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Bone Mineral Density in Chinese Elderly Female Vegetarians, Vegans, Lacto-Vegetarians and Omnivores

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Bone Mineral Density in Chinese Elderly Female Vegetarians, Vegans, Lacto-Vegetarians and Omnivores European Journal of Clinical Nutrition (1998) 52, 60±64 ß 1998 Stockton Press. All rights reserved 0954±3007/98 $12.00 Bone mineral density in Chinese elderly female vegetarians, vegans, lacto-vegetarians and omnivores EMC Lau1, T Kwok2, J Woo2 and SC Ho1 1Department of Community and Family Medicine, The Chinese University of Hong Kong, Hong Kong; and 2Department of Medicine, The Chinese University of Hong Kong Objectives: To compare the bone mineral density and dietary intake of elderly Chinese vegetarian women with omnivores, to compare the bone mineral density of Chinese `vegans' and `lactovegetarians', and to study the relationship between nutrient intake and BMD in vegetarians. Design: A cross-sectional survey. Setting and subjects: A community-based study. The vegetarian women (aged 70±89 y) (n 76) were non- institutionalized subjects. All of them were Buddhists. Their bone mineral density were compared to normal elderly volunteers (aged 70±89 y) (n 109) who were recruited to establish normal BMD ranges. Their dietary intake was compared to omnivorous subjects from a previous dietary survey (n 250). Methods: Dietary assessment was by the 24 h recall method, and bone mineral density was measured by dual-X- ray-densitometry. The analysis of co-variance was used to compare the BMD between vegetarians and omnivores, with adjustment for potential confounders. The BMD in `vegans' and `lactovegetarians' were compared by similar methods. The t-test was used to compare dietary intake between omnivores and vegetarians. The relationship between nutrient intake and BMD was studied by correlation and multiple regression. Results: The dietary calorie, protein and fat intake were much lower, but the sodium=creatinine ratio was much higher in vegetarians than omnivores. The BMD at the spine was similar between vegetarians and omnivores. However, the BMD at the hip was signi®cantly lower in vegetarians at some sites (P < 0.05). There was no signi®cant difference in BMD between `vegans' and `lactovegetarians'. BMD in vegetarians appeared to be positively correlated with energy, protein and calcium intake; and negatively associated with urinary sodium= creatinine levels. Conclusions: There is a relationship between diet and BMD. The BMD at the hip was lower in vegetarians than omnivores, but no difference was observed between `vegans' and `lactovegetarians'. There is a complex relationship between the intake of various nutrient and BMD in vegetarians. Sponsorship: None Descriptors: Bone mineral density; vegetarians; vegans; lacto-vegetarians, omnivores Introduction between vegetarians and omnivores (Tylavsky & Ander- son, 1988; Lloyd et al, 1991; Tesar et al, 1992; Hunt et al, Osteoporosis is rapidly becoming a major public health 1989; Marsh et al, 1988). problem in Hong Kong (Lau et al, 1990). Previous studies have indicated that dietary calcium intake is low in our population (Pun et al, 1989), and such low intakes were Subjects and methods shown to be associated with increased risk of both hip (Lau et al, 1988) and vertebral fracture (Chan et al, 1996). The The research protocol was approved by the Human practice of vegetarianism has a long history in the Chinese Research Ethics Committee of the Chinese University of culture, with a substantial number of elderly women Hong Kong. Informed consent were obtained from all abstaining entirely from animal products. In this group, subjects prior to the study. A cross-sectional survey was vegetarianism is usually practised for religious reasons. A conducted on 76 Chinese vegetarian women aged 70±89 y. study into the bone mineral density of vegetarian Chinese These women had all been vegetarians for over 30 y, and women may enable further understanding into the relation- all were ®t and ambulant. Women who consumed milk for ship between dietary intake and bone health. once a month or more were labelled as `lactovegarians', The bone mass in vegetarians have been studied in and their BMD was compared with the `vegans' or women Caucasians. In the past, the bone mineral content (BMC) who never consumed milk, in the latter part of the analysis. of small members of Caucasian vegetarians has been The 24 h recall method was used for assessing dietary reported to be higher than that of omnivores (Ellis et al, intake. The dietary assessment was administered by a 1972; Marsh et al; 1980; Marsh et al, 1983). However, in single trained interviewer. All subjects were asked to the more recent studies, the BMD was found to be similar recall the actual food and drink consumed, in the last 24 h. Pictures of average portion sizes of food were shown to subjects, and the amount consumed were recorded as a multiple (or fraction) of such sizes. The dietary intake Correspondence: Dr EMC Lau Received 7 July 1997; revised 26 September 1997; accepted 20 September of various nutrients was then calculated using Food Com- 1997 position Tables for South East Asia (Food and Agriculture Bone mineral density in Chinese elderly females EMC Lau et al 61 Organization, 1972). The dietary intake in vegetarians were Table 1 Life-style factors, anthropometric measurements and bone min- compared to values in Chinese omnivorous women, as eral density (BMD) of 76 Chinese vegetarian women and 109 omnivores obtained by similar methods in a previous dietary survey Vegetarians (n 76) Omnivores (n 109) (n 250). Mean (s.d.) Mean (s.d.) BMD at the hip and spine was measured by dual X-ray densitometry (Hologic). The C.V. for measurements at both Age 79.1 (5.2)* 77.0 (3.8) Height 1.45 (0.06) 1.47 (0.06) sites were 1% in our laboratory. The weight and height of Weight 48.8 (9.67) 49.9 (9.12) all subjects were also recorded. The BMD and anthropo- Cigarette smokers (%) 11 16 metric measurements of the vegetarian women were com- Alcohol drinkers (%) 1 2 pared to normal values obtained in omnivorous controls Percentage who walked 96% 97% outdoors every day (%) (n 109). Detailed dietary assessment had not been per- Spine 0.70 (0.13) 0.72 (0.14) formed in this control group. Femoral neck 0.49 (0.078)*** 0.53 (0.082) A fasting 20 ml specimen of urine was collected in a Intertrochantic area 0.69 (0.13) 0.73 (0.14) plain glass bottle, for estimating the sodium and creatinine Ward 0.29 (0.091)** 0.34 (0.094) levels. Urinary sodium was estimated by ¯ame photometry *P < 0.05 by t-test. using an IL-943 ¯ame photometer (Instrumentation **P < 0.05 *** P < 0.001 by ANCOVA, adjusting for age, height, weight, Laboratory Inc. Lexington, MA, USA). Urinary creatinine cigarette smoking and alcohol consumption. were estimated using the `Parallel' Analytic System (Amer- ican Monitor Corporation, Indiana, USA). The coef®cient of variation was 1% for both urinary sodium and creatinine. Table 2 Dietary intake in Chinese vegetarians and omnivores (as compared The dietary intake between the vegetarians and omnivores to Caucasian vegetarians) were compared by the analysis of co-variance (ANCOVA), Chinese Caucasian with adjustments for age, body weight, height, cigarette Chinese vegetarians omnivores vegetariansa smoking and alcohol consumption, and physical activity (as (n 76) (n 250) (n 28) measured as whether subjects walked outdoors every day). None of the study subjects performed recreational activity Median Mean (s.d.) Mean (s.d.) Mean (s.d.) regularly. The dietary intake in Chinese `vegans' and Energy (Kcal) 1112 1142 (340)* 1557 (510) 1652 (347) `lactovegetarians' compared by the t-test; while their Protein (g) 31 35 (16)* 60 (21) 63 (24) BMD was compared by ANCOVA, with adjustments for (% Kcal) 12 12 (3) 16 (5) 15 (4) Carbohydrate (g) 211 211 (61)* 248 (88) 242 (6) age, body weight, height, cigarette smoking and alcohol (% Kcal) 76 75 (9) 64 (12) 59 (8) consumption, and physical activity (as measured by Fat (g) 15 19 (14)* 34 (28) 56 (16) whether subjects walked outdoors every day). (% Kcal) 13 15 (9) 19 (12) 31 (7) To study the relationship between dietary intake and Calcium=1000 Kcal 278 338 (189)* 221 (168) 496 (210) Urinary Na=Cr ratio 23.3 28.4 (18.8)* 17.5 (4.3) NA BMD, correlation coef®cients between dietary intake and Urinary K=Cr ratio 7.0 7.8 (4.4)* 4.3 (4.5) NA BMD were calculated. Multiple regression was then per- formed, with the dietary intake as predictor variables and aData was adapted from Tesar et al, 1992. the BMD as the predicted variables. The dietary intake **P 0.001 by t-test between Chinese vegetarians and omnivores. from our study was compared to the results from a study by Tesar et al (1992). In their study, dietary intake was women (Tesar et al, 1992). The average energy consump- assessed as an average of 24 h record and 6 d dietary tion was signi®cantly lower in vegetarian women than in records. Such methods may yield slightly higher intake omnivores. For the vegetarian women, the main source of than the 24 h record alone. energy intake was from carbohydrates, with a much smaller percentage from fat and protein. The dietary calcium intake, as measured by calcium intake per 1000 Kcal, Results was higher in vegetarian subjects than omnivores. The BMD, anthropometric measurements and life-style factor of high salt intake among vegetarians was re¯ected in the vegetarians and omnivores very high urinary sodium=creatinine ratio. While the diet- The BMD, anthropometric measurements and life-style ary intake of calories, protein, fat and calcium was much factors of vegetarians are shown in Table 1. On the average, lower among Chinese vegetarians than Caucasian vegetar- the vegetarians were 2 y older than omnivores (P < 0.05 by ians, these were very similar between Chinese omnivores the t-test).
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