Monthly Archives: March 2013

What Can I Do To Help My Bones?

If you have Osteopenia (thinning bones; T-score between -1 and -2.5), Osteoporosis (brittle bones; T-score ≤-2.5) or even normal bones, you can always benefit from implementing lifestyle and nutritional changes to help!

Healthy Diet
Make sure you eat enough and avoid malnutrition—eating enough is not a problem for most of us, but eating the right things often is the tricky part! A diet rich in calcium and vitamin D is important. There has been some controversy surrounding Calcium supplementation, so generally Calcium of 1000mg a day is what I recommend now (this is total in a day from supplements and diet). I recommend Vitamin D supplementation of 1000 I.U. to 2000 I.U. daily. If you have Osteopenia or Osteoporosis, then I recommend that you have your blood Vitamin D levels checked and your goal should be in the 40 to 50 range.
Calcium and Vitamin D

Vitamin K: Vitamin K is a useful co-factor in bone metabolism. Most studies for Vitamin K have been done on Japanese women and Vitamin K is widely used in Japan to help prevent bone loss and fractures. Experts do warn caution when deciding to use Vitamin K because most studies were done on the Japanese population and testing on Caucasian population did not show similar reductions in fracture risk or increase in bone density.
Isoflavones: Foods high in isoflavones (a type of ‘phytoestrogens’—plant estrogen) have been shown to help bones. Examples of such foods are: soybeans, chick peas and lentils.


Exercising at least 30 mins three times a week has been shown to reduce risk of hip fractures in older women. Exercise also helps improve your bone density, although this may not be reflective in your actual T-score, but we know that it does help improve the actual mass—we think the effects are likely more by changing architecture of the bone and improving muscle strength as well. Exercising to include walking, jumping, jogging, and resistance training are all excellent to help with your bone health.

Stop Smoking!
I often tell my patients; “there is NOTHING good that comes out of smoking” so might as well just stop and save the money! Here is another reason to quit—help your bones! As quoted from an UpToDate article, “Smoking one pack per day during adult life was associated with a 5 to 10 percent reduction in bone density.”


Certain medicines like steroids, seizure medicines, antacids (especially Proton Pump Inhibitors like Nexium, Protonix, Prevacid, Prilosec) can cause bone loss so you should try to either avoid taking these medicines for a prolonged period of time OR speak with your physicians about alternatives. Of course there are situations where you have to take these medicines (like the seizure medicines) so I often tell my patients to make sure they are good with their Vitamin D supplementation when they are on these medicines. If you have to be on prolonged steroids to treat health problems like Autoimmune Rheumatoid Arthritis, Lupus, or Psoriasis, I would recommend speaking with your doctor about doing a Bone Density Scan (DEXA) after 6 months of being on the medicine to make sure there is no extensive bone loss occurring.


Treasure your bonesBone health has been a topic of a lot of discussions and controversies in the past few years. With new treatment medication options, conflicting reports about calcium supplementation, questionable effects of fosamax and such drugs, it can be quite overwhelming! This post is dedicated to teach patients about the basics of bone density to get a better understanding of what we are looking for.

Strong and healthy bones are very important because it is our bones that keep us strong, mobile, and upright! Weak and unhealthy bones can truly affect the quality, as well as the quantity of our lives. When we talk about “healthy” or “strong” bones we are referring to their mass and density. You can have normal bones, Osteopenia (“thinning” bones) or Osteoporosis (“brittle” bones). Low bone mass/density can put you at high risk for fractures. The density of our bones is measured by a radiological x-ray test called BONE DENSITY (DEXA SCAN)—Dual Energy X-ray Absorptiometry. These DEXA scans give us a number called T-score which has helped standardize our discussion about bones–so when you talk to one doctor about your T-score, another physician knows exactly what you are saying and the health of your bones! T-score is your bone mass compared to normal healthy young adult. There is another number called the Z-score, which is your score compared to patients of your age/gender/ethnicity group. We make our treatment decisions based on the T-score. Although all bones in our body can weaken, we measure the bones in our lower spine and hips. Sometimes if patients have a lot of arthritis in their spine or an artificial hip, we check the arm to measure bone density.

Bone Density Machine
The radiation levels involved in a DEXA scan is very low—almost negligible. The technician doing the test does not need to wear protective shields. For safety reasons, it is recommended the technician sit 3 feet away from the table when a patient is being scanned.

There can be significant difference in technologies used by different manufacturers and sometimes different models of the DEXA machines; therefore, it is very important for you to go to the same facility each time you have a bone density scan to get more consistent readings. Of course if you move out of town due to relocation or can no longer go to the facility due to insurance reasons, then you need to start at a new one.

Courtesy Yale Medical Group

Courtesy Yale Medical Group

Decision to treat low bone density is quite individualized. Not everyone necessarily needs prescription medicines. The World Health Organization released an algorithm to help physicians decide which patient will benefit from treatment and which can be monitored. The algorithm is called “FRAX” score. It is an algorithm that takes into account your Age, Gender, Weight, Height, Ethnicity, Smoking status, Prior fractures, Family History of fractures, Alcohol use, use of steroid medicines, T-score, and history of autoimmune arthritis to help decide if you will benefit from medicines to help with Osteopenia or Osteoporosis. You should speak with your physician to see if you need treatment.

There are many causes of low bone density including family history, low body weight, ethnicity, loss of estrogen for women in menopause, low testosterone in men, medications like steroids and antacids, calcium and vitamin D deficiency, hyperthyroidism (overactive thyroid) to name just a few.

To read more about prevention options, please read “What Can I Do To Help My Bones?”

What’s Up With Vitamin D?

Vitamin-DVitamin D is an essential nutrient that plays an important part in our bodies for balance and metabolism of calcium and bone health. The main source of Vitamin D is from sunlight as sunlight is needed to help convert pro-Vitamin D which is in our skin to the active Vitamin D (called cholecalciferol) which the body can use. Other sources of Vitamin D are through diet such as fortified milk (which means that we as a society have added Vitamin D in the milk we purchase, it is not naturally present in animal milk), fatty fish, cod liver oil, and eggs to name a few.
Vitamin D Sources

Vitamin D deficiency is increasingly being diagnosed for multiple reasons. One of the big ones is because we, frankly, are checking for it! Another big reason is because we have become more of an “indoor society” which limits our sun exposure: we are either indoors at home, inside a building for work, or in our cars trying to get to one of those two places! When we are outside, we use sunscreen which blocks the absorption of the rays needed to do the Vitamin D conversion. Sunscreen is important! So don’t stop using it, especially if recommended by your doctor! People with pigmented skin (African Americans, South Asians, Africans etc) have higher incidence of Vitamin D deficiency than their lighter skin counterparts due to the melanin content in their skin. Melanin is the substance in our skin that gives us our color–more melanin a person has the darker their skin color. Melanin also helps prevent skin cancer because it blocks sun rays absorption, but as you can imagine, this is the same reason why darker pigmented people would have higher risk of low Vitamin D.

During winter people tend to have lower Vitamin D levels because there is less sun around due to shorter days thus less sun exposure. Elderly are more prone to Vitamin D deficiency because they tend to stay indoors more. Residents of certain cold countries such as the Netherlands, Greenland etc are low in Vitamin D due to less sun in those regions.

People who avoid dairy due to medical or personal preferance reasons tend to be low in Vitamin D as well due to lack of dietary intake.

Aside from bone health, Vitamin D helps your immune system. It has been shown to help prevent certain cancers including Melanoma, Prostate Cancer, and Colon Cancer. It helps with autoimmune conditions. Multiple studies have shown Vitamin D to help prevent falls; especially in the elderly population (one of the best ways to prevent bone fractures is to prevent falling!). Vitamin D has also been shown to help with decreasing depression. Certain neurological conditions such as Multiple Sclerosis have shown to benefit from Vitamin D supplementation as well. Low levels of Vitamin D have been associated with development of Dementia or decline in memory.

American Journal of Clinical Nutrition published an article where they found that low levels of Vitamin D were “associated with an increase in all-cause mortality [i.e.: death] and mortality from cardiovascular disease, cancer, and respiratory illness.”

Normal levels of Vitamin D are greater than 30. I typically like most of my patients to be around the 40 to 50 range. I recommend my patients with history of Melanoma keep their Vitamin D above 50. If your Vitamin D is low, your doctor will likely give you the prescription dose of Vitamin D of 50,000 I.U. to take once a week for a typical course of 12 weeks to help restore your levels. It is recommended you go back in at the end of the treatment and get your levels rechecked to see if the levels got better.

Many times I have cases where patients tell me “my Vitamin D always comes as low” or “I had my Vitamin D level checked, it was low, I took the prescription medicine so why is it low again?”. The prescription Vitamin D is an excellent way of helping RESTORE OR INCREASE your levels to a NORMAL range; however, you need to do something on a regular basis to help MAINTAIN and KEEP your levels up. Remember, our main reason for low Vitamin D is our LIFESTYLE: a lack of sun exposed lifestyle, which will not change regardless of the prescription Vitamin D. Therefore, after you are done with your Vitamin D prescription, speak with your physician about MAINTAINENCE Vitamin D. I typically ask my patients to take Vitamin D-3 (cholecalciferol) 1000 I.U. to 2000 I.U. daily to help keep their levels up.