Many people think about osteoporosis as a condition that affects post-menopausal women—one that, if those old “Got Milk?” TV commercials are to be believed, can be solved by drinking enough milk.
Before he was diagnosed with osteoporosis at the age of 45, Dr. Keith McCormick thought the same thing. An avid athlete and Iron Man competitor, Dr. McCormick was training hard one day when he felt a sharp pain in his hip. The pain didn’t stop for several days, so he went in for testing and learned he was riddled with microfractures in his hip caused by severe osteoporosis.
He’s not alone. Globally, one in five men over the age of 50 will get osteoporosis, according to the International Osteoporosis Foundation. (One in three women over 50 will, too.) For a “women’s disease,” one in five is a high ratio.
Every doctor he saw wanted to put him on bisphosphonates and send him on his way. But he didn’t want to take medication for the rest of his life—and he refused to believe that bone loss had a single cause that required a single pharmaceutical solution. A doctor of chiropractic and a former Olympic athlete, he immersed himself in the study of osteoporosis to help himself and his patients.
Today he’s arguably the world leader in nutritional management of patients with bone fragility. He’s the author of The Whole-Body Approach to Osteoporosis; a go-to reference for me and my patients suffering with bone loss; written for the lay audience, it’s meaty enough for clinicians wanting a good jumping-off point for a functional approach to bone health. Keith consults with osteoporosis patients all over the world. But perhaps the greatest testament to his accomplishments? He’s back to competing in Iron Mans.
In today’s blog, I’m going to highlight some of the key takeaways from my conversation with Dr. McCormick on the New Frontiers in Functional Medicine podcast. I’ve pulled out insights on the whole-body causes of osteoporosis—and a bunch of clinical pearls for working with patients. And if this post leaves you hungry for more, be sure to listen to our interview.
What is osteoporosis?
As functional medicine practitioners, we know that the different systems of the body are interconnected. What happens in one system affects the other systems, and vice versa.
Except when it comes to bones. Many practitioners (even those in the functional medicine field) tend to think of bones as separate from everything else. But the mythology (that bones are separate) is a fundamental flaw in our understanding of bones—and of osteoporosis.
The skeleton is a metabolically active organ that is continually being remodeled throughout our lives. This remodeling occurs thanks to two cells: Osteoblasts are cells that instruct the body to build bones. Osteoclasts are cells that instruct the body to break down bone and release the stored minerals (like calcium) into the bloodstream. When these two signaling molecules are coordinated, bones are healthy and strong.
When these two signaling molecules become uncoordinated—a process that is fueled by dysfunctions in other systems in the body—osteoclast production outpaces osteoblast production: bone is broken down faster than it is being built. This is osteoporosis.
Whole Body Causes of Osteoporosis
Osteoblastic activity naturally goes down as a person gets older and osteoclastic activity ramps up.
You might think, “Why don’t osteoclasts naturally get tired and decrease over time, just like osteoblasts?” The reason why—and the key to understanding the whole-body causes of osteoporosis—isn’t aging itself, says McCormick. It’s the things that often accompany aging.
Here’s Dr. McCormick describing some of the factors at play in osteoporosis:
“As a person gets older, they become less anabolic; they get more catabolic. They have more inflammatory problems. They get more inflammatory cytokines, interleukin-1, interleukin-6, tumor necrosis factor and things like that—and that’s what spurs on the osteoclasts.
When there’s background inflammation happening, the osteoclasts lifespan might be shorter, but they become much more aggressive…and start breaking down the bone more.” [Indeed, osteoclasts are a type of macrophage, hence the upregulation with background inflammation. Conversely, osteoblasts are derived from mesenchymal stem cells.]
In my conversation with Dr. McCormick, we do a deep dive on the intricate relationship between osteoblasts, osteoclasts and the signaling molecule RANKL (receptor activator of NFKb). RANKL, a member of the tumor necrosis family, is a fundamental driver of osteoporosis, when in the presence of M-CSF (macrophage colony-stimulating factor) potently upregulating both osteoclast activity and NF-Kb.
Understanding the myriad far-reaching ways in which NFKb is upregulated, including poor diet, dietary antigens, infection, toxin exposures, imbalanced gut microbiome, stress, lack of movement, it makes sense how an individualized systems-wide functional approach to quench the inflammatory cascade is our best chance at turning around pathogenic bone loss.
Whole-Body Treatment for Osteoporosis
In my own practice, I routinely do well treating osteoporosis when it presents in combination with other inflammatory conditions. For example, in a case study book that I authored in 2011, I wrote about a patient with rheumatoid arthritis who also had osteoporosis. When we addressed the rheumatoid arthritis and got her back into balance, her bone density bounced back with relatively little effort and she was no longer osteoporotic as defined by T score. In fact, my patient NEVER started the exercise prescription I was endlessly reminding her about– while I obviously wouldn’t recommend not exercising, her case certainly drives home the system-wide inflammation influence on her bone health.
Dr. McCormick shares loads of clinical pearls about osteoporosis treatment in the podcast. If you regularly work with osteoporosis patients, I strongly encourage you to listen to the episode.
Here are some of the remaining highlights of our conversation:
- Dr. McCormick starts to get nervous when he sees a spine T score of -3. At a -3.5, he considers the short-term use of pharmaceuticals to prevent bone fractures.
- Women of small stature naturally have smaller bone volume, so they may have a T score of -3.5 and not fracture. But some allopathic practitioners will see that number and put them on bisphosphonates. “That’s really criminal,” says McCormick.
- If a person is -4.0 or -4.2 and they fracture, Dr. McCormick puts the patient on a bisphosphonate or Forteo right away. “Nutrition works, but it’s a little slower,” he says. “I want to get these people out of trouble as fast as we can. And if you do a bisphosphonate short term, you’re not going to hurt them.”
- There are three bone resorption markers (bone resorption is the process by which osteoclasts break down bone tissue): N-telopeptide (urine test), C-telopeptide (blood test), and deoxypyridinoline (urine test). “They’re all pretty good and pretty bad at the same time,” he says. “They fluctuate throughout the day so it’s really important to do them at the same time each day.”
- Nutrition pearls:
- Optimize vitamin D. McCormick likes to see levels between 50 and 60
- Optimize vitamin K. Studies suggest that for full osteocalcin carboxylation, a person needs between 200 and 500 micrograms of K2. It’s important not to oversupplement with K2, however, because over-carboxylation of osteocalcin may interfere with testosterone production and pancreatic function
- Optimize alpha lipoic acid. McCormick often uses between 300 and 600 milligrams of ALA with patients.
- Supplement with berberine. Research suggests that berberine may lower osteoclast activity and boost osteoblast activity. He formulates his products with small doses of berberine, between 250 and 300 milligrams
- Increase good fats in the diet. McCormick sees a lot of patients in clinic, especially women, who aren’t getting enough healthy fats in their diet. Increase Omega 3’s and use coconut oil for MCTs.
- Don’t avoid protein. Many patients have read that too much protein can make osteoporosis worse, but protein is the basis for bone and collagen, so patients shouldn’t avoid this critical macronutrient.