Osteoporosis affects an estimated 10.2 million American adults aged 50 and older, of which more than 80% are women. Another 44 million are at risk for osteoporosis due to loss of bone density (osteopenia). Osteoporosis, characterized by low bone mineral density (BMD), poses significant health risks, leading to fractures, reduced mobility, and a diminished quality of life. In a study based on almost 380,000 osteoporitic fractures in females, 10% had another fracture within one year, 18% within two years, and 31% within five years. In 2005, the economic burden of osteoporosis was estimated at 17 billion dollars. This article delves into the prevalence of osteoporosis, highlighting the urgency of its prevention, detection, and treatment, and explores the role of functional medicine in revolutionizing how we approach this widespread condition. (14)

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What is Osteoporosis?

Osteoporosis is a medical condition characterized by a loss of bone density and strength, making bones fragile and more susceptible to fractures. Essentially, the condition reduces the amount of bone tissue, causing bones to become less dense and weaker. 

Bone is a living tissue that undergoes a constant process of remodeling, where old bone is broken down by cells called osteoclasts, and new bone is formed by cells called osteoblasts. In osteoporosis, this balance between bone resorption (breakdown) and bone formation is disrupted, leading to a net loss of bone mass. Over time, this can make bones more brittle and prone to fractures, even from minor stresses or falls. (8) 

Osteoporosis Signs and Symptoms

Osteoporosis is often considered a "silent" disease because it usually doesn't cause noticeable symptoms until a fracture occurs. Fractures related to osteoporosis most commonly occur in the spine, hip, wrist, and other weight-bearing bones. These fractures can lead to chronic pain, reduced mobility, and a decreased overall quality of life. (18, 20) 

In some cases, subtle signs may indicate changes in BMD before fractures occur. These may include (8):

• Loss of greater than 1.5 inches in height and a rounded upper spine
• Receding gum lines and tooth loss
• Weakened hand grip strength
• Brittle fingernails
• Bone pain and muscle cramps

What Are the Possible Causes of Osteoporosis?

Primary osteoporosis is related to aging in conjunction with decreasing sex hormones. While osteoporosis can affect people of all ages and genders, it is most common in postmenopausal women due to the decline in estrogen levels, which plays a protective role in maintaining bone density. Similarly, the gradual decline in testosterone levels that can occur in aging men, termed andropause, can lead to an imbalance in bone remodeling and a higher risk of osteoporosis.

Other diseases or their treatments cause secondary osteoporosis. Medications that can cause secondary osteoporosis include glucocorticoids, anti-epileptics, chemotherapy agents, proton pump inhibitors (PPIs), and thiazolidines. Disease states that can cause osteoporosis include hyperparathyroidism, hyperthyroidism, chronic renal failure, and Cushing's syndrome.

Regardless of their cause, nutrient deficiencies can contribute to osteoporosis by depriving the bones of essential building blocks and regulatory factors. Vitamins D and K, calcium, and magnesium are crucial micronutrients for bone health; insufficient or deficient levels of any of these can negatively impact bone health. Nutrient deficiencies may occur due to poor or restricted diets, eating disorders, and malabsorption syndromes, such as celiac disease and inflammatory bowel diseases. (8, 20)

Other factors increase the risk of developing osteoporosis. These include having a family history of the condition, Caucasian and Asian race, sedentary lifestyle, excessive alcohol consumption, and smoking. (19) 

Functional Medicine Labs to Test for Root Cause of Osteoporosis

Dual-energy X-ray absorptiometry (DEXA) and the Fracture Risk Assessment Tool (FRAX) are two commonly used methods in diagnosing and assessing osteoporosis. DEXA is an imaging technique that measures BMD and is considered the gold standard for diagnosing osteoporosis and assessing fracture risk. DEXA uses a low-dose X-ray to measure the density of specific bones, typically the spine, hip, and sometimes the wrist. The results are reported as T-scores and Z-scores. A T-score of -2.5 or below is diagnostic for osteoporosis. (9) 

FRAX is an online assessment tool developed by the World Health Organization (WHO) that estimates an individual's 10-year probability of having a major osteoporotic fracture or hip fracture based on age, gender, body mass index (BMI), previous fractures, parental history of hip fracture, smoking status, alcohol consumption, glucocorticoid use, and the presence of secondary causes of osteoporosis. FRAX can assist healthcare providers in determining whether medication or other interventions are warranted. (25) 

Comprehensive Metabolic Panel (CMP)

A CMP is a blood test that provides valuable information about a patient's overall health, including their metabolic status, organ function, and electrolyte balance. While a CMP may not directly diagnose osteoporosis, it can offer insights into potential underlying factors, such as impaired kidney and liver function, endocrine disorders, and malnutrition, that contribute to bone health issues. 

Micronutrient Panel

A micronutrient panel is a blood test that measures various vitamins, minerals, and other essential micronutrients in the body. This panel can provide valuable information about a patient's nutritional status, which plays a significant role in bone health and can influence the development of osteoporosis. Nutritional factors are crucial in maintaining bone health, and addressing micronutrient deficiencies is an important aspect of the prevention and management of osteoporosis.

Sex Hormones

A comprehensive hormone panel is a set of blood tests that measure estrogen, progesterone, androgens, and related hormones and proteins circulating in the body. Evaluating hormone levels through a comprehensive panel can provide insights into the underlying hormonal factors affecting bone density. 

Thyroid Panel

A thyroid panel is a set of blood tests that assess the function of the thyroid gland. Because thyroid hormones directly impact bone health, and hyperthyroidism can lead to excessive bone loss, all patients with osteoporosis should have their thyroid function evaluated. 

Comprehensive Stool Analysis

A comprehensive stool analysis is a diagnostic test that offers valuable information about gut health and nutrient absorption, which can influence bone health indirectly. A comprehensive stool test measures markers of digestion, absorption, and inflammation. Abnormal results may indicate the presence of intestinal diseases leading to malabsorption and nutritional deficiencies.

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Conventional Treatment for Osteoporosis

The National Osteoporosis Foundation recommends treatment of postmenopausal women and men with a personal history of hip or vertebral fracture, a T-score of −2.5 or less, or a combination of low bone mass (T-score between −1 and −2.5) and a 10-year probability of hip fracture of at least 3% or any major fracture of at least 20% as calculated by the FRAX Fracture Risk Assessment Tool. (12) 

Fall prevention is a priority for all patients with osteoporosis. In addition to recommending physical therapy or an exercise program comprising weight-bearing and balance training, falls can be prevented by fall-proofing the home, staying up-to-date on eye exams, and wearing comfortable shoes with non-slip soles. (11, 12) 

Other non-pharmacologic treatments should include counseling regarding smoking cessation and minimizing alcohol consumption. The consumption of five ounces of wine, 1.5 ounces of spirits, or 12 ounces of beer daily negatively impacts BMD and increases the risk of falling. (12, 24) 

Oral bisphosphonates are the first-line pharmacologic therapy for patients with osteoporosis. They are antiresorptive agents that work by inhibiting osteoclasts and have been shown in clinical trials to reduce the rate of vertebral and hip fractures. However, an increased risk of jaw osteonecrosis is associated with bisphosphonates when taken for more than five years. (12)

Hormone replacement therapy (HRT), using estrogen with or without progesterone, reduces the rate of bone turnover and resorption in postmenopausal women. In a meta-analysis including 57 trials and about 10,000 women, BMD increased by 6.8% in the spine and 4.1% in the hip after two years of HRT. (24) 

Integrative Medicine Protocol for Osteoporosis

An integrative treatment plan acknowledges the complexity of osteoporosis. By addressing genetic, hormonal, lifestyle, nutritional, and environmental factors, an integrative medicine protocol can be very effective at preventing the development and progression of osteoporosis. 

Therapeutic Diet for Osteoporosis

Studies have shown that incorporating more fruits, vegetables, seafood, and dairy products into the diet can promote healthy bones and BMD. These food groups are rich in vitamins, minerals, antioxidants, and protein required to suppress osteoclast activity and promote bone mineralization. (22) 

In addition to limiting alcohol (discussed above), patients should be counseled to limit caffeine intake to one cup of coffee daily. Consuming more than one cup of caffeinated coffee daily has been associated with increased fracture risk. (12) 

A dietary recall can be helpful to ensure patients are meeting specific nutrient goals for protein, calcium, and vitamin D.

Protein

Protein-rich foods include poultry, red meat, seafood, eggs, legumes, nuts, seeds, and tofu.

Recommended Daily Intake: 1 gram protein per kilogram body weight (24) 

Calcium

Dietary sources of calcium include dairy products, bone-in sardines and salmon, kale, broccoli, and Chinese cabbage.

Recommended Daily Intake: 1,200 mg (24) 

Vitamin D3

Few foods naturally contain vitamin D. Those that do include fatty fish, beef liver, egg yolks, and mushrooms.

Recommended Daily Intake: 800 IU vitamin D3 (24) 

Best Supplements for Managing Osteoporosis

Depending on nutrient deficiencies discovered on lab testing and the patient's dietary intake of bone-essential vitamins and minerals, supplementation of calcium, vitamin D, vitamin K, and magnesium may be recommended to meet daily intake requirements.

Osteo-K

Osteo-K combines calcium, vitamin D, and vitamin K to support strong bones. It contains a type of vitamin K2, MK4, which promotes healthy bone density by directing calcium into the bone matrix. A 2022 systematic review and meta-analysis, including ten randomized controlled clinical trials and over 5,000 women, concluded that MK4 supplementation reduces fracture rate by 62%. 

Dose: 2-3 capsules twice daily

Duration: Ongoing

Magnesium

Magnesium is important for bone mineralization and is a common nutrient deficiency in the United States. People with higher dietary intakes of magnesium have a higher BMD, reducing the risk of bone fractures and osteoporosis. (16) 

Dose: 300-500 mg daily

Duration: Ongoing

When to Retest Labs

A DEXA should be ordered every 1-2 years to monitor osteoporosis and bone density. Functional medicine labs monitoring nutrient status, hormones, and gut health are generally reordered every 3-12 months, as indicated by clinical necessity and doctor/patient preference. 

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Summary

Prevention, early detection, and appropriate treatment are essential in managing osteoporosis and reducing the risk of fractures. Lifestyle modifications, proper nutrition, weight-bearing exercises, and medications, when necessary, can all play a role in maintaining bone health and preventing disease progression.