Bone health

Rethinking the nature of osteoporosis and osteopenia

by Dr. Susan E. Brown, PhD

I first started researching osteoporosis because of two personal experiences that ignited my interest in bone health. The first was my grandmother’s death at the age of 102 after a hip fracture. The second was when I was told at the age of 36 that I had receding gums, which I knew was an early sign of osteoporosis.

As a scientist, asking questions comes naturally to me. So I immediately wanted to know if the common beliefs about a lack of calcium and estrogen causing osteoporosis, and low bone density causing fractures, were true. What I’ve discovered has caused me to totally rethink osteoporosis — and osteoporosis treatment.

Take calcium for example. Women and men in other countries, who have much less calcium in their diets than we do, do not see the high rates of osteoporosis that we experience in the United States. In fact, research shows that cultures with the highest calcium intake have the highest hip fracture rates! The popular assumptions about osteoporosis simply aren’t the whole story.

If you’ve been diagnosed with osteoporosis, osteopenia, or receding gums, or if you simply want to prevent these bone issues, you’re probably looking for answers just as I was — trying to find out how to avoid brittle bones and fractures without turning to HRT, Fosamax, or other prescription bone drugs. When we look at osteoporosis in relationship to the whole body, instead of viewing it as a disorder strictly limited to bone, we see that there are many natural ways to restore and maintain bone health no matter what your age — 2 to 102!

Let’s take a new approach to osteoporosis and osteopenia, so you can understand how preventing and treating osteoporosis involves more than increasing bone density or taking calcium and estrogen.

Osteoporosis definitions and diagnosis — then and now

Many women are confused about the definitions of osteoporosis and osteopenia. The confusion may stem from the fact that these definitions keep changing over time, not to mention the fact that osteopenia wasn’t even heard of 20 years ago. In 1980, the World Health Organization defined osteoporosis as follows:

A chronic fellow progressive condition associated with micro-architectural deterioration of bone tissue that results in low bone mass. As the condition progresses there is an increase in bone fragility and consequently increases in susceptibility to fracture.

As recent as 1993, an individual was diagnosed with osteoporosis only after he or she fractured as an adult in a nontraumatic event.

Then in 1994 an expert panel of the World Health Organization recommended using bone mineral density (BMD) to diagnose osteoporosis. This panel defined “normal bone” as having the average bone density of 25-year-old adults (plus or minus 1.0 standard deviation). Women with bone mineral density values well below this standard (specifically, 2.5 standard deviations below the average) receive an osteoporosis diagnosis, regardless of whether they have fractured a bone. And those who have fractured have what is known as “established osteoporosis.”

In addition, the WHO panel created a new diagnosis, osteopenia, for individuals whose bone mineral density was lower than the average young adult but not in the range of osteoporosis (between 1.0 and 2.5 standard deviations below the average).

The problem with these diagnoses is that osteoporosis is a disease of bone fragility, not simply bone density. The latest research shows that being diagnosed with low bone density doesn’t answer the most important question: what are the chances of fracturing?

Bone mineral density does not predict fractures

For decades doctors and scientists have assumed that osteoporotic fractures happened because bones were thin. They were confident that once bone reached a certain level of thinness (that is, 2.5 standard deviations below the average BMD of 25-year-old females), it was subject to fracture more easily. The thinking was that if we could measure bone density we would be able to predict who would experience an osteoporotic fracture and intervene before this happened.

But almost three decades later, we realize that we cannot predict fracture based only on measurements of bone density because bone does not fracture due to thinness alone. We know this because more than half of the people with thin, “osteoporotic” bone never fracture, while many people with normal bone density do. For example, a study done in 2005 followed more than 8000 women aged 65 and older to assess hip fractures over five years. Out of those women who fractured (243), 54% did not have osteoporotic bone density. Bone density is only one piece to a much more complex picture.

Any definition of osteoporosis, in my opinion, should contain these five criteria:

1. low bone mass
2. architectural deterioration
3. bone fragility
4. poor self-repair
5. higher susceptibility to fracture

Redefining osteoporosis: poor bone self-repair

Regeneration is an important piece of the osteoporosis equation, and one that has been greatly overlooked. Healthy bone is constantly breaking down and rebuilding areas that are worn out and damaged. When bone isn’t healthy, often these self-repair mechanisms become uncoupled, which leads to weakness in the bone structure.

We all understand that roads and bridges remain stronger and intact for longer periods with routine maintenance. Likewise, women with thin bone who have great self-repair mechanisms most likely won’t fracture because they are consistently replacing old bone with newer, stronger bone. This may, in fact, be the case with Chinese and Japanese women, who have thinner bone mass than those of us in the United States but suffer fewer fractures than we do — even into old age.

On the other hand, some bone may “look” dense but still be susceptible to fracture. For example, in a person who has been treated with fluoride, the bone matrix may appear dense with fluoride deposits, but fluoride in the matrix just isn’t as strong as a calcium matrix, so this person may be just as likely to fracture as a woman with a low bone density — or even more likely to fracture than a person with low bone density who has great bone self-repair.

So what about calcium and estrogen?

New research is also transforming the way we think about the causes of osteoporosis. Our bones are largely made of calcium. And one of estrogen’s many responsibilities in the body is to conserve calcium. It does this by increasing calcium absorption and inhibiting the loss of calcium from your bones. Estrogen can also inhibit a bone breakdown hormone called parathyroid hormone. These bare facts make it seem logical that a lack of calcium and estrogen lead to osteoporosis and osteopenia. This was what conventional medicine thought for years, and menopausal women were put on estrogen replacement therapy and supplemental calcium — often without much further thought.

But, as I mentioned above, there are plenty of other cultures who don’t consume as much calcium as we do nor take supplemental estrogen, yet maintain healthy bones throughout life. Research and clinical practice show that calcium is indeed needed for healthy bones, but the amount of calcium you need depends on many other factors. Such factors include intake of other bone-building nutrients, level of sunlight exposure, exercise, and genetics, as well as bone-depleting behaviors like high protein, sugar, fat and salt intake; and tobacco, alcohol or prescription drug use and abuse. Ovary and uterus removal and endocrine system function also play into the amount of calcium an individual needs. So there is much more to preventing osteoporosis and osteopenia than simply adding calcium.

And putting women on estrogen after menopause is based on the assumption that nature made a mistake when tapering our estrogen production after our fertile years. In my opinion, the reason we produce less estrogen is because we don’t need as much estrogen once we’ve passed the childbearing and breastfeeding years. In its wisdom, the body doesn’t waste its efforts. I’ve found that the best results for bone health come when you investigate the whole picture.

A broader perspecitive on fracture risk

The World Health Organization just recently developed a new fracture risk assessment tool, known as FRAX. This web-based tool should be helpful in predicting the ten-year risk of osteoporosis fracture in women (and men) by taking into account several risk factors.

Several studies have been done to determine the most helpful risk factors. Here are 11 key factors that the Women’s Health Initiative found helpful in determining fracture risk:

• age
• self-reported health
• weight
• height
• race/ethnicity
• self-reported physical activity
• history of fracture after age 54
• parental hip fracture
• current smoking
• current corticosteroid use
• treated diabetes

The new FRAX tool adds rheumatoid arthritis, type 1 diabetes, and consumption of alcohol to the list of variables. As more questions are asked and more research is done, I’m sure there will be many more factors added to these lists. From my clinical experience, I would add high bone resorption (breakdown) rates, low serum levels of vitamin D, low serum levels of vitamin K, and the use of various additional prescription medications.

Rethink osteoporosis, and you’ll rethink osteoporosis treatment

We are entering a new and exciting time in bone health. Conventional medicine is starting to realize that osteoporosis is not just about bone density or about calcium or estrogen. In fact, the US Surgeon General wrote in his report on bone health and osteoporosis:

A healthy skeletal system with strong bones is essential to overall health and quality of life... With appropriate nutrition and physical activity throughout life, individuals can significantly reduce the risk of bone disease and fractures.

We’ve started to look at other factors affecting bone health, including inflammation, stress, and the pH of the blood, as part of the overall picture. Our bones work with the entire body, so it makes sense that factors other than bone density are involved in bone health.

Naturally, a better understanding of the causes of osteoporosis and the factors that weaken bone will also change the way we think about treating osteoporosis and preventing fractures. We know that supplemental calcium and estrogen replacement aren’t enough, and we’re starting to understand why bone density drugs aren’t the answer either.

Bone density drugs (bisphosphonates) are designed to increase bone mineral density, but they are not designed to enhance the vital self-repair process of bone. In fact, research shows that within one year of using osteoporosis medication the self-repair process stops altogether. This may explain why they offer limited fracture prevention, and have even contributed to some unusual fractures in women who have used the drugs for more than five years.

Bisphosphonates treat bone density, but remember, bone density usually is not be the real problem! I recommend that women carefully weigh the risks of bisphosphonates against the limited benefits. If you and your healthcare provider decide to use a drug for your bone density, consider it a complement to your bone health regimen, rather than a stand-alone treatment method. Fortunately, the vast majority of women can prevent fractures without the use of drugs by targeting the causes of weak bones.

A final word on taking control of your bone health

Contrary to what the media or even your doctor might be telling you, the high rates of osteoporosis and osteopenia in America are not a result of our population living longer. Our bones are able to last a lifetime with the right support. When we take a closer look at osteoporosis and osteopenia, it’s clear that thin, substandard bone and higher fracture risks are the result of many factors. Our modern lifestyle and diet don’t help. But simply adding calcium or taking Fosamax are not the answers.

Preventing and treating osteoporosis involves a new way of thinking about your body. It involves looking at your bones as one part of the whole system. And working with that system means working with nature to build and maintain healthy bones and healthy bodies. It’s never too late nor too early to lessen your bone burden.

Our Personal Program for Better Bones is a great place to start

The Personal Program for Better Bones promotes natural bone strength and regeneration with nutritional supplements, our exclusive bone builder formula, dietary and lifestyle guidance, and optional phone consultations with our Nurse-Educators. It is based on over 25 years of research and experience and has helped thousands of women reclaim their bone health.

• To learn more about the Personal Program for Better Bones, go to How it works.
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If you have questions, don’t hesitate to call us toll-free at 1-800-685-3275. We’re here to listen and to help.

 

Original Publication Date: 01/01/2009
Last Modified: 08/17/2009
Principal Author: Dr. Susan E. Brown, PhD