Have you ever heard of osteopenia? We investigate a case of increasing osteopenia

On a grey and damp winter’s day, a lovely, beautifully presented woman in her mid-50s came to see me. She just wasn’t feeling her normal self: lots of niggly symptoms had started to bother her and she was concerned as she had friends that kept telling her she was just getting old, but she did not want to accept this perspective.

On discussing the issues with her, nothing was seriously wrong. She had a few aches and pains and was getting repeated doses of low-grade colds and flu infections. It was nothing to make her really ill, but she was experiencing these every few weeks, more frequently since the onset of the cold and wet weather. On the day she came to the clinic, she had just been recovering from yet another cold and had a dry tickly cough. She also had very sensitive dry skin so used large quantities of a commercial moisturiser that appeared to make little long-term difference.

Apart from these, she was gradually putting on a bit of weight: a kilogram every few months despite a strict low-fat diet. She was increasingly fatigued during the day despite a regular good night’s sleep, assisted with low-dose melatonin.

As regards her diet, as her weight had been gradually increasing over the last couple of years she had significantly reduced the fats in her diet and was eating mainly salads without dressing and fruit, with the occasional legumes such as chickpeas or tofu for protein. Philosophically she was committed to a vegetarian diet, almost to the point of being vegan but did add honey to foods, with the occasional egg on weekends.

Recognising this unusual combination of symptoms, I immediately sent her back to her GP to have her vitamin D levels checked.

Because she was interested in health she realised the importance of regular exercise, and during the winter went to the gym regularly three times a week. During the summer she still did a couple of days a week in the gym and supplemented these three days a week with walks through the local streets and parks, always making sure she was adequately protected from skin cancer when outdoors with the regular use of sunscreen to protect her skin, sunglasses to protect her eyes and a hat.

Her levels of exercise were decreasing, however, as she was increasingly getting muscle and joint aches and pains, and was taking magnesium and glucosamine to try and relieve these. This helped a little but didn’t stop the problem.

The results of her recent DEXA bone density scan showed increasing osteopenia, and she was concerned about developing osteoporosis despite the regular weight-bearing exercise.

With all these low-grade symptoms and the fatigue she felt, she was becoming increasingly miserable, helped a little by the melatonin, but this was not enough. She also felt she became increasingly depressed over winter, but luckily this seemed to improve in summer.

Vitamin D

Recognising this unusual combination of symptoms, I immediately sent her back to her GP to have her vitamin D levels checked, and as I expected her levels were very low, which surprised her. She thought that as she lived in a country known for its sunshine she would be fine. Her immediate reaction was that she would have to get out in the sun more.

To obtain vitamin D from the sun you need as a general rule half an hour a day at least of exposure to the sun of face, arms and legs. While the most effective dose is delivered around the hottest part of the day, this is also the riskiest for skin damage, so we usually recommend the exposure to be in the early morning or late afternoon, without sunscreens and without sunglasses. For correct vitamin D production we need UV light on the retina of the eye as well. And since she had shielded herself from the sun so well for many years, her skin and eyes were likely to be very sensitive initially.

Low-fat diets are also a problem, as vitamin D is a fat-soluble nutrient and is obtained from foods like dairy products and eggs. Mushrooms are a good vegetarian source, particularly if they are left in the sun for 30 minutes before cooking, as this increases their vitamin D content significantly. So increasing the “good” fats is necessary; I suggested hemp oil both topically as a moisturiser and internally.

Problems with fat digestion, such as gallbladder or liver problems, are also risk factors for low vitamin D.

I therefore recommended a vitamin D supplement until her symptoms improved, along with the changes in lifestyle that would allow her to obtain this nutrient more naturally. Supplements are effective, but the levels need to be checked every 12 months as overdoses can also occur. The ideal level in Australia is about 100nmol/L; although the medical levels for normal are 50–140nmol/L, these values are too broad and some individuals can be deficient even when they fall into the low normal range medically.

She also needed to increase the protein in her diet, so I also recommended supplements of the cofactors of vitamin D: magnesium, vitamin K2 (taken separately) and zinc (for immune support and as an antiviral), and I also suggested a general calcium hydroxyapatite formula containing boron and the other cofactors to calcium.

After a couple of weeks of supplementing these nutrients and changing her diet, she felt much better and resolved to continue this regime, at least until the end of winter.