Spotlight on bone health in peri- and post-menopause

If you’re approaching the menopause, the chances are you’ve been thinking about managing hot flushes and mood swings but you may not have thought about your bone health. You only see fractures and hip replacements in really old people, right? The link between the menopause and osteoporosis was identified in the 1960s and we now know a great deal about its risk factors and treatment. And prevention is better than cure, right? What can you do pre- peri- and post-menopause to protect your bones? Spoiler alert, it’s not just about calcium!

Bones are dynamic!

When you think of a bone, you think of Dippy the Diplodocus in the Natural History Museum (OK maybe this is just me!). But we see bone as cold, hard matter that doesn’t really do much other than act as a scaffold for muscles to attach to and a protective cage for soft, vulnerable organs. But bones, at least when they are in a living being, are constantly changing, turning over and replenishing themselves. In the process of renewing or remodelling, old bone is actively dissolved and new bone is laid down in a process that uses many nutrients like collagen (a type of protein), vitamin D and minerals like calcium.

Oestrogen helps the keep the bone dissolving process in check so our bone turnover is well balanced – we make as much as we lose. But as hormone levels decrease during the peri-menopause, the rate of bone loss can exceed the rebuilding rate and we see a progressive thinning of bones over time.

If we define the menopause as the time that periods stop completely, then studies show that bone loss begins about a year before the menopause and continues for 3 years afterwards, after which the rate of bone loss slows down (but is still significant). On average, a woman can lose 10% of her bone mineral density during the menopause. In later years, our body’s ability to absorb calcium and make vitamin D can be compromised so this compounds the issue of low oestrogen and further accelerates bone mineral losses in later life.

The effect of this loss of bone mineral density is to make the bones more porous and brittle and therefore more liable to fractures and breaks. Coupled with the age-related loss of muscle mass and strength, which affects balance, falls become more likely and when it happens, you’re more likely to break a bone.

Osteoporosis develops when the loss of bone strength has reached the point where the risk of fracture is increased. 4% of women in their 50s will have fractures related to osteoporosis but this figure rises to 52% at age 80+. I appreciate that this isn’t the most uplifting of reading! Stick with me… it does get better. It’s not all doom and gloom.

Who is most at risk?

Bone mass is influenced by many factors:

• Age – the older you are, the lower your bone mass
• Gender – women are more at risk of low bone mass than men because of the rapid loss of oestrogen at the menopause; men can still get osteoporosis but their risk is lower because they have larger skeletons and do not have a rapid loss of oestrogen although it does slowly decrease with age (yes, men do have oestrogen!)
• Race – Caucasians have a greater risk.
• Early menopause – the average age of menopause is 51; having your last period before the age of 45 is classed as early and increases the risk of osteoporosis because you have low oestrogen levels for longer.
• Low body weight – thought to be either related to a restrictive diet or to the fact that there is less body fat to provide cushioning in a fall.
• A diet low in calcium and vitamin D (often seen in those who don’t eat dairy foods or who spend a lot of time indoors or with their skin covered).
• Genetics – a family history of osteoporosis will increase your risk.
• Previous history of an eating disorder or low body weight that resulted in a loss of periods, as this will mean low oestrogen levels.
• Smoking or excessive alcohol intake.
• Exercise – lack of exercise, especially weight bearing exercise, is linked to lower bone mineral density and reduced muscle mass.

Ultimately, there are some risk factors that you can’t do anything about. But that does not mean that osteoporosis is inevitable, even if you’ve had an early menopause, are Caucasian and getting older. There are things that you can do to look after your bones and most of these things will improve your overall health too.

Get enough calcium and vitamin D

The advice to post-menopausal women is to consume 1200mg calcium and 800IU vitamin D (equivalent to 20 micrograms which is double what the Department of Health advises for the general population).

Calcium foods include dairy products like milk, cheese, yoghurt, cottage cheese and they provide a great source of calcium as well as vitamin B12 and iodine. If you don’t eat dairy, it’s best to eat some fortified products, so choose milk and yoghurt alternatives with added calcium and vitamin D (ideally vitamin B12 and iodine too) and go for calcium fortified breakfast cereals if you eat them. Tofu can also have added calcium so look out for that, particularly if you’re vegan. Other non-dairy sources of calcium include fish with edible bones like canned sardines and pilchards or whitebait, as well as oranges and some green vegetables like kale and broccoli.

The problem with a lot of plant-based sources of calcium like pulses, spinach, dried fruit, nuts and seeds is that they contain what’s known as ‘anti-nutrients’ that can block the absorption of calcium from these foods. It’s not to say you shouldn’t eat them but try to get your calcium from other foods which you eat at a different time from them to make sure you absorb this essential mineral.

Also, bear in mind that calcium supplements can give you tummy issues and can interact with prescription medication or other nutrients like iron, so check with your doctor before you start taking any supplements.

When it comes to vitamin D, there aren’t a whole lot of dietary sources. Oily fish and eggs provide some vitamin D, as do the special mushrooms (not to be confused with magic variety) that are grown under UV lights. Fortified foods can also help but you should ideally take a vitamin D supplement to help you towards you 20 micrograms a day. Also, try to get out in the sun between April and September for 20-30 minutes a day, if you’re fair skinned, without sunscreen (more if you’re darker skinned). Just get some sun on your lower legs or on your arms and this will help your body to make vitamin D on its own. Obviously, if you’re out for longer, then slap on some sunscreen!

Pull your weight

Weight bearing exercise such as walking, jogging, walking up the stairs, lifting weights (either using your own weight in the more intensive Pilates and yoga classes, in boot camp style classes or using weights in the gym) helps to strengthen muscles, reduce the age-related loss of muscle and strength, and improve balance, co-ordination and agility, all of which can help to reduce the risk of falls and potential fractures.

Try to do 3 sessions of weights or weight bearing classes a week and walk or jog daily. Even walking up and down the stairs a few times can help!

Protein power

Protein doesn’t just help you to maintain muscle mass and strength, it’s also a vital component of bones, so a higher protein diet can help to maintain both bone and muscle health. Aim to eat 25-35g protein at each meal (including breakfast). Food suggestions are in last week’s blog but aim to eat a range of protein sources, especially if you’re on a plant-based diet. As long as you’re eating enough calcium, you don’t need to be concerned that eating more protein may reduce your bone mineral density, in spite of what you might read in the media.

Manage your vices

Ideally stop smoking as it will help reduce your risk of high blood pressure, stroke and lung cancer as well as supporting your bone health. And I’m not going to tell you to stop drinking alcohol but try not to overdo it and have a few alcohol-free nights a week please! Drinking 3 or more units a day may be bad for bone health and can increase your risk of falling over and breaking a bone as well as your favourite wine glass!

Obviously, there are also pharmacological routes to reducing risk of osteoporosis as well as treating it further down the line but as a nutritionist, I need to stay in my lane. If you’re considering HRT because you’ve had an early menopause, or if you have osteoporosis, then it’s always best to chat to your GP for advice.

In conclusion, while there are many risk factors for loss of bone mass that we can’t control, there are lots of things we CAN do to look after our bones. After all, we only get one skeleton, so we need to look after it!

Banner image by Evie Shaffer on Unsplash