Guide to better bone health


Dr Thomas Paul
discusses with Dr Anjali Bhatt the
importance of good bone health


Dr Thomas Paul
is the Professor of Endocrinology at
Christian Medical College at Vellore in India. His research
lies in the field of metabolic bone disease.

He has co-ordinated and been the
co-investigator in multicentre trials on


Good bone health

  • Bones are crucial as they support our vital
    organs like brain, heart, lungs and kidneys from injury.
    Our bones store minerals such as calcium and phosphorous
    and release them into the body as and when needed. They provide
    structure to our body anchoring our muscles. Bones change
    constantly as new bones are made and the older bones are broken
    down. When you are young, your body is able to replace bones at
    a fast rate and your body mass also increases. People achieve
    peak bone mass around age 30. After that the bone remodelling
    process slows down and you start losing more bone mass than you
    gain, unless they take action to prevent it.. It is vital to
    take care of your bones as this may prevent the onset of
    osteoporosis. This makes having healthy bones instrumental to
    our health and longevity.

What affects bone health?


A number of factors can affect bone
health.  These factors result in diminished bone density,
early bone loss and an increased risk of fractures.

  • A diet low in calcium
  • Physical inactivity.
  • Regular tobacco and alcohol use
  • Gender, size and age – (Women are at more
    risk than men. Also, thin people with body mass index lower
    than 19 are at a greater risk especially as they age)
  • Race and family history- (Increased risk
    of osteoporosis for people with Caucasian or Asian
    descent.  A parent or sibling who has osteoporosis
    increases your risk)
  • Hormone levels – (Too much thyroid
    hormone, or low estrogen levels in women increase risk. In
    men, low testosterone levels can cause a loss of bone
  • Eating disorders and other conditions –
    (Anorexia or bulimia increase risk. Stomach surgery
    (gastrectomy), weight-loss surgery also increase risk as they
    affect your body’s ability to absorb calcium)
  • Certain medications


Bone health and Diabetes

Observational studies show that there is
decreased bone density in people who predominantly have Type 2
Diabetes.  Bone loss occurs when more bone is resorbed
than is formed by the body. (Bone resorption is a continuously
occurring process involving the breakdown of bone by
specialized cells and then the broken down bone is replaced by
new bone growth) After age 30, bone resorption slowly begins to
exceed new bone formation. This leads to bone loss.

Studies have shown that people with Type 2
Diabetes taking insulin had a greater risk than people taking
oral agents of bone loss. Insulin has anabolic effects on bone
and increases the bone resorption rate resulting in a faster
rate of bone break down than bone reforming. This is also a
factor resulting in bone loss. Studies also suggest that a
reduced rate of bone formation occurs in both forms of Diabetes
during periods of poor blood sugar (glycaemic) control.

There is an increased risk of low bone
mineral density and bone fractures in people with Diabetes. The
magnitude of risk of increased bone loss and abnormal bone
density is higher for Type 1 Diabetes as studies show that
people who have early Type 1 Diabetes do not achieve peak bone
mass. People with Type 1 Diabetes often go through
hypoglycaemia frequently and also display substantial
insulin deficiency and metabolic acidosis from an early age
when peak bone mass is determined. For people with Type 2
Diabetes where onset of Diabetes is usually later in life, the
peak bone mineral density is usually greater

Nutrition and Bone health

Eating a well-balanced diet rich in calcium
and vitamin D is paramount to good bone health. Natural sources
of calcium include tofu (calcium fortified), soy milk (calcium
fortified), green leafy vegetables (e.g., broccoli, brussels
sprouts, mustard greens, kale), chinese cabbage or bok choy,
beans/legumes, sardines/salmon with edible bones, shrimp,
orange juice (calcium fortified), nuts/almonds and dairy
products (e.g., milk, cheese, yogurt).

It is also important to walk in the morning
sun between 9 -11 am for twenty minutes as sun light is the
natural source of Vitamin D.


Obesity and bone health

Abdominal fat (which is more dangerous than
fat found in other places in the body) has a more negative
impact on bone and muscle strength and can boost inflammation.
Researchers at Florida State University have coined the phrase
‘osteosarcopenic obesity’. This occurs due to deteriorating
bone density and muscle mass associated with obesity. They have
found that obese people have a greater risk of falling and
breaking bones.

Obesity is a double edged sword. Obesity
increases bone mass in hip region but may not in other parts
like spine and fore arm so there is some bone protection around
the hip but not the spine.
body mass has a positive effect on bone formation, whether the
mass derived from obesity is beneficial to bone remains a topic
of further study.


Menopause, osteoporosis and bone

Menopause, a natural, biological process, is
the cessation of the monthly menstrual cycle marking an end to
fertility. It is defined as occurring 12 months after your last
menstrual cycle and can occur in your 40s or 50s.


50 per cent of post menopausal Indian women
(above 50 yrs of age) do not achieve peak bone mass resulting
in the high rate of osteoporosis.  Both men and women can
get osteoporosis, but women get it more often because of the
changes in hormones. Osteoporosis causes bones to become weak
and brittle. Osteoporosis-related fractures most commonly occur
in the hip, wrist or spine. The amount of bone mass attained
till the age of 30 and the amount lost after then determines
the age of possibly developing osteoporosis.  The higher
your peak bone mass was (more bone you have “in the bank”)
lowers your risk to develop osteoporosis as you age.

Medication, a healthy diet and weight
bearing exercises are recommended to prevent bone loss and
strengthen already weak bones. Good physical activity, a diet
which includes green vegetables and high calcium is important.
Lifestyle modification forms fundamental corner stone in
tackling both conditions together. 90-100 mg one to two glasses
of undiluted, low fat milk must be consumed every day. Studies
have shown that the Indian population consumes less than 400 mg
of dietary calcium ever day. One or two tablet of calcium
carbonate which contains about 500 mg of calcium must be


Calcium intake

There are many preparations  of calcium
available such as calcium citrate, calcium acetate, calcium
magnate, calcium glucamate. Commonly available is calcium
carbonate which is a cost effective preparation. Calcium
carbonate is preferably to be taken in night with dinner so it
is better absorbed. Other preparations can be taken at any time
of the day but are not cost effective. Cost almost

To conclude

Women with Diabetes need to pay special
attention to the prevention of osteoporosis by maintaining an
adequate calcium and vitamin D intake. It is important to eat a
healthy diet and introduce some form of physical activity in
daily life.

Family and physicians of people with
Diabetes introduce interventions in the home to prevent
accidents for patients with poor vision, sensory and motor



  • After the age of 30, you begin to lose
    bone mass unless you take action to prevent it.
  • Diabetes contributes to bone mineral loss
    by decreasing the formation of newer bones.

What is peak bone mass?

Bones are living tissue like muscles. Even
after they have finished growing in size, bones continue to
developing internally. Bone mass develops all through
childhood, adolescence, the teenage years and even during the
years of early adulthood. Most people reach their peak mass by
the age of 30.

Peak bone mass is the largest amount of bone
tissue that a person has at any point of time in their life. At
the point of peak bone mass, the bones are denser than they
ever before or after.

Recommended Calcium and Vitamin D


Vitamin D (IU/day)

Infants 0 to 6



Infants 6 to 12 months


1 to 3 years old

4 to 8 years old


9 to 13 years


14 to 18 years


19 to 30 years



31 to 50 years



51- to 70-year-old



51- to 70-year-old



>70 years old


19 to 50 years old,



Definitions: mg = milligrams; IU =
International Units

Source: Food and Nutrition Board,
Institute of Medicine, National Academy of Sciences,

Bone mineral density (BMD)

Bone mineral density test is a measure of
bone density, reflecting the strength of bones as represented
by calcium content. Bone mineral density (BMD) tests, like
dual-energy x-ray absorptiometry (DEXA) scan, are used

  • Diagnose bone loss and osteoporosis
  • See how well osteoporosis medicine is
  • Predict your risk of future bone