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Osteoporosis

Osteoporosis is a generalized term for a group of diseases of a number of different etiologies that results in the progressive loss of bone density, and the subsequent fragility of the skeleton. Osteoporotic bones usually display normal mineralization but the bone cortex and trabecular suffer from an increasing loss of density and thickness, although the osteoid seams remain normal. (Berkow 1992; Govan 1990, 796-98; Rubin and Farber 1990, 708-9)

The primary pathology that characterizes osteoporosis is that the processes of bone resporption are greater than those of bone formation. In normalcy, both these events are balanced, such that the rate of bone reabsorption is indentical to that of bone formation. The most common etiological feature appears to be a facet of aging and a decrease in sex hormone production in men and women. Both estrogen and testosterone inhibit osteoclast activity, but with the natural decline in the secretion of these hormones that occurs with aging osteoclast activity begins to outpace osteoblast activity, promoting a net loss in bone density. Osteoporosis is more common in women due to the relatively rapid cessation in estrogen production during menopause, whereas healthy men continue to produce significant amounts of teststerone even into old age. The greatest period of bone density is about the middle of the third decade of life, which continues to plateau for about a decade. This is then followed by loss of bone density at a rate of about 0.3 to 0.5% per year. With the onset of menopause the rate of bone loss can increase to a rate of about 3 to 5% per year. Physical activity however is a method that can prevent bone loss, and thus physical inactivity in the elderly hastens the osteoporotic process (Berkow 1992; Govan 1990, 796-98; Rubin and Farber 1990, 708-9)

Osteoporosis is divided into two main forms: primary and secondary. Primary osteoporosis is associated with menopause in women and normal aging in men. Overall, women are six times more likely to suffer from osteoporosis. Secondary osteoporosis accounts for less than 5% of osteoporosis cases and includes a diverse number of causes, including endocrinal diseases (e.g. hyperthyroidism, Cushing’s disease, diabetes, lactation and pregnancy, hypogonadism, hyperparathyroidism), cirrhosis, inflammatory joint disease, chronic pulmonary diseases, immobilization, drugs (e.g. anticonvulsants, heparin, glucocorticosteroids, ethanol, tobacco), cancer and malabsorption syndromes. (Berkow 1992; Govan 1990, 796-98; Rubin and Farber 1990, 708-9)

The primary clinical manifestations of osteoporosis are bone fractures, usually occurring in the proximal humerus, lower forearm, hip, spine and pelvis. These can cause chronic pain, but not all patients with low bone mass will experience fracture. Radiologic and ultrasonic investigation will yield a finding of thin bone cortices, called osteopenia (‘little bone’); findings in a individual are compared against the typical density of bone found in a healthy individual of the same age, sex and size (‘age-matched’) against the optimal peak bone density of a healthy young adult of the same sex (‘young normal’). The typical osteoporotic patient is of North European descent, female, a smoker, with a history of breastfeeding several children and a lack of sun exposure. As we will explore, these factors are related to important hormonal shifts in large part brought about by environmental factors. (Berkow 1992; Govan 1990, 796-98; Rubin and Farber 1990, 708-9)

The processes regulating bone formation and reabsorption are complex. The process begins with osteoblasts that lay down the organic matrix of bone and mineralize it, followed by osteoclasts that function to resorb bone. Their activities are controlled by a number of hormones including parathyroid hormone [PTH], calcitonin, and estrogen, as well as nutritional sources of vitamin D and locally acting cytokines. As previously stated, the most common cause of osteoporosis is attributed to declining levels of estrogen, which enhances the secretion of a cytokines such as interleukin-1, tumor necrosis factor alpha, granulocyte-macrophage colony-stimulating factor and interleukin-6, which in turn, promotes the recruitment, differentiation and activation of osteoclasts. Interestingly enough, obesity is not a risk factor for osteoporosis, and is actually associated with a higher bone density. It is known that fat serves as a source of estrogen after menopause, and thus women that maintain a good waist to hip ratio with a little extra padding on the hips and thighs, i.e. ‘pear-shaped,’ can reduce their risk of osteoporosis AND diseases associated with the ‘apple-shape’ of truncal abdominal obesity (e.g. diabetes, CVD, cancer, etc.) (Berkow 1992; Govan 1990, 796-98; Rubin and Farber 1990, 708-9)

Nutritional factors are stated to promote a secondary osteoporosis, such as protein malnutrition and scurvy, but can also be seen to play into the pathogenesis of the primary form, namely, with regard to the insufficient dietary intake of Ca, Mg, P, and vitamin D. Among these, deficient dietary calcium is typically suggested as the major dietary component responsible for osteoporosis, and thus many women are suggested to drink milk and take calcium supplements to prevent osteoporosis. Recent studies however have disproved this hypothesis, showing that vitamin D is a more important factor to maintain proper bone mass (Feskanich et al 2003). In temperate countries, the population is a greater risk for vitamin D deficiency due to decreased sunlight hours during winter, increased amount of time spent indoors from previous generations, and the decreased consumption of foods naturally rich in vitamin D such as animal liver and eggs. Moreover, populations that tend to consume less calcium appear to have a decreased risk for osteoporosis (Fujita and Fukase 2000), as in the Japanese, who only consume 400-500 mg of calcium per day, mainly as soybean products, small fish with bones, and vegetables. One recent study suggested that some traditional Japanese foods, such as leafy green vegetables and natto (fermented soybeans) provide higher serum levels of vitamin K2 (menaquinone-7; MK-7), with a statistically significant inverse correlation was found between the consumption of these foods and the incidence of hip fractures in women (Kaneki et al 2001).

Magnesium is an important accessory element required for bone production that is comparatively low in recommended foods such as dairy. Specifically, magnesium is required for the activation of alkaline phosphatase, an enzyme involved in forming calcium crystals in bone (Iseri and French 1984) and for the conversion of vitamin D into 1,25-dihydroxyvitamin D3, its biologically active form (Rude 1985). Researchers evaluated the effect of magnesium supplementation on apparent calcium absorption, bone metabolism and dynamic bone strength in ovariectomized rats as a model of postmenopausal women. The results of this study indicated that magnesium supplementation reduces apparent calcium absorption, but promotes bone formation and prevents bone resorption in ovariectomized rats. Moreover, the results indicated that magnesium supplementation increases the dynamic strength of bone (Toba et al 2000).

The body's acid-base balance is also an important factor in osteoporosis, and the more acidic the blood the greater requirement for alkalization (i.e. bicarbonate ions), at the expense of bone. Thus a diet high in protein without the consumption of alkalizing foods may increase the risk of osteoporosis. Other factors in osteoporosis include a late menarche and early menopause, nulliparity, caffeine ingestion, alcohol use, and cigarette smoking are also important determinants of decreased bone mass. Another factor that is typically not taken into account is the prevalence of celiac disease, which may be more common than previously suspected (Nelsen 2002). Chronic celiac disease, which may present with little or no clinical symptoms, impairs the ability of the gut to absorb minerals such as calcium.

Medical treatment

The medical treatment of osteoporosis emphasizes preventative measures that include supplementing with calcium (up to 1000 mg daily), either with dietary supplements or by drinking milk or calcium-fortified beverages such as orange juice, and eating calcium-rich foods such as canned fish. Weight-bearing exercise such as walking or aerobics and maintaining normal body weight are important factors in maintaining proper bone density. For patients already displaying definite signs and symptoms of osteoporosis similar measures are undertaken, increasing calcium supplementation up to 1500 mg daily, and increasing vitamin D intake to 800 IU (although distinctions are rarely made between the biological activity of ergocalciferol and cholecalciferol). Exercise regimens are carefully constructed to prevent accidents, injuries and fractures.

A variety of drug treatments are used in osteoporosis, some of which are used only in women. Among the most commonly used medications to prevent and treat osteoporosis is estrogen, which has been shown to reduce the risk of hip fracture by up to 50%. It can be taken orally or applied as a transdermal patch. The long term use of estrogens however is associated with negative symptoms such as breast tenderness, weight gain, vaginal bleeding, and an increased risk of breast and endometrial cancers. At one time these effects were thought to be prevented with combination therapy, combining estrogen with synthetic progestins, but this approach has recently come under fire in light of the findings of the recent Women’s Health Initiative Study, a major clinical trial that examined the risks and benefits of combined estrogen and progestin therapy in healthy menopausal women. The clinical trial, which was funded by the National Institute of Health in the United States, was stopped early due to a significant increased risk of invasive breast cancer, as well as increases in coronary heart disease, stroke, and pulmonary embolism that out-weighed any benefits of hormone replacement therapy (HRT). As an alternative to HRT are selective estrogen receptor modulators (SERMs) such as raloxifene which have effects on bone and cholesterol levels that are comparable to those of HRT. While SERMs do not promote estrogen dependent changes, the complaint of hot flushes and the risk of blood clots are comparable to the risks of HRT. Bisphosphonates such as alendronate, risedronate, and etidronate are another commonly prescribed medication in osteoporosis, and in some cases have been shown to increase bone mineral density. Bisphosphonates have an affinity for hydroxyapatite crystals in bone and act as an antiresorptive agent. Common side-effects associated with biphosphonates include nausea, GERD, gastric ulcer and constipation, with little data on the long term effects of taking these drugs in healthy women as a preventative agent.

Holistic treatment

Osteoporosis is to some extent seen as a natural and normal event of aging, although this perspective is one that has been conditions by the increasing prevalence of the disease in Western society. Among the most important considerations in osteoporosis is nutrition. In the research presented in his text Nutrition and Physical Degeneration, dentist and physician Weston Price demonstrates the negative effects of the modern industrialized diet upon bone structure and density, noting that where traditional peoples have adopted this modern diet, there is a commensurate increase in the frequency of dental caries and physical changes that include a narrowing of the face, a decrease in the size of the maxillary arch, pinched nostrils and septum, and an increase in physical deformities. Price further researched these findings by conducting animal experiments, and noted the same types of changes when the animals were subjected to common nutrient deficiencies found in the modern Western diet. Among the more important considerations in maintaining proper bone health which have already been discussed are the status of key nutrients such as vitamin A, C, E, D and K, macro-minerals such as calcium, magnesium, phosphorous and boron, and a balanced assortment of the various trace minerals important in bone health.

In Chinese medicine the bones and marrow are viewed as an extension of the Kidneys, the storehouse of Jing, the vital essence of the body. The marrow, or that which fills the bones and includes the spinal cord and brain, is directly derived from and nourished by the Kidney Jing. In turn, the marrow nourishes bone. The Jing and Marrow specifically relates the status of Kidney Yin, and the head hair is considered to its be and is used to assess the status of the Kidney Yin. The Kidneys are also the site of the Ming Men, the Life Gate Force, which is the ministerial fire that promotes the processes of digestion, growth and metabolism, and is synonymous with the Kidney Yang. As osteoporosis is essentially viewed as a deficiency disease, in particular a deficiency of Kidney Yin and Yang, or more generally, a body-wide deficiency of Qi, Blood and Yin. Chronic illness, overwork, excessive exercise, excessive sexual activity, and chronic fear and anxiety disrupt the function of the Kidneys and promote a depletion of Yin and Yang. A deficiency of Kidney Yin is more likely in scenarios of long-standing heat, whereas a deficiency of Kidney Yang occurs in cold and damp conditions. A deficiency of either however eventually results in a deficiency of the other. This in turn weakens the status of Jing, which cannot support and nourish the marrow and bones, and thus they weaken and degenerate. To some extent this processes is influenced by the activities of the Liver, which is responsible for the nourishment of the muscles and tendons. Thus a deficiency of Liver Blood, or in situations of a constrained Liver Qi, the muscles and sinews will similarly weaken and wither away. The treatment of osteoporosis in Chinese medicine consists primarily of strengthening the Jing, the Kidney Yin and Yang, and supporting the Liver.

In Ayurvedic medicine the health of the bone tissue, or asthi dhatu, is dependent upon the health of the flesh (mamsa) and fat (medas) of the body, which gives rise to bone tissue. Thus the proper digestion and assimilation of the nutrients that form muscle and fat are considered important factors in bone health. Ayurveda also maintains however that each of the dhatus can be nourished independent of the previously formed dhatus, and thus bone tissue can be directly nourished by eating cartilaginous tissues and preparing bone soups. The unique, hollow structure of bone however also speaks the status of Vata, the humor of Wind. The main pathogenic site of Vata is the colon and lower pelvis, the primary site of the elimination of wastes, and in scenarios in which the function of Vata is deranged, its qualities of lightness, dryness and coldness gradually become dominant in the body, and begins to manifest in the bones and joints, promoting osteoporosis.

The following is the basic protocol in the prevention and treatment of osteoporosis:

1. Ensure proper nutrition. The emphasis is upon a well balanced diet rich in minerals and plant fibers. There is much debate about the harm that high protein diets might cause, promoting the mobilization of calcium from bone to act as a buffer in the blood. Consuming an abundance of high fiber, alkalizing vegetables however would appear to maintain the acid-base balance, decreasing the urinary excretion of calcium and magnesium. There is similar debate about the benefits of consuming soy isoflavones, which have a weak estrogenic activity in the body. Generally speaking, the herbalist’s perspective is that consuming isoflavone-rich foods, particularly the legumes of the Phaseolus spp. (e.g. kidney beans, soy, navy beans etc.) may be helpful, but should be processed according to traditional methods (e.g. fermentation) to denature the phytic acid and lectins that can impair nutrient absorption and cause GI distress. Some research has also indicated that isoflavones and other phytoestrogens may act as endocrinal disrupters, and thus should be avoided in concurrent endocrinal dysfunction. In both children and adults the high phosphorous levels found soft drinks is a serious concern, and has been shown to have negative impact upon serum calcium levels, and may promote poor bone health. One important strategy that is used in both Ayurveda and TCM to promote proper bone health is the consumption of animal cartilage and marrow, and drinking generous amounts of soups and broths that have been made by decocting animal bones. The following supplements can be taken in conjunction with the dietary recommendations outlined under Paleolithic Diet.

  • Calcium citrate or malate, 800-1200 mg daily
  • Magnesium citrate or malate, 400-600 mg daily
  • Manganese, 15-30 mg daily
  • Boron, 3 mg daily
  • Zinc, 15-20 mg daily
  • Copper, 1.5-3 mg daily
  • Folic acid, 400-800 mcg daily
  • Vitamin B6, 50-100 mg daily (taken in a B complex)
  • Vitamin C, to bowel tolerance
  • Vitamin D3, 1000-1200 IU daily, taken all year in temperate climates
  • Vitamin K, 200 mcg daily
  • Isoflavones (fermented source), 50-100 mg daily

2. Eliminate bad habits. Regular alcohol consumption, smoking, caffeine and sugar consumption are associated with an increased risk of osteoporosis.

3. Promote proper digestion, assimilation and elimination of wastes.

  • Digestive enzymes, full spectrum, 2-3 capsules with each meal
  • Bitters (e.g. Barberry, Gentian,etc.) to enhance gastric and hepatic secretions
  • Dipanapachana dravyas, to enkindle agni, e.g. Yavani (Trachyspermum spp.), Shunthi (Zingiber officinalis), Pippali (piper longum), Hingu (Ferula foetida)
  • Botanicals to relieve Food Stagnation and strengthen Spleen, e.g. Chen Pi (Citrus reticulata), Shan Zha (Crataegus pinnatifida), Huang Qi (Astragalus membranaceus), Dang Shen (Codonopsis pilosula)
  • Mild aperients (e.g. Cascara, Buckthorn, Turkey Rhubarb, Triphala) to promote proper elimination
  • Probiotics and synbiotics to restore the ecology of the gut

4. Reduce Vata and rebuild the Jing. This is among the more important strategies in Ayurvedic and Chinese medicine in the treatment of osteoporosis, and in the final analysis, are approaches that are more or less synonymous and achieve the same end. Therapies to reduce Vata include promoting proper elimination, steam baths, pranayama, hatha yoga, and the emphasis of sour, salty and sweet tastes along with the generous use of high quality fats and oils in the diet and for regular topical application. Important medicaments to correct Vata include:

  • Shatavari (Asparagus racemosa), Ashwagandha (Withania somnifera), Gokshura (Tribulus terrestris), Amalaki (Emblica officinalis), Brahmi (Bacopa monniera), Musta (Cyperus rotundus), Guggulu (Commiphora mukul), Arjuna (Terminalia arjuna), Tila (Sesamum indica), Yashtimadhu (Glycyrrhiza glabra), Bala (Sida spp.), Kapikachu (Mucuna pruriens), Punarnava (Boerhavia diffusa), Shuktibhasma (purified oyster shell ash), Shringaputa (deer horn ash), Shilajitu, ghee, milk, goat meat
  • Yogaraja guggulu, 2-3 g bid-tid
  • Dashamula arishtam, 12-14 mL bid-tid
  • Mahanarayana taila, applied topically in abhyanga

In TCM, medicaments to strengthen the Kidneys and enhance Jing can be categorized based upon the specific deficiency syndrome, including:

  • Qi deficiency: Ren Shen (Panax spp.), Shan Yao (Dioscorea opposita), Huang Jing (Polygonatum sibiricum)
  • Blood deficiency: Shu Di Huang (Rehmannia glutinosa), He Shou Wu (Polygonum multiflorum), Gou Qi Zi (Lycium chinense), Sang Shen (Morus alba)
  • Yang deficiency: Lu Rong (Deer or Elk velvet), Dong Chong Xia Cao (Cordyceps sinensis), Yin Yang Huo (Epimedium grandiflorum), Bai Ji Tian (Morinda officinalis), Bu Gu Zhi (Psoralea coryfolia), Du Zhong (Eucommia ulmoides)
  • Yin deficiency: Xi Yang Shen (Panax quinquefolium), Tian Men Dong (Asparagus cochinchinensis), Shi Hu (Dendrobium nobile), Han Lian Cao (Eclipta prostata)
  • Ge Jie Da Bu wan, 3-5 capsules bid-tid (contains Gecko)
  • Quan Lu Wan, 4 pills bid-tid (contains 40% deer horn)
  • Ren Shen Lu Rong Wan, 5 pills bid-tid (contains 15% deer horn)
  • Du Zhong Bu Tian Su, 2-4 tablets, bid-tid
  • Jin Kui Shen Qi Wan, 8-10 pills bid-tid
  • Gu Ling Ji, 2 capsules bid-tid

5. Musculoskeletal trophorestoratives, e.g. Nettle (Urtica), Milky Oats (Avena), Horsetail (Equisetum), seaweeds (Fucus, Laminiaria, Macrocystis etc.), mineral-rich foods (e.g. bone broths)

6. Weight-bearing exercise. Moderate weight-bearing exercise including calisthenics and weight-lifting increases bone mass.

7. Additional supplements

  • if unresponsive to natural therapies, natural progesterone cream (synthesized from diosgenin), 400-500 mg/30 mL (1.6% w/v or 3% v/v), 1.25 mL (1/4 tsp) once daily (equal to about 20 mg/day)

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