Tuesday, November 29, 2022

Everything you want to know about strong bones

Bones are living tissue in our bodies, just like our heart, lungs, and muscles. The bone cells take birth, function, and die, just like most other cells.

What is the single best strategy to get and maintain strong bone: Get knowledge. Yes, you heard it right. Getting information is the single most important thing you can do for healthy bones.

Many people I meet look for quick solutions, and ‘sure–fire’, ‘one–size–fits–all’ ways. Unfortunately, there is none. The one size that should fit all actually fits none.

Everyone is different — different age, gender, work profile, exercise habits, family history, constitution, or medical problems. Even you are different at different times — stressed on Wednesday mornings, drunk on Friday nights :-), and depressed on Sunday nights as the weekend gets over.

Your body will respond differently all the time: stress will increase cortisol, which will increase bone breakdown, alcohol will make you vulnerable to falls and fractures, and depressive feelings will increase pro-inflammatory cytokines (whatever that means), causing bone weakening. We will discuss all these in this article, in simple English.

There are literally hundreds of things you can do to get stronger bones. Different ones work in different situations. So, a good knowledge of them will help you make good decisions in various situations.

To understand how to build strong bones, you first need to understand how bones are formed, how they function, grow, weaken, and sometimes, break down. Based on this understanding, you can make many logical judgments on how to strengthen your bones. We will do exactly that in this article.

Since the article is long and detailed, I will give summary points for healthier bones at the end of each big section.

Disclaimer

I should have titled this article “non-medical strategies for getting and maintaining strong bones”. This is since I have no intention of providing any medical advice, nor bypassing any medical advice you have been given currently. Continue with what your doctor has advised you.

Along with that, use many of these small, simple, logical, and sometimes profound, guidelines to build strong bones. If any of these suggestions interfere with your current medical regimen, don’t apply anything yourself. First, discuss these with your doctor and other experts.

You may also wish to click on the myriad links given in the article. They lead to authentic web resources and give you the more detailed information. Those articles are written by practising doctors, nutritionists, or research scientists.

Table of Contents

Bones are living tissue

Most people think that bones are just a part of a rigid skeleton made out of calcium. They imagine the bones to be an inert, rigid mass, inside which our body’s organs and muscles are laid out.

Some health-savvy people know that bones also contain marrow, where blood cells are formed. So they think of bones as some hollow, rigid tubes, made of calcium. Neither of these is proper understandings.

Bones are living tissue in our bodies, just like our heart, lungs, and muscles. The bone cells take birth, function, and die, just like most other cells. One does not notice these dynamic changes in the bones, because newer bone tissue replaces the older ones.

Of course, as we will see, a large part of our bones is non-living matter. But the matter that matters in the bones is the living matter.:-)

Imagine a child growing into a full-grown adult. If the bones were rigid masses, how would they grow or deform? This continues throughout life. Have you not seen an elderly lady with a hunchback, medically called Hyperkyphosis?

The bone tissue is made up of a significant amount of minerals, of which calcium is the main component. That is probably the only difference between the bones and the other body tissues.

So, once a person is dead, his bones don’t decay, unlike other tissues. The bones survive thousands of years after his death. Since we have seen skeletons in horror movies, we mistakenly think that bones are rigid blocks of calcium.

Bone composition and structure

Since we don’t need to appear for a college examination, we will only look at points that help us build strong bones.

We said that bones are living tissues. But for purists, that may not be true. Only about 5% of the volume of the bones are bone cells, or living matter. The remaining part is non–living inorganic (mineral) and organic material. Just like your skin and nails.

10% of the volume of our bones is water.

50% of the volume of our bones is made of organic (calcium is a mineral, and is inorganic) material. Almost all of it is a protein called collagen, the same substance that gives firmness to our skin. (for example, facial wrinkles are formed when the skin starts losing collagen). Start guessing what will happen to your bones if you are deficient in protein.

Tensile strength

Collagen fibers confer elasticity and tensile strength to the bones. Crudely speaking, if you try to bend a bone (elasticity) or pull it apart (tension, or tensile strength), collagen will help resist it.

However, collagen cannot offer compressive strength to the bones. That is, if you try to press the two ends of a bone together, collagen cannot resist it. And when you are standing up, gravity is compressing your bones constantly.

Compressive strength

To hold the bones up against the compressive forces, we need minerals or inorganic mass. There is a mineral called Hydroxyapatite, which is made up of calcium and phosphorous (in a form called, phosphate). This mineral takes nearly 40% volume of the bones.

Two-phase structure

This Hydroxyapatite mineral is dispersed in the collagen matrix, or grid, but is deposited in globs. That is, it is not a one-piece unit. You can visualize the bone as a long, rubbery stick with solid concrete blobs embedded along its length. This is called, in engineering terms, a Two-Phase structure. Such structure confers special properties to the bone.

Consider a piece of chalk. If you give it a fillip with a flick of a finger, it will break. The brittle material will develop a crack, which will propagate to the other end and the piece will break into two.

But, the rigid, but brittle, mineral matter in the bones is not a continuous block. If it develops a small crack or a mini–fracture, it will not propagate further, limiting the damage. The University of Cambridge explains here how the structure of the bone helps it withstand various stresses on it.

Thus, the engineering marvel of the bone comes from its two-phase composition: organic collagen, embedded with inorganic hydroxyapatite.

Similar two-phase materials you know are bamboo and fiberglass. Both are hard but pliable. You can’t break them easily. Unlike chalks.

Obviously, it is neither the organic collagen nor the inorganic hydroxyapatite (calcium and phosphate combination) individually that makes a bone stronger. The organic part will make it more pliable but less rigid. The mineral component will make it more rigid but less flexible.

If you work out the engineering, the optimal ratio of organic to mineral components should be 1:2, by weight. That is roughly the ratio in our weight-bearing bones (some bones, such as those in your ears, are not meant for weight–loading, and so their composition can be different than 1:2).

Note that the numbers we had mentioned earlier were percentages by volume. This 1:2 ratio is by weight. While minerals (40%) take less space than collagen (50%), they are almost double the weight (60%) of the organic collagen material (30%).

Thus, just calcium is not going to make your bones strong; they will need proteins (collagen), too. So don’t go on brainlessly taking calcium supplements, thinking you are making your bones stronger. At some point, you are going to make them too brittle, which will lead to increased fractures.

Medicine also finds out what you learned in the last few minutes. For example, there is a specialized class of medicines, called Bisphosphonates, which are used for increasing bone mineral density. They are more effective than taking plain calcium.

However, read Medscape’s article: Long–term use of bisphosphonates degrades fracture–resistance–toughening mechanisms of bones. In a layperson’s language, if you increase the bone minerals (calcium and phosphates) for too long, you are going to increase bone fractures.

In fact, you might have heard some recent data on how calcium supplements can increase fracture rates. Keep thinking.

Those of you who love arcane, technical stuff, read here about Bone Morphology. It is also good reading if you suffer from insomnia.

How are bones formed and destroyed

Bones are not statues, even with collagen and hydroxyapatite. They keep on breaking down and getting rebuilt.

Our everyday life causes micro-breaks in different parts of the bones. Some cells in the bone rush their repair that damage.

Sometimes, your blood’s calcium levels go low. This is unacceptable since calcium is needed for heart functioning, muscle contraction, and many other functions, whose absence can be life-threatening. So the body secretes some hormones that tell some cells in the bones to extract calcium from the bones and release it into the blood.

Bone Remodeling

The process of bone formation and breakdown is called Bone Remodeling.

It is interesting and worth knowing from the point of view of having strong bones. For example, if you know why some special cells decide to break down the bones, and then how they go about doing that, you can figure out ways to reduce the breakdown.

Nearly 10% of your skeleton is replaced every year. Most of it is to repair the damaged parts or reshape the skeleton for either growth or better support. Some part of it also goes towards regulating calcium in the blood.

If some part of the body faces increased impact or stress, the bones in that area are stimulated to get stronger.

This process is regulated by many hormones such as vitamin D, calcitonin, parathyroid hormone, estrogen (women), and testosterone (men).

Here is a superb YouTube video from Amgen Corporation, which explains how old bone matter is removed and new bone matter laid out.

Video ‘Bone remodeling and modeling’, courtesy of Amgen Corporation.

Osteoblasts

These are cells that form new bone.

Osteoblasts move over the bone matrix, or the underlying grid, and deposit a protein mixture called Osteoid. Collagen is the main component of this mixture. Then, osteoblasts deposit minerals onto this osteoid. Calcium is the main part of this mineral mix.

Anything that will tell your osteoblasts to get active makes your bones stronger

But who, or what tells these osteoblasts to deposit these materials? Read on, for the suspense thriller.

Osteoclasts

These cells do exactly the opposite of osteoblasts. They break down the bone.

Osteoclasts move over the surface of the bone. They secrete acids and enzymes that cause the minerals to come off the bones. These minerals are taken up by the osteoclasts, who release them later into the blood.

Osteoclasts travel over the surface of the bone matrix and secrete acids and enzymes to disintegrate it, forming a little pit on the surface of the bone. As osteoclasts remove the mineral from the bones, those small areas become pitted. This process of bone breakdown is called Bone resorption.

Anything that tells your osteoclasts to slow down, or takes things easy, will keep your bones stronger.

Now, who, or what tells these osteoblasts to remove those minerals? Hold on to the suspense for some more time.

Osteocytes

While osteoblasts are laying down new bone, some of them suddenly get trapped in the bone matrix they are laying. They become some cells, called Osteocytes. Osteocytes become entombed as living mummies in the bone matter. In fact, osteocytes can live as long as we are alive.

However, they are still connected to their neighbouring osteocyte cells. They keep getting nutrients and sending waste products through small channels. There is a blood supply to the ends of such channels. Thus, though osteocytes are embedded in a rigid bone mass, they are alive, exchanging nutrients, and communicating with their neighbouring cells.

It is thought that osteocytes become the sensory cells that measure the impact or stress the bone undergoes. Based on the increased or decreased stress or damage, osteocytes signal to the osteoblasts and osteoclasts whether to form new bone, or break down old bone, or both. They regulate bone mineralisation.

Anything that tells your osteocytes that the bone needs buildup will help you get stronger bones. For example, a rope skipping exercise.

Thus, what appears to you as a hard piece of calcium, is actually an intricate living organ of our body with entombed mummies coordinating a delicate dance of construction and breakdown of living tissue called a bone.

Here is another YouTube video that explains this intricate bone structure.

Microscopic bone structure. Copyright: Erussellscilady

While we do not need to remember the whole science, it is important to know that the bone is made up of many parts, including blood supply and nerves. Go wrong with any of them, and your bone is bound to get, and stay, weaker.

Five stages of bone remodeling

Thus, there are five stages of bones restructuring, namely, activation, resorption, reversal, formation, and termination.

Activation

First, the osteocytes activate osteoclasts. As osteoclasts get ready for action, a working team of various types of cells is formed. Such a unit is called Basic Multicellular Unit (BMU).

Each BMU is about 200 micrometers (1/5th of a millimeter) in size. So, depending on the extent of bone restructuring needed, there are multiple such teams, or BMUs, formed in your bone. Believe it or not!

Resorption

Then, the osteoclasts in the BMU start removing the minerals from the bone area. This is called bone resorption.

These first two steps take about 2 weeks.

Reversal

After the resorption process is over, the osteoclasts signal to the osteoblasts in the BMU to start rebuilding the bone. This is the reversal phase, which takes another 2 weeks.

Formation

Osteoblasts lay down new bone at the place of breakdown. They finish the new bone laying in about 13 weeks.

Termination

The termination phase is just wrapping up this work, and dismantling the BMU team. There is no effect on the bone in this phase.

Thus, it takes about 17 weeks, or 120 days, for bone remodeling. There are a few points to note:

  1. As the bone get remodeled, it is weaker than normal for the first 4 weeks since it is broken down first before strengthening. So, if you start skipping ropes, the bones in your feet will get stronger in 120 days. But, they will be weaker for the first 30–50 days.
    Go easy on your skipping routine, initially. Rome was not built in a day; and so won’t be your bones.
  2. Bone remodeling does not happen only to make the bones stronger or weaker. It happens even when the bones are to be maintained at the same level of strength. An impressive phrase to say the same thing is Bone homeostasis — the process by which the body maintains its bone mass.
  3. Bone homeostasis happens because your bones are always breaking down microscopically and need routine maintenance. So, it is not useless work done by the body.
  4. Sometimes, the body may need extra calcium for a short period of time. This could be for muscles activity or heart functioning. BMUs will be activated for that also. And bone remodeling will take place, but not bone homeostasis.
  5. If you see the average bone density over this 120–day remodeling period, it will be lower than the normal level. This is because, for a good amount of time during this time span, the bone is lower in minerals.
  6. In a BMU, over a complete remodeling cycle, there is a very slight bit of mineral loss. Thus, there is a gradual bone loss over our lifespan. In technical terms, BMU–balance is slightly negative.
  7. BMU–balance becomes more negative, after the menopause in women. This can lead to osteoporosis, or fragile bones, in women.

Thus, bone remodeling happens throughout our lives, for:

  • Repair of bone micro–breakage
  • Requirement of calcium or other minerals in the body
  • Bone homeostasis, in a healthy body

Role of hormones in bone remodeling

We have seen that bone remodeling involves multiple types of cells to coordinate their actions. They communicate with one another through complex signaling mechanisms.

These involve several hormones, such as parathyroid hormone (PTH), vitamin D, growth hormone, cortisol, and calcitonin. Several other chemicals (that are not hormones) are also involved in remodeling. For example, M-CSF, RANKL, VEGF, IL-6 family.

Hormones that affect osteoblasts

Some hormones activate osteoblasts and maintain the bone matrix (the bone structure made of collagen and minerals).

Growth hormone

Your pituitary gland secretes growth hormone (GH), which controls bone growth. It triggers something called chondrocyte proliferation, or increase. This increases the length of long bones, such as your femur and tibia. GH also helps in retaining calcium, which increases bone hardening. It stimulates osteoblasts to make bones denser.

Anything that lowers your growth hormone secretion will make your bones weaker. Read here: How to increase your GH.

Excess body fat lowers GH secretion.

Intermittent fasting increases GH secretion. Read on this website: Various types of fastings.

An increase in insulin decreases GH.

Get adequate sleep. GH secretion is mainly secreted at night when you are sleeping.

If you eat close to bedtime, your insulin levels will stay elevated for at least 2–3 hours after eating. These levels can stay high longer if you are diabetic. This will reduce GH secretion at night. So, avoid eating 2–3 hours before sleeping.

High-intensity exercises help increase GH secretion.

Some supplements such as melatonin (for sleep), L-arginine (an amino acid, through proteins), creatine, and glutamine increase GH secretion.

It is amazing that our body is so interconnected. The things that make you unhealthy, such as disturbed sleep, obesity, and late-night meals, also make your bones unhealthy.

Thyroxine (T4)

It is a hormone secreted by the thyroid gland. It stimulates osteoblasts and the synthesis of the bone matrix.

If you have an underactive thyroid (hypothyroidism), you can get weaker bones.

Estrogen and Testosterone

These are sex hormones. They stimulate osteoblasts and the production of new bone matrix, in girls, and boys, respectively. That causes a growth spurt in adolescence.

In old age, the levels of testosterone drop in men. After menopause, the levels of estrogen drop in women.

With advancing age, bones can get weaker. Certain medications can suppress the sex hormones, leading to weaker bones.

Vitamin D

Calcitriol, the active form of vitamin D, is produced by the kidneys. It stimulates the absorption of calcium in the intestines into the blood. It also increases reabsorption of calcium in the kidneys from the urine. The production of calcitriol is regulated by blood levels of calcium and phosphorus, and a hormone called Parathyroid hormone.

If there is a deficiency of vitamin D, or calcitriol, in the blood, your bones can get weaker.

Cortisol

Cortisol is a stress hormone secreted by the adrenal gland. It inhibits osteoblast formation. It indirectly affects the bones by blocking calcium absorption in the intestines. Cortisol levels go up with stress and help in certain actions which are useful in the short term. But, if one leads a life full of stress, cortisol levels stay high for prolonged periods.

If one has high levels of stress, bones can get weaker due to lower absorption of calcium in the intestines and osteoblast inhibition.

Hormones that affect osteoclasts

Three hormones that affect the osteoclasts are calcitriol, parathyroid hormone (PTH), calcitriol, and calcitonin.

Parathyroid hormone (PTH)

PTH stimulates an increase in the number of osteoclasts and their activity. As a result, calcium is released from the bones into the blood. PTH also promotes the reabsorption of calcium by the kidneys.

The main effect of PTH is to increase the rate at which the kidneys excrete phosphate. This loss of phosphate ion causes the bone mineral, hydroxyapatite, to dissolve. The chemical formula for hydroxyapatite is Ca5(PO4)3(OH). So, after dissolving, it releases new phosphate ions in the blood. But the bone becomes weaker.

The small intestine is also affected by PTH, albeit indirectly. Because another function of PTH is to stimulate the synthesis of vitamin D, and because vitamin D promotes intestinal absorption of calcium, PTH indirectly increases calcium absorption by the small intestine.

High blood levels of calcium cause PTH release. By getting a lot of calcium in your blood, you are not going to make your bones stronger. You need just enough calcium, not more.

Vitamin D

Calcitriol, the active form of vitamin D, also stimulates the release of calcium from the bone. It makes osteoblasts release a chemical called RANKL, which in turn activates osteoclasts, which break down bone.

Vitamin D, thus, can also help in the removal of calcium from bones. Remember, this is not a one–way street, which says more vitamin D, stronger bones. Too much vitamin D and you can lose calcium from the bones.

Calcitonin

Calcitonin is a hormone secreted by the thyroid gland. It has some effects that counteract the effects of PTH. Calcitonin inhibits osteoclasts and stimulates calcium uptake by the bones, thus reducing the calcium in the blood.

HormoneRole
Growth hormoneIncreases length of long bones enhances mineralisation, and improves bone density
Thyroxine (T4)Stimulates bone growth and promotes the synthesis of bone matrix
Estrogen(In females) stimulates osteoblasts and bone production; responsible for an adolescent growth spurt
Testosterone(In males) stimulates osteoblasts and bone production; responsible for an adolescent growth spurt
CortisolInhibits osteoclast formation; blocks calcium absorption in the intestines
Vitamin DStimulates the absorption of calcium and phosphate from the digestive tract
Parathyroid hormoneStimulates osteoclasts and bone resorption; promotes reabsorption of calcium by kidneys
CalcitoninInhibits osteoclasts and stimulates calcium uptake by bones

Bone density and peak bone mass

In the bone remodeling process, we saw that the bone gets broken down and rebuilt continuously. We also learned that each bone remodeling cycle causes a net loss of bone minerals, albeit minuscule. So, how do the bones get built in the first place?

At a young age, there is a process called Bone modeling, which builds bones. This is a one–way process, that keeps on building bone, without a breakdown. As we age, this process slows down rapidly.

Thus, when we are young, two processes are going on in our bodies:

  • Bone modeling, which keeps building the bone mineral density significantly.
  • Bone remodeling, which keeps the bone density constant, or reduces it by a very, very small amount.

A combination of these two decides how strong our bones are built.

Bone modeling dominates till our late 20s, while remodeling dominates as we age. Researchers have found that the amount of resorption becomes larger than the amount of production in our mid–30s, although the difference doesn’t become significant until our 40s or 50s.

The peak bone mass period is around the age of 25. So build up your bone bank before that age is passed. After that age, we begin losing bone mass faster than we build it.

Thus, the best age to make your bones stronger is before you turn 30. This is especially true if you are a woman. After your 30s, you are essentially fighting to keep your bones as strong as they are. And often, it is a losing battle.

Here is my YouTube video explaining why the best time to build strong bones is before the age of 30, and not in the 50s when the bones become weaker:

What is the right age to start making your bones stronger? Copyright: Health Sachet

Some facts about osteoporosis

1 in 2 women and 1 in 4 men will have fractures over their lifetime due to osteoporosis, or fragile bones.

In the first 5 years after menopause, women lose 20% of their bone mass.

According to a 2011 study, women between ages 65 to 69, who broke a hip are five times more likely to die within the next year compared to their strong-hipped peers.

Summary

  • Mechanical stress stimulates the deposition of mineral salts and collagen fibers within bones.
  • Calcium, the predominant mineral in bone, cannot be absorbed from the small intestine if vitamin D is lacking.
  • Vitamin K supports bone mineralization and may have a synergistic role with vitamin D.
  • Magnesium and fluoride, as structural elements, play a supporting role in bone health.
  • Omega-3 fatty acids reduce inflammation and may promote production of new bone tissue.
  • Growth hormone increases the length of long bones, enhances mineralization, and improves bone density.
  • Thyroxine (T4) stimulates bone growth and promotes the synthesis of bone matrix.
  • The sex hormones (estrogen in women; testosterone in men) promote osteoblastic activity and the production of bone matrix, are responsible for the adolescent growth spurt.
  • Calcitriol stimulates the digestive tract to absorb calcium and phosphate.
  • Parathyroid hormone (PTH) stimulates osteoclast proliferation and resorption of bone by osteoclasts.
  • Additional functions of PTH include promoting reabsorption of calcium by kidney tubules and indirectly increasing calcium absorption from the small intestine.
  • Vitamin D plays a synergistic role with PTH in stimulating the osteoclasts.
  • Calcitonin inhibits osteoclast activity and stimulates calcium uptake by bones.

Let us look at strategies and parameters involved in getting and maintaining stronger bones.

Do specific exercises

When there is increased stress or impact on the bones, the cells that form new bones — osteoblasts — start laying more minerals in the region of stress. This will make those bones stronger.

Key characteristics of exercises that help

The University of Michigan scientists found three characteristics of exercises help in improving bone density:

Strain magnitude

Strain magnitude is just a fancy phrase for the amount of force put on bones and muscles. The more the strain, within limits, the more the bone build-up. Weight–lifting, and gymnastics fit the bill.

Strain rate

Higher the speed with which the exercise is performed, the better. Playing fast-paced games such as badminton, and activities such as plyometrics have high strain rates.

Strain frequency

How often is the impact? The more repetitive the impact, the better it is. Running repeats the strain for a long duration.

Helpful exercises

Three types of exercises fit the bill for bone health:

Impact exercises

Many activities involve getting an impact on your body. For example, running or jogging, skipping rope, aerobic dancing, plyometrics, and recreational sports such as tennis, badminton, volleyball, and cricket.

If you already have a problem with bone density, or you are vulnerable to it, avoid very high–impact activities such as skipping rope and plyometrics. You may also tone down activities that can lead to falls, such as rock climbing and trekking. Go speed–walking instead of running.

No, boxing is not a great impact exercise for other reasons.

Weight–bearing exercises

Exercises which in your bodyweight moves and lands on your skeleton will improve bone density. Many impact exercises are weight-bearing, too. Add to them a staircase–climbing, hiking, and trekking.

While swimming is a great exercise, the water reduces the weight put on your skeleton. So don’t expect swimming to build your bones. It is probably worse than even sitting, given that gravity is practically nullified when you swim.

Even though your butt may be bearing your body weight, don’t count playing video games, chess, or bridge as weight-bearing exercises.

In fact, even competitive–grade cycling is found not to help with bone density improvement. This is because cycling does not involve direct bone stress.

I believe mountain biking may be helpful, given the jerky traverse. And I wonder if commuting in cars on potholed city roads help our bones to get stronger.:-)

Yoga, a special case

Some people claim yoga helps in bone building. I personally don’t understand why it should, given its zero-impact nature. However, I don’t want to get into debates or upset anyone. So I leave that choice to you.

One possible way yoga could help bones is by calming your mind and reducing cortisol secretion. Cortisol is a stress hormone and speeds up bone breakdown. In that case, the benefit of yoga for better bones could be in stressed individuals and not on everyone.

Strength–training or resistance exercises

Do strength–training, such as lifting weights.

Prima facie, these appear to be exercises that put pressure on muscles and not bones. However, the forces of muscles pulling against bones seem to be stimulating bone growth.

The advantage of these exercises is the direct strain put on bones is little. So if one already has weak bones, these exercises may be better than impact exercises, to prevent possible fractures.

Use full body weight-bearing exercises that put pressure on the spine and hips, such as squats, lunges, deadlifts and shoulder presses.

Walking is less effective than weight training. In fact, the pecking order for bone–healthy exercises is: jumping, running, weight training, and then walking.

Leg–strengthening and balancing exercises

These exercises won’t necessarily make your bones stronger. But they will help prevent falls and thereby, fractures.

In my opinion, the extra strength of the bones is far less important than better balance and leg–strength that helps prevent stumbling.

I like these 14 exercises for seniors that help improve leg–strength, and sense of balance. They involve a few exercises that can be challenging for untrained leg muscles. If possible, have someone with you the first few times, when you perform these.

What exercises to avoid

If you have a problem of weak bones, don’t do exercises that involve too much bending of your spine. For example, standing toe-touch, or bending backwards. The pressure on the vertebrae rises too much in such exercises.

Also, avoid exercises that have high risk of falls or major impacts. For example, rock climbing and kickboxing.

How much ‘exercise load’ to use

Best exercises load bones with forces greater than normally encountered in life.

Use the concept of Minimal Essential Strain, which is about 10% of the force required to fracture the bone. This level of strain forces osteoblasts, the cells that form new bone, to travel to the site of strain and lay down new collagen. The calcium and other minerals get deposited later on that collagen, strengthening the bone.

Unfortunately, most of you don’t know the amount of force required to fracture your bones. Neither do I. And we don’t want to find that out. So let us leave out minimal essential strain calculations for ourselves. Just keep in mind that the strain needs to be above a certain minimal threshold to affect your bone density.

Unless you are training for winning an Olympics medal, here is a simple bit of advice on resistance training:

For most people, heavyweights and low repetitions are found to be equally effective to light weights and many repetitions. The only requirement is to do repetitions until failure – until you cannot do a repetition at all, while maintaining a proper form.

Single rep max or one-rep max, 1RM, is the maximum amount of weight with which you can do one repetition in a lifting exercise. This weight is so high that you can barely do one repetition on that exercise, such as a squat or a bench press.

It has been found that you can do more repetitions, with lesser weights. And they are all equivalent for muscle growth, and perhaps for bone health:

  • 90% of 1RM with 3 — 4 repetitions
  • 80% of 1RM with 7 — 8 repetitions
  • 70% of 1RM with 10 — 12 repetitions
  • 60% of 1RM with 15 — 18 repetitions

As you age, not injuring yourself becomes more important than getting that six-pack abdomen. So, avoid muscle tears and ligament pulls that can come with weight training.

My advice is to go for 60% of single rep max and do 15 to 18 repetitions, instead of heaving heavy weights and trying to match teenage bodybuilders. Your bones will also thank you for that.

How much time to exercise

Standard exercise recommendation for overall health purposes is 150 minutes a week. A norm is 30 minutes for any 5 days a week.

However, for bone health, even 12 to 20 minutes of weight bearing exercises, thrice a week seemed to help.

Perform weight-bearing, impact exercises for 20 minutes thrice a week.

Add a day or two a week of strength training. Do squats, lunges, shoulder presses, and other standard lifting exercises with 60% of 1RM, 15 repetitions.

Don’t be paranoid about the number of sets, and duration of rest in between. Use common sense. Prevent falls and injury. Err on the side of caution. Don’t do sharp forward or backward ending exercises.

Calcium

People think of our body as some kind of a box — the more you put into it, the more it will have. True, only partially.

Our body is a very efficient machine, with many negative feedback mechanisms that regulate its calcium intake. While you can control how much calcium you can put inside your mouth, the body decides how much of it to absorb.

As per the Food and Nutrition Board, Institute of Medicine, USA, the absorption rate keeps changing with age. In the case of growing children, as well as in pregnant ladies, the body absorbs 60% of the calcium it consumes. In normal adults, the absorption levels drop down to 15–20%.

Bioavailability

Calcium is found in dairy products, oranges, figs, broccoli, and collard greens.

One challenge is the bioavailability of calcium from various sources. Not all calcium in

High calcium food but not more than 500 mg at a time

Calcium absorption pathways are saturable and non–saturable. If you take too much calcium at the same time, the body will not absorb it.

Types of calcium compounds

If you take a calcium supplement, it will contain calcium as a chemical compound. Depending on that compound, there will be merits and demerits of that supplement. Here is a ready reckoner:

Avoid calcium gluconate and calcium lactate. They contain very little elemental calcium.

Take coral calcium or oyster–shell calcium only if the source is of good quality. Cheap sources may have lead contamination.

Calcium Type Pros     Cons
Calcium citrate
21% calcium
Most easily absorbedMost expensive;
doesn’t contain much elemental calcium
Calcium carbonate
40% calcium 
Least expensive;
has more elemental calcium
Must be taken with meals or glass of any acidic juice;
may cause gas or constipation
Calcium phosphate
39% calcium 
Does not cause gas or constipation;
easily absorbed
More expensive than calcium carbonate

Eat vegetables

Vegetable intake is found to help in bone health for 3 reasons.:

Vegetables are a great source of vitamin C, which is known to stimulate osteoblasts, the cells that build new bone. Some studies observe that vitamin C also slows down the activity of osteoclasts, the cells that break down bone.

Some vegetables are great sources of calcium, a mineral that helps in strengthening the bone.

Finally, many vegetables contain certain types of phytonutrients, or plant-based nutrient compounds, called polyphenols, which are found to help in strengthening and maintaining bones.

Protein

Consume dairy products. Drink 2-3 glasses of milk a day or equivalent. Here is a way to calculate your daily calcium consumption.

Vitamin D

The body needs vitamin D to absorb calcium.

Vitamin D has various forms. It has an active form called Calcitriol, which is formed by the kidneys. Calcitriol is needed for the absorption of calcium from food in your intestines.

In certain conditions, such as damaged kidneys or vitamin D deficiency, the body does not make enough calcitriol. If sufficient calcitriol is not present, your body will not absorb the calcium from the food. This will happen even if you eat a lot of calcium-rich foods. In such situations, your body will pull calcium out of the bones for essential needs. This leads to weaker bones.

This calcium—vitamin D interaction is important to understand, especially, in medical conditions such as osteoporosis (brittle bones), osteomalacia (softening of bones), kidney disease (kidneys make calcitriol), and hyperparathyroidism (parathyroid hormone causes bones to release calcium into the blood).

Vitamin D comes in egg yolks, and fish such as salmon and tuna. Many developed countries have vitamin D–fortified beverages such as milk, soy milk, and orange juice.

Different foods contain calcium and vitamin D. There are very few common food sources of the two.

Both food sources don’t need to be eaten together.

If you are taking a calcium supplement, ensure it also has vitamin D.

Vitamin K

Vitamin K is actually a bunch of vitamins, similar in chemical structure. It was discovered initially as a compound that helps in blood clotting, or coagulation. “To Coagulate” in German is “Koagulieren”. Hence, the name vitamin K.

There are two vitamin K forms, Phylloquinone and Menaquinone.

I know you cannot remember such long names. So they have been very creatively named, vitamin K1 and vitamin K2, respectively.

Vitamin K1, or phylloquinone, as the name suggests (phyllo–), is derived from green leafy plants, such as spinach, broccoli, kale, and collard greens.

Vitamin K2, on the other hand, comes from fermented foods and animal sources, such as pork, cheese, and chicken. Animals as well as your gut bacteria can convert some vitamin K1 to vitamin K2.

Just when you thought things are getting easy, they found out there are many subtypes of vitamin K2, depending on something called, the length of its side chain. They are numbered from MK–4 to MK–15. And different food items contain different combinations of these. Studies on ongoing about which of these help for bones, and how.

It is found that the absorption of vitamin K1, obtained from plants, is only about 10% of the eaten quantity. Vitamin K2, on the other hand, is absorbed to much higher levels.

Vitamin K studies on bone health

The reason to get into depth about vitamin K1 and K2 is that, largely, vitamin K1 is not useful for getting stronger bones, and vitamin K2 is.

Vitamin K helps in the deposition of calcium in bones (making them stronger). Simultaneously, it prevents the deposition of calcium in blood arteries and kidneys.

Read for an in-depth reasoning article on this subject: Interpreting the evidence and results of nutrient trials.

Some observational studies have shown the benefit of vitamins K1 and K2 on bone health. Some other studies have shown no benefit of vitamin K1 for bones.

One review study showed MK–4, a type of vitamin K2, reduced the risk of bone fractures. Some other studies showed no difference from vitamin K usage.

Calcium supplementation is claimed to cause the hardening of arteries by calcium deposition in them. One study showed that vitamin K1 did help in that, while vitamin K2 (MK–4, specifically) helped in preventing calcium deposition in the arteries in animals. This should be logical because vitamin K2 activates something called matrix GLA protein (MGP), which reduces calcium deposits in the walls of the arteries.

Why vitamin K2 is better than K1?

Vitamin K is a fat-soluble vitamin. And we know that fat-soluble vitamins are better absorbed in the presence of some dietary fats. Either, vitamin K2 is getting the benefit of higher fat contents that animal products typically have, or there is something that we do not know.

Also, vitamin K1 stays in our blood for a few hours, while vitamin K2 stays for days. Some experts say it is because vitamin K2 has long side chains. They say that since vitamin K2 is in the blood for much longer than vitamin K1, it gets more time to be utilised by the body.

Finally, some experts say that since vitamin K1 is mainly used in the liver, it is less effective.

Hence, vitamin K2 is more effective than vitamin K1.

Vitamin K action on bone health

Once again, as with nutrient trials, the study results are all over the place. As I have mentioned in many articles, the best solution is to look at what those nutrients do in your body, rather than what nutrient effects a trial sees. This is because in different people, other nutrients may mask the effect of that specific nutrient you are studying.

Vitamin K2 supports bone health by modifying osteocalcin, a protein involved in bone formation. This modification enables osteocalcin to bind to minerals in bones and helps prevent the loss of calcium from bones.

Read here for: Vitamin K2 as the promoter of bone health.

For medical professionals

Vitamin K is essential for the production of various proteins of the Gla–protein family.

Out of the 17 members of this family found so far, here are some:
Four different blood coagulation factors, II, VII, IX, and X, are used for blood clotting (need vitamin K1 and K2)
Osteocalcin, a protein used in bone formation (needs vitamin K2)
Matrix GLA–protein (MGP), which prevents the deposition of calcium (calcification) in arterial walls (needs vitamin K2)
Growth arrest-specific 6 (Gas6), involved in cell growth and proliferation (needs vitamins K1 and K2).

As per Dr. Bruce Ames’ Triage theory, when the body becomes deficient in vitamin K, it will continue with immediate, life–saving need of vitamin K, which is making of the blood coagulation factors. The body will postpone the need for the production of osteocalcin, MGP, and Gas6.

Thus, in my view, a person who is deficient in vitamin K will not find much benefit for blood clotting on supplementation; while finding a very significant benefit for bone health. On the other hand, a person who is not deficient in vitamin K will not benefit much from extra vitamin K for bone health.

As we can read above, vitamin K1 is needed for blood clotting; while vitamin K2 is needed for bone health and preventing arterial calcification. So, my view is, vitamin K2, the animal– and fermented products–based vitamin K, will be very useful for bone health.

Read more: Vitamin K: the effect on health beyond coagulation.

Based on the above arguments, vitamin K2 will be useful for bone health in people with a deficient intake of vitamin K2. However, people with normal levels of vitamin K2 may not benefit more from getting stronger bones.

Vitamins K1 and K2 do seem to cause any harm in higher doses. So, supplementation with vitamin K should be safe.

Avoid low calorie meals

Maintain stable weight

Bone health in overweight people

The connection of obesity with bone health is not clear yet. The evidence is confusing at best.

Some studies show that obesity leads to poor bone health. It leads to higher fracture rates due to the stress of excess weight.

However, it is not clear why that should be. More weight should actually act as a stressor to improve bone quality.

Obese people have low blood levels of vitamin D since some of it is forced into fat cells. This may be leading to poor absorption of calcium.

One possible hypothesis is that obesity affects many hormones in our body, which also regulate bone density.

Obesity is an inflammatory disease. Higher levels of inflammation in the body may be leading to more bone loss.

Bone health in underweight people

On the other hand, being underweight is also found to lead to poor bone quality.

Perhaps, one needs to see why someone is underweight. Perhaps, there is an underlying medical reason, causing the underweight status. And that may be leading to low bone density.

Collagen supplement

Collagen is nearly half the volume of your bones. So it may not be surprising if you somehow ingest collagen, your bones would get stronger. However, is there any evidence for that?

The most common collagen product we consume is gelatin. Hydrolysed pharmaceutical-grade gelatin gives you collagen hydrolysate, which is a nutraceutical supplement.

Research is scanty in this subject but a few studies have shown benefit. One study showed the benefit for bone health, of taking such a product along with calcitonin, instead of calcitonin alone. Calcitonin is a hormone normally produced by your thyroid glands that helps reduce blood calcium levels. It does this by reducing the activity of osteoclasts, the cells that break down bone. So calcitonin helps have stronger bones.

So what is the verdict? Can you eat candies, gummies, chocolates, ice–creams, marshmallows, puddings, and cakes, to get more gelatin? I don’t know.

I am telling you this about gelatin to point out that the scientific world is still learning about the complex world of our bones and there are no one-line solutions. Also, it has been found that gelatin and collagen supplements have a very high level of safety. So there is no harm in using them.

It has been found that collagen supplements help in osteoarthritis. And, since the collagen you consume does not know whether it has to fix your joints or your bones, there is no harm in considering it for bones. If nothing else, they will help your joints.

Consider collagen supplements for bone health. But don’t rely on them as your exclusive solution, as the research conclusions are scanty.

Magnesium and zinc

Magnesium

Calcium and magnesium have many important functions in the body individually. However, they work jointly to perform many tasks such as:

  • Contraction and relaxation of muscles
  • Contraction and relaxation of blood capillaries
  • Maintenance of cell membranes
  • Building strong bones and teeth

Thus, having one in sufficient quantity, and the other in inadequate amount, makes them incapable of performing the above duties. In fact, deficiency of magnesium, with adequate calcium intake is a recipe for heart disease and kidney stones. Read: Too little magnesium can affect heart health.

Also, it appears that the ratio of calcium to magnesium is important. A ratio of 2 parts calcium to 1 part magnesium by weight looks reasonable.

Good sources of calcium are dairy products, figs, oranges, broccoli, and collard greens. Good sources of magnesium are green leafy vegetables such as spinach and kale, legumes such as chickpeas, kidney beans, and black beans, fruits such as bananas, figs, and raspberries, vegetables such as broccoli, green beans, asparagus, brussels sprouts, peas, and cabbage, fish such as salmon, mackerel, and tuna, nuts and seeds.

Note that while you need more than 1000 mg of calcium a day, your body cannot absorb more than 500 mg of calcium at any given time. So it is best to split the daily calcium intake over 3 to 4 rounds consumption.

Interestingly, if you take calcium or magnesium in quantities of more than 250 mg at a time, they compete with each other in the intestines for absorption. So it is good to stagger calcium and magnesium intake more than one hour apart.

Take adequate quantities of calcium and magnesium.

They need not be taken together. But if you do, don’t take more than 250 mg at a time of either.

If you are taking a calcium supplement (with vitamin D), make sure you also take magnesium in the ratio of about 2 parts calcium: 1 part magnesium. The same supplement need not have magnesium; you can take two separate ones.

Don’t take calcium more than 500 mg at a time in food or supplement form. Stagger the calcium consumption throughout the day.

250 mg calcium at a time is even more preferred, if you are going to also take magnesium with it, either in food or through a supplement.

Omega-3 fish oils

For Medical Professionals

Omega–3 fatty acids can improve bone strength through many mechanisms:
Effect on calcium balance in the body;
Increasing the production and activation of osteoblasts, the cells that produce new bone;
Change in membrane function;
Reduction in chemicals called cytokines, such as IL–1, IL–6, TNF–alpha, which help in bone–breakdown process;
Modulation of PPAR-gamma.

One of the biggest challenges in space science is weightlessness. Due to microgravity, astronauts start losing bone density and end up with fragile bones.

The National Aeronautics and Space Administration (N.A.S.A.) sponsored many studies to see if omega–3 fatty acids can prevent bone loss. They found that omega–3 fatty acids stop the activation of a chemical called NFkB, which leads to bone and muscle loss. Astronauts who ate fish during 4—6 months of space stay lost lesser bone mass.

Consider family history

75% of your bone structure is genetically determined. So if you have a family history of weak bones, you have a higher chance of getting the same.

There is a family history of weak bones in nearly 20% of osteoporotic women. They found if a woman has one first–relative (parents, or siblings) or grandparent who had osteoporosis, the risk (odds ratio) of her getting osteoporosis is 2.35 times. If more than one such family member has osteoporosis, the risk rises to 8.5 times.

Thus, family history has a very large and independent role in osteoporosis or fragile bones. While you cannot change your family history, you can be better prepared.

Consider country of origin, or ethnicity

Your ethnicity or country of origin may also decide your bone health. For example, Asians have lower bone density than Caucasians, and so can get more fractures. African–American women have a higher bone density than both of them. Their chances of getting hip fractures are half those of the former two groups.

You can use this University of Sheffield’s FRAX tool to get the 10–year probability of getting a hip or other osteoporotic fracture. Select the country of your origin and give basic information. If you do not have your bone mass density data, leave the column blank.

Reduce coffee intake?

Many articles suggest one should reduce coffee intake to a maximum of 2 cups a day. However, I found no direct evidence of it in any research paper.

Epidemiological studies show a relation between coffee consumption and poor bone health. But these are observational studies, not cause and effect studies. People who drink a lot of coffee might be drinking very little milk, which can give calcium.

Physiological studies, which checked the direct effect, found a very little negative effect on bone health. It also found no effect on urinary calcium excretion, which is supposed to be increased with caffeine consumption.

It seems that if you lose more calcium from the urine, your body will get more of it from food sources. So if you are not taking enough calcium in your diet, then it is OK to worry about coffee consumption. Else, don’t bother. Of course, most people are not getting enough calcium, as per International Osteoporosis Foundation.

Cleveland Clinic is honest enough to admit that findings are too conflicting to give an opinion. For example, black tea, which contains caffeine, does not affect bone density.

I don’t know either. But I will sound erudite and advise: “Drink coffee in moderation”. This is always a bit of fail-safe advice, which typically means, “I don’t know”.

Actually, one research paper showed that those who already had osteoporosis problems lost bone density on coffee drinking.

So, it seems that coffee consumption hurts those who are already having bone density loss, while people who are normal are somehow not affected much by coffee drinking. So till we know more, do this:

If you have normal bones (you checked your bone mass density), have normal calcium consumption through diet and supplementation, and are not in some risk category (genetics or post-menopausal), don’t worry about caffeine.

Else, restrict it to two cups of coffee a day, maximum.

Reduce soft drinks?

There are two claims about soft drinks and bones:
The phosphoric acid in them leaches calcium from bones
The caffeine in them excretes calcium through the kidneys

Does phosphoric acid leach calcium from the bones?

Prima facie, this looks obvious. Acid phosphatase is needed for osteoclasts to remove bone minerals when the bone is broken down. Soft drinks that contain phosphoric acid will create an environment of acid phosphatase. Well, at least, the words sound similar.

Soft drinks that contain cola, such as Coca-Cola, have phosphoric acid. And the soft drinks that don’t contain colas, such as ginger ale and lemon-based soft drinks, don’t have phosphoric acid.

The evidence is interesting. Cola soft drinks show a reduction in bone density. Non–cola soft drinks don’t show a reduction in bone density. Convincing?

Well, even your chicken and cheese contain phosphoric acid. Should you stop them? I have no idea.

And, bone density in men is not affected by any of these phosphoric acid devils, while it is affected in women.

Since we don’t see any great wisdom from these results, I will give the least common denominator advice:

If you are vulnerable to bone density loss: stay away from cola–based soft drinks.

If you are vulnerable to bone density loss: non–cola-based soft drinks seem to be fine.

For everyone: since soft drinks are unhealthy in general, why not stay away from them, irrespective of their effect on your bones

Does caffeine from soft drinks excrete calcium from urine?

Well, you can read the whole discussion about drinking coffee and bone density. It shows that caffeine, per se, does not seem to affect much. So it seems that the bad effect of the cola–based soft drinks is mainly due to the phosphoric acid in them. So, I will stick to the same advice, as above:

If you are vulnerable, stay away.

If you are not vulnerable, consider staying away.

Reduce smoking

Why would smoking hamper bone density? Is there some scientific basis, or is it just a ‘catch-all, good–for–everyone’ advice? Here are some reasons:

  • Smoking reduces blood supply all over the body, including the bones.
  • Smoking reduces the activity of osteoblasts, the cells that form new bone.
  • Smoking reduces the absorption of calcium in the intestines.
  • Smoking causes quicker breakdown of estrogen. Estrogen levels are important in women, as well as men, for building and maintaining strong bones.

Reduce alcohol intake

Alcohol consumption affects bone density in several ways. Here are some of them:

  • If you drink a lot of alcohol, more than a couple of drinks, calcium absorption in the intestines reduces.
  • Alcohol also affects the blood balance of calcium.
  • Liver activates vitamin D, which is important for the absorption of calcium. Alcohol affects the liver.
  • Men who drink excessive alcohol produce less testosterone. Testosterone stimulates osteoblasts, the cells that form new bone.
  • Women who drink excessive alcohol develop irregular menstrual cycles. This reduces their blood estrogen levels. Estrogen levels are important for building and maintaining strong bones.
  • People who drink excess alcohol have elevated levels of stress hormone, cortisol. Cortisol reduces formation of new bone and increases breakdown of existing bone mass.
  • Alcohol consumption increases para–thyroid hormone (PTH) secretion. As we have seen above, PTH pulls calcium from the bone, weakening it.
  • Finally, there is a trivial argument about drinking: you are more likely to lose balance, and fall, increasing your chances of a fracture.

Interestingly, most bone density damage due to excessive alcohol drinking is reversible, once you stop drinking.

Stay to less than 2 alcoholic drinks a day, if you are normal.

Consider stopping all alcohol consumption, if you are vulnerable, or trying to improve your bone density.

Reduce salt intake?

Logically, how should salt intake be linked to bone density?

Salt is NaCl, sodium chloride. In your body, it breaks down into ions: The chloride component is acidic and the sodium component is alkaline.

When the body gets excess salt, it tries to eliminate both of these components. Removing chloride is harder than removing sodium. And, so the acidic component in the body starts increasing.

To maintain proper balance and pH in the blood, the body starts pulling alkaline matter from the bones, which is calcium. So the bones start losing calcium, reducing the bone density.

Here are many findings about salt intake and its effect on bone density, all in menopausal women:

Now what? No idea. So here is a wimpy advice:

Why don’t you watch your salt intake for other reasons, such as heart health?

Check your medicines

There are many medicines or drugs, that can cause a loss in bone density. Of course, the right way to approach is not to avoid those medicines, if your doctor has prescribed them. continue with them. Just go the extra mile to ensure that your bones stay strong. Follow the strategies listed above more diligently.

Here are the medications that can cause bone density problems:

Corticosteroids or glucocorticoids

These are the most commonly discussed problem medicines for bone weakening.

Our body makes these steroids naturally, in response to injury, infection, or inflammation. For example, cortisol is secreted in injury situations, where the old micro–damaged bone is broken down to make way for new bone formation.

Synthetic steroids (not to be confused with anabolic steroids, taken by bodybuilders, though they act in a similar manner) are used for similar purposes. Examples are prednisone and dexamethasone. Some uses are:

  • Asthma and COPD (chronic obstructive pulmonary disease)
  • Inflammatory joint conditions such as rheumatoid arthritis and lupus
  • Psoriasis and other skin disease
  • Inflammatory bowel disease

If you notice, the last 3 are diseases that belong to a category called autoimmune conditions. They are characterised by very high inflammation, and glucocorticoids are prescribed for reducing that.

Since these conditions are chronic, steroid use is for a prolonged period, which is a problem. The bones start to weaken within the first 12 weeks of usage itself. The weakening continues as long as the steroids are used.

Postmenopausal women and men above 50 years of age are at a greater risk of bone fractures on using these steroids.

Consider using less than 5 mg a day, if possible.

Acidity or heartburn medicines

Many acidity medicines involve aluminum-containing antacids, or a special class of medicines called proton pump inhibitors (PPIs). They reduce the generation of stomach acid. That reduces the absorption of calcium in the digestive tract. After several years of use of such medicines, the risk of fractures is found to increase.

Doctors advise the use of medicines called Histamine H2–receptor blockers, or H2–blockers, instead of PPIs, in such cases. They also reduce acid secretion but their action is more in the evening, which helps nighttime acidity issues that arise when people are lying down. H2–blockers are less strong than the PPIs. Discuss with your doctor before you do anything.

In Indian herbal medicine, aloe vera juice is found to be excellent for reducing stomach acidity. There are no studies that have checked the use of aloe vera juice with bone health. Logically, I do not see why it would affect bone health. But frankly, I don’t know. So read up more and discuss about aloe vera with your doctor as an alternative for acidity medicines.

Finally, remember that stomach acid is there for a reason. It is your body’s first defense against foodborne bacteria and other dangers. Suppressing acid production is like giving free entry to many of these invaders. You are compromising long–term safety of your body by taking acidity medicines, which suppress stomach acid production. Figure out alternative ways to curb acidity.

Blood pressure lowering medicines

Medicines used to treat hypertension, or high BP can lead to falls in the first few weeks of starting them. This is possibly due to an excessive drop in blood pressure, causing fainting episodes. Nothing to do with the loss of bone density, though.

Diuretics

Diuretics are used to remove excess water from the body, through urine. They help in high blood pressure, as well as kidney and liver disease.

One category of diuretics, called loop diuretics (furosemide or Lasix™), increases the loss of calcium through water excretion in urine.

Interestingly, another category of diuretics, called thiazide diuretics, increases water excretion in urine but reduces calcium loss. Talk to your doctor if you should switch to them.

Excessive thyroid medicine

People who have underactive thyroid are given thyroid medicines. Normal blood levels of thyroid hormones maintain bone density well.

As age increases, the requirement for thyroid medicine goes down. So the thyroid dose needs to be adjusted properly. Only your doctor can do that. If for some reason, your thyroid dose is higher than required, it increases the activity of osteoclasts, the cells that cause a bone breakdown.

Incidentally, taking thyroid medications along with food, calcium, or iron supplements reduces the absorption of the thyroid hormone. So follow your doctor’s advice strictly.

Blood thinners

Some medicines are given for reducing the risk of blood clots or stroke. Some of them interfere with calcium absorption. Long–term use of them can lead to weak bones.

As discussed above, Vitamin K is useful in bone strengthening. Some blood thinners, such as warfarin, affect vitamin K metabolism. This can lead to bone loss and fracture.

Diabetes medicines

Some diabetes medicines increase the risk of fractures.

A commonly used class of diabetes medicines called Thiazolidinediones (TZD) encourages the formation of fat cells in lieu of osteoblasts, the cells that build bones.

Another class of diabetes medicines called Sodium-glucose co-transporter–2 (SGLT–2) inhibitors reduce hip bone density.

Talk to your doctor, if you are concerned.

If you want a detailed explanation, read: Medications that can be bad for your bones.

Anti–convulsive drugs

These medicines are given for seizures or epilepsy. They interfere with vitamin D metabolism in the liver and can lower its levels. Since vitamin D helps calcium absorption, these medicines can lead to bone weakening.

Anti-depressives and mood altering medicines

Some of these are given to combat depression. Some help with sleep problems and others are antipsychotics.

All of them act on the central nervous system. These can cause confusion, drowsiness, low blood pressure, and a drop in muscle tone. A fall, and concomitant fractures, can happen. The biggest risk is in the first few weeks of starting or stopping these medicines.

A class of anti-depressive medicines called SSRI (selective serotonin reuptake inhibitors) increases bone loss in women and is associated with lower bone density in men and children. Discuss with your doctor if you could, instead, take another class of medicines called SNRI (serotonin and norepinephrine reuptake inhibitors).

Breast cancer medicines

These are medicines called aromatase inhibitors. They stop estrogen production, causing very low levels of estrogen in the body to protect against cancer. However, those levels increase the bone breakdown and decrease bone rebuilding.

Be watchful for the fractures of the wrist (Colles’ fracture) and spine.

While you cannot do anything to your cancer medicines, it is good to know that you are getting bone damage. You can adopt many of the strategies discussed in this article to increase bone density.

Injectible contraceptives

These are also female hormone-altering injections. They come with various ingredients. The altered female hormones increase the activity of osteoclasts, the cells that break down bones.

Prostate cancer medicines

Many prostate cancer medicines suppress testosterone production. This can decrease bone formation.

With many medications, you can not change anything. You have to take them. So,:

Be aware.

Discuss with your doctor, if some alternatives are available.

Take extra care to avoid fractures.

Employ many other strategies discussed above.

In conclusion

Consume dairy products.

Get sunlight or Vitamin D supplements.

Do strength training.

Eliminate salt, alcohol, caffeine, soft drinks, and cigarettes.

Check your medications.

First published on: 13th September 2016
Image credit: Chris J Mitchell from Pexels
Last Updated on: 21st December 2021

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