Contributed by Abi Woodliffe-Thomas
Before we get into the link between nutritional science and bone health, it is important to understand what osteoporosis is and how it can develop. With disordered eating patterns, low oestrogen levels are the main driver of significant losses in bone density, as well as undernourishment which means a shortage in the building blocks for healthy bones. Individuals with eating disorders, such as anorexia nervosa, often produce cortisol (the stress hormone) in excess which triggers bone loss.
What is osteoporosis?
Osteoporosis is a disease that weakens bones and causes reduced bone density leading to a heightened susceptibility to break. Osteoporosis often affects bones in the hip, spine and wrist.
While osteoporosis can be avoided, there are some important risk factors to be aware of for developing this degenerative bone condition (1):
Gender - Females (particularly post-menopause) are at an increased risk compared to males, and even more at risk if their mother or family member had the condition
Poor lifestyle – Smoking, excessive caffeine and alcohol intake, with the absence of exercise can increase risk of osteoporosis
Poor nutrition – Restrictive, disordered eating habits such as under eating can contribute to malnutrition. Malnutrition can enhance the development of osteoporosis as the body doesn’t receive enough nutrients in order to protect, build and strengthen bone matter
Amenorrhea (loss of menstrual cycle) – This warning sign for disordered eating is also a red flag for osteoporosis. This is due to the reduction in oestrogen levels which effect calcium uptake and absorption in bones.
A lifelong lack of calcium is one of the leading causes of osteoporosis, contributing to a diminished bone density, early bone loss and an increased risk in fractures. Eating disorders also have a role to play in the disease onset. This is due to the severe restriction of nutrients, persistent impactful force through overtraining and being underweight weakening bones in both men and women (2).
Is osteoporosis different to osteopenia?
People often get confused between osteoporosis and osteopenia. Osteopenia is the stage before osteoporosis which is characterised by a lower than average bone density for your age, yet not low enough to be classified as osteoporosis.
The main difference between the two is the severity of bone loss. Although osteopenia is characterised by bone loss that is less severe than that of osteoporosis, the risk of fractures is still elevated compared to normal bone.
Is osteoporosis reversible?
You can reverse the consequence of osteoporosis; however, you cannot completely reverse the condition. There are varying degrees of osteoporosis severity and several treatments, be it exercise, weight maintenance and/or nutrition can prevent the condition from worsening.
Can amenorrhea impact bone health?
Amenorrhea has a profound impact on a female’s bone density, specifically in adolescence and early 20's as this is a critical period for bone health where bone mass is being laid down. The amount of bone being laid down is enhanced by factors such as calcium intake, vitamin D and a balance of good nutrition and exercise. (3)
Amenorrhea is commonly exacerbated by overtraining (see: Unhealthy Exercise in Eating Disorders) and under-fueling which can lead to a decrease in body weight and essential hormones like oestrogen and progesterone. Oestrogen and progesterone are needed to lay down new bone matter so a reduction in these hormones means that bone is unable to be built up as it needs to.
The effects of nutrition on bone health
There are 3 key nutrients that are needed for good bone health:
Calcium is the most abundant mineral that makes up our bones, followed by magnesium. With 99% of calcium being in our bones and teeth, this mineral is essential (4) for bone and teeth health.
Calcium is found in most dairy products (cheese, yoghurt and milk) as well as spinach, kale, oily fish (with small bones) and fortified foods such as soy and cereals, making it an achievable mineral to consume even when following a dairy-free or vegan diet. We always encourage a food first approach with calcium, however if you are struggling to eat enough book in to see a registered dietitian or your GP to talk about supplementation options.
Our bodies use calcium continuously, so we must replace it regularly via our diet. The recommended daily allowance (RDA) for calcium is dependent on age and sex (5):
1000mg per day for adults, aged 19 to 50 years of age
1200mg per day for women aged over 50 years of age (due to the menopause)
1200mg per day for men once over 70 years of age
It is important to note that for individuals with an eating disorder and/or osteoporosis, recommended calcium intake is higher than the RDA. Individuals should aim to consume 4 serves of dairy foods (or equivalent) a day.
Vitamin D works alongside calcium to promote good bone health. They work as a team, because vitamin D increases our absorption of calcium, which we know is integral for strong, healthy bones.
Vitamin D also improves the function of muscles, which can help your balance and decrease the likelihood of falling and suffering a bone fracture. It is advised that for those living in colder, less sunny climates supplement vitamin D between the months of October and April (6). You can read our blog on vitamin D for more information about sources of vitamin D and supplementation.
Phosphorus works with calcium and vitamin D in your body to keep your bones healthy and strong. Phosphorus is found in protein rich foods like dairy, meat, fish, eggs, legumes/pulses, wholegrains and seeds.
What is the treatment for osteoporosis?
Although you cannot reverse osteoporosis entirely, you can engage in healthy behaviours to stop it from getting worse. In addition to optimising your dietary intake, these are the main lifestyle factors to consider:
Being at a healthy weight is crucial for hormone regulation (oestrogren and progesterone). No matter how good your diet is, if you are not at a healthy weight then your bone health will be impacted.
Exercise isn't just about building muscle strength, it's important for our bone strength too! Our bones are our physical structure and building blocks, so adopting the correct exercise regime dependent on your bone health status is important.
There are three categories in which exercise can help bone health for those with osteoporosis (7):
Our bones are living tissues that get stronger the more we use them. Weight bearing exercise in combination with muscle strengthening exercise is key for bone health (8). If you are recovering from an eating disorder or disordered eating, or have been diagnosed with osteopenia or osteoporosis it is important to seek advice from a qualified medical professional before engaging in any form or physical activity.
If you feel you need support with optimising your diet or overcoming restrictive eating patterns, we're here to help at TC Nutrition. Get in touch to book a free 15 minute discovery call and see how our dietitians can support you.
Follow Abi on instagram @Happetite_ for more nutrition tips and recipe inspiration.
(1) MedicineNet. Osteoporosis Risk Factors. Available at https://www.medicinenet.com/script/main/art.asp?articlekey=20363
(2) nhs.uk. Osteoporosis. Available at: https://www.nhs.uk/conditions/osteoporosis
(3) Gordon, C.M. and Nelson, L.M., 2003. Amenorrhea and bone health in adolescents and young women. Current Opinion in Obstetrics and Gynecology, 15(5), pp.377-384.
(4) Calcium, I., Ross, A., Taylor, C., Yaktine, A. and Valle, H., 2021. Overview of Calcium. Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/books/NBK56060
(5) Ods.od.nih.gov. Office of Dietary Supplements - Calcium. Available at: https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional
(6) nhs.uk. Vitamins and minerals - Vitamin D. Available at: https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-d
(7) Theros.org.uk. Exercise for your bones. Available at: https://theros.org.uk/information-and-support/bone-health/exercise-for-bones
(8) Theros.org.uk. New exercise information and resources for patients with or at risk of osteoporosis. Available at: https://theros.org.uk/healthcare-sector-news/2019-03-15-new-exercise-information-and-resources-for-patients-with-or-at-risk-of-osteoporosis
Image source: https://hspersunite.org.au/bone-density-lower-in-hspers/
Talia Cecchele Nutrition is a team of registered dietitians that specialise in eating disorder recovery, disordered eating, digestive issues and sports nutrition. We aim to bring balance back to nutrition, help you to break free from food rules and find food freedom. We offer virtual consultations and group programs so whether you are based in London, the United Kingdom or around the world we would love to support you. To enquire about a private consultation please fill out a contact form.