Effects of Vitamin D3 Fortified Low-fat Dairy Products on Bone Density Measures in Adults with Abdominal Obesity: A Randomized Clinical Trial

Document Type : RESEARCH PAPER


1 1.International UNESCO center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran 2 Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran 3 Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

2 International UNESCO center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran

3 Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

4 Student Research Committee, Islamic azad University, Mashhad Branch, Mashhad, Iran

5 International UNESCO center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran- Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

6 International UNESCO center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran - Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

7 Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

8 Department of Nutrition Sciences, Varastegan Institute for Medical Sciences, Mashhad, Iran

9 Department of Biochemistry, School of Medicine, Shahid Sadoughi University of Medical sciences and health Services, Yazd, Iran

10 Division of Medical Education, Brighton & Sussex Medical School, Falmer, Brighton, Sussex, UK


Background: Bone disease-related fractures constitute a heavy burden on the healthcare systems and economy.
Vitamin D is an important regulator of bone health and its deficiency is a global problem. This study aimed to evaluate
the effect of the 1,500 IU nano-encapsulated vitamin D used for fortifying low-fat dairy products (milk and yogurt) on
bone health parameters.
Methods: This parallel totally blinded, randomized controlled trial was part of the Ultraviolet Intake by Nutritional
Approach study and conducted on 306 individuals with abdominal obesity. Individuals were randomly assigned to
four groups, including fortified low-fat milk (1,500 IU nano-encapsulated vitamin D3 per 200 g/d), non-fortified low-fat
milk, fortified low-fat yogurt (1,500 IU nano-encapsulated vitamin D3 per 150 g/d), and non-fortified low-fat yogurt,
for 10 weeks between January and March 2019. Bone mineral density (BMD) and trabecular bone score (TBS) were
measured at the baseline and end of the trial. Trabecular bone score and BMD were defined as primary and secondary
Results: There were no significant differences in TBS and BMD between the intervention and control groups at the
end of the trial (P>0.05).
Conclusion: This trial demonstrated no significant effect of nano-encapsulated vitamin D fortified milk and yogurt on
BMD and TBS. There remains a need for longer-term trials regarding bone health outcomes to establish optimal doses
of fortification.
Level of evidence: I


  1. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006;17(12):1726-33.
  2. Nowson CA. Prevention of fractures in older people with calcium and vitamin D. Nutrients. 2010;2(9):975-84.
  3. Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis International. 2014;25(10):2359-81.
  4. Cauley JA, Chalhoub D, Kassem AM, Fuleihan Gel H. Geographic and ethnic disparities in osteoporotic fractures. Nat Rev Endocrinol. 2014;10(6):338-51.
  5. Hernlund E, Svedbom A, Ivergård M, Compston J, Cooper C, Stenmark J, et al. Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos. 2013;8(1-2):136.
  6. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007;22(3):465-75.
  7. Polzonetti V, Pucciarelli S, Vincenzetti S, Polidori P. Dietary Intake of Vitamin D from Dairy Products Reduces the Risk of Osteoporosis. Nutrients. 2020;12(6):1743.
  8. Laird E, Ward M, McSorley E, Strain JJ, Wallace J. Vitamin D and bone health: potential mechanisms. Nutrients. 2010;2(7):693-724.
  9. Bischoff-Ferrari HA, Bhasin S, Manson JE. Preventing Fractures and Falls: A Limited Role for Calcium and Vitamin D Supplements? Jama. 2018;319(15):1552-3.
  10. Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357(3):266-81.
  11. Cranney A, Horsley T, O’Donnell S, Weiler H, Puil L, Ooi D, et al. Effectiveness and safety of vitamin D in relation to bone health. Evid Rep Technol Assess (Full Rep). 2007(158):1-235.
  12. Lips P, Bouillon R, van Schoor NM, Vanderschueren D, Verschueren S, Kuchuk N, et al. Reducing fracture risk with calcium and vitamin D. Clin Endocrinol (Oxf). 2010;73(3):277-85.
  13. Harvey N, Glüer C, Binkley N, McCloskey E, Brandi M-L, Cooper C, et al. Trabecular bone score (TBS) as a new complementary approach for osteoporosis evaluation in clinical practice. Bone. 2015;78:216-24.
  14. Roth DE, Abrams SA, Aloia J, Bergeron G, Bourassa MW, Brown KH, et al. Global prevalence and disease burden of vitamin D deficiency: a roadmap for action in low- and middle-income countries. Ann N Y Acad Sci. 2018;1430(1):44-79.
  15. Girgis CM. Vitamin D and Skeletal Muscle: Emerging Roles in Development, Anabolism and Repair. Calcif Tissue Int. 2020;106(1):47-57.
  16. Wacker M, Holick MF. Vitamin D - effects on skeletal and extraskeletal health and the need for supplementation. Nutrients. 2013;5(1):111-48.
  17. Cesari M, Incalzi RA, Zamboni V, Pahor M. Vitamin D hormone: a multitude of actions potentially influencing the physical function decline in older persons. Geriatr Gerontol Int. 2011;11(2):133-42.
  18. Dary O, Hurrell R. Guidelines on food fortification with micronutrients. World Health Organization, Food and Agricultural Organization of the United Nations: Geneva, Switzerland. 2006:1-376.
  19. Pilz S, März W, Cashman KD, Kiely ME, Whiting SJ, Holick MF, et al. Rationale and Plan for Vitamin D Food Fortification: A Review and Guidance Paper. Front Endocrinol (Lausanne). 2018;9:373-.
  20. Al Khalifah R, Alsheikh R, Alnasser Y, Alsheikh R, Alhelali N, Naji A, et al. The impact of vitamin D food fortification and health outcomes in children: a systematic review and meta-regression. Systematic Reviews. 2020;9(1):144.
  21. Maurya VK, Bashir K, Aggarwal M. Vitamin D microencapsulation and fortification: Trends and technologies. The Journal of Steroid Biochemistry and Molecular Biology. 2020;196:105489.
  22. Walia N, Dasgupta N, Ranjan S, Chen L, Ramalingam C. Fish oil based vitamin D nanoencapsulation by ultrasonication and bioaccessibility analysis in simulated gastro-intestinal tract. Ultrasonics Sonochemistry. 2017;39:623-35.
  23. Ezhilarasi PN, Karthik P, Chhanwal N, Anandharamakrishnan C. Nanoencapsulation Techniques for Food Bioactive Components: A Review. Food and Bioprocess Technology. 2013;6(3):628-47.
  24. Park SJ, Garcia CV, Shin GH, Kim JT. Development of nanostructured lipid carriers for the encapsulation and controlled release of vitamin D3. Food Chem. 2017;225:213-9.
  25. McClements DJ, Öztürk B. Utilization of Nanotechnology to Improve the Handling, Storage and Biocompatibility of Bioactive Lipids in Food Applications. Foods. 2021;10(2):365.
  26. Jafari SM. An overview of nanoencapsulation techniques and their classification. Nanoencapsulation technologies for the food and nutraceutical industries. 2017:1-34.
  27. Vatandost S, Jahani M, Afshari A, Amiri MR, Heidarimoghadam R, Mohammadi Y. Prevalence of vitamin D deficiency in Iran: A systematic review and meta-analysis. Nutr Health. 2018;24(4):269-78.
  28. Cannell J, Hollis B, Zasloff M, Heaney R. Diagnosis and treatment of vitamin D deficiency. Expert opinion on pharmacotherapy. 2008;9(1):107-18.
  29. Sharifan P, Bagherniya M, Bajgiran MM, Safarian M, Vatanparast H, Eslami S, et al. The efficacy of dairy products fortified with nano-encapsulated vitamin D3 on physical and mental aspects of the health in obese subjects; the protocol of the SUVINA trial. Translational Metabolic Syndrome Research. 2021;4:1-9.
  30. Alberti KG, Zimmet P, Shaw J. Metabolic syndrome--a new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med. 2006;23(5):469-80.
  31. Sharifan P, Ziaee A, Darroudi S, Rezaie M, Safarian M, Eslami S, et al. Effect of low-fat dairy products fortified with 1500IU nano encapsulated vitamin D3 on cardiometabolic indicators in adults with abdominal obesity: a total blinded randomized controlled trial. Current Medical Research and Opinion. 2021;37(4):579-88.
  32. Pramyothin P, Holick MF. Vitamin D supplementation: guidelines and evidence for subclinical deficiency. Curr Opin Gastroenterol. 2012;28(2):139-50.
  33. Amiri Z, Nosrati M, Sharifan P, Saffar Soflaei S, Darroudi S, Ghazizadeh H, et al. Factors determining the serum 25-hydroxyvitamin D response to vitamin D supplementation: Data mining approach. BioFactors. 2021.
  34. McClung MR. Do current management strategies and guidelines adequately address fracture risk? Bone. 2006;38(2 Suppl 2):S13-7.
  35. Silva BC, Leslie WD. Trabecular Bone Score: A New DXA-Derived Measurement for Fracture Risk Assessment. Endocrinol Metab Clin North Am. 2017;46(1):153-80.
  36. Loewen A, Chan B, Li-Chan ECY. Optimization of vitamins A and D(3) loading in re-assembled casein micelles and effect of loading on stability of vitamin D(3) during storage. Food Chem. 2018;240:472-81.
  37. Maurya VK, Aggarwal M. Fabrication of nano-structured lipid carrier for encapsulation of vitamin D(3) for fortification of ‘Lassi’; A milk based beverage. J Steroid Biochem Mol Biol. 2019;193:105429.
  38. Syama MA, Arora S, Gupta C, Sharma A, Sharma V. Enhancement of vitamin D2 stability in fortified milk during light exposure and commercial heat treatments by complexation with milk proteins. Food Bioscience. 2019;29:17-23.
  39. Zhou H, Liu J, Dai T, Muriel Mundo JL, Tan Y, Bai L, et al. The gastrointestinal fate of inorganic and organic nanoparticles in vitamin D-fortified plant-based milks. Food Hydrocolloids. 2021;112:106310.
  40. Ferrar L, van der Hee RM, Berry M, Watson C, Miret S, Wilkinson J, et al. Effects of calcium-fortified ice cream on markers of bone health. Osteoporos Int. 2011;22(10):2721-31.
  41. Neyestani TR, Hajifaraji M, Omidvar N, Nikooyeh B, Eshraghian MR, Shariatzadeh N, et al. Calcium-vitamin D-fortified milk is as effective on circulating bone biomarkers as fortified juice and supplement but has less acceptance: a randomised controlled school-based trial. J Hum Nutr Diet. 2014;27(6):606-16.
  42. Bonjour JP, Benoit V, Pourchaire O, Ferry M, Rousseau B, Souberbielle JC. Inhibition of markers of bone resorption by consumption of vitamin D and calcium-fortified soft plain cheese by institutionalised elderly women. Br J Nutr. 2009;102(7):962-6.
  43. Jafari T, Faghihimani E, Feizi A, Iraj B, Javanmard SH, Esmaillzadeh A, et al. Effects of vitamin D-fortified low fat yogurt on glycemic status, anthropometric indexes, inflammation, and bone turnover in diabetic postmenopausal women: A randomised controlled clinical trial. Clin Nutr. 2016;35(1):67-76.
  44. Lerchbaum E, Trummer C, Theiler-Schwetz V, Kollmann M, Wölfler M, Pilz S, et al. Effects of Vitamin D Supplementation on Bone Turnover and Bone Mineral Density in Healthy Men: A Post-Hoc Analysis of a Randomized Controlled Trial. Nutrients. 2019;11(4):731.
  45. Grønborg IM, Tetens I, Andersen EW, Kristensen M, Larsen REK, Tran TLL, et al. Effect of vitamin D fortified foods on bone markers and muscle strength in women of Pakistani and Danish origin living in Denmark: a randomised controlled trial. Nutr J. 2019;18(1):82-.
  46. Al-Khalidi B, Chiu W, Rousseau D, Vieth R. Bioavailability and Safety of Vitamin D3 from Pizza Baked with Fortified Mozzarella Cheese: A Randomized Controlled Trial. Can J Diet Pract Res. 2015;76(3):109-16.
  47. Dagli M, Kutlucan A, Abusoglu S, Basturk A, Sozen M, Kutlucan L, et al. Evaluation of bone mineral density (BMD) and indicators of bone turnover in patients with hemophilia. Bosn J Basic Med Sci. 2018;18(2):206-10.
  48. Daly RM, Brown M, Bass S, Kukuljan S, Nowson C. Calcium- and vitamin D3-fortified milk reduces bone loss at clinically relevant skeletal sites in older men: a 2-year randomized controlled trial. J Bone Miner Res. 2006;21(3):397-405.
  49. Liu C, Kuang X, Li K, Guo X, Deng Q, Li D. Effects of combined calcium and vitamin D supplementation on osteoporosis in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials. Food Funct. 2020;11(12):10817-27.
  50. Reyes-Garcia R, Mendoza N, Palacios S, Salas N, Quesada-Charneco M, Garcia-Martin A, et al. Effects of Daily Intake of Calcium and Vitamin D-Enriched Milk in Healthy Postmenopausal Women: A Randomized, Controlled, Double-Blind Nutritional Study. J Womens Health (Larchmt). 2018;27(5):561-8.
  51. Moschonis G, Manios Y. Skeletal site-dependent response of bone mineral density and quantitative ultrasound parameters following a 12-month dietary intervention using dairy products fortified with calcium and vitamin D: the Postmenopausal Health Study. Br J Nutr. 2006;96(6):1140-8.
  52. Mocanu V, Stitt PA, Costan AR, Voroniuc O, Zbranca E, Luca V, et al. Long-term effects of giving nursing home residents bread fortified with 125 microg (5000 IU) vitamin D(3) per daily serving. Am J Clin Nutr. 2009;89(4):1132-7.
  53. Manios Y, Moschonis G, Panagiotakos DB, Farajian P, Trovas G, Lyritis GP. Changes in biochemical indices of bone metabolism in post-menopausal women following a dietary intervention with fortified dairy products. J Hum Nutr Diet. 2009;22(2):156-65.
  54. Morato-Martínez M, López-Plaza B, Santurino C, Palma-Milla S, Gómez-Candela C. A Dairy Product to Reconstitute Enriched with Bioactive Nutrients Stops Bone Loss in High-Risk Menopausal Women without Pharmacological Treatment. Nutrients. 2020;12(8):2203.
  55. Aspray TJ, Chadwick T, Francis RM, McColl E, Stamp E, Prentice A, et al. Randomized controlled trial of vitamin D supplementation in older people to optimize bone health. Am J Clin Nutr. 2019;109(1):207-17.
  56. Hosseinpanah F, Rambod M, Hossein-nejad A, Larijani B, Azizi F. Association between vitamin D and bone mineral density in Iranian postmenopausal women. J Bone Miner Metab. 2008;26(1):86-92.
  57. Aloia JF, Talwar SA, Pollack S, Yeh J. A randomized controlled trial of vitamin D3 supplementation in African American women. Arch Intern Med. 2005;165(14):1618-23.
  58. Bischoff-Ferrari HA, Vellas B, Rizzoli R, Kressig RW, da Silva JAP, Blauth M, et al. Effect of Vitamin D Supplementation, Omega-3 Fatty Acid Supplementation, or a Strength-Training Exercise Program on Clinical Outcomes in Older Adults: The DO-HEALTH Randomized Clinical Trial. Jama. 2020;324(18):1855-68.
  59. Reid IR, Bolland MJ, Grey A. Effects of vitamin D supplements on bone mineral density: a systematic review and meta-analysis. Lancet. 2014;383(9912):146-55.
  60. Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. Lancet Diabetes Endocrinol. 2018;6(11):847-58.
  61. Winzenberg TM, Powell S, Shaw KA, Jones G. Vitamin D supplementation for improving bone mineral density in children. Cochrane Database Syst Rev. 2010(10):Cd006944.
  62. Mason RS, Rybchyn MS, Brennan-Speranza TC, Fraser DR. Is it reasonable to ignore vitamin D status for musculoskeletal health? Fac Rev. 2020;9:19-.
  63. Avenell A, Mak JC, O’Connell D. Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane Database Syst Rev. 2014;2014(4):Cd000227.
  64. Yao P, Bennett D, Mafham M, Lin X, Chen Z, Armitage J, et al. Vitamin D and Calcium for the Prevention of Fracture: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(12):e1917789.
  65. Bischoff-Ferrari HA, Willett WC, Wong JB, Stuck AE, Staehelin HB, Orav EJ, et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. 2009;169(6):551-61.
  66. Garnero P, Delmas PD. Contribution of bone mineral density and bone turnover markers to the estimation of risk of osteoporotic fracture in postmenopausal women. J Musculoskelet Neuronal Interact. 2004;4(1):50-63.
  67. Shetty S, Kapoor N, Bondu JD, Thomas N, Paul TV. Bone turnover markers: Emerging tool in the management of osteoporosis. Indian J Endocrinol Metab. 2016;20(6):846-52.