Dietitian's Journal

Entries in bone health (7)


More articles from the nutrition information "garden"

Earlier this week I listed links to selected full-text nutrition articles stored in one digital archive. Today, a bit ahead of schedule, I'm sharing more finds: recent articles & studies I've discovered via other "information-gardening" tools & repositories. These include e-newsletters, Twitter and, of course, blogs and the trustworthy, knowledgeable colleagues and mentors who write them.

The MSNBC article, "Is your junk food habit making you depressed?" led me to a recent British Journal of Psychiatry study, Dietary pattern and depressive symptoms in middle age (abstract).

"How to Eat to Defeat Depression", a recent Rodale article, describes a study on diet, depression and anxiety in women; it's available as an abstract and free, full-text PDF file.

(Note: Often the popular press articles do not include full citations so the reader has to do some sleuthing to find the original research reports in the online journals. I've found Google Scholar works well if you have at least one of the investigator's names and date of publication.)

The January 2010 Tufts' Health & Nutrition Letter features this free online article on one of my pet topics, bone health: "Protecting Women’s Bones: Is the Secret Soy or the Asian Diet?".

"From Complex Carbohydrate to Glycemic Index: Tracing the Controversy" is a thorough, articulate and well-referenced review. You can read the free, full-text article here. (Many thanks to Sophie for providing the second link.) 

Kathryn Elliott (of Limes & Lycopene) has written a carbohydrate primer for the lay public, "GI Know-How", an up-to-date, research-based, easy-to-understand article on Glycemic Index (GI) and Glycemic Load (GL). It's an excellent companion piece to the previous article.

And last but not least, a Twitter friend recommended film critic Roger Ebert's poignant essay on what it's like to not be able to eat, drink or talk: Nil by mouth. Perhaps we (especially me) should read it first to remind us of the joy of dining or shared food experieces. Tube feeding, though it can provide nutrients, cannot replace these.


Nutrition & Bone Health: How to build & maintain healthy bones on a plant-based diet

If you haven't already read (or at least skimmed the abstracts) listed in the the previous post, you may want to do so to get the full story -- i.e., bones are made of more than calcium and vitamin D.

Vegan Guidelines (developed by vegan dietitians):

Calcium in the Vegan Diet

FAQs About Vitamin D

Vegan Foods are Good for Bone Health

Meeting Calcium Needs:Tips for Vegans

Bones, Vitamin D, and Calcium

Vegetarian Guidelines (include dairy sources):

Building Bones That Last - Even though more than 5 years old, I've included this resource by Vesanto Melina and Brenda Davis because it contains a table of the calcium content of many different plant foods as well as the percentage of calcium absorbed from each source.

Bone Health for Women - An "all-in-one" web site with pages on Food, Exercise, Supplements, and Tips & Recipes.

Parsley, cottage cheese & yogurt dip

Food Sources of Calcium and Vitamin D - A helpful reference that includes an easy-to-read table of nutrient values for common and not-so-common (e.g., daylily flower, sea cucumber) plant sources of calcium.  Not strictly a vegetarian resource, though, as it includes fish.

Note: The D*action consortium recommends higher Vitamin D supplementation levels than stated in these resources.

Other Greens & Berries posts in this series:

Image credits:
top - Kale Almond Pesto by elana's pantry; bottom - Parsley, cottage cheese & yogurt dip (recipe here)

I've included it here, however, as it has an extensive range of Asian sources plant sources, including

Nutrition & Bone Health: Selective Literature Review

"A generalization from the literature, without a formal metaanalysis, may be that we need adequate supplies of both vitamin D and calcium to obtain significant reductions in nonvertebral fractures (especially hip fractures), and that those effects may be seen only in those persons who have insufficient vitamin D or calcium (or both). In addition, persons need to consume an overall healthful diet that meets all nutrient requirements. Protein for fracture prevention and healing and plenty of fruit and vegetables for overall health are of particular importance. A well-rounded diet is important, and evaluation of one element or vitamin does not give the whole story. [emphasis added.]

So where does that leave clinicians? The best public health recommendation would be that people should consume an overall healthful diet including adequate consumption of both calcium and vitamin D. This meta-analysis highlights the importance of not  segmenting nutrition into heterogeneous populations and isolated nutrients. Bone is not just calcium, and calcium does not function in isolation.

Source: JW Nieves, R Lindsay
Calcium and fracture risk (editorial)
Am J Clin Nutr. 2007 Dec;86(6):1579-80.


Today, I'm publishing the "sifted" results of several literature searches I conducted during the past two weeks.

HA Bischoff-Ferrari, B Dawson-Hughes, J A Baron, PBurckhardt, R Li, DSpiegelman, B Specker, JE Orav, JB Wong, HB Staehelin, E O’Reilly, DP Kiel, and WC Willett
Calcium intake and hip fracture risk in men and women: a metaanalysis of prospective cohort studies and randomized controlled trials
Am J Clin Nutr 2007;86(6):1780–90.
Full article (PDF)

JZ Ilich and JEKerstetter
Nutrition in Bone Health Revisited: A Story Beyond Calcium
J Am Coll Nutr 2000;19(6):715-737.
Full article (PDF)

(Note: Though this review is 9 years old, it led me to other valuable research and review articles and has been cited by many so I'm including it here. All other resources have been published within the past 6 years.)

SA New and DJ Millward
Calcium, protein, and fruit and vegetables as dietary determinants of bone health
Am J Clin Nutr 2003;77(5):1340 - 1341.
Letter to Editor

SA Lanham-New
Fruit and vegetables: the unexpected natural answer to the question of osteoporosis prevention?
Am J Clin Nutr 2006;83(6):1254-1255.
Editorial with detailed reference list & links
Full article (PDF)

CJ Prynne, GD Mishra, MA O'Connell, GMuniz, MA Laskey, L Yan, APrentice and F Ginty
Fruit and vegetable intakes and bone mineral status: a cross-sectional study in 5 age and sex cohorts
Am J Clin Nutr 2006;83(6):1420-1428.
Full article (PDF)

J-P Bonjour
Dietary Protein: An Essential Nutrient For Bone Health
J Am Coll Nutr 2005;24,(90006):526S-536S
Full article (PDF)

A Devine, IM Dick, AF Islam, SS Dhaliwal and RL Prince
Protein consumption is an important predictor of lower limb bone mass in elderly women
Am J Clin Nutr 2005;81(6):1423 - 1428.
Full article (PDF)

RP Heaney and DK Layman
Amount and type of protein influences bone health
Am J Clin Nutr 2008;87(5):1567S - 1570S.

Full text (PDF)

JW Nieves
Osteoporosis: the role of micronutrients
Am J Clin Nutr 2005;81(5):1232S - 1239S.

Full article (PDF)

RK Rude, FR Singer, and HE Gruber
Skeletal and Hormonal Effects of Magnesium Deficiency
J Am Coll Nutr 2009; 28(2):131 - 141.

FA Tylavsky, LA Spence and L Harkness
The Importance of Calcium, Potassium, and Acid-Base Homeostasis in Bone Health and Osteoporosis Prevention
J Nutr 2008;138(1):164S - 165S.

Full article (PDF)

SA Lanham-New
The Balance of Bone Health: Tipping the Scales in Favor of Potassium-Rich, Bicarbonate-Rich Foods
J Nutr 2008;138(1):172S - 177S.

Full article (PDF)


Because of my practice area (neuroscience), I've been focused on brains and neglecting bones -- at least in terms of the evidence for best practice. Collecting these resources wasn't too difficult (thank you, OVIDSP databases and Google Scholar) and reading them has been very interesting, informative and even surprising. I hope you find some of these resources helpful, too.

In my next post (currently in draft stage) I'll be sharing evidence and practical guidelines on how a plant-based diet can build and maintain healthy bones.


Other Greens & Berries posts on nutrition and bone health:

Nutrition in Bone Fracture Prevention & Healing: Part 1
Nutrition in Bone Fracture Prevention & Healing: Part 2
Nutrition in Bone Fracture Prevention & Healing: Part 3


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?