by Selia Cox, MSN, ARNP
Did you know… that we are born with about 300 bones at birth that then fuse together to form 206 bones as adults! Our bones are an integral part of the skeletal system. They serve many major functions in our body including shape and support for movement, protection to vital internal organs, storage site for minerals such as calcium and phosphate and production of red blood cells, platelets, and white blood cells. Bone health is emphasized in older adult years given the risk of bone loss as we age however, there is a lot that we can focus on throughout the whole lifespan. Most individuals reach their peak bone mass between 25-30 years and by age 40 for both sexes, begin to lose bone mass (Demontiero et al., 2012).
When we think about bone health, we often think about osteoporosis which is when are bones become brittle from the loss of tissue because it is the most common bone disease. Bone is viable tissue that undergoes a cyclic pattern of breaking down and being replaced. In adults, 5-10% of the bone is remodeled each year and in the first year of life just about 100% of bone is replaced. Osteoporosis occurs when your body breaks down old bone faster than it builds new bone which decreases the density of bones. Osteopenia is the stage prior to osteoporosis that occurs when bone mass starts to decrease earlier relative to age. To put into numbers, a bone density scan score of -1 and -2.5 is indicated as osteopenia and a score of -2.5 would be the value to be diagnosed with osteoporosis. Both, compromise bone strength, and increases risk of fracture. Osteoporosis is known as a silent disease as it surfaces when it is complicated by fractures with minimal trauma (Office of the Surgeon General (US), 2004).
An important component that complements bone structure is the use of our muscles. In newly described research, there is a co-existence between a decrease in muscle mass which is also known as sarcopenia and a decrease in bone mass which represents osteoporosis and combined is called osteosarcopenia. The rational is that both can increase the risk of fractures due to impaired balance seen with a decrease in muscle mass and a reduction in bone strength (Cosman et al., 2014). At the age of 30, we begin to lose 3-5% per decade of muscle mass. Given the peak of bone mass and how early we begin to start losing bone density and muscle mass, it is even more important to be able to implement strategies to help reduce the risk.
So how does this happen?
There are modifiable and nonmodifiable risk factors that contribute to bone health. Modifiable can be remembered as those risks that you have control over including diet, nutrition, stress and non-modifiable are risks that we do not have control over such as age. Research has shown that smoking, stress, inactive lifestyle, smoking, obesity, inflammation, malnutrition, and estrogen depletion in post-menopausal women have contributed to the increased risk of osteoporosis.
According to CDC (2021), the prevalence of osteoporosis to either the femoral neck or lumbar spine or both increased by 3.2% in adults 50 years old from 2007-2008 (9.4%) and 2017-2018 timeframe (12.6%). Among the groups, women had higher prevalence than men. Like that of osteoporosis, sarcopenia shares risk factors such as aging, and sedentary lifestyle. Loss of muscle decreases metabolic rate, increases risk for falls and loss of strength and balance that can lead to a decrease in functional capacity.
There are many modifiable measures and tools that we can utilize to ensure that we continue to keep our bone health as optimal as possible including movement, nutrition, and screenings.
What are ways to help improve bone and muscle health?
The combination of strength, weight bearing, and resistance training is one of the most important modifiable risk factors to incorporate as it has been shown to help improve bone density by slowing bone loss. Examples of weight bearing exercises include walking, dancing, jogging, running, gardening, body weight exercises. Examples of resistance training includes free weights, medicine balls, and weight machines. There is no set guideline for resistance strength training, but the CDC (2021) recommendation is to aim to complete at least twice per week that works all major muscles groups (legs, hips, back, abdomen, chest, shoulders, arms). Each repetition is one complete movement of an activity such as a sit up. Aim to complete 8-12 repetitions per activity which equals one set. You only need to complete one set for each muscle group to reap the benefits of bone and muscle health and this can be achieved with lighter weights such as 2lb. Ways to know if a weight is too heavy would be lack of control, form, holding of breath, and not allowing for contraction and the extension.
I remember when I first learned about how early we peak with bone density, I wanted to run straight to the gym and start training. It is never too late to start but is important to be mindful in your approach and what is realistic individually for you. There are a lot of great resources that are free but choosing ones that are customizable and provide thorough instructions on how to complete each movement safely helps to avoid injury. An example of one is the Nike Training Club app and not only is it free, but it provides safe explanations at a pace that can work for every “body” with various workouts including body weight, yoga core and much more. On YouTube there are great free yoga videos. I really like, “Yoga with Adriene” as she provides fun, safe and effective classes. Now that you may be ready to add in more exercise into your life, which is great! I highly recommend speaking with your healthcare provider on what works safely for you before starting any new regimen.
Nutrition is another very important nonmodifiable risk factor that we can control. Research has shown that the standard American diet (SAD) that is characterized by high intake of soft drinks, fried foods, processed foods such as sweets, refined grains is inversely correlated with reduction in bone density. When compared to healthy nutritional pattern that includes high intake of fruit, vegetables, whole grains, fish, nuts, legumes were associated with lower risk of fracture. Intake of fruits and vegetables are rich in nutrients that are necessary for bone health including magnesium that aids in activation of vitamin d, vitamin c produces collagen in the bone matrix, and vitamin k is also involved in bone matrix formation (Movassagh et al., 2017). Vitamin d is another essential nutrient that is necessary to help in calcium absorption in the body. Sources of vitamin d includes oily fish such as salmon, sardines, egg yolks, fortified plant milks such as almond, soy or oat. Bones are the main storage site of calcium in the body and provides the strength and structure. Our bodies cannot make it and need to obtain through diet. Good sources of calcium in the diet includes, dark green leafy vegetables, chia seeds, almonds, beans, and lentils. The recommended daily intake of calcium and vitamin d is dependent on age, medical history and would be a great discussion to review with your provider on how to incorporate into your daily routine.
USPSTF guidance recommends screening for osteoporosis with bone measurement in women 65 years and older, women younger than 65 who are post-menopausal as determined by a clinical risk assessment. USPSTF concludes that there is insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men. Just like nutrition and movement, screening is another important tool that you can review with your medical provider to identify your individual risk factors and when a DEXA would be beneficial.
In a conventional approach, DEXA scans are completed starting at age 65 for an individual with an average risk. Someone who is diagnosed with osteopenia is given the guidance to increase calcium supplementation and strength training exercises. As the condition progresses into osteoporosis there are pharmaceutical medications such as Fosamax but comes with potentially serious side effects such as osteonecrosis of the jaw which is the breakdown of bone cells within the jaw.
Depending on age, medical history, and biochemistry the approach to supporting bone health will look different. A collaborative approach including functional medicine can help to individualize and assess the whole picture to help take proactive measures in management. This can include looking at stress, inflammation, nutrition including vitamin and mineral deficiencies, gut health for potential dysbiosis and endocrine including the thyroid and reproductive hormones. I encourage you to look at risk factors you can identify in your life and speak with your provider. With the shifts and changes in seasons and upcoming holidays, this is a great time to explore new foods and activity that you enjoy.
If you would like to take a deeper dive into your health and or have questions, schedule free 10-minute appointment to discuss.
Center for Disease Control and prevention [CDC]. (2021). How much physical activity do adults need.https://www.cdc.gov/physicalactivity/basics/adults/index.htm#:~:text=Try%20to%20do%208%2D12,whatever%20works%20best%20for%20you.
Cosman, F., de Beur, S. J., LeBoff, M. S., Lewiecki, E. M., Tanner, B., Randall, S., Lindsay, R., & National Osteoporosis Foundation (2014). Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 25(10), 2359–2381. https://doi.org/10.1007/s00198-014-2794-2
Demontiero, O., Vidal, C., & Duque, G. (2012). Aging and bone loss: new insights for the clinician. Therapeutic advances in musculoskeletal disease, 4(2), 61–76. https://doi.org/10.1177/1759720X11430858
Ginaldi, L., Di Benedetto, M. C., & De Martinis, M. (2005). Osteoporosis, inflammation, and ageing. Immunity & ageing : I & A, 2, 14. https://doi.org/10.1186/1742-4933-2-14
Office of the Surgeon General (US). Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville (MD): Office of the Surgeon General (US); 2004. 2, The Basics of Bone in Health and Disease. Available from: https://www.ncbi.nlm.nih.gov/books/NBK45504/
Movassagh, E. Z., & Vatanparast, H. (2017). Current Evidence on the Association of Dietary Patterns and Bone Health: A Scoping Review. Advances in nutrition (Bethesda, Md.), 8(1), 1–16. https://doi.org/10.3945/an.116.013326
Sarafrazi N, Wambogo EA, Shepherd JA. Osteoporosis or low bone mass in older adults: United States, 2017-2018. Centers for Disease Control and Prevention, National Center for Health Statistics. Published March 2021. https://www.cdc.gov/nchs/products/databriefs/db405.htm
U.S. Preventative Services Task Force [USPSTF]. (2018). Osteoporosis to prevent fractures: screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening