Aging Clinical and Experimental Research

https://doi.org/10.1007/s40520-019-01130-9

REVIEW

Dietary strategies for mitigating osteosarcopenia in older adults:

a narrative review
Marina De Rui1   · Emine Meral Inelmen1 · Sabrina Pigozzo1 · Caterina Trevisan1 · Enzo Manzato1 · Giuseppe Sergi1

Received: 21 November 2018 / Accepted: 12 January 2019

© Springer Nature Switzerland AG 2019

Abstract
The synchronic loss of bone mineral density and decrease in muscle mass, strength, and function defines the scenario of osteo-
sarcopenia, which is associated with an increased risk of falls and fractures in older adults. An important role in preventing
muscle and bone loss is played by nutritional factors, in particular the intake of proteins, calcium, magnesium and vitamin
D. This review summarizes the available literature concerning the influence of protein intake and supplementation (vitamin
D, Ca, Mg, branched-chain amino acids) on the decline of musculoskeletal integrity in healthy older adults. Furthermore,
in this paper, we attempted to give some suggestions to build up adequate nutritional and dietary strategies against the age-
related loss of muscle and bone mass.

Keywords  Sarcopenia · Osteoporosis · Osteosarcopenia · Older people · Protein intake · Calcium

Introduction skeleton and muscular performance [7]. In the light of epide-

Osteosarcopenia is a geriatric syndrome defined as the syn-
chronic loss of bone mineral density and quality (osteopo-
rosis) and decrease in muscle mass and strength/function
(sarcopenia). This condition has been associated with an
increased risk of falls and fractures even in “healthy” older
adults [1].
As highlighted by the Nutrition Society Spring Confer-
ence 2017, nutritional factors can substantially influence
the development of sarcopenia [2]. Dietary proteins play an
important role in the maintenance of musculoskeletal integ-
rity (MSI) [3], but healthy older adults are still contrast-
ing and excessive intakes of protein may also lead to some
adverse effects. Vitamins and minerals represent further
factors that can influence MSI. Vitamin D is a fundamen-
tal actor for protein synthesis and muscle function [4, 5].
Among minerals, calcium (Ca) and magnesium (Mg) are two
cornerstones of MSI. The former, in fact, has been largely
demonstrated being associated with bone mineral mass
[6], while Mg is a cofactor for enzymes that regulate cal-
cium metabolism and have a strong protective effect on the
* Marina De Rui
marinaderui@gmail.com
1
Geriatrics Division, Department of Medicine‑DIMED,
University of Padova, Via Giustiniani 2, Padua, Italy
miological data, interventional studies have been performed
to explore the potential impact of nutritional interventions
on the age-related loss of muscle mass and function. Protein
supplementation with branched-chain amino acids (BCAAs)
has shown to stimulate muscle protein anabolism in healthy
older adults similarly to younger adults [8, 9]. Hence, the
development of adequate nutritional, supplementation (pro-
tein, vitamin and minerals) and dietary strategies seems to
be essential to promote MSI in healthy older adults and con-
sequently to prevent and slow the sarcopenia process.
This paper attempts to summarize the efficacy of protein,
vitamin and mineral intake to promote MSI.
Methods
Relevant studies were searched through the electronic data-
bases MEDLINE, PubMed, Scopus and Google Scholar
from inception to December 2017. The search strategy used
for the search included the following keywords: “nutrition”,
“malnutrition”, “protein intake”, “vitamin D”, “calcium”,
“magnesium”, “branched chain amino acids supplementa-
tion”, “vegetarian/vegan diets” and “sarcopenia”, “osteopo-
rosis”, “osteosarcopenia”, “bone mineral density”, “skeletal-
muscle integrity”, “healthy older adults”. No geographic and

13
Vol.:(0123456789)

language restrictions were applied. Unpublished/gray litera-
ture studies were not considered in our work.
Osteoporosis + sarcopenia = osteosarcopenia
The most important success of older adults is maintaining a
good physical and functional status. One of the most impor-
tant changes that aging adults have to face is the reduction
of their muscle mass and strength, defined as sarcopenia.
However, although sarcopenia has been a substantial topic
in the scientific literature, the concept of osteosarcopenia,
which was first introduced in 2009 [10], so far has been
under-investigated [11]. Whether osteoporosis and sarcope-
nia should be considered alone or combined into a single
condition is not clear either, because no consensual defini-
tion of osteosarcopenia is largely accepted [12]. However,
these conditions share some relevant aspects and outcomes.
For instance, an Italian report of more than 300 women with
hip frailty fracture found that 58% were also sarcopenic [13],
and a study in 680 older fallers in Sydney reported that oste-
osarcopenic subjects were at higher risk of falls and fractures
[14]. In men aged ≥ 65 years, fracture risk was increased 3.5-
fold in the presence of osteosarcopenia, significantly higher
than having only sarcopenia or osteopenia alone [15].
The findings of a recent study underlines the close inter-
action between bone and muscle in the pathogenesis of
Fig. 1  Role of proteins, calcium, magnesium, vitamin D and branched-chain amino acids (BCAA) for muscle and bone structure and function
13
Aging Clinical and Experimental Research
osteopenia/osteoporosis and sarcopenia [16], suggesting a
biochemical channel of communication between bones and
muscles and the negative synergistic effects on physical per-
formance and bone turnover [17, 18].
Current pharmacological treatments for osteoporosis have
no effect on muscle mass. The prevention of protein mal-
nutrition, as the key of the prevention of osteosarcopenia,
is becoming thus a challenge in advanced age. Adequate
protein, Ca and vitamin D intake should have a dual effect
on bone and muscle and may significantly contribute to
improve functionality and to reduce falls and fracture risk in
advanced age [11]. Figure 1 shows the role of these nutrients
in preventing osteosarcopenia.
Protein status and difficulties in assumption
of dietary protein sources
Protein is essential to support the maintenance of MSI and
protein and amino acids are key components of any healthy
diet, especially in stressful conditions due to the presence
of injuries or diseases [19]. On the other hand, protein-
rich foods intakes are known to decline with age for sev-
eral reasons [20]. First, older people prefer foods that can
be consumed effortlessly and that provide an easy eating
experience. Second, poor chewing ability due to decreased
muscular strength and pain, dental problems and swallowing
Aging Clinical and Experimental Research
difficulties can affect consumption of important protein-rich
foods [21, 22]. Third, older people are more concerned about
food texture compared to younger adults, as they commonly
have difficulty consuming hard, crunchy, dry, and stringy
textured foods; therefore, their intake of important protein
sources, such as red meat, can decline [23]. Finally, the
loss of chemosensory acuity due to medications and aging
itself may also have a negative influence on food choices
and intakes, contributing to the reduction in protein intake
[24–26].
Dietary protein requirements
Protein intake recommendations are suggested by the Rec-
ommended Dietary Allowance (RDA), which report an
estimate of the minimum daily average dietary intake level
that meets the nutrient requirements of nearly all (97–98%)
healthy individuals. However, protein needs have been insuf-
ficiently studied, in particular in advanced age, and the lack
of long-term evaluations [5] until now have limited scientific
evidence on this topic. The RDA for protein, as promul-
gated by the Food and Nutrition Board of the United States
National Academy of Science, is 0.8  g protein/kg body
weight/day for adults, regardless of age [27]. This value rep-
resents the minimum amount of protein required to avoid
progressive loss of muscle mass [27]. However, considering
the involuntary and progressive loss muscle mass and the
number of clinical conditions that may accelerate muscle
loss in aging (e.g., injury, hospitalization, surgery) [27], one
could argue that the dietary protein requirement for older
adults should be higher than the currently recommended
value. In accordance with this hypothesis, substantial evi-
dence indicated that protein intakes higher than the current
RDA can be an important strategy to help promote healthy
aging [28, 29], and prospective studies showed that intake
of up to at least 1.2–1.5 g protein/kg body weight/day seems
to be safe in old people [30].
Do high‑protein intake diets have adverse effects?
Increasing dietary protein frequently raises concerns about
renal health, as it is known that aging is associated with a
loss of renal mass and a decline in glomerular filtration rate
[31], and that chronic high-protein diets in older age can
increase glomerular pressure and filtration rate, leading to
renal damage [32]. High-protein diets have also been linked
to an increased risk of kidney stone formation in predisposed
individuals [33]. However, although it is well-accepted that
a high-protein diet could be harmful in individuals with
existing kidney dysfunction, to our knowledge, there is lit-
tle evidence on the negative effects of high-protein intake in
healthy individuals, as in older people [33].
Are vegetarians/vegans at risk of osteosarcopenia?
Vegetarian nutrition has a growing international following
today, although vegetarians still remain a small minority in
all countries except for India [34]. Data of vegetarian/vegan
seniors are not available, although the typical Mediterranean
diet could be considered a plant-oriented dietary approach
[35].
MSI among vegetarian/vegans has been a concern for
some time. Studies that have compared protein foods from
animal vs. plant source have shown conflicting results on
their associations with bone and muscle mass [36, 37].
As regards bone, vegetarians have demonstrated either
similar or slightly reduced bone mineral density values
compared with omnivores. However, although some studies
found vegetarians, and particularly vegans, being at higher
risk of bone loss compared with non-vegetarians [38], such
difference appeared relatively modest and not clinically sig-
nificant, because if Ca intake is adequate, vegan diets are not
associated with an increased fracture risk [39].
Vitamin D and MSI
Vitamin D deficiency is a very common condition in old
people caused by reduced sunshine exposure, kidney
hydroxylation, vitamin D receptors’ expression and insuf-
ficient vitamin D intake [40].
Vitamin D is considered to play a pivotal role both in
bone and skeletal muscle metabolism [40]. Its deficiency is
associated with muscle atrophy, reduced muscular strength
and power, impaired balance and consequent increased risk
of recurrent falls and fractures [41].
The need for supplementing vitamin D in older adults as a
“mass medicating” knowing that its role on fracture preven-
tion, is still debated [42, 43]. A recent study has shown that
Ca plus vitamin D supplementation significantly reduced
fall risk across various populations [44], whereas its value
in optimizing bone density and in fracture prevention has
been questioned [45, 46].
Current scientific opinion indicates that 800 IU (20 µg) of
vitamin D from all sources should be consumed every day
to prevent falls in men and women older than 60 years [47,
48]. For other authors, a dose of 10 µg/day seemed sufficient
to maintain serum vitamin D concentrations between 75 and
100 nmol/L [49].
Calcium and MSI
Ca has been largely recognized as the “bone nutrient”,
because nearly 99% of the Ca in the adult human body is
contained in bones as hydroxyapatite [38]. Milk and dairy
products are an optimal source of Ca with important effects
on bone health [50].
13

The optimal suggested intake of Ca, and the significance
of Ca deficiency in the pathogenesis of osteoporosis has
been for a long time a matter of debate [51]. Higher Ca
intakes at various ages are associated with higher bone min-
eral density [52], a fact that nevertheless does not necessar-
ily reflect in lower risk of fracture [51].
The current recommendations for Ca intakes are
1000–1200 mg/day in older people. Considering that cal-
cium intake in elderly men and women is lower than recom-
mended (approximately 750 mg/day) [53], a supplementa-
tion of about 500 mg calcium per day could be sufficient,
avoiding side effects that could impair pharmacological
compliance.
Magnesium and MSI
Mg is located approximately at 60% in bone and is essential
for organic bone matrix synthesis [54]. Mg is essential for
normal neurological and muscular function, too. The rec-
ommended daily intake of Mg necessary for bone health in
older age is 320 mg in women and 420 mg in men. Although
Mg deficiency can affect the quality of bone, the relation-
ship between Mg and fractures is uncertain and results are
conflicting [55]. Some studies demonstrated an associa-
tion between higher Mg consumption and increased falls
and fractures [56], while other authors found that dietary
Mg seems to have a protective effect on future osteoporotic
fractures [55].
The role of branched‑chain amino acids (BCAAs)
in sarcopenia
The BCAAs are quite popular among bodybuilders to pro-
mote skeletal muscle hypertrophy. BCAAs make up about
one-third of muscle protein and leucine has been the most
thoroughly investigated [57] as the most powerful among
BCAAs.
Since leucine modulates muscle metabolism, its supple-
mentation could be an effective approach for treating sar-
copenia through the increase of muscle protein synthesis in
the elderly [8, 58]. In fact, leucine intakes > 550 mg/kg/day
have been associated with blood ammonia concentrations
above the normal range.
Supplementation of beta-hydroxy-beta-methylbutyrate
(HMB), a derivate of leucine, also demonstrated a posi-
tive effect on body composition and body strength in the
elderly [9]. It represents a safe and useful oral nutritional
supplement for older sarcopenic patients in combination
with resistance exercise [40, 59]. Consumption of small
amounts (circa 3 g/day) of leucine or HMB resulted in the
acute increase of muscle protein synthesis and suppressed
muscle protein breakdown with no adverse side effects [60].
Moreover, a nutritional supplement containing 1.5 g calcium
13
Aging Clinical and Experimental Research
HMB for 8 weeks in healthy older women, significantly
improved several muscle strength and physical performance
parameters [61].
Whey protein, a fraction (~ 20%) of milk protein, which is
characterized by a high leucine concentration also deserves
to be noted [62]. As for HMB, the ingestion of 21 g of whey
protein has effectively shown to increase muscle protein syn-
thesis rates in both sarcopenic and healthy older men [63].
General comments and recommendations
In the light of the topics discussed above, we can make the
general following comments, that can be limited by the fact
that this paper is a narrative revision of the literature and not
a systematic review.
Life expectancy has increased and the goal of modern
societies is currently living well with greater quality of life
and self-sufficiency in advanced age. Older people are more
susceptible to osteosarcopenia, which represents a severe
global health challenge because of the associated higher risk
of falls and fractures. Diet is an important modulator of MSI
and well-being in advanced age, and nutritional factors could
significantly impact on osteosarcopenia development. Diets
are made of food and food selection is important. However,
no official nutritional guidelines for osteosarcopenia preven-
tion are currently available, and future investigations will be
needed to better clarify the needs and dietary recommenda-
tions to face the decline of bone and muscle mass in older
age (Table 1).
Nutritional strategies (Table 2) may help to promote the
consumption of foods that may prevent or delay the onset
of osteosarcopenia, particularly providing products ready-
to-eat, easy-to-open, and easy-to-bite and chew. Moreover,
dietary interventions should also take into account that the
effects of a single food on health may be influenced (i.e.,
enhanced or counteracted) by other foods.
Optimal protein intake in the diet of older people is essen-
tial to support the inevitable loss of MSI, although precise
recommendations on the type of protein-containing foods
are lacking. Additionally, old osteosarcopenic individuals
may not consume sufficient amounts of high-quality protein,
contained in meat and dairy foods, through diet alone. Oral
protein supplements (e.g., leucine, HMB, whey) are suited to
provide high-quality proteins when diet alone is insufficient
to meet protein requirements. Since dietary animal protein
sources are considered to be complete proteins, while veg-
etable proteins sources are incomplete, oral protein supple-
ments should be added especially to vegetarian/vegan diets
to achieve and maintain MSI.
The influence of dietary protein on the MSI in older
adults is dependent on many other dietary factors such
as vitamin D, Ca and Mg. Food fortification may help in
enhancing the nutritive value of individual portions of
Aging Clinical and Experimental Research

Table 1  Food rich in vitamin D, calcium and magnesium Conclusion

Food Micronutrient content
Our review shows that dietary protein intake plays an
Vitamin D Cod liver oil 1 tsp: 440 IU important role in the development of the loss of MSI,
Salmon, mackerel 3 ounces: 400 IU and an adequate intake of high-quality protein should be
Tuna 3 ounces: 228 IU ensured in older adults. However, many details on pro-
Sardines 3 ounces: 164 IU tein recommendations to prevent or treat osteosarcopenia
Raw milk 1 cup: 98 IU are presently unclear. Vegetarian/vegan seniors, who cur-
Eggs 1 large: 41 IU rently represent a minority of the elderly population, could
Caviar 1 oz: 33 IU become a new challenge, because the young vegetarian/
Calcium Raw milk 1 cup: 300 mg vegan people could become the “new” vegetarian/vegan
Yogurt or kefir 6 oz: 300 mg seniors in the future, and their numbers are increasing in
Kale 1 cup: 245 mg most of the countries. Although long-term randomized
Cheese 1 oz: 224 mg controlled clinical trials are need to confirm the efficacy
Sardines 2 ounces: 217 mg of oral supplementation (leucine, HMB), to date, a varied,
Broccoli 1 ½ cup cooked: 93 mg well-balanced diet seems to be the best way to support the
Okra 1 cup: 82 mg mitigation of osteosarcopenia.
Almonds 1 oz: 76 mg
Bok choy 1 cup:74 mg
Watercress 1 cup: 41 mg Funding  This study did not receive any funding.
Magnesium Spinach, cooked 1 cup: 157 mg
Swiss chard, cooked 1 cup: 150 mg Compliance with ethical standards 
Dark chocolate 1 square: 95  mg
Pumpkin seeds, dried 1/8 cup: 92 mg Conflict of interest  The authors declare that they have no conflict of
Almonds 1 ounce: 75 mg interest.
Black beans 1/2 cup: 60 mg Statement of human and animal rights  This article does not contain
Avocado 1 medium: 58 mg any studies with human participants or animals performed by any of
Figs, dried 1/2 cup: 50 mg the authors.
Yogurt or kefir 1 cup: 46.5 mg
Informed consent  Not applicable.
Banana 1 medium: 32 mg

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