A Holistic Approach to the Prevention and Treatment of Osteoporosis and Osteopenia
What are Osteopenia and Osteoporosis?
The strength of bone is determined by both bone density and bone quality. Osteoporosis is a disease that develops when bone mineral density, bone quality and bone mass decrease. This happens when the components of bone are lost more rapidly and not replenished quickly enough. Osteopenia describes a decrease in Bone Mineral Density (BMD) below normal reference values, yet not low enough to meet the diagnostic criteria for osteoporosis.
How is Osteoporosis Diagnosed?
BMD is measured using X-rays, dual-energy X-ray absorptiometry (DEXA or DXA), or a special CT scan. The DEXA scan is considered the "gold standard” or most accurate test. Your BMD result is compared with the BMD results from healthy 25- to 35-year-old adults of your same sex and ethnicity. The standard deviation is the difference between your BMD and that of healthy young adults. This result is your T-score. Positive T-scores indicate the bone is stronger than normal; negative T-scores indicate the bone is weaker than normal.
According to the World Health Organization, osteoporosis is based on the following bone density levels:
A T-score within 1 standard deviation (+/-) of the young adult mean indicates normal bone density
A T-score of 1 to 2.5 standard deviation below the young adult mean (-1 to -2.5) indicates low bone mass
A T-score of 2.5 standard deviation or more below the young adult mean (more than -2.5) indicates the presence of osteoporosis.
A less commonly prescribed test yet a necessary one according to specialist Dr. R Keith McCormick, who has been studying and treating osteoporosis for forty years, is the Trabecular Bone Score or TBS. This is an add-on to the DEXA test and evaluates pixel gray-level variations in the bone in order to analyze bone microarchitecture and to determine if the trabeculae are disconnected indicating degraded bone quality. The trabeculae are a part of the bone tissue and structure. If you have an appointment for a DEXA test, you can request a TBS add-on.
Bone turnover and bone formation labs can also be an important tool in determining the cause of osteoporosis. If you have high bone turnover it may mean that your osteoclasts are overactive. Osteoclasts are the cells that degrade bone in order to initiate normal bone remodeling. Osteoblasts are the cells that are responsible for new bone formation.
50 million people in the United States have osteopenia. In Post Menopausal women the numbers are even higher: 54% of have osteopenia and 30% have osteoporosis. By age 80 the trend shifts in favor of osteoporosis with 27% of 80 year old women shown to have osteopenia and 70% have osteoporosis. But anyone can develop osteoporosis and as one advances in age it is important to include osteoporosis screening in routine medical care.
Symptoms and Causes of Osteoporosis
Symptoms of osteoporosis include collapsed vertebrae, broken hips, spine, wrists and other bones from even minor falls or bumps. Fractures are among the leading cause of death in seniors as a fracture can increase time in bed leading to pooling of fluid in the lungs which may result in pneumonia.
Risk factors include age, gender, race, menopause, family history, low body weight, insufficient nutrient intake and poor diet, sedentary lifestyle, smoking and overconsumption of alcohol, salt and caffeine.
Risk increases after age 50
Women are four times more likely to develop osteoporosis
After menopause decreasing estrogen increases risk of osteoporosis
Underconsumption of bioavailable food-based calcium, magnesium, potassium, silica, collagen, protein and Vitamins C,D,E and K2
Upstream Dysregulators such as catabolic physiology, and systemic inflammation further drive osteoporosis. Dietary and emotional stress as well as stress from pain and hidden inflammation contribute to the development of osteoporosis. Physiological stress triggers the release of cortisol, a stress hormone, from the adrenal cortex. Cortisol increases the availability of fuel substrates by mobilizing glucose, fatty acids and amino acids. So in excess it’s effect is catabolic, causing the break-down of bone, muscle and gut tissue to increase energy expenditure.
Check out my article here on the detrimental effects of stress on the body. Book a free informational appointment here to learn how Functional Medical testing can assess your stress response as well as detect systemic inflammation and oxidative stress levels.
Studies have shown that osteoporosis is much more common in people with chronic inflammatory conditions such as Crohn’s Disease, Rheumatoid Arthritis and Hashimoto’s. Pro-inflammatory cytokines play an essential role in normal bone remodeling and in the pathogenesis of late-life osteoporosis.
Gut Health is another crucial factor in the development of osteoporosis. Gluten consumption in gluten sensitive individuals causes an immune response which triggers systemic inflammation as well as ramping up osteoclastic activity. Disruption of the gut microbiota also causes decreased absorption of critical nutrients needed to sustain healthy bones. Already with age there is a decrease in the absorptive capabilities of the gut making good nutrition an essential part of the prevention of osteoporosis.
Hyperparathyroidism, a condition where the parathyroid sends out too much parathyroid hormone, can also be a cause of osteoporosis. Parathyroid hormone regulates the level of Calcium and Phosphorus in the bloodstream and tissues. If too much parathyroid hormone is being produced then calcium will be pulled from bone stores increasing the rate of bone turnover. It is crucial to rule out this condition when determining the cause.
You can request the following blood tests from your doctor to screen for the previous conditions:
C Reactive Protein Test (CRP) is essential for determining generalized inflammation in the body.
Homocysteine is an amino acid that, when high, indicates increased bone turnover and stiffer collagen resulting in higher fracture rates.
Gluten Intolerance can be determined with an anti-glaidin IgA test or a test for Celiac Disease.
Parathyroid Hormone Test would diagnosis hyperparathyroidism.
CTX test is a blood test looking at osteoclast, or bone turnover, activity.
P1NP is a blood test for osteoblast, or bone formation, activity.
Does the benefit of calcium supplementation outweigh the associated risks?
A 2007 study in the American Journal of Clinical Nutrition showed that daily supplementation of 1,000 mg of calcium did not reduce the rates of fracture in post-menopausal women and may even increase the rates of hip fracture.
A 2012 study of 24,000 men and women ages 35-64 in peer-reviewed medical journal BMJ saw 140% greater risk of heart attack over an 11 year period while increased consumption of calcium rich foods did not pose any greater risk.
A 2016 federally-funded study at Johns Hopkins University analyzed 10 years of medical tests on more than 2,700 people and concluded that calcium supplementation may raise the risk of plaque build-up in the arteries and cause damage to the heart while consuming a diet high in calcium rich foods may be protective. This study found that ingested calcium supplementation, particularly in older people, doesn’t make it to the skeleton and accumulates in the soft tissues or is completely excreted in the urine which increases the risk of kidney stones and prostate cancer.
A meta-analysis of studies involving 12,000 people published in BMJ found that calcium supplementation increases the risk of heart attack by 31% stroke by 20% and death by all causes by 9%.
Finally a 2020 PubMed study found that calcium supplementation, but not dietary calcium, positively correlates with abdominal aorta calcification in postmenopausal women.
As previously mentioned, calcium supplementation alone seems to have minimal impact in the decrease in risk of fractures. As we age, a key issue is calcium absorption due to defective vitamin D bioavailability and/or activity. Vitamin D is the key regulator of Calcium absorption and with age there is an increase in the enzyme involved in vitamin D catabolism (breakdown). Therefore an increase in supplemental calcium will not overcome insufficient intestinal absorption and the free circulation of calcium may pose a risk to arteries and/or the urinary tract causing or contributing to atherosclerosis and kidney stones, respectively.
Preventative and Holistic Interventions
Diet and lifestyle choices play a critical role in the development of osteoporosis. When it comes to diet, bioavailability is key. Bioavailability is the extent to which a substance reaches its target destination. When considering which foods to introduce into your diet it is important to know which ones are most readily absorbed by your body. For example, while dark leafy greens like spinach have a high amounts of calcium, only about 5% is absorbed by the body due to the presence of a compound called oxalic acid. Oxalic acid binds to calcium in the blood, preventing absorption and sending it to be excreted by way of your urinary tract. Because oxalic acid is water soluble, it can be reduced through blanching or steaming and removing the water before eating the greens.
Diet: It is always best to get the majority of our nutrients through food as they are better absorbed by the body than supplements. It is no longer possible to get everything we need through food but eating a nutrient dense diet of whole, unprocessed foods is arguably the most important factor in preventing or reversing osteoporosis.
Foods high in bioavailable calcium include: Bone in fish, especially sardines, anchovies and salmon, non-leafy cruciferous vegetables like broccoli; leumes, especially lentils and dairy products. I recommend goat kefir or yogurt as goat milk has lower amounts of lactose (milk sugar) and casin (milk protein) so is generally well-tolerated.
Be sure to include foods that promote gut health like bone broth, fermented foods and plenty of fermentable fibers and polyphenols that feed your gut microbiota. Foods highest in polyphenols include blueberries, green and black tea, pomegranate, almonds, olives, flax and cacao.
Exercise: Weight baring exercise is also an essential part of a protocol supporting bone health. I recommend working with a fitness specialist or a physical therapist to develop a good routine of high intensity exercise with progressive resistance, squats and light weights. Excessive weight in the presence of low bone density can be risky and lead to fractures. Experts recommend spine extension exercise but caution against flexion or excessive twisting of the spine as the anterior spine tends to be more delicate and can result in wedge fractures. Walking is an excellent form of exercise but must be brisk to be effective. Consider adding wrist weights or a weighted vest in your walk to meet part of this requirement.
Sleep is arguably the most important factor in overall health. Your brain and body are surprisingly busy while you sleep. The waste management or “glymphatic” system of the central nervous system is active sending fresh fluid to mix with built up waste then flushing it out in a sort of rinse cycle. Other important benefits include: Restorative functions such as tissue repair, muscle growth and protein synthesis, the integration of newly learned information, memory formation, mood regulation and overall well-being just to name a few. Sleep duration of five hours or less is associated with low bone mineral density. One of the restorative functions that the body undergoes during sleep is the process of bone remodeling: old bone tissue is removed and new tissue is formed.
What supplementation do we really need and what other supportive measures can we take?
The following list of nutrients has been shown to be beneficial in the prevention and management of osteoporosis and decreased risk of bone fracture. Always consult with your medical doctor before taking any new supplements in case of adverse drug interactions.
Vitamin C: A powerful anti-inflammatory and antioxidant.
Vitamin D3: Regulator of Calcium absorption and metabolism. The best source of vitamin D is the SUN! Aim for year around levels of 30-70 ng/dl by making sure to get outside daily.
Vitamin E: Tocotrienol, a recently discovered form of Vitamin E is the recommended form over tocopherol. It is a more effective anti-inflammatory and antioxidant.
Vitamin K2: Optimizes calcium use in the body, ensuring it gets into bones and teeth and stays out of soft tissues.
Magnesium: Converts Vitamin D to its active form so that it may assist in Calcium absorption. Magnesium is required for the production and release of parathyroid hormone which, at proper levels, promotes the absorption of calcium from food by the intestines and conservation of calcium by the kidneys.
Silica: The third most abundant trace mineral in the body after iron and zinc, silica is the catalyst for collagen formation and the carrier of calcium into bone
Both Collagen and Silica assist in new bone formation by stimulating osteoblasts and inhibiting osteoclasts, our bone resorbing cells, from breaking down bone.
Folate and B12: Aids in bone mineral density and processes homocysteine, an amino acid that promotes osteoclast levels and reduces osteoblast levels.
Collagen: One of the most abundant proteins found in the body, collagen provides strength and stability to the tissues and plays an important role in the hardness of bones. The best source of collagen is bone broth. Check out my bone broth recipe here
N-Acetyl Cysteine (NAC): A precursor to the most powerful anti-oxidant in the body, glutathione, NAC also helps stabilize blood sugar and helps estrogen in its anabolic, tissue forming, function as well as in its function as an immune modulator.
Berberine and Alpha Lipoic Acid act as powerful anti-oxidants and anti-inflammatories as well as slowing osteoclastic activity. Both are also two of the most essential nutraceuticals in maintaining healthy blood sugar levels.
Please note that not all supplement companies are created equal. After careful research, I am providing my bone health protocol which can be purchased at a discounted price after signing up for a free account here:
Osteoporosis is much more preventable than many of us are led to believe, especially through early detection and proper treatment. Ask your doctor to incorporate osteoporosis screening in your routine medical care and follow the “book an appointment” link below to schedule a Discovery Call with me and learn how Functional Medicine can assist you in your health journey.