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Meta-Analysis
. 2006 Apr 19;2006(2):CD005119.
doi: 10.1002/14651858.CD005119.pub2.

Calcium supplementation for improving bone mineral density in children

T M Winzenberg  1 , K Shaw, J Fryer, G Jones
Affiliations
Meta-Analysis

Calcium supplementation for improving bone mineral density in children

T M Winzenberg et al. Cochrane Database Syst Rev. .

Abstract

Background: Clinical trials have shown that calcium supplementation in children can increase bone mineral density (BMD) although this effect may not be maintained. There has been no quantitative systematic review of this intervention.

Objectives: . To determine the effectiveness of calcium supplementation for improving BMD in children. . To determine if any effect varies by sex, pubertal stage, ethnicity or level of physical activity, and if any effect persists after supplementation is ceased.

Search strategy: We searched CENTRAL, (Cochrane Central Register of Controlled Trials) (Issue 3, 2005), MEDLINE (1966 to 1 April 2005), EMBASE (1980 to 1 April 2005), CINAHL (1982 to 1 April 2005), AMED (1985 to 1 April 2005), MANTIS (1880 to 1 April 2005) ISI Web of Science (1945 to 1 April 2005), Food Science and Technology Abstracts (1969 to 1 April 2005) and Human Nutrition (1982 to 1 April 2005). Conference abstract books (Osteoporosis International, Journal of Bone and Mineral Research) were hand-searched.

Selection criteria: Randomised controlled trials of calcium supplementation (including by food sources) compared with placebo, with a treatment period of at least 3 months in children without co-existent medical conditions affecting bone metabolism. Outcomes had to include areal or volumetric BMD, bone mineral content (BMC), or in the case of studies using quantitative ultrasound, broadband ultrasound attenuation and ultrasonic speed of sound, measured after at least 6 months of follow-up.

Data collection and analysis: Two authors independently assessed trial quality and extracted data including adverse events. We contacted study authors for additional information.

Main results: The 19 trials included 2859 participants, of which 1367 were randomised to supplementation and 1426 to placebo. There was no heterogeneity in the results of the main effects analyses to suggest that the studies were not comparable. There was no effect of calcium supplementation on femoral neck or lumbar spine BMD. There was a small effect on total body BMC (standardised mean difference (SMD) +0.14, 95% CI+0.01, +0.27) and upper limb BMD (SMD +0.14, 95%CI +0.04, +0.24). Only the effect in the upper limb persisted after supplementation ceased (SMD+0.14, 95%CI+0.01, +0.28). This effect is approximately equivalent to a 1.7% greater increase in supplemented groups, which at best would reduce absolute fracture risk in children by 0.1-0.2%per annum. There was no evidence of effect modification by baseline calcium intake, sex, ethnicity, physical activity or pubertal stage. Adverse events were reported infrequently and were minor.

Authors' conclusions: While there is a small effect of calcium supplementation in the upper limb, the increase in BMD which results is unlikely to result in a clinically significant decrease in fracture risk. The results do not support the use of calcium supplementation in healthy children as a public health intervention. These results cannot be extrapolated to children with medical conditions affecting bone metabolism.

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Conflict of interest statement

None known.

Figures

1
1
Funnel plot of studies with femoral neck BMD outcome at end of supplementation period
2
2
Funnel plot of studies with femoral neck BMD outcome at end of longest period of follow‐up after supplementation ceased
3
3
Funnel plot of studies with lumbar spine BMD outcome at end of supplementation period
4
4
Funnel plot of studies with lumbar spine BMD outcome at end of longest period of follow‐up after supplementation ceased
5
5
Funnel plot of studies with total body BMC outcome at end of supplementation period
6
6
Funnel plot of studies with distal radius BMD outcome at end of supplementation period
7
7
Funnel plot of studies with distal radius BMD outcome at end of longest period of follow‐up after supplementation ceased
8
8
Funnel plot of studies with upper limb BMD outcome at end of supplementation period
9
9
Funnel plot of studies with upper limb BMD outcome at end of longest period of follow‐up after supplementation ceased
1.1
1.1. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 1 Femoral neck BMD (mg/cm2) at end supplementation (all data).
1.2
1.2. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 2 Femoral Neck BMD (mg/cm2) at longest point after cessation of supplement (all data).
1.3
1.3. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 3 Lumbar spine BMD (mg/cm2) at end supplementation (all data).
1.4
1.4. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 4 Lumbar Spine BMD (mg/cm2) at longest point after cessation of supplement (all data).
1.5
1.5. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 5 Total Body BMC (mg) at end supplementation (all data).
1.6
1.6. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 6 Distal Radius BMD (mg/cm2) at end supplementation (all data).
1.7
1.7. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 7 Distal Radius BMD (mg/cm2) at longest point after cessation of supplement.
1.8
1.8. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 8 Upper Limb BMD (mg/cm2) at end supplementation (all data).
1.9
1.9. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 9 Upper Limb BMD (mg/cm2) at longest point after cessation of supplement (all data).
1.10
1.10. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 10 Femoral neck BMD (mg/cm2) (end trial) by baseline calcium intake.
1.11
1.11. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 11 Lumbar spine BMD (mg/cm2) (end trial) by baseline calcium intake.
1.12
1.12. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 12 Total Body BMC (mg) (end trial) by baseline calcium intake.
1.13
1.13. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 13 Distal radius BMD (mg/cm2) (end trial) by baseline calcium intake.
1.14
1.14. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 14 Upper limb BMD (mg/cm2) (end trial) by baseline calcium intake.
1.15
1.15. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 15 Femoral neck BMD (mg/cm2) at longest point after supplement ceased by baseline calcium intake.
1.16
1.16. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 16 Lumbar spine BMD (mg/cm2) at longest point after supplement ceased by baseline calcium intake.
1.17
1.17. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 17 Distal radius BMD (mg/cm2) at longest point after supplement ceased by baseline calcium intake.
1.18
1.18. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 18 Upper limb BMD (mg/cm2) at longest point after supplement ceased by baseline calcium intake.
1.19
1.19. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 19 Femoral neck BMD (mg/cm2) (at end supplementation) by sex.
1.20
1.20. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 20 Lumbar spine BMD (mg/cm2) (at end supplementation) by sex.
1.21
1.21. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 21 Total Body BMC (mg) (at end supplementation) by sex.
1.22
1.22. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 22 Distal Radius BMD (mg/cm2) (at end supplementation) by sex.
1.23
1.23. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 23 Upper Limb BMD (mg/cm2) (at end supplementation) by sex.
1.24
1.24. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 24 Femoral neck BMD (mg/cm2) at longest point after supplement ceased by sex.
1.25
1.25. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 25 Lumbar spine BMD (mg/cm2) at longest point after supplement ceased by sex.
1.26
1.26. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 26 Upper limb BMD (mg/cm2) at longest point after supplement ceased by sex.
1.27
1.27. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 27 Femoral neck BMD (mg/cm2) (at end supplementation) by pubertal status.
1.28
1.28. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 28 Lumbar spine BMD (mg/cm2) (at end supplementation) by pubertal status.
1.29
1.29. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 29 Total body BMC (mg) (at end supplementation) by pubertal status.
1.30
1.30. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 30 Distal radius BMD (mg/cm2) (at end supplementation) by pubertal status.
1.31
1.31. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 31 Upper limb BMD (mg/cm2) (at end supplementation) by pubertal status.
1.32
1.32. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 32 Femoral neck BMD (mg/cm2) (at end supplementation) by ethnicity.
1.33
1.33. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 33 Lumbar spine BMD (mg/cm2) (at end supplementation) by ethnicity.
1.34
1.34. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 34 Total body BMC (mg) (at end supplementation) by ethnicity.
1.35
1.35. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 35 Distal radius BMD (mg/cm2) (at end supplementation) by ethnicity.
1.36
1.36. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 36 Upper limb BMD (mg/cm2) (at end supplementation) by ethnicity.
1.37
1.37. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 37 Femoral neck BMD (mg/cm2) at longest point after supplementation ceased by ethnicity.
1.38
1.38. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 38 Lumbar spine BMD (mg/cm2) at longest point after supplementation ceased by ethnicity.
1.39
1.39. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 39 Distal radius BMD (mg/cm2) at longest point after supplementation ceased by ethnicity.
1.40
1.40. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 40 Upper limb BMD (mg/cm2) at longest point after supplementation ceased by ethnicity.
1.41
1.41. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 41 Femoral neck BMD (mg/cm2) (at end supplementation) by physical activity level.
1.42
1.42. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 42 Lumbar spine BMD (mg/cm2) (at end supplementation) by physical activity level.
1.43
1.43. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 43 Total body BMC (mg) (at end supplementation) by physical activity level.
1.44
1.44. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 44 Distal radius BMD (mg/cm2) (at end supplementation) by physical activity level.
1.45
1.45. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 45 Upper limb BMD (mg/cm2) (at end supplementation) by physical activity level.
1.46
1.46. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 46 Femoral neck BMD (mg/cm2) at end supplementation by calcium threshold.
1.47
1.47. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 47 Lumbar spine BMD (mg/cm2) at end supplementation by calcium threshold.
1.48
1.48. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 48 Total body BMC (mg) at end supplementation by calcium threshold.
1.49
1.49. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 49 Distal radius BMD (mg/cm2) at end supplementation by calcium threshold.
1.50
1.50. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 50 Upper limb BMD (mg/cm2) at end supplementation by calcium threshold.
1.51
1.51. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 51 Femoral neck BMD (mg/cm2) at longest point after supplementation ceased end by calcium threshold.
1.52
1.52. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 52 Lumbar spine BMD (mg/cm2) at longest point after supplementation ceased end by calcium threshold.
1.53
1.53. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 53 Distal radius BMD (mg/cm2) at longest point after supplementation ceased end by calcium threshold.
1.54
1.54. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 54 Upper limb BMD (mg/cm2) at longest point after supplementation ceased end by calcium threshold.
1.55
1.55. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 55 Femoral neck BMD (mg/cm2) at end supplementation by duration of supplementation (< 24 months vs >= 24 months).
1.56
1.56. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 56 Lumbar spine BMD (mg/cm2) at end supplementation by duration of supplementation (< 24 months vs >= 24 months).
1.57
1.57. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 57 Total body BMC (mg) at end supplementation by duration of supplementation (< 24 months vs >= 24 months).
1.58
1.58. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 58 Distal radius BMD (mg/cm2) at end supplementation by duration of supplementation (< 24 months vs >= 24 months).
1.59
1.59. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 59 Upper limb BMD (mg/cm2) at end supplementation by duration of supplementation (< 24 months vs >= 24 months).
1.60
1.60. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 60 Femoral neck BMD (mg/cm2) at longest point after supplementation ceased end by duration of supplementation (24.
1.61
1.61. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 61 Lumbar spine BMD (mg/cm2) at longest point after supplementation ceased end by duration of supplementation (24.
1.62
1.62. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 62 Distal radius BMD (mg/cm2) at longest point after supplementation ceased end by duration of supplementation (2.
1.63
1.63. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 63 Upper limb BMD (mg/cm2) at longest point after supplementation ceased end by duration of supplementation (24).
1.64
1.64. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 64 Femoral neck BMD (mg/cm2) at end supplementation by duration of supplementation (< 18months vs >= 18months).
1.65
1.65. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 65 Lumbar spine BMD (mg/cm2) at end supplementation by duration of supplementation (< 18months vs >= 18months).
1.66
1.66. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 66 Total body BMC (mg) at end supplementation by duration of supplementation (< 18months vs >= 18months).
1.67
1.67. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 67 Distal radius BMD (mg/cm2) at end supplementation by duration of supplementation (< 18months vs >= 18months).
1.68
1.68. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 68 Upper limb BMD (mg/cm2) at end supplementation by duration of supplementation (< 18months vs >= 18months).
1.69
1.69. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 69 Femoral neck BMD (mg/cm2) at longest point after cessation of supplementation by duration of supplementation.
1.70
1.70. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 70 Lumbar spine BMD (mg/cm2) at longest point after cessation of supplementation by duration of supplementation.
1.71
1.71. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 71 Distal radius BMD (mg/cm2) at longest point after cessation of supplementation by duration of supplementation.
1.72
1.72. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 72 Upper limb BMD (mg/cm2) at longest point after cessation of supplementation by duration of supplementation.
1.73
1.73. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 73 Femoral neck BMD (mg/cm2) at end supplementation by milk extract vs other calcium supplement.
1.74
1.74. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 74 Lumbar spine BMD (mg/cm2) at end supplementation by milk extract vs other calcium supplement.
1.75
1.75. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 75 Upper limb BMD (mg/cm2) at end supplementation by milk extract vs other calcium supplement.
1.76
1.76. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 76 Femoral neck BMD (mg/cm2) after supplementation ceased by milk extract vs other calcium supplement.
1.77
1.77. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 77 Lumbar spine BMD (mg/cm2) after supplementation ceased by milk extract vs other calcium supplement.
1.78
1.78. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 78 Upper limb BMD (mg/cm2) after supplementation ceased by milk extract vs other calcium supplement.
1.79
1.79. Analysis
Comparison 1 Calcium supplementation vs placebo, Outcome 79 Upper limb BMD (mg/cm2) by calcium intake (lowest quartile vs above lowest quartile).
See this image and copyright information in PMC

Update of

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El‐Husseini 2004 {published data only}
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Fischer 1999a {published data only}
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Fischer 1999b {published data only}
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Gharib 2004 {published data only}
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Grossklaus 1998 {published data only}
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Hampton 2004 {published data only}
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Henderson 1994 {published data only}
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Lau 2004 {published data only}
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Mackelvie 2001 {published data only}
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Maggiolini 1999 {published data only}
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Roux 1995 {published data only}
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Scholz 1993 {published data only}
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Schonau 2004 {published data only}
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    1. Smart EJ, Gilchrist NL, Turner JC, March R, Maguire P, Sadler WA, et al. The effects of dairy supplementation on bone mineral density on teenage girls: baseline randomisation data. Proceedings of the Nutrition Society of New Zealand 1994;19:73‐80.
Solomons 1996 {published data only}
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Soroko 1994 {published data only}
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Specker 1999 {published data only}
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Specker 2002 {published data only}
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Taha 2001 {published data only}
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Teesalu 1996 {published data only}
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ter Meulen 2004 {published data only}
    1. ter Meulen CG, Riemsdijk I, Hene RJ, Christiaans MH, Borm GF, Corstens FH, et al. 36. No important influence of limited steroid exposure on bone mass during the first year after renal transplantation: a prospective, randomized, multicenter study. Transplantation 2004;78(1):101‐6. - PubMed
Torres 2004 {published data only}
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Tounian 2003 {published data only}
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Tucker 2003 {published data only}
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Tussing 2005 {published data only}
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Tylavsky 1992 {published data only}
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Ulrich 1996 {published data only}
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VandenBergh 1995 {published data only}
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Vigano 2004 {published data only}
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Volek 2003 {published data only}
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Wallace 2002 {published data only}
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Wang 1999 {published data only}
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Wang 2003 {published data only}
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Wastney 2003 {published data only}
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Weaver 1999 {published data only}
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Welten 1995 {published data only}
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Whiting 2001 {published data only}
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Whiting 2004 {published data only}
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Winters‐Stone 2004 {published data only}
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Zacharin 2004 {published data only}
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Zhu 2003 {published data only}
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Zhu 2004 b {published data only}
    1. Zhu K, Du X, Greenfield H, Zhang Q, Ma G, Hu X, et al. Bone mass in Chinese premenarcheal girls: the roles of body composition, calcium intake and physical activity. British Journal of Nutrition 2004;92(6):985‐93. - PubMed
Ziccardi 2004 {published data only}
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Zwart 2004 {published data only}
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Zwiauer 2003 {published data only}
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