Impact of Dietary Patterns on Skeletal Health: A Systematic Review and Meta-Analysis of Bone Mineral Density, Fracture, Bone Turnover Markers, and Nutritional Status

Mullath Ullas, A, Boamah, J, Hussain, A, Myrtziou, I and Kanakis, I (2025) Impact of Dietary Patterns on Skeletal Health: A Systematic Review and Meta-Analysis of Bone Mineral Density, Fracture, Bone Turnover Markers, and Nutritional Status. Nutrients, 17 (24). ISSN 2072-6643

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Abstract

Background/Objectives: Dietary patterns play a crucial role in musculoskeletal health; however, the effects of different diets on bone mineral density (BMD), fracture risk, and bone metabolism remain inconsistent across studies. This systematic review and meta-analysis aimed to evaluate the impact of Mediterranean, calorie restriction, high-protein, low-carbohydrate, and ketogenic diets on skeletal outcomes in adults. Methods: A comprehensive search of PubMed/MEDLINE, CENTRAL, and Web of Science was conducted for studies published between January 2000 and June 2025. Eligible randomised controlled trials (RCTs) and cohort studies involving adults (≥18 years) and reporting outcomes related to BMD, fractures, bone turnover markers, and vitamin D or calcium status were included. Risk of bias was assessed using the Cochrane’s Risk of Bias tool for RCTs and the Joanna Briggs Institute checklist for observational studies. Random-effects meta-analyses were performed for outcomes reported by ≥3 comparable studies, presenting standardised mean differences (SMDs) for BMD and hazard ratios (HRs) for fractures. Results: Thirty studies met inclusion criteria, comprising 14 RCTs and 16 observational studies with over 500,000 participants. Pooled analyses showed no significant differences in BMD at the femoral neck (SMD = 0.12, 95% CI −0.80 to 1.04), lumbar spine (SMD = 0.04, 95% CI: −1.12 to 1.03), total hip (SMD = −0.07, 95% CI −0.36 to 0.21), or whole body (SMD = 0.03, 95% CI −0.07 to 0.14) across diet categories. However, adherence to a Mediterranean diet was associated with a significantly reduced hazard of hip and overall fractures (pooled HR = 0.95, 95% CI 0.93–0.96). Calorie restriction consistently increased bone resorption markers, whereas Mediterranean and high-protein diets showed neutral or modestly favourable effects. Vitamin D and calcium status were minimally affected across interventions. Conclusions: While dietary patterns exert diverse effects on skeletal health, consistent evidence supports Mediterranean-style diets as protective against fractures. Calorie restriction may elevate bone turnover, whereas ketogenic and high-protein diets show mixed effects on bone. However, across all analyses, high heterogeneity was observed. Further high-quality RCTs are warranted to clarify these relationships and inform dietary guidance for bone health.

Item Type:	Article
Uncontrolled Keywords:	Mediterranean diet; calorie restriction diet; high-protein diet; low-carbohydrate/ketogenic diet; bone mineral density; fracture; bone health; Humans; Vitamin D; Caloric Restriction; Diet; Bone Remodeling; Diet, Mediterranean; Nutritional Status; Bone Density; Adult; Middle Aged; Female; Male; Fractures, Bone; Randomized Controlled Trials as Topic; Biomarkers; Diet, Ketogenic; Mediterranean diet; bone health; bone mineral density; calorie restriction diet; fracture; high-protein diet; low-carbohydrate/ketogenic diet; Humans; Bone Density; Fractures, Bone; Nutritional Status; Biomarkers; Bone Remodeling; Diet; Diet, Mediterranean; Adult; Female; Vitamin D; Male; Diet, Ketogenic; Middle Aged; Caloric Restriction; Randomized Controlled Trials as Topic; 32 Biomedical and Clinical Sciences; 3202 Clinical Sciences; 42 Health Sciences; Nutrition; Osteoporosis; Dietary Supplements; Prevention; Complementary and Integrative Health; 3.3 Nutrition and chemoprevention; Musculoskeletal; 3 Good Health and Well Being; Humans; Bone Density; Fractures, Bone; Nutritional Status; Biomarkers; Bone Remodeling; Diet; Diet, Mediterranean; Adult; Female; Vitamin D; Male; Diet, Ketogenic; Middle Aged; Caloric Restriction; Randomized Controlled Trials as Topic; 0908 Food Sciences; 1111 Nutrition and Dietetics; 3202 Clinical sciences; 3210 Nutrition and dietetics; 4206 Public health
Subjects:	T Technology > TX Home economics > TX341 Nutrition. Foods and food supply R Medicine > RC Internal medicine
Divisions:	Pharmacy and Biomolecular Sciences
Publisher:	MDPI AG
Date of acceptance:	4 December 2025
Date of first compliant Open Access:	9 October 2026
Date Deposited:	09 Oct 2026 14:25
Last Modified:	09 Oct 2026 14:25
DOI or ID number:	10.3390/nu17243845
URI:	https://researchonline.ljmu.ac.uk/id/eprint/29641

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