As an anthropologist, I have the opportunity to study how different cultures react to change. I enjoy seeing how an idea that at first seems impossible or “radical” eventually becomes accepted by the mainstream.

For example, in January of 1992, AT&T released the first video-telephone, costing a mere $1,499. How many of us realized then that 20 years later it would be common to be video chatting on our cell phones… even on a daily basis?

Thinking back to my work 20 years ago, I was one of the few advocating that there was more to osteoporotic fractures than low bone density and also, that women had natural options to strengthen their bones. Now, let me be clear, I wasn’t saying these things because I was a genius — I was saying them because they were supported by impressive research. But then, as timing would have it, the natural approach became overshadowed with the approval of Fosamax in 1995.

That’s why I was delighted recently to see that leaders in the field are now expanding their perspective regarding what is the best approach for bone health. In a January 18, 2012 article in The New York Times titled “Patients With Normal Bone Density Can Delay Retests, Study Suggests,” medical reporter Gina Kolata writes that the study, which was published in The New England Journal of Medicine, “is part of a broad rethinking of how to diagnose and treat” bone loss.

Kolata then points out how the medical community itself isn’t convinced bone drugs are your best option for bone health. To be exact, Kolata writes “…medical experts no longer recommend the medicines (bisphosphonates) to prevent osteoporosis itself. They no longer want women to take them indefinitely, and no longer consider bone density measurements the sole defining factor in deciding if a woman needs to be treated.”

I am also impressed by Dr. Ethel S. Siris, an osteoporosis researcher at Columbia University interviewed by the Times, who noted that osteopenia is a risk factor, not a disease. I am hoping to talk with Dr. Siri about her work in an upcoming blog post.

I find it encouraging that attitudes seem to be shifting away from such a narrow view of bone health. Let’s hope that the “radical” thoughts about bone drugs and bone health advance as quickly as phone technology!

References:

The New York Times, Kolata, G. Patients With Normal Bone Density Can Delay Retests, Study Suggests, http://www.nytimes.com/2012/01/19/health/bone-density-tests-for-osteoporosis-can-wait-study-says.html?_r=1,(Accessed 01.31.12)

Gourlay, Mararet L, M.D., M.P.H2012. Bone-Density Testing Interval and Transition to Osteoporosis in Older Women. N Engl J Med 2012; 366:225-233 http://www.nejm.org/doi/full/10.1056/NEJMoa1107142 (Accessed 01.31.12)

Today, I read with dismay The New York Times’ health column about vertebral compression fractures. In my opinion, it presented an inaccurate picture of what’s happening when it comes to spinal fractures. I want to address some of the points that stood out for me because I feel this article spreads a lot of fear where it’s just not necessary — and as I mentioned in a recent post, fear itself is damaging to bone!

First, let’s look at the statement that “by age 80, two in every five women [or 40%] have had one or more vertebral compression fractures.” Similar statistics have been bandied about for years, but when I took the time to look for hard data supporting them a few years ago, I found it very difficult to substantiate such high numbers. The sole large-scale study that looked at long-term risk of vertebral fractures, a review by J.A. Cauley and colleagues that came out in 2007, actually debunks this statement. As I noted in my article on spinal fractures at the time, "The results of this study suggest that earlier estimates of spinal vertebral fracture incidence have overestimated real fracture incidence. Over fifteen years, from age 68 to 84, only 18% of all US Caucasian women experienced a vertebral fracture. Overall, counting those who entered the study with an existing vertebral fracture, a little over 26% of all women had radiological evidence of a spinal fracture by age 84. This figure is significant, yet not as worrisome as the 35‐50% estimate previously reported."

I also take issue with the statement that “vertebral fractures are a telltale sign of bone loss.” They’re not — they’re a sign of bone weakness, and there is a difference between the two! While low bone density does increase the risk of fracture, most fractures occur in persons whose bone mineral density is above the osteoporotic range. The strongest predictors of fracture in the Cauley study were advancing age, having low body weight, and the presence of a prior bone fracture — not low bone mineral density.

Now, I have been arguing for years that bone mineral density alone doesn’t predict fracture risk, and the study on which this article is based seems to agree with that assessment on its surface. The study’s authors note that the presence of vertebral fractures in women whose bone density isn’t osteoporotic means that the true diagnosis should be osteoporosis, not osteopenia — and with that, I’d agree. But the follow up statement shows where all this is truly headed: “Asked if such women should receive bone-preserving medication, Dr. Ensrud said emphatically, ‘Yes!’” This position is in direct contrast to the recommendations of the U.S. Surgeon General — that persons with bone loss should be directed to make changes to their dietary and exercise habits first, then assessed and treated for the cause of the bone loss, and then put on bone medications if the situation warrants. (The implicit assumption of Dr. Ensrud’s response is that bone drugs are always warranted.)

The idea of looking for the causes behind skeletal weakness is not even suggested, and the word “exercise” doesn’t appear in the New York Times’ article until the very last line. Yet numerous studies show low vitamin D levels to be a major cause of bone loss and weakening among most of those who fracture. Exercise, as countless more studies have shown, should be the first line of defense against osteoporosis and fractures — and considering that a Mayo Clinic study has shown a 300% reduction in risk of new vertebral fractures from simple back strengthening exercises (far more than ANY bone drug can claim), it is disturbing that Fosamax is mentioned so much more prominently than exercise.

I could go on (and on), but rather than write a novella, I’ll state my primary issue thus: The overall message is that multitudes of postmenopausal women are destined to fracture in their spine, and that they should immediately be given bone drugs for even a minor, unfelt, spinal deformity defined as a “fracture”. I would hope for a more balanced, public-interest analysis of this important health issue from one of the most important news outlets in the United States, if not the world.

One other note before I stop — I also find it troubling that all of these messages are aimed primarily at women. Studies in the U.S., Canada, and several European countries show that older men often have “silent” vertebral fractures (only seen upon X-ray) just as frequently as women do, yet the article makes no mention of looking for these hidden fractures in men and giving them drugs for these symptom-less vertebral deformities.

But here’s the bottom line: women and men with osteoporosis, even those found to have a “silent” symptom-less vertebral deformity in old age, need not automatically be given bone medications. It has been the position of the U.S. government’s top health official for most of the past decade that medication is the last resort, not the first! And that is a message that I hope all my readers get — and pass along.

References

Brody, J.E. 2011. Along the spine, women buckle at breaking points. New York Times June 27, 2011. URL: http://www.nytimes.com/2011/06/28/health/28brody.html (accessed June 29, 2011).

Cauley, J. A., Hochberg, M. C., Lui, L. Y., et al. 2007. Long‐term risk of incident vertebral fractures. JAMA 298(23):2761‐2767.

O'Neill T. W., Felsenberg D., Varlow J., et al. 1996. The prevalence of vertebral deformity in european men and women: the European Vertebral Osteoporosis Study. J. Bone Miner. Res. 11:1010.

Brown, S. E. 2008. Spinal vertebral fractures among US Caucasian women: New statistics and new insights. URL: http://www.betterbones.com/bonefracture/spinalvertebralfracture.pdf.

Davies K. M., Stegman M. R., Heaney R. P., Recker R. R. 1996. Prevalence and severity of vertebral fracture: the Saunders County Bone Quality Study. Osteoporos. Int. 6:160.

Quite frequently women write me to ask: what is strontium and why do you include it  in your Better Bones Builder product?

Well, there’s a short answer and a long answer to that question. Here’s the short answer: Strontium is an element very much like calcium and naturally present in our food and water. A common diet might contain anywhere from one to more than 10 mg of strontium per day. The reason it’s in the Better Bones Builder is that the elemental form (that is to say, the non-radioactive version found in nature) has been shown to promote formation of healthy teeth and bones. So it makes sense to include dietary doses of strontium in comprehensive bone-building formulas such as our Better Bones Builder supplement, because low-dose strontium is a companion nutrient that works with calcium and other minerals to promote bone health.

Now let’s get to the long answer. Where confusion sets in is when people hear about strontium being used by itself to build bone. What most people don’t realize when they read about strontium as “the” solution for bone health is that such talk isn’t referring to dietary doses of elemental strontium — most often, it’s referring to the extremely high-dose strontium that has been developed and patented as a drug therapy for osteoporosis in Europe. This drug, known as Protelos®, contains 680 mg of elemental strontium in 2 grams of strontium ranelate, a synthetic salt that combines strontium with ranelic acid.

One goal of  Protelos is for a small number of strontium atoms to displace calcium atoms in bone. For this effect it is necessary that the strontium drug be taken at least two hours apart from calcium. (This is not necessary for lower dose strontium that is used as a nutrient aiding the development of healthy bones.) Unlike lower doses of strontium, a higher dose may come with side effects like nausea, diarrhea, and, very rarely, memory problems and venous clots. Nonetheless, high-dose strontium osteoporosis therapy has a much better safety record than the bisphosphonate drugs used the U.S. and Canada.

Although Protelos is not available in the U.S. or Canada, we can purchase equally high dose natural forms of strontium as strontium citrate or strontium carbonate — but I hasten to add that you shouldn’t start taking high doses of strontium (or anything else!) without consulting your doctor first!  Keep in mind that high-dose strontium is a bone drug, and, as with all bone drugs, it should only be used when there is a clear high risk of fracture. High risk is defined as a 20% likelihood of a major osteoporotic fracture over the next 10 years.

Some clinicians suggest that strontium citrate (or carbonate) is as effective as the strontium-based drug, but further research needs to be done. Similar to bisphosphonates, we do not know the long-term impact of high-dose strontium on bone and fracture risk. Currently, clinical trials of strontium ranelate have only extended to five years, and the fracture risk efficacy at five years is substantially less than that at two or three years. We do know that high-dose strontium is the safest of all osteoporosis drugs, although not the most potent. So it’s worth talking to your doctor about using strontium if you are at high risk for fracture.

I hope this helps clear up the confusion when it comes to strontium. I will be writing more on strontium in the future, so stay tuned!

Best wishes to everyone.