Associations between age-related changes in bone microstructure and strength and dietary acid load in a cohort of community-dwelling, healthy men and postmenopausal women

Associations between adherence to plant-based diets and osteoporosis and visceral fat area in middle-aged adults: evidence of a large population-based study

Objectives

Although plant-based diets (PBDs) are widely recognized for their cardiovascular benefits, their results on bone remain controversial. This study aimed to assess the association of PBDs with osteoporosis and fat indices in middle-aged adults.

Methods

This analysis included 9,295 adults from the Ravanser Non-Communicable Disease (RaNCD) cohort. Nutritional information was collected through a validated food frequency questionnaire (FFQ), which was used to derive overall, healthy, and unhealthy PBD indices. Participants underwent the bioelectrical impedance analysis (BIA) to measure body fat (BF), fat mass index (FMI), and visceral fat area (VFA).

Results

The highest tertile of healthy PBD was not associated with the odds of osteoporosis than the lowest tertile (OR for men: 1.07; 95%CI: 0.66-1.74 & OR for women: 1.24; 95%CI: 0.79-1.94). However, it was associated with a lower VFA (6.01 cm² for men and 13.64 cm² for women) than the lowest tertile. The highest tertile of overall and unhealthy PBDs was not associated with the odds of osteoporosis in men and women, while they were associated with a higher VFA [(3.22 cm² for men and 4.80 cm² for women) & (3.22 cm² for men and 11.78 cm² for women)] than the lowest tertile, respectively. A significant association was between PBD indices and BF and FMI in both sexes.

Conclusions

These findings suggest that while only healthy PBDs may contribute to improved fat distribution, they do not appear to influence osteoporosis risk. Longitudinal studies are needed to explore the long-term outcome of adherence to PBDs on bone.

Association between dietary acid load and risk of osteoporotic fractures in adults: a systematic review and meta-analysis of observational studies

AIM

We aimed to systematically review and conduct a meta-analysis of the available evidence about the association between dietary acid load (DAL) and fractures in adults.

METHOD

Relevant studies were searched through Web of Science, Scopus, PubMed, and Google Scholar until October 2024. The random-effect model was used to calculate the pooled Odd ratios (OR) and 95% confidence intervals (CIs). Publication bias was evaluated by statistical test of Egger. Subgroup analyses were conducted by study confounders. Moreover, the quality of studies was asessed using the Newcastle Ottawa Scale which is designed for observational studies.

RESULTS

Six studies were included in this review. According to the methodological heterogeneity between studies and their different charactristics, we performed the analysis based on random-effect model that indicated a marginally significant association between DAL and risk of fracture (N event = 5275, Pooled OR: 1.10; 95% CI: 0.99-1.21, P = 0.073) (I2 = 12.9%; P = 0.321). According to subgroup analysis, there was no significant association between DAL and risk of fracture in the cross-sectional effect sizes (N event = 337, OR:0.69; 95%CI:0.47-1.00). There was a significant association between DAL and a greater risk of fracture in cohort studies (N event = 4938, OR:1.12; 95%CI:1.03-1.22, P = 0.006). Also, high-quality studies (OR:1.12; 95%CI:1.03-1.22; P = 0.006) showed a significant association between DAL and fracture risk.

CONCLUSION

DAL was marginally related to a higher risk of fracture. This finding is a trigger for bone health management with a healthy balanced dietary intake.

Dietary Acid Load and Human Health: A Systematic Review and Meta-analysis of Observational Studies

CONTEXT

Dietary acid load (DAL) plays an important role in different aspects of human health.

OBJECTIVE

The aim of this meta-analysis was to systematically synthesize the observational evidence reporting on the associations between the DAL (represented by a potential renal acid load [PRAL] and net endogenous acid production [NEAP]) and a range of health outcomes.

DATA SOURCES

A systematic search of Medline (via PubMed), EMBASE, Scopus, and Web of Science was performed to identify eligible studies.

DATA EXTRACTION

Study screening and risk-of-bias assessment were conducted by 2 independent reviewers.

DATA ANALYSIS

The credibility of each outcome was graded based on predefined criteria: pooled effect size with corresponding 95% CI, 95% prediction interval, heterogeneity, small-study effect, and excess significance bias. In total, 118 observational studies (case-control [n = 22], cross-sectional [n = 65], and cohort [n = 31]) on 38 outcomes were included, incorporating a total population of 1 014 081 participants. Overall, 21/37 and 20/38 of the outcomes reported statistically significant effect sizes for PRAL and NEAP, respectively. The credibility of the evidence for PRAL was rated convincing (class I) for type 2 diabetes (T2D), and as highly suggestive evidence (class II) for overall cancer and systolic blood pressure. By assessing the credibility of the evidence for NEAP, T2D and overall cancer presented convincing evidence (class I) and breast cancer presented highly suggestive evidence (class II). The remaining outcomes presented class III (suggestive) or lower evidence (weak or no association).

CONCLUSION

The higher acid-forming potential of diet was associated with a higher risk of T2D and overall cancer. Since this meta-analysis included observational studies and some of the associations were graded as weak, caution should be exercised in interpreting these associations. Further cohort studies are required with consideration of other factors that can cause biases.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022336050.

Nutrition and Osteoporosis Prevention

PURPOSE OF REVIEW

Osteoporosis affects 50% of women and 20% of men after the age of 50. Fractures are associated with significant morbidity, increased mortality and altered quality of life. Lifestyle measures for fragility fracture prevention include good nutrition including adequate protein and calcium intakes, vitamin D sufficiency, and regular weight bearing physical exercise.

RECENT FINDINGS

Dietary protein is one of the most important nutritional considerations as it affects bone mineral density, trabecular and cortical microstructure, and bone strength. When calcium intake is sufficient, higher dietary protein intake is associated with lower risk of fracture. Dairy products are a valuable source of calcium and high quality protein. Dairy product consumption, particularly fermented dairy products, are associated with a lower risk of hip fracture and vegan diets are associated with increased fracture risk. Other dietary factors associated with reduced fracture risk include at least 5 servings per day of fruits and vegetables, regular tea drinking, adherence to a Mediterranean diet and other dietary patterns which provide fibers, polyphenols and fermented dairy products. Such dietary patterns may confer health benefits through their effect on gut microbiota composition and/or function. A balanced diet including minerals, protein, fruits and vegetables is an important element in the prevention of osteoporosis and of fragility fracture.

Risk Factors for a Higher Dietary Acid Load (Potential Renal Acid Load) in Free-Living Elderly in Poland

BACKGROUND

Dietary composition is one of the factors influencing the acid-base balance of the body by providing acid or base precursors. One of the methods for assessing the acid-forming potential of a diet is to calculate its potential renal acid load (PRAL). The aim of this study was to identify the sociodemographic, lifestyle, and health factors related to the PRAL.

METHODS

Dietary intake was assessed among 133 individuals aged 70+ years using the three-day record method.

RESULTS

The average PRAL value was 15.7 mEq/day (range from -42.4 to +101.7). The diets of a majority of the participants (71.4%) had acid-forming potential (PRAL > 0). From a univariate analysis, the acid-forming potential of the diets was linked mainly to women (65.3% in PRAL > 0 group vs. 10.5% in PRAL < 0 group), people using dietary supplements, those who consumed alcohol, those who assessed their health as being at least good, people with osteoporosis, those hospitalized during the previous year, and those with rather lower physical activity.

CONCLUSIONS

From a multivariate analysis, gender was the strongest predictor of an acid-forming diet, but the following also contributed: an average self-rated health status (compared to good), a good health status (compared to poor), alcohol drinking, hospitalization, lack of nutritional knowledge, and, to a lesser extent, non-frail status (compared to pre-frail). Therefore, more extensive nutritional education in the identified groups is required.

Association Between the Dietary Inflammatory Index and the Risk of Fracture in Chinese Adults: Longitudinal Study

BACKGROUND

Chronic inflammation plays a crucial role in tissue injury, osteoporosis, and fracture. The dietary inflammatory index (DII) is a tool for assessing the potential for inflammation in the diet. However, the association between the DII and fractures remains controversial from previous studies.

OBJECTIVE

We aimed to explore the correlation between the DII and fracture risk in Chinese adults.

METHODS

We included 11,999 adults (5519 men and 6480 women) who were a part of the China Health and Nutrition Survey (1997-2015) prospective cohort. A 3-day, 24-hour meal review method was used to calculate the DII score. The fractures were identified using a questionnaire. Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% CIs for fractures. Subgroup, sensitivity, and restricted cubic spline analyses were performed.

RESULTS

During the 18 years of follow-up (median follow-up 9.0 years), 463 men and 439 women developed fractures. The median DII score was 0.64 (IQR -1.74 to 1.46) for the total sample, 0.75 (IQR -1.68 to 1.50) for men, and 0.53 (IQR -1.79 to 1.42) for women. The DII score had a positive correlation with the risk of fracture among women but not among men. For men, after adjusting for covariates, the HRs for quintiles of DII were 1, 0.96 (95% CI 0.66-1.41), 1.05 (95% CI 0.74-1.49), 0.89 (95% CI 0.62-1.26), and 0.94 (95% CI 0.67-1.34; trend: P=.62). The HRs for women were 1, 1.13 (95% CI 0.72-1.79), 1.24 (95% CI 0.83-1.86), 1.51 (95% CI 1.02-2.22), and 1.62 (95% CI 1.10-2.39; trend: P=.004). The restricted cubic spline analysis showed a significant association between fracture risk and DII score in women (overall association: P=.01); as the DII scores were >0.53, HRs showed a significant upward trend. Women aged <50 years or who are nonsmokers, who are nondrinkers, or with nonabdominal obesity had a positive association between fracture risk and the DII score. In sensitivity analyses, after excluding people with diabetes or hypertension, there was still a positive association between fracture risk and the DII score in women. Among the DII components, the DII scores of protein (trend: P=.03), niacin (trend: P=.002), and iron (trend: P=.02) showed significant associations with the risk of fracture in women.

CONCLUSIONS

Proinflammatory diet consumption increased the fracture risk in Chinese women aged <50 years. The high consumption of anti-inflammatory foods and low consumption of proinflammatory foods may be an important strategy to prevent fractures in women.

Hyperglycemic microenvironment compromises the homeostasis of communication between the bone-brain axis by the epigenetic repression of the osteocalcin receptor, Gpr158 in the hippocampus

Diabetes mellitus (DM) is a chronic metabolic disease, mainly characterized by increased blood glucose and insulin dysfunction. In response to the persistent systemic hyperglycemic state, numerous metabolic and physiological complications have already been well characterized. However, its relationship to bone fragility, cognitive deficits and increased risk of dementia still needs to be better understood. The impact of chronic hyperglycemia on bone physiology and architecture was assessed in a model of chronic hyperglycemia induced by a single intraperitoneal administration of streptozotocin (STZ; 55 mg/kg) in Wistar rats. In addition, the bone-to-brain communication was investigated by analyzing the gene expression and methylation status of genes that encode the main osteokines released by the bone [Fgf23 (fibroblast growth factor 23), Bglap (bone gamma-carboxyglutamate protein) and Lcn2 (lipocalin 2) and their receptors in both, the bone and the brain [Fgfr1 (fibroblast growth factor receptor 1), Gpr6A (G-protein coupled receptor family C group 6 member A), Gpr158 (G protein-coupled receptor 158) and Slc22a17 (Solute carrier family 22 member 17)]. It was observed that chronic hyperglycemia negatively impacted on bone biology and compromised the balance of the bone-brain endocrine axis. Ultrastructural disorganization was accompanied by global DNA hypomethylation and changes in gene expression of DNA-modifying enzymes that were accompanied by changes in the methylation status of the osteokine promoter region Bglap and Lcn2 (lipocalin 2) in the femur. Additionally, the chronic hyperglycemic state was accompanied by modulation of gene expression of the osteokines Fgf23 (fibroblast growth factor 23), Bglap (bone gamma-carboxyglutamate protein) and Lcn2 (lipocalin 2) in the different brain regions. However, transcriptional regulation mediated by DNA methylation was observed only for the osteokine receptors, Fgfr1(fibroblast growth factor receptor 1) in the striatum and Gpr158 (G protein-coupled receptor 158) in the hippocampus. This is a pioneer study demonstrating that the chronic hyperglycemic state compromises the crosstalk between bone tissue and the brain, mainly affecting the hippocampus, through transcriptional silencing of the Bglap receptor by hypermethylation of Gpr158 gene.

Dietary recommendations in the prevention and treatment of osteoporosis

INTRODUCTION

This article presents the initial recommendations of the French Rheumatology Society (Société Française de Rhumatologie - SFR) and the Osteoporosis Research and Information Group (Groupe de Recherche et d'Informations sur les Ostéoporoses - GRIO) on the role of diet in the prevention and treatment of osteoporosis.

METHODS

The recommendations were produced by a working group composed of rheumatologists, physician nutrition specialists and a geriatrician. Fifteen (15) questions pertaining to "daily practices" were preselected by the working group. For the literature review, the working group focussed mainly on the effects of diet on bone mineral density (BMD) and fractures, and primarily on meta-analyses of longitudinal studies and dietary intervention studies.

RESULTS

A Mediterranean-type diet and the daily consumption of 2 to 3 dairy products are recommended. Together, these provide the calcium and "high quality" protein required to maintain a normal calcium-phosphorus balance and bone metabolism, and are associated with lower fracture risk. Conversely, unbalanced Western diets, vegan diets, weight-loss diets in non-overweight individuals, alcohol consumption and daily consumption of sodas are advised against. In terms of the beneficial effects on bone mineral density and fracture risk, current scientific data are either insufficient or too divergent to recommend increasing or restricting the consumption of tea or coffee, vitamins other than vitamin D, vitamin D-enriched or phytoestrogen-rich foods, calcium-enriched plant-based beverages, oral nutritional supplements, or dietary sources of prebiotics and probiotics.

CONCLUSIONS

These are the first set of recommendations addressing the role of diet in the prevention and treatment of osteoporosis. More research is necessary to direct and support guidelines.

Dietary Acid Load and Bone Health: A Systematic Review and Meta-Analysis of Observational Studies

Findings on the association between dietary acid load (DAL) and bone health are conflicting. This study aimed to summarize available studies on the association between DAL and risk of fractures or bone mineral density (BMD) in adults. Online databases including PubMed, Scopus, and Embase were searched for relevant studies published up to June 2021, using pertinent keywords. We identified observational studies (cohort, case-control, and cross-sectional) investigating the association between DAL and risk of fractures or BMD, then selected studies following these reported criteria: RRs with corresponding 95% CIs for the relationship between DAL and fracture risk; correlation coefficients for the association between DAL and BMD; and mean ± SD of BMD values across the categories of DAL. Overall, 17 studies with 80545 individuals were included. There was no significant relationship between the PRAL and fracture risk (Pooled RR: 1.18; 95% confidence interval 0.98 to 1.41, I² = 60.6%). Moreover, a similar association was observed between the NEAP and fracture risk (Pooled RR: 1.41, 95% CI: 0.79 to 2.52, I² = 54.1%). The results of five studies from four publications revealed no significant association between dietary PRAL score and femoral and spinal BMD (WMD femoral = −0.01, 95% confidence interval: −0.02 to 0.01, I² = 76.5%; WMD spinal = −0.01, 95% CI: −0.03 to 0.01, I² = 56.7%). However, being in the highest category of NEAP was significantly associated with a lower femoral and spinal BMD (WMD femoral = −0.01, 95% CI: −0.02 to −0.00, I² = 82.1%; WMD spinal = −0.02, 95% CI: −0.03 to −0.01, I² = 93%). It was showed that adopting diets high in acidity was not associated with risk of fractures. We also found a significant negative relationship between NEAP and BMD. However, DAL based on PRAL was not associated with BMD.

Associations of Calcium Intake and Calcium from Various Sources with Blood Lipids in a Population of Older Women and Men with High Calcium Intake

Promoting calcium intake is a cornerstone for osteoporosis management. Some individuals limit dairy product consumption, a major calcium source, due to their high content in saturated fats and their perceived negative impact on lipid profiles. This study explored the associations of calcium from various sources with blood lipids in community-dwelling elderly (n = 717) from the GERICO cohort. Dietary calcium intake was assessed at several timepoints using a validated food frequency questionnaire (FFQ) and calcium supplement use was recorded. Blood lipids were treated as categorical variables to distinguish those with normal and abnormal levels. Increasing total calcium intake was associated with lower risks for high total cholesterol (p = 0.038) and triglycerides (p = 0.007), and low HDL-cholesterol (p = 0.010). Dairy calcium (p = 0.031), especially calcium from milk (p = 0.044) and milk-based desserts (p = 0.039), i.e., low-fat (p = 0.022) and non-fermented (p = 0.005) dairy products, were associated with a lower risk of high total cholesterol. Greater calcium intakes from total dairies (p = 0.020), milk (p = 0.020) and non-fermented dairies (p = 0.027) were associated with a lower risk of hypertriglyceridemia. No association was observed between calcium from non-dairy sources, cheese or high-fat dairies and blood lipids. Increasing calcium through supplements was associated with lower risks for hypertriglyceridemia (p = 0.022) and low HDL-cholesterol (p = 0.001), but not after adjustments. Our results suggest that higher calcium intakes from dietary sources or supplements are not adversely associated with blood lipids in the elderly, whilst total, and particularly low-fat, dairy products are valuable calcium sources potentially related to favorable lipid profiles.

Dairy products and bone health

Bone mineral mass, geometry and microstructure, hence determinants of fracture risk, result bone accrual during growth and bone loss later in life. Peak bone mass, which is reached by the end of the second decade of life, is mainly determined by genetic factors. Among other factors influencing bone capital, dietary intakes, particularly calcium and protein, play a significant role in peak bone mass attainment. Both nutrients are provided in dairy products, which accounts for 50-60% and 20-30% of the daily calcium and protein intakes, respectively. Children avoiding dairy products are at higher risk of fracture, as are adults or older individuals following a diet devoid of dairy products, like vegans. Various intervention trials have shown some beneficial effects of dairy products on bone capital accumulation during growth and on bone turnover in adults. In observational studies, dairy products intake, particularly the fermented ones, which also provide probiotics in addition to calcium, phosphorus and protein, appear to be associated with a lower risk of hip fracture.

Nutritional intake and bone health

Osteoporotic or fragility fractures affect one in two women and one in five men who are older than 50. These events are associated with substantial morbidity, increased mortality, and an impaired quality of life. Recommended general measures for fragility fracture prevention include a balanced diet with an optimal protein and calcium intake and vitamin D sufficiency, together with regular weight-bearing physical exercise. In this narrative Review, we discuss the role of nutrients, foods, and dietary patterns in maintaining bone health. Much of this information comes from observational studies. Bone mineral density, microstructure-estimated bone strength, and trabecular and cortical microstructure are positively associated with total protein intake. Several studies indicate that fracture risk might be lower with a higher dietary protein intake, provided that the calcium supply is sufficient. Dairy products are a valuable source of these two nutrients. Hip fracture risk appears to be lower in consumers of dairy products, particularly fermented dairy products. Consuming less than five servings per day of fruit and vegetables is associated with a higher hip fracture risk. Adherence to a Mediterranean diet or to a prudent diet is associated with a lower fracture risk. These various nutrients and dietary patterns influence gut microbiota composition or function, or both. The conclusions of this Review emphasise the importance of a balanced diet including minerals, protein, and fruit and vegetables for bone health and in the prevention of fragility fractures.