Slide set that accompanied a public lecture on Nutrients and Bone Health held in London September 2011. The lecture focused on the importance of diet and lifestyle in maintaining healthy bone and preventing osteoporosis. Aspects of diagnosis are reviewed and the use of bone markers to indicate bone turnover are discussed in relation to monitoring the response to treatment.

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

2. By Edward Mitchell, engraver Edinburgh (1829)

4. 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

5. Hollow but strong

6. 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

10. Age & bone density

11. Race & bone density

12. Osteoporosis types

13. Primary Osteoporosis Juvenile 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.

14. Secondary Osteoporosis Genetic Gonadal Endocrine Inflammatory Deficiency states Drug 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

15. Diagnosis

16. Bone density scan (DXA scan)

17. DXA results

18. Age, fracture risk & T-score

19. T-score range

20. T-scores & bone density

22. T-score w.r.t actual bone density

23. 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

24. How CTx is performed Second void morning urine sample Sampled before 10.00am

25. What the results mean Female 3.0 – 7.4 Male 2.3 – 5.5

26. Management

27. The bone cycle

28. Bone health fundamentals

29. 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

30. Protein Protein is essential for muscle function & muscle function is essential for bone health Keep dietary ratio at 3:1 (produce:protein)

31. Calcium

32. Recommended calcium intake Source: UK Scientific Advisory Committee on Nutrition Age 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

33. Calcium in the diet Vegetarian options Information provided courtesy of The Royal Society of Chemistry, Ministry of Agriculture, Fisheries & Food publication "The Composition of Foods" 1992. 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

34. Calcium in the diet Omnivore options Information provided courtesy of The Royal Society of Chemistry, Ministry of Agriculture, Fisheries & Food publication "The Composition of Foods" 1992. 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

35. 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

36. Calcium & Heart Disease 30 % 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

37. Vitamin D

38. Vitamin D dose units 1 mcg of vitamin D = 40 IU Eg. 1,000 IU vit D = 1,000 ÷ 40 = 25mcg (0.025mg)

39. 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

40. Vitamin D synthesis

41. Normal Vitamin D levels What’s normal? UK units measured in nmol/l US units measured in ng/ml In UK below 25nmol (10ng/ml) = deficient Always test for 25-hydroxyvitamin D aka 25(OH)D

42. 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

43. 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)

44. Structurally similar

45. Vitamin D3 vs Vitamin D2 § 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. 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

46. 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)

47. Vitamin K

48. 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

49. Vitamin K Key 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

50. 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

51. Trace elements

52. Boron & Strontium Boron & 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.

53. Key supplements

54. Vitamin D3 (by Enzymatic Therapy, USA) 1000 IU per tablet 2000 IU per chewable tablet

55. OsteoPrime (by Enzymatic Therapy, USA ) OsteoPrime formulated by: Jonathan Wright MD & Alan Gaby MD

56. 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

57. 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

58. OsteoPrime formula

59. 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 day Child dose (under 10’s): 1 x 15-30ml per day

60. Accessible resource