Preventing and Treating Osteoporosis (Webinar Recording)

Hello everyone and welcome! I’m Dr. Michael Greger, coming to you live from my treadmill for our very first CME-approved webinar, continuing medical education for doctors and other medical professionals. As such, I am proud to declare I have no relevant financial relationships with ineligible companies to disclose. (That kind of declaration statement is necessary given a long checkered past of Big Pharma and medical instrument companies secretly propping up paid shills to push their products—so now they just non-secretly prop up paid shills to push their products, but at least it’s a little harder for them to hide, though). But no commercial bias here.

Before I cover the pros and cons of drugs used to treat osteoporosis, I’m going to start us off today covering drugs that may cause it.

(video begins – Acid Reflux Medicine May Cause Osteoporosis)

Nearly 1 in 5 adults in the world may have osteoporosis. That’s hundreds of millions of people. The word “osteo-porosis” literally means porous bone. Now, most of our bone is actually porous to begin with. This is what normal bone looks like inside, but this, is osteoporosis.

Bone mineral density is considered to be the standard measure for the diagnosis of osteoporosis. Although the bone density cut-off for an osteoporosis diagnosis is kind of arbitrary, using the standard definition, osteoporosis may affect about 1 in 10 women by age 60, 2 in 10 by age 70, 4 in 10 by age 80, and 6 or 7 out of 10 by age 90. Osteoporosis is typically thought of as a disease of women, but one third of hip fractures occur in men. The lifetime risk for osteoporotic fractures (for 50-year-old white women and men) are 40% and 13%, respectively.

The good news, is that osteoporosis need not occur. Based on a study of the largest twin registry in the world, less than 30% of osteoporotic fracture risk is heritable, leading the researchers to conclude, “Prevention of fractures [even] in the oldest elderly should focus on lifestyle interventions.” This is consistent with the enormous variation in hip fracture rates around the world, with the incidence of hip fracture varying 10-fold, or even 100-fold between countries, suggesting that excessive bone loss is not just an inevitable-consequence-of-aging.

The United States Preventive Services Task Force, an independent scientific panel that sets evidence-based, clinical prevention guidelines, recommends osteoporosis screening (such as a DXA bone mineral density scan) for all women aged 65 years and older and potentially starting even earlier than 65 for women at increased risk (such as having a parental history of hip fracture, being a smoker or an excessive alcohol consumer, or having low body weight). What should you do if you’re diagnosed, or more importantly, what should you do to never be diagnosed? Before exploring the drugs on offering to treat osteoporosis, there are some drugs that may cause it, so let’s start there.

Stomach acid-blocking “proton pump inhibitor” drugs, so-called PPIs—with brand names like Prilosec, Prevacid, Nexium, Protonix, and AcipHex—are among the most popular drugs in the world, raking in billions of dollars a year…. But then, in 2006, two observational studies out of Europe suggested an association between intake of this class of drugs and increased risk of hip fracture, and by 2010, the growing evidence forced the US Food and Drug Administration to issue a safety alert implicating PPI use with fractures of the hip, wrist, and spine. By now, there’ve been dozens such studies involving more than two million people that, overall, show higher hip fracture rates, among both long- and short-term users… at all, dose, levels….

The irony is that most people taking these drugs shouldn’t even be on them in the first place. These PPIs are only FDA-approved for 10 days of use for the treatment of H. pylori, up to 2 weeks for heartburn, up to 8 weeks for acid reflux disease, and for 2 to 6 months for ulcers. Yet, in a community survey, most users remained on these drugs for more than a year, and more than 60% of patients were taking them for inappropriate reasons, (often wrongly prescribed for quote-unquote “indigestion,” for instance).

Calls to stop this massive overuse from regulatory authorities have fallen on deaf doctor ears. And now that they’re available over-the-counter, the problem of overuse may have gotten even worse. They can be hard to stop taking since many patients experience withdrawal symptoms that can last for weeks. In fact, if you take normal, healthy volunteers without any symptoms and put them on these drugs for two months and then covertly switch them to a placebo without their knowledge, all of a sudden, they can develop acid-related symptoms, such heartburn or acid regurgitation, so ending up worse off than they were before-they-even-started-taking-the-drugs.

In addition to bone fractures, this class of drugs has also been linked to increased risk of other possible long-term adverse effects… such as pneumonia… intestinal infections… kidney failure… stomach cancer… and cardiovascular disease. (In fact, the blood vessel effects could explain the case report “Abrupt-Onset, Profound Erectile Dysfunction in a Healthy Young Man After Initiating Over-the-Counter Prilosec.”) Oh, and also, premature death….

There are individuals with conditions like Zollinjer-Ellison syndrome—stricken with tumors that cause excess stomach acid secretion—for whom the risk versus benefit of long-term use may be acceptable, but that’s a far cry from the 100 million PPIs prescribed annually in the United States alone.

To deal with acid reflux without drugs, recommendations include weight loss, smoking cessation, avoiding fatty meals…. especially within 2 to 3 hours of bedtime…. increased fiber consumption, and, overall, a more plant-based diet because nonvegetarianism is associated with twice the odds of acid reflux-induced inflammation.

Other classes of drugs that have been associated with hip fracture risk include antidepressants, anti-Parkinson’s drugs, antipsychotics, anti-anxiety drugs, oral corticosteroids, and the other major class of heartburn drugs, the H2 blockers, such as Pepcid, Zantac, Tagamet, and Axid.

(video ends)

OK, so excessive bone loss is not just an inevitable-consequence-of-aging, and one of the things we can do to lower our risk and that of our patients is to take into account the potential skeletal side effects of the drugs we take and prescribe.

What about the drugs prescribed to treat osteoporosis? First let me address efficacy:

(video begins – How Well Do Medicines Like Fosamax Work to Treat Osteoporosis?)

Drug therapy for osteoporosis is recommended for those 50 and older with a history of past hip or spine fractures, those with hip or spine “T-scores” of negative 2.5 or less, and postmenopausal women or men 50 and older who don’t make that cut-off—but, have an estimated 20% or higher risk of a major osteoporotic fracture over the subsequent decade, or an estimated 3% or greater risk of hip fracture, specifically.

A T-score is a measure of how dense your bones are compared to a 30-year-old white woman. Since that’s the standard, and we tend to lose bone as we age, you can be labeled as having osteoporosis even if you have completely normal bone density for your age. Of course, just because your bone density may be normal doesn’t mean it’s necessarily optimal, which is why the National Osteoporosis Foundation set out those guidelines for drug treatment. Though, another reason, perhaps, is because it gets substantial funding from the drug industry, that rakes in literally billions of dollars in profits from osteoporosis drugs. What, does the science say?

The primary drug class used to treat osteoporosis is the bisphosphonates, sold as such brands as Fosamax, Actonel, Boniva, and Reclast. They are most effective at reducing vertebral fractures, cutting the risk in postmenopausal women from 2.8% down to 1.4%. That’s a relative risk reduction of 50%, but an absolute risk reduction of only 1.4%, meaning you’d have to treat 71 women to prevent just one woman from getting a vertebral fracture.

Unfortunately, the diagnosis of vertebral fracture is kind of wishy-washy. Depending on how you define the changes on x-ray, the prevalence of vertebral fractures can vary by as much as 3% to 90% in the same elderly population—almost none, to almost all. They’re also poorly predictive of back pain or disability. Vertebral fractures can certainly lead to back pain and reduced physical function, but only about a third are symptomatic—at all. The most harmful fractures, are hip fractures.

Despite most of the clinical trials for osteoporosis treatment being funded by the drug companies themselves, no primary prevention benefit from bisphosphonates has been found for hip fractures. In other words, taking these drugs has not been convincingly shown to prevent fracturing your hip in the first place. However, having a prior fracture doubles your risk of breaking another bone, so, for those at high risk, bisphosphonate drugs may decrease the odds of hip fracture by 25%, though the absolute risk reduction is, again, only about 1%. It may take treating 91 people for three years to prevent one hip fracture.

An overconfidence in the power of pills and procedures for disease prevention may be one of the reasons doctors and patients alike may undervalue diet and lifestyle approaches. In this study, patients were asked to estimate the number of fractures or deaths prevented in a group of 5,000 patients undergoing each drug intervention over a period of 10 years. The vast majority of people tended to wildly overestimate the ability of mammograms and colonoscopies to prevent cancer deaths, the power of drugs like Fosamax to prevent hip fractures, and drugs like Lipitor to prevent fatal heart attacks. No wonder most people continue to rely on drugs to save them! But the dirty little secret is, that most people said they wouldn’t be willing to take many of these drugs if they knew how little benefit these products actually offered.

In a survey of those undergoing bone density scans, the average five-year fracture risk that would motivate most participants to consider preventative medication was 50 to 60%—much higher than their actual risk. Most patients want to be told the truth. They want to be told what the chances are that the drugs will actually benefit them, but there is a tension between the patient’s right to know and the likely reduction in their willingness to take the drug if they knew the truth.

In the bone density scan survey, participants greatly overestimated their own personal risk for hip fracture, thinking it was around 19% over the next 5 years, which is more than ten times higher than their actual risk, of 1.4%. Rather than disabusing them of this overestimate, some suggest physicians should do the opposite: Stoke fears in patients who “refuse to comply with medication recommendations” by increasing their “perceived susceptibility to fragility fractures” as well as their “perceived severity of suffering from a fragility fracture.” Since emotion can be more motivating than reason, and anecdotal evidence can be more effective than evidence evidence, a “graphic scenario of suffering and incapacitation after a hip fracture will enhance emotional perception of this threat.”

But hip fractures can indeed be devastating, and are associated with a significant risk of ensuing death. So, what about all of the lives these drugs must be saving? Well, only about a quarter of the deaths following fractures may be attributable to the fracture itself, so most of the mortality risk may just be a consequence of the comorbidities—that is, the other diseases and poor health status of people who tend to fracture their hips. So, they may have died anyway in that same time frame even if they hadn’t broken any bones. This may help explain why there are, no saved lives. Osteoporosis drug treatments, particularly bisphosphonates, fail to significantly reduce overall mortality.

(video ends)

OK, so the efficacy of the primary drug class used to treat osteoporosis is so slight on an individual basis, that most patients, if truly fully informed, likely wouldn’t take them. And that’s before even talking about the side effects, which I turn to next:

(video begins – Side Effects of Osteoporosis Medications Like Fosamax, Boniva, and Reclast)

Potential lack of efficacy… is not the only reason why most people prescribed bisphosphonate drugs for osteoporosis like Fosamax, Actonel, Boniva, or Reclast may stop taking them within a year. There are two rare but devastating side effects— osteonecrosis of the jaw, and atypical femur fractures—that contributed to around a 50% drop in the use of this class of drugs when they came to light. The New York Times article noting the decline explained the reasoning: “Reports of the drugs’ causing jawbones to rot and thighbones to snap in two have shaken many osteoporosis patients so much, that they say they would rather take their chances with the disease.”

The jaw-rot syndrome that prevents many from initiating treatment for fear of “their jaw falling off” can severely impact many aspects of quality of life but, is exceedingly rare, affecting at most 1 in a thousand patients treated for osteoporosis. Atypical femur fractures can occur more frequently, though, as many as 1 in 300 users treated for three years. They are called “atypical” because they occur not after a fall or trauma, but just during routine activities, like walking, twisting at the waist or even just standing still. Your femur, your thigh bone, the biggest bone in your body—just breaks in half. Too cruel an irony from a drug that’s supposed to protect your bones. This is what it looks like on x-ray. Ouch.

Bisphosphonates work by inhibiting the action of a type of bone cell called osteoclasts. Your entire skeleton is constantly being remodeled with bone added in some spots and taken away in others to conform to changing demands. The cells that are continually laying down new bone are called osteoblasts, and the ones that chisel away old bone are the osteoclasts. It makes sense, then, that curbing the ‘clasts would prevent bone loss. But by reducing the active remodeling process, bisphosphonates might “freeze” the skeleton, allowing for the accumulation of microcracks over time, resulting in stress fractures. Other osteoporosis drugs like den-o-sumab (sold, as “Prolia”) prevent the new formation of osteoclasts in the first place, and have been plagued by the same kinds of rare but disturbing side effects.

As with anything in life, it all comes down to risks versus benefits. How many hip fractures are prevented for every femur that snaps? It depends on your race, and how long you’re on these drugs. After five years in White women, 36 hip fractures are prevented for every atypical femur fracture. Hispanic women only get half the benefit, with about 18 to 1, and for Asian women it’s only about 5 hip fractures prevented for every femur fracture caused. (The study claims it failed to accrue enough data on Black women.) At ten years of drug exposure, the ratios get worse, 16:1 for White women, 5:1 for Hispanic women, and only about 1.5:1 for Asian women, meaning that the devastating fractures prevented and caused in Asian women are nearly comparable.

A nationwide survey of resident physicians found that knowledge regarding osteoporosis diagnosis and treatment was poor, with a particularly striking lack of knowledge regarding the two serious drug side-effects. The good news is, that after stopping the drugs, the risk of femur fracture rapidly drops by 70% within a year, leading to the suggestion that a drug “holiday” be considered after a few years on the drug to help mediate the risk.

(video ends)

How crazy is the atypical femur fracture data? I just can’t get over the irony of it all. OK, so between the lack of sufficient efficacy and these rare but devastating side effects, what can we do personally, and how can we counsel our patients to protect their skeletons? Before we get to lifestyle approaches, let me cover calcium and vitamin D supplements.

(video begins – Are Calcium Supplements Safe?)

In 12 short years, government panels have gone from suggesting widespread calcium supplementation may be necessary to protect our bones to “Do Not Supplement”. What happened? It all started with a 2008 study in New Zealand. Short-term studies had showed that calcium supplementation may drop blood pressures by about a point. Though the effect appears to be transient, disappearing after a few months, it’s better than nothing. And excess calcium in the gut can cause fat malabsorption, by forming soap fat, reducing saturated fat absorption and increasing fecal saturated fat content. And, indeed, if you take a couple Tums along with your half bucket of KFC, up to twice as much fat would end up in your stool, and with less saturated fat absorbed in your system, your cholesterol might drop. So, the New Zealand researchers were expecting to lower heart attack rates by giving women calcium supplements. To their surprise, there appeared to be more heart attacks in the calcium supplement group.

Was this just a fluke? All eyes turned to the Women’s Health Initiative, the largest and longest randomized controlled trial of calcium supplementation. The name may sound familiar—that’s the study that uncovered how dangerous hormone replacement therapy was. Would it do the same for calcium supplements? The Women’s Health Initiative reported no adverse effects. However, the majority of the participants were already taking calcium supplements before the study started; so, effectively the study was just comparing higher versus lower dose calcium supplementation, not supplementation or no supplementation. But what if you go back and just see what happened to the women who started out not taking supplements and then were randomized to the supplement group? Those who started calcium supplements suffered significantly more heart attacks or strokes. Thus, high dose or low dose, any calcium supplementation seemed to increase cardiovascular disease risk.

Researchers went back, digging through other trial data for heart attack and stroke rates in women randomized to calcium supplements with or without vitamin D added, and confirmed the danger and most of the population studies agreed—users of calcium supplements tended to have increased rates of heart disease, stroke, and death.

The supplement industry was not happy, accusing researchers of relying in part on self-reported data—like they just ask if people had a heart attack or not rather than verifying it. And indeed long-term calcium supplementation caused all sorts of gastrointestinal distress including twice the risk of being hospitalized with acute symptoms that may have been confused with a heart attack. But no, the increased risk was seen consistently across the trials whether the heart attacks were verified or not.

OK, but why do calcium supplements increase heart attack risk, but not calcium you get in your diet? Perhaps because when you take calcium pills, you get a spike of calcium in your bloodstream that you don’t get just eating calcium rich foods. Within hours of taking supplemental calcium, the calcium levels in the blood shoot up and can stay up as long as eight hours. This evidently produces what’s called a hypercoagulable state, your blood clots more easily, which could increase the risk of clots in the heart or brain. And, indeed, higher calcium blood levels are tied to higher heart attack and stroke rates. So, the mechanism may be calcium supplements lead to unnaturally large, rapid, and sustained calcium levels in the blood, which can have a variety of potentially problematic effects.

Calcium supplements have been widely embraced on the grounds that they are a natural and, therefore, safe way of preventing osteoporotic fractures. But, it is now becoming clear that taking calcium in one or two daily doses is not natural, in that it does not reproduce the same metabolic effects as calcium in food. And furthermore, the evidence is also becoming steadily stronger that calcium supplementation may not be safe. That’s why most organizations providing advice regarding bone health now recommend that individuals should obtain their calcium requirement from diet in preference to supplements. But if we can’t reach it through diet alone, would the benefits to the bones outweigh the risks to the heart?

(video ends)

We still need to get enough calcium, but it should be through foods, as nature intended, not through tums. Let’s turn from calcium supplement safety, to efficacy

(video begins — Are Calcium Supplements Effective?)

There has been an assumption for decades that as a natural element, calcium supplements must intrinsically be safe, but calcium supplementation is neither natural nor risk-free. But, the same could be said for every medication on the planet. Yet, doctors continue to write billions of prescriptions for drugs every year because the hope at least is that the benefits outweigh the risks. So, what about the benefits of calcium supplements. Yes, heart attacks and strokes can be devastating, but so can hip fractures. The risk of dying shoots up in the months following a hip fracture. About one in five women don’t last a year after a hip fracture, and it may be even worse for men, on average apparently cutting one’s lifespan short by four or five years. And, unfortunately these dismal statistics don’t seem to be getting much better.

So, even if calcium supplements caused a few heart attacks and strokes, if they prevented many more hip fractures, then it might result in a favorable risk-benefit ratio. So, how effective are calcium supplements in preventing hip fractures? We’ve known that milk intake doesn’t appear to help, but maybe that’s because any potential benefit of the calcium in milk may be overshadowed by the increased risk of fracture and death associated with the galactose sugar in milk. So, what about just the calcium in a calcium supplement alone? Calcium intake in general does not seem to be related to hip fracture risk at all, and when people have been given calcium supplements, not only was there no reduction in hip fracture risk, an increased risk is possible. The randomized controlled trials suggested a 64% greater risk of hip fractures with calcium supplementation compared to just getting like a placebo sugar pill.

Where then did we even get this idea that taking calcium supplements might help our bones? It was this influential study, in 1992, that found that a combination of vitamin D and calcium supplements could reduce hip fracture rates 43%. But, this was done on institutionalized women, like in a nursing home, who were vitamin D deficient. They weren’t getting sufficient sun exposure. And, so, if you’re vitamin D deficient and you take vitamin D and calcium, no surprise your bones get better, but for women living independently, out in the community, the latest official recommendations for calcium and vitamin D supplementation to prevent osteoporosis are unambigious: Do not supplement. Why? Because in the absence of compelling evidence for benefit, taking supplements is not worth any risk, no matter how small. Now, this is not to say these supplements don’t play a role in treating osteoporosis, or that vitamin D supplements might not be good for other things, but if you’re just trying to prevent fractures, women living outside of institutions shouldn’t take them and perhaps even in institutions. In this study, instead of giving nursing home residents vitamin D and calcium supplements, they randomized them to sunlight exposure and calcium supplements, and those that got the calcium pills had significantly increased mortality, lived shorter lives than the sunshine only group.

Although calcium supplements don’t appear to prevent hip fractures, they may reduce overall fracture risk by like 10%. So, here’s how the risk-benefit shakes out. If a thousand people took calcium supplements for five years, we would expect 14 excess heart attacks, meaning 14 people would have a heart attack that would not have had a heart attack if they hadn’t started the calcium supplements. So, they were effectively going to the store and buying something that gave them a heart attack, plus ten strokes that otherwise would not have happened, and 13 deaths—people who would have been alive had they not started the supplements. But, that’s all balanced against the 26 fractures that would have been prevented. Now, it’s no fun falling down and breaking your wrist or something, but I think most people would look at risk benefit analysis and conclude that calcium supplements are doing more harm than good.

Given these findings, the use of these supplements should be discouraged, and individuals advised to obtain calcium from their diet instead. Calcium supplements have been associated with elevated risk of myocardial infarction (heart attacks), whereas dietary calcium intake has not. How much calcium should we shoot for? Interestingly, unlike most other nutrients, there’s no international consensus. For example, in the UK, the recommendation for adults is 700 mg a day, but across the pond in the US, it’s up to 1,200 a day. Whenever I see that kind of huge discrepancy between government panels, I immediately think scientific uncertainty, political maneuverings, or both.

Newer data, based on calcium balance studies in which researchers make detailed measurements of the calcium going in and out of people, suggest that the calcium requirement for men and women is lower than previously estimated. They found calcium balance was highly resistant to change across a broad range of intakes, meaning our body is not stupid. If we eat less calcium, our body absorbs more and excretes less, and if we eat more calcium, we absorb less and excrete more to stay in balance. Therefore, current evidence suggests that dietary calcium intake is not something most people need to worry about.

This may explain why in most studies, no relationship was found between calcium intake and bone loss anywhere in the skeleton, because the body just kind of takes care of it. Don’t push it too far, though. Once you get down to just a few hundred milligrams a day, you may get significantly more bone loss. Though there may not be great evidence to support the U.S. recommendations, the UK may have the right idea shooting for between 500 and 1,000 mg a day from dietary sources unless you’ve had gastric bypass surgery or something and need to take supplements. For most people, though, calcium supplements cannot be considered safe or effective for preventing bone fractures.

(video ends)

OK, so calcium supplements appear to be doing more harm than good. What about taking vitamin D supplements?

(video begins – Should Vitamin D Be Taken to Prevent Falls?)

We’ve known for over 400 years that muscle weakness is a common presenting symptom of vitamin D deficiency. Bones aren’t the only organs that respond to vitamin D; muscles do too. But, as we age, our muscles lose vitamin D receptors, perhaps helping to explain the loss in muscle strength as we age.

And indeed, vitamin D status does appear to predict the decline in physical performance as we age, with lower vitamin D levels linked to poorer performance. But, maybe the low vitamin D doesn’t lead to weakness; maybe the weakness leads to low vitamin D. Vitamin D is the sunshine vitamin, and so, if you’re too weak to run around outside, that could explain the correlation with lower levels. To see if it’s cause and effect, you have to put it to the test.

There’s been about a dozen randomized controlled trials: vitamin D supplements versus sugar pills. Put all the studies together, and older men and women do get significant protection from falls with vitamin D, especially among those who start out with relatively low levels, leading the conservative USPSTF, the U.S. Preventive Services Task Force, the official prevention guideline-setting body, and the American Geriatric Society to recommend vitamin D supplementation for those at high risk for falls.

We’re not quite sure of the mechanism, though. Randomized, controlled trials have found that vitamin D boosts global muscle strength, particularly in the quads, which are important for fall prevention—though vitamin D supplements have also been shown to improve balance. So, it may also be a neurological effect, or even a cognitive effect. We’ve known for about 20 years that older men and women who stop walking when a conversation starts are at particularly high risk of falling. Over a six-month timeframe, few of those who could walk and talk at the same time would go on to fall, but 80% of those who stopped when a conversation was initiated ended up falling.

Other high risk groups that should supplement include those who’ve already fallen once, or are unsteady, or on a variety of heart, brain, and blood pressure drugs that can increase fall risk. There’s also a test called “Get-Up-and-Go,” which anyone can do at home. You time how long it takes you “to get up from an armchair, walk 10 feet, turn around, walk back, and sit down.” If it takes you longer than ten seconds, then you may be at high risk.

So, how much vitamin D should you take? It seems to take at least 700 to a thousand units a day. The American Geriatric Society recommends a total of 4,000 a day, though, based on the rationale that this should get about 90% of people up to the target vitamin D blood level of 75 nanomoles per liter. 1,000 should do it for the majority of people, 51%, but they recommend 4,000 to capture 92% of the population. Then, you don’t have to routinely test levels, since you would get most people up there, and it’s considerably below the proposed upper tolerable intake of 10,000 a day. They do not recommend periodic megadoses.

Because it’s hard to get patients to comply with pills, why not just give people one megadose, like 500,000 units, once a year, like when you come in for your flu shot, or something? That way, every year, you can at least guarantee an annual spike in D levels that lasts a few months. It’s unnatural, but certainly convenient (for the doctor, at least). The problem is that it actually increases fall risk—a 30% increase in falls in those first three months of the spike. Similar results were found in other megadose trials. It may be a matter of “too much of a good thing.”

See, “vitamin D may improve physical performance, reduce chronic pain, and improve mood” so much that you start moving around more, and, thereby, increase fall risk. You give people a whopping dose of D, and you get a burst in physical, mental, and social functioning, and it may take time for your motor control to catch up with your improved muscle function. It would be like giving someone a sports car all of a sudden when they’ve been used to driving some beater. You gotta take it slow.

It’s possible, though, that such unnaturally high doses may actually damage the muscles. The evidence they cite in support is a meat industry study showing you can improve the tenderness of steaks by feeding steers a few million units of vitamin D. So, the concern is that such high doses may be over-tenderizing our own muscles, as well. So, yeah, higher D levels are associated with a progressive drop in fracture risk, but too much vitamin D may be harmful.

The bottom line is that vitamin D supplementation appears to help, but the strongest and most consistent evidence for prevention of serious falls is exercise. If you compare the two, yes, taking vitamin D may lower your fall risk, compared to placebo. But, strength and balance training, with or without vitamin D, may be even more powerful.

(video ends)

So periodic annual or even monthly mega-doses may increase risk. What’s the best daily dosing? Let me share a study that came out after I finished that video that may be enlightening:

OK so what we’re looking at here is a year-long randomized double-blind placebo-controlled trial of seven different daily doses of vitamin D for elderly women who started out low in D, which found that the low doses appeared useless, 400 or 800 IU a day, but there was a significant reduction in fall rates among those taking the medium doses (1,600, 2,400, or 3,200 units a day), and a significantly higher fall rate taking 4,000 a day or 10,000 a day compared to the medium doses.

And a three year study found higher doses, 4,000 or 10,000 a day, may also lower bone mineral density

OK, let’s go back to the videos. When I say it’s better to get calcium from foods, most people immediately think dairy, but two videos ago you may have caught me saying “milk intake doesn’t appear to help, but maybe that’s because any potential benefit of the calcium in milk may be overshadowed by the increased risk of fracture and death associated with the galactose sugar in milk.” Wait, what? Let’s definitely address that:

(video begins — Is Milk Good For Our Bones?)

Milk is touted to build strong bones, but a compilation of all the best studies found no association between milk consumption and hip fracture risk, so drinking milk as an adult might not help bones. But what about in adolescence? Harvard researchers decided to put it to the test.

Studies have shown that greater milk consumption during childhood and adolescence contributes to peak bone mass, and is therefore expected to help avoid osteoporosis and bone fractures in later life. But that’s not what they found. Milk consumption during teenage years was not associated with a lower risk of hip fracture, and, if anything, milk consumption was associated with a borderline increase in fracture risk in men.

It appears that the extra boost in total body bone mineral density you get from getting extra calcium is lost within a few years, even if you keep the calcium supplementation up. This suggests a partial explanation for the long-standing enigma that hip fracture rates are highest in populations with the greatest milk consumption. Maybe an explanation why they’re not lower, but why would they be higher?

This enigma irked a Swedish research team, puzzled because studies again and again had shown a tendency of a higher risk of fracture with a higher intake of milk. Well, there is a rare birth defect called galactosemia, where babies are born without the enzymes needed to detoxify the galactose found in milk, so they end up with elevated levels of galactose in their blood, which can cause bone loss even as kids. So maybe, the Swedish researchers figured, even in normal people who can detoxify the stuff, it might not be good for the bones to be drinking it every day. And galactose doesn’t just hurt the bones. That’s what scientists use to cause premature aging in lab animals They slip them a little galactose and you can shorten their lifespan, cause oxidative stress, inflammation, brain degeneration, just with the equivalent of one to two glasses of milk’s worth of galactose a day. We’re not rats, though—but given the high amount of galactose in milk, recommendations to increase milk intake for prevention of fractures could be a conceivable contradiction. So they decided to put it to the test, looking at milk intake and mortality, as well as fracture risk, to test their theory.

A hundred thousand men and women followed for up to 20 years; what did they find? Milk-drinking women had higher rates of death, more heart disease, and significantly more cancer for each glass of milk. Three glasses a day was associated with nearly twice the risk of death. And they had significantly more bone and hip fractures too.

Men in a separate study also had a higher rate of death with higher milk consumption, but at least they didn’t have higher fracture rates. So a dose-dependent higher rate of both mortality and fracture in women, and a higher rate of mortality in men with milk intake, but the opposite for other dairy products like soured milk and yogurt, which would go along with the galactose theory, since bacteria can ferment away some of the lactose. To prove it though, we need a randomized controlled trial to examine the effect of milk intake on mortality and fractures. As the accompanying editorial pointed out, we better figure this out soon, as milk consumption is on the rise around the world.

(video ends)

Darn right we better figure this out!

With the then largest ever study on milk intake and mortality showing such adverse effects, Harvard researchers stepped in with three of their cohorts to form a study twice as big to see if what the Swedish findings were a fluke. Following more than 200,000 men and women for up to three decades, in 2019 they confirmed the bad news. Those who consumed more dairy lived significantly shorter lives. Every half serving more of regular milk a day was associated with 9% increased risk of dying from cardiovascular disease, 11% increased risk of dying from cancer, and an 11% increased risk of dying from all causes put together.

But wait, highly influential advocacy organizations, such as the U.S. National Osteoporosis Foundation or the Europe-based International Osteoporosis Foundation, continue to push dairy, drugs, and calcium supplements. Perhaps their objectivity is compromised by the influence of their commercial sponsors, which include companies that market (you guessed it) dairy, drugs, and supplements.

OK, so what foods may help out bones? Let’s turn to that next:

(video begins — Why Fruits and Vegetables May Reduce Osteoporosis Risk)

Even just a single extra serving of fruits and vegetables per day is associated with lower bone fracture risk. Why? Well, osteoporotic fracture risk is associated with higher levels of inflammation in your blood, for example C-reactive protein, and specifically, a more pro-inflammatory diet. Those eating higher on the dietary inflammatory index have about a 30% greater associated risk of osteoporosis and fracture than those eating more anti-inflammatory diets, and a higher intake of fruit and vegetables decreases inflammation. So that’s one possible reason.

Free radicals may also play a role in eating away at your bone, suggesting that pro-oxidant stress may contribute to osteoporosis. Both the total antioxidant power and capacity of people’s bloodstreams and diets are significantly lower in those with osteoporosis, And how do we squash free radicals and improve antioxidant status? With, fruits and vegetables. For example, consumption of vitamin C-rich foods is associated with lower risk of hip fracture, osteoporosis, and bone loss. Every additional increase of 50mg of dietary vitamin C a day, which is about the amount in one orange, may lower the risk of hip fracture by 5 percent.

The third way fruits and vegetables may help our bones are through acid-base balance. As we grow older, there’s a slight drop in the pH of our blood as our blood becomes more acidic with age. This is thought to be due to the waning ability of our kidneys to exCRETE excess acid. In vitro studies suggest a drop in pH may lead to activation of the cells that break down bone and an inhibition of cells that build bone back up. So how about eating alkaline-forming foods?

The most acid-forming foods are meat and cheese, especially fish, and the most alkaline, or base-forming foods, are fruits and vegetables. This may help explain why if you experimentally remove fruits and vegetables from people’s diets, a marker of bone formation significantly drops, and a marker of bone loss shoots up, and vice-versa when you then add fruits and vegetables back into their daily diets.

The greater the estimated ratio between acid-forming foods and alkaline-forming foods, the greater the risk of hip fracture, supporting the rationale to eat less acidic diets, but this was based on observational data. To prove cause-and-effect, two-year double-blind, randomized controlled trials were performed in which the three added servings of fruits and vegetables or the equivalent of six extra servings, failed to have an effect. But randomize people to the equivalent of nine daily servings of fruits and vegetables worth of an alkaline-forming compound, and you do see a significant increase in bone volume and density in the spine, hip, and throughout the whole body.

Are there any fruits and vegetables that are particularly good? That’s the question I’ll address, next.

(video ends)

OK so observational studies suggest fruit and vegetable consumption may help protect our bones, and an interventional trial of an alkaline load equivalent to 9 servings a day improved bone volume and density. Have any specific fruits or vegetables been tested? Yes, check it out:

(video begins — Onions and Tomatoes Put to the Test for Osteoporosis)

Feeding rats dozens of different foods, the fruit found to preserve their bones the best was the prune, and the leading vegetable was the onion. I’ve talked already about prunes. What about onions?

The country with apparently the highest per capita consumption of onions in the world is Turkey, which also has one of the lowest rates of osteoporotic bone fractures. Turkey may have four times greater daily per capita onion intake than the United States and four times lower hip fracture probabilities. Is that just a coincidence though?

The problem with trying to correlate country-by-country comparisons is that you don’t know if the people within those countries who are actually eating those onions are the ones who are actually avoiding fractures. But in 2017 a prospective study was published in which the fruit and vegetable intake of about 1,500 older women was followed for nearly 15 years and of all of the classes of vegetables, the intake of allium family veggies (such as onions, leeks, and garlic) were the ones most associated with lower risk of bone fractures.

Based on a study of non-Hispanic white women 50 years and older, those who ate onions on a daily basis had an overall bone density 5% greater than those who rarely ate them. That may sound like a lot, but could potentially translate into reducing the risk of hip fracture by more than 20%.

Why onions? Maybe it’s the quercetin. Onions are one of the most concentrated sources of this phytonutrient, which can stimulate the activity of our bone-building cells, at least in a petri dish, and is also a potent inhibitor of the formation of new bone-eating cells.

Or could it be the fructan-fiber-prebiotics in onions? Experimentally infused into the rectum, the short-chain fatty acids created by our fiber-eating gut flora have been shown to stimulate calcium absorption, so much so that adolescents randomized to the type of fiber found in onions—about an onion a day’s worth for a year, significantly increased their bone mineral density over the placebo group.

In the rodent bone preservation study, a number of spices beat out prunes and onions, with the top dog being another allium, garlic. And in the prospective human study, cruciferous vegetables like broccoli came in at a close second to the allium family. Although there are some petri dish data supporting the potential bone benefits of the sulforaphane in cruciferous veggies, inhibiting the formation of bone eating cells, and it appears to protect bone health in mice, the reason I’m singling out onions, is that it’s one of only two vegetables that have actually been put to the test in clinical trials.

But how are you going to come up with a placebo onion for the control group? That’s, why a group of innovative Chinese researchers gave people onion juice, versus a fake onion juice. (I don’t know which sounds worse, but, anything for science!) And, those randomized to the real onion group experienced an improvement in a marker of bone loss over the placebo, but the study didn’t last long enough to see if this translated into tangible bone benefits. But a clinical trial on the other vegetable put to the test, did.

The tomato story, starts out, like the onion story. There’s epidemiological support: In the Framingham Osteoporosis Study, higher intakes of lycopene, the red pigment in tomatoes, were associated with protection against bone loss in older men and women over a period of four years, as well as protection against hip fractures over seventeen years. Perhaps this helps explain why studies show that increased adherence to a more Mediterranean-style diet is associated with about 20% fewer hip fractures.

Then there’s laboratory evidence: Lycopene inhibits bone loss in a petri dish and preserves bone mass in rats. However, so does a green tomato extract, which is richer in compounds such as tomatine rather than lycopene, so maybe there are multiple protective factors in tomatoes. Anyway, let’s feed people some tomato products and see what happens!

Postmenopausal women randomized to lycopene in the form of about a cup and a third of regular tomato juice a day experienced a significant reduction in a marker of bone loss by month two, and the opposite was found after just a month of restricting lycopene consumption (so no tomatoes, watermelon, or other red fruits like pink grapefruit). This suggests that just regular dietary intakes are protective. But does this translate into retaining significantly more bone over time? Postmenopausal women given about two-thirds of a cup of tomato sauce a day for three months suffered significantly less bone loss than those in an age-matched group who didn’t, though it does not appear that the study subjects were assigned randomly, which could bias the results.

So, should we go out of our way to include these specific fruits and vegetables in our diet? Normally we’re just left with a “can’t-hurt” shrug, but a group of New Zealand researchers put together a randomized controlled trial to find out. They developed the Scarborough Fair Diet (named for the presence of presumptive bone-protecting herbs parsley, sage, rosemary, and thyme from the song popularized by Simon and Garfunkel). The diet included prunes, onions, and tomatoes. They compared that to a diet similarly packed with nine or more servings of fruits and vegetables, but ones that were not suspected as having particularly skeleton-saving properties. Markers of bone turnover were measured after three months, and the specially concocted diet of bone-preserving produce did no significantly better than the diet packed with non-bone preserving produce, or a diet with just 6 servings of fruits and veggies a day, suggesting that the focus should just be on stuffing your face with fruits and vegetables of any stripe.

(video ends)

So rather than picking or choosing specific bone-boosting produce, the bottomline, based predominantly on the acid/base study is to just probably eat more fruits and vegetables in general. Let us turn to exercise. What is the best type and frequency of physical activity for bone health?

(video begins— The Best Exercise Type and Frequency for Bone Density)

When it comes to bone health, it’s use it or lose it. Physical activity is considered a widely accessible, low-cost, and highly modifiable contributor to bone health. Exercise transmits forces through the skeleton, generating signals that are detected by your bone-building cells. This is why the National Osteoporosis Foundation, International Osteoporosis Foundation, and other agencies recommend weight-bearing exercises for the prevention of osteoporosis. These include high-impact exercises such as jumping, aerobics, and running, as well as lower impact exercises like walking and weight training to create those mechanical signals that spark bone growth, but sufficient intensity and frequency are critical. The large variation in bone benefit across different studies, from negligible changes to substantial improvements in bone mineral density, has been attributed to the adequacy of the exercise regime.

To improve measures of bone strength at the spine and hip, the most effective exercise training protocol appears to be a combination of progressive resistance and impact training at moderate to high intensity. Low intensity exercise does not appear to be sufficient. For example, while regular walking is often prescribed to prevent osteoporosis, it appears to offer limited benefit for bone loss prevention. On its own, walking has no significant effect on bone mineral density in the spine, wrist, or overall skeleton, but it has been shown to significantly improve hip bone density in studies that have lasted more than 6 months. More effective would be brisk walking, walking with a weighted vest, or combining walking with more vigorous exercises such as jogging, stepping, or stair-climbing. Non-impact activities such as cycling or swimming have been shown to have little or no effect.

An elegant study to determine the optimum frequency of high-impact exercise for bone health involved hopping on one randomly chosen foot, with the person’s other leg acting as the control. Women were randomized to hop 50 times on that one, same leg either seven days a week, four days a week, two days a week, or not at all for six months. And the brief, daily hopping increased hip bone density, but less frequent hopping was not effective. The only group who built significantly more bone in their hip on the jumping compared to non-jumping side within those 6 months was the seven-day-a-week group. If you jump 50 times with about a 10 pound weighted vest on, however, you may be able to preserve your hip bone density with just three sessions a week instead of every day.

Note, weight-bearing impact exercise may be contraindicated, meaning not advisable, in those with severe osteoporosis or recent history of fracture so make sure you check in with your medical professional before you get going.

(video ends)

I love that hopping study. Brilliant! The greatest benefit of exercise may have nothing to do with bone mineral density, though, as I explain the video I’ll close out on, entitled “The Single Most Important Thing to Do to Prevent Osteoporosis Bone Fractures”

(video begins — Fall Prevention Is the Most Important Thing for Preventing Osteoporosis Bone Fractures)

Bone mineral density screening may be a billion-dollar industry, but only 15% of low trauma fractures (meaning from a fall no more than from standing height) are due to osteoporosis in older women. Only 15% of fractures are due to having low bone density. Between the ages of 60 and 80, hip fracture risk increases 13-fold in men and women, whereas the age-related decline in bone mineral density accounted for only a twofold increased risk, so the contribution of declining bone density to the exponential increase in hip fracture risk with age is relatively small. The vast majority of our age-related rise in hip fracture risk appears to have nothing to do with the measured density of our bones.

Without a fall, even fragile hips don’t fracture. Falls are the primary cause of fractures—including vertebral fractures. The disparity between men and women in hip fracture rates is primarily not because men have stronger bones, but because women fall more often. Doctors just asking the simple question “Do you have impaired balance?” can predict about 40% of all hip fractures, more than a bone scan diagnosis of osteoporosis. Even a weak osteoporotic bone is strong enough survive normal life activities without the excessive loading that comes from a fall impact or, in the case of the spine, bending with your back to lift something rather than your knees.

The primacy of falls in fracture risk explains, a number of apparent osteoporosis paradoxes. For example, despite the fact that about 75% of your bone mass may be determined by your genes, the heritability of bone fractures appears negligible at older ages, (because the propensity to fall is much less inherited).

It also explains the poor predictive value of bone density screening for fractures. Adding bone mineral density measures to a hip risk score based just on age, sex, height, weight, the use of a walking aid, and cigarette smoking status did little to improve its predictive power. A provocative editorial published in the Journal of Internal Medicine entitled “Osteoporosis: The Emperor Has No Clothes” suggested that it would be safer and more effective to focus on fall prevention rather than pharmaceutical intervention.

Even though only about 5% of falls result in a fracture, falls are very common amongst the aged. Due in part to age-related muscle weakness, and loss of balance, more than a third of those aged 65 and older fall each year. After a hip fracture, fewer than 50% regain their pre-fracture function in terms of walking ability and independence. What can we do to prevent injurious falls based on dozens of randomized controlled trials? The single intervention most strongly associated with a reduction in fall rates? Exercise. So, exercise doesn’t just boost bone density. More importantly, it also reduces the number of falls over time by 23% and the number of fallers by 15%. So if you followed 1,000 people around age 75 for a year and 480 fell a total of 850 times without exercise, adding exercise would be expected to result in 72 fewer fallers and 195 fewer falls.

Tai Chi appears to reduce falls by 19%, balance and functional exercises (like sit to stand) may reduce falls by 24%, and multiple exercises—typically balance and functional exercise plus strength training—may reduce falls by 34%.

The reduced falls rate then translates into fewer fractures. A recent meta-analysis found that exercise interventions—mostly using a combination of resistance exercise to improve lower limb muscle strength training and balance training—cut fracture rates nearly in half. One year-long trial that combined strength training with step and jumping aerobics, and focused on balance and agility resulted in, 74% fewer fractures over the 5 year period after the study ended. Furthermore, more than 70% of the women in the combo exercise group went those five years without a single injurious fall, compared to less than half of those in the control group.

Trials on hip protectors, which cushion a sideways fall on the hip with plastic shields or foam pads sewn into special underwear, are often plagued with poor compliance. Studies have not found them to be useful for reducing hip fracture rates among those living at home, but trials in nursing homes or residential care facilities do show a small reduction in risk, translating into about 11 fewer people out of a thousand suffering hip fractures due to wearing hip protection.

There are also common-sense measures one can employ. Quality improvement trials involving interventions like patient education have shown a 10% reduction in fall rates. For example, keep things within reach so you don’t need use step stools. Use non-slip mats in the bath and shower, add grab bars in the bathroom, keep floors clutter free, remove small throw rugs or use double-sided tape to keep them from slipping, and make sure all staircases have handrails and adequate lighting. You could also avoid taking walks during inclement weather and for those who walk leashed dogs, consider choosing smaller breeds, or ensuring proper training to prevent them from lunging. Otherwise, the main ways to prevent fractures may not have changed much over the decades, since the classic paper entitled “Strategies for Prevention of Osteoporosis and Hip Fracture.” The main ways to prevent these fractures are to “stop smoking, be active and eat well.”

(video ends)

OK, so we have this bone mineral density-focused mindset in medicine for osteoporosis, because there are billions of dollars invested in scanning and drugging people to track and improve their bone density, but only a small percentage of hip fracture risk has anything to do with bone density. So it’s just like most of the risk of lifestyle diseases like atherosclerotic heart disease or high blood pressure has to do with diet and lifestyle, the money is in the drugs and procedures so that’s where our focus has been, but if we really just cared about people not breaking bones we would be focusing on falls, and we have this miracle intervention called exercise—resistance exercise to improve lower limb muscle strength training combined with balance training cutting fracture rates in half—beating out drugs, with only positive side effects.

(Q&A)

Thanks so much everyone for joining me. Stay safe, be kind, and eat your vegetables.

• All sources cited

Motion graphics by Avo Media

• bone health
• bone loss
• bone mineral density
• exercise
• osteoporosis