10) OSTEOPOROSIS 2010

In the mid-1980’s, osteoporosis became a household word for the first time. It was described as deteriorated thinning bones common in aging. Because bones are made of primarily calcium, the theory was advanced that Americans are not eating enough calcium, and we should take high dose calcium supplements .This theory has been ingrained in Americans minds and accepted as the whole truth.

There are problems with this approach.

1. In “third world” countries, such as African countries prior to the 1960’s, osteoporosis was studied. Osteoporosis was extremely rare. The people in most of these countries drank no milk or ate other dairy food after infancy. Their total calcium intake was very small, mainly coming from fruits and vegetables. The dairy industry has supported this type of research with millions of dollars of grants. Vitamin D drastically increases the absorption of calcium that is taken in, so it makes sense that the calcium requirement is greatly reduced when the vitamin D level is ideal instead of insufficient.

2. The countries with the highest calcium intake per capita are the United States, Denmark, and Israel. The countries with the highest incidence of osteoporosis are the United States, Denmark, and Israel.

3. The Eskimos of North America have the highest incidence of osteoporosis in the world. They take in one of the highest amounts of calcium of any ethnic group. (With the Eskimos, it’s not from dairy, it’s from fish bones). If calcium was a significant factor, they would have among the lowest rate, not the highest rate.

4. And very importantly, the intake of calcium (in the form of supplement tablets) had greatly increased in the United States in the past 25 years. According to the calcium theory, the incidence of osteoporosis and osteoporotic fractures (age-adjusted) should have shown a significant decrease). Instead, it has greatly increased.

The effect on vitamin D on bones has been known for close to a century. Rickets was a disease of soft bones in children that was very common a century ago in the United States among children who were big city dwellers and didn’t get much sun exposure, It was discovered that giving infants 400 units of vitamin D will largely prevent rickets. The public health solution to this was to add 100 units of Vitamin D for every 8 oz. glass of milk. (There is practically no vitamin D in cow’s milk when it is fresh from the cow). It worked; 4 glasses a day (400 units) largely prevents rickets. The dairy industry has been promoting milk for over a century as a source of calcium and vitamin D. However 400 units of vitamin D prevent rickets but nothing else. It raises the vitamin D level an average of only 5 nanograms.

Another problem was that it was believe that the “normal” vitamin D level was 20 ng. This figure was arrived at simply by testing hundreds of “healthy” Americans and finding many fell within a range starting at 20 ng. (This same technique was used in the 1970-‘s in the determination of the “normal” cholesterol level in the 1970’s. Using this method, 250 mg. was determined to be the upper normal limit. It is well known now that this level is associated with a 400% increase in the incidence of heart attacks). It has only been in the last decade that the lowest normal level is considered to be 32 ng. (Labcorp lists 32 to 100 ng. as the normal range. Quest lists 30 to 80 ng., specifically listing 20 to 30 ng. as “insufficient.” Many early osteoporosis studies showed there was a high incidence of osteoporosis in people with vitamin D levels in the 20’s. The wrong conclusion was made that this means that vitamin D was a factor, but not an important factor, in osteoporosis. Reevaluating those hundreds of early studies, it’s now clear that osteoporosis is very rare with vitamin D levels of greater than 32 ng. In fact, studies have proven that bone density is greatest in people with levels over 40 ng. The facts point to the concept that the goal for people with osteoporosis should be at least 40 ng. (In my experience, 700 people with osteoporosis on DEXA scan have been tested; all but 4 of the 600 (99%) have levels less than 32 ng. (the 4 normal levels were in the low 30’s. Other physicians’ experiences (and large research studies) have found the same results.

In the past decade, it has become known that there is a pandemic of vitamin D insufficiency worldwide. This is attributed to living much further from the equator and wearing far more clothes than early humans, less sun exposure and the use of sunscreens (the latter two done in an effort to protect our skin from burning).

Many people are getting 25-hydroxy vitamin D levels ordered by their physicians. (The test is not ordered routinely and up until 5 years ago, virtually no one was getting tested except when ordered by a few pioneering physicians, mostly rheumatologists and the occasional endocrinologist). Now some primary care physicians are ordering it. Many are interpreting it correctly and treating with proper doses. Unfortunately others are not. The following case histories demonstrate this:

1) A 75 year old female suffered a hip fracture, spends a year in the nursing home, never getting a vitamin D level. Upon moving to this area I ordered a test on her; her level was less than 10 ng.

A word about fractures. It is believed that most fractures in the elderly are not the primary result of a fall. Frequently the bone snaps first, the person falls, and everything happens too quickly for the person to realize the pain occurred in the split second before the fall.

2) A 93 year old female suffered a fractured pelvis. Her level was 23 ng. Both these patients were undiagnosed and untreated prior to (and for a time after) their fractures. Shocking as it is, levels are not being obtained routinely on patients with osteoporosis by all physicians. (I have noticed that practically all rheumatologists are ordering the test, and some are treating deficiencies very aggressively).

3) In clinical practice, there is a growing number of physicians who routinely test. Many treat correctly and aggressively. Unfortunately many primary care physicians will test, and treat with insufficient doses for a few months, with no plan to get follow up levels in 6 months. Many physicians suffer from what has been described as “Vitamin D toxicity hysteria.” They feel that treating to a level of 40 or 80 ng. will cause toxicity that occurs when the level is over 150 ng. Scientific studies have shown that this cannot occur unless Vitamin D is taken in amounts over 20,000 units a day for an extended length of time. No physician would ever recommend this amount of vitamin D. A comparison can be made with water. If someone is foolish enough to drink several gallons of water a day, it can cause serious side effects. No one would ever say that because of this, humans should severely restrict their water intake.

Recommendations:

1. It has been recommended now for years that everyone with osteorpososi (and in fact everyone in the United States) get a 25-hydroxy vitamin D level.

2. Treatment to an ideal level is recommended. The scientific evidence proves that treatment goal should be at least 40 ng., and many experts feel 60 to 80 ng. is a more ideal level. (The level found in nature in humans with a lot of sun exposure is over 100 ng. based on sunlight exposure alone). In the case of nursing home patients with fractures, it has been shown that major doses of vitamin D for insufficiency leads to less falls and fractures within 6 months.

3. The public health recommendations are for people who do not get levels. Frequently for adults the maximum is recommended at 2000 units daily. However giving a recommendation without a blood level is equivalent to treating someone with a blindfold on and having no information. I have had one case of a 40 year old female who walked outside 6 miles a day year round in South Jersey. She took no vitamin D supplements and ate little dairy. Her level from the sun alone was 110 ng. She represents one out of 2000 people. Projected to a population of 300 million people, there may be 150,000 Americans who have this level without taking vitamin D.

4. I cannot recommend a specific dose for someone without knowing their level. Out of the 2000 people tested, I have over 1500 low levels, and I have seen follow up levels on most of them. Many people have to take 5,000 to 10,000 units a day to reach an ideal level. However I am not recommending this dose to anyone without obtaining a blood level and then follow-up levels at 6 months. Booster doses can be recommended by a physician for a temporary period of several months to quickly get the level up toward ideal.

5. Vitamin D should not be confused with anti-oxidants, but frequently are. There were exaggerated claims made about anti-oxidants for several decades that were not based on valid scientific medical studies or blood levels; and now in fact the downside of too many anti-oxidants is being discussed. Tens of thousands of studies on vitamin D are extensive and proven.

6. Another difference between anti-oxidant vitamins and Vitamin D: Oncologists do not recommend anti-oxidants with chemotherapy because of interference with chemotherapy. In contrast. Over 80% of cancer patients have very low levels of vitamin D, and there is significant evidence that treating insufficiency will improve results of treatment.

7. The blood test is a simple non-fasting blood test. With the proper diagnosis and coding, my experience has been that all insurance companies that pay for blood tests pay for this one.

8. In many opinions, the failure to diagnose and treat vitamin D deficiency in the last 5 years on osteoporotic patients with fractures represents malpractice. The same applies to the failure of nursing home patients to receive a routine level. This is not a complicated medical issue; once the facts are defined, it’s common sense. Two sayings about common sense certainly apply: “Nothing astonishes mankind so much as common sense.” - Ralph Waldo Emerson. “Common sense is not so common.” – Voltaire.

9. The cost of osteoporosis especially among the elderly is a major public health problem, reaching the billions (and growing each decade even adjusted for age). The government and insurance companies would realize major savings by encouraging testing. Vitamin D Supplements are extremely inexpensive.