Correction to Effect of vitamin K on bone mineral density and fractures in adults: an updated systematic review and meta-analysis of randomised controlled trials

The Dutch multidisciplinary guideline osteoporosis and fracture prevention, taking a local guideline to the international arena

BACKGROUND

In 2018, a grant was provided for an evidence-based guideline on osteoporosis and fracture prevention based on 10 clinically relevant questions.

METHODS

A multidisciplinary working group was formed with delegates from Dutch scientific and professional societies, including representatives from the patient's organization and the Dutch Institute for Medical Knowledge. The purpose was to obtain a broad consensus among all participating societies to facilitate the implementation of the updated guideline.

RESULTS

Novel recommendations in our guideline are as follows: - In patients with an indication for DXA of the lumbar spine and hips, there is also an indication for VFA. - Directly starting with anabolic drugs (teriparatide or romosozumab) in patients with a very high fracture risk; - Directly starting with zoledronic acid in patients 75 years and over with a hip fracture (independent of DXA); - Directly starting with parenteral drugs (denosumab, teriparatide, zoledronic acid) in glucocorticoid-induced osteoporosis with very high fracture risk; - A lifelong fracture risk management, including lifestyle, is indicated from the start of the first treatment.

CONCLUSION

In our new multidisciplinary guideline osteoporosis and fracture prevention, we developed 5 "relatively new statements" that are all a crucial step forward in the optimization of diagnosis and treatment for fracture prevention. We also developed 5 flowcharts, and we suppose that this may be helpful for individual doctors and their patients in daily practice and may facilitate implementation.

[Exercise therapy and basic treatment for osteoporosis]

Physical training is an important component in the prophylaxis of osteoporosis and the prevention of fractures. Physical training not only has a direct effect on muscle strength and muscular performance, but also on the risk of falling and the fear of falling. Therefore, physical training is also an integral part of the basic treatment for osteoporosis. The recommendations for basic treatment are an adequate intake of nutrients, including protein in particular. The intake of calcium and vitamin D in sufficient quantities is also important and, in the case of specific drug therapy, also to avoid side effects and to ensure the therapeutic effect. This article summarizes the recommendations of the updated S3 guideline on the diagnosis and treatment of osteoporosis and explains the background for the recommendations included.

Dietary Vitamin K1 intake is associated with lower long-term fracture-related hospitalization risk: the Perth longitudinal study of ageing women

This study examined the association between dietary Vitamin K1 intake with fracture-related hospitalizations over 14.5 years in community-dwelling older Australian women (n = 1373, ≥70 years). Dietary Vitamin K1 intake at baseline (1998) was estimated using a validated food frequency questionnaire and a new Australian Vitamin K nutrient database, which was supplemented with published data. Over 14.5 years, any fracture (n = 404, 28.3%) and hip fracture (n = 153, 10.7%) related hospitalizations were captured using linked health data. Plasma Vitamin D status (25OHD) and the ratio of undercarboxylated osteocalcin (ucOC) to total osteocalcin (tOC) from serum was assessed at baseline. Estimates of dietary Vitamin K1 intake were supported by a significant inverse association with ucOC : tOC; a marker of Vitamin K status (r = -0.12, p < 0.001). Compared to women with the lowest Vitamin K1 intake (Quartile 1, <61 μg d^-1), women with the highest Vitamin K1 intake (Quartile 4, ≥99 μg d^-1) had lower hazards for any fracture- (HR 0.69 95%CI 0.52-0.91, p < 0.001) and hip fracture-related hospitalization (HR 0.51 95%CI 0.32-0.79, p < 0.001), independent of 25OHD levels, as part of multivariable-adjusted analysis. Spline analysis suggested a nadir in the relative hazard for any fracture-related hospitalizations at a Vitamin K1 intake of approximately 100 μg day^-1. For hip fractures, a similar relationship was apparent. Higher dietary Vitamin K1 is associated with lower long-term risk for any fracture- and hip fracture-related hospitalizations in community-dwelling older women.

Nutrition, Physical Activity, and Dietary Supplementation to Prevent Bone Mineral Density Loss: A Food Pyramid

Bone is a nutritionally modulated tissue. Given this background, aim of this review is to evaluate the latest data regarding ideal dietary approach in order to reduce bone mineral density loss and to construct a food pyramid that allows osteopenia/osteoporosis patients to easily figure out what to eat. The pyramid shows that carbohydrates should be consumed every day (3 portions of whole grains), together with fruits and vegetables (5 portions; orange-colored fruits and vegetables and green leafy vegetables are to be preferred), light yogurt (125 mL), skim milk (200 mL,) extra virgin olive oil (almost 20 mg/day), and calcium water (almost 1 l/day); weekly portions should include fish (4 portions), white meat (3 portions), legumes (2 portions), eggs (2 portions), cheeses (2 portions), and red or processed meats (once/week). At the top of the pyramid, there are two pennants: one green means that osteopenia/osteoporosis subjects need some personalized supplementation (if daily requirements cannot be satisfied through diet, calcium, vitamin D, boron, omega 3, and isoflavones supplementation could be an effective strategy with a great benefit/cost ratio), and one red means that there are some foods that are banned (salt, sugar, inorganic phosphate additives). Finally, three to four times per week of 30-40 min of aerobic and resistance exercises must be performed.

Nutritional intake and bone health

Osteoporotic or fragility fractures affect one in two women and one in five men who are older than 50. These events are associated with substantial morbidity, increased mortality, and an impaired quality of life. Recommended general measures for fragility fracture prevention include a balanced diet with an optimal protein and calcium intake and vitamin D sufficiency, together with regular weight-bearing physical exercise. In this narrative Review, we discuss the role of nutrients, foods, and dietary patterns in maintaining bone health. Much of this information comes from observational studies. Bone mineral density, microstructure-estimated bone strength, and trabecular and cortical microstructure are positively associated with total protein intake. Several studies indicate that fracture risk might be lower with a higher dietary protein intake, provided that the calcium supply is sufficient. Dairy products are a valuable source of these two nutrients. Hip fracture risk appears to be lower in consumers of dairy products, particularly fermented dairy products. Consuming less than five servings per day of fruit and vegetables is associated with a higher hip fracture risk. Adherence to a Mediterranean diet or to a prudent diet is associated with a lower fracture risk. These various nutrients and dietary patterns influence gut microbiota composition or function, or both. The conclusions of this Review emphasise the importance of a balanced diet including minerals, protein, and fruit and vegetables for bone health and in the prevention of fragility fractures.