Osteoporosis and Nutrition

Module 4

Speaking of Bones

Osteoporosis For Health

Professionals

Susan J Whiting

University of Saskatchewan

Learning Objectives

• Understand the 3 critical nutrients for bone: calcium,

vitamin D and protein

– Recommendations for these have recently changed

• Appreciate bone is a living tissue and other nutrients

are needed

– Thei i pa t depe ds o o e’s aseli e diet

• Intend to use dietary recommendations such as CFG

or DASH as these are bone healthy except vitamin D

– A vitamin D supplement always necessary

– These diets are low sodium, high potassium

Acknowledgments and Conflict of Interest

• This presentation is mainly based upon a slide

kit* in development through funding by

Yoplait France, and the following experts have

reviewed its content: – Pr. Jean-Philippe Bonjour, Division of Bone Diseases, Departement of

Internal Medicine, University Hospital, Genève, Suisse

– Pr. Marius Kraenzlin, Division of Endocrinology, Diabetes, and Clinical Nutrition, University Hospital, Bale, Suisse

– Dr. Régis Levasseur, Service de Rhumatologie et Pôle Ostéo-articulaire, CHU Angers, France

– Pr. Michelle Warren, Department of Obstetrics and Gynecology Columbia University Medical Center, New York, USA

– Pr. Susan Whiting, College of Pharmacy and Nutrition, University of Saskatchewan, Canada

*Updates by S. Whiting have not been vetted by the group of experts

Definition of Osteoporosis « …a skeletal disease characterized by low bone mass

and microarchitectural deterioration of bone tissue with a

consequent increase in bone fragility and susceptibility to

fracture »

Consequences: fractures

WHO 1994

Photos: Dempster DW et al., J Bone Miner Res 1986; 1:15. Copyright 1986 © Wiley

Wrist Hip Spine

Pathophysiology of fragility

fracture risk in elderly

Bone formation

Bone resorption

Risk of

falls

Bone mass

and strength

Protective

response

Fracture risk

- Balance

- Muscle mass

- Neuro-muscular function

Undernutrition + Low level of physical activity

Calcium

Vitamin D Protein

Importance of essential

nutrients

Vitamin D metabolism

Inactive form

25(OH)D

Circulating and measured form

Status indicator

Stimulation of intestinal calcium absorption

PTH Hypocalcemia Hypophosphatemia IGF-I

UVB light

Diet

7-dehydrocholesterol

Skin

Kidney

1,25(OH)2D

Active form

1-hydroxylase

25α-hydroxylase

Vitamin D

+

Vitamin D metabolism

Inactive form

25(OH)D

Circulating form

Status indicator

Stimulation of intestinal calcium absorption

UVB light

Diet

7-dehydrocholesterol

Skin

Kidney

1,25(OH)2D

Active form

1-hydroxylase

25α-hydroxylase

Vitamin D

+

1,25 is made intracellularly

Stimulation of cell growth and differentiation in other tissues

Vitamin D metabolism

Inactive form

25(OH)D

Circulating form

Status indicator

Stimulation of intestinal calcium absorption

UVB light

Diet

7-dehydrocholesterol

Skin

Kidney

1,25(OH)2D

Active form

1-hydroxylase

25α-hydroxylase

Vitamin D

+

1,25 is made intracellularly

Stimulation of cell growth and differentiation in other tissues

Endocrine pathway

Autocrine pathway

0

5

10

15

20

25

30

35

40

45

Adults Independent elderly

Elderly in institutions

Hip f racture patients

Seru

l 25(O

H)D

(ng

/ml)

Vitamin D deficiency in

elderly

Double cause of

deficiency with age:

Reduced skin

synthesis of vitamin D

Insufficient sun

exposure

Adapted from Lips P et al., Endocr Rev 2001; 22:477

Se

rum

25

(OH

)D (

ng

/ml)

Osteoporosis Canada 75 nmol/L

IOM 50 nmol/L

Recent Meta-Analysis of Fracture

Risk: NEJM July 5, 2012

• In 11 RCTs involving

over 31,000 people, a

dose response is seen

• To achieve a

significantly reduced HR

for fracture reduction,

25(OH)D levels must be

over 60 nmol/L

Recent Meta-

Analysis of

Fracture Risk: NEJM July 5, 2012

Only when

sufficient vitamin D

is given ( > 792 IU)

to raise levels of

25(OH)D is there a

significant effect

on fracture risk.

Effect of vitamin D on the

risk of falls Fall prevention by 1000 IU vitamin D2 supplementation

in women with a history of falling in the previous year

Prince RL et al., Arch Int Med 2008; 168:103

0

10

20

30

40

First fall in summer/autumn

First fall in winter/spring

27.2 %

35.8 %

27.8 %

25.2 %

Pe

rce

nta

ge

of su

bje

cts

Placebo + calcium citrate

Ergocalciferol + calcium citrate

p<0.05

In 2011 the European Food Safety Authority has approved a health

claim for 800 IU of vitamin D for falls prevention in persons > 60 y

Vitamin D2 (1 000 IU)

+ calcium citrate (1g/d)

Placebo + calcium (1g/d)

2010 Osteoporosis Canada

Recommendations for Vitamin D

Recommended intake for low-risk and younger

adults are 10-25 μg (400–1000 IU) daily

Recommended intake for high-risk and older

adults are 20–50 μg (800–2000 IU) daily

For individuals being treated for osteoporosis, vitamin D

status should be assessed by serum measurement of 25-

hydroxyvitamin D after 3 months of vitamin D

supplementation

To ensure levels are at or above 75 nmol/L

How to reach these

recommendations ? 3 sources of vitamin D

Supplementation Sun exposure Diet

Independent and cumulative effect

Foods with vitamin D

Unlike calcium, few foods contain vitamin D in

significant amounts

Difficult to reach daily recommended intake via diet alone

salmon

Butter or margarine liver

eggs sardines in oil meat

Godar et al., Dermato-Endocrinology 3:4, 243-250; October/November/December 2011

Decline in previtamin D3 synthesis

in skin with age

Calcium

Vitamin D Protein

Importance of essential

nutrients

Calcium during growth

Gender

Bone

gain

Physical activity

Genetics

Menarcheal

age

Skeletal sites

Spontaneous

calcium intake

Other nutrients Pubertal stage

Bonjour JP et al., Le Rhumatologue 2009; 70:19

Calcium attenuates bone

loss in women Lumbar BMD

Mean %

chan

ge (

1 S

EM

)

menopause

Elders P et al., J Clin Endocrinol Metab 1991; 73:533

-9

-6

-3

0

3

6

Early peri Late peri Early post Late post

controls

1000 mg Ca supplements / day

2000 mg Ca supplements / day

Methodology:

248 women 46-55 y

25(OH)D levels similar

~ 18 ng/ml)

2010 Osteoporosis Canada

Recommendations for calcium

Recommended intake for younger adults is

1000 mg daily

Recommended intake for older adults is

1200 mg daily

– New evidence suggests intake does not

need to be higher than these

recommendations

– Excess intake may lead to kidney stones

Examples of equivalence for 300 mg of calcium

1 cabbage of 850 g

1 kg of oranges

300 g of soft white cheese

250 ml of milk

5 baguettes

4 kg of beef

2 yogurts

50 g of Saint Nectaire

30 g of Emmental

2010 Osteoporosis Canada

Recommendations for calcium

Recommended intake for younger adults is

1000 mg daily

Recommended intake for older adults is

1200 mg daily

– New evidence suggests intake does not

need to be higher than these

recommendations

– Excess intake may lead to kidney stones

Keep total intake below Upper Level of

2000 mg

Calcium and Heart Disease Risk

What is the evidence?

In the journal Heart 2012: data from ~24,000 men and

women in Germany, 35-64 y, tracked for an average of

11 years as part of a European cancer and nutrition

study.

What was reported in Abstract (underlining added):

Associations for stroke risk and CVD mortality were overall null. In

comparison with non-users of any supplements, users of calcium

supplements had a statistically significantly increased MI risk

(HR:1.86 95% CI 1.17 - 2.96), which was more pronounced for calcium

supplement only users (HR: 2.39; 95% CI 1.12-5.12)

Kuanrong Li et al. Heart 98:920-925

Calcium Supplements and Heart

Disease? What was reported:

Calcium Is a Threshold Nutrient:

More than adequate is not better

Response (c)

to increasing

intake from C

to D is almost

immeasurable

compared to

(b)

D

0

1

2

3

4

5

6

Ch

an

ge

in B

MD

s (%

pe

r ye

ar)

Total Ca consumed (mg/d) SEM

Placebo

Ca supplement

694 16

1 238 56

1 175 64

36 31 4136

Spontaneous Ca intake< Median: 855 mg/d >

1805 54

Supplementation is effective up to

an intake threshold

Bonjour JP et al., J Clin Invest ; 99:1287

Example in prepubertal girls with high and low calcium intake

Spontaneous calcium intake

Median: 855 mg/d < >

Ch

an

ges in

BM

D (

% p

er

year)

* p < 0.01

*

Duration: 48 weeks

1 805

Calcium

Vitamin D Protein

Importance of essential

nutrients

Protein intake reduces

fracture risk

0.0

0.2

0.4

0.6

0.8

1.0

1.2

Q1 Q2 Q3 Q4

RR

of

hip

fra

ctu

re

Quartiles of total protein intakes

Low intake High intakeLow intake High intake

Protein intake and hip fracture in post-

menopausal women

Munger et al., Am J Clin Nutr 1999; 69:147

RR

of

hip

fra

ctu

re

Quartiles of total protein intake

Protein supplements (20

g.d-1) + calcium + vit D

Placebo (calcium + vit D

only)

P+

Protein supplements (20

g.d-1) + calcium + vit D

Placebo (calcium + vit D

only)

Protein attenuates proximal

femur bone loss

Schürch M et al., Ann Intern Med 1998; 128:801

-6

-5

-4

-3

-2

-1

0

0 6 12

Ch

an

ge

in B

MD

of

pro

xim

al fe

mu

r (%

)Time (months)

Protein supplements (20

g.d-1) + calcium + vit D

Placebo (calcium + vit D

only)

p=0.029

Methodology:

Protein supplement (20 g/d) + calcium + vit D

Isocaloric placebo (calcium + vit D only)

Patients with recent hip fracture

Mean age: 80.7 7.4 years

Duration: 6 months

Placebo and treatment: 550 mg Ca/d

+ 200 000 IU vit D (one time)

Number of hospital stays reduced by 21 days

Functional consequences

of sarcopenia on bone

Negative consequences of insufficient

protein intake in the elderly

Adapted from Rosenberg IH, Am J Clin Nutr 1989; 50:1231

Decreased mobility

Catabolism

Anabolism

Protein balance

Increased risk of falling

Increased risk of fracture

-20

-15

-10

-5

0

5

10

***p < 0.01

Increased milk consumption improves

bone biomarkers in women

Bonjour JP et al., Brit J Nutr 2008;1

Change in b

one b

iom

ark

ers

(%)

PTH CTX P1NP OC BAP IGF-1

*** ***

***

***

Methodology:

Duration: 2 x 6 weeks

2 groups in cross-over: Ca intake 600 mg vs.1 200 mg (600 mg + ½ l of milk)

Protein Recommendations

• For bone, intake should be at least 1 g/kg

• I 2002, OC Guideli es we e Mai tai ade uate p otei

• OC is willing to accept the recommendation of

1 g/kg (compared to RDA of 0.8 g/kg)

• P otei is ot the ad ut ie t fo o e unless calcium intakes are low

No effect of diet acid-ash on

calcium balance

Fenton TR and al., J Bone Miner Res 2009;24:1835-1840

Pro otio of a alkali e diet to preve t calciu loss is ot justified

-3

-2

-1

0

1

2

-50 -25 0 25 50

Chang

e o

f calc

ium

bala

nce

(mm

ol/d

ay)

Change of net acid excretion (mEq/day)

Roughead 05 Roughead 03

Kerstetter 06 Dahl 95 Kerstetter 06

Kerstetter 06 Kerstetter 06

Spence 05

There is no relationship between a change in net acid

excretion and a net loss of whole body calcium.

R² = 0.003

p = 0.38

Change of net acid excretion (mEq/d) Ch

an

ge

of

ca

lciu

m b

ala

nc

e (

mm

ol/

d) 1

0

-1

-2

-3

-50 -25 0 25 50

Vegetarian, vegan diets

and bone health

Vegans diets, lacking milk products or appropriate alternatives,

are low in calcium, protein, and vitamin D as well as other

nutrients important for bone growth and bone maintenance

The vegan diet requires a plant-based milk substitute or a

supplement in order to provide sufficient calcium

Protein may be limited and of poor quality unless there is an effort to

select pulses (beans), nuts, and other protein foods

Ho-Pham LT et al., Am J Clin Nutr 2009; 90:943 Janelle KC, Barr SI. J Am Diet Assoc 1995; 95:180

New SA, Osteoporos Int 2004; 15:679

Vegetarian diets

Vegan diets

Lacto-vegetarian diets provide sufficient calcium and protein

Magnesium

Vitamin K

Polyphenols

Manganese Phosphorus

Vitamin C

Zinc

Potassium Fibre

Carotenes Phytoestrogens

There are potential benefits of many nutrients and food

constituents

Vitamin B12

5 nutrients have received a positive opinion

from EFSA on having evidence for a cause-

effect relationship related to bone

Magnesium

Vitamin K Manganese*

Phosphorus*

Zinc*

* EFSA ruled No current evidence for a deficiency in the population – no health claim approved

39

Some nutrients and food

constituents, in excess, may be

harmful to bone health • Nutrients behave in a U-shape manner, giving rise to deficiencies when

not present in sufficient amounts and to toxicities when present in excess.

• This concept is illustrated in the following figure, where the risk of adverse effects is zero when intakes are below the Upper level (UL).

40

When ingested in excess, these otherwise

beneficial components appear to affect bone

metabolism

Vitamin A#

Alcohol

Sodium*

Caffeine

# UL =3000 mcg retinol * UL = 2300 mg Na

Some populations are at risk of deficiencies in

nutrients that may affect bone health

• Strict vegans: in addition to calcium, vitamin D and protein – B12, zinc

• People on restrictive diet: in addition to calcium, vitamin

D and protein – B12, zinc (if restrict meat), vitamin C, carotenes, potassium if restrict fruit & vegetables.

• Frail elderly people with low appetite: potentially low in all bone healthy nutrients

• Those with an alcohol problem: potentially low in all bone healthy nutrients

All of the food groups are needed to

provide all of the bone healthy nutrients

Nutrient Fruit &

Vegetables

Whole Grains Dairy Meat &

Alternatives

Calcium √ √

Vitamin D √

Protein √ √

Vitamin K √ √

Magnesium √

Manganese √

Zinc √ √

Phosphorus √ √ √

Vitamin C √

Carotenes √

B12 √ √

• A study of dietary patterns in Canadian men and women over 50 y indicated that a nutrient dense diet was protective against incident low-trauma fractures in women:

Dietary pattern research: consume a bone healthy

diet

Langsetmo et al., Am J Clin Nutr2011;93:192–9

whole grains)

*

Ca ada’s Food Guide ensures adequate calcium and protein, and most other nutrients

+ recommends a vitamin D supplement

Following the Food Guide

Ensures Bone Health