Full text of DOI:10.1080/07315724.2001.10719035

Journal of the American College of Nutrition
ISSN: 0731-5724 (Print) 1541-1087 (Online) Journal homepage: http://www.tandfonline.com/loi/uacn20
Calcium Intake and Bone Mass Development
Among Israeli Adolescent Girls
Geila S. Rozen RD, PhD, Gad Rennert MD, Hedy S. Rennert MPH, Gissel Diab
RD, BSc, Dib Daud MD & Sofia Ish-Shalom MD
To cite this article: Geila S. Rozen RD, PhD, Gad Rennert MD, Hedy S. Rennert MPH, Gissel
Diab RD, BSc, Dib Daud MD & Sofia Ish-Shalom MD (2001) Calcium Intake and Bone Mass
Development Among Israeli Adolescent Girls, Journal of the American College of Nutrition,
20:3, 219-224, DOI: 10.1080/07315724.2001.10719035
To link to this article: http://dx.doi.org/10.1080/07315724.2001.10719035
Published online: 24 Jun 2013.
Submit your article to this journal
Article views: 23
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at
http://www.tandfonline.com/action/journalInformation?journalCode=uacn20
Download by: [Australian National University]
Date: 30 May 2016, At: 00:59

Original Research
Calcium Intake and Bone Mass Development Among
Israeli Adolescent Girls
Geila S. Rozen, RD, PhD, Gad Rennert, MD, Hedy S. Rennert, MPH, Gissel Diab, RD, BSc, Dib Daud, MD,
Sofia Ish-Shalom, MD
Department of Diet and Nutrition (G.S.R., G.D.), Metabolic Bone Diseases Unit, Department of Endocrinology (D.D., S.I.-S.),
Rambam Medical Center, Department of Community Medicine and Epidemiology, Carmel Medical Center (G.R., H.S.R.), Haifa,
ISRAEL.
Key words: dietary calcium, double-blind method, bone development, bone density, adolescents, body weight, energy
intake, Israeli, Arab
Objective: To determine the possible relationship between food and life style habits and bone health in
adolescent Israeli females.
Methods: 2,000 adolescent Israeli Jewish and Arab high-school girls (mean age 14.5) completed a
semi-quantitative food frequency questionnaire and a personal history questionnaire. 27 food components were
calculated for each subject. Bone mineral content and density were determined for 112 subjects with calcium
intake below 800 mg/day.
Results: Average calcium intake was found to be 1,260 mg/day, but 20% of all girls had a calcium intake
below 800 mg/day. All low-energy diets were very low in calcium, as mean calcium intake per 1,000 calories
was 411Ϯ128 grams. A large percentage of diets with less than 800 mg calcium were also deficient in
phosphorus (95.2%), magnesium (84.8%), iron (90.5%) and zinc (100%). Due to differences in food sources,
Jewish girls had more phosphorus in their diet, but less magnesium and iron compared to Arab girls. Calcium
and zinc deficiencies in Jewish and Arab diets were similar. A negative correlation was found between body
mass index (BMI) and age at menarche for all girls in the study. Bone mineral density (BMD) measured for girls
with calcium intake below 800 mg/day distributed normally around the average when compared to age matched
controls despite their low calcium intake. There was a strong positive correlation between BMD and bone
mineral content (BMC) at all sites and body weights.
Conclusions: Low calcium intake, other nutritional deficiencies and delayed menarche due to low-energy
diet in the growing period and in adolescence may prevent the formation of healthy bones. There is no evidence
of lower bone mass among the low calcium intake group in the study population at this stage. It remains to be
documented if the window of opportunity for optimal bone accretion for this group will be missed in the future,
possibly leading to increased risk of osteoporosis.
effect on bone accretion, operating within genetic boundaries
[7–10]. The few clinical intervention studies that did not dem-
INTRODUCTION
Some researchers believe that improving peak bone mass
(PBM) could delay or even prevent osteoporosis [1,2]. The
factors that determine PBM can be categorized as either fixed
(i.e., genetic disposition, gender, general health state) or those
that can be influenced (i.e., nutrition, physical activity, smok-
ing, drug treatment choice) [3–6].
onstrate significant association between calcium intake and
bone density may have failed to do so due to confounding
variables such as body weight of subjects, amount of physical
activity and wide variation in subjects’ age and sexual devel-
opment stage. Taking these factors into consideration, new
well-designed clinical studies have now established the positive
influence of adequate calcium intake on bone gain during
growth [11–16].
Balanced nutrition and adequate calcium intake in particular
are major environmental factors believed to have a positive
Address reprint requests to: G.S. Rozen, R.D., Ph.D., Clinical Nutrition Department, Rambam Medical Center, P.O.B. 9602, Haifa 31096, ISRAEL Email address:
rgeila@rambam.health.gov.il
Journal of the American College of Nutrition, Vol. 20, No. 3, 219–224 (2001)
Published by the American College of Nutrition
219

Calcium and Bone Development in Israeli Adolescents
A survey conducted by an Israeli female high-school stu-
dent demonstrated the fact that problematic eating habits are
more common among adolescent girls than boys, as girls show
a greater tendency to go on low-energy (weight-watching)
diets [17]. Consideration of this phenomenon and the well-
established fact that women are at greater risk of developing
osteoporosis served to define the study’s target population as
adolescent girls.
Presented here are the results of a survey of 2,000 adoles-
cent girls in Israel. Nutritional and lifestyle habits and personal
data were collected in an effort to define parameters believed to
be related to bone health.
comply with the requirements (including, for example, humor-
ous remarks and unrealistic responses, such as extreme in-
takes). The adolescents whose questionnaires were discarded
did not differ in age, weight or proportion of post-menarcheal
girls from the girls that where included in the study.
After receiving approval from the hospital review board and
financing from the Chief Scientist of the Israeli Ministry of
Health, consent forms were completed by the parents of 112
girls from the low calcium intake group (mean intake 579Ϯ60
mg Ca/day). Eighty-five girls were Jewish and 27 Arabs, mean
age 14.7Ϯ0.5; all girls were postmenarcheal, mean time since
menarche 20Ϯ11 months. Mean weight was 53Ϯ8 kg, mean
height 161Ϯ6 cm. Bone mineral density (BMD) and bone
mineral content (BMC) were measured at femoral neck (FN),
lumbar spine (LS) and total body (TB) using the dual photon
absorptiometry method (Lunar Corp) [24–25]. Nutritional and
other data including religion, ethnicity, body measurements,
health status and lifestyle factors were processed using the
SPSS statistical package.
MATERIALS AND METHODS
A semi-quantitative food frequency questionnaire (FFQ)
that included all known commercial dairy products (as a known
calcium source) and all “typical” teenage foods (fast foods,
snacks and the like) was developed. Reliability of the question-
naire was checked on a pilot group of 50 girls, who completed
the survey once, then again two months later. There was a good
and significant correlation between the calcium intake data
obtained on both occasions (rϭ0.525, pϭ0.007). Validity for
distribution of calcium intake was shown in previous work
[18–20]. A computer program was designed to calculate the
nutritional values of 27 nutrients in the questionnaire food
products. Database values were taken from food tables of the
Israeli Ministry of Health, information from Israeli food man-
ufactures and international food composition tables [21–23].
In addition to this FFQ, the personal history questionnaire
collected data about personal and medical history, lifestyle
habits such as smoking and use of contraceptives, physical
activity (reported as hours per week) and female development
stage, established by age at menarche.
With permission from the local board of education, 2,000
female students, mean age 14.5 years (range 12 to 16 years),
completed the study questionnaire in the presence of a trained
dietitian. Demographic data of the study population is pre-
sented in Table 1. Of the study population, 1,350 girls were
Jewish and 650 were Arab. The compliance rate was 99%, as
the project was perceived to be a school task. One hundred
eighty-seven questionnaires were discarded due to incorrect
completion, in which it was evident that the girls did not
RESULTS
Mean calcium intake among the study population was 1,260
mg/day. In the study population, 20.4% of Jewish girls and
19.8% of Arab girls consumed less than 800 mg of calcium per
day; 6.4% of Jewish and 7.3% of Arab girls consumed less than
500 mg/day (Fig. 1). Among girls who consumed below 800
mg calcium/day, a marked deficiency in phosphorus (in 95.2%
of the girls), magnesium (in 84.8%), iron (in 90.5%) and zinc
(in 100%) was also observed (Fig. 2).
While calcium and zinc dietary deficiencies were similar
between the ethnic groups, iron and magnesium deficiencies
were more common in the Jewish population, and phosphorus
deficiencies were more common in the Arab population (Table
2). Regarding the former, Jews tended to eat poultry, whereas
Arabs ate more lamb and beef, which are richer in iron and
zinc. The latter results from differences in dietary composition:
among Jewish girls, 18.3% of food intake was of dairy products
rich in phosphorus, compared with 13.3% among Arab girls
(pϽ0.001). Another distinction was the fact that Arab girls ate
nuts and seeds, such as chickpeas and sesame paste, which are
good sources of magnesium, at a rate five times higher than
Jewish girls. The high vitamin C content of both subgroups’
Table 1. Demographic Data of Study Population
Entire Group
Jewish Girls
Arab Girls
Significance
Age, years, mean Ϯ SD
(range)
14.49 Ϯ 0.63
(12–16)
14.54 Ϯ 0.58
(13–16)
14.3 Ϯ 0.78
(12–16)
p Ͻ 0.0001
Weight, kg, meanϮSD
(range)
Height, cm, meanϮSD
(range)
49.4 Ϯ 7.8
(30–80)
161.1 Ϯ 7.3
(128–179)
50.5 Ϯ 7.7
(30–80)
162.4 Ϯ 6.8
(128–179)
45.6 Ϯ 6.8
(30–65)
156.0 Ϯ 8.2
(132–170)
p Ͻ 0.0001
p Ͻ 0.001
220
VOL. 20, NO. 3

Calcium and Bone Development in Israeli Adolescents
Table 2. Percent of Ethnic Group Consuming Less than
Recommended Daily Allowances for Selected Nutrients
Jews
Arabs
Statistical Significance
Phosphorus
Magnesium
Iron
Vitamin C
Zinc
30.4
32.9
46.7
1.1
91.8
51.2
43.8
18.8
29.2
1.0
93.8
47.9
p Ͻ 0.009
p Ͻ 0.005
p Ͻ 0.001
NS
NS
NS
Calcium
were Arab or religious Jews. Mean physical activity was low,
3.5 Ϯ 2.6 hours/week, and took place primarily in school
training programs. In the study population, 97.4% of girls had
reached menarche at the time of the survey. All girls in the
survey had a lower body mass index (BMI) than the parallel
age group of American girls [26]. Arab girls had slightly lower
BMI values than their Jewish counterparts (Fig. 3). A signifi-
cant inverse correlation was observed between the BMI and age
at menarche (rϭ0.27, pϽ0.001) among both the Arab and
Jewish populations (Table 3).
For the 112 girls from the low calcium intake group (mean
intake 579 mg calcium/day Ϯ160, mean age 14.9, all postmen-
archeal girls), BMD measurements were TB 1.05 Ϯ 0.07
g/cm2, LS (L2-L4) 1.08 Ϯ 0.12 g/cm2 and FN 0.99 Ϯ 0.11
g/cm2. When compared with the normal BMD for age-matched
controls from the Lunar normative database for the American
population, Z scores distributed normally around average, de-
spite the fact that the girls were all on a low calcium intake
(Fig. 4) [27].
Fig. 1. Distribution of calcium intake compared with normal distribu-
tion.
diets (99% above US RDA in both) could be explained by the
average fruit and vegetable consumption, which made up 55% of
the Jewish population’s diet and 60% of the Arab population’s.
A highly significant relationship was established (r ϭ 0.76,
pϽ0.001) between calcium and energy intake: 97% of girls
consuming less than 1,200 calories per day (due to following a
weight-watching diet) consumed less than 800 mg calcium/day;
50% of these consumed less than 500 mg calcium/day. In the
group that consumed 2,500 calories/day or more, only 4% had
a calcium intake below 800 mg/day. The mean calcium intake
per 1,000 calories was 411 Ϯ 128 grams, median 393 grams.
No correlation was found between caloric or calcium density
distribution and the age of the girls. These data indicate that it
is virtually impossible to meet the needs for calcium intake
while consuming a low energy diet. Relative protein intake
increased with the decrease of energy intake. Among girls with
an intake below 1,200 calories/day, 15% to 17% of total calo-
ries came from protein, compared to 13.5% in girls with higher
energy intake. This difference was not statistically significant.
Other lifestyle factors affecting bone health for which data
was gathered included smoking, physical activity and age at
Both BMC and BMD showed a strong positive correlation
to weight at all measurement sites. For BMC, TB rϭ 0.77,
pϽ0.0001; LS rϭ0.49, p Ͻ0.0001, and FN rϭ0.55, pϽ0.0001.
For BMD, TB rϭ0.57, pϭ0.0001; LS rϭ0.43, pϭ0.0001, and
FN rϭ0.38 pϭ0.0001. BMD and BMC at all sites were also
Fig. 2. Percent of population with mineral and trace element intake
lower than recommended daily allowance by calcium intake level.
Fig. 3. Percentiles of Body Mass Index (W/S2), for girls age 14.5, from
menarche. A few girls smoked sporadically, although none
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
the USA survey compared with Israeli Jewish and Arab girls.
221

Calcium and Bone Development in Israeli Adolescents
Table 3. Age at Menarche by Mean Body Mass Index (BMI)
correlation between body mass index and later age at menarche.
The bulk of bone accretion is achieved by age 16 in girls, and
estrogen levels play an important positive role in this process.
Late menarche combined with low energy and low calcium
diets may well deprive girls of the adequate chance to maxi-
mize peak bone density, a finding supported by a number of
other studies [39–41].
Mean BMI kg/M2
Age of Menarche (years)
20.71
Ͻ12
12
13
14
NoPeriod
20.13
19.07
18.35
17.92
Data about the prevalence of low energy diets among ado-
lescent girls around the world emphasize the importance of this
issue. According to a survey by the World Health Organization,
an average of 10% of girls reported dieting by age 11 and 25%
by age 15. Israel was reported to have the highest level of girls
on diet for each age group. As many as 60% of girls aged 15 in
the United States believed they should be dieting. The report
also indicated that most girls on low energy diets do not get
professional guidance; only 50% of dieters drink milk once a
day, an amount far from assuring prevention of calcium and
other nutrient deficiencies hazardous for bone health [42,43].
Other interesting data possibly related to bone health were
provided by food source distribution data. More than 50% of
the Middle Eastern diet is based on fruits and vegetables, some
of which contain high concentrations of phytic and oxalic acids.
These elements are able to form nearly insoluble compounds
that are not absorbed by the body and are therefore eliminated
in the feces [44]. These elements are believed to influence the
body’s absorption and utilization of minerals, particularly cal-
cium, phosphate, iron, and magnesium, all of which were found
to be deficient in the diets of the low calcium group.
Fig. 4. Z scores of subjects’ bone mineral density at two measurement
sites, compared with age matched controls.
positively correlated with BMI, but the correlation was not as
strong as with weight alone. Ethnicity had no affect on bone mass.
DISCUSSION
In conclusion, these study findings demonstrate that adoles-
cent Israeli girls, both Arab and Jewish, may constitute a group
at risk for developing less than optimal peak bone mass, due to
their nutritional habits. Lack of adequate energy intake, accom-
panied by inadequate intake of calcium, magnesium and phos-
phorus may combine to cause irreversible damage by jeopar-
dizing the formation of healthy bones during adolescent years.
Although bone mass distribution in the low calcium intake
group did not differ from the normative adolescent data for
population with variable calcium intake, it is possible that each
individual did not reach her optimal PBM within genetic
boundaries, especially given the fact that calcium supplemen-
tation studies demonstrated greater bone accretion during the
calcium enriched nutrition period [15,16]. Failure to achieve
high peak bone mass may result in the earlier onset of osteo-
porosis. These findings thus render appropriate dietary inter-
ventions and education, which can to a significant degree
ameliorate the relevant nutritional deficiencies, crucial for Is-
raeli adolescent girls determined to be at risk.
The results of this study describe the nutritional habits of
Jewish and Arab Israeli adolescent girls from the perspective of
bone health issues and peak bone mass (PBM) formation.
Whereas mean calcium intake was satisfactory (1,260 mg/day)
compared with data from other surveys [28–31], we demon-
strated that 20% of the girls consumed less than 800 mg
calcium per day. All girls on low-energy diets (Ͻ1,200 calo-
ries/day) had a low calcium intake (Ͻ800 mg/day). Mean
calcium intake per 1,000 calories was 411 grams, putting all
girls on low-energy diets in the calcium deficient group and at
a disadvantage for bone mass accretion during the critical
growth period.
Additional nutrient deficiencies identified in the low-cal-
cium diet group were phosphorus, magnesium, iron and zinc.
Whereas iron has no known effect on bone health, zinc, phos-
phorus and magnesium do play a role [32]. In the body, 85% of
phosphorus and 60% of magnesium is set in bone tissue. Zinc
has a role in bone metabolism and development, and there is a
positive correlation between zinc levels and bone strength
[33–35]. Therefore, calcium cannot be the only dietary issue
addressed when considering optimal bone mass achievement.
Nutritional needs for phosphorus and magnesium must also be
considered, as has been done in studies in which milk provided
the main source of added calcium [36–38].
ACKNOWLEGMENT
This study was funded by the Chief Scientist Fund of the
Israeli Ministry of Health.
Another factor that may affect the PBM is the negative
222
VOL. 20, NO. 3

Calcium and Bone Development in Israeli Adolescents
19. Taitano RT, Novotny R, Davis JW, Ross PD, Wasnich RD: Va-
lidity of food frequency questionnaire for estimating calcium in-
take among Japanese and white women. J Am Diet Assoc 95:804–
806, 1995.
REFERENCES
1. Hansen MA, Overgaard K, Riis BJ, Christansen C: Role of peak
bone mass and bone loss in postmenopausal osteoporosis: 12 year
study. Br Med J 303:961–964, 1991.
20. Chu SY, Kolonel LN, Hankin JH, Lee J: A comparison of fre-
quency and quantitative dietary methods for epidemiologic studies
of diet and disease. Am J Epidemiol 119:323–334, 1984.
21. Guggenheim IK, Kaufman NA, Reshef A: “The Composition of
Israeli Foods,” 6th ed [in Hebrew]. Jerusalem: Israel Ministry of
Health, 1985.
2. Carrie Fassler AL, Bonjour JP: Osteoporosis as a pediatric prob-
lem. Pediatr Clin North Am 42:811–824, 1995.
3. Turner JG, Gilchrist NL, Ayling EM, Hassall AJ, Hooke EA,
Sadler WA: Factors affecting bone mineral density in high school
girls. NZ Med J 105:95–97, 1992.
4. Dhuper S, Warren MP, Brooks-Gunn J, Fox R: Effects of hor-
monal status on bone density in adolescent girls. J Clin Endocrinol
Metab 71:1083–1088, 1990.
22. Pennington JAT, Church HN: “Food Values of Portions Com-
monly Used,” 14th ed. Hagerstown, MD: Harper & Row, pp
232–233, 1985.
5. Matkovic V, Fontana D, Tominac C, Goel P, Chesnut III CH:
Factors that influence peak bone mass formation: a study of cal-
cium balance and the inheritance of bone mass in adolescent
females. Am J Clin Nutr 52:878–888, 1990.
23. Paul AA, Southgate DAT: “McCance and Widdowson’s The Com-
position of Foods,” 4th ed. London: H M Stationery Office, 1990.
24. Mazess RB, Collick B, Trempe J, Barden H, Hanson J: Perfor-
mance evaluation of a dual-energy x-ray bone densitometer. Calcif
Tissue Int 44:228–232, 1989.
6. Hustmyer FG, Peakock M, Hui S, Johnston Jr CC, Christian J:
Bone mineral density in relation to polymorphism at the vitamin D
receptor gene locus. J Clin Invest 94:2130–2134, 1994.
7. Bachrach LK: Acquisition of optimal bone mass in childhood and
adolescence. Trends Endocrinol Metab 12:22–28, 2001.
8. Rosen CJ: Pathology of osteoporosis. Clin Lab Med 20:455–468,
2000.
25. Lunar Corporation-Operator’s Manual (1993) Appendix G-
Radiation safety.
26. Frisancho AR: “Anthropometric Standards for the Assessment of
Growth and Nutritional Status.” Ann Arbor: University of Michi-
gan Press, 1990.
27. Gilsanz V, Gibbens DT, Carlson M, Boechat MI, Cann CE, Schulz
EE: Peak trabecular vertebral density: a comparison of adolescent
and adult females. Calcif Tissue Int 43:260–262, 1988.
28. Fleming KH, Heimbach JT: Consumption of calcium in the U.S.:
Food sources and intake levels. J Nutr 124(8 Suppl):1426S–1430S,
1994.
9. Sasaki M, Harata S, Kumasawa Y, Mita R, Kida K, Tsuga M: Bone
mineral density and osteo sono assessment index in adolescents.
J Orthop Sci 5:185–191, 2000.
10. Cromer B, Harel Z: Adolescents: at risk for osteoporosis?. Clin
Pediatr (Phila) 39:565–574, 2000.
11. Lloyd T, Andon MB, Rollings N, Martel JK, Landis JR, Demers
LM, Eggli DF, Kieselhorst K, Kulin HE: Calcium supplementation
and bone mineral density in adolescent girls. JAMA 270:841–844,
1993.
29. Bellu R, Riva E, Ortisi MT, De Noratis R, Santini I, Banderali G,
Giovannini M: Calcium intake in a sample of 35,000 Italian
schoolchildren. J Int Med Res 23:191–199, 1995.
30. Adamson A, Rugg-Gunn A, Bulter T, Appelton D, Hackett A:
Nutritional intake, height and weight of 11–12-year-old Northhum-
brian children in 1990 compared with information obtained in
1980. Br J Nutr 68:543–563, 1992.
12. Sentipal JM, Wardlaw GM, Mahan J, Matkovic V: Influence of
calcium intake and growth indexes on vertebral bone mineral
density in young females. Am J Clin Nutr 54:425–428, 1991.
13. Slemenda C, Miller J, Reister J, Hui S, Johnson Jr CC: Calcium
supplementation enhances bone mineral accretion in young chil-
dren [Abstract]. J. Bone Miner Res 6:S136, 1991.
31. Albertson AM, Tobelmann RC, Marquart L: Estimated dietary
calcium intake and food sources for adolescent females. J Adolesc
Health 20:20–26, 1997.
14. Johnston Jr CC, Miller JZ, Slemenda CW, Reister TK, Hui S,
Christian JC, Peacock M: Calcium supplementation and increases
in bone mineral density in children. N Engl J Med 327:82–87,
1992.
32. Food and Nutrition Board, Institute of Medicine: “Dietary Refer-
ence Intakes (DRI’s) for Calcium, Phosphorus, Magnesium, Vita-
min D, and Fluoride.” Washington DC: National Academy Press,
1997.
15. Lee WTK, Leung SSF, Leung DMY, Tsang HSY, Lau J, Cheng
JCY: A randomized double-blind controlled calcium supplemen-
tation trial, and bone and height acquisition in children. Br J Nutr
74:125–139, 1995.
33. Monnga BS, Dempster DW: Zinc is a potent inhibitor of osteoclas-
tic bone resorption in vitro. J Bone Miner Res 10:453–457, 1995.
34. Eberle J, Schmidmayer S, Erben RG, Stangassinger M, Roth HP:
Skeletal effects of zinc deficiency in growing rats. J Trace Elem
Med Biol 13:21–26, 1999.
16. Bonjour JP, Carrie AL, Ferrari S, Clavien H, Slosman D, Theintz
G: Calcium-enriched foods and bone mass growth in prepubertal
girls: A randomized, double-blind, placebo-controlled trial. J Clin
Invest 99:1287–1294, 1997.
35. Igarashi A, Yamaguchi M: Increase in bone protein components
with healing rat fractures: enhancement by zinc treatment. Int J
Mol Med 4:615–620, 1999.
17. Zavilovitch S, Ish-Shalom S: Calcium intake in adolescent years
and possible effect on the development of osteoporosis [in He-
brew]. Final project in biology, Reali High School, Haifa, 1989.
18. Pietinen P, Hartman AM, Haapa E, Rasanen L, Haapakoski J,
Palmgren J, Albanes D, Virtamo J, Huttunen JK: Reproducibility
and validity of dietary assessment instruments. Am J Epidemiol
128:667–676, 1988.
36. Chan GM, Hoffman K, McMurry M: Effect of dairy products on
bone and body composition in pubertal girls. J Pediatr 126:551–
556, 1995.
37. Cadogen J, Eastell R, Jones N, Barker ME: Milk intake and bone
mineral acquisition in adolescent girls: randomised, controlled
intervention trial. BMJ 315:1255–1260, 1997.
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
223

Calcium and Bone Development in Israeli Adolescents
38. Heaney RP: Food: what a surprise! Am J Clin Nutr 64:791–792,
1996.
42. Story M, Neumark-Sztainer D, Sherwood N, Stang J, Murray D:
Dieting status and its relationship to eating and physical activity
behaviors in a representative sample of US adolescents. J Am Diet
Assoc 98:1127–1135, 1998.
39. Theintz G, Buchs B, Rizzoli R, Slosman D, Clavien H, Sizonenko
PC, Bonjour JP: Longitudinal monitoring of bone mass accumu-
lation in healthy adolescents: evidence for a marked reduction after
16 years of age at the levels of lumbar spine and femoral neck in
female subjects. J Clin Endocrinol Metab 75:1060–1065, 1992.
40. Weaver CM: Meeting female adolescent calcium requirements.
Nutr MD 22:1–5, 1996.
43. WHO Report on Health Behavior of School-Aged Children. Diet-
ing Habits, pp 83–95. Web Site: http://www.ruhbc.ed.ac.uk/hbsc/
44. Allen LH and Wood RJ: Calcium and phosphorus. In Shils ME,
Alson JA, Shike M (eds): “Modern Nutrition in Health and Dis-
ease,” 8th ed. Philadelphia: Lea & Febinger, pp 144–166, 1994.
41. Sabatier JP, Guaydier-Souquieres G, Laroche D, Benmalek A,
Founier L, Denis AY: Bone mineral acquisition during adolescent
and early adulthood: a study in 574 healthy females 10–24 years of
age. Osteoporos Int 6:141–148, 1996.
Received July 28, 2000; revision accepted February 23, 2001.
224
VOL. 20, NO. 3