Understand osteoporosis
Osteoporosis is a condition characterised by weakened bones, which become fragile and more susceptible to fractures. It occurs when the body loses bone and/or makes too little bone. This imbalance leads to a decrease in bone density and strength. Osteoporosis commonly affects the spine, hips, and wrists, although fractures can occur in any bone (1).
Several factors can contribute to the development of osteoporosis, including age, gender (cis women are at higher risk, especially after menopause), genetics, hormonal changes, certain medications, low calcium or vitamin D intake, sedentary lifestyle, smoking, excessive alcohol consumption, and certain medical conditions (2).
The impact of osteoporosis on individuals can be significant. Fractures resulting from weakened bones can lead to chronic pain, reduced mobility, disability, loss of independence, and even mortality, particularly in older adults (2). Hip fractures can have severe consequences, including increased risk of disability and earlier death.
In the UK, osteoporosis is a prevalent condition, particularly among older adults and postmenopausal women*. According to the National Osteoporosis Society, around 3 million people in the UK are estimated to have osteoporosis, and over 500,000 fractures occur annually as a result of the condition (3). These fractures place a considerable burden on healthcare systems and individuals alike, highlighting the importance of prevention, early detection, and management of osteoporosis.
How does osteoporosis work?
Bones are living tissues that are constantly being broken down and rebuilt in a process called remodelling. This remodelling process involves two types of cells: osteoclasts and osteoblasts. Osteoclasts are cells responsible for breaking down old or damaged bone tissue (2). They secrete enzymes and acids that dissolve the bone matrix, releasing minerals such as calcium and phosphorus into the bloodstream. Osteoblasts, on the contrary, are cells that are responsible for building new bone tissue. They produce collagen and other proteins that form the bone matrix and help to keep it mineralised (4).
Bone remodelling is a balanced process, with the activities of osteoclasts and osteoblasts coordinated to maintain bone strength and integrity. However, in osteoporosis, this balance is disrupted, leading to more bone being broken down than rebuilt, or not enough bone being produced (4). Over time, this imbalance between bone resorption and formation results in a decrease in bone density and deterioration of bone microarchitecture, including thinning of trabeculae (the lattice-like structure within bone) and increased bone porosity. These changes further weaken bone strength and increase the risk of fracture.
Hormonal changes play a role in the development of osteoporosis, as decreased oestrogen levels after the menopause and decreased testosterone levels in men can accelerate bone loss (2).
Understanding the root causes
Osteoporosis is a multifactorial condition influenced by both intrinsic (related to individual characteristics) and extrinsic (related to lifestyle and environmental factors). Primary osteoporosis is osteoporosis that occurs as a result of increased age or hormonal, and secondary osteoporosis happens when it is caused by genetics, lifestyle, medical conditions or medications (2).
These are some of the primary causes and exacerbating factors of osteoporosis (2):
- Age: Ageing is a significant risk factor for osteoporosis. As people get older, bone density naturally decreases, and bone remodelling becomes less efficient, leading to bone loss.
- Hormonal changes: Hormonal imbalances play a crucial role in osteoporosis development. In women, decreased oestrogen levels after menopause contribute to accelerated bone loss. Similarly, in men, decreased testosterone levels can lead to bone loss. Thyroid hormones and adrenal hormones also influence bone metabolism (5).
- Genetics: Genetic factors can influence bone density and the risk of osteoporosis. A family history of osteoporosis or fractures may increase an individual’s susceptibility to the condition.
- Nutrition: Inadequate intake of calcium and vitamin D can impair bone health and increase the risk of osteoporosis. Calcium is essential for bone mineralisation, while vitamin D helps the body absorb calcium.
- Lack of physical activity: Weight-bearing exercises help maintain bone density, and a sedentary lifestyle can contribute to bone loss.
- Smoking: Smoking is associated with decreased bone density and impaired bone healing, increasing the risk of fractures.
- Excessive alcohol consumption: Chronic alcohol abuse can interfere with calcium absorption and reduce bone density.
- Medical conditions: Certain medical conditions can increase the risk of osteoporosis, including:
- Endocrine disorders (e.g., hyperthyroidism, Cushing’s syndrome)
- Gastrointestinal disorders (e.g., celiac disease, inflammatory bowel disease)
- Rheumatologic conditions (e.g., rheumatoid arthritis)
- Chronic kidney disease
- Medications: Long-term use of medications such as glucocorticoids (steroids), anticonvulsants, proton pump inhibitors (e.g. omeprazole), and certain cancer treatments can increase the risk of developing osteoporosis.
- Other risk factors: Other factors that may contribute to osteoporosis include low body weight or body mass index (BMI), previous fractures, and ethnicity (Caucasians and Asians are at higher risk).
Signs and symptoms
Osteoporosis is often referred to as a “silent disease” because it typically progresses without symptoms until a fracture occurs (6). It is important to note that not everyone with osteoporosis will experience symptoms, particularly in the early stages of the disease. Regular bone density screenings and assessments can help identify osteoporosis before fractures occur, allowing for early intervention and treatment to prevent further bone loss and reduce fracture risk.
The most common signs and symptoms are bone fractures (often repeated fractures), back pain, and loss of height. Fragility fractures are the hallmark of osteoporosis (1). These fractures can occur with minimal trauma or even from routine activities like bending or coughing. Common fracture sites include the spine (vertebral compression fractures), hips, wrists, and ribs. Back pain can also be a common symptom of osteoporosis. Compression fractures of the vertebrae can cause back pain, which may be sudden or develop gradually (1). This pain can range from mild to severe and may worsen with movement or prolonged standing. Loss of height can also happen as a result of vertebral compression fractures that can lead to a gradual loss of height over time. Multiple fractures can result in a noticeable decrease in stature. Vertebral fractures can also cause changes in spinal alignment, leading to a stooped or hunched posture, known as kyphosis or dowager’s hump (1).
Severe osteoporosis can lead to bone deformities, particularly in the spine and hips, dental problems like loose teeth, gum recession, and difficulty fitting dentures, as well as decreased grip strength that happens because of reduced bone density and muscle weakness.
Herbal solutions
The main herbal strategies to minimise the risk of developing osteoporosis and prevent bone loss are:
- Use of phytoestrogens or herbs with oestrogen-balancing properties
- Bone strengthening and bone promoting medicinal mushrooms
- Medicinal plants that improve bone mineralisation
Medicinal plants that have oestrogen-balancing properties and have been shown to prevent bone loss in postmenopausal people include red clover (Trifolium pratense), black cohosh (Cimicifuga racemosa) and soy (Glycine max).Â
Red clover contains compounds called isoflavones, such as genistein and daidzein, which have oestrogen-like effects in the body. Some studies suggest that red clover may help reduce bone loss in postmenopausal women and improve bone density (7).
Black cohosh is another herb rich in isoflavones, which may have oestrogenic effects. While research on black cohosh for osteoporosis is limited, some in vivo studies suggest it may help prevent bone loss in postmenopausal women as well contribute to fracture healing (8). There are sustainability issues with this plant due to overharvesting so be sure to source from a farm and not wild harvested sources.Â
Soy products also contain oestrogen-balancing isoflavones, particularly genistein and daidzein, and have the potential to help preserve bone density (9). Soy isoflavones seem to help modulate bone remodelling (10). Some observational studies also suggest that regular consumption of soy products is associated with improved bone health (11).
Red sage or danshen (Salvia miltiorrhiza) is a medicinal plant used in traditional Chinese medicine that has been associated with improvement in osteoporosis (12). Red sage contains salvianolic acid, tanshinones, and magnesium lithospermate B, and these are constituents that can help bone growth and improve bone health (12). Salvianolic acids have antioxidant properties that can prevent inflammation as well as free radical production associated with the breakdown of bone (13). Red sage is also a good source of vitamin K, which is needed for bone metabolism (14). A review of 36 clinical trials found that red sage improved osteoporotic changes in more than 80% of the cases studied (12). Even if most of these studies were short-term and small in size, these findings are still relevant. It is important to note that red sage is contraindicated in pregnancy and careful monitoring is needed when used concomitantly with blood thinners (15).
Horsetail (Equisetum arvense) has been traditionally used to improve bone help. Horsetail is particularly rich in silica, a mineral that is essential for healthy bone. Silica is a component of collagen, which is a protein that provides structure to bones. Silica intake can support bone density and strength, potentially helping to prevent bone loss associated with osteoporosis (16). Although the use of horsetail in osteoporosis is mainly supported by traditional use, one study including 122 women showed that the groups taking horsetail experienced improved bone density compared to the group who took calcium (16). One case report associated long-term use of horsetail tincture with vitamin B1 deficiency, so this should be taken into consideration when taking horsetail for a long time (17).
Medicinal mushrooms also have a role in strengthening bone. Reishi (Ganoderma lucidum) contains triterpenoids and polysaccharides, which have been studied for their potential bone-strengthening effects (18). Animal studies suggest that Reishi mushroom extract can help improve bone density and prevent bone loss (18, 19). Likewise, Lion’s Mane (Hericium erinaceus) diterpenoids, erinacines and hericenones, may have neuroprotective and bone-strengthening effects. Some animal studies suggest that lion’s mane mushroom extract may help improve bone density by inhibiting bone destruction (20).
Holistic solutions
Managing osteoporosis involves a combination of nutritional strategies and lifestyle changes aimed at reducing bone loss, improving bone density, and preventing fractures (1).
Keeping a diet rich in calcium containing foods is advisable. Examples of these are â dairy products, leafy green vegetables, tofu and almonds. Adequate vitamin D is necessary for calcium absorption and bone health. Foods rich in vitamin D include fatty fish (such as salmon and mackerel) and egg yolks (21). Protein is also essential for bone health and muscle strength, so it is advisable to include sources of lean protein, such as poultry, fish, beans, lentils, and nuts. High sodium intake can increase calcium excretion and bone loss (22). Similarly, excessive caffeine consumption may interfere with calcium absorption (1). So, keeping a diet low in sodium and low in caffeine is recommended.
There are systematic reviews that support supplementation with a combination of calcium and vitamin D to reduce primary fracture risk and slow age-related declines in bone mineral density. The average overall fracture risk reduction is between 10 and 30% when compared to placebo (23). These positive outcomes when taking supplementation are more prominent in people with osteoporosis, people with already low calcium or vitamin D levels, women taking hormone replacement therapy and older people. Overall fracture risk reduction is in the order of 10â20% (compared to placebo) (23).
Recent meta-analysis and systematic reviews conclude that supplementing with both calcium and vitamin D is a more promising strategy to reduce risk of bone fracture than vitamin D alone (24). When supplementing with calcium it is important to highlight that the absorption of calcium citrate is significantly better than that of calcium carbonate (25). Calcium supplementation is, however, contraindicated in hyperparathyroidism, sarcoidosis, renal impairment and calcium kidney stones (26).
The Framingham Osteoporosis Study found a protective role of carotenoids in bone mineral density. There was a protective association between lycopene intake and 4-year change in the bone mineral density of the lumbar spine in women, and a significant protective association between intakes of total carotenoids, beta-carotene, lycopene, and lutein in bone mineral density in men (27).
Weight-bearing exercises, such as walking, jogging, dancing, and strength training, help stimulate bone formation and improve bone density (1). Balance exercises such as Tai Chi have been claimed to be helpful in fall prevention although the evidence is conflicting (28, 29).
Smoking is associated with decreased bone density and increased fracture risk, so quitting smoking can help improve bone health and reduce the risk of fractures. Limiting alcohol intake is also relevant as excessive alcohol consumption can weaken bones and therefore increase fracture risk (1).
Some people might need medication when the osteoporosis is moderate or severe. These may include bisphosphonates, hormone therapy, selective oestrogen receptor modulators (SERMs), denosumab, or parathyroid hormone analogues (1).
References
- Sözen T, ĂzıĆık L, BaĆaran NĂ. An overview and management of osteoporosis. Eur J Rheumatol. 2017;4(1):46.
- Pouresmaeili F, Kamalidehghan B, Kamarehei M, Goh YM. A comprehensive overview on osteoporosis and its risk factors. Ther Clin Risk Manag. 2018;14:2029-2049.
- Compston J, Cooper A, Cooper C, et al.; National Osteoporosis Guideline Group (NOGG). UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos. 2017;12:1-24.
- Armas LA, Recker RR. Pathophysiology of osteoporosis: new mechanistic insights. Endocrinol Metab Clin North Am. 2012;41(3):475-486.
- Cannarella R, Barbagallo F, Condorelli RA, et al. Osteoporosis from an endocrine perspective: the role of hormonal changes in the elderly. J Clin Med. 2019;8(10):1564.
- Anthamatten A, Parish A. Clinical update on osteoporosis. J Midwifery Womens Health. 2019;64(3):265-275.
- Thorup AC, Lambert MN, Kahr HS, Bjerre M, Jeppesen PB. Intake of novel red clover supplementation for 12 weeks improves bone status in healthy menopausal women. Evid Based Complement Alternat Med. 2015;2015:689138.
- Kolios L, Schumann J, Sehmisch S, et al. Effects of black cohosh (Cimicifuga racemosa) and estrogen on metaphyseal fracture healing in the early stage of osteoporosis in ovariectomized rats. Planta Med. 2010;76(09):850-857.
- Zhang Y, Chen WF, Lai WP, Wong MS. Soy isoflavones and their bone protective effects. Inflammopharmacology. 2008;16:213-215.
- Zheng X, Lee SK, Chun OK. Soy isoflavones and osteoporotic bone loss: a review with an emphasis on modulation of bone remodeling. J Med Food. 2016;19(1):1-14.
- Atmaca A, Kleerekoper M, Bayraktar M, Kucuk O. Soy isoflavones in the management of postmenopausal osteoporosis. Menopause. 2008;15(4):748-757.
- Guo Y, Li Y, Xue L, et al. Salvia miltiorrhiza: an ancient Chinese herbal medicine as a source for anti-osteoporotic drugs. J Ethnopharmacol. 2014;155(3):1401-1416.
- Domazetovic V, Marcucci G, Iantomasi T, Brandi ML, Vincenzini MT. Oxidative stress in bone remodeling: role of antioxidants. Clin Cases Miner Bone Metab. 2017;14(2):209.
- Hao G, Zhang B, Gu M, et al. Vitamin K intake and the risk of fractures: A meta-analysis. Medicine (Baltimore). 2017;96(17):e6725.
- Tam LS, Chan TYK, Leung WK, Critchley JAJH. Warfarin interactions with Chinese traditional medicines: Danshen and methyl salicylate medicated oil. Aust N Z J Med. 1995;25(6):547-548.
- Badole S, Kotwal S. Equisetum arvense: Ethanopharmacological and Phytochemical review with reference to osteoporosis. Int J Pharm Sci Health Care. 2014;1(4):131-141.
- Ortega GarcĂa JA, Angulo MG, Sobrino-Najul EJ, et al. Prenatal exposure of a girl with autism spectrum disorder to ‘horsetail’ (Equisetum arvense) herbal remedy and alcohol: a case report. J Med Case Rep. 2011;5:368.
- Elhassaneen YA, Ragab SS, Salman MS. The potential effects of Reishi mushroom (Ganoderma lucidum) consumption on bone health indices and serum minerals profile disorders induced by CCl4 on rats. PJMPR. 2016;2(1):001-007.
- Yang Y, Yang B. Anti-osteoporosis effect of Ganoderma (lingzhi) by inhibition of osteoclastogenesis. In: Jin Y, ed. Ganoderma and Health: Pharmacology and Clinical Application. CRC Press; 2019:263-269.
- Li W, Lee SH, Jang HD, Ma JY, Kim YH. Antioxidant and anti-osteoporotic activities of aromatic compounds and sterols from Hericium erinaceum. Molecules. 2017;22(1):108.
- Garriguet D. Bone health: osteoporosis, calcium and vitamin D. Health Rep. 2011;22(3):7-14.
- Heaney RP. Role of dietary sodium in osteoporosis. J Am Coll Nutr. 2006;25(suppl 3):271S-276S.
- Yao P, Bennett D, Mafham M, et al. Vitamin D and calcium for the prevention of fracture: a systematic review and meta-analysis. JAMA Netw Open. 2019;2(12):e1917789.
- Yao P, Bennett D, Mafham M, et al. Vitamin D and calcium for the prevention of fracture: a systematic review and meta-analysis. JAMA Netw Open. 2019;2(12):e1917789.
- Sakhaee K, Bhuket T, Adams-Huet B, Rao DS. Meta-analysis of calcium bioavailability: a comparison of calcium citrate with calcium carbonate. Am J Ther. 1999;6(6):313-322.
- Khosla S. What do we tell our patients about calcium and vitamin D supplementation? J Clin Endocrinol Metab. 2011;96(1):69-71.
- Sahni S, Hannan MT, Blumberg J, Cupples LA, Kiel DP, Tucker KL. Inverse association of carotenoid intakes with 4-y change in bone mineral density in elderly men and women: the Framingham Osteoporosis Study. Am J Clin Nutr. 2009;89(1):416-424.
- Chow TH, Lee BY, Ang ABF, Cheung VYK, Ho MMC, Takemura S. The effect of Chinese martial arts Tai Chi Chuan on prevention of osteoporosis: A systematic review. J Orthop Translat. 2018;12:74-84.
- Lee MS, Pittler MH, Shin BC, Ernst E. Tai chi for osteoporosis: a systematic review. Osteoporos Int. 2008;19:139-146.
* This article will refer to cis women and cis men throughout the article where the terms [women] and [men] have been used, respectively.
