Diet and Health Guidelines to Lower Risk of Osteoporosis

Presented by Janice Hermann, PhD, RD/LD

OCES Adult and Older Adult Nutrition Specialist

What Is OsteoporosisGradual reduction in bone mineral density,

causing bones to becomes thin and porousThe fragile bones are at increased risk of

fractureCan fracture or break from a minor fall or

with normal everyday use

SymptomsFractures (spine, hip, and wrist) most

common sitesLoss of heightCurved spineBecause it progresses slowly, many people

don't realize they have osteoporosis until they fracture a bone

Long Term EffectsAffects millions in the United StatesEffects go beyond initial fractureUp to 25% with hip fractures die from

complications within a yearAnother 25% of people who survive never

return to their previous daily living ability

Good NewsFracture risk related to osteoporosis can be

reduced by obtaining maximum bone mass and bone density

Diet, exercise and other lifestyle factors have critical roles in maximizing bone mineral density and lowering the risk of osteoporosis and bone fractures

Understanding BoneThere are two basic types of bone:

CorticalTrabecular bone

Both can lose minerals, but different ways and different rates

Cortical BoneMakes up the dense outer shell of bonePredominately found in the shafts of long

bonesHas a slow turnover rate

Trabecular BoneInner, lacy bone matrix, forms the bone's

internal support systemHas a rapid turnover rate Found in flat bones, such as the vertebrae

and pelvis, and the ends of the long bones

Trabecular BoneRapid turnover rate

Releases calcium into blood, if dietary calcium intake isn’t sufficient to maintain blood calcium levels, and takes up calcium when dietary intake is plentiful

People who have eaten calcium-rich foods throughout the bone-forming years of their youth have dense trabecular bone which provides a reservoir of calcium

Type Of Bone LossIn osteoporosis, loss of both types of bone

occursMajority of loss is trabecular bone

Bone LossTrabecular bone readily gives up calcium

whenever blood calcium levels are lowTrabecular bone loss begins about age 30,

although loss can occur whenever calcium withdrawal exceeds deposit

Bone LossCortical bone also gives up calcium, but at a

slow, steady paceCortical bone loss typically begins at about

age 40 and continues slowly and steadily thereafter

Bone Strength

There are three major factors related to bone strength:Bone mineral densityMicrofracture healingTrabecular integrity

Bone Mineral DensityBone fracture risk increases as bone mineral

density decreasesBone mineral density accounts for as much as

80 to 90% of bone strength

Microfracture HealingIncreasing microfractures increase bone

fragilityBone remodeling and healing slow with age,

and microfractures thought to accumulate

Trabecular IntegrityIntegrity of trabecular bone, bone internal

support system, is an important aspect of bone strength

Thin or disconnected trabecular bone increases the risk of bone fractures

Current Treatment EffectsCurrent lifestyle treatments for osteoporosis

can preserve existing bone mineral densityCurrent treatments cannot reconnect

trabecular bone or restore bone mineral density to normal values

Types of OsteoporosisThere are two main types of osteoporosis

Type I OsteoporosisType II Osteoporosis

Primary and secondary osteoporosisType I and Type II osteoporosis are termed

primary osteoporosisSecondary osteoporosis occurs secondary to

another disease condition

Type I OsteoporosisAge Of Onset 50-70Ratio Female:Male 6:1Type Of Bone LossTrabecularFracture Sites Wrist and SpineMain Causes Rapid loss of estrogen in

women following menopause;Loss of testosterone in men with advancing age

Type I OsteoporosisInvolves rapid loss of trabecular bone

Trabecular bone loss accelerates and bone breaks may occur suddenly

Trabecular bone becomes so fragile even body’s weight can overburden spineVertebrae may suddenly disintegrate and crush down,

painfully pinching nerves

Type II Osteoporosis

Age Of Onset Over 70Ratio Female:Male 2:1Type Of Bone LossTrabecular & CorticalFracture Sites Hip (due to both types of

bone loss over time)Main Causes Reduced calcium

absorption;Increased bone mineral loss;

Increased risk of falling

Type II OsteoporosisInvolves loss of both cortical and trabecular

bone Losses occur slowly, over many years Vertebrae may compress into wedge

shapes forming what is often called a “dowager’s hump”

Factors Affecting Bone Mineral DensitySeveral factors affect bone density:

Non-Modifiable ModifiableAge CalciumGender Vitamin DFamily History Other NutrientsGenetics/Ethnicity Physical Activity

SmokingAlcoholBody Weight

AgeTwo major life stages are critical in

development of osteoporosisFirst is the bone-acquiring stage of childhood and

adolescenceBones gain strength and density through growing years

and into young adulthoodSecond is the bone-losing decades of late

adulthood (especially in women after menopause)

AgeStrongest factor associated with

osteoporosisRisk increases with age

Inefficient bone remodelingDecreased calcium intakeImpaired vitamin D activation and statusImpaired calcium absorption Decreased physical activityHormonal changes favoring bone mineral loss

AgeAge related factors contribute to bone loss

Inefficient bone remodelingCells that build bone gradually become less active, but

those that breakdown bone continue to workAs a result bone loss exceeds bone formation

Decreased calcium intakeLactose tolerance tends to decrease with age

AgeAge related factors contribute to bone loss

Impaired vitamin D activation and statusMany older adults spend less time outdoors in the

sunshine resulting in decreased vitamin D formationDecreased kidney activation of vitamin DSince vitamin D is needed to absorb calcium,

decreased vitamin D formation and activation results in decreased calcium absorption

AgeAge related factors contribute to bone loss

Decreased physical activityHormonal changes favoring bone mineral loss

Some hormones (parathormone, calcitonin, and estrogen) that regulate bone and calcium metabolism change with age and accelerate bone mineral withdrawal

GenderSecond strongest factor associated with

osteoporosisOccurs more in females than males

Lower bone mass densityLower calcium intakeLose trabecular bone at a greater rateLose hormone estrogen, that helps deposit

calcium in bones

GenderMenopause particularly impacts women

Estrogen helps deposit calcium in bones Loss of bone mass rapidly increases during the six

to eight years following menopause, due to the loss of estrogenWomen may lose up to 20 % of bone mass during the six

to eight years following menopause Eventually, rate of bone loss decreases until

women lose bone at a similar rate as men their age

GenderRapid bone losses also occur when young

women’s ovaries fail to produce enough estrogen, causing menstruation to ceaseOvaries may be diseased and must be removedAnorexia nervosa can result in low body weight

which can cause the ovaries to fail to produce enough estrogen resulting in amenorrhea

GenderEstrogen therapy:

Can prevent further bone loss and reduce fracturesHowever, estrogen therapy may increase heart disease

and breast cancer riskWomen must carefully discuss potential benefits and

dangers with their physicianOther prescription medications are available

to prevent or treat osteoporosis Medications work by inhibiting bone-breakdown

cells, thus allowing bone-building cells to build up bone tissue with new calcium deposits

GenderSoy

Phytochemicals commonly found in soybeans mimic estrogen action and stimulate estrogen-sensitive tissuesAs a result, phytochemicals in soy may help to prevent

post-menopausal bone loss However, research is far from conclusive

Some research suggests soy may offer some protection

However, supplements of isolated soy extracts may actually increase cancer risk

GenderIf estrogen deficiency is a major cause of

osteoporosis in women, what is the cause of bone loss in men? Male hormone testosterone appears to play a

role Low levels of testosterone, as occurs after

removal of diseased testes or when testes lose function with aging, results in more fractures

Family HistoryFamily history of osteoporosis is a risk factor

Genetics and EthnicityExact role of genetics is unclear, but most

likely it influences:Peak bone mass achieved during growthBone loss incurred during the later years

Genetics and EthnicityRacial differences in osteoporosis may reflect

genetic differences in bone development African Americans have greater bone density and

a lower rate of osteoporosis than CaucasiansAfrican Americans seem to use and conserve calcium

more efficiently than Caucasians Fractures are twice as likely in Caucasian women 65

years or older than African American women

Genetics and EthnicityOther ethnic groups have a high risk of

osteoporosis Asians from China and Japan, Mexican Americans,

Hispanic people from Central and South American, and Inuit people from St. Lawrence Island typically have lower bone density than Caucasians

Would expect these groups would suffer more bone fractures, but this is not always the case May be explained by genetic, dietary , physical activity

and other lifestyle differences

Genetics and Ethnicity

Although genetics may lay the groundwork, other factors influence the genes’ ultimate expression Diet in general, calcium and vitamin D in

particular Others include physical activity, smoking, alcohol

and body weight

Calcium99% of calcium in bones and teeth1% of body calcium circulates in blood

Regulate heart beat Relax musclesTransmit nerve impulses Blood coagulationComponent of enzymes Acid-base balanceMaintain blood pressure

Why Need Calcium DailyMaintaining blood calcium

Although calcium in blood is small, it is very important

If dietary calcium inadequate to maintain 1 % blood calcium, calcium pulled from the bones

Maintaining blood calcium is one reason calcium in the diet is needed every day

Why Need Calcium DailyBone remodeling

Bones are not static, they constantly being remodeled

Calcium is continuously being removed from bone and new calcium deposited

600 to 700 mg calcium deposited each day in newly forming adult bones

Bone FormationBody deposits greatest amounts of calcium

during growth years to add length and diameter to growing bones

After about age 20, body deposits calcium to increase bone density rather than to increase the length or diameter

Bone Formation

After about age of 30, all individuals, especially women, lose bone mass at a faster rate than it is reformed

Maximizing peak bone mass in early years helps lower risk of osteoporosis in later lifeHave more bone to start with so able to lose

more bone before suffering ill effects

Calcium IntakeMany Americans do not consume enough

calciumWomen and teenage girls especially fall short

of an adequate calcium intake Teenage and young women who do not get

enough calcium, do not maximize their peak bone density and may be at higher risk of osteoporosis

How Much CalciumRecommended Dietary Allowance

Men (19-70 yr): 1,000 mg/dayMen (71+ yr): 1,200 mg/dayWomen (19-50 yr): 1,000 mg/dayWomen (51+ yr): 1,200 mg/day

Upper LevelAdults (19-50 yr): 2,500 mg/dayAdults (51+ yr): 2,000 mg/day

Sources Of CalciumDairy foods main dietary calcium sourceThese foods also contain other nutrients,

such as vitamin D, that help body absorb calcium

If dairy foods omitted from the diet it is difficult to consume adequate amounts of calcium

Other Calcium SourcesSalmon & sardines with eatable bones Tofu processed with calcium sulfateDark green leafy vegetables, such as broccoli,

collards, kale, mustard greens and turnip greens

Foods such as orange juice and breakfast cereals fortified with calcium

Calcium SupplementsFor those unable to consume enough

calcium-rich foods, taking calcium supplements may be appropriate

Selecting a supplement takes some evaluation

Many multivitamin-mineral supplements contain little or no calcium

Calcium SupplementsSingle nutrient calcium supplements are

typically sold as compounds of:Calcium carbonateCalcium citrateCalcium gluconateCalcium lactateCalcium malateCalcium phosphate

Calcium supplements often include vitamin D, magnesium, or both

Calcium SupplementsCalcium supplements made from:

Bone mealOyster shellDolomite (limestone)

are not recommended because they may contain heavy metals, such as lead – which impairs health in numerous ways

Calcium Supplements

Determine how much calcium the supplement providesMost calcium supplements provide between 250

and 1,000 milligrams of calciumTo be safe, total calcium intake from both foods

and supplements should not exceed the upper level:Adults (19-50 yr): 2,500 mg/dayAdults (51+ yr): 2,000 mg/day

Calcium SupplementsBetter to take a low-dose supplement

several times a day rather than a large-dose supplement all at once Taking calcium supplements in doses of 500

milligrams or less improves absorptionSmall doses also help ease the GI distress

(constipation, intestinal bloating, and excessive gas) that sometimes accompanies calcium supplement use

Calcium Supplements

Most healthy people absorbs and use calcium equally well from various supplementsCalcium citrate is an acid form which may help

with absorption for older adults with achlorhidria (low stomach acidity)

Consuming a supplement with a source of vitamin C can help with absorption

Calcium SupplementsWhen to take a supplement

Calcium from supplements are better absorbed when taken with meals

Try to avoid taking calcium supplements with iron supplements or iron rich meals; calcium inhibits iron absorption

Calcium SupplementsSupplement disintegration

When manufacturers compress large quantities of calcium into small pills, the stomach acid has difficulty penetrating the pill

To test a supplement’s ability to dissolve, drop into a 6-ounce cup of vinegar, and stir occasionally

A high-quality formulation will dissolve within half an hour

Calcium SupplementsHowever, before just automatically

depending on a supplement, people should reconsider the benefits of food sources of calcium Foods are the best sources of calciumFoods supply other nutrients bones need in

addition to calciumSupplements should “supplement” not

“replace” the diet

Vitamin DVitamin D helps absorb and deposit calcium

and phosphorous in the bonesThe body can make vitamin D when the skin

is exposed to sunlightSunscreens help reduce the risk of skin

cancer, but sunscreens with a protection factor of 8 and above also prevent vitamin D synthesis

How Much Vitamin DRecommended Dietary Allowance

600 IU/day (Adults 19-50 yr)600 IU/day (Adults 51-70 yr)800 IU/day (Adults 71 + yr)

Upper LevelAdults: 4,000 IU/day

Sources of Vitamin DMilk is an excellent source of vitamin D

because fluid milk is fortified with vitamin DCheese, eggs, some fish (sardines and

salmon)Fortified cereals and margarine also contain

small amounts of vitamin D

Older Adults Lower IntakeOlder adults at greater risk for low vitamin D

intakeLimited sunlight exposure, resulting in lower

vitamin D formationKidneys less efficient at converting vitamin D into

active formLower intake of dairy foods, which contain vitamin

D, if have a problem with lactose intolerance

Other NutrientsMany nutrients have critical roles in bone

formation and maintenanceProteinVitamins: D, C, B12, K, and folateMinerals: calcium, phosphorous, zinc, copper,

magnesium, iron, fluoride & boron Importance of these nutrients can’t be

ignored in the enthusiasm for calcium and vitamin D

Some Excesses Not GoodExcessive protein, especially sulfur-containing

amino acids, and high sodium may increase calcium excretionWhether this effects bone development remains

unclearExcessive alcohol increases calcium excretion

and decreases bone formation

Physical ActivityWeight bearing physical activity

Places mechanical stress, particularly on the ends of the long bones, which stimulates bone remodeling and increases bone formation, making them stronger and denser

Strengthens muscles that in turn pull or tug on bones, which also keeps bones strong

Improves coordination, thus reducing the risk of falls and bone injuries

Physical ActivityWeight bearing physical activity can be

beneficial at various age groupsMaximize bone density in adolescenceMaintain bone density in adultsEven past menopause when most women are

losing bone, weight training improves bone density

Physical ActivityTo keep bones healthy, a person should

engage in weight bearing activities daily Benefits of weight bearing physical activities

are site-specific, bones used in physical activity are strengthened

Include a variety of weight bearing physical activities such as walking, jogging, running, tennis, weight lifting, aerobics and dancing

SmokingSmoking increases the risk of osteoporosis

Shown to lower bone mineral densityPromotes a condition called acidosis, which

stimulates bone lossLowers estrogen levels, in women, further

contributing to bone loss

AlcoholAlcohol in moderate amounts may protect

bone density by decreasing remodeling activity; however

People who abuse alcohol often suffer from osteoporosis and experience more fractures

AlcoholAbusive alcohol use increases the risk of

osteoporosisIncreases fluid loss which can lead to excessive

calcium loss in urineUpsets hormone balance for healthy bonesSlows bone formationStimulates bone breakdownIncreases risk of falling

Body WeightHeavier body weight places mechanical stress

on the bones and promotes bone densityNewer research is showing differences between

weight from lean muscle and fatWeight from lean muscle has beneficial bone effectsExcessive weight from fat, obesity, may increase bone loss

Underweight and excessive weight loss are significant predictors of bone loss and fracture risk

Lowering Risk of OsteoporosisAdequate calcium and vitamin DConsume recommended amount of foods

from the USDA Daily Food Plan food groups to get the variety of nutrients in addition to calcium and vitamin for bone health

Regular weight-bearing physical activityModeration in alcohol, protein and sodiumNot smoking