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Vitamin D – not enough, too much or just right?

The calcium pills I am now prescribed contain Vitamin D.  If you don’t have Vitamin D you don’t absorb the calcium.  If you are lucky and live in a sunny place and can actually get out in the sunshine with some bare skin you can make your own- the closest we come to being like plants, making their food from sunshine.

Living in the UK there just isn’t enough sunshine for much of the year, and in the winter sunny days are too cold to run around naked for a couple of hours at lunchtime.  I used a calculator made available by the Norwegian Institute of Air Research to see how much exposure I’d need outside today (gloomy weather, and guessing a few factor like the ozone level) and got this result:

Recommended UV exposure of face, hands and arms at least every other day to obtain sufficient vitamin D, equivalent of 25 micrograms vitamin D, if no dietary vitamin D is available:
Processing … (this may take a minute)Done
Output:
minimum recommended exposure time (hours:minutes)
24: 0

So I’d need to be outside from dawn to sunset everyday to get anywhere close to the exposure levels- and that is giving myself a day length of twelve hours, which is longer than we have at the moment.  At least that doesn’t say naked, just exposing hands and arms and face.  It didn’t have a box for ‘how much clothing are you going to wear’.

Rickets, which you get from a deficiency of Vit D, used to be very common – with an estimate of 90% of northern European children having rickets in the early 20th C. With less Vit D you absorb less calcium, and the body takes what it needs for other functions from the bones.  Softening of the bones leads to leg bowing in kids.  The harder bones of adults don’t show this bending of the bones, but you can get general bone aches and fatigue as a sign. (the chapter by M Holick I took this from is very interesting if you want to read more about the many aspects of Vit D).

I was surprised to see that the NHS says infants (unless formula-fed) and children up to age 5 should have Vit D supplements everyday, and also pregnant, breastfeeding, housebound and over 65’s should supplement their diet. The MS UK website says older people make less Vit D as their skin is thinner.  Osteoporosis Canada recommends routine vitamin D supplementation for all Canadian adults year round due to their northern climate.

The relationship of Vit D with calcium is a complex one.  Understanding how they interact seems like an important aspect of managing bone health for people like me with osteoporosis. The NHS website states:

Taking too many vitamin D supplements over a long period of time can cause more calcium to be absorbed than can be excreted.
The excess calcium can be deposited in and damage the kidneys. Excessive intake of vitamin D can also encourage calcium to be removed from bones, which can soften and weaken them.

So, if you take too little you can get rickets, which gives you bone pain and deformities.  If you take too much you can wreck your kidneys and give yourself weak bones.  Some studies suggest that Vit K can help keep the calcium in the bones and out of the arteries when used in higher doses than we would normally get through food.

So how much is enough and how do you tell if that is what you are getting? The NHS website says not to take more than 25 micrograms a day.  My prescription pills give me 20 micrograms a day.  I’ve had a blood test to check that this is ok (and heard nothing so presume it is ok) and assume that I’ll get this tested every now and then to be sure I’m not ruining my kidneys.

There seems to be some disagreement on the appropriate levels, with the levels described here being considered much to low by some practitioners. RDAs are based on the levels people need not to be ill, rather than optimal health, so vitamin proponents often say RDAs are too low for people trying to address associated issues.

Vitamin D is fat soluble, and can be stored in the body.  So, if you miss a pill one day you can top up by taking two the next.  I wondered if that meant I should take my pills with a fatty meal, but research on absorption tested by blood plasma levels shows it isn’t important you absorb a bit more with a low fat meal versus either fasting or a high fat meal, but there isn’t a difference in the blood plasma levels in the longer term.  Some types of calcium should be taken with a meal (calcium carbonate), the others can be taken any time.

You can get your Vit D from fortified dairy products( which as a person with lactose intolerance I don’t eat), fatty fish (Yuk!) or, interestingly, mushrooms which are grown under ultraviolet light.  I bought some of those the other week as I spotted them in the supermarket; I had wondered how they came to have more Vit D.  I’m not too sure about eating mushrooms, I sometimes feel a bit glutened after eating them, and they can be grown on grain which leads to a low level of contamination.  The pills seem safer.

It does seem that Vit D might also help with depression– so being in sunshine might cheer you up for that reason too.  It is certainly a lot easier to take a Vit D supplement than hae sunny holidays throughout the winter, however attractive that might be as a proposition.

So what about Vit K?  You get it by eating your dark leafy greens and eggs. Its role in treating osteoporosis is, apparently,  controversial. Some studies suggest that higher Vit K levels reduce osteoporosis, others don’t.  One interesting new bit of information for me is that our gut bacteria manufacture Vit K.  Vit K looks like a complex enough issue that it will need its own investigation.  However, if you have a poorly performing gut (like in Chrones or coeliac disease) you are less likely to absorb Vit K, and when I still ate gluten I got bacterial gut and respiratory tract infections a lot, so took antibiotics these antibiotics would have killed off my VIt K producing bacteria as well as the harmful ones.  It seems likely I would have been Vit K deficient for quite some time and that wouldn’t have helped my bone health.  The Coeliac Society says “the malabsorption that occurs in untreated coeliac disease can lead to multiple nutritional deficiencies. The most common nutritional problems in people with coeliac disease include deficiencies of essential fatty acids, iron, vitamin D, vitamin K, calcium, magnesium, folic acid and zinc.”

The National Osteoporosis Society has these recommendations about VIt D (abbreviated)

“Key recommendations

  • Measurement of serum 25OHD is the best way of estimating vitamin D status.
  • Serum 25OHD measurement is recommended for:

* patients with bone diseases that may be improved with vitamin D treatment
* patients with bone diseases, prior to specific treatment where correcting vitamin D deficiency is appropriate

* patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency.

  • Routine vitamin D testing may be unnecessary in patients with osteoporosis or fragility fracture, who may be co-prescribed vitamin D supplementation with an oral antiresorptive treatment.
  • In agreement with the Institute of Medicine (IOM), we propose that the following vitamin D thresholds are adopted by UK practitioners in respect to bone health:

O serum 25OHD < 30 nmol/L is deficient
O serum 25OHD of 30–50 nmol/L may be inadequate in some people
O serum 25OHD > 50 nmol/L is sufficient for almost the whole population.

  • Oral vitamin D3 is the treatment of choice in vitamin D deficiency.

(occasionally up to 4,000 IU daily), given either daily or intermittently at higher doses.

  • Adjusted serum calcium should be checked 1 month after completing the loading regimen or after starting vitamin D supplementation in case primary hyperparathyroidism has been unmasked.
  • Routine monitoring of serum 25OHD is generally unnecessary but may be appropriate in patients with symptomatic vitamin D deficiency or malabsorption and where poor compliance with medication is suspected.”

So, this is all more complicated than I expected.  It’s going to take me quite a while to unpack all the research on Vit D and its relationship with calcium absorption and use in the body, and any role Vit K has in this equation.

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Water hardness and foolish instructions

I’ve been looking at a lot of issues around medication, posture, exercise and the psychological impact of a diagnosis of osteoporosis. One of the reasons given for poor compliance with medication (people stop taking their pills when the doctors think they should carry on) is the difficulty in coping with the specified way they have to be taken.

Note -alendronic acid or Alendronate is the generic name for this drug, Fosamax is a brand name.

“Taking alendronic acid
It is important that you take alendronic acid in the correct way, as otherwise it can cause irritation and damage as it is swallowed:

Take the tablet/medicine first thing after getting up in the morning. Take it before you eat any food or have anything to drink other than water.
You must drink a large glassful of plain water (not mineral water) as you take your dose. If you are taking tablets, swallow the tablet whole – you must not chew, break, or crush alendronic acid tablets.
It is important that you take your dose while you are standing or sitting in an upright position.
Continue to sit or stand upright for 30 minutes after taking your dose – you must not lie down during this time.
Do not have anything to eat or drink (other than plain water) during the 30 minutes after taking a dose .”  http://www.patient.co.uk/medicine/alendronic-acid-for-osteoporosis-fosamax

You’ll see it says you need to drink “a large glass of water”  – I’ll discuss what this means to the manufacturer and what it means to individuals reading it later.  I want to focus on the phrase not mineral water”.  Now, I grew up in India, where drinking water was boiled and carefully stored, so maybe I think more about water quality than many.  I also had my first job in London, where the water tasted so bad all I drank were tomato cup-a-soup as that was the only think I found that would disguise the flavour.  This predates the ready availability of water filter jugs and bottled water.

I’m also the kind of person that want to know “why not”  and “why do you think that” whenever I hear an instruction.

So why not mineral water?  It turns out that calcium in the water affects the absorption of the drug.

Calcium in water is good for your heart and bone health, and hard water is one of the major sources of calcium for many people.  Water hardness is a sufficiently big component of calcium availability that it has been recommended that GP’s should know the water hardness in their areas http://www.sld.cu/galerias/pdf/sitios/rehabilitacion-bal/how_much_calcium_is_in_your_drinking_water.pdf  .  This same report said that the manufacturers of the pills didn’t know what effect the calcium had on bioavailability of the drug so wouldn’t give a recommendation on the maximum level.

So, don’t take these pills with mineral water as it will reduce the availability and absorption of the drug.  BUT- tap water varies a lot.  Mineral water varies a lot.  I checked the calcium level of my tap water using my suppliers on-line ‘enter your postcode’ service.  I have medium hard water.  I checked the calcium level of the bottled water I keep for trips (very cheap stuff from the supermarket).  That had about one-tenth the amount of calcium in it.  I’d be better off using the mineral water rather than the tap water to take my pill.

I’m not the only one that thinks this is ridiculous.  R.Pelligrini of Bologna University wrote

 “the aforementioned formulation of the package insert is practically a nonsense, owing to the well-known huge differences among waters, both tap and mineral,”http://paperity.org/p/10789431/which-water-for-alendronate-administration

The amount of calcium in water to take the pill with should be specified, then people can make an informed choice.  I discovered that I could get calcium testing kits from the local aquarium/pet fish supply shop for a few pence a time.  I got sent a water hardness test strip with a dishwasher I bought a few years ago.  It is not difficult or expensive to test your water hardness.  Bottles of water specify their mineral content. Deciding which water to use would be easy if one knew the calcium level that didn’t compromise absorption.

Why does this matter?  People could be reducing the effectiveness of their medication by following this ruling.  If they dislike the flavour of their tap water this will make the whole process even less pleasant and possibly reduce compliance.  It also makes it feel arbitrary and controlling – instructions without clarity, a “must” without a reason.  Add to that, if you research the issue it turns out to be nonsense.  What else might one go on to mistrust?

There is also the issue of safety.  I read a query sent to an online help desk for arthritis sufferers.  The questioner said they were about to travel and how could they safely take their alendronate in places where they didn’t know if the tap water was safe to drink.  The reply was  to say tap water was safe in most European countries (the traveller didn’t say where in the world they were planning to go).  I didn’t keep a reference to that question and answer, but it has stuck in my head.  Go ahead, die of dysentery, but don’t take your pill for a long standing, possibly eventually disabling, ailment with bottled water.  Now that is a ridiculous piece of health advice.

 

 

Apologies for the references being such long links in the middle of the text.  I used Google Blogger for years and found shaping my links very easy but WordPress is defeating me for some unknown reason.  I’ll keep working on improving my knowledge and skill.

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BMD, fracture, Krege, Nature, prediction

numbers, numbers….and the mysteries of the invisibility of spinal fractures

The last post looked at the scores on the scans.  These show how my bones compare to other women’s bones, both young and fit, and the same age and fit.  If everyone had great bones and never got osteoporosis, someone would still be the worst.  They don’t tell you anything about what the risk of fracture is by themselves.  I’d like to know if my spine already has the small wedge fractures that lead to dowager’s hump, but I can’t tell that from anything in the current data.

The hip figures are used in an easy to use calculator called FRAX, which you can use at this link sitehttp://www.shef.ac.uk/FRAX/.  You do need to have your hip bone mineral density to work this out.  Based on my score I have a very low risk of fracture in the next ten years, even if I add in the chronic malabsorption caused by my problems with gluten (family history of coeliac disease, don’t know if I have it or one of the other gluten sensitivities).    Action for me would be some general lifestyle advice about eating well, reducing risk of falls by tidying the house, changing style of shoes etc.   With that as the sole bit of data I’d probably stop skiing (which I hardly do anymore) and try to be a bit less chaotic around the house. I already wear very sensible lace-up shoes and never wander around in my socks.

Malabsorption problems like coeliac disease are important in considering bone health.  If you don’t absorb nutrients properly, eating well and exercising properly in the bone building years to thirty will not be as effective in giving you long lasting strong bones.  I had a quick look at some current trials on osteoporosis drugs currently recruiting in the UK, and they all  excluded subjects with malabsorption issues.

So, if the spinal figures are so much worse for me, how likely am I to have a future spinal fracture?  Hard to say…the simple figure says high risk, and that is why I am taking the drugs and trying to learn to move in a way which protects my spine.  One thing that even a small amount of reading tells me is that these spinal fractures are strange and odd things.  I’ll write about what happens shortly, but for the moment a piece of research on the importance of spine imaging for identifying vertebral fracture and for identifying people at high risk for fracture makes an interesting point.

” Among 947 subjects with morphometric vertebral fracture, 66 reported a history of vertebral fracture by questionnaire and 881 did not. Thus, 93% of subjects with a morphometric vertebral fracture were unaware of the fracture. Additionally, among a total of 84 subjects with a history of clinical vertebral fracture by questionnaire, 66 (79%) were found to have a vertebral fracture by morphometric analysis of radiographs, whereas 18 (21%) were found not to have a vertebral fracture.”

http://www.nature.com/bonekeyreports/2013/130904/bonekey2013138/full/bonekey2013138.html

Fracture risk prediction: importance of age, BMD and spine fracture status

John H Krege, Xiaohai Wan, Brian C Lentle, Claudie Berger, Lisa Langsetmo, Jonathan D Adachi, Jerilynn C Prior, Alan Tenenhouse, Jacques P Brown, Nancy Kreiger, Wojciech P Olszynski, Robert G Josse, David Goltzman & on behalf of the CaMos Research Group)

What this shows is that people often don’t know if they have any spinal fractures.  That seems odd, but the individual bones in the spine are held in place by the other vertebrae, the ribs, other bits of tissue, and you can have a lot of fractures and still wander around getting on with life.  If you have ever seen those people, usually elderly women, who are out doing their shopping but walking along with a very bent back so they can only see the ground, they probably have spinal fractures that are visibly disabling but don’t prevent them from getting about.

I would like to know if I had spinal fractures already.  I’ve had years of back problems caused by my extremely pronating feet (flat feet) which I didn’t start correcting until my thirties, and I have used a programme of new prescription orthotics every year since then, combined with very controlling shoes (I found Ariat riding boots excellent, as the stiffness in place for the stirrups held my heel on the orthotics very well) and chiropractors and massage therapists helping to keep me aligned.  For the last six years or so it hasn’t mattered what podiatrist I have been to, I still can’t get rid of the neck pain, and the last two massage therapists I saw left me in pain for weeks.  Something has clearly changed.

It’s not a simple matter to know what state your spine is in.  You need access to complex imaging equipment, expert assessment of the images, and someone in the health system who decides you need to know.  It’s not like deciding to have a dental check up.  It is, of course, completely unnecessary to know if any of my spinal vertebrae are already showing compression fractures, but I’d like to see how the treatment and lifestyle choices I make now affect my spine over the next few decades.  A baseline measure would be good.

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Understanding the diagnosis

We asked the surgeon about a test for osteoporosis.  He said to ask the GP.  It looks as if, from the general reading I have done, that the bone team assume that bone density scans are initiated by GP’s and the GP’s assume that the bone team consider whether they are needed.  It is easy for a patient to slip through this assumption gap.

We asked for a scan. The GP agreed, and a couple of weeks later I was seen in a clean, calm, spacious room, and a week after that the GP had the results.  I have a vague recollection that the GP (who is really lovely and friendly), said she didn’t know what the numbers meant, but the single score prompts an osteoporosis drug and calcium and Vit D supplements if wanted (my scores on calcium and Vit D were fine but I always buy own – it seemed simpler to get the higher dose offered by prescription).

Got the pills, read all the data on the slip inside the packet, read around about side effects and effectiveness…more on that in another post.

 

We took a snapshot on a phone of the scores sent through by the DEXA people.   The hip scan shows that there is an increased risk of fracture (osteopenia) and the spine that there is a high risk of fracture (osteoporosis).  There are lots of numbers but you really only need to look for the summary at the bottom – WHO classification.

 

spine scan

hip scan

Of course, that is sufficient to decide to treat given the current guidelines, but I like to understand what is happening.  The first thing to bear in mind is that these scores are relative -they compare the amount of bone to a fit health thirty year old woman.  They tell you information about the likelihood of a fracture from a very minor fall, or, in the case of the spine, from normal activities like turning over in bed. These scores tell you how you differ from others, and I’ll write about the relative risks they indicate in another blog.

My sister sent me an excellent book called “Yoga for Osteoporosis” by Loren Fishman and Ellen Saltonstall.  The first few chapters of the book contain the best explanation of the statistical tools of Standard Deviation and T and Z scores that I’ve come across and I have three social science degrees and have spent a lot of time in statistics classes.  I’ll refer to this book several times- there’s a great section on how bones behave which I’ll write about later.

I was curious to understand the reports because I’m just generally curious, and the reading I did suggested that it was completely normal to be given a diagnosis of osteoporosis and a medical treatment without any form of explanation. Not surprising then that so many people stop taking the pills.  You get to find out about the side effects (they are described in every single packet of pills) even if you don’t experience them yourself, but you don’t know what is happening to your bones and what you might be able to do to help reduce the chances of disabling injuries. You also don’t get to know if you are improving your bones by the measures you take, unlike things like cholesterol lowering drugs where you can get almost immediate feedback on how effective you are being with lifestyle, diet and medication changes.

So, lets start with T scores.  Presuming the information in this source book (written in the USA) is the same as the UK, the T score tells you how many standard deviations your score is away from that of a healthy 25-30 year old woman.  So, that is how much you differ from someone in their prime.  The Z score tells you how many standard deviations you are away from healthy women of your age, height and weight.  We all lose bone mass from about thirty on- just some lose it a lot faster than others, and the menopause, with its change of hormone levels, makes the whole process speed up.  Men – you aren’t immune to this bone loss either, so don’t think you’re safe from fractures.  A positive score means you have denser bones than average, a negative score less dense.

So the next thing you need to know about is standard deviations – don’t worry, quick and simple explanation.  You need to know if almost everyone is about like you (say if you were an inch shorter than the average height) or if you are very different from the average ( your annual earnings if you are a top movie star).  One standard deviation around the mean includes 68.2% of people – so over two thirds of people will be in that group.  Two standard deviations include 95% of people. Only one percent of people are more than 2.5 standard deviation from the mean. If your bone density is over -2.5 standard deviations from the mean then you have osteoporosis – your bones are less dense than 99 percent of healthy young women.  Between -1 and -2.5 standard deviations from the mean indicates osteopenia – thinning bones but not yet at such a high risk of fracture.

So, peering carefully at my figures, I can see the Z and T scores for both the spine and hip.

Spine  T score    Z score

L1      -3.7            -2.8

L2      -3.0           -2

L3      -3.8           -2.8

L4     -3.9            -2.9

total  -3.6           -2.6

 

Hip

neck   -2.2        -1.2

total   -2.3        -1.7

The other numbers are the density readings the statistical comparison uses.  They would be meaningful to bone specialists.  I don’t need to know to figure out what the scans mean for me.

You’ll notice that the numbers in the second column are smaller than the numbers in the first column.  My bones are much less dense than those of young healthy women, and not quite so much worse than women of my age and build.  One of my lumbar vertebrae scored less than the minus 2.5 standard deviations worse than other women my age (yay!  Go lumbar vertebra 2!).  They average out to -2.6, which puts my lumbar spine in the osteoporotic range- only this area is scanned so I have no idea what the rest of my spine looks like. My lumbar vertebrae are less dense than about 99% of healthy women my age.

 

The hip bone is more dense- I score in the osteopenia range, where the bone has begun to thin and efforts should be made to reduce the onward thinning, but the risk of fracture is not so high. My hip bones are less dense than about 90% of healthy women my age and build.

 

So, why should I care what this means?  I got the pills- why not just take them and hope for the best?  Well, partly because the side effects listed are pretty gross.  Partly because compliance with the medication offered is so poor- so many people stop taking the drugs within the first two years when the risks will only get greater over the rest of their lives.  Partly because it looks as if  postural and exercise changes can make a significant difference, and partly because I’m just chronically nosy.

 

 

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Just a spoonful of sugar…

Read any list of the effects of osteoporosis – broken hips- only thirty percent of people fully recover and twenty percent die. Spinal fractures lead to a slow disintegration of the spine, compressing the torso and making it hard to breathe and eat, and making moving difficult as well as confining people to views of their feet, if you can see past your stomach which gets shoved out, and nothing much else.

I have found a wrist fracture has wiped out three months of my life, with some capacity returning as strength and grip return, though I still have very little flexibility. I also has a screw that sticks up on my wrist , with just a thin cover of skin over it. My first visit to a physiotherapist this week has led to an instruction to learn to love my wrist as it is – I was turning away to avoid looking at the angry purplish lumpy area as she worked it rather painfully- but I need to train all the new nerve endings to behave because at the moment they are reacting as if a tiger was in the room at the slightest touch. I failed to ask the surgeon if the screws were slot or Philips headed- and if I weren’t so reactive I’d be tempted to get a tattoo of a screw head.

So, wouldn’t people diagnosed with osteoporosis be glad there were drugs available to help prevent fractures, and take them assiduously for the rest of their lives if needed? Figures vary in different studies, but about half the people prescribed drugs for osteoporosis stop taking it- and they were giving up in the first year or two. So why would anyone skip a small weekly tablet (which is my prescription) when they might be reducing the impact of a disabling condition?

To start with, read the list of possible side effects. The ones that leap off the page are osteonecrosis of the jaw (rare, admittedly) and a weird seemingly spontaneous fracture of the femur. Add in a variety of digestive issues, ulceration of the oesophagus, diffuse joint pain and several other unpleasant things and the desire to take the medication definitely goes down. I thought this sentence from patient.co.uk was a pretty good indicator of the tone of the general information “A rare side-effect is osteonecrosis of the jaw. This occurs when the jaw bone does not receive enough blood, the bone starts to weaken and die. You must stop taking bisphosphonates if this happens.” It doesn’t explain how to tell this has begun to happen. Oh, and by the way, you can’t have dental implants while on the drug, so hope your teeth don’t fall out. Just as well I gave in and bought an electric flosser after weeks of trying to figure out how to floss my teeth one handed.

Next look at how to take the pills. Eat them first thing in the morning with a full glass of water (what size glass? Why can’t they tell you stuff like that- people are used to buying drinks in different size glasses) and then stay vertical for at least half an hour after this. The length of time to be vertical and foodless varied, with half an hour being the minimum. Don’t take it while still in bed. This is all to help you avoid that pesky oesophageal ulceration. Fine, can do that.

Then you just get four pills, one for each week. Tiny things really. Got to remember to get a repeat prescription every month. Got to remember to take them the same day each week. Are people better at once a day, once a week, once a month or once a year medication? One study I read said the yearly injection could be helpful for compliance but the problem was then that it was the doctors that would have to remember and would that work?

So I take the pills. Hope I don’t get the side effects. Can’t find any charts which show the interval after beginning the drug when the different side effects would be likely to occur if they did. I chose a day for the first pill when I had nothing else scheduled, just to add safety to the process. If I am fine for the first pill will I continue to be ok? If I make it past the first month will I be ok? The first year? No idea.

So now I’m taking these pills. Hoping I don’t get side effects. Hoping it is helping me reduce the bone loss. How can I tell if it is working? Lots of chronic conditions have drugs to help- pills for blood pressure, for arthritic inflammation etc. With all of those you get a programme of testing to make sure that the levels of medication are having the desire effect and are the right dosage. With the osteoporosis pills you are told it might help and that pretty much seems to be it. If there is a programme of monitoring bone density I don’t know about it. There also seems to be a urine test for bone breakdown products that I encountered in one paper, but it was suggesting that was complicated to administer and I didn’t find out anything else about it. It is normal human behaviour to be more dutiful when observed- just read up on any of the studies on hand washing after using the toilet. There are trial projects that show that having a specialist nurse explain your results and follow up a few weeks later (a few weeks!) increased compliance at this early stage.

And the people running the health services fret because compliance with the medication is poor!

Enough for today….wrist has worn out. Curiosity continues.

I have recorded the sources for the studies I have used in writing this blog, but haven’t done official references or any critical analysis of the research papers Please don’t regard this as a scientific report, it is just one curious person trying to figure out a way to manage to get maximum gain and minimum pain.

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Skeletons aren’t forever

I’ve started learning everything I can about osteoporosis, well, not the science but the living. What can I do to make my bones stronger? What can I do to reduce my risks? What are the risks? Why do so many people stop taking the drugs within a couple of year? There are lots of questions and it seems tricky to get all the answers, at least in an easy to understand and act on format. Where’s the local support group? Where’s the learning from others?

I’ve cancelled my Pilates class as the forward bending is bad…so that means I’m going to have more trouble with my pelvic floor not less, and now I learn that, before I sneeze, I need to support my back. So, I’m strolling down the street, with my handbag weighing less than 3lb and other weight of no more than 10lb evenly distributed, I feel a sneeze about to erupt, and I have to quickly and, hopefully discretely, cross my legs, brace my back, fumble for my handkerchief ( I should add I have a broken wrist, which is how the osteoporosis was discovered) and all before the sneeze happens. It seems that one of the main tools for living needed will be some form of slowing down time machine.

I’ve been trying to learn to move more magestically. I watched a bit of video of me and the grand-kid that had been filmed in slow motion. Got to do more of that but maybe not so slow- but need to give up the impetuous movements. I say to my friends when they marvel at some super-fast project I’ve completed that I only have two speeds, one and off. I’m going to have to learn steady.

If I learn stuff I like to share it, so here’s is the beginning of my offering to others in my position. As a side project I am writing this in WordPress rather than Blogger, so that I can learn about this too.

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