by Dr. John Neustadt

This blog provides helpful information and an overview of ways in which you can maintain strong bones. For an even deeper dive into bone health, and to create your holistic plan, read my book, Fracture-Proof Your Bones: A Comprehensive Guide to Osteoporosis.

Your body is constantly breaking down old, worn-out bone and creating new bone. This natural balance is required to maintain strong, healthy bones. However, when the bone breaks down faster than it’s created, bone mineral density (BMD) declines, bones become weaker, and fracture risk increases. 

Osteopenia (pre-osteoporosis) and osteoporosis are diagnosed using a dual-energy x-ray absorptiometry (DEXA) scan that detects your BMD. Repeating BMD tests every 18-24 months can show if the disease is getting worse or improving. The 2018 US Preventative Services Task Force (USPSTF) guidelines for osteoporosis screening recommend BMD testing for all postmenopausal women 65 years and older. Men and women who are younger than that but are at increased risk for osteoporosis should also get screened.¹

However, newer research may eventually result in changes to the screening recommendations to have all men and women screened at earlier ages. A 2019 study in the Journal of the American Osteopathic Association evaluated nearly 200 men and women ages 35-50 and found that one-quarter of them had osteopenia in the hip, showing that meaningful bone loss is occurring much earlier than previously believed.²

The biggest danger with osteoporosis is breaking a bone. Globally the disease causes an estimated 9 million fractures each year.³ When we’re younger, fractures rarely cause dangerous complications. But as we age, they become a lot more dangerous. If you have osteoporosis and break a hip, there’s a 20% chance that you’ll die within a year and your risk for being hospitalized is increased for five years after the fracture.⁴ As if that weren’t bad enough, a study published in the Journal of the American Medical Association determined that your risk for dying is elevated for five years after a vertebral fracture and for 10 years after a hip fracture compared to people who didn’t break a bone.⁵ 

Fortunately, there are proven integrative strategies that increase bone mass and reduce the risk of falls and fractures. 

Rethink Medications

Reversing osteoporosis means identifying and eliminating things that may be causing or exacerbating the disease. Many medications reduce bone density, create osteoporosis, and increase fracture risk. A couple of the more common ones are prednisone and acid-blocking medications. 

Alarmingly, oral prednisone is taken for six months or longer has been found to increase fractures up to 200%. For each 10 mg increase in dosage, there is a 62% increase in risk for bone fracture.⁶ Prednisone is frequently prescribed for autoimmune diseases and irritable bowel disease (IBD), which includes ulcerative colitis (UC) and Crohn’s disease (CD). 

Speak to your doctor to see if there may be an alternative to taking prednisone. You can also seek out the opinion of a healthcare provider trained in integrative medicine. They might offer complementary or alternative approaches to treat the underlying causes of your illness and allow you to wean off the prednisone. 

Acid-blocking medications, which include Prilosec, Protonix, and Aciphex, were never approved by the FDA for longer than two weeks of use, but many people take these medications for far longer than that without realizing the consequences. For each year someone takes these medications, their risk of hip fractures increases. One study published in the Journal of the American Medical Association concluded that after four years, acid-blockers increase the risk of hip fractures by nearly 60%.⁷ 

Antidepressants, thyroid hormone replacement, contraception, and cancer chemotherapy are also known to lower bone density. To learn more, read my blog, Are Medications Causing Your Osteoporosis?  

Exercise

Decades of research documents the positive effect exercise has on bone health. Weight-bearing exercise builds BMD. This type of exercise forces the muscles and bones to work against gravity, making both stronger. While the effects of weight-bearing exercises on the bone can be detected after about four to six months, consistency and persistence are important since the effects are greater when you keep working out for a year.⁸ One European study evaluated the impact one year of a combined weight-bearing training program had on BMD in women ages 66-87 years. The exercise regimen improved hip bone BMD by 8.4%.⁹

It’s important to recognize that there isn’t a one-size-fits-all recommendation. Lifting weights or doing sit-ups may be safe in someone with mild osteoporosis, but dangerous for people with severe osteoporosis. To find the right exercise for you, you must carefully evaluate and define the type, intensity, and duration of a program that will be safe. Some yoga or Pilates exercises may be fantastic for improving balance and strength in someone with osteoporosis. Yet without modifications and an instructor trained as an osteoporosis exercise specialist, even gentle yoga or Pilates may cause fractures in people with osteoporosis where the bones are already quite fragile.

Deciding what’s appropriate for you is based on your muscle strength, range of motion, balance, gait, heart and lung health, additional diseases you may have, bone density, whether you have a history of previous fractures and an assessment of your fall risk. I know as I’ve gotten older, even though my mind thinks I’m still in my 20s, my body lets me know I’m not. For years while I was in medical school, starting my clinic, having our two children, growing my dietary supplement company and writing books, I got out of shape. When I decided to start exercising again, however, I jumped right back into lifting weights and running at the same intensity as I did 15 years earlier. I kept getting injured until I worked with a trainer who could help me slowly and carefully get back in shape.

To create a safe and effective program, an exercise professional needs to understand your goals and your current condition. They also must evaluate how you walk, whether you have a history of falls or surgery, and how you use your body throughout the day. For example, do you sit all day or stand for long stretches of time? You should identify anything that can change a persons’ before you start working out. Failure to do so can create abnormal and dangerous stresses on the body, with damaging consequences. 

Before exercising, make sure to speak with your doctor and work with a professional who can help you create a safe program that will help you reach your goals. 

Diet

When it comes to food, your overall eating pattern is what’s important. A plant-based, alkaline diet that emphasizes whole foods and lean proteins can help. This is essentially the Mediterranean Diet. It’s based on the traditional eating pattern of people from the Mediterranean Sea basin in countries such as Greece, Italy, coastal Spain, and Southern France. 

This way of eating is in stark contrast to the Standard American diet, which is high in acidic foods and contains lots of fried foods, red meat, processed foods, salt, and refined grains. Unfortunately, the Standard American Diet creates chronic disease. There is evidence that this way of eating contributes to osteoporosis and muscle loss.¹⁰

In contrast, the Mediterranean Diet is low in red meat and high in vegetables, fruit, legumes, nuts, whole grains, olive oil, and lean proteins like seafood and chicken. A study that included 177 men and women aged 65 years or older found that people who followed a predominantly Mediterranean Diet were the least likely to fracture a bone when compared to other common dietary patterns.¹¹ 

A 2016 meta-analysis found that following a Mediterranean eating pattern reduced the risk of hip fracture by 21%.¹² And a case-control study of 290 middle-aged women (45–65 years), some with and some without an osteoporosis diagnosis, found that women who strongly adhered to the Mediterranean Diet had a lower risk of bone fracture. When the researchers documented the foods these women were eating, legumes and wine were observed to be protective against fractures, whereas diets that included butter and red meat put people at a higher risk.¹³

You can learn how to eat this way, which researchers have proposed should be included in strategies to promote bone health.¹⁴ 

Dietary Supplements

Several nutrients given as dietary supplements have been shown in studies to maintain bone strength and healthy bone density associated with reduce fracture risk.

Calcium and Vitamin D

Calcium and vitamin D are the nutrients most people think about when it comes to their bones. In fact, the FDA has approved health claims for calcium and vitamin D for bone health. Research has shown that calcium alone does not protect against fractures but does when supplemented with vitamin D3. One study tracked the fracture risk of more than 2,500 people whose average age was 73 years old. Supplementing with 400 IU vitamin D3 and 1,000 mg calcium daily reduced fracture risk by 16%.¹⁵

MK4

While two types of vitamin K2 (MK4 and MK7) can also promote healthy bones and support healthy bone density, only MK4 has been shown to reduce fractures as a primary endpoint in clinical trials, and only at the dose of 45 mg/day. Clinical trials show that 45 mg per day of MK4 can reduce fracture by up to 76%.^16,17 MK4 has also been shown to support bone health and healthy bone density in people:

• taking corticosteroids (eg, prednisone, dexamethasone, prednisolone)^18-21
• who have anorexia nervosa²²
• who have cirrhosis of the liver²³
• who have gone through menopause^24-28
• with decreased mobility (disuse)²⁹
• who have primary biliary cirrhosis³⁰
• taking leuprolide treatment (used to treat endometriosis, uterine fibroids, prostate cancer)³¹

Published studies have followed more than 7,000 volunteers for up to six years taking 45 mg and higher of MK4 daily. Published research has documented the safety in humans of 135 mg/day of MK4, and 250 mg/kg body weight per day in rats.^32,33 These studies concluded that MK4 does not increase the risk of blood clots in people who already have normal blood clotting. To put the animal dose in perspective. If a typical adult is 150 pounds, that would be the same as giving a human more than 17,000 mg MK4, which is nearly 380 times more per day than the 45 mg/day used in the published clinical trials.

Collagen

When collagen degrades, and old bone is broken down and assimilated, breakdown products are released.³⁴ One of these is C-terminal telopeptide (CTX). It can be measured in 24-hour urine, early morning spot urine, and blood samples. One benefit of measures like CTX is that they show changes much faster than can be detected on a DEXA scan.

Research has shown how closely linked this marker is to bone strength and high levels of CTX are associated with increased fracture risk in postmenopausal women.³⁵ A 2000 study published in the Journal of Bone and Mineral Research followed 435 women ages 31-89 years old for an average of five years. The highest urinary and serum CTX results were associated with fractures. If someone also had low bone mineral density and low levels of estrogen, their risk was even higher.³⁶ A different study published the same year in the journal Bone found that elevated CTX is strongly associated with fractures in elderly women.³⁷

The International Osteoporosis Foundation (IOF) and the International Federation of Clinical Chemistry (IFCC) recommend the CTX blood test as a marker for predicting bone health and bone strength.³⁸

The great news is that a clinical trial showed that taking collagen can lower CTX, indicating that collagen helps maintain strong bones. In a study of 51 postmenopausal women, CTX was decreased by taking 5 grams of collagen peptides daily, plus 500 mg calcium and 400 IU vitamin D3, for three months. A control group received only calcium and vitamin D3. CTX decreased almost four times more in the women taking collagen. In the collagen group, CTX decreased 11.4% compared to 3.5% in the volunteers who only took calcium and vitamin D3.³⁹ Given the importance of CTX, significantly decreasing this test result is an important step in doing all you can to maintain strong bones.

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