Using good nutrition to keep your bones strong.
Sheila came to see me out of fear of osteoporosis. Her doctor had told her she was osteopenic, suffering from mild bone loss. This may lead to osteoporosis, a crippling disease resulting in a stooped back and bones that break easily. Besides the cost of this disease, she was more concerned about losing her independence and lowering her quality of life.
I gave her the facts:
- Ten million Americans have osteoporosis – two million men and eight million women – and 34 million are at risk of osteoporosis as they have low bone mass.
- One study published in the Journal of the American Medical Association (JAMA) involving 160 healthy women 50 and older, found full-fledged osteoporosis in seven percent and low bone density in an additional 40 percent. After one year, the fracture rate in women with low bone density was nearly double that of women with normal bones, and four times higher in women with osteoporosis.
- A bone feels like a rock but it isn’t, it's living tissue. The body is continuously making new bone and replacing old bone. We need to give the body a constant supply of bone-building calcium or else we lose bone material.
- Sheila has missed her years to build up maximum strength in her bones, up until age 35, so now she needs to keep her bones strong by knowing what can be done.
- Female: the incidence of osteoporosis is higher with women (25 - 30%) than with men (12 - 15%). Higher consumption of fruits, vegetables and cereals (assessed by a food-frequency questionnaire) was associated with greater femoral bone mineral density in men in a study of 907 adults aged 69-93 years old. (Bone mineral density and dietary patterns in older adults: the Framingham Osteoporosis Study. Am J Clin Nutr 2002;76(1):245-252.) Sheila’s dietary changes will help her husband optimize his bone strength too.
- Menopause: After menopause , estrogen falls to the point where women can't absorb enough calcium to replace the bone they naturally lose. Sheila has always carried a little extra weight, about 20 pounds, which increases her estrogen levels. A little plumpness after menopause is good for her bones.
- Small, thin frame: Sheila is not one of the petite women we envy. She is big-boned and is therefore at lower risk.
- Age: Being 60, Sheila is at increased risk for bone loss. However, a recent study showed that women over 65 reduced bone loss by 12 to 25% over 2 years if they received adequate calcium intake. She has hope.
- Race: Sheila is Caucasian of northern European descent; together with Asians, she is at higher risk. She mentioned her neighbor, an African-American woman, also 60, who does not seem to have the same problem. Actually, African- American people have greater bone mass, although in a study with 18,000 black women, the prevalence of low bone mass and osteoporosis among them was still significant.
- Family history: Genetics play a role as body types run in families. Her mother doesn’t have any fractures. One of Sheila’s grandmothers was in good health and walked upright until she died at age 90 after a stroke. Her other grandmother died at 50 in a car accident and was healthy until then, however we have no bone history with age.
- Poor diet. I went through Sheila’s diet:
- Low calcium intake: This is the main mineral that builds up bone density. Sheila drank milk as a child but does not drink milk, other than in coffee, at present.
- Nutritional deficiencies: Other nutrient deficiencies increase the risk for osteoporosis such as vitamin D, magnesium, manganese, Vitamin K and boron. Sheila is inclined to eat too many empty calorie foods such as bagels and muffins that contain negligible amounts of these nutrients.
- Anorexia: She was never anorexic but mentioned a niece with an eating disorder whose menstruation has stopped. I told her this leads to low estrogen production and increased bone loss and that she should see a registered dietitian right away.
- High protein intake: She had tried a high-protein diet but had stopped it, as she couldn’t cope with the monotony of it. She now realizes that meat and other high-protein foods tend to be high in phosphorus, a mineral that depletes calcium out of the bone. The more phosphorus you consume, the more calcium you need to maintain your bone mineral density.
- Soda: As Sheila only drinks one to two cups of diet soda a day, I was not concerned with the amount of phosphorus from these beverages.
- Vegans (people who eat no animal products at all): A few years ago Sheila tried a vegan diet with no animal products at all. As calcium in milk and dairy products is better absorbed than the calcium found in vegetables or supplements, strict vegetarian diets containing no milk may increase her risk of osteoporosis. She only stayed on this diet for a month but found it too restricting.
- Certain vegetable compounds: Sheila had read that certain vegetables should be avoided. She was not quite right. The oxalates in spinach and sweet potatoes and phytates in legumes and grains do decrease the absorption of calcium but they do contain some calcium themselves and should be in the diet together with calcium rich foods.
- Salt: Should Sheila avoid salt? Well, a high salt intake does increase loss of calcium in the urine, so I gave her a list of high salt foods to limit.
- Coffee: As Sheila loves her morning coffee, I let her keep that. More than two cups a day can decrease bone density in older women. For her second cup I suggested a café latte to compensate for the calcium decrease.
- Alcohol: Sheila wasn’t a big drinker, sometimes having two glasses of wine at a social event. I told her not to have more than one glass of wine a day and to start with a glass of water, taking a sip of water between each sip of wine.
- Excess Vitamin A supplementation: I told her to bring in her supplements. Adding the total vitamin A content of all her supplements reached very high levels however she usually forgot to take them. I sorted out what she had and told her not to buy any supplements in the future without discussing them with a registered dietitian first.
- Poor Habits:
- Smoking. Sheila had stopped smoking in her 30’s, which is good as smoking depletes minerals from the bone and decreases bone-preserving estrogen in her blood.
- Sedentary lifestyle: Sheila goes through phases of being active and not. As sitting around increases the loss of calcium I will plan activity for her.
- Drugs: Drugs can rob the bones of calcium. These include: cortisone, prednisone, thyroid hormones, anticonvulsants and aluminum-based antacids. Sheila is on a thyroid hormone so we will definitely have to focus on calcium-rich foods.
As I explained to Sheila, there are some things you cannot change to lower your risk for osteoporosis: sex, race, build and age.
What can she do to improve her bone strength?
Well, it’s back to common sense: eat well, be active and supplement if necessary.
- I started with planning her daily intake of calcium-rich foods. See table below.
- Milk (including skim milk and 1% milk) is the best. Milk contains lactose and is enriched with vitamin D; both nutrients help with the absorption of calcium. She didn’t have lactose intolerance. Many people who have trouble digesting lactose can drink one or two servings of milk with solid food and not have problems. (Journal of the American College of Nutrition 2000;19 (2S))
- Cheese, fortified cottage cheese and yogurt are also good sources of calcium. Low fat options contain the same amount of calcium as high fat types.
- Canned salmon and sardines with bones
- Other sources of calcium, especially if she felt like trying a vegan day every now and again: calcium-enriched tofu and other soy products, calcium fortified orange juice, collards, turnip greens, rhubarb, broccoli, kale, oranges, almonds
- Vitamin D recommendations are 200 IU/day for people under 50, 400 IU/day for those 51 – 70 years, and 600 IU/day for people over 70 years of age. Supplements greater than 2000IU/day could become a health risk. Vitamin D is not hard to find in food: in fortified (added to) milk, eggs, salmon and sardines with bones, cheese, fortified margarine and fortified breakfast cereals
- Sun: although it’s best to keep out of the sun, a little can supply Sheila with the essential vitamin D. She needs to expose sun to her hands, face and arms three times a week for 5 - 15 minutes before sunscreen is applied. That should be adequate as 80 - 90% of vitamin D comes from exposure to sunlight. During the winter, when Sheila travels to the Northern and Eastern United States where the sun is weak, one cup of milk will supply her with all the vitamin D she needs each day.
- Other nutrients in plant products can increase her bone density: magnesium (seeds, soybeans, wheat germ, seafood); manganese (nuts, avocados, oatmeal); Vitamin K (spinach, broccoli, green cabbage, tomatoes); and boron (applesauce, peaches, pears, cherries). She loves them all. Even fats play a role. Saturated fats can influence bone density negatively, whereas omega 3 fats can be positive. See articles on fats.
- Soy protein and its isoflavones, genistein and daidzein may have a mild protective effect on osteoporosis. More data is becoming available on the use of soy products. In the meantime, include soy-type foods in your diet three times a week. A tasty snack is edamame, the actual soybeans in their pods. They come frozen and can be cooked up in 4 minutes. Frozen soy burgers or a miso soup from the Japanese restaurant contain tofu in a tasty form.
- Lower salt, soda, caffeine and alcohol intake: With Sheila’s awareness of nutritious choices, she will not be consuming these items in excess
Activity (important for bone strength)
- The easiest is walking for a ½ hour 3 times per week. Sheila is already doing this.
- The next best step is to walk every day for a ½ hour to one hour. Sheila plans to increase her walking time.
- Swimming strengthens muscles and gives a good stretch. She will go to a pool near her twice a week.
- Stretching exercises will be done when she watches television, to make her feel good and move her joints
- As Sheila would like to start with weights, I have recommended she find a fitness trainer near her to get her started. Weight-bearing exercises have been proven to prevent bone loss. But there is no need to be too enthusiastic and get hurt.
- Recommended reading for getting started with strength-training: Strong Women Stay Young by Miriam E. Nelson, PhD, exercise physiologist (Bantam Books: New York, 2000)
As Sheila plans to increase her calcium intake from foods, she will not need a daily supplement.
Should a person not get enough calcium from food, and a supplement is needed, which one is best? Studies show that calcium citrate is better absorbed than calcium carbonate. Small doses should be taken throughout the day together with 6 to 8 cups of water to avoid constipation. Be careful when prescribing a calcium supplement for yourself. Preferably, don’t supplement with bone meal or dolomite as these may contain lead. Over supplementing can lead to decreased absorption of iron and zinc as well as kidney stones, so seek professional advice before you buy (and I don’t mean the cashier at the health food store).
What about me?
Do I take supplements? - I’m a woman, Caucasian, postmenopausal and am not on estrogen replacement therapy. No, I don’t take any calcium supplements. Why? Because I love dairy foods, milk in my cereal for breakfast, actually eat scoops of yogurt and cottage cheese as a snack during the day, eat well most of the time, am active nearly every day, have never smoked, and have a moderate intake of caffeine and alcohol. Recommendations for postmenopausal women without estrogen replacement therapy are 1200mg, with estrogen 1000mg calcium per day. Do I get in 1200 mg per day? Probably close, but there is no history of osteoporosis in my family and I am only slightly osteopenic.
What about my mother Wyn?
"At 90, I take one Celebrex every two days for my arthritis. For calcium, I eat three dairy foods a day: milk in my cereal; yogurt as a snack; cheese or cottage cheese. I exercise to keep my bones moving. My father died at 95 of old age and my mother died at 85 from cancer. They did not suffer from bone fractures. I walk with a cane as my one leg is a bit shorter than the other and use a walker when I do my daily walks. My older son, a neurologist, has made me aware of the rapid deterioration of health after bone fractures in older people which keeps me careful. I do have a little arthritis in my back, hand and knees but don’t complain about it."
With the latest study on hormone replacement therapy (HRT), many people were surprised. The results were that a HRT regimen taken by six million American women did more harm than good. In a study with 16,000 women, researchers found that the drugs, a combination of estrogen and progestin, caused small increases in breast cancer, heart attacks, strokes and blood clots. Those risks outweighed the drugs' benefits - a small decrease in hip fractures and a decrease in colorectal cancer. These drugs are also effective for symptoms of menopause, such as hot flashes and night sweats. No woman needs to panic over these findings, as the danger to any individual woman appears very slight. Alternative drugs are available for the prevention of osteoporosis and hip fractures.
Health Tip: Measure bone mineral density, particularly postmenopausal women who have had fractures or a family history of osteoporosis, and all women 65 and older.
The bottom line
1. Increase your intake of low fat dairy products and calcium-fortified foods.
2. Be active.
3. Enjoy life.
I gave this Calcium Content list to Sheila so she could add up her calcium intake every day for a week. This will ensure that she is getting adequate intake. Use this table for your calculations:
Bread, 2 slices, 50 mg
Cereal, 1 cup, 20 - 400 mg (read label)
FRUITS and VEGETABLES
Orange, 1 medium, 50 mg
Broccoli, cooked, 1/2 cup, 50 mg
Kale, turnip greens, cooked, 1/2 cup, 105 mg
Butternut squash, 1/2 cup, 40 mg
Orange juice, fortified, 1 cup, 300 mg
MILK and MILK PRODUCTS
Milk- skim, 1%, 1 cup, 315 mg
Cottage cheese, 1/2 cup, 80 mg
Cottage cheese, calcium fortified, 200 mg
Firm cheese: e.g. cheddar, swiss, 1-1/2 oz, 350 mg
Soft cheese: e.g. camembert, 1-1/2 oz, 200 mg
Parmesan cheese, 1 tbsp, 75 mg
plain, 3/4 cup, 250 mg
fruit-flavored, 3/4 cup, 250 mg
frozen, 1/2 cup, 150 mg
MEAT AND ALTERNATES
Salmon, canned with bones, 3 oz, 225 mg
Sardines, canned with bones, 11 small, 210 mg
Tofu, calcium fortified, 1/3 cup, 150 mg
Baked beans, soybeans, white beans, 1 cup, 150 mg
Chickpeas, 1 cup, 85 mg
Kidney beans, lima beans, lentils, 1 cup, 50 mg
Soy beverage, calcium fortified, 1 cup, 300 mg
Almonds, 1/2 cup, 200 mg
Sesame seeds, 1/2 cup, 105 mg
Soup made with milk, 1 cup, 190 mg
Cereal with 1/2 cup milk, 160 mg
Chili con carne, 1 cup, 65 mg
EXAMPLE OF SHEILA’S DAILY CALCIUM INTAKE
Cereal plus 1/2 cup milk, 160 mg
Orange, 50 mg
1-1/2 oz. cheddar cheese, 350 mg
2 slices bread, 50 mg
175 mL yogurt, fruit flavored, 250 mg
1/2 cup broccoli, 40 mg
1 glass skim milk, 315 mg
Total: 1215 mg plus small amounts in other foods.
Plenty for her, what about you?