Osteoporosis is the silent thief that robs your skeleton of up to 25 per cent of its bone mass by the time you reach 50. Find out how to prevent it. Osteoporosis is the silent thief that robs your skeleton of up to 25 per cent of its bone mass by the time you reach 50. It is now a serious epidemic in Britain. Bones become porous, or ‘osteoporotic’, due to the progressive loss of minerals, mass and density which can result in fractures. Four-fifths of fractures occur after the age of 50 and the risk becomes quite significant from 70 onwards. One in two women and one in five men will suffer a fracture after the age of fifty. It is estimated that the cost by 2020 of treating all fractures resulting from osteoporosis in postmenopausal women will be £2 billion.
Yet skeletal material dating from between 1729 and 1852, unearthed during the restoration of Christ Church, Spitalfields, in London, showed significantly less bone loss in women then than now, despite our supposedly better diet. Investigators found no sign of menopausal change in the unearthed bones. This suggests that some aspect of modern living doesn’t suit our skeletons. Most people think of bones as something rather ‘dead’ – simply the scaffolding on which to hang the rest of the body. But there’s a more plausible theory emerging that suggests bones are a vital part of the metabolic system that controls our intake of energy, the amount of fat we store, how much insulin we produce, and so on. Bones are made from a matrix of collagen, produced by vitamin C, into which bone-building minerals such as calcium, magnesium and potassium are deposited. Although they seem the strongest and most enduring part of us, our bones are in a constant flux, endlessly being destroyed and re-created. Cells called osteoclasts are the bone destroyers, whereas the osteoblasts create new bone – but age slows down this sequence of destruction and renewal. Strategies for improving bone-mass density either focus on stimulating growth, helping to push minerals into the bone, or on preventing its breakdown. Weight-bearing exercise ¬– such as walking – combined with eating sufficient protein, for example, stimulates bone growth. Getting enough vitamin D helps calcium to be absorbed into the bone, while the hormone oestrogen and drugs called bisphosphonates inhibit bone breakdown. B vitamins assist your body’s methylation, and keep your homocysteine level ideal, which also helps to inhibit bone breakdown.
Osteoporosis risk factors
Before we look at the treatments on offer to restore bone mass what are the risk factors? Women are more at risk than men of developing osteoporosis. The female hormones oestrogen and progesterone are protective to women’s bones, just as the male hormone testosterone is protective to men’s. But, from the age of 35, women regularly fail to ovulate, minimising their production of progesterone, the major hormone for bone strength. Women at most risk for developing osteoporosis are those that have had an early menopause (before the age of 45), either naturally, or surgically by removing the womb and one or both ovaries.
Major Well Known Risk Factors
Early menopause Previous fracture from slight injury Anorexia Significant corticosteroid use Bulimia Lost several inches in height Over-dieted Close relatives with brittle bones Over/under exercised Heavy intake of alcohol and drugs Many missed periods History of heavy cigarette smoking Osteoporosis is mostly a ‘silent’ disorder and a fracture is often the first indication of a problem. Loss of height, back pain, tooth loss and a bent posture are indicators for osteoporosis, particularly after the age of 50.
The interplay of hormones is fundamental for preventing osteoporosis. Oestrogen works by removing old damaged bone and when oestrogen levels decline at menopause, bone loss is accelerated. Progesterone is the bone builder as it works on bone cells that rebuild new bone to replace the old bone. The stress hormone cortisol, when chronically elevated, can contribute to bone loss. The balance of parathormone and calcitonin help control calcium balance between the blood and bones. Thyroid hormones, testosterone and growth hormone also affect bone health. Osteoporosis is a slow, progressive disease: bone loss starts in most women from the mid-thirties. It does not happen overnight with the last menstrual period. Children and young adults are generally building bones, between 30 and 40 the balance between bone growth and bone loss is about equal and after 50 bone growth decreases and bone loss increases. Developing, supporting and maintaining bone health is a lifelong commitment. Treatment strategies have largely been focused on HRT, bisphosphonate drugs, e.g. Fosamax, and calcium and vitamin D supplementation. Although, as mentioned earlier, the Women’s Health Initiative trial showed a small decreased risk of hip fracture,
Osteoporosis is the silent thief that robs your skeleton of up to 25 per cent of its bone mass by the time you reach 50. It is now a serious epidemic in Britain. Bones become porous, or ‘osteoporotic’, due to the progressive loss of minerals, mass and density which can result in fractures. Four-fifths of fractures occur after the age of 50 and the risk becomes quite significant from 70 onwards. One in two women and one in five men will suffer a fracture after the age of fifty. It is estimated that the cost by 2020 of treating all fractures resulting from osteoporosis in postmenopausal women will be £2 billion.
Yet skeletal material dating from between 1729 and 1852, unearthed during the restoration of Christ Church, Spitalfields, in London, showed significantly less bone loss in women then than now, despite our supposedly better diet. Investigators found no sign of menopausal change in the unearthed bones. This suggests that some aspect of modern living doesn’t suit our skeletons.
Most people think of bones as something rather ‘dead’ – simply the scaffolding on which to hang the rest of the body. But there’s a more plausible theory emerging that suggests bones are a vital part of the metabolic system that controls our intake of energy, the amount of fat we store, how much insulin we produce, and so on.
Bones are made from a matrix of collagen, produced by vitamin C, into which bone-building minerals such as calcium, magnesium and potassium are deposited. Although they seem the strongest and most enduring part of us, our bones are in a constant flux, endlessly being destroyed and re-created. Cells called osteoclasts are the bone destroyers, whereas the osteoblasts create new bone – but age slows down this sequence of destruction and renewal.
Strategies for improving bone-mass density either focus on stimulating growth, helping to push minerals into the bone, or on preventing its breakdown. Weight-bearing exercise ¬– such as walking – combined with eating sufficient protein, for example, stimulates bone growth. Getting enough vitamin D helps calcium to be absorbed into the bone, while the hormone oestrogen and drugs called bisphosphonates inhibit bone breakdown. B vitamins assist your body’s methylation, and keep your homocysteine level ideal, which also helps to inhibit bone breakdown.
Osteoporosis risk factors
Before we look at the treatments on offer to restore bone mass what are the risk factors?
Women are more at risk than men of developing osteoporosis. The female hormones oestrogen and progesterone are protective to women’s bones, just as the male hormone testosterone is protective to men’s. But, from the age of 35, women regularly fail to ovulate, minimising their production of progesterone, the major hormone for bone strength. Women at most risk for developing osteoporosis are those that have had an early menopause (before the age of 45), either naturally, or surgically by removing the womb and one or both ovaries.
Major Well Known Risk Factors
|Early menopause||Previous fracture from slight injury|
|Anorexia||Significant corticosteroid use|
|Bulimia||Lost several inches in height|
|Over-dieted||Close relatives with brittle bones|
|Over/under exercised||Heavy intake of alcohol and drugs|
|Many missed periods||History of heavy cigarette smoking|
Osteoporosis is mostly a ‘silent’ disorder and a fracture is often the first indication of a problem. Loss of height, back pain, tooth loss and a bent posture are indicators for osteoporosis, particularly after the age of 50.
The interplay of hormones is fundamental for preventing osteoporosis. Oestrogen works by removing old damaged bone and when oestrogen levels decline at menopause, bone loss is accelerated. Progesterone is the bone builder as it works on bone cells that rebuild new bone to replace the old bone. The stress hormone cortisol, when chronically elevated, can contribute to bone loss. The balance of parathormone and calcitonin help control calcium balance between the blood and bones. Thyroid hormones, testosterone and growth hormone also affect bone health.
Osteoporosis is a slow, progressive disease: bone loss starts in most women from the mid-thirties. It does not happen overnight with the last menstrual period. Children and young adults are generally building bones, between 30 and 40 the balance between bone growth and bone loss is about equal and after 50 bone growth decreases and bone loss increases. Developing, supporting and maintaining bone health is a lifelong commitment.
Treatment strategies have largely been focused on HRT, bisphosphonate drugs, e.g. Fosamax, and calcium and vitamin D supplementation. Although, as mentioned earlier, the Women’s Health Initiative trial showed a small decreased risk of hip fracture,  there is now a substantial body of evidence that HRT should not be recommended to women to prevent or treat osteoporosis, and that the risks outweigh the benefits. It seems that bone mass is only preserved in those who take HRT for seven years or more  and, even when you take it for that long, bone mineral density rapidly declines once you stop taking it. Following a European-wide review of the balance of risks and benefits of HRT, it is no longer recommended as first choice of therapy for prevention of osteoporosis, according to advice from the Medicines and Healthcare products Regulatory Agency (MHRA) in 2003.  HRT does, however, remain a treatment option for those who cannot use other osteoporosis prevention therapies or for whom other therapies have been shown to be ineffective, although the decision must be made with care.
Younger women who use short-term HRT will probably gain little or no protection against fracture beyond the age of 70, according to a study from 1993.  At 75, the women’s bone mineral density was found to be only just over 3 per cent higher than that of women that had never taken HRT. So, unless you are prepared to take HRT for life, it is unlikely to protect you against osteoporosis – and the longer you take it, the greater your risk of developing breast and womb cancer. (See ‘Beyond calcium – bone-friendly minerals’, page 170, for ways of building bone density nutritionally.)
Eighteen European specialists reviewed the data on HRT and osteoporosis. No long term benefits were identified. Hip fracture risk was as great for women who stop HRT as those that had never used HRT. Protection from HRT is lost within five years of stopping. Many women cannot tolerate HRT and stop within a year of using it. Other women may trial many forms of HRT before finding one that suits them.
The conclusion of the European specialists was: ‘For healthy women without menopausal symptoms the benefit - risk analysis of HRT for the prevention of osteoporosis is not favourable’. Officially, doctors in the UK are now told that the risks outweigh the benefits, and not to prescribe it for osteoporosis prevention. But it is still commonly prescribed for this reason in other parts of the world.
How effective are bisphosphonates?
The official figure given for the effectiveness of bisphosphonates in lowering the risk of having a hip fracture is 32 per cent, but although this sounds positive it’s very misleading. A study undertaken in 2010 by researchers in Finland and published in the British Medical Journal concluded that if everyone in that country over the age of 50 had been put on a bisphosphonate – that would be 1.86 million people – just 343 hip fractures would have been avoided.  Meanwhile, the drug would have failed to prevent 7,068 of them. That is a long, long way from preventing 32 per cent, so how can the results be so poor and confusing?
The reason is that there is a big difference between how well drugs perform in clinical trials – the 32 per cent – and their results in the real world. Clinical trials are very artificial. As we have pointed out before, subjects are usually quite young, healthy and not taking any other drugs, and nurses will ensure that they take the drug for the trial. The patients who are given them on prescription, however, will very likely be older, frailer and starting to decline; usually they will have three or more other disorders and will be on several drugs for each of them. Furthermore, only about half the drugs prescribed are actually taken.
How effective did bisphosphonates turn out to be when they became available on prescription? As a result of this mismatch between the trials and the real world, the Finnish researchers calculated that if everyone who had at least a 3 per cent risk of developing a fracture over the next ten years were treated with bisphosphonates, for every 667 people who took the drugs only one would avoid a fracture.
Side effects include upset stomach and inflammation of the oesophagus, if you don’t remain sitting upright for 30–60 minutes daily after taking the drug. You might also develop cancer of the jaw bone (although this is rare), and what are called ‘atypical’ fractures of the thigh bone (femur) and a disturbed heart rhythm if you are female. So you need to weigh your chances from benefiting from the drug with that kind of rate of efficacy against the side effects.
What is more, if you are taking one of the proton pump inhibitor (PPI) drugs that suppress stomach acid – often given with bisphosphonates because heartburn can be a side effect – the benefit of the drug can drop to zero.  These stop you making stomach acid, which is required for the absorption of calcium, magnesium and vitamin B12.  These drugs are known to increase the risk of fracture, doubling the risk in those over 50 if taken long term, according to a study in the Journal of the American Medical Association.  If you are on these drugs, at the very least have your homocysteine level checked (see www.yorktest.com).
Many women with digestive problems cannot take Fosamax and it is associated with many side-effects, including esophageal irritation and ulceration, bone and muscle pain. Intravenous Fosamax is linked with a horrendous condition called osteonecrosis of the jaw that results in deterioration and death of the jawbone. Fosamax also increases risk of atrial fibrillation.
Increase your vitamin D level
The amount of vitamin D you have in your blood may also play a major role. Osteoporosis becomes more common as you move north, suggesting a link between sunlight (which produces vitamin D in the body) and this condition. The vital role of vitamin D is well known. It helps deposit calcium and other minerals into the bones’ collagen structure. Numerous studies have shown that the combination of vitamin D – at a daily intake of around 20–30mcg a day, along with 1,000mg-plus of calcium – improves bone mass density and reduces the risk of fractures.
Not only does research show that 75 per cent of people on bisphosphonates don’t respond at all if they have the kind of low levels very common in the UK (below 50 nmol/l) but also getting double that amount would mean that you would be seven times more likely to have a favourable response to the drug.  It only costs your doctor a small amount – a fraction of the cost of a drug prescription– to have your vitamin D levels tested, but if your doctor doesn’t want to test you, you can do it yourself (see www.vitamindtest.org.uk).
It is certainly possible make all the vitamin D you need from sun, depending on how near the equator you are, the season and your skin colour. In the UK, 20 to 30 minutes a day in the summer, with as much of your skin exposed as you are comfortable with, will keep you healthy. But between October and March the sun will provide very little and getting enough from your diet is challenging. Few would be prepared to eat the three portions of oily fish a week and at least half a dozen eggs it would require. So to get around 30mcg that many experts now recommend as the minimum you will need supplements, probably about 15mcg (800iu). But how much?
A meta-analysis of five trials involving patients with corticosteroid-induced bone mass loss showed that this combination of nutrients was effective.  However, not all trials have tallied with this finding. A study in 2005, involving more than 3,000 women at risk for osteoporosis, found no protective effect from giving 1,000mg of calcium plus 800iu of vitamin D (as cholecalciferol). 
Another, published in the New England Journal of Medicine in 2006, found a mild improvement in bone mass density, but no significant reduction of risk for hip fracture from 1,000mg of calcium and 400iu of vitamin D. 
If you are already suffering from joint or muscle pain you might want to experiment with taking a higher dose. You get vitamin D drops providing 25mcg per drop. One or two of these a day can really boost your vitamin D levels. They are well worth trying for a couple of months if you do have muscle or joint pain, or osteopenia or osteoporosis. You want to get your vitamin D level up to 70-100nmol/l.
Calcium alone doesn’t work
‘Bones are made of calcium, and milk is rich in calcium, so drink milk to strengthen bones.’ It’s a good story, but it’s very misleading. A recent review of studies giving calcium supplements finds that calcium alone doesn’t significantly reduce risk of fractures in postmenopausal women  unless vitamin D is also given, and it doesn’t increase bone mass density in children either. Marion Nestle, Professor of Nutrition at New York University, has long campaigned for good food and has also exposed the vested interests behind junk food. She is one of a growing number of experts who point out that there is no clear correlation between rates of osteoporosis and calcium intake from milk.  So, you and many medics may understandably be confused about calcium and bones.
Another recent study found that calcium alone, or even with vitamin D, slightly raised the risk of a heart attack,  while a third study found that getting more than 750mg was a waste of time. But such studies rarely consider the vitamin D levels of the patients, when low levels are linked with a greater risk of heart attack. What is more, giving a single mineral or vitamin is rarely effective.
In relation to calcium, your diet should provide around 800–1,000mg. The average intake is 900mg, because most people have a lot of dairy products. If you don’t have dairy products but do eat seeds, nuts and beans on a regular basis you should still achieve 800mg calcium plus other bone-friendly minerals such as magnesium. To get the ideal 1,000mg intake means supplementing a further 100–200mg, which is what should be in your daily multivitamin–mineral.
Some nutritionists recommend getting 1,200–1,500mg of calcium later in life, which means supplementing a further 400–700mg of calcium in total. There’s nothing wrong with this provided you also supplement the co-factor bone-building nutrients, which include magnesium, zinc, boron and vitamin D. A good multivitamin–mineral should provide these, plus at least 40mcg of vitamin K. This often-forgotten vitamin helps bone formation by stimulating a protein called osteocalcin, which also fixes calcium into the bone. Leafy green vegetables such as spinach, Swiss chard and Brussels sprouts are rich in vitamin K and are also good sources of calcium and magnesium. There are also bone-friendly formulas (see Resources) that might be worth taking as well to ensure you get the optimal levels for bone support.
Is natural progesterone an answer?
Bones have two kinds of cell: osteoblasts, which build new cells; and osteoclasts which get rid of old bone material, such as calcium. Oestrogen, which influences osteoclast cells, doesn’t actually help build new bone. It only stops the loss of old bone. Progesterone, on the other hand, stimulates osteoblasts which actually build new bone. 
In the time leading up to the menopause, most women start to have cycles in which ovulation doesn’t occur (known as anovulatory cycles). After the menopause ovulation never occurs. If no egg is released, no progesterone is produced (because progesterone is only made in the ovary sac once the egg is released). However, the body does continue to produce small amounts of oestrogen. Scientists are now starting to think that it is the relative excess of oestrogen to progesterone – creating, in effect, a progesterone deficiency – that precipitates osteoporosis, rather than the deficiency in oestrogen. This would explain why bone loss commonly starts from the age of 35, long before the actual menopause. In the pre-menopausal years, anovulatory cycles (in which no progesterone is produced) become increasingly common. Loss of bone mass density is known to occur in women who have such anovulatory cycles. 
As mentioned earlier, diet and lifestyle strategies should precede the use of hormone therapy, whether natural or synthetic. Applying natural progesterone when all the building blocks for bone health are not in place is a band-aid approach. If, for example, calcium is deficient in the diet or poorly absorbed due to low levels of stomach acid or ‘leaky’ gut, then relying on progesterone as a bone builder is somewhat missing the point.
Having said that, the late Dr John Lee used natural progesterone with his patients for twenty years and reported excellent results and no known serious side-effects. Dr Lee reported in The Lancet in 1990 that giving nature-identical progesterone, as a transdermal skin cream, was four times more effective than oestrogen HRT, with none of the associated risks.  However two placebo-controlled studies did not find natural progesterone applied according to the recommended standard instructions to be effective in preventing bone loss in postmenopausal women.
Professor Cooper, from Southampton University, reported following their study that there was no indication the creams did any harm, and there were some indications they could be beneficial in terms of reducing severe menopausal symptoms, such as hot flushes and night sweats. 
Natural progesterone, which is prescribable as Projuven, doesn’t increase breast cancer risk and may even help prevent it. As previously mentioned, natural hormones should only be used under the supervision of a medical practitioner experienced in their use.
Osteoporosis is a metabolic problem – not just calcium deficiency
It is important to understand that osteoporosis is not a calcium deficiency disorder - it is a disorder where calcium is lost from bone. 99 per cent of calcium in the body is in bone. Just replacing calcium and giving vitamin D that aids calcium being deposited in bone is linear thinking in terms of managing this devastating, largely preventable disease. Up to 4% bone loss a year can occur by the time a woman reaches her late sixties. Many women are now working beyond sixty and are seeking healthy active retirements.
Dairy products are a good source of dietary calcium and have long been promoted to women as a dietary intervention for the prevention and management of osteoporosis. Almost three-quarters of the world population live in the equatorial zone between the tropic of Cancer and the tropic of Capricorn, where cow’s milk is not used and a diet rich in plant food is depended upon. There is little incidence of osteoporosis in people living in these areas. By comparison there is a high incidence of osteoporosis in Sweden, where the intake of calcium-rich foods is high.
Harvard Medical School researchers reported that drinking lots of milk and eating calcium-rich dairy foods may not help women avoid bone fractures in later life and may, in fact, increase the risk. The 12-year study, which involved over 120,000 women throughout the United States, found that women who drank two or more glasses of milk per day actually had a 45 per cent higher risk of hip fractures and a 5 per cent higher risk of forearm fractures than women who drank less. 
Many nutrients have been shown to be important for bone health, including: calcium, magnesium, phosphorous, boron, zinc, vitamins D, C, K, A, and B6, antioxidant nutrients and protein. Calcium and phosphorous are the two major bone minerals.
The way the body absorbs and handles calcium in the body is very complex. Let’s take a look at why just taking additional calcium is only part of the answer.
Less Well Known Risk Factors
|Too much protein||Too little stomach acid|
|Inappropriate levels of stress||High use of stimulants and fizzy drinks|
|Poor intake of specific nutrients||Poor absorption of specific nutrients|
|Poor use of specific nutrients||High intake of phytates|
|Too much salt||Too much sulphate|
Too much and too little protein
One of the most significant, yet less well-known risk factors for osteoporosis, according to a World Health Organisation research survey, is excessive protein consumption.  This is for two main reasons. Protein is digested in the presence of high levels of acid (hydrochloric acid, or HCl) in the stomach; and women, particularly those over 50 years of age, often produce insufficient levels of this. HCl is also vital for releasing minerals from food, so low levels can lead to poor absorption of minerals, including calcium, magnesium and zinc, all of which are vital for bone health.
The second problem is that foods which are high in protein create strong acids in the body which has to work very hard to neutralise them. It does this by calling on body reserves of what are known as alkalising minerals, most significantly calcium. To maintain life, the blood has to be kept very slightly alkaline, and the body will do this at all costs, even if it means calling on calcium in the bones.
Eskimos - who suffer the highest rates of osteoporosis - have a classic high-protein diet: plenty of seal meat and fish, with very few fruits and vegetables. Fruits and vegetables contain acids, but they are weak and very easy for the body to dispose of. Red meat, chicken, fish, eggs and dairy produce are all high protein foods. The trend towards eating low-fat dairy foods may be protective to your blood vessels, but not as kind to your bones. As soon as the fat content of a food is lowered, the percentage of protein increases. So high intakes of cottage cheese and low-fat yoghurt may not be such a good idea after all. As mentioned earlier, a high percentage of world’s population do not eat dairy products. However, if eating little or no dairy products then it is essential to get good levels of calcium from other foods including nuts, seeds and dark green leafy vegetables.
The Nurse’s Health Study, conducted in the US and analysed by the Harvard School of Public Health, recently found that women who consumed 95g of protein a day, as compared with those who consumed less than 68g a day, had a 22 per cent greater risk of forearm fractures.  In another study, eating more than 80g of protein a day, which is equivalent to bacon and eggs for breakfast and a steak for dinner, was found to increase your risk of osteoporosis. 
This happens because protein is made of amino acids and protein-rich foods therefore generate more acid in the body. Because the body cannot tolerate substantial changes in the acid pH of blood, it neutralises or ‘buffers’ this effect through two main alkaline agents – sodium and calcium. When the body’s reserves of sodium are used up, calcium is taken from the bones – a finding that has been confirmed by ‘metabolic ward’ studies in which people are kept in a controlled environment, fed precise diets and measured for their calcium loss. Such studies have found that a negative calcium balance is created when 95g of protein is consumed while a person eats 500mg of calcium. The calcium intake must be raised to 800mg before calcium balance is achieved – that is to say, when the calcium entering the body is the same as the amount leaving. And the more protein you eat, the more calcium you need. The difference between the Bantus and the Eskimos is their protein consumption. According to a report in the American Journal of Epidemiology, an 11-year study of 40,000 elderly Norwegians also found increased risk of hip fractures among those eating high amounts of non-dairy protein (meat/fish/eggs), as well as among those who had either a high coffee or low calcium intake. 
The fact that high-protein diets lead to calcium deficiency is nothing new. Dr Shalini Reddy from the University of Chicago conducted a six-week study on ten healthy adults eating a low-carb diet. Volunteers lost an average of 9lb over the course of the study – that’s 1½ lb a week. That’s the good news. The bad news was that the acid excretion in the urine, which is an indication of acid levels in the blood, rose by 90 percent in some volunteers. There was also a sharp rise in the amount of calcium excreted in the urine during the low-carbohydrate, high-protein diets, and even the ‘maintenance’ diets for these regimes, despite only a slight decrease in calcium intake. This means the people were losing calcium from the body. Also, urinary citrate, a compound that inhibits kidney stone formation, decreased, implying an increased risk of kidney stone formation.  According to Dr Reddy, ‘Consumption of a low-carbohydrate, high-protein diet for six weeks delivers a marked acid load to the kidney, increases the risk for stone formation, decreases estimated calcium balance, and may increase the risk for bone loss.’ These studies all suggest that such high-protein diets may increase the risk of bone loss over the long term. Of course, we are going to have to wait a while to find out, but I’d rather you weren’t the guinea pig.
Research is also beginning to show that if you eat a high-protein diet, no amount of calcium supplementation can correct the imbalance. In one study, published in the American Journal of Clinical Nutrition, subjects were given a moderately high protein diet (12g nitrogen) and a very high protein diet (36g nitrogen) plus 1400mg of calcium.  The overall loss of calcium was 37mg per day on the 12g nitrogen diet and 137mg per day on the 36g nitrogen diet. The authors concluded that, ‘high calcium diets are unlikely to prevent probable bone loss induced by high protein diets’. The negative effects of too much protein have been clearly demonstrated in patients with osteoporosis. Some medical scientists now believe that a life-long consumption of a high-protein, acid-forming diet may be a primary cause of osteoporosis. 
Of course, this begs the question as to whether eating a lot of dairy produce (high in both protein and calcium) would be protective or contribute to osteoporosis risk. A 12-year study which involved over 120,000 women throughout the US, found that women who drank two or more glasses of milk per day actually had a 45 per cent higher risk of hip fractures and a 5 per cent higher risk of forearm fractures than women who drank less.  The director of the study, Diane Feskanich, said, ‘I certainly would want women to have adequate calcium in their diets, but I would not rely on that as the prime prevention against osteoporosis.’ There is no clear pattern of evidence that drinking milk prevents osteoporosis.
There’s some disagreement about how much protein you need for healthy bones. Ongoing research by Dr Carlos Isales, an endocrinologist at the Georgia Health Sciences University in the US suggests that getting the correct amount and type of amino acids – which are the building blocks of protein – helps to stimulate bone building by affecting the stem cells.
Official figures in both the US and the UK suggest that about a third of patients over 65 eat a diet that is both calorie and protein deficient. That, Isales explains, encourages the stem cells in your bone marrow to make fat rather than bone. ‘Fat is the cheapest thing for your body to make,’ he says ‘so making fat is the default.’
His team has already shown that the bones of mice put on a low-protein diet, which should have made them weaker, stayed strong when they were given an amino acid supplement. Together with vitamin D and calcium, the supplement triggers the signals that tell the body to make bone. You want to achieve at least 20 grams of protein a day from two servings of either fish, meat, eggs, beans, lentils, nuts and seeds.
Many factors can contribute to poor absorption of minerals, besides too little stomach acid. The small intestine is lined with thousands of minute structures called villi that waft about, maximising the body’s ability to absorb nutrients. Foods rich in gluten - wheat, rye, oats and barley - can blunt the villi, decreasing the surface area available for absorption. High intakes of dairy produce can also aggravate the gut membrane, leading to poor absorption. People in cultures that do not consume dairy foods have little incidence of osteoporosis. Another major factor known to interfere with good absorption is an overgrowth in the gut of the yeast organism Candida albicans that is responsible for causing thrush. Diets rich in phytates, found in wheat and soya products, can bind to important minerals in the gut like calcium, magnesium and zinc, impairing their absorption.
Too much stress
Just like too much protein, too much stress makes the body leach calcium from the bones. Stressors include caffeine, nicotine, drugs and physical or emotional pressure. Every time your body is stressed, a red alert signal goes out in the body. Whenever this happens calcium is called out of the bones into the blood to help prepare the body for the perceived danger. A stressful job, relationships, and or relying on tea, coffee, chocolate and cigarettes to see you through the day will almost certainly rob your bones of calcium. To add insult to injury, the calcium is not adequately called back into the bones, as the body hardly gets a chance over the day to perceive that the emergency is truly over. The level of calcium in the blood is very tightly regulated and so if not called back into the bone the body may ‘dump’ calcium on artery walls, in joint tissue or as part of a painful gall or kidney stone. Stressed people often show a high level of calcium in hair, which is another way that the body uses to ‘dump’ calcium.
Other Important Bone Nutrients
|Nutrient||Best Food Sources|
|zinc||nuts, seeds and wholegrains|
|vitamin A||yellow and deep green vegetables|
|vitamin C||berries, potatoes, most fruit and vegetables|
|vitamin K||cauliflower and green vegetables|
|vitamin B6||fruits, vegetables, wholegrains|
Increasingly vitamin K has been shown to be important for bone health. It helps urinary calcium loss and facilitates the binding of osteocalcin (a calcium-binding protein) to hydroxapatite crystals, helping to create the right balance of bone mineralization. Although we take in vitamin K in food, the gut bacteria also make a type of vitamin K, called K2 that we can store in the liver. Antibiotic therapy, stress, and poor digestive function can all upset bacterial balance in the gut, leading to poor manufacture of vitamin K.
Vitamin K2 activates a protein called osteocalcin that directs calcium into bones and teeth. Vitamin K2, in conjunction with vitamin D, has been shown to boost bone density far better than either nutrient alone. Perhaps more importantly, K2 has been shown to reduce fracture risk and improve bone health above and beyond bone mineral density. 
Antioxidant nutrients including vitamin A, C, E, zinc and selenium are important as free radicals are formed when bone is being broken down. As mentioned earlier, when oestrogen levels fall, the rate of bone breakdown is increased, leading to more free radicals being produced.
Certain plant foods contain phytochemicals that have hormone-like activity and cultures whose diets are rich in soya and/or wild yam, which both contain such phytochemicals, show little evidence of osteoporosis. Most interesting is the role of a group of naturally occurring hormone-like substances called isoflavones (a type of phyto-oestrogen) found in soya. These seem to enhance bone-building and prevent the breakdown of bone. Ipriflavone, a derivative of these naturally occurring isoflavones, has been extensively tested and has proven, in over a dozen trials, to increase bone density and decrease bone loss, when given with either calcium, oestrogen HRT or vitamin D, significantly more than when these are given alone. 
The Homocysteine Connection
One interesting discovery is the link between homocysteine, low B12 levels and bone and joint health. Over the last five years there have been more and more studies linking high homocysteine and low B12 levels to increased risk of fractures, osteoporosis and decreased bone mass density, particularly in women. Homocysteine is now thought to damage joints  and other tissue directly. It looks as if homocysteine actually damages bone by encouraging its breakdown and interfering with the collagen matrix which is what holds bone together. Collagen is made from vitamin C which is yet another reason why I recommend a daily intake of 1 gram taken twice a day.
A number of studies suggest that having a high level of homocysteine in your blood may weaken bone and increase the risk of fractures.  One of these was a very large study (involving 2268 men and 3070 women) by Dr. Clara Gjesdal and her colleagues at the University of Bergen in Norway - known as the Hordaland Homocysteine study – which showed that elevated homocysteine and low folate levels were associated with reduced BMD in women, but not in men.  When it was fracture risk that was being evaluated, two surveys from 2004 found a doubling to quadrupling in the incidence of fractures in people with high blood levels of the amino acid homocysteine. 
Dr. Markus Hermann, from the University of Sydney, Australia and colleagues from Germany and Italy reviewed a total of 28 studies and concluded that high homocysteine levels (and possibly B-vitamin deficiencies) have a detrimental effect on bone quality because they stimulate the cells that clear out old bone (osteoclasts). Since there is no direct effect on the bone-BUILDING cells (osteoblasts), old bone ends up being cleared away faster than new bone is produced. 
It is not yet clear if it is the homocysteine itself which is causing the damage to bone and increased fracture risk or whether homocysteine levels are just reflecting low levels or deficiencies of either folate or B12 - nutrients that DO have a direct effect on bone.  Some studies suggest that low folate levels influence bone mineral density (BMD) and/or fracture risk,  while others implicate B12.  Patients with a type of anaemia, called pernicious anaemia (caused by lack of B12 in the blood), have decreased BMD at the lumbar (lower) spine, and in comparison with the general population they have almost double the risk of hip fracture. 
Dr. Rosalie Dhonukshe-Rutten, from Wageningen University in the Netherlands, has shown that low B12 is associated with low BMD in adolescents and that frail elderly women with a B12 deficiency were seven times more likely to have osteoporosis than women with normal B12 levels. Older women, but not men, with low BMD had significantly lower vitamin B12 levels than older women with higher BMD.  This is because B12 has a direct effect on bone-building cells and also stimulates an enzyme involved in the process of forming new bone called alkaline phosphatise, or ALP for short. Another of her studies showed that high homocysteine and low B12 were significantly associated with less bone strength, increased bone turnover and a three times higher risk for fractures in men and women. However, the impact of low B12 was more severe in women than men, whereas high homocysteine was more associated with fractures in men. 
Not many studies have been done to see what effects supplementing homocysteine-lowering nutrients has on BMD and fracture risk. However, since stroke increases the risk of subsequent hip fracture by 2 to 4 times, one Japanese study followed 433 stroke patients, aged 65 and over, for 2 years to see if treatment with folate (5mg) and vitamin B12 (1500 mcg) would have any effect. The combined treatment of folate and B12 was found to be a safe and effective way of reducing the risk of hip fracture in these patients. 
A low level of oestrogen, which is very common in postmenopausal women, also appears to raise homocysteine and increase osteoporosis risk. Theoretically, increasing oestrogen could help lower homocysteine.  This has been shown in some preliminary studies,  but not in others. Until more is understood about how homocysteine and oestrogen are related, we are reluctant to recommend oestrogen HRT as a means to lower homocysteine for two reasons. One is that it is less effective than the nutritional strategy to lower homocysteine; the other is that it carries an increased risk of breast and uterine cancer. ‘Natural’ progesterone HRT (not to be confused with synthetic progestins used in most HRT preparations) does not have these associated risks. But no one has yet investigated whether this lowers homocysteine.
As B vitamins lower levels of homocysteine, supplementing B6, B12 and folic acid, plus TMG, could be a good idea. As many as 2 in 5 people over 60 are B12 deficient, if tested, and the lowest level that corrects B12 deficiency is 500mcg a day. While fish, meat, eggs and milk all contain B12 only milk and fish consumption are linked to increasing blood B12 levels, possibly indicating that these foods have more bioavailable B12. Even so, you are unlikely to get more than 3mcg of B12 from your food. Most B12 experts think that we could all benefit from a daily intake of 10mcg which is the minimum I’d recommend in a good multivitamin.
B6, another homocysteine-lowering vitamin, has also proven helpful for arthritis sufferers. Back in the 1950s, an insightful physician from Mount Pleasant in Texas, Dr John Ellis, found that giving B6 in higher daily doses of 50 mg helped to control pain and restore joint mobility to his arthritic patients.  Vitamin B6 shrinks inflamed membranes that line the weight-bearing surfaces of the joints, perhaps by helping decrease homocysteine and increase SAMe and glutathione, both proven anti-inflammatory agents. B6 also helps to regulate production of the prostaglandins, the body’s own anti-inflammatory agents.
Why a low GL diet might help
Bones are metabolically active. Professor Gerard Karsenty, Chair of Genetics and Development at Columbia University, New York, has found that the insulin you produce after a meal doesn’t only clear sugar but, among other things, it also triggers the ‘clasts’ in your bones to start building, because you’ve got the resources to do so – making bone uses up a lot of energy. That starts a whole sequence: the ‘blasts’ go to work as well, and that releases a hormone called osteocalcin into the bloodstream that stimulates insulin production from the B cells in the pancreas. Other metabolic players become involved, including the hormone, leptin (which signals that you are full from eating) and serotonin from the brain.  This work hasn’t had any practical effect yet, although osteocalcin is being looked as a possible diabetes drug. But it does suggest that ensuring the natural rhythm of bone creation and destruction might also help to maintain a healthy metabolism and that keeping your insulin levels in check by eating a low GL diet might help.
The importance of exercise
Good weight-bearing exercise, such as walking briskly on a regular basis, is a fine way to help keep calcium in the bones. However, if you already have osteoporosis, you will need a gentler programme (see ‘Exercise if you have osteoporosis’ below) as your bones will be too fragile to resist the stresses and strains, which are beneficial in stimulating bone growth in more robust individuals. Having said that, it is important that you take regular gentle exercise to maintain physical function and also to prevent further deterioration.
Osteoporosis Prevention and Reversal Plan
Prevention is far better than looking for a cure and, according to the work of the late Dr Lee, osteoporosis is a reversible disorder. It appears that, even for someone in their seventies, the condition can be reversed. The human body responds marvellously to being provided with the right raw materials needed for health. If hormone replacement therapy is still needed, consider natural progesterone as opposed to oestrogen HRT. The combined supplementation of vitamins and minerals, plus hormones, has not only proven more effective in restoring bone density, but is also more effective in retaining it once hormone replacement therapy is stopped.  Whether or not the complete approach recommended in this book – including diet, low stimulant intake, exercise and supplements – can replace hormone replacement therapy has yet to be put to the test.
Here’s what to do:
- Don’t consume more than 40g of protein a day, or less than 20g. This is not usually a problem for vegetarians, who should aim to have two servings daily of a protein vegetable food, such as lentils, beans or tofu. For a meat-eater this means meat certainly no more than once a day and, ideally, no more than three times a week.
- Supplement a bone mineral formula. This should include 500mg of calcium, 350mg of magnesium, 10 mcg of vitamin D, 2mg of boron, 10mg of zinc, plus vitamin C, 40mcg vitamin K and B vitamins.
- Supplement vitamin D. Ideally, test your vitamin D level and take whatever you need to get up to at least 70nmol/l. Many people need 50mcg (2,000iu) a day for the first three months.
- Consider using natural progesterone cream. If pre-menopausal, check your hormone levels and, if oestrogen-dominant, use natural progesterone. If post-menopausal, use it anyway. Your doctor can prescribe it. In case of difficulty, or for information, contact the Natural Progesterone Information Service at http://www.npis.info.
- Take regular exercise.
- Eat plenty of wholefoods and follow low GL principles.
- Eat plenty of nuts, seeds and yellow and green vegetables. Rely on seeds and nuts for minerals, not dairy products. Dairy products, especially cheese, are high in protein and oestrogenic hormones and low in magnesium. A heaped tablespoon of ground sesame, sunflower, flax or pumpkin seeds will give you significant amounts of calcium, magnesium and zinc, plus essential fats.
- Eat a varied diet that includes some soya milk, tofu and wild yam.
- Reduce animal protein to the minimum. Eat fish rather than meat. Fish is preferable, because it provides more anti-inflammatory essential fats and fewer oestrogenic hormones.
- Avoid ‘junk foods’, fizzy drinks and stimulants, such as coffee.
- Limit alcohol.
- Test your homocysteine and, if high, take a high strenth homocysteine formula providing at least 500mcg of B12, plus folic acid, B6 and other homocysteine lowering nutrients.
- Seek advice from a professional nutritional therapist to check out complicating factors like candidiasis, digestive function and individual supplement requirements.
Tests for Osteoporosis Risk
To assess your risk of osteoporosis, your GP can recommend a bone mineral density scan or a nutritional therapist can recommend a simple urine test.
Bone mineral density (BMD) scans
Two very good techniques are available that give reliable and accurate readings. BMD scans can be requested through your medical practitioner or paid for privately. Dual photon absorptiometry (DPA) is 96-98 per cent accurate for the hips and spinal column. Dual energy X-ray absorptiometry (DEXA) is also 96-98 per cent accurate but does use low-dose X-rays. These detect osteoporosis at moderately advanced stages.
This is a urine test that measures deoxypyridinoline (Dpd), a crosslink of collagen found in bone. This test enables your medical practitioner or nutritional therapist to identify and monitor your risk of bone loss. Dpd is a specific marker for bone resorption, i.e. how quickly old bone is cleared. The test is non-invasive and convenient and can demonstrate response to therapy as early as one month in. Pyrilinks-D is said to identify bone loss early in menopause. Results of a 22-month study involving elderly and pre-menopausal women with elevated Pyrilinks-D values showed double the risk of hip fracture.  Pyrilinks-D values combined with BMD scans predict risk even more accurately.
It is now possible to test for genetic variations in genes that are involved in bone breakdown, inflammation, collagen formation, and how calcium and vitamin D3 regulate bone metabolism. More personalized preventative and therapeutic nutrition strategies can be designed based on findings from genetic testing. The benefit of this type of genetic testing is that diet and lifestyle modifications can generally help reduce risk and or progression.
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