Our lifestyle medicine tips for bone health
By Dr Marissa Kelaher
Why should we care about bone health?
Bone health is an issue many people aren’t even aware of, until they are diagnosed with it - yet prevention and early intervention can have a huge impact further down the track.
Osteoporosis is a condition where the density of our bones (and therefore strength) reduces, and our bones become weak and brittle, and more prone to injury. Osteopenia is when bone density is reduced slightly, but not to the same extent as osteoporosis.
Bone health is important as osteoporosis can lead to fragility fractures as we age (fractures that occur due to reduced bone density), which can have a massive impact on health and well-being.
Looking after our bones can help to significantly reduce the risk of these fractures, so it’s well worth doing!
How common is osteoporosis?
In New Zealand, osteoporosis affects more than 50% of women and 30% of men over 60, but can also affect younger people.
It becomes increasingly common with age - at least 1 in 5 women over age 50 have osteoporosis, and the risk of an osteoporotic hip fracture doubles every 5-6 years in women after menopause.
By age 65, 50% of women and 20% of men will have osteoporosis, and by age 75, 70% of men and women will have it.
1 in 3 women over 50 will have a fragility fracture of their hip, vertebra, or wrist at some point in their lives, while for men, the lifetime risk for fracture is 13-25% (but they are more likely to die as a result of the fracture).
4000 osteoporotic hip fractures occur in New Zealand per year, and hip fractures have a significant impact on health and quality of life.
5 to 20% of people with hip fractures die within one year; while sixty percent of people who have hip fractures will need assistance with their daily activities for the rest of their lives. Other common fractures caused by osteoporosis include vertebral (spinal) fractures, and wrist fractures due to falls.
Fortunately, as with all systems in our body, taking a holistic approach to bone health can both help prevent osteoporosis in the first place, and also help our bone health even after it occurs.
Our bones are something we tend to take for granted, but they handle a huge amount of force throughout our lifetime, and need to be looked after!
How does osteoporosis occur?
Maintaining healthy bones involves a delicate balance between bone formation and bone absorption, as our bones are actually constantly remodelling and changing- they are living structures.
There are two main processes that are constantly occuring in our bones - bone cells called osteoclasts dissolve and absorb old bone tissue, while another type of bone cells, osteoblasts, help to new bone form in the empty spaces created.
If in balance, this process keeps our bones healthy and strong.
Our bones are strongest around age 30, when our bone density peaks, then from that time onwards (for most people), it naturally reduces gradually with age.
This means it’s absolutely vital to pay attention to bone health throughout our life, ideally before diagnoses such as osteopenia or osteoporosis are made - however unfortunately most people don’t give bones a second thought until they occur.
Our bone health actually starts from a very young age, and is partly determined by the nutrition of our mother (whether her calcium and vitamin D levels are adequate), and whether we are breast fed.
Then as children and adolescents, we need enough calcium and vitamin D to keep our growing bones strong, as well as a good diet and plenty of exercise.
Bone health becomes particularly essential during the first few years of menopause, as this is when the hormone changes that are part of menopause can speed up bone loss, and lead to a rapid reduction in bone density. Oestrogen helps to protect bones, and during menopause our estrogen levels drop, and osteoclasts can dissolve bone faster than osteoblasts can make it - leading to osteoporosis.
Bone density can be easily measured as we cover below, and responds well to funded drug treatments such as oral and IV bisphosphonates (Fosamax and Aclasta), which are an important part of osteoporosis treatment.
However bone density is actually not the only aspect that affects the strength of our bones.
For example, even at at 50% of normal bone density, our spine should be able to maintain five times the amount of weight it normally has to carry ie it still stays very strong - yet so many people still get spinal fractures.
It turns out that fracture risk seems to be related not only to bone quantity, but also to bone quality. Fracture risk is highest when both bone density and overall bone quality are low.
How is osteoporosis diagnosed?
Osteoporosis is often picked up either after people have a fragility fracture, or on bone density screening, as there are no symptoms in the early stages of osteoporosis.
Symptoms to be aware of are any loss of height (as the vertebrae of the spine weaken they compress and the spine curves), or unexplained persistent bone pain the lower back or neck. With more advanced osteoporosis, the thoracic (middle) spine can start to curve forward (due to compression of the spinal bones) causing someone to look hunchbacked.
The most common test done for osteoporosis is a DEXA scan (dual-energy x-ray absorptiometry).
This test is painless, and involves a very low amount of radiation (much less than a CT scan); it looks at certain bones in the body, and exposes them to two different X-ray beams with different energy levels at the same time. The results of this give an indication of how dense (strong) the bones are.
Readings for the spine and the hip are most commonly used to diagnose low bone density, and results of DEXA scans are given in T scores and Z scores.
T scores compare your bone density to that of a healthy 30-year-old of the same sex - the more negative the number, the less dense your bones are.
Osteopenia (slightly reduced bone density) is diagnosed if the T score is between -1 and -2.5, while osteoporosis is diagnosed if the score is less than -2.5.
Severe established osteoporosis (SEO) is diagnosed if the T score is less than -2.5 and if you have had a fracture.
Z scores compare your bone density to that of others of the same age, sex, and weight. This number is usually higher than the T score, and is not used to diagnose osteoporosis or osteopenia. Instead it gives an indication of how your bone strength compares to other people your age.
If you are having treatment for osteoporosis, it’s usually recommend that you wait at least 3 years between DEXA tests, as this will allow enough time for changes in bone density to be detected. If you are not being treated, it’s recommended to repeat it every 4-5 years.
DEXA scans are not publically funded for most people in New Zealand unless requested by a hospital specialist, however ACC does fund them in certain situations (usually as part of a fracture prevention program after a first fragility fracture, in people who are not already on osteoporosis treatment)
However despite this it is recommended that DEXA scans should be considered in:
Any adult who has a minimal trauma fracture (a fracture that occurs with low impact ie less force than would be expected to fracture a bone)
Women aged <65 years with risk factors for osteoporosis (see below)
Men aged >70 with risk factors for osteoporosis
Women aged ≥65 years and men aged ≥75 years who are considering actively trying to prevent osteoporosis
All people who take steroid medications (ie prednisone) for >6 months
International guidelines on this vary - for example the North American Menopause Society recommends that all women over age 65 should have a DEXA scan as part of a post-menopausal health check, regardless of risk.
There are also other free tools that can be used to predict the risk of osteoporosis - the main one is the FRAX tool
Guidelines recommend that osteoporosis treatment (bisphosphonate medication) should be offered to anyone with a 10-year FRAX hip fracture risk of ≥3%, or with a T-score ≤-2.5 (or ≤-1.5 for people on long-term steroid therapy).
See the end of this post for more details on bisphosphonates.
WHAT ARE THE RISK FACTORS FOR POOR BONE HEALTH?
There are number of risk factors that influence both bone density and bone health in general.
Some of these can be changed; others cannot, and as mentioned above not everyone who has poor bone health will have a fracture.
However at least 50% of hip fractures can be explained by risk factors that might have been reversible, so being aware of these, and reducing them where possible can make a big difference.
CAUSES OF LOW BONE DENSITY INCLUDE:
Older age, being female, and European or Asian ethnicity
Limited sun exposure
Lack of exercise
Taking a medication that can lower bone density such as oral steroids
Having a first degree relative (ie mother or sibling) with osteoporosis
Health conditions, including anorexia nervosa; type 1 diabetes; elevated parathyroid hormone; low testosterone; overactive thyroid (or taking too much thyroid medication); cushing’s disease; liver disease; malabsorption syndromes such as coeliac disease; rheumatoid arthritis; organ transplant; turner’s syndrome; autoimmune diseases
Starting menstruation at a later age (after 15 years old)
Premature menopause (under 40 years old)
Having prolonged times without having periods (this does not include lack of periods due to contraception)
Smoking
Drinking alcohol
Low body weight, or a history of rapid weight loss (ie after weight loss surgery)
Previous fragility fractures
Increased inflammation in the body
Genetics is not as much of a risk factor as people think - while it may account for 25-45% of a person’s risk of weakened bones, a 25- year study of twins did NOT find that fractures due to lower bone density were caused by inherited genes.
HOW CAN I IMPROVE BONE HEALTH?
So what can be done to prevent or treat low bone density?
Prevention is by far the most important step in keeping your bones healthy, as obviously if we can avoid osteoporosis occuring this is better than trying to play catch up once it has already occured!
But lifestyle changes can also help significantly even after osteoporosis is diagnosed.
A holistic approach to bone density falls into 5 main categories: 1) nutrition, 2) dietary supplements, 3) lifestyle (e.g., physical activity and stopping smoking), 4) fall prevention and safety, 5) medications for bone density
Once low bone density has occurred, treatment can also include pain management and rarely surgery.
NUTRITION
Our body needs several main nutrients to form healthy bones, these include Vitamins D, C, B, and K.
Minerals such as boron, chromium, copper, fluoride, iodine, iron, magnesium, manganese, selenium, silicon, and zinc are also important.
Here are our top nutrition tips for good bone health, based on the most up to date osteoporosis research.
Ensure you are getting enough calcium in your diet, and get this from a variety of sources such as dark leafy greens, brassicas, nuts and seeds. Do NOT rely on dairy products alone, as contrary to popular belief, research shows that dairy products do not have a significant effect on bone health (and some studies show high intakes of dairy may actually worsen it). Calcium supplements are no longer routinely recommended, see supplement section for more detail.
Eat other foods that help strengthen bones, these include alliums (onion family), garlic, fennel, parsley, rocket, green beans, leafy greens, citrus fruit, cucumbers, tumeric and mushrooms. Onions appear to be particularly good for bone health - a recent study from Melbourne showed that women over 50 who ate onions daily had 5% better bone density than those who ate them rarely, this translated to a 20% lower risk of hip fractures! Onions are a powerful prebiotic food, which helps to feed a healthy gut microbiome, this appears to help protect bones.
Include soy in your diet, ideally a few servings a day if possible. Soy has high levels of phytoestrogens - a compound which helps counteract the low oestrogen levels of menopause; and it is high in fibre (for good gut health). Calcium set tofu and calcium enriched soy milk are also great sources of dietary calcium. One small study found that people who ate soy regularly had better bone density than those who did not, while studies using soy supplements have mixed results - meaning as with most things, it’s better to eat whole foods than rely on supplements wherever possible!
Limit alcohol - drinking 7 or more standard drinks of alcohol per week increases the risk of osteoporosis and fractures - note that this is significantly lower than what most people consider a ‘safe’ level to drink. Ideally minimise alcohol, or if you do drink it, limit to a maximum of 1 standard drink per day, and no more than 6 per week.
Coffee is ok, but not in excess. Studies suggest that ensuring caffeine intake is kept under 300 mg daily (just over 2 double shot coffees), is better for bone health , however tea is fine to drink, even when it contains caffeine. Green, black, and oolong teas actually seem to protect against developing osteoporosis. Learn more about coffee, tea, and alcohol in our Reboot courses.
Avoid fizzy drinks (completely if possible). Drinking 5-6 servings of soft drinks per week (particularly cola drinks) can increase your risk of developing osteoporosis. Fizzy drinks are also extremely high in sugar (including fructose), and have no nutritional value. Try replace with carbonated water, cold herbal teas, or other non sweetened drink. Learn more about sugar in our blog post here.
Eat an anti-inflammatory diet. There is increasing evidence emerging that osteoporosis, like many other chronic health issues, is linked in part to chronic, low-grade inflammation. An anti-inflammatory diet is based around mostly whole plant foods, with 5-7 servings/day of veges (especially leafy greens), 2-3 of whole fruit, and daily legumes, whole grains, healthy fats and fermented foods. Red meat is eaten very little, and refined carbohydrates/foods with added sugar/ultraprocessed foods are avoided if possible, or eaten only occasionally. Specific eating patterns such as the Meditteranean diet and DASH diet (a low salt Meditteranean diet used to treat high blood pressure) appear to also help protect the bones, these are again anti-inflammatory and plant focused. We cover anti-inflammatory diets in depth in our Reboot and Nutrition courses if you would like to learn more.
Include enough omega-3 fats in your week. Omega-3 fats are part of an anti-inflammatory diet, they also help prevent osteoclast cells from absorbing too much bone (ie they help improve bone density). Omega 3 fats are found in cold water fish (salmon, herring, sardines), walnuts, ground flaxseed, hemp seeds, chia seeds, and leafy green vegetables. 1 Tbsp/day of these seeds, or eating a portion of oily cold water fish 2 days/week provides enough omega 3. Including Omega 3 also helps to keep a healthy balance between Omega 3 and Omega 6 fats - as having too many Omega 6 fats compared to Omega-3 fats in the body can potentially reduce bone density. If you eat a whole food plant focused anti-inflammatory diet, and intentionally include Omega 3 rich foods, you will have a healthy ratio by default (Omega 6 are mostly found in ultraprocessed foods and some seed oils)
Aim to eat around 8-10 servings of fruits and vegetables daily if you are able to, as diets high in vegetables and low in animal protein (meat), appear to protect against bone loss. A serving is the amount that can fit in the palm of your hand. Try to eat a rainbow of different colored fruits and vegetables, as these all contain different beneficial nutrients, and ensure that you will get enough vitamins, minerals, and anti-oxidants
Move towards a plant focused diet, getting most of your protein from plant sources (such as legumes, nuts, seeds and whole grains), and don’t eat more protein than you need. Protein is promoted as something we need more of, yet research shows most meat heavy Western diets contain far more than we need. Protein is converted to amino acids when we digest it, and some studies have shown that women who eat over 75 grams of protein daily actually have higher levels of these acids in their bloodstreams (which is not a good thing). Other studies have shown that diets that rely mostly on animal protein (rather than plant protein) are linked with lower bone density. As our blood and cells must stay within a very narrow pH range to function, we cope with extra dietary acids by taking calcium out of the bones to neutralize them, to maintain a steady pH level. It is thought that this may be where the link between high protein diets and poorer bone health comes from, and also why dairy is not particularly protective for bones as mentioned earlier. More research is needed to determine to what extent alkaline diets may promote health, but plant focused diets which include healthy carbohydrates and are rich in veges are naturally alkaline, and these diets have multiple other health benefits as well. A good approach is to aim to eat 0.8 - 1g/kg of protein per day, unless you are highly active, in which case you may need more.
Think twice about ketogenic diets. These diets are becoming increasingly popular for weight loss, yet the research shows they may be harmful to bone health. Longterm studies of children on medical ketogenic diets, show that they can reduce bone density, and are associated with a higher risk of fractures. One small study looking at ketogenic diets in athletes also indicated that these diets promoted bone loss far faster than diets containing carbs. The mechanism behind this is again thought to be due to the body needing to take calcium from bones to keep the body’s pH in the right range, in response to the high acid load of ketogenic diets. While research is limited, it makes sense to avoid ketogenic diets if you are concerned about bone health.
Don’t forget about Vitamin D. This plays a particularly important role in bone health, as Vitamin D is needed for our bodies to absorb and use calcium from food. Vitamin D supplements are not recommended routinely for bone health anymore (see supplement section), but preventing deficiency is important. Ideally get your vitamin D from safe sun exposure, but if you are unable to, or if you have low Vitamin D levels on a blood test, then supplementing to keep levels healthy is a sensible and safe approach (provided recommended doses are not exceeded - vit D is toxic in high doses).
Avoid high doses of vitamin A - this is commonly promoted as an antioxidant, and is contained in many multivitamins, however research shows that high doses of vit A (more than 3000IU/day) can increase the risk of bone fractures. Like everything it’s all about having enough but not too much!
SUPPLEMENTS THAT MAY HELP BONE HEALTH:
In general we promote a food first approach, trying to get adequate nutrients from whole foods.
This is safer (as it avoids the risk of overdosing on certain vitamins and minerals), tastier, and means you get the other benefits of food such as fibre, phytonutrients, and more!
As we mentioned above certain vitamins and minerals are particularly important for bone health…but does supplementing these make a difference? Let’s take a look.
Calcium
For many years it was recommended that people at high risk of osteoporosis (or with known osteoporosis), take calcium supplements - as calcium is so important for bone health.
Yet research in recent years has shown that taking calcium supplements (in contrast to getting calcium from your diet) does NOT reduce the risk of fragility fractures, and may even increase fracture risk.
Other research also shows that taking calcium supplements may increase the risk of heart attacks (but not death).
This means that calcium supplements are no longer routinely recommended for bone health, unless you are unable to get enough calcium from your diet.
Calcium requirements are 1300 mg/day for females ages 9-18, 1000 mg /day for ages 19-50, and 1200/day for ages 50 and up. It is particularly crucial to get enough calcium in your diet during the first 3-6 years after menopause, as this is when bone loss rates are highest (due to changes in hormone levels).
If you do need to take calcium supplements (usually only if recommended by a dietician), calcium citrate tends to be most easily absorbed, even in people who are taking medications to suppress acid levels (such as omeprazole or pantoprazole). If you take calcium supplements, it’s recommended that you also take Vitamin D supplements, as this may help to reduce the risk for a heart attack.
Blood tests for calcium do not show whether you are getting enough calcium from your diet, as our bodies are extremely good at keeping calcium levels in the blood stable - meaning if we aren’t getting enough dietary calcium, our body will simply take it out of our bones where 99% of our calcium is stored (which is obviously not great for bone health!).
Some tests, such as parathyroid hormone levels, and urinary calcium excretion can be used to see if the body has enough calcium, but are usually only used when investigating for causes of unexpected osteoporosis (ie osteoporosis that occurs at a young age, or in the absence of traditional risk factors).
A high or low blood level of calcium indicates that another process is occuring (ie hyperparathyroidism), and this will usually be further investigated.
Vitamin D
Vitamin D controls the absorption of calcium in the gut and how it is deposited into bone; helps reduce bone loss; increases bone density; and stimulates muscle growth.
So having enough vitamin D is essential for bone health.
Vit D is found in fatty fish, cod-liver oil, liver, and sun-exposed mushrooms, however foods actually contain very little Vit D, meaning vitamin D via skin exposure to sunlight is the most common way to get it (as our body can produce Vit D).
Exposing your hands, face and arms to the sun for 10 to 15 minutes per day produces enough Vitamin D in most people, however elderly people produce 4x less Vitamin D from sun exposure (so are at higher risk of deficiency).
Twenty minutes of full body sun exposure will give a young Caucasian person 20,000 IU of Vitamin D, although obviously in New Zealands harsh UV particular care is needed (meaning sun exposure is safest at times of lower UV levels ie morning or late afternoon)
People with darker skin tone, who do not go outdoors, who cover up for religious or cultural reasons, who are obese, or who live in areas with low sunlight levels (especially in winter) are also all at higher risk of Vitamin D deficiency.
Recent research appears to show no benefit of routine Vitamin D supplementation of middle aged adults who do NOT have deficiency or known osteoporosis.
In contrast, Vitamin D supplements are recommended if you have Vitamin D deficiency (or are at high risk of it), or known osteoporosis, as it can significantly reduce fracture risk in these situations.
It is also recommended in elderly people, as it can reduce the risk of fractures in this population, and may reduce the risk of falls.
People are often advised to take Vitamin D3 because it is 3 times stronger than D2, however recent research has indicated that either form is effective.
Vitamin D can be taken either daily (800-1000IU/day) or monthly (50,000IU) as it is stored in the body. Very high annual dosing is NOT recommended, as this appears to increase fracture risk.
If you get a blood test for Vitamin D levels (costs may apply), aim to keep these at a minimum of 50nmol/L . Some international osteoporosis guidelines recommend aiming higher - in the upper half of the normal lab range, if possible, ie 75-150nmol/L.
This is because calcium absorption is 65% higher for people with Vitamin D levels of 75nmol/L compared to those with levels below 50nmol/L.
Vitamin K
Vitamin K is a nutrient many people may not associate with bone health, yet our body needs Vitamin K to build bones. It works along with Vitamin D3, and comes in 2 main forms: Vitamin K1 (phylloquinone) is found in green leafy vegetables, while Vitamin K2 (menaquinone) is found in meats, cheeses, and fermented foods, such as fermented soy. A third form, Vitamin K3 has been linked to liver problems and is no longer used.
Studies have found that people with fractures due to low bone density, frequently are deficient in Vitamin K.
A meta-analysis (looking at the results of multiple studies) also found that people with osteoporosis who took Vitamin K supplements had lower rates of both bone loss and fractures (up to 80% for hip fractures).
The doses used in studies have ranged from 1 mg – 10 mg of K1 and 45 mg of K2 each day, and many bone health vit D supplements now also contain vit K as well as a result. It can be a good idea to supplement if you have known osteoporosis, but is not needed for osteoporosis prevention if you have a diet rich in leafy green veges.
Caution-do NOT take vit K supplements if you take warfarin medication, as it stops the warfarin from working.
Magnesium
Magnesium is important in bones, as it helps keep bone flexible, and increases bone mineral density in postmenopausal women. It’s become a popular supplement to take for osteoporosis, but there is very little research at present to support routine supplementation.
If you eat a plant-focused whole food diet you will get plenty of magnesium, but if you have a diet low in veges and high in processed foods, it may be reasonable to take a magnesium supplement.
A standard dose is 400-800 mg daily, higher doses can lead to diarrhea. Magnesium rich foods include dark leafy greens, seeds, beans, fish, whole grains, nuts, dark chocolate, yogurt, avocados, and bananas.
Soy and Other Phytoestrogens.
Phytoestrogens are compounds contained in plants that act like estrogen in the body, they are fairly amazing as their effects depend on how much estrogen is in a woman’s body!
In premenopausal women, phytoestrogens compete with estrogen and will block the effect of estrogen (helping with oestrogen-dependent conditions such as breast cancer and endometriosis), whereas in postmenopausal women (where estrogen concentration is low), they add to the amount of estrogen circulating in the body and can help counteract the effects of low oestrogen.
Research shows that eating soy food increases bone density (as mentioned in the nutrition section), however research on soy supplements are mixed. In general, they are not recommended for bone protection, and it is far better to get your soy phytoestrogens from food.
We have lots of soy-based recipes in our Reboot and Nutrition courses if you’d like to try some out!
EXERCISE
Exercise can have a significant effect on bone density, and is just as important as nutrition to protect bones. Walking, weight-bearing exercise and resistance training are all helpful for bone health (as well as overall health). Exercise helps to stimulate new bone formation (osteoblasts), and also helps reduce the risk of falling (and therefore fractures). It can also help increase the diameter of bones throughout our life.
Types of exercise recommended for bone health include:
weight training/resistance training (to build muscle and stimulate bone growth) at least 2-3 days/week
running, fast walking, (at a rate of at least 6km/hr), or jumping/dancing for at least 150min/week
Tai chi and yoga (these reduce the risk of falling by improving balance, one small study showed daily yoga may also improve bone health in the spine), ideally most days of the week
We cover the health benefits of exercise in depth, how different types affect the body, recommended types and amounts, and ways to incorporate them into your life in our Reboot and Boost your Activity courses if you would like to know more.
SMOKING
Smoking increases the risk of spinal fractures by 13% in women and 32% in men over their lifetimes, while the risk of hip fractures are increased by 31% for women and 40% for men.
The more a person has smoked, the greater the risk. To protect your bones, do not smoke; and if you already smoke, its a great reason to quit! Smoking has multiple health risks, and no health benefits.
MEDICATIONS FOR OSTEOPOROSIS
The main medications used to treat osteoporosis in New Zealand are called bisphosphonates. These can be useful to use alongside lifestyle and nutrition.
Bisphosphonates work by inhibiting osteoclast activity (ie slow down how quickly bones are broken down). They are generally safe to use, but around 20% of people do not respond to them (ie they do not work).
The main risks include muscle and joint pain (after IV administration), osteonecrosis of the jaw bone (especially when given IV), abdominal pain, esophagitis (when taken orally), hip fractures, and potentially heart arrhythmias, although most of these are fortunately rare.
ALENDRONATE (FOSAMAX) - this is an oral bisphosphonate, and is usually taken once a week, at a dose of 35 mg. It reduces the risk of spinal fractures by 47%, and hip fractures by 56%. The most common side effect is stomach or oesophageal irritation, which affects 20–30% of people. It should be taken first thing in the morning on an empty stomach, with a full glass of water, then try to stay upright for at least 30 minutes after to reduce the risk of reflux. Ideally wait around 60-90 minutes before eating after taking it.
RISEDRONATE - this is very similar to alendronate, and is also an oral bisphosphonate. It is slightly less effective (36% fewer vertebral fractures, 39% fewer nonvertebral fractures) so is not used as commonly as Fosamax. It has the same risks, side effects, and should be taken in the same way
ZOLEDRONIC ACID (ACLASTA) - this is an intravenous bisphosphonate, and is usually given every 18-24 months. It reduces the risk of spine fracture by 70%, hip fracture by 41%, and other fractures by 25%. It does not cause gastrointestinal symptoms, but can cause flu-like symptoms after the first dose (affecting approximately 30% of patients), which usually resolve within a few days. The risk of these drops significantly with subsequent infusions (affecting 1-2 % of people). Vitamin D is usually given prior to the infusion, as Aclasta cannot be given if people are Vitamin D deficient.
It is generally recommended to repeat a DEXA scan within 4-5 years after starting bisphosphonates, to assess whether further treatment is needed, as the risks of side effects increase with time.
If the T score on a DEXA has risen above -2.5 after 3 to 5 years of bisphosphonate therapy, and no fractures have occurred, it is safe to stop therapy for up to 5 years (as this will not affect future fracture risk). A DEXA scan can be done again at the end of these 5 years to assess bone density again.
However if the femoral T-score is still ≤-2.5, or you have had new/recurrent fractures, it is recommended to continue treatment for a second 5-year period.
As the risk of side effects (in particular atypical hip fractures) increases over time, it is often advised to take a 1-2 year break from treatment between years 5-10 to help reduce this.
Talk to your doctor about the risks and benefits of any medications for you.
OTHER MEDICATIONS :
Teriparatide, and Denosumab are ‘second line’ medications that are occasionally used for osteoporosis, they usually have specific criteria that must be met, and are generally indicated for people who cannot have bisphosphonates, or do not respond to them, These should be discussed with your doctor if indicated.
HRT
This is not a specific osteoporosis medication, however, it can help improve bone density in women with osteoporosis who have been through menopause within the past 10 years. It is not licenced for osteoporosis treatment, but if taken for other menopausal symptoms (ie hot flushes) it can also protect your bones.
HRT is strongly recommended in women with premature menopause (menopause under age 40), as it protects bones as well as reduces the risk of other health issues.
The newer forms of HRT are generally very safe to use for most women (oestradiol patches and utrogestan) as they are the same as the body’s natural hormones, however talk to your doctor to see if they are an option for you.
We also provide comprehensive menopause health consults NZ wide, and can discuss and prescribe HRT if desired/appropriate to do so, via our Book a Consult page.
Wow, that was a lot to cover, but we hope you have enjoyed it - after all knowledge is power!
And if you’ve found this blog post helpful, please share with someone else who needs to read it.
Finally, if you’d like to learn more about healthy nutrition, exercise, lifestyle, and more please check out our courses and members area - we have Reboot courses, Focus courses, and a Lifestyle Lounge all full of great evidence based whole person health info!
We’d love to see you there ❤️
REFERENCES:
Body JJ, Bergmann P, Boonen S. Nonpharmacological management of osteoporosis: A consensus of the Belgian Bone Club. Osteoporosis Int epub March 2011.
Lash RW, Nicholson JM, Lourdes V, et al. Diagnosis and management of osteoporosis. Prim Care 2009;36:181-98.
Lewiecki EM. Prevention and treatment of postmenopausal osteoporosis. Obstet Gynecol Clin N Am 2008;35:301-15.
Board of Trustees of North American Menopause Society, Position statement: Management of osteroporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause, 2010;17(1):35-54.
Kotsirilos V, Vitetta L, Sali A, et al. Osteoporosis. In A Guide to Evidence-Based Integrative and Complementary Medicine. Sydney, Australia:Churchill Livingstone, 2011.
Kannus P, Palvanen M, Kaprio J, et al. Genetic factors and osteoporotic fractures in elderly people: Prospective 25 year follow up of a nationwide cohort of elderly Finnish twins. BMJ 1999;319:1334-7. 9
Lanou AJ, Berkow SE, Barnard ND. Calcium, dairy products, and bone health in children and young adults: A reevaluation of the evidence. Pediatrics 2005;115:736-43.
Devine A, Hodgson JM, Dick IM, et al. Tea drinking is associated with benefits on bone density in older women. AJCN 2007;86(4):1243-7.
Tucker KL, Morita K, Qiao N, et al. Colas, but not other carbonated beverages, are associates with low bone mineral density in older women: The Framingham Osteoporosis Study. Am J Clin Nutr 2006;84:936-42.
Salari P, Rezaie A, Larijani B, et al. A systematic review of the impact of n-3 fatty acids in bone health and osteoporosis. Med Sci Monit 2008;14(3): RA37-44.
Heaney RP, Layman DK. Amount and type of protein influences bone health. Am J Clin Nutr 2008;87(5):1567S-70S. 15.
Draaisma JMT, Hampsink BM, Janssen M, van Houdt NBM, Linders ETAM, Willemsen MA. The Ketogenic Diet and Its Effect on Bone Mineral Density: A Retrospective Observational Cohort Study. Neuropediatrics. 2019 Dec;50(6):353-358. doi: 10.1055/s-0039-1693059. Epub 2019 Aug 9. PMID: 31398763.
Heikura IA, Burke LM, Hawley JA, Ross ML, Garvican-Lewis L, Sharma AP, McKay AKA, Leckey JJ, Welvaert M, McCall L and Ackerman KE (2020) A Short-Term Ketogenic Diet Impairs Markers of Bone Health in Response to Exercise. Front. Endocrinol. 10:880. doi: 10.3389/fendo.2019.00880
Macdonald HM, Black AJ, Aucott L, et al. Effect of potassium citrate supplementation or increased fruit and vegetable intake on bone metabolism in healthy post-menopausal women: A randomized controlled trial. AJCN, 2008;88(2):465-74.
Feskanich D, Willett WC, Stampfer MJ, et al. Milk, a 12-year prospective study. Am J Public Health 1997;87:992-7.
Bolland MJ, Avenell A, Baron JA, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: Meta-analysis. BMJ 2010;341:c3691.
Natural Medicines Comprehensive Database. Natural Medicines in the Clinical Management of Osteoporosis. Accessed at http://naturaldatabase.therapeuticresearch.com/ce/ceCourse.aspx?s=ND&cs=&pc=09%2D27&cec =1&pm=5, May 2011.
Cleland JGF, Witte K, Steel S. Calcium supplements in people with osteoporosis. BMJ 341:c3856. 20. Bischoff-Ferrari HA, Fracture prevention with vitamin D supplementation: A meta-analysis of randomized controlled trials. JAMA 2005;293:2257-64.
Stransky M, Rysava L. Nutrition as prevention and treatment of osteoporosis. Physiol Res. 2009;58 Suppl 1:S7-11.
LeBoff M, Chou S, Ratliff K, et al. Supplemental Vitamin D and Incident Fractures in Midlife and Older Adults. N Engl J Med 2022; 387:299-309
Reid IR, Bolland MJ, Grey A. Effects of vitamin D supplements on bone mineral density: a systematic review and meta-analysis. Lancet 2014;383:146–55.
Avenell A, Mak JC, O’Connell D. Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane Database Syst Rev 2014 Apr 14;4:CD000227.
Nowson CA, McGrath JJ, Ebling PR, Haikerwai A, Daly RM, Sanders KM, Seibel MJ, Mason RS. Vitamin D and health in adults in Australia and New Zealand: a position statement. Med J Aust 2012;196:686–7.
Cockayne S, Adamson J, Lanham-New S, et al. Vitamin K and the prevention of fractures: Systematic review and meta-analysis of randomized controlled trials. Arch Intern Med 2006;166(12):1256-61.
Bolton-Smith C, McMurdo ME, Paterson CR, et al. Two-year randomized controlled trial of vitamin K1 (phylloquinone) and vitamin D3 plus calcium on the bone health of older women. J Bone Mineral Res 2007;22(4):509-19.
Mutlu M, Argun M, Kilic E, et al. Magnesium, zinc and copper status in osteoporotic, osteopenic, and normal post-menopausal women. J Int Med Res 2007;35(5):692-5.
Price CT, Langford JR, Liporace FA. Essential nutrients for bone health and a review of their availability in the average North American diet. Open Orthop J. 2012;6:143-9.
Promislow JH, Goodman-Gruen D, Slymen DJ, et al. Retinol intake and bone mineral density in the elderly: The Rancho Bernardo Study. J Bone Min Res. 2002;17:1349-58.
Bonaiuti D, Shea B, Iovine R, et al. Exercise for preventing and treating osteoporosis in postmenopusal women. Cochrane Database Syst Rev 2002;(3):CD000333.
Borer KT, Fogleman K, Gross M, et al. Walking intensity for post-menopausal bone mineral preservation and accrual. Bone 2007;41(4):713-21.
Wolf SL, Barnhart HX, Kutner NG, et al. Reducing frailty and falls in older persons: An investigation of Tai Chi and computerized balance training. Atlanta FICSIT Group. J Am Geriatr Soc 1996;44:489-97.
Wayne PM, Kiel DP, Krebs DE, et al. The effects of Tai Chi on bone mineral density in postmenopausal women: A systematic Review. Arch Phys med Rehabil. 2007;88(5):673-80. 34. Ward KD, Klesges RC.
Lu, Yi-Hsueh PhD; Rosner, Bernard PhD; Chang, Gregory MD, PhD; Fishman, Loren M. MD, B Phil (oxon.). Twelve-Minute Daily Yoga Regimen Reverses Osteoporotic Bone Loss. Topics in Geriatric Rehabilitation 32(2):p 81-87, April/June 2016. | DOI: 10.1097/TGR.0000000000000085
A meta-analysis of the effects of cigarette smoking on bone mineral density. Calcified Tisue International;2001;68:259-70. 35. Mezuk B, Eaton WW, Golden SH. Depression and osteoporosis: Epidemiology and potential mediating pathways. Osteoporos Int 2008;19(1):1-12.
Murad MH, Drake MT, Mullan RJ, Mauck KF, Stuart LM, Lane MA, Abu Elnour NO, Erwin PJ, Hazem A, Puhan MA, Li T, Montori VM. Clinical review. Comparative effectiveness of drug treatments to prevent fragility fractures: a systematic review and network meta-analysis. J Clin Endocrinol Metab 2012;97:1871
Adler RA, El-Hajj Fuleihan G, Bauer DC, Camacho PM, Clarke BL, Clines GA, Compston JE, Drake MT, Edwards BJ, Favus MJ, Greenspan SL, McKinney R Jr, Pignolo RJ, Sellmeyer DE. Managing osteoporosis in patients on long-term bisphosphonate treatment: Report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res 2016;31:16–35.
Eastell R, Hannon RA, Wenderoth D, Rodriguez-Moreno J, Sawicki A. Effect of stopping risedronate after long-term treatment on bone turnover. J Clin Endocrinol Metab 2011;96:3367–73