July 25th, 2022
As soon as you are conceived, the process of growing new bone begins in the map of DNA. The first bone cells are noted at the sixth week post conception. This process continues for many years peaking as a teenager and beginning to decline in the third decade of life. The peak decline starts in the sixth decade when sex steroids start to decline significantly. The natural process of bone development is very complicated with many hormones like vitamin D and parathyroid as well as micronutrients necessary for optimal function.
For the purpose of this article, I will focus on those aspects of bone development and maintenance that are controllable as that is what matters in the long run. As we age, it is imperative that we lay down and then maintain as much bone volume as possible. This provides the best starting point for the inevitable declination over time. Osteoblasts are the cells that lay down bone. Osteoclasts are the cells that break down bone. There is a natural balance between these two cell types that allows the human skeletal system to add and remove bone all over the body in response to need following an injury to the bone or other tissue. Think of the coronary arteries of the heart here. Damaged and inflamed coronary arteries will lay down calcium to protect the plaque which is seen on a coronary calcium CT, a screening tool for heart disease risk.
Or, conversely, my shins during my prime soccer years would vacillate between bumpy tibial surfaces and smooth based on shin trauma in game.
Osteopenia and osteoporosis are conditions where the bone volume has significantly deteriorated to the point of fracture risk based on many dysfunctional lifestyle choices and exposures. The biggest concern with early bone loss is major hip and leg fractures after a fall that predispose humans to early death as they age. Falls are an incredibly common cause of accidental death as people age into the 7th decade of life and on. In one study, the authors noted that the excess mortality following a hip fracture was very high with a hazard ratio of 2.78 in the year following the injury in individuals over 60 years of age. (Katsoulis et. al. 2022) That is to say that in the group that is assessed, 2.78 is risk compared to the non fracture group where a hazard ratio of 1 would be no difference. For reference, smoking confers a hazard ratio between 2 and 3 for death versus non smokers. Since bone is laid down during childhood in large volumes, it is imperative that we maximize this period of bone deposition. Thus, the focus in pediatric ages.
The critical aspects of growing solid bone are all in place as long as one follows a few simple natural activities.
First, it is necessary to move and bear weight to stimulate the bones to lay down more of themselves. This was noted early in medicine as patients that were immobilized from injury in hospitals had significant bone loss that increased with the length of immobility. There are mechanoreceptors in bone that recognize movement and signal bone development or bone loss. We need to move every day. We need to move a lot, at least 5,000 to 10,000 steps a day and often with weight. I would also encourage light weight lifting or better yet chores like sweeping the floor, raking leaves, general work around the house for various muscle and bone loading.
Second, it is necessary to get adequate micronutrients in one's diet to build the bone from. We primarily need calcium, magnesium, phosphorus, sodium, potassium, vitamin K2, vitamin D, and vitamin A. All of these minerals and vitamins except for vitamin D and K2 are easily acquired from a mediterranean diet that is predominantly vegetarian based.
Third, vitamin D is involved in helping the intestines to absorb calcium from the food. It is necessary to get adequate sun exposure daily for vitamin D. Spending time in the sun without sunscreen will stimulate your skin to produce vitamin D. Never burn as that damages the DNA of your skin causing cancer risk to increase. The darker your skin, the longer you will need to spend in the sun to get the same vitamin D amount. See this link for more on micronutrients and Vitamin D.
Fourth, we must avoid excessive inflammation which can significantly damage the bodies ability to lay down new bone. The major source of inflammation in humans and especially children is from a standard American processed food diet. Exposure to toxins is a close second. We know from many different systems in the body that the SAD diet promotes the wrong gut microbes, increasing inflammation and decreasing the production of insulin like growth factor 1 which is supposed to increase bone mass.
Fifth, vitamin K2 is produced in the body in our gut by the bacteria E coli converting K1 to K2 as well as some other conversion occurring in certain tissues. It is also obtained dietarily from animal livers and fermented foods like nato, kimchi and kombucha. Emerging research is pointing to vitamin K2 as a cofactor in the development of proteins like osteocalcin which helps lay down bone and matrix GLA protein which helps direct calcium to the bones and away from blood vessels. If you do not consume enough vitamin K or take medicines that block vitamin K like anticoagulants, you are at increased risk for osteoporosis.
What are the known risks for bone loss and osteopenia?
1) Inactivity or lack of weight bearing movement
2) Poor quality diet that is pro inflammatory
3) Using antacid, steroid, anticonvulsant and anticoagulant medications chronically
4) Micronutrient insufficiency
5) Lack of sun exposure
6) Thyroid disease
8) Anorexia and amenorrhea
9) Low estrogen and testosterone hormones
10) Being female adds a layer of risk
11) Drinking excessive amounts of coffee, tea and alcohol
What would a typical week look like for kids in order to have the beginnings of healthy bones for life? For starters, spending time outside without sunscreen (being sure to avoid burning your skin) while working in the yard doing manual chores like weeding, mowing, raking as well as general play will go a long way to alleviating the issues with numbers 1 and 5. The added benefit of work teaches them self esteem and family values. The darker your skin, the longer you will need to spend in the sun to get the same vitamin D amount.
Next, I would recommend a whole foods diet that maximizes vegetables and fruits in a varied pattern over the week. It is best to get all the major players on the plate. Broccoli, cauliflower, dark leafy greens, all berries, beans, nuts and seeds are valuable for bone health as direct micronutrients and by feeding the microbiome. Some other targeted foods for vitamin K2 could include animal livers and fermented foods like sauerkraut, kimchi and nato. I love Wellshire Farms liverwurst from Whole Foods. Make sure the livers are from healthy animals that eat real food and are not pumped full of antibiotics and hormones. See table 2 below for food sources of minerals and vitamins for bone health. This will help balance issues with numbers 2 and 4.
Teach your kids the perils of smoking and consuming excessive amounts of alcohol. Do not shame them so much as explain the science behind the risk of these activities. I often talk about how in medicine the cadavers that are used when professors teach anatomy have a common bond. They all have black lungs from smoking. Limit the over consumption of coffee and tea. 1-3 cups a day of coffee appears healthy for adults. Overconsumption of these beverages can lead to calcium leaching diuresis. This helps with numbers 7 and 11.
Be aware of signs of anorexia or amenorrhea in your teens. Intervene early and aggressively to help mitigate the damage to the whole body from this terrible mental disorder.
Avoid all chemicals where possible as many plastics and chemicals released into society have negative effects on our sex hormones. Smoking and drugs like steroids and proton pump inhibitors are known to reduce bone health over time.
A final repeat and emphasizing note on vitamin K2 as it is near to my heart. This micronutrient is necessary to tell your calcium molecules to go to the bone to be incorporated there. Without adequate amounts of vitamin K2, the matrix GLA protein does not inhibit calcium from going to blood vessels instead of bone. Cardiologists are now testing the coronary artery calcium score as a risk factor for heart disease. It seems prudent to get adequate amounts of vitamin K2 to reduce this signaling risk.
Love your bones,
Breeland Stat Pearls
Katsoulis J Internal Medicine
Gut Microbiota and Bone Formation
Coronary Calcium and K2
Matrix GLA Protein
Nutrients for Bone Health - Look at Table 2 for details