Protein intake, malnutrition, and its association with bone health after a hip fracture: A 3-month prospective study

Inge Groenendijk; Hugo H Wijnen; Diana G Taekema; Lisette CPGM de Groot; Inge Groenendijk; Hugo H Wijnen; Diana G Taekema; Lisette CPGM de Groot

doi:10.3934/publichealth.2025048

AIMS Public Health

2025, Volume 12, Issue 3: 970-988. doi: 10.3934/publichealth.2025048

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Research article

Protein intake, malnutrition, and its association with bone health after a hip fracture: A 3-month prospective study

1.
Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
2.
Department of Geriatrics, Rijnstate Hospital, Arnhem, The Netherlands

Received: 28 March 2025 Revised: 21 July 2025 Accepted: 05 August 2025 Published: 26 September 2025

Background
In this study, we describe the change in protein intake, nutritional status, bone markers, and bone mineral density (BMD) in older patients recovering from a hip fracture, from post-surgery till 3 months. Additionally, we explore the association between protein intake with bone markers, quantitative ultrasound (QUS) and BMD, and nutritional status with QUS and BMD.
Methods
A 3-month prospective study in 96 adults aged ≥70 years with an acute hip fracture was conducted. Assessments after surgery and 3 months included protein intake (questionnaire), nutritional status [Mini Nutritional Assessment Short Form (MNA-SF)], procollagen type I N-terminal propeptide (PINP), C-terminal telopeptide of type I collagen (CTX), insulin-like growth factor 1 (IGF-1), parathyroid hormone (PTH) levels, QUS parameters, and BMD (dual-energy X-ray absorptiometry). Associations were assessed by adjusted linear mixed models.
Results
At baseline, half of the patients (mean age 84 years, 63% females) had a low protein intake (<0.8 g/kg/d), which did not change over time. The patients had significant weight loss (median 3.6 kg) and the prevalence of (being at risk of) malnutrition increased from 20% to 64%. The PINP and IGF-1 levels increased over time, the CTX level remained stable, and the PTH level decreased. The protein intake was only associated with a QUS parameter in females (estimate 0.123, 95% CI 0.022–0.223). A higher pre-fracture MNA-SF status was associated with higher BMD in the total body (estimate 0.048, 95% CI 0.015–0.080), spine (estimate 0.085, 95% CI 0.025–0.144), total hip (estimate 0.055, 95% CI 0.018–0.093), and trochanter (estimate 0.057, 95% CI 0.018–0.096). IGF-1 was associated with PINP (estimate 1.215, 95% CI 0.363–2.066).
Conclusions
A good nutritional status is associated with higher BMD in older hip fracture patients. The role of protein for bone health in these patients remains unclear. After a hip fracture, there is an increase in PINP.
- protein,
- nutritional status,
- bone,
- bone mineral density,
- hip fracture patients
Citation: Inge Groenendijk, Hugo H Wijnen, Diana G Taekema, Lisette CPGM de Groot. Protein intake, malnutrition, and its association with bone health after a hip fracture: A 3-month prospective study[J]. AIMS Public Health, 2025, 12(3): 970-988. doi: 10.3934/publichealth.2025048

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Abstract

Background

In this study, we describe the change in protein intake, nutritional status, bone markers, and bone mineral density (BMD) in older patients recovering from a hip fracture, from post-surgery till 3 months. Additionally, we explore the association between protein intake with bone markers, quantitative ultrasound (QUS) and BMD, and nutritional status with QUS and BMD.

Methods

A 3-month prospective study in 96 adults aged ≥70 years with an acute hip fracture was conducted. Assessments after surgery and 3 months included protein intake (questionnaire), nutritional status [Mini Nutritional Assessment Short Form (MNA-SF)], procollagen type I N-terminal propeptide (PINP), C-terminal telopeptide of type I collagen (CTX), insulin-like growth factor 1 (IGF-1), parathyroid hormone (PTH) levels, QUS parameters, and BMD (dual-energy X-ray absorptiometry). Associations were assessed by adjusted linear mixed models.

Results

At baseline, half of the patients (mean age 84 years, 63% females) had a low protein intake (<0.8 g/kg/d), which did not change over time. The patients had significant weight loss (median 3.6 kg) and the prevalence of (being at risk of) malnutrition increased from 20% to 64%. The PINP and IGF-1 levels increased over time, the CTX level remained stable, and the PTH level decreased. The protein intake was only associated with a QUS parameter in females (estimate 0.123, 95% CI 0.022–0.223). A higher pre-fracture MNA-SF status was associated with higher BMD in the total body (estimate 0.048, 95% CI 0.015–0.080), spine (estimate 0.085, 95% CI 0.025–0.144), total hip (estimate 0.055, 95% CI 0.018–0.093), and trochanter (estimate 0.057, 95% CI 0.018–0.096). IGF-1 was associated with PINP (estimate 1.215, 95% CI 0.363–2.066).

Conclusions

A good nutritional status is associated with higher BMD in older hip fracture patients. The role of protein for bone health in these patients remains unclear. After a hip fracture, there is an increase in PINP.

Abbreviations

BMC

bone mineral content

BMD

bone mineral density

BMI

body mass index

BUA

broadband ultrasound attenuation

CCI

Charlson Comorbidity Index

CFS

Clinical Frailty Scale

CLIA

chemiluminescent immunoassay

CRP

C-reactive protein

CTX

C-terminal telopeptide of type I collagen

coefficient of variation

DXA

dual-energy X-ray absorptiometry

eGFR

estimated glomerular filtration rate

IGF-1

insulin-like growth factor 1

IQR

interquartile range

MNA-SF

Mini Nutritional Assessment Short Form

PTH

parathyroid hormone

PINP

N-amino terminal propeptide of type I collagen

25(OH)D

25-hydroxyvitamin D

RCT

randomized controlled trial

standard deviation

Stiffness Index

SOS

speed of sound

TFNA

TFN-Advanced Proximal Femoral Nailing System

QUS

quantitative ultrasound

Acknowledgments

This work was supported by Jaap Schouten Foundation, the Netherlands (grant number JSF_SU_17_8). The funder had no role in study design; collection, analysis, and interpretation of data; or writing of this article.
This research would not have been possible without the help, trust, and flexibility of all nurses, “AIOS and ANIOS”, geriatricians, and other staff of the Geriatrics Department and Traumatology Department of Rijnstate Hospital. Wendy Brouwer, Winni Schalkwijk and Carlijn de Vries, thank you for helping with collecting data.

Authors' contributions

IG, HHW, DGT, and LCPGMdG designed research; IG, HHW, and DGT conducted research; IG analyzed data; IG wrote paper; LCPGMdG had primary responsibility for final content. All authors have read and approved the final manuscript.

Conflict of interest

All authors declare no conflicts of interest in this paper.

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