Diagnostic tests for causes of osteoporosis

woman-with-man-in-backgroundI can’t help but draw attention to the fact that generally when a man is shown to have osteoporosis by bone mineral density testing or because of a needless fracture, he is immediately given a series of tests looking for the causes of his bone weakening.

Women with osteoporosis, on the other hand, are immediately told to take bone drugs. Most often no tests are done and no attempt made to uncover the causes of osteoporosis.

As a result, many women take bone drugs to cover up the real problem. It’s never discovered that they might be suffering from hyperparathyroidism, excessive loss of calcium in the urine, Celiac Disease, hypercortisolemia or any other of the hidden causes of osteoporosis.

Get thoroughly tested for hidden causes

I believe that any woman experiencing excessive bone weakening should be thoroughly tested for hidden causes.  After all, if a doctor thinks the problem is serious enough to tell a woman to take bone drugs, then it is serious enough to warrant a full diagnostic workup looking for hidden causes of bone weakening.

Just today I saw yet another woman who was told to take bone drugs because of excessive bone loss without any testing looking for the causes.  After working with me she discovered she was losing bone due to an overactive parathyroid gland, which I’ll write about more in an upcoming blog.

What are common diagnostic tests?

Here are some common diagnostic tests that can be used to uncover the underlying causes of osteoporosis:

  • Vitamin D 25(OH)D blood test
  • Ionized calcium test
  • Intact parathyroid hormone blood test (iPTH)
  • 24-hour urine calcium excretion test
  • Thyroid hormone function test (TSH)
  • N-telopeptides crosslinks (NTx) urine marker of bone resorption test
  • N-telopeptides crosslinks (NTx) serum marker of bone resorption test
  • Dpd urine marker of bone resorption test (deoxypyridinium crosslinks test)
  • Vertebral deformity assessment
  • Free cortisol test (blood or saliva)
  • DHEA test (blood or saliva)
  • C-reactive protein test (high sensitivity if possible)
  • Homocysteine test (plasma or serum)
  • Celiac disease and gluten sensitivity test
  • Sex hormone test

You can read more about each diagnostic test in my article What’s the cause of your osteoporosis? Diagnostic tests and what they mean. If you suspect excessive bone weakening I suggest you read, print out and discuss this article with your medical practitioner.

You can also learn more with my video Uncovering the hidden causes of bone loss —medical tests you should know about.

Help for understanding bone density test results

confused-womanHave you had your bone density tested? If so, you may have found yourself confused by what the results really mean.

If not, you may still be stressed about the possibility, which is understandable given how many practitioners talk about low bone density as the inevitable first step toward osteoporosis.

Whatever your situation, I want to reassure you that knowledge is power when it comes to your bone density test results. Not only is there a lot to know about the numbers themselves, but there are several key “ground rules” that are important to better understand bone density test results in general. I encourage you to take these into account when looking at your own test results:

“Ground rules” for understanding more about bone density test results

  1. DEXA scans should be several pages long, have many charts and x-rays of the spine and hip. Obtain copies of your full bone density reports from your DEXA or DXA scans. You’ll want to look at all the results, not just the summary page.
  2. Small changes in bone mineral density are not significant.  Research has shown that at least a 5-6% change on a bone density test is needed to be sure that any change is not simply due to placement on the machine.
  3. Bone density tests do not truly measure bone density.  DXA calculates BMD using area, so it’s not an accurate measurement of true bone mineral density. Those with smaller body size and/or thin, small bones will not get a true measure of their bone density from the scan.
  4. Bone density changes are related to life stage.  The menopause transition generally is a time of accelerated bone loss.
  5. Not all bone density reports are going to look exactly the same.  They may look different, but the reports should all have the same elements.
  6. Using the same type of bone density testing machine is important for comparing results.  Even better is to have the test done in the same location and even with the same operator.

What are the different bone density screening tests?

For more information about the different bone density screening tests, limitations of BMD testing and steps you can take to limit variability in BMD tests, see my article Bone density testing.

You can also learn more about how to read your results with my How to read your bone density test video available as a download or a DVD.

What’s the cause of your osteoporosis? Diagnostic tests and what they mean

One of the basic principles of the Better Bones Program® is that all osteoporosis, all excessive bone loss, or all real increased risk of low-trauma fracture has a cause. To better understand any undetected causes of bone loss, it is important to obtain a medical work-up — that is, further tests that can help find the causes of osteoporosis.

In addition to the standard DEXA bone density test, we suggest that our clients discuss the following tests with their doctor to see which ones are appropriate. Below are examples of tests that could be helpful and the basics of what the test results mean so that you can better discuss your personal situation with your doctor.

Tests to help reveal what causes osteoporosis

Vitamin D 25(OH)D blood test

This test determines your blood level of vitamin D. The results tell you the amount of vitamin D supplementation needed to reach a therapeutic blood level of vitamin D, which is important for adequate calcium absorption and basic bone support.

What your results tell you: The reported “normal” range is very wide, often from 30 to 100 ng/mL. We now know that anything less than 32 ng/mL is likely to seriously limit calcium absorption and lead to bone loss. At the Center for Better Bones, we strive for a 50-70 ng/mL blood level of 25(OH)D.

Ionized calcium test

This is a simple blood test to measure the level of free calcium — that is, the metabolically active portion of calcium not bound to proteins in the blood. This test isn’t meant to assess the appropriateness of your calcium intake as much as it is meant as an indirect test of parathyroid functioning (see below). It can also indirectly tell us some things about vitamin D status.

What your results tell you: The body controls free calcium in the blood very tightly, with a normal laboratory range between 4.8 and 5.2 mg/dL (between 1.2 and 1.3 mmol/L) as reported by the Merck Index. When thinking of bone health, we look for high ionized calcium as a possible indirect indicator of excessive parathyroid hormone activity. A low ionized calcium level might be related to low albumin and low protein status.

Intact parathyroid hormone blood test (iPTH)

High parathyroid hormone levels are associated with excessive bone loss, as an overactive parathyroid gland draws calcium from bone. The medical reasons for this overactivity need to be addressed to halt the excessive bone loss. Also, a normal parathyroid reading in the face of vitamin D deficiency can indicate magnesium inadequacy

What your results tell you: At the Center for Better Bones, we look for an intact parathyroid hormone level within the normal range established by the particular testing laboratory. Two common causes of an excessively high parathyroid hormone level are vitamin D deficiency (which is easily corrected with proper vitamin D3 supplementation and monitoring); and an overactive parathyroid, which is most often due to benign tumors on the parathyroid glands. Correction of this situation often requires surgery to remove the overactive glands.

Excessively high parathyroid hormone levels cause the body to release too much calcium from the bone contributing to bone loss, and more importantly, high blood calcium. A high parathyroid condition is best treated by an endocrinologist.

24-hour urine calcium excretion test

This test looks at how much calcium is being excreted in the urine. For this test, you collect all your urine over 24 hours in a large container for laboratory analysis to measure the amount of calcium in the total volume of urine. Excessive urinary calcium excretion is a common cause of bone loss and osteoporosis.

What your results tell you: The normal laboratory range for a person eating an average diet is around 100 to 250 mg of calcium lost in the urine each day. I consider a calcium loss of more than 250 mg to be a concern. In such cases, the first step is to stop all calcium supplements for 4 to 5 days and then retest the 24-hour urine calcium. If the urine calcium loss is still high, then steps should be taken to reduce this loss of calcium in the urine, as it can cause bone loss. Nutritional, lifestyle, and medical approaches can help.

Thyroid hormone function test (TSH)

TSH is a hormone produced in the pituitary gland that signals the thyroid to produce more of its hormones. If TSH is high, it usually means that the thyroid isn’t producing enough T3 and T4, so checking your TSH level is a simple way of screening for an underactive thyroid. Thyroid hormone levels that are too high or too low can contribute to osteoporosis, as can a dose of thyroid medication that is too high. To screen for overactive thyroid, or to make sure your dose of thyroid medications isn’t too high if you’re already being treated for hypothyroidism, you’ll need tests for free T3 and free T4.

What your results tell you: The common laboratory range for all adults is 0.35 to 5.50 and a more ideal level is 0.35 to 2.0.

Markers of bone resorption tests

Bone resorption (or breakdown) tests measure the amount of one specific bone protein in the urine or blood. As one loses bone this bone protein fragment shows up in the urine and blood in increased amounts. At the Center for Better Bones, we generally use the N-telopeptides crosslinks (NTx) urine test, but there are several others available. One commonly used test is the urine Dpd test (deoxypyridinium crosslinks test). There is also an NTx serum test and the CTX serum test..

As there can be a great deal of day-to-day variation in urine bone breakdown markers, we’ve developed a two-day collection procedure for bone resorption testing for greater accuracy. These instructions can be used for either the urine NTx or the Dpd test.

N-telopeptides crosslinks (NTx) urine marker of bone resorption test

What your results tell you: The test result “normal” range often listed on the test report is very broad. For example, test reports from our local lab list the premenopausal normal range for women as 17-94 nM BCE/mM creatinine and the postmenopausal range as 26-124 nM BCE/mM creatinine. The male range is 3-51. These ranges are far too wide to be useful.

Ideally, a woman would like to have an NTx level near that of the average premenopausal woman, which in the urine is around 35, but levels often soar into the 60s to 80s or higher in and around menopause. For adult men, the mean NTx is 27, which is a more ideal value than the higher numbers. Also, these markers can get very high in rare diseases such as Paget’s Disease and bone cancer. These situations are unusual and understood by a knowledgeable physician familiar with bone resorption testing.

We use the NTx urine test from Osteomark to judge the success of our bone building program. We look to bring the urine NTx level down to the 40’s, which in most cases indicates that bone breakdown has normalized. There are some cases, however, where bone breakdown is very low, but bone build-up is even lower. This condition, known as “low turnover osteoporosis,” is detected when a person has a low NTx, but is still losing significant bone (5-6%) as seen on bone density testing.

N-telopeptides crosslinks (NTx) serum marker of bone resorption test results

What your results tell you: The NTx bone-breakdown marker can also be measured in the blood. The female range listed by the manufacturer is 6.2-19.0 nM BCE/L, with a mean of 12.6. The male range is often listed as 5.4-24.2 nM BCE/L, with a mean of 14.8. Again, this range is too wide to be useful for us at the Center for Better Bones. We look for a result of 12 or somewhat lower in women, and 14 or somewhat lower in men.

Dpd urine marker of bone resorption test (deoxypyridinium crosslinks test)

What your results tell you: This bone resorption test also lists a broad range of normal values — for women, 3.0 to 7.4 nM/mM and for men 2.3 to 5.4 nM/mM. Clinically, adult women should strive for a Dpd test score in the 4’s, and in men an ideal level would likely be somewhat lower.

Vertebral deformity assessment

This is another x-ray test for bone that images each vertebral body of the spine and looks to see if there are deformities or fractures. The Vertebral Deformity Assessment can be done on newer bone density testing machines, with special software that takes a “lateral” view of the spine.

What your results tell you: The radiologist will give a full report of what he or she sees for each vertebral body, reporting any abnormalities, deformities, or fractures.

Free cortisol test (blood or saliva)

Cortisol is a corticosteroid hormone produced by the adrenal cortex, which is part of the adrenal glands. It is usually referred to as the “stress hormone” as it is involved in response to anxiety and stress. Abnormally high cortisol levels are damaging to bone and as such represent a major risk factor for osteoporosis and low-trauma fractures. This test can be done with blood or saliva.

What your results tell you: Cortisol is the “get up and go” hormone that should rise in the early morning and decline during the day. Thus, test results vary by what time of day the test was taken. Testing labs will give their normal range readings and the timing of the test should be taken into account when interpreting test results.

DHEA test (blood or saliva)

Dehydroepiandrosterone (DHEA) is a hormone produced by both the adrenal glands and the ovaries. DHEA helps to neutralize the effects of cortisol. DHEA helps to protect and increase bone density. Stress reduction activities like yoga and meditation can help maintain youthful DHEA level as we age. Low levels of DHEA are a risk factor for osteoporosis. This test also can be done with blood or saliva.

What your results tell you: In saliva testing, the results are often correlated with the results of the cortisol testing. It is also often measured as DHEA-S, that is, DHEA in its sulfated form. Again, each lab will offer its normal range depending on the test used.

C-reactive protein test (high sensitivity if possible)

C-reactive protein is a plasma protein that is held to be a marker of general inflammation within the body. It is a known risk factor for heart disease because heart disease is largely an inflammatory disorder. Osteoporosis is also inflammatory in nature and this test is helpful in detecting unwanted inflammation, which may contribute to bone health problems.

What your results tell you: Generally, in the C-reactive protein (or CRP) test, the lower the score the less inflammation and thus the better reading. I look for a high sensitivity CRP level less than 1.0mg/dL.

Homocysteine test (plasma or serum)

Homocysteine is a non-dietary amino acid, a product of the metabolism of a dietary amino acid, methionine. In the absence of adequate B vitamins, homocysteine can accumulate in the body. High levels of this substance damage collagen and represent powerful risk factors for both cardiovascular disease and for osteoporotic fractures.

What your results tell you: Normal levels of homocysteine in the blood range from 5 to 15 mM/L. At the Center for Better Bones we like to see a homocysteine level of 8 or below.

Celiac disease and gluten sensitivity test

Celiac disease, or even just sensitivity to gluten, can lead to inflammation of the gut. This inflammation is related to a complex inflammatory cascade which can increase bone loss. Also, those with celiac disease suffer from weak indigestion and malabsorption of many nutrients including vitamins A, K, and D. These deficiencies in turn damage bone. If there is any suggestion of gluten sensitivity or celiac disease, appropriate testing should be considered

What your results tell you: There are varied tests used to help determine if one is suffering from the autoimmune disease known as celiac disease, or if there exists the intolerance of gluten sensitivity. Talk with your healthcare practitioner about what might be right for you.

Sex hormone test results

Post-Menopausal Females: Progesterone, Estrogen
Female sex hormones drop naturally at menopause among all women, so I don’t generally suggest testing of these hormones. Those interested in this type of hormone testing, or those taking hormone replacement medications, should be tested for hormone levels by their physician.

Pre-Menopausal Females (reproductive years hormone testing): Progesterone, Estrogen
For women from their teens to menopause, proper levels of sex hormones are very important to bone health. Low levels of either estrogen or progesterone can limit development of optimum peak bone mass. Irregular, or frequently missed, periods should be studied by a knowledgeable physician.

According to noted progesterone researcher, endocrinologist Dr. Jerilynn Prior, some 25% of young women in the US and Canada fail to develop optimum peak bone mass due to undetected ovulatory disturbances which result in low progesterone levels. Testing of estrogen and progesterone can be helpful in pre-menopausal women with a bone health concern.

Both blood and saliva testing are available for pre-menopause sex hormone testing. Each testing laboratory will have its range of normal sex hormone test results.

Sex Hormone Testing in Males: Testosterone and, at times, Estrogen
A common cause of osteoporosis in men is low testosterone; thus a medical work-up for osteoporosis in men almost always includes a test for testosterone. Interestingly enough, estrogen also plays a role in male bone health and at times the physicians will test for estrogen in men with osteoporosis.

Both blood and saliva testing are available for sex hormone tests in men. Each testing laboratory will have its range of normal sex hormone test results.

Everyone deserves the full story on their health

It seems like healthcare has become a knee-jerk reaction of “see a symptom, take a pill,” but we believe that everyone deserves better than that. Your bone loss is a symptom of something that’s just not right in your body — and rather than treating the symptom with medications (and living with the side effects involved, some of which are plain frightening!), I encourage everyone to dig deeper and find out the source of the problem.

Am I Losing Bone Right Now? The NTx Test









Every day women are worried because they’ve been told that a DEXA test shows their bone density is that of an 80-year-old, or that they “must” take bone drugs.

But what worries me is that most of these women have NOT been told whether or not their bone loss is ongoing or if it occurred in the past. Knowing if your bone loss is still taking place is critical when it comes to your risk of excessive bone loss, osteoporosis and fracture.

The NTx test measures current bone loss

I recommend anyone worried about bone loss get an NTx (N-telopeptide) test. Unlike bone density tests which only provide a static snapshot of your bones, an NTx test tells you if your bones are currently breaking down. It does this by measuring molecules from bone excreted in the urine.

Get a video download about the NTx

You can get a video download that features my explanation of the NTx test, how to get one and how to understand the results. This 9 ½-minute video download also includes a transcript for those who prefer the read the information. You can also help educate your physician about the use of the NTx test and why you would like her/him to order this test for you. Get the video now.


3 Simple Tests Help Predict Hip Fracture Risk

Wouldn’t it be remarkable to have one way to predict future hip fracture risk?

Now, thanks to curious Finnish researchers, we have not just one, but three simple tests that can give us better insight into who is likely to break their hip down the road. After some study they settled on three physical tests, failure of which they thought might indicate that one was headed for a hip fracture. According to their findings presented at the recent ASBMR meeting, the highly predictive tests were:



Researchers had 2,791 women with the average age of 59 complete the tests — and then patiently waited 15 years to see who broke their hips.

What Researchers Discovered

Fifteen years later, researchers compared the rate of hip fracture from those women passing all tests to those women who had failed one or more of the tests. Here’s what they discovered:

• Women at age 59 failing any one of these tests had four times the risk for hip fracture, plus any fracture and even death.

• The strongest single determinant for hip fracture risk was the inability to stand on one leg for 10 seconds. In the study, failing this test at age 59 was associated with over eight times increase in hip fracture risk over the next 15 years.

• The inability to squat, touch the floor and stand back up was linked to a 5.2 times increase in hip fracture.

• Those with lowest grip strength at age 59 (or the bottom ¼ of women tested) ended up with over a four-fold increase in hip fracture as compared to women who passed the balance and squatting tests and were in the top ¾ of those tested.

What Does This Mean for You?

I’m encouraged that this research focuses on activities which suggest general fitness —and they are ones we can all practice to help minimize hip fracture risk. I suggest all women consider the following:

1. Balance is of utmost importance, if you do not fall you will not fracture a hip. If you can’t stand on one leg for 10 seconds at any age, I recommend look into exercise to enhance balance. For balance, I favor mindful exercises like Tai Chi and Qi Gong.

2. Leg strength and flexibility are hip-protective. Develop a leg strengthening exercise program. And the next time you are sitting on the floor or squatting, practice getting without using your hands. Full body strength can be enhanced with my Exercising for Bone Health DVD or the Skeletal Fitness DVD.

3. Diminished grip strength is repeatedly associated with vertebral fracture risk, and now we see it linked to hip fracture as well. If those jars are getting hard to open, it’s time to exercise your arms and hands. I like using the isometric OsteoBall exerciser to enhance arm and wrist strength.

For more information about exercise and bone health, read my article here.



Rikkonen, T. (Sept. 12, 2014) Simple functional tests predict hip fracture and mortality in postmenopausal women: 15 year follow-up. ASBMR abstract FRO455, ASBMR Annual Meeting.

Bone density tests aren’t enough. Why a Fracture Risk Assessment is essential.

Susan Brown, PhD

Many women first start wondering about bone health right at the age when the doctor recommends a bone density scan. But from my experience, getting the results of a bone density scan can generate more questions than answers — especially if your doctor isn’t up to date in the latest thinking on bone health. Here’s what you should know about using a bone density test to predict your risk of fracture or excessive bone loss.

What is a bone density test?

You need more than a bone density test to measure the health of your skeleton.

DEXA (Dual-energy x-ray absorptiometry) or other common bone density scans such as single-photon absorptiometry (SPA); broadband ultrasound attenuation (ultrasound); and quantitative computed tomography (QCT) help determine if you have low bone density, one important risk factor for osteoporosis. These tests measure the bone mineral content in various locations of your body (such as the hip or wrist).

The best known bone-density test is the DEXA scan. It’s a precise test and today is considered the gold standard by many conventional doctors as they evaluate bone health.

A bone density test result is generally presented in numbers as grams per cubic centimeter, and also calculated as a “T score” and a “Z score.” Your T-score compares your bone density to what’s considered the ideal density of a young woman. The Z-score compares your density with that of other people your same age and sex. As you’ll see from the chart below, there is also a big void of other information that a bone density test cannot ever tell you.

What a bone density test does — and doesn’t — do

What a bone density test does…What a bone density test
Estimates the mineral content of bone at a specific time.Doesn’t tell you if you are currently losing bone or if you have had low bone density for many years. Significant changes are rarely measurable in less than two years. Also, bone density can fluctuate based on the season.
Measures all body types the same way.Doesn’t take body type into consideration, for example women who are thinner will always have a lower bone density than heavier women.
Measures specifically the amount of minerals in bones to determine bone loss.Doesn’t detect either bone quality or bone strength. Many of the people who are shown to have low bone density on these tests will never suffer an osteoporotic fracture.
Uses a “gold standard” that compares your results to those of a “normal young woman” (your T-score) or measures against the average bone mineral density for people your age and sex (your Z-score).Doesn’t compare your bone density to healthy, fracture-free people of your age.
Delivers results that can vary greatly depending on the machine used — and the technician running it!Doesn’t provide an accurate assessment from test to test. Placement of patient on the machine is important and a 5-6% change from test to test is necessary to be sure the change was not due to errors in placement on the machine.

As you can see, a bone density test is best used as one of many tools to evaluate your bone health!

What are the options that can determine your bone health?

A woman happy to learn her options to determine her bone health.

Consider other bone health tests to get a more rounded perspective of your bone health. At our clinic we like to monitor the results of a woman’s NTx test, which is a blood or urine test that indicates the rate of bone breakdown by measuring a specific molecule, or marker, released during bone resorption. We also measure a woman’s pH level, which can help determine whether her diet and lifestyle are placing an excessive burden on her bones’ reserves of alkalizing compounds.

Why fracture risk assessment is a better indicator of bone health than DEXA

We know that extreme bone loss is often connected to many variables. That’s why I always recommend that my clients take advantage of the new fracture assessments tools. These tools are designed to look at multiple risk factors, with and without bone density measurement. Eleven of these key risk factors identified by the landmark Women’s Health Initiative are:

  • Age
  • Self-reported health
  • Weight
  • Height
  • Race/ethnicity
  • Self-reported physical activity
  • History of fracture after age 54
  • Parental hip fracture
  • Current smoking
  • Current corticosteroid use
  • Treated diabetes

Based on the research showing that a fracture risk assessment is truly the best way to know who will experience an osteoporotic fracture, I’ve developed my own simple Better Bones Fracture Risk Assessment. By answering just a few questions, you can get a much clearer picture about your potential risk of fracture. Get started now.

Directions for a 2-Day Urine Sample Collection for the NTx Bone Resorption Test

Susan Brown, PhDThe day before the urine collection, do not take any extra vitamin C (beyond that in your multi-vitamin). On the morning of each urine collection, do not take any vitamins, food, or coffee before collecting your urine sample. The sample must be taken BEFORE 10 AM.

Day 1

    1. The first thing in the morning, urinate as usual, not saving the urine.
    2. Drink 1 or 2 cups of water. Do not eat or drink anything except water until after you collect the second urine sample. (Thyroid pill is okay.)
    3. Collect a sample of the second morning urine in a clean plastic or glass container. This collection must be taken BEFORE 10 AM.
    4. Refrigerate this sample.

Day 2

  1. Follow steps 1 to 3, collecting your second morning urine in a second container.
  2. In a third container, mix half of each day’s urine. This is the sample you will write your name on and take to the lab designated by your doctor. The leftover urine from each day can be discarded.

Important: Make sure to REFRIGERATE the urine samples in the containers until you take them to the lab. Also, put the samples in a paper bag to avoid sunlight exposure.

Try to do the first urine collection on a Sunday and the second on a Monday.

The tests you need to know for bone health

Whenever a client tells me her doctor says she should take osteoporosis medications, I always respond with the following comment… “If the problem is serious enough to warrant the use of strong bone drugs, then it is serious enough to warrant an investigation into the possible causes of the supposed bone weakening.”

The truth is that many times when we take a closer look, we find there actually isn’t excessive bone weakening, just regular age-related bone loss!  That’s why a health practitioner’s  suggestion — or often demand —  that a patient use bone drugs offers a good opportunity to do a standard medical workup searching for the possible cause of bone loss.

In part 3 of my Better Bones Empowerment Video Series Uncovering the hidden causes of bone loss — medical tests you should know about, I explain which tests you should know about so you can discuss them with your practitioner. There are many baseline medical tests commonly used to help uncover hidden causes of bone weakening or osteoporosis and this Empowerment Series discussion details over a dozen of them including:

• Vitamin D Blood 25(OH)D Test

• Intact Parathyroid Hormone (iPTH) Blood Test

• Ionized Calcium Test

• 24-Hour Urine Calcium Excretion Test

• Celiac Disease and gluten sensitivity

Remember, osteoporosis always has a cause and the best path to life-long bone health is uncovering and correcting the underlying causes of the bone weakening. Empowering yourself with knowledge about these tests is especially important when you already have signs of excessive bone loss or have experienced a low-trauma fracture.

Finally, a few comments regarding your medical records: make it your personal responsibility to obtain copies of all your test results and try to understand, or find out, what they mean. Make sure to keep the medical test reports with your personal records. No one else cares about your bone health as much as you do and no one will suffer the consequences of neglecting your bone health as much as you will. But it is also crucial to remember we all have options and control when it comes to our bone health.

Watch this blog as a video or purchase Uncovering the hidden causes of bone loss — medical tests you should know about now.


Tests included in the medical workup for osteoporosis

The other day, I had an e-mail from a 70-year-old woman who is following the Better Bones approach. She was obviously very frustrated by what she considered a lack of progress. “I’m doing everything I’m supposed to,” she said, noting that she was eating alkaline and testing her pH, exercising daily with weights, meditating, and taking her vitamin supplements religiously. But she’d just had a DEXA scan and was upset because nothing had changed. Her bone density was no different than it had been the last time she’d had her bone density measured 2 years ago, and she couldn’t understand why it hadn’t improved.

At first, this struck me as a little bit funny. She clearly didn’t understand something very important. For a woman after menopause, keeping bone density stable is a big accomplishment! Keep in mind that the average in her 60’s and 70’s loses 1 or 2% of her bone mass every two years. That means that over the course of 3 years, this particular woman had maintained her bone density instead of losing the 1-2% she might normally have expected to lose just from the average wear-and-tear of aging. Compared to a lot of her peers, she’s doing pretty well! In light of the fact that the average women loses as much as 47% bone of her bone mass by her late 80’s, this client’s stability of bone as she ages is a real sign of success.

Then I reconsidered. I thought, “this woman thinks she’s failing at something when she’s succeeding — that’s a problem!” Here she was, beating the odds and keeping her bones stable year after year, yet she felt like she wasn’t doing enough. I did not want her to walk away feeling defeated when she’d just won a wonderful victory. But how to get that point across to her and others like her?

Well, here’s a small analogy for you. Many personal trainers will tell someone they’re helping to lose weight to pay no attention to what the scale says, but instead gauge their weight loss success by how their clothes fit. It’s somewhat the same with bone health. For many of us, “optimal bone health” might mean results not visible to the naked eye or even to a DEXA scan — a strengthening of bone that leaves it more flexible and less prone to fracture, but that doesn’t increase its overall density. Some might also find their bone density stabilizes, as the woman who wrote me did (even if she didn’t recognize this stability for the achievement it is). Some see small gains in bone density, and a few see significant increases in bone density. But for most, the improvement might not really show up on any measurement made by a DEXA scanner.

What you do often get with a natural bone health program is a visible improvement in overall health — stronger nails, more supple skin, healthier teeth and gums, often better digestive health — that signifies that the body is getting what it needs and therefore doesn’t need to tap the bones for resources. Like a pair of suddenly loose pants on a person whose bathroom scale says she hasn’t lost a pound, sometimes the measuring device should be disbelieved if the body itself says that good changes are happening.

It’s also true that one might have such gains but not see them, since (as I’ve commented in earlier blogs) DEXA machines are notorious for having poor accuracy from one scan to another. A DEXA scan must show a change in density of at least 5-6%, according to noted bone researcher Susan Ott, to indicate a definite change in bone density; anything less than that could just be variation in the scanner or operator skill. The woman who e-mailed me, for example, could very well have had an increase in bone density of 1% from year to year, but the variability in DEXA measurements might have masked the increase.

So there are two points I’d like everyone to take away from this. One is that your success might not be measurable or quantifiable in terms of increased bone density—but that doesn’t mean you should discount it. Having stable bone mass as we age is something to celebrate! The other is that the point of a Better Bones Health Package and the approach I’ve long advocated is not to make sure everyone has bones equivalent in density to a 25-year-old athlete, but to give the bones — and the body, too — the resources they need to obtain optimal health.


Mysteries of bone breakdown revealed: the RANK, RANK-L and OPG system

Each minute, within the skeleton, more than a million sites of old worn-out bone are being eaten away by osteoclast cells, while new fresh bone is laid down by other specialized build-up cells known as osteoblasts. Just how this process of bone recycling and rebuilding is controlled has long been a question of scientific speculation.

Here is where RANK, RANK-L, and OPG enter the picture. Scientific breakthroughs have identified these three strange-sounding proteins and how they participate in the bone turnover process — and thereby identified a new place where science and pharmacology can intervene to prevent bone breakdown.

This insight into the nature of bone breakdown has led to the development of a different kind of osteoporosis drug — Prolia, a monoclonal antibody that was approved for postmenopausal osteoporosis by the FDA on June 1st. Prolia works on the RANK, RANK-L, and OPG proteins, but its mechanisms are unfamiliar to most people. So I thought I would familiarize you with what these acronyms mean:

RANK is short for “receptor activator of NF-kB” — a receptor sitting on bone breakdown osteoclast cells waiting to be activated. Once activated, RANK signals osteoclasts to mature, get active, and to begin breaking down bone.

RANK-L is a molecule that binds to RANK, activating it, and initiating the bone-recycling process. In essence, it turns RANK on.

OPG, short for osteoprotegerin, is a competitor of RANK-L. OPG binds to RANK and does not activate the bone breakdown cells. OPG keeps RANK-L from locking on to osteoclasts, and thus limits the bone breakdown activity of the osteoclasts.

So for someone in good health, the RANK/RANK-L/OPG system is a key regulator of bone breakdown, allowing the body to refresh and renew bone without excessive bone breakdown or excessive bone build-up.

Now for the quiz . . . if you want to reduce bone breakdown what would you do? Well, you could either:

  1. Increase OPG so that it would bind to the RANK receptor on the bone breakdown cells and thus deactivate them; or
  2. You could inhibit the ability of RANKL to bind to RANK, thus avoiding the activation of the bone breakdown cells.

The bone drug Prolia takes the second route, inhibiting RANK-L. Sound good? Well it sure can be in some cases, but there is always a price to pay when you interfere with a mechanism of disease instead of addressing the causes of the disease. Two logical questions arise: What other role(s) does activated RANK play in the rest of the body  — roles that taking Prolia might interfere with? And is it good for overall health to inhibit RANK-L? In an upcoming article, I will talk more about this new osteoporosis medication. For now, you can be ahead of the crowd — you know about RANK, RANK-L and OPG.