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Osteoporosis affects mainly women but men are increasingly being diagnosed. It is not a condition of normal aging. It is a result of the interplay between lifestyle factors, nutritional-depletion, immune function and metabolic imbalance.

The patient with reduced bone density and osteoporosis presents significant clinical challenges, often including other health concerns and quality of life issues. I realize some time ago that there were limitations with using only calcium and vitamin D or even the many multi-nutrient bone support products available. Though these were considered the standards of practice, most fell short of adequately addressing osteoporosis. This was a common finding even in patients that faithfully took them for years. Despite this, many continued to have little or no improvement in bone density. Though density was stabilized in some, others were unable to address the condition. In other words, the benefits were unsatisfactory and fell short. How could this be? To find out, I returned to the scientific literature and undertook an exhaustive review of the past and present research. Consequently, a newly revised protocol for patient management was developed.

1.  Diet and Exercise:

  • The Return To Balance Dietary Plan: Reducing the risk of osteoporosis starts with a healthier dietary "Return to Balance" (RTB). The RTB Plan is a modern dietary lifestyle that restores our ancestral EFA and alkaline profile. It can best be described as a combination of Crete Mediterranean and Asian in style, both which have the lowest overall major health risk indicators in the world. This diet is also both bone strengthening and bone sparing. Because it is the most genetically adapted, it continually promotes healthy gene expression. In other words, it fits our genes. Most importantly, it returns the balance of the omega-6/omega-3 essential fatty acid (EFA) ratio to <4:1. It's also a high alkaline diet and maintains a positive potassium/sodium ration >4:1.
  • How? This dietary profile consists of a large proportion of potassium rich plant foods, such as non-starchy vegetables, fruits, berries and herbs. These should be locally grown and organic whenever possible. High phenolic unfiltered extra virgin olive oil, fish, shellfish, walnuts, whole flax meal, green and black tea are also important. Allowed in moderation are whole grains, starchy vegetables, soy, almonds, sesame, legumes, sheep and goat cheese, and local farm eggs. Wild game, organic grass fed meats and free farmed poultry are eaten sparingly by comparison. Regular exercise that is both aerobic and weight bearing should also be a consistent part of any osteoporosis program.

2.  Key Factors & Adjuvant Support:

  • Overview: As the Plan emphasizes, effective osteoporosis support is based on optimizing bone density, quality, and micro-architecture. This plan targets the interplay between acid-alkaline balance, osteoblast activity (bone formation), osteoclast activity (bone resorption), osteocalcin activity, calcium absorption, parathyroid function, healthy inflammatory response, hormonal support, EFA balance, vitamin/mineral nutrition and antioxidant protection. Thus, this plan delivers exceptional bone support not easily previously achieved with other nutrient combinations. The Key Factors below are recommended as the core components that have the most positive effects on bone. The Adjuvant Cofactors provide additional support for further optimizing the effects of the program. Both have been essential to the success of this program.

3.  The Fully-Optimized Osteoporosis Therapy Protocol:

  • Calcium (citrate): 300 mg three times per day at or between meals. Do not take within 2 hours of strontium.
  • Potassium (citrate): 400 mg three times per day at or between meals (may be contraindicated with ACE inhibitors or potassium sparing diuretics).
  • Magnesium (citrate): 150 mg three times per day at or between meals.
  • Vitamin D3: 2000 i.u. per day with meals. (Higher dosage may be needed, based on 25 (OH)-D results).
  • Strontium (citrate): 681 mg at bedtime. Take 2 hours away from dairy foods or calcium supplements (contraindicated in severe kidney disease).
  • Vitamin K: synergistic combination of K1 500-1,000 mcg and K2 (MK-7) 45-90 mcg per day (contraindicated in warfarin use).
  • Melatonin: 3 mg at bedtime (may be contraindicated in depression or autoimmune disease and for individuals using MAO inhibitors and corticosteroids).


  • Omega-3 EFAs from land and sea: Fish oil providing 1-2 g EPA+DHA and flax oil providing 2 grams of ALA per day. Take at meals.
  • Multi-vitamin & Mineral Complex: Choose a comprehensive formula with chelated minerals and activated vitamins.


  • Calcium (citrate): Meeting daily calcium needs is vital, but does not translate to complete osteoporosis support. Calcium targets bone resorption, via effects on parathyroid (PTH) secretion. Calcium citrate, being mildly alkaline and more absorbable, is significantly more effective than calcium carbonate in this respect. The combination with potassium citrate confers an even greater alkali load and can partially offset the effects of an acid forming diet on bone.
  • Potassium (citrate): Potassium citrate supplementation is emerging as an important bone support component. The alkalizing effect of potassium citrate reduces dietary acidity and urinary calcium loss. In the intestinal tract, it may help facilitate calcium absorption in acidic diets. In bone, alkali stimulates osteoclastic formation and lessens osteoclastic resorption. This supports healthy bone mass and bone quality. Potassium chloride or gluconate do not share this same effect. The bone health effects of potassium citrate and calcium citrate may be greater when combined together vs. either alone.
  • Magnesium (citrate): Bone is one of the main magnesium pools in the body. Magnesium provides unique support that helps maintain normal levels of C-reactive protein (CRP) for a healthy inflammatory response. CRP related inflammation has a known inhibitory effect on osteoblast formation and studies suggest it negatively effects osteocalcin formation, bone turnover and bone micro-architecture at levels that also affect cardiovascular health and glucose metabolism. Thus magnesium's inverse effects on CRP levels may have a central role in the tight interplay between the immune system, inflammation and bone quality.
  • Vitamin D3: The vitamin D deficiency epidemic is alarming and prevalent whether people live in a sunny climate or not. Fractures are reduced only when the serum 25(OH)-D concentration is maintained above the threshold for deficiency, 32 ng/mL (80 nmol/L). A minimum amount of 2000 iu per day is recommended. In some patients, even higher amounts in addition to sunlight may be needed to prevent deficiency. The Plan goal is use enough vitamin D in individualized amounts based on 25 (OH)-D levels along with adequate sunlight to achieve and maintain a serum level of 50-60 ng/mL throughout the year. Vitamin D3 has a wide margin for safety and toxicity is not a concern when taken below the newly proposed safe upper limit (SUL) of 10,000 i.u./day.
  • Strontium (citrate): Strontium supports the formation of new bone that is strong and healthy. It promotes normal osteoblast bone formation and lessens osteoclast bone resorption. Almost universally, I see positive influences on DEXA results following daytime calcium and potassium citrate administration along with nighttime strontium citrate supplementation. In my experience, there is an impressive and rapid improvement in the T-score.
  • Vitamin K: Vitamin K promotes healthy bone quality, strength, and micro-architecture. Vitamin K1, besides being a primary coagulation factor in the liver, activates osteocalcin in bone. Vitamin K2 (as MK-7) primarily targets its activity outside the liver in bone and arteries where it helps maintain normal calcium metabolism. Its virtues are superior absorption and bioavailability, and sustained activity at physiological dosages. The Plan approach is to utilize this vitamin K1/K2 synergy along with co-support from vitamin D3. Like vitamin D, the daily needs for vitamin K are not being met in most adults.
  • Melatonin: Could this be the body's master bone health hormone? There is accumulating evidence to support this. It has a growing list of known multi-system benefits because of its strong antioxidant, cellular rejuvenation and gene expression activity. This includes an increasing body of research on the melatonin-bone connection suggesting that this hormone affects both osteoblast and osteoclast function. Aside from its sleep connection, melatonin is a vastly under-utilized supplement.
  • Omega-3 EFA's: Healthy bone maintenance requires omega-3. Patients with insufficient omega-3 status or a high omega-6/3 EFA ratio lose more bone mass vs. individuals with a balanced intake. Eating more omega 3 rich food sources, e.g.: fish, flax, and walnuts are important components of the RTB diet. To achieve the optimal ancestral EFA profile, supplements supplying omega-3 from both land and sea are also recommended.
  • Multvitamin/Mineral Complex: I prefer a basic high quality supplement to complement the Plan protocol. Other combination bone support products are okay as long as the Plan protocol is met. Products containing more than 5,000 i.u. of vitamin A as retinol may have negative effects on bone density and should be avoided.

5.  Suggested Screening and Monitoring:

  • Dual-energy x-ray absorptiometry scanning (DEXA) is the screening tool of choice for measuring bone density for the diagnosis of osteoporosis and to monitor treatment. A T-Score of -2.5 SD below the young adult mean is diagmostic for osteoporosis.
  • Urinary collagen cross-linked N-teleopeptides (NTx) measures the rate of bone resorption from osteoclast activity.
  • New bone formation from osteoblast activity can be measured by bone-specified alkaline phosphatase (BAP, BSAP).
  • 25(OH) D is the indicated test for measuring vitamin D status. Insufficiency = <32 ng/ml (80 nmol/L). Optimal = 50-69 ng/Ml (133-150 nmol/L). the 1-25(OH) D test is not recommended.
  • Other useful adjuvant tests are: vitamin B12 (as MMA), folate, DHEA, testosterone, estrogen, ferritin, lipids, TSH, and parathyroid values.

Most of these tests are routine chemistries that can be assayed at most any lab, including local hospital labs or specialty labs like Labcorp and Quest. Vitamin D, NTx, and hormones may also be tested at labs including Genova Diagnostics, MetaMetrix, Norman Clinical Lab (MMA) or Meridian Valley.

6.  Summary:

The Plan provides a broad-spectrum bone support program for women and men; it goes beyond the basic calcium/magnesium/vitamin D rationale in order to more effectively achieve complete osteoporosis risk-reduction and support. The rationale is to maintain normal bone composition, strength, and resiliency and to lessen fragility. With proper patient adherence and monitoring, the expected outcome of strong and healthy bones is likely to be achieved. The "fully optimized" effects of the Plan also extend beyond the bone matrix and skeletal system to support a healthy heart, mind, and immune system.

Note: The information contained on this website is not intended to be prescriptive. Any attempt to diagnose or treat an illness should come under the direction of a physician who is familiar with nutritional therapy.

These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.
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