Dietitian's Journal


Nutrition in Bone Fracture Prevention & Healing: Part 3


X-ray image of hip, with top of femur broken (source)

 Today, three more resources on bone healing:

  1. A systematic review of nutrition support's effect on hip fracture healing;
  2. A special article on how to conduct a systematic review. Though it was done on hip fracture, the findings and conclusion can be applied to other search topics;
  3. One of the research articles included in the Cochrane Systematic Review.



Source - Cochrane Database of Systematic Reviews. 3, 2009.

Title - Nutritional supplementation for hip fracture aftercare in older people.

Authors - Avenell, Alison;  Handoll, Helen HG

Abstract -

  Background - Older people with hip fractures are often malnourished at the time of fracture, and have poor food intake subsequently.

  Objective - To review the effects of nutritional interventions in older people recovering from hip fracture.

  Search Strategy - We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials
(2006, Issue 1), MEDLINE, six other databases and reference lists. We contacted investigators and handsearched journals.

 Selection Criteria -  Randomised and quasi-randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture.

 Data Collection & Analysis - Both authors independently selected trials, extracted data and assessed trial quality. We sought additional information from trialists, and pooled data for primary outcomes.

 Main Results -

  • Twenty-one randomised trials involving 1727 participants were included.
  • Overall trial quality was poor, specifically regarding allocation concealment, assessor blinding and intention-to-treat analysis, and limited availability of outcome data.
  • Eight trials evaluated oral multinutrient feeds: providing non-protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (15/161 versus 17/176; relative risk (RR) 0.89, 95% confidence interval (CI) 0.47 to 1.68) but may reduce 'unfavourable outcome' (combined outcome of mortality and survivors with medical complications) (14/66 versus 26/73; RR 0.52, 95% CI 0.32 to 0.84).
  • Four trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97) but the studies were heterogeneous regarding case mix. Nasogastric feeding was poorly tolerated. There was insufficient information for other outcomes.
  • Increasing protein intake in an oral feed was tested in four trials. There was no evidence for an effect on mortality (RR 1.42, 95% CI 0.85 to 2.37). Protein supplementation may have reduced the number of long term medical complications.
  • Two trials, testing intravenous vitamin B1 and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of effect for either supplement.
  • One trial, evaluating dietetic assistants to help with feeding, showed a trend for a reduction in mortality (RR 0.57, 99% CI 0.29 to 1.11).

 Conclusion -

  • Some evidence exists for the effectiveness of oral protein and energy feeds, but overall the evidence for the effectiveness of nutritional supplementation remains weak.
  • Adequately sized trials are required which overcome the methodological defects of the reviewed studies.
  • In particular, the role of dietetic assistants requires further evaluation.

Full article (PDF, 740 KB)


Special article:

Source - American Journal of Clinical Nutrition, Vol. 73, No. 3, 505-510, March 2001

Title - Lessons for search strategies from a systematic review, in The Cochrane Library, of nutritional supplementation trials in patients after hip fracture.

Authors - Avenell, Alison;  Handoll, Helen HG, Grant AM


Abstract -

  Background - A key aim when conducting systematic reviews of randomized controlled trials (RCTs) is to include all of the evidence, if possible. Serious bias may result if trials are missed through inadequate search strategies.

 Objective - The objective was to evaluate the search plan for identifying RCTs in nutrition as part of a systematic review, in The Cochrane Library, of nutritional supplementation trials in patients after hip fracture.

 Design - We identified potential studies by searching the electronic databases BIOSIS, CABNAR, CINAHL, EMBASE, HEALTHSTAR, and MEDLINE; reference lists in trial reports; and other relevant articles. We also contacted investigators and other experts for information and searched 4 nutrition journals by hand.

 Results - We identified 15 RCTs that met the predefined inclusion criteria. The search plan identified 8 trials each in EMBASE, HEALTHSTAR, and MEDLINE and 7 in BIOSIS and CABNAR. BIOSIS was the only electronic database source of 2 trials. Eleven trials were identified by searching electronic databases and 2 unpublished trials were identified via experts in the field. We found one trial, published only as a conference abstract, by searching nutrition journals by hand. After publication of the protocol for the review in The Cochrane Library, we were informed of another unpublished trial.

  Conclusions - We found that a limited search plan based on only MEDLINE or one of the other commonly available databases would have failed to locate nearly one-half of the studies. To protect against bias, the search plan for a systematic review of nutritional interventions should be comprehensive.

Full article (PDF, 59 KB)



Source - Age and Ageing 2006 35(2):148-153; doi:10.1093/ageing/afj011

Title - Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward.

Authors - Duncan DG,  Beck SJ,  Hood K and Johansen A

Abstract -

 Objective - to examine how improved attention to nutritional status and dietary intake, achieved through the employment of dietetic assistants (DAs), will affect postoperative clinical outcome among elderly women with hip fracture.

 Design - open prospective randomised controlled trial, comparing conventional nursing care with the additional nutritional support provided by DA.

 Setting - thirty-eight bedded acute trauma ward in a teaching hospital.

 Participants - all but 11 of 344 consecutive admissions with acute nonpathological hip fracture were approached. Three hundred and eighteen (93%) agreed to inclusion. Sixteen were ineligible as they were immediately transferred to another acute ward, were managed conservatively or died preoperatively.

 Primary outcome measure - postoperative mortality in the acute trauma unit.

 Secondary outcome measures - postoperative mortality at 4 months after fracture, length of stay, energy intake and nutritional status.

 Results -  DA-supported participants were less likely to die in the acute ward (4.1 versus 10.1%, P = 0.048). This effect was still apparent at 4 month follow-up (13.1 versus 22.9%, P = 0.036). DA-supported subjects had significantly better mean daily energy intake (1,105 kcal versus 756 kcal/24 h, 95% CI 259–440 kcal/24 h, P<0.001), significantly smaller reduction in mid-arm circumference during their inpatient stay (0.39 cm, P = 0.002) and nonsignificantly favourable results for other anthropometric and laboratory measurements.

 Conclusion - Dietetic or nutrition assistants are being introduced in units across the UK. This, the largest ever study of nutritional support after hip fracture, shows that their employment significantly reduced patients’ risk of dying in the acute trauma unit; an effect that persisted at 4 month follow-up.


Full article
(PDF 108 KB)


Note: Lack of time prevents me from "cutting and pasting" abstracts from and links to all 21 randomised controlled trials included in the Cochrane review, yet I don't want to write a biased post and present only one article (resource #3) with promising results.  Also, as the Cochrane reviewers noted:

"The quality of trial methodology, as reported, was disappointing. Many of the trials failed to report trial methodology in sufficient detail to give top scores on individual items. The impression that the scores for these studies more reflect the quality of reporting rather than trial methodology was strengthened by the changed, generally increased, scores of some items of eight studies upon gaining additional information from the trialists (Brown 1992; Bruce 2003; Day 1988; Espaulella 2000; Hankins 1996; Hartgrink 1998; Houwing 2003; Sullivan 1998)" (page 10).

So for now, I've added the review to my library and as time permits, will look at more of the individual studies, particularly those with high scores for methodology.


Nutrition in Bone Fracture Prevention & Healing: Part 2

I think both dietitians and physiotherapists will be interested in this study and I encourage you to try to obtain a copy of the full article rather than just the abstract. (See my note at the end.) This is very useful practice-based research. Also, the introduction is very well-written and well-referenced.


Research article #1:

Source - Clinical rehabilitation.  20(4):311-23, 2006 Apr.

Title - Nutritional supplementation and resistance training in nutritionally at risk older adults following lower limb fracture: a randomized controlled trial.

Authors - Miller MD, Crotty M, Whitehead C, Bannerman E, Daniels LA

Abstract -

  Objective - To describe the independent and combined effects of oral nutrition supplementation and resistance training on health outcomes in nutritionally at risk older adults following lower limb fracture.

  Design - Randomized controlled trial with 12-week masked outcome assessment.

 Setting -  Teaching hospital.

 Participants - One hundred nutritionally at risk older adults hospitalized following a fall-related lower limb fracture.

 Intervention -  Commenced seven days after injury. Consisted of daily multinutrient energy-dense oral supplement (6.3 kJ/mL) individually prescribed for six weeks (n = 25), tri-weekly resistance training for 12 weeks (n = 25), combined treatment (n = 24) or attention control plus usual care and general nutrition and exercise advice (n = 26).

 Measurements - Weight change, quadriceps strength, gait speed, quality of life and health care utilization at completion of the 12-week intervention.

 Results - At 12 weeks, all groups lost weight: nutrition -6.2% (-8.4, -4.0); resistance training -6.3% (-8.3, -4.3); nutrition and resistance training -4.7% (-7.4, -2.0); attention control -5.2% (-9.0, -1.5). Those receiving resistance training alone lost more weight than those receiving the combined treatment (P= 0.029). Significant weight loss was prevented if supplement was consumed for at least 35 days. Groups were no different at 12 weeks for any other outcome.

Conclusion -

  • Frail, undernourished older adults with a fall-related lower limb fracture experience clinically significant weight loss that is unable to be reversed with oral nutritional supplements.
  • Those receiving a programme of resistance training without concurrent nutrition support are at increased risk of weight loss compared with those who receive a combined nutrition and resistance training intervention.
  • In this high-risk patient group it is possible to prevent further decline in nutritional status using oral nutritional supplements if strategies are implemented to ensure prescription is adequate to meet energy requirements and levels of adherence are high.

Full article
(Note: subscription required. If you're not able to access the article through your library or workplace but need it for your practice [e.g., you see patients/clients with bone fractures] please email me. I can't upload the article to my blog because of copyright restrictions but users can "print, download or email the article for individual use." )




Nutrition in Bone Fracture Prevention & Healing: Part 1

Calcaneus Fracture X-ray (Source: Wikimedia Commons, uploaded by Jojo)

Today I'm beginning a series of posts on the role of nutrition in preventing and recovering from bone fracture. I'll be focusing on the evidence-based literature and the best practice recommendations we can draw from it.

This post summarizes three recent reviews (meta-analyses) on vitamin D and fracture/fall prevention. It also includes a rapid response to the third review article. You may want to read the rapid response first (see end of post) to help your critical appraisal of the three review articles.


Review #1:

Source - Cochrane Database of Systematic Reviews. 3, 2009.

Title - Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis.

Authors - Avenell, Alison;  Gillespie, William J;  Gillespie, Lesley D;  O'Connell, Dianne

Abstract -

  Objectives -To determine the effects of vitamin D or related compounds, with or without calcium, for preventing fractures in older people.

  Search strategy -  We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials ( 2007, Issue 3), MEDLINE, EMBASE, CINAHL, and reference lists of articles. Most recent search: October 2007.

  Selection criteria - Randomised or quasi-randomised trials comparing vitamin D or related compounds, alone or with calcium, against placebo, no intervention, or calcium alone, reporting fracture outcomes in older people.

  Data collection and analysis - Two authors independently assessed trial quality, and extracted data. Data were pooled, where admissible, using the fixed-effect model, or random-effects model if heterogeneity between studies appeared high.

  Main results

  Forty-five trials were included.

  Vitamin D alone appears unlikely to be effective in preventing hip fracture (nine trials, 24,749 participants, RR 1.15, 95% CI 0.99 to 1.33), vertebral fracture (five trials, 9138 participants, RR 0.90, 95% CI 0.42 to 1.92) or any new fracture (10 trials, 25,016 participants, RR 1.01, 95% CI 0.93 to 1.09).

  Vitamin D with calcium reduces hip fractures (eight trials, 46,658 participants, RR 0.84, 95% CI 0.73 to 0.96). Although subgroup analysis by residential status showed a significant reduction in hip fractures in people in institutional care, the difference between this and the community-dwelling subgroup was not significant (P = 0.15).

  Overall hypercalcaemia is significantly more common in people receiving vitamin D or an analogue, with or without calcium (18 trials, 11,346 participants, RR 2.35, 95% CI 1.59 to 3.47); this is especially true of calcitriol (four trials, 988 participants, RR 4.41, 95% CI 2.14 to 9.09). There is a modest increase in gastrointestinal symptoms (11 trials, 47,042 participants, RR 1.04, 95% CI 1.00 to 1.08, P = 0.04) and a small but significant increase in renal disease (11 trials, 46,537 participants, RR 1.16, 95% CI 1.02 to 1.33).

  Authors' conclusions -

  • Frail older people confined to institutions may sustain fewer hip fractures if given vitamin D with calcium.
  • Vitamin D alone is unlikely to prevent fracture.
  • Overall there is a small but significant increase in gastrointestinal symptoms and renal disease associated with vitamin D or its analogues.
  • Calcitriol is associated with an increased incidence of hypercalcaemia.

Abstract & plain language summary

Full article
(PDF, 1.17 MB)


Review #2:

Source - Cochrane Database of Systematic Reviews. 3, 2009

Title - Interventions for preventing falls in older people living in the community.

Authors - Gillespie, Lesley D;  Robertson, M Clare;  Gillespie, William J;  Lamb, Sarah E;  Gates, Simon;  Cumming, Robert G;  Rowe, Brian H

Abstract -

  Objectives - To assess the effects of interventions to reduce the incidence of falls in older people living in the community.

  Search strategy - We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL ( 2008, Issue 2), MEDLINE, EMBASE, CINAHL, and Current Controlled Trials (all to May 2008).

  Selection criteria - Randomised trials of interventions to reduce falls in community-dwelling older people. Primary outcomes were rate of falls and risk of falling.

  Data collection and analysis - Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate.

  Main results

  We included 111 trials (55,303 participants).

  Multiple-component group exercise reduced rate of falls and risk of falling (rate ratio (RaR) 0.78, 95%CI 0.71 to 0.86; risk ratio (RR) 0.83, 95%CI 0.72 to 0.97), as did Tai Chi (RaR 0.63, 95%CI 0.52 to 0.78; RR 0.65, 95%CI 0.51 to 0.82), and individually prescribed multiple-component home-based exercise (RaR 0.66, 95%CI 0.53 to 0.82; RR 0.77, 95%CI 0.61 to 0.97).

  Assessment and multifactorial intervention reduced rate of falls (RaR 0.75, 95%CI 0.65 to 0.86), but not risk of falling.

  Overall, vitamin D did not reduce falls (RaR 0.95, 95%CI 0.80 to 1.14; RR 0.96, 95%CI 0.92 to 1.01), but may do so in people with lower vitamin D levels. [Bolding added for emphasis.]

  Overall, home safety interventions did not reduce falls (RaR 0.90, 95%CI 0.79 to 1.03; RR 0.89, 95%CI 0.80 to 1.00), but were effective in people with severe visual impairment, and in others at higher risk of falling. An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95%CI 0.22 to 0.78).

  Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95%CI 0.16 to 0.73), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95%CI 0.41 to 0.91).

  Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.42, 95%CI 0.23 to 0.75). First eye cataract surgery reduced rate of falls (RaR 0.66, 95%CI 0.45 to 0.95).

  There is some evidence that falls prevention strategies can be cost saving.

  Authors' conclusions -

  • Exercise interventions reduce risk and rate of falls.
  • Research is needed to confirm the contexts in which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective.

Abstract & plain language summary
Full article
(PDF, 2.54 MB)


Review #3:

Source - BMJ 2009;339:b3692, doi: 10.1136/bmj.b3692 (Published 1 October 2009)

Title - Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials

Authors -  Bischoff-Ferrari, HA; Dawson-Hughes, B; Staehelin, HB;  Orav, JE; Stuck, AE; Theiler, R; Wong, J B; Egli, A; Kiel, DP; Henschkowski, J.

Abstract -

 Objective - To test the efficacy of supplemental vitamin D and active forms of vitamin D with or without calcium in preventing falls among older individuals.

 Data sources - We searched Medline, the Cochrane central register of controlled trials, BIOSIS, and Embase up to August 2008 for relevant articles. Further studies were identified by consulting clinical experts, bibliographies, and abstracts. We contacted authors for additional data when necessary.

 Review methods - Only double blind randomised controlled trials of older individuals (mean age 65 years or older) receiving a defined oral dose of supplemental vitamin D (vitamin D3 (cholecalciferol) or vitamin D2 (ergocalciferol)) or an active form of vitamin D (1{alpha}-hydroxyvitamin D3 (1{alpha}-hydroxycalciferol) or 1,25-dihydroxyvitamin D3 (1,25-dihydroxycholecalciferol)) and with sufficiently specified fall assessment were considered for inclusion.

 Results - Eight randomised controlled trials (n=2426) of supplemental vitamin D met our inclusion criteria. Heterogeneity among trials was observed for dose of vitamin D (700-1000 IU/day v 200-600 IU/day; P=0.02) and achieved 25-hydroxyvitamin D3 concentration (25(OH)D concentration: <60 nmol/l v ≥60 nmol/l; P=0.005). High dose supplemental vitamin D reduced fall risk by 19% (pooled relative risk (RR) 0.81, 95% CI 0.71 to 0.92; n=1921 from seven trials), whereas achieved serum 25(OH)D concentrations of 60 nmol/l or more resulted in a 23% fall reduction (pooled RR 0.77, 95% CI 0.65 to 0.90). Falls were not notably reduced by low dose supplemental vitamin D (pooled RR 1.10, 95% CI 0.89 to 1.35; n=505 from two trials) or by achieved serum 25-hydroxyvitamin D concentrations of less than 60 nmol/l (pooled RR 1.35, 95% CI 0.98 to 1.84). Two randomised controlled trials (n=624) of active forms of vitamin D met our inclusion criteria. Active forms of vitamin D reduced fall risk by 22% (pooled RR 0.78, 95% CI 0.64 to 0.94).

 Conclusions - Supplemental vitamin D in a dose of 700-1000 IU a day reduced the risk of falling among older individuals by 19% and to a similar degree as active forms of vitamin D. Doses of supplemental vitamin D of less than 700 IU or serum 25-hydroxyvitamin D concentrations of less than 60 nmol/l may not reduce the risk of falling among older individuals.

and data supplement (trials included in meta-analysis).
Full article (PDF).
Rapid response to this article: Time for a moratorium on meta-analyses of vitamin D?



Vegetarian Lentil Paella

Vegetarian Lentil Paella

If on a Sunday in early Autumn, you have a craving for fresh tomatoes in a warm, cooked dish rather than a  salad, may I suggest Vegetarian Lentil Paella. I don't want to be disloyal to my favourite ratatoulle but if pressed to choose, I think I'd use my last two tomatoes in this recipe:


Vegetarian Lentil Paella
adapted from Better Homes & Gardens Vegetarian Recipes (Cooking for Today)

1 medium red or orange sweet pepper, chopped
1 medium yellow sweet pepper, chopped
2 stalks celery, sliced (1 cup)
1 medium white onion, chopped (1/2 cup)
1 medium red onion, chopped (1/2 cup)
4 cloves garlic, minced
2 tablespoons olive oil
1 cup lentils {addendum - I used split red lentils}
1-3/4 cups vegetable broth
1/8 teaspoon powdered saffron or 1/2 teaspoon tumeric
2 medium tomatoes, seeded and chopped (1 cup)
1 cup fresh or frozen (thawed) peas
1/3 cup pimiento-stuffed olives
1/3 cup pitted ripe olives
1/4 cup snipped cilantro or parsley

In a Dutch oven cook the peppers, celery, onions, and garlic in hot oil till the onion is tender but not brown. Rinse lentils. Add lentils, vegetable broth, and saffron or tumeric to the pepper mixture. Bring to a boil; reduce heat. Cover and simmer for 20 to 30 minutes or till lentils are tender and liquid is absorbed. Stir in tomatoes, peas, stuffed olives, ripe olives, and cilantro or parsley. Heat through. Season to taste before serving. Makes 4 servings.


Food guide comparision:

Vegetarian Lentil Paella

A generous ladle-full (about 375 mL or 1-1/2 cups) of the paella served over a small scoop (about 175 mL or 3/4 cup) of brown basmati rice provides 2 servings of Vegetables, 1-1/2 servings of Grains, and 1 serving of Legumes, Nuts and Other Protein-Rich Foods.

Without consulting a computer program or food composition tables, I can tell you this vegetarian paella is an excellent source of protein, fibre, vitamin C, folate, vitamin A, and the anti-oxidant, lycopene. I'm following Martha Rose Shulman's example and not listing a more detailed nutritional analysis. (Thank you, Kathryn, for pointing out this thoughtful, provocative article -- required reading for anyone at risk of "nutritionism".)  Marion Nestle's comment, in the same article, applies here:

The basis of healthful diets is variety, relatively unprocessed foods, and not eating too much. Variety and processing matter because 'real' (relatively unprocessed) foods contain large numbers of required nutrients but in different amounts and proportions. If you vary food intake, you don't have to worry about individual nutrients because the foods complement each other.

(If you are on special diet for a medical condition, please email me and I will provide you with the nutrient analysis so you can determine if this recipe is appropriate for you.)

Vegetarian Lentil Paella


Where I've been, where I'm going

Katsura Leaves

Katsura leaves after morning rain

Perhaps only I've noticed my month-long absence from The Dietitian's Journal but I think I should write a quick explanation.

This past September I've been on a stay-at-home-vacation in Vancouver and the neighbouring Fraser Valley. Highlights: Plenty of walking, reading, gardening and taking a course that exercised my right brain and under-developed creativity muscles. Lowlight: Ten days ago a family member sustained a severe calcaneal fracture.

So even on vacation I've been in full dietitian role, ensuring my family member consumes a high-protein, high-energy, calcium-rich diet supplemented with vitamin D everyday.  I've also started reviewing the current evidence-based literature on nutrition to support bone healing and will be sharing the best resources here in future blog posts.

See you again next week when I return to work and a more regular blogging schedule.

Sun after rain, the light at the end of September

The light at the end of September