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Issues and O pinions in nutrition

T he v iews e xp re sse d in th is se ctio n a re th ose o f t he a uth ors a nd n ot n ec essa rily th ose o f t he E dito r, th e E dito ria l B oa rd o f T he

J ou rn al , o r th e Americ an In stitu te o fNu tritio n. R e ad ers a re in vite d to re sp on d to th es e e ss ay s b y L et te rs to th e Edit or, s o th at T he

Jo urn al c an se rv e a s a fo rum fo r th e d isc ussio n o f t he se to pic s.

Dietary Protein Increases urinary Calcium

JANE E. K ER STE TTER A riD L INDSA Y H . A LLEN

School o f A ll ied Heal th Profes sions and Department o f Nutr it ional Sciences The Universi ty o f

Connecticut Storrs CT 06269-4017

An increase in dietary protein has been shown by

several investigators to increase urinary losses of cal

cium , resulting in negative calcium balance (1-7). This

has been review ed in detail by Yuen et al. (8). However,

Spencer and colleagues have observed that a high pro

tein diet has little effect on urinary calcium excretion,

and they attributed this to the phosphorus content of

the diet (9-11). Recently, they concluded that com

m only used complex proteins, which have a high phos

phorus content, do not cause urinary calcium loss in

adult hum ans (12). B ecause excess urinary calcium and

negative calcium balance are thought to result in an

increased risk for osteoporosis and nephrolithiasis, it is

im portant to address this discrepancy of opinion. This

paper w ill summarize the available data in adults regard

ing the effects of dietary protein, calcium , and phospho

rus on calcium balance. From the available literature,

we conclude that at calcium and phosphorus intakes

500

400

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S8<

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100 200 300 400

Die taryrotei n0/d

5 6

FIGUR Rela tionship b etw een p ro te in in ta ke and u ri

nary calcium . Each point represents the m ean of a group of

subjects from one o f t he 16 stu dies cited in the text. T he data

re pre se nt 1 54 adu lt ma le a nd female s ub je cts .

typically consum ed by the American adult, increases in

dietary protein do increase urinary calcium , resulting in

a shift of calcium balance in a negative direction.

F igu re summarizes sep arate h um an stu dies an d

illustrates the relationship betw een dietary protein in

take and urinary calcium excretion in 154 adult subjects(1-7, 9, 10, 13-19). The protein was supplied as wheat

gluten, beef, m ilk, egg, soy, lactalbum in or casein in the

form of purified proteins or m ixed foods. Study periods

lasted from 12 to 60 d. A t protein intakes below 200 g/d

the relationship between dietary protein and urinary

calcium is liner (r = 0.67) such that for each 50-g incre

ment of dietary protein an extra 60 mg of urinary cal

cium is lost.

T he relationsh ip betw een dieta ry pro tein a nd u rinary

calcium has also been well documented in rat models

(20-24) and in dairy cows (25). Hypercalciuria from

excessive dietary protein increases the risk of renal

calcium oxalate stones (26-31).

The renal response of humans to dietary protein is

rapid; that is, hypercalciuria is observed within 2 to 4 h

after protein ingestion (32). In hum ans, the calciuria

does not dim inish in long-term experimental periods

lasting from 45 to 60 d (1, 4, 7). The mechanism by

w hich dietary protein influences urinary calcium prob

ably involves several factors. D ietary protein clearly

increases the glomerular filtration rate and thus the

filtered calcium load (4-7, 14, 15, 17, 33). In addition,

the renal fractional reabsorption of calcium is de pressed

by a higher protein diet compared to one with a lower

protein content (4, 5, 7 , 15, 17, 32). The change in

reabsorption has been attributed to the sulfur and acid

load from th e protein (5,17,34,3 5) o r the hyperinsu line-

m ic effect of protein (36).

The protein-induced increase in urinary calcium re

sults in negative calcium balance. Figure 2 illustrates

calcium balance data from 13 separate hum an studies

in which dietary protein was m anipulated in 104 adults

0 02 2-3 166 /9 0 3 .0 0 ©1 990 Ame rica n In stitu te o f N utritio n. R ece iv ed 1 3 J an uary 1 98 9. /. à ‘u tà .120:134-136.

13 4

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DIET A RY PR OT EIN IN CR EA S ES UR IN A RY CA L CIUM

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100-50-X e

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F IGURE Rel ati on sh ip of pr otei n and cal ci um i ntak es to

calcium retention. E ach point represents the m ean of a group

of subjects f rom the 13 studies cited in the tex t. T he data

re presen t 1 04 ad ult m ale an d f em ale su bjects. Pro tein in tak es

are as follow s: 25-74 g/d (open circles), 75-124 g/d (stars),

12 5-1 74 g /d (o pen b ox es) and >1 75 g /d (o pen trian gles).

(1-7, 10, 14-16, 19). A t low protein intak es (25-74 g/d),

calcium balance is close to equilibrium at calcium in

tak es betw een 500 and 1400 m g/d. For healthy indiv id

uals w eighing less than 91/k g, the R DA for protein is

included in this low protein range. A t the ty pical

calcium intak e for adults in W estern populations (400-

1300 m g/d) (37), protein intak es higher than 75 g/d tend

to result in negativ e calcium balance. Figure 2, how ev er,

does not address the issue of phosphorus intak e.

F igu r e 3 illu st r at es ca lciu m b a la n ce d a ta a s a fu n ct ion

of phosphorus intak e from the sam e 13 studies repre

sented in Fig ure 2. A t the ty pical am o unts of phosph orus

consum ed by adults (0.8-1.5 g/d) (37), calcium balance

does appear to be largely dependent on protein intak e.

W e k now that phosphorus clearly decreases urinary

calcium losses (6 , 18) either b y increasing parathy roid

horm one sy nthesis (38) or m ore directly by af fecting

calcium tubular reabsorption (39). S pencer and col

leagues hav e conclu ded that increasing dietary protein

from com monly consum ed com plex proteins also in

creases dietary phosphorus, w hich negates the urinary

calcium losses (9-12). T hese conclusions w ere based on

studies in w hich the addition of red m eat or dairy

products failed to af fect urinary calcium . A lthough in

creased dietary phosphorus can clearly blunt the

hy percalciuretic response to protein and im prov e cal

cium balance, Figure 3 rev eals that the ability to restore

calcium balance to equilibrium is not clear.

For ex am ple, Hegsted et al. (6) m easured calcium

balance in adults at tw o lev els of protein (50 and 150 g)

and phosphorus (1010 and 2525 m g) intak e. A t both

lev els of protein intak e, phosphorus reduced urinary

calcium losses by approx im ately 40% and shif ted cal

cium balance in the positiv e direction. Y e t, calcium

balance w as still negativ e (-25 m g/d) w ith the high

100-50-ç0

0I

g60-¡-100-aU

-150--200-17 5 g /d (op en trian gles).

protein, high pho sphorus diet and urinary hy drox yprol-

ine w as higher, suggesting an increase in bone rà © sorp

tion (6, 19). In addition, there are other ex am ples in

w hich a protein and phosphorus load giv en as anim al

f lesh w ere associated w ith sm all but signif icant in

creases in urinary calcium losses (26, 28, 40).

In sum m ary , strong ev idence link s the intak e of com

m only consum ed dietary proteins to urinary calcium

and calcium balance at ty pical lev els of dietary calcium

and phosphorus. W h en there is an abundance of dietary

calcium and p hosphorus (as w ith a lib eral intak e of dairy

pro ducts), the d ependence of calciu m balance on dietary

pro tein is less pron ounced (19). A t protein intak es abov e

the R DA , m ore calcium is lost in the urine, so calcium

balances tend to be n egativ e.

LITE R A T U R E C ITE D

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E ff ect of lev el of protein intak e on urinary and f ecal calcium and

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2. W A L K ER ,R . M . & L IN K SW T LER ,. M . (1972) C alcium retention

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KER ST ET TE R AND A LL EN

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