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Lu M, Li M, Yi L, Li F, Feng L, Ji T, Zang Y, Qiu J. Effects of 8-week High-Intensity Interval Training and Moderate-Intensity Continuous Training on Bone Metabolism in Sedentary Young Females. J Exerc Sci Fit 2022; 20:77-83. [PMID: 35096081 PMCID: PMC8762074 DOI: 10.1016/j.jesf.2022.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/23/2021] [Accepted: 01/01/2022] [Indexed: 12/15/2022] Open
Abstract
Objective High-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) have been reported as effective exercise modes on bone metabolism. However, very few studies focused on young women with sedentary behavior. The purpose of this study was to investigate the effects of 8-week HIIT on bone metabolism in sedentary young women. Methods 26 healthy, sedentary female participants were randomly assigned to either the HIIT (n = 13, age 23.2 ± 2.9 yr, weight 59.2 ± 7.2 kg, height 162.9 ± 3.3 cm, body mass index 22.3 ± 2.7 kg/m2) or MICT (n = 13, age 21.9 ± 1.7 yr, weight 59.3 ± 6.6 kg, height 160.9 ± 4.4 cm, body mass index 21.6 ± 2.4 kg/m2) group. Both groups completed 8 weeks (3 sessions/week) of training on the treadmill, where the HIIT group were asked to complete 6 × 3-min bouts of running at the intensity of 80–90% maximum oxygen uptake (VO2max) separated by 2-min active recovery at 30–40% VO2max and the MICT group completed 30-min continuous running at the intensity of 60–70% VO2max. The body composition, bone mineral density (BMD), calcaneus quantitative ultrasound, bone turnover markers, and lower limb muscle strength were measured pre and post interventions. Results After 8-week interventions, 1) The total body BMD (HIIT, +8.5%; MICT, +5.5%) significantly increased (p < 0.05) without difference between the two groups (p > 0.05). The calcaneus broadband ultrasound attenuation (CBUA) (HIIT, +16.0%; MICT, +4.6%) and calcaneus stiffness index (CSI) (HIIT, +16.7%; MICT, +2.5%) significantly increased in HIIT group (p < 0.05), but not in MICT group (p > 0.05). 2) The 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) (HIIT, +42.8%; MICT, +24.9%) level increased in both groups with significantly higher changes in HIIT (p < 0.05). 3) The score of standing long jump (HIIT, +10.3%; MICT, +3.8%) and vertical jump (HIIT, +5.3%; MICT, +2.0%) increased in both groups with significantly higher changes in HIIT (p < 0.05). Conclusions It suggested that 8-week HIIT and MICT interventions could improve bone metabolism. Compared with a similar workload of MICT, HIIT elicited superior benefits on bone metabolism.
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Affiliation(s)
- Mingyue Lu
- College of Sport Science School, Beijing Sport University, Beijing, China
| | - Mingxing Li
- College of Sport Science School, Beijing Sport University, Beijing, China
| | - Longyan Yi
- Institute of Sport and Health Sciences, Beijing Sport University, Beijing, China
| | - Feifei Li
- Department of Sport, Physical Education and Health, Hong Kong Baptist University, Hong Kong, China
- Centre for Health and Exercise Science Research, Hong Kong Baptist University, Hong Kong, China
| | - Lin Feng
- College of Sport Science School, Beijing Sport University, Beijing, China
| | - Tianyi Ji
- College of Sport Science School, Beijing Sport University, Beijing, China
| | - Yanpeng Zang
- Department of Sport, Physical Education and Health, Hong Kong Baptist University, Hong Kong, China
| | - Junqiang Qiu
- College of Sport Science School, Beijing Sport University, Beijing, China
- Corresponding author.
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Mohammad Rahimi GR, Niyazi A, Alaee S. The effect of exercise training on osteocalcin, adipocytokines, and insulin resistance: a systematic review and meta-analysis of randomized controlled trials. Osteoporos Int 2021; 32:213-224. [PMID: 32803318 DOI: 10.1007/s00198-020-05592-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 08/07/2020] [Indexed: 02/07/2023]
Abstract
Recently, it has been reported that osteocalcin (OC), in particular its undercarboxylated (ucOC) form, is not only a bone remodeling marker but also an active hormone that intercedes glucose metabolism in humans. This study aimed to determine the impact of an exercise intervention on ucOC, adiponectin, leptin, and insulin resistance (measured by HOMA-IR). PubMed, CINAHL, Medline, Google Scholar, and Scopus databases and reference lists of included studies were searched. Twenty-two randomized controlled trials (RCTs) of exercise training impact in adults were included in the analysis. Results showed an overall significant increase in serum ucOC (MD: 0.15 ng/ml; 95% CI: 0.05 to 0.25) and adiponectin (MD: 2.83 mg/ml; 95% CI: 1.67 to 3.98), a significant decline in leptin (MD: - 4.89 pg/ml; 95% CI: - 6.94 to - 2.84), fasting glucose (MD: - 2.29 mg/dl; 95% CI: - 4.04 to - 0.54), fasting insulin (MD, - 8.90 μIU/ml; 95% CI: - 13.81 to - 3.98), and HOMA-IR (MD: - 1.96; 95% CI: - 3.11 to - 0.80). However, after removal of studies that had prescribed a balanced diet along with exercise intervention, total OC (TOC) levels also increased in the exercise group compared with the control group (MD: 0.36 ng/ml; 95% CI: 0.07 to 0.65). Our findings demonstrate that exercise-induced increases in ucOC are the probable cause of increased adiponectin. Additionally, increases in ucOC itself are probably due to changes in leptin levels and other factors, rather than its direct impact on bone and its osteoblastic activity. Further studies are required to clarify the mechanisms underlying the impact of exercise training on ucOC, adipocytokines, and insulin resistance.
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Affiliation(s)
- Gh R Mohammad Rahimi
- Department of Sports Sciences, Vahdat Institute of Higher Education, Torbat-e-Jam, Iran.
| | | | - S Alaee
- Department of Physical Education, Islamic Azad University, Neyshabur Branch, Neyshabur, Iran
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Sagayama H, Kondo E, Tanabe Y, Ohnishi T, Yamada Y, Takahashi H. Bone mineral density in male weight-classified athletes is higher than that in male endurance-athletes and non-athletes. Clin Nutr ESPEN 2020; 36:106-110. [DOI: 10.1016/j.clnesp.2020.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/27/2019] [Accepted: 01/13/2020] [Indexed: 01/26/2023]
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Gandolfi NRS, Corrente JE, De Vitta A, Gollino L, Mazeto GMFDS. The influence of the Pilates method on quality of life and bone remodelling in older women: a controlled study. Qual Life Res 2019; 29:381-389. [PMID: 31512157 DOI: 10.1007/s11136-019-02293-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The objective of this study was to evaluate the effects of the Pilates method on quality of life and bone remodeling markers in a group of older women. METHODS A longitudinal prospective study with intervention was performed on 40 women aged over 60 years; they were divided into two groups: one submitted to a 50-min Pilates exercise session once a week for 20 weeks (Pilates), and the other was not (Control). Both groups were compared for quality of life using the Medical Outcomes Study 36, and for bone-specific alkaline phosphatase (BSAP) and Type 1 collagen C-telopeptide (CTx) bone remodeling markers. RESULTS The Pilates group presented improvement in the quality of life evaluation scores: physical functioning (67.50 ± 18.88 × 86.25 ± 9.58; p = 0.0232), and physical component summary (65.00 ± 14.39 × 79.70 ± 3.83; p = 0.0220). The Pilates group also presented higher scores than that of Controls after the exercise program: physical functioning (86.25 ± 9.58 × 55.50 ± 20.83, p = 0.0003), physical role (100.00 ± 0.00 × 41.25 ± 46.79, p = 0.0009), emotional role (100.00 ± 0.00 × 48.33 ± 50.12, p = 0.0046), vitality (82.50 ± 14.28 × 60.25 ± 21.43, p = 0.011), physical component summary (79.70 ± 3.83 × 54.90 ± 15.05, p < 0.0001), and emotional component summary (74.10 ± 8.37 × 54.18 ± 22.55, p = 0.0111). No changes were noted in bone remodeling markers [CTx (0.39 ± 0.26 × 0.38 ± 0.22 ng/mL) and BSAP (10.73 ± 2.40 × 11.01 ± 3.56 μg/L)] and did not differ from the Control group both before (CTx: 0.39 ± 0.26 × 0.37 ± 0.17 ng/mL; BSAP: 10.73 ± 2.40 × 10.58 ± 3.49 μg/L; p > 0.05) and after exercise (CTx: 0.38 ± 0.22 × 0.38 ± 0.22 ng/mL; BSAP: 11.01 ± 3.56 × 9.85 ± 3.12 μg/L; p > 0.05). CONCLUSION The group of women submitted to Pilates presented improved quality of life but without changes in bone remodeling.
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Affiliation(s)
| | - Jose Eduardo Corrente
- Biostatistics Department, Institute of Biosciences, Sao Paulo State University - Unesp, Botucatu, Sao Paulo, 18618-687, Brazil
| | - Alberto De Vitta
- Universidade Anhanguera - UNIDERP, Campo Grande, Mato Grosso do Sul, 79037-280, Brazil
| | - Loraine Gollino
- Internal Medicine Department, Botucatu Medical School, Sao Paulo State University - Unesp, Botucatu, Sao Paulo, 18618-687, Brazil
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Oh SB, Lee WY, Nam HK, Rhie YJ, Lee KH. Serum osteocalcin levels in overweight children. Ann Pediatr Endocrinol Metab 2019; 24:104-107. [PMID: 31261474 PMCID: PMC6603608 DOI: 10.6065/apem.2019.24.2.104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/03/2018] [Accepted: 09/09/2018] [Indexed: 12/01/2022] Open
Abstract
PURPOSE Bone plays a role in glucose metabolism through the release of uncarboxylated osteocalcin into the systemic circulation. The identified novel roles for osteocalcin include increasing insulin secretion and sensitivity, energy expenditure, reduction of fat mass, and mitochondrial proliferation and functional enhancement. This study aimed to determine serum osteocalcin levels in overweight children and to investigate the relationships of osteocalcin with glucose metabolism and insulin sensitivity. METHODS After overnight fasting, serum osteocalcin levels were measured in overweight (n=50) children between 6.0 and 12.9 years of age and nonoverweight controls (n=60). Height, weight, fasting serum glucose, insulin, alkaline phosphatase, total cholesterol, and 25 hydroxy vitamin D3 (25(OH)VitD3) were also measured in all subjects. RESULTS There were significant differences in serum osteocalcin levels between the overweight and control groups (64.00±20.44 vs. 89.56±28.63, P<0.001). Serum osteocalcin levels were inversely correlated with body mass index (BMI) (r=-0.283, P=0.003), weight standard deviation score (SDS) (r=-0.222, P=0.020), BMI SDS (r=-0.297, P=0.002), insulin (r=-0.313, P=0.001), and homeostasis model assessment of insulin resistance (HOMA-IR) index (r=-0.268, P=0.005). In the subsequent multiple regression analyses, BMI, HOMA-IR, and age were determined to be independent predicting factors for serum osteocalcin. CONCLUSION Our findings showed associations of serum osteocalcin with glucose metabolism and insulin sensitivity in overweight children, but we could not establish a causal relationship.
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Affiliation(s)
- Seok Bin Oh
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Won Young Lee
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Hyo-Kyoung Nam
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Young-Jun Rhie
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Kee-Hyoung Lee
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
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Campanha-Versiani L, Pereira DAG, Ribeiro-Samora GA, Ramos AV, de Sander Diniz MFH, De Marco LA, Soares MMS. The Effect of a Muscle Weight-Bearing and Aerobic Exercise Program on the Body Composition, Muscular Strength, Biochemical Markers, and Bone Mass of Obese Patients Who Have Undergone Gastric Bypass Surgery. Obes Surg 2017; 27:2129-2137. [PMID: 28285470 DOI: 10.1007/s11695-017-2618-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The effect of an exercise program on the body composition, muscular strength (MS), biochemical markers, and bone mineral density (BMD) of individuals undergoing gastric bypass is unclear. We assessed lean mass (LM), MS, bone remodeling markers, and BMD before and after supervised weight-bearing and aerobic exercise training in obese patients who underwent Roux-en-Y gastric bypass (RYGB). METHODS This study included 37 obese patients (81.1% women, mean age 38.2 years, mean body mass index 42.4 ± 0.5 kg/m2). Whole body densitometry was used to evaluate pre- and postoperative BMD, total body fat, and LM. Serum calcium, parathyroid hormone, 25-hydroxyvitamin D, and bone remodeling markers were measured. MS was determined through the concentric 10 repetition maximum test. Postoperatively, participants were divided into two groups: the training group, who followed an exercise program (TG, n = 18), and the control group, who did not (CG, n = 19). RESULTS After 1 year, the TG showed a lower decrease in total BMD and at the lumbar spine and right hip compared with the CG (p < 0.001). The TG had lower mass reduction and an increase in upper limb LM compared with the CG (both p < 0.05). There was no significant difference between groups in bone markers or calcium metabolism. MS was higher in the TG than the CG (p < 0.05). CONCLUSION The supervised exercise program attenuated lumbar spine and right hip BMD loss and improved LM in the arms and overall MS but did not affect bone remodeling.
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Affiliation(s)
- Luciana Campanha-Versiani
- ICBS, University Center's of Belo Horizonte (UNI-BH), Professor Mario Werneck Avenue, 1685 Estoril, Belo Horizonte, MG, 30455-610, Brazil.
| | | | | | | | | | | | - Maria Marta Sarquis Soares
- Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil.,Felício Rocho Hospital, Belo Horizonte, Brazil
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Soltani S, Hunter GR, Kazemi A, Shab-Bidar S. The effects of weight loss approaches on bone mineral density in adults: a systematic review and meta-analysis of randomized controlled trials. Osteoporos Int 2016; 27:2655-2671. [PMID: 27154437 DOI: 10.1007/s00198-016-3617-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 04/26/2016] [Indexed: 12/15/2022]
Abstract
UNLABELLED We assessed the impact of weight loss strategies including calorie restriction and exercise training on BMD in adults using a systematic review of randomized controlled trials. Weight reduction results in reduced BMD at the hip, but has less effect on the spine. Both calorie restriction and a combination of calorie restriction and exercise result in a decrease in hip bone density, whereas weight loss response to exercise training without dietary restriction leads to increased hip BMD. INTRODUCTION Findings are not consistent on the effect of weight loss on bone mineral density (BMD). We conducted a systematic review on the randomized controlled trials to assess the effect of weight loss strategies, including calorie restriction and exercise programs on BMD in adults. METHODS A structured and comprehensive search of MEDLINE and EMBASE databases was undertaken up to March 2016. Study-specific mean differences (MD) were pooled using a random-effects model. Subgroup analysis and meta-regression were used to find possible sources of between-study heterogeneity. RESULTS Thirty-two randomized controlled trials met predetermined inclusion criteria. The meta-analysis revealed no significant difference on total BMD (MD 0.007, 95 % CI -0.020-0.034, p = 0.608). In contrast, the pooled data of studies showed a significant effect of weight loss on hip BMD (MD -0.008, 95 % CI -0.09 to -0.006 g/cm(2), p < 0.001) and also lumbar spine BMD (MD -0.018 g/cm(2), 95 % CI -0.019 to -0.017, p < 0.001). BMD in the hip site decreased after more than 4 months, especially in those who were obese. Moreover, calorie restriction interventions longer than 13 months showed a significant decreased in lumbar spine BMD. CONCLUSION Weight loss led to significant decreases at the hip and lumbar spine BMD but not at the total. Weight loss response following calorie restriction resulted in a decrease in hip and lumbar spine bone density especially more than 1 year; whereas an exercise-induced weight loss did not.
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Affiliation(s)
- S Soltani
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Hemaat Highway, 1449614535, Tehran, Iran
| | - G R Hunter
- Department of Human Studies School of Education, University of Alabama at Birmingham, EB 205 1720 2nd Ave South, Birmingham, AL, 34294-1250, USA
| | - A Kazemi
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, P. O. Box 14155/6117, Amir Abad, Keshavarz Boulevard, Tehran, Iran
| | - S Shab-Bidar
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, P. O. Box 14155/6117, Amir Abad, Keshavarz Boulevard, Tehran, Iran.
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Qi Z, Liu W, Lu J. The mechanisms underlying the beneficial effects of exercise on bone remodeling: Roles of bone-derived cytokines and microRNAs. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2016; 122:131-139. [PMID: 27179638 DOI: 10.1016/j.pbiomolbio.2016.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/02/2016] [Accepted: 05/07/2016] [Indexed: 12/31/2022]
Abstract
Bone remodeling is highly dynamic and complex in response to mechanical loading, such as exercise. In this review, we concluded that a number of individual factors are disturbing the clinical effects of exercise on bone remodeling. We updated the progress made on the differentiation of osteoblasts and osteoclasts in response to mechanical loading, hoping to provide a theoretical basis to improve bone metabolism with exercise. Increasing evidences indicate that bone is not only a structural scaffold but also an endocrine organ, which secretes osteocalcin and FGF23. Both of them have been known as a circulating hormone to promote insulin sensitivity and reduce body fat mass. The effects of exercise on these bone-derived cytokines provide a better understanding of how exercise-induced "osteokine" affects the whole-body homeostasis. Additionally, we discussed recent studies highlighting the post-transcriptional regulation of microRNAs in bone remodeling. We focus on the involvement of the microRNAs in osteoblastogenesis and osteoclastogenesis, and suggest that microRNAs may be critical for exercise-induced bone remodeling.
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Affiliation(s)
- Zhengtang Qi
- The Key Laboratory of Adolescent Health Assessment and Exercise Intervention (East China Normal University), Ministry of Education, Shanghai 200241, China; School of Physical Education and Health, East China Normal University, Shanghai 200241, China
| | - Weina Liu
- The Key Laboratory of Adolescent Health Assessment and Exercise Intervention (East China Normal University), Ministry of Education, Shanghai 200241, China; School of Physical Education and Health, East China Normal University, Shanghai 200241, China.
| | - Jianqiang Lu
- School of Kinesiology, Shanghai University of Sport, Shanghai 200438, China.
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Moreira LDF, Fronza FCAO, Dos Santos RN, Zach PL, Kunii IS, Hayashi LF, Teixeira LR, Kruel LFM, Castro ML. The benefits of a high-intensity aquatic exercise program (HydrOS) for bone metabolism and bone mass of postmenopausal women. J Bone Miner Metab 2014; 32:411-9. [PMID: 24048909 DOI: 10.1007/s00774-013-0509-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 08/07/2013] [Indexed: 10/26/2022]
Abstract
This study aimed to evaluate the 24-week effects of a high-intensity aquatic exercise program on bone remodeling markers and bone mass of postmenopausal women. In this randomized, controlled trial we studied 108 women (58.8 ± 6.4 years), randomized into Aquatic Exercise Group (AEG), n = 64, performing 24 weeks of aquatic exercises, and Control Group (CG), n = 44, sedentary. They had their fasting morning blood sample collected for the measures of intact parathyroid hormone (iPTH), procollagen type 1 amino-terminal propeptide (P1NP) and carboxy-terminal cross-linking telopeptide of type I collagen (CTx). Bone mass was measured by dual-energy X-ray absorptiometry before and after the intervention. Participants of both groups received a daily supplementation of 500 mg of elementary calcium and 1,000 IU of vitamin D (cholecalciferol). Results showed an augment in bone formation marker (P1NP) only in the AEG (15.8 %; p = 0.001), and although both groups experienced significant enhancements in bone resorption marker (CTx), this increase was less considerable in the AEG (15 % in the AEG and 29 % in the CG). IPTH was increased by 19 % in the CG (p = 0.003) at the end. The femoral trochanter BMD presented a 1.2 % reduction in the CG (p = 0.009), whereas in the AEG no change was observed (p = 0.069). The proposed aquatic exercise program was efficient in attenuating bone resorption raise and enhancing bone formation, which prevented the participants in the AEG from reducing the femoral trochanter BMD, as happened in the CG.
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Michalopoulou M, Kambas A, Leontsini D, Chatzinikolaou A, Draganidis D, Avloniti A, Tsoukas D, Michopoulou E, Lyritis GP, Papaioannou N, Tournis S, Fatouros IG. Physical activity is associated with bone geometry of premenarcheal girls in a dose-dependent manner. Metabolism 2013; 62:1811-8. [PMID: 24054822 DOI: 10.1016/j.metabol.2013.08.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 08/13/2013] [Accepted: 08/13/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine the relationship between habitual physical activity (PA) level and peripheral qualitative computed tomography-determined quantitative tibia characteristics of premenarcheal girls. METHODS Premenarcheal girls matched for age (10-13 years), bone age and maturity level were assigned into: a) low PA group (LPA, n=25), b) moderate PA group (MPA, n=17), and c) high PA group (HPA, n=18). Participants' daily dietary intake, tibia's geometry and serum levels of calcium and vitamin D were assessed. RESULTS Premenarcheal girls demonstrating HPA exhibited greater pericortical thickness, cross-sectional area (CSA) and bone mineral content (BMC) (p<.001) in cortical bone, greater BMC, volumetric bone density (vBMD) and polar stress strength index (SSIp) in trabecular bone (p<0.001-0.05) and greater total BMC (p<.05) and vBMD (p<.01) when compared to their physically inactive or moderately active counterparts. MPA exhibited greater values of cortical BMC (p<.01) and SSIp (p<.05) than LPA. Partial correlation analysis (adjusted for BMI) revealed modest associations between PA score and bone geometry parameters (r=0.36-0.49, p<.05) at 38% of tibia length. CONCLUSIONS Habitual PA affects geometry of both cortical and trabecular areas of a long bone of premenarcheal girls in a dose-dependent manner. Specifically, PA increases both the density and size of cortical bone but only the density of trabecular bone during preadolescence. Given the importance of peak bone mass for future fracture risk, high levels of PA during childhood could be a major target for public health interventions aimed at optimising bone health in prepubertal children when the greatest bone gains occur.
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Affiliation(s)
- Maria Michalopoulou
- Department of Physical Education and Sport Sciences, Democritus University of Thrace, University Campus, 69100 Komotini, Greece
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Suh HS, Hwang IC, Lee KS, Kim KK. Relationships between serum osteocalcin, leptin and the effect of weight loss by pharmacological treatment in healthy, nonsmoking Korean obese adults. Clin Chim Acta 2013; 418:17-21. [DOI: 10.1016/j.cca.2012.11.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 11/23/2012] [Accepted: 11/26/2012] [Indexed: 01/23/2023]
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Wiklund P, Nordström A, Högström M, Alfredson H, Engström P, Gustafsson T, Franks PW, Nordström P. High-impact loading on the skeleton is associated with a decrease in glucose levels in young men. Clin Endocrinol (Oxf) 2012; 77:823-7. [PMID: 22676721 DOI: 10.1111/j.1365-2265.2012.04461.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The skeleton has been suggested to be involved in energy metabolism through osteocalcin (OC), an osteoblast-specific molecule. The objective of this study was to investigate whether high-impact (HI) exercise stimulating bone formation would lead to changes in glucose and lipid metabolism independent of cardiorespiratory effects and whether OC mediates this association. DESIGN Prospective intervention study. METHODS Fifty men aged 20-32 years were allocated to an intervention group or a control group. The intervention group completed six different types of jumps in sets of five, with the frequency of these exercises gradually increasing over 8 weeks. At baseline and after 8 weeks, glycerol concentrations were measured in fat tissue as a marker of lipolysis using microdialysis. Blood samples were assayed for OC and markers of glucose and lipid metabolism. Physical activity was measured using an accelerometer. RESULTS After adjustment for confounders at baseline and changes in physical activity during the intervention period, the intervention was associated with a decrease in levels of glucose (P = 0·04), adrenalin (P = 0·03) and OC (P = 0·04) after adjusting for baseline levels and changes in physical activity. No other differences between the groups were significant, although the trends of the metabolic variables favoured the intervention group. CONCLUSIONS The results of this study suggest that HI loading on the skeleton may affect glucose metabolism independent of the level of aerobic exercise.
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Affiliation(s)
- Peder Wiklund
- Department of Surgical and Perioperative Sciences, Umeå University, Sweden
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Effects of short-term aerobic exercise with and without external loading on bone metabolism and balance in postmenopausal women with osteoporosis. Rheumatol Int 2012; 33:291-8. [DOI: 10.1007/s00296-012-2388-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Accepted: 03/11/2012] [Indexed: 10/28/2022]
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Sullivan TR, Duque G, Keech AC, Herrmann M. An old friend in a new light: the role of osteocalcin in energy metabolism. Cardiovasc Ther 2011; 31:65-75. [PMID: 21975009 DOI: 10.1111/j.1755-5922.2011.00300.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Accumulating evidence suggests interactions between bone and energy metabolism, which may affect the risk of cardiovascular disease. Recent animal studies indicate that osteocalcin (OC) plays a key role in the coordinated regulation of glucose and insulin metabolism while insulin receptors on osteoblasts may regulate bone turnover and circulating OC levels. Association studies, weight loss interventions, and observational data lend some support to the existence and relevance of these mechanisms in humans. However, corroborating evidence from pharmacologic interventions in either bone or glucose metabolism is limited by the number, design, and complex pharmacological effects of the drugs used. Furthermore, such clinical trials are complicated by the alteration of metabolic feedback mechanisms in the insulin resistant state. Purpose-designed studies are needed to further establish the existence and significance of the role of OC and its subfractions in human insulin metabolism. In this review we summarize existing animal evidence regarding the role of OC and its subfractions in bone and energy metabolism and assess current clinical trial evidence relating to the significance and consequences of this relationship in humans.
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Affiliation(s)
- Tim R Sullivan
- Hornsby Kuring-gai Hospital, Northern Sydney Health Service, Hornsby, Australia
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15
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Ma H, Turpeinen T, Silvennoinen M, Torvinen S, Rinnankoski-Tuikka R, Kainulainen H, Timonen J, Kujala UM, Rahkila P, Suominen H. Effects of diet-induced obesity and voluntary wheel running on the microstructure of the murine distal femur. Nutr Metab (Lond) 2011; 8:1. [PMID: 21241467 PMCID: PMC3034661 DOI: 10.1186/1743-7075-8-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 01/17/2011] [Indexed: 12/14/2022] Open
Abstract
Background Obesity and osteoporosis, two possibly related conditions, are rapidly expanding health concerns in modern society. Both of them are associated with sedentary life style and nutrition. To investigate the effects of diet-induced obesity and voluntary physical activity we used high resolution micro-computed tomography (μCT) together with peripheral quantitative computed tomography (pQCT) to examine the microstructure of the distal femoral metaphysis in mice. Methods Forty 7-week-old male C57BL/6J mice were assigned to 4 groups: control (C), control + running (CR), high-fat diet (HF), and high-fat diet + running (HFR). After a 21-week intervention, all the mice were sacrificed and the left femur dissected for pQCT and μCT measurements. Results The mice fed the high-fat diet showed a significant weight gain (over 70% for HF and 60% for HFR), with increased epididymal fat pad mass and impaired insulin sensitivity. These obese mice had significantly higher trabecular connectivity density, volume, number, thickness, area and mass, and smaller trabecular separation. At the whole bone level, they had larger bone circumference and cross-sectional area and higher density-weighted maximal, minimal, and polar moments of inertia. Voluntary wheel running decreased all the cortical bone parameters, but increased the trabecular mineral density, and decreased the pattern factor and structure model index towards a more plate-like structure. Conclusions The results suggest that in mice the femur adapts to obesity by improving bone strength both at the whole bone and micro-structural level. Adaptation to running exercise manifests itself in increased trabecular density and improved 3D structure, but in a limited overall bone growth
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Affiliation(s)
- Hongqiang Ma
- Department of Health Sciences, University of Jyväskylä, Finland.
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16
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Kim SH, Lee JW, Im JA, Hwang HJ. Serum osteocalcin is related to abdominal obesity in Korean obese and overweight men. Clin Chim Acta 2010; 411:2054-7. [PMID: 20831864 DOI: 10.1016/j.cca.2010.08.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 08/31/2010] [Accepted: 08/31/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND Growing evidence suggests a link between body composition and serum osteocalcin. Here we examined such an association between serum osteocalcin and body composition in Korean obese men. METHODS Eighty-six men, aged 20 to 76 years, who visited the obesity clinic at the Division of Family Medicine, Severance hospital, Seoul, Korea were recruited for this study. Abdominal fat computed tomography (CT) scans were performed to measure the visceral fat area (VFA) and subcutaneous fat area (SFA). RESULTS Serum osteocalcin levels were negatively correlated with age, VFA, and VFA/SFA ratio. In addition, serum osteocalcin levels were significantly decreased in obese and overweight subjects with visceral obesity (12.7±3.2) compared to those without visceral obesity (18.6±4.9). Multiple regression analysis showed that serum osteocalcin levels were associated with VFA in obese and overweight men after adjustment for age, insulin resistance, current smoking, alcohol consumption and adiposity indices. CONCLUSION Osteocalcin was inversely related to visceral obesity in Korean obese and overweight men. These results suggest cross-talk between bone and adipose tissue.
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Affiliation(s)
- Sang-Hwan Kim
- Department of Family Medicine, Myongji Hospital, Kwandong University College of Medicine, 697-24, Hwajeong-dong, Deogyang-gu, Goyang, Gyeonggi-do, Republic of Korea
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17
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Uusi-Rasi K, Rauhio A, Kannus P, Pasanen M, Kukkonen-Harjula K, Fogelholm M, Sievänen H. Three-month weight reduction does not compromise bone strength in obese premenopausal women. Bone 2010; 46:1286-93. [PMID: 19857618 DOI: 10.1016/j.bone.2009.10.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Revised: 10/09/2009] [Accepted: 10/13/2009] [Indexed: 10/20/2022]
Abstract
Weight loss is claimed to cause bone loss. This prospective 12-month study evaluated effects of 3-month group-based weight loss with VLED on body composition, bone mass and strength (DXA and pQCT), muscle performance and biomarkers of bone turnover. The assessments were done at baseline and at 3 and 12 months. Sixty-two women of the recruited 75 obese (BMI>30) premenopausal women who completed the study were divided into 3 groups based on the tertiles of weight loss at 3 months. The group means of weight losses were 15.5% (Large), 10.5% (Medium) and 5.9% (Low). Statistical analyses were based on analysis of covariance. Bone turnover increased during the weight reduction period in all groups but practically returned to baseline during the weight maintenance phase. In general, mean bone changes remained marginal (approximately +/-1%) and the amount of weight reduction was not associated with bone loss. The only notable change was the 4% decline in bending strength at the distal radius. These results indicate that in obese premenopausal women, 3-month weight reduction resulted in increased bone turnover but was not deleterious for bone mass or strength at 3 months or after 9-month weight maintenance.
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Affiliation(s)
- Kirsti Uusi-Rasi
- The UKK Institute for Health Promotion Research, Tampere, Finland.
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18
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Rector RS, Loethen J, Ruebel M, Thomas TR, Hinton PS. Serum markers of bone turnover are increased by modest weight loss with or without weight-bearing exercise in overweight premenopausal women. Appl Physiol Nutr Metab 2010; 34:933-41. [PMID: 19935856 DOI: 10.1139/h09-098] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Weight loss improves metabolic fitness and reduces morbidity and mortality; however, weight reduction also reduces bone mineral density (BMD) and increases bone turnover. Weight-bearing aerobic exercise may preserve bone mass and maintain normal bone turnover during weight reduction. We investigated the impact of weight-bearing and nonweight-bearing exercise on serum markers of bone formation and breakdown during short-term, modest weight loss in overweight premenopausal women. Subjects (n = 36) were assigned to 1 of 3 weight-loss interventions designed to produce a 5% reduction in body weight over 6 weeks: (i) energy restriction only (n = 11; DIET); (ii) energy restriction plus nonweight-bearing exercise (n = 12, CYCLE); or (iii) energy restriction plus weight-bearing exercise (n = 13, RUN). Bone turnover markers were measured in serum collected at baseline and after weight loss. All groups achieved a ~5% reduction in body weight (DIET = 5.2%; CYCLE = 5.0%; RUN = 4.7%). Osteocalcin (OC) and C-terminal telopeptide of type I collagen (CTX) increased with weight loss in all 3 groups (p < 0.05), whereas bone alkaline phosphatase was unaltered by the weight-loss interventions. At baseline, OC and CTX were positively correlated (r = 0.36, p = 0.03), but the strength of this association was diminished (r = 0.30, p = 0.06) after weight loss. Modest weight loss, regardless of method, resulted in a significant increase in both OC and CTX. Low-impact, weight-bearing exercise had no effect on serum markers of bone formation or resorption in premenopausal women during weight loss. Future studies that examine the effects of high-impact, weight-bearing activity on bone turnover and BMD during weight loss are warranted.
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Affiliation(s)
- R Scott Rector
- Division of Gastroenterology and Hepatology, University of Missouri, Columbia, MO 65211, USA
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19
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Reinehr T, Roth CL. A new link between skeleton, obesity and insulin resistance: relationships between osteocalcin, leptin and insulin resistance in obese children before and after weight loss. Int J Obes (Lond) 2010; 34:852-8. [PMID: 20065970 DOI: 10.1038/ijo.2009.282] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The skeleton is regarded recently as an endocrine organ that affects energy metabolism. However, there are very limited data available concerning the relationships between the osteoblast-derived hormone osteocalcin, weight status, adiponectin and leptin in obese humans, especially in children. METHODS We analyzed osteocalcin, adiponectin, leptin and insulin resistance (IR) index homeostasis model assessment (HOMA) in 60 obese and 19 age- and gender-matched normal weight children. Furthermore, these parameters were determined in 60 obese children after participating in an outpatient 1-year lifestyle intervention based on exercise, behavior and nutrition therapy. RESULTS Sixty obese children had significantly lower osteocalcin levels (26.8+/-0.8 ng ml(-1)) than 19 normal weight controls (32.2+/-2.3 ng ml(-1)). Boys (29.9+/-1.1 ng ml(-1)) showed significantly (P=0.046) higher osteocalcin levels compared with girls (26.4+/-1.2 ng ml(-1)). In stepwise multiple linear regression analysis adjusted for age, gender and pubertal stage, osteocalcin was significantly negatively related to leptin and HOMA, but not to adiponectin. Changes of osteocalcin in the course of 1 year correlated significantly negatively with changes of IR index HOMA (r=-0.25), standard deviation score-body mass index (SDS-BMI) (r=-0.33) and leptin (r=-0.50). Substantial weight loss in 29 obese children led to a significant increase in osteocalcin and a significant decrease in leptin and HOMA. In 31 obese children without substantial weight loss, osteocalcin levels did not change significantly in the course of 1 year. CONCLUSION Osteocalcin levels were lower in obese children and were related to IR and leptin both in cross-sectional and longitudinal analyses. Therefore, osteocalcin might be a new promising link between obesity and IR.
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Affiliation(s)
- T Reinehr
- Department of Pediatric Nutrition Medicine, Vestische Hospital for Children and Adolescents Datteln, University of Witten/Herdecke, Germany.
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20
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Lester ME, Urso ML, Evans RK, Pierce JR, Spiering BA, Maresh CM, Hatfield DL, Kraemer WJ, Nindl BC. Influence of exercise mode and osteogenic index on bone biomarker responses during short-term physical training. Bone 2009; 45:768-76. [PMID: 19520194 DOI: 10.1016/j.bone.2009.06.001] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Revised: 03/18/2009] [Accepted: 06/01/2009] [Indexed: 11/24/2022]
Abstract
Prescribing exercise based on intensity, frequency, and duration of loading may maximize osteogenic responses in bone, but a model of the osteogenic potential of exercise has not been established in humans. In rodents, an osteogenic index (OI) has been used to predict the osteogenic potential of exercise. The current study sought to determine whether aerobic, resistance, or combined aerobic and resistance exercise programs conducted over eight weeks and compared to a control group could produce changes in biochemical markers of bone turnover indicative of bone formation. We further sought to determine whether an OI could be calculated for each of these programs that would reflect observed biochemical changes. We collected serum biomarkers [bone-specific alkaline phosphatase (BAP), osteocalcin, tartrate-resistant acid phosphatase (TRAP), C-terminal telopeptide fragment of type I collagen (CTx), deoxypyridinoline (DPD), 25-hydroxy vitamin D (25(OH)D), and parathyroid hormone (PTH)] in 56 women (20.3+/-1.8 years) before, during and after eight weeks of training. We also measured bone mineral density (BMD) at regional areas of interest using DXA and pQCT. Biomarkers of bone formation (BAP and osteocalcin) increased in the Resistance and Combined groups (p<0.05), while biomarkers of bone resorption (TRAP and DPD) decreased and increased, respectively, after training (p<0.05) in all groups. Small changes in volumetric and areal BMD (p<0.05) were observed in the distal tibia in the Aerobic and Combined groups, respectively. Mean weekly OIs were 16.0+/-1.9, 20.6+/-2.2, and 36.9+/-5.2 for the Resistance, Aerobic, and Combined groups, respectively. The calculated osteogenic potential of our programs did not correlate with the observed changes in biomarkers of bone turnover. The results of the present study demonstrate that participation in an eight week physical training program that incorporates a resistance component by previously inactive young women results in alterations in biomarkers of bone remodeling indicative of increased formation without substantial alterations in markers of resorption.
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Affiliation(s)
- Mark E Lester
- Military Performance Division, U.S. Army Research Institute of Environmental Medicine, Building 42, Kansas Street, Natick, MA 01760, USA
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21
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Fernández-Real JM, Izquierdo M, Ortega F, Gorostiaga E, Gómez-Ambrosi J, Moreno-Navarrete JM, Frühbeck G, Martínez C, Idoate F, Salvador J, Forga L, Ricart W, Ibañez J. The relationship of serum osteocalcin concentration to insulin secretion, sensitivity, and disposal with hypocaloric diet and resistance training. J Clin Endocrinol Metab 2009; 94:237-45. [PMID: 18854399 DOI: 10.1210/jc.2008-0270] [Citation(s) in RCA: 206] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT Bone has recently been described as exhibiting properties of an endocrine organ by producing osteocalcin that increases insulin sensitivity and secretion in animal models. OBJECTIVE AND DESIGN We aimed to evaluate circulating osteocalcin in association with insulin sensitivity and insulin secretion in three different studies in nondiabetic subjects: one cross-sectional study in 149 men (using minimal model), and two longitudinal studies in two independent groups (one formed by 26 women, and the other by 9 men and 11 women), after a mean of 7.3 and 16.8% weight loss, and after a mean of 8.7% weight loss plus regular exercise. RESULTS In the cross-sectional study, circulating osteocalcin was associated with insulin sensitivity, mainly in lean subjects, and with insulin secretion (only in lean subjects). A mean of 16.8%, but not 7.3% weight loss, led to significant increases in circulating osteocalcin. However, a mean of 8.7% weight loss plus regular exercise led to the more pronounced effects on the serum osteocalcin concentration, which increased in parallel to reduced visceral fat mass, unchanged thigh muscle mass, and increased leg strength and force. The postintervention serum levels of osteocalcin were associated with both insulin sensitivity (r = 0.49; P = 0.03) and fasting triglycerides (r = -0.54; P = 0.01). The change in visceral fat was the parameter that best predicted the change in serum osteocalcin, once age, body mass index, and insulin sensitivity changes were controlled for (P = 0.002). CONCLUSION Circulating osteocalcin could mediate the role of bone as an endocrine organ in humans.
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Affiliation(s)
- Jose Manuel Fernández-Real
- Department of Diabetes, Institut d'Investigació Biomédica de Girona, CIBER Fisiopatología de la Obesidad y Nutrición CB06/03/010, 17007 Girona, Catalonia, Spain.
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Rector RS, Thyfault JP, Wei Y, Ibdah JA. Non-alcoholic fatty liver disease and the metabolic syndrome: An update. World J Gastroenterol 2008; 14:185-92. [PMID: 18186553 PMCID: PMC2675112 DOI: 10.3748/wjg.14.185] [Citation(s) in RCA: 213] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Sedentary lifestyle and poor dietary choices are leading to a weight gain epidemic in westernized countries, subsequently increasing the risk for developing the metabolic syndrome and nonalcoholic fatty liver disease (NAFLD). NAFLD is estimated to affect approximate 30% of the general US population and is considered the hepatic manifestation of the metabolic syndrome. Recent findings linking the components of the metabolic syndrome with NAFLD and the progression to nonalcoholic steatohepatitis (NASH) will be reviewed; in particular, the role of visceral adipose tissue, insulin resistance, and adipocytokines in the exacerbation of these conditions. While no therapy has been proven effective for treating NAFLD/NASH, common recommendations will be discussed.
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Miyahara K, Wang DH, Mori K, Takahashi K, Miyatake N, Wang BL, Takigawa T, Takaki J, Ogino K. Effect of sports activity on bone mineral density in wheelchair athletes. J Bone Miner Metab 2008; 26:101-6. [PMID: 18095071 DOI: 10.1007/s00774-007-0789-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Accepted: 06/29/2007] [Indexed: 11/26/2022]
Abstract
The present study carried out a measurement of body composition and a nutrition survey, targeting 28 male wheelchair athletes and comparing them with 25 male physically able healthy athletes as the controls. The DXA method was used to measure bone mineral density (BMD), percentage of body fat (% body fat), and lean body mass (LBM). Possible factors affecting the BMD of the wheelchair athletes with spinal injuries were analyzed including age, body part, type of sport, area of injury, length of injury, and the length of time it took before restarting sports activity after injury. BMD in the arms, body trunk, legs, and entire body was measured. There were no significant differences in the BMD of the wheelchair athletes by age group (from 20 to 29, from 30 to 39, and 40 years and older), by sports (basketball, track and field, and tennis), and by area of injury (high and low paraplegia). BMD in the legs (r = -0.549, P < 0.01), body trunk (r = -0.414, P < 0.05), and entire body (r = -0.452, P < 0.05) of the wheelchair athletes was negatively correlated with the period since injury; however, no such a relationship was observed in the arms. In addition, the multiple regression analysis for BMD of each body region showed that the earlier the wheelchair athletes restarted sports after injury, the higher values the BMD of legs (r = -0.467, P < 0.05), body trunk (r = -0.469, P < 0.05), and entire body (r = -0.488, P < 0.05), independent of age and sports. The leg BMD of the wheelchair athletes was lower than that of the physically able athletes, with a BMD 76.5% of the controls. The present study suggests that restarting sports activity in a timely manner after treatment and rehabilitation for the injury is useful in preventing loss of BMD in wheelchair athletes and ultimately improving their quality of life.
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Affiliation(s)
- Kimiko Miyahara
- Department of Public Health, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama 700-8558, Japan
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