Osteoporosis is a decrease in bone density along with microscopic damage to the architecture of the bone, increasing the risk of fractures. It roots in childhood, but the disease does not present until 50-60 years of age. Most people are asymptomatic until diagnosed!
Osteoporosis is the most common bone disease in the world and generally affects post-menopausal women. Osteoporosis care is expensive, costing over $13 billion per year! By 80 years of age, we have a 15% risk of a fracture. By 90 years of age, the fracture risk increases to 25%. Fractures sustained in older years have devastating impacts on health as well as a 25% possibility of death.
Most of my patients are shocked when diagnosed. They’ve always tried to eat well, exercise, and take calcium with vitamin D, so when they see me, their functional medicine physician, they want answers to how this happened and what they can do. As always, it is best to discuss a real case and see how it unfolds to find root causes.
S.K. is a 63-year-old woman with no past medical concerns who was diagnosed with osteoporosis by routine bone density testing. She entered menopause at 56 years of age but felt well and elected to decline hormone therapy. She increased her calcium, added vitamin D with K, along with resistance training and cardio, believing she was doing everything correctly. After her diagnosis, her physician recommended Fosamax, but she wanted a more natural route that addressed the root causes of her osteoporosis.
With all patients, I construct a timeline to appreciate the various complexities of their life. This is especially important with osteoporosis because bone health is determined early in life with nutrition, lifestyle, and genetics. Unfortunately for S.K., her childhood was complicated. Her prenatal and delivery history were uncomplicated, but she was a vaginal delivery, which is important because vaginal fluids swallowed at birth seed the future gut microbiome. Unfortunately, she was not breast-fed and only received bottle-feedings. Bottle feeding does not contribute to the growing microbiome and immune system like breastfeeding does.
Her childhood home was chaotic. Her adverse childhood event score (ACEs) was high, 4/10. ACEs refer to abuse, neglect, and traumatic experiences in childhood that directly affect long-term adult health. A score of 4 or more is considered very high and can lead to medical complications that do not follow any known trajectory, as well as an increased risk of financial and job insecurity.
As a functional medicine physician, a high ACE score means there may be multiple areas of the body negatively affected. First, the stress axis, which develops in childhood, is set to a constant fight and flight mode when surrounded by trauma. It is during childhood that humans learn to be happy and joyful. Children need to feel safe and loved to maintain a healing state, but when life is dysfunctional, the stress axis shifts to constant hypervigilance, which increases total body inflammation. When the body is inflamed, growth and development may not be optimized, including bone health. Second, this constant fight and flight inflammatory state negatively affects the gut microbiome.
A healthy gut microbiome has the density and abundance of a rainforest, but trauma impedes its diversity. It can also increase inflammation within the gut, which decreases absorption of critical nutrients for bone health, as well as the production of key vitamins that occur in the intestines. Furthermore, due to the chaotic household, her childhood diet consisted mostly of processed foods, with little to no vegetables and fruits outside of American standards like potatoes and corn. She consumed soda regularly and drank milk occasionally. I question if she ever reached her full bone potential.
Another red flag from childhood was her recurrent strep throat and antibiotic use. She developed strep throat about once or twice per year for 4-5 years during elementary school. As a teenager, she used oral antibiotics to control acne for a few months. These repeat antibiotic courses can further decrease the microbial diversity and abundance in the gut, which can increase the risk of 'bad' bacteria (a pathogen) to enter her microbiome and/or a yeast overgrowth to occur. This can increase intestinal inflammation, leading to a decrease in digestion and absorption of critical nutrients for health (including bone health).
Lastly, she had a head trauma after falling from a swing. She was never diagnosed with a concussion, but if the head was hit hard enough to remember, the gut-brain axis was most certainly affected. The brain is the consistency of Jell-O, so head injuries, big and small, can cause the 'Jell-O' to slosh around, increasing brain and gut permeability as well as negatively impacting the gut microbiome.
She was relatively healthy as an adult. She had three children after the age of 30 and breastfed all of them for 1.5 years. Prolonged breastfeeding past one year in some studies is associated with osteoporosis, but the association diminishes if you have more children.
She has had mercury amalgams that were removed by a regular dentist with no protection against swallowing the mercury. The body realizes mercury is not good for it
and stores it deep inside the bone. When bones thin, Mercury is released, increasing inflammation and immune dysregulation which only worsens osteoporosis.
She entered menopause rather uneventfully at 56 years of age, but the last 3-4 years have been very stressful. She is caring for her father who was the main abuser in childhood. She is also the caretaker of her sister who struggles with mental health, drugs, and alcohol. Her childhood trauma was triggered again.
During her appointment, she complained of many GI symptoms of bloating, gas, diarrhea alternating with constipation. She had headaches, occasional joint pain in her knees and feet, as well as difficulty sleeping due to stress. Her symptoms suggest increased intestinal permeability, aka leaky gut. I recommended a functional medicine stool study to evaluate her ability to absorb nutrients, assess gut inflammation, and microbial diversity along with comprehensive blood work. Her laboratory study was normal except for a low vitamin D (23ng/dl), high reverse T3 but otherwise normal thyroid functions (suggesting chronic stress and adrenal dysfunction), low magnesium levels, and an elevated NTX level (a bone turnover marker). Her stool study showed an inability to absorb protein, inflammation, low beneficial bacteria, and a yeast overgrowth.
I started her on a gut healing protocol with SBI protect, high doses of probiotics and Betaine, which help increase hydrochloric acid in the stomach to help break down protein. I prescribed an antifungal for a few weeks and then slowly added prebiotics to help improve her gut microbiome diversity. She will continue with high doses of probiotics and prebiotics for many months. For her bones and overall health, I recommended using Algae Cal, Magnesium Malate 600mg at night, Vitamin D 10,000 units for 2 months followed by 5000 units daily, as well as high doses of Vitamin K with more K2 since it is more bio-available. Vitamin K directs calcium to the bones. For her stress, I recommended Adaptogens twice per day along with lifestyle strategies.
Lifestyle strategies included sleep, movement, and nutrition information. For sleep, I recommended 8-9 hours in bed rather than 7 hours. Most people toss and turn for an hour each night, so time in bed is not equivalent to time asleep. Providing the body adequate time to mend is crucial, especially during stress. I also recommended a strict bedtime routine with calming activities such as breathing techniques, sleep yoga, and journaling, especially the list for tomorrow so she is not thinking about her 'to-do list' as soon as she awakens. In the morning, I recommended meditation or breathing techniques in bed, sitting up with her covers over her for ten minutes. Instead of skipping breakfast, I recommended a morning smoothie with many of her vitamins, vegan protein, veggies/fruits, and good fats like nut butter, flax/chia seeds, and MCT oil
to help with energy and focus. Her lunch and dinner meals were similar to her clean eating, but I recommended that half the plate be full of various vegetables, and the other half consisting of protein, good fats, and one serving of grains, starchy vegetables, or fruit. Her movement must include weight-bearing and resistance training. She elected to hike two days, do yoga one day, and weightlift two days.
After a few months, her gut symptoms mostly resolved unless she deviated from her protocol. Her vitamin D and magnesium levels were optimized. Her NTX, a bone turnover marker, was decreasing. She elected to start low-dose hormone replacement, which I think will help not only for her bones but her mental health. Hormones are best started within 10 years of menopause. At the six-month mark, her NTX was normal which is the desired level suggesting she is not losing bone. Insurance does not cover another bone density until 2 years but the next bone density, I will order will have a trabecular score which measures not just the quantity of bone but the quality of bone to better assess fracture risk. Her stress is still high, but she feels her resilience (her ability to get up after another stressful event) is better.
With a multifaceted strategy addressing the intricate interplay of her past, present, and future, she not only improves bone health but also nurtures a profound sense of well-being—an inspiring reminder of the body's capacity for healing and renewal when supported with comprehensive care.