Running head: CRITICAL APPRAISAL TOPIC
Title: Critical Appraisal Topic
Marina Rath
University of Mary
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Date: July 25, 2015
Appraised by: Marina Rath, FNP-S
The incidences of osteoporosis and osteoporosis-related fractures vary, with the lowest incidence
being reported in the Mediterranean area of Europe. The beneficial effect is mainly attributed to
a specific eating pattern. The Mediterranean diet consists of a complex array of naturally
occurring bioactive molecules with antioxidant, anti-inflammatory and alkaline properties that
may carry the bone-sparing effect (Perez & Velasco, 2014).
Case Presentation
A 68 year old women presents to your office for an annual exam. She reports that her previous
provider diagnosed her with osteopenia based on the results of DEXA scan. She would like to
know if she should follow any particular dietary recommendations.
Clinical Question in PICO Format
In adult population, does Mediterranean diet compared to no particular diet pattern improves
bone heath including reduction of possible fractures?
Summary and Appraisals of Key Evidence
Article One
Article one’s level of evidence is a level 2b (according to the Centre for Evidence Based
Medicine, Oxford). It was a cohort study of 188,795 adults from eight European countries. The
purpose of the study was to explore the association of adherence to Mediterranean diet and hip
fracture incidents. The participants were followed for 9 year interval (802 overall hip fractures
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were recorded). Participants’ diet was evaluated by a Mediterranean diet score (a 10-point scale).
Increased adherence to Mediterranean diet was associated with a 7 % decrease in hip fracture
incidence. Using increments close to one standard deviation of daily intake, in the overall
sample, high vegetable and high fruit intake was associated with decreased hip fracture
incidence, whereas high meat intake was associated with increased incidence. Excessive ethanol
consumption was also found to be a risk factor.
Strengths of the study were in its prospective design, the relatively long follow-up, and the
employment of validated research instruments. The limitation of the study was in the fact that the
results were dependent on the accuracy of self-reported hip fractures (Benetou et al., 2013).
Article Two
Article's two level of evidence is level 3a (according to the Centre for Evidence Based Medicine,
Oxford). The purpose of this study was to examine the evidence on the effects of Mediterranean
diet on bone health. In their systematic review, Perez and Velasco (2014) examined a number of
cohort studies from PubMed and other databases.
The authors noted that there is a limited number of studies available where the relationship
between Mediterranean Diet and bone health has been examined. These studies do report
conflicting results. On the one hand, adherence to a traditional Mediterranean diet has been
associated with higher bone mineral density and lower fracture risk. On the contrary, several
studies failed to show any association between adherence to the Mediterranean diet and indices
of bone mass.
The limitation of the study: it does not indicate the designs of the studies that were examined for
their evidence. We do not know if they were randomized controlled studies, cohort studies, or
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case-control studies. The strength of the study: it tried to fill the gap regarding the
limited knowledge on the association between Mediterranean diet and bone health (by
summarizing the studied evidence).
Clinical Bottom Line:
The Mediterranean diet is characterized by a high intake of olive oil, plant products, fish and
seafood; a low intake of dairy, meat and meat products; and a moderate alcohol intake (Naska &
Trichopoulou, 2013). The adherence to Mediterranean diet appears to protect against bone
fracture occurrence, although more large-scale studies are needed in order to clarify the effect of
this diet on bone health (Benetou et al., 2013; Perez & Velasco, 2014). This knowledge can
be beneficial to health care providers working with general adult and geriatric population as well
as population at risk for osteoporosis and/or at risk for bone fractures.
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References
Benetou, V., Orfanos, P., Pettersson-Kymmer, U., Bergström, U., Svensson, O., Johansson, I., &
... Trichopoulou, A. (2013). Mediterranean diet and incidence of hip fractures in a
European cohort. Osteoporosis International, 24(5), 1587-1598. doi:10.1007/s00198012-2187-3
Naska, A., & Trichopoulou, A. (2014). Back to the future: the Mediterranean diet
paradigm. Nutrition, Metabolism & Cardiovascular Diseases, 24(3), 216-219.
doi:10.1016/j.numecd.2013.11.007
Pérez, A., & Velasco, A. (2014). Adherence to Mediterranean diet and bone health. Nutricion
Hospitalaria, 29(5), 989-996. doi:10.3305/nh.2014.29.5.7332