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How to Best Invest in your Bones

The importance of peak bone mass
  • Healthy bones are essential throughout our lives
  • Bones are living tissues that continuously undergo regeneration with removal of old bone and replacement by new bone
  • During times of growth (children and teenagers), more new bone is laid down than what is removed and so bones get bigger, denser and stronger
  • This process continues until peak bone mass is achieved which is when the bones are at their strongest and most dense
  • Peak bone mass occurs typically in late 20s and after that the balance slowly changes and bone resorption outpaces new bone formation
  • Around 90% of peak bone mass is accumulated by 18 years for women and 20 years for men
  • Therefore, the first 20 years of life is the best time to invest and accumulate as much bone as possible which is achieved with optimal levels of vitamin D, calcium and exercise
  • Men overall achieve a larger peak bone mass than women
  • Between 30 years and menopause, women (like men) have minimal change in total bone mass
  • After menopause though, women experience a rapid bone loss which then slows down
  • If it drops low enough it can lead to osteoporosis
  • It is therefore prudent to invest as much as possible in the earlier years to maximise the peak bone mass and to continue to take measures to reduce the rate of bone loss later in life
  • A 10% increase in peak bone mass can postpone development of osteoporosis by 13 years
Factors that affect peak bone mass and risk of osteoporosis
  • Numerous factors affect peak bone mass
    • Genetic:
      • These are factors you are born with and cannot change e.g. age, gender, race, body size, and family history
      • Thought to have the biggest impact ~75%
      • Over 60 genes have already been identified in relation to bone mineral density
    • Environmental:
      • These are factors that surround you throughout life e.g. exercise, diet, hormonal, medication, lifestyle, smoking, and alcohol
      • Less of an impact but the only ones that can be modified ~25%
  • Age: 
    • As one gets older the risk of osteoporosis increases and this is due to:
    • Reduced protective effect of sex hormones
    • Increased risk of vitamin D insufficiency
    • Reduced calcium absorption 
    • Reduced stresses on bones from less exercise and muscle mass
  • Gender: 
    • Males tend to have bigger peak bone mass than women
    • Before puberty boys and girls have similar rates of growth in their bone masses
    • After puberty, boys acquire bone at a great rate and this continues until ~30 years
    • Women lose bone at a greater pace after the menopause and because they have lower peak bone mass they have less bone to lose
    • Women as a result are 4 times as likely as men to develop osteoporosis
  • Race:
    • African American and Hispanic females manage to achieve greater peak bone mass than white and Asian females and as a result they are more protected against osteoporosis
  • Body size:
    • Small framed individuals (more common in women) are at greater risk as they have less bone stock in reserve to draw from as they age
  • Family history:
    • Positive family history of osteoporosis has been shown to greatly affect the patient’s risk of osteoporosis but also their peak bone mass
  • Hormonal:
    • Oestrogen has a protective effect on bones by inhibiting bone resorption:
      • This is the process by which bone is broken down by bone cells called osteoclasts
      • This means that the longer women are exposed to oestrogen the greater the benefit for their bones
      • Women who start their menstrual cycles younger and start their menopause later have had longer exposure to oestrogen and so reach a greater peak bone mass
      • Abnormal cessation of periods (amenorrhoea) such as due to extremely low body weight (anorexia) or from excessive exercise (e.g. Female Athlete Triad) or low oestrogen levels in postmenopausal women and those on certain treatments for breast cancer all increase the risk of osteoporosis
      • Men with low testosterone levels (e.g. following chemotherapy for prostate cancer) have increased risk of osteoporosis:
        • Testosterone stimulates cells in bone called osteoblasts to lay down new bone
        • A small portion of testosterone is normally converted to oestrogen and this has been shown to be the bigger determinant of bone health in men
    • Other hormones that can increase risk of osteoporosis are overactive thyroid, parathyroid and adrenal glands
  • Nutrition:
    • Calcium is an essential mineral required for bone mineralisation and consequently bone strength (see below)
    • Calcium deficiency can have a significant impact on peak bone mass
    • Vitamin D deficiency is a well-known risk factor for development of osteoporosis and a key nutrient together with calcium in the initial treatment against osteoporosis
    • Surgery that has removed parts of stomach or intestine can reduce the amount of nutrients (e.g. calcium) that are absorbed 
    • Diets low in protein have an adverse effect on bone strength
    • Consumption of soft drinks with inorganic phosphate additives such as Colas increases the risk of fragility fractures 
  • Exercise: 
    • Exercise is essential for bone health throughout life
    • Bones are living tissues and they get stronger when under stress
    • Hence people who live a sedentary lifestyle or patients who lie in bed for periods of time and astronauts exposed to low gravity for periods of time have weakened bones
    • Gentle aerobic exercise like walking is insufficient to improve bone strength
    • More brisk walking and hiking are more beneficial than normal walking
    • Exercises like cycling and swimming whilst being a great aerobic exercise they are considered low impact and do not make bones stronger and in fact if not combined with other strength and resistance training can weaken the bones 
    • Strength and resistance training:
      • The heavier the weights one can lift the more beneficial for the bones
      • Therefore, for bone health lifting a heavier weight less times is more beneficial than a lighter weight more times
    • High impact activities such as jumping, sprinting and plyometrics are very beneficial for building bone strength because they subject the bones to multiple times the body weight over a fraction of a second that the foot is in contact with the ground
    • Exercise has the added benefit of helping to improve muscle strength, balance, coordination, reaction times all of which help prevent falls and fractures:
      • This is especially important for people with osteoporosis and the elderly
    • A medical consultation should be considered prior to commencing exercise for those over 40 years or have health conditions such as heart problems, high blood pressure, diabetes or obesity
    • In the presence of osteoporosis care should be taken when exercising in order to minimise risk of fracture:
      • Avoid movements that bend or twist the spine
      • Avoid high impact activities e.g. running, jumping
  • Lifestyle behaviours:
    • Smoking:
      • Smoking is thought to inhibit the action of cells that lay down new bone called osteoblasts
      • It increases the breakdown of oestrogen which is known to have a protective effect
      • Reduces body weight which has adverse effect on bone density
      • Induces an earlier menopause
      • Reduces calcium and vitamin D absorption
      • It increases production of cortisol in the body (a naturally occurring steroid)
      • The impact of smoking is more drastic when it starts at a younger age and in heavy smokers
    • Alcohol:
      • Consumption of >4units/day is detrimental to bone strength
    • Sedentary lifestyle:
      • Bones become weaker as they are subjected to lower stresses 
Prevention
  • By maintaining a healthy lifestyle, exercise and nutrition throughout life, is the best investment in achieving as strong bones as possible early in life and therefore minimising the risk of developing osteoporosis later in life
  • The genetic factors which have the greatest influence on someone’s risk of osteoporosis cannot be modified, so the focus will need to be on optimising the aforementioned modifiable risk factors
The role of calcium
  • Calcium is a mineral:
    • >99% is found in bones and teeth
    • It adds strength to the bones and helps them withstand stresses
  • A mineral is a chemical element (inorganic substance) that is an essential nutrient required by the body in order to carry out functions necessary for life
  • Essential nutrient is one that is required by the body to carry out its normal functions:
    • They cannot be synthesised from other ingested nutrients
  • There are four groups of essential nutrients:
    • Minerals
    • Vitamins
    • Essential fatty acids
    • Essential amino acids
  • Calcium is the most abundant mineral in our bodies:
    • The other major minerals in the body are phosphorus, potassium, sodium and magnesium
  • Since calcium is a mineral it cannot be made in the body and so it must be absorbed from food that is consumed
  • If there is inadequate consumption of calcium, then bone is broken down as it has the largest reserves of calcium in the body (increased activity by bone cells called osteoclasts) and calcium is released into the bloodstream:
    • Over time this will reduce bone mineral density, and therefore weaken the bones and lead to osteoporosis
What is the daily recommended intake of Calcium?
  • The recommended daily intake varies for men and women and also varies with age:

Recommended Daily Allowance in milligrams (mg)
Group Age Recommended Daily Calcium Intake (mg)
Men and Women 9-18 years 1300 mg
Men and Women 19-50years 1000 mg
Men 51-70 years 1000 mg
Women 51-70 years 1200 mg
Men and Women >70 years 1200 mg
Pregnant or nursing women 14-18 years 1300 mg
Pregnant of nursing women 19-50 years 1000 mg
Which foods have high calcium?
  • Dairy products are the biggest sources of calcium:
    • Milk, yoghurt, cheese
  • Other sources are:
    • Broccoli, kale, green leafy vegetables
    • Salmon, sardines, other soft bone fish
    • Tofu
    • Bread, pasta, grains
    • Cereals fortifies with calcium
What are the symptoms of low calcium?
  • Low vitamin D causes reduced calcium absorption and this in turn causes:
    • Osteoporosis and osteopaenia
    • Fatigue:
      • Low energy and feeling tired
      • Dizziness
      • Sleepiness
    • Muscle problems:
      • Cramps
      • Muscle ache and spasms
    • Neurological:
      • Paraesthesia (pins and needles) or numbness to hands, feet and around mouth
      • Confusion
      • Memory loss
      • Hallucinations
    • Skin problems: 
      • Dry and itchy skin
      • Eczema:
        • Inflammation of the skin leading to itchiness and skin to be cracked and rough
      • Psoriasis:
        • A chronic autoimmune disorder where skin cells multiply 10 time faster than normal
        • Leads to scaling of the skin typically over knees, elbows and scalp
        • Can also lead to arthritis of joints such as the knee
      • Alopecia:
        • Autoimmune disorder leading to hair loss
      • Weak and brittle nails
    • Painful Premenstrual Syndrome:
      • Daily supplementation with 500mg/day can significantly reduce premenstrual depression, fatigue, oedema and pain in women with Premenstrual Syndrome
    • Dental Problems:
      • Weak roots, brittle teeth, tooth decay
      • In infants this can lead to delay in tooth formation
Further helpful information can be found here on: 

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