• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

One meta-analysis (a systematic review of 19 studies), five RCTs and two cross-sectional studies found an association between supplemental vitamin D and bone mineral density (BMD) in post-menopausal women and older adult men. Vitamin D dosage ranged from 400 IU to 1,400 IU (10mcg to 35 mcg) per day, however it is difficult to determine the optimal dosage and the effect of vitamin D alone, since varying combinations of nutrients were used including calcium and vitamin K. One additional RCT with a supplement containing 200 IU (five mcg) of Vitamin D and other nutrients found an improvement in bone turnover markers, but no effect in bone mineral density. Further research is needed to determine the independent association between supplemental vitamin D and bone mineral density in post-menopausal women and older adult men.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

One meta-analysis/systematic review, combining the results of 13 RCTs suggest that supplementation with vitamin D₃ (400 IU to 800 IU) plus calcium (500mg to 1,200mg) may be beneficial in reducing the incidence of fractures in institutionalized older adults. The reduction of fractures might be accounted for by higher mean serum levels of 25(OH)D (at least 74nmol per L), due to good volunteer compliance. One RCT concluded that supplementation with 100,000 IU vitamin D₂ every four months, does not significantly reduce fractures in institutionalized older adults. Further research is needed to determine the role of vitamin D₃ and vitamin D₂ supplementation alone in reducing the incidence of fractures.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

Research indicates that a low intake of calcium may be associated with increased adiposity.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

Several studies report that total daily intakes of calcium below recommended levels (1,000 mg per day for adults ages 19-50 years and 1,200 mg per day for adults over age 51) are associated with increased body weight, body fat, BMI, waist circumference and relative risk of obesity in white and black adults. However, it is unclear if this is a result of a poor overall diet.

In one cohort study, no association between these variables and recommended levels of calcium intake was found. Several randomized controlled trials based on levels of total daily calcium above recommended levels have shown conflicting results. Four trials have shown a loss of body weight and body fat (especially from the trunk region of the body) both in the absence of energy restriction and with modest energy restriction (-500 kcal per day), while two trials report no significant differences in weight loss or maintenance.

Further studies establishing a causal relationship between total daily calcium intake, calcium supplementation or dairy intake and weight management are needed.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

For newly diagnosed children and adults with celiac disease, studies report that compliance with a gluten-free dietary pattern results in significant improvements in nutritional laboratory values, such as serum hemoglobin, iron, zinc and calcium, as a result of intestinal healing and improved absorption.   However, adherence to the gluten-free dietary pattern may result in a diet that is high in fat and low in carbohydrates and fiber, as well as low in iron, folate, niacin, vitamin B-12, calcium, phosphorus and zinc.  A small number of studies in adults show a trend toward weight gain after diagnosis; further research is needed in this area.  

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

Based on ten studies, two of which were conducted in the US, only the following micronutrients had lower intake among vegetarians than non-vegetarians:

• B-12
• Vitamin C
• Calcium
• Zinc

Vegetarians did not meet dietary standard (in at least one country) for:

• B-12 (in UK)
• Iron (in US, for both vegetarians and omnivores)
• Folate (in Germany, though lower rate of deficiency than among omnivores)
• Zinc (in UK)

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

Six studies (five non-US, one with combined US and non-US samples; all but one of positive quality) were identified that examined the bioavailability of different micronutrients in vegetarian versus non-vegetarian pregnant women. Of the micronutrients examined in the research, only serum B₁₂ levels were significantly lower in non-vegan vegetarians than non-vegetarians. Additionally, one study reported that lower B₁₂ levels are more likely to be associated with high serum tHCY in ovolactovegetarians than low meat eaters or omnivores.

While zinc levels were not significantly different between non-vegan vegetarians and non-vegetarians, vegetarians who have a high intake of calcium may be at risk for zinc deficiency (because of the interaction between phytate, calcium and zinc).

Based on limited evidence, plasma folate levels may actually be higher among some vegetarian groups than non-vegetarians.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

Seven studies were reviewed to evaluate dietary treatment of diarrhea/malabsorption in people with HIV infection. Many of these studies did not provide information on medications.  Two studies regarding fat malabsorption reported that consumption of medium chain triglycerides resulted in fewer stools, decreased stool fat and weight and increased fat absorption. Two studies regarding vitamin A and beta-carotene supplementation reported decreased gut permeability and risk of severe watery diarrhea. Further research regarding amino acid-based elemental diets, probiotics, pancreatic enzyme therapy, calcium carbonate, glutamine and the BRAT diet in people with HIV/AIDS is warranted, as well as the effect of medications.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

Clinical trials and cross-sectional studies have reported reduced bone mineral content and bone mineral density in untreated children, adolescents and adults with celiac disease; both of these parameters improve significantly with compliance to a gluten-free dietary pattern for at least 1 year.  Compliance with dietary treatment initiated during childhood or adolescence allows achievement of a normal bone mineralization.  However, studies in untreated adults have shown that a gluten-free dietary pattern improves but may not normalize bone mineral density; successful treatment depends on the age at diagnosis, as patients who do not receive treatment in childhood and adolescence may never reach peak bone mass.  Further studies are needed regarding the effects of calcium and vitamin D supplementation on bone mineral content and bone mineral density, as well as hormone replacement therapy for postmenopausal women. 

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

Current available evidence shows no significant effects or relationships between any of the following dietary factors and breast milk production in healthy adult lactating women (mean±SD BMI ranged from 21.4±0.9 to 25.2±4.2): short periods (less than 10 weeks) of reduced calorie intake (25% to 35% energy deficit), increased or decreased fluid intake (±25% to 50%), increased protein intake (1.5grams per kg per day), three types of nutrition supplement (i.e., Coleus amboinicus soup, fenugreek seeds capsules; sugar-coated Moloco+B₁₂ tablets) and calcium intake.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

• Detail
• Quality Rating Summary
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• Worksheets
  • Barbosa L, Butte NF, Villalpando S, Wong WW, Smith EO. Maternal energy balance and lactation performance of Mesoamerindians as a function of body mass index.  Am J Clin Nutr. 1997; 66: 575-583. 
  •  Damanik R, Wahlqvist M, Wattanapenpaiboon N. Lactagogue Effects of Torbangun, a Bataknese Traditional Cuisine. Asia Pacific Journal of Clinical Nutrition. 2006; 15(2): 267-274.
  • Dusdieker LB, Hemingway DL, Stumbo PJ.  Is milk production impaired by dieting during lactation?  AJCN. 1994; 59: 833-840.
  • Dusdieker LB, Stumbo PJ, Booth BM, Wilmoth RN. Prolonged Maternal Fluid Supplementation in Breast-Feeding. Pediatrics.1990; 86: 737-740.
  • Laskey MA, Prentice A, Hanratty LA, Jarjou LM, Dibba B, Beavan SR, Cole TJ.  Bone changes after 3 mo of lactation: influence of calcium intake, breast-milk output, and vitamin-D receptor genotype.  Am J Clin Nutr. 1998; 67: 685-692. 
  • McCrory MA, Nommsen-Rivers LA, Mole PA, Lonnerdal B, Dewey KG.  Randomized trial of the short-term effects of dieting compared with dieting plus aerobic exercise on lactation performance. American Journal of Clinical Nutrition 1999; 69: 959-967. 
  • Morse JM, Ewing G, Gamble D, Donahue P.  The effect of maternal fluid intake on breast milk supply:  a pilot study.  Canadian Journal of Public Health. 1992 May-Jun; 83(3): 213-216. 
  • Motil KJ, Montandon CM, Hachey DL, Boutton TW, Klein PD, Garza C.  Relationships among lactation performance, maternal diet, and body protein metabolism in humans. Eur J Clin Nutr. 1989; 43: 681-691. 
  • Motil KJ, Thotathuchery M, Bahar A, Montandon CM.  Marginal dietary protein restriction reduced nonprotein nitrogen, but not protein nitrogen, components of human milk. J Am Coll Nutr. 1995; 14 (2): 184-191. 
  • Okamura T, Takeuchi T, Nishi O, Yaginuma T, Kawana T.  Effects of low-caloric diet in puerperium on prolactin, TSH, estradiol and milk secretion.  Acta Obst Gynaec Jpn. 1987; 39(11): 2059-2055. 
  • Strode MA, Dewey KG, Lonnerdal B. Effects of short-term caloric restriction on lactational performance of well-nourished women. Acta Paediatr Scand. 1986; 75: 222-229.

The findings from ten studies do not support a strong relationship between increasing calcium intake and lowered blood pressure in healthy and hypertensive adults.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.