Many medical doctors and some patients reminisce about pre-digital times. Back then it was simple; patients came in need for help, and their doctors had the answers, cherishing their monopoly on medical information. In the third millennium that is no longer the case. From speaking for themselves since the eighties, patients have evolved and turned to mutiny, no longer taking anything for granted. The medical establishment has lost its monopoly. Often enough patients turn to their doctor with print outs from the internet, informing their doctor about the latest developments regarding their condition. But things can get even more absurd, as Thijs Klompmaker’s story proves. This Amsterdam waiter is the uncrowned king of medical autodidacts. Since years he works fulltime in Grand Café-restaurant l'Opera, at the Rembrandt Square. Foreign scientists and professors are not convinced and consistently keep addressing him as Doctor or Professor since he astonished them with his 2005 publication in the Medical Hypotheses, an established international scientific magazine.

Acne project

Klompmaker can hardly believe it himself: “I’m extremely stubborn”, he says about himself. “Probably that helped”. He also wants to stress that the encouragements of others made it happen. “Prof. dr. Hans Dehmelt, 1989 Nobel prize winner for physics eventually convinced me to go for a publication.” And all this started with acne. “In puberty I started suffering from bad acne”, Klompmaker looks back in time. “As a consequence I started experimenting with my diet. If I consumed little protein, my skin was better. Salt and hot spices were aggravating as well. Drastically cutting out everything that could possibly bad for my skin, my skin totally cleared up. After that I started experimenting with adding excluded foods back into my diet.” For years he invested time in this acne project, which culminated in “The Free Acne Book”, published on the internet under the pseudonym Wai Genriiu. In this book aspects of the diet are based on scientific findings. “Working on that, I discovered that the diet supplies us with sufficient of all nutrients; all except one: calcium.” Which gave way for a new medical project. “My initial idea was that dieters would need supplementary calcium. So I started researching the possible effects.” This calcium research became a fascination and led to new views. “As a result I now think that lifetime high calcium intakes, as recommended in Western countries, have adverse effects on long term bone health.”

Prevention aimed at bone mineral density

Research has shown that ‘caloric restriction’, a relatively low intake of calories, increases lifespan. “It retards age-related physiological and biochemical processes. In as much as speeding in your car will make it last less long. And I think that also your bones will last longer if you consume less calcium, as this will save the age-related capacity of your bones to compose new bone.” Klompmaker was first alerted when he compared osteoporosis incidence in different countries. “Osteoporosis – which is fundamentally different from low bone mineral density that is reversible – cannot be cured. But it can be prevented. Since decades prevention is aimed at maximizing peak bone mineral density (BMD). In contrast, in countries with the highest average bone mineral density, osteoporosis-related bone fracture incidence in the elderly is most prevalent.” Japanese have a lower BMD than Europeans, and hip fracture incidence is lower as well. “This difference cannot be attributed to genetic differences, as BMD in Japanese women born in the US is similar to those in Caucasian American women. In Gambia calcium intake, average bone mineral density as well as osteoporosis-related bone fracture incidence is very low. And again, this cannot be attributed to genetic differences.”

Exhaustion of osteoblasts

After having read hundreds of scientific articles, Klompmaker developed a hypothesis in which many facts are combined. “It seems that BMD does not represent long term bone health, but just the strength of the bones at that moment. In the disease osteoporosis there is a relative lack of osteoblasts. Osteoblasts give way to bone composition. Osteoporosis is specific for the elderly. I suspect that osteoporosis is about the premature ageing and exhaustion of those osteoblasts.” In aiming to prevent osteoporosis, doctors should focus on age-related osteoblast replicative capacity (ARORC) rather than BMD. “The ARORC represents the long term capacity of your bones to regenerate new bone. In comparison to healthy bones, in osteoporotic bones less osteoblasts are available. Keeping BMD at constantly high levels comes with high rates of bone turnover, which leads to local exhaustion of osteoblast replicative capacity. Eventually this results in the incapacity to repair micro fractures and increased fracture risks.

“No lifetime high calcium intake”

Increasingly the pieces of the osteoporosis-puzzle began to fit. “In post-menopausal women osteoporotic fracture risk is increased due to decreased estrogen levels. It is often assumed that estrogen only inhibits activity of osteoclasts, which break down one. Studies, however, show that estrogens also decrease activity of osteoblasts. Sufficient estrogen therefore protects osteoblasts against premature exhaustion. Opposingly, corticosteroids, as in Prednison, increase osteoporotic fracture risk because they increase osteoblast death rates. And a high calcium diet does the same thing; it increases osteoblast activity and death rates.” In Klompmaker’s view, elderly better put dairy products and calcium supplements aside. “Of course my theory needs to be proven first, but what has been proven already, is that a high calcium intake only has a temporary positive effect on bone strength, but not on long term bone health, and can never cure osteoporosis. Moreover, statistics show that the eventual effects are adverse. As osteoporosis is about premature aging, there is no possible cure. What is possible is slowing down this process, which is certainly not accomplished by a high intake of calcium.” Klompmaker is keen to make clear that his theory is not about the temporary effect of calcium intake on bone strength. “What concerns me, are the eventual effects of a lifetime high calcium intake on bone metabolism in old age. Regarding prevention, everybody agrees that this needs to be achieved in the first fifty years of life. If my hypothesis is correct, a high calcium intake has detrimental effects on eventual bone health. This requires correcting the current calcium recommendations of about 1,000 mg per day. I suspect that 300 to 500 mg is enough, as it is the average calcium intake in countries where osteoporotic bone fracture incidence is the lowest.”

Osteoclasts and osteoblasts

Bone is not dead tissue, but a living organ with high levels of vascularity and metabolism activities. Bone is constantly being remodeled, which is absolutely not just about repairing visible fractures, but specifically about repairing tiny micro-fractures, invisible for the naked eye. Bone strength and fracture risk is determined by the capacity to properly repair such micro fractures in combination with the level of mineralization In the repairing and replacing of bone two cell-systems are crucial: osteoclasts and osteoblasts. Osteoclasts decompose redundant or damaged cells, whereas osteoblasts create new bone. In response to the influx of calcium osteoblasts produce the matrix upon which calcium may precipitate. In doing so, approximately 50 to 70% of the involved osteoblasts die. “The greater the influx of calcium, the greater the level of osteoblast activity”, Thijs Klompmaker explains. “And the more osteoblasts die. These higher death rates cause a decrease in the ARORC (age-related osteoblast replicative capacity), which means that their capacity will be exhausted sooner.”

Tests in mice

Lots of water will flow through the Amsterdam Amstel River before Thijs Klompmaker’s hypothesis will result in changes in medical practice. In his view, tests in mice are required. “That way the effects of various levels of lifetime calcium intakes on eventual bone fracture toughness can be determined” There is international support for his plan, which he launched in his article published in Medical Hypotheses. “A number of scientific researchers and health professionals have responded to my article. They were particularly surprised by the different role that calcium-osteoblast interaction may play. Many of them declared to look forward to seeing the results of such tests.” Klompmaker is in the process of planning these tests. “I have found a facility where I can keep the required mice. No, my osteoporosis project has not ended yet.”

Text Toine de Graaf
Photography Menno Stassen
Translation Thijs Klompmaker