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CHAPTER 6
Bone Health and the Vegetarian
I. INTRODUCTION
Keeping bones healthy begins with establishing good nutrition and lifestyle
habits that continue throughout life. When an individual adopts a healthy diet and
lifestyle, the risk of developing the debilitating bone disease, osteoporosis, as well
as other chronic health problems, is greatly reduced.
Proper diet and healthy lifestyle habits practiced throughout life can maximize
bone growth and mass during childhood and adolescence, maximize the attainment
of peak bone mass in young adulthood, and minimize bone loss later in life. To meet
these goals an individual should (1) consume a diet adequate in calcium, phosphorus,
vitamin D, and moderate in protein and sodium; (2) engage in weight-bearing
exercise regularly; (3) and refrain from smoking and excessive alcohol intake. In
addition, estrogen replacement therapy may be appropriate for some women. Many
vegetarians currently practice diet and lifestyle habits that are conducive to bone
health. For more detailed information about bone health, refer to the Bone Basics
section in Chapter 5, “Dairy Foods and Osteoporosis.”
In this chapter we will review the health effects of a vegetarian diet, focusing
primarily on its impact on osteoporosis risk. When attempting to evaluate whether
the vegetarian diet influences osteoporosis risk or the risk of other diseases, it is
important to keep in mind the specific type of vegetarian diet being followed (e.g.,
lacto-ovo, vegan). Disease risk may be modulated not only by diet, but by other
healthy lifestyle habits (i.e., exercising regularly, not smoking, using alcohol in
moderation) often practiced by vegetarians. In studies evaluating mortality and
disease prevention, it is often difficult to separate the effect of diet from the role of
other lifestyle factors. We will also examine the impact of the amount and source
of dietary protein, as well as other dietary factors including calcium, vitamin D,
phosphorus, sodium, and fiber on bone health.
© 2000 by CRC Press LLC

8731-Ch06.fm Page 252 Monday, November 25, 2002 2:46 PM
II. VEGETARIANISM
A. Types
A vegetarian generally is defined as one who abstains from meat, fish, and
poultry. However, vegetarians exhibit a wide variety of eating habits. When reading
the literature on the health effects of the vegetarian diet, keep in mind the specific
type of diets that are being compared.
• A semi-vegetarian eats dairy products, eggs, chicken, and fish, but no other animal
flesh.
• A pesco-vegetarian eats dairy products, eggs, and fish, but no other animal flesh.
• A lacto-ovo-vegetarian eats dairy products and eggs, but no animal flesh.
• A lacto-vegetarian eats dairy products, but no animal flesh or eggs.
• An ovo-vegetarian eats eggs, but no dairy products or animal flesh.
• A pollo-vegetarian eats dairy products, eggs, and poultry, but no other animal flesh.
• A vegan eats no animal products of any kind. Veganism is the most restrictive form
of vegetarianism.
Most who follow a vegetarian diet do so for its potential health benefits, while
others are motivated by religious beliefs, or by ecological or animal rights concerns.1
B. How Many Vegetarians are There?
Although the number of vegetarians (who eat no meat, poultry, or fish) has
remained stable over the past several years, the interest in part-time vegetarianism,
those who eat meatless dinners several times a week and look for vegetarian entrées
in restaurants, appears to be growing. Depending on how “vegetarian” is defined,
anywhere from 1 to 38 million Americans currently follow a vegetarian diet.
When strictly defined as those who never eat meat, fish, or fowl, a 1997 Roper
Poll estimated the number of vegetarians to be about 1% of the population or 2
million people.2 About one third to one half (0.3 to 0.5% of the population) of these
vegetarians are vegans and eat no animal products of any kind. Even among those
who don’t consider themselves vegetarians, there is a trend for consumers to be
more “vegetarian aware.” A report in Food Technology cites survey results from
1983 and 1985 indicating that nearly three quarters of American households were
firmly entrenched in a daily routine of meat and potatoes. By 1992, however, only
29% of shoppers believed it was necessary to eat meat every day.3 Based on the
results of several recent polls, the Vegetarian Resource Group estimates that currently
between 20 and 30% of the population purchases natural and vegetarian foods
regularly.2
Vegetarianism is gaining popularity among teens, apparently due to increased
sensitivity about animals. A 1995 Roper poll of 8 to 17 year olds found that more
teens than adults are following this dietary pattern.4 Almost 2% of teens are vege-
tarian (never eat meat, fish, or fowl). Higher percentages of 8 to 12 year olds and
13 to 17 year olds when compared to adults “do not ever eat” meat (8%, 8%, and

6%, respectively), poultry (8%, 6%, and 3%, respectively), fish (19%, 17%, and 4%,
respectively), eggs (9%, 8%, and 4%, respectively). These data, particularly when
coupled with the finding that 4% of 8 to 12 year olds and 3% of 13 to 17 year olds
avoid all dairy products, have sparked concern among health professionals.5 Teens
with an inadequate consumption of calcium and dairy foods are at risk for low peak
bone density and osteoporosis later in life. It must be remembered, however, that
while an estimated 2% of adults (from the 1997 poll)2 and 3% of teenagers (from
the 1995 poll)4 avoid dairy products, all do not do so because they are vegetarian.
Approximately 1/2 of 1% of American adults avoid dairy products because they are
following a vegan diet.
C. Health Effects of a Vegetarian Diet and Lifestyle
Vegetarian diets are often lower in saturated fat and cholesterol and higher in
dietary fiber, folate, anti-oxidant vitamins (such as E and C), carotenoids, and
phytochemicals, than most omnivorous diets.6 The potential benefits of a vegetarian
diet and lifestyle may include a lower risk of obesity, cardiovascular disease, hyper-
tension, diabetes mellitus, and some forms of cancer, though differences in disease
rates are often related to factors other than diet.6
Often those who choose a vegetarian diet embrace other healthy lifestyle habits,
such as not smoking, engaging in regular exercise, and maintaining a healthy weight,
which are associated with lower chronic disease risk.7 Researchers in Britain recently
investigated the role of dietary habits in mortality among 11,000 vegetarians and
health conscious people.8 Overall, the cohort had a mortality about half that of the
general population. Daily consumption of fruit, not vegetarian status per se, was
associated with reduced mortality from ischemic heart disease, cerebrovascular
disease, and all causes combined. When comparing disease risk among vegetarians
and omnivores, it is important to carefully evaluate the types of diets being compared
(i.e., vegan, lacto-ovo, semi-vegetarian) and the composition of those diets, as well
as how well lifestyle factors other than diet are controlled.
Often it is not the presence or absence of meat in the diet that attenuates disease
risk and mortality rate. In some omnivorous populations that follow a “prudent” diet,
the fat, saturated fat, and cholesterol content of the diet may be similar to that of
vegetarians.9 Investigators from Australia reviewed the evidence linking vegetarian
diets to lower blood pressure.10 Evidence that diet effectively lowers blood pressure,
they conclude, has been seen most clearly in those who follow a strict lacto-ovo-
vegetarian diet. Compared to a typical Western diet, the lacto-ovo-vegetarian diet is
lower in saturated fat, higher in dietary fiber, fruits and vegetables, and dairy products.
The review states that blood pressure is not influenced by the absence of meat protein
per se. This conclusion has been supported by the results of the DASH (Dietary
Approaches to Stop Hypertension) trial.11 This study demonstrated that a low fat diet
rich in fruits and vegetables and lowfat dairy foods was effective in reducing blood
pressure. In fact, it was as effective as medication for those with mild hypertension.
Whether vegetarians live longer than nonvegetarians is difficult to determine,
since few studies of all-cause mortality have been conducted that compare these
groups. Two major studies of this kind had differing results.12,13 A more recent study

evaluated various lifestyle characteristics of 1904 German vegetarians to determine

which might be associated with decreased mortality after 11 years of follow-up. 14
The majority of participants were lacto- or lacto-ovo-vegetarians; only 6% were
vegan. In men, activity level and body mass index were the most important
determinants of total mortality. For women, mortality was significantly reduced
among moderate (ate fish or meat occasionally) vs. strict vegetarians (avoided fish
and meat completely), and among those with a higher activity level. Body mass
index did not affect mortality in females. Since moderate vegetarians, especially
women, had a lower risk of death than strict vegetarians, the authors suggest that
“the choice of a wide variety of foods and sound nutritional planning may be more
important than an absolute avoidance of meat.” In addition, a greater proportion
of moderate vegetarians claimed to have chosen the vegetarian lifestyle to improve
their overall health, so may have paid more attention to the nutritional adequacy
of their diet.
There appears to be no overwhelming evidence that vegetarians live longer than
nonvegetarians. Mortality rates may be affected by overall diet, socioeconomic
differences, selective factors relating to who chooses to become and remain a veg-
etarian, and overall health consciousness.15
III. FACTORS INFLUENCING BONE HEALTH
Both heredity and environmental factors (including diet and exercise) influence
bone density. While one cannot change the genetic determinants of bone structure
or other uncontrollable factors that influence bone mass, such as gender, ethnicity,
age, hormonal status, and body frame size/weight,16 there are many things one can
do to improve bone health.
A. Heredity
Investigators estimate the role of heredity in determining bone density to be 50

to 80%. Krall and Dawson-Hughes compared bone density among family members
(men and women) of 40 families, and examined the association between bone density
and environmental factors. They estimated that heredity and environmental factors
exerted an equal effect on bone density.17 Studies in twins indicate that about 75%
or 80% of the variability in bone density, size, and bone turnover is explained by
genetic factors.18,19
Experimental data support the hypothesis that peak bone size, bone mass, and
bone density in young women are strongly influenced by genetic factors from fathers
as well as from mothers. By the age of 16 years, daughters had attained 90% to
97% of the bone size, mass, and density of their premenopausal mothers.20 Inherit-
ance may influence both the level of peak bone mass and the rate at which bone is
lost after menopause.21 Since bone mass is partly hereditary, young women whose
mothers have been diagnosed with osteoporosis may be at increased risk themselves,
and should be especially careful to control the environmental factors affecting bone.
Johnston and Slemenda, in a review of the determinants of peak bone mass, say,

“Genetic factors are important in determining peak bone mass, but environmental
factors such as calcium nutrition and exercise are important in maximizing the
genetic potential.”22
B. Environment
1. Diet
Building and maintaining healthy bones requires adequate amounts of many

nutrients, including calcium, vitamin D, phosphorus, zinc, and magnesium. Manga-
nese and copper are needed in smaller amounts as well.23 Calcium is the major
building block of bone; adequate amounts are needed throughout life to maintain a
healthy skeleton. Vitamin D, manufactured in the body from sunlight or obtained in
the diet, facilitates calcium absorption and the incorporation of calcium into bone.
The primary dietary source of vitamin D is vitamin D fortified milk. Excessive
sodium, protein, and fiber intake can decrease the amount of calcium that is available
to build and remodel bone, either by decreasing calcium absorption or increasing
calcium excretion.23 Though these excesses are not particularly harmful in them-
selves when calcium intake is adequate, they will aggravate calcium deficiency if
calcium intake and/or absorption is low. Increasing calcium in the diet will neutralize
the negative effects of any of these excesses. Sodium, protein, and fiber will be
discussed in more detail later in this chapter.
2. Lifestyle
Exercise and physical work increase bone density and strength. Both weight-
bearing and resistance exercises are important for building and maintaining bone
mass and density.16 Weight-bearing exercises include walking, jogging, impact aer-
obics, stair climbing, dancing, and hiking. Swimming and bicycling are not weight-
bearing. The usual prescription for maintaining bone health is brisk walking; how-
ever, many women over the age of 75 who have led a sedentary lifestyle, do not
have the aerobic capacity to engage in a walking program.24 This loss of strength
can be reversed by a carefully planned progressive exercise program.
It is estimated that increasing physical activity will have an overall benefit of 4
to 8% on bone mass, depending on the type of exercise and the skeletal site mea-
sured.22 Exercise has many advantages as a therapy, since it is inexpensive, readily
available, and enjoyable. A small percentage increase in bone mass can have a large
effect on fracture reduction. For example, for every percentage point of bone lost,
the risk of fracture increases by 8 to 10%. Increasing an individual’s muscular
strength and balance to prevent falls is probably the most important contribution of
exercise overall.
There is evidence that exercise should be encouraged in childhood, adolescence,
and young adulthood, to improve the attainment of peak bone mass and help reduce
the risk of osteoporosis later in life. Sports activities had a positive effect on the
bone density of the spine and hip among pubertal girls25 and boys ages 4 to 20.26
The results of recent cross-sectional studies in college age and young adult women,

showed that at least moderate exercise along with adequate calcium intake had a
positive effect on bone mineral density.27,28 French researchers, studying the deter-
minants of bone mineral density in children and adolescents, found that weekly
sports activity significantly influenced both vertebral and femoral bone density,
especially in girls during puberty.25 Calcium intake was also a significant, indepen-
dent determinant of bone density for both sexes. A majority of the participants found
to have low bone mass, had calcium intakes below 1,000 mg/d (the Recommended
Dietary Allowance in France for 10 to 12 year olds). A review of the effects of
physical activity on bone mineral density in postmenopausal women concludes that
a calcium intake of at least 1000 mg/d is needed in order for physical activity to
have a positive effect on bone.29
Studies have shown that moderate intensity, low or high impact exercise three
days per week 30 or walking for 50 min. 4 days per week31 for one year improved
bone density in postmenopausal women. A review of both cross-sectional and
prospective studies of bone density and exercise concludes that an exercise regimen
should include both vigorous strength and aerobic training. 32 The National
Osteoporosis Foundation recommends weight-bearing exercise four times a week
and resistance training two to three times a week.16
Cigarette smoking increases by about 50% a person’s risk of osteoporosis leading
to fracture. Compared to nonsmokers, women smokers have lower levels of estrogen,
possibly producing lower bone density. Estrogen replacement therapy is less effective
in smokers, so shouldn’t be relied upon to counteract the damage to bone caused
by cigarette smoking.33 In order to evaluate the effect of cigarette smoking on bone
density, a group of Australian researchers compared the bone density in the spine,
leg, and hip of 41 pairs of female twins who had differing smoking habits.34 In the
20 twin pairs whose smoking habits differed the most, the heaviest smoking twin
had bone density 9.3% lower in the spine, 6.5% lower in the leg, and 5.8% lower
in the hip. The authors conclude that women who smoke one pack of cigarettes per
day throughout adulthood can expect to lose an average of 5 to 10% in bone density
by the time of menopause.34
Consuming alcohol to excess is also damaging to bone, perhaps more so than
cigarette smoking. Excess alcohol intake may harm the bones by reducing calcium
absorption, decreasing calcium intake (and that of other nutrients), and causing liver
damage, which alters calcium metabolism.35
A low calcium intake will further aggravate the negative effects of inactivity,
smoking, or excessive alcohol intake. However, taking extra calcium will not neu-
tralize the effects of any of these excesses.
3. Lifestage or Disease State
Age and certain diseases can increase a person’s need for calcium. Dietary
adjustments should be made to meet the increased need for calcium. Elderly persons
may need more calcium than younger adults because they have decreased vitamin
D production and reduced calcium absorption.36 A number of diseases common in
older adulthood, such as gastrointestinal disorders and renal insufficiency, can
decrease calcium absorption and/or increase calcium excretion, thereby increasing

calcium need. Chronic laxative use, as well as other medications, can increase
calcium need.
IV. THE VEGETARIAN DIET AND OSTEOPOROSIS RISK
Differences in the prevalence of osteoporosis between vegetarians and nonveg-

etarians are not well documented. Some cross-cultural studies have shown that
people living in countries with low calcium intake and primarily vegetarian diets do
not have the high incidence of fracture seen in Western cultures where calcium intake
is higher.37 However, actual calcium intake is difficult to obtain from these societies,
and no doubt genetic, lifestyle, and other confounding factors unique to that popu-
lation play an important role in determining osteoporosis risk. Therefore, only
comparisons between groups within the same population will yield plausible and
valid conclusions.38
Osteoporosis and other disease rates do not vary markedly between vegetarians
and nonvegetarians in the U.S. when differences in lifestyle factors such as exercise,
smoking, and alcohol habits are taken into account. Any claimed reductions in
osteoporosis risk as a result of consuming a vegetarian diet are based on studies that
contain no dietary data or assessment of lifestyle habits that affect bone.39,40 The
randomized, controlled trial is the “gold standard” for evaluating either therapeutic
or nutritional interventions and for establishing causation.41 However, the hypothesis
that the avoidance of animal protein reduces osteoporosis risk is not supported by
experimental data from well-controlled studies. Studies conducted in the U.S. in
which dietary and other lifestyle factors were carefully assessed and controlled, and
where calcium intake was at or above recommended levels, showed no difference
in bone mineral density between lacto-ovo-vegetarian and omnivorous premeno-
pausal or postmenopausal women.42,43,44.45,46 Hunt et al. found that while bone density
decreased steadily with age, it did not differ significantly between the lacto-ovo-
vegetarian and omnivorous women studied (Figure 6.1).43 Similarly Reed et al. (Table
6.1) found that neither distal nor mid-radial bone mineral content or density differed
between 49 lacto-ovo-vegetarian and 140 omnivorous elderly women (average age
81 years).45 Tylvasky and Anderson found no difference in bone mass between 88
lacto-ovo-vegetarian and 278 omnivorous postmenopausal women when adjusted
for age.46 Marsh et al. found no difference in bone mineral density between vegetarian
and omnivorous men.47 Barr et al., however, found that in a small group of Canadian
women ages 20 to 40, vegetarians (lacto-ovo and vegan) had significantly lower
bone mineral density of the spine than nonvegetarians.48 The differences in bone
mineral density between groups were explained by the vegetarian’s lower bone mass
and lower body weight/body fat and lower intake of some nutrients. The vegetarians
had lower intakes of zinc, vitamin B12, and calcium (vegans only) than did the
nonvegetarians.
Lacto-vegetarians who have calcium intakes above recommended levels do not
seem to be at risk for osteoporosis.49 The vegan’s low calcium intake, use of foods
high in phytates, oxalates, and fiber, and tendency to be underweight are character-
istics that likely increase this risk of osteoporosis. However, to our knowledge,

Figure 6.1 Bone mineral content/bone width (BMC/BW) of the cortical radius by decade of
age (x ± SEM). No significant differences were found between omnivores and
vegetarians within decades. The difference between decades was significant (p
<0.0001, analysis of variance). Values are not shown for the small numbers of
postmenopausal women aged ð 50 y (two omnivores and six vegetarians) and >
90 y (one omnivore and four vegetarians). (From Hunt, I. F., Murphy, N. J.,
Henderson, C., Clark, V. A., Jacobs, R. M., Johnston, P. K., and Coulson, A. H.,
Am. J. Clin. Nutr., 50(3), 517, 1989. With permission.)
Table 6.1 Bone Variables of Study Groups: Unadjusted and Adjusted for Age and
Lean Body Mass (LBM), 1988*
Unadjusted Means Means Adjusted for Age and LBM
Variable DBMC DBMD MBMC MBMD DBMC MBMD MBMC MBMD
Lacto-ovo-vegetarian 709.3 323.1 673.9 530.2 802.9 351.2 728.0 543.0
diet (n = 49)
Omnivorous diet 658.3 303.3 654.2 528.6 823.8 358.7 727.5 529.7
(n = 140)
* DBMC, distal-bone mineral content; DBMD, distal-bone mineral density; MBMC, midradial-
bone mineral content; MBMD, midradial-bone mineral density.
(From Reed, J. A., Anderson, J. J. B., Tylavsky, F. A., and Gallagher, Jr., P. N., Am. J. Clin.
Nutr., 59 (Suppl.), 1197s, 1994. With permission.)

sufficiently large controlled studies comparing bone density of vegans and nonveg-
etarians in the U.S. have not been conducted, possibly because there are few vegans
from which to build a study population. A small number of strict vegetarians have
been studied as part of a larger group. Marsh et al. found that vegans (n = 11) had
lower bone densities than lacto-ovo or semi-vegetarians who included some fish,
chicken, or meat in their diets; however, there were too few subjects in each group
for statistical analysis.50 Barr et al. found that vegan women (n = 8) did not have
lower bone mineral density than lacto-ovo-vegetarian women, though their calcium
intake was 300 mg/d lower.48 However, no conclusions can be drawn from such a
small sample. Vegetarians as a group, though, had lower bone density than nonveg-
etarians. The authors recommend that vegetarian women maintain a generous intake
of calcium and other bone-related nutrients.
Reports on the bone density of the elderly Chinese provides good insight on the
skeletal status of vegans, and the relative importance of calcium and protein in the
diet.51-54 Studies conducted by Zhao et al. and Hu et al. compare bone mass between
individuals living in different areas of China whose diets vary widely, providing a
unique opportunity to evaluate the impact of different dietary patterns on bone mass.
If low calcium intake contributes to osteoporotic fracture, one would expect to find
the evidence in populations that have a range of low to high calcium intakes, rather
than in countries like the United States where intakes are predominantly higher
(though well below requirements).23 China provides ideal conditions for such a study.
China is a vast country in which dietary patterns can vary widely, and people are
not highly mobile. Therefore one may evaluate the impact of lifetime adherence to
a particular diet.
A study conducted among 2169 subjects aged 45 to 75 years investigated the
influence of diet on health problems occurring in the elderly in six areas of China,
including rural farming, fishing, herding, and urban areas.51 Bone status of males
and females was evaluated as part of the larger survey. Chinese living in rural areas
typically have low calcium intakes and obtain calcium and protein primarily from
plant sources. The data revealed that bone density of the distal radius was higher
among women living in pastoral areas of China where dairy foods comprise a large
portion of the diet, when compared to those living in rural, nondairy consuming
areas. Bone density of both the distal- and mid-radius was positively related to total
calcium and dairy calcium intake. In 376 healthy elderly subjects, bone density was
positively related to calcium intake. Those who had low calcium intakes (<700
mg/day) had the lowest bone density.
Associations between dietary calcium and bone status were investigated in 843
middle-aged and elderly (35 to 75 years) women who lived in five rural counties
where eating patterns and calcium intakes varied.52 Figure 6.2 shows the types of
foods eaten in each county. County YA (Xianghuangqi) and WA (Tuoli) are located
in two pastoral areas of China, but county WA is termed semi-pastoral, because the
women only drank milk tea and consumed no cheese or other dairy products. The
rest of the counties, CD (Jiexiu), SB (Cangxi), and LC (Changle) were selected from
rural farming areas where no milk or dairy foods were available. A 3-day dietary
survey was conducted in each household to determine usual food intakes for each
subject. The average daily intake of selected nutrients of women in the five survey

Figure 6.2 Dietary patterns of middle-aged and elderly women in the five survey counties:
YA, Xianghuangqi; WA, Tuoli; CD, Jiexiu; SB, Cangxi; LC, Changle. Intakes of milk
and dairy foods were expressed as grams dry weight per day. (From Hu, J.-F.,
Zhao, X.-H., Parpia, B., and Campbell, T. C., Am. J. Clin. Nutr., 58, 398, 1993.
With permission.)
counties is presented in Table 6.2. Bone mass was measured at both the distal- and
mid-radius of the nondominant arm by a single-photon absorptiometer. Only in
county YA, where dairy products were consumed regularly, did the calcium intake
approach the Chinese recommended allowance of 800 mg/d.
The five survey counties were grouped into pastoral, semi-pastoral, and non-
pastoral based the frequency of dairy food consumption. Bone mass declined with
age in all areas, beginning as early as age 35; decline in bone mass accelerated after
age 50 (Figure 6.3). Women in the dairy-consuming county (pastoral) had a higher
peak bone mass at age 35. This suggests that the greater bone mass at each age was
primarily the result of differences in the attainment of peak bone mass, rather than
differences in bone mass later in life. This conclusion is supported by Matkovic et
al.55 who demonstrated that calcium is an important determinant of peak bone mass.
In county YA (pastoral with a high consumption of dairy foods) dietary calcium
remained positively associated with all bone variables even after adjustment for age
and/or body weight. These women had a 20% greater bone mass at the distal radius,
than women in non-pastoral areas with lower calcium intakes.

Table 6.2 Average Daily Nutrient Intakes of Women in the Five Survey Counties*
Xianghuangqi Tuoli Jiexiu Cangxi Changle
(n = 142) (n = 147) (n = 156) (n = 151) (n = 168)
Energy (kJ) 6303 ± 1704c 6237 ± 7461 ± 1898b 10268 ± 3227a 7319 ± 1767b
1724c
Carbohydrate 216 ± 59c 228 ± 64c 336 ± 93b 498 ± 164a 328 ± 84b
(g)
Fat
(g) 38 ± 18a 42 ± 27a 24 ± 12b 26 ± 16b 27 ± 15b
(% of 22.3 ± 6.7b 24.5 ± 10.3a 12.6 ± 5.6c 9.9 ± 5.2d 13.6 ± 5.1c
energy)
Protein
(g) 75 ± 27a 51 ± 17c 57 ± 15b 57 ± 18b 49 ± 13c
(g/kg body 1.5 ± 0.5a 1.0 ± 0.4c 1.1 ± 0.3c 1.3 ± 0.4b 1.0 ± 0.3c
wt)
Calcium (mg) 724 ± 333a 369 ± 153b 359 ± 159b 328 ± 133b 230 ± 104c
Dairy foods 217 ± 110a 113 ± 71b 5 ± 2c 0c 0c
(g) †
Dairy calcium
(mg) 516 ± 296a 152 ± 99b 6 ± 4c 0c 0c
(% of total 67.3 ± 14.2a 34.6 ± 11.9b 0.7 ± 0.3c 0c 0c
calcium)
Phosphorus 1130 ± 360a 909 ± 235c 996 ± 261b 1003 ± 306b 689 ± 168
(mg)
Calcium: 0.6 ± 0.2a 0.4 ± 0.2b 0.4 ± 0.1b 0.3 ± 0.1b 0.3 ± 0.1b
phosphorus
*x ± SD; n = 764. Means not sharing the same letter superscript are significantly different for the
five counties. P < 0.05 (Duncan’s multiple-range test).
†Dry weight.
From Hu, J., et al., Am. J. Clin. Nutr., 58, 219, 1993. With permission.
The results of the study by Hu et al. provide important information about whether
calcium from non dairy sources is as effective as calcium from dairy foods in
maintaining bone mass. The women living in the semi-pastoral county of YA had
an average calcium intake of 369 mg/d of which 34.6% came from dairy foods; the
women living in the three non-pastoral counties had similar calcium intakes (Table
6.2), but none was provided by dairy foods. Dairy calcium was more significantly
correlated with bone mass than was nondairy calcium. In fact, nondairy calcium
showed no association with bone variables after adjustment for age and/or body
weight. In a separate analysis, the consumption of milk, hard cheese, and other dairy
foods by women in counties YA and WA, were positively associated with bone
mineral content and bone mineral density at the distal- and mid-radius. The authors
suggest that the nondairy calcium consumed by the Chinese women in this study
may be less bioavailable due to binding with phytates and other components of
vegetable foods. Further studies may help clarify this issue.
A recent study conducted among 258 postmenopausal Taiwanese vegetarian
women, linked long-term adherence to a vegan diet with significantly lower bone
mineral density of the hip (after controlling for other variables), when compared
to those with a shorter or less strict adherence to a vegan diet.53 Low BMI and
protein intake contributed to bone loss in this population. In addition, the calcium

Figure 6.3 Age-related changes in distal radius bone mineral density (BMD) of women in
pastoral, semipastoral, and nonpastoral areas (x ± SEM). (From Hu, J.-F., Zhao,
X.-H., Jia, J.-B., Parpia, B., and Campbell, T. C., Am. J. Clin. Nutr., 58, 219, 1993.
With permission.)
intake of these women was extremely low (approximately 350 mg/d), less than
50% of the level recommended in China. The authors conclude that to prevent
osteoporosis in this population, nutritional supplementation of calcium and protein
should be considered.
Lau et al. compared the bone density of elderly Chinese lacto-vegetarians, vegans,
omnivores, and Caucasian vegetarians.54 When compared to the omnivores, the bone
mineral density of the hip of the vegetarians was significantly and consistently lower.
Dietary energy, protein, and calcium intake were positively associated with bone
mineral density at all sites. Urinary sodium/creatinine ratios were negatively correlated
with bone mineral density of two sites within the hip. The average calcium intake of
vegetarians in this study was quite low, 328 mg/d, and was likely below this popula-
tion’s threshold for maintaining bone mass. The bone mineral density of the lacto-
vegetarians was not significantly different from that of the vegans. (The definition of
a lacto-vegetarian is that they consumed milk at least once a month.) The authors
suggested that although the calcium intake of the lacto-vegetarians was higher than
that of the vegans, its beneficial effect may have been offset by the lower protein and
energy intake (both below recommended levels). Adequate calories and protein are
important for building bone mass. It is important to note that the diet of Chinese
vegetarians differs considerably from that of Caucasian vegetarians. In this study, the
dietary intake of calories, protein, fat, and calcium were much lower among Chinese

vegetarians than among Caucasian vegetarians. The diet of the Chinese omnivores was
similar to that of the Caucasian vegetarians in all respects except calcium. Chinese
omnivores had an average calcium intake of only 334 mg/d, while the Caucasian
vegetarians consumed an average of 819 mg of calcium daily.
Since the diets of the two cultures are so different, conclusions about the bone
health status of Chinese vegetarians do not necessarily apply to vegetarians living
in the United States. Although vegans living in China appear to be at high risk for
low bone density and osteoporosis, studies among a large sample of U.S. vegans
are needed to determine if they are at similar risk. Hip fracture rates in Hong Kong
and other parts of Asia are rising, though they are still substantially lower than in
the United States.56 In addition to diet, other factors, such as bone mass, body weight,
physical labor, latitude, reproductive history, femur anatomy, and differences in data
collection, contribute to reported hip fracture risk.57 Obviously, many factors con-
tribute to fracture risk, but the data from China provide clear evidence that consuming
adequate amounts of protein and calcium (particularly from dairy foods), is important
to maintaining the bone health of vegetarians.
V. FACTORS OF VEGETARIAN DIETS THAT AFFECT BONE HEALTH
A. Calcium
1. Intake Recommendations and Consumption Patterns
There is widespread recognition that an adequate calcium intake throughout life

helps to optimize peak bone mass and prevent age-related bone loss, and thus protects
the skeleton from osteoporosis and fracture.58,59 Adequate calcium intake may have
the added benefits of decreased risk of developing hypertension and colorectal
cancer.60,61,62 (See Chapters 3 and 4.)
In 1997 the National Academy of Sciences (NAS) updated the recommendations
for calcium intake, as well as the other bone related nutrients (vitamin D, phosphorus,
magnesium, and fluoride). 59 (Table 6.3) The calcium recommendations were
increased for several age groups. Children (9 through 13) and teens (14 through 18)
are encouraged to consume 1300 mg of calcium/d to optimize peak bone mass.
Calcium recommendations for adults were increased to 1000 mg/d (from 800 mg/d)
for 19 through 50 year olds, and to 1200 mg/d (from 800 mg) for adults over age
50. Lacto-vegetarians can meet these recommendations by the consumption of 3 or
4 servings of milk and milk products daily. Vegans will use a combination of calcium-
containing plant foods, calcium-fortified foods (Table 6.4), and supplements to meet
calcium intake recommendations. The NAS recommendations for calcium intake,
now expressed as Adequate Intakes (AI) rather than Recommended Dietary Allow-
ances (RDA), are consistent with the amount of calcium needed for maximal calcium
retention, increased bone mass, and reduced risk of osteoporosis. (Adequate Intakes
are set when there is not enough data to establish an Estimated Average Intake upon
which the RDA is set. They are used similarly as the RDAs, to establish intake goals
for individuals.) The new NAS recommendations for calcium are more in line with

Table 6.3 Dietary Reference Intakes for Bone-related Nutrients

Magnesium
Recommended
Dietary Allowance
mg/dl
Calcium Phosphorus Vitamin D
Adequate Recommended Adequate
Life-Stage Intake Dietary Intake
Group mg/d Allowance mg/d Males Females µg/d
0–6 months 210 100* 30* 30* 5
6–12 months 270 275* 75* 75* 5
1–3 years 500 460 80 80 5
4–8 years 800 500 130 130 5
9–13 years 1,300 1,250 240 240 5
14–18 years 1,300 1,250 410 360 5
19–30 years 1,000 700 400 310 5
31–50 years 1,000 700 420 320 5
51–70 years 1,200 700 420 320 10
> 70 years 1,200 700 420 320 15
Pregnancy
ð 18 years 1,300 1,250 400 5
19–50 years 1,000 700
19–30 years 350
31–50 years 360
Lactation
ð 18 years 1,300 1,250 360 5
19–50 years 1,000 700
19–30 years 310
31–50 years 320
* Adequate Intake
Source: IOM, Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D,
and Fluoride, Food and Nutrition Board, National Academy Press, 1997. With permission.
those of The National Institutes of Health (NIH) Expert Panel on Optimal Calcium
Intake released in 199463 and supported by the American Medical Association.64
The NIH Expert Panel recommends 800 mg calcium/day for children 1 to 10 years,
1200 to 1500 mg calcium/day for older children and young adults 11 to 24 years,
1000 mg calcium/day for adult men and women 25 to 50 years, 1000 to 1500 mg
calcium/day for postmenopausal women, and 1500 mg calcium/day for all men and
women over age 65.63 The consensus statement issued by the panel indicated that
calcium-rich foods such as dairy foods are the preferred source of calcium.
Vegetarians who consume a diet relatively low in protein and sodium and engage
in regular weight-bearing exercise, may have a lower calcium requirement than those
who consume the typical Western diet, upon which current calcium recommenda-
tions are based. However, calcium requirements for vegans have not been established.
Therefore vegans are encouraged to meet the calcium requirements established for
their age group by the National Academy of Sciences, Institute of Medicine.6

Table 6.4 Food Sources of Calcium and Vitamin D

Milligrams per
Calcium Serving
Dairy Foods
Cow’s milk, 1 cup 300
Yogurt, 1 cup 275–400
Cheddar cheese, 11/2 oz. 306
Legumes (1 c cooked)
Chickpeas 78
Great northern beans 121
Navy beans 128
Pinto beans 82
Black beans 103
Vegetarian baked beans 128
Soyfoods
Soybeans, 1 c cooked 175
Tofu, 1/2 c 120–350
Tempeh, 1/2 c 77
Textured vegetable protein 85
Soymilk, 1 c 84
Soymilk, fortified, 1 c 250–300
Soynuts, 1/2 c 252
Nuts and Seeds (2 Tbsp)

Almonds 50
Almond butter 86
Vegetables (1/2 c cooked)

Bok choy 79
Broccoli 89
Collard greens 178
Kale 90
Mustard greens 75
Turnip greens 125
Fruits
Dried figs, 5 258
Calcium-fortified orange juice, 1 c 300
Other Foods
Blackstrap molasses, 1 Tbsp 187

Table 6.4 Food Sources of Calcium and Vitamin D (continued)

Milligrams per
Calcium Serving
Vitamin D Micrograms per

Servings
Fortified cow’s milk 2.5
Fortified ready-to-eat cereals, 3/4 c 1.0–2.5
Fortified soymilk or other nondairy milk, 1 c 1.0–2.5
Sources: Package information and data from: Pennington J. Bowe’s and
Church’s Food Values of Portions Commonly Used, 16 ed., Lippincott-
Raven, 1994; Hytowitz, D. B., Matthews, R. H., Composition of Foods:
Legumes and Legume Products, Washington, D.C., U.S. Department
of Agriculture, 1986, Agriculture Handbook No. 8-16.
Adapted from: Position of The American Dietetic Association: Vegetarian
Diets, J. Am. Dietetic Assoc., 97(11), 1317, 1997. With permission.
Approximately 75% of Americans are not meeting current calcium recommen-

dations.65 Intakes of milk and milk group foods are similarly low, particularly among
females and older adults. Americans are consuming an average of only 1.5 servings
per day of Milk Group foods, which is slightly more than half the two to three
servings recommended in USDA’s Food Guide Pyramid.66 Lacto-ovo-vegetarians
have calcium intakes comparable to those of nonvegetarians6, and their calcium
utilization tends to be adequate.67 There is some evidence that the calcium intakes
of vegans is generally lower than that of the population in general.59 For example,
a study conducted among vegetarian and nonvegetarian women found that the mean
calcium intake of vegans participating in the study (578 mg/d) was significantly
lower than that of either the nonvegetarians (950 mg/d) or the lacto-vegetarians (875
mg/d).68 The authors suggest that vegans consider supplementation with calcium.
2. Food Sources of Calcium and Absorption
How well dietary calcium is absorbed from the intestine is a major factor in
determining how much calcium is available for the body to use. It has long been
recognized that calcium absorption increases as intake decreases. For example, when
healthy women reduced their calcium intake from 2000 mg/d to 300 mg/d (50 to
7.5 mmol/d), their fractional whole body retention of ingested calcium (an index of
calcium absorption) increased from 27 to 37%.69 Calcium absorption increases
during times of increased need, such as pregnancy, and decreases with aging. Vitamin
D, either synthesized from sunlight or provided by vitamin D-fortified milk products,
facilitates calcium absorption.
Vegans are at greater risk for inadequate calcium nutrition because of low calcium
intakes, coupled with the presence in many plant foods of several inhibitors of
calcium absorption such as phytic and oxalic acids. Phytates and oxalates form
insoluble salts with calcium, thereby reducing its absorbability. Calcium bioavail-
ability from food depends on the combined effects of the total calcium content of
the meal and the presence of elements that either enhance or inhibit its absorption.

In general, calcium absorption is inversely proportional to the oxalic acid content

of the food. Therefore, calcium bioavailability is very low for both American and
Chinese varieties of spinach and rhubarb, intermediate for sweet potatoes, and
highest from low oxalate vegetables such as kale, broccoli, and bok choy.70
Weaver and colleagues in two separate articles, provide useful data on the
bioavailability of calcium from a number of dairy and plant foods.49,70 Using calcium
absorption data, and the amount of calcium contained in a typical food serving, they
translated this data into the number of servings an individual would need to consume
to equal the amount of calcium absorbed from 240 ml of milk (Table 6.5).49
Milk and other dairy products are the richest food source of calcium. Dairy foods
provide 73% of the calcium in the U.S. food supply.71 Soybeans and green leafy
vegetables such as kale, broccoli, and bok choy contain less calcium per serving
than milk, but the calcium in these vegetables is absorbed as well or slightly better
than calcium from milk. Almost no calcium is absorbed from spinach, and calcium
from navy, pinto, or red beans (only fair sources of calcium) is absorbed only half
as well as from milk. Based on this information, one must consume approximately
2 1/2 cups of broccoli, 6 cups of pinto beans, or 30 cups of unfortified soy milk to
deliver the same amount of calcium absorbed from one 8 ounce glass (240 ml) of
milk. The authors state, “The low calcium content of common plant sources including
most vegetables, fruits and cereal grains, makes it difficult for most Americans to
meet their requirements exclusively through these foods, even when the bioavail-
ability of calcium from these sources is high and the larger servings sizes of many
vegetarians are taken into account.”70
Results of a recent study indicate that, despite differences in diet composition
between lacto-ovo-vegetarians and nonvegetarians (i.e., protein, sodium, fiber),
young women with an adequate calcium intake were able to compensate for these
differences to maintain mineral balance. Researchers at the USDA Agricultural
Research Service studied zinc absorption, mineral balance, and blood lipid concen-
trations in 21 women (average age 33 years) consuming controlled lacto-ovo-vege-
tarian and nonvegetarian diets.72 The calcium intake of both groups approached 1000
mg/d, the amount currently recommended for this age group. Apparent calcium
absorption in the lacto-ovo-vegetarian women was decreased when compared to the
nonvegetarians (22% vs. 30%), most likely due to the presence of inhibitors of
calcium absorption (i.e., phytates, wheat bran). This was partially compensated for
by a decrease in urinary calcium excretion. The net result was a slightly, but not
significantly, lower calcium balance in the lacto-ovo-vegetarians. Similar homeo-
static adjustments compensated for differences in intake of other minerals as well.
Although the lacto-ovo-vegetarian’s diet contained more copper, magnesium, and
manganese than the nonvegetarians, mineral balance did not differ between groups.
It remains to be determined whether homeostatic mechanisms can maintain calcium
balance at the lower calcium intakes typical of the vegan diet.
B. Vitamin D
Vitamin D is essential for maintaining a healthy mineralized skeleton primarily

by maintaining blood concentrations of calcium to a level necessary for deposition

Table 6.5 Food Sources of Bioavailable Calcium

Estimateda
Fractionalc absorbable Servings
Serving Calciumb absorption Ca/serving needed to =
Foodd size (g) content (mg) (%) (mg) 240 ml milk (n)
Milk 240 300 32.1 96.3 1.0
Almonds, dry 28 80 21.2 17.0 5.7
roasted
Beans, pinto 86 44.7 17.0 7.6 12.7
Beans, red 172 40.5 17.0 6.9 14.0
Beans, white 110 113 17.0 19.2 5.0
Broccoli 71 35 52.6 18.4 5.2
Brussel sprouts 78 19 63.8 12.1 8.0
Cabbage, 85 79 53.8 42.5 2.3
Chinese
Cabbage, green 75 25 64.9 16.2 5.9
Cauliflower 62 17 68.6 11.7 8.2
Citrus punch 240 300 50.0 150 0.64
with CCM
Fruit punch with 240 300 52.0 156 0.62
CCM
Kale 65 47 58.8 27.6 3.5
Kohlrabi 82 20 67.0 13.4 7.2
Mustard greens 72 64 57.8 37.0 2.6
Radish 50 14 74.4 10.4 9.2
Rutabaga 85 36 61.4 22.1 4.4
Sesame seeds, 28 37 20.8 7.7 12.2
no hulls
Soy milk 120 5 31.0 1.6 60.4
Spinach 90 122 5.1 6.2 15.5
Tofu, calcium set 126 258 31.0 80.0 1.2
Turnip greens 72 99 51.6 51.1 1.9
Watercress 17 20 67.0 13.4 7.2
a Calcium content (mg) x Fx abs.
b
An average was used for beans, broccoli, and mustard greens processed different ways.
c Adjusted for load; for milk, this is fractional absorption (Fx abs) = 0.889-0.0964 ln load; for low-
oxalate vegetables, after adjusting by the ratio of fractional absorption determined for kale
relative to milk at the same load, the equation becomes Fx abs = 0.959-0.0964 ln load. For tofu
and soy milk, fractional absorption was assumed to be equal to high phytate soybeans. For
sesame seeds and almonds, the ratio of fractional absorption of sesame and almonds compared
with nonfat dry milk in rats was applied to calcium absorption from milk in humans. Calcium
absorption from beans was calculated similarly from rat data. The ratio of fractional absorption
from citrus punch (Sunny Delight Plus Calcium; Procter and Gamble, Cincinnati, OH) and fruit
punch (Hawaiian Punch Plus Calcium; Procter and Gamble, Cincinnati, OH) was compared with
fluid milk in rats and applied to calcium absorption from milk in humans.
d Based on 1/2-cup serving size except for milk, citrus punch, and fruit punch (1 cup) and almonds
and sesame seeds (1 oz).
From Weaver, C. M. and Plawecki, K. L., Am. J. Clin. Nutr., 59 (Suppl.), 1238s, 1994. With
permission.
into bone. Vitamin D, in its active form (1,25 [OH]2 D), increases the efficiency of
calcium absorption, especially when calcium intakes are low. Vitamin D insuffi-
ciency in adults decreases calcium absorption by up to 50%.73 The major source of
vitamin D is the exposure of the skin to sunlight. Vitamin D can also be obtained

through foods, though very few foods naturally contain vitamin D (i.e., egg yolks,
liver). The major dietary source of vitamin D is fortified milk. 98% of milk produced
in the U.S. is voluntarily fortified to the level of 400 IU/quart. Vitamin D synthesis
from sun exposure may not be adequate for persons in northern parts of the country
in the winter, for those using sunscreen, or for elderly shut-ins.73 Therefore, dietary
sources of vitamin D such as vitamin D-fortified milk, cereals, and margarine, are
important.
The results of a study conducted in Finland, where there is no ultraviolet B light
from October to March to synthesize vitamin D, demonstrated that those following
a strict vegan diet were at increased risk of vitamin D deficiency. Low serum
25(OH)D concentrations led to secondary hyperparathyroidism.74 In this study,
intakes of calcium and vitamin D, as well as serum concentrations of 25(OH)D and
parathyroid hormone, were compared between middle-aged white vegetarians
grouped according to dietary practices (1) strict vegetarians; (2) lacto-vegetarians;
(3) lacto-ovo-vegetarians consuming some fish; (4) vegetarians taking vitamin D
supplements or exposed to sunshine; and (5) omnivores. Strict vegetarians failed to
meet the 1989 RDA for calcium (800 mg) and had a calcium intake significantly
lower than the control group of omnivores (Figure 6.4). All vegetarians had a dietary
vitamin D intake that was lower than the recommended dietary allowance of 5 µg
(200 IU); it was significantly lower in all vegetarian groups than in the control group
(Figure 6.5). Serum 25(OH)D concentration reflects nutritional vitamin D status.
Figure 6.6 shows that the strict vegetarians have a significantly lower concentration
Figure 6.4 Dietary calcium intake (x ± SD) in the groups studied. G1 (group 1), strict vege-
tarians; G2 (group 2), lacto-vegetarians; G3 (group 3), lacto-ovo-vegetarians con-
suming some fish; G4 (group 4), vegetarians taking vitamin D supplements or
exposed to sunshine; C, control group. Group 1 differs from the control group at
P < 0.000. (From Lamberg-Allardt, C., Kärkkäinen, M., Seppänen, R., and Biström,
H., Am. J. Clin. Nutr., 58, 684, 1993. With permission.)

Figure 6.5 Dietary vitamin D intake (x ± SD) in the groups studied. G1 (group 1), strict vege-
tarians; G2 (group 2), lacto-vegetarians; G3 (group 3), lacto-ovo-vegetarians con-
suming some fish; G4 (group 4), vegetarians taking vitamin D supplements or
exposed to sunshine; C, control group. Group 1 differs from the control group at P
< 0.000, group 2 at P < 0.001, group 3 at P < 0.011, and group 4 at P < 0.006.
(From Lamberg-Allardt, C., Kärkkäinen, M., Seppänen, R., and Biström, H., Am. J.
Clin. Nutr., 58, 684, 1993. With permission.)
of 25(OH)D than the control group; values for most subjects were below the lower
reference limit. Vegans also had higher serum concentrations of parathyroid hormone
(PTH) than in the control group, indicating secondary hyperparathyroidism (Figure
6.7). PTH was negatively correlated with serum concentrations of 25(OH)D. Serum
alkaline phosphatase was also elevated in vegans, indicating increased bone turnover
in these subjects.
Vitamin D fortification of dairy products is largely responsible for the elimination
of rickets in this country. However, rickets has reemerged as a public health problem
in vegan infants who are breast-fed for more than six months without access to
supplementary feedings or supplements that contain vitamin D, as well as in young
children of other vegetarians who use few or no vitamin D-fortified milk products.
Reliance on sunshine alone, especially in northern climates, is unlikely to provide
enough vitamin D to protect infants and young children against rickets.15
The elderly have the additional risk of both decreased rate of vitamin D (cal-
citriol) synthesis by the kidney and a decreased ability to form provitamin D 3 upon
exposure to ultraviolet light.75 A study conducted in postmenopausal women showed
that daily supplementation of their diet with 400 International Units (IU) of vitamin
D reduced winter bone loss and improved spinal bone density.76 Another study
showed that a single oral dose of 2.5 mg (100,000 IU) of vitamin D3 was effective
in maintaining satisfactory vitamin D status of the elderly in the winter months.77
In addition, homebound elderly persons are likely to suffer from vitamin D defi-
ciency.78 In response to the growing body of evidence indicating that the elderly

Figure 6.6 Serum 25-hydroxyvitamin D concentration (x ± SD) in the groups studied. G1

(group 1), strict vegetarians; G2 (group 2), lacto-vegetarians; G3 (group 3), lacto-
ovo-vegetarians consuming some fish; G4 (group 4), vegetarians taking vitamin
D supplements or exposed to sunshine; C, control group. Group 1 differs from the
control group at P < 0.01. (From Lamberg-Allardt, C., Kärkkäinen, M., Seppänen,
R., and Biström, H., Am. J. Clin. Nutr., 58, 684, 1993. With permission.)
Figure 6.7 Serum intact parathyroid hormone concentration (x ± SD) in the groups studied.
G1 (group 1, n = 10), strict vegetarians; G2 (group 2, n = 6), lacto-vegetarians;
G3 (group 3, n = 13), lacto-ovo-vegetarians consuming some fish; G4 (group 4,
n = 14), vegetarians taking vitamin D supplements or exposed to sunshine; C,
control group (n = 11). Group 1 differs from the control group at P < 0.000. (From
Lamberg-Allardt, C., Kärkkäinen, M., Seppänen, R., and Biström, H., Am. J. Clin.
Nutr., 58, 684, 1993. With permission.)

need higher levels of vitamin D to help maintain bone mass, in 1997 the National
Academy of Sciences raised the recommendations for older Americans.59 NAS
recommends 400 IU/d for adults ages 51 to 70 and 600 IU/d for adults aged 71 or
older; 200 IU/d is recommended for all other age groups (Table 6.3). These recom-
mendations assume that vitamin D production from sunlight is limited.
Vegan diets may lack vitamin D, since vitamin D-fortified cow’s milk is the
major dietary source. Sunlight exposure is the most important factor in maintaining
vitamin D status. If sunlight exposure is inadequate (less than 5 to 15 minutes/d on
face, hands, and arms, two to three times a week), consumption of vitamin D-fortified
foods or vitamin D supplements is recommended.6
C. Phosphorus
Phosphorus makes up about half the weight of bone mineral and is as important
as calcium for bone health. Phosphorus must be provided in the diet in adequate
quantity for both mineralization and maintenance of the skeleton.23
A homeostatic system maintains blood levels of calcium and phosphorus within
narrow tolerance limits. This system consists of a feedback loop involving three major
target organs, the intestine, the kidney, and bone, responding to hormonal signaling
from parathyroid hormone (PTH), 1,25 (OH)2 D 3, and possibly calcitonin.79
Although the metabolism of calcium and phosphorus are closely linked, the
NAS, upon evaluating the available data for bone-related nutrients, concluded that
it is not necessary to maintain calcium and phosphorus intakes within a strict 1:1
ratio.59 The report also states that it is doubtful whether phosphorus intakes within
the range currently consumed in the U.S. adversely affect bone health.59
Phosphorus recommendations are no longer tied to calcium. The recommenda-
tions are based on the amount of dietary phosphorus needed to maintain serum
inorganic phosphate levels necessary for cellular functions and bone formation.59
The NAS recommends higher intakes of phosphorus for adolescents than for adults
(1250 mg/d vs. 700 mg/d) (Table 6.3).
Phosphorus intake has increased about 10 to 15% over the past 20 years, likely
due to higher consumption of soft drinks and an increased use of phosphates as
additives in processed foods.59 According to the 1994–96 Continuing Survey of Food
Intakes by Individuals, the average phosphorus consumption in adults over age 20 is
1459 mg for males (twice the recommended level) and 1017 mg for females (about
1.5 times the recommended amount). Adolescent males 12 to 19 years have the highest
phosphorus consumption, 1635 mg/d. Phosphorus intakes may be underestimated,
however, since nutrient databases may not reflect the current increased use of phosphate
salts in processed foods.59 The NAS set an upper limit for phosphorus intake of 4 g/d
for children and adolescents (9 to 18 years) and adults (19 to 70 years), and an upper
limit of 3 g for toddlers and children (age 1 to 8 years) and adults over age 70.59 It
has been estimated that people who prefer processed or convenience foods, could have
a phosphorus intake of 2.5 times the recommended amount.80
Milk and most dairy foods, except some processed cheeses, have nearly a 1:1
calcium to phosphorus ratio and provide about one third of the phosphorus in the food
supply.71 Most other foods have a much lower ratio. Meat, fish, and poultry have the

greatest amount of phosphorus relative to calcium and provide about 25% of the
phosphorus in the food supply.71 Phosphorus is found in virtually every food. Even
though vegetarians avoid meat, phosphorus is provided in the diet by vegetables, grains,
dairy products (if used), and any processed foods or soft drinks they might consume.
Studies that compare bone density between vegetarians and omnivores show little or
no difference in calcium to phosphorus ratios between these groups.55,56,57
D. Protein
Dietary protein is necessary for the synthesis of new bone matrix. The amount
of protein in the diet as well as the source of protein has an effect on the amount
of calcium that will be retained by the body to build and remodel bones. Too little
protein causes decreased absorption of calcium;81 too much protein in the diet causes
greater urinary calcium loss. An increase in dietary protein induces an increase in
urinary calcium excretion, so that each additional gram of protein consumed results
in a calcium loss of about 1 mg.82 When the calcium intake is adequate, the amount
of calcium absorbed is great enough to compensate for the increased obligatory
losses in the urine caused by a higher protein intake, thereby preventing adverse
affects on the skeleton.38
The amino acid profile of proteins, specifically the proportion of sulfur contain-
ing amino acids, determines to a large extent the protein’s calciuric effect. The sulfur
amino acids, methionine and cystine, produce an acidic urine causing calcium loss
but this explains less than half of the increased calcium loss.83 The increased filtering
rate of the kidneys, as well as increases in certain hormone levels when dietary
protein is increased, also contribute to urinary calcium loss. Vegetarian diets (includ-
ing lacto-ovo) generally produce a more neutral or alkaline urine than do omnivorous
diets and less calcium may be required to achieve calcium balance.84
Ball and Maughan compared the blood and urine acid-base status between 33
omnivorous and vegetarian premenopausal women.85 Blood pH was higher and urine
pH was lower, though not significantly so, in the omnivorous women when compared
to the vegetarians. Calcium intakes between groups were similar and adequate (approx-
imately 1000 mg/d). Omnivores had higher daily intakes of protein (69.9 gm vs. 55
gm), sodium (2691 mg vs. 2139 mg), and slightly higher excretion of calcium (154
mg vs. 128.8 mg) than the vegetarians. These differences were not statistically signif-
icant. Since both protein and sodium intakes were higher in the omnivores compared
to the vegetarians, the authors state that “the interaction between these two factors
could explain the increased excretion of calcium despite a similar dietary intake.”85
Nevertheless, the difference in calcium excretion was small (25.2 mg/d). The impact
on bone was not measured. However, as pointed out previously, when the calcium
intake is adequate (as in these study subjects), the body is better able to adapt to higher
protein intakes without adversely affecting the skeleton.38
Gram for gram, milk, soybean, and vegetable protein have a lower amount of
the sulfur containing (acid-producing) amino acids than do cereal grains, chicken,
beef, or fish. For example, chicken, whole wheat flour, flank steak, milk, tofu, and
broccoli contain 46, 40, 38, 34, 27, and 6 milligrams of methionine and cystine per
gram of protein, respectively.86 Following a vegetarian diet does not necessarily

mean that intake of sulfur containing amino acids (or total protein) will be low.
Wheat and cereal grains which are a dietary staple in many less developed countries
are quite high in sulfur amino acids. In a study of dietary intakes and urinary calcium
excretion in women in China, rice and millet were found to be positively correlated
with urinary calcium probably due to their relatively high content of sulfur containing
amino acids.52 A vegetarian in this country who eats 1/2 cup of dry roasted soybean
nuts (34 gm protein) will be getting more methionine and cystine (1008 mg) than
in 3 ounces of flank steak (800 mg), and almost four times as much as in an 8 ounce
glass of milk (275 mg). In free-living populations, urinary calcium excretion is most
likely determined by the acid-base status of the total diet.52 As Weaver, Proulx, and
Heaney state in their discussion of this subject, “Following a vegetarian diet does
not guarantee that significant differences in urinary calcium will exist between
vegetarians and omnivores.”70
1. Protein in Perspective
There is little evidence that high protein intakes reduce bone mass or increase
fracture risk in free-living human beings.38 The four well-controlled studies men-
tioned earlier involving premenopausal or postmenopausal women showed no dif-
ference in bone mineral density between lacto-ovo-vegetarians and nonvegetari-
ans.42-46 The diets of these subjects did not differ significantly in calcium or
phosphorus content. No significant differences were seen in bone mineral density
between the groups, even though the diets of the nonvegetarians were significantly
higher in protein (averaging 63 to 77 g/day), and of course contained animal protein.
Though bone density in both the vegetarians and omnivores decreased with age,
bone mineral density did not differ between groups even for women 80 to 90 years
of age.43,45 More recently, Feskanich et al. found no association between protein
intake and hip fractures in the U.S. Nurse’s Health Study.87
The body of evidence from studies where diet and lifestyle factors were evaluated
suggests that the source of protein in the diet is not a significant factor influencing
bone density. If meat eating per se were a cause of significant calcium loss, one
would find a difference in urinary calcium loss between vegetarians and nonvege-
tarians. However, urinary calcium concentrations were similar between vegetarian
and omnivorous pre- and postmenopausal women.42,44
There is evidence that a low protein intake, especially by the very elderly, may
contribute to the problem of osteoporosis.23 A study by Reed et al. among elderly
women reported that in fact protein exerted a slightly positive effect on bone den-
sity.45 Bonjour et al. found that protein supplementation reduced further bone loss
in elderly patients with hip fracture.88
2. A Matter of Balance
If bone health is to be maximized, amounts of protein, calcium, sodium, and

phosphorus in the diet should be close to recommended levels.
Since the body needs more calcium when the diet is high in protein, some find
it useful to speak in terms of a calcium to protein ratio for achieving the proper

dietary balance of these nutrients. In a study which examined the rate of bone gain
in college aged women, the calcium to protein ratio was the single most important
determinant of bone gain.89 The calcium to protein ratio predicted bone mineral
density of the spine and hip in a group of Chinese women (ages 31 to 40) living in
Hong Kong.90 Based on this information, Heaney has recommended that the calcium
to protein ratio be used to evaluate the adequacy of calcium intake.82,38 Using the
calcium to protein ratio adjusts for the counterbalancing effects of calcium and
protein on the calcium economy. Though the ideal ratio has yet to be determined,
a good reference point is probably the recommended level for both of these nutri-
ents.82 For an adult woman, the daily recommended level for calcium is 1000 mg
and the RDA for protein is 50 g, yielding a ratio of 20:1 (mg/g). However, the
average woman has a calcium to protein ratio of only 10:1 (635 mg of calcium/62.5
g of protein).65
There is evidence that current protein intakes should not be of concern for bone
health if calcium consumption is adequate. For example, Baran et al. supplemented
the diets of premenopausal women with an additional 500 to 600 mg of calcium
with dairy foods (1500 mg/d total). Participants experienced no deterioration of
calcium balance, even though their protein intake at the end of the 3-year study was
107 g/d (calcium to protein ratio of 14:1).91 Hunt found that in postmenopausal
women who consumed approximately 800 mg of calcium per day, a high meat intake
(10 ounces/d) did not increase urinary calcium excretion or impair calcium balance
or indexes of bone metabolism.92 Duff and Whiting tested the acute effects of several
dietary factors on calcium excretion in children.93 Increasing milk protein from
approximately 12 g to approximately 29 g did not increase urinary calcium excretion.
Calcium consumption is well below recommended levels for a large percentage
of women, teenage girls, and older adults in the U.S. In a review of strategies for
vegetarians to achieve an adequate calcium intake, Weaver et al. propose that those
following a plant-based diet could either (1) consume a diet low in protein and/or
low sulfur amino acid content, or (2) increase calcium consumption to offset the
effect of a higher protein diet. According to the authors, the latter strategy is less
restrictive and will be easier to continue long-term.70
Because milk and hard cheeses have a calcium to protein ratio in the range of
36:1, these foods are an excellent way to improve the calcium to protein ratio of the
diet. Fruits and vegetables also provide a major source of alkali to the diet, and serve
to buffer an acid load.94 The recently published DASH study (that demonstrated that
a diet rich in lowfat dairy foods, fruits, and vegetables can substantially lower blood
pressure) found that adding additional servings of fruits and vegetables to a typical
American diet decreased excretion of urinary calcium between 157 and 110 mg/d.11
In an article that discusses how vegetarians can meet their calcium needs, Weaver
states, “the lacto-ovo-vegetarian diet when evaluated on the basis of calcium to
protein ratio appears to be the safest approach to minimizing protein-induced calcium
losses and maximizing calcium balance.”70 In her evaluation of the effect of dietary
protein on bone, Massey states, “Even if the major source of dietary protein is meat,
adverse effects may be counterbalanced by generous amounts of calcium from other
foods such as milk and increased consumption of fruits and vegetables, especially
those rich in calcium.”94

E. Sodium
A dietary excess of sodium increases urinary calcium loss and will therefore
interfere with the body’s ability to conserve calcium in response to a low calcium
intake.23 In fact, sodium may be the most important nutritional factor influencing
urinary calcium loss (more important than protein or caffeine).70 Sodium and calcium
compete for reabsorption in the renal tubules. Among individuals whose plasma
calcium and glomerular filtration rate are within the normal range, the main deter-
minant of obligatory calcium excretion is the filtered load of sodium. Urinary
calcium rises 0.5 to 1.5 mmol (11.5 to 34.5 mg) for every 100 mmol (2300 mg)
increase in dietary sodium. The effect of dietary sodium on urinary calcium excretion
is much more apparent when calcium intake is below 25 mmol/d (1000 mg).95
In order for optimal peak bone mass to be attained by young adulthood, children
and young adults must maintain a positive balance between calcium intake and
obligatory losses in feces, urine, and sweat. In normal children, the most important
determinants of calcium retention in the body is dietary calcium intake and urinary
excretion of calcium.96 Matkovic et al. found that in early pubertal girls, dietary
calcium had a positive and urinary calcium excretion a negative association with
bone mineral density.96 Sodium intake was the primary determinant of urinary
calcium excretion. The authors conclude that sodium intake may influence the
calcium requirement for adolescents. A short-term load test in prepubertal children,
however, showed no association of sodium and urinary calcium excretion.93
Although discrepancies have been observed in the results between studies in
free-living subjects and loading studies, the totality of evidence from both types of
studies supports the conclusion of Nordin that for every 100 mmol (2300 mg) of
sodium excreted by normal, healthy persons, there is approximately 1 mmol (23
mg) loss of urinary calcium.97 This relationship was also recently observed in
Japanese adults age 20 to 49 and 50 to 79.98 In addition, excretion of hydroxyproline
(marker for bone resorption) was positively and significantly correlated to urinary
sodium excretion, a measurement of sodium intake.
Studies of sodium supplementation in men and women have shown a positive
association between 24-hour urinary sodium excretion and urinary excretion of
calcium.99,100 Devine et al. found that a high sodium intake measured as urinary
sodium excretion was associated with increased bone loss of the hip in postmeno-
pausal women.101 A calcium intake of about 1700 mg/d was required to achieve
calcium balance in this population, who had a mean sodium intake of about 3 g.
The authors state that calcium balance could also have been achieved at a sodium
intake of 2300 mg/d (the RDI) and at the currently recommended calcium intake
for this age group of 1200 mg/d.
Estrogen-deprived women excrete more calcium relative to sodium in the fasting
state than do premenopausal or estrogen-replete women. It is thought that estrogen,
as well as parathyroid hormone, promotes tubular reabsorption of calcium. The rise
of urinary calcium at menopause may represent a “calcium leak” due to estrogen
deficiency. A study evaluating the relationship between urinary sodium and urinary
calcium in women found that when women increased their daily sodium intake from
50 mmol (1153 mg) to 150 mmol (3450 mg), obligatory loss of calcium increased by

1 mmol/d (40 mg).102 Since obligatory calcium loss determines bone resorption, a high
salt intake by postmenopausal women can be considered a risk factor for osteoporosis.95
To minimize the negative effects of a high sodium diet on bone, an individual
has the following options (1) increase calcium intake to increase calcium absorption;
this will allow the body to offset any extra urinary calcium loss; (2) decrease sodium
intake to decrease urinary calcium loss; or (3) both increase calcium and decrease
sodium a modest degree. The latter may be the easiest to achieve.70 Although
available evidence suggests that excessive salt consumption may contribute to bone
loss, additional research is needed in order to make recommendations for the pre-
vention or treatment of osteoporosis.97
F. Fiber
Vegetarians typically have higher fiber diets than nonvegetarians. High intakes
of dietary fiber may interfere with calcium absorption as well as with the absorption
of other minerals, probably because of associated inhibitors of mineral absorption.
There seems to be agreement among most researchers that phytate, a compound
found principally in the outer hull of cereal grains, interferes with mineral absorp-
tion.23,103 Heaney estimates that if an adult doubled his intake of wheat bran fiber
from 10 g to 20 g per day, he might expect a 6 to 10% decrease in calcium
availability.23 Wheat bran co-ingested with milk reduces the absorbability of calcium
in milk.104 Weaver et al. found that consuming wheat bran cereal (16 g wheat bran)
with calcium carbonate reduced the usual increase in calcium absorption that follows
an increased calcium intake.105 The authors conclude that the phytic acid and/or fiber
in wheat bran cereal has a high capacity to bind calcium at “all reasonable calcium
intake levels.” Half of any amount of calcium added (five different calcium loads
ranging from 0.5 to 15.5 mmol or 20 to 620 mg) was bound. A decrease in calcium
absorption due to wheat bran is most significant for individuals with low calcium
intake or for those most vulnerable to nutritional inadequacies, such as the very
young, pregnant or lactating women, and the elderly. Increasing dietary calcium can
easily compensate for this decrease in calcium availability.
A recent study in healthy young men demonstrated that supplementation with
soluble (inulin) and partly soluble (sugar beet) fiber can enhance calcium balance
as well as that of other minerals.106 Inulin is a fructo-oligosaccharide currently used
in various agro-food industries, including the dairy and cheese industry. Supplemen-
tation with inulin, when compared to the control diet, significantly increased the
absorption of calcium. Presumably the fermentation process in the colon enhances
the solubility of calcium and other minerals. Because of its high calcium (and
magnesium) content, the quantity of calcium absorbed on the sugar beet fiber diet
was significantly greater than that of the control diet, although the fractional absorp-
tion of the minerals studied was not altered. Sugar beet fiber increased the partici-
pant’s calcium intake by about 30%. Increased ingestion of both fiber foods improved
calcium balance in these subjects. The digestibility of calcium in calcium-rich foods,
such as dairy products, can be improved by the addition of inulin.106
Elderly individuals following a high fiber vegetarian diet are at increased risk
of calcium deficiency, since calcium absorption is already decreased at this age. For

example, intestinal absorption of calcium was decreased by 13.5% in elderly vol-

unteers who added 30 g of wheat bran to their usual diet.107 More recently, elderly
subjects fed a high fiber (10.5 g) meal experienced a 20% decrease in calcium
absorption when compared with those fed a low fiber (0.5 g) meal. The authors
concluded that calcium requirements may be increased in elderly individuals con-
suming a high fiber diet.108
Interpretation of studies examining calcium bioavailability under conditions of
high and low fiber intake can be difficult. Results may be confounded when calcium
in the test diet is contributed by a fiber source with low bioavailability such as wheat
bran. Thirty grams of fiber is the amount recommended as the daily reference value
(DRV) for a 2500 calorie diet. The results of these studies suggest that at this level
of fiber intake, individuals should consume calcium at or above the recommended
level.
VIII. SPECIAL CHALLENGES OF VEGETARIAN DIETS
A. Pregnancy and Lactation
Pregnancy and lactation place additional nutritional demands on the mother to

provide for fetal growth and milk production.109 While the nutrient and energy needs
of pregnant women can be met with either a lacto-ovo-vegetarian or vegan diet,6
pregnant vegans have increased nutritional challenges. Calcium and vitamin D (in
addition to iron, zinc, vitamin B12, and riboflavin) are nutrients of particular concern
for vegan women during pregnancy and lactation.67,109 A low calcium intake has
been demonstrated to increase the risk of pregnancy-induced hypertension.110 The
American Dietetic Association recommends that vegan women who are pregnant
eat adequate amounts of calcium-rich foods and supplement their diet with and 10
µg of vitamin D (if sun exposure is limited), and with vitamin B12 during pregnancy
(2.0 µg) and lactation (2.6 µg).6
A review of studies conducted in lactating women consuming macrobiotic diets,
found that vegetarian women had lower calcium intakes (486 mg/d vs. 1038mg/d),
lower serum concentrations of 25(OH)D, and higher concentrations of 1,25(OH)2D
than did nonvegetarian women.109 The differences in vitamin D status between
vegetarian and nonvegetarian mothers were most apparent in the winter and spring
months, when exposure to sunlight is minimal. Because parathyroid hormone levels
were not elevated, it is unclear whether the elevated 1,25(OH)2D concentrations
indicate an adverse affect on bone, or whether adequate adaptation occurred
(increased calcium absorption) to maintain calcium homeostasis.
Vegetarian mothers usually breastfeed their infants. Human milk from vegetar-
ians, especially if the vegan diet is followed, is lower in vitamin D, as well as vitamin
B12 and other water-soluble vitamins than that of nonvegetarian mothers. Therefore,
vegan infants should be supplemented with those nutrients. Vegan mothers should
use calcium-rich foods and/or calcium supplements during lactation to meet the
current calcium recommendation of 1000 mg/d.67

B. Adolescence
Teens who adopt a vegetarian diet will need guidance in meal planning to assure
nutritional adequacy during rapid growth.6 Although adopting a vegetarian diet does
not in itself lead to eating disorders, vegetarian diets are somewhat more common
among adolescents with eating disorders than among adolescents in general.111,68
Researchers in Canada compared the dietary intakes of female adolescents (ages
14 to 19) who consumed vegetarian, semi-vegetarian, and omnivorous diets.112 Lacto-
ovo-vegetarians and semi-vegetarians were more at risk for nutrient inadequacies of
protein, calcium, iron, zinc, and riboflavin than were omnivores, though omnivores
were also at risk for inadequate intakes of iron and zinc. The researchers expressed
concern that calcium intakes were below recommendations and may not be adequate
to optimize bone mass. They emphasized that diets of vegetarian teens be well
planned to ensure adequate nutrient density for growth.
Adequate calcium and optimal vitamin D status is necessary to optimize bone
mass during stages of rapid growth. Researchers in the Netherlands investigated the
influence of consuming a macrobiotic diet for at least 6 years on the development
of peak bone mass in adolescents aged 9 to 15 years.113 They found that children of
both sexes who followed a macrobiotic diet had significantly lower bone mineral
content at almost all sites measured, the total body, spine, femoral neck, radius, and
the trochanter in girls, when compared to controls. The authors conclude that a low
calcium intake and limited vitamin D status, along with other aspects of the mac-
robiotic diet contributed to low bone mass. Macrobiotic children also consumed less
energy, protein, fat, riboflavin, and vitamin B12, and more fiber, thiamin, and non-
heme iron than controls. Although it was not possible to identify exactly which
nutrients were responsible for the differences in bone mass, the authors recommend
that children following a macrobiotic or vegan diet add dairy products (as a source
of calcium) and fatty fish (as a source of vitamin D and vitamin B12) to their diets.
IX. CALCIUM SUPPLEMENTS
If for whatever reason an individual does not wish to include dairy products in
the diet, a calcium and vitamin D supplement may be needed. According to a
Vegetarian Times survey, approximately 45% of all vegetarians take vitamin and/or
mineral supplements.114 The elderly, young children, and pregnant or lactating
women are at greatest risk of deficiency. Therefore, these groups may have the
greatest need for supplements of calcium or vitamin D. Calcium absorption from
supplements (calcium carbonate and calcium lactate) is about the same as its absorp-
tion from dairy foods.115,116,117 Calcium supplements vary greatly in solubility, as
one supplement may be several thousand times more soluble than another. But when
intestinal calcium absorption was tested in human subjects, very little difference was
found between calcium carbonate, calcium phosphate, and calcium citrate.118 Some
supplements contain a higher percentage of calcium than others (calcium carbonate),
requiring fewer tablets to meet the targeted intake.

The American Dietetic Association (ADA) as well as most health professional

groups recommend that “the best strategy for promoting optimal health and reducing
the risk of chronic disease is to obtain adequate nutrients from a wide variety of
foods.”119 ADA acknowledges that nutrient supplementation can be useful in situa-
tions when dietary selection is limited, as in the vegan diet. They recommend
supplementation for vegans with vitamin B12 and with vitamin D when exposure to
sunlight is limited. They also recommend that practitioners assess the calcium intake
for all individuals. Those with low calcium intakes should first be encouraged to
increase their consumption of foods naturally rich in calcium, such as dairy foods.
Calcium-fortified foods and/or calcium supplements may be recommended for those
unwilling or unable to consume milk and milk products.
Supplement use increases the risk of nutrient imbalances and toxicity, which are
less likely to occur when nutrients are obtained from foods.119 Individuals choosing
to use supplements should not take them at levels higher than recommended for
their age/gender group, and their use should ideally be monitored by a physician or
registered dietitian. For example, supplementing the diet with large amounts of
calcium can reduce the amount of phosphorus absorbed and could lead to phosphate
deficiency in those with a low phosphate intake (i.e., some elderly persons).23
X. BENEFITS OF CALCIUM-RICH FOODS
Foods contain a wide range of nutrients and other constituents that are not
provided by a single supplement. Dietary patterns, rather than individual nutrients,
are the most important determinants of nutritional adequacy. Calcium researchers
from Creighton University found that adult women with a low calcium intake (less
than two thirds of the 1989 RDA of 800 mg) also had significantly lower intakes of
protein and 9 other vitamins and minerals. Over half (53%) of the women with a
low calcium intake were judged to have “poor diets” (low intakes for five or more
of the nine nutrients studied).120 Fleming and Heimbach found similar nutrient def-
icits among teenage girls who did not drink milk.121 They compared the diets of
teenage girls (13 to 18 years) who drank milk with those who didn’t. They found
that girls who didn’t drink milk had lower intakes of vitamins A, B6, B12 , folate,
riboflavin, calcium, magnesium, and potassium. Increasing the calcium intake
through supplementation still leaves other nutrient deficiencies. A four-year longi-
tudinal study among 64 postmenopausal women in Australia demonstrated that skim
milk powder was superior to calcium supplements at improving diet quality.122 When
compared to the women who took a calcium supplement (1000 mg/d in addition to
calcium provided by their diet), those who increased their calcium intake to 1600
mg/d with skim milk also significantly increased their intakes of protein, potassium,
magnesium, phosphorus, riboflavin, thiamin, and zinc. They did so without increas-
ing their total fat or saturated fat intake. According to Dr. Robert Heaney, a noted
calcium researcher, “Food is always the best source of nutrition for our bodies
because it helps meet total nutrient needs. When you drink milk, you’re getting an
entire nutrient package.”123

A study conducted among pubertal girls (ages 9 to 13) in Utah demonstrated

that increasing their consumption of dairy foods (choice of products) to meet calcium
recommendations increased bone mineralization in the spine and total body without
increasing fat intake, weight gain, or body fatness.124 Compared to controls, those
who ate extra dairy foods had higher intakes of calcium, phosphorus, vitamin D,
and protein.
Researchers in Oregon demonstrated that it is feasible to increase food calcium
to 1500 mg/d in free-living adults by increasing the consumption of calcium-rich
foods, and that doing so improves the quality of the total diet.125 Nutrient intake was
compared between those who consumed 1500 mg of calcium per day primarily from
dairy foods and those taking a 1000 mg calcium supplement or a placebo. Intake of
calcium, magnesium, phosphorus, potassium, thiamine, riboflavin, and vitamins C
and D increased in the diets of those consuming dairy foods, but not in those taking
a calcium carbonate supplement (1000 mg/d) or the placebo. The authors state that
“a diet that consistently excludes or limits dairy foods will not only provide less
calcium, but may also limit those nutrients that track with calcium from foods.”
Increasing the amount of dairy foods in the diet for 12 weeks did not increase blood
lipid levels or lead to weight gain.
The results of these studies clearly demonstrate that when adults or teens meet
current calcium intake recommendations with food, particularly dairy foods, the
nutritional quality of the diet is improved without increasing overall fat intake or
causing weight gain. It is particularly important for health professionals to commu-
nicate this information to young women who exclude dairy foods from their diet
due to concerns about weight gain.
XI. THE VALUE OF MILK AND MILK PRODUCTS IN VEGETARIAN DIETS
Dairy products are recommended as an important part of a vegetarian diet by

researchers in bone mineral metabolism.49,50 Evidence indicates that vegetarian
women who have included milk and other dairy foods in their diet over a lifetime
have the best chance of maintaining adequate bone density as they age. Soy beverage,
even if fortified with calcium, is not nutritionally equivalent to cow’s milk. An 8
ounce serving of soybean beverage contains no vitamin B12, only about half the
phosphorus, 40% of the riboflavin, and 10% of the vitamin A in a serving of cow’s
milk.86
Milk can be an important source of high quality protein in a vegetarian diet. A
high percentage of milk protein is retained by the body for maintenance and growth;
it contains all of the essential amino acids needed by the body and is easily digested.
The amino acid distribution of milk is ideal for calcium utilization. Milk has a higher
proportion of lysine, which enhances calcium utilization (increases intestinal absorp-
tion and renal conservation),126 and a lower proportion of the sulfur containing amino
acids, methionine and cystine, which decrease calcium utilization. The relative
surplus of lysine in milk also makes it the perfect companion to vegetable proteins,
particularly cereals, which are low in lysine.127

Lacto-vegetarians also reap the following benefits:
• Milk and milk products provide significant amounts of calcium, phosphorus, mag-
nesium, and zinc in proportions important for bone health. Milk and milk products
are the major source of calcium in the American diet.
• Milk, yogurt, and hard cheeses have a surplus of calcium relative to protein
(approximately 36:1), making them ideal foods for maximizing bone health.
• Lacto-vegetarians are less likely to have deficiencies in calcium or vitamin D.
Studies have shown that lacto-vegetarians have adequate bone density.
• Vitamin D-fortified dairy products can afford protection from calcium and vitamin
D depletion during times of growth or increased need, such as with adolescents,
elderly persons, or during pregnancy and lactation.
• Milk (as well as eggs) provides an easily digestible form of protein, and one that
is of high biologic value. Milk and other dairy foods can supply a significant
amount of the protein requirement of the vegetarian diet and are recommended in
the diets of vegetarian athletes.128
• Including milk in the diet improves its overall nutritional quality because of the
many nutrients it delivers (see Chapter 1).120,121,122,125
XII. CONCLUSION
Some prefer the vegetarian lifestyle for sociological, animal rights, or religious
reasons. However, there is no bone health justification for insisting that nonvegetar-
ians avoid animal foods such as meat and dairy products, just as there is no bone
health justification for urging vegetarians to give up the vegetarian diet and lifestyle.15
Both vegetarians and nonvegetarians can achieve optimal bone health if they
follow a few simple guidelines:
• Consume a diet adequate in calcium, phosphorus, vitamin D, and moderate in

protein and sodium.
• Engage in regular exercise.
• Refrain from lifestyle habits like smoking and excessive alcohol consumption, both
of which decrease bone density.
It is never too late to adopt good habits of diet and health. Although one cannot
completely reverse years of neglect, benefits can be gained at any stage of life.
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Bone Health and the Vegetarian

© 2000 by CRC Press LLC

B. How Many Vegetarians are There?

© 2000 by CRC Press LLC

C. Health Effects of a Vegetarian Diet and Lifestyle

© 2000 by CRC Press LLC

evaluated various lifestyle characteristics of 1904 German vegetarians to determine

III. FACTORS INFLUENCING BONE HEALTH

Investigators estimate the role of heredity in determining bone density to be 50

© 2000 by CRC Press LLC

Building and maintaining healthy bones requires adequate amounts of many

© 2000 by CRC Press LLC

3. Lifestage or Disease State

© 2000 by CRC Press LLC

IV. THE VEGETARIAN DIET AND OSTEOPOROSIS RISK

Differences in the prevalence of osteoporosis between vegetarians and nonveg-

© 2000 by CRC Press LLC

© 2000 by CRC Press LLC

© 2000 by CRC Press LLC

© 2000 by CRC Press LLC

© 2000 by CRC Press LLC

© 2000 by CRC Press LLC

V. FACTORS OF VEGETARIAN DIETS THAT AFFECT BONE HEALTH

1. Intake Recommendations and Consumption Patterns

There is widespread recognition that an adequate calcium intake throughout life

© 2000 by CRC Press LLC

Table 6.3 Dietary Reference Intakes for Bone-related Nutrients

© 2000 by CRC Press LLC

Table 6.4 Food Sources of Calcium and Vitamin D

Nuts and Seeds (2 Tbsp)

Vegetables (1/2 c cooked)

© 2000 by CRC Press LLC

Table 6.4 Food Sources of Calcium and Vitamin D (continued)

Vitamin D Micrograms per

Approximately 75% of Americans are not meeting current calcium recommen-

2. Food Sources of Calcium and Absorption

© 2000 by CRC Press LLC

In general, calcium absorption is inversely proportional to the oxalic acid content

Vitamin D is essential for maintaining a healthy mineralized skeleton primarily

© 2000 by CRC Press LLC

Table 6.5 Food Sources of Bioavailable Calcium

© 2000 by CRC Press LLC

© 2000 by CRC Press LLC

© 2000 by CRC Press LLC

Figure 6.6 Serum 25-hydroxyvitamin D concentration (x ± SD) in the groups studied. G1

© 2000 by CRC Press LLC

© 2000 by CRC Press LLC

© 2000 by CRC Press LLC

If bone health is to be maximized, amounts of protein, calcium, sodium, and

© 2000 by CRC Press LLC

© 2000 by CRC Press LLC

© 2000 by CRC Press LLC

© 2000 by CRC Press LLC

example, intestinal absorption of calcium was decreased by 13.5% in elderly vol-

VIII. SPECIAL CHALLENGES OF VEGETARIAN DIETS

A. Pregnancy and Lactation

Pregnancy and lactation place additional nutritional demands on the mother to