| Bone is living tissue that constantly undergoes | | | | It's clear that supplements (and drugs) can be |
| remodeling - old bone is replaced by new bone. | | | | effective when compared to a placebo. What is not |
| Osteoporosis is the most common human bone | | | | so obvious is whether or not supplements to prevent |
| disease and is characterized by low bone mass or | | | | bone loss work any better than eating a diet that |
| bone mineral density (BMD) and loss of bone tissue. | | | | provides similar nutrient values as in the supplements. |
| Osteoporosis develops when bone that is lost is not | | | | Collectively most studies support the notion that if |
| replaced by new bone. This results in a decreased | | | | people get enough calcium, vitamin D, vitamin K, and |
| bone mass and the increased risk for fractures. The | | | | boron from their diets and lead an active lifestyle, |
| many common causes of osteoporosis range from | | | | they will achieve and maintain healthy bone densities. |
| lack of physical stress (exercise) on the bones, | | | | The dilemma is that substantial portions of the |
| malnutrition, low hormone levels (ie estrogens, | | | | population do not get the required amounts those |
| androgens, IGF-1), and old age. Secondary causes | | | | nutrients. While counseling is often tried, this group is |
| may be due to glucocorticoid therapy, where | | | | usually comprised of older adults who may have |
| cortisol-like compounds, usually given to control | | | | deeply established lifestyle patterns. Supplementation |
| inflammation, increase the rate of bone loss. | | | | may be an appropriate recommendation as long as |
| Osteoporosis was once viewed as a disease that | | | | they remember to take the appropriate pills in the |
| primarily concerned older women due to decreasing | | | | correct doses at the correct times. |
| levels of estrogen during the postmenopausal years. | | | | Calcium is the most important specific nutrient for |
| Estrogen causes increased osteoblastic (bone | | | | developing peak bone mass and preventing bone loss. |
| formation) activity and after menopause, minimal | | | | Recommended intakes of calcium to prevent or treat |
| estrogen is secreted from the ovaries. However, | | | | osteoporosis are 1,000 - 1,500 mg per day for older |
| since the recognition of The Female Athlete Triad, | | | | adults. Calcium may displace or be displaced from |
| osteoporosis, osteopenia, and stress fractures are | | | | being absorbed by other minerals. Calcium |
| now a concern for much younger women. It is also | | | | supplements should generally be taken at separate |
| evident that more and more men appear to be | | | | times from other mineral supplements or foods that |
| developing osteoporosis as well. According to the | | | | contain minerals if one wants to maximize calcium |
| National Institutes of Health (NIH), 10 million people | | | | absorption. They can be taken with juices and |
| have osteoporosis and another 18 million have low | | | | vitamins. Vitamin D is needed for optimal calcium |
| bone mass, with the odds favoring that these people | | | | absorption and has a recommended intake of |
| will also develop osteoporosis (1). This is very | | | | 400-600 IUs per day. Vitamin D on its own has |
| unfortunate because osteoporosis is largely | | | | limited therapeutic value for people with normal |
| preventable. | | | | vitamin D levels (12), but can increase bone density in |
| The NIH defines osteoporosis as a "skeletal disorder | | | | people with depressed serum levels (13). |
| characterized by compromised bone strength | | | | Since so much research has focused on calcium and |
| predisposing to an increased risk of fracture." A | | | | vitamin D, other dietary constituents are often |
| common mistake is to think of osteoporosis simply | | | | overlooked. Boron initially received attention for use |
| as the result of bone loss. For individuals that never | | | | as an intervention to treat and prevent arthritis. In |
| reach optimal bone mass, osteoporosis may develop | | | | parts of the world where boron intake are less than |
| without substantial bone loss. For further reading on | | | | one milligram per day, arthritis incidence rates are |
| osteoporosis, the NIH Consensus Statement at | | | | 20-70%. In other places where boron intakes are |
| (INSERT URL HERE) is an excellent place to start. | | | | three to ten milligrams per day, arthritis occurs in |
| This article will cover more recent developments, | | | | 10% or less of the population. A significant favorable |
| address some ongoing concerns, and offer some | | | | response has been reported with 6 mg per day. The |
| practical interpretations. | | | | combination of 45 mg/d vitamin K2 and .75 |
| Exercise: What Do We Need To Do? | | | | micrograms of vitamin D3 increases bone density in |
| To improve the quality of their bones, people need | | | | post menopausal women with osteoporosis (14). |
| specific exercise programs and directions on how to | | | | Vitamin C is also correlated with increase bone |
| do the exercises. In the case of young female | | | | density in postmenopausal women taking calcium and |
| athletes who may be over-exercising, an appropriate | | | | undergoing estrogen therapy (15). The supplement |
| recommendation may be to reduce their training | | | | intake ranged from 100-5,000 mg/d with an average |
| volume. This article will assume that the individual is | | | | intake of 745 mg/d. |
| older and lack of exercise is the problem. It's clear | | | | One supplement that has received lots of marketing |
| that not all exercise protocols are effective, so the | | | | attention is ipriflavone. Ipriflavone is a synthetic |
| focus will be on what has been proven in research | | | | isoflavone sold over the counter. In some European |
| and what is applicable today. There is a strong | | | | countries it is considered to be one of the first and |
| relationship between muscle mass, strength and bone | | | | most effective treatment approaches to combating |
| density (2, 3). A simple interpretation is that in | | | | osteoporosis. Studies on ipriflavone however offer |
| general, stronger people have stronger bones. In | | | | mixed results, with some indicating that it increases |
| controlled studies where subjects were | | | | bone mineral density and others indicating that it does |
| strength-trained, bone density also increased, thus | | | | not. A recent study published in JAMA indicated that |
| lending support to cross-sectional studies (4, 5). | | | | there was no effect on bone mineral density and |
| Recent research using rats even suggests that | | | | that lymphocyte concentration decreased significantly |
| resistance exercise may be more beneficial than | | | | (16). |
| aerobic training for stimulating bone formation (6). | | | | Several companies have produced supplements |
| While there is no guarantee the same results will be | | | | marketed as anti-osteoporotic agents. Based upon |
| found in people, animal studies do allow researchers | | | | the doses above, a supplement recipe for |
| to exert greater control over the study as well as | | | | osteoporosis would consist of 1,000 - 1,500 mg/d of |
| study mechanisms that may be difficult to study in | | | | calcium, 400-600 IUs of vitamin D/d, 745 mg of |
| people. Unlike pharmacological and nutritional | | | | vitamin C/d, 45 mg/d of vitamin K and 6 mg/d of |
| approaches, strength training can influence multiple | | | | boron. There is no research at this point in time that |
| risk factors for osteoporosis and other diseases by | | | | has examined the effects of simultaneously giving all |
| increasing strength, balance and muscle mass | | | | of the above agents on bone density. Whether or |
| simultaneously. | | | | not the combined use these supplements is more |
| Strength training or resistance exercise is not simply | | | | effective than some smaller combination is a matter |
| going to the gym and "pumping iron." A properly | | | | of opinion. The most appropriate place to try this |
| designed program can address balance, flexibility, | | | | supplemention protocol is in clinical practice where a |
| cardiovascular conditioning and agility. These are often | | | | competent professional monitors patients. A greater |
| overlooked fitness components that can easily be | | | | concern is that individuals may self-prescribe these |
| incorporated into a program. Programs are designed | | | | agents without monitoring and/or guidance from a |
| based upon what a client has available to them | | | | competent professional. |
| (equipment, location, etc) and what they can actually | | | | Putting It Into Practice Today |
| do (physical limitations, contraindications, personal | | | | One of the problems with research on preventing |
| goals, etc). In previous research elderly subjects lifted | | | | bone loss or increasing bone mineral density is that |
| food items (ie soup cans, bags of potatoes, milk | | | | there are many variables to control for. Activity |
| containers, etc) and improved their strength, muscle | | | | patterns can vary considerably and the results of a |
| mass, bone density, body composition and mental | | | | nutritional intervention may reflect the synergistic |
| outlook. | | | | effects of nutrition plus exercise, even though only |
| Research in the past had older subjects lift weights in | | | | the nutritional component was carefully monitored. |
| a very slow and controlled fashion because of the | | | | Another issue is that when bone mineral density has |
| fear that fast or explosive movements may harm | | | | reached a certain critical point, significant interventions |
| them. Today things are approached very differently. | | | | from a statistical perspective may mean little from a |
| One of the consequences of aging is that there is a | | | | practical perspective. That is while the subject's bone |
| decrease in function in faster twitch motor units and | | | | density increased, they may still fracture their bones |
| hence muscle fibers. Observations so far indicate that | | | | at the same rate as before the study. This makes |
| power-type training in the elderly may be very | | | | interpreting the results somewhat problematic. |
| beneficial in multiple areas, including improved speed, a | | | | A simple and prudent strategy is to get people to |
| decrease in medications for blood pressure, blood | | | | perform resistance exercise where balance is |
| glucose control, and decrease in depression. It's easy | | | | challenged (ie they work against gravity). The |
| to get depressed when you can't move around. | | | | program should incorporate progression so as they |
| A properly designed exercise program is preceded by | | | | get stronger, they will perform more challenging |
| a doctor's approval and a physical assessment to | | | | tasks. The diet should provide at least .8 g/kg body |
| determine the individual's functional capacity, joint | | | | mass per day and not more than 1.8 g/kg per day if |
| integrity, and muscular strength. For example if a | | | | resistance training. It is generally understood that |
| subject has weak legs and is without joint problems, | | | | most nutrients can be obtained from the diet, |
| single legged squats to a bed or chair can work well. | | | | however a substantial portion of the population has |
| Initially the range of motion is limited, and with | | | | signs of low levels for one or more nutrients relating |
| improvements in strength and balance, the range of | | | | to bone health. While recommendations for lifestyle |
| motion is increased. The chair or bed provide a | | | | modifications are certainly warranted, compliance |
| safety measure so the subject does not squat too | | | | does not appear to be very high over the long-term. |
| deep too fast. Push-ups and straight leg sit-ups (on a | | | | Supplementation of one or more of the following |
| bed or carpet with the lower back pushing down | | | | may be warranted: 1,000 - 1,500 mg/d of calcium, |
| against the bed/carpet) are also very effective | | | | 400-600 IUs of vitamin D/d, 745 mg of vitamin C/d, |
| movements. Try to select movements that make | | | | 45 mg/d of vitamin K and 6 mg/d of boron. Ideally |
| balance difficult, use primarily body weight (or some | | | | such strategies would occur under the guidance of a |
| fraction) as resistance, use full range of motion unless | | | | competent professional. |
| contraindicated, and emphasize the lifting phase at a | | | | References |
| one or two tempo (subject says "one" or "one-two" | | | | 1. Anonymous, Osteoporosis prevention, diagnosis, |
| and tries to complete the movement at the same | | | | and therapy. JAMA, 2001. 285(6): p. 785-95. |
| time), with the lowering phase usually about twice as | | | | 2. Huuskonen, J., et al., Determinants of bone mineral |
| long. The main point here is that we know resistance | | | | density in middle aged men: a population- based |
| exercise works to increase or prevent loss of bone | | | | study. Osteoporos Int, 2000. 11(8): p. 702-8. |
| mass (with many other positive benefits), now let's | | | | 3. Proctor, D.N., et al., Relative influence of physical |
| see how we can make it fun, yet appropriate for the | | | | activity, muscle mass and strength on bone density. |
| people we work with. | | | | Osteoporos Int, 2000. 11(11): p. 944-52. |
| Diet: What Can We Recommend? | | | | 4. Kerr, D., et al., Resistance training over 2 years |
| Recommending an increased intake of dairy products | | | | increases bone mass in calcium-replete |
| along with some sunlight will work with some people, | | | | postmenopausal women. J Bone Miner Res, 2001. |
| but usually not most elderly clients. Other dietary | | | | 16(1): p. 175-81. |
| factors be bone saving. Fruit and vegetable intake | | | | 5. Ringsberg, K.A., et al., The impact of long-term |
| has a positive relationship with bone density (7, 8). | | | | moderate physical activity on functional performance, |
| While there may be other explanations for these | | | | bone mineral density and fracture incidence in elderly |
| positive relationships, there is overwhelming evidence | | | | women. Gerontology, 2001. 47(1): p. 15-20. |
| that supports their prudent recommendation. The | | | | 6. Notomi, T., et al., A comparison of resistance and |
| standard recommendations apply - five to nine | | | | aerobic training for mass, strength and turnover of |
| servings each day for adults, with lots of variety. | | | | bone in growing rats. Eur J Appl Physiol, 2000. 83(6): |
| Results of the Framingham Osteoporosis Study | | | | p. 469-74. |
| indicated that even after controlling for multiple | | | | 7. Tucker, K.L., et al., Potassium, magnesium, and fruit |
| factors, a lower protein intake increased bone loss | | | | and vegetable intakes are associated with greater |
| (9). | | | | bone mineral density in elderly men and women. Am J |
| Studies on rats indicate that high protein diets do not | | | | Clin Nutr, 1999. 69(4): p. 727-36. |
| adversely affect bone turnover and in support of the | | | | 8. New, S.A., et al., Dietary influences on bone mass |
| Framingham Study, show that low protein intake | | | | and bone metabolism: further evidence of a positive |
| lowers IGF-1 and induces IGF-1 resistance in | | | | link between fruit and vegetable consumption and |
| osteoblasts (10, 11). Given that most elderly people | | | | bone health? Am J Clin Nutr, 2000. 71(1): p. 142-51. |
| consume insufficient protein, a low protein intake | | | | 9. Hannan, M.T., et al., Effect of dietary protein on |
| appears to be more of a concern than a high protein | | | | bone loss in elderly men and women: the Framingham |
| intake when it comes to preventing osteoporosis. | | | | Osteoporosis Study. J Bone Miner Res, 2000. 15(12): |
| While terms such as high and low are often used | | | | p. 2504-12. |
| based upon the relative percentage of calories | | | | 10. Bourrin, S., et al., Dietary protein restriction lowers |
| contributed to the diet from protein, this can be very | | | | plasma insulin-like growth factor I (IGF-I), impairs |
| misleading. A better strategy to determine the | | | | cortical bone formation, and induces osteoblastic |
| adequacy of protein intake is relative to body mass | | | | resistance to IGF-I in adult female rats. Endocrinology, |
| and activity pattern of the individual. The RDA for | | | | 2000. 141(9): p. 3149-55. |
| protein is .8 g/kg of body mass. However, strength | | | | 11. Creedon, A. and K.D. Cashman, The effect of high |
| training increases the upper recommendation to as | | | | salt and high protein intake on calcium metabolism, |
| high as 1.8 g/kg of body mass. | | | | bone composition and bone resorption in the rat. Br J |
| Soybeans and flaxseed (oil or meal) are excellent | | | | Nutr, 2000. 84(1): p. 49-56. |
| sources of phytoestrogens. Phytoestrogens are plant | | | | 12. Hunter, D., et al., A randomized controlled trial of |
| chemicals that can modulate estrogen function. Many | | | | vitamin D supplementation on preventing |
| phytoestrogens have been implicated either indirectly | | | | postmenopausal bone loss and modifying bone |
| or indirectly to have an impact on bone turnover. | | | | metabolism using identical twin pairs. J Bone Miner |
| While there still isn't enough evidence to say exactly | | | | Res, 2000. 15(11): p. 2276-83. |
| how these foods may influence bone tissue, there is | | | | 13. Kantorovich, V., et al., Bone mineral density |
| sufficient evidence to warrant recommending their | | | | increases with vitamin D repletion in patients with |
| consumption. Given the common problem that older | | | | coexistent vitamin D insufficiency and primary |
| people have of eating enough calories, the real trick is | | | | hyperparathyroidism. J Clin Endocrinol Metab, 2000. |
| how to get this group to actually eat what may help | | | | 85(10): p. 3541-3. |
| them. For other groups, many people just don't see | | | | 14. Iwamoto, J., T. Takeda, and S. Ichimura, Effect of |
| the value in taking time to plan out and make all the | | | | combined administration of vitamin D3 and vitamin K2 |
| healthy foods they know they should be eating. A | | | | on bone mineral density of the lumbar spine in |
| practical example that has worked very well for | | | | postmenopausal women with osteoporosis. J Orthop |
| some people is to make smoothies or some type of | | | | Sci, 2000. 5(6): p. 546-51. |
| blended mixtures. A scoop of why protein mixed in | | | | 15. Morton, D.J., E.L. Barrett-Connor, and D.L. |
| with some frozen berries and flaxseed meal supplies | | | | Schneider, Vitamin C supplement use and bone |
| lots of nutrients that can benefit bone. It is quick, | | | | mineral density in postmenopausal women. J Bone |
| convenient, can be stored for later consumption and | | | | Miner Res, 2001. 16(1): p. 135-40. |
| transported to another location. For variety, switch | | | | 16. Alexandersen, P., et al., Ipriflavone in the |
| between flaxseed oil and meal, use different fruits, | | | | treatment of postmenopausal osteoporosis: a |
| and alternate between soy and whey proteins. | | | | randomized controlled trial. JAMA, 2001. 285(11): p. |
| Supplementation: Do We Really Need Everything On | | | | 1482-8. |
| The Market? | | | | |