Bone Health 101
An everyday guide to strong bones for a lifetime
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by Dr. Cathy Carlson-Rink, Naturopathic Physician |
As both a Naturopathic Doctor and practicing midwife with many years of clinical experience, I have gained a special insight into the health issues that concern women today. The most important of these, for many of us, is bone health. I have put together this fun and interesting booklet, as an introduction to bone health and osteoporosis. It includes lifestyle, nutrition and exercise tips along with some great recipes and snack ideas that you can use to improve bone health for you and your family. I hope you will also find it a useful and informative guide to help you understand how calcium works and how to best evaluate the quality of the many calcium supplements on the market today.
Yours in health,
Dr. Cathy Carlson-Rink
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Biography
Dr. Cathy Carlson-Rink is a licensed Naturopathic Physician and Registered Midwife in general family practice with a focus on pregnancy, and women's & children's health. She completed her Bachelor of Science with Distinction in Physical Education and a major in Health and Fitness through the University of Saskatchewan and her Doctor of Naturopathic Medicine (ND) with a postgraduate specialization in midwifery at Bastyr University in Seattle, Washington. She is recognized across Canada as the first Naturopathic Physician also to practice as a Registered Midwife.
Dr Cathy Carlson-Rink with daughters Magena (standing) and Cloe
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Questions for Dr. Cathy Carlson-Rink can be directed to cathy@bonehealth101.com
Bone Health
Throughout a Lifetime
Osteoporosis is a disease characterized by loss of bone mass, deterioration of bone structure and increased risk of fracture. It is often known as "the silent thief" because if not prevented or if left untreated, bone loss can occur and progress without symptoms. Prevention of osteoporosis throughout a lifetime is essential. Each stage of life, categorized by growth and maintenance, has different challenges in terms of prevention and nutritional needs.
GROWTH
Pregnancy & Lactation
An unborn baby's nutritional requirements increase as he or she grows, particularly in the last trimester when skeletal growth is most rapid. If the mother's absorption and utilization of nutrients is insufficient, the baby's requirements may be drawn from her bones, increasing her risk of osteoporosis later in life (1). However, with adequate nutrition, pregnancy can positively influence bone mass. Some women who have had three or more children show a 30–40% reduction in bone fractures when compared to those who had not given birth (2).
Childhood & Adolescence (boys & girls)
Awareness has increased regarding the loss of bone later in life, yet very little attention has been given to the other half of the equation–gaining bone during the growing years when the proper growth of the skeleton is paramount. From birth to puberty, skeletal growth increases sevenfold and another threefold during adolescence (3) with approximately 90% of bone being laid down by age 17 (3,4). To this end, osteoporosis is being called "a pediatric disease with geriatric consequences", because the stage for osteoporosis is set by the quality of bone in childhood. During this stage of life, a large amount of calcium is needed to construct bone. However, it is estimated that between the ages of 9 and 19, only 19% of girls and 52% of boys have adequate calcium intake (5).
Furthermore, the increase in junk food and soft drink consumption (up 500% since the 1950s) causes calcium to be pulled out of the body, leading to an even greater risk of bone loss (4). We are already seeing the effects as frequent fractures and the incidence of rickets has returned among teens and children (6). During this stage of life, emphasis should be placed on putting bone in the bank for later in life.
MAINTENANCE
Childbearing Years
By age 30, it is generally accepted that a woman's bones are at their peak of strength and thickness. However, recent research indicates that nutrition and lifestyle choices can positively influence bone mineral concentration (bone strength) well past age 40 (4). The stronger bones are when a woman enters menopause, the less likely it is that a fracture will occur.
Menopausal Years
During this stage of life, ovaries are producing less estrogen, increasing the rate at which bone is broken down (7). Supplemental calcium that is not dependent on stomach pH, age or hormonal status is especially needed during this time. Effective supplementation can reduce fractures by about 25% (8). Even with an average age of 84 years, fracture incidence can still decrease (9). If bone loss has already occurred, calcium requirements may increase considerably.
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Osteoporosis is being called "a pediatric disease with geriatric consequences" because the stage for osteoporosis is set by the quality of bone in childhood. |
Adult Male
Currently, one in eight men over 50 has osteoporosis. Around age 65 or 70, men experience a similar loss of bone mass to that of menopausal women due to lowered hormone levels and a decreased ability to absorb nutrients essential for bone health (10).
RISK FACTORS
There are a number of recognized risk factors for osteoporosis. Some factors can be influenced by the choices you make; other factors are beyond your control. Awareness can provide extra motivation to help yourself in the ways you are able, and can aid you and your health care provider in decisions that affect your well-being. Prevention of osteoporosis throughout the life cycle is essential. Do not wait to start making changes so healthy bones can be a part of your future.
Factors that influence bone health (8)
FACTORS YOU CAN CHANGE
• Ensure adequate absorption and proper utilization of calcium, magnesium, zinc and vitamin D
• Avoid severe caloric restriction and yo-yo dieting
• Avoid excessive protein, salt, sugar and caffeine consumption
• Optimize digestion for maximum nutrient absorption
• Engage in an active lifestyle that includes both weight bearing and strength training exercise
• Decrease alcohol consumption and don't smoke
• Normalize hormone levels
• Avoid over the counter medications such as antacids and laxatives
• Increase awareness of medications that increase risk of bone disease
• Minimize risk of falling
FACTORS YOU CAN'T CHANGE
• History of osteoporotic fractures in either parent or a sibling doubles the risk • Those with slight physical builds and/or fair complexions are at greater risk • Caucasian and Asians are at highest risk • Women reach a lower peak bone mass than men, increasing their risk • Bones become weaker and less dense with age 
Healthy Bones
and How They're Built
Bone is a living tissue that is constantly being broken down and rebuilt. Calcium is one of the many factors involved in this process (10). You should not, however, try to fulfill your daily calcium requirements with a supplement. Your diet will already provide you with a portion of the RDI, (based on dietary calcium), and you should only rely on a high quality, balanced supplement to provide the remainder. This encourages a more beneficial ratio of calcium to magnesium consumption.
THE BALANCING ACT
A high intake of calcium will not necessarily result in bone gain or even in the prevention of bone loss. A higher ratio of calcium to magnesium will inhibit their subsequent absorption and utilization, setting the stage for weak bones and overcalcification of the body (11). The latest research is showing us that the regular use of a balanced calciu magnesium supplement, which has been formulated to provide adequate absorption and proper utilization of calcium is superior at maintaining bone health compared to increased calcium intake alone (12).
In my practice, I determine the quality of a supplement by how effectively it addresses the three main processes that calcium is involved in:
• Absorption • Utilization • Excretion Calcium and Magnesium – Partners in Bone Health
FACTORS THAT PREVENT ADEQUATE CALCIUM ABSORPTION & UTILIZATION
• Magnesium deficiency (12)
• Low solubility of supplement (14)
• Low stomach acid (hypochlorhydria) (25)
• Imbalance of co-factors (12)
• Excess phosphorus, sugar, salt, caffeine & protein (25)
SYMPTOMS OF INADEQUATE CALCIUM ABSORPTION & UTILIZATION
• Calcium deposits in the joints
• Bone fractures
• Osteoporosis
• Muscle cramps
• High blood pressure
• Kidney stones or gallstones
• Brittle nails
• PMS
• Restlessness and sleep problems
FACTORS THAT DEPLETE MAGNESIUM
• Excess calcium
• Tension and stress
• Excess coffee, sugar, sodium and processed foods
SYMPTOMS OF A MAGNESIUM DEFICIENCY• Restlessness and sleep problems • PMS and menstrual cramps • Muscle spasms and cramps • Heart palpitations • Headaches
| Your diet already provides you with a portion of the calcium you need, the rest should come from a balanced Calcium Magnesium supplement. |
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CALCIUM ABSORPTION
Both the delivery system and the compound or "form" of calcium in a supplement need to be soluble (dissolvable) for optimum absorption.
Delivery System
After travelling through the digestive tract, the average person will have dissolved either 20% of a tablet or 30% of a capsule, accessing either 20% or 30% of its elemental calcium (13). At this stage of absorption, any calcium from the undissolved portion of the supplement will be eliminated via the colon, possibly causing constipation, gas and bloating (12). A liquid solution is highly soluble and does not need to be dissolved, providing approximately 98% (13) of its elemental calcium. Because liquid solutions are extremely efficient at providing nutrients, they can therefore use much lower doses compared to solid supplements while still providing as much or more utilizable calcium but without the waste.
Form of Calcium
I recommend calcium lactate and calcium gluconate for two reasons. They are the most soluble organic forms of calcium suitable for use in liquid solutions; and they are highly soluble throughout the entire digestive tract (14). Calcium lactate and gluconate are able to utilize both types of absorption sites in the small intestine:
Active transport sites are located at the beginning of the small intestine. They require the presence of adequate amounts of vitamin D and are limited to approximately 500mg of calcium absorption at any one time.
Passive diffusion sites are located in the more alkaline environment at the end of the small intestine. These sites allow much greater calcium absorption regardless of dosage, stomach acid levels, vitamin D intake, age, gender or hormone status and are limited only by intestinal transit time (14). Only soluble forms of calcium can take advantage of passive diffusion sites.
Calcium gluconate has also been shown to encourage the simultaneous absorption of the necessary co-factor magnesium (15) and is thirty times more soluble than inorganic calcium carbonate (14).
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Only soluble forms of calcium can be absorbed regardless of dosage, stomach acid levels, vitamin D intake, age, gender or hormonestatus. |
I do not recommend the use of inorganic forms of calcium because they are not soluble in liquid and their absorption is almost completely restricted to active transport sites only. The body prefers a more soluble form and so will choose to absorb calcium lactate and gluconate over carbonate if they are present at the same time (14).
Calcium citrate is organic and therefore soluble, but very bitter when used in liquid (16,17). It is a good choice, however, if you need to choose a capsule.
Food Sources
In a liquid solution, natural fruit juice provides an ideal food source to facilitate the simultaneous absorption of calcium and zinc (18).
Nutritive Herbs
Such as african malva (hibiscus), horsetail and red raspberry supply natural calcium and other minerals, while others like chamomile and fennel stimulate digestion and reduce bloating (19).
CALCIUM UTILIZATION
North Americans have the highest rate of milk and calcium supplement consumption – yet still have the highest rate of osteoporosis in the world. This is because the improper utilization of calcium, caused by insufficient magnesium and other needed co-factors, results in abnormal, fragile bone structure (20,12).
Unless sufficient magnesium is present, calcium will not be correctly deposited into bone and instead will deposit in soft tissue, causing kidney and gallstones, joint discomfort and other calcification problems, as well as increased atherosclerotic plaque (21).
Higher Magnesium to Calcium Ratio
Osteoporosis is not, generally speaking, a problem of insufficient calcium intake but rather of incorrect calcium utilization. It is magnesium that is needed to encourage the correct utilization of calcium by the body (22).
Abnormally shaped bones are built when magnesium is insufficient (12). Abnormally shaped bones may appear dense, but are still weaker than normal bone and can break more easily. Magnesium is the most consistently observed nutrient to increase bone strength (23); yet dietary intake studies consistently show that large numbers of individuals may be at risk for magnesium deficiency (12). This is why I recommend a liquid supplement that has a higher ratio of magnesium to calcium for prevention of osteoporosis.
Dr. Guy Abraham MD, used a ratio of 1.2:1 magnesium to calcium, along with other factors in a nine month study that resulted in a significant 11% increase in bone mass versus only 0.7% in the untreated group. When given to postmenopausal women, the same 1.2:1 ratio resulted in a bone density 16 times greater than those who followed dietary advice alone (24).
Vitamin D and Zinc
Clinical trials have shown vitamin D enhances the absorption of calcium at the active transport sites and reduces bone breakdown (20). Zinc is needed for protein formation in the framework of the bone (22).
A bone healthy diet and lifestyle, combined with highly soluble, supplemental nutrients that can be absorbed regardless of age, gender and hormone levels, is the best way for all age groups to minimize their risk of osteoporosis.
What to look for in a calcium supplement
FOR ABSORPTION
• Easy-to-Digest Liquid Solution provides more contact with absorption sites and does not require dissolving, leaving approximately 98% (13) of the elemental calcium available for absorption
• Highly Soluble Calcium Lactate & Gluconate which can be readily absorbed regardless of age, nutrition or hormone status (7)
• A Useable Calcium Dosage that satisfies daily supplemental calcium needs and is safe for long-term supplementation
• Food Source such as fruit juice to assist the simultaneous absorption of calcium and co-factors
FOR UTILIZATION
• Higher Magnesium to Calcium Ratio to facilitate bone strength and proper calcium utilization to help prevent calcium deposits in soft tissue (12)
• Added Zinc and Vitamin D because they are co-factors in the maintenance of healthy bones and teeth
ADDITIONAL FEATURES
• Added Herbs which are rich in minerals, stimulate digestion and reduce bloating
• No Harmful Additives such as lead, pesticide residues, preservatives or food colouring
Exercise can increase peak bone mass in children and adolescents, maintain and possibly increase bone mass in adults and can help to minimize bone loss in older adults (27). If an exercise is enjoyable, you will be more likely to do it. 30 minutes to 1 hour, four times a week can decrease fractures by 50%-70% (28). Recommended exercises can be divided into two categories: weight bearing and resistance.
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WEIGHT BEARING EXERCISES (29)
• Dancing
• Tennis
• Jogging
• Stair climbing
• T'ai Chi (improves balance) (30)
• Walking
RESISTANCE EXERCISES
• Weight training (31)
• Water exercises
• Elastic bands
BENEFITS OF EXERCISE (7)
• Increase muscle mass, strength & endurance
• Improve flexibility & mobility
• Improve balance and reduce the risk of falling (29)
• Reduce muscle wasting & bone loss
• Reduce lower back pain & body fat
• Maintain vigour, physical capabilities & health as you age |
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CAUTION: If you have low bone mass, avoid high impact exercises and exercises that flex, bend or twist the spine (29). If you are over 40, have osteoporosis, have a family history of early onset heart disease, have health problems or are unsure of your health, check with your health care provider before starting an exercise program.
A lot of importance has been placed on getting enough calcium-rich foods in our diet. However, some foods high in calcium, such as cow's milk, are also low in magnesium (8 parts to 1) which creates a magnesium deficiency and may contribute to the development of weaker bones (7) The latest studies are revealing that balanced amounts of dietary calcium and magnesium result in a better accumulation and maintenance of bone density when compared to a diet emphasizing calcium alone (32,33). Diets high in magnesium, potassium, fruits, and vegetables, with adequate protein and limited amounts of junk foods show a better accumulation and maintenance of bone density among older adults (32,33).
EXCRETION
The three main factors causing the excretion of calcium are dietary factors, the solubility of the supplement form and the dosage of calcium. Up to 50% of absorbed calcium (12) is excreted via the kidneys due to dietary factors. Undissolved calcium from supplements is excreted via the colon, while high doses of calcium cause reduced absorption and increased excretion via the colon.
Dietary factors that cause the excretion of calcium
• Phosphorus, found in high amounts in carbonated and processed foods, is one of the leading dietary causes contributing to osteoporosis. North Americans easily exceed 100% of the RDI for phosphorus, however; magnesium inhibits the absorption of phosphorus, further reinforcing its importance in the diet (12).
• Excess salt, sugar and caffeine causes calcium to be excreted via the kidneys.
• Excessive animal protein increases urinary calcium excretion and removes calcium from bone to buffer the acidic by-products of protein metabolism (28).
Not only is it important to have a balanced supplement and lifestyle, but a balanced diet as well. Nutrition, exercise and a quality supplement all work hand in hand to build strong bones throughout a lifetime.
Bone Healthy
Recipes and Snack Ideas
CREAM OF BROCCOLI SOUP
2 cups milk (soy or dairy)
1 cup chopped raw broccoli
1 Tbsp. butter
1 cup vegetable stock
Blend in blender until smooth. Put in pot and bring to boil. Simmer for 20 minutes, garnish with your favourite veggies and serve.
HOMEMADE HUMMUS
2 cup cooked chickpeas (reserve water)
1/2 cup tahini (sesame paste)
1/3 cup freshly squeezed lemon juice
1Tbsp. each olive and flax oil
Salt, pepper and garlic to taste
Add chickpea water to desired consistency if needed. Use as a dip for crackers, rice cakes and veggie sticks.
SUCCULENT SUPPER SALAD
Salad:
1/2 head romaine lettuce
1 bunch of kale
1/2 bunch arugula
1 cup chopped red cabbage
1 apple, cut into bite sized pieces
1 ripe avocado, cut into bite sized pieces
1/4 cup raisins
1/4 cup toasted almonds
3 scallions, finely sliced
1 or 2 fresh tomotoes, cut in wedges
1 cup alfalfa sprouts
Dressing:
1/4 cup nut or seed oil (cold expressed)
3 Tbsp. of balsamic vinegar
2 tsp. Dijon mustard
2 tsp. of maple syrup
1/8 tsp. paprika
1/4 tsp. of soy sauce
Wash the lettuces and greens. Spin or pat dry. Tear greens into bite-sized pieces and place in a large salad bowl. Add all other salad ingredients. Set aside. Put all ingredients for dressing in a small bowl or jar and shake. Add to salad before serving and toss well. (modified from "Feeding the Whole Family" by Cynthia Lair)
BONE FRIENDLY SNACK IDEAS
• Fruit Smoothie
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1 cup yogurt, 1/2 banana, 1/2–1 cup of frozen fruit such as blueberries, strawberries, or raspberries |
• Bone Building Trail Mix
1/2 cup of raw almonds, 1/2 cup raw cashews, 1/2 cup raw sunflower seeds, 1/2 cup seedless raisins
• Rice cakes with almond, sesame or cashew butter with fruit sweetened jam
• Figs and dates
1. Williams, B.W.-R.S.R., Nutrition in Pregnancy and Lactation. 5th ed. 1993, Toronto: Mosby-Year Book, Inc.
2. The National Institute of Health.
3. Peacock, M., Calcium Absorption Efficiency and Calcium Requirements in Children and Adolescents. American Journal of Nutrition, 1991. 54: p. 261S-265S. 4. Anderson, J.J.B. and P. Rondano, Peak Bone Mass Development of Females: Can Young Adult Women. Journal of the American College of Nutrition, 1996. 15(6): p. 570-574. 5. http://www.nichd.nih.gov/milk/whycal/enough_cal.cfm
6. http://www.soundmedicine.iu.edu/archive/2002/mystery/kids_calcium.html
7. http://www.mayoclinic.com
8. Best Clinical Practices Chapter 13: International Position Paper on Women's Health and Menopause: A Comprehensive Approach, NIH Office of Research on Women's Health, and Giovanni Lorenzini Medical Science Foundation
9. Maurice E. Shils, J.A.O., Moshe Shike & A. Catherine Ross, ed. Modern Nutrition In Health and Disease. 9th ed. 1999, Lippincott= Williams & Williams: New York.
10. Guyton, A., Textbook of Medical Physiology. Eighth ed. 1991, Philadelphia: W.B. Saunders Company.
11. Camara-Martos, F. and M. Amaro-Lopez, Influence of Dietary Factors on Calcium Bioavailability. Biological Trace Element Research, 2002. 89: p. 43-52.
12. Celotti, F. and A. Bignamini, Dietary Calcium and Mineral/Vitamin Supplementation: a controversial problem. The Journal of International Research, 1999(27): p. 1-14.
13. The Physician's Desk Reference, p.1542
14. Pansu, D., et al., Solubility and Intestinal Transit Time Limit Calcium Absorption in Rats. Journal of Nutrition, 1993. 123(8): p. 1396-404.
15. Chonan, O., et al., Effects of Calcium Gluconate on the Utilization of Magnesium and the Nephrocalcinosis in Rats Fed Excess Dietary Phosphorus and Calcium. J. Nutr. Sci. Vitaminol., 1996. 42: p. 313-323.
16. http://www.foodproductdesign.com/archive/2000/0900ffa_04.html
17. http://exchange.healthwell.com/ffn/FFN_backs/jun_02/calcium.cfm
18. Bratman, S., The Natural Health Bible. 2nd ed. 2000, Rocklin,CA: Prima Health.
19. Pedersen, M., Nutritional Herbology. 1st ed. 1987, Bountiful, Utah: Pedersen Publishing. 377.
20. Schaafsma, A., P.F.d. Vries, and W. Saris, Delay of Natural Bone Loss by Higher Intakes of Specific Minerals and Vitamins. Critical Reviews in Food Science and Nutrition, 2001. 41(3): p. 225-249.
21. Gaby, Alan R. Every Woman's Essential Guide to Preventing and Reversing Osteoporosis Prima Health, 1990.
22. Gur, A. et al., The Role of Trace Minerals in the pathogenesis of postmenopausal osteoporosis and a new effect of calcitonin. Journal of Bone and Mineral Metabolism, 2002. 20: p. 39-43.
23. Jones, G., M. Riley, and T. Dwyer, Maternal Diet during pregnancy is associated with bone mineral density in children: a longitudinal study. European Journal of Clinical Nutrition, 2000. 54: p. 749-756.
24. Abraham, G. E., and H. Grewal, A Total Dietary Program Emphasizing Magnesium Instead of Calcium. Effect on Mineral Density of Calcaneous Bone in Postmenopausal Women on Hormonal Therapy. Journal of Reproductive Medicine, 1990 35: 503-507.
25. Murray, M.T., Encyclopedia of Nutritional Supplements. 1996, Rocklin: Prima Publishing.
26. Fairweather-Tait, S.J. and B. Teucher, Iron and Calcium Bioavailability of Fortified Foods and Dietary Supplements. Nutrition Reviews, 2002. 60(12): p. 360-367.
27. http://www.osteo.org/newfile.asp?doc=r707i&doctitle=Exercise+and+Bone+Health&doctype=HTML+Fact+Sheet
28. Hudson, T.S., Osteoporosis: An Overview for Clinical Practice. Journal of Naturopathic Medicine. 7(1): p. 27-34.
29. The Osteoporosis Report. September/October 1989.
30. Qin, L., et al., Regular Tai Chi Chuan Exercise May Retard Bone Loss in Post Menopausal Women: A Case-Control Study. Arch Phys Rehabil, October 2002. 83: p. 1355-1359.
31. Cussler, E.C., et al., Weight Lifted in Strength Training Predicts Bone Change in Menopausal Women. Med. Sci. Sports Exerc, 2003. 35(1): p. 10-17.
32. Tucker, K.L., M.T. Hannan, and D.P. Kiel, The acid-base hypothesis: diet and bone in the Framingham Osteoporosis Study. European Journal of Clinical Nutrition, 2001. 40: p. 231-237.
33. Buclin, T., et al., Diet Acids and Alkalis Influence Calcium Retention in Bone. Osteoporosis International, 2001. 12: p. 493-499.
Questions for Dr. Cathy Carlson-Rink can be directed to cathy@bonehealth101.com
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