THREE STEPS TO UNBREAKABLE BONES - VITAMIN D, CALCIUM AND EXERCISE - www.iofbonehealth.org
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THREE STEPS TO UNBREAKABLE BONES VITAMIN D, CALCIUM AND EXERCISE www.iofbonehealth.org
normal bone osteoporotic bone
WHAT IS OSTEOPOROSIS?
Osteoporosis is a disease characterized A COMMON DISEASE A GROWING PUBLIC HEALTH
by low bone mass and deterioration PROBLEM
in the microarchitecture of bone It is estimated that worldwide an
tissue, leading to an increased risk of osteoporotic fracture occurs every 3 The risk of sustaining a fracture
fracture. Osteoporosis occurs when seconds. At 50 years of age, one in increases exponentially with age due
the bone mass decreases more quickly three women and one in five men will not only to the decrease in bone
than the body can replace it, leading suffer a fracture in their remaining mineral density, but also due to the
to a net loss of bone strength. As a lifetime. For women this risk is higher increased rate of falls among the
result the skeleton becomes fragile, than the risk of breast, ovarian and elderly. The elderly represent the fastest
so that even a slight bump or fall can uterine cancer combined. For men, growing segment of the population.
lead to a broken bone, (referred to as the risk is higher than the risk for Thus as life expectancy increases for the
a fragility fracture). Osteoporosis has prostate cancer. Approximately 50% majority of the world’s population, the
no signs or symptoms until a fracture of people with one osteoporotic financial and human costs associated
occurs – this is why it is often called a fracture will have another, with with osteoporotic fractures will increase
‘silent disease’. the risk of new fractures rising dramatically unless preventative action
exponentially with each fracture. is taken.
Osteoporosis affects all bones in the
body, however fractures occur most
frequently in the vertebrae (spine),
wrist and hip. Osteoporotic fractures
of the pelvis, upper arm and lower leg Fractures due to osteoporosis
are also common. Osteoporosis itself
is not painful but the broken bones
can result in severe pain, significant can cause significant disability
disability and even mortality. Both hip
and spine fractures are also associated
with a higher risk of death - 20% of and loss in quality of life
those who suffer a hip fracture die
within 6 months after the fracture.
2
FOREWORD
Eating well and staying physically
active are two essential components
of a healthy lifestyle. These are also
the pillars of osteoporosis prevention
at all stages of life. Although genetics
largely determine the size and density
of your bones, lifestyle factors such
as regular exercise and good nutrition
also play key roles.
Good nutrition fuels our bone
health by providing our body with
the necessary quantities of vitamins,
calcium, and high quality proteins that
are required to maintain bone and
muscle strength. Vitamin D has been
found to be of particular importance
to bone health. In this report, we raise
awareness of the broad prevalence of
vitamin D deficiency and recommend
supplementation with vitamin D in Heike A. Bischoff-Ferrari MD DrPH
all adults age 60 years and older Director Centre on Aging and Mobility, University of Zurich
for its proven reduction of falls and and City Hospital Waid
fractures. Notably, vitamin D plays SNF-Professor Dept. of Rheumatology and Institute of
a critical role in bone development Physical Medicine, University Hospital Zurich
in children and correlates positively
with bone density in younger adults.
Apart from its benefit on calcium
uptake in the bowel, vitamin D has a healthy diet, it is never too soon or too to raise awareness of the importance
direct effect on muscle. As sufficient late to start. There is always a benefit, of maintaining sufficient daily levels
vitamin D is not obtained from an regardless of age. of vitamin D, calcium, protein and
otherwise healthy diet and direct physical activity to maintain bone
daily sun exposure, which is the main The combination of staying active, health, at all ages. However, as
stimulus from vitamin D production eating a diet rich in calcium and underlined by our special focus
in the skin, is limited in most adults, ensuring that you are not vitamin on vitamin D, we wish to address
supplementation should be considered. D deficient offers tremendous a growing public health concern:
opportunities to improve bone and falls and fall-related fractures in
Engaging in physical activity has many muscle health and reduce the risk of our ageing populations. Seventy-
health benefits and is absolutely osteoporosis. Importantly, the benefits five per cent of all fractures occur
essential for strong bones and muscles. derived from healthy nutrition with in individuals age 75 and older.
Thus, it is important to strengthen your adequate vitamin D may be enhanced As muscles weaken elderly people
muscles and bones to reduce your risk by greater physical activity. This is become frail, experiencing functional
of osteoporosis, falls and fractures. why this year’s ‘World Osteoporosis decline and a tendency to fall. The
Walking 4 hours a week at a brisk Day’ campaign message merges these ultimate goal of our public healthcare
speed has been associated with about three components in “Embrace a bone policy (and certainly the personal
a 40% reduction in hip fractures1. healthy lifestyle”. Applied together goal of everyone as they age!) is
Simple targeted exercise programmes each component enhances the other to have seniors remain physically
have been shown to improve bone for optimal bone and muscle health. independent and active members of
density and functional mobility, their communities. Muscle and bone
resulting in 10 to 50% fewer falls in The overall objective of this year’s health are the key targets to help
frail and active older adults2,3,4. As for a World Osteoporosis Day campaign is achieve this goal.
3
BONE AND MUSCLE STRENGTH
A team in osteoporosis and falls prevention
A primary risk factor for a fracture is consequent increase in risk of further of individuals aged 65 and older is
a fall, with over 90% of all fractures falls8. Thus, strengthening bone and predicted to increase from 25% to
occurring after a fall5. Thus, critical muscle is critical for the prevention of 40% by 2030 in Europe15-19 and in
for the understanding and prevention falls and fractures. large parts of the Western World20, 21,
of fractures, especially at older age, the number of fall related fractures
is the close relationship between falls Better muscle strength for the will increase substantially. As both
and muscle weakness. Individuals prevention of falls is also important vitamin D and exercise have been
with better muscle strength have as falling is a frequent event at older proven to improve bone health and
stronger bones, fall less, and have age. Thirty percent of those 65 years reduce falls by 20 to 50%, this report
fewer fractures. Mechanistically, the or older, and 40-50% of those 80 promotes these two effective, well-
circumstances5 and the direction6 of years or older, report having had a tolerated and easy to implement
a fall determine the type of fracture, fall over the past year9, 10. Serious strategies for unbreakable bones.
whereas bone density and mechanical injuries occur with 10-15% of falls,
factors such as better muscle strength resulting in fractures in 5% and hip
or better padding around the hip, fracture in 1-2%11. As an independent
critically determine whether a fall will determinant of functional decline12,
result in a fracture7. Moreover, falling falls lead to 40% of all nursing home
may result in self-imposed reduction admissions13. Recurrent fallers may
in physical activity due to fear of have close to a 4-fold increased
further falls, but which, paradoxically, odds of sustaining a fall-related
may result in reduced bone density fracture compared to individuals with
and muscle strength with a a single fall14. As the proportion
4
EAT WELL: Calcium, protein & vitamin D!
Our skeleton is sensitive to mechanical Bone is a living and metabolically throughout the life cycle. In addition,
loading ,and bone mineral density active tissue and therefore undergoes vitamin D supplementation has been
can be improved by weight-bearing constant renewal throughout life. As shown to improve function and reduce
physical activity. In addition, our with other organs, our bones need the risk of falls and fractures among
bones have nutritional needs. Thus, to be fueled with key nutrients and older adults.
the combination of staying active, energy. A healthy and balanced diet
eating a healthy, calcium-rich diet plus for strong bones will provide key While our calcium needs can be
taking a vitamin D supplement offers micronutrients (vitamins and minerals) covered by a nutritious diet, it is
tremendous opportunities to improve as well as macronutrients (protein, fat, important to realize that the same is not
bone and muscle health and reduce carbohydrates) to provide the building true for vitamin D. It is nearly impossible
the risk of osteoporosis. Moreover, the blocks for bone and the energy needed to get enough vitamin D from food
benefit of a “bone healthy diet rich for its renewal. This report highlights as it is only found in small amounts in
in natural calcium sources with added the importance of two significant certain foods; secondly, it is difficult for
vitamin D” may be enhanced by greater nutrients, calcium and protein, which most adults (especially older people) to
physical activity or reduced by the lack are building blocks for healthy bones get enough daily sunlight exposure to
of it. This is why this report merges and muscles plus one nutrient, vitamin also reach adequate levels. Therefore
all concepts — applied together each D, that allows optimal availability of supplementation is recommended
concept elevates the other for optimal calcium from a healthy diet and has in those over 60 years. For calcium,
bone and muscle health. a direct effect on muscle strength. All as highlighted in this report, dietary
three nutrients have been shown to sources are the preferred option and
be important for preserving bone mass supplementation with calcium should
only be targeted to those who do
not get sufficient calcium from their
diet and who are at high risk for
osteoporosis.
Calcium, protein and vitamin D - all
three nutrients are important for
preserving bone mass throughout the
life cycle
5
CALCIUM
Calcium is a key structural component APPROXIMATE CALCIUM LEVELS IN FOODS
of bone and is built into bone as a
Food Serving Size Calcium (mg)
mineral complex that includes calcium
and phosphate. Our skeleton houses Milk, whole 236 ml 278
99% of our body’s calcium stores. Milk, semi-skimmed 236 ml 283
Calcium built into bone also serves Milk, skimmed 236 ml 288
as a calcium reservoir for maintaining
calcium levels in the blood. Calcium is Goats milk, pasteurized 236 ml 236
absorbed in the small intestine both Yoghurt, low fat, plain 150 g 243
by passive diffusion and by active Yoghurt, low fat, fruit 150 g 210
absorption regulated by vitamin D.
Yoghurt, Greek style, plain 150 g 189
Individuals who have more vitamin
D are able to absorb more calcium22. Fromage frais, fruit 100 g 86
Therefore, in combination with vitamin Cream, single 15 g 13
D, it is thought that a minimum total
Cheese, cheddar type 40 g 296
calcium intake of about 800 mg per
day may be sufficient23,24. This amount Cheese, cottage 112 g 142
of calcium can be achieved by a Cheese, mozzarella 28 g 101
healthy diet that contains a daily dose Cheese, Camembert 40 g 94
of calcium-rich foods (for example: 1
glass of milk or slice of hard cheese = Ice cream, dairy, vanilla 75 g 75
300 mg calcium; 1 glass of calcium- Tofu, soya bean, steamed 100 g 510
rich mineral water = 200 mg calcium; Soya drink 236 ml 31
4 sardines = 500 mg; 28 grams of
Soya drink, calcium-en- 236 ml 210
almonds = 75 mg calcium).
riched
See food table on right
Broccoli, cooked 112 g 45
Curley kale, cooked 112 g 168
Apricots, raw, stone re- 160 g 117
Individuals who have more vitamin D moved
Orange, peeled 160 g 75
are able to absorb more calcium
Figs, ready to eat 220 g 506
Almonds 26 g 62
Brazil nuts 20 g 34
Sardines, canned in oil 100 g 500
Pilchards, canned in tomato 110 g 275
sauce
Whitebait, fried 80 g 688
Bread, white , sliced 30 g 53
Bread, wholemeal, sliced 30 g 32
Pasta, plain, cooked 230 g 85
Rice, white, basmati, boiled 180 g 32
Food Standards Agency (2002) McCance and Widdowson’s The
Composition of Foods, Sixth summary edition. Cambridge: Royal Society
of Chemistry
6
embrace calcium rich foods
Dietary sources of calcium are 3. calcium tablets can reduce HOW DOES CALCIUM IMPROVE
preferred to supplementation for intestinal phosphate absorption26, BONE HEALTH?
several reasons: which may be detrimental as
a balanced calcium-phosphate Calcium performs various functions
1. calcium-rich foods such as dairy ratio is needed for bone in the body and is needed for muscle
(milk, yoghurt, cheese) and nuts mineralization. The latter may be contraction and as a building block of
contain additional nutrients primarily a concern in the senior bone. A calcium-rich diet is especially
valuable for bone and muscle population27, where phosphate important to build bone during the
health, especially high-quality deficiency is found in about 10 highest rate of bone growth, which
protein; to 15% of women over 60 years is in childhood and adolescence.
old28. Each increase in calcium Supporting bone health early in life
2. high-dose calcium supplement intake by 500 mg/ will help protect us from developing
supplementation (1000 mg and day decreases phosphorus osteoporosis later in life. As well, when
more) may not be beneficial for absorption by 166 mg26, so a bone density is decreasing in later
cardiovascular health25 whereas calcium supplement of 1000 mg years, a calcium-rich diet helps us to
calcium-rich foods are not may shift an elderly person on a maintain bone mineral density. This
associated with an increased relatively low phosphorus intake applies to men and women of all ages.
cardiovascular risk; into phosphate deficiency26,29.
Conversely, dairy products provide While calcium supplements in later
both calcium and phosphate. life have shown a small benefit on
bone mineral density30,31, calcium
supplements in vitamin D deficient
IOM* DIETARY REFERENCE INTAKES FOR CALCIUM individuals have not been shown to
reduce the risk of fracture27. Also,
Calcium calcium supplementation without
Life Stage Group Estimated Average Recommended Dietary vitamin D supplementation may
Requirement (mg/day) Allowance (mg/day) contribute to an increased risk
Infants 0 to 6 months - - of hip fracture27. Thus, vitamin
D supplementation plays a key
Infants 6 to 12 months - - role in bone health — calcium
1-3 years old 500 700 supplementation alone is insufficient
4-8 years old 800 1,000 to prevent fractures. The focus in
fracture prevention has therefore
9-13 years old 1,100 1,300
shifted to vitamin D supplementation
14-18 years old 1,100 1,300 in combination with a healthy calcium-
19-30 years old 800 1,000 rich diet. See table on left
31-50 years old 800 1,000
Notably, these recommendations
51-70 year old males 800 1,000 of total calcium intake do not take
51-70 year old females 1,000 1,200 additional vitamin D supplementation
>70 years old 1,000 1,200 into consideration. As discussed in the
text above, individuals who have more
14-18 years old, pregnant/ 1,100 1,300 vitamin D are able to absorb more
lactating calcium. Therefore, in combination
19-50 years old, pregnant/ 800 1,000 with vitamin D, a lower total calcium
lactating intake of about 800 mg per day is
* Institute of Medicine of the National Academies in the USA likely sufficient. This is the amount
**For infants, Adequate Intake is 200 mg/day for 0 to 6 months of age and 260 mg/day for 6 to of calcium that can be achieved by a
12 months of age. healthy diet that contains a daily dose
of calcium-rich foods.
7
PROTEIN
HOW DOES PROTEIN IMPROVE protein intake may have a positive intake has been shown to increase the
BONE HEALTH? influence on bone and muscle health benefit of exercise on bone mineral
is via an increase in blood levels of content43, confirming that the benefit
Protein is a building block for strong Insulin-like Growth Factor -1 (IGF-1). of staying active for stronger bones is
bones and muscles. Similar to Regular daily milk intake results in a enhanced with protein-rich nutrition.
calcium and vitamin D, insufficient measurable increase in IGF-1 blood
protein intake is detrimental to levels in children40. This may also be ARE THERE ADVERSE EFFECTS
bone development32 and bone mass achieved with protein supplements OF A HIGHER PROTEIN INTAKE
maintenance later in life33-36. As well, a as demonstrated in one study among ON BONE HEALTH?
low protein intake is associated with a senior hip fracture patients35. IGF-1,
reduction in muscle mass throughout produced by the liver, promotes bone Some studies have claimed that a
the life cycle and seniors with decreased and muscle formation, and supports high protein intake may contribute to
protein intake are more vulnerable to the conversion of vitamin D into its increased calcium loss via the kidneys
muscle weakness, sarcopenia (age- active form (1,25-dihydroxyvitamin D)41. and have suggested that a protein
related decline in muscle mass and rich diet may be detrimental for bone
function) and frailty, all contributing to The latter mechanism (via vitamin health. This hypothesis has been
an increased risk of falling37-39. D) explains in part how a higher disproved as the increased calcium
protein intake promotes calcium and excretion after a protein-rich meal does
As with vitamin D, protein intake phosphate uptake in the intestine. In not contribute to a negative calcium
has a dual benefit on osteoporosis addition, some amino acids (protein balance44. Furthermore, it could not
prevention, as it helps build stronger components) have a direct stimulatory be confirmed that animal proteins, by
bones and muscles. One of the effect on calcium uptake in the increasing the acid load in our body,
mechanisms by which a higher intestine42. In children, a higher protein lead to bone loss. In fact, there is no
Low protein intake is associated
with a reduction of muscle mass
throughout the life cycle
8
embrace protein rich foods
convincing evidence that plant protein
sources are superior to animal protein
sources44. Both plant and animal
protein sources appear to promote
stronger bones and muscles for
osteoporosis prevention.
SOURCES OF PROTEIN
Dairy products are a good dietary
source of protein necessary for
stronger bones and muscles.
Additional protein sources include PROTEIN BENEFITS SPECIFIC trials with protein supplementation in
nuts, legumes, fish and meat. The TO SENIORS AT RISK OF HIP senior hip fracture patients resulted
current Recommended Daily Allowance FRACTURES in fewer deaths, shorter hospital stay,
(RDA)* is 1.5 g/kg each day in infants, and a higher likelihood of return to
1.1 g/kg each day in children age Elderly hip fracture patients are the independent living35,47,48. In one of
1 to 3 years, 0.95 g/kg each day most vulnerable to malnutrition and these studies it was demonstrated that
in children age 4 to 13, 0.85 g/kg protein deficiency. Low protein intake, blood IGF-1 levels increased in seniors
each day in teens age 14 to 18, and like vitamin D deficiency, contributes who received protein supplements35.
0.8 g/kg per day for adults aged 19 to an increased risk for hip fracture36,45, Furthermore, increasing protein
and older. Notably, based on recent although a higher milk intake did not intake has a beneficial effect on bone
epidemiological and clinical studies, a reduce the risk of hip fracture in a mineral density in senior men and
protein intake higher than the current summary of available data from large women taking vitamin D plus calcium
RDA (1.0 to 1.2 g/kg per day) may be cohort studies among women, while supplements, suggesting an additive
beneficial for bone and muscle health a benefit among men could not be benefit of these nutrients49.
among the senior population39. excluded46. Notably, several clinical
PROTEIN SOURCES
Food Protein (g)
1 ounce meat, fish, poultry 7
1 large egg 6
4 ounces milk 4
4 ounces low-fat yoghurt 6
4 ounces soy milk 5
3 ounces tofu, firm 13
1 ounce cheese 7
1/2 cup low-fat cottage cheese 14
1/2 cup cooked kidney beans 7
1/2 cup lentils 9
1 ounce nuts 7
2 tablespoons peanut butter 8
1/2 cup vegetables 2
1 slice bread 2
1/2 cup of most grains/pastas 2
*Recommended Daily Allowances; US Department of Agriculture
9
OTHER LIFESTYLE FACTORS THAT
NEGATIVELY IMPACT ON BONE
HEALTH
There are other important lifestyle factors that impact negatively on bone health. These include
smoking, excessive alcohol and low body mass index.
ALCOHOL
Studies have shown that more than two units of alcohol per day can increase the risk of osteoporotic
and hip fractures in both men and women50. More than four units of alcohol per day can double the
fracture risk. While some of this increased risk is due to decreased bone mineral density, some of the
risk is also due to other poorly understood factors, which may include general deterioration of health
and the increased likelihood of falling, especially in the elderly51.
SMOKING
Smoking also increases the risk of osteoporotic fractures52. Studies of nearly 60,000 people in
Canada, U.S.A., Europe, Australia and Japan show that smoking increases the risk of hip fracture by
up to 1.8 times52. Conversely, the risk of hip fracture declines after smoking cessation53. Although
the risk of fracture from smoking increases with age, cigarette smoke has an early effect on
bones. Studies have shown that young male smokers, 18-20 years old, have reduced bone mineral
densityand an increased risk of osteoporosis later in life 54,55.
LOW BODY
MASS INDEX
The body mass index, or BMI, is a measure of how lean someone is and can be used as a guide
to measure his or her osteoporosis risk56. A BMI of 20 to 25 is generally considered to be ideal. BMI
below 19 is considered underweight and a risk factor for osteoporosis.
10VITAMIN D embrace vitamin D
HOW DOES VITAMIN D • it improves strength and thresholds, a similar distribution is
IMPROVE BONE HEALTH? function61, increases bone mineral found in children.
density24, and reduces the risk
Vitamin D is essential for bone of falls and fractures by about Most vulnerable to vitamin D
development and maintenance 20%, including fracture of the deficiency are:
throughout life. Vitamin D has several hip (based on evidence from
key functions: clinical trials of oral vitamin D • seniors in general and especially
supplementation60,62) those living in nursing homes or
• it assists in calcium absorption22 institutionalized care
VITAMIN D DEFICIENCY
• it has a downward regulatory effect • individuals living in northern
on parathyroid hormone level23 Prevalence latitudes with minimal sunshine
resulting in reduced bone loss57 exposure
Depending on the threshold (see
• it ensures correct renewal and Thresholds on page 12) it has been • individuals who are obese
mineralization of bone58 established that 50 to 70 percent of
the European and 30 to 50 percent of • individuals who have a
• it has a direct stimulatory effect the US adult population is vitamin D disease that reduces vitamin D
on muscle tissue59 and thereby deficient. When applying the same uptake from the intestine (i.e.
reduces the risk of falling60 inflammatory bowel disease)
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11• individuals who have a darker for optimal bone health (hip bone supplementation at a dose of 700 to
skin tone density – data in younger, middle- 1000 IU per day reduces the risk of
aged, and senior adults73, fracture falls60 and fractures62 by about 20%,
• individuals who for medical or prevention – data in senior adults62).
cultural reasons cannot expose Based on large cohort studies, • and the safety of such a
their skin to the sun additional safety advantages of recommendation74.
reaching the desirable threshold
Definition of 75 nmol/l include a reduction in Therefore, measurement of serum
cardiovascular risk and colo-rectal 25-hydroxyvitamin D level in the
Defining universal diagnostic cancer74. These additional benefits blood to evaluate vitamin D status
thresholds of vitamin D status is of vitamin D need to be confirmed in should be targeted to individuals at
complicated due to the lack of large clinical trials. risk for severe vitamin D deficiency
standardized testing methods and See table below and the potential need of larger
the variability across population vitamin D doses to correct their
groups. However, as a general Who should be tested for deficiency. Individuals who:
guidance, vitamin D deficiency vitamin D deficiency with
can be defined as a 25(OH)D a 25-hydroxyvitamin D • have a minimal trauma fracture
level of less than 50 nmol/l (< 20 measurement?
ng/ml) , where increased bone • have dark skin tone
resorption and increased parathyroid We can assess vitamin D status by
hormone (PTH) levels have been measuring 25-hydroxyvitamin D in • are obese
documented. Levels lower than 25 the blood. International guidelines
nmol/l (< 10 ng/ml) are considered recommend this measurement should • are taking anti-epileptic drugs
severe deficiency, and can induce not be used as a screening tool in a
adverse effects such as rickets in large majority of the population, but • have malabsorption
infants and osteomalacia in adults. should be targeted to those at risk
Between 50 and 74 nmol/l (20–29 for severe vitamin D deficiency that • have medical conditions that
ng/ml), vitamin D levels are not may need greater doses of vitamin D prevent them from going into the
considered optimal and therefore than recommended at the population sun without protection
termed insufficient. In this range, level. In people with osteoporosis, a
PTH levels may be in the normal 25-hydroxyvitamin D measurement • cover most of their body for
range, but fracture risk reduction is advised. People at risk of cultural or religious reasons
may not be achieved. Vitamin D osteoporosis and generally everyone
adequacy is defined in adults as a aged 60 years and older are advised We do not recommend broad
threshold of at least 75 nmol/l (30 to take vitamin D supplements at a population screening for vitamin D
ng/ml), the threshold where fracture dose of 800 – 1000 IU per day based deficiency in individuals who are not at
risk reduction was achieved in on the 2010 IOF Position Statement risk because the prevalence of vitamin
randomized controlled trials62. on vitamin D75. D insufficiency is high and the cost of
screening far exceeds the minimal cost
Vitamin D adequacy needs to be This recommendation is based on: of supplementation.
established in children, however in
younger (age 19-49),middle-aged • the broad deficiency of vitamin D,
(age 50-64) and senior adults (age
65+) most data suggest that a level • the evidence from clinical trials
of no less than 75 nmol/l is needed that showed that vitamin D
OVERVIEW OF VITAMIN D THRESHOLDS
< 25 nmol/l (< 10 ng/ml) = severe deficiency
25 - 49 nmol/l (10 -19 ng/ml) = deficiency
50 -74 nmol/l (20 -29 ng/ml) = insufficiency
75 - 110 nmol/l (30 - 44 ng/ml) = adequacy
12IOF vitamin D recommendations are
SOURCES OF VITAMIN
D – SUNLIGHT, FOOD,
800 to 1000 IU/day for fall and fracture SUPPLEMENTATION
Sunlight
prevention in adults aged 60 and older
The main source of vitamin D is
sunlight (UVB irradiation). Our skin
can make vitamin D from exposure
Why seniors are most reasons and decreasing protein to sunlight. However, for the reasons
vulnerable to vitamin D intake with age). outlined below, sunlight is not a
deficiency reliable source of vitamin D and there
Why children and younger adults are also associated risks of skin ageing
Vitamin D deficiency is very common in are at risk of vitamin D deficiency and cancer.
the elderly. The reasons for this are:
• The average person exposes only Reasons why sunshine exposure is
• In the elderly, the skin produces about 5% of their skin to the sun. not a reliable source of vitamin D
4-times less vitamin D when
exposed to the sun, as compared • Nowadays, most people are • All of Europe (and in many other
to younger people. aware of the dangers of sunburn parts of the globe...) does not get
and skin cancer and wear sun sufficient UVB irradiation intensity
• Seniors tend to avoid direct protective clothing and sunscreen. during the months November
sunshine exposure – avoiding However, a sunscreen of factor 6 to end of March, allowing for
the hot weather by staying cool already blocks most of the vitamin minimal skin production of vitamin
at home or using sun protective D production in the skin. D independent of age during the
measures such as wearing a hat winter season. Notably, at latitudes
and sunscreen. • In today’s society, children tend to of above and below 33° , vitamin
spend less time playing outdoors. D synthesis in the skin is low or
• Seniors generally have a The majority of adults work absent during most of the winter.
decreased consumption of fish indoors, for example in offices, This area includes all of Europe
(possibly driven by economic stores or factories. (and also the Mediterranean).
13• As the half-life of vitamin D is 3 to with a 4-times lower capacity to independent of age64,65. Several
6 weeks, there is a seasonal peak produce vitamin D in their skin studies have shown that clothing
of vitamin D status in northern compared to younger adults63. worn for cultural or religious
latitudes in September, followed by Further, seniors tend to avoid reasons can have an adverse effect
a rapid decrease, with the lowest direct sun exposure which on vitamin D status and bone
point beginning in November explains the large segment of health66. A sunscreen factor of 6
and reaching an all-time low in seniors with vitamin D deficiency already blocks most of the vitamin
early spring. Thus, even if we residing in southern areas with D production in the skin65. Solar
get sufficient vitamin D during ample sunshine availability elevation angle (i.e. time of day),
the summer, this may not secure (e.g. Mediterranean, Northern cloud cover, air pollution, altitude,
vitamin D status in the winter Australia). and surface reflection have an
months and early spring time. impact on vitamin D production in
• The use of sunscreen and sun the skin67. Exposure measurements
• Skin production of vitamin D protective clothing reduces are related to a horizontal plane,
declines with age, leaving seniors skin production of vitamin D while vertical surfaces such as the
Natural Nutritional Sources of IU vitamin D
Vitamin D
Wild salmon 600 to 1000 IU per 100 grams
Farmed salmon 100 to 250 IU per 100 grams
Sardines, canned 300 to 600 IU per 100 grams
Mackerel, canned 250 IU per 100 grams
Tuna, canned 236 IU per 100 grams
Cod liver oil 400 to 1000 IU per table spoon
Shiitake mushrooms, fresh 100 IU per 100 grams
Shiitake mushrooms, sun dried 1600 IU per 100 grams
Egg yolk 20 IU/yolk
14face, arms and legs receive much fortification. Vitamin D that is taken fall and fracture reduction without
lower UVB doses compared to a orally as a supplement is best absorbed prior testing for vitamin D deficiency.
horizontal plane. Thus, in practice if taken with food as it is a fat-soluble Thus, both institutions have similar
much longer exposure times than vitamin72. When compared in clinical recommendations on the dose of
expected are needed to produce trials, vitamin D3 has been shown to vitamin D as this reflects the vitamin
a certain amount of vitamin D. be more efficient than vitamin D2 in D doses tested in clinical trials,
The UVB exposure time needed to reducing falls60 and fractures62. however, they differ in their threshold
produce 800 IU vitamin D differs recommendation. For osteoporosis
by skin type and season. For an Natural nutritional sources of vitamin prevention and the prevention of falls
8% body surface exposure (face D are limited. Larger amounts are only and fractures, the higher threshold
and hands) during midday the present in fatty fish, such as salmon72. of 75 nmol/l is recommended by this
exposure time will vary between See table on previous page report. See table below
about 30 minutes to 1 hour in the
summer time, and up to about 20 Vitamin D supplementation and Safety of vitamin D
hours in the winter 68-70. recommendations supplementation
Nutritional sources of vitamin D There are two international Vitamin D is a fat soluble vitamin.
recommendations regarding vitamin Therefore very high doses may lead
Food sources of vitamin D are rather D that are relevant to the population to intoxication. A safe upper intake
limited, and include fatty fish, such as at large and individuals at risk of level has been defined for all age
salmon, mackerel, and herring. Farm osteoporosis. For the population at groups76. The safe upper limit intake
salmon will provide only half as much large the Institute of Medicine of the recommendation is 1000 IU/day from 0
vitamin D as wild salmon71. We would National Academies in the USA (IOM) to 6 months, 1500 IU/day from 6 to 12
have to eat two servings of fatty fish a defined vitamin D recommendations months, 2500 IU from age 1-3 years,
day to reach a recommended intake of throughout the life cycle with the 3000 IU from age 4-8 years, and 4000
800 IU vitamin D per day for fracture goal to reach a 25-hydroxyvitamin IU from age 9 and older, including
reduction72. Additional sources are D threshold of about 50 nmol/l (see pregnant and lactating women.
eggs and liver (1 egg contains about recommendations below)76. The IOM
40 IU of vitamin D). Some countries recommends 600 IU vitamin D per day In a 2010 benefit-risk assessment
fortify margarines and milk with in all individuals age 1-70, and 800 IU of vitamin D the authors found no
vitamin D. For example, in the USA, in adults age 71 years and older. pattern of evidence to suggest that
one glass of milk is fortified with 100 risk (hypercalcemia – increased blood
IU vitamin D. The IOF had a different target calcium levels) is elevated from daily
in their 2010 position paper for intakes of vitamin D up to 10,000 IU or
Vitamin D comes in two forms. vitamin D, designed to ensure serum 25(OH)D up to 240 nmol/L74,
Vitamin D3 (cholecalciferol) is the optimal fall and fracture reduction75. which are far higher intakes and
version of vitamin D that is made in Based on this target, IOF defined blood concentrations than those
our skin and found in fatty fish and a 25-hydroxyvitamin D threshold necessary to achieve the benefits for
eggs. Vitamin D2 (ergocalciferol) is of 75 nmol/l. Given the broad bone and muscle strength (800 IU
a closely related molecule of plant prevalence of vitamin D deficiency, vitamin D intake per day and target
origin. Both vitamin D2 and vitamin D3 IOF recommends 800 to 1000 IU in 25-hydroxyvitamin D blood level of
are used in supplements and for food all adults at 60 years and older for 75 nmol/l).
Age Group in Years Public Intake Recommendations Public Intake Recommendations
for Vitamin D for Vitamin D
Institute of Medicine IOF
0-1 * Not assessed
1-59 600 IU/day Not assessed
60-70 600 IU/day 800 to 1000 IU/day
71+ 800 IU/day 800 to 1000 IU/day
Target 25(OH)D level in nmol/l 50 nmol/l for bone health in all ages 75 nmol/l for fall and fracture
prevention
*adequate intake is 400 IU/day
IOF includes all individuals with osteoporosis independent of age and states that higher intake levels may be needed in some individuals
to reach a serum blood level of 75 nmol/l 25(OH)D
15KEEP MOVING: Exercise & bone
Our skeleton is sensitive to gravity and Measurable differences in fracture have shown that the most physically
weight-bearing physical activity as a risk are also observed between those active young girls gain about 40%
stimulus to maintain and build bone habitually active (non-athletic) and more bone mass than the least active
and prevent muscles from wasting. sedentary individuals81. girls of the same age. Other studies
HOW DOES PHYSICAL
ACTIVITY IMPROVE BONE
HEALTH?
Studies confirm a benefit of exercise
It is thought that exercise, especially
during childhood and adolescence,
may change bone structure and on BMD, muscle strength and the
geometry (such as greater diameter
of bones and stronger trabecular
architecture), which may reduce prevention of falls
the risk of fracture later in life77.
Throughout the life cycle, there
is a strong positive relationship
between physical activity and bone
health. Being active benefits bone THE IMPORTANCE OF PHYSICAL have shown that boys who did the
and muscle strength regardless of ACTIVITY IN YOUTH most vigorous daily activity had 9%
age1,78. In contrast, immobilization of more bone area and 12% more bone
the skeleton (in the form of bed rest, Laying down the ‘bone foundation’ strength than less active boys81.
casting or spinal cord injury) leads in youth gives advantages later in life.
to bone loss, muscle wasting, and Most people reach their ‘peak bone The concern is that, with the advent of
increased susceptibility to fracture mass’ in their 20s. This is when bones computers, TV and electronic games,
within a few weeks79. A perfect have achieved their maximum density many children and teenagers are living
example of unloading of the skeleton and strength. For example, in girls, the increasingly sedentary lifestyles. To
can be seen with astronauts, who bone tissue accumulated during the ensure that their children are getting
lose considerable bone and muscle ages 11 to 13 approximately equals enough exercise, parents need to
mass due to prolonged periods of the amount of bone lost during the 30 encourage daily weight-bearing
weightlessness in space. years following menopause. Studies physical activities and sports.
The rapid bone loss with
immobilization mimics many years of
‘ageing’ and may help us understand
how detrimental inactivity is to our
bones and how important it is to
maintain a physically active lifestyle.
Clinical studies which compare
individuals who exercise with groups
who do not have demonstrated
significantly higher BMD in those who
exercise regularly80. Exceptions occur
with high-intensity non weight-bearing
activities, such as swimming, and in
amenorrhoeic athletes (hormonal
changes due to high-intensity
sportive activities), who may have a
BMD similar or worse than controls.
16embrace an active lifestyle
LIFETIME PHYSICAL ACTIVITY bearing aerobic exercise (such as • Effective activity does not have to be
AND PRESERVATION OF BONE brisk walking, hiking, stair climbing weight-bearing. Resistance training
HEALTH AT OLDER AGE or jogging), high intensity progressive (lifting weights) is an effective non
resistance training (lifting weights) weight-bearing activity.
Several observational studies support and high impact exercise (such as
a beneficial association between jumping or rope skipping) increase • Aerobic activity that is non
a greater lifetime physical activity BMD by 1 to 4% per year in pre- and weight-bearing (such as
and preservation of BMD, as well postmenopausal women84. More swimming or cycling) does not
as a lower risk of hip, humerus and vigorous exercise interventions seem enhance bone density.
vertebral fracture, at older age1,82. It to produce greater effects84. It should
was also suggested that exercising be noted that casual walking may not • Lifting heavy weights is more
prior to age 40 is associated with a reduce fracture risk. However, a large effective than lifting light weights.
lower risk of falling in seniors83. Thus, cohort study supports a benefit of
we get rewarded for being active brisk walking on reducing the risk of • Lifting heavy weights rapidly
when we were young even much later hip fracture (more than 4 hours a week (power training) seems to be
in life. may reduce hip fractures by 41%1). more effective than lifting heavy
weights slowly (traditional
WHICH EXERCISE PROGRAMMES FACTS ABOUT EXERCISE AND resistance training).
ARE EFFECTIVE? BONE HEALTH85
• Rapid movements are more
While we lack evidence from • Rapid, short bursts of high stimulating than slow movements.
large trials that test exercise in the intensity and/or high impact
prevention of fractures, several studies activities such as jogging, jumping • Muscles connected to the bones
confirm a benefit of exercise on BMD, and rope skipping are more that are most susceptible to
muscle strength, and the prevention stimulating to bone cells than fracture (hip, wrist, thoracic
of falls. Based on these studies78, sustained, low impact activity such spine) should be targeted with
moderate to high intensity weight- as walking. specific exercises.
SIMPLE STEPS TO KEEP MOVING!
Staying active by brisk walking or other weight-bearing physical activities directly addresses key risk factors for osteoporotic
fractures. These include low bone mineral density, muscle weakness, poor balance, falling and fear of falling. The first
step is to overcome being inactive - in your daily life. Include simple strategies to keep moving!
1
Take the stairs instead of
the elevator.
2
Walk small distances
instead of relying
3
Make it a habit to go for
a walk (or some other
4
Stand on one leg while
performing tasks of daily
on the car or public activity) each day – set living: i.e. while brushing
transportation. daily and weekly goals. your teeth, waiting for
the coffee machine,
washing up.
17EXERCISE PRECAUTIONS IN • insert a few jumps during Strengthening the upper extremities is
PEOPLE WITH DIAGNOSED television commercials. also important for falls prevention.
OSTEOPOROSIS AND
FRACTURES • jump or hop rather than walk up a Notably, these exercise programmes
flight of stairs. are effective in seniors living in the
• With existing osteoporosis, community and those living in nursing
caution should be applied with • stand on one leg while washing care. Further, recent studies suggest
activities and sports that have the the dishes or while you wait for that instructed but unsupervised
potential of severe injury, such the coffee machine. exercise programmes are effective and
as ice skating, downhill skiing, demonstrate a significant reduction
mountain biking. • use stairs instead of elevators. of falls, both in seniors living in the
community86 and seniors with an acute
• People at risk for osteoporotic • walk briskly for 10 minutes or hip fracture87.
fracture should avoid deep more several times a day.
backbends and activities that
involve forward bending of the
spine, particularly while carrying
an object (for example, lawn
bowls, sit ups with straight legs
or simply bending over to pick
up something from the floor), as Weight-bearing exercise programmes
this movement in the presence of
osteopenia increases the risk of
anterior compression fractures of that improve gait speed, muscle strength
the thoracic vertebrae.
• Involve a health care professional and balance in seniors can translate into
(your doctor, physiotherapist,
exercise physiologist) in your
exercise programme design as a 25-50% reduction in falls
supervised, targeted exercise
programmes are recommended.
• Programmes that include muscle
strengthening, balance training
and coordination exercises are
highly recommended. EXERCISE BENEFITS ON FALLS Tai Chi has been successful in reducing
PREVENTION falls among healthy older individuals,
• In frail seniors with poor balance, and physically inactive community-
mobilization without balance and Many studies demonstrate that simple dwelling older individuals, while frail
strength training may increase the weight-bearing exercise programmes older individuals and fallers may not
risk of fracture. Thus, mobilization improve gait speed, muscle benefit as much. Programmes that
should be supervised by strength, and balance in seniors, support cognitive function within an
physiotherapists and supported by which translates into a 25-50% fall exercise programme may be of great
strength and balance training. reduction2,3,4. As falls are the primary value for fall prevention. Earlier studies
risk factor for fractures, the rationale suggested that fall risk is increased
ADD EXERCISE TO YOUR DAILY is that these interventions should also in seniors unable to walk while
ACTIVITIES protect against fractures, although this talking (stop walking when talking –
needs confirmation in large clinical reduced ability to perform two tasks
Find ways to incorporate short exercise studies. The recommendation is that simultaneously). This concept was
intervals into normal daily activities. exercise programmes for fall and tested in a music-based multitask
For many people, this may be more fracture prevention should include exercise programme, which improved
successful than planning structured balance training and lower and gait and balance and reduced fall risk
exercise classes away from home. upper extremity strength training. in community-dwelling seniors4.
18EXAMPLES OF EXERCISE PROGRAMMES
THAT ARE SUCCESSFUL IN INCREASING
BONE DENSITY
1
about 50 jumps (approximately
8 cm high) three to six days per
2
two or three sets of 8 to 10
repetitions of each of 6 to 8
3
45 to 60 minutes of weight-
bearing aerobic exercise three
week. weight lifting exercises three days per week (i.e. brisk
days per week. walking)
19LOVE YOUR
BONES EXERCISE
• Move it or lose it! Longer term
immobilization, such as through
bed rest, leads to rapid bone
loss and increased susceptibility
to fracture.
FAST FACTS
• Studies comparing groups of
individuals who exercise compared
to those who don’t have
demonstrated higher BMD in the
athletic group.
NUTRITION & EXERCISE: • Exercising prior to age 40 is
associated with a lower risk of
THE BUILDING BLOCKS falling in seniors.
FOR HEALTHY BONES • Moderate to high intensity
weight-bearing aerobic exercise,
high intensity progressive
resistance training (lifting weights)
and high impact exercise (e.g.
jumping or rope skipping) has
embrace an active lifestyle
been shown to increase BMD
by 1 to 4% per year in pre- and
postmenopausal women.
• Rapid, short bursts of high
intensity and/or high impact
activities such as jogging, jumping
and rope skipping are more
stimulating to bone cells than
sustained, low impact activity
such as walking. Aerobic activity
that is nonweight-bearing (such
as swimming or cycling) does not
enhance bone density.
• Simple targeted exercise
programmes have been shown to
improve bone density and functional
mobility, result in 25 to 50% fewer
falls in frail and active older adults.
• Mobilization in frail seniors should
be supervised and supported by
strength and balance training.join our unbreakable embrace
www.worldosteoporosisday.org
World Osteoporosis Day 2011 is supported by these Global Sponsors
CALCIUM & VITAMIN D
PROTEIN • Vitamin D assists calcium
absorption and has a direct effect
• Calcium is a key structural on muscle.
component of bone.
• Vitamin D deficiency is common
•
Show your support for
Natural calcium sources, such as
dairy products, sardines and nuts,
and a healthy nutrition cannot
compensate deficiency.
people with osteoporosis
are preferred calcium sources and
also provide high-quality protein. • Above and below latitudes of
approximately 33°, vitamin
• This silent
Individuals whodisease threatens
have more vitamin our health, D synthesis in the skin is low
happiness and independence as we
D are able to absorb more calcium. or absent during most of
Therefore, in combination with the winter (which includes
age.
vitaminDoD, asomething
minimum totalabout
calciumit! 10 to 15 all of Europe, including the
minutes of safe
intake of about sunshine
800 mg per day is a day, a Mediterranean area).
likely sufficient in most individuals.
balanced diet rich in calcium and daily.
This amount of calcium can be • Skin production of vitamin D
achieved by a healthy diet that declines with age, leaving seniors
find out how to get involved at:
contains a daily dose of calcium-
rich foods.
with a 4-times lower capacity to
produce vitamin D in their skin
www.worldosteoporosisday.org compared to younger adults.
• Calcium supplements should
embrace calcium rich foods
be combined with vitamin D for • Evaluation of vitamin D status
optimum effect. World Osteoporosis Day 2011 is supported by these Global Sponsors
should only be targeted to
individuals at risk for severe
• Both plant and animal protein deficiency: people who have
sources appear to promote stronger suffered a minimal trauma
bones and muscles for osteoporosis fracture, have dark skin tone,
prevention. are obese, have malabsorption,
embrace vitamin D
have medical conditions which
• In children, a higher protein intake has prevent them from going
been shown to increase the benefit of outdoors without protection
exercise on bone mineral content. or cover most of their body for
cultural or religious reasons.
• Seniors with decreased protein
intake are more vulnerable to • Vitamin D supplementation has
muscle weakness, sarcopenia, been shown to reduce the risk of
and frailty, all contributing to an falls and fractures by about 20%,
increased risk of falling. including fractures of the hip.
• Several clinical trials with protein • IOF recommends vitamin D
supplementation in senior hip supplementation for people at
fracture patients resulted in fewer risk of osteoporosis and generally
deaths, shorter hospital stay, and everyone aged 60 years and older
a higher likelihood of return to (recommendation: 1000 IU
independent living. vitamin D per day).REFERENCES
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