Musculoskeletal disease is a broad term which encompasses many different conditions that can affect the bones, joints, tendons, ligaments and muscles. Conditions include osteoarthritis, rheumatoid arthritis, osteoporosis, fibromyalgia, sarcopenia and many more. Symptoms can range from stiffness, pain, swelling, joint deformity and restricted movement.
Public Health Impact
Musculoskeletal conditions affect over 14.9 million people nationally1 and are the second most common reason for absence from work in the UK.2 The NHS alone spends over £5 billion annually in treating and supporting these conditions1 and on a global scale it is estimated that 20–33% of the population live with a musculoskeletal condition.3
These statistics are concerning and are set to increase. It is important therefore to understand the major risk factors at play – these include, sedentary lifestyles, poor nutrition/hydration, obesity and an ageing population.
In 2018 Public Health England launched the 5-year Musculoskeletal Health Improvement Programme in response to the global health and economic concerns. Its vision to “Improve the musculoskeletal health of the population.”1 It set out to do this through a whole-systems approach with a key focus on dietary health.
We are often advised to eat healthily to promote and maintain our brain health or the health of our hearts – and this is also crucial for our musculoskeletal health. Eating a varied, well-balanced, nutrient-rich diet is a good place to start, as an insufficiency of key nutrients puts yourself at risk for bone, muscle or joint disease. Nutrition can play many roles – it can modulate the immune system, be tailored to help suppress pain and inflammation and provide specific nutrients needed for growth, maintenance and repair. Symptoms can therefore often be reduced, or conditions may be evaded altogether by implementing nutritional strategies.
Skip to key takeaways
One key component of bone and muscle health is protein. Bone is predominantly made up of proteins and minerals – collagen is the main protein that provides bone with strength and flexibility. Consuming sufficient dietary protein is vital for growth, renewal and maintenance, and it is important that intake is sufficient over the life course. Eating a diet that is low in protein is likely to increase the risk for weaker bones and muscle and thus raise your chances of a fall, fracture or disease. Quality animal protein such as grass-fed meat and organic free-range poultry is a good choice and sources for vegetarians including dairy and eggs (if tolerated) and vegan sources such as lentils, beans, nuts and seeds. It is advisable however to soak these prior to consumption to increase digestibility and to lower phytate levels, which can bind to nutrients rendering them unavailable.
The B vitamin group has been found to have positive effects on bone health. B6, B9 and B12 are cofactors for the enzymes that are involved in the metabolism of homocysteine, and deficiencies have been shown to coincide with elevated homocysteine levels. High levels of homocysteine can impair bone health by increasing osteoclast activity resulting in increased bone resorption. This explains its relationship with decreased bone mineral density and why it is implicated in increased fracture risk.4,5 High levels of homocysteine have also been linked to lower muscle strength in women.6 Good sources of B vitamins include wholegrains, dark leafy vegetables, meat, fish, eggs and dairy products.
Vitamin C helps in the formation of collagen which provides structure for minerals in the bone. It also plays a role in stimulating osteoblast activity and thus bone formation. In addition, it has been shown that vitamin C can have positive effects on calcium absorption.7 Fruit and vegetables are excellent sources of vitamin C, particularly citrus fruits. They are also good sources of other vitamins, minerals and fibre and have an alkalising effect on the body which can help to balance out the acid-forming effects of protein in the diet.
Calcium is an integral component of bone and is the most abundant mineral in our body – 99% of total body calcium is found in the bone. The formation of bone and its maintenance is a process that spans our lifetime and is in a continual state of activity. Much research now supports the importance of maternal and in-utero nutrition for healthy bones in later life. The two main cells involved in remodelling of the bone are osteoclasts and osteoblasts. Osteoclasts break down the bone (resorption), and osteoblasts are responsible for the formation of new bone. Calcium is essential for the formation of new bone. Blood concentrations of calcium must be kept within a specific range to maintain essential functions in the body, such as muscle contraction. If the diet is low in calcium the body responds by releasing the parathyroid hormone, which instructs the bones to release calcium. Over time, this can weaken bones and leave them prone to disease. Diseases such as osteoporosis occur when bone resorption exceeds bone formation.
Calcium cannot be made by the body so must be delivered via food or supplementation. In addition, our ability to absorb calcium lessens as we age leaving us even more prone to disease. It is important therefore, that adequate levels of calcium are reached through diet to prevent bone resorption. In addition to dairy products, other calcium-rich foods include dark leafy vegetables, fortified foods and soft-bone fish such as sardines and salmon.
Phosphorus also provides a structural role and is involved in osteoblastic activity. Fizzy drinks often contain phosphoric acid and there is some research that over consumption may interfere with calcium absorption and thus increase the loss of calcium from the bone. We all know that soda is bad for our health so avoidance of it is recommended.
Vitamins D & K
Vitamin D is a fat-soluble vitamin which has very important effects on musculoskeletal health. It is fundamental to bone health as it regulates calcium and phosphorus and is required for their absorption from food. It is also needed for new bone formation as it stimulates osteoblast activity. Vitamin D is positively associated with immune function and deficiencies have been implicated in autoimmune diseases such as Rheumatoid Arthritis and other inflammatory conditions.8,9
Vitamin D deficiency can lead to a range of musculoskeletal problems including muscle weakness, bone pain, increased risk of falling and low bone mass and has been linked to many other conditions such as osteoporosis and rickets.meta-analyses have clearly shown a significant reduced risk of fractures in subjects supplementing with calcium with vitamin D.10,11
In 2019, The British Nutrition Foundation warned that low levels of vitamin D in the UK were extremely concerning and that younger people were at risk from developing osteoporosis and osteomalacia (adult form of rickets).12
It is difficult however, to obtain adequate levels of vitamin D from food alone, particularly in the winter months. In 2016 Public Health England advised that everyone should be supplementing with vitamin D and in the form of D3 as it is more bioavailable. Food sources of vitamin D include fatty fish, eggs yolk and butter.
Vitamin K has been shown to work synergistically with vitamin D and have positive effects on bone mineral density, calcium balance and bone metabolism.13 (Those on blood thinning medication should consult their doctor before taking vitamin K supplements.) Good sources of vitamin K are found in green leafy vegetables such as kale/ collard greens and spinach.
The majority of the magnesium in our body is located within our bones and plays a key role in the formation of new bone and for maintaining density. There is much research showing that sufficient intake of magnesium correlates with increased bone mineral density, and thus important for conditions such as osteoporosis. Magnesium also plays an important role in helping muscles to relax. It does this by aiding the absorption of calcium, which helps to stop the calcification of soft tissue and muscle. A deficiency in magnesium can thus contribute to tension throughout the joints and muscles.
Many dietary factors can deplete magnesium such as the over-consumption of fizzy drinks, alcohol, caffeine and sugar. Avoidance or reduction in these with an increased consumption of dark leafy vegetables, nuts, seeds and wholegrains should ensure the body receives sufficient magnesium. It is important to be mindful of the increased need for magnesium as we age, this is due to factors such as decreased absorption, illness and/or medications
Zinc is needed for bone tissue renewal and mineralisation and plays a vital part in the regulation of bone homeostasis. Zinc is also important for the immune system and has been implicated in pathologies where zinc deficiency and inflammation have been observed together. The results from a systematic review and meta-analysis showed that zinc concentrations in subjects with autoimmune disease (including Rheumatoid arthritis) were lower than control groups.14 Diets that are low in protein may be at risk for zinc deficiency. Foods that provide good levels of zinc include red meat and poultry, wholegrains, pumpkin seeds and legumes.
Inflammation often lies at the heart of disease and musculoskeletal conditions often have an inflammatory component. They are however, often grouped as either inflammatory (e.g. rheumatoid arthritis) or non-inflammatory (e.g. osteoporosis). Osteoarthritis is known as a degenerative joint disease and more common as we age due to wear and tear and loss of cartilage. Although not typically an inflammatory condition, there is much research now that shows inflammatory mediators in its initiation and progression. Whatever the musculoskeletal condition, following an anti-inflammatory diet may have great benefit.
Anti-inflammatory foods include lots of vegetables and some fruit, healthy fats such as fatty fish, olive oil and avocado and others such as ginger and turmeric. Avoidance of processed foods is recommended as these can be high in sugars and unhealthy fats, which are inflammatory. Grains containing gluten are often problematic for many so removal of these is suggested as is the removal of dairy if it is a problem. There are many alternative sources of calcium available if dairy is removed as mentioned above.
Obesity is predominantly linked to diet and lifestyle choices and is thought to be a key co-morbidity of many musculoskeletal conditions, in particular it is closely related to the development of osteoarthritis.15 Being obese puts extra pressure on the joints and bones and can be directly linked to the development of musculoskeletal conditions or exacerbate existing ones. Obesity also creates low-grade inflammation in the body and many common inflammatory pathways have been implicated in the pathogenesis of the interrelated tissues of the musculoskeletal system.16 Public Health England have highlighted tackling obesity as fundamental in addressing musculoskeletal health in their 5-year health programme.
A Westernised diet includes foods that are often nutrient poor but energy dense and typically include high amounts of refined sugar, grains and unhealthy fats. All of which have been shown to contribute to weight gain and inflammation. Consuming plenty of fruits and vegetables, lean protein, nuts and seeds with healthy fats are good choices. As obesity promotes inflammation in the body eating an anti-inflammatory diet is recommended (as outlined above).
While it is important, we are ingesting all the nutrients needed for musculoskeletal health, it is also important to consider the health of our gut. There is much research that links inflammation of the gut with the decreased absorption of nutrients. With regard to musculoskeletal health this can affect the absorption of bone-loving nutrients such as Magnesium, Calcium and Vitamin D/K as mentioned. Inflammation of the gut may also increase the likelihood of developing conditions such as osteoporosis, as inflammation can interfere with the delicate balance between bone resorption and formation. For example, research has shown that there is a strong correlation between gut microbe dysregulation and decreased bone density in patients with osteoporosis.17 Ensuring that measures are taken to support the integrity of the gut may prove beneficial. See our blogs on gut health:
Adequate hydration must go hand-in-hand with proper nutrition. Water helps to lubricate joints, deliver nutrients to cells and remove waste, and helps with the normal functioning of the digestive system
Musculoskeletal conditions can affect all age groups and are not confined to old age nor should they be an inevitable part of ageing. There is much we can do to help protect our musculoskeletal health. Implementing diet and lifestyle changes can go a long way to safeguard against developing musculoskeletal disease, help to change disease progression and to lessen the impact of symptoms.
- Protein – Consuming sufficient dietary protein is vital for growth, renewal and maintenance.
- B Vitamins – Deficiencies in B6, B9 & B12 have been shown to coincide with elevated homocysteine levels. High homocysteine can impair bone health. Implicated in increased fracture risk, low muscle strength and decreased bone mineral density. Good sources include green leafy vegetables, meat, fish, eggs and dairy.
- Calcium – Integral component of bone and essential for the formation of new bone. Most abundant mineral in body. If diet is low in calcium the body responds by releasing the parathyroid hormone, which instructs the bones to release calcium. Over time, this can weaken bones and leave them prone to disease. Good sources include dairy, dark leafy vegetables, fortified foods and soft-bone fish such as sardines and salmon.
- Phosphorus – Provides a structural role and is involved in osteoblastic activity. Fizzy drinks often contain phosphoric acid and there is some research that over consumption may interfere with calcium absorption and thus affect bone health.
- Vitamin D – Regulates calcium and phosphorus and is required for their absorption. Also needed for new bone formation as it stimulates osteoblast activity. Positively associated with immune function – deficiencies have been implicated in Rheumatoid Arthritis. Deficiency can lead to muscle weakness, bone pain, low bone mass, osteoporosis. Difficult to obtain adequate levels from food alone, particularly in the winter. Public Health England advises everyone should be supplementing with vitamin D. Food sources include fish, eggs yolk and butter.
- Vitamin K – Works synergistically with vitamin D and has positive effects on bone mineral density, calcium balance and bone metabolism. Good sources are found in green leafy vegetables such as kale/ collard greens and spinach.
- Magnesium – Key role in the formation of new bone and maintaining density. Also important in helping muscles to relax. Encourages the absorption of calcium which helps stop soft tissue and muscle from calcifying. Good sources include dark leafy vegetables, nuts, seeds and wholegrains. Soda, alcohol, caffeine and sugar can easily deplete magnesium. We have an increased need for magnesium as we age.
- Zinc – Needed for bone tissue renewal and mineralisation. Zinc is important for the immune system and deficiency has been implicated in autoimmune disease. Good levels of zinc include red meat, poultry, wholegrains, pumpkin seeds and legumes.
- Inflammation – Musculoskeletal conditions often have an inflammatory component. Incorporating foods into your diet that exert an anti-inflammatory effect can be beneficial.
- Obesity – Thought to be a key co-morbidity of many musculoskeletal conditions. Being obese puts extra pressure on the joints and bones. Obesity creates low-grade inflammation and many inflammatory pathways have been implicated in the pathogenesis of the interrelated tissues of the musculoskeletal system. Westernised diet includes foods that are often nutrient poor but energy dense.
- Gut Microbiota – Inflammation of gut linked with the decreased absorption of nutrients – this can affect the absorption of Magnesium, Calcium, Vitamin D/K. Inflammation can interfere with the delicate balance between bone resorption and formation. Strong correlation between gut microbe dysregulation and decreased bone density in patients with osteoporosis.
- Hydration – Water helps to lubricate joints, deliver nutrients to cells, remove waste, and helps with the normal functioning of the digestive system
If you have questions regarding the topics that have been raised, or any other health matters, please do contact me (Amanda) by phone or email at any time.
Amanda Williams and the Cytoplan Editorial Team
- NHS England (2019) Musculoskeletal Health: A 5 year strategic framework for prevention across the lifecourse Department of Health and Social care working with Public Health England and Department for Work and Pensions. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/810348/Musculoskeletal_Health_5_year_strategy.pdf (Accessed 10th March 2020)
- Michael Comer (2017) Sickness absence in the UK labour market – Office for National Statistics, Office for National Statistics. Available at: https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/labourproductivity/articles/sicknessabsenceinthelabourmarket/2018 (Accessed: 10 March 2020).
- WHO (2019) Musculoskeletal Conditions [online] Available at: https://www.who.int/news-room/fact-sheets/detail/musculoskeletal-conditions [Accessed 10th March 2020]
- Van Meurs, J. B. J. et al. (2004) ‘Homocysteine Levels and the Risk of Osteoporotic Fracture’, New England Journal of Medicine, 350(20), pp. 2033-2041+2113. doi: 10.1056/NEJMoa032546.
- Dai, Z. and Koh, W. P. (2015) ‘B-vitamins and bone health–a review of the current evidence’, Nutrients. MDPI AG, pp. 3322–3346. doi: 10.3390/nu7053322.
- Vidoni, M. L. et al. (2018) ‘Relationship between Homocysteine and Muscle Strength Decline: The Baltimore Longitudinal Study of Aging.’, The journals of gerontology. Series A, Biological sciences and medical sciences, 73(4), pp. 546–551. doi: 10.1093/gerona/glx161.
- Choi, H. K. et al. (2019) ‘Vitamin C activates osteoblastogenesis and inhibits osteoclastogenesis via Wnt/β-catenin/ATF4 signaling pathways’, Nutrients. MDPI AG, 11(3). doi: 10.3390/nu11030506.
- Kostoglou-Athanassiou, I. et al. (2012) ‘Vitamin D and rheumatoid arthritis’, Therapeutic Advances in Endocrinology and Metabolism. SAGE Publications, 3(6), pp. 181–187. doi: 10.1177/2042018812471070.
- Jones, A. N. and Hansen, K. E. (2009) ‘Recognizing the musculoskeletal manifestations of vitamin D deficiency.’, The Journal of musculoskeletal medicine. NIH Public Access, 26(10), pp. 389–396. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21984863 (Accessed: 25 March 2020).
- Yao, P. et al. (2019) ‘Vitamin D and Calcium for the Prevention of Fracture: A Systematic Review and Meta-analysis’, JAMA network open. NLM (Medline), 2(12), p. e1917789. doi: 10.1001/jamanetworkopen.2019.17789.
- Weaver, C. M. et al. (2016) ‘Calcium plus vitamin D supplementation and risk of fractures: an updated meta-analysis from the National Osteoporosis Foundation’, Osteoporosis International. Springer London, 27(1), pp. 367–376. doi: 10.1007/s00198-015-3386-5.
- Low levels of vitamin D in UK ‘extremely concerning’, warns the British Nutrition Foundation (2019). Available at: https://www.foodnavigator.com/Article/2019/11/21/Low-levels-of-vitamin-D-in-UK-extremely-concerning-warns-the-British-Nutrition-Foundation# (Accessed: 20 March 2020).
- Hamidi, M. S., Gajic-Veljanoski, O. and Cheung, A. M. (2013) ‘Vitamin K and Bone Health’, Journal of Clinical Densitometry, 16(4), pp. 409–413. doi: 10.1016/j.jocd.2013.08.017.
- Sanna, A. et al. (2018) ‘Zinc status and autoimmunity: A systematic review and meta-analysis’, Nutrients. MDPI AG. doi: 10.3390/nu10010068.
- Lewis, R. et al. (2019) ‘Strategies for optimising musculoskeletal health in the 21 st century’, BMC Musculoskeletal Disorders. BioMed Central Ltd. doi: 10.1186/s12891-019-2510-7.
- Collins, K. H. et al. (2018) ‘Obesity, metabolic syndrome, and musculoskeletal disease: Common inflammatory pathways suggest a central role for loss of muscle integrity’, Frontiers in Physiology. Frontiers Media S.A. doi: 10.3389/fphys.2018.00112.
- II, D. Y. et al. (2019) ‘Linkage of microbiota and osteoporosis: A mini literature review’, World Journal of Orthopedics. Baishideng Publishing Group Co, 10(3), pp. 123–127. doi: 10.5312/wjo.v10.i3.123.