Osteoporosis - practical nutritional considerations
Osteoporosis is a modern disease of Western Society. It is an inevitable part of metabolic syndrome - that constellation of symptoms which arises when one eats too much sugar, high sugar fruits, grains and refined carbohydrates. Primitive societies eating stoneage diets do not suffer from osteoporosis. So the underlying principle for avoiding osteoporosis is that we should mimic primitive cultures eating a Stone Age Diet and living a toxin free life. This does not mean you need to run around half naked in a rabbit skin loin cloth depriving yourself of the pleasures of 21st Century Western life. We need to cherry pick from the good things of both civilisations!
[In fact, more often I now prescribe the ketogenic diet - please see Ketogenic diet - the practical details and My book The PK Cookbook - Go Paleo-ketogenic and get the best of both worlds.]
Evolutionarily correct lifestyle
To produce strong healthy bones, one needs two essential elements - first of all, the stimulus to lay down bone and secondly, the raw materials to do so. It is the old story - if you do not use it, you lose it and disuse atrophy of bones occurs just like disuse atrophy of muscles. The body has to be metabolically prudent and will only develop in response to demand. One reason why astronauts can only spend a short time in space is because as soon as they become weightless, no forces pass through bone and they develop severe osteoporosis. Putting a patient to bed has a similar effect. We now know that the mechanism by which this occurs is called the piezo-electric effect. The forces of gravity through bones create fluctuating electrical charges which stimulate the formation of new bone. It is these changing forces which appear to be the most powerful stimulus, which is why "rebounding" has long been a popular treatment to prevent osteoporosis - it is fun, fairly effortless and puts changing gravitational fields through all weight bearing bones. But any form of exercise is going to be highly beneficial and desirable. This is one reason why CFS is a major risk factor for osteoporosis - sufferers cannot exercise.
The medical profession would have us believe that the only important constituent of bone is calcium. Actually bone is made up of many different minerals including, in order of proven importance, magnesium, calcium, strontium, boron, silicon, selenium, zinc, chromium and maybe others. For its formation it also requires a whole range of vitamins, essential fatty acids and amino acids. All these nutrients are supplied liberally by a stoneage diet based on meat, fish, eggs, nuts, seeds and vegetables. Western civilisation now gets 70% of its calories from four foods, namely grains, dairy, potato and sugar - sugar is already a refined food, most grains are eaten refined, as are potatoes. The refining process strips out many essential micronutrients and these are further depleted by storage, cooking, packing and light. In addition to this, many other substances we consume have a diuretic effect, in particular tea and coffee and alcohol, and this further strips essential micronutrients from the body. There are a great many studies which show that modern Western diets are markedly deficient in these essential micronutrients. By following my standard recommendations for supplements combined with a stoneage, or better still the PK, diet and exercise you will prevent osteoporosis.
We need daily sunshine to prevent osteoporosis
The most important vitamin for protecting against osteoporosis is vitamin D. There are no major food sources of vitamin D. Levels in milk are low and this may be because of the modern agricultural practice of keeping cows indoors - they too make vitamin D from sunshine and if they do not get sunshine exposure, then they will not have any vitamin D either. Vitamin D is present in cod liver oil, but one would have to eat about half a salmon a day in order to get a reasonable dose of vitamin D. Really the only serious source of vitamin D is from sunshine. Humans evolved in hot climates, where the effect of sunshine on the skin resulted in high levels of circulating vitamin D and this is probably the physiological norm. At present we are running blood levels of vitamin D, which are only about half of the desirable level. The incidence of osteoporosis increases the further away from the Equator one lives. My personal view is that if you do not get a daily dose of sunshine (by which I mean 20 minutes exposure to face, arms and chest), then you should take a vitamin D supplement. There was an interesting study of patients in a residential home being given a high dose vitamin D prescribed to prevent hip fractures. Interestingly hip fracture rate was reduced almost immediately, far too soon for vitamin D to have any impact on bone density. The reason for this was that vitamin D improved the muscular strength, balance and co-ordination of residents, which made them very much less likely to fall over.
One hour of Mediterranean sunshine would supply about 10,000iu of vitamin D. This occurs through the action of sunshine on cholesterol in the skin. If the body perceives a deficiency in vitamin D then it responds by pushing out more cholesterol, so that when the sunshine does come along, vitamin D can be made more efficiently. Therefore, raised cholesterol may well be one symptom of vitamin D deficiency. My recommendations are that during the winter months we should all routinely be taking 2,000iu of cholecalciferol daily. For people with osteoporosis I often use up to 50,000iu per week.
The right sort of vitamin D
British National Formulary contains several preparations of calcium and vitamin D. These preparations are doomed to failure for two reasons. First of all osteoporosis is not a symptom of calcium deficiency; actually magnesium is far more important as a trace element in preventing osteoporosis. Giving a calcium supplement further inhibits absorption of magnesium and is therefore more likely to make the situation worse. Secondly, the dose of vitamin D in the supplement is inadequate. Most contain 400iu of vitamin D. This is equivalent to two minutes of Mediterranean sunshine, which is totally insufficient to raise plasma levels of vitamin D. Thirdly, vitamin D is often present as ergocalciferol, which has only a quarter of the physiological effect (so equivalent to about 20 seconds of sunshine!). The reasons for these disastrously low doses may be to do with normal ranges in the blood. Humans evolved running naked under the African sun and in Africa serum D3 levels are usually over 100. In this country the normal range is said to be about 20-70. The levels will vary according to the time of year that they are checked. It is likely that people in northern climes are chronically deficient in D3 and this has resulted in normal ranges being set disastrously low.
Is also protective against osteoporosis. The main source of vitamin K comes from friendly fermenting bugs in our gut. See Probiotics one natural source of vitamin K is green leafy vegetables - so eat plenty of these! Clinically problems arise in people taking Warfarin, which is a vitamin K blocker. Warfarin puts one at risk of osteoporosis so it is vital to pay attention to all other departments - see below. One can also take vitamin K supplements, say menadione 10mgs daily.
Dairy products INCREASE the risk of osteoporosis
Dairy products are a risk factor for osteoporosis. See []. It is a myth that dairy prevents such! Dairy products may be rich in calcium, but they contain low levels of magnesium. There is evidence to suggest that actually magnesium is more important in the prevention of osteoporosis than calcium. The ratio of calcium to magnesium and dairy products is ten parts to one, whereas our physiological requirements are for two parts calcium to one part magnesium. Furthermore, these two elements compete with each other for absorption and so excessive levels of calcium simply further reduce the ability to absorb magnesium. Primitive people eating a stoneage diet often have no dairy products and they have no osteoporosis. The standard advice that dairy products will protect against osteoporosis is based on highly dubious science.
Strontium and Osteoporosis
Strontium tends to accumulate in bone - especially where active remodeling is taking place. In 1959, researchers at the Mayo Clinic investigated the effect of strontium in 32 individuals suffering from osteoporosis.
Each patient received 1.7 grams of strontium per day as strontium lactate. Eighty-four percent of the patients reported marked relief of bone pain, and the remaining 16 percent experienced moderate improvement. No significant side effects were seen, even with prolonged (up to three years) administration of strontium. X-rays taken at the beginning and end of the study showed "probable" increased bone mass in 78 percent of the cases. This is not surprising, considering the symptomatic improvement reported by the patients. Unfortunately, measurement of bone mass in 1959 was pretty crude, leading the researchers to qualify their interpretation of the X-rays. Sophisticated tests such as dual photon absorptiometry and CT scanning as used today were not available at the time this study was conducted.
Nevertheless, because of the "strontium scare" of the 1950s, little follow-up was conducted until nearly 30 years later. In 1986, scientists administered 0.27 percent strontium to mice in their drinking water. This resulted in an increased rate of bone formation and decreased rate of bone resorption.
In another study, rats given extra strontium showed increased bone formation and greater bone density than rats fed a control diet. These reports suggested that the amount of strontium we ingest may reduce our risk of developing osteoporosis, and that strontium may play a role in the prevention of osteoporosis.
In 1985, Dr. Stanley C. Skoryna of McGill University in Montreal conducted a small-scale study that pointed to a potential role for strontium in the treatment of humans. Three men and three women with osteoporosis were each given 600 to 700 mg/day of strontium in the form of strontium carbonate. Bone biopsies were taken in each patient at the iliac crest (hip bone), before and after six months of treatment with strontium. Biopsy samples showed a 172 percent increase in the rate of bone formation after strontium therapy, with no change in bone resorption. The patients receiving strontium remarked that the pains in their bones had diminished and their ability to move around had improved.
Recently, interest in strontium has been rekindled by a number of studies using the strontium salt of ranelic acid (strontium ranelate). A large multi-center trial known as the strontium ranelate (SR) for treatment of osteoporosis (STRATOS) trial was designed to investigate the efficacy and safety of different doses of strontium in the treatment of postmenopausal osteoporosis.
The study included 353 osteoporotic women with at least one previous vertebral fracture and low scores of lumbar bone density. Patients received placebo or strontium in doses of 170, 340 or 680 mg/day for two years. The scientists evaluated lumbar and hip bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA). They also determined the incidence of new vertebral fractures, as well as several biochemical markers of bone metabolism. Lumbar BMD increased in a dose-dependent manner as shown in Figure 1.
Also, there was a significant reduction in the number of patients with new vertebral fractures in the second year of the group receiving the 680 mg/day dose. In the 680 mg/day group, there was also a significant positive change in markers of bone metabolism. The authors concluded that the 680 mg/day dose offered the best combination of efficacy and safety, and stated without equivocation that strontium ranelate therapy increased vertebral BMD and reduced the incidence of vertebral fractures.
A much larger trial by the same research team included 1,649 osteoporotic postmenopausal women. These subjects received 2 gm/day of strontium ranelate (providing 680 mg strontium) or placebo for three years. Calcium and vitamin D supplements were also given to both groups before and during the study. In addition to suffering fewer fractures, patients in the strontium group noted a risk reduction of 49 percent in the first year of treatment and 41 percent during the three-year study period. Patients in the strontium group increased lumbar bone mineral density by an average of 14.4 percent and femoral neck BMD an average of 8.3 percent. The authors concluded that "treatment of postmenopausal osteoporosis with strontium ranelate leads to early and sustained reductions in the risk of vertebral fractures."
There have been concerns that strontium causes venous thrombo-embolism. This is not biologically plausible. I suspect this issue has arisen for two possible reasons. The NHS prescribable strontium is made up with the artificial sweetener aspartame - this is known to cause thromboembolism. Secondly this NHS prescribable strontium is an unnatural salt - strontium ranelate. This does not occur in Nature (if it did then it could not be patented by the drug companies). One should use a natural salt such as strontium chloride or strontium carbonate.
For more information see Strontium breakthrough against osteoporosis
The Ageing Process
However, the most important risk factor for osteoporosis is age. With age metabolism becomes less efficient and therefore there is a greater need for micronutrients. This occurs when appetite and food intake decline as people become more sedentary. Therefore, it is my view that with advancing age, one should be taking a good multivitamin, multi-mineral, essential fatty acids and vitamin C and D as a routine dietary supplement. See Nutritional Supplements
Furthermore as we age we get less good at making stomach acid and this impairs absorption of minerals - see Hypochlorhydria
With age hormone levels decline and again there is good evidence in the literature which links osteoporosis with declining levels of anabolic hormones. The best documented are, of course, the sex hormones, such as testosterone, oestrogen and progesterone. The problem with replacing these hormones is that their long term use is associated with increased risk of cancer and arterial disease. Indeed, the latest advice from the Royal College of Obstetricians & Gynaecologists is that no woman should be taking hormone replacement therapy long term because of these increased risks. The two other hormones which are important for normal bone metabolism are DHEA and human growth hormone. The levels of these hormones decline in parallel with increasing age and, indeed, may partly account for the aging process. Certainly, when I measure salivary DHEA levels in people over the age of 60, they are consistently low. Some schools of thought advocate the routine taking of DHEA 25mg daily after the age of 60. DHEA in these doses is not associated with any long term risks of malignancy or arterial disease. I used to treat DHEA deficiency with DHEA. However, I believe pregnenolone is more physiological because it is upstream of all adrenal hormones including progesterone and cortisol. Cholesterol is the raw material from which steroid hormones are made in the body. The next biochemical step is pregnenolone- this is the mother and grandmother of all steroid hormones. Starting off with pregnenolone means that all steroid hormones can be naturally synthesised in the correct physiological balance. In theory this should greatly simplify the business of prescribing and monitoring hormones because the body can do its own natural balancing act. Indeed, it is possible it may be slightly protective. Exogenous (supplied from outside) human growth hormone is too expensive as a routine therapy for osteoporosis, but there are interventions that can be done which improve endogenous (originating from inside the organism) production. Older readers may recall nanny telling them that one hour's sleep before midnight is worth two hours after midnight. She was right. It is during the hours of sleep before midnight that one gets optimal production of human growth hormone. Production can further be improved by exercise, particularly isometric exercise such as weights. Furthermore, a diet of low glycaemic index also improves hGH production and this, of course, is what characterises the primitive stoneage diet.
Chemicals, including pesticides, persistent organic pollutants (POPs) and heavy metals effectively accelerate the normal ageing process - and this includes causing osteoporosis. Indeed a paper published in Bone Metabolism clearly showed that organophosphate pesticides cause osteoporosis. Anyone who has been occupationally exposed should be checked with a bone density scan and then do a detox regime. See Detoxification
Low stomach acid means that minerals will not be properly absorbed. As we age our ability to make stomach acid declines, this often results paradoxically in symptoms of too much acid and our doctors prescribe acid blockers - which of course makes the situation much worse. Proton pump inhibitors are a major risk factor for osteoporosis! See Hypochlorhydria
Conventional Treatment of Osteoporosis has its problems!
- Hormone replacement therapy is a major risk factor for cancer, heart disease and chronic fatigue syndrome and should be avoided.
- Bisphosphonates (eg Foasamax) - these may improve the bone density but they make the bone more brittle. They often make people feel very nauseated. Very few of my CFS patients tolerate this drug. Up to 10% of takers may develop osteonecrosis of the jaw.
- Calcium - when given in high doses, and on its own, calcium blocks the absorption of other minerals especially magnesium which is arguably more important than calcium in treating osteoporosis.
- Vitamin D - many prescribed forms of vitamin D are actually ergocalciferol ie D2. This is only 25% as effective as D3. The dose is prescribed is usually far too low to be of any use.
- NHS Strontium - this is now available on NHS prescription to treat osteoporosis, This would be excellent news but for the fact that the preparation is made up in a powder containing aspartame - an artificial sweetener which is nasty toxic stuff!
To Prevent Osteoporosis
- Eat a stoneage diet which avoids dairy products and is based on foods of low glycaemic index. More often I now prescribe the ketogenic diet - please see Ketogenic diet - the practical details and My book The PK Cookbook - Go Paleo-ketogenic and get the best of both worlds.
- Take micronutrient supplements including multivitamins, minerals (e.g. my Mineral Mix), essential fatty acids and vitamin C.
- Get as much sunshine as possible without actually burning (it is the burning that causes skin damage and increases risk of cancer). On sunless days take a vitamin D supplement.
- Take regular Exercise, 12 minutes a week is enough, to stimulate formation of bone and improve endogenous growth hormone production.
- Get a good night's sleep on a regular basis aiming for our physiological requirement, namely nine hours sleep between 9.30pm and 6.30am.
- At the age of 60 arguably everyone should measure their own DHEA levels and maybe supplement with this as well.
- Check for hypochlorhydria.
- Do not take stomach acid blockers.
- Consider a detox regime where there is evidence of toxic stress.
- Do not take HRT.
To Treat Established Osteoporosis
All of the above plus
- Extra vitamin D - up to 50,000iu per week
- Strontium carbonate or chloride 500mgs daily OR strontium citrate 300 mg x 2 daily - (I stock the latter)
- Take pregnenolone 50mgs sublingually daily. As we age our ability to make this declines.
- Take glucosamine or better still my Joint Mix
- Take vitamin K such as 10mgs daily. Probiotics. Or grow E. Coli (mutaflor) which synthesizes vitamin K in the gut. []
- Measure thyroid function - both underactive and overactive thyroids can cause osteoporosis.
- Do a detox regime - see Detoxification
- Get bone density scans done every two years to make sure the regimes is working.
To diagnose osteoporosis - bone density scan
A brilliant scanning service is available from Osteoscan! The practice is based in Mid-Wales, but it may be possible to arrange scan in other locations. Contact the company directly - e-mail Simon on firstname.lastname@example.org or telephone on 01497 847020.
My experience is that the above regimes are almost free from side effects, improve bone density reliably well and there is no need to take the drugs such as the bone builders, which almost invariably make people feel ghastly!
Do these nutritional regimes actually work?
I have gathered 14 patients who have had bone density scans done before and after treatment in which only nutritional supplements (as above) have been used. In every case the bone density either remained the same or was improved (ie the bone became more dense). So whilst the numbers are small the statistics are convincing.
- Adrenocortex Stress Profile (salivary)
- DHEA (saliva) single
- Thyroid profile: free T3, free T4 and TSH
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