Friday, December 4, 2015

Balance Builds Healthy Bones

By Felicity Curtain, Accredited Practising Dietitian 

With 99 percent of the body’s calcium found within our bones, the well-known link between calcium-rich foods and strong bones is understandable. But calcium does not act alone to strengthen and maintain our bones, and emerging evidence supports the important role of a balanced diet containing adequate dietary protein, phosphorus, potassium, magnesium, and zinc, in promoting strong bones. We delve into the latest evidence on dietary patterns linked with strong bones in children and adolescents, a critical time for building bone density.

Healthy bones – the foundation for a healthy body
Strong bones are vital for protecting internal organs, providing structural support for daily activities. Failing to achieve peak bone mass early in life leaves an individual with less reserve to endure the normal losses that occur with advancing age.

Traditionally, the nutrition focus for bone health has centred on calcium and calcium-rich dairy products. While calcium does take centre stage, other individual factors also play essential roles in the production of healthy bones. These include vitamin D (mostly from sunlight) for its role in the absorption and utilisation of calcium(1); protein which is a key constituent of bone tissue and assists in the repair and maintenance of the skeleton(2); minerals such as zinc, magnesium, and phosphorus which are important for bone mineralisation, as well as potassium which promotes an alkaline environment and prevents skeletal calcium from being mobilised to maintain normal pH levels(3).

With a deeper understanding of the essential role of a range of nutrients for bone formation and maintenance, the importance of a balanced diet for optimal bone health is apparent. Indeed, the latest research on bone health has looked beyond any single food or nutrient to total dietary patterns that are linked with strong bones.

What does the latest research say?
Adolescence is a crucial period for bone health and development, with as much as one-quarter of adult bone mass built over roughly two years (ages 12-14 for girls, and 13-15 for boys)(4). A recently published longitudinal study of 1,024 Australians aged 14 and 17 at baseline investigated dietary patterns during adolescence, and their associations with later bone density.

Through dietary analysis two types of dietary patterns emerged.  Pattern one was considered high-protein, high-calcium, high-potassium, and was characterised by high intakes of dairy products, whole grains, legumes; yellow, red, leafy green, and cruciferous vegetables; steamed, grilled, or canned fish; fresh and dried fruit, and plain mineral water – reflective of the dietary guidelines.  Pattern one was low in soft drinks, chips, takeaway foods, processed meats, and other discretionary foods.

Conversely, pattern two was high-protein, low-calcium, and low-potassium, and included high intakes of red meat, poultry, processed meats; steamed, grilled, canned or fried fish; eggs, and takeaway foods.  Pattern two was low in dairy products, fruit, cake and cookies, whole grains and legumes.

Higher consumption of dietary pattern one, the diet which reflected a balanced diet at age 14 was associated with higher bone mineral density at the age of 20, though no observable difference was noted with the dietary pattern at age 17(5). This suggests that adequate nutrition through the consumption of a balanced diet during early adolescence may be more important for bone development, than in late adolescence.

Similarly, a Korean study of school girls aged 9-11 years compared dietary patterns with subsequent changes in anthropometric measures and bone mineral density. One hundred and ninety eight girls were included, and dietary data was categorised into two patterns: ‘egg and rice’ and a more varied dietary pattern including ‘fruit, nuts, milk beverage, egg and grains’.  While the two patterns showed similar results for change in body mass index and percentage body fat, subjects adhering to the latter, more balanced dietary pattern, which included a higher intake of dairy products and grains, had a greater increase in bone mineral density(6).

In both of these studies, it is evident that the dietary pattern associated with greater bone health, was also linked to higher intake of calcium rich dairy products. This is not surprising as we know from previous research that dairy foods themselves (i.e. milk) have a favourable effect on bone mass(7). However, more recent research on dietary patterns shows that higher intakes of calcium, as well as other key nutrients including protein, potassium, magnesium, phosphorous and zinc, found in foods such as grains and legumes, are also important for bone health(5). To further substantiate this claim future research should aim to assess the independent effect of non-dairy based foods, rich in protein, potassium, magnesium, phosphorous and zinc on bone formation, maintenance and strength.

The take-home message
These findings re-iterate that it is not single nutrients or food groups in isolation that promote health and wellbeing, but rather the complex action and interaction of nutrients and foods obtained through a balanced diet as a whole.

Given the importance of a balanced diet in early adolescence for long-term bone health, it is particularly concerning that adolescents tend to have the least balanced diets, with the highest proportion of energy intake from nutrient poor discretionary choices (i.e. pizza, pies, muffins)(8), and the lowest intakes of nutrient rich whole grains(9).  When it comes to grain foods, teenagers should be encouraged to swap nutrient-poor discretionary foods for healthier core grains, choosing whole grain more often, as well as a variety of dairy products, fruit, vegetables (which includes legumes) and lean meat/alternatives, as part of a balanced diet. Practically, this could be as easy as choosing a whole grain breakfast cereal with fruit and yoghurt in the morning, opting for whole grain crackers with cheese for morning tea, and adding legumes into the families favourite spaghetti Bolognese recipe.

1.         Bone Health and Osteoporosis: A Report of the Surgeon General: Office of Surgeon General; 2004.
2.         Peters BS, Martini LA. Nutritional aspects of the prevention and treatment of osteoporosis. Arq Bras Endocrinol Metabol. 2010;54(2):179-85.
3.         Palacios C. The role of nutrients in bone health, from A to Z. Critical reviews in food science and nutrition. 2006;46(8):621-8.
4.         Teens: Healthy Bones Action Week; 2015. Available from:
5.         van den Hooven EH, Ambrosini GL, Huang R-C, Mountain J, Straker L, Walsh JP, et al. Identification of a dietary pattern prospectively associated with bone mass in Australian young adults. The American journal of clinical nutrition. 2015.
6.         Noh HY, Song YJ, Lee JE, Joung H, Park MK, Li SJ, et al. Dietary patterns are associated with physical growth among school girls aged 9-11 years. Nutr Res Pract. 2011;5(6):569-77.
7.         Du XQ, Greenfield H, Fraser DR, Ge KY, Liu ZH, He W. Milk consumption and bone mineral content in Chinese adolescent girls. Bone. 2002;30(3):521-8.
8.         ABS. Australian Health Survey: Nutrition First Results - Foods and Nutrients, 2011-12. Australian Bureau of Statistics, 2014.
9.         GLNC. 2014 Australian Grains and Legumes Consumption and Attitudinal Report. Unpublished: 2014.