The Osteoporosis Rx

Readers Summary

  1. What are the rules that govern The Osteoporosis Rx?
  2. Does old age cause osteoporosis?
  3. Are synthetic hormones as good as bioidentical hormones?
  4. What is the exercise Rx for osteoporosis?
  5. What is The Osteoporosis Rx?

Osteoporosis is a disease in which the bones become weak and are more likely to break. People with osteoporosis most often break bones in the hip, spine, and wrist. If you think this problem is not common, let me pick up the rock you must have been sleeping under. In the United States, more than 60 million people either already have osteoporosis or are at high risk, due to low bone mass.   Many people falsely believe that fats and proteins can harm bone density because of some flawed data in childhood epilepsy data.  Recently, these ideas have been overturned. 

RULE 1. If one is leptin resistant, Wolff’s law is null and void, and you are at very high risk for a fractured vertebrae or hip/wrist. You should stop here and go read EMF-8 Quantum Bone for the pathophysiology of this disease.  The key features are to increase your spring water intake to 1-1.5 gallons of non fluoridated water a day and strict avoidance of artifical light and the use of pulsed EMF technology devices.  This means that “normal conventional wisdom osteoporotic treatments” and exercise will not heal or strengthen a bone until the underlyig pathophysiology is repaired first. When a person has high levels of leptin, it eventually drives cortisol higher and this stimulates even more inflammatory cytokines from cells. As this occurs, LR develops all over the body. Cortisol is one of the major hormones involved in the sympathetic nervous system. When cortisol is chronically high, as I told you in the Hormone 101 blog, it’s bad news. When someone is leptin resistant, they block osteocalcin’s main function and this causes osteoporosis. This is one major reason why fat people lose their bone. It also definitely proves that Wolff’s law is null and void when you are LR. Even resistance exercise maybe harmful when this occurs. Bone only strengthens when the underlying hormonal terroir is working properly. In LR, it is seriously broken.  Ketosis is protective to bone.

RULE 2. Andropause and Menopause are associated with osteoporosis, and not caused by it. In both situations the best treatment to overcome it is to change your diet to a high fat and protein diet. You would be a wise patient to avoid all bisphosphonate drugs until it’s too late. This will be hard to do, because most clinicians will push drug treatments over evolutionary medicine treatments. Remember The Seven Dwarfs of menopause: Itchy, bitchy, sleepy, sweaty, bloated, forgetful, and all dried up…and the bones are real dried up!

RULE 3. A bad diet is a common cause of osteoporosis, or osteopenia, and not menopause or andropause. Low vitamin K2, dehydration, and poor intracellular magnesium status are the major players.  Vitamin K2 is a fat soluble vitamin so eating fats is a smart play.  Bad hormones assays are additive to the problem. Hormones are a proxy for the amount of electrons in our mitochondria.  This ties directly to a high redox potential.  This is important to understand because I see 30% of patients below 35 yrs old now suffering with bad bone when I perform a spine surgery on them. I find this incidentally often at surgery, when we are inserting a screw into the bone and it feels like the screw is going in sheetrock compared to a wall stud. Once this happens, I run some tests post op and find out that they do have it. I no longer rely on bone density testing. If you go and have a formal bone density study done, often its findings make the doctor believe that you have no bone issues present. Why? Because the standard bone density tests are neither sensitive or specific enough to pick up more subtle disease. The gold standard in diagnosis occurs when a surgeon places a screw or needle into the bone at surgery or biopsy. Nothing is more accurate. It also must be remembered that osteoporosis in evolution will not affect the entire skeleton uniformly all at once. It tends to affect certain areas before others, and can give a patchy distribution over the skeleton. This also is another reason why the bone density exams are off because they represent and arithmetic average of the bones sampled, and not the true overall bone density. The most accurate place to check bone density is in the wrist, because in this area, humans rarely get weak bone or osteoarthritis that can falsely elevate the result. Yes, osteoarthritis is the most common cause of false positive testing with standard bone density testing. Just about everyone in the USA has OA over the age of fifty. Sadly, few clinicians realize this and most imaging centers and hospitals do not spend the extra money to buy the scanning equipment to get accurate bone assays. I send all my cases to my endocrinologist, who has bought the wrist module needed for accuracy for his own bone density scanner. It is that important.

RULE 4. Osteoporosis is conventionally thought of as a disease of aging. That has to stop because it is old school conventional wisdom. What is closer to the truth is the patient’s diet. The worse the patient’s diet is, the more likely osteoporosis will be present regardless of age. The younger generation has massive unrecognized osteopenia present, because they have lived surrounded by processed food. I found this out the hard way in many spine surgeries over the last 15 years. This is due to the SAD, which causes high inflammation levels, low vitamin D levels (from lack of D in the diet), pregnenolone steal syndrome (reducing formation of D in body) and liberal use of sun block and lack of outdoor activity to gain sun exposure. I wrote about this and shared it with some of my spine and orthopedic colleagues in 2007. I was ignored back then. Two weeks ago the North American Spine Society met in Chicago. An abstract was presented at this meeting by a Dr. Jacob Buchowski. His paper won the Whitecloud Award during our recent IMAST meeting this year. It was also a hot topic talked about during the recent NASS meeting. The subject of his 2011 paper was finding an alarmingly high rate of low pre-operative vitamin D status in spine fusion patients. In his paper, he mentions that there is now 1 billion people worldwide with Vitamin D levels below 30 ng/mL. 27% of those with hypo-vitaminosis have levels below 20 ng/mL. These people carry excessive risks for spine surgery or any bone surgery. This very fact means that their prognosis is going to be suboptimal, no matter how well the surgery is done. Bad substrate bone cannot be overcome with technique, hardware, or bone morphogenic proteins. It is like trying to build a house with termite infested wood.

Sadly, most surgeons and patients only find this out during the surgery because few surgeons are screening in depth for this now very common disease. The bigger concern I have always had is that patients who are undergoing this type of surgery get simultaneous spikes in cortisol the day of surgery (due to stress), and in the post operative period for weeks, and this causes a massive transient pregnenolone steal syndrome. They also get pre op and post op antibiotics that alter their gut flora and effect the Vitamin K recycle and can cause gut dysbiosis for up to 12 months post treatment. This further deteriorates the bone quality for surgery and recovery post operatively. It is the perfect storm for a suboptimal outcome if you do not expect it. Moreover, recent orthopedic data on peri-operative total knee replacements have confirmed my clinical experience over the last ten years. The cortisol release is a massive risk for osteoporosis. The hormonal response to this can be tested and proved but few surgeons and physicians even consider it. In our hospital, four years ago, I convinced one of my pulmonologists, Dr. Michael Ramos, to check all of our patients Vitamin D levels in our ICU to test my hypothesis. During this time, he did not find one person with a normal Vitamin D level. Needless to say, this made an impact upon him, and caused him to become proactive. In our pharmacy at the time, we did not have Vitamin D3 on the formulary, because organized medicine never gave this situation a second thought. Dr Ramos sent me cadres of patients with vertebral fractures because pulmonary issues (smoking) put people at tremendous risk for developing bad bone. I spoke to Dr. Ramos often about my surgical findings, and my belief that any patient under a stressor has huge implications for development of bad bone, especially if they were eating a SAD. Sadly, most patients in most hospitals do just that. The food they are given is based upon the flawed USDA pyramid concept. This is reinforced by the employed nutritionists and dietitians who are trained to believe that a high carb, low fat diet is Optimal. So patients get no real help for osteoporosis when they are in the hospital. Dr. Ramos was critical in getting vitamin D3 on our pharmacy’s formulary, but even today we do not have all the tools we need to fight this disease (paleolithic diet options, DHEA, K2, bio-identical estrogen or progesterone creams). They do have testosterone available in injectable forms, but not in creams for ladies. I have my patients bring their medications I prescribe to the hospital to take. Most of my patients are able to leave the hospital the same day so we try to avoid this issue. Surgeries have gone from quite invasive ten years ago to today, being very minimally invasive because of the epidemiological trends I have seen occur over the last 15 years in our population. The key to surgical success these days is not the operation, but in finding a surgeon who treats osteoporosis aggressively before any surgery is done. This is the best way to get to Optimal results.  The key point for patients and PCP’s:  Vitamin D3 needs vitamin K2 to work optimally.  Giving one without the other wont work well.

RULE 5. If you have risk factors, you must have lab testing done preoperatively. In my first blog on osteoporosis, I told you all about osteocalcin and its importance in osteoporosis. This test is not done in most hospitals in the USA. Scary, is it not? There are over 1 million osteoporotic spine fractures yearly in the USA, and we are not even able to perform the best test to assess it. Moreover, the test that is used by most clinicians for fracture risk since 2008 called the FRAX test has been found to be extremely inaccurate. I have also mentioned, above that standard bone density studies are not sensitive or specific enough to be considered reliable in patients eating a SAD loaded in carbohydrates. I find the best screening study in my own clinic is a MRI, and a history and physical. It shows loss of cancellous bone, and increases of fat in the vertebral bodies or of long bones. Often, I also have labs like an HS CRP and Vitamin D level done, that also help confirm the diagnosis. Once these are present, I then begin to assess their real future risk with hormone assays.

In 2004, the JAMA had a double blind study done on the effects of DHEA in humans. People on the drug lost two pounds, and those on a placebo gained a pound. We know today that DHEA helps in weight loss, but what I found interesting in this study was that the women in the group lost 10% of the abdominal fat (proved with an abdominal MRI) and men lost 7% of their abdominal fat. This is the fat that causes IL-6 (closely related to Leptin’s chemical structure) and cortisol to rise. Elevated cortisol causes osteoporosis to occur. DHEA also helps to enzymatically alter cortisol back to cortisone; this strongly inactivates cortisol production from abdominal fat and leptin resistance. This is one of the reasons I like my at risk osteopenics patients to consider supplementing with DHEA before I ever touch them in surgery. It directly lowers cortisol levels, and simultaneously increases the sex steroid hormones that protect the bone stock from further losses in the peri operative period. High cortisol levels are consistently found in most American osteopenics due to LR. This can be offset by the surgeon by restoring DHEA, estrogen, progesterone, and testosterone to the upper quartile of normal adult youthful levels. Remember that these drugs are rarely on a hospital formulary. It means you need to have a doctor “reading the tea leaves” before you ever hit the operating room for any reason.

Progesterone has two major effects that are positive for bone. The first is that is stops osteoclasts from resorbing newly laid down bone when the person is eating a high protein and fat diet that is good for bone formation. The second lesser known effect is that progesterone is thermogenic. It raises body temperature and helps us burn fat and improve our body composition by increasing our lean muscle mass to fat ratio. This lessens the chance that we become LR and IR, and protects the newly laid down bone from bone resorption due to an elevated cortisol.

Estrogen and testosterone are both anabolic for bone formation in humans. Most clinicians are fully aware of the risks of bone loss for post-menopausal women. Few still seem to be aware that andropause carries the same risks for men. Andropause and perimenopause also occur earlier chronologically when inflammation exists due to many causes. Less than 10% of men have had normal free and total testosterone levels in my clinic over the last ten years when they are tested. It is now routinely tested for in my clinic. In menopause, less than 20% of women are on bone protective hormonal replacement, because of the terribly flawed Women’s Health Initiative Study done in the early 2000′s. Today, this study is misinterpreted and it has set back osteoporosis treatment tremendously in my view. Because of this study, even fewer women are on any progesterone replacement, which blocks bone resorption. Fewer still are using testosterone creams for bone mass protection. I have never seen one pre-op osteocalcin level drawn in any osteopenic patient at risk for diagnosis or surveillance. I believe this is because it is not offered at most facilities nationally.

What is The Osteoporosis Rx Treatment

  1. Cortisol must be neutralized after its elevation can be found. The most common reason is LR today in the USA from a SAD loaded in carbohydrates. LR nullifies Wolff’s law. Diet modification to a high fat and high protein paleolithic diet is treatment option number one in most cases. Renal osteodystrohy is one of the few causes where protein has to be limited, but fats can be used liberally to support bone mass. Pastured butter (K2 source) and grass fed meats with eggs, bacon, and coconut oil is preferred. All the hormones that are anabolic for bone formation are derived from LDL cholesterol in our diet. Vegans should pay close attention to those biologic facts. PUFA’s and carbohydrates should be extremely limited during treatment, to avoid future fractures because they generate inflammatory cytokines that favor disease progression.
  2. Age and weight are not completely indicative of real bone risk. Inflammation is, and it should be followed clinically to assess risk. Bone density testing is worthless, unless a wrist module is added to it. I have had patients in their 20′s paralyzed from osteopenic fractures.
  3. Smoking carries a 100 fold risk of developing osteoporosis. It must cease for any treatment to work
  4. Excessive drinking also elevates the risk. More than 4 oz a day is a problem.
  5. I personally avoid all conventional osteoporotic drugs because of side effect risks. In surgical cases, I now completely avoid the use of all synthetic derived bone morphogenic proteins in older patients with osteoporosis. (InFuse by Medtronic)
  6. I use high dose Vitamin D3, K2, Magnesium, in doses based upon lab data and on the severity of disease.
  7. I replace all sex steroid hormones to the top quartile found in young adults. Bio-identical HRT is preferred. I avoid synthetic hormones at all costs. Often this is tough, because many physicians are not aware of the organic chemistry of why synthetic hormones are suboptimal for the human steroid receptor.
  8. Exercise is an excellent treatment for osteoporosis. However, one must remember that if one has LR, exercise exacerbates the risk of fracture because Wolff’s law is null and void. The Exercise Rx (written below) requires Wolff’s law to be operational to work. Too often it is not. Exercise will increase growth hormone secretion which is very anabolic for bone mass accrual. Most older people have horrendous GH levels measured by IGF-1 levels. In people with IGF-1 levels below 100, I recommend use of arginine, ornathine, turmeric, and resveratrol, because all increase bone mass. Resveratrol increases bone morphogenic proteins directly.
  9. Walking is a great start for those who are debilitated. I tell my patients to park far away from doors to facilitate walking. I encourage water aerobics because of its low impact and its good skeletal effects even when Wolff’s law is null and void. I also encourage yoga and meditation for endogenous control of cortisol. Biofeedback is also a consideration if it is in the budget.
  10. Strict avoidance of NSAID’s and steroids for all osteopenics or spine fusions due to bone mass losses. These medications also cause a leaky gut and gut dysbiosis and is a major cause of persistent inflammation and bone loss.
  11. Any stressor should be aggressively treated. I usually will double doses of D3, K2, and Mg during ICU or the preoperative times.
  12. In older patients, I trim back all meds that cause osteoporosis, and I advocate strongly for hormone replacement. Progesterone is the critical for women and testosterone for men. Estrogen and testosterone are added often to women’s treatment plan by their PCP’s or Ob/GYN’s
  13. I try to limit radiation exposure to all patients with osteopenia because of its effects on bone stock.
  14. I have all thoracic fracture patients follow up with their lung specialists because each fracture limits pulmonary functioning by 5-8% and is a major cause of disability.
  15. Any spine fracture should be aggressively treated surgically as soon as it is diagnosed on STIR MRI.
  16. I keep an open dialogue with patients and family about bone risks going forward and make sure they know what to discuss with their PCPs going forward.
  17. An ounce of prevention really saves a point of cure with this disease. Mobility is the key to optimal recovery. We want patients moving naturally as soon as possible to stimulate bone formation after the diet is optimized.
  18. I do not advocate any use of Calcium with this disease because I mandate a change of diet and this diet provides ample Magnesium and Calcium and there is no need for supplementation. (Epi-paleo Rx devoid of most dairy raw or otherwise)
  19. In the severe cases, I will ask for an endocrine consult to consider Forteo and PTH if it is warranted. This is quite rare, but can be a huge help in complicated spine fractures in older patients.
  20. I advocate sun exposure for natural Vitamin D production in patients with low 06/3 ratios.

Fall prevention and the exercise Rx

After the diet is re tooled to an Epi-paleolithic diet and the underlying leptin resistance is dealt with, everything should be done to prevent falls that can cause fractures. This is where exercise comes in. I am a major advocate of lifting weights for both men and women no matter their baseline condition. If the patient is wheelchair bound, they can lift dumbbells while they watch TV and wear weighted ankle and wrist bracelets. The reason is simple. This will restore bone faster than any single thing we can offer once the dietary problem is repaired. Men and women with osteoporosis need to take care not to fall down. Falls can break bones and are a major source of disability. Once mobility is limited, the death rate can begin to grow exponentially. The goal is to restore natural mobility as soon as possible in this disease.

Some reasons people fall are:

  • Poor vision
  • Poor balance
  • Certain diseases that affect how you walk
  • Some types of medicine, such as sleeping pills.
  • Some tips to help prevent falls outdoors are:
  • Use a cane or walker
  • Wear rubber-soled shoes so you don’t slip
  • Walk on grass when sidewalks are slippery
  • In winter, put salt or kitty litter on icy sidewalks.

Some ways to help prevent falls indoors are:

  • Keep rooms free of clutter, especially on floors
  • Use plastic or carpet runners on slippery floors
  • Wear low-heeled shoes that provide good support
  • Do not walk in socks, stockings, or slippers
  • Be sure carpets and area rugs have skid-proof backs or are tacked to the floor
  • Be sure stairs are well lit and have rails on both sides
  • Put grab bars on bathroom walls near tub, shower, and toilet
  • Use a rubber bath mat in the shower or tub
  • Keep a flashlight next to your bed
  • Use a sturdy step stool with a handrail and wide steps
  • Add more lights in rooms
  • Buy a cordless phone to keep with you so that you don’t have to rush to the phone when it rings and so that you can call for help if you fall.

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Comments

  1. @Sandy You are correct. I remove all patients from all statins when they have osteoporosis because it blocks normal cholesterol synthesis that is required for the hormones that control bone density. Moreover, there is scant evidence that primary prevention for all elderly patients with hypercholesterolemia would save lives or reduce morbidity. There is really no good data that statins do anything for women for primary prevention over the age of 60. In men that number appears to be seventy. Therefore this is something you must discuss with your prescribing doctor. I suggest most people read my blog, What really causes heart disease before they ever agree to fill a Rx for a statin. Cholesterol does not cause heart disease. Inflammation does. There are better strategies to manage inflammation and heart disease risk in my view. I have pulled my own elderly family off all their statins in the last 5 years and all of them have shown dramatic improvements in muscle aches, mobility and in bone mass accural.

  2. Thank you, Dr. K. As always, I'm bookmarking to reread.

  3. Cú Chul says:

    what is the Rx for OA? thank you

  4. @Cu that is easy…..the Leptin Rx. OA at its core is a LR issue.

  5. @John If you think I have missed the mark on recommending Ca and Bisphosphonates as first line treatments I want you to read this comment made by a famous physician. "The person who takes medicine must recover twice, once from the disease and once from the medicine." William Osler, M.D.

    And just so you know the average half life for the current generation of bisphosphonate drugs is now 14 years. Are you still wondering why your mom broke her femur 4 years after she treated her osteoporotic fracture with fosamax? Again, the optimal treatment for osteoporosis is a high fat and high protein diet, loaded in pastured butter eggs, grass fed meat, offal, and coconut oil. When your mom eats this way and then she can start exercising. If she exercises too early she likely will break her other femur or develop a jaw problem because the half life of her drug she was left on for 7 years is 14 yrs. That drug will be in her osteoclasts a real long time. Think about those implications and then re read Dr Osler's quote again and see if my Rx is off.

  6. Interesting!

    I came across your blog this weekend and can't put my laptop down.

    This posting is going change my practice! Diet manipulation as a powerful treatment for osteoporosis.

    Questions:

    1. Osteoporosis and PUFA's, important to limit significantly fish oils and olive oil? Yet these are anti-oxidants and anti-inflammatory balancing the immune response in the body.

    2. IGF1 levels > 100 are known to be associated with increased rates of cancer. They are associated with IR too. I'm concerned about the negative potential of this intervention.

    3. Do you test for Vitamin D receptor polymorphisms?

    4. Do you follow osteocalcin levels?

    Great info, thanks!

    • @M Chris link

      Questions:
      1. Osteoporosis and PUFA's, important to limit significantly fish oils and olive oil?Yet these are anti-oxidants and anti-inflammatory balancing the immune response in the body. Answer: It depends upon clinical context and baseline 06/3 levels. Most people with osteoporosis have horrendous 06/3 levels and dont know it because few test for it. If they have bad levels I use fish oil but I get them off olive oil and move to ghee, pastured butter, coconut oil and palm oil.

      2. IGF1 levels & GH less than 100 are known to be associated with increased rates of cancer. They are associated with IR too. I'm concerned about the negative potential of this intervention. Answer, me I am not. When people have this level of disease it is a sign they are close to dead metabolically. When you realize this then you have to ask yourself as a clinician this question……would would it take to turn around the Titanic if you saw the iceberg early? Deck Music or radical changes? Deck music = Calcium and bisphosphonates and radical changes are making abrupt massive lifestyle changes that go against conventional medical advice. I feed them tons of fats and protein.
      3. Do you test for Vitamin D receptor polymorphisms? Answer. No but It is easy to figure out when you test them serially over two yrs. Read my vitamin D blog and I bet you see why.
      4. Do you follow osteocalcin levels? Answer Oh yes I do. I believe I am the only one in my area who does. I am a huge proponent of Vitamin K2 use for this reason. See I don't believe in just treating osteoporosis……I believe in curing it. And I have many patients in Nashville who no longer break bones when they listen to what I tell them. If they go back to a SAD they will be back. SAD = planned obsolescence for fractures.

  7. What do you think of rebounders (mini trampolines) and the soon to be available vibration plates (Marodyne Medical) for bones?

    • @Alexandra Context? for an 80 yr old women with 8 vertebral fractures? Nope. For a 25 yr old recovering anorexic……yep. Context is what you get from a clinician who thinks before action.

  8. Is your hormone replacement protocol the same for those of us who have undergone hysterectomy and oophorectomy? Thank you for all you have done and continue to do.

  9. Excellent post! Would be interested in reading a detailed post on coronary artery disease and reversal possibilities. There is much out there ranging from Ornish/Esselstyn to William Davis. Be great to hear your thoughts on it including particle sizes/amounts/mediterranean diet, etc. Thanks.

  10. "I replace all sex steroid hormones to the top quartile found in young adults.

    Bio-identical HRT are preferred.

    I avoid synthetic hormones at all costs."

    Nothing less, thank you.

    I have a questions about transport proteins:

    SHBG (testosterone, estradiol)

    albumin

    Transcortin (Cortisol, Progesterone, Aldosterone, 11-Deoxycorticosterone)

    thyroxine-binding globulin (TBG), transthyretin (T4, T3)

    they can be at levels: normal, low or high

    please discuss more common reasons of why low or why high, and how to get them back into good levels.

  11. Nice! On that interview with Jimmy Moore you mentioned how you were treating a lot of these cases just with diet. Makes sense, without he building locks, the bones break apart. My grandmother has osteoporosis and the doctors were giving her drugs without much effect. Then she started eating more nutrients and got significantly better! Keep on fighting the good fight.

  12. "Aging" is simply an excuse for poor health now. It's a farce these days when 30yr olds are claiming their neolithic diseases/poor energy is due to "old age". They need to wise up.

    • @Dan H……Art DeVany, Jeff Life and hopefully me will prove that is completely wrong. Optimal is possible no matter your age if you know what to do when you are 20, 30, 40, 50, 60 or any age.

  13. I've been working on the leptin reset for several weeks now, and have lost almost all the weight I need to lose, and my belly is almost completely flat now (wow)! I've had zero RA pain for almost 2 wks now. So with LS and a primal diet, could my autoimmune disease be improved/cured so I no longer need plaquenil? If the med leads to osteoporosis, I want to discontinue it before it becomes a problem. (I will consult with my rheumatologist before doing anything–I trust him and he's pretty progressive-I'll share this site and info with him also.)He's concerned that if I quit plaquenil and RA comes back, we may need bigger, badder drugs to fight with. Thanks Dr. K!

    • @Chris W Great news. You might want to stay tuned to my next blog because it is all about what one should consider doing after the Leptin Rx is completed and you hit all the small littel clinical targets I mentioned in the Leptin FAQ blog. I am sure you will be quite interested in it based upon your question. This is precisely how I have been living the last 5 years after I figured out how to reset a hypothalamus with the Leptin Rx rules of neuroplasticity.

  14. Thanks for another great post! I have two questions:

    1. Do you think that cracking joints – e.g., when getting up quickly from a seated position – are a symptom that indicates bone problems?

    2. You mention high dose D3, K2, and Mg based on lab data and severity of disease. What are the dosing ranges for each supplement here? Obviously, this isn't something that people should do without consulting with their doctor, but I'm interested in what a dosage table for this would like. I'd like to see how dosage levels correspond to ranges of the variables for which you test.

    • @Eric S
      1. Do you think that cracking joints – e.g., when getting up quickly from a seated position – are a symptom that indicates bone problems? No I dont. This reflects gases like Nitrogen in joints. It could mean joint problems however.

      2. You mention high dose D3, K2, and Mg based on lab data and severity of disease. What are the dosing ranges for each supplement here? Obviously, this isn't something that people should do without consulting with their doctor, but I'm interested in what a dosage table for this would like. I'd like to see how dosage levels correspond to ranges of the variables for which you test. Ranges without testing D3 5000-50000 IU a day, K2 45 mcgs to 45 mgs a day, Mg 250mgs to 1600 mgs a day maybe considered based upon testing with your doctor helping you out. You can order these tests and discuss the results with the doctor or consult with one who can explain it to you and put it in proper context.

  15. Thanks for the reply. One short follow-up:

    Any quick thoughts on how to think about, or act upon, potential joint problems?

    • @Eric S The most common cause of joint issues in the USA is by far LR. I treat this every day in my clinic as a spine surgeon. It destroys joints and discs. I usually treat it very aggressively with diet changes and other nutraceuticals if the patient wants to try aggressive conservative therapies. I am a huge fan of Krill Oil with astaxanthin for my own patients with bad facets and disc disease. In fact I was just asked about this by Jen Sinkler who is an editor at Experience Life magazine. She quoted me about this very topic in her upcoming April issue. (experiencelife.com)

  16. Dr. Kruse,

    How much Krill Oil do you recommend?

  17. Dr. Kruse,

    Along with magnesium, vitamin D3 and Vitamin K2 how much DHEA would you suggest for a 58 year old, postmenopausal woman, who just came off of bio-identical HRT? I have just begun to take 10mg daily. Should I, perhaps, start at 5mg or am I alright with the 10mg?

  18. Excellent article, Dr. K.

    One way for the osteoporotic to help prevent falls is to wear water shoes around the house…and outdoors if they don't mind the looks. This is because water shoes have incredibly sticky rubber that's designed to grip wet rocks.

    Note that there are expensive water shoes that look like running shoes, with a big chunky heel: that's not what you want. The right kind are relatively minimal with no heel rise, and should cost $20 or less (I've seen them under $10).

    JS

    • @JS its an excellent thought and i have used it but guess what the response was? The men were ok with it but the ladies complained that their bunions and deformed feet are bothered by these shoes! I still recommend they do it because painful feet do not come close to the pain of an osteoporotic spine fracture.

  19. The part about falls struck a chord. So many women starting perimenopause or menopause complain of loss of balance. Not true vertigo (room looks like it's spinning) but rather a feeling of disequalibrium. This can become chronic. No cure offered other than anti-nausea drugs or vestibular rehab exercises. Some find relief with acupuncture albeit temporarily. Docs find no cause in over 90% of cases and chalk it up to "hormonal fluctions" to which the inner ear and vestibular system are allegedly exquisitely sensitve to. Our grandmother's didn't use hormone replacement and they weren't all getting dizzy mid-40s and beyond. So I am curious if decades of following a crap sleep schedule combined with the drop in hormones could be playing a role. Can leptin reset — especially getting to bed early — help restore vestibular system or is this totally off base? I'm curious because one ear doc I saw (I saw several and no answers othere than we are seeing this all the time in middle aged and older women) but this one is also a surgeon and his response was restorative sleep and cutting back on caffeine (he himself never has caffeine so he may just be a caffeine phobe) are essential for maintaining balance. He said if your sleep is not restorative, you will be dizzy. Could a person who has no issues falling and staying asleep still be missing out on truly restorative sleep because the timing is wrong — too late a bedtime? Plus too heavy a meal too late at night so the body is digesting through the night — not restorative? The mention of balance and falls above got me thinking but maybe I'm totally off-base.

  20. Forgot to add, I do have a patulous eustachian tube issue on one side so that may also be the cause. Still — osteoporosis runs heavily on one side of my family and several of the women also complained of dizziness — tinnitus in some of the men and women — so maybe ear/balance connection is genetic in my case but can't help wondering about how spending half a century on a sleep schedule opposite of ideal maybe has damaged me irreparably. Even when I was a pre-teen and teen , I would stay up extremely late — midnight and way beyond — reading, doing artwork, watching tv or hanging out with my father.

  21. Dr. Kruse,

    With regard to osteocalcin – I just had this test for the first time and my result was 19 ng/mL (range is 9-38). What does this tell me about my Vitamin K2 levels? Do I want to take more K2 to see if the lab value increases, i.e. closer to the top of the range?

    • @Paul What kind of test was it? carboxy or uncarboxy OC? The units seem off for this test. The test for vitamin K status is uncarboxylated osteocalcin……..specifically, not just osteocalcin.

  22. Dr. Kruse,

    It was just osteocalcin. Thanks, it try again. Does osteocalcin tell me anything at all?

  23. Dr. Kruse,

    My mom was diagnosed with osteoporosis in her left hip, and osteopenia in her right hip a year or so ago (she is 55), and unfortunately started taking Fosamax in May of 2011. As of late, she's been experiencing a host of horrible symptoms ranging from extreme gas to bloating to acid reflux to chest pains. She has stopped the medication, as suggested by her doctor, but her doctor has now advised her to go for the Reclast infusion which is an IV treatment that lasts for a year. I have read so many horror stories about this stuff, and cannot let her go through with the procedure. She is currently taking 2,000 IU of Vitamin D3 along with 400 mcg of Vitamin K2. Her serum calcium levels were fine according to her latest blood work. She's been eating a paleo diet for a few months now as well (I've been making sure she eats lots of offal, liver particularly, as well as good fats from raw grass-fed butter, raw grass-fed kefir, coconut oil, ghee, grass-fed meats, and organic vegetables, etc. I'm going to make sure she does some weight-baring exercise as often as possible, 3-4x a week. Would higher dosages of D3, K2, and Mg help? Fermented cod liver oil? Please give me some suggestions. I'm absolutely terrified by the idea of this Reclast infusion; not only have I read awful things about it, but its safety hasn't been evaluated for nearly long enough that doctors even know the potential risks over time. I would really appreciate some advice for the next step she can go without turning to these drugs. I don't know what to do!

    • @Erica……this post says it all. I am not sure what else I can offer. I dont use reclast. She needs to completely change her life style and eat totally primal with a very low carbohydrate total. I put my bad osteoporotics on ketogenic paleolithic diets on high dose K2 and D3. The doses she is on are quite low.

  24. What doses would you recommend?

  25. Her D level was within "normal" range, I'm not sure of the specific number though. Possibly over 40?

  26. And regarding diet, should she eliminate all fruit, (decaf) coffee, dairy? She already doesn't eat any grains, and lots of good healing saturated fats from raw grass-fed butter, ghee, coconut oil, grass-fed meats, etc.

  27. Thank you, I will let her know. Also, what numbers, other than vitamin d, do you specifically need?

    • Erica all the things I check are listed in the blog. it should be clear. It does not appear she has had a good work up just a conventional one……she and you need to step it up and use this blog as your measuring stick. No hand holding. You have the info to cure her now.

  28. Thank you. Sorry for the repetitive questions, I'm just very overwhelmed and scared. I might go ahead and show this to her doctor. I will immediately implement everything you have lined up here.

    • @Erica do not be scared. This is a complete nutritional disease that can be reversed totally of your mother eats a strict ketogenic paleolithic diet alone…….if you add back the supplements it will help faster. This post is crystal clear that you the patient has total control You need to regain your composure and tell your mother and doctor you know precisely what to do to help your mother.

  29. Thank you for your reassurance. I will do just that. I'm starting her on a high dose of d3 and k2, and will add in magnesium and some other supplements as well.

    One last diet related question- what is your stance on grass-fed raw dairy products like yogurt, cheese (which I know is high in natural k2), etc.

    • @Erica……there are some in the blogosphere and on paleohacks that would tell you to avoid high Vitamin D 3 supplementation. I think this is far safer than taking the synthetic drugs your physicians have recommended to your mom. This is why I do not advocate these for my own patients. Some still opt for them from their endocrinologist or PCP's but this does not make it correct. I tend to let evolutionary principles guide me now. We are designed to make Vitamin D daily from sun and get it from food in the winter and fall. I would suggest you and your mom begin to use evolutionary medicine to guide your future healthcare choices.

    • @Erica……for your mom I would avoid all dairy except eggs, pastured butter and raw heavy cream.

  30. Thank you again, so very much.

  31. Jack, you said no NSAIDs, which means Advil, right? What then do you recommend instead for pain?

  32. Jodi. No advil! It causes a leaky gut! I like Krill oil for pain with extra astaxathin added in. I use 4 mgs to 8 mgs a day for this.

  33. Cassie Bond says:

    Hi Jack,

    My husband has been on low carb, medium protein, high fat diet for about a year.

    He does not eat any junk "low carb food" He eats no vegetable oils but some nuts. No gluten.

    Lots of coconut oil.

    He just had a Dexa scan and has bad osteoporosis which is worse in the femur compared to the spine. He had this test after he had broken his tibia far too easily.

    He also has arterial calcification.

    He is 65 years, 6 foot tall and weighs about 75 kilos. He has a small pot belly but otherwise lean.

    He has just started on 45gm of Vitamin K2 (MK-4) per day plus D3, magnesium and other supplements that you suggest.

    His tests show: Australian readings.

    Ferritin levels: 254 ug/L (massively improved as only 76, 4 years ago)

    B12: Good (doc didn't give me copy)

    Reverse T3: 695 pmo1/L (range 140-540)

    CRP: 1 mg/L (range 0-10)

    Testosterone: 34.9 nmo1/L (range 11.0-40.0)

    Osteocalcin: 2.2 ug/L (range 3.1 – 13.7)

    HDL: 2.1 mmo1/L (range 0.9 – 1.5) Keeps improving in the last few years

    LDL: 3.9 mmo1/L (range 0.0- 4.0) same as above

    Vitamin D: 107 pmo1/L (range 65-175)

    My question is this:

    Why has does he have such a high Reverse T3 and a low CRP?

    From what I have read from you the CRP should be high too?

    Thank you

    Cassie

  34. Cassie Bond says:

    Hi Jack,

    You were right about his cortisol level.

    I found a test from 3 years ago showing his salivary cortisol at 19.30 nmo1/L (range 6.00-42.00)

    Could he use 7 keto DHEA instead? I think he was on DHEA a few years ago and stopped it because he felt bad. I have read some people have a problem with DHEA.

    Also he was displaying definite signs of Alzheimers. He started with coconut oil & later the low carb diet and the signs have greatly diminished. Phew!

    But all this fits with his Neolithic disease.

    If you have any other suggestions I would be most grateful?

    Thank you

    Cassie

  35. @Dr. J regarding your email on your wife……..at 50 years old most women have a serious issue with the pituitary and estrogen dominance and not loss. Many have this backward because if you lose progesterone you can elevate E2 relatively too. Cortisol is raised in E2 cases too in men and women. Estrogen dominance is pro growth cycle and activates mitosis of the prolactin-secreting cells of the pituitary. This activation of PRL can causes or deepen the osteoporosis seen in either sex. I think most postmenopausal women need this prolactin angle dealt with it.

  36. Penka Nikolova says:

    Dear Dr. Kruse,

    I enjoyed your talk at the Paleo Summit! Thank you for the very informative presentation. I visited your web page and have been reading various blogs you have posted.

    I wonder what your view is about the effect of Tamoxifen on bone /joint health! I was Dx with early stage of breast cancer in 2008 and had bilateral mastectomy (no nodes involved, no chemo or radiation!). After being on Tamoxifen for 3 and 1/2 years I stopped taking it a month ago against the advice of my doctor whose plan was to put me on Zoladex in addition to the tamoxifen and with time to switch me to Aromatase inhibitors. I am 55 and do not like taking Px medication yet I agreed to take Tamoxifen as I was very stressed having lost my only sister to IBS cancer who was 46!We were Dx 3 months from each other!

    I am research scientist and a lecturer and have done a lot of reading and research in the past 3-4 years on all matters related to alternative medicine. I am on Paleo diet now for about 1 year, have done metabolic typing and have been doing resistance workout 4 times a week for the past 18 months. In addition I have been taking Vit D3 2000 IU, fish oil with (omega-3 1100mg/day, which has 765 EPA and 240 DHA), Vit C-as ascorbate-2 g /day, 200 mg Lipoic acid, Q10-200-300 mg/day, Zinc-30 mg/day, Enzyme digest, Probiotic-as I am constipated, B complex and Rhodiola Rosea-as I did saliva test and that indicated adrenal fatigue stage 2 border line 3.Yet the blood test done by endocrinologist -concluded that all is OK!

    I had given on milk and cheese, grains, gluten but eat nuts (mostly almonds, pistachios, pine nut). Trying to eat less fruit but with limited success. I do not take coffee, alcohol and had never smoked. I was mostly vegetarian who was eating lots of fish up until about 18 months ago when I slowly changed to Paleo and follow it very strictly-do not eat rice, potatoes and other starches but have carrots.

    I recall that my oncologist said that the pain I had in my neck, shoulders and back are related to the Tamoxifen. I know too that having stopped it -it would take a long while to get it out of my body. For the past two months I have been doing coffee enemas to detox-almost daily for about 1 1/2 months and now 3 times a week.

    As my cancer was ER(+) and PR(+) I am avoiding all products with soya and avoid supplements and even foods that might affect my hormones especially the ER.

    I wonder what is your view on the link between Tamoxifen and bone health and what advice would you provide to someone like me.

    Kind regards:

    Penka

    • @Penka I am no fan of Tamoxifen at all. Best treatment for steroid positive breast Ca is cold thermogenesis and high krill supplementation. I just posted about that today on MDA……I think it was on page 2015-2022 you can check it out on the monster thread there. You need to read the entire cold thermogenesis series I am in now……could save your life.

  37. Wow, I really needed this information. But after reading all of your blogs many times I still have some questions specific to my conditions.

    I have several conditions associated with osteoporosis. I am a 64 y.0. widow of a rural family practice physician who worked an ave. of 90 hrs/wk while I raised 6 children, one of whom is learning disabled and has Tourettes. That equals chronic stress.

    Exercised vigorously as a teen and moderately thorough most of life but treatment for broken foot and subsequent plantar fascitis has curtailed exercise for last 8 years. Just starting to be able to walk for exercise again.

    5'3", 138 pounds, BMI 124.4 after losing 28 pounds on homeopathic hCG in 2 rounds recently. Went straight to paleo for 2 weeks since that.

    Multiple food allergies, hay fever, eosinophilic esophagitis and GERD resolved by Nissan wrap. Elimination of wheat and milk from diet has helped the other allergies. Intermittent use of Fluonase and other mild inhaled prescriptions for esophagitis and chronic sinusitis. PPI's for at least three years

    SAD treated with Prozac for 18 months, 10 years ago. SAD not as severe for several years since while exercising regularly in early morning. I live in dreary Pacific Northwest.

    Osteoporotic of upper and lower spine diagnosed about 2 months ago, hip OK, no wrist evaluation. Given one month dose of Evista 10 years ago without evaluation based on mother's history and that I was a thin, white , female.

    One dose of Boniva about 2 mo. ago. Multiple side effects so have taken no more and found this blog looking for alternatives.

    High blood pressure contolled with 5mg Novasc generic.

    Possibly something else going on as I have occasional right leg weakness and unresponsiveness beginning with my fourth pregnancy which is also when my food allergies worsened. This weakness has only happened about three or four times in 30 years though.

    Have been very careful to follow the nutritional recommendations of the period so have followed a basic food pyramid diet for most of my life. Have been close to obesity twice buy lost 20 pounds in a year on a low fat, high fiber diet, then lost another 20 pounds the next year on Phen-fen. Gained it back over 15 years. Recently lost 28 pounds on homeopathic hCG, 2 rounds. Followed the hCG immediately with 2 weeks of Paleo and feel really good. Have lost another pound, have more energy, better sleep and waking feeling refreshed.

    body reshaping nicely.

    Questions are, since it seems I am LR, possibly IR, most likely leaky gut and osteoporotic do I use the Paleo diet without nightshades and dairy plus supplimentation for the osteoporosis and at the same time implement recommendations for the leaky gut or do a leaky gut scenario for awhile followed at some time by a osteoporotic diet?

    Also what is considered severe osteoporosis such that a keto diet would be recommended? And does that keto diet need to be followed indefinitely?

    Do I add hormone replacement of wait to see what diet alone does?

    Have not have labs done, gyn doc just wants me on Boniva and to follow up with him in two years. Haven't found a Paleo sympathetic doc in this rural area so am thinking of having my own labs done after a year or so on Paleo or do I definitely need labs now?

  38. Thank you.

    Trying to marry all three now. Looks like for the marriage to be harmonious besides the basic diet and suppliments I need to use K2 instead of butter and eliminate eggs, is that correct?

    Do I use MCT or coconut oil?

  39. Paul Adams says:

    Dr. Kruse,

    I’m not sure if you are still responding to posts on this blog but I have been following your osteoporosis prescription since you first presented it here in November 2011. I currently see an endocrinologist who specializes in metabolic bone disease and, while she has read your blogs on osteoporosis, she remains skeptical. When I first came to see her, my Vitamin D levels were almost non-existent and my PTH levels were very high. Over the past few years, the D levels have risen with supplementation to almost 90 and my PTH levels had decreased to normal. But, now even though my D levels are high and my serum calcium normal, my PTH has been creeping up over the past year. It is @80 with 60 high normal. My doctor doesn’t understand what is going on and has told me to take more calcium supplements. But I’m not sure that this is the answer. What do you think? I am currently taking 40 mg. of Carlson’s K2 daily in divided doses.

    • @Paul Adams…….its OK for them to be skeptical…….but the fact remains your not doing well and what is her answer? I think I would be skeptical of CW advice that has not change your situation but that is for you to decide. I reverse osteoporosis. I no longer treat it as she does.

  40. Paul Adams says:

    Dr. Kruse,

    I completely agree with you which is why I am follwoing your prescription. But my PTH is rising and I don’t know why or what to do about it. I take high dose Vitamin D and K, magnesium malate, am on HRT, strict ketogenic paleo diet, lots of coconut oil, etc. Of course the phenobarbital is a problem as it is the cause of the osteoporosis in the first palce but when I tried to switch to aother drugs, I had seizures – lot of seizures with injuries. Any idea what to look for?

    • @Paul Adams With a high PTH you have to be worried about a benign Parathyroid tumor…..hypocalcemia, kidney diseases, muscle cramps, numbness and tingling of extremities
      If calcium levels are low and PTH levels high, then the parathyroid glands are responding as they should and producing appropriate amounts of PTH. Depending on the degree of hypocalcemia, a doctor may investigate a low calcium level further by measuring vitamin D, phosphorus, and magnesium levels. This is a pretty standard W/u and I have no idea why your doc is not doing it.

  41. Paul Adams says:

    That’s the problem. She has done all that and my calcium, Vitamin D, phosphorus and magnesium levels are solid. Maybe it’s the phenobarbital. What a horrible drug.

  42. Paul Adams says:

    Do you think CT would allow me to get off phenobarbital? Sometimes when I get very cold and start to shiver, it’s led to a seizure.

    • @Paul Adams……very tough call. Long term phenobarbital is tough. I am not really sure but that is something you need to actively talk to with your doctor to see if they would allow you to slowly wean yourself from it.

  43. Paul Adams says:

    Oh, I’ve tried several times. Even since I was diagnosed with osteoporosis 5 years ago. Weaned of the phenobarbital as I titrated to another drug (Lamictal, Keppra, Zonegran). A couple months were fine then massive seizures. The drug has really ruined me. My skeleton is rotting. I eat Keto Paleo and follow all of your advice so closely. But I think the drug has done its work.

    • @Paul Adams…..you might correct. But the story of Jean Calment should make you realize if you do more right you can overcome some bad things in your life. She smoked for 119 yrs of her life but did just about every other thing correctly.

  44. Paul Adams says:

    Thanks. You’re a good person.

  45. Paul Adams says:

    Dr. Kruse,

    I recently went to my dentist and she asked if I had changed my diet since my last visit. I explained that I was eating a primarily keogenic paleo diet. She said that explained the calculus on my teeth. Now I never have calculus which is why she asked. She said a high protein, low carb diet will change the pH of the mouth.

    I’m confused becuase I think I recall you saying that calculus deposits on the teeth might indicate a problem with Vitamin K deficiency. Ever since reading your Osteoporosis Rx, I have been taking 40 mg. of Carlson’s Vitamin K daily. Does this make sense?

  46. Paul Adams says:

    But isn’t calculus on one’s teeth a sign that the body is depsoting calcium incorrectly, i.e. not in the bone but in the mouth, heart and arteries? I had no (or minimal)calculus prior to the diet change and Vitamin K supplementation. I’m confused. Sorry.

    • @Paul I must have read your comment wrong. I thought you said you had less calculus? If you have more, I doubt with your diet and K2 levels that is the source. Because both of those reduce the risk of getting it.

  47. Paul Adams says:

    She said a high protein diet makes the body acidic, “If the body becomes acidic it will bring into action the buffering systems, one of which is the phosphate system. To make phosphate available the body will break down bone and release both calcium and phosphate. If the blood has an increased concentration of free calcium and phospate then so will the saliva. A combination of free calcium, phosphate and a pH of 6-6.5 in the saliva will encourage calculus formation.”

    If this is true, it would seem to bode poorly for someone with osteoporosis.

  48. Hi Jack!

    Very interesting, but not surprising, idea to treat OA with paleo diet and vitamin D supplements. I have atlantoaxial facet OA, the result of a MVA 5 years ago. Other than that healthy, nonsmoker, etc. I had a c1-c2 fusion last April that failed, and we do not know why. I had a revision surgery in January and had screws and rods installed. I used to follow a better diet and exercise regime, but the chronic pain over the past 2 years has unleashed my sweets cravings…..so, I guess the question is: Is it safe to switch to a paleo diet at 14 weeks post-op, or is there evven a small possibility that it may inhibit fusion at all?
    Any advice would be greatly appreciated!
    Thanks!
    Monica

    • Monica you need the paleo diet pronto with a lot of animal protein for your bone healing and you need my CT protocol written on 2/11/2012. If you want to see some patient outcomes watch the videos at the end of my blogs CT 9 and CT 10.

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