Bone health

Inflammation and your bones — prevent osteoporosis by cooling the fire

by Marcelle Pick, OB/GYN NP

We hear so much in the media about osteoporosis and osteopenia that almost every woman I see has questions about her bone health these days. Often women think that osteoporosis is a familial disease that they can’t do much to prevent aside from drinking more milk, building muscle strength, or taking a drug. But there is actually much more to maintaining healthy bones than calcium, weight-training, or bone drugs. And one connection that is often overlooked is reducing inflammation.

Though Chinese Medicine has acknowledged inflammation in its practice for several thousand years, Western medicine is just starting to recognize its far-reaching effects. While our bodies’ inbuilt inflammatory process is crucial to our survival, new research is revealing how low-grade chronic “fire” lies at the root of nearly all the chronic and degenerative diseases so prevalent here in the West — heart disease, metabolic syndrome, cancer, and also osteoporosis. When it comes to bone health, a body suffering from chronic inflammation can send messages that disrupt the natural remodeling process that our bones undergo on a regular basis. And for many, the unfortunate result after years of this simmering fire is brittle, osteoporotic bone.

The good news is that there is so much you can do in your life to limit inflammation and decrease your likelihood of developing osteoporosis and osteopenia, as well as other inflammatory conditions. So let’s take a closer look at how inflammation affects our bones and what you can do to dampen the fire naturally.

What is inflammation?

Inflammation is the basic mechanism of your immune system. It is the body’s built-in defense system to ward off disease and heal wounds. You might be wondering what your immune system has to do with your bones. Well one of the first things I tell my patients is that inflammation is like an opportune weed in the garden — it can grow (often starting in the GI tract) and spread to overrun all systems of the body, including our bones. But we also have to be mindful of the fact that without some inflammation, we wouldn’t be able to heal.

To differentiate between helpful inflammation and when it can be harmful, let’s first look at the differences between acute and chronic inflammation. Acute inflammation is a short-term process your body undergoes to heal an injury or fight infection. Pro-inflammatory hormones are released and trigger white blood cells to attend to the injury or foreign body. These cells are responsible for cleaning up damaged tissue and clearing away infection. We recognize acute inflammation by redness, heat, swelling, and pain.

But chronic or systemic inflammation isn’t as easy to pick up on. Most of the time my patients aren’t aware of it as it develops, because it’s a low-grade process that keeps the immune system “quietly” active, but not enough to see obvious swelling and redness, or always to feel pain, for that matter — at least at first. (Once they take measures to address it, however, they are often surprised by how much better they feel.)

The ongoing immune cell activation that occurs with chronic inflammation can be caused by poor nutrition, allergies and sensitivities, autoimmune disorders, toxic exposures, and excessive stress, among others. Ultimately it can impair any other system in the body, including our musculoskeletal system. Many people live with chronic pain as a result of systemic inflammation. As you can see from the chart above, there are numerous inflammatory disorders that may contribute to or accompany inflammation in the bones, as well as the joints. For information on arthritis and other related concepts, see our inflammation section.

Aluminum, mercury, lead and other heavy metals are all around us. We have mercury in our mouths, lead in our water, aluminum in our deodorants (and antacids!). We know that heavy metal toxicity inflames our system but to what level it affects bone loss has yet to be discovered. Some people don’t detox heavy metals as well as others. This can have a deleterious affect on gastrointestinal, kidney, and liver function — all of which can affect bone remodeling and calcium absorption.

How does inflammation affect my bones?

When it comes to strong bones, our bodies rely on a dynamic coupling between the cells that break down old bone and those that build new bone. If the immune system is persistently activated, this process becomes uncoupled and the osteoclasts, the cells that break down bones, begin to run amok. Just as the inflammatory process is essential for healing the body, osteoclasts are essential for healthy bone turnover. But when there is imbalanced activity between osteoclasts and osteoblasts, the cells that build up bone, we begin to see more bone breakdown than building.

Let’s look at some of the ways these cells interact and signal one another. Osteoblasts are primarily responsible for turning osteoclast production and activity on and off. They do this via a system of signaling proteins called cytokines. The main cytokine messengers in the inflammation–bone dynamic are a triad known as RANK/RANK-L/OPG. RANK and RANK-L are essentially activators of osteoclasts, whereas OPG (osteoprotegerin) is the inhibitor. When ongoing inflammation is present, RANK-L predominates over OPG, causing more osteoclasts to be generated and stay active longer than they should, disrupting the natural balance.

Clues to understanding this system have recently been found within our stem cells (see the illustration below). Both our immune cells and our osteoclasts originate from a common parent cell called the hematopoietic (meaning “blood-making”) stem cell. Osteoblasts originate from a different cell line, starting with the mesenchymal stem cell, a type of parent cell that can differentiate into many other kinds of cells, including muscle, cartilage, bone, tendons, skin, and fat. As a result of the common origins of immune cells and osteoclasts, when chronic inflammation ramps up our immune response, osteoclast activity gets ramped up, too.

We can think of it like a faucet that is controlled by osteoblasts under normal circumstances. In good health, we are comfortable with balanced “water temperature” — warm enough, but not scalding. When we’re inflamed, osteoblasts lose regulatory control. It’s as if the temperature dial on the hot water tank is turned up too high, and no matter how much cold water (or OPG) the osteoblast contributes, it’s not enough to compete with the hot (or RANK-L).

The diagram illustrates how RANK-L binds to the RANK receptors on the surface of an osteoclast to turn preosteoclasts into mature, active ones. OPG, on the other hand, dials down osteoclast activity in two ways. It acts as a decoy receptor to block the RANK receptor, which keeps preosteoclasts from maturing. It also inactivates mature osteoclasts by signaling that it’s time for them to die. As with all living things, our cells have a normal life cycle; this programmed cell death is called apoptosis. If RANK-L overrules OPG, osteoclasts survive beyond their normal lifespan — they just keep on going and going.

We still don’t fully understand inflammatory bone erosion, so this is simplifying a very complicated process. We do know there are many other factors at play. On top of upregulating RANK-L over OPG, our immune/inflammatory response generates an entire cascade of messengers throughout the body that directly and indirectly affect bone remodeling.

There are multiple cytokine messengers that not only stimulate our immune system, but also play a role in osteoclast activity. IL-6 (interleukin-6) is one example of a cytokine that plays a major role in the inflammatory process, as well as promoting the maturation of osteoclast cells. Both mature and immature osteoclasts have receptors for IL-6 on their cell surfaces, and are stimulated by it. Osteoclasts also have receptors for other proinflammatory cytokines, including IL-1 (interleukin-1) and TNF-α(tumor necrosis factor alpha), both of which lead to increased bone breakdown. These cytokines also play important roles in aging, heart disorders, IBS, obesity, and other systems, as well as cancer risk. So it makes sense that quieting the inflammatory response in your body can make an enormous difference on multiple levels.

Kindling for the fire

The next question women often have is: How did I get here? First let me explain that environmental conditions and lifestyle can set the stage in the body to favor inflammation: smoking, alcohol use, gluten sensitivity, diets high in red meat, and so on. There are too many to go into detail here — but I’d like to touch on a few key areas of impact that I think are very important: estrogen imbalance, chronic stress, and digestive imbalance.

Many women know estrogen plays a role in bone health, but they may not know that estrogen has a quieting effect on the inflammatory “noise” in our bodies. In terms of bone health, estrogen can limit RANK-L and other pro-osteoclast transcription factors to help regulate osteoclast activity. But as we approach menopause and estrogen starts to decline, these messengers increase in activity (or become “louder,” as I like to say), accelerating bone breakdown. Yet a decline in estrogen is perfectly natural for our bodies as we transition through menopause, and as long as we are providing our bodies with the support they need during this transition, diminishing estrogen levels alone do not lead to inflammatory bone loss.

Chronic stress leads to bone loss through a form of hormonal imbalance known as cortisol dominance or hypercortisolism. While acute stress can enhance our immune and inflammatory response in the short-term, Mother Nature never intended for us to experience chronic unremittent stress. Stemming from daily frustration, anxiety, worry, anger, poor eating habits, over-exercise and so on, chronically elevated cortisol inhibits bone formation. The data on this effect are preliminary, but high cortisol levels have been linked with higher rates of osteoporotic fractures. (See our articles on adrenal health for more information.)

Perhaps more fundamental to inflammatory bone loss than estrogen for many women is digestive health. This is often where I look first in a woman with symptoms of systemic inflammation. Yes, estrogen helps keep the fire at bay, but imbalance in the digestive tract, in my experience, almost always lies at the root of systemic inflammation.

Why is this? There is to some extent a chicken-or-egg dynamic at play here. So many factors can perturb digestion, triggering an inflammatory response in the gut; but it’s likewise common for inflammation in our gut to trigger or worsen weak digestion. Either way, the body isn’t digesting properly.

In the case of food allergies and sensitivities, such as lactose or gluten intolerance, the integrity of the gut’s mucosal lining is disrupted, leading to a condition commonly referred to as “leaky gut.” The damaged mucosal membrane then allows particles of undigested food to pass into the blood stream, which in turn prompts the body to turn on its defenses and mount an immune response. A heightened immune response not only upregulates osteoclast activity, it can lead to further allergies and sensitivities to fuel the fire. Other conditions in the gut linked with inflammation include irritable bowel syndrome (IBS) and dysbiosis (microbial imbalance).

So, as you’ll see below, the GI tract is often the first place to start when you want to limit inflammation. Taking a functional medicine approach, we can adopt several measures to effectively quiet inflammation in the gut and break this vicious cycle of dysbiosis, inflammation, and accelerated bone erosion.

What you can do to dampen the fire and protect your bones — the Women to Women perspective

Thankfully, you have lots of choices when it comes to limiting inflammatory bone loss. My advice is to take stock of your lifestyle and eating habits now — no matter where you are with your bones — and look at small changes you can make to cool the fire. Whether you’re simply concerned about preserving your bones or you’ve already been diagnosed with osteoporosis or osteopenia, it’s never too late to influence bone health. And if you have symptoms of inflammation or any inflammatory condition — including osteoporosis — there are many safe, natural, and effective measures you can take today to change the outcome for your bones tomorrow.

Here are some recommendations I’ve found to be powerful for my patients:

• Cultivate healthy gut flora. This is so important for your health on several levels. The GI tract is where we absorb all the nutrients we need for day-to-day cellular function, and malabsorption means we miss out on essential nutrients. The problem often stems from a lack of beneficial bacteria that help us digest food, absorb nutrients, and ward off troublesome pathogens like systemic yeast. You can help maintain friendly floral colonies by eating plenty of fiber; incorporating “living” foods like yogurt, kefir, sauerkraut, and kimchee into your daily diet; and moderating your intake of red meat. If dysbiosis is a problem for you, taking a probiotic supplement regularly may be more helpful in restoring and maintaining healthy gut flora. We formulated our own Balanced Biotic to contain both beneficial bacteria and a competitive yeast. For more information on cultivating a healthy gut, see our other articles on digestion and GI health.
• Follow an anti-inflammatory, highly alkalizing diet. If you read our articles regularly, you’ve heard me say it again and again — food is our best medicine. In the wisdom we see time and again throughout the natural world, an anti-inflammatory diet has everything in common with an alkalizing diet. This way of eating — lots of alkalizing fruits and vegetables, adequate healthy protein, and the highest-quality fats — is so important to your overall health and well-being, especially when it comes to your bones! So just say no to trans fats and other low-grade oils, and limit red meat, refined grains, and sugars. These foods and all the additives for coloring, flavoring, and preserving them, fan the flames of inflammation in our bodies. Consider slow-cooking, and simmering foods in place of frying. These methods preserve the nutrients and reduce the oxidative stress caused by deep-fried foods. For more suggestions, see our article on the natural approach to reducing inflammation.
• Eliminate gluten from your diet. Recent studies indicate a direct relationship between gluten reactivity and severity of osteoporosis. Many more people than previously thought are gluten sensitive. And whether you have outright celiac disease or mild to moderate intolerance of gluten, when your immune system views the gluten molecule as “foreign,” it amplifies your inflammatory response, which, over time, puts your bones in jeopardy. Luckily, the many gluten-free foods available on the market today make it much easier to adopt a gluten-free diet. Since many of the foods that contain gluten are likewise acid-forming, by removing it from your diet you’ll also be adopting a more alkaline diet, doubling the benefit for your bones.
• Detox regularly. Food allergies and sensitivities can ramp up inflammation in the body, placing your bones at risk. To better identify any problematic foods or substances, you may want to experiment with an elimination diet — removing a suspected item from your diet for two weeks, then reintroducing it to see how you feel. I’ve learned over the years that food sensitivities often fall below our radar screen — gluten intolerance, in particular — where many women don’t realize the extent to which a certain food sickens them until they eliminate it. If you know or think you may be allergic or sensitive to certain foods, you may want to see an allergist or functional medicine practitioner for testing and consultation. Acupuncture has also been found helpful in ameliorating the effects of inflammation, quieting the immune response, and facilitating the detoxification process.
• Incorporate omega-3 fatty acids in your diet. Over the years I’ve been in practice, there has been a tidal wave of research published on the anti-inflammatory benefits of omega-3 fatty acids, and it’s hard to overemphasize how important they are in stopping inflammation from damaging your health. With the ongoing shift away from the diets of our ancestors, these fats have become increasingly scarce in our modern American diets — with serious implications for our health on every level, including our bones. Eating more foods that are rich in omega-3’s, like wild Pacific salmon, mackerel, walnuts, and flax seed, can be one of the easiest ways to offset the effects of inflammation on your bones. You might also benefit from a high-quality omega-3 supplement like the one we offer in our Personal Program.
• Supplement with vitamin D. Another superstar in recent health news, vitamin D is not just crucial to the health of your bones. Low vitamin D levels have been linked with increased cancer risk, type 1 diabetes, and heart disease, too. All the molecular underpinnings are not yet clear to us, but these conditions all have an inflammatory component. Vitamin D helps us absorb calcium in the gut, and also modulates the immune system to regulate osteoclast activity. Exposure to sunlight is nature’s way of providing ample vitamin D to your body, but not everyone gets enough healthy sun exposure, and even if you do, not everyone’s body manufactures D effectively through this mechanism. Recently, it was estimated that as many as a billion people worldwide are vitamin D deficient! For all these reasons we highly recommend 2000 IU of supplemental vitamin D3 per day.
• Supplement with vitamin K. Until recently, we have only poorly understood the central role of this vitamin in bone health. We now know that there is actually a family of K vitamins, but they are still typically lumped together as simply vitamin K. We have also learned recently how this group of vitamins helps limit calcium loss in the kidneys, and that it’s instrumental to the action of several proteins needed for bone building. Certain plant foods are good sources of vitamin K1, and traditional fermented foods like sauerkraut, natto, and kimchee, as well as certain cheeses, are good sources of vitamin K2. But the truth is, most of us get precious little of either form in our diets. Recognizing both the importance of K and its relative scarcity prompted us to formulate our own Better Bones products with optimal vitamin K1 and K2 levels. (For women whose concern for bone health is perhaps not so immediate, or for whom inflammation is not worrisome, our foundational Essential Nutrients contains a healthy baseline dose of vitamin K1.)
• Be sure you are getting enough magnesium (Mg). Studies have linked magnesium deficiency with reduced bone mass and increased bone fragility. The mechanism for this appears to be through the RANK/RANK-L/OPG triad described above, with a diet low in magnesium resulting in increased numbers of osteoclasts and higher bone resorption. So be sure to eat plenty of magnesium-rich foods such as spinach, almonds, avocados, and soybeans. And since nearly everyone’s diet is less than perfect, taking a good multivitamin/mineral supplement containing magnesium is a good idea.
• Consider DHEA, whey, milk basic protein, and amino acids. Supplementing with DHEA, whey, milk basic protein, and amino acids such as L-arginine, glutamine, ornithine, lysine, and glycine can help to increase insulin growth factor-1 (IGF-1). This leads to a state in the body more favorable for bone building. Note that this requires working closely with a functional medicine clinician, and monitoring biomarkers of bone turnover, to assess changes. Some women have difficulty tolerating this kind of supplementation, so an individualized approach is needed, working together with your body and your practitioner to achieve the desired results. There is also topical glutathione, a combination of cysteine, glutamic acid, and glycine, that works for some women who can’t tolerate oral amino acid supplements.
• Use NTx testing as a tool to track bone breakdown and measure progress. Most insurance companies don’t cover the high cost of a bone mineral density test (DEXA) for most women under the age of 60. So in addition to a DEXA for older women, and instead of tracking bone health by DEXA for younger women, there is a test called NTx that you can do on your own to measure how quickly your bone is breaking down. As bone breaks down, protein by-products (N-telopeptides) are excreted into the urine, and the NTx test measures these markers of bone breakdown. As you implement your bone-building program, retesting once every three months or so will give you a good idea about your progress. Keep in mind that the ranges for “normal” on NTx tests vary by company, so to track your progress accurately you will want to be sure to order your test kits from the same place every time.
• Obtain an hs-CRP test to evaluate for systemic inflammation. When C-reactive protein (CRP) is elevated, it indicates the presence of an inflammatory process in the body. But chronic inflammatory processes aren’t detected by the standard CRP lab tests requested by most conventional practitioners. I always do a high-sensitivity CRP (hs-CRP) on my patients because it allows me to detect low-lying inflammatory processes and intervene earlier on. If you’re concerned about inflammation, consider requesting this test.

Support for the future

I know the idea of osteoporosis and especially fracture can make women fearful of the future. As we move beyond menopause and look forward to the years of calm and stability, the last thing we want to worry about is fragile bone. Know that our bones, like the heart, the lungs and the brain, are living tissue, tissue that needs good nutrition, exercise, and support from tip to toe.

You aren’t helpless when it comes to supporting your bones. Inflammation can smoulder below the surface, disrupting the natural balance between your bone breakdown and bone growth, but you can do something about it. Taking steps today to calm chronic inflammation in your body is one of the best things you can do for the future of your bones — and your whole being

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References & further reading on inflammation and your bones

 

Last Modified: 05/25/2011
Principal Author: by Marcelle Pick, OB/GYN NP