World Osteoporosis Day — A Hidden Risk You Might Overlook

 Tiejun Tang

Today is World Osteoporosis Day. Osteoporosis is a global health issue, and with the increasing aging of the population, its incidence continues to rise. According to the International Osteoporosis Foundation (IOF), about 200 million people worldwide suffer from osteoporosis. Every three seconds, someone experiences a fracture due to osteoporosis.

There are many causes of osteoporosis. Advancing age, decreased estrogen levels in postmenopausal women, and vitamin D deficiency are well-known risk factors. However, I would like to draw attention to another often-overlooked cause of osteoporosis, hoping to raise awareness among both doctors and patients.

Over the past two years, I have seen several patients diagnosed with osteoporosis, one of whom even suffered a pathological lumbar fracture. The common factor among these patients was long-term use of proton pump inhibitors (PPIs), a class of Western medications used to suppress stomach acid.

Studies have shown that long-term PPI use may be associated with an increased risk of hip, spine, and overall fractures. This may be due to reduced calcium absorption or a direct effect of PPIs on bone cell function [1]. Research has reported that five commonly used PPIs in clinical practice have varying degrees of adverse effects leading to osteoporosis [2].

There are several possible mechanisms by which PPIs may induce osteoporosis. First, gastric acid plays an essential role in the ionization of dietary calcium, which is critical for calcium absorption. PPIs, by inhibiting gastric acid secretion, may interfere with this process, thereby impairing calcium absorption[3]. The second possible mechanism is that PPIs directly affect bone metabolism. Studies have found that omeprazole may increase bone resorption by upregulating osteoclast gene expression and promoting the release of calcium ions into the bloodstream, thus influencing bone cells [4].

To prevent PPI-induced osteoporosis, there are two possible strategies. One is to use H2 receptor antagonists as an alternative to PPIs, which may reduce the risk of osteoporosis, though long-term use may cause other side effects. Another approach is to use natural herbal medicines as substitutes for Western acid-suppressing drugs.

Traditional Chinese Medicine (TCM) has shown great potential in both the prevention and treatment of osteoporosis, with its multi-target and multi-pathway regulatory effects. Active compounds in Chinese herbs—such as flavonoids, polyphenols, saponins, and polysaccharides—can modulate key signaling pathways including Wnt/β-catenin and RANKL/OPG. These effects promote osteoblast differentiation, inhibit osteoclast activity, alleviate oxidative stress and inflammation, and improve gut microbiota imbalance, ultimately restoring bone microenvironment homeostasis [5].

In my previous blog posts, I have discussed the mechanisms by which Chinese herbalmedicine can prevent and treat vitamin D deficiency, as well as its therapeuticeffects on osteoarthritis. On this World Osteoporosis Day 2025, I would like to remind everyone be aware of PPI-induced osteoporosis—do not harm your bones in the process of protecting your stomach.

References

1. Saowanee N. et al. Proton pump inhibitors and risk of fracture: a systematic review and meta-analysis of observational studies. Am
   J Gastroenterol. 2011 Jul;106(7):1209-18.
2. Jingkai Di et al. Evaluating the risk of osteoporosis-related adverse events with proton pump inhibitors: a pharmacovigilance study. Front Pharmacol. 2025 Jul 11;16:1582908.
3. G. Graziani et al. Effect of gastric acid secretion on intestinal phosphate and calcium absorption in normal subjects. Nephrol Dial Transplant. 1995;10(8):1376-80.
4. Mohamed I. Zanaty et al. Effect of Omeprazole on Osteoblasts and Osteoclasts in vivo and in the in vitro Model Using Fish Scales. Biochemistry (Mosc). 2021 Oct;86(10):1192-1200.
5. Chaoqun Song et al. The role of active constituents in traditional Chinese medicine for primary osteoporosis: a mechanistic review. Front Endocrinol (Lausanne). 2025 Sep 16;16:1647984.