HUN3800

Literature Review Paper

Is Prolonged Breastfeeding A Risk Factor For Postmenopausal Osteoporosis?

Ashley Thompson

N00820309

November 15, 2016

Introduction

Osteoporosis is the most commonly occurring bone disease in humans. 1 It is

defined as being a skeletal disorder characterized by compromised bone strength that

increases the risk for fractures with vertebral fractures being the most common.

Osteoporosis results in a bone mineral density value of more than 2.5 standard

deviations below the population average for young adults. Many factors related to

calcium homeostasis affect bone mineral density. 2 A negative calcium balance results in

bone mineral loss because calcium is removed from bones to maintain calcium

concentration in serum.2 Fractures resulting from osteoporosis are associated with

morbidity and high health costs. Elderly men and women are most at risk for

osteoporosis development and osteoporotic fractures. Early detection and treatment is

key in order to prevent osteoporosis and decrease the risk for fractures.

Calcium plays an essential role in bone health. It is important to consume

adequate amounts in order to achieve peak bone mass and to help reduce bone

mineral losses or reduce the risk of osteoporosis with aging. Most of the calcium

present in the body, about 99%, is found in bone. The dietary reference intake for

calcium in the United States for adults aged 19-50 years is 1000mg/day and increases

to 1200 mg/day for adults over 51 years. When calcium intakes that is so low that

plasma calcium concentrations cannot be maintained, calcium is taken from the

skeleton leading to that decrease of bone mass.3 Ensuring a sufficient intake of calcium

during childhood and adolescence (when bone formation is at its peak) is important for

maximizing peak bone mass. Long-term low calcium intakes are believed to lead to
decreased peak bone mass that is attributed to health implications and risk of

osteoporosis later in life.3

Bone density and lactation

Diminishing estrogen levels in women, with the onset of menopause, leads to

excessive bone resorption that is not fully compensated for by an increase in bone

formation.1 Womens bone-mass peak is achieved at age 27.4 It is important for young

women to build good bone mass and for older women to maintain it. Women are more

vulnerable for developing osteoporosis because of increased risk factors. Breastfeeding

is among one of these risk factors especially in women with inadequate calcium intake.

Other contributing factors to consider that lead to decreased bone mineral density while

breastfeeding are the age of pregnancy, number of pregnancies, and the duration of

lactation.

Lactating women lose anywhere between 250-400 mg of calcium daily through

breast milk.5 This directly affects bone metabolism and calcium homeostasis in the

mother.5 During gestation calcium absorption increases, however this does not occur

during the lactation period.6 Around 3% to 7% of maternal bone mineral density has

been lost by the sixth month of lactation and the loss increases up to as much as 10%

for women who breastfeed for twelve months. 7 Bone loss is known to be restored within

six to twelve months after weaning in mothers who breastfed for fewer than six month. 7

It is unclear whether this bone loss is fully restored in women who breastfed for twelve

months or whether total lactation duration is associated with bone mineral density later

in life.7 Thus, raising the question Is prolonged breastfeeding a risk factor for

postmenopausal osteoporosis? There is controversy in different studies over the years

on whether prolonged periods of breastfeeding are beneficial or detrimental to a

womans bone mineral density.

Multiparity and prolonged breastfeeding

Several studies conducted examined the impact of multiple pregnancies and total

duration of breastfeeding on bone mineral density. In 2013, a study completed by Gloria

Tsvetov et al. sought to further investigate this. It was hypothesized that if bone loss is

not completely restored postpartum, subsequent pregnancies and lactation may

ultimately increase the risk of osteoporosis (Tsvetov). In this study the aim was to

evaluate the effect of number of deliveries and total breastfeeding time on bone mineral

density in a group of healthy premenopausal and postmenopausal women. A group of

500 women ranging in age 35-55 years participated in the study. The women were

questioned about the total number of deliveries and duration of breastfeeding after each

delivery. The average age of the women was 47 years. At least sixty percent of the

women were premenopausal while the postmenopausal women were within 5 years of

the last menstrual cycle. Calcium intake for the women mostly came from the diet with

only 15% using supplementation.8 The spine being the most common site for bone

mineral density loss, tests were repeated specifically for this area. Age, number of

births, and breastfeeding duration all had a significant effect on spinal bone mineral

density. Each additional month of breastfeeding increased the odds of a low bone

mineral density later in life by 2.7% (6.6% for postmenopausal women), when

controlling for menopausal status, BMI, and number of births. 8 When just looking at the

spine, each additional month of breastfeeding increased the odds of a low bone mineral

density by 4.1% (7.1% for postmenopausal women).8 The results of the study concluded
that increased breastfeeding duration was found to have negative effects on bone

mineral density where as the number of births had no effect. Postmenopausal women

had increased odds of a low bone mineral density by 6.6% for each additional month of

breastfeeding. Contradictory to the findings by this study, a second study performed on

postmenopausal women in Sri Lanka revealed no negative effects on bone mineral

density from prolonged breastfeeding and multiparity. 9

Breastfeeding and osteoporotic fractures

The most common type of osteoporotic fracture is vertebral fractures, which are

associated with persistent pain, disability, and poor quality of life. 10 The aim of a study,

performed at the outpatient clinic for diagnosis and treatment of osteoporosis at the

Geriatrics Unit of Padova University, was to identify any association between duration of

breastfeeding and vertebral fractures in a large group of postmenopausal women. 10 A

group of women totaling 752 were selected. They were split into five groups based on

months spent breastfeeding: never, 0-6 months, 6-12 months, 12-18 months, and over

18 months. Those that had never breastfed were used for reference. Osteoporotic

vertebral fractures were reported for 178 (23%) of the women. 10 These women also had

lower femoral and lumbar bone mineral density values. The study found a significant

association between long periods of lactation and frailty vertebral fractures. 10 This was

particularly apparent in women whose cumulative lactation period lasted 18 months or

longer. As mentioned earlier bone mass is usually recovered after weaning and because

of this most women will rarely develop fragility fractures during lactation. However, long

periods of breastfeeding most likely lead overall to a major bone mineral density loss

and incomplete bone mass recovery, consequently resulting in a higher risk of vertebral
fractures later in life.10 A second study done to evaluate the correlation between

breastfeeding and osteoporotic fractures revealed a decrease in bone mineral density.

However, the breastfeeding duration was, on average, only 6 months and bone loss

was regained after weaning.11 Unlike the first study, this one was completed with

premenopausal women ranging in age from 18 to 40 years. This could have some effect

on why there was less bone loss and less fracture risks due to the fact that fracture risk

naturally increases with the progression of age.

Breastfeeding and osteoporosis in highly susceptible populations

A contributing factor that raises concern for an increased risk of developing

osteoporosis is an inadequate intake of calcium and vitamin D. This concern is even

greater for underdeveloped areas or cases with low socioeconomic status because they

lack the education and nutrients to obtain a sufficient amount of nutrients during

pregnancy and breastfeeding. A study published by the International Osteoporosis

Foundation and National Osteoporosis Foundation aimed to determine whether the

breastfeeding duration is a risk factor for osteoporosis in postmenopausal women, on

terms with sufficiency of calcium intake and vitamin D. 6 A total of 1231 women ranging in

age from 45 to 70 years participated in the study. The women were divided into two

groups based on their dietary calcium intake. The lower intake group consumed

<800mg/day and the higher intake group consumed >800mg/day.6 Levels of vitamin D

were classified as deficient if they were <20 ng/mL and insufficient if the level was

between >20 and <30ng/mL.6 Findings from this study showed increases in the

development of osteoporosis at the femur neck and within the lumbar spine and the

overall development of osteoporosis in the group that had a breastfeeding duration of

>24 months and had deficient and insufficient vitamin D levels and daily calcium intakes

were <800mg/day.6 The results of this study indicate that supplementation of nutrients

may be necessary since a longer duration of breastfeeding may affect maternal bone

health later in life. It is important for women to consume a sufficient amount of calcium

and vitamin D even before pregnancy and lactation in order to compensate for the

losses they will experience later in life.

Conflicting Results

There is controversy on whether breastfeeding is overall beneficial or harmful to

the mother. While most of the studies reviewed support that increased duration and

multiparity have negative effects on bone mineral density and the risk for osteoporosis

several found it acts as a protective measure. A study of Gambian women with low

intakes of calcium revealed that bone density is recovered after lactation. The calcium

intake for the group of 33 women was well under the international recommendations at

only 300-400mg/day and duration of lactation was 52 weeks. The study also suggested

that repeated periods of breastfeeding do not place a woman with an insufficient

calcium intake at a greater risk of skeletal depletion. 12 Another study aimed to test

whether higher parity and longer duration of breastfeeding is associated with lower risk

of hip, wrist, or fragility fractures related to osteoporosis in a group of postmenopausal

women. The average number of births for each woman was 3 and average duration of

breastfeeding was 13 months. They reported a reduced risk for hip fractures and no

difference in bone mineral density when using high parity as a parameter. 13 A final study

hypothesized that long lactation promotes periosteal bone apposition thus, increasing

maternal bone strength. A group of 206 women who had breastfeed in total more than
33 months had greater hip and tibia bone strength index estimates compared to the

mothers who had breastfed less than 12 months. They found this attributable to larger

bone size however, not higher bone mineral density. 14 While these few studies show a

positive correlation in relation to breastfeeding and prevention of osteoporosis the

inconsistency of results with all studies makes it apparent future studies need to done.

Conclusion

To conclude, breastfeeding has been associated with decreases in bone mineral

density especially during the first six months. This raises the concern for developing

osteoporosis and thus, increased risk of fractures. Studies have been performed to

evaluate the correlation between breastfeeding and bone loss leading to the

development of osteoporosis. However, the results are often conflicting with each other

especially when adjusting for certain parameters. A major point most studies agreed on

was that an adequate intake of dietary calcium was needed to ensure healthy bone

mass. During lactation, women have a period of hypoestrogenemia, which can

negatively affects calcium metabolism. There are a number of other contributing factors

leading to the loss of bone mineral density while lactating and increasing the risk for

postmenopausal osteoporosis. The duration of breastfeeding was a huge factor in many

of the studies. Although studies have found that after weaning a womans bone density

returns to normal, this is not always the case for prolonged periods. It was shown that

postmenopausal women who were prolonged breast-feeders for more than one year per

child had a lower lumbar spine bone mineral density than those who did so for a shorter

duration.5 For many women the decrease in bone mineral density led to osteoporosis

thus, creating even more problems in their future. Contrary to these findings some
studies have shown no increased risk of osteoporosis development with prolonged

breastfeeding and some have even found that breastfeeding may protect against the

risk of osteoporotic fractures in the future. Due to the inconsistent and conflicting results

from the studies reviewed it is clear that more research needs to be performed in order

to get a full understanding of the association between calcium intakes, breastfeeding

and the risk of osteoporosis. The majority of studies concluded that there were no

conflicts of interest but it is clear that future studies need to be done. The studies

reviewed in this paper line up with hypothesized question of Is prolonged breastfeeding

a risk factor for postmenopausal osteoporosis?

Application to dietetic practice

Osteoporosis is a huge cause of morbidity and mortality due to age-related

fractures.15 Postmenopausal women who develop osteoporosis as a result of insufficient

calcium intake and prolonged breastfeeding face the economical burden and diminished

way of life associated with it. As a registered dietitian the data and information from

these studies would be useful in educating women on taking the preventative measures

to decrease the risk for developing osteoporosis. Many women are not consuming

enough dietary calcium to meet the dietary recommended intake. Since peak bone

mass occurs around mid twenties it is crucial that proper education is started early on.

Implementing a program in schools or free clinics may help women get the education

they about the importance of bone health. Women may also be hesitant to breastfeed in

fear that it may be harmful to them later in life. Having a lactation specialist in

conjunction with a dietitian in the hospital after delivery may be helpful in educating

about proper calcium intake and what they can do to prevent an irreversible decrease in
bone mineral density. The overall goal would be to raise awareness about the

importance of a sufficient calcium intake leading up to the age of peak bone mass. This

would potentially lower bone loss as age progresses and lessen the risk of developing

osteoporosis and the fractures that accompany the disease. As a result the economic

burden could be lowered in the years to come.

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