Module I
MEDICAL DISCLAIMER The information in this program is for educational purposes only. It is meant to as a guide towards health and does not replace the evaluation by and advice of a qualified licensed health care professional. For detailed interpretation of your health and specific conditions, consult with your physician.
OUTLINE & NOTES, MODULE I / page 1 COURSE OUTLINE - Module I I. What are bones made of? II. III. IV. What factors influence bone health? What changes occur to bones over a lifetime? What causes poor bone density? V. Is an acidic diet a contributing factor? Will an alkaline diet reverse bone loss? VI. What role does diet play? VII. What foods cause poor bone density? VIII. What activities cause bone loss? IX. What tests diagnose osteoporosis? X. How to read a bone density test (DEXA scan): What values constituent osteopenia and osteoporosis? Where do you want your numbers to be? XI. Does low bone density happen to men too? XII. Is there a link between menopause / hormones and bone density? XIII. Does stress influence bone loss? XIV. Do bone density drugs work? XV. Is there a serious concern about fractures of the femur? Are there other drugs that cause low bone density?
page 2 / THE COMPLETE BONE HEALTH SOLUTION COURSE NOTES - Module I INTRODUCTION Your skeleton is a masterpiece of nature. When healthy, it lasts a lifetime. In fact your bones continually remodel and rebuild themselves every ten years. They provide the structure for your body, determine your height, and build your blood cells. Besides minerals, bones are built of protein, particularly collagen type 1. Supportive tissues include cartilage, ligaments, and tendons, and have their own nerve connections and blood vessels. During normal wear and tear, microdamage takes place and bones need sufficient nutrients for daily repair. Osteoporosis is the progressive deterioration without corrective repair that results in diminished bone density. This leads to inadequate bone strength to perform normal daily activities, and which can result in fractures. Osteoporosis is caused by an imbalance in the bone remodeling cycle in which bone resorption is not adequately compensated for by bone formation. Osteoporosis Osteoarthritis Osteogenesis imperfecta Osteomalacia Osteomyelitis Osteonecrosis Paget s Disease Rickets Rheumatoid Arthritis BONE DISEASES
OUTLINE & NOTES, MODULE I / page 3 (BONE DISEASES, cont...) I consider osteoporosis a vicious degenerative disease of the bone and bone forming mechanisms where poor lifestyle and nutritional deficiencies and imbalances play a major role. Because it s a slow progressive disease, it s silent but once discovered it s not likely that it will be completely cured. However, you can arrest the process and reverse even severe osteoporosis enough to prevent easy fracture. Osteoporosis is a major national health problem. Osteoporosis and low bone mass effect almost 44 million U.S. women and men aged 50 and older, which is about 55% of adults over age 50. Healthy bones are resilient, hard to break, and last a lifetime. However, a lot can go wrong with you bones resulting in a vast array of diseases. The primary causes of bone diseases are nutrient deficiency and the modern Western diet. Sedentary lifestyle also plays a major role. MYTH #1 FIVE OSTEOPOROSIS MYTHS False: Osteoporosis is a calcium deficiency disease. True: Calcium supplements alone don t work. Plant sources of calcium are important in bone health. MYTH #2 False: Osteoporosis is incurable, and the only way to treat it is with drugs. True: Drugs have profound side effects. Natural methods work. MYTH #3 False: Osteoporosis is simple bone lose and it happens to everyone during aging. True: Osteoporosis is a highly complex disease. Bones should last a lifetime. MYTH #4 False: Osteoporosis is only a problem with women. True: Osteoporosis can occur in men. MYTH #5 False: An alkaline diet completely prevents or cures osteoporosis. True: Metabolic acidosis increases bone lose. Acid/Alkaline balance is important for health.
page 4 / THE COMPLETE BONE HEALTH SOLUTION DIAGNOSING OSTEOPOROSIS A medical evaluation to diagnose osteoporosis and estimate your risk of breaking a bone may involve one or more of the following steps: Medical history Physical examination FRAX score Bone density test Laboratory tests Additional tests to learn information about your bone health may include: X-rays Vertebral fracture assessments (VFAs) Bone scans MEDICAL HISTORY Age Gender Menopause Personal history of broken bones as an adult Family history of broken bones and osteoporosis Whether you smoke or drink too much alcohol Your dietary habits, including how much calcium and vitamin D you get Your exercise and physical activity habits Whether you have had an eating disorder such as anorexia nervosa Whether you have had regular periods (premenopausal women) Testosterone and DHEA-Sulfate levels (men and women) Estradiol levels (women) Whether you take any medicines or have any medical conditions that may cause bone loss PHYSICAL EXAMINATION Your healthcare provider may measure you to see if you have lost height and examine your spine to see if it is curving forward. After the age of 50, you should have your height checked without shoes every year at the same healthcare provider s office. Bone Density Test. A bone density test is the only test that can diagnose osteoporosis before a broken bone occurs. This test helps to estimate the density of your bones and your chance of breaking a bone. The National Osteoporosis Foundation recommends a bone density test of the hip and spine by a central DXA machine to diagnose osteoporosis. DXA stands for dual energy x-ray absorptiometry.
OUTLINE & NOTES, MODULE I / page 5 FRAX SCORE If you have low bone density (osteopenia), the fracture risk assessment tool called FRAX can help estimate your chance of breaking a bone within the next 10 years. This makes it easier to decide whether you might benefit from taking an osteoporosis medicine. If you have low bone density, your DXA report may include your FRAX score along with your bone density. BONE DENSITY TESTS A bone density test, also called densitometry or DXA scan (DEXA), determines whether you have osteoporosis or are at risk of osteoporosis. Osteoporosis is a disease that causes bones to become more fragile and more likely to break. A bone density test uses X-rays to measure how many grams of calcium and other bone minerals are packed into a segment of bone. It is a fairly accurate predictor of your risk of fracture. Interpreting Bone Density Studies: T-scores and Z-scores The T-score compares your bone density with that of an average healthy young adult of your sex. If your T-score is -2.0, your bone density is lower than average by two standard deviations. Your Z-score tells you how your bone mass compares with that of someone your age. If your Z-score is -0.5, your bone density is less than the norm for people your age by one-half of a standard deviation. The World Health Organization has defined the following categories based on bone density in white women: Normal bone: T-score better than -1 Osteopenia: T-score between -1 and -2.5 Osteoporosis: T-score less than -2.5 Established (severe) osteoporosis (T-score -3.0)
page 6 / THE COMPLETE BONE HEALTH SOLUTION LABORATORY TESTS Blood calcium levels 24-hour urine calcium measurement Thyroid function tests (low TSH associated with hyperthyroidism or too much thyroid hormone medication is associated with increased bone remodeling cycles resulting in inability to build healthy bone) Parathyroid hormone levels (low PTH associated with low serum calcium levels and high serum phosphate = decreased GI calcium absorption; high PTH with high calcium levels and low phosphate = increased GI calcium absorption resulting in high bone turnover rate, which can cause osteoporosis) Testosterone Estradiol DHEA-Sulfate 25-hydroxyvitamin D test to determine whether the body has enough vitamin D Urinary biochemical marker tests, NTx BIOCHEMICAL MARKERS IN URINE N-Telopeptide Cross-links (NTx) The NTx test measures the concentration of cross-linked N-telopeptides of type I collagen. Levels of NTx correlate with the rate of bone resorption. Bone resorption rates exceeding bone formation results in a net loss of bone and ultimately osteopenia or osteoporosis. Osteoporotic fractures are a major source of morbidity and mortality in older women. The NTx test is intended for use in predicting skeletal response to hormonal antiresorptive therapy in postmenopausal women. The NTx test can also be used to monitor the efficacy of antiresorptive therapy in postmenopausal women, women with osteoporosis, and individuals with Paget disease. High levels suggest rapid bone turnover and are clinically associated with bone loss. Ntx Values Normal value, adult male: 3-51 mm BCE/mmol creatinine Normal value, adult female: 5-65 mm BCE/mmol creatinine Optimal level: Within the normal range Pyridinium Crosslinks are products of reactions during collagen maturation. Higher than normal levels are associated with osteoporosis. Pyridinium Values Normal value, adult male and female: 12.8 25.6 nmol/mmol creatinine Optimal level: Within the normal range
OUTLINE & NOTES, MODULE I / page 7 NEGATIVE DIETARY INFLUENCES Acidic diet High salt Excessive caffeine (more than 3 cups of coffee or strong tea daily) Cola drinks (high caffeine, sugar, and phosphorous) Excessive alcohol drinking Dietary deficiencies associated with the modern Western diet low in trace minerals and key vitamins Low calcium Low magnesium, high phosphorous High oxalate (oxalic acid) foods (spinach, beet greens, chard, tea and coffee) High phytates (phytic acid) foods (Brazil nuts, wheat bran, soy and other dried legumes) CAUSES OF BONE LOSS Multiple factors influence bone health and are associated with bone loss. Genetics, early childhood diet, nutrient factors during aging, hormones, exercise, and food choices all influence bone development and loss. The Western diet, in particular the modern American diet, is the reason for the osteoporosis epidemic. Besides being overly acidic (meat, sugar, sodas), it is low in vegetables and imbalances between minerals. Calcium and phosphate are critical minerals for healthy bones and teeth. Calcium is the most important nutrient for strong bones. Low calcium or impaired calcium absorption and high phosphate is associated with osteoporosis. Vitamin D3 (1,25-dihydrooxyvitamin D or calcitriol) and parathyroid hormone are the two most important hormones for regulating intestinal absorption of calcium and phosphate. Serum Vitamin D, 25-Hydroxy Values* Normal values: 32.0 100.0 ng/ml Desirable levels: Greater than 39.0 ng/ml Optimal levels: 70.0 100.0 ng/ml *Vitamin D3 Levels tend to be very low in adults from the developed countries in the northern hemisphere. Low levels impair GI calcium absorption. Serum Calcium Values* Normal values: 8.7 10.2 mg/dl Desirable levels: Mid-range Optimal levels: 9.2-10.0 mg/dl *Serum calcium level is a function of the rate calcium enters the body from GI absorption and levels through bone demineralization, GI excretion in the stool, and Kidney excretion in the urine.
page 8 / THE COMPLETE BONE HEALTH SOLUTION MEDICAL CONDITIONS ASSOCIATED WITH OSTEOPOROSIS Diabetes (high glucose shuts down bone building mechanisms) Lupus and Rheumatoid arthritis (steroid use and inflammation) Multiple sclerosis (due to steroid use) Asthma (due to steroid use) Celiac disease (reduced GI nutrient absorption) FDA APPROVED DRUGS FOR PREVENTION AND/OR TREATMENT Alendronate and alendronate plus vitamin D3 (Fosamax and Fosamax plus D ) Ibandronate (Boniva ) Risedronate and risedronate with calcium (Actonel and Actonel with Calcium) Zoledronic Acid (Reclast ) Calcitonin (Fortical and Miacalcin ) Estrogen (multiple brand names available) Estrogen Agonists/Antagonists also known as Selective Estrogen Receptor Modulators (SERMs) Raloxifene (Evista ) Parathyroid Hormone Teriparatide (Forteo ) RISKS OF BISPHOSPHONATE DRUGS These are powerful drugs that cause dramatic changes in bone physiology. UPSET STOMACH/ESOPHOGEAL INFLAMMATION The most common side effect of bisphosphonate medications is stomach upset. The medication can cause inflammation of the esophagus, and even lead to erosions of the surface of the esophagus. When taking an oral bisphosphonate, it is recommended that you remain upright for 30 to 60 minutes after taking the medication. OSTEONECROSIS OF THE JAW Osteonecrosis is a problem that causes bone cell death. Data suggests a higher chance of jaw osteonecrosis in patients taking bisphosphonate medications. This complication typically occurs in people taking IV doses of bisphosphonates, and is usually seen after a patient on bisphosphonate medication has had dental surgery involving the jaw. BONE, JOINT, AND MUSCLE PAIN There have been reports of patients having severe muscle, joint, and/or bone pain after taking bisphosphonate
OUTLINE & NOTES, MODULE I / page 9 medications. This complication may arise days, months, or even years after starting bisphosphonate therapy. If severe muscle or bone pain is a problem, stopping the bisophosphonate medication should be considered. Speak to your doctor about your symptoms. FEMUR FRACTURE Fractures can occur with some patients taking bisphosphonate medications for lengthy time periods. Research has investigated this finding to determine if the medication could contribute to these unusual types of fractures. It is still unclear if long-term use of bisphosphonates may contribute to fracture risk, but you should discuss with your doctor if you should be taking these medications longer than 4 years. There is a low risk of subtrochanteric femur fracture, but long-term concerns about wide population use of these drugs remains a concern among holistic physicians. ATRIAL FIBRILLATION This was found more commonly in patients taking some bisphosphonate medications, especially in elderly women. In reviews of other data, however, this association was not seen. Thus, it is unknown if this is a true side effect of the medication, but the FDA did put out a warning for doctors to be aware of this potential association. DRUGS THAT MAY CAUSE BONE LOSS Aluminum-containing antacids Antiseizure medicines (only some) such as Dilantin or Phenobarbital Aromatase inhibitors such as Arimidex, Aromasin and Femara Cancer chemotherapeutic drugs Cyclosporine A and FK506 (Tacrolimus) Gonadotropin releasing hormone (GnRH) such as Lupron and Zoladex Heparin Lithium Medroxyprogesterone acetate for contraception (Depo-Provera ) Methotrexate Proton pump inhibitors (PPIs) such as Nexium, Prevacid and Prilosec Selective serotonin reuptake inhibitors (SSRIs) such as Lexapro, Prozac and Zoloft Steroids (glucocorticoids) such as cortisone and prednisone Tamoxifen (premenopausal use) Thiazolidinediones such as Actos and Avandia Thyroid hormones in excess
page 10 / THE COMPLETE BONE HEALTH SOLUTION WHAT DOES IT ALL MEAN? YOUR GOAL The primary goal is to increase your BMD. Other goals may be to reduce inflammation, regulate hormones, and improve circulation as part of the holistic treatment that addresses underlying causes. STEP #1 Have a plan ( My Osteoporosis Plan ) and partner with a knowledgeable health care provider. STEP #2 Get Tested. STEP #3 Define the main factor(s) causing your bone loss: poor diet, sedentary lifestyle, vitamin D deficiency, not enough calcium, low estrogen. STEP #4 Make lifestyle changes: exercise regularly, eliminate bone-depleting foods, get off bone-depleting drugs, and eat a bone healthy diet. STEP #5 Take supplements and nutraceuticals, and bio-identical hormones if indicated.
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