Optimizing Bones for Your Future Health
Written By: Nancy Palermo, MD
Edited by: Thrive Carolinas
Osteoporosis affects an estimated 10.2 million American adults aged 50 and older, of which more than 80% are women.
Another 44 million are at risk for osteoporosis due to loss of bone density (osteopenia). Osteoporosis, characterized by low bone mineral density (BMD), poses significant health risks, leading to fractures, reduced mobility, and a diminished quality of life. In a study based on almost 380,000 osteoporotic fractures in females, 10% had another fracture within one year, 18% within two years, and 31% within five years. More concerning is the mortality rate after a hip fracture can be as high as 36% within a year of the break.
The physical and economic burden of osteoporosis is underrated.
In the U.S., osteoporosis is responsible for two million broken bones and $19 billion in related costs every year. By 2025, osteoporosis is predicted to cause approximately three million fractures, accounting for $25.3 billion in annual expenses. As with any other disease, prevention is critical. This article delves into bone health, discusses the detection and management of bone loss, and explores the role of functional medicine in revolutionizing how we approach this widespread condition.
Bone Basics
Bone is not inert. It is living tissue, heavily vascularized, and involved in several bodily functions.
Bone comprises two types: Compact or cortical and Trabecular or spongy bone.
The cortical bone makes up what is termed the shaft of long bones. The bone marrow is located within this bone. Our bones contain 99% of the body’s calcium and 85% of its phosphorus. These minerals are used for different bodily functions, but calcium plays a role in acid-base balance and helps the body maintain a healthy pH. More calcium is released from the bone when the body is acidic. For example, when a patient has inflammation from poor diet and lifestyle habits, there is a greater release of calcium from the bones. Other inflammatory conditions like metabolic disorders can also drive calcium out of the bones to neutralize the body’s overall blood pH.
How does bone growth/loss progress through life?
You’ll see growth in childhood, then plateauing, and then gradual loss starting in your mid-20s. The amount of bone formed is varied but can be affected by what we do or do not do. It is like a retirement account. The more you put in, the more you can withdraw when you retire.
Flattening, plateauing, or timing of loss is also genetic and individual, but that’s the most amenable to exercise intervention.
Then you throw in menopause (average age about 52 to 54 or something), and for women, you’ll see that loss rapidly accelerate for probably 5-8 years. This is because circulating estrogen almost vanishes from your blood. Estrogen is an incredibly important hormone for bones because of its effect on osteoclasts: it largely inhibits osteoclasts. Estrogen keeps a check on the osteoblasts and prevents them from over-resorbing. Osteoclasts have a bit of a party for a few years and resorb bone like crazy. And so that explains why women at menopause have this dramatic loss of bone for years. Then it levels out again in women and sort of matches men
There are four types of cells found within bone and it is important to understand their roles so you can understand how bone loss and bone growth can occur.
- The main one is an osteocyte: that’s your standard bone cell that sits in bone tissue in its little cave. It always senses the environment and can be considered the “project manager,” dictating what needs to happen in the bone. It is responsible for maintaining the tissue around it and for sensing what’s going on in the tissue environment.
- Osteoblasts (osteocyte precursors) are the ones that when they attach to a bone surface, they release osteoid (which is the new bone tissue), which then becomes mineralized. Think of the osteoblasts as the construction crew building new projects. They are bone-forming cells.
- Osteoclasts are these big multinucleated cells that also attach to bone surfaces and resorb bone in packets. You can think of these cells as the demolition crew, though not all demolition is bad. They are derived from the hematopoietic system and are like macrophages. They are influenced by things that affect our immune system.
This is important and is not a bad thing. It allows bones to adapt to what we need. For example, if we are doing weight-bearing exercise, our bones can adapt and grow to adjust to the increased weight. Even gaining weight can have a positive effect on bone density, though this is not how we want to gain bone mass!!
Bone remodeling is one of the most important ways to maintain our skeleton, eliminate microdamage, and adapt to mechanical loading.
Resorption and formation occur throughout life. We release calcium into the blood when we need it for all those other things. This is how bone is so dynamic. The role of releasing calcium when required is significant.
Our bones contain 99% of the body’s calcium and 85% of its phosphorus. These minerals are used for different bodily functions, but calcium plays a role in acid-base balance and helps the body maintain a healthy pH. More calcium is released from the bone when the body is acidic. For example, when a patient has inflammation from poor diet and lifestyle habits, there is a greater release of calcium from the bones. Other inflammatory conditions like metabolic disorders can also drive calcium out of the bones to neutralize the body’s overall blood pH.
What other factors play a role in bone formation or loss?
Hormones
All hormones can play a role in building or breaking down muscles and bones. For example, estrogen and testosterone can be considered bone builders, and cortisol, the stress hormone, is a bone and muscle breakdown hormone. This is why stress needs to be considered when managing bone loss. Additionally, long-term use of steroids, like prednisone, can also reduce bone density for the same reasons. Estrogen plays an essential role in the maintenance of bone in men and women.
Men lose estrogen, too, but not as rapidly as women going through menopause.
Estrogen specifically manages loss by managing osteoclastic (bone breakdown) activity. As estrogen levels start dropping, women can lose as much as 3% of their bone mass annually.
Thyroid hormones also affect bone health. Low thyroid levels and high thyroid levels can both contribute to bone loss. The thyroid produces calcitonin, which regulates the body’s calcium supply. The thyroid hormones T3 and T4 also aid in the control of growth and metabolism. However, too high thyroid hormones can have a greater effect on bone loss.
Nutrition & Diet
Nutrient deficiencies may occur due to poor or restricted diets, eating disorders, and malabsorption syndromes, such as celiac disease and inflammatory bowel diseases. Nowadays, nutrient deficiencies are more commonly related to the Standard American Diet ( SAD diet ). Inadequate intake of bone-specific nutrients can contribute to osteopenia, which is the precursor to osteoporosis. In addition, the SAD diet is processed, leading to inflammatory conditions that increase the loss of calcium from the bones.
- Calcium is a crucial mineral for building and maintaining strong bones. Hydroxyapatite is a mineral form of calcium phosphate that is the primary component of the inorganic matrix of bones and teeth. It provides the structural framework of bones. Good sources of calcium include dairy products, leafy green vegetables (such as broccoli and kale), fortified plant-based milks, and calcium supplements if needed.
- Vitamin D plays a critical role in calcium absorption and utilization. It helps regulate calcium levels in the blood and supports bone mineralization. The primary source of vitamin D is sunlight exposure, but it can also be obtained from fatty fish (e.g., salmon, mackerel), fortified dairy products, egg yolks, and supplements.
- Phosphorus works in conjunction with calcium to form hydroxyapatite. Good sources of phosphorus include dairy products, meat, fish, nuts, and legumes.
- Magnesium helps to activate vitamin D, influences the concentration of parathyroid hormone (PTH), and is a regulator of osteoblast and osteoclast cellular activity.
- Vitamin K is necessary for the synthesis of proteins involved in bone mineralization. It helps direct and bind calcium to the bone matrix. Green leafy vegetables (e.g., spinach, kale), broccoli, and fermented foods are rich in vitamin K.
Adequate protein intake is essential for bone health. Protein makes up a large portion of bone mass and volume, creating the structural framework for mineralization. Collagen is the body’s most prevalent type of protein, comprising 25-35% of total protein mass. Vitamin C, copper, and manganese are essential micronutrient cofactors for the endogenous production of collagen.
As we mentioned, the bones also play a role in managing the body’s pH.
The bones act as a buffering system to keep the blood’s pH perfect at 7.4. Diets full of processed foods, sugar, excess daily meat, and alcohol can produce acid in the bloodstream. To raise the pH, the body releases calcium to do the job. The calcium is released to the kidneys to buffer the acid load. You can test the pH of your urine to see how acidic your urine is and know without testing if you are losing more calcium.
Restricting highly acidic foods can help your body manage its blood pH.
This is a critical role that is rarely discussed in conventional settings. A more alkaline diet would be low in added sugars and processing and 70% plant-based. Eating more fruits, vegetables, and leafy greens would help, as would regularly adding nuts and seeds to the diet. If the remaining 30% is acidic, your body can manage this better, though still avoiding sugar, alcohol, and highly processed foods is optimal for other health reasons as well.
It is important to get calcium in the diet. Still, Vitamin D and K2, as well as minerals like magnesium and phosphorus, are key to getting the calcium deposited into the bone. Vitamin D is vital for increasing the absorption of calcium from the intestine. Both calcium and magnesium are essential for activating Vitamin D and transporting minerals over cell membranes. Vitamin K2 helps direct calcium into the bones. Taking calcium supplements may be beneficial, but take only 600 mg daily and try to take it alone as calcium can bind to other important minerals like magnesium and zinc. Also, excessive amounts of calcium can increase the risk of deposition in different tissues like our blood vessels and organs.
Exercise
We learned the power of weight training and weight-bearing exercises from the astronauts. When in prolonged weightlessness, astronauts would suffer from bone deterioration. Bones need to grow. Tension and resistance keep bones strong and lead to continued growth. It is best to stress them with weighted exercises to get maximal results. High (jumping jacks, jump rope, jump squats) and low impact (strength and resistance exercises, yoga, elliptical, and walking) exercises that include resistance can be beneficial too, but we need to do both. Running, biking, and swimming are great, but if not coupled with strength training, they can lead to bone loss. Sitting can be like being in space. We need to move.
Specific exercises may be better for our bones.
For example, in a 1992 Stanford study comparing elite athletes to non-exercisers, the researchers found that swimmers and cyclists had the same bone density as non-exercisers. Football players and gymnasts had the best bone density. This does not mean you need to take up these sports, but it supports the idea that strength and weight-bearing types of exercise are optimal for bone building. Jump squats, jumping jacks, weighted squats, and lunges are examples of exercises that can mimic the benefits of these sports.
Things out of our control
Some of the risk factors for fractures and osteoporosis are out of your control. These include Caucasian or Asian ethnicity, older age, thinness or small bones in women, a history of fractures, low body weight, primary relatives with osteoporosis, early menopause, rheumatoid arthritis, gastric– or intestinal-bypass surgery, hysterectomy with ovary removal, and thyroidectomy. Even these situations can be proactively remedied.
Factors that are within your control include smoking, alcohol consumption, a sedentary lifestyle, poor diet, and the long-term use of certain symptom-controlling medications, such as proton pump inhibitors, or PPIs. Medications that can cause secondary osteoporosis include glucocorticoids, anti-epileptics, chemotherapy agents, proton pump inhibitors (PPIs), and thiazolidines. Because of the hormonal influences on bone health, men who are being treated for prostate cancer with androgen deprivation therapy may be at increased risk of osteoporosis.
Anything that increases inflammation (infection, dysbiosis, intestinal permeability, autoimmune diseases) increases the activity of osteoclasts and macrophages and can lead to bone loss. While these things are somewhat out of our control a clean diet and lifestyle is preventive of them.
Who is at risk to develop osteoporosis? Everyone!!
How is Osteoporosis or its precursors diagnosed?
A Bone density test should be done by age 55. It is inexpensive and typically covered by insurance. The test shows the density, but we also need to know the quality of the bone. Bone density only gives us 50% of the bone strength story. Some DEXA tests can look specifically at the trabecular bone to see if it is disconnected, thus reducing the strength of the bone. Unfortunately, we do not have access to these types of studies here in Charlotte.
Osteoporosis should be diagnosed from hip BMD according to the definition of the World Health Organization: a T-score of -2.5 is definitive of osteoporosis, but a T-score between -1.0 and -2.5 is osteopenia (or low bone mass). The T score compares the patient to that of a young 20-something-year-old, and the Z score compares the patient to others the same age.
Are there ways to address bone loss without medication?
Let’s go back to the basics. Addressing the things that can cause bone loss can help reverse it. Some of the things that do bring it down easily are alpha-lipoic and N-acetyl cysteine, berberine, getting rid of other things in their diet, making sure they’re not losing calcium in their urine, and making sure the pH of their body is better. The more acidic they are, the worse things are.
And going back to the basics, ensure they’re getting vitamin D, magnesium, and vitamin K. What does vitamin K do? It carboxylates or activates the osteocalcin. And what’s osteocalcin? It’s produced by your bone cells, a protein that essentially is a nucleator for the hydroxyapatite crystal, and you must activate that for the crystal to form. I usually say 500-700 micrograms of K2 MK-4, 50-100 micrograms of K2 MK-7, and probably 500 to 1000 for K1. If you do that, there’s enough carboxylation of osteocalcin going on. So that’s enough.
Protein is huge. As people get older, they do not eat enough protein.
What about the role of hormone replacement therapy in osteoporosis care?
The popular study by the Women’s Health Initiative 25 years ago basically scared an entire generation of physicians and women away from HRT. And because of that, not only has there been an unnecessary abundance of symptoms associated with menopause, but the real hidden tragedy has been the larger epidemic of osteopenia and osteoporosis in a group of women who may have otherwise received estrogen as they went through menopause.
Hormone replacement therapy (HRT), using estrogen with or without progesterone, may help reduce the rate of bone turnover and resorption in postmenopausal women. In a meta-analysis including 57 trials and about 10,000 women, BMD increased by 6.8% in the spine and 4.1% in the hip after two years of HRT.
A Word about Curcumin
2024 research has shown the bone effects of this powerful root.
Curcumin supplementation has been shown to reduce bone turnover markers and increase bone mineral density in postmenopausal women with osteopenia or osteoporosis. (Kheiridoost et al.) Curcumin modulates inflammatory signaling pathways and immune cell activity in ways that protect against joint degeneration and bone loss (Atabaki et al.)
Your Bone Health Plan
- Build your diet around whole, minimally processed foods rich in bone-building nutrients like calcium, magnesium, vitamin D, and vitamin K2. While these foods are foundational to bone health, adding a bone-building supplement like Klaire Lab Osteothera is an insurance policy to ensure you are not getting insufficient levels of these nutrients.
- Regular weight-bearing exercise stimulates bone formation and improves muscle strength and balance. Aim for at least 150 minutes per week.
- Optimize vitamin D status by testing your levels and supplementing to achieve a blood level of 50-60 ng/mL.
- Consider supplementing with a bioavailable curcumin formulation, especially if you are at increased risk for osteoporosis or have been diagnosed with osteopenia or osteoarthritis. A dose of 500 mg per day is safe and effective.
- Manage chronic inflammation by minimizing processed foods, optimizing sleep and stress, optimizing gut health and addressing underlying health conditions.