Men's Osteoporosis Support GroupBook Review "Building Bone Vitality"
Book Review "Building Bone Vitality" by Amy Joy Lanou, Ph.D. and Michael Castleman, Foreword by Dean Ornish, M.D. McGraw-Hill Publishing, 2009, ISBN: 0071600191 Summary: The authors reviewed more than 1,200 research articles dealing with osteoporosis and concluded the preponderance of research found that a low-acid diet is what is needed to prevent and/or treat osteoporosis. Along with that diet, weight-bearing exercise is also extremely important for bone health as shown by most studies. Milk and dairy products have not been proven, according to a majority of the research, to be important for bone health, and some research shows those products to be detrimental. A modern diet that is high in meat, dairy and grain proteins, creates a state of metabolic acidosis which must be neutralized (buffered) by the calcium compounds that are in bone. This long-term state of metabolic acidosis with persistent loss of bone calcium can then lead to low bone mineral density, osteoporosis and/or fractures. The low-acid diet should counteract these negative bone effects.
Part I. Why the Calcium Theory is Wrong. The conclusion is that the countries that consume the most dairy have the greatest number of fractures. Four tables are provided that show the hip fracture rate by country, but which don't actually show the percentage of milk/dairy consumption per capita. That would have been a nice addition. They note, "Put another way, total calcium consumption among women in China, Peru, Sri Lanka, and many other non-Western countries is only about 500 milligrams a day, yet fracture rates are very low."
Along with dairy and calcium they discuss Vitamin D, exercise, race/genetics and Epidemiology with a side bar discussing the staggering toll of osteoporosis in the United States. This includes over 10 million Americans with osteoporosis over the age of 50 and the fact that over 1.5 million Americans have a fracture each year with 300,000 of them being hip fractures, the most expensive, painful and detrimental osteoporosis-related fractures. They also mention that osteoporosis is not just a women's disease, but explain that up to 25% of hip fractures occur in men.
Worth the price of the book is the explanation of the types of research studies that have been conducted on the topic of osteoporosis, and which types can be taken more seriously than others. They suggest that clinical trials using humans would be the ideal study, however, the perfect study would also be too expensive. Here are some of the alternatives scientists have to use instead. Prospective studies that follow a group into the future. Retrospective and cross-section trials that look back in time, e.g., to try to determine what is different between a group that has suffered hip fractures and matched controls who did not. Bone density studies that use bone mineral density as a proxy for fracture risk. Meta-analysis, which combines several small studies statistically into a large group by pooling the results.
Next they discus the number and type of studies regarding milk, dairy and calcium supplements and their ability to prevent fractures. Their conclusion is that the preponderance of the data, and the strongest of the types of studies done, find no significant correlation between the consumption of milk, dairy or calcium supplements and the reduction of fracture risk. They find the same results regarding children consuming milk, dairy and calcium to help prevent fractures later in life--it doesn't help.
Their discussion of vitamin D as an aid to fracture prevention shows more mixed results, with an average reduction in fracture risk of about 17% combining all studies, although the number of studies positive for vitamin D and negative for it are about even.
The bottom line regarding all these studies is that milk, dairy, calcium supplements and vitamin D don't provide an ideal answer for osteoporosis fracture prevention or treatment. As a viable alternative they suggest low-acid eating. This concept was first suggested in 1968 in The Lancet by Wachman and Bernstein. As a nice feature the authors provide a side bar that recaps all the evidence for their stated positions.
Part II. The Bone Vitality Prescription: Low-acid Eating and Daily Walking. First they describe what they mean by low-acid eating. This doesn't mean the foods are non-acidic in the stomach or intestine, but that when they get into the blood stream they are alkaline as opposed to acidic. The difference being that acid-forming foods must be neutralized (buffered) to keep the blood in a very narrow pH range. Such foods are buffered by the breakdown of bone compounds, which results in lost calcium. Over time this can lead to low bone mineral density, and/or osteoporosis.
Several studies are cited which show that excess animal protein ingestion leads to the acidic blood condition as shown by increased calcium in the urine. This is also called metabolic acidosis in several articles on the Men's Osteoporosis website. Provided tables show the effect on urine acidity of common foods. This is what has been described under the heading of potential renal acid load (PRAL) in several articles on this website. In short, vegetables, fruits, some beans, and some beverages are base-forming, they raise the blood and urine pH. The higher the pH the more alkaline it is, the lower the pH, the more acid it is. The total range is from 1 to 14. Flesh foods, most nuts, cheese, dairy, eggs, and grains are acid-forming. Base-forming foods are negative (have a minus sign) and acid-forming foods are positive (have a plus sign). Thus if you ate a food with a value of -2 and one of +2, the net effect would be zero, not acidic nor basic to the urine or blood. Food that was -4 and +2 would have a net base-forming effect of -2. More later on this topic, but the goal would always be to eat foods that add up to a net negative number to keep the urine and blood alkaline, and thus prevent removal of bone calcium to buffer the blood stream acidity.
A picture is worth a thousand words, and the diagrams on pages 64-65 show that dramatically. These come from a 2000 study of worldwide fracture rates compared to animal protein intake. All show a strong correlation to increased hip fracture rates with increased animal protein intake, or, vice versa, decreased hip fracture rates in those with higher vegetable protein intake. This article is also available online for free at http://biomed.gerontologyjournals.org/cgi/content/full/55/10/M585. They cite four other studies that corroborate this study's results.
There is a table with the calcium content of several non-dairy foods that shows it is possible to get adequate calcium eating a non-dairy diet. The suggestion is that a vegan diet is ideal as a low-acid diet, and that it has several other positive health consequences. But they point out that a low-acid diet need not be completely vegan. It is simply a matter of counteracting the acid-forming foods with even more of the base-forming foods. They later provide simple recipes to show how this can easily be done.
There is a chapter devoted to explaining why a forty-year-old idea, the low-acid diet, can be seen as new. This discusses the influence of the fast-food industry, government regulations (the food pyramids), the influence of the dairy industry, and other ideas that have held back the low-acid idea until now.
A chapter also covers the seventeen other nutrients that are involved in bone formation. Obviously flesh products, dairy, and calcium supplements don't provide all these additional nutrients. Each nutrient's importance is listed and foods supplying them are listed. The suggestion is that the produce isle is a better place to find these essential ingredients than the supplement isle. This chapter also lists some of the weaknesses of DXA (dual-energy X-ray absorptiometry) bone density testing and mentions the new FRAX (fracture risk assessment) online tool that supplements DXA, giving a more reliable 10-year fracture risk score than DXA alone.
There is a chapter regarding those who disagree with the concept of low-acid eating with rebuttals to their ideas. One of the concepts for increased protein to prevent fractures involves older, malnourished individuals who are helped by the protein. The authors conclude that any food, protein or otherwise, would be beneficial for people in such a poor state of nutritional health.
In summarizing all the evidence for the low-acid diet as an aid to preventing or treating osteoporosis, the authors admit it is not a perfect concept, but feel, based upon the preponderance of evidence, it is the best explanation at this time. They present all the reference abstracts they used, describe how to look them up on PubMed, and even offer to ship copies to interested readers if they will pay for the expense of doing so, $250.
There are two chapters devoted to describing how to gradually shift to a low-acid diet with recipes for representative meals. There is also information on how to develop low-acid foods and meals that kids will like.
The authors suggest that exercise is as important as low-acid eating for bone health. The type of exercise suggested is weight-bearing, such as, walking jogging, weight lifting, etc. It is also important to reduce fractures by fall prevention, such as, exercises to strengthen muscles and improve balance. Lists are provided to show what you can do to reduce the risk of tripping or falling around the house.
Part III. A discussion of other risk factors for osteoporosis, such as diabetes, corticosteroids, and other medications. This includes the various osteoporosis medications and whether it is wise to take them, including positive mention of thiazide diuretics as one inexpensive, effective alternative to discuss with your physician. There is also a short chapter on the benefit to the planet that would occur if more people ate a diet with less meat in it, citing highlights from the Food and Agriculture Organization of the United Nations report, "Livestock's Long Shadow." The impact of livestock production on the environment is astounding.
The concluding chapter gives an evidence-based approach as to why they suggest the low-acid diet and weight-bearing exercise as the best approach to treating and preventing osteoporosis. Additionally there are several appendixes listing the research abstracts that support each position they discuss in the various chapters so you can look up the facts for yourself if you so desire.
Editor's comments. I have to admit to a positive bias toward this book since I am a vegan and have followed a low-acid diet for the last several months after arriving at similar conclusions to the authors before I read Building Bone Vitality. So take my comments with that in mind.
Regarding the correlation between countries where people drink the most milk and increased fracture rates, it was not mentioned, but note that height could also be an issue since people of lower stature would have less tendency to fracture a bone in a fall than someone who is taller. See this Wikipedia article on this topic: http://en.wikipedia.org/wiki/Human_height. For instance, the Australians are on average 17 cm taller than Japanese. Exercise that makes individuals less apt to fall and lifestyles that have fewer objects upon which to trip could also provide an explanation why some countries have lower fracture rates. One could envision more sedentary people in more industrialized countries where milk and dairy consumption is higher than in less industrialized countries. This could lead to a "couch-potato lifestyle" where milk and dairy are consumed more than in the less industrialized countries with lower dairy consumption. This then being a less obvious reason for fewer fractures in the low dairy consumption countries.
The bulk of the research they provide does seem to lean in the direction of the ideas they promote, but, as they state, it surely isn't all the literature that backs their position. I think one could safely take either side of the issue and provide important research results to substantiate your position. One problem will be convincing your physician of your conclusion that a low-acid diet is the way to treat osteoporosis. Almost certainly most care providers will want the standard regimen of an FDA-approved medication. For one thing, there could likely be medico-legal issues if physicians suggest non-drug osteoporosis therapy and you suffer a hip or spinal fracture while on nothing but the low-acid diet. This will be a possibility until the study the authors suggest finally gets done: Fosamax vs. Nature's Osteoporosis Pills (Raisins). [Note that raisins appear to be used here as a proxy for the low-acid diet, which could include any foods that adequately balance the intake of acid-promoting foods]. Until such research shows convincingly that a low-acid diet can prevent or treat osteoporosis and related fractures with equal or better efficacy than Fosamax, or other bisphosphonates, the low-acid diet will likely take a back seat to the powerful pharmacology industry when your physician prescribes osteoporosis therapy.
The authors don't mention it in the book, but there are also several studies that have found that compounds or drinks that create a metabolic alkaline condition provide evidence that promotes a low-acid diet. That is, it isn't just foods that can create an alkaline condition in the blood stream and urine, drinks or alkaline-forming salts can also. See this abstract which is available with free text for more information on alkaline-forming salts. The following abstract and free full text article show the beneficial effect of an alkaline-forming mineral water.
Also not mentioned in the book, but, if you decide to follow the authors' suggestions, I recommend verifying that your diet is adequately low-acid by using urine pH dipsticks routinely. Remer and Manz did a study that showed 0.83 correlation between the NAE (net acid excretion) of the diet and the urine pH. Do a Google or other search for http://www.vivalis.si/literatura/2a95.pdf and download the free PDF to read the article. In essence the article showed a nearly direct correlation between urine pH and the PRAL (NAE) of the diet. Thus you would expect to see an alkaline urine pH if your diet is adequately alkaline-forming. I am able to maintain my urine pH at or near 8 consistently by eating a very low-acid diet. In short, if your low-acid diet is truly low acid, you can easily verify that by testing your urine pH. If the pH is neutral or alkaline, you are truly eating low-acid. If not, then you need to be more careful about not eating too much acid-producing foods, or to eat more alkaline-forming foods. Check the charts in the book to see where you might have gone wrong if your urine pH is still acidic. As always, discuss the low-acid diet and urine pH testing with your care provider if you embark on this method.
Here's a tip I suggest for a quicker method to look up abstracts at PubMed. The authors recommend the single citation matcher, but I find just placing the author's name and the year of the article in the main page query block is usually adequate. Obviously if the author's name is Jones or Smith this won't work, there will be hundreds of pages. But an unusual name will often pop up the abstract or just a few to check. First try just the last name, and then try adding first and middle initials if you know them. If there are several authors listed for the article, pick the most complex and unusual name for the query block. So in the query block at PubMed, place, e.g., Sebastian A 2000, to get the article the authors used that provided the excellent diagrams of the relationship between animal protein and fracture rate. PubMed doesn't indicate it is available as free full text, but it is if you click on the Full Text icon link.
How does one explain why so many studies have different and/or conflicting findings? I'm not sure I have the answer, but one might be to look at it from the standpoint of whether the participants were, e.g., deficient in calcium or vitamin D when they began the study. If so, you would expect to have improvement by supplying the item they were lacking. If, however, they had no shortage of that vitamin or mineral, then you would not expect improvement by supplying more. Also the various studies differ in how much calcium or vitamin D they supplied. It could also matter, regarding calcium, how and when it was taken. A small amount taken several times daily would give more absorbed calcium that if the full dose was taken at one time. As shown above in the article that found improvements when potassium citrate was given, but not when potassium chloride was used, the metals in the salt, calcium, potassium, etc., are probably secondary to the alkaline-forming ability of the non-metallic component, citrate or carbonate as opposed to chloride or oxide. Thus it wouldn't be that the calcium was lacking, but that the citrate alkalized the metabolic state improving calcium homeostasis. Additionally many studies have given relatively low amounts of vitamin D to study participants. According to the latest research, that amount could have been doubled or tripled to give ideal results. The study's results would indicate that vitamin D was ineffective, whereas, it might have been so only because it was given in an inadequate dose. Surely there are many other reasons that the results are in conflict, but these provide just a few ideas that appear logical.
Regarding the topic of harm from excess animal protein, I want to mention that it is also implicated in other disease conditions in humans. Rather than list all this myself, I am linking an article by Dr. John McDougall covering this topic. He cites the research on each problem area regarding high animal protein intake that you can check for yourself if you wish.
In summary, I highly suggest that everyone with osteoporosis, or who wants to avoid having it, read Building Bone Vitality. It is loaded with good information that should educate you to help make better osteoporosis-related healthcare decisions. Read it and make up your own mind as to whether the authors have provided adequate research data to back up their theory that a low-acid diet combined with weight-bearing exercise will treat or prevent osteoporosis and related fractures.
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