Breaking Down Osteoporosis: The Silent Disease Affecting 200 Million People
Although osteoporosis is oftentimes thought of as an older person’s disease, as a Functional Nutrition Dietitian, it won’t surprise you that in my practice I think about bone health and use nutrient-dense foods to prevent bone loss when healthy bones are still forming.
If you are like most Americans, then you have been led to believe that drinking 3 cups of milk per day and taking calcium supplements is the key to keeping bones strong and decreasing risk of osteoporosis. But as you will see, the truth is not so straightforward.
Osteoporosis: A Silent Disease
After bones mature, their density declines about 0.5 to one percent every year. For a few demographics, such as postmenopausal women, that may increase to two to three percent annually. Unlike other conditions, bone loss often occurs without any symptoms.
Eventually, weak and brittle bones can lead to osteoporosis, the most common human bone disease. Osteoporosis can result when bone loss occurs too quickly or bone formation occurs too slowly. Bone resembles a sponge wrapped in a protective shell. With osteoporosis, holes within that “sponge” become more prevalent and bigger, weakening the bone.
With an aging population and longer lifespan, osteoporosis has become a global epidemic:
-Around 200 million people have this disease.
-Women are four times more likely to develop osteoporosis than men.
-Women lose bone most quickly during the few years after menopause and sometimes won’t realize they even have osteoporosis until they develop pain, like back pain, or a fracture.
What Causes Osteoporosis?
Osteoporosis isn’t an inevitable outcome of getting older. Some risk factors for developing this disease are out of your control. Genetics, having a thin or small frame, or being postmenopausal (especially if you have early menopause) all increase your risk.
Many other risk factors, however, are within your control. They include:
- Excessive alcohol
- Lack of physical movement
- Certain medications
- A low nutrient intake
Bone health is complex, involving a variety of inflammatory and anti-inflammatory cytokines and hormones that help regulate the activity of osteoblasts, the process that helps form bones, and osteoclasts, the process that breaks down bones. Achieving balance or homeostasis is key. Anything that hinders that balance can increase your risk of disease, including hormonal imbalances.
Maintaining healthy bones also depends on several seemingly non-related systems, including the immune system and the gut microbiome. For example, osteoporosis is a well established complication of celiac disease because there is malabsorption happening in the small intestine. The small intestine absorbs nutrients into the bloodstream. A damaged lining that could occur from celiac disease means that absorbing nutrients like vitamin D and calcium is difficult. Even if you get enough nutrients in your diet or through supplements, people with celiac disease often have deficiencies.
Women who are diagnosed with osteoporosis or experiencing several unexplained fractures in their 30s and 40s may want to talk to their doctor about pursuing lab testing for celiac disease or other underlying contributors. This is especially true if you have a family history of celiac disease and have not yet been screened. Addressing these concerns can reduce bone loss and protect against further damage.
Chronic inflammation also seems to be a significant driver of osteoporosis. “Inflamm-ageing” describes age-related disorders, including lower bone mass that can increase risk of osteoporosis. Chronic inflammatory disorders like inflammatory bowel diseases (IBD) can increase the risk of osteoporosis. Studies have shown that TNF-alpha, involved in the development of IBD, creates bone erosion. So do certain life transitions, including menopause, which can increase that low-grade inflammation.
Put another way: Rarely does one culprit contribute to osteoporosis. The good news is that you have the ability to manage these underlying factors. When you focus on your immune system and gut, you’re also supporting bone health. Choosing optimal foods that lower inflammation may be a proactive approach to reduce your risk of osteoporosis.
Another way to reduce your risk of osteoporosis involves actually knowing your risk factors and paying attention to signals that could suggest osteoporosis. They include:
- Losing an inch or more of height
- Posture changes, such as stooping or bending forward
- Shortness of breath
- Pain in the lower back
A bone mineral density test, which measures bone density at various points in the body, can help predict your risk of osteoporosis. Talk with your healthcare practitioner about your specific condition and potential ways to keep bones healthy.
Regardless of risk factors, what goes on the end of your fork can go a long way toward reducing osteoporosis. And no, that does not necessarily mean dairy. (You can find some delicious dairy-free ideas here.) A diet low in fruits and vegetables, for instance, may increase risk of fractures, especially among postmenopausal adults. A food-as-medicine approach to osteoporosis means:
- Eating foods that provide bone-supporting micronutrients
- Addressing chronic inflammation and oxidative stress
- Getting adequate protein
- Balancing hormones
Stronger bones and a reduced risk of disease are within your reach, starting with your very next meal!
Vitamins and Minerals for Bone Health
To better understand osteoporosis, many studies isolate specific nutrients. Researching how calcium or vitamin D can benefit this disease, for instance, can better predict how nutrients impact osteoporosis. Many of these nutrients – in this case, vitamin D and calcium – work together.
Here are the key nutrients for bone health:
Calcium gains the spotlight, and for good reason: About one to two percent of a human’s body weight is calcium, and over 99 percent of this mineral is found in your teeth and bones. Low calcium intake can lead to low bone mass, rapid bone loss, and high rates of fractures.
Most of us get less than half of the recommended amount of calcium. Our needs change across our lifespan, too: there is a higher need for calcium between the ages of 9-18 years old (1,300 mg/day), postmenopausal women (ages 50+ need 1,200 mg/day) and older men (ages 71+ need 1,200 mg). Your body becomes less efficient at absorbing nutrients including calcium as you age. Chronic medical problems and medications can also impair calcium absorption.
Too much calcium can be as problematic as too little, potentially interfering with the body’s absorption of other nutrients. Excessive calcium from dietary supplements may also increase the risk of kidney stones and cardiovascular disease. Using calcium supplements without getting other bone-supporting nutrients may create more harm than good. Many contain poorly absorbable forms of calcium, but they also often lack other nutrients – in their correct amounts and forms – that your bones require.
You can get calcium and other bone supporting nutrients through dairy-based sources. If you do not have a dairy sensitivity or allergy then you may consider incorporating some organic dairy into your diet. A 2018 study found that dairy consumption in older men and women is associated with lower risk of hip fractures. I would recommend fermented milk products like yogurt or kefir, which may provide large amounts of these nutrients.
In the same breath, you can absolutely get adequate levels of calcium from plant-based food sources. Non-dairy sources of calcium include canned sardines (325mg per 3 oz), cooked collard greens (268mg per 1 cup), cooked spinach (245 mg per 1 cup), canned salmon with bone (181mg per 3 oz), navy beans (128mg per 1 cup), almond butter (100mg per 2 tbsp), tahini (100mg per 2 tbsp), and kale (94mg per 1 cup). You may also benefit from dairy-free milks that are fortified with calcium, such as Califia Farms Unsweetened Almond Milk that provides 430 mg per 1 cup.
Calcium is a key player, but hardly the only important nutrient for bone health.
Vitamin D goes hand-in-hand with calcium, helping the small intestine absorb minerals like calcium. If your diet is deficient in vitamin D then the body cannot efficiently use calcium from the diet and will draw it out of the skeleton, which can lead to weakening of the bones. You can get vitamin D from three sources: sunlight, food, and supplements. Because most people don’t get enough vitamin D from the sun and it’s difficult to get from food alone, many people benefit from additional vitamin D3 supplementation.
Very few foods provide rich sources of this fat-soluble vitamin. Those that do provide vitamin D include egg yolks, fatty fish like wild salmon, and some mushrooms.
Phosphorus works with calcium and vitamin D to support bone health. About 85 percent of this mineral is in your bones and teeth and the other 15% is in your blood and soft tissues. Foods that are rich in phosphorus include wild salmon, scallops, sardines, and chicken. You can also get phosphorus from plant-based sources like lentils, sunflower seeds and pumpkin seeds, but they are stored in the form of phytic acid which makes it harder for humans to absorb. The best way to increase absorption is by soaking or sprouting any plant-based sources. You can also get phosphorus from dairy foods like organic yogurt and cottage cheese, if you do not have reactions from dairy.
Magnesium is another bone-supporting mineral that about 75 percent of Americans are deficient in. These deficiencies impact osteoporosis directly and indirectly, creating a low-grade inflammation in the process. Most people require additional magnesium supplementation. I recommend taking Magnesium Glycinate in the evening, up to 300mg per night, as this is one of the most bioavailable forms. If you struggle with constipation then try adding Magnesium Citrate. Foods rich in magnesium include spinach, black beans, almonds, cashews, pumpkin seeds, avocado and dark chocolate.
Vitamin K also supports bone health. This fat-soluble vitamin helps activate proteins that direct calcium into bones (where it needs to be) while blocking calcium from entering soft tissue (where it shouldn’t go). Vitamin K comes in two forms. Plants and green vegetables contain phylloquinone or vitamin K1, whereas intestinal bacteria synthesize menaquinone or vitamin K2.
The major form of vitamin K in bone is menaquinone-4 (MK-4), which belongs to the vitamin K2 family. Therapeutic amounts of menaquinones, specifically MK-4, have been used to manage osteoporosis in Japan since 1995. A synthetic vitamin K2 chemically identical to MK-4 may help prevent fractures in postmenopausal women with osteoporosis.
Green leafy vegetables are also good sources of vitamin K, which may help lower the risk of fractures. Other foods that provide vitamin K2 include natto or fermented soy beans and (in smaller amounts) whole eggs and some meats. I recommend all soy be organic.
Other Micronutrients & Antioxidants
Other bone-supporting vitamins, minerals and anxiotixants include:
Vitamin C, which helps synthesize collagen.
Zinc, which supports bone formation and mineralization.
Potassium, which supports bone mineral density by neutralizing the body’s acid load and reducing calcium loss from bone.
Antioxidants, which can be found in foods like berries. Research suggests people who eat more berries may have higher bone mass.
Some of these, such as vitamin C, also work as antioxidants. Additionally, polyphenols including anthocyanins in berries, provide antioxidant protection for healthy bones.
With all of these nutrients, balance is key. High amounts of phosphorus with a low intake of calcium, for instance, can reduce bone mass. Too much calcium can prevent magnesium absorption. While they can occur from your diet, I often see these imbalances occur when clients take too much of one nutrient such as calcium while neglecting others like magnesium.
Protein & Collagen
Protein makes up about 50 percent of your bone volume and about one-third of its mass. One review found that a protein-rich diet – amounts above the current Recommended Dietary Allowances or RDAs– could help reduce bone loss and hip fracture risk. In older people with osteoporosis, adequate protein intake is associated with higher bone mineral density, a slower rate of bone loss, and reduced risk of hip fractures. This is why the 2019 European guidelines state that daily calcium intake paired with sufficient dietary protein is a key dietary intervention for osteoporosis in postmenopausal women.
I recommend focusing specifically on getting amino acids that aid in collagen formation such as glycine, proline, and lysine that you can find in bone broth, grass-fed beef protein powder, and collagen or gelatin protein powder. Adequate vitamin C from the diet can also help support collagen formation.
Further Considerations to Prevent Osteoporosis
You can only get so far with nutrition if you are not supporting other avenues for finding health. To prevent osteoporosis or reduce the impact that this disease can have, you will also want to address:
Deep, Consistent Sleep
Research with postmenopaual women shows that insufficient sleep may contribute to low bone mineral density, increasing the risk of osteoporosis. Sleep is critical for bone health but provides a ton of other benefits, which I talk about in this article.
Weight-bearing and resistance exercise are great for bone health. The recommendation specifically includes regular weight-bearing exercise that is tailored to your own individual needs and abilities. If you have osteoporosis, you’ll want to avoid certain types of exercise, such as high-impact exercise.