Healthy bones are one of the most important factors in maintaining a higher quality of life as we age. Fractures resulting from osteoporosis are more likely among older adults, and often so debilitating that many people never fully recover from them. In fact, a relatively high percentage of the elderly die within a year of a hip fracture.
Most healthcare practitioners agree that frail health, more than any other factor, contributes to the risk of fracture due to osteoporosis. They also know that creating and maintaining good overall health is fundamental to creating strong bones and preventing fractures later in life.
Maintaining good bone health requires more than simply drinking your milk and taking a multivitamin. Your overall health—including bone health— is influenced by a multitude of things including nutrition and hormones, but also your exercise habits, your emotional state, environmental factors, and your genetic makeup.
Some of these influences, such as genetics, you have no control over; but you can have a positive impact on your bone health by making the right choices in other aspects of your life, starting right now.
Bones are living parts of the body that are constantly undergoing a remodeling process of breaking down (called bone resorption) and being rebuilt. Each year approximately 20 to 40 percent of the skeleton is renewed.
Younger people’s bodies make new bone faster than it is broken down, with peak bone mass occurring sometime during their 20s. During their late 30s, bone tissue begins to break down faster than it is rebuilt, which starts a decline in bone density that accelerates with age. For women, the acceleration of bone loss is even more pronounced after menopause.
Ideally, you want to begin healthy bone production when you are young. Then, you need to work to maintain bone health as long as possible. If you begin with strong healthy bones, there’s a better chance of avoiding fractures later in life.
When you lose bone mass at an excessive rate after you reach your peak bone mass, your bones can get porous and increasingly brittle as you age, which can lead to a higher risk of fracture.
However, bone health is a continuum, ranging from healthy bones through osteoporosis. A diagnosis of osteoporosis is confirmed only after a fracture has occurred and only if that fracture is a result of low impact trauma, such as a fall.
Not everyone who has low bone mass gets a fracture, and not everyone who suffers a fracture has low bone mass. Osteoporosis is far more complex than that, as will be discussed below.
Measuring Bone Health
Defining “normal” bones is difficult because there are so many different ways of looking at bone health, and trying to measure it across genders, ages and ethnic groups produces somewhat surprising results. For example, Asian women tend to have lower bone mass than Caucasian women, but do not have as many hip fractures. Hispanic women have about half as many fractures as Caucasian women, but their bone density measurements appear to be about the same.
Despite these anomalies, bone mineral density (BMD) remains the default definition of “bone health” primarily because it is currently the easiest aspect of bone health to measure. Most research, treatment, and prevention approaches are focused on BMD even though it has not been a reliable predictor of fracture.
The most common method of measuring BMD is dual-energy x-ray absorptiometry (DEXA or DXA), which involves taking x-rays, usually of the hip and spine, the two most common fracture sites. DEXA results are presented as T-scores that indicate the standard deviation above or below “normal,” which is defined as the bone density of a healthy 25-year-old woman. A person with a T-score of –1 to –2.5 is labeled as probably having osteopenia (low bone mass), and a score of less than –2.5 means that person is labeled as probably having osteoporosis (although the confirmed diagnosis occurs only after a fracture has occurred). For more information regarding other BMD testing technologies, see the Women’s International Pharmacy Osteoporosis newsletter.
In The Myth of Osteoporosis: What Every Woman Should Know About Creating Bone Health, Gillian Sanson argues that the “accuracy and precision of bone density testing and its validity as a means to diagnose osteoporosis is increasingly controversial. … Osteoporosis is a complex condition that is still not fully understood. Diagnosis is, therefore, not as simple as it may appear.”
Osteoporosis is defined by the World Health Organization as “a progressive systemic skeletal disease, characterized by low bone mass and micro-architectural deterioration of bone tissue [emphasis added], with a consequent increase in bone fragility and susceptibility to fracture.” Note that this definition identifies two main risk factors: loss of bone mass or quantity and loss of bone strength or quality.
DEXA measures only bone quantity (bone density or mass), not bone strength. Bone strength is determined by its micro-architecture, which includes its shape and how the cells provide cross-bracing, as well as its ability to repair damage. But, because of difficulties in measuring those characteristics of micro-architecture, bone strength has been ignored as an important aspect of bone health.
Bone density alone has become the focus of research and the current default definition of osteoporosis, primarily because the technology to adequately measure bone strength does not yet exist.
Dr. Alan R. Gaby agrees that DEXA has its limits. In his book Preventing and Reversing Osteoporosis, Dr. Gaby explains that while testing is useful for monitoring bone health in high-risk patients, it should not be used for diagnosis. He explains that, based on the above T-scores, at least half of the population of post-menopausal women would have the “disease” osteopenia.
The fact remains that low DEXA T-scores do not necessarily equate to a high risk for osteoporosis. According to Dr. Gaby, lifestyle changes and/or supplements can often be used to minimize the risk of osteoporotic fracture, without the use of prescription drugs.
Factors Affecting Bone Health
Many lifestyle factors contribute to a decrease in bone mass, including:
- The harmful effects of smoking cigarettes, consuming alcohol, and consuming excess protein
- Lack of exercise (especially weight-bearing exercise)
- Hormone imbalance and nutritional deficiencies
However, the factor that contributes the most to a high risk of bone fracture is frail health as a result of the aging process.
Effects of Aging
Loss of bone density does occur with age, but not everyone suffers a fracture as a result. Other aging factors tend to be more critical risk factors. For example, the effects of aging tend to heighten the risk of falling, which is considered by many to be the most critical osteoporotic fracture risk factor. Many of the conditions that increase the likelihood of an elderly person falling and possibly breaking a hip can be symptoms of old age, such as:
- Poor eyesight
- Decreased muscle strength
- Lack of coordination
- Shakiness or tremors
- Weak balance
- Mental confusion
Many of these symptoms may also be the side effects of medications, or complicated by medications, which means they are more likely to occur in conjunction with another condition or illness. Osteoporosis is rarely the only condition for which an elderly person is being treated.
Another age-related factor that affects bone health is a decline in sex hormone levels, which may partially explain why postmenopausal women face a higher risk of osteoporotic fracture than men of the same age.
Hormones that play a crucial role in maintaining bone health include:
- The estrogen hormones (estrone, estriol and estradiol), which inhibit bone resorption
- Progesterone, which stimulates bone formation
- Testosterone, which stimulates bone formation and calcium absorption
- DHEA, which is a precursor hormone that increases the levels of estrogen, progesterone and testosterone, while also inhibiting bone resorption and stimulating bone formation
- Human growth hormone (HGH), which also stimulates bone formation and inhibits resorption
- Calcitonin, which inhibits bone resorption
- Parathyroid hormone, which promotes bone formation by controlling calcium and phosphorous
However, any condition or behavior that affects hormone balance can have an impact on bone health. For example, chronic stress, which leads to overactive adrenal glands, and overactive thyroid or parathyroid glands are also associated with osteoporosis. Therefore, maintaining optimal hormone balance is also crucial to maintaining strong, healthy bones—at any age.
Dr. Gaby and others promote natural hormone supplements for maintaining hormone balance, which is key to preventing bone loss, especially during menopause. If you and your healthcare practitioner decide to treat a hormone imbalance, be aware that not all hormone therapies are created equal. There are fundamental differences between bioidentical hormones (i.e., those that are identical to the hormones found in the human body) and those that are not.
Commonly prescribed hormone replacement therapy (HRT), such as Premarin (conjugated equine estrogens) and PremPro (conjugated equine estrogens/medroxyprogesterone), are not bioidentical hormones and are associated with some health risks (as discussed extensively in the findings of the WHI study).
Bioidentical hormone supplements that are prescribed in the dose necessary to restore hormones to optimal levels are effective in achieving and maintaining hormone balance, with few side-effects, and they are not associated with the same health risks as synthetic HRT.
Maintaining healthy bones also involves a well-balanced diet including essential bone-building nutrients, such as calcium, magnesium, vitamin D, and others.
Calcium & Magnesium
Typically, osteoporosis does not stem from inadequate calcium intake, but from inadequate calcium absorption. In order for the body to absorb calcium, it also needs comparable amounts of magnesium, another mineral. Without a sufficient supply of magnesium, the body only absorbs a fraction of the calcium available, with the excess calcium being stored or used by the body in potentially harmful ways.
The body stores some of this excess calcium along arterial walls, eventually forming atherosclerotic plaque. An overabundance of calcium can also contribute to kidney stones, which can grow and eventually block the urinary tract. Too much calcium can also cause arthritis pain or lead to gout, another painful condition.
Milk and dairy products are good sources of calcium; however, they are not the best sources available. While dairy foods do contain high amounts of calcium, they lack the additional nutrients required for calcium absorption, specifically magnesium. Dairy products also contain high amounts of protein, which prevents a significant portion of the available calcium from being absorbed.
Green leafy vegetables, asparagus, broccoli, cabbage, oats, legumes, almonds, sesame seeds, tofu, and seafood, especially salmon and sardines (eaten with the bones), are excellent sources of calcium. The calcium from these non-dairy sources is more readily absorbed than the calcium from milk, partially because plant proteins do not inhibit absorption as animal proteins do. In addition, legumes and leafy green vegetables such as kale and collard greens offer the added bonus of being high in magnesium, which promotes calcium absorption.
Medications can also interfere with calcium absorption and vice versa. For example, drugs such as corticosteroids and anticonvulsants inhibit calcium absorption, thereby potentially contributing to an increased risk of fracture with long-term use.
Conversely, calcium supplements impair the absorption of some blood pressure medications and antibiotics, as well as thyroid hormones, creating more challenges for the treatment of some conditions.
Similar drug interactions with magnesium, iron, and zinc have also been identified. For these reasons, it is very important to discuss any and all supplements and medications with your healthcare practitioner to ensure optimal treatment of any condition.
Vitamin D, which we get primarily from exposure to the sun’s rays, is also essential to calcium absorption. “You can eat as much calcium-rich food as you want to, but if you don’t have enough vitamin D in your body, you won’t be able to absorb that calcium into your bones” explains Dr. Michael F. Holick in his book, The UV Advantage.
Most elderly people, especially if they are frail or bedridden, have insufficient levels of vitamin D, which contributes to their risk of fracture. Without enough vitamin D, their bone remodeling process is compromised and bone breakdown quickly surpasses the rate of rebuilding, resulting in porous, brittle, and weak bones.
Even though milk and other foods have “vitamin D added,” Dr. Holick believes that sunshine is a better source of vitamin D and, therefore, a better osteoporosis preventative. Dr. Holick reports on a study “of senior citizens living in Maine, which showed that they lose 3 to 4 percent of their bone mass in the fall and winter and regained it in the spring and summer months.” He says that “just a few minutes of unprotected sun exposure on your face, hands, and arms (or arms and legs) on sunny days is enough for most people.”
In Nutrition and Healing, Dr. Jonathan V. Wright discusses the benefits of strontium as they relate to bone health. (Strontium, which is in the same mineral family as calcium and magnesium, is not the same as strontium 90, which is the radioactive form.)
Dr. Wright reports on studies as far back as the early 20th century that demonstrate strontium’s positive effects on bone health. A 1910 study showed that “strontium appeared to be uniquely effective in stimulating rapid formation of bone.” In the 1920s, and again in the 1950s, studies concluded that “calcium and strontium work better together than calcium alone for building bone.” Then in 1985, “in addition to its anti-resorptive activity, strontium was found to have anabolic (tissue-building) activity in bone.”
In summary, research has demonstrated that strontium promotes bone growth and tissue building, and enhances the value of calcium in the bone-building process. Strontium is difficult to get as a nutrient from food because it is typically available only in very small quantities. Foods with the highest levels of strontium include root and leafy vegetables, legumes, whole grains, seafood, and spices.
While most people are aware that nutritional deficiencies contribute to an increased risk of fracture, they may not realize that a sedentary lifestyle is also a key contributing factor. Dr. Gaby believes that physical activity plays a crucial role in maintaining bone mass throughout life. He explains how exercise at any age actually improves the bone remodeling process: “bones develop in a way that resists the forces acting upon them. This means that repeated application of a physical stress will actually cause that bone to remodel and become stronger. … Conversely, immobilization and weightlessness result in accelerated bone loss.”
Although it is important not to overdo it, an exercise program offers benefits at any age. In fact, evidence suggests that “women with the lowest BMD tend to show the greatest response to exercise,” according to Sanson. In addition to promoting bone building, exercise also improves muscle tone and balance, which also helps to prevent falling and reduce the threat of fractures.
Treatment vs. Prevention of Osteoporosis
Treatments for osteoporosis do exist and seem to be heavily promoted. However, it is far easier and healthier overall to prevent osteoporosis than it is to treat it once it has set in.
Sanson believes that “the excessive attention to loss of bone density has shifted focus from modifiable risk factors to drug therapies.” She concurs that “eliminating other risk factors and secondary causes of bone loss can do more to prevent fracture than attempting to increase bone density via medications.”
Dr. Gaby concurs that bone health cannot be fully maintained with supplements and prescription drugs. His advice is that “Each and every one of us needs to do everything in our power to maintain bone health, but that doesn’t mean you should take a drug. instead, you need to get started on a bone maintenance and building program, and the earlier you start the better.”