Updated Recommendations for Development of Peak Bone Mass

Following a systematic evidence review, the National Osteoporosis Foundation (NOF) has developed practice guidelines based on the graded strength of current evidence.

The National Osteoporosis Foundation (NOF) has released new recommendations providing new position statements on attaining peak bone mass through lifestyle factors.

The NOF performed a comprehensive systematic, evidence based review of scientific literature published from January 2000 through December 2014. A keyword search was performed for the terms bone, adolescent, and child, and articles were screened for topics including macronutrients,calcium, vitamin D, and exercise.  To narrow the search, the NOF excluded articles that did not describe randomized clinical trials or observational studies, interventions that were less than 6 months in duration, and studies that did not address bone outcomes.

The remaining articles then were rated based on the extent of scientific evidence provided, utilizing a level of evidence grading system utilized by the American Society for Nutrition and the American Diabetes Association.

The best scientific evidence existed surrounding the beneficial effects of calcium intake and physical activity on achieving peak bone mass, especially in the developmental periods of late childhood and puberty. Good evidence was found to support the beneficial role of vitamin D and dairy consumption in the development and maintenance of bone health. Additionally, researchers found that low intake of fruit and vegetables may lead to deficiencies in vitamins A, C, E, K, and potassium, which can have a negative effect on bone health.

Injection of depot medroxyprogesterone acetate (DMPA) showed a consistent detrimental effect on bone in three studies; as a result, the NOF assigned a level of evidence of B to the unfavorable effects of DMPA injections on bone health.

The NOF called for more rigorous and scientifically supported trial data on other lifestyle choices that can affect bone growth in development, and for more public programs to prioritize the building of peak bone mass.

Summary and Clinical Applicability

The National Osteoporosis Foundation (NOF) recommends lifestyle choices that promote optimal bone health throughout development, giving the best evidence (grade A) score to the effects of optimal calcium intake and physical activity, particularly in late childhood and peripubertal years. Good evidence also supports the role of adequate intake of vitamin D and dairy to support bone structure. Currently, there is no good evidence to support implementation of DMPA injections. There is also a need for further research into other lifestyle changes that can support the primary objectives outlined in the recommendation.

The  greatest potential to build bone mass and achieve peak levels of bone density is in children and adolescents, thus a prime opportunity exists to adopt lifestyle practices that will have the greatest impact in preventing osteoporosis later in life.


Weaver CM, Gordon CM, Janz KF, et al. The National Osteoporosis Foundation’s position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations. Osteoporosis International. pp 1-106. Published online: February 8, 2016.