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Osteoporosis: A Nutrition Fact Sheet for Health Professionals

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Nutrition has long been established as a key factor in building and maintaining bone strength. While calcium and vitamin D are crucial nutrients for bone health, energy, protein and other vitamins and minerals all play a role. The risk of developing osteoporosis is influenced by life-long dietary intake of these nutrients in combination with regular weight-bearing activity and not smoking.

Dietary calcium

Calcium is essential for bone health and the recommended intake (RDA) is 800 mg/day for children, adults and older people, increasing to 1200 mg for teenagers, pregnant and lactating women1 . Unfortunately, 16% of women in Ireland are consuming less than the estimated average requirement of calcium2. The National Children’s Food Survey also found that 28% boys and 37% girls aged 5-12 years have inadequate calcium intakes3.

The richest sources of calcium in the diet are milk, cheese and yogurt. Three servings a day will help meet calcium needs of an adult or child; five servings are recommended during adolescence and pregnancy. Smaller amounts of calcium may be obtained from other food sources, such as green vegetables, bread and sardines. It should be noted however that the bioavailability of calcium from non-dairy sources is lower. Foods fortified with calcium and vitamin D such as milk and yoghurt can also be useful.

Recommended Daily Allowances of Calcium and Vitamin D1

 

Age (years)

Calcium (mg/day)

Vitamin D (µg/day)

Babies

0-1

N/A

5 (as supplement) 4

Children

1-3

800

10

 

4-6

800

0-10

 

7-10

800

0-10

Males & Females

11-14

1200

0-15

 

15-18

1200

0-15

Males & Females

19-64

800

0-10

 

65+

800

10

 

Pregnancy

1200

10

 

Lactation

1200

10

 

Vitamin D

Vitamin D is primarily produced by the action of UVB light on the skin, with a limited number of foods also providing vitamin D (oily fish, egg yolks, liver and fortified dairy products). Due to Ireland’s northerly latitude (and the use of sunscreens) production from UVB light is compromised. This, together with poor dietary intakes, has contributed to wide-spread sub-optimal vitamin D status. Recent research has confirmed that low vitamin D status (25 hydroxyvitamin D < 50nmol/l) is more prevalent than previously believed, particularly in postmenopausal women5. Dietary sources should therefore be encouraged in all ages.

Dietary recommendations for vitamin D are expressed in micrograms (µg or mcg) or International Units (IU).

  • To convert IU to µg- Multiply by 0.025 e.g. 400IU*0.025= 10µg

  • To convert µg to IU- Divide by 0.025

 

Calcium and vitamin D supplements

If it is not possible to achieve adequate calcium and vitamin D intake through diet, supplements may be recommended. A meta-analysis of calcium and vitamin D supplementation found that calcium and vitamin D supplementation reduced bone loss and fracture risk in adults aged 50 years and older6. The National Osteoporosis Foundation in the USA recommends 1000mg-1200mg calcium and 800-1000IU of vitamin D for adults (aged 50 years and older)7.

Vitamin D given alone has not been found to reduce risk of fracture8 but has been shown to reduce falls if vitamin D status was low at baseline9.

Note: Recent studies have investigated a possible link between supplemental calcium intake and cardiovascular disease10 11. This is an area of ongoing research with no consensus at present12 13.

Other Dietary Factors

Alcohol

High alcohol intakes increase risk of osteoporosis; some research suggests that even 2-4 drinks per day may be harmful to bone tissue and the authors advise that one drink per day for women and two drinks per day for men is a safe level14.

For overall health the recommended limits in Ireland are:

A high alcohol intake will also increase risk of falls and injury and should be a consideration when assessing falls risk.

Caffeine

It has been suggested that a high caffeine intake is a risk factor for osteoporosis, with some groups advising a consumption of no more than 4 strong cups of coffee a day or less15, 16. Caffeine is found in coffee, tea, cola-type drinks, energy drinks and chocolate. Consumption of fizzy drinks has been found to displace milk intake in teenagers and may contribute to sub-optimal bone development in this age group.

Soy

There is inconclusive evidence that soy has a beneficial effect on bone health. The available evidence does not support a recommendation for the use of soy for this purpose17.

Other vitamins and minerals

Various research studies suggest a role for different vitamins and minerals in bone health18. The evidence suggests that vitamin C and K may have positive effects on bone. However it is recommended that these nutrients are obtained from a balanced diet with adequate fruit and vegetables as the evidence is not sufficient to recommend supplementation19.

Omega 3 fatty acids

It has been suggested that omega 3 fatty acids have a beneficial effect on bone health but the evidence at present is limited by the small number of studies. From the studies to date it appears that any potential benefit of omega 3 fatty acids on bone may be enhanced by concurrent administration of calcium20.

Groups at increased risk

Low Body Mass Index (BMI)

Low BMI and low body weight have been identified as risk factors for osteoporosis21. Frail older people, those with eating disorders and some athletes may have a low BMI and are therefore at greater risk of developing osteoporosis.

Malnourished adults

Malnourished adults particularly those with an inflammatory condition are at increased risk of bone loss22. Nutritional screening tools can be used to identify those at risk who may require some intervention or referral to a dietitian. Tools include the Malnutrition Universal Screening Tool (MUST) devised by BAPEN23. In older people there are many factors which may contribute to poor nutritional status, including- difficulties eating (e.g. badly fitting dentures), poor appetite, loneliness, social isolation, difficulties accessing and preparing food and ill health. Identifying and managing any problems can have a significant impact on nutritional status24.

Older people should also be assessed for dehydration, as this can exacerbate dizziness and increase risk of falls and injury. A minimum of 8 glasses of fluid daily will improve these symptoms25.

Those on weight reducing diets

Bone loss has been shown to be accelerated during weight loss 26. This may increase risk of osteoporosis in dieters, particularly in those following restrictive diets. In addition, dieters may be excluding sources of calcium in the diet, such as dairy foods, in the belief that they are fattening. Whereas evidence shows that weight reducing diets higher in dairy foods, dietary calcium, and protein with daily exercise protect bone during weight loss27.

Other medical conditions

Particular attention should be paid to the calcium intakes of individuals at risk of osteoporosis due to conditions such as coeliac disease, malabsorption or inflammatory bowel disease. Those on long-term corticosteroids are also at greater risk of osteoporosis28.

Healthy eating advice

A healthy balanced diet will ensure that all nutrients necessary for bone health are provided in the diet. This can be achieved by following the principals of the food pyramid. Those at low risk of osteoporosis should be given general health and well being advice, including information on alcohol, caffeine, smoking, calcium and vitamin D. Those identified to be at high risk may need further assessment and dietary advice to improve nutritional status and reduce risk of fracture.

Updated by Laura Keaskin, MINDI, October 2013

Review date: October 2015

© 2013 Irish Nutrition and Dietetics Institute, INDI. All rights reserved. May be reproduced in its entirety provided source is acknowledged. This information is not meant to replace advice from your medical doctor or individual counselling with a dietitian. It is intended for educational and informational purposes only.

References:

  1. Food Safety Authority of Ireland (FSAI) (1999) Recommended Dietary Allowances for Ireland, Dublin: FSAI.
  1. Irish University Nutrition Alliance (IUNA) (2011) National Adult Nutrition Survey, Dublin: IUNA.

  1. Irish University Nutrition Alliance (IUNA) (2005) National Children’s Food Survey, Dublin: IUNA.

  1. Food Safety Authority of Ireland (FSAI) (2007) Recommendations for a National Policy on Vitamin D supplementation for Infants in Ireland, Dublin: FSAI.

  1. Hill, T.R., O'Brien, M.M., Lamberg-Allardt, C., Jakobsen, J., Kiely, M., Flynn, A. and Cashman, K.D. (2006) ‘Vitamin D status of 51-75-year-old Irish women: its determinants and impact on biochemical indices of bone turnover’, Public Health Nutrition, 9(2), 225-233.

  1. Tang, B.M., Eslick, G.D., Nowson, C., Smith, C. and Bensoussan, A. (2007) ‘Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis’, Lancet, 370(9588), 657-666.

  1. National Osteoporosis Federation (2013) Clinician’s guide to prevention and treatment of Osteoporosis, Washington, DC: National Osteoporosis Foundation.

  2. Avenell, A., Gillespie, W.J., Gillespie, L.D. and O'Connell, D. (2009) ‘Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis’, Cochrane Database Systematic Review, (2):CD000227.

  1. Karlsson, M.K., Magnusson, H., von Schewelov, T. and Rosengren, B.E. (2013) ‘Prevention of falls in the elderly--a review’, Osteoporosis International, 24(3), 747-762.

  1. Xiao, Q., Murphy, R.A., Houston, D.K., Harris, T.B., Chow, W.H. and Park, Y. (2013) ‘Dietary and supplemental calcium intake and cardiovascular disease mortality: the National Institutes of Health-AARP diet and health study’, JAMA Internal Medicine, 173(8), 639-646.

  2. Li, K., Kaaks, R., Linseisen, J. and Rohrmann, S. (2012) ‘Associations of dietary calcium intake and calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg)’, Heart, 98(12), 920-925.

  1. Van Hemelrijck, M., Michaelsson, K., Linseisen, J. and Rohrmann, S. (2013) ‘Calcium intake and serum concentration in relation to risk of cardiovascular death in NHANES III’, PLoS One, 8(4), e61037.

  1. Rojas-Fernandez, C.H., Maclaughlin, E.J., Dore, N.L. and Ebsary, S. (2012) ‘Assessing the potential adverse consequences of supplemental calcium on cardiovascular outcomes: should we change our approach to bone health?’, The Annals of Pharmacotherapy, 46 (5), 696-702.

  1. Maurel, D.B., Boisseau, N., Benhamou, C.L. and Jaffre, C. (2012) ‘Alcohol and bone: review of dose effects and mechanisms’, Osteoporosis International 23(1), 1-16.

  2. Hallström, H., Wolk, A., Glynn, A. and Michaëlsson, K. (2006) ‘Coffee, tea and caffeine consumption in relation to osteoporotic fracture risk in a cohort of Swedish women’, Osteoporosis International, 17(7), 1055-1064.

  1. Liu, H., Yao, K., Zhang, H., Zhou, J., Wu, T. and He, C. (2012) ‘‘Coffee consumption and risk of fractures: a meta-analysis’, Archives of Medical Science, 8(5), 776–783.

  1. Alekel, D.L., Van Loan, M.D., Koehler, K.J., Hanson, L.N., Stewart, J.W., Hanson, K.B., Kurzer, M.S. and Peterson, C.T. (2010) ‘‘The Soy Isoflavones for Reducing Bone Loss (SIRBL) Study: a 3-y randomized controlled trial in postmenopausal women’, The American Journal of Clinical Nutrition, 91(1), 218–230.

  1. Levis, S. and Lagari, V.S. (2012) ‘The role of diet in osteoporosis prevention and management’, Current Osteoporosis Reports, 10(4), 296-302.

  1. Nieves, J.W. (2013) ‘Skeletal effects of nutrients and nutraceuticals, beyond calcium and vitamin D’, Osteoporosis International, 24(3), 771-786.

  1. Orchard, T.S., Pan, X., Cheek, F., Ing, S.W. and Jackson, R.D. (2012) ‘A systematic review of omega-3 fatty acids and osteoporosis’, British Journal of Nutrition. 107 (S2), S253-260.

  1. Morin, S., Tsang, J.F. and Leslie, W.D. (2009) ‘Weight and body mass index predict bone mineral density and fractures in women aged 40 to 59 years’, Osteoporosis International,  20(3), 363-370.

  1. Montalcini, T., Romeo, S., Ferro, Y., Migliaccio, V., Gazzaruso, C. and Pujia, A. (2013) ‘Osteoporosis in chronic inflammatory disease: the role of malnutrition’, Endocrine, 43(1), 59-64.

  1. Stratton, R.J., Hackston, A., Longmore, D., Dixon, R., Price, S., Stroud, M., King, C. and Elia, M. (2004) ‘Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the 'malnutrition universal screening tool' ('MUST') for adults’, British Journal of Nutrition, 92(5), 799-808.

  1. Feldblum, I., German, L., Castel, H., Harman-Boehm, I. and Shahar, D.R. (2011) ‘Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial’, Journal of the American Geriatrics Society, 59(1), 10-17.

  1. HSE (2008) Strategy to Prevent Falls and Fractures in Ireland’s Ageing Population- Report of the National Steering Group on the Prevention of Falls in Older People and the Prevention and Management of Osteoporosis throughout Life, Dublin: HSE

  1. Pritchard, J.E., Nowson, C.A. and Wark, J.D. (1996) ‘Bone loss accompanying diet-induced or exercise-induced weight loss: a randomised controlled study’, International Journal of Obesity and Related Metabolic Disorders, 20(6), 513-520.

  1. Josse, A.R., Atkinson, S.A., Tarnopolsky, M.A. and Phillips, S, M. (2012) ‘Diets higher in dairy foods and dietary protein support bone health during diet- and exercise-induced weight loss in overweight and obese premenopausal women’, The Journal of Clinical Endocrinology and Metabolism, 97(1), 251-260.

 
  1. Compston, J. (2010) ‘Management of glucocorticoid-induced osteoporosis’, Nature Reviews Rheumatology, 6(2), 82-88.

 
 





 

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