As Malaysia moves towards becoming an ageing nation by 2030, concerns over osteoporosis are growing, but so too are misconceptions about what truly keeps bones strong.
For decades, public health messaging and dietary advice have closely linked bone health with calcium intake. Milk, supplements and calcium-rich foods have long been promoted as the foundation of strong bones. As a result, many people have come to believe that calcium alone is sufficient.
However, health experts caution that this perception may create a false sense of security as bone strength is influenced by a combination of biological, nutritional and lifestyle factors beyond calcium alone.
“Many assume that calcium alone is sufficient, when in fact bone health is far more complex than that,” said physiology expert Associate Prof Dr Badariah Ahmad.
MISCONCEPTIONS ABOUT CALCIUM
In clinical practice, misconceptions about calcium intake are often reflected in patient behaviour, particularly the over-reliance on supplements without proper assessment of dietary needs.
Dr Badariah, who is also deputy head of the School of Medicine and Health Sciences (Engagement & Partnerships Unit) at Monash University Malaysia, told Bernama that many people tend to self-supplement without understanding whether it is necessary.
In terms of calcium supplementation, she said this often occurs without evaluating calcium intake from daily food sources, particularly among those who perceive supplements as a preventive measure even in the absence of deficiency.
Excessive calcium intake, especially from supplements, does not necessarily improve bone strength and may instead increase risks such as kidney stones and gastrointestinal discomfort, including constipation.
According to Dr Badariah, the safest approach is to meet the recommended daily calcium intake (approximately 1,000 to 1,200 milligrammes depending on age and sex), primarily through food, with supplements used only when medically indicated.
Commenting on calcium intake through food, she said many Malaysians tend to focus on milk while overlooking other calcium-rich sources such as small fish with edible bones like ikan bilis (dried anchovies), as well as tofu, leafy green vegetables, nuts and fortified soy products.
She also cautioned that high intake of salt and heavily processed foods may increase calcium loss through urine, gradually weakening bone strength over time.
Dr Win Min Thein, an associate professor of orthopaedics at the School of Medicine in the Faculty of Health and Medical Sciences at Taylor’s University, concurred that bone health is shaped not by calcium supplementation alone but by a combination of hormonal, nutritional and lifestyle factors.
“(For example) osteoporosis (a common bone disease) involves both loss of bone mass and deterioration of bone structure, not just low calcium levels,” he said.
He said even individuals with adequate calcium intake may still experience bone loss if other factors are not addressed, including hormonal changes, nutritional deficiencies and sedentary lifestyles.
He added that smoking and excessive alcohol consumption further weaken bone strength by disrupting bone formation and increasing fracture risk.
He also stressed the importance of maintaining adequate levels of physical activity, saying that bones require mechanical stress to maintain strength and structural integrity.
“Without sufficient mechanical stimulation, bones gradually lose their ability to remain strong,” he said.
BONE IS NOT JUST CALCIUM
Dr Win added that bone is a living tissue that continuously undergoes remodelling – a dynamic process in which specialised cells regulate the balance between bone formation (osteoblasts) and breakdown (osteoclasts), enabling the skeleton to repair microdamage and adapt to mechanical stress.
This continuous process ensures structural integrity, but when the balance is disrupted, bone quality gradually deteriorates over time, often without early symptoms.
To illustrate this, Dr Win likened bone to a constructed structure.
“Calcium acts as the cement, collagen forms the framework, and bone cells are the workers maintaining the structure,” he said.
In this context, calcium represents only one component of a broader biological system, rather than the sole determinant of bone strength.
“Bone strength depends not only on mineral content but also on the integrity of its collagen framework, which provides structural support.
“Hence, without a strong underlying structure, increasing calcium intake alone offers limited benefit and may create a false sense of security among individuals who rely heavily on supplements,” he added.
Elaborating on bone health across one’s lifespan, Dr Badariah explained that childhood and adolescence represent a critical phase for building peak bone mass, which determines long-term bone strength and resilience.
However, modern lifestyles characterised by reduced physical activity and limited sunlight exposure can negatively affect this development, even in a tropical country like Malaysia.
Another concern is that in adulthood, bone loss can occur gradually without noticeable symptoms, often leading to delayed diagnosis when fractures eventually occur.
“Many patients only begin to pay attention to bone health after complications arise,” she said, adding that by then, significant damage has already taken place.
SCREENING
Screening tools such as bone density scans can help identify at-risk individuals earlier, particularly those with factors such as low body weight, smoking, a sedentary lifestyle, or long-term medication use.
“For menopausal women, reduced oestrogen levels accelerate bone loss, increasing the risk of osteoporosis within a relatively short period.
“For older adults, fractures, particularly hip fractures, can result in long-term disability, reduced independence and higher mortality risk,” she added.
She stressed that preventive measures must begin early, and these include maintaining an active lifestyle, performing weight-bearing exercises regularly, and walking and climbing stairs to support overall bone health and reduce long-term risk.
Dr Win also underscored the importance of establishing healthy lifestyle habits early in life to support long-term bone strength.
Dr Badariah said from a clinical perspective, healthcare providers should place greater emphasis on lifestyle assessments during consultations with patients, including assessing their physical activity, habits such as smoking and alcohol consumption, and fall risk.
“Exercise should be prescribed just like medication, with clear and practical guidance, while patients also need to understand that supplements work best when combined with (physical) movement, proper nutrition and healthy habits,” she said.
She said lifestyle changes are often overlooked because their benefits are gradual and less visible compared to medication.
“We can help people take a more holistic approach to bone health rather than relying too heavily on supplements alone,” she added.
