Posted on by Village Green Nutrition Team
Guest Blogger: Lisa Jo Finstrom
Lisa Jo Finstrom is a licensed nutritionist in Bethesda, Maryland, who speaks English and Spanish. She believes that a whole food approach to life, balanced with daily movement and stress management is the key to a healthy lifestyle.
For osteoporosis, doctors generally recommend a total of 1200 mg of calcium from diet and supplements. When the diet is lacking in calcium, supplementation can help, although taking too much can increase the chances of kidney stones and heart attacks (Tella & Gallagher, 2014). Before considering calcium supplementation, it is important to figure out your total dietary calcium intake.
There are lots of free apps that can help with a nutrient breakdown, including www.cronometer.com. Once you know how much calcium is in your diet, it is time to select an absorbable form of calcium. Calcium carbonate requires robust stomach acid and gastric juices and is therefore not ideal for older women. Many drug store calcium products are made from calcium carbonate. However, there are many good calcium products to choose from, including calcium citrate, algae-based calcium, and hydroxyapatite.
Vitamin D plays many roles in the body, including facilitating the absorption of calcium. Half of patients diagnosed with osteoporosis are deficient in vitamin D. Studies show that levels of at least 32 are needed to maximize calcium absorption. According to research, if individuals who are low in vitamin D commit to consistently taking calcium and vitamin D, their risk of hip fractures drops significantly (Khazai, Judd & Tangricha, 2008).
While I usually recommend both calcium and vitamin D for bone health, I am conservative with the dosages. I do not subscribe to the idea that more is better. Often the opposite is true.
For example, In a recent randomized control study, about 300 healthy participants were divided into three groups and each group was given either 400, 4,000, or 10,000 IUs of vitamin D for 3 years. The expectation was that the higher the dose of vitamin D, the bigger the improvement to BMD, bone mineral density. The complete opposite proved to be true.
The groups given 4,000 and 10,000 IU of vitamin D resulted in a loss of radial density. The 10,000 IU group also experienced a loss of tibia density. Furthermore, in other studies, high-dose intermittent vitamin D has been linked to an increased risk of falls.
This study and others suggest that caution is warranted when it comes to high-dose vitamin D use for bone health. Limitations of the study include the fact that participants were all healthy and did not have either osteoporosis or vitamin D levels below 30. Notably, there was also no placebo group (Burt, Billington, and Rose, et al., 2019).
However, a true vitamin D deficiency can be a serious problem. For example, it is a known cause of bone pain, a common complaint with severe osteoporosis (Habib, Naqi & Thillaiappan, 2020).
First of all, it is important to clarify that vitamin K2 is not the same as K1. K2 comes from animal sources and is necessary to activate special proteins that direct calcium to bone and teeth and keep it out of the cardiovascular system.
K1 is from plant sources such as leafy greens and is known for its ability to help the blood to clot so that a simple injury does not cause excessive bleeding. Industrial food production tends to reduce the amount of K2 found in Western diets. Therefore, I almost always recommend that anyone with bone concerns supplement with vitamin K2.
Amazingly, taking vitamin K2, together with calcium and vitamin D, “rivals bisphosphonate therapy without the toxicity” (Schwalfenberg, 2017). Bisphosphonates are a class of commonly-prescribed osteoporosis medications such as Fosamax; possible side effects include nausea, as well as pain in the bone, joints and muscles. Probably the scariest complication is osteonecrosis or the “death” of the jawbone. While rare and usually linked to dental issues, according to the Bone Health & Osteoporosis Foundation, cases have been reported in which there is no link to poor oral dental health ( n.d.)
Many people do not realize the vital role that vitamin A plays in maintaining bone health. Vitamin A is also known as retinol. Preformed retinol comes from animal sources. Provitamin A comes from plant sources, such as beta carotene from carrots. Both forms, in appropriate amounts, help maintain strong bones. Generally speaking, studies show a positive association with bone health and vitamin A status. However, some studies suggest excess vitamin A can inhibit vitamin D. It should also be noted that the studies relied on very high doses of synthetic forms of preformed vitamin A (Lee et al., 2021).
In a recent in vitro study using synthetic bone grafts, vitamin A was found to promote osteoblasts (bone-promoting cells) and to inhibit osteoclasts (bone-degrading cells) (Vu, Kushram & Bose, 2022). As a reminder, in vitro refers to studies performed outside of a living organism, often in a Petri dish or similar vessel. In contrast, in vivo refers to studies done with living organisms, from animals such as rats to human participants in a clinical trial.
Vitamin A also plays an important role in the all-important calcium cycle. Vitamin D promotes the absorption of much-needed calcium, and vitamin K2 directs it to where it is needed. It then falls to vitamin A to help excrete excess calcium through the urine (Rheaume-Bleue, 2012).
My personal preference is to eat a variety of vitamin A-rich foods, as well as to supplement with a natural form of vitamin A derived from cod liver. I am only aware of one vitamin A supplement that is 100% cod liver oil derived and it is made by Blue Bonnet.
Vitamins D3, K2 and A work together synergistically and ideally should be kept in balance. I usually recommend that clients with concerns about bone health take all three. I also caution that taking high dose vitamin D could inadvertently lower their vitamin A levels (Rheaume-Bleue, 2012).
Other Helpful Supplements
There are many other supplements marketed to help keep bones strong. Strontium is one example and should be taken only if recommended by a licensed practitioner.
There are also myriad minor players that play a big role in bone health. Boron is a great example. Boron supports bone health by helping to keep estrogen and vitamin D levels at a healthy level. It is fairly easy to get adequate boron from the diet. For example, common foods such as apples, coffee and dried beans are an excellent source of boron.
Lastly, collagen is a popular and very low risk supplement to consider. Flavorless powdered products can easily be stirred into coffee. Collagen is a main component of bone and is also found in muscle tissue. I often recommend my bone-conscious clients consider collagen supplementation.
While supplements are important for bone health, there is no substitute for a good diet, as well as weight bearing exercise. The worst foods for bone health include a high sugar diet, soda and excess caffeine. A sedentary lifestyle weakens the bones. So do periods of high stress and certain commonly-prescribed medications.
Burt, L. A., Billington, E.O. & Rose, M.S. (2019) Effect of high-dose vitamin D supplementation on volumetric bone density and bone strength: a randomized control study. JAMA Network.https://jamanetwork.com/journals/jama/fullarticle/2748796
Habib, A. M., Nagi, K., Thillaiappan, N. B., Sukumaran, V., & Akhtar, S. (2020). Vitamin D and Its Potential Interplay With Pain Signaling Pathways. Frontiers in immunology, 11, 820. https://doi.org/10.3389/fimmu.2020.00820
Khazai, N., Judd, S. E., & Tangpricha, V. (2008). Calcium and vitamin D: skeletal and extraskeletal health. Current rheumatology reports, 10(2), 110–117. https://doi.org/10.1007/s11926-008-0020-y
Lee, M.M. F., K-Y Chin, Ima-Nirwana, S. & Wong, S.K. (2021) Vitamin A and bone health: a review of current evidence. Molecules. https://www.mdpi.com/1420-3049/26/6/1757/htm
Rheaume-Bleue, K. (2012) Vitamin K2 and the Calcium Paradox. Collins :John Wiley & Sons, Canada.
Tella, S. H., & Gallagher, J. C. (2014). Prevention and treatment of postmenopausal osteoporosis. The Journal of steroid biochemistry and molecular biology, 142, 155–170. https://doi.org/10.1016/j.jsbmb.2013.09.008
Schwalfenberg G. K. (2017). Vitamins K1 and K2: The Emerging Group of Vitamins Required for Human Health. Journal of nutrition and metabolism, 2017, 6254836. https://doi.org/10.1155/2017/6254836
Side effects of bisphosphonates. (n.d.) Bone Health & Osteoporosis Foundation, BHOF. https://www.bonehealthandosteoporosis.org/patients/treatment/medicationadherence/side-effects-of-bisphosphonates-alendronate-ibandronate-risedronate-and-zoledronic-acid/
Vu, A.A. Kushram, P. & Bose, S. (2022) Effects of vitamin A (retinol) release from calcium phosphate matrices and porous 3D printed scaffolds on bone cell proliferation and maturation. ACS Publications, Applied Bio Materials 5 (3), 1120-1129 DOI: 10.1021/acsabm.1c01181
Disclaimer:The included information is not meant to or should not be used to replace or substitute medical treatment, recommendations, or the advice of your physician or health care provider. The information contained within is strictly for educational purposes and is based on evidence-based nutrition. If you believe you have a medical problem or condition, please contact your physician or healthcare provider.
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