Discussion of Diet, Nutrients & Osteoporosis
Protein: Vegetarian diets, animal protein, & protein supplementation
There is a great deal of conflicting research about the importance of protein1-13 in vegetarian versus non-vegetarian diets in protection against osteoporosis and whether that protein coming from supplements is relevant. In addition, there is (surprisingly) conflicting evidence whether protein supplementation improves health.14-16 Dietary protein increases protein loss in urine,17 which should indicate greater osteoporosis risk, but normal bone structure needs protein in the diet and low protein in the diet as been connected to low bone density.19
There are a number of factors that influence bone density and health: amount of protein in normal diet, the protein source, calcium consumption, weight loss, and the balance of acids and bases in the diet. Another factor is IGF - insulin-like growth factor.
Taking these factors into account, the conclusion is that high protein diets are connected to greater bone mass when calcium consumption is adequate.116
Does it matter whether the protein comes from animal or vegetable sources?
Plant proteins are as effective as animal proteins if all of the amino acids necessary for metabolism are present.
Animal proteins provide all amino acids.
Plant proteins require combinations such as (for milk, for example) milk plus rice, wheat, corn and soy, or plus wheat and peanuts; milk plus peanuts or sesame seed; milk plus beans; or milk plus potatoes. The classic book on this subject is Frances Moore Lappe's Diet for a Small Planet. Some researchers have found that a high ratio of animal proteins to vegetable proteins is not beneficial. The over-abundance of acid compared to base precursors in the acid-base balance of the body results in a net acid load that may have adverse results for bone health117 as well as many other conditions. Animal proteins provide mostly acid precursors; vegetable proteins provide mostly base precursors.117
What may be even more important in considering animal versus vegetable proteins is the presence of carcinogens and other toxins in many non-organic meat products, and the unknown risks of GMO (non-organic) vegetables.
Researchers have found that increased short-term salt in the diet result in higher calcium loss in urine, which suggests that with time, high salt consumption may contribute to bone loss.20 Increased salt in the diet has been seen to increase a indicators that are loosely or closely connected to bone loss in postmenopausal women.21-23 While a clear link between salt consumption and osteoporosis has been made, there is a clear connection between salt consumption and hypertension, and another clear link between hypertension and bone loss.118 Therefore medical practitioners generally recommend that using less salt and eating fewer processed and restaurant foods is a good idea, since they are often heavily salted. Even this latter trend, however, is slowly beginning to change.
Caffeine also increases loss of calcium in the urine.24 Caffeine consumption has been tied to higher hip fracture risk25 and to lower bone mass in women who consumed inadequate calcium26, and some speculate that adding milk to your coffee offsets much of the negative potential for bone loss. Because coffee is increasingly seen (in moderate amounts) to be beneficial for other conditions such as heart disease119, colorectal cancer120 and depression.121
Current research does not indicate conclusively that drinking tea changes the risk of fractures in postmenopausal women in the US.122
Patients who drink carbonated beverages reportedly have more fractures than those who do not,30 although short-term intake of soft drinks doesn't seem to change bone health indicators.31 Phosphoric acid, however, found in many soft drinks has been found to be connected to low levels of blood calcium.32
Also see the discussion on protein, above. Whole soy foods such as soy milk, tofu, roasted soy beans, tempeh, and seiten may be beneficial in preventing or slowing osteoporosis. Soy isoflavones have been found to protect against bone loss in animal studies.34 In one double-blind study, women who were given soy protein powder (at least 40 grams/daily) had less spinal bone loss.35 A three year long-term study found that soy isoflavones were modestly effective in lowering bone loss.124
Note, soy protein isolate, found in many soy protein supplements, has not been found to have a positive effect on bone health123 and has been found to actually have a negative effect on hair growth.125
There has been a good deal of argument about the helpfulness of dairy products on osteoporosis. One meta-analysis suggests that various products have a varying benefits.36 Nonfat milk seems to have the greatest potential for good because it has less salt and higher amount of calcium. Cheeses may do more harm than due to their high salt content and low calcium content.
In addition milk, an animal protein contributes to a more acidic precursor base in the body, upsetting the acid-base balance - which does contribute to osteoporosis.117
Calcium supplements are insufficient when they are the only calcium source but they do lesson osteoporosis.41 Higher calcium consumption is not always tied to lower osteoporosis risk, but several years into women's menopause, supplementing with calcium does appear to be helpful in a modest way.44 Meta-analysis of trials indicates that supplementing with calcium is helpful for premenopausal women.47 Medical practitioners generally recommend supplementing with calcium to partly lessen osteoporosis risk. 800 to 1,000 mg of supplemental calcium are usually recommended in addition to that normally in daily diet. It should be noted that vegetables and fruits such as rhubarb, spinach, figs, orange juice, tofu, seeds such as sesame seeds, and fish such as mackerel, sardines and salmon have very high calcium levels, in some cases higher than milk.
One nutrient that increases the ability of bones to absorb calcium is Vitamin D. The amount of vitamin D in the blood is directly tied to bone strength.60 Often see, mild vitamin D deficiency is often seen even in active elderly people and contributes to bone loss with aging.61 Double-blind research has demonstrated that supplementing with vitamin D helps reduce bone mass loss in those who don't get enough vitamin D in their diet62, 63 However, research reporting benefit from vitamin D generally also include supplementation with calcium67 so the relative importance of vitamin D is a little unclear.68 Elderly people tend to have poorer balance and generally instability in the muscles compared to younger people, so falls are more common.69 In this respect, vitamin D combined with calcium is helpful and falls are fewer. 70
Medical professionals suggest supplementing with 400-800 IU vitamin D daily if the diet is insufficient and especially if the person rarely gets any exposure to sunlight. About 5-30 minutes of sunlight twice a week is all that is needed for good vitamin D reception. If you are tanned or darker skin, then 15-20 minutes (without clouds) is all that is needed. Note that in the wintertime northern states don't receive enough sunlight because the sun is so low on the horizon.
Isoflavonoids are a subclass of flavonoids. The isoflavonoids from legumes, especially soy beans, are the most studied.129
Ipriflavone is derived from soy isoflavonoids. It also helps bones absorb calcium. Ipriflavone is a man-made flavonoid that comes from daidzein, a soy isoflavone. It helps the process of calcium moving to bone and slows bone deterioration. Most double-blind research has demonstrated that it is effective in stopping or slowing bone loss and improve bone density.48-58
Research finds that 4 grams daily of fish oil over 4 months improved absorption of calcium along with new bone formation in older women.71 Combining it with evening primrose oil may help even more. In one controlled study, women receiving 6 grams of a combined evening primrose oil and fish oil over 3 years had no spinal bone loss and 3.1% spine density gain in the last year and a half of the study. Evening primrose oil is an antioxidant with anti-inflammatory capacity.
Bone formation requires vitamin K; low blood vitamin K levels are seen in those with osteoporosis73, 74 and low amounts of vitamin K in their diet.75, 76 Vitamin K is naturally found in green leafy vegetables such as kale, collards, spinach and turnip greens. Other research found that only for postmenopausal women, calcium loss through urine was reduced by consuming 1mg vitamin K daily77 and that those who already have osteoporosis vitamin K2 supplementation (45mg/daily) increased bone density after 6 months and additionally lowered bone loss after a year or two.78-80 There have been similar result for vitamin K supplementation.81-82
Poor absorption of magnesium is tied to a high risk for osteoporosis83 and in turn, low blood85 and bone84 magnesium levels exist in those with osteoporosis. It has been found that supplementing with magnesium reduced bone loss indicators in men.86 Likewise, in a 2 year controlled study, 87% of those who supplemented with 250-750mg daily magnesium increased bone mass and/or stopped bone loss87 Medical professionals generally suggest that osteoporosis patients supplement with 350mg/ daily.
Interestingly, another study looking at postmenopausal women using hormone replacement that therapy with magnesium (600mg/daily), calcium (500mg/daily), B vitamins, vitamin C, vitamin D, the minerals copper, zinc, manganese, and boron, as well as other nutrients for an 8-9 month trial.88 The patients were instructed to limit protein consumption, favor vegetable rather than animal protein, avoid processed foods, and limit consumption of sugar, salt, alcohol, tea, coffee, tobacco, and chocolate. The results were that done density increased by 11%, compared to 0.7% for only with hormone replacement therapy.
Blood and bone zinc levels are low89 and zinc lost in urine is high90 in those with osteoporosis, Adding just 10mg/daily zinc (from food sources) was 2 times as likely to result in fractures than when zinc was greater in the diet.91 It also has been found that supplementing with calcium alone is not as effective in supplementing with calcium along with other minerals such as zinc and copper.92 Medical professionals suggest that supplementation with 10-30mg/daily is helpful.
Bone growth requires copper. Research has demonstrated that 3mg daily copper reduces bone loss93 taken over a long period, such as several years, but that such supplementation doesn't help over a shorter period like 6 weeks.94 Some medical professionals suggest 2-3mg/daily copper especially. Note, this is especially important in the case of zinc supplementation since it depletes copper stores in the body. If you take zinc for more than a week or two, you need to supplement with copper as well.
Supplementing with boron is possibly helpful in reducing calcium and magnesium loss through urine.95-96 If you are already take magnesium supplements, then boron is found to help retain calcium even more.97 Note, while boron reduces calcium loss98 this happened when estrogen and testosterone levels were increased, so supplementing with magnesium is probably better than supplementing with boron.
Manganese deficiency has been noted in women with osteoporosis.100 A combination of minerals including manganese seems to halt or slow bone loss.101 A study examining deer antlers has proposed that manganese deficiencies may cause calcium to not "stick" to bones, giving rise to osteoporosis. The research also linked manganese depletion after the onset of osteoporosis to Parkinson's and Alzheimer's diseases.126 Some medical professionals suggest 10-20mg/daily for those concerned with bone loss.
Normal bone creation requires trace amounts of silicon,102 and silicon supplementation increases animal bone formation.103 Some minor research supports this104 but best supplementation levels remain unknown. The key, as is the case with many trace minerals, is to have a diet that is not restricted to only a few foods, but to have a broad based diet, and a water source that includes trace minerals.
Strontium is another trace mineral that may be important to bone formation. Women with osteoporosis may have poor strontium absorption.105 Over the years there has been some evidence that long term strontium (not radio-active strontium!) supplementation is helpful.106 It may be that this type of supplementation protects the integrity of the bone surface. Decreased bone pain has also been reported.108
Folic Acid, Vitamins B6 & B12
Osteoporosis is often caused by homocysteinuria, linked with high levels of homocysteine in the blood. Folic acid, and vitamins B6 and B12 reduce homocysteine levels. Medical practitioners believe these vitamins lessen osteoporosis because they lower homocysteine109 Research substantiates that thinking127,128 In order to lower homocysteine levels, common amounts of folic acid, vitamins B6 and B12 in most multivitamins and B-complex supplements will be sufficient.
Early trials indicate that it is possible that progesterone may reduce the risk of osteoporosis.110 One trial used externally applied progesterone cream along with changes in diet, amount of exercise taken, supplement with vitamins and calcium and estrogen therapy - and noted marked improvement in bone density over a three-year period in a small group, but this study did not control for the same factors without progesterone.111 Other preliminary studies have indicated that adding natural progesterone to estrogen therapy did not improve the beneficial effects of estrogen taken alone112 and that progesterone applied externally did not reduce bone loss over a one year period.113 In another preliminary study, bone mineral density increased among healthy elderly men and women who were given 50 mg per day of DHEA as a supplement114 but it is unknown whether such supplementation would be helpful to patients with established osteoporosis.
Botanical Treatment Options
Horsetail is a rich source of silica; early trials suggest that it may help maintain bone mass, but it has not been studied.
Black cohosh has been shown to improve bone mineral density in animals fed a low calcium diet,115 but it has not been studied for this purpose in humans.
Research and footnotes
116. Amount and type of protein influences bone health, Robert P Heaney and Donald K Layman, Am J Clin Nutr May 2008 vol. 87 no. 5 1567S-1570S
117. A high ratio of dietary animal to vegetable protein increases the rate of bone loss and the risk of fracture in postmenopausal women, Deborah E Sellmeyer, Katie L Stone, Anthony Sebastian, Steven R Cummings, and for the Study of Osteoporotic Fractures Research Group, Am J Clin Nutr January 2001 vol. 73 no. 1 118-122
118. Salt intake, hypertension, and osteoporosis, Caudarella R, Vescini F, Rizzoli E, Francucci CM., GVM Hospitals of Care and Research, Cotignola, Italy, J Endocrinol Invest. 2009;32(4 Suppl):15-20.
119. Tea and Coffee Consumption and Cardiovascular Morbidity and Mortality, J. Margot de Koning Gans, Cuno S.P.M. Uiterwaal, Yvonne T. van der Schouw, Jolanda M.A. Boer, Diederick E. Grobbee, W. M. Monique Verschuren, Joline W.J. Beulens, Arteriosclerosis, Thrombosis, and Vascular Biology. 2010; 30: 1665-1671
120. Coffee consumption and risk of colorectal cancer: a meta-analysis of case-control studies, Carlotta Galeone, Federica Turati, Carlo La Vecchia and Alessandra Tavani, Cancer Causes and Control, 2010, Volume 21, Number 11, Pages 1949-1959
121. Coffee, tea and caffeine intake and the risk of severe depression in middle-aged Finnish men: the Kuopio Ischaemic Heart Disease Risk Factor Study Anu Ruusunena c1, Soili M Lehtoa, Tommi Tolmunena, Jaakko Mursua, George A Kaplana and Sari Voutilainena, Public Health Nutrition (2010), 13 : pp 1215-1220
122. Habitual Tea Consumption and Risk of Osteoporosis: A Prospective Study in the Women's Health Initiative Observational Cohort, Z. Chen, M. B. Pettinger, C. Ritenbaugh, A. Z. LaCroix, J. Robbins, B. J. Caan, D. H. Barad and I. A. Hakim, Am. J. Epidemiol. (2003) 158 (8): 772-781.
123. The effect of soy protein isolate on bone metabolism, Gallagher, J. Christopher MD; Satpathy, Ruby MD; Rafferty, Karen RD; Haynatzka, Vera PhD, Menopause: May/June 2004 - Volume 11 - Issue 3 - pp 290-298
124. The Soy Isoflavones for Reducing Bone Loss (SIRBL) Study: Three year effects on pQCT bone mineral density and strength measures in postmenopausal women, Shedd-Wise, Alekel, Hofmann, Hanson, Schiferl, Hanson, Van Loan,J Clin Densitom. 2011 Jan-Mar; 14(1): 4757.
125. The Effects of Whey Protein Concentrate vs. Whey Protein Isolate on Hair
126. Tomas Landete-Castillejos. Alternative hypothesis for the origin of osteoporosis: The role of Mn. Frontiers in Bioscience, 2012; E4 (1): 1385
127. van Meurs J.B., Dhonukshe-Rutten R.A., Pluijm S.M., van der Klift M., de Jonge R., Lindemans J., de Groot L.C., Hofman A., Witteman JC, van Leeuwen JP, Breteler M.M., Lips P., Pols H.A., Uitterlinden A.G. Homocysteine levels and the risk of osteoporotic fracture. New England Journal of Medicine, May, 2004
128. McLean R.R., Jacques P.F., Selhub .J, Tucker K.L., Samelson E.J., Broe K.E., Hannan M.T., Cupples L.A., Kiel D.P. Homocysteine as a predictive factor for hip fracture in older persons. New England Journal of Medicine, May, 2004
129. K.A. Head, Ipriflavone: an important bone-building isoflavone, Alternative Medicine Review, February, 1999.