Joyce Liporace, M.D.July 2015

Bone Health

Nutrition-Healthy diet, Vitamins/Minerals

Hydration

Sleep

Exercise

People with epilepsy are at increased risk for osteoporosis and fractures.

Bone loss is increased by many seizure medications.

Most important-Bone disease can be improved with treatment if it’s diagnosed.

Bone is a dynamic structure. It is remodeled throughout life. Peak bone mass is reached by age 20-25.

Osteoblasts-bone forming cells

Osteoclast-bone resorbing cells

Bone is remodeled throughout life to maintain skeletal vitality

Osteoblasts form new bone by secreting collagen

Bone structure

Osteoclasts break down boneUnder normal conditions, the net change in remodeling is zero.

Women reach peak bone mass by age 25. After age 25, we lose 1% of bone each year,

until menopause. With menopause, women lose 4-5% of bone

each year. Over a lifetime, women lose 45% of

vertebral bone and 55% of their femur.

Few patients with risk factors for bone disease are offered screening.

If diagnosed early, metabolic bone disease can be reversed with treatment and fractures may be prevented.

Osteoporosis: diminishing bone mass, deteriorating bone architecture, and subsequent fracture.

Osteopenia: precursor to osteoporosis Osteoporosis is a silent disease until fracture occurs It is preventable and treatable

Gender Race Limited weight-bearing exercise Low dietary calcium High protein, alcohol, caffeine intake High soft drink consumption Medications

Reports of low bone mineral density due to liver effects and low Vit D (1970)

Dilantin and Phenobarbital-decreased Vitamin D levels (1972)

Depakote linked with low bone density Newer drugs are also being studied

Two to three fold increased risk of fracture in epilepsy patients

4 fold increased risk of hip fracture after age 40 in men and women

DEXA scan (dual X-ray absorptiometry) It takes less than 10 minutes, no

needles. Bone mineral density (BMD) of spine

and hip are compared to gender matched controls at peak bone mass.

There is a 50% increase in fracture for every SD below normal bone

T score >1

T score -1 to -2.5

T score -2.5 or lower

Normal

Osteopenia

Osteoporosis

T score=Bone Mineral Density compared to gender matched controls at peak bone mass

Need to influence bone mass early in life to reduce fracture later in life

Calcium 1200 to 1800 mg/day Vitamin D 2,000 IU/day (or higher) Weight-bearing exercise Avoidance of tobacco Limit caffeine and alcohol intake

Optimal intake of calcium for most adults is 1200-1800 mg daily

It cannot be absorbed without vitamin D You can only absorb 600 mg of calcium at a time It is best to get calcium from dietary sources and limit

supplements Vitamin D 2,000 IU each day (more if Vitamin D level

is low)

All men and women with epilepsy need a DEXA scan For those with osteopenia, begin diet and nutritional

changes For those with osteoporosis, see a specialist for

treatment

Bisphosphonatates Alendronate (Fosamax) Risedronate (Actonel) Ibandronate (Boniva) Zoledronic acid (Reclast)

Reduce action of mature osteoclasts Reduces fracture by 50% Need to take on an empty stomach Side effects-gastrointestinal disturbance, esophageal

irritation Should not take for more than 5 years

Denosumab (Prolia) is a newer medication shown to reduce the risk of osteoporotic fracture in women and men. Unrelated to bisphosphonates, denosumab might be used in people who can't take a bisphosphonate, such as some people with reduced kidney function.

Teriparatide (Forteo) is typically reserved for men and postmenopausal women who have very low bone density, who have had fractures or whose osteoporosis is caused by steroid medications. Teriparatide is the only osteoporosis medication that has the potential to rebuild bone and actually reverse osteoporosis.

Eat a balanced diet with a variety of food Adults should eat no more than 70 grams of fat a day Reduce vegetable oils and increase intake of omega 3

fats (avoid trans fats) Eat “complex carbohydrates”-whole wheat, brown rice,

lentils, chickpeas Protein is found in meat and fish but also nuts, seeds,

lentils and beans Eat regular meals

Special high fat diet to mimic the effects of starvation

Main fuel source is fat (ketones), not glucose

Difficult to maintain Some people find benefit with medium

chain triglyceride diet or Atkins diet

Complicated question-many people try to avoid monosodium glutamate (MSG), refined sugars, artificial sweeteners, glutamate, cured meats

Avoid excessive caffeine Soy is plant estrogen (tofu, soymilk, miso,

soybeans) Alcohol Energy drinks

Essential nutrients that your body needs in small amounts to work properly

Disturbances in calcium, magnesium or sodium can cause seizures (even in people without epilepsy)

Main source is sunlight-our skin makes Vitamin D

Found in fish oils/flesh, supplemented milk

Essential for bone health and may also lower the risk of heart attacks and stroke. Some studies suggest it reduces symptoms of the common cold and the flu.

Deficiency has been linked with high ammonia levels, especially with use of Depakote

Many people will feel better with carnitine replacement, especially those on Depakote with a high ammonia level.

Megavitamins and minerals can cause harm

Some vitamins are fat soluble and you can become toxic by taking too much.

Fat soluble vitamins are Vitamins A,D,E, and K.

Stored in fat cells and in the liver

Sleep deprivation is a trigger for seizures Most adults require 8 hours of sleep a night,

children require more sleep Practice good sleep “hygiene” Consider getting a sleep study if you wake

up feeling tired, you snore or you have restless sleep.

Promotes general health, improves bone density, lowers BP, relieves stress, reduces depression

It is rare for exercise to cause seizures-caution with hyperventilation or feeling overheated.

Need to be safe when exercising-supervised, avoid treadmills. Caution with swimming.

Our bodies need water to function properly Many adults are not drinking enough water Suggest at least 64 ounces a day (more if

you exercise) Taking in too litter water or losing too much

water leads to dehydration. Symptoms of mild dehydration include thirst, dark urine, pains in joints and muscles, headaches and constipation.