Bone health is influenced by much more than just calcium intake and is critical to healthy aging and long-term health. Peak bone mass is typically reached by age 17 in females and 21 in males, with 95% of adult bone mass formed by these ages.¹ After age 30, bone mass gradually decreases, influenced by both genetics and lifestyle factors like diet, physical activity, and hormone levels.¹ Failure to achieve peak bone mass in early adulthood increases the risk of bone density disorders, including early osteopenia or osteoporosis.¹ Osteopenia is a condition where bone density is lower than normal but not low enough to be classified as osteoporosis. Osteoporosis is a more advanced and progressive disease marked by significantly reduced bone mineral density, weakened bone structure, and a higher risk of fractures.^1-3

Bone is not a static structure; it is a highly dynamic and metabolically active tissue constantly undergoing remodeling through tightly regulated formation and resorption processes.⁴ Bone not only provides mechanical support and organ protection but also serves as a reservoir for essential minerals, maintaining calcium and phosphate balance in the body. Disruptions in this continuous remodeling process can impair bone strength and structure, contributing to disease and increased fracture risk. Dietary deficiencies in calcium and vitamin D, along with a sedentary lifestyle, smoking, excessive alcohol use, and long-term use of certain medications (such as steroids, cancer therapies, and antidepressants) are all factors that increase risk.²

Currently, 34 million Americans have osteopenia.¹ Women are disproportionately affected; 54% of postmenopausal women are osteopenic, and 30% are osteoporotic, with rates shifting further toward osteoporosis by age 80 and beyond.^1,3 Often asymptomatic until a fracture occurs, bone density problems such as osteoporosis are considered a “silent” disease with serious consequences.¹ Healthcare providers play a pivotal role in early identification, prevention, and management through risk assessment, lifestyle counseling, medication, and nutritional support.

Key Nutrients for Bone Health 

Nutrition plays a vital role in maintaining bone health across the lifespan. Emerging research highlights the importance of overall dietary patterns and specific nutrients like calcium, vitamin D, and phosphorus. A scoping review of 49 human studies showed that adherence to healthy, nutrient-rich eating patterns such as the Mediterranean diet or the Healthy Eating Index (HEI) (emphasizing fruits, vegetables, whole grains, lean proteins, legumes, nuts, and low-fat dairy) is associated with improved bone mineral density and reduced risk of osteoporosis and fractures.^5,6 In contrast, Western-style diets high in meat, fried foods, added sugars/sugar-sweetened beverages, and refined grains may negatively impact bone health.⁵ 

Studies clearly show that adequate protein, calcium, and vitamin D intake supports bone density.^6.7 Calcium and vitamin D work together to support bone health because vitamin D aids calcium absorption in the gut.^7.8 Inadequate levels of either nutrient can lead to reduced bone mineral density and increased risk of osteoporosis and fractures, especially in older adults.⁸  The National Institutes of Health recommends 1000mg of calcium for females and males 19-50 years, 1200mg for females 50 or older, and 1200 mg for all people 70 or older.⁹ Vitamin D serum levels are considered adequate for bone and overall health in healthy individuals at ≥50 nmol/L or ≥20 ng/mL and blood testing can help patients understand if the recommended dietary allowances (RDAs) of 600IU for people 51-70 years and 800IU for people 70 years and older is enough for them.¹⁰ 

While supplements may help deficient individuals, both animal and plant-based food sources like dairy, fish like salmon, fortified plant-based products, and plant sources of calcium (tofu, kale, spinach, chia seeds, beans) offer additional benefits by providing protein and other key nutrients.^7-9 Studies have shown that the positive effects of dietary protein on bone health appear to be dependent on sufficient calcium levels; protein, calcium, and vitamin D are closely intertwined when it comes to promoting strong bones.⁸

Nutrients like phosphorus, magnesium, vitamin C, and vitamin K are also essential for maintaining bone density and supporting bone formation, mineralization, and overall bone health.^6.7 Healthcare professionals should assess a patient’s diet to ensure they meet the recommended nutrients through food and/or dietary supplements. Flavonoid polyphenols found in fruits and vegetables, including compounds like quercetin, rutin, luteolin, kaempferol, and naringin, have also been shown to reduce the risk of osteoporosis through their antioxidant and anti-inflammatory properties.⁷

Emerging research suggests collagen supplementation may support bone health by improving bone mineral density and mass.¹¹ Human and animal studies indicate that collagen peptides may effectively help manage conditions like osteoporosis, though more research on dosing and timing is needed to make recommendations specifically for bone health.¹¹

Physical Activity for Bone Health

Physical activity is a critical modifiable factor for maintaining and improving bone health across the lifespan.¹² In children and adolescents, moderate to vigorous weight-bearing exercises (gymnastics, soccer, etc) are strongly associated with higher bone mineral density, improved bone structure, and long-term fracture prevention.¹² Although the impact of exercise on bone mineral density is less pronounced in older adults, even short durations of moderate to vigorous activity have been linked to better bone health scores and reduced osteoporosis risk.¹²

Weight-bearing and resistance exercises are the most effective for improving and maintaining bone mineral density, particularly in older adults. Activities such as jumping, jogging, aerobics, and weightlifting have shown the most significant benefits, while walking and swimming have little to no effect on bone mineral density.⁶ Aerobic and resistance training can enhance bone formation and reduce bone loss, especially when supported by adequate nutrition. For example, replacing sedentary time with physical activity in women aged 50-85 years (N=1052) has shown up to a 12% reduced risk of osteoporosis in the spine and decreased fracture risk.¹³

Takeaways for Healthcare Providers

Client bone health should be addressed across the lifespan with a comprehensive, individualized approach. Healthcare providers can encourage patients to consume a nutrient-dense diet beyond calcium, emphasizing overall dietary quality to support bone metabolism and work with each individual to assess their diet for possible deficiencies. Regular resistance and weight-bearing exercise at all ages is recommended to help preserve bone density, and health care professionals can help tailor fitness strategies based on each patient’s unique risk factors, health status, and life stage.

References:

1. Varacallo MA, Seaman TJ, Jandu JS, Pizzutillo P. Osteopenia. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2025. PMID: 29763053.
2. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Osteoporosis. National Institutes of Health. Reviewed December 2022. Accessed April 5, 2025. https://www.niams.nih.gov/health-topics/osteoporosis
3. Looker AC, Hamner HC. Osteoporosis or Low Bone Mass in Older Adults: United States, 2017–2018. National Center for Health Statistics Data Brief No. 405. Centers for Disease Control and Prevention. Published April 2021. Accessed April 5, 2025. https://www.cdc.gov/nchs/products/databriefs/db405.htm
4. Wawrzyniak A, Balawender K. Structural and metabolic changes in bone. Animals. 2022;12(15):1946.
5. Movassagh EZ, Vatanparast H. Current Evidence on the Association of Dietary Patterns and Bone Health: A Scoping Review. Adv Nutr. 2017;8(1):1-16.
6. Papadopoulou SK, Papadimitriou K, Voulgaridou G, Georgaki E, Tsotidou E, Zantidou O, Papandreou D. Exercise and nutrition impact on osteoporosis and sarcopenia—the incidence of osteosarcopenia: a narrative review. Nutrients. 2021;13(12):4499.
7. Martiniakova M, Babikova M, Mondockova V, Blahova J, Kovacova V, Omelka R. The role of macronutrients, micronutrients and flavonoid polyphenols in the prevention and treatment of osteoporosis. Nutrients. 2022;14(3):523.
8. Webster J, Dalla Via J, Langley C, Smith C, Sale C, Sim M. Nutritional strategies to optimise musculoskeletal health for fall and fracture prevention: Looking beyond calcium, vitamin D and protein. Bone reports. 2023 Dec 1;19:101684.
9. National Institutes of Health Office of Dietary Supplements. Calcium—Health Professional Fact Sheet. Updated July 24, 2024. Accessed April 6, 2025. https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/.
10. National Institutes of Health Office of Dietary Supplements. Vitamin D—Health Professional Fact Sheet. Updated July 26, 2024. Accessed April 10, 2025. https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/
11. Campos LD, Junior VD, Pimentel JD, Carregã GL, Cazarin CB. Collagen supplementation in skin and orthopedic diseases: A review of the literature. Heliyon. 2023 Apr 1;9(4).
12. Sheng B, Li X, Nussler AK, Zhu S. The relationship between healthy lifestyles and bone health: A narrative review. Medicine. 2021;100(8):e24684.
13. Ricci C, Gervasi F, Havemann Nel L, Smuts CM, Kruger SH, Leitzmann MF. Substitution of sedentary time with light physical activity is related to increased bone density in US women over 50 years old. An iso‐temporal substitution analysis based on the national health and nutrition examination survey. European journal of sport science. 2019;19(10):1404-13.