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, 27 (4), 1281-1386

The National Osteoporosis Foundation's Position Statement on Peak Bone Mass Development and Lifestyle Factors: A Systematic Review and Implementation Recommendations


The National Osteoporosis Foundation's Position Statement on Peak Bone Mass Development and Lifestyle Factors: A Systematic Review and Implementation Recommendations

C M Weaver et al. Osteoporos Int.


Lifestyle choices influence 20-40 % of adult peak bone mass. Therefore, optimization of lifestyle factors known to influence peak bone mass and strength is an important strategy aimed at reducing risk of osteoporosis or low bone mass later in life. The National Osteoporosis Foundation has issued this scientific statement to provide evidence-based guidance and a national implementation strategy for the purpose of helping individuals achieve maximal peak bone mass early in life. In this scientific statement, we (1) report the results of an evidence-based review of the literature since 2000 on factors that influence achieving the full genetic potential for skeletal mass; (2) recommend lifestyle choices that promote maximal bone health throughout the lifespan; (3) outline a research agenda to address current gaps; and (4) identify implementation strategies. We conducted a systematic review of the role of individual nutrients, food patterns, special issues, contraceptives, and physical activity on bone mass and strength development in youth. An evidence grading system was applied to describe the strength of available evidence on these individual modifiable lifestyle factors that may (or may not) influence the development of peak bone mass (Table 1). A summary of the grades for each of these factors is given below. We describe the underpinning biology of these relationships as well as other factors for which a systematic review approach was not possible. Articles published since 2000, all of which followed the report by Heaney et al. [1] published in that year, were considered for this scientific statement. This current review is a systematic update of the previous review conducted by the National Osteoporosis Foundation [1]. [Table: see text] Considering the evidence-based literature review, we recommend lifestyle choices that promote maximal bone health from childhood through young to late adolescence and outline a research agenda to address current gaps in knowledge. The best evidence (grade A) is available for positive effects of calcium intake and physical activity, especially during the late childhood and peripubertal years-a critical period for bone accretion. Good evidence is also available for a role of vitamin D and dairy consumption and a detriment of DMPA injections. However, more rigorous trial data on many other lifestyle choices are needed and this need is outlined in our research agenda. Implementation strategies for lifestyle modifications to promote development of peak bone mass and strength within one's genetic potential require a multisectored (i.e., family, schools, healthcare systems) approach.

Keywords: Bone mineral content; Diet; Nutrition; Peak bone mass; Physical activity.

Conflict of interest statement

Endorsing societies

This scientific statement has been reviewed and endorsed by the following scientific societies:

American Bone Health

American College of Sports Medicine

Endocrine Society

National Osteoporosis Foundation

Society for Women’s Health Research


This scientific statement was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Osteoporosis Foundation in making this published report as sound as possible and to ensure that the report meets standards for both objectivity and evidence. We thank the following individuals for their peer review of this scientific statement:

Sue A. Shapses, PhD

Rutgers, The State University of New Jersey

Kimberly O’Brien, PhD

Cornell University

Urszula T. Iwaniec, PhD

Oregon State University

This scientific statement was peer reviewed by the National Osteoporosis Foundation Research Committee and Osteoporosis International. This scientific statement was approved by the National Osteoporosis Foundation Board of Directors.

Sources of financial support

Funding for the manuscript was provided by the Alliance for Potato Research and the Dairy Research Institute.

Conflicts of interest

TCW is employed by the National Osteoporosis Foundation. CMW, CMG, KFJ, HJK, JML, RL, MO, and BSZ have no disclosures.


Fig. 1
Fig. 1
Bone mass across the lifespan with optimal and suboptimal lifestyle choices
Fig. 2
Fig. 2
Peak BMC gain and peak height velocity in boys and girls from longitudinal DXA analysis. Adapted from Bailey et al. [3]
Fig. 3
Fig. 3
Changes in structural composition of bone throughout the lifespan
Fig. 4
Fig. 4
Incidence of fractures of the distal forearm from birth through young adulthood. Adapted from Khosla et al. [29]
Fig. 5
Fig. 5
Flow diagram of the systematic review on peak bone mass

Comment in

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    CA Mautalen. Osteoporos Int 27 (10), 3133-4. PMID 27080705.
  • 2016 The Year That Was: Bone Strength
    KF Janz. Pediatr Exerc Sci 29 (1), 23-25. PMID 28271807.
    Of all the lifestyle strategies for increasing bone strength during the growing years, physical activity is one of the most efficacious. This commentary highlights two ex …

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