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BONES AND JOINTS -
ABOUT OSTEOPOROSIS

By John R. Lee, M.D. and Virginia Hopkins

Although cardiovascular disease is the leading cause of death among American women, osteoporosis is the disease they are most likely to develop as they age. Four out of ten white women in the U.S. will fracture a hip, spine, or forearm due to osteoporosis. As many as five out of ten will develop small fractures in their spine, causing great pain and a shrinking in height. This amounts to 15 to 20 million people affected by a crippling and painful disease that is almost entirely preventable and reversible.

Osteoporosis is a gradual decrease in bone mass and density that can begin as early as the teen years. Bone mass should be at its peak in our late 20s or early 30s, but thanks to a poor diet and lack of exercise, many women are already losing bone in their 20s. Bone loss occurs more rapidly in women than in men, especially right around the time of menopause, when an abrupt drop in estrogen and progesterone accelerates bone loss.

When you think of your bones you may imagine a dead skeleton, but your bones are living tissue, just like the rest of your body, and they need a good supply of nutrients and regular exercise. New bone is constantly being made, while old bone is being reabsorbed and excreted by the body. Our larger long bones, such as our arm bones and leg bones, are very dense, and they are completely replaced about every 10-12 years. Our less dense bones, such as our spine and the ends of our long bones, are less dense and turn over every 2-3 years. Thus, as you can see, we always have the opportunity to be creating better bone for ourselves.

We all hear about how having enough calcium in the diet and taking estrogen can help prevent osteoporosis, but there is a much bigger nutritional and lifestyle picture to look at when we are talking about preventing this bone-robbing disease. You'll be happy to know that for the vast majority of women, there is no need to take estrogen to prevent osteoporosis.

The most important element of bones is minerals. Without minerals we don't have bones. The most important bone minerals are calcium, magnesium, potassium, phosphorous and fluoride. Equally important is the balance between the minerals. Too much phosphorous or fluoride will create poor bone structure. (Nearly all of us already ingest too much fluoride.) Without enough magnesium, the calcium can't be absorbed onto the bone. Vitamins are also involved. For example, vitamin B6 works with magnesium to get calcium onto your bones.

The hormones testosterone, estrogen and progesterone are also actively involved in the making and unmaking of bone. Testosterone and progesterone build bone, while estrogen appears to indirectly slow bone loss.

In osteoporosis, the old bone is being reabsorbed faster than new bone is being made, causing the bones to lose density and become thinner and more porous. The integrity and strength of our bones is related to bone mass and density. The bones of a woman with osteoporosis gradually become thinner and more fragile. A progressive loss of bone mass may continue until the skeleton is no longer strong enough to support itself. When that happens, bones can spontaneously fracture. As bones become more fragile, falls or bumps that would not have hurt us before, can cause a fracture. Bone loss seems to be most severe in the spine, wrists and hips. Unfortunately there are usually no signs or symptoms of osteoporosis until a fracture occurs.

 

Early Signs of Osteoporosis

Sudden insomnia and restlessness
Nightly leg and foot cramps
Persistent low back pain
Gum disease, loose teeth
Gradual loss of height

Your Risk of having osteoporosis is higher if you:

Are a woman
Have a family history of osteoporosis
Are white
Are thin
Are short
Went into menopause early
Have a low calcium intake
Don't exercise
Smoke cigarettes
Drink more than two alcohol drinks daily
Are on chronic steroid therapy (e.g. Prednisone)
Are on chronic anticonvulsant therapy
Are taking drugs which can cause dizziness
Are hyperthyroid
Eat too much animal protein intake
Use antacids regularly
Drink more than two cups of coffee daily

How Aware of Osteoporosis Are You?

A Gallup poll sponsored by the National Osteoporosis Foundation found that:

  • 75% of women believed they were familiar with osteoporosis, but
  • 80% were not aware that it was responsible for disabling fractures,
  • 90% percent were surprised to learn that osteoporosis frequently causes death, and
  • 60% could not identify the risk factors of osteoporosis.

Should You Take Hormone Replacement Therapy to Prevent Osteoporosis?

There is a misperception that osteoporosis begins at menopause. In reality, bone mass begins declining in most women in their mid-thirties, accelerates for 3-5 years around the time of menopause, and then continues to decline at the rate of about 1-1.5% per year. Because bone loss accelerates at menopause, and because estrogen levels decline at menopause, conventional medicine has adopted the belief that osteoporosis is an estrogen deficiency disease that can be cured with estrogen replacement therapy. This is only partly true. The missing piece of this puzzle is diet and lifestyle, plus the bone-building hormone progesterone, which drops much more precipitously at menopause than estrogen does. (When I refer to progesterone, I mean the natural hormone, not the synthetic progestins. Read my books for details on the differences.)

There is no question that estrogen can slow bone loss around the time of menopause, but the scientific evidence is very clear that after 5-6 years, bone loss continues at the same rate, with or without estrogen. A very large study published in the New England Journal of Medicine in 1995, studying risk factors for hip fractures in white women, which followed over 9500 women for eight years, found no benefit in estrogen supplementation in women over the age of 65. If estrogen was the only known treatment for osteoporosis, it might be worth taking it to get the small saving in bone density, despite all the risks and side effects. But since it's clear that progesterone, combined with proper diet and exercise, steadily increases bone density regardless of age, there are very few women who should ever need to take estrogen for osteoporosis.

Women who need estrogen tend to be those who are petite, slim and small-boned. After menopause, a woman’s fat cells make estrogen, but a slim woman may not be making enough to keep up with bone loss. Those women may need a very low dose of estradiol.

There are a number of pharmaceutical drugs being used to treat osteoporosis, none of which work very well, and all of which have unpleasant side effects. One of the best known is Fosamax, a bisphosphonate drug that can slow bone loss. Unfortunately, the old bone which is saved by using Fosamax is eventually structurally unsound, and after three or four years it has no benefit, and I suspect it tends to increase the rate of hip fracture after about five years. For awhile fluoride was being touted as an osteoporosis drug, but like Fosamax, it only slows bone loss temporarily, and the long term consequence is an increased rate of hip fracture due to structurally unsound bone. Another conventional medicine osteoporosis drug is called Calcitonin-salmon (Calcimar). This is a hormone made by the thyroid gland that can temporarily slow bone loss. Again, the long term side effects are not well known, and its effectiveness diminishes rapidly after a few years.

Progesterone and Osteoporosis

One of the most important factors in osteoporosis is a lack of progesterone, which causes a decrease in new bone formation. Years of clinical experience giving women progesterone showed me that using a natural progesterone cream will actively increase bone mass and density and can reverse osteoporosis. These patients consistently show as much as a 29 percent increase in bone mineral density in three years or less of progesterone therapy. After treating hundreds of patients with osteoporosis over a period of 15 years, I found that those women with the lowest bone densities experienced the greatest relative improvement, and those who had good bone density to begin with, maintained their strong bones.

Postmenopausal women using a transdermal (on the skin) progesterone cream or oil should use the equivalent of 15-20 mg daily for three weeks out of the month, with a week off each month to maintain the sensitivity of the progesterone receptors. You can read Dr. John R. Lee's book What Your Doctor May Not Tell You About Menopause for details on how to use progesterone cream.

Exercise for Strong Bones: Use 'Em Or Lose 'Em

Lack of exercise is one of the primary causes of osteoporosis. Using your bones keeps them strong and healthy. Weight-bearing exercise is the only thing besides progesterone found to actually increase bone density in older women. By weight-bearing I mean exercise that uses your bones. Brisk walking counts as weight-bearing exercise, but add some hand-held weights and it's even better. Pushing a vacuum cleaner or lawn mower, gardening, dancing, and aerobic exercise also qualify.

Your exercise plan should include a minimum of 20 minutes of weight bearing exercise three to four times a week. An hour is even better. In contrast to women who exercise, those who don't continue to lose bone, regardless of what else they are doing. Studies of elderly people who fall and break a bone show that these people had poor flexibility, poor leg strength, instability when first standing, and difficulty getting up and down in a chair. Exercise can help increase flexibility, strength, and coordination. A weight lifting program of just half an hour three to four times a week can significantly improve bone density. You don't need to go to the gym to do a weight lifting program. You can lift a can of peas or a small carton of milk. Women with advanced osteoporosis should work with a physical therapist to create a safe, effective program to reduce the risk of fracture. The Asian movement exercises such as yoga, tai chi and chi kung can also be excellent for improving strength, flexibility and coordination.

Dietary Guidelines for Osteoporosis
You May Be Surprised to Learn that this is Not a Calcium Deficiency Disease

Now that scientists know the process of preventing osteoporosis begins early in life, (check out the article on osteoporosis on www.johnleemd.com for details) we're hearing about sugary drinks fortified with calcium for teenagers, antacids with calcium, and calcium supplements. Osteoporosis is not a calcium deficiency disease, it is a disease of excessive calcium loss. In other words, you can take all the calcium supplements you want, but if your diet and lifestyle choices are unhealthy, or you're taking prescription drugs that cause you to lose calcium, you will still lose more calcium from your bones than you can take in through diet.

In fact, getting adequate calcium is only a small part of the prevention picture. Please pass up the sugary drinks and antacids. The damage that refined sugar will do to a growing teenage body or even an adult body far outweighs any benefit that might come from a little calcium supplementation. There is even some evidence that sugar depletes calcium, so the added calcium in these drinks may only be balancing out the damage done by the sugar. The same goes for antacids containing calcium. Since antacids tend to cause you to lose calcium, the added calcium may only offset that damage.

Having pointed out that osteoporosis is not a calcium deficiency disease, I want to assure you that getting adequate calcium is an important factor in preventing osteoporosis. Some good food sources of calcium are snow peas, broccoli, leafy green vegetables such as spinach, kale, beet and turnip greens; almonds, figs, beans, nonfat milk, yogurt and cottage cheese. I don't want you to depend on milk to get your calcium. This is because milk has a poor calcium to magnesium ratio. Your body needs a certain amount of magnesium in order to get the calcium into your bones -- without magnesium, calcium can't build strong bones.

In fact, magnesium deficiency may be more common in women with osteoporosis than calcium deficiency. Although many fruits and vegetables have some magnesium in them, especially good sources of magnesium are whole grains, wheat bran, leafy green vegetables, nuts (almonds are a very rich source of magnesium and calcium), beans, bananas and apricots.

Trace minerals are also important in helping your body absorb calcium. Eating plenty of green leafy vegetables gives you calcium along with these helpful trace minerals. Boron and manganese are especially important. Foods that contain boron include apples, legumes, almonds, pears and green, leafy vegetables. Foods that include manganese include ginger, buckwheat and oats.

The organic matter in our bones consists mainly of collagen, the "glue" that holds together skin, ligaments, tendons and bones. Zinc, copper, beta carotene and vitamin C are all important to the formation and maintenance of collagen in the body.

A Calcium/Magnesium Supplement is Good Health Insurance 

Everyone should have at least 600 mg of easy-to-absorb calcium daily. Although you can easily get that much with a healthy diet, taking a calcium/magnesium supplement is an excellent form of health insurance. In fact, calcium supplements can help slow bone loss in some women. To be incorporated into bone, calcium requires the help of enzymes, which require magnesium and vitamin B6 to work properly. We tend to be more deficient in magnesium and B6 than we do in calcium.

All calcium supplements are not the same. The best absorbed form is called calcium citrate. Avoid the oyster shell calcium, as it can be contaminated with heavy metals. If you're female and over the age of 12, you should be taking 300 mg of calcium, combined with 200 mg of magnesium every day. If you can find a formula that also includes vitamin B6, so much the better. Menopausal women can take 600 mg of calcium daily with 400 mg of magnesium.

Sunshine is the Best Medicine

Vitamin D is another important ingredient in the recipe for strong bones because it stimulates the absorption of calcium. A deficiency of vitamin D can cause calcium loss. The best way to get vitamin D is from direct sunlight on the skin. Sunlight stimulates a chain of events in the skin leading to the production of vitamin D in the liver and kidneys. (This is why liver and kidney disease can produce a vitamin D deficiency.) Going outside for just a few minutes a day can give us all the vitamin D we need, and yet many people don't even do that. They go from their home, to their car, to their office, and back home, without spending more than a few seconds outdoors. Many elderly people are unable to get outside without assistance, but this should be a priority for their caretakers.

Stomach Acid

As we age, we tend to produce less stomach acid. To be absorbed, calcium, requires vitamin D and stomach acid. For this reason, it's important to avoid antacids and the H2 blockers such as Tagamet and Zantac, which block or suppress the secretion of stomach acid. Contrary to what the makers of heartburn and indigestion remedies would have you believe, the last thing in the world most people need is less stomach acid. Heartburn and indigestion are caused by poor eating habits and a lack of stomach acid. Ulcers are caused by a bacteria, not by too much stomach acid. A simple way to improve your calcium absorption may be to take a betaine hydrochloride supplement just before or with meals, to increase your stomach acid. You can find betaine hydrochloride at your health food store.

The Collagen Vitamins and Minerals

Collagen is the tissue that makes up your bone. To build collagen you need vitamin A (or beta carotene), zinc and vitamin C. Vitamin C is especially important, as it is the primary ingredient in the collagen matrix. I recommend you take 1,000 mg daily of vitamin C, in an esterfied form to prevent stomach problems.

Diet

  1. Reduce or eliminate soda pop and other carbonated beverages.
  2. Keep meat consumption to a reasonable level (no more than once a day).
  3. Eat plenty of fresh, green vegetables and whole grains.
  4. Eat foods high in flavonoids, which help stabilize collagen structures, such as blueberries, raspberries and hawthorne berries.

Supplements

  1. Calcium citrate, 600 mg daily with meals
  2. Magnesium (citrate, glycinate, oxide or malate), 600-900 mg daily with meals
  3. Folic acid, 200 mcg daily
  4. Vitamin C, 1,000 mg twice daily
  5. Vitamin B6, 50-100 mg daily between meals
  6. Zinc, 15 mg daily with meals
  7. Beta carotene, 15,000 iu daily
  8. Trace Minerals, including 1-3 mg of boron and manganese.
To Prevent Osteoporosis AVOID: Soda Pop and a High protein Diet

I believe that one of the leading contributors to osteoporosis in the U.S. is carbonated soft drinks containing phosphorous. Research has shown a direct link between too much phosphorous and calcium loss. If you're guzzling down a couple of fizzy soft drinks a day, you're most likely creating bone loss.

Our other source of excessive phosphorous in the U.S. is eating too much meat. The average American gets more than enough protein, so for most of us it can only help to cut down on our meat consumption. A recent trend among those who love food but don't love the consequences of too much fat and protein is to use meat as a garnish or flavoring in a meal, rather than as a major portion. Fill up on vegetables and complex carbohydrates (whole grains, potatoes, rice, corn, beans), and use meat to enrich your meals. Beans are an excellent and nutritious source of protein and contain many important vitamins and minerals.

Coffee, Alcohol, and Cigarette Smoking

Here's yet another good reason to either give up coffee and alcohol or use them in moderation. And do I need to tell you how important it is to stop smoking now! (It's never too late to reap the benefits of quitting smoking.) Each of these substances creates a negative calcium balance in the body. Substances called phytates and oxylates bind with calcium in the large intestine and form insoluble salts, rendering the calcium useless. The bone mineral content of smokers is 15-30% lower in women and 10-20% lower in men. Cigarette smoking is a significant risk factor for osteoporosis. Twice as many women with osteoporosis smoke as compared with women who do not have osteoporosis.

Aluminum

Don't take antacids with aluminum and don't use aluminum cooking pots. It has been shown that small amounts of aluminum-containing antacids increase the urinary and fecal excretion of calcium, inhibit absorption of fluoride, and inhibit absorption of phosphorus, creating a negative calcium balance. The calcium is excreted instead of being utilized.

Diuretics

Diuretics are medicines that cause water loss in the body. Along with the water you lose minerals, most notably calcium, magnesium and potassium. They are commonly used in conventional medicine to treat high blood pressure, swelling of the lower legs, and congestive heart disease. People who use diuretics have a higher risk of fracture. If you need to use a diuretic, try a gentle herbal one such as dandelion root in a tincture, capsule or tea.

Fluoride

What's so bad about fluoride? You probably think it just builds good teeth. There is good, solid scientific evidence that fluoridated drinking water increases your risk of hip fractures by 20-40%. So much fluoride has been put into our water and toothpaste over the past 30 years that levels in our water, food and drink are very high. While eating a normal diet the average person exceeds the recommended dose. There is also evidence that ingesting high levels of fluoride can cause abnormal bone growth. Please avoid fluoride, in all forms including toothpastes and mouthwashes.

You can be thankful if you live in an unfluoridated community because it's not easy to get rid of fluoride in your tap water. Distillation and reverse osmosis are the only two reliable methods for removing fluoride. Other water filters may work at eliminating fluoride for a short period of time, but fluoride binds so strongly and quickly to filter materials such as charcoal, that the binding sites become fully occupied after a short time. If you are at a high risk for osteoporosis, I recommend you spend the money on a water filter that removes fluoride.

High Dose Cortisone

A well known risk for osteoporosis is long term treatment with the synthetic cortisones such as Prednisone. Since the cortisones (or more properly, glucocorticoids) are closely related to progesterone in their molecular structure, the theory is that they compete for the same receptor sites on bone-building cells. However, while progesterone gives bones the message to grow, the cortisones give bones the message to stop growing. If you must be on a cortisone, talk to your doctor about using a low dose natural cortisone called hydrocortisone rather than the synthetic cortisones. You can refer him or her to the book Safe Uses of Cortisol by William Jefferies.

Bone Mineral Density (BMD) Testing

One of the best ways to find out if you're losing bone is to have someone measure your height, and then check it every six months or so. If you start losing height, that's a sure sign that you're losing bone on your spine. I recommend that women at risk for osteoporosis get a bone mineral density measurement as they're going into menopause. That way you'll have a baseline with which to compare later bone density tests, to measure your progress. The safest and most accurate ways to measure bone are with Photon Absorptiometry, and Dual Energy X-ray Absorbtiometry (DEXA), which is 96-98% accurate and uses very low-dose x-rays. I don't recommend CAT scans, as they use too high a level of X-rays. A newer technique for measuring bone loss is called "Urinary Excretion of Pyridinium," which measures a substance in the urine that can indicate rapid bone turnover rate.

OSTEOPOROSIS PREVENTION AND REVERSAL In a Nutshell

Lifestyle

  1. If you're smoking, stop now.
  2. Reduce or eliminate coffee and alcohol. (No more than one cup of coffee and one alcohol drink per day. If you are at a high risk I advise elimination.)
  3. Get some weight bearing exercise at least one hour three times a week or 20 minutes daily.
  4. Avoid antacids, and hydrochloric acid (H2) blockers such as Tagamet, Zantac and Pepcid.
  5. Avoid prescription drugs that cause bone loss, such as diuretics and synthetic cortisones.
  6. If you are over the age of 50, avoid fluoride in toothpastes, mouthwash and tap water. If you live in a fluoridated community and are at a high risk for osteoporosis, invest in a water filter that eliminates fluoride