View the original NY Times article here, published June 1, 2016 by Gina Kolata.
“Last month, three professional groups, the American Society for Bone and Mineral Research, the National Osteoporosis Foundation and the National Bone Health Alliance — put out an urgent call for doctors to be more aggressive in treating patients at high risk, and for patients to be more aware of the need for treatment. It followed a flurry of recent articles in medical journals documenting and bemoaning patients’ abandonment of traditional osteoporosis drugs. But osteoporosis experts are afraid their efforts will do little to change minds.”
The The New York Times article pointed out that there are many people who have advanced osteoporosis that are not getting the treatment they need, medications. They do not define high risk in the article, but let’s assume they mean high risk of fractures. I agree with this assertion. As an alternative doctor I am frequently asked about alternative ways to treat osteoporosis. For those who have a high risk of fracture, and especially for those who have sustained a low-force fracture, I recommend a full court press – conduct a nutrition/dietary analysis, rule out secondary causes, and improve gastrointestinal health. And yes, medications should certainly be on the table.
On the other hand, how many people are taking osteoporosis medications that do not need to be on them? No studies that I am aware of look at this problem. I think that a large percentage of people who are prescribed osteoporosis medications do not meet the “high risk” criteria. As a result, these patients are being exposed to potentially harmful side effects unnecessarily.
When Fosamax first came on the scene in the 1990s, it was widely prescribed to treat osteoporosis and also prescribed to prevent osteoporosis. Then, years later the risk factors for osteonecrosis of the jaw and atypical femur fractures were discovered to be a side effect of long-term use of this type of medication. That experiment did not work out so well for the “small percentage” of people who suffered the horrendous femur fractures and areas of jaw bone death we hear discussed today.
It is also important to keep in mind that bone density measurements – which play a large part in a doctor’s diagnosis about the severity of a patient’s osteoporosis – forms only part of the bone health picture (albeit a big piece). In fact, some people can have normal bone density and sustain a fragility fracture of a major bone. This too should alert you and your doctor that something may be wrong with your bones and that something may be bone quality. Poor diets, smoking or other health conditions such as Celiac disease (gluten intolerance) can impact bone quality negatively. One way to think about bone quality is flexibility. Can your bones withstand impact, bend a little? The same issues above over time can also result in bone loss. In my opinion, all of these issues that affect both bone density and bone quality should be addressed before considering medications.
We hear about atypical fractures of the femur (thigh bone) because they are so rare. Are there other fractures that are caused by long-term BP use? We do not hear about other fractures because it's hard to prove. Let me give you a couple of examples from people I know. One started on Fosamax when she had a low bone density reading (osteopenia) and had no fractures. Seven years later her sacrum broke in two and she had fractures in her pelvis. I do not think that she would have sustained these fractures had she not been on the medication for seven years. Can I prove this? No, but I have seen a number of cases that are in this category. Another woman I know was on Fosamax for 10 years, so you would think that her spine would be able to withstand walking through her kitchen. However, one of her vertebrae flattened with no trauma. There is no way to definitively link these kinds of fractures to the use of medications because yes, they can happen to people who have never taken bone medications. The only one we can really attribute to long-term use of osteoporosis medications is the atypical femur fracture. And, what these fractures represent is poor bone quality, extremely low bone density or both. In the examples that I used here both women had only low bone density not osteoporosis.
What can patients do?
Patients need to learn what I call being, “bone literate” meaning:
From my point of view nutrition and exercise should always be part of every bone health program. If the osteoporosis is so severe that patients are fracturing easily, then exercise should be significantly limited. Some people with osteoporosis, no history of fractures, and a low fracture risk can maintain a robust exercise program.
At the same time, however, I agree with endocrinologist and bone specialist Dr. Steven Harris regarding his concern about the promotion of diet and exercise for patients with fragile bones, which, he said, is insufficient to protect them from fractures. He also notes that it gives people a false sense that they can control their risk. He is right about this and I too have had many conversations with people who are so frightened about taking medications that they do not realize that they are putting them selves at great risk by not taking them.
It is very difficult to gain significant bone density as we age especially after the age of 35 and with each decade it is even more difficult. However, we can take steps to improve bone quality and some of us can gain some bone density, but it takes serious work and it will not reverse advanced osteoporosis.
We can make a difference in our bone health though diet, exercise and healthy digestion.Studies have shown that people in nursing homes who were given more protein reduced their fracture risk, for example.
From my point of view, I do think that most of us can impact the health of our bones at any time in our lifes, but we cannot reverse advanced osteoporosis with fragile bones through nutrition and exercise alone. I think we need to blend the best that natural medicine has to offer and be grateful that Western medicine can intervene in serious osteoporosis cases.
What can shed light on the condition of an individual’s bone health is to do good detective work with our health care providers and determine whether or not active bone loss is occurring. It’s equally important to do proper lab tests and other evaluations to see if there is a secondary cause for bone loss.
An example of a secondary cause for bone loss and osteoporosis: A parathyroid tumor that is causing your blood calcium to be high. High blood calcium is never a good thing and should be addressed. Treatment for the tumor is to remove it. Once removed some people will actually gain some bone density on their own. However, the gain may only be about 8% and does not mean that someone with advanced osteoporosis will not need medications to maintain their physical independence.
There is a lack of bone literacy even in the health care field. Most doctors do not know how to thoroughly assess bone health through a full evaluation, including lab work. An example of this problem is when doctors recommend medications to patients who are at low fracture risk with borderline osteoporosis or low bone density (osteopenia) and no fractures. For some small-boned people, low bone density can be normal because of their small skeletal structure; and in fact, they may not have actually lost bone density. The size of your bones is not taken into consideration by the automatic analysis of the DXA machine that is used to evaluate bone density.
What we do need is for health care providers to do a thorough workup on those at risk – and especially for doctors who are prescribing medications to be fully trained on all the medications available and whether or not they are appropriate. Everyone’s bones are different and should be viewed that way.
Informed patients can be in the drivers seat and work with their doctors to make the best decisions about their bone health - remember to be INformed, INquisitive (not combative) and INsistant if your doctor is not carefully assessing your case. It is not possible to assess bone health in a 30 minute appointment.
A complete bone health assessment should include lab work, a 5-7 day diet diary that also includes notes on gastrointestinal symptoms.
Nutrition matters, gastrointestinal health matters and so does exercise - you need to learn where in the spectrum of osteoporosis you are.