Osteoporosis

Osteoporosis is a generalized skeletal disorder, characterized by compromised bone strength which predisposes individuals to an increased risk of fracture.

  • Bone strength reflects bone density and bone quality.
  • Osteoporosis is defined as a bone mineral density measurement (in the spine or hip) showing a t score below −2.5
  • Osteopenia – is defined as a t score between -1 and -2.5.  This is a statistical diagnosis.

Risk factors for fractures from the Women’s Health Initiative include a woman’s age, her self-reported health status, her weight and height, her race, her level of physical activity.  Other important factors are a history of a fracture after age 54 years, family history of a parental hip fracture, current smoking, current corticosteroid use, and/or treated diabetes.

The FRAX website helps you to calculate your personal risk of a hip fracture over the next 10 years. It can help you determine the value of medication in reducing your risk.  The number needed to treat is a concept that helps explain how many people need to take a medication for one person to be helped (ie. to prevent a fracture.)  TheNNT.org is a website that reviews this evidence.

Exercise:

  • Walking reduces risk of hip fracture by 41%
  • Balance training reduces the risk of falls – yoga, tai chi
  • Weight training strengthens bones and muscles
  • High impact exercises that are novel stresses may be best.  A table listing exercise intensity for beginners, moderate and high impact exercise can be found here.
  • BEST trial studied a set of exercises to maintain bone density.  Do these 6 exercises two-three times a week 1.Wall squat; 2. One-arm dumbbell military press  3.Leg press   4. Lat pull-down  5. Seated row   6. Back extension
  • A description of a new trial of yoga for bone health can be found here.  The 12 poses, by their English names, were tree, triangle, warrior II, side-angle, twisted triangle, locust, bridge, supine hand-to-foot I, supine hand-to-foot II, straight-legged twist, bent-knee twist and corpse pose. Each pose was held for 30 seconds. The daily regimen, once learned, took 12 minutes to complete.

A short video in which Dr Maizes explains the diet and supplements useful for preventing osteoporosis is on the Dr Oz website.

Diet:  Follow an anti-inflammatory diet.  This involves three principles:

Eat Fruits and Vegetables for your antioxidants

  • Seven to ten servings a day of vegetables and fruit.
  • Choose fruits and vegetables of all colors especially berries, tomatoes, orange and yellow fruits, and dark leafy greens.
  • Choose organic produce whenever possible.  Learn which conventionally grown crops are safest at www.ewg.org.

 Get sufficient Omega 3 in your diet or take a supplement

  • Sources include salmon (preferably fresh or frozen wild Alaskan, or canned sockeye), sardines packed in water or olive oil, herring, black cod (sablefish, butterfish), omega-3 fortified eggs, flaxseeds (preferably freshly ground), and walnuts.
  • Many people benefit from a fish oil supplement.  The dose will vary; in general look for one that has both EPA and DHA totaling 1000 mg. (this is different from the label reading 1000 mg of fish oil.  The EPA + DHA should equal 1000 mg)

 Eat low on the glycemic index (to avoid bursts of insulin.)

  • Eat more whole grains, beans, winter squashes, and sweet potatoes.
  • Avoid foods made with wheat flour and sugar, especially bread, crackers, cereals, and most packaged snack foods (including chips and pretzels).  Flour – whether it is white or whole wheat is a high glycemic index food.

Pay attention to the calcium content of foods.  Between 750-1500 mg are needed.  Calculate the approximate amount in your food and then add supplement as needed.

Milk (8 oz = 300 mg)    —   Yogurt (8 oz = 275-325 mg)

Cheese:

  • Calcium rich cheeses including cheddar, Swiss, Edam, Monterey Jack, Provolone, Parmesan, Romano, part-skim mozzarella (1 oz = 200-300 mg)
  • Moderate calcium containing cheeses including American, Gouda, Colby, whole milk mozzarella, feta, fontina, blue cheese, Camembert (1 oz = 100-200 mg)
  • Calcium “poor” cheeses Brie and Neufchatel (1 oz = 20-50 mg)

Salmon (3 oz canned, with bones = 180 mg)

Legumes: Soybeans (1/2 cup cooked = 90 mg;  White beans (1 oz cooked = 160 mg)

Leafy Greens: Spinach (1/2 cup = 120 mg); Turnip greens (1/2 cup = 100 mg) ; Broccoli (1/2 cup cooked or raw = 90 mg)

Dried figs (10 = 270 mg)

Almonds (1 oz dry roasted = 80 mg)

Calcium supplements are all mixtures of calcium and other compounds.  For example calcium carbonate is 40% calcium and 60% carbonate.  Read labels carefully for the amount of “elemental” calcium in the supplement.  If your diet contains little calcium rich foods, you may supplement beyond your diet.

Vitamin D is critical to healthy bone formation. Check your 25(OH) Vitamin D level to help determine your need.  Vitamin D can be obtained from sunshine, foods rich in Vitamin D, or supplements.  As we get older we are less able to convert sunshine to Vitamin D

Vitamin D rich foods include:   Salmon- Chinook, Coho, pink Humpback, Sockeye (3 ounces = 730 IU);  Sardines, Pacific, canned (3 ounces = 430 IU);   Tuna, canned, light or white (3 ounces = 50 IU);  Milk (fortified, 1 cup = 100 IU);   Fortified rice or soy beverage (1 cup = 80 IU);   Egg yolk (1 = 25 IU)

Increase your soy foods to more than 5 grams per day – From whole or minimally processed soy foods.  Fermented soy (tempeh, miso, and natto) may be more bioavailable.   Avoid soy isolates.

  • Soy milk (1 cup =16 grams)
  • Tofu  (¼ block = 6 grams)
  • Tempeh (1/2 cup = 16 grams)
  • Soybeans (1/2 cup = 12 grams)
  • Miso (1/2 cup = 16 grams)

Protein – sufficient protein is needed to build bones.  0.8 g/kg is necessary for the average person’s needs; for adults over the age of 65, 1.0 g/kg may be better.  Eat more vegetable protein, especially beans and soybeans.

 Foods to avoid

  • Excess coffee (more than 4 cups a day)
  • Alcohol (more than 2 beverages per day)
  • Processed foods and fast food

Vitamins and Minerals:

  • The best way to obtain your daily vitamins, minerals, and micronutrients is by eating a diet high in fresh foods with an abundance of fruits and vegetables.
  • Calcium helps prevent fractures. The ideal amount recommended differs depending on the country you live in.  In the US 1200 mg a day is recommended – this is from all sources – food and supplement.  Other countries recommend much lower amounts.
  • In addition, supplement your diet with the following antioxidant cocktail:
    • Vitamin C, 200 milligrams a day
    • Vitamin E, 400 IU of natural mixed tocopherols and tocotrienols(d-alpha-tocopherol with other tocopherols)
    • Selenium 200 micrograms
    • Mixed carotenoids, 10,000 to 15,000 IU daily

Your daily multivitamin-multimineral supplement should also provide at least 400 micrograms of folic acid and at least 1,000 IU of vitamin D.  Boron, manganese, zinc, and copper should be present in small amounts.  There should be no iron.

Medications:

Reduction in fractures is considered to be the only relevant end point for the assessing drugs used in the treatment of osteoporosis.  Ask your doctor about the number needed to treat when weighing beginning a medication. Or look it up yourself using a very useful website: thennt.com

  • Bisphosphonates
    • Aledronate (Fosamax) (10 mg daily or 70 mg weekly)
    • Risedronate (Actonel)  (5 mg daily or 35 mg weekly)
    • Ibandronate (Boniva) (2.5 mg daily or 150 mg monthly)
    • Zoledronic Acid (Reclast, Zometa) IV once a year
  • Selective Estrogen Receptor Modulators (SERMs)
    • Raloxiphene (Evista)
  • Estrogen (various regimens)
  • Parathyroid Hormone (Forteo) 20-40μg/day
  • Monoclonal Antibody (Donusumab)

In these interviews with Dr Andrew Weil, Dr Maizes discusses the effectiveness of Boniva and Reclast.