Diet, exercise and lifestyle changes that can keep your bones healthy and prevent osteoporosis during perimenopause and menopause
• Bone density naturally decreases from your late 30s but falling hormone levels speed up the decline
• Taking the right dose and type of hormones can increase bone density
• Learn how exercise can strengthen your bones and what to eat to rebuild them
Your bones are made up of a type of connective tissue that contains cells, collagen fibres, blood vessels and minerals such as calcium and phosphorus. These help your bone grow and repair itself. The term bone density relates to the amount, or thickness, of minerals in bone tissue. It is a measure of how strong and healthy your bones are. By your late 30s, your bone density starts to decrease. This loss of bone density makes your bones weaker, less pliable and therefore more susceptible to breaking.
RELATED: Hormones and bone health
How does menopause affect bone health?
Women are more affected by a loss of bone strength in the years before, during, and after menopause, as levels of oestradiol (oestrogen, the key hormone for protecting and maintaining bone density), progesterone and testosterone decline during this time. Your bone is breaking down at a faster rate than your body can grow new bone tissue when hormone levels are low.
The prevalence of osteoporosis, when the loss of bone density is reduced and there is a greater risk of bones breaking, varies among populations but in the UK, almost 80% of people diagnosed with osteoporosis are women [1].
Half of women over the age of 50 will experience a fragility fracture in their lifetime (compared to 20.7% of men) [2].
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Will I get osteoporosis?
Osteoporosis develops slowly over several years and is often only diagnosed when a fall or low impact causes a bone to break. Osteoporosis is not usually painful until a bone is broken, but broken bones in the spine are a common cause of long-term pain.
A family history of osteoporosis increases your risk of developing osteoporosis, but other factors will increase your risk of having osteoporosis too. Smoking and heavy drinking can damage your bone-building cells, and a diet lacking the important nutrients calcium and vitamin D may not give your bones what they need to grow new bone tissue. Women over 50, who do not take HRT, have inadequate levels of hormones in their bodies leading to an increased risk of osteoporosis occurring.
If your doctor suspects you have osteoporosis, they can often work out your future risk of breaking a bone using an online programme such as FRAX or Q-Fracture. The only way to actually know your bone density is for you to have your bone density measured by having a DEXA scan.
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Do I need a DEXA scan?
This simple and painless scan uses radiation (a much lower dose than a standard X ray) to measure bone density. The scanner can use your bone density measurement to compare with people of the same age and gender, giving a good indication as to whether you are at risk of, or have already developed, osteoporosis.
Under NHS criteria you may be offered a DEXA scan if you have already broken a bone, have rheumatoid arthritis, have been on oral steroids for more than three months, had menopause under 45 years, have large gaps (of more than a year) between periods, if you are menopausal and also smoke or drink heavily, or if you are underweight with a BMI of less than 21. Some people need a scan to confirm that their risk of breaking a bone is high enough to need treatment. However, many clinics will offer DEXA scans to women who are otherwise healthy but just want to know their bone density.
Why do I need to look after my bones?
Building and strengthening your bones will help reduce the risk of a low impact fracture. If you are diagnosed with reduced bone density, you should consider taking HRT (the right dose and type of hormones; oestradiol, progesterone and testosterone, are important) and performing adequate exercise can help to improve your bone density.
The impact of some fractures, for instance hip fracture, can be huge. Once a fragility fracture has occurred, patients are five times more likely to experience a second fracture within the next two years [3].
Some osteoporotic fractures are associated with premature mortality [4], and the mortality rate within one year of a fracture is 22% [5]. In the UK, the number of fracture-related deaths is comparable to or exceeds that for some of the most common causes of death such as lung cancer, diabetes, chronic lower respiratory diseases [1].
How can I look after my bones?
HRT can help prevent and repair bone loss and reduce the risk of fracture – it is associated with a 30% significant reduction in vertebral and non-vertebral fractures [6].
Oestradiol slows down the rate of bone loss and even promotes new bone growth which helps keep bones stronger for longer. Progesterone collaborates with oestradiol, helping bone formation and preventing bone loss. Testosterone plays an important role in maintaining bone mineral density, and in menopausal women, treatment with both testosterone and oestradiol is more effective in increasing bone mineral density than oestradiol alone [7].
You can read more about the benefits of HRT on your bone health in our article Can HRT and testosterone prevent osteoporosis?
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What exercise strengthens bones?
Bones usually become stronger as you use them and give them work to do. The best exercise for bone strength is combining weight-bearing exercise with impact and muscle-strengthening exercise. Aim to perform strengthening activities at least two days a week and at least 150 minutes of moderate intensity activity, or 75 minutes of vigorous intensity activity, a week [8].
The Royal Osteoporosis Society has a guide to exercising for bone health [9].
Weight-bearing exercise
This is when your feet and legs support your own weight. You can vary the impact by using different body positions, directions and speeds, for instance by following short, harder bursts with lighter periods of activity.
Low impact: walking, marching, stair climbing, gentle heel drops and stamping
Medium impact: dancing, jogging, team and racket sports, skipping, hopping, normal jumping, and stamping
High impact: netball, volleyball, basketball, high jumping, tuck jumps, star jumps, athletic events.
Muscle-strengthening exercise
Strengthening your muscles encourages your bones to respond by renewing themselves and maintaining or improving their strength. Use weights or resistance bands or your own body weight, for example by doing press-ups or plank. Yoga and Pilates are strength exercises, but they also improve your balance and flexibility, which can help prevent falls occurring.
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What diet helps to strengthen bones?
A healthy, balanced diet that includes the five main food groups will help your bones stay healthy and strong. In particular, a Mediterranean diet – one that’s high in vegetables, nuts, beans, cereals, fish and unsaturated fats (like olive oil) and low in meat and dairy – can help maintain bone mineral density. Be sure your diet includes these vital nutrients:
Calcium
Calcium gives your bones the strength and hardness they need to cope with your everyday activities. Foods that are calcium-rich include: dairy products such as milk, yoghurt, kefir and cheese, green leafy vegetables, other vegetables like cabbage and broccoli, nuts such as almonds, sesame seeds, soft fish bones found in sardines and whitebait, dried fruit, pulses, tofu and fortified foods and drink, like breakfast cereal and alternative plant-based milks.
Vitamin D
Vitamin D helps your body absorb and use calcium. You can get vitamin D from safe sunlight exposure, from your diet and from vitamin D supplements. Foods naturally rich in vitamin D include oily fish and egg yolks. Some foods, such as bread and cereals, have vitamin D added to them, which is normally advertised on the packaging.
Iron
Low levels of iron have been shown to contribute to loss of bone tissue (bone strength) in postmenopausal women and individuals with osteoporosis are often deficient in iron. Although meat is rich in iron, it should be consumed in moderation. Good, non-meat foods that are a great source of iron include spinach, broccoli, kale, Swiss chard, lentils, chickpeas, red kidney beans, soy beans, cashews, sesame seeds and baked potatoes.
Prebiotics
A healthy gut increases the amount of minerals helpful for bone-building being absorbed into the bloodstream. Prebiotic foods (garlic, onions, bananas, apples, whole grains, and pulses) and fermented foods (yoghurt, kefir, sauerkraut) help increase calcium absorption.
RELATED: Can the Mediterranean diet help menopausal symptoms?
What else can I do?
Even if you eat vitamin-D rich foods it’s unlikely you’ll get all the vitamin D you need from food alone, so a supplement can help. The Department of Health recommends that everyone should consider taking a daily vitamin D supplement during the autumn and winter due to the lack of natural sunlight and sunlight hours, as it plays an important role in muscle function and bone health.
While the general guideline for supplementation in the UK is 10 micrograms (400 IU) per day for adults, National Osteoporosis Guideline Group recommends postmenopausal women who have an identified vitamin D insufficiency or risk factors for vitamin D insufficiency consume vitamin D from foods and vitamin D supplements of at least 800IU/day [10].
Be aware that smoking slows down the cells that build bone in your body. This means smoking could reduce your bone strength and increase your risk of breaking a bone. People who smoke are also found to be at higher risk of breaking their hip as they get older. However, if you give up smoking, your risk of breaking a bone is lower than if you were still smoking [11].
RELATED: Menopause and smoking: what you need to know
In the short term, drinking a lot of alcohol can make you unsteady on your feet, making you more likely to trip, fall and break a bone. Long term, drinking a lot of alcohol increases your risk of osteoporosis. Try to stick to the government recommendation of no more than 14 units of alcohol per week and have regular days where you don’t drink at all.
RELATED: Alcohol and the menopause
Through a combination of eating the right foods, being active and leading a healthy lifestyle you can support your body to build and maintain your bones, keeping them strong and healthy for as long as possible.
