Osteoporosis: A New approach
What is Osteoporosis?
Osteoporosis, or thinning of the bones, is a big industry in the United States, with millions of dollars spent on testing and treatments that are usually expensive and have side effects. Of course, nobody wants to have a bone fracture. Is it needed, or is there a simple solution to help preserve bone health?
First, an explanation of what osteoporosis is. Osteoporosis is defined by a DXA test that looks at the bone density in a bone density machine, in the lumbosacral area (back), the hip area (femoral), and sometimes in the forearm (radius). They give 2 scores. One is the T-score, which is the bone density compared to a young person of the same gender. Osteoporosis is defined as a T-score that is greater than -2.5 standard deviations from that of a young person. No other test in medicine compares people to a young person, so, from Dr. Friedman’s view, this does not make that much sense. The osteoporosis experts say you do not want to decrease bone density, but, in general, bone density does decrease with age.
Probably the more accurate test, which is not used, would be the Z-score, which is the bone density compared to people of the same age and gender. Most elderly patients, especially women, will have at least osteopenia, which is defined as a T-score between -1.0 and -2.5. Many of them will also have osteoporosis, defined as a T-score greater than -2.5, even though the chances of fracture are pretty low.
Bone density is influenced by multiple hormonal factors, including estrogen decline after menopause and thyroid hormone levels, which are often overlooked when osteoporosis is treated in isolation.
The reason why bone density is done is to prevent fractures. Most fractures occur with falls, so it makes more sense to prevent people from falling, in addition to trying to keep their bones strong. Little emphasis is done on working on muscle strength and balance to help prevent people from falling.
Bone density markers
In addition to, or sometimes instead of, a bone density test, Dr. Friedman recommends a urine test called a urinary N-telopeptide (N-Tx) that is done on the second urination of the day. Dr. Friedman has an article on this on his website at
https://www.goodhormonehealth.com/best-tests-to-predict-likelihood-of-a-fracture/.
This test tells what is happening with bone breakdown currently, while the DXA scan looks at bone density over one’s whole life. Therefore, they can be done together, with the urinary N-telopeptide telling what is happening now and the bone density telling what is happening over one’s life.
If high, urinary N-telopeptide shows active breakdown and is bad, while a urinary N-telopeptide at a normal level shows normal bone turnover and is favorable. Dr. Friedman uses this test to determine who should get treatment and who should not get treatment for osteoporosis.
The test is also helpful in patients with hypothyroidism on treatment and having a suppressed TSH. A high N-telopeptide might lead Dr. Friedman to lower the thyroid dose, while a normal N-telopeptide might lead Dr. Friedman to keep the same dose.
More information on thyroid conditions can be found here.
Osteoporosis medicines
The current osteoporosis medicines are either older drugs, of which the main one is alendronate, that work modestly well but is hard to take because you have to take it standing for a half hour. Otherwise, you can get esophageal and stomach problems. It is usually given once a week. It is inexpensive, but it can lead to depression, and it also leads to what is called atypical fractures.
Atypical fractures, as opposed to regular fractures, occur without trauma and are usually in the large bone in the thigh called the femur bone. The last thing someone wants is an atypical fracture, where your bone just snaps in half without any fall. The risk of these atypical fractures is relatively high, although less than the amount of the typical fractures prevented by the medicine but is still a serious side effect. Alendronate may need to be held for dental procedures. This should be discussed with your oral surgeon.
The new medicines are extremely expensive and may or may not be covered by insurance and also have side effects. One is called Prolia, which is a shot given in a doctor’s office twice a year. This drug is also associated with atypical fractures and is quite expensive. Another drug is called Forteo, which is a daily shot and does build up bone, but it also has a fair amount of side effects.
Another drug that Dr. Friedman sometimes uses, with very little side effects but only modest effects on the bone, is called raloxifene. It is a selective estrogen-receptor modulator (SERM) and has the beneficial effects of estrogen on the bone, but not the detrimental effects. This medicine is well tolerated and not too expensive.
Estrogen decline during menopause plays a significant role in bone loss.
Calcium and Vitamin D
Recent studies have suggested that calcium pills, which used to be given to strengthen bones, are actually detrimental overall and lead to a higher rate of heart disease. The detrimental effects of calcium supplementation on the heart outweigh the beneficial effects on the bones, and Dr. Friedman does not recommend calcium supplementation.
Vitamin D supplementation does seem to help prevent fractures to a small degree and is probably beneficial. Dr. Friedman recommends taking vitamin D so that the 25-hydroxyvitamin D level is between 30 and 50.
Low Sodium and Falls
Chronic hyponatremia (low sodium) with a serum NA < 135 mmol/L is associated with increased falling leading to fractures and should be corrected. All patients with known or suspected osteoporosis should have electrolytes measured at least annually.
Correcting the low sodium is likely to prevent falls and fractures to a greater extent than expensive osteoporosis medicines. Low dose furosemide (Lasix) is a good option to raise sodium if it is between 130 and 135 mmol/L. Other options are available for a sodium < 130 mmol/L.
So what does Dr. Friedman recommend to prevent and treat osteoporosis?
Two common sense things. One is exercise, and one is eating a healthy, plant-based diet. Exercise has been shown to increase bone density and helps with muscle strength, which helps prevent falls, which, as Dr. Friedman says, is the major reason why people break bones.
Dr. Friedman recommends a combination of aerobic and weightbearing exercises to increase bones. The exercises can include just walking or more strenuous exercises, depending on the health of the individual. The more exercise, the better.
Exercise is especially important in patients experiencing muscle loss from aging or from weight loss medications such as GLP-1 receptor agonists.
The second treatment Dr. Friedman recommends is getting your calcium from plant sources. Studies have shown that dairy products actually increase fracture rates and are not recommended. However, plant-based calcium is better absorbed than dairy-based calcium.
Broccoli, kale, and spinach do contain a lot of calcium and are better sources for calcium intake. Other high-calcium plant-based foods include tofu, fortified nut milks, beans, tahini, sweet potatoes, watercress, okra, chia seeds, and almonds. This approach aligns with a broader lifestyle medicine focus.
There are some supplements Dr. Friedman recommends for bone health. The most important one is vitamin K2 at a dose of 150 mcg twice a day. This can be purchases on Amazon. It has very little side effects. This is different from vitamin K1, which affects clotting and should not be taken by someone who is on a blood thinner. Vitamin K2 can be taken by people on blood thinners, and it does help improve bone density with very little detrimental effects. Boron is another supplement that can also help prevent osteoporosis and decrease osteoarthritis. Avocados and nuts contain boron. A reasonable dose of boron supplementation is 10 mg twice a day. Strontium citrate at a dose of 750 mg a day is also helpful for bone health.
Overall, Dr. Friedman rarely uses osteoporosis medicines but rather recommends preventing falls by increased exercise and eating a plant-based diet.
Please look at these webinars from Lifestyle Medicine expert, Michael Greger, MD
https://nutritionfacts.org/webinar/preventing-and-treating-osteoporosis/
https://nutritionfacts.org/video/fall-prevention-is-the-most-important-thing-for-preventing-osteoporosis-bone-fractures/