High calcium intake does not prevent fractures

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.

 

Strong back muscles can lower future fracture risk

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 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, resistive 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, resistive 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.

 

Bone fractures – A wake-up call

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.

 

U.S. hip fracture rates on the decline

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.

 

How many women experience an osteoporotic fracture?

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.

Bone mineral density alone does not predict fracture

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.

How many people who fracture a hip are vitamin D deficient?

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 inadequate levels of vitamin D in his or her blood.

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.

 

Tubal ligation linked to increased risk of spinal fracture

When I was researching the first edition of my book, Better Bones, Better Body, I came across a single scientific study reporting that tubal sterilization disrupted endocrine functioning and was likely linked to increased risk of fracture. As the body is one whole, interacting unit, it made sense to me that the natural hormonal flow would be disrupted by having the “tubes tied” and this might well impact bone health.

Research by Dr. Grace Wyshak from Harvard School of Public Health has confirmed this speculation. Tubal sterilization disturbs ovarian function and is associated with more menstrual and menopausal symptoms and an increased risk of vertebral fracture. Specifically, she found a 2.7 to 3.3 times increased risk of vertebral fracture among women who had undergone tubal sterilization.

This is important because tubal ligation is used more than any other single form of birth control in the US and worldwide. In 1995, 34.6% of ever-married US women between the ages of 35-44 had undergone tubal ligation. Little by little we are finding more hidden underlying causes of our current bone health crisis and discovering new areas of health maximization we need to work on. A safe, effective, yet bone-preserving birth control method is clearly one of them!

 

References:

Wyshak, G. 2005. Tubal ligation and the risk of vertebral fracture. Osteoporosis International, 16, 651-658.