7 Diet, Supplements and Natural Alternatives

As healthy children running around and jumping everywhere, and as active young adults walking, dancing and going to the gym, we invested in our own personal ‘bone bank’ through doing natural weight-bearing exercise, which encouraged strong bones. There is some firm evidence that strength training is beneficial for bones – good news because we know that gym work is on the rise for some young adults. But building ourselves a strong skeleton isn’t the end of the story! At around the age of 30 years both men and women will start to lose bone and indeed muscle (see Chapter 2). This bone loss is a natural part of the ageing process but will vary greatly from one person to another. One person may lose bone slowly, while another person’s fast loss may result in more than averagely porous bones.

For all of us, it’s essential to eat a well-balanced diet rich in calcium and vitamin D. These two are the body’s natural bone builders, but getting enough vitamin D naturally can be hard because most comes from sunlight. Vitamin D is very important for our bone health (across all ages) and ensuring that you get enough vitamin D is essential. The vitamin D recommendations published by the Royal Osteoporosis Society in 2018 advise people aged 65 and over, and people who are not exposed to much sun, to consume 10 micrograms of vitamin D a day. The 10 microgram supplement may appear on the label as 400 IU – 1 microgram equals 40 international units (IU).

Vitamin D is made naturally in our skin during the summer months from exposure to the sun’s ultraviolet B (UVB) rays. We require vitamin D to help our body to absorb the calcium, but exposure can be limited in many Northern European countries, including the UK, and also for those who are unwell and/or are confined indoors and for those who wear body concealing clothing for cultural reasons. You will get some vitamin D during April to September because the UVB rays from the sun are of the right wavelength to allow our bodies to make vitamin D. But during the winter we get no vitamin D from sunlight (even if it is a sunny autumn/winter’s day, we’re too far away from the sun), and so it is important to get enough sun exposure for vitamin D in the summer. It is difficult to ensure high vitamin D levels through food products as vitamin D is in a limited number of foods.

That said, vitamin D is available from nuts, especially Brazil nuts and almonds; some fruits, including oranges, apricots and dried figs; oily fish; egg yolk; liver; and some fortified foods, including fat spreads, breakfast cereals and soya drinks.

A healthy, nutritious diet will help preserve healthy bones and skin, as well as fight disease and boost immunity. If you are a menopausal woman, perhaps it’s time to look at your eating habits and to make some changes. For a healthy adult skeleton, ensure your diet is both varied and nutritious. Look at what makes up a healthy diet and follow the advice shown in Public Health England’s Eatwell guide, shown above. If you are concerned about your eating habits, speak to the practice nurse/dietician at your local GP surgery.

What should we eat to beat osteoporosis? As adults we constantly require sufficient calcium and vitamin D to strengthen and maintain our bones, helping to slow down the rate of bone loss.

A well-balanced and nutritious diet is made up of a wide variety of foods from the four main food groups shown on the NHS Eatwell chart. These groups are:

• fruits and vegetables

• carbohydrates such as bread, potatoes, pasta and cereals

• dairy products (and alternatives)

• beans, pulses, fish, eggs, meat and other proteins

The Eatwell guide shows the proportion of different foods that make for well-balanced, healthy eating. Get it right, and your diet should provide you with all the vitamins, minerals and energy you need to live a happy and healthy life, and it will help reduce the risk of other chronic diseases. Make a note of what you eat over a week, try to get a good balance, and eat the recommended proportions from the four different food groups. Eating a mixture of foods from each food group ensures you have a range of different nutrients for good health, and will also help you maintain strong bones.

At any age we should aim to watch our diet, so check your body mass index (BMI) to ensure you have a healthy body weight. Eating for your bones’ sake is common sense and can feature exciting and delicious meals full of the vitamins and minerals you need. And they need not be fattening. Substituting low-fat versions of dairy foods can provide equivalent amounts of calcium and may contain not less but slightly more, because the calcium is in the non-fat part of dairy products.

All of us should aim to eat at least five portions of fruit and vegetables a day (a portion is about the amount in a handful). Eating a variety of different coloured fruits and vegetables will mean you are consuming a range of essential nutrients. If you are watching your weight, why not try snacking on raw fruits and vegetables as I do, instead of reaching for biscuits and chocolate when you are hungry or stressed?

If you are older and frail, you may be eating less than you used to. But even when eating smaller amounts, try to keep your meals to the same proportions as shown on the Eatwell guide. It is vital for you to have a healthy balanced diet and essential that you eat enough protein as you get older, because low levels of protein appear to increase the risk of hip fracture. Keep a careful eye on rapid weight loss (if your clothes start to feel incredibly loose, for example) and if this does happen, talk to your GP or the practice nurse/dietician.

Foods for healthy bones

What specific foods should we be eating to keep our bones healthy?

More fruit and vegetables; at least five portions a day:

• Choose a rainbow of different-coloured fruit and vegetables to ensure you get the range of essential nutrients you need, including some calcium.

• Some – including oranges and potatoes – are also rich in potassium, which helps ensure that the body retains its calcium.

Dairy products such as milk, butter and yogurt play an important part in you getting sufficient calcium and vitamin D.

Plenty of wholegrain foods such as brown rice and pulses for more minerals, vitamins and fibre.

More fish, especially oily fish such as mackerel, a good source of vitamin D. Try to eat two portions a week:

• Oily fish – such as mackerel, salmon, pilchards and sardines – are good sources of calcium, particularly canned fish with soft, edible bones; the calcium is in the bones!

• Taking fish oil supplements may also be of benefit – particularly if you are not keen on fish. Be careful of cod liver oil: this is extracted from the liver of the cod, and the vitamin A content can be high. So consider taking a vitamin D supplement with fish oils instead.

Less saturated fats and sugar. Learn to check out food labels: 5g or more of saturated fat per 100g and 10g or more of sugars per 100g is a lot. The Eatwell guide suggests cutting down on saturated fats and sugar, but do remember that dairy products play an important part in getting calcium and vitamin D.

Less salt. Again, check out food labels: 0.5g or more of sodium per 100g is high. It’s important to keep your salt intake to a minimum. A high salt/sodium intake is not good for health in general and is associated with high blood pressure. High salt intakes can result in high calcium losses in the urine, and this is not good for bone health in the long term.

Don’t ignore fortified foods, including fat spreads, breakfast cereals, soya drinks and some powdered milks.

Many of us get the recommended amount of calcium we need from dairy foods such as milk, cheese and yogurt, which have the additional advantage of being good sources of protein and other micronutrients, also important for bone and general health. If you don’t eat dairy products, you will need to include lots of other calcium-rich foods: green leafy vegetables, like broccoli and curly kale; almonds; pulses, beans and lentils; sesame seeds and tahini (sesame seed spread); dried fruit, including figs; edamame; tofu (soya protein) and fortified soya drinks.

It’s worth noting that a vegetarian diet is not a risk factor for osteoporosis, and vegetarians and vegans do not seem to have poorer bone health than the rest of the population. All white flour products have calcium added to them and are therefore a good source of calcium for the population, and an increasing number of commercial mineral waters contain significant amounts of calcium.

Some people cannot tolerate lactose, the natural sugar found in milk, because they don’t produce enough lactase, the enzyme needed to digest lactose. When undigested lactose passes through the system unabsorbed, it will ferment in the large intestine, causing stomach cramps, bloating, flatulence and diarrhoea. Some people find they can tolerate only small amounts. Lactose intolerance affects 5–10 per cent of North Europeans and North Americans of European origin – and as much as 90 per cent of Asian, African and Caribbean populations.

If you are lactose intolerant, make sure you enjoy plenty of non-dairy, calcium-rich foods and fortified foods (see above). Supermarket shelves are increasingly filled with supplemented foods that claim to be good for you because they are fortified with vitamins and minerals. These may prove a convenient way of improving your intake of specific nutrients, such as vitamin D. But remember, it’s a well-balanced diet that provides a range of nutrients to keep bones strong, not just one with added minerals or vitamins.

Personally, I find it essential to kick-start my day by eating breakfast. My daily cereals (without added sugar) give me the energy to get going. I add a variety of fruits, berries, bananas and citrus, to provide me with vitamins and antioxidants, plus a couple of spoonfuls of natural yogurt containing calcium. So try to eat breakfast. A balanced meal when you wake up plus regular meals throughout the day will help maintain your health and well-being. There is some evidence to show that skipping breakfast can reduce the nutritional quality of the diet and is associated with higher body weight, and the evidence also shows that breakfast skippers actually eat more! Having missed breakfast, many hit a mid-morning slump and tend to gorge on any handy ‘bad stuff’.

How much calcium do we need?

Calcium is necessary for both healthy bones and teeth and gives bones strength and rigidity. Our bodies contain about 1kg of this important mineral and 99 per cent of this is found in our bones. Most people should be able to get enough calcium through healthy eating. Adults need 700mg of calcium a day as part of a well-balanced, healthy diet, but people taking osteoporosis drug treatments may be advised to have a daily intake of around 1000mg. Government advisers on nutrition set recommended daily levels of intake of nutrients. This is called the reference nutrient intake (RNI). To meet the daily requirements of most of the adult population (97.5 per cent), 700mg of calcium is sufficient. Below 400mg, a Lower Reference Nutrient Intake (LRNI) is very likely to be insufficient. There is good evidence in the scientific literature that having a calcium intake below 400mg/day is detrimental to bone health. Do not worry if your calcium intake does not quite reach the RNI of 700mg a day; it is the average daily amount that is important. A low calcium intake on one day, when you achieve the right amount on most days, will not have a long-term detrimental effect on your bone strength.

You can usually get enough calcium as part of healthy eating. For example, your daily requirement for calcium can be achieved by consuming three portions of dairy products such as a combination of a 200ml glass of milk, a yogurt, plus a matchbox-sized portion of Cheddar cheese (or non-dairy substitutes). The calcium in soya milk is as well absorbed as the calcium from cow’s milk, but it is important to be aware that soya milk is not naturally high in calcium like cow’s milk is, so check on the label that it is fortified with calcium. The Royal Osteoporosis Society (ROS) has a wealth of information about calcium on its website, including a list to help you choose foods that are high in calcium. See https://theros.org.uk/information-and-support/looking-after-your-bones/nutrition-for-bones/calcium/calcium-rich-food-chooser

If you have a low calcium intake from your diet, then you may be advised to take a calcium supplement – as I was told to do. One or two tablets a day are usually recommended, to top up the amount that you get from your food and drink. Look at how much elemental calcium (the actual amount of calcium) the supplement provides. For instance, 1250 mg of calcium carbonate provides 500mg calcium. Supplements vary widely but most will provide between 300mg and 1000mg of elemental calcium. If you aren’t sure, discuss your situation with your doctor; for some medical conditions, you may need specific advice about whether you should take a supplement, and how much you need. Doctors sometimes prescribe supplements because you are taking osteoporosis drug treatments and they want to be certain you are getting sufficient amounts. Recently, health professionals have recognised that it’s best first to assess what calcium you may be getting naturally before prescribing supplements. Eating healthily for strong bones requires a balance of vitamins and other nutrients, including calcium. Osteoporosis is not a disease of calcium deficiency, and having a very high calcium intake or taking calcium supplements isn’t a guarantee against osteoporosis. Try to calculate roughly how much you are getting from food and drink in a day, and then work out how much supplement you may require to ensure that you get the calcium you need.

Taking more than about 2500mg of calcium a day on a regular basis could lead to medical problems, including a high level of calcium in the blood, known as milk-alkali syndrome. Unfortunately for some people calcium supplements can cause nausea as well as other effects, such as constipation or diarrhoea, or bloating of the stomach. Too much calcium might also interfere with the absorption of other minerals, such as iron and magnesium. There are some medical conditions that cause high blood calcium levels (the body stops regulating levels in the blood in the normal way), which can make you very unwell and, in this case, you would be advised not to take supplements.

There are many other nutrients that may play a part in keeping bones strong – vitamins such as B, C and K, and minerals such as magnesium, copper and zinc – but more research is needed to fully understand their role. These nutrients are all readily available through a balanced diet, and a wide range of foods from all the main food groups will probably mean you are getting enough and do not need to take supplements.

Of particular growing interest to researchers is the role played by magnesium in maintaining our skeletal health. Good sources of this important mineral include wholewheat, green leafy vegetables, beans, nuts and seeds.

A healthy diet maintains good health and prevents illness and disease, including heart disease and osteoporosis. This cannot be emphasised enough. Today a typical UK diet is far from healthy and all too often is the cause of many medical problems. It is a well-known fact that women in the Far East, who still eat a traditional diet of Eastern (not Western) food, have fewer menopausal problems, less breast cancer, less heart disease and less osteoporosis than their sisters in the UK and the US do. Until the Western diet arrived in Japan, heart disease and menopausal symptoms were virtually unknown! Traditional ingredients of Japanese cuisine are renowned for their health benefits, and low-fat, bite-sized sushi is the world’s healthiest fast food. Sushi is perfectly balanced with soya containing plant oestrogens, seaweed rich in calcium, sesame oil and seeds. The oily fish supplies essential fatty acids, raw vegetables contain antioxidants and fibre, and rice also provides fibre.

It is possible that a traditional Japanese diet protects women, thanks to the soya products that contain phytoestrogens. These are chemicals found naturally in many plants, and are thought to lower cholesterol, protect against cancer and improve bone density. There is ongoing research into the role of phytoestrogens, though the evidence to date does not support additional supplementation of the diet with these products.

Research shows that Japanese women regularly eat a diet containing 20–100mg of isoflavones, whereas their Western sisters consume a diet that contains less than 5mg. Isoflavones are able to exert effects that are both oestrogenic (similar to that of natural oestrogen) and anti-oestrogenic (blocking oestrogen production), and these foods act to normalise and regulate the systems of the body, and have a balancing effect on hormones. They can help to reduce such low-oestrogen symptoms as hot flushes and night sweats during menopause. Soya is an important source of protein for much of the world, but the amounts of hormone-balancing properties obtained from these natural sources vary greatly, and many of them need to be consumed in large quantities to provide enough phytoestrogen to be of benefit. Obviously it is difficult to ensure that sufficient phytoestrogen is being supplied by diet alone, which makes dependence on natural alternatives as a treatment somewhat unreliable. This is especially important for women whose ovaries have been removed and who are in greater need of bone protection.