Building Better Bones: A Guide to Risk Factors, Nutrition, and Lifestyle Habits

Bone health is something many people overlook until it’s too late — but the foundations are laid much earlier than most realise. This guide covers the key risk factors for bone loss, from lifestyle habits like smoking and inactivity to the role of essential nutrients including calcium, vitamin D, K2,...

Building Better Bones: A Guide to Risk Factors, Nutrition, and Lifestyle Habits

Bone health is an area many people give very little thought to until there is an issue, or until ageing has an effect. But understanding bones, their importance and how to maximise bone health is important from a much earlier age than many people realise.

Peak Bone Mass

Whilst bone can appear to be a static and unchanging tissue, it is constantly regenerating and requires the right conditions to maintain its strength and stability. One of the most important factors to consider in bone health is peak bone mass. Bone mass increases steadily through childhood and puberty and peaks by the age of 25–30 years. After this age it decreases steadily, with a sharper drop after menopause for women.1 Therefore, the longer we live, the smaller the proportion of our lives are given over to building bone density and more time is in the bone loss phase. Studies suggest that increasing peak bone mass by as little as 10% could delay the onset of osteoporosis by 13 years in most people and reduce the risk of later-life fractures by as much as 50%.2

Osteoporosis

Osteoporosis is a condition that causes the bone to become weak, which can increase the risk of fractures and breakages. 2 million women in the UK currently have osteoporosis and 180,000 fractures are the result of this condition each year.3 Osteopenia is often the forerunner of osteoporosis and refers to lower than normal bone density. An increasingly ageing population has led to increases in the prevalence of osteoporosis.

Lifestyle and bone

A sedentary lifestyle has a large impact on the long-term health of the bones. Exercise, particularly weight-bearing exercise, is well established as supporting bone density.4 The pulling forces that muscles and tendons exert on the bones and the stress of impact all cause very slight, but normal, deformations in the bones which trigger the formation of new bone tissue. This can be useful for the formation of peak bone mass in younger people and for the ongoing maintenance of bone density during ageing. Evidence even suggests that, as weak bone deforms more than strong bone and the response to exercise is therefore greater, regular physical exercise may even reverse bone loss.5

There also seems to be an association between sarcopenia (age-related muscle loss) and osteoporosis, which is now being called osteosarcopenia.6 This makes sense as a loss in muscle mass and function means that there is less force being applied to the bones, limiting their potential for remodelling. The combination of the two conditions also has serious implications for long-term health and mortality, as they both make falls more likely and the risk of fractures is also increased. As both conditions are strongly linked to physical activity and exercise, a sedentary lifestyle is even more important to avoid.7

Menopause is also known to have a significant effect on bone health, with significant bone mass being lost. The drop in oestrogen which occurs at this time is closely linked to decreases in bone mass.8

Diet and lifestyle can also affect the development of peak bone mass and the rate at which bone mass is lost. Carbonated drinks, especially colas, have been linked to decreased bone mineralisation.9 It is not clear if this is due to the simple replacement of calcium-rich drinks with carbonated ones, or whether there are compounds within colas which are having specific detrimental effects. Some studies have shown that the caffeine and phosphoric acid in these drinks may be to blame. Caffeine inhibits calcium absorption,10 whilst phosphoric acid stimulates the release of calcium from the bones. Drinking soft drinks such as colas tends to be associated with younger people who are then limiting their peak bone mass.

Smoking and drinking are also considered to have negative effects on bone health. Nicotine inhibits calcium absorption and other substances within cigarettes are associated with bone mineral loss.11 Several studies have shown that smoking can reduce bone mineral density in both men and women.12 Alcohol appears to reduce the production of osteoblasts, the cells involved in building new bone.13

Nutrients and bone health

Improvements in bone mass will be limited by dietary factors and our intake of bone-building nutrients. Calcium is perhaps the most familiar of these, and an adequate calcium intake is essential for the composition of bone, along with collagen.14

Vitamin D intake and status is closely linked to calcium, and low vitamin D impairs the absorption of dietary calcium.15 This in turn leads to low calcium in the blood, which encourages the release of this mineral from the bone to maintain blood levels. Over the long term this will lead to low bone mineralisation and the development of osteoporosis. Numerous studies of vitamin D, both alone and in combination with calcium, have shown that it is associated with higher bone mineral density (BMD) and a lower risk of fracture.16

Vitamin K intake is also vital for bone, as it is required for the deposition of calcium in the bones. Vitamin K2 in the MK-7 form is the preferable form, as K1 is excreted too quickly and only has time to affect the liver.17 K2 as MK-4 has a negligible effect on K2 levels in the body.18 However, vitamin K2 as MK-7 is not generally widely consumed in the diet, as the main sources are fermented foods, particularly natto. Whilst the bacteria in the gut are known to produce some K2, this may not be enough. Therefore, supplementation with a good K2/MK-7 product is likely to be useful for most adults, particularly those concerned about bone health.

Magnesium is particularly relevant for bone health, and studies have shown that around 70% of women and 50% of men in the UK do not consume a sufficient level of this mineral from their diets. Low magnesium has been shown to soften bone and increase inflammation.19 It is also required for vitamin D to work correctly in the body, which then supports magnesium absorption.20 Several studies have shown a link between low magnesium and osteoporosis,21 and there is also evidence to show that consuming enough magnesium before puberty leads to better bone mass in adulthood. Supplementation of girls with magnesium for 12 months also assisted the development of higher bone mass.22

Protein is also important for bone health and mass, with studies suggesting that amino acids from protein have a bone-building effect.23 Many studies, looking at both sexes and ages from 18 to 77 years, have linked protein intake with higher bone mineral density in various bones, including the femur, neck and spine. The results seem to be particularly relevant to both adolescent and young adult women, when peak bone mass is being laid down,24 and for post-menopausal women25 when loss of BMD is at its highest. Protein also has a better effect on bones when calcium intake is sufficient.26 Protein intake is also associated with muscle mass and may be useful for preventing or slowing age-related muscle loss.

Diet and supplements

The importance of a healthy diet cannot be underestimated for bone health, and this should focus on sources of protein and bone-building nutrients, whilst also choosing foods to reduce inflammation. A Mediterranean-style diet is probably a good basis for a bone-healthy diet. It focuses on fruits and vegetables, foods such as nuts and seeds which contain both minerals and omega-3 and omega-6 fatty acids, olive oil, lean meats and oily fish (such as herring, mackerel, salmon and sardines) which are also rich in omega-3 fats. Dairy and eggs can also be included as good sources of calcium, protein and vitamin D. Processed foods are avoided, with an emphasis on fresh, unprocessed or minimally processed foods which are naturally much lower in sugar, salt and trans and hydrogenated fats. This diet is also high in foods which reduce inflammation, such as omega-3 fatty acids and herbs and spices, and lower in added sugars, red meat and carbonated beverages which are not only associated with inflammation but may directly affect bone health.

In terms of supplements, the focus should be on vitamin K2 in the MK-7 form, as this is probably the most difficult to obtain from the diet, since fermented foods rich in this form of vitamin K are rarely eaten in the UK.

Vitamin D should also be considered, especially during the winter months or for older people, particularly those in residential care, as both age and lack of sun exposure can reduce vitamin D levels. Currently the recommendation is 400iu (10µg) for adults in the winter, but this is judged to be insufficient by many experts.27,28

If protein intake from the diet is a concern, supplementary protein can be considered in the form of whey or soya protein. Studies show that both forms appear to help reduce bone loss and reduce the risk of fracture in those with osteoporosis.29,30 Soy protein also appears to aid calcium absorption and improve muscle strength and mass.

Soya foods also offer the benefits of compounds called phyto-oestrogens — plant compounds which weakly mimic the action of oestrogen and are often recommended for menopausal symptoms. Studies suggest that they may be of particular benefit for post-menopausal bone loss,31 by inhibiting bone resorption and stimulating bone formation, at intakes of around 90–100mg a day.32,33

Reducing chronic inflammation is also important for reducing bone density loss and supporting bone health.34 Omega-3 fatty acid supplements which provide EPA and DHA should be considered, as data shows that the intake of oily fish is low in the UK and omega-3 intakes are particularly poor when compared to other fats. Numerous studies have found a strong link between the use of fish oil and the reduction of inflammation.35 Turmeric is also very closely involved in reducing the production of many inflammatory compounds.36

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