When we think about reducing dairy in the diet (milk, yogurt and cheese), most of us instinctually worry about calcium and bone health. This hard wired concern stems from years of compelling advertising. While we're not wrong, dairy products do contain calcium, how much does this actually reduce our risk for fractures? How much calcium are we getting in our diets right now, anyway?
Contrary to popular belief, milk consumption at any age does not appear to lower our fracture risk later in life (1). While there does appear to be an association between total dietary calcium intake and fracture risk, milk does not appear to make a difference.
Researchers from Harvard followed over 90,000 postmenopausal women for 22 years, confirming that "greater milk consumption during teenage years was not associated with a lower risk of hip fracture in older adults" (3). How can that be? As with most of medicine, it's complicated. Let me do my best to explain.
In this 4 part article, we'll chat about: - bone health (bone mineral density), - discuss if we should be taking calcium supplements, - learn about a surprising food that we can eat that has been shown to make a difference, and explore calcium rich plant food sources
Bone Mineral Density (BMD)
Bone mineral density peaks during our younger years before slowly declining later in life (2). While many of us picture our bones as permanent structures, they are constantly being broken down and repaired by our bodies. This balance of break down and repair slowly offsets over time, leading to a decline in bones density as we age, especially after menopause.
We measure our bone mineral density (BMD) with DEXA scan to determine our bone mass, but these test results do not strongly correlate with the actual strength of our bones, which is what really matters (2). So it's not perfect, but it's also the best test that we have available right now.
"Most fragility fractures arise in people who do not have osteoporosis in whom BMD would be considered normal or low-normal (osteopenic). During growth BMD increases, not necessarily because the bone is getting stronger, but because the bone is getting bigger. BMD does not differentiate between growth in size and increased mineralisation of the bone so has its limitation as a form of assessment during growth. This can be illustrated by two individuals with similar BMD but different likelihoods of sustaining a fracture. For example, a growing girl who has not achieved peak bone mass may have a similar BMD value to her grandmother but has a much lower fracture risk than her grandmother" (2)
While dietary calcium is an important factor, weight bearing exercise is just as important for keeping our bones strong. We should all be strength training, at minimum twice a week, and this is even more important when we are nearing our optimal weight. I'll let Dr. Gregor explain this further in the video below:
Calcium supplements
Dietary calcium: calcium that comes naturally as part of a whole food
Supplemental calcium: calcium concentrated into a pill that is taken
Okay, so should we all just take a supplement to ensure that we are getting enough? Surprisingly, the answer appears to be "no" yet again. I'm sorry, don't yell at me!
You see our body absorbs calcium in two ways, through an active transport mechanism in the gut (especially when our stores are low) as well as through passive transport. This makes it difficult to determine how much calcium each of us absorbs at a single meal, because this amount will likely vary from person to person.
While most major medical associations recommended getting adequate dietary calcium (as in eating foods containing calcium), there is some concern about taking calcium supplements. In fact, the most recent recommendations from the United States Preventative Service Task Force (USPSTF) recommend against routine supplementation to prevent osteoporotic fractures (4).
"The USPSTF concludes with moderate certainty that daily supplementation with 400 IU or less of vitamin D and 1000 mg or less of calcium has no net benefit for the primary prevention of fractures in community-dwelling, postmenopausal women" (4).
What's the harm in taking a calcium supplement?
Well, aside from the small risk of causing kidney stones, there is an unexpected concern that calcium supplements could potentially lead to a slightly increased risk for calcification of our arteries, possibly leading to more cardiac events (see the graph below)(5)(9). While this remains controversial because we need more large-scale trials, this is not something to take lightly. In the words of Marion Nestle and Malden Nesheim, “In the absence of compelling evidence for benefit, taking supplements is not worth any risk, however small” (6).
An unexpected solution.
Alright, but there has to be a fix! What should we be eating to improve our bone density? The answer to that question is unexpected as well. The solution apperas to be with eating more Prunes.
Prunes? Yes, that wasn't a typo. Prunes. Researchers chose dried plums because they are known for their high antioxidant ranking. You see, our bones are made of more than just calcium, and it appears that the antioxidants found in fruits and vegetables are closely related to bone health (7).
They found that eating 5-6 prunes per day does appears to lower fracture risk in women with low bone density (osteopenia) (8). And this was compared to taking a calcium supplement (8). Prunes significantly outperformed calcium supplements and reduced the activity of the enzymes in our body that break down bone (8).
Do dried plums have any advantage over fresh ones? Nope. If we're trying to cut calories, then snacking on 5-6 fresh prunes per day is a great option!
We still need to consume adequate dietary calcium.
If we're living here in the US, then most of us are aware of the recommendation to get 1,000 mg of calcium per day through food. That said, outside of the US, organizations like the World Health Organization (WHO) recommend 500 mg/day, and over in the UK they recommend consuming 700 mg/day (10). Who are we supposed to listen to? According to Harvard Health, 700 mg per day is where we should be aiming (10).
Where do we get our calcium on a plant pedominant diet? (10)(11)(13)
Plant Milks: 8 ounces (1 cup) typically contains around 350-400 mg
Tofu: 1/4 lb (1 cup) averages around 350-400 mg
Collard Greens: 1/2 lb averages 360 mg
Broccoli Raab: 1/2 lb averages 200 mg
White canned beans: 1 cup averages 190 mg
Kale: 1/2 lb averages 180 mg
Canned Salmon (with bones): a standard 3 ounce can averages 180 mg
Edamame: 1/2 lb averages 175 mg
Bok choy: 1/2 lb averages 160 mg
Tempeh: 1/4 lb averages 80 mg
Almonds: 1/4 cup contains 95 mg
Prunes or plums: 6 plums averages 25 mg
What do I think? I think that plums appear to be a novel way to improve our bone health and I do not generally recommend taking calcium supplements until we better understand the risks. As with most nutrients, they are best consumed as part of the whole plant food source that they came in. While it is prudent to be mindful of choosing enough calcium rich foods, continuing to include dairy doesn't appear to make a difference, and could make other things worse (like heart attack and stroke risk). And finally, we should all be strength training more often (twice a week), not just to improve our bone strength but as a tool to build muscle and stay independent.
Phew! That was a lot of information! It's common to feel a bit overwhelmed when making dietary changes, especially if you are doing this on your own. That's why Lifestyle Medicine Maine is here to guide you through the nuance and focus our efforts on what matters most. If you want reassurance that you're taking steps in the right direction from a nutrition literate medical provider, then look no further! Get started today by sending me a message or scheduling a free video consult. Note that Lifestyle Medicine Maine only has a limited number of spots available in an effort to maintain adequate availability for current members.
References
Milk intake and risk of hip fracture in men and women: A meta-analysis of prospective cohort studies. Bischoff-Ferrari et al. Journal of Bone and Mineral Research. (2010) https://doi.org/10.1002/jbmr.279
Dairy foods and bone accrual during growth and development. Iuliano et al. Academic Press. (2020) https://doi.org/10.1016/B978-0-12-815603-2.00011-5
Milk consumption during teenage years and risk of hip fractures in older adults. Feskanich et al. JAMA Pediatrics. (2014) 10.1001/jamapediatrics.2013.3821
Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Community-Dwelling Adults: Preventive Medication To Supplement or Not to Supplement: The U.S. Preventive Services Task Force Recommendations on Calcium and Vitamin D. (2018) https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/vitamin-d-calcium-or-combined-supplementation-for-the-primary-prevention-of-fractures-in-adults-preventive-medication#bootstrap-panel--5
Cardiovascular Impact of Calcium and Vitamin D Supplements: A Narrative Review. Zarzour et al. Endocrine and Metabolism. (2023) https://doi.org/10.3803/EnM.2022.1644
Nestle and Nesheim. Annals of Internal Medicine. (2013) https://doi.org/10.7326/0003-4819-158-9-201305070-00605
Fruit and vegetables: the unexpected natural answer to the question of osteoporosis prevention? Lanham-New. American Journal of Clinical Nutrition. (2006) 10.1093/ajcn/83.6.1254
Comparative effects of dried plum and dried apple on bone in postmenopausal women. Hooshmand et al. British Journal of Nutrition. (2011) 10.1017/S000711451100119X
Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial. Bolland et al. British Medical Journal (BMJ). (2008) 10.1136/bmj.39440.525752.BE
Surprising foods that boost bone health. Harvard Health Publishing. (2022) https://www.health.harvard.edu/womens-health/surprising-foods-that-boost-bone-health
Plums, uncooked, dried (prunes). Nutrition Value. (n.d.) https://www.nutritionvalue.org/Plums%2C_uncooked%2C_dried_%28prunes%29_nutritional_value.html?size=1+prune%2C+pitted+%3D+9.5+g
Tempeh by Lightlife Foods, Inc. Nutrition Value (n.d.) https://www.nutritionvalue.org/Tempeh_by_Lightlife_Foods%2C_Inc._365644_nutritional_value.html?size=1+ounce+%3D+28.3495+g
How much calcium do you really need? Harvard Health Publishing. (2022) https://www.health.harvard.edu/staying-healthy/how-much-calcium-do-you-really-need
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