Menopause and Bone Health

Bone health is about more than consuming enough calcium. Find out how other nutrients, exercise, and medications affect your bones.

How Bones Function

Bones do more than keep you upright, act as anchors for muscle and connective tissue that allow you to move, and protect your vital organs (thank you, skull and ribs!). Bones’ rigid exteriors mask the frenzy of activity taking place inside. They’re constantly churning out cells that carry oxygen, fight infection, and aid in blood clotting. Bones also store minerals that provide skeletal strength and support overall health.

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Once you’re done growing, bone is maintained by processes that continually build new bone cells while removing old ones. Bone mass reaches its peak by about age 30, after which bone tissue begins a gradual decline.

Menopause accelerates bone loss. That’s because estrogen slows the breakdown of bone cells, and declining levels means you lose bone tissue faster than you can make it. You lose the most bone during the first few years after your last menstrual period and bone loss levels off after that.  Lower bone mass increases the risk of breaking a bone in your hip, spine, wrist, or forearm. 

Osteoporosis is a chronic condition characterized by very low bone mass, also called bone density. Low bone density (osteopenia) is when bone mass measures below normal levels, but not low enough to be classified as osteoporosis. The most common test for bone density is a technique called DXA (dual-energy X-ray absorptiometry). Experts in the U.S. recommend screening for osteoporosis in all women 65 years and older and postmenopausal women younger than 65 years who are at increased risk for bone disease, like me.

A few years ago, my doctor ordered a DXA test because I take a medication that reduces bone tissue.  Certain conditions including diabetes, inflammatory bowel disease, liver disease, kidney disease, multiple sclerosis, and rheumatoid arthritis, are also associated with weaker bones and if you have one of these conditions, you may merit a DXA test before the age of 65. My diagnosis of “mild osteopenia” fueled me to double down on my efforts to preserve my bone tissue.

Hormone Therapy and Bone Health

Everyone loses bone with age, but it’s the amount that counts. It’s best to have as much bone tissue as possible on board before menopause happens, but if you’re in midlife, that’s water under the bridge. Estrogen with or without progestogen (also known as progestin) can help you keep the bone you have.  Hormone therapy is approved for the prevention of postmenopausal osteoporosis.

However, not everyone can take hormone therapy, nor do they want to. In addition, hormone therapy is not a free pass. You still need to make an effort to preserve as much bone tissue as possible going forward.

Nutrition and Bone Health

Nutrition for bone health involves an array of nutrients that work together to support the structure and function of bones.  

Calcium

Calcium is the most abundant mineral in the body and it’s also the dominant component of bones.  Although nearly all calcium resides in the skeleton, the body must maintain a certain blood level for a normal heart rhythm, muscle contraction, and other functions. When your calcium intake is low, or when your body doesn’t absorb enough calcium, or both, the body “borrows” the calcium it needs from the bones. A steady, adequate intake of calcium allows the body to “repay” the bones to better maintain reserves. Menopause chips away at bone strength by hastening calcium loss from bones.

Dairy foods are naturally rich in calcium, and fortified foods, such as soy milk, provide the most calcium.  Suggested daily calcium intake increases to 1,200 milligrams (about the amount in four servings of dairy foods) after age 50, which you can get from food, supplements, or a combination.  I take 600 milligrams (mg) of supplemental calcium daily and eat two to three servings of dairy foods per day to meet my calcium needs.

Vitamin D

Vitamin D maximizes the body’s absorption of calcium from food and supplements. It also regulates calcium’s movement in and out of bones to help maintain calcium balance in the blood. Your body makes vitamin D. Vitamin D production starts when skin is exposed to strong ultraviolet B rays (think summertime sunshine).

Though vitamin D production in the body contributes to satisfying needs, most people don’t produce enough vitamin D for a variety of reasons, including a lack of exposure to sunlight. The body can store the vitamin D that it makes, but many women avoid the sun or wear sunscreen that blocks vitamin D production.  On top of that, women may not get the vitamin D they need from food because few choices are naturally rich in the nutrient. For example you would need to drink 48 ounces of milk, which is fortified with vitamin D, to meet the daily requirement.  

I live in Boston, where the sun is strong enough to make vitamin D for just six months of the year.  I take a vitamin D supplement with 15 micrograms, the suggested daily amount, every day because I wear strong sunscreen and avoid the sun.  I also eat salmon and tuna, which are good sources of vitamin D, twice or more weekly, and drink 16 ounces of fortified milk every day. (Nearly all brands of yogurt have no vitamin D, and cheese has none.)

Photo by Anders Jildén on Unsplash

Magnesium

Half of all the magnesium in your body resides in the bones where it lends strength and structure.  Like calcium, the body pulls magnesium from the bones to maintain a certain blood level, and low magnesium intakes are linked to lower bone density.

Plant foods, such as legumes, nut, seeds, vegetables and whole grains, provide the most magnesium. The suggested daily magnesium intake for women over age 31 and older is 320 mg, but most women don’t get enough of this mineral.

According to the U.S. Food and Drug Administration, digoxin and proton pump inhibitors (PPI), such as omeprazole (Prilosec) and lansoprazole (Prevacid), used to treat gastroesophageal reflux disease and peptic ulcer disease, can deplete magnesium from the body. I take a PPI and I also take supplemental magnesium to help offset the effects of the medication.

Vitamin C

Vitamin C is essential in the production of collagen in the bone matrix, which supports the inner workings of bone. Vitamin C is also a powerful antioxidant that helps prevent damage to bone cells caused by oxidative stress. Oxidative stress is the result of unstable molecules called reactive oxygen species and also known as “free radicals.” Inflammation and oxidative stress contribute to bone tissue loss over time.

Citrus fruits, strawberries, kiwi, red bell peppers, and tomatoes are top vitamin C sources. Smoking decreases vitamin C levels in the body, and the suggested daily vitamin C intake for smokers is higher than for nonsmokers (110 mg versus 75 mg). Exposure to secondhand smoke also decreases vitamin C levels in the blood. In addition, smoking can lead to premature menopause which means fewer years of protective estrogen.

Protein

Muscles hold your joints and bones in the most functional and least painful positions and prevent falls that can break a bone. You know that adequate protein intake (combined with exercise – more on that in a minute) is essential to make and preserve muscle tissue. Protein is also necessary for adequate bone density.

Experts suggest that women over the age of 50 consume 1 to 1.2 grams of protein per kilogram (kg) every day to support bone and muscle. (To convert pounds to kg, divide by 2.2.) For a 150-pound woman (68 kg), that amounts to about 81 grams of protein daily. I prefer the higher end of the expert recommendation because protein also contributes to eating satisfaction and can make weight control easier.

Fiber

The beneficial microbes that live in your gut feast on fiber from food and produce compounds called short chain fatty acids (SCFA). Short chain fatty acids promote bone density and reduce inflammation. They increase the absorption of calcium and magnesium from the gut and protect the gut barrier from “leaking.” A strong gut barrier reduces the chances of lipopolysaccharide (a component of gut cells) making its way into the blood and to the bones where it causes inflammation that damages bone tissue.

Experts suggest about 30 grams of fiber daily for women. Plant foods are the only fiber sources. Include at least five servings of fruits and vegetables and at least three servings of whole grains, as well as legumes, lentils, and edamame, to help satisfy daily fiber needs. 

Vitamin K

Vitamin K is essential for making one of the main proteins in bone tissue. The beneficial bacteria in the gut produce some of the vitamin K you need. The remainder must come from food.

Dark green leafy vegetables have the most vitamin K. The suggested intake for women over the age of 19 is 90 micrograms (mcg) of vitamin K daily, which amounts to about 1 cup of raw spinach or ½ cup cooked broccoli. Certain medications, including anticoagulants, antibiotics, antiseizure drugs, and cholestyramine, interfere with vitamin K, and you may need more, or less, vitamin K if you take them.

After reading a randomized control trial in The American Journal of Clinical Nutrition about prunes and bone density, I started eating six prunes every day. The study found that consuming 50 grams of prunes (about six) daily for six months prevented bone density loss at the hip in postmenopausal women. Six prunes provides about one-third of the daily requirement for vitamin K and three grams of fiber, and that’s not all. Prunes also have polyphenols, which are beneficial plant compounds that nurture gut bacteria and help reduce inflammation, and they supply potassium, too. Evidence suggests that potassium supports bone health, although the reason isn’t clear. Potassium may reduce acidity in the blood that has an adverse effect on bone. Potassium is widely available from an array of plant foods including soy products and from milk, chicken, salmon, and beef.

Exercise and Bone Health

Exercise supports muscle and bone health and improves balance. Weight-bearing activities exert force on your muscles and makes them stronger. Examples include jogging, running, brisk walking, tennis, and dancing. Resistance training, such as weight lifting, bands, and your own body weight, improve muscle and bone strength.

Aim for 150 minutes of moderate-intensity aerobic exercise and at least two sessions of moderate-intensity resistance training weekly. Though I run regularly, I do less aerobic activity than when I was in my 30s and 40s, when resistance training was an afterthought. Now, resistance training is just as important to me as aerobic activity and I include two to three sessions weekly. I also walk the dog every day for a total of about 10 miles a week.

Bottom Line: What to Eat for Bone Health

There is no singular eating pattern for bone health. That said, a balanced plant-based plan (not necessarily animal-free) with adequate fiber and protein is a good starting point. It may be difficult to satisfy your needs for some of the other nutrients that support bones, including calcium and vitamin D. Dietary supplements can fill in small nutrient gaps to help prevent osteoporosis, but there’s no need take large doses.

In addition to diet and exercise, over-the-counter and prescription medications can affect bones.  Ask your doctor or pharmacist if the medications you take influence bone health. This list of medications from the International Osteoporosis Foundation is also helpful.

How do you take care of your bones? Let me know!