tests came back normal. Plus, I had none of the symptoms typically seen with tropical sprue, Whipple's disease, Crohn's disease, Zollinger-Ellison syndorome, or any of the other 20 or so absorption disorders described in the medical texts.

When I began to look more closely at my diet I discovered that even Americans eating a fairly "good" diet aren't getting enough omega 3s. If highly processed foods, especially ones made with hydrogenated oils, are a large part of ones diet, imbalances of fatty acids become even more common. Looking back to my intense training years, I was certainly not as vigilant about eating well or for that matter eating at all. At times when money was tight I may have just let meals slide, and certainly processed foods were part of my diet. Even so, I felt there had to be more to this picture than just diet. Currently I was eating more healthy foods, avoiding junk foods, and consuming salmon and other cold water fish that were good sources of omega 3s. I knew that eating healthily and taking in good quality nutrients was only one part of the complex process of nourishment for life and growth. There just had to be more to this story.

I went back to thinking about problems that could interfere with the absorption of nutrients, like poor digestion or malabsorption. The more I read about osteoporosis, the more celiac disease popped up in the writing. But the endocrinolgist had ruled out celiac disease. Or had he? I went over the prior lab work from over a year before and found the test results for anti-tissue transglutaminase IgA (tTGA) (the blood test for celiac disease). The result: 19 U/mL with a reference range of less than 20 units as negative, 21 to 24 units as borderline, and 25 units and over as positive for celiac disease. Yes, it looked like I was negative for celiac disease. But I got to thinking, how can this be a pregnancy "yes/no" type test? It didn't seem like that at all. What was this tTGA test testing for anyhow? When I found out that transglutaminase was an enzyme released by gluten damaged enterocytes (cells lining the intestinal tract) and their microvilli (small appendages for better absorption of nutrients) in the gut it clicked! If my test result was 19 U/mL and 20 is borderline positive, well, there MUST be some kind of damage to my gut taking place. Maybe not total damage to the extent that my gut's microvilli 
were totally atrophied (flattened) (which is what happens in Celiac disease) but damaged none-the-less.

Celiac disease is an intolerance to gluten in wheat, barley, and rye that causes all kinds of abdominal symptoms. Bloating, diarrhea, constipation, these are all symptoms of celiac disease. The more I read about the disorder the more intrigued and excited I got—especially when I came upon the term, silent celiacs. These are people who have celiac disease but have few or no symptoms at all when they eat food with gluten in it. Now I was really thinking, maybe my 19 U/mL for tTGA was significant after all.

I had none of the typical bloating, constipation, diarrhea, kind of symptoms seen with celiac. But I did have intense abdominal pain after hard runs that I was now relating, at least in part, to Gilbert's syndrome. With this elevated tTGA test result it occurred to me that although I may not have full blown celiac disease I sure could have a sensitivity of some kind to gluten. A sensitivity severe enough to cause some loss of absorption or an influence of some kind on my bone health. I knew I needed to do some more testing on my own. The next two tests I did were the antibodies for gliadin (gluten), IgG and IgA. The results: 36 and 42 units respectively. With a reference range of less than 20 units being negative and 20 or more units indicating that antibodies to gliadin were detected, I knew this was significant. I may not have celiac disease with microvilli flattening but there was enough sensitivity to gluten that the enterocytes were "leaking" transglutaminase. These cells were certainly not happy and indeed were causing an immune inflammatory response.

With these results, the possibility of nutrient malabsorption was a concern. And even if the damage from gluten in my diet wasn't severe enough to cause severe malabsorption my research uncovered a little known fact. One that most doctors have no idea exists. Bone loss caused by gluten sensitivity is not simply from the malabsorption of nutrients. A person's sensitivity to gluten can lead to bone loss through two completely different physiological mechanisms. Besides causing damage to enterocyte microvilli which leads to malabsorption, gluten sensitivity triggers a systemic rise in proinflammatory cytokines. These cytokines, along with the release of a protein called zonulin by the enterocytes, causes the tight junctions between the cells to separate forming the condition of "leaky gut". Gluten and other huge molecules enter through these large openings setting off a systemic inflammatory response (thus the elevated anti-gliadin IgG and IgA tests). When this occurs for months and years at a time, it can produce a chronic systemic inflammatory response. Yes, I was now seeing real, specific threads in this entangled web of bone loss. It was one of the most powerful aha moments in my life.

"Hang out with your fear when you're feeling afraid. Follow its movement. Become intimate with it. Fear is an opportunity. Approach it like a tracker in the forest — watch where it goes, what it does, what it eats, where it eats, where it rests, where it turns, where it stops, where it hides. Embrace it. Stay with it."
                                                                                Paul Rezendes, The Wild Within

 ... Stay tuned for Part X of DX Severe Osteoporosis

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