Essential factors for healthy bones (at any age)

The strength of our bones is not solely determined by genetics; controllable lifestyle factors like diet and physical activity also play a crucial role. Research indicates that these factors contribute significantly, accounting for 10–50 percent of bone mass and structure (Office of the Surgeon General US, 2004). Once individuals reach peak bone mass in late adolescence, it becomes imperative to preserve as much of this bone mass as possible throughout adulthood to optimise bone health. In this article we will explore the things you can do to promote healthy bones at any age.

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Nutrition

Research indicates that the makeup of one's diet can significantly impact the development and preservation of bone mass across the lifespan. This is primarily achieved through the provision of bone-building nutrients and by influencing the absorption and retention of these essential elements. Two key nutrients that have been identified as crucial for bone health are calcium and vitamin D.

Calcium:

Calcium has been singled out as a public health concern because it is critically important to bone health and in many countries, the average daily intake is far below the amount recommended for optimal bone health (Balk et al., 2017). One key reason for these low levels of calcium intake relates to the reduced intake of dairy products due to health concerns surrounding dairy consumption. For more information on dairy and its impact on health you can refer to: Dairy and human health: Is it really so bad?

It can be confidently stated that higher calcium intake increases bone mineral density in children and adolescents (Wosje & Specker, 2000), and helps maintain and prevent bone loss in older adults (Welten 1995; Shea, 2002). It should be noted that adequate calcium levels should be consistent and maintained long-term to see these positive effects (Office of the Surgeon General US, 2004).

Recommended calcium intakes vary according to age and assigned gender at birth. You can find a table of these recommended intakes here: https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/

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Vitamin D:

Vitamin D is emerging as highly important in many aspects of health (read about its role in immunity here: Separating fact from fiction: Popular cold and flu treatments). It is a key vitamin for good bone health because it aids in the absorption and utilisation of calcium (Office of the Surgeon General US, 2004). Like calcium, the prevalence of vitamin D deficiency is of concern in many countries (Amerein, 2020). Certain factors put an individual at increased deficiency risk such as a lack of exposure to sunlight, how much body surface is covered by clothing or sunscreen, the degree of skin pigmentation, and age.

Vitamin D deficiency leads to decreased calcium absorption which puts an individual at risk of a below-average bone mineral density (BMD) and its associated problems such as osteoporosis and bone fractures (Lips, 2001). In children, vitamin D deficiency is known to cause inadequate mineralisation of the growing skeleton, leading to rickets (Goldring et al., 1995). Studies where adults are supplemented with vitamin D (often alongside calcium) have observed significant improvements in BMD, reduction in bone loss, and reduced fracture risk (Sunyecz, 2008; Laird et al., 2010).

The main source of vitamin D is sunlight, and most people throughout the world get their supply of vitamin D by exposure to sunlight. However, dietary vitamin D and supplementation can help one meet their required levels. The most accurate way to measure how much vitamin D is in your body is the 25-hydroxy vitamin D blood test. This is especially advisable if you have risk factors for deficiency, such as limited sun exposure, darker skin, older age, obesity, malabsorption issues, or specific dietary choices like vegetarianism or veganism.

Daily supplementation of 1000-2000iu of vitamin D has been determined to be safe and enough to achieve sufficient levels in the body (Dědečková et al., 2023).

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Other micronutrients:

Aside from calcium and vitamin D, several other nutrients have been identified as playing an important role in bone health such as phosphorus, magnesium, and fluoride (IOM, 1997). Other nutrients/dietary components that appear to positively affect bone health include vitamin K, vitamin C, copper, manganese, zinc, and iron (Office of the Surgeon General US, 2004). However, as they are consumed in sufficient amounts by most people they have not been as thoroughly researched as calcium and vitamin D.

In summary, people who consume adequate amounts of calcium and vitamin D throughout life are more likely to achieve optimal bone mineral density and are less likely to lose bone later in life.

Physical activity

Physical activity is highly important for bone health throughout life. Increasing physical activity at any point throughout the lifespan positively affects bone health. Conversely, reductions in physical activity can result in bone loss (Carter & Hinton, 2014).

Exercise can affect bone through either impact with the ground (gravitational loading) or through muscle contractions (muscle loading). Both these forces require the bone to adapt to increased demands, increasing BMD, bone size, cortical area, and strength (Daly et al., 2006). Gravitational loading has a particularly profound influence on skeletal health and studies on different types of athletes have found that those who participate in the highest-impact sports have the greatest BMD (Carter & Hinton, 2014). It should be noted that the positive impact of weight-bearing activities only affects the bone mass of the specific sites receiving the impact. For example, lifting weight with arms will not improve bone density of the legs therefore, it is important to train all parts of the body.

However, lower-impact forms of exercise also have their role to play in bone health through their ability to improve balance and coordination and maintain muscle mass, which can help prevent falls. Falls commonly result in bone fractures so preventing falls is important in older adults particularly.

This article provides some great suggestions on exercises that will promote bone health:

https://www.niams.nih.gov/health-topics/exercise-your-bone-health

In summary, individuals looking to improve and protect their bone health should consider incorporating high-impact exercises, and balance training into their routine. Positive changes can be made at any age.

Body weight

Both low body weight and weight loss have been associated with reductions in bone mass and increases in fracture risk. Low body weight increases the risk of hip fracture in older women and weight loss of 10 percent or more in older women also increases the risk of hip fracture (Office of the Surgeon General US, 2004). Inherently, weight loss is associated with bone loss so achieving weight loss while maintaining skeletal integrity is key. Salamone et al., (1999) found that while women who lost weight did lose more bone than weight-stable women, however, the loss was lessened among those who increased their physical activity. Consuming adequate calcium during weight loss may also help prevent bone loss, at least in postmenopausal women (Ricci et al., 1998).

In summary, those looking to lose weight through restricting calories should aim to increase physical activity through weight-bearing activities and ensure their calcium and vitamin D intakes are sufficient to protect their bone health.

Smoking

Smoking has a detrimental effect on bone health, contributing to an increased risk of osteoporosis and fractures (Al-Bashaireh et al., 2018). The harmful chemicals in cigarettes, such as nicotine and carbon monoxide, interfere with the body's ability to absorb calcium. Additionally, smoking accelerates bone loss by disrupting the balance between bone formation and resorption, leading to weakened bones over time. Furthermore, smoking reduces estrogen levels in both men and women, which can further worsen bone loss. It also has indirect influences on bone mass through alteration of body weight, parathyroid hormone, adrenal hormones, sex hormones, and increased oxidative stress on bony tissues (Al-Bashaireh et al., 2018)

A recent meta-analysis, using data from 10 different observational studies from around the world, found that smoking was associated with an increased risk of hip and other fractures in both men and women (Kanis et al., 2005). Even after adjusting for the lower BMD and body mass index that is often observed in smokers, the risk of hip fracture was 55 percent higher in smokers than in non-smokers.

In summary, it is strongly recommended to avoid smoking for the sake of bone health.

In conclusion, the strength and health of our bones are influenced by a combination of factors. While genetics may play a significant role in determining bone mass, lifestyle factors such as diet, physical activity, and avoiding harmful habits are equally crucial. It is imperative to prioritise bone health by adopting a balanced diet rich in nutrients, especially calcium and vitamin D, engaging in regular physical activity, maintaining a healthy body weight, and avoiding smoking. By incorporating these habits into our daily lives, we can optimise bone health, reduce the risk of osteoporosis and fractures, and enjoy better overall well-being throughout life.

*Disclaimer*

The information presented in this article is for educational purposes only and is based on our interpretation of the current research. Individuals are recommended to consult with a qualified healthcare professionals or registered dietitians for personalised guidance and recommendations tailored to their individual needs and circumstances.

References:

Al-Bashaireh, A. M., Haddad, L. G., Weaver, M., Chengguo, X., Kelly, D. L., & Yoon, S. (2018). The effect of tobacco smoking on bone mass: An overview of pathophysiologic mechanisms. Journal of Osteoporosis, 2018, 1206235. https://doi.org/10.1155/2018/1206235

Amrein, K., Scherkl, M., Hoffmann, M., Neuwersch-Sommeregger, S., Köstenberger, M., Tmava Berisha, A., Martucci, G., Pilz, S., & Malle, O. (2020). Vitamin D deficiency 2.0: An update on the current status worldwide. European Journal of Clinical Nutrition, 74(11), 1498–1513. https://doi.org/10.1038/s41430-020-0558-y

Balk, E. M., Adam, G. P., Langberg, V. N., Earley, A., Clark, P., Ebeling, P. R., Mithal, A., Rizzoli, R., Zerbini, C. A. F., Pierroz, D. D., Dawson-Hughes, B., & International Osteoporosis Foundation Calcium Steering Committee (2017). Global dietary calcium intake among adults: a systematic review. Osteoporosis International, 28(12), 3315–3324. https://doi.org/10.1007/s00198-017-4230-x

Carter, M. I., & Hinton, P. S. (2014). Physical activity and bone health. Missouri Medicine, 111(1), 59–64.

Daly, R. M., & Bass, S. L. (2006). Lifetime sport and leisure activity participation is associated with greater bone size, quality and strength in older men. Osteoporosis International, 17(8), 1258–1267. https://doi.org/10.1007/s00198-006-0114-1

Dědečková, E., Viták, R., Jirásko, M., Králová, M., Topolčan, O., Pecen, L., Fürst, T., Brož, P., & Kučera, R. (2023). Vitamin D3 supplementation: Comparison of 1000 IU and 2000 IU dose in healthy individuals. Life (Basel, Switzerland), 13(3), 808. https://doi.org/10.3390/life13030808

Goldring, S. R., Krane, S. M., & Aviolo, L. V. (1995). Disorders of calcification: Osteomalacia and rickets. In L. J. D., (Ed.), Endocrinology, 3rd edition (pp. 1204–1227). Philadelphia (PA): WB Saunders.

Institute of Medicine (US) Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. (1997). Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. National Academies Press (US).

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Karimian, P., Ebrahimi, H. K., Jafarnejad, S., & Delavar, M. A. (2022). Effects of vitamin D on bone density in healthy children: A systematic review. Journal of Family Medicine and Primary Care, 11(3), 870–878. https://doi.org/10.4103/jfmpc.jfmpc_2411_20

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