Curr Osteoporos Rep
DOI 10.1007/s11914-012-0119-y
EPIDEMIOLOGY AND PATHOPHYSIOLOGY (RA ADLER, SECTION EDITOR)
The Role of Diet in Osteoporosis Prevention
and Management
Silvina Levis & Violet S. Lagari
# Springer Science+Business Media, LLC (outside the USA) 2012
Abstract Diet, a modifiable osteoporosis risk factor, plays
an important role in the acquisition and maintenance of bone
mass. The influence of diet on bone begins in childhood;
even maternal diet can influence bone mass in the offspring.
A good general nutritional status and adequate dietary pro-
tein, calcium, vitamin D, fruits, and vegetables have a pos-
itive influence on bone health, while a high caloric diet and
heavy alcohol consumption have been associated with lower
bone mass and higher rates of fracture. The evidence for a
role of other minerals and vitamins in skeletal health is not
as strong, but recent evidence suggests that vitamins C and
K might also have an effect on bone.
Keywords Diet . Nutrition . Osteoporosis . Fractures .
Bone health
Introduction
Although heritability explains a significant part of an indi-
vidual’s bone mass, other factors can also profoundly affect
S. Levis (*)
Geriatrics Institute and Department of Medicine,
University of Miami Miller School of Medicine,
P.O. Box 016960 (D-503), Miami, FL 33101, USA
e-mail: slevis@med.miami.edu
S. Levis
Geriatric Research, Education, and Clinical Center,
Bruce W. Carter Veterans Affairs Medical Center,
Miami, FL 33125, USA
S. Levis : V. S. Lagari
Endocrinology Section,
Bruce W. Carter Veterans Affairs Medical Center,
Miami, FL 33126, USA
e-mail: vlagarilibhaber@med.miami.edu
S. Levis : V. S. Lagari
Department of Medicine,
University of Miami Miller School of Medicine,
Miami, FL 33125, USA
skeletal health. Nutrition and physical activity have a strong
influence on the acquisition and maintenance of bone mass.
During childhood, adequate dietary intake can help an indi-
vidual increase bone mass and reach peak bone mass; in
adults, proper nutrition can slow down bone remodeling. It
is increasingly recognized that in addition to adequate intake
of calcium and vitamin D other nutrients might play an
important role in bone health [1]. General nutritional status
and dietary protein, fat, fruits, vegetables, and alcoholic
beverages play a key role in skeletal growth and mainte-
nance of bone mass. Diet is a modifiable risk factor for
osteoporosis and an easy target for osteoporosis prevention
and treatment programs. However, it is difficult to isolate
and study each dietary component. Instead, many have
examined different food groups, types of diet, or nutritional
status. This update on the effect of diet on skeletal health
mostly includes original articles published between January
2011 and June 2012. This review reports findings of epide-
miologic, observational, and intervention studies of the ef-
fect of diet on bone health in humans, but does not include
animal or in vitro studies, or studies of dietary supplements.
Calcium
More than 99 % of the body’s calcium is in the bones and
teeth. Insufficient calcium intake results in secondary hy-
perparathyroidism, which in turn increases bone turnover
and accelerates bone loss. Although there is general agree-
ment regarding the importance of having an adequate calci-
um intake for bone health, there is no consensus on the
appropriate daily dose, as reflected by the wide range of
calcium intake recommendations from different organiza-
tions, ranging from 700 mg in the UK to 1300 mg in
Australia and New Zealand [2–4]. Recognizing the role of
calcium in skeletal health, the Institute of Medicine in the
United States has made specific recommendations on calci-
um intake requirements listed in the Table 1 [5••]. The
recommended dietary allowance, or RDA, was based on

Table 1 Institute of Medicine 2011 Dietary Allowance (RDA) and
Tolerable upper Limit (TUL) recommendations for calcium
Age RDA (mg/day) TUL (mg/day)
19–50 1000 2500
51–70 (men) 1000 2000
51–70 (women) 1200 2000
71 and older 1200 2000
Pregnant or lactating women 1000 2500
Recommended Dietary Allowance (RDA) covers the requirement of
≥97.2 % of the population; Tolerable upper Limit (TUL) is not a target
intake but the level above which there is a risk of adverse effects
accepted skeletal health endpoints, which included optimal
calcium absorption, bone density, osteoporotic fractures,
and osteomalacia.
It has been consistently shown that the US population does
not meet the current RDA recommendations. National Health
and Nutrition Examination Survey (NHANES) is a survey of a
representative group of the US civilian, non-institutionalized
population. Assessment of both dietary and supplemental
calcium intake in the US population in NHANES 2003–
2006, suggests that calcium intake declines in older American
adults, partly due to a concomitant decline in energy intake
[6]. Both men and women age 50 and older have a median
intake considerably below the RDA. Median dietary calcium
intake in men declined by 22 % from the youngest to the
oldest group, from 942 mg daily to 728 mg daily. In women,
calcium intake declined 14 % from the youngest to the oldest,
from 628 mg daily to 589 mg daily. The survey reported that
about 50 % of adults take calcium supplements and that, with
age, the level of dietary calcium decreased while the frequen-
cy of use of supplements increased. However, the increase in
calcium supplement use did not suffice to counteract the
decrease in dietary consumption. Women not using calcium
supplements also had lower dietary calcium intake, which
remained constant throughout the lifespan. In contrast, sup-
plement users had a steady decrease in dietary calcium, most
evident in older women, suggesting an age-related greater
reliance on supplements.
Time and again, epidemiologic and prospective studies
have supported the role of adequate calcium intake in the
prevention of osteoporosis and fractures, particularly in pop-
ulations who are deficient. A prospective, longitudinal study
based on the Swedish Mammogram Cohort that followed over
61,000 women and assessed their diet by repeated food fre-
quency questionnaires, determined that daily dietary calcium
intake below 700 mg was associated with increased risk of
fracture and that the highest reported calcium intake did not
further reduce fracture risk [7•]. A study conducted in south-
eastern Brazil showed that known osteoporosis risk factors
such as age, time since menopause, and maternal history of
Curr Osteoporos Rep
fracture were associated with low bone mineral density
(BMD). In this population, diet did not influence risk in spite
of 55 % of participants having low calcium intake [8]. It is
important to note that assessments of calcium intake are prone
to inaccuracies; food frequency questionnaires might overes-
timate calcium intake and underestimate total energy intake
[9, 10]. Assessments based on 24-hour recall might include or
omit foods that are eaten on other days, or report food com-
position, and portion size incorrectly [11]. Furthermore, in the
design of calcium supplementation clinical trials, habitual
dietary calcium intake is not always accounted despite its
potential influence on the outcome of the study.
Clinicians frequently prescribe calcium supplements, but
often patients prefer to increase their calcium intake through
diet [12]. Two French studies have evaluated the effects of 2
daily servings of calcium- and vitamin D-fortified soft cheese
providing a daily dose of 400 mg of calcium, 2.5 mcg (100 IU)
of vitamin D3, and 13.8 g of protein vs usual diet [13, 14]. One
of the studies was conducted in older institutionalized women
mean age 87±6 years with hypovitaminosis D and calcium
intake below 700 mg/day. After 6 weeks, there were signifi-
cant increases in 25-hydroxyvitamin D levels, higher levels of
serum insulin-like growth factor-I (IGF-I), a bone anabolic
factor, and significant reductions in 2 markers of osteoclast
activity and bone resorption, bone specific acid phosphatase
tartrate resistant acid phosphatase isoform 5b (TRAP 5b), and
serum carboxy-terminal cross-linked telopeptide of type I
bone collagen (CTX) [13]. The same intervention was tested
in younger women, mean age 56±3.9 years, who were, on
average, within 7.5 years from menopause and had calcium
intake below 650 mg/day [14]. After 6 weeks, there was no
difference between the intervention and the control groups in
CTX. However, women in the intervention group had lower
levels of TRAP 5b and higher levels of IGF-I. These findings
suggest that in this population of menopausal women with
baseline low calcium intake and hypovitaminosis D, bone
resorption, and the risk of fractures could be reduced with
the long-term consumption of 2 portions of soft plain cheese
that supply additional protein, calcium, and vitamin D.
Vitamin D
Severe vitamin D deficiency (25-hydroxyivitamin D <10 ng/
mL) is associated with rickets and osteomalacia. Recent evi-
dence suggests that gastrointestinal calcium absorption and
bone mineralization are inadequate in vitamin D insufficiency,
which some define as 25-hydroxyivitamin D levels <20 ng/
mL and others as <30 ng/mL. In addition to supporting
skeletal health, improving vitamin D status in elderly individ-
uals reduces the risk of falling, thus, having a dual effect in the
prevention of fractures. Few foods naturally contain vitamin
D. Therefore, in most adults residing in urban areas or in
Curr Osteoporos Rep
northern latitudes, adequate levels depend on sun exposure or
vitamin supplements. In some countries, the most common
dietary sources of vitamin D are vitamin D-fortified milk or
milk substitutes, other dairy products, and cereals. The dose of
vitamin D in these fortified foods is usually small and may not
be sufficient to maintain normal serum levels in all individ-
uals, particularly in those at higher risk of vitamin D insuffi-
c i e n c y o r d e f i c i e n c y, s u c h a s p e r s o n s w h o a r e
institutionalized, obese, older, or have darker skin.
Minerals
Although it is generally agreed that adequate protein, calcium,
and vitamin D are the most important nutrients for bone
growth and skeletal health, several studies suggest that other
minerals might also play a role in bone metabolism, and thus
osteoporosis risk. A 2-year supplementation study with 2 mg
of copper and 12 mg of zinc daily in postmenopausal women
receiving adequate calcium and vitamin D supplementation,
reported that zinc supplementation might be beneficial to bone
health in those with usual intakes of less than 8 mg daily, but
not in those consuming adequate amounts [15].
Fruits and Vegetables
Dietary fruits and vegetables have the potential to affect
bone health. Fruits and vegetables contain (1) minerals such
as potassium, magnesium, and calcium; (2) antioxidants
such as polyphenols; (3) phytoestrogens; and (4) vitamin
C and vitamin K, both necessary for the synthesis of the
bone matrix. In addition, diets rich in fruits and vegetables
result in lower dietary acid load due to their high content of
potassium and magnesium. (An acid environment is known
to stimulate osteoclasts and reduce osteoblast activity.)
Reactive species are produced as a result of normal
cellular processes and play an important role in cell signal-
ing and gene transcription. Reactive species include free
radicals, reactive oxygen species, and reactive nitrogen spe-
cies. Oxidative stress develops when there is an imbalance
between the production of reactive species and the ability of
the body to control them using antioxidants. Oxidative
stress contributes to the development of many chronic dis-
eases, including osteoporosis [16]. Exogenous antioxidants
in the diet play an important role in reducing oxidative stress
[17]. Exogenous antioxidants are rich in vitamin C, the
primary antioxidant, vitamin E, and carotenoids and can be
found in most fruits, vegetables, nuts, and seeds. It has been
suggested that bone anabolic action derived from the diet is
through the targeting of bone morphogenetic protein signal-
ing pathways.
The Canadian Multicentre Osteoporosis Study, a population-
based cohort, evaluated the association between dietary patterns
and fracture in postmenopausal women and men age 50 years
and older [18•]. The study found that increased intake of
nutrient-dense foods was associated with a lower fracture risk,
independent of other important risk factors. The magnitude of
the association was comparable to the association between
tobacco smoking and fracture. The authors propose that the
population fracture burden could be reduced by encouraging
the consumption of fruits, vegetables and whole grains, in
addition to other public health measures. In a study of dietary
patterns and bone density among over 3000 Scottish women, a
healthy diet that included high intake of fruits and vegetables
was associated with decreased bone resorption, while a diet rich
in processed foods was linked to decreased bone density [19].
A systematic review of studies in women 45 years of age
and older had opposite findings. It concluded that there is
little evidence to support any significant role of dietary fruit
and vegetable intake on markers of bone turnover, bone
mineral density, and fractures [20]. However, the authors
acknowledge that there was considerable risk of bias and
heterogeneity between the studies.
Protein
Epidemiologic studies have shown a positive association
between protein intake and bone health, including increased
bone density and reduced fracture risk [21]. Results of a
recent prospective cohort study in more than 2000 Chinese
men and women age 65 and older that assessed food intake
by a food frequency questionnaire and examined changes in
bone density over 10 years, suggested that in older men,
higher fish intake was associated with smaller bone loss in
the hip, while lower protein intake was associated with
greater hip bone loss [22]. However, some claim that
the acidifying properties of diets high in protein ad-
versely affect bone metabolism and result in increased
calcium urinary excretion and bone loss, as described in
the section below [23].
Type of Diet
It is not clear if individual dietary components or the type of
diet have the greatest influence on bone metabolism.
Western Diet
Cross-sectional data from NHANES 1999–2000 and 2001–
2002 was used to evaluate the influence of healthy eating and
markers of bone turnover in postmenopausal women age
45 years and older [10]. The study found a negative

association between milk intake and urinary NTX, a marker of
bone resorption; women in the lowest tertile of milk intake
had the highest NTX. There was no dose–response, suggest-
ing that there is no further improvement in bone metabolism
once a sufficient intake is achieved. However, the high fre-
quency of zero values in subcategories of foods usually in-
cluded in a healthy diet, such as fish, dark-green vegetables,
citrus fruits, and milk, cheese and yogurt, could have limited
the effect of these foods on skeletal health. In addition, those
in the highest tertile of energy-adjusted (mg sugar/kcal) added
sugar intake had the highest levels of bone alkaline phospha-
tase, a marker of osteoblastic activity, supporting previous
evidence that high candy consumption, which usually indi-
cates a nutrient-poor diet, is associated with low BMD in older
women [24]. In the UK twin study, the traditional 20th
century English diet consisting of mostly fried fish, fried
potatoes, legumes, red meats, savory pies, and cruciferous
vegetables, was associated with lower bone density [25•].
As in the NHANES study, the UK twin study was unable
to show that a diet high in fruit and vegetables was
associated with higher bone density, as previously shown
in the Framingham cohort, partly because the average
intake of fruits and vegetables in the UK twin study was
low. The Framingham Heart Study is a longitudinal cohort
started in 1948 to examine risk factors for heart disease. A
substudy of the Framingham cohort conducted in elderly
adults found that in men, a diet high in fruit, vegetables
and cereal was associated with higher bone density [24].
In women, results were not as clear, but those consuming
more fruits, vegetables, and cereal tended to have higher
bone density. Both men and women consuming the most
candy had significantly lower bone density than other
groups.
Vegetarian Diet
It has been proposed that, as a result of the absence of
animal and dairy products in their diet, vegans and vegeta-
rians have lower bone mass due to a lifelong low intake of
protein and calcium. The effect of a vegetarian diet on bone
loss was examined in 210 postmenopausal women, half of
whom were omnivores and half vegans. After 2 years, bone
loss was comparable in the 2 groups, although vegans had
higher prevalence of vitamin D insufficiency [26].
Asian Diet
In Western diets, dairy products are the main source of
calcium, potassium, magnesium, and protein. Milk con-
sumption in Asian diets is usually low [27]. The Korean
National Health and Nutrition Examination Survey
reported a daily calcium intake of about 500 mg among
adults aged 50 to 65 years, with milk consumption limited
Curr Osteoporos Rep
to an average of one half cup per day [28]. Dark green
vegetables are also a source of dietary calcium. Although
their calcium content and bioavailability is much lower, if
consumed in large quantities, dark green vegetables might
provide an adequate daily calcium dose in people who do
not drink milk. In Asian populations, vegetables might be
an important source of calcium, as shown by a prospective
study in Korean women between the ages of 50 and 70,
which reported that after adjusting for potential confound-
ers the intake of plant-derived calcium was associated with
higher bone density [29]. The average vegetable intake in
the cases was 6 to 8 servings per day.
Acid vs Alkaline Diet
Although recent evidence has demonstrated that sufficient
protein intake is necessary to maintain bone integrity, it has
been suggested that diets high in animal protein should be
considered a risk factor for osteoporosis and fractures [30].
The “acid ash hypothesis” claims that acid-generating diets,
such as those rich in protein, dairy products, and grains
cause the release of bicarbonate from the bone to neutralize
the acid and prevent systemic acidosis [23]. The hypothesis
proposes that the resulting resorption of bone mineral and
increased urinary calcium excretion produces overall rapid
loss of skeletal calcium and bone mass. Alkaline or “acid
ash” diets, supplements and salts are being marketed with
the claim of counteracting the allegedly adverse skeletal
effect of an acid diet [31].
In order to clarify the role of protein in bone metabolism,
postmenopausal women were given a low-protein diet with
low-potential renal acid load vs a high-protein diet with
high-potential renal acid load over 1 week [32•]. The high
meat protein diet increased the fractional absorption of
dietary calcium, which almost compensated for the in-
creased urinary calcium excretion caused by the high renal
acid load. The high meat diet did not change markers of
bone resorption or formation but increased IGF-1 and de-
creased parathyroid hormone levels, suggesting a beneficial
effect on bone health [32•]. A meta-analysis and systematic
review restricted to trials of high-quality randomized, and
prospective observational trials at low risk of bias, conclud-
ed that there is no evidence to support the hypothesis that
acid from a modern diet results in osteoporosis, or that an
alkaline load from either diet or supplements prevents the
disease [33]. Although the data shows a positive association
between acid load from diet and urinary calcium excretion,
there is no support for any causal relationship with whole
body calcium balance, markers of bone resorption, or
changes in bone density, or fractures. The review also con-
cluded that consuming foods or alkaline supplements to
offset dietary acid is unlikely to result in improved bone
health.
Curr Osteoporos Rep
Caloric Intake
Obesity increases the risk for chronic illnesses, such as
diabetes and cardiovascular disease. In the US, adults age
60 and over are more likely to be obese than young adults;
over 42 % of adult women are obese [34]. Although it has
been assumed that obesity protects against bone loss be-
cause of increased mechanical loading, a recent study in
premenopausal obese women determined that visceral ab-
dominal adipose tissue has a detrimental effect on bone
mineral density [35]. Low-calorie diets are often recommen-
ded to combat obesity, and some have raised the concern
that the chronic consumption of a diet low in calories,
proteins, and minerals could adversely affect bone health.
In fact, studies of overweight or obese postmenopausal
women on low-calorie diets have demonstrated that there
is bone loss associated to weight loss. A recent study exam-
ined the role of caloric restriction on bone health in older
women of normal weight [36]. Bone density was maintained
in those with 80 % to 100 % caloric intake of the recom-
mended daily requirement (RMDR). Those having an ex-
tremely low daily caloric intake of about 55 % of the RMDR
had lower femoral BMD and a trend towards lower bone
density in the spine, raising concerns for non-obese older
women who might limit their caloric intake to maintain a
slim body habitus.
Influence of Prenatal Diet
Prenatal nutrition can have a considerable influence on
postnatal health. Prenatal nutrition depends on the maternal
diet during the gestation period. Both maternal caloric ex-
cess as well as caloric restriction can affect skeletal acqui-
sition in the offspring [37].
Alcohol
Alcoholism is a major cause of secondary osteoporosis.
Although mild to moderate alcohol intake has been associ-
ated with high bone density, high alcohol consumption is
associated with osteoporosis and falls. Though the mecha-
nism by which mild to moderate alcohol consumption
results in improved bone health is unknown, it might be
explained by decreased bone remodeling, as evidenced by
lower levels of osteocalcin, CTX, and C-telopeptide of type
I bone collagen (NTX) after light alcohol intake [38]. One
daily drink for women and 2 for men is considered safe for
bone health [39, 40]. A recent meta-analysis reported lower
risk of fractures in persons consuming 0.5 to 0.1 alcoholic
drinks per day, compared with abstainers [41]. On the other
hand, heavy alcohol consumption is associated with
increased bone loss and risk of fractures [39]. The mecha-
nism is multifactorial, with uncoupling of bone remodeling
and increased bone loss. Chronic heavy consumption causes
inhibition of osteoblast proliferation, reductions in osteo-
blast number and activity, and increased osteocyte apopto-
sis, resulting in decreased bone formation. Also, bone
resorption markers are increased with heavy alcohol con-
sumption, which also induces oxidative stress, resulting in
increased signaling of receptor activator of nuclear factor-
κB ligand-receptor activator of nuclear factor-κB (RANKL-
RANK), and enhanced osteoclastogenesis. In addition, ex-
cessive alcohol intake increases oxidative stress and bone
marrow fat accumulation. Furthermore, lower testosterone
and estrogen levels have been reported in alcoholic men and
women, respectively. Lastly, the poor nutritional status,
decreased caloric intake, smoking, sedentary lifestyle, and
liver disease that might be associated with alcoholism could
worsen the deleterious effects of alcohol on bone, which
appear to be dependent on the dose and duration.
A study of over 2000 postmenopausal twins enlisted in a
UK register evaluated the association of diet and alcohol
intake to bone density [25•]. This UK twin study avoided
the usual confounding effects of age and genotype and
found a positive association between alcohol intake from
wine only and spinal bone density. In a study of nonagenar-
ian and centenarian Chinese women, current and former
alcohol consumption more than doubled the risk of osteo-
porotic fracture [42]. The Fujiwara-kyo Osteoporosis Risk
in Men Study, conducted in over 2000 Japanese men found
that after adjusting for several confounders, alcohol intake
was positively correlated with bone density, up to a daily
intake of 55 g [43]. In those men consuming ≥55 g per day,
alcohol intake was inversely correlated with bone density.
Non-alcoholic Beverages
The consumption of soft drinks, because of their caffeine
and high phosphoric acid content, has been considered a risk
factor for osteoporosis, although it is also believed that the
adverse effect is mainly due to the displacement of healthier
beverages. In the Framingham Osteoporosis Study, cola
beverage intake was associated with lower BMD in the hip
[44]. A recent study in postmenopausal American-Indian
women of the Northern Plains and American Southwest
with osteoporosis did not find any association between soda
consumption and osteoporosis risk [45]. However, analyses
confirmed confounding between soda consumption and age
and BMI, suggesting that any potential effects of soda
consumption on bone health are largely mediated through
these factors. Green tea contains naturally occurring poly-
phenols, which are known to have anti-oxidative properties.
Although no clinical trials have been published, in vitro

studies suggest that green tea might have beneficial effects
on osteoblasts [46, 47]. In South America, Yerba Mate tea
consumption is often preferred to coffee or black tea. A
study from Argentina suggested that the daily consumption
of at least 1 L of Yerba Mate tea was associated with higher
bone density in the lumbar spine and femoral neck [48].
Conclusion
Much attention has been given to the importance of calcium,
vitamin D, and protein intake for skeletal health. Consider-
ably less is known about the effects of other nutrients on
bone, although recent reports have supported the importance
of potassium, magnesium, vitamin K, fruits, and vegetables.
Studies have suggested that fat, phosphorus, vitamin C, and
several trace minerals, including manganese, zinc, copper,
and silicon might also influence skeletal health [24]. Exces-
sive consumption of caffeine, carbonated beverages, and
sodium has been reported to have a negative effect on
calcium balance, but the evidence is not strong. The detri-
mental effects of excessive alcohol use are well accepted. As
is the case for the prevention and management of many
chronic illnesses, most studies confirm the positive role of
a healthy diet to maintain bone health.
Disclosure The authors reported no potential conflicts of interest
relevant to this article.
References
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance
1. Macdonald HM, New SA, Golden MH, Campbell MK, Reid DM.
Nutritional associations with bone loss during the menopausal
transition: evidence of a beneficial effect of calcium, alcohol, and
fruit and vegetable nutrients and of a detrimental effect of fatty
acids. Am J Clin Nutr. 2004;79(1):155–65. Epub 2003/12/20.
2. Department of Health and Ageing (Australia), National Health and
Medical Research Council (Australia), Ministry of Health (New Zea-
land). Nutrient reference values for Australia and New Zealand, in-
cluding recommended dietary intakes. 2006. Available at:
www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/n35.pdf.
Accessed 14 Sep 2012.
3. NHS Choices. Vitamins and minerals: calcium. Available at:
www.nhs.uk/conditions/vitamins-minerals/pages/calcium.aspx.
Accessed 14 Sep 2012.
4. Nordic nutrition recommendations 2004. Integrating nutrition and
physical activity. 4th ed. Nordic Council of Ministers; 2004.
5. •• IOM (Institute of Medicine). Dietary reference intakes for cal-
cium and vitamin D. Washington, DC: The National Academic
Curr Osteoporos Rep
Press; 2011. Calcium and vitamin D intake recommendations for
the US population.
6. Mangano KM, Walsh SJ, Insogna KL, Kenny AM, Kerstetter JE.
Calcium intake in the United States from dietary and supplemental
sources across adult age groups: new estimates from the National
Health and Nutrition Examination Survey 2003–2006. J Am Diet
Assoc. 2011;111(5):687–95. Epub 2011/04/26.
7. • Warensjo E, Byberg L, Melhus H, Gedeborg R, Mallmin H,
Wolk A, et al. Dietary calcium intake and risk of fracture and
osteoporosis: prospective longitudinal cohort study. BMJ.
2011;342:d1473. Epub 2011/05/26. Reports minimal calcium in-
take for fracture prevention.
8. Nahas EA, Kawakami MS, Nahas-Neto J, Buttros Dde A, Cangussu
L, Rodrigues AB. Assessment of risk factors for low bone mineral
density in Brazilian postmenopausal women. J Int Menopause Soc
Climacteric. 2011;14(2):220–7. Epub 2010/07/21.
9. Messerer M, Wolk A. Sensitivity and specificity of self-reported
use of dietary supplements. Eur J Clin Nutr. 2004;58(12):1669–71.
Epub 2004/07/01.
10. Hamidi M, Tarasuk V, Corey P, Cheung AM. Association between
the healthy eating index and bone turnover markers in US post-
menopausal women aged ≥ years. Am J Clin Nutr. 2011;94
(1):199–208. Epub 2011/05/13.
11. Kohlmeier L, Mendez M, McDuffie J, Miller M. Computer-
assisted self-interviewing: a multimedia approach to dietary as-
sessment. Am J Clin Nutr. 1997;65(4 Suppl):1275S–81. Epub
1997/04/01.
12. Rafferty K, Watson P, Lappe JM. The selection and prevalence of
natural and fortified calcium food sources in the diets of adolescent
girls. J Nutr Educ Behav. 2011;43(2):96–102. Epub 2011/03/12.
13. Bonjour JP, Benoit V, Pourchaire O, Rousseau B, Souberbielle JC.
Nutritional approach for inhibiting bone resorption in institution-
alized elderly women with vitamin D insufficiency and high prev-
alence of fracture. J Nutr Health Aging. 2011;15(5):404–9. Epub
2011/04/30.
14. Bonjour JP, Benoit V, Rousseau B, Souberbielle JC. Consumption
of vitamin D-and calcium-fortified soft white cheese lowers the
biochemical marker of bone resorption TRAP 5b in postmeno-
pausal women at moderate risk of osteoporosis fracture. J Nutr.
2012;142(4):698–703. Epub 2012/02/24.
15. Nielsen FH, Lukaski HC, Johnson LK, Roughead ZK. Reported
zinc, but not copper, intakes influence whole-body bone density,
mineral content, and T score responses to zinc and copper supple-
mentation in healthy postmenopausal women. Br J Nutr. 2011;106
(12):1872–9. Epub 2011/07/08.
16. Reid IR. Relationships between fat and bone. Osteoporos Int.
2008;19(5):595–606. Epub 2007/10/30.
17. Da Costa LA, Badawi A, El-Sohemy A. Nutrigenetics and modu-
lation of oxidative stress. Ann Nutr Metab. 2012;60 Suppl 3:27–
36. Epub 2012/05/25.
18. • Langsetmo L, Hanley DA, Prior JC, Barr SI, Anastassiades T,
Towheed T, et al. Dietary patterns and incident low-trauma frac-
tures in postmenopausal women and men aged ≥50 years: a
population-based cohort study. Am J Clin Nutr. 2011;93(1):192–
9. Epub 2010/11/12. Reports the beneficial effect of a healthy diet
on bone.
19. Hardcastle AC, Aucott L, Fraser WD, Reid DM, Macdonald HM.
Dietary patterns, bone resorption and bone mineral density in early
post-menopausal Scottish women. Eur J Clin Nutr. 2011;65
(3):378–85. Epub 2010/12/24.
20. Hamidi M, Boucher BA, Cheung AM, Beyene J, Shah PS. Fruit
and vegetable intake and bone health in women aged 45 years and
over: a systematic review. Osteoporos Int. 2011;22(6):1681–93.
Epub 2010/12/18.
21. Promislow JH, Goodman-Gruen D, Slymen DJ, Barrett-Connor E.
Protein consumption and bone mineral density in the elderly: the
Curr Osteoporos Rep
Rancho Bernardo Study. Am J Epidemiol. 2002;155(7):636–44.
Epub 2002/03/27.
22. Chan R, Woo J, Leung J. Effects of food groups and dietary
nutrients on bone loss in elderly Chinese population. J Nutr Health
Aging. 2011;15(4):287–94. Epub 2011/03/26.
23. Buclin T, Cosma M, Appenzeller M, Jacquet AF, Decosterd LA,
Biollaz J, et al. Diet acids and alkalis influence calcium retention in
bone. Osteoporos Int. 2001;12(6):493–9. Epub 2001/07/12.
24. Tucker KL, Chen H, Hannan MT, Cupples LA, Wilson PW, Felson
D, et al. Bone mineral density and dietary patterns in older adults:
the Framingham Osteoporosis Study. Am J Clin Nutr. 2002;76
(1):245–52. Epub 2002/06/26.
25. • Fairweather-Tait SJ, Skinner J, Guile GR, Cassidy A, Spector
TD, MacGregor AJ. Diet and bone mineral density study in post-
menopausal women from the TwinsUK registry shows a negative
association with a traditional English dietary pattern and a positive
association with wine. Am J Clin Nutr. 2011;94(5):1371–5. Epub
2011/09/24. Reports the beneficial effect of a healthy diet on bone.
26. Ho-Pham LT, Vu BQ, Lai TQ, Nguyen ND, Nguyen TV. Vegetar-
ianism, bone loss, fracture and vitamin D: a longitudinal study in
Asian vegans and non-vegans. Eur J Clin Nutr. 2012;66(1):75–82.
Epub 2011/08/04.
27. Charoenkiatkul S, Kriengsinyos W, Tuntipopipat S, Suthutvoravut
U, Weaver CM. Calcium absorption from commonly consumed
vegetables in healthy Thai women. J Food Sci. 2008;73(9):H218–
21. Epub 2008/11/22.
28. Korea Institute for Health and Social Affairs, Ministry of Health
and Welfare. Report on 2007. Seoul: Korean National Health and
Nutrition Examination Survey; 2009.
29. Park HM, Heo J, Park Y. Calcium from plant sources is beneficial
to lowering the risk of osteoporosis in postmenopausal Korean
women. Nutr Res. 2011;31(1):27–32. Epub 2011/02/12.
30. Allen LH, Oddoye EA, Margen S. Protein-induced hypercalciuria:
a longer term study. Am J Clin Nutr. 1979;32(4):741–9. Epub
1979/04/01.
31. The AcidAlkaline Diet–optimal health with alkaline foods. Available
at: http://www.acidalkalinediet.com/Alkaline-Foods-Chart.htm.
Accessed 14 Sep 2012.
32. • Cao JJ, Johnson LK, Hunt JR. A diet high in meat protein and
potential renal acid load increases fractional calcium absorption and
urinary calcium excretion without affecting markers of bone resorp-
tion or formation in postmenopausal women. J Nutr. 2011;141
(3):391–7. Epub 2011/01/21. This study contributes to our under-
standing of how protein intake influences calcium metabolism.
33. Fenton TR, Tough SC, Lyon AW, Eliasziw M, Hanley DA. Causal
assessment of dietary acid load and bone disease: a systematic
review & meta-analysis applying Hill's epidemiologic criteria for
causality. Nutr J. 2011;10:41. Epub 2011/05/03.
34. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity
in the United States, 2009–2010. CDC, National Center for Health
Statistics, Number 82, January 2012.
35. Bredella MA, Torriani M, Ghomi RH, Thomas BJ, Brick DJ,
Gerweck AV, et al. Determinants of bone mineral density in obese
premenopausal women. Bone. 2011;48(4):748–54. Epub 2011/01/
05.
36. Caporaso F, Frisch F, Sumida KD. Compromised bone health in
non-obese, older women with low caloric intake. J Community
Health. 2011;36(4):559–64. Epub 2010/11/26.
37. Devlin MJ, Bouxsein ML. Influence of pre- and peri-natal nutrition
on skeletal acquisition and maintenance. Bone. 2012;50(2):444–
51. Epub 2011/07/05.
38. Sripanyakorn S, Jugdaohsingh R, Mander A, Davidson SL,
Thompson RP, Powell JJ. Moderate ingestion of alcohol is asso-
ciated with acute ethanol-induced suppression of circulating CTX
in a PTH-independent fashion. J Bone Miner Res. 2009;24
(8):1380–8. Epub 2009/03/05.
39. Maurel DB, Boisseau N, Benhamou CL, Jaffre C. Alcohol and
bone: review of dose effects and mechanisms. Osteoporos Int.
2012;23(1):1–16. Epub 2011/09/20.
40. Tucker KL, Jugdaohsingh R, Powell JJ, Qiao N, Hannan MT,
Sripanyakorn S, et al. Effects of beer, wine, and liquor intakes on
bone mineral density in older men and women. Am J Clin Nutr.
2009;89(4):1188–96. Epub 2009/02/27.
41. Berg KM, Kunins HV, Jackson JL, Nahvi S, Chaudhry A, Harris Jr
KA, et al. Association between alcohol consumption and both
osteoporotic fracture and bone density. Am J Med. 2008;121
(5):406–18. Epub 2008/05/06.
42. Du F, Birong D, Changquan H, Hongmei W, Yanling Z, Wen Z, et
al. Association of osteoporotic fracture with smoking, alcohol
consumption, tea consumption and exercise among Chinese non-
agenarians/centenarians. Health Aging. 2011;15(5):327–31. Epub
2011/04/30.
43. Kouda K, Iki M, Fujita Y, Tamaki J, Yura A, Kadowaki E, et al.
Alcohol intake and bone status in elderly Japanese men: baseline
data from the Fujiwara-kyo osteoporosis risk in men (FORMEN)
study. Bone. 2011;49(2):275–80. Epub 2011/05/03.
44. Tucker KL, Morita K, Qiao N, Hannan MT, Cupples LA, Kiel
DP. Colas, but not other carbonated beverages, are associated
with low bone mineral density in older women: the Framingham
Osteoporosis Study. Am J Clin Nutr. 2006;84(4):936–42. Epub
2006/10/07.
45. Supplee JD, Duncan GE, Bruemmer B, Goldberg J, Wen Y,
Henderson JA. Soda intake and osteoporosis risk in postmenopausal
American-Indian women. Public Health Nutr. 2011;14(11):1900–6.
Epub 2011/01/07.
46. Holzer N, Braun KF, Ehnert S, Egana JT, Schenck TL, Buchholz
A, et al. Green tea protects human osteoblasts from cigarette
smoke-induced injury: possible clinical implication. Langenbeck's
Arch Surg/Deutsche Gesellschaft fur Chirurgie. 2012;397(3):467–
74. Epub 2011/12/14.
47. Shen CL, Yeh JK, Cao JJ, Chyu MC, Wang JS. Green tea and bone
health: evidence from laboratory studies. Pharmacol Res. 2011;64
(2):155–61. Epub 2011/04/09.
48. Conforti AS, Gallo ME, Saravi FD. Yerba Mate (Ilex paraguariensis)
consumption is associated with higher bone mineral density in post-
menopausal women. Bone. 2012;50(1):9–13. Epub 2011/09/17.