Calcium and Protein and Bone Health in Vegans

There is good evidence that vegan diets can prevent heart disease and they are likely to lower risk for cancer as well. But does going vegan improve your bone health? I see some post or infographic in social media nearly every week claiming that a vegan diet protects against osteoporosis.

The theory is that animal protein, through its acidifying action, “leaches” calcium from bones, eventually weakening them and causing bone fractures. If that’s true, it means that those of us who eat no animal protein are likely to have better bone health.  And maybe even lower calcium needs.

Unfortunately, it’s not true. Or at the very least, the evidence in support of this relationship has fizzled over the years. I’ve written about this before, but it remains such a pervasive and potentially harmful belief that it deserves an occasional revisit.

The theory has its roots in research published in 1992 showing that hip fractures were more common in countries with high animal protein intakes. The simplistic interpretation of this is that people who eat more animal protein have more osteoporosis. But hip fractures don’t equal osteoporosis. For example, in some countries where hip fracture rates are low, rates of spinal fractures are actually higher.(1)

In fact, it appears that the factors protecting against hip fracture often have little to do with diet or with bone health. They are more about ethnic differences in bone anatomy and also in cultural habits that affect the risk of falling. (2,3)  In contrast, spinal fractures are likely to reflect bone health. So if low-protein consumers are more likely to suffer from spinal fractures, this tells us that protein might actually be a protective factor in bone health.

In fact, quite a bit of research shows this to be true. In the Iowa Women’s Health Study for example, older women with higher protein intakes were less likely to fracture a hip.(4) In the Adventist Health Study, women eating more protein from either plants or animal foods were less likely to fracture their wrists.(5) In other studies, older women who ate more protein had better bone mineral density.(6,7)

It shouldn’t be surprising. Protein is an integral part of bones and it also improves calcium absorption.(8) It’s also important for maintaining muscle strength with aging, which in turn helps to support healthy bones.

And it seems that protein’s acidifying effects may not even be relevant to bone health. A 2009 meta-analysis found that acid production (measured by acid compounds in the urine) was not associated with calcium balance or with bone loss.(9) A 2012 review of studies on protein, calcium and bone health concluded that high-protein diets did not impair calcium balance or bone health. (10)

So, based on what we know right now, vegans don’t appear to have any particular advantage when it comes to bone health.  Instead, it’s important for us to give some attention to both calcium and protein in our diets. Vegans have been slow to accept this, in part because there is such a wealth of misinformation about it on the internet and in popular books. And, of course, it’s hard to let go of these concepts when we want to paint the most enticing picture possible of vegan diets.

As always, though, bad nutrition information for vegans can’t have a happy outcome. I hear from those who have bought into the outdated science on protein and bone health and ended up with osteoporosis. They took a casual approach to calcium in their diet, believing that they were protected by their lower protein intake. Maybe they would have gotten osteoporosis anyway, of course. It’s a complex disease that involves a host of risk factors. But at the very least, we should promote information that minimizes that risk.

 

1.  Bow CH, Cheung E, Cheung CL, et al. Ethnic difference of clinical vertebral fracture risk. Osteoporos Int 2012;23:879-85.

2.  Wetzsteon RJ, Hughes JM, Kaufman BC, et al. Ethnic differences in bone geometry and strength are apparent in childhood. Bone 2009;44:970-5.

3.   Aoyagi K, Ross PD, Davis JW, Wasnich RD, Hayashi T, Takemoto T. Falls among community-dwelling elderly in Japan. J Bone Miner Res 1998;13:1468-74.

4.   Munger RG, Cerhan JR, Chiu BC. Prospective study of dietary protein intake and risk of hip fracture in postmenopausal women. Am J Clin Nutr 1999;69:147-52.

5.   Thorpe DL, Knutsen SF, Beeson WL, Rajaram S, Fraser GE. Effects of meat consumption and vegetarian diet on risk of wrist fracture over 25 years in a cohort of peri- and postmenopausal women. Public Health Nutr 2008;11:564-72.

6.  Promislow JH, Goodman-Gruen D, Slymen DJ, Barrett-Connor E. Protein consumption and bone mineral density in the elderly : the Rancho Bernardo Study. Am J Epidemiol 2002;155:636-44.

7.  Devine A, Dick IM, Islam AF, Dhaliwal SS, Prince RL. Protein consumption is an important predictor of lower limb bone mass in elderly women. Am J Clin Nutr 2005;81:1423-8.

8.  Kerstetter JE, O’Brien KO, Caseria DM, Wall DE, Insogna KL. The impact of dietary protein on calcium absorption and kinetic measures of bone turnover in women. J Clin Endocrinol Metab 2005;90:26-31.

9.  Fenton TR, Lyon AW, Eliasziw M, Tough SC, Hanley DA. Meta-analysis of the effect of the acid-ash hypothesis of osteoporosis on calcium balance. J Bone Miner Res 2009;24:1835-40.

10. Calvez J, Poupin N, Chesneau C, Lassale C, Tome D. Protein intake, calcium balance and health consequences. Eur J Clin Nutr 2012;66:281-95

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64 Responses to Calcium and Protein and Bone Health in Vegans

  1. Jeannie August 19, 2013 at 7:06 pm #

    Great post, as always! I have encountered the acidifying protein-leaching calcium theory from so many vegans online and in-person that it’s nice to have another good reference to point people to.

  2. evelyn August 20, 2013 at 8:46 am #

    Hi Ginny:

    Thanks so much for this – always good to be informed.

    Was there a protein threshold given that was considered protective? Is the standard of .8/kg of protein a day considered low? Protective?

    Many thanks!
    Evelyn

    • Ginny Messina August 20, 2013 at 12:52 pm #

      Evelyn, ideal protein intake is a topic of debate among the experts. And it’s possible that vegan needs are a little bit higher than the RDA because of digestibility of plant proteins. Also, older people might need more. In some cases, protein supplements or intakes higher than the RDA have been found to be protective–but I don’t know that there is enough evidence to actually recommend that.

      My main point really is that the fact that vegans typically consume less protein than omnivores is not protective, as has been promoted. I’m going to follow this post up with some specific recommendations, though.

      • evelyn August 20, 2013 at 2:07 pm #

        Ginny:

        I look forward to seeing what you find.

        Thanks for the great work you do, it’s very much appreciated.

        Many thanks!
        Evelyn

  3. Marian August 20, 2013 at 9:02 am #

    Brief and interesting, as ever. I also believe that physical activity has an important role to play in building and maintaining bone health.

    • Ginny Messina August 20, 2013 at 12:53 pm #

      Yes, physical activity is extremely important!

      • Noel August 20, 2013 at 4:26 pm #

        Ginny,
        thanks for posting. what do you think about the role of vitamin D in bone health and in the studies you published? I’ve been researching bone health for a while now because I’m half east asian and according to the statistics, am more likely to develop osteoporosis. I’ve read that weight-bearing exercise and Vitamin D may be more important than calcium in the diet and that excess calcium can lead to mineral deposits and crystals forming in certain organs.

        • Isa August 24, 2013 at 4:32 pm #

          Hi Noel,

          I’m not Ginny, but I hope I can shed a bit of light on your questions. Imho vitamin D is a very important (and often overlooked) factor regarding bone health. It’s also interesting that those studies that showed a correlation between protein intake and bone health weren’t specifically conducted with vegans in mind but omnivores instead – and if you get your protein from animal products you also take up vitamin D3, something you don’t if you eat a plant based diet. The only way for vegans to get sufficient vit D3 is through enough exposure to direct sunlight. UV-Radiation however has gotten a really bad reputation lately because everybody is totally scared of skin cancer and wrinkles. People wear facial creams with (chemical and potentially toxic) sun protection all the time, even in winter and, depending on where you live, sunlight in winter is scarce anyway. And I’m not even talking about people stuck in offices who hardly get a chance to soak up enough sunlight during the day. So if you life on the northern hemisphere and unless you eat a traditional Inuit-Diet chances are high that your vit D levels aren’t stellar. Fortunately blood tests for vit D can be easily done and aren’t very expensive, so I would recommend to get tested and to substitute vit D3 in case your levels are low. However keep in mind that vit D3 supplementation can elevate your dietary need for magnesium and calcium so you don’t miss out on them. Additional factors for bone health include vitamin K (unfortunately vit K2 occurs only in animal products and natto) and even zinc seems to play a role.

          Regarding those calcium crystals (kidney stones): I think the biggest risk factor for kidney stones is if you don’t drink enough water. Crystals are far more likely to build up when you don’t flush your kidneys regularly. Also, high intake of oxalate (e.g. large amounts of spinac, rhubarb, etc.) and refined sugar is linked with an increased risk for kidney stones – too much animal protein too, but that’s not something that concerns vegans. There are also studies that link kidney stones to calcium supplementation, so I guess it’s always better to meet your demand via dietary sources (rich vegan sources are e.g. poppy seeds!!, sesame, nettle, parsley, dried figs, kale and hemp seeds) or to take only a sensible dose as a supplement.

  4. Vee August 20, 2013 at 9:07 am #

    What about vegans doing weight training for bone health? I’ve seen you mention that before as well.
    I’m also interested in how you’d recommend estimating a target for daily protein… Thanks for another excellent post!

    • Ginny Messina August 20, 2013 at 12:55 pm #

      Weight training should help a lot, vegan or not.

      I recommend about 0.4 grams of protein per pound of ideal body weight.

      • Vicki Saunders, M.S. R.D. August 22, 2013 at 9:44 pm #

        I too have been recommending the .41 grams/lb ever since I saw the Jane Kerstetter study that showed calcium absorption dropping after 4 days of a diet lower than that in protein, (and leading to secondary hyperparathyroidism.)

  5. Barbara DeGrande August 20, 2013 at 10:47 am #

    Just had bone density test done yesterday; will be curious to see the results. I also do weight training and have exercised throughout my life. I am vegan for ethical reasons so the results won’t dissuade me at all, but I do think it is important to get accurate nutritional information so we can reflect it when we do outreach. Thank you!

  6. Kristin Bash August 20, 2013 at 11:10 am #

    Thank you for posting – I’ve been trying to discuss this topic rationally for a while, but it’s such a vegan myth it’s difficult to get people to stick to facts. A quick question for you – do the studies you reference adjust for confounding factors such as overall body weight and activity levels? For example, I believe osteoporosis is more prevalent among women with lower BMIs, which is also associated with people following lower protein vegan diets. So – could BMI be confounding these results? Thanks again!

  7. Andrea August 20, 2013 at 12:01 pm #

    I find this to be a specious argument. How do you define enough or high or lacking in protein? Vegans often have healthier protein levels than omnivores, most of whom eating a SAD, have protein levels that are too high. Instead, you seem to be feeding into a far worse ridiculous myth: that vegans don’t eat enough protein. The vegans you cite who thought they were somehow protected from osteoporosis by eating a diet lower in protein (lower than what?) does not support your contention.

    And the most common foods vegans eat for protein, like beans and legumes, contain calcium as well. Leaving out junk-food vegans, we also consume far more leafy greens and other foods with calcium by default by not filling our plates with animals. Finally, the HSPH DOES correlate dairy and meat with acid leaching and bone loss

    • Ginny Messina August 20, 2013 at 12:59 pm #

      No, I didn’t say at all that vegans don’t get enough protein. However, the research shows pretty consistently that our diets are typically lower in protein than the diets of meat-eaters. All I’m saying is that this does not translate to protection from osteoporosis.

      Whether vegans would do well to increase protein intake is something I don’t know. However, vegans do need to pay more attention to calcium since, again, we often have intakes that are too low. This isn’t to say that vegans can’t get enough calcium. We can easily get enough.

      And if the HSPH is still talking about protein leaching calcium from bones, then they need to update their knowledge on the subject.

      • Rebecca March 10, 2014 at 6:52 am #

        You keep talking about ‘protein levels’- I hear you. But the research I’ve seen was about the absorption of calcium specifically from dairy. Not saying that we don’t need protein- just saying that dairy specifically is not as great a calcium source as we once believed it was?

    • Valerie Sims August 23, 2013 at 4:47 pm #

      Thank you.

  8. ilse August 20, 2013 at 12:20 pm #

    Great information! I have also always read about (and in turn, shared) the dairy/acidifying/osteoporosis theory ..
    I am also curious about the the protective protein threshold.

    And also, what then do you attribute the stats regarding highest rates of osteoporosis in countries with the highest rates of dairy intake to?

    • Ginny Messina August 20, 2013 at 1:00 pm #

      Ilse, there is no evidence that countries with highest dairy intakes have the most osteoporosis. Again, these are studies looking at hip fracture rates. When we look at hip fracture rates across cultures, they don’t reflect bone health very well.

  9. Danica August 20, 2013 at 2:17 pm #

    Great post! I recently posted about calcium and vitamin D on my blog (http://veganutritionist.com/how-do-you-get-your-calcium-if-you-dont-consume-dairy/ and http://veganutritionist.com/the-importance-of-vitamin-d-in-addition-to-calcium/). I wish I would have read this post first. I’d heard this myth too, but as you said, there’s so much conflicting info online, so it’s tough to know what to believe sometimes.

  10. Annemarie August 20, 2013 at 10:37 pm #

    Thanks for the informative post. For me personally the damage has already been done but it’s so important the facts are out there. I have been vegan since 19 yrs old. At 51, (a year after entering menopause) I was diagnosed with osteoporosis with a high risk for fracture. My family doctor said it could have been the drop in my estrogen levels. The endocrinologist said it was because I was a “skinny white woman”. I wondered if I wasn’t absorbing the calcium supplements I had taken over the years. I’m 55 yrs old now and since the diagnosis have worked hard at maintianing my bone density through exercise and supplements.

    • Vicki Saunders, M.S. R.D. August 22, 2013 at 9:53 pm #

      I experienced the same thing at about the same time in my life. About one year after menopause, I was dropping bone density fairly rapidly and also had significant knee pain. I found out that my vitamin D level was insufficient and correcting that took away all of the knee pain except the part caused by a torn miniscus. My drop in bone density also leveled out. My preventive health M.D. recommended that I take the vitamin D, vitamin K2, and trans-dermal hormones. It took 4 years of steady reversal, but my bone density is back in the normal range without taking any other meds. I do believe in weight bearing exercise, but this happened at a time when I was quite limited because of knee pain and a subsequent surgery for miniscus repair, so my experience has been that you can correct it even if you can’t do much walking etc.

  11. Daniel August 21, 2013 at 1:00 am #

    Thanks for this post Ginny, what are you recommending except from protein and calcium for improving bone health? Isn’t there also something to do with sport (heavy lifting?) that can strengthen bones?

    And this is just my own experience but I’ve been diagnosed with an osteopenia (early stage of osteoporosis) from an bone scan, I am male, I was 25 years old (after 3years of being vegan) and a lifetime of inactivity and unhealthy habits… so yes, it really does happen.

    • Isa August 24, 2013 at 4:57 pm #

      Hi Daniel,

      I think you should check:
      - your vitamin D level (and supplement if this is low – along with magnesium and vitamin k2)
      - your calcium level (and adjust your diet, esp. with vitamin D3 supplementation. Maybe take a calcium supplement.)

      Further you can improve your bone status with sport – any sport (as it will strengthen muscles and therefore prevent injuries and fractures) and esp. weight lifting and high impact training (be careful if you have osteopenia and talk to your doctor beforehand!) so that your body gets the info to bring more calcium into your bones.

      I heard that chinese shaolin monks have a much higher bone density than normal people because of their training (and all that edge-of-the-hand brick destroying ;-)). That doesn’t mean that you should go out there and try your hand at shaolin techniques but it illustrates quite well how your body adapts to the demands of your life. If you lead a life that doesn’t necessarily require a lot of bones (e.g. sitting in front of a computer all day) than you body won’t keep them.

  12. Kevin August 21, 2013 at 1:45 am #

    I’m vegan, and always will be, but for the last year and half I have been suffering from a very bad vitamin D deficiency. I had been having nigh-time back pain, muscular pain, sleep problems, and depression for about a year before figuring out what it was. I was delighted when I found what the problem actually was, as I’d been worried that it could be anything from early-onset arthritis to a spinal chord tumour, so to find out that it was treatable was great. But I’d never have suspected it, as I’m a white Irish guy in his 20′s living in the UK, which is sunnier than home, and our skin is evolved to mop up sunshine. I’ve been taking very strong supplements for about three months now, and whereas the depression and muscular pain are gone, the night time back pain persists, and may for some time. Funnily enough, one of my best friends, also pasty and Irish, and vegetarian, found out she had been dealing with the same problem within a few weeks of me.

    I know these are just individual cases, but the epidemiological studies do show that we vegans are at higher risk of vitamin D deficiency, which prevents calcium absorption leading to bone weakening. This needs to be more well publicised within the vegan community, as I really think supplementing, and checking your blood levels for B vitamins, iron and vitamin D is really important for those who need it.

    As I say, I will always be vegan, for ethical reasons, but I will never again be complacent about the potential effects this has on my health (good and bad). It is an extreme diet, and not one our species has evolved to live on. I know that by accident I have put so many friends and family off the idea of vegetarianism over the last year, and have only given them fuel for their argument that it’s not healthy. I study cancer epidemiology, so I can at least retort with the evidence for decreased risk of diabetes, obesity, cardiovascular disease and (some) cancers; I just hope we can get the message out that dietary deficiencies are a real problem among the vegan community, and we need to trust the studies conducted and modern medicine if we’re going to deal with it.

    • Isa August 24, 2013 at 5:02 pm #

      Yes, here too. I’m not Irish but white as a sheet and red haired. And still I had a horrific vitamin D deficiency last year, perversely right after the end of summer (where there SHOULD be enough sunlight for vitamin D production). On the other hand being prone to sunburns didn’t exactly help with all this sunlight intake as the normal media is very vocal about the risks (cancer, premature aging, wrinkles …) but never talks about vitamin D deficiency.

  13. Kevin August 21, 2013 at 1:47 am #

    Sorry, I know that was slightly off topic, but needed a good rant!

  14. Julia August 21, 2013 at 6:37 am #

    Do you recommend calcium supplements? I have heard bad things about those. Specific recommendations would be great. Thank you!

  15. Kim Gawitt August 21, 2013 at 8:17 am #

    Thank-you for sharing this information! As a newbie vegan (a little more than 2 months) I am reading all I can and do find quite a bit of conflicting information. I was wondering if you had any dietary seggestions for me. I have degeneritive disc disease and stenosis of the cervical spine. The Ortho only suggests pain killers…… nothing to actually protect myself. I avoid the pain meds as much as possible. I would rather protect and heal myself naturally! Thank-you so much for this blog!

  16. Melissa @ Food and Loathing August 21, 2013 at 7:33 pm #

    Thanks for the post! Other vegans seem to get angry when I tell them this. But I just want all vegans to be the MOST healthy that is possible!

    I have difficulty eating enough calcium, and I really try. My major green leafy is spinach, but I understand that the calcium in spinach isn’t easily used/absorbed, or something like that? I recently switched from my usual 2 tablespoons of ground flax in my morning cereal to 3 tablespoons of white chia (black chia has 18% of the calcium RDA, white chia, according to the Whole Foods bulk bin nutrition info, has 40%, I think it said). I also ONLY use fortified soy milk or other non-dairy milk. My favorite one is Califia Farms almond milk, which has 45% of the calcium RDA. Most non-dairy milks are not fortified, unfortunately, but the Whole Foods soy milk has I think 25% of the calcium RDA.

    Anyway, despite all this, I still struggle. I feel like I couldn’t possibly fit all the food into my belly that I need to reach certain nutritional guidelines. I purposefully choose things that are a little higher in calcium but I’m still usually under the 100% mark of the RDA for calcium. I would really love some more advice about this.

  17. Spiral August 22, 2013 at 4:16 am #

    Here is a study that should clarify this issue.

    http://www.ncbi.nlm.nih.gov/pubmed/21811293

    Some excerpts from the study. . . . .

    “The prevalence of vitamin D insufficiency in vegans was higher than in omnivores (73% versus 46%; P 1⁄4 0.0003).”

    “Conclusions: Vegan diet did not have adverse effect on bone loss and fracture. ”

    “Corticosteroid use and high intakes of animal protein and animal lipid were negatively associated with bone loss.”

    The study discussed the role of calcium in the diet.

    “We found no significant effects on dietary calcium and vitamin D on bone loss. Dietary calcium intake in the present study’s participants was relatively low, but it did not have adverse effect on bone loss. Indeed, the average dietary calcium intake among vegans was only 375mg/day, much lower than the intakes observed in non-vegetarians (683 mg/ day). In both groups, the dietary calcium intake was well below the recommended level of 1000 mg/day. Nevertheless, the low levels of dietary calcium did not have any adverse effect on either BMD or bone loss in both vegetarians and omnivores.”

    The study also discussed the role of Vitamin D:

    “Disturbingly, almost 3/4 vegans had 25(OH)D levels at the level of insufficiency and more than a quarter at the level of deficiency. Although these prevalence rates were significantly higher than non-vegetarians, the difference did not seem to translate into adverse effect on bone density or bone loss. Indeed, we found no significant correlation between 25(OH)D and BMD or changes in BMD. Although the null association could be attributed to sample size, measurement errors of both BMD and 25(OH)D, and the duration of follow-up, the finding suggests that vitamin D may have modest effect, if any, on the rate of bone loss in postmenopausal women.”

    • Ginny Messina August 22, 2013 at 11:57 am #

      Spiral, to get a good balanced understanding of any of these issues, you really have to look at all of the research, not just single studies. Any study will have limitations. In this case, the overall rates of bone fractures were extremely high in both groups, and the dietary intake data of the vegan nuns seemed questionable–like it was way underestimated. So I wouldn’t put too much emphasis on this particular study.

  18. Gena August 23, 2013 at 8:52 am #

    Ginny, I have been awaiting this post eagerly, as I just attempted to wade through the research myself. I’m amazed at how well you summarized something so complex without cutting corners–an ability I seem to lack entirely, and you possess to a stunning degree :)

    I was diagnosed with osteopenia in my early twenties, and told that parts of my skeleton resembled those of a peri-menopausal or menopausal woman, thanks to my eating disorder. I’ve had to be mindful of calcium intake since, both through diet and a the steady use of a supplement. My scans now are greatly improved, but I’ve learned the hard way that this is not something to take lightly. It disturbs me that the acid/alkaline account of bone loss has been so carelessly distributed through the vegan community (I say this as someone who disseminated the theory widely myself at one point). The last thing we need is a future generation of vegans who become unusually susceptible to fractures.

    Thanks for posting this.

  19. Brandon Becker August 23, 2013 at 4:23 pm #

    I grew up taking calcium supplements, as my parents bought them for themselves and my sister and I just took them too. That habit just stuck with me when I went vegan. I don’t ever take more than 50% a day (usually I take around 25-35%), though, as I already drink fortified soy milk and eat a good amount of leafy greens.

  20. Sejal August 24, 2013 at 10:55 am #

    I find a major flow in your article. *Animal* protein does increase your chances of osteoporosis/bone problems. It’s a fact substantiated by many studies. The key issue reg. osteoporosis is not protein, but the type of protein. And, though this article mentions ‘animal protein’ once at the top, all of the studies that are cited only compare high or low protein intake. NONE looks into the ratio of animal to plant protein intake. To me it looks as if you somehow just looked into one study of 1992 which too is about protein in general (not animal protein), and got hung up on it! There are several studies taking to account animal vs plant protein, concluding that animal protein (especially milk protein) is the major cause for osteoporosis (other that some of the obvious factors like vit D, sugar, caffein, workout). Here, I am citing the major ones:

    1) The Harvard Nurses’ Health Study of 77,761 women, aged 34 to 59 followed for 12 years, found that those who drank three or more glasses of milk per day had no reduction in the risk of hip or arm fractures compared to those who drank little or no milk, even after adjustment for weight, menopausal status, smoking, and alcohol use. In fact, the fracture rates were slightly, but significantly, higher for those who consumed this much milk, compared to those who drank little or no milk. [Feskanich D, Willett WC, Stampfer MJ, Colditz GA. Milk, dietary calcium, and bone fractures in women: a 12-year prospective study. Am J Publ Health 1997;87:992-7]

    2) A six-month study of people on Atkins diet (Which is of course a diet high in animal protein intake!) found that people who adopted the Atkins diet actually excreted 50% more calcium in the urine after six months on the diet! [http://www.atkinsexposed.org/atkins/76/]

    3) A study on metabolic acidosis, done by a group at University of califronia, summerized a total of 87 surveys in 33 countries (which is a lot!) where they were able to compare the ratio of vegetable to animal prtein on the induction of bone fractures in different countries. It reported that the fracture rate increses with the animal protein intake. It also concluded that it’s not just how much animal protein the person eats that matters, but the amount of plant protein taken to attenuate the negative effect of animal protein also matters. [Frassetto LA, Todd KM, Morris C, Jr., et al. "world incidence of hip fracture in elderly women relation to consumption of animal and vegetable foods" J.Gerentology 55 (2000): M585-M592]

    4) A good resource from PCRM confirming the above findings: http://www.pcrm.org/health/healthcare-professionals/nutrition-curriculum/section-seven-preventing-and-reversing#questions

  21. Ginny Messina August 24, 2013 at 5:06 pm #

    Sejal, as I talked about in my post, comparing hip fracture rates across cultures doesn’t tell us anything about bone health and osteoporosis. And the increased amounts of calcium seen in the urine with higher protein/animal protein intake are believed now to be due to the fact that more calcium is being absorbed from the diet.

    And since protein from grains is just as acidifying as protein from animal foods, the comparison of animal protein to plant protein doesn’t hold up.

    The fact is that you can pull out a few studies to try to make the case that protein of one type or another is bad for bones, and many groups are still doing that. The most current findings don’t support it and I think it’s better for vegans to make dietary decisions based on what is known right now about protein and bone health rather than to try to defend outdated beliefs.

  22. Arun August 25, 2013 at 3:08 am #

    Hi Ginny,
    Thank you for your post, and I hope that, through your article, you are only warning vegans to be careful about calcium and protein.

    However, I am a bit disappointed at your tone, and agree with Andrea that you are almost suggesting that vegans get insufficient protein, while it is the case that people on a SAD get dangerously high levels of protein.

    Also, I would have been happier if you had suggested good plant based sources of calcium (not supplements). While warning about potential problems, you could also offer some solution, even if you need to repeat information from your previous posts. Or at least some pointers.

    Coming to the paper, if this study compares hip/spinal fracture incidence of people consuming animal and vegetable protein within the same ethnic group, then it would have been really interesting.

    For Japan, which, according to the study, has the highest incidence of vertebral fractures, 30% of morphometric vertebral fractures were classified as clinical vertebral fractures (similar to Sweden). Is there a flawless definition of morphometric vertebral fractures?

    It may be that protein from some grains may be just as acidifying as animal protein. However, not all grains are acidifying (certainly not sprouted grains). Moreover, grains are just a part of a well planned vegan diet. Beans and legumes are very high in protein, and they are not acidifying, particularly when sprouted (unlike animal protein).

    Also, vegans (leave junk food vegans aside) eat a variety of grains, beans, fruits and vegetables. They are all low in sodium (unlike meat, eggs and dairy products which are naturally high in sodium, in addition to acidifying protein), and high in potassium, which is good for bones.

    Unlike Vitamins B12 or D, a variety of plant foods (PCRM’s 4 food group, Dr. John McDougall’s diet, etc.) provide all nutrients our body needs, including calcium and protein. In most cases there is no need to supplement with calcium fortified food.

    Here is a table of calcium rich foods (Source: Nutritive Value of Indian Foods, published by National Institute of Nutrition, India). (I’m sure there will be US local plant foods which have similar or more calcium).

    Table 1: Calcium (mg) content in 100g of Food Items
    Food Item Calcium Content
    Cow’s Milk 120
    Finger Millet 344
    Black chickpeas 202
    Green gram 124
    Black gram 154
    Horsegram 287
    Kidney beans 260
    Agathi Greens 1130
    Betel Leaves 230
    Curry Leaves 830
    Corriander (Cilantro) 184
    Moringa Leaves 440
    Methi (Fenugreek) Leaves 395
    Jack fruit seeds 133
    Badam (Almonds) 230
    Til (Sesame seeds) 1470

    • Ginny Messina August 25, 2013 at 9:54 am #

      Arun, you’re right that I should have linked to posts about how to get adequate protein and calcium from plant foods. I’m planning a follow up post on that issue, however, since it was too much info to put in one post. And I wanted to focus on one important point here in order to correct an important myth in the vegan community–which is that lower protein intake does not protect bone health.

      And the point of that paper was to show that comparing bone health among different ethnic groups is complex and that hip fracture rates don’t necessarily provide the information we need.

      What is the evidence that sprouted grains are less acidifying than cooked grains? Are they lower in sulfur-containing amino acids?

      And yes, of course you can get all of the nutrients you need with the exceptions of vitamins B12 and D on a vegan diet without supplements. It does take some attention to food choices however; it doesn’t just automatically happen. And it may be more practical for some people to use fortified foods to achieve adequate calcium intake.

      Finally, the amount of calcium in 100 grams of a food isn’t necessarily relevant to human diets. For example, 100 grams of cilantro is more than 6 cups. So the amount of calcium in a cup of cilantro is less than 30 mg. We also have to consider how much of the calcium is absorbed, something that varies greatly among foods.

      But none of that is really relevant to my post which was about the relationship of protein to bone health and about the fact that vegans need to share current and factual information about this rather than try to defend beliefs that may not be to our long term benefit.

  23. Dan Hackam August 25, 2013 at 5:36 pm #

    “And yes, of course you can get all of the nutrients you need with the exceptions of vitamins B12 and D on a vegan diet without supplements.”

    Not sure. What about DHA (if you consider it a nutrient) and iodine (definitely a nutrient). I suppose if you consume seaweed you can get your iodine that way, but if you consider DHA to be essential, there’s no way to get it from a vegan diet without specifically supplementing with it (i.e. no amount of precusor ALA will produce sufficient quantities of DHA in a vegan).

    Some other things I have had a hard time getting from a vegan diet are vitamin A (900 RDE per day) and choline, but perhaps that’s just the diet I am eating.

  24. Arun August 25, 2013 at 6:15 pm #

    Hi Ginny,
    Thank you for considering doing a follow-up post on calcium and protein. That will be equally helpful for vegans. I request you to consider including whole foods too, in addition to fortified foods/supplements; and including sources of calcium that have superior bio-availability, as you have pointed out.

    Thank you once again for your plan, vegans (particularly new vegans) will benefit a lot from it.

  25. Konstantinos August 26, 2013 at 2:25 am #

    Hello,

    I would like to ask why in the vegan food guide of your book (Vegan for life) and in the article (from http://www.theveganrd.com/food-guide-for-vegans), you consider as 1 serving of calcium rich food, 1/2 cup cooked or 1 cup raw leafy vegetables which is different from the vegetarian food guide pyramid which consider as 1 serving, 1 cup cooked or 2 cup raw leafy vegetables.

    To be more exact, I mean the pyramid from the paper below, page 772, paragraph “Calcium rich foods”

    http://www.metabolicdiet.com/pdfs/veg_food_guide.pdf

    “Calcium-rich foods: Adults should choose a minimum of
    eight servings of calcium-rich foods daily. Each serving also
    counts toward choices from one of the other food groups in
    the guide. For example, 1 cup of certain cooked leafy green
    vegetables counts as a serving from the calcium-rich foods
    group and as 2 servings from the vegetable group.”

    Why is this difference. Shouldn’t I rely on the pyramid?

    Which is the right one quantity of vegetables for serving of calcium rich food?

    Thank you!!

    Kostas

  26. Christina Arasmo Beymer September 3, 2013 at 10:34 am #

    Excellent article!!

  27. EV September 18, 2013 at 3:23 pm #

    I think it’s also important when looking at any study that compares vegan diets to other diets, that vegans don’t necessarily all eat what many here would consider a healthy, balanced diet composed of whole foods, rich in nutrients. It’s certainly possible to eat a vegan diet lacking in many essential nutrients, just as it is possible to eat a poor omnivore diet. This fact tends to skew many studies of vegans, blaming the diet for a lack of nutrients, when it’s really just a junketarian diet that’s to blame. Vegan diets rich in whole foods offer a variety of calcium sources without the demonstrated downside risks of supplements.

    • Ginny Messina September 23, 2013 at 8:12 am #

      EV, many vegans will actually meet needs more easily by including some fortified foods in their diets. I don’t know of any evidence that those who eat exclusively whole foods will meet their calcium needs any more easily than someone using fortified juices or plant milks, for example. And it’s fine to use small doses of calcium supplements if necessary.

  28. Paul Appleby September 30, 2013 at 4:17 am #

    As if to underline the points made in this article, the following study found a higher fracture risk in vegans compared with other diet groups, a difference that was attributed to “their considerably lower mean calcium intake”. The good news is that there was no difference in fracture risk between the four diet groups among study participants who consumed at least 525 mg/day calcium.

    http://www.ncbi.nlm.nih.gov/pubmed/17299475/

  29. jane November 20, 2013 at 5:43 am #

    I am so discouraged. I have hyperparathyroidism and it is possibly linked to my diet . I have been vegan for 2 years. I can not afford to be organic and eat all the good things i need to . I have tried supplements and they do not work. Please advise.

    • Brandon Becker November 21, 2013 at 4:54 pm #

      How do you know it’s linked to your diet? What supplements have you tried? What has your doctor said?

  30. werner November 22, 2013 at 7:20 pm #

    Despite following all of the leaders in the plant-based world, I had not heard this was considered ‘fizzling evidence’. Per your comment: “I see some post or infographic in social media nearly every week claiming that a vegan diet protects against osteoporosis” I HARDLY consider Dr. T. Colin Campbell or Dr. Amy Lanou to be erroneously posting things on the internet. I am a registered nurse in health education and a vegan – how do you explain the rampant statistics for kidney stones and subsequent improvement with WFPB diet. I will stick with the original thought for now. P. S. I would never drink orange juice.

    • Ginny Messina November 24, 2013 at 5:24 pm #

      Werner, instead of “sticking with the original thought,” why not read the more updated research on this issue? As a health professional, you know that we have to move forward with the research, not try to defend outdated beliefs. Have you looked at the articles I cited in my post?

  31. Lisa January 30, 2014 at 9:02 am #

    Concomitant conditions also matter. I’m finding out that psoriasis/psoriatic arthritis AND also the drugs used to treat them, causes loss of bone density.

  32. Amy March 20, 2014 at 10:40 am #

    Hi Ginny,

    Thanks for writing about this. I am a trained biologist (who has published peer-reviewed research) who is now studying nutrition and I am an ethical vegan as well. Naturally, vegan nutrition is something I spend most of my free time reading about, which is why I very much enjoy yours and Jack’s scientific, unbiased work. The acid-ash hypothesis on osteoporosis is something I’ve been curious about and of course, I’ve read much of the information out there that you alluded to that supports the hypothesis and points to vegan diets as beneficial for bone health due to this. It was very interesting to read your alternative point of view.

    What is your take on the critique of the meta-analysis you cited? (Study found here: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0028135/ and critique found under “Quality Assessment”) It implies that the meta-analysis findings may not be accurate. The study readily reported that they only included 5 studies in the analysis too (I know they said this is due to the quality of their inclusion criteria but they didn’t discuss that as thoroughly as I believe is warranted, as the critique succintly points out).

    “The review question was clear and inclusion criteria were detailed for all aspects. A number of relevant data sources were accessed and attempts were made to minimise language bias. There was no apparent search for unpublished material and publication bias was not formally assessed, which meant that some bias in this respect was a possibility. The review process was poorly reported, which made it difficult to judge whether there were attempts to minimise error and bias. The absence of any systematic method of assessing risk of bias meant that the reliability of the included studies was unclear. It is unclear to what extent the chosen method of synthesis took account of the potential breakdown of randomisation and possible confounding/interactions over time periods arising from the inclusion of cross-over study designs. Given the various potential methodological limitations, the reliability of the authors’ conclusion is uncertain.”

    Just trying to figure out the facts over here. Thanks in advance for your response.

    Best,
    Amy

    • Ginny Messina March 21, 2014 at 8:51 am #

      Thanks, Amy. I hadn’t seen that critique. It doesn’t surprise me too much, since this is often a problem with meta-analyses. They are only as good as the studies being included in the analysis. So, I wouldn’t make definitive conclusions based on this study alone. And I do think it’s possible that a diet high in protein and in foods (fruits and veggies) that produce a more alkaline environment could be the answer. So a vegan diet with lots of legumes (and calcium)!

      Thanks for the link.

  33. Anne March 30, 2014 at 4:51 am #

    Hi! I was wondering; Could it be eating and drinking things with sugar could cause bone loss? It seems people with more narrow faces tend to eat more sugar and people who don’t eat sugar have a wider jawline. Depletion of calcium? Also doesn’t dairy naturally have sugar in it? Thanks.

  34. Elaine April 24, 2014 at 3:23 am #

    Thanks for the informative article! I have been strict vegan for 3.2 years and my osteoporosis has gotten much worse as a vegan. I was diagnosed as an omnivore in 2006 with T score -3.2 L spine and -1.8 hip. This was at the age of 34 and one year after a total hysterectomy and loss of both ovaries. I wanted to get a baseline being in surgical menopause and was shocked at those numbers. I should mention I have been on thyroid meds for hypothyroidism for 23 years (since I was 16), and have always been a low normal weight and rather thin for my 5’5.5″ frame. I have always been very active as well. I did smoke for nine years but quit the day of my first dexa scan in 2006 and have stayed quit. After forcing myself to gain some weight, supplementing with calcium/d, increased weight bearing exercise, and getting on a better hrt I could absorb, I had a second dexa in 2007 and scores improved: -3.0 spine and -1.2 hip. Unfortunately I fell into anorexia nervosa quite suddenly and am still battling it years later. I had another dexa in 2010 in a period of recovery from my eating disorder and scores were -3.0 spine and -1.6 hip, so slightly worse but not as bad as I thought. No surprise since I had gotten to a very low weight (bmi 14.8) for quite a while the prior year. Then in February 2011 I went vegan overnight for ethical reasons and have been strongly committed since. My weight is still slightly lower than normal range but has not changed from when I was an omnivore. I still supplement calcium/D (vegan versions) and do weight bearing exercise intensively. Calories have been similar. I did relapse for a period of one year into my anorexia in 2013 but have recovered that lost weight. I eat a very healthy whole foods diet, rarely eat out, no soda pop in years, limited salt and sugar. I had a recent dexa scan this year in March and my scores were shocking: -3.6 T score L spine and -1.8 hip. It has been discouraging that my spine scores decreased so much more as a vegan than as an omnivore even though I was in worse shape as an omnivore with my ED. In comparing my two lifestyles, the only differences I can find to account for the increased loss as a vegan is that it is harder for me to get as much protein, especially in periods of restriction. As an omnivore when I was somewhat restricting I could eat a cup of nonfat Greek yogurt daily and get tons of protein and calcium for very little calories for example. My protein intake as a vegan has been consistently hitting 30-40 grams which for me is not good considering I workout at the fitness center over an hour a day five days a week as well as cycle to work and hike, canoe, mountain bike etc. The other factor I believe that has made the difference has been thyroid related. Since becoming vegan in 2011 I have had to have my thyroid meds lowered three times. I would get symptoms of insomnia, frequent urination, feeling wired etc and get my TSH checked and it was supressed to almost nothing. I used to take 112 mcg for years but since going vegan it was lowered to 100 mcg and now 88 mcg. I don’t quite understand why this is happening but the excessive thyroid med I am sure has contributed to my bone loss. At any rate, I am at a loss of what to do now aside from eat more and gain weight (I was 105 lbs when I had my recent dexa and have now gotten up to 108 and am trying to improve my caloric intake and fight my ED. I was 92 lbs last year at 5’5.5″ but as an omnivore in the midst of my anorexia my weight was 89-90 lbs). I do believe that lack of protein is a big factor for me. I see a rheumatologist in May. I have been trying to avoid the osteoporosis meds all along except my hrt I can’t live without (tried and I was a mess being in surgical menopuase and so young). But now with my lower scores I am considering them. I have suffered several pelvic strains and Achilles tendinitis in 2012 and had extensive xrays due to debilitating pain but no fractures were found (but radiologist commented on my terrible bones). Still my left pelvic area hurts all the time and I am really worried. I want to stay committed to being vegan but I certainly can’t afford to be as relaxed about my health as I was before. I can’t ignore that my scores have gotten far worse as a vegan than as an omnivore dealing with the same issues. This has been a wake up call for me to push myself harder to recover from my ED and pay more attention to what I am eating. I do think that vegans should not be so dismissive of the importance of protein in our diet. Thanks again for the article! I could use all the help I can get.

    • Ginny Messina April 29, 2014 at 11:14 am #

      Elaine, definitely you need to eat more protein and gain a little bit of weight. I hope you’ll get help with the ED. If you can deal with that, you’ll be able to make better food choices to protect your bone health. Good luck with this. It sounds like you know what you need to do and are working hard on it.

  35. Polly June 18, 2014 at 7:24 am #

    I dislike how this article seems to use plant protein and animal protein interchangeably, especially when supposedly discussing a vegan diet. Animal proteins and plant proteins react differently in the body especially when looking at what is attached to animal proteins in food. Also the only evidence really discussed are studies that are meant to conclude to “protein must help bone strength.” On the contrary, there is actual scientific evidence that discusses the process that causes animal proteins to leach calcium from the bone. Methionine which is found in high percentages in animal proteins (chicken, steak, etc.) breaks down into sulfur and sulfuric acid, and in these high percentages causes the blood to become acidic. Due to the body needing to neutralize the blood, the body leaches calcium phosphate out of the bones and uses the phosphate to neutralize the blood. The unneeded calcium is then passed to the kidneys and released through urine. This process has been recorded in numerous studies and is highly more believable than the conclusionary evidence presented above. Also, how does it make since that countries with the highest intake of animal proteins and milk and protein in general have the highest rates of osteoporosis? We all know protein is an important factor in a healthy diet; however, we need to see that there is a difference in getting protein from animals and getting protein from plant sources.

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