Strong and Healthy Bones
Low bone density and osteoporosis are nuanced topics, and particularly important to women’s health. I am passionate about these issues and want to provide some resources to help you better understand this compelling topic.
Importantly, the essential elements for preserving bone health and treating osteoporosis include:
1. KEEPING INFLAMMATION LOW
2. ENJOYING A NUTRIENT DENSE, LOW INFLAMMATORY DIET
3. FINDING WAYS TO MOVE YOUR BODY EVERYDAY
The fundamentals about osteoporosis in relation to these three important factors.
WHAT IS OSTEOPOROSIS?
Osteoporosis is a condition of weak or porous bones. Literally, when broken down into the Latin and Greek origins of this term, we have:
Osteo, “bone”
Poros, “full of pores” or “minute openings”
-osis, “a state of disease”
As defined by the National Institutes of Health, “Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fractures of the hip, spine, and wrist.”
In other words, osteoporosis is a combination of low bone mineral density and compromised structural integrity (or microarchitecture). It is not only the density of the bone that is less than optimal, it is also the quality of the bony structure.
We are concerned about osteoporosis because one in two women, and one in four men, over the age of 50, will suffer from an osteoporosis-related fracture. And nearly 24% of patients over the age of 50 who experience a hip fracture will die within one year of that fracture. This is a serious cause of both morbidity and mortality that can be prevented.
AM I AT RISK FOR OSTEOPOROSIS?
While there are several key risk factors that we cannot change (such as age, gender and ethnicity), there are many ways in which we can reduce our risk and improve our bone health. It’s important to know what risk factors you do have so you can decide how aggressive you want to be in adopting supportive diet and lifestyle changes and in monitoring your bone health.
Risk Factors You Cannot Change:
Older age
Caucasian or Asian descent
Low body weight (generally less than 127 lbs) and/or petite frame
Early menopause (before 45 years old)
Primary relative with osteoporosis or known genetic predisposition
Conditions Associated with Osteoporosis:
(an incomplete list adapted from the National Institutes of Health and National Osteoporosis Foundation, including the more common conditions):
Nutritional deficiencies, which may be associated with malabsorption or gut microbial imbalances
Inflammatory bowel disease, including Crohn’s and ulcerative colitis
Diabetes mellitus
Rheumatoid arthritis
Depression
Eating disorders, namely anorexia and bulimia
Celiac disease
Breast cancer
Hypochlorhydria, or low stomach acid
Endometriosis
Polycystic ovarian disease, or PCOS
Premature ovarian failure
Hyperparathyroidism
Untreated hyperthyroidism or hypothyroidism, or excessive thyroid hormone replacement
Chronic amenorrhea
Lifestyle (Past and Present):
Daily alcohol consumption
Heavy caffeine intake, generally considered more than three servings daily
Cigarette smoking
Diet high in sugar
Daily soft drinks
Excessive salt intake
Diet high in processed and other fast foods
Low nutrient density diet, or overly restrictive diet that excludes key nutrients
Sedentary lifestyle
Excessive exercise (when associated with low body fat and amenorrhea)
AM I TAKING ANY MEDICATIONS THAT INCREASE MY RISK OF OSTEOPOROSIS?
A list of some of the most commonly prescribed medications that can increase risk of osteoporosis:
Proton pump inhibitors (PPIs including Nexium, Prevacid and Prilosec)
Long-term corticosteroids (e.g., prednisone, cortisone, and hydrocortisone)
Aluminun containing antacids, such as Gaviscon
SSRIs (e.g., Prozac, Zoloft)
Depo-Provera
Long term antibiotic use
Thiazolidinesdiones (diabetes medications)
Excessive thyroid hormone, especially T3
A more comprehensive list can be found at American Bone Health:
https://americanbonehealth.org/bone-health/medications-that-can-be-bad-for-your-bones-2/
HOW CAN I BETTER UNDERSTAND MY RISK?
One of the most important measurements in understanding the risk of fracture is bone mineral density (BMD), quantified using a DXA scan, or “dual-energy x-ray absorptiometry.”
A DXA report will provide you both a T-score and a Z-score.
The T-score is the more significant of these calculated measurements, and is the numerical score used in diagnosing osteoporosis.
The T-score represents a comparison between your bone density and the average bone density of a 26-29 year old of the same gender.
The Z-score is a number representing a comparison between your bone mineral density with an average bone density of people the same age and gender.
Osteoporosis is diagnosed when the T-score is -2.5 or lower, in women or men over 50 years of age, or in postmenopausal women regardless of age (because of the significant bone loss that occurs during the five to ten years surrounding the menopausal transition, with some women losing as much as 20% of bone density during this time!)
The lower your bone mineral density, the higher the risk of fracture. However, this methodology only measures bone density, not the quality or strength (which is dependent more on the microarchitecture). So, this is not the whole story!
FRAX Fracture Risk Assessment Tool
https://www.sheffield.ac.uk/FRAX/tool.aspx?country=9
Created by the World Health Organization (WHO) to help assess fracture risk beyond DXA testing. This risk assessment tool provides an estimation of your ten-year fracture risk, both hip fracture and major osteoporotic fractures. This strategy can be used without having a prior DXA scan.
Initially intended to provide a guideline for considering a medication for osteoporosis, the guideline recommendation is to consider medication if:
Risk for hip fracture is equal to or greater than 3%
Risk for a major osteoporotic fracture is equal or greater to 20%
FORE’s Fracture Risk Calculator
https://riskcalculator.fore.org/Default.aspx
FORE (Foundation for Osteoporosis Research and Education) developed another Fracture Risk Calculator (FRC), which includes a few more variables.
It’s important to note that there is no perfect test to diagnosis osteoporosis (perhaps short of a very painful and invasive bone biopsy, which I would not recommend). The benefits and aims of a DXA scan, the FRAX tool, and FORE Fracture Risk Calculator, are NOT to confirm a definitive diagnosis, but rather to aid in the consideration of how best to support optimal bone health.
SHOULD I BE TAKING A CALCIUM SUPPLEMENT TO “BUILD” BONE STRENGTH?
Calcium is in fact a critical mineral for our bones. However, research over the past several decades not only questions whether or not supplemental calcium decreases fracture risk, but these studies also raise concerns that calcium supplementation may increase the risk of heart disease.
Importantly, it should be noted that obtaining calcium from your diet is not correlated with the increased health risk found when taking calcium supplements.
It is hypothesized that calcium supplements may abnormally elevate the blood’s level of calcium such that the calcium is deposited along artery walls (referred to as calcified plaque)
So we need to carefully consider whether or not it is advisable to take a calcium supplement, and how to assure the safest approach to beneficial supplementing.
WHAT CAN YOU DO?
First, track your food and beverage intake for five days, eating your typical diet. Use a nutrient tracker such as:
Wholesome app, http://www.wholesomeapp.com/track
Cronometer, https://cronometer.com/
Depending on your age and any known risk factors for decreased bone mineral density, you should be getting around 800 to 1,200 mg of calcium daily.
If you’re not getting this we can talk about ways to adjust your diet, both to favor calcium rich foods and also ways to improve calcium absorption.
Some of the best food sources for calcium:
Sheep and goat dairy (if you tolerate dairy)
Traditional canned wild caught salmon and sardines (these contain the soft, small bones)
Dark leafy greens
Certain nuts and seeds (preferably soaked or sprouted to improve digestibility and lower phytates)
If dietary tweaks still don’t provide you with enough calcium, then it may be appropriate to consider supplementing
What’s the safest calcium supplement?
I favor microcrystalline hydroxyapatite concentrate (MCHC), which is well absorbed and provides more comprehensive bone nourishment. This is derived from whole bone and thus contains trace amounts of other minerals and cofactors that support healthy bone. (As with all supplements, the source and quality/purity are important.)
Since we can only absorb about 500 mg of calcium from our GI tract at once, if you’re taking more than 500 mg, divide the dosing over two, or even three meals.
Is calcium enough?
In addition to obtaining adequate amounts of calcium, and all the more important if you’re obtaining calcium from supplements, I recommend other key nutrients:
Necessary:
Magnesium glycinate, about 400-700 mg daily
Vitamin D3, taken to optimize your blood level around 50-70 ng/ml
Vitamin K2, about 150-300 mcg daily
Optional:
Boron
B Complex, including an active form of B12 and methyltetrahydrofolate (L-MTHF)
There are some “bone support” formulas available from high quality supplement companies that make it easy to obtain all these nutrients from one supplement.
WHAT ABOUT PRESCRIPTION MEDICATIONS FOR OSTEOPOROSIS?
Medications for osteoporosis unfortunately do not “cure” this condition, and bone density gained over the course of prescription treatment can be lost within one to three years of stopping these medications. (And due to serious side effects, these medications should only be taken for a maximum of two to five years.)
The most common type of medications currently available for osteoporosis are “antiresorptives,” meaning they inhibit the removal of old bone, by inhibiting osteoclasts. (Biology primer: Two of the more important cell types to be aware of here are osteoclasts and osteoblasts. I remember their respective roles by thinking, osteoclasts crush bone and osteoblasts build bone.)
Bisphosphonates are the most common class of antiresorptive medications, and these include Fosamax (alendronate), Boniva (ibandronate sodium), Actonel (risedronate) and Reclast (zoledronic acid). As antiresorptives, these medications interfere with the osteoclasts ability to remove bone.
While the osteoclasts are prevented from removing the old bone, it seems that osteoblasts continue to build new bone, at least for the first six months to two years. Thus, there is an increase in bone mineral density, and according to the Fracture Intervention Trial (FIT), there is a statistically significant reduction in hip fractures.
But given the serious potential side effects, I take any recommendation to start these medications only with significant caution.
Side effects include:
Stomach cramps and other GI discomfort
Oral bisphosphonates may irritate the esophagus (and should not be used when gastroesophageal reflux is present)
Bone, joint and muscle pain
Delayed fracture healing
While rare, the most concerning side effects include:
Atypical, low-trauma fracture of the femoral neck
Osteonecrosis of jaw
Teriparatide (Forteo) is a different class of medication, considered an “anabolic.” It is a synthetic parathyroid hormone that increases osteoblast activity in building bone. While Forteo is currently reserved for patients with severe osteoporosis, or those who have been on bisphosphonates for five years or longer, this drug appears promising.
While Forteo also has a list of side effects, the data to date is encouraging. Since it has not been in clinical use for as long, it must be noted that we may not yet know all of the side effects.
Relying upon the available information, I currently believe that research studies show an increase in bone density and a reduction of hip fracture in some patients. The evidence indicates that when bisphosphonates are used in the appropriate situation for a limited amount of time, and within the context of a more comprehensive treatment approach (including targeted dietary, supplement and exercise interventions), they can lessen the fracture risk in certain patients.
CAN HORMONE REPLACEMENT BE USED TO HELP MY BONES?
It is my current belief that bioidentical hormone replacement therapy (BHRT) is a reasonable and effective strategy to help prevent bone loss in women without contraindications to hormone replacement (such as estrogen sensitive breast cancer), particularly around the menopausal transition.
Hormone replacement therapy does stabilize bone density prior to and during menopause, allowing for a meaningful reduction in hip fractures. However, for estrogen to reduce hip fractures decades after menopause, women must continue this therapy for at least ten years, if not longer.
For maximal bone support, women may have to start estrogen replacement at the time of menopause, and continue this indefinitely.
ADDITIONAL RESOURCES:
“Dr. Lani’s No-Nonsense Bone Health Guide” by Lani Simpson, DC, CCD
An excellent and comprehensive resource. Purchase here
2007 Study in the American Journal of Clinical Nutrition
Calcium supplements do not reduce fracture rates in postmenopausal women, and may even increase rate of hip fracture. Read more
2015 Systematic Review
Meta-analysis determined that “Increasing calcium intake from dietary sources or by taking calcium supplements produces small non-progressive increases in BMD, which are unlikely to lead to a clinically significant reduction in risk of fracture.” Read more
2014 Study
Looking at microcrystalline hydroxyapatite supplementation. Read more