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Dr Sharma Diagnostics



Osteoporosis and Osteopoenia


Osteoporosis is the medical term for bones that are demineralising (predominantly losing calcium but also losing other minerals) thereby at increased risk of fracture. A lower than expected bone density with no statistical increased risk of fracture is termed osteopenia.

This is a common problem affecting up to one in ten women after the age of 60 and one in three after the age of 70. Men also have this problem at a lower rate. It is recognized now that many factors lead to fractures, not just bone density. Age, genetics, heredity, body weight, certain diseases, incorrect diet, lack of exercise and trauma all play important roles.


Diagnosis, Tests and Investigations

Unfortunately, diagnosis is often not made until a fall leads to a fracture and x-rays indicate that the bone is thin. Regular X-rays are not the way to quantitatively assess bone density. This is done by using a specialised low-dose x-ray known as the DXA (previously known as a DEXA Scan) or Quantitative Ultrasound (qUS).

There are other techniques done at specialist centres such as
  • Single Photon Absorptiometry (SPA),
  • Quantitative computed Tomography (qCT) and
  • Radiographic Absorptiometry (RA)

DXA/DEXA is still considered the 'high street' gold standard, with established clinical efficacy and only low radiation dose. It has very good precision & accuracy (sensitivity and specificity).

The other tests are, possibly, less precise than DEXA, tend to be more expensive and deliver a larger radiation exposure. (1)

Dual-emission X-ray absorptiometry (DXA) measures bone mineral density (BMD). Two X-ray beams of different low intensity are aimed usually at the top of the femur (leg bone) in the hip and also the lower spine (lumbar) vertebrae. The computer, taking into account the tissue density of the leg, determines the amount of X-ray absorbed, what the bone density is. The results are compared to the expected density of an individual of the same age.

Dual-energy X-ray absorptiometry is the most widely used and most thoroughly studied bone density technology. Statistically 68% of repeat scans fall within what is known as one standard deviation which can be the difference between normality, osteopenia or osteoporosis. Scanning machines vary from centre to centre and even within the same centre the same machine may show a marked variation on the same patient. We also know that exercise can rapidly increase bone density and so having a DEXA scan performed after, say, a 2-3 mile walk could lead to variability and influence accuracy (1a).

One major disadvantage of DXA is that it does not differentiate between cortical (outer) and trabaceular (inner) bone so a thin inner bone may be hidden by a thicker less supportive outer plate.

Joint


Also, previously fractured bones or scans in those with spinal deformities may give inaccurate results.

Changes in qUS of the heel (the area generally measured) may not reflect changes in BMD at the spine or hip.

However a review of studies suggest that qUS is a useful tool in determining fracture risk (2). There is some evidence that qUS of the heel can predict fracture risk of hip and spine independently of BMD measurements (3). qUS in addition to BMD evaluation by DEXA may give a better estimate of fracture risk than DEXA scanning alone (4).


Other tests

It is also important to rule out lead and other heavy metal toxicity. This should if possible include white blood cell metal sensitivity testing as metals in bone may not show up in urine or faecal tests

The most easily available test is DPD Urinalysis. This compound increases in the urine when bone is being broken down more quickly than it is able to be built up. There is strong evidence that this sort of testing especially if combined with BMD scanning can predict risk of fracture even in pre-menopausal women. (5)

There are now investigations from simple blood analysis known as Genomic tests that can indicate who might be at genetic risk of osteoporosis and what dietetic, environmental and life-style changes might benefit each individual. OsteoGenomic test results need to be interpreted by a doctor in light of the individual patient and their medical and family history.

There are Conventional blood tests, that are often grouped together, indicate increased bone ‘turn over’ or loss but do not really alter therapy choices.
  • Serum total alkaline phosphatase
  • Serum bone–specific alkaline phosphatase
  • Serum osteocalcin
  • Serum type 1 procollagen (C-terminal/N-terminal)
  • Urinary hydroxyproline
  • Urinary total pyridinoline (PYD)
  • Urinary free deoxypyridinoline (DPD)
  • Urinary collagen type 1 cross-linked N-telopeptide (NTX)
  • Urinary or serum collagen type 1 cross-linked C-telopeptide (CTX)
  • Bone sialoprotein (BSP)
  • Tartrate-resistant acid phosphatase 5b

Recommended Screening Investigations:
  • DPD urinalysis
  • Bone density blood evaluation
  • DXA scan or for routine scanning Bone density ultrasonography (qUS)
  • OsteoGenomic profile

For those with established osteopoenia or osteoporosis investigate the above and also:
  • Faecal and urine metal toxicity
  • White blood cell metal sensitivity

Treatment

Exercise

Muscle strengthening plays an equal or possibly greater role than weight-bearing exercise in the management of osteoporosis. Even walking may have benefits for bone mineralization and is the most affordable. Resistive exercises usually require light weights, isometric or minimally isotonic resistance such as compressible balls or cushions, or elastic bands. Weight-bearing exercises such as walking and jogging play a very important role in aerobic conditioning and can have a modest effect in the prevention of osteoporosis (15).

Life Style and Diet

Do not smoke. Excess alcohol (possibly only half of the standard health recommendation of more than 20 units a week in men and 14 in women) will adversely influence bone density.

Exercise benefits are enormous and one of the most important methods of increasing bone density is weight-bearing exercise. Weight-bearing exercise is simply walking carrying enough weight to be noticed but not muscularly taxing (a back pack with suitable weight, for example). Around 40 minutes a day is required if bone density is low and perhaps half that for prevention.

Under or overeating can interfere with bone metabolism, as can missing out on sunshine (for the vitamin D).

Please start by reviewing this comment by NutriGold:
http://updates.nutrigold.co.uk/assets/pdf/newsletters/NG-Education_Newsletter-Preventing-Osteoporsis.pdf

Review on line calcium-rich foods and pick those you like and eat more of them. Although there is controversy, cow’s products may not be the best things for bone stability according to some authorities(16)

A more alkaline diet is of importance. Please review the following link for more information. http://www.osteopenia3.com/Diet-for-Osteopenia.html and also consider making this sauerkraut a part of your weekly menu: http://recipes.mercola.com/raw-sauerkraut-recipe.aspx and select some alkaline juice recepies for smoothies etc https://www.google.co.uk/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=alkaline%20juices%20recipes

Avoid Oestrogen pollution

Harmful oestrogens are abundant in our water supply due to their being taken by the female population as the oral contraceptive pill and then urinated into our water supply. Many industrial processes form oestrogens that are leached into our water supply, soil and our atmosphere and one of the worst supplies of oestrogens comes from heated plastics – even a sun-warmed water bottle may be a risk. The water we drink from taps, if not filtered through a reverse osmosis purifier, has the potential of being “bad for you”. Oestrogens can accumulate in the body especially if we genetically lack high activity in a process of detoxification called methylation – Oestrogenomic testing can advise us of that.

Some authorities note that the highest levels of osteoporosis are found in the Western world where more milk is drunk and more oestrogens are ingested unwittingly (14).

On that point, fat tissue makes natural oestrogens and thinner post-menopausal women have a slightly higher tendency towards osteoporosis than those with a certain amount of fat. Too much fat unfortunately leads to an increased risk too.

Conventional Drug treatment

Conventional treatment principally uses drugs known as bi-phosphanates. This is often given in combination with pharmaceutical grade calcium and Vitamin D.

Special hormone replacement therapy drugs known as SERMs can be used as they have been shown to pinpoint their activity on bones (as opposed to other tissues where HRT may have an influence such as breast, skin, ovaries, etc.).

The mineral strontium is also being used in certain pharmaceutical developed drugs.

All of these, unfortunately, have potential side-effects and in the case of the biphosphonates they can be very serious particularly the development of jawbone necrosis (death of tissue) (6). It is not a popular drug with dentists nor with women prescribed them who statistically tend not to take the optimum amount (7). I have doubts that it will remain a widely prescribed drug as more information comes forward about its potential risks and side-effects including stomach ulcers, atrial fibrillation and fractures in unusual sites and oesophageal cancer. (8,9)

That said the conventional attitude is that, in the balance, apparently the risks are currently less than the benefits from such drugs.

Calcium in Osteoporosis

The use of calcium carbonate, the most used and prescribed pharmaceutical source, may actually carry a risk of reducing bone density due to various mechanisms (9a). In part many calcium supplements do not get to the bones and specifically calcium carbonate settles in the arteries increasing risk of heart attack (11)

A 1000 kg elephant needs up to 9 gms of calcium a day (10) this generally comes from food like leaves and bark. Our osteoporotic population (predominantly women over 60) weigh generally 1/20th of that of an elephant and so should aim at 450 mgs daily. Doctors generally prescribe between 1200-2000mg daily. Accepting we are not necessarily metabolising in the same way, the bones of an elephant apparently require proportionately far less calcium dosage than that of a woman.

This is because calcium that is found in nature is generally in a combination of calcium with phosphate molecules and therefore enters into bones very easily. We have evolved receptors for this task.

Vitamin D deficiency is very common in countries where sunshine is not in abundance and has become a bigger problem since we have become scared of the sun because of the fear of skin cancers. It is extremely important to expose as much skin to as much sun for as long as is possible ensuring that the skin does not pinken, redden or, of course, burn. The actual dosage that is recommended for the average adult is, in most Vitamin D researchers’ and experts’ opinions, far below that which should be taken. Osteoporosis demands daily supplemental levels of 2000 IU or more (12).

Vitamin K is also required for bone assimilation as are certain amino acids (proteins) that are required to make the mesh upon which the calcium, boron, strontium and other required minerals sit.

Bioidentical hormone replacement therapy

Oestrogens are known to enhance bone density but, actually, progesterone may also do the job. and do so more efficiently. As women go through menopause both these natural hormones diminish. The orthodox world is able to produce oestrogens from pharmaceutical sources that are accepted by the body without too many side-effects and risks. The same cannot be said for artificial progesterone. called progestins. Therefore, artificial oestrogen as HRT is often prescribed but progesterone is not, except in small doses to balance the oestrogen intake.

Bioidentical progesterone has to be prescribed by a physician. bHRT needs to be taken transdermally (through the skin) or, better still but less well liked, sub-lingually (under the tongue). We are very aware of oestrogen and of progesterone sensitive tumours (13) and so tests are required before and during prescribing bHRT (or any HRT) to promote safety first.

Stress and Osteoporosis

There is strong evidence that psychological stress effects bone density (13a).
Research has focused on the production and activity of stress hormones such as cortisol, epinephrine and norepinephrine all of which can influence bone metabolism.

As in all conditions, but perhaps more so in such chronic and complex issues such as osteoporosis, meditation, Tai chi, Qi Gong, Yoga (all to a degree weight bearing) are so very important.


Recommended basic supplementation:

TRICATIONE (- a natural nutritional supplement obtained from the aerial part of the Spring horsetail (Equisetum arvense ) , which is rich in vegetal silica, combined with a specific marine oily extract to enhance a better cell membrane penetration.)

Tisso Pro Osteo Complete – a bone supplement including Eastern andplant extracts and Western supplements (12a) https://drive.google.com/file/d/0B8ToBiT4VsbiQ3pPWDJHa2N5dUE/view

Nutrigold’s citrate based Bone Support Formula

PROTEIN POWDER - preference is for an amino combination from Germany called Amino Spezial

VIT D 1000IU - 2 x daily (minimally but must be Dr prescribed)

VITAMIN K - c.50 micrograms daily


Consider in cases of unrelenting or severe osteoporosis & in consultation with an integrated doctor the following:

Pereira mirifica – animal studies and human anecdotal reports suggest this herb, with evidence of safety in its use, can be prescribed by a doctor.

Bioidentical HRT (progesterone, oestrogen, testosterone)
This was a format of therapy promoted in the 1990s but as artificial progesterone (progestins) were too toxic, studies seemed to have dried up. With the availability now of bHRT we can re-visit the therapy. We can go on to the use of bHRT Oestrogen (and testosterone) but there is a slight risk of reintroducing periods in women and creating feminising effects in men (breast growth).

Chelation if metal toxicity found (17).


References
  1. http://www.dimond3.org/Dublin 2006/2 DEXA QA Training for Physicists/7 Accuracy of DEXA & other methods.pdf
    1. Med Sci Sports Exerc. 2013 Jan;45(1):178-85. doi: 10.1249/MSS.0b013e31826c9cfd. Effects of exercise sessions on DXA measurements of body composition in active people. Nana A1, Slater GJ, Hopkins WG, Burke LM
  2. Hernandez, CALCIFIED TISSUE INTERNATIONAL Volume 74, Number 4, 357-365.
  3. (Nephrol. Dial. Transplant. (1999)14 (8): 1917-1921)
  4. Nelson H, et al. Portland: Oregon Health & Science University Evidence-based Practice Center; 2001).
  5. (J Bone Miner Res. 2005 Oct;20(10):1813-9. Epub 2005 Jun 20 and Journal of Bone and Mineral Research Volume 13, Issue 2, pages 297–302, February 1998)
  6. Lehrer S, Montazem A, Ramanathan L, et al J Oral Maxillofac Surg. 2009 Jan;67(1):159-61. doi: 10.1016/j.joms.2008.09.015.
  7. (Osteoporos Int. 2007 Aug;18(8):1023-31).
  8. (Journal of the American Medical Association 23rd Feb 2011),
  9. BMJ 2010;341:c4444)
    1. http://www.greenmedinfo.com/blog/how-too-much-calcium-can-break-your-bones
  10. (McCullagh 1969).
  11. http://www.sciencebasedmedicine.org/calcium-supplements-and-heart-attacks-more-data-more-questions/
  12. http://www.osteoporosis.ca/news/press-releases/new-vitamin-d-guidelines/
    1. https://drive.google.com/file/d/0B8ToBiT4VsbiQ3pPWDJHa2N5dUE/view
  13. http://www.johnleemd.com/store/pgattack.html
    1. Osteoporosis and Stress Kumano H, Clin Calcium. 2005 Sep;15(9):1544-7. http://www.ncbi.nlm.nih.gov/pubmed/16137956
  14. http://saveourbones.com/osteoporosis-milk-myth/
  15. Exercise for Osteoporosis - Is Walking Enough? Swezey, Robert L., M.D., Spine, 1996;21:2809-2813
  16. http://saveourbones.com/osteoporosis-milk-myth/
  17. Various papers on associations of metal with osteoporosis - https://scholar.google.co.uk/scholar?q=chelation+in+osteoporosis&hl=en&as_sdt=0&as_vis=1&oi=scholart&sa=X&ved=0ahUKEwianPL-gLTNAhXsK8AKHdMiBWYQgQMIGjAA

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