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Diet and Osteoporosis

By James J. Kenney, PhD, RD, FACN. Copyright Food & Health
Communications, Inc. All Rights Reserved.

Diet and Osteoporosis............................................................................................1
Bone Physiology..................................................................................................2
Pathology of Osteoporosis...................................................................................3
Medical Diagnosis and Treatment of Osteoporosis.............................................4
Keeping Homocysteine Levels Low Is A Good Idea............................................5
Does Milk Do A Body Good?...............................................................................6
Who Should Take a Calcium Supplement?.........................................................7
Impact of Caffeine, Phosphorus and Protein.......................................................8
Excess Vitamin A May Increase Osteoporosis....................................................8
A Lack of Vitamin K May Contribute to Bone Loss..............................................9
Increased Potassium May Reduce Bone Loss....................................................9
Trace Minerals May Reduce Bone Density.......................................................10
A Little Fluoride Is Good But Is More Better?....................................................10
Dietary Salt Increases Bone Loss.....................................................................10
Tobacco and Alcohol..........................................................................................12
The Bottom Line.................................................................................................13

Osteoporosis is a medical condition that results in the loss of bone structure and
strength. It currently afflicts more than 25 million Americans putting them at
greatly increased risk of broken hips, wrists and collapsed vertebrae. About 1.5
million broken bones each year are attributed to osteoporosis and the medical
cost of treatment is in excess of $10 billion. About half of these fractures are to
back vertebrae, which can cause a lot of pain and deformity. There are also more
than 200,000 hip fractures annually in the US and these are often very
debilitating and can lead to long-term nursing home care.

Osteoporosis is a disease many health professionals will be seeing a lot more in
the decades ahead because the average age of the US population will continue
to rise. The loss of some bone mass appears to be partly a natural part of the
aging process itself. However, dietary and other lifestyle factors can slow down or
accelerate the loss of bone strength that occurs with increasing age.
Osteoporosis, like cardiovascular disease and diabetes, is associated with an
increased risk of dying. Osteoporosis weakens bones to the point where
relatively little trauma can cause a fracture. Both men and women who suffer a
low-trauma fracture have been shown to have an increased mortality rate. A 5-
year prospective cohort study in Australia found that all major fractures were


associated with increased mortality and the increase was even greater for men
than for women.1

Studies of fossilized human bone suggest that our ancient human ancestors
usually had a greater peak bone mass than modern men and women living in
industrialized societies today. Their loss of skeletal mass with age also appeared
to be considerably slower than that of modern people living in Westernized
societies.2 Part of the reason our ancient ancestor generally had stronger
skeletons throughout life than Americans today was their much greater level of
physical activity. The average American today is very sedentary compared to
Paleolithic humans. The bones of modern day hunter-gatherers are also
generally stronger on average than people living in more modern societies.
Research has shown that a sedentary lifestyle contributes to osteoporosis and
weight-bearing exercise like walking is associated with stronger bones. 3 One
year of strength training has been shown to increase bone mineral density (BMD)
in women 50-70y.4

It seems clear that the vast majority of Americans would have stronger bones
and a reduced risk of osteoporosis if they were more physically active. It should
be noted that while exercise is generally good for bone health, it could also cause
problems if excessive. Teenage girls involved in athletics, who diet frequently, are
at high risk for osteopenia (low bone mineral content), stress fractures and
broken bones, particularly if they also develop amenorrhea. Amenorrhea can
result from chronic dieting particularly if it leads to a severe eating disorder like
anorexia nervosa. Prolonged amenorrhea associated with dieting and/or
excessive exercise can lead to marked osteopenia, which probably greatly
increases the risk of early osteoporosis when these young females reach
menopause. Osteopenia can also develop in boys and young men who diet

Genetic factors also influence skeletal strength. There are also racial differences
in the susceptibility of developing osteoporosis. People whose ancestors came
from sub-Saharan Africa in general tend to have a greater peak bone mass than
those whose ancestors came from Europe or Asia. However, osteoporosis occurs
in all human populations and tends to be more prevalent in people with smaller or
more slender bones. The risk for an individual is greater if their mother and/or
other close relatives developed osteoporosis at a fairly young age. It is clear that
the risk of developing osteoporosis is due in part to many different environmental
factors, which interact with genetic factors and the aging process.

Bone Physiology
There are 2 structural components of bone. One is the bone matrix (osteoid),
which is composed largely of collagen, but also contains other proteins such as
osteocalcin and ostepontin. The other component of bone is the minerals
deposited in this connective tissue matrix. These minerals are composed largely
of hydroxyapatite, which is a crystalline structure composed mostly of calcium


which are largely responsible for the build up of new bone tissue. It is primarily the drop in osteoblast cell activity with age that sets the stage for 3 . Calcitrol (1. small wrist bones and iliac crest of the hipbone are all rich in trabecular bone that adds structural strength to the outer cortical bone. By age 40y the activity of the osteoblasts starts to slow down to the point where new bone formation falls behind the breakdown of old bone by the osteoclasts. Trabecular bone has a large surface area and greater blood supply than cortical bone making it more responsive to changes in circulating hormones (e. or micro fractures. These minerals provide the rigidity of bones whereas the protein matrix supplies strength and some flexibility. Estrogen appears to function by inhibiting the action of PTH on osteoclasts. This is called cortical bone. During this stage of life the osteoblast create new bone faster than the osteoclasts are breaking it down. Bone is a living tissue that is constantly being built up and broken down. It acts to enhance calcium absorption from the gut. There are two major types of bone in the human body. testosterone) that can affect bone metabolism than cortical bone. One type of bone remodeling cells is the osteoblasts. parathyroid hormone. When the diet does not contain enough calcium to maintain blood levels it can be released from the bone.g. PTH also reduces calcium excretion in the urine. In children.25 dihydroxyvitamin D) is produced from vitamin D in a two-step process involving the liver and kidneys. Calcitonin is released in response to a rise in serum calcium and directly inhibits the osteoclasts and slows the breakdown of bone minerals. The release of PTH results in the release of calcium from the bone by stimulating osteoclast activity. Parathyroid hormone (PTH) is released from the parathyroid glands when serum calcium levels start to fall too low.phosphate and calcium carbonate. The vertebrae. This process is called remodeling and depends primarily on the function of two different types of cells. estrogen. When this structural material is lost in osteoporosis it sets the stage for low-trauma fractures. calcitonin. The other type of bone cell involved in remodeling is the osteoclasts whose role it is to break down bone tissue. Trabecular bone is much less dense and composed of spicules that have a sponge-like appearance. Bone also serves as a source of stored minerals (especially calcium). Around age 30y most people attain what is called peak bone mass. About 80% of the bone mass is tightly packed bone such as that in the shafts of the long bones of the arms and legs. in the bone that over time could lead to larger fractures if the damaged bone tissue is not being continuously remodeled. the growth of new bone exceeds bone breakdown. There are several hormones that regulate serum calcium levels that also affect the bone remodeling process. This breakdown of bone tissue is actually necessary to maintain bone health because normal living results in small stress cracks.. Serum calcium must be maintained between a fairly narrow range or muscle cramping (tetany) or calcification of soft tissues can occur.

4 . The result is women end up with a lower BMD in their last 10-20 years of life much more frequently than men. Drugs That Increase Bone Loss Corticosteroids Lithium Phenytoin (Dilantin) Tetracycline Phenobarbital Thyroid Hormone Heparin Methotrexate Aluminum-Containing Antacids Cyclosporin Phenothiazine Derivatives ________________________________________________________________ ___________ One major difference between the risk of developing osteoporosis and that of developing most other common degenerative diseases such as Type 2 diabetes mellitus. Women experience an accelerated loss of bone following the hormonal changes associated with menopause. atherosclerosis and hypertension is that being overweight is associated with a decreased risk of developing osteoporosis. The result is that bone mass starts to decline in all people with increasing age. 2. Even today about 20% of all osteoporosis related fractures occur in men. Women normally have a lower peak bone mass than men. They have a much greater risk of broken bones over their lifetime. The average loss of bone for older women (10 years past menopause) slows to about 0. Nevertheless. 3. Table 1. it would be a mistake to believe that men are not at risk for osteoporosis.osteoporosis. which is similar to that of older men.5% per year. Women are more likely to develop osteoporosis than men for 3 main reasons. With better control of cardiovascular disease risk factors many more men can expected to live long enough to develop osteoporosis and suffer a broken bone as a result in the future. All men experience a considerable loss of bone by the time they are in their 70's and 80's. 1. This loss of BMD weakens bone to the point where even a minor trauma can result in a major fracture. The risk of most other degenerative diseases increases with increasing body mass index (BMI). Women generally live longer than men so they continue to experience the bone loss associated with aging for a longer time. Pathology of Osteoporosis Age is probably the most important predictor of BMD.5 Some drugs can cause a significant loss of BMD if taken for prolonged periods (See Table 1. below). As much as 5-7% of BMD can be lost the first year or two after menopause starts. For several years after menopause women experience a marked decline in bone mass of at least 1-2% per year. The second most important predictor of osteoporosis is genetic factors. which may account for as much as 70% of the variation in BMD of people the same sex and age.

Even though there are tests to accurately measure BMD and diagnose the loss of BMD long before the loss of bone puts someone at very high risk of broken bones. The benefits of increased body weight in terms of fractures is partially offset by the greater stress placed on bones in falls. The difference in BMD of the wrist bones of overweight and lean individuals is less than for weight bearing bones in the back. etc. This is because amenorrhea appears to result primarily from very low body fat stores. BMD increases with increasing body weight. Therefore. A much cheaper but somewhat less accurate measure of BMD than DXA is an ultrasound-scanning device that measure bone density in the heel in about 10-15 seconds. gallstones. Body weight has less impact on bones that are not weight bearing. so too can finding below average BMD for one's age. wrist or ruptured vertebrae becomes the way advanced osteoporosis is first discovered. It should also be kept in mind that while there are treatments for osteoporosis that can strengthen bone somewhat (at least in the short-run) and reduce the risk of fractures. mortality as well as the social and economic costs of osteoporosis. Medical Diagnosis and Treatment of Osteoporosis Osteoporosis. 7 DXA can also be used to screen for people who are at high risk of developing osteoporosis due to below average BMD. As with all degenerative diseases an "ounce of prevention" is by far the most cost effective public health strategy for reducing the morbidity. The result is that a broken hip. the risk of osteoporosis is somewhat reduced in overweight and obese individuals compared to those who are normal weight or underweight. is often without symptoms until the disease process is far advanced.6 The gain of some body fat in very thin girls and young women will help to increase peak bone mass and probably reduce the risk of osteoporosis later in life. ultrasound scanning of bone density of the heel is appropriate for community screening and use in a doctor's office. diagnosing osteoporosis and assessing the rate of progression of osteoporosis. like high blood pressure and atherosclerosis. 5 .However. there is no safe and effective treatment that can entirely replace bone lost to osteoporosis. many doctors are still reluctant to order such screening tests. Very thin young women who have amenorrhea are at a higher risk for broken bones. hips and legs. some types of cancer. Because of its low cost. Just as finding a high cholesterol level or high blood pressure in a patient can often help motivate him/her to improve his/her diet and lifestyle. no one would advocate gaining a lot of weight to prevent bone loss because the benefits would be more than offset by an increased risk of morbidity and mortality from CVD. even in patients with a number of risk factors. The use of an estrogen containing "contraceptive" pill in girls with amenorrhea is probably medically justifiable to increase peak bone mass until sufficient body fat is gained to restore a normal reproductive cycle. Dual-energy X-ray absorptiometry (DXA) remains the gold standard for assessing BMD. diabetes. Of course.

Biphosponates have been shown to both increase BMD 11. after age 75y the impact of even long-term estrogen therapy was only 3.13 The bone formed in the treatment of 6 . However. there is a new class of drugs called selective estrogen receptor modulators (SERMs). Calcitonin cannot be taken in pill form because of its peptide structure. Risedronate). it has been shown to be quite effective at preventing the rapid loss of bone that occurs during the first 5-10 years after menopause. appears to be most effective if given early in menopause. Women who took estrogen for seven or more years after menopause were shown to have significantly greater BMD up to age 75y compared to women who did not take estrogen (+11.10 While there is a lot of media hype about the use of soy products and even isolated soy isoflavones to treat osteoporosis there is insufficient evidence at this time to warrant the use of isolated soy isoflavone supplements to treat osteoporosis. Raloxifene. Thiazide diuretics can also help reduce the loss of bone in both men and women who are taking corticosteroids. Calcifidiol is a safer form of vitamin D and can also be used to enhance calcium absorption and slow bone breakdown with much less danger of hypercalcemia. it can now be delivered via a nasal spray as well as injection. It is most helpful in men being treated with corticosteroids. which depress testosterone production. or those who do not wish to take estrogen replacement after menopause. Alendronate. another SERM. Calcitrol. 9 Isoflavones found in soy products appear to act somewhat like SERM and have shown some potential in reducing bone loss. However. Calcitonin. which is the active form of vitamin D.2% greater). which are chemically related to pyrophosphate act by inhibiting osteoclast activity and slowing the breakdown of bone. can be quite toxic and can dangerously elevate serum calcium levels. Estrogen therapy may modestly increase the risk of breast cancer so many women would prefer not to take it. which inhibits bone resorption by osteoclast. For women who are at higher risk of breast cancer. Its use can probably only be justified in patients receiving long- term glucocorticoids which markedly increase the risk of bone loss. because it appears to help prevent bone loss.There are a number of drugs that can be used to treat and/or help prevent osteoporosis. which can be considered. 12 and also to reduce the risk of fractures. However. has been approved by the FDA for treating osteoporosis. However. Biphosphonates (Etidronate. the use of soymilk fortified with calcium and vitamin D (and cobalamin) is a sensible substitution for cow's milk in the diet of vegans or people who do not wish to consume cow's milk.2% greater BMD compared to women who did not take estrogen. However. Patients receiving this drug must have their serum calcium closely monitored to avoid hypercalcemia. Tamoxifin can be used to treat breast cancer patients who also have osteoporosis because it has been shown to help conserve bone. because Tamoxifen has undesirable side effects it is not appropriate for treating or preventing osteoporosis. 8 Testosterone can help increase bone formation in men with low BMD and low testosterone levels.

It should not be taken before bed or lying down. vitamin B-12 and either choline and/or betaine can lower elevated homocysteine levels. It is important that a healthy diet be adopted early in life because it along with appropriate exercise will enable an individual to attain the greatest possible peak bone mass given their genetic make-up. By contrast diets high in fatty meats and particularly processed meats like hot dogs. As homocysteine levels rise above 9mg/dl the risk of heart attacks. sausages. Fosomax has been approved for preventing as well as treating osteoporosis in high-risk women with below normal BMD. There is already more than enough reason to take steps to lower the homocysteine level in the blood if it is moderately elevated but until the results of a new study were published in the New England Journal of Medicine in May there was no good evidence to suggests lowering homocysteine levels might also prevent damage to the bones leading to hip fractures. bologna and pepperoni raise blood pressure. 14 Biphosphatonates can cause esophageal reflux making them difficult for some patients to take.” 15 Supplements of folic acid. This system uses a weak electrical current to stimulate the healing of fractures. Researchers in Holland examined the risk of hip fractures in men and women age 55 and older. A similar devise is now being tested to see if an electrical current can stimulate the growth of bone in patients with osteoporosis. strokes and developing of Alzheimer’s disease goes up. cholesterol levels and markedly increase the level of homocysteine in the blood particularly for several hours after every high protein meal. We will now take a look at how dietary variables can impact the risk of developing osteoporosis. Another promising treatment for healing broken bones was recently approved by the FDA (Orthofix's Physio-Stim).osteoporosis with biphophonates appears to be histologically normal and overall safety was similar to that of a placebo. Fasting homocyteine levels and LDL levels are also elevated in 7 . vitamin B-6. To minimize the risk of esophageal difficulties Fosomax (alendronate) should be taken with a full glass of plain water 30 minutes before consuming breakfast or a beverage like coffee. Hip fractures are the number one cause of elderly people being forced into nursing homes. Keeping Homocysteine Levels Low Is A Good Idea For many years doctors have known that people very high levels of homocysteine in their blood often develop severe osteoporosis early in life. After several years of follow-up they found that the people whose homocysteine level was in the top 25% were twice as likely to suffer a hip fracture as those whose homocysteine levels were in the bottom 25% of the group. The authors of this study conclude “An increased homocyteine levels appears to be a strong and independent risk factor for osteoporotic fracture in older men and women. Even moderately elevated levels of homocysteine in fasting blood are strongly associated with an increased risk of cardiovascular disease.

fruits. the connection between dairy product calcium and stronger bones was even stronger than for calcium from other sources. which prevents most of the calcium from being absorbed. These same dietary factors also contribute to the loss of BMD with increasing age. and legumes. vegetables and nonfat dairy products. their diet was much higher in both calcium and protein than that of Americans.18 This may be because some high calcium vegetables like spinach and rhubarb are high in oxalic acid. This may be due not only to a lower intake of calcium but also because they generally have a much lower 8 . previous milk consumption in young women has been associated with greater bone density. which contribute to the development of strong bones by age 30 y or so. whole grains. However. In addition to a much more active lifestyle. There is already convincing evidence that lowering high cholesterol levels reduces the risk of osteoporosis and hip fractures. The most obvious and well publicized of the dietary factors associated with weaker bones is a lack of calcium. People who do not get outdoors and do not drink milk or vitamin D fortified soymilk. in part because they did not drink milk. Since vegetable proteins tend to be lower in sulfur-containing amino acids they appear to have much less effect on urinary calcium excretion than sulfur-rich animal proteins. One of the most obvious differences between the diet of modern day Americans and that of our ancient ancestors was the consumption of milk. our ancient ancestors also consumed a diet that was drastically different than that of modern day Americans. Indeed. Some people have argued that our ancient ancestors had much stronger bones on average than do modern day Americans today. 16 It could be argued that our ancient ancestors had much stronger bones on average than does the average American today and they did not drink milk. It seems likely that some of these dietary differences could be contributing to the weaker bones of modern day humans. While milk is fairly high in sulfur-containing amino acids. Indeed. This may be due primarily to the higher content of sulfur-containing amino acids found in animal proteins compared with proteins from plants. Does Milk Do A Body Good? There are a number of dietary factors.people who eat more fatty animal products and fewer whole grains. vegetables. claims that it may increase the risk of osteoporosis do not appear accurate. 17 A study of 843 Chinese women found that BMD was positively associated with calcium from dairy products. This new data demonstrating a strong connection between modestly elevated homocysteine levels and an increased risk in hip fractures provides yet another reason to discourage Americans from following fad diets high in protein. may be at increased risk of osteoporosis. Another possible factor contributing to the loss of BMD is the excessive intake of protein and particularly animal protein. salt and animal fats and low in fruits.

It seems clear that most research suggests that drinking milk is more likely to decrease the risk of osteoporosis despite the fact that some of its constituents if consumed in excessive amounts may have a negative impact on BMD. it is clear that their bones were far stronger on average than those of Americans today. particularly in the winter months. The bones of most Americans would likely be stronger if they regularly consumed 2 servings of nonfat milk daily. from the fossils of our ancient ancestors. consume a much more vegetarian diet than our ancestors did and yet their bones are stronger still.intake of vitamin D than people who consume milk. Second. In some studies of older Americans who consumed more protein. 9 . those who believe more protein is beneficial to bone strength point to clinical trials in which children who consume more protein tend to build stronger bones than those who consume less. On the other hand. First. What About Protein? One of the most hotly debated controversies in clinical nutrition today is whether a diet higher in protein has a positive or negative effective on bone strength and bone mineral density (BMD). the great apes. Research has shown lower serum 25-OH vitamin D (the metabolically active form of vitamin D) and higher levels of parathyroid hormone (usually associated with the mobilization and loss of bone calcium) in middle-aged vegans compared to vegetarians that include dairy products in their diets. Those who are against protein point to the fact that vegetarians tend to have stronger bones than people who eat more meat and the clinical trials showing increased loss of calcium in the urine when meat or protein intake is increased. the risk of bone fracture was reduced. our ancient ancestors were for the most part hunter-gatherers and ate a diet that was likely considerably higher in protein than the diet of most Americans. 19 People who live in high northern latitudes and do not drink milk should be encouraged to take a vitamin D supplement during the winter months. However. Our Ancient Ancestors Had Strong Bones If we look at this problem from an evolutionary perspective. the large amount of saturated fat and cholesterol found in whole milk clearly raise serum cholesterol and increase the risk of atherosclerotic heart disease and stroke. two things are clear. The bones of our closest “relatives”. People that do not consume many calcium-rich leafy vegetables like collards and kale may also benefit from a calcium supplement. Other dairy products are good sources of calcium but unlike milk they are not fortified with vitamin D.

These are metabolized to sulfate and phosphates. meat. Most high protein foods of animal origin such as cheese. Grains also on balance tend to result in more acid that alkaline in the blood and urine when metabolized. fish. Reducing salt helps reduce calcium excretion and replacing it with MSG alkalanizes the urine. Research has shown that replacing sodium from salt with MSG results in far less acidic urine and also cuts the loss of calcium in the urine. which should help strengthen bones A diet low in meat. These minerals oppose the acids that form from the metabolism of protein-rich foods that are high in phosphorus and sulfur. One way to cut the net acid load on the body is to replace added salt in the diet with MSG. eggs. processed meats. It is also important to minimize the foods that tend to generate excess acidity like refined grains. and with MSG in place of salt. magnesium). It showed that while higher protein intake was generally associated with stronger bones. even when those grains are whole. although not as much as most animal products. it is also very important to get enough calcium. Potatoes and yams have more of an alkalizing effect than grains. and cheeses. 10 . which make the urine more acid. cheese. which should reduce not only the risk of osteoporosis but also most kidney stones. salt and refined grains and much higher in fruits. 20 Fruits and vegetables are very high in potassium and also can have a lot of calcium and/or magnesium. Also their diets differed in many other ways which impact bone strength than simply being higher in protein. vegetables.Our ancient ancestors had stronger bones in part because they were much more physically active than modern people today. Normal metabolism generates lactic acid and other organic acids that tend to acidify the urine. A recent study examined the long-term impact of dietary protein and other factors on bone development in children from 6 to 18 years. the beneficial impact of more protein in the diet was greatly diminished if the diet had relatively little alkalinizing minerals (calcium. Bottom line: While research now shows that diets with more protein do help strengthen bones. potassium and magnesium by eating more fruits and vegetables. In addition these foods can generate more uric acid. Increased dietary salt is known to increase the loss of calcium in the urine even though its impact on the acid-base balance in the body is neutral because sodium is a strong base but chloride is a strong acid. can be used to alkalinize the urine and reduce the risk of osteoporosis and most kidney stones. poultry and eggs generate more acidity in the body. potassium.

How much calcium one should take as a supplement depends on his/her dietary intake of calcium. Chewable sources of calcium. nonfat dairy products and a little seafood. may be appropriate for those who cannot swallow pills. After that time it should be breaking up and should fall apart fairly easily if pressed with a spoon.Who Should Take a Calcium Supplement? People who cannot or do not wish to consume milk regularly may find it very difficult to meet the recommended calcium intake of 1200 to 1300 mg for some age groups. vitamins and other phytochemicals that may help maintain adequate BMD into old age. such Tums. As we shall see. manganese and other divalent cations. Calcium supplements are probably warranted in treating people with osteoporosis who are also taking 11 . It should be noted that calcium supplements could reduce the absorption of iron. Calcium citrate tends to be a little less constipating than calcium carbonate. One problem with calcium supplements is that those that are poorly formulated may not dissolve and simply pass through the digestive tract. Also. there is no way supplements can be a substitute for a healthier diet with more fruits. Bone meal and dolomite calcium supplements are best avoided as they may be contaminated with lead. cadmium or other heavy metals. which influence calcium absorption and/or excretion. There is also a calcium supplement in the form of a chocolate candy cube that may be appropriate for some individuals (Viactiv). Perhaps the best calcium supplement for children and young adults is calcium carbonate because it has the highest ratio of calcium to the anion of all calcium supplements. It also depends on the amount of other substances in the diet. A deficiency of these trace minerals may contribute to osteoporosis or other nutritional problems. While calcium supplements may be of some benefit in individuals with a poor diet. The diet of most people who shun milk will not contain adequate vitamin D to meet their needs. vegetables. whole grains. The average calcium intake for women in America is only about 500 mg/day. legumes. to ensure adequate calcium absorption is important that adequate vitamin D stores be maintained either by diet. zinc. Younger people and older people with normal stomach acidity absorb calcium carbonate nearly as efficiently as calcium citrate. these dietary factors can all increase the loss of calcium from the body. supplementation or sunlight. If it remains very hard then it may not be well absorbed. Such foods contain trace minerals. Older people who have achlorhydria (about 15-20% of those 60y +) will often do better with a calcium citrate supplement because it is less dependent on stomach acid than calcium carbonate for absorption. It is likely that the amount of calcium needed could be reduced if the American diet were not so high in salt. and foods with an acidic residue such as meats. Place the supplement in a glass with warm vinegar for about 15 minutes. A simple test can help determine if a calcium supplement may be difficult to absorb. soft drinks and other caffeine-rich beverages.

000 mg of calcium for the prevention of fractures in postmenopausal women. The US Preventive Task Force recommends:24  The Task Force recommends against daily supplements of less than 400 IU of vitamin D3 and less than 1. 22 A calcium intake up to 2000 mg daily appears to be safe for most people. Phosphorus and Protein A heavy consumption of caffeine may also contribute to an increased loss of calcium from the body and thus contribute to bone loss over time. BMD can be impacted by many dietary factors besides calcium and vitamin D and avoiding osteoporosis may depend as much on what is avoided as what is consumed.000 IU so even higher doses up to this level may be safe except for hypersentive individuals. Calcium and Vitamin D supplements are not proven to prevent fractures. zinc and other trace minerals. Daily supplements of 500 mg of calcium and 700 IU (17. even 1000 mg of calcium supplementation may increase constipation in some people. Impact of Caffeine. A study of 205 healthy nonsmoking. other researchers have failed to 12 .000 mg of calcium for the prevention of fractures in postmenopausal women.prescription drugs in an attempt to strengthen remaining bone and reduce the risk of fractures.21 It appears that supplements of calcium and vitamin D may help reduce the risk of broken bones in older Americans. Also. Total body sun exposure can easily supply 10. post-menopausal women found that those who were consuming less than 800 mg of calcium daily and were also consuming more than 450 mg of caffeine daily had a lower BMD than the women who consumed more calcium and/or less caffeine. However.5 mcg) of vitamin D have been shown to reduce bone loss and the incidence of broken bones in older men and women.  The Task Force found that the current evidence is insufficient to make a recommendation on daily supplements greater than 400 IU of vitamin D3 and greater than 1. which should also help delay the development of osteoporosis when they reach old age.25 However.  The Task Force found that the current evidence is also insufficient to make a recommendation on vitamin D and calcium supplements for the prevention of fractures for men and premenopausal women. It is also likely that a calcium supplement in teenagers who shun dairy products may help to increase peak bone mass. 23 However. A vitamin D intake up to 2000 IU or 50 mcg is safe for nearly everyone. high doses of supplemental calcium may reduce the absorption of iron.

high intakes of both protein and phosphorus have been associated with a lower BMD in young women. retinol is added to margarine and there is also a lot of retinol in cod liver oil.33 More research is clearly needed to confirm the link between excessive intake of vitamin A and an increased loss of bone mass. Consuming a diet high in phosphorus and low in calcium has been shown to result in elevated parathyroid hormone (PTH) secretion. It also means avoiding liver and not consuming too many servings of dairy products and particularly 13 . 32 These two countries also have a very high intake of milk and milk products. who are at high risk for future bone loss and get less than the RDA of calcium. often displacing milk from the diet. Sweden fortifies all low and nonfat dairy products with retinol or vitamin A at about twice the level at which it is found in whole milk. The result is that the intake of retinol intake in Norway and Sweden is about 6 times higher than in most other European countries and it is this excessive intake of retinol (>1. 34 Based on current evidence it seems prudent to advise people at risk of osteoporosis to limit their intake of pre-formed vitamin A (retinol) to the RDA level of 800 RE or 0. The ancestral diet of humans was generally higher in calcium. which is a commonly used supplement in these countries. phosphorus and protein than that of modern day Americans. 29 However. Soft drinks are often high in both phosphorus and caffeine. the role played by dietary phosphorus in BMD appears to be complicated. They are becoming an increasingly popular beverage for girls and young women. Excess Vitamin A May Increase Osteoporosis The highest rates of osteoporosis and hip fractures in the world are in Norway and Sweden. 30 A diet high in meat.8 mg of retinol per day. will likely reduce peak bone mass in the young and increase the risk of developing osteoporosis in later years. phosphorus and calcium on BMD and the risk of fractures. However. In addition. 27 Women. 28 However. The negative impact of caffeine on BMD was greatest in those women who did not consume milk on a daily basis.000/d) that may be contributing to osteoporosis in Norway and Sweden.31 Indeed the rate of hip fractures in these two countries is 7 times higher than that in other European countries. This means food supplements with retinol should be avoided. with the regular use soft drinks instead of nonfat milk as a beverage. should probably be advised to limit caffeine intake. As people grow older they appear to have a lower capacity to clear high levels of ingested retinol from the body. More research is needed to sort out the long-term impact of diets high in protein. as should supplements of cod liver oil.26 Moderate intake of caffeine is certainly not a major factor in the development of osteoporosis. the lifetime intake of the amount of caffeine in as little as 2 cups of coffee per day is associated with decreased BMD in older women.5 mg or 5. Increased dietary phosphorus has actually been shown to help prevent the increased loss of calcium normally seen with the increased intake of dietary sulfur-containing amino acids.find a consistent association between dietary caffeine intake and the loss of bone.

It should be noted that an excessive intake of vitamin D (more than 2000 IU daily) could be toxic and damage the kidneys and cause calcification of soft tissues. A prospective analysis of the Nurses' Health Study Cohort found that low intakes of vitamin K were associated with an increased risk of hip fracture in these women. A Lack of Vitamin K May Contribute to Bone Loss When most people think of vitamin K. 35 Osteocalcin is an important bone matrix protein synthesized by the osteoblasts and appears to be involved in the mineralization of the matrix. Others may be taking coumidin or other anticoagulants and have been told to avoid vitamin K rich foods and supplements as these may increase the risk of blood clots. Many elderly people have a low intake of vitamin K.) and most of the best food sources of vitamin D are high in retinol. vitamin K mediates the gamma-carboxylation of glutamyl residues on several different bone proteins. which have been fortified with retinol. they think of its role in blood clotting. More research is needed to determine the optimal intake of vitamin K for older people to help slow the loss of bone. 36 Many elderly people may take antibiotics that reduce the formation of vitamin K by the microflora of the gut. Those who are house bound or in a nursing home and cannot get regular exposure to UV light should take a similar supplement year round. most notably osteocalcin. it may be prudent to encourage older people to spend 10-15 minutes in the sun (without a sunscreen) several times a week. These include milk. eggs. Increased vitamin K intake is associated with a decreased loss of calcium in the urine. Those who live in northern states should take a vitamin D supplement with about 200-300 IU. The RDA was determined to be adequate for normal blood clotting but the optimal amount of vitamin K for bone formation may be several times higher. 14 . There is no evidence that vitamin A from plants (as beta-carotene and other carotenoids) increases the risk of osteoporosis although high doses of beta-carotene may be toxic. However. of vitamin D daily during the winter months because sunlight contains insufficient UV light to make vitamin D during this time and body stores of vitamin D can drop too low after 2-3 months of inadequate intake. Also most multivitamins contain both retinol and vitamin D. Sunscreens block UV light.those. It should also be noted that most of the best dietary sources of vitamin D are also high in retinol.38 While most Americans probably get close to the recommended amount of vitamin K (80 mcg) it is not clear that this is optimal for healthy bone formation and maintenance. liver and fatty fish. which is necessary for the conversion of cholesterol to vitamin D in sun exposed skin. Since the recommended intake of vitamin D for older Americans is so high (400 IU. primarily because they eat few dark green leafy vegetables.37 Undercarboxylated osteocalcin in the serum has been associated with reduced levels of vitamin K and lower BMD.

Remarkably those taking the supplements of vitamin K had reductions in hip fractures of 77% compared to those given a placebo. Vitamin K2 is made up of menaquinones that can be synthesized in the human gut by micro-organisms. and kale. There are two main forms of vitamin K. Fractures of the vertebrae were cut by 60% and all other fractures were reduced by 81%. Long ago it was hypothesized that the mobilization of bone minerals to buffer excessive acid in the blood could contribute to an increased loss of bone over time and osteoporosis. Osteocalcin is a protein needed to bind calcium to the bone matrix.” Increased Potassium May Reduce Bone Loss The metabolism of the typical American diet with its high intake of meat and low intake of fruits and vegetables tends to yield an excess of endogenous acid. People who have heard of vitamin K may be familiar with its important role in blood coagulation but few realize it is also necessary for making a protein called osteocalcin. The human skeleton serves as a reservoir of calcium that can be mobilized to prevent the blood pH from dropping too low (becoming too acidic). broccoli. lettuce.40 It seems likely that an increased intake of fruits and vegetables with their high potassium intake may help prevent osteoporosis. oral potassium bicarbonate at a dose sufficient to neutralize endogenous acid improves calcium and phosphorus balance increases bone formation and reduces the rate at which bone is resorbed. Vitamin K1 is called phyoquinone or phytonadione and is found mainly in green vegetables like spinach. which is chiefly obtained from green leafy vegetables and certain vegetable oils. about 90% of the vitamin K in the American diet comes from vegetables. An inadequate intake of vitamin K may reduce this protein to the point where bone mineral density is reduced and bone structure is compromised. None of the individual studies reported any serious side effects from the vitamin K supplements although there did appear to be some increase in GI problems. The authors of this study conclude “From a clinical perspective.Most people have heard it is important to get enough calcium and vitamin D to grow and maintain strong bones that can resist fracture but few have heard of the bone strengthening effects of vitamin K.41 They suggested consuming more vegetables and fruits would reduce the acid load on the body and limit the loss of calcium 15 . cheese. A recent meta-analysis examined 7 studies in which elderly subjects were given either 15 (one study) or 45mg of vitamin K2 or a placebo. There is also a synthetic form of vitamin K3 but it is not recommended for human consumption.39 In postmenopausal women. Wachman and Bernstein theorized that the elevated renal acid load from meat. There are several kinds of these menaquinones and small amounts occur in meats and fermented products like cheeses and natto. and phosphate-rich foods may contribute to the development of osteoporosis. grains. However. Drs. Back in 1968. the results of this review suggest that patients at risk for fractures should be encouraged to consume a diet rich in vitamin K.

Dawson-Hughes concluded that alkalinizing the urine “… had a favorable effect on bone resorption and calcium excretion. Dawson-Hughes examined the impact of adding either sodium or potassium bicarbonate supplements to neutralize the increased renal acid load produced by a typical modern diet in 171 subjects age 50 and older.”42 Another study that examined the impact of dietary protein and other factors on bone development in children from 6 to 18 years showed that while higher protein intake was generally associated with stronger bones. They found both alkalizing supplements reduced urinary calcium and urinary N-telopeptide – a marker for more rapid bone breakdown. It is important to cut back on foods like meats. It is likely then consuming more potassium-rich foods and cutting back on cheese. and phosphate-rich foods and drinks would help alkalinize the blood and urine and likely slow or even partially reverse the loss of bone minerals associated with osteoporosis. A study by Dr. that acidify the blood and urine and contribute to the loss of BMD over time. Dr. vitamin K. calcium. Jehle and colleagues examined the impact of giving 201 healthy older people (>65y) either 60mEq of potassium citrate or a look alike placebo for two years. cheeses. potassium. While salt has little impact on acid-base balance. white flour and other refined carbohydrates will be much lower in many essential trace minerals than the diet consumed by our ancient ancestors during the evolution of man. which are excellent sources of both potassium.being lost in the urine to buffer the increased renal acid load. Trace Minerals May Reduce Bone Density A diet rich in refined fats and oils and/or sugar.. magnesium and trace minerals involved in bone metabolism in older men and women was shown to contribute to the maintenance of BMD in a 4 year longitudinal study. Bottom Line: Americans should consume more potassium-rich foods like fruits and vegetables to help stop or reverse bone loss. Replacing some salt with MSG would also reduce renal acid load and calcium excretion. magnesium). only those receiving the potassium supplement saw a reduction in their renal acid load and experienced a significant increase in their bone mineral density (BMD). it also contributes to increased urinary calcium loss and so should also be limited in diet of those at risk for osteoporosis. sodas.e. the beneficial impact of more protein in the diet was greatly diminished if the diet was lower in alkalinizing minerals (i. This suggests increasing the alkali content of the diet may attenuate bone loss in healthy older adults. meats. 44Those receiving the placebo saw no change or modest declines in BMD. Those who already have weakened bones may also benefit from replacing even some of the whole grain products in their diets with more potatoes and yams as the latter are much higher in potassium and would reduce their renal acid load and the loss of BMD. eggs. etc.43 A study published online by Dr. An increased consumption of fruits and vegetables. 16 . After 2 years. All subjects also received supplements of vitamin D and calcium. 45 It is clear that people at risk for osteoporosis should be encouraged to consume more fruits and vegetables.

manganese.Boron appears to be used by osteoblasts in bone formation and seems to mimic some of the effects of estrogen. celiac disease and Crohn's disease) appears to be a risk factor for the development of osteoporosis and osteomalacia.51 More research is needed to determine the amount of various trace minerals necessary for optimal bone health. since high doses of fluoride can cause nausea. Mega doses of fluoride do increase BMD. particularly when the diet is low in magnesium. There is no evidence that levels of boron in excess of what one would already get from a healthy diet are beneficial. so a boron supplement would be of questionable value. However. copper. could lead to a weaker bone matrix but there are no studies. However.g. A Little Fluoride Is Good But Is More Better? In the past high intakes of fluoride supplements (e.46 A supplement of 3 mg daily of boron was shown to increase beta-estradial and testosterone levels in older subjects. One study of postmenopausal women found that the addition of these 4 minerals to a calcium supplement helped slow the loss bone in these older women.g. Zinc. phosphorus and magnesium in the urine. 52 In any case.50 Iron is another trace mineral involved in bone metabolism. which suggest that a lack of either of these nutrients plays a role in the development of osteoporosis. Legumes and nuts are also good sources of boron. A low serum magnesium level. a deficiency of either iron or vitamin C. Boron's function in bone formation appears to be related to magnesium metabolism. which is necessary for the maturation of the collagen matrix. 47 Whether or not boron is absolutely required for healthy bone formation in humans is still a matter of some debate. It serves as a catalytic co-factor for ascorbic acid in the hydroxylation of proline and lysine. which is often seen in patients with chronic alcoholism. while a large dose of fluoride increase BMD there is also evidence that bone with an excessive fluoride content is more susceptible to micro fractures because of alterations in the structure of the hydroxyapatite (where fluoride atoms displace hydroxyl ions).. Boron is a required mineral for fruiting plants so consuming a diet with plenty of fruits and vegetables should supply adequate boron. Fluoride may make bone more rigid and brittle and is not likely to reduce the overall fracture rate in people with osteoporosis. Diets low in copper may contribute to osteoporosis by interfering with the formation of the protein support structure for new bone. gastric bleeding and vomiting and may 17 . legumes and dark green vegetables are the best dietary sources of magnesium and supply trace minerals and other factors that may improve bone health.48 49 Whole grains. diabetes mellitus and malabsorption syndromes (e. 75 mg/d) were believed to build stronger bone. and fluoride are al involved in the formation of healthy bone. it seems likely that a modern Western diet with a lot of refined foods may result in low enough intakes of some essential minerals to undermine the formation and remodeling of healthy bones. Boron appears to reduce the excretion of calcium. In theory.

62 While increased dietary phosphate can blunt the increased calcium excretion caused by a high protein intake. It seems likely that dramatically reducing dietary salt would help prevent many broken bones in America every year. The scientific evidence is very consistent that excessive intake of dietary salt greatly increases the loss of calcium in the urine.54 Clearly more research is needed before high-dose fluoride supplements can be accepted as a useful treatment of osteoporosis. 56 A study in New Zealand showed that there was a progressive increase in urinary calcium excretion as dietary salt intake increased from 70 to 220 mmol/d (or about 1600 to 5000 mg of sodium). Data from this study suggested that reducing dietary sodium from 5000 to 1600 mg daily would reduce the loss of calcium in the urine by 32% in men and 27% in women. One must increase the intake of dietary calcium by approximately 1000 mg daily to prevent bone loss in postmenopausal women who are ingesting an extra 2000 mg of sodium as salt daily. 60 In postmenopausal women.57 Simply put. increased dietary phosphate has no impact on the increased excretion of calcium caused by adding more salt to the diet. Even 5500 mg of sodium when given as either sodium citrate or sodium bicarbonate did not increase urinary calcium excretion as sodium chloride does. Dietary Salt Increases Bone Loss One of the most important factors contributing to an increased loss of calcium in the urine and the development of osteoporosis has been widely ignored by most clinicians and the mass media. It is hard to escape the conclusion that the amount of salt added to commercial foods and at home in all modern societies must play a major role in the development of ostepenia and eventually osteoporosis. it should be noted that the problem with increased urinary excretion of calcium with increased dietary salt is not caused by the sodium ion alone.55 Results of a longitudinal study suggested that reducing dietary sodium excretion by 50% (from 3450 to 1725 mg/d) would be as effective in slowing the loss of bone as increasing dietary calcium by 891 mg/d. the more calcium you'll excrete. Using low- sodium baking powder (which contains potassium bicarbonate) in place of regular baking powder (which contain sodium bicarbonate) will also help to reduce urinary calcium excretion and presumably also the loss of BMD. an increase in dietary salt has been shown to increase urinary calcium excretion61 and lead to an increased loss of bone minerals. However. 58 Those concerned with either the development of essential hypertension or osteoporosis would also be better advised to consume MSG rather than salt or sea salt. Increased salt intake has also been associated with reduced peak bone mass and a more rapid loss of BMD in older people. 59 It has been shown that both a lack of calcium and/or an excess of salt in the diet leads to a reduction in bone density in young females.even increase the risk of hip fracture53 and all fractures. the more salt you eat. 63 18 .

Switching from a typical American diet to the DASH diet resulted in about a 10% reduction in osteocalcin.An excessive intake of dietary salt is the primary causal factor in the development of essential hypertension. 100 & 150mmol of Sodium/day) with either a typical American diet or with the DASH diet. it seems likely that combining a DASH-style diet with a low sodium intake should improve bone metabolism and may help prevent the development of osteoporosis. Increasing dietary sodium (as salt) was associated with a greater loss of calcium in the urine on both the DASH diet and the more typical American diet.66 Because older Americans will develop either high blood pressure. 68 In theory. Urinary calcium excretion was increased somewhat more on the typical American diet than on the DASH diet. osteoporosis or both it is perplexing that the media and most health professionals do not more strongly encourage people to reduce their salt intake. A low salt intake combined with a diet higher in fruits. fruits. urinary calcium loss was not significantly increased on the American diet compared to the DASH diet. a hormone associated with more rapid breakdown of bone. Calcium excretion was also increased significantly more with increasing dietary salt in subjects with high blood pressure compared to those who were normotensive. the data showing a strong correlation between urinary sodium and both urinary calcium and urinary hydroxyproline (a marker for bone loss) certainly suggests that the unnaturally high intake of salt in all modern human populations plays a major role in the development of osteoporosis.67 In addition numerous studies have shown that increasing dietary salt intake leads to an increased loss of calcium in the urine and an increased serum parathyroid hormone level. Compared to a typical Americican diet the DASH diet contains more whole grains.65 While there is no prospective human data on the long-term impact of reducing dietary salt on BMD. Another marker of bone breakdown called C-terminal telopeptide of type 1 collagen (CTX) was also about 16-18% lower on the DASH diet than the more typical American diet. Low-Sodium DASH Diet Improves Bone Metabolism Epidemiological studies have found that people who consume more fruits and vegetables tend to have stronger bones.64 High blood pressure is also associated with increased bone loss in elderly white women. 19 . vegetables and low-fat dairy products and less meat and other foods high in saturated fat as well as less sugar and refined carbohydrates.Sodium trial enabled researchers to examine the impact of 3 different levels dietary salt (50. This new study specifically examined the individual and combined impact of different levels sodium intake and consuming the DASH diet on bone metabolism. whole grains and nonfat dairy products (DASH-style diet) should slow the loss of bone mineral density as people age by improving bone metabolism. vegetables. A recent studied examined the combined impact of either the DASH diet versus a more conventional American diet each fed with 3 different levels of dietary sodium intake. The DASH. However.

In addition. the typical American diet often lacks adequate calcium.” 69 Given the fact that most older Americans have or will soon develop hypertension and that most are also at risk of developing osteoporosis it seems prudent to encourage all older Americans to adopt a low-sodium DASH-style diet. 74 The Bottom Line Osteoporosis is a disease characterized by the gradual loss of bone mass with age. 72 Moderate alcohol consumption may increase estrogen levels and this may not only be part of the reason it increases BMD but also why it has been associated with an increased risk of breast cancer. which if sustained may improve bone mineral status. An excessive intake of phosphorus. 70 A meta-analysis of 48 studies showed that the more a women smoked. found that moderate alcohol intake (11-20 g/day) was associated with a significant increase in trochanteric bone mineral density in elderly women compared with no alcohol intake. manganese and copper for optimal bone health. magnesium.73 Once recent study. retinol. moderate alcohol consumption appears if anything to reduce the loss of BMD. or about 1-3 glasses of wine. potassium. boron. the greater her risk of fracture. But the beneficial effect of alcohol on bone mineral density was no longer apparent at alcohol intake above the moderate level.The authors of this study conclude. alcohol and fluoride may also increase the risk of bone fractures but more research is needed to determine how much is too much. Tobacco and Alcohol Smoking cigarettes has long been known to contribute to osteoporosis in part because smokers are thinner and lower BMI is associated with lower BMD. “…the DASH diet significantly reduced bone turnover. animal protein (which increases endogenous acid production) and caffeine will likely increase the loss of calcium in the urine. Its development is influenced by genetic factors as well as by dietary and other lifestyle factors. Clearly. even moderate intake of alcohol can increase the risk of falls and thus increase the risk of a broken bone. A diet high in salt. as do some prescription and over-the-counter drugs. Smoking and inactivity also increase the risk of osteoporosis. 3-7 glasses of beer or 1-3 shots of liquor per day or a combination of these. published in the American Journal of Epidemiology. soft drinks and meat and high in fruits and vegetables with 2- 3 servings of nonfat milk daily coupled with an active lifestyle (with plenty of weight bearing exercise) is probably best for preventing osteoporosis and bone 20 . beneficial effects on bone health. vitamins K & D and perhaps trace minerals such as zinc.71 The impact of alcohol on bone loss and the risk of fractures is more complicated. The DASH diet and reduced sodium intake may have complementary. A diet lower in salt. A reduced sodium intake reduced calcium excretion in both diet groups and serum osteocalcin in the DASH group. However. Heavy drinking contributes to both bone loss and fractures. Total bone mineral density was significantly lower in women with alcohol intake of 30g/day or more compared with non-drinkers.

However. References: 21 . dietary treatment alone is insufficient to minimize the risk of bone fractures although a healthy diet should remain a valuable adjunctive therapy for people with osteoporosis who are taking drugs such estrogen or alendronate to strengthen bones. A reduction in dietary salt and animal protein will reduce the loss of calcium in the urine and help maintain adequate BMD into old age. vitamin D and perhaps other nutrients should be considered when the patient does not comply with a healthy diet prescription.fractures. Supplements of calcium. once osteoporosis is established.

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