Supplementing for Bone Health

A meta-analysis published by the British Medical Journal in July 2010 came to the conclusion that high dose calcium supplements increased the risk of myocardial infarction. The meta-analysis itself was flawed in many ways and discredited by those who reviewed it.

However the question that those educated in nutrition and nutritional supplementation are more concerned with is: Why are medical practitioners still prescribing high doses of calcium in isolation from other nutrients, or with only the addition of vitamin D, for osteoporosis anyway?

Strong healthy bone formation is the result of the presence of multiple minerals and vitamins working under the correct control of metabolic signallers such as the hormone oestradiol and parathyroid hormone. 

 

Bonescropsmall.jpg 
Bone is continually broken down (resorbed) and rebuilt (mineralised) throughout life by cells called osteoclasts and osteoblasts respectively. When bone is resorbed at a rate faster than it is mineralised bone density reduces causing bone weakness (osteopaenia) which can lead to bone brittleness (osteoporosis) which carries with it a high risk of bone fracture. A misconception about the loss of bone density is that only bone hardness is lost when in actuality the architecture within the centre of the bone becomes sparser.

Minerals calcium and phosphorous, in the form calcium phosphate, form the majority of the bone in the body and provide the bone with the property of rigidity and ‘compressive strength’ which allows bone to resist to pressure. While calcium and phosphorous bring the quality of hardness to bones, without a scaffolding to be deposited on hard materials are of little use.

The importance of collagen

For bone to perform healthily and remain intact it must have properties in addition to hardness including tensile strength. Tensile strength allows the bone to resist pulling and twisting forces. Tensile strength is provided by the collagen fibers that make up the connective tissue that runs through the bone and comprises the majority of the bone matrix - the woven inner fabric of the bone, upon which calcium and phosphate are deposited.

Collagen formation requires multiple nutrients including silica, manganese, copper, amino acids (from protein), high amounts of vitamin C and magnesium. A deficiency in any one of these nutrients impairs collagen formation. It has been found that a deficiency in magnesium interferes with collagen formation and the development of the bone matrix1,2

A picture begins to develop of the importance of multiple nutrients in bone formation, health and strength and therefore resistance to fractures.

The other bone nutrients

Bone metabolism is influenced by the activity of number of nutrients and though the role of each nutrient is not always completely understood much is known, a few examples follow. What is clear is that multiple nutrients essential to the complex process of bone metabolism, not just one or two.
Vitamin D has multiple roles in bone metabolism one of the most important of which is in increasing the absorption of calcium in the gut as well as increasing the absorption of phosphorous and magnesium.3

Interestingly the 2010 meta-analysis excluded trials in which vitamin D was given alongside calcium because vitamin D supplementation has been associated with decreased mortality.4

Vitamin K is required for bone protein formation by the osteoblast cells5 and affects the calcium balance. Human studies have demonstrated that vitamin K can not only increase bone mineral density in osteoporotic people but also actually reduce fracture rates.6

Vitamin K1 or phylloquinone is found in green plants. Vitamin K2 or menaquinone is normally produced by bacteria in the large intestine. When there is a decline in the number of intestinal bacteria, such as from the use of broad spectrum antibiotics, production of vitamin K2 is reduced. Additionally the intestines may suffer damage due to lower numbers of bacteria and have reduced ability to absorb vitamin K. Therefore the daily or at least regular use of a quality probiotic supplement is not only good for gut health, it is also good for your bones.

Boron is required for bone metabolism via a regulatory effect on oestrogen and a boron deficiency adversely effects bone formation and maintenance.7

As mentioned above, copper plays a crucial role in collagen formation and a copper deficiency can impair collagen formation, decreasing resistance to fracture via torsional (twisting) forces, increasing fractures in animal models.8

Zinc affects bone mineralsation by activating osteoblastic (bone building) cell activity and inhibiting osteoclastic (bone resorbing) cell activity. The regulatory effect of zinc compounds on bone is greater than the effect of bone-regulating hormones (eg. Oestrogen) and a zinc deficiency contributes to bone deterioration.9

Manganese is important for the skeletal development. Manganese deficiency is associated with decreased bone resorption and decreased synthesis of the organic matrix within the bone.10 The serum level of manganese in a group of osteoporotic postmenopausal women was measured and found to be significantly lower than age-matched controls.10

While these nutrients are often required in comparatively smaller amounts by mass than calcium and magnesium, their roles are no less crucial. There is no guarantee that we are receiving these nutrients in our diet due to modern food production methods that do not allow fruit and vegetables to mature slowly and that deplete the soil of mineral content. It is also well known that New Zealand’s volcanic soils are deficient in many minerals. Therefore it seems pertinent that the range of known bone nutrients be provided together, if they are provided at all.

The role of Magnesium

As bone nutrients go, magnesium is of particular interest for a couple of reasons: it’s structural role in building bone, it’s enzymatic role in building bone, and its well known and intimate relationship to the highly prescribed ‘bone mineral’ – calcium.

As with calcium, the majority of the magnesium in the body is found in the bones (about 60%). Here it forms part of the bone's crystal lattice or "scaffolding" upon which the calcium and phosphorous are deposited.

Firstly, magnesium is in fact required for the metabolism of calcium and it is magnesium that regulates active calcium transport. A magnesium deficiency alters calcium metabolism and effects the hormones that regulate calcium deposition.11

It is well know that the hormone oestrogen has positive and protective effects on bone metabolism. What is not as well known is that there is data to suggest that this may be due to oestrogen increasing magnesium retention and bone uptake of magnesium.12

You only have to throw a stone to hit a study that highlights the critical roles of magnesium in bone mineralisation.   

Magnesium supplementation improves bone density,13,14,15,16 prevents fractures17 and bone resorption,18 increasing the dynamic strength of bone and does all this in spite of reducing calcium absorption.

It is no surprise then that studies show that a magnesium deficiency results in altered bone and mineral metabolism which results in bone loss19 and impaired bone growth leading to reduced bone mass, osteopaenia, and increased skeletal fragility.20,21

Not only does magnesium on its own promote bone formation and density, and a magnesium deficiency reduce bone formation increasing the risk of osteoporosis but where there is magnesium deficiency, calcium provides no preventative effect against osteoporosis.22

Consider then the worrying reality that calcium and magnesium share transport mechanisms and compete for absorption in the body and that one of the causes of low magnesium absorption and high magnesium excretion is hypercalcaemia23 or high blood calcium. The exact same hypocalcaemia brought about by the calcium supplements prescribed by medical practitioners to people suffering from or at high risk of developing osteoporosis.

In fact studies conducted over 70 years ago showed that magnesium deficient rats fed diets high in calcium and vitamin D produced rats with more brittle bones than control rats.24

In these animals skeletal changes occurred that are similar to those seen in the disease osteopetrosis.23 Osteopetrosis24, sometimes called ‘marble bone disease’ is a disorder where bones become harder and there is excess bone formation but despite this bones are more brittle than normal bones and there is increased risk of fracture.

If you are puzzled as to why high dose isolated calcium is to this day regularly prescribed to those with reduced bone density, you will be more frustrated (or perhaps angry) than puzzled to know that in a 2007 meta-analysis (summary) of studies looking at the relationship between calcium intake and hip fractures that included over 200,000 men and women, showed that there was no reduction in hip fracture risk associated with calcium supplementation and that an increased risk was possible.27

Low levels of magnesium coupled with high doses of calcium are not just bad news for your bones either. Low magnesium levels can result in calcium deposition in soft tissues and magnesium supplementation may prevent the formation of calcifications.28

Calcification is the depositing of calcium in a soft tissue that leads to its hardening. The word atherosclerosis translates literally to ‘arteries’ and ‘hardening’ and it is the process of atherosclerosis or hardening of the arteries precedes cardiovascular disease.

In the commentary of the above mentioned meta-analysis authors stated: “calcium supplements acutely elevate serum calcium levels29 possibly accelerating vascular calcification, Vascular calcification is an established risk factor for cardiovascular disease and predictive of vascular event rates”30 and “because calcium supplements increase bone density it is possible that they may also increase vascular calcification and thereby cardiovascular events” – such as heart attacks.

A key point about these conclusions is that these risks are restricted to the ingestion of high dose calcium supplements and do not apply to supplements that contain multiple nutrients or to diets high calcium. 

 

Greenssquare.jpg 
The fact is that healthy bone formation is the result of the activities and interrelationships of multiple nutrients, minerals as well as vitamins, under influence from multiple biological messengers in response to the environment within the body. To ignore this widely accessible information is not only ignorant, but negligent and dangerous.

Ultimately it pays to be as well educated as you can on the subject of your own health and if you are to take nutritional advice take it from health professionals who have studied nutrition and are trained in the science of nutritional supplementation.

 

The Dairy paradox

The debate as to whether the consumption of moderate to high volumes of milk and dairy products is health promoting or damaging continues.  There is much conflicting information so we will leave this subject for now and address the issue of primary lactose intolerance which is a problem for some populations. It is more common in children of African, Mexican, American Indian, and Asian descent than in white children.31,32 Many children with lactose intolerance can drink small amounts of milk without discomfort, especially when accompanied by other foods. Intolerance of the consumption of 250 mL or less of milk is rarely seen in preadolescents, and the addition of small amounts of lactose-containing food to the diet may decrease the severity of lactose intolerance.31

 

For bone health, include the following:

1. Include foods high in magnesium – nuts and seeds, dark green leafy vegetables, whole grains.

2. Include foods high in calcium – sesame seeds, sardines, soft fish bones (i.e. tin salmon), dark green leafy vegetables, whole grains, nuts and molasses.

3. Avoid foods that promote the excretion of these minerals from the body or inhibit mineral uptake - excess fat, salt, sugar, coffee, ethanol (alcohol) and phosphoric acid (found in carbonated drinks). Additionally excretion is promoted by excess sweating, intense, prolonged stress and various prescription medications including antibiotics.

4. As an adjunct to a healthy diet take a mineral complex that:
  a. Provides calcium and magnesium in a ratio between 1:2 and 2:1
  b. Provides other macro minerals and trace minerals – boron, chromium, copper, iodine, iron, manganese, molybdenum, potassium, selenium, silica, zinc etc and provides vitamin D.

5. Include health giving, phyto-oestrogen containing foods and herbs in your diet and health care regime:
  a. Foods that contain phyto-oestrogens - flax seeds, soy beans, lentils, chickpeas, split peas, mung beans, alfalfa sprouts.
  b. Herbs that contain phyto-oestrogens - black cohosh, red clover, dong quai, liquorice, alfalfa, kudzu.

 

References

  1. Bernick and Hungerford (1965)
  2. Trowbridge and Seltzer (1967)
  3. Y. Seino, S. Ishizuka, M. Shima and H. Tanaka, Osteoporosis International, vitamin D in bone formation, Volume 3, Supplement - 1, 196-198, Session IX: Treatment: Vitamin D Metabolites
  4.  Autier P, Gandini S. Vitamin D supplementation and total mortality: a meta-analysis of randomized controlled trials. Arch Intern Med 2007;167:1730-7.
  5. Bügel S, Vitamin K and bone health., Proc Nutr Soc., 2003 Nov;62(4):839-43.
  6. Weber P., Vitamin K and bone health, Nutrition 2001 Nov-Dec;17(11-12):1024.
  7. Nielsen FH., Magnes Trace Elem., Studies on the relationship between boron and magnesium which possibly affects the formation and maintenance of bones., 1990;9(2):61-9.
  8. William Opsahl* et al, Journal of Nutrition, Role of Copper in Collagen Cross-linking and Its Influence on Selected Mechanical Properties of Chick Bone and Tendon1 http://jn.nutrition.org/cgi/content/abstract/112/4/708 viewed 23 Aug 2010
  9. Masayoshi Yamaguchi, Role of zinc in bone formation and bone resorption, The Journal of Trace Elements in Experimental Medicine, Volume 11, Issue 2-3, pages 119–135, 1998.
  10. Linda Strause and , Paul Saltman, Role of Manganese in Bone Metabolism, Nutritional Bioavailability of Manganese, Chapter 5, pp 46–55, Publication Date (Print): October 05, 1987, Department of Biology (B-022), University of California—San Diego, La Jolla, CA 92093.
  11. Elisaf M, Milionis H, Siamopoulos K. Hypomagnesemic hypokalemia and hypocalcemia: Clinical and laboratory characteristics. Mineral Electrolyte Metab 1997;23:105-12.  http://ods.od.nih.gov/factsheets/magnesium.asp
  12. (N. Goldsmith and Baumberger, 19671.
  13. Tucker KL, Hannan MT, Chen H, Cupples LA, Wilson PW, Kiel DP. Potassium, magnesium, and fruit and vegetable intakes are associated with greater bone mineral density in elderly men and women. Am J Clin Nutr 1999;69(4):727-36.
  14. Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes: Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride. National Academy Press. Washington, DC, 1999.
  15. Stendig-Lindberg G. Tepper R. Leichter I. Trabecular bone density in a two year controlled trial of peroral magnesium in osteoporosis. Department of Physiology and Pharmacology, Sackler. Faculty of Medicine, Tel Aviv University, Israel. Manges Res. 1993 Jun;6(2):155-63.
  16. Effects of high calcium intake on bone metabolism in magnesium-deficient rats.Magnes Res. 2005 Jun;18(2):97-102.
  17. Authors; Sojka JE. Weaver CM. Title; Magnesium supplementation and osteoporosis. [Review] [32 refs] Source; Nutrition Reviews. 53(3):71-4, 1995 Mar.
  18. Journal of Nutrition. 2000;130:216-220.
  19. Authors; Rude RK. Kirchen ME. Gruber HE. Stasky AA. Meyer MH. Title; Magnesium deficiency induces bone loss in the rat. Source; Mineral & Electrolyte Metabolism. 24(5):314-20, 1998.
  20. Authors; Rude RK. Kirchen ME. Gruber HE. Meyer MH. Luck JS. Crawford DL. Title; Magnesium deficiency-induced osteoporosis in the rat: uncoupling of bone formation and bone resorption. Source; Magnesium Research. 12(4):257-67, 1999 Dec.
  21. Duckworth et al. (1940)
  22. Effects of high calcium intake on bone metabolism in magnesium-deficient rats.Magnes Res. 2005 Jun;18(2):97-102
  23. MD,FACP Updated: June 20, 2002 http://www.emedicine.com/med/topic3382.htm
  24. Orent et al. (1934) and Watchorn and McCance (1937)
  25. Storey (1960)
  26. http://en.wikipedia.org/wiki/Osteopetrosis
  27. Bischoff-Ferrari HA, Dawson-Hughes B, Baron JA, Burckhardt P, Li R, Spiegelman D, et al. Calcium intake and hip fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trials. Am J Clin Nutr 2007;86:1780-90.
  28. Planells E, Llopis J, Perán F, Aranda P. (1995). "Changes in tissue calcium and phosphorus content and plasma concentrations of parathyroid hormone and calcitonin after long-term magnesium deficiency in rats.". J Am Coll Nutr. 14 (3): 292–8. PMID 8586780.
  29. Reid IR, Schooler BA, Hannon S, Ibbertson HK. The acute biochemical effects of four proprietary calcium supplements. Aust N Z J Med 1986;16:193-7.[ISI][Medline]
  30. Pletcher MJ, Tice JA, Pignone M, Browner WS. Using the coronary artery calcium score to predict coronary heart disease events: a systematic review and metaanalysis. Arch Intern Med 2004;164:1285-92.
  31. American Academy of Pediatrics, Committee on Nutrition. Carbohydrate and dietary fiber: lactose. In: Kleinman RE, ed. Pediatric Nutrition Handbook. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003:250–252
  32. American Academy of Pediatrics, Committee on Nutrition. Practical significance of lactose intolerance in children: supplement. Pediatrics. 1990;86:643–644

This educational publication was created by naturopath and personal Trainer Clare Tyler, North Shore City, New Zealand.
© All content is subject to copyright Health & Herbs International Ltd 2010 and may not be copied or reproduced, in part or full, for commercial purposes.

 
 
Copyright © 2008 Health & Herbs International Ltd  www.healthandherbs.co.nz
Website Design by Labyrinth Solutions  |  Content Management by Contegro