A Guide to Bone Health

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    Bone Health

    Bone health is important at all ages.

    Making sure infants and children are able to maintain bone health to keep up with their growth is essential and as we get older it is more vital than ever to be aware of our bone health. As we age, we are more prone to developing bone fractures which can limit our movement and impact our overall health.

    It has been seen that bone fractures as we get older are actually one of the main culprits which cause us to have mobility issues, ill health and a loss of independence for the individual.

    It has been seen that over the age of 30, which is our peak bone mineral density, we start to develop bone density loss. This is because our body is no longer able to replace the bone tissue at the rate we are losing it.

    The Skeleton

    Using our skeleton for support and movement

    The skeleton is vital for the normal functioning of the body. Some of its key functions are to:

    • Support
    • Protect our vital organs from damage
    • Movement
    • Storage of essential minerals (including calcium and phosphorus
    • Blood cell production (red blood cells which carry oxygen and white blood cells which protect against infection and platelets)
    • Endocrine regulation (releases hormone osteocalcin, involved in the regulation of blood sugar and fat deposit)

    These functions mean that we really shouldn’t take our bone health for granted.

    What Increases Fracture Risk?

    Osteoporosis

    Osteoporosis is where the body loses too much bone, makes too little bone, or both of these.

    It is estimated that it affects around 3 million people in the UK (National Osteoporosis Society, 2017). This means that the bone becomes weak and is more likely to break when we fall over and in highly serious cases, this can even be when someone sneezes (National Osteoporosis Foundation, 2017).

    The bone becomes porous and holes and spaces within the bone are larger than those found within healthy bones, meaning that they are more likely to break.

    Most commonly, we find fractures that are caused by osteoporosis are on the spine, wrist and hip. As we get older we are at greater risk of developing osteoporosis and, also, fractures and women are at a higher risk than men, due to having a lower peak bone mass, plus bone loss increases for several years after the menopause.

    However, this doesn’t mean that men aren’t affected by this silent disease. 1 in 2 women, and 1 in 5 men over the age of 50 will break a bone as a result of osteoporosis (National Osteoporosis Society, 2017). It’s a public health problem which affects millions around the world (Pepa and Brandi, 2016).

    Rickets and Osteomalacia

    Rickets and osteomalacia are the same thing where the bones become soft and weak. However, rickets is found within children and osteomalacia in adults.

    Rickets can cause bone deformities when the bones are forming and can cause bowed legs, curved spine, thickening of the ankles, knees and wrists (NHS, 2015).

    Children who suffer with rickets are more likely to fracture their bones, as well. Similarly in adults, osteomalacia makes our bones soft and weak and therefore more prone to fractures, due to the bones not getting enough of the minerals they need.

    What Can We Do to Help Maintain Bone Health?

    Calcium and Vitamin D

    I’m going to talk about these two together as vitamin D plays a role in the absorption and utilisation of calcium.

    Calcium is probably the most well-known factor which has a role in our bone health by keeping our bones strong and is the most promoted within public health due to concerns that we do not eat enough. However, without a good source of vitamin D we are not able to absorb and utilise this calcium from foods (Office of the Surgeon General (US), 2004).

    A cohort study found that adults over 60 years of age, who had a higher yoghurt intake had an increased bone mineral density and also better physical functioning scores than those taking the lowest intake of yoghurt (Laird et al., 2017).

    Making sure that we get an adequate amount of both calcium and vitamin D is vital for our bone health.

    Vitamin D is known as the sunshine vitamin as most of it is made from sunlight on our skin. You can also get it from foods including:

    • oily fish
    • eggs
    • fortified foods

    You can read more about vitamin D and its role on our health in our blog here.

    I think the main source of calcium which we all think about would be milk and dairy products such as cheese but you can also get calcium from:

    • green leafy vegetables (broccoli and cabbage)
    • tofu and soya beans
    • soya drinks which have been fortified with calcium
    • bony fish (fish where you also eat the bones, such as sardines and pilchards)
    • nuts
    • breads which have been fortified

    If consuming a dairy free diet, it is important that you ensure that you are getting your calcium from other sources – it is still safe to do but just important to be aware.

    It has been shown that when women aged 75 had a sufficient level of vitamin D they had significantly lower incidents of hip fractures and you can read more about this study here.

    Studies have found that when children and adolescents have a higher intake of calcium, their bone mineral density also increases and this also had an increased effect on the beneficial impact of physical activity on bone health (Office of the Surgeon General (US), 2004). When elderly women received supplementation of vitamin D and calcium, hip fractures were reduced by 43% in comparison to those on placebo (Office of the Surgeon General (US), 2004).

    If you want to read more about the different daily guideline amounts for how much calcium you need (this varies from age and also if you are at different stages in the lifecycle: pregnancy; lactation; menopausal etc.) you can check on this BDA Food Fact Sheet: Calcium available here.

    If you are at risk of vitamin D deficiency (which during the winter months, most of us are at an increased risk of deficiency in the UK), it is recommended to take a 10mcg supplement. To read more about vitamin D, you can read the BDA Food Fact Sheet: Vitamin D available here.  If you take too much vitamin D in a supplement form over a long period of time it leads to too much calcium to be built up in the body and can in turn weaken the bones and damage your kidneys and heart (NHS, 2017).

    Magnesium

    Magnesium is found in a wide variety of foods, ranging from:

    • cheese
    • peanuts
    • sardine
    • cod
    • wholemeal bread
    • almonds
    • brown rice
    • lentils

    Most of the magnesium found in our body is located within our bones – around 67% of total body magnesium (Kunutsor et al., 2016). However, it is also an integral part of all cells, and even plays a role in the functioning of some of the enzymes, as well as utilising energy.

    It has been indicated that there is a chance that when dietary intake of magnesium is low but not deficient it can impact bone and mineral metabolism and in itself become a risk factor for osteoporosis (Rude et al., 2009).

    Sardines are a source of magnesium

    It has been shown that magnesium intake has been positively associated with bone mass density (Pepa and Brandi, 2016). One study followed 2,245 middle aged men for 20 years and it was found that those with lower blood levels of magnesium have an increased risk of fractures, – they found this was particularly on their hips. Those who were found to have high levels of magnesium (22 individuals), did not experience any fractures over the 20 years (Kunutsor et al., 2016). In healthy adolescent girls (8-14 years) it was found that magnesium supplementation helped increase integrated hip bone mineral content (Carpenter et al., 2006). You can read more about why we need magnesium for other functions in our blog here.

    In late stages of adolescence, bone density increases, however, if the individual is lacking in vitamin D, calcium and magnesium, it may lead to an increased risk of fractures later on in life. It is essential that we make sure that children are getting enough of the right nutrients to help reduce their risk.

    Phosphorus

    Flatbread with Hazelnut Pesto

    This is a mineral which has many different functions and roles. One of its functions is helping us to develop and build strong bones and teeth. Around 85% of the body’s phosphorus is found within the skeleton (Office of the Surgeon General (US), 2004). You can get phosphorous from:

    • meat
    • poultry
    • fish
    • dairy products
    • eggs
    • nuts and seeds
    • beans
    • whole grains
    • garlic

    Taking high doses for an extensive period of time however can reduce the amount of calcium in the body, increasing risk of fractures.

    Other Vitamins and Minerals

    Vitamin C also helps to keep our bones and joints healthy. Citrus fruits and bell peppers are a couple of sources of vitamin C. Other nutrients which help to play a role in our bone health are vitamin K, potassium, copper, manganese, zinc and iron.

    Protein

    Proteins are made up of amino acids which are the building blocks of life. They are found in all of our body tissues, which means that they are found within our bones.

    It has been found that a low protein intake of below 0.8g/kg of body weight per day, is observed in patients that have had hip fractures. It was also found that when supplemented with protein it helps to reduce post-fracture bone loss (Bonjour, 2011).

    Creamy Coronation Tofu with Turmeric

    Another study found that in elderly men and women, lower protein intakes were significantly related to bone loss at femoral (thigh bone) and spine sites and those in the lowest quartile of protein intake showed the greatest bone loss (Hannan et al., 2000). This does not mean that you need to be consuming excess quantities of protein but trying to achieve the recommended 0.8g/kg of body weight. However, there is concern that this intake level may be too low for the elderly, due to the reduced response and ultilisation to dietary protein in our body (Bonjour, 2011).

    Examples of meat-based proteins are:

    • chicken
    • beef
    • pork
    • fish.

    If you follow a vegetarian diet, this blog gives you suitable vegetarian options.

    It is important that you still ensure you are getting an adequate amount of calcium to maintain bone health, as well as protein.

    Lifestyle Choices That Can Impact Bone Health

    Sleep

    Something that maybe we wouldn’t usually associate with our bone health is sleep but actually it’s been found to have an impact!

    In a study on Chinese women, those who had a decreased sleep duration had lower bone mineral density, this was especially apparent in those middle-aged and elderly (Fu et al., 2011).

    In healthy men, a study has found that after 3 weeks of sleep restriction, there was a reduction in levels of a marker of bone formation in the blood, however another marker for bone breakdown or resorption was not altered. This creates an increased risk of osteoporosis due to a bone loss window, where bone loss overtakes bone formation (Endocrine Society, 2017). A systematic review and meta-analysis found that there was a significant association between obstructive sleep apnea and osteoporosis (Upala et al., 2016).

    Weight

    It is important to maintain a healthy body weight throughout our life, not only for our bone health but numerous other areas as well.

    Obesity has been associated with deficiencies in calcium and vitamin D, it impacts on our bone metabolism and increase in fracture risk (Harper et al., 2016).

    There has also been a study which showed that an association between a BMI over 30kg/m2 (obese) and an increased risk of fractures to ankle and upper leg (Harper et al., 2016). This has been found in both males and females (Xiang et al., 2017).

    Scarily as well, it has been found that obese adolescents are doing damage to their bones which is irreparable, causing their bones to become more porous and prone to fracturing, even later on in life if weight loss is achieved (Radiological Society of North America, 2016).

    Vitamin D is a fat soluble cell which means that when we have excess fat, it can get trapped within the fat cells (Radiological Society of North America, 2016). This concern also transfers onto children (Kelley et al., 2017). However, being underweight can also impact and increase your risk of osteoporosis and bone fracture. If you have a BMI below 19kg/m2 which is underweight you are at a higher risk (BDA, 2016)

    Hormones

    When a woman’s oestrogen (hormone) levels drop, either due to menopause, or if they have had their ovaries removed, it causes an increase in a rate of bone loss. This decrease in oestrogen, also causes an impact on our body’s ability to absorb calcium, which as we have seen above, in itself causes a decrease in our bone mass (Sardesai, 2011).

    Studies have shown that women going through the menopause have bone loss (of 2-3% yearly), which then gradually begins to decrease for around 8-10 years until annual bone loss becomes similar to rates premenopausal. Bone density also decreases in men as they get older – the decrease in testosterone can also cause a decrease (Sardesai, 2011). Thyroid hormone can also impact bone health. Too much of it and it can speed up the rate at which bone is lost, which means that your body may not be able to replace at the speed bone is lost (hyperthyroidism) (British Thyroid Foundation, 2015).

    Exercise for Bone Health

    Exercise is essential for good bone health. Weight-bearing exercising, like brisk walking, has been shown to maintain bone health. Those who lead a sedentary lifestyle and those who are no longer active are more at risk of a decrease in bone mineral density and therefore osteoporosis, than those who remain active.

    Exercise isn’t just important for bone health, it also helps us to maintain and build muscle which helps to support our bones. It has been shown to have a positive impact on bone density in postmenopausal women (Howe et al., 2011).

    One study looked at resistance training and jump training for 12 months which had an increase in bone formation and bone mineral density in the whole body, in men aged 25 to 60 years who had low bone mass (Hinton et al., 2017).

    Another study found that children and adolescents who consistently watched TV a lot (over 14 hours a week), had a lower peak bone mass at 20 years old (McVeigh et al., 2016). If our peak bone mass is reduced it means that we are more at risk of developing osteoporosis later on in life.

    It has been demonstrated that during childhood it is important to take part in physical activity as it plays an important part of our bone strength (Gabel et al., 2017). Resistance training has also been shown to help maintain bone mineral density in those who already have osteoporosis (Kawao and Kaji, 2017).

    Alcohol and Smoking

    Smoking can lead to weakened bones, increasing your risk of osteoporosis and fractures.

    It has also been shown that drinking a large amount of alcohol can also increase your risk of osteoporosis. This may be due to excess alcohol interfering with the body’s ability to absorb calcium.

    Salmon contains vitamin D, which helps the absorption of calcium. Try our recipes for One Tray Salmon with Vegetables

    Uncontrollable Factors

    Those who are from a white or Asian descent, are at a greater risk of osteoporosis and are more likely to develop osteoporosis and women are at greater risk than males. If you have a close family member such as a parent or sibling who has had osteoporosis, it puts you at a greater risk. However, as we all get older our risk increases.

    Conclusion

    From above you can probably guess that a well-balanced diet is one of the main factors which can help to prevent bone loss and also maintain bone health.

    It is just a part of life that we go through which means we lose bone but it’s important to try and make sure that you are getting enough nutrients to prevent excess loss. Exercise has also been shown to be an important factor, by preventing muscle wasting, known as sarcopenia, which is something that also increases as we get older.

    Preventing muscle wasting in this way can help to reduce the risk of falling and injuries that can be associated with it like fractures.

    It is best to try and achieve all your nutrients through your diet but if you are considering supplementing, please talk to your GP or a health professional so that you make the right decision. If you are concerned with your bone health and if you’ve had a fracture recently talk to your GP about this concern and they can discuss further action.

    References:

    BDA. (2016). Food Fact Sheet: Osteoporosis. Available here.

    Bonjour, JP. (2011). Protein intake and bone health. International Journal for Vitamin and Nutrition Research, 81(2-3), pp. 134-142. Available here.

    British Thyroid Foundation. (2015). Thyroid Disorders and Osteoporosis. Available here.

    Carpenter, TO. DeLucia, MC. Zhang, JH. Bejnerowicz, G. Tartamella, L. Dziura, J. Petersen, KF. Befroy, D. and Cohen, D. A randomized controlled study of effects of dietary magnesium oxide supplementation on bone mineral content in healthy girls. The Journal of Clinical Endocrinology & Metabolism, 91(12), pp. 4866-4872. Available here.

    Endocrine Society. (2017). Prolonged sleep disturbance can lead to lower bone formation. Available here.

    Fu, X. Zhao, X. Lu, H. Jiang, F. Ma, X. and Zhu, S. (2011). Association between sleep duration and bone mineral density in Chinese women. Bones, 49(5), pp. 1062-1066. Available here.

    Gabel, L. Macdonald, HM. Nettelfold, L. and McKay, HA. (2017). Physical activity, sedentary time, and bone strength from childhood to early adulthood: a mixed longitudinal HR-pQCT study. Available here.

    Hannan, MT. Tucker, KL. Dawson-Hughes, B. Cupples, LA. Felson, DT. And Kiel, DP. (2000). Effects of dietary protein on bone loss in elderly men and women: The Framingham Osteoporosis Study. Journal of Bone and Mineral Research, 15(12), pp.2504-2512. Available here.

    Harper, C. Pattinson, AL. Fernando, HA. Zibellini, J. Seimon, RV. And Sainsbury, A. (2016). Effects of obesity treatments on bone mineral density, bone turnover and fracture risk in adults with overweight or obesity. Hormone Molecular Biology and Clinical Investigation, 28(3), pp. 133-149. Available here.

    Hinton, PS. Nigh, P. and Thyfault, J. (2017). Serum sclerostin decreases following 12 months of resistance- or jump-training in men with low bone mass. Bone, 96, pp. 85-90. Available here.

    Howe, TE. Shea, B. Dawson, LJ. Downie, F. Murray, A. Ross, C. Harbour, RT. Caldwell, LM. And Creed, G. (2011). Exercise for preventing and treating osteoporosis in postmenopausal women. The Cochrane Database of Systematic Reviews, 7. Available here.

    Kawao, N. and Kaji, H. (2017). Influences of resistance training on bone. Clinical Calcium, 27(1), pp. 73-78. Available here.

    Kelley, JC. Crabtree, N. and Zemel, BS. (2017). Bone density in the obese children: clinical considerations and diagnostic challenges. Calcified Tissue International, 100(5), pp. 514-527. Available here.

    Kunutsor, SK. Whitehouse, MR. Blom, AW. And Laukkanen, JA. (2016). Low serum magnesium levels are associated with increased risk of fractures: a long-term prospective cohort study. European Journal of Epidemiology, pp. 1-11. Available here.

    Laird, E. Molloy, AM. McNulty, H. Ward, M. McCarroll, K. Hoey, L. Hughes, CF. Cunningham, C. Strain, JJ. Casey, MC. (2017). Greater yoghurt consumption is associated with increased bone mineral density and physical function in older adults. Osteoporosis International. Available here.

    McVeigh, JA. Zhu, K. Mountain, J. Pennell, CE. Lye, SJ. Walsh, JP. And Straker, LM. (2016). Longitudinal trajectories of television watching across childhood and adolescence predict bone mass at age 20 years in the Raine study. Journal of Bone and Mineral Research, 31(11), pp. 2032-2040. Available here.

    National Osteoporosis Foundation. (2017). What is Osteoporosis and what causes it?. Available here.

    National Osteoporosis Society. (2017). What is Osteoporosis?. Available here.

    NHS Choice. (2015). Rickets and osteomalacia. Available here.

    NHS Choice. (2017). Vitamin D. Available here.

    Office of the Surgeon General (US). 2004). Bone health and osteoporosis: a report of the surgeon general. Determinants of Bone Health. Available here.

    Pepa, GD. and Brandi, ML. (2016). Microelements for bone boost: the last but not the least. Clinical Cases in Mineral and Bone Metabolism, 13(3), pp. 181-185. Available here.

    Radiological Society of North America. (2016). Obesity in adolescence may cause permanent bone loss. EurekaAlert!. Available here.

    Rude, RK. Singer, FR. And Gruber, HE. (2009). Skeletal and hormonal effects on magnesium deficiency.  The Journal of the American College of Nutrition, 28(2), pp. 131-141. Available here.

    Sardesai, V. (2011). Factors contributing to bone mass: Sex. Introduction to Clinical Nutrition (3rd edition). CRC Press. Page 400. Available here.

    Upala, S. Sangguankeo, A. and Congrete, S. (2016). Association between obstructive sleep apnea and osteoporosis: a systematic review and meta-analysis. International Journal of Endocrinology and Metabolism, 14(3), e36317. Available here.

    Xiang, BY. Huang, W. Zhou, GQ. Hu, N. Chen, H. and Chen, C. (2017). Body mass index and the risk of low bone mass-related fractures in women compared with men: A PRISMA-compliant meta-analysis of prospective cohort studies. Medicine (Baltimore), 96(12), pp. e5290. Available here.

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    Daisy has a Master’s Degree in Public Health Nutrition, which is Association for Nutrition (AFN) accredited. She, also, has a BSc degree in Psychology and Cognitive Neuroscience; and has completed an AFN accredited Diet Specialist Nutrition course. She is Lucy’s sister and is the Lucy Bee voice on all aspects of nutrition and its effect on the body. In addition to this, Daisy is shadowing a nutritionist in Harley Street and working for an NHS funded project, The Diabetes Prevention Programme.