ALEXANDRIA UNIVERSITY

FACULTY OF MEDICINE
DEPARTMENT OF PHYSIOLOGY

NAME: DR. NDAHURA ALLI

SPECIALTY: ORTHOPEDIC SURGERY AND TRAUMATOLOGY
TOPIC: DIETARY NEEDS TO KEEP HEALTHY BONES
Bone is metabolically active throughout life

Our bones are in a perpetual state of turnover throughout life, such that the entire skeleton is
replaced every decade1. This process is known as the bone remodelling cycle. Osteoclast cells
are recruited to sites of microdamage to remove old bone (bone resorption). Once they have
completed their task, osteoblast cells – bone forming cells – deposit new bone to fill the gap
created by the osteoclasts. For the total amount of bone to remain constant, the rate of bone
resorption needs to be equivalent to the rate of bone formation. Put simply, in healthy and
well-nourished children and adolescents the rate of formation exceeds the rate of resorption.
During adulthood, a comparative period of balance between formation and resorption
maintains the amount of bone mass. After menopause, women undergo a period of rapid bone
loss, as bone resorption outstrips formation, due to the lack of protective oestrogen2. In men,
bone loss tends to accelerate after age 70 years3.

A well-balanced diet, which is rich in calcium, vitamin D and protein, and with adequate
intake of other important micronutrients, is essential to maintain a healthy skeleton during
adulthood. Regular weight-bearing exercise also plays an important part in ensuring good
adult bone health. This report provides adults with information on diet to minimize the
probability that osteoporosis, and the fragility/pathologic fractures it causes, will disrupt their
quality of life and independence in the years ahead. Furthermore, lifestyle choices which can
result in early onset of osteoporosis will be considered. Current evidence concerning the
place of nutritional supplements is also summarized.
Key components of a ‘bone healthy’ diet
Calcium

At all ages, calcium plays a key role in bone health. Calcium is absorbed in the small
intestine both passively and by an active transport mechanism which requires vitamin D. In
addition to mineralizing the skeleton, calcium plays a critical role in nerve and muscle
function. An inadequate intake of calcium results in lower levels of calcium in the blood.
When this occurs a highly effective compensation mechanism is initiated. Calcium-sensing
receptors (CaSR) located on the parathyroid glands, which are small endocrine glands located
in the neck, act as a highly accurate sensor of blood calcium levels4. When blood calcium
becomes too low, Parathormone (PTH) is released, which increases levels by several
mechanisms:
1. Stimulating osteoclast cells to resorb bone and release calcium by acting on the osteoblast
2. Increasing gastrointestinal calcium absorption by activating vitamin D
3. Reabsorption of calcium by the kidneys
Milk and other dairy foods are the most readily available sources of calcium in the diet. Other
good food sources of calcium include certain green vegetables (e.g., broccoli, curly kale);
whole canned fish with soft, edible bones such as sardines or pilchards; nuts (almonds and
Brazil nuts in particular); and tofu set with calcium.

It should also be noted that some mineral waters and tap waters provide a valuable source of
calcium, which can also be helpful to people who are lactose intolerant. For example, calcium
concentration of tap water varies from 1 mg/L to 135 mg/L across the USA and Canada, and
filtration can remove almost 90% of calcium5. Some mineral waters have been shown to have
more than 200 mg/L. For people who choose to obtain a proportion of their dietary calcium
intake from water, it is important to know precisely how much calcium is present in the water
they drink.

World Health Organization/Food and Agriculture Organization of the United Nations:

WHO/FAO Dietary Reference Intake for calcium for adults aged 25–50 years is 1,000
mg/day.
The observed deficit in calcium intakes raises the question of the role of calcium supplements
in healthy individuals. An ongoing debate in the scientific community has sought to establish
the risk-benefit ratio of calcium supplementation with respect to beneficial effects on bone
health as compared to adverse impacts on the cardiovascular system. Supplements should be
used only as needed to bring total calcium intake to the recommended level in healthy adults.

Vitamin D

The primary source of vitamin D comes from sun exposure, which triggers synthesis in the
skin. Vitamin D3 is synthesised in the skin when 7-dehydrocholesterol is exposed to
Ultraviolet rays-class B (UV-B) in sunlight. After transfer to the liver, it is metabolized to 25-
hydroxyvitamin D, which is currently considered to be the best marker of vitamin D status.
Subsequent secondary hydroxylation to 1,25-dihydroxyvitamin D in the kidney produces the
biologically active form of the hormone.

Vitamin D synthesis is dependent on several factors, including latitude, skin pigmentation

and use of sunscreen. During the winter months, individuals living at latitudes higher than
33° in the northern or southern hemispheres do not receive adequate UV-B exposure to
synthesize vitamin D in their skin. Consequently, vitamin D insufficiency is observed
throughout the world, including sunny countries such as Australia, where sunscreen use to
prevent skin cancer has become commonplace.

Assisting calcium absorption from food in the intestine

• Ensuring correct renewal and mineralization of bone

• Down regulation of PTH so reducing PTH-induced bone loss
• Increasing BMD
• Directly stimulating muscle tissue and so reducing falls risk

Vitamin D insufficiency has become a global problem due to factors such as increasingly
indoor lifestyles. Very few foods are naturally rich in vitamin D, but some good sources
include Wild salmon, Farmed salmon Sardines, Mackerel, Tuna, Cod liver oil, Egg yolk. The
Institute of Medicine (IOM) Recommended Dietary Allowances (RDA) for vitamin D for
adults aged 19–70 years (as cholecalciferol) is 600 IU per day (15 μg/day)6.

Adults at elevated risk of having inadequate levels of vitamin D include:

Inhabitants of latitudes with minimal exposure to sunlight

• Individuals who are obese

• Individuals with a darker skin tone
• Individuals who cannot expose their skin to the sun for medical or cultural reasons
• Individuals with diseases that reduce uptake of vitamin D from the intestine

Protein
Protein is a source of amino acids which are needed to maintain bone structure. Protein also
stimulates insulin-like growth factor I (IGF-l) release, which may increase production of bone
matrix by increasing osteoblast activity. In 2009, the first systematic review and meta-
analysis of the relationship between dietary protein and bone health in healthy human adults
was published7. The investigators reported a positive association between protein intake and
bone mineral density (BMD) and bone mineral content (BMC), and a reduction in markers of
bone resorption. Whilst the effect size was small, and a relationship between dietary protein
and fracture risk was not identified, current healthy eating guidelines were considered
appropriate with respect to bone health.

Vitamin K

Vitamin K is required to make osteocalcin, which is the second most abundant protein in
bone after collagen. Epidemiological studies have suggested that diets high in vitamin K are
associated with a lower risk of hip fractures in older people8. Good food sources of vitamin K
include leafy green vegetables such as lettuce, spinach, cabbage and kale, liver, some
fermented foods such as fermented cheeses and natto (fermented soybeans) and dried fruit
(e.g., prunes).
Accordingly, further studies are needed to determine the role of vitamin K supplements for
the prevention and treatment of osteoporosis.

B Vitamins and Homocysteine

Homocysteine is an amino acid which can interfere with collagen synthesis, the main protein
in bone. When blood levels of vitamin B6, vitamin B12 and folic acid are low, homocysteine
levels can rise. Accordingly, inadequacy of B vitamins could compromise bone health, a
notion supported by observational studies which found an association between high
homocysteine levels and lower BMD, and increased hip fracture risk in older people.
However, a 2014 review concluded that inconsistencies within the current evidence base
necessitate definitive studies to be conducted to evaluate the role of B vitamins in prevention
of osteoporosis9.

Vitamin A

The role of vitamin A in bone health is controversial10. High intake of preformed vitamin A,
which can be obtained from animal food sources such as liver, other offal, and fish oils, has
been associated with osteoporosis and hip fracture. However, carotenoids, which are
precursors to vitamin A, have been associated with improved bone health.
Carotenoids can be obtained from green leafy vegetables, carrots, pumpkins, red and yellow
peppers, mangoes, papaya, and apricots.
Magnesium

Approximately half of total body magnesium is stored in the skeleton11. Magnesium plays an
important role in bone formation through stimulating proliferation of osteoblasts. Magnesium
deficiency is rare in well-nourished populations. However, because magnesium absorption
decreases with age, the elderly can be at risk of mild magnesium deficiency. Good sources of
magnesium include green vegetables, legumes, nuts, seeds, unrefined grains, fish, and dried
fruit (apricots, prunes, raisins).
Zinc

Zinc plays a role in bone tissue renewal and mineralisation. Zinc deficiency is usually
associated with calorie and protein malnutrition and has been reported to be common in
community-dwelling older people12. While vegetarian diets do not necessarily have lower
zinc intakes, the bioavailability of zinc may be lower for vegetarians, so higher intakes may
be required. Sources of zinc include lean red meat, poultry, whole grain cereals, pulses,
legumes, and dried fruit (peaches, prunes, apricots).

Dietary phytoestrogens

Estrogen deficiency is a major contributory factor to the development of osteoporosis in

women, and hormone replacement therapy (HRT) remains the mainstay for prevention of
bone loss in postmenopausal women13. Recently, as a consequence of poor uptake and
adherence of HRT as well as potential concerns over an increased risk of malignancy and
other side effects associated with the use of HRT, attention has been focused on the so-called
dietary phytoestrogens as possible safe alternatives, or at least adjuncts, to HRT.
Phytoestrogens are nonsteroidal compounds naturally occurring in foods of plant origin
(especially soy-based foods) that structurally resemble natural oestrogens and compete with
them for binding estrogen receptors14.

Currently, the data from human intervention studies are mixed in relation to potential
beneficial effects of phytoestrogens on bone health14. One of the most cited works in support
of their potential beneficial effects for bone is that of Morabito et al.15, who reported the
findings of their randomized double-blind, placebo-controlled study in which the effects of
purified genistein (a soy-based isoflavone) supplementation (56 mg/d) and continuous HRT
for 12 months on bone metabolism and BMD were evaluated and compared in early
postmenopausal women. Genistein supplementation significantly increased BMD in the
femur and lumbar spine, effects that appeared to be of similar magnitude to those achieved
with HRT15. The dose of genistein used in this study, however, far exceeds that naturally
present in the normal Western diet14 and could realistically be achieved only by
supplementation or by the function food approach. A recent critical review of the health
effects of soybean phytoestrogens in postmenopausal women concluded that there is a
suggestion, but no conclusive evidence, that isoflavones from the sources studied so far have
a beneficial effect on bone health16. Further research is needed to clarify the role of dietary
phytoestrogens in osteoporosis prevention.

Diet and bone health in childhood and adolescence

About 90% of total adult bone mass is accrued by age 20, and a significant proportion of this
is achieved during puberty alone. Thus, gaining an understanding of the role of dietary
components in bone metabolism and bone mass in these early life stages is important because
finding new strategies to maximize the accretion of bone during growth may help reduce the
risk of osteoporosis in later life.

The importance of dietary calcium to bone health in childhood and adolescence has been
emphasized. There is some concern about the proportion of adolescents, particularly girls,
who appear to be failing to meet the dietary recommended level of calcium. Adolescence also
appears to be the life stage during the first 2 decades of life that has the highest prevalence of
low vitamin D status. It is well established that prolonged and severe vitamin D deficiency
leads to rickets in children. Less severe vitamin D deficiency, although it does not cause
rickets, may prevent children and adolescents from reaching their genetically programmed
height and peak bone mass. For example, results from studies in adolescents provide
evidence of a possible adverse effect of vitamin D deficiency and insufficiency for bone
health in children. A recent 12-months intervention study with supplemental vitamin D shows
the benefits to BMC in adolescent Finnish girls. There is a need to consider various strategies
for increasing vitamin D status of adolescents.

Beyond the effect of calcium and vitamin D, there have been a number of recent studies that
show the importance of other nutrients and food components. Kalkwarf et al investigated the
relation between vitamin K intake (and status) and indices of bone health in children and
adolescents (aged 3–16 y). Their findings suggest that better vitamin K status was associated
with decreased bone turnover in healthy girls consuming a typical U.S. diet. However,
vitamin K status was not consistently associated with BMC. O'Connor et al. showed that
better vitamin K status was associated with increased BMC in healthy peripubertal Danish
girls, although no effects on bone metabolism were evident. Thus, there is a need for well-
designed, randomized vitamin K1 supplementation trials in children and adolescents to
confirm epidemiological findings of an association between vitamin K status and bone health.

As mentioned previously, there is a growing body of evidence to show that nondigestible

oligosaccharides (especially inulin-type fructans) can enhance calcium absorption. This is
particularly the case in adolescents, and the studies illustrating this have been reviewed
elsewhere. One recent study merits particular mention, namely that of Abrams et al.18, who
recently reported the findings of a 12-mo randomized, placebo-controlled intervention trial
with an inulin-type fructan (Synergy) in 9- to 13-y-old boys and girls. They found that
calcium absorption was significantly higher in the inulin-type fructan-supplemented group
than in the placebo (maltodextrin) control group at 8 weeks but also, interestingly, after 12
months18. Furthermore, there was evidence that the additional calcium absorbed was retained
within the body for use by skeletal tissue. The group receiving the inulin-type fructan had a
greater increment in both BMC and BMD than did the control group18. These findings
strongly suggest that addition of selective nondigestible oligosaccharides to food represents
an opportunity for increasing the uptake and utilization of calcium present in the diet.

It is also of interest that inulin-type fructans have been suggested to positively influence
postmeal satiety and food intake, which might be of potential application in tacking
childhood obesity, not only of importance for its own sake but also because childhood obesity
has been shown to increase risk of childhood fracture17.

Conclusion:
The lack of effective treatments for degenerative diseases such as osteoporosis places
increased emphasis on a preventative approach, including dietary strategies. In addition, it
offers considerable opportunities for the development of functional foods. The development
of nutritional policies as well as of functional foods for bone health must be based on a
detailed understanding of the influence of dietary constituents on health. Particularly in the
case of functional foods, their development must be supported by independent and
appropriate scientific evidence to demonstrate efficacy with respect to claimed health
benefits. Thus, more research on the role of diet on bone health is required. In addition, more
emphasis should be placed on understanding the role of diet and nutrition on bone health
during childhood and adolescence.
References:

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