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A slow decline in bone health is part of the aging process. Peak bone mass is typically achieved between the ages of 20 and 25 but decreases after that. Studies show that, by age 70, total body bone mass reduces by 30-40%. (1,2)

With an aging population and longer life expectancy, bone-related diseases like osteoporosis and osteosarcopenia are becoming a global concern. Lifestyle modifications, optimal nutrition support, and targeted supplementation can give the body the building blocks for strong bones throughout the lifespan. This article examines various bone health influencers, modifiable risk factors, supplements, and nutrition recommendations for strong bones. Let’s dive in!

 

Figure 1: Bone mass throughout the life cycle (3)

What is osteoporosis?

Osteoporosis is a silent disease without apparent symptoms. According to Zmerly and Akkawi, it’s “characterized by reduced bone mass and altered bone architecture, resulting in increased bone fragility and increased fracture risk.” (4)

Diagnosis of osteoporosis relies on a DEXA scan of the hips and spine. A T-score of -2.5 or less indicates osteoporosis. (2,4)

Two types of osteoporosis

There are two subdivisions of osteoporosis: primary and secondary.

Primary osteoporosis

Bone loss that occurs during the human aging process. There are two subtypes of primary osteoporosis including postmenopausal (type 1) and senile osteoporosis (type 2)

Postmenopausal osteoporosis (Type 1)	Occurs in women due to estrogen deficiency. Low estrogen leads to more bone resorption and less bone formation. (2)
Senile osteoporosis (Type 2)	Occurs in both men and women due to aging.

 

Secondary osteoporosis

Bone loss due to specific clinical conditions like hyperparathyroidism, celiac disease, and kidney disease. (5)

 

What is osteosarcopenia?

Osteosarcopenia is a unique condition that combines low bone density and low muscle mass. While osteoporosis and sarcopenia are different musculoskeletal diseases, they share similar pathophysiological pathways associated with aging. The coexistence of the two has been coined “the hazardous duet” due to the associated adverse health outcomes. (6,7)

Risk factors for osteosarcopenia include:

• Aging
• Low BMI
• Physical inactivity
• Inadequate protein intake

A 2020 study in PLoS One found that low BMI was the strongest factor related to the development of osteosarcopenia. (7)

Potential mediators of bone loss

In an enrichment presentation in IFNA Track 2, Dr. John Neustadt dives into various modifiable risk factors influencing bone health, such as inflammation, medications, stress, and sleep.

Inflammation

Chronic inflammation and proinflammatory cytokines (e.g., TNF-a, IL-1, IL-6, IL- 11, IL-15) are associated with a catabolic state resulting in the loss of lean muscle mass and a reduction in bone formation.

Medications

Certain medications can impact bone health, like cancer drugs, glucocorticoids (Prednisone, Hydrocortisone), proton-pump inhibitors (Prilosec, Nexium), and H2 receptor antagonists (Zantac, Pepcid).

Long-term use of acid-blocking medications, in particular, is well-known to cause bone loss. In fact, in 2010, the FDA warned of potential PPI-induced risk of hip, spinal, or radial fractures. (8)

Stress

Chronic stress is associated with an increased risk of systemic inflammation. These inflammatory factors may harm bone health due to promoting osteoclasts (bone eaters) and destroying osteoblasts (bone building). Furthermore, HPA-axis dysfunction and elevated cortisol over time may inhibit intestinal absorption of calcium and negatively impact bone health. (9)

Sleep

A 2019 cross-sectional study examined the association between self-reported hours of sleep and bone health in a sample of 11,084 women. Women who reported sleeping less than 5 hours per night had significantly lower BMD than those who slept at least 7 hours per night. (10)

 

Bone supporting nutrients

Unsurprisingly, a diverse diet rich in whole foods, protein, and phytonutrients is ideal for optimizing bone health. This section highlights six specific nutrients shown to support bone health.

Protein

Adequate protein intake is essential for preserving bone and muscle mass, especially as we age. According to Rizzoli et al., “protein intake is associated with higher BMD, a slower rate of bone loss, and reduced risk of hip fracture, provided that dietary calcium intakes are adequate.” (11,12)

Unfortunately, an estimated 38% of adult men and 41% of adult women eat less than the RDA (0.8 g/kg) for protein. Experts recommend a 1.2-2.0 g/kg daily protein intake with at least 2.5–3 g of leucine per meal. (6,13)

Studies also show that whey protein, collagen, beta-hydroxy-beta-methyl butyrate (HMB), and creatine may support optimal bone health by stimulating muscle-protein synthesis. (6,14)

Calcium

The link between dietary calcium intake and bone strength in older adults is still debated. One cross-sectional study including 2,906 adults aged 60 and over showed a connection between higher dietary calcium intake and improved lumbar spine BMD. (15)

In contrast, an analysis of a randomized controlled trial found that dietary calcium intake did not affect bone loss in postmenopausal women. (16)

Calcium supplementation is another hot topic. Clinical guidelines from the National Osteoporosis Foundation and the American Society for Preventive Cardiology state that “calcium intake from food and supplements that does not exceed the tolerable upper level of intake (defined by the National Academy of Medicine as 2000–2500 mg/d) should be considered safe from a cardiovascular standpoint.” (17)

Some studies show that calcium plus vitamin D supplementation may reduce the risk of fractures by 10-23%. One study found that supplementing with 800 IU of vitamin D and 500-1,000mg of calcium is adequate to support bone health. The same study also found that intestinal absorption of calcium citrate is 24% better than calcium carbonate. (18,19)

Vitamin D

Vitamin D deficiency is a major cause of bone disease in the elderly.

Due to the lack of vitamin D in food, supplementation is often necessary, especially for older adults. According to a 2019 systematic review in JAMA, combined supplementation of 800 IU of vitamin D and 1,200 mg of calcium daily is recommended to reduce fracture risk in older adults. (20)

Tailoring vitamin D supplementation to serum vitamin D and genetic markers like VDR is preferred. In the IFNA Lab Reference Ranges PDF, optimal serum vitamin D (25-0H) is 50-70 ng/dL.

Vitamin K

Known for its role in coagulation, vitamin K also plays a key role in bone health. (21, 22)

There are three main types of vitamin K:

Vitamin K1 or phylloquinone (PK)	Synthesized by plants and cyanobacteria, it’s the primary dietary source of vitamin K in Western diets via leafy greens, dairy, grains, and fruits.
Vitamin K2 or menaquinones (MKs)	There are 13 subtypes of vitamin K2, but MK-4 and MK-7 are the most common. MK-4 is the most predominant type of vitamin K in the body. All MK subtypes are either synthesized by Bacteroides in the large intestine or by bacteria in some foods, like fish, liver, eggs, and fermented foods. Natto is especially rich in MK-7. MK-7 has the highest bioactivity and half-life compared to MK-4. (23)
Vitamin K3 or menadione	Synthetically produced form of vitamin K commonly used in livestock and pet feed. The liver can convert vitamin K3 into MK-4.(22)

 

Studies show supplemental vitamin K2 (MK-4 or MK-7) can help support bone health. A 3-year study involving 244 postmenopausal women found that 180 μg MK-7 per day improved bone health and strength at the lumbar spine and femoral neck. (24)

A separate meta-analysis found that MK-4 supplementation reduced spinal fractures by 60%, and hip fractures by 77%. (25, 26)

No Tolerable Upper Intake limit is set for Vitamin K. Human coagulation studies have used up to 135 mg/day MK-4 with no significant increase in coagulation risk. (27, 28)

Use caution when supplementing with MK-7 as it’s derived from natto, a soy product. Individuals with food allergies/sensitivities may have tolerance issues.

Magnesium

While it might not be as popular as calcium, vitamin D, and vitamin K, magnesium plays a significant role in optimal bone health.

A 2018 study investigated the correlation between BMD and serum magnesium levels in 132 postmenopausal osteoporotic women compared to 81 healthy postmenopausal women. The results showed that osteoporotic women had significantly lower serum magnesium concentrations than the healthy control group. (29, 30)

Melatonin

Studies show that melatonin may positively affect bone health and BMD. While the direct mechanism is still unclear, it may be related to melatonin’s ability to support the sleep cycle. This is important to consider, as some studies show that postmenopausal women with low BMD often have disrupted circadian rhythms and poor sleep quality.

 

Food as medicine approach

Different eating patterns impact bone health in different ways. Unsurprisingly, adherence to a Mediterranean-style diet may be protective against osteoporosis. Studies show that following a Mediterranean diet is associated with higher BMD and a reduced risk of hip fracture in postmenopausal women. However, subjects with better adherence to this eating style typically had higher vitamin D values, suggesting that higher vitamin D was the reason for the protective effects. Either way, research shows positive health outcomes from a Mediterranean eating style. (31, 32, 33)

 

Conclusion

While the research on nutrition and bone-related diseases continues to evolve, we know that supporting optimal bone health starts at birth and continues throughout the lifespan. Targeted supplementation and an anti-inflammatory, nutrient-rich diet can provide a solid bone-supporting foundation, especially for the aging population.

Learn more about nutritional strategies for bone health with Dr. John Neustadt in Track 2, Enrichment Presentation, Module 8!

To learn more about a functional nutrition approach to bone health, register for your IFNA training today!

by Tori Eaton, RDN, LDN, IFNCP

 

References

1. NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteoporosis prevention, diagnosis, and therapy. JAMA. 2001;285(6):785–795. doi:10.1001/jama.285.6.785
2. Ji MX, Yu Q. Primary osteoporosis in postmenopausal women. Chronic Dis Transl Med. 2015;1(1):9-13. doi: 10.1016/j.cdtm.2015.02.006.
3. Bone biology. International Osteoporosis Foundation. Accessed Feb 27, 2023. (https://www.osteoporosis.foundation/health-professionals/about-osteoporosis/bone-biology
4. Akkawi I, Zmerly H. Osteoporosis: current concepts. Joints. 2018;6(2):122-127. doi: 10.1055/s-0038-1660790.
5. Mirza F, Canalis E. Management of endocrine disease: secondary osteoporosis: pathophysiology and management. Eur J Endocrinol. 2015;173(3):R131-51. doi: 10.1530/EJE-15-0118.
6. Kirk B, Zanker J, Duque G. Osteosarcopenia: epidemiology, diagnosis, and treatment-facts and numbers. J Cachexia Sarcopenia Muscle. 2020;11(3):609-618. doi: 10.1002/jcsm.12567
7. Okamura H, Ishikawa K, Kudo Y, et al.. Risk factors predicting osteosarcopenia in postmenopausal women with osteoporosis: A retrospective study. PLoS One. 2020;15(8):e0237454. doi: 10.1371/journal.pone.0237454.
8. Possible increased risk of fractures of the hip, wrist, and spine with the use of proton pump inhibitors. USDA. Accessed Feb 27, 2023. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/fda-drug-safety-communication-possible-increased-risk-fractures-hip-wrist-and-spine-use-proton-pump
9. Bedford JL, Barr SI. The relationship between 24-h urinary cortisol and bone in healthy young women. Int J Behav Med. 2010;17(3):207-15. doi: 10.1007/s12529-009-9064-2.
10. Ochs-Bolcom H, Hovey K, Andrews C, et al. Short sleep is associated with low bone mineral density and osteoporosis in the women’s health initiative. 2022;35(2):261-268. https://doi.org/10.1002/jbmr.3879
11. Rizzoli R, Biver E, Bonjour JP, et al. Benefits and safety of dietary protein for bone health-an expert consensus paper endorsed by the European Society for Clinical and Economical Aspects of Osteopororosis, Osteoarthritis, and Musculoskeletal Diseases and by the International Osteoporosis Foundation. Osteoporos Int. 2018;29(9):1933-1948. doi: 10.1007/s00198-018-4534-5
12. Protein and other nutrients. International Osteoporosis Foundation. Accessed Feb 27, 2023. https://www.osteoporosis.foundation/health-professionals/prevention/nutrition/protein-and-other-nutrients
13. Baum J, Kim I, Wolfe R. Protein consumption and the elderly: what is the optimal level of intake? 20168;8(6):359. doi: 10.3390/nu8060359.
14. Candow D, Forbes S, Chilibeck P, et al. Effectiveness of creatine supplementation on aging muscle and bone: focus on falls prevention and inflammation.Clin.Med. 2019; 8(4):488. https://doi.org/10.3390/jcm8040488
15. Yao X, Hu J, Kong X, Zhu Z. Association between dietary calcium intake and bone mineral density in older adults. Ecol Food Nutr. 2021;60(1):89-100. doi: 10.1080/03670244.2020.1801432.
16. Bristow S, Horne A, Gamble G, et al.. Dietary calcium intake and bone loss over 6 years in osteopenic postmenopausal women. J Clin Endocrinol Metab. 2019;104(8):3576-3584. doi: 10.1210/jc.2019-00111.
17. Kopecky S, Bauer D, Gulati M, Nieves J, et al. Lack of evidence linking calcium with or without vitamin D supplementation to cardiovascular disease in generally healthy adults: a clinical guideline from the national osteoporosis foundation and the American society for preventive cardiology. Ann Intern Med. 2016;165(12):867-868. doi: 10.7326/M16-1743.
18. Larsen E, Mosekilde L, Foldspang A. Vitamin D and calcium supplementation prevents osteoporotic fractures in elderly community dwelling residents: a pragmatic population-based 3-year intervention study. J Bone Miner Res. 2004;19(3):370-8. doi: 10.1359/JBMR.0301240.
19. van der Velde R, Brouwers J, Geusens P, et al. Calcium and vitamin D supplementation: state of the art for daily practice. Food Nutr Res. 2014;58. doi: 10.3402/fnr.v58.21796.
20. Yao P, Bennett D, Mafham M, et al. Vitamin D and Calcium for the Prevention of Fracture: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(12):e1917789. doi:10.1001/jamanetworkopen.2019.17789
21. Eden R, Coviello J. Vitamin k deficiency. StatPearls. July 4, 2022. Accessed Feb 27, 2023. https://www.ncbi.nlm.nih.gov/books/NBK536983/
22. Rodríguez-Olleros Rodríguez C, Díaz Curiel M. Vitamin k and bone health: a review on the effects of vitamin k deficiency and supplementation and the effect of non-vitamin k antagonist oral anticoagulants on different bone parameters. J Osteoporos. doi: 10.1155/2019/2069176.
23. Akbari S, Rasouli-Ghahroudi AA. Vitamin k and bone metabolism: a review of the latest evidence in preclinical studies. Biomed Res Int. 2018;2018:4629383. doi: 10.1155/2018/4629383.
24. Knapen M, Drummen N, Smit E, et al. Three-year low-dose menaquinone-7 supplementation helps decrease bone loss in healthy postmenopausal women. Osteoporos Int. 2013;24:2499–2507 https://doi.org/10.1007/s00198-013-2325-6
25. Cockayne S, Adamson J, Lanham-New S, Shearer M, Gilbody S, Torgerson D. Vitamin K and the prevention of fractures: systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2006;166(12):1256-61. doi: 10.1001/archinte.
26. Orimo H, Nakamura T, Hosoi T, et al. Japanese 2011 guidelines for prevention and treatment of osteoporosis—executive summary. Arch Osteoporos. 2012;7:3–20. https://doi.org/10.1007/s11657-012-0109-9
27. Ushiroyama T, Ikeda A, Ueki M. Effect of continuous combined therapy with vitamin K(2) and vitamin D(3) on bone mineral density and coagulofibrinolysis function in postmenopausal women. Maturitas. 2002;41(3):211-21. doi: 10.1016/s0378-5122(01)00275-4.
28. Neustadt J. Is high dose vitamin k safe? NBI. Accessed Feb 27, 2023. https://www.nbihealth.com/is-high-dose-vitamin-k-safe/
29. Rondanelli M, Faliva M, Tartara A, et al. An update on magnesium and bone health. 2021;34:715–736. https://doi.org/10.1007/s10534-021-00305-0
30. Mederle O, Balas M, Ioanoviciu S, et al.. Correlations between bone turnover markers, serum magnesium and bone mass density in postmenopausal osteoporosis. Clin Interv Aging. 2018;13:1383-1389. doi: 10.2147/CIA.S170111.
31. Muñoz-Garach A, García-Fontana B, Muñoz-Torres M. Nutrients and dietary patterns related to osteoporosis. Nutrients. 2020;12(7):1986. doi: 10.3390/nu12071986.
32. Rivas A, Romero A, Mariscal-Arcas M, et al. Mediterranean diet and bone mineral density in two age groups of women. Int J Food Sci Nutr. 2013;64(2):155-61. doi: 10.3109/09637486.2012.718743.
33. Palomeras-Vilches A, Viñals-Mayolas E, Bou-Mias C, et al. Adherence to the mediterranean diet and bone fracture risk in middle-aged women: a case control study. Nutrients. 2019;11(10):2508. doi:10.3390/nu11102508