1
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Smit A, Meijer O, Winter E. The multi-faceted nature of age-associated osteoporosis. Bone Rep 2024; 20:101750. [PMID: 38566930 PMCID: PMC10985042 DOI: 10.1016/j.bonr.2024.101750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
Age-associated osteoporosis (AAOP) poses a significant health burden, characterized by increased fracture risk due to declining bone mass and strength. Effective prevention and early treatment strategies are crucial to mitigate the disease burden and the associated healthcare costs. Current therapeutic approaches effectively target the individual contributing factors to AAOP. Nonetheless, the management of AAOP is complicated by the multitude of variables that affect its development. Main intrinsic and extrinsic factors contributing to AAOP risk are reviewed here, including mechanical unloading, nutrient deficiency, hormonal disbalance, disrupted metabolism, cognitive decline, inflammation and circadian disruption. Furthermore, it is discussed how these can be targeted for prevention and treatment. Although valuable as individual targets for intervention, the interconnectedness of these risk factors result in a unique etiology for every patient. Acknowledgement of the multifaceted nature of AAOP will enable the development of more effective and sustainable management strategies, based on a holistic, patient-centered approach.
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Affiliation(s)
- A.E. Smit
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden, the Netherlands
| | - O.C. Meijer
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden, the Netherlands
| | - E.M. Winter
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden, the Netherlands
- Department of Medicine, Center for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands
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2
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Storz MA, Ronco AL. Dietary acid load decreases with age and is associated with sagittal abdominal diameter: a nationally representative quantification study in US adults. Aging Clin Exp Res 2023; 35:2191-2200. [PMID: 37516720 PMCID: PMC10519865 DOI: 10.1007/s40520-023-02508-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/12/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Dietary acid load (DAL) has been associated with frailty and hip fractures in older adults, who often have a reduced kidney function and thus compromised buffering capacities. Studies to quantify DAL in older adults are scarce and controversies persist as to whether DAL in- or decreases with age. AIM To enhance the understanding of DAL in older individuals, we examined its relationship with increasing age and selected anthropometric data in a well-characterized sample of US adults. METHODS Secondary data analysis of nationally representative data from the National Health and Nutrition Examination Surveys data (NHANES 2011-2016). The sample included n = 3018 adults aged 60+, which may be extrapolated to represent n = 45,113,471 Americans. DAL was estimated using 4 formulas, including Potential Renal Acid Load (PRAL) and Net Endogenous Acid Production (NEAP). RESULTS All employed DAL scores tended to decline with increasing age. Participants aged 80 years or older yielded the lowest DAL scores. The average US citizen aged 60+ consumed an acidifying diet, yet there were sex-specific differences in the adjusted means for some scores. NEAP was positively correlated with both body mass index (r = 0.26, p < 0.001) and the sagittal abdominal diameter (r = 0.31, p < 0.001) in this nationally representative sample. CONCLUSION The previously reported phenomenon of increasing DAL values in older people in non-Western countries may not apply to the US. Our findings may constitute an important step towards a better understanding of DAL in older US adults, and highlight the need for additional population-specific research in the field.
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Affiliation(s)
- Maximilian Andreas Storz
- Department of Internal Medicine II, Centre for Complementary Medicine, Freiburg University Hospital Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Alvaro Luis Ronco
- Unit of Oncology and Radiotherapy, Pereira Rossell Women's Hospital, Montevideo, Uruguay
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3
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Sakr H, Khired Z, Moghadas M. In Rats, Whole and Refined Grains Decrease Bone Mineral Density and Content through Modulating Osteoprotegerin and Receptor Activator of Nuclear Factor Kappa B. Biomedicines 2023; 11:1686. [PMID: 37371781 DOI: 10.3390/biomedicines11061686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Wheat is a staple grain in most parts of the world and is also frequently used in livestock feed. The current study looked at the impact of a wheat grain diet on bone turnover markers. Thirty male rats (n = 10) were separated into three groups of ten. The rats in Group 1 were fed a chow diet, while the rats in Group 2 were provided whole grains. The rats in Group 3 were fed refined grains. Each rat's bone mineral content (BMC) and bone mineral density (BMD) were measured after 12 weeks in the tibia of the right hind limb. We also looked at the amounts of bone turnover indicators in the blood. TRAP-5b (Tartrate-resistant acid Phosphatase 5b), NTx (N-telopeptide of type I collagen), DPD (deoxypyridinoline), alkaline phosphatase (ALP), and osteocalcin (OC), as well as the levels of Receptor Activator of Nuclear Factor Kappa B (RANK) and osteoprotegerin (OPG). Rats fed whole and refined grains showed lower BMC and BMD (p < 0.05) than the control group rats. The grain diet resulted in lower OPG, OC, and ALP levels than the chow-fed rats, as well as significantly higher (p < 0.05) levels of RANK, DPD, TRAB 5b, and NTx. In a rat model, an exclusive whole or refined grain diet lowered bone turnover and mass.
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Affiliation(s)
- Hussein Sakr
- Department of Physiology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat 123, Oman
| | - Zenat Khired
- Surgical Department, Jazan University, Jazan 45142, Saudi Arabia
| | - Marzieh Moghadas
- Department of Physiology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat 123, Oman
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4
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Moe OW, Maalouf NM, Sakhaee K, Lederer E. Preclinical and Clinical Evidence of Effect of Acid on Bone Health. Adv Chronic Kidney Dis 2022; 29:381-394. [PMID: 36175076 DOI: 10.1053/j.ackd.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Acid can have ill effect on bone health in the absence of frank clinical acidosis but affecting the bone mioneral matrix and bone cells via complex pathways botyh ascute;y and chronically. While the reaction of bone to an acid load is conserved in evolution and is adaptive, the capacity can be overwhelmed resulting in dire consequences. The preclinical an clincl evidence of the acdi effect on bone is very convincing and the clinical evidence in both association and interventiopn studies are also quite credible, The adverse effects of acid on bone is underappreoicated, under-investigated, and the potential benefits of alkali therapy is not generrally known.
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Affiliation(s)
- Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX; Department of Physiology, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Naim M Maalouf
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Khashayar Sakhaee
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Eleanor Lederer
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX; Medical Service, VA North Texas Health Care System, Dallas, TX
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5
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Ling CW, Miao Z, Xiao ML, Zhou H, Jiang Z, Fu Y, Xiong F, Zuo LSY, Liu YP, Wu YY, Jing LP, Dong HL, Chen GD, Ding D, Wang C, Zeng FF, Zhu HL, He Y, Zheng JS, Chen YM. The Association of Gut Microbiota With Osteoporosis Is Mediated by Amino Acid Metabolism: Multiomics in a Large Cohort. J Clin Endocrinol Metab 2021; 106:e3852-e3864. [PMID: 34214160 DOI: 10.1210/clinem/dgab492] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Indexed: 01/15/2023]
Abstract
CONTEXT Several small studies have suggested that the gut microbiome might influence osteoporosis, but there is little evidence from human metabolomics studies to explain this association. OBJECTIVE This study examined the association of gut microbiome dysbiosis with osteoporosis and explored the potential pathways through which this association occurs using fecal and serum metabolomics. METHODS We analyzed the composition of the gut microbiota by 16S rRNA profiling and bone mineral density using dual-energy X-ray absorptiometry in 1776 community-based adults. Targeted metabolomics in feces (15 categories) and serum (12 categories) were further analyzed in 971 participants using ultra-high-performance liquid chromatography coupled to tandem mass spectrometry. RESULTS This study showed that osteoporosis was related to the beta diversity, taxonomy, and functional composition of the gut microbiota. The relative abundance of Actinobacillus, Blautia, Oscillospira, Bacteroides, and Phascolarctobacterium was positively associated with osteoporosis. However, Veillonellaceae other, Collinsella, and Ruminococcaceae other were inversely associated with the presence of osteoporosis. The association between microbiota biomarkers and osteoporosis was related to levels of peptidases and transcription machinery in microbial function. Fecal and serum metabolomics analyses suggested that tyrosine and tryptophan metabolism and valine, leucine, and isoleucine degradation were significantly linked to the identified microbiota biomarkers and to osteoporosis, respectively. CONCLUSION This large population-based study provided robust evidence connecting gut dysbiosis, fecal metabolomics, and serum metabolomics with osteoporosis. Our results suggest that gut dysbiosis and amino acid metabolism could be targets for intervention in osteoporosis.
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Affiliation(s)
- Chu-Wen Ling
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Zelei Miao
- Zhejiang Provincial Laboratory of Life Sciences and Biomedicine, Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, China
| | - Mian-Li Xiao
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Hongwei Zhou
- Microbiome Medicine Center, Division of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- State Key Laboratory of Organ Failure Research, Southern Medical University, Guangzhou, China
| | - Zengliang Jiang
- Zhejiang Provincial Laboratory of Life Sciences and Biomedicine, Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, China
- Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Hangzhou, China
| | - Yuanqing Fu
- Zhejiang Provincial Laboratory of Life Sciences and Biomedicine, Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, China
- Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Hangzhou, China
| | - Feng Xiong
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Luo-Shi-Yuan Zuo
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Yu-Ping Liu
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Yan-Yan Wu
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Li-Peng Jing
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Hong-Li Dong
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Geng-Dong Chen
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Ding Ding
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Cheng Wang
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Fang-Fang Zeng
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Hui-Lian Zhu
- Department of Nutrition, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Yan He
- Microbiome Medicine Center, Division of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ju-Sheng Zheng
- Zhejiang Provincial Laboratory of Life Sciences and Biomedicine, Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou, China
- Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Hangzhou, China
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Yu-Ming Chen
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health; Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
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Akhavan Zanjani M, Rahmani S, Mehranfar S, Zarrin M, Bazyar H, Moradi Poodeh B, Zare Javid A, Hosseini SA, Sadeghian M. Soy Foods and the Risk of Fracture: A Systematic Review of Prospective Cohort Studies. Complement Med Res 2021; 29:172-181. [PMID: 34547749 DOI: 10.1159/000519036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 08/16/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The primary objective of our study was to systematically review all available prospective cohort studies which investigated the association of soy food intake and incident fracture risk. METHODS We searched PubMed, Scopus, and Embase databases for relevant studies up to June 2021. SYNTHESIS Of 695 records, a total of 5 cohort studies were included in the current systematic review. Two studies that were performed in China evaluated hip fracture while 2 studies that were done in Singapore evaluated any kind of fractures. The other study was conducted in Japan and evaluated osteoporosis fractures. All studies used a face-to-face interview to assess the dietary intake of soy foods. All 5 cohort studies were determined to be of high quality. One study considered soy food as a part of a vegetables-fruit-soy food dietary pattern. Others reported the association of dietary intake of soy foods with the risk of fractures. CONCLUSION The evidence from prospective cohort studies was suggestive for a protective role of soy foods, alone or within a dietary pattern, in the risk of incident fracture among Asian women, particularly for those in early menopause and those who used fermented soy products. But for men, the association was not significant. However, more cohort studies, including non-Asian populations, are required to confirm this association fully.
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Affiliation(s)
- Mohsen Akhavan Zanjani
- Division of Kinesiology, School of Health and Human Performance, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sepideh Rahmani
- Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sanaz Mehranfar
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, University of Medical Sciences, Tehran, Iran
| | - Milad Zarrin
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hadi Bazyar
- Nutrition and Metabolic Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Department of Nutrition, School of Allied Medical Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Bahman Moradi Poodeh
- Department of Laboratory, Lahijan Branch, Islamic Azad University, Lahijan, Iran
| | - Ahmad Zare Javid
- Nutrition and Metabolic Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Department of Nutrition, School of Allied Medical Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Seyed Ahmad Hosseini
- Nutrition and Metabolic Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Department of Nutrition, School of Allied Medical Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mehdi Sadeghian
- Nutrition and Metabolic Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Department of Nutrition, School of Allied Medical Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Shefa Neuroscience Research Center, Khatam Alanbia Hospital, Tehran, Iran
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7
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Mitchell A, Fall T, Melhus H, Wolk A, Michaëlsson K, Byberg L. Is the effect of Mediterranean diet on hip fracture mediated through type 2 diabetes mellitus and body mass index? Int J Epidemiol 2021; 50:234-244. [PMID: 33367703 PMCID: PMC7938512 DOI: 10.1093/ije/dyaa239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND We examined whether the inverse association between adherence to a Mediterranean diet and hip fracture risk is mediated by incident type 2 diabetes mellitus (T2DM) and body mass index (BMI). METHODS We included 50 755 men and women from the Cohort of Swedish Men and the Swedish Mammography Cohort who answered lifestyle and medical questionnaires in 1997 and 2008 (used for calculation of the Mediterranean diet score 9mMED; low, medium, high) and BMI in 1997, and incident T2DM in 1997-2008). The cumulative incidence of hip fracture from the National Patient Register (2009-14) was considered as outcome. RESULTS We present conditional odds ratios (OR) 9[95% confidence interval, CI) of hip fracture for medium and high adherence to mMED, compared with low adherence. The total effect ORs were 0.82 (0.71, 0.95) and 0.75 (0.62, 0.91), respectively. The controlled direct effect of mMED on hip fracture (not mediated by T2DM, considering BMI as an exposure-induced confounder), calculated using inverse probability weighting of marginal structural models, rendered ORs of 0.82 (0.72, 0.95) and 0.73 (0.60, 0.88), respectively. The natural direct effect ORs (not mediated by BMI or T2DM, calculated using flexible mediation analysis) were 0.82 (0.71, 0.95) and 0.74(0.61, 0.89), respectively. The path-specific indirect and partial indirect natural effects ORs (through BMI or T2DM) were close to 1. CONCLUSIONS Mediterranean diet has a direct effect on hip fracture risk via pathways other than through T2DM and BMI. We cannot exclude mediating effects of T2DM or BMI, or that their effects cancel each other out.
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Affiliation(s)
- Adam Mitchell
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Tove Fall
- Department of Medical Sciences, Molecular Epidemiology, Uppsala University, Uppsala, Sweden
| | - Håkan Melhus
- Department of Medical Sciences, Clinical Pharmacogenomics and Osteoporosis, Uppsala University, Uppsala, Sweden
| | - Alicja Wolk
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
- Institute of Environmental Medicine, Cardiovascular and Nutritional Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Karl Michaëlsson
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Liisa Byberg
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
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8
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Weaver CM. Plant Protein Meal Patterns May Compromise Bone Health. J Nutr 2021; 151:7-8. [PMID: 33244590 DOI: 10.1093/jn/nxaa346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 09/23/2020] [Accepted: 10/08/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Connie M Weaver
- Purdue University, West Lafayette, IN, USA.,Weaver and Associates Consulting, LLC, Colorado Springs, CO, USA
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9
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Yamamoto K, Kugimiya W, Maeda H, Yano H, Kusumoto KI, Nabetani H. Trends in Plant-Based Substitutes for Animal Proteins. J JPN SOC FOOD SCI 2020. [DOI: 10.3136/nskkk.67.459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Kazutaka Yamamoto
- Food Research Institute, National Agriculture and Food Research Organization
| | | | | | - Hiroyuki Yano
- Food Research Institute, National Agriculture and Food Research Organization
| | - Ken-Ichi Kusumoto
- Food Research Institute, National Agriculture and Food Research Organization
| | - Hiroshi Nabetani
- Food Research Institute, National Agriculture and Food Research Organization
- Faculty of Home Economics, Tokyo Kasei University
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10
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Abstract
The present paper reviews published literature on the relationship between dietary protein and bone health. It will include arguments both for and against the anabolic and catabolic effects of dietary protein on bone health. Adequate protein intake provides the amino acids used in building and maintaining bone tissue, as well as stimulating the action of insulin-like growth factor 1, which in turn promotes bone growth and increases calcium absorption. However, the metabolism of dietary sulphur amino acids, mainly from animal protein, can lead to increased physiological acidity, which may be detrimental for bone health in the long term. Similarly, cereal foods contain dietary phytate, which in turn contains phosphate. It is known that phosphate consumption can also lead to increased physiological acidity. Therefore, cereal products may produce as much acid as do animal proteins that contain sulphur amino acids. The overall effect of dietary protein on physiological acidity, and its consequent impact on bone health, is extremely complex and somewhat controversial. The consensus is now moving towards a synthesised approach. Particularly, how anabolic and catabolic mechanisms interact; as well as how the context of the whole diet and the type of protein consumed is important.
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11
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The Effect of Self-Reported Lactose Intolerance and Dairy Consumption on Bone Mineral Density Among American Hip Arthroplasty Patients: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17197182. [PMID: 33008062 PMCID: PMC7579615 DOI: 10.3390/ijerph17197182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/20/2020] [Accepted: 09/29/2020] [Indexed: 11/17/2022]
Abstract
The relationship between osteoporosis and lactose intolerance is unclear. This study aims to evaluate the association between self-reported lactose intolerance and symptom severity caused by lactose malabsorption and bone mineral density (BMD). A total of 496 American hip arthroplasty patients took part in this study. Information on BMD and socio-demographic factors were retrospectively extracted from medical records. BMD of the lumbar spine (LS), femoral neck of the operative hip (FNOH), and femoral neck of the non-operative hip (FNH) were measured via dual-energy x-ray absorptiometry scans (DXA). Patients also completed a survey regarding dietary and lifestyle habits from the time of surgery. We found that 9.3% of participants reported lactose intolerance and 33.3%% suffered from either osteopenia or osteoporosis in at least one (location). The population that did not self-identify as lactose intolerant consumed significantly more dairy (p < 0.0001) and animal protein (p = 0.004) than those with intolerance. There was no significant difference in BMD between self-identified lactose intolerant individuals and non-lactose intolerant individuals. In a stepwise multiple regression analysis, body mass index (BMI) and age were the only common predictors of BMD for all locations (p < 0.05). However, yogurt intake was a significant predictor of BMD of FNOH in the multivariate analysis. This study suggests that lactose intolerance is not associated with bone mineral density. We also found that being vegan or vegetarian may increase the risk of low BMD.
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12
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De Vincentis A, Behr AU, Bellelli G, Bravi M, Castaldo A, Cricelli C, Galluzzo L, Iolascon G, Maggi S, Martini E, Momoli A, Onder G, Paoletta M, Roselli M, Ruggeri M, Santacaterina F, Tritapepe L, Zurlo A, Antonelli Incalzi R. Management of hip fracture in the older people: rationale and design of the Italian consensus on the orthogeriatric co-management. Aging Clin Exp Res 2020; 32:1393-1399. [PMID: 32358728 DOI: 10.1007/s40520-020-01574-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hip fracture (HF) is a burdening health problem in older people. The orthogeriatric approach has been shown to favour functional recovery and reduce mortality, but its implementation in clinical practice cannot rely upon shared management protocols and greatly varies among different healthcare systems. Here, we present the rationale and design of the Italian consensus document on the management of HF in older people. METHODS A panel of multidisciplinary experts from ten Italian scientific societies involved in the care of HF and including geriatricians, orthopaedics, anaesthesiologists, physiatrists and general practitioners, will join to establish the content validity of a list of statements. A Delphi consensus methodology will be applied to obtain the opinions of the panel and to provide the final recommendations. OBJECTIVES The document will include indications on the following relevant topics: (1) optimal care path of older subjects with HF; (2) management of comorbidities and pre-operative alteration of physiological parameters; (3) management of selected categories of patients at expected increased risk of adverse outcomes; (4) continuity of care out of hospital; (5) screening and correction of risk factors for HF in older subjects; (6) information and divulgation of shared management strategies. The objective of the consensus will be to inform clinicians, patients, researchers, and health policy makers about the best management strategies for HF in older people and their inherent limitations, thus facilitating communication between stakeholders and promoting the most cost/effective models of care.
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Affiliation(s)
- Antonio De Vincentis
- Geriatric and Gerontology Department, Campus Bio-Medico University of Rome, via Alvaro del Portillo, 200, 00128, Rome, Italy.
| | - Astrid Ursula Behr
- Operative Unit of Anesthesia and Resuscitation, Hospital of Camposampiero, Padua, Italy
| | - Giuseppe Bellelli
- Acute Geriatric and Orthogeriatric Unit, S. Gerardo Hospital, Monza, Italy
- Milano-Bicocca University, Milan, Italy
| | - Marco Bravi
- Physical and Rehabilitation Medicine Department, Campus Bio-Medico University of Rome, Rome, Italy
| | | | | | - Lucia Galluzzo
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Ageing, Istituto Superiore di Sanità, Rome, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Emilio Martini
- Orthogeriatric Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile Di Baggiovara, Modena, Italy
| | - Alberto Momoli
- Orthopedic and Traumatology Unit, San Bortolo Hospital, Vicenza, Italy
| | - Graziano Onder
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Ageing, Istituto Superiore di Sanità, Rome, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mauro Roselli
- Orthopedic and Traumatology Unit, "Maria Vittoria" Hospital, Torino, Italy
| | - Mauro Ruggeri
- Società Italiana Di Medicina Generale (SIMG), Firenze, Italy
| | - Fabio Santacaterina
- Physical and Rehabilitation Medicine Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Luigi Tritapepe
- Operative Unit of Anesthesia and Intensive Care Medicine, San Camillo-Forlanini Hospital, Rome, Italy
| | - Amedeo Zurlo
- Geriatric and Orthogeriatric Unit, Arcispedale S. Anna, University of Ferrara, Ferrara, Italy
| | - Raffaele Antonelli Incalzi
- Geriatric and Gerontology Department, Campus Bio-Medico University of Rome, via Alvaro del Portillo, 200, 00128, Rome, Italy
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Darling AL, Manders RJF, Sahni S, Zhu K, Hewitt CE, Prince RL, Millward DJ, Lanham-New SA. Dietary protein and bone health across the life-course: an updated systematic review and meta-analysis over 40 years. Osteoporos Int 2019; 30:741-761. [PMID: 30903209 DOI: 10.1007/s00198-019-04933-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 03/04/2019] [Indexed: 12/31/2022]
Abstract
We undertook a systematic review and meta-analysis of published papers assessing dietary protein and bone health. We found little benefit of increasing protein intake for bone health in healthy adults but no indication of any detrimental effect, at least within the protein intakes of the populations studied. This systematic review and meta-analysis analysed the relationship between dietary protein and bone health across the life-course. The PubMed database was searched for all relevant human studies from the 1st January 1976 to 22nd January 2016, including all bone outcomes except calcium metabolism. The searches identified 127 papers for inclusion, including 74 correlational studies, 23 fracture or osteoporosis risk studies and 30 supplementation trials. Protein intake accounted for 0-4% of areal BMC and areal BMD variance in adults and 0-14% of areal BMC variance in children and adolescents. However, when confounder adjusted (5 studies) adult lumbar spine and femoral neck BMD associations were not statistically significant. There was no association between protein intake and relative risk (RR) of osteoporotic fractures for total (RR(random) = 0.94; 0.72 to 1.23, I2 = 32%), animal (RR (random) = 0.98; 0.76 to 1.27, I2 = 46%) or vegetable protein (RR (fixed) = 0.97 (0.89 to 1.09, I2 = 15%). In total protein supplementation studies, pooled effect sizes were not statistically significant for LSBMD (total n = 255, MD(fixed) = 0.04 g/cm2 (0.00 to 0.08, P = 0.07), I2 = 0%) or FNBMD (total n = 435, MD(random) = 0.01 g/cm2 (-0.03 to 0.05, P = 0.59), I2 = 68%). There appears to be little benefit of increasing protein intake for bone health in healthy adults but there is also clearly no indication of any detrimental effect, at least within the protein intakes of the populations studied (around 0.8-1.3 g/Kg/day). More studies are urgently required on the association between protein intake and bone health in children and adolescents.
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Affiliation(s)
- A L Darling
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK.
| | - R J F Manders
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK
| | - S Sahni
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre St, Boston, MA, 02131, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - K Zhu
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - C E Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - R L Prince
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - D J Millward
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK
| | - S A Lanham-New
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK
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Schopen K, Ewald AC, Johannes BW, Bloch W, Rittweger J, Frings-Meuthen P. Short-Term Effects of Lupin vs. Whey Supplementation on Glucose and Insulin Responses to a Standardized Meal in a Randomized Cross-Over Trial. Front Physiol 2017; 8:198. [PMID: 28443026 PMCID: PMC5385353 DOI: 10.3389/fphys.2017.00198] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 03/16/2017] [Indexed: 01/26/2023] Open
Abstract
Background: Whey protein is known to reduce postprandial glycaemia in people with type 2 diabetes mellitus. Lupin as a vegetable source of protein could be considered as an alternative, as the percentage of vegetarian and vegan consumers is raising. The present study compares the acute glycemic effects of whey and lupin in healthy volunteers following a carbohydrate-rich reference meal. Methods In cross-over design, three standardized meals (reference meal; reference meal + whey; reference meal + lupin) were provided to 12 healthy male and female volunteers, aged between 23 and 33, in a balanced, randomized order. Volunteers' blood glucose and insulin concentrations were analyzed at baseline and at seven time points following the ingestion of the meals. Results: The supplementation of whey or lupin significantly blunted the postprandial increase in blood glucose concentrations compared to the reference meal (p < 0.001). In the overall statistical analysis, this effect was comparable for whey and lupin [Δ AUC whey-lupin = 8%, 0-60 min area under the curve (0-60 min AUC), p = 0.937], with a blunting effect of -46% by whey (p = 0.005, 0-60 min AUC) and of -54% by lupin (p < 0.001, 0-60 min AUC). When comparing whey and lupin data only, the insulin increase was found to be more pronounced for whey protein than for lupin supplementation (Δ AUC whey-lupin = 39%, 0-60 min AUC, p = 0.022). However, when comparing the insulin response of each supplementation to the one of the reference meal, no differences could be detected (whey p = 0.259, 0-60 min AUC; lupin p = 0.275, 0-60 min AUC). Conclusions: Results suggest that lupin and whey can both lower the increase of postprandial blood glucose concentrations to a comparable extent, implying the usability of lupin to reduce postprandial glycaemia. However, the insulin response following the supplementations to a carbohydrate-rich meal seems to differ for these two protein sources.
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Affiliation(s)
- Kathrin Schopen
- Department of Space Physiology, Institute of Aerospace Medicine, German Aerospace CenterCologne, Germany.,Department of Molecular and Cellular Sport Medicine, Institute of Cardiovascular Research and Sport Medicine, German Sport University CologneCologne, Germany
| | - Ann C Ewald
- Department of Space Physiology, Institute of Aerospace Medicine, German Aerospace CenterCologne, Germany
| | - Bernd W Johannes
- Department of Space Physiology, Institute of Aerospace Medicine, German Aerospace CenterCologne, Germany
| | - Wilhelm Bloch
- Department of Molecular and Cellular Sport Medicine, Institute of Cardiovascular Research and Sport Medicine, German Sport University CologneCologne, Germany
| | - Jörn Rittweger
- Department of Space Physiology, Institute of Aerospace Medicine, German Aerospace CenterCologne, Germany.,Department of Pediatrics and Adolescent Medicine, University of CologneCologne, Germany
| | - Petra Frings-Meuthen
- Department of Space Physiology, Institute of Aerospace Medicine, German Aerospace CenterCologne, Germany
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Bonjour JP. The dietary protein, IGF-I, skeletal health axis. Horm Mol Biol Clin Investig 2017; 28:39-53. [PMID: 26985688 DOI: 10.1515/hmbci-2016-0003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 02/12/2016] [Indexed: 12/29/2022]
Abstract
Dietary protein represents an important nutrient for bone health and thereby for the prevention of osteoporosis. Besides its role as a brick provider for building the organic matrix of skeletal tissues, dietary protein stimulates the production of the anabolic bone trophic factor IGF-I (insulin-like growth factor I). The liver is the main source of circulating IGF-I. During growth, protein undernutrition results in reduced bone mass and strength. Genetic defect impairing the production of IGF-I markedly reduces bone development in both length and width. The serum level of IGF-I markedly increases and then decreases during pubertal maturation in parallel with the change in bone growth and standing height velocity. The impact of physical activity on bone structure and strength is enhanced by increased dietary protein consumption. This synergism between these two important environmental factors can be observed in prepubertal boys, thus modifying the genetically determined bone growth trajectory. In anorexia nervosa, IGF-I is low as well as bone mineral mass. In selective protein undernutrition, there is a resistance to the exogenous bone anabolic effect of IGF-I. A series of animal experiments and human clinical trials underscore the positive effect of increased dietary intake of protein on calcium-phosphate economy and bone balance. On the contrary, the dietary protein-induced acidosis hypothesis of osteoporosis is not supported by several experimental and clinical studies. There is a direct effect of amino acids on the local production of IGF-I by osteoblastic cells. IGF-I is likely the main mediator of the positive effect of parathyroid hormone (PTH) on bone formation, thus explaining the reduction in fragility fractures as observed in PTH-treated postmenopausal women. In elderly women and men, relatively high protein intake protects against spinal and femoral bone loss. In hip fracture patients, isocaloric correction of the relatively low protein intake results in: increased IGF-I serum level, significant attenuation of postsurgical bone loss, improved muscle strength, better recovery, and shortened hospital stay. Thus, dietary protein contributes to bone health from early childhood to old age. An adequate intake of protein should be recommended in the prevention and treatment of osteoporosis.
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Byberg L, Bellavia A, Larsson SC, Orsini N, Wolk A, Michaëlsson K. Mediterranean Diet and Hip Fracture in Swedish Men and Women. J Bone Miner Res 2016; 31:2098-2105. [PMID: 27345330 DOI: 10.1002/jbmr.2896] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/10/2016] [Accepted: 06/23/2016] [Indexed: 12/26/2022]
Abstract
A Mediterranean diet, known to have beneficial effects on cardiovascular health, may also influence the risk of hip fracture although previous studies present discrepant results. We therefore aimed to determine whether the rate of hip fracture was associated with degree of adherence to a Mediterranean diet. We combined two Swedish cohort studies consisting of 37,903 men and 33,403 women (total n = 71,333, mean age 60 years) free of previous cardiovascular disease and cancer who answered a medical and a food-frequency questionnaire in 1997. A modified Mediterranean diet score (mMED; range, 0 to 8 points) was created based on high consumption of fruits and vegetables, legumes and nuts, whole grains, fermented dairy products, fish, and olive/rapeseed oil, moderate intake of alcohol, and low intake of red and processed meat. Incident hip fractures between January 1, 1998, and December 31, 2012, were retrieved from the National Patient Register. Hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for potential confounders were calculated using Cox proportional hazards regression. Differences in age at hip fracture were calculated using multivariable Laplace regression. During follow-up, 3175 hip fractures occurred at a median age of 73.3 years. One unit increase in the mMED was associated with 6% lower hip fracture rate (adjusted HR = 0.94; 95% CI, 0.92 to 0.96) and with a 3-month higher median age at hip fracture (50th percentile difference = 2.8 months; 95% CI, 1.4 to 4.2). Comparing the highest quintile of adherence to the mMED (6 to 8 points) with the lowest (0 to 2 points) conferred an adjusted HR of hip fracture of 0.78 (95% CI, 0.69 to 0.89) and a 12-month higher median age of hip fracture (50th percentile difference = 11.6 months; 95% CI, 4.2 to 19.0). Results were similar in men and women. We conclude that higher adherence to a Mediterranean-like diet is associated with lower risk of future hip fracture. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Liisa Byberg
- Department of Surgical Sciences, Orthopedics, Uppsala University, Uppsala, Sweden
| | - Andrea Bellavia
- Unit of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Susanna C Larsson
- Unit of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Nicola Orsini
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Alicja Wolk
- Unit of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Karl Michaëlsson
- Department of Surgical Sciences, Orthopedics, Uppsala University, Uppsala, Sweden
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Increased intake of vegetables, but not fruits, may be associated with reduced risk of hip fracture: A meta-analysis. Sci Rep 2016; 6:19783. [PMID: 26806285 PMCID: PMC4726403 DOI: 10.1038/srep19783] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/17/2015] [Indexed: 01/21/2023] Open
Abstract
Association between dietary intake of vegetables and fruits and risk of hip fracture has been reported for many years. However, the findings remain inconclusive. We conducted a meta-analysis to evaluate the relationship between intake of vegetables and fruits, and risk of hip fracture. Literature search for relevant studies was performed on PubMed and Embase databases. Five observational studies were included in the meta-analysis. Summary hazard ratio (HR) with corresponding 95% confidence interval (CI) was calculated from pooled data using the random-effects model irrespective of heterogeneity. Sensitivity and subgroup analysis were performed to explore possible reasons for heterogeneity. The summary HR for hip fracture in relation to high intake vs. low intake of only vegetables, only fruits, and combined intake of fruits and vegetables, was 0.75 (95% CI, 0.61–0.92), 0.87 (95% CI, 0.74–1.04), and 0.79 (95% CI, 0.61–1.03), respectively. Subgroup analyses based on study design, geographical location, number of cases, and gender showed similar results. Increased intake of vegetables, but not fruits, was found to be associated with a lower risk of hip fracture. Large prospective clinical trials with robust methodology are required to confirm our findings.
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Abstract
Osteoporosis is normally the result of a wrong life-style (diet, physical inactivity, smoke, dental hygiene, intestinal dysbiosis,…) and environmental toxicity which stimulate the chronic expression of inflammatory genes and alter the immuno-endocrine balance. A natural approch should face all the factors involved, leading the patients to become aware of their own responsability, and helping them with natural therapies, healthy food and life-style which support their body in the process of self-healing.
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Affiliation(s)
- Emanuela Bartolozzi
- Nutritionist and Homeopath, Expert in Environmental Medicine, Adjunct Professor University of Florence, Florence, Italy
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Curtis E, Litwic A, Cooper C, Dennison E. Determinants of Muscle and Bone Aging. J Cell Physiol 2015; 230:2618-25. [PMID: 25820482 DOI: 10.1002/jcp.25001] [Citation(s) in RCA: 201] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 03/24/2015] [Indexed: 12/12/2022]
Abstract
Loss of bone and muscle with advancing age represent a huge threat to loss of independence in later life. Osteoporosis represents a major public health problem through its association with fragility fractures, primarily of the hip, spine and distal forearm. Sarcopenia, the age related loss of muscle mass and function, may add to fracture risk by increasing falls risk. In the context of muscle aging, it is important to remember that it is not just a decline in muscle mass which contributes to the deterioration of muscle function. Other factors underpinning muscle quality come into play, including muscle composition, aerobic capacity and metabolism, fatty infiltration, insulin resistance, fibrosis and neural activation. Genetic, developmental, endocrine and lifestyle factors, such as physical activity, smoking and poor diet have dual effects on both muscle and bone mass in later life and these will be reviewed here. Recent work has highlighted a possible role for the early environment. Inflammaging is an exciting emerging research field that is likely to prove relevant to future work, including interventions designed to retard to reverse bone and muscle loss with age.
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Affiliation(s)
- Elizabeth Curtis
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Tremona Road, Southampton, England
| | - Anna Litwic
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Tremona Road, Southampton, England
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Tremona Road, Southampton, England
| | - Elaine Dennison
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Tremona Road, Southampton, England
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Bihuniak JD, Insogna KL. The effects of dietary protein and amino acids on skeletal metabolism. Mol Cell Endocrinol 2015; 410:78-86. [PMID: 25843057 PMCID: PMC5852680 DOI: 10.1016/j.mce.2015.03.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 03/27/2015] [Accepted: 03/30/2015] [Indexed: 10/23/2022]
Abstract
Dietary protein is required for optimal skeletal growth and maturation. Although Recommended Dietary Allowances (RDAs) exist for global dietary protein intake, the level and sources of dietary protein that are optimal for skeletal health over the life continuum have not been established. This is partly due to the difficulty in quantifying the effects of variable levels of a nutrient's intake over a lifetime as well as the complex nature of the relationships between dietary protein and calcium economy. Areas of current uncertainty include the precise source and amount of dietary protein required for optimal skeletal accretion and maintenance of skeletal mass, as well as the site-specific effects of dietary protein. The cellular and molecular mechanisms that underpin the actions of dietary protein on mineral metabolism and skeletal homeostasis remain unclear. This review attempts to summarize recent data bearing on these questions.
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Affiliation(s)
- Jessica D Bihuniak
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, 06269-1101, USA; Department of Internal Medicine, Section of Endocrinology, Yale University, New Haven, CT, 06269-1101, USA.
| | - Karl L Insogna
- Department of Internal Medicine, Section of Endocrinology, Yale University, New Haven, CT, 06269-1101, USA
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22
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Protein intake and lumbar bone density: the Multi-Ethnic Study of Atherosclerosis (MESA). Br J Nutr 2014; 112:1384-92. [PMID: 25192416 DOI: 10.1017/s0007114514002220] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Dietary protein has been shown to increase urinary Ca excretion in randomised controlled trials, and diets high in protein may have detrimental effects on bone health; however, studies examining the relationship between dietary protein and bone health have conflicting results. In the present study, we examined the relationship between dietary protein (total, animal and vegetable protein) and lumbar spine trabecular volumetric bone mineral density (vBMD) among participants enrolled in the Multi-Ethnic Study of Atherosclerosis (n 1658). Protein intake was assessed using a FFQ obtained at baseline examination (2000-2). Lumbar spine vBMD was measured using quantitative computed tomography (2002-5), on average 3 years later. Multivariable linear and robust regression techniques were used to examine the associations between dietary protein and vBMD. Sex and race/ethnicity jointly modified the association of dietary protein with vBMD (P for interaction = 0·03). Among white women, higher vegetable protein intake was associated with higher vBMD (P for trend = 0·03), after adjustment for age, BMI, physical activity, alcohol consumption, current smoking, educational level, hormone therapy use, menopause and additional dietary factors. There were no consistently significant associations for total and animal protein intakes among white women or other sex and racial/ethnic groups. In conclusion, data from the present large, multi-ethnic, population-based study suggest that a higher level of protein intake, when substituted for fat, is not associated with poor bone health. Differences in the relationship between protein source and race/ethnicity of study populations may in part explain the inconsistent findings reported previously.
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Nicoll R, McLaren Howard J. The acid-ash hypothesis revisited: a reassessment of the impact of dietary acidity on bone. J Bone Miner Metab 2014; 32:469-75. [PMID: 24557632 DOI: 10.1007/s00774-014-0571-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 01/16/2014] [Indexed: 12/11/2022]
Abstract
The acid-ash hypothesis states that when there are excess blood protons, bone is eroded to provide alkali to buffer the net acidity and maintain physiologic pH. There is concern that with the typical Western diet, we are permanently in a state of net endogenous acid production, which is gradually reducing bone. While it is clear that a high acid-producing diet generates increased urinary acid and calcium excretion, the effect of diet does not always have the expected results on BMD, fracture risk and markers of bone formation and resorption, suggesting that other factors are influencing the effect of acid/alkali loading on bone. High dietary protein, sodium and phosphorus intake, all of which are necessary for bone formation, were thought to be net acid forming and contribute to low BMD and fracture risk, but appear under certain conditions to be beneficial, with the effect of protein being driven by calcium repletion. Dietary salt can increase short-term markers of bone resorption but may also trigger 1,25(OH)2D synthesis to increase calcium absorption; with low calcium intake, salt intake may be inversely correlated with BMD but with high calcium intake, salt intake was positively correlated with BMD. With respect to the effect of phosphorus, the data are conflicting. Inclusion of an analysis of calcium intake may help to reconcile the contradictory results seen in many of the studies of bone. The acid-ash hypothesis could, therefore, be amended to state that with an acid-producing diet and low calcium intake, bone is eroded to provide alkali to buffer excess protons but where calcium intake is high the acid-producing diet may be protective.
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Affiliation(s)
- Rachel Nicoll
- Department of Public Health and Clinical Medicine and Heart Centre, Umea University, Umeå, Sweden,
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Meessen JMTA, Pisani S, Gambino ML, Bonarrigo D, van Schoor NM, Fozzato S, Cherubino P, Surace MF. Assessment of mortality risk in elderly patients after proximal femoral fracture. Orthopedics 2014; 37:e194-200. [PMID: 24679208 DOI: 10.3928/01477447-20140124-25] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 09/05/2013] [Indexed: 02/03/2023]
Abstract
Mortality after hip fracture is a major problem in the Western world, but its mechanisms remain uncertain. This study assessed the 2-year mortality rate after hip fracture in elderly patients by including hospital factors (eg, intervention type, surgical delay), underlying health conditions, and, for a subset, lifestyle factors (eg, body mass index, smoking, alcohol). A total of 828 patients (183 men) 70 to 99 years old experiencing a hip fracture in 2009 in the province of Varese were included in the study. The risk factors for death were assessed through Kaplan-Meier analysis and Cox proportional hazards analysis. Hip fracture incidence per 1000 persons was higher in women (8.4 vs 3.7 in men) and in elderly patients (12.4 for 85-99 years vs 4.4 for 70-84 years). The mortality rate after 1, 6, 12, and 24 months was 4.7%, 16%, 20.7%, and 30.4%, respectively. For the province of Varese, sex (hazard ratio, 0.39 for women), age group (hazard ratio, 2.2 for 85-99 years), and Charlson Comorbidity Index score (hazard ratio, 2.06 for score greater than 1) were found to be statistically significant. The 2-year mortality rate in hip fractures is associated with sex, age, and comorbidities. Male sex, age older than 85 years, and Charlson Comorbidity Index score greater than 1 are associated with a higher risk. Surgical delay was significant in the Kaplan-Meier survival time analysis but not in the Cox hazard analysis, suggesting that early surgery reduces risk in patients with numerous comorbidities.
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Jesudason D, Nordin BC, Keogh J, Clifton P. Comparison of 2 weight-loss diets of different protein content on bone health: a randomized trial. Am J Clin Nutr 2013; 98:1343-52. [PMID: 24047916 DOI: 10.3945/ajcn.113.058586] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND It has been hypothesized that hip-fracture rates are higher in developed than in developing countries because high-protein (HP) Western diets induce metabolic acidosis and hypercalciuria. Confounders include interactions between dietary protein and calcium, sodium, and potassium. OBJECTIVE We determined whether an HP or a high-normal-protein (HNP) weight-loss diet caused greater loss in bone mineral density (BMD) over 24 mo. DESIGN The Weight Loss, Protein and Bone Density Study was conducted from 2008 to 2011 in 323 overweight [body mass index (BMI; in kg/m(2)) >27] postmenopausal women, with a total hip BMD t score less than -2.0. Subjects were randomly assigned to receive an isocaloric calcium-replete HP (≥90 g protein/d) or HNP (<80 g protein/d) weight-loss diet, with the aim of a difference of 20 g protein/d. A total of 186 subjects (90 subjects in the HP group, 96 subjects in the HNP group) completed 12 mo, and 137 subjects (69 subjects in the HP group, 68 subjects in the HNP group) completed 24 mo. RESULTS Biomarkers confirmed a difference in protein intake of 16 and 13.1 g at 12 and 24 mo, respectively. Mean (±SE) weight loss was equal; HP subjects lost 7.9 ± 0.9 kg and HNP subjects lost 8.9 ± 0.9 kg at 24 mo. Subjects lost 1-2% BMD annually at lumbar spine vertebrae 2-4, the forearm, the femoral neck, and hip. ANCOVA showed no effect of the HP or HNP diet (P > 0.05 for diet and diet-time interactions). A diet-by-time analysis showed that the HNP diet increased C-terminal telopeptide and osteocalcin (P ≤ 0.001 for each) despite hypercalciuria (P = 0.029). CONCLUSION High dietary protein intake during weight loss has no clinically significant effect on bone density but slows bone turnover. This trial was registered at the Australian and New Zealand Clinical Trials Registry (http://www.anzctr.org.au) as ACTRN12608000229370.
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Affiliation(s)
- David Jesudason
- From Food and Nutritional Sciences, Commonwealth Scientific and Industrial Research Organisation, Adelaide, Australia (DJ, JK, and PC); the Centre of Clinical Research Excellence in Human Nutrition, University of Adelaide, Adelaide, Australia (DJ and PC); the Endocrinology Department, The Queen Elizabeth Hospital, Adelaide, Australia (DJ); Clinical Chemistry, South Australia Pathology, Adelaide, Australia (BECN); and the University of South Australia, Frome Road, Adelaide, Australia (JK and PC)
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26
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Amodu A, Abramowitz MK. Dietary acid, age, and serum bicarbonate levels among adults in the United States. Clin J Am Soc Nephrol 2013; 8:2034-42. [PMID: 24052219 DOI: 10.2215/cjn.03600413] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Greater dietary acid has been associated with lower serum bicarbonate levels in patients with CKD. Whether this association extends to the general population and if it is modified by age are unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study examined the association of the dietary acid load, estimated by net endogenous acid production, with serum bicarbonate levels in adult participants in the National Health and Nutrition Examination Survey 1999-2004. RESULTS The mean serum bicarbonate was 24.9 mEq/L (SEM=0.1), and the mean estimated net endogenous acid production was 57.4 mEq/d (SEM=0.4). Serum bicarbonate was linearly associated with age, such that the oldest participants had the highest serum bicarbonate levels. After multivariable adjustment, participants in the highest quartile of net endogenous acid production had 0.40 mEq/L (95% confidence interval, -0.55 to -0.26) lower serum bicarbonate and a 33% (95% confidence interval, 3 to 72) higher likelihood of acidosis compared with those participants in the lowest quartile. There was a significant interaction by age of the association of net endogenous acid production with serum bicarbonate (P=0.005). Among participants 20-39, 40-59, and ≥60 years old, those participants in the highest net endogenous acid production quartile had 0.26 (95% confidence interval, -0.49 to -0.03), 0.60 (95% confidence interval, -0.92 to -0.29), and 0.49 (95% confidence interval, -0.84 to -0.14) mEq/L lower serum bicarbonate, respectively, compared with participants in the lowest quartile. CONCLUSION Greater dietary acid is associated with lower serum bicarbonate in the general US population, and the magnitude of this association is greater among middle-aged and elderly persons than younger adults.
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Affiliation(s)
- Afolarin Amodu
- Division of Nephrology, Department of Medicine and, †Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
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Scialla JJ, Anderson CAM. Dietary acid load: a novel nutritional target in chronic kidney disease? Adv Chronic Kidney Dis 2013; 20:141-9. [PMID: 23439373 PMCID: PMC3604792 DOI: 10.1053/j.ackd.2012.11.001] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 11/06/2012] [Accepted: 11/12/2012] [Indexed: 02/07/2023]
Abstract
Nonvolatile acid is produced from the metabolism of organic sulfur in dietary protein and the production of organic anions during the combustion of neutral foods. Organic anion salts that are found primarily in plant foods are directly absorbed in the gastrointestinal tract and yield bicarbonate. The difference between endogenously produced nonvolatile acid and absorbed alkali precursors yields the dietary acid load, technically known as the net endogenous acid production, and must be excreted by the kidney to maintain acid-base balance. Although typically 1 mEq/kg/day, dietary acid load is lower with greater intake of fruits and vegetables. In the setting of CKD, a high dietary acid load invokes adaptive mechanisms to increase acid excretion despite reduced nephron number, such as increased per nephron ammoniagenesis and augmented distal acid excretion mediated by the renin-angiotensin system and endothelin-1. These adaptations may promote kidney injury. Additionally, high dietary acid loads produce low-grade, subclinical acidosis that may result in bone and muscle loss. Early studies suggest that lowering the dietary acid load can improve subclinical acidosis, preserve bone and muscle, and slow the decline of glomerular filtration rate in animal models and humans. Studies focusing on hard clinical outcomes are needed.
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Affiliation(s)
- Julia J Scialla
- Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA.
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Abstract
Dietary proteins are found in animal products, plant products and single-cell organisms. Proteins are present in variable proportions in these different food sources and the different proteins also differ in their amino acid composition, dietary indispensable amino acid content and physico-chemical properties. Different criteria can be used to define dietary protein requirements and different markers can be used to assess nutritional protein quality according to the criteria used for protein requirement estimation. The current approach to determining protein requirements is related to nitrogen balance and the dietary indispensable amino acid score approach relates protein quality to the capacity of protein to allow reaching nitrogen balance by providing nitrogen and indispensable amino acids. A second approach considers more directly protein nitrogen utilization by the body and includes measurement of protein digestibility and of the efficiency of dietary nitrogen retention at maintenance or for protein deposition at the whole body level or in more specific body areas. Another approach is related to protein turnover and protein synthesis in relation to maintenance and/or efficiency for deposition or development (growth) at the whole body level or for different and more specific target tissues such as muscle or bone. Lastly, protein quality can also be evaluated from different markers used as risk factors for metabolic dysfunction and disorders related for instance to insulin resistance, diabetes and obesity or cardio-vascular disease. The accuracy and relevance of these different approaches is discussed regarding the capacity of the different protein sources (i.e. animal as meat, milk or eggs, legume as soya or pea, or cereal as wheat or rice) to satisfy protein requirements according to these different criteria and markers.
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Alam I, Alam I, Paracha PI, Pawelec G. Higher estimates of daily dietary net endogenous acid production (NEAP) in the elderly as compared to the young in a healthy, free-living elderly population of Pakistan. Clin Interv Aging 2012; 7:565-73. [PMID: 23271903 PMCID: PMC3526881 DOI: 10.2147/cia.s37158] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Dietary intake has been shown to influence the acid–base balance in human subjects; however, this phenomenon is poorly understood and rarely reported for the least well-studied segment of older people in a developing country. The aims of the present study were to: (1) quantify estimates of daily net endogenous acid production (NEAP) (mEq/d) in a sample of otherwise healthy elderly aged 50 years and above; and (2) compare NEAP between the elderly and young to determine the effects of aging, which could contribute to changes in the acid–base balance. Analyses were carried out among 526 elderly and 131 young participants (aged 50–80 and 23–28 years, respectively), all of whom were free of discernible disease, nonsmokers, and not on any chronic medication. Selected anthropometric factors were measured and 24-hour dietary recall was recorded. We used two measures to characterize dietary acid load: (1) NEAP estimated as the dietary potential renal acid load plus organic acid excretion, the latter as a multiple of estimated body surface area; and (2) estimated NEAP based on protein and K. For the young and elderly, the ranges of NEAP were 12.1–67.8 mEq/d and 2.0–78.3 mEq/d, respectively. Regardless of the method used, the mean dietary acid–base balance (NEAP) was significantly higher for the elderly than the young (P = 0.0035 for NEAP [elderly, 44.1 mEq/d versus young 40.1 mEq/d]; and P = 0.0035 for the protein:potassium ratio [elderly, 1.4 mEq/d versus young 1.1 mEq/d]). A positive and significant correlation was found between NEAP and energy, protein, and phosphorus (P < 0.05 for all trends). The findings from this study provide evidence of the relatively higher production of NEAP in older people, possibly as an effect of higher consumption of certain acid-producing foods by the elderly.
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Affiliation(s)
- Iftikhar Alam
- Department of Agriculture, Bacha Khan University Charsadda, Khyber Pakhtunkhwa (KPK), Pakistan.
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O'Connell TC, Kneale CJ, Tasevska N, Kuhnle GGC. The diet-body offset in human nitrogen isotopic values: a controlled dietary study. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 2012; 149:426-34. [PMID: 23042579 PMCID: PMC3483624 DOI: 10.1002/ajpa.22140] [Citation(s) in RCA: 292] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 08/10/2012] [Indexed: 11/09/2022]
Abstract
The "trophic level enrichment" between diet and body results in an overall increase in nitrogen isotopic values as the food chain is ascended. Quantifying the diet-body Δ(15) N spacing has proved difficult, particularly for humans. The value is usually assumed to be +3-5‰ in the archaeological literature. We report here the first (to our knowledge) data from humans on isotopically known diets, comparing dietary intake and a body tissue sample, that of red blood cells. Samples were taken from 11 subjects on controlled diets for a 30-day period, where the controlled diets were designed to match each individual's habitual diet, thus reducing problems with short-term changes in diet causing isotopic changes in the body pool. The Δ(15) N(diet-RBC) was measured as +3.5‰. Using measured offsets from other studies, we estimate the human Δ(15) N(diet-keratin) as +5.0-5.3‰, which is in good agreement with values derived from the two other studies using individual diet records. We also estimate a value for Δ(15) N(diet-collagen) of ≈6‰, again in combination with measured offsets from other studies. This value is larger than usually assumed in palaeodietary studies, which suggests that the proportion of animal protein in prehistoric human diet may have often been overestimated in isotopic studies of palaeodiet.
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Affiliation(s)
- T C O'Connell
- Department of Archaeology and Anthropology, University of Cambridge, UK.
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Abstract
Numerous studies have investigated the relationship between soy foods, soy protein, or isoflavone extracts and markers of bone health and osteoporosis prevention, and have come to conflicting conclusions. Research on dietary patterns, rather than on specific food ingredients or individual foods, may offer an opportunity for better understanding the role of soy foods in bone health. Evidence is reviewed regarding the question of whether soy foods contribute to a dietary pattern in humans that supports and promotes bone health. Soy foods are associated with improved markers of bone health and improved outcomes, especially among Asian women. Although the optimal amounts and types of soy foods needed to support bone health are not yet clear, dietary pattern evidence suggests that regular consumption of soy foods is likely to be useful for optimal bone health as an integral part of a dietary pattern that is built largely from whole plant foods.
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Jones J. Wheat Belly—An Analysis of Selected Statements and Basic Theses from the Book. CEREAL FOOD WORLD 2012. [DOI: 10.1094/cfw-57-4-0177] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- J. Jones
- St. Catherine University, St. Paul, MN, U.S.A
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Dietary patterns and bone mineral status in young adults: the Northern Ireland Young Hearts Project. Br J Nutr 2012; 108:1494-504. [PMID: 22214826 DOI: 10.1017/s0007114511006787] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Studies of individual nutrients or foods have revealed much about dietary influences on bone. Multiple food or nutrient approaches, such as dietary pattern analysis, could offer further insight but research is limited and largely confined to older adults. We examined the relationship between dietary patterns, obtained by a posteriori and a priori methods, and bone mineral status (BMS; collective term for bone mineral content (BMC) and bone mineral density (BMD)) in young adults (20-25 years; n 489). Diet was assessed by 7 d diet history and BMD and BMC were determined at the lumbar spine and femoral neck (FN). A posteriori dietary patterns were derived using principal component analysis (PCA) and three a priori dietary quality scores were applied (dietary diversity score (DDS), nutritional risk score and Mediterranean diet score). For the PCA-derived dietary patterns, women in the top compared to the bottom fifth of the 'Nuts and Meat' pattern had greater FN BMD by 0·074 g/cm(2) (P = 0·049) and FN BMC by 0·40 g (P = 0·034) after adjustment for confounders. Similarly, men in the top compared to the bottom fifth of the 'Refined' pattern had lower FN BMC by 0·41 g (P = 0·049). For the a priori DDS, women in the top compared to the bottom third had lower FN BMD by 0·05 g/cm(2) after adjustments (P = 0·052), but no other relationships with BMS were identified. In conclusion, adherence to a 'Nuts and Meat' dietary pattern may be associated with greater BMS in young women and a 'Refined' dietary pattern may be detrimental for bone health in young men.
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35
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Gagné L, Maizes V. Osteoporosis. Integr Med (Encinitas) 2012. [DOI: 10.1016/b978-1-4377-1793-8.00037-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
High-protein (HP) diets exert a hypercalciuric effect at constant levels of calcium intake, even though the effect may depend on the nature of the dietary protein. Lower urinary pH is also consistently observed for subjects consuming HP diets. The combination of these two effects was suspected to be associated with a dietary environment favorable for demineralization of the skeleton. However, increased calcium excretion due to HP diet does not seem to be linked to impaired calcium balance. In contrast, some data indicate that HP intakes induce an increase of intestinal calcium absorption. Moreover, no clinical data support the hypothesis of a detrimental effect of HP diet on bone health, except in a context of inadequate calcium supply. In addition, HP intake promotes bone growth and retards bone loss and low-protein diet is associated with higher risk of hip fractures. The increase of acid and calcium excretion due to HP diet is also accused of constituting a favorable environment for kidney stones and renal diseases. However, in healthy subjects, no damaging effect of HP diets on kidney has been found in either observational or interventional studies and it seems that HP diets might be deleterious only in patients with preexisting metabolic renal dysfunction. Thus, HP diet does not seem to lead to calcium bone loss, and the role of protein seems to be complex and probably dependent on other dietary factors and the presence of other nutrients in the diet.
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Abstract
There is now a significant amount of research that demonstrates the health benefits of vegetarian and plant-based diets, which have been associated with a reduced risk of obesity, diabetes, heart disease, and some types of cancer as well as increased longevity. Vegetarian diets are typically lower in fat, particularly saturated fat, and higher in dietary fiber. They are also likely to include more whole grains, legumes, nuts, and soy protein, and together with the absence of red meat, this type of eating plan may provide many benefits for the prevention and treatment of obesity and chronic health problems, including diabetes and cardiovascular disease. Although a well-planned vegetarian or vegan diet can meet all the nutritional needs of an individual, it may be necessary to pay particular attention to some nutrients to ensure an adequate intake, particularly if the person is on a vegan diet. This article will review the evidence for the health benefits of a vegetarian diet and also discuss strategies for meeting the nutritional needs of those following a vegetarian or plant-based eating pattern.
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Affiliation(s)
- Kate Marsh
- Northside Nutrition and Dietetics, Chatswood, Australia
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Fenton TR, Tough SC, Lyon AW, Eliasziw M, Hanley DA. Causal assessment of dietary acid load and bone disease: a systematic review & meta-analysis applying Hill's epidemiologic criteria for causality. Nutr J 2011; 10:41. [PMID: 21529374 PMCID: PMC3114717 DOI: 10.1186/1475-2891-10-41] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 04/30/2011] [Indexed: 01/19/2023] Open
Abstract
Background Modern diets have been suggested to increase systemic acid load and net acid excretion. In response, alkaline diets and products are marketed to avoid or counteract this acid, help the body regulate its pH to prevent and cure disease. The objective of this systematic review was to evaluate causal relationships between dietary acid load and osteoporosis using Hill's criteria. Methods Systematic review and meta-analysis. We systematically searched published literature for randomized intervention trials, prospective cohort studies, and meta-analyses of the acid-ash or acid-base diet hypothesis with bone-related outcomes, in which the diet acid load was altered, or an alkaline diet or alkaline salts were provided, to healthy human adults. Cellular mechanism studies were also systematically examined. Results Fifty-five of 238 studies met the inclusion criteria: 22 randomized interventions, 2 meta-analyses, and 11 prospective observational studies of bone health outcomes including: urine calcium excretion, calcium balance or retention, changes of bone mineral density, or fractures, among healthy adults in which acid and/or alkaline intakes were manipulated or observed through foods or supplements; and 19 in vitro cell studies which examined the hypothesized mechanism. Urine calcium excretion rates were consistent with osteoporosis development; however calcium balance studies did not demonstrate loss of whole body calcium with higher net acid excretion. Several weaknesses regarding the acid-ash hypothesis were uncovered: No intervention studies provided direct evidence of osteoporosis progression (fragility fractures, or bone strength as measured using biopsy). The supporting prospective cohort studies were not controlled regarding important osteoporosis risk factors including: weight loss during follow-up, family history of osteoporosis, baseline bone mineral density, and estrogen status. No study revealed a biologic mechanism functioning at physiological pH. Finally, randomized studies did not provide evidence for an adverse role of phosphate, milk, and grain foods in osteoporosis. Conclusions A causal association between dietary acid load and osteoporotic bone disease is not supported by evidence and there is no evidence that an alkaline diet is protective of bone health.
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Affiliation(s)
- Tanis R Fenton
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
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40
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Jesudason D, Clifton P. The interaction between dietary protein and bone health. J Bone Miner Metab 2011; 29:1-14. [PMID: 20972896 DOI: 10.1007/s00774-010-0225-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Accepted: 09/02/2010] [Indexed: 11/27/2022]
Abstract
The role of dietary protein in bone health has been controversial. On the one hand, a plentiful supply of dietary amino acids has been considered important to support bone remodeling while on the other hand there have been concerns that the dietary acid load associated with protein consumption promotes hypercalciuria and loss of bone calcium stores. This article reviews the effect of dietary protein on bone mass and bone density, and the effect on markers of bone resorption and formation and also on fracture risk, looking at both cross-sectional and longitudinal studies and examining both meat and vegetable protein including soy and milk basic protein. The results are not entirely consistent and suggest that the interaction between dietary protein and other components in a mixed diet, such as calcium intake and vegetables and fruit to neutralize acid, are important and may determine whether high-protein diets are beneficial to bone health. Overall the results suggest that dietary protein has a modest beneficial effect on bone markers and bone density. This effect has yet to be consistently linked to reduced fracture risk, probably because of the role of other etiological factors such as the risk of falls. There is not enough evidence currently to suggest that animal protein is superior or inferior to vegetable protein, or that milk or soy protein, respectively, is more favorable than other protein sources.
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Affiliation(s)
- David Jesudason
- Food and Nutritional Sciences, Commonwealth Scientific and Industrial Research Organisation (CSIRO), Adelaide, BC, SA 5000, Australia.
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41
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Sahni S, Cupples LA, McLean RR, Tucker KL, Broe KE, Kiel DP, Hannan MT. Protective effect of high protein and calcium intake on the risk of hip fracture in the Framingham offspring cohort. J Bone Miner Res 2010; 25:2770-6. [PMID: 20662074 PMCID: PMC3179277 DOI: 10.1002/jbmr.194] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 06/29/2010] [Accepted: 07/14/2010] [Indexed: 11/21/2022]
Abstract
The effect of protein on bone is controversial, and calcium intake may modify protein's effect on bone. We evaluated associations of energy-adjusted tertiles of protein intake (ie, total, animal, plant, animal/plant ratio) with incident hip fracture and whether total calcium intake modified these associations in the Framingham Offspring Study. A total of 1752 men and 1972 women completed a baseline food frequency questionnaire (1991-1995 or 1995-1998) and were followed for hip fracture until 2005. Hazard ratios (HRs) were estimated using Cox proportional hazards regression adjusting for confounders. Baseline mean age was 55 years (SD 9.9 years, range 26 to 86 years). Forty-four hip fractures occurred over 12 years of follow-up. Owing to significant interaction between protein (total, animal, animal/plant ratio) and calcium intake (p interaction range = .03 to .04), stratified results are presented. Among those with calcium intakes less than 800 mg/day, the highest tertile (T3) of animal protein intake had 2.8 times the risk of hip fracture [HR = 2.84, 95% confidence interval (CI) 1.20-6.74, p = .02] versus the lowest tertile (T1, p trend = .02). In the 800 mg/day or more group, T3 of animal protein had an 85% reduced hip fracture risk (HR = 0.15, 95% CI 0.02-0.92, p = .04) versus T1 (p trend = .04). Total protein intake and the animal/plant ratio were not significantly associated with hip fracture (p range = .12 to .65). Our results from middle-aged men and women show that higher animal protein intake coupled with calcium intake of 800 mg/day or more may protect against hip fracture, whereas the effect appears reversed for those with lower calcium intake. Calcium intake modifies the association of protein intake and the risk of hip fracture in this cohort and may explain the lack of concordance seen in previous studies.
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Affiliation(s)
- Shivani Sahni
- Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
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Levin SM. Should dairy products be promoted to Chinese Americans? JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION 2010; 110:1811-1812. [PMID: 21111086 DOI: 10.1016/j.jada.2010.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Indexed: 05/30/2023]
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Zanovec M, O'Neil CE, Keast DR, Fulgoni VL, Nicklas TA. Lean beef contributes significant amounts of key nutrients to the diets of US adults: National Health and Nutrition Examination Survey 1999-2004. Nutr Res 2010; 30:375-81. [PMID: 20650344 DOI: 10.1016/j.nutres.2010.06.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Revised: 06/02/2010] [Accepted: 06/03/2010] [Indexed: 10/19/2022]
Abstract
Consumption of lean meat is a valuable addition to a healthy diet because it provides complete protein and is a rich source of vitamin B(12), iron, and zinc. The objective of this study was to examine the nutritional contribution of total beef and lean beef (LB) to the American diet using the USDA definition of LB as defined in MyPyramid. Twenty-four-hour dietary recall data from adults 19 to 50 years of age (n = 7049) and 51+ years (n = 6243) participating in the National Health and Nutrition Examination Survey 1999-2004 were assessed. Lean beef was defined as beef with <9.28 g fat per 100 g (excess was discretionary fat). Fifty percent of adults 19 to 50 years and 41% of adults 51+ years consumed beef on the day of the dietary recall. Total beef consumed among adults 19 to 50 and 51+ years was 49.3 +/- 1.4 g (1.74 oz/d) and 37.1 +/- 1.2 g (1.31 oz/d), respectively. In adults 19 to 50 and 51+ years, LB contributed 3.9% and 3.7% to total energy; 4.5% and 4.1% to total fat, 3.8% and 3.6% to saturated fatty acids; 13% and 11% to cholesterol intake; 15% and 14% to protein; 25% and 20% to vitamin B(12); 23% and 20% to zinc; and 8% and 7% to iron, respectively. Beef was also an important food source of many other nutrients, including niacin, vitamin B(6), phosphorus, and potassium. In addition, beef provided only 1% of total sodium intake. Consumption of beef contributed significantly to intake of protein and other key nutrients by US adults.
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Affiliation(s)
- Michael Zanovec
- School of Human Ecology, Louisiana State University Agricultural Center, Baton Rouge, LA 70803, USA
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Messina M, Messina V. The role of soy in vegetarian diets. Nutrients 2010; 2:855-88. [PMID: 22254060 PMCID: PMC3257705 DOI: 10.3390/nu2080855] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 07/31/2010] [Accepted: 08/03/2010] [Indexed: 12/30/2022] Open
Abstract
Soyfoods have long been prized among vegetarians for both their high protein content and versatility. Soybeans differ markedly in macronutrient content from other legumes, being much higher in fat and protein, and lower in carbohydrate. In recent years however, soyfoods and specific soybean constituents, especially isoflavones, have been the subject of an impressive amount of research. Nearly 2,000 soy-related papers are published annually. This research has focused primarily on the benefits that soyfoods may provide independent of their nutrient content. There is particular interest in the role that soyfoods have in reducing risk of heart disease, osteoporosis and certain forms of cancer. However, the estrogen-like effects of isoflavones observed in animal studies have also raised concerns about potential harmful effects of soyfood consumption. This review addresses questions related to soy and chronic disease risk, provides recommendations for optimal intakes, and discusses potential contraindications. As reviewed, the evidence indicates that, with the exception of those individuals allergic to soy protein, soyfoods can play a beneficial role in the diets of vegetarians. Concerns about adverse effects are not supported by the clinical or epidemiologic literature. Based on the soy intake associated with health benefits in the epidemiologic studies and the benefits noted in clinical trials, optimal adult soy intake would appear to be between two and four servings per day.
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Affiliation(s)
- Mark Messina
- Department of Nutrition, School of Public Health, Loma Linda University, Loma Linda, California, USA
- Nutrition Matters, Inc., Port Townsend, WA 98368, USA;
| | - Virginia Messina
- Department of Nutrition, School of Public Health, Loma Linda University, Loma Linda, California, USA
- Nutrition Matters, Inc., Port Townsend, WA 98368, USA;
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Deriemaeker P, Aerenhouts D, Hebbelinck M, Clarys P. Nutrient based estimation of acid-base balance in vegetarians and non-vegetarians. PLANT FOODS FOR HUMAN NUTRITION (DORDRECHT, NETHERLANDS) 2010; 65:77-82. [PMID: 20054653 DOI: 10.1007/s11130-009-0149-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A first objective of the present study was to estimate the acid-base balance of the food intake in vegetarians and non-vegetarians. A second objective was to evaluate if additional input of specific food items on the existing potential renal acid load (PRAL) list was necessary for the comparison of the two dietary patterns. Thirty vegetarians between the age of 18 and 30 years were matched for sex, age and BMI with 30 non-vegetarians. Based on the 3-days food diaries the acid-base status of the food intake was estimated using the PRAL method. Mean PRAL values as estimated with the standard table yielded an alkaline load of -5.4 +/- 14.4 mEq/d in the vegetarians compared to an acid load of 10.3 +/- 14.4 mEq/d in the nonvegetarians (p<0.001). Mean PRAL values as estimated with the extended table yielded an alkaline load of -10.9 +/-19.7 mEq/d in the vegetarians compared to an acid load of 13.8 +/- 17.1 mEq/d for the non-vegetarians (p<0.001). The findings of this study indicate that vegetarian food intake produces more alkaline outcomes compared to non-vegetarian diets. The use of the standard PRAL table was sufficient for discrimination between the two diets.
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Affiliation(s)
- Peter Deriemaeker
- Department of Biometry and Biomechanics, Faculty of Physical Education and Physical Therapy, Vrije Universiteit Brussel, Brussels, Belgium.
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Berkemeyer S. Net acid excretion capacity is related to blood hydrogen ion and serum carbon dioxide. Metabolism 2010; 59:338-42. [PMID: 19793591 DOI: 10.1016/j.metabol.2009.07.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 07/29/2009] [Accepted: 07/31/2009] [Indexed: 11/26/2022]
Abstract
Acid-base imbalance due to dietary food patterns has emerged as one of the hypotheses leading to modern-day diseases. This study examined if a new method to assess the renal ability to excrete an acid load, that is, the net acid excretion capacity (NAEC), constructed from net acid excretion (NAE) and urine pH, relates to blood hydrogen ion concentration ([H+]) and serum carbon dioxide concentration ([CO2]). In a second analysis, NAE to pH relationship was examined, and is de facto treated to be linear. This study used historical, cross-sectional data of 58 repeated measurements from 8 subjects for the primary measurements of NAEC, blood [H+], and serum [CO2]. Using fixed models, higher NAEC associated with lower [H+] and higher [CO2]. Using hierarchical models, the interindividual variations in [H+] and [CO2] explained the variations in NAEC. In the second analysis (n = 59), a quadratic NAE to pH relationship (NAE = -846.77 + 341.47 pH - 31.50 pH(2)) can be reported. Net acid excretion capacity, a noninvasive tool to assess the renal ability to excrete an acid load, has a physiologic base to it, in that it captures the inherent nonlinear relations of NAE to pH explaining endogenous [H+] retention/excretion. A higher vegetable and fruit consumption might relieve NAEC and allow excess [H+] loss via both renal and respiratory routes.
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Affiliation(s)
- Shoma Berkemeyer
- University of Bochum, Department of Geriatrics-Marienhospital Herne, D-44627 Herne, Germany.
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Ho-Pham LT, Nguyen PLT, Le TTT, Doan TAT, Tran NT, Le TA, Nguyen TV. Veganism, bone mineral density, and body composition: a study in Buddhist nuns. Osteoporos Int 2009; 20:2087-93. [PMID: 19350341 DOI: 10.1007/s00198-009-0916-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2008] [Accepted: 03/04/2009] [Indexed: 10/20/2022]
Abstract
SUMMARY This cross-sectional study showed that, although vegans had lower dietary calcium and protein intakes than omnivores, veganism did not have adverse effect on bone mineral density and did not alter body composition. INTRODUCTION Whether a lifelong vegetarian diet has any negative effect on bone health is a contentious issue. We undertook this study to examine the association between lifelong vegetarian diet and bone mineral density and body composition in a group of postmenopausal women. METHODS One hundred and five Mahayana Buddhist nuns and 105 omnivorous women (average age = 62, range = 50-85) were randomly sampled from monasteries in Ho Chi Minh City and invited to participate in the study. By religious rule, the nuns do not eat meat or seafood (i.e., vegans). Bone mineral density (BMD) at the lumbar spine (LS), femoral neck (FN), and whole body (WB) was measured by DXA (Hologic QDR 4500). Lean mass, fat mass, and percent fat mass were also obtained from the DXA whole body scan. Dietary calcium and protein intakes were estimated from a validated food frequency questionnaire. RESULTS There was no significant difference between vegans and omnivores in LSBMD (0.74 +/- 0.14 vs. 0.77 +/- 0.14 g/cm(2); mean +/- SD; P = 0.18), FNBMD (0.62 +/- 0.11 vs. 0.63 +/- 0.11 g/cm(2); P = 0.35), WBBMD (0.88 +/- 0.11 vs. 0.90 +/- 0.12 g/cm(2); P = 0.31), lean mass (32 +/- 5 vs. 33 +/- 4 kg; P = 0.47), and fat mass (19 +/- 5 vs. 19 +/- 5 kg; P = 0.77) either before or after adjusting for age. The prevalence of osteoporosis (T scores < or = -2.5) at the femoral neck in vegans and omnivores was 17.1% and 14.3% (P = 0.57), respectively. The median intake of dietary calcium was lower in vegans compared to omnivores (330 +/- 205 vs. 682 +/- 417 mg/day, P < 0.001); however, there was no significant correlation between dietary calcium and BMD. Further analysis suggested that whole body BMD, but not lumbar spine or femoral neck BMD, was positively correlated with the ratio of animal protein to vegetable protein. CONCLUSION These results suggest that, although vegans have much lower intakes of dietary calcium and protein than omnivores, veganism does not have adverse effect on bone mineral density and does not alter body composition.
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Affiliation(s)
- L T Ho-Pham
- Pham Ngoc Thach University of Medicine, Ho Chi Minh, Vietnam
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48
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Darling AL, Millward DJ, Torgerson DJ, Hewitt CE, Lanham-New SA. Dietary protein and bone health: a systematic review and meta-analysis. Am J Clin Nutr 2009; 90:1674-92. [PMID: 19889822 DOI: 10.3945/ajcn.2009.27799] [Citation(s) in RCA: 183] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There has been a resurgence of interest in the controversial relation between dietary protein and bone health. OBJECTIVE This article reports on the first systematic review and meta-analysis of the relation between protein and bone health in healthy human adults. DESIGN The MEDLINE (January 1966 to September 2007) and EMBASE (1974 to July 2008) databases were electronically searched for all relevant studies of healthy adults; studies of calcium excretion or calcium balance were excluded. RESULTS In cross-sectional surveys, all pooled r values for the relation between protein intake and bone mineral density (BMD) or bone mineral content at the main clinically relevant sites were significant and positive; protein intake explained 1-2% of BMD. A meta-analysis of randomized placebo-controlled trials indicated a significant positive influence of all protein supplementation on lumbar spine BMD but showed no association with relative risk of hip fractures. No significant effects were identified for soy protein or milk basic protein on lumbar spine BMD. CONCLUSIONS A small positive effect of protein supplementation on lumbar spine BMD in randomized placebo-controlled trials supports the positive association between protein intake and bone health found in cross-sectional surveys. However, these results were not supported by cohort study findings for hip fracture risk. Any effects found were small and had 95% CIs that were close to zero. Therefore, there is a small benefit of protein on bone health, but the benefit may not necessarily translate into reduced fracture risk in the long term.
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Affiliation(s)
- Andrea L Darling
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom.
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Ho-Pham LT, Nguyen ND, Nguyen TV. Effect of vegetarian diets on bone mineral density: a Bayesian meta-analysis. Am J Clin Nutr 2009; 90:943-50. [PMID: 19571226 DOI: 10.3945/ajcn.2009.27521] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The association between vegetarian diets and bone mineral density (BMD) is controversial because of conflicting findings from previous studies. OBJECTIVE The aim of this study was to estimate the effect of vegetarian diets on BMD by using a meta-analytic approach. DESIGN A systematic electronic literature search was conducted to identify all relevant articles on the association between vegetarian diet and BMD. Nine studies of 2749 subjects (1880 women and 869 men) were included in the analysis. Traditional and Bayesian methods of meta-analysis were applied to synthesize the data. RESULTS Overall, BMD was approximately 4% lower in vegetarians than in omnivores (95% CI: 2%, 7%) at both the femoral neck and the lumbar spine. Compared with omnivores, vegans had a significantly lower lumbar spine BMD (6% lower; 95% CI: 2%, 9%), which was more pronounced than in lactoovovegetarians (2% lower; 95% CI: 1%, 4%). The probability that BMD was > or =5% lower in vegetarians than in omnivores (or approximately 0.3 SD) was 42% for the femoral neck and 32% for the lumbar spine. There was no evidence of publication bias. There was a moderate degree of between-study heterogeneity; the coefficient of heterogeneity varied between 46% and 51%. CONCLUSION The results suggest that vegetarian diets, particularly vegan diets, are associated with lower BMD, but the magnitude of the association is clinically insignificant.
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Affiliation(s)
- Lan T Ho-Pham
- Department of Internal Medicine, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
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Berkemeyer S. Acid-base balance and weight gain: are there crucial links via protein and organic acids in understanding obesity? Med Hypotheses 2009; 73:347-56. [PMID: 19410381 DOI: 10.1016/j.mehy.2008.09.059] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 09/09/2008] [Accepted: 09/12/2008] [Indexed: 11/17/2022]
Abstract
Obesity is associated with ever increasing social costs posing a general public health challenge. The most obvious reason for obesity, given healthy body functioning, is a positive calorie balance. This article delves into the lesser studied realm of the relationship of weight gain, in particular adipose tissue gain, with increased hydrogen ion concentration, taking protein and organic acids as important caveats in this discussion. The review opens the topic with the contradictory result of various studies reporting a positive relationship between chronic metabolic acidosis and weight loss. It goes to explain a process of weight gain, primarily adipose tissue gain, on acidogenic diets. Insufficient dietary protein could lead to muscle loss, and individual organic acids might indicate if there is any fatty acid oxidation or accumulation of hydrogen ion. The solution to the acid accumulation is discussed not in protein limitation but an increase in the consumption of vegetables and fruits. Finally, this review article based on studies published puts forward a physiological basis including a hypothesis to explain the possible link between hydrogen ion concentration and weight gain. This link could possibly explain the development of diseases and aging partially, and warrants research.
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Affiliation(s)
- Shoma Berkemeyer
- Ruhr-Universität-Bochum, Klinik für Altersmedizin und Frührehabilitation, Studienbüro, Room 23, Widumerstr. 8, 44627 Herne, Germany.
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