The best rule of thumb is to eat at least five servings of fruits and vegetables for every serving of red meat, chicken, or fish that you eat. I also recommend that one day a week you eat no meat or dairy (essentially a vegan diet), getting your protein instead from beans, tofu, and other plant-based sources. The fact is that for the vast majority of time that humans have been on this planet—over 200,000 years—our main source of food has been nuts, seeds, and fruits foraged in season, plus animal protein. Agriculture, and the grain-and dairyrich diets that it made possible, has existed for a mere 10,000 years. And recent research into Paleolithic nutrition has found that hunter-gatherer societies—even those in existence today—are healthier on all levels than those whose food sources are primarily grain-based. Plus, they don’t have osteoporosis.47
Since, as Castleman puts it, calcium is important for the brick part of the bone wall, it’s still a good idea to take calcium supplements. I prefer mineral supplements that are chelated with amino acids for maximum absorption—calcium citrate, calcium citratemalate, or a mixture of any of the following: calcium ascorbate, calcium fumarate, calcium succinate, or calcium tartrate. Microcrystalline hydroxyapatite is also a good source of bone-building calcium. Make sure that you take magnesium along with the calcium. A 1:1 ratio of calcium to magnesium is ideal, but 2:1 is also acceptable. (See Resources.) Green leafy vegetables, such as spinach, kale, broccoli, and collard greens, are good dietary sources of calcium.
Although Tums are now being promoted as calcium supplements, I do not consider them a good choice. For one thing, Tums is an antacid that decreases hydrochloric acid levels in the stomach—and hydrochloric acid is necessary for optimal absorption of calcium. Many people already have inadequate levels of hydrochloric acid as they age, which can lead to digestive problems. Why make that worse? For another, Tums contains no magnesium or any of the other nutrients needed for bone building. Magnesium deficiency is as much a problem in bone health as inadequate calcium, and because calcium and magnesium work in critical balance, they should be supple-mented together. In fact, too much unbalanced calcium can actually decrease the body’s ability to absorb magnesium from food. Dietary surveys have shown that 80–85 percent of American women consume less than the RDA for magnesium already. High, unbalanced calcium intake can also block the uptake of manganese, decrease iron absorption, interfere with vitamin K synthesis, and increase fecal phosphorous excretion. Finally, very high doses of calcium carbonate (4–5 g per day), which is the type of calcium in antacids, can cause a serious, kidney-damaging disorder known as milk alkali syndrome.48
WHAT ABOUT BONE-BUILDING DRUGS?
Far too many doctors prescribe one of the newer bone-building drugs as the first line of treatment for any woman who shows any sign of decreased bone mass—even those who are very far from having actual osteoporosis or even significant osteopenia. However, there are many safe and effective alternatives that work more naturally with the wisdom of the body.
Here’s a brief rundown of the most commonly available bonebuilding prescription drugs. Like hormone therapy, these work only as long as a woman is on them.
BISPHOSPHONATES: The bisphosphonates are the most widely prescribed antiresorptive agents and are currently considered the first-line treatment for postmenopausal osteoporosis. These drugs interfere with osteoclast function, thus preventing bone breakdown and turnover. That may seem beneficial, but the truth is that this can actually make the bone more brittle, because without the breakdown part of the equation, the bone gets too thick for blood vessels to be able to nourish it. Animal studies show that these drugs also interfere with the normal repair of microdamage to bone, which eventually weakens the very thing the drug was meant to strengthen.
Research on humans confirms that there is indeed reason for caution. For example, in a 2005 study on the bisphosphonate alendronate (Fosamax) done at the University of Texas Southwestern Medical Center, all the patients in the study were found to have severe depression of bone formation.49 In some cases, spontaneous nontraumatic spinal or atypical femur fractures have been reported.50 In the fall of 2010, the FDA required all bisphosphonates used to treat osteoporosis (most notably alendronate and risedronate) to carry warning labels disclosing the possible increased risk for these atypical femur fractures. Even though these fractures account for less than 1 percent of all hip and femur fractures, a task force investigating the risk reported that 94 percent of the 310 cases under study involved patients who had been taking bisphosphonates, most for more than five years. (The majority of these patients had felt a telltale pain in their groin or thigh weeks or even months before the fracture occurred.) The warning labels also suggest that patients taking these drugs be periodically reevaluated for their need to continue taking them because the optimal length of time for taking the drugs has not been determined.
Bisphosphonates had been initially hailed as a potent way to fight thinning bones because trials showed that in women with osteoporosis, alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) reduced the incidence of hip, vertebral, and nonvertebral fracture by almost 50 percent, particularly in the first year of treatment.51 But these results are seen only in women who already have osteoporosis; the reduced risk is not seen in healthy women trying to prevent bone loss in the future. A 2008 article in the British Medical Journal estimated that doctors would have to treat 100 women with these drugs to benefit just one woman.52
The side effects of bisphosphonates range from merely bothersome to downright dangerous. Some of the more common side effects of Actonel, for example, include back pain, joint pain, stomach pain, nausea, and vomiting. Fosamax may cause nausea, constipation, and heartburn. In some studies, up to a third of the participants had stomach-acid-related complaints, and one in eight required treatment. Some even developed severe esophageal ulcers.53 About 50 percent of women stop treatment within a year because of such side effects. Some women on this drug have suffered osteonecrosis of the jaw—death of the bone tissue, a condition that is not treatable.54 Others have found that they require root canals soon after beginning alendronate. Both of these serious side effects are likely to be caused by the inadequate circulation problem described above.
Bisphosphonates stay in the body for decades, even after women stop taking them, because they bind tightly to bone. It will be at least another ten years before we truly know their long-term effect on bone health. So in the meantime, bisphosphonates, if used at all, should be reserved for much older postmenopausal women (seventy or older) with major risk factors for osteoporosis. Even in those cases, experts are now calling for a “drug holiday” after five years of treatment for most women who take these drugs.55
My opinion is that these drugs should be used cautiously, but they do have a place, especially in women who are at very high risk for osteoporosis. After all, women who suffer hip fractures show a significant increase in mortality. I prefer maximizing bone health with a regimen that combines vitamin D, exercise, and estrogen over taking bisphosphonates, but for some women, the benefits of these drugs may outweigh the risks.
EVISTA (RALOXIFENE): This selective estrogen receptor modulator (SERM), like the related drug tamoxifen, has an estrogenic effect on bone but antiestrogenic effects on breast tissue. Though Evista has been shown to help build bone, and though it decreases spinal fractures by 40 percent, it has not resulted in a decrease in the incidence of hip fractures, for reasons that aren’t yet clear.56 Side effects include hot flashes. I’m also very concerned about the possibility of dementia risk with this drug because, like tamoxifen, it blocks the well-known beneficial effects of estrogen (including the estrogen our bodies make on their own) on brain cells.
CALCITONIN: Calcitonin is a naturally occurring peptide that partially blocks osteoclast activity and regulates calcium loss in the urine. This is an injectable or nasal synthetic form of the parathyroid hormone. It reduces the risk of spinal but not hip fractures and also reduces pain from new spinal fractures. Side effects
include nausea and flushing. Most experts agree that the bisphosphonates work better.57 Bottom line: everyone with low bone density needs to have enough vitamin D, magnesium, and calcium, and needs to eat a lowacid diet. Weight-bearing exercise on a regular basis is also essential (see below). Many might also benefit from alendronate or risedronate once weekly (or ibandronate once monthly), but I’d prefer all women try natural methods first.
GET STRONG
Regardless of your diet, supplements, or any drugs you may be on, the big news is that weight-bearing exercise in general and strength training in particular play a crucial role in creating and maintaining healthy bones. If you don’t currently exercise regularly, you’re not alone. Sixty percent of the U.S. population is sedentary, which is one of the main reasons why osteoporosis has reached such epidemic pro-portions. Remember, it is not the aging process per se that causes bones to thin—it’s the fact that too many women slow down and stop using their muscles.
Weight-bearing exercise helps build bone by stimulating the mineralization and remodeling process. Every major muscle in our bodies is attached to underlying bone by tendons. So each time a muscle contracts, it exerts a force on the bone to which it is anchored. (We know that in tennis players, for example, the bone density in the racket arm is significantly greater than in the other arm.)
Yoga and tai chi can also help build bone mass. For example, a 2009 study from Thailand concluded that weight-bearing yoga training had a positive effect on bone for postmenopausal women, reducing their risk of osteoporosis.58 (Not surprisingly, the researchers also reported that the yoga training promoted a better quality of life!)
But the most studied method of strengthening bone is weight lifting. Miriam Nelson, Ph.D., of Tufts University, has done groundbreaking research that shows how weight training can slow down and even reverse bone loss. Dr. Nelson studied two groups of postmenopausal women, none of whom were on estrogen replacement, bone-building drugs, or any special supplements. Both groups were sedentary but healthy at the start of the program. One group remained sedentary while the other began a simple exercise program. At the end of one year the women who lifted weights for forty minutes twice per week had turned back the clock in several ways. Their scores on strength tests increased to match those of women in their late thirties or early forties. Without dieting, they trimmed down; muscle is less bulky than fat. Their balance improved greatly, warding off falls. The biggest payoff: while the sedentary control group lost about 2 percent of their bone density during the year, the women who strength-trained gained 1 percent.59 Dr. Nelson’s research also shows that higher-impact activities (including vertical jumping and stair climbing) can help build bone when they’re done safely. She recommends a comprehensive exercise program including weight-bearing aerobic exercise, strength training, vertical jumping (when appropriate and for women under fifty), balance exercises, and stretching.
But stronger bones aren’t the only benefit of getting strong. Dr. Nelson noted an unexpected but very exciting change in the women who did weight training—a change that I’ve also seen repeatedly. Within a few weeks the weight-lifting women felt happier, more energetic, and more self-confident. As their muscles began to get stronger, they became more active and daring. In order to control the study, they had agreed not to join other fitness programs. But these former couch potatoes were now going canoeing, inline skating, or dancing because they wanted to. Nelson also confirmed that weight training, like aerobic exercise, lifts depression and helps arthritis.60
The joys and benefits of fitness are so numerous that I want to do everything in my power to motivate you to get strong. Of all the ways to stay vital, healthy, and attractive, exercise probably gives the most return for the time spent. Whatever your age and condition right now, physical exercise can improve it and give you a new lease on life—guaranteed. In 1994 researchers proved this by instituting a strength-training program in frail nursing-home patients with an average age of eighty-seven. The exercise group did forty-five-minute strength-training sessions for the hips and knees three days per week. Within ten weeks, their strength increased by over 100 percent. In a nonexercising control group, strength declined by about 1 percent. The improved muscle strength after exercise was unrelated to the age, sex, medical diagnosis, or functional level of the participant. After the strength-training program some of the participants who had previously used walkers required only a cane. Exercise also improved stair-climbing ability, speed of walking, and overall level of physical activity.61 In a 2009 study, researchers showed that elderly patients who followed a home-based physiotherapy program along with taking high-dose supplementation of vitamin D significantly reduced their rate of falls and hospital readmission.62
If these kinds of results are possible in frail octogenarians in nursing homes, think what could happen for a fifty-year-old couch potato. The average midlife woman of today is expected to live until at least age eighty-five, if not a hundred. You cannot afford to let your muscles and bones slip into decline at midlife. There are too many potentially high-quality years ahead. And there’s not a single drug, technological breakthrough, or genetic development on the horizon that can or ever will come close to providing you with the benefits you can derive yourself from getting and staying strong. Besides, women who exercise regularly live six years longer than nonexercisers. If you think you don’t have time to exercise, I suggest that you reconsider. Slowly shuffling along with a walker instead of striding confidently takes up a lot of time. And dying six years prematurely is truly a colossal waste of time.
Almost every woman I know is too busy to exercise. There are always more things to get done in a day than you have time for. If you wait to exercise until you get everything else done, you are waiting for a miracle. Like muscles that won’t get stronger until you reach down and pick up a heavy weight, exercise won’t happen in your life unless you make it as much a priority as brushing your teeth or taking a shower. The first thing that must change if you are to exercise regularly is your mind. No excuses.
WHAT WOULD IT TAKE TO GET YOU MOVING?
~ Do you enjoy moving your body? Recall a moment in your life in which you were captivated by the sheer joy of dancing, running, swimming, or jumping. When was the last time you felt this way?
~ When was the last time that you felt that pleasurable sense of complete relaxation that comes from spending a day immersed in the pleasures of some activity—skiing, hiking, sailing, dancing, or inline skating?
~ What types of activities did you enjoy as a child? As a teenager?
~ If you do not exercise now, why not?
~ If you don’t exercise now, when did you stop? Why?
~ Do you feel that you don’t have time to exercise? Why not?
HEALING YOUR FITNESS PAST
When my mother turned eighty several years ago, my whole extended family gathered in my hometown for a big party and other activities that included downhill and cross-country skiing, as well as snowshoeing. My mom kept right up with her grandchildren and still skis beautifully. Every summer, she leads a group of fortysomethings on a hiking expedition in the Adirondacks that they call Camp Edna. These women love benefiting from my mother’s experience and expertise. So at an age when many women have relegated themselves to the sidelines, my mother is not only coaching the game, she is also actively playing it. She often gets up at six, mows the huge lawn on the farm where I grew up, waters all the flowers, then plays two sets of tennis with her friends. Sometimes she plays golf, too.
My mother’s physical activity level is way out there, and I don’t see it as a standard to which I or anyone else should aspire unless they find it as satisfying as she does. But my mother’s physical condition and prowess have helped me (and my daughters) understand that physical decline and weakness need not be part of growing older. In fact, it’s a legacy I received before birth: my mother skied and hiked through all her pregnancies and later carried each of us children in a backpack during these same activities.
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