Osteoporosis: Prevention is an Ounce of Protection

Introduction:
Osteoporosis is a disease that causes bones to become weak and brittle. This dangerous condition
increases one’s risk of broken bones. The breaks occur most often in the hips, spine, and wrist areas. You will not necessarily know you have osteoporosis as there are no obvious signs and symptoms. A broken bone is often the first indication. Therefore, prevention and awareness of risk factors is key to addressing this issue.

The skeleton serves as the bony framework essential for providing strength and stability to the body, while also protecting the internal organs. Comprised of calcium salts and a blend of other minerals along with collagen fibers, the bones form a sturdy matrix. Ninety-nine percent of calcium in the body is stored in the bones. This reservoir of calcium is important not only for bone but also to serve as an acid-base buffer for the blood. If the blood is too acidic, calcium is stripped from bones to neutralize the acidity. This will occur even at the expense of losing bone strength. The bone matrix is dynamic, constantly undergoing the process of building new bone and breaking down old bone. This occurs at varying rates throughout life. When new bone formation exceeds old bone dismantling, stronger bone develops; and vice versa. The life cycle that bone modeling and remodeling goes through tends to follow a pattern. Low bone density occurs between ages 10 to 14 years and peaks at about 20 years of age. It stabilizes around age 40 years then gradually declines at about 2% per year for 10 years postmenopausal. Bone mass density (BMD) is related to bone strength. Genetics contributes to Sixty to eighty percent of bone mass. The remaining influencing factors are nutrition, physical activity, smoking status, and chronic illnesses. By maintaining or enhancing BMD you can significantly reduce the risk of developing osteoporosis. For instance, a 2% rise in hip (BMD) results in a 28% decrease in the risk of vertebral fractures and a 16% decrease in hip fractures; similarly, a 6% increase in hip BMD leads to a 66% reduction in vertebral fracture risk and a 40% reduction in the risk of hip fractures. When a person has fragile bones, minor actions like bumping into things can produce fractures. Difficulties can occur after a fall and there is a substantial risk of needing care in a nursing home or becoming crippled.

Statistics:
In 2017-18, osteoporosis occured at a higher incidence in women than men, 18.8 % and 4.2% respectively and higher among those 65 and older.

What Happens to Cause Osteoporosis?
Low (BMD) leads to osteoporosis, characterized by porous, weak, and thin bones. This occurs when bone formation is less frequent than bone dismantling, especially when essential components for building the bone matrix are deficient.

Osteoporotic changes reviewed in various stages:

Stage 1) Initially there is a decrease in mineral density (leaching). This occurs around age 30 years old. Stage 2) Bone resorption, the process of breaking down old bone, happens at a quicker pace than bone remodeling, which focuses on building new bone. Symptoms may appear in the jawbone, including receding gums, brittle fingernails (such as chipped or thinning nails), and a weaker grip strength in the hand. Stage 3) In women aged 45 to 55, menopause leads to a 10% to 30% decrease in bone density due to falling estrogen levels. Men over sixty also experience bone density loss from reduced testosterone, making bones more fragile and increasing fracture risk from minor impacts. Treatment begins at this stage. Stage 4) Multiple fractures may arise, causing individuals to struggle with daily activities, standing, and getting in and out of the car. Symptoms can include a reduction in height, a hunched neck, back pain, and poor posture. At this stage, treatment is initiated.

Who is at Risk and What Conditions Contribute to Osteoporosis
The groups at highest risk are:

• female (1:5 after age 50 vs 1:20 for men)
• White or Asian
• Family history
• Diet
• Low physical activity
• Contributory medications (i.e., corticosteroids, acid blockers, certain seizure
medications)
• Underweight
• Smoking and heavy alcohol consumption

The Journal of the American Medical Association reported that, over 40 years, hip fractures declined by 4% annually, coinciding with a decrease in smoking rates from 38% in the 1970s to 15% in 2010. Heavy drinking also decreased from 7% to 4.5% in the same period.

Universal recommendations for preventing osteoporosis include:
1. Increase fruit and vegetables.
2. Calcium – include a diet with adequate amounts:
a. People aged 50-70 total Calcium 1000mg/day.
b. Women 51 years and over and men seventy-one and over 1,200 mg/day.
c. Add calcium supplements to meet total need.
3. Vitamin D 800-1000 units/day including supplements for age 50 and over.
a. Monitor vitamin D levels (25-hydroxy vitamin D)
b. Goal 30-50 ng/mL
c. The dose of Vitamin D needed to obtain adequate levels may be more due to malabsorption or other reasons.
4. Weight bearing exercises, strength training.
5. Assess risk factors for falls and counsel patients on risks for falls and osteoporosis.
a. Home design
b. Medications that cause drowsiness
c. Walking or vision disorders
6. Stop smoking and decrease alcohol consumption.

It is also important to do BMD testing according to the guidelines and counsel on risk for fractures. A BMD Scan or Dual-energy X-ray absorptiometry (DEXA) scans the hip, spine and wrist for density and translates the information into images that are read by a radiologist. The National Osteoporosis

Foundation recommends the scan be done every 2 years starting at age 65 for women and seventy for men. However, those with significant risk factors may require a personalized frequency schedule.

Calcium: Its Role and Important Considerations Regarding Supplementation

Calcium has other functions in addition to strengthening bone. It is also important in supporting the heart rate, muscle control, and acid base balance in the blood stream. Calcium is found in dairy, vegetables, and beans. Phytates in beans can reduce calcium absorption, so soaking them before cooking is recommended. Many foods are also fortified with calcium, so check labels for total calcium content. Most calcium products should be taken with food (citrate is an exception) and in divided doses. It is best to start low and gradually increase the daily dose to the desired amount. It is important to add up all sources of calcium to accurately determine the total daily dose. Calcium carbonate is the most widely used form of calcium. This form of calcium provides more elemental calcium per milligram than other forms of calcium. Carbonate is a hard substance and difficult to absorb from the digestive tract. This form of calcium is more likely to generate negative side effects and calcification of the arteries that calcium supplements are criticized for. The citrate form is easier to absorb and can be taken without regard to meals. However, it contains less elemental calcium per milligram compared to carbonate. Calcium in high doses, particularly the harder forms, can accumulate in the arteries and precipitate heart attacks. It is important to add vitamin K2 with high dose calcium supplements and vitamin D doses greater than 2000 IU for proper absorption and deposition of calcium into the bone rather than soft tissue and arteries. Calcium from food sources does not cause the problems of tissue calcification brought on by the calcium supplements. Taking 1000 to 1500mg of calcium per day does not improve osteoporotic status. In most instances not more than 700-900mg a day is needed. More is not necessarily better; absorption and proper utilization is what matters most.

Vitamin D: Its Role and Special Considerations

Vitamin D acts more like a hormone in terms of its properties and the way it works in the body. It is most noted for increasing calcium absorption. It is also credited for:
• Preventing osteoporosis, osteopenia, rickets, osteomalacia and fractures.
• Preventing certain types of cancer (i.e., colon, prostate, breast, pancreatic).
• Preventing heart disease, stroke, type 2 diabetes, and other inflammatory diseases.
• Decreasing the risk for dementia, depression, and other brain diseases.
The fact that every cell in the body has Vitamin D receptors increases the probability that it has an
increased role in metabolic functions in the body.

The primary sources of Vitamin D are:

• Food sources- fatty fish (i.e., salmon, sardines)
• Greens i.e., collards, broccoli, kale)
• Multivitamins and Vitamin D supplements
• Fortified yogurt, milk, orange juice, cereals, and cheeses
• Mushrooms
• Skin exposure to sunlight

Universal guidelines for dosing Vitamin D (Daily Dose)

• Adults get 400-800 IU for under 50 years.
• Adults get 800-1000 IU for 50 years and over.
• The safe upper limit is at most 4000 IU.

The following are risk factors for having low Vitamin D levels:

• Darker skin individuals
• Obese individuals
• Persons with celiac disease
• Persons on certain seizure medications
• Genetics (i.e., VDR gene)
• Indoor confinement (i.e., nursing home patients)

A frequent issue is the slow rise in Vitamin D levels for dark-skinned individuals and obese people. Vitamin D, a fat-soluble substance, gets locked into the fat stores and is not easily released into the blood stream of obese people. Higher doses are required to elevate Vitamin D levels. Weight loss leads to the release of this vitamin. Additionally, people with darker skin have a natural protection from sunlight, resulting in less effective activation of Vitamin D in the skin, which explains the higher prevalence of low Vitamin D levels.

Treatment Guidelines

1. There is no universal treatment for osteoporosis; therapy should be individualized.
2. Approved medications:
a. Bisphosphonates (alendronate, ibandronate, risedronate)
b. Calcitonin
c. Estrogen agonist/antagonist (raloxifene)
d. Hormone replacement therapy
e. Parathyroid hormone
f. RANK ligand inhibitor (denosumab)
g. Sclerostin inhibitor
3. Do not dispense indefinite therapy.
4. Reassess BMD changes and drugs- consider 5-year holiday (oral) and 3-year holiday (IV) for
bisphosphonates for patients no longer at high risk.
5. Communicate risk/benefit.
6. After a fracture, do a risk assessment and treat accordingly.
Despite existing guidelines, more than fifty-four million women over fifty are affected by osteoporosis. A major issue is that, in many cases, following fracture repair, there is insufficient follow-up intervention to mitigate the risk of further fractures. Reassessing previous treatments and evaluating the risk of falls often does not happen. Regardless of the severity of the fracture, low BMD is a key contributing factor. Encouraging patients to enhance their BMD can significantly improve outcomes for future fractures.

Osteocytes: The Command center for bone remodeling:

Bone modeling/remodeling depends on three different cells: osteoblasts, osteoclasts, and osteocytes. Research has shown that it is the osteocytes that dictate bone remodeling. The osteoblasts are responsible for the building and laying down of new bone. The osteoclasts are responsible for the breaking down of old bone. The osteocytes are the architect or brain and instruct the osteoblasts and osteoclasts on what they are supposed to do.

According to the research data lead by researcher Paola Pajevic of Boston University working with National Aeronautics and Space Administration (NASA) astronauts in space, osteocytes sense the mechanical force applied to the bone and therefore dictate what type of action should be taken regarding bone remodeling. Astronauts are known to experience metabolic changes in their bone structure like that seen in osteoporosis.

It is the near weightlessness of astronautsin space that mimicsthose who are bedridden or have paralysis that produces this effect on the bones. Thus, weight bearing exercises are important to reducing the risk of developing osteoporosis.

The quality and life of the osteocytes are important to the performance of the osteoblasts and osteoclasts. If the osteocytes become damaged or die this will impact the work done by the osteoblasts and osteoclasts. Free radicals damage osteocytes.Free radicals are highly unstable molecules in the body that can accumulate during normal metabolic processes and can cause damage to lipids, proteins, and DNA. Increasing the risk for developing certain diseases like cancer and diabetes.

Antioxidants, which neutralize free radicals, are key to improving the functioning of the osteoblasts and osteoclasts. Adding antioxidants to the proper nutrients in the right quantities can preserve the life and quality of the osteocytes.

Focusing on the bone building process.

What is needed to produce a better bone matrix:
A. The right amount and type of calcium
B. Vitamin D to better absorb calcium.
C. Vitamin K2 to direct calcium intake to the bones.
D. Vitamin C to serve as the antioxidant.
E. Add magnesium to boost osteoblasts.
F. Add other important minerals.

Minerals important to laying down bone:

• Zinc
• Copper
• Manganese
• Selenium
• Strontium
• Nickel
• Boron
• Vanadium
• Potassium
• Silica
• Phosphorus

There are various bone-building formulations available that differ slightly in the minerals included and the dosage. No one specific combination is superior to others. Find one with evidence of bone density improvement and check for contraindications. A closer look at one’s condition, genetics, and deficiencies will help determine which minerals will be most important. It is highly recommended before adding minerals to have mineral levels checked.

Drug interactions do occur with these ingredients. Typically, products that contain minerals should be taken away from certain drugs: antacids, certain antibiotics, blood thinners.

Low BMD is the one factor that is always present in osteoporosis and contributes to the risk for fracture. Restoring BMD is critical. If bone loss occurs at the rate of 1% a year, gaining 1% a year in bone mass can offset this loss.

Summary of Actions to Take for Prevention of Osteoporosis and Bone Maintenance

• Provide the right type and amount of bone remodeling ingredients (i.e., vitamin D, vitamin C,
minerals).
• Maintain BMD with weight bearing activities.
• Keep the commander (osteocytes) strong and in command of antioxidants.
• Correct hormonal imbalances (i.e., estrogen, testosterone).
• Avoid preventable risk factors for osteoporosis (i.e., smoking, excess alcohol intake).

References https:

1. Aibar-Almazán A, Voltes-Martínez A, Castellote-Caballero Y, Afanador-Restrepo DF, Carcelén-Fraile MDC, López-Ruiz E. Current Status of the Diagnosis and Management of Osteoporosis. Int J Mol Sci. 2022 Aug 21;23(16):9465. doi: 10.3390/ijms23169465. PMID: 36012730; PMCID: PMC94089322.

2. Sarafrazi N, Wambogo EA, Shepherd JA. Osteoporosis or low bone mass in older adults: United States, 2017–2018. NCHS Data Brief, no 405. Hyattsville, MD: National Center for Health Statistics. 2021. DOI: https://dx.doi.org/10.15620/cdc:103477.

3. Sabri SA, Chavarria JC, Ackert-Bicknell C, Swanson C, Burger E. Osteoporosis: An Update on Screening, Diagnosis, Evaluation, and Treatment. Orthopedics. 2023 Jan-Feb;46(1):e20-e26. doi: 10.3928/01477447-20220719-03. Epub 2022 Jul 25. PMID: 35876780; PMCID: PMC10084730.

4. Heravi AS, Michos ED. Vitamin D and Calcium Supplements: Helpful, Harmful, or Neutral for Cardiovascular Risk? Methodist Debakey Cardiovasc J. 2019 Jul-Sep;15(3):207-213. https://doi: 10.14797/mdcj-15-3-207. PMID: 31687100; PMCID: PMC6822648.

5. Uda, Yuhei & Spatz, Jordan & Hussein, Amira & Garcia, Joseph & Lai, Forest & Dedic, Chris & Fulzele, Keertik & Dougherty, Sean & Eberle, Margaret & Adamson, Chris & Misener, Lowell & Gerstenfeld, Louis & Divieti Pajevic, Paola. (2021). Global transcriptomic analysis of a murine osteocytic cell line subjected to spaceflight. The FASEB Journal. 35. 10.1096/fj.2

6. Domazetovic V, Marcucci G, Iantomasi T, Brandi ML, Vincenzini MT. Oxidative stress in bone remodeling: role of antioxidants. Clin Cases miner Bone Metab. 2017 May-Aug; 14(2):209-216. doi:10.11138/ccmbm/2017.14.1.209. Epub 2017 Oct 25. PMID:29263736; PMCID: PMC5726212.

Leave a Comment Cancel Reply