Adherence to a Mediterranean diet and risk of fractures in French older persons

Fermented Dairy Products, Musculoskeletal and Mental Health in Older Adults: is There Evidence to Support Benefits that go Beyond Those of Non-Fermented Dairy Products?

Fermented dairy products have recently gained popularity due to their purported health benefits, nevertheless, their role in ageing remains uncertain. This narrative review aims to evaluate evidence from observational (prospective) and interventional studies on the potential benefits of fermented dairy product consumption for musculoskeletal and mental health in older adults. Additionally, it seeks to determine whether any observed benefits surpass those of non-fermented dairy products and to identify directions for future research. Prospective studies support either favourable or neutral associations of fermented dairy products with outcomes of musculoskeletal health or neutral associations with mental health outcomes, whilst it remains unclear if the benefits observed with fermented dairy products go beyond those of the non-fermented dairy foods. Few interventional studies suggest overall favourable effects of yogurt and cheese on musculoskeletal health in older adults but given their small number (N = 6) and heterogeneity, they do not allow a clear assessment or definitive recommendations for fermented dairy intake. Interventional studies reporting mental health outcomes are largely lacking for this age group (N = 1). Given the very limited evidence for the effectiveness of fermented dairy products, future well-designed prospective and randomized controlled trials are needed to better understand their benefits (especially compared to those of non-fermented dairy foods), their characteristics and the quantities required to offer protection against musculoskeletal and/or mental health ageing.

Mediterranean Diet and Risk of Hip Fracture: A Systematic Review and Dose-Response Meta-Analysis

CONTEXT

Hip fractures are a major public health concern. Understanding their epidemiologic and biological links with diet and cardiovascular risk may have important implications for prevention.

OBJECTIVE

To assess the dose-response association of Mediterranean diet (MD) adherence with the risk of hip fracture.

DATA SOURCES

A systematic search was conducted in the PubMed, Scopus, and Web of Science databases for prospective studies. Search terms were "Mediterranean Diet" and "Fracture."

DATA EXTRACTION

Data were extracted from 8 studies, encompassing 15 cohorts that included 503 174 individuals. Methodological quality was assessed using the Risk of Bias in Nonrandomized Studies of Interventions.

DATA ANALYSIS

The "meta" and "dosresmeta" packages were used in R Studio Software. The results demonstrated that high and moderate MD adherence were associated with a reduced risk of hip fracture (relative risk [RR] = 0.71 [95% CI, 0.55-0.91]; and RR = 0.78[(95% CI, 0.65-0.93], respectively). The effect of the association was similar in men and women. The dose-response pattern of the association was linear: each point increase in MD adherence was associated with a 5.25% reduction in hip fracture risk.

CONCLUSIONS

Adherence to MD is associated with a reduction in hip fracture risk, following a linear dose-response pattern. This supports the promotion of this dietary pattern for improving bone health.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42023402284.

The effects of popular diets on bone health in the past decade: a narrative review

Bone health encompasses not only bone mineral density but also bone architecture and mechanical properties that can impact bone strength. While specific dietary interventions have been proposed to treat various diseases such as obesity and diabetes, their effects on bone health remain unclear. The aim of this review is to examine literature published in the past decade, summarize the effects of currently popular diets on bone health, elucidate underlying mechanisms, and provide solutions to neutralize the side effects. The diets discussed in this review include a ketogenic diet (KD), a Mediterranean diet (MD), caloric restriction (CR), a high-protein diet (HP), and intermittent fasting (IF). Although detrimental effects on bone health have been noticed in the KD and CR diets, it is still controversial, while the MD and HP diets have shown protective effects, and the effects of IF diets are still uncertain. The mechanism of these effects and the attenuation methods have gained attention and have been discussed in recent years: the KD diet interrupts energy balance and calcium metabolism, which reduces bone quality. Ginsenoside-Rb2, metformin, and simvastatin have been shown to attenuate bone loss during KD. The CR diet influences energy imbalance, glucocorticoid levels, and adipose tissue, causing bone loss. Adequate vitamin D and calcium supplementation and exercise training can attenuate these effects. The olive oil in the MD may be an effective component that protects bone health. HP diets also have components that protect bone health, but their mechanism requires further investigation. In IF, animal studies have shown detrimental effects on bone health, while human studies have not. Therefore, the effects of diets on bone health vary accordingly.

Fruit and Vegetable Consumption and the Risk of Bone Fracture: A Grading of Recommendations, Assessment, Development, and Evaluations (GRADE)-Assessed Systematic Review and Dose-Response Meta-Analysis

Researchers have examined the link between consuming fruit and vegetables and the incidence of fractures for many years. Nevertheless, their findings have been unclear. Furthermore, the dose-dependent relationship has not been examined, and the level of certainty in the evidence was not evaluated. We carried out a dose-dependent meta-analysis examining the relation between fruit and vegetables intake and fracture incidence. PubMed, Web of Sciences, and Scopus were searched until April 2023 for cohort studies evaluating the relation between fruit and vegetables and fracture incidence. Summary relative risks (RRs) were computed from complied data by applying random effects analysis. To examine the level of evidence, we utilized the approach called the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Ten cohort studies comprising 511,716 individuals were entered. There was a nonsignificant relation between fruit and vegetables, as well as only fruit intake and any fracture risk. In contrast, high versus low analysis presented that vegetables consumption was linked to a 16% decrease in any type of fracture incidence (RR 0.84; 95% confidence interval [CI], 0.75 to 0.95; I 2 = 83.1%; n = 6). Also, per one serving/day (200 g/day) increments in vegetables consumption, there was a 14% decline in the fracture risk (RR 0.86; 95% CI, 0.77 to 0.97; I 2 = 84.7%; n = 5; GRADE = moderate). With moderate certainty, a greater consumption of only vegetables, but not total fruit and vegetables or only fruit, might reduce the risk of fracture. These associations were also evident in dose-response analysis. Large intervention trials are demanded to approve our findings. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Types of dairy foods and risk of fragility fracture in the prospective Nurses' Health Study cohort

BACKGROUND

Fragility fractures present enormous health challenges for women. Dairy products provide many bone-beneficial nutrients, such as calcium and vitamin D. Individual dairy foods may exert different effects on bone health.

OBJECTIVES

The aim of this study was to investigate the associations between total dairy, yogurt, milk, and cheese and fragility fracture risk among females in the prospective Nurses' Health Study (NHS) conducted in the United States.

METHODS

In the current analysis, 103,003 females with mean age of 48 y were followed from 1980-2004. Proportional hazards models were used to estimate risk of first fracture (of the wrist, hip, or vertebrae) by intakes of dairy foods (total dairy, milk, yogurt, or cheese) obtained from a food frequency questionnaire. Fractures that were caused by high-trauma events were not included. We relied on self-reported data for wrist and hip fractures whereas for vertebral fractures, medical records were used to confirm cases.

RESULTS

A total of 5495 incident fracture cases were documented during follow-up. After controlling for relevant confounding variables, consumption of ≥2 servings/d of total dairy (compared with <1 serving/d) was associated with lower fracture risk (hazard ratio [HR]: 0.74; 95% confidence interval [CI]: 0.61, 0.89). More than 2 servings of milk per day (compared with <1 serving/d) were associated with a lower fracture risk (HR: 0.85; 95% CI: 0.77, 0.94). Intakes of calcium, vitamin D, and protein from nondairy sources did not modify the effects of total dairy or milk on fracture risk. There was no association between yogurt intake and fracture risk. Intake of cheese (≥1 servings/d compared with <1 serving/wk) was weakly associated with lower fracture risk (HR: 0.89; 95% CI: 0.79, 0.99).

CONCLUSIONS

Higher total dairy, milk, and cheese intakes are associated with lower risks of fracture in females in the NHS.

Dairy intake and risk of hip fracture in prospective cohort studies: non-linear algorithmic dose-response analysis in 486 950 adults

Previous studies on the relationship between dairy consumption and hip fracture risk have reported inconsistent findings. Therefore, we aimed to conduct an algorithmically driven non-linear dose-response meta-analysis of studies assessing dairy intake and risk of developing incident hip fracture. Meta-analysis from PubMed and Google Scholar searches for articles of prospective studies of dairy intake and risk of hip fracture, supplemented by additional detailed data provided by authors. Meta-regression derived dose-response relative risks, with comprehensive algorithm-driven dose assessment across the entire dairy consumption spectrum for non-linear associations. Review of studies published in English from 1946 through December 2021. A search yielded 13 studies, with 486 950 adults and 15 320 fractures. Non-linear dose models were found to be empirically superior to a linear explanation for the effects of milk. Milk consumption was associated with incrementally higher risk of hip fractures up to an intake of 400 g/d, with a 7 % higher risk of hip fracture per 200 g/d of milk (RR 1⋅07, 95 % CI 1⋅05, 1⋅10; P < 0⋅0001), peaking with 15 % higher risk (RR 1⋅15, 95 % CI 1⋅09, 1⋅21, P < 0⋅0001) at 400 g/d versus 0 g/d. Although there is a dose-risk attenuation above 400 g/d, milk consumption nevertheless continued to exhibit elevated risk of hip fracture, compared to zero intake, up to 750 g/d. Meanwhile, the analysis of five cohort studies of yoghurt intake per 250 g/d found a linear inverse association with fracture risk (RR 0⋅85, 95 % CI 0⋅82, 0⋅89), as did the five studies of cheese intake per 43 g/d (~1 serving/day) (RR 0⋅81, 95 % CI 0⋅72, 0⋅92); these studies did not control for socioeconomic status. However, no apparent association between total dairy intake and hip fracture (RR per 250 g/d of total dairy = 0⋅97, 95 % CI 0⋅93, 1⋅004; P = 0⋅079). There were both non-linear effects and overall elevated risk of hip fracture associated with greater milk intake, while lower risks of hip fracture were reported for higher yoghurt and cheese intakes.

Cheese consumption and multiple health outcomes: an umbrella review and updated meta-analysis of prospective studies

This umbrella review aims to provide a systematic and comprehensive overview of current evidence from prospective studies on the diverse health effects of cheese consumption. We searched PubMed, Embase, and Cochrane Library to identify meta-analyses/pooled analyses of prospective studies examining the association between cheese consumption and major health outcomes from inception to August 31, 2022. We reanalyzed and updated previous meta-analyses and performed de novo meta-analyses with recently published prospective studies, where appropriate. We calculated the summary effect size, 95% prediction confidence intervals, between-study heterogeneity, small-study effects, and excess significance bias for each health outcome. We identified 54 eligible articles of meta-analyses/pooled analyses. After adding newly published original articles, we performed 35 updated meta-analyses and 4 de novo meta-analyses. Together with 8 previous meta-analyses, we finally included 47 unique health outcomes. Cheese consumption was inversely associated with all-cause mortality (highest compared with lowest category: RR = 0.95; 95% CI: 0.92, 0.99), cardiovascular mortality (RR = 0.93; 95% CI: 0.88, 0.99), incident cardiovascular disease (CVD) (RR = 0.92; 95% CI: 0.89, 0.96), coronary heart disease (CHD) (RR = 0.92; 95% CI: 0.86, 0.98), stroke (RR = 0.93; 95% CI: 0.89, 0.98), estrogen receptor-negative (ER-) breast cancer (RR = 0.89; 95% CI: 0.82, 0.97), type 2 diabetes (RR = 0.93; 95% CI: 0.88, 0.98), total fracture (RR = 0.90; 95% CI: 0.86, 0.95), and dementia (RR = 0.81; 95% CI: 0.66, 0.99). Null associations were found for other outcomes. According to the NutriGrade scoring system, moderate quality of evidence was observed for inverse associations of cheese consumption with all-cause and cardiovascular mortality, incident CVD, CHD, and stroke, and for null associations with cancer mortality, incident hypertension, and prostate cancer. Our findings suggest that cheese consumption has neutral to moderate benefits for human health.

The Influence of the Mediterranean Dietary Pattern on Osteoporosis and Sarcopenia

Diet is a modifiable factor in bone and muscle health. The Mediterranean diet (MedDiet) is rich in nutrients and contains key bioactive components with probable protective effects on muscle and bone deterioration. Osteoporosis (OP) and sarcopenia are diseases that increase frailty and susceptibility to fracture, morbidity and mortality. Therefore, it is necessary to combat them in the population. In this regard, MedDiet adherence has proven to be beneficial to bone mineral density (BMD), muscle mass, physical function, OP and sarcopenia. Hence, this diet is proposed as a therapeutic tool that could slow the onset of osteoporosis and sarcopenia. However, there is doubt about the interaction between the MedDiet, strength and fracture risk. Perhaps the amount of EVOO (extra virgin olive oil), fruits, vegetables and fish rich in anti-inflammatory and antioxidant nutrients ingested has an influence, though the results remain controversial.

Evidence-Based Dietary Practices to Improve Osteoarthritis Symptoms: An Umbrella Review

While there is some research investigating whole foods or diets that are easily understood and accessible to patients with osteoarthritis, specific nutrients or nutraceuticals are more commonly identified. Unfortunately, guidelines and evidence surrounding individual nutrients, extracts, and nutraceuticals are conflicting and are more difficult to interpret and implement for patients with osteoarthritis. The purpose of this umbrella review is to provide a comprehensive understanding of the existing evidence of whole foods and dietary patterns effects on osteoarthritis-related outcomes to inform evidence-based recommendations for healthcare professionals and identify areas where more research is warranted. A literature search identified relevant systematic reviews/meta-analyses using five databases from inception to May 2022. Five systematic reviews/meta-analyses were included in the current umbrella review. Most evidence supported the Mediterranean diet improving osteoarthritis-related outcomes (e.g., pain, stiffness, inflammation, biomarkers of cartilage degeneration). There was little to no evidence supporting the effects of fruits and herbs on osteoarthritis-related outcomes; however, there was some suggestion that specific foods could potentiate symptom improvement through antioxidative mechanisms. The overall lack of homogeneity between the studies limits the conclusions that can be made and highlights the need for quality research that can identify consumer-accessible foods to improve osteoarthritis-related symptoms.

Alcohol Consumption and Risk of Fractures: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies

Alcohol consumption remains inconsistently correlated with fracture risk, and a dose-response meta-analysis for specific outcomes is lacking. The objective of this study was to quantitatively integrate the data on the relationship between alcohol consumption and fracture risk. Pertinent articles were identified in PubMed, Web of Science, and Embase databases up to 20 February 2022. Combined RRs and 95% CIs were estimated by random- or fixed-effects models. Restricted cubic splines were used to model linear or nonlinear relationships. Forty-four articles covering 6,069,770 participants and 205,284 cases of fracture were included. The combined RRs and 95% CIs for highest compared with lowest alcohol consumption were 1.26 (1.17-1.37), 1.24 (1.13-1.35), and 1.20 (1.03-1.40) for total, osteoporotic, and hip fractures, respectively. A linear positive relationship between alcohol consumption and total fracture risk was detected (Pnonlinearity = 0.057); the risk was correlated with a 6% increase (RR, 1.06; 95% CI: 1.02, 1.10) per 14 g/d increment of alcohol consumption. J-shaped relationships of alcohol consumption with risk of osteoporotic fractures (Pnonlinearity < 0.001) and hip fractures (Pnonlinearity < 0.001) were found. Alcohol consumption of 0 to 22 g/d was linked to a reduced risk of osteoporotic fractures and hip fractures. Our findings show that any level of alcohol consumption is a risk factor for total fractures. Moreover, this dose-response meta-analysis shows that an alcohol consumption level of 0 to 22 g/d is related to a reduction in the risk of osteoporotic and hip fractures. The protocol was registered in the International Prospective Register of Systematic Reviews (CRD42022320623).

Association between dairy consumption and cardiovascular disease events, bone fracture and all-cause mortality

Dairy products are important constituents of a healthy and balanced diet, but their association with health outcomes remains to be established. We investigated the association of total dairy, total fermented dairy, and different dairy subtypes (including total/high-fat/low-fat milk, yogurt, cheese, butter, and cream) and the risk of cardiovascular disease (CVD), coronary heart disease (CHD), bone fracture and all-cause mortality among 1746 Danish healthy men and women (30–60 years, 52%female). Hazard ratios (HRs) and 95% CIs were estimated using the multivariable Cox proportional hazard models. During a mean follow-up of 30 years, incident cases of CVD (n = 904), CHD (n = 332), fracture (n = 447) and all-cause mortality (n = 680) were reported. High intake of total fermented dairy was associated with lower fracture risk (HR 0.67, 95% CI: 0.51–0.90, P = 0.02) than observed in the lowest tertile of the fermented dairy group. Furthermore, high intake of low-fat milk was associated with lower risks of CVD (HR 0.84, 95% CI: 0.68–1.03, P = 0.03), CHD (HR 0.82, 95% CI: 0.59–1.16, P = 0.04), and all-cause mortality (HR 0.77, 95% CI: 0.61–0.97, P = 0.004) compared with the lowest tertile of low-fat milk group. No associations were found with other dairy subtypes. The findings from this prospective cohort study suggest an inverse association between total fermented dairy and fracture risk, and also inverse associations were found between low-fat milk consumption and risk of CVD, CHD and all-cause mortality.

Diet Quality and Measures of Sarcopenia in Developing Economies: A Systematic Review

Sarcopenia refers to common age-related changes characterised by loss of muscle mass, strength, and physical performance that results in physical disability, poorer health status, and higher mortality in older adults. Diet quality is indicated as a potentially modifiable risk factor for sarcopenia. However, the association between diet quality and sarcopenia in developing economies appears to be conflicting. Hence, we conducted a systematic review of the literature from developing economies examining the relationship between diet quality and at least one of the three components of sarcopenia, including muscle mass, muscle strength, and physical performance, and the overall risk of sarcopenia. No restrictions on age and study design were employed. We identified 15 studies that met review inclusion criteria. There was heterogeneity among the studies in the diet quality metric used and sarcopenia-related outcomes evaluated. Longitudinal evidence and studies relating diet quality to a holistic definition of sarcopenia were lacking. Although limited and predominantly cross-sectional, the evidence consistently showed that diet quality defined by diversity and nutrient adequacy was positively associated with sarcopenia components, such as muscle mass, muscle strength, and physical performance.

Understanding the Protective Effect of Phytate in Bone Decalcification Related-Diseases

Myo-inositol hexaphosphate (phytate; IP6) is a natural compound that is abundant in cereals, legumes, and nuts, and it can bind to crystal surfaces and disturb crystal development, acting as crystallization inhibitor. The adsorption of such inhibitors to crystal faces can also inhibit crystal dissolution. The binding of phytate to metal cofactors suggests that it could be used for treatment of osteoporosis. Our in-vitro study showed that phytate inhibits dissolution of hydroxyapatite (HAP). The effect of phytate was similar to that of alendronate and greater than that of etidronate. This led us to perform a cross-sectional study to investigate the impact of consumption of IP6 on bone mineral density (BMD) in post-menopausal women. Our data indicate that BMD and t-score of lumbar spine increased with increasing phytate consumption, and a phytate consumption higher than 307 mg/day was associated with a normal BMD (t-score > −1). These data suggest that phytate may have a protective effect in bone decalcification by adsorbing on the surfaces of HAP, and a daily consumption of phytate-rich foods (at least one serving/day of legumes or nuts) may help to prevent or minimize bone-loss disorders, such as osteoporosis. However, further studies are needed to gain a better understanding about the mechanism of inhibition of phytate in bone-related diseases (see graphical abstract).

Dietary interventions for better management of osteoporosis: An overview

Osteoporosis is a public health concern and a cause of bone loss, increased risk of skeletal fracture, and a heavy economic burden. It is common in postmenopausal women and the elderly and is impacted by dietary factors, lifestyle and some secondary factors. Although many drugs are available for the treatment of osteoporosis, these therapies are accompanied by subsequent side effects. Hence, dietary interventions are highly important to prevent osteoporosis. This review was aimed to provide a comprehensive understanding of the roles of dietary nutrients derived from natural foods and of common dietary patterns in the regulation of osteoporosis. Nutrients from daily diets, such as unsaturated fatty acids, proteins, minerals, peptides, phytoestrogens, and prebiotics, can regulate bone metabolism and reverse bone loss. Meanwhile, these nutrients generally existed in food groups and certain dietary patterns also play critical roles in skeletal health. Appropriate dietary interventions (nutrients and dietary patterns) could be primary and effective strategies to prevent and treat osteoporosis across the lifespan for the consumers and food enterprises.

A systematic review and meta-analysis of prospective cohort studies on the association between alcohol intake and risk of fracture

Previous studies on the association between alcohol intake and risk of fracture have reached conflicting findings. The aim of this systematic review and meta-analysis of prospective cohort studies was to summarize earlier studies on the association of alcohol intake with risk of fracture. A systematic search of PubMed, Scopus, and ISI Web of Science was conducted up to November 2020. Prospective cohort studies that had considered alcohol consumption as the exposure variable and fracture as the main outcome or as one of the outcome variables were included in this systematic review. Publications in which odds ratios (ORs), rate or risk ratios (RRs), or hazard ratios (HRs) and 95% confidence intervals (CIs) were reported, were included in the meta-analysis. In total, 40 prospective cohort studies including 5,084,303 participants and 170,916 subjects with fracture were included in this systematic review; of them 38 studies with a total sample size of 5,053,117 participants and 169,560 cases of fracture were included in the meta-analysis. Using a random-effects meta-analysis, we found a significant positive association between alcohol consumption and risk of total fractures (RR: 1.35; 95% CI: 1.01, 1.81) and any fractures (RR: 1.24; 95% CI: 1.11, 1.38). However, no significant association was observed between alcohol intake and risk of hip fractures (RR: 1.19; 95% CI: 0.96, 1.48), osteoporotic fractures (RR: 2.01; 95% CI: 0.76, 5.34), vertebral fractures (RR: 0.98; 95% CI: 0.68, 1.40), and wrist fractures (RR: 0.99; 95% CI: 0.85, 1.16). In conclusion, we found that alcohol consumption was positively associated with risk of total fractures and any fractures. However, we did not observe any significant association between alcohol consumption and risk of hip, osteoporotic, vertebral, and wrist fractures.

Dietary Patterns and Pediatric Bone

PURPOSE OF REVIEW

Much of what we know about dietary patterns (DPs) and bone is derived from cross-sectional studies in adults. Given, establishing healthy bones during childhood serves as a blueprint for adult bone, it is important to better understand the role of DPs on pediatric bone. The purpose of this review is to determine if DPs influence bone strength in children.

RECENT FINDINGS

The majority of studies investigating the role of DPs on pediatric bone are cross-sectional in design and examine data-derived "a posterori" DPs. Overall, the DPs characterized by high intakes of fruits and vegetables demonstrated positive effects on pediatric bone. Results from both "a posteriori" and "a priori" DPs approaches in children suggests that DPs dominated by the intake of fruits and vegetables might be beneficial for pediatric bone. Future studies may consider "a priori" DPs interventions to better understand relationship between DPs and pediatric bone.

Nutrient and Dietary Patterns in Relation to the Pathogenesis of Postmenopausal Osteoporosis-A Literature Review

Postmenopausal women tend to be susceptible to primary osteoporosis due to its association with oestrogen deficiency. There is emerging evidence that an unhealthy dietary pattern drives an increase in the risk of postmenopausal osteoporosis (PO), whereas a healthy dietary pattern may decrease its occurrence. In this narrative literature review, we sought to review the role of nutrient and dietary patterns in the pathogenesis of PO. Therefore, we searched and reported all research articles from 2001 to May 2020 in Web of Science, Cinahl and Scopus that have researched a relationship between nutrient and/or dietary patterns and postmenopausal osteoporosis. Nutrients such as calcium, phosphorus, magnesium and vitamin D have been proven to be beneficial for bone health. Meanwhile, for the dietary patterns, foods such as dairy products especially milk, fibre and protein-rich foods, e.g., meat were directly linked to a positive association with bone mineral density (BMD). Likewise, fruits, vegetables and probiotic and prebiotic foods were reported for its positive relationship with BMD. Therefore, aside from physical activity, nutrition and diet in adequate proportions are suggested to be an important tool for ameliorating osteoporosis and bone health issues in older age.

Milk Consumption for the Prevention of Fragility Fractures

Results indicating that a high milk intake is associated with both higher and lower risks of fragility fractures, or that indicate no association, can all be presented in the same meta-analysis, depending on how it is performed. In this narrative review, we discuss the available studies examining milk intake in relation to fragility fractures, highlight potential problems with meta-analyses of such studies, and discuss potential mechanisms and biases underlying the different results. We conclude that studies examining milk and dairy intakes in relation to fragility fracture risk need to study the different milk products separately. Meta-analyses should consider the doses in the individual studies. Additional studies in populations with a large range of intake of fermented milk are warranted.

Dietary Inflammatory Index and the Risk of Frailty Among Older Adults: A Systematic Review and Meta-Analysis

A systematic review and meta-analysis was conducted to comprehensively examine the association between Dietary Inflammatory Index (DII®) score and risk of frailty. Frailty risk were available from five studies comprising 13,908 older adults. Furthermore, frailty related parameters were extacted from two studies with 7,539 individuals. A pooled adjusted odds ratio analysis indicated that there was an association between DII® score and frailty risk (OR = 1.24, 95%CI: 1.6-1.33, P < 0.001, I² = 0.0%). The results of frailty related parameters demonstrated that DII® score was associated with weakness risk (OR = 1.12, 95%CI: 1.05-1.19, P = 0.014, I² = 0.0%), but not other frailty-related parameters including exhaustion, low BMI or low physical activity. The results of this meta-analysis suggest that older adults who exhibit higher DII® scores have an increased frailty risk. Further prospective cohort studies with longer follow-up periods, are needed to support this possible association between DII® score and frailty risk.

Systematic review and meta-analysis of the association between dairy consumption and the risk of hip fracture: critical interpretation of the currently available evidence

In the present meta-analysis, reductions in the risk of hip fracture with milk consumption were only observed among American adults, but not among Scandinavian adults, possibly because milk products are more commonly fortified with vitamin D in the former population than in Scandinavian countries. The reduction in the risk of hip fracture was also observed with yogurt consumption, which is often associated with healthy lifestyles and dietary patterns that contribute to improved bone health.

INTRODUCTION

Although dairy products contain bone-beneficial nutrients, the association between dairy consumption and the risk of hip fracture remains equivocal. Fueling this uncertainty, the elevated risk of hip fracture in association with milk consumption was observed in a cohort of Swedish women. A systematic review and meta-analysis of prospective cohort studies was performed to critically evaluate the association, or lack thereof, between dairy consumption (milk, yogurt, and cheese) and the risk of hip fracture.

METHODS

A random effects model was used to generate the summary relative risks (RRs) with their 95% confidence intervals (CIs) for the associations of interest.

RESULTS

In the meta-analysis of the highest versus lowest category of consumption, higher consumption of yogurt (RR 0.78, 95% CI 0.68, 0.90), but not milk (RR 0.86, 95% CI 0.73, 1.02) or cheese (RR 0.85, 95% CI 0.66, 1.08), was associated with a lower risk of hip fracture. For milk, the reduced risk of fracture with higher milk consumption was observed in the USA (RR 0.75, 95% CI 0.65, 0.87), but not in Scandinavian countries (RR 1.00, 95% CI 0.85, 1.17). These findings were further supported by the fact that American studies (RR 0.93, 95% CI 0.88, 0.98; per 1 glass/day), but not Scandinavian studies (RR 1.01, 95% CI 0.95, 1.07; per 1 glass/day), demonstrated a linear association between milk consumption and the risk of hip fracture.

CONCLUSIONS

The cumulative evidence from prospective cohort studies reassuringly suggests that the risk of hip fracture may not be elevated among people who consume milk, yogurt, and cheese, and that a greater consumption of milk or yogurt may even be associated with a lower risk of hip fracture depending on the factors that may differ across the population of interest.

Dietary Approaches to Stop Hypertension, Mediterranean, and Alternative Healthy Eating indices are associated with bone health among Puerto Rican adults from the Boston Puerto Rican Osteoporosis Study

BACKGROUND

Conflicting results on associations between dietary quality and bone have been noted across populations, and this has been understudied in Puerto Ricans, a population at higher risk of osteoporosis than previously appreciated.

OBJECTIVE

To compare cross-sectional associations between 3 dietary quality indices [Dietary Approaches to Stop Hypertension (DASH), Alternative Health Eating Index (AHEI-2010), and Mediterranean Diet Score (MeDS)] with bone outcomes.

METHOD

Participants (n = 865-896) from the Boston Puerto Rican Osteoporosis Study (BPROS) with complete bone and dietary data were included. Indices were calculated from validated food frequency data. Bone mineral density (BMD) was measured using DXA. Associations between dietary indices (z-scores) and their individual components with BMD and osteoporosis were tested with ANCOVA and logistic regression, respectively, at the lumbar spine and femoral neck, stratified by male, premenopausal women, and postmenopausal women.

RESULTS

Participants were 59.9 y ± 7.6 y and mostly female (71%). Among postmenopausal women not taking estrogen, DASH (score: 11-38) was associated with higher trochanter (0.026 ± 0.006 g/cm2, P <0.001), femoral neck (0.022 ± 0.006 g/cm2, P <0.001), total hip (0.029 ± 0.006 g/cm2, P <0.001), and lumbar spine BMD (0.025 ± 0.007 g/cm2, P = 0.001). AHEI (score: 25-86) was also associated with spine and all hip sites (P <0.02), whereas MeDS (0-9) was associated only with total hip (P = 0.01) and trochanter BMD (P = 0.007) in postmenopausal women. All indices were associated with a lower likelihood of osteoporosis (OR from 0.54 to 0.75). None of the results were significant for men or premenopausal women.

CONCLUSIONS

Although all appeared protective, DASH was more positively associated with BMD than AHEI or MeDS in postmenopausal women not taking estrogen. Methodological differences across scores suggest that a bone-specific index that builds on existing indices and that can be used to address dietary differences across cultural and ethnic minority populations should be considered.

Mediterranean Diet and Osteoarticular Diseases

Background:

Besides the well-known positive effect on the reduction of the risk of cardiovascular diseases, in the latest decades growing evidence has accumulated on the beneficial effects of MD on various aspects of health outcomes. Nevertheless, data concerning the existence of a direct positive effect of MD, irrespective of its beneficial effect on body weight, in osteo-articular diseases, are still controversial. In osteo-articular diseases, a pro-inflammatory environment is highlighted, with an increased systemic levels of pro-inflammatory cytokines.

Objective:

Our objective is to investigate the effects of adherence to the Mediterranean diet and osteo-articular diseases.

Conclusion:

Many foods included in MD, have anti-inflammatory properties, due to the presence of nutrients, such as polyunsaturated (PUFA) and monounsaturated (MUFA) fats. The two types of polyunsaturated fatty acids, omega-3 and omega-6, have opposing effects on the inflammatory process. Omega-6 stimulates the production of pro-inflammatory cytokines, while omega-3 fatty acids exert anti-inflammatory effects, including significant reductions in the release of pro-inflammatory cytokines. Some studies have shown that the dietary pattern of MD consumption has an important role in the prevention and development of inflammatory arthritis. Nevertheless, the possible influence of MD on chronic osteo-articular diseases is very limited, this review updates the main experimental and clinical evidences concerning the potential beneficial effects of the Mediterranean Diet on the most diffuse osteo-articular chronic and degenerative joint disease.

Fermented Milk Products and Bone Health in Postmenopausal Women: A Systematic Review of Randomized Controlled Trials, Prospective Cohorts, and Case-Control Studies

Milk and milk product consumption is positively associated with bone mineral density (BMD). Emerging evidence suggests that fermented milk products (FMPs) may have specific beneficial effects on skeletal health. We conducted a systematic review and meta-analysis to assess the effect of FMPs on bone health indicators in postmenopausal women given their increased risk for osteoporosis and fragility fractures. Electronic databases were searched for randomized controlled trials (RCTs) and prospective cohort and case-control studies that examined the relation between FMPs and bone health outcomes (fracture incidence, BMD, BMD T-score, and percentage change in bone turnover markers) in postmenopausal women. Two reviewers independently conducted abstract and full-text screenings and data extractions. Risk of bias was assessed using the RoB 2.0 tool and the Newcastle-Ottawa scale for interventional and observational studies. Pooled RRs were obtained using a random-effects model by the DerSimonian-Laird method. Three RCTs, 3 prospective cohorts, and 3 case-control studies met the inclusion criteria. Results of the meta-analysis of 3 cohort studies (n = 102,819) suggest that higher yogurt consumption was associated with reduced hip fracture risk (pooled RR: 0.76; 95% CI: 0.63, 0.92, I2 = 29%), but no difference in hip fracture risk was found between higher and lower cheese consumption (pooled RR: 0.89; 95% CI: 0.73, 1.10, I2 = 0%). Case-control studies revealed that cheese intake had either a null or a protective effect against osteoporosis (BMD T-score ≤-2.5). Daily yogurt or cheese intervention (<2 mo) decreased bone resorption marker concentrations, but had no effect on bone formation markers. In postmenopausal women, of the FMPs studied, only greater yogurt consumption was associated with a reduced risk of hip fracture compared with low or no intake. Daily cheese intake may be associated with higher BMD T-scores, but evidence was limited. Additional and longer-term trials examining these relations are warranted.

Adherence to the Mediterranean Diet and Bone Fracture Risk in Middle-Aged Women: A Case Control Study

The prevention of bone mass loss and related complications associated with osteoporosis is a significant public health issue. The Mediterranean diet (MD) is favorably associated with bone health, a potentially modifiable risk factor. The objective of this research was to determine MD adherence in a sample of women with and without osteoporosis. In this observational case-control study of 139 women (64 women with and 75 without osteoporosis) conducted in a primary-care health center in Girona (Spain), MD adherence, lifestyle, physical exercise, tobacco and alcohol consumption, pathological antecedents, and FRAX index scores were analyzed. Logistic multilinear regression modeling to explore the relationship between the MD and bone fracture risk indicated that better MD adherence was associated with a lower bone risk fracture. Non-pharmacological preventive strategies to reduce bone fracture risk were also reviewed to explore the role of lifestyle and diet in bone mass maintenance and bone fracture prevention.

Alcohol intake, specific alcoholic beverages, and risk of hip fractures in postmenopausal women and men age 50 and older

BACKGROUND

Although a number of studies have examined the association between alcohol intake and hip fractures, few have considered specific alcoholic beverages separately.

OBJECTIVES

We prospectively assessed total alcohol and specific alcoholic beverage consumption and risk of hip fractures in US men and women.

METHODS

Health, lifestyle information, and hip fractures were self-reported on biennial questionnaires between 1980 and 2014 in 75,180 postmenopausal women from the Nurses' Health Study, and between 1986 and 2014 in 38,398 men aged ≥50 y from the Health Professionals Follow-Up Study. Diet was assessed approximately every 4 y with a semiquantitative FFQ. RRs were computed for hip fracture using Cox proportional hazards models, adjusting for potential confounders.

RESULTS

We ascertained 2360 incident low trauma hip fractures in women and 709 in men. Among women, RRs for low trauma hip fractures compared with nondrinkers were 0.89 (95% CI: 0.80, 0.99) for an average daily consumption of <5.0 g, 0.81 (95% CI: 0.70, 0.94) for 5.0 to <10.0 g, 0.83 (95% CI: 0.71, 0.96) for 10.0 to <20.0 g, and 0.93 (95% CI: 0.78, 1.10) for ≥20.0 g. Among men, risk declined linearly with higher alcohol consumption (P-trend = 0.002). Multivariable RR compared with nondrinkers was 0.77 (95% CI: 0.59, 1.01), 0.69 (0.49, 0.96), and 0.67 (0.48, 0.95) for an average intake of 10 g/d to <20 g/d, 20 g/d to <30 g/d, and 30.0 g/d or more, respectively. In women, the alcoholic beverage most significantly associated with hip fracture risk was red wine (RR per serving = 0.59; 95% CI: 0.45, 0.79). In men, there was no clear association with specific alcoholic beverages.

CONCLUSION

In these 2 US cohorts, low to moderate alcohol consumption, when compared with no consumption, was associated with a lower risk of hip fractures, particularly with red wine consumption among women.

Successful Brain Delivery of Andrographolide Loaded in Human Albumin Nanoparticles to TgCRND8 Mice, an Alzheimer's Disease Mouse Model

Andrographolide (AG) was encapsulated in human albumin nanoparticles (AG NPs), and their crossing properties of the blood-brain barrier (BBB), brain distribution, and effects in TgCRND8 mice were evaluated. The development of appropriate NP formulations is mandatory because of the scarce BBB permeability properties of AG. Developed NPs had proper size (mean size: 159.2 ± 4.5 nm), size distribution (PDI nearby 0.12 ± 0.01), and ζ potential (-24.8 ± 1.2 mV), which were not affected by sodium fluorescein (NAF) loading. When AG was loaded to NPs, it slightly affected their size (210.4 ± 3.2 nm) and ζ potential (-20.3 ± 1.5) but not the PDI. Both NAF and AG had a remarkable encapsulation efficiency (more than 99%). The in vitro release of AG from the NPs reached the highest percentage (48%) after 24 h, and the Higuchi’s equation was found to be the best fitting model (R² = 0.9635). Both AG and AG NPs did not alter the viability of N2a murine neuroblastoma cells when compared with the untreated control cells. In the step-down inhibitory avoidance test, AG NPs administered to TgCRND8 mice significantly improved their performance (P < 0.0001), reaching levels comparable to those displayed by wild-type mice. In the object recognition test, treated and untreated animals showed no deficiencies in exploratory activity, directional movement toward objects, and locomotor activity. No cognitive impairments (discrimination score) were detected in TgCRND8 mice (P < 0.0001) treated with AG NPs. After acute intravenous administration (200 µl), NPs loaded with the probe NAF were detected in the brain parenchyma of TgCRND8 mice. Immunofluorescent analyses evidenced the presence of NPs both in the pE3-Aβ plaque surroundings and inside the pE3-Aβ plaque, indicative of the ability of these NPs to cross the BBB and to penetrate in both undamaged and damaged brain tissues. Furthermore, the immunohistochemical analysis of GFAP-positive astrocytes in the hippocampus of Tg mice evidenced the anti-inflammatory activity of AG when AG NPs were intraperitoneally administered. AG was not effective in counteracting amyloid Aβ aggregation and the resulting toxicity but significantly decreased the oxidative stress levels. In conclusion, AG NPs have extraordinary versatility, nontoxicity, nonimmunogenicity, strong biocompatibility, high biodegradability, and astonishing loading capacity of drug.

The effect of milk consumption on bone and fracture incidence, an update

Milk is a major source of high bioavailable calcium in most developed countries with an average calcium content of 1150 mg/L, providing a ready means of meeting the daily requirements. Its content in other minerals, phosphorus, vitamins, iodine, proteins, potassium and various nutrients is supposed to be beneficial for skeleton growth and bone strength. Studies on the effects of milk or whey extracts in animal trials and on surrogate markers in humanlike bone remodeling markers or bone mineral density and many observational studies in large cohorts show positive effects on bone health or risk of hip fracture. Nevertheless, a few contradictory epidemiological studies showed an increased risk of hip fractures in subjects drinking higher quantities of milk. These conflicting results may be due to the large number of confounders and methodological issues as recall bias. Most of the experts state that there are no proven effect of milk consumption on the risk of hip fractures in a way or the other. Of a scientific point of view, there is no reason to remove from the diet of large populations an aliment rich in calcium and other interesting nutrients.

Metformin use and risk of fracture: a systematic review and meta-analysis of observational studies

INTRODUCTION

No study is available summarizing earlier publications on the association between metformin use and risk of fracture. This systematic review and meta-analysis were conducted to summarize earlier findings on the association between metformin use and risk of fracture.

METHODS

We conducted a systematic search on all published articles up to October 2018 using online databases including PubMed/Medline, ISI Web of Science, and Scopus. Observational studies that considered metformin use as the exposure variable and bone fracture as the main outcome variable or as one of the outcome variables and participants included were 18 years and older were included in the systematic review. Publications in which hazard ratios (HRs), rate or risk ratios (RRs), or odds ratios (ORs) were reported as effect size were included in the meta-analysis.

RESULTS

Totally, three cohort studies, one cross-sectional study, one nested case-control study, and one case-control study were included in this systematic review and meta-analysis. When seven effect sizes from six studies were combined, a significant inverse association between metformin use and risk of fracture was observed (RR 0.82; 95% CI 0.72, 0.93). No significant between-study heterogeneity was found (I² = 22.4%, P_{heterogeneity} = 0.25). In addition, no evidence of publication bias was seen using Egger's test (P = 0.99).

CONCLUSION

We found that metformin use was inversely associated with the risk of fracture.

Effects of Milk and Dairy Products on the Prevention of Osteoporosis and Osteoporotic Fractures in Europeans and Non-Hispanic Whites from North America: A Systematic Review and Updated Meta-Analysis

Nutrition plays an important role in bone health. The aim of our study was to update the evidence regarding dairy intake, osteoporotic fracture (OF) risk, and prospective bone mass density (BMD) evolution assessed by dual-energy X-ray absorptiometry in Europeans and non-Hispanic whites from North America. A systematic search was conducted in MEDLINE, EMBASE, and Scopus for papers published from 1 January, 2000 to 30 April, 2018. The eligibility criteria were as follows: healthy adults; measurable dairy exposure; hip, vertebral, wrist or OF as outcomes; and cohort or case-control studies. Two independent investigators conducted the search and the data extraction. A pooled analysis was conducted with random-effects models. Publication bias and meta-regression were considered. Ten cohort studies relating to OF risk were selected for meta-analysis. Three papers reporting BMD changes associated with dairy intake could not be aggregated in the meta-analysis. The pooled HRs of the highest compared with the lowest levels of dairy intake were 0.95 (95% CI: 0.87, 1.03; I2 = 82.9%; P-heterogeneity < 0.001) for OF at any site; 0.87 (95% CI: 0.75, 1.01; I2 = 86.7%; P-heterogeneity < 0.001) for hip fractures; and 0.82 (95% CI: 0.68, 0.99; I2 = 0.0%; P-heterogeneity = 0.512) for vertebral fractures. Concerning BMD, the selected studies described a 1.7-3% lower hip BMD in young and postmenopausal women with poor intake of milk in their youth, a positive relationship between baseline milk ingestion and the percentage of trochanter BMD change in elderly people, and a positive correlation between milk consumption and BMD change at the radius in women aged >65 y. In conclusion, in the studied population, the highest consumption of dairy products did not show a clear association with the total OF or hip fracture risks; however, a diminished risk of vertebral fracture could be described. The results regarding BMD change were heterogeneous and did not allow for a definitive conclusion.

Adherence to a Mediterranean Diet and Bone Mineral Density in Spanish Premenopausal Women

The Mediterranean diet (MD) has been associated with an improvement in health and an increase in longevity. Certain components of a MD can play a role in the prevention of osteoporosis and/or hip fracture. We investigated the association between the degree of adherence to a MD and bone mineral density (BMD) measured in several bone areas in a population of Spanish premenopausal women. We analyzed 442 premenopausal women aged 42.73 ± 6.67 years. Bone measurements were obtained using quantitative bone ultrasound (QUS) for the phalanx, dual energy X-ray absorptiometry (DXA) for the lumbar spine, Ward’s triangle, trochanter, and hip, and peripheral quantitative computed tomography (pQCT) for the non-dominant distal forearm. MD adherence was evaluated with MedDietScore. Amplitude-dependent speed of sound (Ad-SOS), BMD, and volumetric bone mineral density (vBMD) (total, trabecular, and cortical bone density) were positively associated with higher adherence to the MD (p < 0.05). Adherence to the MD was significantly associated with QUS, BMD, and vBMD in multiple regression analysis; QUS: Ad-SOS (m/s) β = 0.099 (p = 0.030); BMD (g/cm²): femur neck β = 0.114 (p = 0.010) and Ward’s triangle β = 0.125 (p = 0.006); vBMD (mg/cm³): total density β = 0.119 (p = 0.036), trabecular density β = 0.120 (p = 0.035), and cortical density β = 0.122 (p = 0.032). We conclude that the adherence to the MD was positively associated with better bone mass in Spanish premenopausal women.

Positive Association between Dietary Inflammatory Index and the Risk of Osteoporosis: Results from the KoGES_Health Examinee (HEXA) Cohort Study

Previous studies have found that diet’s inflammatory potential is related to various diseases. However, little is known about its relationship with osteoporosis. The aim of this study was to investigate the association between the dietary inflammatory index (DII^®) and osteoporosis risk in a large-scale prospective cohort study in Korea. This prospective cohort study included 159,846 participants (men 57,740; women 102,106) from South Korea with a mean follow-up of 7.9 years. The DII was calculated through a validated semi-quantitative FFQ (SQFFQ), and information on osteoporosis was self-reported by the participants. Analyses were performed by using a multivariable Cox proportional hazard model. Higher DII scores were associated with higher osteoporosis risk (HR 1.33; 95% CI 1.12–1.58). In women, a higher DII score indicated a higher risk of osteoporosis (HR 1.33; 95% CI 1.11–1.59). However, a hazards ratio of similar magnitude in men was not significant (HR 1.32; 95% CI 0.64–2.71). Post-menopausal women had higher risks of osteoporosis for higher DII scores (HR 1.33; 95% CI 1.09–1.63), whereas among pre-menopausal women, the relationship was not statistically significant (HR 1.39; 95% CI 0.87–2.21). Also, there was an increase in osteoporosis risk when the DII increased among women participants with irregular physical activity (HR 1.53; 95% CI 1.17–2.01); however, there was no statistically significant increase in osteoporosis risk among women participants with regular physical activity (HR 1.19; 95% CI 0.93–1.52). A more pro-inflammatory diet was significantly associated with higher osteoporosis risk in women. Given the similar magnitude of the hazards ratio, studies with sufficient numbers of men are warranted.

A Mediterranean-like dietary pattern with vitamin D3 (10 µg/d) supplements reduced the rate of bone loss in older Europeans with osteoporosis at baseline: results of a 1-y randomized controlled trial

Background

The Mediterranean diet (MD) is widely recommended for the prevention of chronic disease, but evidence for a beneficial effect on bone health is lacking.

Objective

The aim of this study was to examine the effect of a Mediterranean-like dietary pattern [NU-AGE (New Dietary Strategies Addressing the Specific Needs of the Elderly Population for Healthy Aging in Europe)] on indexes of inflammation with a number of secondary endpoints, including bone mineral density (BMD) and biomarkers of bone and collagen degradation in a 1-y multicenter randomized controlled trial (RCT; NU-AGE) in elderly Europeans.

Design

An RCT was undertaken across 5 European centers. Subjects in the intervention group consumed the NU-AGE diet for 1 y by receiving individually tailored dietary advice, coupled with supplies of foods including whole-grain pasta, olive oil, and a vitamin D3 supplement (10 µg/d). Participants in the control group were provided with leaflets on healthy eating available in their country.

Results

A total of 1294 participants (mean ± SD age: 70.9 ±4.0 y; 44% male) were recruited to the study and 1142 completed the 1-y trial. The Mediterranean-like dietary pattern had no effect on BMD (site-specific or whole-body); the inclusion of compliance to the intervention in the statistical model did not change the findings. There was also no effect of the intervention on the urinary biomarkers free pyridinoline or free deoxypyridinoline. Serum 25-hydroxyvitamin D significantly increased and parathyroid hormone decreased (P < 0.001) in the MD compared with the control group. Subgroup analysis of individuals with osteoporosis at baseline (site-specific BMD T-score ≤ -2.5 SDs) showed that the MD attenuated the expected decline in femoral neck BMD (n = 24 and 30 in MD and control groups, respectively; P = 0.04) but had no effect on lumbar spine or whole-body BMD.

Conclusions

A 1-y intervention of the Mediterranean-like diet together with vitamin D3 supplements (10 µg/d) had no effect on BMD in the normal age-related range, but it significantly reduced the rate of loss of bone at the femoral neck in individuals with osteoporosis. The NU-AGE trial is registered at clinicaltrials.gov as NCT01754012.

Depletion and repletion of fruit and vegetable intake alters serum bone turnover markers: a 28-week single-arm experimental feeding intervention

This study was designed to evaluate the effects of elevated fruit and vegetable intake on bone turnover markers. In all, twenty-nine subjects (nine male and twenty female, with a mean age of 32·1 (sem 2·5) years) participated in a 28-week single-arm experimental feeding intervention trial and consumed a prescribed low-fruit and vegetable diet for 6 weeks (depletion-1), a provided high-fruit and vegetable diet for 8 weeks (fruit: 360-560 g; vegetables: 450-705 g), another prescribed low-fruit and vegetable diet for 6 weeks (depletion-2) and then their usual diets for 8 weeks (repletion). Serum bone-related biomarkers were analysed with commercial ELISA kits. Plasma carotenoid levels decreased as a result of the depletion phase and increased with the high-fruit and vegetable diet. Compared with the baseline, depletion-1 resulted in higher serum bone resorption marker C-terminal telopeptide of type 1 collagen (CTX) and lower bone formation marker alkaline phosphatase (BAP) (CTX, 0·68 (sem 0·05) v. 0·97 (sem 0·08) ng/ml and BAP, 10·7 (sem 0·7) v. 9·5 (sem 0·8) µg/l for the baseline and the depletion-1, respectively, P<0·05). High intake of fruit and vegetables decreased serum CTX (P<0·05) to 0·60 (sem 0·04) ng/ml and increased serum BAP to 11·3 (sem 0·7) µg/l (P<0·05), compared with the depletion-1 phase. Serum concentrations of CTX were inversely correlated and those of BAP were positively correlated with blood lycopene. These data show that increased fruit and vegetable consumption at or above federal dietary guidance may be beneficial to bone health.

Mediterranean diet and hip fracture incidence among older adults: the CHANCES project

The association between adherence to Mediterranean diet (MD) and hip fracture incidence is not yet established. In a diverse population of elderly, increased adherence to MD was associated with lower hip fracture incidence. Except preventing major chronic diseases, adhering to MD might have additional benefits in lowering hip fracture risk.

INTRODUCTION

Hip fractures constitute a major public health problem among older adults. Latest evidence links adherence to Mediterranean diet (MD) with reduced hip fracture risk, but still more research is needed to elucidate this relationship. The potential association of adherence to MD with hip fracture incidence was explored among older adults.

METHODS

A total of 140,775 adults (116,176 women, 24,599 men) 60 years and older, from five cohorts from Europe and the USA, were followed-up for 1,896,219 person-years experiencing 5454 hip fractures. Diet was assessed at baseline by validated, cohort-specific, food-frequency questionnaires, and hip fractures were ascertained through patient registers or telephone interviews/questionnaires. Adherence to MD was evaluated by a scoring system on a 10-point scale modified to be applied also to non-Mediterranean populations. In order to evaluate the association between MD and hip fracture incidence, cohort-specific hazard ratios (HR), adjusted for potential confounders, were estimated using Cox proportional-hazards regression and pooled estimates were subsequently derived implementing random-effects meta-analysis.

RESULTS

A two-point increase in the score was associated with a significant 4% decrease in hip fracture risk (pooled adjusted HR 0.96; 95% confidence interval (95% CI) 0.92-0.99, p_{heterogeneity} = 0.446). In categorical analyses, hip fracture risk was lower among men and women with moderate (HR 0.93; 95% CI 0.87-0.99) and high (HR 0.94; 95% CI 0.87-1.01) adherence to the score compared with those with low adherence.

CONCLUSIONS

In this large sample of older adults from Europe and the USA, increased adherence to MD was associated with lower hip fracture incidence.

Association of dietary patterns of American adults with bone mineral density and fracture

OBJECTIVE

In a representative sample of US adults, we investigated the associations of nutrient patterns (NP) with bone mineral density (BMD) and fractures.

DESIGN

Cross-sectional.

SETTING

US community-based National Health and Nutrition Examination Survey (NHANES).

SUBJECTS

Participants with measured data on dietary intake and BMD from 2005 to 2010 were included. Principal components analysis was used to identify NP. BMD was measured using dual-energy X-ray absorptiometry. ANCOVA, adjusted logistic and linear regression models were employed, accounting for the complex survey design and sample weights.

RESULTS

We included a total of 18 318 participants, with 47·0 % (n 8607) being men. The mean age was 45·8 years with no sex difference. Three NP emerged, explaining 55·9 % of the variance in nutrient consumption. Multivariable-adjusted linear regressions revealed significant inverse associations between the 'high-energy' NP (rich in carbohydrates and sugar, total fat and saturated fat) and total femur, femoral neck, trochanter and intertrochanter BMD (β coefficient: -0·029, -0·025, -0·034 and -0·021, respectively, all P<0·001), while there were significant associations between the 'nutrient-dense' NP (rich in vitamins, minerals and fibre) and 'healthy fat' NP (high dietary PUFA and MUFA) and BMD at total femur, femoral neck, trochanter and intertrochanter (all P<0·001). In adjusted logistic regression models, the odds of hip, wrist or spine fractures did not vary significantly across NP quartiles.

CONCLUSIONS

Nutrient-dense and healthy fat NP are associated with higher BMD at various bone sites, while the high-energy NP is inversely associated with BMD measures.

Association between Diet Quality Scores and Risk of Hip Fracture in Postmenopausal Women and Men Aged 50 Years and Older

BACKGROUND

Although a number of studies showed a lower risk of hip fractures with high-quality diets, few of them were conducted in the United States.

OBJECTIVE

This prospective analysis examined the association between several diet quality indexes and risk of hip fractures in US men and women.

DESIGN

This is a prospective cohort study.

PARTICIPANTS/SETTING

The participants were 74,446 postmenopausal women from the Nurses' Health Study and 36,602 men aged 50 years and older from the Health Professionals Follow-Up Study in the United States.

MAIN OUTCOME MEASURE

Hip fractures were self-reported on biennial questionnaires between 1980-2012 in women, and between 1986-2012 in men.

STATISTICAL ANALYSIS

Diet was assessed every 4 years with a validated food frequency questionnaire. Relative risks were computed for hip fracture by quintiles of the Alternate Mediterranean Diet score (aMed), the Alternate Healthy Eating Index-2010 (AHEI-2010), and the Dietary Approaches to Stop Hypertension score using Cox proportional hazards models, adjusting for potential confounders.

RESULTS

Two thousand one hundred forty-three incident hip fractures in women and 603 in men were reported during follow-up. A significant inverse trend was observed with the cumulative AHEI-2010 score in women (relative risk comparing extreme quintiles 0.87, 95% CI 0.75 to 1.00; P for trend=0.02). There was also a suggestion of an inverse association with the Dietary Approaches to Stop Hypertension score (P for trend=0.03). In addition, significant inverse trends were observed between all three diet quality scores and hip fractures in women younger than age 75 years but not older women. There was no clear association between diet quality indexes and hip fracture in men.

CONCLUSIONS

Higher AHEI-2010 scores were associated with a lower risk of hip fractures in US women. The inverse associations with diet quality may be more apparent among those younger than age 75 years.

Relationship between the Mediterranean dietary pattern and musculoskeletal health in children, adolescents, and adults: systematic review and evidence map

Context: An understanding of the modifiable effects of diet on bone and skeletal muscle mass and strength over the life course will help inform strategies to reduce age-related fracture risk. The Mediterranean diet is rich in nutrients that may be important for optimal musculoskeletal health. Objective: The aim of this systematic review was to investigate the relationship between a Mediterranean diet and musculoskeletal outcomes (fracture, bone density, osteoporosis, sarcopenia) in any age group. Data Sources: Ten electronic databases were searched. Study Selection: Randomized controlled trials and prospective cohort studies that investigated a traditional Mediterranean diet, published in any language, were eligible. Studies using other designs or other definitions of the Mediterranean diet were collated separately in an evidence map. Data Extraction: Details on study design, methods, population, dietary intervention or exposure, length of follow-up, and effect on or association with musculoskeletal outcomes were extracted. Results: The search yielded 1738 references. Data from eligible randomized controlled trials (n = 0) and prospective cohort studies (n = 3) were synthesized narratively by outcome for the systematic review. Two of these studies reported on hip fracture incidence, but results were contradictory. A third study found no association between the Mediterranean diet and sarcopenia incidence. Conclusions: Overall, the systematic review and evidence map demonstrate a lack of research to understand the relationship between the Mediterranean diet and musculoskeletal health in all ages. Systematic Review Registration: PROSPERO registration number IDCRD42016037038.

Dairy product consumption and risk of hip fracture: a systematic review and meta-analysis

BACKGROUND

Dairy product consumption may affect the risk of hip fracture, but previous studies have reported inconsistent findings. The primary aim of our meta-analysis was to examine and quantify the potential association of dairy product consumption with risk of hip fracture.

METHODS

We searched the databases of PubMed and EMBASE for relevant articles from their inception through April 17, 2017. The final analysis included 10 cohort studies and 8 case-control studies. Random-effects models were used to estimate the pooled risk. Subgroup and dose-response analyses were conducted to explore the relationships between the consumption of milk and the risk of hip fracture.

RESULTS

After pooling the data from the included studies, the summary relative risk (RR) for hip fracture for highest versus lowest consumption were 0.91 (95% CI: 0.74-1.12), 0.75 (95% CI: 0.66-0.86), 0.68 (95% CI: 0.61-0. 77), 1.02 (95% CI: 0.93-1.12) for milk, yogurt, cheese, and total dairy products in cohort studies, respectively. Higher milk consumption [Odds ratio (OR), 0.71, 95% CI: 0.55-0. 91] was associated with lower risk of hip fracture for highest versus lowest consumption in case-control studies. After quantifying the specific dose of milk, the summary RR/OR for an increased milk consumption of 200 g/day was 1.00 (95% CI: 0.94-1.07), and 0.89 (95%CI: 0.64-1.24) with significant heterogeneity for cohort and case-control studies, respectively; There was a nonlinear association between milk consumption and hip fracture risk in cohort, and case-control studies.

CONCLUSIONS

Our findings indicate that consumption of yogurt and cheese was associated with lower risk of hip fracture in cohort studies. However, the consumption of total dairy products and cream was not significantly associated with the risk of hip fracture. There was insufficient evidence to deduce the association between milk consumption and risk of hip fracture. A lower threshold of 200 g/day milk intake may have beneficial effects, whereas the effects of a higher threshold of milk intake are unclear.

Pro-inflammatory dietary pattern is associated with fractures in women: an eight-year longitudinal cohort study

In this study, during 8 years of follow-up, we reported that higher dietary inflammatory index values were associated with a higher risk of incident fractures in women, but not in men, after adjusting for potential confounders.

INTRODUCTION

Inflammation is a key risk factor for many adverse outcomes in older people. While diet is a potential source of inflammation, little is known about the impact of inflammatory diet on fractures. Thus, we investigated whether higher Dietary Inflammatory Index (DII)™ ® scores are associated with fractures in a cohort of North American people.

METHODS

This longitudinal study with a follow-up of 8 years included 3648 participants (1577 males and 2071 females; mean age = 60.6 years) with/at risk of knee osteoarthritis participating with in the Osteoarthritis Initiative. DII scores were calculated using the validated Block Brief 2000 Food Frequency Questionnaire, categorized into sex-specific quintiles. Information on fractures was obtained through self-reported history of fractures at hip, spine, and forearm. The relationship between baseline DII score and incident fracture was assessed through a Cox's regression analysis, adjusted for potential baseline confounders, and reported as hazard ratios (HRs).

RESULTS

During 8 years of follow-up, 560 individuals developed fractures (15.4%). Adjusting for 10 potential confounders, women in the highest DII score quintile (i.e., most pro-inflammatory diet) had a significantly higher risk for fractures (HR = 1.46; 95% CI = 1.02-2.11) compared to women in the lowest quintile. An increase in one standard deviation of DII scores significantly predicted fracture onset in women (adjusted HR = 1.14; 95% CI = 1.02-1.27). The association between DII score and fractures was not significant among men or in the sample as whole.

CONCLUSION

Pro-inflammatory diet is associated with a higher incidence of fractures in women but not men.

Adherence to the Mediterranean Diet and the Risk of Frailty in Old People: A Systematic Review and Meta-Analysis

BACKGROUND

Frailty is a common geriatric syndrome in old people. It remains controversial whether Mediterranean diet could prevent old people from developing into frailty. The aim of this study is to summarize the relevant studies and assess the effectiveness of adherence to Mediterranean diet on frailty in old people.

METHOD

A systematic search of MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials was conducted to identify all relevant studies up to Oct 2017. We included studies regarding the associations between adherence to Mediterranean diet and risk of frailty among elders. A meta-analysis was performed to explore the effects of Mediterranean diet on frailty.

RESULTS

Six studies matched the inclusion criteria, of which five were prospective and one was cross-sectional. A total of 10,210 participants from the five prospective cohort studies were included to perform the meta-analyses. In comparison with lowest adherence to Mediterranean diet, elders with highest adherence to Mediterranean diet were significantly associated with lower risk of frailty in the future (RR= 0.56, 95% CI=0.36-0.89, p=0.015). Furthermore, the pooled estimates from four studies performed among participants in western countries (European and North American) showed that higher adherence to Mediterranean diet was associated with a 52% reduced risk of frailty (RR= 0.48, 95% CI=0.32-0.72, p<0.001). However, one study showed no association between Mediterranean diet and frailty among Asian elders (RR=1.06, 95% CI=0.83-1.36, p=0.638).

CONCLUSION

A higher adherence to Mediterranean diet is associated with a lower risk of frailty in old people. Meanwhile, the benefits may be more obvious among elders from western countries.

An application of partial least squares for identifying dietary patterns in bone health

In a large cohort of older women, a mechanism-driven statistical technique for assessing dietary patterns that considers a potential nutrient pathway found two dietary patterns associated with lumbar spine and femoral neck bone mineral density. A "healthy" dietary pattern was observed to be beneficial for bone mineral density.

INTRODUCTION

Dietary patterns represent a broader, more realistic representation of how foods are consumed, compared to individual food or nutrient analyses. Partial least-squares (PLS) is a data-reduction technique for identifying dietary patterns that maximizes correlation between foods and nutrients hypothesized to be on the path to disease, is more hypothesis-driven than previous methods, and has not been applied to the study of dietary patterns in relation to bone health.

METHODS

Women from the Aberdeen Prospective Osteoporosis Screening Study (2007-2011, n = 2129, age = 66 years (2.2)) provided dietary intake using a food frequency questionnaire; 37 food groups were created. We applied PLS to the 37 food groups and 9 chosen response variables (calcium, potassium, vitamin C, vitamin D, protein, alcohol, magnesium, phosphorus, zinc) to identify dietary patterns associated with bone mineral density (BMD) cross-sectionally. Multivariable regression was used to assess the relationship between the retained dietary patterns and BMD at the lumbar spine and femoral neck, adjusting for age, body mass index, physical activity level, smoking, and national deprivation category.

RESULTS

Five dietary patterns were identified, explaining 25% of the variation in food groups and 77% in the response variables. Two dietary patterns were positively associated with lumbar spine (per unit increase in factor 2: 0.012 g/cm2 [95% CI: 0.006, 0.01]; factor 4: 0.007 g/cm2 [95% CI: 0.00001, 0.01]) and femoral neck (factor 2: 0.006 g/cm2 [95% CI: 0.002, 0.01]; factor 4: 0.008 g/cm2 [95% CI: 0.003, 0.01)]) BMD. Dietary pattern 2 was characterized by high intakes of milk, vegetables, fruit and vegetable juices, and wine, and low intakes of processed meats, cheese, biscuits, cakes, puddings, confectionary, sweetened fizzy drinks and spirits while dietary pattern 4 was characterized by high intakes of fruits, red and white meats, and wine, and low intakes of vegetables and sweet spreads.

CONCLUSION

Our findings using a robust statistical technique provided important support to initiatives focusing on what constitutes a healthy diet and its implications.

Abdominal Obesity and Risk of Hip Fracture: A Systematic Review and Meta-Analysis of Prospective Studies

Data on the association between general obesity and hip fracture were summarized in a 2013 meta-analysis; however, to our knowledge, no study has examined the association between abdominal obesity and the risk of hip fracture. The present systematic review and meta-analysis of prospective studies was undertaken to summarize the association between abdominal obesity and the risk of hip fracture. We searched online databases for relevant publications up to February 2017, using relevant keywords. In total, 14 studies were included in the systematic review and 9 studies, with a total sample size of 295,674 individuals (129,964 men and 165,703 women), were included in the meta-analysis. Participants were apparently healthy and aged ≥40 y. We found that abdominal obesity (defined by various waist-hip ratios) was positively associated with the risk of hip fracture (combined RR: 1.24, 95% CI: 1.05, 1.46, P = 0.01). Combining 8 effect sizes from 6 studies, we noted a marginally significant positive association between abdominal obesity (defined by various waist circumferences) and the risk of hip fracture (combined RR: 1.36; 95% CI: 0.97, 1.89, P = 0.07). This association became significant in a fixed-effects model (combined effect size: 1.40, 95% CI: 1.25, 1.58, P < 0.001). Based on 5 effect sizes, we found that a 0.1-U increase in the waist-hip ratio was associated with a 16% increase in the risk of hip fracture (combined RR: 1.16, 95% CI: 1.04, 1.29, P = 0.007), whereas a 10-cm increase in waist circumference was not significantly associated with a higher risk of hip fracture (combined RR: 1.13, 95% CI: 0.94, 1.36, P = 0.19). This association became significant, however, when we applied a fixed-effects model (combined effect size: 1.21, 95% CI: 1.15, 1.27, P < 0.001). We found that abdominal obesity was associated with a higher risk of hip fracture in 295,674 individuals. Further studies are needed to test whether there are associations between abdominal obesity and fractures at other bone sites.

Adherence to Mediterranean diet in relation to bone mineral density and risk of fracture: a systematic review and meta-analysis of observational studies

PURPOSE

We aimed to systematically review available data on the association between adherence to MD and BMD as well as risk of fractures and to summarize this information through a meta-analysis.

METHODS

Previous studies in the field of adherence to MD in relation to BMD and risk of fracture were selected through searching PubMed, Scopus, ISI Web of Science and Google Scholar databases prior to June, 2016 using Mesh and non-Mesh relevant keywords.

RESULTS

In the meta-analysis of four effect sizes, obtained from three studies, we found that adherence to MD was associated with a 21% reduced risk of hip fracture (overall RR 0.79; 95% CIs 0.72-0.87). Adherence to MD was positively associated with lumber spine^'s (mean difference of BMD comparing highest and lowest categories of MD score 0.12; 95% CI 0.06-0.19 g/cm²), femoral neck (0.10; 0.06-0.15 g/cm²) and total hip (0.11; 0.09-0.14 g/cm²) BMD. Meta-regression of included observational studies revealed a significant inverse linear association between Mediterranean diet score and risk of hip fracture, such that one unit increase in the score of Mediterranean diet was associated with a reduction in the risk of hip fracture (RR 0.95, 95% CI 0.92-0.98 p = 0.01).

CONCLUSION

Adherence to MD was associated with a reduced risk of fracture as well as with a higher mean BMD.

Vegetable and Fruit Intake and Fracture-Related Hospitalisations: A Prospective Study of Older Women

The importance of vegetable and fruit intakes for the prevention of fracture in older women is not well understood. Few studies have explored vegetable and fruit intakes separately, or the associations of specific types of vegetables and fruits with fracture hospitalisations. The objective of this study was to examine the associations of vegetable and fruit intakes, separately, and specific types of vegetables and fruits with fracture-related hospitalisations in a prospective cohort of women aged ≥70 years. Vegetable and fruit intakes were assessed at baseline (1998) in 1468 women using a food frequency questionnaire. The incidence of fracture-related hospitalisations over 14.5 years of follow-up was determined using the Hospital Morbidity Data Collection, linked via the Western Australian Data Linkage System. Fractures were identified in 415 (28.3%) women, of which 158 (10.8%) were hip fractures. Higher intakes of vegetables, but not fruits, were associated with lower fracture incidence. In multivariable-adjusted models for vegetable types, cruciferous and allium vegetables were inversely associated with all fractures, with a hazard ratio (HR) (95% confidence interval) of 0.72 (0.54, 0.95) and 0.66 (0.49, 0.88), respectively, for the highest vs. lowest quartiles. Increasing vegetable intake, with an emphasis on cruciferous and allium vegetables, may prevent fractures in older postmenopausal women.

Associations of lower vitamin D concentrations with cognitive decline and long-term risk of dementia and Alzheimer's disease in older adults

INTRODUCTION

Hypovitaminosis D has been associated with several chronic conditions; yet, its association with cognitive decline and the risk of dementia and Alzheimer's disease (AD) has been inconsistent.

METHODS

The study population consisted of 916 participants from the Three-City Bordeaux cohort aged 65+, nondemented at baseline, with assessment of vitamin D status and who were followed for up to 12 years.

RESULTS

In multivariate analysis, compared with individuals with 25(OH)D sufficiency (n = 151), participants with 25(OH)D deficiency (n = 218) exhibited a faster cognitive decline. A total of 177 dementia cases (124 AD) occurred: 25(OH)D deficiency was associated with a nearly three-fold increased risk of AD (hazard ratio = 2.85, 95% confidence interval 1.37-5.97).

DISCUSSION

This large prospective study of French older adults suggests that maintaining adequate vitamin D status in older age could contribute to slow down cognitive decline and to delay or prevent the onset of dementia, especially of AD etiology.

Adherence to a Mediterranean-style diet and incident fractures: pooled analysis of observational evidence

Purpose

The Mediterranean diet is associated with decreased morbidity and mortality from various chronic diseases. Adherence to a Mediterranean-style diet has been suggested to have protective effects on bone health and decreases the incidence of bone fractures, but the evidence is not clear. We conducted a systematic review and meta-analysis of available observational studies to quantify the association between adherence to a Mediterranean-style diet, as assessed by the Mediterranean Diet Score (MDS), and the risk of fractures in the general population.

Methods

Relevant studies were identified in a literature search of MEDLINE, EMBASE, Web of Science, and reference lists of relevant studies to October 2016. Relative risks (RRS) with 95% confidence intervals (CIs) were aggregated using random-effects models.

Results

Five observational studies with data on 353,076 non-overlapping participants and 33,576 total fractures (including 6,881 hip fractures) were included. The pooled fully adjusted RR (95% CI) for hip fractures per 2-point increment in adherence to the MDS was 0.82 (0.71–0.96). Adherence to the MDS was not associated with the risk of any or total fractures based on pooled analysis of only two studies.

Conclusion

Limited observational evidence supports a beneficial effect of adherence to a Mediterranean-style diet on the incidence of hip fractures. Well-designed intervention studies are needed to elucidate the relationship between adherence to a Mediterranean-style diet and the risk of adverse bone health outcomes such as fractures.

Extra virgin olive oil consumption reduces the risk of osteoporotic fractures in the PREDIMED trial

BACKGROUND & AIMS

The incidence of osteoporotic fractures is lower in countries in the Mediterranean basin. Virgin olive oil, a key component of the Mediterranean Diet (MDiet), with recognised beneficial effects on metabolism and cardiovascular health, may decrease the risk of osteoporotic fractures. The aim to this study was to explore the effect of chronic consumption of total olive oil and its varieties on the risk of osteoporosis-related fractures in a middle-aged and elderly Mediterranean population.

METHODS

We included all participants (n = 870) recruited in the Reus (Spain) centre of the PREvención con DIeta MEDiterránea (PREDIMED) trial. Individuals, aged 55-80 years at high cardiovascular risk, were randomized to a MedDiet supplemented with extra-virgin olive oil, a MedDiet supplemented with nuts, or a low-fat diet. The present analysis was an observational cohort study nested in the trial. A validated food frequency questionnaire was used to assess dietary habits and olive oil consumption. Information on total osteoporotic fractures was obtained from a systematic review of medical records. The association between yearly repeated measurements of olive oil consumption and fracture risk was assessed by multivariate Cox proportional hazards.

RESULTS

We documented 114 incident cases of osteoporosis-related fractures during a median follow-up of 8.9 years. Treatment allocation had no effect on fracture risk. Participants in the highest tertile of extra-virgin olive oil consumption had a 51% lower risk of fractures (HR:0.49; 95% CI:0.29-0.81. P for trend = 0.004) compared to those in the lowest tertile after adjusting for potential confounders. Total and common olive oil consumption was not associated with fracture risk.

CONCLUSIONS

Higher consumption of extra-virgin olive oil is associated with a lower risk of osteoporosis-related fractures in middle-aged and elderly Mediterranean population at high cardiovascular risk.

Current Evidence on the Association of Dietary Patterns and Bone Health: A Scoping Review

Nutrition is an important modifiable factor that affects bone health. Diet is a complex mixture of nutrients and foods that correlate or interact with each other. Dietary pattern approaches take into account contributions from various aspects of diet. Findings from dietary pattern studies could complement those from single-nutrient and food studies on bone health. In this study we aimed to conduct a scoping review of the literature that assessed the impact of dietary patterns (derived with the use of both a priori and data-driven approaches) on bone outcomes, including bone mineral status, bone biomarkers, osteoporosis, and fracture risk. We retrieved 49 human studies up to June 2016 from the PubMed, Embase, and CINAHL databases. Most of these studies used a data-driven method, especially factor analysis, to derive dietary patterns. Several studies examined adherence to a variety of the a priori dietary indexes, including the Mediterranean diet score, the Healthy Eating Index (HEI), and the Alternative Healthy Eating Index (AHEI). The bone mineral density (BMD) diet score was developed to measure adherence to a dietary pattern beneficial to bone mineral density. Findings revealed a beneficial impact of higher adherence to a "healthy" dietary pattern derived using a data-driven method, the Mediterranean diet, HEI, AHEI, Dietary Diversity Score, Diet Quality Index-International, BMD Diet Score, Healthy Diet Indicator, and Korean Diet Score, on bone. In contrast, the "Western" dietary pattern and those featuring some aspects of an unhealthy diet were associated inversely with bone health. In both a priori and data-driven dietary pattern studies, a dietary pattern that emphasized the intake of fruit, vegetables, whole grains, poultry and fish, nuts and legumes, and low-fat dairy products and de-emphasized the intake of soft drinks, fried foods, meat and processed products, sweets and desserts, and refined grains showed a beneficial impact on bone health. Overall, adherence to a healthy dietary pattern consisting of the above-mentioned food groups can improve bone mineral status and decrease osteoporosis and fracture risk.