Bone Health Follow-up March 2010

There's a tremendous amount of controversy, isn't there, about adverse drug reactions and potential risk benefits for various pharmaceuticals. And then people want to juxtapose that against natural products and say, well, you know, the natural product approaches towards managing conditions is safer than that of drugs. But then drugs might have more therapeutic efficacy. It's a big swirling debate and it's been going on for many, many years. And I fully intended and probably will go on for years in the future. But one of the class of drugs that has really received a lot of attention recently are these drugs that are employed for the management of bone loss and the risk to osteoporosis or for the treatment of osteoporosis. And as you know, there are a variety of members of the drug family that are employed for this application, including things like selective estrogen response modulators or SERMs that have names like raloxifen or tamoxifen. There's the bisphosphonates that are also related to prevention of bone loss and the treatment of bone demineralization and osteoporosis. And then on the other hand you've got natural approaches which include things like weight bearing exercise and proper management of estrogen in women and calcium. And of course the vitamin D story that we've spoken to extensively over the last several months. And then of course vitamin K, which is the emerged to play a bigger role in understanding of bone loss with the effect it has on the formation of bone mineral protein. So all of these are kind of going back and forth as to what is the best approach. Well, we were recently very pleased to have a discussion with what is considered, I think by many to be the individual who might be on that short list of the world's most renowned professionals in the area of understanding bone dynamics and bone physiology. Dr. Ego Seaman from Melbourne University in Australia. And Dr. Seaman has published extensively in his group over the last 20 years in this field and actually won the Osteoporosis Researcher of the Year award just last year. And his point, which I think is a very important point, is that there is a difference between bone density, which is what's generally measured in the clinic, and bone strength. Now, they're interrelated. I don't want to say that they're totally independent one to the other, but they're not exactly the same thing. When a woman has or a man has a bone density test, they're measuring the radiographic density of the matrix of minerals that are in the bone, the so called calcium hydroxyapatite portion of bone and how much of that bone will absorb that energy of the diagnosis and is going to be related to their bone density. And we always assume that the more dense a bone, in other words, the more minerals that are in the bone, the more calcified it is, the stronger the bone will be. But it turns out that the principal component of bone strength isn't the minerals themselves, it's the matrix upon which the minerals are laid down. It's the protein matrix, the collagen and unique mossy formation of this architecture of bone upon which the minerals are later crystallized. And that mossy kind of collagenous protein matrix produces extraordinarily important component of bone strength. So it would be possible to have the architecture of bone, the collagenous protein, slightly demineralized, but still have strong bone, or it would be conversely possible to have rather high mineral content of bone, but because the breakdown of the the architectural structure occurs, that its strength is compromised. So you'll notice I've just said that bone strength and bone density are not exactly the same. They're correlated, but not exactly the same. And the reason I'm saying that is that if you look at women who have spontaneous fractures, coles fractures of their wrist, or compression fractures of their spinal vertebra, you'll often find that there are women whose bone density is reasonably good, but their bone strength is low and they've undergone spontaneous fractures. So with that in mind, the question is what it is that really increases bone strength, not just bone density. Now, that goes into the use of various pharmaceuticals in comparison to various other natural therapeutics, because as we know, these bisphosphonates, which are a class of drugs that are used very frequently for women with osteoporosis, do in fact increase bone density quite dramatically. However, they also have been demonstrated to have some reasonably off target adverse effects, like increased risk to osteonecrosis of the jaw, where it's now being seen that there are certain people, and again, I want to say it's the exception, not the rule, who actually have loss of strength of bone in other regions. So they may be increasing their appendicular skeletal mass, but they may be decreasing specific other bone integrity that leads to things like necrosis, which means bone breakdown and bone injury. And in the jaw, this is being seen in some individuals on these bisphosphonates. So it's not just like a straight and narrow kind of clear direction that everybody that's been seen to have a diagnosis of bone loss should be on a specific class of drugs and that there'll be 100% hit rate in improving their outcome. I think there are multiple components for decision making. Now with all of that in mind, what would I recommend? That's an interesting question. Well, I think always starting with lifestyle intervention first and looking at the relative effect that it has on bone integrity is important. Going back again to weight bearing, exercise, going back to proper diets, staying away from too high sweet, too high salt diets that are too high in proteins that cause loss of bone. These are principally animal proteins that are rich in sulfur containing amino acids. Medications, overuse of things like non steroidal anti inflammatory drugs can actually have an adverse effect on bone density. So there's a whole variety of lifestyle habits and dietary habits. Then we get into specific therapeutic nutrients like calcium of course in a bioavailable form. Magnesium plays a role also in bone integrity. Certainly the vitamin D connection and its metabolism into the125 dihydroxy hormonal form of vitamin D. And now as I said, the vitamin K component is starting to be more seen as important because there are many people not eating dark green leafy vegetables which is a major source of vitamin K. So all of those are important. Then there's lastly the question as to what happens to the mineral matrix upon which bone is built. What actually maintains its integrity and that is related to in fact partly the inflammatory potential. Potential in the bone. When the bone is under an inflammatory burden. This might be an inflammation from an infection elsewhere in the body. Could be a viral infection, it could be a bacterial chronic infection. It could be a toxic exposure to a heavy metal like a lead or a cadmium or a mercury. These kind of events can enhance immunological surveillance of the bone. That enhances inflammation of the bone and reduces the integrity of the bone mineral matrix. So this for many people would be kind of new information. Do you mean if I had a gut inflammatory problem, it might produce a weak bone and the answer is yes. Or if I had a chronic sinus infection or a periodontal problem in my oral cavity with an infection, could that produce a weak bone? And the answer is yes. All of this has to be put into context when one is developing a comprehensive approach towards bone strength and bone integrity. Well, I hope I've given you something and news to use here to recognize. It's not just one size fits all. It's not just a drug for a solution. You have to look at the full complex of interactions to understand the connection. Thanks very much.