Annual injection of vitamin D and fractures of aged bones

Is there a differential response to alfacalcidol and vitamin D in the treatment of osteoporosis?

: There is a decline in serum 25 hydroxyvitamin D (25OHD), 1,25 dihydroxyvitamin D (1,25(OH)2D), and calcium absorption with advancing age, which may lead to secondary hyperparathyroidism and bone loss. Studies show a relationship between serum 25OHD and bone density in older men and women, with an inverse correlation between bone density and parathyroid hormone (PTH). Vitamin D supplementation in this age group improves calcium absorption, suppresses PTH, and decreases bone loss. Vitamin D many also reduce the incidence of hip and other nonvertebral fractures, particularly in the frail elderly who are likely to have vitamin D deficiency. Patients with established vertebral osteoporosis have lower calcium absorption than age-matched control subjects, possibly due to reduced serum 1,25(OH)2D or to relative resistance to the action of vitamin D on the bowel. Malabsorption of calcium in women with vertebral crush fractures does not usually respond to treatment with physiological doses of vitamin D, but can be corrected by pharmacological doses of vitamin D or by low doses of calcitriol or alfacalcidol. In a recent randomized, controlled study in 46 elderly women with radiological evidence of vertebral osteoporosis, alfacalcidol 0.25 micro;g twice daily improved calcium absorption, decreased serum PTH, and reduced alkaline phosphatase, whereas vitamin D2 500-1000 IU daily had no effect over the 6-month study period. Studies of the effect of the vitamin D metabolites in the management of elderly women with established vertebral osteoporosis have yielded conflicting results, but suggest that alfacalcidol and calcitriol may decrease spinal bone loss and reduce the incidence of vertebral fractures. Although vitamin D supplementation decreases bone loss and fracture risk in the frail elderly, vitamin D metabolites may prove more useful in the treatment of elderly women with vertebral osteoporosis.

Therapy of osteoporosis: calcium, vitamin D, and exercise

Calcium supplementation has long been regarded as a fundamental part of the prevention and treatment of postmenopausal osteoporosis, but it is only in recent years that clear evidence has emerged demonstrating its impact on bone mass. Calcium supplementation does not completely arrest postmenopausal bone loss but slows the rate of decline by 30 to 50%. The effect of calcium supplementation on fracture incidence in postmenopausal women has not been established. Vitamin D deficiency is common in the frail elderly, particularly in countries where fortification or food with this vitamin is not practiced. Treatment of vitamin D deficiency has been associated with significant reductions in the number of hip fractures. The role of the potent vitamin D metabolites, calcitriol and alphacalcidol, in the management of postmenopausal osteoporosis is not clear. Although some studies show substantial benefits in bone density or fracture rate from the use of these compounds, the published data are inconsistent. In general, hormone replacement therapy and the potent bisphosphonates produce greater effects on bone density and there is a greater consistency among the results of the published studies of these other interventions. Controlled trials of exercise interventions in postmenopausal women show that exercise can positively influence bone density by a few percent. Exercise interventions in the elderly have been reported to decrease fall frequency by 10%. This latter effect may have a greater impact on fracture frequency than the modest benefits of exercise on bone-density.

Age considerations in nutrient needs for bone health

Age exerts a major influence on the nutritional needs for bone health. Age influences the nutrient requirements for bone health by influencing: the growth and development of bone; the deposition of minerals leading to peak bone mass; the rate of bone loss; the levels of hormones which influence bone; the absorption and retention of nutrients required for optimal bone health, physical activity, food intake, and the level of sun exposure. Adequate calcium intake benefits bones at any age. However, dietary calcium needs vary at different ages. In June 1994, a National Institutes of Health expert panel recommended higher calcium intakes than current Recommended Dietary Allowance for several age groups. Many population groups in the United States, including young girls and women, continue to consume significantly less calcium than current recommended levels. In addition, diets low in calcium are often low in many other essential nutrients important for good bone health, including vitamin D, vitamin B6, and magnesium. Dietary recommendations for bone health should be placed in the full context of the total diet rather than a singular emphasis on calcium. To truly benefit consumers, dietary recommendations for bone health should emphasize consumption of foods high in calcium as part of a healthy diet and a healthy lifestyle.

Age considerations in nutrient needs for bone health: older adults

Current knowledge of the relation between nutrition and bone health in the elderly is sufficient, if applied, to lead to a reduction in fractures in the aged of from 30-60%. The critical nutrients are calcium and vitamin D, and possibly phosphate as well. Additionally, nutritional measures, especially protein repletion, dramatically improve outcomes from hip fracture. Fortunately the indicated interventions have a favorable cost-benefit relationship, especially when skim milk is used as the source of the needed nutrients.

Using economics to prioritize research: a case study of randomized trials for the prevention of hip fractures due to osteoporosis

OBJECTIVES

To assess the role of economics, in combination with clinical judgement, for setting research priorities, using osteoporosis prevention (and, as a result, hip fracture prevention) as an example.

METHODS

Modelling the cost and effectiveness of each of six potential interventions to prevent hip fractures over the 5-year length of a randomized trial (vitamin D injection; thiazide diuretics; hormone replacement therapy; oral calcium and vitamin D; calcium alone; calcitonin). Drug costs were derived from the Monthly Index of Medical Specialties (MIMS); averted fracture costs and estimates of effectiveness were derived from published sources.

RESULTS

Vitamin D injection proved to be the most potentially cost-effective treatment with a cost-effectiveness ratio of 584 Pounds. If averted costs are included, this leads to a saving of 9,176,496 Pounds per 100,000 women treated. By contrast, the most expensive therapy was calcitonin (marginal cost-effectiveness ratio of 433,548 Pounds). This suggests that priority should be given to trials assessing the effectiveness of vitamin D injections.

CONCLUSIONS

Relatively simple economic modelling exercises can inform research priorities and could help optimize the use of scarce research resources.

Vitamin D treatment and bone mineral density in the aged

The purpose of this study was to investigate whether long-term vitamin D treatment increased bone mineral density in the aged. The bone mineral density in the distal forearm and femoral neck did not differ between nine residents (mean age 81.0 years) of an old peoples' home who had received an annual injection of 150,000 IU ergocalciferol during the foregoing 2-7 years (mean 5.1 years) and nine age-, weight- and height-matched control subjects who had subnormal 25 hydroxyvitamin D level. The alkaline phosphatase and parathyroid hormone levels were clearly higher when the 25 hydroxyvitamin D level was below 10 nmol/1. The authors suggest that the ability of vitamin D treatment to diminish fracture incidence may derive from improved bone quality, not measurable by the standard dual energy X-ray absorptiometry, and/or improved nervous and muscular control of movements to counter the tendency to fall.

Prevention of hip fractures: drug therapy

Drug therapy to prevent hip fractures may be considered for postmenopausal women with low bone mass and elderly people with risk factors for hip fracture. As most hip fractures occur 25 years or more after menopause, drug therapy may have to be prescribed for many years to be effective. A preventative drug should be effective, safe, and without side effects. Estrogen therapy decreases bone loss and hip fracture incident, but the effect wears off when treatment is stopped. The positive effect of estrogens on cardiovascular disease should be balanced against the increased risk of breast cancer with long-term use. The newer bisphosphonates are potent inhibitors of bone resorption and decrease bone loss substantially. Again, the effect may wear off after the drug is stopped. The bisphosphonates appear to be safe, but long-term data are lacking. Calcium and/or vitamin D may prevent bone loss in late postmenopausal women and elderly people. The combination was shown to prevent hip fractures and other peripheral fractures in elderly nursing home residents. No single drug will be used more than 10-15 years. Therefore, a public health strategy should be developed with a logical sequence of drug and nondrug interventions for the successful prevention of hip fractures.

Osteoporotic fractures: background and prevention strategies

OBJECTIVES

To review current knowledge of the epidemiology, pathogenesis, prevention and treatment of osteoporosis, with particular reference to issues related to the menopause.

METHODS

Peer-reviewed publications were assessed.

RESULTS

Much international variation exists in the prevalence of osteoporosis and the incidence of fracture. Risk fractures for osteoporosis are numerous. The menopause and other causes of hypogonadism in both women and men strongly predispose to osteoporosis. Various endocrinopathies, especially glucocorticoid excess, also are important. The contribution of family history may be explained by one or more genetic markers. Poor vitamin D and calcium nutrition, smoking, high alcohol consumption and inactivity increase risk. Reduced bone mass is a major risk factor for fracture, although the magnitude of that risk may vary between populations. In addition, bone fragility, length of the femoral neck (for hip fracture), history of prior fracture (for vertebral fracture) and falls affect fracture risk. Useful methods for measuring bone density are available for both epidemiologic surveillance and for clinical practice. Dual energy x-ray absorptiometry is the most desirable method in clinical care settings. Some risk factors can be modified for prevention of osteoporosis. Postmenopausal bone loss can be inhibited with estrogen or estrogen plus progestin therapy. Bone loss in the elderly may be moderated with calcium and vitamin D supplementation. Maintenance of muscle tone and strength through exercise may reduce falls. CONCLUSIONS. Osteoporosis is a large and growing health problem in many countries. Prevention of osteoporosis is a high priority, especially because treatment of the established disease remains sub-optimal. Prevention requires immediate, intermediate-term and long-term strategies. First line therapy for established osteoporosis in women in many countries is estrogen or estrogen plus progestin, calcium and vitamin D. Prospects for improved prevention of osteoporotic fractures are encouraging.

Hip fractures: incidence, risk factors, energy absorption, and prevention

The present review summarizes the pathogenic mechanisms leading to hip fracture based on epidemiological, experimental, and controlled clinical studies. The estimated lifetime risk of hip fracture is about 14% in postmenopausal women and 6% in men. The incidence of hip fractures increases exponentially with aging, but the time trend in increasing age-specific incidence may finally reach a plateau. Postmenopausal women suffering earlier non-hip fractures have an increased risk of later hip fracture. The relative risk is highest within the first years following the fracture. Nursing home residents have a high risk of hip fracture (annual rate of 5-6%), and their incidence of falls is about 1.5 falls/person per year. Most hip fractures are a result of a direct trauma against the hip. The incidence of falls on the hip among nursing home residents is about 0.29 falls/person per year and about 20% of these traumas lead to hip fracture. Women with hip fractures have a lower body weight compared with controls, and they may also have less soft tissue covering the hip, even when adjusted for body mass index, indicating a more android body habitus. Experimental studies show that the passive energy absorption in soft tissue covering the hip may influence the risk of hip fracture and be an important determinant for the development of hip fracture, perhaps even more important than bone strength. External hip protectors were developed and tested in an open randomized nursing home study. The rate of hip fracture was reduced by 50%, corresponding to 9 of 247 residents saved from sustaining a hip fracture. This review points to the essentials in the development of hip fracture: risk of fall; type of fall; type of impact; energy absorption; and last, bone strength, which is the final permissive factor leading to hip fracture. Risk estimation and prevention of hip fracture may prove realistic when these issues are taken into consideration.

Caffeine does not affect the rate of gain in spine bone in young women

The effect of nutrition and dietary caffeine consumption and physical activity on bone gain in women during the third decade of life was determined in a longitudinal, descriptive study of 145 healthy college-aged women. Estimates of caffeine and other dietary intakes were determined by repeated 7-day diet diaries. Measurements of bone mineral in the spine and total body mineral content were determined by dual-photon absorptiometry. Measures of physical activity were ascertained by physical activity monitor. The mean estimated caffeine, calcium and protein intakes for the young women students were 103 +/- 106 mg/day (mean +/- SEM), 831 +/- 334 mg/day (mean +/- SEM) and 66 +/- 16 g/day (mean +/- SEM) respectively. The median rates of bone gain were 5.9% for spine bone mineral content, 6.8% for spine bone mineral density and 12.5% for total body bone mineral. In a multiple regression analysis the significant predictors (+ or -) of the rate of gain were age (-), activity (+), calcium intake (+) and protein intake (-). Caffeine consumption was not associated with significant reduction in rates of bone gain. While calcium and protein nutrition affect bone gain in the third decade of life in women, moderate caffeine intake (one cup of coffee per day, or 103 mg) appears to be safe with respect to bone health in this age group.

A comparison of the effects of alfacalcidol treatment and vitamin D2 supplementation on calcium absorption in elderly women with vertebral fractures

Although vitamin D supplementation in the frail elderly improves calcium absorption, suppresses parathyroid hormone, decreases bone loss and reduces the risk of fractures, such treatment may be ineffective in patients with vertebral osteoporosis, because of impaired vitamin D metabolism or resistance to the action of vitamin D metabolites on the bowel. We have therefore performed a randomized, single masked study comparing the effects of alfacalcidol treatment (0.25 micrograms twice daily) and vitamin D2 supplementation (500-1000 units daily) on calcium absorption and bone turnover in 46 elderly women (median age 69 years, range 64-79 years) with radiological evidence of vertebral fractures. Serum 25-hydroxyvitamin D increased significantly after 3 and 6 months of treatment with vitamin D2 (p < 0.001), but was unchanged in the group receiving alfacalcidol. Serum 1,25-dihydroxyvitamin D did not change significantly in either group over the study period. Fractional 45Ca absorption increased after 3 months of treatment with alfacalcidol (p < 0.05), but was unchanged with vitamin D2. There was also a reduction in plasma intact parathyroid hormone and serum alkaline phosphatase after 6 months of treatment with alfacalcidol (p < 0.05) which was not seen in the group receiving vitamin D2. Our study shows that vitamin D2 supplementation is ineffective in stimulating calcium absorption in elderly women with vertebral osteoporosis. By increasing calcium absorption in such patients, alfacalcidol may prove more effective than vitamin D in the management of vertebral osteoporosis.

Present and future of osteoporosis therapy

In the 50-year "modern" history of osteoporosis, there have been about 17 antifracture studies with sufficient attention to design to allow inference regarding efficacy. Antivertebral fracture efficacy has been reported with etidronate, estrogen patch, calcitonin, and 1,25-dihydroxyvitamin D. Two studies using fluoride were positive, and two were negative. Hip fractures have been neglected. One study showed efficacy of hip protectors, one showed efficacy of vitamin D and calcium in nursing home dwellers. The source of most hip fractures is the community. One community based antihip fracture efficacy study using annual injections of vitamin D was positive. There have been no antivertebral or antihip fracture studies in men, or in corticosteroid-related osteoporosis in men or women. Lack of independently repeated demonstration of efficacy, small fracture numbers, and data pooling in some of these (the best) studies leave great uncertainty. Estrogen and bisphosphonates appear to be the best options at this time. New data suggest that calcium supplementation is likely to reduce the rate of bone loss and perhaps reduce fracture rates. The challenge is to maintain and restore the constituents of bone mineral density (BMD), that is: to promote periosteal and endosteal bone formation; reduce endosteal bone resorption and cortical porosity; and increase trabecular thickness, number, and connectivity. There are many opportunities, for instance, intermittent parathyroid hormone (PTH) increases bone strength and, with estrogen, may increase connectivity. The anabolic effects of PTH may be partly mediated by IGF-1. IGF-1 increases periosteal, endosteal, and trabecular bone formation, cortical and trabecular width, and trabecular and endocortical connectivity.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of Vitamin D in the Pathogenesis and Treatment of Osteoporosis

Alterations in vitamin D metabolism normally occur after the menopause and with aging. Increases in skeletal remodeling as a consequence of estrogen deficiency lead to increased bone resorption, suppression of serum 1,25-dihydroxy-vitamin D and intestinal absorption of calcium and increases in urinary calcium. Age-related changes in vitamin D metabolism include diminished dermal production of 7-dehydrocholesterol, the precursor of previtamin D(3), vitamin D deficiency as a consequence of inadequate intake or exposure to sunshine (individuals may be institutionalized or housebound), a decline in intestinal vitamin D receptors and diminished intestinal absorption of calcium and secondary hyperparathyroidism which leads to further bone loss. These changes also have been implicated in the pathogenesis of senile osteoporosis. Treatment with vitamin D and its analogues such as 1,25-dihydrox-yvitamin D(3 )is sometimes of value in preventing bone loss and fractures in patients with postmenopausal osteoporosis and senile osteoporosis. However, the drugs have not been approved for treatment and prevention of osteoporosis.

Influence of age and body mass on the effects of vitamin D on hip fracture risk

The role of vitamin D in the prevention of hip fracture is controversial and protective effects appear to be confined to the institutionalized and elderly population. The aim of this study was to assess the interaction of age and body mass index (BMI) on the effects of vitamin D on the risk of hip fracture in the community. We studied 1634 women with low-energy fractures of the hip aged 50 years or older, and 3532 age-matched controls from 14 centres in six Mediterranean countries (the MEDOS study), with a structured retrospective questionnaire. The use of vitamin D supplements was associated with a modest and non-significant decrease in the risk of hip fracture (RR = 0.74; 95% confidence interval (CI) 0.53-1.03; p = 0.07). The risk reduction was influenced by age and body mass. Women aged above 80 years had a significant decrease in the relative risk of hip fracture (RR = 0.63; 95% CI 0.40-0.98) as did women with a BMI below 20 kg/m2 (RR = 0.45; 95% CI 0.24-0.84). Elderly women were more likely to have a low BMI but the elderly did not appear to benefit from vitamin D where their BMI was 20 kg/m2 or higher. The findings could not be explained by differences in sun exposure or in physical exercise. We conclude that the use of vitamin D for the prevention of hip fracture might usefully be targeted to the frail and elderly.

Risk factors for hip fracture in a high incidence area: a case-control study from Oslo, Norway

The aim of this population-based matched case-control study was to evaluate the effect of risk factors for hip fracture in Oslo, Norway, which has some of the highest incidence rates ever reported. The study population comprised all non-institutionalized persons 50 years or older living in the catchment area of two Oslo hospitals, and cases were 246 patients admitted for hip fracture during a 1-year period. The controls were randomly selected from the study population, matched 1:1 for age and sex. Hip fracture was associated with lean body stature, smoking, low grip strength and decreased levels of physical activity, and inversely with length of education. In addition, hip fracture was inversely related to indicators of total food intake (number of meals per day, frequency of dinners, and slices of bread per day). A relation between hip fracture and low vitamin D intake was also suggested, whereas no association with dietary calcium intake was found. Finally, increased risk of fracture was seen in persons reporting two or more hospital admissions in the previous 2 years, and in those reporting weight reduction due to poor appetite during the previous year. In conclusion, the risk factor pattern for hip fracture was much the same in the elderly population of Oslo as previously described in other populations with a lower incidence of fracture. This study also indicates a relation between hip fracture and low food intake.

Bone mineral density predicts non-spine fractures in very elderly women. Study of Osteoporotic Fractures Research Group

To determine the ability of bone density to predict fractures in very elderly women, we examined the association of bone density with non-spine, hip, wrist and humerus fractures in 8699 Caucasian women aged 65-79 years and 1005 women aged 80 years and older who were participants in the prospective Study of Osteoporotic Fractures. Follow-up averaged 4.9 (+/- 1.0) years after baseline measurement of appendicular bone density (single-photon absorptiometry; Osteon-Osteo Analyzer) and 2.9 (+/- 0.6) years after measurement of hip and anteroposterior lumbar spine bone density (dual-energy X-ray absorptiometry; Hologic QDR 1000) at a later examination. In general, measurements of bone density in the oldest women retained their predictive value for fractures. Among women aged 80 and over a 1 standard deviation decrease in bone density of the distal radius was associated with an increased risk of non-spine (relative risk: 1.6; 95% confidence interval: 1.3, 1.8), wrist (1.7; 1.2, 2.4) and humerus fracture (2.9; 1.8, 4.7), while a 1 standard deviation decrease in femoral neck bone density was associated with an increased risk of non-spine (1.9; 1.6, 2.4), humerus (2.4; 1.2, 4.7) and hip fracture (2.1; 1.4; 3.2). However, only trochanteric but not femoral neck fractures were associated with low bone density in these oldest women. The excess risk of fracture in women with below-median bone density was greater in those aged 80 years and over compared with the younger women: 38.4 v 20.4 per 1000 woman-years for non-spine fracture and 12.2 v 3.2 per 1000 woman-years for hip fracture.(ABSTRACT TRUNCATED AT 250 WORDS)

Osteoporosis-2044

It is likely that by 2044 biomedical and public health forces will be able to control bony fragility to a substantially greater degree than we have succeeded in doing today, but that demographic and lifestyle forces already at work will offset those gains, perhaps substantially. On the other hand, economic and social forces outside of our control will decrease the prevalence of skeletal fragility--harshly, I fear--either by strengthening old bones the hard way, or by decreasing the numbers of the elderly, or both. The final outcome will be the algebraic sum of the effects of these countervailing forces, which is impossible to estimate with any assurance. My guess is that osteoporosis will be less of a problem in 2044, though, unfortunately, for the wrong reasons.

Osteoporosis: visions for care and prevention--a conference report

Osteoporosis, a bone-thinning disease that leads to fractures, affects 25 million Americans, mostly women. The good news is that this disease is preventable and treatable. Adequate nutrition, for example, is estimated to reduce the impact of osteoporosis by as much as one half. The bad news is that unless more attention is given to communicating preventive strategies, osteoporosis and its related costs will continue to escalate. To make osteoporosis a priority among health professionals and communicators, The American Dietetic Association, in cooperation with National Diary Council, held a conference on this subject in November 1993. Recognized national experts addressed the issue of osteoporosis from various perspectives. This article summarizes the information presented at this conference. Prevention of osteoporosis focuses on increasing peak bone mass, which is usually reached between the age of 30 to 35 years, and reducing bone loss in later years. Bone health is influenced by three major interacting factors: diet, exercise, and estrogen. To optimize bone health, accumulating scientific findings support intakes of calcium and vitamin D exceeding current Recommended Dietary Allowances (RDAs) for these nutrients. Unfortunately, most women in the United States, in particular female adolescents, do not consume the RDA for calcium. Although recommendations to prevent osteoporosis can be made, there are several obstacles to translating these recommendations into action. Examples include failure to inspire people to make lifestyle changes early in life and to provide understandable recommendations. To be facilitators of change and not just nutrition experts, dietitians and other health professionals need to overcome these obstacles and to effectively market the risks of and prevention strategies for osteoporosis.(ABSTRACT TRUNCATED AT 250 WORDS)

ADSA Foundation Lecture. Low calcium intake: the culprit in many chronic diseases

Calcium is the fifth most abundant element in the earth's crust and is necessary for both plant and animal life today. Moreover, the natural diets of all mammals are rich in calcium. The diet of Stone Age human adults is estimated to have contained from 50 to 75 mmol of calcium (2000 to 3000 mg)/d, three to five times the median calcium intake of present-day US adults. Human physiology has adapted to this environmental abundance with an intestinal absorptive barrier and inefficient renal conservation of calcium. Although mammalian physiology contains mechanisms by which organisms can adjust to temporary environmental shortages, chronic calcium retention has a number of health consequences, most notably bone fragility, high blood pressure, and colon cancer. Evidence indicates that improvement in calcium intake (or in vitamin D status) prevents some portion of each of these multifactorial problems. At least 14 intervention studies have established the skeletal benefit of increased calcium intake during growth and among women in the late postmenopause. Other evidence suggests that adequate calcium may protect against salt-sensitive and pregnancy-associated hypertension and that high intakes of both dietary calcium and vitamin D reduce development of precancerous changes in colonic mucosa.

Can we stop bone loss and prevent hip fractures in the elderly?

The two main determinants of hip fractures are falls and bone loss leading to an intrinsic femoral fragility. Substantial femoral bone loss continues throughout old age, with a continuous and exponential increase in the risk of hip fracture; thus any reduction or arrest of this loss will induce an important reduction in the incidence of hip fracture. Preventive measures may be achieved during childhood by increasing peak bone mass with calcium and exercise, by using long-term estrogen replacement therapy after menopause, but also by using vitamin D and calcium supplements for late prevention in the elderly. Vitamin D insufficiency and a deficit in calcium intake are very common in the elderly living either in institutions or at home and the cumulative response to these deficits is a negative calcium balance which stimulates parathyroid hormone secretion. This senile secondary hyperparathyroidism is one of the determinants of femoral bone loss and can be reversed by calcium and vitamin D supplements. We have shown in a 3-year controlled prospective study that the daily use of supplements (1.2 g calcium and 800 IU vitamin D3) given in a large population of 3270 elderly ambulatory women living in nursing homes reduced the number of hip fractures by 23% (intention-to-treat analysis). In parallel, serum parathyroid hormone concentrations were reduced by 28% and low baseline serum 25-hydroxyvitamin D concentration returned to normal values. After 18 months of treatment the bone density of the total proximal femoral region had increased by 2.7% in the vitamin D3-calcium group and decreased by 4.6% in the placebo group (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Bone mass, nutrition, and other lifestyle factors

Since the proceedings of the last Consensus Conference on Osteoporosis were published as a supplement to The American Journal of Medicine in November 1991, there has been a plethora of well-documented studies reported in the literature. This article will address some of the issues concerning the relation between bone mass and nutrition raised in those studies.

Prevention of hip fractures

For a 50-year old Caucasian woman today, the risk of a hip fracture over her remaining life-time is about 17%. Tomorrow the situation will clearly be worse because the continuous increase in life expectancy will cause a three-fold increase in worldwide fracture incidence over the next 60 years. Through diagnostic bone mass measurements at the hip and assessment of biochemical parameters, a great deal has been learned in recent years about reduction of hip fracture risk. Preventive strategies are based on prevention of falls, use of hip protectors, and prevention of bone fragility. The latter includes the optimization of peak bone mass during childhood, postmenopausal estrogen replacement therapy, and also late prevention consisting in reversing senile secondary hyperparathyroidism, which plays an important role in the decrease of skeletal strength. This secondary hyperparathyroidism, which results from both vitamin D insufficiency and low calcium intake, is preventable with vitamin D3 and calcium supplements. They have recently been shown capable of providing effective prevention of hip fractures in elderly women living in nursing homes, with a reduction of about 25% in the number of hip fractures noted in a 3-year controlled study in 3,270 women (intention-to-treat analysis). In conclusion, it is never too early to reduce the risk of osteoporosis and never too late to prevent hip fractures.