Osteoporosis is indeed becoming a household word, with more and more women being told they are likely to suffer an osteoporotic fracture. With this growing “fracture fear” in mind, we make special note of the recent data on declining US hip fracture incidence.

As detailed in a study by the Mayo Clinic, the hip fracture incidence among Caucasian women in the US peaked in the 1950s and has declined since then. Specifically, there was a 9% fall in hip fracture prevalence from 1973 to 1982. The hip fracture incidence for US Caucasian men peaked in the late 1980s.

This study can be found in the journal Osteoporosis International, vol. 8, no. 1, Feb 1998.

Forteo™ is promoted as a rising star on the osteoporosis scene, a bone drug that actually builds new bone, rather than just halting bone loss. By various mechanisms, Forteo “tricks” the body into building substantial new bone mass and short-term studies show Forteo actually reduces fracture more than other bone drugs. Sure, it is very expensive and has to be given by daily self-administered injections, but still, the large bone density increases and unprecedented reduction of both spinal and hip fractures are impressive.

While all this sounds great, when we look more carefully, we see Forteo has a variety of serious drawbacks and side effects. First, it is experimental and poorly tested. It also brings with it a series of potential adverse effects. These adverse effects include the development of bone cancer in animals, the potential to cause excessive new bone formation, high blood calcium, nausea, immunologic responses, leg cramps, hypotension, depression, and dizziness. For these reasons (not to mention its expense), I do not think Forteo is a worthwhile option for the treatment of osteoporosis in the majority of patients.

To read my full analysis of the Forteo drug, see my article Forteo™ – is this bone drug too good to be true?.

While exercise is generally good for bone, a study of male endurance cyclists reports that serious cyclists lose significant hip bone mineral density during the biking season. This new research as well as earlier studies document that over time many endurance cyclists end up with low bone density. So, if exercise is good for bone, why do endurance cyclists lose hip bone during the biking season? 

Researchers report several factors which contribute to bone loss among serious cyclists. These include:

(1) Cycling is not weight-bearing and yields comparatively low skeletal strain (the skeletal strain of exercise encourages bone formation).
(2) Endurance cyclists do a great deal of this non-weight-bearing exercise, averaging over 13 hours per week, and perhaps do this activity instead of other exercise which might be weight-bearing and bone-building.
(3) Cyclists experienced an increase in parathyroid hormone, likely subsequent to excessive loss of calcium through the skin with sweating. Excess parathyroid hormone tends to increase bone breakdown.
(4) Cyclists likely did not consume enough calories for their heavy training. Also, I would add that they likely did not consume enough of the 20 key bone-building nutrients.
(5) The physiological stress of such training produces bone-damaging stress hormones and pro-inflammatory cytokines.

The Better Bones perspective on this research finding would include, but also go beyond, the above five proposed causal factors. As we see it, intense physical activity places various stresses on the body resulting in increased oxidative damage, increased bone-depleting low grade metabolic acidosis, and increased losses of many nutrients in the sweat. All these factors suggest the need for a higher level of not only calcium, but of all the 20 key bone nutrients. Further, ample antioxidants should be consumed by endurance athletes. These nutrients should be taken, perhaps in liquid form, just before or during the exercise itself. In addition, special attention should be given to reducing any exercise-induced metabolic acidosis with the Alkaline for Life® Diet and the use of alkalizing mineral compounds as necessary.

Reference:
Barry, DW, and Kohrt, WM. 2008. BMD decreases over the course of a year in competitive male cyclists. J Bone Miner Res, 23(4):484-491.

Does being Asian-American really increase your risk of fracture? Being “Asian or Asian-American” always figured high on the standard list of osteoporosis risk factors. So naturally, one is led to think that Asians and Asian-Americans are at high risk for osteoporotic fracture—particularly Asian-American women who are in or past menopause.

When we actually look at the fracture statistics, however, we find that postmenopausal Asian-American women have the lowest fracture rate of women in any US ethnic group. In a study of nearly 200,000 women, Asian-Americans were found to experience one-third the osteoporotic fractures of Caucasian and Hispanic women, and they even fractured much less than Native American and African-American women.

So, why is being Asian-American always listed as a big risk factor for osteoporosis? This is because Asian-Americans are generally thinner and have lower bone density than other ethnic groups. Yet the study shows that although they have lower bone density, they still fracture much, much less often.

This interesting paradox supports my long-standing position that bone mineral density is not a good predictor of fracture risk. As I have been saying for years now, many factors influence fracture risk, not just bone density. In fact, over half of all women who fracture do not have very low bone density.

To learn about the variety of risk factors contributing to osteoporotic fracture, take a look at my article, Rethinking the Causes of Osteoporosis.

Reference: Barrett-Conner, E. et al. 2005. Osteoporosis and fracture risk in women of different ethnic groups. J Bone Miner Res, 20(2):185-194.

My recent blog on the bone-building action of prunes drew a lot of attention and generated several interesting follow-up questions. Let me answer your questions as best I can.

Q. Wouldn’t eating 9-10 prunes a day cause diarrhea and/or gas?

A. As we well know, prunes have a laxative effect. The studies using 9-10 prunes a day, however, found that if people introduce the prunes slowly, taking a few to start and adding more over time, they do not experience excessively loose stools. Also, at the Center for Better Bones we find that soaking or lightly cooking the prunes also helps improve their digestibility, as does eating them warmed a bit, if necessary. Another tip is to spread your prunes out over at least 2 meals. Incidentally, prunes make a tasty dessert or sweet addition to hot cereal.

Q. Will eating all these prunes each day cause me to gain weight?

A. As it appears, consuming prunes did not cause weight gain and, in fact, prune researcher, Dr. Bahram Arjmandi specifically addresses this question, suggesting that prunes are so satisfying that they can actually aid in weight control. Also, recent work at the San Diego State University found snacking on prunes twice a day curbed the appetite while improving blood lipids, which actually aids weight management.

Q. I try to keep my blood sugar under control. Wouldn’t eating these prunes harm my blood sugar?

A. As Dr. Arjmandi reports, “Because prunes are low on the glycemic scale, they should not be a problem for people with diabetes.”

Q. Does drinking prune juice have the same effect as eating prunes?

A. All of the research I have found uses whole prunes, so I have to say that we simply do not know if prune juice would have the same bone-building impact.

Q. You list prunes as being an “acid-forming food.” So how can they help bones?

A. We have to remember that foods have many qualities, and not all acid-forming foods are bad for bones. In fact, protein is acid forming and yet adequate protein is essential for optimum bone health. Although prunes are slightly acid-forming, they contain phenolic and flavonoid plant compounds, which increase bone growth factors, so overall their impact on bone is very positive.

In April 2008 the U.S. National Osteoporosis Foundation published its new criteria for osteoporosis treatment, “Clinician’s Guide to Prevention and Treatment of Osteoporosis.” This handbook sets forth their official suggestions for treatment, which basically boil down to two sets of criteria for determining if a person should be given osteoporosis drugs. One criterion is based on bone density alone; the other concerns the assessment of fracture risk based on multiple risk factors other than bone density.

The guidelines were designed to help doctors determine who to treat and were well intended, but I can’t help but ask, “What do they mean?" What do these new NOF guidelines mean for women (the majority of osteoporosis patients), and just how many women would be treated with osteoporosis drugs if these guidelines were followed by doctors around the country?

Interestingly enough these same questions were asked by researchers from the noted U.S. Study of Osteoporotic Fractures. The answer they came up with is quite astounding. Applying these new criteria to women in the large, representative Study of Osteoporotic Fractures these researchers calculate that at least 72% of white women aged 65 and older, and 93% of women aged 75 and over, would be told to take osteoporosis drugs.

To me this is startling and rather frightening. First, as reported by the U.S. Surgeon General, only 17% of white women aged 50 older will experience a hip fracture in their life; 15% a vertebral fracture, and 16% a forearm fracture. Second, the side effects of these drugs are well noted and substantial -- and they would be recommend to the vast majority of older Caucasian women. Third, I am perplexed at such a strong focus on drug therapy these days when science is now documenting the many life-supporting ways we can both prevent osteoporotic fracture and at the same time build better overall health. For example, many researchers, myself included, estimate that nearly half of all osteoporotic fractures could be prevented with adequate vitamin D supplementation with even greater results possible if all the key 20 bone-building nutrients were consumed in adequate amounts.

If you are interested in avoiding the risks of osteoporosis drug therapy, know that there are science-based, natural alternatives, and I am happy to share these with you. You can start by assessing your fracture risk through our simple fracture risk and bone health profile.

Wishing you all Better Bones and a Better Body.

References:

Donaldson, MG et al. Estimates of the proportion of older white women who would be recommended for pharmacological treatment by the new U. S. National Osteoporosis Foundation Guidelines. J Bone Mineral Res 2009; 24 (4): 675-674.

U.S. Surgeon General. Bone Health and Osteoporosis: A Report of the Surgeon General. U.S. Dept of Health and Human Services, Rockville, MD, 2004.

Brown, S.E. Vitamin D and fracture reduction: An evaluation of the existing research. Altern Med Rev 2008; 13(1): 21-33.

My friend and fellow osteoporosis researcher Dr. Bahram Arjmandi says yes, the humble prune can reverse bone loss, and his research data is looking strong. For more than a decade Dr. Arjmandi of Florida State University in Tallahassee has tested a wide variety of “functional foods” for their potential impact on bone health. He has studied soy, blueberries, strawberries, raisins, dates, and finally prunes. No other natural substance, he reports, comes near to having the bone-building effect of prunes. Further, when I saw him at the ASBMR international bone meeting last fall, he reported he had never seen any natural substance produce such consistent beneficial bone-building results.

Dr. Arjmandi’s several successful animal and human studies document that special phenolic compounds in dried plums up-regulate growth factors linked to bone formation (such as IGF-1) and counter the activity of factors that inhibit bone formation (such as TNF-alpha). It probably also helps that prunes are one of the foods highest in antioxidants and also contain generous amounts of various key bone nutrients including potassium, boron, and copper. While Dr. Arjmandi has found other natural substances capable of halting bone loss, prunes were the only food found to actually restore lost bone.

This summer Dr. Arjmandi and colleagues will complete a landmark, controlled human clinical trial on prunes and bone health. For this study, 120 post-menopausal women have been taking either 100 grams of prunes (9-10 a day) or an equivalent portion of dried apples for one year. While it will be a few more months before all the research data is in, thus far 30 women in the prune group have had at least a 6% increase in hip bone, and one woman had an exceptional 11% increase consuming prunes over the year. Preliminary data from a segment of research subjects found that all prune-eaters showed at least some improvement in bone mass by six months into the study.

For several years I have heard Dr. Arjmandi speak of his prune research and read many of his research articles. It makes sense: if you could limit factors that hinder bone formation, such as inflammation and oxidative stress, and at the same time up-regulate new bone formation growth factors, and provide key bone nutrients, you could well accomplish the unthinkable and stimulate new bone formation with a simple, wholesome food substance.

At the Center for Better Bones, a group of us (including myself) are doing our own “prune experiment.” If you are inclined to join us, take Dr. Arjmandi’s advice and start slowly with a few prunes a day, working up to the full 9-10 over time. I have found soaked or stewed prunes are easier to digest, and Dr. Arjmandi has found that prunes do not lead to either weight gain or increased blood sugar levels. Also they should help build new bone in men as well as women.

References:

Arjmandi, BH et al. 2002. Dried plums improve indices of bone formation in postmenopausal women. Journal of Women’s Health & Gender-Based Medicine, 11:61-68.

Hooshmand, S and Arjmandi, BH. 2009. Viewpoint: Dried plum, an emerging functional food that may effectively improve bone health. Ageing Res Rev, Apr 8:122-7.

If you are thinking that you should have a bone mineral density retest every year or two, you should know that Canadian osteoporosis authorities might disagree. Summer 2008 findings from the large Canadian Multicentre Osteoporosis Study led researchers to suggest that bone density testing in middle-aged and older adults can be delayed for intervals of up to five years in the absence of risk factors for bone loss, unless a therapeutic intervention is being monitored. 

As the researchers report, while current guidelines recommend that measurements of bone density be repeated once every two or three years, their data suggest that, at this rate of testing, the average person would exhibit changes well below the margin of error. “Consequently … repeat measurements of bone density could be safely delayed for intervals of up to 5 years unless a therapeutic intervention is being monitored or there are additional clinical risk factors for bone loss, such as corticosteroid use.”

The study included 4,433 women and 1,935 men, and interestingly enough, bone loss was found to begin earlier in men—between 25 and 39 years of age. Bone loss in women appeared to begin between ages 40 and 44, with the greatest rate of decline between ages 50 and 54, followed by a slower decline. Then from age 70 onwards both women and men experienced another phase of accelerated bone loss.

And what about those at high risk for excessive bone loss and/or fracture? 

We at the Center for Better Bones monitor high-risk individuals on our natural bone-building programs with regular bone resorption tests every six months or so and bone density testing at 2 to 3 year intervals.

For details on testing the success of your bone building program using bone resorption markers see my articles, Bone testing - assessing bone breakdown and bone loss, and Bone density testing.

Finally, if you wonder whether you are at high risk for osteoporosis, check into our interactive Bone Fracture Risk Assessment Questionnaire.

Reference:
Berger, C. et al. 2008. Change in bone mineral density as a function of age in women and men and association with use of anti-resorptive agents. CMAJ, 178(13):1660-8.

For some time now we have been hearing reports of strange jaw bone decay (osteonecrosis) associated with the use of Fosamax® and other bisphosphonate osteoporosis drugs including Actonel® and Boniva®. We have been told, however, that the risk of this frightful side effect (1) was extremely low (on the order of 1/1000 of a percent) and (2) involved those taking the bone drugs intravenously. As the dust clears and non-commercially financed studies are surfacing however, we see a different story. As recently reported by the University of Southern California Dental School in Los Angeles, the risk of jaw bone damage from oral bisphosphonate use is both real and significant.

This 2008 study looked at Dental School patients who were on, or had taken, Fosamax and who also were being treated for active osteonecrosis of the jaw (a "rotting" or death of jaw bone tissue). The study identified 208 patients with a history of Fosamax use and found that 4% of these had active osteonecrosis of the jaw. All osteonecrosis cases occurred after either simple tooth extraction or denture trauma that resulted in jawbone exposure. In 4% of all cases, the jaw was simply not able to heal itself from the trauma of tooth extraction or other injury. This is not an insignificant number and it is a far cry from the 1/1000 of a percent risk previously suggested by medical authorities. On the other hand, of the University's 13,522 patients without a history of Fosamax use, 4,384 underwent tooth extraction without a single development of post-surgery jaw osteonecrosis.

From the Better Bones Perspective, this is not at all surprising. There are likely many mechanisms by which these osteoporosis drugs damage the self-repair capacity of bone. For one, the drugs greatly reduce not only the unwanted bone breakdown, but they also equally reduce the desired new bone build-up. This curtailing of bone renewal limits the self-repair, self-renewal process of bone breakdown and build-up. The development of "jaw rotting" after jaw bone trauma is one manifestation of this severe repair deficit.

Reference: Sedghizadeh, PP, et al. 2009. Oral bisphosphonate use and the prevalence of osteonecrosis of the jaw: An institutional inquiry. J Am Dent Assoc, 140(1):61-66.

Greetings to all,

Some of you might be wondering why you have not heard from me for several months—no newsletters, few e-mail notices. Well, over the past year I have been very busy writing numerous new articles for our redesigned web site, betterbones.com. My goal was, and is, to produce the world’s most informative and useful website on natural bone health. I am very pleased with the new site and hope you like it too. I would love to hear your comments.

In these new articles, I’ve tried to share the many exciting developments in the field of bone health and to capture some of the things we know about bone health that are in contrast to the conventional wisdom about osteoporosis. One article that I’d like to share with you now is a summary of 10 major common myths about osteoporosis. In this article, “It’s More Than Just Thin Bone—The Top 10 Myths about Osteoporosis,” and on my entire web site, I work to sort fact from fiction, helping you to better understand the true nature, causes, and best prevention and treatment of osteoporosis and osteopenia.

It is great to be back in touch with you. I will be writing this blog every two weeks, highlighting the new science of bone health. Let me know what you think of the “The Top 10 Myths about Osteoporosis” and my new betterbones.com website.