Osteoporosis is a disease of the bones in which there is a loss of both bone mineral density (BMD) and bone strength. It is a global issue, affecting 10.2 million adults over the age of 50 in the US alone, with nearly 9 million people suffering worldwide from osteoporotic-related fractures. With the numbers expected to rise as the population continues to age, there is no better time than now to emphasize the importance of leading a lifestyle that promotes optimal bone health throughout the lifespan.  

Bones are a matrix of living cells whose health is largely dependent on their host. Bones come in different shapes and sizes and function in supporting the overall structure and movement of the body by playing a vital role in protecting organs. They are home to an incredible matrix of collagen, minerals (especially calcium), hormones, growth factors, and immune cells. Bone marrow, found within the center of the bone, contains stem cells that are responsible for the formation of red blood cells (RBC), white blood cells (WBC), and platelets, all of which are essential for the human body to thrive.  

The skeletal system undergoes annual remodeling as an important bone health and regeneration process. This process is intricate and, depending on the circumstances, can be sped up or slowed down. The primary cells responsible for building and breaking down bone are osteocytes, osteoclasts, and osteoblasts. Osteocytes help to keep bone tissue alive and healthy. Osteoblasts build new bones. Osteoclasts are formed by monocytes (immune cells) in the bone marrow. In order to make room for the new bone, old bone must be destroyed and removed by osteoclasts. When osteoclasts break down more bone than osteoblasts can build, a reduction in bone mass begins and leads to osteoporosis.  

Bone density is not the only important factor when it comes to bone health. Ensuring that people maintain appropriate muscle strength to support their bones and prevent injury is crucial. This loss of strength as we age leads to reduced function, range of motion, and increases one's risk of falls. Let's compare bones to trees. Trees must be strong to stay rooted in the ground and hold the weight of their limbs. They must be able to bend and withstand the forces of Mother Nature. If that tree is weak and inflexible, a strong gust of wind can cause it to break. Bones are very similar. Not only do they need to be strong and dense, but they must also be flexible to withstand full ranges of motion, so they do not break under pressure, as is often the case in osteoporosis.  

Understanding what lifestyle choices will have the most significant impact on bone health is important to prevent osteoporosis as you age.

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Osteoporosis Signs & Symptoms

Unlike other diagnoses, Osteoporosis is often silently occurring "behind-the-scenes." Unfortunately, most individuals are not aware of the health of their bones until they either have undergone routine screening or they've sustained a fracture. There are, however, some very subtle changes that may be a sign or symptom of osteoporosis. These include:

• Loss of > 1.5 inches in height and a rounded upper spine: This occurs as a result of the bones in the vertebrae collapsing due to reduced density (i.e., weakness). On x-ray, one may find evidence of small fragility fractures. For some, a fragility fracture in the absence of a BMD scan is diagnostic of osteoporosis.
• Dental Health: If jawbones are less dense, they will shrink in size. This will affect how the gum is attached to the bone and may result in receding gum lines. Other dental disorders or infections may suggest poor bone health.
• Hand Grip Strength: Grip strength is a strong indicator of decline in older adults when impaired. A weak grip strength correlates with low BMD.  
• Weak, Brittle Finger Nails: Nails share similar properties to bones. Although there are many reasons in a person's life for why they may not have strong nails, like occupation, hobbies, cleaning chemicals, or time in the water, poor nail quality may suggest suboptimal bone health.  
• Muscle and Bone Pain: These can signify low Vitamin D, an essential nutrient in bone health. Individuals with Vitamin D deficiency have experienced pain symptoms.
• Night Cramps: These painful cramps may be due to low levels of calcium, magnesium, and vitamin K, all of which are important nutrients in bone health.
• Fractures: In persons over 50, sustaining a fracture often results in Bone Mineral Density (BMD) assessment. Interestingly enough, some literature regarding fractures and osteoporosis suggests that, although there is a very well-known association between lower BMD and increased fracture risk, osteoporosis is not the leading cause of fractures and can only predict them in 30% of cases.  

Osteoporosis Possible Causes

The health of bones is a reflection of the health and balance in the entire systemic body. Bone density decreases as a normal part of aging, but it is prudent to explore root causes when this process is accelerated. These include:  

Age, Gender & Race

It is well-known that women, especially over the age of 50, account for the most cases due to shifts in hormones as she enters peri-menopause, menopause, and post-menopause. However, women of younger age can certainly be affected. Interestingly, men can also struggle with low bone density.  They account for 29% of osteoporotic-related fractures and, when the hip is involved, are associated with higher morbidity and mortality rates, compared to women. Hormones play an essential role in bone health by helping with bone metabolism and the activity of osteoblasts. Aside from one's gender and age, race can also play a role, with Native Americans having the highest incidence.  

Sedentary Lifestyle

Lack of movement contributes to a reduction in bone density and muscle mass and results in weakness, gait instability, and loss of balance.

As we age, this loss of muscle mass, called sarcopenia, is associated with higher rates of falls and fragility fractures seen in osteoporosis.

Chronic Stress

Chronic stress wreaks havoc in many ways. First, stress triggers immune system activation. The body needs calcium (and other minerals) to be freed up to aid in countering inflammation during this process. If there aren't enough available minerals in the body, the bone is broken down to make these minerals available.

Second, stress causes a reduction of stomach acid that impairs the body's ability to properly digest the many essential nutrients, minerals, and amino acids needed for healthy bones.

Third, sustained levels of stress also contribute to high levels of cortisol, a stress hormone. When cortisol is elevated, it signals the body to lose more calcium in urine rather than helping to ensure that it is properly deposited in the bones.

Lastly, chronic stress affects hormone levels. In the role of bone health, all hormones are important; however, progesterone and estrogen play critical roles. Estrogen plays a positive role in bone biology and osteoporosis prevention and treatment, primarily by decreasing bone resorption. Progesterone appears to play a differing but physiological role in partnership with estrogen in achieving optimal peak bone mass.

Diet

A diet high in refined sugar causes oxidative damage to the endothelial lining of blood vessels and organ systems. This oxidative stress stimulates an immune system response, increasing cortisol levels and resulting in more calcium loss from the bone.  

Medications

Proton Pump Inhibitors (PPIs) and other acid-suppressing medications are associated with increased risk of osteoporosis, even in young adults. PPIs are widely prescribed and, by design, work to reduce the amount of stomach acid that is produced. As a result of decreased stomach acid, proteins in foods cannot be broken down to release essential amino acids and other nutrients necessary to maintain proper bone health.

Other medications like steroids, diuretics, seizure medications, antidepressants, chemotherapeutic drugs, and anticoagulants can affect bone metabolism.  

Nutrient Deficiencies

Calcium has been viewed as the most important nutrient for bone health. However, several nutrients work together to maintain bone density. For example, Vitamin D increases calcium absorption and utilization. Vitamin K is required to make osteocalcin, which helps bind calcium in the bone. With low levels of any of these, bone mineral density is impaired.

Food Sensitivities

Eating food that your body sees as a threat causes inflammation in the gut. The inflammation triggers immune system activation, which, as previously mentioned, causes the breakdown of bone. Moreover, the associated inflammation affects the ability to properly digest and absorb the proper nutrients for bone health.

Toxins

High toxic exposure contributes to chronic inflammation that breaks down bone density. Toxins can range from heavy metals, like lead or aluminum, to chemicals in personal hygiene products, like triclosan or endocrine-disruptors. Pesticides, plastics, alcohol, and smoking are other examples.  

Genetics

Like in many diseases, genetics may increase one's chances of developing Osteoporosis.

Functional Medicine Labs to Test for Osteoporosis

Scans

The traditional method of assessing BMD is via a Dual-energy Xray Absorptiometry (DXA) scan, a low-dose x-ray. The USPTF recommends screening for Osteoporosis to begin at age 65 for women. The data is insufficient to support routine screening in men. However, people with and of the risk mentioned above may be recommended to have earlier screening.

The findings of a DEXA scan will provide a T-score that compares the health of bones to that of a healthy 30-year-old. Normal bone density is considered having a T-score greater than -1.

Osteopenia, a condition with early signs of bone loss, presents a T-Score between -1 and -2.5.

T-Scores that fall below -2.5 are consistent with Osteoporosis. The DEXA scan will also provide a Z-Score, which compares findings with the same age, gender, and race.  

FRAX

An additional tool used to assess fracture risk is called the Fracture Risk Assessment Tool (FRAX). By taking one's age, gender, race, BMD scores, and other relevant medical history, this tool can help to predict a person's 10-year risk of having a fracture. Along with implementing specific lifestyle changes, this can be a helpful guide to determine whether or not pharmacologic management would be appropriate.

Labwork can often give some clues into the health of our bones. These include:

Basic Laboratory Markers

Traditional lab work can provide great insights into bone health. A Comprehensive Metabolic Panel, CBC w/ differential & platelets, and Vitamin D 25OH will provide information about nutrient levels, the health of blood cells, and the immune system.

Inflammation

Inflammation, as a driver of osteoporosis, can be assessed by testing C-Reactive Protein (hs-CRP) and ferritin. CRP will be elevated if inflammation is present. Ferritin is the body's primary storage of iron, and although primarily used to evaluate anemia, it can point towards a chronic, simmering infection if it is elevated. Either of these labs can help explore further root causes of osteoporosis.  

Hormones

Hormones Panel: Hormone health is integral for optimal bone density as they direct osteoblast and osteoclast activity.

Testing sex hormones like estrogen, progesterone, cortisol, and DHEA will be helpful guides.

The Parathyroid hormone (PTH) helps regulate calcium and is another helpful marker.  

Gut Inflammation

When there is a concern for inflammation or dysbiosis, obtaining a Comprehensive Stool Test can be helpful. Here, you will identify any possible pathogens and inflammatory markers present in the stool.

Food Sensitivity Testing

Eliminating food triggers can help reduce systemic inflammation allowing bone health to be restored.
Toxins

Total-Tox Burden & Organic Acid

‍This is an incredibly comprehensive test that provides information about metabolic processes, amino acid health, and toxic burden, all of which play critical roles in bone health. In persons whose overall symptoms are more complex, this information helps prioritize the steps towards healing.  

Functional Medicine Treatment for Osteoporosis

Food as Medicine

Learning which foods nourish our bodies the most is essential for the health of all of our body systems. Whole, organic foods will reduce gut inflammation and shift the microbiome to an optimal state.

Consider gluten and dairy-free if there is a presence of autoimmunity. In addition, our choices in beverages are equally important. Drinking plenty of clean water should be prioritized. Limit or avoid alcohol. Not only are many beverages high in sugars, artificial flavors, and coloring that provide empty calories and promote oxidative stress, some, like soda, contain properties that promote calcium loss in urine.

Move Your Body

Specifically for bone health, weight-bearing exercises stimulate bone regrowth. These can include strength training, HIIT, jump roping, jogging, dancing, or hiking. Incorporating movements that increase flexibility is also essential. Stretching after work-outs, when watching TV, or incorporating yoga classes into your schedule are excellent ways to ensure flexible muscles and joints. Remember, we need strength and flexibility to achieve optimal bone health and function in the long term.

Eating Hygiene

How you chew your food matters. Whether you're eating in a calm, relaxed space or on the run in between kids, activities will also affect how your body can digest food. We must be in a relaxed, parasympathetic state for proper digestion and absorption to occur. Make an effort to chew your food 20-30 times before swallowing. This will force you to slow down, enjoy your meal, and enhance digestion.

Reduce Stress

An essential part of overall health is reducing the level of stress experienced, especially if this stress is sustained. Ways to reduce stress include deep breathing exercises, meditation, journaling, faith or spirituality practices, singing, dancing, snuggling with a pet or loved one, or time outdoors. Find a hobby that brings joy and passion. By decreasing stress, you will shift from a sympathetic, fight or flight state to a parasympathetic, rest and digest state, which will reduce inflammation.  

Reduce Toxins

Choose foods without preservatives, chemicals, fillers, or pesticides. Swab out synthetic fragrances with high-quality essential oils. Search the EWG database for healthier alternatives to your home and personal hygiene products. Eat fish low in mercury (ex/ salmon, sardines, anchovies, haddock).

Supplements

Depending on deficiencies found in bloodwork, supplements may be necessary. Osteoporosis is most commonly associated with vitamin D, Calcium, Vitamin K2, and magnesium deficiencies. Calcium is best obtained from foods given the risk of cardiovascular events and kidney stones related to calcium supplementation. In the presence of Vitamin D deficiency, it is vital that individuals over 40 also take Vitamin K2 to ensure that calcium is being properly escorted into your bones where it is wanted, rather than into your blood vessels and organs where it causes calcification.  

Hormone Replacement Therapy

Hormone Replacement Therapy (HRT): A controversial topic for some; however, the decline in hormones is often a driver of osteoporosis. Using HRT, estrogen or progesterone can help by preventing the action of osteoclasts from breaking down bone. Depending on risk factors, HRT may be an important tool in preventing and treating osteoporosis.  

Pharmaceuticals

There are several medications available for the treatment of osteoporosis, including HRT. Currently, bisphosphonates are the first-line treatment. They work in stopping the pathway of osteoclasts in breaking down bone; however; as a result, they impede the action of new bone formation. Bisphosphonates also come with significant side effects that may limit their use. That being said, osteoporosis medications play an important role in disease management, especially if used in the short term to slow down the rate of bone destruction while supporting the body in other ways to heal and rebuild.  

Summary

Osteoporosis is a disease that affects many men and women as they age. Since signs and symptoms of osteoporosis are subtle, it is imperative that people take a proactive stance on optimizing bone health and preventing accelerated bone loss.

These lifestyle choices can and should start in one's teens, 20s, and 30s to have strong, flexible bones in the later years of life. Prioritizing healthy nutrition and stress reduction and engaging in weight-bearing and stretching activities are necessary steps in preventing and treating osteoporosis.