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Fruit and vegetable intake and bone health in women aged 45 years and over: a systematic review

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Abstract

Summary

High fruit and vegetable intake may be associated with improved bone status among women aged ≥45 years. This is the first systematic review that specifically assessed this association and identified research gaps. The benefits of fruit and vegetables (F&V) on bone health remain unclear. Further studies are needed.

Introduction

F&V have several components that are beneficial to bones. Some studies report that high F&V intake is associated with improved bone status in middle aged and aged women; however, findings are inconsistent. The objective was to systematically review observational and interventional studies that investigated the effects of F&V intake on incidence of osteoporotic fractures, bone mineral density (BMD), and bone turnover markers (BTM) in women aged ≥45 years and to identify potential research gaps.

Methods

Electronic databases were searched, and peer-reviewed manuscripts published in English, with F&V intake as a main dietary exposure, were included. Data selection, extraction, and evaluation of risk of bias were performed independently by two reviewers.

Results

Eight studies were included. One cohort study reported cross-sectional as well as longitudinal data. There was significant between-study heterogeneity in design, definition, and amount of F&V intake, outcomes, analyses, and reporting of results. Two studies had low, two had moderate, and four had high risk of bias. Among reports with low or moderate risk of bias, two cross-sectional analyses reported positive associations between F&V intake and BMD of the forearm, lumbar spine, or total hip, whereas one randomized controlled trial and two prospective cohort analyses reported no effects. One trial reported no associations between F&V and BTM.

Conclusions

Based on limited evidence, the benefits of F&V on bone health remain unclear for women aged ≥45 years. Further studies with low risk of bias are needed.

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Acknowledgments

We sincerely thank Ms. Elizabeth Uleryk for her assistance in developing and executing the search strategy as well as Dr. Kyarash Safakish (MD) for his review of excluded citations based on titles and abstracts to ensure all citations met the exclusion criteria.

Contributions

MH was involved in project conception, development of review protocol, and study oversight and wrote the initial draft. BAB, PSS, and AMC, respectively, were all involved in the design and execution of the review and made substantial revisions to the manuscript. AMC provided advice and interpreted findings on bone health, BAB on nutrition, and PSS, JB, and AMC on conducting systematic reviews and meta-analysis. MH and PSS reviewed the selected full-text articles and determined the risk of bias independently. BAB reviewed the selected articles and extracted data to ensure information was complete. The risk of bias tool was designed by PSS and modified by MH for studies in the field of nutrition and bone health. All authors commented on and approved the final manuscript. AMC has primary responsibility for final content.

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Women’s Health and Osteoporosis Programs, University Health Network, 200 Elizabeth Street, 7 Eaton North-228-A, Toronto, ON, M5G 2C4, Canada

    M. Hamidi

  2. Women’s Health and Osteoporosis Programs, University Health Network, 200 Elizabeth Street, 7 Eaton North-221, Toronto, ON, M5G 2C4, Canada

    A. M. Cheung

  3. Institute of Medical Science, University of Toronto, Toronto, ON, Canada

    M. Hamidi & A. M. Cheung

  4. Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada

    B. A. Boucher

  5. Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada

    B. A. Boucher

  6. Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

    B. A. Boucher, A. M. Cheung, J. Beyene & P. S. Shah

  7. Divisions of General Internal Medicine and Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada

    A. M. Cheung

  8. Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    A. M. Cheung & J. Beyene

  9. Population Health Sciences, Research Institute of the Hospital for Sick Children, Toronto, ON, Canada

    J. Beyene

  10. Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada

    J. Beyene

  11. Department of Pathology and Molecular Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada

    J. Beyene

  12. Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada

    J. Beyene & P. S. Shah

Authors
  1. M. Hamidi
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  2. B. A. Boucher
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  3. A. M. Cheung
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  4. J. Beyene
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  5. P. S. Shah
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Corresponding author

Correspondence to A. M. Cheung.

Appendices

Appendix A: search strategy

MEDLINE

exp “Bone and Bones”/or bone mineral density.mp. or (bone mineral density) .ti,ab. or exp Bone Density/or bone remodeling/or bone regeneration/or bone resorption/or (Biological Markers/and “Bone and Bones”/) or exp Osteoporosis, Postmenopausal/or exp Osteoporosis/or exp Fractures, Bone/or (bone adj2 turnover).ti,ab. or (bone adj2 marker*).ti,ab. or (bone adj2 biomarker*).ti,ab. or (bone adj2 formation).ti,ab.

exp fruit/or exp vegetables/or (Fruit* and Vegetable*).mp. or fruit*.mp. or vegetable*.mp. or (fruit* adj2 vegetable*).ti,ab.

(clinical trial, all or clinical trial, phase I or clinical trial, phase II or clinical trial, phase III or clinical trial, phase IV or clinical trial or controlled clinical trial or meta-analysis or multicenter study or randomized controlled trial).pt. or exp Clinical Trials as Topic/or exp cross-sectional studies/or exp clinical trial/or exp clinical trials as topic/or exp clinical trials, phase I as topic/or exp clinical trials, phase II as topic/or exp clinical trials, phase III as topic/or exp clinical trials, phase IV as topic/or exp controlled clinical trials as topic/or exp randomized controlled trials as topic/or exp multicenter studies as topic/or exp intervention studies/or exp twin studies as topic/or epidemiologic studies/or exp study characteristics/or exp epidemiologic study characteristics as topic/or exp epidemiologic research design/or exp case-control studies/or exp retrospective studies/or exp cohort studies/or exp longitudinal studies/or exp follow-up studies/or exp prospective studies/or observational study.mp.

EMBASE

  1. 1.

    exp bone/or exp bone demineralization/or exp bone mineralization/or exp bone density/or exp fracture/or exp bone fragility/or exp osteoporosis/or exp fragility fracture/or exp bone mass/or bone metabolism/or exp bone mineral/or exp bone remodeling/or exp bone regeneration/or exp bone turnover/or exp osteoporosis/or exp postmenopause osteoporosis/or exp primary osteoporosis/or exp secondary osteoporosis/or exp bone regeneration/or exp bone remodeling/or exp bone density/or exp bone turnover/or exp bone/or exp ossification/or (bone adj2 turnover).ti,ab. or (bone adj2 marker*).ti,ab. or (bone adj2 biomarker*).ti,ab. or (bone adj2 formation).ti,ab.

  2. 2.

    fruit/or vegetable/or (fruit* and vegetable*).mp. or fruit*.mp. or vegetable*.mp. or (fruit* adj2 vegetable*).ti,ab.

  3. 3.

    exp clinical study/or exp intervention study/or exp longitudinal study/or exp prospective study/or exp retrospective study/or exp case control study/or exp hospital based case control study/or exp population based case control study/or exp clinical trial/or exp multicenter study/or exp phase 1 clinical trial/or exp phase 2 clinical trial/or exp phase 3 clinical trial/or exp phase 4 clinical trial/or exp controlled clinical trial/or exp randomized controlled trial/or ct.fs. or clinical trial/or phase 1 clinical trial/or phase 2 clinical trial/or phase 3 clinical trial/or phase 4 clinical trial/or controlled clinical trial/or randomized controlled trial/or multicenter study/or meta analysis/or (random: or (doubl: adj2 dummy) or ((Singl: or double: or trebl:) adj25 (blind: or mask:)) or RCT or RCTs or (control: adj25 trial:) or multicent: or placebo: or metaanalysis: or (meta adj5 analys:) or observational stud:).ti,ab.

  4. 4.

    1 and 3 and 2

CAB

  1. 1.

    exp fruit/or fruits/or exp vegetables/or fruit*.mp. or vegetable*.mp. or (fruit* and vegetable*).mp. or (fruit* adj2 vegetable*).ti,ab.

  2. 2.

    clinical trials/or (random: or (doubl: adj2 dummy) or ((Singl: or double: or trebl:) adj25 (blind: or mask:)) or RCT or RCTs or (control: adj25 trial:) or multicent: or placebo: or metaanalysis: or (meta adj5 analys:) or sham or effectiveness or efficacy or compar:).ti,ab. or exp trials/or exp randomized controlled trials/or exp clinical trials/or exp trials/or exp randomized controlled trials/or exp epidemiological surveys/or (observational study or case–control study or cohort sutdy or cross-sectional study).mp.

  3. 3.

    osteoporosis/or osteoporosis, postmenopausal/or exp bone formation/or exp bone resorption/or exp bones/or exp bone mineralization/or exp bone density/or exp bone fractures/or exp demineralization/or (bone adj2 turnover).ti,ab. or (bone adj2 marker*).ti,ab. or (bone adj2 biomarker*).ti,ab. or (bone adj2 formation).ti,ab.

  4. 4.

    1 and 3 and 2

PUBMED

(“Bone Density”[Mesh] OR (“Biological Markers”[Mesh] AND “Bone and Bones”[Mesh]) OR “Bone Remodeling”[Mesh] OR “Bone Resorption”[Mesh] OR “bone formation”[All Fields] OR “Bone turnover”[All Fields] OR “bone metabolism”[All Fields] OR “bone and bones”[MeSH Terms] OR “Fractures, Bone”[Mesh] OR “Osteoporosis”[Mesh] OR “Osteoporosis, Postmenopausal”[Mesh]) AND (“fruit”[MeSH Terms] OR “vegetables”[MeSH Terms] OR “fruit”[All Fields] OR “fruits”[All Fields] OR “vegetables”[All Fields] OR “vegetable”[All Fields]) AND (“Epidemiologic Methods”[Mesh] OR “Epidemiologic Study Characteristics as Topic”[Mesh] OR “Clinical Trials as Topic”[Mesh])

Appendix B

Table 5 Risk of bias for observational studies—developed by authors
Full size table
Table 6 Risk of bias for intervention trials (modified Cochrane Collaboration's tool)
Full size table

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Hamidi, M., Boucher, B.A., Cheung, A.M. et al. Fruit and vegetable intake and bone health in women aged 45 years and over: a systematic review. Osteoporos Int 22, 1681–1693 (2011). https://doi.org/10.1007/s00198-010-1510-0

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