Bone Density and Bone Strength
Bone Density and Bone StrengthBone Density and Bone Strength

Bone is living tissue. Like all tissues in the body, it is constantly being built up and broken down. So the bones you have now are not the bones you had ten years ago! If you have osteoporosis your bones are no longer as strong as they should be, and your risk of fracture is increased. However, there are many things we can do to strengthen our bones as we get older.

Our ageing population is affected by an increased incidence of certain conditions, one of which is osteoporosis. This serious and disabling disease is characterised by decreased bone mineral density (BMD) and thinning of bone tissue, which lead to bone fragility and fracture.


There are two central factors responsible for the development of primary osteoporosis (osteoporosis not due to another cause such as an endocrine or metabolic disorder). The first of these is oestrogen deficiency after the menopause – oestrogen has a protective effect on bone, which is lost as levels decline. Secondly, ageing reduces the ability of the intestine to adapt to a low-calcium diet and maintain adequate calcium absorption. In addition, vitamin D helps the gut absorb calcium, and absorption of this vitamin and its formation in the body when the skin is exposed to sunlight also decline with ageing.


Peak bone mass is reached by the age of 18 in women and 20 in boys, which makes youth the best time to invest in bone health. Adequate calcium intake and exercise are essential for building bones that will remain strong in later life.

The rate of bone loss in women increases after menopause, at approximately 50 years of age. The period of maximum bone loss lasts for 5 to 7 years, with loss of 3 to 5% per year.


Osteoporosis most commonly affects postmenopausal Caucasian and Asian women, but other people can have it too. In fact, 20% of people with osteoporosis are men, and the mortality rate following all types of fractures is much higher in men than in women.

Bone Density and Bone Strength

A further cause of osteoporosis is never achieving adequate bone mass. Girls or young women with anorexia nervosa have significantly reduced bone mass. Exercise helps in achieving greater peak bone mass, and long-term immobility makes bones weaker. Nutritional deficiencies and heredity are other risk factors. The genes we inherit from our parents have a major impact on our bone health – some studies have suggested that 80% of the factors that determine peak bone density are genetic.


Routine screening by means of a DEXA scan (dual-energy X-ray absorptiometry) is recommended at age 65 and older. DEXA allows measurement of BMD and calculation of fracture risk, making it the ideal screening method. I usually recommend that my patients have their first scan soon after menopause, so that we have a baseline to measure from. A t-score is given, with less than minus 1 being normal, minus 1 to 2.5 indicating osteopenia (bone loss that is not as severe as osteoporosis), and more than minus 2.5 indicating osteoporosis. The BMD is compared with that of a normal young adult.


The five major goals of treatment are prevention of fractures, maintenance or addition of bone mass, relief from the symptoms of fractures and skeletal deformity, optimisation of physical function, and reduction of the economic burden caused by complications of the disease.

Conventional treatment of osteoporosis includes bisphosphonates, oestrogen receptor modulators, and hormones. Hormone replacement therapy (HRT) is no longer recommended, although it was used in the past because it increases bone mass and reduces the risk of fracture in postmenopausal women. However, more recently it has been shown that HRT increases the risk of breast cancer, stroke and venous thrombo-embolism, disadvantages that outweigh its skeletal benefit.

Bone Density and Bone Strength

Follow-up tests after osteoporosis has been diagnosed include measurement of parathyroid hormone, thyroid hormone, 24-hour urinary calcium and 25-OH vitamin D to rule out any other causes or deficiencies. A newer test called N-telopeptide is a urine test that measures bone turnover. It is useful to determine whether treatment is working, but it should not replace a DEXA scan as the screening test.


Prevention is always better than cure. In the case of osteoporosis, prevention can include prescription medications, vitamin and dietary supplements, lifestyle and behaviour modification, or a combination of these measures, with the aim of reducing loss of bone substance and reinforcing the skeletal structure.

Exercise, especially weight-bearing exercise, helps to retain bone mass and also improves strength and balance, decreasing the risk of falling and breaking a bone.

A vegetarian diet is associated with a lower risk of developing osteoporosis over age 65. Results of studies that have tried to find out whether animal protein increases urinary excretion of calcium are mixed, but we know that sugar does increase calcium loss due to inhibition of renal calcium absorption by the hormone insulin. Caffeine intake can accelerate bone loss, and alcohol can result in decreased bone formation when more than 2 drinks a day are consumed; however, a low intake of alcohol is associated with increased BMD in women and a decreased risk of hip fracture.

In short, changing your lifestyle can help reduce your chances of developing osteoporosis. A healthy whole-foods diet, high in vegetables, especially dark-green leafy ones, fruits, legumes, whole grains and good fats in nuts, seeds and fish, and low in animal protein, sugar, alcohol and bad fats, is recommended.


The following supplements are recommended.

Calcium. You need about 1 000 milligrams a day before the menopause. A healthy diet provides about 500 to 600 mg a day, so 400 mg needs to be supplemented. After the menopause you’ll need 1 200 to 1 500 mg. There are various forms of calcium. Hydroxyapatite is a natural mixture of calcium and phosphorus, trace minerals and glycosaminoglycans and is easily absorbable. Calcium bisglycinate (chelated) and citrate/malate/aspartate (bound complex) are good, and no stomach acid is needed for absorption (stomach acid levels decrease with age). Buffered calcium with ascorbates is good too, and again no acid is needed for absorption. Calcium carbonate is less well absorbed, as adequate stomach acid is needed. Absorption of calcium citrate is 25% higher than that of carbonate.

Magnesium is an important component of bone, and 400 to 700 mg a day is recommended. The best forms are the soluble ones such as malate, citrate and glycinate, and the worst the insoluble ones like chloride, carbonate and oxide.

Vitamin D3. A review of women with osteoporosis hospitalised for hip fractures found 50% to be deficient in vitamin D. Get tested early – I even recommend testing in children. The amount you’ll need to supplement with will be determined by the result of the blood test.

Vitamin K2 is required for the production of osteocalcin, the protein matrix on which mineralisation occurs. The dosage is 45 mg a day.

B vitamins play a number of roles, especially vitamin B6 and folic acid in homocysteine metabolism.

Boron 2 to 3 mg a day reduces urinary excretion of both calcium and magnesium.

Silica, manganese and phosphorus are thought to aid calcium uptake into the bone.

Zinc helps with calcium assimilation. Take 20 to 40mg a day.

Isoflavones. Synthetic isoflavone (ipriflavone 600 mg a day) helps bring calcium into the bones.

Essential fatty acids increase calcium absorption in the intestines and reduce calcium excretion.

Strontium increases BMD and has been shown to reduce the incidence of fractures by more than 40% over a 3-year period. The dosage is 680 mg a day in divided doses. It needs to be taken at a separate time to calcium but with magnesium, calcium and vitamin D to be safe for bones overall.

In conclusion, if you are concerned about your bone health, especially if your mother or grandmother has osteoporosis, start to take care of your bones at a young age with exercise and a good diet. Take a good-quality multivitamin with enough calcium and magnesium, and get your vitamin D levels tested. On reaching menopause, have your first DEXA scan done to determine your risk. If the scan reveals osteopenia or osteoporosis, make sure you are getting sufficient exercise and eating healthily. Don’t just head straight for pharmaceutical drugs – there are many very effective natural medicines without their side-effects. I recommend that you consult a holistic health care provider who can recommend a treatment programme that is likely to work for you, and monitor its effectiveness.

Further reading:

  1. Hudson T. Women’s Encyclopedia of Natural Medicine. McGraw-Hill, 1999.
  2. Sarris J, Wardle J. Clinical Naturopathy: An Evidence Based Guide to Practice. Churchill Livingstone, 2010.
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