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Condition - Osteoporosis

Brittle bone disease

By Dr Pieris Nicola

Osteoporosis is a skeletal disorder characterised by low bone mass and compromised bone strength, resulting in weak and fragile bones and an increased risk of fracture. The National Osteoporosis Society in the UK estimate that about 3 million people are affected by osteoporosis.

Bones may seem like hard lifeless structures, but they are, in fact, a living tissue that is constantly being built up and broken down by the body. Osteoblasts are the name for cells that originate in the bone marrow and contribute to the production of new bone; and their counterpart is the osteoclast, a cell that is responsible for breaking down bone. Any time bone is broken down faster than new bone is made, you are losing bone mass and osteoporosis can occur.

White postmenopausal women are at greatest risk for developing the disease because their protective levels of the hormone oestrogen have declined. Following the onset of the menopause declining oestrogen levels can lead to a rapid loss of bone mass, because oestrogen decreases the rate of bone breakdown by osteoclasts and may also lower urinary calcium loss and increase intestinal calcium absorption, leaving the skeleton abnormally fragile and increasing the risk of hip, spine, and wrist fractures. It is estimated that 50,000 wrist fractures, 70,000 hip fractures, and 120,000 vertebral fractures occur each year. Fractures of the hip and spine are one of the most serious consequences of osteoporosis and contribute to disability, dependence, and increase the risk of death.

The number of osteoporosis cases in women of other racial groups and ages and men is also expected to increase over the next decades as life expectancy increases and the world population expands.

Osteoporosis is usually without symptoms or pain until the condition has progressed. As a result, the development of osteoporosis is hard to track, and is more often an incidental finding while undergoing evaluation for another problem, particularly via an x-ray (were as much as 50% of bone loss may have occurred already). In that respect, the focus of action must be on ‘maintaining strong bones’.


Risk Factors

Osteoporosis is a multifactorial disorder in which bone mass and the risk of osteoporotic fractures are determined by a large number of factors including:

  • Female gender.
  • Low level of physical activity – in particular weight-bearing exercise.
  • Increased age.
  • Body weight and composition.
  • Nutrition (see below).
  • Genetics.
  • Heredity.
  • Smoking.
  • Increased alcohol and caffeine intake.
  • Stress.
  • Hormone levels (i.e. oestrogen, progesterone deficiency).

Nutrition is only one factor contributing to its development but remains of great interest because it is a modifiable determinant. As a result, nutritional strategies that may prevent age-related osteoporosis and improve the quality of life are urgently needed, and are safer options than the use of hormone replacement therapy (HRT), which has been associated with a number of risks and side effects.

There are some diseases or conditions that can also increase the risk of osteoporosis including:

  • Hypochlorhydria (low gastric acid secretion).
  • Metabolic disease (i.e. hyperthyroidism).
  • Chronic diseases of the liver, kidney, and intestine.
  • Lactose intolerance.
  • Early menopause or the removal of the ovaries at a young age (under 45 years).
  • Behavioural distortion of eating associated with the eating disorders anorexia nervosa and bulimia.
  • Chronic stress.
  • Poor sleep patterns.

Certain medications may also increase the risk including:

  • Glucocorticoids.
  • Anticonvulsants.
  • Thyroid medication.
  • Proton-pump inhibitors.
  • Anticoagulant drugs.
  • Prolonged use of loop diuretics. 
  • Prolonged use of steroid drug treatment.

Nutritional Determinants of Bone Health

There have been a number of nutritional factors examined for associations with osteoporosis and bone mass. These include:

  • Calcium. Bones and teeth contain 99% of the body’s calcium and therefore a sufficient supply is required to build and maintain the skeleton. Intake of calcium supplements (recommended by the British national Osteoporosis Society for those with osteoporosis) may have a beneficial effect on bone mass especially when consumed consistently and long-term.
  • Magnesium. Around 60% of the body’s magnesium is located in bones and may be important in stimulating bone formation and supporting calcium balance, by promoting the normal secretion of parathyroid hormone and the activation of vitamin D.
  • Trace minerals including boron, copper, and manganese. Boron may play an important role in maintaining calcium balance and hence bone health. In addition, it may also be necessary for the activation of vitamin D within the body - vital to bone health. Copper is required for the cross-linking of collagen which is critical for its stability. Both Zinc and Manganese are cofactors for enzymes essential to bone tissue and may be important for the maintenance of bone mass.
  • Vitamin K2 plays an important role in bone metabolism. This is not surprising considering the presence of vitamin K-dependent proteins in bone.
  • Vitamin D3 regulates calcium balance and is also required for optimal calcium absorption. Calcium absorption is a critical factor for calcium balance in the body.
  • Vitamin C is a cofactor for collagen formation and synthesis of hydroxyproline and hydroxylysine (major components of collagen).
  • Collagen is a key element in the organic matrix of bone.
  • B-vitamin (B Complex) status (folic acid, B6, and B12) may be a risk factor for decreased bone health. However, low levels may also result in elevated homocysteine levels, which may adversely affect bone health.
  • Long chain omega-3 fatty acids present in fish oil, and omega-6 fatty acids present in starflower oil and hemp seed oil may have a positive effect on bone metabolism and may help maintain or possibly increase bone mass, and calcium absorption.
  • Phyto-oestrogens present in fermented soy products and flaxseeds may reduce the acceleration in bone mineral loss associated with reduced oestrogen output during the menopause, thereby helping to maintain bone density.
  • Certain plants are also rich in organic pigments called Carotenoids (i.e. Beta-carotene), which may also have a protective role for bone mineral density in older men and women.

Dietary intakes of the above nutrients may positively affect bone mass (many of these nutrients are present in a multivitamin/mineral combination and some are available as separate items).

Dietary Advice

  • Consuming a diet low in sodium (sodium chloride) and high in potassium-rich, bicarbonate-rich foods (e.g., fruits and vegetables) has emerged as an important modifiable protective factor for bone health.
  • Consume oily fish including the bones (e.g. in tinned mackerel, sardines, and salmon) which are high in calcium and good sources of omega-3 fatty acids. Nuts and seeds (including walnuts, flaxseeds, and almonds) and healthy oils (cold pressed flax, walnut, and hemp seed oils) are also rich in essential fats and nutrients that may be beneficial to bone health.
  • Eat foods high in calcium and vitamin D. Good sources of calcium include moderate amounts of low-fat dairy products (avoid excess); and dark green, leafy vegetables. Good sources of vitamin D include oily fish and free range eggs.
  • Reduce red meat consumption and avoid soft drinks which are high in phosphoric acid. A low calcium:phosphorus ratio is associated with increased parathyroid hormone secretion which will draw calcium from bones.
  • Increase your intake of whole grains, green leafy vegetables, nuts (esp. almonds), bananas and apricots, which are rich in magnesium.
  • Avoid excessive use of alcohol. High levels of alcohol intake have been associated with an increased risk of osteoporosis, possibly by interfering with the absorption of calcium and the activation of vitamin D within the body.
  • Reduce caffeine consumption. High caffeine consumption may increase the amount of calcium lost from the kidneys, increasing the risks of osteoporotic fractures. 
  • Avoid an excessive intake of dairy products. Dairy products are acid-yielding foods which may increase bone loss. Try alternatives to dairy milk including rice and soya milk.
  • Habitual green tea consumption may increase bone mineral density.
  • Consume sufficient amounts of protein. Protein is an important component of bone tissue. Beans and pulses are good vegetarian sources of protein as well as fibre.
  • Reduce dietary salt intake. Salt may increase urinary calcium excretion.
  • Avoid refined carbohydrates (including sugar, and white flour products - bread, rolls, croissants, pasta, processed cereals, cakes and pastries). Refined carbohydrates may increase urinary calcium loss.

Lifestyle Recommendations

  • Regular exercise may play an important role in preserving bone and maintaining bone mass, in particular weight-bearing activities such as walking, jogging, and aerobics.
  • Sunshine. Regular and sensible exposure to sunlight will help to boost your body’s production of vitamin D, which may in turn have a beneficial effect on bone health.
  • Avoid smoking. Smoking has been associated with low bone mineral density and poor intestinal calcium absorption.

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