Dietary Patterns in Relation to Bone Mineral Density Among Menopausal Iranian Women


The association of dietary patterns and bone health is not yet well known, and findings from the rare previous studies conducted on this issue are contradictory. We assessed the dietary patterns in relation to bone mineral density (BMD) in a sample of menopausal Iranian women. In this cross-sectional study, 160 menopausal women aged 50–85 were studied and their femoral neck and lumbar spine BMDs were measured by dual-energy X-ray absorptiometry. Dietary intakes were assessed with a validated 168-item food frequency questionnaire, and dietary patterns were identified by a principal component factor analysis method. Overall, six dietary patterns emerged, two of which had a significant association with BMD. After adjusting for potential confounders, women who had higher scores for the first (high in high-fat dairy products, organ meats, red or processed meats and nonrefined cereals) and the second (high in French fries, mayonnaise, sweets and desserts and vegetable oils) dietary patterns we identified were more likely to have BMD below the median in the lumbar spine (odds ratio 2.29; 95 % confidence interval 1.05–4.96; p = 0.04) and the femoral neck (odds ratio 2.83, 95 % confidence interval 1.31–6.09; p < 0.01), respectively, compared to women with lower scores. Dietary patterns abundant in foods with high content of saturated fatty acids (similar to factor 1) or with low density of nutrients (similar to factor 2) are detrimental to bone health in menopausal Iranian women. These findings highlight the importance of proper food selection for maintaining bone health.

This is a preview of subscription content, access via your institution.


  1. 1.

    Genant HK, Cooper C, Poor G, Reid I, Ehrlich G, Kanis J, Nordin BE, Barrett-Connor E, Black D, Bonjour JP, Dawson-Hughes B, Delmas PD, Dequeker J, Ragi Eis S, Gennari C, Johnell O, Johnston CC Jr, Lau EM, Liberman UA, Lindsay R, Martin TJ, Masri B, Mautalen CA, Meunier PJ, Khaltaev N et al (1999) Interim report and recommendations of the World Health Organization Task-Force for Osteoporosis. Osteoporos Int 10:259–264

    PubMed  Article  CAS  Google Scholar 

  2. 2.

    Jamshidian Tehrani M, Kalantari N, Azadbakht L, Rajaie A, Hooshiar-rad A, Golestan B et al (2003) The prevalence of osteoporosis among women aged 40–60 in Tehran. Iran J Endocrinol Metab 5:271–276

    Google Scholar 

  3. 3.

    Abolhassani F, Mohammadi M, Soltani A (2004) Burden of osteoporosis in Iran. Iranian J Publ Health (suppl 1):18–28.

  4. 4.

    Sambrook P, Cooper C (2006) Osteoporosis. Lancet 367(9527):2010–2018

    PubMed  Article  CAS  Google Scholar 

  5. 5.

    Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 22:465–475

    PubMed  Article  Google Scholar 

  6. 6.

    McGuigan FE, Murray L, Gallagher A, Davey-Smith G, Neville CE, Van’t Hof R, Boreham C, Ralston SH (2002) Genetic and environmental determinants of peak bone mass in young men and women. J Bone Miner Res 17:1273–1279

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Kitchin B, Morgan S (2003) Nutritional considerations in osteoporosis. Curr Opin Rheumatol 15:476–480

    PubMed  Article  CAS  Google Scholar 

  8. 8.

    Jacques PF, Tucker KL (2001) Are dietary patterns useful for understanding the role of diet in chronic disease? Am J Clin Nutr 73:1–2

    PubMed  CAS  Google Scholar 

  9. 9.

    Hu FB (2002) Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol 13:3–9

    PubMed  Article  CAS  Google Scholar 

  10. 10.

    Newby PK, Tucker KL (2004) Empirically derived eating patterns using factor or cluster analysis: a review. Nutr Rev 62:177–203

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Kant AK (2004) Dietary patterns and health outcomes. J Am Diet Assoc 104:615–635

    PubMed  Article  Google Scholar 

  12. 12.

    Hu FB, Rimm E, Smith-Warner SA, Feskanich D, Stampfer MJ, Ascherio A, Sampson L, Willett WC (1999) Reproducibility and validity of dietary patterns assessed with a food-frequency questionnaire. Am J Clin Nutr 69:243–249

    PubMed  CAS  Google Scholar 

  13. 13.

    Jacobs DR Jr, Steffen LM (2003) Nutrients, foods, and dietary patterns as exposures in research: a framework for food synergy. Am J Clin Nutr 78(suppl 3):508S–513S

    PubMed  CAS  Google Scholar 

  14. 14.

    Okubo H, Sasaki S, Horiguchi H, Oguma E, Miyamoto K, Hosoi Y, Kim MK, Kayama F (2006) Dietary patterns associated with bone mineral density in premenopausal Japanese farmwomen. Am J Clin Nutr 83:1185–1192

    PubMed  CAS  Google Scholar 

  15. 15.

    Tucker KL, Chen H, Hannan MT, Cupples LA, Wilson PW, Felson D, Kiel DP (2002) Bone mineral density and dietary patterns in older adults: the Framingham Osteoporosis Study. Am J Clin Nutr 76:245–252

    PubMed  CAS  Google Scholar 

  16. 16.

    Hardcastle AC, Aucott L, Fraser WD, Reid DM, Macdonald HM (2011) Dietary patterns, bone resorption and bone mineral density in early post-menopausal Scottish women. Eur J Clin Nutr 65:378–385

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    McNaughton SA, Wattanapenpaiboon N, Wark JD, Nowson CA (2011) An energy-dense, nutrient-poor dietary pattern is inversely associated with bone health in women. J Nutr 141:1516–1523

    PubMed  Article  CAS  Google Scholar 

  18. 18.

    Kontogianni MD, Melistas L, Yannakoulia M, Malagaris I, Panagiotakos DB, Yiannakouris N (2009) Association between dietary patterns and indices of bone mass in a sample of Mediterranean women. Nutrition 25:165–171

    PubMed  Article  Google Scholar 

  19. 19.

    Langsetmo L, Poliquin S, Hanley DA, Prior JC, Barr S, Anastassiades T, Towheed T, Goltzman D, Kreiger N, CaMos Research Group (2010) Dietary patterns in Canadian men and women ages 25 and older: relationship to demographics, body mass index, and bone mineral density. BMC Musculoskelet Disord 11:20

    PubMed  Article  Google Scholar 

  20. 20.

    Esfahani FH, Asghari G, Mirmiran P, Azizi F (2010) Reproducibility and relative validity of food group intake in a food frequency questionnaire developed for the Tehran Lipid and Glucose Study. J Epidemiol 20:150–158

    PubMed  Article  Google Scholar 

  21. 21.

    Ghaffarpour M, Houshiar-Rad A, Kianfar H (1999) The manual for household measures, cooking yields factors and edible portion of foods. Agriculture Sciences Press, Tehran

    Google Scholar 

  22. 22.

    Azar M, Sarkisian E (1980) Food composition table of Iran. National Nutrition and Food Research Institute, Shaheed Beheshti University, Tehran

    Google Scholar 

  23. 23.

    Goldberg GR, Black AE, Jebb SA, Cole TJ, Murgatroyd PR, Coward WA, Prentice AM (1991) Critical evaluation of energy intake data using fundamental principles of energy physiology: 1. Derivation of cut-off limits to identify under-recording. Eur J Clin Nutr 45:569–581

    PubMed  CAS  Google Scholar 

  24. 24.

    Johansson L, Solvoll K, Bjorneboe GE, Drevon CA (1998) Under- and overreporting of energy intake related to weight status and lifestyle in a nationwide sample. Am J Clin Nutr 68:266–274

    PubMed  CAS  Google Scholar 

  25. 25.

    Aadahl M, Jorgensen T (2003) Validation of a new self-report instrument for measuring physical activity. Med Sci Sports Exerc 35:1196–1202

    PubMed  Article  Google Scholar 

  26. 26.

    Rezazadeh A, Rashidkhani B, Omidvar N (2010) Association of major dietary patterns with socioeconomic and lifestyle factors of adult women living in Tehran. Iran Nutr 26:337–341

    Google Scholar 

  27. 27.

    Kim JO, Mueller CW (1978) Factor analysis: statistical methods and practical issues. Sage, Thousand Oaks

    Google Scholar 

  28. 28.

    Akhbari H (2007) The distribution of bone mineral density in healthy women in Tehran. Turk J Med Sci 37:27–30

    Google Scholar 

  29. 29.

    Moayyeri A, Soltani A, Bahrami H, Sadatsafavi M, Jalili M, Larijani B (2006) Preferred skeletal site for osteoporosis screening in high-risk populations. Public Health 120:863–871

    PubMed  Article  Google Scholar 

  30. 30.

    Corwin RL, Hartman TJ, Maczuga SA, Graubard BI (2006) Dietary saturated fat intake is inversely associated with bone density in humans: analysis of NHANES III. J Nutr 136:159–165

    PubMed  CAS  Google Scholar 

  31. 31.

    Cooper C, Atkinson EJ, Hensrud DD, Wahner HW, O’Fallon WM, Riggs BL, Melton LJ III (1996) Dietary protein intake and bone mass in women. Calcif Tissue Int 58:320–325

    PubMed  CAS  Google Scholar 

  32. 32.

    Kato I, Toniolo P, Zeleniuch-Jacquotte A, Shore RE, Koenig KL, Akhmedkhanov A, Riboli E (2000) Diet, smoking and anthropometric indices and postmenopausal bone fractures: a prospective study. Int J Epidemiol 29:85–92

    PubMed  Article  CAS  Google Scholar 

  33. 33.

    Michaelsson K, Holmberg L, Mallmin H, Wolk A, Bergstrom R, Ljunghall S (1995) Diet, bone mass, and osteocalcin: a cross-sectional study. Calcif Tissue Int 57:86–93

    PubMed  Article  CAS  Google Scholar 

  34. 34.

    Weiss LA, Barrett-Connor E, von Muhlen D (2005) Ratio of n-6 to n-3 fatty acids and bone mineral density in older adults: the Rancho Bernardo Study. Am J Clin Nutr 81:934–938

    PubMed  CAS  Google Scholar 

  35. 35.

    Haag M, Magada ON, Claassen N, Bohmer LH, Kruger MC (2003) Omega-3 fatty acids modulate ATPases involved in duodenal Ca absorption. Prostaglandins Leukot Essent Fatty Acids 68:423–429

    PubMed  Article  CAS  Google Scholar 

  36. 36.

    Watkins BA, Li Y, Lippman HE, Feng S (2003) Modulatory effect of omega-3 polyunsaturated fatty acids on osteoblast function and bone metabolism. Prostaglandins Leukot Essent Fatty Acids 68:387–398

    PubMed  Article  CAS  Google Scholar 

  37. 37.

    Parhami F (2003) Possible role of oxidized lipids in osteoporosis: could hyperlipidemia be a risk factor? Prostaglandins Leukot Essent Fatty Acids 68:373–378

    PubMed  Article  CAS  Google Scholar 

  38. 38.

    Corwin RL (2003) Effects of dietary fats on bone health in advanced age. Prostaglandins Leukot Essent Fatty Acids 68:379–386

    PubMed  Article  CAS  Google Scholar 

  39. 39.

    Wachman A, Bernstein DS (1968) Diet and osteoporosis. Lancet 1(7549):958–959

    PubMed  Article  CAS  Google Scholar 

  40. 40.

    Bushinsky DA (2001) Acid–base imbalance and the skeleton. Eur J Nutr 40:238–244

    PubMed  Article  CAS  Google Scholar 

  41. 41.

    Sellmeyer DE, Stone KL, Sebastian A, Cummings SR (2001) A high ratio of dietary animal to vegetable protein increases the rate of bone loss and the risk of fracture in postmenopausal women. Study of Osteoporotic Fractures Research Group. Am J Clin Nutr 73:118–122

    PubMed  CAS  Google Scholar 

  42. 42.

    Krieger NS, Sessler NE, Bushinsky DA (1992) Acidosis inhibits osteoblastic and stimulates osteoclastic activity in vitro. Am J Physiol 262(3 pt 2):F442–F448

    PubMed  CAS  Google Scholar 

  43. 43.

    Ilich JZ, Kerstetter JE (2000) Nutrition in bone health revisited: a story beyond calcium. J Am Coll Nutr 19:715–737

    PubMed  CAS  Google Scholar 

  44. 44.

    Tucker KL, Hannan MT, Chen H, Cupples LA, Wilson PW, Kiel DP (1999) Potassium, magnesium, and fruit and vegetable intakes are associated with greater bone mineral density in elderly men and women. Am J Clin Nutr 69:727–736

    PubMed  CAS  Google Scholar 

  45. 45.

    Macdonald HM, New SA, Golden MH, Campbell MK, Reid DM (2004) Nutritional associations with bone loss during the menopausal transition: evidence of a beneficial effect of calcium, alcohol, and fruit and vegetable nutrients and of a detrimental effect of fatty acids. Am J Clin Nutr 79:155–165

    PubMed  CAS  Google Scholar 

  46. 46.

    New SA, Bolton-Smith C, Grubb DA, Reid DM (1997) Nutritional influences on bone mineral density: a cross-sectional study in premenopausal women. Am J Clin Nutr 65:1831–1839

    PubMed  CAS  Google Scholar 

  47. 47.

    Whiting SJ, Boyle JL, Thompson A, Mirwald RL, Faulkner RA (2002) Dietary protein, phosphorus and potassium are beneficial to bone mineral density in adult men consuming adequate dietary calcium. J Am Coll Nutr 21:402–409

    PubMed  CAS  Google Scholar 

  48. 48.

    Booth SL, Broe KE, Gagnon DR, Tucker KL, Hannan MT, McLean RR, Dawson-Hughes B, Wilson PW, Cupples LA, Kiel DP (2003) Vitamin K intake and bone mineral density in women and men. Am J Clin Nutr 77:512–516

    PubMed  CAS  Google Scholar 

  49. 49.

    Heaney RP (1998) Excess dietary protein may not adversely affect bone. J Nutr 128:1054–1057

    PubMed  CAS  Google Scholar 

  50. 50.

    Heaney RP (1996) Age considerations in nutrient needs for bone health: older adults. J Am Coll Nutr 15:575–578

    PubMed  CAS  Google Scholar 

  51. 51.

    Bonjour JP, Schurch MA, Rizzoli R (1997) Proteins and bone health. Pathol Biol (Paris) 45:57–59

    CAS  Google Scholar 

  52. 52.

    Macdonald HM, New SA, Fraser WD, Campbell MK, Reid DM (2005) Low dietary potassium intakes and high dietary estimates of net endogenous acid production are associated with low bone mineral density in premenopausal women and increased markers of bone resorption in postmenopausal women. Am J Clin Nutr 81:923–933

    PubMed  CAS  Google Scholar 

  53. 53.

    Hannan MT, Tucker KL, Dawson-Hughes B, Cupples LA, Felson DT, Kiel DP (2000) Effect of dietary protein on bone loss in elderly men and women: the Framingham Osteoporosis Study. J Bone Miner Res 15:2504–2512

    PubMed  Article  CAS  Google Scholar 

  54. 54.

    Promislow JH, Goodman-Gruen D, Slymen DJ, Barrett-Connor E (2002) Protein consumption and bone mineral density in the elderly: the Rancho Bernardo Study. Am J Epidemiol 155:636–644

    PubMed  Article  Google Scholar 

  55. 55.

    Rapuri PB, Gallagher JC, Haynatzka V (2003) Protein intake: effects on bone mineral density and the rate of bone loss in elderly women. Am J Clin Nutr 77:1517–1525

    PubMed  CAS  Google Scholar 

  56. 56.

    Dawson-Hughes B, Harris SS (2002) Calcium intake influences the association of protein intake with rates of bone loss in elderly men and women. Am J Clin Nutr 75:773–779

    PubMed  CAS  Google Scholar 

  57. 57.

    Devine A, Dick IM, Islam AF, Dhaliwal SS, Prince RL (2005) Protein consumption is an important predictor of lower limb bone mass in elderly women. Am J Clin Nutr 81:1423–1428

    PubMed  CAS  Google Scholar 

  58. 58.

    Lin PH, Ginty F, Appel LJ, Aickin M, Bohannon A, Garnero P, Barclay D, Svetkey LP (2003) The DASH diet and sodium reduction improve markers of bone turnover and calcium metabolism in adults. J Nutr 133:3130–3136

    PubMed  CAS  Google Scholar 

  59. 59.

    New SA, Robins SP, Campbell MK, Martin JC, Garton MJ, Bolton-Smith C, Grubb DA, Lee SJ, Reid DM (2000) Dietary influences on bone mass and bone metabolism: further evidence of a positive link between fruit and vegetable consumption and bone health? Am J Clin Nutr 71:142–151

    PubMed  CAS  Google Scholar 

  60. 60.

    McGartland CP, Robson PJ, Murray LJ, Cran GW, Savage MJ, Watkins DC, Rooney MM, Boreham CA (2004) Fruit and vegetable consumption and bone mineral density: the Northern Ireland Young Hearts Project. Am J Clin Nutr 80:1019–1023

    PubMed  CAS  Google Scholar 

  61. 61.

    Prynne CJ, Mishra GD, O’Connell MA, Muniz G, Laskey MA, Yan L, Prentice A, Ginty F (2006) Fruit and vegetable intakes and bone mineral status: a cross sectional study in 5 age and sex cohorts. Am J Clin Nutr 83:1420–1428

    PubMed  CAS  Google Scholar 

  62. 62.

    Zalloua PA, Hsu YH, Terwedow H, Zang T, Wu D, Tang G, Li Z, Hong X, Azar ST, Wang B, Bouxsein ML, Brain J, Cummings SR, Rosen CJ, Xu X (2007) Impact of seafood and fruit consumption on bone mineral density. Maturitas 56:1–11

    PubMed  Article  Google Scholar 

  63. 63.

    Kaptoge S, Welch A, McTaggart A, Mulligan A, Dalzell N, Day NE, Bingham S, Khaw KT, Reeve J (2003) Effects of dietary nutrients and food groups on bone loss from the proximal femur in men and women in the 7th and 8th decades of age. Osteoporos Int 14:418–428

    PubMed  Article  CAS  Google Scholar 

  64. 64.

    Buclin T, Cosma M, Appenzeller M, Jacquet AF, Décosterd LA, Biollaz J, Burckhardt P (2001) Diet acids and alkalis influence calcium retention in bone. Osteoporos Int 12:493–499

    PubMed  Article  CAS  Google Scholar 

  65. 65.

    Massey LK (1998) Does excess dietary protein adversely affect bone? Symposium overview. J Nutr 128:1048–1050

    PubMed  CAS  Google Scholar 

  66. 66.

    Remer T, Manz F (1995) Potential renal acid load of foods and its influence on urine pH. J Am Diet Assoc 95:791–797

    PubMed  Article  CAS  Google Scholar 

  67. 67.

    Remer T, Manz F (1994) Estimation of the renal net acid excretion by adults consuming diets containing variable amounts of protein. Am J Clin Nutr 59:1356–1361

    PubMed  CAS  Google Scholar 

  68. 68.

    Martinez ME, Marshall JR, Sechrest L (1998) Factor analysis and the search for objectivity. Am J Epidemiol 148:17–19

    PubMed  Article  CAS  Google Scholar 

Download references


We thank the participants for their enthusiastic support. We are grateful to the members of National Nutrition and Food Technology Research Institute for their kind collaboration. This work was supported by a grant from “National Nutrition and Food Technology Research Institute (WHO Collaborating Center)” of Shahid Behehshti University of Medical Sciences, Iran.

Author information



Corresponding author

Correspondence to Bahram Rashidkhani.

Additional information

The authors have stated that they have no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Karamati, M., Jessri, M., Shariati-Bafghi, SE. et al. Dietary Patterns in Relation to Bone Mineral Density Among Menopausal Iranian Women. Calcif Tissue Int 91, 40–49 (2012).

Download citation


  • Bone mineral density
  • DEXA
  • Diet
  • Dietary patterns
  • Epidemiology
  • Iran
  • Menopause
  • Osteoporosis