A Functional Medicine Osteopenia Protocol: Testing, Nutrition, and Specialized Supplements

Thirty-four million Americans are currently afflicted with osteopenia; however, the incidence is expected to increase exponentially as our population ages. By 2030, over 20% of the United States population is expected to be over age 65. (33) 

Early diagnosis and treatment of osteopenia are crucial as they prevent further bone loss and reduce the risk of fractures. They provide an opportunity for lifestyle modifications that support bone health, such as dietary changes, exercise, and stress management. Early detection also enables timely consideration of pharmacological interventions if necessary. Overall, addressing osteopenia early contributes to long-term bone health, better quality of life, and the maintenance of mobility and independence. This article will discuss a functional medicine approach to treating osteopenia. 

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What Is Osteopenia?

Osteopenia is characterized by low bone mineral density (BMD), which means the bones have lost some of their calcium and other minerals, making them weaker and more prone to fractures. It is a precursor to osteoporosis, a more severe condition where bone density is significantly reduced. Although osteopenia may not cause noticeable symptoms, it is important to address this condition to prevent the progression to osteoporosis.

What Causes Osteopenia?

An imbalance between bone remodeling and resorption processes in the body primarily causes osteopenia. Bone remodeling is a continuous process involving removing old bone tissue (resorption) and forming new bone tissue (deposition). This process helps maintain the strength and integrity of the skeletal system. (24) 

In osteopenia, there is an increased rate of bone resorption compared to bone deposition. Several factors can contribute to this imbalance: 

Aging

Bone density naturally decreases with age. Even in healthy people, bones begin to break down faster than they build up after age 35, causing bone density decreases by less than 1% annually (22). 

Hormonal Imbalances

Hormonal changes can also accelerate bone loss. Estrogen plays a vital role in maintaining bone density by suppressing the function of osteoclasts (cells responsible for breaking down old bone tissue) and promoting the activity of osteoblasts (cells responsible for building new bone tissue). Therefore, in states of low estrogen, such as in menopausal women, the rate of bone breakdown can surpass that of bone formation, leading to bone loss. 

Similarly, progesterone and testosterone play a role in maintaining bone health in men and women by supporting bone formation and inhibiting bone resorption. Low progesterone and testosterone levels, which can also occur with aging, can increase the risk of osteopenia. 

Other endocrine conditions characterized by excess thyroid hormone (hyperthyroidism) or parathyroid hormone (hyperparathyroidism) can increase bone resorption and calcium release from bones, leading to weaker bones. (22).  

Nutrient Deficiencies

Inadequate intake of bone-specific nutrients can contribute to osteopenia. 

Calcium is a crucial mineral for building and maintaining strong bones. Hydroxyapatite is a mineral form of calcium phosphate that is the primary component of the inorganic matrix of bones and teeth. It provides the structural framework of bones. Good sources of calcium include dairy products, leafy green vegetables (such as broccoli and kale), fortified plant-based milks, and calcium supplements if needed.

Vitamin D plays a critical role in calcium absorption and utilization. It helps regulate calcium levels in the blood and supports bone mineralization. The primary source of vitamin D is sunlight exposure, but it can also be obtained from fatty fish (e.g., salmon, mackerel), fortified dairy products, egg yolks, and supplements.

Phosphorus works in conjunction with calcium to form hydroxyapatite. Good sources of phosphorus include dairy products, meat, fish, nuts, and legumes.

Magnesium helps to activate vitamin D, influences the concentration of parathyroid hormone (PTH), and is a regulator of osteoblast and osteoclast cellular activity.

Vitamin K is necessary for the synthesis of proteins involved in bone mineralization. It helps direct and bind calcium to the bone matrix. Green leafy vegetables (e.g., spinach, kale), broccoli, and fermented foods are rich in vitamin K.

Adequate protein intake is essential for bone health as protein makes up a large portion of bone mass and volume, creating the structural framework for mineralization. Collagen is the body's most prevalent type of protein, comprising 25-35% of total protein mass. Vitamin C, copper, and manganese are essential micronutrient cofactors for the endogenous production of collagen. 

Stress

Chronic stress has adverse effects on bone density. When the body experiences stress, activation of the HPA axis results in the release of cortisol. Elevated cortisol over an extended period can lead to increased bone resorption, impaired bone formation, nutrient imbalances, and reduced estrogen and testosterone levels (35). This is why chronic use of corticosteroid medications, such as prednisone, is also associated with an increased risk of osteopenia (22).  

Lifestyle Factors

Lack of physical activity, especially weight-bearing exercise, and prolonged periods of inactivity can lead to reduced bone density (35).  

Smoking has been linked to decreased bone density and an increased risk of fractures. Smoking interferes with bone remodeling and reduces estrogen levels in both men and women, contributing to bone loss. (1) 

Chronic and excessive alcohol intake can have detrimental effects on bone health. It interferes with the absorption and utilization of calcium, decreases bone formation, and increases the risk of fractures. (17) 

Insufficient body weight, such as in cases of underweight individuals or those with eating disorders, can lead to decreased bone density. 

Certain medications, such as long-term use of glucocorticoids (steroids) or proton pump inhibitors (PPIs), can contribute to bone loss and osteopenia (35). 

Osteopenia Symptoms

Osteopenia is often called a "silent" condition because it typically doesn't cause noticeable symptoms in its early stages. People with osteopenia may not experience pain or physical manifestations until the disease progresses, leading to more severe bone loss or fractures. (22) 

How Is Osteopenia Diagnosed?

Osteopenia is diagnosed using a dual-energy X-ray absorptiometry (DEXA) scan, which measures bone mineral density. The results of this scan are compared to the bone density of a healthy young adult of the same sex, and a T-score is assigned. A T-score between -1 and -2.5 standard deviations below the average indicates osteopenia, while a T-score below -2.5 signifies osteoporosis. (33) 

Functional Medicine Labs That Can Help Individualize Treatment for Osteopenia

Functional medicine labs are beneficial tools to assess underlying factors for low bone density so that functional medicine providers can create personalized and effective treatment plans for reversing and preventing bone loss.

Nutritional Assessment

A comprehensive nutritional assessment, such as Genova Diagnostic's NutrEval, analyzes biomarkers related to nutrient status, inflammation, and metabolism. The results of this test can be used to identify nutrient deficiencies and risks associated with low bone density, evaluate the patient's overall dietary patterns, and help personalize dietary recommendations to ensure nutritional needs are met. 

Comprehensive Hormonal Panel 

Doctors should order a thyroid panel, PTH, and sex hormones to rule out endocrine imbalances contributing to dysfunctional bone remodeling and reduced bone mass.

Comprehensive Gut Assessment

Gut health is important for proper absorption of nutrients and supporting healthy hormonal levels required for maintaining bone health. Especially in patients with multiple nutrient deficiencies or symptoms of hormone imbalances, thoroughly evaluating the gut for signs of inflammation, dysbiosis, and malabsorption with a comprehensive stool analysis and serum celiac disease panel may be beneficial in addressing the underlying cause of the disease.

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Functional Medicine Treatment Protocol for Osteopenia

A functional medicine approach to treating osteopenia focuses on addressing underlying factors contributing to increased bone resorption. The core treatment options for osteopenic patients involve education on maintaining healthy bone mass levels through lifestyle modifications, optimizing nutrition with targeted dietary supplementation, and correcting root causes (e.g., chronic stress, digestive dysfunction, hormonal imbalances) based on lab findings.

Therapeutic Diet and Nutrition Considerations for Osteopenia

A nutrient-dense, anti-inflammatory diet, such as the Mediterranean diet, supports bone health by providing essential nutrients required for improving bone density and mineral content, reducing the risk of fractures, decreasing bone resorption, and reducing systemic levels of inflammation in the body. Additionally, this type of diet will support the endocrine and digestive systems of the body. A diet rich in fish, fruit, vegetables, legumes, low-fat dairy, nuts and seeds, and whole grains will provide sufficient protein and bone-essential micronutrients. (36)

Studies also show that incorporating prunes into the diet reduces bone resorption and inflammation, conferring osteoprotective effects.

Exercise Recommendations for Osteopenia

A combination of weight-bearing, resistance training, and balance training exercise is best for encouraging osteogenesis and preventing falls, which increases the risk of bone fractures. Weight-bearing exercises include walking, stair climbing, and jogging. Resistance training puts more stress on bones to make them stronger and involves using weight machines, free weights, and resistance bands. Yoga and tai chi are forms of exercise that can improve strength and balance. (9) 

Supplements Protocol for Osteopenia

The following discusses various supplements commonly used in treating osteopenia, including their potential benefits and dosage recommendations. This article will not discuss supplements specific to healing the gut or balancing hormones, but this should be included for patients whose lab results indicate it is necessary.

Osteo-K Minis

In addition to providing 400 mg of calcium and 2000 IU of vitamin D daily, Osteo-K Minis also deliver 45 mg of MK4, a type of vitamin K2 supported by more than 25 clinical trials to maintain strong bones. Studies have shown that combined calcium and vitamin D supplementation can prevent osteoporotic hip fractures in postmenopausal women. Additional studies show that 45 of MK4 daily decreases vertebral fractures by 60%, hip fractures by 73%, and all nonvertebral fractures by 81% in osteoporotic patients.

Dose: 2 capsules twice daily with food

Duration: at least one year

Collagen

Patients not meeting daily protein requirements through diet alone should add collagen peptides into their supplemental routine. Research suggests that 5 grams daily can improve bone density (8, 14). Other research suggests that taking up to 15 grams of collagen peptides daily to meet protein requirements is safe. 

Dose: 5 grams daily

Duration: at least one year

Melatonin

Melatonin, a hormone produced by the pineal gland, is known for its role in sleep regulation but may also benefit bone health. It has antioxidant and anti-inflammatory effects, reducing oxidative stress and inflammation linked to osteoporosis. Melatonin regulates bone metabolism by influencing osteoblast and osteoclast activity. It also aids calcium balance, which is crucial for bone mineralization, and its role in regulating the circadian rhythm indirectly supports bone health by promoting good sleep patterns and reducing stress. Recent studies have shown that taking melatonin before bed may positively affect bone health and increase bone mineral density in postmenopausal women after one year of treatment. (18)

Dose: 3 mg nightly before bed

Duration: at least one year

When to Retest Labs

A DEXA should be ordered every 1-2 years to monitor osteopenia and bone density. Functional medicine labs monitoring nutrient status, hormones, and gut health are generally reordered every 3-12 months, as indicated by clinical necessity and doctor/patient preference. 

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Summary

In this article, we delve into applying a functional medicine approach for treating osteopenia, a condition characterized by decreased bone density. Functional medicine takes a comprehensive and personalized approach to address the underlying factors contributing to osteopenia, including nutrient deficiencies, hormonal imbalances, gut health, stress, and lifestyle factors. By targeting these root causes through dietary and lifestyle modifications, stress management, and natural supplements, a functional medicine approach aims to support bone health and prevent further bone loss.