Building Better Bones
What is good for the bones is good for the rest of you, too.
Bone health has become a major concern for people as we get older and sedentary. And it is a major selling point for dairy products. So, there can and has been many conflicts of interest in getting to the truth of what really is helpful for growing and keeping strong bones.
About one of every two women will have an osteoporotic bone fracture in their lifetime, while about one in four men also will. You have seen how people shrink as they get older. Elderly people usually are much shorter than when they were younger and stronger. Their bones have literally gotten smaller, and usually more brittle. The bones can become so brittle that the hip bone breaks first and then a person falls as a result of the fracture. And you don’t want that to be you.
While some shrinkage may be inevitable, as well as some loss of strength, taking proper care of your body over the years and decades will pay back multiple dividends as you get older.
I have a much older, much longer article on this topic, but here are the main points in a form that gets you the information in a much shorter article. After all, not everyone wants to read a 12+ page paper examining the evidence for this and against that. Many of you just want to know what to eat and consume to have strong bones, and you don’t need all of the research details of how much risk reduction was caused by which nutrient.
Calcium
Contrary to much advertising, calcium, and especially dairy products, are not the main food for stronger bones. In several long-term studies of populations intake of calcium was not related to risk of fracture.
A review by Lanou et al [1] found that in 37 studies of children and adolescents and dairy and bone health 27 of these studies found no relation between dairy or unsupplemented dietary calcium intake and measures of bone health. In the remaining 10 studies the effects were small and 3 studies were confounded by intake of vitamin D. There was not even a modestly consistent benefit of dairy products nor total dietary calcium for child or young adult bone health. Lanou et al also pointed out that studies have found exercise to be a more important factor for children and adolescents to achieve peak bone strength than calcium intake.
Not only does calcium not help build strong bones, but supplemental calcium could deadly. Several researchers have found a higher risk of a heart attack in several different randomized controlled trials for the groups taking supplemental calcium, but not a higher risk of heart attacks from getting calcium from foods [2–9]. Of course, this result is questioned by others [10, 11] as calcium is kind of a “sacred cow” or maybe a “cash cow” to many. Since this is a contentious point, I left a several references in here for you to peruse at your leisure.
Osteoporosis Drugs
Remodeling of bones is a constant process, with a balance struck between the osteoblasts building new bones and osteoclasts breaking down old bone material. This remodeling process keeps your bones fresh and strong. Over a period of about 10 years you have a whole new skeleton. The main mechanism of the bisphosphonate class of drugs used for osteoporois is to slow down the breaking down of old bones by osteoclast cells. This makes your bones look more dense on bone scans, which helps sell the drugs, but it may not be true that they are stronger. Old dense bones are marginally better than new weak bones, but there has to be another choice, right? It turns out that bisphosphonate drugs are also a risk factor for getting what is called osteonecrosis of the jaw [12], which is a non-healing hole in the jaw leaking nasty toxins into the bloodstream after a dental surgery. No thanks, I’ll pass on that one. So, it is best to avoid the drugs and make dietary and lifestyle choices that promote better bones.
What About Protein?
Does animal protein cause a loss of bone minerals? The concept put forward is that when you eat lots of animal products the protein causes a loss of calcium into the urine so that you end up with weaker bones. But it turns out that animal protein also causes an increase in calcium absorption, so it works out that animal protein does not cause a net loss of bone minerals.
Even so, there is some evidence that plant protein is more protective for bone health than animal protein. Data from 33 countries shows that hip fracture rates varied from 0.8 fracture per 100,000 person-years in Nigeria to nearly 200 fractures per 100,000 person-years in Germany [13]. The figure below shows the cross-sectional relationship between the hip fracture rates in 33 countries as a function of the ratio of vegetable to animal protein intake. In countries where plant protein intake was greater than animal protein intake there were less fractures. In a follow-up prospective study to the 33 countries study, Sellmeyer et al found that while BMD was not related to the ratio of animal to vegetable protein, the women with the highest ratios of animal to vegetable protein lost bone faster (0.78%/year vs. 0.21%/year), and they had a 3.7-fold higher risk of hip fracture [14]. So, it may be true that an animal product rich diet will give a person stronger peak bone mass density in their youthful years, but it seems to be that such a diet will induce greater losses of this bone and result in more fractures over time in their middle-aged and older years. But maybe it is more than just the protein in the meat and the vegetables, because these foods are different in many ways.
Fruits & Vegetables
Plants provide a lot more than protein, just as animal products also provide a lot more than protein. The potassium and magnesium and organic acids, which break down into alkaline bicarbonate, mitigate the metabolic acidosis that comes from eating a large amount of animal products. A population study in Scotland of about 3,000 women near menopause tested the relation between bone health, potassium and protein intake. Adequate protein intakes were found beneficial to bone health, but higher potassium intakes were still significantly correlated with higher BMD at the femoral neck and urinary markers of bone resorption [15]. So don’t forget to eat your fruits and veggies.
Vitamin C
Vitamin C plays several roles in the body related to bones, as pointed out by Dr. Thomas Levy [16]: it reduces oxidative stress in bone tissue as an antioxidant, it promotes the growth and activity of osteoblasts (the cells which build new bone), it suppresses the activity of osteoclasts (the cells which break down old bone), it is essential for the formation of collagen, a major protein in bone, and it promotes the cross-linking of the collagen matrix in bones to improve its tensile strength. Higher intakes of dietary and supplemental vitamin C have been shown in multiple studies to promote stronger bones and fewer osteoporotic fractures [17–19].
Magnesium
While calcium has been heavily promoted for preventing osteoporosis, magnesium has been quietly researched as a potential factor in promoting stronger bones. Good sources of magnesium include nuts, seeds, fruits, and vegetables, so dietary intake of magnesium is often correlated with intakes of potassium, vitamin C, and carotenoids, which all contribute to better bone health by themselves. So, it can be difficult to tease out the effects of just a single nutrient when it is usually consumed in foods containing many other nutrients. Even so, the evidence has grown over the last decade that magnesium itself is an important mineral for strong, fracture resistant bones.
A review in 2021 looked at 28 studies of dietary intake of magnesium, blood levels of magnesium, and supplemental intake of magnesium in relation to bone mass density and fracture risk [20]. The researchers found lower serum magnesium levels were related to the presence of osteoporosis and that hypomagnesia was present in about 30-40 percent in post-menopausal women. Lower dietary intakes of magnesium were related to lower bone mass density and higher fracture risk. And supplemental magnesium intake is related to short-term markers of better bone strength and lower fracture risk.
Vitamin D
Vitamin D has been in to spotlight for over 20 years now. It doesn’t take a lot of vitamin D to make strong bones, but even higher intakes, usually around 5,000 IU per day or higher, are beneficial for overall health and for skeletal health as well. A study in Romania showed that elderly men and women eating a daily bread roll fortified with 5,000 IU of vitamin D and 800 mg calcium optimized their blood levels of 25-hydroxy vitamin D and increased their hip bone mass density by 28 percent [21]. This is an incredible bone density increase, as an annual 3% increase is typical for the best current drugs. It is clear from this study that vitamin D levels need to be optimized, not just increased a little bit to really get stronger, denser bones.
Vitamin K
Low levels of vitamin K are a risk factor for weak, brittle bones. Vitamin K is a necessary cofactor for a modification, called gamma carboxylation, of osteocalcin. This modification of 3 glutamic acids in the peptide chain of osteocalcin enables the protein to bind to hydroxyapatite, the mineral portion of bone. Vitamin K thus directs calcium to be deposited in bone tissue. (Vitamin K also prevents calcium from being deposited in soft tissues like arterial walls, but that is for another article.) Observational studies have shown greater rates of hip fractures among those with low amounts of vitamin K.
Vitamin K comes in a few different forms—K1 (phylloquinone) from vegetables and K2 (menaquinones, a few different forms like MK-4, MK-7, MK-9) from animal products. There are benefits to the K2 forms that don’t appear to come from the K1 form of vitamin K. Both K1 and K2 have been shown to be protective to bone health. Eating leafy greens and other green vegetables every day gets you a healthy dose of vitamin K1.
Homocysteine (Folate-B6-B12)
Elevated levels of homocysteine result from low intakes of B vitamins, specifically B-6, B-12, and folate. Hyperhomocysteinemia is an established risk factor for heart disease and also for dementia. Several reports have shown that high levels of homocysteine also put a person at risk for bone fractures. Taking a B-12, B-6, folate supplement will lower homocysteine levels, but it hasn’t been proven yet that doing so will lower the risk of osteoporotic fractures.
Hormones
Hormone replacement therapy, HRT, for women used to be a thriving business for doctors and drug companies. An artificial estrogen, Premarin, from pregnant mares, was given to post-menopausal women to replace the levels of estrogen that had been present in their bodies before menopause. Premarin did increase bone density, but it came with the side effects of increased risk of breast cancer, heart attacks, strokes, and blood clots in the legs and lungs, detected in the Women’s Health Initiative in 2002. HRT with Premarin was discontinued, but there still is a place for hormone replacement therapy with natural, bio-identical hormones.
Dr. John Lee’s name is synonymous with natural progesterone cream. In his medical practice he found that women with low bone density could gain new bone mass by using a natural progesterone cream. In his published results the lower the initial bone density the higher the increase until BMD was normalized, with an average gain of 22 percent over 3 years for women with very low BMD [22].
Poor Digestion
Poor or weak digestion is a problem for many people as they get older. People generate less hydrochloric acid in their stomachs with age thus decreasing the absorption of minerals. Taking antacids and proton pump inhibitors like omeprazole (Prilosec®) further exacerbate the problem. This can cause many problems, including weaker bones. Digestive enzymes have helped many people improve digestion. Betaine hydrochloride is often used to deliver more hydrochloric acid to the stomach, though it shouldn’t be used if it isn’t needed. Testing first would make sense.
Exercise, especially Weight-Bearing Exercise
Bones are a living piezoelectric crystal. This means that bones respond to physical stress and convert it into an electric current directing bone growth and remodeling to best meet the stress put on them. This is the mechanism for how exercise or the lack of it affects bones. Weightlessness in space travel causes a rapid decrease in bone mass [23]. Complete bed rest also decreases bone mass quickly. The saying “use it or lose it” applies equally well to our bones as it does to our muscles. In fact, those individuals with stronger muscles have stronger bones as well.
In children and adolescents it has been estimated that exercise is a more important factor in bone density and strength than calcium intake [24]. Athletes have been found to have stronger bones compared to sedentary controls in numerous studies. Weight-bearing exercise is the most effective form of exercise for making your bones stronger. Lifting heavy weights, for example, is a safe and excellent exercise for bone health. An 8‑month trial of heavy weight lifting and impact exercise by 60-70 year old women with low bone density found significant improvements in bone density and functional strength compared to a low-intensity exercise program [25]. The figure below shows the dramatic difference between the results of strength training with heavy weights and low intensity exercise.
Building Blocks for Better Bones
Here is a summary of what you need to have strong bones and a healthy body at the same time.
Eat a plant-based diet based on whole foods with sufficient plant protein. Junk foods do not build a healthy body or strong bones. Plant foods should be favored over animal foods.
Eat lots of vegetables. The strength of a plant-based diet is in the vegetables. Vegetables provide bone-promoting magnesium, potassium, vitamin C, vitamin K, folate and organic acids. Even heavy meat eaters will benefit from eating lots of vegetables.
Do weight bearing exercise. Lifting heavy weights can be done safely and is a proven method for even older people to get stronger bones.
Take supplemental vitamin C, for multiple reasons, including stronger bones.
Take supplemental vitamin D, or get enough sunshine to optimize 25(OH)D levels.
Women may use natural hormone replacement with natural progesterone with benefit.
References
1. Lanou AJ, Berkow SE, Barnard ND (2005) Calcium, Dairy Products, and Bone Health in Children and Young Adults: A Reevaluation of the Evidence. Pediatrics 115:736–743. http://pediatrics.aappublications.org/content/115/3/736
2. Anderson JJB, Kruszka B, Delaney JAC, He K, Burke GL, et al (2016) Calcium Intake From Diet and Supplements and the Risk of Coronary Artery Calcification and its Progression Among Older Adults: 10‐Year Follow‐up of the Multi‐Ethnic Study of Atherosclerosis (MESA). Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease 5:. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5121484/
3. Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, et al (2010) Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ 341:c3691. https://pubmed.ncbi.nlm.nih.gov/20671013/
4. Bolland MJ, Grey A, Avenell A, Gamble GD, Reid IR (2011) Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women’s Health Initiative limited access dataset and meta-analysis. BMJ 342:d2040. http://www.bmj.com/content/342/bmj.d2040
5. Bolland MJ, Grey A, Reid IR (2013) Calcium supplements and cardiovascular risk: 5 years on. Ther Adv Drug Saf 4:199–210. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4125316/
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7. Reid IR, Bristow SM, Bolland MJ (2015) Cardiovascular complications of calcium supplements. J Cell Biochem 116:494–501. https://onlinelibrary.wiley.com/doi/10.1002/jcb.25028
8. Tankeu AT, Ndip Agbor V, Noubiap JJ (2017) Calcium supplementation and cardiovascular risk: A rising concern. J Clin Hypertens (Greenwich) 19:640–646. https://onlinelibrary.wiley.com/doi/10.1111/jch.13010
9. Li K, Kaaks R, Linseisen J, Rohrmann S (2012) Associations of dietary calcium intake and calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg). Heart 98:920–925. http://heart.bmj.com/content/98/12/920
10. Pana TA, Dehghani M, Baradaran HR, Neal SR, Wood AD, et al (2021) Calcium intake, calcium supplementation and cardiovascular disease and mortality in the British population: EPIC-norfolk prospective cohort study and meta-analysis. Eur J Epidemiol 36:669–683. https://link.springer.com/article/10.1007/s10654-020-00710-8
11. Heaney RP, Kopecky S, Maki KC, Hathcock J, MacKay D, et al (2012) A Review of Calcium Supplements and Cardiovascular Disease Risk. Adv Nutr 3:763–771. http://advances.nutrition.org/content/3/6/763
12. Sedghizadeh PP, Stanley K, Caligiuri M, Hofkes S, Lowry B, et al (2009) Oral bisphosphonate use and the prevalence of osteonecrosis of the jaw: An institutional inquiry. J Am Dent Assoc 140:61–66. http://jada.ada.org/cgi/content/abstract/140/1/61
13. Frassetto LA, Todd KM, Morris RC, Sebastian A (2000) Worldwide incidence of hip fracture in elderly women: relation to consumption of animal and vegetable foods. J Gerontol A Biol Sci Med Sci 55:M585-92. http://biomed.gerontologyjournals.org/cgi/content/abstract/55/10/M585
14. Sellmeyer DE, Stone KL, Sebastian A, Cummings SR (2001) A high ratio of dietary animal to vegetable protein increases the rate of bone loss and the risk of fracture in postmenopausal women. Study of Osteoporotic Fractures Research Group. Am J Clin Nutr 73:118–22. https://pubmed.ncbi.nlm.nih.gov/11124760/
15. Macdonald HM, New SA, Fraser WD, Campbell MK, Reid DM (2005) Low dietary potassium intakes and high dietary estimates of net endogenous acid production are associated with low bone mineral density in premenopausal women and increased markers of bone resorption in postmenopausal women. Am J Clin Nutr 81:923–33. https://pubmed.ncbi.nlm.nih.gov/15817873/
16. Levy TE (2013) Death By Calcium, First Edition. Medfox Publishing
17. Sahni S, Hannan MT, Gagnon D, Blumberg J, Cupples LA, et al (2009) Protective effect of total and supplemental vitamin C intake on the risk of hip fracture - A 17-year follow-up from the Framingham Osteoporosis Study. Osteoporos Int 20:1853–1861. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2766028/
18. Morton DJ, Barrett-Connor EL, Schneider DL (2001) Vitamin C supplement use and bone mineral density in postmenopausal women. J Bone Miner Res 16:135–140. https://pubmed.ncbi.nlm.nih.gov/11149477/
19. Kim YA, Kim KM, Lim S, Choi SH, Moon JH, et al (2015) Favorable effect of dietary vitamin C on bone mineral density in postmenopausal women (KNHANES IV, 2009): discrepancies regarding skeletal sites, age, and vitamin D status. Osteoporos Int 26:2329–2337. https://link.springer.com/article/10.1007%2Fs00198-015-3138-6
20. Rondanelli M, Faliva MA, Tartara A, Gasparri C, Perna S, et al (2021) An update on magnesium and bone health. Biometals 34:715–736. https://pubmed.ncbi.nlm.nih.gov/33959846/
21. Raloff J (2005) Bread and Chocolate, No Longer D-Minimus. Science News Online 167:. https://www.sciencenews.org/blog/food-for-thought/bread-and-chocolate-no-longer-d-minimus
22. Lee JR (1990) Osteoporosis reversal with transdermal progesterone. Lancet 336:1327. https://pubmed.ncbi.nlm.nih.gov/1978152/
23. Smith SM, Nillen JL, Leblanc A, Lipton A, Demers LM, et al (1998) Collagen cross-link excretion during space flight and bed rest. J Clin Endocrinol Metab 83:3584–91. https://pubmed.ncbi.nlm.nih.gov/9768669/
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25. Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, et al (2018) High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. J Bone Miner Res 33:211–220. https://pubmed.ncbi.nlm.nih.gov/28975661/