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Dietary Protein Increases urinary Calcium

JANE E. KERSTETTER*

AriD LINDSAY H. ALLEN**

*School of Allied Health Professions and **Department of Nutritional Sciences, The University of
Connecticut, Storrs, CT 06269-4017
typically consumed by the American adult, increases in
dietary protein do increase urinary calcium, resulting in
a shift of calcium balance in a negative direction.
Figure 1 summarizes 16 separate human studies and
illustrates the relationship between dietary protein in
take and urinary calcium excretion in 154 adult subjects
(1-7, 9, 10, 13-19). The protein was supplied as wheat
gluten, beef, milk, egg, soy, lactalbumin or casein in the
form of purified proteins or mixed foods. Study periods
lasted from 12 to 60 d. At protein intakes below 200 g/d,
the relationship between dietary protein and urinary
calcium is liner (r = 0.67) such that for each 50-g incre
ment of dietary protein an extra 60 mg of urinary cal
cium is lost.
The relationship between dietary protein and urinary
calcium has also been well documented in rat models
(20-24) and in dairy cows (25). Hypercalciuria from
excessive dietary protein increases the risk of renal
calcium oxalate stones (26-31).
The renal response of humans to dietary protein is
rapid; that is, hypercalciuria is observed within 2 to 4 h
after protein ingestion (32). In humans, the calciuria
does not diminish in long-term experimental periods
lasting from 45 to 60 d (1, 4, 7). The mechanism by
which dietary protein influences urinary calcium prob
ably involves several factors. Dietary protein clearly
increases the glomerular filtration rate and thus the
filtered calcium load (4-7, 14, 15, 17, 33). In addition,
the renal fractional reabsorption of calcium is depressed
by a higher protein diet compared to one with a lower
protein content (4, 5, 7, 15, 17, 32). The change in
reabsorption has been attributed to the sulfur and acid
load from the protein (5,17,34,35) or the hyperinsulinemic effect of protein (36).
The protein-induced increase in urinary calcium re
sults in negative calcium balance. Figure 2 illustrates
calcium balance data from 13 separate human studies
in which dietary protein was manipulated in 104 adults

500

o
o

400

I300-

e 200
o
100

e
o

S8<

o
o

100

200
300
400
Dietary
protein
(0/d)

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600

FIGURE 1 Relationship between protein intake and uri

nary calcium. Each point represents the mean of a group of
subjects from one of the 16 studies cited in the text. The data
represent 154 adult male and female subjects.

0022-3166/90 $3.00 1990 American Institute of Nutrition. Received 13 January 1989. /. ut-.120:134-136.

134

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An increase in dietary protein has been shown by

several investigators to increase urinary losses of cal
cium, resulting in negative calcium balance (1-7). This
has been reviewed in detail by Yuen et al. (8). However,
Spencer and colleagues have observed that a high pro
tein diet has little effect on urinary calcium excretion,
and they attributed this to the phosphorus content of
the diet (9-11). Recently, they concluded that com
monly used complex proteins, which have a high phos
phorus content, do not cause urinary calcium loss in
adult humans (12). Because excess urinary calcium and
negative calcium balance are thought to result in an
increased risk for osteoporosis and nephrolithiasis, it is
important to address this discrepancy of opinion. This
paper will summarize the available data in adults regard
ing the effects of dietary protein, calcium, and phospho
rus on calcium balance. From the available literature,
we conclude that at calcium and phosphorus intakes

135

DIETARY PROTEIN INCREASES URINARY CALCIUM

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0.6

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FIGURE 3 Relationship of protein and phosphorus intakes

to calcium retention. Each point represents the mean of a
group of subjects from the 13 studies cited in the text. The data
represent 104 adult male and female subjects. Protein intakes
are as follows: 25-74 g/ (open circles), 75-124 g/d (stars),
125-174 g/d (open boxes) and >175 g/d (open triangles).

(1-7, 10, 14-16, 19). At low protein intakes (25-74 g/d),

calcium balance is close to equilibrium at calcium in
takes between 500 and 1400 mg/d. For healthy individ
uals weighing less than 91/kg, the RDA for protein is
included in this "low protein" range. At the typical
calcium intake for adults in Western populations (4001300 mg/d) (37), protein intakes higher than 75 g/d tend
to result in negative calcium balance. Figure 2, however,
does not address the issue of phosphorus intake.
Figure 3 illustrates calcium balance data as a function
of phosphorus intake from the same 13 studies repre
sented in Figure 2. At the typical amounts of phosphorus
consumed by adults (0.8-1.5 g/d) (37), calcium balance
does appear to be largely dependent on protein intake.
We know that phosphorus clearly decreases urinary
calcium losses (6, 18) either by increasing parathyroid
hormone synthesis (38) or more directly by affecting
calcium tubular reabsorption (39). Spencer and col
leagues have concluded that increasing dietary protein
from commonly consumed complex proteins also in
creases dietary phosphorus, which negates the urinary
calcium losses (9-12). These conclusions were based on
studies in which the addition of red meat or dairy
products failed to affect urinary calcium. Although in
creased dietary phosphorus
can clearly blunt the
hypercalciuretic
response to protein and improve cal
cium balance, Figure 3 reveals that the ability to restore
calcium balance to equilibrium is not clear.
For example, Hegsted et al. (6) measured calcium
balance in adults at two levels of protein (50 and 150 g)
and phosphorus (1010 and 2525 mg) intake. At both
levels of protein intake, phosphorus reduced urinary
calcium losses by approximately 40% and shifted cal
cium balance in the positive direction. Yet, calcium
balance was still negative (-25 mg/d) with the high

protein, high phosphorus diet and urinary hydroxyproline was higher, suggesting an increase in bone rsorp
tion (6, 19). In addition, there are other examples in
which a protein and phosphorus load given as animal
flesh were associated with small but significant in
creases in urinary calcium losses (26, 28, 40).
In summary, strong evidence links the intake of com
monly consumed dietary proteins to urinary calcium
and calcium balance at typical levels of dietary calcium
and phosphorus. When there is an abundance of dietary
calcium and phosphorus (as with a liberal intake of dairy
products), the dependence of calcium balance on dietary
protein is less pronounced (19). At protein intakes above
the RDA, more calcium is lost in the urine, so calcium
balances tend to be negative.

LITERATURE CITED
1. JOHNSON,N. E., ALCANTARA,
E. N. & LINKSWILER,
H.M. (1970)
Effect of level of protein intake on urinary and fecal calcium and
calcium retention in young adult males. /. Nutr. 100: 1425-1430.
2. WALKER,R. M. & LINKSWTLER,
H. M. (1972) Calcium retention
in the adult human male as affected by protein intake. /. Nutr.
102: 1297-1302.
3. ANAND, C. R. & LINKSWILER,
H. M. (1974) Effect of protein
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741-749.
5. SCHUETTE,
S. A., ZEMEL,M. B. & LINKSWILER,
H. M. (1980) Stud
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H. M.
(1981) Urinary calcium and calcium balance in young men as
affected by level of protein and phosphorus intake. /. Nutr. 111:
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FIGURE 2 Relationship of protein and calcium intakes to

calcium retention. Each point represents the mean of a group
of subjects from the 13 studies cited in the text. The data
represent 104 adult male and female subjects. Protein intakes
are as follows: 25-74 g/d (open circles), 75-124 g/d (stars),
125-174 g/d (open boxes) and >175 g/d (open triangles).

136

KERSTETTER AND ALLEN

Nutr. 113:1374-1380.
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(1953) Calcium metabolism in dairy cows as studied with 45Ca.
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W. G., HEYBURN,P. J., PEACOCK,M., HANES,F. A. &
SWAMINATHAN,
R. (1979) The effect of high animal protein in
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W. G. & PEACOCK,
M. (1982) The pattern of urinary
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J. G., LEVITT,A. J. &.CRUTHERS,
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