Calcium and vitamin D intake influence bone mass, but not short-term fracture risk, in Caucasian postmenopausal women from the National Osteoporosis Risk Assessment (NORA) study

Ex Vivo Biomechanical Bone Testing of Pig Femur as an Experimental Model

This study investigates the mechanical behavior of femur bones under loading conditions, focusing on the transition from elastic to plastic deformation and eventual fracture. The force-displacement curves reveal distinct phases of deformation, with an initial linear relationship indicating elastic behavior, followed by deviation from linearity marking the onset of plastic deformation. Fracture occurs beyond a critical load, leading to a sharp drop in the force-displacement curve. The maximum fracture force varies among specimens and is influenced by bone geometry, size, cross-sectional area, and cortical thickness. Post-failure analysis highlights additional insights into fracture mechanics and bone material toughness. Reinforcing bones with screws enhances their strength, which is evident in the higher fracture forces observed in force-displacement diagrams. Fixation procedures following fractures further increase bone strength. Comparing specimens with and without strengthening underscores the effectiveness of reinforcement methods in improving bone mechanical properties. After analyzing the results, it is evident that femur bones with reinforcement can withstand greater loads, and they can also absorb higher impact energies while remaining in the elastic deformation range and without suffering permanent plastic damage. This study provides valuable insights into bone biomechanics and the efficacy of reinforcement techniques in enhancing bone strength and fracture resistance.

A prospective study of lifestyle factors and bone health in breast cancer patients who received aromatase inhibitors in an integrated healthcare setting

PURPOSE

Fracture and osteoporosis are known side effects of aromatase inhibitors (AIs) for postmenopausal hormone receptor positive (HR+) breast cancer (BC) patients. How modifiable lifestyle factors impact fracture risk in these patients is relatively unknown.

METHODS

We conducted a prospective cohort study to examine the association of lifestyle factors, focusing on physical activity, with risk of incident major osteoporotic fracture and osteoporosis in 2152 HR+ BC patients diagnosed from 2006 to 2013 at Kaiser Permanente Northern California and who received AIs. Patients self-reported lifestyle factors at study entry and at 6-month follow-up. Fracture and osteoporosis outcomes were prospectively ascertained by physician-adjudication and bone mineral density (BMD) values, respectively. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated from multivariable proportional hazards regression. Models were adjusted for age, menopausal status, race/ethnicity, body mass index (BMI), AJCC stage, breast cancer treatment, prior osteoporosis, and prior major fracture.

RESULTS

Over a median 6.1 years of follow-up after AI initiation, 165 women experienced an incident osteoporotic fracture and 243 women had osteoporosis. No associations were found between overall moderate-vigorous physical activity and fracture risk, although < 150 min/week of aerobic exercise in the 6 months after BC diagnosis was associated with increased fracture risk (HR=2.42; 95% CI: 1.34, 4.37) compared with ≥ 150 min/week (meeting physical activity guidelines). Risk was also higher for never or infrequently engaging in aerobic exercise (HR=1.90; 95% CI: 1.05, 3.44). None or infrequent overall moderate-vigorous physical activity in the 6 months before BC diagnosis was associated with increased risk of osteoporosis (HR=1.94; 95% CI: 1.11; 3.37).

CONCLUSIONS

Moderate-vigorous physical activity during the immediate period after BC diagnosis, particularly aerobic exercise, was associated with lower risk of major osteoporotic fractures in women on AI therapy.

IMPLICATIONS FOR CANCER SURVIVORS

Findings may inform fracture prevention in women on AI therapy through non-pharmacologic lifestyle-based strategies.

Associations of dietary intakes of calcium, magnesium and soy isoflavones with osteoporotic fracture risk in postmenopausal women: a prospective study

The role of dietary factors in osteoporotic fractures (OFs) in women is not fully elucidated. We investigated the associations between incidence of OF and dietary calcium, magnesium and soy isoflavone intake in a longitudinal study of 48 584 postmenopausal women. Multivariable Cox regression was applied to derive hazard ratios (HRs) and 95 % confidence intervals (CIs) to evaluate associations between dietary intake, based on the averages of two assessments that took place with a median interval of 2⋅4 years, and fracture risk. The average age of study participants is 61⋅4 years (range 43⋅3–76⋅7 years) at study entry. During a median follow-up of 10⋅1 years, 4⋅3 % participants experienced OF. Compared with daily calcium intake ≤400 mg/d, higher calcium intake (>400 mg/d) was significantly associated with about a 40–50 % reduction of OF risk among women with a calcium/magnesium (Ca/Mg) intake ratio ≥1⋅7. Among women with prior fracture history, high soy isoflavone intake was associated with reduced OF risk; the HR was 0⋅72 (95 % CI 0⋅55, 0⋅93) for the highest (>42⋅0 mg/d) v. lowest (<18⋅7 mg/d) quartile intake. This inverse association was more evident among recently menopausal women (<10 years). No significant association between magnesium intake and OF risk was observed. Our findings provide novel information suggesting that the association of OF risk with dietary calcium intake was modified by Ca/Mg ratio, and soy isoflavone intake was modified by history of fractures and time since menopause. Our findings, if confirmed, can help to guide further dietary intervention strategies for OF prevention.

The influence of vegetarian and vegan diets on the state of bone mineral density in humans

There are so many literatures about vegetarians being less prone to chronic, noninfectious diseases, which are, however, the main cause of the decline in quality of life and mortality in developed countries.However, according to various scientific sources, vegetarian and especially vegan diets often contain less saturated fats, protein, calcium, vitamins D and B12, or long-chain ω-3 PUFAs. One of the most common pathology associated with a predominantly plant diet is osteopenia and osteoporosis. An analysis of 13 studies has shown that vegetarians and vegans are at a higher risk of reducing of bone mineral density, thereby increasing the incidence of fractures.At the same time, plant-based diets are usually richer in many other micronutrients important for bone health: vitamins C and K, carotenoids, potassium, magnesium, manganese, copper, or silicon. Moreover, with the deepening of our knowledge about the role of nutrients in the body and the features of the nutritional status of the population, the quality of vegetarian and vegan diets also increases. They are less and less prone to micronutrient deficiencies. Recent studies show that BMD, as well as the risk of osteoporotic fractures, at least in vegetarians, equaled these indicators in omnivores.

Diet Modulates the Effects of Genetic Variants on the Vitamin D Metabolic Pathway and Bone Mineral Density in Mexican Postmenopausal Women

BACKGROUND

Macro- and micronutrients, such as proteins, vitamin D, and calcium (Ca), are important dietary factors that can modify bone mineral density (BMD). Genetic factors can interact with diet, affecting an individual's predisposition to osteoporosis.

OBJECTIVES

This study aimed to evaluate the associations between macro- and micronutrient intakes and BMD in Mexican postmenopausal women, and their interactions with genetic polymorphisms involved in the vitamin D metabolic pathway.

METHODS

We analyzed data from 317 postmenopausal women from the Health Workers Cohort Study, a longitudinal cohort studied in Cuernavaca, Mexico. Postmenopausal women participated in 2 data collection waves (2004-2006 and 2010-2011), with a mean time of 6.4 years. Dietary intake was assessed with a semi-quantitative FFQ. BMD (femoral neck, hip, and lumbar spine) was measured by DXA. Hybrid mixed-effects regression models were used to assess the associations of dietary macro- and micronutrients on BMD, after adjusting for confounding factors and for diet and single nucleotide polymorphism interactions.

RESULTS

At baseline, the median age was 57 years (IQR, 50-64). Mean femoral neck, hip, and lumbar spine BMDs decreased over time. We observed statistically significant longitudinal associations for diet (Ca, vitamin D, magnesium, phosphorus, and protein intake) and BMD. Increases of vitamin D, Ca, and protein intakes by 1 SD were associated with mean increases in the femoral neck BMD (0.083 SD, 0.064 SD, and 0.130 SD, respectively). Multiple significant interactions were identified between several loci (CYP2R1, CYP24A1, CYP27B1, VDR, and DHCR7/NADSYN1) and diet for BMDs (femoral neck, hip, and lumbar spine), mainly for protein intake.

CONCLUSIONS

Our data support associations of vitamin D, Ca, protein, phosphorous, and magnesium consumption with BMD in Mexican postmenopausal women and suggest possible gene-diet interactions. These results could facilitate future personalized nutrition recommendations to help prevent low BMD.

Coexistence of Osteomalacia in Osteoporotic Hip Fractures in More Than 50 Years Age Group

INTRODUCTION

Osteomalacia is a hitherto common orthopaedic condition and is commonly coexists with osteoporosis. However, the identification of osteomalacia always slips under the radar and more emphasis is given to diagnosis and management of osteoporosis. Identification of osteomalacia is equally relevant as management of the osteoporotic fractures is different with or without osteomalacia.

METHODS

This was a prospective study design that included patients 50 years or above of either sex presented with proximal femur fractures. Osteoporosis was identified by DEXA scan of hip and lumbar spine. Metabolic tests including serum calcium, phosphorus, ALP and vitamin D levels were done. Histopathological diagnosis of osteomalacia was performed on bony tissues that were taken during surgery from a site adjacent to the fracture and histological examination was performed on non-decalcified paraffin sections using special stains.

RESULTS

A total of 45 patients was included in study. Mean age was 68.7 years (53-85 years). Abnormal values of serum calcium, phosphorus, ALP, vitamin D were noted in 44.4%, 22.2%, 53.3% and 48.9% patients, respectively. On histopathology, 73.17% patients showed osteomalacia. No significant correlation was found between serum biochemical markers and histopathology except with serum Vitamin D (p value - 0.004).

CONCLUSION

The majority of patients with osteoporotic hip fractures had coexisting osteomalacia. Abnormal biochemical values were not significantly associated with osteomalacia. Hence, histopathology remains the gold standard for the diagnosis of osteomalacia. Further research is needed to identify a biomarker that may enable the clinician to diagnosis and treat osteomalacia well in time.

Dietary Diversity and the Risk of Fracture in Adults: A Prospective Study

Nutrition plays an important and modifiable role in bone health. This study aimed to investigate the effect of dietary diversity on the risk of any type of fracture in adults. Data from the China Health and Nutrition Survey collected between waves 1997 and 2015 were used. A total of 10,192 adults aged 40 years and older were included in the analysis. Both dietary diversity score (DDS) based on Chinese dietary guidelines (DDS-CDG) and minimum dietary diversity for women (DDS-MDD-W) were computed. Cox proportional hazards regression models were conducted to determine the association. Stratified analyses were conducted in women by the age of fracture using the case-control study approach. In men, higher scores in both the DDS-CDG (hazard ratio (HR) 0.70, 95% CI 0.56-0.88) and DDS-MDD-W (HR 0.67, 95% CI 0.54-0.82) were associated with decreased risk of fracture, however, the associations were not significant in women (DDS-CDG: HR 0.94, 95% CI 0.79-1.12; DDS-MDD-W: HR 0.93, 95% CI 0.79-1.09). In the stratified analyses, higher DDS-CDG (odds ratio (OR) 0.74, 95% CI 0.58-0.95) and higher DDS-MDD-W (OR 0.76, 95% CI 0.60-0.95) were associated with lower risks of fracture in women aged 40 to 60 years; in women aged over 60 years, no association was observed (DDS-CDG: OR 1.10, 95% CI 0.83-1.46; DDS-MDD-W: OR 1.00, 95% CI 0.79-1.27). In summary, higher dietary diversity was associated with decreased risk of fracture in men and middle-aged women, but not in women aged over 60 years.

Effects of combined calcium and vitamin D supplementation on osteoporosis in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The aim of the present study was to explore whether combined calcium and vitamin D supplementation is beneficial for osteoporosis in postmenopausal women.

METHODS

We searched the PubMed, Cochrane library, Web of science and Embase databases and reference lists of eligible articles up to Feb, 2020. Randomized controlled trials (RCTs) evaluating the effect of combined calcium and vitamin D on osteoporosis in postmenopausal women were included in the present study.

RESULTS

Combined calcium and vitamin D significantly increased total bone mineral density (BMD) (standard mean differences (SMD) = 0.537; 95% confidence interval (CI): 0.227 to 0.847), lumbar spine BMD (SMD = 0.233; 95% CI: 0.073 to 0.392; P < 0.001), arms BMD (SMD = 0.464; 95% CI: 0.186 to 0.741) and femoral neck BMD (SMD = 0.187; 95% CI: 0.010 to 0.364). It also significantly reduced the incidence of hip fracture (RR = 0.864; 95% CI: 0.763 to 0.979). Subgroup analysis showed that combined calcium and vitamin D significantly increased femoral neck BMD only when the dose of the vitamin D intake was no more than 400 IU d^-1 (SMD = 0.335; 95% CI: 0.113 to 0.558), but not for a dose more than 400 IU d^-1 (SMD = -0.098; 95% CI: -0.109 to 0.305), and calcium had no effect on the femoral neck BMD. Subgroup analysis also showed only dairy products fortified with calcium and vitamin D had a significant influence on total BMD (SMD = 0.784; 95% CI: 0.322 to 1.247) and lumbar spine BMD (SMD = 0.320; 95% CI: 0.146 to 0.494), but not for combined calcium and vitamin D supplement.

CONCLUSION

Dairy products fortified with calcium and vitamin D have a favorable effect on bone mineral density. Combined calcium and vitamin D supplementation could prevent osteoporosis hip fracture in postmenopausal women.

A Review of Nutritional Requirements of Adults Aged ≥65 Years in the UK

Appropriate dietary choices in later life may reduce the risk of chronic diseases and rate of functional decline, however, there is little well-evidenced age-specific nutritional guidance in the UK for older adults, making it challenging to provide nutritional advice. Therefore, the aim of this critical review was to propose evidence-based nutritional recommendations for older adults (aged ≥65 y). Nutrients with important physiological functions in older adults were selected for inclusion in the recommendations. For these nutrients: 1) recommendations from the UK Scientific Advisory Committee for Nutrition (SACN) reports were reviewed and guidance retained if recent and age-specific, and 2) a literature search conducted where SACN guidance was not sufficient to set or confirm recommendations for older adults, searching Web of Science up to March 2020. Data extracted from a total of 190 selected publications provided evidence to support age-specific UK recommendations for protein (1.2 g·kg-1·d-1), calcium (1000 mg·d-1), folate (400 μg·d-1), vitamin B-12 (2.4 μg·d-1), and fluid (1.6 L·d-1 women, 2.0 L·d-1 men) for those ≥65 y. UK recommendations for carbohydrates, free sugars, dietary fiber, dietary fat and fatty acids, sodium, and alcohol for the general population are likely appropriate for older adults. Insufficient evidence was identified to confirm or change recommendations for all other selected nutrients. In general, significant gaps in current nutritional research among older adults existed, which should be addressed to support delivery of tailored nutritional guidance to this age group to promote healthy aging.

Milk and dairy product consumption in patients with inflammatory bowel disease: Helpful or harmful to bone mineral density?

OBJECTIVES

Limiting the consumption of milk and dairy products (DPs) constitutes a risk factor for osteoporosis in patients with inflammatory bowel disease (IBD). The aim of this study was to evaluate bone mineral density (BMD) and the frequency of osteopenia and osteoporosis in patients with IBD. We also investigated the correlation between BMD and consumption of milk and DPs, as well as with calcium, phosphate, and parathyroid hormone (PTH) and 25-hydroxyvitamin D [25(OH)D] serum concentration levels.

METHODS

The study comprised 208 patients with IBD. Densitometric measurements were performed using the dual-energy x-ray absorpiometry. Before (IBD-I) and after the diagnosis (IBD-II) of IBD, we used a questionnaire to assess the consumption of milk and DPs. Serum concentrations of PTH, 25(OH)D, calcium, and phosphate were determined.

RESULTS

The prevalence of osteopenia and osteoporosis in the IBD patient group was 48.1%. At the same time, 87% of patients with IBD reported milk consumption. Patients from this group with proper bone mass amounted to 91.7%, whereas patients with osteopenia and osteoporosis comprised 82% (P = 0.0382) of patients. In patients with IBD who consumed milk, femoral neck BMD (0.97 ± 0.17 g/cm²) was higher than in those not drinking milk (0.897 ± 0.154 g/cm²; P = 0.0587). The percentage of patients with IBD consuming DPs was 96.2%; however, this number decreased after diagnosis and was equal to IBD-II: 83% (P < 0.0001). Additionally, concentration levels of 25(OH)D decreased in the IBD group (21.82 ± 10.82 ng/dL).

CONCLUSION

Not only does IBD entail a high prevalence of osteoporosis, but BMD values are also indirectly affected by the fact that patient consumption of milk and other DPs decreases after diagnosis.

Changes in Bone Mineral Density in Women With Breast Cancer: A Prospective Cohort Study

BACKGROUND

Cancer treatment-induced bone loss is an important long-term effect among breast cancer survivors. Little is known, however, about the pattern of bone loss and the factors associated with it.

OBJECTIVE

The aim of this study was to examine annual bone health changes and factors associated with bone loss for 3 years after diagnosis among women with breast cancer.

METHODS

Ninety-nine newly diagnosed women with breast cancer (mean age, 51.1 years) were enrolled in a prospective longitudinal study. Bone mineral density (BMD) was measured with dual-energy x-ray absorptiometry at baseline and yearly for 3 years.

RESULTS

During the 3-year follow-up, the proportion of women who had osteopenia or osteoporosis increased from 33.3% to 62.5%. The BMD of the participants significantly decreased 6.8% in the lumbar spine, 4.6% in the femur neck, and 3.5% in the total hip, with bone loss the greatest in the first year. In multiple linear regression analysis, chemotherapy was significantly associated with bone loss at all sites, and premenopausal status at diagnosis was significantly related to bone loss at the lumbar spine. We found no significant relationship between health behavior status and BMD change at any site.

CONCLUSION

Women newly diagnosed with breast cancer can lose up to 6.8% of BMD during a 3-year follow-up. Chemotherapy and premenopausal status are important risk factors for bone loss.

IMPLICATIONS FOR PRACTICE

Identification of premenopausal women at diagnosis and monitoring BMD before and after chemotherapy are key for promoting bone health in women with breast cancer.

Gut microbiota composition and bone mineral loss-epidemiologic evidence from individuals in Wuhan, China

We explored the association between gut microbiota composition and bone mineral loss in Chinese elderly people by high-throughput 16S ribosomal RNA (rRNA) gene sequencing. Compared with controls, a smaller number of operational taxonomic units (OTUs), several taxa with altered abundance, and specific functional pathways were found in individuals with low-bone mineral density (BMD).

INTRODUCTION

Gut microbiota plays important roles in human health and associates with a number of diseases. However, few studies explored its association with bone mineral loss in human.

METHODS

We collected 102 fecal samples from each eligible individual belonging to low-BMD and control groups for high-throughput 16S rRNA gene sequencing.

RESULTS

The low-BMD individuals had a smaller number of OTUs and bacterial taxa at each level. At the phylum level, Bacteroidetes were more abundant in the low-BMD group; Firmicutes were enriched in the control group; Firmicutes and Actinobacteria positively correlated and Bacteroidetes negatively correlated with the BMD and T-score in all subjects. At the family level, the abundance of Lachnospiraceae in low-BMD individuals reduced and positively correlated with BMD and T-score; meanwhile, BMD increased with increasing Bifidobacteriaceae. At the genus level, low-BMD individuals had decreased proportions of Roseburia compared with control ones (P < 0.05). Roseburia, Bifidobacterium, and Lactobacillus positively correlated with BMD and T-score. Furthermore, BMD increased with rising abundance of Bifidobacterium. Functional prediction revealed that 93 metabolic pathways significantly differed between the two groups (FDR-corrected P < 0.05). Most pathways, especially pathways related to LPS biosynthesis, were more abundant in low-BMD individuals than in control ones.

CONCLUSIONS

Several taxa with altered abundance and specific functional pathways were discovered in low-BMD individuals. Our findings provide novel epidemiologic evidence to elucidate the underlying microbiota-relevant mechanism in bone mineral loss and osteoporosis.

Calcium intake, bone mineral density, and fragility fractures: evidence from an Italian outpatient population

This study was performed in 1000 adult Italian subjects to focus on the effects of dietary calcium intake on bone health. A higher fracture risk appears to be associated with a reduced calcium intake. An adequate daily calcium intake is recommended to counteract osteoporotic fractures.

PURPOSE

The principal aim of the present study was to focus on the effects of dietary calcium intake on bone mineral density (BMD) and fragility fractures in a representative sample of an adult Italian outpatient population.

METHODS

The study group consisted of 1000 consecutive adult Italian subjects [838 women (F) and 162 men (M)] referred to the Bone Metabolic Diseases Unit for the evaluation of their bone metabolism. Daily dietary calcium intake was assessed using a specific food frequency questionnaire (FFQ). Other evaluations included fracture risk, lumbar and femoral BMD, heel ultrasound, fragility fractures, plasma concentration of parathyroid hormone ([PTH]) and 25-hydroxy-vitamin D ([25(OH)D]), and urinary calcium.

RESULTS

Only 10.4% of the subjects (n = 104; 71 F and 33 M) had a daily calcium intake adequate for adults (≥1000 mg/day). No correlation was found between calcium intake and BMD. The transition from a daily dietary calcium intake <400 mg/day to a daily dietary calcium intake ≥400 mg/day was associated with a reduced fracture probability ratio at any site [from 42 to 21% (p < 0.05)]. Subjects with one or more vertebral fractures had a significantly lower dietary calcium intake (<400 mg/day) than did subjects without vertebral fractures, and they practiced physical activity only occasionally (p = 0.030).

CONCLUSIONS

Daily dietary calcium intake is lower than the recommended daily intake in an Italian ambulatory population, and a higher fracture risk appears to be associated with a reduced calcium intake. An age-adequate daily calcium intake, combined with regular physical activity, is strongly recommended in order to counteract fragility fractures.

Low calcium and vitamin D intake in Korean women over 50 years of age

Inadequate calcium and vitamin D intake is a possible risk factor of osteoporosis. Our purposes were to estimate calcium and vitamin D intake in Korean women, and to determine associated risk factors for low calcium and vitamin D intake. This is a multicenter, hospital-based, and cross-sectional study on osteoporosis. In this study, 1516 women of 50 years or older were involved. Dietary calcium and vitamin D intake were evaluated using the self-reporting KCAT questionnaire. Average daily calcium intake was 662.8 ± 473.8 mg, and vitamin D intake 9.5 ± 10.7 μg. In multivariate analysis, older age (OR 1.02, 95 % CI 1.00-1.04, p = 0.001), and rural residence (OR 2.43, 95 % CI 1.34-4.43, p = 0.004) were significant risk factors for lower calcium intake, and older age (OR 1.03, 95 % CI 1.02-1.04, p < 0.001), and rural residence (OR 1.85, 95 % CI 1.10-3.11, p < 0.001) were significant risk factors for lower vitamin D intake. About 70 % of women aged 50 years or older had calcium and vitamin D intake below the recommended dietary intake. Older age and rural residence were significant risk factors for lower calcium and vitamin D intake in Korean women.

The association between osteoporotic hip fractures and actinic lesions as a biomarker for cumulative sun exposure in older people-a retrospective case-control study in Argentina

The aim of this study was to analyze the association between the presence of actinic lesions (solar keratosis and non-melanoma skin cancer) and osteoporotic hip fractures in older patients. Both pathologies are common conditions in this age group. Since cumulative sun exposure is difficult to quantify, the presence of actinic lesions can be used to indirectly analyze the association between ultraviolet radiation and osteoporotic hip fractures. This was an observational case-control study. We reviewed the centralized medical records of patients with hip fracture (cases, n = 51) and patients with other diseases hospitalized in the same institution and period (controls, n = 59). The mean age of the patients was 80 ± 8.3 years (range 50-103 years). Differences in maternal hip fracture history were found between cases and controls (14.8 and 8 %, respectively; p = 0.047). Falls history in the past year was higher in cases than in controls (p < 0.0001). Actinic lesions were observed in 32.7 % of patients (prevalence rate 23.5 % in cases, 40.7 % in controls; p = 0.04). When considering patients with actinic lesions, controls have a higher FRAX score compared with cases. Although sun exposure is recommended for bone health, it represents a risk factor for actinic lesions. The presence of actinic lesions may indicate a lower osteoporotic hip fracture risk. A balance between adequate lifetime sun exposure and protection against its adverse effects is required for each patient, in the context of geographic location.

Vitamins, Are They Safe?

The consumption of a daily multivitamin among people all over the world is dramatically increasing in recent years. Most of the people believe that if vitamins are not effective, at least they are safe. However, the long term health consequences of vitamins consumption are unknown. This study aimed to assess the side effects and possible harmful and detrimental properties of vitamins and to discuss whether vitamins can be used as safe health products or dietary supplements. We performed a MEDLINE/PubMed, EMBASE, Scopus and Google Scholar search and assessed reference lists of the included studies which were published from 1993 through 2015. The studies, with an emphasis on RCTs (randomized controlled clinical trials), were reviewed. As some vitamins such as fat-soluble vitamins (vitamin A, vitamin D, vitamin E), and also some of the water-soluble vitamins like folic acid may cause adverse events and some like vitamin C is widely taken assuming that it has so many benefits and no harm, we included relevant studies with negative or undesired results regarding the effect of these vitamins on health. Our recommendation is that taking high-dose supplements of vitamins A, E, D, C, and folic acid is not always effective for prevention of disease, and it can even be harmful to the health.

Factors affecting changes in the serum levels of 25-hydroxyvitamin D: a 3-year follow-up of the ROAD study

In this 3-year population-based cohort study, among 1346 subjects, the mean annual change in the serum 25-hydroxyvitamin D levels was 7.6 %/year, which tended to increase during the 3-year period. Multivariate regression analysis indicated that the L2-4 bone mineral density and total daily energy intake were significant independent associated factors.

INTRODUCTION

The aim of this study was to clarify the change rate of the serum levels of 25-hydroxyvitamin D (25D) and the associated factors in a general Japanese population during a 3-year period.

METHODS

The baseline survey of Research on Osteoarthritis/osteoporosis Against Disability study (ROAD), a large-scale population-based cohort study, was performed between 2005 and 2007, and a follow-up survey was repeated 3 years later. Among 1690 participants at baseline, the change rate of the serum 25D levels were assessed in 1346 individuals (79.6 %; 458 men and 888 women) who completed measurements of 25D at both the baseline and follow-up examinations. The change rate was calculated, and the factors associated with the changes in the 25D levels were determined using multivariate regression analysis after adjustment for age, gender, body mass index, participated month, and regional differences at baseline.

RESULTS

The mean (standard deviation) change rate of the 25D levels in all subjects was 7.6 (13.3) %/year (men, 8.2 [12.4] %/year; women, 7.3 [13.7] %/year). Multivariate regression analysis indicated that higher bone mineral density at lumbar spine L2-4 (p = 0.05) and total daily energy intake (p = 0.04) were significantly associated with the change rate of the 25D levels.

CONCLUSIONS

The serum levels of 25D tended to increase over the 3-year period, and higher lumbar bone mineral density and daily energy intake were found to be associated with increases in the 25D levels over time.

Calcium intake and risk of fracture: systematic review

OBJECTIVE

To examine the evidence underpinning recommendations to increase calcium intake through dietary sources or calcium supplements to prevent fractures.

DESIGN

Systematic review of randomised controlled trials and observational studies of calcium intake with fracture as an endpoint. Results from trials were pooled with random effects meta-analyses.

DATA SOURCES

Ovid Medline, Embase, PubMed, and references from relevant systematic reviews. Initial searches undertaken in July 2013 and updated in September 2014.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials or cohort studies of dietary calcium, milk or dairy intake, or calcium supplements (with or without vitamin D) with fracture as an outcome and participants aged >50.

RESULTS

There were only two eligible randomised controlled trials of dietary sources of calcium (n=262), but 50 reports from 44 cohort studies of relations between dietary calcium (n=37), milk (n=14), or dairy intake (n=8) and fracture outcomes. For dietary calcium, most studies reported no association between calcium intake and fracture (14/22 for total, 17/21 for hip, 7/8 for vertebral, and 5/7 for forearm fracture). For milk (25/28) and dairy intake (11/13), most studies also reported no associations. In 26 randomised controlled trials, calcium supplements reduced the risk of total fracture (20 studies, n=58,573; relative risk 0.89, 95% confidence interval 0.81 to 0.96) and vertebral fracture (12 studies, n=48,967. 0.86, 0.74 to 1.00) but not hip (13 studies, n=56,648; 0.95, 0.76 to 1.18) or forearm fracture (eight studies, n=51,775; 0.96, 0.85 to 1.09). Funnel plot inspection and Egger's regression suggested bias toward calcium supplements in the published data. In randomised controlled trials at lowest risk of bias (four studies, n=44,505), there was no effect on risk of fracture at any site. Results were similar for trials of calcium monotherapy and co-administered calcium and vitamin D. Only one trial in frail elderly women in residential care with low dietary calcium intake and vitamin D concentrations showed significant reductions in risk of fracture.

CONCLUSIONS

Dietary calcium intake is not associated with risk of fracture, and there is no clinical trial evidence that increasing calcium intake from dietary sources prevents fractures. Evidence that calcium supplements prevent fractures is weak and inconsistent.

Breast cancer and osteoporosis - management of cancer treatment-induced bone loss in postmenopausal women with breast cancer

The incidence of breast cancer (BC) in postmenopausal women is continuously rising. Due to early diagnosis and various treatment designs, the long-term clinical outcome has improved. Frequent settings are chemotherapy as well as endocrine treatment. Both have proven to interfere with bone health resulting in cancer treatment-induced bone loss (CTIBL). Whereas chemotherapy is associated with increased bone resorption, aromatase inhibitor (AI) therapy reduces residual estrogen and is associated with decreased bone mineral density. Independent of the AI administered, the loss of bone mineral density is twice as high compared to healthy postmenopausal women. As a consequence of CTIBL, both chemotherapy and AI treatment can lead to a significantly increased fracture risk. Therefore, several guidelines have emerged for the management of CTIBL in women with BC, including strategies to identify and treat those at high risk for fractures. Further research on tracking guideline adherence examining the feasibility and practicability of guideline implementation to bridge the gap between determined scientific best evidence and applied best practice is needed to adjust these guidelines in the future.

The effect of calcium and vitamin D supplementation on osteoporotic rabbit bones studied by vibrational spectroscopy

Fourier transform infrared spectroscopy is utilized to examine the effects of increased calcium, vitamin D, and combined calcium-vitamin D supplementation on osteoporotic rabbit bones with induced inflammation. The study includes different bone sites (femur, tibia, humerus, vertebral rib) in an effort to explore possible differences among the sites. We evaluate the following parameters: mineral-to-matrix ratio, carbonate content, and non-apatitic species (labile acid phosphate and labile carbonate) contribution to bone mineral. Results show that a relatively high dose of calcium or calcium with vitamin D supplementation increases the bone mineralization index significantly. On the other hand, vitamin D alone is not as effective in promoting mineralization even with high intake. Mature B-type apatite was detected for the group with calcium supplementation similar to that of aged bone. High vitamin D intake led to increased labile species concentration revealing bone formation. This is directly associated with the suppression of pro-inflammatory cytokines linked to induced inflammation. The latter is known to adversely alter bone metabolism, contributing to the aetiopathogenesis of osteoporosis. Thus, a high intake of vitamin D under inflammation-induced osteoporosis does not promote mineralization but suppresses bone resorption and restores metabolic balance.

Vegetarian diets and bone status

Osteoporosis is a common chronic condition associated with progressive loss of bone mineral density (BMD) and compromised bone strength, with increasing risk of fracture over time. Vegetarian diets have been shown to contain lower amounts of calcium, vitamin D, vitamin B-12, protein, and n-3 (ω-3) fatty acids, all of which have important roles in maintaining bone health. Although zinc intakes are not necessarily lower quantitatively, they are considerably less bioavailable in vegetarian diets, which suggests the need for even higher intakes to maintain adequate status. At the same time, healthy vegetarian diets tend to contain more of several protective nutrients, including magnesium, potassium, vitamin K, and antioxidant and anti-inflammatory phytonutrients. On balance, there is evidence that vegetarians, and particularly vegans, may be at greater risk of lower BMD and fracture. Attention to potential shortfall nutrients through the careful selection of foods or fortified foods or the use of supplements can help ensure healthy bone status to reduce fracture risk in individuals who adhere to vegetarian diets.

Long-term dietary vitamin D intake and risk of fracture and osteoporosis: a longitudinal cohort study of Swedish middle-aged and elderly women

CONTEXT

The importance of dietary vitamin D for osteoporotic fracture prevention is uncertain.

OBJECTIVE

Our objective was to investigate associations between dietary vitamin D intake with risk of fracture and osteoporosis.

DESIGN AND PARTICIPANTS

In the population-based Swedish Mammography Cohort (including 61 433 women followed for 19 years), diet was assessed by repeated food frequency questionnaires.

SETTING

The study was conducted in 2 municipalities in central Sweden.

MAIN OUTCOME MEASURE

Incident fractures were identified from registry data. In a subcohort (n = 5022), bone mineral density was determined by dual-energy x-ray absorptiometry and serum 25-hydroxyvitamin D was measured using HPLC-tandem mass spectrometry.

RESULTS

A total of 14 738 women experienced any type of first fracture during follow-up, and 3871 had a hip fracture. Multivariable-adjusted hazard ratio (HR) for any first fracture was 0.96 (95% confidence interval, 0.92-1.01) for the lowest (mean, 3.1 μg/d) and 1.02 (0.96-1.07) for the highest (mean, 6.9 μg/d) quintile compared with the third quintile of vitamin D intake. The corresponding HR for a first hip fracture was 1.02 (0.96-1.08) for the lowest and 1.14 (1.03-1.26) for the highest quintile. Intakes >10 μg/d, compared with <5 μg/d, conferred an HR of 1.02 (0.92-1.13) for any fracture and an HR of 1.27 (1.03-1.57) for hip fracture. The intake of vitamin D did not affect the odds for osteoporosis, although higher levels were associated with higher bone mineral density (0.3%-2%, P < .0001). A positive association was observed between vitamin D intake and serum 25-hydroxyvitamin D.

CONCLUSIONS

Dietary intakes of vitamin D seem of minor importance for the occurrence of fractures and osteoporosis in community-dwelling Swedish women.

Nutritional education in the primary prevention of osteoporosis in perimenopausal and postmenopausal women

Osteoporosis affects millions of people in the whole world and brings about far-reaching physical and psycho-social consequences for patients and financial ones for the health care system, and therefore it is classified as one of public health problems and treated as a social disease. Women belong to the increased osteoporosis illness risk group due to lower top bone mass reached earlier in life as compared to men and due to hormonal changes occurring in the menopausal period, which affect loss of the bone mineral density (BMD). Limitation of the osteoporosis-related financial and social costs increase requires efficient preventive actions on the level of early, primary, secondary or tertiary prevention. At all the four osteoporosis prevention phases, the crucial role is played by health education and nutrition education, the latter being the key element of the former one. The nutritional education purpose is to acquaint patients with nutrition recommendations that are the basic element of the osteoporosis prevention and to make them change their nutrition habits, which will improve their osseous metabolism. The education should be based on results of the latest scientific researches and focus on recommendations relating to proper supplementing of calcium and vitamin D, simultaneously including all the other nutrition components, necessary to decrease the osteoporosis risk. The primary prevention oriented to a specific group at risk for osteoporosis, including peri- or postmenopausal women, should be provided in cooperation with the different levels’ medical professionals and it should focus on causing positive changes in patients both as regards nutrition habits and physical activities.

Calcium intake and osteoporosis: the influence of calcium intake from dairy products on hip bone mineral density and fracture incidence - a population-based study in women over 55 years of age

OBJECTIVE

The incidence of osteoporosis increases with age and is most frequently observed in postmenopausal women. The objective of the present population-based cohort study was to assess the influence of Ca intake from dairy sources on hip bone mineral density and hip fracture incidence in a group of Polish women over 55 years of age.

DESIGN

The main outcome measures included: bone mineral density, the number of previous fractures and the reported Ca intake from dairy sources, assessed by a diet questionnaire.

SETTING

The RAC-OST-POL Study was conducted in the District of Raciborz in the south of Poland.

SUBJECTS

The study was carried out in a group of 625 women, randomly recruited from the general population of women aged >55 years.

RESULTS

Median Ca intake from dairy products was lower in the group of women with femoral neck T-score ≤-2·5 than in the group with T-score >-2·5 (275 v. 383 mg/d; P = 0·0019). For total hip score, the difference was close to borderline significance (P = 0·0698). Median Ca intake from dairy products was lower in the group of women with previous fractures than in those without fracture history (336 v. 395 mg/d; P = 0·0254). The main dairy source of Ca in the analysed group included milk drinks, rennet cheese and milk.

CONCLUSIONS

Higher dairy Ca intake is recommended, since a number of the women analysed were unable to satisfy their Ca requirement exclusively from their diet.

Dairy products, dietary calcium and bone health: possibility of prevention of osteoporosis in women: the Polish experience

The objective of the study was to analyze the consumption of dairy products and dietary calcium by women in the context of bone mineral density and to assess opportunities to prevent osteoporosis in a dietary manner. The study was carried out with 712 Polish women. In 170 women aged 32 to 59 bone mineral density (BMD) was measured. The data on the consumption of dairy products and dietary calcium and some other osteoporosis risk factors was collected from 712 women. The average calcium intake from a diet was 507 mg/day. Only 2% of the women met Polish calcium intake recommendations. During adulthood, dairy product consumption or dietary calcium intake did not differ significantly between women with low BMD (below −1 SD) and women with regular BMD (≥−1 SD) (47.4 vs. 44.3 servings/week and 459 vs. 510 mg/day, respectively, p > 0.05). The odds ratios adjusted for age, menstruation and BMI in women with upper BMD tercile in comparison to the reference group (bottom tercile) was 2.73 (95% CI: 1.14, 6.55; p < 0.05) for the daily consumption of dairy products during the pre-school period and 2.40 (95% CI: 1.01, 5.70; p < 0.05) for the daily consumption of dairy products during the school period. Two clusters of women were established. In the S1 cluster, low BMD (below −1 SD) was associated with older age (≥50 years), lack of menstrual cycle. In the S2 cluster, regular BMD (≥−1 SD) was related to younger aged women (<50 years), presence of menstrual cycle, consumption of higher level of dairy products (≥28 servings/week) during adulthood and daily intake of dairy products during childhood and adolescence. The results indicate that good bone health to the large extent depended upon the combined impact of dietary factors and some non-modifiable risk factors of osteoporosis such as age and the presence of menstruation. Consumption of dairy products in childhood and adolescence may improve bone mineral density and reduce the risk of osteoporosis in adult women.

The association between osteoporosis and hypertension: the role of a low dairy intake

Hypertension and related cardiovascular diseases are reported to be associated with osteoporosis. A nutritional pathway related to dairy intake has been postulated for both diseases. The aim of this study was to assess calcium intake from dairy sources as a possible pathogenic link between osteoporosis and hypertension. This was a cross-sectional observational study performed on 3,301 postmenopausal women referred for a densitometry screening. Osteoporosis was diagnosed by lumbar dual-energy X-ray absorptiometry and hypertension was defined by blood pressure data and/or the use of antihypertensive medication. Dairy food consumption was evaluated using a weekly food-frequency questionnaire. The odds of being affected by osteoporosis, hypertension, or both diseases were calculated for quartiles of dairy intake by logistic regression analyses. Women with hypertension were affected more frequently by osteoporosis (33.2 vs. 23.3 %; p = 0.000), and there was a higher prevalence of hypertension among women with osteoporosis (32.2 vs. 22.5 %; p = 0.000). The proportion of women with hypertension, osteoporosis, and both diseases significantly increased across decreasing quartiles of dairy intake. A dairy intake in the lowest quartile was a significant predictor of osteoporosis [OR (95 % CI): 1.43 (1.12, 1.82)] and hypertension [OR (95 % CI): 1.46 (1.15, 1.85)] when compared to the highest quartile. Similarly, a low dairy intake was associated with increased odds to have both the diseases [OR (95 % CI): 1.60 (1.10, 2.34)]. From these results we conclude that osteoporosis and hypertension are associated in postmenopausal women, and a low dairy intake may increase the risk of both diseases, acting as a possible pathogenic link.

Anorexia and eating patterns in the elderly

Objectives

To evaluate the change in eating habits occurring in community- dwelling and institutionalized elderly subjects with senile anorexia.

Design

Cross- sectional, observational.

Setting

Community, nursing homes and rehabilitation or acute care facilities in four Italian regions.

Participants

A random sample of 526 subjects, aged 65 years and older (217 free living individuals, 213 residents in nursing homes, and 93 patients in rehabilitation and acute wards).

Measurements

All subjects underwent a multidimensional geriatric evaluation of: nutritional status, anthropometric parameters, health and cognitive status, depression, taste, chewing and swallowing function, and some hormones related to appetite. Diet variety was assessed, considering the frequency of consumption of different food groups (milk and dairy products; meat, fish, and eggs; cereals and derivatives; fruit and vegetables).

Results

In anorexic elderly subjects the global food intake was reduced, and the eating pattern was characterized by the reduced consumption of certain food groups (“meat, eggs and fish” and “fruit and vegetables”) whereas the frequency of consumption of milk and cereals remained almost unchanged. Nutritional parameters were significantly better in normal eating subjects and correlated with diet variety.

Conclusion

Because of the high prevalence of senile anorexia in the geriatric population and its impact on the nutritional status, further research should be prompted to establish an intervention. protocol allowing the early diagnosis of anorexia of aging, aimed at identifying its causes and at optimizing treatment of anorexic patients.

Aromatase inhibitor-associated bone loss and its management with bisphosphonates in patients with breast cancer

Postmenopausal women have an increased risk of osteopenia and osteoporosis due to loss of the bone-protective effects of estrogen. Disease-related processes may also contribute to the risk of bone loss in postmenopausal women with breast cancer. One of the most common and severe safety issues associated with cancer therapy for patients with breast cancer is bone loss and the associated increase in risk of fractures. This paper reviews the recent literature pertaining to aromatase inhibitor (AI)-associated bone loss, and discusses suggested management and preventative approaches that may help patients remain on therapy to derive maximum clinical benefit. A case study is presented to illustrate the discussion. We observed that AIs are in widespread use for women with hormone receptor-positive breast cancer and are now recommended as adjuvant therapy, either as primary therapy or sequential to tamoxifen, for postmenopausal women. AIs target the estrogen biosynthetic pathway and deprive tumor cells of the growth-promoting effects of estrogen, and AI therapies provide benefits to patients in terms of improved disease-free survival. However, there is a concern regarding the increased risk of bone loss with prolonged AI therapy, which can be managed in many cases with the use of bisphosphonates and other interventions (eg, calcium, vitamin D supplementation, exercise).

Vitamin D threshold to prevent aromatase inhibitor-related bone loss: the B-ABLE prospective cohort study

Aromatase inhibitor (AI)-related bone loss is associated with increased fracture rates. Vitamin D might play a role in minimising this effect. We hypothesised that 25-hydroxy-vitamin D concentrations [25(OH)D] after 3 months supplementation might relate to bone loss after 1 year on AI therapy. We conducted a prospective cohort study from January 2006 to December 2011 of a consecutive sample of women initiating AI for early breast cancer who were ineligible for bisphosphonate therapy and stayed on treatment for 1 year (N = 232). Serum 25(OH)D was measured at baseline and 3 months, and lumbar spine (LS) bone mineral density at baseline and 1 year. Subjects were supplemented with daily calcium (1 g) and vitamin D(3) (800 IU) and additional oral 16,000 IU every 2 weeks if baseline 25(OH)D was <30 ng/ml. Linear regression models were fitted to adjust for potential confounders. After 1 year on AI therapy, 232 participants experienced a significant 1.68 % [95 % CI 1.15-2.20 %] bone loss at LS (0.017 g/cm(2) [0.012-0.024], P < 0.0001). Higher 25(OH)D at 3 months protected against LS bone loss (-0.5 % per 10 ng/ml [95 % CI -0.7 to -0.3 %], adjusted P = 0.0001), and those who reached levels ≥40 ng/ml had reduced bone loss by 1.70 % [95 % CI 0.4-3.0 %; adjusted P = 0.005] compared to those with low 25(OH)D levels (<30 ng/ml). We conclude that improved vitamin D status using supplementation is associated with attenuation of AI-associated bone loss. For this population, the current Institute of Medicine target recommendation of 20 ng/ml might be too low to ensure good bone health.

Frequency of dairy consumption and functional disability in older persons

OBJECTIVES

To examine the association between dairy products consumption frequency and functional disability in older persons.

DESIGN

Data were from the 2005 Korea National Health and Nutrition Examination Survey (KNHANES), consisting of 747 (324 men, 423 women) aged 65 years and older living in the community. Frequencies of milk and milk products consumption were obtained using a food frequency questionnaire and functional disability was assessed using the instrumental activities of daily living (IADL) and ADL scales. Logistic regression analyses were conducted to examine the association of dairy consumption frequency with IADL and ADL disability.

RESULTS

In men, dietary intake of dairy products was associated with a significantly reduced risk of IADL disability after controlling for known functional disability risk factors and other dietary factors (p for trend, 0.038). Compared with men who consumed dairy products < 1 time/week, those who consumed ≥ 1 time/day had a reduced risk of IADL disability (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.13-0.91). Meanwhile, milk and milk products consumption was not significantly associated with ADL disability. In women, dairy products consumption was not significantly associated with physical disability.

CONCLUSION

Frequent milk and milk products consumption is inversely associated with IADL disability in older men. Further research is needed to ascertain the protective effect of dairy products consumption on functional disability in older persons.

Bone health in a prospective cohort of postmenopausal women receiving aromatase inhibitors for early breast cancer

OBJECTIVE

Baseline bone health in postmenopausal women is poorly characterized in prospective series of early breast cancer (EBC) patients candidates to aromatase inhibitor (AI) therapy. Our objective is to comprehensively evaluate bone health in a prospective clinical cohort of patients recruited prior to adjuvant AI therapy, with the aim of establishing potential AI impact on bone loss and fractures.

METHODS

From January 2006 to April 2010, we consecutively included 343 women with EBC who were about to start adjuvant AI therapy. Participants were assessed at baseline (before AI initiation) and at 3 months, with annual assessments thereafter. Bone mineral density (BMD), spine X-ray, bone metabolism (vitamin D [25(OH)D], bone turnover markers [BTM]), arthralgia and quality of life are measured.

RESULTS

Mean age was 61.9 years; 197 (57.4%) had been previously treated with tamoxifen; 145 (42.3%) were taking exemestane, 187 (54.5%) letrozole, and 11 (3.2%) anastrozole. Analysis of baseline data shows only 59 women (17.7%) had normal BMD; 200 (60.1%) had osteopenia and 74 (22.2%) had osteoporosis; 39 women (11.4%) had a prevalent fracture, 293 (89.1%) had 25(OH)D insufficiency (<30 ng/ml), and 61 (18.5%) severe deficiency (<10 ng/ml). Low 25(OH)D concentrations were associated with lower BMD and 233 (67.9%) participants had some degree of arthralgia.

CONCLUSIONS

Low bone mass, prevalent fractures and vitamin D insufficiency were highly prevalent among candidates to adjuvant AI for EBC. Therefore, it is crucial to assess BMD, prevalent fractures and 25(OH)D concentrations before starting AI therapy and during follow-up.

Whole bone mechanics and bone quality

BACKGROUND

The skeleton plays a critical structural role in bearing functional loads, and failure to do so results in fracture. As we evaluate new therapeutics and consider treatments to prevent skeletal fractures, understanding the basic mechanics underlying whole bone testing and the key principles and characteristics contributing to the structural strength of a bone is critical.

QUESTIONS/PURPOSES

We therefore asked: (1) How are whole bone mechanical tests performed and what are the key outcomes measured? (2) How do the intrinsic characteristics of bone tissue contribute to the mechanical properties of a whole bone? (3) What are the effects of extrinsic characteristics on whole bone mechanical behavior? (4) Do environmental factors affect whole bone mechanical properties?

METHODS

We conducted a PubMed search using specific search terms and limiting our included articles to those related to in vitro testing of whole bones. Basic solid mechanics concepts are summarized in the context of whole bone testing and the determinants of whole bone behavior.

RESULTS

Whole bone mechanical tests measure structural stiffness and strength from load-deformation data. Whole bone stiffness and strength are a function of total bone mass and the tissue geometric distribution and material properties. Age, sex, genetics, diet, and activity contribute to bone structural performance and affect the incidence of skeletal fractures.

CONCLUSIONS

Understanding and preventing skeletal fractures is clinically important. Laboratory tests of whole bone strength are currently the only measures for in vivo fracture prediction. In the future, combined imaging and engineering models may be able to predict whole bone strength noninvasively.

Calcium intake in the United States from dietary and supplemental sources across adult age groups: new estimates from the National Health and Nutrition Examination Survey 2003-2006

BACKGROUND

Adequate lifelong calcium intake is essential in optimizing bone health. Recent National Health and Nutrition Examination Survey data were used to quantify variation in calcium intake across adult age groups and to relate age-associated changes in calcium intake with energy intake. Additional goals were to assess differences in dietary calcium intake between supplemental calcium users and nonusers and to evaluate associations between age and calcium density in the diet.

DESIGN

This cross-sectional analysis determined calcium and energy intake for National Health and Nutrition Examination Survey respondents during 2003-2006. Diet was assessed with 24-hour recall and supplement use via questionnaire. Trends in median intakes for dietary calcium, total calcium, and energy across age categories were assessed using survey analysis methods. Nutrient density was represented using calcium to energy intake ratios.

RESULTS

The analyses included data from 9,475 adults. When compared to the 19- to 30-year age group, median dietary calcium intake was lower in the ≥81-year age group by 23% in men (P<0.001) and by 14% in women (P=0.003). These reductions coincided with 35% and 28% decreases, respectively, in median energy intake (P<0.001 for each sex). In contrast, the frequency of calcium supplement use increased (P<0.001) with age in both men and women. Yet, among female supplement users, the decline in median dietary calcium intake was greater than in nonusers (P=0.02). Calcium density in the diet significantly increased relative to age in men and women (P<0.001 for each sex); however, dietary and total calcium to energy ratios were insufficient to meet target ratios inferred by adequate intake standards after age 50 years.

CONCLUSIONS

Although supplemental calcium use and calcium density were highest in older age groups, they were not sufficient in meeting recommended levels. New approaches to increasing the frequency and level of calcium supplement use to enhance calcium density in diets may be necessary to reduce osteoporosis risk among older Americans.

Nutritional aspects of the prevention and treatment of osteoporosis

Osteoporosis is a global health problem characterized by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture. Nutrition plays a critical role in reducing the risk of osteoporosis through its effect on all of these fragility factors, especially on the development and maintenance of bone mass. An adequate calcium, vitamin D and protein intake resulted in reduced bone remodeling, better calcium retention, reduced age-related bone loss, and reduced fracture risk. Recent evidence indicates that a healthy dietary pattern including dairy products (mainly fat free), fruit and vegetables and adequate amounts of meat, fish and poultry is positively related to bone health. Furthermore, mineral and vitamin supplementation should be closely monitored by health professionals since it could have adverse effects and be insufficient to ensure optimal protection of bone health.

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.

Tanning predicts bone mass but not structure in adolescent females living in Hawaii

OBJECTIVES

To evaluate the relationship between facultative skin pigmentation, which predicts circulating levels of plasma 25-hydroxymitamin D, and several measures of bone mass and structure in a cross sectional sample of adolescent females living in Hawaii.

METHODS

Our sample was composed of adolescent females (n = 94) living in Hawaii where seasonal sun exposure is minimal, and who self-identified as either white (n = 16) or Asian (n = 78). Bone mineral content (BMC) of the total body, the lumbar spine and the hip, and cross sectional area (CSA) and section modulus (Z) at the proximal femur were quantified using DXA. Facultative skin pigmentation was measured at the forehead and non-facultative skin pigmentation was measured at the inner arm using a Chroma Meter CR-200b colorimeter.

RESULTS

There were no significant differences between ethnic groups in terms of skin pigmentation. The difference between a* taken at the forehead and inner upper arm significantly predicted BMC at the lumbar spine, total hip, and total body. Other measures of skin pigmentation were not significant predictors of any other measure of skeletal integrity.

CONCLUSIONS

The difference between facultative and non-facultative skin pigmentation for a* is a significant predictor BMC, but not bone structure. Our findings are limited by an inability to control for long term UVA and UVB exposure and lack of a measure of serum 25(OH)D status. Further research is needed to examine these questions, particularly in populations who live at high latitudes where a winter season limits vitamin D(3) synthesis.

Aromatase inhibitor-associated bone and musculoskeletal effects: new evidence defining etiology and strategies for management

Aromatase inhibitors are widely used as adjuvant therapy in postmenopausal women with hormone receptor-positive breast cancer. While the agents are associated with slightly improved survival outcomes when compared to tamoxifen alone, bone and musculoskeletal side effects are substantial and often lead to discontinuation of therapy. Ideally, the symptoms should be prevented or adequately treated. This review will focus on bone and musculoskeletal side effects of aromatase inhibitors, including osteoporosis, fractures, and arthralgias. Recent advances have been made in identifying potential mechanisms underlying these effects. Adequate management of symptoms may enhance patient adherence to therapy, thereby improving breast cancer-related outcomes.

Vitamin D deficiency and bone mineral density in postmenopausal women receiving aromatase inhibitors for early breast cancer

OBJECTIVE

Aromatase inhibitors (AI) treatment leads to an increased risk of bone loss and fractures. In a group of women with early breast cancer (EBC) and baseline Vitamin D deficiency (<30 ng/ml) who are treated with AI, we aim to describe: serum levels of Vitamin D, bone mineral density (BMD), calcium intake, and the increase of serum 25(OH)D accomplished in 3 months of treatment with Vitamin D supplements.

STUDY DESIGN

Prospective, non-randomized clinical trial.

METHODS

In 232 consecutively included women with EBC in treatment with AI, we assessed baseline calcium intake, serum levels of 25(OH)D, BMD and, spine X-ray. All received Calcium and Vitamin D supplements, and those with vitamin deficiency received 16,000 IU Vitamin D every 2 weeks. Serum levels of 25(OH)D were newly assessed after treatment. All the baseline evaluation was performed before starting AI treatment.

RESULTS

Mean age at baseline (+/-SD) was 63.2+/-8.8 years. In 150 (64.9%) cases, the women had been treated previously with tamoxifen; 101 (43.7%) started exemestane, 119 (51.5%) letrozole, and 11 (4.8%) anastrozole. The AI were initiated within 6 weeks after surgery or after the last cycle of chemotherapy. At baseline, 88.1% had 25(OH)D levels <30 ng/ml, 21.2% had severe deficiency (<10 ng/ml), and 25% of the participants had osteoporosis. Mean daily calcium intake was low (841+/-338). We found a significant association between 25(OH)D levels and BMD at baseline, which remained significant in femoral neck BMD after multivariate adjustment. Plasma 25(OH)D levels improved significantly at 3 months follow-up in those treated with high dose Vitamin D supplements: mean increase 32.55 ng/ml (95%CI 28.06-37.03).

CONCLUSIONS

Our study suggests a high prevalence of commonly unrecognized Vitamin D deficiency in women with EBC treated with AI, a known osteopenic agent. Our results support the need for a routine assessment of 25(OH)D levels and, when necessary, supplementation in these patients.

Updated fracture incidence rates for the US version of FRAX

On the basis of updated fracture and mortality data, we recommend that the base population values used in the US version of FRAX be revised. The impact of suggested changes is likely to be a lowering of 10-year fracture probabilities.

INTRODUCTION

Evaluation of results produced by the US version of FRAX indicates that this tool overestimates the likelihood of major osteoporotic fracture. In an attempt to correct this, we updated underlying fracture and mortality rates for the model.

METHODS

We used US hospital discharge data from 2006 to calculate annual age- and sex-specific hip fracture rates and age-specific ratios to estimate clinical vertebral fracture rates. To estimate the incidence of any one of four major osteoporotic fractures, we first summed these newly derived hip and vertebral fracture estimates with Olmsted County, MN, wrist and upper humerus fracture rates, and then applied 10-20% discounts for overlap.

RESULTS

Compared with rates used in the current FRAX tool, 2006 hip fracture rates are about 16% lower, with greatest reductions observed among those below age 65 years; major osteoporotic fracture rates are about one quarter lower, with similar reductions across all ages.

CONCLUSIONS

We recommend revising the US-FRAX by updating current base population values for hip fracture and major osteoporotic fracture. The impact of these revisions on FRAX is likely to be lowering of 10-year fracture probabilities, but more precise estimates of the impact of these changes will be available after these new rates are incorporated into the FRAX tool.

Predicting ambient ultraviolet from routine meteorological data; its potential use as an instrumental variable for vitamin D status in pregnancy in a longitudinal birth cohort in the UK

BACKGROUND

Maternal vitamin D status in pregnancy has been postulated to have important effects on intrauterine development. UVB radiation is not commonly measured but is the prime determinant of circulating 25-hydroxyvitamin-D [25-(OH)D] and is highly dependent on regional weather including cloud cover, ozone and sunshine hours.

METHODS

Using linear regression we described the relationship between estimated ambient-erythemal ultraviolet (eUV) exposure in Oxford (1990-95) and total hours of sunshine and month in order to forecast eUV in nearby regions, whilst adjusting for regional variations in weather. The forecast was validated with empirical data collected from Cornwall and then predicted for the Avon region. Total 98-day prenatal ambient-eUV was then predicted in 355 expectant mothers in the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort and its relationship with maternal vitamin D status was determined.

RESULTS

Estimated ambient-eUV was strongly associated with measured ambient-eUV (r(2) = 0.989) with a near 1:1 prediction for the validation data set [beta = 0.99, 95% confidence interval (CI) 0.913, 1.067 r(2) = 0.980]; strong seasonal associations were observed between eUV in the last trimester of pregnancy and maternal serum 25-(OH)D concentrations (r(2) = 0.40).

CONCLUSION

This technique of prediction could be applied to existing cohorts allowing the relationship between maternal vitamin D status and the health of the offspring to be studied via instrumental variable analysis.

Dairy and bone health

Bone health is the resultant of bone mass, bone architecture, and body mechanics. Nutrition supports all three components, with the principal nutrients concerned being calcium, protein, and vitamin D. Potassium, magnesium, zinc, and several vitamins are also involved to varying extents. Given modern food sources, it is difficult to devise a diet that is "bone healthy" without including three servings of dairy per day, not just because of dairy calcium, but dairy protein and potassium as well.