Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis

Effects of three-monthly oral 150,000 IU cholecalciferol supplementation on falls, mobility, and muscle strength in older postmenopausal women: a randomized controlled trial

Daily vitamin D in addition to calcium supplementation reduces falls and fractures in older women. However, poor adherence to therapy is a common clinical problem. To examine the effects of supervised oral 3-monthly vitamin D therapy on falls, muscle strength, and mobility, we conducted a 9-month randomized, double-blind, placebo-controlled trial in 686 community-dwelling ambulant women aged over 70 years. Participants received either oral cholecalciferol 150,000 IU every 3 months (n = 353) or an identical placebo (n = 333). All participants were advised to increase dietary calcium intake. Falls data were collected 3-monthly. At baseline, 3, 6, and 9 months, muscle strength was measured by a handheld dynamometer and mobility by the Timed Up and Go (TUG) test. Serum 25 hydroxyvitamin D (25OHD) was measured in a subgroup of 40 subjects. Mean age at baseline was 76.7 ± 4.1 years. The average serum 25OHD value at baseline was 65.8 ± 22.7 nmol/L. By 3, 6, and 9 months after supplementation, 25OHD levels of the vitamin D group were approximately 15 nmol/L higher than the placebo group. Calcium intake did not change significantly between baseline (864 ± 412 mg/day) and 9 months (855 ± 357 mg/day). Faller rates in the two groups did not differ: vitamin D group, 102 of 353 (29%); placebo group, 89 of 333 (27%). At 9 months, compared to placebo or baseline, muscle strength, and TUG were not altered by vitamin D. In conclusion, oral cholecalciferol 150,000 IU therapy administered 3-monthly had neither beneficial nor adverse effects on falls or physical function. These data together with previous findings confirm that intermittent large doses of vitamin D are ineffective or have a deleterious effect on falls. Thus despite adherence issues with daily vitamin D replacement, an intermittent, high-dose vitamin D regimen cannot be supported as a strategy to reduce falls and fractures.

Plasma selenium, zinc, copper and lipid levels in postmenopausal Turkish women and their relation with osteoporosis

It has been shown that the trace elements and lipids play role in the growth, development and maintenance of bones. We aimed to investigate serum selenium (Se), zinc (Zn), copper (Cu) and lipid (total cholesterol, triglyceride (TG), high density lipoprotein-cholesterol, low-density lipoprotein-cholesterol) levels in postmenopausal women with osteoporosis, osteopenia and in healthy controls, and to determine the relationship between Se, Zn, Cu and lipid parameters and bone mineral density (BMD). The study included 107 postmenopausal women; 35 healthy (group 1), 37 osteopenic (group 2) and 35 osteoporotic (group 3). The women in all three groups were carefully matched for body mass index (BMI). Serum concentrations of Se, Zn and Cu were measured by atomic absorption spectrophotometry. Plasma Se, Cu, Zn and lipid levels were similar in all groups (p > 0.05). When we combined the women in each of the three groups, and considered them as one group (n = 107) we found a positive correlation between BMI and lumbar vertebra BMD, femur neck BMD, femur total BMD; a positive correlation between TG and femur neck BMD, femur total BMD; a positive correlation between Zn and lumbar vertebra BMD (total T score) (p < 0.05). There was no correlation between Se, Cu, Zn, P and lipid parameters (p > 0.05). Although BMI has a positive effect on BMD, trace elements and lipids, except Zn and TG, did not directly and correlatively influence BMD. Further studies are needed to clarify the role and relationship of trace elements and lipid parameters in postmenopausal osteoporosis.

Nutrition, bone, and aging: an integrative physiology approach

Osteoporosis, a condition associated with significant morbidity and mortality, is prevalent in the growing elderly population. Aging is associated with characteristic changes in the complex pathways of bone remodeling and in patterns of food intake. Whereas the traditional focus of nutritional supplementation for protection of bone health has centered around calcium and vitamin D, a multitude of nutrients have been identified with effects on bone, both individually and in combination. An integrative physiology approach can assist in formulating a deeper understanding of the complex interactions of nutrition and aging with bone, with the goal of identifying modifiable risk factors for the prevention of bone loss.

A comprehensive bone-health management approach for men with prostate cancer receiving androgen deprivation therapy

For advanced and metastatic prostate cancer, androgen deprivation therapy (adt) is the mainstay of treatment. Awareness of the potential bone-health complications consequent to adt use is increasing. Many studies have shown that prolonged adt leads to significant bone loss and increased fracture risk that negatively affect quality of life. Clinical practice guidelines for preserving bone health in men with prostate cancer on adt vary across Canada. This paper reviews recent studies on bone health in men with prostate cancer receiving adt and the current evidence regarding bone-health monitoring and management in reference to Canadian provincial guidelines. Based on this narrative review, we provide general bone-health management recommendations for men with prostate cancer receiving adt.

Classical and emerging roles of vitamin D in hepatitis C virus infection

According to the Institute of Medicine, the risk of clinically significant vitamin D deficiency increases at 25-hydroxyvitamin D levels below 20 ng/mL. By this standard, most cirrhotic hepatitis C virus- (HCV-) positive patients and many noncirrhotic patients are vitamin D-deficient. The high prevalence of vitamin D deficiency among HCV patients is a cause for concern for several specific reasons. Classic studies established the importance of vitamin D and calcium in maintaining bone. Vitamin D's beneficial effects on bone are likely to be vital for HCV-infected patients because these individuals have a high prevalence of low bone mineral density. Many pharmaceutical agents reduce bone density and exposure to these drugs may increase bone disease in HCV-positive patients. Bone loss occurs following liver transplantation and bone density is often low in patients with HIV/HCV co-infection who are on combination antiretroviral therapy. Some evidence suggests that ribavirin reduces bone density, underscoring the special need to monitor vitamin D in patients receiving HCV treatment and to prescribe supplements, as appropriate. In addition to its role in calcium metabolism, vitamin D is also an immune modulator that reduces inflammation while enhancing protective immune responses. Higher vitamin D levels are associated with less liver fibrosis and less inflammation in HCV patients. Recent studies show that low vitamin D levels are associated with treatment failure among HCV-infected patients receiving pegylated-interferon and ribavirin. If confirmed, these findings will provide an additional reason to ensure adequate levels of vitamin D. Information about how to monitor vitamin D status and how to use vitamin D supplements most effectively in HCV-infected patients is provided.

Effect of diet and lifestyle factors on bone health in postmenopausal women

Our objective was to examine the effect of nutritional intake and lifestyle factors on bone mass in postmenopausal Saudi women. A total of 122 apparently healthy postmenopausal Saudi women were recruited from the Center of Excellence for Osteoporosis Research in Jeddah. A questionnaire on lifestyle habits and dietary intake was administered to all participants. Anthropometric and bone mineral density (BMD) values were measured. Fasting blood samples were taken to measure concentrations of bone-related parameters and hormones. Most of the sample population was found to be vitamin D deficient with a serum vitamin D level below 50 nmol/l. Those participants with normal BMD values had significantly lower serum vitamin D levels than osteopenic individuals (P < 0.05). Overall, mean total caloric, total fat, and saturated fat intakes were above recommended levels. Almost 60% of the total study population had lower calcium intake than the estimated average requirements whereas the whole population had vitamin D intake level below the estimated average requirements. Only BMD of the femoral neck showed significant correlations with serum vitamin D level and dietary cholesterol intake. After adjustment for confounding variables; serum vitamin D levels were significantly correlated with cholesterol intake. Dietary calcium intake was significantly correlated with intake of protein and fiber whereas dietary vitamin D intake was significantly correlated with intake level of total fat, all fatty acids, cholesterol, and fiber. Our findings reveal the important role of dietary vitamin D and calcium in osteopenic patients and the likely requirement for supplementation of these nutrients in the Saudi population.

Current options for the management of postmenopausal osteoporosis

INTRODUCTION

Osteoporosis is a well-recognized disease with severe consequences if left untreated. The prevention of osteoporosis-associated fractures should include fall prevention, calcium supplementation and life-style advice, as well as pharmacological therapy using agents with proven antifracture efficacy.

AREAS COVERED

This manuscript offers an evidence-based critical assessment of the currently available efficacy data on all new chemical entities that have been granted a marketing authorization for the management of primary osteoporosis in women.

EXPERT OPINION

The availability of new therapeutic agents makes clinical decision making in osteoporosis more complex. Therapeutic decisions should be based on a balance between the benefits and risks of treatment, which must be carefully considered in each particular case, both by the physician and the patient. Indeed, no single agent is appropriate for all patients. Therefore, treatment decisions should be made on a tailor-made basis, taking into account all measures of treatment effect and risk, before making informed judgments about the best individual treatment option.

[2011 Up-date of the consensus statement of the Spanish Society of Rheumatology on osteoporosis]

OBJECTIVE

Due to increasing improvement in the diagnosis, evaluation and management of osteoporosis and the development of new tools and drugs, the Spanish Society of Rheumatology (SER) has promoted the development of recommendations based on the best evidence available. These recommendations should be a reference to rheumatologists and other health professionals involved in the treatment of patients with osteoporosis.

METHODS

Recommendations were developed following a nominal group methodology and based on a systematic review. The level of evidence and degree of recommendation were classified according to the model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through Delphi technique. Evidence from previous consensus and available clinical guidelines was used.

RESULTS

We have produced recommendations on diagnosis, evaluation and management of osteoporosis. These recommendations include the glucocorticoid-induced osteoporosis, premenopausal and male osteoporosis.

CONCLUSIONS

We present the SER recommendations related to the biologic therapy risk management.

Vitamin D and the postmenopausal population

Vitamin D, a hormone critical to the body's maintenance of serum calcium and phosphorus concentrations, is currently the subject of much scientific interest. Low levels of vitamin D have been observed in many populations and epidemiological studies have suggested a link between this biochemical state and a range of diseases, such as cancer, diabetes and multiple sclerosis. While the consequence of vitamin D deficiency is well documented for bone (rickets and osteomalacia), with mixed findings relating to falls and fractures, a causal link between vitamin D deficiency and these wider health outcomes has not been established. If these relationships were found to be causal, the morbidity and mortality resulting from low levels of vitamin D could be substantial; the current evidence base, however, most robustly supports the assessment of serum 25(OH)-vitamin D in the context of specific symptoms, low bone mineral density or biochemical abnormalities, rather than as an entity to treat in its own right or as the basis for a population-wide screening programme.

The pathogenesis, diagnosis, investigation and management of osteoporosis

With an increasingly ageing population, osteoporosis and osteoporosis-related fractures is fast becoming an important public health problem placing a considerable economic burden on health service resources. This does not account for the substantial pain, disability and indeed mortality incurred after a fracture, particularly a hip fracture. Osteoporosis is a systemic skeletal disorder which results from an imbalance in bone remodeling. This leads to a reduction in bone strength and increased susceptibility to fracture. It affects up to 1 in 2 women and 1 in 5 men. In the past 2 decades, there have been significant advances in bone biology which have helped in the understanding of the pathogenesis of osteoporosis and have led to improved therapies. In developing strategies for fracture prevention, it is important to identify those individuals with the highest fracture risk who will require pharmacological intervention. Treatment is aimed at fracture prevention and includes modification of general lifestyle factors which have been linked to fractures in epidemiological studies and ensuring optimum calcium and vitamin D intake as adjunct to active anti-fracture therapy. A number of drugs are now approved for the treatment of osteoporosis. This review article will describe the pathogenesis of osteoporosis and focus on the methods currently in use for the identification of patients at high fracture risk and will highlight their usefulness and limitations. The existing anti-fracture pharmacotherapies and those in development will be reviewed. Assessment of their effectiveness including the use of biochemical markers of bone turnover in this clinical context will be reviewed.

Fracture hospitalizations between years 2000 and 2007 in Switzerland: a trend analysis

In Switzerland, the total number and incidence of hospitalizations for major osteoporotic fractures increased between years 2000 and 2007, while hospitalizations due to hip fracture decreased. The cost impact of shorter hospital stays was offset by the increasing cost per day of hospitalization.

INTRODUCTION

The aim of the study was to establish the trends and epidemiological characteristics of hospitalizations for major osteoporotic fractures (MOF) between years 2000 and 2007 in Switzerland.

METHODS

Sex- and age-specific trends in the number and crude and age-standardized incidences of hospitalized MOF (hip, clinical spine, distal radius, and proximal humerus) in women and men aged ≥45 years were analyzed, together with the number of hospital days and cost of hospitalization, based on data from the Swiss Federal Statistical Office hospital database and population statistics.

RESULTS

Between 2000 and 2007, the absolute number of hospitalizations for MOF increased by 15.9% in women and 20.0% in men, mainly due to an increased number of non-hip fractures (+37.7% in women and +39.7% in men). Hospitalizations for hip fractures were comparatively stable (-1.8% in women and +3.3% in men). In a rapidly aging population, in which the number of individuals aged ≥45 years grew by 11.1% (women) and 14.6% (men) over the study period, the crude and age-standardized incidences of hospitalizations decreased for hip fractures and increased for non-hip MOF, both in women and men. The length of hospital stay decreased for all MOF in women and men, the cost impact of which was offset by an increase in the daily costs of hospitalization.

CONCLUSIONS

Between years 2000 and 2007, hospitalizations for MOF continued to increase in Switzerland, driven by an increasing number and incidence of hospitalizations for non-hip fractures, although the incidence of hip fractures has declined.

[Are calcium and vitamin D supplements for everyone?: Cons]

Calcium and vitamin D supplements are one of the most widely used treatments in the field of bone metabolism and, especially due to its frequency, in the case of the osteoporosis. Sometimes the use of these treatments can be easily justified because there is plenty of evidence or because prescription is mandatory. But other times, not only because of the possibility of adverse events, the indication of these therapies is more controversial. Furthermore, and particularly in the context of osteoporosis, it may be suggested that prescribing calcium and vitamin D supplements to the general population may reduce the impact of disease.

GRADE guidelines: 7. Rating the quality of evidence--inconsistency

This article deals with inconsistency of relative (rather than absolute) treatment effects in binary/dichotomous outcomes. A body of evidence is not rated up in quality if studies yield consistent results, but may be rated down in quality if inconsistent. Criteria for evaluating consistency include similarity of point estimates, extent of overlap of confidence intervals, and statistical criteria including tests of heterogeneity and I(2). To explore heterogeneity, systematic review authors should generate and test a small number of a priori hypotheses related to patients, interventions, outcomes, and methodology. When inconsistency is large and unexplained, rating down quality for inconsistency is appropriate, particularly if some studies suggest substantial benefit, and others no effect or harm (rather than only large vs. small effects). Apparent subgroup effects may be spurious. Credibility is increased if subgroup effects are based on a small number of a priori hypotheses with a specified direction; subgroup comparisons come from within rather than between studies; tests of interaction generate low P-values; and have a biological rationale.

Vitamin D supplementation for prevention of mortality in adults

BACKGROUND

The available evidence on vitamin D and mortality is inconclusive.

OBJECTIVES

To assess the beneficial and harmful effects of vitamin D for prevention of mortality in adults.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, LILACS, the Science Citation Index Expanded, and Conference Proceedings Citation Index-Science (to January 2011). We scanned bibliographies of relevant publications and asked experts and pharmaceutical companies for additional trials.

SELECTION CRITERIA

We included randomised trials that compared vitamin D at any dose, duration, and route of administration versus placebo or no intervention. Vitamin D could have been administered as supplemental vitamin D (vitamin D(3) (cholecalciferol) or vitamin D(2) (ergocalciferol)) or an active form of vitamin D (1α-hydroxyvitamin D (alfacalcidol) or 1,25-dihydroxyvitamin D (calcitriol)).

DATA COLLECTION AND ANALYSIS

Six authors extracted data independently. Random-effects and fixed-effect model meta-analyses were conducted. For dichotomous outcomes, we calculated the risk ratios (RR). To account for trials with zero events, meta-analyses of dichotomous data were repeated using risk differences (RD) and empirical continuity corrections. Risk of bias was considered in order to minimise risk of systematic errors. Trial sequential analyses were conducted to minimise the risk of random errors.

MAIN RESULTS

Fifty randomised trials with 94,148 participants provided data for the mortality analyses. Most trials included elderly women (older than 70 years). Vitamin D was administered for a median of two years. More than one half of the trials had a low risk of bias. Overall, vitamin D decreased mortality (RR 0.97, 95% confidence interval (CI) 0.94 to 1.00, I(2) = 0%). When the different forms of vitamin D were assessed separately, only vitamin D(3) decreased mortality significantly (RR 0.94, 95% CI 0.91 to 0.98, I(2) = 0%; 74,789 participants, 32 trials) whereas vitamin D(2), alfacalcidol, or calcitriol did not. Trial sequential analysis supported our finding regarding vitamin D(3), corresponding to 161 individuals treated to prevent one additional death. Vitamin D(3) combined with calcium increased the risk of nephrolithiasis (RR 1.17, 95% CI 1.02 to 1.34, I(2) = 0%). Alfacalcidol and calcitriol increased the risk of hypercalcaemia (RR 3.18, 95% CI 1.17 to 8.68, I(2) = 17%). Data on health-related quality of life and health economics were inconclusive.

AUTHORS' CONCLUSIONS

Vitamin D in the form of vitamin D(3) seems to decrease mortality in predominantly elderly women who are mainly in institutions and dependent care. Vitamin D(2), alfacalcidol, and calcitriol had no statistically significant effect on mortality. Vitamin D(3) combined with calcium significantly increased nephrolithiasis. Both alfacalcidol and calcitriol significantly increased hypercalcaemia.

Sex and gender considerations in male patients with osteoporosis

BACKGROUND

Osteoporosis remains underrecognized and undertreated in both men and women, but men who sustain fragility fractures experience greater morbidity and mortality. While men exhibit advanced comorbidity at the time of hip fracture presentation, there are distinct sex- and gender-specific factors related to the pathophysiology and treatment of osteoporosis that further influence morbidity and mortality.

QUESTIONS/PURPOSES

With a selective review of the literature, we evaluated sex- and gender-based differences contributing to increased morbidity and mortality in men with osteoporosis. WHERE ARE WE NOW?: Sex-specific differences in bone biology and morphology may affect the pathophysiology of osteoporosis, choice of pharmacotherapy, and surgical implant selection. Additionally, estrogen metabolism may play a key role in both fracture prevention and healing. Gender-based differences in recommendations for screening and prevention between men and women may influence the severity at which osteoporosis is recognized. Primary, secondary, and tertiary prevention efforts in men lag behind those of women. This may be due to a lack of consensus regarding screening guidelines for osteoporosis in men but may be attributed to lack of awareness in the physician and patient about osteoporosis and its potentially debilitating consequences. WHERE DO WE NEED TO GO?: These disparities are a call to action for healthcare providers to raise awareness for early prevention and treatment of this potentially debilitating disease, particularly in men. HOW DO WE GET THERE?: Continued prospective research on the differences between men and women diagnosed with osteoporosis is needed, as well as sex-specific stratification of data in all studies on osteoporosis.

[Senile osteoporosis: an update]

Knowledge of the mechanisms underlying the development of osteoporosis in the elderly has advanced greatly in the past few years. After an initial sudden loss of bone mineral mass in the peri-menopausal period there follows a more progressive and gradual loss that has also been seen in men. This initial drop in bone mass is due to a significant increase in bone resorption. There is also a significant reduction in bone formation with age that is mainly due to osteoblastogenesis in the bone marrow passing to a second plane, transferring its main role to adipogenesis. In this article, the latest evidence on the pathophysiology of senile osteoporosis is reviewed, highlighting the mechanisms of action of available treatments. Potential future treatments are also considered, which include new therapeutic approaches based on the pathophysiology of osteoporosis in the elderly, mainly on the potential reversibility of the adipogenesis.

A randomized controlled trial of vitamin D dosing strategies after acute hip fracture: no advantage of loading doses over daily supplementation

BACKGROUND

There remains uncertainty regarding the appropriate therapeutic management of hip fracture patients. The primary aim of our study was to examine whether large loading doses in addition to daily vitamin D offered any advantage over a simple daily low-dose vitamin D regimen for increasing vitamin D levels.

METHODS

In this randomized controlled study, patients over age 50 with an acute fragility hip fracture were enrolled from two hospital sites in Ontario, Canada. Participants were randomized to one of three loading dose groups: placebo; 50,000 IU vitamin D2; or 100,000 IU D2. Following a placebo/loading dose, all patients received a daily tablet of 1,000 IU vitamin D3 for 90 days. Serum 25-hydroxy vitamin D (25-OHD) was measured at baseline, discharge from acute care (approximately 4-weeks), and 3-months.

RESULTS

Sixty-five patients were enrolled in the study (44% male). An immediate rise in 25-OHD occurred in the 100,000 group, however there were no significant differences in 25-OHD between the placebo, 50,000 and 100,000 loading dose groups after 4-weeks (69.3, 84.5, 75.6 nmol/L, p = 0.15) and 3-months (86.7, 84.2, 73.3 nmol/L, p = 0.09), respectively. At the end of the study, approximately 75% of the placebo and 50,000 groups had reached the target therapeutic range (75 nmol/L), and 44% of the 100,000 group.

CONCLUSIONS

In correcting vitamin D insufficiency/deficiency in elderly patients with hip fracture, our findings suggest that starting with a lower daily dose of Vitamin D3 achieved similar results as providing an additional large loading dose of Vitamin D2. At the end of the study, all three groups were equally effective in attaining improvement in 25-OHD levels. Given that a daily dose of 1,000 IU vitamin D3 (with or without a loading dose) resulted in at least 25% of patients having suboptimal vitamin D status, patients with acute hip fracture may benefit from a higher daily dose of vitamin D.

TRIAL REGISTRATION

Clinical Trials # NCT00424619.

Effectiveness of oral nutritional supplementation for older women after a fracture: rationale, design and study of the feasibility of a randomized controlled study

BACKGROUND

Malnutrition is a problem for many older people recovering from a hip and other major fractures. Oral supplementation with high calorie high protein nutrients is a simple intervention that may help older people with fractures to improve their recovery in terms of rehabilitation time, length of hospital stay and mortality. This paper reports a pilot study to test the feasibility of a trial initiated in a hospital setting with an oral supplement to older people with recent fractures.

METHOD

A randomized controlled trial with 44 undernourished participants admitted to a hospital following a fracture. The intervention group (n = 23) received a high calorie high protein supplement for forty days in addition to their diet of choice. The control group (n = 21) received high protein milk during their hospital stay in addition to their diet of choice and their usual diet when discharged from hospital.

RESULTS

All participants were women and their mean age was 85.3 (± 6.1) years. Twenty nine (65%) participants had a hip fracture. At baseline no differences were measured between the two groups regarding their nutritional status, their cognitive ability or their abilities in activities of daily living. There were no significant differences between the intervention and control group with reference to nutritional or functional parameters at 40 day and 4 month follow-ups. Median length of stay in hospital was 18.0 days, with 12 participants being readmitted for a median of 7.0 days.

CONCLUSION

It is feasible to perform a randomised trial in a hospital and community setting to test the effect of an oral high energy high protein supplement for older people. Due to the limited number of participants and incomplete adherence with use of the supplements no conclusion can be drawn about the efficacy or effectiveness of this intervention.

Calcium citrate and vitamin D in the treatment of osteoporosis

The combination of calcium with vitamin D (vitamin D(3) [colecalciferol]) forms the basis of preventive and therapeutic regimens for osteoporosis. A number of studies have suggested that the combination of calcium and vitamin D is effective when administered at respective dosages of at least 1200 mg and 800 IU per day, although efficacy is, as expected, affected by patient compliance. Overall, treatment with this combination appears to be effective in reducing the incidence of non-vertebral and hip fractures. Also, in all drug studies (of antiresorptive and anabolic agents and strontium ranelate) that demonstrated a reduction in risk of osteoporotic fractures, patients also took calcium and vitamin D supplements. An important finding in this regard is that vitamin D levels have been demonstrated to be inadequate in more than half of women treated for osteoporosis in the US and Europe. The capacity of the small intestine to absorb calcium salts depends on the solubility and ionization of the salts. These properties vary for different salts, with fasting calcium citrate absorption being greater than that of calcium lactogluconate and calcium carbonate. Calcium citrate formulations taken between meals may help to prevent abdominal distension and flatulence, as well as minimize the risk of renal calculus formation, thus helping to optimize patient compliance. Therefore, calcium citrate combined with vitamin D is the combination of choice for the prevention or treatment of osteoporosis.

Elastomer femoroplasty prevents hip fracture displacement In vitro biomechanical study comparing two minimal invasive femoroplasty techniques

The purpose of this study was to test femur strength and the ability to prevent fracture displacement of two minimal invasive Elastomer femoroplasty techniques.

METHODS

A total of sixteen fixed human cadaveric femur pairs were used. From each pair one femur was randomly assigned for Elastomer femoroplasty. In these femora we drilled a 3.5mm entrance in the lateral cortex. Cavities for the Elastomer were created by: group A, balloon and group B an excentric drill. All femora were fractured by simulating a fall on the greater trochanter. Neck-shaft-angles on plain anterior posterior radiographs were measured to determine fracture displacement.

FINDINGS

There was no significant difference in fracture load between controls and treated femora for group A, 2904N (SD 1091) versus 2803N (SD 627) and group B, 2773N (SD 747) versus 2597N (SD 834). In group A the mean displacement was 35° (SD 14) for the control femora and 3° (SD 2) for the treated femora (P<0.001). In group B the mean displacement was 38° (SD 10) for the controls and 8° (SD 13) for the treated femora (P<0.001).

INTERPRETATION

The results of this study show that minimal invasive Elastomer femoroplasty prevents fracture displacement of the proximal femur. We found no significant compromise in load-to-fracture after minimal invasive balloon or excentric drill femoroplasty.

Cardiovascular effects of calcium supplementation

Trials in normal older women and in patients with renal impairment suggest that calcium supplements increase the risk of cardiovascular disease. To further assess their safety, we recently conducted a meta-analysis of trials of calcium supplements, and found a 27-31% increase in risk of myocardial infarction and a 12-20% increase in risk of stroke. These findings are robust because they are based on pre-specified analyses of randomized, placebo-controlled trials and show consistent risk across the trials. The fact that cardiovascular events were not primary endpoints of any of these studies will introduce noise but not bias into the data. A recent re-analysis of the Women's Health Initiative suggests that co-administration of vitamin D with calcium does not lessen these adverse effects. The increased cardiovascular risk with calcium supplements is consistent with epidemiological data relating higher circulating calcium concentrations to cardiovascular disease in normal populations. There are several possible pathophysiological mechanisms for these effects, including effects on vascular calcification, on the function of vascular cells, and on blood coagulation. Calcium-sensing receptors might mediate some of these effects. Because calcium supplements produce small reductions in fracture risk and a small increase in cardiovascular risk, there may be no net benefit from their use. Food sources of calcium appear to produce similar benefits on bone density, although their effects on fracture are unclear. Since food sources have not been associated with adverse cardiovascular effects, they may be preferable. Available evidence suggests that other osteoporosis treatments are still effective without calcium co-administration.

What is the role of the orthopaedic surgeon in management of fragility fractures?

Fragility fractures are the most prevalent trauma condition that orthopaedic surgeons face today. Osteoporosis and susceptibility to falls are the key predisposing factors. Despite evidence supporting the impact of treating osteoporosis on reducing the incidence of fragility fractures, it is often left untreated. Orthopaedic surgeons are often the first physicians to assess and treat the patient after a fragility fracture. Their role therefore does not end in the skillful fixation of the fractures, but they have a unique opportunity to ensure that preventive measures are implemented. This includes falls prevention, investigation of possible causes underlying osteoporosis, attention to diet, exercise, calcium, and vitamin D supplementation as well as prescription of anti-resorptive and anabolic medication. The need for a dedicated multidisciplinary team needs to be emphasized and therefore effective communication between the different parties is of paramount importance.

Advances in glucocorticoid-induced osteoporosis

Glucocorticoid-induced osteoporosis (GIOP) is one of the most important side effects of glucocorticoid use, as it leads to an increased risk of fractures. Recently, many published studies have focused on the cellular and molecular mechanisms of bone metabolism, the pathophysiology of GIOP, and the intervention options to prevent GIOP. In this review, recent advances in GIOP are summarized, particularly recent progress in our understanding of the mechanisms of GIOP resulting in improved insight that might result in the development of new treatment options in the near future.

Calcium supplementation: balancing the cardiovascular risks

Calcium supplementation has been widely accepted as a key strategy in the prevention and treatment of osteoporosis. Its role has been undermined, to some extent, by its disappointing effects on fracture in randomised controlled trials, but its use has continued to be encouraged on the grounds that it is physiologically appealing, and is unlikely to cause harm. The latter assumption is now under threat from accumulating evidence that calcium supplement use is associated with an increased risk of myocardial infarction and, possibly, stroke. The latest data, based on meta-analysis of trials involving 29,000 participants, indicate that this risk is not mitigated by co-administration of vitamin D, and that the number of cardiovascular events caused is likely to be greater than the number of fractures prevented. These findings indicate that calcium supplementation probably does not have a role as a routine preventative agent and that dietary advice is the appropriate way to attain an adequate calcium intake in most situations. Patients at high risk of fracture need to take interventions of proven anti-fracture efficacy. Available evidence suggests that this efficacy is not dependent on the co-administration of calcium supplements.

Dietary calcium intake and risk of fracture and osteoporosis: prospective longitudinal cohort study

OBJECTIVE

To investigate associations between long term dietary intake of calcium and risk of fracture of any type, hip fractures, and osteoporosis.

DESIGN

A longitudinal and prospective cohort study, based on the Swedish Mammography Cohort, including a subcohort, the Swedish Mammography Cohort Clinical.

SETTING

A population based cohort in Sweden established in 1987.

PARTICIPANTS

61,433 women (born between 1914 and 1948) were followed up for 19 years. 5022 of these women participated in the subcohort.

MAIN OUTCOME MEASURES

Primary outcome measures were incident fractures of any type and hip fractures, which were identified from registry data. Secondary outcome was osteoporosis diagnosed by dual energy x ray absorptiometry in the subcohort. Diet was assessed by repeated food frequency questionnaires.

RESULTS

During follow-up, 14,738 women (24%) experienced a first fracture of any type and among them 3871 (6%) a first hip fracture. Of the 5022 women in the subcohort, 1012 (20%) were measured as osteoporotic. The risk patterns with dietary calcium were non-linear. The crude rate of a first fracture of any type was 17.2/1000 person years at risk in the lowest quintile of calcium intake, and 14.0/1000 person years at risk in the third quintile, corresponding to a multivariable adjusted hazard ratio of 1.18 (95% confidence interval 1.12 to 1.25). The hazard ratio for a first hip fracture was 1.29 (1.17 to 1.43) and the odds ratio for osteoporosis was 1.47 (1.09 to 2.00). With a low vitamin D intake, the rate of fracture in the first calcium quintile was more pronounced. The highest quintile of calcium intake did not further reduce the risk of fractures of any type, or of osteoporosis, but was associated with a higher rate of hip fracture, hazard ratio 1.19 (1.06 to 1.32).

CONCLUSION

Gradual increases in dietary calcium intake above the first quintile in our female population were not associated with further reductions in fracture risk or osteoporosis.

[Vitamin D and fractures in the elderly]

Osteoporosis and the subsequent fractures caused by this are a source of morbidity and mortality in the elderly population. It is also often the start of the cascade that culminates in frailty and dependence. Vitamin D has a direct relationship with the appearance of osteoporosis and with the risk of fractures. Receptors of this vitamin have also recently been described in other organs and systems of the body that are associated with muscle strength, cancer and overall mortality. Deficiency of this vitamin in the elderly population in Spain is very prevalent, both in the community and the hospitalised elderly. The diagnosis and treatment are straightforward and cheap. Its efficacy in the prevention of osteoporosis and in the appearance of fractures is perfectly demonstrated. In this review, we will look at the physiology and actions of this vitamin, as well as the principal studies that have demonstrated its effectiveness in the elderly population.

Nutritional approach for inhibiting bone resorption in institutionalized elderly women with vitamin D insufficiency and high prevalence of fracture

BACKGROUND

Nutritional approach to the deterioration of bone integrity and increased fracture risk appears to be particularly appropriate in elderly women living in nursing homes.

OBJECTIVE

To investigate the beneficial effect of the consumption of soft plain cheese on bone resorption markers in institutionalized elderly women.

DESIGN

Prospective, randomized crossover controlled study.

SETTING

Six French nursing homes or other institutions for elderly.

PARTICIPANTS

Institutionalized women ≥ 65 years old with low vitamin D status and calcium intake below 700 mg/day.

INTERVENTION

Consumption of soft plain cheese made of semi-skimmed milk which was fortified by both vitamin D3 (+1.25 µg/100g) and milk extracted Ca, thus achieving a total Ca content of 151 mg/100g as compared to about 118 mg/100g for standard fresh cheese. Two servings were taken every day during the 6 weeks that preceded or followed a period of 6 weeks without soft plain cheese consumption.

MEASUREMENTS

The primary end point was the change in serum carboxy terminal cross-linked telopeptide of type I collagen (CTX) selected as a marker of bone resorption.

RESULTS

29 women aged 73-94 yr were selected, 21 of them with mean age 87.2±6.1 years remained compliant. The intervention increased calcium and protein intakes by 51% (904±228 vs. 599±122 mg/d) and 33 % (74.2±17.1 vs. 55.6±12.7 g/d, mean±SD), respectively. The dietary intervention was associated with a statistically significant increase in serum levels of both 25OHD and IGF-I, while those of [corrected] CTX and TRAP5b were significantly reduced. Compliance was 93,4 %. The daily consumption of two servings of soft plain cheese was well accepted in terms of tastiness and appetite suited portion size.

CONCLUSION

This randomized crossover controlled trial demonstrates that in elderly women living in nursing homes, the consumption of soft plain cheese increasing the supply of vitamin D, calcium and proteins, could reduce bone resorption and thereby reduce the risk of incidental fragility fractures in the long term.

Aging and osteoporosis in breast and prostate cancer

As people with cancer survive longer, and as the US population ages, skeletal effects of cancer treatment are becoming more pronounced. This is particularly true for breast and prostate cancer survivors because of the high average age of patients with these malignancies, the propensity of older adults in general toward the development of osteoporosis, and the wide use of therapeutic agents in these cancers that negatively impact bone health. Various therapies used in the treatment and prevention of cancer may cause decreases in bone mineral density and an increased risk of debilitating fracture, even in the absence of bone metastases. Aging is both a baseline risk factor in the development of osteoporosis and bony fracture, as well as a predictor of poor outcome after fracture. A variety of mechanisms may be responsible for the development of bone loss in patients with breast or prostate cancer. Cytotoxic chemotherapy may directly exert long-term toxic effects on bone. Chemotherapy and endocrine therapy can induce hypogonadism, leading to an increased rate of bone loss. The risk of skeletal events in older adults due to cancer therapy should be appreciated by all oncologists, geriatricians, and internists. The following review may serve as a guide to the skeletal side effects of cancer therapy in older adults with breast or prostate cancer, how to screen for treatment-related bone loss, and how to best prevent and/or treat skeletal events.

Changes in total body bone mineral density following a common bone health plan with two versions of a unique bone health supplement: a comparative effectiveness research study

BACKGROUND

The US Surgeon General's Report on Bone Health suggests America's bone-health is in jeopardy and issued a "call to action" to develop bone-health plans that: (1) improve nutrition, (2) increase health literacy and, (3) increase physical activity. This study is a response to this call to action.

METHODS

After signing an informed consent, 158 adults agreed to follow an open-label bone-health plan for six months after taking a DXA test of bone density, a 43-chemistry blood test panel and a quality of life inventory (AlgaeCal 1). Two weeks after the last subject completed, a second group of 58 was enrolled and followed the identical plan, but with a different bone-health supplement (AlgaeCal 2).

RESULTS

There were no significant differences between the two groups in baseline bone mineral density (BMD) or in variables related to BMD (age, sex, weight, percent body fat, fat mass, or fat-free mass). In both groups, no significant differences in BMD or related variables were found between volunteers and non-volunteers or between those who completed per protocol and those who were lost to attrition.Both groups experienced a significant positive mean annualized percent change (MAPC) in BMD compared to expectation [AlgaeCal 1: 1.15%, p = 0.001; AlgaeCal 2: 2.79%, p = 0.001]. Both groups experienced a positive MAPC compared to baseline, but only AlgaeCal 2 experienced a significant change [AlgaeCal 1: 0.48%, p = 0.14; AlgaeCal 2: 2.18%, p < 0.001]. The MAPC in AlgaeCal 2 was significantly greater than that in AlgaeCal 1 (p = 0.005). The MAPC contrast between compliant and partially compliant subjects was significant for both plans (p = 0.001 and p = 0.003 respectively). No clinically significant changes in a 43-panel blood chemistry test were found nor were there any changes in self-reported quality of life in either group.

CONCLUSIONS

Following The Plan for six months with either version of the bone health supplement was associated with significant increases in BMD as compared to expected and, in AlgaeCal 2, the increase from baseline was significantly greater than the increase from baseline in AlgaeCal 1. Increased compliance was associated with greater increases in BMD in both groups. No adverse effects were reported in either group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01114685.

Physical activity and bone mineral density in adolescents with vitamin D deficiency

INTRODUCTION

Studies have shown that physical activity (PA) is superior to many other environmental factors in determining bone mineral density (BMD), but none has examined the independent relationship between PA and vitamin D status.

PURPOSE

The aim of this study was to assess the relationship among amount of PA, vitamin D (25(OH)D), and BMD.

METHODS

A total of 166 female ballet dancers and sedentary adolescents were divided by tertiles of serum levels of 25(OH)D (< 11.3, 11.3-14.9, and > or = 15 ng·mL(-1)). Diet, PA, and menstruation were assessed by questionnaires; BMD was measured in three sites by dual-energy x-ray absorptiometry.

RESULTS

Across 25(OH)D tertiles, there were no differences in mean participant age, weight, height, PA, calcium and energy intake, BMD, or parathyroid hormone. PA was positively associated with BMD in participants with vitamin D deficiency. Multivariable regression analysis, controlling for age, body mass index, parathyroid hormone, and bone turnover markers, showed that total body, femoral neck, and lumbar spine BMD were all positively related to PA, with regression coefficients increasing as vitamin D levels dropped across tertiles.

CONCLUSIONS

PA is positively related to BMD in vitamin D-deficient female adolescents and with increasing magnitude as serum vitamin D levels drop. These findings suggest that PA may counteract the detrimental effect of marked vitamin D deficiency on bone mass.

The 2011 IOM report on vitamin D and calcium requirements for north america: clinical implications for providers treating patients with low bone mineral density

Vitamin D is an essential nutrient for skeletal mineralization and maintenance of bone mass. Most healthy individuals can meet their vitamin D requirements through dietary means, modest supplementation and solar exposure for short periods of time. The serum level of 25OHD that determines adequacy is 20 ng/ml, which corresponds with consumption of 6-800 IU of vitamin D per day, according to the Institute of Medicine review. There is still debate about whether higher doses of vitamin D are required for treating patients with osteoporosis.

Effects of food groups and dietary nutrients on bone loss in elderly Chinese population

OBJECTIVE

To examine the effects of food groups and dietary nutrients on bone loss in elderly Chinese population.

DESIGN

Prospective cohort study.

SETTING

A longitudinal study started at 2001 in Hong Kong.

PARTICIPANTS

1225 Chinese men and 992 women aged 65 years and over in the community.

METHODS

Daily intake of food groups and dietary nutrients at baseline was assessed by a food frequency questionnaire. Nutrient intake was adjusted for energy intake by residual method. Linear regression was used to examine the association of BMD change and food group or energy-adjusted nutrient intake with adjustment for demographic, anthropometric, lifestyle factors, and daily energy intake (for food group only).

RESULTS

Higher fish intake was associated with smaller bone loss in hip (B=-0.611, p=0.004) and femoral neck (B=-0.724, p=0.040) in men. None of the food groups were associated with bone loss in both measured sites in women. For men, lower intake of protein (B=-0.012, p=0.003), phosphorus (B=-0.0008, p=0.001), sodium (B=-0.0002, p=0.023) and isoflavone (B=-1.084, p=0.030) was associated with greater BMD loss in hip, whereas lower intake of protein (B=-0.018, p=0.006) and sodium (B=-0.0004, p=0.018) was associated with greater BMD loss in femoral neck. However, these significant associations disappeared after further adjustment for energy-adjusted calcium and vitamin D intakes. None of the nutrients were associated with BMD loss in both measured sites in women.

CONCLUSIONS

Greater fish intake may help to reduce bone loss in this sample of elderly Chinese men. The significant association between various nutrients and bone loss in elderly Chinese men was likely due to the influence of dietary calcium and vitamin D intakes. The role of food groups and dietary nutrients on bone health in this sample of elderly Chinese women seems to be minimal.

Overcoming problems with adherence to osteoporosis medication

Nonadherence to pharmacological treatment in osteoporosis is a well-recognized problem. As in other chronic diseases, adherence to osteoporosis treatment is poor, resulting in enormous burden on patients and healthcare resources. Most importantly, low adherence rates consistently result in increased rates of fractures. However, it seems that efforts to evaluate and improve rates of both compliance and persistence are increasing. The extension of dosing intervals may be an element, among others, allowing improvements in therapeutic adherence. Improved patient education, enhancing healthcare provider-patients interaction, taking into account patient's preferences and involving them in treatment decisions may improve adherence.

Can vitamin D supplementation prevent bone loss in persons with MS? A placebo-controlled trial

Multiple sclerosis (MS) is a possible cause of secondary osteoporosis. In this phase II trial we assessed whether a weekly dose of 20,000 IU vitamin D₃ prevents bone loss in ambulatory persons with MS age 18–50 years. ClinicalTrials.gov ID NCT00785473. All patients managed at the University Hospital of North Norway who fulfilled the main inclusion criteria were invited to participate in this double-blinded trial. Participants were randomised to receive 20,000 IU vitamin D₃ or placebo once a week and 500 mg calcium daily for 96 weeks. The primary outcome was the effect of the intervention on percentage change in bone mineral density (BMD) at the hip, the spine, and the ultradistal radius over the study period. Of 71 participants randomised, 68 completed. Mean serum 25-hydroxyvitamin D [25(OH)D] levels in the intervention group increased from 55 nmol/L at baseline to 123 nmol/L at week 96. After 96 weeks, percentage change in BMD did not differ between groups at any site. BMD decreased at the hip, by 1.4% in the placebo group (95% CI −2.3 to −0.4, SD 2.7, p = 0.006) and by 0.7% in the treatment group (−1.6 to 0.2, 2.7, p = 0.118), difference 0.7% (−1.9 to 0.7, p = 0.332). Findings were not altered by adjustment for sex or serum 25(OH)D. Supplementation with 20,000 IU vitamin D₃ a week did not prevent bone loss in this small population. Larger studies are warranted to assess the effect of vitamin D on bone health in persons with MS.

Reducing hip fractures in the elderly

Clinical question:

Is there evidence that hip protectors and vitamin D with calcium supplementation reduce hip fractures in the elderly?

Results:

The results are that vitamin D and calcium supplementation reduce incidence of hip fractures. Hip protectors provide some benefit in reducing hip fractures in elderly patients in residential facilities.

Implementation:

Primary care providers should assess patients for the risk of hip fracture and consider using hip protectors and nutritional supplementaton in selected individuals to prevent fractures.