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Welcome everyone! I’m Dr. Trish Murray – physician, author, and the Health Catalyst Speaker. Tonight, we’re going to take a deep dive into bone health. Folks, first of all, at birth we have around 270 soft bones. As we grow, some fuse together leaving us, as we become an adult human body, with 206 bones, twenty-six of which are in each foot and fifty-four of which in each hand and wrist. We have a lot to cover, so let’s dive in!
Now before getting too in depth, I want to share some facts about bones. Arms are the most commonly broken, accounting for almost half of all adult broken bones. The collarbone is the most commonly broken bone among children. Bones stop growing in length during puberty, but bone density and the strength of bones will change over the course of our lives. Bones are made up of calcium, phosphorus, sodium, and other minerals, as well as the protein collagen.
Bones function as the skeleton of the human body and protect organs from impact damage. They also produce red and white blood cells. We’ll get into more details as we move forward!
You may not know this, but bones are living, active tissues that are constantly being remodeled. They support the body structurally, they protect our vital organs, and they allow us to move. Additionally, bones provide an environment for bone marrow, where blood cells are created, and they act as a storage area for minerals, particularly calcium. More than 99 percent of our body’s calcium is held in our bones and teeth; however, bones are mostly made of the protein collagen.
Many people take collagen supplements in capsules or possibly as a powder for their fingernails and their hair, but you need to know that collagen is also essential for your bone and your connective tissue health.
Bones have an internal structure that is similar to if you visualize a honeycomb. This is able to make them rigid yet relatively light. Bones are composed of two types of tissue:
- A hard outer layer that is dense, strong, and durable, called compact (or cortical) bone. It makes up around 80 percent of adult bone mass.
- The second type of bone is called cancellous bone or spongy bone, and this consists of a network of what is called “trabeculae” or rod-like structures. It is lighter, less dense, and more flexible than compact bone.
Bones are continually being remodeled. Again, we’ve said they’re alive! They are not static structures. This process involves three main cell types. We’re going to go over each one now:
- Osteoblasts are responsible for making new bone and repairing older bone. Osteoblasts produce a protein mixture called osteoid, which is mineralized and becomes bone. They also manufacture hormones, including prostaglandins.
- These are inactive osteoblasts that have become trapped in the bone that they have just created. They maintain connections to other osteocytes and to osteoblasts. They are important for communication within the bone tissue, to let the bone know when it needs to create more or decrease some.
- These are large cells with more than one nucleus. Their job is to break down bone. They release enzymes and acids to dissolve minerals in bone and digest them. This process is called resorption. Osteoclasts help remodel injured bones and create pathways for nerves and blood vessels to travel.
Optimal bone health is always a matter of the right balance between building new bone by osteoblasts and the resorption or breakdown of older bone cells by osteoclasts.
In addition to supporting the frame of the body and protecting internal organs, bones provide several metabolic functions. Again, bone is living tissue. It’s very involved in our metabolism. Let’s look at a few examples:
- Storing minerals
- Bones act as a reserve for minerals, particularly calcium and phosphorous.
- They also store some growth factors, such as insulin-like growth factor. This is a hormone similar in molecular structure to insulin which plays an important role in childhood growth and has an anabolic affect in adults.
- Bones can raise or reduce calcium in the blood by either forming bone and taking calcium out of the blood or breaking down bone in a process called resorption and putting more calcium into the blood.
- Fat storage
- Fatty acids can be stored in the adipose tissue of your bone marrow which is deep in bones.
- pH balance (the acid/base balance)
- Bones can release or absorb alkaline salts, resulting in the blood to stay at the right pH level.
- Bones can absorb heavy metals and other toxic elements from the blood.
- Endocrine function
- Bones release hormones that act on the kidneys and influence blood sugar regulation and fat deposition.
Back in the 1970s, it was determined that our bones secrete a protein called osteocalcin that not only rebuilds the skeleton but also acts as a hormone to keep blood sugar levels in check and burn fat. It is also been shown to be important for maintaining brain function and physical fitness; restoring memory in aged mice has been studied and boosting performance during exercise in older mice as well as in humans. Wow! Did you have any idea that our bones were that involved with that many metabolic functions?
The process of bone remodeling is done in two phases. First, with the resorption when osteoclasts break down bone. The second phase involves formation when new bone tissue is laid down by osteoblasts. Remodeling allows the body to fix damaged sections, reshape skeleton during growth, and regulate calcium levels. Hormones such as parathyroid hormone, calcitonin, vitamin D, estrogen in women, and testosterone in men control bone remodeling so the breakdown or the building and the balance between that. This may surprise you – approximately 10 percent of an adult’s skeleton is replaced every single year!
Now a hormone that we definitely need to discuss when we talk about bone health is cortisol. This is our primary stress hormone. This hormone has a negative effect on bone, by reducing osteoblasts from building bone and turning up the activity of osteoclasts that break down bone. It also has an indirect mechanism such as calcium malabsorption, so you’re not going to absorb the calcium as much. You’re also going to urinate more calcium out of your body, this is called hypercalciuria. And you’re going to have hypogonadism due to high cortisol, which means your sex hormones (testosterone and estrogen) are going to be reduced and therefore affect your bone health.
So, if you are someone, or someone you know is, under chronic stress or always anxious, this can be a primary cause of osteoporosis or low bone density as we age.
Now that was a lot! Is everyone still with me here? Now, that was covering the bone anatomy and physiology and the heavy-duty science stuff. Now, let’s talk about how to keep bones healthy!
Once you reach 30 years of age, you have achieved your peak bone mass. Fortunately, many nutrition and lifestyle habits after 30 (if you’re focused on them and you work hard on them) can help you build strong bones and maintain the density of your bones as you age.
Let’s talk about ways to do that. First of all, you definitely need to eat your veggies because vegetables are a great source of vitamin C. Vitamin C stimulates the production of bone-forming cells (osteoblasts). Some studies even suggest that vitamin C’s antioxidant effects may protect bone cells from damage.
Now, vitamin C can also be supplemented. Many people take about 500 mg a day or maybe 1000 mg a day. I don’t know that everybody knows that you can supplement vitamin C to what’s called bowel tolerance. This means you can go up in your dose of vitamin C until it causes loose stools. Then, of course, once you have started getting loose stools from the increased vitamin C, back off and get back down to a dose that is not causing bowel disruption. This might be as high as 3000, 4000, 5000, even as high as 6000 mg a day. Folks, right now with COVID-19 out there and the coronavirus, I would highly suggest you dose vitamin C up to bowel tolerance and take a bunch of it. It’s going to boost your immune system as well.
Bone density describes mineral density, and vegetable intake increases mineral density leading to stronger bones.
Strength training and weight-bearing exercises are essential for bone health. One of the best types of activity for bone health are weight-bearing or high-impact exercise, because this promotes the formation of new bone.
There’s been many studies in older men and women who performed weight-bearing exercise showed increases in bone mineral density, bone strength, bone size, as well as reductions in markers of bone turnover and inflammation.
Some great weight-bearing exercises include things like Tai Chi (which would be quite gentle on the bones, but it is moving and weight-bearing), yoga, hiking, golf, all sorts of exercises outdoors. I also offer on my website at discoverhealthfmc.com in the Health Library a series of Exercise Videos on weight resistance and on core strength that are completely free! Everything in my Health Library on the website discoverhealthfmc.com is free, including my Discover Health Podcasts. Check out this free resource, because you don’t want to miss out. It’s a great resource for maintaining your optimal health!
Protein is essential to bone health; however, getting too little or too much can cause adverse effects. Approximately 50% of bone is made up of protein. Research has shown that low protein intake may affect rates of bone formation and breakdown.
High protein diets may come with their own risks. Concerns have been raised that high-protein diets leach calcium from your bones in order to counteract the increased acidity in the blood from all of the protein from meat. However, with adequate calcium intake, this may not be as much of an issue.
If you are eating the typical Standard American Diet with meat portions like Fred Flintstone, you need to increase your veggies and decrease your meat intake to a better balance. Also, if you are a vegan or a vegetarian, you need to be sure to research how to get the right balance of what are called complete proteins in your diet for optimal bone and overall health.
Calcium is the most important mineral for bone health and should be consumed every day. Many people think that dairy is the main and only source of calcium and that’s just not true. Dark leafy greens such as bok choy, Chinese cabbage, kale, collard greens, and turnip greens all provide excellent sources of calcium. In fact, just one cup of cooked turnip greens provides 20% of your daily requirement! Folks, if you’re eating upwards of five servings of dark green leafy vegetables a day then you’re getting your calcium from them! If you’re dairy sensitive, you don’t have to worry – you’re still getting your calcium from dark leafy greens.
Also, there are other high calcium foods that include seeds, sardines and canned salmon, beans and lentils, as well as dairy products such as cheese and yogurt.
Vitamin D and vitamin K are essential for building strong bones.
Vitamin D helps to absorb calcium, and low vitamin D levels are associated with low bone density. The sun typically is what activates vitamin D formation; however, if you live far from the equator like we do up here in New Hampshire or you use sunscreen a lot you can easily be lacking in vitamin D. I will also tell you that even people living in Florida that are out in the sun a lot can be found to be low in vitamin D. Consuming fatty fish and liver can provide good sources of vitamin D and other foods that might be fortified with vitamin D can also supplement.
You also can take a supplement of vitamin D. Actually, vitamin D is a fat-stored supplement or vitamin and you can store too much of it. Studies have shown that to supplement daily with between 2000 – 4000 IU (International Units) of vitamin D3 is typically not going to get anyone into a toxic state. That would be a range you could consider taking on a daily basis. Between 2000 – 4000 IU of vitamin D3.
Vitamin K helps protein and minerals bind to the bone. Small amounts of vitamin K can be found in liver, eggs, meat, and fermented foods like cheese, sauerkraut, and a soybean product called natto.
Basically, vitamin D ensures that calcium is absorbed easily, and vitamin K2 activates the protein we discussed earlier, osteocalcin, which integrates the calcium into the bone. Without vitamin D3 and K2, calcium cannot do its job effectively.
You’ve got to understand that low-calorie diets can be harmful to bone health. Studies have shown that diets providing fewer than 1000 calories per day can lead to lower bone density in normal-weight, overweight, or even obese individuals. If weight loss is your goal, and you have been having trouble losing weight and you feel like you’re eating like a bird and you still can’t lose weight then you’re going to need to look at it from a different avenue.
I would suggest you consider going to my website and obtaining my Detox Plus Program. It’s available in the shop of my website discoverhealthfmc.com. What it is is you’re going to implement a three-week detox and then systematically re-challenge the foods that you’ve eliminated in order to identify your own individual food sensitivities that may be causing inflammation and hormonal imbalance that are causing your weight problems. After most people have done this, they are well on their way to finding the trigger for their weight problem and changing their food habits for the better.
Many people don’t realize weight loss involves bone loss; however, this is less pronounced in obese individuals experiencing weight loss than in normal-weight individuals that are experiencing weight loss.
Folks, being underweight can also be extremely harmful to bone health. In fact, research shows that being underweight increases the risk of osteopenia and osteoporosis. Low body weight is the main factor contributing to reduced bone density and bone loss among postmenopausal women.
Additionally, the other thing that a lot of people do is they have yo-yo dieting that they’re doing. This can be harmful to your bones, since repeated loss and regaining of weight is particularly detrimental to calcium and to bone health.
While calcium is king when it comes to bone health minerals, a number of other minerals also play a role in optimal bone health. Magnesium plays a crucial role in converting vitamin D into the active form that promotes calcium absorption. Foods high in magnesium include avocados, nuts, legumes, seeds, tofu, and whole grains. So be sure to boost your intake of these different things. Potassium neutralizes the acid in your body that can leach calcium out of your bones. Sweet potatoes are a great source of both calcium and potassium.
Zinc is a trace mineral needed in minimal amounts. It helps make up the mineral portion of your bones. Excellent sources of zinc include beef, shrimp, spinach, flaxseeds, oysters, and pumpkin seeds.
Healthy fats, such as omega-3 fatty acids, have been shown to help protect against bone loss during the aging process. In a typical diet now and particularly the Standard American Diet and even those eating pretty darn healthy diets, the balance of omega-3 fatty acids and omega-6 fatty acids isn’t correctly balanced. We are usually too high in omega-6 and don’t get enough omega-3 fatty acids. In order to increase your omega-3 intake you would want to increase your intake of chia seeds, flaxseeds, and walnuts.
One can also supplement, of course, fish oil high in omega-3 fatty acids. The typical dose daily of omega-3 fatty acids in fish oil is usually between 1000 – 3000 mg per day. If you’re someone with high cholesterol, you also would want to take omega-3 fatty acids as fish oil, and you would want to be up higher to around 3000 mg a day. Just be aware, of course, that fish oil taken as a supplement at high dosages like 3000 or 4000 mg a day is also going to be thinning your blood. If you’re on blood thinners, you want to be careful and I’m sure you’ve already been told not to take fish oil with blood thinners.
The use of tobacco products and alcohol consumption contributes to weak bones. Research suggests women who have more than one alcoholic drink a day, and men who have two or more drinks daily may have an increased risk of osteoporosis. We do need to be careful in that regard with alcohol.
In women, bone density decreases dramatically at menopause due to dropping estrogen levels. The prolonged absence of menstruation before menopause also increases the risk of osteoporosis. In men, low testosterone levels also can cause a loss of bone mass.
What I want to make sure people understand is in the functional medicine world, the sex hormones (estrogen and testosterone) can be tested to determine levels. There are treatments that can be done to take supplemental hormones. That’s done a lot in the traditional medical model, but what I want you to understand is that in the functional medical world we want to get more to the root cause.
In functional medicine it is emphasized to first look “upstream” at the hormones that affect the production and mechanism of the sex hormones that are considered what’s called “downstream.” These more upstream hormones we’ve talked earlier about cortisol which when it is elevated steals in what’s called “cortisol steal.” It steals from the production of estrogren and testosterone. Also, thyroid hormone needs to be optimally balanced and functioning optimally to maintain optimal bone health and optimal estrogen and testosterone levels. Really, you want to get these things looked at if you haven’t in order to optimize your bone health as well as your sex hormone health.
Some studies report collagen supplementation as a way to help protect bone health. Collagen is the main protein found in bones. It contains the amino acids glycine, proline, and lysine, which help build bone, muscle, ligaments, and other tissues. A 24-week study found that giving postmenopausal women with osteoporosis a combination of collagen and the hormone calcitonin led to a significant reduction in markers of collagen breakdown.
We can’t have a talk about bone health and bone density as we age getting into osteoporosis or osteopenia without talking about the different medications that are out there that can be helpful, but they are not without risk. Let’s take a few slides to talk about that.
This slide lists the different bisphosphonates. Bisphosphonates are the most commonly prescribed medications used to treat osteoporosis. As a category they are called antiresorptive therapy which means they slow the body’s normal breakdown of bone to reduce the risk of fractures. The different bisphosphonates include:
- Actonel—a tablet you take daily or weekly
- Boniva—an injection you can get once every three months
- Fosamax—a tablet you take either daily or weekly. (It’s been around the longest and is the most commonly prescribed.)
- Reclast—a treatment you can actually take intravenously initially and every two years after that.
Again, the biphosphonates are not without side effects or concern. They have been shown to decrease fractures in people with osteoporosis, but actually studies have not been clear if they do so for those with osteopenia. It depends on where you are on the spectrum of bone loss. Again, they are not without side effects.
Side effects of biphosphonates include heartburn or irritation of the esophagus. When you take a pill of a biphosphonate you must take it on an empty stomach. You must drink a lot of water to make sure that it gets down past the esophagus and into the stomach. You need to wait at least thirty minutes. You need to be upright; you should not be laying down, and you shouldn’t be bending over. If this medicine gets up into your esophagus it can do damage to your esophagus and irritate it.
Another side effect of biphosphonates is they can cause an ongoing muscle or bone aches and pains. The most dangerous of side effects that could happen, but it happens more in people who have been on these medicines for more than five years, is osteonecrosis of the jawbone which is actually when the bone of your jaw in an area will start to degenerate and break down. Also, the last one here is an atypical fracture of the thigh bone. We’re talking about a medicine that is supposed to increase our bone density and protect us from bone fractures, which it has shown in studies to do, but also if we’re on the medicine too long, or in some percentage of people, it may cause an actual atypical fracture of the thigh.
Now, the biphosphonates are not the only medicines. There are other medicines in the bone density world. These are listed here and I’m going to go through each one. First of all, one called denosumab (Prolia) is actually considered a biologic drug that slows bone loss.
Next would be hormone replacement therapy (HRT) or estrogen therapy. The problem with this is we’re really not prescribing this anymore specifically for bone health because it’s been found by research that hormone replacement therapy increases the risk of breast cancer, heart disease, and stroke in some women. Therefore HRT is not being prescribed specifcally to treat osteoporosis because the risks are thought to outweight the benefits.
Next, another medicine is called raloxifene (Evista), and this is another antiresorptive option. The way that this works is this medicine has been used in breast cancer treatment for a long time. What it does is it mimics estrogen therefore decreases the turnover of bone; however, this medicine has been showen to increase risk of blood clots and so people who are at risk of blood clots or heart disease should not be on Evista.
Finally, teriparatide (Forteo) is recommended for people who’ve possibly already had a fracture and are at high risk of having another fracture. This drug works by stimulating the creation of new bone, as opposed to the antiresorptives that stop bone breakdown. So, Forteo is a synthetic version of a hormone called parathyroid hormone which is responsible for promoting the acitivity of osteoblasts to produce more bone. Again, all of these medicines can have side effects. Forteo can raise calcium levels in blood, therefore it might increase the risk of kidney stones.
So, there are a number of different medicines that can help with maintaining better bone density as we age, but there are side effects to consider. If you have definitive osteoporosis by a bone mineral density (BMD) test then be sure to talk with your doctor about your individual options and what would be best for you!
We covered a lot of information today so here’s a quick recap on some great ways to help maintain bone health:
- Eat your veggies
- Perform weight-bearing exercise
- Get the right balance of protein in your diet
- Boost your calcium intake
- Eat foods rich in vitamin D, vitamin K, magnesium, potassium, and zinc (you can also consider taking those in a multivitamin)
- Avoid low-calorie diets
- Ditch the tobacco and limit your alcohol intake
- Talk to your doctor about hormones and other types of bone density enhancing medications if you have osteoporosis
- Try a collagen supplement
Remember that we list for you all of the resources I used to create this talk on our closed Discover Health Facebook Group. Anyone can join! All you need to do is go to Facebook, go to our Discover Health Functional Medicine Center Facebook Page, and just request to join our Discover Health Facebook Group. Everybody’s allowed in, it’s just we need to make sure we create that group so we can communicate with each other as a closed group.
Every day after I do these webinars, we post a list there for all members of our closed Discover Health Facebook Group of all of the links to the different online resources I used to produce these talks. If you have an interest, make sure to join our Discover Health Facebook Group. The other thing is that in our Discover Health Facebook Group, every Monday our Health Coach Trish Chaput does a Coach’s Corner. She also has very themed ideas throughout the week. Like one day is a recipe day and another day is another theme and so on. You also can ask us questions. It’s a communication device. If after we’re done tonight and you have questions after I’ve finished and you think of a question tomorrow or the next day, be sure to join our Discover Health Facebook Group and you can ask your questions through that method.
Thank you so much for taking part in this experience. Take care everyone!
- The Roles and Mechanisms of Actions of Vitamin C in Bone: New Developments
- Short-term Bone Formation Is Greatest Within High Strain Regions of the Human Distal Radius: A Prospective Pilot Study
- Low Protein Intake: The Impact on Calcium and Bone Homeostasis in Humans
- Postmenopausal Osteoporosis. Treatment with Calcitonin and a Diet Rich in Collagen Proteins
- Hormone Replacement Therapy for Menopause