Bone Health: Many people need bone support. Will more turn to dietary supplements?

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Call it healthy aging, getting old in style, or gracefully aging; the older we get, the more our bodies wear down and slow down—and the more consumers look for ways to thwart the process. Bone health is a main concern in aging. Nutritional interventions can play a significant role in the fight against adverse bone-related aging—if consumers choose to use them.

Who Needs Support?

Women especially need bone support as they age. “Of the 10 million Americans diagnosed with osteoporosis, it is estimated that 80% of them are women,” says Justin Marsh, CEO of dietary supplements brand Arthur Andrew Medical. “Estrogen is essential for optimal bone health, and women are at an increased risk of developing osteoporosis compared to men because of hormonal changes at menopause.”

Supplementation even from an earlier age is beneficial. “Even young adult women are often interested in preemptive nutrients if fracture or premature bone loss are genetically inherent within the family,” Marsh adds.

Women are currently the category’s biggest customers. “The most engaged consumer looking for bone-supporting supplementation is still women,” says Michael A. Smith, MD, director of education for supplements brand Life Extension.

The Council for Responsible Nutrition’s (CRN; Washington, DC) 2020 Consumer Survey on Dietary Supplements affirms this. The survey found that while 21% of total dietary supplement users took supplements to support bone health, more women (25%) are doing so than men (17%).

But men need support, too. “The male consumer tends to be underserved, particularly men over the age of 50, who also need to be aware of calcium intake and bone health,” Smith continues.

To no one’s surprise, bone health supplement consumers naturally skew older. CRN’s survey breaks down the age range of bone health dietary supplement users as such: age 18-34 (18%), age 35-54 (19%), age 55+ (25%).

Usage also differs by socioeconomic status, says Susan H. Mitmesser, PhD, vice president of science and technology for supplements company Pharmavite. Unfortunately, this means that many who need bone-supporting supplements the most can’t afford them.

“For many Americans 50 years and older who are low-income, access to foods rich in calcium or vitamin D may be an issue,” Mitmesser says. For instance, a recent study¹ Pharmavite conducted compared calcium and vitamin D intakes against poverty markers. “[It] found that individuals with low income and food insecurity are not getting enough of these essential bone health nutrients and are at higher risk for osteoporosis,” she says.

Calcium + Vitamin D

It’s clear that many consumers still aren’t getting enough of even the basic bone health essentials. For instance, says Mitmesser, “The nutrients that are essential for bone health and reduce the risk for low bone density, osteoporosis, fractures, and falls are calcium and vitamin D.”

Unfortunately, she says, according to recent data from the National Health and Nutrition Examination Survey (NHANES), Americans are deficient in these nutrients. Among those older than 50, more than 60% (72% females, 51% males) have inadequate calcium intake, while 37% (24% females, ~40% males) have inadequate vitamin D intake. She adds: “Only 30% of Americans age 50 or older supplement with calcium and vitamin D (24% females, 38% males).”

The powerhouse duo of calcium and vitamin D is essential to bone health. Our needs for these nutrients change with age. Mitmesser explains: “Our bones are living tissues that provide structural support and mobility for the body as well as a major storage site for nutrients like calcium. Bone tissue is constantly being remodeled throughout life. During childhood and adolescence, new bone tissue is formed and broken down, allowing bones to grow. During adulthood, bone remodeling—i.e., the removal and replacement of bone—replaces brittle bones and releases calcium and other minerals when needed. Bone degradation begins in our mid-30s, leading to inevitable loss of bone mass as we age.”

The way our bones utilize calcium changes as we age. Life Extension’s Smith explains: “During childhood and adolescence, bone building is at a maximum, and therefore the need for calcium is at a maximum. Once we reach middle adulthood, the bone building and bone breakdown processes are about equal. However, past 50 years of age, bone breakdown tends to dominate over bone building.”

He concludes: “Our calcium requirements can change over a lifetime, yet one thing is consistent: the need for balanced daily intake of calcium throughout all stages of life.”

Vitamin D, meanwhile, is calcium’s righthand man due to its role in calcium absorption and bone mineralization. Fortunately, says Smith, more physicians are testing for vitamin D levels. Vitamin D has now gained support as an essential bone nutrient among the medical community.

He adds: “Since our ability to synthesize vitamin D in the skin declines over a lifetime, the need to replenish [it] through food and supplementation becomes important as we age. For example, in childhood the natural production of vitamin D upon UVB ray exposure is at its peak. By the time we reach 18 years of age, the production can start to fall to about 80% of what an eight-year-old can make. And, into the 80^th decade of life, the production can potentially drop down below half of what an eight-year-old can make.”²

Of the two supplement ingredients, calcium is still the most popular. “The bone health market continues to be dominated by calcium,” says Smith. “It is the most recognized ingredient by most consumers, even though the calcium market has seen little growth over the last few years.”

Mitmesser points out that you also get calcium naturally from such food sources as dairy and soy, some dark leafy vegetables, nuts, legumes, and calcium-fortified foods.

But without supplements, it’s tough to maintain optimal vitamin D levels. “Direct midday sunlight exposure to UVB rays is required to synthesize vitamin D3 in the skin,” Smith says. “However, due to concerns for skin health, many people try to avoid direct sunlight, cover up, or wear sunscreen, which can hinder vitamin D synthesis.”

Today, supplement brands are combining an array of bone health ingredients, including vitamin D and calcium. While doing so, they are also keeping up with any new findings on what is optimal—and what might not be.

For calcium, Smith says, some researchers are reevaluating the typical dosage range of 1000-1200 mg. Some research now indicates that supplemental calcium dosing may only need to be 600-1000 mg, according to a Harvard Health Letter.³

“The common medical prescription of supplementary calcium is outdated and is now being considered dangerous, as it can contribute to heart disease,” Marsh agrees.

Researchers are also studying the importance of other critical but under-the-radar nutrients—like vitamin K.

Vitamin K

Vitamin K—particularly vitamin K₂—is still gaining awareness among bone health customers compared to calcium and vitamin D. Talk to industry folks, however, and they’ll tell you that this powerful vitamin has been a bone health staple for quite a while.

“Vitamin K2 encourages the cellular activity of osteoblasts, the specialized cells that regulate bone mineralization,” Smith explains. “Vitamin K₂ helps activate osteocalcin, a protein made by osteoblasts that is responsible for binding to calcium and fixing it to the bone matrix. A lack of vitamin K₂ results in underactive osteocalcin, which greatly slows down the bone mineralization process.”

Vitamin K₂ is also essential to preventing calcium buildup where it’s not wanted. Says Marsh: “Increased calcium tends to bind to arteries and cause cardiovascular stiffening…Vitamin K₂ directs the transportation of calcium toward the bones and away from the walls of the arteries, making vitamin K₂ and vitamin D an ideal combination for bone health.”

For this reason, vitamin K₂ should not be left out of the bone health puzzle. “There is an overwhelming emphasis on calcium and vitamin D combinations in bone health products, while the inclusion of vitamin K is largely neglected” when in fact it’s as important a cofactor as D₃, Marsh says.

“Vitamin D₃ combined with K₂ has been shown to be highly beneficial for both strong bones and cardiovascular health,” he explains. “The vitamins work together to ensure calcium is absorbed into the bones while preventing calcium buildup in the blood vessels. Additionally, K vitamins could be the missing link that consumers need for optimal bone health, as it channels calcium away from the heart and arterial mineralization and shuttles it toward the bones where it belongs.”

When it comes to vitamin K, form is important. “The form of vitamin K that has a big impact on supporting bone density is vitamin K₂, known as the menaquinones,” Smith says.

Supplementing with K₂ is essential. “The problem is that the menaquinones are more difficult to get from the food alone,” Smith explains. “Vitamin K₂ is found in foods that are high in saturated fats, like cheese, which many people try to avoid, and unfortunately low-fat versions have far less vitamin K₂ content.⁴ So, getting adequate amounts of vitamin K₂ from food sources alone can be extremely challenging.”

Also important: while clinical research supports the use of menaquinone-4 (MK-4), a form of vitamin K₂, to support bone mineral density and reduce fractures in postmenopausal women with osteoporosis⁵, some say menaquinone-7 (MK-7) is better absorbed⁶.

Marsh says vitamin K₂ “could be identified by scientists as a ‘complex’ like B vitamins—not just one form of K₂ is more important than a perfectly balanced proportion of all the subsets. The debate over which version of K₂ is better will undoubtedly be overruled by the science of which ratios of these MKs is best.”

Collagen

Then there’s collagen, which has become a superstar ingredient in dietary supplements, food, and drinks, appearing in everything from collagen-infused teas, waters, veggie drinks, creamers, vinegar, and shots to powders, effervescent tablets, oats, butter, snack bars, and bone broth soup packets.

Collagen has been found to stimulate collagenic tissue regeneration and help reduce and prevent joint pain, bone density loss, and skin aging.⁷ In postmenopausal women, collagen peptides increased bone mineral density and favorably shifted bone markers, “indicating increased bone formation and reduced bone degradation,” according to German researchers.⁸

Collagen is the most abundant protein in the body. Similar to other nutrients naturally produced in the body, its production slows with age, which is why supplementation via foods, nutricosmetics, or otherwise is so important, especially for women.

Luckily, collagen lends itself well to popular delivery formats like food and drink. In fact, up to 76% of consumers age 26 to 55 agreed that healthy aging started with what they ate and drank, according to Innova Market Insights 2019 research. Healthy-aging claims now make regular appearances on food products and beverages. Alongside joint health, energy/alertness, and immune health, bone health is a growing active-health claim in global food and beverage launches.

Collagen products now span supplement and beverage aisles, from drink mixes and beverages such as milk and dairy alternatives to adult and children powder formulas. Even big players like Nestlé China are entering the space with its 2020 launch of a glucosamine sulfate milk powder designed to support bone density.

The Future of Bone Health

Bone health is a top priority for some, but not all, consumers. Many would like to see that change as new research emerges on old and new ingredients. Consumer education and product innovation will be the key to growing this market segment for young and old.

“For children and adolescents, bone health products and education should focus on building strong bones, whereas bone health products and education for older adults should focus on preventing bone loss and other conditions,” Mitmesser says. “Based on recent research, socioeconomic status and access to foods high in calcium and vitamin D should be considered when developing bone health products and education and outreach efforts.”

“Researchers and clinicians should assess intake of calcium and vitamin D from food sources, fortified foods, and supplements to determine adequacy of nutrient intake in their patients,” she continues. “Product makers should target bone health products to specific consumers—for example, a ‘bone builder’ supplement for adolescents to support bone growth and strength.”

Industry players remain optimistic. Says Smith: “Although the bone health market is flat, there is still a large and proactive consumer base that is looking to maintain healthy bones.”

References

1. Marshall K et al. “Inadequate calcium and vitamin D intake and osteoporosis risk in older Americans living in poverty with food insecurities.” Plos One. Published online ahead of print July 8, 2020.
2. MacLaughlin J et al. “Aging decreases the capacity of human skin to produce vitamin D₃.” The Journal of Clinical Investigation, vol. 76, no. 4 (October 1985): 1536-1538
3. Harvard Health Letter. “Do We Really Need All That Calcium?” Harvard Health Publishing, Harvard Medical School. Published online March 2008. Accessed here. https://www.health.harvard.edu/staying-healthy/do-we-really-need-all-that-calcium
4. Xueyan F et al. “Multiple vitamin K forms exist in dairy foods.” Current Developments in Nutrition. Published online June 1, 2017.
5. Iwamoto J. “Vitamin K₂ therapy for postmenopausal osteoporosis.” Nutrients, vol. 6, no. 5 (May 16, 2014): 1971-1980
6. Toshiro S. et al. “Comparison of menaquinone-4 and menaquinone-7 bioavailability in healthy women.” Nutrition Journal. Published online November 12, 2012.
7. Juher TF et al. “An overview of the beneficial effects of hydrolysed collagen intake on joint and bone health and on skin ageing.” Nutrición Hospitalaria, vol. 32 suppl (July 18, 2015): 62-66
8. König D et al. “Specific collagen peptides improve bone mineral density and bone markers in postmenopausal women—a randomized controlled study.” Nutrients, vol. 10, no. 1 (January 16, 2018): 97