Nutritional aspects of bone health

Accidental vitamin D3 overdose in a young man

Vitamin D3 (VD3) is a fat-soluble vitamin that can accumulate in the body and lead to toxicity by increasing 25(OH) D levels when consumed in large amounts. Maintaining 25(OH) D levels greater than 30 ng/mL is crucial for overall health due to the significant role of vitamin D in the body. The most common causes of VD3 intoxication are manufacturing errors or self-administration. Currently, there is no definitive data on the dose and duration of VD3 consumption that leads to toxicity. The maximum daily doses of VD3 that can be tolerated without causing adverse effects are not established. The maximum recommended amount for long-term supplementation is 2,000 units per day. Vitamin D3 toxicity (VDT) can present in various scenarios, ranging from asymptomatic to gastrointestinal, and in severe cases with neuropsychiatric and life-threatening symptoms. We report the case of a 29-year-old man who presented with symptoms of VDT following an accidental overdose of VD3 over 2 weeks.

Effect of a 3-month L-carnitine supplementation and resistance training program on circulating markers and bone mineral density in postmenopausal women: a randomized controlled trial

BACKGROUND

Higher circulating levels of trimethylamine N-oxide (TMAO), which is a metabolite that can be produced by the gut microbiota from L-carnitine (LC), have been associated with bone mineral density (BMD). Because LC supplementation can improve bone density and microstructural properties in animal models, this study aimed to examine the effects of 12 weeks of LC supplementation on BMD and selected blood markers involved in bone metabolism of postmenopausal women participating in a resistance training (RT) program.

METHODS

Twenty-seven postmenopausal women, who had not been treated for osteoporosis, with a total T-score above - 3.0 and no diet differences completed 12 weeks of RT. The participants' diets were supplemented with either 1 g of LC-L-tartrate and 3 g of leucine per day (LC group) or 4 g of leucine per day as a placebo (PLA group), in a double-blind fashion.

RESULTS

After the intervention in the LC group, plasma total carnitine and serum decorin levels were higher than the corresponding preintervention values (p = 0.040 and p = 0.042, respectively). Moreover, plasma TMAO and serum SPARC levels were higher in the LC group than the corresponding postintervention values in the PLA group (p < 0.001 and p = 0.030, respectively). No changes in the BMD were observed after 3 months of the intervention.

CONCLUSIONS

Twelve weeks of LC supplementation during RT program increased plasma TMAO levels and appeared to affect signaling molecules, as indicated by the increase in the resting SPARC and decorin levels, with no significant modification in the BMD.

TRIAL REGISTRATION

Retrospectively registered at the ClinicalTrials.gov (NCT05120011).

Post hip fracture orthogeriatric care-a Canadian position paper addressing challenges in care and strategies to meet quality indicators

INTRODUCTION

Osteoporosis is a major disease state associated with significant morbidity, mortality, and health care costs. Less than half of the individuals sustaining a low energy hip fracture are diagnosed and treated for the underlying osteoporosis.

OBJECTIVE

A multidisciplinary Canadian hip fracture working group has developed practical recommendations to meet Canadian quality indicators in post hip fracture care.

METHODS

A comprehensive narrative review was conducted to identify and synthesize key articles on post hip fracture orthogeriatric care for each of the individual sections and develop recommendations. These recommendations are based on the best evidence available today.

CONCLUSION

Recommendations are anticipated to reduce recurrent fractures, improve mobility and healthcare outcomes post hip fracture, and reduce healthcare costs. Key messages to enhance postoperative care are also provided.

Personalized dietary advices provided by a dietitian increase calcium intake in outpatients with multiple sclerosis-Results from a randomized, controlled, single-blind trial

Background and aims

Multiple sclerosis (MS) is associated with osteoporosis, possibly due to neurological disability and decreased calcium intake. The objective of this study was to evaluate the efficacy of a personalized nutritional advice program by a dietitian compared to the delivery of a standard advice form to optimize dietary calcium intake in outpatients with MS.

Methods

We performed a randomized, controlled, parallel trial comparing the efficacy of a personalized dietary advice (PDA) program to standard advice form (SAF) to increase daily calcium intake in MS patients. The study population was composed by patients with relapsing-remitting MS aged 18-69 years old. PDA program consisted in dietary advice delivered by a dietitian at baseline, 1 month, and 3 months. Calcium and nutrient intake in patients from both groups was evaluated at baseline and 6 months using a dietary survey.

Results

Of the 194 patients screened for inclusion, 182 patients were included (79% female, median age of 42 years, and median EDSS of 2.0), and randomized to SAF (n = 92) or PDA (n = 90). At 6 months, median calcium intake increased by 241 mg/day in the PDA group and decreased by 120 mg/day in the SAF group (p < 0.0001). However, the median calcium intake was 947 mg/day in the SAF group and 778 mg/day in the PDA group at baseline (p = 0.0077), potentially favoring the effect of dietary advice. Complementary analyses focusing on patients with insufficient calcium intakes at baseline revealed comparable values in both groups (p = 0.69). Of those, patients included in the PDA group obtained significantly higher calcium intakes at 6 months than patients from the SAF group (p = 0.0086) independently of EDSS, PASAT, HADS and EQ-5D scores.

Conclusion

This work shows the efficacy of dietary management based on personalized advice program over 3 months to durably increase calcium consumption in MS patients with insufficient calcium intake.

Clinical trial registration

clinicaltrials.gov, identifier NCT02664623.

Bone fragility during the COVID-19 pandemic: the role of macro- and micronutrients

Bone fragility is the susceptibility to fracture due to poor bone strength. This condition is usually associated with aging, comorbidities, disability, poor quality of life, and increased mortality. International guidelines for the management of patients with bone fragility include a nutritional approach, mainly aiming at optimal protein, calcium, and vitamin D intakes. Several biomechanical features of the skeleton, such as bone mineral density (BMD), trabecular and cortical microarchitecture, seem to be positively influenced by micro- and macronutrient intake. Patients with major fragility fractures are usually poor consumers of dairy products, fruit, and vegetables as well as of nutrients modulating gut microbiota. The COVID-19 pandemic has further aggravated the health status of patients with skeletal fragility, also in terms of unhealthy dietary patterns that might adversely affect bone health. In this narrative review, we discuss the role of macro- and micronutrients in patients with bone fragility during the COVID-19 pandemic.

The Impact of an Adapted Physical Activity Program on Bone Turnover, Physical Performance and Fear of Falling in Osteoporotic Women with Vertebral Fractures: A Quasi-Experimental Pilot Study

Physical activity has been indicated as a potential strategy to counteract osteoporosis (OP). This study of post-menopausal women with osteoporotic vertebral fractures investigated the effect of an adapted physical activity (APA) program on two serum bone turnover biomarkers (Bone Alkaline Phosphatase, B-ALP and C-terminal telopeptide of type 1 collagen, CTX-1), functional capacity (6-Minutes Walking Test, 6MWT), and risk and fear of falls (Tinetti and Falls Efficacy scale). The APA group (n = 12) performed a 1-h group session twice per week for 6 months whereas the control group (n = 9) was asked to maintain their current lifestyle. The exercise program did not affect the serum concentrations of B-ALP and CTX-1 biomarkers measured at the baseline and after 6 months in women of the APA group. Moreover, at the end of intervention no significant differences in serum concentrations for either biomarker was observed between the two study groups. Interestingly, when compared to the control group, women in the APA group showed significant improvement in the functional capacity measures by 6MWT (p = 0.037) and a decrease of the risk and fear of falls as indicated by the Tinetti test (p = 0.043). Based on these findings, exercise could provide new perspectives for the care and management of OP.

Critical illness and bone metabolism: where are we now and what is next?

Critical illness refers to the clinical signs of severe, variable and life-threatening critical conditions, often accompanied by insufficiency or failure of one or more organs. Bone health of critically ill patients is severely affected during and after ICU admission. Therefore, clinical work should focus on ICU-related bone loss, and early development and implementation of related prevention and treatment strategies: optimized and personalized nutritional support (high-quality protein, trace elements and intestinal prebiotics) and appropriate physiotherapy and muscle training should be implemented as early as possible after ICU admission and discharge. At the same time, the drug regulates excessive metabolism and resists osteoporosis.

Dietary Acid Load Was Positively Associated with the Risk of Hip Fracture in Elderly Adults

Previous studies have shown that dietary acid load (DAL) harms bone health, but the evidence is inconsistent and insufficient. This study examined the relationships between DAL and the risk of hip fracture. This case−control study contained 1070 pairs of 1:1 age-, city-, and gender-matched incident cases and controls (mean age, 71 years) recruited in Guangdong, China. Dietary information was collected using a validated 79-item food frequency questionnaire through face-to-face interviews. DAL was estimated based on established algorithms for the potential renal acid load (PRAL) and net endogenous acid production (NEAP). Higher PRAL and NEAP were dose-dependently associated with a higher risk of hip fracture in both the conditional logistic regression model and restricted cubic spline analysis after adjusting for potential covariates. The multivariate-adjusted odds ratios and 95% CI of hip fracture for tertiles 2 and 3 (vs. 1) of DAL were 1.63 (1.18, 2.25) and 1.92 (1.36, 2.71) for PRAL and 1.81 (1.30, 2.53) and 2.55 (1.76, 3.71) for NEAP in all participants (all p-trends < 0.001), respectively. Subgroup analyses showed more pronounced associations in participants with a lower body mass index. Our findings suggested positive associations between the estimated DAL and the risk of hip fractures in the elderly Chinese population.

BCAT1 promotes osteoclast maturation by regulating branched-chain amino acid metabolism

Branched-chain aminotransferase 1 (BCAT1) transfers the amine group on branched-chain amino acids (BCAAs) to alpha-ketoglutarate. This generates glutamate along with alpha-keto acids that are eventually oxidized to provide the cell with energy. BCAT1 thus plays a critical role in sustaining BCAA concentrations and availability as an energy source. Osteoclasts have high metabolic needs during differentiation. When we assessed the levels of amino acids in bone marrow macrophages (BMMs) that were undergoing receptor activator of nuclear factor κB ligand (RANKL)-induced osteoclast differentiation, we found that the BCAA levels steadily increase during this process. In vitro analyses then showed that all three BCAAs but especially valine were needed for osteoclast maturation. Moreover, selective inhibition of BCAT1 with gabapentin significantly reduced osteoclast maturation. Expression of enzymatically dead BCAT1 also abrogated osteoclast maturation. Importantly, gabapentin inhibited lipopolysaccharide (LPS)-induced bone loss of calvaria in mice. These findings suggest that BCAT1 could serve as a therapeutic target that dampens osteoclast formation.

When Incorporated into Fruit Sorbet Matrix, Are the Fructans in Natural Raw Materials More Beneficial for Bone Health than Commercial Formulation Added Alone?

We assessed the extent to which fructans from various sources and added in various forms (raw materials in diet alone or incorporated into a strawberry matrix) differ in their effectiveness towards selected parameters related to bone health under calcium hypoalimentation in growing female Wistar rats. The aim of this study was to evaluate the levels of selected parameters involved in calcium metabolism, in response to a 12-week restriction of Ca intake: serum ions (Ca, Mg, P); the activity of alkaline phosphatase—using a BS 120 analyzer; the markers of bone turnover (osteocalcin, CTX; using a Rat-MidTMOsteocalcinEIA Kit and RatLapsTMEIA, respectively); and the bone mineral content (BMC) and density (BMD), using a Norland Excell Plus Densitometer. Among the examined markers, the CTX concentration increased dramatically under calcium hypoalimentation. The presence of Jerusalem artichoke (independently of the form of addition) and yacon root powder (with strawberry sorbet matrix) in the rats’ diet led to a significantly lower CTX concentration than was observed in the low-calcium control group. The type of fructan influenced the bone mass content. When fructan was added to the low-calcium diet as an ingredient of sorbet, it exerted more pronounced effects on the biochemical parameters of bone metabolism than when added alone, in the growing-female-rat model.

The global approach to rehabilitation following an osteoporotic fragility fracture: A review of the rehabilitation working group of the International Osteoporosis Foundation (IOF) committee of scientific advisors

PURPOSE

To conduct a review of the current state of the evidence for rehabilitation strategies post-fragility fracture.

METHODS

Narrative review conducted by the Rehabilitation Working Group of the International Osteoporosis Foundation Committee of Scientific Advisors characterizing the range of rehabilitation modalities instrumental for the management of fragility fractures.

RESULTS

Multi-modal exercise post-fragility fracture to the spine and hip is strongly recommended to reduce pain, improve physical function, and improve quality of life. Outpatient physiotherapy post-hip fracture has a stronger evidence base than outpatient physiotherapy post-vertebral fracture. Appropriate nutritional care after fragility fracture provides a large range of improvement in morbidity and mortality. Education increases understanding of osteoporosis which in turn increases utilization of other rehabilitation services. Education may improve other health outcomes such as pain and increase a patient's ability for self-advocacy.

CONCLUSION

Rehabilitation interventions are inter-reliant, and research investigating the interaction of exercise, nutrition, and other multi-modal therapies may increase the relevance of rehabilitation research to clinical care.

Sarcopenic Dysphagia, Malnutrition, and Oral Frailty in Elderly: A Comprehensive Review

Frailty is a highly prevalent condition in the elderly that has been increasingly considered as a crucial public health issue, due to the strict correlation with a higher risk of fragility fractures, hospitalization, and mortality. Among the age-related diseases, sarcopenia and dysphagia are two common pathological conditions in frail older people and could coexist leading to dehydration and malnutrition in these subjects. “Sarcopenic dysphagia” is a complex condition characterized by deglutition impairment due to the loss of mass and strength of swallowing muscles and might be also related to poor oral health status. Moreover, the aging process is strictly related to poor oral health status due to direct impairment of the immune system and wound healing and physical and cognitive impairment might indirectly influence older people’s ability to carry out adequate oral hygiene. Therefore, poor oral health might affect nutrient intake, leading to malnutrition and, consequently, to frailty. In this scenario, sarcopenia, dysphagia, and oral health are closely linked sharing common pathophysiological pathways, disabling sequelae, and frailty. Thus, the aim of the present comprehensive review is to describe the correlation among sarcopenic dysphagia, malnutrition, and oral frailty, characterizing their phenotypically overlapping features, to propose a comprehensive and effective management of elderly frail subjects.

Postmenopausal osteoporosis: current status of bone densitometry

Osteoporosis is the most common of all metabolic bone disorders characterized by loss of bone strength, due to modifications in bone turnover. It leads to bone fragility and increased fracture risk. Because of the increasing aging of the world population, the number of people affected by osteoporosis is continuously increasing. The WHO operational definition of osteoporosis, based on a measurement of bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), identifies patients at greatest risk of fracture. However, in the population overall a greater total number of fractures occurs in individuals with BMD values above threshold for osteoporosis diagnosis; for this reason, algorithms have been developed to improve the identification of individuals at high fracture risk, including clinical risk factors for fracture. The correct diagnosis of osteoporosis with an appropriate and accurate use of diagnostic imaging results in better management in terms of adequate treatment and follow-up. Moreover, screening strategies will improve identification of patients who are most likely to benefit from drug treatment to prevent fracture. All women after the age of 65 years previously untested and women after the age of 50 years with previous low trauma fractures should be screened by DXA. In fact, osteoporosis-related fractures cause a significant increase in morbidity and mortality, decreasing the quality of life, with an increasing social and economic burdens. For this reason, fracture risk assessment should be a high priority amongst health measures.

The Use of Mushrooms and Spirulina Algae as Supplements to Prevent Growth Inhibition in a Pre-Clinical Model for an Unbalanced Diet

Today’s eating patterns are characterized by the consumption of unbalanced diets (UBDs) resulting in a variety of health consequences on the one hand, and the consumption of dietary supplements in order to achieve overall health and wellness on the other. Balanced nutrition is especially crucial during childhood and adolescence as these time periods are characterized by rapid growth and development of the skeleton. We show the harmful effect of UBD on longitudinal bone growth, trabecular and cortical bone micro-architecture and bone mineral density; which were analyzed by micro-CT scanning. Three point bending tests demonstrate the negative effect of the diet on the mechanical properties of the bone material as well. Addition of Spirulina algae or Pleurotus eryngii or Agaricus bisporus mushrooms, to the UBD, was able to improve growth and impaired properties of the bone. 16SrRNA Sequencing identified dysbiosis in the UBD rats’ microbiota, with high levels of pro-inflammatory associated bacteria and low levels of bacteria associated with fermentation processes and bone related mechanisms. These results provide insight into the connection between diet, the skeletal system and the gut microbiota, and reveal the positive impact of three chosen dietary supplements on bone development and quality presumably through the microbiome composition.

How can the orthopedic surgeon ensure optimal vitamin D status in patients operated for an osteoporotic fracture?

In this narrative review, the role of vitamin D deficiency in the pathophysiology, healing of fragility fractures, and rehabilitation is discussed. Vitamin D status can be assessed by measuring serum 25(OH)-vitamin D level with standardized assays. There is a high prevalence of vitamin D insufficiency (25(OH)D < 50 nmol/l (i.e., 20 ng/mL)) or deficiency (25(OH)D < 25 nmol/l (i.e., 10 ng/mL)) in patients with fragility fractures and especially in those with a hip fracture. The evidence on the effects of vitamin D deficiency and/or vitamin D supplementation on fracture healing and material osseointegration is still limited. However, it appears that vitamin D have a rather positive influence on these processes. The fracture liaison service (FLS) model can help to inform orthopedic surgeons, all caregivers, and fractured patients about the importance of optimal vitamin D status in the management of patients with fragility fractures. Therefore, vitamin D status should be included in Capture the Fracture® program as an outcome of FLS in addition to dual-energy X-ray absorptiometry (DXA) and specific antiosteoporosis medication. Vitamin D plays a significant role in the pathophysiology and healing of fragility fractures and in rehabilitation after fracture. Correction of vitamin D deficiency should be one of the main outcomes in fracture liaison services.

Consumption of Calcium and Knowledge About Calcium Sources and Nutrition Labels Among Lower Secondary School Students in Thailand

Objective

A three study research program was conducted to identify high calcium products available in the market (study I), identify high calcium products that were known or consumed by lower secondary school students in the last three months (study II), and identify the amount and sources of calcium that students had consumed in the prior 24 hours, their knowledge about sources of high calcium and how to interpret calcium information on nutrition labels of food packages (study III).

Methods

In study I, a cross-sectional market survey was employed. In studies II and III, a school-based cross-sectional survey was employed. The survey population was students enrolled in grades 7–9 (11–14 years old) in a medium-sized lower secondary school in semi-urban Khon Kaen, Thailand. A total of 309 students were invited, with 168 and 209 students participating in studies II and III, respectively. Data were collected with self-administered questionnaires.

Results

Ninety-three high calcium products were identified. Only 49 were known or consumed by students in the last three months. The median amount of calcium consumed in the previous 24 hours was 410 mg (IQR: 160, 983). Only 31.1% of students (65/209) consumed more than the Thai recommended daily intake (TRDI) of calcium (800mg) in the previous 24 hours. Their main source of calcium was milk. Other high calcium items that were consumed were malt drink, minnow, canned fish, calcium fortified soy milk and Chinese kale. The overall average knowledge score was 6.5±2.4 out of a maximum of 17. The average knowledge scores for high calcium food sources and for interpreting the calcium information on a sample nutrition label were 4.6+1.8 (out of 12), and 1.9±1.2 (out of 5), respectively.

Discussion

Students should be introduced to high calcium products in their community such as hard tofu, minnow, and small freshwater shrimp. Educational programs on nutrition label interpretation are needed.

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.

Rethinking of osteoporosis through a sex- and gender-informed approach in the COVID-19 era

Standards and models of reference for osteoporosis (OP) have been developed for female individuals as they are more likely to be affected by the disease. Nonetheless, OP is also responsible for one-third of hip fractures in male individuals suggesting that a sexblinded approach to OP may lead to miss opportunities for equity in bone health. OPrelated fractures, especially hip fractures, are a matter of immediate concern as they are associated with limited mobility, chronic disability, loss of independence, and reduced quality of life in both sexes. When it comes to sociocultural gender, the effect of gender domains (i.e., identity, roles, relations, and institutionalized gender) on development and management of OP is largely overlooked despite risk factors or protective conditions are gendered. Clinical trials testing the efficacy and safety of anti-OP drugs as well as non-pharmacological interventions have been conducted mainly in female participants, limiting the generalizability of the findings. The present narrative review deals with the sex and gender-based challenges and drawbacks in OP knowledge and translation to clinical practice, also considering the impact of coronavirus disease 2019 pandemic.

Efficacy of shear strain gradients as an osteogenic stimulus

The question of which mechanical variables are responsible for inducing osteogenic activity is unresolved despite extensive experimental and theoretical investigation. Candidate variables include strain magnitude, loading frequency, the interaction of magnitude and frequency (strain rate), and strain gradients. An additional challenge is discerning the coordination of periosteal and endosteal expansion during growth, and whether this coordination (or lack thereof) is fully dependent or partially independent of the local mechanical environment. In this study, under the assumption that calculated stresses correspond to relative strain magnitudes, we specify alternative growth algorithms of bone cross-sectional size and geometry to explore skeletal growth under alternative scenarios of osteogenic activity that are tracking 1) an attractor stress, 2) local stress magnitude or 3) steepness of stress gradients. These developmental simulations are initiated from two initial geometries (symmetrical and asymmetrical ellipses) under a time-varying torsional load whose magnitude is proportional to body size growth in a model primate. In addition, we model endosteal expansion under three conditions hypothesized in the literature, in which endosteal expansion is 1) independent of the mechanical milieu, 2) completely dependent on the mechanical milieu, and 3) a "hybrid" model in which intrinsic biological (independent) growth is operative early but gives way to mechanically-sensitive (dependent) growth at later ages. Three variables were recorded over each growth simulation: the safety factor (ratio of yield stress to actual stress), an efficiency ratio (invested bone area per unit of stress), and proximity to an isostress condition (an optimal design criterion in which stress is invariant throughout the structure). The attractor stress algorithm produces the most "adapted" bones in terms of mechanical competence and economy of material. Localized osteogenic activity that is guided in direct proportion to stress magnitude produces competent bones but with variable adult geometries depending on conditions of endosteal expansion. Stress gradients also produce functional but relatively inefficient bones, with widely variable safety factors during growth and heterogeneous stress fields. If, in fact, the osteocyte network monitors strain gradients to generate osteogenic signals, the resulting morphology is competent but falls well short of an optimal mechanical solution.

Updated approach for the management of osteoporosis in Turkey: a consensus report

As a result of the current demographics, increased projections of osteoporosis (OP) and prevalence of the disease in Turkey, a panel of multidisciplinary experts developed a thorough review to assist clinicians in identifying OP and associated fracture risk patients, diagnosing the disease with the appropriate available diagnostic methods, classifying the disease, and initiating appropriate treatment. The panel expects to increase the awareness of this prevalent disease, decrease consequences of OP with corresponding cost savings and, ultimately, decrease the overall burden of OP and related fractures in Turkey.

BACKGROUND

OP is not officially accepted as a chronic disease in Turkey despite the high prevalence and predicted increase in the following years. However, there are areas where the country is performing well, such as having a country-specific fracture risk assessment model, DXA access, and the uptake of FRAX. Additional efforts are required to decrease the existing treatment gap estimating 75-90% of patients do not receive pharmacological intervention for secondary prevention, and the diagnosis rate is around 25%.

METHODS

A selected panel of Turkish experts in fields related to osteoporosis was provided with a series of relevant questions to address prior to the multi-day conference. Within this conference, each narrative was discussed and edited by the entire group, through numerous drafts and rounds of discussion until a consensus was achieved. Represented in the panel were a number of societies including The Turkish Osteoporosis Society, The Society of Endocrinology and Metabolism of Turkey (SEMT), and The Turkish Society of Physical Medicine and Rehabilitation.

RESULTS

Standardized general guidelines to identify OP and related fractures and at-risk population in Turkey, which will enable clinicians to accurately and effectively diagnose the disease, treat the appropriate patients with available pharmacological and non-pharmacological treatments and decrease the burden of the disease.

CONCLUSIONS

This manuscript provides a review of the current state of OP and related fractures in Turkey. Moreover, this manuscript reviews current international guidelines and national studies and proposes a number of helpful country-specific classifications that can be used by healthcare providers caring for the at-risk population. Additionally, the panel proposes practical recommendations that should be implemented nationally in order to decrease the burden of OP and related fractures and effectively preventing the burden in future generations.

How to manage osteoporosis before the age of 50

This narrative review discusses several aspects of the management of osteoporosis in patients under 50 years of age. Peak bone mass is genetically determined but can also be affected by lifestyle factors. Puberty constitutes a vulnerable period. Idiopathic osteoporosis is a rare, heterogeneous condition in young adults due in part to decreased osteoblast function and deficient bone acquisition. There are no evidence-based treatment recommendations. Drugs use can be proposed to elderly patients at very high risk. Diagnosis and management of osteoporosis in the young can be challenging, in particular in the absence of a manifest secondary cause. Young adults with low bone mineral density (BMD) do not necessarily have osteoporosis and it is important to avoid unnecessary treatment. A determination of BMD is recommended for premenopausal women who have had a fragility fracture or who have secondary causes of osteoporosis: secondary causes of excessive bone loss need to be excluded and treatment should be targeted. Adequate calcium, vitamin D, and a healthy lifestyle should be recommended. In the absence of fractures, conservative management is generally sufficient, but in rare cases, such as chemotherapy-induced osteoporosis, antiresorptive medication can be used. Osteoporosis in young men is most often of secondary origin and hypogonadism is a major cause; testosterone replacement therapy will improve BMD in these patients. Diabetes is characterized by major alterations in bone quality, implying that medical therapy should be started sooner than for other causes of osteoporosis. Primary hyperparathyroidism, hyperthyroidism, Cushing's syndrome and growth hormone deficiency or excess affect cortical bone more often than trabecular bone.

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.

RANKL/RANK/OPG Pathway: A Mechanism Involved in Exercise-Induced Bone Remodeling

Bones as an alive organ consist of about 70% mineral and 30% organic component. About 200 million people are suffering from osteopenia and osteoporosis around the world. There are multiple ways of protecting bone from endogenous and exogenous risk factors. Planned physical activity is another useful way for protecting bone health. It has been investigated that arranged exercise would effectively regulate bone metabolism. Until now, a number of systems have discovered how exercise could help bone health. Previous studies reported different mechanisms of the effect of exercise on bone health by modulation of bone remodeling. However, the regulation of RANKL/RANK/OPG pathway in exercise and physical performance as one of the most important remodeling systems is not considered comprehensive in previous evidence. Therefore, the aim of this review is to clarify exercise influence on bone modeling and remodeling, with a concentration on its role in regulating RANKL/RANK/OPG pathway.

Magnesium Intake Predicts Bone Turnover in Postmenopausal Black South African Women

This prospective study investigated the association between nutrient intake, dietary patterns, and changes in bone turnover and bone mineral density (BMD) in postmenopausal urban black South African women over two years. These women (n = 144) underwent BMD measurements at the distal radius, lumbar spine, femoral neck (FN), as well as a biochemical analysis which included the parathyroid hormone (PTH), 25-hydroxyvitamin D, C-Telopeptide of type I collagen (CTX-1) in 2010 and 2012. Their dietary intake was assessed in 2010 using a food frequency questionnaire, and sociodemographic and health information was collected. Four dietary patterns explained 54.4% of the variance of dietary intake, namely staple foods and processed meats, home cooking, snacking, and high sugar. Dietary magnesium negatively correlated with CTx-1 in 2012 (r = −0.21, p = 0.02), calcium correlated with distal radius BMD in 2010 (r = 0.22, p = 0.01) and 2012 (r = 0.24, p = 0.005), and the snacking dietary pattern score correlated with FN BMD in 2010 (r = 0.18, p = 0.03) and 2012 (r = 0.21, p = 0.02). The baseline CTx-1 and dietary magnesium intake predicted 22% of the variance in percentage change of CTx-1 over two years (p < 0.001).The magnesium intake predicted short-term bone resorption over two years.

The L-type amino acid transporter LAT1 inhibits osteoclastogenesis and maintains bone homeostasis through the mTORC1 pathway

L-type amino acid transporter 1 (LAT1), which is encoded by solute carrier transporter 7a5 (Slc7a5), plays a crucial role in amino acid sensing and signaling in specific cell types, contributing to the pathogenesis of cancer and neurological disorders. Amino acid substrates of LAT1 have a beneficial effect on bone health directly and indirectly, suggesting a potential role for LAT1 in bone homeostasis. Here, we identified LAT1 in osteoclasts as important for bone homeostasis. Slc7a5 expression was substantially reduced in osteoclasts in a mouse model of ovariectomy-induced osteoporosis. The osteoclast-specific deletion of Slc7a5 in mice led to osteoclast activation and bone loss in vivo, and Slc7a5 deficiency increased osteoclastogenesis in vitro. Loss of Slc7a5 impaired activation of the mechanistic target of rapamycin complex 1 (mTORC1) pathway in osteoclasts, whereas genetic activation of mTORC1 corrected the enhanced osteoclastogenesis and bone loss in Slc7a5-deficient mice. Last, Slc7a5 deficiency increased the expression of nuclear factor of activated T cells, cytoplasmic 1 (Nfatc1) and the nuclear accumulation of NFATc1, a master regulator of osteoclast function, possibly through the canonical nuclear factor κB pathway and the Akt-glycogen synthase kinase 3β signaling axis, respectively. These findings suggest that the LAT1-mTORC1 axis plays a pivotal role in bone resorption and bone homeostasis by modulating NFATc1 in osteoclasts, thereby providing a molecular connection between amino acid intake and skeletal integrity.

Dairy- and supplement-based calcium intake in adulthood and vertebral dimensions in midlife-the Northern Finland Birth Cohort 1966 Study

Among a representative sample of 1064 Northern Finns, we studied the association of dairy- and supplement-based calcium intake in adulthood with vertebral size in midlife. Inadequate calcium intake (< 800 mg/day) from age 31 to 46 predicted small vertebral size and thus decreased spinal resilience among women but not men.

INTRODUCTION

Small vertebral size predisposes individuals to fractures, which are common among aging populations. Although previous studies have associated calcium (Ca) intake with enhanced bone geometry in the appendicular skeleton, few reports have addressed the axial skeleton or the vertebrae in particular. We aimed to investigate the association of dairy- and supplement-based Ca intake in adulthood with vertebral cross-sectional area (CSA) in midlife.

METHODS

A sample of 1064 individuals from the Northern Finland Birth Cohort 1966 had undergone lumbar magnetic resonance imaging at the age of 46, and provided self-reported data on diet and Ca intake (dairy consumption and use of Ca supplements) at the ages of 31 and 46. We assessed the association between Ca intake (both continuous and categorized according to local recommended daily intake) and vertebral CSA, using generalized estimating equation and linear regression models with adjustments for body mass index, diet, vitamin D intake, education, leisure-time physical activity, and smoking.

RESULTS

Women with inadequate Ca intake (< 800 mg/day) over the follow-up had 3.8% smaller midlife vertebral CSA than women with adequate Ca intake (p = 0.009). Ca intake among men showed no association with vertebral CSA.

CONCLUSIONS

Inadequate Ca intake (< 800 mg/day) from the age of 31 to 46 predicts small vertebral size and thus decreased spinal resilience among middle-aged women. Future studies should confirm these findings and investigate the factors underlying the association of low Ca intake in women but not in men with smaller vertebral size.

Chocolate and chocolate constituents influence bone health and osteoporosis risk

Bone loss resulting in increased risk for osteoporosis is a major health issue worldwide. Chocolate is a rich source of antioxidant and antiinflammatory flavonoids and dietary minerals with the potential to benefit bone health. However, other chocolate constituents such as cocoa butter, sugar, and methylxanthines may be detrimental to bone. Human studies investigating the role of chocolate consumption on serum bone markers and bone mineral density (BMD) have been inconsistent. A contributing factor is likely the different composition and thereby the nutrient and bioactive content among chocolate types. White and milk chocolate are high in sugar and low in flavonoids and most minerals. Dark chocolate (45-85% cocoa solids) is high in flavonoids, most minerals, and low in sugar with ≥70% cocoa solids resulting in higher fat and methylxanthine content. The aim of this review was to examine the relationship between chocolate consumption and its constiuents, including flavonoid content, on bone health and osteoporosis risk. Studies showed postmenopausal women had no bone effects at moderate chocolate intakes, whereas adolescents consuming chocolate had greater longitudinal bone growth. Based on flavonoid and mineral content, unsweetened cocoa powder appeared to be the best option followed by dark chocolate with higher cocoa content in terms of supporting and preserving bone health. Determining dietary recommendations for chocolate consumption relative to bone health is important because of the growing popularity of chocolate, particularly dark chocolate, and an expected increase in consumption owing to suggestions of health benefits against various degenerative diseases.

European guidance for the diagnosis and management of osteoporosis in postmenopausal women

Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis.

INTRODUCTION

The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2013. This manuscript updates these in a European setting.

METHODS

Systematic reviews were updated.

RESULTS

The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; monitoring of treatment; assessment of fracture risk; case-finding strategies; investigation of patients; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment.

CONCLUSIONS

A platform is provided on which specific guidelines can be developed for national use.

Calcium Intake in Bone Health: A Focus on Calcium-Rich Mineral Waters

Calcium is an essential element that plays numerous biological functions in the human body, of which one of the most important is skeleton mineralization. Bone is a mineralized connective tissue in which calcium represents the major component, conferring bone strength and structure. Proper dietary calcium intake is important for bone development and metabolism, and its requirement can vary throughout life. The mineral composition of drinking water is becoming relevant in the modulation of calcium homeostasis. In fact, calcium present in mineral drinking waters is an important quantitative source of calcium intake. This, together with its excellent bioavailability, contributes to the maintenance of the bone health. This article aims to examine studies that assessed the bioavailability of the calcium contained in calcium-rich mineral waters and their impact on bone health, including original data collected in a recent study in humans.

Postmenopausal osteoporosis: Assessment and management

Osteoporosis increases the risk of fractures, which are associated with increased mortality and lower quality of life. Patients with prevalent fracture are at high risk to of sustaining another one. Optimal protein and calcium intakes, and vitamin D supplies, together with regular weight bearing physical exercise are the corner stones of fracture prevention. Evidence for anti-fracture efficacy of pharmacological interventions relies on results from randomised controlled trials in postmenopausal women with fractures as the primary outcome. Treatments with bone resorption inhibitors, like bisphosphonates or denosumab, and bone formation stimulator like teriparatide, reduce vertebral and non-vertebral fracture risk. A reduction in vertebral fracture risk can already be detected within a year after starting therapy.

Total flavonoid extract of Epimedium herb increases the peak bone mass of young rats involving enhanced activation of the AC10/cAMP/PKA/CREB pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Epimedium sagittatum brevicornum Maxim. is an important traditional Chinese herb that has long been used to promote bone fracture healing and treat osteoporosis.

AIM OF THE STUDY

Achieving peak bone mass by adolescence has now been accepted to be fundamental for preventing osteoporosis in adulthood life. This study investigated the possibility of increasing peak bone mass in young rats using the total flavonoid extract of Epimedium herb (TFE).

MATERIALS AND METHODS

TFE was intragastrically administered to one-month-old Wistar rats at a low (100 mg/kg), middle (200 mg/kg) or high dose (400 mg/kg). Whole body bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry every two weeks. When BMD of any one of TFE groups was found to be significantly higher than that of the control, all rats were sacrificed, serum samples were collected for bone turnover biochemical assays, and femurs, tibiae and vertebrae were isolated and used in BMD, mechanical, micro-structural, histomorphometric and mechanistic studies.

RESULTS

Administration of TFE at middle and high doses for two months significantly increased the whole body, femoral and vertebral BMDs, and improved the bone mechanical and micro-architectural properties. The serum turnover biochemical results and the enhanced expression levels of bone-formation regulatory genes (Runx-2, OSX, and BMP-2) demonstrated that TFE administration increased bone formation but had no effect on bone resorption. The increased phosphorylation levels in femurs of PKA and CREB and expression of AC10 (the only soluble form of adenylyl cyclase) and the increased serum cAMP level after 4 h of TFE administration indicated that TFE promoted bone formation by activating the AC10/cAMP/PKA/CREB pathway in vivo.

CONCLUSIONS

Oral administration of TFE at 200 mg/kg for two months can increase the peak bone mass of growing rats, suggesting the possibility of using total flavonoid extract of Epimedium herb to increase the peak bone mass in adolescence which is important for preventing osteoporosis in adult life.

Development of Vitamin D Toxicity from Overcorrection of Vitamin D Deficiency: A Review of Case Reports

Over the past two decades, vitamin D level measurements have become some of the most frequently ordered tests in the laboratory. This increase is due to a growing awareness of widespread vitamin D deficiency and scientific data suggesting the beneficial effects of vitamin D in various diseases. A literature search was carried out in PubMed for cases reporting vitamin D intoxication and overdose. Thirteen articles were included in this review. Intoxication was severe in the reported cases. Patients presented with serum vitamin D concentrations ranging between 150 and 1220 ng/mL and serum calcium concentrations between 11.1 and 23.1 mg/dL. Most of the reported patients showed symptoms of vitamin D toxicity such as vomiting, dehydration, pain, and loss of appetite. The underlying causes included manufacturing errors, overdosing by patients or prescribers, and combinations of these factors. Our literature search highlights the fact that even though vitamin D intoxication is rare, it does occur and therefore patients and prescribers should be more cognizant of the potential dangers of vitamin D overdose.

Positive Correlations Between Free Vitamin D and Bone Variables in a Group of Young Lebanese Women

Optimizing bone mass in adulthood is of great importance to prevent the occurrence of osteoporosis in later age. Vitamin D is an essential component of bone health. Low-serum vitamin D is associated with low bone mineral density (BMD), which is an important predictor of fracture risk. However, most cells, apart from renal tubular cells, are exposed to free rather than to total 25-hydroxyvitamin D. Whether free vitamin D would be a better marker than total vitamin D is still under debate. The aim of the present study was to explore the relationships between serum total vitamin D, vitamin D-binding protein (BP), free vitamin D, and bone parameters in a group of young Lebanese women. This study included 88 young female adults aged between 18 and 35 yr. Body composition and BMD were assessed by dual-energy X-ray absorptiometry, and the lumbar spine trabecular bone score was derived. Bone mineral content (BMC) and BMD were measured at the whole body (WB), the lumbar spine (L1-L4), the total hip (TH), and the femoral neck (FN). To evaluate hip bone geometry, dual-energy X-ray absorptiometry scans were analyzed at the FN, the intertrochanteric region, and the femoral shaft by the Hip Structure Analysis program. The cross-sectional area, the index of axial compression strength, and the section modulus (Z), as well as index of bending strength, were measured from bone mass profiles. Composite indices of FN strength (compressive strength index [CSI], bending strength index, and impact strength index [ISI]) were calculated as previously described. Direct measurement of free 25-hydroxyvitamin D concentrations was performed by immunoassay, which detects free vitamin D by ELISA on a microtiter plate. Serum vitamin D BP was measured using a Quantikine ELISA kit, which employed the quantitative sandwich enzyme immunoassay technique. Serum free vitamin D was positively correlated with WB BMC (r = 0.26, p < 0.05), WB BMD (r = 0.29, p < 0.05), L1-L4 BMD (r = 0.28, p < 0.05), TH BMD (r = 0.34, p < 0.01), FN BMD (r = 0.29, p < 0.05), CSI (r = 0.24, p < 0.05), and ISI (r = 0.28, p < 0.05). No positive correlations were detected between the total vitamin D level, the vitamin D BPs, and BMD. The positive associations between free vitamin D and several bone variables (WB BMC, WB BMD, L1-L4 BMD, TH BMD, FN BMD, CSI, bending strength index, and ISI) remained significant after adjustment for weight. In conclusion, the current study suggests that the free vitamin D serum level is a stronger positive determinant of bone parameters and hip bone strength indices in young female adults than total serum vitamin D.

Pediatric dual-energy X-ray absorptiometry in clinical practice: What the clinicians need to know

The importance of childhood and adolescence for bone development and mineral accrual is increasingly accepted, leading to a need of suitable methods for monitoring bone health even in pediatric setting. Among the several different imaging methods available for clinical measurement of bone mineral density (BMD) in children, dual-energy X-ray absorptiometry (DXA) is the most widely available and commonly used due to its reproducibility, negligible radiation dose and reliable pediatric reference data. Nevertheless, DXA in children has some technical specific features that should be known by those physicians who interpret and report this examination. We provide recommendations for optimal DXA scan reporting in pediatric setting, including indications, skeletal sites to be examined, parameters to be measured, timing of follow-up BMD measurements. Adequate report and analysis of DXA examinations are essential to prevent over- and underdiagnosis of bone mineral impairment in pediatric patients. In conclusion, a complete and exhaustive DXA report in children and adolescents is mandatory for an accurate diagnosis and a precise monitoring of pediatric bone status.

10 years of 25-hydroxyvitamin-D testing by LC-MS/MS-trends in vitamin-D deficiency and sufficiency

In early 2000's vitamin-D deficiency was shown to be prevalent in several countries including the United States (US). Studies exploring the role of vitamin-D metabolism in diverse disease pathways generated an increased demand for vitamin-D supplementation and an immense public interest in measurement of vitamin-D metabolite levels. In this report, we review the role of vitamin-D metabolism in disease processes, clinical utility of measuring vitamin-D metabolites including 25-hydroxyvitamin-D (25(OH)D), 1,25-dihydroxyvitamin-D and 24,25-dihydroxyvitamin-D and discuss vitamin-D assay methodologies including immunoassays and liquid chromatography mass spectrometry (LC-MS/MS) assays. We also provide examples of vitamin-D toxicity and insight into the trends in serum 25(OH)D levels in the US population based on 10 years of data from on serum 25(OH)D values from ~5,000,000 patients who were tested at the Mayo Medical Laboratories between February 2007-February 2017.

Clinical guidelines for the prevention and treatment of osteoporosis: summary statements and recommendations from the Italian Society for Orthopaedics and Traumatology

BACKGROUND

The Italian Society for Orthopaedics and Traumatology conceived this guidance-which is primarily addressed to Italian orthopedic surgeons, but should also prove useful to other bone specialists and to general practitioners-in order to improve the diagnosis, prevention, and treatment of osteoporosis and its consequences.

MATERIALS AND METHODS

Literature reviews by a multidisciplinary team.

RESULTS

The following topics are covered: the role of instrumental, metabolic, and genetic evaluations in the diagnosis of osteoporosis; appraisal of the risk of fracture and thresholds for intervention; general strategies for the prevention and treatment of osteoporosis (primary and secondary prevention); the pharmacologic treatment of osteoporosis; the setting and implementation of fracture liaison services for tertiary prevention. Grade A, B, and C recommendations are provided based on the main levels of evidence (1-3). Toolboxes for everyday clinical practice are provided.

CONCLUSIONS

The first up-to-date Italian guidelines for the primary, secondary, and tertiary prevention of osteoporosis and osteoporotic fractures are presented.

Effects of the National School Lunch Program on Bone Growth in Japanese Elementary School Children

The Japanese school lunch program with milk was designed to supply 33-50% of the necessary nutrients per day and 50% of the recommended dietary allowance for calcium, which is difficult to obtain from Japanese meals. Although this program contributes to the mental and physical development of children, the effect of these meals on the bone growth in children remains unknown. Therefore, we compared the effect of school lunch with milk on bone growth between elementary school children attending schools that did not enforce the school lunch with milk program (box-lunch group) and those attending schools that did enforce the program (school-lunch group). The study subjects included fourth-grade children during the 2009-2013 school years, of whom 329 children were in the school-lunch group and 484 children in the box-lunch group. The bone area ratio of the right calcaneus was evaluated using quantitative ultrasound (Benus III). Dietary intakes were assessed using brief self-administered diet history questionnaires. The subjects were asked to record their activities for 3 d so that the mean physical activity intensity and the time spent sleeping could be estimated. The bone area ratios (%) were significantly higher in the school-lunch group than in the box-lunch group (males 31.0±0.3 vs. 30.3±0.2; females 30.6±0.2 vs. 29.7±0.2). This tendency did not change even after adjustment for confounding factors associated with bone growth. The results suggest that nutrients supplied by the Japanese school lunch program contributed to increased bone growth in elementary school children.

Serum Preadipocyte Factor 1 Levels Are Not Associated with Bone Mineral Density among Healthy Postmenopausal Korean Women

BACKGROUND

Multipotent mesenchymal stem cells can differentiate into adipocytes or osteoblasts through closely regulated lineage-control processes. However, adipocyte precursor cells release preadipocyte factor 1 (Pref-1), which inhibits the differentiation of mesenchymal stem cells into mature adipocytes and osteoblasts. Previous studies have also reported an inverse association between Pref-1 levels and bone mineral density (BMD) among patients with anorexia nervosa.

METHODS

In this retrospective study, we examined the correlations between Pref-1 levels and BMD among 124 healthy postmenopausal women (>50 years old). The patients had provided information regarding their clinical characteristics, and underwent blood testing and serum Pref-1 testing.

RESULTS

The subjects' mean age was 59.9±7.1 years and the median time since menopause onset was 9.1 years. A history of osteoporotic fracture was identified in 23 subjects (19%). Serum Pref-1 levels were not significantly correlated with BMD values at the lumbar spine (R²=0.038, P=0.109), femur neck (R²=0.017, P=0.869), and total hip (R²=0.041, P=0.09), and multivariate analyses with adjustment for age and body mass index also did not detect any significant correlations. Subgroup analyses according to a history of fracture also did not detect significant associations between Pref-1 levels and BMD values.

CONCLUSION

In our study population, it does not appear that serum Pref-1 levels are significantly associated with BMD values and osteoporosis.

Dietary patterns explaining differences in bone mineral density and hip structure in the elderly: the Rotterdam Study

BACKGROUND

Evidence on the association between dietary patterns, measures of hip bone geometry, and subsequent fracture risk are scarce.

OBJECTIVE

The objective of this study was to evaluate whether dietary patterns that explain most variation in bone mineral density (BMD) and hip bone geometry are associated with fracture risk.

DESIGN

We included 4028 subjects aged ≥55 y from the Rotterdam study. Intake of 28 food groups was assessed with the use of food-frequency questionnaires. BMD, bone width, section modulus (SM; reflecting bending strength) and cortical buckling ratio (BR; reflecting bone instability) were measured with the use of dual-energy X-ray absorptiometry. BMD and geometry-specific dietary patterns were identified with the use of reduced rank regression. Fracture data were reported by general practitioners (median follow-up 14.8 y).

RESULTS

We identified 4 dietary patterns. Of the 4, we named 2 patterns "fruit, vegetables, and dairy" and "sweets, animal fat, and low meat," respectively. These 2 patterns were used for further analysis. Independently of confounders, adherence to the fruit, vegetables, and dairy pattern was associated with high BMD, high SM, low BR, and low risk of fractures [HR (95% CI) for osteoporotic fractures: 0.90 (0.83, 0.96); for hip fractures: 0.85 (0.81, 0.89) per z score of dietary pattern adherence]. Adherence to the sweets, animal fat, and low meat pattern was associated with high bone width, high SM, high BR, and high risk of fractures [HR (95% CI) for osteoporotic fractures: 1.08 (1.00, 1.06); for hip fractures: 1.06 (1.02, 1.12) per z score].

CONCLUSION

The fruit, vegetables, and dairy pattern might be associated with lower fracture risk because of high BMD, high bending strength, and more stable bones. The sweets, animal fat, and low meat pattern might be associated with higher fracture risk because of widened, unstable bones, independently of BMD. Dietary recommendations associated with bone geometry in addition to BMD might influence risk of fractures.

Protein/amino-acid modulation of bone cell function

Nutrients (protein, carbohydrates and fats) have traditionally been thought of as fuels simply providing the energy for cellular metabolic activity. According to the classic view, if nutrients are available, then anabolic pathways are activated, and if nutrients are not available, catabolic pathways are activated. However, it is becoming increasingly clear that nutrient effects on bone cells (stem cells, osteoblasts and osteoclasts) are complex, some nutrients promote bone formation, whereas others interfere with bone formation or actually promote bone break down. At an organ level, nutrient intake can suppress bone breakdown and modulate the activity of the calcium/vitamin D/parathyroid hormone axis. At a cellular level, nutrient intake can impact cellular energetics either through a direct mechanism (binding or uptake of the nutrient into the cell) or indirect (by elevating nutrient-related hormones such as insulin, insulin-like growth factor 1 or incretin hormones). It is also becoming clear that within a nutrient class (for example, protein), individual components (that is, amino acids) can have markedly different effects on cell function and impact bone formation. The focus of this review will be on one nutrient class in particular, dietary protein. As the prevalence of inadequate dietary protein intake increases with age, these findings may have translational implications as to the optimal dietary protein content in the setting of age-associated bone loss.

Lean Mass and Body Fat Percentage Are Contradictory Predictors of Bone Mineral Density in Pre-Menopausal Pacific Island Women

Anecdotally, it is suggested that Pacific Island women have good bone mineral density (BMD) compared to other ethnicities; however, little evidence for this or for associated factors exists. This study aimed to explore associations between predictors of bone mineral density (BMD, g/cm²), in pre-menopausal Pacific Island women. Healthy pre-menopausal Pacific Island women (age 16–45 years) were recruited as part of the larger EXPLORE Study. Total body BMD and body composition were assessed using Dual X-ray Absorptiometry and air-displacement plethysmography (n = 83). A food frequency questionnaire (n = 56) and current bone-specific physical activity questionnaire (n = 59) were completed. Variables expected to be associated with BMD were applied to a hierarchical multiple regression analysis. Due to missing data, physical activity and dietary intake factors were considered only in simple correlations. Mean BMD was 1.1 ± 0.08 g/cm². Bone-free, fat-free lean mass (LMO, 52.4 ± 6.9 kg) and age were positively associated with BMD, and percent body fat (38.4 ± 7.6) was inversely associated with BMD, explaining 37.7% of total variance. Lean mass was the strongest predictor of BMD, while many established contributors to bone health (calcium, physical activity, protein, and vitamin C) were not associated with BMD in this population, partly due to difficulty retrieving dietary data. This highlights the importance of physical activity and protein intake during any weight loss interventions to in order to minimise the loss of muscle mass, whilst maximizing loss of adipose tissue.

A phase IV, two-armed, randomized, cross-over study comparing compliance with once-a-month administration of vitamin D3 to compliance with daily administration of a fixed-dose combination of vitamin D3 and calcium during two 6-month periods

In a randomized, cross-over study, once monthly administration of vitamin D3 was preferred over a once daily administration of a fixed-dose combination of vitamin D3 and calcium, with a better compliance but without any significant difference in the increase in vitamin D levels.

INTRODUCTION

The aim of the present study was to compare a once-monthly administration of vitamin D3 to a daily administration of a fixed-dose combination of vitamin D3 and calcium during two treatment periods of 6 months.

METHODS

One hundred volunteers aged 50 years old or older were randomized to receive either one drinkable ampoule containing 25,000 IU vitamin D3 (D-Cure®, SMB) once monthly (group VD) or one chewable tablet containing 1000 mg calcium carbonate + 800 IU vitamin D3 (Steovit Forte®, Takeda) once daily (group VDCa) during 6 months. After the first 6 months of treatment, the groups were reversed according to the randomized cross-over design. Treatment compliance (i.e. the primary outcome), preference, acceptability and vitamin D levels and adverse events were all collected.

RESULTS

For the two periods, the patients had a significantly higher compliance in the VD group than in the VDCa group (p < 0.0001). During the study, 50 (56.8 %) patients preferred the VD treatment, 16 (18.2 %) patients preferred the VDCa, and for 22 (25.0 %) patients, neither treatment was preferred. At the end of the first 6 months of treatment, the mean (SD) increase of 25(OH)D was 6.57 ng/mL (8.19) in the VD group and 3.88 ng/mL (10.0) in the VDCa group (p = 0.16 between groups).

CONCLUSION

In this study, a once-monthly administration of vitamin D3 was preferred over a once-daily administration of a fixed-dose combination of vitamin D3 and calcium, with a better compliance but without any significant difference in the increase in vitamin D levels.