Bone Health 101 Part III Treatments

Treatments: Medical

Hormone Therapy. Estrogen therapy can prevent bone loss at the time of menopause. Bone density usually remains stable as long as estrogen is taken, but bone loss happens quickly when estrogen is stopped. Other osteoporosis drugs (bisphosphonates) may then be used for a few years to prevent the rapid loss that occurs if estrogen is discontinued. For women who cannot take estrogen, bisphosphonates are approved to prevent the rapid bone loss of early menopause and then, after several years, can be stopped, at least temporarily. 

Raloxifene is considered in women a few years beyond menopause who no longer have hot flashes, are not yet at high risk for hip fracture and do not have risk factors for venous thrombosis. Anti-remodeling drugs (bisphosphonates and denosumab) are usually chosen for women at high risk of fracture. These treatments improve bone density modestly and reduce fracture risk by as much as 70%. However, these drugs do not rebuild the skeleton nor repair the damaged bone structure. 

If you have been diagnosed with significant bone loss, the most common pharmaceuticals prescribed are Fosamax (generic alendronate) and Actonel (generic risedronate). They work by slowing down the rate of bone loss. Results are often limited in some patients and for those with mild bone loss, there is little evidence these drugs help (4). EVENITY is a newer drug claiming to promote bone regrowth. For women at very high fracture risk, bone-building therapies are recommended as initial treatment, followed by an anti-remodeling drug to maintain the skeletal benefits. 

Lifestyle Medicine: Prevention and Restoration

Lifestyle measures help keep bones healthy but won’t prevent estrogen induced rapid bone loss.

Nutrition. 

Calcium: Ensure your diet includes foods high in calcium such as sardines, nut milks (e.g. almond), broccoli, non fat plain yogurt, firm tofu, bok choy, collard greens, kale, cottage cheese, canned salmon, milk. Some foods high in calcium may not be easily absorbed by the body eaten raw however such as brocoli. The average woman between 18-50 years should consume 1,000 mg of calcium, and those over 50 should get 1200 mg. This may require supplementation in the form of a daily calcium pill. Adequate vitamin D levels are required to enable calcium absorption. A supplement is likely required in geographic areas such as Canada, with less sunlight, in particular, during winter months

Vitamin D (D2 & D3) + K2: Vitamin D helps with Calcium absorption and is particularly important for women who get little sun. Medical recommendations are 800 units (IU)/day (4). The middle reference range is 30 to 100 mg, 55 appears to be the sweet spot for women. It is best to get a baseline blood test to know how much you should take. If you are starting at a level of 25mg for example, and you want to increase by 30 to get to 55, you will take 3000 units (1000 UI for every 10 point increase in your D levels). It will take approximately 3 months to raise your levels. Liquid Vitamin D spray may be even more bio-available (better absorption). Consider taking vitamin D if you are a woman in menopause or you get minimal sun.  

Magnesium: Magnesium is valuable for bone reformation. Research shows an improvement in bone mineral density and fracture rates with magnesium (14). There are a number of types of magnesium including  citrate, carbonate, and oxide, with the recommended dosages varying between 250 and 1800 mg.

Omega-3 Fatty Acids: Omega-3 fatty acids have been shown to reduce fracture risk and improve bone health. While more research is required, a review of the current research suggests fortified foods (e.g. eggs with Omega-3) in combination with calcium may be the most beneficial approach for bones (15, 16). There is an important study called VITAL-Bone Health which is examining the connection between Vitamin D and Omega-3. This will hopefully shed further evidence on the topic.

Collagen: Bioactive collagen peptide supplementation has been shown to significantly improve bone formation and bone density in postmenopausal women (17). 

Protein: High quality protein is important for bone maintenance among other things. Aiming for approximately 20 grams of protein per meal is a good estimate without doing technical calculations. Some good quality protein sources include: chicken breasts, salmon, turkey, flank steak, shrimp, eggs, tuna, cottage cheese, Greek yogurt, beans and lentils. 

Alkaline Diets: Eating a diet high in acid-forming foods can harm your bones because when there is extra acid in your body, your bones release mineral compounds to alkalize (neutralize the acid). The minerals released by the bones are the same mineral compounds your body needs to keep your bones strong. To alkalize your diet, eat plenty of whole grains, fruits and vegetables. Include a little lean protein with every meal, but avoid eating too much red meat. As you do this, try to reduce your intake of processed foods. 

Weight bearing exercise: Weight bearing exercise stimulates bone remodeling. Strength training with heavy weights is ideal. However, running (for which you have to carry your body weight) and walking with a weighted vest are also great (1, 4, 6). You can find weighted vests in sport equipment stores such as Sports Check and on-line including on Amazon. Recommendations for the amount of time and frequency can vary. Start with 30 minutes 3 times per week. It is also important to  include balance training activities to help prevent falls and the severity of fall injuries (6).

While osteoporosis cannot be cured, it can be prevented in most women starting with a healthy lifestyle that includes the elements outlined above. In addition, hormone therapy, in particular estrogen  recommended for women at risk. If you have osteoporosis, managing it is long term, life-long endeavor, usually involving treatment with different drugs in various sequences. 

References

1. https://choosingwiselycanada.org/wp-content/uploads/2017/05/DEXA-EN.pdf

2. Chidi-Ogbolu N, Baar K. Effect of Estrogen on Musculoskeletal Performance and Injury Risk. Front Physiol. 2019 Jan 15;9:1834. doi: 10.3389/fphys.2018.01834. PMID: 30697162; PMCID: PMC6341375.

3. Perry SD, Bombardier E, Radtke A, Tiidus PM. Hormone replacement and strength training positively influence balance during gait in post-menopausal females: a pilot study. J Sports Sci Med. 2005 Dec 1;4(4):372-81. PMID: 24501551; PMCID: PMC3899653.

4. Melton LJ 3rd, Chrischilles EA, Cooper C, Lane AW, Riggs BL. Perspective. How many women have osteoporosis? J Bone Miner Res. 1992 Sep;7(9):1005-10. doi: 10.1002/jbmr.5650070902. PMID: 1414493.

5. Hansen D, Pelizzari P, Pyenson B. Medicare Cost of Osteoporotic Fractures-2021 Updated Report. Milliman, Inc.: Seattle, WA, 2021.

6. McPhee C, Aninye IO, Horan L. Recommendations for Improving Women's Bone Health Throughout the Lifespan. J Womens Health (Larchmt). 2022 Dec;31(12):1671-1676. doi: 10.1089/jwh.2022.0361. Epub 2022 Nov 7. PMID: 36346282; PMCID: PMC9805882.

7. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 2022;33(10):2049–2102

8. US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for osteoporosis to prevent fractures: US Preventive Services Task Force recommendation statement. JAMA 2018;319(24):2521–2531.

9. Snow CM, Shaw JM, Winters KM, Witzke KA. Long-term exercise using weighted vests prevents hip bone loss in postmenopausal women. J Gerontol A Biol Sci Med Sci. 2000 Sep;55(9):M489-91. doi: 10.1093/gerona/55.9.m489. PMID: 10995045.

10. Shaw JM, Snow CM. Weighted vest exercise improves indices of fall risk in older women. J Gerontol A Biol Sci Med Sci. 1998 Jan;53(1):M53-8. doi: 10.1093/gerona/53a.1.m53. PMID: 9467434.

11. https://www.jospt.org/doi/10.2519/jospt.2015.4842 

12. Clark D, Nakamura M, Miclau T, Marcucio R. Effects of Aging on Fracture Healing. Curr Osteoporos Rep. 2017 Dec;15(6):601-608. doi: 10.1007/s11914-017-0413-9. PMID: 29143915; PMCID: PMC6517062.

13. https://osteoporosis.ca/medical-conditions-that-can-cause-bone-loss-falls-and-or-fractures/ 

14. Rondanelli M, Faliva MA, Tartara A, Gasparri C, Perna S, Infantino V, Riva A, Petrangolini G, Peroni G. An update on magnesium and bone health. Biometals. 2021 Aug;34(4):715-736. doi: 10.1007/s10534-021-00305-0. Epub 2021 May 6. PMID: 33959846; PMCID: PMC8313472.

15. Sharma T, Mandal CC. Omega-3 fatty acids in pathological calcification and bone health. J Food Biochem. 2020 Aug;44(8):e13333. doi: 10.1111/jfbc.13333. Epub 2020 Jun 17. PMID: 32548903.

16. Orchard TS, Pan X, Cheek F, Ing SW, Jackson RD. A systematic review of omega-3 fatty acids and osteoporosis. Br J Nutr. 2012 Jun;107 Suppl 2(0 2):S253-60. doi: 10.1017/S0007114512001638. PMID: 22591899; PMCID: PMC3899785.

17. https://www.sciencedirect.com/science/article/abs/pii/S1551714415000191

18. König D, Oesser S, Scharla S, Zdzieblik D, Gollhofer A. Specific Collagen Peptides Improve Bone Mineral Density and Bone Markers in Postmenopausal Women-A Randomized Controlled Study. Nutrients. 2018 Jan 16;10(1):97. doi: 10.3390/nu10010097. PMID: 29337906; PMCID: PMC5793325.