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Osteoporosis: Complementary and
alternative treatments
By Gautam J. Desai, DO, and
Carrie M. Moore, OMS II
Osteoporosis is a serious condition. Without proper diagnosis and timely treatment,
the consequences can be significant. Patients with osteoporosis may be unaware of
the associated morbidity and mortality
rates from its complications.
Today’s primary care physicians should
educate their patients about adopting a holistic approach to managing osteoporosis,
including prescription medication, weightbearing exercise and a healthy lifestyle.
Patients often have questions about the
myriad of readily available herbal and natural supplements that are touted as beneficial for bone health, and these patients may
seek guidance from their osteopathic
physicians. What follows is information on
some common products, with an emphasis on interactions and side effects. Some aspects of an integrated approach to managing osteoporosis follow.
Taking a close look
at botanicals
Phytoestrogens are substances that are
similar in action to estrogen and are found
in various plants and foods. There are conflicting data on phytoestrogens and their
effects on bone mineral density (BMD).
Some studies report that phytoestrogens
are beneficial for bone resorption and
BMD in postmenopausal women while
other studies have reported no effect.1,6,8,13
There are three main types of phytoestrogens: lignans, coumestans and isoflavones. Lignans are found in flaxseed,
lentils, grains, fruits and vegetables.
Coumestans are found in bean sprouts,
spinach, clover, and other plants. The most
potent phytoestrogens—genistein and
daidzein—are isoflavones, which are found
in soybeans, chickpeas and lentils.2
Soybean (glycine soja)
Soy protein was shown to be mildly beneficial for increasing bone mineral content
(BMC) in postmenopausal women in one
randomized, double-blinded, placebocontrolled trial. However, no significant increase in BMD was shown.3
A significant decrease in urinary deoxypyridinoline and increased serum insulin-like growth factor I (IGF-I)—both
indicators of decreased bone metabolism—
were observed in individuals who received
40 grams of soy protein daily for three
months.4
Soy protein had the greatest affect on
women who were not on hormone therapy.5 It should be noted that the soy diet was
not as effective as hormone therapy for increasing the markers of bone turnover.4
In another double-blinded trial, 40
grams of soy protein per day increased
lumbar spine density in postmenopausal
women. A supplement containing 56 milligrams of isoflavone per day did not have
the same beneficial effect as getting the
isoflavones from soy protein.4,6
One challenge to a patient’s desire to use
soy protein rather than isoflavone supplements is the amount of soy that must be
consumed—200 milligrams of isoflavones
equal approximately 0.3 milligrams of
conjugated estrogen. Soymilk contains
about 20 milligrams of isoflavones per
cup, and tofu contains 80 milligrams of
isoflavones per cup. To obtain the equivalent of 0.3 milligrams of conjugated estrogen (the lowest recommended dose for
therapy), a patient would need to consume
two to three cups of tofu or drink 10 glasses of soymilk. Some studies conducted with
large dietary intakes of soy revealed that a
significant number of participants were
unable to tolerate such a diet, as evidenced
by the discontinuation rate.
A large, double-blinded, randomized
one-year trial did not support the hypothesis that isoflavones from soy protein have
beneficial effects on BMD (a surrogate endpoint),7 whereas another study reported
a reduced fracture rate (the more important
clinical outcome) in postmenopausal
women who consumed soy.8 Much conflicting information exists with respect to
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the use of soy isoflavones in the treatment
of patients with osteoporosis. While it
seems likely that soy isoflavones have many
health benefits, the evidence for using soy
as an alternative treatment for patients with
osteoporosis remains inconclusive. Some
potential interactions and recommendations are as follows:
Levothyroxine
Because decreased absorption of levothyroxine has been noted, soy should be avoided for at least two hours after the ingestion
of levothyroxine, but clearer data are lacking about timing.
Tamoxifen
Effects of tamoxifen may be decreased with
the use of soy. DOs should avoid concomitant use of soy until more information is
available.
Iron supplements
Possible decreased absorption of iron
with soy consumption. Iron supplements
should be avoided within two hours of
soy ingestion.
Warfarin
Warfarin effectiveness and changes in international normalized ratio (INR) may result
from concomitant soy use. Monitor INR
closely in patients on warfarin who are either beginning or stopping soy foods, milk,
and supplements.4
Black cohosh
(cimicifuga racemosa)
One 12-week trial of postmenopausal
women revealed that black cohosh extract
increased levels of bone-specific alkaline
phosphatase, a metabolic marker for bone
formation (p=0.0358).
Women who received conjugated estrogen or a placebo did not show the same elevation in bone-specific alkaline phosphatase.4 This suggests that black cohosh
may be beneficial in the treatment of patients with osteoporosis, but the lack of
data on bone density and fracture risk
makes this evidence inconclusive.
12
Some potential interactions and recommendations are as follows:
Antihypertensives
Antihypertensives may be potentiated;
avoid concomitant soy use.
Tamoxifen
Tamoxifen effects may be enhanced; use
the combination of tamoxifen and soy with
caution until more information is available.
Iron
Iron products may form insoluble complexes when taken with black cohosh. Iron
should be avoided within two hours of ingesting black cohosh.4
Red clover (trifolium pratense L)
In a randomized, double-blinded, placebocontrolled trial, treatment of postmenopausal women with a red clover-derived isoflavone supplement for 12 months
showed a significant decrease in loss of
BMD and lumbar bone mineral content
(BMC) compared with placebo. An increase in a bone formation marker (bone
specific alkaline phosphatase) was also
demonstrated.4 These results are promising, but more trials are necessary to conclude that red clover is an effective alternative treatment for osteoporosis.
Some potential interactions and some
recommendations follow:
Pregnancy and breastfeeding
Avoid with pregnancy and breastfeeding
and in patients with estrogen receptor positive neoplasia.
Wild yam (dioscorea villosa)
Wild yam (dioscorea villosa)—also known
as China root, devil’s bones, and Mexican
yam—is commonly sold in the United
States for women’s health, including osteoporosis treatment. Yet there is no evidence
that it is effective for osteoporosis.4
Some potential interactions with wild yam
are as follows:
Indomethacin
Possible decrease in plasma levels of
indomethacin.
Anticoagulants
Possible increased risks of bleeding. Concomitant soy use should be avoided.
Estrogen
Possible additive estrogenic effect.4
Contraceptives/Estrogen
Possible decrease in contraceptive effectiveness or increase in side effects.
Herba epimedii (HEP)
Progesterone
Possible decreased effectiveness of progesterone.
Tamoxifen
Decreased tamoxifen effectiveness in animal studies. Concomitant soy use should
be avoided.
Herba epimedii is a commonly used herb
prescribed for the treatment of osteoporosis in China.
HEP has been shown to significantly
decrease urinary calcium excretion, suppress serum alkaline phosphatase activity,
and increase osteoblastic activity in rats.
HEP may be of promise in the future, if
human trials can reproduce these results.9
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Taking a holistic approach
Exercise has been associated with improvements in BMD and a decreased risk of hip
fractures. In a study of more than 61,000
postmenopausal women, those who
walked four or more hours per week had a
41% lower risk of hip fracture than those
who walked less than one hour per week.1
It is recommended that women should
engage in at least 30 minutes of weightbearing exercise—walking or jogging—
three times per week. Some sources recommend 20 minutes per day, and an expert
panel at the Institute of Medicine recently
recommended at least one hour per day.10
There is no convincing evidence that
high-intensity exercise such as running offers a greater benefit than lower-intensity
exercises such as walking.
The positive benefits on bone density
that exercise offers are quickly lost once the
exercise is stopped, which is why it is very
important for women to choose an activity that they enjoy and will maintain long
term.1
Vitamins, minerals, tobacco and alcohol all affect bone formation. Supporting
nutrients such as vitamin B6 (pyridoxine),
vitamin B12, and vitamins C, D, E and K,
magnesium, copper, boron, folic acid,
manganese, selenium, silicon, strontium,
zinc, are all needed for healthy bone formation, as is sufficient intake of calcium.10
Nicotine and nonnicotine tobacco
components have been shown to depress
osteoblastic activity in a number of in vitro
and animal studies. Studies suggest that
smoking may induce osteoblastic depression, either directly or via hormonal
changes.11
Alcohol is a known risk factor for osteoporosis. In addition, animal studies have
shown that reduced weight-bearing exercise
increases the detrimental effects of alcohol
on cortical bone by further inhibiting bone
formation.12
As osteopathic physicians, our goal is to
prevent disease. We can promote good
health starting with well-child visits and
talking with parents about the importance
of a balanced diet. Healthy lifestyle issues
need to be discussed, including exercise.
In treating patients who have already progressed to either osteopenia or osteoporosis, it is important to discuss all aspects of
treatment with them, not just prescription
medications. In addition, patients are often
reticent to bring up the subject of herbal
products. Hence, osteopathic physicians
should routinely ask patients about their
use of these products and educate them
about any potential side effects or interactions.
As further research is done on herbal
and over-the-counter products, we will learn
more about how these products can be used
in the battle against osteoporosis. ❙ ww
References
1. Rosen H, Drezner M. UpToDate (Accessed March 30 2006). Overview of the
management of osteoporosis in women.
Updated Sept 13 2005.
2. Martin K, Rosen H, Barbieri R. UpToDate 13.3. (Accessed March 30, 2006).
Preparations for postmenopausal hormone
therapy. Updated April 29 2005.
3. Chen Y-M, Ho SC, Lam SSH, et al. Soy
isoflavones have a favorable effect on
bone loss in Chinese postmenopausal
women with lower bone mass: A double-blind, randomized, controlled trial.
The Journal of Clinical Endocrinology &
Metabolism 88:(10):4740-4747.
4. PDR for Herbal Medicines, 3rd edition,
2004; Thompson PDR; 93-97:67981:747-57.
5. Arjmandi BH, Khalil DA, Smith BJ, et
al. Soy protein has a greater effect on
bone in postmenopausal women not on
hormone replacement therapy, as evidenced by reducing bone resorption and
urinary calcium excretion. The Journal
of Clinical Endocrinology & Metabolism
88:(3):1048-1054.
6. Supplement: Fourth international symposium on the role of soy in preventing and
treating chronic disease. The American
Society for Nutritional Sciences 2002;
132: 588S-619S.
7. Kreijkamp-Kaspers S, Kok L, Grobbee
DE, et al. Effect of soy protein containing isoflavones on cognitive function,
bone mineral density, and plasma lipids
in postmenopausal women. JAMA.
2004; 292: (1):65-74.
8. Zhang X, Shu X-O, Li H, et al. Prospective cohort study of soy food consumption and risk of bone fracture among
postmenopausal women. Archives of
Internal Medicine 2005; 165: 1890-1895.
9. Xie F, Wu C-H, Lai W-P, et al. Evidencebased complementary and alternative
medicine: The osteoprotective effect
of herba epimedii (HEP) extract in vivo
and in vitro. September 2005; 2(3): 353361.
10. Kligler B, Lee RA, Kessler G. Integrative Medicine: Integrative Approach to
Osteoporosis. April 2 2004, edition 1,
Chapter 24.
11. Laroche M, Lasne Y, Felez A, et al. Osteocalcin and smoking. Rev Rhum Ed
Fr. 1994 June; 61:(6):433-6
12. Hefferan TE, Kennedy AM, Evans GL,
et al. Disuse exaggerates the detrimental effects of alcohol on cortical bone.
Clinical & Experimental Research. January 2003; 27:(1):111-117.
13. Spence LA, Lipscomb ER, Cadogan J,
et al. The effect of soy protein and soy
isoflavones on calcium metabolism in
postmenopausal women: a randomized
crossover study. The American Journal
of Clinical Nutrition. April 2005;
81:(4):916-922.
Gautam J. Desai, DO, is physician educator in the department of medical affairs and
associate professor in the department of family medicine and OPP at Kansas City University of Medicine and Biosciences College
of Osteopathic Medicine.
Carrie M. Moore, OMS-2, is a secondyear osteopathic medical student at
Kansas City University of Medicine and
Biosciences College of Osteopathic Medicine.
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