J Nutr Health Aging.

2018;22(2):216-221
© Serdi and Springer-Verlag International SAS, part of Springer Nature

TEA CONSUMPTION IS ASSOCIATED WITH INCREASED BONE STRENGTH

IN MIDDLE-AGED AND ELDERLY CHINESE WOMEN
H. HUANG1, G.-Y. HAN1, L.-P. JING, Z.-Y. CHEN, Y.-M. CHEN, S.-M. XIAO
Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China. 1. These authors contributed equally to this work.
Corresponding author: Su-Mei Xiao and Yu-Ming Chen, Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-Sen University, 74 Zhongshan Er Road,
Guangzhou 510080, P. R. China, Tel: 86-20-87330151 and 86-20-87330605, Fax: 86-20-87330446, Email: xiaosm3@mail.sysu.edu.cn and chenyum@mail.sysu.edu.cn

Abstract: Objectives: Previous studies found that tea consumption was related to a reduction in the risks of some
chronic diseases, but limited data are available on bone health. This study aimed to examine the associations
of tea consumption with hip bone strength in Chinese women. Design: Cross-sectional study. Setting: The
participants were from the ongoing Guangzhou Nutrition and Health Study. This was a cohort study started
in 2008. The examination data conducted between June 2010 and December 2013 were used. Participants: A
total of 1,495 Chinese women aged more than 40 years were included. Measurements: Tea consumption, socio-
demographic information and lifestyle habits were collected by a face-to-face questionnaire. Hip bone mineral
density (BMD) and geometric parameters, i.e. cross-sectional area (CSA), section modulus (Z) and buckling
ratio (BR), were generated by dual-energy X-ray absorptiometry. The associations of tea consumption with bone
phenotypes were detected by analysis of covariance and multiple linear regression models after adjusting for
age, body mass index, years since menopause, physical activity, dietary-protein intake, dietary-calcium intake,
calcium tablet intake, drinking status and smoking status. Results: Tea drinkers (n = 732) had approximately
1.9% higher BMD (p < 0.05) and 3.6% lower BR (p < 0.05) than non-tea drinkers (n = 763). The dose-response
relationships of BMD, BR or CSA with total tea consumption were identified (p-trend < 0.05). Tea drinking was
found to be a significant and independent predictor of BMD (β = 0.068, p < 0.05) or BR (β = -0.079, p < 0.05).
Conclusion: Tea consumption was associated with increased bone strength in middle-aged and elderly Chinese
women.

Key words: Osteoporosis, tea consumption, bone mineral density, bone geometry.

Introduction production, and most of it is consumed in China and Japan.

Osteoporosis is a progressive systemic skeletal disorder
characterised by low bone mass and microarchitectural
deterioration of bone tissue that leads to a decrease in bone
strength and an increased risk of fracture. With the aging of the
population, osteoporosis has become a serious public health
problem worldwide. Women are around four times more likely
to develop osteoporosis than men because of their generally
lighter and thinner bones in conjunction with a decrease in
their estrogen levels after menopause (1). Approximately half
of all women over 50 years old suffer an osteoporotic fracture
sometime in their life (2). Bone mineral density (BMD) and
bone geometry are two major determinants of bone strength and
two independent predictors in assessing the risk of osteoporotic
fracture (3, 4). Investigation of both is indispensable to improve
the accuracy of fracture risk prediction and the understanding of
bone strength and osteoporosis.
Tea, which is derived from Camellia sinensis, is one of the
most frequently consumed beverages throughout the world.
More than 30 countries cultivate tea, with an annual production
of 3.8 million tons (5). According to the degree of fermentation,
tea is mainly classified into three categories: green tea (non-
fermented), oolong tea (semi-fermented) and black tea
(fermented). Black tea constitutes ~78% of the world’s tea
production and is one of the most popular kinds consumed in
Western countries. Green tea accounts for ~20% of the total
Received October 25, 2016
Accepted for publication January 4, 2017
216
Oolong tea, mainly cultivated in southern China, constitutes
~2% of the total tea production (6). In addition, there is a
kind of post-fermented tea: dark tea, e.g. Pu-er tea, which is
a well-known traditional tea in China (7). Previous studies
found that tea drinking was related to a reduction in the risks
of neurocognitive disorders, diabetes, cardiovascular diseases,
cancers and some other chronic disorders (8-11). Recently,
studies also indicated that tea may affect bone metabolism.
The polyphenols in tea may inhibit osteoclasts and stimulate
osteoblasts by decreasing reactive oxygen species and pro-
inflammatory mediators (12, 13).
Some studies have detected the relationship between tea
consumption and BMD, but the results are controversial.
Habitual tea consumption was found to have a positive effect
(14, 15), no effect (16) or even a weak inverse effect (17, 18)
on BMD. In addition, studies about the effect of tea on bone
geometry were limited. Therefore, in this study, we aimed to
evaluate the associations of tea consumption with both BMD
and bone geometry in middle-aged and elderly Chinese women.
Methods
Subjects
The participants of this study were from the ongoing
Guangzhou Nutrition and Health Study, a cohort study started
in 2008 that was designed to assess the determinants of
Published online March 1, 2017, http://dx.doi.org/10.1007/s12603-017-0898-z
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osteoporosis and cardiometabolic outcomes (19). The data
from the first follow-up examination conducted between June
2010 and December 2013 were used. Women over 40 years of
age were recruited by posting local advertisements, by sending
invitation letters to residential buildings, by giving health talks
or from referrals in the local community. All of the participants
were residents of urban Guangzhou, China for over 5 years.
Excluded were subjects with chronic diseases or conditions
that might affect bone mass and metabolism, such as having a
history of metabolic bone disorder or left hip fracture, chronic
medical illness, endocrine diseases including hyperthyroidism,
medications that might affect bone and calcium metabolism,
bilateral oophorectomy, major gastrointestinal operations,
premature menopause at age < 40 years, or being prescribed
medicines such as calcitonin, bisphosphonates, selective
estrogen receptor modulators and active vitamin D3
metabolites. Ultimately, 1,495 women with bone measurement
data and who responded to the questionnaires were included in
this study. The study was approved by the Ethics Committee
of the School of Public Health of Sun Yat-Sen University, and
written informed consent was obtained from each participant.
Tea consumption
All of the participants completed a face-to-face interview
performed by trained staff using a structured questionnaire.
Socio-demographic information, history of disease and
medications, lifestyle habits and reproductive histories were
collected. There were four questions on tea drinking. The first
question was: “Have you drunk tea twice or more times per
week in the past year?” Subjects who answered “yes” were
coded as tea drinkers and then completed questions on the
number of times of tea drinking per week (times), the total
consumed quantities (kg) of tea and the types of tea (i.e. green
tea, black tea, oolong tea and dark tea) over the past year.
BMD and bone geometry
The BMD (g/cm2) at the femur neck (FN) of the left hip
was measured by dual-energy X-ray absorptiometry (DXA,
Discovery W; Hologic Inc., Waltham, MA, USA). DXA images
of the hip proximal femur were reprocessed with the Hip
Structure Analysis (HSA) program included in the APEX
software (v3.2, Hologic Inc.) (20). Three HSA-generated
bone geometry parameters, i.e. cross-sectional area (CSA,
cm 2), section modulus (Z, cm 3) and buckling ratio (BR),
were analysed in this study. CSA is the amount of (cortical
equivalent) bone surface area in the cross-section after
excluding all of the trabecular and soft tissue spaces, and it
indicates the resistance to a loading force directed along the
bone axis (21). Z indicates the bending strength for maximum
bending stress in the image plane. BR is the relative thickness
of the narrow neck cortex and represents an estimate of the
cortical stability in buckling. An increase in BR indicates
that the bone is becoming less stable and weaker. The in-vivo
coefficients of variation were 1.92%, 1.55%, 2.99% and 4.62%
217
for BMD, CSA, Z and BR at the FN, respectively.
Assessments of covariates
Dietary intake was assessed using a quantitative and 81-item
food frequency questionnaire (22). For each food item, the
subjects were asked how often (never, per year, per month,
per week and per day) they had consumed over the past year.
Dietary nutrients and total energy intake were calculated based
on the China Food Composition Table (23). Calcium tablet
intake was recorded if the subjects had taken the calcium
supplement over 30 times within the past year. The subjects
who smoked more than 100 cigarettes in their lifetime were
defined as active smokers. Those who lived or worked in a
room with an individual who smoked more than one cigarette or
more than 5 minutes per day for at least one year were defined
as passive smokers. Drinkers were individuals that had ever
drunk alcoholic beverages at least once a week for more than
6 months. The daily physical activity including occupational
activities, leisure-time activities and household-chores but
except for sitting and lying, was evaluated using metabolic
equivalent (MET) hours per day (24). Weight (kg) and height
(cm) were measured at the same time, and body mass index
(BMI, kg/m2) was calculated.
Statistical analysis
Descriptive statistics were determined for all variables
according to their distribution. They are presented as the
mean and standard deviation (SD), median and interquartile
range, or number (n) and percentage. Differences in bone
phenotypes between tea drinkers and non-tea drinkers were
assessed by using analysis of covariance. Further comparisons
were conducted among subgroups classified by total tea
consumption or the times of tea drinking per week. Moreover,
the assessments and inferences of the relationships between
tea consumption and bone phenotypes were conducted using
multiple linear regression models. All analyses were adjusted
for confounding factors including age, BMI, years since
menopause (YSM), physical activity, dietary-protein intake,
dietary-calcium intake, calcium tablet intake, drinking status
and smoking status. The dietary nutrient intakes were adjusted
for total energy intake using a residual method. Statistical
analyses were performed with SPSS 20.0 (SPSS, Inc., Chicago,
IL, USA). A p < 0.05 in a two-tailed test was considered
significant.
Results
General characteristics of the participants
The basic information of the participants is shown in Table
1. The median age of the 1,495 women was 58 years old, and
the median YSM was 8 years. Among all subjects, 732 (49.0%)
were tea drinkers and 763 (51.0%) were non-tea drinkers.
For the 732 tea drinkers, the median values of the times of
tea drinking per week and total tea consumption over the past
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TEA CONSUMPTION IS ASSOCIATED WITH INCREASED BONE STRENGTH IN MIDDLE-AGED

year were 7 times and 4.2 kg, respectively. The numbers of Differences in bone phenotypes between tea drinkers and
individuals who drank green tea, black tea, oolong tea and non-tea drinkers
dark tea were 109 (14.9%), 110 (15.0%), 229 (31.3%) and 284 Table 2 shows the differences in the mean values of BMD,
(38.8%), respectively. The medium values of dietary nutrient BR, CSA and Z between tea drinkers and non-tea drinkers. Tea
intakes were around 65.90 g/d and 575.03 mg/d for protein and drinkers had a higher BMD (p = 0.032) and a lower BR (p =
calcium, respectively. Approximately 29.6% of the participants 0.005) than non-tea drinkers after adjusting for confounding
had taken calcium tablets more than 30 times in the past year, factors, including age, BMI, YSM, physical activities, dietary-
28.5% were active or passive smokers and 3.3% were alcohol protein intake, dietary-calcium intake, calcium tablet intake,
drinkers. The mean (SD) values of BMD, BR, CSA and Z of drinking status and smoking status. For CSA and Z, the mean
all subjects were 0.844 (0.144) g/cm2, 10.929 (2.784), 2.434 values were all consistently higher in tea drinkers than non-
(0.394) cm2 and 1.105 (0.224) cm3, respectively. tea drinkers, although the differences were not statistically
significant in this sample (p > 0.05). The mean differences
Table 1 in BMD, BR, CSA and Z between tea drinkers and non-tea
Basic characteristics of studied women (n = 1,495) drinkers were 0.016 g/cm2 (1.9%), -0.400 (3.6%), 0.028 cm2
(1.2%) and 0.011cm3 (1.0%), respectively.
Variable Mean ± SD / median (25th~75th)
/ n (%) Table 2
Age (year) 58.0 (55.0~62.0) Differences of BMD and bone geometric parameters between
Height (cm) 155.07 ± 5.37 the groups of non-tea drinker and tea drinker (n = 1,495)
Weight (kg) 56.16 ± 8.33
Variable Non-tea drinkers Tea drinkers p-value
BMI (kg/m2) 23.34 ± 3.20
(n = 763) (n = 732)
YSM (year) 8.0 (5.0~12.0)
BMD (g/cm2) 0.836 (0.005) 0.852 (0.005) 0.032
Physical activities (MET · h/d) a 33.18 (30.31~37.24) BR 11.125 (0.100) 10.725 (0.102) 0.005
Energy intake (kcal/d) 1505.59 (1264.86~1777.62) CSA (cm2) 2.420 (0.014) 2.448 (0.014) >0.050
Dietary-protein intake (g/d) 65.90 (52.95~80.52) Z (cm3) 1.100 (0.008) 1.111 (0.008) >0.050
Dietary-calcium intake (mg/d) 575.03 (437.40~715.85) Values were expressed as mean and standard error. Bone phenotypes were adjusted for
Calcium tablets intake (n, %) 443 (29.6) age, body mass index, years since menopause, physical activities, dietary-protein intake,
dietary-calcium intake, calcium tablet intake, drinking status and smoking status. BMD,
Smoker (n, %) 426 (28.5) bone mineral density; BR, buckling ratio; CSA, cross sectional area; Z, section modulus.
Alcohol drinker (n, %) 49 (3.3)
Tea drinker (n, %) 732 (49.0) Dose-response relationships of tea consumption with bone
phenotypes
Times of tea drinking (times/week) 7.0 (3.0~7.0)
To assess the dose-response relationships of tea consumption
Total tea consumption (kg) 4.2 (2.0~8.3)
with bone phenotypes, the subjects were further categorised into
Types of tea several subgroups by their tea drinking habits. As displayed
Green tea (n, %) 109 (14.9) in Table 3 and Figure 1, there were significant trends of
Black tea (n, %) 110 (15.0) increased BMD, CSA (p = 0.006 and 0.042) and decreased BR
Oolong tea (n, %) 229 (31.3) (p = 0.003) with the larger quantity of total tea consumption.
Compared with those who consumed less than 1.0 kg over the
Dark tea (n, %) 284 (38.8)
past year, the individuals who consumed more than 4.2 kg of
BMD (g/cm ) 2
0.844 ± 0.144
tea had approximately 3.0% higher BMD, 4.7% lower BR and
BR 10.929 ± 2.784 2.0% higher CSA, respectively. In the 732 tea drinkers, the
CSA (cm2) 2.434 ± 0.394 differences in bone phenotypes among the subgroups classified
Z (cm3) 1.105 ± 0.224 by the types of tea (green, black, oolong and dark tea) were not
Values were presented as mean ± standard deviation (SD), median and interquartile significant (p > 0.05).
range (25th~75th), or number (n) and percentage (%). a. Physical activities including
daily occupational activities, leisure time and household chores, were evaluated using
metabolic equivalent hours per day (MET · h/d). BMI, body mass index; YSM, years
Contributions of tea consumption to bone phenotypes
since menopause; BMD, bone mineral density; BR, buckling ratio; CSA, cross sectional Multiple linear regression models were then performed
area; Z, section modulus. to evaluate the contributions of tea consumption to bone
phenotypes (Table 4). The results showed that tea consumption
was a significant predictor of BMD and BR independent of
age, BMI, YSM, physical activities, dietary-protein intake,
dietary-calcium intake, calcium tablet intake, drinking status

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Table 3
Results of dose-response relationships of bone phenotypes with the studied variables of tea consumption (n = 1,495)

BMD (g/cm2) BR CSA (cm2) Z (cm3)

Total tea consumption (kg)
<1.0 (n = 763) 0.836 (0.005) 11.125 (0.100) 2.420 (0.014) 1.099 (0.008)
1.0~4.2 (n = 373) 0.843 (0.007) 10.847 (0.141) 2.428 (0.019) 1.100 (0.011)
>4.2 (n = 359) 0.861 (0.007) 10.597 (0.145) 2.470 (0.020) 1.122 (0.012)
p-trend 0.006 0.003 0.042 >0.050
Times of tea drinking per week
≤1 (n = 763) 0.836 (0.005) 11.125 (0.100) 2.420 (0.014) 1.099 (0.008)
2~6 (n = 309) 0.851 (0.008) 10.642 (0.155) 2.435 (0.021) 1.096 (0.012)
≥7 (n = 423) 0.853 (0.007) 10.788 (0.135) 2.458 (0.018) 1.121 (0.011)
p-trend >0.050 >0.050 >0.050 >0.050
Values were expressed as mean and standard error. Bone phenotypes were adjusted for age, body mass index, years since menopause, physical activities, dietary-protein intake, dietary-
calcium intake, calcium tablet intake, drinking status and smoking status. BMD, bone mineral density; BR, buckling ratio; CSA, cross sectional area; Z, section modulus

Table 4
Results of multiple linear regression analysis of tea consumption variables with BMD and bone geometric parameters (n = 1,495)

Variable Tea drinking (yes/no) Total tea consumption (kg)

Standardized β p-value Standardized β p-value
BMD (g/cm2) 0.054 0.032 0.068 0.007
BR -0.072 0.005 -0.079 0.002
CSA (cm2) 0.035 >0.050 0.048 >0.050
Z (cm3) 0.025 >0.050 0.037 >0.050
Bone phenotypes were adjusted for age, body mass index, years since menopause, physical activities, dietary-protein intake, dietary-calcium intake, calcium tablet intake, drinking status
and smoking status. BMD, bone mineral density; BR, buckling ratio; CSA, cross sectional area; Z, section modulus.

and smoking status. The standardized regression coefficients of
tea drinking and total tea consumption were 0.054 (p = 0.032)
and 0.068 (p = 0.007) for BMD, -0.072 (p = 0.005) and -0.079
(p = 0.002) for BR, respectively.
Discussion
The associations of tea consumption-related variables with
hip BMD and bone geometry in middle-aged and elderly
Chinese women were evaluated in this study. The results
showed that tea drinking was a protective factor for BMD and
BR, and the habit of drinking tea could also be beneficial for the
other parameter of bone strength, i.e. CSA.
Our data suggested that tea drinking could maintain the
cortical stability and strength of bone. BR is the relative
thickness of the narrow neck cortex and is an estimate of the
cortical stability in buckling. Gnudi et al. evaluated the ability
of bone structural parameters measured at the FN, i.e. CSA, Z
and BR, to predict the risk of hip fracture. They found that BR
was the best predictor, and its ability to predict fracture risk
was equal to that of FN BMD (25). In the present study, the
tea drinkers had lower BR than the non-tea drinkers. BR was
219
also observed to have a significant and negative dose-response
relationship with total tea consumption. Previous association
studies of tea consumption and bone geometric structure are
limited. Nonetheless, the findings from the animal model study
into the influence of tea on bone may be instructive. Chen et
al (26) observed that with the 12 weeks supplementation of
(-)-epigallocatechin-3-gallate (EGCG), a bioactive substance in
tea, the ovariectomy-induced osteopenic rats showed increased
bone volume, trabecular number, and trabecular thickness and
decreased trabecular separation, which suggested the protective
effects of EGCG on bone microarchitecture. Recently, Ng et
al (27) in 2,398 individuals aged more than 55 years found
that tea consumption was related to the better performance in
physical function. In addition, a 6-month randomised placebo-
controlled trial conducted in postmenopausal osteoporotic
women suggested that the polyphenols in tea could improve leg
strength (28). These studies indirectly support the role of tea in
promoting the stability and strength of bone.
The positive association between tea drinking and BMD at
the hip was also observed in this study. This was consistent
with the findings in previous studies conducted in both Chinese
and other populations (15). Hegarty et al (29) carried out
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TEA CONSUMPTION IS ASSOCIATED WITH INCREASED BONE STRENGTH IN MIDDLE-AGED
a cross-section study in 1,256 Britain women aged 65-76
years. They observed that BMD in tea drinkers was around
3.0% greater than those who did not drink tea. A study in
Taiwanese found that tea drinkers had an increased BMD
than non-tea drinkers at the total body, hip regions and
lumbar spine, especially in tea drinkers with a larger quantity
of tea consumption (30). In this study, we also identified
the significant and positive trend of BMD with total tea
consumption over the past year. In addition, a prospective
analysis in 1,027 Australian women found that after a 4-year
follow-up, tea drinkers lost about 1.6% hip BMD, but non-
tea drinkers lost approximately 4.0% (31). All these results
supported that tea consumption was favorable for bone mass.
Figure 1
The relative values of bone phenotypes of each subgroup of (a)
total tea consumption or (b) times of tea drinking per week to
the reference group
Vertical bars were the percentage differences of each sub-group relative to the group of
total tea consumption < 1.0 kg (a) or times of tea drinking per week ≤ 1 time (b). Error
bars were the standard errors of the mean values. Values were adjusted for age, body mass
index, years since menopause, physical activities, dietary-protein intake, dietary-calcium
intake, calcium tablet intake, drinking status and smoking status. *p-trend < 0.05. BMD,
bone mineral density; BR, buckling ratio; CSA, cross sectional area; Z, section modulus.
The bone-protective effects of tea may be attributed to
the chemical compounds in it. Animal studies found that a
moderate intake of tea polyphenols could enhance bone strength
and quality (12). Tea catechins, including EGCG, epicatechin-
3-gallate, epigallocatechin and epicatechin, are the main
components in tea polyphenols. These substances can benefit
bone via their antioxidant activities and their capability to
scavenge reactive oxygen species (12). As a potent antioxidant,
220
EGCG was shown to reduce the levels of excessive reactive
oxygen species, increase the activity of alkaline phosphatase,
and up-regulate the expression of runt-related transcription
factor 2 through the bone morphogenetic protein 2 signalling
pathway, thus promoting the proliferation of osteoblasts and
formation of bone (32). The chemical constituents differ for
different types of tea with varied levels of fermentation (33).
The amount of EGCG was found to be much lower in other
types of tea than in green tea (34). Theaflavins and thearubigins
are the representative substances in black tea. Recently, Das
et al (35) observed that the extract of black tea could protect
against ovariectomy-induced oxidative stress of mononuclear
cells and its associated progression of bone loss by reducing
the activated osteoclasts. In addition, studies also found that the
bioactive substances in oolong tea or Pu-er tea had the strong
antioxidative effects and the scavenging capacity of free radical
(36, 37).
The findings in this study might be generalisable to ordinary
urban middle-aged and elderly women in southern China. The
results were obtained from a considerable sample size of 1,495
women recruited from communities in Guangzhou city, with
consideration given to a relatively large range of confounding
factors and with good assessments of bone phenotypes.
Nonetheless, there were also several limitations. This study
only investigated the tea drinking habits of subjects over the
past year, which might not accurately reflect their long-term
habits of tea drinking. However, tea drinking is generally a
relatively stable habit, and Guangzhou is a city with a very
long history of tea culture and with a large proportion of tea
drinkers. Approximately half of the studied subjects were tea
drinkers, and the times of tea drinking per week and the total tea
consumption over the past year were highly correlated (r = 0.94,
p < 0.001). Thus, the present data might reflect the long-term
habits of tea drinking to some extent. Finally, this was a cross-
sectional study, and thus the findings cannot establish temporal
relationships or causality. A future longitudinal analysis of the
effects of tea consumption on bone strength will be of interest
when the ongoing cohort study is completed.
In summary, this study suggested a protective effect of tea
drinking on both bone mass and geometric structure in middle-
aged and elderly Chinese women. As tea is a traditional and
popular beverage in China, its role in bone health merits further
investigations.
Acknowledgments: This study was supported by the National Natural Science
Foundation of China (No. 81273049, 81400857), the Natural Science Foundation
of Guangdong Province (No.2014A030313132), and the 5010 Program for Clinical
Researches by Sun Yat-Sen University, Guangzhou, China (No. 2007032). We thank other
team members for their contribution in the data collection.
Conflicts of Interest: The authors declare no conflict of interest.
Ethical standards: The experiments comply with the current laws of China in which
they were performed. The protocol was approved by the Ethics Committee of the School of
Public Health of Sun Yat-Sen University.
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