Osteoporosis Diet

Definition

Osteoporosis, most commonly referred to as “thinning of the bones,” is a disease in which bone mineral density is reduced, which can cause the bones to become brittle and fragile and easily fracture. Although there is no cure for osteoporosis, it can be prevented. Healthy diets, along with weight-bearing exercise, are key factors in the prevention and treatment of osteoporosis. The focus of the osteoporosis diet is on optimizing bone health at every stage in life and is based on a normal balanced diet with an emphasis on calcium-rich foods and vitamin D.

Calcium

Age

U.S. recommended dietary allowance (mg/day)

FAO and WHO recommendations (mg/day)

Children 1-3 yrs.

700

500

Children 4-6 yrs.

600

Children 4-8 yrs.

1,000

Children 7-9 yrs.

700

Children 9-13 yrs.

1,300

Children 10-18 yrs.

1,300

Adolescents 14-18 yrs.

1,300

Males 51-70 yrs.

1,000

Females 51-70 yrs.

1,200

Males 70≥ yrs.

1,300

Post-menopause women

1,300

Adults 71 +

1,200

FAO = Food and Agriculture Organization

WHO = World Health Organization

mg = milligram

Origins

The National Osteoporosis Federation (NOF) estimates that about 75 million people in the United States, Europe, and Japan have osteoporosis. That includes about 54 million people in the United States alone. One in two women and one in four men age 50 and older are predicted to break a bone due to osteoporosis. By 2050, the NOF estimates that bone disease will cause hip fractures in men to increase by 310% and in women to increase by 240%. Every year in the United States, osteoporosis causes two million broken bones and 19 billion dollars in related costs. By 2025, those numbers may increase to three million fractures and 25 billion dollars. In other parts of the world, such as Africa and Asia, the incidence is much lower, but according to the World Health Organization (WHO), it is projected that the greatest increase in osteoporosis will take place in developing countries.

Despite being one of the world's most common diseases, osteoporosis is only now receiving international recognition. As recently as the early 1970s, it was thought that weak and broken bones were an unavoidable consequence of growing old.




Osteoporosis in the vertebrae Osteoporosis is most common in the hips, wrist, and vertebrae (spine). The vertebrae are most important because these bones support the body to stand and sit upright.





Osteoporosis in the vertebrae Osteoporosis is most common in the hips, wrist, and vertebrae (spine). The vertebrae are most important because these bones support the body to stand and sit upright. The vertebrae on the left is normal and the vertebrae on the right has been affected by osteoporosis.
SOURCE: National Women's Health Center, U.S. Department of Health and Human Services.

Description

The osteoporosis diet emphasizes a healthy diet including plenty of protein-containing foods, such as lean meats, eggs, fish, and soy, alongside fruits, vegetables, and foods containing calcium and vitamin D.

Many foods contain calcium, but not all are good sources because the calcium may not be well absorbed. Some nondairy sources of calcium, such as cereals and pulses (legumes), contain compounds that bind to the calcium and reduce its ability to be absorbed. Examples of such compounds include oxalates in spinach and rhubarb, and phytates in pulses such as lentils, chickpeas, and beans, as well as cereals, soy, and seeds. They do not always interfere with the absorption of calcium from other foods, but some combinations do. For example, eating cereal with milk reduces calcium absorption.

The most readily absorbed sources of dietary calcium include:

Some foods and drinks are fortified with calcium, such as breads, cereals, orange juice, and soymilk. These products should be specifically labeled as such.

Vitamin D




Reduced bone mass over time.





Reduced bone mass over time.
(Panther Media GmbH/Alamy Stock Photo)

In some countries, vitamin D is added to breakfast cereals, grain products and pastas, milk, milk products, margarine, and infant formula. In the United States, milk has been fortified since the 1930s. In 2003, the U.S. Food and Drug Administration (FDA) approved the addition of vitamin D to calcium-fortified juice and juice drinks. Canada has mandatory fortification of milk and margarine. In the United Kingdom, all margarine is fortified with vitamin D, and it is added voluntarily to other fat spreads and some breakfast cereals. In Australia, margarine and some milk products are fortified. Finland introduced fortification of milk and margarines in 2003, and Sweden made it mandatory in milk in 2007. Other European countries have not set any food fortification standards.

In the late 2010s, researchers were concerned about vitamin D deficiencies, which were thought to be increasing worldwide. A 2017 study estimated that 50% of the world's population was low in vitamin D. More than 80% of the body's vitamin D requirement naturally comes from the ultraviolet rays of sunlight, but many people live at latitudes where they cannot get adequate sun exposure all year. Normal serum vitamin D level is thought to be about 30 ng/mL, and scientists believe this level is necessary for optimal health. The study recommended supplementation with vitamin D for anyone with less than optimal sun exposure; recommendations were 1000 IU for light-skinned individuals, and 2000 IU for dark-skinned and older adults. Vulnerable groups such as the obese, the disabled, and pregnant women might need as much as 4000 IU. These amounts also vary by country.

Protein

During growth, low protein intake can impair bone development and increase the risk for osteoporosis later in life. Protein also helps maintain muscle mass and strength; this is particularly important for the elderly, to help prevent falls and fractures. A study published in 2018 found that adding supplemental whey protein to a diet that included animal protein might reduce the risk of fracture in postmenopausal women with osteoporosis; dietary proteins alone did not seem to have be enough to reduce the risk.

Protein sources include lean red meat, poultry, eggs, fish, and dairy, as well as legumes (lentils, kidney beans), tofu, soymilk, vegetables, nuts, seeds, and grains. Some questions have been raised regarding the effect of animal versus vegetable protein on bone health, and it had been suggested that vegetable protein might be more beneficial, but a study published in 2018 found no difference between soy and animal protein on bone health.

Fruit and vegetables Vitamin K

Vitamin K is required for the production of osteocalcin, which is important for bone mineralization. Vitamin K may not only increase bone mineral density in osteoporotic people, but also reduce fracture rates. This benefit is not well understood, and there is still inadequate evidence to show that increasing vitamin K in the diet would be effective in preventing or treating osteoporosis. Good dietary sources of vitamin K are green leafy vegetables such as spinach, lettuce, cabbage, and kale; liver; fermented cheeses; and soybeans. Following the recommendation of five portions of fruit and vegetables a day helps to optimize vitamin K intake.

Magnesium

Magnesium is a mineral that helps keep blood calcium levels constant. Magnesium deficiency contributes to osteoporosis by acting on bone cells and causing inflammation. The elderly are most at risk of low magnesium levels, as magnesium absorption rates decrease and excretion rates increase with age. Good food sources of magnesium are green leafy vegetables, legumes, nuts, seeds, and whole grains.

Zinc

Zinc is a constituent of hydroxylapatite, the main mineral component of bone. Dietary sources include whole grain products, brewer's yeast, wheat bran and germ, seafood, meats, and poultry. Zinc from animal sources is more easily absorbed than vegetable sources, so vegetarians may be at risk for low levels of zinc and should consult their physicians regarding supplementation.

Function

The osteoporosis diet focuses on maintaining or building strong bones throughout life. Bone density at any time depends on the amount of bone formed by the early twenties of one's life. Fracture risk is highest in those who do not achieve an adequate peak bone mass (the highest level of bone strength achieved) and those who lose bone rapidly with age, particularly after menopause (for females). Increased calcium intakes during the growth phase of childhood and adolescence helps to maximize peak bone mass. An increase of 10% in peak bone mass in adolescence reduces the risk of an osteoporotic fracture by 50% during adulthood.

Once peak bone mass is achieved, bone turnover is stable in both sexes until around age 40, and so the nutritional requirement for calcium remains stable during this time. Even after reaching full skeletal growth, adequate calcium intake is important because the body loses calcium every day through shed skin, nails, hair, sweat, urine, and feces.

Bone loss begins from about the age of 40 years. It is part of the normal aging process, but for women, this bone loss is accelerated further at the time of menopause, which typically occurs between the ages of 40 and 50. In addition, intestinal calcium absorption decreases and calcium excretion in the urine increases, so the body will compensate for low blood calcium levels by drawing on calcium in the bones. In the elderly, a decreased capacity of the skin to synthesize vitamin D and less exposure to sunlight due to decreased mobility raises the risk for low vitamin D status. Increasing calcium and vitamin D in the diet and ensuring an adequate amount of time spent outdoors during the summer months are important.

Outside of age-related bone loss, other groups are at risk for developing osteoporosis, including:

For those people at increased risk for osteoporosis, calcium and vitamin D supplements may be needed to meet daily requirements. The types of supplements available vary by country, so individuals should take medical advice before using them.

Benefits

Adequate calcium intake helps maximize peak bone mass early in life and protect against osteoporosis later in life. Vitamin D is important for the development and maintenance of bone. It helps the body absorb calcium and deposit it in the bone. A deficiency in vitamin D can cause a softening of the bone. Rickets in children and osteomalacia in adults are examples of extreme vitamin D deficiency. Osteoporosis is a possible result of long-term, low levels of vitamin D.

Calcium recommendations

Research on recommended calcium intake has focused on either meeting requirements or on optimizing bone density. Calcium requirements for adults may vary among geographic regions and cultures because of differing dietary, genetic, and lifestyle factors, including physical activity and sun exposure.

As of 2018, there was no single internationally accepted recommended calcium intake. In 1997, the American calcium guidelines were set significantly higher than the previous recommendations set in 1989, following a 1994 NIH conference on calcium intake. Recommended calcium levels were increased from 1,200 to 1,300 milligrams (mg) per day for adolescents and teens. Adults had an increase of 200 mg to 1,000 mg daily, and adults after 50 years of age were increased from 800 mg to 1,200 mg daily. The National Osteoporosis Foundation in 2018 recommended these levels of calcium intake.

In contrast, other developed countries have lower recommended levels. For example, the United Kingdom Department of Health recommends that adults receive 700 mg of calcium each day, all of which should come from diet. In France, for adolescents from age 15 to 18 years, 1,200 mg is recommended, while in Nordic countries the amount recommended is 900 mg for boys.

Despite the United States' higher recommendations, surveys indicate that actual calcium intakes are often inadequate. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMSD), many published studies have shown that low calcium intake throughout a person's life is associated with increased fractures and lower bone mass. The NIAMSD states that national nutrition surveys have shown most people in the United States do not receive sufficient amounts of calcium on a daily basis to grow and maintain healthy bones.

Vitamin D recommendations

People get vitamin D in three ways: through the skin, from the diet, and from supplements. According to the NIAMSD, most medical professionals in the United States recommend a daily consumption of 600 IU of vitamin D up to the age of 70 years. For men and women 71 years and older, the intake of vitamin D should be increased to 800 IU daily, which can be received from supplements or vitamin D–rich foods. The Institute of Medicine (of the National Academies) recommends a maximum daily intake of 4,000 IU for adults. Physicians may sometimes prescribe higher doses for people who are unable to go outdoors or are otherwise showing signs of deficiency.

The RDAs for vitamin D in the United States, according to the Office of Dietary Supplements (National Institutes of Health), are:

As with calcium, evidence from surveys shows that intake levels fall below the recommendations. The IOF estimates in 2011 that 50%–70% of European adults and 30%–50% of American adults were deficient in vitamin D. In South Asia and the Middle East, a deficiency of vitamin D in all age groups is common. Consequently, the IOF recommends that people at risk for osteoporosis and those 60 years of age and older take vitamin D supplements at the recommended dosage of 800 to 1,000 IU per day.

In addition to calcium and vitamin D, evidence suggests that other nutrients are beneficial to bone health, including magnesium, zinc, vitamins A, B, C, and K; however, some of the evidence is weak and controversial.

Precautions

Too much of certain foods or nutrients can hinder bone health:

KEY TERMS
Alkali—
A chemical substance that neutralizes acids.
Celiac disease—
A disorder caused by a sensitivity to gluten, which then causes the digestive system to ineffectively process fat.
Chronic obstructive pulmonary disease—
A chronic occurrence of both bronchitis and emphysema, which causes the airways to become narrowed.
Crohn's disease—
A chronic inflammatory disease that is usually found within the lower intestinal tract.
Fracture—
A break in a bone.
Lactose—
A sugar composed of glucose and galactose.
Menopause—
A period in the life of women when menstruation decreases and eventually ends, which typically occurs between the ages of 40 and 50 years.
Osteomalacia—
A bone-softening disease found in adults. The same disease is called rickets in children.
Rickets—
With the technical name of rachitis, a bone-softening disease found primarily in children that is caused by a lack of vitamin D.

Risks

Calcium has the potential to compete with the absorption of other important minerals, such as iron. Individuals with iron deficiency who are taking iron supplements should avoid taking calcium supplements at the same time.

Research and general acceptance

The notion that adequate calcium and vitamin D are key to reducing the risk of osteoporosis is accepted by all mainstream medical associations and member societies of the IOF, and calcium and vitamin D are part of the recommended dietary guidelines for many countries.

On September 29, 2008, the FDA amended the regulations on its calcium and osteoporosis health claim to include vitamin D. Thus, food manufacturers are allowed to claim on product labels that the ingestion of calcium and vitamin D can reduce the risk of osteoporosis.

Yet, the benefit of consuming the large amounts of calcium currently recommended for adults is still under debate. Countries with high calcium intakes such as the United States and Sweden have some of the highest rates of osteoporosis. In contrast, countries such as Gambia, China, Peru, and India have a much lower fracture incidence, despite an average calcium intake of 300 milligrams per day, less than one-third of the amount recommended in the United States.

Differing dietary, genetic, and lifestyle factors, including physical activity and sun exposure, may account for these countries's low fracture rates, but some hypothesize that the differences are related to high intakes of animal protein, which includes dairy products. High protein increases the acid load in the body. To neutralize the acid, the body pulls calcium from bones, which may increase bone loss and the risk of osteoporosis. As such, some experts believe the focus of dietary guidelines should be aimed at encouraging everyone to eat more calcium-rich plant-based foods, instead of consuming more dairy foods. Fruits and vegetables are considered alkali-rich foods that do not need neutralizing and are more beneficial to bone health. In addition, they are low in calories and full of fiber and antioxidants. More studies are needed to understand the implications of this acid-base balance for long-term skeletal health.

QUESTIONS TO ASK YOUR DOCTOR

See also Alkaline diet ; Calcium ; Iron ; Magnesium ; Soy ; Vitamin C ; Vitamin D ; Vitamin K ; Vitamins ; Whole grains ; Zinc .

Resources

BOOKS

Abelson, Abby. The Cleveland Clinic Guide to Osteoporosis. New York: Kaplan, 2010.

Alexander, Ivy M., and Karla A. Knight. 100 Questions & Answers about Osteoporosis and Osteopenia. 2nd ed. Sudbury, MA: Jones and Bartlett, 2011.

Anderson, John J. B., Sanford C. Garner, and Philip J. Klemmer, eds. Diet, Nutrients, and Bone Health. Boca Raton, FL: CRC Press, 2012.

Lorenzo, Joseph, et al., eds. Osteoimmunology: Interactions of the Immune and Skeletal Systems. 2nd ed. London: Elsevier, 2016.

Reid, David M. The Handbook of Osteoporosis. London: Springer Healthcare, 2011.

Schneider, Diane L. The Complete Book of Bone Health. Amherst, NY: Prometheus, 2011.

PERIODICALS

Caroli, A., et al. “Invited Review: Dairy Intake and Bone Health: A Viewpoint from the State of the Art.” Journal of Dairy Science 94, no. 11 (November 2011): 5249–62.

Fenton, Tanis R., et al. “Phosphate Decreases Urine Calcium and Increases Calcium Balance: A Meta-Analysis of the Osteoporosis Acid-Ash Diet Hypothesis.” Nutrition Journal 15, no. 8 (2009): 41.

North American Menopause Society. “The Role of Calcium in Peri- and Postmenopausal Women: 2006 Position Statement of The North American Menopause Society.” Menopause 13, no. 6 (November–December 2006): 862–77.

Price, Charles T., Joshua R. Langford, Frank A. Liporace. “Essential Nutrients for Bone Health and a Review of Their Availability in the Average North American Diet.” Open Orthopaedics Journal 12, no. 6 (April 2012): 143–49. http://dx.doi.org/10.2174/1874325001206010143 (accessed April 15 2018).

Prynne, Celia J., et al. “Fruit and Vegetable Intakes and Bone Mineral Status: A Cross Sectional Study in 5 Age and Sex Cohorts.” American Journal of Clinical Nutrition 83, no. 6 (2006): 1420–28.

Saldana, Tina M., et al. “Carbonated Beverages and Chronic Kidney Disease.” Epidemiology 18, no. 4 (July 2007): 501–6.

WEBSITES

Food Standards Agency. FSA Nutrient and Food Based Guidelines for UK Institutions. London, UK: FSA, October 2007. https://www.food.gov.uk/sites/default/files/multimedia/pdfs/nutrientinstitution.pdf (accessed April 15, 2018).

Higdon, Jane, Victoria J. Drake, and Barbara Delage. “Calcium.” Linus Pauling Institute, Oregon State University. http://lpi.oregonstate.edu/mic/minerals/calcium (accessed April 15, 2018).

International Osteoporosis Foundation. “Vitamin D.” https://www.iofbonehealth.org/osteoporosis-musculoskeletal-disorders/osteoporosis/prevention/vitamin-d (accessed April 15, 2018).

National Health Services (UK). “Calcium.” https://www.nhs.uk/conditions/vitamins-and-minerals/calcium/ (accessed April 15, 2018).

NIH Osteoporosis and Related Bone Diseases National Resource Center. “Calcium and Vitamin D: Important at Every Age.” National Institute of Arthritis and Musculoskeletal and Skin Diseases. https://www.bones.nih.gov/health-info/bone/bone-health/nutrition/calciumand-vitamin-d-important-every-age (accessed April 15, 2018).

Office of Dietary Supplements. “Fact Sheet for Health Professionals: Calcium.” National Institutes of Health. https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/ (accessed April 15, 2018).

Office of Dietary Supplements. “Fact Sheet for Health Professionals: Vitamin D.” National Institutes of Health. https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ (accessed April 15, 2018).

U.S. Department of Agriculture, National Agricultural Library. “DRI Tables and Application Reports.” Food and Nutrition Information Center. https://www.nal.usda.gov/fnic/dri-tables-and-application-reports (accessed March 15, 2018).

U.S. Food and Drug Administration. “Guidance for Industry: Health Claims on Calcium and Osteoporosis; and Calcium, Vitamin D, and Osteoporosis.” May 2009. https://www.fda.gov/food/guidanceregulation/guidancedocumentsregulatoryinformation/ucm152626.htm (accessed April 15, 2018).

ORGANIZATIONS

Academy of Nutrition and Dietetics, 120 S. Riverside Plaza, Ste. 2190, Chicago, IL, 60606-6995, (312) 899-0040, (800) 877-1600, amacmunn@eatright.org, http://www.eatright.org .

International Osteoporosis Foundation, 9, rue Juste-Olivier, Nyon, Switzerland, CH-1260, 41 22 994-0100, Fax: 41 22 994-0101, info@iofbonehealth.org, http://www.iofbonehealth.org .

National Institute of Arthritis and Musculoskeletal and Skin Diseases, 1 AMS Circle, Bethesda, MD, 20892-3675, (301) 495-4484, (877) 22-NIAMS (226-4267), Fax: (301) 718-6366, NIAMSinfo@mail.nih.gov, http://www.niams.nih.gov .

National Institute on Aging, 31 Center Drive, Building 31, Room 5C27, Bethesda, MD, 20892, (800) 222-2225, TTY: (800) 222-4225, niaic@nia.nih.gov, http://www.nia.nih.gov .

National Osteoporosis Foundation, 1150 17th St. NW, Ste. 850, Washington, DC, 20036, (202) 223-2226, (800) 231-4222, Fax: (202) 223-2237, http://www.nof.org .

NIH Osteoporosis and Related Bone Diseases National Resource Center, 2 AMS Cir., Bethesda, MD, 20892-3676, (202) 223-0344, TTY: (202) 466-4315, (800) 624-BONE (2663), Fax: (202) 293-2356, NIHBoneInfo@mail.nih.gov, http://www.bones.nih.gov .

Tracy J Parker, RD
Revised by Amy Hackney Blackwell, PhD

  This information is not a tool for self-diagnosis or a substitute for professional care.