Nutrition: The Role of A Diet Rich Fruit and Vegetable in Osteoporosis

The Role of Fruits and Vegetables in the Management of Osteoporosis:

Osteoporosis is defined as a generalized skeletal disorder characterized by compromised skeletal bone strength, which predisposes individuals to an increased risk of fracture. Osteoporosis is a significant cause of pain, disability, and death throughout the world. Integrative medicine makes use of a range of strategies to reduce the risk of osteoporosis, including an anti-inflammatory diet, supplements, stress reduction, and lifelong exercise lifestyle.

Osteoporosis is a multifactorial disease arising from genetic, hormonal, metabolic, mechanical, and immunological factors. Bones provide the support structure for our bodies, protect the vital organs, and play a central role in mineral and acid-base balance. The two main types of bone cells are osteoblasts (which synthesize the organic bone matrix and mediate calcification) and osteoclasts (which resorb bone to allow for metabolic requirements and for repair and remodelling). 

Bone mass reaches its peak by around 30 years of age, but repair and renewal of the bone continue throughout adult life, with approximately 15 % of the bone mass turning over each year. Bone is dynamic and constantly responding to a range of hormonal, metabolic, neurological, and mechanical signals. Bone loss usually begins in the fourth decade in both men and women. Women typically lose 0.5 % to 0.9 % of the bone density per year during the perimenopause, 1 % to 3 % during menopause years, and 1 % per year into old age. On the average, women lose 35 % of the cortical bone and 50 % of their trabecular bone over their lifetimes. Men are half as likely as women to experience a fracture as they reach higher peak bone mass, have a larger cortical thickness, and have better preservation of bone microstructure. 

 

The Role of Inflammation:

 

Chronic inflammation is implicated in the process of aging. ^{1, 2} and posited to play a role in the development of a wide range of diseases, including cardiovascular diseases, Alzheimer's disease, diabetes and cancer. ^{3, 4} Growing evidence indicates that osteoporosis is also, in part, a result of chronic low-grade inflammation ^{5, 6} Proinflammatory cytokines, such as interleukin -6 (IL-6), interleukin-1 (IL-1), and tumour necrosis factor-alpha (TNF-alpha), promotes accelerated bone loss by the activation of osteoclasts, and enhanced breakdown of the extracellular matrix. ⁷ Furthermore, suppression of proinflammatory cytokines appears to support the growth of new bone. For instance, TNF-alpha inhibitors, such as etanercept, have been found to improve BMD (bone mineral density) in patients with spondyloarthropathy. ⁸ It is widely recognized that patients with systemic inflammatory conditions, such as rheumatoid arthritis, inflammatory bowel disease, multiple sclerosis, and SLE (systemic lupus erythematosus), are at increased risk of bone loss. ⁹

 

The Role of Nutrition:

 

Fruits and vegetables are a rich source of anti-inflammatory and antioxidant compounds, and diets rich in fruits and vegetables are associated with both increased peak bone mass and improved bone health in older populations. ^10-13 The bone-building effects of fruits and vegetables may result from several factors including: anti-inflammatory and antioxidant phytonutrients; alkalinizing effects; the provision of nutrient such as potassium, vitamin K, and vitamin C; and the presence of other unknown compounds and synergistic effects. Thus, an anti-inflammatory diet that includes abundant fruits and vegetables, whole grains, legumes, and healthy fats is recommended as the foundation of an integrated bone health plan.

 

Acid-Base Issue:

 

The skeleton plays a key role in acid-base homeostasis. ¹⁴ In bone, minute reductions in the local pH can stimulate osteoclast activity while also impairing the activity of osteoblast. ¹⁵ A diet high in animal protein and low in fruits and vegetables tends to produce a chronic low-grade metabolic acidosis that may be harmful to the skeleton. ^16-20 Fruits and vegetable generate bicarbonate that can buffer the acidifying effects of animal protein, alkalinize the urine, and significantly lower urinary calcium excretion. ²¹ In a study by Buclin et al., acid-forming diets increased calcium excretion by 74 % as compared to base-forming diets. ²² Balanced diets with adequate protein along with abundant fruits and vegetables are therefore recommended. ^{23, 24} 

In addition to effects on acid-base balance, the benefits of plant foods also appear to be related to pharmacologically active components, including specific monoterpenes, ²⁵ flavonoids, and phenol ²⁶ that may be responsible for the observed beneficial effects on bone. 

Muhlbauer described 25 plant foods as " bone resorption inhibitory items" (BRIFT). These include garlic, rosemary, Italian parsley, sage, thyme, parsley, dill, onion, arugula, prune, fennel, orange, leek, yellow boletus, wild garlic, field agaric, red cabbage, celeriac, red wine, and lettuce. 

 

Microbiome and Bone Health:

 

There is emerging evidence that the human microbiome plays a significant role in many dimensions of health, including brain function, immune response, levels of inflammation, body weight, and cancer risk. ^{27 - 28} The gut microbiome has also been shown to influence bone health. In animal studies, prebiotic feeding aimed at enhancing production of short chain fatty acids by intestinal bacteria resulted in increased fractional calcium absorption and increased bone density and strength. ²⁹

A study by Ohlsson et al. found that treatment with probiotics can diminish bone loss related to sex-steroid deficiency in mice. ³⁰ Several human trials in adolescent girls and boys have found that prebiotic supplementation can increase the numbers of bifidobacteria, enhance calcium absorption, and increase bone mineralization ^{31, 32}

 In general, a healthy, diverse microbiome can be supported by including cultured and fermented foods in the diet, eating a diet rich in "microbiota-accessible carbohydrates" (MACs) ³³ and avoiding unnecessary antibiotics. Ongoing research may clarify how the health of the microbiome can be supported and enhanced in order to sustain bone health. 

 

Vegetarian and Vegan Diets:

 

Plant-based diets area associated with a lower risk of chronic disease and reduced overall mortality. ³⁴ In 2009, the American Dietetic Association issued a position statement stating: "...appropriately planned vegetarian diets, including total vegetarian or vegan diets are healthful, nutritionally adequate, and may provide health benefits in the prevention and treatment of certain diseases". ³⁵   In practice, vegetarians and vegans are more likely to have low intakes of vitamin D ³⁶, calcium, vitamin B12, and omega-3 fatty acids. In tropical countries like Malaysia where sunlight is plenty, vitamin D deficiency is less likely even though in my experience I have seen quite a number of cases of rickets both in poor communities in rural areas of the country, and also in the paediatric wards at the Kuala Lumpur Hospital 

Vegetarian and vegan source of zinc are also less bioavailable although this can be supplemented by 15 mg of elemental zinc daily. On the other hand, healthy vegetarian or vegan diets contain plentiful amounts of magnesium, potassium, vitamin K, and antioxidant and anti-inflammatory phytonutrients. A number of studies have shown that vegetarian, especially vegan, diets may increase the risk of osteoporosis and bone fractures. ³⁷ In a meta-analysis by Ho-Pham et al. BMD was, on average, 4 % lower in vegetarians (all types) and 6 % lower in vegans. ³⁸ The EPIC-Oxford study examined fracture risk in more than 34,000 meat eaters, fish eaters, vegetarians, and vegans, and reported fracture risk was highest in vegans. However, when only subjects with adequate calcium intake were included, no statistical difference was shown in fracture risk among any of the groups.  ³⁹   A longitudinal study of Asian vegans and omnivores reported a higher rate of bone loss in the omnivore group, with fracture risk found to be the same in both groups. Lower body weight, higher intake of animal protein and fats, and corticosteroid use were all associated with a greater rate of bone loss. ⁴⁰

 If vegans and vegetarians follow the principles of an anti-inflammatory diet and ensure adequate intake of calcium and vitamin D, they should be able the benefits of a plant-based diet without increasing their risk of osteoporosis and bone fractures. 

 There are also other benefits using nutrition and nutrition supplements using calcium, vitamin D, essential fatty acids, protein, vitamin K, magnesium, trace minerals, vitamin C, soybeans, botanical medicines, tea (Camellia sinensis), exercise, and harmless substances such as sodium, caffein, smoking, alcohol, pharmaceuticals, steroids, bisphosphonates, selective oestrogen receptor modulators, calcitonin, teriparatide, denosumab, and even vitamin A. But to discuss all of them even as brief as possible would run into an estimated 30 - 40 more pages which would tire me out, and I would not want that for the sake of my health.

Even all the citations and references from research papers mentioned here, I must leave them out from typing as this is only meant to be a short article meant for doctors and interested readers.

Perhaps it would be far more useful for me to write an article on cancer on how to manage them using integrated approaches rather than using a standalone treatment such as chemotherapy, radiation, surgery, immunotherapy, etc, etc.., as used in conventional allopathic medicine that does not work at all with high incidences of relapses. Even that is an immensely huge subject to write on as there are so many types of cancers requiring different integrated approaches. But I shall try.

Maybe I shall start off with lung cancer first, then on colorectal cancer, then on liver diseases for my next few articles since lung cancer is the third most common cancer after breast, colorectal cancers in Malaysia, with lung cancer on the rise in recent years even among women who hardly smoke. I shall try but give me time to rest first if we continue on this subject on osteoporosis.