Combined effects of physical activity and calcium on bone health in children and adolescents: a systematic review of randomized controlled trials

  • Xi Yang
  • Yi Zhai
  • Jian Zhang
  • Jing-Yi Chen
  • Dan Liu
  • Wen-Hua ZhaoEmail author
Review article



A better understanding of the role of exercise and nutrition in bone health is significant for preventing osteoporosis. The aim of this review was to assess the combined effects of physical activity and calcium intake on improving bone mineral density in children and adolescents.


A search of electronic databases (MedLine, ISI Web of Science, Science Direct) and the literature references were performed. Randomized controlled trials published between 1997 and 2017, evaluating the effect of both physical activity and calcium intake intervention on bone mineral density or bone mineral content among children aged 3–18 years were selected. The Improved Jadad Rating Scale was used to assess the methodological quality of the included studies. Study characteristics were summarized in accordance with the review’s PICO criteria. Changes in bone mineral content were detected at several different bone sites.


A total of nine studies involving 908 participants were included in this review. The combined intervention of physical activity and calcium increased bone mineral in children and adolescents, especially when baseline calcium intake level was low and among participants on the stage of early puberty.


Regular physical activity combined with high level of calcium intake is beneficial for bone health in young population. Further research is needed to evaluate the dose–response associations and long-term effects of the interaction between physical activity and calcium intake.


Adolescents Bone health Calcium Children Physical activity 


Author contributions

XY contributed to the data abstraction, analysis plan, and manuscript draft and was responsible for eligible papers assessment and subsequent drafts. YZ, JYC and DL independently performed the selection of articles and identification of references. JZ was responsible for eligible papers assessment and subsequent drafts. WHZ was responsible for the design of the review protocol and interpretation of the results. All authors were involved in the conception of the review, the revision of the manuscript and finally approval of the version to be published. This work should be attributed to the National Institution for Nutrition and Health, Chinese Center for Disease Control and Prevention as well as the Department of science and technology management, Chinese Center for Disease Control and Prevention.


This research was supported by the National Institution for Nutrition and Health and Chinese Center for Disease Control and Prevention. This work was funded by the National Scientific and Technological Basic Resources Investigation Program “Research and application of nutrition and health system for children aged 0–18 years in China” (2017FY101107).

Compliance with ethical standards

Ethical approval

Not needed.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Compston J. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis (WHO technical report series no 843). Ann Rheum Dis. 1995;54:548.CrossRefGoogle Scholar
  2. 2.
    Murray CJL, Barber RM, Foreman KJ, Ozgoren AA, Abd-Allah F, Abera SF, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. Lancet. 2015;386:2145–91.CrossRefGoogle Scholar
  3. 3.
    Svedbom A, Hernlund E, Ivergård M, Compston J, Cooper C, Stenmark J, et al. Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos. 2013;8:137.CrossRefGoogle Scholar
  4. 4.
    Zhang ZH, Zhang ZR, Liu HZ, Yuan W. A retrospective study of osteoporosis prevalence in mainland China using -2.0 SD as diagnosis criteria. Chin J Osteoporos. 2016;22:1–8 (in Chinese).Google Scholar
  5. 5.
    Bishop N, Arundel P, Clark E, Dimitri P, Farr J, Jones G, et al. Fracture prediction and the definition of osteoporosis in children and adolescents: the ISCD 2013 pediatric official positions. J Clin Densitom. 2014;17:275–80.CrossRefGoogle Scholar
  6. 6.
    Henwood M, Binkovitz L. Update on pediatric bone health. J Am Osteopath Assoc. 2009;109:5–12.PubMedGoogle Scholar
  7. 7.
    Khoshhal KI. Childhood osteoporosis. J Taibah Univ Med Sci. 2011;6:61–76.Google Scholar
  8. 8.
    van der Sluis IM, de Muinck Keizer-Schrama SM. Osteoporosis in childhood: bone density of children in health and disease. J Pediatr Endocrinol Metab. 2001;14:817–32.PubMedGoogle Scholar
  9. 9.
    Baxter-Jones AD, Faulkner RA, Forwood MR, Mirwald RL, Bailey DA. Bone mineral accrual from 8 to 30 years of age: an estimation of peak bone mass. J Bone Miner Res. 2011;26:1729–39.CrossRefGoogle Scholar
  10. 10.
    Goulding A, Jones IE, Taylor RW, Manning PJ, Williams SM. More broken bones: a 4-year double cohort study of young girls with and without distal forearm fractures. J Bone Miner Res. 2000;15:2011–8.CrossRefGoogle Scholar
  11. 11.
    Gunter KB, Almstedt HC, Janz KF. Physical activity in childhood may be the key to optimizing lifespan skeletal health. Exerc Sport Sci Rev. 2012;40:13–21.CrossRefGoogle Scholar
  12. 12.
    Report on nutrition and health of children in China. China student nutrition and health promotion. 2015.Google Scholar
  13. 13.
    Richards JB, Kavvoura FK, Rivadeneira F, Styrkársdóttir U, Estrada K, Halldórsson BV, et al. Collaborative meta-analysis: associations of 150 candidate genes with osteoporosis and osteoporotic fracture. Ann Intern Med. 2009;151:528–37.CrossRefGoogle Scholar
  14. 14.
    Tai V, Leung W, Grey A, Reid IR, Bolland MJ. Calcium intake and bone mineral density: systematic review and meta-analysis. BMJ. 2015;351:h4183.CrossRefGoogle Scholar
  15. 15.
    McManus AM, Mellecker RR. Physical activity and obese children. J Sport Health Sci. 2012;1:141–8.CrossRefGoogle Scholar
  16. 16.
    Yang Y, Yang X, Zhai F, Cheng Y. Dietary guidelines for Chinese. J Acad Nutr Diet. 2016;116:A37.CrossRefGoogle Scholar
  17. 17.
    Weaver CM, Alexander DD, Boushey CJ, Dawson-Hughes B, Lappe JM, LeBoff MS, et al. Calcium plus vitamin D supplementation and risk of fractures: an updated meta-analysis from the National Osteoporosis Foundation. Osteoporos Int. 2016;27:367–76.CrossRefGoogle Scholar
  18. 18.
    Gómez-Bruton A, Matute-Llorente Á, González-Agüero A, Casajús JA, Vicente-Rodríguez G. Plyometric exercise and bone health in children and adolescents: a systematic review. World J Pediatr. 2017;13:112–21.CrossRefGoogle Scholar
  19. 19.
    Braun SI, Kim Y, Jetton AE, Kang M, Morgan DW. Prediction of bone mineral density and content from measures of physical activity and sedentary behavior in younger and older females. Prev Med Rep. 2015;2:300–5.CrossRefGoogle Scholar
  20. 20.
    2018 Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee scientific report. Washington, DC: U.S. Department of Health and Human Services; 2018. p. 2018.Google Scholar
  21. 21.
    Whisner CM, Castillo LF. Prebiotics, bone and mineral metabolism. Calcif Tissue Int. 2018;102:443–79.CrossRefGoogle Scholar
  22. 22.
    Li PH, Wang M, Wang-fu BH. Comparison of physical activity levels between Chinese children and youth and global AHKC reports. Chin J Health Educ. 2017;33:100–2 (in Chinese).Google Scholar
  23. 23.
    Johannsen N, Binkley T, Englert V, Neiderauer G, Specker B. Bone response to jumping is site-specific in children: a randomized trial. Bone. 2003;33:533–9.CrossRefGoogle Scholar
  24. 24.
    Winzenberg T, Shaw K, Fryer J, Jones G. Effects of calcium supplementation on bone density in healthy children: meta-analysis of randomised controlled trials. BMJ. 2006;333:775.CrossRefGoogle Scholar
  25. 25.
    French SA, Fulkerson JA, Story M. Increasing weight-bearing physical activity and calcium intake for bone mass growth in children and adolescents: a review of intervention trials. Prev Med. 2000;31:722–31.CrossRefGoogle Scholar
  26. 26.
    Julián-Almárcegui C, Gómez-Cabello A, Huybrechts I, González-Agüero A, Kaufman JM, Casajús JA, et al. Combined effects of interaction between physical activity and nutrition on bone health in children and adolescents: a systematic review. Nutr Rev. 2015;73:127–39.CrossRefGoogle Scholar
  27. 27.
    Ward KA, Roberts SA, Adams JE, Lanham-New S, Mughal MZ. Calcium supplementation and weight bearing physical activity—do they have a combined effect on the bone density of pre-pubertal children? Bone. 2007;41:496–504.CrossRefGoogle Scholar
  28. 28.
    Specker B, Binkley T. Randomized trial of physical activity and calcium supplementation on bone mineral content in 3- to 5-year-old children. J Bone Miner Res. 2003;18:885–92.CrossRefGoogle Scholar
  29. 29.
    Prentice A, Ginty F, Stear SJ, Jones SC, Laskey MA, Cole TJ. Calcium supplementation increases stature and bone mineral mass of 16- to 18-year-old boys. J Clin Endocrinol Metab. 2005;90:3153–61.CrossRefGoogle Scholar
  30. 30.
    Iuliano-Burns S, Saxon L, Naughton G, Gibbons K, Bass SL. Regional specificity of exercise and calcium during skeletal growth in girls: a randomized controlled trial. J Bone Miner Res. 2003;18:156–62.CrossRefGoogle Scholar
  31. 31.
    Courteix D, Jaffré C, Lespessailles E, Benhamou L. Cumulative effects of calcium supplementation and physical activity on bone accretion in premenarchal children: a double-blind randomised placebo-controlled trial. Int J Sports Med. 2005;26:332–8.CrossRefGoogle Scholar
  32. 32.
    Bass SL, Naughton G, Saxon L, Iuliano-Burns S, Daly R, Briganti EM, et al. Exercise and calcium combined results in a greater osteogenic effect than either factor alone: a blinded randomized placebo-controlled trial in boys. J Bone Miner Res. 2007;22:458–64.CrossRefGoogle Scholar
  33. 33.
    Stear SJ, Prentice A, Jones SC, Cole TJ. Effect of a calcium and exercise intervention on the bone mineral status of 16–18-y-old adolescent girls. Am J Clin Nutr. 2003;77:985–92.CrossRefGoogle Scholar
  34. 34.
    French SA, Story M, Fulkerson JA, Himes JH, Hannan P, Neumark-Sztainer D, et al. Increasing weight-bearing physical activity and calcium-rich foods to promote bone mass gains among 9–11 year old girls: outcomes of the Cal-Girls study. Int J Behav Nutr Phys Act. 2005;2:8.CrossRefGoogle Scholar
  35. 35.
    Hovell MF, Nichols JF, Irvin VL, Schmitz KE, Rock CL, Hofstetter CR, et al. Parent/child training to increase preteens’ calcium, physical activity, and bone density: a controlled trial. Am J Health Promot. 2009;24:118–28.CrossRefGoogle Scholar
  36. 36.
    Haakonssen EC, Ross ML, Knight EJ, Cato LE, Nana A, Wluka AE, et al. The effects of a calcium-rich pre-exercise meal on biomarkers of calcium homeostasis in competitive female cyclists: a randomised crossover trial. PLoS One. 2015;10:e0123302.CrossRefGoogle Scholar
  37. 37.
    Lanham-New SA, Thompson RL, More J, Brooke-Wavell K, Hunking P, Medici E. Importance of vitamin D, calcium and exercise to bone health with specific reference to children and adolescents. Nutr Bull. 2007;32:364–77.CrossRefGoogle Scholar

Copyright information

© Children's Hospital, Zhejiang University School of Medicine 2020

Authors and Affiliations

  • Xi Yang
    • 1
    • 2
  • Yi Zhai
    • 3
  • Jian Zhang
    • 1
  • Jing-Yi Chen
    • 1
  • Dan Liu
    • 1
  • Wen-Hua Zhao
    • 1
    Email author
  1. 1.National Institution for Nutrition and HealthChinese Center for Disease Control and PreventionBeijingChina
  2. 2.Department of Science and Technology ManagementChinese Center for Disease Control and PreventionBeijingChina
  3. 3.China National Clinical Research Center for Neurological DiseasesCapital Medical UniversityBeijingChina

Personalised recommendations