Even if you’re not interested in bone health, I encourage you to read this entire article since it outlines a fatal conceptual flaw that physicians, scientists, nutritionists and the rest of the public keep getting sucked into which influences their health and nutrition decisions in a profoundly negative way. I’m going to call this the fallacy of “Direct Translational Nutrition” or DTN. We’ll come back to this concept of DTN after I introduce a case study. Also be sure to read to the end so you can take advantage of my bone-boosting breakfast juice recipe!
Meena (not her real name) is a 42-year-old Indian female engineer who came to see me after developing prediabetes. I noticed in her health record that she also had fairly significant osteopenia, which is low bone density, and was on her way to developing osteoporosis, which is really low bone density that increases the risk of bone fractures, at the young age of 42! Normally we don’t do bone scans to screen for osteoporosis in women so young, but she had a strong family history of osteoporosis and an ankle fracture that was not due to any injury.
Having a fractured bone without any direct injury causing the fracture is a warning sign that bones are fragile, in which case a bone scan becomes warranted. I asked her about this and she told me: “I was shocked. I eat yogurt and a glass of milk every day and take my calcium supplement. I never thought I could be at risk for osteoporosis at such an early age.”
The Fallacy of Direct Translational Nutrition (DTN)
DTN is when we naively underestimate the complexity of the human body and think the nutrients we consume directly translate into the development of structures in our body made out of those same nutrients. That may work in some instances, like how eating sugar will raise your blood sugar, but in most cases it's not that direct of an effect. Before we see how erroneous DTN applies to bone health and the development of Meena's premature osteopenia, let's review two other examples which I discuss in detail in my book and throughout this blog.
DTN Misconception #1- Dietary Fat Will Make You Fat
Gaining body fat is a complex process under the regulation of multiple hormones like insulin, leptin and cortisol which in turn are impacted by factors such as carbohydrate intake, sleep, and stress to name a few. If eating dietary fat truly made us fat, then the preceding years of low-fat eating should have eradicated, rather than propagated the epidemic of global obesity. If dietary fat made you fat, then all of the vegetarian Indian patients in my practice who eat no animal fat and have conscientiously limited other sources of dietary fat in the name of good nutrition, would be slender, energetic and disease-free, but instead they are obese, diabetic and full of chronic health conditions.
DTN Misconception #2- Dietary Cholesterol Will Raise Blood Cholesterol Leading to the Formation of Artery Clogging Plaques
Over 80 percent of the cholesterol production in your body has nothing to do with cholesterol coming from your diet. If you eat nutrient dense foods like eggs that happen to also have dietary cholesterol, your overall health will benefit from the multiple other nutrients in eggs, with little to no adverse impact from the cholesterol in the yolks. Read my prior post on eggs for more information.
DTN and Bone Health
So now let’s apply the fallacy of DTN to bone health. What’s the first nutrient that comes to mind when you think of bone health? Calcium, right? So obviously for you to fortify your bones, you need to drink your milk, eat your yogurt, and swallow calcium tablets, right? What makes this association even more powerful is the visual connection. Just like dietary fat visually resembles heart attack causing plaques (check out my prior post that shows images of ghee compared to plaques), we also think of bones as being white just like a nice tall glass of milk, a slice of swiss cheese, or a bowl of plain yogurt. The image below is a perfect example of how we have been brainwashed into DTN, where milk is being poured directly into a bone making us think the calcium in the milk is being cemented into our bone, making it stronger.
This study from 9/2015, a comprehensive meta-analysis published in the prestigious British Medical Journal, showed that dietary and calcium supplement intake had an insignificant impact on bone density and no impact on reducing fracture risk, which is what we really care about when it comes to bone health.
Meena, like so many other women, thought all that nice white-colored, calcium-enriched food she was consuming was adding density to her bones. However, she failed to realize that a combination of her sedentary lifestyle, her limited sun exposure, her nutrient deficient diet, and her prediabetes, in addition to a potential genetic tendency towards osteoporosis were the real culprits in reducing her bone density.
Keep in mind that her lifestyle risks for osteoporosis are far more powerful than her genetic tendency. We see plenty of patients with no family history of osteoporosis who develop this condition due to their diet, activity and behavior patterns. Meena could have tripled her intake of dairy foods and supplements and still ended up with fragile bones. This was a failed case of DTN.
Diabetes and Insulin Resistance Impair Bone Health
How does Meena's prediabetes put her bones at risk? What really gives bones its strength is a protein called collagen, which forms the scaffolding upon which bone is laid down. Excess glucose (from prediabetes, diabetes, metabolic syndrome, etc.) binds and damages collagen, which impairs proper bone formation. This study shows a link between diabetes and osteoporosis.
Notice in the image below how glucose causes a crosslink beteen the collagen fibers, which will interfere with collagen's function. Collagen not only makes bones stronger, it also keeps skin smoother and prevents wrinkling. When my patients cut sugar and reverse their diabetes, their faces actually look younger, and improved collagen function is one of the reasons. Conditions like diabetes actually accelerate aging by interfering with normal protein function, which you can read more about in this post.
What does Improve Bone Health?
Bone metabolism and physiology is a highly complex and dynamic process involving a cycling between bone deposition and removal (aka “resorption”)…in with the new bone, out with the old bone and repeat! This is influenced by multiple hormones (thyroid, parathyroid, calcitonin, growth hormone, etc.), and so simplifying bone health down to a glass of milk or a calcium tablet undermines the intricate process of maintaining bone strength throughout your lifetime. Let me list off some of the most important factors that improve bone density and overall bone health.
1. Weight Bearing Exercises: Weight bearing exercises or activities mean you are on your feet so your bones and muscles work against gravity. The impact of your body weight with the pulling of muscles on your bones stimulates your body to build new bone. Keep in mind that although swimming and biking are great forms of exercise, they are not weight bearing and would not be optimal for building bone mass. Some examples of weight bearing exercises include:
- Walking, hiking, running
- Gardening and yard work
- Dancing and aerobics
- Sports: soccer, basketball, tennis and other racket sports, golf (walking instead of using a cart)
- Weight training, especially using free weights
- Dance and group exercise classes
2. Vitamin D: Vitamin D increases the absorption of calcium from your intestinal tract. Your dietary calcium is hardly available to your body and bones if your vitamin D levels are deficient like they are in so many of my patients. Most of our vitamin D comes from sunlight and some from our diet. Read this post for more information.
3. Magnesium: Magnesium is an essential mineral involved in a multitude of cellular processes. Magnesium allows vitamin D to be converted to its active form, it stimulates the thyroid gland to produce a hormone called calcitonin which helps keep calcium in the bones, and magnesium impacts overall calcium balance in the body.
Unfortunately today many of us are suffering from magnesium deficiency due to changes in our soil and in our diet. We'll cover magnesium in a future post, but for now be sure to eat magnesium rich foods like dark leafy greens, nuts, and seeds.
4. Potassium: Dietary potassium is important for bone health and this study shows how potassium reduces the breakdown of bone (aka bone resporption). Potassium, like magnesium comes primarily from plant-based sources like leafy greens, nuts, seeds and fruit (especially avocados).
4. Vitamin K2: The vitamin K I learned about in medical school was vitamin K1 which is involved with blood clotting and found predominantly in plant based foods. Vitamin K2 is a different form that helps calcium deposit in places we need it (bones and teeth) and keeps it out of our soft tissues and arteries where calcium can do harm. There are some studies linking calcium supplementation to heart disease risk and this may be a factor in individuals who are deficient in vitamin K2 since the calcium is going to the arteries rather than to the bones. There have been conflicting reports about this association so further studies are indicated. How do you get vitamin K2 through the diet?
While vitamin K1 comes primarily from plants, vitamin K2 comes from animal sources and fermented foods and is typically lacking in a Western diet. Interestingly in countries like Japan where vitamin K2 is more predominant in the diet, national guidelines encourage intake to reduce osteoporosis risk. Sources include:
- Egg yolk
- Natto (fermented soybeans) and Miso
- Hard and soft cheeses
- Chicken liver
Although I mentioned getting calcium from dairy may not have a significant effect on bone health, grass-fed, dairy-derived fat and egg yolks would have a better overall effect on bone health. Aside from calcium, grass-fed dairy fat contains vitamin K2 in addition to anti-inflammatory fats like CLA (conjugated linoleic acid). Inflammation is another process that can have a negative impact on bone health, so consuming high quality dairy may help combat this. Drinking skim or lowfat milk would not have much vitamin K2 and would lack CLAs. If you are worried about dairy fat, be sure to read this post to put your mind at ease.
5. Bone broth: Bone broth has become very popular in food news these days. There are no well established studies to date documenting that bone broth improves bone density, which would be a case of true DTN with bone broth building stronger bones! However, I have spoken to many patients and clinicians who swear by the healing effects of bone broth. I've had athletes tell me they recover quicker from training and injuries, and patients suffering from autoimmune conditions who felt bone broth was key to their recovery.
To learn more about bone broth, check out the posts of my good friends Mark Sisson from Mark's Daily Apple, who provides some great details here, and Michelle Tam from Nom Nom Paleo who gives practical tips on making bone broth with this post. This is the perfect season (Fall/Winter) to add a nice cup of hot bone broth to your arsenal of healing foods.
6. Minimizing Anti-Bone Factors: There are actually some foods we eat that are removing minerals and nutrients from our body. Anti-nutrients like phytic acid from a grain-centric diet actually binds some of the key vitamins and minerals for bone health we've already discussed like vitamin D, magnesium, and calcium. Read this post to learn how phytic acid from grains (like whole wheat chapatis) has been linked to osteoporosis in adults and weaker bones in children. Soda intake and excess caffeine intake has also been potentially correlated with a loss of calcium, but it's not conclusive whether this significantly raises osteoporosis risk.
Improving stress may reduce inflammation, which is another risk to your bones, while getting more high quality sleep will help your body produce more bone and muscle-boosting growth hormone. I know the above is a long list and my free e-book, Recharge, will give you some practical tools to optimize all of the above. Sign up for the newsletter and you'll get a free copy sent to you directly.
Today's modern day seniors are unfortunately more sedentary than ever. Retirement used to mean more time to spend outdoors hiking, gardening and traveling, but for many of today's seniors they are spending more time on their computers, tablets and other devices. If you have elderly family members or loved ones, be sure you are encouraging them to follow all of the advice in this blog because they are especially susceptible to the more immediate disabilities associated with thinning bones.
Make sure they wear an activity tracker and are getting enough steps, are performing additional weight bearing exercises, are eating a nutrient dense diet and getting adequate sun exposure. I've had family members and many patients suffer completely preventable hip fractures due to osteoporosis which led to disability and in some cases death, due to complications from surgery and from being completely immobilized in bed.
Unlike osteoarthritis (aka arthritis), osteoporosis does not cause pain, until a debilitating fracture occurs. Be vigilant with family members especially if they have become sedentary and mostly home bound.
Should You Throw Out Your Calcium Supplements?
I’m definitely not asking you to throw out your calcium supplements. We need better studies to learn which individuals may benefit (if any) from calcium supplementation and further studies to understand the potential risks. What I've hopefully highlighted for you here is that building stronger bones takes far more effort than swallowing calcium pills. I wish it were that easy!
Just like taking a vitamin D supplement doesn’t allow you to avoid safe sun exposure, or taking an antioxidant pill doesn’t mean you don’t have to eat plants rich in natural antioxidants, taking a calcium supplement as we’ve learned is an ineffective replacement for a bone-healthy lifestyle
Dr. Ron's Bone Boosting Breakfast
I know the list of items for boosting bone health may seem daunting, but one of my go-to breakfasts in the morning (if I'm not intermittent fasting), involves juicing together the following ingredients:
- ~4 leaves of Kale
- Fistful of Spinach
- 8 Almonds
- 3-4 tbsp Seeds (any combo of chia, hemp and/or flax depending on my mood!)
- 1/2 Green apple
- Fistful of frozen berries
- Fresh ginger, mint and basil
- Filtered water (can use almond milk, high quality dairy, yogurt, etc. as your base)
With regards to bone health, this concoction is loaded with magnesium and potassium and provides plant-derived calcium, especially from the kale. Notice how it's mostly veggies and very little fruit unlike many of my patients who love blending predominantly fruit smoothies that send their blood glucose levels to the ceiling. You have the option of using high quality dairy as your base if you want more dairy-derived calcium.
I will often have this alone or with a couple of soft-boiled eggs to get the additional nutrients, including the vitamin K2 to push calcium into my bones. The core ingredients are really just dark greens, nuts and seeds to maximize the key minerals and in addition to a juice, you can wrap these into an omelet or drop them into a stir-fry. These ingredients also happen to be great for lowering blood pressure, improving insulin resistance (prediabetes, diabetes) and lowering inflammation.
For extra credit, drink or eat this outdoors while getting some vitamin D from the sun and squeeze in a walk or one of the other weight-bearing exercises we discussed. Now that will boost bone health far more than a glass of milk!