Tags Posts tagged with "Osteoporosis"

Osteoporosis

Dairy may not be as beneficial as we have been led to believe. Stock Photo
Does calcium really reduce risk?

By David Dunaief, M.D.

Dr. David Dunaief

The prevalence of osteoporosis and low bone mass increase dramatically as we age. According to the Centers for Disease Control, over 48 percent of those ages 65 and older in the U.S. are affected by low bone mass, and 16.4 percent by osteoporosis (1).

Why do we care? Because they may lead to increased risk of fracture and, subsequently, lower mobility, which may have significant quality of life impacts (2). That is what we know. But what about what we think we know?

For decades we have been told that if we want strong bones, we need to consume dairy. This has been drilled into our brains since we were toddlers. Dairy has calcium and is fortified with vitamin D, so it could only be helpful, right? Not necessarily.

The data is mixed, but studies indicate that dairy may not be as beneficial as we have been led to believe. Even worse, it may be harmful. The operative word here is “may.” We will investigate this further. Vitamin D and calcium are good for us. But do supplements help prevent osteoporosis and subsequent fractures? Again, the data are mixed, but supplements may not be the answer for those who are not deficient.

Holes in the dairy paradigm

The results of a large, observational study involving men and women in Sweden showed that milk may be harmful (3). When comparing those who consumed three or more cups of milk daily to those who consumed less than one, there was a 93 percent increased risk of mortality in women between the ages of 39 and 74. There was also an indication of increased mortality based on dosage.

For every one glass of milk consumed there was a 15 percent increased risk of death in these women. There was a much smaller, but significant, 3 percent per glass increased risk of death in men. Women experienced a small, but significant, increased risk of hip fracture, but no increased risk in overall fracture risk. There was no increased risk of fracture in men, but there was no benefit either. There were higher levels of biomarkers that indicate oxidative stress and inflammation found in the urine.

This study was 20 years in duration and is eye-opening. We cannot make any decisive conclusions, only associations, since it is not a randomized controlled trial. But it does get you thinking. The researchers surmise that milk has high levels of D-galactose, a simple sugar that may increase inflammation and ultimately contribute to this potentially negative effect, whereas other foods have many-fold lower levels of this substance.

Ironically, the USDA recommends that, from 9 years of age through adulthood, we consume up to three servings of dairy per day (4). This is interesting, since the results from the previous study showed the negative effects at this recommended level of milk consumption. The USDA may want to rethink these guidelines.

Prior studies show milk may not be beneficial for preventing osteoporotic fractures. Specifically, in a meta-analysis that used data from the Nurses’ Health Study for women and the Health Professionals Follow-up Study for men, neither men nor women saw any benefit from milk consumption in preventing hip fractures (5).

Calcium disappointments

Unfortunately, it is not only milk that may not be beneficial. In a meta-analysis involving a group of observational studies, there was no statistically significant improvement in hip fracture risk in those men or women ingesting at least 300 mg of calcium from supplements and/or food on a daily basis (6).

The researchers did not differentiate the types of foods containing calcium. In a group of randomized controlled trials analyzed in the same study, those taking 800 to 1,600 mg of calcium supplements per day also saw no increased benefit in reducing nonvertebral fractures. In fact, in four clinical trials the researchers actually saw an increase in hip fractures among those who took calcium supplements. A weakness of the large multivaried meta-analyses is that vitamin D baseline levels, exercise and phosphate levels were not considered.

Vitamin D benefit

Finally, though the data is not always consistent for vitamin D, when it comes to fracture prevention, it appears it may be valuable. In a meta-analysis involving 11 randomized controlled trials, vitamin D supplementation resulted in a reduction in fractures (7). When patients were given a median dose of 800 IUs (ranging from 792 to 2,000 IUs) of vitamin D daily, there was a significant 14 percent reduction in nonvertebral fractures and an even greater 30 percent reduction in hip fractures in those 65 years and over. However, vitamin D in lower levels showed no significant ability to reduce fracture risk.

Just because something in medicine is a paradigm does not mean it’s correct. Milk may be an example of this. No definitive statement can be made about calcium, although even in randomized controlled trials with supplements, there seemed to be no significant benefit. Of course, the patients in these trials were not necessarily deficient in calcium or vitamin D.

In order to get benefit from vitamin D supplementation to prevent fracture, patients may need at least 800 IUs per day, which is the Institute of Medicine’s recommended amount for a relatively similar population as in the study.

Remember that studies, though imperfect, are better than tradition alone. Prevention and treatment therefore should be individualized, and deficiency in vitamin D or calcium should usually be treated, of course. Please, talk to your doctor before adding or changing any supplements.

References:

(1) cdc.gov (2) JAMA. 2001;285:785-795. (3) BMJ 2014;349:g6015. (4) health.gov. (5) JAMA Pediatr. 2014;168(1):54-60. (6) Am J Clin Nutr. 2007 Dec;86(6):1780-1790. (7) N Engl J Med. 2012 Aug. 2;367(5):481.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com. 

Yoga can be an effective way to increase bone density. Photo from Metro
Overtreatment and undertreatment of osteopenia and osteoporosis are common

By David Dunaief, M.D.

Dr. David Dunaief

As we get older, bone fractures can have potentially life-altering or life-ending consequences. Osteoporosis is a silent disease where there is bone loss, weakening of the bones and small deleterious changes in the architecture of the bone over time that may result in fractures with serious consequences (1). It affects millions of patients, most commonly postmenopausal women.

One way to measure osteoporosis is with a dual-energy X-ray absorptiometry (DXA) scan for bone mineral density. Osteopenia is a slightly milder form that may be a precursor to osteoporosis. However, we should not rely on the DXA scan alone; risk factors are important, such as a family or personal history of fractures as we age. The Fracture Risk Assessment Tool (FRAX) is more thorough for determining the 10-year fracture risk. Those who have a risk of fracture that is 3 percent or more should consider treatment with medications. A link to the FRAX tool can be found at www.shef.ac.uk/FRAX.

Most of us have been prompted all our lives to consume calcium for strong bones. In fact, the National Osteoporosis Foundation recommends that we get 1,000 to 1,200 mg per day of calcium from diet and supplements if we are over age 50, although recommendations vary by sex and age (2). However, research suggests that calcium for osteoporosis prevention may not be as helpful as we thought.

The current treatment paradox

Depending on the population, we could be overtreating or undertreating osteoporosis. In the elderly population that has been diagnosed with osteoporosis, there is undertreatment. One study showed that only 28 percent of patients who are candidates for osteoporosis drugs are taking the medication within the first year of diagnosis (3). The reason most were reluctant was that they had experienced a recent gastrointestinal event and did not want to induce another with osteoporosis medications, such as bisphosphonates. The data were taken from Medicare records of patients who were at least age 66.

On the other hand, as many as 66 percent of the women receiving osteoporosis medications may not have needed it, according to a retrospective study (4). This is the overtreatment population, with half these patients younger, between the ages of 40 and 64, and without any risk factors to indicate the need for a DXA scan. This younger population included many who had osteopenia, not osteoporosis.

Do we all need calcium?

Calcium has always been the forefront of prevention and treatment of osteoporosis. However, two studies would have us question this approach. Results of one meta-analysis of 59 randomized controlled trials showed that dietary calcium and calcium supplements with or without vitamin D did increase the bone density significantly in most places in the body, including the femoral neck, spine and hip (5). Yet the changes were so small that they would not have much clinical benefit in terms of fracture prevention.

Another meta-analysis of 44 observational dietary trials and 26 randomized controlled trials did not show a benefit with dietary or supplemental calcium with or without vitamin D (6). There was a slight reduction in nonsignificant vertebral fractures, but not in other places, such as the hip and forearm. Dietary calcium and supplements disappointed in these two trials.

Does this mean calcium is not useful? Not so fast!

In some individual studies that were part of the meta-analyses, the researchers mentioned that dairy, specifically milk, was the dietary source on record, and we know milk is not necessarily good for bones. But in many of the studies, the researcher did not differentiate between the sources of dietary calcium. This is a very important nuance. Calcium from animal products may increase inflammation and the acidity of the body and may actually leach calcium from the bone, while calcium from vegetable-rich, nutrient-dense sources may be better absorbed, providing more of an alkaline and anti-inflammatory approach.

What can be done to improve the situation?

Yoga has become more prevalent and part of mainstream exercise. This is a good trend since this type of exercise may have a big impact on prevention and treatment of osteoporosis. In a small pilot study of 18 participants, the results showed that those who practiced yoga had an increase in their spine and hip bone density compared to those who did not (7).

The researchers were encouraged by these results, so they performed another study. The results showed that 12 minutes of yoga daily or every other day significantly increased the bone density from the start of the study in both the spine and femur, the thigh bone (8). There was also an increase in hip bone density, but this was not significant. The strength of the study includes its 10-year duration; however, this trial did not include a control group. Also, while 741 participants started the trial, only 227 finished. Of those, 202 were women. 

Significantly, prior to the study there were 109 fractures in the participants, most of whom had osteoporosis or osteopenia, but none had yoga-related fractures by the end of the trial. The “side effects” of yoga included improved mobility, posture, strength and a reduction in anxiety. The researchers provided a road map of specific beneficial poses. Before starting any exercise program, consult your physician.

The moral of the story is that exercise is beneficial. Yoga may be another simple addition to this exercise regimen. Calcium may be good or bad, depending on its dietary source. Be cautious with supplemental calcium; it does have side effects, including kidney stones, cardiovascular events and gastrointestinal symptoms, and consult with your doctor to assess whether you might be in an overtreatment or undertreatment group when it comes to medication.

References:

(1) uptodate.com. (2) nof.org. (3) Clin Interv Aging. 2015;10:1813-1824. (4) JAMA Intern Med. online Jan. 4, 2016. (5) BMJ 2015; 351:h4183. (6) BMJ 2015; 351:h4580. (7) Top Geriatr Rehabil. 2009; 25(3); 244-250. (8) Top Geriatr Rehabil. 2016; 32(2); 81-87.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.    

Are we over- or undertreating?

By David Dunaief, M.D.

Dr. David Dunaief

How do we protect one of our most valued assets, our infrastructure? Not roads and bridges, but our bones. When we think of bone fractures as a child or young adult, we think of short-term pain and inconvenience, but usually we recover without long-term consequences.

However, as we get older, fractures can be a lot more significant, with potentially life-altering or life-ending consequences. Osteoporosis is a silent disease that affects millions of patients, most commonly, but by no means exclusively, postmenopausal women. The trend is for low bone mass and osteoporosis diagnoses to increase by 29 percent from 2010 to 2030.

Osteoporosis is where there is bone loss, weakening of the bones and small deleterious changes in the architecture of the bone over time that may result in fractures with serious consequences (1).

One way to measure osteoporosis is with a dual-energy X-ray absorptiometry (DXA) scan for bone mineral density. Osteopenia is a slightly milder form that may be a precursor to osteoporosis. However, we should not rely on the DXA scan alone; risk factors are important, such as a family or personal history of fractures as we age. The Fracture Risk Assessment Tool (FRAX) is more thorough for determining the 10-year fracture risk. Those who have a risk of fracture that is 3 percent or more should consider treatment with medications. A link to the FRAX tool can be found at www.shef.ac.uk/FRAX.

Most of us have been told since we were young that we need more calcium to make sure we have strong bones. In fact, the National Osteoporosis Foundation recommends that we get 1,000 to 1,200 mg per day of calcium if we are over 50 years old (2). Recommendations vary by sex and age. This would be mostly from diet but also from supplements. However, the latest research suggests that calcium for osteoporosis prevention may not be as helpful as we thought.

The under/overmedication treatment paradox

Depending on the population, we could be overtreating or undertreating osteoporosis. In the elderly population that has been diagnosed with osteoporosis, there is undertreatment. One study showed that only 28 percent of patients who are candidates for osteoporosis drugs are taking the medication within the first year of diagnosis (3). The reason most were reluctant was that they had experienced a recent gastrointestinal event and did not want to induce another with osteoporosis medications, such as bisphosphonates. The data were taken from Medicare records of patients who were at least 66 years old.

On the other hand, as many as 66 percent of the women receiving osteoporosis medications may not have needed it, according to a retrospective study (4). This is the overtreatment population, with half these patients younger, between the ages of 40 and 64, and without any risk factors to indicate the need for a DXA scan. This younger population included many who had osteopenia, not osteoporosis.

Also, the DXA scan may have shown osteoporosis at what the researchers described as nonmain sites in one-third of patients diagnosed with the disease. Main sites, according to the International Society for Clinical Densitometry recommendations, would be the anterior-posterior spine, hip and femoral neck. A nonmain site in this review was the lateral lumbar spine. Before you get a DXA scan, make sure you have sufficient risk factors, such as family or personal history of fracture, age and smoking history. When the DXA scan is done, make sure it is interpreted at the main sites. If you are not sure, have another physician consult on the results.

We all need calcium to prevent osteoporosis, right?

Calcium has always been the forefront of prevention and treatment of osteoporosis. However, two studies would have us question this approach. Results of one meta-analysis of a group of 59 randomized controlled trials showed that dietary calcium and calcium supplements with or without vitamin D did increase the bone density significantly in most places in the body, including the femoral neck, spine and hip (5). Yet the changes were so small that they would not have much clinical benefit in terms of fracture prevention.

Another meta-analysis of a group of 44 observational dietary trials and 26 randomized controlled trials did not show a benefit with dietary or supplemental calcium with or without vitamin D (6). There was a slight reduction in nonsignificant vertebral fractures, but not in other places, such as the hip and forearm. Dietary calcium and supplements disappointed in these two trials.

Does this mean calcium is not useful? Not so fast!

In some individual studies that were part of the meta-analyses, the researchers mentioned that dairy, specifically milk, was the dietary source on record, and we know milk is not necessarily good for bones. But in many of the studies, the researcher did not differentiate between the sources of dietary calcium. This is a very important nuance. Calcium from animal products may increase inflammation and the acidity of the body and may actually leach calcium from the bone, while calcium from vegetable-rich, nutrient-dense sources may be better absorbed, providing more of an alkaline and anti-inflammatory approach. This would be a good follow-up study, comparing the effects of calcium from animal and plant-based dietary sources.

What can be done to improve the situation?

Studies have shown that yoga can help prevent osteoporosis by improving mobility, posture and strength.

Yoga used to be on the fringe of society. Now, it has become more prevalent and part of mainstream exercise. This is a good trend since this type of exercise may have a big impact on prevention and treatment of osteoporosis. In a small pilot study, the results showed that those who practiced yoga had an increase in their spine and hip bone density compared to those who did not (7). There were 18 participants in this trial.

The researchers were encouraged by these results, so they increased the number of participants in another study. The results showed that 12 minutes of yoga daily or every other day significantly increased the bone density from the start of the study in both the spine and femur, the thigh bone (8). There was also an increase in hip bone density, but this was not significant. The strength of the study includes its 10-year duration. However, one weakness was that this trial did not include a control group.

Another was that 741 participants started the trial, but only 227 finished, less than one-third. Of those, 202 were women. Significantly, prior to the study there were 109 fractures in the participants, most of whom had osteoporosis or osteopenia, but none had yoga-related fractures by the end of the trial. The “side effects” of yoga include improved mobility, posture, strength and a reduction in anxiety. The researchers gave a nice road map of specific beneficial poses. Before starting a program, consult your doctor.

The moral of the story is that exercise is beneficial. Yoga may be another simple addition to this exercise regimen. Calcium may be good or bad, depending on its dietary source. Be cautious with supplemental calcium; it does have side effects, including kidney stones, cardiovascular events and gastrointestinal symptoms, and consult with your doctor to assess whether you might be in an overtreatment or undertreatment group when it comes to medication.

References: (1) uptodate.com. (2) nof.org. (3) Clin Interv Aging. 2015;10:1813-1824. (4) JAMA Intern Med. online Jan. 4, 2016. (5) BMJ 2015; 351:h4183. (6) BMJ 2015; 351:h4580. (7) Top Geriatr Rehabil. 2009; 25(3); 244-250. (8) Top Geriatr Rehabil. 2016; 32(2); 81-87.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Men as well as women are at risk

By David Dunaief, M.D.

Dr. David Dunaif

Osteoporosis is a very tricky disease. What do osteoporosis, high blood pressure and high cholesterol have in common? They are all asymptomatic until the later stages. You can’t directly measure the progression or risk of osteoporosis fractures; you can only make an educated guess. The medical community does this mainly by using the Fracture Risk Assessment Tool (FRAX) score (1). FRAX estimates the 10-year risk of fracture in an untreated patient. You can find this tool at www.shef.ac.uk/FRAX.

There are a number of risks including genetics — family history, advanced age and demographics, with Asians being at highest risk — lifestyle, medications such as steroids and chronic diseases. A specific chronic disease that has come into focus relatively recently is heart disease. We will discuss this in more detail. Also, it does not seem that diabetes, neither type 1 nor type 2, contributes to osteoporosis (2).

When we think of osteoporosis, we tend to associate it predominately with postmenopausal women; however, it does affect a significant number of men.

Back pain, caused by changes in the vertebrae, may be the first sign that you have osteoporosis.

Treatments range from lifestyle modifications including diet, exercise and smoking cessation to supplements and medications. The medications that are considered first-line therapy are bisphosphonates, such as Reclast or Zometa (zoledronic acid), Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate) and Didronel (etidronate).

While all of these drugs have reduced fractures, zoledronic acid has shown disappointing results in reducing fracture risk in the elderly population.

The relatively new medication on the block is Prolia (denosumab), an injectable human monoclonal antibody that works through a different mechanism of action, though the result is the same; it blocks the osteoclastic (breakdown) activity of the bone (3). It has been shown to increase bone mineral density, or thickening of the bone, and reduce fracture risk. Prolia was approved at the end of 2012, so it has not been on the market nearly as long as the bisphosphonates. However, like bisphosphonates, it does have side effects.

As far as supplements go, exciting news is that melatonin may help to increase bone mineral density. Let’s look at the research.

The forgotten sex: men

Rarely are men the forgotten sex when it comes to medical research, but osteoporosis is an exception. Approximately one-third of fractures occur in men, resulting in a 37 percent mortality rate. One in five men over the age of 50 will experience a fracture with osteoporosis as a contributing factor. The predictions are that these rates will climb precipitously and that men need to be treated appropriately (4). Currently, less than 50 percent of men with osteoporosis are receiving treatment (5).

Is bariatric surgery useful?

Though bariatric surgery has been shown to have a number of benefits for many chronic diseases, osteoporosis is not one of them. In the Swedish Obesity Study, results show that women who underwent bariatric surgery were at 50 percent increased risk of fractures as well as long-term osteoporosis (6). The results in men were not statistically significant. The duration of the study was 25 years. The authors hypothesize that malnutrition may play a role in causing this effect. Supplementation may be important to overcome this, as well as frequent follow-ups with blood tests to track micronutrient levels.

Heart disease, really?

When we think of heart disease, we associate it with lots of complications, but osteoporosis is not typically one of them. Well, think again. In the Hertfordshire Cohort Study, results show that there was a significantly increased risk of wrist fracture of the radius in those with heart disease (7). These results were shown overall. However, when the sexes were analyzed separately, this effect held true for men but was not true for women, although the results in women did trend toward significance. This may be an example where men are at greater risk than women. Therefore, it may be important to think about osteoporosis when someone is diagnosed with heart disease, especially since it is not intuitive. Lifestyle factors could be a contributor to this association, as well as estrogen deficiency.

A bisphosphonate that disappointed

Bisphosphonates are the mainstay of treatment for osteoporosis, increasing bone density and decreasing fracture risk. However, zoledronic acid had surprisingly disappointing results in a randomized controlled trial (RCT) (8). Results showed that while zoledronic acid increased bone density over two years, it did not decrease the risk of fracture in elderly women in nursing homes. This does not necessarily have broad implications for other bisphosphonates. There were also weaknesses in this trial, the most serious being that fracture risk was not a primary end point. Additionally, the study may have been too small. However, this still is a very intriguing study.

Melatonin for osteoporosis

What could melatonin possibly have to do with osteoporosis? There are surprisingly positive results with melatonin. In a very small RCT, melatonin in combination with 800 mg/day of vitamin D3 and 800 mg/day of calcium increased bone density significantly in the spine and femoral neck over a one-year period, compared to the control, or placebo, arm containing vitamin D3 and calcium of similar dosage (9).

Interestingly, with melatonin the amount of calcium excreted through the urine in a 24-hour measurement decreased by 12.2 percent. There was a dose-related curve, where melatonin 3 mg/day in combination with vitamin D3 and calcium showed greater results than 1 mg/day of melatonin, which showed significant results over the control arm.

This was a preliminary study involving 81 postmenopausal women divided into three groups. Fracture risk reduction was not an end point. Larger studies with fracture risk as a primary end point are needed. Having said this, these results are exciting. A caveat: If you’re going to use calcium 800 mg/day, it’s best if you split the dose into 400 mg twice a day; the body does not typically absorb more than 500 mg of calcium at one time.

Though medications such as bisphosphonates and a monoclonal antibody may have an important place in the treatment of osteoporosis, not all medications may be equal. It is important to treat with lifestyle modifications including potentially supplements — melatonin, calcium and vitamin D3 — as well as diet, exercise and overall behavior modifications. Heart disease’s unexpected association with osteoporosis is a good reason to treat the whole patient, not just the disease. And don’t forget that men may have this disease too!

References: (1) uptodate.com. (2) Exp Clin Endocrinol Diabetes. 2001;109 Suppl 2:S493-514. (3) epocrates.com. (4) iofbonehealth.org. (5) J Bone Miner Res. 2014;29:1929-1937. (6) ECO 2015. Abstract T8:OS3.3. (7) Osteoporos Int. 2015;26(7):1893-1901. (8) JAMA Intern Med. Online April 13, 2015. (9) J Pineal Res. Online June 3, 2015.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Bones: What is beneficial and what is not?
Dr. David Dunaief

The prevalence of osteoporosis is increasing especially as the population ages. Why is this important? Osteoporosis may lead to increased risk of fracture due to a decrease in bone strength (1). That is what we do know. But what about what we think we know?

For decades we have been told that if we want strong bones, we need to drink milk. Advertising slogans have morphed from “Milk does a body good” to “Got Milk?” to “Milk Life.” Celebrities have worn milk mustaches to show how important it is to our diet. This has been drilled into our brains since we were toddlers. Milk has calcium and is fortified with vitamin D, so milk could only be helpful, right? Not necessarily.

The data is mixed, but studies indicate that milk may not be as beneficial as we have been led to believe. Even worse, it may be harmful. The operative word here is “may.” We will investigate this further. Vitamin D and calcium are good for us. But do supplements help prevent osteoporosis and subsequent fractures? Again the data is mixed, but supplements may not be the answer for those who are not deficient.

Of course, we know which drugs are potentially beneficial for osteoporosis; however, which one works the best for whom may be unclear. There are minimal head-to-head trials comparing different drugs (2). They all have beneficial reductions in fracture risk in patients with osteoporosis, but they also have side effects.

What do the guidelines tell us about those who are at potential risk for osteoporosis and fracture? A study looked at the predictability, or reliability, of the United States Preventive Services Task Force (USPSTF) recommendations for screening patients for osteoporosis. Unfortunately, the study showed that USPSTF guidelines were a nominal improvement over chance (3). In other words, the guidelines were able to predict only 24 percent of patients who ended up developing osteoporosis between the ages of 50 and 64.

Milk — it’s not what you think

Recent studies involving men and women in Sweden showed that milk may be harmful.

The results of a large, observational study involving men and women in Sweden showed that milk may be harmful (4). When comparing those who consumed three or more cups of milk daily to those who consumed less than one, there was a 93 percent increased risk of mortality in women between the ages of 39 and 74. There was also an indication of increased mortality based on dosage.

For every one glass of milk consumed there was a 15 percent increased risk of death in these women. There was a much smaller, but significant, 3 percent per glass increased risk of death in men. Women experienced a small, but significant, increased risk of hip fracture, but no increased risk in overall fracture risk. There was no increased risk of fracture in men, but there was no benefit either. There were higher levels of biomarkers that indicate oxidative stress and inflammation found in the urine.

This study was 20 years in duration and is eye-opening. We cannot make any decisive conclusions, only associations, since it is not a randomized controlled trial. But it does get you thinking. The researchers surmise that milk has high levels of D-galactose, a simple sugar that may increase inflammation and ultimately contribute to this potentially negative effect, whereas other foods have many-fold lower levels of this substance.

Ironically, the USDA recommends that, from 9 years of age through adulthood, we consume three cups of dairy per day (5). This is interesting, since the results from the previous study showed the negative effects at this recommended level of milk consumption. The USDA may want to rethink these guidelines.

Prior studies show milk may not be beneficial for preventing osteoporotic fractures. Specifically, in a meta-analysis that used data from the Nurses’ Health Study for women and the Health Professionals Follow-up Study for men, for each additional glass of milk per day during the teenage years there was a 9 percent increased risk of hip fracture in men only (6). However, this effect was negated when height was taken into account. Neither men nor women saw any benefit from milk consumption in preventing hip fractures. In other words, the milk you drank during your teenage years might not reduce hip fractures later in life.

Calcium disappointments

Unfortunately, it is not only milk that may not be beneficial. There was a meta-analysis that included observational studies and clinical trials. In the meta-analysis involving a group of observational studies, there was no statistically significant improvement in hip fracture risk in those men or women ingesting at least 300 mg of calcium from supplements and/or food on a daily basis (7).

The researchers did not differentiate the types of foods containing calcium. In a group of randomized controlled trials analyzed in the same study, those taking 800 to 1,600 mg of calcium supplements per day also saw no increased benefit in reducing nonvertebral fractures. In fact, in four clinical trials the researchers actually saw an increase in hip fractures among those who took calcium supplements. A weakness of the large multivaried meta-analyses is that vitamin D baseline levels, exercise and phosphate levels were not taken into account.

Vitamin D benefit

Finally, though the data is not always consistent for vitamin D, when it comes to fracture prevention, it appears it may be valuable. In a meta-analysis (involving 11 randomized controlled trials), vitamin D supplementation resulted in a reduction in fractures (8). When patients were given a median dose of 800 IUs (ranging from 792 to 2,000 IUs) of vitamin D daily, there was a significant 14 percent reduction in nonvertebral fractures and an even greater 30 percent reduction in hip fractures in those 65 years and over. However, vitamin D in lower levels showed no significant ability to reduce fracture risk.

Just because something in medicine is a paradigm does not mean it’s correct. Milk may be an example of this. Also, ironically, the “Milk Life” slogan may need an overhaul, especially in women between the ages of 39 and 74 years old, where there is a potential increased risk of mortality. No definitive statement can be made about calcium, although even in randomized controlled trials with supplements there seemed to be no significant benefit. Of course, the patients in these trials were not necessarily deficient in calcium or vitamin D.

In order to get benefit from vitamin D supplementation to prevent fracture, patients may need at least 800 IUs per day, which is the Institute of Medicine’s recommended amount for a relatively similar population as in the study. Also, different drugs have different benefits and side effect profiles.

Remember that studies, though imperfect, are better than tradition alone. Prevention and treatment therefore should be individualized, and deficiency in vitamin D or calcium should usually be treated, of course. Please, talk to your doctor before adding or changing any supplements.

References: (1) JAMA. 2001;285:785-795. (2) Ann Intern Med. 2014;161(10):711-723. (3) NAMS 2014 Meeting: Abstract S-13. Oct. 16, 2014. (4) BMJ 2014;349:g6015. (5) choosemyplate.gov. (6) JAMA Pediatr. 2014;168(1):54-60. (7) Am J Clin Nutr. 2007 Dec;86(6):1780-1790. (8) N Engl J Med. 2012 Aug. 2;367(5):481.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Osteoporosis is a very tricky disease. What do osteoporosis, high blood pressure and high cholesterol have in common? They are all asymptomatic until the later stages. You can’t directly measure the progression or risk of osteoporosis fractures; you can only make an educated guess. The medical community does this mainly by using the Fracture Risk Assessment Tool (FRAX) score (1). FRAX estimates the 10-year risk of fracture in an untreated patient. You can find this tool at www.shef.ac.uk/FRAX.

There are a number of risks including genetics — family history, advanced age and demographics, with Asians being at highest risk — lifestyle, medications such as steroids and chronic diseases. A specific chronic disease that recently has come into focus is heart disease. We will discuss this in more detail. Also, it does not seem that diabetes, neither type 1 nor type 2, contributes to osteoporosis (2).

When we think of osteoporosis, we tend to associate it predominately with postmenopausal women; however, it does affect a significant number of men.

Treatments range from lifestyle modifications including diet, exercise and smoking cessation to supplements and medications. The medications that are considered first-line therapy are bisphosphonates, such as Reclast or Zometa (zoledronic acid), Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate) and Didronel (etidronate).

While all of these drugs have reduced fractures, recently zoledronic acid showed disappointing results in reducing fracture risk in the elderly population.

The relatively new medication on the block is Prolia (denosumab), an injectable human monoclonal antibody, that works through a different mechanism of action, though the result is the same; it blocks the osteoclastic (breakdown) activity of the bone (3). It has been shown to increase bone mineral density, or thickening of the bone, and reduce fracture risk. Prolia was approved at the end of 2012, so it has not been out long. Like bisphosphonates, it does have side effects.

As far as supplements go, the most exciting news is that melatonin may help to increase bone mineral density. Let’s look at the research.

The forgotten sex: men
Rarely are men the forgotten sex when it comes to medical research, but osteoporosis is an exception. Approximately one-third of fractures occur in men, resulting in a 37 percent mortality rate. One in five men over the age of 50 will experience a fracture with osteoporosis as a contributing factor. The predictions are that these rates will climb precipitously and that men need to be treated appropriately (4). Currently, less than 50 percent of men with osteoporosis are receiving treatment (5).

Is bariatric surgery useful?
Though bariatric surgery has been shown to have a number of benefits for many chronic diseases, osteoporosis is not one of them. In the Swedish Obesity Study, results show that women who underwent bariatric surgery were at 50 percent increased risk of fractures as well as long-term osteoporosis (6). The results in men were not statistically significant. The duration of the study was 25 years. The authors hypothesize that malnutrition may play a role in causing this effect. Supplementation may be important to overcome this, as well as frequent follow-ups with blood tests to track micronutrient levels.

Heart disease, really?
When we think of heart disease, we associate it with lots of complications, but osteoporosis is not typically one of them. Well, think again. In the Hertfordshire Cohort Study, results show that there was a significantly increased risk of wrist fracture of the radius in those with heart disease (7). These results were shown overall. However, when the sexes were analyzed separately, this effect held true for men but was not true for women, although the results in women did trend toward significance. This may be an example where men are at greater risk than women. Therefore, it may be important to think about osteoporosis when someone is diagnosed with heart disease, especially since it is not intuitive. Lifestyle factors could be a contributor to this association, as well as estrogen deficiency.

A bisphosphonate that disappointed
Bisphosphonates are the mainstay of treatment for osteoporosis, increasing bone density and decreasing fracture risk. However, zoledronic acid had surprisingly disappointing results in a randomized controlled trial (RCT) (8). Results showed that while zoledronic acid increased bone density over two years, it did not decrease the risk of fracture in elderly women in nursing homes. This does not necessarily have broad implications for other bisphosphonates. There were also weaknesses in this trial, the most serious being fracture risk was not a primary end point. Additionally, the study may have been too small. However, this still is a very intriguing study.

Melatonin for osteoporosis
What could melatonin possibly have to do with osteoporosis? Am I just trying to put you to sleep? No. There are surprisingly positive results with melatonin. In a recent very small RCT, melatonin in combination with 800 mg/day of vitamin D3 and 800 mg/day of calcium increased bone density significantly in the spine and femoral neck over a one-year period, compared to the control, or placebo, arm containing vitamin D3 and calcium of similar dosage (9).

Interestingly, with melatonin the amount of calcium excreted through the urine in a 24-hour measurement decreased by 12.2 percent. There was a dose-related curve, where melatonin 3 mg/day in combination with vitamin D3 and calcium showed greater results than 1 mg/day of melatonin, which showed significant results over the control arm. This was a preliminary study involving 81 postmenopausal women divided into three groups. Fracture risk reduction was not an end point. Larger studies with fracture risk as a primary end point are needed. Having said this, these results are exciting.

Though medications such as bisphosphonates and a monoclonal antibody may have an important place in the treatment of osteoporosis, not all medications may be equal. It is important to treat with lifestyle modifications including potentially supplements — melatonin, calcium and vitamin D3 — as well as diet, exercise and overall behavior modifications. Heart disease’s unexpected association with osteoporosis is a good reason to treat the whole patient, not just the disease. And don’t forget that men may have this disease too!

References:
(1) uptodate.com. (2) Exp Clin Endocrinol Diabetes. 2001;109 Suppl 2:S493-514. (3) epocrates.com. (4) iofbonehealth.org. (5) J Bone Miner Res. 2014;29:1929-1937. (6) ECO 2015. Abstract T8:OS3.3. (7) Osteoporos Int. 2015;26(7):1893-1901. (8) JAMA Intern Med. Online April 13, 2015. (9) J Pineal Res. Online June 3, 2015.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website medicalcompassmd.com or consult your personal physician.