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What Doctors Don't Tell You

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October 2020 (Vol. 5 Issue 7)

An answer to osteoporosis

About the author: 
Cate Montana

An answer to osteoporosis image

The latest evidence about osteoporosis shows that it has little to do with not enough calcium and everything to do with the state of your ability to absorb food. Cate Montana investigates

In the early 1970s, Keith McCormick was winning Junior National Championships in the pentathlon, an athletic competition made up of five events: pistol shooting, fencing, horse jumping, swimming and cross-country running.

The ancient Olympic pentathlon—running, jumping, spear-throwing, discus and wrestling—was considered the most difficult event of all, with the winner crowned Victor Ludorum, "the winner of the games," and its modern equivalent is no less grueling.

Keith was a powerful athlete who trained anywhere from 12 to 15 hours a day for years. In 1976, he was an alternate member of the US Summer Olympic pentathlon team in Montreal, Canada. He also competed and placed second and fourth with several World Championship teams.

His passion for fitness extended to his career, and in 1982 Keith graduated from the National College of Chiropractic and became a sports-oriented chiropractor. He also kept up a regular training routine and continued to compete in triathlons and Ironman competitions.

And then in 1999, at age 45, his hip started hurting badly during a track workout. "I couldn't even finish the workout, which was very weird," he says. "I messed around with it for a couple of weeks or so, and since it wasn't getting better, I saw a friend of mine who's an orthopedic surgeon, and he took X-rays of my hips."

The surgeon didn't like what he saw, so he ordered a bone density scan. It came up with a T-score of -4.3, well into the osteoporosis range. The T-score shows how much a person's bone density differs from the bone density of a healthy 20-year-old. A T-score of -2.5 or below is diagnosed as osteoporosis.

McCormick next went to an endocrinologist close to his practice in Belchertown, Massachusetts, but the new doctor didn't know anything more about osteoporosis than his patient.

"Back then, 20 years ago, I knew zero about it," McCormick says. "He sat me down in his office, pulled this book off the shelf and opened it up to osteoporosis with this list of 20 things to check for, and started at the top of the list. I was just aghast."

McCormick matched none of those known causes of osteoporosis. He didn't smoke. He didn't drink. He'd exercised all his life and wasn't obese. Osteoporosis didn't run in his family. When he'd reached the end of the list, the doctor told him, "Well, it looks like you've got just regular osteoporosis," and handed him prescriptions for a bisphosphonate (a class of drugs that prevents the loss of bone density) and a thiazide diuretic to decrease the loss of calcium in his urine.

"I said, 'Doctor, I'm not here for a prescription. I just want to find out why I've got osteoporosis. I'm 45, and you want me to take these drugs for the next 45 years?' It didn't make any sense to me."

Determined to stay off pharmaceuticals, understand the disease that was crippling him and heal himself naturally, Keith launched into a long period of study, eventually teaming up with Dr Lawrence Raisz, head of the Division of Endocrinology and Metabolism at the University of Connecticut Health Center, who was doing experimental research on the disease.

With Dr Raisz' help, Keith improved his diet, adding more calcium-rich veggies, and started taking supplements. But the process of recovery was slow—too slow. With a T-score of -4.3, his bones were just too weak for his lifestyle, and even though he radically cut back on his athletic activities, within the next five years he broke or fractured at least 15 bones.

"I would barely do anything, and I would break a rib," he says. "I was really fragile, and I didn't know what the heck I was doing. It was terrible. You get so caught up in yourself and so worried, and you think you are this fragile terrible person that didn't take care of themselves. I never took a drug in my life. I never drank alcohol. I never did anything bad. But osteoporosis lays this huge guilt trip on you that you didn't take care of yourself. Psychologically, it's traumatic."

After the fifteenth broken bone, he capitulated and started on Forteo, an injectable hormone that stimulates the activity of bone-building cells (osteoblasts and osteoclasts) in the bone matrix. In two years, he went from a T-score of -4.3 to -3.3, at which point the fractures stopped, and he took himself off the drug, ramping up his own natural healing approach.

He'd learned a lot in the preceding years—especially about the relationship between gut health, the immune system and osteoporosis. He discovered he had the markers indicating an allergy to gluten and went gluten-free. He began taking alpha-lipoic acid because his research showed it to be one of the most important supplements for osteoporosis, along with N-acetyl cysteine (NAC), calcium, magnesium, trace minerals and vitamins D and K. He also added fish oil and probiotics to his diet.

By 2010, he was back competing at an international level, placing seventh in his age group in the Ironman Triathlon World Championships in Hawaii. In 2011, he placed ninth.Today he is still a competitive athlete and a globally renowned specialist in helping people recover from osteoporosis.

"When I work with patients, I am for winning this game," he says. "I don't care how I have to win it except to not hurt the person in the process. I don't intend for them to be on a drug for a long time, and if they don't have to take a drug then I don't put them on it. We simply adjust nutrition, diet and exercise, things like that.

"People come to me with T-scores commonly below -4.5, and this is an emergency kind of thing. We have to get these people out of trouble quick. If they only have a -2.8 or -3.0, that's not a big deal. We can usually handle that with just nutrition. But everybody is different."

Getting to the cause
Osteoporosis doesn't just happen. A sedentary lifestyle, obesity, excessive alcohol consumption and a protein-rich diet are commonly cited factors, and cigarette smoking increases the risk of bone fractures by 15 percent.1 Chronic psychological stress ups the risk for osteoporosis as well.2

A wide variety of drugs can promote bone loss and increase the risk of fracture, including the blood thinners heparin and warfarin, diuretics (so-called "water pills"), the immune suppressants cyclosporine and cortisone, SSRI antidepressants, medroxyprogesterone (used in birth control), diabetes drugs, thyroid hormone, chemotherapy drugs and drugs such as proton pump inhibitors that reduce the amount of acid in the stomach.3

A feature of many of these drug classes is that they interfere, directly or indirectly, with phosphorous and calcium metabolism in the body.

But the common denominator in most, if not all of the "causes" of osteoporosis cited above is the fact that they negatively impact gut health and trigger inflammatory responses that adversely affect the immune system.

"Anything that ramps up the immune system is going to affect your bones because the osteoclasts that break down bone are a form of white blood cell," says McCormick. "So they are extremely closely related to your immune system."

The bone marrow contains two kinds of stem cells, the "starter" cells that develop into all the cells in the body: hematopoietic (HSCs) and mesenchymal (MSCs). MSCs become, among other things, osteoblasts, the cells that build bone, while the osteoclasts that break down bone are one of the cell types originating from HSCs.4

Normally, osteoblasts and osteoclasts work together to break down older, weaker bone tissue and rebuild it stronger than before. But, as McCormick explains, if there is a disruption in the way the HSCs and MSCs differentiate, you can experience increased osteoclast activity and decreased osteoblast activity.

This means that, over time, you have more and more cells breaking down bone and fewer and fewer cells building it up, resulting in bone loss.

"Anything that riles up your immune system, like gut issues, is going cause immune cells to send out what's called pro-inflammatory cytokines like interleukins and tumor necrosis factor, and all these different chemical messengers ramp up the immunological response system," says McCormick. "Osteoclasts respond to that inflammatory response in the gut and ramp up."

Because they are essentially specialized white blood cells, osteoclasts are extremely sensitive to inflammatory cytokines. Chronic inflammation in any area of the body can stimulate them to speed up bone resorption.1

Osteoporosis is also highly related to collagen. "Your bones are made up of minerals, osteoblasts, osteoclasts and collagen, which itself is made up of many types of protein, which are in turn made up of various amino acids," says Dr Eugene Zampieron, a naturopath and expert on osteoporosis from Woodbury, CT.

"Amino acids are the smallest part of the protein, and without proper hydrochloric acid in the stomach you can't digest amino acids such as glycine, lysine, thiamine, glutamine and proline. And all of these are very important amino acids that build collagen.

"If you don't have the raw materials for the body to build the collagen in the first place, then you can never rebuild it. So osteoporosis is very much a collagen disease."

Zampieron has successfully treated many patients with severe osteoporosis without pharmaceutical drugs, and says it really depends on how dedicated a person is to uncovering the underlying cause, looking for the things that conventional doctors don't consider, and then sticking to a program of healing.

"It might take some time and detective work, but you've got to do your due diligence," he says. "I had one patient who had had osteoporosis for years. She'd tried minerals and totally changed her diet, and it had no effect. Finally she came to me, and I did a stool analysis looking for indicators of malabsorption.

"I looked at the foods she was eating, and sure enough, she was highly sensitive to wheat gluten and that created almost a subclinical celiac disease. So, no matter how many minerals she would take, she couldn't absorb them. Once she got off of those inflammatory foods, her amino acid levels went up, and now we are finally making some progress."

Science is only now beginning to make headway on the subtle and systemic causes of osteoporosis. After 20 years of work and study, to this day McCormick isn't sure what triggered the condition in him.

"I think it's usually a combination of things," he says. "For me, gluten was one major part. But I think a huge part was that I trained really hard when I was in the '76 Olympic Games. I've been on seven world championship teams. I've done five Ironmans. I'd do a five-hour bike ride and wouldn't take any nutrition with me at all.

"I think it all caught up with me. I thought I was indestructible. But the reality is that I am a little bit vulnerable. We all are."

Winning against osteoporosis
Keith McCormick was a world-class pentathlete, but severe osteoporosis sidelined his active lifestyle when he was only in his forties. As a chiropractor, he dedicated himself to learning about the underlying causes of the disease. A decade later, he was back competing in the Ironman Triathlon World Championships, and he applies the same competitive intensity to helping others recover from osteoporosis. "When I work with patients, I am for winning this game."

Osteoporosis tests
A bone density scan is the only test used to diagnose osteoporosis because it tells you if you have normal bone density, low bone density (osteopenia) or osteoporosis.
However, as Dr Eugene Zampieron warns, "A bone scan shows that osteoporosis is there, but it doesn't show the cause. You really need to get lab work done, because the lab work will determine the way the practitioner should go with handling the case."

Dr Keith McCormick agrees. He says two of the most important tests to have done are those for markers of bone reabsorption and bone formation. Bone resorption markers include tartrate-resistant acid phosphatase (TRAP) and collagen breakdown products (such as pyridinium cross-links, galactosyl hydroxylysine and cross-linked telopeptides CTx and NTx.)

If these markers are high, it indicates that the osteoclasts are ramped up, and if the osteoclasts are proliferating, that is a strong indicator some sort of inflammation may be involved.

A test for P1nP (total procollagen type 1 N-terminal propeptide) is the preferred marker for bone formation and an indication of how much osteoblast activity is happening. If that's low, you know your body is not making bone.

A 24-hour urine calcium test screens for calcium loss from the blood serum. If that's high, it indicates you might have a parathyroid issue. There is a PTH test to see if the parathyroid hormones are elevated.

Primary hyperparathyroidism (PHPT) is considered a cause of secondary osteoporosis because the condition promotes osteoclast activity and bone resorption.1

A cytokine panel blood test measures cytokines—small proteins that immune cells use to communicate—including interleukin (IL)-1 beta, IL-6, IL-8 and tumor necrosis factor alpha, all of which are involved in inflammation and can induce damage when elevated.

Dr Zampieron recommends a test for the amino acid homocysteine, because a high serum homocysteine concentration may weaken the bone by interfering with collagen structures, thereby increasing the risk of osteoporotic fracture.2

If you are on pharmaceuticals
As Zampieron points out, patients who take certain pharmaceutical drugs long-term are likely candidates for osteoporosis.

If you're on proton pump inhibitors or H2 blocking drugs, which many people take in an attempt to limit stomach acid production, it's going to inhibit your ability to absorb amino acids and create a general malabsorption of nutrients vital to building and keeping bone.

If you're taking such drugs, he suggests running a full nutrient profile to look at calcium, manganese, magnesium, strontium, boron, zinc and other nutrient levels.

Zampieron also recommends testing for deficiencies in vitamin D and vitamin K, especially for people who take blood-thinning drugs.

The trouble with DEXA
DEXA, or dual-energy X-ray absorptiometry, is a noninvasive test to measure bone mineral density (BMD). The US National Osteoporosis Foundation recommends a bone density test of the hip and spine using a central DEXA machine as the gold-standard test for bone strength and to diagnose osteoporosis.

A DEXA scanner is a machine that takes a two-dimensional picture of a three-dimensional object (your bones). It produces two X-ray beams, one high-energy beam and the other low-energy.

The machine measures the level of X-rays that pass through the bone from each beam. Based on the difference between the two beams, your doctor can calculate your bone density, based on the amount of bone mineral content divided by the bone area.

Unfortunately, DEXA results can be imprecise for a number of reasons. A major problem is that with this test, a larger bone will seem to indicate superior strength, but may in fact have the same density as a smaller bone.1 This means people with a smaller frame stand a statistically higher risk of being misdiagnosed with a DEXA scan than someone who is large-boned.

In addition, studies show that total body mass index (BMI) impacts "precision errors" when scanning the lumbar spine, femoral neck, total hip and total body bone mineral density.2 In other words, obesity affects the results of the scan.

This means that two people might have the exact same bone density, levels of calcium and strength in their bones, but the DEXA scanner frequently reads the bone density information differently because of their weight.

Another serious issue with DEXA scans is technician error. An accurate BMD reading is largely dependent on the skill of the technologist in placing the patient in the same position for different scans.

On top of that, measurements from different brands of DEXA machines vary and are often subject to different standards, and the accuracy of comparative measurements taken with different instruments is often poor.3

"The main reason why there are a lot of errors in DEXA scans is the way the technician sets the person up and sets up the machine," says Dr Keith McCormick. "And then there's also the way the radiologist reads it. So when I do a consult with somebody, I don't ask for the radiologist's report. I want the bone density printout from the machine itself."

DEXA scans are recommended every year or so for people with osteoporosis to monitor the amount of change in bone density, so the attending physician can adjust treatment accordingly. But the vagaries of DEXA scans are often easily seen when scans are compared over time.

"The report is usually about four pages and has little pictures on it," says McCormick. "And if I can see the pictures and I can say, 'Oh, look! They internally rotated that femur more this year than last year,' that's going to change the results. It's really easy to screw it up. There are regions of interest that we want scanned, and if the technician puts the region of interest just a millimeter different from one scan to another, it can change the reading."

McCormick nevertheless continues to use bone density scans. "You just really have to look at them closely. You have to hope that the technician is good. And if it isn't good, I ask for a re-do on it."

The milk myth
Calcium has many functions in the body, including bone development and maintenance, regulating blood pressure, and blood clotting and wound healing. However, despite the continuing insistence by the milk industry that calcium from dairy products builds strong bones, calcium deficiency is no longer considered to be the culprit at work behind osteoporosis.

Studies now show that dietary calcium intake is not associated with fracture risk. And there is no clinical evidence to show that increasing calcium from food sources prevents fractures.1

In fact, studies show that women who drink large amounts of milk have a higher incidence of bone fractures than those who don't.2 And hip fractures are more common in people who consume more dairy products and take in high levels of calcium.3

Things to take and do
"Osteoporosis is more than a calcium deficiency," says naturopath Eugene Zampieron. "And it's not about what you eat. It's about what you absorb. As far as diet goes, you find really bad osteoporosis in vegetarians and really bad osteoporosis in meat eaters. There's really no consensus as to what the best diet is. It's based on the individual."

That said, here are a few recommendations for preventing osteoporosis from occurring in the first place.

Calcium malate chelate.
Suggested daily dose: 500-700 mg/day

Magnesium malate chelate.
Suggested daily dose: 300-400 mg/day

Microcrystalline hydroxyapatite concentrate.
Suggested daily dose: 500 mg/day

Vitamin K. (in the form of MK4)
Suggested daily dose: 50-90 micrograms/day

Vitamin D. Get tested to see how much you need. "Some of my patients take 7,000 mg a day, and some people take 1,000," says McCormick. "Test in March or April because that's at the end of winter. If you test at 50 [nanograms per milliliter, ng/mL] then take 1,000 mg a day. If you're at 20 [ng/mL], then jack it up to 5,000 mg per day."

Rehmannia, an herb used in Chinese medicine that helps osteoblasts make new bone and downregulates the osteoclasts that destroy bone. Rehmannia may reduce blood glucose. Do not take if on diabetes medication.
Suggested daily dose: as a tincture, use 4-12 mL/day; dried herb, 10-30 g/day

Black cohosh, a selective estrogen receptor modulator that has been shown to have good effects on the bone. Black cohosh may not be safe for women who are pregnant, have had breast cancer or who have endometriosis. Do not take if you are at risk for seizures, stroke, blood clots or have liver disease. Do not take if you are using birth control pills, hormone replacement therapy, blood pressure medication or sedatives.
Suggested daily dose: 20-40 mg tablets of extract twice/day. Not recommended to take for more than six months

Drynaria fortunei (Gu-Sui-Bu), a Chinese herbal remedy known as "mender of shattered bone," is good for trauma to the bones and possibly osteoporosis.
Suggested daily dose: 1 mL/day

Walk. Play tennis or pickleball. Jog. If you play golf, walk instead of using a cart and carry your own bag. Take the stairs. Strength training and resistance exercise are known to be highly beneficial for the preservation of bone and muscle mass. Use a rebounder. If you are not mobile, use a full body vibrating machine like the ones NASA developed to maintain bone mass in astronauts.

Dr Keith McCormick, DC:
Dr Eugene Zampieron, ND:

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