Natural treatments for osteoporosis

DEFINITION: Treatment of bone loss caused by aging, smoking, lack of exercise, and other factors.

• PRINCIPAL PROPOSED NATURAL TREATMENTS: Calcium and vitamin D, genistein and other isoflavones, ipriflavone, strontium, vitamin K
• OTHER PROPOSED NATURAL TREATMENTS: Black cohosh, black tea, boron, dehydroepiandrosterone, Epimedium brevicornum, estriol, fish oil, gamma-linolenic acid, reducing high homocysteine with folate and vitamin B₁₂, magnesium, manganese, phosphorus, progesterone, royal jelly, silicon, Tai Chi, trace minerals
• HERBS AND SUPPLEMENTS TO USE WITH CAUTION: Vitamin A

Introduction

Many factors are known or suspected to accelerate the rate of bone loss. These factors include smoking, alcohol, low calcium intake, lack of exercise, various medications, and several illnesses. Excessive consumption of vitamin A may also increase the risk of osteoporosis, and rapid weight loss may increase the risk in postmenopausal women. Several studies have also shown extreme, raw-food vegan and vegetarian diets lead to significant bone thinning.

In general, women are far more prone to osteoporosis than men. For this reason, the following discussion focuses almost entirely on women.

Hormone replacement therapy prevents or reverses osteoporosis in women. However, long-term use of hormone replacement therapy has been found to be unsafe, so conventional medical treatment for osteoporosis in women centers mainly on drugs in the bisphosphonate family, including Fosamax (taken with calcium and vitamin D).

Exercise, especially weight-bearing exercise, almost certainly helps strengthen bone (although the evidence for this is weaker than one might expect). Minimal evidence suggests that the Chinese exercise Tai Chi may also provide some benefit.

Principal Proposed Natural Treatments

There is good evidence that people with osteoporosis, or who are at risk for it, should take calcium and vitamin D supplements regardless of what other treatments they may be using. Substances called isoflavones found in soy and other plants may be helpful for osteoporosis (and for general menopausal symptoms). Vitamin K and a supplement called strontium ranelate have also shown promise. A semisynthetic isoflavone called ipriflavone has shown considerable promise for osteoporosis, but safety concerns have decreased its popularity.

Calcium and vitamin D. Calcium is necessary to build and maintain bone, and vitamin D is required for the body to absorb calcium. Many people need more calcium in their daily diet. Although the body can manufacture vitamin D when exposed to the sun, supplemental vitamin D may be necessary because of the common use of sunscreen.

Calcium supplements such as calcium citrate, calcium carbonate, and calcium phosphate are available. The body easily absorbs calcium citrate supplements, including Citrical and Solgar, and calcium phosphate supplements like Posture are also well-absorbed by the body. Cost-effective calcium carbonate supplements like Tums and Rolaids may cause gas or constipation and should be taken with food.

According to most studies, calcium supplements (especially as calcium citrate and taken with vitamin D) help slow bone loss in postmenopausal women. Contrary to some reports, milk is also a valuable source of calcium for this purpose. Any improvements in bone density rapidly disappear once the supplements are stopped. People who ensure that they continue calcium use may do better than those who occasionally forget. Vitamin D without calcium, however, does not appear to offer more than minimal bone-protective benefits for older adults.

The effect of calcium and vitamin D supplementation in any form is relatively minor and may not be strong enough to reduce the rate of osteoporotic fractures. A large study of more than three thousand postmenopausal women between sixty-five and seventy-one found that three years of daily supplementation with calcium and vitamin D was not associated with a significant reduction in the incidence of fractures. The use of calcium supplements early in life might prevent problems later, especially when children also engage in physical exercise; however, study results are somewhat contradictory.

One study found benefits for older men using a calcium- and vitamin D-fortified milk product. However, there are some concerns that excessive calcium intake could raise the risk of prostate cancer in men.

Vitamin D and calcium taken together may also have a modestly protective effect against the severe bone loss caused by corticosteroid drugs such as prednisone. Certain other supplements may enhance the effects of calcium and vitamin D. One study found that adding various trace minerals (zinc at 15 milligrams [mg], copper at 2.5 mg, and manganese at 5 mg) produced further improvement. However, copper by itself may not be helpful.

There is some evidence that essential fatty acids may also enhance the effectiveness of calcium. In one study, sixty-five postmenopausal women were given calcium with either a placebo or a combination of omega-6 fatty acids (from evening primrose oil) and omega-3 fatty acids (from fish oil) for eighteen months. At the end of the study period, the group receiving essential fatty acids had higher bone density and fewer fractures than the placebo group. However, a similar twelve-month double-blind trial of forty-two postmenopausal women found no benefit from essential fatty acids. The explanation for the discrepancy may lie in the differences among the women studied. The first study involved women living in nursing homes, while the second studied healthier women living on their own. The second group of women may have been better nourished and already receiving sufficient essential fatty acids in their diet. Vitamin K may also enhance the effect of calcium.

Vitamin D may offer another benefit for osteoporosis in older adults. Most, though not all, studies have found that vitamin D supplementation improves balance in older adults (especially women) and reduces the risk of falling. Because the most common adverse consequence of osteoporosis is a fracture caused by a fall, this could offer a meaningful benefit. Also, there is weak preliminary evidence that calcium supplementation in healthy, postmenopausal women may slightly increase the risk of cardiovascular events, such as myocardial infarction.

Genistein and other isoflavones. Soy contains substances called isoflavones that produce effects in the body somewhat similar to the effects of estrogen. (For this reason, they are called phytoestrogens.) Although study results are not entirely consistent, growing evidence suggests that genistein and other isoflavones can (like estrogen) help prevent bone loss.

For example, in a one-year, double-blind, placebo-controlled study, ninety women ages forty-seven to fifty-seven were given genistein at a dose of 54 mg per day or standard hormone replacement therapy (HRT) or placebo. The results showed that genistein prevented bone loss in the back and hip to approximately the same extent as HRT. No adverse effects on the uterus or breast were seen. A subsequent two-year double-blind study of 389 postmenopausal women with mild bone loss found that 54 mg of genistein plus calcium and vitamin D improved bone density to a greater extent than did calcium and vitamin D alone. However, a fairly high percentage of participants given genistein experienced substantial digestive distress.

In a one-year, double-blind, placebo-controlled study of 203 postmenopausal Chinese women, soy isoflavones at 80 mg daily had mildly positive protective effects on bone mass in the hip. This supplement contained 46.4 percent daidzein, 38.8 percent glycitein, and 14.7 percent genistein.

Another study evaluated an isoflavone supplement made from red clover (Trifolium pratense), containing 6 mg biochanin A, 16 mg formononetin, 1 mg genistein, and 0.5 mg daidzein daily. In this one-year, double-blind, placebo-controlled study of 205 people, the use of red clover isoflavones significantly reduced loss of bone in the lumbar spine. Benefits were also seen in a one-year, double-blind, placebo-controlled study using an extract made from the soy product tofu.

However, it is unclear if consuming foods rich in isoflavones offers the same benefits. For example, in a placebo-controlled study involving 237 healthy women in the early stages of menopause, consuming isoflavone-enriched foods (providing an average of 110 mg of isoflavone daily) for one year did not affect bone density or metabolism. However, a review of research conducted in the first two decades of the twenty-first century found isoflavones positively impact overall health, including a reduced risk of osteoporosis.

The effect of isoflavones on bone may be more complex than that of estrogen. Bones undergo two opposite processes at once: bone breakdown and bone formation. Estrogen acts on the first of these processes by inhibiting bone breakdown. Isoflavones may affect both sides of the equation at once, inhibiting bone breakdown while at the same time enhancing new bone formation.

In about one in three people, intestinal bacteria convert some soy isoflavones into a substance called equol. Isoflavones may have a greater bone-protecting effect in such equol producers.

Strontium. Growing evidence indicates that the mineral strontium (as strontium ranelate) is effective as an aid in the treatment of osteoporosis. The best and largest study on strontium was a double-blind, placebo-controlled study of 1,649 postmenopausal women with osteoporosis. In this three-year study, a dose of strontium ranelate at 2 grams (g) daily significantly increased bone density in the spine and hip and significantly decreased the rate of vertebral fractures.

While some treatments for osteoporosis act to increase bone formation and others act to decrease bone breakdown, some evidence suggests that strontium ranelate has a dual effect, providing both these benefits at once. There is one major caveat, however. All major controlled clinical trials of strontium ranelate have involved some of the same researchers. Entirely independent confirmation is needed. It is not clear to what extent the “ranelate” portion of strontium ranelate is necessary for this benefit or whether other strontium salts would work too. (The strontium used in these studies is not the same as the radioactive strontium that was such a concern during the decades of above-ground atomic testing in the mid-twentieth century.)

Vitamin K. Increasing but inconsistent evidence indicates that vitamin K may help prevent osteoporosis. It may work by reducing bone breakdown rather than by enhancing bone formation.

Perhaps the best evidence for a beneficial effect comes from a three-year, double-blind, placebo-controlled trial of 181 women. Participants, all postmenopausal women between the ages of fifty and sixty years, were divided into three groups: placebo, calcium plus vitamin D plus magnesium, or calcium plus vitamin D plus magnesium plus vitamin K (at a dose of 1 g daily). Researchers monitored bone loss by using a standard dual-energy X-ray absorptiometry bone density scan. The results showed that the study participants using vitamin K with the other nutrients did not lose as much bone as those in the other two groups. However, another placebo-controlled trial involving 452 older men and women with normal levels of calcium and vitamin D failed to demonstrate any beneficial effects of 500 micrograms per day of vitamin K supplementation on bone health over three years.

Ipriflavone. Ipriflavone is a semisynthetic variation of soy isoflavones. Ipriflavone appears to help prevent osteoporosis by interfering with bone breakdown. Estrogen works in much the same way, but ipriflavone does not appear to produce estrogenic effects anywhere else in the body other than in bone. For this reason, it probably does not increase the risk of breast or uterine cancer. However, it also does not reduce the hot flashes, night sweats, mood changes, or vaginal dryness of menopause. In addition, it may cause health risks of its own.

Numerous double-blind, placebo-controlled studies involving more than seventeen hundred participants have examined the effects of ipriflavone on various forms of osteoporosis. Overall, it appears that ipriflavone can stop the progression of osteoporosis and perhaps reverse it to some extent. For example, a two-year double-blind study followed 198 postmenopausal women who had evidence of bone loss. At the end of the study, there was a gain in bone density of 1 percent in the ipriflavone group compared to a loss of 0.7 percent in the placebo group.

Conversely, the largest and longest study of ipriflavone found no benefit. In this three-year trial of 474 postmenopausal women, no differences in the extent of osteoporosis were seen between ipriflavone and placebo groups. However, for reasons that are not clear, the researchers in this study gave women only 500 mg of calcium daily. All other major studies of ipriflavone gave participants 1,000 mg of calcium daily. Ipriflavone may require a higher dose of calcium to work properly.

Ipriflavone may also be helpful for preventing osteoporosis in women who are taking Lupron or corticosteroids, medications that accelerate bone loss. (However, the combined use of ipriflavone and drugs that suppress the immune system, such as corticosteroids, presents risks.)

There is some evidence that combining ipriflavone with estrogen may improve benefits against osteoporosis. However, it is not known whether such combinations increase or decrease the other benefits and adverse effects of estrogen-replacement therapy. Finally, for reasons that are not clear, ipriflavone appears to be able to reduce pain in osteoporosis-related fractures.

Other Proposed Natural Treatments

Magnesium supplements are often said to help build strong bones, but only minimal evidence supports this claim. It has been suggested (though with little meaningful supporting evidence) that the typical American diet causes the body to become acidic, leading to bone loss. One study tested potassium citrate as a treatment for bone loss, believing that this supplement would counteract this hypothesized diet-related acidity. This one-year study of 161 postmenopausal women indicated that potassium citrate reduced bone loss to a greater extent than the potassium chloride placebo. This study had numerous problems in design, analysis, and reporting, so its results are unreliable. It may, however, indicate that the citrate part of potassium citrate has some bone-protective effects. If this is true, it could explain why calcium citrate has, in some studies, proven more effective for treating or preventing osteoporosis than other forms of calcium.

Observational studies hint that higher levels of homocysteine might increase the risk of osteoporosis. Vitamins B₁₂, B₆, and folate are known to reduce homocysteine levels. On this basis, supplementation with these vitamins has been proposed to prevent or mitigate the effects of osteoporosis. One double-blind study found weak evidence that supplemental folate and vitamin B₁₂ (known to reduce homocysteine) might reduce the risk of osteoporotic fractures in people who had had a stroke. However, two other studies failed to find that the use of mixed B vitamins had any positive effect on bone density or chemical markers of bone turnover.

Some evidence suggests that the hormone dehydroepiandrosterone (DHEA) may be helpful for preventing or treating osteoporosis, especially in postmenopausal women older than age seventy years. Also, one study found weak evidence that DHEA might be helpful for preventing the osteoporosis that sometimes develops in women with anorexia nervosa.

Chinese studies suggest that the herb Epimedium brevicornum has phytoestrogenic effects and, on this basis, may be helpful for preventing bone loss. (E. brevicornum is related, but not identical, to E. sagittatum, otherwise known as horny goat weed.)

Preliminary evidence suggests that black tea may help protect against osteoporosis. Similarly weak evidence hints that the herb black cohosh (Actaea racemosa or Cimicifuga racemosa) might help prevent osteoporosis. Although it has long been stated that high phosphorus intake from the consumption of soft drinks might lead to osteoporosis, there is no solid evidence for this claim. Elevated intake of phosphorus may help prevent osteoporosis. The reason is that bone contains both calcium and phosphate.

According to one preliminary study, but not another, boron may be helpful for preventing osteoporosis. However, there are some concerns that boron supplements may raise levels of the body’s own estrogen, especially in women on estrogen-replacement therapy, and therefore might present an increased risk of cancer. To increase boron intake, one should eat more fruits and vegetables.

One study widely advertised as showing that silicon is helpful for osteoporosis actually failed to show much of anything. Extremely weak evidence hints at possible benefits for osteoporosis through the use of royal jelly.

Although it has long been believed that consuming too much protein (especially animal-based protein) increases the risk of osteoporosis, the balance of available evidence suggests that a high protein intake may help strengthen bone. One study found that calcium supplements may better strengthen bones in people with relatively high protein intake than in those with lower intake.

Some research suggests that water fluoridation helps prevent osteoporosis, while others suggest it causes the condition. However, modern evidence suggests that it does neither. Studies investigating geographical regions with and without water fluoridation and the incidence of hip fractures and osteoporosis diagnoses have failed to find any correlation.

Progesterone. Many books promote the idea that natural progesterone prevents or even reduces osteoporosis. In this case, the term “natural” means the same progesterone found in the body. It is still made synthetically, but it is called natural progesterone to distinguish it from its chemical cousins known as progestins. Generally, prescription progesterone is actually a progestin.

The progesterone-osteoporosis story began with test-tube and other preliminary studies suggesting that progesterone or progestins can stimulate the activity of cells that build bone. Subsequently, a poorly designed and uncontrolled study (actually, a series of case histories from one physician’s practice) purportedly demonstrated that progesterone cream can slow or even reverse osteoporosis.

However, a one-year double-blind trial of 102 women using either progesterone cream (providing 20 mg progesterone daily) or placebo cream, along with calcium and multivitamins, found no evidence of any improvements in bone density attributable to progesterone. Furthermore, in a three-year study of 875 women, combination treatment with estrogen and oral progesterone was no more effective for osteoporosis than estrogen alone.

Estriol. Some alternative medicine practitioners have popularized the use of a special form of estrogen called estriol, claiming that, unlike standard estrogen, it does not increase the risk of cancer. However, this claim is unfounded.

Controlled trials performed in Japan have found that estriol helps prevent bone loss in menopausal women, although one small study found no benefit. However, like other forms of estrogen, oral estriol stimulates the growth of uterine tissue. This leads to a risk of uterine cancer.

In a placebo-controlled study of 1,110 women, greater uterine tissue stimulation was seen among women given estriol orally (1 to 2 mg daily) than those given placebo. Another large study found that oral estriol increased the risk of uterine cancer. In another study of 48 women given estriol at a dose of 1 mg twice daily, uterine tissue stimulation was seen in the majority of cases.

In contrast, a twelve-month double-blind trial of oral estriol (2 mg daily) in sixty-eight Japanese women found no effect on the uterus. It may be that the high levels of soy in the Japanese diet altered the results. Additionally, test-tube studies suggest that estriol is just as likely to cause breast cancer as any other form of estrogen. Women who use estriol should consider it like any other form of estrogen.

Other herbs that lack scientific evidence but have been proposed as treatments or prevention methods for osteoporosis include horsetail (Equisetum arvense), kelp (Fucus vesiculosus), oat straw (Avena sativa), carotenoids, and melatonin.

Herbs and Supplements to Use with Caution

Some research suggests that excessive intake of vitamin A may increase the risk of osteoporosis. Herbs and supplements may interact adversely with drugs used to treat osteoporosis, so people should be cautious when considering the use of herbs and supplements.

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