Calcium – a scoping review for Nordic Nutrition Recommendations 2023

Jóhanna E. Torfadóttir; Kirsti Uusi-Rasi

doi:10.29219/fnr.v67.10303

Jóhanna E. Torfadóttir Centre of Public Health Sciences, University of Iceland, Reykjavik, Iceland; and Directorate of Health, Reykjavik, Iceland
Kirsti Uusi-Rasi The UKK Institute for Health Promotion Research, Tampere, Finland

DOI: https://doi.org/10.29219/fnr.v67.10303

Keywords: calcium, minerals, bone, nutrition, recommendations

Abstract

The aim of this scoping review was to conduct evidence-based documentations between calcium (Ca) intake and health outcomes for updating dietary reference values (DRVs) and food-based dietary guidelines (FBDGs) in the sixth edition of Nordic Nutrient Recommendations (NNR2023). The systematic literature search was limited to reviews on human data published between 2011 and June 2021. Systematic reviews (SRs) and original publications of relevance for this scoping review were included. A common practice of designing studies on health outcomes related to Ca supplement intake is to examine combined Ca and vitamin D, and therefore, a combination of Ca with vitamin D (CaD) was included in this review. In total, 27 studies addressing the association between dietary or supplemental Ca on bone health, bone mineral density (BMD), pregnancy-related outcomes, cardiovascular diseases (CVD), cancers, obesity, and mortality were reviewed. SRs showed that both dietary and supplemental Ca intakes were positively associated with BMD, but evidence did not support the benefit in fracture prevention. Current evidence did not support that Ca or CaD supplementation increases risk of coronary heart disease or all-cause mortality in older adults, but that Ca may be beneficial for hypertension, especially in young people. Increasing Ca intake may be beneficial during pregnancy, especially for those at high risk of pre-eclampsia due to ethnicity, age, high BMI, and those with low baseline Ca intake. The associations between high Ca intake and cancers were varied, with strong evidence that high consumption of dairy products is protective against colorectal cancer and limited-suggestive evidence that dairy products and diets high in Ca might also be protective against breast cancer. Moreover, there is limited-suggestive evidence that dairy products and diets high in Ca increase the risk of prostate cancer. Based on current evidence, Ca intake is beneficial or neutral in relation to most of the outcomes evaluated in this review. Data from the Nordic countries show that average Ca intake is around the same as previously recommended by NNR. However, the average Ca intake in the Baltic countries is below the recommendations.

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References

1.
Weaver CM. 2003 W.O. Atwater Memorial Lecture: defining nutrient requirements from a perspective of bone-related nutrients. J Nutr 2003; 133(12): 4063–6. doi: 10.1093/jn/133.12.4063

2.
Weaver CM, Gordon CM, Janz KF, Kalkwarf HJ, Lappe JM, Lewis R, et al. The National Osteoporosis Foundation’s position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations. Osteoporos Int 2016; 27(4): 1281–386. doi: 10.1007/s00198-015-3440-3

3.
Medicine Io. Dietary reference intakes for calcium and vitamin D. Washington, DC: Press TNA; 2011.

4.
Bolland MJ, Barber PA, Doughty RN, Mason B, Horne A, Ames R, et al. Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial. BMJ 2008; 336(7638): 262–6. doi: 10.1136/bmj.39440.525752.BE

5.
Tucker KL. Vegetarian diets and bone status. Am J Clin Nutr 2014; 100(Suppl 1): 329S–35S. doi: 10.3945/ajcn.113.071621

6.
Handel MN, Heitmann BL, Abrahamsen B. Nutrient and food intakes in early life and risk of childhood fractures: a systematic review and meta-analysis. Am J Clin Nutr 2015; 102(5): 1182–95. doi: 10.3945/ajcn.115.108456

7.
Weaver CM, Proulx WR, Heaney R. Choices for achieving adequate dietary calcium with a vegetarian diet. Am J Clin Nutr 1999; 70(3 Suppl): 543S–48S. doi: 10.1093/ajcn/70.3.543s

8.
Blomhoff R, Andersen R, Arnesen EK, Christensen JJ, Eneroth H, Erkkola M, et al. Nordic Nutrition Recommendations 2023. Copenhagen: Nordic Council of Ministers; 2023.

9.
Arnesen EK, Christensen JJ, Andersen R, Eneroth H, Erkkola M, Hoyer A, et al. The Nordic Nutrition Recommendations 2022 – structure and rationale of qualified systematic reviews. Food Nutr Res 2020; 64: 4403. doi: 10.29219/fnr.v64.4403

10.
Arnesen EK, Christensen JJ, Andersen R, Eneroth H, Erkkola M, Hoyer A, et al. The Nordic Nutrition Recommendations 2022 – handbook for qualified systematic reviews. Food Nutr Res 2020; 64: 4404. doi: 10.29219/fnr.v64.4404

11.
Christensen JJ, Arnesen EK, Andersen R, Eneroth H, Erkkola M, Høyer A, et al. The Nordic Nutrition Recommendations 2022 – Principles and methodologies. Food Nutr Res. 2020; 64: 4402. doi: 10.29219/fnr.v64.4402

12.
Høyer A, Christensen JJ, Arnesen EK, Andersen R, Eneroth H, Erkkola M, et al. The Nordic Nutrition Recommendations 2022 – prioritisation of topics for de novo systematic reviews. Food Nutr Res 2021; 65: 7828. doi: 10.29219/fnr.v65.7828

13.
World Cancer Research Fund/American Institute for Cancer Research. Meat, fish and dairy products and the risk of cancer 2018. Available from: dietandcancerreport.org [cited January 2022].

14.
Uusi-Rasi K, Karkkainen MU, Lamberg-Allardt CJ. Calcium intake in health maintenance – a systematic review. Food Nutr Res 2013; 57: 21082. doi:10.3402/fnr.v57i0.21082

15.
Worth GK, Retallack RW, Devlin RD, Jefferies M, Gutteridge DH. Ionized calcium: aspects of technique and some factors affecting results. Clin Chim Acta 1981; 114(2–3): 283–6. doi: 10.1016/0009-8981(81)90403-4

16.
Agostoni C, Canani RB, Fairweather-Tait S, Heinonen M, Korhonen H, La Vieille S, et al. Scientific opinion on dietary reference values for calcium. EFSA J 2015; 13(5): 4101. doi: 10.2903/j.efsa.2015.4101

17.
Rojas-Fernandez CH, Maclaughlin EJ, Dore NL, Ebsary S. Assessing the potential adverse consequences of supplemental calcium on cardiovascular outcomes: should we change our approach to bone health? Ann Pharmacother 2012; 46(5): 696–702. doi: 10.1345/aph.1Q627

18.
Chiodini I, Bolland MJ. Calcium supplementation in osteoporosis: useful or harmful? Eur J Endocrinol 2018; 178(4): D13–D25. doi: 10.1530/EJE-18-0113

19.
Anderson JJ, Klemmer PJ. Risk of high dietary calcium for arterial calcification in older adults. Nutrients 2013; 5(10): 3964–74. doi: 10.3390/nu5103964

20.
Palacios C, Hofmeyr GJ, Cormick G, Garcia-Casal MN, Pena-Rosas JP, Betran AP. Current calcium fortification experiences: a review. Ann N Y Acad Sci 2021; 1484(1): 55–73. doi: 10.1111/nyas.14481

21.
Reid IR, Bolland MJ. Calcium and/or vitamin D supplementation for the prevention of fragility fractures: who needs it? Nutrients 2020; 12(4): 1011. doi: 10.3390/nu12041011

22.
Jilka RL, Weinstein RS, Parfitt AM, Manolagas SC. Quantifying osteoblast and osteocyte apoptosis: challenges and rewards. J Bone Miner Res 2007; 22(10): 1492–501. doi: 10.1359/jbmr.070518

23.
Civitelli R, Armamento-Villareal R, Napoli N. Bone turnover markers: understanding their value in clinical trials and clinical practice. Osteoporos Int 2009; 20(6): 843–51. doi: 10.1007/s00198-009-0838-9

24.
Quesada Gomez JM, Blanch Rubio J, Diaz Curiel M, Diez Perez A. Calcium citrate and vitamin D in the treatment of osteoporosis. Clin Drug Investig 2011; 31(5): 285–98. doi: 10.2165/11584940-000000000-00000

25.
Teucher B, Dainty JR, Spinks CA, Majsak-Newman G, Berry DJ, Hoogewerff JA, et al. Sodium and bone health: impact of moderately high and low salt intakes on calcium metabolism in postmenopausal women. J Bone Miner Res 2008; 23(9): 1477–85. doi: 10.1359/jbmr.080408

26.
Sellmeyer DE, Schloetter M, Sebastian A. Potassium citrate prevents increased urine calcium excretion and bone resorption induced by a high sodium chloride diet. J Clin Endocrinol Metab 2002; 87(5): 2008–12. doi: 10.1210/jcem.87.5.8470

27.
Springmann M, Wiebe K, Mason-D’roz D, Sulser TB, Rayner M, Scarborough P. Health and nutritional aspects of sustainable diet strategies and their association with environmental impacts: a global modelling analysis with country-level detail. Lancet Planet Health 2018; 2(10): e451–61. doi: 10.1016/S2542-5196(18)30206-7

28.
Hansen TH, Madsen MTB, Jorgensen NR, Cohen AS, Hansen T, Vestergaard H, et al. Bone turnover, calcium homeostasis, and vitamin D status in Danish vegans. Eur J Clin Nutr 2018; 72(7): 1046–54. doi: 10.1038/s41430-017-0081-y

29.
Ho-Pham LT, Nguyen ND, Nguyen TV. Effect of vegetarian diets on bone mineral density: a Bayesian meta-analysis. Am J Clin Nutr 2009; 90(4): 943–50. doi: 10.3945/ajcn.2009.27521

30.
Ma X, Tan H, Hu M, He S, Zou L, Pan H. The impact of plant-based diets on female bone mineral density: evidence based on seventeen studies. Medicine (Baltimore) 2021; 100(46): e27480. doi: 10.1097/MD.0000000000027480

31.
Neufingerl N, Eilander A. Nutrient intake and status in adults consuming plant-based diets compared to meat-eaters: a systematic review. Nutrients 2021; 14(1): 29. doi: 10.3390/nu14010029

32.
Itkonen ST, Paivarinta E, Pellinen T, Viitakangas H, Risteli J, Erkkola M, et al. Partial replacement of animal proteins with plant proteins for 12 weeks accelerates bone turnover among healthy adults: a randomized clinical trial. J Nutr 2021; 151(1): 11–19. doi: 10.1093/jn/nxaa264

33.
Nordic Council of Ministers. Nordic Nutrition Recommendations 2012: integrating nutrition and physical activity. 5th ed. Copenhagen: Nordic Council of Minsters; 2014, 627 p.

34.
Lemming EW, Pitsi T. The Nordic Nutrition Recommendations 2022 – food consumption and nutrient intake in the adult population of the Nordic and Baltic countries. Food Nutr Res 2022; 66: 8572. doi: 10.29219/fnr.v66.8572

35.
Shkembi B, Huppertz T. Calcium absorption from food products: food matrix effects. Nutrients 2021; 14(1): 180. doi: 10.3390/nu14010180

36.
Booth AO, Huggins CE, Wattanapenpaiboon N, Nowson CA. Effect of increasing dietary calcium through supplements and dairy food on body weight and body composition: a meta-analysis of randomised controlled trials. Br J Nutr 2015; 114(7): 1013–25. doi: 10.1017/S0007114515001518

37.
Li P, Fan C, Lu Y, Qi K. Effects of calcium supplementation on body weight: a meta-analysis. Am J Clin Nutr 2016; 104(5): 1263–73. doi: 10.3945/ajcn.116.136242

38.
Consensus conference: osteoporosis. JAMA 1984; 252(6): 799–802. doi: 10.1001/jama.1984.03350060043028

39.
Bauer DC. Clinical practice. Calcium supplements and fracture prevention. N Engl J Med 2013; 369(16): 1537–43. doi: 10.1056/NEJMcp1210380

40.
Grey A, Bolland M. Web of industry, advocacy, and academia in the management of osteoporosis. BMJ 2015; 351: h3170. doi: 10.1136/bmj.h3170

41.
Lewis JR, Radavelli-Bagatini S, Rejnmark L, Chen JS, Simpson JM, Lappe JM, et al. The effects of calcium supplementation on verified coronary heart disease hospitalization and death in postmenopausal women: a collaborative meta-analysis of randomized controlled trials. J Bone Miner Res 2015; 30(1): 165–75. doi: 10.1002/jbmr.2311

42.
Myung SK, Kim HB, Lee YJ, Choi YJ, Oh SW. Calcium supplements and risk of cardiovascular disease: a meta-analysis of clinical trials. Nutrients 2021; 13(2): 368. doi: 10.3390/nu13020368

43.
Chung M, Tang AM, Fu Z, Wang DD, Newberry SJ. Calcium intake and cardiovascular disease risk: an updated systematic review and meta-analysis. Ann Intern Med 2016; 165(12): 856–66. doi: 10.7326/M16-1165

44.
Asemi Z, Saneei P, Sabihi SS, Feizi A, Esmaillzadeh A. Total, dietary, and supplemental calcium intake and mortality from all-causes, cardiovascular disease, and cancer: a meta-analysis of observational studies. Nutr Metab Cardiovasc Dis 2015; 25(7): 623–34. doi: 10.1016/j.numecd.2015.03.008

45.
Cormick G, Ciapponi A, Cafferata ML, Belizan JM. Calcium supplementation for prevention of primary hypertension. Cochrane Database Syst Rev 2015; 6: CD010037. doi: 10.1002/14651858.CD010037.pub2

46.
Harvey NC, D’Angelo S, Paccou J, Curtis EM, Edwards M, Raisi-Estabragh Z, et al. Calcium and vitamin D supplementation are not associated with risk of incident ischemic cardiac events or death: findings from the UK Biobank cohort. J Bone Miner Res 2018; 33(5): 803–11. doi: 10.1002/jbmr.3375

47.
Bray F, Laversanne M, Weiderpass E, Soerjomataram I. The ever-increasing importance of cancer as a leading cause of premature death worldwide. Cancer 2021; 127(16): 3029–30. doi: 10.1002/cncr.33587

48.
Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021; 71(3): 209–49. doi: 10.3322/caac.21660

49.
Monteith GR, Prevarskaya N, Roberts-Thomson SJ. The calcium-cancer signalling nexus. Nat Rev Cancer 2017; 17(6): 367–80. doi: 10.1038/nrc.2017.18

50.
Hidayat K, Chen GC, Zhang R, Du X, Zou SY, Shi BM, et al. Calcium intake and breast cancer risk: meta-analysis of prospective cohort studies. Br J Nutr 2016; 116(1): 158–66. doi: 10.1017/S0007114516001768

51.
World Cancer Research Fund/American Institute for Cancer Research. Continuous Update Project Expert Report 2018. Diet, Nutrition, physical activiy and prostate cancer. Available from: dietandcancerreport.org [cited January 2022].

52.
Markozannes G, Tzoulaki I, Karli D, Evangelou E, Ntzani E, Gunter MJ, et al. Diet, body size, physical activity and risk of prostate cancer: an umbrella review of the evidence. Eur J Cancer 2016; 69: 61–69. doi: 10.1016/j.ejca.2016.09.026

53.
Harrison S, Lennon R, Holly J, Higgins JPT, Gardner M, Perks C, et al. Does milk intake promote prostate cancer initiation or progression via effects on insulin-like growth factors (IGFs)? A systematic review and meta-analysis. Cancer Causes Contr 2017; 28(6): 497–528. doi: 10.1007/s10552-017-0883-1

54.
Shui IM, Mucci LA, Wilson KM, Kraft P, Penney KL, Stampfer MJ, et al. Common genetic variation of the calcium-sensing receptor and lethal prostate cancer risk. Cancer Epidemiol Biomarkers Prev 2013; 22(1): 118–26. doi: 10.1158/1055-9965.EPI-12-0670-T

55.
Wilson KM, Shui IM, Mucci LA, Giovannucci E. Calcium and phosphorus intake and prostate cancer risk: a 24-y follow-up study. Am J Clin Nutr 2015; 101(1): 173–83. doi: 10.3945/ajcn.114.088716

56.
Research. WCRFAIfC. Diet, nutrition, physical activity and colorectal cancer2018. Available from: dietandcancerreport.org [cited January 2022].

57.
Veettil SK, Wong TY, Loo YS, Playdon MC, Lai NM, Giovannucci EL, et al. Role of diet in colorectal cancer incidence: umbrella review of meta-analyses of prospective observational studies. JAMA Netw Open 2021; 4(2): e2037341. doi: 10.1001/jamanetworkopen.2020.37341

58.
Gueguen L, Pointillart A. The bioavailability of dietary calcium. J Am Coll Nutr 2000; 19(2 Suppl): 119S–36S. doi: 10.1080/07315724.2000.10718083

59.
Norat T, Riboli E. Dairy products and colorectal cancer. A review of possible mechanisms and epidemiological evidence. Eur J Clin Nutr 2003; 57(1): 1–17. doi: 10.1038/sj.ejcn.1601522

60.
Goon S, Kim H, Giovannucci E. Population attributable risk for colorectal and breast cancer in England, Wales, Scotland, Northern Ireland, and the United Kingdom [version 1; peer review: 1 approved, 1 not approved]. AMRC Open Res 2021; 3: 11. doi: 10.12688/amrcopenres.12980.1

61.
Yang Y, Wang X, Yao Q, Qin L, Xu C. Dairy product, calcium intake and lung cancer risk: a systematic review with meta-analysis. Sci Rep 2016; 6: 20624. doi: 10.1038/srep20624

62.
Song X, Li Z, Ji X, Zhang D. Calcium intake and the risk of ovarian cancer: a meta-analysis. Nutrients 2017; 9(7): 679. doi: 10.3390/nu9070679

63.
Areco VA, Kohan R, Talamoni G, Tolosa de Talamoni NG, Peralta Lopez ME. Intestinal Ca(2+) absorption revisited: a molecular and clinical approach. World J Gastroenterol 2020; 26(24): 3344–64. doi: 10.3748/wjg.v26.i24.3344

64.
Heaney RP, Recker RR, Stegman MR, Moy AJ. Calcium absorption in women: relationships to calcium intake, estrogen status, and age. J Bone Miner Res 1989; 4(4): 469–75. doi: 10.1002/jbmr.5650040404

65.
Moser-Veillon PB, Mangels AR, Vieira NE, Yergey AL, Patterson KY, Hill AD, et al. Calcium fractional absorption and metabolism assessed using stable isotopes differ between postpartum and never pregnant women. J Nutr 2001; 131(9): 2295–9. doi: 10.1093/jn/131.9.2295

66.
Peacock M. Calcium absorption efficiency and calcium requirements in children and adolescents. Am J Clin Nutr 1991; 54(1 Suppl): 261S–65S. doi: 10.1093/ajcn/54.1.261S

67.
Huncharek M, Muscat J, Kupelnick B. Impact of dairy products and dietary calcium on bone-mineral content in children: results of a meta-analysis. Bone 2008; 43(2): 312–21. doi: 10.1016/j.bone.2008.02.022

68.
Van den Heuvel E, Steijns J. Dairy products and bone health: how strong is the scientific evidence? Nutr Res Rev 2018; 31(2): 164–78. doi: 10.1017/S095442241800001X

69.
Silk LN, Greene DA, Baker MK. The effect of calcium or calcium and vitamin D supplementation on bone mineral density in healthy males: a systematic review and meta-analysis. Int J Sport Nutr Exerc Metab 2015; 25(5): 510–24. doi: 10.1123/ijsnem.2014-0202

70.
Tai V, Leung W, Grey A, Reid IR, Bolland MJ. Calcium intake and bone mineral density: systematic review and meta-analysis. BMJ 2015; 351: h4183. doi: 10.1136/bmj.h4183

71.
Bolland MJ, Leung W, Tai V, Bastin S, Gamble GD, Grey A, et al. Calcium intake and risk of fracture: systematic review. BMJ 2015; 351: h4580. doi:10.1136/bmj.h4580

72.
Bolland MJ, Grey A, Reid IR. Should we prescribe calcium or vitamin D supplements to treat or prevent osteoporosis? Climacteric 2015; 18(Suppl 2): 22–31. doi: 10.3109/13697137.2015.1098266

73.
Kahwati LC, Weber RP, Pan H, Gourlay M, LeBlanc E, Coker-Schwimmer M, et al. Vitamin D, calcium, or combined supplementation for the primary prevention of fractures in community-dwelling adults: evidence report and systematic review for the US preventive services task force. JAMA 2018; 319(15): 1600–12. doi: 10.1001/jama.2017.21640

74.
Zhao JG, Zeng XT, Wang J, Liu L. Association between calcium or vitamin D supplementation and fracture incidence in community-dwelling older adults: a systematic review and meta-analysis. JAMA 2017; 318(24): 2466–82. doi: 10.1001/jama.2017.19344

75.
Yao P, Bennett D, Mafham M, Lin X, Chen Z, Armitage J, et al. Vitamin D and calcium for the prevention of fracture: a systematic review and meta-analysis. JAMA Netw Open 2019; 2(12): e1917789. doi: 10.1001/jamanetworkopen.2019.17789

76.
Tricco AC, Thomas SM, Veroniki AA, Hamid JS, Cogo E, Strifler L, et al. Comparisons of interventions for preventing falls in older adults: a systematic review and meta-analysis. JAMA 2017; 318(17): 1687–99. doi: 10.1001/jama.2017.15006

77.
Iuliano S, Poon S, Robbins J, Bui M, Wang X, De Groot L, et al. Effect of dietary sources of calcium and protein on hip fractures and falls in older adults in residential care: cluster randomised controlled trial. BMJ 2021; 375: n2364. doi:10.1136/bmj.n2364

78.
Cigolle CT, Ha J, Min LC, Lee PG, Gure TR, Alexander NB, et al. The epidemiologic data on falls, 1998–2010: more older Americans report falling. JAMA Intern Med 2015; 175(3): 443–5. doi: 10.1001/jamainternmed.2014.7533

79.
An LB, Li WT, Xie TN, Peng X, Li B, Xie SH, et al. Calcium supplementation reducing the risk of hypertensive disorders of pregnancy and related problems: a meta-analysis of multicentre randomized controlled trials. Int J Nurs Pract 2015; 21(Suppl 2): 19–31. doi: 10.1111/ijn.12171

80.
Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L, Torloni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev 2014; 6: CD001059. doi: 10.1002/14651858.CD001059.pub4

81.
Patrelli TS, Dall’asta A, Gizzo S, Pedrazzi G, Piantelli G, Jasonni VM, et al. Calcium supplementation and prevention of preeclampsia: a meta-analysis. J Matern Fetal Neonatal Med 2012; 25(12): 2570–4. doi: 10.3109/14767058.2012.715220

82.
Buppasiri P, Lumbiganon P, Thinkhamrop J, Ngamjarus C, Laopaiboon M, Medley N. Calcium supplementation (other than for preventing or treating hypertension) for improving pregnancy and infant outcomes. Cochrane Database Syst Rev 2015; 2: CD007079. doi: 10.1002/14651858.CD007079.pub3

83.
Booth A, Camacho P. A closer look at calcium absorption and the benefits and risks of dietary versus supplemental calcium. Postgrad Med 2013; 125(6): 73–81. doi: 10.3810/pgm.2013.11.2714

84.
Balk EM, Adam GP, Langberg VN, Earley A, Clark P, Ebeling PR, et al. Global dietary calcium intake among adults: a systematic review. Osteoporos Int 2017; 28(12): 3315–24. doi: 10.1007/s00198-017-4230-x

85.
Hunt CD, Johnson LK. Calcium requirements: new estimations for men and women by cross-sectional statistical analyses of calcium balance data from metabolic studies. Am J Clin Nutr 2007; 86(4): 1054–63. doi: 10.1093/ajcn/86.4.1054

86.
EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA). Scientific opinion on the tolerable upper intake level of calcium. EFSA J 2012; 10(7): 2814. doi: 10.2903/j.efsa.2012.2814

87.
Ratajczak AE, Zawada A, Rychter AM, Dobrowolska A, Krela-Kazmierczak I. Milk and dairy products: good or bad for human bone? Practical dietary recommendations for the prevention and management of osteoporosis. Nutrients 2021; 13(4): 1329. doi: 10.3390/nu13041329