Protein intake and lumbar bone density: the Multi-Ethnic Study of Atherosclerosis (MESA). Biomarker-calibrated protein intake and bone health in the Women's Health Initiative clinical trials and observational study. The Relation between Dietary Protein, Calcium and Bone Health in Women: Results from the EPIC-Potsdam Cohort Dietary protein intake and risk of osteoporotic hip fracture in elderly residents of Utah. Dietary protein and calcium interact to influence calcium retention: a controlled feeding study. Identification of a dietary pattern prospectively associated with bone mass in Australian young adults. Long-term protein intake and dietary potential renal acid load are associated with bone modeling and remodeling at the proximal radius in healthy children. Association of protein intake with bone mineral density and bone mineral content among elderly women: The OSTPRE fracture prevention study Dietary protein is associated with musculoskeletal health independently of dietary pattern: the Framingham Third Generation Study. Dietary phytochemical intake from foods and health outcomes: a systematic review protocol and preliminary scoping Whey Protein Supplementation and Higher Total Protein Intake Do Not Influence Bone Quantity in Overweight and Obese Adults Following a 36-Week Exercise and Diet Intervention. [Optimization of calcium intake for the prevention of osteoporosis and osteoporotic fractures: a review of the evidence]. Examining the theory‐effectiveness hypothesis: A systematic review of systematic reviews Bone Size and Bone Mass in 10-Year-Old Danish Children: Effect of Current Diet
 Calcium intake in health maintenance – a systematic review Effect of dietary protein supplements on calcium excretion in healthy older men and women. The Effect of a Whey Protein Supplement on Bone Mass in Older Caucasian Adults. Effect of protein supplementation during a 6-month strength and conditioning program on areal and volumetric bone parameters. Short-term changes in calcium but not protein intake alter the rate of bone resorption in healthy subjects as assessed by urinary pyridinium cross-link excretion. Calcium intake influences the association of protein intake with rates of bone loss in elderly men and women. Veganism, bone mineral density, and body composition: a study in Buddhist nuns Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: A Clinical Practice Guideline from the American College of Physicians A high ratio of dietary animal to vegetable protein increases the rate of bone loss and the risk of fracture in postmenopausal women. Study of Osteoporotic Fractures Research Group. Dietary Protein Intake and Coronary Heart Disease in a Large Community Based Cohort: Results from the Atherosclerosis Risk in Communities (ARIC) Study Soy proteins and isoflavones affect bone mineral density in older women: a randomized controlled trial. Effects of dietary protein and glycaemic index on biomarkers of bone turnover in children. Protein consumption and bone fractures in women. Maternal first-trimester diet and childhood bone mass: the Generation R Study. Diets higher in dairy foods and dietary protein support bone health during diet- and exercise-induced weight loss in overweight and obese premenopausal women. The effectiveness of education or behavioral interventions on adherence to phosphate control in adults receiving hemodialysis: a systematic review protocol New approach to osteopenia in phenylketonuric patients Nutritional factors that influence change in bone density and stress fracture risk among young female cross-country runners. The effects of a two-year randomized, controlled trial of whey protein supplementation on bone structure, IGF-1, and urinary calcium excretion in older postmenopausal women. Protein intake: effects on bone mineral density and the rate of bone loss in elderly women. Controlled high meat diets do not affect calcium retention or indices of bone status in healthy postmenopausal women. Bone gain in young adult women. A lifecourse study of bone resorption in men ages 49-51years: the Newcastle Thousand Families cohort study. Effectiveness of interventions that assist caregivers to support people with dementia living in the community: a systematic review. Effects of food groups and dietary nutrients on bone loss in elderly Chinese population Creation of a database to assess effects of omega-3, omega-6 and total polyunsaturated fats on health: methodology for a set of systematic reviews The effectiveness of interventions to reduce undernutrition and promote eating in older adults with dementia: A systematic review The ratio of animal protein intake to potassium intake is a predictor of bone resorption in space flight analogues and in ambulatory subjects. Benefits of post-operative oral protein supplementation in gastrointestinal surgery patients: A systematic review of clinical trials. Comparison of 2 weight-loss diets of different protein content on bone health: a randomized trial. Fermented dairy products consumption is associated with attenuated cortical bone loss independently of total calcium, protein, and energy intakes in healthy postmenopausal women Intake of total, animal and plant protein and subsequent changes in weight or waist circumference in European men and women: the Diogenes project Effectiveness of interventions that assist caregivers to support people with dementia living in the community: a systematic review Vitamin K-containing dietary supplements: comparison of synthetic vitamin K1 and natto-derived menaquinone-7.
Dietary protein has been shown to increase urinary Ca excretion in r and omised 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 population s may in part explain the inconsistent findings reported previously BACKGROUND The effects of dietary protein on bone health are controversial . OBJECTIVE We examined the relation between protein intake with fracture and  bone mineral density ( BMD )  within the Women 's Health Initiative ( WHI ) . DESIGN This prospect i ve analysis included 144,580 women aged 50 - 79 y at baseline in the WHI clinical trials ( CTs ) and observational study ( OS ) that recruited participants in 1993 - 1998 with follow-up through 2011 . Self-reported clinical fractures were collected semiannually through the original end of the trials ( WHI CTs ) and annually ( WHI OS ) by question naires . Hip fracture was adjudicated by a central review of radiology reports . BMDs for total body , hip , and spine were measured at baseline and 3 and 6 y in 9062 women at 3 WHI clinics by using dual-energy X-ray absorptiometry .  Protein intake was assessed via food-frequency question naire and calibrated by using biomarkers of energy and protein intakes . Associations between protein intake and fracture were estimated by using Cox proportional hazards regression , and the relation between protein intake and BMD was estimated by using linear regression . RESULTS Median biomarker-calibrated protein intake was 15 % of energy intake . Per 20 % increase in calibrated protein intake ( percentage of energy ) , there was no significant association with total fracture ( HR : 0.99 ; 95 % CI : 0.97 , 1.02 ) or hip fracture ( HR : 0.91 ; 95 % CI : 0.84 , 1.00 ) , but there was an inverse association with forearm fracture ( HR : 0.93 ; 95 % CI : 0.88 , 0.98 ) . Each 20 % increase in calibrated protein intake was associated with a significantly higher BMD for total body ( mean 3-y change : 0.003 g/cm² ; 95 % CI : 0.001 , 0.005 g/cm² ) and hip ( mean 3-y change : 0.002 g/cm² ; 95 % CI : 0.001 , 0.004 g/cm² ) . CONCLUSIONS Higher biomarker-calibrated protein intake within the range of usual intake was inversely associated with forearm fracture and was associated with better maintenance of total and hip BMDs . These data suggest higher protein intake is not detrimental to bone health in postmenopausal women Background / Aims : The role of dietary protein in bone health is controversial . The objective of the present study was to examine the association between protein intake , dietary calcium , and bone structure measured by broadb and ultrasound attenuation ( BUA ) . Methods : Our analysis includes 8,178 female study participants of the European Prospect i ve Investigation into Cancer and Nutrition ( EPIC ) Potsdam Study . Ultrasound bone measurements were performed on the right os calcis , and BUA was determined . Dietary intake was assessed by a st and ardized food frequency question naire . We applied linear regression models to estimate the association between dietary protein and BUA . Results : After multivariate adjustment , high intake of animal protein was associated with decreased BUA values ( β = –0.03 ; p = 0.010 ) whereas high vegetable protein intake was related to an increased BUA ( β = 0.11 ; p = 0.007 ) . The effect of dietary animal protein on BUA was modified by calcium intake . Conclusion : High consumption of protein from animal origin may be unfavourable , whereas a higher vegetable protein intake may be beneficial for bone health . Our results strengthen the hypothesis that high calcium intake combined with adequate protein intake based on a high ratio of vegetable to animal protein may be protective against osteoporosis UNLABELLED The role of protein intake in osteoporosis is unclear . In a case-control study in Utah ( n = 2501 ) , increasing level of protein intake was associated with a decreased risk of hip fracture in men and women 50 - 69 years of age but not in those 70 - 89 years of age . Protein intake may be important for optimal bone health . INTRODUCTION Protein is an important component of bone , but the role of dietary protein intake in osteoporosis and fracture risk remains controversial . MATERIAL AND METHODS The role of dietary protein intake in osteoporotic hip fracture was evaluated in a statewide case-control study in Utah . Patients , 50 - 89 years of age , with hip fracture ( cases ) were ascertained through surveillance of 18 Utah hospitals during 1997 - 2001 . Age- and gender-matched controls were r and omly selected . Participants were interviewed in their place of residence , and diet was assessed using a picture-sort food frequency question naire previously reported to give a useful measure of usual dietary intake in the elderly Utah population . The association between  protein intake  and risk of hip fracture was examined across quartiles of protein intake and stratified by age group for 1167 cases ( 831 women , 336 men ) and 1334 controls ( 885 women , 449 men ) . RESULTS In logistic regression analyses that controlled for gender , body mass index , smoking status , alcohol use , calcium , vitamin D , potassium , physical activity , and estrogen use in women , the odds ratios ( OR ) of hip fracture decreased across increasing quartiles of total protein intake for participants 50 - 69 years of age ( OR : 1.0 [ reference ] ; 0.51 [ 95 % CI : 0.30 - 0.87 ] ; 0.53 [ 0.31 - 0.89 ] ; 0.35 [ 0.21 - 0.59 ] ; p < 0.001 ) . No similar associations were observed among participants 70 - 89 years of age . Results from analyses stratified by low and high calcium and potassium intake did not differ appreciably from the results presented above . CONCLUSION Higher total protein intake was associated with a reduced risk of hip fracture in men and women 50 - 69 years of age but not in men and women 70 - 89 years of age . The association between  dietary protein intake  and risk of hip fracture may be modified by age . Our study supports the hypothesis that adequate dietary protein is important for optimal bone health in the elderly 50 - 69 years of age BACKGROUND The effect of meat protein on calcium retention at different calcium intakes is unresolved . OBJECTIVE The objective was to test the effect of dietary protein on calcium retention at low and high intakes of calcium . DESIGN In a r and omized controlled feeding study with a 2 x 2 factorial crossover design , healthy postmenopausal women ( n = 27 ) consumed either approximately 675 or approximately 1510 mg Ca/d , with both low and high protein ( providing 10 % and 20 % energy ) for 7 wk each , separated by a 3-wk washout period . After 3 wk , the entire diet was extrinsically labeled with (47)Ca , and isotope retention was monitored by whole-body scintillation counting . Clinical markers of calcium and bone metabolism were measured . RESULTS High compared with low dietary protein significantly increased calcium retention from the low-calcium ( 29.5 % compared with 26.0 % absorbed ) but not the high-calcium diet ( 18 % absorbed ) . For the low-calcium diet , this effect nearly balanced a protein-related 0.5-mmol/d greater urinary calcium excretion . Protein-related calciuretic effects were independent of dietary calcium . Testing at 1 , 2 , 3 , 5 , and 7 wk showed no long-term adaptation in urinary acidity or urinary calcium excretion . High compared with low dietary protein decreased urinary deoxypyridinoline and increased serum insulin-like growth factor I without affecting parathyroid hormone , osteocalcin , bone-specific alkaline phosphatase , or tartrate-resistant acid phosphatase . CONCLUSIONS In healthy postmenopausal women , a moderate increase in dietary protein , from 10 % to 20 % of energy , slightly improved calcium absorption from a low-calcium diet , nearly compensating for a slight increase in urinary calcium excretion . Under practical dietary conditions , increased dietary protein from animal sources was not detrimental to calcium balance or short-term indicators of bone health BACKGROUND Relatively little is known about the relations between dietary patterns and bone health in adolescence , which is a period of substantial bone mass accrual . OBJECTIVES We derived dietary patterns that were hypothesized to be related to bone health on the basis of their protein , calcium , and potassium contents and investigated their prospect i ve associations with bone mineral density ( BMD ) , bone area , and bone mineral content ( BMC ) in a cohort of young adults . DESIGN The study included 1024 young adults born to mothers who were participating in the Western Australian Pregnancy Cohort ( Raine ) Study .  Dietary information was obtained from food-frequency question naires at 14 and 17 y of age . Dietary patterns were characterized according to protein , calcium , and potassium intakes with the use of reduced-rank regression . BMD , bone area , and BMC were estimated with the use of a total body dual-energy X-ray absorptiometry scan at 20 y of age . RESULTS We identified 2 major dietary patterns . The first pattern was positively correlated with intakes of protein , calcium , and potassium and had high factor loadings for low-fat dairy products , whole grains , and vegetables . The second pattern was positively correlated with protein intake but negatively correlated with intakes of calcium and potassium and had high factor loadings for meat , poultry , fish , and eggs . After adjustment for anthropometric , sociodemographic , and lifestyle factors , a higher z score for the first pattern at 14 y of age was positively associated with BMD and BMC at 20 y of age [ differences : 8.6 mg/cm(2 ) ( 95 % CI : 3.0 , 14.1 mg/cm(2 ) ) and 21.9 g ( 95 % CI : 6.5 , 37.3 g ) , respectively , per SD increase in z score ] . The z score for this same pattern at 17 y of age was not associated with bone outcomes at 20 y of age . The second pattern at 14 or 17 y of age was not associated with BMD , BMC , or bone area . CONCLUSIONS A dietary pattern characterized by high intakes of protein , calcium , and potassium in midadolescence was associated with higher BMD and BMC at 20 y of age . Our results indicate that high consumption of low-fat dairy products , whole grains , and vegetables in adolescence are associated with beneficial effects on bone development BACKGROUND Protein and alkalizing minerals are increasingly described as playing a major role in influencing bone status , not only in the elderly but also in children and adolescents . OBJECTIVE We examined whether the long-term dietary protein intake and diet net acid load are associated with bone status in children . DESIGN In a prospect i ve study design in 229 healthy children and adolescents aged 6 - 18 y , long-term dietary intakes were calculated from 3-d weighed dietary records that were collected yearly over the 4-y period before a one-time bone analysis . Dietary acid load was characterized as potential renal acid load ( PRAL ) by using an algorithm including dietary protein , phosphorus , magnesium , and potassium . Proximal forearm bone variables were measured by peripheral quantitative computed tomography . RESULTS After adjustment for age , sex , and energy intake and control for forearm muscularity , BMI , growth velocity , and pubertal development , we observed that long-term  dietary protein intake  was significantly positively associated with periosteal circumference ( P < 0.01 ) , which reflected bone modeling , and with cortical area ( P < 0.001 ) , bone mineral content ( P < 0.01 ) , and polar strength strain index ( P < 0.0001 ) , which reflected a combination of modeling and remodeling . Children with a higher dietary PRAL had significantly less cortical area ( P < 0.05 ) and bone mineral content ( P < 0.01 ) . Long-term calcium intake had no significant effect on any bone variable . CONCLUSIONS Long-term dietary protein intake appears to act anabolically on diaphyseal bone strength during growth , and this may be negated , at least partly , if dietary PRAL is high , ie , if the intake of alkalizing minerals is low Abstract It has been hypothesized that high protein intakes are associated with lower bone mineral content ( BMC ) . Previous studies yield conflicting results and thus far no studies have undertaken the interaction of body mass index ( BMI ) and physical activity with protein intakes in relation to BMC and bone mineral density ( BMD ) . Objective To evaluate the associations of dietary total protein ( TP ) , animal protein ( AP ) and plant protein ( PP ) intakes with BMC and BMD and their changes . We tested also the interactions of protein intake with , obesity ( BMI ≤30 vs. > 30 kg/m2 ) and physical activity level ( passive vs. active ) . Design / Setting Prospect i ve cohort study ( Osteoporosis Risk-Factor and Fracture-Prevention Study ) . Participants / measures At the baseline , 554 women aged 65 - 72 years filled out a 3-day food record and a question naire covering data on lifestyle , physical activity , diseases , and medications . Intervention group received calcium 1000 mg/d and cholecalciferol 800 IU for 3 years . Control group received neither supplementation nor placebo . Bone density was measured at baseline and year 3 , using dual energy x-ray absorptiometry . Multivariable regression analyses were conducted to examine the associations between protein intake and BMD and BMC . Results In cross-sectional analyses energy-adjusted TP ( P≤0·029 ) and AP ( P≤0·045 ) but not PP ( g/d ) were negatively associated with femoral neck ( FN ) BMD and BMC . Women with TP≥1·2 g/kg/body weight ( BW ) ( Ptrend≤0·009 ) had lower FN , lumbar spine ( LS ) and total BMD and BMC . In follow-up analysis , TP ( g/kg/BW ) was inversely associated with LS BMD and LS BMC . The detrimental associations were stronger in women with BMI < 30 kg/m2 . In active women , TP ( g/kg/BW ) was positively associated with LS BMD and FN BMC changes . Conclusions This study suggests detrimental associations between protein intake and bone health . However , these negative associations maybe counteracted by BMI > 30 kg/m2 and physical activity Background : Above-average dietary protein , as a single nutrient , improves musculoskeletal health . Evaluating the link between dietary protein and musculoskeletal health from a whole-diet perspective is important , as dietary guidelines focus on dietary patterns . Objective : We examined the prospect i ve association of novel dietary protein food clusters ( derived from established dietary pattern techniques ) with appendicular lean mass ( ALM ) , quadriceps strength ( QS ) , and bone mineral density ( BMD ) in 2986 men and women , aged 19 - 72 y , from the Framingham Third Generation Study . Design : Total protein intake was estimated by food-frequency question naire in 2002 - 2005 . A cluster analysis was used to classify participants into mutually exclusive groups , which were determined by using the percentage of contribution of food intake to overall protein intake . General linear modeling was used to 1 ) estimate the association between protein intake ( grams per day ) and BMD , ALM , appendicular lean mass normalized for height ( ALM/ht2 ) , and QS ( 2008 - 2011 ) and to 2 ) calculate adjusted least-squares mean outcomes across quartiles of protein ( grams per day ) and protein food clusters . Results : The mean ± SD age of subjects was 40 ± 9 y ; 82 % of participants met the Recommended Daily Allowance ( 0.8 g · kg body weight-1 · d-1 ) . The following 6 dietary protein food clusters were identified : fast food and full-fat dairy , fish , red meat , chicken , low-fat milk , and legumes  . BMD was not different across quartiles of protein intake ( P-trend range = 0.32 - 0.82 ) ; but significant positive trends were observed for ALM , ALM/ht2 ( P < 0.001 ) , and QS ( P = 0.0028 ) . Individuals in the lowest quartile of total protein intake ( quartile 1 ) had significantly lower ALM , ALM/ht2 , and QS than did those in the higher quartiles of intake ( quartiles 2 - 4 ; ( P ranges = 0.0001 - 0.003 , 0.0007 - 0.003 , and 0.009 - 0.05 , respectively ) . However , there were no associations between protein clusters and any musculoskeletal outcome in adjusted models . Conclusions : In a protein-replete cohort of adults , dietary protein is associated with ALM and QS but not with BMD . In this study , dietary protein food patterns do not provide further insight into beneficial protein effects on muscle outcomes Introduction Dietary phytochemicals are found in plant-based foods such as fruits , vegetables and grains and may be categorised in a nested hierarchical manner with many hundred individual phytochemicals identified to date . To associate phytochemical intakes with positive health outcomes , a fundamental step is to accurately estimate the dietary phytochemical intake from foods reported . The purpose of this systematic review protocol is to describe the process to be undertaken to summarise the evidence for food-based dietary phytochemical intakes and health outcomes for adults . Methods and analysis The review will be undertaken following the PRISMA guidelines and the Cochrane H and book for Systematic Review s of Interventions using the Review Manager software . Phytochemical subclasses ( phenolic acids , flavanols , etc ) will be used to search for relevant studies using the Web of Science and Scopus scientific data bases . The retrieved studies will be screened based on inclusion of natural whole food items and health outcomes . Phytochemical studies related to cardiovascular disease , cancer , overweight , glucose tolerance , digestive , reproductive , macular and bone health and mental disorders , fatigue and immunity will be examined based on prior scoping . The evidence will be aggregated by the food types and health outcomes . Comparison of differences in the outcomes for r and omised controlled trials and observational studies will be undertaken . The strength of the review lies in its focus on whole food items and health conditions rather than one type of phytochemical related to one single health condition . Subgroup and sensitivity analyses will be conducted where an adequate number of publications are found per phytochemical subclass . Dissemination By comparing the outcomes from experimental and observational studies , the review will determine whether the overall conclusions related to the phytochemical subclasses are the same between study types for the identified health conditions . This is useful to public health policymakers and health professionals alike . Trial registration number # CRD42014015610 BACKGROUND Controversy exists concerning the effects of higher total protein intake ( TPro ) on bone health , which may be associated with reduced bone mineral density ( BMD ) . However , whey protein ( WP ) may induce bone formation because of its basic component , milk basic protein . OBJECTIVE This study assessed the effects of WP supplementation , TPro , and change in TPro ( postsupplementation - presupplementation ) on BMD and bone mineral content ( BMC ; total body , lumbar spine , total femur , and femoral neck ) in overweight and class I obese middle-aged adults following an exercise intervention . METHODS This analysis used data from a double-blind , r and omized , placebo-controlled 36-wk WP supplementation trial , wherein participants consumed a 1.7-MJ ( 400-kcal ) supplement ( 0 , 20 , 40 , or 60 g WP/d ) along with their otherwise unrestricted diet while participating in a resistance and aerobic exercise intervention ( 3 d/wk ) . TPro was the summation of WP and habitual dietary intakes ( 4-d food record ) . Statistical analyses for WP were based on group and bone data [ n = 186 , 108 women ; mean ± SD age : 49 ± 8 y ; body mass index ( BMI ; in kg/m2 ) : 30.1 ± 2.8 ] , whereas TPro was based on dietary and bone data ( n = 113 , 70 women ; age 50 ± 8 y ; BMI 30.1 ± 2.9 ) . RESULTS WP supplementation , regardless of dose , did not influence BMD or BMC following the intervention . By using a multiple linear regression model , TPro ( expressed as g/d or g · kg-1 · d-1 ) and change in TPro ( expressed as g/d ) were not associated with responses over time in total or regional BMD or BMC . By using a cluster analysis approach [ < 1.0 ( n = 41 ) , 1.0 - 1.2 ( n = 28 ) , and ≥1.2 g · kg-1 · d-1 ( n = 44 ) ] , TPro was also not associated with responses in total or regional BMD or BMC over time . CONCLUSION WP supplementation and total dietary protein intake did not negatively or beneficially influence bone quantity in overweight and obese adults during a 9-mo exercise intervention . This trial was registered at clinical trials.gov as NCT00812409 One of the main focuses of lifestyle modification for the prevention of osteoporosis and osteoporotic fractures  in Japan is improvement in dietary calcium intake . However , virtually no r and omized controlled trial to assess the preventive effects of administration of calcium on the risk of fractures has been conducted in Japan . In this study , we review ed all the scientific papers currently available from medical literature data bases to propose evidence -based recommendations on the preventive procedures for osteoporosis . The result of the present systematic review gives the evidence showing that calcium supplementation or optimal dietary calcium intake increases bone density in childhood and adolescence and reduces the risk of fracture due to osteoporosis in the elderly people regardless of the gender . The evidence also supports the current health policy guiding the elderly to increase their dietary calcium intake in daily life PURPOSE Health interventions based on theory may be more effective than those that are not . This review of review s synthesizes all published r and omized controlled trial ( RCT ) meta-analytic evidence from the last decade to examine whether theory-based interventions were found to be associated with more effective  adult health behaviour change interventions . METHODS Systematic review s including meta-analyses were identified by search ing Medline , CINAHL , PsycINFO , and CDSR . A narrative synthesis was used to summarize and analyse the evidence . Only review s including RCTs of health behaviour change interventions with adults aged 18 + published from 2007 to 2017 were included . RESULTS Of 8,659 articles , nine systematic review s met inclusion criteria . The majority of review s ( n = 8) suggested no increased effectiveness for theory-based compared to non-theory-based interventions for effectiveness of outcomes relating to health behaviour . Less than half of the RCTs included in the review s reported the use of theory ( 85/183 ) . Two review s suggested interventions based on control theory , motivational interviewing , or self-determination theory were associated with greater effectiveness for physical activity and /or dietary interventions and outcomes . Method ological and reporting issues limit the conclusions . CONCLUSIONS Theory-based interventions as currently operationalized in systematic review s were not found to be more effective than non-theory-based interventions . Method ological and reporting issues at study and review level may not reflect the true utility of theory use within health behaviour interventions . The promotion of theory use may benefit from using a multifaceted argument , rather than a narrow focus of increased effectiveness . Statement of contribution What is already known on this subject ? Theory use is regularly promoted by cl aim ing that it will lead to more effective behaviour change interventions . Theory use has been frequently linked to effectiveness within systematic review s of behaviour change interventions . The theory-effectiveness hypothesis has not been systematic ally examined at the systematic review level . What does this study add ? Theory use as operationalized by systematic review authors was not associated with increased effectiveness within systematic review s examining r and omized controlled trials of behaviour change interventions in adults . Interventions based on control theory , motivational interviewing , or self-determination theory were associated with greater effectiveness for physical activity and /or dietary interventions and outcomes . Theory use should be promoted using a multifaceted argument , and assertions for increased effectiveness of theory-based interventions should only be used in domains where specific evidence exists to support this cl aim Abstract : Lifestyle factors , such as diet , are believed to be involved in modifying bone health , although the results remain controversial , particularly in children and adolescents . The objective of the study was to identify associations between dietary factors and whole body bone measurements in 10-year-old children . The study was a cross-sectional analysis of a r and om sample of 105 healthy Danish children , aged 10 years ( 9.97 ± 0.09 ) . Whole body bone mineral content ( BMC ) and bone area ( BA ) were determined by dual-energy X-ray absorptiometry . The influence of diet ( 7 day food records ) on BMC and BA were examined in bi- and multivariate analyses . The mean intakes of calcium , protein , phosphorus and sodium were 1226 mg , 78 g , 1523 mg and 3.3 g , respectively . In bivariate analyses , BMC and BA were strongly positively correlated with height ( p<0.001 ) and weight ( p<0.001 ) , and with intakes of energy ( p<0.005 ) and several nutrients . BMC was adjusted for size by including BA , height and weight in the multiple linear regression , and BA was adjusted for size by including height and weight in the multiple linear regression . In multivariate analyses , size-adjusted BMC was positively associated with calcium intake ( p = 0.02 ) . Size-adjusted BA was positively associated with dietary protein ( p = 0.003 ) , and negatively associated with intakes of sodium ( p = 0.048 ) and phosphorus ( p = 0.01 ) . In conclusion , calcium intake was positively associated with bone mineralization . There was a positive association between protein and BA , while for phosphorus and sodium the association was negative . The findings suggest that in addition to calcium , the intake of other nutrients influences bone development in prepubertal children Background Calcium ( Ca ) is an essential nutrient for the human body . Despite lively research , there is uncertainty about Ca requirements in terms of desirable health outcomes including an upper intake level above which the potential for harm increases . Objectives The aim was to conduct a review to up date requirements and desirable or harmful health effects of Ca on the current scientific evidence . Methods We search ed Medline and Swemed from January 2000 to December 2011 and included all systematic review s that reported Ca supplementation or usual Ca intake on health outcomes . Meta-analyses , r and omized clinical trials and cohort studies were included in the second search between May 2009 and March 2011 and an additional search covering studies till the end of 2011 . This review concentrated on studies reporting independent effects of Ca , although a few recent trials report sole effects of Ca on health outcomes , most trials use Ca in combination with vitamin D vs. placebo . Results In total , we review ed 38 studies addressing the effects of Ca on bone , pregnancy-related outcomes , cancers , cardiovascular outcomes , obesity , and mortality .  There was a lot of heterogeneity in the study protocol s , which made it difficult to draw any strong conclusions . According to the literature , high Ca intake seems to have a small positive effect on bone mineral content ( BMC ) or bone mineral density ( BMD ) in children and postmenopausal women . We did not find any consistent evidence on the effects of Ca on bone health in premenopausal women or men . Also , the evidence that Ca supplementation reduces fracture incidence is scarce and inconsistent . Maternal diet may influence the peak bone mass of offspring but more studies are required . There was no overall effect of Ca intake on cancers . Ca was associated with a decreased risk of breast cancer and a slightly increased risk of prostate cancer in two of the three studies . No associations were found with other cancers . We found no consistent association between cardiovascular outcomes and  Ca  intake except for blood pressure . A small decrease of 2–4 mmHg in systolic blood pressure was found in pregnant and in hypertensive subjects with Ca supplementation . Review ed studies did not show consistent evidence relating Ca intake to either mortality or obesity . Conclusion Based on this evidence , there is no need to change the Nordic recommendations for Ca intake . However , due to heterogeneity in the studies it is difficult to interpret the results and provide single summary statement Currently there is no consensus on the impact of dietary protein on calcium and bone metabolism . This study was conducted to examine the effect of increasing protein intake on urinary calcium excretion and to compare circulating levels of IGF-I and biochemical markers of bone turnover in healthy older men and women who consumed either a high or a low protein food supplement for 9 wk . Thirty-two subjects with usual protein intakes of less than 0.85 g/kg.d were r and omly assigned to daily high ( 0.75 g/kg ) or low ( 0.04 g/kg ) protein supplement groups . Isocaloric diets were maintained by advising subjects to reduce their intake of carbohydrates . Selected biochemical measurements were made at baseline and on d 35 and either d 49 or 63 . Changes in urinary calcium excretion in the two groups did not differ significantly over the course of the study . The high protein group had significantly higher levels of serum IGF-I ( P = 0.008 ) and lower levels of urinary N-telopeptide ( P = 0.038 ) over the period of d 35 - 49 or 63 . We conclude that increasing protein intake from 0.78 to 1.55 g/kg.d with meat supplements in combination with reducing carbohydrate intake did not alter urine calcium excretion , but was associated with higher circulating levels of IGF-I , a bone growth factor , and lowered levels of urinary N-telopeptide , a marker of bone resorption . In contrast to the widely held belief that increased protein intake results in calcium wasting , meat supplements , when exchanged isocalorically for carbohydrates , may have a favorable impact on the skeleton in healthy older men and women CONTEXT It has been assumed that the increase in urine calcium ( Ca ) that accompanies an increase in dietary protein was due to increased bone resorption . However , studies using stable Ca isotopes have found that dietary protein increases Ca absorption without increasing bone resorption . OBJECTIVE The objective of the study was to investigate the impact of a moderately high protein diet on bone mineral density ( BMD ) . DESIGN This was a r and omized , double-blind , placebo-controlled trial of protein supplementation daily for 18 months . SETTING The study was conducted at two institutional research centers . PARTICIPANTS Two hundred eight older women and men with a body mass index between 19 and 32 kg/m(2 ) and a self-reported protein intake between 0.6 and 1.0 g/kg participated in the study . INTERVENTION Subjects were asked to incorporate either a 45-g whey protein or isocaloric maltodextrin supplement into their usual diet for 18 months . MAIN OUTCOME MEASURE BMD by dual-energy x-ray absorptiometry , body composition , and markers of skeletal and mineral metabolism were measured at baseline and at 9 and 18 months . RESULTS There were no significant differences between groups for changes in L-spine BMD ( primary outcome ) or the other skeletal sites of interest . Truncal lean mass was significantly higher in the protein group at 18 months ( P = .048 ) . C-terminal telopeptide ( P = .0414 ) , IGF-1 ( P = .0054 ) , and urinary urea ( P < .001 ) were also higher in the protein group at the end of the study period . There was no difference in estimated glomerular filtration rate at 18 months . CONCLUSION Our data suggest that protein supplementation above the recommended dietary allowance ( 0.8 g/kg ) may preserve fat-free mass without adversely affecting skeletal health or renal function in healthy older adults BACKGROUND Skeletal loading and proper nutrition are necessary for optimal bone health . The appropriate amount of dietary protein to maximize skeletal health , however , is under constant debate . OBJECTIVE To determine if 6 months of protein supplementation in conjunction with a strength and conditioning training program improves areal and volumetric bone mineral density ( BMD ) . DESIGN Fifty-two apparently healthy males and females ages 18 - 25 years were r and omized to protein supplement ( PRO , Myoplex , EAS , Inc. Golden CO ) containing 280 kcal , 42 g protein , 21 g carbohydrate , and 1.5 g fat ) or calorically equivalent carbohydrate control ( CS ) . All subjects participated in a 5 sessions/week strength and conditioning program .  Volumetric and areal BMD measurements were made by peripheral quantitative computed tomography ( pQCT ) of the tibia and whole body DXA . pSSI a measure of torsional bone strength , based on structural and material properties was obtained by pQCT . RESULTS Measurements at the 20 % tibia by pQCT revealed that overall there were significant increases in cortical vBMD ( 4.3 + /- 1.3 mg/cm(3 ) ) , cortical area ( 1.9 + /- 0.6 cm(2 ) ) , cortical thickness ( 0.05 + /- 0.02 mm ) and pSSI ( 67 + /- 24 mm(3 ) ) , and a decrease in endosteal circumference ( - 0.5 + /- 0.2 mm ) over the intervention period ( all , P < 0.05 ) . None of the changes in DXA measures were found to differ by group or sex , there was a trend for a greater increase in whole body BMC among the carbohydrate compared to protein supplemented group and a greater increase among males ( 16 + /- 8 g ) compared to females ( -9 + /- 9 g ) ( P = 0.06 ) . CONCLUSIONS The results of this study indicate that the consumption of additional protein does not improve measurements of vBMD or bone size during a 6-month strength and conditioning program . Longer duration studies may be necessary to determine the influence of increased dietary protein on bone in young adults . Males and females may have different bone responses to increased protein intake while participating in a strength and conditioning program This study was conducted to determine whether the markers of bone resorption , pyridinium cross-links of collagen , are sensitive to changes in dietary protein and calcium intake . Fifteen young healthy subjects ( 7 males and 8 females ) participated in three 5-d diet periods . Dietary intake during each dietary period consisted of : 1 ) low nitrogen and low calcium [ 0.49 + /- 0.11 g protein/ ( kg.d ) , 429 + /- 190 mg calcium/d ] ; 2 ) low nitrogen and high calcium [ 0.44 + /- 0.08 g protein/(kg.d ) , 1643 + /- 171 mg calcium/d ] ; and 3 ) a high nitrogen and high calcium [ 2.71 + /- 0.75 g protein/(kg.d ) , 1589 + /- 633 mg calcium/d ] diet , and this was compared with subjects ' baseline dietary intake [ 0.99 + /- 0.51 g protein/(kg.d ) , 589 + /- 152 mg calcium/d ] . The order of these diets was r and omly assigned . Twenty-four-hour and 3-h urine sample s were collected before and during each dietary period and were analyzed for pyridinium cross-links ( pyridinoline , deoxypyridinoline ) , nitrogen and creatinine . The rate of pyrdinium cross-link excretion did not vary with protein intake but was approximately 33 % lower ( P < 0.01 ) during periods of high compared with low calcium intake . These data indicate that a short-term increase in calcium intake is accompanied by a reduced rate of bone resorption and that this effect is independent of dietary protein intake BACKGROUND There is currently no consensus on the effect of dietary protein intake on the skeleton , but there is some indication that low calcium intakes adversely influence the effect of dietary protein on fracture risk . OBJECTIVE The objective of the present study was to determine whether supplemental calcium citrate malate and vitamin D influence any associations between  protein intake and change in bone mineral density ( BMD ) . DESIGN Associations between protein intake and change in BMD were examined in 342 healthy men and women ( aged > or = 65 y ) who had completed a 3-y , r and omized , placebo-controlled trial of calcium and vitamin D supplementation . Protein intake was assessed at the midpoint of the study with the use of a food-frequency question naire and  BMD  was assessed every 6 mo by dual-energy X-ray absorptiometry . RESULTS The mean ( + /-SD ) protein intake of all subjects was 79.1 + /- 25.6 g/d and the mean total calcium intakes of the supplemented and placebo groups were 1346 + /- 358 and 871 + /- 413 mg/d , respectively . Higher protein intake was significantly associated with a favorable 3-y change in total-body BMD in the supplemented group ( in a model containing terms for age , sex , weight , total energy intake , and dietary calcium intake ) but not in the placebo group . The pattern of change in femoral neck BMD with increasing protein intake in the supplemented group was similar to that for the total body . CONCLUSION Increasing protein intake may have a favorable effect on change in BMD in elderly subjects supplemented with calcium citrate malate and vitamin 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 r and omly sample d 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 vali date d food frequency question naire . Results There was no significant difference between vegans and omnivores in LSBMD ( 0.74 ± 0.14 vs. 0.77 ± 0.14 g/cm2 ; mean ± SD ; P = 0.18 ) , FNBMD ( 0.62 ± 0.11 vs. 0.63 ± 0.11 g/cm2 ; P = 0.35 ) , WBBMD ( 0.88 ± 0.11 vs. 0.90 ± 0.12 g/cm2 ; 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 ≤ −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 The National Institutes of Health 's consensus conference ( 1 ) defined osteoporosis as a skeletal disorder characterized by compromised bone strength predisposing to an increased risk for fracture . Bone strength reflects the integration of two main features : bone density and bone quality .Bone quality refers to architecture , turnover , damage accumulation ( e.g. , microfractures ) , and mineralization . Although osteoporosis can affect any bone , the hip , spine , and wrist are most likely to be affected . Osteoporosis affects an estimated 44 million Americans or 55 % of people 50 years of age or older . Another 34 million Americans are estimated to have low bone mass , meaning that they are at an increased risk for osteoporosis . Osteoporosis can be diagnosed by the occurrence of fragility fracture . In patients without fragility fracture , osteoporosis is often diagnosed by low bone density .  Dual x-ray absorptiometry ( DXA ) is the current gold st and ard test for diagnosing osteoporosis in people without an osteoporotic fracture .  Dual x-ray absorptiometry results are scored as st and ard deviations ( SDs ) from a young healthy norm ( usually female ) and reported as T-scores . For example , a T-score of 2 indicates a bone mineral density that is 2 SDs below the comparative norm . The international reference st and ard for the description of osteoporosis in postmenopausal women and in men age 50 years or older is a femoral neck bone mineral density of 2.5 SD or more below the young female adult mean ( 2 ) . Low bone density , as measured by DXA , is an imperfect predictor of fracture risk , identifying fewer than half the people who go on to have an osteoporotic fracture . Screening guidelines for women are well established ( 3 ) , and the American College of Physicians ( ACP ) recently published guidelines on screening for men ( 4 ) . This guideline presents the available evidence on various pharmacologic treatments to prevent fractures in men and women with low bone density or osteoporosis . Medications used to treat osteoporosis may affect different parts of the skeletal system differently , and efficacy for vertebral fractures does not necessarily imply efficacy for nonvertebral fractures . The target audience for this guideline is all clinicians and the target patient population is all adult men and women with low bone density or osteoporosis . These recommendations are based on the systematic evidence review by MacLean and colleagues ( 5 ) and the Agency for Healthcare Research and Quality sponsored Southern California Evidence -Based Practice Center evidence report ( 6 ) . The drugs currently approved for prevention of osteoporosis include alendronate , ib and ronate , risedronate , zoledronic acid , estrogen , and raloxifene . The drugs currently approved for treatment of osteoporosis include alendronate , ib and ronate , risedronate , calcitonin , teriparatide , zoledronic acid ( in postmenopausal women ) , and raloxifene . Testosterone , pamidronate , and etidronate are not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Methods The literature search done by MacLean and colleagues for the systematic review ( 5 ) included studies from MEDLINE ( 1966 to December 2006 ) , the ACP Journal Club data base , the Cochrane Central Register of Controlled Trials ( no date limits ) , the Cochrane Data base of Systematic Review s ( no date limits ) , Web sites of the United Kingdom National Institute of Health and Clinical Excellence ( no date limits ) , and the United Kingdom Health Technology Assessment Program ( January 1998 to December 2006 ) . The review ers limited their search to English- language publications and human studies . They derived evidence for comparative benefits of various treatments exclusively from r and omized , controlled trials , whereas they included evidence from other types of studies for short- and long-term harms . Two physicians independently abstract ed data about study population s , interventions , follow-up , and outcome ascertainment by using a structured form . For each group within a r and omized trial , a statistician extracted the sample size and number of persons reporting fractures . Two review ers , under the supervision of the statistician , independently abstract ed information about adverse events . The statistician or the principal investigator resolved disagreements . This guideline is based on an evaluation of 76 r and omized , controlled trials , 4 of which were identified in the up date d search , and 24 meta-analyses that were included in the efficacy analyses . The analyses of adverse events included 491 articles , representing 417 r and omized trials , 25 other controlled clinical trials , 11 open-label trials , 31 large observational studies , and 9 case reports of osteonecrosis among bisphosphonate users . MacLean and colleagues ' background article ( 5 ) includes details about the methods used for the systematic evidence review . The ACP rates the evidence and recommendations by using the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) system with minor modifications ( Table 1 ) . In addition , the evidence review ers used predefined criteria to assess the quality of systematic review s and r and omized trials , based on internal and external validity assessment s detailed in the Quality of Reporting of Meta-Analyses ( QUOROM ) statement ( 7 ) . Table 1 . The American College of Physicians ' Guideline Grading System The objective of this guideline is to synthesize the evidence for the following questions : What are the comparative benefits in fracture reduction among and also within the following treatments for low bone density :  bisphosphonates , specifically alendronate , risedronate , etidronate , ib and ronate , pamidronate , and zoledronic acid ; calcitonin ; estrogen for women ; teriparatide ; selective estrogen receptor modulators ( SERMs ) , specifically raloxifene and tamoxifen ; testosterone for men ; vitamins and minerals , specifically vitamin D and calcium ; and the combination of calcium plus vitamin D ? How does fracture reduction result ing from treatments vary among individuals with different risks for fracture as determined by bone mineral density ( borderline , low , or severe ) , previous fractures ( prevention vs. treatment ) , age , sex , glucocorticoid use , and other factors ( such as community-dwelling vs. institutionalized or vitamin Ddeficient vs. not ) ? What are the short- and long-term harms ( adverse effects ) of these therapies , and do these vary by specific sub population s ? Comparative Benefits of Drugs versus Placebo in Fracture Reduction Evidence from 24 meta-analyses ( 830 ) and 35 additional r and omized trials published after the meta-analyses ( 3165 ) described the effect of 9 of the 14 agents ( alendronate , etidronate , risedronate , calcitonin , estrogen , teriparatide , raloxifene , calcium , and vitamin D ) on fracture incidence . For 4 agents ( ib and ronate , pamidronate , zoledronic acid , and tamoxifen ) , the review ers found no meta-analyses and instead gathered the evidence from 14 r and omized trials ( 6679 ) . No studies were found that reported fracture rates for testosterone . Three r and omized trials ( 35 , 80 , 81 ) and 1 meta- analysis ( 82 ) evaluated the combination of calcium plus vitamin D  on fractures .  Bisphosphonates Good- quality evidence showed that alendronate , etidronate , ib and ronate , and risedronate prevent vertebral fractures . In addition , evidence from good- quality studies demonstrated that both alendronate and risedronate prevent nonvertebral and hip fractures . Two large r and omized trials showed that zoledronic acid prevents vertebral and nonvertebral fractures in high-risk population s and reduces the risk for hip fracture ( 67 , 74 ) . Ib and ronate has not been shown to reduce nonvertebral fractures ( 68 ) . Of the 6 fairly small trials that looked at vertebral fractures , 1 demonstrated a statistically significant reduction in fractures with pamidronate relative to placebo ( 0.14 [ 95 % CI , 0.03 to 0.72 ] ) ( 73 ) . However , after these data were pooled , the pooled risk estimate for fractures for pamidronate relative to placebo was not significant ( 0.52 [ CI , 0.21 to 1.24 ] ) ( 6 ) . Calcitonin Fair- quality evidence shows that calcitonin reduces vertebral fractures ( 83 , 84 ) . Good- quality evidence indicates that calcitonin does not reduce nonvertebral fractures ( 13 , 16 ) . Estrogen Good- quality evidence shows that estrogen reduces the incidence of vertebral ( 29 , 85 ) , nonvertebral ( 86 ) , and hip fractures ( 85 ) . Teriparatide Good- quality evidence shows that teriparatide prevents vertebral fractures . The evidence related to teriparatide preventing nonvertebral fractures is mixed ; 1 large r and omized trial showed a reduction in nonvertebral fractures ( 34 ) but 2 small trials did not ( 87 , 88 ) . SERMs Good- quality evidence shows that raloxifene prevents vertebral fractures , but that tamoxifen has no effect on vertebral fractures ( 8991 ) . In addition , both raloxifene and tamoxifen had no effect on hip fractures ( 91 ) . Tamoxifen is not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Testosterone No studies reported fracture rates for testosterone . Calcium and Vitamin D In the studies evaluated by MacLean and colleagues ( 5 ) , the evidence for the effect of calcium alone on reduction of fractures is complex . Most studies of pharmacologic agents for osteoporosis include calcium and vitamin D as part of the treatment regimen . Evidence from 1 meta- analysis ( 27 ) and several r and omized trials ( 35 , 48 , 51 , 92 ) showed no significant difference between calcium and placebo in preventing vertebral , nonvertebral , and hip fractures in postmenopausal women . However , nonadherence to therapy may influence this result , and 1 trial with a prespecified analysis of adherent patients found a reduction in fracture risk ( 48 ) . A recent meta- analysis ( 82 ) concluded that the relative risk ( RR ) for fracture with calcium alone was 0.90 ( CI , 0.80 to 1.00 ) , but it did not include a modestly large trial with negative results ( 35 ) . MacLean and colleagues ( 5 ) BACKGROUND Different sources of dietary protein may have different effects on bone metabolism . Animal foods provide predominantly acid precursors , whereas protein in vegetable foods is accompanied by base precursors not found in animal foods . Imbalance between dietary acid and base precursors leads to a chronic net dietary acid load that may have adverse consequences on bone . OBJECTIVE We wanted to test the hypothesis that a high dietary ratio of animal to vegetable foods , quantified by protein content , increases bone loss and the risk of fracture . DESIGN This was a prospect i ve cohort study with a mean ( + /-SD ) of 7.0+/-1.5 y of follow-up of 1035 community-dwelling white women aged > 65 y.  Protein intake  was measured by using a food-frequency question naire and  bone mineral density was measured by dual-energy X-ray absorptiometry . RESULTS Bone mineral density was not significantly associated with the ratio of animal to vegetable protein intake . Women with a high ratio had a higher rate of bone loss at the femoral neck than did those with a low ratio ( P = 0.02 ) and a greater risk of hip fracture ( relative risk = 3.7 , P = 0.04 ) . These associations were unaffected by adjustment for age , weight , estrogen use , tobacco use , exercise , total calcium intake , and total protein intake . CONCLUSIONS Elderly women with a high dietary ratio of animal to vegetable protein intake  have more rapid femoral neck bone loss and a greater risk of hip fracture than do those with a low ratio . This suggests that an increase in vegetable protein intake and a decrease in animal protein intake may decrease bone loss and the risk of hip fracture . This possibility should be confirmed in other prospect i ve studies and tested in a r and omized trial Background Prospect i ve data examining the relationship between dietary protein intake and incident coronary heart disease ( CHD )  are inconclusive . Most evidence is derived from homogenous population s such as health professionals . Large community-based analyses in more diverse sample s are lacking . Methods We studied the association of protein type and major dietary protein sources and risk for incident CHD in 12,066 middle-aged adults ( aged 45–64 at baseline , 1987–1989 ) from four U.S. communities enrolled in the Atherosclerosis Risk in Communities ( ARIC ) Study who were free of diabetes mellitus and cardiovascular disease at baseline .  Dietary protein intake was assessed at baseline and after 6 years of follow-up by food frequency question naire . Our primary outcome was adjudicated coronary heart disease events or deaths with following up through December 31 , 2010 . Cox proportional hazard models with multivariable adjustment were used for statistical analyses . Results During a median follow-up of 22 years , there were 1,147 CHD events . In multivariable analyses total , animal and vegetable protein were not associated with an increased risk for CHD before or after adjustment . In food group analyses of major dietary protein sources , protein intake from red and processed meat , dairy products , fish , nuts , eggs , and legumes were not significantly associated with CHD risk . The hazard ratios [ with 95 % confidence intervals ] for risk of CHD across quintiles of protein from poultry were 1.00 [ ref ] , 0.83 [ 0.70–0.99 ] , 0.93 [ 0.75–1.15 ] , 0.88 [ 0.73–1.06 ] , 0.79 [ 0.64–0.98 ] , P for trend = 0.16 ) . Replacement analyses evaluating the association of substituting one source of dietary protein for another or of decreasing protein intake at the expense of carbohydrates or total fats did not show any statistically significant association with CHD risk . Conclusion Based on a large community cohort we found no overall relationship between protein type and major dietary protein sources and risk for CHD BACKGROUND Soy foods contain several components ( isoflavones and amino acids ) that potentially affect bone . Few long-term , large clinical trials of soy as a means of improving bone mineral density ( BMD ) in late postmenopausal women have been conducted . OBJECTIVE Our goal was to evaluate the long-term effect of dietary soy protein and /or soy isoflavone consumption on skeletal health in late postmenopausal women . DESIGN We conducted a r and omized , double-blind , placebo-controlled clinical trial in 131 healthy ambulatory women aged > 60 y. Ninety-seven women completed the trial . After a 1-mo baseline period , subjects were r and omly assigned into 1 of 4 intervention groups : soy protein ( 18 g ) + isoflavone tablets ( 105 mg isoflavone aglycone equivalents ) , soy protein + placebo tablets , control protein + isoflavone tablets , and control protein + placebo tablets . RESULTS Consumption of protein powder and isoflavone pills did not differ between groups , and compliance with the study powder and pills was 80 - 90 % . No significant differences in BMD were observed between groups from baseline to 1 y after the intervention or in BMD change between equol and non-equol producers . However , there were significant negative correlations between total dietary protein ( per kg ) and markers of bone turnover ( P < 0.05 ) . CONCLUSIONS Because soy protein and isoflavones ( either alone or together ) did not affect BMD , they should not be considered as effective interventions for preserving skeletal health in older women . The negative correlation between dietary protein and bone turnover suggests that increasing protein intakes may suppress skeletal turnover . This trial was registered at Clinical Trials.gov as NCT00668447 For decades , it has been debated whether high protein intake compromises bone mineralisation , but no long-term r and omised trial has investigated this in children . In the family-based , r and omised controlled trial DiOGenes ( Diet , Obesity and Genes ) , we examined the effects of dietary protein and glycaemic index ( GI ) on biomarkers of bone turnover and height in children aged 5 - 18 years . In two study centres , families with overweight parents were r and omly assigned to one of five ad libitum-energy , low-fat ( 25 - 30 % energy ( E% ) ) diets for 6 months : low protein/low GI ; low protein/high GI ; high protein/low GI ; high protein/high GI ; control . They received dietary instructions and were provided all foods for free . Children , who were eligible and willing to participate , were included in the study . In the present analyses , we included children with data on plasma osteocalcin or urinary N-terminal telopeptide of collagen type I ( U-NTx ) from baseline and at least one later visit ( month 1 or month 6 ) ( n 191 in total , n 67 with data on osteocalcin and n 180 with data on U-NTx ) . The level of osteocalcin was lower ( 29.1 ng/ml ) in the high-protein/high-GI dietary group than in the low-protein/high-GI dietary group after 6 months of intervention ( 95 % CI 2.2 , 56.1 ng/ml , P=0.034 ) . The dietary intervention did not affect U-NTx ( P=0.96 ) or height ( P=0.80 ) . Baseline levels of U-NTx and osteocalcin correlated with changes in height at month 6 across the dietary groups ( P<0.001 and P=0.001 , respectively ) . The present study does not show any effect of increased protein intake on height or bone resorption in children . However , the difference in the change in the level of osteocalcin between the high-protein/high-GI group and the low-protein/high-GI group warrants further investigation and should be confirmed in other studies Dietary protein increases urinary calcium losses and has been associated with higher rates of hip fracture in cross-cultural studies . However , the relation between protein and risk of  osteoporotic bone fractures among individuals has not been examined in detail . In this prospect i ve study , usual dietary intake was measured in 1980 in a cohort of 85,900 women , aged 35 - 59 years , who were participants in the Nurses ' Health Study . A mailed food frequency question naire was used and incident hip ( n = 234 ) and distal forearm ( n = 1,628 ) fractures were identified by self-report during the following 12 years . Information on other factors related to osteoporosis , including obesity , use of postmenopausal estrogen , smoking , and physical activity , was collected on biennial question naires . Dietary measures were up date d in 1984 and 1986 . Protein was associated with an increased risk of forearm fracture ( relative risk ( RR ) = 1.22 , 95 % confidence interval ( Cl ) 1.04 - 1.43 , p for trend = 0.01 ) for women who consumed more than 95 g per day compared with those who consumed less than 68 g per day . A similar increase in risk was observed for animal protein , but no association was found for consumption of vegetable protein . Women who consumed five or more servings of red meat per week also had a significantly increased risk of forearm fracture ( RR = 1.23 , 95 % Cl 1.01 - 1.50 ) compared with women who ate red meat less than once per week . Recall of teenage diet did not reveal any increased risk of forearm fracture for women with higher consumption of animal protein or red meat during this earlier period of life . No association was observed between  adult protein intake  and the incidence of hip fractures , though power to assess this association was low BACKGROUND Maternal diet during pregnancy has been suggested to influence bone health in later life . OBJECTIVE We assessed the association of  maternal first-trimester dietary intake during pregnancy with childhood bone mass .  DESIGN In a prospect i ve cohort study in 2819 mothers and their children , we measured first-trimester daily energy , protein , fat , carbohydrate , calcium , phosphorus , and magnesium intakes by using a food-frequency question naire and homocysteine , folate , and vitamin B-12 concentrations in venous blood . We measured childhood total body bone mass by using dual-energy X-ray absorptiometry at the median age of 6.0 y. RESULTS Higher first-trimester maternal protein , calcium , and phosphorus intakes and vitamin B-12 concentrations were associated with higher childhood bone mass , whereas carbohydrate intake and homocysteine concentrations were associated with lower childhood bone mass ( all P-trend < 0.01 ) . Maternal fat , magnesium intake , and folate concentrations were not associated with childhood bone mass . In the fully adjusted regression model that included all dietary factors significantly associated with childhood bone mass , maternal phosphorus intake and homocysteine concentrations most-strongly predicted childhood bone mineral content ( BMC ) [ β = 2.8 ( 95 % CI : 1.1 , 4.5 ) and β = -1.8 ( 95 % CI : -3.6 , 0.1 ) g per SD increase , respectively ] , whereas maternal protein intake and vitamin B-12 concentrations most strongly predicted BMC adjusted for bone area [ β = 2.1 ( 95 % CI : 0.7 , 3.5 ) and β = 1.8 ( 95 % CI : 0.4 , 3.2 ) g per SD increase , respectively ] . CONCLUSION Maternal first-trimester dietary factors are associated with childhood bone mass , suggesting that fetal nutritional exposures may permanently influence bone development CONTEXT Consolidation and maintenance of peak bone mass in young adulthood may be compromised by inactivity , low dietary calcium , and diet-induced weight loss . OBJECTIVE We aim ed to determine whether higher intakes of dairy foods , dietary calcium , and protein during diet- and exercise-induced weight loss affected markers of bone health . PARTICIPANTS Participants included premenopausal overweight and obese women . DESIGN /INTERVENTION Ninety participants were r and omized into three groups ( n = 30 per group ) : high protein and high dairy ( HPHD ) , adequate protein and medium dairy ( APMD ) , and adequate protein and low dairy ( APLD ) , differing in dietary protein ( 30 , 15 , or 15 % of energy , respectively ) , dairy foods ( 15 , 7.5 , or < 2 % of energy from protein , respectively ) , and dietary calcium ( ∼1600 , ∼1000 , or < 500 mg/d , respectively ) . OUTCOME MEASURES Serum and urine bone turnover biomarkers , serum osteoprotegerin ( OPG ) , receptor activator of nuclear factor-κB lig and ( RANKL ) , PTH , 25-hydroxyvitamin D , leptin , and adiponectin measured at 0 and 16 wk . RESULTS All groups lost equivalent body weight ( P < 0.05 ) . N-telopeptide , C-telopeptide ( CTX ) , urinary deoxypyridinoline , and osteocalcin increased in APLD ( P < 0.01 ) , whereas in HPHD , osteocalcin and procollagen 1 amino-terminal propeptide ( P1NP ) increased ( P < 0.05 ) , and all resorption markers remained unchanged . P1NP to CTX and OPG to RANKL ratios increased in HPHD ( P < 0.005 ) , and P1NP to CTX ratio decreased in APLD ( P < 0.05 ) . PTH decreased in HPHD and APMD vs. APLD ( P < 0.005 ) , and 25-hydroxyvitamin D increased in HPHD ( P < 0.05 ) , remained unchanged in APMD , and decreased in APLD ( P < 0.05 ) . Leptin decreased and adiponectin increased in APMD and HPHD only ( P < 0.001 ) . CONCLUSIONS Hypoenergetic diets higher in dairy foods , dietary calcium , and protein with daily exercise , favorably affected important bone health biomarkers vs. diets with less of these bone-supporting nutrients Review question / objective The objective of this review is to identify the effectiveness of education or behavioral interventions on adherence to phosphate control in adults with end stage kidney disease ( ESKD ) receiving hemodialysis ( HD ) . Background Hyperphosphatemia occurs in people with ESKD as a result of the kidneys ' reduced ability to excrete an ingested phosphate load.1,2 Hyperphosphatemia significantly lowers the serum calcium concentration , stimulating the release of parathyroid hormone ( PTH ) , causing secondary hyperparathyroidism.3–6 In ESKD , hyperphosphatemia also slows the activation of vitamin D which leads to impaired absorption of calcium from the gastrointestinal tract , result ing in reduced mobilization of calcium and phosphate from the bones , and causing metabolic bone disease.2,6,7 The reduced mobilization of both phosphate and calcium enables these two minerals to bind together creating a calcium‐phosphate product . At a serum concentration of > 1.78mmol/L the calcium‐phosphate product crystallizes and is deposited within the soft tissue and vasculature.6,8,9 In ESKD the development of vascular calcification of the arterial media ( i.e. calciphylaxis ) is a major contributing factor of morbidity and mortality.4,5,9,10 Methods of phosphate control Hyperphosphatemia is a wellrecognized risk factor for renal osteodystrophy and cardiovascular mortality in people with ESKD.1,4,11 Collectively this is called chronic kidney disease ‐ mineral bone disorder ( CKD‐MBD ) . Treatment of hyperphosphatemia requires a combination of dietary phosphate restrictions , use of oral phosphate binder therapy to reduce intestinal phosphate absorption , vitamin D3 ( calcitriol ) supplementation and adequate dialysis prescription to promote removal of phosphate.12–15 The treatment goal is to maintain serum phosphate levels at near normal , 0.7 ‐ 1.6mmol/L ( 3.5 ‐ 5.5 mg/dL)16 , and that sustained control of serum phosphate is a strong predictor of improved survival in people receiving HD.11 However approximately 40 % of patients receiving HD have a serum phosphate level of > 1.6mmol/L.16 Dietary phosphate restriction The implementation of dietary phosphate restrictions is the first step in treating hyperphosphatemia . The average daily adult diet contains approximately 800‐1500 mg of phosphate which is absorbed mostly in the duodenum and jejunum.17 However , there is a linear relationship between phosphate and protein intake.1 In general , foods high in phosphate such as milk and meat are rich in protein . For each gram of protein , there is approximately 13‐15 mg of phosphate.17 The recommended protein intake for a HD patient is 0.8 g per kg of body weight per day.7,18 However , the dietary restrictions necessary to sustain acceptable serum phosphate in HD patients could lead to protein malnutrition.4,7,19 Therefore , dietary phosphate restriction is not sufficient to control serum phosphate levels to current national/international guidelines .19 Phosphate binders The mainstay treatment of hyperphosphatemia is the use of oral phosphate binder medication.1,20 Phosphate binders lower phosphate absorption in the intestines by binding to and sequestering phosphate in the gastrointestinal tract , forming insoluble products that are not readily absorbed.21 The Dialysis Outcomes and Practice Patterns Study ( DOPPS ) involving 23,898 patients on HD at 923 facilities in 12 countries found that 88 % of patients were prescribed phosphate binders and 12 % were not . This study found a 25 % lower mortality rate ( HR , 0.75 ; 95 % CI , 0.68‐0.83 ) in patients who were prescribed phosphate binders versus those not prescribed phosphate binder medication.11 However , most people receiving phosphate binding medication do not achieve target serum phosphate level.3 Hemodialysis The basic conventional four‐hour thrice‐weekly HD removes approximately 700‐1,000 mg of phosphate per session , result ing in a weekly reduction of 2100‐3000mg.8,21,22 Effective phosphate removal through HD is complicated by phosphate 's biphasic elimination from the body . Kinetic studies have shown that serum phosphate levels drop rapidly in the first one to two hours of HD treatment and then reach a plateau.8,22 Soon after HD , a rebound of serum phosphate occurs to a rise of about 30‐40 % . This is because of the slow influx of elements to the extracellular space after a st and ard HD session.3,8,22 It has been recognized that increasing dialysis frequency or duration leads to reduced serum phosphate.19 Data from the Frequent Haemodialysis Network nocturnal trial showed that daily or extended nocturnal HD led to an average decrease in serum phosphate levels of 0.4mmol/L ( 95 % CI : 0.3‐0.7mmol/L ) compared with conventional four‐hour thrice‐weekly HD treatment.23 In spite of the relatively low removal rates of phosphorus achieved by HD it is indicative that HD alone can not correct the phosphate levels that are associated with the usual dietary content of phosphate.21,22 Therefore , successful treatment of hyperphosphatemia requires patients adhering to a combination of dietary phosphate restrictions,8 use of oral phosphate binder therapy to reduce intestinal phosphate absorption21 and adequate HD prescription to promote removal of phosphate.24 Adherence to phosphate control Research on adherence to phosphate control date s back to 1960.14 However , the use of education and behavioral interventions to improve long term adherence to phosphate control has been subjected to less investigation in people with ESKD . Several research studies indicate education and behavioral interventions could help individuals change their behavior and hence increase adherence to phosphate control.5,13,20,25,26 A number of studies have used different educational interventions , carried out by either nurses or dieticians . The education sessions were one‐on‐one or group , and verbal or video was used to provide the education.13,14,27,28 Also , structured psychological approaches aim ed at helping patients to change their beliefs , consequently developing healthy behavior , have been used to produce positive results in improving adherence to diet , medication and HD treatment.28–31 These studies illustrate that theoretical and empirically based behavioral approaches are feasible and can result in a positive reduction of serum phosphate level . However , further developments of clinical ly useful behavioral and educational strategies are needed to sustain long term adherence with phosphate control . A literature search of the Cochrane central register of controlled trials , JBI , Prospero international prospect i ve register of systematic review and Campbell collaboration systematic review s was conducted and only one systematic review of relevance to this topic was found . This systematic review was of r and omized controlled trials of educational and counselling interventions to improve dietary phosphate adherence in both HD and pre‐dialysis patients .26 However , this systematic review did not include all treatment methods that are used in combination to control phosphate . The control of serum phosphate levels in people receiving HD continues to be a challenge for practitioners and is of clinical significance to patient outcomes . If left untreated hyperphosphatemia significantly increases the risk of morbidity and mortality in people with ESKD.12 It is important to review studies that have been undertaken comparing the outcomes of education and behavioral interventions , regardless of study design , targeting patient adherence to dietary phosphate intake , phosphate binder medication and HD treatment Aim : To study bone mineralization in a group of phenylketonuric patients and to search for a possible relationship between bone mineral density , dietary control , serum minerals and nutrition intake . The response to treatment with low‐dose 1.25‐(OH)2 vitamin D in patients with osteopenia was evaluated . Methods : Twenty‐eight phenylketonuric patients ( age range : 10–33 y ) on dietary treatment were investigated . Bone density at the lumbar spine ( Dual Energy X‐ray Absorptiometry ) , bone formation markers ( osteocalcin and bone alkaline phosphatase ) , serum minerals , index of dietary control and protein , vitamin D and mineral intakes were determined . Results : Of the patients studied , 78.6 % had good dietary compliance ( 462 ± 89 μmol/L ) . Mean protein , vitamin D and mineral intakes met the recommended dietary allowances ( RDAs ) . Nevertheless , 8 patients had calcium intakes lower than 1000 g/d , and a positive correlation between Z‐score and calcium ( r= 0.585 ; p= 0.002 ) or phosphorus intake ( r= 0.546 ; p= 0.005 ) was observed . Osteopenia was detected in 14 patients ( 50 % ) . Moreover , bone alkaline phosphatase in phenylketonuric patients older than 18 y of age was significantly lower than that in controls ( p > 0.0001 ) . No correlation was found between bone mineral density , age , serum minerals , bone formation markers or index of dietary control . Treatment with 0.25 μg/d calcitriol significantly increased bone density in 6 patients OBJECTIVE To identify nutrients , foods , and dietary patterns associated with stress fracture risk and changes in bone density among young female distance runners . DESIGN AND SETTING Two-year , prospect i ve cohort study . Observational data were collected in the course of a multicenter r and omized trial of the effect of oral contraceptives on bone health . PARTICIPANTS One hundred and twenty-five female competitive distance runners ages 18 - 26 years . ASSESSMENT OF RISK FACTORS Dietary variables were assessed with a food frequency question naire . MAIN OUTCOME MEASUREMENTS Bone mineral density and content ( BMD/ BMC ) of the spine , hip , and total body were measured annually by dual x-ray absorptiometry ( DEXA ) .  Stress fractures were recorded on monthly calendars , and had to be confirmed by radiograph , bone scan , or magnetic resonance imaging . RESULTS Seventeen participants had at least one stress fracture during follow-up . Higher intakes of calcium , skim milk , and dairy products were associated with lower rates of stress fracture . Each additional cup of skim milk consumed per day was associated with a 62 % reduction in stress fracture incidence ( P < .05 ) ; and a dietary pattern of high dairy and low fat intake was associated with a 68 % reduction ( P < .05 ) . Higher intakes of skim milk , dairy foods , calcium , animal protein , and potassium were associated with significant ( P < .05 ) gains in whole-body BMD and BMC . Higher intakes of calcium , vitamin D , skim milk , dairy foods , potassium , and a dietary pattern of high dairy and low fat were associated with significant gains in hip BMD . CONCLUSIONS In young female runners , low-fat dairy products and the major nutrients in milk ( calcium , vitamin D , and protein ) were associated with greater bone gains and a lower stress fracture rate . Potassium intake was also associated with greater gains in hip and whole-body BMD The effects of dietary protein on bone structure and metabolism have been controversial , with evidence for and against beneficial effects . Because no long-term r and omized , controlled studies have been performed , a two-year study of protein supplementation in 219 healthy ambulant women aged 70 to 80 years was undertaken . Participants were r and omized to either a high-protein drink containing 30 g of whey protein ( n = 109 ) or a placebo drink identical in energy content , appearance , and taste containing 2.1 g of protein ( n = 110 ) . Both drinks provided 600 mg of calcium . Dual-energy X-ray absorptiometric ( DXA ) hip areal bone mineral density ( aBMD ) , 24-hour urinary calcium excretion , and serum insulin-like growth factor 1 ( IGF-1 ) were measured at baseline and at 1 and 2 years . Quantitative computed tomographic ( QCT ) hip volumetric bone mineral density ( vBMD ) and a femoral neck engineering strength analysis were undertaken at baseline and at 2 years . Baseline average protein intake was 1.1 g/kg of body weight per day . There was a significant decrease in hip DXA aBMD and QCT vBMD over 2 years with no between-group differences . Femoral neck strength was unchanged in either group over time . The 24-hour urinary calcium excretion increased significantly from baseline in both groups at 1 year but returned to baseline in the placebo group at 2 years , at which time the protein group had a marginally higher value . Compared with the placebo group , the protein group had significantly higher serum IGF-1 level at 1 and 2 years ( 7.3 % to 8.0 % , p < .05 ) . Our study showed that in protein-replete healthy ambulant women , 30 g of extra protein increased IGF-1 but did not have beneficial or deleterious effects on bone mass or strength . The effect of protein supplementation in population s with low dietary protein intake requires urgent attention BACKGROUND The role of dietary protein in bone metabolism is controversial . OBJECTIVE We investigated the associations of dietary protein intake with baseline bone mineral density ( BMD ) and the rate of bone loss over 3 y in postmenopausal elderly women . DESIGN Women aged 65 - 77 y ( n = 489 ) were enrolled in an osteoporosis intervention trial . We studied the associations of protein intake as a percentage of energy with baseline BMD and the rate of bone loss in 96 women in the placebo group ( n = 96 ) . We also examined the effect of the interaction of dietary  calcium  intake with protein intake on BMD . RESULTS In the cross-sectional study , a higher intake of protein was associated with higher BMD . BMD was significantly higher ( P < 0.05 ) in the spine ( 7 % ) , midradius ( 6 % ) , and total body ( 5 % ) in subjects in the highest quartile of protein intake than in those in the lower 2 quartiles . This positive association was seen in women with calcium intakes > 408 mg/d . There was no significant effect of protein intake on hip BMD . In the longitudinal study of the placebo group , there was no association between protein intake and the rate of bone loss . CONCLUSIONS The highest quartile of protein intake (: 72 g/d ) was associated with higher BMD  in elderly women at baseline only when the calcium intake exceeded 408 mg/d . In the longitudinal study , no association was seen between protein intake and the rate of bone loss , perhaps because the sample size was too small or the follow-up period of 3 y was not long enough to detect changes Calcium balance is decreased by an increased intake of purified proteins , although the effects of common dietary sources of protein ( like meat ) on calcium economy remain controversial . We compared the effects of several weeks of controlled high and low meat diets on body calcium retention , using sensitive radiotracer and whole body scintillation counting methodology . Healthy postmenopausal women ( n = 15 ) consumed diets with similar calcium content ( approximately 600 mg ) , but either low or high in meat ( 12 vs. 20 % of energy as protein ) for 8 wk each , in a r and omized crossover design . After 4 wk of equilibration of each diet , calcium retention was measured by extrinsically labeling the 2-d menu with (47)Ca , followed by whole body scintillation counting for 28 d. Urinary and blood indicators of bone metabolism were also determined for each diet . Calcium retention was not different during the high and low meat dietary periods ( d 28 , mean + /- pooled SD : 17.1 and 15.6 % , + /-0.6 % , respectively ; P = 0.09 ) . An initially higher renal acid excretion in subjects consuming the high meat compared with the low meat diet decreased significantly with time . The diets did not affect urinary calcium loss or indicators of bone metabolism . In conclusion , under controlled conditions , a high meat compared with a low meat diet for 8 wk did not affect calcium retention or biomarkers of bone metabolism in healthy postmenopausal women .  Calcium retention is not reduced when subjects consume a high protein diet from common dietary sources such as meat OBJECTIVE To test whether bone mass increases in healthy nonpregnant white women during early adult life after cessation of linear growth ; and to test whether various self-chosen levels of physical activity and nutrient intake or use of oral contraceptives influences this increase in bone mass . DESIGN Longitudinal prospect i ve study of up to 5 years of 156 healthy college-aged women full-time students attending professional schools in universities in the Omaha , Neb , area . SETTING University medical center . PARTICIPANTS A convenience sample of healthy women students from Omaha-area professional schools . Any c and i date with an illness , condition , or medication ( except  oral contraceptives ) thought to affect general health or bone mass was excluded . INTERVENTIONS None . OUTCOME MEASURES Clinical and family histories of disease , particularly osteoporosis ; oral contraceptive use ; bone mineral densities of the spine , forearm , and total body by dual- and single-photon absorptiometry ; estimates of nutrient intake by repeated 7-day diet diaries ;  and  measures of physical activity using a physical activity monitor . RESULTS The median gain in bone mass for the third decade of life , expressed as a percentage per decade , was 4.8 % for the forearm , 5.9 % for lumbar bone mineral content , 6.8 % for lumbar bone mineral density , and 12.5 % for total body bone mass ( P < .0001 in all cases ) . By both bivariate and multiple regression analysis the rate of gain in bone density of the spine was negatively correlated with age and positively correlated with calcium/protein intake ratio and physical activity ( multiple r = .31 ; P = .004 ) . Bivariate analysis showed that use of oral contraceptives was associated with greater gain in total body bone mass ( r = .31 , P = .01 ) . The estimated age when mineral acquisition ceased ranged from 28.3 years to 29.5 years at the several study sites . CONCLUSIONS Gain in bone mass occurs in healthy young women during the third decade of life . Physical activity and dietary calcium intake both exert a positive effect on this bone gain . Use of oral contraceptives exerts a further independent positive effect . Changes in life-style among college-aged women , involving relatively modest increases in physical activity and calcium intake , may significantly reduce the risk of osteoporosis late in life It has been suggested that bone health in adulthood is programmed by development in utero . Most previous investigations addressing this topic have focussed on bone mineral density or content , rather than other indicators of bone health , such as biochemical markers of bone turnover . This study investigated whether potential predictors , from different stages of life , influence bone resorption in men aged 49 - 51years in the Newcastle Thous and Families birth cohort . The cohort originally consisted of all 1142 births in the city of Newcastle upon Tyne , UK in May and June 1947 . Detailed information was collected prospect ively during childhood , including birth weight and socio-economic circumstances . At 49 - 51years of age , 574 study members completed a detailed ' Health and Lifestyle ' question naire , including the European Prospect i ve Investigation of Cancer ( EPIC ) food frequency question naire and 412 study members attended for clinical examination , including 172 men in whom bone resorption was assessed by measurement of serum beta C-telopeptide of type 1 collagen ( CTX ) .  A significant trend was seen between increasingly disadvantaged socio-economic status at birth and increased bone resorption ( p=0.04 , r-squared 2.6 % ) . However , birth weight , st and ardised for sex and gestational age , was not associated with serum CTX ( p=0.77 , r-squared 0.05 % ) . Significant trends were also seen between increasing total energy intake ( p=0.03 , r-squared 2.9 % ) , dietary intake of saturated fat ( p=0.02 , r-squared 2.6 % ) , protein ( p=0.04 , r-squared 2.5 % ) and carbohydrates ( p=0.04 , r-squared 2.6 % ) and higher serum CTX . However , on adjustment for total energy intake , none of the other dietary variables was significant at the univariate level maintained significance . Our findings suggest that early socio-economic disadvantage and later dietary factors may be associated with increased  bone resorption in middle aged men . However , as little of the variance in serum CTX was explained by the variables included within this investigation , further longitudinal studies , with sufficient statistical power , are required to assess predictors of bone resorption in adulthood and their relative importance OBJECTIVES The objective of this review was to assess the effectiveness of interventions that assist caregivers to provide support for people living with dementia in the community . INCLUSION CRITERIA Types of participants Adult caregivers who provide support for people with dementia living in the community ( non-institutional care).Types of interventions Interventions design ed to support caregivers in their role such as skills training , education to assist in caring for a person living with dementia and support groups/programs . Interventions of formal approaches to care design ed to support caregivers in their role , care planning , case management and specially design ated members of the healthcare team - for example dementia nurse specialist or volunteers trained in caring for someone with dementia . Types of studies This review considered any meta-analyses , systematic review s , r and omised control trials , quasi-experimental studies , cohort studies , case control studies and observational studies without control groups that addressed the effectiveness of interventions that assist caregivers to provide support for people living with dementia in the community . SEARCH STRATEGY The search sought to identify published studies from 2000 to 2005 through the use of electronic data bases . Only studies in English were considered for inclusion . The initial search was conducted of the data bases , CINAHL , MEDLINE and PsychINFO using search strategies adapted from the Cochrane Dementia and Cognitive Improvement Group . A second more extensive search was then conducted using the appropriate Medical Subject Headings ( MeSH ) and keywords for other available data bases . Finally , h and search ing of reference lists of articles retrieved and of core dementia , geriatric and psycho geriatric journals was undertaken . ASSESSMENT OF QUALITY Method ological quality of each of the articles was assessed by two independent review ers using appraisal checklist developed by the Joanna Briggs Institute and based on the work of the Cochrane Collaboration and Centre for Review s and Dissemination . DATA COLLECTION AND ANALYSIS St and ardised mean differences or weighted mean differences and their 95 % confidence intervals were calculated for each included study reported in the meta- analysis . Results from comparable groups of studies were pooled in statistical meta- analysis using Review Manager Software from the Cochrane Collaboration . Heterogeneity between combined studies was tested using st and ard chi-square test . Where statistical pooling was not appropriate or possible , the findings are summarised in narrative form . RESULTS A comprehensive search of relevant data bases , h and search ing and cross referencing found 685 articles that were assessed for relevance to the review . Eighty-five papers appeared to meet the inclusion criteria based on title and abstract , and the full paper was retrieved . Of the 85 full papers review ed , 40 were accepted for inclusion , three were systematic review s , three were meta- analysis , and the remaining 34 were r and omised controlled trials . For the r and omised controlled trials that were able to be included in a meta- analysis , st and ardised mean differences or weighted mean differences and their 95 % confidence intervals were calculated for each . Results from comparable groups of studies were pooled in statistical meta- analysis using Review Manager Software and heterogeneity between combined studies was assessed by using the chi-square test . Where statistical pooling was not appropriate or possible , the findings are summarised in narrative form . The results are discussed in two main sections . Firstly it was possible to assess the effectiveness of different types of caregiver interventions on the outcome categories of depression , health , subjective well-being , self-efficacy and burden . Secondly , results are reported by main outcome category . For each of these sections , meta- analysis was conducted where it was possible ; otherwise , a narrative summary describes the findings . EFFECTIVENESS OF INTERVENTION TYPE Four categories of intervention were included in the review - psycho-educational , support , multi-component and other . Psycho-educational Thirteen studies used  psycho-educational interventions  , and all but one showed positive results across a range of outcomes . Eight studies were entered in a meta- analysis . No significant impact of psycho-educational interventions was found for the outcome categories of subjective well-being , self-efficacy or health . However , small but significant results were found for the categories of depression and burden . Support Seven studies discussed support only interventions and two of these showed significant results . These two studies were suitable for meta- analysis and demonstrated a small but significant improvement on caregiver burden . Multi-component Twelve of the studies report multi-component interventions and 10 of these report significant outcomes across a broad range of outcome measures including self-efficacy , depression , subjective well-being and burden . Unfortunately because of the heterogeneity of study design s and outcome measures , no meta- analysis was possible . Other interventions Other interventions included the use of exercise or nutrition which result ed in improvements in psychological distress and health benefits . Case management and a computer aided support intervention provided mixed results . One cognitive behavioural therapy study reported a reduction in anxiety and positive impacts on patient behaviour . EFFECTIVENESS OF INTERVENTIONS USING SPECIFIC OUTCOME CATEGORIES In addition to analysis by type of intervention it was possible to analyse results based on some outcome categories that were used across the studies . In particular the impact of interventions on caregiver depression was available for meta- analysis from eight studies . This indicated that multi-component and psycho-educational interventions showed a small but significant positive effect on caregiver depression . Five studies using the outcome category of caregiver burden  were entered into a meta- analysis and findings indicated that there were no significant effects of any of interventions . No meta- analysis was possible for the outcome categories of health , self-efficacy or subjective well-being . IMPLICATION S FOR PRACTICE From this review there is evidence to support the use of well- design ed psycho-educational or multi-component interventions for caregivers of people with dementia who live in the community . Factors that appear to positively contribute to effective interventions are those which : Factors which do not appear to have benefit in interventions are those which Objective To examine the effects of food groups and dietary nutrients on  bone loss in elderly Chinese population . Design Prospect i ve cohort study . Setting : A longitudinal study started at 2001 in Hong Kong . Participants 1225 Chinese men and 992 women aged 65 years and over in the community . Methods Daily intake of food groups and dietary nutrients at baseline was assessed by a food frequency question naire . Nutrient intake was adjusted for energy intake by residual method . Linear regression was used to examine the association of BMD change and food group or energy-adjusted nutrient intake with adjustment for demographic , anthropometric , lifestyle factors , and daily energy intake ( for food group only ) . Results Higher fish intake was associated with smaller bone loss in hip ( B=−0.611 , p=0.004 ) and femoral neck ( B=−0.724 , p=0.040 ) in men . None of the food groups were associated with bone loss in both measured sites in women . For men , lower intake of protein ( B=−0.012 , p=0.003 ) , phosphorus ( B=−0.0008 , p=0.001 ) , sodium ( B=−0.0002 , p=0.023 ) and isoflavone ( B=−1.084 , p=0.030 ) was associated with greater BMD loss in hip , whereas lower intake of protein ( B=−0.018 , p=0.006 ) and sodium ( B=−0.0004 , p=0.018 ) was associated with greater BMD loss in femoral neck . However , these significant associations disappeared after further adjustment for energy-adjusted calcium and vitamin D intakes . None of the nutrients were associated with BMD loss in both measured sites in women . Conclusions Greater fish intake may help to reduce bone loss in this sample of elderly Chinese men . The significant association between various nutrients and bone loss  in elderly Chinese men was likely due to the influence of dietary calcium and vitamin D intakes . The role of food groups and dietary nutrients on bone health in this sample of elderly Chinese women seems to be minimal Objective To create a data base of long-term r and omised controlled trials ( RCTs ) comparing higher with lower omega-3 , omega-6 or total polyunsaturated fatty acid ( PUFA ) , regardless of reported outcomes , and to develop methods to assess effects of increasing omega-6 , alpha-linolenic acid ( ALA ) , long-chain omega-3 ( LCn3 ) and total PUFA on health outcomes . Design Systematic review search , methodology and meta-analyses . Data sources Medline , Embase , CENTRAL , WHO International Clinical Trials Registry Platform , Clinical trials.gov and trials in relevant systematic review s. Eligibility criteria RCTs of ≥24 weeks ' duration assessing effects of increasing ALA , LCn3 , omega-6 or total PUFAs , regardless of outcomes reported . Data synthesis Methods included r and om-effects meta-analyses and sensitivity analyses . Funnel plots were examined , and subgrouping assessed effects of intervention type , replacement , baseline diabetes risk and use of diabetic medications , trial duration and dose . Quality of evidence was assessed using Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) . Results Electronic search es generated 37 810 hits , de-duplicated to 19 772 titles and abstract s. We assessed 2155 full-text papers , conference abstract s and trials registry entries independently in duplicate . Included studies were grouped into 363 RCTs comparing higher with lower omega-3 , omega-6 and /or total PUFA intake of at least 6 months ’ duration —the Data base . Of these 363 included RCTs , 216 RCTs were included in at least one of our review s of health outcomes , data extracted and risk of bias assessed in duplicate . Ninety five RCTs were included in the Data base but not included in our current review s. Of these 311 completed trials , 27 altered ALA intake , 221 altered LCn3 intake and 16 trials altered omega-3 intake without specifying whether ALA or LCn3 . Forty one trials altered omega-6 and 59 total PUFA.The remaining 52 trials are ongoing though 13 ( 25 % ) appear to be outst and ing , or constitute missing data . Conclusions This extensive data base of trials is available to allow assessment of further health outcomes Executive summary Background Older adults with dementia may have feeding difficulties for several reasons : they may experience deterioration in motor and cognitive skills making eating difficult , they may forget to eat , fail to recognise food or they may suffer from dysphagia . Food intake is often poor and malnutrition is common , leading to adverse health outcomes . This review specifically focussed on how best to promote and achieve ‘ normal ’ eating and feeding in older adults with dementia , in order that undernutrition and its consequences could be avoided . Review Objectives The aim was to identify and assess the effectiveness of interventions that encouraged eating and minimised risk of undernutrition in older adults with dementia . Types of Participants Adults over the age of sixty with dementia in any care setting ( who were not living independently ) . People receiving enteral tube feeding were excluded . Types of Interventions Any intervention that promoted dietary intake e.g. changes in practice of health care workers , family or volunteers , educational interventions , changes in food service . Types of Outcomes The primary outcomes were improvement in dietary intake and /or nutritional status . Measurements included : dietary intake , anthropometry , clinical outcomes , functional indicators . Types of Studies R and omised controlled trials , controlled trials and quasi‐experimental studies with a ‘ before and after ’ design . Search Strategy The search strategy aim ed to find both published and unpublished studies using a three‐step approach . Papers were limited to the English language and a date restriction of 1999 to 2009 was set . Critical appraisal Papers selected for retrieval were assessed by two independent review ers for method ological validity prior to inclusion in the review . Disagreements that arose between the review ers were resolved through discussion . Data Extraction For quantitative studies , data was extracted using a data extraction form developed to include specific details about the interventions , population s , study methods and outcomes of significance to the review question and specific objectives . This was based on the JBI data extraction tool from MAStARI and 2 review ers extracted data independently . Data synthesis Heterogeneity in study design s , interventions and outcomes meant meta‐ analysis was not possible . Findings were discussed in a narrative summary . Results The review included 11 studies . This included one RCT , 1 r and omised crossover study , 3 controlled non‐r and omised trials , 6 quasi‐experimental studies . None of the studies provided robust evidence , however there was moderate evidence ( Level 3 ) to support a Grade B recommendation for improvements in dietary intake and /or nutritional status with the following interventions : education of healthcare staff , simple environmental manipulations such as the use of high contrast tableware or small dining rooms , the introduction of something of interest such as an aquarium or background music , or the provision of feeding assistance , provision of enhanced menus , use of a de central ised food service , enhanced nutritional screening combined with increased dietetic time .  Conclusion There is moderate ( Level 3 ) evidence to support each of the interventions appraised in this review . Implication s for Practice There is moderate support that warrants consideration of the interventions listed above . Careful monitoring of weight of individual residents would help to determine the effectiveness of any such change in delivery of care . Implication s for Research Future research into interventions to improve eating and minimise undernutrition in older people with dementia should feature the following : inclusion of reliable outcome measures , full details of interventions , r and omisation of participants , inclusion of control groups , adequate sample sizes , longitudinal follow up , consideration of baseline demographics of intervention groups , and experimental design that allows the determination of the effectiveness of individual definable changes in delivery of care BACKGROUND Bone loss is a critical concern for space travelers , and a dietary countermeasure would be of great benefit . Dietary protein and potassium-associated bicarbonate precursors may have opposing effects on the acid-base balance in the body and therefore on bone loss . OBJECTIVE In 2 studies , we examined the ability of dietary protein and potassium to predict markers of bone metabolism . DESIGN In the first study , 8 pairs of male identical twins were assigned to 1 of 2 groups : bed rest ( sedentary , or SED , group ) or bed rest with supine treadmill exercise in a lower-body negative pressure chamber ( EX group ) . In a second study , groups of 4 subjects lived in a closed chamber for 60 or 91 d , and dietary data were collected for two or three 5-d sessions . Urinary calcium , N-telopeptide , and pyridinium cross-links were measured before bed rest ; on bed rest days 5 - 6 , 12 - 13 , 19 - 20 , and 26 - 27 ; and daily during the chamber studies . Data were analyzed by Pearson 's correlation ( P < 0.05 ) . RESULTS The ratio of animal protein intake to potassium intake was significantly correlated with N-telopeptide in the SED group during bed rest weeks 3 and 4 ( r = 0.77 and 0.80 ) and during the 91-d chamber study ( r = 0.75 ) . The ratio of animal protein intake to potassium intake was positively correlated with pyridinium cross-links before bed rest in the EX group ( r = 0.83 ) , in the EX group during bed rest week 1 ( r = 0.84 ) , and in the SED group during bed rest week 2 ( r = 0.72 ) but not during either chamber study . In both studies , these relations were not significant with the ratio of vegetable protein intake to potassium intake . CONCLUSIONS The ratio of animal protein intake to potassium intake may affect bone in ambulatory and bed-rest subjects . Changing this ratio may help to prevent bone loss on Earth and during space flight AIM To evaluate published trials examining oral post-operative protein supplementation in patients having undergone gastrointestinal surgery and assessment of reported results . METHODS Data base search es ( MEDLINE , BIOSIS , EMBASE , Cochrane Trials , Cinahl , and CAB ) , search es of reference lists of relevant papers , and expert referral were used to identify prospect i ve r and omized controlled clinical trials . The following terms were used to locate articles : " oral ' ' or " enteral ' ' and " postoperative care ' ' or " post-surgical ' ' and " proteins ' ' or " milk proteins ' ' or " dietary proteins ' ' or " dietary supplements ' ' or " nutritional supplements ' ' . In data bases that allowed added limitations , results were limited to clinical trials that studied humans , and publications between 1990 and 2014 . Quality of collated studies was evaluated using a qualitative assessment tool and the collective results interpreted . RESULTS Search es identified 629 papers of which , following review , 7 were deemed eligible for qualitative evaluation . Protein supplementation does not appear to affect mortality but does reduce weight loss , and improve nutritional status . Reduction in grip strength deterioration was observed in a majority of studies , and approximately half of the studies described reduced complication rates . No changes in duration of hospital stay or plasma protein levels were reported . There is evidence to suggest that protein supplementation should be routinely provided post-operatively to this population . However , despite comprehensive search es , clinical trials that varied only the amount of protein provided via oral nutritional supplements ( discrete from other nutritional components ) were not found . At present , there is some evidence to support routinely prescribed oral nutritional supplements that contain protein for gastrointestinal surgery patients in the immediate post-operative stage . CONCLUSION The optimal level of protein supplementation required to maximise recovery in gastrointestinal surgery patients is effectively unknown , and may warrant further study 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 r and omly 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 clinical ly significant effect on bone density but slows bone turnover . This trial was registered at the Australian and New Zeal and Clinical Trials Registry ( http://www.anzctr.org.au ) as ACTRN12608000229370 Summary A longitudinal analysis of bone microstructure in postmenopausal women of the Geneva Retirees Cohort indicates that age-related cortical bone loss is attenuated at non-bearing bone sites in fermented dairy products consumers , not in milk or ripened cheese consumers , independently of total energy , calcium , or protein intakes . Introduction Fermented dairy products ( FDP ) , including yogurts , provide calcium , phosphorus , and proteins together with prebiotics and probiotics , all being potentially beneficial for bone . In this prospect i ve cohort study , we investigated whether FDP , milk , or ripened cheese consumptions influence age-related changes of bone mineral density ( BMD ) and microstructure . Methods Dietary intakes were assessed at baseline and after 3.0 ± 0.5 years with a food frequency question naire in 482 postmenopausal women enrolled in the Geneva Retirees Cohort . Cortical ( Ct ) and trabecular ( Tb ) volumetric ( v ) BMD and microstructure at the distal radius and tibia were assessed by high-resolution peripheral quantitative computerized tomography , in addition to areal ( a ) BMD and body composition by dual-energy X-ray absorptiometry , at the same time points . Results At baseline , FDP consumers had lower abdominal fat mass and larger bone size at the radius and tibia . Parathyroid hormone and β-carboxyterminal cross-linked telopeptide of type I collagen levels were inversely correlated with FDP consumption . In the longitudinal analysis , FDP consumption ( mean of the two assessment s ) was associated with attenuated loss of radius total vBMD and of Ct vBMD , area , and thickness . There was no difference in aBMD and at the tibia . These associations were independent of total energy , calcium , or protein intakes . For other dairy products categories , only milk consumption was associated with lower decrease of aBMD and of failure load at the radius . Conclusion In this prospect i ve cohort of healthy postmenopausal women , age-related Ct bone loss was attenuated at non-bearing bone sites in FDP consumers , not in milk or ripened cheese consumers , independently of total energy , calcium , or protein intakes . Study registration IS RCT N11865958 ( http://www.is rct n.com Background : As protein is considered to increase thermogenesis and satiety more than other macronutrients , it may have beneficial effects on prevention of weight gain and weight maintenance . Objective : The objective of this study is to assess the association between the amount and type of dietary protein , and subsequent changes in weight and waist circumference ( WC ) . Methods : 89 432 men and women from five countries participating in European Prospect i ve Investigation into Cancer and Nutrition ( EPIC ) were followed for a mean of 6.5 years . Associations between the intake of protein or subgroups of protein ( from animal and plant sources ) and changes in weight ( g per year ) or WC ( cm per year ) were investigated using gender and centre-specific multiple regression analyses . Adjustments were made for other baseline dietary factors , baseline anthropometrics , demographic and lifestyle factors and follow-up time . We used r and om effect meta-analyses to obtain pooled estimates across centres . Results : Higher intake of total protein , and protein from animal sources was associated with subsequent weight gain for both genders , strongest among women , and the association was mainly attributable to protein from red and processed meat and poultry rather than from fish and dairy sources . There was no overall association between intake of plant protein and subsequent changes in weight . No clear overall associations between intakes of total protein  or any of the subgroups and changes in WC were present . The associations showed some heterogeneity between centres , but pooling of estimates was still considered justified . Conclusion : A high intake of protein was not found associated with lower weight or waist gain in this observational study . In contrast , protein from food items of animal origin , especially meat and poultry , seemed to be positively associated with long-term weight gain . There were no clear associations for waist changes Objectives The objective of this review was to assess the effectiveness of interventions that assist caregivers to provide support for people living with dementia in the community . Inclusion criteria Types of participants Adult caregivers who provide support for people with dementia living in the community ( non‐institutional care ) . Types of interventions Interventions design ed to support caregivers in their role such as skills training , education to assist in caring for a person living with dementia and support groups/programs . Interventions of formal approaches to care design ed to support caregivers in their role , care planning , case management and specially design ated members of the healthcare team ‐ for example dementia nurse specialist or volunteers trained in caring for someone with dementia . Types of studies This review considered any meta‐analyses , systematic review s , r and omised control trials , quasi‐experimental studies , cohort studies , case control studies and observational studies without control groups that addressed the effectiveness of interventions that assist caregivers to provide support for people living with dementia in the community . Search strategy The search sought to identify published studies from 2000 to 2005 through the use of electronic data bases . Only studies in English were considered for inclusion . The initial search was conducted of the data bases , CINAHL , MEDLINE and PsychINFO using search strategies adapted from the Cochrane Dementia and Cognitive Improvement Group . A second more extensive search was then conducted using the appropriate Medical Subject Headings ( MeSH ) and keywords for other available data bases . Finally , h and search ing of reference lists of articles retrieved and of core dementia , geriatric and psycho geriatric journals was undertaken . Assessment of quality Method ological quality of each of the articles was assessed by two independent review ers using appraisal checklist developed by the Joanna Briggs Institute and based on the work of the Cochrane Collaboration and Centre for Review s and Dissemination . Data collection and analysis St and ardised mean differences or weighted mean differences and their 95 % confidence intervals were calculated for each included study reported in the meta‐ analysis . Results from comparable groups of studies were pooled in statistical meta‐ analysis using Review Manager Software from the Cochrane Collaboration . Heterogeneity between combined studies was tested using st and ard chi‐square test . Where statistical pooling was not appropriate or possible , the findings are summarised in narrative form . Results A comprehensive search of relevant data bases , h and search ing and cross referencing found 685 articles that were assessed for relevance to the review . Eighty‐five papers appeared to meet the inclusion criteria based on title and abstract , and the full paper was retrieved . Of the 85 full papers review ed , 40 were accepted for inclusion , three were systematic review s , three were meta‐ analysis , and the remaining 34 were r and omised controlled trials . For the r and omised controlled trials that were able to be included in a meta‐ analysis , st and ardised mean differences or weighted mean differences and their 95 % confidence intervals were calculated for each . Results from comparable groups of studies were pooled in statistical meta‐ analysis using Review Manager Software and heterogeneity between combined studies was assessed by using the chi‐square test . Where statistical pooling was not appropriate or possible , the findings are summarised in narrative form . The results are discussed in two main sections . Firstly it was possible to assess the effectiveness of different types of caregiver interventions on the outcome categories of depression , health , subjective well‐being , self‐efficacy and burden . Secondly , results are reported by main outcome category . For each of these sections , meta‐ analysis was conducted where it was possible ; otherwise , a narrative summary describes the findings . Effectiveness of intervention type Four categories of intervention were included in the review ‐ psycho‐educational , support , multi‐component and other . Psycho‐educational Thirteen studies used  psycho‐educational interventions , and all but one showed positive results across a range of outcomes . Eight studies were entered in a meta‐ analysis . No significant impact of psycho‐educational interventions was found for the outcome categories of subjective well‐being , self‐efficacy or health . However , small but significant results were found for the categories of depression and burden . Support Seven studies discussed support only interventions and two of these showed significant results . These two studies were suitable for meta‐ analysis and demonstrated a small but significant improvement on caregiver burden . Multi‐component Twelve of the studies report multi‐component interventions and 10 of these report significant outcomes across a broad range of outcome measures including self‐efficacy , depression , subjective well‐being and burden . Unfortunately because of the heterogeneity of study design s and outcome measures , no meta‐ analysis was possible . Other interventions Other interventions included the use of exercise or nutrition which result ed in improvements in psychological distress and health benefits .  Case management and a computer aided support intervention provided mixed results . One cognitive behavioural therapy study reported a reduction in anxiety and positive impacts on patient behaviour . Effectiveness of interventions using specific outcome categories In addition to analysis by type of intervention it was possible to analyse results based on some outcome categories that were used across the studies . In particular the impact of interventions on  caregiver depression was available for meta‐ analysis from eight studies . This indicated that multi‐component and psycho‐educational interventions showed a small but significant positive effect on caregiver depression . Five studies using the outcome category of caregiver burden  were entered into a meta‐ analysis and findings indicated that there were no significant effects of any of interventions . No meta‐ analysis was possible for the outcome categories of health , self‐efficacy or subjective well‐being . Implication s for practice From this review there is evidence to support the use of well‐ design ed psycho‐educational or multi‐component interventions for caregivers of people with dementia who live in the community . Factors that appear to positively contribute to effective interventions are those which : Provide opportunities within the intervention for the person with dementia as well as the caregiver to be involved Encourage active participation in educational interventions for caregivers Offer individualised programs rather than group sessions Provide information on an ongoing basis , with specific information about services and coaching regarding their new role Target the care recipient particularly by reduction in behaviours Factors which do not appear to have benefit in interventions are those which : Simply refer caregivers to support groups Only provide self help material s Only offer peer Vitamin K is a cofactor in the production of blood coagulation factors ( in the liver ) , osteocalcin ( in bone ) , and matrix Gla protein ( cartilage and vessel wall ) . Accumulating evidence suggests that for optimal bone and vascular health , relatively high intakes of vitamin K are required . The synthetic short-chain vitamin K(1 ) is commonly used in food supplements , but recently the natural long-chain menaquinone-7 ( MK-7 ) has also become available as an over-the-counter ( OTC ) supplement . The purpose of this paper was to compare in healthy volunteers the absorption and efficacy of K(1 ) and MK-7 .  Serum vitamin K species were used as a marker for absorption and osteocalcin carboxylation as a marker for activity . Both K(1 ) and MK-7 were absorbed well , with peak serum concentrations at 4 hours after intake . A major difference between the 2 vitamin K species is the very long half-life time of MK-7 , result ing in much more stable serum levels , and accumulation of MK-7 to higher levels ( 7- to 8-fold ) during prolonged intake . MK-7 induced more complete carboxylation of osteocalcin , and hematologists should be aware that preparations supplying 50 mug/d or more of MK-7 may interfere with oral anticoagulant treatment in a clinical ly relevant way
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 population s studied ( around 0.8–1.3 g/Kg/day ) .
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 population s studied .
This systematic review and meta- analysis analysed the relationship between dietary protein and bone health across the life-course .