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 Clinical Management Series
Natural Medicines in the Clinical Management of Osteoporosis
Vitamins and Minerals | Estrogenic Agents and SERMs | Miscellaneous
The Bottom Line | References
 

There are some misconceptions about osteoporosis. Some people think osteoporosis is always the result of accelerated bone loss in later life. Or they think osteoporosis only affects elderly women. It's true that the major risk factors are being female and being older. But there are many other factors that are important.

Risk Factors for Osteoporosis13792
  • Low body weight
  • Low body mass index (BMI)
  • Lack of exercise/sedentary lifestyle
  • Alcohol abuse
  • Smoking
  • Estrogen deficiency
  • Family history of osteoporosis

Low bone mass and structural deterioration of the bone are the hallmarks of osteoporosis. Osteoporosis occurs when bone resorption (osteoclast activity) exceeds bone formation (osteoblast activity). Over time, this results in fragile bones and an increased risk of fractures, usually of the hip, spine, or wrist.

Estrogen decreases bone resorption by decreasing osteoclast activity. In women, rapid bone loss occurs after menopause when estrogen levels fall. Women may lose as much as 20% of their bone mass within 5 to 7 years after menopause.

Osteoporosis is most common in white and Hispanic women. It occurs about twice as often in these populations compared to black women. The reason is that black women have about 20% greater bone mass.

Similarly, men have about 20% greater bone mass than women. Due to their larger skeletons, bone loss in men often starts later in life and progresses more slowly. Only about 20% of osteoporosis patients are men. Nonetheless, osteoporosis can still be a big problem in older men. By age 60, white men have a 25% chance of having a fracture. The mortality associated with osteoporotic hip fracture is 2 to 3 times greater in men than women.

Osteoporosis can also be the result of a variety of conditions including endocrine disorders, gastrointestinal diseases that cause malabsorption, end-stage renal disease, hyperthyroidism, malnutrition, and many other conditions. Corticosteroids and anticonvulsant drugs can also increase the risk of osteoporosis. These "secondary" forms of osteoporosis can occur at any age.

Commonly Used Conventional and Natural Medicines for Osteoporosis*
Bisphosphonates
   Alendronate (Fosamax)
   Etidronate (Didronel)
   Pamidronate (Aredia)
   Risedronate (Actonel)
   Tiludronate (Skelid)
   Zoledronic acid (Zometa)
Estrogenic Agents
   Conventional Medicines
      Conjugated estrogens (Premarin, others)
   Natural Medicines
      Alfalfa (Medicago sativa)
      DHEA
      Dong quai (Angelica sinensis)
      Licorice (Glycyrrhiza glabra)
      Panax ginseng
Selective Estrogen Receptor Modulators (SERMs)
   Conventional Medicines
      Raloxifene (Evista)
   Natural Medicines
      Flaxseed (Linum usitatissimum)
      Ipriflavone
      Red clover (Trifolium pratense)
      Soy (Glycine max)
Vitamins & Minerals
   Boron
   Calcium
   Copper
   Fluoride
   Magnesium
   Manganese
   Strontium
   Vitamin D & Analogues
   Vitamin K
   Zinc
Miscellaneous
   Conventional Medicines
      Calcitonin (Miacalcin)
      Teriparatide (Forteo)
   Natural Medicines
      Black tea
      Green tea
      Oolong tea
*Note: Many natural products are tried for osteoporosis, but very few have reliable evidence that they work. Inclusion in this list does NOT imply that these products are effective for osteoporosis.

Several steps can be taken to reduce the risk of developing osteoporosis and subsequent fractures. High-impact, weight-bearing exercise, such as weight training, can increase bone strength. Lower impact exercise such as walking is also good, but does not seem to have as much effect on bone mineral density.

Adequate calcium and vitamin D intake are considered the mainstay therapy for both preventing and treating osteoporosis. Adequate calcium intake during childhood and adolescence is essential to achieve peak bone mass during the third decade of life.

In premenopausal women over 40, bone loss typically occurs at a rate of 0.5% to 1% per year. This bone loss is much more pronounced if dietary calcium intake is below the recommended amount.2571,2578 Bone loss can be reduced significantly by supplementing with 1000 mg calcium/day.

In the 5 years immediately after menopause, calcium supplementation has very little effect on bone loss.2569,2570,2575,2576 This is because the rapid loss of estrogen during menopause causes a high bone resorption rate, which increases serum calcium levels. Therefore, intestinal absorption of calcium is diminished.2570 However, after this 5-year period, calcium supplementation again has a significant benefit on bone loss. The typical rate of bone loss in postmenopausal women who are not taking calcium supplements is about 2% annually.2572,2576 Taking calcium 1000-1600 mg/day decreases this rate by 0.25% to 1% annually.977,979,981,2569,2571,2572,2575,2576,2578,6850

Institute of Medicine Daily Dietary Reference Intakes (DRI) for Elemental Calcium in Men and Women
Age DRI
1-3 years 500 mg
4-8 years 800 mg
9-18 years 1300 mg
19-50 years 1000 mg
51+ years 1200 mg
Pregnant or Lactating (under 19 years) 1300 mg
Pregnant or Lactating (19-50 years) 1000 mg

The majority of studies show that long-term calcium supplementation decreases primary fracture rates by 30% to 35% for vertebral bone and 25% for hip bone.2576 It is estimated that 30 years of continuous calcium supplementation after menopause might result in a 10% improvement in bone mineral density, and a 50% overall reduction in fracture rates, compared with women who do not take calcium supplements.2570

Supplements must be continued indefinitely since the effects of 2 years of calcium supplements on bone mineral density are largely lost within 2 years after discontinuing the supplements.981,2576,6853,12932

Practice Pearl
Explain to women the importance of maintain daily adherence to getting adequate calcium. A recent, well-publicized study suggested that taking calcium 1000 mg plus vitamin D 400 IU daily for 7 years only modestly improves bone mineral density and does not significantly reduce fracture risk in postmenopausal women. But close analysis revealed that adherence to the treatment regimen was low. In women who were at least 80% adherent, the combination of calcium plus vitamin D did significantly reduce the risk of hip fractures by about 29%.14282

Keep in mind that women are not the only people who need calcium supplements. Adequate calcium is important to prevent bone loss in older men too.

Calcium is formulated as a variety of salts including carbonate, citrate, lactate, gluconate, and phosphate (tribasic) salts. There are many variables in calcium absorption, and not surprisingly, results from bioavailability studies are inconsistent.

Despite a lot of advertising to the contrary, there doesn't seem to be clear superiority of one product over another. Calcium carbonate (OS-Cal, others) is better absorbed when taken with food.1816,1842 Other calcium salts can be taken without regard to meals. Calcium citrate (Citracal) is more soluble than calcium carbonate because its absorption isn't affected by gastric acidity.10938 Calcium citrate is a good choice for patients who have LOW gastric acidity...the elderly or patients taking acid-blocking drugs. Calcium gluconate and lactate are also soluble salts, but they provide less elemental calcium per tablet. In most cases, tell patients to try a calcium carbonate or calcium citrate product first.

Practice Pearl
Calcium supplements should be given in 3 or 4 divided doses daily. Absorption is greatest when each dose does not exceed 500 mg.

500 mg Elemental Calcium is Equivalent To % Elemental Calcium
1250 mg calcium carbonate 40%
2350 mg calcium citrate 21%
1282 mg calcium phosphate (basic) 39%
3846 mg calcium lactate 13%
5556 mg calcium gluconate 10%

Vitamin D is often overlooked as a necessary component for preventing and treating osteoporosis. The major functions of vitamin D are to maintain serum calcium within a normal range, enhance intestinal absorption of calcium, and increase the mobilization of stem cells to become osteoblasts.

Vitamin D is normally produced in the skin following sun exposure. But this process is affected by aging. People over 65 years of age need 2 or 3 times the amount of vitamin D because their skin only produces about 25% as much vitamin D as the skin of adults in their 20s or 30s.7555

Vitamin D comes in many forms. The most important ones are ergocalciferol (vitamin D2) from food...and cholecalciferol (vitamin D3) from the skin via the sun. Both forms are inactive until transformed by the kidney to 1,25-hydroxyvitamin D (calcitriol).

Multiple clinical studies and meta-analyses suggest that the combination of calcium plus vitamin D is beneficial for the primary prevention of fractures.980,1836,8818,10932,12926,12930,12933,12934,12952 Some evidence even suggests that vitamin D without calcium might be beneficial for preventing fracture risk.12933 This might be due to vitamin D's effect on falls. Vitamin D deficiency is linked to an increased risk of falling. Some evidence suggests that taking vitamin D can reduce the risk of falling by about 22% in older adults.11916 Recommend vitamin D 400-800 IU in combination with calcium for most patients.

Drug therapy for treatment and prevention of osteoporosis includes bisphosphonates (Fosamax, etc), hormone replacement (Premarin, etc), selective estrogen receptor modulators (SERMs), calcitonin (Miacalcin), and parathyroid hormone.

Bisphosphonates are considered the most effective agents for decreasing the risk of fractures.

Hormone replacement therapy with estrogen used to be considered the gold-standard therapy for preventing osteoporosis and related fractures. But estrogen has fallen out of favor due to concerns about increased risks for stroke, heart disease, and cancer.

Raloxifene (Evista) is a selective estrogen receptor modulator (SERM) used for preventing and treating osteoporosis. It has the beneficial effects of estrogen on bone, but does not have some of the potentially harmful effects in other tissues. There could also be the added benefit of decreased risk of breast cancer. Postmenopausal women who take raloxifene for osteoporosis also seem to have a 60% reduced risk of developing breast cancer. The downside is that raloxifene, like estrogen, can increase the risk for clotting. There are developing concerns about the use of raloxifene and the potential risk for stroke. For more information see the Pharmacist's Letter/Prescriber's Letter Detail-Document #220502.

Calcitonin (Miacalcin) and the recombinant human parathyroid hormone teriparatide (Forteo) are considered last line agents or in cases of severe osteoporosis.

Practice Pearl
Remind patients on drug therapy for osteoporosis, that calcium and vitamin D are still necessary. Explain to them that drug treatment works best when combined with adequate calcium and vitamin D.

In addition to the standard therapy with calcium and vitamin D, several other natural products are promoted for preventing osteoporosis.

 
 
 
  Question #1
Which of the following increase the risk of osteoporosis?
  • View brands containing:
    -Calcium
    -Vitamin D
      Question #2
    Which of the following statements is TRUE?
  •   Question #3
    Which of the following is TRUE?
  •   Question #4
    What is the most appropriate DAILY calcium plus vitamin D combination for a postmenopausal woman?
  • Vitamins and Mineralsreturn to top 

    Magnesium is becoming the hot new supplement for osteoporosis. Lots of supplements now include magnesium, often in combination with calcium...Citracal Plus, Caltrate Plus, etc. Many people are saying that magnesium plus calcium is better than just calcium. Magnesium deficiency is thought to be a risk factor for postmenopausal osteoporosis.7555 Some epidemiological evidence also links dietary intake of magnesium to increase bone mineral density.12501,12502,12503,12504 Preliminary clinical research also suggests that taking magnesium supplements might decrease bone loss in women with postmenopausal osteoporosis.9104 So far, there's not enough evidence to back up the claim that magnesium plus calcium is better than just calcium. A magnesium supplement probably isn't necessary for most people, unless they don't get enough magnesium from dietary sources.

    Practice Pearl
    Advise patients not to overdo it if they take magnesium supplements. Too much magnesium can cause diarrhea. Tell patients not to take more than 350 mg/day.

    Fluoride has been an on-again, off-again treatment for osteoporosis for the past 30+ years. Unlike other treatments which inhibit bone resorption, fluoride stimulates osteoblast activity and is thought to increase bone mineral density. But tell patients to not to use fluoride for osteoporosis. High doses used to increase bone mass can actually decrease bone elasticity and strength, which increases the risk for nonvertebral fractures, and possibly vertebral fractures. Plus, it can cause bone pain and gastrointestinal side effects.8949,9129

    Researchers are investigating low-dose (25 mg/day), sustained-release fluoride. The idea is to provide the benefits of fluoride without the problems associated with higher doses. In combination with calcium and vitamin D, low-dose, sustained-release fluoride seems to reduce the risk of vertebral fracture without increasing the risk of other fractures.9103 Sounds exciting, but it's too early to recommend low-dose fluoride treatment for osteoporosis.

    Manganese levels are lower in women with osteoporosis. Manganese is essential for enzymatic activity required for bone formation.7135 Preliminary evidence suggests that bone mineral density improves when trace minerals, including manganese, are added to calcium supplementation.1994,7135 However, research on manganese for osteoporosis is scant. Counsel patients not to rely on manganese for osteoporosis, alone or in combination with calcium.

    Zinc is concentrated in bone and muscle. Zinc deficiency causes a reduction in osteoblastic activity and in the synthesis of collagen and chondroitin.9106 Preliminary evidence suggests that zinc in combination with calcium, manganese, and copper might be better at increasing bone mineral density in postmenopausal women than calcium alone.1994,7135 But research on zinc for osteoporosis is limited. Don't recommend using zinc, alone or with calcium, until more is known about the role of trace elements for osteoporosis.

    Boron is promoted to improve bone quality and strength. Boron might affect calcium and vitamin D metabolism or increase the effect of estrogen on bone.10940,10941,10942,10943 But there's no evidence it can increase bone mineral density or reduce fracture risk. Don't recommend it.

    Copper slows bone turnover by inhibiting osteoblast and osteoclast activity.9106 Copper deficiency seems to have a negative effect on bone. But copper deficiency is rare, except in patients who can't eat.7555 Preliminary evidence suggests that copper in combination with calcium, manganese, and zinc might be better at increasing bone mineral density in postmenopausal women than calcium alone.1994,7135 But research on copper for osteoporosis is limited. Tell patients to hold off on copper.

    Practice Pearl
    Explain to patients that a separate supplement for individual minerals is rarely necessary. Except for calcium, a basic multivitamin that contains minerals usually provides all that is needed.

    Strontium is an element that is physically and chemically similar to calcium. About 90% of strontium in the body is found in bone. Strontium seems to enhance the replication of preosteoblastic cells. It also appears to increase bone formation and possibly reduce bone resorption by inhibiting osteoclast activity.11396,11399,11753 Researchers are studying a specific form of this mineral called Strontium ranelate (Protelos). This form appears to reduce the risk of vertebral fractures by 40% in postmenopausal women with osteoporosis.11392,11393,11395 This form of strontium probably won't be on the market for several more years. In the meantime, several other strontium supplements are being marketed for osteoporosis. Advise patients against using these. It's not known if these other forms are effective. And there's not enough information about long-term safety.

    Vitamin K seems to affect bone in addition to blood. Endogenous vitamin K is responsible for activation of osteocalcin.6797,7130 Osteocalcin is a protein produced by osteoblasts and helps attract calcium to bone. There is some evidence that low vitamin K intake is associated with reduced bone mineral density and increased fractures in people with osteoporosis.55,60,61,62,837,6193,7131 Additional evidence suggests that taking a specific form of vitamin K, vitamin K2, also known as menaquinone, 45 mg/day might reduce absolute hip fracture rates by 6%, vertebral fracture rates by 13%, and non-vertebral fracture rates by 9% in postmenopausal women and others at risk for osteoporosis.14387 There is also some evidence that another form of vitamin K, vitamin K1, also known as phytonadione, 1 mg/day can reduce the decline of bone mineral density in postmenopausal women.14387

    Counsel patients that their best bet is to get vitamin K from their diet. Tell them foods rich in vitamin K1 (phytonadione) include cabbage, cauliflower, spinach, cereals, and soybean. Vitamin K2 (menaquinone) is found in meats and cheeses.

    		 
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    -Magnesium
    -Fluoride
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    -Manganese
    -Zinc
    -Boron
    -Copper
      Question #5
    Which of the following would be appropriate to tell a patient about minerals for osteoporosis?
  • View brands containing:
    -Strontium
    -Vitamin K
    Estrogenic Agents and SERMsreturn to top 

    Several natural medicines seem to have estrogenic or estrogen-like effects. Many of these are promoted for postmenopausal osteoporosis prevention.

    Dong quai (Angelica sinensis), Panax ginseng, alfalfa (Medicago sativa), and licorice (Glycyrrhiza glabra) all seem to have estrogenic effects and are sometimes promoted for osteoporosis prevention. But tell patients there's no reliable clinical evidence that these products are effective for prevention bone mineral density loss or osteoporosis.

    Dehydroepiandrosterone (DHEA) is an endogenous hormone produced in the adrenal glands. In the body it is converted to androstenedione, which is then metabolized to androgens or estrogens. In a low-estrogen environment, such as postmenopause, DHEA tends to have more estrogenic effects. As a result, DHEA is sometimes promoted for postmenopausal prevention of osteoporosis. So far, the evidence is promising, but preliminary. Some evidence suggests that taking DHEA orally 50-100 mg/day can improve bone mineral density in older women and men with osteoporosis or osteopenia.12563,12564 Tell patients that it is still too soon to use DHEA for preventing osteoporosis. More evidence is needed about long-term safety and effectiveness.

    Practice Pearl
    Tell patients not to waste their money on products that contain wild yam. Wild yam contains diosgenin, which is sometimes used commercially to synthesize DHEA and other steroids in a laboratory. But in the body diosgenin is NOT converted to DHEA. There's no evidence wild yam has any effect on bone.

    Some plants with estrogenic activity, known as "phytoestrogens," seem to have activity similar to the selective estrogen receptor modulator (SERM) raloxifene. In some tissues they have estrogenic effects and in other tissues they have antiestrogen effects. These phytoestrogens also seem to have different effects depending on the amount of estrogen in the environment. For example, in premenopausal women, phytoestrogens are more likely to compete with endogenous estrogens for receptor sites. Because phytoestrogens have a more mild estrogenic effect than endogenous estrogen, the overall effect is to decrease estrogenic effects on tissues. In postmenopausal women, the opposite is true. Because there is low estrogen, the phytoestrogens increase overall estrogenic effects in the tissue.

    Soy (Glycine max) is one of the best known phytoestrogens. Soy contains the isoflavones genistein and daidzein. These isoflavones appear to have SERM-like effects. Most evidence suggests that taking soy protein can increase bone mineral density (BMD), or slow bone loss, and improve biochemical markers of bone turnover in peri- and postmenopausal women.842,6449,9775,11081,11082,12044 The effect seems to be dependent upon the content of isoflavones. Taking isoflavones 80-90 mg daily, in 40 grams of soy protein, seems to be needed to improve BMD.842,6449,9775 Lower intake of isoflavones might not be as beneficial. There is limited evidence on the ability of soy to decrease fracture risk. Some evidence suggests postmenopausal Asian women who consume higher amounts of soy protein in their diet have a lower risk of developing fractures compared to women consuming less soy protein. This effect appears to be more prominent for women in early postmenopause.13181 So far, there is no reliable information about the effects of soy on fracture risk in women from Western cultures.

    It is important to keep in mind that not all evidence has been positive. Some research suggests that soy protein does not significantly improve BMD in some postmenopausal women.4952,12034,14064,14254 The reasons for these inconsistent findings are not entirely clear. Most likely different findings are due different formulations of soy used, different age groups studied, and varying study designs.

    Explain to women that taking soy protein might result in modest improvements. Advise women NOT to use purified soy extracts in tablets or capsules. These products have not been shown to be beneficial for reducing bone loss.

    Practice Pearl
    There is concern about the use of soy and other phytoestrogens in women with breast cancer because estrogen use can increase breast cancer risk. There is evidence that soy might increase breast cell proliferation in healthy women.3980,3981 However, in a 2-week study of soy isoflavones 200 mg/day in patients with breast cancer, soy isoflavones did not seem to stimulate breast cancer cell growth.11042 Some preclinical studies suggest that soy might have protective effects against breast cancer.3976 Additional preliminary evidence suggests that different effects might occur with different concentrations of soy isoflavones. Low in vitro concentrations seem to stimulate breast tumor growth, while high in vitro concentrations seem to inhibit tumor growth.14363 Because there is insufficient reliable information about the effects of soy preparations in patients with breast cancer, a history of breast cancer, or a family history of breast cancer, therapeutic use of soy should be done with caution in these patients.956,7072,7655,8192

    Red clover (Trifolium pratense) also contains isoflavones similar to those found in soy. But so far, red clover has not been found to have the same beneficial effect of soy on bone loss. Preliminary evidence suggests that taking a specific red clover extract (Promensil, Novogen) 40 mg/day for a year does NOT seem to increase bone mineral density in women aged 49 to 65 years.6127 Advise women not to rely on red clover for osteoporosis prevention.

    Ipriflavone is a semisynthetic isoflavone manufactured in the laboratory from the isoflavone daidzein. Ipriflavone enhances osteoblast function and inhibits bone resorption, mainly by inhibiting recruitment of osteoclasts.2173,2176,2179 Unlike the natural isoflavones in soy, ipriflavone doesn't have direct estrogenic effects and won't help menopausal symptoms.

    Ipriflavone in combination with calcium seems to prevent bone loss in postmenopausal osteoporosis.430,432,433,2169,2170,2175 At least 1000 mg per day of calcium seem to be necessary for greatest benefit. One study using ipriflavone with only 500 mg/day of calcium found no effect on bone mineral density.1196

    Ipriflavone also provides relief from back pain caused by spinal compression. For some patients, it can be as effective as inhaled calcitonin for pain from osteoporotic fractures.432,2175,4756,4757

    Advise women interested in trying ipriflavone to use it under supervision of a health professional. Warn them that ipriflavone can decrease lymphocytes in some patients, which might affect their immune system. Lymphocytes can decrease by about 27% in patients after 6 months of use, and then lymphocyte levels usually stabilize. White blood cell (WBC) count should be monitored in patients using ipriflavone long-term. Consider discontinuing ipriflavone if lymphocytes drop below 1000 per microliter. Lymphocyte counts seem to normalize in most patients within 12 months after stopping ipriflavone.1196

    Flaxseed (Linum usitatissimum) is a rich source of alpha-linolenic acid and long-chain n-3 polyunsaturated fatty acids. Flaxseed also contains lignans, one of the major groups of phytoestrogens. But flaxseed doesn't seem to have any estrogenic effect on bone.10952,12910 Don't recommend it.

    		 
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    -Dong quai
    -Panax ginseng
    -Alfalfa
    -Licorice
    -DHEA
      Question #6
    Which of the following supplements has been shown to increase bone mineral density AND decrease fracture rate?
  • View brands containing:
    -Soy
    View brands containing:
    -Red clover
      Question #7
    Soy isoflavones are most similar to:
  • View brands containing:
    -Ipriflavone
      Question #8
    Which of the following would be appropriate monitoring for a woman who takes ipriflavone?
  • View brands containing:
    -Flaxseed
    Miscellaneousreturn to top 

    There's growing interest in the possible benefits of tea for osteoporosis. Patients often talk about tea as if all teas are the same. But there are all sorts of herbal teas that might contain a variety of herbal medicines. For this discussion, we're talking about your basic, plain tea. Regular tea comes from the same source but is processed differently to produce green tea, black tea, or oolong tea. Green tea is unfermented tea. Oolong tea is partially fermented. Black tea is completely fermented.

    Green, black, and oolong teas contain several compounds that researchers think might affect bone. These teas contain a lot of fluoride, which can have a beneficial effect on bone mass. They also have a high isoflavonoid content with possible estrogenic effects. There's also some speculation that the polyphenols and tannins in tea might indirectly benefit bone mineral density.

    Green and oolong teas are reported to increase bone mineral density of the total body, spine, and hip in men and women who consume them for at least 6 years.8116 Black tea is associated with increased bone mineral density and reduced hip fracture risk in men and women.6404,10949,10950

    Previously, caffeine-containing beverages, including tea, have been associated with increased risk of osteoporosis. However, it appears that the predominant caffeine-containing beverage in these studies was coffee, which has been linked to INCREASED hip fracture risk.6404 It is not known whether caffeine per se adversely affects bone.

    		 
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    -Green tea
    -Black tea
    -Oolong tea
    The Bottom Linereturn to top 

    As the old saying goes, an ounce of prevention is worth a pound of cure. Recommend screening for appropriate patients. Bone mineral density screening is generally recommended for women 65 years and older without risk factors. Screening should begin at age 60 for women with an increased risk.13792

    Getting adequate calcium and vitamin D is the cornerstone of osteoporosis prevention and treatment. Calcium and vitamin D are the only two supplements that have been consistently shown to decrease fracture rates. Dietary sources are preferable, but many people should get a calcium and vitamin D supplement, especially if they don't get sufficient high-calcium foods and exposure to the sun. Recommend either calcium carbonate or calcium citrate for most patients.

    Remind patients that even if they take medication for osteoporosis, such as a bisphosphonate, a calcium and vitamin D supplement is still important.

    Soy isoflavones or ipriflavone seem to help prevent bone loss. In combination with adequate calcium and vitamin D, ipriflavone can increase bone mineral density. Counsel women interested in soy to stick with soy protein.

    Many herbs are promoted for osteoporosis, but there's not enough good clinical evidence to support their use. Some trace minerals might help for osteoporosis prevention. But evidence is too preliminary to recommend separate mineral supplements. A multiple vitamin supplement generally supplies all of the trace minerals needed.

    Emphasize the importance of diet and lifestyle for preventing and treating osteoporosis. Appropriate exercise is a bone-builder. Tell patients that smoking and excessive alcohol use is bad for bones.

    		 
      
     
    Recommendation Chart for Natural Medicines Used for Osteoporosis *
    Safety/EffectiveLikely
    Safe    		Possibly
    Safe    		Insufficient
    Evidence    		Possibly
    Unsafe    		Likely
    Unsafe    		Unsafe
    Effective      
    Likely
    Effective
    -Calcium
    -Ipriflavone
    -Vitamin D
         		     
    Possibly
    Effective
    -Copper
    -Magnesium
    -Manganese
    -Soy
    -Strontium
    -Vitamin K
    -Zinc
     
    -DHEA
         		 
    -Fluoride
    (high dose)
         		  
    Insufficient
    Evidence
    -Alfalfa
    -Black tea
    -Boron
    -Green tea
    -Oolong tea
     
    -Dong quai
    -Licorice
    -Panax ginseng
    -Red clover
         		    
    Possibly
    Ineffective
    -Flaxseed
         		     
    Likely
    Ineffective    		      
    Ineffective      
     KEY:
     Consider recommending this product.
     Don't recommend using this product.
     Recommend against using this product.

    * These proposed recommendations are based solely on the Safety and Effectiveness Ratings contained in Natural Medicines Comprehensive Database. This assumes use of high-quality, uncontaminated products and the use of typical doses. Keep in mind that some products are never appropriate for some patients due to concomitant disease states, potential drug interactions, or other clinical factors. Use your clinical judgment before recommending any product.

    References return to top
    55Olson RE. Osteoporosis and vitamin K intake. Am J Clin Nutr 2000;71:1031-2.
    60Bitensky L, Hart JP, Catterall A, et al. Circulating vitamin K levels in patients with fractures. J Bone Joint Surg Br 1988;70:663-4.
    61Hart JP, Shearer MJ, Klenerman L, et al. Electrochemical detection of depressed circulating levels of vitamin K1 in osteoporosis. J Clin Endocrinol Metab 1985;60:1268-9.
    62Hodges SJ, Akesson K, Vergnaud P, et al. Circulating levels of vitamins K1 and K2 decreased in elderly women with hip fracture. J Bone Miner Res 1993;8:1241-5.
    430Ohta H, Komukai S, Makita K, et al. Effects of 1-year ipriflavone treatment on lumbar bone mineral density and bone metabolic markers in postmenopausal women with low bone mass. Horm Res 1999;51:178-83.
    432Agnusdei D, Bufalino L. Efficacy of ipriflavone in established osteoporosis and long-term safety. Calcif Tissue Int 1997;61,Suppl 1:S23-7.
    433Gennari C, Adami S, Agnusdei D, et al. Effect of chronic treatment with ipriflavone in postmenopausal women with low bone mass. Calcif Tissue Int 1997;61,Suppl 1:S19-22.
    837Feskanich D, Weber P, Willett WC, et al. Vitamin K intake and hip fractures in women: a prospective study. Am J Clin Nutr 1999;69:74-9.
    842Potter SM, Baum JA, Teng H, et al. Soy protein and isoflavones: their effects on blood lipids and bone density in postmenopausal women. Am J Clin Nutr 1998;68:1375S-9S.
    956Barnes S. Phytoestrogens and breast cancer. Baillieres Clin Endocrinol Metab 1998;12:559-79.
    977Storm D, Eslin R, Porter ES, et al. Calcium supplementation prevents seasonal bone loss and changes in biochemical markers of bone turnover in elderly New England women: a randomized, placebo-controlled trial. J Clin Endocrinol Metab 1998;83:3817-25.
    979Riggs BL, O'Fallon WM, Muhs J, et al. Long-term effects of calcium supplementation on serum parathyroid hormone level, bone turnover, and bone loss in elderly women. J Bone Miner Res 1998;13:168-74.
    980Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med 1997;337:670-6.
    981Devine A, Dick IM, Heal SJ, et al. A 4-year follow-up study of the effects of calcium supplementation on bone density in elderly postmenopausal women. Osteoporos Int 1997;7:23-8.
    1196Alexandersen P, Toussaint A, Christiansen C, et al. Ipriflavone in the treatment of postmenopausal osteoporosis: A randomized controlled trial. JAMA 2001;285:1482-8.
    1816Allen LV. Nutritional Products. In: Covington TR, Ed. Handbook of Nonprescription Drugs. Washington, DC: American Pharmaceutical Association;1996:361-92.
    1836Chapuy MC, Arlot ME, Duboeuf F, et al. Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med 1992;327:1637-42.
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