Preventing Malnutrition to Reduce Fracture Risk in Aged Care Residents. A Dairy-Based Protein, Calcium, and Vitamin D Supplement Reduce Falls and Femoral Neck Bone Loss in Aged Care Residents: A Cluster Randomized Trial

  • Sandra IulianoEmail author


Falls and fracture rates are high in ambulatory aged care residents, and malnutrition may contribute to falls and fracture risk by influencing bone’s material composition and structure. We aimed to test if a dairy-based protein (10 g/day), calcium (600 mg/day), and vitamin D (960 IU/day) supplement formulated to increase intakes to recommended levels would reduce falls and fracture risk in ambulatory low-level aged care residents.

This was a cluster-randomized, single-blind intervention involving 813 residents (mean age 86.1 ± 5.9 years, 76 % female) from 16 low-level aged care facilities in Melbourne, Australia. Twelve months of observation in all facilities was followed by 8 months of food-based supplementation (intervention) or usual intake (controls). Number of fallers and non-vertebral fractures was assessed in all residents, and serum 25(OH)D, PTH, osteocalcin, bone mineral density (BMD) by densitometry, bone structure and volumetric BMD at the distal radius and tibia using high-resolution pQCT, balance (Lord’s balance test), and functionality (timed up and go, walking velocity) were tested in a subset of 84 residents. Repeated measures ANOVA and logistic regression models were used to compare cases and controls.

Among the whole sample, supplementation reduced the number of fallers by 42 % (OR = 0.58, 95 % CI: 0.44–0.78, p < 0.001). Among the 58 of 84 participants with follow-up data, supplementation slowed bone loss at the proximal femur, maintained serum 25(OH)D, and reduced PTH by 16 ± 8 %, p < 0.03.

Fortifying foods with protein, calcium, and vitamin D reduced falls in ambulatory aged care residents and is an accessible and inexpensive approach to reduce falls and slow the progression of bone fragility in the elderly.


Aged care Bone loss Calcium Dairy supplementation Elderly Falls Fractures • Protein Vitamin D 



Thanks to the research team: nurses Sheila Matthews, Judy Tan, and Kylie King; technicians Alison Evans and Ali GhasemZadeh; staff Xiao Fang Wang and Qingju Wang; collaborator Julie Woods; department head Ego Seeman; and the staff and residents of the participating care facilities. Funding support was provided by Dairy Australia and the Gardiner Foundation.


  1. 1.
    Gaskill D, Black LJ, Isenring EA, Hassall S, Sanders F, Bauer JD. Malnutrition prevalence and nutrition issues in residential aged care facilities. Australas J Ageing. 2008;27(4):189–94.PubMedCrossRefGoogle Scholar
  2. 2.
    Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr. 2003;22(3):235–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Rondanelli M, Opizzi A, Antoniello N, Boschi F, Iadarola P, Pasini E, et al. Effect of essential amino acid supplementation on quality of life, amino acid profile and strength in institutionalized elderly patients. Clin Nutr. 2011;30(5):571–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Volkert D, Pauly L, Stehle P, Sieber CC. Prevalence of malnutrition in orally and tube-fed elderly nursing home residents in Germany and its relation to health complaints and dietary intake. Gastroenterol Res Pract. 2011;2011:247315.PubMedGoogle Scholar
  5. 5.
    Isenring EA, Bauer JD, Banks M, Gaskill D. The Malnutrition Screening Tool is a useful tool for identifying malnutrition risk in residential aged care. J Hum Nutr Diet. 2009;22(6):545–50.PubMedCrossRefGoogle Scholar
  6. 6.
    Woods J, Walker K, Iuliano-Burns S, Straus B. Malnutrition on the menu: nutritional status of institutionalised elderly Australians in low-level care. J Nutr Health Aging. 2009;13(8):693–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Meijers JM, Halfens RJ, Wilson L, Schols JM. Estimating the costs associated with malnutrition in Dutch nursing homes. Clin Nutr. 2012;31(1):65–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Fagerstrom C, Palmqvist R, Carlsson J, Hellstrom Y. Malnutrition and cognitive impairment among people 60 years of age and above living in regular housing and in special housing in Sweden: a population-based cohort study. Int J Nurs Stud. 2011;48(7):863–71.PubMedCrossRefGoogle Scholar
  9. 9.
    Woo J, Chi I, Hui E, Chan F, Sham A. Low staffing level is associated with malnutrition in long-term residential care homes. Eur J Clin Nutr. 2005;59(4):474–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Nieuwenhuizen WF, Weenen H, Rigby P, Hetherington MM. Older adults and patients in need of nutritional support: review of current treatment options and factors influencing nutritional intake. Clin Nutr. 2010;29(2):160–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Leslie WS. Improving the dietary intake of frail older people. Proc Nutr Soc. 2011;70(2):263–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Roubenoff R, Hughes VA. Sarcopenia: current concepts. J Gerontol A Biol Sci Med Sci. 2000;55(12):M716–24.PubMedCrossRefGoogle Scholar
  13. 13.
    Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010;39(4):412–23.PubMedCrossRefGoogle Scholar
  14. 14.
    Landi F, Liperoti R, Russo A, Giovannini S, Tosato M, Capoluongo E, et al. Sarcopenia as a risk factor for falls in elderly individuals: results from the ilSIRENTE study. Clin Nutr. 2012;11:22424775.Google Scholar
  15. 15.
    Bischoff-Ferrari HA, Can U, Staehelin HB, Platz A, Henschkowski J, Michel BA, et al. Severe vitamin D deficiency in Swiss hip fracture patients. Bone. 2008;42(3):597–602.PubMedCrossRefGoogle Scholar
  16. 16.
    Chen JS, Sambrook PN, Simpson JM, Cameron ID, Cumming RG, Seibel MJ, et al. Risk factors for hip fracture among institutionalised older people. Age Ageing. 2009;38(4):429–34.PubMedCrossRefGoogle Scholar
  17. 17.
    Australian Government Department of Health and Ageing. Aged care in Australia. 2006. Accessed 22nd Aug 2012.
  18. 18.
    Kanis JA, Johnell O, Oden A, Sembo I, ­Redlund-Johnell I, Dawson A, et al. Long-term risk of osteoporotic fracture in Malm. Osteoporos Int. 2000;11(8):669–74.PubMedCrossRefGoogle Scholar
  19. 19.
    Sambrook PN, Seeman E, Phillips SR, Ebeling PR. Preventing osteoporosis: outcomes of the Australian Fracture Prevention Summit. Med J Aust. 2002;176(Suppl):S1–16.PubMedGoogle Scholar
  20. 20.
    Randell A, Sambrook PN, Nguyen TV, Lapsley H, Jones G, Kelly PJ, et al. Direct clinical and welfare costs of osteoporotic fractures in elderly men and women. Osteoporos Int. 1995;5(6):427–32.PubMedCrossRefGoogle Scholar
  21. 21.
    Sanders KM, Seeman E, Ugoni AM, Pasco JA, Martin TJ, Skoric B, et al. Age- and gender-specific rate of fractures in Australia: a population-based study. Osteoporos Int. 1999;10(3):240–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Chang KP, Center JR, Nguyen TV, Eisman JA. Incidence of hip and other osteoporotic fractures in elderly men and women: Dubbo Osteoporosis Epidemiology Study. J Bone Miner Res. 2004;19(4):532–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Chapuy MC, Arlot ME, Duboeuf F, Brun J, Crouzet B, Arnaud S, et al. Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med. 1992;327(23):1637–42.PubMedCrossRefGoogle Scholar
  24. 24.
    Australian Institute of Health &Welfare. Residential aged care in Australia 2005–06: a statistical overview. 2006. Accessed 22nd Aug 2012.
  25. 25.
    Visvanathan R, Macintosh C, Callary M, Penhall R, Horowitz M, Chapman I. The nutritional status of 250 older Australian recipients of domiciliary care services and its association with outcomes at 12 months. J Am Geriatr Soc. 2003;51(7):1007–11.PubMedCrossRefGoogle Scholar
  26. 26.
    Woods JL, Walker KZ, Iuliano Burns S, Strauss BJ. Malnutrition on the menu: nutritional status of institutionalised elderly Australians in low-level care. J Nutr Health Aging. 2009;13(8):693–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Pasco JA, Sanders KM, Henry MJ, Nicholson GC, Seeman E, Kotowicz MA. Calcium intakes among Australian women: Geelong Osteoporosis Study. Aust N Z J Med. 2000;30(1):21–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Bannerman E, Magarey AM, Daniels LA. Evaluation of micronutrient intakes of older Australians: The National Nutrition Survey–1995. J Nutr Health Aging. 2001;5(4):243–7.PubMedGoogle Scholar
  29. 29.
    Kurpad AV, Vaz M. Protein and amino acid requirements in the elderly. Eur J Clin Nutr. 2000;54 Suppl 3:S131–42.PubMedCrossRefGoogle Scholar
  30. 30.
    Morais JA, Chevalier S, Gougeon R. Protein turnover and requirements in the healthy and frail elderly. J Nutr Health Aging. 2006;10(4):272–83.PubMedGoogle Scholar
  31. 31.
    Sambrook PN, Cameron ID, Cumming RG, Lord SR, Schwarz JM, Trube A, et al. Vitamin D deficiency is common in frail institutionalised older people in northern Sydney. Med J Aust. 2002;176(11):560.PubMedGoogle Scholar
  32. 32.
    Promislow JH, Goodman-Gruen D, Slymen DJ, Barrett-Connor E. Protein consumption and bone mineral density in the elderly: the Rancho Bernardo Study. Am J Epidemiol. 2002;155(7):636–44.PubMedCrossRefGoogle Scholar
  33. 33.
    Hannan MT, Tucker KL, Dawson-Hughes B, Cupples LA, Felson DT, Kiel DP. Effect of dietary protein on bone loss in elderly men and women: the Framingham Osteoporosis Study. J Bone Miner Res. 2000;15(12):2504–12.PubMedCrossRefGoogle Scholar
  34. 34.
    Ammann P, Bourrin S, Bonjour JP, Meyer JM, Rizzoli R. Protein undernutrition-induced bone loss is ­associated with decreased IGF-I levels and estrogen deficiency. J Bone Miner Res. 2000;15(4):683–90.PubMedCrossRefGoogle Scholar
  35. 35.
    Wengreen HJ, Munger RG, West NA, Cutler DR, Corcoran CD, Zhang J, et al. Dietary protein intake and risk of osteoporotic hip fracture in elderly residents of Utah. J Bone Miner Res. 2004;19(4):537–45.PubMedCrossRefGoogle Scholar
  36. 36.
    Ammann P, Laib A, Bonjour JP, Meyer JM, Ruegsegger P, Rizzoli R. Dietary essential amino acid supplements increase bone strength by influencing bone mass and bone microarchitecture in ovariectomized adult rats fed an isocaloric low-protein diet. J Bone Miner Res. 2002;17(7):1264–72.PubMedCrossRefGoogle Scholar
  37. 37.
    Bourrin S, Toromanoff A, Ammann P, Bonjour JP, Rizzoli R. Dietary protein deficiency induces osteoporosis in aged male rats. J Bone Miner Res. 2000;15(8):1555–63.PubMedCrossRefGoogle Scholar
  38. 38.
    Garnero P, Sornay-Rendu E, Delmas PD. Low serum IGF-1 and occurrence of osteoporotic fractures in postmenopausal women. Lancet. 2000;355(9207):898–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Bourrin S, Ammann P, Bonjour JP, Rizzoli R. Dietary protein restriction lowers plasma insulin-like growth factor I (IGF-I), impairs cortical bone formation, and induces osteoblastic resistance to IGF-I in adult female rats. Endocrinology. 2000;141(9):3149–55.PubMedCrossRefGoogle Scholar
  40. 40.
    Schurch MA, Rizzoli R, Slosman D, Vadas L, Vergnaud P, Bonjour JP. Protein supplements increase serum insulin-like growth factor-I levels and attenuate proximal femur bone loss in patients with recent hip fracture. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1998;128(10):801–9.PubMedGoogle Scholar
  41. 41.
    Delmi M, Rapin CH, Bengoa JM, Delmas PD, Vasey H, Bonjour JP. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet. 1990;335(8696):1013–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Honkanen R, Kroger H, Alhava E, Turpeinen P, Tuppurainen M, Saarikoski S. Lactose intolerance associated with fractures of weight-bearing bones in Finnish women aged 38–57 years. Bone. 1997;21(6):473–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of withdrawal of calcium and vitamin D supplements on bone mass in elderly men and women. Am J Clin Nutr. 2000;72(3):745–50.PubMedGoogle Scholar
  44. 44.
    Seeman E. Evidence that calcium supplements reduce fracture risk is lacking. Clin J Am Soc Nephrol. 2010;5 Suppl 1:S3–11.PubMedCrossRefGoogle Scholar
  45. 45.
    Dawson-Hughes B, Dallal GE, Krall EA, Sadowski L, Sahyoun N, Tannenbaum S. A controlled trial of the effect of calcium supplementation on bone density in postmenopausal women. N Engl J Med. 1990;323(13):878–83.PubMedCrossRefGoogle Scholar
  46. 46.
    Recker RR, Hinders S, Davies KM, Heaney RP, Stegman MR, Lappe JM, et al. Correcting calcium nutritional deficiency prevents spine fractures in elderly women. J Bone Miner Res. 1996;11(12):1961–6.PubMedCrossRefGoogle Scholar
  47. 47.
    Compston JE, Seeman E. Compliance with osteoporosis therapy is the weakest link. Lancet. 2006;368(9540):973–4.PubMedCrossRefGoogle Scholar
  48. 48.
    Simmons SF, Patel AV. Nursing home staff delivery of oral liquid nutritional supplements to residents at risk for unintentional weight loss. J Am Geriatr Soc. 2006;54(9):1372–6.PubMedCrossRefGoogle Scholar
  49. 49.
    Gosney M. Are we wasting our money on food supplements in elder care wards? J Adv Nurs. 2003;43(3):275–80.PubMedCrossRefGoogle Scholar
  50. 50.
    Manders M, de Groot CP, Blauw YH, Dhonukshe-Rutten RA, van Hoeckel-Prust L, Bindels JG, et al. Effect of a nutrient-enriched drink on dietary intake and nutritional status in institutionalised elderly. Eur J Clin Nutr. 2009;63(10):1241–50.PubMedCrossRefGoogle Scholar
  51. 51.
    Smoliner C, Norman K, Scheufele R, Hartig W, Pirlich M, Lochs H. Effects of food fortification on nutritional and functional status in frail elderly nursing home residents at risk of malnutrition. Nutrition. 2008;24(11–12):1139–44.PubMedCrossRefGoogle Scholar
  52. 52.
    Bonjour JP, Benoit V, Pourchaire O, Ferry M, Rousseau B, Souberbielle JC. Inhibition of markers of bone resorption by consumption of vitamin D and calcium-fortified soft plain cheese by institutionalised elderly women. Br J Nutr. 2009;102(7):962–6.PubMedCrossRefGoogle Scholar
  53. 53.
    Bibbins-Domingo K, Chertow GM, Coxson PG, Moran A, Lightwood JM, Pletcher MJ, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med. 2010;362(7):590–9.PubMedCrossRefGoogle Scholar
  54. 54.
    Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med. 1997;336(16):1117–24.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2013

Authors and Affiliations

  1. 1.Department of EndocrinologyUniversity of Melbourne/Austin HealthWest HeidelbergAustralia

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