Medical Nutrition Therapy for Osteoporosis

  • Oluwapelumi Elizabeth AbodunrinBSc.Public Health,Babcock University; Master of Public Health (MPH), Newcastle University
  • Philip James ElliottB.Sc. (Hons), B.Ed. (Hons) (Cardiff University), PGCE (University of Strathclyde), CELTA (Cambridge University) , FSB, MMCA

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Did you know that what you eat can play a crucial role in reducing your risk of developing osteoporosis? This is a condition where bones become progressively thinner and more fragile, which increases the likelihood of them fracturing.

Osteoporosis (OP) is often termed the ‘silent disease’ because it can go undetected until a fracture occurs, which means making lifestyle choices to prevent its hidden development is a priority. 

This article highlights the significance of ‘Medical Nutrition Therapy’ (MNT) in preventing and managing osteoporosis. Essential nutrients such as calcium, vitamin D, and protein play a crucial role in maintaining optimal bone health. 

As you go through the following information, pay attention to the key takeaway points which emphasise the importance of specific nutrients, the role played by physical activity, and also highlight the foods and factors that can negatively impact bone health. Your journey to stronger, healthier bones begins with the knowledge within these pages.

Overview of osteoporosis

Osteoporosis is a Greek term that means ‘porous bone’ or ‘bone with holes’.1 Osteoporosis is also called a ‘silent disease’ because most people do not have any symptoms and the condition is often only discovered after a bone is broken.3

With this disease bones become increasingly thinner and weaker over time, increasing the risk of sustaining bone fractures, especially in the hip, wrist, and spine even after a minor fall or other small traumas and stresses that would not normally result in a problem. Among these, hip fractures are the most serious and potentially life-threatening.2,9 

Due to the increase in the number of elderly in the population, osteoporosis is a global health problem.5 Osteoporosis mainly occurs in women after they have ceased menstruation (post-menopause) and in elderly men.4 It is observed that after age 50, 1 in 2 women and 1 in 4 men will have an osteoporosis-related fracture.5

The following factors have been associated with an increased risk of osteoporosis-related fracture.7

Being a silent disease, many people with osteoporosis are not diagnosed until a fracture occurs.7 However, in postmenopausal women, wrist fractures are considered to be a less serious yet important alerting sign for osteoporosis.6,7

Medical nutrition therapy (MNT) for osteoporosis

Medical nutrition therapy (MNT) is an evidence-based process aiming to treat or manage a disease through nutrition.11,12 Health-promoting behaviours, such as consuming a healthy diet, can lessen the impact of osteoporosis. 

Nutrition with adequate dietary protein, calcium, vitamin D, fruits and vegetables has a positive impact on bone health – dietary patterns with a high intake of dairy products, fruits, and whole grains may influence bone health positively.2,12

On the other hand, a diet high in calories, and heavy alcohol consumption have been associated with bone weakening and high rates of fracture.2,12

Key nutrients to include in medical nutrition therapy for osteoporosis

Calcium

Calcium plays a major role in bone strength and is of prime nutritional importance in osteoporosis, being essential for bone health throughout life.5 Since bone contains about 99% of the body’s calcium, sufficient calcium intake is necessary across the whole lifespan for its proper growth, development, and maintenance.5,7 If we don't get enough calcium, our body takes it from our bones, making them weaker and more prone to breaking. So, it is crucial to eat foods rich in calcium to help prevent osteoporosis. 

The calcium intake required increases with age. It is recommended that men above 65 years and postmenopausal women should consume at least 1200 mg of elemental calcium per day. However, the ‘European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis, and Musculoskeletal Diseases’ and the International Osteoporosis Foundation’ after a review of evidence current in 2019 reached the conclusion that calcium supplements alone cannot reduce the risk of fracture.9 

To get this amount, you can include a combination of the following foods that can make up a total of 1200mg of calcium intake per day.5

FoodServing SizeCalcium (mg)
Milk, skimmed, semi-skimmed, whole)1 cup280
Yoghurt, low-fat, fruit ½ cup210
Cheddar cheeseMedium size chunk296
Soya drink, calcium-enriched 1 cup210
Broccoli, cooked½ cup45
Curly kale, cooked½ cup168
Apricots, raw, stone removed 4 fruit117
Orange, peeled 1 fruit75
Bread, wholemeal, sliced1 medium slice32
Rice, white, basmati, boiled Medium portion32
Tofu, soya bean, steamed ½ cup510
Almonds 12 whole62
Sardines, canned in oil 4 sardine500

Milk (skimmed, semi-skimmed, whole) yoghurt, and cheese (mozzarella, cheddar, camembert, feta) are rich sources of calcium.

Other commonly available good sources include

  • eggs, meat, fish, white beans, lentils, cereals, wholemeal bread 
  • fruits (dried figs, dried grapes, oranges, apricots) 
  • vegetables (cress, broccoli, lettuce, okra, carrots) 
  • nuts and seeds (almonds, hazelnuts, walnuts)
  • meals (quiche, pasta with cheese, omelette with cheese, lasagna, cheeseburger) 
  • tofu, wakame, seaweed

Vitamin D

Vitamin D is a fat-soluble vitamin that plays an important role in protecting bones, by helping the body absorb calcium in the gut, by ensuring appropriate renewal and mineralisation of bone, and by keeping muscles strong thereby reducing the risk of falls. 

Approximately, 70-80% of the vitamin D in the body is made in the skin when it is exposed to sunlight. However, only a limited number of foods contain vitamin D. 

For individuals 50 years or older, recommended consumption of vitamin D is 800-1,000 IU daily.7 To meet this need, you could include a combination of the following foods to meet the recommended daily Vitamin D intake.

FoodServing sizeIU per serving
Cod liver oil1 tbsp924
Margarine, fortified1 ½ tbsp62
Liver, lamb’s, fried 100g/size of palm36
Sardines, canned in brine100g/size of palm184
Mackerel, grilled 100g/size of palm352
Tuna, canned in brine 100g/size of palm144

Generally, 10-20 minutes of daily sun exposure before 10 AM and after 2 PM on bare skin (face, hands, and arms) is required to produce sufficient vitamin D. Unfortunately, many of us spend most of our time indoors. Consequently, low levels of vitamin D have become a worldwide problem and there is concern that this is harming bone health. 

Protein

Protein is a central part of a complete diet for adults. Though physical growth occurs only during the early years of life, the need to maintain, repair and remodel muscle and bone continues throughout life.5 

The organic component of bone is comprised of more than thirty proteins with type I collagen being the most abundant (greater than 90% of the proteins), making up an estimated 22% to 30% of the bone mass. This protein, type I collagen, is the major structural component of the bone matrix (the scaffolding on which bone grows and is renewed).8,13

The Bone Health and Osteoporosis Foundation recommends the following as good sources of lean protein:

FoodServing Size
Beans and peas – e.g., black beans, chickpeas, kidney beans, soya beans, split peas, white beans¼ cup
Seafood – e.g., crab, lobster, mussels, clams, shrimp1 oz
Egg whiteFrom 1 or 2 eggs
Fish – e.g., mackerel, salmon, sardine, trout, sea bass, haddock, tuna1 oz
Low-fat dairy – (5gm or less of fat per serving) e.g., low-fat milk (8oz), hard cheese (1oz), cottage cheese or ricotta (¼ cup), yoghurt (6 oz)
Soya foods – e.g., tofu (2oz), tempeh (1oz), ‘texture vegetable protein’ (1oz), 
Meats (lean cuts and game) – beef, lamb, pork, veal, skinless poultry, venison, rabbit 1 oz

Some supporting nutrients in medical nutrition therapy for osteoporosis:

Vitamin K

Vitamin K is important for bone health as it activates several proteins involved in bone formation. Insufficient dietary intake of vitamin K is associated with osteoporosis leading to bone loss and fractures. 

Dietary sources high in vitamin K include green leafy vegetables (e.g., lettuce, spinach, cabbage, and mustard greens), as well as prunes, liver, fermented cheeses, and soya bean products.

Magnesium and phosphorous

Approximately, 85% of phosphorus and 60% of magnesium in the body is found in bones. So, they both are important to maintain bone health. 

Good sources of magnesium include green vegetables, legumes, nuts, seeds, unrefined grains, and fish. While dairy products, meat, and fish are rich sources of phosphorus.5

Other recommendations 

A healthy balanced diet that includes at least 5 fruits and vegetables per day and enough protein (aim for meat, fish, dairy, or vegetarian alternatives –like tofu or pulses – twice a day), helps to provide all of the vitamins and minerals that are needed for bone health. Also, prunes are a great source of vitamin K and good snacks! 

Foods and factors that can negatively affect bone health

The Bone Health and Osteoporosis Foundation strongly recommends smoking cessation to support the prevention of osteoporosis as the use of tobacco products is harmful to bone health. Also, an alcohol intake of more than two drinks a day for women or three drinks a day for men can be harmful to bone health. Moreover, excessive alcohol intake is advised against particularly in the case of the elderly because it reduces calcium absorption and increases the risk of falls.7

Additionally, caffeine and salt can increase calcium loss from the body and should not be taken in excessive amounts.

Importance of regular physical activity for patients with osteoporosis

As recommended by the International Osteoporosis Foundation, beyond nutrition, the inclusion of weight-bearing exercises, such as walking or resistance training, contributes significantly to enhancing bone density. Those who suffer osteoporosis fractures can benefit from special exercises and training under medical supervision to improve muscle strength and function, leading to greater mobility and improved quality of life. 

However, movements and exercises such as: sit-ups and excessive bending at the waist, twisting movements such as a golf swing, and jumping may not be suitable for people with osteoporosis, particularly if they have vertebral fractures.7

Calcium and vitamin D supplements for osteoporosis

Increasing calcium in your diet should be tried first before using calcium and vitamin D supplements to increase calcium. When adequate dietary calcium intake cannot be achieved, calcium supplement tablets could be considered. Although no consistent results have been found for the benefits of calcium or vitamin D supplements taken on their own, supplementation with a combination of both calcium and vitamin D has been shown to have some benefits in terms of reducing the incidence of fractures.7,9 A common calcium carbonate tablet recommended contains 600 mg of calcium and 800 IU of vitamin D.10

Summary

Osteoporosis, meaning "porous bone," is a condition leading to weakened bones and increased fracture risk. It is often termed the "silent disease" due to the absence of symptoms until fractures occur. 1 in 2 women and 1 in 4 men over the age of 50 are known to have an osteoporosis-related fracture. Causes include hormonal changes, poor diet, certain medical conditions, medications, and lifestyle factors. 

Medical Nutrition Therapy (MNT) is vital, emphasising nutrients like calcium, vitamin D, and protein. Key recommended foods include dairy, fish, leafy green vegetables and fruits. Exercise, particularly weight-bearing activities, is crucial. Avoiding excessive alcohol, caffeine, and salt is recommended due to their negative impact on bone health. 

References

  1. Ziaka S, Amorim T, Vliora M, Gkiata P, Mantzios K, Ntina G, et al. Nutraceutical supplementation based on colostrum as osteoporosis treatment: a pilot study. Food and Nutrition Sciences [Internet]. 2021 Jul 7 [cited 2024 Jan 26];12(7):659–69. Available from: https://www.scirp.org/journal/paperinformation.aspx?paperid=110385
  2. Pouresmaeili F, Kamalidehghan B, Kamarehei M, Goh YM. A comprehensive overview on osteoporosis and its risk factors. Therapeutics and Clinical Risk Management [Internet]. 2018 [cited 2024 Jan 26];14:2029. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6225907/
  3. Ferdous HS, Afsana F, Qureshi NK, Rouf RSB. Osteoporosis: a review. BIRDEM Medical Journal [Internet]. 2015 [cited 2024 Jan 26];5(1):30–6. Available from: https://www.banglajol.info/index.php/BIRDEM/article/view/28371
  4. Akkawi I, Zmerly H. Osteoporosis: current concepts. Joints [Internet]. 2018 Jun [cited 2024 Jan 26];06(02):122–7. Available from: http://www.thieme-connect.de/DOI/DOI?10.1055/s-0038-1660790
  5. Peters BSE, Martini LA. Nutritional aspects of the prevention and treatment of osteoporosis. Arq Bras Endocrinol Metabol. 2010 Mar;54(2):179–85. Available from: https://www.scielo.br/j/abem/a/3ZCSXgMsLvmZ4FKTWJHJ8Wb/?lang=en
  6. Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause [Internet]. 2021 Sep [cited 2024 Jan 26];28(9):973. Available from: https://journals.lww.com/menopausejournal/abstract/2021/09000/management_of_osteoporosis_in_postmenopausal.3.aspx
  7. LeBoff MS, Greenspan SL, Insogna KL, Lewiecki EM, Saag KG, Singer AJ, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2022 Oct;33(10):2049–102. Available from: https://link.springer.com/content/pdf/10.1007/s00198-021-05900-y.pdf
  8. Guo D, Zhao M, Xu W, He H, Li B, Hou T. Dietary interventions for better management of osteoporosis: An overview. Crit Rev Food Sci Nutr. 2023;63(1):125–44. Available from: https://www.tandfonline.com/doi/full/10.1080/10408398.2021.1944975
  9. Chen LR, Hou PH, Chen KH. Nutritional support and physical modalities for people with osteoporosis: current opinion. Nutrients [Internet]. 2019 Nov 20 [cited 2024 Jan 26];11(12):2848. Available from: https://www.mdpi.com/2072-6643/11/12/2848
  10. Kitchin B. Nutrition counseling for patients with osteoporosis: a personal approach. Journal of Clinical Densitometry [Internet]. 2013 Oct 1 [cited 2024 Jan 26];16(4):426–31. Available from: https://www.sciencedirect.com/science/article/pii/S1094695013001522
  11. Packard PT, Heaney RP. Medical nutrition therapy for patients with osteoporosis. J Am Diet Assoc. 1997; 97(4):414–7. Available from: https://pubmed.ncbi.nlm.nih.gov/9120196/
  12. Singhato A, Khongkhon S, Rueangsri N, Booranasuksakul U. Effectiveness of Medical Nutrition Therapy to Improve Dietary Habits for Promoting Bone Health in People Living with Chronic HIV. Annals of Nutrition & Metabolism [Internet]. 2020 [cited 2024 May 24]; 76(5):313–21. Available from: https://www.jstor.org/stable/48620567.
  13. Feng X. Chemical and Biochemical Basis of Cell-Bone Matrix Interaction in Health and Disease. Curr Chem Biol [Internet]. 2009 [cited 2024 May 24]; 3(2):189–96. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2790195/.

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With vast experience in medical writing, I am well-versed in writing evidence-based, well-researched, and up-to-date content on various medical topics. I have a great interest and expertise in writing medical blogs, web content, and scholarly articles. Regarding my degree, I have a great passion for computer-aided drug designing CADD.

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