Arresting Bone Loss in a post-menopausal woman

Arresting Bone Loss in a Post-Menopausal Osteoporotic Woman without the Use of Bisphosphonates

 

L. Kelly

 

Abstrac

There are many dietary recommendations to assist with the treatment of osteoporosis – and some appear to be helpful. However, none has emerged as a replacement for bisphosphonates.

I report on the effects of dietary treatment of a 71 year-old woman with advanced osteoporosis, a fifteen-plus year history of consistent and progressive bone mineral density (BMD) decline and loss of one inch in height.  Over the fifteen-year period she has consistently refused bisphosphonates. She came to my practice asking about possibilities for herbal or nutritional intervention.

I accepted her as a patient. This report describes the dietary intervention and the results: after fifteen months in total, the DXA scan showed zero bone loss.

Introduction 

Typical dietary recommendations for post-menopausal women include vitamin D supplementation, calcium supplementation, and more recently vitamin K supplementation.

Studies of supplementation with both vitamin D and calcium range from fewer hip factures to ineffective, and are therefore generally considered adjuncts to treatment.Sufficient protein is also needed for osteoporosis prevention and treatment.5  

Vitamin K and isoflavones are also considered as alternative therapies. Vitamin K plays a role in synthesis of bone proteins such as osteocalcin, which is involved in mineralization. Isoflavones have shown clearly to be useful in bone loss prevention. Short-term RCTs indicate that there may be benefit with as little as 40-60mg isoflavones from soy or red clover.4

Case

A 69 year old woman presented to my office in 2011 with long-term bone loss.  Her DXA scan records dated from 1999. They showed a steady loss of BMD in the spine – Table 1 – and femur, and a slower rate of decline in the hip.   She reported no fracture.  She reported no use of hormones at any time in her life including no hormone replacement therapy.

Table 1

Spine                        1999                  2001           2009                    2011            2013

T score                        -1                 -1.7                        -2.7                     -2.9            -2.9

Having routinely declined Alendronic acid, patient was advised by her physician to undertake a course of Zoledronic acid injection. She was unwilling. She sought my advice about treatment for osteoporosis that did not include the use of bisphosphonates.

Discussion

Anticipated bone loss from the decline in hormone production in post-menopausal women appears to be approximately +/- 5% as measured against FSH stage 420.  The patient I report, and many patients in the West, present upwards of this as they age, and suffer relatively high rates of fracture 21. Medicare’s expenditure on fracture from falls exceeded $19 billion in 200022.  

Those fracture rates can be traced equally across the US and much of Western Europe but fracture rates are significantly lower in China and India14. Given the distinctly different dietary cultures East and West, these patterns suggest that one of the root causes of high fracture rates in the West is diet.  

I designed a dietary protocol based on a multi-pronged approach towards calcium absorption and avoidance of bone resorption.

Milk provides an excellent source of protein and calcium, as well as phosphatase. Components of milk are thought to favor the intestinal absorption of calcium by keeping it in a soluble form until it reaches the distal intestine, where it can be absorbed by unsaturable routes that are independent of vitamin D. The best known are lactose proteins and phosphopeptides4.

Many in vivo and in vitro studies on proteins and phosphopeptides have demonstrated a positive effect of these molecules on calcium absorption.4

Phosphopeptides – in particular those derived from the enzymatic hydrolysis of caseins – have been shown to sequester calcium.4  Phosphopeptides therefore help to keep calcium in solution until it reaches the distal intestine, facilitating its absorption by passive diffusion.

It is now clear that lactose, like other slowly-absorbed sugars, must be at the site of absorption. In this case it prolongs the passive, vitamin D-independent absorption of calcium in the ileum. The effects may be spectacular, doubling absorption, if a high dose of lactose (15% to 30% of intake) is given.4

Intestinal absorption does not necessarily reflect bio-availability because calcium must be retained and used in bone formation and mineralization. Phosphorus must also be present for the production of hydroxyapatite.  The dissociation of calcium intake from that of phosphorus (if, for example, the calcium source is not ingested with the meal and/or this source contains no P) may restrict bone mineralization.4  

Unfortunately the high heat of pasteurization denatures both alkaline phosphatase and milk protein.3 Lack of high-heat pasteurization should allow calcium to be more bio-available as both the phosphatase and the structure of the protein would be intact. 

My assumption was that along with continued vitamin D supplementation, calcium absorption would become more efficient with the consumption of unpasteurized milk.a, b

Based on this assumption, we formulated a breakfast that included the additional vitamins and minerals required for ideal bone health.  The breakfast comprises unpasteurized milk plus six organic seeds, several types of nuts, two dried fruits, fresh fruit and unsulphured blackstrap molasses. In combination this provides high natural forms of calcium as well as magnesium and phosphorous and a small amount of phytoestrogen; also high levels vitamin E, balanced trace minerals and vitamin A.

Additionally I instructed the patient to reduce intake of grains which are high in phytic acid7. Phytic acid binds with calcium and other minerals rendering them unavailable.  For the same reason, I instructed her to eliminate soy products that are not fermented, and to add fermented soy to her diet.  Unfermented soybeans have relatively high levels of phytic acid.  The fermentation process reduces the phytic acid substantially and frees the isoflavones.6 I also asked the patient to use only sprouted nuts and seeds, as sprouting reduces the naturally-occurring phytic acid in both. 

It is shown that isoflavones – specifically when daidzein and genistein are metabolized by intestinal bacteria into equol – inhibit bone resorption6,8. Evidence from animal studies consistently shows that appropriate doses of isoflavones inhibit bone loss in osteoporotic animals without exhibiting adverse effects on reproductive organs or serum hormone levels. 6,8

I also instructed supplementation with vitamin K.  Vitamin K is a necessary ingredient in bone building.11,12  In animals Vitamin K2 is the main storage form of Vitamin K and has several subtypes.  Bacteria in the colon convert K1 into K2. Subtype Menaquinone-4 is synthesized by animal tissue and is found in meat, eggs and dairy products. Menaquinone-7 is synthesized by commensal gut bacteria or during fermentation. Osteoporosis15,16 and coronary heart disease17 are strongly associated with lower levels of K2. Vitamin K2 (MK-7) deficiency is also related to severe aortic calcification and all-cause mortality.18

The mineral-binding capacity of osteocalcin requires vitamin K-dependent gamma-carboxylation of three glutamic acid residues. Epidemiological studies have demonstrated a relationship between vitamin K and age-related bone loss (osteoporosis).7,11 

The Nurses’ Health Study followed more than 72,000 women for ten years. In an analysis of this cohort, women whose vitamin K intakes were in the lowest quintile (1/5) had a 30% higher risk of hip fracture than women with vitamin K intakes in the highest four quintiles. A study in over 800 elderly men and women, followed in the Framingham Heart Study for seven years, found that men and women with dietary vitamin K intakes in the highest quartile (1/4) had a 65% lower risk of hip fracture than those with dietary vitamin K intakes in the lowest quartile (approximately 250 mcg/day vs. 50 mcg/day of vitamin K).9,13

The patient was enthusiastic and reported full compliance. After fifteen months in total the DXA Scan showed zero bone loss.

Bone-Building Plan

 

The next step is to increase BMD. Toward that end the patient has begun a program that includes the following: breakfast as before, natural forms of vitamin K2 including both MK-4 and MK-7, bone broth, a bone-building vinegar, and additional supplements.

Documentation includes CTX, Bone-specific alkaline phosphatase, Propeptide type 1 collagen (PICP), and Serum N-terminal osteocalcin. These tests will be repeated in six months.  The DXA scan will be repeated in two years. 

A Second Patient

Another patient, a 60 year-old female whose osteoporosis is further advanced, has started on the plan.  We will obtain a starting point DXA scan, I will report on her results in 2 years.

 

Laura Kelly L.Ac, MATCM 

The author wishes to thank Helen Bryman Kelly for her help in developing this article.

 

No disclosures or conflicts of interest.

 

 

a While there are scare figures associated with unpasteurized  milk, there are 515 times more illness from L-mono in delicatessen meats and 29 times more illness from L-mono in pasteurized milk. On a per-serving basis, delicatessen meats were ten times more likely than unpasteurized milk to cause illness.19

b Both patients reside in a state where it is legal to buy unpasteurized milk from a farm that 1/ holds a Dairy Farm Certificate of Registration and 2/ meets bottling, testing and inspection requirements of the state’s Department of Agricultural Resources.

 

 

References

 

1.       Susan J. Whiting, PhD, Hassanali Vatanparast, MD, Geriatrics and Aging, 2005; 8(9):14020 Nutritional Interventions in Osteoporosis

2.      Brown JP, Josse RG.  2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada.   CMAJ 2002;167(10Suppl):S1-34. (Errata 2003:168:544)

3.      Aschaffenberg R, Mullen JEC (1949). “A rapid and simple phosphatase test for milk”. Journal of Dairy Research 16: 58–67. doi:10.1017/S0022029900005288.

4.      Guéguen L, Pointillart A. J Am Coll Nutr. 2000 Apr;19(2 Suppl):119S-136S.

5.      Bell J, Whiting S. Elderly women need dietary protein to maintain bone mass. Nutr Rev 2002;60:337-41.

6.      Atkinson C, Compston JE, Day NE, et al. The effects of phytoestrogen isoflavones on bone density in women: a double-blind, randomized, placebo-controlled trial. Am J Clin Nutr 2004;79:326-33.

7.      Journal of the American Oil Chemists’ Society  March 1981, Volume 58, Issue 3, pp 493-495

8.      Uehara M. J Clin Biochem Nutr. 2013 May;52(3):193-201. doi: 10.3164/jcbn.13-2. Epub 2013 May 1

9.      Tsukamoto Y, Ichise H, Yamaguchi M: Prolonged Intake of Dietary Fermented Soybeans (Natto) with the Reinforced Vitamin K2 (Menaquinone-7) Enhances Circulating ? – Carboxylated Osteocalcin Concentration in Normal Individuals. Journal of Health Science 2000, 46(4):317-321.

10.   Hofbauer LC, Brueck CC, Shanahan CM, Schoppet M, Dobnig H. Vascular calcification and osteoporosis–from clinical observation towards molecular understanding. Osteoporos Int. 2007;18(3):251-9; Plantalech L, Guillaumont M, Vergnaud P, Leclercq M, Delmas PD. Impairment of gamma carboxylation of circulating osteocalcin (bone gla protein) in elderly women. J Bone Miner Res. 1991;6(11):1211-6

11.   Diane Feskanich, et al, Am J Clin Nutr January 1999 vol. 69 no. 1 74-79;

12.    Lee NK, Sowa H, Hinoi E, Ferron M, Ahn JD, Confavreux C, Dacquin R, Mee PJ, McKee MD, Jung DY, Zhang Z, Kim JK, Mauvais-Jarvis F, Ducy P, Karsenty G (August 2007). “Endocrine regulation of energy metabolism by the skeleton”. Cell 130 (3): 456–69. doi:10.1016/j.cell.2007.05.047. PMC 2013746. PMID 17693256

13.   Shiraki M, Shiraki Y, Aoki C, Miura M. Vitamin K2 (menatetrenone) effectively prevents fractures and sustains lumbar bone mineral density in osteoporosis. J Bone Miner Res 2000; 15:515-521

14.   Hip fracture incidence map, National Osteoporosis Foundation, http://www.iofbonehealth.org/facts-and-statistics/hip-fracture-incidence-map

15.   Ikeda; Iki, M; Morita, A; Kajita, E; Kagamimori, S; Kagawa, Y; Yoneshima, H (2006). “Intake of fermented soybeans, natto, is associated with reduced bone loss in postmenopausal women: Japanese Population-Based Osteoporosis (JPOS) Study”. The Journal of nutrition 136 (5): 1323–8. PMID 16614424

16.   Katsuyama; Ideguchi, S; Fukunaga, M; Saijoh, K; Sunami, S (2002). “Usual dietary intake of fermented soybeans (Natto) is associated with bone mineral density in premenopausal women”. Journal of nutritional science and vitaminology 48 (3): 207–15. doi:10.3177/jnsv.48.207. PMID 12350079

17.   Sano; Fujita, H; Morita, I; Uematsu, H; Murota, S (1999). “Vitamin K2 (menatetrenone) induces iNOS in bovine vascular smooth muscle cells: no relationship between nitric oxide production and gamma-carboxylation”. Journal of nutritional science and vitaminology 45 (6): 711–23. doi:10.3177/jnsv.45.711. PMID 10737225

18.   Geleijnse; Vermeer, C; Grobbee, DE; Schurgers, LJ; Knapen, MH; van der Meer, IM; Hofman, A; Witteman, JC (2004). “Dietary intake of menaquinone is associated with a reduced risk of coronary heart disease: The Rotterdam Study”. The Journal of nutrition 134 (11): 3100–5. PMID 15514282

19.   Intrepretive Summary – Listeria Monocytogenes Risk Assessment, Center for Food Safety and Applied Nutrition, Sept. 2003, page 17

20.   J Clin Endocrinol Metab. 2010 May; 95(5): 2155–2162. Published online 2010 March 9. doi:  10.1210/jc.2009-0659PMCID: PMC2869543Amount of Bone Loss in Relation to Time around the Final Menstrual Period and Follicle-Stimulating Hormone Staging of the TransmenopauseMaryFran R. Sowers, Huiyong Zheng, Mary L. Jannausch, Daniel McConnell, Bin Nan, Sioban Harlow, and John F. Randolph, Jr.

21.   CDC morbidity and mortality weekly report, October 18, 1996. Vol.45  No.41

22.   Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention 2006;12:290–5

1 thought on “Arresting Bone Loss in a post-menopausal woman

  1. As was pointed out by Osteoporosis International: “Even if there was no change in BMD, it is not possible to be sure that this was the result of intervention by nutritional means in these two patients as suggested by the author. It is also possible that the subjects had slow remodelling and had changes below the level of detection possible during the 15 months. It is also possible that bone loss occurred but at the same time, arthritic changes obscured the bone loss.” All this is possible, however it is also possible that this intervention indeed worked. We will see in the future.

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