Osteoporosis and Osteopenia

Dr. Weyrich's Naturopathic Functional Medicine Notebook

Overview

Osteoporosis and osteopenia are bone disorders in which the bone is weakened by demineralization. Osteopenia is a milder form of the disorder, and may progress to osteoporosis if not treated.

Diagnosis is made by a dual-energy x-ray absorptiometry (DEXA) scan (which is a highly correlated surrogate measure of bone strength). Osteopenia is defined as a bone mineral density T-score between -1.0 and -2.5, while osteoporosis is defined as a bone mineral density T-score below -2.5. (A T-score of -1.0 represents one standard deviation below the bone density of an average 30-year-old white woman). Although there is some radiation exposure during a DEXA scan, it has been estimated to only be equivalent to the amount received flying across the country (cosmic radiation exposure at crusing altitudes of about 5 miles up is somewhat higher than at Earth's surface).

Postmenopausal women and patients on long-term high doses of corticosteroids are most at risk of developing osteoporosis.

Osteoporosis presents a significant risk for bone fractures, most commonly in the proximal femur (hip), vertebrae (spine), and distal forearm (wrist) [ACE-AHFS, pg 395]. While most hip fractures are due to falls, most vertebral fractures result in increased kyphosis ("dowager's hump") and are due to routine activities such as bending or lifting light objects [Cooper1992].

Although good lifestyle and therapy can reduce the rate of progression, age related loss of bone mineral density is a natural part of aging. This loss occurs at a rate of approximately 5 to 10% per decade beginning in the third decade of life. If untreated, bone loss in women is especially rapid during the first five years following menopause [Snow-Harter1991].

Risk factors for developing osteoporosis include [National Osteoporosis Foundation 2008]:

• Patients has a small, thin frame.
• Patient is Caucasian or Asian.
• Patient or first-degree relative has had a broken a bone as an adult.
• Patient is a postmenopausal woman.
• Patient has had an early or surgically induced menopause.
• Patient has taken high doses of thyroid medication or used high doses of glucocorticoids (e.g. > 5 mg a day prednisone) for three or more months.
• Patient has taken immunosuppressive medications or chemotherapy to treat cancer.
• Patient's diet is low in dairy products and other sources of calcium.
• Patient is physically inactive.
• Patient smokes cigarettes.
• Patient drinks alcohol in excess.

Dr. Weyrich adds additional risk factors:

• Long-term anti-acid medication use, especially H2-blockers and proton-pump inhibitors.
• Hypochlorhidria.
• Low vitamin D intake and living far from the equator.

Etiology

Bone health is affected by a balance between a number of hormones, including calcitonin, parathyroid hormone, estrogen, testosterone, progesterone, prolactin, corticosteroids, thyroid hormones, insulin-like growth factor I (IGF-I), growth hormone, and Vitamin D.

According to [Starr2005, pg 77], osteoporosis can result from either hypothyroid or hyperthyroid conditions. He writes:

Bones may become abnormally thickened and their infrastructure weakened due to hypothyroidism. After the patient is placed on thyroid hormones, the bones begin to remodel. Stronger, thinner bones gradually replace the weak infrastructure. The remodeling process may take as long as 6 or 12 months after an adequate dosage of thyroid hormones is given.

Note that Dr. Starr [and Dr. Weyrich] use basal body temperature and the patient's symptom picture rather than TSH levels to titrate thyroid supplement dosage. This may result in TSH levels being measured that are below the "normal" range, raising concerns among some practitioners that the patient's thyroid status has been over-corrected, and that the supposed hyperthyroid condition will aggravate osteoporosis. Dr. Starr reports that this is not the case in clinical practice, and cites additional studies that agree with this point of view [Starr2005, pg 78; Wenzel1992; Franklin1992; Muller1995].

Diagnosis

The National Osteoporosis Foundation guidelines indicate that Bone Mineral Density testing should be performed on:

• All women aged 65 and older regardless of risk factors.
• Younger postmenopausal women with one or more risk factors (other than being white, postmenopausal, and female).
• Postmenopausal women who present with fractures (to confirm the diagnosis and determine disease severity).

Other indications (that may be covered by Medicare for patients over 65 years old every 2 years, but are subject to revision due to government health care cost containment measures) include [ACE-AHFS, pg 401]:

• Estrogen-deficient women at clinical risk for osteoporosis.
• Individuals with vertebral abnormalities.
• Individuals receiving, or planning to receive, long-term glucocorticoid (steroid) therapy.
• Individuals with primary hyperparathyroidism.
• Individuals being monitored to assess the response or efficacy of an approved osteoporosis drug therapy.

According to the American Council on Exercise, "there is some controversy regarding whether the appropriate level of serum vitamin D needed for bone health is 50 or 80 nmol/L" [ACE-AHFS, pg 403].

Differential Diagnosis

• Hypothyroid
• Hyperthyroid

Treatment

A general naturopathic approach is described below. Consult your doctor to adapt to your situation and to avoid interactions with prescription drugs:

• Evaluate and remove sources of risk of fall: remove clutter from floors, add "grab bars", correct sources of dizziness, including pharmaceutical side-effects. Consider physical therapy to improve muscle strength and balance. Ensure eye-sight is corrected. Consider use of a walker or cane.
• Evaluate and correct hormonal imbalances.
• Diet:
  • Avoid excess protein intake (approximately 0.25 gram protein per pound of body weight is a good starting point). However, caloric restriction or improper balance of nutrients can interfere with healthy bone remodelling.
  • Increase alkaline ash-containing foods and decrease acid ash-containing foods [Marz1999, pg 339].
  • Minimize coffee, alcohol, and tobacco usage.
• Balanced mineral supplement [Marz1999]. Do not take too much calcium, as it can interfere with the absorption of other minerals. Orange juice will help with absorption:
  • 1000 mg of calcium in the form of calcium citrate (since calcium citrate is about 20% calcium, about 5 grams of calcium citrate is required).
  • 1000 mg of magnesium.
  • 30 mg of zinc.
  • 20 mg of manganese.
  • 2 mg of copper.
  • 3 mg of boron.
  • 1 mg silica.
• Vitamins:
  • 20,000 IU Vitamin A (this amount can be obtained from approximately 5 teaspoons of cod-liver oil a day).
  • 2,000 to 5,000 IU Vitamin D3 (2,000 IU can be obtained from approximately 5 teaspoons of cod-liver oil a day).
  • 7 mg Vitamin K1.
  • 5 mg Folic Acid.
  • 500 mcg Vitamin B12 (necessary to balance folic acid).
• Digestive Aids (as needed):
  • Ox Bile (to aid absorption of Vitamins D3, K1, and A, as well as fish oil).
  • Betaine HCl (to aid absorption of minerals).
• Low-impact weight-bearing exercises, especially to stabilize core muscles and to improve balance. Although the greatest increase in bone density is seen with high-impact training in young gymnasts, whose bodies regularly experience ground reaction forces of 15 times bodyweight [Bass1998], this benefit must be balanced against the danger of joint trauma that will predispose or exacerbate osteoarthritis at ground reaction forces exceeding 6 times normal bodyweight. The American Council on Exercise gives specific exercise recommendations [ACE-AHFS, pp 406-414].

Pharmaceutical interventions include [ACE-AHFS, pg 404]:

• Estrogen hormone replacement: Estrogen acts as an antiresporptive by downregulating the activity of osteoclasts in the bone. However, the Women’s Health Initiative study [Rossouw2002] showed that while both conjugated equine estrogen (Premarin) and conjugated equine estrogen + medroxyprogertone acetate (Prempro) both substantially reduced the risk of osteoporotic fractures, the results showed an elevated risk for stroke and cardiovascular events with the combined conjugated equine estrogen + medroxyprogertone acetate therapy, especially if women over the age of 70 began treatment. While some questions have been raised regarding the quality of the study, current medical opinion suggests that estrogen hormone replacement should be used only for short-term use around menopause in symptomatic women at risk for fracture [Sambrook2006]. Note that this study was with non-bioidentical forms of both estrogen and progesterone and the results may not extend to bioidentical hormone replacement with a mixture of E2 and E3. Also note that the arm of the study without medroxyprogertone did not show a problem. Estrogen replacement therapy is contraindicated in women who smoke, due to an increased risk of thromboembolism.
• Selective Estrogen Receptor Modulators (SERMs): (raloxifene/Evista; tamoxifene/Nolvadex; plant-derived isoflavones, synthetic isoflavones/Ipriflavone/Livial; Other SERMs in Phase III clinical trials include droloxifene, levormeloxifene, arzoxifene, and lasofoxifene). SERMs (both synthetic and plant-derived) have structures similar to estrogen, and may bind more or less strongly to various estrogen receptors and have greater or lesser effect on different estrogen receptors throughout the body. According to the American Council on Exercise, the most studied is raloxifene/Evista; it has been found to be less effective than bisphosphonates, especially on non-vertebral fractures such as the hip. Due to their action at the same cellular receptors, potential side effects and risks of SERMs may be similar to estrogens (although most naturopaths feel that the risk of plant-derived sterols is lower than that of conjugated equine estrogen).
• Bisphosphonates: (alendronate/Fosamax; risedronate/Actonel; etidronate/Didronel; ibandronate/Boniva; zolendronate/Zometa/Reclast). Bisphosphonates are integrated into the bone matrix itself during bone remodelling, and work by preventing bone resporption. Bisphosphonates remain in the bone for decades, and can affect bone remodelling for up to five years after the drugs are discontinued. Oral administration may cause gastrointestinal intolerance, and patients must be able to remain upright for at least 30 minutes following an oral dose to avoid damage to the esophagus. Although these drugs may persist in the bone for years and supress remodelling, long-term safety and efficacy studies are not available [Keen2007]. There have also been reports of rare osteonecrosis of the jaw associated with bisphosphonate use, although mainly in patients receiving high doses in combination with cancer treatment.
• Parathryroid hormone supplement: (Forteo). In low doses parthyroid hormone acts mainly to stimulate bone formation; in high levels found in hyperparathyroidism it has the contrary effect of increasing bone resorption. Clinical trials showed good risk reduction for both new vertebral and non-vertebral fractures; however the benefit appeared to recede after discontinuation of therapy, so Forteo is only recommended for courses of therapy of less than two years [Sambrook2006].
• Calcitonin hormone supplement: (MiaCalcin, Calcimar nasal spray). Calcitonin inhibits osteoclastic activity, thus reducing bone resorption [Iwamoto2002]. Side effects may include headaches and flushing.
• Calcitriol/Rocaltrol: Vitamin D.
• Stronitium ranelate: (Availabile in Europe; in Phase III clinical trials in the USA). Although its exact mechanism is unclear, it appears to both increase bone formation while also reducing bone resorption.

Exciting new sugical interventions have been recently introduced to treat stress (compression) fractures of the vertebral column, in which a special bone cement is injected into the compressed body of the damaged vertebrae. This treatment gives both increased bone strength [Steens2007] and pain relief [Afzal2007; Steens2007]. Although the technique gives rapid and permanent relief, it is only applicable to freshly fractured bone [personal communication from Dr. Robert E. Gear, Jr.]. Unfortunately, many vertebral compression fractures are not immediately diagnosed.

Hypotheses

Some practitioners recommend supplementation with strontium, which is chemically similar to magnesium and calcium. Dr. Weyrich has not evaluated the merits of this recommendation. Note that food-grade strontium supplements do not contain the radioactive isotope strontium-90.

ICD-9 Codes

ICD9-Code	Description	Comments
733.00	Osteoporosis NOS
733.01	Osteoporosis - Senile
733.90	Osteopenia

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References

Unless specifically noted above, references used in the construction of this web page include the following:

[FDM] Lecture notes from Functional Medicine University.

[SCNM] Lecture notes from Southwest College of Naturopathic Medicine.

[UT] Lecture notes from the University of Tennessee graduate programs in Chemistry and Biochemistry.

[ACE-AHFS] American Council on Exercise. "Advanced Health & Fitness Specialist Manual" Chapter 16: Osteoporosis and Osteopenia.

[Afzal2007] Afzal et al. (2007). Cited by [ACE-AHFS, pg 405].

[Bass1998] Bass et al. (1998). Cited by [ACE-AHFS, pg 406].

[Cooper1992] Cooper et al. (1992). Cited by [ACE-AHFS, pg 396].

[Franklin1992] J.A. Franklin et al. Long term thyroxine treatment and bone mineral density. Lancet 340:9-13 (1992). Cited by [Starr2005].

[Gaby1994] Gaby A. Preventing and Reversing Osteoporosis: Every Women's Essential Guide. Rockland, CA: Prima Publishing (1994). [Cited by Starr2005].

[Iwamoto2002] Iwamoto et al. (2002). Cited by [ACE-AHFS, pg 404].

[Keen2007] Keen (2007). Cited by [ACE-AHFS, pg 404].

[Marz1999] Marz Russell B. Medical Nutrition from Marz, Second Edition. Portland, OR: Omni-Press (1999).

[Muller1995] C.G. Muller et al. Possible limited bone loss with suppressive thyroxine therapy is unlikely to have clinical relevance. Thyroid 5(2):81-87 (1995). Cited by [Starr2005].

[National Osteoporosis Foundation 2008] National Osteoporosis Foundation. "Osteoporosis: Can It Happen to You?" (2008). Washington, DC, 20037. Cited by [ACE-AHFS, pg 397].

[Paul1988] Paul TL, et al. Long-term L-thyroxine therapy is associated with decreased hip bone density in premenopausal women. JAMA. 259(21):3137-3141 (1988). [Cited by Starr2005].

[Ross1991] Ross DS, et al. Serum osteocalcin in patients taking l-thyroxine who have subclinical hyperthryoidism. Journal of Clinical Endocrinology and Metabolism. 72(2):507-509 (1991). [Cited by Starr2005].

[Rossouw2002] Rossouw et al. (2002). Cited by [ACE-AHFS, pg 403].

[Sambrook2006] Sambrook & Cooper (2006). Cited by [ACE-AHFS, pg 403].

[Snow-Harter1991] Snow-Harter & Marcus (1991). Cited by [ACE-AHFS, pg 397].

[Starr2005] Mark Starr. Hypothyroidism Type 2: The Epidemic. Columbia, MO: Mark Starr Trust (2005).

[Steens2007] Steens et al. (2007). Cited by [ACE-AHFS, pg 405].

[Wenzel1992] K. Wenzel. Bone minerals and levothyroxine. Lancet 340:435-436 (1992). Cited by [Starr2005].

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