Bone Basics:
Strong bones are critical for our health. They support weight no matter what activity we are doing: walking, running, playing golf and tennis. Peak bone mass is formed from our teenage years and for some, through their 20’s. Our bones are a living part of our body, like any other tissue, and are constantly being broken done and re-formed in a process called bone remodeling. Cells called osteoblasts build bone, and cells call osteoclasts resorb bone.
After 35-45 years of age, bone begins to break down – essentially there is more bone being reabsorbed than there is being bone built.
Why is this Important?
About half of all American adults over the age of 50 (54 million Americans) are at risk for breaking a bone. In fact, 1 in 2 women (50%) and 1 in 4 men (25%) will break a bone due to osteoporosis in their lifetime. Sadly, 24% of hip fracture patients over the age of 50 die within the year following their fracture. There are 300,000 hip fracture patients annually and 25% of them will need nursing home support, and 50% never regain the same function they had previous to their hip fracture.
The National Osteoporosis Foundation recommends taking control of your Bone Health through diet, exercise and lifestyle. So let’s get to work!
There are a few factors at play that we cannot control:
Gender: Fractures from osteoporosis are twice as likely in women than men. This is partially due to men weighing more and having greater peak bone mass. Additionally, women lose 7-10% of bone mass 3-5 years after the onset menopause due to the decline in estrogen. While testosterone plays more of a role in bone health in men, their loss of testosterone happens later in life, which is another reason why they have less fractures.
Race: Caucasians and Southwest Asians have less dense bones than Africans Americans, so their risk for osteoporosis is higher.
Body Weight/Size: People who weigh less have a lower bone mass, therefore a greater chance of osteoporosis.
Early Menopause/Hysterectomy: Due to an early decline in estrogen, this can cause early in life bone loss.
dditionally, there are factors at play which we do have control over:
Smoking: Tobacco has been shown to weaken bones.
Alcohol: Excessive alcohol consumption over the long term inhibits calcium absorption, therefore reduces bone formation. Two or less alcoholic drinks per day is recommended by the National Osteoporosis Foundation.
Exercise: Weight-bearing exercise over your life span can strengthen bones (ex: walking, jogging, lifting weights, jumping, running, racquet sports – NOT cycling or swimming). The great news, increasing weight-bearing exercise. no matter the age, can increase bone density! 30-45 minutes, 5 days a weeks is recommended.
Diet: Food is medicine and it plays a huge role in the development, or break down, of bones. Strong bones require ample dietary protein and vitamin C to support the main framework of bone, along with plenty of calcium and other minerals. Dietary Vitamin D is also crucial to bone health as well.
*Discussed in detail below.
Pharmaceuticals: Proton-Pump Inhibitors (PPI’s) are used to treat acid reflux related diseases such as GERD. PPI’s have been associated with increased hip fracture risk, especially at high doses. (Note: do not start of stop taking any prescription medications without doctor approval)
Stress: Reducing stress levels reduces systemic wide inflammation and there is evidence that osteoporosis can be a result of low grade inflammation. Meditation, walks in nature, and breath work are all ways to reduce stress.
Nutrition:
Calcium: 99% of the calcium found in the body is in the bones. However, it’s not what you eat, but what you absorb that matters. So eating enough dietary calcium and/or supplementing will not equate to strong bones if you aren’t also consuming enough Vitamin D, Vitamin K and protein. Based upon the chart below, determine how much calcium you need and estimate what you get from your diet. If on average, you are below what is needed then consider a supplement. It is important to note that the body can only absorb 500mg of calcium at a time.
- Calcium Carbonate: Has to be taken with food and can have GI side effects such as constipation and bloating.
- Calcium Citrate: Can be taken with or without food. Not likely to have GI side effects like calcium carbonate, but is more expensive and requires more tablets to be taken.
*Calcium citrate has better bioavailability by about 25%
*Do not take these with iron supplements, thyroid medications, PPI’s, zinc or some antibiotics
Vitamin D: One of it’s main functions is to sustain balanced levels of calcium and phosphorus in the body, which favor bone growth. When the body is deficient in vitamin D, it can only absorb about 10-15% of dietary calcium and therefore there is not enough calcium available for strong bones.
Vitamin K: Vitamin K works in collaboration with Vitamin D to trigger bone growth. Vitamin K2 is required as a key part of healthy, strong bones.
Protein: Protein helps maintain healthy bones and increases the absorption of calcium in your gut. Several studies show that increasing the ratio of vegetable to animal based protein sources is protective against fractures. For older individuals .45-.55g/lb is a good reference range.
MEN:
< 50 years of age:
- 1,000 mg calcium
- 400-800 IUs vitamin D
50-70 years of age:
- 1,000 mg calcium
- 800-1,000 IUs Vitamin D
> 71 years of age:
- 1,200 mg calcium
- 800-1,000 IUs Vitamin D
- 120 mcg Vitamin K
WOMEN:
< 50 years of age:
- 1,000 mg calcium
- 400-800 IUs Vitamin
> 50 years of age:
- 1,200 mg calcium
- 800-1,000 IUs Vitamin D
- 90 mcg Vitamin K
*Vitamin D supplementation should take into account the patient’s serum vitamin D levels from labs. Some may need a higher dose to start to get them to 40ng/mL range necessary for fracture prevention.
*Studies have shown that amount much higher than these intakes for Vitamin K (250 mcg/day or more) may be needed for optimum bone health.
Sources:
CALCIUM: Milk, Yogurt, Dried Figs, Salmon, Sardines (with bones), Hard Cheeses (Cheddar, Swiss, Monterey Jack, Provolone, Romano, Part-skim Mozzarella), White Beans, Spinach, Turnip Greens, Soybeans, Broccoli, Bok Choy, Almonds. *Fortified foods: OJ, Milks, cereal
VITAMIN D: Sunlight, Cod Liver Oil, Trout, Salmon, Sardines, Eggs. Tuna Fish. *Fortified foods: OJ, Milks
VITAMIN K1: Collards, Turnip Greens, Spinach, Kale, Broccoli, Soybeans, Carrot juice, Pumpkin, Pomegranate juice.
VITAMIN K2: Butter, Animal Based Foods, Egg Yolks, Fermented Foods, Fermented Soy – Natto.
Harmful to Bone Health:
Foods that stop bone break down: garlic, rosemary, parsley, sage, thyme, dill, onion, arugula, prune, fennel, orange, leek, yellow boletus, red cabbage, red wine, lettuce.
Coffee & Soda: A diet high in coffee and/or soda can leach minerals from the bone.
Acid-Base Balance: In general, eating a diet high in animal protein and low in fruits and vegetables puts the body in a state of being too acidic and this impairs bone building activity.
In a Nutshell:
In a nutshell, a well rounded anti-inflammatory diet with ample fruits and vegetables and with enough protein, calcium, vitamin D, and vitamin K is supportive for strong bones. Additionally, weight-bearing exercise for at least 30 minutes, 5 days a week also encourages healthy bones (bonus points if it’s outside so you can get more vitamin D). Quit smoking and drink alcohol in moderation. And reduce stress in a way that works for you!
References:
- Smolin LA, Grosvenor MB. Nutrition: Science and Applications. Fort Worth, TX: Saunders College Publ.; 1997.
- Healthy Bones for Life. Patient’s Guide. National Osteoporosis Foundation. 2014. http://www.bonehealthandosteoporosis.org/wp-content/uploads/NOF-Health-Bones-For-Life-Patients-Guide.pdf. Accessed March 7, 2022.
- National Osteoporosis Foundation Fast Facts: https://www.bonehealthandosteoporosis.org/wp-content/uploads/2015/12/Osteoporosis-Fast-Facts.pdf
- Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA. 2006;296(24):2947-2953. doi:10.1001/jama.296.24.2947
- Lips P, Bouillon R, van Schoor NM, et al. Reducing fracture risk with calcium and vitamin D. Clin Endocrinol (Oxf). 2010;73(3):277-285. doi:10.1111/j.1365-2265.2009.03701.x
- Sakhaee K, Bhuket T, Adams-Huet B, Rao DS. Meta-analysis of calcium bioavailability: a comparison of calcium citrate with calcium carbonate. Am J Ther. 1999;6(6):313-321. doi:10.1097/00045391-199911000-00005
- Muhlbauer R.C, Li F. Effect of vegetables on bone metabolism. Nature. 1999;401(6751):343–344.
- Rakel, D. (2017). Integrative Medicine (4th ed.). Elsevier – OHCE. https://bookshelf.health.elsevier.com/books/9780323496186
- Schwalfenberg GK. Vitamins K1 and K2: The Emerging Group of Vitamins Required for Human Health. J Nutr Metab. 2017;2017:6254836. doi:10.1155/2017/6254836
- Gaffney-Stomberg E, Insogna KL, Rodriguez NR, Kerstetter JE. Increasing dietary protein requirements in elderly people for optimal muscle and bone health. J Am Geriatr Soc. 2009 Jun;57(6):1073-9. doi: 10.1111/j.1532-5415.2009.02285.x. Epub 2009 Apr 30. PMID: 19460090.