How to Maintain Good Bone Health

Ways to support your treatment by keeping bones healthy.

“Metastatic bone disease is most commonly seen with specific cancer types—notably those with metastasis from the breast (70%), prostate (85%), lung (40%) and kidney (40%)—as well as multiple myeloma (MM) (95%).” - Coleman R.E. Clin Cancer Res. 2006; 12: 6243s-6249s

Preventing bone loss is helpful no matter what your age or condition. Fractures to the

hip or spine are particularly concerning especially as they are weight bearing bones. When these bones are healthy, they can withstand significant impact; however, when you have low bone- density, even a minor fall may result in a fracture. Fractures related to decrease in bone density are associated with loss of mobility and social functioning, reduced quality of life, and poor survival.

“The skeleton is a frequent target of metastatic disease. It can be the first and sometimes the only site of advanced disease, contributing greatly to the burden of care in cancer patients.” - Roodman GD. N Engl J Med 2004;350:1655–1664.

Bone loss from cancer therapy is faster and more severe than bone loss from aging; rates

of bone loss are up to 7-fold higher when they occur from cancer therapy. Women with breast cancer receiving an aromatase inhibitor or ovarian suppression should be assessed for fracture risk based on clinical risk factors and bone mineral density. Premenopausal women should also be informed of the potential risk of bone loss before beginning anticancer therapy. Ideally, all women should get their bone density checked by a test called the DEXA scan (dual energy X-ray absorptiometry) which is a type of X ray that measures your bone density. A bone density scan measures the strength of the bone by looking at the amount of calcium it contains in the hip, femoral neck and  lower spine. Depending on how low your bone mineral density is, you may be diagnosed with osteopenia or osteoporosis.

Getting a DEXA scan prior to starting cancer treatment and followed by yearly DEXA scans can monitor your risk for fracture.

The fracture risk assessment (FRAX®) calculator is a tool that is used to estimate the

10-year risk of hip and non-hip vertebral fractures.  FRAX® uses the age, height, weight, sex and a variety of other risk factors to assess your personal risk. Before starting treatment for cancer, talking about your personal risk factors for osteoporosis is important. Here is a checklist of risk factors that can predispose you to accelerated bone loss. These risk factors include being small and thin, family history of osteoporosis or hip fracture as well as height loss of more than 1-1/2 inches or stooped posture amongst others. Please see this second checklist that you can take to your doctor visit to discuss how to monitor and reduce your risk for fractures, especially if you are on chemotherapy and hormone therapy. If you do get medications for osteoporosis such as bisphosphonates or denosumab, make sure you talk to your physician about the precautions and expected side effects of those medications.

You cannot change some risk factors for osteoporosis but you can take the following steps to keep your bones strong during treatment and in survivorship.

1. Eat a variety of nutrient-rich foods every day including 3-4 servings of fruits and

vegetables each day. Fruits and vegetables provide essential micronutrients as well as

antioxidants associated with higher bone density. Fruits and vegetables also affect the

acid-base balance of the diet which can affect the balance of osteoblast activity versus

osteoclast activity. However it is not the acidity or alkalinity of the food or drinks we put

in our mouth that is the concern here, but what happens to their components after

ingestion and metabolism. Most fruits and vegetables yield an alkaline residue in the

body, which helps prevent bone loss. Studies have also shown that carotenoids such as

beta carotene, lycopene, lutein and zeaxanthin, as found in many fruits and vegetables

can increase bone density, although the mechanism of this is not clear. 

2. Take adequate protein every day. Older adults may become protein malnourished due

to inadequate intake of protein and a reduced ability to use available protein because of

age-related changes in metabolism, immunity, as well as hormone imbalances. Dietary

protein is crucial for the maintenance of bone tissue as well as for bone growth. Bone is

35% protein and requires a supply of amino acids to be used for protein turnover.

Protein intake stimulates the release of the hormone IGF-1 which increases muscle mass

and bone growth. While there is some suggestion that excessive increased protein intake

can result in bone loss this has been largely proven to be not clinically significant. Protein

sources can be plant or animal based and have different amino acid profiles. Eating lean,

minimally processed animal protein, white fish, yogurt, cheese, low fat cottage cheese

and various plant based proteins such as lentils, beans, peas, tofu, edamame, tempeh

etc can help maintain optimal bone health.

Also Read : Improve Your Diet to Decrease Cancer Risk

3. Maintain your calcium intake at the correct level. Your bones contain 99.5% of the

total calcium in your body. Premenopausal women should consume at least 1000 mg of

calcium, while postmenopausal women should consume 1200 mg (total diet plus

supplement). You should not consume more than 2000 mg of calcium per day (total diet

plus supplement) due to the risk of side effects. It is best to get calcium from the foods

you eat. Foods rich in calcium such as dairy foods (milk, yogurt, cheese), dark green,

leafy vegetables (bok choy, broccoli collard greens, kale, and turnip greens), fish

(sardines, salmon), almonds, tofu or calcium-fortified foods. If you don't eat dairy there

are several other sources to get your daily dose of calcium. The bioavailability of calcium

is an important consideration to keep in mind. The absorption of calcium from dairy

products and fortified foods is about 30%. In the case of plants, certain compounds in

plants like oxalic acid, phytic acid can decrease calcium absorption by forming

indigestible salts with calcium, decreasing its absorption. As a result, absorption of

calcium is only 5% for spinach, whereas it is much higher, at 27%, for milk. Depending

on the type of diet you follow, you should be mindful of your dietary sources of calcium

and make sure you eat a balanced meal.

4. Get your regular dose of Vitamin D. Vitamin D is not a vitamin, rather it functions as

a hormone that is essential for bone health. Vitamin D decreases bone loss and lowers

the risk of fracture, especially in older men and women. Along with calcium, vitamin D

also helps to prevent and treat osteoporosis. To absorb calcium efficiently, an adequate

amount of vitamin D must be present. The skin, liver and kidneys work together to

synthesize the active form of vitamin D. Exposure to the UV rays from the sun converts

a molecule made from cholesterol in your skin to vitamin D.  Vitamin D in its active

form acts on the intestine, kidneys, and bones to maintain normal levels of blood calcium

and phosphorus. The primary effect of vitamin D is increased calcium absorption in the

small intestine but also maintenance of serum calcium and phosphate concentrations, as

well as by its action on bone growth and remodeling. If you are unable to get about 20

minutes of exposure to the morning sun because of where you live, a Vitamin D

supplement prescribed by your physician based on your blood levels may be necessary.

The current recommendation is that postmenopausal women consume at least 800

international units (20 micrograms) of vitamin D per day. Lower levels of vitamin D are

not as effective, while high doses can be toxic, especially if taken for long periods of

time. Although the optimal intake has not been clearly established in premenopausal

women, 600 international units (15 micrograms) of vitamin D daily is generally

suggested. There are only a few good natural food sources of vitamin D, including fatty

fish such as mackerel, salmon, sardines, and tuna. Small amounts of vitamin D are added

to all milk and some types of soy milk, rice milk, almond milk, yogurt, cheese, juice, and

nutrition bars. 

5. Don’t forget magnesium. It helps your body regulate the levels of calcium and Vitamin

D and is found in green vegetables, nuts, seeds, avocados, legumes and whole grains. The

current recommendation for adults 19-51+ years is 310-320 mg for women. A good rule

of thumb is to eat a daily diet that includes some magnesium-rich foods and take a

supplement if directed by a physician to correct a deficiency if blood levels are low.

6. Be physically active. Your bones get stronger and denser when you make them work.

Weight-bearing exercise especially can help preserve your bone health. Some examples

are running, tennis or pickleball, and weight training. When you do weight-bearing

exercise, you put stress on the bones. That triggers the bone cells to build more bones,

which can lead to increased bone strength. This process is called osteogenic loading.

Walking, climbing stairs, and dancing are also  exercises that strengthen your bones by

moving your body against gravity when you are upright. Tai Chi and yoga are examples

of physical activity that improve posture and balance to help decrease your risk for falls

and fractures. Avoid exercises that increase your risk of falls. Extension exercises are

better at protecting your spine from vertebral fractures than flexion exercises where your

back is curved forward.

7. Don't smoke or vape.

8. Limit your alcohol intake. Before drinking alcohol, it is important to speak to your

health care provider about possible interactions with your medication or your medical

condition. Too much alcohol can be bad for your bones and your overall health.

Excessive alcohol interferes with the balance of calcium as well as interferes with the

production of vitamin D.

9. Take precaution against falls. Preventing falls, especially if you already have low bone

density is important. Most broken bones occur as a result of a fall that can be prevented.

Some actions to prevent falls at home include using nightlights, removing or securing

scatter rugs, using handrails on stairs, using grab bars in the shower and bathroom, using

a seat riser on the toilet, and getting rid of clutter. Be careful of little pets that can get

underfoot and trip you. Clean up spills immediately and don't use floor polish which can

cause you to slip.  If you are on medication that causes drowsiness, you should be extra


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Reason to Hope

Chemotherapy-driven estrogen loss is known to drive bone loss, but significant data suggests the
existence of an estrogen-independent mechanism of bone loss.  A new study in mice suggests
that a biological process known as cellular senescence, which can be induced by cancer
treatments, may play a role in bone loss associated with chemotherapy and radiation. These
findings may lead to treatments for therapy-induced bone loss, significantly increasing quality of
life for cancer survivors.
DOI: 10.1158/0008-5472.CAN-19-2348