Osteoporosis: Looking Beyond Bone Density

Osteoporosis develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes, leading to increased risk of fractures [1]. It affects approximately 10 million Americans, 80% of whom are women [2]. Traditionally, a treatment plan for osteoporosis has consisted of doing weight bearing exercise, taking calcium and adding pharmaceuticals. Is this enough? Does it make a difference? Or has bone density testing led us down a narrow path because it can be measured? Perhaps we need to take a step back and look at the bigger picture of a more multi-faceted approach to preventing bone fractures.

Young, healthy bones are constantly being remodeled, but with osteoporosis the normal remodeling of bones gets out of balance and the rate of loss becomes greater than the rate of new bone growth. While men can get osteoporosis, women are four times more likely to develop the disease mainly due to the loss of estrogen in menopause [3]. Over 50% of postmenopausal white women will have an osteoporotic-related fracture and only 33% of senior women who have a hip fracture will be able to return to independence [4]. In his 2023 book, Outlive, Peter Attia, MD discussed mortality after a hip fracture: “Up to one-third of people over sixty-five who fracture their hip are dead within a year. Even if a person does not die from the injury, the setback can be the functional equivalent of death in terms of how much muscle mass and, hence, physical capacity is lost during the period of bed rest.” [5]

These are scary statistics and why women over the age of 65 are routinely tested for osteoporosis. The standard bone density test, using DXA, is usually done every two years [6]. It’s an objective measure so it’s one we can easily monitor for changes, but is it the best way to evaluate risk? The authors in this study suggest that our focus should be on fall prevention, rather than osteoporosis, since the strongest risk factor for fracture is falling, not osteoporosis [7].

Sarcopenia, the loss of muscle mass and strength, is a big factor in determining frailty and loss of function and is often associated with falls and death [8]. While peak bone mass likely peaks between age 25 and 30, muscle mass can continue to increase. The best way to safeguard against falls and maintain your independence is to protect your skeletal muscle-mass [9]. Bone loss may be inevitable, but muscle health can be improved at any age.

A Multi-Faceted Approach:

Nutrition

Protein is crucial for bone and muscle growth, as well as metabolic function. 40% of your body is protein; your bones, ligaments, tendons, liver, brain, skin and fingernails are all built from proteins. Getting enough will help your overall health and longevity. Dr. Lyon recommends consuming 1 gram of protein per pound of ideal body weight. Shoot for at least 30 grams of high quality protein in your first and last meal of the day.
Calcium helps create the outer shell and increase stiffness of bone. In the groundbreaking book, Estrogen Matters, Avrum Bluming, MD explains the difference between bone density and the resilience of bone. Calcium helps create the outer shell and increases stiffness, but flexibility is important too. Tensile strength decreases as we get older, causing more brittle bones [10].
It’s not just about calcium [11]! Calcium, magnesium and vitamins D and K2 all work together. It’s best to get calcium through food such as yogurt and cheese, or sardines with bones (a great source of calcium and Omega-3 fatty acids!). For absorption of calcium, Vitamin D is essential. Magnesium helps to activate Vitamin D, and Vitamin K2 directs calcium to the bones (rather than the arteries). Be sure you’re getting enough of all of these!

Estrogen Replacement Therapy

Over 20 years after Time Magazine published an article erroneously linking hormone replacement therapy to breast cancer, there is still a lot of skepticism around prescribing bioidentical hormones as estrogen levels decline before and during menopause. In fact, it has been shown that estrogen is protective against osteoporosis and does not increase the risk of breast cancer [12], [13]. It seems to be the most effective treatment for preventing osteoporosis if given within 10 years of the menopause transition [14] [15].

Exercise

Resistance training is critical to increase muscle mass and strength, and again, it’s one of the most important things you can do to prevent falls. Consider adding a weight vest to your resistance training or any weight bearing exercise such as walking or running. For women, the amount of bone you have prior to menopause will partly determine your future risk of osteoporosis so it’s best to build bone throughout your life [16].
Balance training is important for fall prevention as it helps to improve stability and coordination. A study from 2022 showed that the ability to stand on one leg for 10 seconds decreased mortality risk in older individuals [17]. Balance training helps to increase proprioception, the conscious or unconscious awareness of one’s bodily movements and position [18]. The better body awareness we have, the quicker we can react to alterations in movement, such as tripping and falling.
Whole-body vibration training, such as on the Power Plate, is a great way to add force to the bones without having to add more weight. The power plate induces forces on the skeletal system through acceleration; it adds a greater amount of gravity to the body putting more force therefore helping to strengthen the bones. We love this option because you can use your body weight and it has been shown to be an effective tool for improvements in bone density and balance [19].
Power training has been shown to be effective in fall prevention in older adults [20] because it improves reaction time. Even a brand new exerciser can do low grade plyometric exercises that improve power. Consider adding some small hops, jump rope or more advanced box jumps to your program. Also simply increasing the speed of an exercise will help to increase power. Using training variables to change up your program will help your body and your bones!

Preventing falls should begin in our teens with healthy workout and nutrition habits to increase strength and bone density. However, it’s never too late! Whether you are 16 or 76, now is your time to strengthen your bones, increase your muscle and ensure a long, healthy life of independent living.

*Disclaimer: The information in this blog is for informational purposes only. Please always consult your doctor before considering any new diet, supplementation, or other changes to your normal nutrition and health routine.

References:

[1] Osteoporosis

[2] Bone Health and Osteoporosis: What Women Need to Know

[3] The New Menopause by Mary Claire Haver, MD

[4] https://www.ncbi.nlm.nih.gov/books/NBK441901/

[5] Outlive by Peter Attia, MD

[6] Patient education: Bone density testing (Beyond the Basics)

[7] Shifting the Focus in Fracture Prevention from Osteoporosis to Falls

[8] Sarcopenia in older adults – PMC

[9] Forever Strong by Dr. Gabrielle Lyon

[10] Estrogen Matters by Avrum Bluming, MD and Carol Tavris, PhD

[11 ]The role of nutrients in bone health, from A to Z