Lifestyle for healthy bones

How to keep your bones strong during the menopause

• Bone density naturally decreases from your late 30s but falling oestrogen levels speed up the decline
• Keeping active and exercising can strengthen your bones
• Learn what to eat to rebuild bones and what to limit or avoid

Our bones are made up of a type of connective tissue. This tissue contains cells, collagen fibres, blood vessels and minerals such as calcium and phosphorus. These help the 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 naturally decrease. This loss of bone density makes your bones weaker, less pliable and therefore more susceptible to breaking.

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What’s the link between bone health and menopause?

Women are more affected by a loss of bone strength in the years before, during, and after the menopause, as oestrogen (the key hormone for protecting and maintaining bone density) rapidly declines during this time. Your bone is breaking down at a faster rate than your body can grow new bone tissue.

To build and strengthen your bones plus encourage bone repair it’s important to eat a healthy, well-balanced diet and live an active life involving exercise. This will help reduce the risk of injury to your bones, often as a result of a fall, and reduce the chance of a bone break if an accident does occur.

One in three women over 50 years old will sustain a fracture to the hip, for example, and this can have serious consequences to your health. Even after the initial recovery, a hip fracture can affect your ability to carry out daily activities such as eating, dressing, washing or shopping; 40% of women who fracture their hip are not able to walk again without an aid or assistance – the physical and psychological impacts 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 [1].  

What is osteoporosis?

Osteoporosis is when the loss of bone density is severe and there is a greater risk of bones breaking. It develops slowly over several years and is often only diagnosed when a fall or sudden 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 means you are more susceptible to bone weakening but other factors will increase your chance of having osteoporosis too. Smoking and heavy drinking damages your bone-building cells, a diet lacking the important nutrients calcium and vitamin D does not give your bones what they need to grow new bone tissue and women over 50, who do not take HRT, have inadequate levels of oestrogen in the body to protect the bones from deterioration.

If your doctor suspects you have osteoporosis, they can work out your future risk of breaking a bone using an online programme such as FRAX or Q-Fracture. They may also refer you for a bone density scan to measure your bone strength, known as a DEXA scan.

Do I need a DEXA scan?

This non-invasive scan uses radiation (a much lower dose than a standard X ray) to measure bone density. The scanner can use the bone density measurement to compare against people of the same age and sex, 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 arthrititis, ave been on oral steroids for more than three months, had the menopause under 45 years due to natural onset, surgery, or treatments for cancer, have large gaps (of more than a year) between periods, if you are postmenopausal 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.

The best exercise for your bones

Bones get 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 follow government guidelines of performing 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 [2]. The Royal Osteoporosis Society provides detailed information on exercising for bone health [3].

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.

Food for your 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.

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. National Osteoporosis Guideline Group recommends vitamin D is consumed from foods and vitamin D supplements of at least 800IU/day if patients have an identified vitamin D insufficiency or risk factors for vitamin D insufficiency [5]. 

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 begins to return to normal.

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.

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HRT can help prevent and repair bone loss and reduce the risk of fractures by 50%. This is because oestrogen slows down the rate of bone loss and promotes new bone growth.

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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.

References

1. Falchetti A., Mohseni M., Tramontana F., Napoli N. (2021), ‘Secondary prevention of fragility fractures: where do we stand during the COVID-19 pandemic?’ J Endocrinol Invest, Nov; 44(11):2521-2524. doi: 10.1007/s40618-021-01552-1

2. NHS.uk (2021) ‘Physical activity guidelines for adults aged 19 to 64’

3. Royal Osteoporosis Society ‘Osteoporosis: Exercise for bone health’

4. Gambacciani M., Levancini M. (2014), ‘Hormone replacement therapy and the prevention of postmenopausal osteoporosis’, Prz Menopauzalny. 13(4):213-20. doi: 10.5114/pm.2014.44996

5. National Osteoporosis Guideline Group UK (2021) ‘Clinical guideline for the prevention and treatment of osteoporosis’