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Bone Health and the Vitamin D Controversy
Healthy Living - December 3, 2013
William Sturrock, MD
Osteoporosis is a disease that affects over 45 million Americans, and is found in 55 percent of the population over age 50. It is found more frequently in women; however, it has been recently recognized as also occurring in men, particularly over age 65. There has been good research which shows that there are many conditions predisposing to unhealthy bones which can result in osteoporotic fractures to include cigarette smoking and postmenopausal status, long-term COPD or inflammatory bowel disease, heavy alcohol consumption, decreased physical activity, seizure disorders and certain cancers particularly prostate cancer. Recently with the recognition that many men also demonstrate low testosterone levels as they age, it has been shown that a good percentage of these individuals will also have osteoporosis unless treated. There are also studies suggesting that high consumption of carbonated soft drinks and other problems associated with nutrition will increase risk for unhealthy bones.
Because prevention is much smarter than waiting for problem to develop, many experts have recommended increased calcium intake as well as vitamin D, which is essential for bone metabolism.
Experts recommend that at least 1200 mg of calcium with 600 units of vitamin D for adults under 65 and 800 units for older adults should be taken by patients at risk. There is an interesting fact of human physiology that exposure of our skin to sunlight will actually allow us to manufacture vitamin D, and some individuals have tried to increase the vitamin D levels by getting more sun. Unfortunately the American Dermatology Association does not recommend increasing our sun exposure, due to the risk of skin cancer.
Recently our ability to measure vitamin D levels and has added some additional confusion because many individuals living in northern climates can have an abnormally low levels due to the fact they are having much less sun exposure. In addition there have been a lot of suggestive connections between low vitamin D levels and conditions such as fatigue and depression. This has led some clinicians to recommend patients try to take vitamin D for these conditions as well, and there has been much increased vitamin D testing without clear guidelines for treatment. There is a well-known endocrinologist from Bangor, Clifford Rosen, MD who has been working with the National Institutes of Health on the issue of what levels of vitamin D are ideal, and whether clinicians should be using it to treat conditions other than osteoporosis. I agree with his previous recommendations that at this point we should not have any false expectations that vitamin D is a primary therapy for conditions such as fatigue or depression. He also has questioned the wisdom of high-dose vitamin D treatment for patients whose levels are close to normal.
I am most interested in the fact that men develop osteoporosis about 10 years later than women do, and some experts recommend that they be screened for osteoporosis by bone density testing at age 70. Certainly if they do have any of the secondary risk factors, particularly prostate cancer, they should be screened just as we do for all post-menopausal women. In addition we should be checking for this potential problem in all men who had long-standing problems with low testosterone, particularly if there is some reason why they cannot take testosterone supplementation.
Osteoporosis by itself may not be a problem however it can lead to very painful and disabling fractures that can occur spontaneously or with minimal trauma. A 60-year-old man has a 25% chance of having an osteoporotic fracture in his lifetime, with the risk women of vertebral or hip fracture being 3 times higher than that in men. In particular hip fractures have a high association with mortality due to prolonged bedrest but may be necessary to heal.
Testing for osteoporosis is very simple, and has been standardized by doing a bone scan with reference to the bone densities that are normally found in healthy young adults. When you are scan with a focus on the high risk areas to include the femoral neck in the hip area as well as the vertebral bodies of the spine. Each person will have a T score and this measures from a standard deviations it is from normal bone. If the T score is between -1 and -2.5, this meets the criteria for osteopenia and preventive treatment is especially important. If the T score is the below -2.5, most experts would recommend prescription medications. In addition there is a separate calculation called a FRAX score which takes into account that person's height, weight, age, and other medical risk factors such as long-term steroid medications. Even if a person does not have osteoporosis but has a FRAX score that suggests here she is at high risk for a fracture in the next 10 years, most bone experts would also recommend prescription treatment.
Prescription treatment comes in many forms, from a daily oral medication, and other versions which can be taken less frequently such as once a week or once a month. In addition there are medications that can be given by a simple shot or IV drip that may improve bone strength for up to 6-12 months after treatment. The stronger versions are usually reserved for patients with very severe conditions or secondary problems with certain cancers.
Side effects of these medications can include esophageal irritation, so many physicians would advise a person remained seated or standing rather than lying down for several hours after taking them. Another problem can be seen with dental issues stemming from a condition known as osteonecrosis of the jaw, and this has led to some dentist questioning the value of these medicines. However bone experts believe there are ways to decrease the chance of developing dental problems and that if these medications are truly needed one should not allow these dental issues to prevent therapy.