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Osteoporosis

Osteoporosis

Description

Osteoporosis literally means porous bone. Although the entire skeleton may be involved, bone loss is usually greatest in the spine, hips and ribs. Since these bones bear a great deal of weight, they are then susceptible to pain, deformity or fracture.

Normally there is a decline in bone mass after the age of 40. This bone loss is accelerated in patients with osteoporosis. Many factors can result in excessive bone loss and different variants of osteoporosis exist. All of these other causes of accelerated bone loss should be ruled out before a diagnosis of osteoporosis is made. Postmenopausal osteoporosis is the most common form of osteoporosis currently.

Although considered by many to be just a loss of calcium in the bones, osteoporosis involves both the mineral (inorganic) and the non-mineral (organic matrix) of bone. This is the first clue that there is more to osteoporosis than a lack of dietary calcium. In fact, lack of dietary calcium in the adult results in a separate condition known as osteomalacia or "softening of the bone." The two conditions, osteomalacia and osteoporosis, are different in that in osteomalacia there is only a deficiency of calcium in the bone. In contrast, in osteoporosis there is a lack of both calcium and other minerals as well as a decrease in the non-mineral framework (organic matrix) of bone. Primarily composed of collagen and other proteins, little attention has been given to the important role this organic matrix plays in maintaining bone structure.

It is currently estimated 15 million persons in the United States have osteoporosis with nearly one-third of all women over the age of 60 being affected. Although many physicians recommend estrogen replacement for their postmenopausal women, at present time it is generally agreed the risk outweighs the benefit in the majority of women who are at risk for osteoporosis. Instead, a greater emphasis should be placed on those nutritional and lifestyle factors. In the severe case, improvement may result by the administration of estrogen, 1,25- (OH)2D3, or calcitonin (all of these are prescription medications).

Causes

Many general dietary factors have been implicated in the development of osteoporosis: low calcium-high phosphorus intake, high protein diet, high acid-ash diet, and trace mineral deficiencies to name a few. In addition to these strong dietary associations with osteoporosis, other things implicated in the development of osteoporosis include: hypochlorhydria; a disturbance in vitamin D metabolism; and several hormonal factors.

Hypochlorhydria
The absorption of calcium is dependent first on becoming ionized in the intestines. This has been the major problem with the most widely used form of calcium used for supplementation, calcium carbonate. In order for calcium carbonate and other insoluble calcium salts to be absorbed they must first be solubilized and ionized by stomach acid. This is where the problem arises for many individuals. In studies with postmenopausal women, it has been shown about 40% are severely deficient in stomach acid a condition known as hypochlorhydria. It has been shown that patients with insufficient stomach acid output can only absorb about 4% of an oral dose of calcium as calcium carbonate while a person with normal stomach acid can typically absorb about 22%. Patients with low stomach acid secretion need a form of calcium already in a soluble and ionized state, like calcium citrate, calcium lactate or calcium gluconate. About 45% of the calcium is absorbed from calcium citrate in patients with reduced stomach acid compared to 4% absorption for calcium carbonate. This clearly demonstrates ionized calcium is much more beneficial than insoluble calcium salts like calcium carbonate in patients with reduced stomach acid secretion. It has also been demonstrated calcium is more bioavailable from calcium citrate than from calcium carbonate in normal subjects as well. In any event, calcium citrate appears to be the best form to supplement with at this time for best absorption.

Vitamin D
Vitamin D stimulates the absorption of calcium. Since vitamin D can be produced in our bodies by the action of sunlight on 7-dehydrocholesterol in the skin, many experts consider it more of a hormone than a vitamin. The sunlight changes the 7-dehydrocholesterol into vitamin D3 (cholecalciferol). It is then transported to the liver and converted by an enzyme into 25-hydroxycholcalciferol (25-OHD3) which is five times more potent than cholecalciferol (D3). The 25-hydroxycholecalciferol is then converted by an enzyme in the kidneys to 1,25-dihydroxycholecalciferol (1,25-(OH)2D3), which is ten times more potent than cholecalciferol and the most potent form of vitamin D3. Disorders of the liver or kidneys results in impaired conversion of cholecalciferol to more potent vitamin D compounds. In many patients with osteoporosis there are high levels of 25- OHD3 while the level of 1,25-(OH)2D3 is quite low. This signifies an impairment in conversion of 25-OHD3 to 1,25-(OH)2D3 by the kidney in osteoporosis. Many theories have been proposed to account for this decreased conversion including relationships to estrogen and magnesium deficiency.

Hormonal factors
The concentration of calcium in the blood is strictly maintained within very narrow limits. If levels start to decrease there is an increase in the secretion of parathyroid hormone by the parathyroid glands (there are four parathyroid glands nestled in the thyroid gland that secretes this hormone) and a decrease in the secretion of calcitonin by the thyroid and parathyroids. If calcium levels in the blood start to increase there is a decrease in the secretion of parathyroid hormone and an increase in the secretion of calcitonin. An understanding of how these hormones increase (parathyroid hormone) and decrease (calcitonin) serum calcium levels is necessary in understanding osteoporosis.

Parathyroid hormone increases serum calcium levels primarily by increasing the activity of the cells that breakdown bone (osteoclasts), although it also decreases the excretion of calcium by the kidneys and increases the absorption of calcium in the intestines. In the kidneys, parathyroid hormone increases the conversion of 25-OHD3 to 1,25-(OH)2D3. One if the theories relating bone loss to estrogen deficiency is as follows: an estrogen deficiency makes the cells that breakdown bone (osteoclasts) more sensitive to parathyroid hormone resulting in increased bone breakdown thereby raising serum calcium levels. This leads to a decreased parathyroid hormone level which results in diminished levels of active vitamin D and increased calcium excretion as well. Evidence in osteoporosis patients seems to support this theory.

Calcitonin acts on lowering serum calcium levels by increasing the activity of the cells building bone (osteoblasts). Obviously this is a very desirable effect. Low calcitonin levels are found in postmenopausal osteoporosis and may be responsible for this type of bone loss. Recently calcitonin (isolated from salmon) has demonstrated remarkable effects in clinical studies and holds much promise in treating severe osteoporosis. Since calcitonin secretion can be increased by an elevation in serum calcium levels, this may be one of the ways calcium supplementation exerts its protective effect.

Lifestyle factors in the development of osteoporosis
Coffee, ethanol, and smoking induce a negative calcium balance and are associated with an increase risk of developing osteoporosis. As smokers tend to drink more coffee and ethanol, and consume a diet high in refined carbohydrate, it is very difficult to control for these other variables when trying to determine why smokers have a 15-30% lower bone mineral content compared to non-smokers. Smoking in relationship to causing osteoporosis is probably a greater statement of a lifestyle than a direct causal relationship.

Physical exercise consisting of one hour of moderate activity three times a week has been shown to prevent bone loss. In fact, this type of exercise has actually been shown to increase the bone mass in postmenopausal women. Walking is probably the best exercise to start with. In contrast to exercise, immobilization doubles the rate of urinary and fecal calcium excretion resulting in a significant negative calcium balance.

Signs & Symptoms

Osteoporosis is a condition without major signs and symptoms until the disease has progressed to a very serious extent at which time such things as severe backache, loss of height due to vertebral compression and develop of a "widow's hump." Severe bone loss may result in spontaneous fractures of the vertebrae or hip.

Nutritional Supplements

Structure & Function:
        Bone Support &
        Multi Vitamin/Multi Mineral Formulas


---------------------------------
General Supplements
---------------------------------

Adult
Bee propolis*
Calcium (citrate)1,000 mg
DHEA*
Folic acid 900 mcg
Magnesium (citrate) 500 mg
Melatonin*
N-A Glucosamine*
Proanthocyanidins*
Vitamin B-6 25 mg
Vitamin B-121,000 mcg


Vitamin K*

* Please refer to the respective topic for specific nutrient amounts.

Calcium

Supplementation of calcium has been shown to be effective in reducing age-related bone loss. Many experts are recommending a daily calcium intake of 1,500 mg. This typically means supplementation in the range of 1,000 to 1,200 mg is required. As mentioned above, the absorption and retention of calcium is dependent on a complex interplay of hormones and other factors. The initial approach is supplementation with the most bio-available form of calcium. At this time, calcium citrate appears to be the best form of calcium to supplement with both in regards to better absorption and decreased risk of developing kidney stones.

Concern has arisen that increased calcium supplementation may result in increased calcium oxalate nephrolithiasis. Calcium citrate appears to bypass this justifiable concern. While urinary calcium will rise in patients consuming calcium citrate, some of citrate's effects inhibit the formation of kidney stones. Specifically citrate has the ability to reduce urinary saturation of calcium oxalate and calcium phosphate, and retard the nucleation and crystal growth of calcium salts. While the use of non-citrate calcium supplements may increase the risk of developing calcium oxalate kidney stones while on the other hand calcium citrate appears to greatly reduce this risk.

One natural source is dolomite, although concerns have been expressed about other minerals within the same rock sample.


Magnesium

Magnesium supplementation is as important as calcium supplementation. Osteoporotics have lower bone magnesium content and other indicators of magnesium deficiency than people without osteoporosis. In human magnesium deficiency, there is a decrease in serum concentration of the most active form of vitamin D (1,25-dihydroxycholecalciferol or 1,25-(OH)2D3). This could be either due to the enzyme needed in the conversion of 25-OHD3 to 1,25-(OH)2D3 or mediation of parathyroid hormone and calcitonin secretion. Intake of dairy foods fortified with vitamin D results in decreased magnesium absorption. This combined with the high number of osteoporotics that cannot tolerate milk (27-47%) indicates that milk may not be an appropriate food to prevent osteoporosis.


Vitamin B-6, folic acid, and vitamin B-12

Low levels of these nutrients are quite common in the elderly population and may cause osteoporosis. These vitamins are important in the conversion of the amino acid methionine to cysteine. If deficient in these vitamins or if a defect exists in the enzymes responsible for this conversion, there will be an increase in homocysteine. This compound has been implicated in a variety of conditions including arteriosclerosis (hardening of the arteries) and osteoporosis. Increased homocysteine concentrations in the blood have been demonstrated in postmenopausal women and is thought to play a role in osteoporosis by interfering with collagen cross-linking leading to a defective bone matrix. Since osteoporosis is known to be a loss of both the organic and inorganic phases of bone, this theory has much credence as it is one of the few that addresses both factors. Folic acid supplementation has been shown to reduce homocysteine levels but vitamin B-6 and B-12 are necessary for this to occur.

It should be noted ( for those who like to obtain their nutrients from natural sources) that brewer's yeast has been stated to be contra-indicated for osteoporosis.


Vitamin K

The major non-collagen protein in bone is osteocalcin. This protein is dependent on vitamin K to be in its active form. Vitamin K is necessary for the gamma-carboxylation of the glutamic acid portion of osteocalcin allowing the osteocalcin to chelate the calcium and hold it into place within the bone. A deficiency of vitamin K could lead to impaired mineralization of the bone due to inadequate osteocalcin levels. Vitamin K is found in green leafy vegetables and may be one of the protective factors of a vegetarian diet. Vitamin K deficiency is quite high in individuals with chronic gastrointestinal disorders or poor fat absorption.



Note: All amounts are in addition to those supplements having a Recommended Dietary Allowance (RDA). Due to individual needs, one must always be aware of a possible undetermined effect when taking nutritional supplements. If any disturbances from the use of a particular supplement should occur, stop its use immediately and seek the care of a qualified health care professional.

Nutrient Depletion

Low levels of B-complex (Vitamin B-6, folic acid, and vitamin B-12) are quite common in the elderly population and may contribute to osteoporosis.

It is important to maintain an adequate diet rich in calcium and vitamin D while taking e.g. Calcitonin.

Osteoporotics have lower bone magnesium content and other indicators of magnesium deficiency than people without osteoporosis.

The major non-collagen protein in bone is osteocalcin. This protein is dependent on vitamin K to be in its active form. Vitamin K deficiency is quite high in individuals with chronic gastrointestinal disorders or poor fat absorption.

Drug Interactions

Alendronic acid is generally well tolerated; although mild gastrointestinal adverse events predominate, the frequency of these is low.

Table: Benefits and Disadvantages of HRT

Positive EffectsNegative Effects
(Decreased)(Increased)
Bone lossVaginal bleeding, nausea, breast tenderness [estrogen]
Fracture rateFluid retention, weight gain, PMS [progestogen]
Menopausal symptomsBreast cancer
Heart disease mortalityVenous thromboembolism
Alzheimer's disease



Biphosphonates [e.g. alendronic and etidronic acids [Etidronate (Didronel)] inhibit bone resorption. Several others are expected on the market within the next few years (e.g. clodronic acid, ibandronic acid, pamidronic acid, risedronic acid, tiludronic acid and zoledronic acid). Treatments have resulted in modest gains in bone mineral density (5-8% over 3 years) but reduced new vertebral fractures by half. (Black, 1996 and Harris, 1993)

As a class they are poorly absorbed from the gastrointestinal tract and need to be taken on an empty stomach at least 2 hours before the next meal. (Sahota, 1997)

Dietary Considerations

Many general dietary factors have been implicated in the development of osteoporosis: low calcium-high phosphorus intake, high protein diet, high acid-ash diet and trace mineral deficiencies to name a few. Therefore, a High Calcium Diet is recommended.

A vegetarian diet (both lacto-ovo and vegan) is associated with a lower risk of osteoporosis. Although bone mass in vegetarians does not differ significantly from omnivores in the third, fourth, and fifth decades, there are significant differences in the later decades. This indicates the decreased incidence of osteoporosis in vegetarians is not due to increased initial bone mass, but rather decreased bone loss.

Several factors are probably responsible for this decrease in bone loss observed in vegetarians. Most important is probably a lowered intake of protein and phosphorus. A high-protein diet or a diet high in phosphates is associated with increasing the excretion of calcium in the urine. Raising daily protein from 47 to 142 grams doubles the excretion of calcium in the urine. A diet this high in protein is common in the United States and may be a significant factor in the increased number of people suffering from osteoporosis in this country.

Following sugar intake, there is an increase in the urinary excretion of calcium. Considering the average American consumes in one day 150 grams of sucrose, plus other refined simple sugars, and a glass of a carbonated beverage loaded with phosphates, along with the high-protein, it is little wonder that so many suffer from osteoporosis in this country. When lifestyle factors are also taken into consideration, it is very apparent why osteoporosis has become a major medical problem.

In general, a diet high in vegetables, but low in fat and animal products, should be adopted. Refined carbohydrate and ethanol intake should be held to a low level and carbonated beverages loaded with phosphates should be completely eliminated.

Homeopathic Remedy

Long Term Treatment

1. Calcarea carbonica - 30C
2. Calcarea fluorica tinct. - 30C

Treatment Schedule

Doses cited are to be administered on a 3X daily schedule, unless otherwise indicated. Dose usually continued for 2 weeks. Liquid preparations usually use 8-10 drops per dose. Solid preps are usually 3 pellets per dose. Children use 1/2 dose.

Legend

X = 1 to 10 dilution - weak (triturition)
C = 1 to 100 dilution - weak (potency)
M = 1 to 1 million dilution (very strong)
X or C underlined means it is most useful potency

Asterisk (*) = Primary remedy. Means most necessary remedy. There may be more than one remedy - if so, use all of them.

References

Boericke, D.E., 1988. Homeopathic Materia Medica.

Coulter, C.R., 1986. Portraits of Homeopathic Medicines.

Kent, J.T., 1989. Repertory of the Homeopathic Materia Medica.

Koehler, G., 1989. Handbook of Homeopathy.

Shingale, J.N., 1992. Bedside Prescriber.

Smith, Trevor, 1989. Homeopathic Medicine.

Ullman, Dana, 1991. The One Minute (or so) Healer.

Herbal Approaches

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Herbs
-----------


Blackberries
Blueberries
Hawthorn berry
Horsetail

Note: The misdirected use of an herb can produce severely adverse effects, especially in combination with prescription drugs. This Herbal information is for educational purposes and is not intended as a replacement for medical advice.

Discussion:

Procyanidins are responsible for the deep red-blue color of many berries including: hawthorn berries, blackberries, blueberries (bilberry), etc. Procyanidins are remarkable in their ability to stabilize collagen structures. Since collagen is the major protein structure in bone, stabilization of its integrity and structure appears very much indicated. Supplementation with a concentrated extract of those berries rich in these types of flavonoids may offer significant benefit in preventing osteoporosis. Hawthorn berry (Crataegus oxycantha) is a particularly rich source.

Horsetail provides silica.

Newall has compiled a list of hormonally Active Herbs:

HerbEffect
Agnus CastusHormonal imbalance disorders
AlfalfaEstrogenic, in vivo
AniseedEstrogenic
BayberryMineralocorticoid
Cohosh, BlackEstrogenic
Fucus / KelpHyper-/hypothyroidism reported.
GinsengEstrogenic, human
HorseradishMay depress thyroid activity
LicoriceMineralocorticoid activity, human.
estrogenic in vivo, in vitro
Motherwortoxytocic
Pleurisy RootEstrogenic
Red CloverEstrogenic in vivo
Saw PalmettoEstrogenic and anti-androgenic in vivo,
human use in prostate cancer.
VervainInhibition of gonadotrophic activity
Wild CarrotEstrogenic



References:

Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health-care Professionals. London: The Pharmaceutical Press, 1996.

Aromatherapy - Essential Oils

Chamomile Essence,Cardamom Essence,
Cypress Essence,Lavender Essence,
Melissa Essence,Rosemary Essence,
Sandalwood Essence,Thyme Essence.


Related Health Conditions

AcheHyperthyroidism
AcromegalyInflammation
AgingMalnutrition
AlcoholismMenke's syndrome
AnemiaOral contraceptives
BackachePaget's disease
FracturePain
Cushing's syndromePulmonary disease
Diabetes mellitusScurvy
EpilepsyStress



Abstracts

References

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