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Gerry Gajadharsingh writes:
Bone is a living tissue, constantly replenishing itself with new cells provided we boost it with nutrition and physical activity. Keeping your bones in robust health will help to protect against osteoporosis, a condition that affects 3.5 million people in the UK, and which Queen Camilla has sought to highlight as the president of the Royal Osteoporosis Society (ROS). Not only does the condition cause 50 per cent of women and 20 per cent of men over 50 to break a bone, but emerging evidence also suggests it might play a role in the decline of brain function.
Medicine has historically focused on single active ingredient medications, although more recently science is starting to accept that combining different active components in medications can be sometimes more beneficial to patients.
The concept of using different active components has been accepted in the nutritional supplement world for quite some time. Given that patients have individual and unique physiologies, it’s likely that they need several active components of whatever the intervention is to optimise the beneficial effects. It is rare to find any single thing that benefits 100% of the population.
Osteoarthritis (sometimes called “wear and tear” or degenerative arthritis), is incredibly common as we all get older. Many people tend to accept it as a consequence of age, previous damage or trauma to joints, or sporting activity leading to overuse on specific joint structures. From a functional medical perspective, I would tend to also focus on the things that we might be able to change, the vascular support for the joint (adequate arterial supply and venous drainage), good function of the supporting connective tissue structures such as muscles, fascia and cartilage, the function of the joint itself (both in range and quality of movement) as well as the physiology of the patient in relation to their diet and nutrition, which has a significant impact on the health of the joint.
Medical interventions, such as partial or total replacement, for advanced osteoarthritic change for example in hip joints, is now well established unusual very successful.
However, the old adage, prevention is better than cure, suggests that intervening well before the joint has passed the point of no return, deserves consideration.
The other common concern regarding bone health is bone density (the hardness of bone structure). Decreasing bone density or mass or when the quality or structure of bone changes is called Osteopenia and is the initial stage of bone loss, which can progress to osteoporosis, a more severe condition. The difference between osteoporosis and osteopenia is usually based on what we call T scores obtained in a bone density scan (DXA). A T score >-1 is considered normal, T -1 to T -2.5 suggests Osteopenia, a T score <-2.5 means Osteoporosis.
A T score compares current bone density (when the scan was performed) to peak bone density, usually at 30 yoa in a woman, set at 0.
DXA, is normally considered the goal standard for bone density measurement, attempts to measure bone density in the lumbar spine and the hips. Interestingly, it does not measure bone density in the thoracic spine (which is of particular importance to Osteopaths and some of the techniques they use in this area). It is also sometimes hard to interpret if there is coexisting osteoarthritic change which can lay down increased bone tissue particularly in specific areas of the lumbar spine.
NHS Guidance says that you may need to have a bone density scan if you’re: over 50 with a risk of developing osteoporosis or under 50 with other risk factors, such as smoking, long term steroid treatment or a previous broken bone.
In practice it is not that simple. NHS screening for osteoporosis is recommended for women who are 65 years old or older and for women who are 50 to 64 and have certain risk factors, such as having a parent who has broken a hip.
For men it is sometimes harder to obtain a DXA and the guidelines are >75 years of age. I had a male patient recently (58 years old) who had been vegan for three years and I had to justify my private request for DXA (which is correct as it does involve a small amount of ionising radiation), as he fell outside the guidelines. I was able to secure him a DXA which confirmed osteoporosis.
it just goes to show that guidelines are guidelines, imaging such as DXA should be based on clinical considerations not just guidelines (taking into account not to expose patients to unnecessary ionising radiation).
Online tools such as FRAX are often used to gauge the threshold for requesting a DXA.
There are also biochemical markers (via blood tests) such as Crosslaps DPD (increased levels indicate increased bone resorption), alkaline phosphate (increased levels indicate enhanced osteoblastic activity), calcium, phosphate and Vitamin D.
Normal bone metabolism is maintained by a balance between osteoclastic bone resorption and osteoblastic bone formation, ensuring stable bone mass.
The parathyroid glands also have a part to play. The main function of the parathyroid glands is to make the parathyroid hormone (PTH). This chemical regulates the amounts of calcium, phosphorus and magnesium in the bones and blood.
Bone density decreases when the body loses too much bone, makes too little bone, or both. As a result, bones become weak and may break.
The bones most often affected are the hips, spine, and wrists. Women are four times more likely to get osteoporosis than men because of a decrease in Oestrogen after menopause.
By the way a private DXA is about £100
Nutrient Support
Calcium, Magnesium and Vitamin D
Historically medical literature suggests that a lifelong lack of calcium plays a role in the development of osteoporosis. Low calcium intake contributes to diminished bone density, early bone loss and an increased risk of fractures. Eating disorders and severely restricting food intake and being underweight weakens bone in both men and women. Let’s see what happens when long term data emerges from the new GLP1 agonists, if patients don’t focus on eating healthily and are just focused on weight loss.
https://www.thehealthequation.co.uk/unseen-cost-of-weight-loss-and-aging-tackling-sarcopenia/
Whilst understandable and for decades, the main focus of bone density management/osteoporosis prevention has been in the form of calcium supplementation (and latterly the introduction of Vitamin D). In functional medicine, we’ve always had an issue with just taking calcium without balancing it with magnesium.
The same receptors that regulate calcium also impact magnesium. Studies have found that calcium directly or indirectly competes with magnesium for intestinal absorption and transport, especially if calcium intake is much higher than magnesium intake.
Our body doesn’t rely on magnesium to absorb calcium. But without it, calcium can become toxic, depositing itself in soft tissues, kidneys, arteries and cartilage rather than in bones where it has the greatest benefit. Research has specifically confirmed the laying down of excess calcium in arterial structure therefore increasing cardiovascular risk.
Obtaining calcium by food from the diet carries a minimal risk compared to calcium supplementation, it is because of the much higher levels of calcium attained in supplementation hitting the system all at once.
Vitamin D levels enhance calcium supplementation.
Kidney function is also important. A good proxy for estimating kidney function is something called estimated glomerular filtration rate (eGFR). The number you see on a blood test result report equates approximately to a percentage. So, the best number you can get for example on a TDL lab report is eGFR >90. The cut-off is lower than 60, which usually needs investigation. There are many conditions such as diabetes, chronic kidney disease and medications such as proton pump inhibitors which can reduce eGFR. Dehydration is also another common cause as is simply age, probably aggravated by the fact that as many people get older, they take multiple medications. As kidneys work harder and their filtration mechanisms go down it is thought that this allows chemicals to build up in the body, including calcium.
Any clinician familiar with functional medical approaches will have known for years that calcium and magnesium normally need to be taken together if you’re going to use supplementation, as they both work closely together and minimise the laying down of excess calcium in other body tissues. Therefore, if a standard dose of calcium is 1000 mg we usually need between 400 and 500 mg of magnesium (although it depends on the type of magnesium supplement used), as most functional clinicians use the ratio 2:1.
https://www.thehealthequation.co.uk/calcium-supplements-linked-to-worse-outcome-in-aortic-stenosis/
https://www.thehealthequation.co.uk/calcium-and-cv-risk-are-supplements-and-vitamin-d-to-blame/
The primary source for dietary intake of Magnesium (Mg) is derived from fruits and vegetables, but it is recognised that Magnesium content in fruits and vegetables has dropped in the last fifty years, and about 80% of this metal is also lost during food processing. Stress, alcohol, caffeine, certain prescription, drugs, even excessive or deficient vitamin D levels can all adversely affect magnesium levels.
Magnesium deficiency may contribute to osteoporosis by affecting calcium metabolism and bone density.
So, calcium with magnesium and vitamin D so far, but what about other nutrients?
Boron
In 1994, in the Journal of Environmental Health Perspectives, Rex Newnham, an Osteopath in Yorkshire published a paper regarding the importance of Boron, which is a trace mineral and its relationship to healthy bones and joints. Building on research from the early 60s including epidemiologic evidence that in areas of the world where boron intakes usually are 1.0 mg or less/day the estimated incidence of arthritis ranges from 20 to 70%, whereas in areas of the world where boron intakes are usually 3 to 10 mg, the estimated incidence of arthritis ranges from 0 to 10%.
Boron plays an important role in osteogenesis, and its deficiency has been shown to adversely impact bone development and regeneration. Boron influences the production and activity of steroid hormones, actions via which this trace mineral is involved in the prevention of calcium loss and bone demineralization.
Boron supplementation also increased an active form of oestrogen and thyroid hormone in blood. These hormones are involved in the maintenance of healthy bones.
Note Care is suggested with Boron supplementation for women with conditions where increased Oestrogen can be harmful e.g. some forms of breast and uterine cancer.
3mg of Boron is still the dosage used in high-quality bone density support nutritional supplements.
Vitamin K
Vitamin K’s key role is to help heal injuries through blood clotting and strengthen bones. Researchers suggest that this vitamin has other benefits too, such as easing morning sickness and protecting cognitive functions, including thinking, memory, learning, and organizing skills. It may also help protect heart health.
What about negative nutrient effects?
There is also research, linking the consumption of carbohydrates, especially those with a high glycaemic load (the report below refers to glycaemic index, which doesn’t take into account the available carbohydrate content) and its negative effect on bone density. It’s both the quantity and the quality of the carbohydrate, that’s important in relation to bone health. The mechanism has been attributed to acute increases in glucose and insulin levels after consumption of high–glycaemic index (load) food, which causes increased oxidative stress and secretion of inflammatory cytokines, such as interleukin 6 and tumour necrosis factor alpha (TNF alpha), that activate cells in bone that increase bone loss. Don’t forget, that vegetables are also carbohydrates, but they tend to have a much lower glycaemic load (therefore, not precipitating such an elevated insulin response). Processing carbohydrates (smoothies and juices) increases the amount of free sugar available. It’s one of the reasons why I’m not a big fan of overconsumption of smoothies or juices whether it’s fruit or vegetables!”
https://www.thehealthequation.co.uk/what-impact-do-carbs-have-on-bone-health/
What about low bone density and brain function?
It is known that there is an association with hormones, and in women in particular decreasing oestrogen after the menopause has a significant association with bone loss. It is possible that in men there is also an association with decrease in testosterone as men get older.
A Dutch research team showed that participants with the lowest bone density were 42 per cent more likely to develop dementia than people in the highest group, suggesting bone density reduction might precede cognitive decline.
In a new study published in the journal Neurology, a team of Dutch researchers from Erasmus University Medical Centre in Rotterdam reported how people with low bone density may have an increased risk of developing dementia compared to people with better bone strength. In an eleven-year study of 3,651 people with an average age of 72, none of whom had dementia at the start of the investigation, 688 people or 19 per cent of participants went on to develop the condition. When the researchers cross-referenced cognitive tests with x-rays of bone density taken every four to five years, they discovered that a significantly higher number of those with the lowest body bone density scores had developed dementia compared to people with good bone health.
https://www.thehealthequation.co.uk/bone-density-and-its-relationship-to-decline-in-brain-function/
Other Suggestions for Improving Bone Health
Don’t rely just on vitamin D
Vitamin D is “extremely important for bone health”, says Ian Varley, associate professor in exercise physiology at Nottingham Trent University. Partly this is because it enables the gut to absorb and utilise other bone-friendly nutrients such as calcium and phosphate obtained in the diet. The government recommends a supplement of just 10mcg between October and April when sunlight, the main source, is scarce although an ROS survey found that 54 per cent of people don’t take it.
“If you are deficient in vitamin D or prone to low levels because you don’t spend much time outdoors and don’t get it from food, then a dietary supplement of 10mcg is probably necessary all year round,” Varley says.
A supplement won’t work in isolation, however — you’ll need to address other aspects of bone health such as calcium and other micronutrient intake and exercise. Last year, a New England Journal of Medicine study reported that healthy adults in their fifties or older who took vitamin D daily for five years did not have a lower risk of fractures than people who didn’t take the supplement.
“You can also get too much vitamin D,” Varley says. “In one study, older people with osteoporosis who were given very high doses of vitamin D had an increased risk of fractures because their muscles were weakened by toxicity and they were prone to falling and breaking bones.” Advice from the NHS is “not to take more than 100mcg (4000IU) a day as it could be harmful” so beware of supplements containing such high amounts.
Physical Activity, Regular weight-bearing exercise
In the age groups that these exercises are necessary, patients are often have coexisting musculoskeletal conditions that can make these sorts of exercises quite challenging so this needs to be done with some thought.
Women, spend two minutes jumping
Weight-bearing and high-impact exercises — anything that requires you to carry your own bodyweight through a series of jumps and jolts — work by applying forces that pull down on the skeleton to strengthen it and are essential for maintaining healthy bones. Running, dancing and sports that involve an element of jumping such as tennis, basketball and football are fantastic for bones.
If you don’t have time for those then two minutes of specific bone-building exercises performed three times a week could make a difference, according to a research team from the University of Hull and Manchester Metropolitan University. Performing one jump or high skip from standing every four seconds — or even every 15 seconds if you wanted a longer rest — helped to maintain strong bones in early post-menopausal women in their fifties. “Jumps and jolts are fantastic for bone health,” Peel says. “We should all do them often if we can.”
Men, do more hops, lunges and squats
High-impact, weight-bearing exercise is as important for men as it is for women, with weight and resistance training shown to be beneficial for boosting male bone health. A University of Missouri study of men aged 25-60 with low bone mass found that both those who performed resistance training exercises such as weighted lunges and squats twice a week or a jumps workout including single-leg and double-leg jumps and hops three times a week for a year had lower levels of a protein called sclerostin, which has a negative effect on bone formation. Both exercise groups also displayed higher levels of IGF-1, a hormone associated with bone strength. “Anything that puts the skeleton under this beneficial stress is helpful for men as well as women,” Peel says. “When your muscles pull on your bones it gives them extra work to do and they respond by renewing themselves and maintaining or improving their strength.”
Adjust your coffee intake
A high intake of caffeine (about 6-8 cups of coffee a day) has been shown to leach calcium from bones and excrete it in urine, but 2-3 cups daily has been shown to have a potential bone-boosting effect. A study published in the Journal of Clinical Endocrinology and Metabolism found that metabolites of coffee produced during its digestion appeared to produce better bone density in the lumbar spine and the neck of femurs in habitual coffee drinkers. “I’ve been involved in osteoporosis research for three decades and the consensus is that moderate caffeine probably won’t make much difference to bone health,” Peel says. “And an occasional high intake is unlikely to be harmful either.”
Have a regular sauna
Regular exposure to heat can have a protective effect on bone density, with one study suggesting that spending time in warmer temperatures of about 34C boosts bone strength and prevents the loss of bone density that leads to osteoporosis. “It seems that changes in the composition of gut microbiota are triggered by heat and that translates into beneficial bone mineral changes,” Varley says. If extended summer holidays abroad are out, then a regular sauna might suffice. Spanish researchers showed that men who took three saunas a week for 12 weeks had better bone mineral density and bone mineral content by the end of their trial. “If you have access to a sauna in theory it would do the trick,” Varley says.
Sort out excessive snoring
Obstructive sleep apnoea, or OSA, is a condition where the walls of the throat relax to cause abnormal breathing patterns and lower levels of oxygen in the body. According to the British Lung Foundation, it is estimated to affect about 1.5 million people although 85 per cent of the people thought to have it remain undiagnosed. It’s particularly common in male, middle-aged, elderly and overweight people and one of the key symptoms is excessive snoring.
According to recent research from the University of Buffalo in New York, those who have OSA might also be more prone to weaker bones. Thikriat Al-Jewair, associate professor of orthodontics at Buffalo and lead author of the paper used a special type of x-ray called “cone beam computed tomography” to assess bone health in the heads and necks of 38 adults, 50 per cent of whom had OSA. She found that those with sleep apnoea had significantly lower bone mineral density than those without it. Al-Jewair says treating the condition could reduce “propensity for low bone-mineral density” — if you are a heavy snorer, your GP may refer you to a sleep clinic for tests.
The mechanism seems to be decreased oxygen. But don’t forget with many breathing pattern disorders which affect many people, the issue is generally one of an inability to retain enough carbon dioxide (because they breathe too deeply, or they breathe too fast), and low CO2 in the body, compromises oxygen delivery on a cellular level. Many people also chronic mouth breathers, which also tends to aggravate obstructive sleep apnoea, as well as being designed to smell our nose was also designed to breathe with!”
Don’t take PPI’s (Proton Pump Inhibitors) Long Term
“Proton pump inhibitors (PPIs) are a very commonly prescribed drug such as Omeprazole, (also available over the counter), for symptoms such as Gastro Oesophageal Reflux Disease (GORD). Used, in the short term, they can certainly give symptom relief in many patients. I read an article several years ago, after they first appeared, suggesting that they should not really be used long term. Obviously, this was not read by patients nor some of their prescribers, as many patients seem to have taken them long term. Like many drugs taken long term, there will be a consequence, some of the adverse effects from PPI’s are now being realised. Many clinicians also notice an adverse effect on magnesium levels, an important mineral that the body needs for many of its systems to work properly.
https://www.thehealthequation.co.uk/do-ppis-increase-the-risk-for-renal-damage-or-mortality/