What are the nutritional recommendations (calorie intake, protein, calcium, vitamin D, and other micronutrients) for an adult patient with a fracture, including adjustments for older age or chronic kidney disease?

Dietary Management in Fracture Cases

Focus on adequate overall nutrition with calcium-rich foods and vitamin D supplementation based on individual risk-benefit assessment, while avoiding routine high-dose protein or calcium/vitamin D supplementation for fracture prevention, as evidence shows these are generally ineffective at preventing future fractures. 1

Core Nutritional Recommendations

Calcium and Vitamin D Strategy

• Emphasize dietary calcium intake through calcium-rich foods rather than relying solely on supplements, as the evidence for supplementation preventing fractures is weak. 1
• Target 1000-1200 mg/day of calcium through diet and supplements combined. 2
• Provide 800 IU/day of vitamin D supplementation, which when combined with calcium reduces non-vertebral fractures by 15-20% and falls by 20%. 2
• Avoid high pulse-dose vitamin D (single loading doses), as one RCT showed a dramatic reduction in falls with loading dose vitamin D3 within 7 days post-hip fracture (falls rate 250 vs 821.4 per 1000 patient-days), but this approach requires careful consideration of individual risk-benefit profile. 1, 2

Critical caveat: Standard vitamin D (800 IU) and calcium (1000 mg) supplementation in older people with osteoporotic fracture history appears generally ineffective at preventing future hip or new fractures. 1

Protein Intake

• Insufficient evidence exists to recommend routine oral protein supplementation for functional outcomes following hip fracture. 1
• However, observational data suggests higher dietary protein intake is associated with lower hip fracture risk when calcium supply is sufficient. 3
• Ensure adequate protein through whole foods, particularly dairy products which provide both protein and calcium. 3

Micronutrients Beyond Calcium and Vitamin D

• Encourage consumption of at least 5 servings per day of fruits and vegetables, as lower intake is associated with higher hip fracture risk. 3
• Consider vegetable-derived nutrients including nitrate and vitamin K1 for muscle strength, physical function, and bone quality. 4
• Ensure adequate intake of vitamins A and D and other micronutrients essential for bone health and fracture healing. 5

Comprehensive Nutritional Approach

Multicomponent Interventions

Implement multicomponent nutritional interventions including adequate nutrition, fall prevention, and education as part of fracture management, particularly for high-risk patients. 1

Dietary Patterns

• Promote adherence to Mediterranean diet or prudent dietary patterns, which are associated with lower fracture risk. 3
• Emphasize dairy products, particularly fermented dairy, as hip fracture risk appears lower in consumers of these products. 3
• Ensure balanced diet with optimal protein, calcium, minerals, fruits and vegetables for bone health and fracture prevention. 3

Post-Operative Nutritional Considerations

• Meet post-operative resting energy expenditure (REE) needs, as adequate energy intake reduces post-operative complications and length of stay. 6
• Consider multinutrient feeds in hip fracture aftercare, as they reduce the incidence of unfavorable outcomes including mortality and complications combined. 7

Lifestyle Modifications

Alcohol and Smoking

• Limit alcohol intake to less than 2 units/day (≤50 g/day), as higher intakes increase fracture risk through direct bone effects and increased fall risk. 1
• Mandate smoking cessation, as tobacco adversely affects bone mass and consistently increases osteoporotic fracture risk. 1, 2

Special Population Considerations

Older Adults (≥50 years)

• Focus discussion on actual versus recommended calcium and vitamin D intake levels rather than automatic supplementation. 1
• Ensure adequate nutrition to support functional recovery, as malnutrition is common in this population. 6
• Maintain healthy weight and increase fresh fruit/vegetable consumption while lowering sodium intake. 1

Chronic Kidney Disease

While the provided evidence does not specifically address CKD adjustments, general principles suggest:

• Exercise caution with calcium supplementation to avoid vascular calcification
• Adjust vitamin D formulation and dosing based on CKD stage
• Monitor phosphorus intake carefully
• Coordinate with nephrology for specific mineral metabolism management

Plant-Based Diets

• Recognize that vegan/plant-based diets without careful planning may have long-term negative musculoskeletal consequences. 4
• Ensure adequate calcium, vitamin D, protein, and vitamin B12 supplementation in those following plant-based diets. 4

Critical Pitfalls to Avoid

• Do not rely on calcium supplementation alone without vitamin D and consideration of bisphosphonates, as calcium alone has no demonstrated fracture reduction effect. 2
• Do not assume protein supplementation will improve functional outcomes post-fracture, as evidence is insufficient. 1
• Do not prescribe routine high-dose calcium/vitamin D supplementation expecting fracture prevention in those with prior osteoporotic fracture, as evidence shows this is generally ineffective. 1
• Do not overlook the importance of overall dietary pattern by focusing solely on individual nutrients. 3

Integration with Comprehensive Care

Coordinate nutritional management within multidisciplinary fracture liaison services, which reduce re-fracture rates by approximately 30% compared to usual care. 1