The Secret Life of Bones Marcus Webb BSc ND DO Osteopath & Naturopath

By Edward Mitchell, engraver Edinburgh (1829)

What we shall discuss tonight

• A brief look at bones and bone density

• Common causes of poor bone quality

• Key nutrients and their use & controversies

• Key dietary issues & supplements

• A brief look at bones and bone density

• Common causes of poor bone quality

• Key nutrients and their use & controversies

• Key dietary issues & supplements

206 bones in the body

The smallest bones are in your ears

There are 14 bones in the face

Bones are 75% water

Your thigh bone is stronger than concrete and its hollow!

Tooth enamel is the strongest substance in the body

Your skeleton only makes up 14% of your body weight

Some bone facts

Hollow but strong

Excavations at a Chinese cave have yielded a 40,000-year-old partial human

skeleton, including this lower jaw.

In the right environment bones can last a very long time

National Academy of Sciences 2007

Age & bone density

Race & bone density

Osteoporosis types

Primary OsteoporosisJuvenile type (8-14year olds)

Rare, gonadal dysfunction, bone pain and fracture

Type-1 (50-65 year old, Postmenopausal)

Characterized by a phase of accelerated bone loss. This bone loss occurs primarily from trabecular bone.Fractures of the forearm, wrist and vertebral bodies are common.

Type-2 (70+ year old, age-related)

Fractures occur in cortical and trabecular bone.In addition to wrist and vertebral fractures, hip fractures are common in this group.

Secondary OsteoporosisGenetic Gonadal Endocrine Inflammatory Deficiency

statesDrug Other

Cystic fibrosis Androgen insensitivity

Acromegly Inflammatory bowel disease

Calcium deficiency Anticonvulsants Lymphome, multiple myeloma

Ehler-Danlos Female athlete syndrome

Adrenal insufficiency

Ankylosing spondylitis

Magnesium deficiency

Antipsychotics Leukemia, haemophillia

Haemochromatosis Hyperprolactinemia Cushings syndrome Rheumatoid arthritis

Protein deficiency Antiretroviral Thalassemia, sickle cell disease

Marfans syndrome Panhypopituitarism Diabetes mellitus Syetemic lupus erythematosus

Vitamin D deficiency Aromatase inhibitors

Metastatic disease

Prophyria Premature menopause

Hyper-parathyroidism

Sarcoidisis Coeliac disease Prednisone Immobility, depression

Osteogenesis imperfecta

Turners syndrome Hyperthyroidism Chronic liver disease Malabsorption syndromes

Lithium Multiple sclerosis

Homocystinuria Klinefelters syndrome

Prolactinoma Metabolic acidosis Primary biliary cirrhosis

Methotrexate Emphysemia

Idiopathic hypercalciuria

Anorexia nervosa Oestrogen deficiency

Amyloidosis Gastrectomy SSRI’s Alcoholism

Gaucher disease Bulimia nervosa Pregnancy Ochtonosis Bariatic surgery Thyroxine Chronic renal disease

Diagnosis

Bone density scan(DXA scan)

DXA results

Age, fracture risk & T-score

T-score range

T-scores & bone density

T-score w.r.t actual bone density

CrossLaps (CTx)

(DPD) deoxypyridinoline

90% of the organic matrix of bone is Type 1 Collagen

In mature bone the DPD Cross links provide rigidity

DPD is excreted un-metabolized in urine and is

unaffected by diet , making it suitable for assessing

resorption

How CTx is performed

Second void morning urine sample

Sampled before 10.00am

Second void morning urine sample

Sampled before 10.00am

What the results mean

Female 3.0 – 7.4

Male 2.3 – 5.5

Female 3.0 – 7.4

Male 2.3 – 5.5

Management

The bone cycle

Bone health fundamentals

Diet basics

Key points

Sugar: high intakes related to higher urinary calcium loss

Refined grains & flour: 60% calcium & 85% magnesium loss by refining process

Caffeine: high intakes related to higher urinary calcium loss

Alcohol: osteoporosis is common in chronic alcoholics, but other factors at play!

Protein: high intakes related to higher urinary calcium loss

Fizzy drinks: phosphoric acid intake linked with bone loss

Protein

Protein is essential for muscle function &muscle function is essential for bone health

Keep dietary ratio at 3:1 (produce:protein)

Protein is essential for muscle function &muscle function is essential for bone health

Keep dietary ratio at 3:1 (produce:protein)

Calcium

Recommended calcium intakeAge range Calcium intake

Children (7-12 yrs) 800mg

Teenagers: Girls (11-18 yrs) 800mg

Teenagers: Boys (11-18 yrs) 1,000mg

Men (20-60 yrs) 700mg

Men (over 60 yrs) 1,500mg

Women (20-60 yrs) 700mg

Women (over 60 yrs) 700mg

Pregnant woman 700mg

Breastfeeding woman 700 + 500mg

Source: UK Scientific Advisory Committee on Nutrition

Calcium in the dietVegetarian options

Food Amount of calcium

100g Tahini (sesame paste) 680mg

100g Sesame seeds 670mg

100g Tofu (steamed) 510mg

100g Dried figs (4-6 figs) 250mg

100g Okra (cooked) 220g

100g Watercress 170mg

100g Cooked spinach 160mg

100g Cooked Curly kale 150mg

100g Wholemeal bread 106mg

Information provided courtesy of The Royal Society of Chemistry, Ministry of Agriculture, Fisheries & Food publication "The Composition of Foods" 1992.

Calcium in the dietOmnivore options

Food Amount of calcium

100g Fried whitebait 860mg

100g Edam cheese 795mg

100g Cheddar cheese 736mg

100g Sardines in oil 500mg

100g Sardines in tomatoe sauce 430mg

100g Yoghurt (low fat) 122mg

100ng Tuna (tinned in oil) 12mg

Information provided courtesy of The Royal Society of Chemistry, Ministry of Agriculture, Fisheries & Food publication "The Composition of Foods" 1992.

Common calcium considerations

Types of calcium

Intake levels

Age / sex

Level of gastric acidity

Use of PPI’s

Calcium deposition issues

Drug interactions eg. antibiotics, alendronate

High or low blood calcium (2.05 – 2.60 mmol/l) indicated endocrine disease in most cases

Calcium & Heart Disease30 % increase in incidence of myocardial infarction (BMJ 2010; 341:c3691)

BMJ study looked at 15 RCT’s where calcium was taken as mono-therapy

Data obtained from studies relating to calcium & osteoporosis NOT calcium & heart disease

6 % decrease in cardiovascular related deaths (J Bone Miner Res 2011; 26:35-41)

BMJ double-blind trial: 1,200mg calcium taken for 5 years

Non-significant 6% decrease in cardiovascular disease-related death

Vitamin D

Vitamin D dose units

1 mcg of vitamin D = 40 IU

Eg. 1,000 IU vit D = 1,000 ÷ 40 = 25mcg (0.025mg)

Vitamin D intake

According to the Food Standards Agency;

“For guidance purposes only, a level of 0.025 mg (1000 IU) day supplementary vitamin D would not be expected to cause adverse effects in the general population.”Source: http://www.food.gov.uk/multimedia/pdfs/evm_d.pdf

According to the Food Standards Agency;

“For guidance purposes only, a level of 0.025 mg (1000 IU) day supplementary vitamin D would not be expected to cause adverse effects in the general population.”Source: http://www.food.gov.uk/multimedia/pdfs/evm_d.pdf

Vitamin D synthesis

Normal Vitamin D levels

What’s normal?

UK units measured in nmol/lUS units measured in ng/ml

In UK below 25nmol (10ng/ml) = deficient

Always test for 25-hydroxyvitamin Daka 25(OH)D

What’s normal?

UK units measured in nmol/lUS units measured in ng/ml

In UK below 25nmol (10ng/ml) = deficient

Always test for 25-hydroxyvitamin Daka 25(OH)D

Vitamin D levels

Recent work has indicated that 85% of those with levels less that 50 nmol/l

(20ng/ml) had poor response to bisphosphonate therapy

Aim for 75nmol/l (30ng/ml)See: www.vitamindcouncil.org

Recent work has indicated that 85% of those with levels less that 50 nmol/l

(20ng/ml) had poor response to bisphosphonate therapy

Aim for 75nmol/l (30ng/ml)See: www.vitamindcouncil.org

Common vitamin D considerations

Asian origin

Avoidance of the sun

Living in northern latitudes

Avoids meat

Avoids oily fish

Type of vitamin D (D2 / D3)

Structurally similar

Vitamin D3 vs Vitamin D2

Vitamin D3(Cholecalciferol)

Vitamin D2(Ergocalciferol)

Made in the body Not produced in land plants or animals

Naturally derived supplement from wool grease (lanolin) from sheep

Yeast/fungus/synthetic derived supplement

Significantly increases vitamin D levels in the body §

Moderately increases vitamin D levels in the body §§

Recommended for optimal bone health Alternative form appropriate for strict vegetarians or vegans

§ In a 2011 study: The results showed that Vitamin D3 is actually 87% more potent than Vitamin D2. Since it has greater potency and lower cost, D3 should

be the preferred treatment option when correcting vitamin D deficiency. The Journal of Clinical Endocrinology & Metabolism March 1, 2011 vol. 96 Vitamin D3 Is

More Potent Than Vitamin D2 in Humans

§ § In a 2008 study: A 1000 IU dose of vitamin D2 daily was as effective as 1000 IU vitamin D3 in maintaining serum 25-hydroxyvitamin D levels and did not

negatively influence serum 25-hydroxyvitamin D3 levels. Therefore, vitamin D2 is equally as effective as vitamin D3 in maintaining 25-hydroxyvitamin D status. The

Journal of Clinical Endocrinology & Metabolism. 2008 Mar;93(3):677-81. Epub 2007 Dec 18.Vitamin D2 is as effective as vitamin D3 in maintaining circulating

concentrations of 25-hydroxyvitamin D.

Dietary vitamin D

Food Amount of vitamin D

Cod liver oil (1 tablespoon) 1,360IU (34mcg)

80g Salmon 447IU (11mcg)

80g Mackerel 388IU (10mcg)

80g Tuna 154IU (4mcg)

100g Beef liver 49IU (1.2mcg)

1 large Egg (in the yolk) 41IU (1mcg)

100g Swiss cheese 6IU (0.15mcg)

Vitamin K

Vitamin K

Vit K Type Name Source

Vitamin K1 Phylloquinone(phytonadione)

Plant; spinach, Swiss chard, cabbage, kale, cauliflower, broccoli & sprouts.

Vitamin K2 Menaquinone Gut & fermentation, Natto

Vitamin K3 Menadione Synthetic

Vitamin K4 Menadiol Synthetic

Vitamin KKey points

Low K1 levels commonly found in patients with osteoporotic fractures

Vitamin K is known to promote bone mineralization

Vitamin K taken along side vitamin D significantly reduces bone loss

Increases osteocalcin production

Encourages blood clotting so care with anticoagulants

Antibiotics (over 10 days of use) reduces vitamin K because of the effect on gut flora

Dietary vitamin K1

Food Amount of vitamin K1

130g Cooked Curly kale 1,147mcg

180g Cooked spinach 889mcg

144g Cooked turnip 529mcg

156g Cooked broccoli 220mcg

156 Cooked Brussel sprouts 219mcg

10g Raw Parsley 164mcg

160g Cooked Okra 64mcg

Trace elements

Boron & StrontiumBoron & bones

Boron supplements (3mg) reduce the urinary excretion of calcium and magnesium

Effects on calcium & magnesium possibly via regulating oestrogen / testosterone levels

Naturally found in: almonds, hazel nuts, Brazil nuts, dried apricots, avocado, dates & especially high in raisins

Strontium & bones

Diet normally delivers 1-3mg per day, significant amounts lost in flour refining

Known to stimulate bone formation and inhibit loss

High intakes associated with thyroid and pituitary dysfunction

Naturally found in: spinach, lettuce, carrots, peas, beans, potatoes and celery as well as grains such as wheat & barley – amounts depend on the soil they are grown in.

Key supplements

Vitamin D3(by Enzymatic Therapy, USA)

1000 IU per tablet 2000 IU per chewable tablet

OsteoPrime formulated by: Jonathan Wright MD & Alan Gaby MD

OsteoPrime(by Enzymatic Therapy, USA)

OsteoPrime(by Enzymatic Therapy, USA)

Key points

1. Betaine HCL (20mg per day)

2. Mixture of calcium salts

3. 600mg elemental calcium (per day)

4. Balanced magnesium level

5. Vitamin K (as K1 phytonadione)

6. Vitamin D3

7. Boron & strontium

Dose: 2 capsules/tablets twice a day

OsteoPrime™ Calcium profile

Calcium delivered as;150 mg

Elemental calcium per

1 capsule

600 mg Elemental

calcium per 4 capsules

Carbonate 64.00 mg 256.00 mg

Tri-calcium phosphate 48.00 mg 192.00 mg

Lactate 13.50 mg 54.00 mg

Chelate 13.50 mg 54.00 mg

Citrate 11.00 mg 44.00 mg

150mg 600mg

OsteoPrime formula

Liquid Calcium, Vit D & phosphorus(by Webber Naturals, Canada)

Ingredients Amount per 30ml

Calcium (Tricalcium Phosphate, Calcium Citrate)

1000mg

Phosphorus (Tricalcium Phosphate)

200mg

Vitamin D3 (Cholecalciferol) 10mg (400IU)Purified water, glycerin, inulin, maltodextrin, citric acid, natural blueberry flavour, sodium ascorbate, sodium benzoate, potassium sorbate, xanthan gum.

Adult dose: 2 x 30ml per dayChild dose (under 10’s): 1 x 15-30ml per day

Accessible resource

Contact details

Hadley Wood Healthcare28 Crescent WestHadley WoodBarnet, Herts.EN4 0EJ

t. 0208 441 8352e. marcus@hadleywoodhealthcare.co.ukblog. www.hadleywoodhealthcare.wordpress.com