Air Pollution Worsens Osteoporosis

Results from a population-based cross-sectional analysis

By Jacob Schor, ND, FABNO

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Ranzani OT, Milà C, Kulkarni B, Kinra S, Tonne C. Association of ambient and household air pollution with bone mineral content among adults in peri-urban South India. JAMA Netw Open. 2020;3(1):e1918504.


This was a population-based cross-sectional analysis.


The analysis included 3,717 members of the Andhra Pradesh Children and Parents Study cohort, who were recruited from 28 villages near Hyderabad, South India, during 2009 to 2012. Mean age was 35.7 years, and just under half of the participants (46%) were women.

Exposure Measurements

Annual mean ambient particulate matter air pollution less than 2.5 µm in aerodynamic diameter (PM2.5) and black carbon (BC) levels at the residence, estimated by land-use regression and self-reported use of biomass cooking fuel

Outcome Measures

The primary outcome was bone mineral content (BMC) measured in grams, corrected by bone area at the lumbar spine and left hip, as measured by dual-energy X-ray absorptiometry (DEXA). A secondary outcome was bone mineral density measured in grams per square centimeter.

The authors put forth several possible mechanisms why fine particulates might affect bone mass. Perhaps the simplest is that exposure increases systemic inflammation and oxidative stress, which then leads to increased bone loss.

Separate linear mixed models were fitted with nested random intercepts (household within villages) for each exposure-outcome pair and were sequentially adjusted for potential confounders. Data analysis was conducted between April 2019 and July 2019.

Key Findings

Ambient air pollution was associated with lower BMC. In fully adjusted models, PM2.5 was associated with lower BMC in the spine (mean difference, –0.57 g per 3 μg/m3 increase in PM2.5) and hip (mean difference, –0.13 g per 3 μg/m3 increase in PM2.5). After confounder adjustment, exposure to PM2.5 was also associated with lower bone mineral density in the spine (mean difference, –0.011 g/cm2 per 3 μg/m3 increase in PM2.5) and hip (mean difference, –0.004 g/cm2 per 3 μg/m3 increase in PM2.5). Exposure to black carbon was associated with lower BMC in the spine (mean difference, –1.13 g per 1 μg/m3 increase in BC) and hip (mean difference, –0.35 g per 1 μg/m3). There was no association between biomass fuel use and spine BMC.

Practice Implications

There is already a substantial body of evidence linking fine particulate air pollution to a wide variety of noncommunicable diseases.1 Whether or not osteoporosis should be added to this list of diseases has been unclear. Some studies have shown an association between fine particulate exposure and lower bone density or risk of fracture.2,3 Others have not.4 One study found an increase in forearm fracture risk in older men but not younger women or men.5 Another study reported an increase in hip fractures in older women exposed to gaseous air pollutants but no significant effect from fine particulates.6 Though the studies to date have not produced consistent results, the idea that fine particulates might be associated with osteoporosis not only remains but now is reinforced by the results of this current study by Ranzani et al.

The authors put forth several possible mechanisms why fine particulates might affect bone mass. Perhaps the simplest is that exposure increases systemic inflammation7 and oxidative stress,8 which then leads to increased bone loss.

A 2015 paper reported faster bone turnover in children exposed to higher levels of fine particulates.9 It seems reasonable to assume the same will occur in adults. It’s also been suggested that higher levels of pollution block ultraviolet-light exposure, which may affect calcium homeostasis by lowering vitamin D production.10

Ranzani et al reported that the association between fine particulate exposure and low bone mass was greater for the lumbar spine, which is mainly composed of trabecular bone, than for the hip, which has a higher proportion of cortical bone. Trabecular bone apparently is more responsive to oxidative stress from fine particulates than cortical bone is.11

Whatever the cause, the link between fine particulate air pollution and osteoporosis is looking stronger with this publication, and it is time we incorporate this concern about air quality into our treatment protocols for patients at risk or suffering from decreased bone mass.

Our list of chronic health conditions associated with fine particulate exposure continues to lengthen. The suggestion made by our late colleague Walter Crinnion that getting patients to purchase air filters might be the single most important intervention they could make to improve their health seems more prophetic as time goes on.

About the Author

Jacob Schor ND, FABNO, is a graduate of National College of Naturopathic Medicine, Portland, Oregon, and recently retired from his practice in Denver, Colorado. He served as president to the Colorado Association of Naturopathic Physicians and is a past member of the board of directors of the Oncology Association of Naturopathic Physicians and American Association of Naturopathic Physicians. He is recognized as a fellow by the American Board of Naturopathic Oncology. He serves on the editorial board for the International Journal of Naturopathic Medicine, Naturopathic Doctor News and Review (NDNR), and Integrative Medicine: A Clinician's Journal. In 2008, he was awarded the Vis Award by the American Association of Naturopathic Physicians. His writing appears regularly in NDNR, the Townsend Letter, and Natural Medicine Journal, where he is the Abstracts & Commentary editor.


  1. Schraufnagel DE, Balmes JR, Cowl CT, et al. Air pollution and noncommunicable diseases: a review by the Forum of International Respiratory Societies’ Environmental Committee—part 2, air pollution and organ systems. Chest. 2019;155(2):417-426.
  2. Prada D, Zhong J, Colicino E, et al. Association of air particulate pollution with bone loss over time and bone fracture risk: analysis of data from two independent studies. Lancet Planet Health. 2017;1(8):e337-e347.
  3. Alvaer K, Meyer HE, Falch JA, Nafstad P, Søgaard AJ. Outdoor air pollution and bone mineral density in elderly men: the Oslo Health Study. Osteoporos Int. 2007;18(12):1669-1674.
  4. Calderón-Garcidueñas L, Mora-Tiscareño A, Francolira M, et al. Exposure to urban air pollution and bone health in clinically healthy six-year-old children. Arh Hig Rada Toksikol. 2013;64(1):23-34.
  5. Alver K, Meyer HE, Falch JA, Søgaard AJ. Outdoor air pollution, bone density and self-reported forearm fracture: the Oslo Health Study. Osteoporos Int. 2010;21(10):1751-1760.
  6. Mazzucchelli R, Crespi Villarias N, Perez Fernandez E, et al. Short-term association between outdoor air pollution and osteoporotic hip fracture. Osteoporos Int. 2018;29(10):2231-2241.
  7. Smith BJ, Lerner MR, Bu SY, et al. Systemic bone loss and induction of coronary vessel disease in a rat model of chronic inflammation. Bone. 2006;38(3):378-386.
  8. Zhou Q, Zhu L, Zhang D, et al. Oxidative stress-related biomarkers in postmenopausal osteoporosis: a systematic review and meta-analyses. Dis Markers. 2016;2016:7067984.
  9. Liu C, Fuertes E, Flexeder C, et al. Associations between ambient air pollution and bone turnover markers in 10-year old children: results from the GINIplus and LISAplus studies. Int J Hyg Environ Health. 2015;218(1):58-65.
  10. Zhao Y1, Wang L2, Liu H, et al. Particulate air pollution exposure and plasma vitamin D levels in pregnant women: a longitudinal cohort study. J Clin Endocrinol Metab. 2019;104(8):3320-3326.
  11. Goettsch C, Babelova A, Trummer O, et al. NADPH oxidase 4 limits bone mass by promoting osteoclastogenesis. J Clin Invest. 2013;123(11):4731-4738.