Nutr Res Pract.  2025 Apr;19(2):155-169. 10.4162/nrp.2025.19.2.155.

Strategies for preventing bone loss in populations with insufficient calcium and vitamin D intake

• Yeum KJ
• Ju S
• Choe U

• KMID: 2566806
• DOI: http://doi.org/10.4162/nrp.2025.19.2.155

Abstract

Calcium and vitamin D are essential nutrients for maintaining skeletal health, yet deficiencies in these nutrients are particularly widespread in regions such as Asia and Africa. Inadequate intake of these nutrients in these areas has been associated with diminished bone integrity and a rising incidence of osteoporosis. This review examines the underlying mechanisms of bone loss driven by calcium and vitamin D deficiencies, emphasizing their crucial roles in bone metabolism. It also presents strategies to improve nutrient intake, such as fortification of staple foods and supplementation, along with lifestyle modifications including increased physical activity, sun exposure, and dietary education, to prevent bone loss effectively. Special consideration is given to vulnerable populations, including older adults, individuals with limited sun exposure, and those with dietary restrictions, who are at higher risk of deficiency. The review further evaluates public health strategies, including government-initiated fortification and educational programs, as essential measures for tackling widespread nutrient deficiencies. Lastly, it explores future avenues for addressing calcium and vitamin D deficiencies, including the potential role of digital health tools, personalized nutrition, and innovative public health policies to alleviate the global burden of bone-related diseases.

Keyword

Bone diseases; calcium; vitamin D deficiency; dietary intervention

Figure

• 

  Fig. 1 Strategies for ensuring adequate intake of calcium, vitamin D, and related micronutrients.

• 

  Fig. 2 Suggested lifestyle and behavioral approaches to prevent bone loss in populations with insufficient calcium and vitamin D intake.

• 

  Fig. 3 Special considerations for vulnerable populations in supporting skeletal health.UV, ultraviolet.

• 

  Fig. 4 Public health strategies for preventing bone loss in calcium and vitamin D deficient populations.

Reference

1. Heaney RP. The bone remodeling transient: interpreting interventions involving bone-related nutrients. Nutr Rev. 2001; 59:327–334. PMID: 11669238.

2. Reid IR, Bristow SM. Calcium and bone. Handb Exp Pharmacol. 2020; 262:259–280. PMID: 31792679.

3. Holick MF. Vitamin D deficiency. N Engl J Med. 2007; 357:266–281. PMID: 17634462.

4. Shlisky J, Mandlik R, Askari S, Abrams S, Belizan JM, Bourassa MW, Cormick G, Driller-Colangelo A, Gomes F, Khadilkar A, et al. Calcium deficiency worldwide: prevalence of inadequate intakes and associated health outcomes. Ann N Y Acad Sci. 2022; 1512:10–28. PMID: 35247225.

5. Bourassa MW, Abrams SA, Belizán JM, Boy E, Cormick G, Quijano CD, Gibson S, Gomes F, Hofmeyr GJ, Humphrey J, et al. Interventions to improve calcium intake through foods in populations with low intake. Ann N Y Acad Sci. 2022; 1511:40–58. PMID: 35103316.

6. Segurel L, Bon C. On the evolution of lactase persistence in humans. Annu Rev Genomics Hum Genet. 2017; 18:297–319. PMID: 28426286.

7. Anguita-Ruiz A, Aguilera CM, Gil Á. Genetics of lactose intolerance: an updated review and online interactive world maps of phenotype and genotype frequencies. Nutrients. 2020; 12:2689. PMID: 32899182.

8. Reid IR, Bolland MJ. Calcium and/or vitamin D supplementation for the prevention of fragility fractures: who needs it? Nutrients. 2020; 12:1011. PMID: 32272593.

9. Mithal A, Wahl DA, Bonjour JP, Burckhardt P, Dawson-Hughes B, Eisman JA, El-Hajj Fuleihan G, Josse RG, Lips P, Morales-Torres J, et al. Global vitamin D status and determinants of hypovitaminosis D. Osteoporos Int. 2009; 20:1807–1820. PMID: 19543765.

10. Palacios C, Gonzalez L. Is vitamin D deficiency a major global public health problem? J Steroid Biochem Mol Biol. 2014; 144(Pt A):138–145. PMID: 24239505.

11. Dennison E, Mohamed MA, Cooper C. Epidemiology of osteoporosis. Rheum Dis Clin North Am. 2006; 32:617–629. PMID: 17288968.

12. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006; 17:1726–1733. PMID: 16983459.

13. Compston JE, McClung MR, Leslie WD. Osteoporosis. Lancet. 2019; 393:364–376. PMID: 30696576.

14. Liu X, Wu Y, Bennett S, Zou J, Xu J, Zhang L. The effects of different dietary patterns on bone health. Nutrients. 2024; 16:2289. PMID: 39064732.

15. Joo NS, Dawson-Hughes B, Kim YS, Oh K, Yeum KJ. Impact of calcium and vitamin D insufficiencies on serum parathyroid hormone and bone mineral density: analysis of the fourth and fifth Korea National Health and Nutrition Examination Survey (KNHANES IV-3, 2009 and KNHANES V-1, 2010). J Bone Miner Res. 2013; 28:764–770. PMID: 23045165.

16. Thomas SD, Need AG, Tucker G, Slobodian P, O’Loughlin PD, Nordin BE. Suppression of parathyroid hormone and bone resorption by calcium carbonate and calcium citrate in postmenopausal women. Calcif Tissue Int. 2008; 83:81–84. PMID: 18553042.

17. Lips P. Vitamin D deficiency and secondary hyperparathyroidism in the elderly: consequences for bone loss and fractures and therapeutic implications. Endocr Rev. 2001; 22:477–501. PMID: 11493580.

18. Anderson PH, Atkins GJ, Turner AG, Kogawa M, Findlay DM, Morris HA. Vitamin D metabolism within bone cells: effects on bone structure and strength. Mol Cell Endocrinol. 2011; 347:42–47. PMID: 21664230.

19. Bikle DD. Vitamin D and bone. Curr Osteoporos Rep. 2012; 10:151–159. PMID: 22544628.

20. Lips P. Interaction between vitamin D and calcium. Scand J Clin Lab Invest Suppl. 2012; 243:60–64. PMID: 22536764.

21. Heaney RP. Vitamin D and calcium interactions: functional outcomes. Am J Clin Nutr. 2008; 88:541S–544S. PMID: 18689398.

22. Sfeir JG, Drake MT, Khosla S, Farr JN. Skeletal aging. Mayo Clin Proc. 2022; 97:1194–1208. PMID: 35662432.

23. Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, Lindsay R. National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014; 25:2359–2381. PMID: 25182228.

24. Ross AC, Manson JE, Abrams SA, Aloia JF, Brannon PM, Clinton SK, Durazo-Arvizu RA, Gallagher JC, Gallo RL, Jones G, et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab. 2011; 96:53–58. PMID: 21118827.

25. Ministry of Health and Welfare. The Korean Nutrition Society. Dietary Reference Intakes for Koreans 2015. Sejong: Ministry of Health and Welfare;2016.

26. Heaney RP, Recker RR, Weaver CM. Absorbability of calcium sources: the limited role of solubility. Calcif Tissue Int. 1990; 46:300–304. PMID: 2110852.

27. Heaney RP, Dowell MS, Barger-Lux MJ. Absorption of calcium as the carbonate and citrate salts, with some observations on method. Osteoporos Int. 1999; 9:19–23. PMID: 10367025.

28. Ross EA, Szabo NJ, Tebbett IR. Lead content of calcium supplements. JAMA. 2000; 284:1425–1429. PMID: 10989406.

29. Schaafsma A, van Doormaal JJ, Muskiet FA, Hofstede GJ, Pakan I, van der Veer E. Positive effects of a chicken eggshell powder-enriched vitamin-mineral supplement on femoral neck bone mineral density in healthy late post-menopausal Dutch women. Br J Nutr. 2002; 87:267–275. PMID: 12064336.

30. Giustina A, Bouillon R, Dawson-Hughes B, Ebeling PR, Lazaretti-Castro M, Lips P, Marcocci C, Bilezikian JP. Vitamin D in the older population: a consensus statement. Endocrine. 2023; 79:31–44. PMID: 36287374.

31. Holick MF, Chen TC, Lu Z, Sauter E. Vitamin D and skin physiology: a D-lightful story. J Bone Miner Res. 2007; 22(Suppl 2):V28–V33. PMID: 18290718.

32. Webb AR, Engelsen O. Calculated ultraviolet exposure levels for a healthy vitamin D status. Photochem Photobiol. 2006; 82:1697–1703. PMID: 16958558.

33. Wacker M, Holick MF. Sunlight and vitamin D: a global perspective for health. Dermatoendocrinol. 2013; 5:51–108. PMID: 24494042.

34. Young AR, Narbutt J, Harrison GI, Lawrence KP, Bell M, O’Connor C, Olsen P, Grys K, Baczynska KA, Rogowski-Tylman M, et al. Optimal sunscreen use, during a sun holiday with a very high ultraviolet index, allows vitamin D synthesis without sunburn. Br J Dermatol. 2019; 181:1052–1062. PMID: 31069787.

35. Rebelos E, Tentolouris N, Jude E. The role of vitamin D in health and disease: a narrative review on the mechanisms linking vitamin D with disease and the effects of supplementation. Drugs. 2023; 83:665–685. PMID: 37148471.

36. Vieth R. Vitamin D supplementation: cholecalciferol, calcifediol, and calcitriol. Eur J Clin Nutr. 2020; 74:1493–1497. PMID: 32704098.

37. Holick MF, Chen TC. Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutr. 2008; 87:1080S–1086S. PMID: 18400738.

38. Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr. 1999; 69:842–856. PMID: 10232622.

39. Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM. Endocrine Society. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011; 96:1911–1930. PMID: 21646368.

40. Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, Gamble GD, Reid IR. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ. 2010; 341:c3691. PMID: 20671013.

41. Rude RK, Gruber HE, Wei LY, Frausto A, Mills BG. Magnesium deficiency: effect on bone and mineral metabolism in the mouse. Calcif Tissue Int. 2003; 72:32–41. PMID: 12370796.

42. Calvo MS, Tucker KL. Is phosphorus intake that exceeds dietary requirements a risk factor in bone health? Ann N Y Acad Sci. 2013; 1301:29–35. PMID: 24472074.

43. Iwamoto J, Takeda T, Sato Y. Effects of vitamin K2 on the development of osteopenia in rats as the models of osteoporosis. Yonsei Med J. 2006; 47:157–166. PMID: 16642543.

44. Rude RK, Singer FR, Gruber HE. Skeletal and hormonal effects of magnesium deficiency. J Am Coll Nutr. 2009; 28:131–141. PMID: 19828898.

45. Calvo MS, Lamberg-Allardt CJ. Phosphorus. Adv Nutr. 2015; 6:860–862. PMID: 26567206.

46. Takeda E, Yamamoto H, Yamanaka-Okumura H, Taketani Y. Increasing dietary phosphorus intake from food additives: potential for negative impact on bone health. Adv Nutr. 2014; 5:92–97. PMID: 24425727.

47. Heaney RP, Layman DK. Amount and type of protein influences bone health. Am J Clin Nutr. 2008; 87:1567S–1570S. PMID: 18469289.

48. Bonjour JP. Protein intake and bone health. Int J Vitam Nutr Res. 2011; 81:134–142. PMID: 22139564.

49. Heaney RP. Effects of caffeine on bone and the calcium economy. Food Chem Toxicol. 2002; 40:1263–1270. PMID: 12204390.

50. Yatabe MS, Yatabe J, Takano K, Murakami Y, Sakuta R, Abe S, Sanada H, Kimura J, Watanabe T. Effects of a high-sodium diet on renal tubule Ca2+ transporter and claudin expression in Wistar-Kyoto rats. BMC Nephrol. 2012; 13:160. PMID: 23199000.

51. Caudarella R, Vescini F, Rizzoli E, Francucci CM. Salt intake, hypertension, and osteoporosis. J Endocrinol Invest. 2009; 32:15–20. PMID: 19724161.

52. Weber P. Vitamin K and bone health. Nutrition. 2001; 17:880–887. PMID: 11684396.

53. Knapen MH, Schurgers LJ, Vermeer C. Vitamin K2 supplementation improves hip bone geometry and bone strength indices in postmenopausal women. Osteoporos Int. 2007; 18:963–972. PMID: 17287908.

54. Iwamoto J, Sato Y, Takeda T, Matsumoto H. High-dose vitamin K supplementation reduces fracture incidence in postmenopausal women: a review of the literature. Nutr Res. 2009; 29:221–228. PMID: 19410972.

55. Vähävihu K, Ylianttila L, Kautiainen H, Viljakainen H, Lamberg-Allardt C, Hasan T, Tuohimaa P, Reunala T, Snellman E. Narrowband ultraviolet B course improves vitamin D balance in women in winter. Br J Dermatol. 2010; 162:848–853. PMID: 20105173.

56. Tangpricha V, Turner A, Spina C, Decastro S, Chen TC, Holick MF. Tanning is associated with optimal vitamin D status (serum 25-hydroxyvitamin D concentration) and higher bone mineral density. Am J Clin Nutr. 2004; 80:1645–1649. PMID: 15585781.

57. Kohrt WM, Bloomfield SA, Little KD, Nelson ME, Yingling VR. American College of Sports Medicine. American College of Sports Medicine position stand: physical activity and bone health. Med Sci Sports Exerc. 2004; 36:1985–1996. PMID: 15514517.

58. Frost HMA. A 2003 update of bone physiology and Wolff’s Law for clinicians. Angle Orthod. 2004; 74:3–15. PMID: 15038485.

59. Winters-Stone KM, Snow CM. Site-specific response of bone to exercise in premenopausal women. Bone. 2006; 39:1203–1209. PMID: 16876495.

60. Hong AR, Kim SW. Effects of resistance exercise on bone health. Endocrinol Metab (Seoul). 2018; 33:435–444. PMID: 30513557.

61. Youkhana S, Dean CM, Wolff M, Sherrington C, Tiedemann A. Yoga-based exercise improves balance and mobility in people aged 60 and over: a systematic review and meta-analysis. Age Ageing. 2016; 45:21–29. PMID: 26707903.

62. Chow TH, Lee BY, Ang ABF, Cheung VYK, Ho MMC, Takemura S. The effect of Chinese martial arts Tai Chi Chuan on prevention of osteoporosis: a systematic review. J Orthop Translat. 2017; 12:74–84. PMID: 29662781.

63. Ward KD, Klesges RC. A meta-analysis of the effects of cigarette smoking on bone mineral density. Calcif Tissue Int. 2001; 68:259–270. PMID: 11683532.

64. Kanis JA, Johnell O, Oden A, Johansson H, De Laet C, Eisman JA, Fujiwara S, Kroger H, McCloskey EV, Mellstrom D, et al. Smoking and fracture risk: a meta-analysis. Osteoporos Int. 2005; 16:155–162. PMID: 15175845.

65. Berg KM, Kunins HV, Jackson JL, Nahvi S, Chaudhry A, Harris KA Jr, Malik R, Arnsten JH. Association between alcohol consumption and both osteoporotic fracture and bone density. Am J Med. 2008; 121:406–418. PMID: 18456037.

66. Kanis JA, Johansson H, Johnell O, Oden A, De Laet C, Eisman JA, Pols H, Tenenhouse A. Alcohol intake as a risk factor for fracture. Osteoporos Int. 2005; 16:737–742. PMID: 15455194.

67. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012; 2012:CD007146. PMID: 22972103.

68. Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, Roth EA, Shekelle PG. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ. 2004; 328:680. PMID: 15031239.

69. Gallagher JC, Sai AJ. Vitamin D insufficiency, deficiency, and bone health. J Clin Endocrinol Metab. 2010; 95:2630–2633. PMID: 20525913.

70. Kirkpatrick SI, Dodd KW, Parsons R, Ng C, Garriguet D, Tarasuk V. Household food insecurity is a stronger marker of adequacy of nutrient intakes among Canadian compared to American youth and adults. J Nutr. 2015; 145:1596–1603. PMID: 25995277.

71. Kim HJ, Oh K. Household food insecurity and dietary intake in Korea: results from the 2012 Korea National Health and Nutrition Examination Survey. Public Health Nutr. 2015; 18:3317–3325. PMID: 25828606.

72. Looker AC, Johnson CL, Lacher DA, Pfeiffer CM, Schleicher RL, Sempos CT. Vitamin D status: United States, 2001-2006. NCHS Data Brief. 2011; 1–8.

73. Oh YT, Goh TX, Chong JC, Yang WY, Arasu K. Knowledge, attitude regarding osteoporosis, dietary calcium intake and food sources of calcium among Chinese young adults in Klang Valley, Malaysia. Discov Public Health. 2024; 21:58.

74. Hodges JK, Cao S, Cladis DP, Weaver CM. Lactose intolerance and bone health: the challenge of ensuring adequate calcium intake. Nutrients. 2019; 11:718. PMID: 30925689.

75. Looker AC, Dawson-Hughes B, Calvo MS, Gunter EW, Sahyoun NR. Serum 25-hydroxyvitamin D status of adolescents and adults in two seasonal subpopulations from NHANES III. Bone. 2002; 30:771–777. PMID: 11996918.

76. Batieha A, Khader Y, Jaddou H, Hyassat D, Batieha Z, Khateeb M, Belbisi A, Ajlouni K. Vitamin D status in Jordan: dress style and gender discrepancies. Ann Nutr Metab. 2011; 58:10–18. PMID: 21252499.

77. Dash S, Gupta S, Epari V, Patra PY. Association of vitamin D levels in coal miners: a case-control study. Indian J Community Med. 2020; 45:181–183. PMID: 32905228.

78. Pilz S, März W, Cashman KD, Kiely ME, Whiting SJ, Holick MF, Grant WB, Pludowski P, Hiligsmann M, Trummer C, et al. Rationale and plan for vitamin D food fortification: a review and guidance paper. Front Endocrinol (Lausanne). 2018; 9:373. PMID: 30065699.

79. Weaver CM, Alexander DD, Boushey CJ, Dawson-Hughes B, Lappe JM, LeBoff MS, Liu S, Looker AC, Wallace TC, Wang DD. Calcium plus vitamin D supplementation and risk of fractures: an updated meta-analysis from the National Osteoporosis Foundation. Osteoporos Int. 2016; 27:367–376. PMID: 26510847.

80. Adebayo FA, Itkonen ST, Öhman T, Kiely M, Cashman KD, Lamberg-Allardt C,. on behalf of the Odin Consortium. Safety of vitamin D food fortification and supplementation: evidence from randomized controlled trials and observational studies. Foods. 2021; 10:3065. PMID: 34945616.

81. Shea MK, Strath L, Kim M, Doàn LN, Booth SL, Brinkley TE, Kritchevsky SB. Perspective: Promoting healthy aging through nutrition: a research centers collaborative network workshop report. Adv Nutr. 2024; 15:100199. PMID: 38432592.

82. Rizzoli R, Boonen S, Brandi ML, Burlet N, Delmas P, Reginster JY. The role of calcium and vitamin D in the management of osteoporosis. Bone. 2008; 42:246–249. PMID: 18055288.

83. Hien VT, Khan NC, Mai le B, Lam NT, Phuong TM, Nhung BT, Nhien NV, Nakamori M, Yamamoto S. Effect of community-based nutrition education intervention on calcium intake and bone mass in postmenopausal Vietnamese women. Public Health Nutr. 2009; 12:674–679. PMID: 18667112.

84. Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY. Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2013; 24:23–57. PMID: 23079689.

85. Wang F, Zheng J, Cheng J, Zou H, Li M, Deng B, Luo R, Wang F, Huang D, Li G, et al. Personalized nutrition: a review of genotype-based nutritional supplementation. Front Nutr. 2022; 9:992986. PMID: 36159456.

86. Voltan G, Cannito M, Ferrarese M, Ceccato F, Camozzi V. Vitamin D: an overview of gene regulation, ranging from metabolism to genomic effects. Genes (Basel). 2023; 14:1691. PMID: 37761831.

87. Rivera-Paredez B, Quezada-Sánchez AD, Denova-Gutiérrez E, Torres-Ibarra L, Flores YN, Salmerón J, Velázquez-Cruz R. Diet modulates the effects of genetic variants on the vitamin D metabolic pathway and bone mineral density in Mexican postmenopausal women. J Nutr. 2021; 151:1726–1735. PMID: 33847345.

88. Roizen JD, Levine MA. Vitamin D therapy and the era of precision medicine. J Clin Endocrinol Metab. 2020; 105:e891–e893. PMID: 31665328.

89. Palacios C, Hofmeyr GJ, Cormick G, Garcia-Casal MN, Peña-Rosas JP, Betrán AP. Current calcium fortification experiences: a review. Ann N Y Acad Sci. 2021; 1484:55–73. PMID: 32949062.

90. Saleem S, Khan Z, Hussain I, Khan F, Al-Asmari F, Khan FA, Zafar AA, Rahim MA, Eliasse Z, Ramadan MF. Evaluating the effect of vitamin D3 fortification on physicochemical and sensory properties of yogurt. Cogent Food Agric. 2024; 10:2350145.

91. Alhussein G, Hadjileontiadis L. Digital health technologies for long-term self-management of osteoporosis: systematic review and meta-analysis. JMIR Mhealth Uhealth. 2022; 10:e32557. PMID: 35451968.

92. Sosa-Holwerda A, Park OH, Albracht-Schulte K, Niraula S, Thompson L, Oldewage-Theron W. The role of artificial intelligence in nutrition research: a scoping Review. Nutrients. 2024; 16:2066. PMID: 38999814.

93. Saag JL, Danila MI. Remote management of osteoporosis. Curr Treatm Opt Rheumatol. 2022; 8:143–151. PMID: 36068838.