DEAR READER: Osteoporosis occurs when the normal buildup and breakdown of minerals in healthy bones falls out of balance. The condition is difficult to detect in its early stages, but the first clue is often a bone fracture, loss of height, back pain, stooped shoulders or through a routine bone density (X-ray) study.

There are a number of prescription medications; however, as you may be aware, several can lead to osteonecrosis of the jaw and other serious complications.

The recommendation for people 51 and older is 1,200 milligrams of calcium per day. Vitamin D is of equal importance in order to utilize the calcium and should not exceed 2,000 IU daily for healthy people. Therefore, in answer to your question, it all depends on how much calcium and D is present in the vitamin regimen you are taking. Read the ingredient label. If necessary, switch to combinations of calcium and D available at your local pharmacy in single-tablet form.

Beyond that, don’t smoke, avoid alcohol, maintain good posture, eat well, and exercise.

To provide related information, I am sending you a copy of my Health Report “Osteoporosis.” Other readers who would like a copy should send a self-addressed stamped No. 10 envelope and a $2 check or money order to Newsletter, P.O. Box 167, Wickliffe, OH 44092-0167. Be sure to mention the title or print an order form off my website at www.AskDrGottMD.com.

I will see my doctor in August. She will not be happy, but I really do not care.

DEAR READER: The medication you have been prescribed (Fosamax) and the calcium with D supplement are both in the proper dosage to combat osteoporosis. I am sure your prescribing physician indicated that you should take the alendronate with a full glass of water a half-hour prior to your first food of the day. It should not be taken at bedtime with food, mineral water, coffee, tea or juice, as these beverages will reduce the absorption of the medication.

One inactive ingredient in the product is lactose, a sugar commonly found in milk that is used as a diuretic in some medications. I am uncertain exactly how much lactose is in alendronate but herein could be your problem. I read about one individual who was part of a 2009 study involving almost 50,000 men and women who indicated his or her sugar level rose 10 points and continued to rise while on alendronate. There was no further documentation or comment so I can only pass the information on to you. Beyond that observation, I have been unable to find any documented test studies that confirm elevated sugar levels in people who have been prescribed the medication.

I assume you have bone-density testing (DEXAs) on a timely basis and suggest you have another at the appropriate time. Determine any progress since being on the medication and then have a frank discussion with your primary-care physician about your concerns. If there is no improvement in your osteoporosis, perhaps she will be responsive to your discontinuance of the medication, even if it is only for a short trial period. In the interim, I cannot see that the calcium with vitamin D will do any harm and in fact, it might be just what the doctor ordered, if you will excuse the pun.

You have a right to make decisions regarding your health. Your doctor should either present an opposing view as to why the alendronate sodium should be continued, make a substitute to something you both agree upon, or she should go along with your decision. Perhaps an appointment with a nutritionist might even be appropriate.

If there is no other basis for your elevated sugar counts, express your concerns. I can understand and support a physician taking aggressive steps to prevent fractures in a woman your age. Yet, if there is a direct connection to it causing the elevation, the last thing you need is to replace one medical problem with another. In the interim, exercise as much as possible and eat a healthful diet rich in fruits and vegetables. If questions still remain in your mind, request a referral for a second opinion.

To provide related information, I am sending you copies of my Health Reports “Osteoporosis” and “Diabetes Mellitus.” Other readers who would like copies should send a self-addressed stamped No. 10 envelope and a $2 check or money order for each report to Newsletter, P.O. Box 167, Wickliffe, OH 44092-0167. Be sure to mention the title(s) or print an order form off my website at www.AskDrGottMD.com.

DEAR READER: Yes, you can. Your physician can strongly recommend a medication or course of treatment and indicate why he feels it is necessary, but the bottom line is that it’s your body. I am sure that he has your best interests at heart, but perhaps a calcium plus vitamin D supplement will suffice. Therefore, before getting into any shouting match, I suggest you speak with him and review all options.

The first step by the oral surgeon was to take me off Boniva. He said we would only watch the exposed bone for six months, that there was a chance the bone would fall out on its own. When he wanted my family physician’s permission to go off the Boniva and I got it, I learned my physician was not so sure about it.

After eight months, the bone has grown down, and some has chipped off. Last week, the oral surgeon pulled an area the size of a lima bean out. The current plan is to continue to watch it in the hope the dead bone comes out completely on its own in the next four months. He told me all along it would be a year before he would consider it safe to do surgery if any of the bone needs to be removed. Half the torus palatinus has effectively dissolved. He indicated we might want to consider removing the other half to prevent bone from dying there. I would like to avoid surgery if I can.

I take good care of my teeth, and I am a 62-year-old female who runs, lifts weights, takes calcium, and tries to do all the right stuff to prevent further damage to my bones from osteoporosis. What do you think of the idea of removing the other half of the torus palatinus?

DEAR READER: The torus palatinus is a benign bony growth known as an exostosis located in the middle of the hard palate in the roof of the mouth. Generally, it doesn’t require treatment unless it becomes so large it interferes with function or dental placement. In fact, the most common reason for surgical removal is that dentures do not fit well. The procedure is relatively simple.

I am well aware of the issues of necrotic bone from medications taken to fight osteoporosis. The issue came to light several years ago and even today prevents a great number of women from taking the recommended medications.

I can offer my personal opinion but must defer to your oral surgeon regarding surgical removal of the half torus palatinus that remains. If the necrotic (dead) bone ejects on its own, your problems are likely solved. If not, speak with another surgeon for a second opinion and guidance on what the best course of action is for your situation. I know this isn’t what you want to hear, and the waiting must be terribly frustrating.

Some considerations are whether any sharp projections interfere with eating and talking, and whether you constantly irritate your tongue if there are projections. Good luck.

To provide related information, I am sending you copies of my Health Reports “An Informed Approach to Surgery” and “Osteoporosis.” Other readers who would like copies should send a self-addressed stamped No. 10 envelope and a $2 check or money order for each report to Newsletter, P.O. Box 167, Wickliffe, OH 44092. Be sure to mention the title(s) or print an order form off my website at www.AskDrGottMD.com.

Can you tell me what could be causing my low vitamin D level? Do you believe that this is the issue, or are the low levels caused by something else?

DEAR READER: Vitamin D is a fat-soluble vitamin that is essential for promoting calcium absorption, maintaining adequate serum calcium and phosphate levels, bone growth and remodeling, reduction of inflammation, and neuromuscular and immune function.

If your levels are low, you are at risk of developing weak, brittle and/or deformed bones. This could also affect your immune system, making you more susceptible to infection, allergens and more. Your low vitamin D level may indeed be the cause of your allergies, which are causing your cold and flu-like symptoms; however, this does not explain why you have a low D level to begin with.

In healthy people, vitamin D deficiency can typically be avoided by adequate sun exposure and a well-balanced diet. Because there are very few foods that naturally contain D, fortified cereals and dairy products are the best way to achieve sufficient dietary amounts.

Older adults, breastfed infants and those with limited sun exposure, dark skin or fat malabsorption are at increased risk of developing deficiency. Obese individuals may have difficulty absorbing vitamin D from sun exposure because the subcutaneous fat essentially blocks part of the D from entering the bloodstream. Those who have undergone gastric bypass may also have difficulty because most forms of this surgery bypass the upper small intestine where D is absorbed.

Symptoms of vitamin D deficiency typically go unnoticed. The most common consequence is weakened bones, also known as rickets in children, osteomalacia in pre-menopausal women and men, and osteoporosis is post-menopausal women. There may be an increased risk of developing cancer, especially that of the digestive tract. There is also research suggesting deficiency may play a role in the prevention and treatment of diabetes types 1 and 2, hypertension, glucose intolerance, multiple sclerosis and more. However, because these studies have not been randomized clinical trials, the implications will continue to be debated until definitive proof is found.

According to the Food and Nutrition Board (FNB) at the Institute of Medicine of the National Academies, adequate intakes (AIs) for healthy people between birth and age 50 should be 200 IU of vitamin D daily. Those aged 51 and over should double that. Recently, the American Academy of Pediatrics issued its own recommended intakes that exceed those of the FNB. This led to an expert committee formation by the FNB, which decided that recommended intakes be re-evaluated. To the best of my knowledge, the decision of this committee should be made public later in 2010. Tolerable upper-intake levels (ULs) for those between birth and 12 months is 1,000 IUs; age 1 and older is 2,000 IUs daily. This, too, was challenged and is currently under review.

I suggest that you speak to your physician to request that the underlying cause be found. It may be as simple as not getting enough sun exposure and may be helped by exposure without sunblock for 15 or 20 minutes each day. Longer unprotected exposure is not recommended because of the increased risk of developing skin cancer.

If the cause cannot be found, follow your physician’s advice regarding supplementation and including more vitamin D-enriched foods into your diet.

You should also be watchful for signs of excess intake. Most commonly, these symptoms are nonspecific and include nausea, weakness, constipation, weight loss, vomiting and poor appetite. If healthy people continually take levels above the UL, it may result in elevated blood levels of calcium, which may cause confusion and other mental-status changes, as well as heart-rhythm abnormalities. There is also an increased risk of developing kidney stones, especially when used in conjunction with calcium; however, because you are deficient and under the care of a physician, these are not likely to result.

To provide related information, I am sending you a copy of my Health Report “Vitamins and Minerals.” Other readers who would like a copy should send a self-addressed stamped No. 10 envelope and a $2 check or money order to Newsletter, P.O. Box 167, Wickliffe, OH 44092. Be sure to mention the title. Order forms are also available for printing on my Web site at www.AskDrGottMD.com.

I have enclosed some article from different sources on the importance of vitamin D and hope that you will re-evaluate your position on the necessary amount of the essential vitamin.

DEAR READER:
Thank you for including the back-up information. My position on the amount of necessary vitamin D in the daily diet is directly related to various government sources that indicate 400 IU is adequate for healthy individuals. However, this does not mean that current research is incorrect.

As more studies are done, several sources have found that vitamin D deficiency is on the rise among infants, children, teens, adults and seniors. Further studies need to be done to determine why this is happening and what steps we can take to prevent future generations from developing this deficiency.

Interestingly, the body stores vitamin D but it cannot be activated for use until exposed to ultraviolet B. Simply being outside for 15 minutes in the sun everyday can provide dramatic results.

I do not recommend that patients increase their vitamin D intake but I can encourage them to see their physicians to discuss the issue. A simple blood test may be all that is needed to determine if a deficiency is present. If it is, simple supplementation may be all that is required but a referral to an endocrinologist or other specialist may be advised to determine if there is a more serious underlying cause.

Vitamin D deficiency can lead to several problems, the most common of which is weak, brittle bones. This can lead to fractures which can take extended periods of time to heal because unhealthy bone does not heal as quickly or as well as normal bone. It has also been linked with thyroid disease, cancer, diabetes, stroke, asthma, heart failure and more.

Several physicians who specialize in bone health have begun recommending the recommended daily intake be increased to about 1000 IU, which is currently more than double the standard. Until further studies have shown that this will benefit a majority of the population without serious side effects, I must stick to the old guidelines but am willing to change my opinion when more definitive results are available.

To give you related information I am sending you copies of my Health Reports “Osteoporosis” and “Vitamins and Minerals”. Other readers who would like copies should send a self-addressed, stamped number 10 envelope and $2 per report to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title(s).

DEAR READER:
Chronic use of steroids can lead to osteoporosis. I assume this is the cause of your problem. I urge you to start taking 1000-1500 mg of calcium and 800 IU of vitamin D daily immediately.

For added benefit I recommend you discontinue the steroid medications. Ask your dermatologist about non-steroid, alternative treatments. While psoriasis and eczema are annoying, they are harmless and both have shown positive responses to some home remedies such as medication chest rubs or banana peels.

As for osteoporosis medications, speak to your physician or an endocrinologist who will be able to answer your questions and quell your concerns.

To give you related information, I am sending you copies of my Health Reports “Osteoporosis” and “Dermatitis, Eczema and Psoriasis”. Other readers who would like copies should send a self-addressed, stamped number 10 envelope and $2 per report to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title(s).

After experiencing jaw problems from using Fosamax, I found a great natural product that is affordable and works well. Called OsteoValin (osteoval carbonate forte), it is manufactured by the Carter-Reed Company. It is not a calcium supplement. It is supposed to be taken in addition to a bone health regimen. It assists the body in building new bone mass while reducing bone loss.

I have been using the product for 18 months, along with a quality calcium/magnesium supplement and my last bone density test showed great results. For me there have been no side effects. OsteoValin can be ordered by calling 1-800-898-5153. Their customer service is excellent and they won’t try to sell other products to you.

DEAR READER:
I have no experience with this product, having never even heard of it before your letter. You were kind enough to enclose a pamphlet on the supplement. I also did some brief research on the ingredients in OsteoValin.

According to the pamphlet, the main ingredients are a special blend of strontium carbonate, quercetin and hesperidin.

Quercetin is a plant-based flavonoid found in large quantities in apples, onions, red wine, teas and more. It appears to have anti-inflammatory and antioxidant properties.

Hesperidin is another flavonoid found in lemons, oranges and other citrus fruits. It is primarily used to improve blood flow and may improve endometriosis, PMS, hemorrhoids, and uterine fibroid tumors.

The final main ingredient is strontium carbonate. Strontium is a natural alkaline, metallic element which can be used to create several different types, including strontium carbonate, ranelate and others. It is NOT to be confused with strontium-90 which is radioactive and results from nuclear fallout.

Strontium is found in food, water and in trace amounts in the human skeleton. While, I couldn’t find anything directly linking strontium carbonate to improved bone health, I did find several references to medical studies done using strontium ranelate. In 2004, the New England Journal of Medicine had a report that showed the use of the supplement (in conjunction with calcium and vitamin D) led to early and sustained reductions in vertebral fractures in postmenopausal women. It also reported that there were no significant differences in the number of serious side effects between the supplement and placebo.

In addition, strontium ranelate has been approved for the treatment of osteoporosis in the United Kingdom under the name Protelos. Furthermore, in December 2008, the results of a head-to-head study were released in the journal “Osteoporosis International” that showed that Protelos improved bone volume, whereas Fosamax did not. The study was small, comprising only 88 postmenopausal women over a period of two years. It was, however, double-blind, meaning the researching physicians and patients didn’t know which medication they were giving or receiving.

While I cannot comment on the efficacy of OsteoValin, I cannot argue with your results. I must urge anyone interested in trying the supplement to consult his or her physician first. Especially those people taking prescription medications.

To give you related information, I am sending you a copy of my Health Report “Osteoporosis”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

Recently while in my pharmacy picking up more supplements, I found a new product called “Citracal plus Bone Density Builder”. The bone density builder is apparently an ingredient called genistein which has been proven to increase significantly bone density (at least according to the package label).

Do you have any information on this product? If there is a chance it could do what it says, I would like to try it but as it is more expensive than traditional calcium plus D, I would rather not waste my money if it is truly no different.

DEAR READER:
Osteoporosis occurs when our bodies can no longer make bone as fast as it is broken down. This typically occurs as a result of old age but can be related to several medical disorders such as hypothyroidism, Paget’s disease and others.

Individuals with osteoporosis are at an increased risk of developing spinal compression fractures. They are also prone to severe bone breaks due to minor trauma. These fractures can be difficult to treat and may take many months to heal or may not properly heal at all.

Most doctors recommend patients with osteopenia or osteoporosis take calcium plus D supplements as well as prescription medications such as Fosamax or Boniva. The vitamin D aids absorption of the calcium into the bones while the prescriptions help the bone create new bone.

The drawback to prescription osteoporosis medication is that most cause stomach upset and other gastro-intestinal consequences. In some cases this is severe enough to warrant stopping the medication. I assume this is what happened to you. However, since the introduction of osteoporosis medication, there have been several advances including injectable or IV forms of the medications. There is even a nasal spray variety as well as one that is derived from parathyroid hormones.

As for the “Citracal plus Bone Density Builder”, I am not familiar with the product but did find some information. It is a typical calcium plus D supplement that also contains genistein. Genistein is a soy-derived isoflavone. It is also a phyotestrogen (plant based estrogen). According to a study released in June 2007, treatment with 54 mg of genistein daily for two years may prevent bone loss caused by estrogen deficiency. The study was randomized, double-blind and placebo-controlled involving postmenopausal women. The study was only done on 389 women with osteopenia and did not include information about fractures. Women in the genistein treatment group had more gastro-intestinal problems then the calcium plus D only group.

I recommend you speak to your doctor about the possibility of taking this supplement or one of the alternative prescriptions but caution you to not expect any miracles. Perhaps a referral to an endocrinologist is in order.

To give you related information, I am sending you a copy of my Health Report “Osteoporosis”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

I am at a loss as to what could be causing this and my gastroenterologist now wants me to see an ear-nose-and-throat specialist. Do you have any suggestions?

DEAR READER:
A metallic taste in the mouth can be an early sign of vitamin D overdose. Since you don’t say what dosage you take, I cannot be sure if this may be the cause of your problem. Nexium, Forteo and metoclopramide do not list this as a side effect.

Since you have osteoporosis, taking a calcium plus D supplement is recommended. You should be taking 1200-1500 mg of calcium and 400-600 IU of vitamin D daily. Vitamin D can be harmful but only when taken in extremely high amounts, usually over an extended period of time (months or even years), before symptoms are seen.

I believe your gastroenterologist’s referral to an ear-nose-and-throat physician is appropriate. He or she can order testing to determine if there is some correctable abnormality causing the taste perversion.

I would also like to add that metoclopramide is listed for short-term use only in patients who do not respond to conventional GERD treatment (such as Nexium). I could not find a time-frame but this may be something to discuss with your primary care physician or gastroenterologist.

Forteo also has a restricted time-frame for usage. Because of the potential for increased risk of developing a malignant form of bone cancer, the drug has received a black box warning. It should only be used as a last resort for resistant osteoporosis or for individuals who cannot tolerate other medications such as Fosamax and Boniva. Even in this instance, it is not to be taken for more than two years because the risk of side effects increases.

If you are taking the Forteo because of adverse effects from more traditional osteoporosis medication (namely, gastrointestinal upset), I suggest your return to your primary care physician or endocrinologist and ask about the possibility of using the newest form of Boniva which is available as an IV drip. Another option may be the once yearly Reclast injection. Injectable forms of these medications reduce or eliminate the risk of stomach upset and other gastrointestinal side effects.

To give you related information, I am sending you copies of my Health Reports “Osteoporosis” and “Hiatal Hernia, Acid Reflux and Indigestion”. Other readers who would like copies should send a self-addressed, stamped number 10 envelope and $2 per report to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title(s).