Osteoporosis – General Recommendations

Osteoporosis – General Recommendations by Nicholas Gonzalez, M.D.

Osteoporosis is a serious problem affecting millions of American women and men. It can be progressive, relentless, lead to serious fractures and in the US about 15,000 deaths yearly as a secondary result. Don’t despair, the good news is that most of the time osteoporosis can be halted in its tracks and reversed with natural, nutritional approaches.

Most conventional researchers associate the problem with women post menopause, because of the reductions in estrogen and progesterone production. During the first couple years after a woman enters menopause, bone loss appears highly accelerated, before slowly to a steady, yearly rate of decline. If progressive, women can at times lose close to 50% of their total bone density compared to their bones in their teenage years, when bone density is greatest.

I thought it would be helpful, since the problem is so pervasive, to delve a little into bone physiology. Our bones are not like the pillars of an ancient Greek stone temple, but more like a living tree with extreme metabolic activity, capable of growth, repair, and remodeling. We all realize that after a fracture, even if serious, our bones can generally repair the damage quite nicely.

In fact, in each of us, all our bones, from the skull to the little toe of our feet, continually remodel and reshape themselves every day. This activity results from the activity of two general classes of bone cells, the osteoclasts and osteoblasts. The osteoclasts dispersed through all our bones secrete a number of enzymes that essentially dissolve bone. The osteoblasts, on the other hand, secrete enzymes and calcium hydroxyapatite, the main form of calcium found in bone, that fills out the blanks left by the osteoclastic activity.

Ideally, osteoclast behavior should be nicely balanced by the osteoblasts, so that every minute of our lives, our bones are reshaping and rebuilding in equilibrium, so that our bones become neither too weak (as in osteoporosis) or too dense. This coordinated activity helps keep our bones strong, to deal with the extraordinary physical demands we place on them every day. After all, without continual rebuilding, our bones would gradually wither away from the wear and tear of normal activity. Just think of the pressure we put on our skeleton with walking, or running, or jumping, or lifting.

With osteoporosis, the balance between bone resorption and bone formation goes astray, with osteoclastic activity more pronounced. In this regard, whether we are women or men, our hormones come in to play. Estrogen, one of the two main female hormones along with progesterone, blocks excessive activity specifically of the osteoclasts, keeping bone absorption under normal control. Progesterone on the other hand, stimulates the osteoblasts into action, signaling these cells to create and secrete new bone to keep up with the osteoclasts.

In menopause, secretion of both estrogen and progesterone falls rapidly, with loss of the normal controls over bone remodeling evident in a woman’s younger years. Now, menopause is not a disease, nor should it lead to a disease like osteoporosis under ideal circumstances. In my experience, if estrogen and progesterone secretion fall in tandem, bone resorption and formation fall equally, and though our bones may not be as resistant to stress as a 20-year old’s, osteoporosis should not be a problem. However, often hormone secretion falls unequally, often with progesterone deficiency predominating. In such a circumstance, bone resorption dominates, and over time, bone thinning and eventually osteoporosis will follow.

Most men synthesize both estrogen and progesterone, though in much smaller amounts than women. These hormones do play a role in male bone health, but testosterone is of far greater importance, stimulating bone formation, more effectively than either estrogen or progesterone – hence the reason young men generally have denser bones than young women. As we now recognize, men go through a “malepause,” associated with some decreased testosterone production, though the process usually occurs slowly over time, not as dramatically as in women. Most often the male hormone levels do not fall to the levels seen with estrogen and progesterone.

Osteoporosis can develop for reasons other than reduce secretion of these specific hormones. Excess thyroid hormone, either due to hyperthyroidism or the overuse of thyroid medications, can stimulate significant bone loss over time. And, importantly, vitamin D deficiency, even if only minor and chronic, can lead to bone loss, and eventually osteoporosis.

In recent decades, conventional researchers have assumed vitamin D deficiency to be rare, since the addition of synthetic vitamin D in milk products. But recent epidemiological studies have confirmed that vitamin D deficiencies are not only common in adults, but perhaps epidemic.

Vitamin D is an unusual nutrient, more a hormone than a vitamin. By definition, vitamins are naturally occurring substances absolutely essential for normal metabolism, but which we cannot make ourselves and must be taken in with our food. Vitamin D differs from its vitamin cousins because we can actually synthesize it in our bodies from the alleged plaque of modern medicine, cholesterol. Contrary to the dictates of so many experts, cholesterol is not the enemy of mankind but an essential life sustaining nutrient, required to help keep all our cell membranes together, an essential component of myelin, the sheath around all nerves, and the precursor to all our steroid hormones – estrogen, progesterone, testosterone, and vitamin D.

Vitamin D begins forming via the action of sunlight on our skin, where dermal cells convert cholesterol into a primitive form of vitamin D. In an elegant series of steps, first our liver, then our kidneys, transform this pre vitamin D in the active form of vitamin D.

However, with panic abounding because of sun exposure and skin cancer, we tend to avoid the sun more than ever. Also, vitamin D occurs only in a few foods such as fish, particularly fish liver and other animal livers – hardly main staples of the American diet – so vitamin D deficiency, despite its addition to milk, has creeped up to become a major public health problem.

Vitamin D stimulates the absorption of calcium from food, and helps direct calcium into the bones, instead of into the soft tissues like the kidney, where it does little good. With vitamin D deficiency, we cannot absorb calcium efficiently no matter how much we consume as food, so deficiency often follows. In response, the body secretes a hormone, parathyroid hormone, that draws out calcium from the bones so the mineral is available for normal cellular activity. Over time the bone loss due to even chronic mild vitamin D deficiency can be substantial.

I find in my own practice that many patients exhibit vitamin D deficiency when they start with me, requiring aggressive supplementation of the natural, vitamin D3 form. In the old days – the old days being 30 years ago – doctors obsessed about vitamin D toxicity, which as it turns out has been grossly overstated. Even doses of the natural vitamin D in the range of 10,000 units do not seem to be toxic, though the water-soluble synthetic forms do seem to be far more toxic than the natural version. I commonly push the dose to the 3,000 range with good results long term. I use calcium supplements in variable doses depending on the individual metabolism of the patient but rarely find that dietary calcium deficiency is the problem. Patients just can’t absorb the calcium in their food because they lack adequate vitamin D. Many of my patients in fact seem to be overloaded with calcium when they start treatment with me, thanks to the rush to supplement so many foods, even orange juice, with the mineral.

More recently researchers have associated vitamin D deficiency with a host of problems that have nothing do to with bone strength, such as diminished immune function, depression, mood swings, most recently, even heart disease. So, with any diagnosis of osteoporosis, vitamin D is the first place to start.

As always, for all my patients, I prescribe a full nutritional program, involving individualized diet, individualized supplement protocols, and detoxification routines. With this approach I rarely fail to get significant improvement with osteoporosis. I also have prescribed the bisphosphonate class of drugs, widely advertised on TV, for my cancer patients with malignancy-related bone loss. These drugs do stimulate osteoblasts to secrete more bone, but unfortunately, the resulting crystalline lattice is not normal bone. Recently, osteonecrosis of the jaw, a very serious problem in which the bone literally dies, has been reported in patients taking the IV forms of the bisphosphonates. Fortunately, with my full nutritional approach I rarely have to prescribe these drugs, and in fact, I rarely prescribe hormones. Most commonly, I find that with an aggressive nutritional program with adequate vitamin D, the bones will stabilize and regrow without relying on hormone replacement therapy.

So, there you have it, my thoughts on bone physiology and my approach to Osteoporosis treatment.

By Nicholas Gonzalez, M.D.