The Role of Diet as a Modifiable Risk Factor in the Prevention of Osteoporosis

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This Position Stand provides an evaluation of diet as a modifiable risk factor in the prevention of osteoporosis. There is an abundance of scientific evidence, which demonstrates the significance of nutrition in the support of bone capital accumulation and wider skeletal health (Wood et al., 2013; Rizzoli, 2008; Ilich and Kerstetter, 2000). This text predominantly focuses on Calcium and vitamin D, as they are two of the most heavily revised nutrients within the context of skeletal system, however, the implications of wider nutrients are also considered. The effect size of diet is evaluated across the whole of the population, as some evidence has suggested that it can be more influential in sub-groups such as children, adolescents, the elderly, and menopausal women (Bianchi, 2007; Hannan et al., 2000; Neer et al., 2001). Thus, it was deemed appropriate to provide an individualistic evaluation of society. Findings from the current literature body are varied, consequently, few nutrients have universally accepted reference values. Position Stands are required to assess the clinical effectiveness of set nutrients at a specific point in time. Curre-ntly, there is enough evidence to make basic recomm-endations for calcium and vitamin D. On the contrary, there is inadequate evidence to make firm recommendations for other nutrients.

Potential Recommendations:

Calcium intake: >500 mg/d

Vitamin D intake: >400IU

The implications of wider modifiable risk factors such as physical activity and hormone regulation are also considered within this text. Some evidence has indicated such factors can alter the effects that certain nutrients have on the skeletal system (Winters and Snow, 2001; Turner and Pavalko, 1998). In light of these findings, it could be suggested wider considerations need to be made in the development of future reference values. Moreover, this text briefly considers a multi-factorial approach to controlling the effects of osteoporosis, as a method of yielding more substantial results.


The skeletal system is continuously involved in a remodelling process, which involves the formation and resorption of bone (Courtney et al., 1994). This process is made possible by multicellular units, which aid in the production and removal of bone tissue (Francis, 2007). Osteoclast cells carry enzymes that penetrate the bone and erode segments of trabecular matter, whilst osteoblast cell aid in the remineralisation and formation of new bone mass (Frost, 1966). Osteoporosis occurs when regulated bone accretion is compromised and the structural integrity of the bone is reduced (Aaron, 1975).

Those who suffer with osteoporosis typically illicit few signs and symptoms, prior to encoun-tering problems such as fragility breaks and fractures (Izaks, 2007). Following problems that occur as a result of osteoporosis, individuals are likely to experience chronic pain and reduced functionality (Kanis, 1994). Across the United Kingdom, it is estimated that 300,000 people suffer with the disease (Kanis et al., 2012 cited in NHS Annual Reports). In terms of fracture rates, over 300,000 fragility fractures are recorded in the UK every year, with hip fractures alone accounting for over 1.3 million hospital bed days (Mitchell, 2009). Emergency hospital admissions for breaks and fractures in the UK, results in more bed days, than heart attack, heart failure, and stroke cases combined (Mitchell, 2009 cited in NHS Annual Reports). Treating osteoporosis is estimated to cost the National Health Service (NHS) £2 billion each calendar year, highlighting the scale of the problem (Mitchell, 2009 cited in NHS Annual Reports).

Although heritability contributes extensively in overall bone mass, other factors can have a notable impact on wider skeletal health (Macdonald et al., 2004). There is evidence that suggests diet can be used as a modifiable risk factor, which can minimise the effects of osteoporosis (Rizzoli, 2008). During adulthood, the main aim of nutritional adjustment should be to maintain existing bone mass (Francis, 2007). It remains unclear whether adults can actively increase bone mass with the adjustment of certain lifestyle factors (Wamoto, 2013). Meta-analyses have indicated dietary adjustment does not always result in significant developments of skeletal composition. However, diet remains an important factor in the maintenance of healthy bones (Cumming, 1990; Welton, Kemper, and Staveren, 1995).

There is significant debate surrounding the value of certain nutrients in the context of skeletal health (Prentice, 2004). Thus, such reviews need to analyse the literature body to assess the clinical effectiveness of certain nutrients.

Measuring Osteoporosis

A clinical diagnosis for osteoporosis is typically made when BMD is more than -2.5 SD below the young adult mean of the population (Kanis et al., 2009). A low BMD is a sign of sub-optimal bone mass, which can be acquired during puberty or as a result of accelerated bone loss later in life (Gafni and Baron, 2004). Low BMD readings are heavily associated with an increased prevalence of fragility fractures (Sabin et al., 1995). Thus, low BMD has remained one of the primary risk factors for osteoporosis.

Research has indicated BMD is capable of measuring 60-80% of bone strength variance (Courtney et al., 1994). However, the accuracy of BMD is often contested. Some studies report errors between 25%-41% when using BMD as a sole measure for osteoporosis (Glüer et al., 1995). Glüer et al. (1995) suggested BMD scores are heavily influenced by body size and composition, two factors unaccounted for during standard analysis. In addition, non-specific reference values exist for children and adolescents, as a result of this, it is unclear how usable current reference values are in younger populations (Gafni and Baron, 2004). Despite these caveats, a large evidence base exists that supports the use of BMD as a primary identification tool for osteoporosis (Preston, 2004).

Identifying genuine osteoporosis has previously been associated with relative error and difficulty (Winzenberg et al., 2003). This is often attributed to a lack of clarity in the definition and diagnosis of osteoporosis (Preston, 2004). Some research has suggested using wider measures in conjunction with BDM, so that the disease can be more competently identified within practice (Yasuda, Kaleta, and Bromme, 2005). A significant limitation of BMD, is that mineral content needs to be compromised before a diagnosis can be made (Winzenberg et al., 2003). In high-risk populations such as young individuals and female athletes, methods that detect problems at an earlier stage would provide a greater window for intervention to take place (Yasuda, Kaleta, and Bromme, 2005).

Blood and urinary analysis can detect certain chemical biomarkers, which can reflect the overall health of the skeletal system (Yasuda, Kaleta, and Bromme, 2005). One study reviewing female athletes, indicated that markers of bone turnover were between 33% and 71% lower in certain athletes (Garenero et al., 2013). Thus, such measures should be considered within the appropriate populations. However, as a result of the inequalities which exist in female sport, it seems unlikely methods with such expense will seriously considered by the relevant bodies (Heinonen et al., 1995). Research that surrounds “the female athlete triad”, has previously identified that more efficient measures for screening osteoporosis and secondary osteop-orosis need to be established. However, significant developments are yet to be put in place (Garenero et al., 2013). More precise methods for measuring osteoporosis, may be capable of providing a greater reflection of the impact certain nutrients have on skeletal health.
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Calcium intake

Calcium intake is one of the most widely revised topics in the prevention of osteoporosis (Prentice, 2004). Furthermore, it is a key mineral used in the formation of bone mass, which is essential throughout all stages of life (Francis, 2007). Inadequate calcium intake is associated with secondary hyperparathyroidism, which leads to increased bone turnover and accelerated bone loss (Ilich and Kerstetter, 2000). Although it is generally agreed that sufficient calcium intake is an important part of skeletal health, universally accepted intake values are yet to be established. For example, the National Health Service (2016) in ...

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