Hone In On Your Bones

Hello again, friends and followers! Thank you for continuing to read my blog posts, I hope you have found them easy to read and informative. If there are any questions or conditions that you would like me to focus on specifically, feel free to leave your suggestions in the comments area below my posts, or e-mail me directly at drgoldsman@torontohealthclinic.ca.

November is Osteoporosis Awareness Month and, although I have been lecturing quite a bit on the topic this month, I could not let November go by without posting some information for all of you! So, without further adieu….

Postural changes associated with Osteoporosis.

What is Osteoporosis?

The word osteoporosis means “porous bones”, and that is essentially what it is! It is the leading bone disease in the world and results in an increase in fracture risk. Osteoporosis (OP) can occur in both men and women; however, the incidence in women is far greater. The form of OP that is most common in women occurs after menopause, and is referred to as Primary Type 1, or Postmenopausal OP. Primary Type 2, or Senile OP, occurs after the age of 75, and is seen in both males and females at a ratio of 2:1. Finally, secondary OP may arise at any age and can affect men and women equally. This form of OP results from chronic predisposing medical problems or diseases.

How do you get Osteoporosis?

There are many, many ways that one may acquire OP. The disease process is complex, and more than 30 genes in your DNA are associated with the development of OP. Basically, there are two main cells that act on your bones – Osteoblasts and Osteoclasts. Osteoblasts act to build up new bone and osteoclasts do the opposite – they resorb bone, or break it down. Like all other cells and tissues in your body, bone is constantly being broken down and replaced by these two specific cells. This is normal and occurs in all people. The ratio of break down to build up is generally even. OP results when your osteoclasts are breaking down more bone than is being made to replace it.

A. Normal, healthy  bone.
B. Osteoporotic bone - note the porous appearance.

What are the risk factors?

Risk factors for OP are numerous. I have broken them down into Flexible and Inflexible factors. Flexible factors can be modified and can impact a change on your bone. These are the ones typically targeted with prevention programs. The Inflexible risk factors are those that we cannot change.

Inflexible Risk Factors:

-Advancing age

-Female gender - sorry, ladies! 

-Estrogen deficiency following menopause or surgery that removes the female organs

-Testosterone deficiency in men has similar, but less pronounced effects

-Caucasian or Asian descent

-Family history of OP - heritability can be as high as 80%!

-Previous history of fracture – you are 2x more likely to have another fracture than someone of the same sex and age who has not had a previous fracture

-Small stature – under 127lbs or anorexics (current OR previous)

Flexible Risk Factors:

-Alcohol use – small amounts are probably beneficial, according to the most recent research, however, chronic heavy drinking (more than 3 units per day – a unit = one ounce) can increase your fracture risk.

-Vitamin D deficiency – deficiency in this vitamin is very common in most people, especially the elderly. Too little vitamin D in your body is associated with an increase in the production of Parathyroid Hormone (PTH). PTH acts directly to increase bone resorption by osteoclasts, leading to bone loss.

-Cigarette smoking – the mechanisms of the effect of tobacco on bone mass are unclear, but it has been proposed that tobacco inhibits osteoblast (remember – bone builders!) activity. On top of this, smoking results in an increase in the breakdown of estrogen, a lower body weight, and early menopause – all of which contribute to a low Bone Mineral Density (BMD).


-Malnutrition – good nutrition has a complex and important role in maintaining bone health. Identified and well researched risk factors include low dietary calcium and/or phosphorus, magnesium, zinc, boron, iron, fluoride, copper, vitamins A, K, E, and C. Excess sodium is also a risk factor, as it increases the acidity of your blood (common in high protein diets as well). A high acid content in the blood has been shown to increase your risk for OP and subsequent fractures.

-Impaired neuromuscular function – this is a huge (HUGE) risk factor for fractures. Speak to your chiropractor – it is our specialty to ensure that your neuromusculoskeletal system is in good health!


-Sedentary lifestyle – Let me teach you about Wolff’s Law: bone in a healthy person or animal will adapt to the loads it is placed under. If you increase the load on a particular bone, the body will act to remodel this bone over time to become stronger and resist this specific load – the internal structure of the bone can and does undergo changed to adapt to these loads. The opposite is also true – if the load to a bone decreases (say, by living an inactive lifestyle), the bone will become weaker as a result as there is no stimulus to promote bone building. This is why exercise can increase your peak bone mass, or all the bone you will ever have (90% of which is acquired between the ages of 12 and 18 – inform your daughters!). Physical inactivity can lead to significant bone loss.

-Certain diseases and medications that affect calcium absorption or bone remodeling can lead to OP as well. The most common medications that affect your ability to build and maintain strong bones are glucocorticoids (prednisone), barbiturates and other anti-epileptics, anticoagulants and warfarin, proton pump inhibitors, and chronic lithium use. If you are currently on any of these medications, speak with your health care professional about your supplementation options!

A common outcome of OP - the vertebral compression fracture.
The weakened bone collapses in on itself, leading to the classic 'hump back' posture.

Can someone PLEASE explain what BMD is!?

BMD stands for Bone Mineral Density. In OP, BMD is reduced. The World Health Organization defines OP by a BMD that is 2.5 standard deviations (or more) below the mean peak bone mass (average of young, healthy adults) as measured by DXA. DXA is the type of bone scan that is used to determine one’s bone mineral density, it stands for Dual-emission X-ray absorptiometry and is different from a nuclear bone scan.

DXA recommendations: Women over the age of 65 should get a DXA scan. At risk women should consider getting a scan at age 60 or before. The ‘at risk’ category includes different clinical risk factors, including: prior fragility fracture, use of glucocorticoids, heavy smoking, excess alcohol intake, rheumatoid arthritis, history of parental hip fracture, chronic renal and liver disease, chronic respiratory disease, long-term use of phenobarbitone or phenytoin, celiac disease, inflammatory bowel disease, and other risks.

The following table lists the clinical guidelines for diagnosing OP from a DXA scan. The DXA scan gives your result as a T-score, and standard deviations are used to categorize your OP and/or fracture risk:

Normal bone	T-score greater than -1
Osteopenia (decreased bone mineral density)	T-score between -1 and -2.5
Osteoporosis	T-score less than -2.5
Severe (established) osteoporosis	T-score less than -2.5 and 1+ osteoporotic fractures

What can I do about it?

Prevention is KEY! Since you acquire 90% of all the bone you will ever have by the ages of 12-18, and reach your peak bone mass by age 30, informing your daughters about nutritional prevention and exercise is the best way to get them started, especially if you or your family members have OP! Most OP prevention programs target the flexible risk factors I discussed earlier. If you are already living with OP, maintaining the level of bone mineral density you have is important. Here are some things you can do to help build and retain bone mass:

Lifestyle Changes:
-In short – work to change the flexible risk factors in your life. Smoking cessation and decreasing alcohol intake are commonly recommended for OP prevention. Exercise! The weight-bearing kind! Activities such as walking, jogging, stair climbing, yoga, and weight lifting all work to exert the right stresses on your bone to help maintain bone mass. If you have osteopenia or osteoporosis already, consult your spine care professional before beginning a program to avoid potential fractures.

Nutritional Changes:

-Proper nutrition includes a diet sufficient in Calcium and Vitamin D. Alone, Vitamin D does not prevent fractures – it needs to be combined with calcium. Calcium comes in 2 forms: carbonate and citrate. Carbonate is lower in cost, and due to this fact, it is usually a person’s first choice. It is important to understand that, although the cost is less, the quality of the calcium and it’s ability for absorption is significantly decreased. If you are taking proton-pump inhibitors or H2 blockers, your ability to absorb calcium is even less. I highly recommend a Calcium Citrate supplement that is paired with Magnesium. I personally take Douglas Labs Cal/Mag in addition to my Multivitamin (Also made by Douglas Labs – Ultra Preventative X). This brand can be hard to locate, so if you would like more information or would like to order from them, you can call my office at (416) 850-0598 and we will get them for you! Magnesium is important to take with calcium – and most people don’t know this! Calcium in the absence of magnesium WILL build bone, but not resilient, strong bone. Magnesium helps bones to withstand impact, which is a crucial property of good bone. A 2:1 ratio of Calcium to Magnesium is recommended.

Medications:

-As you probably know, I am a chiropractor – a drugless practitioner. I do not prescribe or promote pharmaceuticals; however, it is important to know what is out there in the case that you truly require them. Here is a quick overview of the most common pharmaceuticals prescribed to help with OP. Bisphosphonates are the first-line medical treatment for OP and are also used for prevention in high-risk cases. Estrogen replacement therapy has been used to a long time to help prevent OP, but, at this time, it is not recommended unless there are other indications for its use. There is uncertainty and controversy over hormone replacement therapy and it is still being determined whether estrogen should be recommended for women in the first 10 years following menopause. If you have questions regarding any medications, I urge you to speak to your pharmacist! I love pharmacists – they are my #1 source for information on any medication!

That's it for now - What changes in YOUR life will you make TODAY?!