Osteoporosis drugs in the United States are widely overprescribed, and this is bad for a few reasons.
First, studies are now showing that lifestyle changes alone can profoundly increase bone mineral density and reduce fracture risk.
Second, most osteoporosis drugs have incredibly long half- lives (longer than most other drugs!). They are the gift that keeps on giving, which is good because they work well when needed, but it is also bad because this could lead to overexposure, thus increasing the risk of side effects.
I encourage patients to ask their doctors about taking a “drug holiday” after being on one of these drugs for 3 to 5 years. Thanks to two important trials of alendronate (Fosamax), it is now known that taking a break won’t increase fracture risk significantly, even if users do lose some bone. (If there is serious bone loss in the hip or spine after stopping the drug, it should be started again ASAP .)
Now let’s talk about those side effects. There are some nasty yet rare problems that can occur over time after being on osteoporosis drugs, including atrial fibrillation, potentially irreversible and incurable bone loss in the jawbone because of an infection (osteonecrosis), bone and muscle pain, damage to the esophagus and esophageal cancer, and bizarre upper leg fractures (known as atypical femur fractures) after minimal trauma.
Again, these side effects are extremely rare, and the drugs have been a miracle for many people, but patients should always be thinking of how to minimize exposure to the drugs while still preserving bone mineral density. One last thing to keep in mind: Almost every successful trial of both new and old osteoporosis drugs also used moderate intakes of calcium or vitamin D (or both) to increase the effectiveness of the medication.
What is Osteoporosis?
Osteoporosis is thinning of the bones, which causes them to become weak and break. It’s the most common bone disease, and it affects women two to three times more often than men. However, men have a higher risk of dying from an initial fracture, so it really is an equal opportunity problem.
Most osteoporosis-related fractures occur in the hip, spine, or wrist, which are the areas evaluated during a bone mineral density (BMD) test. Dual-energy x-ray absorptiometry, or DEXA, is the most widely used bone density exam (it delivers just 10 percent of the radiation of a normal x-ray).
There are other detection methods, including a quantitative CT scan (QCT) and a heel ultrasound (HUS), but my favorite is DEXA, mainly because it is safe and low cost, has been well studied in relation to fractures, and looks directly at the most common fracture sites.
BMD results come in the form of a T-score for the hip, spine, and wrist, which is essentially a comparison between your BMD and that of an average 25- to 30- year-old who has no bone loss. A T-score of -2.5 or lower (measured in standard deviations from what is seen in a younger person) means osteoporosis (significant or severe bone loss).
So, a T-score of -1 to -2.5 is indicative of osteopenia (moderate bone loss), and greater than -1 is considered minimal bone loss. It’s not unusual to have osteoporosis of the lower spine, osteopenia of the hip, and normal wrist BMD, or some other combination. You should also receive a Z-score, which compares your BMD to the average of someone your age so you can see what is “normal” for your age group. Doctors use these scores along with other data to determine treatment.
What are the Best Supplements For Treating Osteoporosis?
1. (tie) Calcium 1,000 to 1,200 milligrams a day and vitamin D800 to 1,000 IU a day or the amount needed to normalize the 25-OH vitamin D test
I’m lumping these together because taking calcium without vitamin D doesn’t make much sense—vitamin D improves the absorption of calcium, and both help increase bone density and muscle coordination. Before you roll your eyes and think, Well I heard recently that calcium and vitamin D do not prevent fractures, I want to make sure you have the full story. First, keep in mind that calcium and vitamin D have been a part of almost every successful osteoporosis drug clinical trial.
Both nutrients together have been shown to reduce bone fractures in compliant users. In the largest clinical trial of these supplements to prevent bone loss and fractures ever completed (the Women’s Health Initiative, or WHI study), women who took calcium (1,000 milligrams) and vitamin D (400 IU) daily—or at least most days of the week—for 7 years had a 29 percent reduction in hip fractures compared to a placebo.
Almost 5 years after the study ended, the women still reported fewer vertebral (spine) fractures, which are the most common osteoporotic break, but no significant difference in hip fractures. In statistical terms, this basically means that for every 10,000 women taking supplements every year, there would be four fewer vertebral fractures. Not amazing, but no other supplement has ever been shown in a major clinical trial to have this impact on fractures.
In addition, both supplements reduce parathyroid hormone, which can cause bone loss when levels are high, and they may improve coordination, which can lower the risk of falls.
The current Recommended Dietary Allowance for calcium is 1,000 to 1,200 milligrams per day, ideally from food sources (cereal, veggies, fish, dairy, or fortified milk) that may work as well as or even better than taking supplements because food provides small quantities of calcium over the day with other nutrients (versus just taking a supplement in the morning), which improves absorption and incorporation into the bone. Taking too much calcium can increase the risk of kidney stones though, and some researchers believe it may also increase the risk of calcification of the arteries and heart attacks. No one knows yet if this is true, but I recommend erring on the side of moderation.
In the WHI trial, hip fractures were nonsignificantly lower in women with vitamin D blood levels that were approaching normal, which is 30 to 40 ng/mL on a 25-OH vitamin D test in my world. This is another example of where supplementing may not help much if you’re not substantially low in D. However, I believe—and studies support this—that normal doses of vitamin D (and raising your D levels naturally through weight loss and exercise) really help to prevent falls, especially in the elderly and frail. Receptors for this vitamin are found in most tissues and cells, including muscle tissue.
By improving the ability of the muscles to finely coordinate activity, you lower the risk of slipping and falling. The current National Institutes of Health recommendation is 600 IU per day for people 70 or younger and 800 IU for those 71 and older. (I think dosage should be either 1,000 IU or based on blood testing and lifestyle factors.)
There are two primary types of vitamin D supplements: vitamin D2, which comes from a plant source, and vitamin D3, which usually comes from sheep lanolin (there’s also a new plant source that is just hitting the market).
Most major clinical trials for bone loss prevention have used D3, but many studies suggest D2 is equally as or just slightly less effective than D3. I like both of them, but once it’s easier to get vitamin D3 from plants, I will probably recommend that one more often. A new form of vitamin D known as 25-OH vitamin D3, similar to what is measured in the blood, may be available soon, and it may have even greater ability to raise blood levels.
Finally, let me reiterate here what I have emphasized throughout this book: You can get sufficient calcium and vitamin D for bone loss and fracture prevention almost exclusively from lifestyle changes and diet. If you can’t consume enough that way, then and only then should you make up the deficit with supplements.
The food world is loaded with calcium (almond milk has about 450 milligrams per 8 ounces), and now many foods are fortified with vitamin D. Recent major clinical studies (the WHI, for example) have shown that most people are getting plenty of calcium and vitamin D from their diets; the need to supplement, especially calcium, is decreasing.
What Supplements Are Useless For Treating Osteoporosis?
Found in bone, strontium is similar to calcium in structure. In fact, the human body absorbs it as if it were calcium. You can find it in seawater, wheat bran, root veggies, meat, and dairy products. Not much is known about the side effects of the supplement, strontium citrate.
However, we know more about the prescription drug, strontium ranelate. Strontium ranelate is a good osteoporosis prescription medication that has been approved in many countries around the world, but not yet in the United States. It appears to work as well in men with osteoporosis as in postmenopausal women with osteoporosis, and it has been shown to reduce the risk of vertebral and nonvertebral bone fractures. It doesn’t just stop bone loss; it also strengthens existing bone and may promote bone growth. Strontium ranelate has a long track record of success in the drug world (up to 10 years), and overall it appeared to have similar side effects to a placebo.
Recently, however, there has been a concern about its potential to have cardiovascular toxicity, especially in people who are at high risk. I was going to make strontium ranelate an honorable mention, but because of this new heart- health data, I had to move it to this section. With the new drug concerns, I can’t recommend the supplement form right now either.
Vitamins K1 (phylloquinone) and K2 (menaquinone)
These have been touted to prevent bone loss primarily based on dietary studies (eating foods that contain them), but well-done clinical trials have not shown a consistent increase in bone density at major skeletal sites. Advocates argue that vitamin K2 (and even K1) might reduce the risk of bone fractures, although studies have not addressed this well and results have been inconsistent. I remain skeptical until someone can show a true consistent benefit here. (I hope they can.)
These supplements do not work better than a placebo at preventing bone loss in women who are already getting 1,000 to 1,200 milligrams of calcium and vitamin D daily and who are within 5 years of menopause (perimenopausal or early menopausal). It’s women who have vitamin D levels below 20 ng/mL who seem to be getting some small benefit from soy supplements. If you’re concerned about bone loss, you need to address any vitamin D deficiency before you consider doing anything else.
Boron, omega-3s, and the “latest and greatest” bone health supplements.
Manufacturers continue to advertise that boron, omega-3s, and whatever is the supplement du jour are bone healthy, but the reality is they have weak data. You can easily get many of these so-called bone-support nutrients from even a moderately unhealthy diet (the pizza-with-flaxseed-and-beer diet).
What Lifestyle Changes Can Help With Osteoporosis?
Heart healthy = bone healthy?
You bet! People with heart disease have a higher risk of fractures, which I believe shows a link between bone loss and heart disease. Individuals who are active and do aerobic (weight-bearing) and resistance-training exercise, maintain normal to low cholesterol, and do other things to reduce their risk of heart disease appear to have a lower risk of bone fractures. I cannot emphasize enough how your bones and muscles follow the “use it or lose it” philosophy. Daily cardio workouts (walking, jogging, or group exercise classes) and twice-weekly strength sessions should be a part of almost everyone’s weekly routine to help prevent bone loss. New research from Australia suggests daily moderate and intense exercise may work as well as calcium and vitamin D and some medications for improving BMD. And, of course, quit using tobacco!
Moderate your alcohol intake
Too much increases bone loss, but drinking in moderation (one a day for women and one or two for men) might slightly help bones by acting as a weak estrogen, which is needed for bone formation and to prevent loss. However, it’s not a reason to start drinking if you don’t currently imbibe. Did you know that beer contains silicon, which helps maintain bones? Just another reason I will never give up drinking it!
Get calcium and vitamin D in your diet
Five or 10 years ago it was difficult to get calcium from food and beverages, but today it’s easy. Dairy products, almond milk, mushrooms, egg yolks, kale, and fatty fish are better than pills any day.
Yes, your body makes vitamin D from sunlight, but telling people to get more sun is one of the dumbest recommendations out there (second only to telling someone to use a tanning bed). Ultraviolet light is a carcinogen and accelerates aging. Vitamin D is so inexpensive and easy to purchase, and it doesn’t increase your risk of dying young.
Eat more C
This vitamin is essential for creating collagen, improving bone repair, and strengthening bones. I have tested it in the past and it appeared to improve some bone markers. It’s best to get it from food sources, which is really just another way of saying, “Eat a heart-healthy diet.”
Cut out sodas
The more soda you drink, the less room you have for foods that contain real nutrients, like calcium (it’s a phenomenon called milk displacement). Plus, the phosphoric acid in large amounts of soda might increase bone loss.
Maintain a healthy weight
Being underweight (body mass index below 18.5) increases the risk of bone loss.
Review your medications. Some drugs, such as acid reflux medications, can increase the risk of osteoporosis or fractures.
Practice fall prevention
Educate yourself on all the ways to reduce falls and fractures, including wearing shoes with good traction, installing grab bars in the tub or shower, improving lighting, tossing out throw rugs, getting your vision checked, using a nonslip rubber mat in the bath, and improving your balance and coordination through exercise.
What Else to Know About Treating Osteoporosis?
- The World Health Organization (WHO?—sorry, nerd joke) created an incredible tool called FRAX that can predict your 10-year fracture risk. It’s a breeze to complete—there are 12 simple questions—but you will need results from your DEXA or some other type of bone test as well. When evaluated together by your doctor, the information helps give a clearer picture of your real-world risk of suffering a fracture in the next decade. It’s similar to how your cholesterol level by itself can predict your odds of having a heart attack, but adding lifestyle, family history, blood pressure, and blood sugar information can more precisely define your risk.
- Many patients ask me about hormone replacement therapy drugs for bone loss (estrogen or progesterone). And this works well as long as you’re willing to accept the risk, which is a higher incidence of breast cancer, cardiovascular disease, and dementia. If you’re going to use it, you should be on the lowest possible dose of hormones and should also normalize your calcium and vitamin D intake.
- Since cholesterol-lowering drugs might also reduce bone loss by blocking cells that break down bone, I wish someone would do a study of red yeast rice extract (see the High Cholesterol section) to prevent bone loss. I bet you it would yield some positive results.