Lifestyle and Drugs to Prevent and Treat Osteoporosis

On April 9, 2019, the U.S. Food and Drug Administration approved a new osteoporosis drug called Evenity. Bones are constantly changed by bone cells called osteoblasts that grow new bone and osteoclasts that remove old bone cells. Evenity is a monoclonal antibody that blocks the effects of the protein sclerostin that encourages the growth of osteoclasts that remove old bone cells. So when you block osteoclasts that remove old bone cells, you increase the size and strength of bones even though you are not increasing the osteoblasts that grow new bone. Evenity has a slightly increased risk for heart attacks and strokes and is very expensive, may not be covered by insurance, and is licensed only for postmenopausal women at high risk for fractures. Another similar drug called Prolia (denosumab) is already on the market.

Your bones are strongest at age 30. After that, you spend the rest of your life losing bone as well as muscle mass. More than 44 percent of adults over age 50 in the U.S. suffer from increased risk for breaking bones when they fall (J Bone Miner Res, 2014 Nov; 29(11): 2520–2526). Up to 25 percent of patients who develop osteoporotic bone fractures suffer another fracture within 10 years, so most doctors treat people who break bones from falling with drugs to slow down their progressive loss of bone (JAMA Netw Open, July, 2018;1(3):e180844). Fewer than 10 percent of women take medications to treat osteoporosis after their first hip fracture (JAMA Netw Open, 2018;1(3):e180826), probably because of the high cost of these drugs and the slightly increased risk for breaking jaw or hip bones in those who take the drugs for more than four years.

Lifestyle Factors to Make Bones Stronger Because aging causes everyone to lose bone size and strength, everyone should follow the lifestyle rules for slowing bone loss with aging. These include:

• regular weight-bearing exercise

• a healthful anti-inflammatory diet

• not smoking

• restricting alcohol

• getting sufficient dietary calcium and vitamin D

• avoiding drugs that weaken bones

• avoiding obesity and diabetes

Anti-Inflammatory Diet Helps to Prevent Osteoporosis Your bones remodel and change all the time, with cells called osteoblasts constantly building bones and other cells called osteoclasts taking old cells out. If your immune system is over-active, it can slow down the osteoblasts to weaken bones (Endocrinology, Jan 2004;145(1):447–452). Your immune system is supposed to kill germs that attack you, and then when the germs are gone, your immune cells and chemicals are supposed to dampen down. If your immune system stays active when the threat is gone, it can use the same defenses against invading germs to attack you. This is called inflammation. Anti-inflammatory foods help to dampen down your immune system, while pro-inflammatory foods damage tissue to turn your immune system on. Anti-inflammatory foods include vegetables, fruits, whole grains, beans, nuts and seeds. Pro-inflammatory foods include meat, fried foods, sugar-added foods and all drinks with sugar in them.



• A study that followed 3648 women for eight years found that those who ate the most pro-inflammatory diets were at increased risk for osteoporosis and bone fractures (Osteoporosis International, October 13, 2017;1-9).

• Older men who ate the most dietary fiber in cereals, fruits, vegetables, nuts and beans had the least hip bone loss as they aged (Journal of Bone and Mineral Research, October 13, 2017).

Avoid Overweight and Diabetes Since obese people often have big bones, doctors used to think that excess weight would strengthen bones, but it does not. When blood sugar levels rise too high, sugar sticks to the outer membranes of cells and destroys them. This applies to bone cells and explains why diabetes is a major risk factor for osteoporosis (World J Diabetes, Aug 15, 2013;4 (4): 101–113). All risk factors for diabetes are also risk factors for osteoporosis: excess belly fat, insulin resistance, high blood sugar levels, and lack of exercise (Clinical Endocrinology, April 15, 2019). The bones of diabetics are significantly weaker than those of non-diabetics (Bone, Dec 2015;81:152-160). Overweight diabetics have a very high rate of osteoporosis (Diabetes & Metabolism, June 2008;34(3):193-205) and bone fractures (J Bone and Min Res, November 2012;27(11):2231–2237).

Get Calcium and Protein From Your Food Most scientists feel that you need an adequate amount of calcium to keep your bones strong (Maturitas, 2018;107:7), but a review of the world's literature shows that neither a high calcium diet nor calcium pills strengthen the bones of people over 50 (British Medical Journal, published online Sep 30, 2015). Another study showed that dietary calcium appears to have no effect on the rate of fractures in postmenopausal women (Nutrition, June, 2009;25(6):647-54). Furthermore, no evidence exists that consuming more calcium than the recommended dietary allowance will result in better bone health or any other health benefits. (Ann Intern Med, October 25, 2016). People who take in relatively low amounts of calcium on a plant-based diet are not at higher risk for fractures than those who take in much larger amounts of calcium (Journal of Bone and Mineral Research, May 23, 2016). A review of 33 different clinical trials involving more than 51,000 participants, older than 50, found no significant association between calcium or vitamin D supplements and a person's risk of hip fracture or other broken bones, compared with people who received placebos or no treatment at all (JAHA, Dec 19, 2016;5(16):004413). See Get Calcium from Foods, Not Pills

Some people believe incorrectly that high protein intake causes acid loading that takes calcium out of bones. A review of studies shows that excess protein does not increase fracture risk (Am J Clin Nutr, 2009;90:1674-92). Adequate protein intake helps to keep bones strong (Am J Epidemiol, 1996;143:472-9) and most experts now feel that a low protein intake, not excess protein intake, is associated with osteoporosis (J Clin Nutr, 2017;105:1528-1543).

Available Drugs to Treat Osteoporosis

• Bisphosphonates include brand names Fosamax, Boniva, Skelid, Reclast, Zometa, Bonefos, Actonel and Aredia, and their generic equivalents. Bones are constantly shedding and making new cells, and after age 30, bones lose more cells than they replace, causing a progressive loss of bones. Bisphosphonate drugs do not build new bone; they slow down the loss of old bone cells. On rare occasions, they have been linked to increased risk for fractures of hip and jaw bones.



• Zoledronic acid or zoledronate is a bisphosphonate given intravenously once a year. It reduces the rate of loss of old bone cells. It has been shown to reduce vertebral fracture risk by 70 percent, hip fractures by 41 percent and other fractures by 25 percent. It should not be given to people with kidney damage.



• Teriparatide (brand name Forteo) is a form of parathyroid hormone given in one-a-day injections. It has been shown to reduce vertebral fracture risk by 65 percent and non-vertebral fractures by 53 percent in treatment lasting 18 months. Side effects include leg cramps, nausea and dizziness, and the drug may be associated with increased bone cancer risk.



• Denosumab (brand name Prolia) is a human monoclonal antibody that over three years has reduced vertebral fracture risk by 68 percent, hip fracture risk by 40 percent and other fractures by 20 percent. It is given as a twice-yearly injection. Side effects include low calcium, skin rashes and infections.



• Romosozumab-aqqg (brand name Evenity) is the new drug recently approved by the FDA. Evenity is a monoclonal antibody similar to Prolia. One dose of Evenity consists of two injections, one immediately following the other, given once a month by a health professional. The injections can be given for only one year as the drug stops working after about 12 doses.

My Recommendations Osteoporosis risk increases with aging in everyone. Drugs may be necessary to prevent fractures for certain people who have osteoporosis, but they can also have side effects. You and your doctor need to discuss these and make your decisions.

The lifestyle habits that help to prevent osteoporosis (listed above) are the same ones that reduce risk for heart attacks, diabetes, dementia, strokes and other life-shortening diseases, so they should be followed by everyone. The recommended lifestyle changes have only positive effects.

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