You've been diagnosed with osteopenia or osteoporosis on your latest bone scan, now what?
This journey starts at the office of your family physician when they discuss your t-score, what it means, and what they recommend to manage it. We know that this can be a jarring conversation, and it's difficult to understand what your options are when you first get your results. In today's article, we're going to summarize a few of the treatment options you're likely to hear about, and how they stack up in the research with how effective they are.
**Disclaimer: I am not a family physician, nor would I ever try to take the role of one. This article is meant for informational purposes and is not medical advice. Before making any large medical decisions, contact your family physician.
Supplementation
Often thought of as the first line of defence, supplementation to support bone density is something that many people choose to do even before getting their first bone scan. Below we'll go over some of the common supplements and you'll see how they all work together to facilitate increases in bone density.
Calcium
Ah, calcium. The first thought and apparent silver bullet when it comes to bone density, but did you know that calcium is also critically important in the transmission of nerve signals, the contraction of muscles, maintaining your heart rate and clotting blood? It sounds like those dairy farmers were really onto something after all!
For non-dairy eaters, foods that are good sources of calcium include leafy greens (like spinach and kale), squash, almonds, sardines, chia seeds, beans and lentils.
Calcium has been shown to be effective in increasing bone density in doses over 1200mg/day but no more than 2000mg/day, with diet being the best source of calcium compared to supplementation.
Vitamin D
Also known as the sunshine drug, Vitamin D is something that those of us living at or above the 45th parallel don't see a lot of for half of the year. Vitamin D is formed naturally when the body is exposed to UV rays from the sun, and deficiencies are linked to a whole host of conditions ranging from autoimmune problems to mental health issues, and (of course) osteoporosis. When we look at the role of Vitamin D in bone density, it serves as an important helper for Calcium, increasing its absorption into the body to be used for all of its vital functions.
Vitamin D has been shown to assist with bone density in dosages of around 800IU per day, though your dosage may be higher or lower based on where you live, how often you're outside, and the time of year (talk to your doctor, friends!).
Magnesium
Remember how Vitamin D is a helper for Calcium? Well, it turns out that Magnesium is a helper for Vitamin D! Magnesium converts Vitamin D into its active form so that it can facilitate the absorption of Calcium.
Magnesium, like calcium, plays a critical role in the body when it comes to nerve transmission, regulation of heart rate, and muscle contraction in addition to its contribution to bone density. In fact, 60% of the magnesium in your body is actually contained in your bones, and lower amounts of magnesium measured in the blood are typically seen in postmenopausal women who also have osteoporosis.
Some common food sources of magnesium include nuts and seeds, leafy greens, whole grains, beans and legumes, pumpkin seeds, and chia seeds.
Magnesium has been shown to be effective in building and maintaining bone density in dosages of 300-500mg per day and, shockingly, food sources are always best!
Protein
Protein is a bit of a double-whammy when it comes to bone density. First, about 50% of your bone volume is actually made up of proteins integrated into the bone matrix as collagen. Second, protein facilitates building and maintaining muscle mass, and larger muscle masses exert greater forces on the bones, helping signal the body to build up their density (more on that later!).
When it comes to bone density, it's easy to focus on the minerals like calcium and magnesium, but protein plays an enormous role in the overall health of postmenopausal women. Higher intakes of protein were associated with greater lean body mass (more muscle), lower body fat percentage, lower risk of frailty and higher physical function, not to mention that protein requirements actually INCREASE as we age!
The current dietary recommendations for protein are 0.8g/kg of body mass daily, though further research is suggesting that 1.1 - 1.6g/kg may actually be better associated with the benefits noted above. Using that as a guideline, 0.8g/kg should serve as an absolute minimum, and ranges above 1.1g/kg may be considered ideal.
Medication
Medications for building bone density are most commonly prescribed to women who fall under the category of osteoporosis, but may also be prescribed to people who generally fall under higher risk levels for fractures.
Most medications that are prescribed fall under the category of bisphosphonates, and some of the brands you might see are Fosamax (weekly pill), Actonel (weekly or monthly pill), Boniva (monthly pill or quarterly injection), and Reclast (annual injection). These medications, though they're delivered in different ways, all do the same thing: prevent the body from breaking down bone.
Prolia is another injectable medication that is separate from bisphosphonates, and is often used in people who either don't respond to, or have side effects from bisphosphonates. Though it's a different drug, the ultimate effect it has is the same: it slows down the breakdown of bone.
Side effects of medication can be a major limitation for some women, and we always encourage discussing the various options with your family doctor if you do notice unpleasant symptoms associated with your medication.
The important thing about medication is that it slows down the reabsorption of bone (osteoclast activity), but it doesn't necessarily promote the development of new bone (osteoblast activity). So, while medications alone can slow down the progression of osteopenia and osteoporosis, they work best when combined with our next line of treatment: resistance training.
Resistance Training - The Most Important Supplement of All
In order to understand the importance of resistance training, it's helpful to first understand how bone works. We have two main types of cells when it comes to maintaining bone mass: osteoclasts which are responsible resorption of bone, and osteoblasts which are responsible for the formation of new bone. The balance of the two decides whether you build, maintain, or lose bone.
After menopause, women tend to have higher osteoclast activity, and lower osteoblast activity, meaning they break down bone faster than they build it. Bisphosphonate medications will slow down osteoclast activity, tipping the scales to either slow bone loss or maintain current density. The best-case scenario would leave you with slightly greater net osteoblast activity (because remember, we've slowed down the osteoclasts, we haven't actually sped up the osteoblasts).
Enter Wolff's Law, aka the use it or lose it principle.
Wolff's Law states that bones will naturally adapt and change in response to the loads placed on them regularly. That means that higher loads, more often result in improvements in bone strength, and light or no load results in lower bone strength.
Stress to the bone in the form of loading will increase osteoblast activity to increase bone strength by increasing bone density.
This is potentially the most important piece of information in this post: bone strength is determined by the loads we routinely place on them, so if you've been told to be careful and slow down after a fracture, that advice may actually be doing more harm than good. The best thing to do is start participating in a strength training program under the guidance of a trained professional. Obviously, we're partial to our Barbells4Bones program here at CONNECT, but other programs like BoneFit and GLADD may be an excellent fit for you.
Summarizing The Treatments
This is important: research shows that all of these methods are helpful for increasing bone density and reducing fracture risk, but it overwhelmingly shows that these methods are best when combined.
Supplementation and Diet: Provides all of the building blocks necessary to make and preserve bone, ingesting more than just calcium alone makes sure that your body is able to absorb and use that vital mineral.
Medication: Slows down osteoclasts, but does not increase osteoblasts, because of this it is able to slow down bone loss but doesn't facilitate increased bone density as well. There is a chance of side effects that can be very unpleasant for some people, and hardly noticeable in others.
Resistance Training: Increases osteoblast activity AND can slow down osteoclasts via Wolff's "use-it-or-lose-it" Law. However, it can only build bone if the building blocks are present.
If we take our three primary treatments together, here is what happens: medications will slow down the osteoclasts, reducing the rate of bone loss, exercise further decreases osteoclast activity and increases osteoblast activity, increasing the rate of bone production, building more bone with the building blocks provided by supplementation and diet.
For visual learners, let's look at the possible scenarios when it comes to bone density, starting with the worst-case scenario: doing nothing.
Scenario 1: Doing Nothing
In this case, our person does not participate in resistance training or exercise, their diet is low in bone building blocks, and they aren't currently on medication for bone density. The end result is greater osteoclast activity than osteoblast activity and a greater loss of bone density. This is actually a fairly common scenario before low bone density is detected on a scan.
Scenario 2: Maintaining Bone Density
In this scenario, low bone density has probably been detected on a scan, and the first line of defence is making sure the nutritional building blocks are present, and potentially looking at adding in a bone-preserving bisphosphonate medication. In this scenario, medication is decreasing osteoclast activity, and the osteoblasts that are working are able to build some bone because nutritional building blocks are present. The end result is balanced activity between osteoblasts and osteoclasts, which will preserve bone density at best, or, at the very least, slow the loss of bone.
Scenario 3: Active Bone Management
In this scenario, we have our best, multifaceted approach to managing bone density. We have the nutritional building blocks present to create bone, and we encourage bone growth with regular resistance training to take advantage of Wolff's Law and increase osteoblast activity. In this scenario, medication may or may not be used to decrease osteoclast activity, but either way, the end result is an increase in bone density (and quality of life, and function, and longevity, and a decrease in pain, among other things!)
The best part of all three scenarios? You have a ton of control over your bone density. No, you can't stop menopause (or time), but you can take steps to improve your bone density and reduce your fracture risk over time.
Barbells4Bones is our way of helping. It is an exercise class that you can join once or twice per week where you can participate in resistance training with other women over the age of 55 in a safe and fun environment. We offer an Introductory Series for those who are brand new to exercise or resistance training, and our regular classes are now offered 4 days each week (and counting!). Our athletes will tell you that the classes are not easy, but each workout is scaled to meet your abilities, and there is no shortage of community within our groups. If you're interested in learning more about Barbells4Bones, or joining our next series, head to www.connectrehab.com/barbells4bones for more information.
Clare Donaldson is a Registered Physiotherapist, new mom, Crossfit enthusiast, poor but passionate hockey player, and genuine lover of all things physiotherapy. She is especially interested in keeping moms of all ages strong and healthy throughout their lives. When she's not at CONNECT, you can find Clare hiking with her dog, Moose, or spending time with her young family. To find Clare at CONNECT, click here