Vitamin C for Osteopenia or Osteoporosis Fractures?

I love it when I get questions from all of you. This helps me keep this blog relevant.

This week, I was asked about the value of taking high doses of Vitamin C after a fracture (for instance, after a broken wrist).

Is it helpful? Is it necessary?

First, you should know if you are actually at risk for Vitamin C insufficiency.

According to Crook et al. (2021), about 41% of the U.S. population has Vitamin C insufficiency. In their analysis, they found that the groups with the highest risk of insufficiency were males, adults aged 20–59, Black and Mexican Americans, smokers, individuals with increased BMI, middle and high poverty levels, and those with food insecurity. Women over 60 were actually the least likely to have insufficiency.

But what if you have osteoporosis or osteopenia? Should this diagnosis change your Vitamin C intake?

Brzezińska et al. asked this very question in 2020. Their paper was titled "Role of Vitamin C in Osteoporosis Development and Treatment-A Literature Review". The scientists reviewed 66 studies published between 2000-2020. They concluded that a balanced, well-rounded diet was the most appropriate way to achieve bone health, while the role of high-dose supplements was not established. Future studies may help us understand supplements better.

The balanced, well-rounded diet was further confirmed by a study by Zeng and colleagues (2020) in their paper titled "Can Dietary Intake of Vitamin C-Oriented Foods Reduce the Risk of Osteoporosis, Fracture, and BMD Loss? This group dug into the connection between vitamin C-rich foods and bone health by looking at 13 studies. They concluded that people who regularly consumed vitamin C-oriented foods had a reduced risk of osteoporosis and fractures.

Important Note - these studies suggest that dietary intake is the best solution, not supplements.

How Can You Boost Your Vitamin C Intake?

Here are some easy tips to make sure you're getting your daily dose of this bone-loving vitamin:

• Fruit: Start your day with a delicious fruit that includes vitamin C- like oranges, kiwis, cantaloupe, or strawberries.

• Veggie Power: Make veggies like broccoli, Brussels sprouts, red or green peppers, and kale a regular part of your meals.

A Little Sunshine ☀️ on Your Plate: Think of vitamin C as a little sunshine on your plate. It not only helps your bones but also boosts your overall well-being. Plus, it's an easy and tasty addition to your meals. The more color on your plate, the better - eat the rainbow.

What if you have a fracture? Should you increase your Vitamin C to assist with healing?

Yes, if your PCP recommends it. According to a 2022 Systematic Review by Barrios-Garay, "vitamin C seems to accelerate bone regeneration without adverse events". They do not have specific recommendations on the dose. This is something you should discuss with your PCP if/when you fracture.

Go out and enjoy those vitamin C-rich foods and let the goodness soak into your bones. I think organic, locally-grown fruits and vegetables are your best bet. Cancel the supplements and spend your money on the best quality food you can afford.

If you have any specific questions or topics you'd like me to cover in future blog posts, please feel free to reach out.

Andrea Trombley PT, DPT

References

Barrios-Garay K, Toledano-Serrabona J, Gay-Escoda C, Sánchez-Garcés MÁ. Clinical effect of vitamin C supplementation on bone healing: A systematic review. Med Oral Patol Oral Cir Bucal. 2022 May 1;27(3):e205-e215. doi: 10.4317/medoral.24944. PMID: 35368012; PMCID: PMC9054165.

Brzezińska, O., Łukasik, Z., Makowska, J., & Walczak, K. (2020). Role of Vitamin C in Osteoporosis Development and Treatment-A Literature Review. Nutrients, 12(8), 2394. https://doi.org/10.3390/nu12082394

Crook, J., Horgas, A., Yoon, S. J., Grundmann, O., & Johnson-Mallard, V. (2021). Insufficient Vitamin C Levels among Adults in the United States: Results from the NHANES Surveys, 2003-2006. Nutrients, 13(11), 3910. https://doi.org/10.3390/nu13113910

Zeng LF, Luo MH, Liang GH, Yang WY, Xiao X, Wei X, Yu J, Guo D, Chen HY, Pan JK, Huang HT, Liu Q, Guan ZT, Han YH, Zhao D, Zhao JL, Hou SR, Wu M, Lin JT, Li JH, Liang WX, Ou AH, Wang Q, Li ZP, Liu J. Can Dietary Intake of Vitamin C-Oriented Foods Reduce the Risk of Osteoporosis, Fracture, and BMD Loss? Systematic Review With Meta-Analyses of Recent Studies. Front Endocrinol (Lausanne). 2020 Feb 3;10:844. doi: 10.3389/fendo.2019.00844. PMID: 32117042; PMCID: PMC7008177.

Will Prunes help me build stronger bones?

Eating prunes can help you get the nutrients you need to keep your bones strong

Have you heard that prunes are good to eat to prevent osteopenia or osteoporosis?

It's true.

​ The Prune Study, published in 2022, found prunes to be effective in preserving bone density. The study was conducted over 12 months, and the postmenopausal women ate 50g or 100g of prunes daily. That is roughly 6 prunes to get to 50g. The 100g prune group lost many participants, suggesting eating that many prunes isn't feasible.

Women who consumed 50g of prunes had a decreased risk of fracture compared to the control group at one year. While the control group lost 1.1% of bone mass, the 50g prune group maintained their bone density.

I will be honest, I tend to eat 2 prunes a day, fewer than the amount recommended by the authors of the study. But I am also weight training and I haven't had a fracture. This seems like an easy addition to what I am already doing.

You can decide what feels right for your body and your bone situation.

Be sure to check with your primary care physician and/or pharmacist if you are taking medications that may interact with this many prunes. While they are a good source of Vitamin K and good for bone health, foods high in Vitamin K, such as broccoli, cabbage, chard, kale, and prunes, may counteract the effects of blood thinners.

Takehome tips:​
Eat a wide variety of foods
Get enough protein in your meal to help feel full and build muscle
Drink plenty of water to stay hydrated, especially when you are working out and lifting weights
Food before Pharmacy - get your nutrition from your food rather than supplements whenever possible.

✅Enjoy your food, nourish your body,

Andrea Trombley PT, DPT

References:

Damani, J. J., Oh, E. S., De Souza, M. J., Strock, N. C., Williams, N. I., Nakatsu, C. H., Lee, H., Weaver, C., & Rogers, C. J. (2023). Prune Consumption Attenuates Proinflammatory Cytokine Secretion and Alters Monocyte Activation in Postmenopausal Women: Secondary Outcome Analysis of a 12-Mo Randomized Controlled Trial: The Prune Study. The Journal of nutrition, S0022-3166(23)72732-6. Advance online publication. https://doi.org/10.1016/j.tjnut.2023.11.014

De Souza, M. J., Strock, N. C. A., Williams, N. I., Lee, H., Koltun, K. J., Rogers, C., Ferruzzi, M. G., Nakatsu, C. H., & Weaver, C. (2022). Prunes preserve hip bone mineral density in a 12-month randomized controlled trial in postmenopausal women: the Prune Study. The American journal of clinical nutrition, 116(4), 897–910. https://doi.org/10.1093/ajcn/nqac189

Whole Body Vibration or Heel Drop for Osteoporosis and Osteopenia?

Your time is precious, how should you spend it? You want to address your osteopenia or osteoporosis and prevent further bone loss, but how?

Let's talk about Whole Body Vibration (WBV) as a way to increase bone density.

I get asked about WBV fairly often. When you first find out that your bone density is not what you thought it was, it is normal to want to do everything you can to improve it. Maybe WBV is the thing you should be doing.

What does the most recent research tell us about whole-body vibration?

In January 2023, The journal, Osteoporosis International released Effectiveness of whole-body vibration on bone mineral density in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials and meta-analysis with some interesting findings.

After evaluating 21 studies, it was concluded that WBV at a high frequency (30 Hz), low magnitude (0.3g), and high cumulative dose (>7000 minutes) is effective at increasing bone density at the lumbar spine. This is a lot of time on a vibration plate. You would need to be on the vibration plate for about 20 minutes a day for over a year to get this benefit. And, because the benefits were mostly seen with high-frequency settings, this type of protocol is not safe for those who are at a high risk of fracture.

​What does this mean?

When we look at the benefits of WBV compared to a regular exercise program, there is no difference; meaning they both help.

At this time, we don't know if the benefits of WBV last. A few more drawbacks to WBV include access, most people do not have a WBV plate, and the expense of buying one that has these specific parameters and will last over 7000 minutes is not cheap. There is also some conflicting information about whether you should stand on the plate with flexed knees or not. For anyone with knee arthritis, this may be difficult to do.

Another systematic review released in July 2023, Impacts of Whole-Body Vibration on Muscle Strength, Power, and Endurance in Older Adults: A Systematic Review and Meta-Analysis, found that lower body strength improved with WBV. Most of the included studies were of low quality, and they concluded that there was no difference between WBV and other types of exercise.

We do know that regular resistance and cardiovascular exercise have many benefits beyond bone and lower body strengthening that WBV doesn't have. This includes improvement in:
👉heart disease risk,
👉improving depression,
👉helping with weight management
👉decreased hot flashes.

This means exercise, including weight training, resistance training, and cardio workouts is a much better use of your time and money.

Takeaway: Spend your 20 minutes a day doing resistance exercise, rather than standing on a vibration plate. Spend your money on an exercise class or coach rather than buying a vibration plate.

To go along with exercises that benefit your bones, see my Exercise Tip heel drops and foot stomping. The way to increase bone density comes down to anatomy. Bone is stimulated to form in relation to the forces put through it, particularly compression. What better way to compress bone than stomping around or doing heel drops? Of course, if you have an active fracture, don't do these exercises.

What do you think?

If you need help getting started with a consistent exercise routine, I am here to help. Join my waitlist and be the first to get the details of my upcoming Strong Women, Strong Bones 4-week Jumpstart program.

I look forward to helping you build bone and healthy habits,

Andrea​ Trombley PT, DPT
​

References:​
de Oliveira, R. D. J., de Oliveira, R. G., de Oliveira, L. C., Santos-Filho, S. D., Sá-Caputo, D. C., & Bernardo-Filho, M. (2023). Effectiveness of whole-body vibration on bone mineral density in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials. Osteoporosis International: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 34(1), 29–52. https://doi.org/10.1007/s00198-022-06556-y

Gonçalves de Oliveira R, Coutinho HMEL, Martins MNM, Bernardo-Filho M, de Sá-Caputo DDC, Campos de Oliveira L, Taiar R. Impacts of Whole-Body Vibration on Muscle Strength, Power, and Endurance in Older Adults: A Systematic Review and Meta-Analysis. J Clin Med. 2023 Jul 3;12(13):4467. doi: 10.3390/jcm12134467. PMID: 37445502; PMCID: PMC10342949.

Bone Strength, Vitamin D and Muscle Strength - All Connected!

The research on osteoporosis and osteopenia is hard to find, but there are indications that it is being studied more and more. And now the connection between bone loss and muscle loss is also getting attention.

I came across this brand-new study and wanted to share it.

​The association of vitamin D with bone microarchitecture, muscle strength, and mobility performance in older women in long-term care.

It was published in the journal Bone in November, 2023.

I have written about Vitamin D before. You probably all know that I have low Vitamin D levels which were discovered with a blood test. My primary symptom was bone pain when I went to bed at night - not a symptom any of us want.

I was lucky to have a great physician who caught this, but unfortunately, after 2 years of increasing my Vitamin D and sunlight, my levels were still low. I now take prescription strength Vitamin D and will have my levels checked again next summer.

Back to the study.

The study was designed to see if there was a connection between three variables:
1. ​Vitamin D levels​
​2. Bone status using Trabecular Bone Score (TBS),
​3. Muscle strength using gait speed and grip strength

The Trabecular Bone Score is a way to evaluate bone microarchitecture indirectly and may help predict fragility fractures. It is a score taken from the lumbar spine DEXA (dual-energy X-ray absorptiometry) image. It is an advancement in DEXA technology but not all machines are capable of calculating this score.

The TBS is produced from a scanned image. The trabecular bone number, separation, and connectivity density are scored. A high TBS represents a strong, fracture-resistant microarchitecture, while a low TBS reflects weak, fracture-prone microarchitecture. It cannot be used accurately if you have had a lumbar fracture, or have a BMI above 37. It is not a stand-alone test, it is used to complement the original DEXA.

In the study, a connection was made between low Vitamin D levels, lower-quality bone, and lower strength. The study was relatively small, and the authors note that other factors could be at play.

I am sure there will be studies that go into this in-depth in the near future.

Takeaways​
* Vitamin D levels are easy to evaluate with your next blood work - go ahead and ask to have them checked.
* Keeping your muscles strong will improve your grip strength and gait speed, and will reduce your fall risk
* You may have a TBS on your next DEXA report, let's see how this helps us figure out our risk of fracture.

I hope this was helpful. I thought you might still have questions about the TBS, so I wrote more about it here: What Is A Trabecular Bone Score?

✅ Stay strong and retire active,

Andrea Trombley PT, DPT

References:

Haeri NS, Perera S, Greenspan SL. The association of vitamin D with bone microarchitecture, muscle strength, and mobility performance in older women in long-term care. Bone. 2023 Nov;176:116867. doi: 10.1016/j.bone.2023.116867. Epub 2023 Aug 5. PMID: 37544395; PMCID: PMC10528338.​

Rajan, R., Cherian, K. E., Kapoor, N., & Paul, T. V. (2020). Trabecular Bone Score-An Emerging Tool in the Management of Osteoporosis. Indian journal of endocrinology and metabolism, 24(3), 237–243. https://doi.org/10.4103/ijem.IJEM_147_20​

Osteoporosis Exercise Guidelines⭐

I you are a woman over 50 with osteoporosis, or osteopenia or are at risk, you probably have questions about the best exercises you should do to stay strong for years to come.

I am sending out a big thank you 🙏 to the Canadian Medical Association Journal for publishing these guidelines on osteoporosis management a few weeks ago.

Clinical Practice Guidelines are something astute healthcare providers look forward to in order to stay on top of the most current research. Guidelines like these are compiled by a group of healthcare professionals who go through all of the research and provide best-practice treatment recommendations. This is a time-consuming process, and the results often change what healthcare providers recommend to their patients.

While the guidelines are meant for healthcare providers, I think it is helpful for anyone with bone loss to know what the evidence for intervention supports and what it debunks. The complete document is sort of long, but there are 25 recommendations and 10 good practice statements you can check out.

I am going to highlight a few things I think are worth knowing, but of course, you can read the whole guide here.​

👉Recommendations (Check out tables #2-4 in the guide):

#1: Exercise.

💪 Balance and functional training more than 2 times per week. This includes reaching beyond the comfort zone, increasing repetitions and sets over time, changing the pace, and moving while doing something - all to improve balance and reduce the risk of falls.

#2 Nutrition.

Calcium from food, NOT FROM SUPPLEMENTS. Get 1200mg per day from calcium-rich foods.
​Vitamin D - It is hard to get the recommended dose from food, a supplement of 400 IU/day may be appropriate.
​Other - if you have a healthy diet, they suggest no supplementation of protein, vitamin K, or magnesium to prevent fractures. If you are on medications, consult your physician for your own plan.

#3 Fracture Risk.

Use the FRAX tool to assess risk.
✅Bone Mineral Density testing in postmenopausal females and males who
a. are aged 50–64 years with a previous osteoporosis-related fracture or ≥ 2 clinical risk factors OR
b. are aged ≥ 65 years with 1 clinical risk factor for fracture OR
c. are aged ≥ 70 year

#4 Pharmacological Recommendations​
Before initiating pharmacotherapy, good practice includes assessing for secondary causes of osteoporosis, and for potential limitations when considering specific osteoporosis pharmacotherapy.
Check out the complete table #4 for all recommendations, including specific medications and durations.

I hope you found this helpful.

I think one of the biggest challenges I see when women are first diagnosed with osteoporosis or osteopenia is the immediate desire to load up on supplements. While I understand the desire to take action and make up for something that might be missing in your diet, supplements are more often than not, not absorbed and therefore useless, expensive, and at times, harmful. I recommend supplements ONLY if you have been SPECIFICALLY told to take them by YOUR physician. DO NOT fall for the marketing of unregulated, untested supplements sold online, in health stores, or by personal trainers.

👉There is some specific research for very few supplements that can help with muscle 💪 and bone strength: vitamin D, Collagen, and creatine. Other than that, most vitamins, minerals, and protein should be taken in as food. Spend your money on organic food, exercise programs for women over 50 or exercise equipment - you will get more bang for your buck!

If you do see something that you want to try, please check with your doctor to make sure it isn't going to interact with the medication you are taking.

And remember, bone strength 🦴 is built by using it, not by ingesting the building blocks. Get out there and build bone by lifting weights.

​
Stay strong and retire active,

Andrea Trombley PT, DPT

Reference:
CMAJ 2023 October 10;195:E1333-48. doi: 10.1503/cmaj.221647

Knee Arthritis, Is Exercise Making it Worse?

Once again, I have been scouring the internet for recent research on exercise to see what is hot 🔥 and relevant for those of us over 50, 60, 70, 80, and beyond. This week, let's talk about knee arthritis and ageism.

First, I want to congratulate you for participating in sports in your younger years, this was most likely beneficial to your health today, including your joint health. Unless you were a high-level elite athlete, your risk of developing osteoarthritis is the same as someone who has been sedentary. In this review article from 2016, the authors concluded:

"Moderate daily recreational or sport activities, whatever the type of sport,
are not a consistent risk factor for clinical or radiographic knee/hip OA."

Stop beating yourself up for running, or playing tennis, or whatever your sport was. You were active, and you are better off for it. The authors point out that physical activity helps more than it harms. The good stuff you get from physical activity:

"soft-tissue extensibility, blood flow, and synovial fluid mobility,
normal joint range of motion and ... essential nutrients to the cartilage matrix."

These are all GOOD things!

But some of you may have arthritis nonetheless. What should you do about it now?

In the September 2023 issue of the Journal of Geriatric Physical Therapy, a systematic review and meta-analysis, addressed this question. Should someone continue resistance training or add it in the presence of knee osteoarthritis?

The short answer is YES.

The average age of the subjects in the review was 64.2 years. The resistance training programs varied in length from 4-120 weeks, with a frequency between 2-7 times per week. Because it was a review, there was not a consistent exercise intervention. Some studies used weight machines, others used theraband or ankle weights. All of the studies worked to strengthen the quadriceps and hamstring muscle groups in some way.

The conclusions - Resistance training 2 times per week, above 50% of your one rep max, and consistently done beyond 4 weeks can help knee symptoms, function, and strength.
​
If you have not been strengthening your knees but would like to start, I have these two exercises for you.

The Straight Leg Raise, and the Quad Set. These are particularly helpful to know before any type of surgery, or after surgery, or to stay strong when standing exercises don't feel great. I am particularly fond on the leg press machine if you have access to one.

If your knees are feeling good but you need to be sure to keep your strength, start working on higher-demand exercises like the squat.​

Now I want to touch on the subject of ageism.

Definition from the American Psychological Association: Ageism is defined as discrimination against older people because of negative and inaccurate stereotypes—and it’s so ingrained in our culture that we often don’t even notice.

A recent comment in my Osteoporosis and Osteopenia Exercise group got me thinking about how important it is to keep pushing back on the stereotypes of aging. This sentence from this study in JAMA in 2022, really struck me:

Associating poor health with old age may be the most deeply rooted aging stereotype, despite evidence to the contrary (for example, 82.3% of participants in the current study rated their physical health as good or better).

I want to list a few examples of the questions that were asked in this study to determine if the participants were experiencing everyday ageism (you can read the whole list here):

​
I hear, see or read jokes about old age, aging, or older adults
I hear, see or read things suggesting that older adults and aging are unattractive or undesirable
People insist on helping me with things I can do on my own
People assume I have difficulty hearing or seeing things
Having health problems is a part of getting older

As a physical therapist, I can tell you I have been yelled at and called names many times for pushing older clients too hard by their well-meaning relatives. It started during my very first clinical rotation, right up to today in my Facebook group - MY Facebook group, about exercise! The irony.

Let's end ageism.​

✅ Stay strong and retire active,

Andrea Trombley PT, DPT

Addendum: This article by orthopedic surgeon Howard Luks backs up all I said here! Three Words that Cause Harm: "Bone on Bone"

References

Allen, J. O., Solway, E., Kirch, M., Singer, D., Kullgren, J. T., Moïse, V., & Malani, P. N. (2022). Experiences of Everyday Ageism and the Health of Older US Adults. JAMA network open, 5(6), e2217240. https://doi.org/10.1001/jamanetworkopen.2022.17240

Lefèvre-Colau, M. M., Nguyen, C., Haddad, R., Delamarche, P., Paris, G., Palazzo, C., Poiraudeau, S., Rannou, F., & Roren, A. (2016). Is physical activity, practiced as recommended for health benefit, a risk factor for osteoarthritis?. Annals of physical and rehabilitation medicine, 59(3), 196–206. https://doi.org/10.1016/j.rehab.2016.02.007

Wang, Huan PhD1; Ma, Baoan MD1; Wang, Guotuan PhD2; Wang, Pu PhD1; Long, Hua PhD1; Niu, Shun PhD1; Dong, Chuan PhD1; Zhang, Hongtao PhD1; Zhao, Zhen PhD1; Ma, Qiong PhD1; Hsu, Chihw-Wen PhD3,4; Yang, Yong PhD5; Wei, Jianshe PhD2,6. Dose-Response Relationships of Resistance Training in Adults With Knee Osteoarthritis: A Systematic Review and Meta-analysis. Journal of Geriatric Physical Therapy ():10.1519/JPT.0000000000000394, September 29, 2023. | DOI: 10.1519/JPT.0000000000000394