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Better Bones Blog
Dr. Susan E. Brown

Protein intake and fracture risk: A double-edged sword?

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My Alkaline For Life® diet classifies protein foods as acid-forming, which makes many people wonder if a lower protein intake might be better for bones. But protein is essential for bone health and almost half of all bone (by volume) is actually made of protein in the form of the flexible bone protein matrix which contains embedded mineral crystals. Several studies show that protein intake above the current RDA — around 50 g a day for females and 63 g for males — can actually benefit bone.

There is a caveat about high protein intake

If you increase your protein intake you must balance it by taking in more foods and supplements that provide vital alkalizing compounds to buffer any excess acid produced when your body metabolizes dietary proteins. See my article on the benefits of protein for more details.

This recommendation for protein intake is supported by a paper presented at the recent annual meeting of the American Society for Bone and Mineral Research (ASBMR). Researchers analyzed 12-year follow-up data from the Framingham Offspring Study, looking for correlations between hip fracture risk and high-protein diets, and how fracture risk might be offset by higher intake of calcium.

Acidifying protein can damage bone by causing a loss of calcium in the urine. The study’s finding showed that, in people who take in high amounts of protein and low amounts of calcium (less than 800 mg a day), hip fracture risk is almost 3 times higher than those with a lower protein intake. However, those who have high animal protein intake and 800 mg of daily calcium exhibit an 85% reduction in hip fracture risk.

So high-protein intake does not necessarily damage bone and can instead be good for bone tissue. But for that to happen, you simply must offset the impact of protein’s acid-forming nature. These researchers found that a good way to compensate is to take in more calcium in order to reduce the loss of calcium through the urine. At the Center for Better Bones, we believe that the best way to balance a high-protein diet is to take in a full range of alkalizing compounds from food and supplements.

You can keep your acid load in check with our Better Bones, Better Body Ph Test Kit.

 

Reference:

Sahni, S, Cupples, L, McLean, R, et al. 2009. Protein intake: A double edge calcium-related sword for hip fracture risk. ASBMR 31st annual meeting, Presentation number 1056.

 

Better Bones Blog
Dr. Susan E. Brown

Encouraging data on declining hip fractures

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Let’s face it: the number one fear of most people with osteoporosis is fracturing a hip, and for good reason. Hip fractures are physically and financially debilitating, and may even shorten your lifespan. But new research gives us reason to be hopeful: the U.S. hip fracture rate is falling.

This may come as a surprise considering the inflammatory headlines from the U.S. Department of Health and Human Services only weeks ago, declaring dramatic increases in osteoporosis-linked fractures. That data would strike fear into the heart of any woman with a less-than-average T-score! But while it’s true that a larger number of fractures are being diagnosed today than years ago, the rate of fractures — adjusted to the population — is actually shrinking.

Specifically, the reports are as follows:

• Between 1993 and 2003 hospitalizations for hip fracture decreased by 5% and the age-adjusted rates of hip fracture for women and men fell by about 20%.  This is data from the US Nationwide Impatient Sample. (Gehlbach et al. 2007)

• From 1985 through 2005 the Canadian hip fracture rate, adjusted by age, fell by 32% in women and 25% in men. (Leslie et al. 2009)

From my perspective, the most important take-away from this data is that this trend of decreasing hip fractures was well under way long before the new osteoporosis drugs became popular, and scientists agree that this decline in fracture incidence is not due to use of osteoporosis medications.

In fact, I would go so far as to say that the decline is in spite of the use of these medications, which have questionable  benefits with long-term use  and which may even increase the risk of non-traumatic fractures in some women who take them for more than 5 years.

So what can you do to help this encouraging trend to continue? Nourish your bones! Many of the factors that cause hip fractures are within your control, and no one has the power to change them but you. To learn more about opportunities to improve your bone health, take our Bone Health Profile.

 

References:

Gehlbach, SH, et al.  2007. Trends in hospital care for hip fracture.  Osteoporosis International, 18(5):585-591.

Leslie, WD, et al. 2009. Trends in hip fracture rates in Canada. JAMA, 302(8):883-889.

 

Better Bones Blog
Dr. Susan E. Brown

A “dowager’s hump” does not always mean spinal fracture

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Much of the fear generated around osteoporosis stems from pictures of stooped, hump-backed, downward-looking elderly women. This vertebral deformity, often called a “dowager’s hump” and technically known as “kyphosis,” has come to be a dreaded tell-tale sign of the crippling potential of osteoporosis. New research, however, indicates that contrary to popular opinion, this feared spinal deformity does not necessarily indicate that one has a vertebral fracture. Nor does having a dowager’s hump seem to predict the probability of a future spinal fracture.

Actually, this new Australian research is of great interest to me. In my office I have seen more than one very stooped, elderly woman whom I might well think was crippled by osteoporosis, yet her bone tests showed no such problem. While the dowager’s hump and severe kyphosis can be caused by multiple spinal fractures, it often is not. In fact, the relationship between kyphosis and spinal fracture was so weak that these Australian researchers concluded that the existence of even severe kyphosis is only of limited value in determining a person’s risk of having a vertebral deformity and is no value in determining that individual’s risk of future vertebral fracture. Spinal deformities and vertebral fractures can only be reliably diagnosed using x-ray technology or by means of vertebral fracture assessment, also known as vertebral morphometry deformity assessment. Thus, if I see someone very worried about spinal fractures, I suggest that they ask their physician for a spinal x-ray or a vertebral fracture assessment.

So, if having a dowager’s hump or kyphosis does not necessarily mean you have osteoporosis, what else might it mean? Well, the most common reason for such a hump is postural slouching associated with a loss of musculoskeletal integrity and strength. For many, standing tall and holding good posture is an exercise in itself. Other non-fracture reasons include certain diseases, developmental or congenital causes, and nutritional issues such as rickets from vitamin D deficiency.

 

Reference:

Prince, RL, et al. 2007. The clinical utility of measured kyphosis as a predictor of the presence of vertebral deformities. Osteoporosis International, 18:621-627.

 

Better Bones Blog
Dr. Susan E. Brown

High calcium intake does not prevent fractures

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Years ago, in the first edition of my book, Better Bones, Better Body, I noted that high calcium intakes did not seem to prevent fractures. Cross-cultural data, in fact, suggested that countries with the highest calcium intake actually had the highest rates of osteoporotic hip fractures. Recently, sophisticated meta-analysis of the major published studies on the topic confirm my early breakthrough observation—and go beyond it to suggest possible risks of high, imbalanced calcium intakes. High calcium intakes do not prevent fractures, and may actually increase risk of hip fracture among some.

In my blog post, “Vitamin D is more important than calcium” I report on the US NHANES 111 survey finding that only for women with very low vitamin D levels is a higher calcium intake associated with better bone density. The large national survey (Bischoff-Ferrari et al. 2009) found that if women were not deficient in vitamin D (that is they had a vitamin D level above 20 ng/mL), a calcium intake higher than 566 mg per day was not associated with any greater bone density than with an intake of 566 mg calcium per day.

I doubt this lack of association between bone density and higher calcium intake among all but the vitamin D deficient came as a surprise to Bischoff-Ferrari and colleagues.

And why do I say these researchers were likely not surprised?

Because these scientists had already carefully analyzed all the studies on calcium intake and fracture risk.

• In 2005, Bischoff-Ferrari et al. conducted an overview analysis of studies on vitamin D and fracture prevention and concluded, ‘Thus, additional calcium supplementation may not be critical for non-vertebral fracture prevention once 700-800 IU of vitamin D are provided.” (Bischoff-Ferrari et al. 2005)

• Then again in 2007, the same group conducted a monumental meta-analysis of all major studies looking at calcium intake and risk of hip fracture. As they reported, “Pooled results from prospective cohort studies suggest that calcium intake is not significantly associated with hip fracture risk in women or men. Pooled results from randomized controlled trials show no reduction in hip fracture risk with calcium supplementation and an increased risk is possible. For any nonvertebral fractures, there was a neutral effect in the randomized trials.” (Bischoff-Ferrari et al. 2007)

And what about the possible increased risk of fracture they suggest?

In their meta-analysis they found four clinical trials which reported separate results for hip fracture. These clinical trials involving 6,504 subjects found a 64% greater risk of hip fractures with calcium supplementation. While this question of if, and how, high calcium intake could actually increase hip fracture risk is both complicated and speculative, a logical explanation the researchers mention is that “calcium alone may not prevent hip fractures in women” and that other nutrients are essential for bone strength. The other nutrients they mention include vitamin D, protein, and phosphorus — at least one of which (phosphorus) can be detrimentally impacted by high calcium intakes health.

All this new research supports our long-standing Better Bones position that at least 20 nutrients are key to bone health and that all these nutrients should help keep one nutrient in balance with the others.

 

References:

Bischoff-Ferrari, HA, et al. 2005. Fracture prevention with vitamin D supplementation: A meta-analysis of randomized controlled trials. JAMA, 293(18): 2257-2264.

Bischoff-Ferrari, HA, et al. 2007. Calcium intake and hip fracture risk in men and women: A meta-analysis of prospective cohort studies and randomized controlled trials. Am J Clin Nutr, 86:17980-90.

Bischoff-Ferrari, HA, et al. 2009. Dietary calcium and serum 25-hydroxyvitamin D status in relation to BMD among U.S. adults. J of Bone Miner Res, 24(5):935-942.

 

Spinal Fracture
Dr. Susan E. Brown

Spinal Fracture – How Strong Back Muscles Can Help You!

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Exercise builds muscle and bone, but the benefits are held to disappear upon exercise cessation — or so it appeared, anyway. A recent exercise study from the Mayo Clinic, however, documented powerful spinal fracture reduction eight years after cessation of a back strengthening exercise program. Eight years after stopping this two-year exercise program, past exercisers had significantly greater bone density, and nearly a 2.7 times lower vertebral compression fracture incidence, than non-exercising controls.

This study found that healthy postmenopausal women can reduce their 10-year risk of vertebral fracture by nearly 300% with one simple back exercise performed 5 days a week. As suggested by this study, back-strengthening exercise is far more effective at reducing spinal fracture than any drug therapy and is totally safe — a true Better Bones, Better Body® Approach. Let’s look at the study in detail.

This Mayo Clinic study involved 50 healthy Caucasian postmenopausal women ages 58–75, with no back pain or injury. The women were divided into 2 groups for a 2-year randomized controlled exercise trial. Twenty-seven women performed progressive, resistance back-strengthening exercises, and twenty-three served as non-exercising controls. Measurements were made of back extensor muscle strength, bone mineral density, and spinal deformity.

At baseline, back extensor muscle strength was similar in both groups (exercisers at 39.4 kg and controls at 36.9 kg) and there was no significant difference in bone mineral density. By the end of the 2-year study period, exercisers had increased back extensor strength by some 70% while controls gained 32% in strength and there was no significant difference in bone mineral density between the two groups. At 10 years, the exercising group had lost 16.5% of their baseline back strength (down to 32.9 kg from 39.4) and the control had lost 27.1% of their baseline strength (down to 26.9 from 36.6 kg). The difference in back strength was still significant at 10 years. Overall, exercisers lost 1.65% back muscle strength per year while controls lost 2.7% a year. Bone density declined in both groups, but at 10 years, exercisers had significantly greater bone density than controls. Most importantly, among past exercisers, spinal compression fractures rates were 2.7 lower even 8 years after cessation of the back-strengthening exercise program.

And what was this effective exercise program? Women were instructed in progressive, resistance weight-lifting exercise for the back extensor muscles. They used a backpack that contained weights equivalent to 30% of the maximal isometric back extensor strength. Lying in a prone position (on their stomachs) they lifted the backpack ten times (see illustration). As their back strength increased, the amount of weight lifted was increased. The maximum weight of the backpack was 50 lbs. Women did the 10 repetitions of this back weight-lifting exercise 5 days a week for 2 years.

 

Reference:

Sinaki, M, et al. 2002. Stronger back muscles reduce the incidence of vertebral fractures: A prospective 10-year follow-up of postmenopausal women. Bone, 30(6):836-841.

 

Better Bones Blog
Dr. Susan E. Brown

Bone fractures – A wake-up call

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Thirty years ago, I was impressed to hear a panel of cancer survivors declare that they were glad they had developed cancer. Looking back, they appreciated the cancer because facing this serious challenge caused them to move ahead and improve their lives in unprecedented ways. Recently, I was equally impressed by a call from a client of mine (I’ll call her “Sally”) who declared that she had come to see a recent leg fracture as a challenge with hidden blessings.

Seeing a bone fracture as a wake-up call and a “window of opportunity”

Two summers ago, Sally, at age 57, knew she had osteoporosis. From her work with me that summer, we discovered that her vitamin D level was inadequate, that her parathyroid hormone was elevated and nearly out of the normal range, that she was losing excessive calcium in her urine, and that her acid-alkaline balance was less than optimal. Her tests also showed, as I expected they would, that she was experiencing an undesirably high rate of bone breakdown. All of these factors not only suggested on-going bone loss, but also indicated increased fracture risk.

From consulting with me that summer, Sally knew that she had an excessively low bone density, that the bone loss was on-going, and that there were at least four causes for this bone loss, which I could help her correct. All this she knew from our work together, yet at that time she did not implement the Better Bones approach I developed for her. Her bone health concern was overshadowed by other seemingly more important health issues, including chronic fatigue and debilitation, multiple chemical sensitivities, allergies, and a heavy metal burden. For the next 19 months, I did not hear from Sally.

In the spring of this year, Sally called me. She had experienced a low-trauma leg fracture two months earlier. The fracture repair was a bit complicated, requiring surgery with a bone graft, a metal insert, and screws. While untoward and painful, this fracture experience catapulted Sally into high gear. Although limited by chronic fatigue and environmental illness, she realized she had to, and could, take care of herself during this time of challenge. Financially she could not ask her husband to stop working in order to take care of her; she had to find the energy and fortitude to do it herself. With this burst of clarity, she began to take her bone health challenge seriously.

For starters, she began the complete Better Bones nutritional supplement program I had suggested 19 months before. She also optimized her vitamin D level, normalized her urine calcium excretion, and worked our Alkaline for Life® diet with great earnest. Further, she implemented an adrenal support program that I had suggested early on. Even more, she saw the fracture with all its pain and disability as a challenge—a wake-up call to move forward and improve her overall health. She came to see the fracture as a blessing, instead of a curse. Today, some months after the fracture, healing is going well and Sally is seeing the overall health benefits of her fracture-inspired, positive changes. She is actually feeling more energetic, healthier, more positive, and more invigorated than she has in many years. As she mentioned to me, she has come to see the truth of the old Chinese proverb that a crisis can become an opportunity.

As we at the Center for Better Bones like to say, “It is never too late to begin building and rebuilding bone strength.”

For further information on the Better Bones perspective, see my article, A natural approach to bone health.

 

Better Bones Blog
Dr. Susan E. Brown

U.S. hip fracture rates on the decline

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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.

 

Better Bones Blog
Dr. Susan E. Brown

How many women experience an osteoporotic fracture?

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A few months ago one of our readers asked me to estimate just how many people in the U.S. actually experience an osteoporotic fracture. Sometimes it is difficult to tell fact from fiction and to sort out a pharmaceutical-induced “osteoporosis scare” perception from real fracture data.

Taking this reader’s question to heart, I asked myself , “How do we really know how many people actually have an osteoporotic fracture?”  It became quickly obvious that this is not an easy question to answer, largely because many people suffer “silent”spinal fractures that are never reported to physicians. In fact, it is estimated that two-thirds of all spinal fractures are undiagnosed; thus, they never enter into the official statistics. For example, my father at age 85 was in a car accident and it was incidentally discovered on x-ray that he had had two previous spinal fractures in his upper back. He had never noticed any pain, nor had any reason to think there might be a spinal deformity. Even now at age 98 he has no back pain, but has lost several inches of height.

Equally, many rib fractures are never reported. What we do know about, however, are most of the hip fractures that occur. The total number of hip fractures in the US is held to be somewhat over 300,000 a year. Some hip fractures, however, do slip by the statistics, such as the one experienced by my grandmother. At the age of 101, she fell in the bathtub and fractured her hip. She refused to go to the doctor and said that she “had taken care” of her two sons for a hundred years and they should now take care of her. She went to bed and remained there for one year to the day, at which point she died in her sleep.

So groups like the National Osteoporosis Foundation have made it their business to estimate how many osteoporotic fractures do occur. Their statistic is that one half of women age 50 and older will experience one or another osteoporotic fracture during their lifetime. They also report that one in four men over the age of 50 will also have an osteoporotic fracture in their remaining lifetime.

Granted it is in the best interest of the National Osteoporosis Foundation to seek out the highest possible fracture statistic estimates, and they likely include a great many inconsequential spinal vertebral fractures that were never noticed by the people experiencing them.

In my estimation of fracture incidence, I tend to include only fractures of significance and do not pay much attention to the undiagnosed spinal vertebral fractures. In this sense it is probably fair to say that 30% of US Caucasian women will experience one or another meaningful osteoporotic fractures in their lifetime. For example, looking at spinal fractures alone, I would mention a recent 15-year study looking at 2,700 US Caucasian women. At the onset of the study the average age was 69. Over the next 15 years, 18% of these women suffered a spinal fracture. Finally, the longer you live, the more likely you are to fracture. By the age of 90 about 32% of all females and 17% of all males in the US have experienced a hip fracture (See Susan Ott’s website: http://courses.washington.edu/bonephys/).
References:

Cooper, C. and Melton, L.J. 1992. Vertebral fracture: How large the silent epidemic? BMJ, 304, 793-794.
Cauley, J. et al. 2007. Long-term risk of incident vertebral fractures. JAMA, 298(23), 2761-2767.

Better Bones Blog
Dr. Susan E. Brown

Bone mineral density alone does not predict fracture

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Recently, two international studies verified what we in the Center for Better Bones have been saying for years about the fact that you cannot predict who will fracture by bone mineral density.

In a 2006 German study, it was determined that 7.8 million Germans have osteoporosis as defined by bone density.   That is, 7.8 million Germans have a bone density that is -2.5 standard deviations or more below the average bone mineral density of a young adult.  Of this total, only 4.3% were found to experience one or more clinically recognized fractures.  That is, even though millions of people have osteoporosis as defined by bone density, only 4 out of 100 of these people with osteoporosis actually experienced a meaningful fracture.

Looking at their data another way, a second group of international researchers looked at data from two large trials (the SOTI and TROPOS trials) comparing fracture incidence with bone mineral density among 6740 women.  Overall, of all the fractures that occurred in both studies, only 18% occurred in women with an “osteoporotic” bone density (that is, a bone density of equal to or greater than -2.5 SD T score).  The vast majority of women who fractured had an “osteopenia” bone density, not an “osteoporotic” bone density.

 

References:

Haussler, B., et al. 2007. Epidemiology, treatment and costs of osteoporosis in Germany: The bone EVA study. Osteoporosis International 18(1):77-84. (Epub ahead of print Sep 2006)

Seeman, E., et al. 2008. Strontium ranelate reduces the risk of vertebral fractures in patients with osteopenia. Jr. Bone and Mineral Research, 23(3), 433-438.

Vitamin D Deficiency
Dr. Susan E. Brown

Vitamin D Deficiency and the Association with Hip Fractures

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The recent explosion of research on vitamin D has made most of us aware that adequate vitamin D is essential for bone health. The degree of its importance, however, is underscored by world-wide research suggesting that practically everyone who experiences an osteoporotic (low-trauma) hip fracture has a Vitamin D deficiency.

In Minnesota, they looked at 82 adult minimal trauma fractures in people ages 52-97. Ninety-seven percent of all 82 fractures were hip fractures. All but two of the hip fracture patients had low vitamin D levels (below 30 ng/mL). In a large British study, vitamin D deficiency was found in 95% of hip fracture patients as were 78% of hip fracture patients in a recent Boston study.

Such findings have led researchers to ask if vitamin D level is not the best predictor of hip fracture risk. Our research at the Center for Better Bones and the Better Bones Foundation would lead us to agree that low vitamin D should indeed be considered as a major, if not the major, risk factor for hip fracture.

 

References:

Gallacher, S.J. et al. 2005. Prevalence of vitamin D deficiency in Scottish adults with non-vertebral fragility fractures. CMRO, 21, 1355-1361.

Glowacki, J. et al. 2006. Importance of vitamin D in the design of hospital hip fracture care pathways. ASBMR Meeting Abstract #T46.

Malavolta, N. et al. 2005. The relationship of vitamin D status to bone mineral density in an Italian population of postmenopausal women. Osteoporos Int, 16, 1691-1697.

Simonelli, C. et al. 2005. Prevalence of vitamin D inadequacy in a minimal trauma fracture population. CMRO, 21, 1069-1074.