The human skeleton’s 206 bones provide the basic structural frame for the rest of the body. The compact or hard bone includes the mineralized portion of bone. It represents most of the bone mass, and provides the strength the skeleton needs to support the body. The trabecular or soft bone houses the cells responsible for bone remodeling: osteoclasts resorb bone by removing minerals and breaking up collagen; osteoblasts build bone by laying down new collagen and mineralizing the collagen matrix. The balance of osteoclast and osteoblast activities shifts in favor of bone resorption as we age, and particularly in women after menopause. The result is a reduction in bone mineral density, or osteopenia, which can eventually lead to osteoporosis and increased risk of fracture.
In women, most bone loss occurs during the first eight to ten years after menopause. During this critical window, a number of things can be done to slow bone loss, including staying physically active, not smoking, and eating a diet rich in fruits and vegetables, high in legumes including soy, sufficient in omega-3 fatty acids like those in fish, moderate in animal protein, and low in sugar, sodium, caffeine, soft drinks, and alcohol. In addition, a number of nutritional supplements have been found to support bone mineralization through their effects on calcium metabolism.
Calcium
Calcium is the most substantial mineral component of structural bone. In addition to dairy foods, there are many dietary sources of calcium, including green vegetables, beans, soy foods, nuts and seeds, blackstrap molasses, figs, sea vegetables, and bony fish. Findings from some studies suggest that getting adequate dietary calcium might prevent bone loss and fractures, [i] but there is no conclusive evidence linking dairy foods—the main source of calcium in the standard American diet—to bone health. [ii] [iii]
Calcium supplements have long been recommended as a way to boost calcium intake, which is notoriously low in many subsets of Americans. Supplementing with calcium and vitamin D has been associated with increased bone mineral density in peri- and postmenopausal women, [iv] [v] shorter healing time in women with osteoporosis-related upper arm fractures, [vi] and reduced bone loss in men and women over the age of 60. [vii] The combination of calcium and vitamin D was also found to reduce the fracture rate in elderly people living at a Northern latitude, [viii] and to prevent tooth loss in people over 65. [ix]
It is important to note that supplementing with calcium alone does not appear to have a significant fracture-preventing effect. [x] [xi] The most recent report from the ongoing National Health and Nutrition Examination Survey (NHANES) presented findings showing no clear correlation between calcium intake and fracture risk. [xii] Even with vitamin D, supplementation appears to be of little value in women with adequate calcium intake and normal blood levels of vitamin D. [xiii] In light of the growing body of evidence that other nutrients influence calcium metabolism and bone cell activity in critical and complex ways, researchers have begun to question whether the current calcium supplement recommendations are too high. [xiv] [xv]
Low stomach acid, such as is seen in many elderly people and in people using medications that reduce stomach acid secretion, hinders the absorption of calcium carbonate, the least expensive and most widely used form of calcium. Calcium citrate and calcium citrate malate, however, appear to be effectively absorbed even in people with hypochlorhydria and achlorhydria. [xvi] [xvii]
Vitamin D3/Cholecalciferol
Vitamin D3 (cholecalciferol) is produced in sun-exposed skin and activated through a series of chemical reactions that take place in the liver and kidneys. Once in its active form, calcitriol, it raises calcium levels by increasing calcium absorption in the intestines and resorption in the kidneys. It also modulates bone remodeling by osteoclasts and osteoblasts.
Vitamin D2 (ergocalciferol) is not produced by humans, but in some sun-exposed invertrebrates, fungi, and plants. While vitamin D2 is often used in nutritional supplements and is able to raise blood levels of 25-hydroxyvitamin D (25(OH)D, the standard measure of vitamin D status), supplementing with vitamin D3 appears to be more effective at improving vitamin D status. [xviii]
Supplementing with vitamin D3 plus calcium reduced bone loss and nonvertebral fracture incidence in community dwelling elders in one study, [xix] but had no effect on fracture risk in another study. [xx] An increase in bone mineral density and reduction in bone loss was observed in people who had experienced an osteoporosis-related hip fracture and subsequently supplemented with vitamin D3 plus calcium. [xxi] Researchers conducting a meta-analysis noted a trend toward a reduced risk of falling in postmenopausal women taking vitamin D3. [xxii]
Low and deficient vitamin D levels are highly prevalent in people who avoid sun exposure due to health concerns or cultural traditions, use sunscreen, have dark skin, or live in northern latitudes. In a study involving North American women with osteoporosis, 52% were found to have suboptimal vitamin D status (<30 ng/ml 25(OH)D). [xxiii] Because vitamin D insufficiency has been linked to increased risks of osteoporosis and other chronic diseases including heart disease, diabetes, and cancer, new recommendations for vitamin D supplementation are being considered. [xxiv] [xxv] A routine recommendation of 1,000 IU per day is considered safe and reasonable, [xxvi] [xxvii] and higher amounts are likely indicated for people with osteoporosis or known vitamin D insufficiency. [xxviii]
Magnesium
Magnesium, often thought of as the counterpart to calcium, is found in foods such as nuts, seeds, whole grains, and legumes. It functions primarily intracellularly, and interacts closely with the other cationic minerals, such that magnesium deficiency can cause hypocalcaemia and hypokalaemia, [xxix] overly high calcium intake can cause a relative or absolute magnesium deficiency, [xxx] and low potassium intake (generally due to lack of fruits and vegetables in the diet) can lead to increased excretion of calcium and magnesium. [xxxi] [xxxii] Women with osteoporosis have been found to have low intracellular [xxxiii] and serum [xxxiv] [xxxv] magnesium levels, and chronically low magnesium levels have also been associated with diabetes, hypertension, and coronary artery disease. [xxxvi] Low magnesium intake is common [xxxvii] and has been associated with lower bone mineral density in Caucasians [xxxviii] and a higher risk of hip fracture in a Japanese community. [xxxix] People with high magnesium intake have been found to have higher bone mineral density and less bone loss over time than people with low intake. [xl] [xli] In preliminary trials, increasing dietary magnesium [xlii] and magnesium supplementation [xliii] have both been found to improve bone mineral density in postmenopausal women with osteoporosis.
Most nutritional guidelines recommend a 2:1 ratio of calcium to magnesium, as it is believed that an excessively high calcium intake can disrupt the balance between calcium and magnesium, increasing the risk of cardiovascular consequences such as hypertension and thrombosis. [xliv] Given magnesium’s important role in thrombus prevention as well as maintaining healthy blood pressure, regular heart rhythm, and normal cardiac muscle function, [xlv] an induced relative magnesium deficiency could explain the increased incidence of cardiovascular disease seen in women using calcium and calcium plus vitamin D in some [xlvi] [xlvii] (though not all [xlviii] ) studies.
Boron
Humans have a trace requirement for the mineral, boron, which is found in fruits, vegetables, and nuts. Although its role in the body is not fully understood, boron appears to help regulate the levels of other minerals, including calcium, magnesium, and phosphorus. A low-boron diet has been linked to increased urinary excretion of both calcium and magnesium, while supplemental boron seems to limit these mineral losses. [xlix] [l] [li] Boron has also been found to reduce urinary calcium loss in people with a magnesium-deficient diet. [lii] The need for boron appears to be enhanced in cases of magnesium, potassium, and vitamin D deficiencies. [liii]
Lysine
The essential amino acid, lysine, is a necessary nutrient for the synthesis of biochemical proteins including muscle tissue, hormones, antibodies, and enzymes. In addition, lysine increases calcium absorption and reduces urinary calcium excretion, leading to an overall positive impact on calcium balance. [liv] Research using bone cells derived from osteopenic rats suggests that lysine stimulates osteoblast proliferation and activity, and might thereby promote bone building. [lv] [lvi] This may partially explain the negative impact of a low-protein diet on bone health. [lvii] [lviii]
By increasing calcium absorption and osteoblast activity, lysine might be useful in treating osteoporosis. In two controlled trials, calcitonin plus a combination of lysine, arginine, and lactose was found to improve bone mineral density and reduce bone loss more than calcitonin alone in elderly people with osteoporosis. [lix] [lx]
Horsetail (Equisetum arvense)
Horsetail is a common weed in many parts of the United States. In traditional herbal medicine, it is used in the treatment of urinary tract infections, hemorrhage and bleeding, superficial wounds, and benign prostatic hyperplasia. It is know to be rich in antioxidant phenolic compounds [lxi] as well as minerals. [lxii] In particular, the stems of horsetail contain high levels of silica and silicic acids, [lxiii] which support bone and collagen formation.
Women and men with high dietary intake of silicon have higher bone density than women with low intake. [lxiv] Supplementing with silicon led to improved hip bone density in women with osteoporosis, [lxv] and augmented the bone-building effects of calcium plus vitamin D in women with osteopenia. [lxvi] Horsetail extract, in a preliminary trial, was more effective at increasing bone density than a calcium/silicon combination taken by women over the course of one year. [lxvii]
Strontium
Strontium is a metal element that occurs naturally in the form of the mineral, strontianite. A compound made with strontium and ranelic acid (strontium ranelate) has been developed and marketed in Europe and other parts of the world as a drug for the treatment of osteoporosis. This drug is not available in the US or Canada, but strontium salts, such as strontium citrate and strontium carbonate, are increasingly common ingredients in bone-building nutritional supplements.
In vitro research suggests that strontium becomes incorporated into the bone mineral crystal matrix. [lxviii] Strontium also appears to stimulate the production of mature osteoblasts and inhibit osteoclast formation and activity in the trabecular bone, increasing the capacity of bone to lay down mineralized matrix. [lxix] [lxx]
Strontium ranelate has been subjected to a number of clinical trials and has been found to be safe and effective for the treatment of osteopenia and osteoporosis. [lxxi] One study identified the minimum effective dose for improving bone mineral density to be 1 gram per day. [lxxii] It has also been shown to significantly reduce the incidence of vertebral (approximately 24–40% reduction) and non-vertebral (approximately 15% reduction) fractures over study periods of three to five years, particularly in women at high risk for fracture and women over 80 years old. [lxxiii] [lxxiv] [lxxv] [lxxvi] [lxxvii] In postmenopausal women with osteoporosis, strontium use has been associated with better physical and emotional functioning, less pain, and higher overall quality of life. [lxxviii] Strontium ranelate has also been found to prevent cartilage loss associated with osteoarthritis, [lxxix] and reduce back pain in people with spinal osteoarthritis. [lxxx]
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