February 12, 2018
6 min read

For healthy bones, adopt an overall healthy diet

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The body’s bone health needs differ during one’s lifetime, which means the optimal amount of some nutrients may change accordingly. Although many nutrients in supplement form have been touted for bone health, research on these supplements has largely been inconclusive.

According to Jeri W. Nieves, PhD, associate professor of clinical epidemiology at Columbia University and Helen Hayes Hospital, supplementation is generally not necessary to maintain bone health across a lifetime. Instead, she said, adequate amounts of many nutrients can easily be accessed through the food we eat.

“There are a lot of nutrients that are important for bone health,” Nieves said. “If individuals eat a varied, nutrient-rich diet, get the recommended calories, protein and calcium, and include plenty of fruits and vegetables, most of their nutrient needs will probably be met.”

Endocrine Today about the importance of nutrition to bone health, common food sources of various nutrients, and nutrients that may need to be added to a healthy diet.

What does the research say about supplementing various nutrients to achieve optimal bone health?

Nieves: The data are tentative in terms of vitamins and minerals, say, vitamin K or vitamin C, other than calcium and vitamin D. Calcium and vitamin D are an exception; there is a wealth of information supporting their value as bone-healthy nutrients, with some studies evaluating supplements. For all the other nutrients, I suggest that people follow a diet like the Dietary Guidelines for Americans, which features a plate with half fruits and vegetables, one-quarter protein and one-quarter grains. Following those guidelines, people would probably do fine in terms of anything other than calcium and vitamin D.

Would these needs vary in different populations ?

Nieves: An important nutrient of concerns that change with age is protein. While most people consume too much protein, older adults tend not to consume enough protein.

A serving size of your protein source should take up quarter of your plate and should be about the size of a deck of cards. Most people eat much more than that. When people get older though, they start following what’s called “tea and toast” diets. Older patients might be living alone, find cooking difficult and just have less of an appetite. So, they choose easy things to eat and don’t always make sure they consume protein foods that are really important.

Low protein consumption might be associated with lower bone density and lower physical performance, and some data suggest higher hip fracture rates with low protein intakes. We want to make sure we focus on helping older adults get a healthy diet that includes the proper amount of protein. That’s why we have Meals on Wheels and different resources for these populations.


What other nutrient requirements change with age?

Nieves: There are subtle differences in the calcium that’s required as we age. The time when the most calcium is required is in adolescence. Teenagers need about 1,300 mg because they’re building that skeleton; they’re trying to attain peak bone mass. Around 1,300 mg is required from age 9 to 18 years. After that, everyone needs 1,000 mg per day until women are older than 50 years and men are older than 70 years. At that point, calcium needs increase up to 1,200 mg per day.

Additionally, there’s something called the tolerable upper limit. That is the calcium intake you don’t want to exceed. Calcium is the nutrient with the narrowest optimal range, and people should not go above 2,000 mg per day. It’s important to try to get that exact amount and not to think that more is better. Definitely, with calcium, more is not better. Get the required amount, but don’t take any extra because there’s no proof it will benefit you. In fact, there is some concern that it can lead to adverse outcomes.

Is it difficult to calibrate the exact amount of calcium without going over?

Nieves: One important thing to remember is that this requirement is based on both diet and supplements. Many people hear they need 1,200 mg of calcium, and they’ll just go to a store and get a supplement for 1,200 mg. If they’re already consuming 1,000 mg in their diet, they’ll definitely be over the tolerable upper limit. The goal should be to get calcium from food first, and then if you need a little bit more to reach 1,200 mg, you can consider a small supplement just to reach that number.

What are some of the adverse events that occur when someone exceeds the upper limit of calcium?

Nieves: There is a lot of debate about that. One concern is kidney stones, and another is cardiac issues. Prostate cancer in men is also a potential risk. There are not definitive data for the adverse cardiac events, but there are also no data that exceeding the required amount of calcium is beneficial, either. I would emphasize that I am not saying that calcium is bad. Even for those side effects, consuming too much calcium through food sources alone is not shown to cause problems. We promote finding sources of calcium from food first, and only if you can’t add some simple changes to your diet, then maybe consider a supplement.


What are some food sources of calcium?

Nieves: A major source of calcium is dairy foods, such as milk, yogurt and cheese. Even low-fat dairy foods have the calcium you need. Dark green, leafy vegetables, such as bok choy, collards and kale, are great, as well as some nuts, such as almonds, soy nuts and beans, are some good natural sources. There are also fortified sources, such as some cereals and some of the milk alternatives. If you buy an almond milk or a rice milk, check the food label to see if calcium is added. It is important to realize that most milk alternatives do not contain a significant amount of protein, with the exception of soy milk and the some newer milk alternatives with added protein.

Could these fortified foods be considered supplemental?

Nieves: No, there is a difference between eating fortified foods and supplements. The food matrix affects calcium absorption. When you take a supplement, you’re basically taking calcium alone, whereas when calcium is added to, say, soy milk, it’s within that food matrix surrounded by proteins and other things that slow digestion.

What are the required amounts of vitamin D?

Nieves: That amount changes a bit with age, too, but not as much as calcium. The daily requirement is 600 IU, and after age 70 years, it increases to 800 IU. Vitamin D has a lot more wiggle room in terms of upper limits. You could go as high as 4,000 IU per day, and some doctors may recommend more vitamin D for certain conditions, including bariatric surgery patients, sometimes older adults, and people with certain conditions, such as diabetes. That is something that should be discussed between the individual patient and their doctor.

For vitamin D, natural dietary sources are more limited. Fatty fish is an excellent source of vitamin D as well as protein. If we could get people to eat more fish with their meals, it would be great. Vitamin D is also found in UV-treated mushrooms and egg yolks. All cow’s milk is fortified with vitamin D, and some juices and yogurts are also. It’s a good idea for patients to read food labels and understand what nutrients they’re consuming.

Are there any diets that are detrimental to bone health?

Nieves: In my field, studying nutrition and diseases, we’ve been putting a lot more focus on the diet as a whole, or the dietary pattern. Some interesting work has been done where researchers found that people who had diets higher in fruits and vegetables, whole grains, poultry, fish and nuts, low-fat dairy products — generally a healthy diet — did better in terms of bone health. That’s very similar to the diet that the Dietary Guidelines for Americans recommends. Researchers have also found that diets high in soft drinks, fried food, meats, desserts and processed foods have a negative impact on bone health.

There has also been concern that in younger patients, high-protein diets may not be good for the skeleton, particularly if they aren’t getting enough calcium. Poor diets overall have been found to lead to bone loss and potential fractures. We want should focus on an overall healthy dietary pattern.

What recommendations would you make to patients for improving their bone health?

Nieves: It’s important not to think of just following a bone-healthy diet; it’s more useful to think of your diet and your overall health. The dietary guidelines are made to help prevent various diseases; they don’t reduce only your risk for osteoporosis, but also reduce the risks for cancer and heart disease. Following that overall healthy diet with lots of fruits and vegetables, whole grains and lean proteins is a great idea for overall health. If you want to add to your bone health, just think of that healthy plate with a little glass of milk or whatever kind of calcium- and vitamin D-rich beverage you want to drink. Try to add a calcium-fortified orange juice instead of regular orange juice. Make small changes in your diet to make a difference in your overall bone health. Start small and move forward.

Our website for the New York State Osteoporosis Prevention and Education Program, www.nysopep.org, has a lot of helpful nutritional information including hints on how to read a food label. – by Jennifer Byrne

For more information:

New York State Osteoporosis Prevention and Education Program. Available at: www.nysopep.org. Accessed Feb. 7, 2018.

Jeri Nieves, PhD, can be reached at 55 Route 9W, West Haverstraw, NY 10993; email jwn5@cumc.columbia.edu.

Disclosure: Nieves reports no relevant financial disclosures.