By Doug Bremner
Given the modest outcomes and risks of the bisphosphonate drugs it is natural that women would look to alternative approaches for bone density loss prevention. For a long time estrogen replacement therapy was hailed as a natural way to prevent bone loss associated with the loss of estrogen after menopause. The Women's Health Initiative (WHI) indeed showed that hormone replacement therapy (HRT) prevented bone loss and reduced the risk of osteoporotic fracture (WGWHII 2002). However HRT was found in this controlled trial to have unacceptable risks, including increasing the risk of breast, ovarian, and uterine cancer, as well as stroke, heart attack, and gall bladder disease. Overall the risks were greater than the benefits (Wassertheil-Smoller et al 2003).
Studies have shown modest increases in bone mineral density with soy but as yet have not evaluated effects on fractures. Observational studies have found a relationship between magnesium, which may be low in the diet of some elderly people, but as yet no randomized controlled studies of the effects of magnesium on bone density and fracture have been reported.
Doctors routinely recommend supplementation with calcium and Vitamin D to prevent osteoporosis and bone fractures in postmenopausal women. Taking calcium increases calcium in the blood, making more available for uptake into the bone. With normal aging, there is a decrease in calcium absorption by the stomach. Vitamin D (cholecalciferol) is known increase calcium absorption in the gut, as well as acting synergistically with calcium to promote bone density. This has led to the common practice of prescribing calcium and Vitamin D supplementation for the prevention of hip fractures. It sounds so good and all makes logical sense, and it can't hurt, so why not go ahead and do it?
However, just because you become deficient in something with aging, doesn't mean that supplementation will correct the problem. Studies have shown that calcium and vitamin D supplementation in people over age 65 increased total bone density, but not necessarily in areas that matter, like the femoral neck, which causes hip fracture (Dawson-Hughes et al 1997). Moreover, the changes in bone mineral density in areas like the femoral neck, were present only for men, and not women. This is important since osteoporotic fractures primarily affect women. The only studies which showed that calcium and Vitamin D prevented hip fractures were done in French women who had osteoporosis and were living in nursing homes (Chapuy et al 1994). However these women may have calcium and/or Vitamin D deficiency due to diet or lack of sunlight from being in a nursing home.
Other studies in individuals outside nursing homes found no beneficial effects from Vitamin D and calcium supplementation in terms of hip fracture prevention (Porthouse et al 2005). One study of patients who had a fracture and became immobile did not find any benefit of Vitamin D and calcium in the prevention of secondary fractures (RECORD 2005). The Women's Health Initiative (WHI) included 36,282 premenopausal women age 50 to 79 who were randomly assigned to receive 1000 mg of calcium with 400 IU of Vitamin D-3 or placebo with a follow-up of 7 years for assessment of bone fracture. Supplementation did not reduce the risk of hip fracture. Although there was an increase in hip bone density, there was also an increase in kidney stones (Jackson et al 2006). Since increasing hipbone density has no practical benefit and is not related to reducing the risk of hip fracture, while increasing kidney stones is definitely negative, I do not recommend these supplements.
Eat a well-rounded, balanced diet with fruits, vegetables, and a moderate amount of cheese, yogurt and other dairy products, and you should get enough calcium in your diet to minimize bone loss with aging.
In the wintertime take long walks in the sun-this will stimulate Vitamin D production (most Vitamin D is generated internally after exposure to the sun). If someone in your family is elderly and doesn't get out much or is confined, wheel them out of doors so they can get some sun exposure.
Physical activity and exercise plays a dramatic role in prevention of fractures. Studies have shown that the simple act of aging is ten times more important in terms of fracture risk than bone mineral density.
The most critical thing to do to prevent fractures is to keep active. Loss of muscle strength is part of aging, but we can profoundly delay these effects through active exercise. It is clear from the studies that the people who get hip fractures are those who become frail and inactive, and more likely to fall.
In fact, osteoporotic fractures of the hip are inversely related to exercise. Furthermore, although bone thinning contributes to the risk of fracture, it is primarily related to a loss of balance and falling, which is also maintained by exercise in old age. In fact, there is no difference in bone density between those with and without fractures.
The best exercise for increasing bone-mass is strength training. Numerous studies demonstrate that engaging in regular resistance exercises increase bone mass, most especially spinal bone mass. A research study by Ontario's McMaster University found that a yearlong strength-training program increased the spinal bone mass of postmenopausal women by nine percent. And it found that women who do not participate in strength training lose bone density.
The good news is that you do not have to become an Iron Man to derive benefit from resistance and weight training. A whole variety of exercises yield bone-building benefits, although working with weights at a gym with a trained professional is one safe way to get into this form of activity, especially if you have never done it before. Weight lifting, even with as little as 2, 5, or 10 pound weights to start, dancing, stair-climbing, walking on an incline (uphill), and brisk walking are all weight-bearing exercises, which promote mechanical stress in the skeletal system, can contribute to the placement of calcium in bones.
How does this work? When you are doing weight bearing exercise, you are exerting force on parts of your bones. The body reacts to this by stimulating osteoblasts, those cells that are responsible for laying down calcium in the bone and building up the bones. The body is in effect responding to the message that more bone strength is needed, much as it does when it increases muscle mass and tone with exercise. And the good news is that it builds up bone strength in a better way than bisphosphonates. Rather than randomly laying down calcium in parts of the bone that may not greatly enhance the strength of the bone, like bisphosphonates do, exercise results in a laying down of calcium in parts of the bone that matter. And what is more, the effects don't wear off after five years.
While good for your cardiovascular system and overall health, aerobic exercises such as biking and swimming do not strengthen the bones. If you can do both forms of exercise, good for you! If not, and you are heading toward menopause, or are menopausal, focus on strength training - it does give you some aerobic benefits. A moderate investment of time is all that's needed - 15 to 30 minutes of weight training, two to three times per week provides the bone density you need to prevent osteoporosis if you work all your different muscle groups and let your muscles rest for a day between workouts. Of course, it's great if you can start resistance training before you enter menopause, but even if you start later you will avoid the expected loss of bone and even increase bone density slightly.
So what is the bottom line for preventing osteoporosis without prescription medications?
First things first, diet and exercise.
Based on the evidence I also do not recommend getting BMD or screening X-rays for vertebral "fractures" which you don't know about, since I don't think these represent fractures in the way you and I think of them, more than a settling of the vertebrae, which is part of normal aging.
Instead of getting screenings I recommend that you follow my advice for prevention.
Men should not be treated for osteoporosis.
If don't have a history of fracture, you shouldn't get your bone mineral density checked and you shouldn't consider treatment for osteoporosis.
Don't ever use raloxifene, teriparatide, or calcitonin for osteoporosis treatment. The risks outweigh the benefits.
Women who have a painful fracture can consider getting your bone mineral density checked. If you are found to have osteoporosis you can talk to your doctor and consider taking bisphosphonates. Think about what I have said here, put that together with your own situation and make your own decision.
Don't feel like you have to take drugs. If you do take them don't do it for more than five years.
Chapuy MC, Arlot ME, Delmans PD, Meunier PJ (1994): Effect of calcium and cholecalciferol treatment for three years on hip fractures in elderly women. British Medical Journal 308:1081-1082.
Dawson-Hughes B, Harris SS, Krall EA, Dallal GE (1997): Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. New England Journal of Medicine 337:670-676.
Jackson RD, LaCroix AZ, Gass M, et al (2006): Calcium plus vitamin D supplementation and the risk of fractures. New England Journal of Medicine 354:669-83.
Porthouse J, Cockaynes S, King C, et al (2005): Randomised controlled trial of calcisum and supplementation with cholecalciferol (vitamin D 3) for prevention of fractures in primary care. British Medical Journal 330:1-6.
RECORD (2005): Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium Or vitamin D, RECORD): a randomised placebo-controlled trial. Lancet 365:1621-1628.
Wassertheil-Smoller S, Hendrix SL, Limacher M, et al (2003): Effect of estrogen plus progestin on stroke in postmenopausal women: The Women's Health Initiative: A randomized trial. Journal of the American Medical Association 289:2673-2684.
WGWHII (2002): Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women's Health Initiative Randomized Controlled Trial. Journal of the American Medical Association 288:321-333.
Learn more about alternatives to medications and hidden risks of prescription medications in
'Before You Take That Pill: Why the Drug Industry May be Bad for Your Health: Risks and Side Effects You Won't Find on the Label of Commonly Prescribed Drugs, Vitamins and Supplements', by researcher and physician J. Douglas Bremner, MD.
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