How Effective Are Osteoporosis Drugs?

Smoking attacks bones severely and increases the risk of a hip fracture at some point in life by about half. In addition, smoking impairs bone healing—so much so that surgeons ask themselves whether they should even operate on smokers anymore, because the complications with wound and bone healing are so high. But what if you smoke cannabis instead of tobacco? I address that in see.nf/joints. Bottom line: High cannabis consumption does not appear to be an independent predictor of weakened bones.

How Effective Are Osteoporosis Drugs?

Osteoporosis medication is recommended for women past menopause or men over 50 who have already had hip or vertebral fractures, or people with a hip or spine T-score of ≤ –2.5 percent, or those who have different values but are estimated to have a 20 percent higher risk over the next ten years of a major osteoporotic fracture, or, more specifically, a hip-fracture risk of at least 3 percent.

The T-score? That is the measure of bone density compared to the average 30-year-old white woman (no joke). Because we lose bone mass as we age, we can suffer from osteoporosis even if we have a completely normal bone density for our age. But even if our bone density is normal, that does not necessarily mean it is optimal. That is why the National Osteoporosis Foundation developed guidelines for drug treatment. Another reason may be that the foundation is substantially supported by the pharmaceutical companies that literally make billions in profits from osteoporosis drugs. What does the science say? I discuss the numbers in see.nf/drugefficacy. In summary, surveys show that most people would not take these osteoporosis drugs if they knew the truth. But everyone has to decide that for themselves.

Are Osteoporosis Drugs Safe?

Most of those who take such medications stop taking them again before a year is up, and not only because they do not notice any effect. Two rare but serious side effects are osteonecrosis of the jaw and atypical femur fractures. When they became known, use of these medications fell by more than 50 percent. An article about it in the New York Times began like this: "Reports that the drugs cause jaws to rot away and thigh bones to snap in two have shaken many osteoporosis patients so much that they would rather accept the disease." In see.nf/drugsafety I go into how likely such side effects are and what you can do to reduce the risk.

Are Calcium Supplements Safe, and Do They Work?

Are there supplements that can reduce the risk of osteoporosis? In the chapter "Maintaining Muscle" I discuss how creatine can positively affect the muscle health of older people, which could reduce the risk of falls, but it did not stand up to closer scrutiny. The vast majority of studies found no benefit of creatine for bone health. And what if you supplement with calcium and vitamin D?

Over the last twelve years, experts changed their recommendation for general calcium supplementation to prevent osteoporosis toward advising patients to "take no supplements," and to this day most still adhere to that. What exactly happened there, I show in see.nf/calciumsafety. In summary, it appears that calcium supplements increase heart attack and stroke risk because they very quickly lead to unnaturally high and persistent calcium levels in the blood, which can result in abnormal blood clotting.

A heart attack or stroke is a catastrophe, but so is a broken hip. How effective are calcium supplements if you want to avoid hip fractures? So far, no association at all has been shown between calcium and hip-fracture risk. If anything, calcium carries a 64 percent higher risk of fractures compared with placebo, as randomized controlled trials show. In see.nf/calciumeffectiveness I discuss how anyone even got the idea that taking calcium supplements would benefit bones. In short, the data suggest that most people do not need to worry about calcium intake through diet, because the body can absorb more and excrete less when intake is low. But do not overdo it. If you drop down to just a few hundred milligrams a day, you can lose significantly more bone mass.

The Best Vitamin D Dosage to Prevent Falls

Too much vitamin D can also do harm. In see.nf/vitamindfalls I discuss the studies showing that periodic high doses—such as a one-time dose of 500 000 units per year—can increase fall risk (placebos were used for comparison). More frequent falls also occurred when 100 000 or 60 000 units were administered once per month. In a randomized, placebo-controlled double-blind study in which older women received seven different doses of vitamin D for a year, it turned out that the middle doses (1600, 2400, or 3200 units a day) led to significantly fewer falls than the low (400 or 800 units a day) or higher doses (4000 or 4800 units a day). In addition, bone density fell especially in women when they took 4000 or 10 000 units a day for three years. It is possible to have too much of a good thing.

Does Milk Really Do It?

Which foods are good for our bodies? You immediately think of milk, but that is probably just an empty advertising promise. There are no randomized controlled trials on this, and most meta-analyses of cow’s milk consumption and hip fractures in population studies point to no overall protection. In fact, Dr. Walter Willett, the former chair of the Department of Nutrition at Harvard, went so far as to claim that milk may even contribute to the high number of hip fractures in countries with the highest milk consumption. This mystery prompted a Swedish research team to conduct several studies with 100 000 men and women whom they followed for up to 20 years. The scientists found that milk consumption increased the number of bone and hip fractures and shortened the participants’ lives.

As I explore in see.nf/milkbones, galactose seems to be to blame, a breakdown product of the milk sugar lactose. Normally, galactose is used by scientists to make lab animals age prematurely. In one of these studies, the "animals with the shortened life span showed signs of neurodegeneration, mental retardation, and cognitive dysfunction, their immune system responded more poorly, and their reproductive capacity was reduced." And it did not take much—converted to humans, one or two glasses of milk a day. But humans are not lab animals. For example, we have known for almost 100 years that you can trigger cataracts in rats with lots of lactose or galactose. Whether dairy products have the same effect in humans, the epidemiological data are inconsistent.

Because what was at the time the largest study on milk consumption and mortality showed such impairments, Harvard researchers, using three of their cohorts, set up a study twice as large to test whether the results from Sweden might have been mere chance. After following more than 200 000 men and women for more than 30 years, they confirmed the bad news in 2019. Those who ate and drank more dairy products lived significantly shorter lives. Each additional half-serving of regular milk a day meant a 9 percent higher risk of dying from cardiovascular disease, an 11 percent higher risk of cancer death, and an 11 percent higher overall mortality risk. More on this in the video see.nf/milkupdate.