Physical activity in middle-aged women and hip fracture risk: the UFO study

Associations of accelerometer-estimated free-living daily activity impact intensities with 10-year probability of osteoporotic fractures in adults

PURPOSE

Accelerometers are used to objectively measure physical activity; however, the relationship between accelerometer-based activity parameters and bone health is not well understood. This study examines the association between accelerometer-estimated daily activity impact intensities and future risk estimates of major osteoporotic fractures in a large population-based cohort.

METHODS

Participants were 3165 adults 46 years of age from the Northern Finland Birth Cohort 1966 who agreed to wear a hip-worn accelerometer during all waking hours for 14 consecutive days. Raw accelerometer data were converted to resultant acceleration. Impact magnitude peaks were extracted and divided into 32 intensity bands, and the osteogenic index (OI) was calculated to assess the osteogenic effectiveness of various activities. Additionally, the impact peaks were categorized into three separate impact intensity categories (low, medium, and high). The 10-year probabilities of hip and all major osteoporotic fractures were estimated with FRAX-tool using clinical and questionnaire data in combination with body mass index collected at the age of 46 years. The associations of daily activity impact intensities with 10-year fracture probabilities were examined using three statistical approaches: multiple linear regression, partial correlation, and partial least squares (PLS) regression.

RESULTS

On average, participants' various levels of impact were 8331 (SD = 3478) low; 2032 (1248) medium; and 1295 (1468) high impacts per day. All three statistical approaches found a significant positive association between the daily number of low-intensity impacts and 10-year probability of hip and all major osteoporotic fractures. In contrast, increased number of moderate to very high daily activity impacts was associated with a lower probability of future osteoporotic fractures. A higher OI was also associated with a lower probability of future major osteoporotic fractures.

CONCLUSION

Low-intensity impacts might not be sufficient for reducing fracture risk in middle-aged adults, while high-intensity impacts could be beneficial for preventing major osteoporotic fractures.

Assessing the association between a sedentary lifestyle and prevalence of primary osteoporosis: a community-based cross-sectional study among Chinese population

OBJECTIVES

To reveal the association between a sedentary lifestyle and the prevalence of primary osteoporosis (POP).

DESIGN

A community-based cross-sectional study was conducted.

SETTING

This study was conducted in communities in Hefei city, Anhui province, China.

PARTICIPANTS

A total of 1346 residents aged 40 and above underwent POP screening via calcaneus ultrasound bone mineral density (BMD) testing and completed a questionnaire survey.

OUTCOME MEASURES

The average daily sitting time was included in the study variable and used to assess sedentary behaviour. The 15 control variables included general information, dietary information and life behaviour information. Logistic regression was used to analyse the association between the POP prevalence and study or control variables in different models.

RESULTS

1346 participants were finally included in the study. According to the 15 control variables, the crude model and 4 models were established. The analysis revealed that the average daily sitting time showed a significant correlation with the prevalence of POP in the crude model (OR=2.02, 95% CI=1.74 to 2.36, p<0.001), Model 1 (OR=2.65, 95% CI=2.21 to 3.17, p<0.001), Model 2 (OR=2.63, 95% CI=2.19 to 3.15, p<0.001), Model 3 (OR=2.62, 95% CI=2.18 to 3.15, p<0.001) and Model 4 (OR=2.58, 95% CI=2.14 to 3.11, p<0.001). Besides, gender, age and body mass index showed a significant correlation with the POP prevalence in all models.

CONCLUSIONS

This study suggests a potential association between a sedentary lifestyle and the prevalence of POP within the Chinese population. Modifying sedentary behaviours could contribute to a reduction in POP risk. However, longitudinal cohort studies are necessary to confirm this hypothesis in the future.

Modifiable lifestyle factors associated with fragility hip fracture: a systematic review and meta-analysis

INTRODUCTION

Among the various hip fracture predictors explored to date, modifiable risk factors warrant special consideration, since they present promising targets for preventative measures. This systematic review and meta-analysis aims to assess various modifiable risk factors.

MATERIAL AND METHODS

We searched four online databases in September 2017. We included studies that reported on modifiable lifestyle risk factors for sustaining fragility hip fractures. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS). The inclusion criteria consisted of (1) adult patients with osteoporotic hip fracture, (2) original study, (3) availability of full text articles in English, and (4) report of a modifiable lifestyle risk factor.

RESULTS

Thirty-five studies, containing 1,508,366 subjects in total, were included in this study. The modifiable risk factors that were significantly associated with an increased risk of hip fracture were the following: weight < 58 kg (128 lbs) (pooled OR 4.01, 95% CI 1.62-9.90), underweight body mass index (BMI) (< 18.5) (pooled OR 2.83, 95% CI 1.82-4.39), consumption of ≥ 3 cups of coffee daily (pooled OR 2.27, 95% CI 1.04-4.97), inactivity (pooled OR 2.14, 95% CI 1.21-3.77), weight loss (pooled OR 1.88, 95% CI 1.32-2.68), consumption of ≥ 27 g (approx. > 2 standard drinks) alcohol per day (pooled OR 1.54, 95% CI 1.12-2.13), and being a current smoker (pooled OR 1.50, 95% CI 1.22-1.85). Conversely, two factors were significantly associated with a decreased risk of hip fracture: obese BMI (> 30) (pooled OR 0.58, 95% CI 0.34-0.99) and habitual tea drinking (pooled OR 0.72, 95% CI 0.66-0.80).

CONCLUSION

Modifiable factors may be utilized clinically to provide more effective lifestyle interventions for at risk populations. We found that low weight and underweight BMI carried the highest risk, followed by high coffee consumption, inactivity, weight loss, and high daily alcohol consumption.

Effects of changes in regular physical activity status on hip fracture: A nationwide population-based cohort study in Korea

Objective

Hip fracture incidence is increasing with rapid aging of the population and regular physical activity (RPA) is an important modifiable protective factor for fracture. However, the association between the risk of hip fractures and changes in RPA status in the general population remains unknown. Thus, we explore the association between the risk of hip fracture and changes in RPA status.

Methods

We studied 4,984,144 individuals without fractures within a year whose data were registered in the Korean National Health Insurance Service database. Baseline physical activity level was assessed using a standardized self-reported questionnaire during two consecutive national health screening surveys performed in Korea from 2009 to 2012. The risk of hip fracture between 2013 and 2016 according to change in RPA was prospectively analyzed. Participants were divided into those who were always inactive, became inactive, became active, and were always active.

Results

Compared to participants who were always inactive, those who became inactive exhibited a 0.12/1,000 person-years (PY) reduction in hip fracture incidence rate (IR) [aHR: 0.865; 95% confidence interval (CI): 0.824–0.908]. Participants who became active, and those who were always active, exhibited a 0.24/1,000 PY reduction in IR (aHR: 0.827; 95% CI: 0.787–0.870) and a 0.39/1,000 PY reduction in IR (aHR: 0.691; 95% CI: 0.646–0.740), respectively.

Conclusion

Changes in RPA status were associated with the risk of hip fracture; consistent RPA was related to the maximum benefit for risk reduction in the general population.

Gender and Age Differences in Hip Fracture Types among Elderly: a Retrospective Cohort Study

Objectives: To investigate the differences in distribution of intracapsular and extracapsular hip fractures among genders and age groups treated surgically. Materials and methods: This is a nine-year retrospective cohort study. The type of hip fractures, age, and sex-related as well as overall incidence among 2 430 patients aged over 65, surgically treated at the "Venizeleio" General Hospital of Heraklion, Crete, Greece, were explored and evaluated. Outcomes: Women suffered hip fractures 2.9 times more often than men. The majority of patients hospitalized with hip fracture were above 75 years of age (62.3% in females and 59.3% in males). The proportion of extracapsular and intracapsular fractures were 59.6% and 40.4% in men and 62.7% and 37.2% in women, respectively. Extracapsular-intertrochanteric fractures were found to increase dramatically with age in women (from 52.3% in patients younger than 75 to 58.8% in those older than 75; p-value=0.007), while in men they slightly increased with age (57.7% in patients older than 75, compared to 55.7% in those less than 75; p-value=0.62). Conclusion: The pattern of hip fractures was found to differ between genders and age groups in the present patients' population. Most likely, these findings reflect differences in the nature and rate of bone loss, and frequency of falling events between males and females. It has become evident that the two main hip fracture types (extracapsular and intracapsular) are distinct clinical entities. Hence, they should be addressed independently in terms of underlying causes and prevention strategies.

BMD-Related Genetic Risk Scores Predict Site-Specific Fractures as Well as Trabecular and Cortical Bone Microstructure

CONTEXT

It is important to identify patients at highest risk of fractures.

OBJECTIVE

To compare the separate and combined performances of bone-related genetic risk scores (GRSs) for prediction of forearm, hip and vertebral fractures separately, as well as of trabecular and cortical bone microstructure parameters separately.

DESIGN, SETTING, AND PARTICIPANTS

Using 1103 single nucleotide polymorphisms (SNPs) independently associated with estimated bone mineral density of the heel (eBMD), we developed a weighted GRS for eBMD and determined its contribution to fracture prediction beyond 2 previously developed GRSs for femur neck BMD (49 SNPs) and lumbar spine BMD (48 SNPs). Associations between these GRSs and forearm (ncases = 1020; ncontrols = 2838), hip (ncases = 1123; ncontrols = 2630) and vertebral (ncases = 288; ncontrols = 1187) fractures were evaluated in 3 Swedish cohorts. Associations between the GRSs and trabecular and cortical bone microstructure parameters (n = 426) were evaluated in the MrOS Sweden cohort.

RESULTS

We found that eBMDGRS was the only significant independent predictor of forearm and vertebral fractures while both FN-BMDGRS and eBMDGRS were significant independent predictors of hip fractures. The eBMDGRS was the major GRS contributing to prediction of trabecular bone microstructure parameters while both FN-BMDGRS and eBMDGRS contributed information for prediction of cortical bone microstructure parameters.

CONCLUSIONS

The eBMDGRS independently predicts forearm and vertebral fractures while both FN-BMDGRS and eBMDGRS contribute independent information for prediction of hip fractures. We propose that eBMDGRS captures unique information about trabecular bone microstructure useful for prediction of forearm and vertebral fractures. These findings may facilitate personalized medicine to predict site-specific fractures as well as cortical and trabecular bone microstructure separately.

Physical activity and skeletal health in adults

The purpose of this Review is to examine the associations between physical activity and skeletal health, with an emphasis on observational studies with fracture outcomes and randomised controlled trials (RCTs) of physical activity interventions in adults older than 40 years. In general, increased physical activity-primarily leisure time activity or moderate or vigorous physical activity-is associated with a 1-40% lower risk of hip and all fractures. The primary limitation of these studies relates to health status; healthy people are more likely to exercise and less likely to fracture. Although there is no sufficiently powered RCT of exercise with a fracture outcome, there is evidence that some types of exercise prevent falls and bone loss, and meta-analyses support the anti-fracture effectiveness of exercise. RCTs and meta-analyses suggest that programmes combining impact exercise with moderate or high-intensity progressive resistance exercise might maintain or improve bone mass and prevent fractures, and that functional strength and balance training prevents falls.

Low risk for hip fracture and high risk for hip arthroplasty due to osteoarthritis among Swedish farmers

We aimed to study the risk of hip fracture and risk of hip arthroplasty among farmers in Sweden. Our results indicate that farming, representing an occupation with high physical activity, in men is associated with a lower risk of hip fracture but an increased risk of hip arthroplasty.

INTRODUCTION

The risks of hip fracture and hip arthroplasty are influenced by factors including socioeconomic status, education, urbanization, latitude of residence, and physical activity. Farming is an occupation encompassing rural living and high level of physical activity. Therefore, we aimed to study the risk of hip fracture and risk of hip arthroplasty among farmers in Sweden.

METHODS

We studied the risk of hip fracture, and hip arthroplasty due to primary osteoarthritis, in all men and women aged 35 years or more in Sweden between 1987 and 2002. Documented occupations were available in 3.5 million individuals, of whom 97,136 were farmers. The effects of age, sex, income, education, location of residence, and occupation on risk of hip fracture or hip arthroplasty were examined using a modification of Poisson regression.

RESULTS

A total of 4027 farmers and 93,109 individuals with other occupations sustained a hip fracture, while 5349 farmers and 63,473 others underwent a hip arthroplasty. Risk of hip fracture was higher with greater age, lower income, lower education, higher latitude, and urban area for all men and women. Compared to all other occupations, male farmers had a 20% lower age-adjusted risk of hip fracture (hazard ratio (HR) 0.80, 95%CI 0.77-0.84), an effect that was not seen in female farmers (HR 0.96, 95% CI 0.91-1.01). Both male and female farmers had a higher age-adjusted risk for hip arthroplasty.

CONCLUSIONS

Our results indicate that farming, representing an occupation with high physical activity, in men is associated with a lower risk of hip fracture but an increased risk of hip arthroplasty.

Germline genetics of cancer of unknown primary (CUP) and its specific subtypes

Cancer of unknown primary site (CUP) is a fatal cancer diagnosed through metastases at various organs. Little is known about germline genetics of CUP which appears worth of a search in view of reported familial associations in CUP. In the present study, samples from CUP patients were identified from 2 Swedish biobanks and a German clinical trial, totaling 578 CUP patients and 7628 regionally matched controls. Diagnostic data specified the organ where metastases were diagnosed. We carried out a genome-wide association study on CUP cases and controls. In the whole sample set, 6 loci reached an allelic p-value in the range of 10-7 and were supported by data from the three centers. Three associations were located next to non-coding RNA genes. rs2660852 flanked 5'UTR of LTA4H (leukotriene A4 hydrolase), rs477145 was intronic to TIAM1 (T-cell lymphoma invasion and metastases) and rs2835931 was intronic to KCNJ6 (potassium channel, inwardly rectifying subfamily J, member 6). In analysis of subgroups of CUP patients (smokers, non-smokers and CUP with liver metastases) genome-wide significant associations were noted. For patients with liver metastases associations on chromosome 6 and 11, the latter including a cluster of genes DHCR7 and NADSYN1, encoding key enzymes in cholesterol and NAD synthesis, and KRTAP5-7, encoding a keratin associated protein. This first GWAS on CUP provide preliminary evidence that germline genes relating to inflammation (LTA4H), metastatic promotion (TIAM1) in association with lipid metabolic disturbance (chromosome 11 cluster) may contribute to the risk of CUP.

Defining the genetic susceptibility to cervical neoplasia-A genome-wide association study

A small percentage of women with cervical HPV infection progress to cervical neoplasia, and the risk factors determining progression are incompletely understood. We sought to define the genetic loci involved in cervical neoplasia and to assess its heritability using unbiased unrelated case/control statistical approaches. We demonstrated strong association of cervical neoplasia with risk and protective HLA haplotypes that are determined by the amino-acids carried at positions 13 and 71 in pocket 4 of HLA-DRB1 and position 156 in HLA-B. Furthermore, 36% (standard error 2.4%) of liability of HPV-associated cervical pre-cancer and cancer is determined by common genetic variants. Women in the highest 10% of genetic risk scores have approximately >7.1% risk, and those in the highest 5% have approximately >21.6% risk, of developing cervical neoplasia. Future studies should examine genetic risk prediction in assessing the risk of cervical neoplasia further, in combination with other screening methods.

Around 1% of women with cervical human papillomavirus (HPV) infection progress to cervical cancer. Previous studies had indicated that a person’s genetic makeup could predispose to HPV-associated cervical cancer, and that some of the genes likely to be involved include the immune-related human leukocyte antigen (HLA) genes among the major histocompatibility complex (MHC). However, it has been difficult to determine which alleles might be associated with cervical pre-cancer or cancer due to the complex and high level of co-inheritance of MHC alleles. Here, we performed a genome-wide association study that assessed the correlation of genetic variants among those with cervical cancer and healthy controls. We show that host genetics is a major determinant of HPV-associated cervical cancer, with 36% of liability due to common genetic variants in the population, and identify both risk and protective HLA alleles. Our study was also sufficiently powerful to identify particular residue variants on a number of the immune-related proteins that provide risk or protection, providing further insight into the biological basis for cervical cancer development. Our findings could lay the foundation for screening for people at increased risk of developing cancer following HPV infection, and aid in the treatment and prognosis of cervical cancer.

Exercise, muscle, and the applied load-bone strength balance

A fracture occurs when the applied load is greater than the bone can withstand. Clinical practice guidelines for the management of osteoporosis include recommendations for exercise; one of the few therapies where the proposed anti-fracture mechanisms that include effects on both bone strength and applied loads, where applied loads can come in the form of a fall, externally applied loads, body weight, or muscle forces. The aim of this review is to provide an overview of the clinical evidence pertaining to the potential efficacy of exercise for preventing fractures in older adults, including its direct effects on outcomes along the causal pathway to fractures (e.g., falls, posture, bone strength) and the indirect effects on muscle or the muscle-bone relationship. The evidence is examined as it pertains to application in clinical practice. Considerations for future research are discussed, such as the need for trials in individuals with low bone mass or students that evaluate whether changes in muscle mediate changes in bone. Future trials should also consider adequacy of calorie or protein intake, the confounding effect of exercise-induced weight loss, or the most appropriate therapeutic goal (e.g., strength, weight bearing, or hypertrophy) and outcome measures (e.g., fracture, disability, cost-effectiveness).

High Cardiorespiratory Fitness Is Associated with Reduced Risk of Low Bone Density in Postmenopausal Women

PURPOSE

The goal of this study was to determine the association between cardiorespiratory fitness (CRF) and bone mineral density (BMD) of the femoral neck (FN) in postmenopausal women using existing Cooper Center Longitudinal Study data.

MATERIALS AND METHODS

A cohort of 1,720 predominantly healthy Caucasian women (57.1 ± 6.9 years) underwent preventive medical examinations that included CRF assessment by maximal Balke treadmill testing and measurement of BMD by dual-energy X-ray absorptiometry. CRF was estimated from total treadmill time and categorized into five categories of CRF (further defined as fitness category 1 = low fitness, 2-3 = moderate fitness, and 4-5 = high fitness). Logistic regression was used to characterize the association between CRF and BMD, adjusting for age, weight, and resistance activity level.

RESULTS

Overall, the mean body-mass index (BMI) for all subjects was 25.0 ± 4.5 kg/m2, although BMI was in the obese range in the low fitness group. The prevalence of osteoporosis (T-score ≤ -2.5 at the FN) was greater in the low fit group than moderate or high fit (5.8% vs. 3.0% or 3.9%, respectively); with a similar pattern seen for prevalence of osteopenia (T-score > -2.5 and ≤ -1.0 at the FN) (47.5% vs. 46.4% or 44.8%, respectively). Higher age and lower weight were associated with low BMD. Fully adjusted logistic regression models showed an inverse association between CRF and low BMD of the FN. For T-score ≤ -1.0, the primary outcome, the odds ratio (OR) was 0.50 (95% confidence interval [CI] 0.32-0.79) for moderate fitness, and OR of 0.32 (95% CI 0.21-0.51) for high fitness was seen. For T-score ≤ -2.5 at the FN, OR was 0.30 (95% CI 0.11-0.80) for moderate fitness, and OR was 0.29 (95% CI 0.12-0.71) for high fitness.

CONCLUSION

Increased CRF levels are associated with reduced risk for low bone density in postmenopausal women.

Increasing Level of Leisure Physical Activity Could Reduce the Risk of Hip Fracture in Older Women: A Dose-Response Meta-analysis of Prospective Cohort Studies

We carried out the study to investigate and quantitatively assess the potential association between current level of physical activity and the risk of osteoporosis hip fracture in older women. Relevant publications before October 2015 were identified using the PubMed and Ovid searching tools. A dose-response meta-analysis was carried out to combine and analysis results. Fourteen prospective studies were included in the meta-analysis. A general analysis of 9 studies showed a significant inverse relationship between increasing level of physical activity and risk of hip fracture in older women [relative risk (RR) = 0.93, 95% confidence interval (95% CI): 0.91-0.96]. The result of a sensitivity analysis was consistent with the general analysis (RR = 0.94, 95% CI: 0.93-0.96). The association between increasing level of physical activity and risk of wrist fracture was not statistically significant in a general analysis of three studies (RR = 1.004, 95% CI: 0.98-1.03). A potential direct association between increasing level of physical activity and risk of wrist fracture was observed after removing 1 study with the greatest weight (RR = 1.01, 95% CI: 1.00-1.03). No significant publication bias was observed in our analysis. Our results show that increasing level of physical activity within an appropriate range may reduce the risk of hip fracture but not the risk of wrist fracture in older women.

Behavioural Risk Factors in Mid-Life Associated with Successful Ageing, Disability, Dementia and Frailty in Later Life: A Rapid Systematic Review

BACKGROUND

Smoking, alcohol consumption, poor diet and low levels of physical activity significantly contribute to the burden of illness in developed countries. Whilst the links between specific and multiple risk behaviours and individual chronic conditions are well documented, the impact of these behaviours in mid-life across a range of later life outcomes has yet to be comprehensively assessed. This review aimed to provide an overview of behavioural risk factors in mid-life that are associated with successful ageing and the primary prevention or delay of disability, dementia, frailty and non-communicable chronic conditions.

METHODS

A literature search was conducted to identify cohort studies published in English since 2000 up to Dec 2014. Multivariate analyses and a minimum follow-up of five years were required for inclusion. Two reviewers screened titles, abstracts and papers independently. Studies were assessed for quality. Evidence was synthesised by mid-life behavioural risk for a range of late life outcomes.

FINDINGS

This search located 10,338 individual references, of which 164 are included in this review. Follow-up data ranged from five years to 36 years. Outcomes include dementia, frailty, disability and cardiovascular disease. There is consistent evidence of beneficial associations between mid-life physical activity, healthy ageing and disease outcomes. Across all populations studied there is consistent evidence that mid-life smoking has a detrimental effect on health. Evidence specific to alcohol consumption was mixed. Limited, but supportive, evidence was available relating specifically to mid-life diet, leisure and social activities or health inequalities.

CONCLUSIONS

There is consistent evidence of associations between mid-life behaviours and a range of late life outcomes. The promotion of physical activity, healthy diet and smoking cessation in all mid-life populations should be encouraged for successful ageing and the prevention of disability and chronic disease.

Influence of repeated effort induced by a 6-min walk test on postural response in older sedentary women

According to the latest recommendations, adults should exercise regularly at moderate intensity to improve aerobic fitness and body composition. However, it is unknown whether aerobic exercise at submaximal intensity has detrimental effects on balance in older sedentary adults. We explored the effects of two 6-min walk tests (6MWTs) on the postural responses in 49 sedentary women between 60 and 76 years old. We assumed that an increase in the center of pressure (COP) fluctuations or a loss in the complexity of the COP time series would be a sign of a deleterious effect on balance. We used kinematic stabilometric parameters, recurrence quantification analysis (RQA) and the central tendency measure (CTM). We refer to the measures obtained through RQA and CTM methods by dynamical measures. Repeated-measures analysis of variance showed no significant differences between the three sets of postural kinematic measures (before vs. after the first vs. after the second 6MWT). However, we observed significant differences between the three sets for the CTM measure in the antero-posterior direction (p < 0.002), RQA determinism in the medio-lateral (ML) direction (p < 0.0001), and RQA entropy in the ML direction (F = 5.93; p < 0.004).Our results indicate that the effects of moderate-intensity walking exercise on posture are not revealed by classical postural kinematic measures but only by dynamical measures. The loss of complexity in the COP time series observed after both the first and second 6MWTs may indicate presymptomatic deterioration in the postural adaptive capabilities of sedentary older women.

Occupational physical demand and risk of hip fracture in older women

OBJECTIVES

Hip fractures are leading causes of disability, morbidity and mortality among older women. Since physical activity helps maintain physical functioning and bone mineral density, occupational physical demand may influence fracture risk. This study investigates the association of occupational physical demand with hip fracture incidence among women.

METHODS

The Women's Health Initiative Observational Study is a multiethnic cohort of 93,676 postmenopausal women, 50-79 years of age at enrolment, enrolled from 1994 to 1998 at 40 geographically diverse clinical centres throughout the USA. Outcomes including hip fractures were assessed annually and up to 3 jobs held since age 18 years were reported by each woman. Occupational physical demand levels were assigned for each job through linkage of occupational titles with Standard Occupational Codes and the Occupational Information Network. Average, cumulative and peak physical demand scores both before and after menopause and throughout women's work life were estimated.

RESULTS

Women were followed through 2010 for an average of 11.5 years; 1834 hip fractures occurred during this time. We did not observe an overall association of occupational physical demand with subsequent risk of hip fracture after adjusting for age, race/ethnicity, birth region and education.

CONCLUSIONS

Previous research on occupations and hip fracture risk in women is inconclusive. This study was able to take critical risk periods into account and control for confounding factors in a large cohort of older women to show that overall occupational physical demand neither increases nor decreases risk of hip fracture later in life.

Effect of coffee intake on hip fracture: a meta-analysis of prospective cohort studies

Several observational studies suggest an association between coffee intake and hip fracture risk. However, the results among them are inconsistent. We aimed to evaluate the association between coffee consumption and risk of hip fracture by performing a meta-analysis of prospective cohort studies. PubMed, Embase, and Web of Science were searched through July 2014 to identify studies that met pre-stated inclusion criterion and reference lists of retrieved articles were reviewed. Information on the characteristics of the included study, risk estimates, and control for possible confounding factors were extracted independently by two authors. A random effects model of meta-analysis was used to calculate the pooled risk estimate. Ten prospective cohort studies involving 5408 patients with hip fracture and 205,930 participants were included in this systematic review. Compared with individuals who did not or seldom drink coffee, the pooled relative risks of hip fracture was 1.13 (95% confidence interval: 0.86 to 1.48) for individuals with the highest coffee consumption. Exception of any single study did not materially alter the combined risk estimate. Visual inspection of funnel plot and Begg’s and Egger’s tests did not indicate evidence of publication bias. In summary, integrated evidence from prospective cohort studies does not suggest a statistically significant association between coffee consumption and risk of hip fracture in developed countries.

Vitamin D receptor variability and physical activity are jointly associated with low handgrip strength and osteoporosis in community-dwelling elderly people in Taiwan: the Taichung Community Health Study for Elders (TCHS-E)

We studied 472 elders to assess joint association of vitamin D receptor (VDR) variability and physical activity on low handgrip strength (LHS) and osteoporosis (OST). Our findings showed that higher risks of OST were associated with physically inactive elders with some specific VDR variations, highlighting the importance of promotion program for physical activity.

INTRODUCTION

The aim of this study was to determine the joint association between VDR variability and physical activity on LHS and OST in community-dwelling elders.

METHODS

Bone mineral density of the lumbar spine (LS), the femoral neck (FN), and the total hip were measured by dual-energy X-ray absorptiometry. Four single-nucleotide polymorphisms (SNPs) (rs7975232, rs1544410, rs2239185, and rs3782905) of the VDR gene were examined in 472 participants.

RESULTS

Physical inactivity and each of the four SNPs were jointly associated with a significantly greater risk of LHS in people than that associated with each of the VDR SNPs or low physical activity alone. Physically inactive men with the AG or AA genotype of rs2239185 had a significantly greater risk of overall, LS, and FN OST than those of physically active men with the GG genotype [odds ratio (OR) 3.57, 95 % confidence interval (CI) 1.10-11.65; OR 4.74, 95 % CI 1.43-15.70; and OR 5.06, 95 % CI 1.08-23.71, respectively]. Similarly, physically inactive women with the CG or CC genotype of rs3782905 and the AG or AA genotype of rs1544410 had a significantly greater risk of FN OST than physically active women with the GG genotype (OR 5.33, 95 % CI 1.23-23.06 and OR 5.36, 95 % CI 1.11-25.94, respectively).

CONCLUSIONS

VDR polymorphisms and physical activity are jointly associated with LHS and OST in elders. Health care programs should promote physical activity among elders as a cost-effective way to prevent LHS and OST, especially in those who may be genetically predisposed.

Histomorphometrical analysis on the effects of two therapeutic ultrasound intensities on fracture healing in aged rats

Introduction Experimental studies conducted in young animals show that therapeutic ultrasound (TUS) has been successfully used to shorten the healing time of bone fractures. However, they were not found in the literature, studies comparing the effect of different intensities of UST in aged animals. Objective To test the efficacy of intensity 1.0 W/cm2 and of 0.5 W/cm2 in the consolidation of experimental fracture of the tibia from aged Wistar rats. Materials and methods Three groups of 15 month old rats were submitted to a midshaft osteotomy of the tibia and then, the hind member was immobilized with a metal splint and plaster of Paris, wrapping the knee and ankle joint. One group (L), received ultrasound at 0.5 W/cm2; the other group (I), were exposed to ultrasound at 1.0 W/cm2. One control group (C), did not receive the ultrasound. Fifteen animals (five from each group) were euthanatized at the end of the first week and fifteen (five from each group) at the end of the third week. The progress of the fracture healing was performed for each group by morphometric analysis of histological sections of the fracture region. Results and conclusion The results showed that fractures treated with ultrasound at 1.0 W/cm2 healed significantly faster than did the fractures treated with ultrasound at 0.5 W/cm2 and the control.

Too Fit To Fracture: a consensus on future research priorities in osteoporosis and exercise

An international consensus process identified the following research priorities in osteoporosis and exercise: study of exercise in high-risk cohorts, evaluation of multimodal interventions, research examining translation into practice and a goal to examine fracture outcomes.

INTRODUCTION

To identify future research priorities related to exercise for people with osteoporosis with and without osteoporotic spine fracture via international consensus.

METHODS

An international expert panel and representatives from Osteoporosis Canada led the process and identified opinion leaders or stakeholders to contribute. A focus group of four patient advocates identified quality of life, mobility, activities of daily living, falls, bone mineral density, and harms as outcomes important for decision-making. Seventy-five individuals were invited to participate in an online survey asking respondents to define future research priorities in the area of osteoporosis and exercise; the response rate was 57%. Fifty-five individuals from seven countries were invited to a half-day consensus meeting; 60% of invitees attended. The results of the online survey, knowledge synthesis activities, and results of the focus group were presented. Nominal group technique was used to come to consensus on research priorities.

RESULTS

Research priorities included the study of exercise in high-risk cohorts (e.g., ≥ 65 years, low BMD, moderate/high risk of fracture, history of osteoporotic vertebral fractures, hyperkyphotic posture, functional impairments, or sedentary), the evaluation of multimodal interventions, research examining translation into practice, and a goal to examine fracture outcomes. The standardization of outcomes or protocols that could be evolved into large multicentre trials was discussed.

CONCLUSIONS

The research priorities identified as part of the Too Fit To Fracture initiative can be used to inform the development of multicentre collaborations to evaluate and implement strategies for engaging individuals with osteoporosis in a safe and effective exercise.

Musculoskeletal disorders in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by airway obstruction and inflammation but also accompanied by several extrapulmonary consequences, such as skeletal muscle weakness and osteoporosis. Skeletal muscle weakness is of major concern, since it leads to poor functional capacity, impaired health status, increased healthcare utilization, and even mortality, independently of lung function. Osteoporosis leads to fractures and is associated with increased mortality, functional decline, loss of quality of life, and need for institutionalization. Therefore, the presence of the combination of these comorbidities will have a negative impact on daily life in patients with COPD. In this review, we will focus on these two comorbidities, their prevalence in COPD, combined risk factors, and pathogenesis. We will try to prove the clustering of these comorbidities and discuss possible preventive or therapeutic strategies.

Too Fit To Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture

SUMMARY

A consensus process was conducted to develop exercise recommendations for individuals with osteoporosis or vertebral fractures. A multicomponent exercise program that includes balance and resistance training is recommended.

INTRODUCTION

The aim was to develop consensus on exercise recommendations for older adults: (1) with osteoporosis and (2) with osteoporotic vertebral fracture(s).

METHODS

The Grading of Recommendations Assessment, Development, and Evaluation method was used to evaluate the quality of evidence and develop recommendations. Outcomes important for decision making were nominated by an expert panel and patient advocates. They included falls, fractures, bone mineral density (BMD), and adverse events for individuals with osteoporosis/vertebral fractures, and pain, quality of life, and function for those with vertebral fracture. Meta-analyses evaluating the effects of exercise on the outcomes were reviewed. Observational studies or clinical trials were reviewed when meta-analyses were not available. Quality ratings were generated, and informed the recommendations.

RESULTS

The outcome for which evidence is strongest is falls. Point estimates of the effects of exercise on falls, fractures, and BMD vary according to exercise type. There is not enough evidence to quantify the risks of exercise in those with osteoporosis or vertebral fracture. Few trials of exercise exist in those with vertebral fracture. The exercise recommendations for exercise in individuals with osteoporosis or osteoporotic vertebral fracture are conditional. The panel strongly recommends a multicomponent exercise program including resistance and balance training for individuals with osteoporosis or osteoporotic vertebral fracture. The panel recommends that older adults with osteoporosis or vertebral fracture do not engage in aerobic training to the exclusion of resistance or balance training.

CONCLUSIONS

The consensus of our international panel is that exercise is recommended for older adults with osteoporosis or vertebral fracture, but our recommendations are conditional.

Hip fracture risk and cadmium in erythrocytes: a nested case-control study with prospectively collected samples

Several studies have investigated the relation between bone mass density and cadmium exposure, but only few studies have been performed on fractures and biomarkers of cadmium. This study analyzed the association between hip fracture risk and cadmium in erythrocytes (Ery-Cd). Prospective samples from the Northern Sweden Health and Disease Study's biobank were used for 109 individuals who later in life had sustained a low-trauma hip fracture, matched with two controls of the same age and gender. The mean concentration of Ery-Cd (±SD) in case samples was 1.3 ± 1.4 versus 0.9 ± 1.0 μg/L in controls. The odds ratio (OR) was 1.63 [95% confidence interval (CI) 1.10-2.42] for suffering a hip fracture for each microgram per liter increase in Ery-Cd. However, when taking smoking into consideration (never, former, or current), neither Ery-Cd nor smoking showed a statistically significant increase in fracture risk. Using multiple conditional logistic regression with BMI, height, and smoking, the estimated OR for a 1-μg/L increase in Ery-Cd was 1.52 (95% CI 0.77-2.97). Subgroup analysis showed an increased fracture risk among women (OR = 1.94, 95% CI 1.18-3.20, for a 1 μg/L increase), which also remained in the multiple analysis (OR = 3.33, 95% CI 1.29-8.56). This study shows that fracture risk is associated with Ery-Cd. It is, however, not possible to draw firm conclusions on whether cadmium is the causal factor or whether other smoking-related factors cause this association. Subgroup analysis shows that cadmium is a risk factor for hip fracture among women.

Exercise, nutrition and managing hip fracture in older persons

PURPOSE OF REVIEW

Lifestyle factors play a role in both the genesis and recovery from fragility fracture. The purpose of this review is to summarize recent evidence for exercise and nutrition in the management of hip fracture.

RECENT FINDINGS

Recent randomized controlled trials of exercise have primarily consisted of isolated resistance training or multimodal home-based programs. More robust, long-term, or supervised training is generally associated with greater clinical benefits, including muscle strength, mobility, and function. Recent nutritional interventions have included multinutrient supplements, nutritional counseling and support, and vitamin D/calcium supplementation. Isolated nutritional interventions have not consistently shown significant impact on long-term outcomes after hip fracture, although improvements in body weight, biochemical indices, complication rates, and mobility have been reported. Overall, there is marked heterogeneity in the robustness of responses seen to hip fracture treatment studies. Few large, long-term, multicomponent interventions with clinically relevant outcomes of functional independence, need for residential care, mortality, and quality of life have been reported.

SUMMARY

Evidence-based approaches to hip fracture should include comprehensive risk-factor assessment and treatment for sarcopenia/dynapenia, balance impairment, undernutrition of protein, energy, vitamin D and calcium, depression, cognitive impairment, sensory impairment, social isolation, and comorbid illness with exercise, nutrition and other modalities.

Association between physical activity and risk of fracture

Prospective studies that have examined the association between physical activity and fracture risks have reported conflicting findings. We performed a meta-analysis to evaluate this association. We searched MEDLINE (1966 to February 1, 2013), EMBASE (1980 to February 1, 2013), and OVID (1950 to February 1, 2013) for prospective cohort studies with no restrictions. Categorical, heterogeneity, publication bias, and subgroup analyses were performed. There were 22 cohort studies with 1,235,768 participants and 14,843 fractures, including 8874 hip, 690 wrist, and 927 vertebral fractures. The pooled relative risk (RR) of total fractures for the highest versus lowest category of physical activity was 0.71 (95% confidence interval [CI], 0.63-0.80). The analysis of fracture subtypes showed a statistically significant inverse relationship between a higher category of physical activity and risk of hip and wrist fracture. The risk of hip or wrist fracture was 39% and 28% lower, respectively, among individuals with the highest category of physical activity than among those with the lowest category (95% CI, 0.54-0.69 and 0.49-0.96, respectively). The association between physical activity and vertebral fracture risk was not statistically related (RR, 0.87; 95% CI, 0.72-1.03). There was no evidence of publication bias. There was a statistically significant inverse association between physical activity and total fracture risk, especially for hip and wrist fractures. Additional subject-level meta-analyses are required for a more reliable assessment of subgroups and types of physical activity.

TRPV4 deficiency causes sexual dimorphism in bone metabolism and osteoporotic fracture risk

We explored the role of transient receptor potential vanilloid 4 (TRPV4) in murine bone metabolism and association of TRPV4 gene variants with fractures in humans. Urinary and histomorphometrical analyses demonstrated reduced osteoclast activity and numbers in male Trpv4(-/-) mice, which was confirmed in bone marrow-derived osteoclast cultures. Osteoblasts and bone formation as shown by serum procollagen type 1 amino-terminal propeptide and histomorphometry, including osteoid surface, osteoblast and osteocyte numbers were not affected in vivo. Nevertheless, osteoblast differentiation was enhanced in Trpv4(-/-) bone marrow cultures. Cortical and trabecular bone mass was 20% increased in male Trpv4(-/-) mice, compared to sex-matched wild type (Trpv4(+/+)) mice. However, at the same time intracortical porosity was increased and bone matrix mineralization was reduced. Together, these lead to a maximum load, stiffness and work to failure of the femoral bone, which were not different compared to Trpv4(+/+) mice, while the bone material was less resistant to stress and less elastic. The differential impacts on these determinants of bone strength were likely responsible for the lack of any changes in whole bone strength in the Trpv4(-/-) mice. None of these skeletal parameters were affected in female Trpv4(-/-) mice. The T-allele of rs1861809 SNP in the TRPV4 locus was associated with a 30% increased risk (95% CI: 1.1-1.6; p=0.013) for non-vertebral fracture risk in men, but not in women, in the Rotterdam Study. Meta-analyses with the population-based LASA study confirmed the association with non-vertebral fractures in men. This was lost when the non-population-based studies Mr. OS and UFO were included. In conclusion, TRPV4 is a male-specific regulator of bone metabolism, a determinant of bone strength, and a potential risk predictor for fractures through regulation of bone matrix mineralization and intra-cortical porosity. This identifies TRPV4 as a unique sexually dimorphic therapeutic and/or diagnostic candidate for osteoporosis.

Prospective observational study of physical functioning, physical activity, and time outdoors and the risk of hip fracture: a population-based cohort study of 158,057 older adults in the 45 and up study

Low levels of physical activity or sun exposure and limitations to physical functioning (or disability) have been identified as possible risk factors for hip fracture. However, these factors are closely related, and data on their independent and joint association with risk of hip fracture are limited. A total of 158,057 individuals aged ≥45 years sampled from the general population of New South Wales, Australia, from the prospective 45 and Up Study completed a baseline postal questionnaire in 2006 to 2009 including data on physical activity (Active Australia questionnaire); sun exposure (usual time outdoors); and physical functioning (Medical Outcomes Score-Physical Functioning; scored 0 to 100). Incident first hip fractures were ascertained by linkage to administrative hospital data (n = 293; average follow-up 2.3 years). The relative risk (RR) of hip fracture was estimated using Cox proportional hazards. Poorer physical functioning, lower physical activity, and less time outdoors were positively related to each other at baseline and individually associated with significantly increased hip fracture risk. However, physical activity and time outdoors were not significantly related to hip fracture risk after adjustment for baseline physical functioning or when analysis was restricted to those with no or mild baseline physical limitation. In contrast, physical functioning remained strongly related to hip fracture risk after adjustment for the other two factors; compared with the group without limitation (100), the RR of hip fracture among those with mild (75-95), moderate (50-70), severe (25-45), and greatest (0-20) level of physical limitation was 1.38 (95% confidence interval [CI] 0.88-2.14), 2.14 (1.29-3.53), 3.87 (2.31-6.44), and 5.61 (3.33-9.42), respectively. The findings suggest that limitation in physical functioning, but not physical activity or time outdoors, is strongly related to hip fracture risk. The apparent increased risk of hip fracture previously described for low physical activity or sun exposure may be, at least in part due to uncontrolled confounding.

Active commuting reduces the risk of wrist fractures in middle-aged women-the UFO study

SUMMARY

Middle-aged women with active commuting had significantly lower risk for wrist fracture than women commuting by car/bus.

INTRODUCTION

Our purpose was to investigate whether a physically active lifestyle in middle-aged women was associated with a reduced risk of later sustaining a low-trauma wrist fracture.

METHODS

The Umeå Fracture and Osteoporosis (UFO) study is a population-based nested case-control study investigating associations between lifestyle and fragility fractures. From a cohort of ~35,000 subjects, we identified 376 female wrist fracture cases who had reported data regarding their commuting habits, occupational, and leisure physical activity, before they sustained their fracture. Each fracture case was compared with at least one control drawn from the same cohort and matched for age and week of reporting data, yielding a total of 778 subjects. Mean age at baseline was 54.3 ± 5.8 years, and mean age at fracture was 60.3 ± 5.8 years.

RESULTS

Conditional logistic regression analysis with adjustments for height, body mass index, smoking, and menopausal status showed that subjects with active commuting (especially walking) were at significantly lower risk of sustaining a wrist fracture (OR 0.48; 95 % CI 0.27-0.88) compared with those who commuted by car or bus. Leisure time activities such as dancing and snow shoveling were also associated with a lower fracture risk, whereas occupational activity, training, and leisure walking or cycling were unrelated to fracture risk.

CONCLUSION

This study suggests that active commuting is associated with a lower wrist fracture risk, in middle-aged women.

Role of calcium during pregnancy: maternal and fetal needs

Although the demand for additional calcium during pregnancy is recognized, the dietary reference intake for calcium was lowered for pregnant women in 1997 to amounts recommended for nonpregnant women (1,000 mg/day), and recently (November 2010) the Institute of Medicine report upheld the 1997 recommendation. It has been frequently reported that women of childbearing age do not consume the dietary reference intake for calcium and that calcium intake in the United States varies among ethnic groups. Women who chronically consume suboptimal amounts of calcium (<500 mg/day) may be at risk for increased bone loss during pregnancy. Women who begin pregnancy with adequate intake may not need additional calcium, but women with suboptimal intakes (<500 mg) may need additional amounts to meet both maternal and fetal bone requirements. The objective of this review is to elucidate the changes in calcium metabolism that occur during pregnancy as well as the effect of maternal calcium intake on both maternal and fetal outcomes.

Pourcain B, Xiao Y, Timpson NJ, Smith GD, Reid IR, Ring SM, Sambrook PN, Karlsson M, Dennison EM, Kemp JP, Danoy P, Sayers A, Wilson SG, Nethander M, McCloskey E, Vandenput L, Eastell R, Liu J, Spector T, Mitchell BD, Streeten EA, Brommage R, Pettersson-Kymmer U, Brown MA, Ohlsson C, Richards JB, Lorentzon M. WNT16 influences bone mineral density, cortical bone thickness, bone strength, and osteoporotic fracture risk

We aimed to identify genetic variants associated with cortical bone thickness (CBT) and bone mineral density (BMD) by performing two separate genome-wide association study (GWAS) meta-analyses for CBT in 3 cohorts comprising 5,878 European subjects and for BMD in 5 cohorts comprising 5,672 individuals. We then assessed selected single-nucleotide polymorphisms (SNPs) for osteoporotic fracture in 2,023 cases and 3,740 controls. Association with CBT and forearm BMD was tested for ∼2.5 million SNPs in each cohort separately, and results were meta-analyzed using fixed effect meta-analysis. We identified a missense SNP (Thr>Ile; rs2707466) located in the WNT16 gene (7q31), associated with CBT (effect size of -0.11 standard deviations [SD] per C allele, P = 6.2 × 10(-9)). This SNP, as well as another nonsynonymous SNP rs2908004 (Gly>Arg), also had genome-wide significant association with forearm BMD (-0.14 SD per C allele, P = 2.3 × 10(-12), and -0.16 SD per G allele, P = 1.2 × 10(-15), respectively). Four genome-wide significant SNPs arising from BMD meta-analysis were tested for association with forearm fracture. SNP rs7776725 in FAM3C, a gene adjacent to WNT16, was associated with a genome-wide significant increased risk of forearm fracture (OR = 1.33, P = 7.3 × 10(-9)), with genome-wide suggestive signals from the two missense variants in WNT16 (rs2908004: OR = 1.22, P = 4.9 × 10(-6) and rs2707466: OR = 1.22, P = 7.2 × 10(-6)). We next generated a homozygous mouse with targeted disruption of Wnt16. Female Wnt16(-/-) mice had 27% (P<0.001) thinner cortical bones at the femur midshaft, and bone strength measures were reduced between 43%-61% (6.5 × 10(-13)<P<5.9 × 10(-4)) at both femur and tibia, compared with their wild-type littermates. Natural variation in humans and targeted disruption in mice demonstrate that WNT16 is an important determinant of CBT, BMD, bone strength, and risk of fracture.

Does radiographic emphysema correlate with low bone mineral density?

PURPOSE OF REVIEW

Several large epidemiologic studies have shown an association between chronic obstructive pulmonary disease (COPD) and osteoporosis. Recent studies have further implied an emphysema-specific association with low bone mineral density independent of obstruction severity.

RECENT FINDINGS

This review will outline the studies demonstrating an independent association between radiographic emphysema and decreased bone mineral density and will discuss potential disease mechanisms, including systemic inflammation and immune-mediated factors, linking these disease processes.

SUMMARY

Radiographic emphysema should be considered an independent risk factor in studies examining the mechanisms underlying COPD-related bone loss. Future research focused on the relationship between emphysema and low bone mineral density could provide mechanistic insight and result in the development of targeted therapies designed to halt progression of both disease processes.

Strontium ranelate prevents bone loss in a rat model of localized muscle paralysis

Twenty-one 3.5-month-old female Sprague-Dawley rats were randomly assigned to three groups: BTX group, in which each rat received a single intramuscular injection of 2 U of Clostridium botulinum toxin (BTX) in the quadriceps femoris muscle of the right hind limb; BTX + SR group, in which each rat received a BTX injection and a dose of strontium ranelate (dose level of 625 mg/kg/day); and the control group. All the rats were killed at 9 weeks post-treatment. It was showed that BTX-induced rats a rapid loss of body weight in the first 3 weeks, after which their body weight showed a slow increase similar to that observed in the control rats. The net body weight loss was mainly attributed to muscle atrophy. BTX caused remarkable bone degradation in either the trabecular bone or the cortical bone of the disuse femur. The deteriorations in the bone mass and bone microstructure were locally limited and could be prevented by strontium ranelate treatment. Biomechanical analysis showed that strontium ranelate treatment improved the mechanical performance of the tibia in BTX-treated rats. It was showed that a clinical-corresponding dose of strontium ranelate could prevent bone loss in long-term immobilized rats.

Physical activity and hip fracture disability: a review

Objective. The present paper examines pertinent literature sources published in the peer-reviewed English language between 1980 and November 1, 2010 concerning hip fractures. The aim was to highlight potential intervention points to offset the risk of incurring a hip fracture and its attendant disability. Methods. An in-depth search of the literature using the key terms: disability, epidemiology, hip fracture, prevention, and risk factors was conducted, along with data from the author's research base detailing the disability associated with selected hip fracture cases. All articles that dealt with these key topics were reviewed, and relevant data were tabulated and analyzed. Results. Hip fractures remain an important but potentially preventable public health problem. Among the many related remediable risk factors, low physical activity levels are especially important. Related determinants of suboptimal neuromuscular function also contribute significantly to hip fracture disability. Conclusion. Physical activity participation can help to reduce the prevalence and excess disability of hip fractures and should be encouraged.