Manhattan Physical Medicine and Rehabilitation, LLP
November 18, 2008
Better Living through Sophistry? The Catch - H-2
Some of the most widely used medicines for the stomach are bad for the bones: The well-known proton pump inhibitors, such as Nexium, Protonix, and Proventil are linked to hip fracture by some, but not all recent studies.1-3 However, most agree that the risk of fracture goes up and bone mineral density goes down when you start to take these stomach-sparing drugs. The catch is that since many of the anti-osteoporosis drugs are bad for the stomach, people often take these proton pump inhibitors along with them. So in order to enable you to take a medicine that helps your bones, you also take a medicine that hurts your bones! Of course they each have other side-effects too, which unfortunately do not cancel each other out.
There are two mechanisms for this effect: less calcium absorption by a stomach that has reduced acid content, (the main effect of a proton pump inhibitor), and a tipping of the balance away from bone-making and toward bone resorption.
Has Anybody seen my Cal?
For people with osteoporosis we recommend:
1500 mg of calcium daily
800 units of vitamin D daily
People over 75 should lower their calcium to 500 mg daily.
Do you have the Heart for this?
With Fosamax, the incidence of atrial fibrillation, a rhythm-breaking rapid heartbeat that is associated with stroke and other cardiac abnormalities, may be increased more than we said before (in the June Newsletter). Actually, a recent study shows it is as much as 86 percent with Fosamax, and possibly with other bisphosphonate medications, including Reclast.4-7 The president of the National Osteoporosis Foundation, Dr. Ethel Siris notes that the study deriving these numbers focused on people that had taken the drug in the past as well as people taking the medicine now.
Corticosteroids: Friend and Foe
The connection between steroids and osteoporosis is well-known, but the actual strength of the relationship is not often tested. Now there is evidence that more than 5 mg per day for three months is a risk factor for osteoporosis.8 Other studies put the predicted loss in bone mineral density at 15% and as high as 25-30% for more than one year of using these sometimes unavoidable medications. Continuous use of more than 10 mg. beyond 90 days amplified the risk of hip and spine fracture by 5 and 6 times, respectively. Greater dosages and duration raised fracture risks 7 and a staggering 17 times respectively! This does not mean that you should stop taking these medications if your doctor has prescribed them. But if you are taking them, exercise. And if you exercise, there is a safe, self-regulating, portable, time-tested and very effective one that has positive side-effects. And it is easy to pronounce: Yoga.
Good News Department
Google your way to a DEXA-By-Proxy
Perhaps because of the lengthening wait for DEXA scans in some European capitals, an on-line service assesses the ten year risk of fracture for men over 50 and postmenopausal women.
Paste this into your mailer and answer the questions, which are about your weight and height, whether you smoke, drink, use steroids, etc.
It takes into account risk factors including BMI, use of steroid tablets, smoking status and alcohol consumption to calculate risk of hip fracture or a major osteoporotic fracture.
It will take 2-3 minutes.
Good News Department
Amendment to Wollf's Law
Leonardo Da Vinci once reviewed the nature of boney development and its necessary consequences. Since we are 90% water, and the volume of something is directly proportional to its weight, the cube, or third power of a dimension is related to weight. But the strength of a bone is related to its cross-sectional area, and therefore varies with the square, or second power of its dimensions. Therefore, he reasoned, there is a constant ratio between an animal's size, and the cross-sectional area of its bones. Further, Leonardo calculated the mass of our mostly water-filled body, and the strength of calcium-reinforced bone. He came up with a number that defined the ratio of cross sectional area of a bone to its length.
Yet, strange to tell, applying this to different creatures found here on Earth, in every case yet examined, Leonardo was wrong. The reason appears to be that Leonardo was thinking like an architect: The relationships of weight, support strength and diameter are well-known to engineers. The dynamic properties of running, dancing and wrestling humankind and creatures of every kind were not.
In an earlier newsletter we put Wollf's law in the limelight:
The architectonic of bone follows the lines of force to which it is exposed.The forces generated by our muscles and the inertial and mechanical moments they generate are far stronger than gravity. Note how we leap in the air, tear down the goalposts, and move furniture. These increased strains do a great deal to shape and strengthen our bones. The development of the hip bone illustrates this:
Even the normal pressures of walking stimulate realignment of the femur to its characteristic shape. At birth our thigh-bones are as straight as little unpointed arrows. As we acquire the skill of walking, the pressures on the femur are grossly skewed toward the midline because we support ourselves on one leg as we swing the other one forward. This causes reinforcement at the groin side of the hip, and some small stimulation at the outside of the hip, where various muscles are attached. Over time this inclines the upper part of the femur toward the pelvis, while only a small area, where muscles attach, on the outside of the bone get prominent.
What makes this happen? It is not gravity; gravity applies equally to all parts of the bone. This is not genetic development, or it would happen to the bones of those that do not walk. it is the influence of strong forces applied to one side of the bone. The truth of this comes out by comparing the developing femur in healthy children versus unfortunate children that have, for various regions, been unable to walk, and thus unable to generate the forces we have been talking about.
Yoga generates even greater forces than walking, of course, and may do so symmetrically. Therefore the bones are stimulated even more strongly, promoting a proportional increase in their strength. This is what we showed in the pilot study, and what we hope to make even more persuasive with the current work, in which you're involved.
Non-conclusive but nice
We're doing a controlled, careful study of yoga's effect on bone strength and osteoarthritis. That requires all the elements you've undergone: pre-study testing, and exact calibration of the results two years later. However, we also get anecdotal reports:
Dear Loren,
We exchanged few emails 2 years ago on some health-related aspects of yoga practice, you might remember.
I wanted to share two stories of my students. One is along the lines of your osteo research. Woman in her 50s started yoga after not so great densiometry results. Two years later (and she's following just a regular course, not particulary osteo oriented) she rechecked her bones and there was significant improvement.
The other is more dramatic, woman with mitral valve prolapse, who according to her doctor, was to be operated in a couple of months, started practicing yoga. That was four years ago. Since then she's been checked with both ultrasound and with more invasive method and both showed no further degradation of valve. Doctors find it very unusal, she's amazed. What I'd like to ask you is - are you aware of some cases where the process actually reversed itself?
Are you working on a new book? Keep up the good work!"
Sincerely, Danijel Dubičanac, Zagreb, Croatia,
danijel@ashtanga.hr
[Danijel wouldn't mind a couple of comments on what's reported here. [You must paste this address into your mailer to write Danijel. Please cc us if you would like at Loren@sciatica.org ]
Nature's Answers to Osteoporosis and Osteoarthritis
Still in the Good News Department:
1. Researchers at Nuffield College, the graduate institution at Oxford University, recently announced that they have isolated a natural bodily constituent that balances creation and resorption of bone.
2. Nature9 carried a full-length article on PGC1 alpha, a substance freed from muscles during moderate exercise, (e.g., yoga) that reduces inflammation, and with it, reduces incidence and severity of such diverse conditions as diabetes type II, Alzheimer's disease, arthritis, and possibly bone loss.
Humankind's continued probing
Merck is currently working on a new compound known as JTT-305. By the time it comes out, if it comes out, the name will probably be a little more memorable, like "Bone-up" or the like. JTT-305 stimulates osteocytes to make more bone, instead of medicines like the bisphosphonates that work to inhibit osteoclasts, the cells that reabsorb bone. JTT-350 copies nature's way of building bone when we are young, and does not interfere with the normal and necessary process of upkeep that is performed by the osteoclasts. However, side-effects and contraindications for this medicine are not fully known at this juncture.
Doesn't eat, shoots, and leaves (the video for you)
We shot the video "Twelve Poses vs Osteoporosis" last week, and after a month or so of editing, we will send it (free) to participants in the Yoga for Osteoporosis study that indicate they'd like it. There is a 5-minute introduction, and then a 12 minute watch-and-do sequence, with 30 seconds on each side of 9 poses, 30 seconds for each of two symmetrical poses, and almost two minutes for savasana, the final resting pose. The idea is to help you do the postures more frequently, more time-efficiently, and more safely. After you've heard the introduction, you can just skip it and start the DVD at the second track every time.
Although absolutely no injuries have been reported by patients doing the current set of yoga poses for 2-3 years, we've changed the forward bends a little in the interests of safety. They are the same 12 poses that you'll now see on the website, only in the video they are live, with running verbal instructions. We ask that you do not copy or disseminate the DVD at all. We are serious about it, and will send interested parties an agreement to that effect.
Models:
Sally Hess, Professor of Choreography, Swarthmore College
Robin Janis, Iyengar Yoga Instructor, New York City
Loren Fishman, Physician and yoga therapist
Instructions read by:
Alex Neil, Broadway and TV actor.
Director:
Charlotte Glynn, Festival-invited documentary film maker
Camera:
Edwin Martinez, Harvard-trained photographer
For more information, see the website and/or write Loren@sciatica.org.
Bulletin Board
For perplexities or to share, we now have a bulletin board as well: just go to: http://groups.google.com/group/yoga-and-osteoporosis
If you don't have an account at gmail, then you first have to sign up (free) at gmail.com, and then go to the above address. That will send our web-mistress a notice, and she'll let you join in the group.
The bulletin board is to seek and give questions and answers and experiences from and to others.
The study directors are also available for comments, questions, criticisms and suggestions.
Elise Weiss, M.D.
Sarah Schmidhofer
Loren Fishman, M.D.
References:
1. Kaye JA, Jick H. "Proton pump inhibitor use and risk of hip fractures in patients without major risk factors." Pharmacotherapy. 2008 Aug;28(8):951-9. – Found no adverse effects on bone from PPIs.
2. Yu EW, Blackwell T, Ensrud KE, Hillier TA, Lane NE, Orwoll E, Bauer DC. "Acid-Suppressive Medications and Risk of Bone Loss and Fracture in Older Adults." Calcif Tissue Int. 2008 Sep 24. – Some increase in fracture risk; some loss of bone mineral density with PPIs.
3. Yang YX, Lewis JD, Epstein S, Metz DC. "Long-term proton pump inhibitor therapy and risk of hip fracture." JAMA. 2006 Dec 27;296(24):2947-53. – There is an increase that increases with length of exposure.
4. Heckbert SR, Li G, Cummings SR, Smith NL, Psaty BM. "Use of alendronate and risk of incident atrial fibrillation in women." Arch Intern Med. 2008 Apr 28;168(8):826-31.
5. Cauley JA, Ensrud KE. "Considering competing risks . . . Not all black and white." Arch Intern Med. 2008 Apr 28;168(8):793-5. No abstract available.
6. Sørensen HT, Christensen S, Mehnert F, Pedersen L, Chapurlat RD, Cummings SR, Baron JA. "Use of bisphosphonates among women and risk of atrial fibrillation and flutter: population based case-control study." BMJ. 2008 Apr 12;336(7648):813-6.
7. Cummings SR, Schwartz AV, Black DM. "Alendronate and atrial fibrillation." N Engl J Med. 2007 May 3;356(18):1895-6.
8. Steinbuch M, Youket TE, Cohen S. "Oral glucocorticoid use is associated with an increased risk of fracture." Osteoporos Int. 2004 Apr;15(4):323-8.
9. Handschin C and Spiegelman BM. "The role of exercise and PGC1alpha in inflammation and chronic disease." Nature. (454) July 24, 2008: 463-469.
Comments, Questons, Criticism Suggestions
e-mail: Loren@sciatica.org
or write
Elise Weiss, M.D.
1009 Park Avenue
New York, NY 10028