This randomized control trial sought to determine if a higher-dose vitamin D supplementation improves bone mineral density. Low bone mineral density increases the risk of osteoporosis and finding ways to prevent the development of this prevalent disease is needed. We also need to know the implications of excess vitamin D supplementation on bone.

This double-blind randomized control trial took place over three years. The 311 participants were placed in either the 400 IU/day, 4,000 IU/day and 10,000 IU/day group. The study found that among healthy adults, treatment with 4000 IU per day or 10 000 IU per day, resulted in statistically significant lower radial BMD. 

Clinical implications: This is important because many people are proposing that the current RDA for vitamin D is too low. Much research like this needed to be able to assess if this is the case. As clinicians, we need to make sure we are recommending vitamin D supplementation in a healthy range. 

Study #2: Teucher, Birgit, et al. “Sodium and Bone Health: Impact of Moderately High and Low Salt Intakes on Calcium Metabolism in Postmenopausal Women.” American Society for Bone and Mineral Research, John Wiley & Sons, Ltd, 14 Apr. 2008, asbmr.onlinelibrary.wiley.com/doi/full/10.1359/jbmr.080408. 

I looked at two studies involving sodium and bone health.  Calcium and vitamin D tend to garner a lot of attention with regards to bone health but I believe that sodium is also very important to consider regarding bone health, especially when the Average American sodium intake is +3,900 mg/day.  I was curious as to what sodium level may be detrimental to bone health.   

Study #1: High sodium intakes (> 2 grams/day) were associated with negative bone turnover markers which the researchers indicate suggests that excessive sodium intake might accelerate bone turnover. 

Study #2: 3.9 grams/day and 11.2 grams/day of sodium.  Study looked at both sodium and calcium intake.  Low calcium intake was associated with negative bone calcium balance in both high and low sodium diets.  Even with a moderate calcium intake of 1284 mg/day the bone balance was positive with low sodium (3.9) intake but with a high sodium intake (11.2 g/day) bone balance was not positive.  (granted….11.2 grams/day is a lot!)

After I reviewed these two articles I then ran across the article published in the JCEM: Sodium Intake and Osteoporosis.  Findings from the Women’s Health Initiative.  Carbone, L., Johnson, K. C., Huang, Y., Pettinger, M., Thomas, F., Cauley, J., Crandall, C., Tinker, L., LeBoff, M. S., Wactawski-Wende, J., Bethel, M., Li, W., & Prentice, R. (2016). Sodium Intake and Osteoporosis. Findings From the Women's Health Initiative. The Journal of clinical endocrinology and metabolism, 101(4), 1414–1421. https://doi.org/10.1210/jc.2015-4017

I immediately jumped to the conclusion section of the above article and the authors state that the “current recommendations for sodium intake are unlikely to significantly affect osteoporosis”. (The article was published in 2016 and reference the 2010-2015 Dietary Guidelines for Americans which recommended: the IOM tolerable upper intake level of 2300 mg Na/day).  Note: this is still the current recommendation in the 2020-2025 DGA.  

The role sodium plays with regards to cardiovascular health is well established and the general population is likely more aware of this relationship than the role that sodium plays in bone health.  I think this information is important to share with patients/clients because some patients may not be concerned about cardiovascular health but may be concerned about bone health and I don’t think that sodium is always at the top of the list when discussing nutrients and bone health. It’s an important conversation to have with patients/clients regarding the recommended daily sodium intake limit of 2300 mg/day and another reason that supports the rationale for the current recommendation from the Academies that is included in the 2020-2025 Dietary Guidelines for Americans.   

Why is this study important:  This review interlinks IBD (Inflammatory Bowel Disease) and Osteosarcopenia (a disorder of simultaneous sarcopenia and osteoporosis) in a discussion regarding the risk of Osteosarcopenia in IBD patients and the importance of providing nutritional considerations and treatment of both disorders. 

Key findings and nutritional science: Osteosarcopenia is the collective disorder of both muscle and bone tissue loss, which are being considered more interrelated due to both hormonal pathways as well as mechanical interactions between muscle and bone. 

Patients with IBD often present with Osteosarcopenia due to various risk factors associated with IBD such as malnutrition, malabsorption, decreased physical activity, chronic inflammation among others (refer to Tables 2, 3).  This review noted that more than 50% of patients with IBD have an abnormal lumbar BMD (Bone Mineral Density).  Low BMI is also associated with a low BMD and in IBD patients, BMI is often “significantly” lower than in healthy individuals.  

Some nutritional recommendations for these patients might have more direct advantages, such as vitamin D, which is necessary for bone health and may impact muscle development. Other beneficial treatment recommendations are less direct, for example, an increase in protein intake will help to increase muscle mass, which in turn (may) lead to an increase in physical activity, resulting in the benefit of increased bone density.  

Clinical implications:  Loss of muscle is common in patients presenting with IBD and they also belong to a higher risk category for osteoporosis.  Osteosarcopenia increases the risk of falls and fractures which can cause further deterioration in the state of health in IBD patients.  Knowing that IBD patients are at increased risk for Osteosarcopenia, clinical treatment recommendations should look to treat patients holistically, recommending adequate nutritional supplementation and physical activity therapy. 

This study is significant because it analyzed the literature of the time to come to a consensus on the efficacy of calcium and vitamin D supplementation and their role on the skeletomuscular system. It is important to note that this paper was published in 2016 and there is still a debate on the benefits of calcium supplementation.

 One key finding from this study and how does it relate to nutritional sciences

This paper did a really good job combining evidence from different sources and I appreciated the big takeaways from author’s analysis. One should be mindful of their bodies needs when considering calcium supplementation. The researchers concluded that vitamin supplementation can have side effects. Most of these are concerned with the GI tract but some more severe side effects include calcium impact on the kidneys, especially in terms of renal stones. They have also concluded that the link between calcium supplementation and cardiovascular events are not well supported by the literature. I think some of these off-target effects are due to the variety of roles that calcium plays in the body, with bone health and maintenance being just one of them. 

Calcium can be found in a variety of dietary sources and adequate levels can be absorbed in the body with a well-balanced diet. 

Clinical implication

With the above information in mind, the researcher’s have also concluded that calcium and vitamin D supplementation together is beneficial for patients who are at high risk of insufficiency and for those receiving treatment for osteoporosis. It is important for providers to be able to recognize people who are risk and encourage supplementation when appropriate.  

 

This study is important because it looks at the effect dried plum has on bone density in osteopenic postmenopausal women. The researchers recruited 48 osteopenic postmenopausal women to a randomized controlled trial. The women were split into three groups for the study. The first group consumed 50 grams of dried plum daily for six months. The second group consumed 100 grams of dried plum daily for six months. The third group consumed a control diet that did not include dried plums. 

One key finding in this study is that the groups with dried plums seemed to have less loss of total body bone mineral density compared to the control group. However, there were no significant differences between the 50g of dried plums daily group and the 100g of dried plums daily group. These findings suggest that consuming 50g of dried plums daily may be just as effective as consuming 100g of dried plums daily to prevent bone loss.   

This study is important clinically because it shows that a small addition in our diet can influence bone health. I did not know the effect dried plums had on bone health before reading this article, so this topic was really new and interesting to me. I found several articles that suggested that dried plums could inhibit bone resorption and promote bone formation and I think that this is an interesting concept to keep in mind when discussing diet with osteopenic patients. 

This study is important because it focuses on the effects of nutrition on bone density and could provide a means of supplementation that is more agreeable to some patients. The author conducted a study previously that compared dried plums (prunes) to dried apples in increasing BMD and the key finding was that found that the prunes were significant in increasing BMD in the ulna and spine compared to the control. This follow up study found that both the higher and lower doses of prunes prevented loss of bone density. The participants were osteopenic elderly females, all post-menopausal. While calcium and vitamin D are commonly studied, I thought it would be interesting to research other non-traditional means of improving bone density, as there is a large portion of my patient population that are non-compliant with medications but are willing to eat/drink foods to improve their health. While calcium and vitamin D are natural means of improving bone density and decreasing osteoporosis, there still are often supplemented in the pill form, and there is a cohort of elderly and a growing number of younger patients who are adverse to taking pills or “medications and would rather do something simpler/cheaper/more natural. I feel that with some patients, especially ones who may already eat prunes for constipation, telling them to eat 4-5 prunes a day (50g) may be easier for them than prescribing them an oyster shell calcium/D.

This systemic review is important because it investigates the importance of vitamin d supplementation in bone density and osteoporosis. Vitamin D along with calcium have long been regarded as very important dietary factors contributing to a decrease in bone density and osteoporosis. A deficiency in vitamin D in the diet is a major risk factor for osteoporosis and increasing endogenous vitamin d through supplementation may be a way to help patients increase bone density and decrease osteoporosis risk.  

This review analyzed thousands of different studies and looked at vitamin D supplementation effect on bone density throughout several different regions of the body. The meta-analysis did find a slight increase in bone density in the femoral neck bone but was not attributed to vitamin d but more so an artifact chance finding. Based on the results from this systemic review and meta-analysis it can be concluded that vitamin d supplementation as a stand-alone preventative measure without and dietary vitamin d deficiency is not worthwhile and does not produce any effect on bone density. From a nutrition perspective this shows that maintain a healthy balanced diet is the best medicine for prevention and/or risk. Supplements especially from over-the-counter corner nutrition stores are often not regulated by the FDA and therefore we have no way to be sure of what’s in them. Getting micronutrients through diet is the best way to be sure what and how much we are ingesting. 

In the clinic this meta-analysis proves the importance of dietary intervention and education. This research found that supplementation did not provide any benefit when there was no dietary fail or previous risk for vitamin d deficiencies. If we can get patients on board with consuming a balanced diet and not turning to supplements to get micronutrients it is the most beneficial and natural way to be sure we know what we are ingesting. As I mentioned above, supplementation is on the rise and there is supplement stores out there that are more driven to make sales than they are to help people. 

Bisphosphonates are one of the important groups of medication taken orally for osteoporosis treatment. This review paper is important because the authors examine the effects of food, beverages, and dietary supplements that are consumed during treatment with bisphosphonates and the possible effects on pharmacokinetics and pharmacodynamics. 

They examined the drug Risedronate and found that, when taking the immediate release form of the drug, it was best to take it one hour before breakfast. This is because taking it with a meal further increases the already low oral bioavailability. However, in a study conducted with delayed-release Risedronate taken directly after a meal, they found it had the same oral bioavailability as the immediate release tablet taken 30 minutes before breakfast.

Since one in three women and one in five men in their 50’s is expected to experience an osteoporotic fracture in their lifetime, learning how drugs commonly used to treat osteoporosis interact with food, beverages, and supplements is very clinically relevant to their treatment.