I’m going through my backlog of research on bones in order to write a reader-friendly version of the tome that is Bones, Vitamin D, and Calcium on VeganHealth.org.

In January 2012, a report from China was released of a randomized clinical trial comparing the effects of cow’s milk and soymilk on bone mineral density (BMD) in postmenopausal women (1).

The women were divided into three groups: soy, cow’s, and control. The women knew which treatment they were receiving, while the control group got nothing. The milk and soymilk had 250 mg of calcium and they drank one serving per day.

BMD was measured in the spine, hip, and femur at 6, 12, and 18 months.

In the cow’s milk group, BMD increased in the hip and femur. In the soymilk group, BMD did not change significantly, but showed a downward trend in all three locations. In the control group, there was a downward trend in all three locations that only reached significance in the femur at 18 months.

It should be strongly noted that the participants were asked to avoid calcium from other milks and supplements during the trial which means their total calcium intake was probably quite low and I’m somewhat amazed that their BMD didn’t decrease more or in all three groups. Total calcium intake during the study period was not reported.

Compliance was 93.1% in the cow’s milk group and 82.5% in the soymilk group. This might explain a small amount of the differences between those groups. Other possibilities are that calcium in fortified soymilk is known to quickly settle to the bottom of the milk where it might not be ingested but left in the container, and that milk contains phosphorus and growth factors that might increase BMD.

This is just one small study and more work needs to be done before any conclusions should be drawn.

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Reference

1. Gui JC, Brašić JR, Liu XD, Gong GY, Zhang GM, Liu CJ, Gao GQ. Bone mineral density in postmenopausal Chinese women treated with calcium fortification in soymilk and cow’s milk. Osteoporos Int. 2012 May;23(5):1563-70. Epub 2012 Jan 27. | link

IMPORTANT UPDATE: On October 1, 2014 the European Medicines Agency’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended that strontium ranelate (Protelos/Osseor, Servier) no longer be used to treat osteoporosis because of data demonstrating serious negative side effects.

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Three of the six people who answered my request for information about successfully increasing bone mineral density (BMD) used strontium. A week ago, I had never even heard of strontium as a supplement for bone health, but I have come to find that it’s all the rage!

Strontium is a mineral that has some properties similar to calcium. It appears to cause both an increase in bone formation and a decrease in bone breakdown. Strontium ranelate has been approved for use as a drug in Europe. The FDA has not approved strontium ranelate, but strontium citrate is available in the U.S. The ranelate is separated from the strontium in the digestive tract and has no pharmacological value, so strontium citrate and other versions are thought to be similarly effective.

The Cochrane Database group published a systematic review of the evidence for treating low BMD or osteoporosis with strontium ranelate in 2006, and later updated it in 2008 (1). They concluded:

“There is silver level evidence to support the efficacy of strontium ranelate for the reduction of fractures (vertebral and to a lesser extent, non-vertebral) in postmenopausal osteoporotic women and an increase in BMD in postmenopausal women with/without osteoporosis. Diarrhea may occur, however, adverse events leading to study withdrawal were not significantly increased. Potential vascular and neurological side-effects need to be further explored.”

2 grams per day is the amount typically given and found to be especially effective.

Since 2008, a bit more evidence has come to light:

A 5-year study comparing strontium ranelate to a placebo group was extended to 10 years, but without a placebo group (2). The participants were also put on calcium (< 1000 mg/day) and vitamin D (400 to 800 IU/day). It was an open label trial, meaning the participants knew they were taking strontium ranelate. The extra five years of strontium showed it to be as effective as the first five years, which had been effective at preventing fractures and a loss of BMD.

In March of 2012, the European Medicines Agency issued a press release cautioning people with a history of venous thromboembolism or who are immobilized or bed ridden not to use strontium ranelate (3). They also recommended that people over 80 not use strontium ranelate. Finally, people should be aware of potential skin rashes with its use and discontinue if a skin rash or other allergic reaction occurs.

Please talk to your doctor before taking strontium!

References

1. O’Donnell S, Cranney A, Wells GA, Adachi J, Reginster JY. Strontium ranelate for preventing and treating postmenopausal osteoporosis. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005326. DOI: 10.1002/14651858.CD005326.pub3. | link. PubMed: link

2. Reginster JY, Kaufman JM, Goemaere S, Devogelaer JP, Benhamou CL, Felsenberg D, Diaz-Curiel M, Brandi ML, Badurski J, Wark J, Balogh A, Bruyère O, Roux C. Maintenance of antifracture efficacy over 10 years with strontium ranelate in postmenopausal osteoporosis. Osteoporos Int. 2012 Mar;23(3):1115-22. | link

3. European Medicines Agency confirms positive benefit-risk balance of Protelos/Osseor, but recommends new contraindications and revised warnings. March 16, 2012. Accessed February 27, 2013. | link

IMPORTANT UPDATE: On October 1, 2014 the European Medicines Agency’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended that strontium ranelate (Protelos/Osseor, Servier) no longer be used to treat osteoporosis because of data demonstrating serious negative side effects.

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I heard from six people, all vegan, who have improved their bone mineral density (BMD). Three of them used strontium and I will have more to say about strontium tomorrow ̶ assuming no other nutrition or other crisis!

It should be strongly noted, this is only anecdotal evidence and I am not recommending anyone do anything based on these results without first talking to their doctor.

Here are the results:

A 72-year old woman whose BMD has gone up since age 50 on a regimen of:

a) Increasing calcium to recommended levels
b) Doing an hour of weight bearing exercise most days (about 6 days a week)
c) Vitamin D

A woman who improved her osteopenia on a regimen of:

a) Weight bearing exercise
b) Calcium
c) Magnesium
d) Strontium
e) Vitamin K2
f) Vitamin D3
g) Increased a variety of foods, you can read more by clicking here

A woman who improved her osteoporosis to osteopenia since 2005 with less than a year of drugs and then:

a) Strontium
b) Weight lifting

A woman whose bone mineral density improved after almost a year of:

a) Strontium citrate

A 41-year old man diagnosed with vitamin D deficiency and osteopenia improved bone mineral density after a year of:

a) Vitamin D
b) Calcium

A woman who improved her BMD while taking Fosamex and whose BMD “plummeted” when she went off it.

A note on strontium and BMD scans from WebMd: “[I]t’s important to note that while strontium may increase bone density, improvements seen on bone density testing may appear more impressive than they really are… you should let the radiologist know before you have the bone mineral density test.”

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[Thank you for all the responses to my request for information on increasing bone mineral density! I received a lot of responses and am still working my way through them.]

Because I’m planning to write a more reader-friendly version of VeganHealth.org’s Bones, Vitamin D, and Calcium, I decided to check in on the research on protein and bone health. In so doing, I found a 2012 review from a group of researchers in France who declared having no conflicts of interest (1).

There has been an enormous amount of research on protein and bone health and their review had almost 4 pages of references. I will hit the highlights of what they found:

– Many clinical trials show that adding purified proteins to the diet increases calcium excretion through the urine.

– Phosphorus, in which meat and dairy are rich, counteracts the increase of calcium in the urine between 40 and 65%.

– Findings that older people in Western countries have higher hip fracture rates are confounded by the fact that people in Western countries live longer, protein intakes were not estimated for individuals, and there are ethnic differences in bone structure and lifestyles.

– High protein diets increase acid excretion in the urine, but this can be handled by the body’s acid buffer system without the need for calcium.

– Studies measuring whole-body calcium balance (as distinct from excretion) in relation to high protein diets have been mixed, but this might partly be due to the difficulty in measuring calcium balance and because high protein diets might reduce calcium balance when calcium intakes are particularly low.

– In low-calcium, but not high-calcium diets, higher protein intakes probably increase calcium absorption from the digestive tract causing an increase in calcium excretion in the urine.

– Fruits and vegetables are beneficial to bone health, probably due to their high potassium and magnesium content. This could cause confounding in protein studies because diets high in protein are often low in fruits and vegetables.

– As I describe in my post Protein Intake and Bone Health, Darling et al. (2009) found that a large majority of the cross-sectional surveys and cohort studies have reported either no association or a beneficial association between protein and bone mineral density.

– There is some evidence that a beneficial effect of protein on bones is only seen when calcium intake and vitamin D status is adequate.

– Maintenance of adequate bone strength and density with aging is dependent on adequate muscle mass which is dependent on adequate intake of protein.

– An increase in IGF-1 is most likely the mechanism for increased bone health with higher protein intakes.

They conclude, “Although HP [high protein] diets induce an increase in net acid and urinary calcium excretion, they do not seem to be linked to impaired calcium balance and no clinical data support the hypothesis of a detrimental effect of HP diet on bone health, except in the context of inadequate calcium supply.”

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Reference

1. Calvez J, Poupin N, Chesneau C, Lassale C, Tomé D. Protein intake, calcium balance and health consequences. Eur J Clin Nutr. 2012 Mar;66(3):281-95. | link

Are there any vegans out there who have been diagnosed with osteopenia or osteoporosis and have successfully increased their bone mineral density (confirmed by measurements by a doctor)?

If you prefer to email me privately, please send me a note through my contact form (click here).

Thank you!

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If button doesn’t work, please click through to website. Thank you!

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Vegan for Life: Everything You Need to Know to Be Healthy and Fit on a Plant-Based Diet from Amazon.com

As promised last week, here is a write-up of the 2009 studies associating poor bone health with low B12 status in vegetarians. This is an important reason for lacto-ovo vegetarians, as well as vegans, to make sure they are getting a reliable source of vitamin B12.

VeganHealth.org’s Bones, Vitamin D, and Calcium updated:

“A 2009 cross-sectional study from Slovakia compared lacto-ovo vegetarian women to omnivores. They found that the vegetarians’ higher homocysteine (16.5 vs. 12.5 µmol/l; 78% vs. 45% were elevated) and lower vitamin B12 levels (246 vs. 302 pmol/l; 47% vs. 28% were deficient) were associated with significantly lower bone mineral density in the femur (1). Participants were not allowed to have been taking vitamin or mineral supplements. The researchers did not measure calcium intake or vitamin D status.

“Another 2009 cross-sectional study of German omnivores, lacto-ovo vegetarians, and omnivores, and Indian lacto-ovo vegetarians and omnivores found higher markers of bone turnover associated with low vitamin B12 status (2). The findings were no worse for the lacto-ovo vegetarians than the vegans, indicating that poor bone health can start with just moderate B12 deficiency. None of the participants were taking B12, calcium, or vitamin D supplements.”

References

1. Krivosikova Z, Krajcovicova-Kudlackova M, Spustova V, Stefikova K, Valachovicova M, Blazicek P, Nemcova T. The association between high plasma homocysteine levels and lower bone mineral density in Slovak women: the impact of vegetarian diet. Eur J Nutr. 2009 Oct 7. | link

2. Herrmann W, Obeid R, Schorr H, Hübner U, Geisel J, Sand-Hill M, Ali N, Herrmann M. Enhanced bone metabolism in vegetarians–the role of vitamin B12 deficiency. Clin Chem Lab Med. 2009;47(11):1381-7. | link

[Erratum from yesterday’s post on Vitamin A: The amount of vitamin A in the chart at VeganHealh.org in mangoes was listed as 181 for 1 cup. I copied the amount from the wrong column – it is actually 89 for 1 cup.]

Commenting on a report by the International Osteoporosis Foundation (IOF), Ginny Messina, MPH, RD has an interesting post on retaining muscle and bone mass in older age, Staying Strong on a Vegan Diet: Protein and Muscles.

Ginny also has added the Food Guide 4 Vegans from our book, Vegan For Life, to her website, which provides a convenient way, especially for new vegans, to see how to eat in order to meet all the nutrition requirements.

I noticed that the new USDA nutrient database seemed to have changed the amounts of calcium in some of the greens they had listed. I have updated Table 5 in Bones, Vitamin D, and Calcium at VeganHealth.org.

The USDA database lists a number of different versions for foods – for each type of greens, for example, there are a half dozen to a dozen entries. In the past, I’ve tried to take the most usual or average them out. This time, in updating Table 5, I used the exact entry and I included a number of entries for some of the foods.

Unfortunately, the amount of calcium in broccoli was lowered from 50 to 31 mg per serving. Other greens seemed to stay about the same.

From March 20, 2012:

I was wondering if you saw this study [showing that increased vitamin D intake, but not increased dairy and calcium, protected adolescent girls against stress fractures] that went around yesterday, and saw PCRM’s release on it. I only read the abstract, but didn’t see that higher intakes of calcium was correlated with higher risk of bone fracture. I was wondering what you thought about this, because I remember you referencing some studies showing that vegans have higher rates of bone fracture, and that the difference went away when the vegans had high enough intakes of calcium. Was that because they were getting the calcium from plant sources, you reckon?

Answer:

It is only one study (EPIC-Oxford, 2007) showing vegans to have a higher fracture rate, the only study measuring fracture rates in Western vegans. It showed that the category of vegans getting less than 525 mg/day of calcium had a higher fracture rate than other diet groups, but that vegans getting more calcium had the same rate.

I did see PCRM’s press release on this study and have since obtained a copy of the paper. Although not mentioned in the abstract, the study found a trend towards increased risk of stress fracture with increased calcium intakes, among girls in the high impact activity category, though the finding was not statistically significant.

These results have little bearing, one way or the other, on my recommendations that vegans get more than 525 mg/day of calcium (and preferably 700 – 1,000 mg/day). The lowest category of calcium intake was 541 mg/day. The second lowest was 825 mg/day and that category didn’t have a practically different risk compared to the lowest category. It wasn’t until the middle category of calcium intake, an average of 1,111 mg per day, that there was a strong trend towards higher risk of stress fracture (though, again, it wasn’t statistically significant).

Here are some excerpts from the paper’s discussion:

“Our findings are not consistent with those reported in a prospective study of 125 young adult female competitive distance runners, which found that higher intakes of calcium and dairy products predicted lower rates of stress fracture and that higher intakes of vitamin D, calcium, and dairy foods were all associated with significant gains in hip bone mineral density during the 2 years of follow-up.

“Our findings are supported by several studies that have found no association between dairy intake and bone health in children and adolescents. While 2 randomized trials reported a positive relationship between dairy product consumption and measures of bone health, most cross-sectional, retrospective, and prospective studies did not. A review of calcium intake, dairy product intake, and bone health found that the vast majority of controlled studies of dairy supplementation or total dietary calcium intake show that, although very low calcium intake may be harmful to bone development, increases in dairy or total dietary calcium intakes higher than 400 to 500 mg/d are not correlated with nor represent a predictor of bone mineral density or fracture rate in children or adolescents.”

The evidence appears to be mixed as to whether calcium intakes higher than 400 to 500 mg in children and adolescents is protective, harmful, or neutral. EPIC-Oxford remains the most important finding for vegans.

Reference

Sonneville KR, Gordon CM, Kocher MS, Pierce LM, Ramappa A, Field AE. Vitamin D, Calcium, and Dairy Intakes and Stress Fractures Among Female Adolescents. Arch Pediatr Adolesc Med. 2012 Mar 5. [Epub ahead of print] | link

I’ve had a study on the acid load of vegan diets in my queue for awhile now and finally read it carefully. I just added this to the Bones, Vitamin D, and Calcium article at VeganHealth.org:

“Sulfur-containing amino acids are more prevalent in animal products, although they are also found in high amounts in many grains. A 2011 study from Germany tracked the diets of 98 vegans and 56 near-vegans for a week and used models to predict the effect of their diets on renal acid load. They found both diets to be neutral, whereas other studies show a typical omnivorous diet to be more acid producing (1).”

One thing that surprised me about this study was that they estimated that the vegans were consuming an average of 854 mg/day of calcium. That’s one of the higher estimates I’ve seen and the study didn’t indicate that they included supplements or calcium from fortified foods.

Since they merely estimated the acid load from models, rather than actually measuring it directly, the conclusion should be taken with some caution. And, as I’ve said many times before, the acid load of a vegan diet might not have all that much to do with the risk of osteoporosis for vegans – calcium and vitamin D appear to be much more important (see the link above on bones for more information).

Reference

1. Ströhle A, Waldmann A, Koschizke J, Leitzmann C, Hahn A. Diet-dependent net endogenous acid load of vegan diets in relation to food groups and bone health-related nutrients: results from the German Vegan Study. Ann Nutr Metab. 2011;59(2-4):117-26. Link