One of the worst things that can happen to you is to fall. If you're unlucky enough to break your ankle or hip, it can change your life forever. Instead of concentrating on osteoporosis as a cause of broken bones, let's get real. If you don't fall, you're not likely to break anything. So the question is: How can you prevent falls?

Falls occur when your center of gravity moves away from an invisible line that runs from your midsection to your feet. Once your tummy and lower spine move outside this center – your core — you're at a higher risk for falling. If you have any curvature of your spine, you're at a greater risk because your midsection is not in alignment with the rest of your body.

But having a straight spine doesn't ensure you won't fall. Whenever you reach for something on a high shelf, or carry a bag of groceries, you may be off-center. If someone bumps into you or you trip on a curb while you're leaning forward, you're more likely to fall. And if you have weak leg muscles, your balance can also be unstable.

When exercise isn't enough

Researchers at the Mayo Clinic know this. They tried to improve the balance in older women whose spines were curved from osteoporosis. So they made a two-pound weighted back brace to keep these women's torsos aligned above their feet. The women wore this support for four weeks and did specific daily exercises. The result was less back pain and better balance, but their leg muscles were no stronger.

Here's why I predict the benefits from this treatment will be short-lived.

A weighted back support may help your alignment while you're wearing it. But when you take it off, your body will try to return to its original position. Home exercises may strengthen your long back muscles, but they don't recruit the small, deep muscles that support them.

In addition, wearing a weighted back support is uncomfortable. You may be able to force your body into better alignment with a device like this, and everyone benefits from regular exercising. But an integrated approach that combines your mind and body will have far greater effects than a purely physical approach.

The mind/body approach reeducates your body

The Mayo Clinic study just involves physical changes, not paying attention to your breathing or posture. The exercises and brace do their work whether you pay attention or not. But when your body and mind work together, you get better results.

Most therapeutic exercises strengthen large muscles. But when you concentrate on your movements while you exercise instead of letting your mind wander, your subconscious mind steps in. You begin strengthening both your large and small muscles even when you don't know anything about their function. Visualization re-programs your muscles to work properly. Eventually, all of your muscles work together even when you're not exercising or paying attention.

Yoga is one form of exercise that integrates the mind with the body. I've found another one I like even better for strength and balance. It's called Pilates.

What is Pilates?

Pilates is a system of conditioning developed by Joseph Pilates in the 1920s. Originally a weak, sickly child, he created a series of exercises that restored his health. His exercises were the foundation for today's Pilates exercises. You can do these exercises either on a floor mat or on a piece of equipment with pulleys called the Reformer. The floor exercises are excellent and will work just fine.

Pilates exercises make you stronger, more flexible, and less likely to fall because they re-educate your body to use all of your muscles. By strengthening both your large muscles and the deep, small endurance muscles that are responsible for your strength, they take the strain off the larger muscles and give them added support. You need to add concentration and correct breathing to an exercise to recruit the small supportive muscles. Bottom line: less pain, greater range of motion, and fewer falls.

Pilates exercises are gentle and simple. And you only need to repeat each one three to five times. As you perform each exercise, concentrate on doing it with the correct form: breathing deeply and tightening your tummy. This combines the mental with the physical.

Pilates doesn't weigh you down, isn't painful, and has permanent effects. Re-alignment, strength, and balance occur when you concentrate on your movements and breathe properly as you exercise. Eventually, your body takes over and "remembers" how to stand, move, or perform an exercise without falling or getting hurt. By being conscious of your form and breath while you exercise, you create a result that's similar to the weighted back support and exercises — without the need to walk around with weights strapped on your back, or doing exercises that just target larger muscles.

Many exercises are called "Pilates"

Pilates is the name given to a type of exercise with characteristics stemming from Joseph Pilates' work. Not all Pilates exercises are the same. They can vary greatly from teacher to teacher. I've researched the subject for you and found resources that my personal Pilates teacher, Kathleen Langermann, and I think would best help people over 50.

You can learn Pilates from a video or DVD. Be sure to get one that's appropriate for those of us over 50. The two I suggest are: Pilates for Beginners (VHS and DVD) and Easy Pilates (DVD only). Pilates for Beginners shows basic fundamentals you need before doing the exercises, then teaches Pilates. Easy Pilates concentrates on the proper form and has easy-to-follow routines. Both are available from Gaiam (877-989-6321) and at most Barnes & Noble and Borders bookstores, Target, Amazon.com, and many health food stores.

My experience

I've been doing Pilates exercises — both on a mat and on the Reformer — for over a year, and I'm excited about the changes in my body. My body is more stable than ever. When I paddle my kayak, I have greater strength and endurance. I don't injure myself easily. I stand and sit straighter because my body reminds me that it feels most natural when it's in better alignment. And after more than 40 years, my chronic low back pain is gone.

Exercising used to be a chore that I fit into my schedule when I could. Pilates has changed this. I'm convinced that a mind/body approach to exercising will give you better results than wearing a back brace or doing other exercises.

Siler, Brooke. The Pilates Body, Broadway Books, 2000.

Sinaki, et al. "Significant reduction in risk of falls and back pain in ostoporotic-kyphotic women through a spinal proprioceptive extension exercise dynamic (SPEED) program," Mayo Clinic Proceedings, July 2005.

What You Haven't Been Told About the Stress-Osteoporosis Connection

You probably know that stress can make you tired, depressed, cause insomnia, and lead to weight gain. But did you know that it pulls calcium out of your bones? Not many people do. In fact, the stress-osteoporosis connection is hardly ever mentioned in books on stress, osteoporosis, hormones, or menopause!

If you've been exercising, eating a healthy bone-conserving diet, and taking your supplements faithfully, you may think you're doing enough to protect your bones. Not necessarily. Chronic stress can lead to brittle bones even after you've done everything else right.

Look at cortisol

Cortisol is one of many hormones secreted by your adrenal glands in response to any type of stress. Its levels are normally highest in the morning and lowest at night. High early morning cortisol wakes you up, and lower late evening cortisol lets you sleep well. If your cortisol is low in the morning, you'll find it's difficult to wake up and you are likely to feel tired throughout the day. If it remains high at night, you may be depressed and have difficulty sleeping.

All of us experience occasional bursts of cortisol in response to daily stresses — like when another car nearly misses hitting your car or you hear that a good friend is very sick. These reactions are normal and won't cause thinning bones. Not if your cortisol levels re-adjust after each event.

But when your adrenal glands keep secreting this hormone inappropriately, they can leave you with high cortisol. Some medications, such as prednisone, cortisone, and other steroids, trigger your adrenal glands to keep secreting cortisol, as well. Over time, high cortisol can lead to exhausted adrenal glands and chronically low cortisol levels.

When you have high cortisol throughout the day, you feel exhausted all the time. In addition to what you feel, this excess cortisol pulls calcium out of your bones and interferes with its absorption, putting you at risk for losing bone density.

Measuring cortisol levels

Fortunately, you can now measure your cortisol and find out whether or not yours is chronically high with a simple saliva test your doctor can order. The test consists of saliva samples taken at four different times during the day and night. This is because cortisol fluctuates at specific times. The combined results show whether or not your hormone levels rise and fall when they should and indicate whether or not you are secreting too much. It also measures DHEA, a hormone that balances cortisol. One reason for high cortisol could be low DHEA, so it's important to get both hormones tested.

This Adrenal Function Test is available through a number of laboratories. I particularly like Aeron LifeCycles (800-631-7900) because they accept Medicare for full payment and will work with you if you can't find a qualified doctor to order this test. A number of insurance companies also pay for this test that costs $141.

You may remember that I wrote about a test, Pyrilinks-D, which measures the rate at which your bone breaks down and rebuilds itself. If you happen to have had this test, also available through Aeron, evaluating your cortisol levels may be your next step.

There are a number of natural solutions, should you find that your cortisol is too high. They include improving your diet, getting regular exercise, and taking one or more of a number of nutritional supplements.

Natural ways to regulate cortisol

Begin with daily exercise, meditation or prayer, and a sensible diet. Then support your adrenal glands with supplements. I like using a classification of supplements called adaptogens because they regulate your body's response to stress. They turn on areas that have been turned off, and vice versa. I've talked about adaptogens in the past, and you can read these articles on my website. But let me tell you briefly about some of the best adaptogens that help regulate cortisol.

Rhodiola rosea is an adaptogen used in Chinese traditional medicine that prevents stress-induced heart damage. Low doses of a standardized extract have worked to lower stress in a number of studies. Try taking one capsule twice a day, or 20 drops of an extract (HerbPharm, 800-348-4372).

Withania somnifera, or ashwaganda, is an Ayurvedic herb. It's found in many formulas that have significant anti-stress activity. Both Rhodiola and ashwaganda, along with Cordyceps mushrooms, are used in Adrenamin, an anti-stress formula available through ProThera (888-488-2488). This is one formula I recommend to help regulate high cortisol levels (one capsule, twice a day).

Eleutherococcus senticosus (formerly called Siberian ginseng) isn't a true ginseng. It's an excellent adaptogen that slows down excess cortisol excretion caused by stress. I've used Eleuthero, as it's called, for decades. It's a safe product, most potent in an alcohol base. HerbPharm makes an excellent product available in many health food stores.

DHEA, or dihydroepiandrosterone, is the hormone that is often low when cortisol is high. You can buy it in any health food store – but don't. Some supplements don't contain the amount of DHEA listed on the labels. Besides, I strongly believe that hormones should be dispensed through your doctor. If you get the Adrenal Function Test, your doctor will know how much DHEA you should take. Too much can cause facial hair, rashes, and other side effects. Never self-administer DHEA or other hormones (except one to three mg of melatonin for insomnia). Hint: You may need only 5-10 mg.

Magnesium: It's cheap and has a profound effect on stress. If you are magnesium-deficient, and some doctors believe that most people are, stress increases your risk for heart disease, arrhythmias, and sudden death. Any stress — physical or emotional — increases your need for magnesium. Magnesium also helps carry calcium into the bones, so it's an important nutrient for your bones on several counts. How much should you take? Whatever your bowels can tolerate up to 1,000 mg. Use a magnesium glycinate or amino acid chelate, which is well absorbed, and avoid poorly absorbed magnesium oxide. From 100-400 mg of magnesium, along with a good multi, should be enough for most people.

Avoid stimulants

Keep your caffeine intake low. Don't take herbs like ephedra (Ma Huang) that stimulate the adrenal glands. Avoid guarana, the seeds of a Brazilian plant, with about twice the amount of a chemical that is almost identical to caffeine.

Bottom line: If you've been under stress for a long time, have difficulty sleeping, are depressed, and can't wake up in the morning without help (like coffee or tea), you may have chronically high cortisol. Get your levels tested first, then begin a serious stress-reduction plan. It should be an integral part of any osteoporosis-prevention plan.

Brown, Susan E., PhD. Better Bones, Better Body, Keats Publishing, 1996.

Maslova, L.V., et al. "The cardioprotective and antiadrenergic activity of an extract of Rhodiola rosea in stress," IuB Eksp Klin Farmakol, November-December 1994.

Talbott, Shawn, PhD. The Cortisol Connection, Hunter House, 2002.

More Ways to Eliminate Insomnia

Last month, I gave you a number of tips to help end your sleepless nights. Some of them were lifestyle changes, while others included relaxing herbs and minerals. If these suggestions were not enough, there's more you can do. You can get a good night's sleep by using the appropriate homeopathic remedy.

There are numerous homeopathic remedies to choose from that can help you get the rest you need. Select the one that most accurately fits your sleep disturbance pattern. You may have all of the listed symptoms, or just one of them.

Aconite: You are extremely anxious, restlessness, have a fear of dying. You experience heart palpitations, are drowsy during the day and awake at night, may have nightmares or disturbing dreams. Fresh air makes you feel good.

Arsenicum album: Worry and anxiety keep you awake, especially between midnight and 2:00 a.m. Your insomnia worsens your anxiety. You are restless in bed and may get up to make a cup of tea. You like warm drinks and being warm.

Chamomilla: You're irritable or in pain and can't get to sleep. You like cold water and sour lemonade. You don't like coffee.

Coffea: You have an overactive mind and are often wide-awake at 3:00 a.m. You're particularly sensitive to noise, light, touch, and caffeine from any source.

Ignatia: You sigh and yawn a lot, but can't sleep. You have wide mood swings and are both high-strung and emotional. Grief keeps you awake. Breathing deeply, moving around, and being alone make you feel better.

Nux vomica: You're irritable, impatient, and frequently wake up at 3:00 – 4:00 a.m and have difficulty falling back to sleep. When you finally do, you wake up tired. It's difficult for you to switch off your mind and stop thinking about problems at home or work. Alcohol, caffeine, or eating rich, spicy foods keep you awake.

Pulsatilla: At first you feel too hot and throw your covers off, then you feel too cold and pull them back up. One thought keeps repeating in your mind and keeps you awake. You sleep with your hands above your head and wake up feeling overheated.

Sepia: During the day you're tired, but at night you have difficulty falling asleep. You're depressed, and your inability to get a good night's sleep is depressing. You wake up early, can't get back to sleep, and feel sleep-deprived in the morning. Your fatigue gives you headaches and causes dizziness. Exercise helps, and just sitting around makes this condition worse.

Using homeopathics

Don't be confused by the many dilutions available. The dilution you want for a sleep remedy is 30C — considered to be a medium potency. This means that one part of the original substance was diluted 30 times in 99 parts of water. Nothing remains in the tiny pellets or liquid except the energy from the original substance. There's no trace of any chemicals it once contained. The more times a remedy has been diluted, the stronger the effect. Low potency remedies have been diluted up to 15 times.

Take the remedy once at night for 10 days, an hour before going to bed. Repeat for one more cycle if necessary. You can find the remedies in this article at most health food stores or through www.homeopathic.com (800-359-9051).

Homeopathics are compatible with most medications. However, they should not be taken with antibiotics, antifungals, chemotherapy, steroids, or narcotic drugs. Don't use them an hour before or after coffee, mint (toothpaste), garlic, and other strong tastes or odors. These could cancel out the effects of the remedies. Take them first thing in the morning or just before bedtime.

If you don't get relief after using a homeopathic remedy for one or two 10-day cycles, you may need some help finding the specific remedy your body needs. Ask practitioners of integrative medicine (doctors, acupuncturists, naturopaths) or at health food stores to help you find a homeopath. I've seen homeopathy work wonders in my patients and me. It's a safe, inexpensive solution to numerous health problems — including insomnia.

Cummings, S., MD and D. Ullman, MPH. Everybody's Guide to Homeopathic Medicines, Jeremy P. Tarcher, 1997.

Reichenberg-Ullman, J., ND, MSW. Whole Woman Homeopathy, Prima Health, 2000.

Trivieri, L., Jr., and J.W. Anderson. Alternative Medicine: The Definitive Guide, Second Edition, Celestial Arts, 2002.

Health Detective

When and Why Echinacea Works

There have been many arguments both for and against using the herb echinacea to fight colds and flu. Some studies show it works while others say it doesn't. This is confusing, especially when winter colds are prevalent. A recent Swiss study may explain these mixed responses.

This study concentrated on a particular group of phytochemicals (plant chemicals) found in echinacea called alkylamides. Some of them "turn on" genes in your immune cells. They also regulate your immune system and lengthen the amount of time it makes substances called tumor necrosis factor-alpha (TNF-a). TNF-a increases your immune respond to infection. This means that echinacea products high in alkylamides should outperform all others and work when other echinacea products don't.

These alkylamides are highest in fresh extracts of the whole root of E. purpurea. One particular alkylamide, found in the root of E. augustifolia, makes other protective alkylmides in E. purpurea even more bioavailable. The combination is said to be better than either of these species.

After reading the Swiss study, I wondered why Organic Echinacea Plus herb tea from Traditional Medicinals (found in most health food stores) works as well as it does. Or why the echinacea extracts from HerbPharm (800-348-4372) are so effective. The answer is simple. They both use high-quality raw materials in their products and monitor each batch of the final product to make sure it contains enough active ingredients.

For instance, independent lab tests on Echinacea Plus tea found that its raw materials do, indeed, increase TNF-a. A double-blinded, placebo-controlled study published in 2000 proved that this echinacea tea works if it's taken at the first sign of a cold or flu. Just be sure to steep it for 15 minutes and drink five cups of tea the first day, four the second, and one less each subsequent day.

Bottom line: If you want an effective echinacea product, shop for quality, not price. Don't base your selection on a single study quoted by any company. Let me help you find some of the better herb companies. I have no financial interest in any of them. Just your best interest. I'll have more about herbs and herb companies in future issues.

Ask Dr. Nan

Q: I have trouble swallowing. I get a choking sensation and then a burning in my chest. I'm taking Nexium, but it's not working. What do you suggest I do? — M.G., Miami, PA

A: Here's what I would do: First, don't take Nexium if it doesn't help. It neutralizes stomach acid, which is needed to break down and use protein and many important minerals.

Second, get another opinion from a doctor of integrative medicine or from an acupuncturist — someone who looks at your body differently from your regular doctor. You need a diagnosis before you can look for a solution.

Third, try an elimination diet and eat rice, vegetables, and protein only. If this relieves your condition, your symptoms may be caused by something you're eating.

Finally, if you have dry eyes and a dry mouth as well, have your doctor check for Sjongren's Syndrome. This is an autoimmune condition where fluids in the body dry up causing numerous symptoms, including yours.

Q: I have had intense vaginal pain since menopause. I understand it's called vulvodynia. What can you suggest to reduce or alleviate this pain? — M.K.B., North Platte, NE

A: Vulvodynia causes a burning or shooting pain in the vulva, the area around the vagina. Doctors don't know what causes it. It could be anything from food allergies, genetics, a chemical sensitivity (perhaps to propylene glycol, which is found in some vaginal lubricants), and systemic Candida. Obviously, the treatment will vary according to the cause.

I think that candida is an overlooked cause of vulvodynia and is worth exploring. To reduce your colonies of bad bacteria and get more of the good bacteria, stop eating all sugars, take an anti-fungal supplement (you can find these in health food stores) and increase your probiotics (friendly bacteria).

For more information on candida and the best probiotics I've found, check my website, www.womenshealthletter.com.

Q: I'm confused about protein. You say we need about 60 grams of protein a day and Dr. McDougall says we need much less. Who should I believe? — S.C.R., Grand Rapids, OH

A: The information I'm giving you about protein is based on research showing that higher protein intake protects a woman's bones and corrects insulin resistance. Dr. McDougall says that "rice alone would provide 71 grams of highly useable protein and white potatoes would provide 64 grams of protein85". This is true if you eat enough of them.

One baked potato with skin contains 4.7 grams of protein. You'd need to eat nearly 14 potatoes to get the 64 grams the good doctor calculated. This translates to four potatoes for one 20-gram meal. One potato is enough to cause blood sugar levels to skyrocket in anyone with insulin sensitivity, a common problem. Ask any diabetic or someone with hypoglycemia what four or more potatoes do to their blood sugar!

I stand by my original statement that it's difficult, but possible, for a vegetarian to get enough protein. If, like me, you're on an exercise program to build muscle mass and protect your bones, you may need even more than 20 grams of protein per meal.

Kirschmann, G.J. and J.D. Nutrition Almanac, Fourth Edition, McGraw-Hill, 1996.

McDougall, John. The McDougall Newsletter, vol 2, issue 10, December 2003.