During adulthood, a comparative period of balance between bone formation and resorption maintains the amount of bone mass. A well-balanced diet, which is rich in calcium, vitamin D and protein, and with adequate intake of other important micronutrients, is essential to maintain this balance and avoid premature bone loss. This is especially important for women, as menopause brings with it a period of rapid bone loss, with bone resorption outstripping bone formation due to the lack of protective oestrogen.  

In seniors, a bone-healthy diet helps to slow the rate of bone loss and preserves muscle function. Malnutrition is common among the elderly for numerous reasons [5]Hickson, M., Malnutrition and ageing. Postgrad Med J, 2006. 82(963): p. 2-8.

, including the fact that they may have reduced appetite or be less inclined to cook balanced meals. 
In addition to higher calcium intake, seniors may need more dietary protein and vitamin D than the young. Both these nutrients help prevent muscle wasting (sarcopenia) and thereby help lower the risk of falls and fractures. 

Inadequate calcium in seniors may result from:

• Decreased overall dietary energy intake, including sources of calcium
• Decreased intestinal absorption of calcium, exacerbated by low vitamin D status
• Decreased capacity of intestinal cells to adapt to low calcium intake
• Decreased retention of calcium by the kidneys

Inadequate vitamin D in seniors may result from:

• Less frequent exposure to sunlight for the housebound
• Decreased capacity of the skin to synthesize vitamin D
• Decreased renal capacity to convert vitamin D to its active form

Inadequate protein in seniors may result from:

• Low overall dietary intake 
• Decreased anabolic responses to ingested protein
• Increased need for protein to offset inflammatory and catabolic conditions

Attention to adequate intake of certain nutrients is particularly important in patients with osteoporosis or at increased risk for osteoporosis and fractures. National and regional osteoporosis management guidance typically provide recommendations for bone nutrition. Generally, guidelines advise:

• Intakes of at least 1000 mg/day of calcium and 800 IU of vitamin D are advised in the general management of patients at increased risk of fracture or with osteoporosis. [4]Rizzoli, R., et al., Management of osteoporosis of the oldest old. Osteoporos Int, 2014. 25(11): p. 2507-29.
  
  [6]Kanis, J.A., et al., European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int, 2019. 30(1): p. 3-44.
  
  
• Dietary sources of calcium are preferred. As calcium-rich foods, dairy products contain additional nutrients (e.g. protein) that also contribute to bone health.
• Calcium supplementation should be considered for those who cannot get enough calcium from their diet and who are at high risk for osteoporosis.
• In patients receiving osteoporosis therapy, combined calcium and vitamin D supplements in a daily dose of 0.5–1.2 g and 400–800 IU, respectively, are generally recommended, since most trial evidence for the efficacy of interventions is based on co-administration of calcium and vitamin D supplements [7]Harvey, N.C., et al., The role of calcium supplementation in healthy musculoskeletal ageing : An expert consensus meeting of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Foundation for Osteoporosis (IOF). Osteoporos Int, 2017. 28(2): p. 447-462.
  
  . Some studies have shown that calcium and vitamin D supplements may decrease secondary hyperparathyroidism and reduce the risk of proximal femur fracture, particularly in the elderly living in nursing homes [8]Tang, B.M., et al., Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet, 2007. 370(9588): p. 657-66.
  
  [9]Weaver, C.M., et al., Calcium plus vitamin D supplementation and risk of fractures: an updated meta-analysis from the National Osteoporosis Foundation. Osteoporos Int, 2016. 27(1): p. 367-76.
  
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• Calcium supplements should be taken with a meal to improve tolerance and increase calcium absorption. While side effects of calcium supplementation may include renal stones and gastrointestinal symptoms, increased cardiovascular risk related to calcium supplementation is not convincingly supported by current evidence [7]Harvey, N.C., et al., The role of calcium supplementation in healthy musculoskeletal ageing : An expert consensus meeting of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Foundation for Osteoporosis (IOF). Osteoporos Int, 2017. 28(2): p. 447-462.
  
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• There is some evidence that vitamin D supplements and calcium may reduce the risk of fracture and falls provided the daily dose of vitamin D is greater than 700 IU [10]Bischoff-Ferrari, H.A., et al., Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ, 2009. 339: p. b3692.
  
  [11]Bischoff-Ferrari, H.A., et al., A pooled analysis of vitamin D dose requirements for fracture prevention. N Engl J Med, 2012. 367(1): p. 40-9.
  
  . In contrast, studies with large annual doses of vitamin D have reported an increased risk of hip fracture and, in one study, also of falls [12]Sanders, K.M., et al., Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA, 2010. 303(18): p. 1815-22.
  
  [13]Smith, H., et al., Effect of annual intramuscular vitamin D on fracture risk in elderly men and women--a population-based, randomized, double-blind, placebo-controlled trial. Rheumatology (Oxford), 2007. 46(12): p. 1852-7.
  
  . The upper limit of vitamin D dose that is beneficial on falls may be lower than previously estimated [14]Bischoff-Ferrari, H.A., et al., Monthly High-Dose Vitamin D Treatment for the Prevention of Functional Decline: A Randomized Clinical Trial. JAMA Intern Med, 2016. 176(2): p. 175-83.
  
  [15]Smith, L.M., J.C. Gallagher, and C. Suiter, Medium doses of daily vitamin D decrease falls and higher doses of daily vitamin D3 increase falls: A randomized clinical trial. J Steroid Biochem Mol Biol, 2017. 173: p. 317-322.
  
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• Intakes of at least 1 g/kg body weight of protein are recommended in the general management of patients with osteoporosis and even 1.2 g/kg in the elderly [1]Bauer, J., et al., Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc, 2013. 14(8): p. 542-59.
  
  [16]Rizzoli, R., et al., The role of dietary protein and vitamin D in maintaining musculoskeletal health in postmenopausal women: a consensus statement from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Maturitas, 2014. 79(1): p. 122-32.
  
  . A recent expert consensus found that in seniors with osteoporosis, dietary protein intake above currently recommended levels may help to reduce bone loss and fracture risk, especially at the hip, provided calcium intakes are adequate [17]Rizzoli, R., et al., Benefits and safety of dietary protein for bone health-an expert consensus paper endorsed by the European Society for Clinical and Economical Aspects of Osteopororosis, Osteoarthritis, and Musculoskeletal Diseases and by the International Osteoporosis Foundation. Osteoporos Int, 2018.
  
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• In patients who have sustained an osteoporosis fracture, sufficient protein intake helps to decrease medical complications following fracture. Intervention studies using an oral dietary preparation that normalizes protein intake can improve the clinical outcome after hip fracture [2]Feldblum, I., et al., Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial. J Am Geriatr Soc, 2011. 59(1): p. 10-7.
  
  [18]Rizzoli, R., Nutritional aspects of bone health. Best Pract Res Clin Endocrinol Metab, 2014. 28(6): p. 795-808.
  
  and reduce the length of stay for rehabilitation in hospital [19]Schurch, M.A., et al., Protein supplements increase serum insulin-like growth factor-I levels and attenuate proximal femur bone loss in patients with recent hip fracture. A randomized, double-blind, placebo-controlled trial. Ann Intern Med, 1998. 128(10): p. 801-9.
  
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• Fruits and vegetables contain an array of vitamins, minerals, antioxidants and alkaline salts - some or all of which can have a beneficial effect on bone. Studies have shown higher fruit and vegetable consumption is associated with beneficial effects on bone density in elderly men and women while less than 5 servings per day may be a risk factor for hip fractures [20]Lin, P.H., et al., The DASH diet and sodium reduction improve markers of bone turnover and calcium metabolism in adults. J Nutr, 2003. 133(10): p. 3130-6.
  
  [21]Qiu, R., et al., Greater Intake of Fruit and Vegetables Is Associated with Greater Bone Mineral Density and Lower Osteoporosis Risk in Middle-Aged and Elderly Adults. PLoS One, 2017. 12(1): p. e0168906.
  
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Together with nutritional advice, patients should be advised to take regular weight-bearing exercise, tailored to their individual needs and abilities.