Osteoporosis prevention is about much more than just taking a calcium supplement. Sure, calcium is part of the story, but let’s take a deeper dive and review many of the overlooked angles associated with age-related, hormone associated bone loss. From that vantage point we can review the new strategies and techniques available to slow bone loss and potentially increase bone density.
According to the National Institutes of Health, approximately 34 million Americans have osteoporosis. Another 18 million have a decreased bone mass, called osteopenia, and are at risk for progressing into Osteoporosis. The name Osteoporosis means “porous bone”. It is a disorder of bone characterized by reduced mineral density and bone mass. This condition can result in broken bones, or fractures, especially of the hip, wrist, and spine.
If bone loss is severe, the fracture can occur from simple activities like lifting a chair, a big sneeze or just bending over to pick something up. Although it is more common in older women, men can also develop osteoporosis. According to statistics, one of every 2 women and 1 in every 4 men older than 50 years of age will have an osteoporosis-related fracture in their lifetime.
Your bone strength and density is determined by how much calcium and other supportive minerals are maintained in the bone. There are many factors that influence the ability to maintain bone mineralization. Your body continuously breaks down and re-builds bone. Before your 30’s you make more bone than you break down and so bone density is normally increasing. After your mid-30s, your body continues to make new bone, but at a slower speed so you can lose more bone than you make. If you add a number of lifestyles and predetermined risk factors to this equation, you can progress into a state of weakened bone at any age. So, what are the primary risk factors for developing osteoporosis?
Osteoporosis risk factors that are not in your control:
- Your sex. Women are 4X as likely to develop osteoporosis than are men.
- Age. The older you get, the greater your risk of osteoporosis.
- Family history and genetic predisposition for bone loss.
- Body frame size.
- Diminished minerals in the food supply.
Critical bone-health factors that you can control:
- Weight-Bearing Exercises
- Levels of Caffeine & Soda Consumption
- Vitamin Therapies
- Individual Hormone Considerations
- Using natural alternatives to Medications that cause bone loss
- Chronic Elevation of Stress Hormones
By examining these risk factors in deeper detail, we will gain valuable insight into the power of the tools that we can use to decrease risk of bone loss and even improve bone density. Let’s Dive In!
• Age. Women are 4X as likely to develop osteoporosis than men for a number of reasons. One statistical fact that is often overlooked is Age. Because women typically live longer than men, the older you are, the more progressive bone loss can be. I will not suggest shortening your lifespan as an acceptable treatment for Osteoporosis, but statistically speaking….. KIDDING.
• Menopause. There is a very powerful hormonal relationship between Estrogen and Calcitonin, the hormone in charge of regulating blood calcium levels. This is the most direct relationship with women and menopausal bone loss. Pre-Menopausal Estrogens, specifically Estradiol or E2, can stimulate levels of calcitonin that will balance the blood calcium levels. After a woman’s menstrual cycle stops, the primary circulating estrogen in the body becomes Estrone, E1, which is ten times weaker than Estradiol. So not only do a woman’s estrogen levels drop with menopause but they also become weaker forms of estrogen. This combination of factors will decrease levels of calcitonin and, in effect, decrease bone mineralization and density. It is worth noting that the hormone Progesterone has been clearly demonstrated to stimulate calcitonin as well.
• Body Frame. What does your body frame have to do with bone density? The thinner you are, the lower your circulating levels of Estrogen. While a woman is in menstrual years the majority of her estrogens are made from the ovaries. Post-menopausal estrogens are made primarily from body fat. Thus, women who are thin have less circulating estrogen. Having less estrogen is beneficial for decreasing the risk of estrogen-driven cancers, but directly increases the risk for osteoporosis.
This presentation is not just limited to menopause though. College female athletes who are too thin to menstruate or miss three or more periods in a row can also start to have bone density problems. Without a menstrual cycle (amenorrhea), the level of estrogen is lowered, causing an increased loss of bone density and strength. Sports that promote being thin for appearances, such as gymnastics, cheerleading, figure skating and competitive dancing are at higher risk. Endurance sports athletes like long-distance runners, track and field, cyclists and rowers are also at an increased risk.
• Family history and genetics. There are individuals who are genetically more likely to have lower levels of circulating estrogen. The gene COMT, Catechol O-methyltransferase, is partly in control of this hormone pathway. If you have a (-/-), (Val/Val), copy of the COMT gene you fall into this category. The new understanding of genetics and how they affect physiology gives us access to the tools to support the modification of these factors. For an extremely reasonable price, (under $200), you can download your raw data from a 23 & Me or Ancestry gene report and have the COMT gene analyzed through many different companies. The one I use in my practice is Stratagene. WWW.strategene.org.
• Diminished mineralization of foods. Studies from the Biochemical Institute at the University of Texas, Austin, led a team that analyzed 43 fruits and vegetables from 1950 to 1999 that reported reductions in vitamins, minerals, and protein over time. Using USDA data, it was found that broccoli had 130 mg of calcium in 1950. 49 years later, that number was only 48 mg. This decline in nutritional value contributes to the need for nutritional supplementation to optimize body chemistry.
Eating organic can also be helpful. Studies from the University of California showed that organic tomatoes can have as much as 30 percent more phytochemicals than conventional ones.
Other insights to optimizing minerals from the diet:
1) Look for the brighter colored veggies that will have a higher nutrient content.
2) Steaming veggies like broccoli and carrots can release the nutrients more readily than if raw or boiled. Similarly, tomatoes release more nutrition if lightly sautéed or roasted.
3) Smaller veggies tend to be more densely packed with minerals and nutrients per serving so the biggest tomato in the basket might not pack the best punch.
4) Eat your veggies within a week of buying them and try to keep them whole. The nutrients in most fruits and vegetables start to diminish as soon as they’re picked, so for optimal nutrition, eat all produce within 1 week of buying.
5) Lastly, avoid cutting your veggies up and storing them that way. The nutrients from your veggies can denature more rapidly when exposed to oxygen, so keep them whole until you are ready to eat your meal.
• Weight-Bearing Exercise. When astronauts started to explore outer space, one thing they didn’t expect to find was that they can lose up to 10 percent of their bone mass in three months. To help overcome the effects of bone loss while in orbit, astronauts have to engage in physical exercise for two and a half hours a day, six times a week. Elaborate exercise equipment has been developed to reproduce the effects of gravity to help prevent this. My favorite was a 1-million-dollar treadmill with bungy cords strapped to the astronaut to re-create the effect of gravity. I wonder how smooth a million-dollar treadmill would feel to run on?
The brain is capable of observing stress on the human frame and compensating by increasing calcium density in the bones for protection. When our muscles contract and pull on the tendons, the tendons in turn pull on the bone and the brain will signal the body to increase bone density where the stress is placed. With this knowledge, resistive strength training can be used to increase bone density. You can visit YouTube and search for “bone density exercises”. There are hundreds of Yoga, Pilates and Physical Therapy experts who are demonstrating bone-building techniques.
Exercise also increases strength, coordination, and balance. Experts recommend 1/2 hour of weight-bearing exercise daily. These are important tools to help prevent falls that cause fractures, especially in the elderly. Activities like Tai-Chi have been celebrated for improving balance and decreasing the risk of a fall.
• Diet. OK here we go, debate time. A 12-year Harvard study of 78,000 women published in the American Journal of Public Health showed: “Women consuming greater amounts of calcium from dairy foods had significantly increased risks of hip fractures, while no increase in fracture risk was observed for the same levels of calcium from nondairy sources”. This truth goes against years and years of brainwashing from advertising “GOT MILK” campaigns. To this day I have patients tell me that their physician suggest increase dairy consumption to support bone density. There is calcium in dairy products, but if it is not absorbable and able to be used by your body, it is not supportive of bone mineralization.
Let’s talk about the Standard American Inflammatory Diet and calcium loss. I have never asked any patients, who I have evaluated for osteoporosis, to increase dairy consumption to help improve bone density. I have asked all of them to avoid a diet high in caffeine, soda, and inflammatory foods. I have asked all of them to consume a diet high in phytonutrients from all of the colors of vegetables.
Great non-dairy sources of Calcium include:
- chia seeds
- pink salmon
- dried figs
- white beans
- sunflower seeds
- broccoli rabe
- sesame seeds
- sweet potatoes
- butternut squash
Diseases associated with gut inflammation, such as Crohn’s disease, have been shown to impair calcium absorption. The inflammation that is central to RA (Rheumatoid Arthritis) is a risk factor for osteoporosis in itself. Data shows that both active inflammation in the bone, and systemic inflammation, lead to an increased risk of osteoporosis and osteoporotic fractures.
Many studies have compared and contrasted the relationship between dairy, caffeine and soda consumption, high animal protein diets and levels of osteoporosis. The results have been more frustrating than promising because there is very low consistency in the findings. The basic truth is that consuming a highly inflammatory diet causes poor calcium absorption. The problem with the heated debates between researchers and various study results is that everyone’s optimal diet is unique. If you start with finding the most anti-inflammatory diet for the individual first, it is my clinical observation that health and optimal mineral absorption follows.
• Vitamin Therapies.
1) Calcium. Bone consists of an inorganic and organic matrix. The inorganic matrix is approximately 75% of the dry weight of bone and is mainly calcium hydroxyapatite crystals. MCHC, Microcrystalline hydroxyapatite, is whole bone food and provides a highly absorbable and a superior source of calcium. This source of calcium also provides other essential minerals such as magnesium, potassium, zinc, copper, manganese, silicon, and iron to support bone health and strength. Calcium is more readily absorbed in an acidic environment. Some forms of calcium, like calcium carbonate (TUMS) are less beneficial to bone health. To support the absorption of calcium I often have patients take their MCHC Calcium with a digestive enzyme to break it down into the most absorbable form.
2) Magnesium. Magnesium works hand in hand with calcium for optimal bone health by increasing bone density and preventing bone loss. Magnesium is found in many dietary sources like greens, nuts, seeds, dry beans and whole grains. A diet high in refined carbohydrates, white bread and sugars often causes a magnesium deficiency so increased doses of magnesium can be needed to optimize for junk food eaters.
3) Vitamin K is important for the maintenance of healthy bones. Vitamin K is found in green, leafy vegetables such as broccoli, brussels sprouts, collard greens, lettuce, and spinach. Vitamin K vitamins can thin the blood and should be avoided with patients taking blood thinning medications unless they are supervised by a physician.
4) Omega-3 fatty acids. Supplements containing essential fatty acids, such as those found in fish oil, can help maintain or possibly increase bone mass. Essential fatty acids appear to increase the amount of calcium that your body absorbs, diminish the amount of calcium lost in urine, improve bone strength, and enhance bone growth. Foods rich in essential fatty acids, including cold-water fish, can help raise the amount of essential fatty acids in your diet and lower inflammation. Fish oil is also a blood thinner so should be used carefully if you are on medications that thin your blood.
5) Vitamin D. Observing Blood levels of vitamin D is a very valuable tool to supporting bone health. Blood levels of 25 hydroxy Vitamin D3 below 10 ng/ml is considered a severe deficiency. Below 30 is clinically deficient. Between 30-60 is considered sub-optimal. Between 60-80 is considered optimal for bone density. Vitamin D3 supplementation can be used to optimize levels. A sun exposure that can pink your skin will release around 10,000 I/U of vitamin D3 in your dermis. A sunblock with SPF above 15 will block 100% of vitamin D absorption.
6) Strontium Citrate. As an alkaline earth element, strontium is similar to calcium in its absorption in the gut, incorporation in bone, and elimination from the body through the kidneys. Treatment with strontium is used to making more strontium available to the body and due to its molecular similarity to calcium, adds the benefit of bone stability. Studies of bone treated with strontium for three years have found the element still present in the bone a decade later.
• Hormone Considerations. Both Estradiol (E2) and Progesterone (P4) were found to have significant stimulatory effects on the hormone calcitonin. Increased calcitonin will improve bone re-mineralization. There is increasing evidence that progesterone can be used to improve bone re-mineralization in both pre and post-menopausal women. I have successfully used trans-dermal progesterone as a combination therapy with vitamin support and dietary/lifestyle modification to observe increased bone density on many of my patients follow up dexa/osteoporosis scans. I am not talking about using progestins discussed in many studies. Progestins are a form of synthetic progesterone that I consider to be less preferable than the more bio-identical form of Progesterone.
Estrogens can be also used to improve bone health. There is evidence that the “safe” use of Estrogen replacement therapy within the first five years of menopause can decrease the severity of bone loss. It is extremely important that any individual using hormone therapy be supervised by a clinician who has ruled out the associated cancer risk factors. “Safe use of Estrogen” includes a clinical overview of body composition, family history, genetic potentials, lifestyle risk factors and blood work assessment prior to using any hormone therapy. It is my clinical opinion that bio-identical Estrogens are preferential to the C.C.E. (Conjugated Equine Estrogen) Hormone Replacement Therapies that are often prescribed.
• Using natural alternatives to medications that cause bone loss. Certain medications have the side effect of causing mal-absorption of minerals required for optimal bone health. Many of these medications are clinically relevant and natural supports can be used along-side of them. Other medications might be able to be discontinued with appropriate clinical supervision.
1) Corticosteroids can weaken bones and suppress new bone formation or bone repair. The ability to discontinue a long tern steroid use is determined by what the drug is being used for. Many times, a balanced anti-inflammatory diet and vitamin regimen can be used to minimize doses of steroids or even create the optimal environment where the steroids are not needed. Supportive nutrition to optimize bone mineralization should be considered while on this form of medication.
2) PPI or ant-acid medications for Heartburn inhibit stomach acid secretion that is required for optimal absorption of calcium. A listed side effect of long-term use of these medications is osteoporosis. 90% of the patients I see who take PPI medications are able to discontinue them with diet modification and supportive vitamin therapies to repair the stomach inflammation and lining. Supportive nutrition to optimize bone mineralization should be considered while on this form of medication.
3) Medroxyprogesterone – Studies on Birth control pills and depo provera shots have shown a gradual decline in bone density over time with some users. A “gradual decline” in bone density can be more compromising to future bone health than it sounds. This is primarily because the years that birth control pills are used are classically the years where bone building and growth is still active. Secondarily, hormonal birth control causes a magnesium deficiency that can contribute to bone loss.
The decision to discontinue hormonal birth control is individual as there are many alternative forms of contraception and many opinions regarding effectiveness, convenience and use. No matter how young you are, vitamin therapies to support bone density and to offset magnesium deficiency should be considered.
4) Heparin. This medication used for blood clots can only be discontinued with a clinician who can monitor the coagulative nature of your blood. Supportive nutrition to offset bone loss can still be used in adjunct with this therapy.
5) Opiate pain medications. Long term use of opiate medications can lower hormone levels and cause a secondary osteoporosis. Supporting the hormone loss and bone mineralization is important while taking long term opiate medications for pain.
6) Other drugs that lower bone density but will be unlikely to be discontinued are chemotherapy drugs, organ transplant anti-rejection medications, loop diuretics and methotrexate. Most of these medications can be taken along with bone building support. Individual contraindications need to be investigated with the prescribing physician or administering pharmacist.
• Chronic Elevation of Stress Hormones. A condition called Cushing’s Syndrome causes elevated levels of Cortisol, one of your primary stress hormones. This chronic increase in glucocorticoid hormone causes osteoporosis. Elevated cortisol levels directly inhibit bone formation and indirectly influence the skeleton via effects on reproductive hormones, growth hormone, muscle and fat tissue, intestinal calcium absorption, and ability of the kidneys to excrete calcium.
No bone density conversation would be complete without the suggestion that chronic high levels of stress in your life can have a smaller, yet similar effect. If your stress level is consistently above a 7 on a scale from 1-10, it is worth checking blood or salivary levels of cortisol to be sure that the levels are not significantly elevated. If so, being reminded that relaxation, mindfulness, prayer, guided imagery, a regular exercise regimen, decreasing caffeine consumption, maintaining a regular sleep wake cycle and avoidance of high stress triggers can balance stress hormone levels very effectively. Simply stated, lowering stress levels can improve your chances of re-mineralizing your bones.
In a Functional Medicine office, many patients will present for a natural alternative to the medical approach to managing bone loss. Some patients do not tolerate the medications prescribed and others are concerned about the potential side effects. It is worth a brief discussion on the most common class of drugs prescribed for osteoporosis called Bisphosphonates. General side effects are:
• Fever and flu-like symptoms. …
• Low levels of calcium in your blood …
• Bone and joint pain. …
• Changes in bowel movements. …
• Tiredness and low energy levels. …
• Feeling sick. …
• Changes to your kidneys. …
• Irritation of the esophagus…
• Jaw Necrosis / erosion of the jaw bone…
• Atypical Femur Fractures
Bisphosphonates are a group of medicines that slow down or prevent bone loss, thus strengthening bones. Bisphosphonates inhibit osteoclasts which are cells that responsible for breaking down bone. Common names for this group of drugs are Actonel, Fosamax, Boniva, Reclast, Aredia and Didronel. These drugs are considered safe for many, but the prescribing physician is supposed to determine if the benefits outweigh the potential risk.
There is proof that these medications will increase bone density but there is debate about the health of a bone that has lost the natural activity of gaining and losing minerals. Bone is a dynamic structure and requires the removal and replacement of new bone to stay strong. While the description of preventing bone loss sounds promising and beneficial, phosphonates are strong complexing agents used in bleach-containing detergents and are actually metabolic poisons that kill cells in your body. For this reason, many health minded individuals will look for natural alternatives to exhaust prior to considering the traditional medical route.
That is a lot of information. To summarize, there are many controllable factors to supporting your bone density naturally. Preventing bone loss is a reasonable expectation. Building bone density is possible if all of the individual factors are optimized properly. A combination of stress management, diet modification, hormonal support, weight bearing resistive exercises and patient specific vitamin therapies can be used to enhance bone health, prevent bone loss and offset damage from specific medications.
Clinical supervision is suggested to determine an individual treatment protocol because everyone has unique needs. A basic nutritional support for 150lb post-menopausal females who are taking no prescription medications, who have some of the osteoporosis risk factors discussed and who want to support bone health is outlined below;
Super-Cal-Plus with K2 and Magnesium (2 tablets 2x day)
Betazyme (1 capsule 2x day taken with the calcium)
Vitamin D3 (dose determined by blood levels and body weight)
Omega-Mend (1 capsule 2x day)
Progesterone (Dose determined by individual risk factors)