Your 6 must-know bone facts, and the action you need to take

Our experts:

• Sarah Leyland, Senior Clinical Advisor with the Royal Osteoporosis Society (ROS)
• Dr Animesh Singh, consultant rheumatologist 
• Jenna Hope, registered nutritionist 

How much thought do you give to your skeleton? For many of us, the first time we think about our bones is when we break one.

Indeed, most of us dismiss bone diseases such as osteoporosis as something that only affects menopausal and older women. However it affects many more of us than we think, with one in five men and half of women over 50 breaking a bone due to osteoporosis. Some people who take certain long-term medicines as a vital part of managing other health conditions, are also at risk of weakened bones.

It will probably be only if we experience repeated fractures that we realise that something is wrong - but by then action to help build up our bones is long overdue.

What we need to know is that the work of strengthening our skeleton begins in childhood and continues throughout our lives.

“People think that bones are dead, inert things. But they’re alive and living like any other organ,” says Sarah Leyland, Senior Clinical Advisor with the Royal Osteoporosis Society (ROS). “The bones themselves are made up of an outer shell and inside there is a honeycomb mesh structure, which is like a scaffolding. Bone cells wear away and rebuild as part of the normal turnover of bone, but sometimes this gets out of balance - more bone is worn away than rebuilt. We talk about osteoporosis as bone ‘thinning’ but it can be useful to think of the holes in that honeycomb mesh as getting bigger – more porous and less dense.”

Here’s our expert guide to adopting a bone-friendly lifestyle to keep breaks and fractures at bay at any age.

1. Childhood is crucial for your bones

“Childhood and the teen years are very important both in terms of bone health and also developing the habits that you carry into adult life,” says London-based consultant rheumatologist Dr Animesh Singh.

"Around 80 to 90 per cent of peak bone mass - the overall strength and density of your bones - is achieved by the time you’re leaving your teenage years. This is 18 for girls and 20 or 21 for boys.

When you enter adulthood, your bones are their most dense and strong. But to optimise that, you really need to be setting good habits early on,” he says.

What to do:

Healthy eating habits can have a huge part to play in bone health, according to registered nutritionist Jenna Hope (jennahopenutrition.com), and these can be established in childhood. “Protein, calcium, Vitamin D, phosphorus and magnesium all support our bone health.

“Eating a diet based around wholefoods is typically best for bone health. Try to avoid ultra-processed, high salt, high sugar foods as these types of diets can contribute to inflammation which can over time cause accelerated bone breakdown,” she says.
“Plant based and vegan diets can increase the risk of poor bone health. However, if you’re supplementing or consuming fortified dairy alternatives then it is possible to still support your bone health on these diets.”

She adds that it’s recommended for everyone to supplement with Vitamin D, which helps regulate the amount of calcium in the body, throughout the winter months. The NHS advises that children over the age of one and adults need 10 mcg of vitamin D a day. Being active, doing regular exercise – anything from team sports to swimming – is also key.

2. Hormones are bones biggest helpers

“Oestrogen in women is a really critical hormone in building and maintaining bone density,” says Dr Singh.

However, teenage girls’ oestrogen levels can be affected by several factors including eating disorders, excess exercise and stress.

“If a girl’s period is delayed or menstruation starts and then stops, that means oestrogen levels are lower and you’re not building up your bone density. So when it’s finally normalised, your body is playing catch up, laying down bone but at a slower rate.”

Then during menopause the drop in oestrogen speeds up bone loss, putting women over-50 at greater risk of developing osteoporosis.

What to do:

“There is a class of drugs called bisphosphonates which you can take as a tablet, injection or infusion,” says Sarah. These medicines slow down the cells that break down bone, helping bones stay stronger for longer. They’re mainly used to reduce the risk of fractures in conditions like osteoporosis.

The ROS advises that HRT may help to prevent osteoporosis in the years around menopause. “Women who have early menopause might take HRT to the age of 50 and then be reassessed,” adds Sarah.

3. Watch out for bowed legs in children

When children have a severe vitamin D and calcium deficiency they can develop the so-called ‘Victorian disease’ of rickets. This is a condition in which bones are weak and soft, causing legs to bow outwards and leave a wide gap between the knees.

There has been an increase in cases of rickets, which is linked with social deprivation, in the UK, according to NHS Wales. “The number of rickets cases is still relatively small, but studies have shown a significant number of people in the UK have low levels of vitamin D in their blood.”

What to do:

Treatment includes eating more calcium and vitamin-D rich food or taking supplements. Calcium is found in milk, cheese, yoghurt, green leafy vegetables and sesame seeds.

4. There are factors affecting your bones without you realising it

Genetics play a key role in your skeletal health. But there are other factors, more within your control, that also have a part to play – such as medication.

For instance, long-term use of corticosteroids – anti-inflammatory medicines used to treat illnesses including asthma and autoimmune conditions – can lower bone density. Sarah adds: “Breast cancer treatments that suppress residual hormones, the aromatase inhibitors, have a poor effect on bones.”

Undiagnosed coeliac disease, an autoimmune condition caused by a reaction to gluten, can also lead to osteoporosis because it reduces the gut’s ability to absorb calcium.

What to do:

Definitely don’t stop taking your medication, but have a conversation with your GP or specialist about how you can best support your bone health while you are taking them, advises Sarah. “This may include supplements, lifestyle changes, and, if needed, bone-strengthening medicines.”

“Check your risk,” says Dr Singh. “If you’re on long-term steroids, breast cancer treatments or have digestive issues, ask your doctor about your bone health.” He also advises having a bone density scan (DEXA) to show if your bones are weaker than they should be.

Getting enough calcium through dairy, green vegetables and fortified food and vitamin D, from sunlight and supplements, if needed are also paramount.

“Weight-bearing exercises like walking, jogging or resistance training help keep bones strong and avoid smoking and excess alcohol, as both weaken bones,” he says.

5. Signs of thinning bones are well-hidden

“Osteoporosis is a pain-free condition – you don’t feel that you’re losing bone,” says Sarah. However signs that you could have the condition include a curved spine, back pain or even loss of height.

“Some women get spinal fractures, where the bones in your spine become squashed down and it can change the shape of their spine,” she explains.

Dr Singh adds: “These fractures can decrease lung volume – you can’t take a deep breath in because it’s so painful – and increases the risk of pneumonia.”

What to do:

You can check your risk of developing osteoporosis via the Royal Osteoporosis Society’s Great British Bone Check campaign. Developed by the ROS it’s a free, three-minute tool can help people understand their future risk of the disease.

If you have osteoporosis or are at risk of developing it, then exercise – particularly strength-training – can play a powerful role in not just strengthening your bones, but improving overall health and balance. This, in turn, can reduce the chance of trips and falls.

The ROS advises doing muscle-strengthening exercises for 20 to 30 minutes, two or three days a week. Using bands and weights, lift the most weight you can for eight to 12 repetitions; build up to three sets of each exercise (one set is eight to 12 repetitions).

6. When breaking a bone is a red flag

Breaking a bone without a major accident, for instance just falling from a standing height, is a potential sign of osteoporosis, says Sarah.

“Hip fractures are reflective of poor muscle mass – the way you fall is different if you don’t have that strength,” says Dr Singh. “They’re linked with higher morbidity: 20 to 30 per cent of patients will die within a year of fracturing their hip.”

What to do:

To find out if your break or fracture is a result of weak bones, patients can have a DEXA scan. “This measures how much bone mineral there is and then compares that amount to the average adult. You then get a sense of how your bones compare to a healthy adult,” Sarah explains.

Patients receive a ‘T score’: above -1 is normal, between -1 and -2.5 shows bone loss and is defined as osteopenia, the stage before osteoporosis, and below -2.5 shows bone loss and is defined as osteoporosis.

The results are then taken alongside a fracture risk assessment. Risk factors include if you’re a woman over 50, or if you’re under-50 but have coeliac disease, long-term steroid use or are a smoker.

For more on the Royal Osteoporosis Society’s Great British Bone Check, visit thegreatbritishbonecheck.org.uk
To learn more about the Royal Osteoporosis Society, visit theros.org.uk

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