NUTR 302

Background
Bone is a living, dynamic tissue that undergoes continuous resorption (or breakdown) of old or
injured bone and formation of new bone (Christenson, 1997). Development of maximal bone
mass in early life is an important step toward the prevention of osteoporosis in later life
(Cashman, 2002). Osteoporosis is a disease of the skeleton, which is characterized by low bone
mass (or bone mineral density), deterioration of bone tissue, and an increase in bone fragility
and risk of fractures (Cashman, 2002). Osteoporosis is most commonly observed in men and
women over the age of 65; however, bone mass in later life depends on the peak bone mass
achieved early in life, i.e. between the ages of 20 to 35 years (Stipanuk, 2000; Cashman, 2002).

Diet composition is an important determinant of bone mineral density, especially during periods
of growth (Cashman, 2002). Calcium plays a key structural role in the formation of bone mineral.
Approximately 99% of calcium in the body is found in the bones, in the form of calcium
phosphate (Stipanuk, 2000). A significant positive relationship has been observed between
lifetime history of calcium intake and peak bone mineral density (Stipanuk, 2000). Chronic
calcium deficiency resulting from inadequate intake or poor intestinal absorption is one of
several important causes of reduced bone mass and osteoporosis (Cashman, 2002). Thus,
attainment of maximum bone density during growth requires sufficient dietary calcium, along
with a positive balance between calcium retention and calcium excretion (Matkovic et al., 1995).
Of course, there are numerous other factors besides diet that affect bone density, including
genetics, gender, age, body frame size, ethnicity, physical activity levels, and smoking and
alcohol consumption patterns (Cashman, 2002).

Several nutrients have been implicated as playing a role in calcium metabolism and ultimately
bone health. Vitamin D plays a critical role in bone mineralization as it acts to maintain plasma
calcium and phosphate concentrations so that skeletal mineralization occurs (Stipanuk, 2000).
Vitamin D helps to stimulate intestinal calcium absorption, such that Vitamin D deficiency leads
to substantial decreases in the efficiency of dietary calcium absorption (Stipanuk, 2000). Until
recently, dietary protein was thought to contribute to bone loss by increasing urinary calcium
excretion; however, recent studies suggest that increased protein intake can increase calcium
absorption, offsetting the effects on urinary calcium excretion and potentially benefiting bone
health (Weaver et al., 2006). Dietary sodium has been shown to increase the excretion of calcium
in the urine and elevated urinary calcium excretion has been associated with lower bone mass
(Matkovic et al., 1995). Therefore, there is some concern that higher dietary sodium intakes
could have a negative impact on calcium retention and bone density. Since it is often difficult to
quantify dietary intake of sodium or salt, urinary sodium excretion is often used as a surrogate
measure of sodium intake (Matkovic et al., 1995)

The assessment of bone density is now commonly done using dual energy X-ray absorptiometry
(DXA). Different types of DXA scans can assess the mineral content of the whole skeleton or
the mineral content at specific sites (i.e. those most susceptible to fracture) (World Health
Organization, 2003). Bone density scans of particular sites of the skeleton (spine, wrist, or
hip) are required to properly diagnose osteoporosis, as these sites are the most vulnerable to

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fracture (WHO, 2003). The DXA scan you received as part of the NUTR 301 lab provides a
measure of your whole body bone density, and therefore cannot be used to directly diagnose
osteoporosis or your risk of fractures. However, your whole body bone density can provide a
measurement of your overall bone status and how your bone density compares to others in your
age group. Bone density values are expressed in absolute numbers such as g/cm2, but also in
relation to a reference population in standard deviation units. Standard deviation units used
in relation to a healthy young adult population are called T scores, whereas Z scores are
compared to age-matched controls. A T score or Z score of -1 would signify a bone density that
was 1 standard deviation below the average of the young adult reference population or the age-
matched population, respectively (Lane, 2006).

DXA scanning is considered the gold standard for assessing bone mineral density and ultimately
fracture risk (Lane, 2006). However, sometimes biochemical markers of bone turnover (e.g.
urinary calcium, serum alkaline phosphatase) are used to estimate the rates of bone resorption
and bone formation (WHO, 2003). Urinary calcium concentration, corrected for creatinine, has
been used as a marker of bone resorption (Christenson, 1997) and increased urinary calcium
excretion has been associated with lower bone mass in some studies (Matkovic et al., 1995;
Tsuda et al., 2001; Vezzoli et al., 2005; Asplin et al., 2006). However, it should be noted that
urinary calcium levels can be markedly affected by diet (e.g. calcium and sodium intake), renal
function, and hormone levels, and more sensitive markers of bone resorption are being studied.

Although urinary calcium concentration is used as a reflection of serum calcium concentration,

blood tests are also required in order to identify causes of abnormal calcium metabolism (Foley
& Boccuzzi, 2010). A 24-hour collection with volume is more accurate in diagnosing high
urinary calcium than a random measurement (Jones et al., 2012), however a random calcium
measurement can be performed and expressed in relation to creatinine (Foley & Boccuzzi,
2010).

Purpose
The purpose of this lab is to examine the role of calcium and other micronutrients in calcium
metabolism and bone health.

Procedures
For this lab you will refer to your results from the following assessment procedures:
1. DXA bone scan to obtain your whole body bone mineral density (from NUTR 301)
2. Food intake analysis to obtain your average daily micronutrient intakes (from Lab 1)
3. Urinary concentration of electrolytes (sodium, calcium) sample from Lab 2)

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Results
1. Download results from eClass. This will include simple linear regression results examining the
predictive value of the following relationships (1st variable as x, 2nd variable as y):

Urinary electrolyte excretion & bone mineral density
• Urinary sodium and bone density
• Urinary calcium and bone density
Dietary intake and bone mineral density
• Sodium intake and bone density
• Calcium intake and bone density
Dietary intake and urinary excretion
• Sodium intake and urinary sodium
• Sodium intake and urinary calcium
• Calcium intake and urinary calcium
Urinary excretion of electrolytes
• Urinary sodium and urinary calcium

Table: Present the above results nclude the R2 a p - value for each relationship.
Figure: in graphical format
including the line of best fit and R2 value.

Table: how your daily intake

urinary excretion of calcium and sodium bone density results
Z-score

Discussion
You hypothesized about how well the independent variables would predict the
dependent variables in this lab. Provide a rationale for the expected relationships. Make sure
you explain factors likely to be affecting the linear regression results (both expected
and unexpected, biological vs methodological, dietary and other factors). Consider results
from previous labs in your discussion.

If
you put your calcium intake into the class linear equation do
predict your bone density accurately? Why or why not?

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References
Asplin, J.R., Donahue, S., Kinder, J., & Coe, F.L. (2006) Urine calcium excretion predicts
bone loss in idiopathic hypercalciuria. Kidney International 70: 1463-1467.

Cashman, K.D. (2002) Calcium intake, calcium bioavailability and bone health. British
Journal of Nutrition 87: S169-S177.

Christenson, R.H. (1997) Biochemical markers of bone metabolism: an overview. Clinical

Biochemistry 30: 573-593.

Foley, K.F. & Boccuzzi, L. (2010) Urine Calcium: Laboratory Measurement and Clinical
Utility. Laboratory Medicine 41: 683–686.

Lane, N.E. (2006) Epidemiology, etiology, and diagnosis of osteoporosis. American Journal of
Obstetrics and Gynecology 194: S3-11.

Matkovic, V., Ilich, J.Z., Andon, M.B., Hsieh, L.C., Tzagournis, M.A., Lagger, B.J., & Goel,
P.K. (1995) Urinary calcium, sodium, and bone mass of young females. American Journal of
Clinical Nutrition 62: 417-425.

Stipanuk M.H. (2006) Biochemical and physiological aspects of human nutrition. W.B.
Saunders, Philadelphia, PA.

Tsuda, K., Nishio, I., & Masuyama, Y. (2001) Bone mineral density in women with essential
hypertension. American Journal of Hypertension 14: 704-707.

Vezzoli, G., Soldati, L., Arcidiacono, T., Terranegra, A., Biasion, R., Russo, C.R., Lauretani,
F., Bandinelli, S., Bartali, B., Cherubini, A., Cusi, D., & Ferucci, L., (2005) Urinary calcium is
a determinant of bone mineral density in elderly men participating in the InCHIANTI study.
Kidney International 67: 2006-2014.

Weaver, C.M., Rothwell, A.P., & Wood, K.V. (2006) Measuring calcium absorption and
utilization in humans. Current Opinion in Clinical Nutrition and Metabolic Care 9: 568-574.

World Health Organization. (2003) Prevention and management of osteoporosis: report of a

WHO scientific group. Technical Report Series 921. Geneva: World Health Organization.

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