Menopause and Osteoporosis-A Dietitian’s Bone Health Guide

Menopause and osteoporosis are closely related, and both can have significant impacts on a women's health. Menopause is a completely natural part of aging while osteoporosis is not. Osteoporosis affects the bones, making them weak and brittle, leaving them prone to fracture. Menopause doesn’t cause osteoporosis, but bone loss does accelerate during the menopausal transition. Now is the time to take action to decrease your risk.

In this article, we will discuss the prevalence of osteoporosis among menopausal women, the impact of menopause on bone health, and how to prevent or slow down menopause-related bone loss.

The impact of menopause on bone health

Menopause has a significant impact on bone strength due to declining estrogen levels. Estrogen plays a major role in bone formation. The time of most rapid bone loss is one year before your final menstrual period, lasting about 3 years. According to Dr. Jen Gunter in her book, The Menopause Manifesto, on average “a woman can lose 6 percent of her bone mass during these three years, but some women can lose a lot more-up to 3-5% a year. After this period of rapid loss, bone is lost at a higher rate than before menopause”. This loss of bone density, makes bones weaker and more brittle, increasing the risk of osteoporosis.

Along with the loss of bone density, menopause can also affect the way that the body absorbs calcium, which is essential for strong bones. As a woman goes through menopause, the body may become less efficient at absorbing calcium from the gut, which can put us at risk of low bone density.

The good news is that osteoporosis is preventable and treatable. If we haven’t thought much about our bones when we were younger, the menopausal transition is the perfect time to make sure we do all that we can to keep our bones healthy.

Am I at risk?

It is estimated that about half of all women over the age of fifty will have postmenopausal osteoporosis or be at risk of developing the condition.

Whether we end up with osteoporosis or not depends on many factors, including age, race, and lifestyle choices.

The most common risk factors are:

• Age: Bone density loss tends to accelerate as women get older.
• Family history: Women who have a family history of osteoporosis are at an increased risk of developing the condition themselves.
• Race: White and Asian women are more likely to develop osteoporosis than women of other races.
• Age of menopause: an earlier menopause means more life lived after, increasing the period of bone loss.
• Lifestyle factors: Smoking, excessive alcohol consumption, and a lack of exercise can all increase the risk of osteoporosis.

Take this quiz  for your own risk assessment.

What are the signs osteoporosis?

The scary part is that in many cases, osteoporosis is not diagnosed until a person experiences a fracture. However, there are some signs and symptoms that can indicate the presence of osteoporosis:

Bone fractures: as already mentioned one of the most common symptoms of osteoporosis is a bone fracture. These fractures can occur with minimal trauma, such as a fall from standing height or even a sneeze. According to Osteoporosis Canada, fractures from osteoporosis are more common than heart attack, stroke and breast cancer combined.

Loss of height: Over time, osteoporosis can cause the bones in the spine to become weak and compressed, leading to a loss of height.

Back pain: Osteoporosis can cause the bones in the spine to become weak and brittle, leading to back pain.

Stooped posture: As the bones in the spine become weak and compressed, a person may develop a stooped posture.

Bone deformities: In severe cases, osteoporosis can cause the bones to become deformed, leading to a curvature of the spine or bowing of the legs.

The only way to know for sure if you have or are on the way to having osteoporosis is by a bone density scan. When and if you should have this test is a great conversation to have with your health care provider.

How can I prevent osteoporosis during menopause?

The menopause transition is a prime time to take steps to prevent or slow down menopause-related bone loss. Positive lifestyle changes include:

• Eating a healthy diet: Certain eating styles could help protect against osteoporosis and improve bone mineral density. Studies show that a Mediterranean-style diet could help protect against fracture and osteoporosis risk and help maintain healthy bone and muscle mass. Focusing on foods rich in calcium and vitamin D can help to maintain bone density and prevent bone loss.
• Regular physical activity: Weight-bearing exercises, such as walking, jogging, and dancing, can help to strengthen bones, prevent bone loss and lower our risk of fractures.
• Avoid smoking and excessive alcohol consumption: Smoking and alcohol consumption increases the risk of bone loss and osteoporosis.

Calcium

Calcium is an essential mineral that plays a vital role in preventing osteoporosis. 99% of our calcium is found in our bones and teeth, helping to provide strength and structure. It is also needed for your heart, muscle and nerves so if the body in not getting enough calcium, it may draw calcium out of the bones, leading to weaker bones and an increased risk of osteoporosis.

How much calcium should I be getting?

Women 19-50 years old need about 1000 mg of calcium, and women over 50 need 1200 mg of calcium per day (NIH, 2022).

Good Food Sources of Calcium

I encourage clients to get as much calcium as possible from food. Unlike supplements, calcium-rich foods contain other important bone building nutrients such as vitamin D, magnesium and potassium. Calcium supplements may increase kidney stone formation and possibly lead to increased risk of cardiovascular disease. We don’t need to worry about that when we get our calcium from our diet.

Foods high in calcium:

1. Dairy products: Dairy products, such as milk, cheese, and yogurt, are some of the best sources of calcium. They are also a good source of other essential nutrients like protein, vitamin D, and potassium. Plant based milks are fortified with calcium and vitamin D as well so check the nutrition label.
2. Sardines: Sardines are small, oily fish that are packed with calcium. They are also a good source of protein, omega-3 fatty acids, and vitamins B12 and D.
3. Tofu: Tofu is a popular plant-based protein source that is high in calcium. It is also a good source of other nutrients like iron, and magnesium.
4. Broccoli: Broccoli is a good source of calcium, as well as other essential vitamins and minerals like vitamin C and potassium.
5. Leafy green vegetables: Dark, leafy greens, such as kale, collard greens, and spinach, are high in calcium. They are also a good source of other nutrients like fiber, vitamin K, and iron.
6. Almonds: Almonds are a good source of calcium, as well as other essential nutrients like protein, fiber, and magnesium.
7. Fortified foods: Many foods, such as orange juice, cereal, and bread, are fortified with calcium. Check the label to see how much calcium is in a serving of the food you are considering.
8. Black-eyed peas: Black-eyed peas are a good source of calcium, as well as other essential nutrients like protein, fiber, and iron.
9. Dried figs: Dried figs also give us fiber, potassium, and magnesium.

Check out this cool free calculator to see how much you are currently getting in your diet.

Looking for more non-dairy sources of calcium? Check out this post: Calcium without the Cow.

If you are struggling to get enough from your diet alone then topping up with a supplement should be okay. Just don’t go over the upper tolerable limit of 2000 mg/day.

What calcium supplements are the best?

You want to check the label of your supplement for the total amount of elemental calcium.

Calcium carbonate is 40% elemental calcium and is best absorbed in an acidic gastric pH. Meaning you should take them with meals. Tums are an easy and cheap form of calcium carbonate.

Calcium citrate is approximately 21% elemental calcium and can be taken at any time as it does not require an acidic pH for absorption. It is suitable for those with low stomach acid(achlorhydria) or those taking stomach acid blockers.

Other calcium supplements, such as calcium gluconate or calcium lactate, are not recommended as they contain a very small amount of elemental calcium.

Our bodies have trouble absorbing more than 500 mg at a time so spreading out our calcium foods and supplements throughout the day is a good idea.

Vitamin D

Getting enough calcium is not the sole answer to keeping your bones strong. Vitamin D is critical to your bone health as well. The body needs vitamin D to help absorb calcium from our gut so being low in vitamin D can lead can to a deficiency of calcium, even if you are taking enough.

The amount of vitamin D needed varies depending on a person's age, gender, and other factors. According to the National Institutes of Health(NIH) women 19-69 need 600 IU and women age 70 and over need 800 IU of vitamin D per day. Osteoporosis Canada recommends higher amounts at 800-2000 IU daily for women over 50.

Vitamin D is produced in our body when our skin is exposed to the sun’s rays. In Northern countries, we don’t get as much sun as we need to make adequate amounts. As well, our skin’s ability to make vitamin D declines as we age. For this reason, I do recommend a supplement in addition to eating vitamin D-rich foods.

Vitamin D does have other health benefits, such as supporting our immune function and maintaining muscle strength.

Vitamin K

Like vitamin D, vitamin K is produced in the body. It is essential for blood clotting and regulating bone metabolism.

Vitamin K deficiency is pretty rare as billions of bacteria in our gut make this vitamin. That being said, it is important to make sure we have a good amount in our diets.

The recommended daily intake for women 19 years or older is 90 micrograms/day. There is no established upper limit.

Foods high in vitamin K:

1. Leafy green vegetables: Dark, leafy greens are the best source of vitamin K. Some examples include kale, spinach, collard greens, and Swiss chard.
2. Broccoli: Broccoli is a good source of vitamin K. It also contains calcium and vitamin C, which are important for maintaining healthy bones.
3. Brussels sprouts: Brussels sprouts are a good source of vitamin K, as well as vitamins C and A.
4. Cabbage: Along with vitamin K, cabbage has other essential nutrients like vitamin C and fiber.
5. Soybeans/edamame: Soybeans are also a good source of plant-based protein and fibre.
6. Kiwi Fruit: Kiwi Fruit are a good source of vitamin K, as well as fiber, potassium, and vitamin A.
7. Natto: Natto is a traditional Japanese dish made from fermented soybeans. It is a rich source of vitamin K, as well as protein, fibre and potassium.

The effects of vitamin K on bone density in healthy women going through the menopausal transition isn’t clear. More evidence is needed to determine if vitamin K supplementation can help prevent weakening bones. There is a good review (PMID:33255760) showing that postmenopausal women and those who already have osteoporosis lowered their chance of getting a fracture with vitamin K supplements.

At this point, it is safe  to say you want to make sure you are eating your greens.

Protein

The relation between dietary protein intake and bone health has been a topic of great debate over the past several decades. Protein is essential to build and maintain bones but exactly how much and what kind is still unclear.

Increased levels of dietary protein (≥0.8 g/kg body weight/day) are associated with higher bone density, a slower rate of bone loss and a reduced risk of hip fracture.

Higher protein intakes( 1.3g/kg-1.5 g/Kg/day) are often recommended  to support greater muscle mass and strength, both have a positive impact on bone mass. 

But some worry that intakes greater than 1.5 g/kg body weight /day increase the calcium lost in our urine, upsetting our calcium balance.

Bottom line:  until we have high-quality, long-term studies, I counsel my clients to aim for 1.0-1.2 grams of protein/kg/day. Including more plant-based sources proteins is good for our overall health and may have a direct benefit on our bones as well.

Tofu, soy milk and edamame which contain compounds called isoflavones, have been shown to benefit  bone density by stimulating bone formation and decrease bone loss.

Best Exercise for osteoporosis

Like the rest of your body, your bones thrive on movement. Every time you move, your muscles pull on the bones to get you going. The more  movements stress your skeleton, the more your body responds by making your bones stronger and denser.

Three types of exercise are recommended: weight-bearing, resistance exercise and back-strengthening exercises.

Weight-bearing exercises are done on your feet with your body supporting your weight. This type of movement helps to slow the mineral loss in the bones of your legs, hips and spine. Walking, running, dancing and sports like tennis or pickleball force you to work against gravity, and the impact on the ground stimulates your skeleton. Swimming and cycling do get your muscles moving which can be helpful, but you want to make sure include  some impact movement as well.

Resistance exercise or strength training is also an excellent bone builder. Creating resistance for your muscles to push or pull against makes them stronger.  As we age our muscle fibers begin to shrink in both number and size. This is accelerated for women due to the loss of estrogen. The use of weights, weight machines or resistance bands can prevent this muscle loss.

Posture exercises, those that strengthen your upper back  and core muscles care known to prevent back pain and reduce compression fractures in the spine.

Exactly for how long and how much you need to exercise is still up for debate. This recent meta-analysis looked at over 75 studies but couldn’t come up with  any one specific recommendation as all studies used different exercise programs and the participants were quite varied in age, menopausal status, etc.

At this point, use it or lose it and something is better than nothing, is probably a good mantra.

Most health promotion guidelines recommend an accumulation 150 minutes of weight bearing exercise and 2-3 strength sessions per week. I would aim for that.

Things to Avoid, Limit or Replace

In addition to focusing on positive bone-building habits, it’s important to be aware of what may be harmful to our bones as well.

Smoking

According to Dr. Jen, ‘there are multiple ways smoking negatively affects bone health. Peak bone mass is lower and bone loss is accelerated throughout the lifetime, but especially after menopause. Older women who smoke lose an additional 2% of bone density for every 10 years after menopause.”

Alcohol

Research about alcohol and bone health is ongoing. According to the NIH, “human and animal studies clearly demonstrate that chronic, heavy alcohol consumption compromises bone health and increases the risk of osteoporosis. In particular, heavy alcohol use decreases bone density and weakens bones’ mechanical properties. 

The effect of moderate alcohol consumption on bone health is less clear. Some research in humans has indicated that moderate drinking may boost bone mass, whereas animal studies have contradicted that idea.”

Health Canada has just come out with new guidelines for alcohol consumption, after reviewing the latest health and safety research. Two standard drinks or less per week is recommended.

Coffee

While the evidence is not super clear, it may be wise to limit your intake of coffee.  A meta-analysis in 2017 found that women with high coffee consumption had a higher fracture risk than women with low coffee consumption, and each additional daily cup of coffee significantly increased fracture risk.

Most osteoporosis organizations around the world suggest a limit of 4 cups(8oz/250 ml)per day.

A bit of encouraging news is that you might be able to swap out your coffee for tea. It is thought that the polyphenols in tea have a positive effect on bone loss and fracture risk.

But its best to drink tea at least an hour outside of mealtimes, to optimize calcium intake.

There’s no doubt that as you go through the menopausal transition you are going to lose bone. But the good news is that osteoporosis develops slowly over time. You can take steps right now to take care of your bones.

Good bone health means choosing the Mediterranean style of eating, making sure you are getting enough calcium and vitamin D and exercising regularly. That will go a long way towards keeping your bones strong. Stopping smoking and liming alcohol will help as well.

Want to make sure you diet is optimized for menopause? Book a connection call with me today.