There is substantial evidence that insufficient dietary protein intake is deleterious for bone health, but there is a strong debate as to whether an excess of dietary protein may be associated with osteoporosis. It has long been known that increasing dietary protein increases urinary calcium excretion. Until recently, the prevailing view was that bone was the source of the extra urinary calcium excreted during a high-protein diet. Several reviews have summarized the complex literature on the potential impact on bone of dietary protein. One mechanism by which high dietary protein could induce bone loss may be related to the acid load generated by the protein metabolism. While renal metabolism represents the principal mechanism by which fixed metabolic acid loads are handled by the body, renal buffering may be incomplete, particularly with aging. Under those circumstances, the skeleton may be calledon to act as a buffer to neutralize acid generated from high-protein diets. Liberation of buffer from bone comes at the expense of mineral dissolution and ultimately bone loss. Even mild acidosis could have profound effects: if bone is mobilized to buffer only 1 mEq of acid each day, 15% of the total body calcium in an average person would be lost in a decade. This theory has recently been challenged, in particular following a series of short-term experimental studies that suggested that dietary protein might influence calcium intestinal absorption, and that most of the extra urinary calcium excreted during a high-protein diet originate from the intestine rather than from bone.7 However, the relative contribution of diet and bone to protein-induced calciuria remains controversial, and the long-term impact of high protein diets on bone health is still unclear.
Results of observational epidemiological studies have not helped to clarify the nature of the effect of high dietary protein intakes on the skeleton. Numerous studies showed a positive association with bone mass,10-14 but others showed no association,15, 16 while others still showed a negative association with at least one bone site.17-19 Fewer studies have evaluated the effect of protein intake on fracture risk. Two of them found a decreased risk of fracture with higher protein intake,20, 21 while three others showed an opposite trend, in particular with proteins from animal sources.