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“Some bone loss is going to occur in men and women, which is a normal part of the aging process,” says Robert Recker, M.D., who has conducted bone research at the Creighton University School of Medicine, in Omaha. “But if lifestyle changes are made early and not just when the prospect of osteoporosis looms overhead, then there’s a good chance fractures can be avoided.”

Bone mass stops developing at age 35 and bones start slowly losing calcium thereafter until menopause occurs at about age 50 and triggers a more drastic calcium drain. “The strength of a woman’s bones at age 35 will determine how she handles the high-risk years,” says Stanton Cohn, Ph.D., professor of medicine, school of medicine, State University of New York at Stony Brook, and head of the medical physics division of the Brookhaven National Laboratory, Upton, New York. “The years before age 35 are crucial. A woman can increase calcium intake and exercise between ages 35 and 50 and have some impact, but by that time, all she’s trying to do is maintain what’s already there.”

The amount of calcium needed daily depends on several factors. The government’s Recommended Daily Allowance is 800 milligrams. Experts generally agree, however, that the calcium RDA should be higher, possibly 1,200 milligrams for teenagers, 1,000 milligrams for women age 20 through menopause, 1,200 milligrams for pregnant women and anywhere from 1,000 to 1,500 milligrams after menopause, depending on whether estrogen is also being taken.

How to get the necessary calcium depends on personal preference. A glass of low-fat milk contains about 300 milligrams of calcium, so several would meet the RDA. But there are plenty of other sources: low-fat cheeses, yogurt and ice cream; red kidney, lima and soybeans; blackstrap molasses; fruits, such as watermelon, oranges, raisins and strawberries; fish, especially sardines and salmon when they have soft bones that can be eaten; Brazil nuts, almonds and sunflower seeds; and green, leafy vegetables, which is where the cow gets the calcium for milk in the first place.

Enough calcium can be obtained from food alone. A report in the New England Journal of Medicine (January 31, 1985) concluded that the calcium intake of hunter-gatherer tribes still roaming the earth and living lifestyles similar to people who lived in preagricultural days is more than 1,500 milligrams a day, which exceeds the current highest suggested daily requirement. They ingest no dairy products, and possess sturdy bones just by eating which they pluck, pull or catch.

Some people have trouble sticking to a balanced diet, and others just don’t like dairy products, in which case calcium supplements may be in order. The most widely recommended are calcium-carbonate tablets, which contain almost three times more calcium than other types of supplements (and that means fewer tablets to swallow).

Some people prefer to take their supplements with meals, while others take them at bedtime; both approaches seem to work, although the experts question whether taking large doses at once is wise. “It’s probably best to take it slowly throughout the day instead of in a sudden shot all at once. If you overload, there’s a chance that a good bit will be lost through body wastes,” says Dr. Cohn.

Moderation is the watchword. Megadoses of calcium that exceed 2,000 milligrams a day can in rare cases lead to kidney stones and constipation.

There are knowledgeable people in the world who are, for lack of a better phrase, slightly bone dumb; people who think milk is for children and that fibula and tibia are Shakespearean characters; people who believe that brittle bones and the “dowager’s hump” are inevitable aspects of growing old. Young women shrug off that clinical-sounding word “osteoporosis” as something that afflicts only grandmothers, and young men tune out talk of the bone-degenerating condition because it’s a woman’s problem.

It is these people, those whose knowledge of bones comes from cutting apart a frozen chicken, who should consider the words of experts like Jon Block, M.D. “Worrying about osteoporosis after it shows up is like closing the barn door after the horse has already gone. We need to take precautions earlier because you can do very little to reverse the condition once it occurs,” says Dr. Block, a member of the osteoporosis research program in the University of California at San Francisco’s radiology department.

Previously, osteoporosis efforts have concentrated on treating the condition, but today there’s more attention paid to prevention. The target audience is young women, preferably in the teen years, and the goal is to make them aware of changes they can make that could help them avoid the crippling bone condition.

Unwelcome Sign of the ‘rimes

Osteoporosis was once scarcely recognized because most people didn’t live long enough for their bones to deteriorate. As average life expectancy increased, however, doctors noticed that older women broke their wrists more often than older men, which one German surgeon in 1882 blamed on tripping on long skirts. Wiser men have since put fashion aside and learned that menopause’s hormonal changes trigger the loss of bone strength. That’s because following menopause there is a dramatic decrease in the production of estrogen, a sex hormone that maintains bone strength.

Today the average woman will live to see at least 78 candles on her birthday cake, which means she will also spend more than one-third of her life in the postmenopausal stage, when osteoporosis is a high risk. “More women are getting older and living longer, as are men, so the situation for both sexes stands to get much worse unless something is done,” says James A. Nicotero, M.D., director of the osteoporosis diagnostic center at St. Francis Medical Center in Pittsburgh.

Almost 20 million people have some form of osteoporosis, and at least one million people annually break bones that are weakened by osteoporosis. About 50,000 people die each year from complications due to osteoporosis, with many victims incapacitated for life.

Your Mother Didn’t Know!

How osteoporosis occurs is clearer now than in mother’s day. Calcium, a silver-white metal that’s a dominant element in bone, is stored in the skeleton. When more is needed to maintain bones, teeth and other bodily functions than is taken in, a calcium deficiency is created. A federal survey shows that up to 50 percent of males between 18 and 34 have diets deficient in calcium, while two-thirds of women between 18 and 74 fail to take in enough calcium each day.

When the reserves are taxed day after day without being adequately restocked, bones become porous and brittle (hence the name “brittle bone disease”) and break easily. Vertebrae can collapse and the resulting dowager’s hump can cause severe back pain. Once bone weakens it is difficult to rebuild it to its original strength; there’s no cure per se and the objective is to keep the deterioration from worsening.

Women have more trouble with calcium than men and lose bone mass faster, which is why osteoporosis is eight times more common in women. There are plenty of physical factors: Because of smaller body size, women generally have less bone mass to start with; bone loss begins at an earlier age; pregnancy and breastfeeding appear to take a heavy toll, since one skeleton supplies calcium for two lives; women are more likely to go on weight-reducing diets that typically are low in calcium; and women live longer than men.

There are also social factors: Women smoke and drink alcohol more than their grandmothers did, and both smoking and drinking have been implicated in calcium loss; soft drinks and fast foods low in calcium are dietary staples; the think-thin mentality keeps many women away from calcium-rich foods; activity appears to stimulate bone development, but many women live sedentary lifestyles.

In the winter, getting enough vitamin D can be a problem for anyone living in the northern latitudes. One reason is that the sun is lower in the sky. The sun’s-ultraviolet rays have trouble punching through the atmosphere, which is thicker at that low angle. There are also fewer hours of daylight and more clouds. Too, when it’s cold outside, few of us are inspired to take a sun bath. Sitting next to a nice, sunny window doesn’t help, either. Glass filters out Sol’s ultraviolet rays.

Suppose you live in West Thumb, Wyoming, and it’s been snowing there continually since October. Can you still get enough sunshine to meet your needs? Maybe not. “In the winter, in the northern part of the United States, I’d say the chances are you aren’t going to get enough vitamin D by skin,”

says Hector DeLuca, Ph.D., chairman of biochemistry at the University of Wisconsin. For the vulnerable elderly, some of whom may get very little sunlight even in the summer, the need for vitamin D can be particularly acute.

Fortunately, the sun is not the only source of vitamin D. There are some simple ways for the elderly—and the rest of us—to get enough vitamin D while we’re huddled up next to the radiator, waiting for spring.

We can consume more dairy foods. If you’re tallying up international units of vitamin D, a quart of fortified milk holds 400 I.U.

Vitamin D also is abundant in certain oily fish, such as salmon, mackerel and sardines. You’ll find 500 I.U. of vitamin D in flounce helping of salmon and 275 I.U. in the same size serving of mackerel.

Fish-liver oils are extremely rich in vitamin D. There are, for example, 1,200 I.U. of vitamin D in a tablespoon of codliver oil.

Other foods do contain vitamin D, including liver, butter, cheese, eggs and beef. Some cereal products also are fortified. However, vitamin D is not plentiful in vegetables.

Be aware that because the body can store excess vitamin D in fat, large doses of vitamin D, taken over time, can cause serious health problems. That’s a very unusual problem, but something to keep in mind. When vitamin D dosage hits the thousands-of-I.U level, that’s when trouble can begin.

If too much vitamin D in the diet can cause illness, what about sunshine? Can you overdose on vitamin D after a relaxing afternoon on the golf course? Not to worry. At a certain point, your body knows when to turn off the vitamin D tap. It’s self-regulating, like a thermostat.

“Sunshine is the way you were meant to get your vitamin D,” says Dr. DeLuca. “The amount of vitamin D that can be made in the skin is limited.” We can safely get all the vitamin D most of us require in a multivitamin tablet, which Drs. Ober and DeLuca recommend as “insurance.”

“Most of these vitamins have 400 units of vitamin D, which is a safe amount. But I really wouldn’t want most people going beyond that,” says Dr. Ober.

Exactly how much vitamin D does the average person need? The Recommended Dietary Allowance of vitamin D is 400 international units (I.U) daily.

Thanks to the sun, most of us get enough vitamin D without even trying. But for those who spend little time outdoors or cover up every available patch of sun-receptive skin, vitamin D deficiency can be both painful and potentially crippling.

In adults, prolonged vitamin D deficiency may lead to osteomalacia (soft bones) or osteoporosis (brittle bones). There’s more to osteomalacia and osteoporosis than just a reduction in the amount of calcium going to your bones. Your body needs calcium for other purposes—to keep your heart beating rhythmically, to regulate muscle contractions, to promote blood coagulation and, in general, to keep your body’s cells glued together. When your body doesn’t get enough vitamin D, the bones don’t get calcium, but neither does the rest of your body. So it responds to immediate calcium needs by siphoning calcium from the bones.

The early warning signs of osteomalacia are bone tenderness or pain, back pain, irritability and weakness. These symptoms often are dismissed as the inevitable consequences of old age. But it’s not necessarily so. Left undiagnosed, osteomalacia sufferers ultimately may have trouble making it up a flight of stairs and, in the worst cases, might not be able to walk.

The link between vitamin D deficiency and osteoporosis is not as clear. Osteoporosis patients are believed to suffer a calcium deficiency. Some patients do absorb calcium more efficiently with the administration of vitamin D in its hormonal form. Research suggests, however, that not all cases of osteoporosis respond as well to increased vitamin D. An estimated 20 million Americans, most of them postmenopausal women, suffer from osteoporosis, believed to be a result of reduced production of estrogen in the body. This condition interferes with the conversion of vitamin D to a hormone, so the bones are deprived of calcium.

Certain illnesses make it hard for some people’s bodies to process vitamin D. These include liver, kidney or parathyroid disease, and vitamin D-dependency rickets, a hereditary disorder. Vitamin D along with calcium has been found useful in treating these problems, but in doses well beyond the RDA of 400 units.

Certain anticonvulsant drugs—phenobarbital and phenytoin, for instance—also can abnormally speed up the breakdown of vitamin D. Supplementation is required to reverse osteomalacia caused by these drugs but, again, in doses that must be medically prescribed.

Nursing mothers and pregnant women also may require additional vitamin D and calcium. However, in these cases, supplements should not be taken without a doctor’s recommendation.

Children can also suffer vitamin D deficiency, and their bones, too, can turn soft. This condition in young people, characterized by bow legs and pigeon chest, is called rickets.

In the early days of the Industrial Revolution, as soot, smoke and dust rose high into the sky, blocking sunlight, rickets emerged as a serious problem among children. Today, thanks in large part to vitamin D-fortified dairy products, vitamin D deficiency is uncommon among American children.

Of growing concern, however, are recent reports of vitamin D deficiency among senior citizens, even in the midst of America’s Sun Belt.

“What we see happening in our society is that people, particularly as they get older, have a tendency to avoid sunlight purposely,” says John L. Omdahl, Ph.D., a biochemist, of the University of New Mexico School of Medicine.

All things being equal, says Dr. Omdahl, a 7~year-old man shouldn’t need more vitamin D than a man 50 years younger. As a practical matter, though, many older Americans do need more vitamin D because their bodies don’t make enough to begin with.

Why not?

There are a variety of reasons, Dr. Omdahl explains.

Many older people worry that exposure to sunlight may lead to skin cancer. Or perhaps they just have trouble getting around, so they remain indoors. And in the winter, in particular, they are reluctant to venture outside into the cold.

Contributing to the deficiency is insufficient vitamin D in the diet. Many older people have trouble digesting milk products, says Dr. Omdahl, so they don’t consume enough dairy foods to meet nutritional requirements.

It also is believed that as we get older, our bodies become less able to absorb calcium. Likewise, blood levels of vitamin D hormone also diminish.

Particularly telling is a 1982 study of elderly residents in Albuquerque, New Mexico. According to the study, which Dr. Omdahl coauthored, elderly Americans appear to be getting less vitamin D than the RDA of 400 I.U. Sixty percent of the elderly New Mexicans took in less than 100 units a day. Most were not taking vitamin D supplements and they avoided sunlight, which was abundantly available.

Vitamin D deficiency is uncommon in the United States, says Dr. Omdahl. But among the elderly, particularly city dwellers, vitamin D deficiency does occur. “What percentage of the elderly that is, we’re still trying to determine,” says Dr. Omdahl. “But it is something that should be of concern to the general population.”

One of the best friends your bones ever had just traveled 93 million miles to get here. It’s sunlight, and if you aren’t outside welcoming it, well, maybe you don’t know what you’re missing. But your bones do.

The sun, that untiring nuclear furnace, brightens our days, warms our cold bodies and melts the snow. But the sun is more than just a pretty face. The sun’s rays also trigger an ingenious biochemical process in our skin that stimulates the production of vitamin D, and that’s good for our bones, too.

Get enough sunlight—just 10 to 20 minutes a day, experts say—and your skin will manufacture all the vitamin D your body needs.

Fortunately, most Americans get plenty of vitamin D. But a number of the nation’s elderly—though no one knows exactly how many—live in the shadows, locked away from the light of Earth’s shining star. As a result, their bodies don’t make enough vitamin D. Neither do they get enough vitamin D in their diet, a secondary but important source of the vital nutrient.

Why is vitamin D so important? Think of vitamin D as a bus. Every day, calcium—an essential mineral—takes a ride on that bus. Its destination: your bones.

Calcium makes your bones strong and hard. Without calcium, your bones can become dangerously soft or brittle. But calcium has to have a way of getting from your gastrointestinal tract to your bones. That’s where vitamin D comes in.

Vitamin D formed in the skin is converted in the liver to a prohormone, 25-hydroxyvitamin D. It’s then converted once again in the kidney to an active hormone, 1,25 vitamin D, or calciferol. This hormone is what moves calcium along on its way to your waiting skeleton.

“The main thing vitamin D does is help the GI tract absorb calcium,” says Patrick Ober, M.D., of the Bowman Gray School of Medicine, in Winston-Salem, North Carolina. “Calcium won’t be absorbed and it won’t ever be utilized unless it can be transported into the bloodstream, and that’s the function of vitamin D.”

Dr. Ellison braved life and limb by trying his substitution theory on high-school students, and found that despite a few exceptions, the foods prepared with polyunsaturates passed the test.

“Many of the oils used in schools and for commercial food preparation are high in saturated fats. We wanted to see if using polyunsaturated products would be acceptable because if so, then it could make a big difference in the health of a lot of people who eat out in restaurants and in cafeterias at school or work,” says Dr. Ellison.

The list of ingredients included safflower, sunflower and corn oils; margarine, cheese and salad dressings high in polyunsaturates; potato chips fried in poly oil; even ice cream with a fat content that was 80 percent polyunsaturate. “With the exception of some commercially prepared meats, all of the products we used can be found on market shelves,” he says. (The foods used in the USDA blood-pressure research were also grocery-store variety.)

Substituting skim for whole milk also helps, as does eating lean meat with all visible fat trimmed off, including removing chicken skin. When buying processed foods, label reading is advised, since some products—crackers and cookies, for instance—contain saturated fat to increase shelf life. Be particularly wary of items containing coconut or palm oils, two widely used and highly saturated fats.

Weight-loss programs should also be given a careful eye, since a diet may be devoid of the essential fatty acids that the body needs, Dr. Galland advises.

Other scientists around the globe are just beginning to dabble with polyunsaturates, with some encouraging initial findings. Doctors in England report using a diet high in essential fatty acids to calm hyperactive children, and there are documented cases of polyunsaturates helping people who suffer from arthritis, allergies and multiple sclerosis.

While the research continues, the best approach is one of moderation. Says Dr. Lewis, “The biggest mistake people could make is to assume that radically increasing their intake of polyunsaturates will help even more. Fats are fats, regardless of the type, and you should cut back wherever possible. If you have to use a fat, make sure it’s a polyunsaturate.”

In general, only about 30 percent of daily calories should come from fat; of that 30 percent, at least 10 percent should be polyunsaturates to counteract the 10 percent saturated fats that you’re bound to ingest.

The remaining 10 percent should be monounsaturates, the beneficial fats that were previously thought to be neutral. “Our initial research shows that monounsaturates may be just as effective at lowering blood cholesterol,” says Fred Mattson, Ph.D., professor of medicine and former head of the lipid research clinic at the University of California at San Diego. “Monounsaturates may even be more beneficial because they don’t lower HDL cholesterol levels like excessive polyunsaturates do. But people shouldn’t worry about getting enough because a normal diet usually supplies all that are needed.”

The best thing about all of the good fats is that they can be had without having to stare at a bland, lifeless dinner plate. Substitution is the word for the day.

“You can easily make subtle, what I call passive, changes in the way you prepare foods that may make a difference in long-range health,” says R. Curtis Ellison, M.D., professor of  medicine and pediatrics at the University of Massachusetts Medical Center, in Worcester.

While they still aren’t sure how it works, researchers believe that polyunsaturates also decrease the risk of clotting in the bloodstream, which means less of a chance of a heart attack or stroke. One of the more popular theories is that the polys block the release of an acid in the cells that encourages clotting. Research so far has shown that diets high in saturated fats fill blood cells with this acid, priming the person for a potential clotting problem.

One source of polyunsaturates that’s suspected of blocking this clotting acid is fish oil, which is gathering attention in scientific circles. West German researchers found that daily doses of cod-liver oil help prevent clumping of platelets, the chief characters in the clotting process. The supplemental fish oil also lowers thromboxane (a substance that causes clotting and vessel constriction, and increases bleeding times), another indication that clotting risk is eased (Circulation, March, 1983).

According to Leo Galland, M.D., and a growing number of other experts, more fish should be in everyone’s diet because they are high in a type of polyunsaturated fatty acid called omega-3, which keeps the harmful clotting factors from getting together. “Nationwide there’s a deficiency in omega-3,” says Dr. Galland, who has conducted research on the role of fatty acids on health and currently codirects a New York clinic specializing in nutritional medicine. “A majority of the population should increase their intake of omega-3. The best source is fish that live in cold climates, such as salmon, tuna, herring, sardines, even lobster and oysters. It’s also in green, leafy vegetables and linseed oil, but not as concentrated as in fish.”

That She Blows

Fish oil is also being touted as a way to lower blood pressure, a claim reinforced by that same West German study. The researchers found that the cod-liver oil lowered systolic blood pressure an average of almost ten points.

The strongest evidence that polyunsaturates lower blood pressure comes from a military base near San Francisco that houses the U.S. Department of Agriculture’s Western Human Nutrition Research Center. There, research has shown that by increasing the polyunsaturated-fat intake from the current norm of 3 to 4 percent up to 6 to 7 percent of total calories, blood pressure may drop 10 to 15 percent.

Exactly how this happens is unclear, according to center director James Iacono, Ph.D., but the most plausible theory is that the good fats improve kidney function and cause more sodium and potassium, known contributors to high blood pressure, to be excreted in urine.

The most appetizing aspect of Dr. Iacono’s research is that an easy-to-follow menu produces the desired results. “In the past two studies, we lowered blood pressure in 40- to 60-year-old men and women without reducing their intake of meat, dairy products or salt,” he says. “You just have to use lean meats, low-fat dairy products and keep salt intake to the usual 8 to 12 grams a day.”

One phase of the research was conducted in Finland, land of the highest death rate related to cardiovascular disease and the home of people who consume massive amounts of saturated fat. People on a low-fat diet emphasizing polyunsaturates showed dramatic blood-pressure reductions, whereas those on a low-sodium diet had only slight reductions, says Dr. Iacono.

“The important thing to remember is that we’re talking about two kinds of cholesterol,” says Richard L. Jackson, Ph.D., of the department of pharmacology and cell biophysics at the University of Cincinnati College of Medicine. “We’re looking for a ratio of polyunsaturates to saturates that will lower levels of LDL cholesterol, which is the unwanted type, and maintain high levels of the beneficial HDL cholesterol. It’s been shown that an extremely high polyunsaturate/saturate ratio will lower HDL levels.”

Dr. Jackson and several colleagues found that it doesn’t take radical shifts in the polyunsaturate/saturate balance to achieve some healthful effects. They concluded that a polyunsaturate/saturate ratio of one-to-one, rather than the harder-to-consume ratio of four-to-one used in previous studies, lowered LDL levels better while maintaining HDL.

One of the easiest ways to clog arteries and raise blood pressure is to eat saturated fats, which usually originate in land animals—meat and full-fat dairy products, for instance. While the body needs some saturated fat to function properly, it can manufacture almost all it needs. The surplus we ingest just causes trouble.

Fat versus Fat

On the other hand, polyunsaturated fats, which usually come from vegetables, seeds, nuts and aquatic creatures, can displace the saturated fats and, in a sense, neutralize their negative effects. But this healthy blocking can only occur if the polyunsaturates outnumber the saturates, which, for most red-blooded Americans, is usually not the case.

Unfortunately, Americans are eating far more of the bad than the good. “In general, we’re consuming 2^7^2 times more saturated fat than polyunsaturated fat,” says Jon Lewis, Ph.D., a pathologist at the Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina, who has conducted long-term studies on fats and human nutrition. “We know without a doubt that saturated fats do unhealthy things, such as drive up cholesterol levels, but people are still eating too much.”

Ideally, roughly equal amounts of the two fats, along with another type called monounsaturated that has many of the same characteristics as polyunsaturates, should be the rule of thumb, a recommendation that resulted from the 1977 Senate Select Committee on Nutrition and Human Needs. That group also concluded that no more than 30 percent of a day’s calories should come from fat; currently, we get about 40 percent.

When the Senate committee convened almost a decade ago, cholesterol was undoubtedly in the back of the members’ minds. Today, it’s in the public forefront, mainly because almost one million people annually die from diseases of the heart and blood vessels that are often the result of excess cholesterol.

The sad fact is that many of the deaths might have been prevented. As early as 1950 evidence surfaced that vegetable fats lowered cholesterol levels while animal fats caused an increase. In the ensuing years, more studies emerged reinforcing the theory. Yet, as with almost any facet of medicine, there are two sides to every story.