The Gerson Institute of Ayurvedic Medicine

Scott Gerson, M.D., Ph.D. (Ayurveda) Medical Director, Jupiter Medical Center Dept. of Integrative Medicine Division of Education and Research

Jupiter Medical Center at The Calcagnini Center for Mindfulness
1210 S. Old Dixie Highway, Jupiter, Florida 33458, Suite M-117.2

 

Lake Mary Clinic and Panchakarma Facility: at 635 Primera Blvd. Lake Mary, Florida 32746

 

 Telephone: (561) 263-MIND (6463); option #2 or (561) 510-3833

The Ayurvedic Approach to Osteoporosis (Asthi-Majja Kshaya)

© Scott Gerson, M.D. 2017

The Modern Medical Perspective

Osteoporosis is a disease of the skeletal system that is characterized by deterioration of bone tissue microarchitecture, along with a decrease in bone strength and—to a lesser degree—bone density. It can occur at any age, although it is most prevalent in Caucasian and Asian, small-boned women over 60. The term osteoporosis describes a condition inside the bones in which large porous areas develop mainly in the trabecular bone as opposed to the cortical bone, weakening the bone structure. Bone is a living tissue that maintains a balance through the bone-creating activity of osteoblasts, with the bone-destroying (resorptive) activity of osteoclasts. When factors such as advancing age, low BMI, lack of weight-bearing exercise, excessive alcohol and soft drink consumption, smoking, etc. cause a change in this balance toward reabsorption, bone mass decreases. If bone weakens enough to reach its “fracture threshold,” bone that was earlier able to withstand a minor stress, such as a fall or trauma, becomes subject to break or fracture more easily. Osteoporosis in fact used to be diagnosed by a person over the age of 65 sustaining a bone fracture due to a fall. Today with the advent of the DEXA scamn, T-scores and Z-scores, there is much controversy about what constitutes osteoporosis. You can read for yourself on the web about the backroom maneuvers by Big Pharma to develop dual-energy x-ray absorptiometry (DEXA) scanners, biphosphonate drugs, change the medical definition of “osteoporosis,” and increase the number of people with this newly defined disease to tens of millions globally. It reads like a made-for-tv script.

Osteoporosis is caused by a loss of bone strength. Most physicians are taught that bone density is the value for assessing bone strength as well as the response to osteoporosis drug treatment. However, in scientific circles, bone density is known to account for only approximately 10-20% of bone strength. The correct understanding of bone strength includes a number of other features of bone that collectively are called bone quality. The problem is that bone strength and bone quality are difficult to measure. Bone quality is not even accurately defined or completely understood. It is therefore described provisionally as a combination of all the known physical factors that determine how well a bone can resist fracturing, including: bone microarchitecture, accumulated microscopic damage, the quality of collagen, the size of mineral crystals, and the rate of bone turnover. I believe there are additional non-physical factors as well (e.g. see below: doshic balance, dhatu agni, purisha dhara kala, majjavaha srota). 

However, regardless of this controversy and confusion surrounding bone strength vs. bone quality, it appears clear that the most important time to focus on building healthy bones is during the first 3 decades of life. But there are many effective and natural interventions that can be instituted at any time thereafter. Providing a clean whole-food diet sufficient in bone-building nutrients, avoiding lifestyle risk factors, and regular weight bearing exercise, may be the best protection against, and in some cases cure for, this disease.

There are two major determinants of bone strength and quality in later life: (1) the extent of peak bone strength in early adulthood and (2) the rate of natural bone quality loss thereafter. Both these determinants are governed by complex interactions of genetic, environmental, nutritional, hormonal, age-related, and lifestyle factors. Since many of the risk factors for osteoporosis are self-regulated, Ayurvedic physicians are well-positioned to have a direct impact on this disease through lifestyle education. An increased risk of osteoporosis is also directly linked to the use of many prescription and over-the-counter drugs:  thyroid hormones, steroids, anticonvulsants, aluminum containing antacids, loop diuretics, gonadotropin-releasing hormones, and many others. An experienced Ayurvedic physician will have knowledge of natural therapies that may be equally effective for specific health conditions, but without any risk for interfering with bone quality.

Modern drug therapies for osteoporosis include bisphosphonates, such as alendronate (Fosamax) and risedronate (Actonel) and selective estrogen receptor modulators (SERMs) like raloxifene (Evista). These drugs are associated with a growing list of concerns, including research that suggests a link between the use of bisphosphonates and esophageal cancer. A once-per-month tablet, ibandronate sodium (Boniva), claims the advantage of greater convenience but still has a host of adverse effects, such as back pain, esophageal irritation, heartburn, and ulcers.

Hormone replacement therapy (HRT) was previously promoted as a treatment for osteoporosis, and may, in fact, be somewhat useful for decreasing bone loss. However, this benefit stops if hormone therapy is discontinued. In addition, many women refuse hormone therapy due to other known or perceived adverse effects. 

If you are willing to endure the risks and adverse effects of the above mentioned pharmaceutical agents they can be effective. But since the non-pharmacological prevention and treatment of osteoporosis is possible, we can be proactive against this disease through the purification/rejuvenation Panchakarma procedures of Ayurveda, intelligent personalized nutrition, an increase in weight-bearing exercise training, and judicious use of time-tested Ayurvedic herbal medicines. Ayurvedic medicine recognizes the importance of a whole-food diet that includes naturally occurring bone-nourishing elements (i.e., calcium, magnesium, vitamin D, boron, strontium, vitamin K, etc) but does not recommend the use of supplements. This includes bone morphogenic proteins—a kind of growth factor which pharmaceutical companies are developing as the up and coming newest profitable drug. Stay away from this.

A Few Preliminary Ayurvedic Concepts

“Dosa dhatu mala mulam hi sariram.” With this concise sloka from the Caraka Samhita (c. 200 BC), Ayurveda reveals the healthy human body as the dynamically balanced state of dosha, dhatu and mala (bioenergies, tissues and wastes).  This same point is further elaborated on by Acharya Sushruta a century later with his famous definition of health as “the equilibrium of dosha, dhatu, mala, agni, kriya and prasannata (serenity, clarity) of atma, indriya and manas”. As the Astanga Samgraha (c. 500 AD) further declares: “Shareeram dharayenthe dhatvaharashcha sarvada” meaning the support of the human body is accomplished by entirely dhatu and ahara (tissues and food). Among the sapta dhatus (seven tissues), the ashti dhathu (bone tissue) is the one which is bestowed with the supreme function of shareera dharana (bodily support). Asthi dhatu confers structure to the body and protects the vital organs. A human being without asthi dhatu would be a formless blob of soft tissues. Thus, Asthi dhatu can accurately be viewed as the scaffolding by which humankind stands upright and noble. Any discord in the equilibrium of the doshas and dhatus leads to disease.

Osteoporosis in Ayurveda

Facts: Bones increase in size and strength during the first 2.5 decades of life, with acceleration during adolescence. This is followed by a period of consolidation. Peak adult bone mass is reached at about the age of 35 years for cortical bone and a little earlier for trabecular bone. Bone mass (but not necessarily strength) subsequently declines with aging. This is a universal phenomenon, occurring in both sexes and in all races. At all ages, women have less bone mass than do men.

Osteoporosis corresponds most closely to the condition known in Ayurveda as Asthi-majja kshaya. In our classical text books Asthi-majja kshaya is not actually named as a separate disease entity, but rather as one of several consequences which can emerge as a result of Dhatu-kshaya (diminution of tissue). Asthisaushirya, meaning “porous bones,”is another condition not mentioned as a separate condition but as a symptom ofMajjakshaya. In addition to being the well-known source of the functionally important hemopoetic tissues, majja dhatu also represents the collagen, fat and protein within the bones which provide strength and unctuousness. The Caraka Samhita, Sutrasthana, Chapter 17 describes eighteen types of dhatu-kshaya. It is here that we first see a description which closely resembles our modern-day disease called osteoporosis. The signs and symptoms of this condition are described later in several other all the texts of Ayurveda: thinness, brittleness and lightness of the bones. In addition, other accompanying signs are described: looseness of joints, hair loss from body and beard, tooth weakness, and unhealthy nails.

The samprapti involves vata prakopa (spread) in both the large intestine and asthi dhatu and sthanasamsraya (relocation) to majja dhatu. Asthi dhatu is formed from the posaka (“providing nourishment”) part of meda dhatu (fat tissue) in the purisha dhara kala, situated in the pakwashaya (large intestines), where it is transformed to asthi dhatu by asthiagni. Similarly, Majja dhatu is formed from posaka fraction of the asthi dhatu as it flows through the majjavaha srota and is acted on by the majjagni. The health of Majja dhatu depends on the state of the majjagni. But in asthi-kshaya, Vata increase infiltrates majja dhara kala and majjagni becomes distorted and irregular. This causes majja dhatu (marrow tissue) to be of inferior quality and quantity.           

This condition and its pathology is eloquently understood by the concept of ashraya-ashrayi bhava—a very important and impressive theory given by Vagbhata in the text Astanga Hridaya. This is a theory which describes the relationship between Dosha and Dhatu. Here is what is said:

Vata resides in Asthi (bones); Pitta resides in Rakta (blood) and Sweda (sweat); Kapha resides in rest of the Dhatus (tissues) and Mala (waste products).

In case of Pitta and Kapha, when there is an increase of Pitta or Kapha, there is also a corresponding increase of tissues and waste products associated with them. For example, if Pitta increases, then sweat and blood also increase. The same rule applies to decrease as well. But in case of Vata and Asthi it is exactly opposite: if Vata increases, then Asthi decreases and vice versa. They are inversely related to each other. (AH Su 26-27).

This relationship helps in knowing both the hetu (cause) and chikitsa (treatment) of a vyadhi (disease) as nourishment of Asraya and Asrayi is similar. The ahara, vihara or aushadha that increase or decrease the dosha will increase or decrease the corresponding asraya (dhatu and mala). As we have said above, however, the above mentioned rule is not applicable to asthi dhatu and vata dosha.

Causes (Nidana) of Osteoporosis

For any disease, the causative factors described in Ayurveda can be classified into four groups:

1. Ahartmaka Nidana (Dietary) 2. Viharatmaka Nidana (Lifestyle Regimens) 3. Manas Nidana (Psychological) 4. Anya Nidana (Other)

With respect to Asthi-Majjaksaya (osteoporosis) here are the classically observed causes: 

Ahartmaka Nidana (Dietary)

 Aptarpana (lack of nourishing food); Alpashana (inadequate quantity of food); Excessive consumption of Laghu, Katu ahara (light, spicy foods); Ruksha (excessively dry food without oil/ghee);

Viharatmaka Nidana (Lifestyle Regimen)

 Ativyayama (excessive aerobic exercise; lack of weight bearing exercise);Vishamadupchara (faulty treatment); Asriksraava (excessive bleeding); Ati Adhva gamana (excessive walking or jogging); Vega Vidharana (control natural urges).

Manshika Nidana (Psychological)

 Chinta (stress, tension); Shoka (sadness); Krodha (anger); Bhaya (fear)

Others: Chirkalaj roga (any chronic illness), Aghata (trauma)

Ayurvedic Treatment of Asthi-Majja Kshaya (Osteoporosis)

In Ayurveda, management of any disorder is divided into essential three parts:

 1. Nidana parivarjana (Removal of the cause(s) 2. Samshodhana (Strong purifying therapies) 3. Samshamana (Gentle, balancing therapies)

Nidana parivarjana. Removal of the cause(s). This is the first line of treatment of any disease and it is most important line of treatment for Asthi kshaya also. Ayurveda says that nidana, the root of the samprapti process (samprapti=developmental stages of disease), must be avoided for best management of the disease. In osteoporosis the factors, i.e., Ahartamaka, Viharatmaka, manas and others which are responsible for the causation of the diseases should be avoided (see above section on “Causes of Osteoporosis.”)

Samshodhana therapy.  In short, this refers to a profound biopurification or cleansing of the tissues. Shodhana therapies are procedures by which the aggravated doshas or the accumulated improperly digested products of digestion in the tissues are eliminated after loosening and mobilizing them from their respective sites. Panchakarma is the principal and most effective method for Samshodhana therapy and is recommended at the commencement of treatment and then once or twice each year. I have extensively reviewed Panchakarma procedures in other articles and book chapters so will not elaborate here except to mention the supreme importance of basti karma (therapeutic enemata) and that Tikta Basti (decoctions of bitter-tasting plants) is indicated in osteoporosis. The duration of basti therapy is dependent on rogi- and rogapariksha features (qualities of the patient and the disease) and can be:

 1. Karma vasti — Total of 30 enemas: 6 oil-based then 24 alternating decoction-based and oil-based enemas                                                                                                                2. Kala vasti — Total of 16 enemas: 6 decoction-based and 10 oil-based                                                                                                                                                                          3. Yoga vasti — Total of 8 enemas: 2 oil-based then 6 alternating decoction-based and oil-based enemas

Samshamana therapy. These are gentler therapies. Among the upakrama, meaning “frequent rituals” (six types of ritual therapies-snehana, swedana, rukshana, langhana, stambhana, brihana), snehana (oil application) and swedana (fomentation) can be administered for shaman purpose in asthi-khaya. In fact any activity, food, medicine, or thought which possess vata shamaka (vata-pacifying) properties is considered as an ideal for samshamana therapy.

Ayurveda advises the avoidance of the followingapathyadietary articles: bitter, pungent, astringent taste dominant substances; dry, cold, light, and excessively spicy predominant substances;Shushkamamsa (dry meat); Shushkashaka (dry vegetables); Madya (alcohol); excessive eating; fasting; heavy exercise; excessive sexual intercourse; day sleep; night awakening; suppression of natural urges. Avoid medicines corticosteroids, anticonvulsant, and other medications known to decrease bone strength; avoid smoking and all other etiological factors which cause aggravation of Vata.

Traditionally used medicines for Asthi-majja khaya (osteoporosis): Single drugs: Asthi shrinkhala ghrita, Shatavari, Ashwagandha churna, Shuddha guggulu, Mukta pisti, Praval pisti, Shankhabhama. Compound drugs: Yograj guggulu, Rasayana churna, Triphala guggulu, Laxadi guggulu, and many others.

How to Best Assess Bone Quality and response to Therapy

There is no precise way to do this. One thing is for certain, DEXA scans are not the answer and are not an acceptable surrogate measurement of bone quality.

Bone turnover markers (BTM) may be a better method. In clinical practice, patients who show no changes in bone density on their DEXA scan may still be responding to therapy, and that response can often be detected by the levels of bone turnover markers. These include: bone-specific alkaline phosphatase (BALP), osteocalcin, and N-terminal propeptide of type 1 procollagen (P1NP); markers specific to bone resorption include N-telopeptide of type 1 collagen (NTX), C-terminal telopeptide of type 1 collagen (CTX), and pyridinoline cross-links. But BTM’s are also not without their own limitations. Their measurement is complicated by large random intra-patient variability (i.e. the same patient will often have different values the same day!), variability due to age, gender, body mass index, circadian, and menstrual variation. In addition, to my knowledge, different labs are using different biochemical assay methods resulting poor standardization of most of these marker assays. All of these issues have caused some confusion and slowed their extensive use by many physicians.

The Benefit of Weight Bearing Exercise

We’ve all heard this before, and for once, it’s actually true. Exercise, and specifically weight-bearing exercise, has an important impact on bone strength. But most people (including many physicians) don’t know its best practical application. Weight-bearing exercises include: weight training, hiking, climbing stairs, walls, trees, etc., and walking up an incline. All of these activities force the bones to work against gravity and are effective at increasing bone strength and quality.

There are three aspects of any exercise that determine how effective it will be in stimulating increases in bone strength:

  1. The degree of bone strain (how much impact the exercise has on the bones)    
  2. The maximum strain frequency (how often maximum vs. minimum strain is applied)                    
  3. The strain duration (how long maximum strain occurs per unit of time)

The general recommendation for most people in average physical condition is to perform any of these weight-bearing exercise 3 times per week for 15 to 20 minutes. It may come as a surprise to many that such a short duration is sufficient to increase bone quality. Well—not so fast… Since each bone and joint will respond to the strain load individually exercises needs to focus on each one for that 15 minute period. However, many exercises address multiple sites simultaneously (e.g. walking on an incline affects hips, knees, ankles, femur, tibia, fibula, and to a lesser extent the lower spine).

Effective Dietary Interventions

The best approach to getting sufficient nutrients to build and maintain strong bones is to consistently make healthy, organic, whole food choices according to your Prakriti (constitution) and the seasons, however it should be modified in almost all cases towards Vata-pacifying foods. Your diet, and not supplements, is the ideal source for all the bone-specific nutrients mentioned below.

Calcium

Calcium is the most abundant mineral in the human body. It is well recognized for its importance in the development of bones and teeth, in the function of muscles, and has many other functions as well. The common wisdom is that 1,000–1,200 mg/day of calcium is required (varies with age, weight, sex, etc.).The best food sources of calcium are milk and other dairy, whole grains, beans, almonds and other nuts, and dark green leafy vegetables like kale, spinach, collard greens and swiss chard.

A comprehensive literature review published in the British Medical Journal (2010) questioned the widely held belief that using calcium supplements in place of diet is healthy. The reviewers of this meta-analysis concluded that people who took a 500 mg/day calcium supplement experienced an increased risk of myocardial infarction when compared to those who did not take calcium supplements. It is also not surprising that there is a long list of possible interactions between calcium supplements (but not dietary calcium) with pharmaceutical drugs. These facts should make us all reevaluate our ubiquitous use of calcium supplementation.

Magnesium

Magnesium is important for more than 300 important metabolic processes, including building bone, forming adenosine triphosphate, maintaining normal nerve and muscle function, and absorbing calcium. Adults need about 300-400 mg per day. Dietary sources of magnesium include nuts, whole grains, dark green vegetables, avocado, banana, soy, fish, meat, and legumes. Magnesium deficiency has been associated with bone loss in several studies.

Vitamin D

Vitamin D is essential for the formation and maintenance of bone tissue, through its regulation of calcium and phosphorous absorption from the intestines into the bloodstream and numerous other metabolic effects. Vitamin D increases the number and activity of osteoblasts, reduces the activity of osteoclasts, and normalizes the turnover of bone. It also helps prevent an over-secretion of parathyroid hormone (PTH) which can activate osteoclasts to increase bone reabsorption, contributing to osteoporosis.

Vitamin D is synthesized when sunlight is absorbed by the skin and transforms 7-dehydrocholesterol into vitamin D3 (cholecalciferol). D3 is shuttled to the liver where it is converted to 25-hydroxycholecalciferol, which is then transformed into 1,25-dihydroxycholecalciferol (calcitriol). Calcitriol is 10 times more potent than vitamin D3. Magnesium and boron act as cofactors in this reaction. Food sources of vitamin D include fish and fish oils. Also in Caucasians, 30 minutes in the summer sun in a bathing suit can initiate the release of 50,000 IU (1.25 mg) vitamin D into the circulation within 24 hours of exposure! Dietary vitamin D appears to be most effective as a therapy for osteoporosis when combined with dietary calcium.

Dietary Vitamin D has no adverse effects, however Vitamin D supplements can cause intoxication if taken higher doses long-term. Symptoms include weakness, nausea, vomiting, and poor appetite. Toxicity may be seen when serum vitamin D concentration is consistently >200 ng/ml.

Boron

Boron is ubiquitous throughout the human body, with the highest concentrations found in the bones and dental enamel. Fruits, vegetables, soybeans, and nuts can be rich sources of boron. Although there is currently no RDA for it, boron appears to be indispensable for healthy bone function, possibly because of its effects on reducing the excretion and absorption of calcium, magnesium, and phosphorus. It also affects signal transmissions across cell membranes by acting indirectly as a proton donor, which influences ion gradients that are involved with cell/cell communication. Boron may be involved in the synthesis of steroidal vitamins and hormones, such as vitamin D, 17 beta-estradiol, and testosterone. One study found that boron supplementation as an isolated nutrient was not useful in terms of preventing bone loss. Breast cancer patients are often cautioned not to use more than 3 mg a day due to references of boron’s ability to increase endogenous estrogen. A fatal dose in adults is 15 to 20 g and in children 3 to 6 g. Repeated intakes of small amounts can cause accumulative toxicity, so its best to avoid taking boron in any non-dietary unnatural form.

Strontium

Strontium is a soft silver-yellow, alkaline earth metal forming about 0.034% of all igneous rock in the form of the sulfate mineral celestite (SrSO4) and the carbonate strontianite (SrCO3).Foods containing strontium range from very low e.g. oranges (0.5 ppm) to high, e.g. onions (50 ppm) and lettuce (75 ppm).

The evidence for benefits of strontium in osteoporosis is scant and contradictory; in fact most of the publication on strontium are regarding its toxic effect on bone, especially in children. In people with chronic kidney failure, strontium may cause osteomalacia, a condition in which bone is softened due to lack of mineral content. Strontium can replace calcium in bone and because it has a larger atomic weight can artificially increase bone mineral density measurements. Also people with low calcium should never take strontium. Strontium chromate is known to cause lung cancer. Interestingly, most of the published studies are with strontium ranelate, not the strontium carbonate form often used in supplements. Also the vast majority of these “positive” ranelate studies were funded by the pharmaceutical company who holds the patent. For these and many other reasons, I strongly advise against using strontium supplements of any kind.

Vitamin K

Vitamin K is a fat-soluble vitamin known for its effect in blood clotting, which it partly accomplishes due to its ability to bind calcium ions (Ca2+).  Despite being fat-soluble the body does not store significant amounts of vitamin K and it needs replenishment through dietary intake (don’t worry—its widely available) and production by our innate colonic bacteria. Fortunately, vitamin K is to a great extent recycled, which means that even the small amount that is present can be used by the body many times. Therefore, Vitamin K deficiency is rare. Vitamin K is found in dark green vegetables such as kale, Swiss chard, parsley, and spinach, in cruciferous vegetables such as broccoli, cauliflower and brussel sprouts and to some extent in olive and soybean oils.

Three known vitamin K–dependent proteins have been isolated in bone: matrix Gla protein, and osteocalcin and protein S. There are 2 naturally occurring forms of vitamin K: vitamin K1 (phylloquinone), synthesized by plants, and vitamin K2 (menaquinone) synthesized by bacteria.

Vitamin K2 has been shown to improve carboxylation of osteocalcin and matrix-Gla protein to their active forms, two proteins that may play roles in calcium metabolism. In addition, vitamin K2 dietary intake has been shown to lower the risk of coronary calcification and coronary heart disease, and a randomized controlled trial has demonstrated that it can reduce arterial stiffness. In osteoporosis, menaquinone (K2) has been shown to decrease the rate of bone loss at the lumbar spine and forearm and reduce the risk of fracture. In cancer, menaquinone intake has been shown to reduce overall incidence and mortality.

However, unlike dietary vitamin K, the clinical benefits of vitamin K2 supplementation have failed to show any significant benefit. The lack of effect of vitamins and other supplements is not a new occurrence.

Take vitamin D. For decades it was established that there is a minimum daily requirement to prevent rickets. But then, just several years ago, it became suddenly popular to check vitamin D blood levels. And many people were found to have "low" vitamin D levels. Quickly, many diseases that never before were linked to vitamin D, were found to be associated with "vitamin D deficiency." But later it turned out that many laboratories were not conducting tests in equivalent ways and their research methodologies were fraught with extensive errors.

After extensive study by objective third-party scientists, the Agency for Healthcare Research and Quality (AHRQ) issued a report in 2014 that there is noconsistent correlation between vitamin D and health outcomes such as cardiovascular disease, all-cause mortality, several types of cancer, or bone health. Note that last condition.

Conclusion

Bone physiology and bone strength are very complex issues that have important unique nuances in every unique individual. Owing to several unique features of asthi-majja kshaya, Ayurveda considers it curable but only with difficulty (Yapya). These features include: Gambhira Dhatu(bone and marrow are deep-seated tissues),Svabhava Balapravritta Vyadhi(it is a natural phenomenon due to old age) andBhedawastha(if not prevented in early life it easily reaches the complicated stage of pathogenesis). Management of established loss of bone strength is difficult—but possible by comprehensive intervention as outlined above. Obviously, prevention of the condition through intelligent diet and lifestyle is vitally important andshould be commenced early. Also, while the bone mineral densitometry score does have some small contributing relationship to bone strength, it is certainly not an accurate surrogate measurement for osteoporosis.

[1] Newberry SJ, Chung M, Shekelle PG, et al. Vitamin D and Calcium: A Systematic Review of Health Outcomes (Update). Rockville (MD): Agency for HealthcareResearch and Quality (US); 2014 Sep. (Evidence Reports/Technology Assessments, No. 217.)Available from: https://www.ncbi.nlm.nih.gov/books/NBK253540/