The importance of nutrition for musculoskeletal health

The number of people suffering from musculoskeletal conditions has grown, globally, by 25% over the last decade – and this is only increasing as time goes by. Some of the most common conditions that fall into the musculoskeletal category include osteoporosis, back pain and osteoarthritis – with the latter making up around half the number of those suffering from a musculoskeletal condition.

Our blog this week is provided Miguel Toribio-Mateas, one of Britain’s leading nutrition practitioners and the chairman of BANT (British Association for Applied Nutrition and Nutritional Therapy). In this week’s blog Miguel discusses the importance of diet and nutrition in the prevention and management of conditions related to musculoskeletal health.

Miguel will be speaking at our upcoming practitioner education event on May 13th, alongside two other expert speakers. To find out more about this event, and to book your place, please follow this link.

The importance of nutrition for musculoskeletal health

Can a healthy diet promote musculoskeletal health, aiding the prevention and management of conditions related to bone, muscle, and connective tissue? I’d say “most definitely yes”.

Conversely, if your diet isn’t diverse enough you may be suffering from insufficiency of some key nutrients needed by these interconnected tissues and thus putting yourself at greater risk for bone, muscle and joint disease, including the dreaded loss of muscle and bone mass associated with sarcopenia and osteoporosis, conditions experienced as part of the “typical” ageing process in today’s societies around the world.

In this blog today I’m covering the essential pieces in the jigsaw that is the health of the musculoskeletal system. In order to optimise structural integrity, the following nutrients are required by our body:


Achieving and maintaining optimal muscle and bone mass requires adequate protein intake, particularly as we age. A protein-deficient diet is likely to weaken your muscles, increasing the risk of falls and fractures. As diet advice abounds on the internet, I see an increasing number of people in my clinics who have tried to “eat clean” following some celebrity on social media, unknowingly lowering the amount of protein they have everyday so much that they have actually ended up feeling exhausted. Liver and muscle cells contain some of the largest amounts of mitochondria in the body. Mitochondria are responsible for making energy (adenosine tri-phosphate, or ATP) so if you “starve” muscle by cutting protein levels right down, you’re likely to feel weak.

Whilst animal protein is highly bioavailable, (i.e. ready to use by our body of building and repairing tissue wherever it’s needed) some say that you can’t get comparable quality protein from plants, which is a myth.

Yes, those who eat meat can enjoy lean red meat, poultry and fish, as their sources of high quality protein, but lacto-ovo vegetarians get equally good protein from eggs and dairy. Vegan protein sources include pulses, e.g. lentils, beans, as well as soya products (e.g. tofu), nuts and seeds.

Fruits and vegetables

Apart from providing a wide array of vitamins, minerals, fibre and antioxidants, fruit and vegetables are also a source of alkaline salts which lower the acid load of protein on bone and kidney.

Some studies have shown that those consuming higher amounts of fruit and vegetables have better bone density in older age. The more variety the better, I ask my clients to aim for at least 50 different foods every week, and to make sure they include a range of different brightly coloured fruit and vegetable on their plate daily. This is illustrated beautifully in the “Eat A Rainbow” poster published by BANT (British Association for Applied Nutrition and Nutritional Therapy) in 2015, which you can find via this link.

Vitamins and Minerals

B Vitamins

The B vitamin group is particularly important for structural integrity, not least because it features some key “methyl donors” such as folate (folic acid), vitamin B12 and vitamin B6 that help keep the toxic aminoacid homocysteine under control.

Homocysteine is a known independent risk factor for cardiovascular disease and cognitive impairment, but some studies also suggest that high homocysteine levels may be linked to lower bone density and higher risk of hip fracture in the elderly. So it is possible that the same B vitamins used to keep homocysteine in check may also play a protective role in preventing osteoporosis and, potentially, reducing fracture risk.

B vitamin sources include poultry – such as chicken or turkey, as well as fish, wholegrains such as oats and brown rice, eggs, green leafy vegetables and soya beans. Aiming for variety and avoiding getting stuck with the same foods every week is important. Again, following my recommendation to aim to eat a minimum of 50 different per week, of all colours you can get, will ensure you have some good sources of B vitamins in the mix.


Calcium cannot be generated by the human body, so it must come from outside sources such as food or dietary supplements. Vitamin D is important for the absorption of calcium from the stomach and for the functioning of calcium in the body.

Calcium is essential for bone growth, a lifelong process during which cells called osteoclasts digest old, weak bone cells that have less calcium than when they were new. Then vitamin D stimulates cells called osteoblasts, enabling new bone to form.

Osteoblasts use calcium to create new layers of bone cells to replace the ones destroyed by the osteoclasts, then the process starts all over again when the the residual calcium in those cells is released into the bloodstream.

Calcium intake is important throughout your lifetime as it contributes to build priceless stores within the skeletal system that minimise calcium leaching from the bones in later life. There is plenty of calcium in dairy foods, but also in dark green, leafy vegetables, as well as in nuts and fortified foods such as tofu and some cereals, as well as in fish, particularly if you eat the soft bones as you would to with tinned sardines, for example.

Some people don’t tolerate certain types of dairy ( e.g. cow’s milk) but they are absolutely fine with other types (e.g. goat’s milk and fermented cow’s milk). Explore your options and try to find foods that you enjoy whilst supporting structural function.

Some fad diets that are not carefully planned can provide very low levels of calcium. Please consult with a professional if you’re in doubt as to whether you’re getting enough of this precious nutrient.

Foods rich in calcium such as sardines, bean, dried figs, almonds, cottage cheese, hazelnuts, parsley leaves, blue poppy seed, broccoli, italian cabbage, cheese, milk

Foods rich in calcium such as sardines, bean, dried figs, almonds, cottage cheese, hazelnuts, parsley leaves, blue poppy seed, broccoli, italian cabbage, cheese, milk

Vitamins D and K

Vitamin D is a fat-soluble vitamin that helps your body absorb calcium and phosphorus. Having the right amount of vitamin D, calcium, and phosphorus is important for building and keeping strong bones.

Vitamin D is not very bioavailable from food sources and is best made in the skin as a result of exposure to sunlight. As this can be problematic in countries where sun is a premium commodity, food supplements are recommended during the winter months. Aside from being involved in calcium metabolism, as seen above, vitamin D supplementation and higher dietary calcium together are effective for fracture risk reduction.

Vitamin D improves muscle strength and reduces the risk of falls. Frail older patients with low baseline levels of vitamin D (<30 nmol/L) show the highest therapeutic benefit. Vitamin K is required for the correct mineralisation of bone.

Some evidence suggests low vitamin K levels lead to low bone density and increased risk of fracture in the elderly. Vitamin K sources include leafy green vegetables such as lettuce, spinach and cabbage, liver and some fermented cheeses and soya bean products.

Vitamin D has traditionally been extracted from fish oil or lanolin, the oil coating sheep’s wool. Vitamin D from fish oil could potentially contain traces of mercury, so I always advise my clients to check labels and read about the company’s manufacturing processes before buying a food supplement. There are also some concerns about the extraction methods involved in making vitamin D from lanolin, which involve several toxic chemicals.

For these two reasons I have only been recommending vegan vitamin D for the last few years. It’s made from lichen, and sourced and manufactured sustainably. By the way, I refer to vitamin D3 (cholecalciferol) and not vitamin D2 (ergocalciferol). Vitamin D3 is the biologically active form of the vitamin, found in every cell in our bodies. When your skin is exposed to sunlight, a reactive process converts cholesterol into vitamin D3. Vitamin D2 is the plant version of D3 that plants and produce when exposed to UV light. It’s normally the type of vitamin D added to fortified foods. Most studies exploring the effects of vitamin D food supplements are based on vitamin D3, and this is the type that even Public Health England recommends supplementing with.

With regards to vitamin K, there are many forms of this nutrient and research shows that some are more bioavailable than other. A specific form called MK-7 (short for menaquinone-7) seems to provide a double whammy of goodness by supporting musculoskeletal health whilst having mild anti-inflammatory activity. Those taking blood thinners should consult with their health professional before taking vitamin K supplements.

Vitamin A

The role of vitamin A in bone health is controversial. Foods of animal origin such as liver and other offal, fish liver oils, dairy foods and egg yolk, contain vitamin A as retinol, which is readily available for the body to use, whilst plant foods contain precursors of vitamin A called carotenes, e.g. beta carotene in carrots.

Carotenes are responsible for some of the green in green leafy vegetables (like kale), and for the red and yellow in coloured fruits and vegetables, like in peppers. Consumption of vitamin A in amounts well above the recommended daily intake may have adverse effects on bone. But fear not. Really high levels of vitamin A are probably only achieved through over-use of supplements, and intakes from food sources are not likely to pose a problem.

It is advisable that you check with your health professional if you think you may be overdoing it or are taking supplements without following professional advice. You should also refrain from taking vitamin A supplements if you’re pregnant as bioaccumulation of this nutrient can affect your unborn baby. Always seek professional advice.


Magnesium also plays an key role in forming bone mineral, and although it is very rare to get magnesium deficiency is rare in populations that are well nourished, some individuals may be at mild risk of magnesium deficiency, particularly the elderly as as magnesium absorption decreases with age. Magnesium deficiency contributes to osteoporosis directly by acting on crystal formation and on bone cells, and indirectly by impacting on the secretion and the activity of parathyroid hormone and by promoting low grade inflammation.

Whilst I believe that you can get all the calcium you need from your diet, adding some supplementary magnesium may be a good idea for some. It adds to the plentiful magnesium provided by green leafy vegetables, pulses, nuts, seeds, whole grains and fish. Controlling and maintaining magnesium balance represents a helpful intervention to optimise bone integrity and health as we age.


This mineral is required for bone tissue renewal and mineralisation. Although it makes up a small percentage of the bone, zinc is needed to form hydroxylapatite which is a naturally occurring crystalline calcium complex. Hydroxylapatite crystals form the bulk of bones and teeth and modified forms of hydroxyapatite actually account for about half of the weight of the bone. Therefore, zinc is important to the proper mineralisation of bones by contributing to its bone mass. Zinc also works as a co-factor modulating the activity of the immune system and is involved in learning, memory formation, cellular signalling, gene expression and the metabolism of DNA and RNA. You can end up experiencing zinc deficiency as a result of extreme calorie restriction, as well as as a result of protein malnutrition. Some badly planned diets that contain dangerously low protein levels which contributes to impaired bone growth and repair. Sources of zinc include lean red meat, poultry, whole grain cereals and pulses.

So what is the key to achieving optimal musculoskeletal health?

It is safe to say that vitamin D is possibly the key nutrient for musculoskeletal health, particularly because it supports calcium metabolism, and calcium, as explained above, is a major building-block of bone tissue (the skeleton houses 99% of the body’s calcium stores). As vitamin D is enables your body to absorb calcium, the two work as an inseparable tandem. However as a clinician for me the key is variety. A diet that contains plenty of colourful vegetables, some brightly coloured fruits, and good sources of protein, whether animal or vegetarian, is likely to provide you with the range of nutrients that work as a complex matrix to support bone and muscle health.



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