Soft drink and milk consumption, physical activity, bone mass, and upper limb fractures in children: a population-based case-control study

The Effects of Dairy Product Supplementation on Bone Health Indices in Children Aged 3 to 18 Years: A Meta-Analysis of Randomized Controlled Trials

Childhood and adolescence are critical periods for optimizing skeletal growth. Dairy products are valuable sources of bone-beneficial nutrients, particularly calcium and protein. A random-effects meta-analysis of published randomized controlled trials was performed to quantitatively assess the effects of dairy supplementation on bone health indices in children and adolescents. The PubMed and Web of Science databases were searched. Dairy supplementation increased whole-body bone mineral content (BMC) (+25.37 g) and areal bone mineral density (aBMD) (+0.016 g/cm2), total hip BMC (+0.49 g) and aBMD (+0.013 g/cm2), femoral neck BMC (+0.06 g) and aBMD (+0.030 g/cm2), lumbar spine BMC (+0.85 g) and aBMD (+0.019 g/cm2), and height (0.21 cm). When expressed as a percentage difference, whole-body BMC was increased by 3.0%, total hip BMC by 3.3%, femoral neck BMC by 4.0%, lumbar spine BMC by 4.1%, whole-body aBMD by 1.8%, total hip aBMD by 1.2%, femoral neck aBMD by 1.5%, and lumbar spine aBMD by 2.6%. Dairy supplementation increased serum insulin-like growth factor I concentrations (19.89 nmol/L) and reduced concentrations of urinary deoxypyridinoline (-1.78 nmol/mmol creatinine) and serum parathyroid hormone (-10.46 pg/mL) but did not significantly affect the serum concentrations of osteocalcin, bone alkaline phosphatase, and C-terminal telopeptide of type 1 collagen. Serum 25-hydroxyvitamin D concentrations (+4.98 ng/mL) increased with vitamin D-fortified dairy supplementation. The positive effects on bone mineral mass parameters and height were generally consistent across subgroups defined by sex, geographical region, baseline calcium intake, calcium from the supplementation, trial duration, and Tanner stages. In summary, dairy supplementation during growth leads to a small but significant increase in bone mineral mass parameters, and these findings are generally supported by the changes in several biochemical parameters related to bone health.

Excessive fructose intake inhibits skeletal development in adolescent rats via gut microbiota and energy metabolism

Excessive fructose intake from desserts and beverages may influence bone development among adolescents. The gut microbiota (GM) and energy metabolism play important roles in bone development. In this study, 40 female adolescent rats were randomly assigned to the control group, the fructose group with two concentrations, and the glucose group as the positive control group. After 10 weeks, serum glucose and lipids were detected by means of an automatic analyzer, and the bone microstructure was analyzed by Micro-CT. Then, the GM was determined via 16S rRNA sequencing analysis, and energy metabolism was detected by measuring serum carbohydrate metabolites. At last, bone metabolism markers were measured via ELISA kits. The results showed that excessive fructose intake could increase body weight and influence the glucolipid metabolism of female adolescent rats. Meanwhile, the bone microstructures were impaired with excessive fructose intake. Mechanistically, excessive fructose intake shifted the GM of rats with the decrease of Lachnospiraceae, Ruminococcaceae, and increase of Allobaculum, Lachnospiraceae. Energy metabolism analysis suggested that most metabolites of fructose did not enter the tricarboxylic acid cycle to provide energy for the body’s development. Furthermore, serum bone metabolism markers showed that excessive fructose intake could decrease both bone formation and resorption. Our results suggested that excessive fructose intake could inhibit skeletal development in adolescents. One potential mechanism might be that it affected the intestinal microbiota homeostasis in the juvenile body, thus changing the energy metabolism level, and ultimately affecting the bone metabolic balance.

The impact of lifestyle on forearm fractures in children: A retrospective cohort analysis

BACKGROUND AND OBJECTIVES

Forearm fractures are frequent in children. It is important to identify predisposing factors for increased fracture risk. This retrospective analysis aimed to investigate the correlation between forearm fractures in children and co-factors such as age, TV consumption, consumption of soft drinks, the kind of soft drinks consumed as well as physical activity in daily life and BMI.

METHODS

This retrospective cohort analysis compared 355 participants at the age of 4 to 12 between 2017 and 2018 with and without forearm fractures in children. It was based on a questionnaire to assess the above-mentioned cofactors regarding behavior and lifestyles choices and aimed to identify whether or not these lead to an increased risk of forearm fractures. For statistical analysis logistic regression was used.

RESULTS

Logistic regression showed a significant effect on forearm fractures in children for the variables age (Odds ratio 3.3 [95% confidence interval 1.5-7.3], P = .003), TV consumption (Odds ratio 5.4 [95% confidence interval 2.5-22.6], P < .001), consumption of soft drinks (Odds ratio 2.6 [95% confidence interval 1.2-5.6], P = .013), and the kind of soft drinks consumed (Odds ratio 3.1 [95% confidence interval 1.5-6.3], P = .003), [Nagelkerkes-R² = 0.458; Chi² = 85.037; df = 6]) with a strong effect according to Cohen (f² = 0.84).

CONCLUSION

The study showed a significant correlation between TV and soft drink consumption and increased risk for forearm fractures in children. TV consumption and consumption of soft drinks should be reduced in children to prevent forearm fractures.

Prospective Associations of Sugar-Sweetened Beverage Consumption During Adolescence with Body Composition and Bone Mass at Early Adulthood

BACKGROUND

Adolescents have a higher consumption of sugar-sweetened beverages (SSBs) than other age groups, but little is known of the impact of SSB intake during adolescence on body composition and bone mass in early adulthood.

OBJECTIVES

Associations of SSB intake from 14 to 20 y with fat, lean, and bone mass at 20 y of age were evaluated.

METHODS

Study participants were 1137 offspring (562 females) from the Raine Study. Food intake, including SSB consumption in servings/d (1 serving = 250 mL), was estimated using FFQs at 14, 17, and 20 y of age. DXA scanning at 20 y measured whole body fat mass, lean mass, and bone mineral content (BMC). Using latent class growth analysis, 4 SSB intake trajectory classes were identified: consistently low (n = 540, intakes mostly <0.5 serving/d), increasing (n = 65), decreasing (n = 258), and consistently high (n = 274, intakes mostly >1.3 servings/d).

RESULTS

Median total SSB intake was 0.8, 0.7, and 0.5 serving/d, and median carbonated SSB intake was 0.3, 0.3, and 0.4 serving/d at 14, 17, and 20 y, respectively. Mean ± SD BMI (in kg/m2) was 23.9 ± 4.2 at 20 y. After adjustment for covariates including sex, demographic, energy intake, and maternal factors, individuals with "consistently high" SSB consumption had significantly higher total body fat mass at 20 y than those with "consistently low" consumption (23.3 ± 0.6 compared with 21.2 ± 0.4 kg, P = 0.004), which remained significant after further adjustment for "Healthy" and "Western" dietary patterns (23.2 ± 0.6 compared with 21.2 ± 0.4 kg, P = 0.011). No significant associations were observed between SSB intake trajectory classes and lean body mass or BMC at 20 y.

CONCLUSIONS

In this cohort, consistently higher consumption of SSBs in adolescence and early adulthood are associated with increased fat mass but not with bone mass at 20 y of age.

Sugar-sweetened beverage consumption and bone health: a systematic review and meta-analysis

BACKGROUND

Current evidence demonstrate that sugar-sweetened beverages (SSBs) and bone health are related; however, there has been only a few reviews on the link between SSBs and bone health. A systematic review and meta-analysis was performed to investigate the association between SSBs consumption and bone health in chidren and adults.

METHODS

Relevant studies of SSBs and bone health published up to 15 March 2021 were searched using PubMed, the Web of Science, Cochrane Library, and a reference search. A random-effects meta-analysis was conducted to estimate the standardized mean difference (SMD). Subgroup analyses were performed to identify whether effects were modified by age, sex, measured skeletal sites, type of SSBs, and SSBs intake questionnaire.

RESULTS

Twenty-six publications including 124,691 participants were selected on the review. The results from this meta-analysis showed a significant inverse association between SSBs intake and bone mineral density (BMD) in adults (ES: -0.66, 95% CI: - 1.01, - 0.31, n = 4312). Eighteen of the 20 studies included in the qualitative-only review in children and adults supported the findings from the meta-analysis. When subgroup analysis was performed according to skeletal site, a large effect was found on whole body BMD (ES: -0.97, 95% CI: - 1.54, - 0.40). There was a moderate effect on BMD in females (ES: -0.50, 95% CI: - 0.87, - 0.13). There was a moderate or large effect on BMD in individuals aged under 50 years (under 30 years: ES: -0.57, 95% CI: - 0.97, - 0.17; 30 to 50 years: ES: -1.33, 95% CI: - 1.72, - 0.93). High consumption of carbonated beverages had a moderate effect on BMD (ES: -0.73, 95% CI: - 1.12, - 0.35).

CONCLUSION

The meta-analysis showed that SSBs consumption such as carbonated beverages were inversely related to BMD in adults. Qualitative review supported the results of meta-analysis.

TRIAL REGISTRATION

This review was registered in the PROSPERO database under identifier CRD42020164428 .

Vitamin D levels in Irish children with fractures: A prospective case-control study with 5 year follow-up

INTRODUCTION

Twenty-five-hydroxy-vitamin D3 (25-OH-vit D) is a prohormone that is essential for normal calcium homeostasis and bone metabolism. Understanding its role is an important component of the proper care of the pediatric orthopaedic patient. The aim of this study was to determine whether children in Ireland with fractures have increased prevalence of 25-OH-Vit D deficiency compared with age matched controls and to ascertain the relationship between a low 25-OH-vit D level and the incidence of fractures in Irish children. We hypothesised that children presenting to our centre following a fracture would have significantly lower 25-OH-vit D.

METHODS

A prospective case-control study at a large urban tertiary referral academic hospital located in Dublin, Ireland was completed over a 14 month period from June 2014 to August 2015. A total of 116 subjects, distributed as cases (n = 58) and controls (n = 58) were included in this study. Whole blood (10 ml) was taken in two serum bottles from each patient. Serum 25-hydroxy-vitamin D3 levels were measured. An age matched control group was generated from other children attending the hospital, who also had vitamin D levels measured for different clinical reasons. We followed up both the fracture and control group for the next 5 years to assess the repeat fracture rate.

RESULTS

Fifty-eight patients with a fracture requiring operative intervention, were included in the study. Statistical analysis was performed comparing to 58 age and sex-matched controls. The mean vitamin D level for the fracture group was 63.2 nmol/L (SD = 27.3), which was higher than the mean of the controls (62.5 nmol/L) (SD = 21.3) (p = 0.86), but this difference was found not to be statistically significant in unadjusted analysis. There was no statistically significant difference in the number of patients classified with low serum Vitamin D levels (<50 nmolL), with the fracture group consisting of 22 (37.9%) patients, and the control group of 17 patients (29.3%) (p = 0.33) with a level below 50 nmol/L. At five-year follow-up, 11 of the 58 patients (18.9%) in the fracture group went on to have a further fracture compared with eight patients (13.7%) from the control group. Out of these 11 from the fracture group five (45.45%) had been found to have a low serum 25-OH-Vit D level five years previously. Out of the eight controls that presented with a fracture within the five-year period, 3 (37.5%) had had a low vitamin D level at the origin of this study.

CONCLUSION

The results of this study show that children presenting to our institution with low energy fractures have a prevalence of 38% 25-hydroxy-vitamin D deficiency. This study included children from age 1 to 16 primarily Caucasian encompassing all fracture types resulting from accidental trauma. Our findings suggest that in an Irish pediatric population vitamin D status may impact fracture risk with more than one-third being deficient in this review.

Associations between cola consumption and bone mineral density in Korean adolescents and young adults: a cross-sectional study using data from the Korea National Health and Nutrition Examination Survey, 2008-2011

The present study aimed to elucidate the relationship between cola consumption and bone mineral density (BMD) in Korean adolescents and young adults. We used data from the Korea National Health and Nutrition Examination Survey 2008–2011. A total of 2499 adolescents and young adults aged 12–25 years were included. The study participants were classified as cola drinkers and non-cola drinkers according to 24-h dietary recall data. BMD was measured using dual X-ray absorptiometry. In the male population, whole body, whole femur and femoral neck BMD in cola drinkers were lower than that of non-cola drinkers by 4% (95% CI −0⋅071, −0⋅007), 5% (−0⋅092, −0⋅012) and 5% (−0⋅090, −0⋅001), respectively. In both sex groups, cola drinkers had less frequent milk consumption than non-cola drinkers. However, there were no significant differences in cola consumption according to calcium intake in both sexes. In conclusion, cola intake and BMD were inversely associated with Korean male adolescents and young adults. Considering the importance of peak bone mass attainment at adolescents and the increasing trend in carbonated beverage consumption in South Korea, further studies are needed to elucidate the causality between cola intake and lower BMD.

Idiopathic Osteoporosis and Nephrolithiasis: Two Sides of the Same Coin?

Idiopathic osteoporosis and nephrolithiasis are formidable health problems showing a progressive increase in their incidence and prevalence in the last decades. These temporal trends were observed in both pediatric and adult populations worldwide. Epidemiological and experimental studies indicate that both disorders show several common pathogenic environmental and genetic factors. In this review, we analyzed the clinical characteristics common to the two disorders and the state-of-the-art knowledge regarding the genetic predisposition and the environmental factors recognized as triggers in adult and pediatric ages. As a result of this work, we propose to consider idiopathic nephrolithiasis and osteoporosis as two possible expressions of a unique clinical syndrome. Accordingly, the clinical approach to both disorders should be modified in order to program an efficient primary and secondary prevention strategy.

Fracture risk factors among children living in New Zealand

Factures are common during childhood. There are limited data available regarding relationships between bone fracture history and calcium intake, sugar sweetened beverages (SSBs) intake, vitamin D status, physical activity (PA), ethnicity, and body composition in New Zealand (NZ) children. Identifying groups of NZ children at risk of fracture and associated predictors may help to improve bone quality during childhood and decrease the risk of fractures throughout life. The aim of this study was to investigate fracture history and associated risk factors in New Zealand children. Children aged 8-12 years were recruited. Capillary blood spots collected from a finger prick were as analyzed for 25(OH)D concentrations. Bioelectrical impedance analysis (InBody720, Seoul, Korea) was used to measure body fat percentage (%BF). Information about fracture history, siblings' history of fractures, family osteoporosis history, PA, ethnicity, and intake of calcium containing foods, and SSBs was collected using questionnaires. Children (n = 647, 354 girls), mean ± SD age 9.8 ± 0.7 years were recruited from six Auckland primary schools. NZ European (n = 252) (NZE) and South Asian (n = 68) children reported the lowest (20.2 %) and highest (44.1 %) fracture incidence, respectively. NZE compared to South Asian children, had higher 25(OH)D concentrations (74.6 ± 19.8 vs. 48.4 ± 19.3 nmol/L, P < 0.001), higher total calcium intake (764.0 ± 394.4 vs. 592.7 ± 266.3 mg/d, P < 0.018), and lower %BF (19.5 ± 6.6 vs. 23.4 ± 8.4, P < 0.003). Māori children had the next highest fracture rate (32.5 %). This group had adequate 25(OH)D (64.2 ± 18.9 nmol/L), but high %BF (23.9 %) and most participated in vigorous PA. After stratifying by sex, binary logistic regression analysis revealed the main determinants of fracture history for boys were high %BF, low 25(OH)D, low calcium intake, high SSBs consumption, siblings' fracture history, family osteoporosis history, and being South Asian; and in girls, high SSBs consumption, siblings' fracture history, and family osteoporosis history. We found South Asian ethnicity was a significant risk factor for boys. Some children were at high risk of vitamin D deficiency and for whom supplementation may be necessary in winter. Good nutrition (especially good sources of calcium and reducing SSBs intakes) should be recommended to children during growth and development to reduce their risk of fractures.

Bone Growth is Influenced by Fructose in Adolescent Male Mice Lacking Ketohexokinase (KHK)

Fructose is metabolized in the cytoplasm by the enzyme ketohexokinase (KHK), and excessive consumption may affect bone health. Previous work in calcium-restricted, growing mice demonstrated that fructose disrupted intestinal calcium transport. Thus, we hypothesized that the observed effects on bone were dependent on fructose metabolism and took advantage of a KHK knockout (KO) model to assess direct effects of high plasma fructose on the long bones of growing mice. Four groups (n = 12) of 4-week-old, male, C57Bl/6 background, congenic mice with intact KHK (wild-type, WT) or global knockout of both isoforms of KHK-A/C (KHK-KO), were fed 20% glucose (control diet) or fructose for 8 weeks. Dietary fructose increased by 40-fold plasma fructose in KHK-KO compared to the other three groups (p < 0.05). Obesity (no differences in epididymal fat or body weight) or altered insulin was not observed in either genotype. The femurs of KHK-KO mice with the highest levels of plasma fructose were shorter (2%). Surprisingly, despite the long-term blockade of KHK, fructose feeding resulted in greater bone mineral density, percent volume, and number of trabeculae as measured by µCT in the distal femur of KHK-KO. Moreover, higher plasma fructose concentrations correlated with greater trabecular bone volume, greater work-to-fracture in three-point bending of the femur mid-shaft, and greater plasma sclerostin. Since the metabolism of fructose is severely inhibited in the KHK-KO condition, our data suggest mechanism(s) that alter bone growth may be related to the plasma concentration of fructose.

A narrative review of the effects of sugar-sweetened beverages on human health: A key global health issue

The provision of healthy and safe food is vital for human health, and the addition of unnecessary sugars in foodstuffs is an important global issue, leading to multiple long- and short-term health issues and spiraling costs for individuals and governments alike. The negative effect of excess sugar consumption contributes to adverse health conditions, including obesity, type 2 diabetes, and poor oral health in both high and low resource settings. A key plank of governmental and health promotion bodies' nutritional guidance is to raise public awareness of "hidden" sugars, salt, and fats, such as found in processed foods and sugar-sweetened beverages (SSBs), and guide individuals to reduce their consumption. This rapid narrative review brings together some of the key issues identified in the literature around the consumption of SSBs, including patterns of consumption, the general impact on human health and nutrition, specific effects on oral health and the oral microbiome, and strategies to address over-consumption. The range of long-term adverse effects on health is often misunderstood or unknown by the public. However, some strategies have succeeded in reducing the consumption of SSBs, including public health strategies and interventions and the imposition of taxes or levies, and this article makes recommendations for action.

Consumption of Cow's Milk in Early Childhood and Fracture Risk: A Prospective Cohort Study

Cow's milk is consumed by most North American children, yet the relationships between the volume and fat content of cow's milk consumed and childhood fracture risk are unclear. Our primary objectives in this study were to evaluate whether the volume or fat content of cow's milk consumed at 1-3 years of age was associated with the risk of fracture between 3 and 10 years of age. This was a prospective cohort study of 2,466 children enrolled in Toronto, Ontario, Canada, between 2008 and 2016. The primary exposure was volume of cow's milk consumed between the ages of 1 and 3 years, and the secondary exposure was average percentage of milk fat consumed by each child during the same period. The primary outcome was a parental report of child fracture at ages 3-10 years. In the primary and secondary adjusted analyses, no association between milk volume and fracture risk (adjusted relative risk = 1.04, 95% confidence interval: 0.87, 1.26) or between milk-fat content and fracture risk (adjusted relative risk = 1.05, 95% confidence interval: 0.84, 1.31) was observed. In this study, we did not identify a protective association of early childhood cow's milk volume or fat consumption with fracture risk in later childhood. Future prospective research is needed to understand whether cow's milk is beneficial for fracture prevention through the life course.

High Consumption of Soft Drinks Is Associated with an Increased Risk of Fracture: A 7-Year Follow-Up Study

(1) Background: Fracture causes a substantial burden to society globally. Some studies have found that soft drinks consumption was associated with the risk of fractures. We aimed to assess the association in the Chinese population; (2) Methods: Data from 17,383 adults aged 20 to 75 years old attending the China Health and Nutrition Survey (CHNS) between 2004 and 2011 were analyzed. Soft drinks consumption and fracture occurrence were self-reported. The cross-sectional and longitudinal associations between soft drink and fracture was assessed using multivariable mixed-effect logistic regression and Cox regression; (3) Results: After adjusting for sociodemographic and lifestyle factors and dietary patterns, compared with those who did not consume soft drinks, participants with daily consumption of soft drinks had an odds ratio (95%CI) of 2.72 (95%CI: 1.45-5.09) for fracture. During a mean 5-year follow-up, there were 569 incident fracture cases. Compared with non-consumers, those with daily soft drinks consumption had a hazard ratio (95%CI) of 4.69 (95%CI: 2.80-7.88) for incident fracture; (4) Conclusions: Soft drinks consumption is directly associated with the risk of fracture. Reducing soft drinks consumption should be considered as an important strategy for individual and population levels to maintain bone health.

Risk of Recurrent Fracture: A Population-Based Study

OBJECTIVES

To determine if children who sustain a fracture in childhood had an increased rate of fracture later in childhood or early adulthood. The a priori null hypothesis was that children who sustained a fracture would not have an increased rate of future fractures compared with children who did not sustain a fracture when controlling for important covariates.

METHODS

This is a population-based retrospective cohort study using health care databases in Ontario. Approximately 2.5 million healthy children aged 0 to 15 years living in Ontario, Canada between April 1, 2003, and March 31, 2004, were included and followed for 7 years. The exposure was occurrence of any fracture during a 1-year baseline period. The main outcome was any fractures during a 7-year follow-up period.

RESULTS

A total of 43 154 children suffered a fracture during the baseline year (17.5 fractures per 1000 child years). Children with a baseline fracture had a 60% higher rate of fracture (incidence rate ratio: 1.60; 95% confidence interval: 1.46-1.75; P < .0001) during the follow-up period after adjustment for sex, rurality, history of previous fracture, and the occurrence of other injuries (head and soft-tissue).

CONCLUSIONS

The occurrence of a fracture during childhood was associated with an increased rate of future fractures compared with children who did not suffer a fracture. Attempting to improve childhood bone health by targeting children who present to a fracture clinic with multiple fracture risk factors may be a useful strategy for secondary prevention of fractures and may have beneficial effects on long-term bone health.

An epidemiological evaluation of fractures and its determinants among Lebanese schoolchildren: a cross-sectional study

The purpose of this study is to establish the prevalence and determinants of fractures among 974 Lebanese schoolchildren aged 8-18. Fractures might be less common in the Lebanese pediatric population compared to western populations. Male gender and high SES are independent risk factors for fractures, while 25(OH)D and BMI have no impact.

PURPOSE

To establish the prevalence of fractures among Lebanese schoolchildren and its relationship with age, gender, BMI, 25 hydroxyvitamin D (25(OH)D) levels, and socioeconomic status (SES).

METHODS

In this cross-sectional study, 974 Lebanese schoolchildren aged 8-18 years old, mean age 13.37 ± 2.92 (508 boys and 466 girls), were recruited from 10 schools with different SES. For each participant, a questionnaire was used to collect data regarding history of fractures. Serum 25(OH)D was also measured.

RESULTS

The prevalence of Lebanese children sustaining ≥ 1 fracture was 16.9% and was higher in boys compared to girls (22.2% vs 11.1%, p < 0.0001). A 71.3% of fractures were localized in the upper limbs and 20% of participants had at least one displaced fracture. Children who sustained a fracture had a non-significant higher BMI compared to those without (p = 0.096). The percentage of children with fractures was higher in children from high SES compared to those from middle and low SES (respectively 23.3% vs. 16.3% and 13.8%, p < 0.0001). Fractures occurred at a younger age in girls compared to boys, but this difference was non-significant (p = 0.13). 25(OH)D levels were significantly higher in children with fractures compared to those without (p = 0.017). Finally, female gender was protective against upper limb fractures (p = 0.009). In a logistic regression analysis, male gender and high SES were independently associated with fractures, while BMI and 25(OH)D were not.

CONCLUSION

Our study demonstrates that the prevalence of fractures in the Lebanese pediatric population might be lower than western populations. It also confirms that male gender and high SES are independent risk factors for fractures, while 25(OH)D and BMI were not independently associated with fracture risk.

Intestinal Absorption of Fructose

Increased understanding of fructose metabolism, which begins with uptake via the intestine, is important because fructose now constitutes a physiologically significant portion of human diets and is associated with increased incidence of certain cancers and metabolic diseases. New insights in our knowledge of intestinal fructose absorption mediated by the facilitative glucose transporter GLUT5 in the apical membrane and by GLUT2 in the basolateral membrane are reviewed. We begin with studies related to structure as well as ligand binding, then revisit the controversial proposition that apical GLUT2 is the main mediator of intestinal fructose absorption. The review then describes how dietary fructose may be sensed by intestinal cells to affect the expression and activity of transporters and fructolytic enzymes, to interact with the transport of certain minerals and electrolytes, and to regulate portal and peripheral fructosemia and glycemia. Finally, it discusses the potential contributions of dietary fructose to gastrointestinal diseases and to the gut microbiome.

Roles of Vitamins D and K, Nutrition, and Lifestyle in Low-Energy Bone Fractures in Children and Young Adults

The research on skeletal system health in children and young adults, while recognizing the important role of calcium and vitamin D, goes beyond these nutritional standards. This review focuses on the role of vitamin K in combination with vitamin D and other factors in bone health. The current understanding is that maintaining bone health and prevention of low-energy fractures in any pediatric population includes nutritional factors combined with an active lifestyle. Calcium, vitamin D, and vitamin K supplementation contribute independently and collectively to bone health. The beneficial role of vitamin K, particularly vitamin K2 as menaquinone-7 (MK-7), in bone and cardiovascular health is reasonably well supported scientifically, with several preclinical, epidemiological, and clinical studies published over the last decade. Osteocalcin and matrix-Gla (glutamate-containing) protein (MGP) exemplify vitamin K-dependent proteins involved in building bone matrix and keeping calcium from accumulating in the arterial walls, respectively. An important part of the mechanism of vitamin K involves carboxylation and posttranslational activation of the family of vitamin K-dependent proteins, which prevent expression of pro-inflammatory factors and support improvement in bone mineral concentration, bone mineral density, and the quality of bone matrix. Understanding the combined approach to a healthy skeletal system in children and young adults, including the roles of vitamins D and K, calcium, healthy diet, and exercise, is particularly important in view of reports of subclinical insufficiency of vitamins D and K in otherwise healthy pediatric populations with low-energy bone fractures.

Dietary Food-Additive Phosphate and Human Health Outcomes

Dietary intake of phosphorus is required for human health, and dietary reference intakes for phosphorus have been established. Food-grade phosphates are used as additives to provide a wide range of technical functions in food production. Phosphates are often the most efficient ingredients to provide the required functionality in many applications, and in some cases, there are not effective and approved alternatives. However, many investigators have expressed concern about the quantities of phosphorus and food-additive phosphate present in the diets of many populations. This paper presents the outcome of an extensive review of 110 primary research articles focused on identifying evidence that substantiates or refutes associations of total dietary phosphorus and food-additive phosphate intake with health and disease in humans. The lack of conclusive evidence prevented the drawing of firm conclusions about the safety and possible risks of food-additive phosphate in the general population, which is consonant with the overall assessments of authoritative institutions who have concluded that available data are insufficient to make the required determinations. Despite the inadequacy of the evidence currently available, many of the authors of the publications reviewed for this paper expressed concerns about the quantities of phosphorus and food-additive phosphate in the diets of the populations and subpopulations they studied. At the same time, most of these authors offered only qualified conclusions and expressed themselves tentatively. In addition, authors of primary research publications, authors of review articles, and authoritative institutions have called for the conduct of further research.

Vitamin D and Fracture Risk in Early Childhood: A Case-Control Study

The objective of this study was to evaluate the association of vitamin D intake and serum levels with fracture risk in children under 6 years of age. A case-control study was conducted in Toronto, Ontario, Canada. Cases were recruited from the fracture clinic at the Hospital for Sick Children, and matched controls were obtained from the TARGet Kids! primary-care research network. Controls were matched to cases on age, sex, height, and season. Fracture risk was estimated from conditional logistic regression, with adjustment for skin type, fracture history, waist circumference, outdoor free play, neighborhood income, soda consumption, and child's birth weight. A total of 206 cases were recruited during May 2009-April 2013 and matched to 343 controls. Serum 25-hydroxyvitamin D concentration (per 10-nmol/L increment: adjusted odds ratio (aOR) = 0.95, 95% confidence interval (CI): 0.88, 1.03) and intake of cow's milk (<2 cups/day vs. 2 cups/day: aOR = 0.95 (95% CI: 0.60, 1.52); >2 cups/day vs. 2 cups/day: aOR = 1.39 (95% CI: 0.85, 2.23)) were not significantly associated with reduced odds of fracture. A statistically significant association was observed between child use of vitamin D supplements and decreased odds of fracture (yes vs. no: aOR = 0.42, 95% CI: 0.25, 0.69). Vitamin D supplementation, but not serum 25-hydroxyvitamin D level or milk intake, was associated with reduced fracture risk among these healthy young children.

The Impact of Fat and Obesity on Bone Microarchitecture and Strength in Children

A complex interplay of genetic, environmental, hormonal, and behavioral factors affect skeletal development, several of which are associated with childhood fractures. Given the rise in obesity worldwide, it is of particular concern that excess fat accumulation during childhood appears to be a risk factor for fractures. Plausible explanations for this higher fracture risk include a greater propensity for falls, greater force generation upon fall impact, unhealthy lifestyle habits, and excessive adipose tissue that may have direct or indirect detrimental effects on skeletal development. To date, there remains little resolution or agreement about the impact of obesity and adiposity on skeletal development as well as the mechanisms underpinning these changes. Limitations of imaging modalities, short duration of follow-up in longitudinal studies, and differences among cohorts examined may all contribute to conflicting results. Nonetheless, a linear relationship between increasing adiposity and skeletal development seems unlikely. Fat mass may confer advantages to the developing cortical and trabecular bone compartments, provided that gains in fat mass are not excessive. However, when fat mass accumulation reaches excessive levels, unfavorable metabolic changes may impede skeletal development. Mechanisms underpinning these changes may relate to changes in the hormonal milieu, with adipokines potentially playing a central role, but again findings have been confounding. Changes in the relationship between fat and bone also appear to be age and sex dependent. Clearly, more work is needed to better understand the controversial impact of fat and obesity on skeletal development and fracture risk during childhood.

Association between Vitamin D Receptor Polymorphism and Serum Vitamin D Levels in Children with Low-Energy Fractures

OBJECTIVE

Fractures of bones, especially forearm fractures, are very common in children and their number is increasing. This study was designed to determine the impact of vitamin D serum levels and vitamin D receptor (VDR) polymorphisms on the occurrence of low-energy fractures in children.

METHODS

The study group consisted of 100 children with clinically relevant bone fractures and a control group consisted of 127 children without fractures. Total vitamin D [25(OH)D3 plus 25(OH)D2] serum concentrations were evaluated in every patient. Genotypes for 4 restriction fragment length polymorphisms of the vitamin D receptor gene (FokI, ApaI, TaqI, and BsmI) were determined by standard polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) techniques.

RESULTS

Differences in concentrations of vitamin D were observed between the group with bone fractures (median = 12 ng/ml) and the control group (median = 16 ng/ml; p = 0.000044). Higher levels of vitamin D reduced the risk of fracture by 1.06 times (p = 0.0005). No impact of particular VDR polymorphism on the occurrence of low-energy fractures in children was detected. However, there were significant differences in the prevalence of FokI polymorphism genotypes between the fracture and control groups (p = 0.05). Furthermore, the recessive "aa" genotype of ApaI polymorphism and the dominant "TT" genotype of TaqI polymorphism were associated with higher levels of vitamin D (p = 0.005 and p = 0.036, respectively).

CONCLUSIONS

Vitamin D deficiency is an independent risk factor for fractures in children. ApaI polymorphism recessive "aa" and TaqI polymorphism dominant "TT" genotypes are associated with higher levels of vitamin D in serum.

Osteoporosis: Is milk a kindness or a curse?

Cow's milk is often severely criticized as a cause of multiple health problems, including an increased risk of fractures. A close look at the scientific literature shows a striking contradiction. On the one hand, experimental studies of surrogate markers (e.g., bone turnover markers and bone mineral density [BMD]) usually indicate benefits from drinking cow's milk. On the other, the findings from epidemiological studies are conflicting and disconcerting. In all age groups, including children and postmenopausal women, consuming cow's milk, powdered milk supplements, or whey protein is associated with a slower bone turnover and unchanged or higher BMD values. These benefits are particularly marked in populations where calcium deficiency is prevalent, for instance in Asian countries. No interventional studies have addressed the fracture risk potentially associated with drinking cow's milk. The only available data come from epidemiological observational studies, whose results are conflicting, with a lower fracture risk in some cases and no difference or a higher risk in others. Several hypotheses have been offered to explain these findings, such as a deleterious effect of D-galactose, lactose intolerance, and acid overload. Epidemiological studies face many obstacles when seeking to detect effects of a single food, particularly the multiplicity of interactions among foods. Furthermore, reliable dietary intake data must be collected over prolonged periods, often long before the occurrence of a fracture, and defective recall may therefore introduce a major yet often unrecognized bias, particularly in populations where calcium deficiency is uncommon. To date, there is no conclusive evidence that we should modify our currently high level of consumption of cow's milk.

Fracture risk and correlating factors of a pediatric population with attention deficit hyperactivity disorder: a nationwide matched study

The aim of this study was to investigate the risk of fracture and the difference between sexes from a nationwide database of fracture risk among children aged 4-17 years with or without attention deficit hyperactivity disorder (ADHD, ICD-9-CD codes 314). The Longitudinal Health Insurance Database (LHID 2000) was used to analyze fracture characteristics of children from the National Health Insurance that covered 96.1% of the Taiwanese population (N=21.4 million). A total of 7200 ADHD children aged between 4 and 17 years whose diagnosis had been confirmed in at least three outpatient clinics between 1 January 2000 and 31 December 2009 were included, and a cohort of 36 000 children without ADHD matched for age, sex, and urbanization was recruited for analysis. The incidence rate of fractures in ADHD children was 21.0 (95% confidence interval=19.4-22.7) per 1000 person-years, significantly (P<0.001) higher than 15.0 (95% confidence interval=14.4-15.6) in non-ADHDs. After adjusting by age, sex, urbanization level, and geographic region, the statistically significant (P<0.001) hazard ratios (HR) of fracture for ADHD children compared with non-ADHD children included 1.62 in girls and 1.38 in boys, 1.53 in the skull, neck, and trunk (ICD-9-CM 800-809), 1.28 in the upper extremity (ICD-9-CM 810-819), and 1.84 in the lower extremity (ICD-9-CM 820-829). The HR also (P<0.001) increased significantly in all age groups, including 1.35 in 4-6, 1.37 in 7-9, and 1.54 in 10-17 years. ADHD should be listed among risk factors of children's fractures in each sex, all age groups, and all body areas that the parents, teachers, caregivers of ADHD children, and pediatric orthopedists should be aware of. Besides, ADHD girls were more affected than ADHD boys, especially after 10 years of age, whereas the adjusted HR was the highest in the lower extremities. Nationwide analysis matched for age and sex showed that ADHD should be considered the risk factor of children's fracture, especially for girls older than 10 years of age.

The National Osteoporosis Foundation's position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations

Lifestyle choices influence 20-40 % of adult peak bone mass. Therefore, optimization of lifestyle factors known to influence peak bone mass and strength is an important strategy aimed at reducing risk of osteoporosis or low bone mass later in life. The National Osteoporosis Foundation has issued this scientific statement to provide evidence-based guidance and a national implementation strategy for the purpose of helping individuals achieve maximal peak bone mass early in life. In this scientific statement, we (1) report the results of an evidence-based review of the literature since 2000 on factors that influence achieving the full genetic potential for skeletal mass; (2) recommend lifestyle choices that promote maximal bone health throughout the lifespan; (3) outline a research agenda to address current gaps; and (4) identify implementation strategies. We conducted a systematic review of the role of individual nutrients, food patterns, special issues, contraceptives, and physical activity on bone mass and strength development in youth. An evidence grading system was applied to describe the strength of available evidence on these individual modifiable lifestyle factors that may (or may not) influence the development of peak bone mass (Table 1). A summary of the grades for each of these factors is given below. We describe the underpinning biology of these relationships as well as other factors for which a systematic review approach was not possible. Articles published since 2000, all of which followed the report by Heaney et al. [1] published in that year, were considered for this scientific statement. This current review is a systematic update of the previous review conducted by the National Osteoporosis Foundation [1]. [Table: see text] Considering the evidence-based literature review, we recommend lifestyle choices that promote maximal bone health from childhood through young to late adolescence and outline a research agenda to address current gaps in knowledge. The best evidence (grade A) is available for positive effects of calcium intake and physical activity, especially during the late childhood and peripubertal years-a critical period for bone accretion. Good evidence is also available for a role of vitamin D and dairy consumption and a detriment of DMPA injections. However, more rigorous trial data on many other lifestyle choices are needed and this need is outlined in our research agenda. Implementation strategies for lifestyle modifications to promote development of peak bone mass and strength within one's genetic potential require a multisectored (i.e., family, schools, healthcare systems) approach.

Nutrient and food intakes in early life and risk of childhood fractures: a systematic review and meta-analysis

BACKGROUND

The identification of detrimental dietary patterns early in life may contribute to reducing the high incidence of fracture among healthy children. However, information based on a systematic review of the effect of various dietary foods and nutrients on fracture risk is lacking.

OBJECTIVE

We conducted a systematic review and meta-analysis of observational studies that examined the association between dietary intake or serum nutritional concentrations and childhood fractures.

DESIGN

Studies published up until June 2015 were identified on the basis of a literature search in Medline, Web of Science, and Scopus databases and by hand searching references by first author based on predefined inclusion criteria. A meta-analysis was carried out for case-control studies that examined differences in mean calcium intake in the case compared with the control group. Random-effects analysis was performed on the basis of the effect estimates derived as the differences in mean calcium intakes between cases and controls.

RESULTS

From a total of 1960 articles, we identified 18 observational studies, which were primarily case-control in design. Randomized controlled trials were absent, potentially because of unethical aspects related to the enrollment of children randomly assigned to certain dietary exposures and later fracture rates. Overall, fracture risk seemed to be associated with milk avoidance, high energy intake, high cheese intake, high intake of sugar-sweetened beverages, and no breastfeeding. The pooled effect size of the 9 case-control studies that examined mean calcium intake, which had appropriate data for the meta-analysis, showed no association (P = 0.99) with fair heterogeneity (I(2) = 69.3%, P = 0.001) with the use of the random-effects model.

CONCLUSIONS

On the basis of a systematic review of studies that were judged to be of high or medium quality, there is an indication that some nutritional factors seem to be associated with an increased fracture risk among children. The results may be inflated by selection bias, bias in diet reporting, or residual confounding. More high-quality longitudinal observational or intervention studies are needed on the subject.

Maternal dietary patterns during pregnancy in relation to offspring forearm fractures: prospective study from the Danish National Birth Cohort

Limited evidence exists for an association between maternal diet during pregnancy and offspring bone health. In a prospective study, we examined the association between dietary patterns in mid-pregnancy and offspring forearm fractures. In total, 101,042 pregnancies were recruited to the Danish National Birth Cohort (DNBC) during 1996–2002. Maternal diet was collected by a food frequency questionnaire. Associations were analyzed between seven dietary patterns extracted by principal component analysis and offspring first occurrence of any forearm fracture diagnosis, extracted from the Danish National Patient Register, between time of birth and end of follow-up (<16 year) (n = 53,922). In multivariable Cox regression models, offspring of mothers in the fourth vs. first quintile of the Western pattern had a significant increased risk (Hazard ratio, 95% confidence interval: 1.11, 1.01–1.23) of fractures, and there was a borderline significant positive trend (p = 0.06). The other dietary patterns showed no associations and neither did supplementary analyses of macro- and micronutrients or single food groups, except for the intake of artificially sweetened soft drinks, which was positively associated with offspring forearm fractures (p = 0.02). In the large prospective DNBC high mid-pregnancy consumption of Western diet and artificially sweetened soft drinks, respectively, indicated positive associations with offspring forearm fractures, which provides interesting hypotheses for future research.

The epidemiology of fractures in otherwise healthy children

Fractures in otherwise healthy children are important because they are common, impact on daily activity, and may identify those who may have an increased fracture risk as adults. This review covers the descriptive epidemiology of fractures in healthy children (aged 0-16) and provides an overview of what is known about the child-related determinants of fractures, dividing associations into those that are potentially modifiable and those that are not. Maternal-related influences during pregnancy have not been covered, nor have determinants related to the injury such as trauma level, landing surface, injury type, the physical environment, or societal impacts. Age, gender, low bone mass, and exposure to injury are the child-related determinants of fractures with the highest quality research showing a convincing association.

Bone quality and strength are greater in growing male rats fed fructose compared with glucose

Optimization of peak bone mass during adolescence is important for osteoporosis prevention. Studies in rodents and humans have demonstrated the harmful effects of sugar intake on bone health. With the high levels of sucrose in the diets of adolescents, it is necessary to understand the influence of glucose and fructose on growing bones. This study compared the effects of dietary glucose and fructose on bone formation, microarchitecture, and strength. Because of the different metabolic effects of glucose and fructose, we hypothesized that their individual effects on bone would be different. Eighteen male Sprague-Dawley rats (age, 60 days) were randomly assigned to high-fructose (n = 9; 40% fructose, 10% glucose) or high-glucose diet (n = 9; 50% glucose) for 12 weeks. Bone measurements included histology and histomorphometry of trabecular bone in the distal femur and a 3-point bending test of the whole tibia. Whole liver mass and postprandial serum glucose, insulin, and triglycerides were used to assess differences in energy metabolism between the diets. There were no differences in food intake, body weight, or visceral adiposity between groups, but fructose consumption led to heavier livers (P = .001) and elevated serum triglycerides (P = .00). The distal femurs of fructose-fed rats had greater bone volume (bone volume/total volume; P = .03), lower bone surface (bone surface/bone volume; P = .02), and thicker trabeculae (trabecular thickness; P = .01). The tibias of the fructose-fed rats also withstood a greater maximum flexure load (P = .032). These results indicate that consumption of the high-fructose diet resulted in stronger bones with enhanced microarchitecture than consumption of the high-glucose diet.

The oslo health study: a dietary index estimating frequent intake of soft drinks and rare intake of fruit and vegetables is negatively associated with bone mineral density

Background. Since nutritional factors may affect bone mineral density (BMD), we have investigated whether BMD is associated with an index estimating the intake of soft drinks, fruits, and vegetables. Methods. BMD was measured in distal forearm in a subsample of the population-based Oslo Health Study. 2126 subjects had both valid BMD measurements and answered all the questions required for calculating a Dietary Index = the sum of intake estimates of colas and non-cola beverages divided by the sum of intake estimates of fruits and vegetables. We did linear regression analyses to study whether the Dietary Index and the single food items included in the index were associated with BMD. Results. There was a consistent negative association between the Dietary Index and forearm BMD. Among the single index components, colas and non-cola soft drinks were negatively associated with BMD. The negative association between the Dietary Index and BMD prevailed after adjusting for gender, age, and body mass index, length of education, smoking, alcohol intake, and physical activity. Conclusion. An index reflecting frequent intake of soft drinks and rare intake of fruit and vegetables was inversely related to distal forearm bone mineral density.

Chronic non-cholestatic liver disease is not associated with an increased fracture rate in children

Chronic liver disease in adults is a risk factor of osteoporosis, but little is known about risk of fractures in children with non-cholestatic liver disease. The aim of this study was to investigate associations among the severity of liver fibrosis, bone mass and low-energy fractures in children. History of fractures, anthropometry, and bone mass and size were examined in 39 Caucasian children (25 boys, 14 girls) aged 7.1-18 years (mean 11.9 ± 3.1) with chronic hepatitis B and liver fibrosis evidenced by liver biopsy. Severity of liver fibrosis was based on histological classification according to the method of Batts and Ludwig (mild, 1-2 scores; advanced, 3 scores) and Ishak (1-3 and 4-5 scores, respectively). Bone mineral content (BMC), density (BMD) and body composition were determined in the total body and lumbar spine using dual energy X-ray absorptiometry. Seven subjects (4 girls, 3 boys; 18% of the sample) had low BMD in the total body and lumbar spine region (Z-scores below -2.0). No associations were found among BMC, BMD, bone size and the severity of liver fibrosis. Nine boys (36% of all boys) and one girl reported repeated fractures (forearm, wrist, tibia, ankle, humerus), showing trends similar to the prevalence in general population. Fractures were neither associated with lower BMD/BMC nor with scores of liver fibrosis. Deficits in BMD in children with chronic hepatitis B are not associated with the severity of liver fibrosis. This study suggests that non-cholestatic liver disease does not increase the risk of low-energy fractures during growth. From the practical perspective, however, children with chronic liver disease should be screened for history and clinical risk factors for fractures rather than referred to bone density testing.

Nutritional factors that influence change in bone density and stress fracture risk among young female cross-country runners

OBJECTIVE

To identify nutrients, foods, and dietary patterns associated with stress fracture risk and changes in bone density among young female distance runners.

DESIGN AND SETTING

Two-year, prospective cohort study. Observational data were collected in the course of a multicenter randomized trial of the effect of oral contraceptives on bone health.

PARTICIPANTS

One hundred and twenty-five female competitive distance runners ages 18-26 years.

ASSESSMENT OF RISK FACTORS

Dietary variables were assessed with a food frequency questionnaire.

MAIN OUTCOME MEASUREMENTS

Bone mineral density and content (BMD/BMC) of the spine, hip, and total body were measured annually by dual x-ray absorptiometry (DEXA). Stress fractures were recorded on monthly calendars, and had to be confirmed by radiograph, bone scan, or magnetic resonance imaging.

RESULTS

Seventeen participants had at least one stress fracture during follow-up. Higher intakes of calcium, skim milk, and dairy products were associated with lower rates of stress fracture. Each additional cup of skim milk consumed per day was associated with a 62% reduction in stress fracture incidence (P < .05); and a dietary pattern of high dairy and low fat intake was associated with a 68% reduction (P < .05). Higher intakes of skim milk, dairy foods, calcium, animal protein, and potassium were associated with significant (P < .05) gains in whole-body BMD and BMC. Higher intakes of calcium, vitamin D, skim milk, dairy foods, potassium, and a dietary pattern of high dairy and low fat were associated with significant gains in hip BMD.

CONCLUSIONS

In young female runners, low-fat dairy products and the major nutrients in milk (calcium, vitamin D, and protein) were associated with greater bone gains and a lower stress fracture rate. Potassium intake was also associated with greater gains in hip and whole-body BMD.

Forearm fractures in children and bone health

PURPOSE OF REVIEW

Summary highlighting the evidence that bone health may affect forearm fracture risk in children.

RECENT FINDINGS

Although the incidence of other fractures and injuries are decreasing, the incidence of forearm fractures is increasing in otherwise healthy children. There is a growing volume of research that forearm fracture risk in children may be related to deficiencies in parameters of bone health. Available evidence of this relationship was summarized and included direct links to bone health (measurement of bone properties), indirect links to bone health (diet, vitamin D status, BMI), and genetic analyses.

SUMMARY

There is consistent and convincing evidence of an association between bone mineral density and forearm fracture risk in children. Studies of calcium intake and supplementation are less extensive in scope but suggest that effects of calcium deficiency on the radius may contribute to childhood forearm fracture risk. Forearm fracture risk in obese children is likely to reflect a combination of suboptimal bone health status and behavioral characteristics. Published data on the role of vitamin D status and genetic factors are limited but merit further consideration. Further investigation is needed to better understand the factors contributing to forearm fracture risk in children and translate this knowledge into effective clinical prevention and practice.

Pattern of fractures across pediatric age groups: analysis of individual and lifestyle factors

Background

Knowledge of the epidemiology of children's fractures is essential to develop preventive strategies. The aim of this study was to analyze the individual/lifestyle determinants of fractures across pediatric age groups.

Methods

A cross-sectional study was performed in the first six months of 2008 through questionnaire on a sample of children from an outpatient clinic for pediatric fractures. Differences in gender, anatomic site, circumstances and location of fracture occurrence, behavioural lifestyle, and calcium intake were investigated among three different age classes (pre-school children, school children, and adolescents).

Results

The sample consisted of 382 subjects (2-14 years of age) sustaining a fracture after low or moderate trauma. Males were at a higher risk of fractures than females; greater than two-thirds of injuries occurred after low-energy trauma and the upper limb was more frequently involved. With increasing age, the male/female ratio and time spent in sports participation increased (p < 0.001), while calcium intake and time spent in sedentary behaviors decreased (p < 0.001 and < 0.003, respectively). Gender discordance existed in pre-school children with respect to the anatomic location, and in school children and adolescents with respect to the dynamics. In the adolescent group, males were more physically active and also more sedentary than females. Fractures most frequently occurred in homes (41.6%), followed by playgrounds and footpaths (26.2%), sports facilities (18.3%), and educational facilities (13.9%), with gender differences existing only in adolescence. Twenty-three percent of the subjects sustained one or more fractures in the past. The percentage of recurrent fractures increased with age (p = 0.001), with a similar trend in both genders.

Conclusions

Gender differences were shown in the prevalence of injuries, characteristics, and circumstances across ages. These differences may be explained by the related changes in behaviors, together with attending different places. Individual and lifestyle factors can in part explain the variability in the occurrence of fractures and can also address targeted preventive strategies.

An update on the epidemiology of pediatric fractures

Despite public health measures to prevent childhood injuries, the incidence of pediatric fractures is increasing. This fracture incidence is dependent on many demographic factors, the various contributors to bone health, and an individual's risk-taking behavior. Although traditional play activities continue to be the prevalent causes for fractures, there is an evolving array of new sport and recreation activities that carry significant fracture risk. The following review article outlines the developing epidemiology of pediatric fractures by analyzing some of the individual risk factors that influence fracture incidence as well as the variety of activities that are associated with these fractures.

Associations between parental limits, school vending machine purchases, and soft drink consumption among Kentucky middle school students

OBJECTIVE

To examine associations between parental limits on soft drinks and purchasing soft drinks from school vending machines and consuming soft drinks among middle school students.

DESIGN

Secondary analysis of cross-sectional data from the middle school Youth Risk Behavior Survey.

SETTING

Eight public middle schools in central Kentucky.

PARTICIPANTS

All sixth- through eighth-grade students in 7 schools and all eighth-grade students in 1 school (n = 4,049).

VARIABLES MEASURED

Self-reported parental limits on soft drink intake, school vending machine soft drink purchases, soft drink consumption, and control variables.

ANALYSIS

Chi-square and binary logistic regression analyses.

RESULTS

Compared to students with no parental limits on soft drink consumption, students with the strictest limits were less likely to purchase soft drinks from school vending machines and consume soft drinks; conversely, students with minor parental limitations were more likely to consume soft drinks. The odds of consuming soft drinks were nearly 4 times greater when students purchased soft drinks from school vending machines than when they did not.

CONCLUSIONS AND IMPLICATIONS

Further research may enhance understanding of the influence of varying degrees of parental limitations. Efforts to reduce children's soft drink consumption may be augmented by policies limiting soft drink purchases in schools.

Evaluation of effectiveness of class-based nutrition intervention on changes in soft drink and milk consumption among young adults

BACKGROUND

During last few decades, soft drink consumption has steadily increased while milk intake has decreased. Excess consumption of soft drinks and low milk intake may pose risks of several diseases such as dental caries, obesity, and osteoporosis. Although beverage consumption habits form during young adulthood, which has a strong impact on beverage choices in later life, nutrition education programs on beverages are scarce in this population. The purpose of this investigation was 1) to assess soft drink and milk consumption and 2) to evaluate the effectiveness of 15-week class-based nutrition intervention in changing beverage choices among college students.

METHODS

A total of 80 college students aged 18 to 24 years who were enrolled in basic nutrition class participated in the study. Three-day dietary records were collected, verified, and analyzed before and after the intervention. Class lectures focused on healthful dietary choices related to prevention of chronic diseases and were combined with interactive hands on activities and dietary feedback.

RESULTS

Class-based nutrition intervention combining traditional lecture and interactive activities was successful in decreasing soft drink consumption. Total milk consumption, specifically fat free milk, increased in females and male students changed milk choice favoring skim milk over low fat milk. (1% and 2%).

CONCLUSION

Class-based nutrition education focusing on prevention of chronic diseases can be an effective strategy in improving both male and female college students' beverage choices. Using this type of intervention in a general nutrition course may be an effective approach to motivate changes in eating behaviors in a college setting.

Association between long-term consumption of soft drinks and variables of bone modeling and remodeling in a sample of healthy German children and adolescents

BACKGROUND

Soft drinks are thought to displace milk in diets of children and adolescents and therefore might affect variables of bone modeling and remodeling.

OBJECTIVE

We assessed the association between long-term consumption of several types of soft drinks and bone variables in children and adolescents.

DESIGN

Long-term dietary data from 3-d weighed dietary records collected by 228 healthy children and adolescents enrolled in the DONALD Study in 4 y of study participation were used for data analysis. Variables of bone modeling and remodeling of the radius were assessed by using peripheral quantitative computed tomography.

RESULTS

After adjustment for age, sex, total energy intake, muscle area, BMI SD scores, and growth velocity, long-term consumption of all soft drinks and uncaffeinated soft drinks was negatively associated with bone mineral content (P < 0.05), cortical area (P < 0.05), and polar strength strain index (P < 0.05), all of which reflect a combination of bone modeling and remodeling. Long-term consumption of caffeinated soft drinks was negatively associated with polar strength strain index (P < 0.01) and periosteal circumference (P < 0.05), which reflect bone modeling. Milk intake was positively associated with polar strength strain index (P < 0.05). Consumption of all soft drinks was negatively associated with total protein and milk intake, but was not associated with potential renal acid load.

CONCLUSIONS

Long-term consumption of caffeinated and uncaffeinated soft drinks appears to have bone catabolic effects in boys and girls. This effect is mainly mediated by the negative association with total protein intake and is not primarily based on milk displacement.

Vigorous physical activity increases fracture risk in children irrespective of bone mass: a prospective study of the independent risk factors for fractures in healthy children

Low bone mass is a determinant of fractures in healthy children. Small studies provide limited evidence on the association between ethnicity, birth weight, family size, socioeconomic status, dietary calcium intake, or physical activity and fracture incidence. No studies have investigated whether these determinants of fracture risk act through affecting bone mass or through other mechanisms. The aim of this study was to use a population-based birth cohort to confirm which variables are determinants of fracture risk and to further study which of these risk factors act independently of bone mass. Children from the Avon Longitudinal Study of Parents and Children have been followed up from birth to 11 yr of age. Maternal self-reported data have been collected contemporaneously on early life factors, diet, puberty, and physical activity. These were linked to reported fractures between 9 and 11 yr of age. Multivariable logistic regression techniques were used to assess whether these potential determinants were independent of, or worked through, estimated volumetric BMD or estimated bone size relative to body size measured by total body DXA scan at 9.9 yr of age. A total of 2692 children had full data. One hundred ninety-three (7.2%) reported at least one fracture over the 2-yr follow-up period. Children who reported daily or more episodes of vigorous physical activity had double the fracture risk compared with those children who reported less than four episodes per week (OR, 2.06; 95% CI, 1.21-1.76). No other independent determinants of fracture risk in healthy children were found. In conclusion, reported vigorous physical activity is an independent risk factor for childhood fracture risk. However, the interrelationship between physical activity, bone mass, and childhood fracture risk suggests that the higher bone mass associated with increased physical activity does not compensate for the risk caused by increased exposure to injuries.

Determinants of skeletal age deviation in a cross-sectional study

OBJECTIVE

Skeletal age deviation (SAD) is associated with bone mass and fracture risk in children, but factors determining this are unknown. The aim of this population-based cross-sectional study was to describe the factors associated with SAD.

METHODS

A convenience sample of 640 male and female children aged 7-17 yr was studied. All were assessed for body composition (dual-energy x-ray absorptiometry), diet, strength, dexterity, habitual physical activity, sunlight exposure, smoking, and medication use. Skeletal age was assigned using the Tanner-Whitehouse-2 method.

RESULTS

Subjects with a SAD greater than the 75th percentile had significantly higher height, weight, and Tanner stage compared with all other subjects. Bone-free lean mass, fat mass, and grip strength were positively associated with SAD. In multivariate analysis, ever smoking and use of inhaled corticosteroids were negatively associated with SAD, whereas milk drinking was positively associated with SAD. There was no significant association between sunlight exposure, television watching, light, or strenuous exercise and SAD.

CONCLUSIONS

The results of this study should be regarded as hypothesis generating but are biologically plausible and suggest that body composition, strength, diet, ever smoking, and inhaled corticosteroid use may be determinants of bone maturity relative to age and thus affect fracture risk in children. However, more studies are necessary to explore other determinants of SAD such as genetic and perinatal factors and whether SAD influences peak bone mass.

Bone fragility contributes to the risk of fracture in children, even after moderate and severe trauma

We prospectively examined whether the relationship between skeletal fragility and fracture risk in children 9.9 +/- 0.3 (SD) yr is affected by trauma level. Bone size relative to body size and humeral vBMD showed similar inverse relationships with fracture risk, irrespective of whether fractures followed slight or moderate/severe trauma.

INTRODUCTION

Fracture risk in childhood is related to underlying skeletal fragility. However, whether this relationship is confined to low-trauma fractures or whether skeletal fragility also contributes to the risk of fracture caused by higher levels of trauma is currently unknown.

MATERIALS AND METHODS

Total body DXA scan results obtained at 9.9 yr of age were linked to reported fractures over the following 2 yr in children from the Avon Longitudinal Study of Parents and Children. DXA scan results that were subsequently derived included total body less head (TBLH) bone size relative to body size (calculated from TBLH area adjusted for height and weight) and humeral volumetric BMD (vBMD; derived from subregional analysis at this site). Trauma level was assigned using the Landin classification based on a questionnaire asking about precipitating causes.

RESULTS

Of the 6204 children with available data, 549 (8.9%) reported at least one fracture over the follow-up period, and trauma level was assigned in 280 as follows: slight trauma, 56.1%; moderate trauma, 41.0%; severe trauma, 2.9%. Compared with children without fractures, after adjustment for age, sex, socioeconomic status, and ethnicity, children with fractures from both slight and moderate/severe trauma had a reduced bone size relative to body size (1133 cm(2) in nonfractured children versus 1112 cm(2) for slight trauma fractures, p < 0.001; 1112 cm(2) for moderate/severe trauma fractures, p = 0.001) and reduced humeral vBMD (0.494 g/cm(3) in nonfractured children versus 0.484 g/cm(3) for slight trauma fractures, p = 0.036; and 0.482 g/cm(3) for moderate/severe trauma fractures, p = 0.016).

CONCLUSIONS

Skeletal fragility contributes to fracture risk in children, not only in fractures caused by slight trauma but also in those that result from moderate or severe trauma.

Fractures during growth: potential role of a milk-free diet

Dietary calcium deficiency may increase fracture risk. In girls, 29.4% of fracture cases and 11.8% of controls without fracture had a history of milk-free diet. The odds ratio (OR) for fracture with a milk-free diet in girls was 4.6, p < 0.01. In boys, 23% of cases and 19% of controls had a history of a milk-free diet; OR = 1.3, NS). A milk-free diet due to cow's milk allergy is associated with increased fracture risk in girls.

INTRODUCTION

An intake of calcium below the reference daily intake (RDI) of 800-1200 mg/day during growth is thought to increase fracture risk even though convincing evidence for this view is scarce. The paucity of evidence may be partly due to many trial participants being calcium replete. Children and adolescents with cow's milk allergy (CMA) avoid milk and have a calcium intake below the RDI. The aim of this study was to examine the association between consumption of a milk-free diet and fracture risk.

METHODS

In this case-control study conducted in Poland, 57 boys and 34 girls aged 2.5-20 years with fractures (cases) were randomly matched by age and sex with 171 boys and 102 girls without fractures (controls). Weight and height were examined using standard methods. Bone mineral density (BMD) and body composition were measured using dual-energy X-ray absorptiometry. Conditional logistic regression and Bayesian analyses were used to determine the proportion of the fracture risk attributable to a milk-free diet.

RESULTS

In girls, 29.4% of cases and 11.8% of controls had a history of milk-free diet producing an odds ratio (OR) for fracture associated with a milk-free diet of 4.6 (95% confidence interval [CI]: 1.4-15.5, p < 0.01). In boys, 23% of cases and 19% of controls had a history of a milk-free diet; OR = 1.3 (95% CI: 0.6-2.7, NS). If the prevalence of CMA in the population is 5%, only 6.7% of the fractures occurring are attributable to CMA and the associated nutritional deficit.

CONCLUSIONS

Cow's milk allergy is associated with increased fracture risk in girls. Whether this association is due to the illness, calcium deficit or a deficit in other milk nutrients is uncertain. These data suggest that the contribution of milk-free diet to fracture liability among children and adolescents is modest.

Osteoporosis in children and adolescents

In recent years, the issue of low bone density in children and adolescents has attracted much attention. The classical definition of osteoporosis should be valid at any age, yet its practical applicability to children and adolescents remains a matter of debate and there is no consensus on a diagnosis based solely on the BMD value. The clinical relevance of uncomplicated low bone density in the young and its long-term consequences remain difficult to evaluate and there is only preliminary evidence that the BMD value is a predictor of fracture risk in growing subjects. Moreover, the interpretation of densitometric data in the young is difficult because the "normal" BMD values to be used for comparison are continuously changing with age, and in addition, depend on several variables, such as gender, body size, pubertal stage, skeletal maturation and ethnicity. Although Z-score values below -2 are generally considered a serious warning, most bone specialists make a diagnosis of osteoporosis in children and adolescents only in the presence of low BMD and at least one fragility fracture. The scope of this review is limited to presenting a picture of the available knowledge. The literature on fractures will be presented in detail, since fractures are one of the key elements in the debate. There are countless papers on fractures in childhood and adolescence, but very few of them attempt to identify fragility fractures, and still fewer develop the concept of osteoporosis in the young in relation to fractures. The different forms of primary and secondary osteoporosis, the more technical aspects of bone densitometry in pediatrics, and the delicate issue of treatment will be discussed only briefly.

Adolescent screen-viewing behaviour is associated with consumption of sugar-sweetened beverages: The role of habit strength and perceived parental norms

The association between adolescent screen-viewing behaviour (i.e., television viewing and computer use) and the consumption of sugar-sweetened beverages was studied in a Dutch sample of adolescents (N=383) using self-administered questionnaires. In particular, the previously understudied role of habit and perceived parental norms in the execution of these behaviours was investigated. Results showed that screen-viewing behaviour was associated with consumption of sugar-sweetened beverages (r=.32). Habit strength of both behaviours correlated with a large effect size (r=.50). The interaction between both behaviours was underlined by the finding that consumption of sugar-sweetened beverages was explained by perceived parental norms regarding screen-viewing behaviour (beta=.12; adjusted for the behaviour and perceived parental norm regarding sugar-sweetened beverage consumption). Consequences of the identified role of habit and parental norms in the interplay between sedentary behaviour and consumption of sugar-sweetened beverages among adolescents are discussed.