The current pharmaceutical standard of care for management of bone loss is supplemental calcium and the bisphosphonate drug class. The generics for the latter have the name formula of : ”XYZ – dronate”. Currently there are six versions on the market, and they are prescribed more than 25 million times per year. Obviously, brittle and broken bones are not only a big problem, they are also big business. Both excess calcium and anti-absorptive prescription drugs can be problem prone, as we will discuss. While both may have a place in osteoporosis management, in this article we will discuss their potential downsides, as well as the what and why of the frontline measures that should be your foundation for building stronger bones at or after menopause.
Bisphosphonates: the engine or the caboose?
A recent review of the bisphosphonate class of ‘anti-resorptive’ drugs showed an associated risk for all fracture types over time. Wait a minute, isn’t that NOT the idea? An article in the May 2017 issue of the Journal of the American Geriatric Society concluded that for “older women at high risk of fracture, 10 to 13 years of bisphosphonate use was associated with higher risk of any clinical fracture than 2 years of use.”1 Side effects of this drug class can include bone pain, flu like symptoms, rash, reflux and other digestive problems and in some cases, osteonecrosis of the jaw. In 2013, the maker of one of the more popular versions of this drug class paid $27.7 million to settle a bone jaw deterioration side effect law suit to 1200 affected patients. This is not to say some patients may benefit from this drug class, but it would be wise to consider your non-pharmaceutical alternatives, and make this class of medications the caboose, not the engine on the track to better bone health.
Its 6 hours after a meal, do you know where your calcium is?
Calcium is one of the most important structural ingredients in strong bones. It is useful to visualize your body’s calcium stores as being in a continual state of dynamic flux. Most of the body’s calcium is in the bones, while your cells and blood have smaller and very tightly regulated levels. Unfortunately, as we age, the deposition of calcium in soft tissues becomes another compartment. One of the most concerning manifestations of this is the calcification of arteries, limiting blood flow and raising blood pressure. If we take more calcium to build bone, but then don’t assure that it gets into the bone, we will contribute to soft tissue calcification and eventually, arterial blockages. 2,3
Calcium: optimizing bone building, minimizing soft tissue deposits
Over the years, I’ve found four key non-drug measures to deal with this ‘calcium steal’, which can reverse osteoporosis and minimize the related calcified plaque formation in most of my patients. Most of the time, we have been able avoid resorting to bisphosphonates. I’ll also mention one related and under-diagnosed medical condition for you to consider. These include:
1) Weight bearing exercise: You knew I was going to say this, didn’t you? We have two major cell types in the bone cortex: osteoblasts, which build bone; and osteoclasts, which reabsorb and remodel bone. These two are in an ongoing state of equilibrium. Healthy bone remodels itself all the time. Without healthy stress, though, in working against gravity, the osteoclasts get the upper hand and net bone is lost. We need to promote a healthy amount of osteoblast bone building by challenging the bone, which is why we call it ‘weight bearing’. So, while swimming is great exercise, your buoyancy negates the gravity effect. Walking and strength training are two of the best choices to activate your bone building cells and build bone density.
2) Vitamin D3: This critical nutrient acts on virtually every cell in the body, but in this scenario is particularly important in helping you to absorb dietary calcium from the gut, direct it to the bone, and then integrate it with new bone formation. Low Vitamin D can allow excess calcium to be diverted to soft tissue, rather than to bone cortex deposition. A study published this month in the Journal of the American Heart Association showed that high-dose calcium supplementation of more than 1000 mg/day (and the National Institutes of Health does recommend a total daily intake of 1,200 mg for women older than 50 years of age) increased the risk for strokes. It also showed that the addition of vitamin D in these individuals offset that risk.2 Another study found in the American Family Physician reviewed a series of studies including 12,000 women which showed that the incidence of acute MI increased by 20-30% with calcium supplementation.3 This finding again emphasizes the theme of this article: calcium that is not directed into bone building ends up in the wrong places. If you are over 40, it is essential to know your Vitamin D3 level, and augment it to at least the middle of the ‘normal range’, a number in the ~50-70 ng/dl range.
3) Vitamin K2: The role of this nutrient in calcium management and bone health has been under-recognized until recently. While we know that both Vitamin K1 and K2 are involved with blood clotting, K2’s role in moderating key calcification enzymes has only been better defined since the 1980’s. Vitamin K2 has three key actions:
-It activates a bone building protein called osteocalcin
-It activates an enzyme called MGP, which resides in the vascular system, and is a potent inhibitor of local arterial calcification.
-K2 also helps prevent arterial calcification by transporting calcium away from areas where it shouldn’t be, such as the lining of blood vessels, and directing it to the bone cortex for deposition. Remediating a Vitamin K2 deficiency has even been shown to regress arterial calcification.
Vitamin K-2 is an essential part of midlife bone support. While fermented vegetables and natto soy are especially good food sources for K1, most of us are not likely to eat these daily. Aim for an intake 200 mcg per day along with your Vitamin D3, and make sure to take both with a meal, as they are fat soluble and won’t absorb well without food.
4) Non-reproductive levels of estrogen support: If you mention post-menopausal estrogen support in a room full of doctors, you might think that someone had just dropped a grenade. After traditional therapy was given a big fat black eye with the 2001 Women’s Initiative Study on hormone replacement therapy outcomes, appropriate estrogen use was placed on the back burner, and is still vastly under prescribed. The combination studied included synthetic progestins, animal sourced estrogens and a lack of individualization in therapy, all of which contributed to an unacceptable side effect profile. This therapy was and all too often continues to be standard fare, and should be avoided. I recommend individualized bio-identical hormone support for many pre and post-menopausal indications, including the benefit of estrogen in signaling bone cortex to maintain its calcium. The progesterone and female appropriate testosterone in such formulas also add bone benefit. Multiple studies show that HRT can decrease the incidence of osteoporotic bone fractures by as much as 25% to 50%. Not surprisingly, calcium held in bones is not playing mischief in the arteries. Long-term use of hormone replacement, particularly estrogen, is associated with lower rates of coronary artery calcification in older women.4
As always, multiple factors, including excess cancer risk in some patients must be considered when considering estrogen supplementation.
5) Undiagnosed hyperparathyroidism: Around one of fifty women over 50 will develop an overactive parathyroid gland. Excess parathyroid hormone liberates calcium from the bone, and the resulting imbalance can cause many symptoms, sometimes described as “moans, groans, stones, and bones…with psychic overtones.” More specifically, one can see:
-Loss of energy and chronic fatigue as the most common symptom.
-Low grade depression, loss of enthusiasm, more easily irritated
-Loss of concentration, cognitive/memory impairment.
-Osteoporosis or osteopenia.
– Kidney Stones, especially a concern if they are recurrent
-Bone aches; typically in the legs and arms.
-Reduced sex drive.
-Thin or lost hair, especially in the front
-High blood pressure, especially if suddenly worse or difficult to control.
Blood testing for elevated parathyroid activity includes serum calcium and the PTH (parathyroid hormone) level, interpreted in light of one’s symptoms. For authoritative online information on this disorder, go to www.parathyroid.com
Yes, you can manage menopause and your risk for osteoporosis as well as minimizing the potential for blocked arteries, all at the same time. Make sure that before you push high calcium intake, or add prescription drugs that you have addressed the foundational basics we’ve discussed above.
1 “Long-Term Oral Bisphosphonate Therapy and Fractures in Older Women: The Women’s Health Initiative Drieling R, LaCroix A, et.al.
2 “Risk of Ischemic Stroke Associated With Calcium Supplements With or Without Vitamin D: A Nested Case‐Control Study.” Abajo F, Rodriquez-Martin S, et.al. http://jaha.ahajournals.org/content/6/5/e005795
3 “Does Widespread Calcium Supplementation Pose Cardiovascular Risk? Yes: The Potential Risk Is a Concern.” Reid, I and Bolland J. http://www.aafp.org/afp/2013/0201/od1.html
4 “Estrogen therapy and coronary-artery calcification. Manson, Allison MA, et.al. https://www.ncbi.nlm.nih.gov/pubmed/17582069