‘Dem Bones, ‘Dem Dry Bones
One of the most important factors behind mankind’s perpetual aggravation by bones and joints is that we see them as mechanical, fixed structures instead of as evolving, living tissue.
It is only natural, since most people have seen and touched a human skeleton in a biology class and have seen that it is articulated and functions like a tinker toy set. I am one of the worst offenders, having broken most of my bones and beaten up my joints before I even finished college. Until medical students enter practice and observe first-hand how the supposed mechanical frames of their patients evolve over the years, they usually regard the skeleton as a structure on which to hang the rest of the body. Let us contemplate bones in the non-linear light of quantum mechanics instead of in terms of pulleys, levers and hinges, the domain of classical Newtonian physics.
My first clear understanding of the human skeleton came when I was working in a remote area of the Philippines on a public health project. On a day off, I borrowed a mask and snorkel and skin- dived the coast, fixing to drift a mile or two with the current. The world I witnessed floating over a coral reef during next few hours would change my understanding of biology. The reef was not unlike a human bone: solid, yet full of holes. It had two distinct surfaces. One was soft, colorful, complex and living and the other was bare, white and dead. The dead coral created the foundation on which the living coral thrived. It was so thick that it comprised the actual bed of the ocean. The sand appeared to be mostly dead coral that had been broken off and pulverized by the waves. The sand was littered with the shells of crabs and mollusks, as well as with dead bits of the reef. The living coral covered the dead foundation, its multicolored polyps waving in the current, visibly ingesting plankton that were illuminated by the sun. As you touched the polyps, they would recoil and close, then reopen when they thought the danger was gone. Miniature fish, barnacles, stars, anemones, fans and mollusks were hiding in the coral’s crevices, while bigger fish lurked, ready to gulp down any prey. “Where did this reef come from?” I wondered. “Where did it get all the material to build itself up?” I continued to drift. Hours seemed like minutes, my skin became wrinkled, as the otherworldly flora and fauna paraded before my drifting form.
When I finally crawled out of the sea, I had begun to fathom my experience. The old coral and abandoned shells were a repository of calcium that kept calcium dissolved in the sea water where it was taken up by the living coral polyps and turned into new coral skeleton. I was witnessing a massive recycling of calcium by countless tiny polyps that were creating a huge living organism miles long. Over hundreds of years, the coral’s backbone had accumulated and organized itself into a matrix of honeycombed caverns and tunnels that harbored this unthinkable diversity of far- fetched creatures, which in turn would attract food for the coral. My reef was a non-linear, self- referral system, nourishing itself by nourishing all that lived around it. And the backbone that held the whole system together was calcium. I also saw fishermen dynamiting the reef, stunning fish to float to the surface where they could be scooped up. This ancient, living creature with its delicate ecology was being destroyed.
Years later, when Leora appeared in my office complaining that her period had stopped, I remembered my afternoon in the Philippines. She was a young woman who had been on a diet, a diet to end all diets. A little overweight all her life, she had begun to lose weight and then couldn’t stop. She had learned to control her natural hunger and the weight kept coming off because she still thought she was fat. Her ribs were showing, even her pelvic bones could be seen where one expected buttocks. She had no breasts and her eyes were sunken.
“When was your last period?” I asked.
“About a year ago,” she replied.
A bone density test revealed early osteoporosis, an uncommon finding in a woman this young, as well as other metabolic and hormonal abnormalities. Basically, this troubled young woman had lost all the fat stores that held her estrogen, and without estrogen, her body’s bone-dissolving cells were working unopposed, turning her bones into soluble blood calcium where it would be redistributed to muscles and other organs.
Leora’s bones were just like my coral reef, a precarious, constantly changing structure in dynamic equilibrium with their milieu, constantly being remodeled, constantly being reabsorbed and reconstituted. Leora was stealing timbers from the house to feed the stove, without replacing them. Thinking of the skeleton as a river instead of a structure is the key to healthy bones. Our bones change so quickly that astronauts returning from a week or two in space, where their skeletons have virtually no stress, lose substantial amounts of bone mineral and even the ability to stand due to muscle weakness.
Unlike our own view of bones, the ancient Sanskrit texts of Ayurveda, the medical science of the Vedic civilization, regard bone (asthi — from which we get our root osteo) as a fluid, highly refined tissue and the precursor of the bone marrow and immune system, which is not far from our current understanding of embryology. Nails, teeth, skin, and hair are seen as the byproducts of the formation of bone, and the health of the bones can be estimated by examining these tissues.
The body is constantly calculating its demands and its resources. The parathyroid glands need to keep the blood calcium level within narrow limits to prevent seizures and cramps. Your physiology knows it needs a certain amount of new calcium from the diet to replace calcium lost in the urine and its most available source is your bones. Since bone mineral is in constant flux, it is important to keep the balance sheet in the black. Here are a few ways to do that:
1. MEASURE YOUR HEIGHT YEARLY. If your doctor doesn’t do it, do it yourself. Pick a doorjamb and make a mark, like when you were growing up. If you see you are starting to grow down, see your physician.
2. GET A BONE DENSITY MEASUREMENT. For women, the first should be during the perimenopausal period, but men should get one by age 60, especially if they have been on steroids or used tobacco. A DEXA scan of the hip and spine is the gold standard. When you book the scan, ask if the imaging center plans to upgrade their equipment soon, because you should repeat the scan 2-3 years later on the identical equipment in order to detect a small change in bone density. If bone density changes, you won’t know if it is due to a difference in equipment. You need two measurements to know whether the density is going down and if so, how quickly. A urine test for byproducts of bone breakdown can help monitor your progress in between DEXA scans.
3. WALK. EVERY TIME WE TAKE A STEP, the stress on the bone creates a small piezoelectric current along the shaft of the bone and functions as a stimulus for bone deposition. Lifting weights and swimming will help the bones in your arms and shoulders, but you need weight bearing exercise like walking, tennis or jumping rope to avoid hip fractures, the most common cause of disability from bone mineral loss. The amount of exercise required to improve the bones turns out to be surprisingly little. I write on my prescription pad (so patients take it more seriously) “Rx: Take 40 minutes of progressive exercise two times per week.” Studies have shown that this little exercise will help most sedentary people regain nearly all the bone lost to osteoporosis. In addition this little amount of exercise increases strength by 50-75%, increases energy levels 27%, increases balance, decreases the risk of a fall, decreases weight, and makes people look both thinner and younger. However, studies have shown that exercise won’t help people who take less than 1000 mg of calcium a day, and calcium won’t help people who aren’t moderately active.
4. TAKE PLENTY OF CALCIUM IN YOUR DIET, preferably as dairy. Milk is rich in other ingredients such as magnesium, potassium and vitamin D that make the calcium more absorbable. Make no bones about it, the mineral is so finicky that it is poorly absorbed in any other form, and most women get less than 70% of what they need. There is lots of calcium in spinach, but its oxalic acid reduces absorption. The calcium in wheat bran is so tightly bound that the gut cannot pry them apart. Meat also reduces absorption. If you can’t tolerate a cup of skim milk (302 mg), use cheese (218 mg/oz), cottage cheese (212 mg/cup) or yogurt (400 mg/cup!). Try a yogurt shake with equal parts yogurt and water, adding a little sugar and fresh fruit. Take your dairy by itself for easier digestion and for improved absorption of its calcium. Boil your milk with a pinch of fresh grated ginger root if it gives you gas or mucus and don’t take it with meals, since meat, fish, vegetables and salad may just make it curdle. Taking dairy instead of supplements has a fringe benefit according to a study in the New England Journal of Medicine: a drop in blood pressure of 5.5 points if the person also takes healthy doses of fresh produce, a reduction that equates with a significant drop in heart disease. For patients with hypertension the drop was 11.4 points, equivalent to medications. The cow is sacred in Ayurveda, and for a good reason!
5. TAKE CALCIUM SUPPLEMENTS to make up for what you don’t get in your diet. The irony for women is that calcium is most helpful when there is plenty of estrogen to stimulate its deposition. After menopause, when estrogen levels are low, a much smaller fraction of ingested calcium ever ends up in the bones. Yet most women who start calcium supplements begin only after menopause, or worse, once bone demineralization has become advanced. As we age, our calcium requirement goes up not simply because calcium is more rapidly leached from the bones, but also because it is not being absorbed as efficiently. Picking a calcium supplement is easy. If you have sluggish digestion, use calcium citrate or calcium gluconate, because calcium carbonate, otherwise known as chalk, is more difficult to absorb. If you have acid indigestion, if you can’t swallow big pills, or if you are on a budget, use calcium carbonate (marketed as Tums or Rolaids) but look for a product without the artificial flavorings and colorings used in the name brands. Avoid “natural” sources like bone meal and dolomite, which may contain mercury. Take calcium with your meal to enhance its absorption by 10% and you will be getting magnesium and other minerals that are otherwise included in many calcium supplements. Most women need 500 mg of calcium with two meals a day, more if you are older, pregnant or nursing or have rapid bone loss.
6. GET PLENTY OF SUNSHINE. Walking outdoors accomplishes this, and is much more fun than a treadmill. Your skin needs sunlight to make vitamin D for proper bone metabolism and absorption. If you are over 50 you’ll need more than 15 minutes per day, but 5-15 is fine for younger people.
7. REMEMBER THAT ULTIMATELY you want to reduce your risk of fracture and loss of height, and that bone density is not the only determinant of bone strength. The other factors are the quality of the bone crystals and their architecture. The most effective bone, like a Gothic cathedral, bears stress along arches, buttresses, and beams, thus lightening the bones and providing space for the precious marrow that forms our blood elements. Biphosphonate drugs (like Fosamax and Actonel) increase bone density and reduce the risk of fractures, but perhaps not to the same degree. They block the cells that rob calcium from the bones, allowing the body to form new bone without its previous remodeling. This is like nailing extra two by fours onto a house to reinforce it without asking an architect exactly where to put them. The house may be denser, but no stronger. To avoid this dilemma, get walking.
8. IF YOU ARE A POSTMENOPAUSAL WOMAN and not taking hormone replacement, take plenty of phytoestrogens in your diet. Men are protected by continuous testosterone secretion, but after 50 women lose the precious stuff that keeps their density from heading downhill. Replacement reduces the risk of fractures of both hip and spine, even in women over 75! In my practice I prescribe estrogen from natural sources for women whose bones are losing density rapidly and who have no contraindication to estrogen replacement. Options to hormone replacement include soy products like tofu, tofu dogs or burgers, miso, soy sauce as well as soy isoflavone or citrus bioflavinoid supplements. One study showed improvements from topically applied progesterone supplements available in health food stores. Other options include the Ayurvedic herb vitex nirgundi, black cohosh or dong quai, but they haven’t been studied in clinical trials.
9. AYURVEDIC MEDICINE RECOMMENDS a tiny amount of a highly refined quality of calcium to function as a seed crystal for new bone. Pearl, coral, conch shells and mother of pearl are all used, but the latter three are the least expensive. These minerals can be ground into a fine powder in a clean coffee or pepper grinder. Take one sixteenth of a teaspoon in addition to your usual supplement. Herbs that can be taken with calcium to improve its absorption include heartleaf moonseed (guduchi), licorice, and asparagus root (shatavari) as well as sesame seeds, best taken roasted and rolled into balls with a little honey or as tahini, used instead of peanut butter.
10. REMEMBER THE CORAL REEF. Your bones are alive and changing and in a few years you’ll replace all the atoms in your skeleton.
Jay Glaser, MD is a board certified internist in Massachusetts.