How to Strengthen Bones

This week’s practice, in short

1. Make sure you don’t have gluten sensitivity (or of course celiac disease)

2. Optimize exercise:

   • Eat before you exercise if at all possible

   • Prefer weight bearing exercise to swimming

   • Strength training helps as does “impact” exercise such as plyometrics

3. Make sure you eat enough protein, as well as take in enough but not too much calcium and vitamin D (ideally have levels checked)

4. Test bone density with a DEXAscan by age 65 if no risk factors; by age 50 if you have risk factors, which include just about all medical conditions, family history, or experiencing a fracture under conditions that were not highly obvious

5. Engage in small acts that have been shown to make a difference:

   • Eat 2 prunes daily and 1 teaspoon blackcurrant powder

   • Hop on each foot 50 times when you go for a walk

   • Add back extensions if you work out in a gym

Favorite Finds

1. My bible for osteoporosis is Keith McCormick’s Good Bones, available on his website.

2. Yoga can improve bone density. The following routine is supported by research.

3. My favorite physical therapist is Alyssa Kuhn. She offers exercises to prevent osteoporosis on YouTube.

4. I have a $2.00 detailed guide to take you through many of the important steps relevant to bone health, including diet, ideal exercise and nutrient levels, and blood tests you will need to optimize your bone health;

5. Note: this post may contain ads for specific products; any income from these ads will be donated to the California Native Plant Society.

DEEP DIVE into BONES

Who is at risk?

Low bone density is a growing problem in the US, in part due to our growing population of elderly people, and in part due to the fact that many commonly used medications increase osteoporosis risk.

A very large number of medical issues raise osteoporosis risk. Persons in the following situations should get a bone density scan before the usual age of 65. Some may want one as sooner as age 50:

• weight under 120-127 lbs, or with BMI < 20

• first degree relative with osteoporosis

• use of steroids (including inhaled and topical steroids), PPIs, antidepressants such as SSRIs and SNRIs

• breaking a bone as an adult (with a mild or moderate accident)

• women: late onset of menses, irregular menstrual period, early menopause

• men, delayed puberty, low libido, erectile dysfunction, low testosterone

• overall poor health, kidney, lung, liver, or GI issues, including irritable bowel syndrome, high insulin resistance, and anemia; Alzheimer’s disease; high LDL; very high HDL, endometriosis, hyperprolactinemia, Cushing’s syndrome, and thyroid problems; primary hyperparathyroidism; Gilbert syndrome (high bilirubin is harmful to bones); sarcopenia, cancer, high blood pressure

• significant lead exposure

• too high or too low selenium level

• bipolar illness not treated with lithium

• genetic disorders including Ehlers Danlos, hemochromatosis, hypophosphatasia, X-linked hypophosphatemia, and familial hypercalciuric hypercalcemia

• sleep problems, smoking, alcohol, drug use

• failure to attain optimal peak bone mass before it starts to decline: in one animal study, a 10% increase in bone mass delayed the development of osteoporosis by 13 years. If the peak bone mass is low at age 25 it's likely that you will develop OP as an adult

• consuming more than 300 mg of caffeine per day, especially those with a vitamin D receptor genetic variant

• autoimmune disorders

• dietary iron overload.

• anorexia nervosa.

• The ApoE4 allele is a risk factor for osteoporosis and cardiovascular disease. ApoE2 is also associated with lower bone mineral density

• Non-celiac, gluten sensitivity, and wheat allergy

• gastric bypass

• MGUS (monoclonal gammopathy of unknown significance)

• hearing loss

• shingles: in patients who developed shingles there is a 4.5 X risk of developing osteoporosis. The risk is even higher for those who develop post herpetic neuralgia.

More situations related to bone loss:

• Toxins: BPA, organophosphates, glyphosate, persistent organic pollutants, microbial trans glutamate (imitation crab meat, meatballs, baked goods, cheese, yogurt, hotdogs, beef, tofu, salad dressing) especially for celiac patients.

• Asthma, and other atopic illnesses, anything with high IgE. Histamine intolerance,

• Heavy metals, aluminum, lead, cadmium, mercury. Fluoride increases heavy metal absorption into the body and can cause skeletal fluorosis.

• Triclosan can disrupt bacterial activity, accumulates in bone, and is linked to higher incidence of osteoporosis.

• Medication glucocorticoids, opioids, Depo-Provera, oral contraceptives, PPI, Avandia and Actos, SSRIs, SNRIs, antiepileptic drugs, aromatase inhibitors and other anti-estrogen medications, chemotherapy, gonadotropin releasing hormone agonists/antagonist and androgen deprivation therapy, medroxyprogesterone acetate, anticoagulants, barbiturates, chemotherapy, lithium (actually might be bipolar illness and not the lithium), methotrexate, and premenopausal tamoxifen.

How do weak bones develop?

Bone is a connective tissue with the addition of minerals for stiffness. Thus it needs at a minimum a full supply of:

• protein

• collagen

• calcium

• vitamin D, vitamin K2 (activates the enzymes that build bone)

• B vitamins

• omega 3 fatty acids, especially DHA

• magnesium, boron, and silicon

Bone is constantly being remodeled, thus it adapts to prevailing conditions. This also allows the repair of “microfractures” which occur on a daily basis. The task is performed by osteoblasts (cells that build bone) and osteoclasts (cells that break down bone). These cells wait for signals from the body and the body’s environment. If the balance of building and breakdown is not favorable, the outcome is bone loss and low bone density.

Thus, to remodel bone efficiently, patients need:

• sleep (always needed to to repair and rebuild)

• exercise (impact exercise, strength exercise, and certain yoga exercises have been found helpful — more details below)

• conditions that favor higher melatonin levels (like regular sleep-wake cycles and avoiding light at night)

• normal levels of inflammation and oxidative stress

• relevant nutrients

• absence of toxic levels of metabolites and xenobiotics

Diagnosis

When should you order a bone density scan:

• Regular screening age is 65 years old for men and women

• Sooner (age 50 for example) if patients have risk factors (see Epidemiology section).

Osteopenia is diagnosed when the T score is below -1.0 (-1.0 to -2.4), and osteoporosis when the T score is below -2.5. It’s not an absolute that a certain number means you will get a fracture. This can depend on your general build, your reflexes, your strength, and also on your balance.

Medications 

We should pay attention to underlying nutrient deficiencies, and problems of inflammation and oxidative stress.

1. Calcitonin can be used in the right candidates.

2. Selective estrogen receptor modulators (SERMs, like tamoxifen and raloxifene) have limited usefulness, may increase the risk of abnormal clots, and only help with spine fractures.

3. Bisphosphonates can be ideal for short-term use (3-5 years) in people with very low bone density scores. These include oral options (such as Fosamax), as well as intramuscular or intravenous options. They may be especially useful when osteoporosis results from steroid use. Consider adding Coenzyme Q10 and vitamin E.

4. Hormone therapy with estradiol, progesterone, and testosterone can improve osteoporosis.

There have been concerns about each of these medications:

• bisphosphonates cause “microcracks” in bones, which accumulate over time, leading to the recommendation that these medications be time-limited to 3-5 years;

• bisphosphonates may, in maybe 1 in 1000 cases, lead to jaw bone osteonecrosis and atypical femur fractures. Monitoring some blood tests can help predict problems with these medications. The risk is higher with more years of treatment. Nevertheless these medications prevent many more fractures (see the NNT) than they cause;

• oral bisphosphonates (Fosamax) can cause significant heartburn that may not resolve when the medication is stopped;

• injectable bisphosphonates (Boniva and Reclast) can cause muscle and joint aches that last for weeks or months.

Other medications:

• Forteo can be very useful, but stops working after 18 months or so, and must be followed by a year of bisphosphonates (otherwise you get bone loss). It is potentially less useful in highly inflamed patients and patients with low IGF-1 (low anabolic (building) activity);

• Prolia also results in rebound bone loss when you stop. However it can be used for years.

Non-Medication Options

SUPPLEMENTS

• There are many options and in my opinion they should be individualized with a knowledgeable functional medicine physician!

FOODS

• Especially recommended: oranges, broccoli, onions, flaxseed, sardines, almonds, dried prunes (2 a day), and blackcurrant powder

• For everyone: adequate protein intake (at least 0.8g of protein per kg of body weight, or even up to the updated recommendation of 1.2 or 1.6 g of protein per kg of body weight), as long as calcium intake is adequate

• A vegan or vegetarian diet is not consistently associated with better or worse fracture risk (Sotos-Prieto, et al).

• Calcium from dairy: the literature is divided on this. The idea that dairy is an acidic food, thus causing calcium loss as the bone tries to buffer this acid, is no longer considered correct. There’s something called the hydration membrane, and that’s the first place the body goes to buffer the blood pH. Towards the end of the day, as the bloodstream starts tending towards acidification, the body goes to the hydration membrane to even things out.

• If we don’t eat enough fruits and vegetables, then the hydration membrane is not replete, and then the body has to break down bone to buffer blood pH.

EXERCISE

• Exercise may improve bone quality without improving bone density

• The most useful appears to be exercise that causes extreme loading on bones, such as plyometrics, and hiking downhill (you may need to work with a physical therapist or trainer to learn how to do these safely) and there is some debate as to whether this helps in postmenopausal women; however it may help neuromuscular coordination and reduce the chance of falling in the first place

• Exercise that combines high intensity strength (heavy weights, especially certain exercises that strengthen the spine) with high loads —- note that not everyone agrees that we have enough data on this, however, muscle strength in the spine prevents stooping, which in itself may prevent osteoporotic fracture of the spine)

• Also, forceful muscle contractions cause muscles to make “myokines,” communication substances that signal bones to build up stronger

• Tai chi and balance exercises reduce the chance of falls

• An Australian study combining squats, deadlifts, overhead presses, and impact exercise (drop jumps) for 8 months showed a 3% increase in bone density in participants (vs. mild worsening for placebo).

• The spine improves most easily, as it has more trabecular bone, which is more metabolically active. The femoral neck can also improve a little. The femur shaft itself is almost all cortical bone and harder to improve.

• Evidence for the use of weighted vests is weak and of low quality. Some experts feel that steady state exercise with a weighted vest (going for a walk for example) is too long-lasting and NOT likely to be better than a walk without a weighted vest.

CAUTION: when there is significant osteoporosis, movements that cause pressure on the vertebra (especially bending and twisting) can result in vertebral fractures. All bending forward should be done with straight spine (not rounded).

AND of course if you are changing your exercise regimen, please consult with your physician first.

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