The effect of a fortified milk drink on vitamin D status and bone turnover in post-menopausal women from South East Asia

Strategic food vehicles for vitamin D fortification and effects on vitamin D status: A systematic review and meta-analysis of randomised controlled trials

There has been growing interest in the potential of vitamin D food fortification in Europe as a means of addressing low vitamin D status. The WHO-FAO suggest that choosing a suitable food vehicle and ensuring the combination of the food vehicle and the fortificant will be efficacious and effective are of key importance to a successful food fortification programme. Our key objective was to conduct a systematic review and meta-analysis to investigate the effect of various animal- and plant-based food vehicles fortified with vitamin D (as D3 or D2) on circulating 25-hydroxyvitamin D [25(OH)D] concentrations. A list of prioritised food vehicles was established and we searched PubMed, Embase, Scopus and Web of Science for randomised controlled trials (RCTs) which used these vehicles individually, and which met prespecified criteria. The searches identified 49 papers which described suitable RCTs using vitamin D-fortified bread/savoury biscuits (n = 5), orange juice (n = 5), UV-mushrooms (n = 8), cheese (n = 3), yogurt (n = 5), fluid milk (n = 13), powdered milk (n = 5), eggs (n = 2), edible oils (n = 4), or breakfast cereal (n = 1). No suitable RCTs were identified for rice, maize flour, butter, margarine or dairy spreads, plant-based milk or yogurt alternatives. Random-effects meta-analyses of each food vehicle individually indicated weighted mean differences (WMD) in 25(OH)D in the range ∼9-35 nmol/L (3-15 RCT arms, depending on vehicle), and all statistically significant (P < 0.01-0.0001), with the exception of UV-mushrooms (P = 0.06). Heterogeneity was variable (I2 =33-99%, depending on vehicle), but subgroup analysis based on vitamer and dose reduced it in some instances. Sub-group analysis on the basis of whether the food vehicles were from plant-based or animal-based origin showed no significant difference in WMD (15.2 versus 15.9 nmol/L, respectively; P = 0.48). These results support the use of various animal- and plant-based food vehicles for vitamin D fortification to improve circulating 25(OH)D concentrations in populations. This work was registered with PROSPERO as CRD42023439883.

Fortification of Staple Foods for Household Use with Vitamin D: An Overview of Systematic Reviews

Vitamin D deficiency is a global public health concern with significant implications for bone health and chronic disease prevention. Our aim was to summarize the evidence from Cochrane and other systematic reviews evaluating the benefits or harms of vitamin D fortification of staple foods for household use. In April 2023, we systematically searched Ovid MEDLINE, Embase, Epistemonikos and the Cochrane Database of Systematic Reviews for systematic reviews investigating the effects of vitamin D fortification of food in general populations of any age. We used Cochrane methodology and assessed the methodological quality of included studies using AMSTAR (A MeaSurement Tool to Assess Systematic Reviews). We assessed the degree of overlap among reviews. All outcomes included in systematic reviews were assessed. The protocol is registered in PROSPERO (registration number: CRD42023420991). We included 27 systematic reviews out of 5028 records for analysis. Overall, 11 out of 12 systematic reviews calculating pooled estimates reported a significant increase in serum 25(OH)D concentrations. The mean change in serum 25(OH)D concentrations per additional 100 units of vitamin D ranged from 0.7 to 10.8 nmol/L. Fortification of food with vitamin D showed a reduction in the prevalence of vitamin D deficiency based on high-certainty evidence. Parathormone (PTH) levels were described to decrease, bone mineral density to increase, while the effects on other bone turnover markers were inconsistent. Fortification did not significantly impact most anthropometric parameters, but it seemed to positively influence lipid profiles. In summary, fortification of food with vitamin D results in a reduction of vitamin D deficiency and might increase serum 25(OH)D concentrations, to varying extents depending on the fortified vehicle and population characteristics. Additionally, fortification may have a positive impact on bone turnover and lipid metabolism but may only have a limited effect on anthropometric parameters.

Determinants and Effects of Vitamin D Supplementation in Postmenopausal Women: A Systematic Review

Hormonal fluctuations, excessive clothing covering, sunscreen use, changes in body fat composition, a vitamin D-deficient diet, and a sedentary lifestyle can all predispose postmenopausal women to vitamin D deficiency. An effective supplementation plan requires a thorough understanding of underlying factors to achieve the desired therapeutic concentrations. The objective of this study was to conduct a systematic review of the predictors that affect vitamin D status in postmenopausal women. From inception to October 2022, we searched MEDLINE, Embase, Web of Science, Scopus, and clinical trial registries. Randomized clinical trials of postmenopausal women taking supplements of vitamin D with serum 25-hydroxyvitamin D (25(OH)D) measurement as the trial outcome were included. Two independent reviewers screened selected studies for full-text review. The final assessment covered 19 trials within 13 nations with participants aged 51 to 78. Vitamin D supplementation from dietary and pharmaceutical sources significantly increased serum 25(OH)D to optimal levels. Lower baseline serum 25(OH)D, lighter skin color, longer treatment duration, and prolonged skin exposure were all associated with a better response to vitamin D supplementation in postmenopausal women.

Dairy products and bone health

Bone mineral mass, geometry and microstructure, hence determinants of fracture risk, result bone accrual during growth and bone loss later in life. Peak bone mass, which is reached by the end of the second decade of life, is mainly determined by genetic factors. Among other factors influencing bone capital, dietary intakes, particularly calcium and protein, play a significant role in peak bone mass attainment. Both nutrients are provided in dairy products, which accounts for 50-60% and 20-30% of the daily calcium and protein intakes, respectively. Children avoiding dairy products are at higher risk of fracture, as are adults or older individuals following a diet devoid of dairy products, like vegans. Various intervention trials have shown some beneficial effects of dairy products on bone capital accumulation during growth and on bone turnover in adults. In observational studies, dairy products intake, particularly the fermented ones, which also provide probiotics in addition to calcium, phosphorus and protein, appear to be associated with a lower risk of hip fracture.

The Effects of Milk Supplementation on Bone Health Indices in Adults: A Meta-Analysis of Randomized Controlled Trials

Milk contains a number of bone-beneficial nutrients. However, milk, due to the D-galactose content, might have unfavorable effects on bone health. A meta-analysis of randomized controlled trials (RCTs) was performed to clarify the effects of milk supplementation on bone mineral density (BMD), bone turnover markers [N-terminal telopeptide of type I collagen (NTx), C-terminal telopeptide of type 1 collagen (CTx), osteocalcin, bone alkaline phosphatase (BALP), and procollagen type 1 N-propeptide (P1NP)], and hormonal indices related to bone metabolism [parathyroid hormone (PTH), 25-hydroxyvitamin D [25(OH)D], and insulin-like growth factor 1 (IGF-1)] in adults. The PubMed and Web of Science databases were searched. A random-effects model was used to estimate the pooled effect sizes. A total of 20 RCTs were included. The trial duration ranged from 1 mo to 36 mo. Milk supplementation resulted in a small but significant increase in BMD at the hip (+0.004 g/cm2; n = 9 RCTs) and lumbar spine (+0.025 g/cm2; n = 7), but did not significantly affect whole-body BMD (n = 3) and femoral neck BMD (n = 7). Milk supplementation reduced the concentrations of P1NP (-5.20 ng/mL; n = 9), CTx (-0.16 ng/mL; n = 9), and NTx (-8.66 nmol bone collagen equivalents/mmol creatinine; n = 3). The concentrations of osteocalcin (n = 9) and BALP (n = 3) were not affected by milk supplementation. Reduced parathyroid hormone PTH (-1.01 pg/mL; n = 13) concentrations and increased IGF-1 (+1.79 nmol/l; n = 4) concentrations were observed with milk supplementation. 25(OH)D (+3.73 ng/mL; n = 11) concentrations were increased with vitamin-D fortified milk supplementation. The addition of milk to the diet may potentially increase the likelihood of preventing bone loss by restoring bone homeostasis through the modulation of the calcium-vitamin D-PTH axis, bone remodeling rate, and growth hormone/IGF-1 axis.

Vitamin D Food Fortification and Biofortification Increases Serum 25-Hydroxyvitamin D Concentrations in Adults and Children: An Updated and Extended Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Low vitamin D status is a global public health issue that vitamin D food fortification and biofortification may help to alleviate.

OBJECTIVES

We investigated the effect of vitamin D food fortification and biofortification on circulating 25-hydroxyvitamin D (25(OH)D) concentrations. We expanded the scope of earlier reviews to include adults and children, to evaluate effects by vitamin D vitamer, and investigate linear and nonlinear dose-response relations.

METHODS

We conducted a systematic review and meta-analysis. We searched CINAHL, MEDLINE, PubMed, Embase, the Cochrane Library, and gray and unpublished literature sites for randomized controlled trials, including people of all ages, with the criteria: absence of illness affecting vitamin D absorption, duration ≥4 wk, equivalent placebo food control, dose quantification, dose ≥5 μg/d, baseline and endpoint or absolute change in 25(OH)D concentrations reported, random allocation, and participant blinding. Quality was assessed using the Jadad Scale.

RESULTS

Data from 34 publications (2398 adults: 1345 intervention, 1053 controls; 1532 children: 970 intervention, 562 controls) were included. Random-effects meta-analysis of all studies combined (mean dose 16.2 μg/d) indicated a pooled treatment effect of 21.2 nmol/L (95% CI: 16.2, 26.2), with a greater effect for studies using cholecalciferol than ergocalciferol. Heterogeneity was high (I2  > 75%). Metaregression analyses for all studies combined suggested positive effect differences for baseline circulating 25(OH)D concentrations <50 nmol/L, dose ≥10 μg/d and a negative effect difference when the intervention arm included a calcium dose ≥500 mg/d greater than the control arm. Dose-response rates were found to be nonlinear (Wald test for nonlinearity P < 0.001). For all studies combined, a threshold occurred at ∼26 nmol/L for a dose of ∼21 μg/d.

CONCLUSIONS

These results support use of vitamin D food fortification to improve circulating 25(OH)D circulations in populations. This work was registered with PROSPERO as CRD42020145497.

Next Generation Sequencing of 502 Lifestyle and Nutrition related Genetic Polymorphisms reveals Independent Loci for Low Serum 25-hydroxyvitamin D Levels among Adult Respondents of the 2013 Philippine National Nutrition Survey

OBJECTIVE

The study determined the relationship of serum vitamin D levels and 502 lifestyle and nutrition related genetic polymorphisms among adult respondents of the 2013 Philippine National Nutrition Survey (NNS).

METHODOLOGY

A total of 1,160 adult respondents of the 2013 NNS living in the National Capital Region, Philippines were enrolled. Of the 1,160 sequenced samples, 833 passed the stringent quality control based on multiple parameters and were used for further analysis. Total serum 25-hydroxyvitamin D [25(OH)D] was determined using electro-chemiluminescence binding assay method. Genomic DNA was used for targeted next generation sequencing of 502 lifestyle and nutrition related polymorphisms. Analysis of variance, followed by Tukey post hoc analysis, was employed to compare 25(OH)D serum levels across genotypes.

RESULTS

Of the study participants, 56% was classified as having low serum 25(OH)D. The lower serum 25(OH)D was observed in the following gene/genotypes: KNG1 rs11924390 T/T; ANKH rs2454873 G/G; NPFFR2 rs4129733 T/G; SH2B1 rs4788102 G/A; RAP1A rs494453 T/T and CRHBP rs7728378 T/C. These genes were previously associated to the risk of osteoporosis, obesity, type 2 diabetes mellitus, and stress response.

CONCLUSION

Large-scale analysis of genes has shown great utility in the discovery of genetic factors that play a role in vitamin D nutrition. Interestingly, loci found in this Filipino population cohort were mostly independent from the canonical vitamin D synthesis and metabolism pathways. Understanding how genetic variations interact with nutrition and lifestyle may aid in the prevention of diseases through screening and identification of susceptible patients who would not benefit from regular supplementation with vitamin D because of genetic alterations and may also be used as basis for future development of functional food enriched with vitamin D.

Is Zinc an Important Trace Element on Bone-Related Diseases and Complications? A Meta-analysis and Systematic Review from Serum Level, Dietary Intake, and Supplementation Aspects

Bone-related diseases are very common problems, especially in the elderly population. Zinc takes part in the growth and maintenance of healthy bones. This meta-analysis aims to evaluate the effects of zinc supplementation or dietary zinc intake on serum zinc levels and bone turnover markers. A systematical research was performed with 2899 articles in PubMed, WoS, and Scopus for relevant articles in English which have mean/standard deviation values of serum zinc levels, dietary zinc intake/zinc supplementation (mg/day), and bone turnover markers up to February 2020. In the overall analysis, serum zinc level was significantly lower in patients with osteoporosis compared with controls (p 0.0002). Dietary zinc intake decreased in the fracture group compared with controls according to subgroup analysis patients with fracture (p 0.02). Zinc supplementation was effective on the femoral neck (p < 0.0001) and lumbar spine (p 0.05) bone mineral density (BMD). In the correlation analysis of the data obtained from all of the included studies, serum osteocalcin (p 0.0106, r - 0.9148) correlated with serum zinc level. In conclusion, serum zinc level and dietary zinc intake could have an essential role in preventing osteoporosis. Zinc supplementation might improve bone turnover markers for bone formation such as serum osteocalcin and serum alkaline phosphatase and also, BMD at the site of the femoral neck.

Randomised Controlled Trial of Nutritional Supplement on Bone Turnover Markers in Indian Premenopausal Women

Young Indian women may be at risk of poor bone health due to malnutrition. The aim of this study was to examine the effects on bone metabolism of a nutritional supplement in women aged 25 to 44. The nutritional supplement was a protein-rich beverage powder fortified with multi-micronutrients including calcium (600 mg), vitamin D (400 IU), and vitamin K (55 mcg) per daily serving, while a placebo supplement was low-protein non-fortified isocaloric beverage powder. This 6-month randomised, controlled trial showed favorable changes in bone turnover markers (decreased) and calcium homeostasis; such changes in older adults have been associated with slowing of bone loss and reduced fracture risk. For example, serum CTX decreased by about 30% and PINP by about 20% as a result of the increase in calcium intake. There were also changes in the ratio of carboxylated to undercarboxylated osteocalcin and such changes have been linked to a slowing of bone loss in older subjects. For example, the ratio increased by about 60% after 3 months as a result in the improvement in vitamin K status. Finally, there were improvements in the status of B vitamins, and such changes have been associated with reductions in homocysteine, but it is uncertain whether this would affect fracture risk. The product was generally well tolerated. This study shows the nutritional supplement holds promise for improved bone health among young Indian women.

The Role of Milk Components, Pro-, Pre-, and Synbiotic Foods in Calcium Absorption and Bone Health Maintenance

Increasing peak bone mass during adolescence and reducing bone loss in later life are two approaches to reduce the risk of osteoporosis with aging. Osteoporosis affects a large proportion of the elderly population worldwide and the incidence is increasing. Milk consumption is an accepted strategy in building peak bone mass and therefore may reduce the risk of osteoporosis. In childhood calcium, phosphorous, and growth factors are the important components to support bone growth but in adults the positive influence on bone density/maintenance may also be due to other bioactive proteins/peptides or lipids in milk acting directly in the gastrointestinal tract (GIT). Lactose has been known to increase calcium absorption; galactooligosaccharides (GOS) are derived from lactose and are non-digestible oligosaccharides. They have been shown to improve mineral balance and bone properties as well as causing increases in bifidobacteria in the gut, therefore a prebiotic effect. Supplementation with fortified milk and dairy products with added prebiotics, increased both calcium and magnesium absorption and caused some modulation of gut microbiota in animals and humans. Fermented milk is now also recognized to contain highly active components such as vitamins, peptides, oligosaccharides, and organic acids. In this review, the role of milk and milk components in improving calcium absorption and thereby supporting bone health is discussed. In addition, some reference is made to the significance of combining the inherent beneficial components from milk with fortificants/nutrients that will support bone health through adulthood. Novel data suggesting differences in diversity of the microbiota between healthy and osteoporotic women are provided.

Systematic review and meta-analysis of the association between dairy consumption and the risk of hip fracture: critical interpretation of the currently available evidence

In the present meta-analysis, reductions in the risk of hip fracture with milk consumption were only observed among American adults, but not among Scandinavian adults, possibly because milk products are more commonly fortified with vitamin D in the former population than in Scandinavian countries. The reduction in the risk of hip fracture was also observed with yogurt consumption, which is often associated with healthy lifestyles and dietary patterns that contribute to improved bone health.

INTRODUCTION

Although dairy products contain bone-beneficial nutrients, the association between dairy consumption and the risk of hip fracture remains equivocal. Fueling this uncertainty, the elevated risk of hip fracture in association with milk consumption was observed in a cohort of Swedish women. A systematic review and meta-analysis of prospective cohort studies was performed to critically evaluate the association, or lack thereof, between dairy consumption (milk, yogurt, and cheese) and the risk of hip fracture.

METHODS

A random effects model was used to generate the summary relative risks (RRs) with their 95% confidence intervals (CIs) for the associations of interest.

RESULTS

In the meta-analysis of the highest versus lowest category of consumption, higher consumption of yogurt (RR 0.78, 95% CI 0.68, 0.90), but not milk (RR 0.86, 95% CI 0.73, 1.02) or cheese (RR 0.85, 95% CI 0.66, 1.08), was associated with a lower risk of hip fracture. For milk, the reduced risk of fracture with higher milk consumption was observed in the USA (RR 0.75, 95% CI 0.65, 0.87), but not in Scandinavian countries (RR 1.00, 95% CI 0.85, 1.17). These findings were further supported by the fact that American studies (RR 0.93, 95% CI 0.88, 0.98; per 1 glass/day), but not Scandinavian studies (RR 1.01, 95% CI 0.95, 1.07; per 1 glass/day), demonstrated a linear association between milk consumption and the risk of hip fracture.

CONCLUSIONS

The cumulative evidence from prospective cohort studies reassuringly suggests that the risk of hip fracture may not be elevated among people who consume milk, yogurt, and cheese, and that a greater consumption of milk or yogurt may even be associated with a lower risk of hip fracture depending on the factors that may differ across the population of interest.

Food fortification with multiple micronutrients: impact on health outcomes in general population

BACKGROUND

Vitamins and minerals are essential for growth and maintenance of a healthy body, and have a role in the functioning of almost every organ. Multiple interventions have been designed to improve micronutrient deficiency, and food fortification is one of them.

OBJECTIVES

To assess the impact of food fortification with multiple micronutrients on health outcomes in the general population, including men, women and children.

SEARCH METHODS

We searched electronic databases up to 29 August 2018, including the Cochrane Central Register of Controlled Trial (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register and Cochrane Public Health Specialised Register; MEDLINE; Embase, and 20 other databases, including clinical trial registries. There were no date or language restrictions. We checked reference lists of included studies and relevant systematic reviews for additional papers to be considered for inclusion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs, quasi-randomised trials, controlled before-after (CBA) studies and interrupted time series (ITS) studies that assessed the impact of food fortification with multiple micronutrients (MMNs). Primary outcomes included anaemia, micronutrient deficiencies, anthropometric measures, morbidity, all-cause mortality and cause-specific mortality. Secondary outcomes included potential adverse outcomes, serum concentration of specific micronutrients, serum haemoglobin levels and neurodevelopmental and cognitive outcomes. We included food fortification studies from both high-income and low- and middle-income countries (LMICs).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened, extracted and quality-appraised the data from eligible studies. We carried out statistical analysis using Review Manager 5 software. We used random-effects meta-analysis for combining data, as the characteristics of study participants and interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables, using the GRADE approach.

MAIN RESULTS

We identified 127 studies as relevant through title/abstract screening, and included 43 studies (48 papers) with 19,585 participants (17,878 children) in the review. All the included studies except three compared MMN fortification with placebo/no intervention. Two studies compared MMN fortification versus iodised salt and one study compared MMN fortification versus calcium fortification alone. Thirty-six studies targeted children; 20 studies were conducted in LMICs. Food vehicles used included staple foods, such as rice and flour; dairy products, including milk and yogurt; non-dairy beverages; biscuits; spreads; and salt. Fourteen of the studies were fully commercially funded, 13 had partial-commercial funding, 14 had non-commercial funding and two studies did not specify the source of funding. We rated all the evidence as of low to very low quality due to study limitations, imprecision, high heterogeneity and small sample size. When compared with placebo/no intervention, MMN fortification may reduce anaemia by 32% (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.56 to 0.84; 11 studies, 3746 participants; low-quality evidence), iron deficiency anaemia by 72% (RR 0.28, 95% CI 0.19 to 0.39; 6 studies, 2189 participants; low-quality evidence), iron deficiency by 56% (RR 0.44, 95% CI 0.32 to 0.60; 11 studies, 3289 participants; low-quality evidence); vitamin A deficiency by 58% (RR 0.42, 95% CI 0.28 to 0.62; 6 studies, 1482 participants; low-quality evidence), vitamin B2 deficiency by 64% (RR 0.36, 95% CI 0.19 to 0.68; 1 study, 296 participants; low-quality evidence), vitamin B6 deficiency by 91% (RR 0.09, 95% CI 0.02 to 0.38; 2 studies, 301 participants; low-quality evidence), vitamin B12 deficiency by 58% (RR 0.42, 95% CI 0.25 to 0.71; 3 studies, 728 participants; low-quality evidence), weight-for-age z-scores (WAZ) (mean difference (MD) 0.1, 95% CI 0.02 to 0.17; 8 studies, 2889 participants; low-quality evidence) and weight-for-height/length z-score (WHZ/WLZ) (MD 0.1, 95% CI 0.02 to 0.18; 6 studies, 1758 participants; low-quality evidence). We are uncertain about the effect of MMN fortification on zinc deficiency (RR 0.84, 95% CI 0.65 to 1.08; 5 studies, 1490 participants; low-quality evidence) and height/length-for-age z-score (HAZ/LAZ) (MD 0.09, 95% CI 0.01 to 0.18; 8 studies, 2889 participants; low-quality evidence). Most of the studies in this comparison were conducted in children. Subgroup analyses of funding sources (commercial versus non-commercial) and duration of intervention did not demonstrate any difference in effects, although this was a relatively small number of studies and the possible association between commercial funding and increased effect estimates has been demonstrated in the wider health literature. We could not conduct subgroup analysis by food vehicle and funding; since there were too few studies in each subgroup to draw any meaningful conclusions. When we compared MMNs versus iodised salt, we are uncertain about the effect of MMN fortification on anaemia (R 0.86, 95% CI 0.37 to 2.01; 1 study, 88 participants; very low-quality evidence), iron deficiency anaemia (RR 0.40, 95% CI 0.09 to 1.83; 2 studies, 245 participants; very low-quality evidence), iron deficiency (RR 0.98, 95% CI 0.82 to 1.17; 1 study, 88 participants; very low-quality evidence) and vitamin A deficiency (RR 0.19, 95% CI 0.07 to 0.55; 2 studies, 363 participants; very low-quality evidence). Both of the studies were conducted in children. Only one study conducted in children compared MMN fortification versus calcium fortification. None of the primary outcomes were reported in the study. None of the included studies reported on morbidity, adverse events, all-cause or cause-specific mortality.

AUTHORS' CONCLUSIONS

The evidence from this review suggests that MMN fortification when compared to placebo/no intervention may reduce anaemia, iron deficiency anaemia and micronutrient deficiencies (iron, vitamin A, vitamin B2 and vitamin B6). We are uncertain of the effect of MMN fortification on anthropometric measures (HAZ/LAZ, WAZ and WHZ/WLZ). There are no data to suggest possible adverse effects of MMN fortification, and we could not draw reliable conclusions from various subgroup analyses due to a limited number of studies in each subgroup. We remain cautious about the level of commercial funding in this field, and the possibility that this may be associated with higher effect estimates, although subgroup analysis in this review did not demonstrate any impact of commercial funding. These findings are subject to study limitations, imprecision, high heterogeneity and small sample sizes, and we rated most of the evidence low to very low quality. and hence no concrete conclusions could be drawn from the findings of this review.

A Vitamin D, Calcium and Leucine-Enriched Whey Protein Nutritional Supplement Improves Measures of Bone Health in Sarcopenic Non-Malnourished Older Adults: The PROVIDE Study

Alterations in musculoskeletal health with advanced age contribute to sarcopenia and decline in bone mineral density (BMD) and bone strength. This decline may be modifiable via dietary supplementation. To test the hypothesis that a specific oral nutritional supplement can result in improvements in measures of bone health. Participants (n 380) were participants of the PROVIDE study, a 13-week, multicenter, randomized, controlled, double-blind, 2 parallel-group study among non-malnourished older participants (≥ 65 years) with sarcopenia [determined by Short Physical Performance Battery (SPPB; 0-12) scores between 4 and 9, and a low skeletal muscle mass index (SMI; skeletal muscle mass/BW × 100) ≤ 37% in men and ≤ 28% in women using bioelectric impedance analysis] Supplementation of a vitamin D, calcium and leucine-enriched whey protein drink that comprises a full range of micronutrients (active; 2/day) was compared with an iso-caloric control. Serum 25-hydroxyvitamin D [25(OH)D], parathyroid hormone (PTH), biochemical markers of bone formation (osteocalcin; OC, procollagen type 1 amino-terminal propeptide; P1NP) and resorption (carboxy-terminal collagen crosslinks; CTX), insulin like growth factor 1 (IGF-1) and total-body BMD were analysed pre- and post-intervention. Serum 25(OH)D concentrations increased from 51.1 ± 22.9 nmol/L (mean ± SD) to 78.9 ± 21.1 nmol/L in the active group (p < 0.001 vs. control). Serum PTH showed a significant treatment difference (p < 0.001) with a decline in the active group, and increase in the control group. Serum IGF-1 increased in the active group (p < 0.001 vs. control). Serum CTX showed a greater decline in the active group (p = 0.001 vs. control). There were no significant differences in serum OC or P1NP between groups during the intervention. Total body BMD showed a small (0.02 g/cm²; ~ 2%) but significant increase in the active group after supplementation (p = 0.033 vs. control). Consuming a vitamin D, calcium and leucine-enriched whey protein supplement for 13 weeks improved 25(OH)D, suppressed PTH and had small but positive effects on BMD, indicative of improved bone health, in sarcopenic non-malnourished older adults.

A randomised controlled trial comparing the efficacy of micellised and fat-soluble vitamin D3 supplementation in healthy adults

Nanoemulsion formulation of vitamin D3 have been shown to have better bioavailability than the coarse emulsion preparation in vitro and in vivo animal studies. In the absence of randomised trial in humans, comparing the efficacy of nanotechnology-based miscellised vitamin D3 over conventional vitamin D3, we undertook this study. A total of 180 healthy adults were randomised to receive either micellised (DePura, group A) or conventional vitamin D3 (Calcirol, group B) at a monthly dose of 60 000 IU (1500μg) for 6 months. The outcome parameters were serum 25-hydroxyvitamin D (25(OH)D), parathyroid hormone (PTH), Ca, phosphate, alkaline phosphatase and urinary Ca:creatinine ratio. A total of eighty-nine subjects in group A and seventy-seven in group B completed the trial. Subjects in both the groups had a significant increase in their serum 25(OH)D levels following supplementation (group A: 21·5 (sd 10·9) to 76·7 (sd 18·8) nmol/l (P&lt;0·001); group B: 22·8 (sd 10·4) to 57·8 (sd 16·0) nmol/l (P&lt;0·001)). Participants in micellised group had an additional increase of 20·2 (95 % CI 14·0, 26·4) nmol/l in serum 25(OH)D levels (P&lt;0·001). The difference between the groups was 17·5 (95 % CI 11·8, 23·1) nmol/l, which remained statistically significant (P&lt;0·001) even after adjustment for age and sex. Significant decline in mean serum PTH was observed in both the groups. No hypercalcaemia or hypercalciuria was noted. Although supplementation with both the preparations resulted in a significant rise in serum 25(OH)D levels, micellised vitamin D3 appeared to be more efficacious in achieving higher levels of serum 25(OH)D.

Dairy foods and bone health throughout the lifespan: a critical appraisal of the evidence

The consumption of high-Ca, high-protein dairy foods (i.e. milk, cheese, yogurt) is advocated for bone health across the lifespan to reduce the risk of low-trauma fractures. However, to date, the anti-fracture efficacy of dairy food consumption has not been demonstrated in randomised controlled trials but inferred from cross-sectional and prospective studies. The anti-fracture efficacy of dairy food consumption is plausible, but testing this requires a robust study design to ensure outcomes are suitably answering this important public health question. The evidence of skeletal benefits of dairy food consumption is equivocal, not because it may not be efficacious but because the study design and execution are often inadequate. The key issues are compliance with dietary intervention, dropouts, sample sizes and most importantly lack of deficiency before intervention. Without careful appraisal of the design and execution of available studies, precarious interpretations of outcomes may be made from these poorly designed or executed studies, without consideration of how study design may be improved. Dairy food interventions in children are further hampered by heterogeneity in growth: in particular sex and maturity-related differences in the magnitude, timing, location and surface-specific site of bone accrual. Outcomes of studies combining children of different sexes and maturity status may be masked or exaggerated by these differences in growth, so inaccurate conclusions are drawn from results. Until these critical issues in study design are considered in future dairy food interventions, the anti-fracture efficacy of dairy food consumption may remain unknown and continue to be based on conjecture.

Concepts, benefits and perspectives of functional dairy food products

The rising awareness of the consumers towards the health benefits of food has resulted in the development of the so-called functional foods. These added value products which refer to prevention and/or therapeutic effects of food beyond its nutritional value, are especially useful for health improvement and reduction of medical care costs. The combination between health and nutrition and its potential to improve the quality of life has become one of the key attention points of consumers who are aware of and are seeking nutritional solutions to their health concerns. Milk and dairy products have been used in human nutrition for thousands of years, providing important nutrients for the human body such as proteins, fats and calcium. It is now widely recognized that in addition to their basic nutritive role they also exert functional properties beneficial for human health, so the development of functional dairy products is one of the fastest growing areas in the dairy industry as well as one of the largest sectors in the global market of functional foods. This review provides a brief overview of the health benefits and the natural functionality of dairy products as well as the challenges together with the future perspectives of their application as delivery vehicles for beneficial compounds to the human body. Keywords: functional foods, milk, dairy products

Higher Dairy Intakes Are Associated with Higher Bone Mineral Density among Adults with Sufficient Vitamin D Status: Results from the Boston Puerto Rican Osteoporosis Study

Background

Dairy foods have been shown to improve bone mineral density (BMD) in non-Hispanic whites. Puerto Rican adults have a higher prevalence of osteoporosis and vitamin D deficiency than non-Hispanic whites. However, there is little understanding of lifestyle influences on bone in this population.

Objective

The aim of this study was to examine associations of dairy intakes with BMD among adults from the Boston Puerto Rican Osteoporosis Study with and without adequate serum vitamin D status.

Methods

A total of 904 participants in this cross-sectional analysis provided dietary intakes with a culturally tailored food-frequency questionnaire. Dairy food groups were calculated [total dairy, modified dairy (without cream or dairy desserts), fluid dairy (milk + yogurt), cheese, yogurt, and cream and desserts]. BMD (grams per centimeter squared) was measured using dual-energy X-ray absorptiometry. Vitamin D status was defined as sufficient (serum 25-hydroxyvitamin D [25(OH)D] ≥20 ng/mL) or insufficient (<20 ng/mL). General linear models were used to examine associations between dairy intake and BMD, stratified by vitamin D status.

Results

Of the total sample, 73% were women, of whom 87% were postmenopausal. Mean ± SD age was 60.0 ± 7.6 y and mean ± SD body mass index (kg/m2) was 32.3 ± 6.6. Mean serum 25(OH)D (range: 4-48 ng/mL) was 14.3 ± 3.6 ng/mL in insufficient individuals and 26.0 ± 5.5 ng/mL in sufficient individuals. In the full sample, higher intakes of modified dairy foods (β = 0.0015, P = 0.02) and milk (β = 0.0018, P = 0.04) were associated with higher femoral neck (FN) BMD. Among those who were vitamin D sufficient, higher intakes of total dairy (P = 0.03-0.07), fluid dairy (P = 0.01-0.05), and milk (P = 0.02-0.09) were significantly related to higher FN and lumbar spine BMD, respectively. Among vitamin D-insufficient participants, dairy intakes were not associated with BMD (P-range = 0.11-0.94).

Conclusions

Dairy food intakes were associated with higher BMD among adults, particularly those with sufficient vitamin D status. Future studies should confirm findings longitudinally and assess culturally acceptable lifestyle interventions to improve bone health among Hispanic adults. This trial was registered at clinicaltrials.gov as NCT01231958.

Benefits and safety of dietary protein for bone health-an expert consensus paper endorsed by the European Society for Clinical and Economical Aspects of Osteopororosis, Osteoarthritis, and Musculoskeletal Diseases and by the International Osteoporosis Foundation

A summary of systematic reviews and meta-analyses addressing the benefits and risks of dietary protein intakes for bone health in adults suggests that dietary protein levels even above the current RDA may be beneficial in reducing bone loss and hip fracture risk, provided calcium intakes are adequate. Several systematic reviews and meta-analyses have addressed the benefits and risks of dietary protein intakes for bone health in adults. This narrative review of the literature summarizes and synthesizes recent systematic reviews and meta-analyses and highlights key messages. Adequate supplies of dietary protein are required for optimal bone growth and maintenance of healthy bone. Variation in protein intakes within the "normal" range accounts for 2-4% of BMD variance in adults. In older people with osteoporosis, higher protein intake (≥ 0.8-g/kg body weight/day, i.e., above the current RDA) is associated with higher BMD, a slower rate of bone loss, and reduced risk of hip fracture, provided that dietary calcium intakes are adequate. Intervention with dietary protein supplements attenuate age-related BMD decrease and reduce bone turnover marker levels, together with an increase in IGF-I and a decrease in PTH. There is no evidence that diet-derived acid load is deleterious for bone health. Thus, insufficient dietary protein intakes may be a more severe problem than protein excess in the elderly. Long-term, well-controlled randomized trials are required to further assess the influence of dietary protein intakes on fracture risk.

Effects of 1α,25 Dihydroxyvitamin D3 on Pro-inflammatory Cytokines of Palmitic Acid Treated Thp-1 Cells

The level of saturated fatty acids, such as palmitic acid (PA), correlates with chronic inflammation in obese and metabolic syndrome patients. However, low level of vitamin D₃ is observed in those conditions. The aim of this study is to investigate effects of 1α,25(OH)₂ D₃ on PA-treated THP-1 cells. Using quantitative real-time polymerase chain reaction, we measure mRNA expression of pro-inflammatory cytokines: TNF-α, Interleukin (IL)-1β, IL-6, and chemokine IL-8 under PA and 1α,25(OH)₂ D₃ influence. PA, at all concentrations (25-100 μM), enhanced LPS stimulatory effect on those mRNA expression compared to LPS-treated and -untreated cells. Combination with 1α,25(OH)₂ D₃ increased cytokine expression at high (10^-6 M) and high-normal (10^-8 M) concentrations compared to PA + LPS and LPS alone, both for 2 and 24 h. However, low-normal (10^-10 M) and low (10^-12 M) levels of 1α,25(OH)₂ D₃ could not enhance PA effect, but mRNA expression of pro-inflammatory cytokine was higher than LPS-treated cells. Upstream pathway of 1α,25(OH)₂ D₃ , which is cholecalciferol, also gave the similar result. Further, inhibition of calcium pathway does not play a role in this mechanism. Thus, these findings support pro-inflammatory effect of PA and vitamin D₃ on innate immune response, especially on fat-induced inflammation.

PRACTICAL APPLICATION

The effect of vitamin D₃ on chronic inflammation in obesity is uncertain. This study shows an in vitro possibility that vitamin D₃ could exaggerate inflammation when combined with high SFAs. The idea of using vitamin D₃ supplement to modulate inflammation in fat-related inflammation needs further refined experiments before its clinical application.

25-Hydroxyvitamin D as a Biomarker of Vitamin D Status and Its Modeling to Inform Strategies for Prevention of Vitamin D Deficiency within the Population

There is substantial evidence that the prevalence of vitamin D deficiency is unacceptably high in the population, and this requires action from a public health perspective. Circulating 25-hydroxyvitamin D [25(OH)D] is a robust and reliable marker of vitamin D status and has been used by numerous agencies in the establishment of vitamin D dietary requirements and for population surveillance of vitamin D deficiency or inadequacy. In a wider context, modeling of serum 25(OH)D data and its contributory sources, namely dietary vitamin D supply and UVB availability, can inform our understanding of population vitamin D status. The aim of this review is to provide the current status of knowledge in relation to modeling of such vitamin D-relevant data. We begin by highlighting the importance of the measurement of 25(OH)D and its standardization, both of which have led to new key data on the prevalence of vitamin D deficiency and inadequacy in North America and Europe. We then overview how state-of-the-art modeling can be used to inform our understanding of the potential effect of ergocalciferol and 25(OH)D on vitamin D intake estimates and how meteorological data on UVB availability, when coupled with other key data, can help predict population serum 25(OH)D concentration, even accounting for seasonal fluctuations, and lastly, how these in silico approaches can help inform policymakers on strategic options on addressing low vitamin D status through food-based approaches and supplementation. The potential of exemplar food-based solutions will be highlighted, as will the possibility of synergies between vitamin D and other dairy food-based micronutrients, in relation to vitamin D status and bone health. Lastly, we will briefly consider the interactions between season and vitamin D supplements on vitamin D status and health.

Peripheral skeleton bone strength is positively correlated with total and dairy protein intakes in healthy postmenopausal women

BACKGROUND

Bone mineral content (BMC) and bone mineral density (BMD) are positively correlated with dietary protein intakes, which account for 1-8% of BMC and BMD variances. However, the relation between bone strength and microstructure, which are variables that are not captured by areal bone mineral density (aBMD), and dietary protein intakes, particularly from specific dietary sources, has not been clearly established.

OBJECTIVE

We investigated the association between the peripheral skeleton-predicted failure load and stiffness, bone microstructure, and dietary protein intakes from various origins (animal, divided into dairy and nondairy, and vegetable origins) in healthy postmenopausal women.

DESIGN

In a cross-sectional study in 746 Caucasian women aged 65.0 ± 1.4 y, we measured the aBMD with the use of dual-energy X-ray absorptiometry, the distal radius and tibia bone microstructures with the use of high-resolution peripheral quantitative computerized tomography, and bone strength with the use of a finite element analysis, and we evaluated dietary protein and calcium with the use of a validated food-frequency questionnaire.

RESULTS

Mean dietary calcium and protein intakes were greater than recommended amounts for this class of age. The predicted failure load and stiffness at the distal radius and tibia were positively associated with total, animal, and dairy protein intakes but not with vegetable protein intake. Failure load differences were accompanied by modifications of the aBMD and of cortical and trabecular bone microstructures. The associations remained statistically significant after adjustment for weight, height, physical activity, menopause duration, calcium intake, and the interaction between calcium and protein intake. A principal component analysis of the volumetric BMD and bone microstructure indicated that trabecular bone mainly contributed to the positive association between protein intakes and bone strength.

CONCLUSIONS

These results, which were recorded in a very homogeneous population of healthy postmenopausal women, indicate that there is a beneficial effect of animal and dairy protein intakes on bone strength and microstructure. Specifically, there is a positive association between the bone failure load and stiffness of the peripheral skeleton and dietary protein intake, which is mainly related to changes in the trabecular microstructure. This trial was registered at www.controlled-trials.com as ISRCTN11865958.

Targeted next generation sequencing of the entire vitamin D receptor gene reveals polymorphisms correlated with vitamin D deficiency among older Filipino women with and without fragility fracture

This study aimed to discover genetic variants in the entire 101 kB vitamin D receptor (VDR) gene for vitamin D deficiency in a group of postmenopausal Filipino women using targeted next generation sequencing (TNGS) approach in a case-control study design. A total of 50 women with and without osteoporotic fracture seen at the Philippine Orthopedic Center were included. Blood samples were collected for determination of serum vitamin D, calcium, phosphorus, glucose, blood urea nitrogen, creatinine, aspartate aminotransferase, alanine aminotransferase and as primary source for targeted VDR gene sequencing using the Ion Torrent Personal Genome Machine. The variant calling was based on the GATK best practice workflow and annotated using Annovar tool. A total of 1496 unique variants in the whole 101-kb VDR gene were identified. Novel sequence variations not registered in the dbSNP database were found among cases and controls at a rate of 23.1% and 16.6% of total discovered variants, respectively. One disease-associated enhancer showed statistically significant association to low serum 25-hydroxy vitamin D levels (Pearson chi-square P-value=0.009). The transcription factor binding site prediction program PROMO predicted the disruption of three transcription factor binding sites in this enhancer region. These findings show the power of TNGS in identifying sequence variations in a very large gene and the surprising results obtained in this study greatly expand the catalog of known VDR sequence variants that may represent an important clue in the emergence of vitamin D deficiency. Such information will also provide the additional guidance necessary toward a personalized nutritional advice to reach sufficient vitamin D status.

Tackling inadequate vitamin D intakes within the population: fortification of dairy products with vitamin D may not be enough

Dietary recommendations for vitamin D are designed by authoritative agencies to prevent vitamin D deficiency in the population, and while individual target intakes around the globe vary, they are generally between 10 and 20 μg/day [400-800 IU/day], depending on age, assuming little or no sunshine exposure. National dietary surveys report usual intakes of vitamin D that are much lower than these targets, at about 3-7 μg/day [120-280 IU/day], depending on usual diet, age, sex, and mandatory or voluntary fortification practices, and there is widespread dietary inadequacy around the globe. While acknowledging the valuable contribution fortified milk makes to vitamin D intakes among consumers, particularly in children, and the continued need for fortification of milk and other dairy products, additional strategic approaches to fortification, including biofortification, of a wider range of foods, have the potential to increase vitamin D intakes in the population and minimize the prevalence of low serum 25(OH)D without increasing the risk of excessive dosing. Careful consideration must be given to the range of products used for fortification and the amount of vitamin D used in each; there is a need for well-designed and sustainable fortification, and biofortification strategies for vitamin D, which use a range of foods to accommodate dietary diversity. Clinical patients may require additional consideration in terms of addressing low vitamin D status.

Nutrition and bone health in women after the menopause

Osteoporosis affects one out of three postmenopausal women. Their remaining lifetime risk of fragility fractures exceeds that of breast cancer. The risk of osteoporosis and/or fragility fractures can be reduced through healthy lifestyle changes. These include adequate dietary intakes of calcium, vitamin D and protein, regular weight-bearing exercise, reduction in alcohol intake and smoking cessation. European guidance for the diagnosis and management of osteoporosis in postmenopausal women recommends a daily intake of at least 1000 mg/day for calcium, 800 IU/day for vitamin D and 1 g/kg body weight of protein for all women aged over 50 years. The development of programs that encourage lifestyle changes (in particular balanced nutrient intakes) are therefore essential for the reduction of osteoporosis risk.

Differential effects of calcium- and vitamin D-fortified milk with FOS-inulin compared to regular milk, on bone biomarkers in Chinese pre- and postmenopausal women

PURPOSE

To compare the effects of a high-calcium vitamin D-fortified milk with added FOS-inulin versus regular milk on serum parathyroid hormone, and bone turnover markers in premenopausal (Pre-M) and postmenopausal (PM) women over 12 weeks.

METHODS

Premenopausal women (n = 136, mean age 41 (±5) years) and postmenopausal women [n = 121, mean age 59 (±4) years] were recruited, and each age group randomised into two groups to take two glasses per day of control = regular milk (500 mg calcium per day) or intervention (Int) = fortified milk (1000 mg calcium for pre-M women and 1200 mg calcium for PM women, 96 mg magnesium, 2.4 mg zinc, 15 µg vitamin D, 4 g FOS-inulin per day). At baseline, week 4 and week 12 serum minerals and bone biochemical markers were measured and bone density was measured at baseline.

RESULTS

Mean 25-hydroxyvitamin D [25(OH) vitamin D3] levels among groups were between 49 and 65 nmol/L at baseline, and over the 12 weeks of supplementation, the fortified milk improved vitamin D status in both Int groups. CTx-1 and PINP reduced significantly in both Pre-M and PM groups over the 12 weeks, with the changes in CTx-1 being significantly different (P < 0.035) between PM control and PM Int groups at week 12. Parathyroid hormone levels were significantly reduced in all groups over time, except for control PM group where levels increased at 12 weeks.

CONCLUSION

The overall pattern of responses indicates that while both regular milk and fortified milk reduce bone resorption in young and older women, fortified milk is measurably more effective.

Does fortification of staple foods improve vitamin D intakes and status of groups at risk of deficiency? A United Kingdom modeling study

BACKGROUND

More than one-fifth of the United Kingdom population has poor vitamin D status (serum 25-hydroxyvitamin D [25(OH)D] concentration <25 nmol/L), particularly individuals with low sun exposure or poor dietary intake.

OBJECTIVE

We identified the fortification vehicle and concentration most likely to safely increase population vitamin D intakes and vitamin D status.

DESIGN

Wheat flour and milk were identified as primary fortification vehicles for their universal consumption in population groups most at risk of vitamin D deficiency including children aged 18-36 mo, females aged 15-49 y, and adults aged ≥65 y. With the use of data from the first 2 y (2008-2010) of the National Diet and Nutrition Survey Rolling Program, we simulated the effect of fortifying wheat flour and milk with vitamin D on United Kingdom food consumption. Empirically derived equations for the relation between vitamin D intake and the serum 25(OH)D concentration were used to estimate the population serum 25(OH)D concentration for each fortification scenario.

RESULTS

At a simulated fortification of 10 μg vitamin D/100 g wheat flour, the proportion of at-risk groups estimated to have vitamin D intakes below United Kingdom Reference Nutrient Intakes was reduced from 93% to 50%, with no individual exceeding the United Kingdom Tolerable Upper Intake Level; the 2.5th percentile of the population winter serum 25(OH)D concentration rose from 20 to 27 nmol/L after fortification. The simulation of the fortification of wheat flour at this concentration was more effective than that of the fortification of milk (at concentrations between 0.25 and 7 mg vitamin D/100 L milk) or of the fortification of milk and flour combined.

CONCLUSION

To our knowledge, this study provides new evidence that vitamin D fortification of wheat flour could be a viable option for safely improving vitamin D intakes and the status of United Kingdom population groups at risk of deficiency without increasing risk of exceeding current reference thresholds.

Nutritional aspects of bone health

Bone mass, geometry and microstructure, and bony tissue material level properties determine bone strength, hence the resistance to fracture. At a given age, all these variables are the consequence of the amount accumulated and of the structure developed during growth, up to the so-called peak bone mass, and of the bone loss and microstructure degradation occurring later in life. Genetic factors primarily contribute to the variance of the determinants of bone strength. Nutritional intakes are environmental factors that influence both processes, either directly by modifying modelling and remodelling, or indirectly through changes in calcitropic hormone secretion and action. Some effects of nutrition on the offspring bone could take place during foetal life. There are interplays between genetic factors, nutritional intakes and physical exercise. Among the nutrients, sufficient dietary intakes of calcium and protein are necessary for bone health in childhood and adolescence as well as later in life.

Dairy products, yogurts, and bone health

Fracture risk is determined by bone mass, geometry, and microstructure, which result from peak bone mass (the amount attained at the end of pubertal growth) and from the amount of bone lost subsequently. Nutritional intakes are an important environmental factor that influence both bone mass accumulation during childhood and adolescence and bone loss that occurs in later life. Bone growth is influenced by dietary intake, particularly of calcium and protein. Adequate dietary calcium and protein are essential to achieve optimal peak bone mass during skeletal growth and to prevent bone loss in the elderly. Dairy products are rich in nutrients that are essential for good bone health, including calcium, protein, vitamin D, potassium, phosphorus, and other micronutrients and macronutrients. Studies supporting the beneficial effects of milk or dairy products on bone health show a significant inverse association between dairy food intake and bone turnover markers and a positive association with bone mineral content. Fortified dairy products induce more favorable changes in biochemical indexes of bone metabolism than does calcium supplementation alone. The associations between the consumption of dairy products and the risk of hip fracture are less well established, although yogurt intake shows a weakly positive protective trend for hip fracture. By consuming 3 servings of dairy products per day, the recommended daily intakes of nutrients essential for good bone health may be readily achieved. Dairy products could therefore improve bone health and reduce the risk of fractures in later life.

Postprandial metabolic responses of serum calcium, parathyroid hormone and C-telopeptide of type I collagen to three doses of calcium delivered in milk

Acute doses of Ca rapidly increase serum Ca and reduce bone resorption concomitant with a reduction in serum parathyroid hormone (PTH) levels. The physiological response to a dose of Ca in milk and to a Ca salt may be different. The present study investigated Ca absorption patterns with increasing levels of fortification in milk, and the response to one dose of a Ca salt. A group of twenty-eight Asian women aged 20–45 years volunteered to attend the laboratory over several weeks. The fasted volunteers were randomised to one of three experimental drinks: 200 ml skimmed milk containing 250, 500 or 1000 mg Ca. A subgroup of seven volunteers also received a calcium gluconate/carbonate salt containing 1000 mg Ca in 200 ml water. Serial blood samples and urine were collected for 5 h from baseline. Different doses of Ca in milk resulted in a graded response in serum corrected Ca, PTH and C-telopeptide of type I collagen (CTx) but not ionised Ca. Serum Ca increased in response to all milk drinks and from 2 to 5 h the blood Ca levels were significantly different for the 250 and 1000 mg doses, as was the integrated response between the loads. The PTH response to the two higher doses was significantly more than following the 250 mg dose. The integrated response for CTx and urinary Ca between all three doses of Ca in milk was significantly different. A dose of Ca salt elicited a more immediate response reaching a plateau faster, and declining faster to baseline. Fortified milk is a safe matrix for delivering larger doses of Ca.

Vitamin D supplementation for prevention of mortality in adults

BACKGROUND

Available evidence on the effects of vitamin D on mortality has been inconclusive. In a recent systematic review, we found evidence that vitamin D3 may decrease mortality in mostly elderly women. The present systematic review updates and reassesses the benefits and harms of vitamin D supplementation used in primary and secondary prophylaxis of mortality.

OBJECTIVES

To assess the beneficial and harmful effects of vitamin D supplementation for prevention of mortality in healthy adults and adults in a stable phase of disease.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, LILACS, the Science Citation Index-Expanded and Conference Proceedings Citation Index-Science (all up to February 2012). We checked references of included trials and pharmaceutical companies for unidentified relevant trials.

SELECTION CRITERIA

Randomised trials that compared any type of vitamin D in any dose with any duration and route of administration versus placebo or no intervention in adult participants. Participants could have been recruited from the general population or from patients diagnosed with a disease in a stable phase. Vitamin D could have been administered as supplemental vitamin D (vitamin D3 (cholecalciferol) or vitamin D2 (ergocalciferol)) or as an active form of vitamin D (1α-hydroxyvitamin D (alfacalcidol) or 1,25-dihydroxyvitamin D (calcitriol)).

DATA COLLECTION AND ANALYSIS

Six review authors extracted data independently. Random-effects and fixed-effect meta-analyses were conducted. For dichotomous outcomes, we calculated the risk ratios (RRs). To account for trials with zero events, we performed meta-analyses of dichotomous data using risk differences (RDs) and empirical continuity corrections. We used published data and data obtained by contacting trial authors.To minimise the risk of systematic error, we assessed the risk of bias of the included trials. Trial sequential analyses controlled the risk of random errors possibly caused by cumulative meta-analyses.

MAIN RESULTS

We identified 159 randomised clinical trials. Ninety-four trials reported no mortality, and nine trials reported mortality but did not report in which intervention group the mortality occurred. Accordingly, 56 randomised trials with 95,286 participants provided usable data on mortality. The age of participants ranged from 18 to 107 years. Most trials included women older than 70 years. The mean proportion of women was 77%. Forty-eight of the trials randomly assigned 94,491 healthy participants. Of these, four trials included healthy volunteers, nine trials included postmenopausal women and 35 trials included older people living on their own or in institutional care. The remaining eight trials randomly assigned 795 participants with neurological, cardiovascular, respiratory or rheumatoid diseases. Vitamin D was administered for a weighted mean of 4.4 years. More than half of the trials had a low risk of bias. All trials were conducted in high-income countries. Forty-five trials (80%) reported the baseline vitamin D status of participants based on serum 25-hydroxyvitamin D levels. Participants in 19 trials had vitamin D adequacy (at or above 20 ng/mL). Participants in the remaining 26 trials had vitamin D insufficiency (less than 20 ng/mL).Vitamin D decreased mortality in all 56 trials analysed together (5,920/47,472 (12.5%) vs 6,077/47,814 (12.7%); RR 0.97 (95% confidence interval (CI) 0.94 to 0.99); P = 0.02; I(2) = 0%). More than 8% of participants dropped out. 'Worst-best case' and 'best-worst case' scenario analyses demonstrated that vitamin D could be associated with a dramatic increase or decrease in mortality. When different forms of vitamin D were assessed in separate analyses, only vitamin D3 decreased mortality (4,153/37,817 (11.0%) vs 4,340/38,110 (11.4%); RR 0.94 (95% CI 0.91 to 0.98); P = 0.002; I(2) = 0%; 75,927 participants; 38 trials). Vitamin D2, alfacalcidol and calcitriol did not significantly affect mortality. A subgroup analysis of trials at high risk of bias suggested that vitamin D2 may even increase mortality, but this finding could be due to random errors. Trial sequential analysis supported our finding regarding vitamin D3, with the cumulative Z-score breaking the trial sequential monitoring boundary for benefit, corresponding to 150 people treated over five years to prevent one additional death. We did not observe any statistically significant differences in the effect of vitamin D on mortality in subgroup analyses of trials at low risk of bias compared with trials at high risk of bias; of trials using placebo compared with trials using no intervention in the control group; of trials with no risk of industry bias compared with trials with risk of industry bias; of trials assessing primary prevention compared with trials assessing secondary prevention; of trials including participants with vitamin D level below 20 ng/mL at entry compared with trials including participants with vitamin D levels equal to or greater than 20 ng/mL at entry; of trials including ambulatory participants compared with trials including institutionalised participants; of trials using concomitant calcium supplementation compared with trials without calcium; of trials using a dose below 800 IU per day compared with trials using doses above 800 IU per day; and of trials including only women compared with trials including both sexes or only men. Vitamin D3 statistically significantly decreased cancer mortality (RR 0.88 (95% CI 0.78 to 0.98); P = 0.02; I(2) = 0%; 44,492 participants; 4 trials). Vitamin D3 combined with calcium increased the risk of nephrolithiasis (RR 1.17 (95% CI 1.02 to 1.34); P = 0.02; I(2) = 0%; 42,876 participants; 4 trials). Alfacalcidol and calcitriol increased the risk of hypercalcaemia (RR 3.18 (95% CI 1.17 to 8.68); P = 0.02; I(2) = 17%; 710 participants; 3 trials).

AUTHORS' CONCLUSIONS

Vitamin D3 seemed to decrease mortality in elderly people living independently or in institutional care. Vitamin D2, alfacalcidol and calcitriol had no statistically significant beneficial effects on mortality. Vitamin D3 combined with calcium increased nephrolithiasis. Both alfacalcidol and calcitriol increased hypercalcaemia. Because of risks of attrition bias originating from substantial dropout of participants and of outcome reporting bias due to a number of trials not reporting on mortality, as well as a number of other weaknesses in our evidence, further placebo-controlled randomised trials seem warranted.

Nutrition and bone health: turning knowledge and beliefs into healthy behaviour

Primary osteoporosis prevention requires healthy behaviours, such as regular physical exercise and adequate dietary intakes of calcium, vitamin D and protein. Calcium and vitamin D can decrease postmenopausal bone loss and prevent fracture risk. However, there is still a high prevalence of calcium and vitamin D insufficiency in women aged 50+ years. Dietary sources of these nutrients are the preferred choice, and dairy products represent a valuable dietary source of calcium due to the high content, high absorptive rate and relatively low cost. Furthermore, dairy products also contain other key nutrients including vitamin D, phosphorus and protein that contribute to bone health. Studies of women's beliefs and behaviours with respect to osteoporosis highlight poor knowledge of the importance of dietary nutrient intakes and low concern regarding bone health. Osteoporosis educational programmes exist to help women change behaviours relevant to bone health. Such programmes can have positive influences on women's knowledge, attitudes, perceived norms, motivation and behaviours. Increased awareness of the consequences of low calcium and vitamin D intakes may promote women's attitudes towards dietary sources, in particular dairy products, and lead to better adherence to health recommendations. Increasing dietary nutrient intakes through educational initiatives should be further developed to aid the prevention of osteoporosis and the efficacy of osteoporosis management.

Micronutrient fortification of food and its impact on woman and child health: a systematic review

BACKGROUND

Vitamins and minerals are essential for growth and metabolism. The World Health Organization estimates that more than 2 billion people are deficient in key vitamins and minerals. Groups most vulnerable to these micronutrient deficiencies are pregnant and lactating women and young children, given their increased demands. Food fortification is one of the strategies that has been used safely and effectively to prevent vitamin and mineral deficiencies.

METHODS

A comprehensive search was done to identify all available evidence for the impact of fortification interventions. Studies were included if food was fortified with a single, dual or multiple micronutrients and impact of fortification was analyzed on the health outcomes and relevant biochemical indicators of women and children. We performed a meta-analysis of outcomes using Review Manager Software version 5.1.

RESULTS

Our systematic review identified 201 studies that we reviewed for outcomes of relevance. Fortification for children showed significant impacts on increasing serum micronutrient concentrations. Hematologic markers also improved, including hemoglobin concentrations, which showed a significant rise when food was fortified with vitamin A, iron and multiple micronutrients. Fortification with zinc had no significant adverse impact on hemoglobin levels. Multiple micronutrient fortification showed non-significant impacts on height for age, weight for age and weight for height Z-scores, although they showed positive trends. The results for fortification in women showed that calcium and vitamin D fortification had significant impacts in the post-menopausal age group. Iron fortification led to a significant increase in serum ferritin and hemoglobin levels in women of reproductive age and pregnant women. Folate fortification significantly reduced the incidence of congenital abnormalities like neural tube defects without increasing the incidence of twinning. The number of studies pooled for zinc and multiple micronutrients for women were few, though the evidence suggested benefit. There was a dearth of evidence for the impact of fortification strategies on morbidity and mortality outcomes in women and children.

CONCLUSION

Fortification is potentially an effective strategy but evidence from the developing world is scarce. Programs need to assess the direct impact of fortification on morbidity and mortality.

Determinants of serum levels of vitamin D: a study of life-style, menopausal status, dietary intake, serum calcium, and PTH

Background

Low blood levels of vitamin D (25-hydroxy D3, 25OHD3) in women have been associated with an increased risk of several diseases. A large part of the population may have suboptimal 25OHD3 levels but high-risk groups are not well known. The aim of the present study was to identify determinants for serum levels of 25OHD3 in women, i.e. factors such as lifestyle, menopausal status, diet and selected biochemical variables.

Methods

The study was based on women from the Malmö Diet and Cancer Study (MDCS), a prospective, population-based cohort study in Malmö, Sweden. In a previous case–control study on breast cancer, 25OHD3 concentrations had been measured in 727 women. In these, quartiles of serum 25OHD3 were compared with regard to age at baseline, BMI (Body Max Index), menopausal status, use of oral contraceptives or menopausal hormone therapy (MHT) , life-style (e.g. smoking and alcohol consumption), socio-demographic factors, season, biochemical variables (i.e. calcium, PTH, albumin, creatinine, and phosphate), and dietary intake of vitamin D and calcium. In order to test differences in mean vitamin D concentrations between different categories of the studied factors, an ANOVA test was used followed by a t-test. The relation between different factors and 25OHD3 was further investigated using multiple linear regression analysis and a logistic regression analysis.

Results

We found a positive association between serum levels of 25OHD3 and age, oral contraceptive use, moderate alcohol consumption, blood collection during summer/ autumn, creatinine, phosphate, calcium, and a high intake of vitamin D. Low vitamin D levels were associated with obesity, being born outside Sweden and high PTH levels.

Conclusions

The present population-based study found a positive association between serum levels of 25OHD3 and to several socio-demographic, life-style and biochemical factors. The study may have implications e. g. for dietary recommendations. However, the analysis is a cross-sectional and it is difficult to suggest Lifestyle changes as cause- effect relationships are difficult to assess.

Bone health comparison in seven Asian countries using calcaneal ultrasound

BACKGROUND

Bone density measurements by DXA are not feasible for large population studies, whereas portable ultrasound heel scanners can provide a practical way of assessing bone health status. The purpose of this study was to assess bone health in seven Asian countries using heel ultrasound.

METHODS

Stiffness index (SI) was measured and T-scores generated against an Asian database were recorded for 598,757 women and 173,326 men aged over 21 years old using Lunar Achilles (GE Healthcare) heel scanners. The scanners were made available in public centres in Singapore, Vietnam, Malaysia, Taiwan, Thailand, Indonesia and the Philippines.

RESULTS

The mean SI was higher for men than women. In women SI as well as T-scores declined slowly until approximately 45 years of age, then declined rapidly to reach a mean T-score of < -2.5 at about 71-75 years of age. For men, SI as well as the T-score showed a slow steady decline to reach a mean of -2.0 to -2.5 at about 81-85 years. The results for females indicate that there are differences in the rate of decline between countries (significant differences between the slopes at P < 0.05). Vietnam had the fastest decrease for both T-Score and SI, resulting in this population having the poorest bone health of all countries at older ages. The results for males aged 46-85 years indicate that there are no significant differences in the rate of decline between countries for SI and T-Score. In both men and women aged 46-85 years, Vietnam and Indonesia have the lowest SI as well as T-Score for all age groups. For Vietnam and Indonesia, more than 50% of the women could be at risk of having osteoporosis and related fractures after the age of 70, while in Thailand and the Philippines this was >80 years.

CONCLUSIONS

The heel scan data shows a high degree of poor bone health in both men and women in Asian countries, raising concern about the possible increase in fractures with ageing and the expected burden on the public health system.

Distribution of serum βCTX in a population-based study of postmenopausal women taking into account different anti-osteoporotic therapies (the FRODOS Cohort)

This cross-sectional study evaluated the distribution of serum cross-linked C-telopeptides of collagen type I (βCTXs) in postmenopausal women, the characteristics of bone remodeling, and the factors influencing this bone marker, especially the use of anti-osteoporotic drugs. Women (n = 4,175) aged 59-70 years randomly selected from the community were invited to participate, measuring βCTXs and lumbar and femoral bone mineral density at recruitment. Risk factors for osteoporosis and the use of anti-osteoporotic treatment were collected with a structured questionnaire. We evaluated the percentage of women with increased (βCTXs >0.620 ng/mL) and decreased bone turnover (βCTXs <0.100 ng/mL) and those reaching the so-called treatment target (values of βCTXs within the lower half of the reference range for healthy young premenopausal women). Two thousand nine hundred sixty-eight women (70 %) participated (2,405 non-treated and 563 treated). Increased and decreased bone turnover was observed in 16.4 and 1.8 %, respectively, of non-treated women with significant differences compared with treated women (9.7 and 14.2 %, respectively, p < 0.001); 28 % of non-treated osteoporotic individuals had increased bone turnover versus 14 % of osteopenic participants and 8.8 % of women with normal bone density (p < 0.001). Women receiving bisphosphonates presented the highest percentages of decreased bone turnover (27 %) and βCTXs (43 %) within the treatment target. Increased bone turnover is observed in 16.4 % of non-treated postmenopausal women and is more frequent in individuals with osteoporosis, whereas decreased bone turnover is unusual. Most participants taking bisphosphonates had values within the treatment target, but nearly one quarter had decreased bone turnover.

Designer foods and their benefits: A review

Designer foods are normal foods fortified with health promoting ingredients. These foods are similar in appearance to normal foods and are consumed regularly as a part of diet. In this article we have reviewed the global regulatory status and benefits of available designer foods such as designer egg, designer milk, designer grains, probiotics, designer foods enriched with micro and macronutrients and designer proteins. Designer foods are produced by the process of fortification or nutrification. With the advances in the biotechnology, biofortification of foods using technologies such as recombinant DNA technology and fermentation procedures are gaining advantage in the industry. The ultimate acceptability and extensive use of designer foods depend on proper regulation in the market by the regulatory authorities of the country and by creating consumer awareness about their health benefits through various nationwide programs.

Dairy foods and osteoporosis: an example of assessing the health-economic impact of food products

Osteoporosis has become a major health concern, carrying a substantial burden in terms of health outcomes and costs. We constructed a model to quantify the potential effect of an additional intake of calcium from dairy foods on the risk of osteoporotic fracture, taking a health economics perspective.

INTRODUCTION

This study seeks, first, to estimate the impact of an increased dairy consumption on reducing the burden of osteoporosis in terms of health outcomes and costs, and, second, to contribute to a generic methodology for assessing the health-economic outcomes of food products.

METHODS

We constructed a model that generated the number of hip fractures that potentially can be prevented with dairy foods intakes, and then calculated costs avoided, considering the healthcare costs of hip fractures and the costs of additional dairy foods, as well as the number of disability-adjusted life years (DALYs) lost due to hip fractures associated with low nutritional calcium intake. Separate analyses were done for The Netherlands, France, and Sweden, three countries with different levels of dairy products consumption.

RESULTS

The number of hip fractures that may potentially be prevented each year with additional dairy products was highest in France (2,023), followed by Sweden (455) and The Netherlands (132). The yearly number of DALYs lost was 6,263 for France, 1,246 for Sweden, and 374 for The Netherlands. The corresponding total costs that might potentially be avoided are about 129 million, 34 million, and 6 million Euros, in these countries, respectively.

CONCLUSIONS

This study quantified the potential nutrition economic impact of increased dairy consumption on osteoporotic fractures, building connections between the fields of nutrition and health economics. Future research should further collect longitudinal population data for documenting the net benefits of increasing dairy consumption on bone health and on the related utilization of healthcare resources.

Hypovitaminosis D in adults with inflammatory bowel disease: potential role of ethnicity

BACKGROUND

Although vitamin D deficiency occurs in inflammatory bowel disease (IBD), it is currently unclear to what extent ethnicity affects vitamin D levels. Our aim was therefore to determine the ethnic variation in serum 25-hydroxyvitamin D status and its association with disease severity in adults with IBD.

METHODS

We conducted a prospective cohort study in ambulatory care IBD patients. Clinical disease severity was assessed through validated questionnaires. Serum 25-hydroxyvitamin D levels were used for vitamin D status. C-reactive protein (CRP), ferritin and hemoglobin (Hgb) levels were correlated with serum 25-hydroxyvitamin D levels.

RESULTS

Sixty ulcerative colitis (UC) and forty Crohn's disease (CD) patients were enrolled comprising 65 % Caucasians and 29 % South Asians. However, South Asians had consistently lower average serum 25-hydroxyvitamin D levels (All 44.8 ± 18.1 nmol/L, UC 48.2 ± 18.3 nmol/L, CD 24.3 ± 13.3 nmol/L). Hypovitaminosis D was found in 39 % of All, 36.7 % of UC and 42.5 % of CD patients. A significantly higher proportion of South Asians were vitamin D deficient when compared to Caucasians in All and CD groups (58.6 % vs. 30.8 %, p = 0.01 and 85.7 % vs. 32.3 %, p < 0.01, respectively).

CONCLUSIONS

A significantly higher percentage of South Asians had hypovitaminosis D when compared to Caucasians. Disease severity trended towards an inverse relationship with vitamin D status in all South Asian and Caucasian CD patients, although most patients in this study had only mild to moderate disease. We suggest that vitamin D supplementation should be considered in all adult IBD patients.

An updated systematic review and meta-analysis of the efficacy of vitamin D food fortification

Food fortification is a potentially effective public health strategy to increase vitamin D intakes and circulating 25-hydroxyvitamin D [25(OH)D] concentrations. We updated a previous systematic review to evaluate current evidence from randomized controlled intervention studies in community-dwelling adults of the effect of fortified foods on 25(OH)D concentrations. Ovid MEDLINE, PubMed, CINAHL, Embase, and Cochrane Central Register of Controlled Trials were searched for randomized controlled intervention studies with vitamin D-fortified foods in free-living adults and data on circulating 25(OH)D. Two reviewers independently screened 441 papers for eligibility and extracted the relevant data. A meta-analysis of the absolute mean change in circulating 25(OH)D concentrations was conducted using a random effects model. Sixteen studies from 15 publications were included, of which 14 showed a significant effect of fortified foods on 25(OH)D concentrations. Heterogeneity was high (P = <0.0001, I(2) = 89%) and was partly explained by dose, latitude (range, 3-60°), and baseline 25(OH)D (range, 24.0-83.6 nmol/L). When combined in a random effects analysis (n = 1513; 767 treated, 746 controls), a mean individual intake of ~11 μg/d (440 IU/d) from fortified foods (range, 3-25 μg/d) increased 25(OH)D by 19.4 nmol/L (95% CI: 13.9, 24.9), corresponding to a 1.2 nmol/L (95% CI: 0.72, 1.68) increase in 25(OH)D for each 1 μg ingested. Vitamin D food fortification increases circulating 25(OH)D concentrations in community-dwelling adults. Safe and effective food-based strategies could increase 25(OH)D across the population distribution and prevent vitamin D deficiency with potential benefit for public health.

High-calcium, vitamin D fortified milk is effective in improving bone turnover markers and vitamin D status in healthy postmenopausal Chinese women

BACKGROUND/OBJECTIVES

Risk for developing osteoporosis increases in Asia. The purpose of the study was to evaluate the impact of a high-calcium vitamin D fortified milk (HCM) intervention on parathyroid hormone (PTH) levels, vitamin D status and markers of bone turnover in postmenopausal Chinese women.

SUBJECTS/METHODS

Sixty three women (>55 years) were assigned to receive two servings of either a calcium/vitamin D fortified milk or a control drink for 12 weeks. PTH, serum 25 (OH)D levels, C-telopeptide of type I collagen (CTX) levels and procollagen type I N-terminal propeptide (PINP) were measured at baseline, 2, 8 and 12 weeks of supplementation.

RESULTS

Daily calcium intake at baseline ranged between 260 and 482 mg for the HCM, and 252 and 692 mg for the control group. HCM improved serum 25 (OH)D levels significantly (33.13-39.49 nmol/l), while remaining similar in the control group (29.27-28.21 nmol/l). The difference between the groups were significant at week 2, 8 and 12. The percentage change in PTH levels in the HCM group was significant from week 2 onwards compared to the control drink (P<0.017, P<0.05 and P<0.001 at weeks 2, 8 and 12, respectively). Plasma CTX of the HCM group reduced by 25% between weeks 0 and 2, remaining significantly lower and at similar levels up to week 12. The difference between the HCM and control group for PINP reached significance at weeks 8 (P=0.011) and 12 (P=0.003).

CONCLUSIONS

The HCM intervention significantly improved vitamin D status and reduced bone turnover over 12 weeks in postmenopausal Chinese women.

Urbanization of black South African women may increase risk of low bone mass due to low vitamin D status, low calcium intake, and high bone turnover

Globally, rural to urban migration is accompanied by changes in dietary patterns and lifestyle that have serious health implications, including development of low bone mass. We hypothesized that serum 25 (OH) vitamin D3 (25[OH]D3) levels will be lower, bone turnover higher, and nutrition inadequate in urban postmenopausal black women, increasing risk for low bone mass. We aimed to assess the prevalence of risk factors for low bone mass in 1261 black women from rural and urban areas in the North West Province of South Africa (Prospective Urban and Rural Epidemiology-South Africa project). Fasting blood samples were taken; and participants were interviewed to complete questionnaires on self-reported diseases, fractures, and dietary intakes. Bone health markers were assessed in a subgroup of 658 women older than 45 years. Specific lifestyle risk factors identified were inactivity, smoking, injectable progestin contraception use, and high alcohol consumption. Dietary risk factors identified were low calcium and high animal protein, phosphorous, and sodium intakes. The 25(OH)D3 and C-terminal telopeptide (CTX) levels were significantly higher in the rural vs the urban women older than 50 years. Parathyroid hormone (PTH) levels increased with age in both groups. The 25(OH)D levels were inversely correlated with CTX and PTH in rural women. In urban women, PTH and CTX were correlated while dietary calcium was inversely correlated with CTX and PTH with 25(OH)D3. The combination of low dietary calcium (<230 mg/d), marginally insufficient 25(OH)D3 status, and raised PTH may result in increased bone resorption. Further research is required to assess bone health and fracture risk in black African women.

Assessment of substantia nigra echogenicity in German and Filipino populations using a portable ultrasound system

OBJECTIVES

Transcranial sonography of the substantia nigra for diagnosing premotor stages of Parkinson disease has been attracting increasing interest. Standard reference values defining an abnormal increased echogenic size (hyperechogenicity) of the substantia nigra have been established in several populations using high-end stationary ultrasound systems. It is unknown whether a portable ultrasound system can be appropriately used and how the Filipino population would compare with the well-studied white population.

METHODS

We prospectively studied substantia nigra echogenic sizes and third ventricle widths in 71 healthy adult German participants and 30 age- and sex-matched Filipino participants using both a well-established stationary ultrasound system (in the German cohort) and a recently distributed portable ultrasound system (in both ethnic cohorts).

RESULTS

Mean substantia nigra echogenic sizes, cutoff values defining abnormal hyperechogenicity, and intra-rater reliability were similar with both systems and in both ethnic cohorts studied. The Filipino and German participants did not differ with respect to the frequency of insufficient insonation conditions (each 3%) and substantia nigra hyperechogenicity (10% versus 9%; P = .80). However, third ventricle widths were smaller in the Filipino than the German participants (mean ± SD, 1.6 ± 1.1 versus 2.4 ± 1.0 mm; P = .004).

CONCLUSIONS

The frequency of substantia nigra hyperechogenicity appears to be homogeneous in white and Asian populations. Screening for this feature may well be performed with a present-day portable ultrasound system.

Effects of calcium-fortified ice cream on markers of bone health

Premenopausal women with low calcium intakes consumed calcium-fortified ice cream daily for 28 days. Bone markers, NTX, CTX and PTH decreased significantly by 7 days, with some evidence of a calcium dose-dependent effect. Bone marker responses were observed within 1 h of consuming ice cream. Body weight remained constant over 28 days.

INTRODUCTION

Dietary calcium is important for lifelong bone health. Milk is a good source of bioavailable calcium, but consumption has declined among young adults. The aims were to determine whether calcium-fortified ice cream, a palatable source of calcium, produces significant, sustainable changes in bone turnover markers and parathyroid hormone (PTH) in premenopausal women with calcium intake below recommended UK levels.

METHODS

Eighty women, ages 20-39 years (calcium intake <750 mg/day) were randomised to consume lower saturated fat/sugar ice cream containing 96, 244, 459 or 676 mg calcium daily for 28 days. Urinary NTX/Cr, serum CTX, PINP, 1,25D and PTH were measured (baseline, days 1, 7 and 28). Acute changes in CTX and PTH were measured over 5 h (n = 29 women).

RESULTS

There were significant mean decreases by 7 days in NTX/Cr, CTX, PTH and 1,25D and increases in PINP (one sample t tests), with a significant dose-dependent effect on CTX analysis of covariance. Only CTX remained suppressed at 28 days. Serum CTX and PTH decreased within 1 h. Body weight did not change significantly between baseline and 28 days.

CONCLUSIONS

Daily consumption of calcium-fortified ice cream by premenopausal women may significantly reduce levels of the bone resorption marker serum CTX, without stimulating weight gain. The ice cream could be incorporated into the diet to replace low-calcium snacks and thus help individuals with habitually low calcium intakes to meet recommended intakes. The 244 mg calcium preparation would provide more than a quarter of the UK daily recommended nutrient intake for premenopausal women.

Hypovitaminosis D in developing countries-prevalence, risk factors and outcomes

Hypovitaminosis D is a prevalent disorder in developing countries. Clinical manifestations of hypovitaminosis D include musculoskeletal disorders, such as nonspecific muscle pain, poor muscle strength and low BMD, as well as nonmusculoskeletal disorders, such as an increased risk of respiratory infections, diabetes mellitus and possibly cardiovascular diseases. In developing countries, the prevalence of hypovitaminosis D varies widely by and within regions; prevalence ranges between 30-90%, according to the cut-off value used within specific regions, and is independent of latitude. A high prevalence of the disorder exists in China and Mongolia, especially in children, of whom up to 50% are reported to have serum 25-hydroxyvitamin D levels <12.5 nmol/l. Despite ample sunshine throughout the year, one-third to one-half of individuals living in Sub-Saharan Africa and the Middle East have serum 25-hydroxyvitamin D levels <25 nmol/l, according to studies published in the past decade. Hypovitaminosis D is also prevalent in children and the elderly living in Latin America. Risk factors for hypovitaminosis D in developing countries are similar to those reported in Western countries and include extremes of age, female sex, winter season, dark skin pigmentation, malnutrition, lack of sun exposure, a covered clothing style and obesity. Clinical trials to assess the effect of vitamin D supplementation on classical and nonclassical clinical outcomes in developing countries are needed.