Importance of vitamin D and calcium at older age

Emerging Parameters Justifying a Revised Quality Concept for Cow Milk

Milk has become a staple food product globally. Traditionally, milk quality assessment has been primarily focused on hygiene and composition to ensure its safety for consumption and processing. However, in recent years, the concept of milk quality has expanded to encompass a broader range of factors. Consumers now also consider animal welfare, environmental impact, and the presence of additional beneficial components in milk when assessing its quality. This shifting consumer demand has led to increased attention on the overall production and sourcing practices of milk. Reflecting on this trend, this review critically explores such novel quality parameters, offering insights into how such practices meet the modern consumer's holistic expectations. The multifaceted aspects of milk quality are examined, revealing the intertwined relationship between milk safety, compositional integrity, and the additional health benefits provided by milk's bioactive properties. By embracing sustainable farming practices, dairy farmers and processors are encouraged not only to fulfill but to anticipate consumer standards for premium milk quality. This comprehensive approach to milk quality underscores the necessity of adapting dairy production to address the evolving nutritional landscape and consumption patterns.

The influence of vitamin D on handgrip strength in elderly trauma patients

BACKGROUND AND OBJECTIVES

The treatment of elderly patients is an increasing challenge and the long-term sequelae often affect activities of daily living and quality of life in those patients. Handgrip strength (HGS) appears as a promising value to predict the outcome after trauma in elderly patients and to assess the overall muscle strength. Besides the possible role of psychological and hormonal factors, vitamin D may have a positive influence. Furthermore, some data suggest that Vitamin D is beneficial regarding muscle strength and possibly prevents further falls and injuries in orthogeriatric patients. The purpose of this study was to identify if Vitamin D is an influencing factor for HGSin elderly trauma patients.

MATERIALS AND METHODS

94 elderly patients in a Level I Trauma Center aged 60 years or older were prospectively enrolled and HGS as well as serum 25-OH Vitamin D concentration (VDC) were measured. In addition, the standardized questionnaires Barthel Index (BI), Parker Mobility Score (PMS), Short Physical Performance Battery (SPPB), Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls (SARC-F) and European Quality of Life 5 Dimensions 5 Levels Questionnaire (EQ-5D-5L), were used to record mental health status and demographic data.

RESULTS

HGS is mainly related to age and sex in elderly trauma patients. HGS was higher in men (mean_male = 27.31 kg (± 8.11), mean_female = 15.62 kg (± 5.63), p < 0.001 and decreased with age (β_age = - 0.58, p < 0.001). A significant negative correlation between HGS and VDC exists in the overall sample (β_VDC = - 0.27, p_VDC < 0.008), which still remains after adjusting for age (p_VDC < 0.004), but is not significant after adjustment for both main confounders, age and sex (p_VDC < 0.08). Furthermore, the HGS was lower in pateints who reported frequent falls, stumbling, dizziness or a late onset of menopause, and decreased if patients felt anxious or depressed during measurements (β_{anxiety+depression} = - 0.26, p_{anxiety+depression} < 0.01).

CONCLUSIONS

These results do not support the hypothesis that Vitamin D has a positive influence on muscle strength measured by HGS. Nevertheless, this study could confirm the usefulness of HGS as a tool to detect the risk for frequent falls or stumbling. Furthermore, HGS seems to be associated with dizziness and age at onset of menopause. A significant decrease of HGS could also be shown in patients with anxiety and depression. This underlines the importance of interdisciplinary treatment of elderly trauma patients and needs to be taken into account for further studies, as especially the psychological motivation seems to have a significant influence and is sometimes not considered enough in elderly musculo-skeletal patients.

Updates on Osteoporosis in Men

Osteoporosis is less common in men than women; however, the mortality rate associated with major fragility fractures is higher in men. The diagnosis of osteoporosis is established by measurement of bone mineral density or by the presence of a fragility fracture, especially spine or hip fracture. However, many men at high risk of fracture will not meet the T-score criteria for osteoporosis, so fracture risk calculation, with a tool such as FRAX, should be performed. Bone-active agents should be prescribed for men at high risk of fracture to decrease fracture risk, and therapy must be individualized.

Cardiovascular risk assessment in osteoporotic patients using osteoprotegerin as a reliable predictive biochemical marker

Osteoprotegerin (OPG), a member of the tumour necrosis factor receptor (TNFR) superfamily of proteins known to be involved in a large number of biological systems, plays a pivotal role in bone remodelling. In addition to the roles of OPG in bone metabolism, it has been reported to be associated with a high cardiovascular risk in patients with metabolic syndrome. In most cases, the exact functions of OPG remain to be established; however, the widespread expression of OPG suggests that this molecule may have multiple biological activities, mainly in the cardiometabolic environment. The aim of this study was to evaluate the value of OPG as a predictive marker for cardiovascular and metabolic risk in osteoporotic patients. The study group comprised patients with osteoporosis, in order to evaluate the association between OPG serum levels and cardiovascular pathology. Our results revealed significant correlations between classical biochemical bone and metabolic parameters, such as osteocalcin and parathyroid hormone with lipid and glucose biomarkers, sustaining the crosstalk between calcium and bone parameters and cardiovascular risk. The OPG serum level proved to have a significant and independent predictive value for metabolic syndrome (MetS) as a cardiovascular risk standard in osteoporotic patients. The OPG serum levels were increased in patients with MetS as a protective response against the atherosclerotic lesions. The serum levels of 25-hydroxy vitamin D had significant and independent predictive value for cardiovascular and metabolic risk in our subjects, sustaining the active role of vitamin D beyond the area of bone metabolism.

Does Milk Consumption Contribute to Cardiometabolic Health and Overall Diet Quality?

Although milk consumption is recommended in most dietary guidelines around the world, its contribution to overall diet quality remains a matter of debate in the scientific community as well as in the public domain. This article summarizes the discussion among experts in the field on the place of milk in a balanced healthy diet. The evidence to date suggests at least a neutral effect of milk intake on health outcomes. The possibility that milk intake is simply a marker of diets higher in nutritional quality cannot be ruled out. This review also identifies a number of key research gaps pertaining to the impact of milk consumption on health. These need to be addressed to better inform future dietary guidelines.

Acute effect of a supplemented milk drink on bone metabolism in healthy postmenopausal women is influenced by the metabolic syndrome

Background

Dietary factors acutely influence the rate of bone resorption, as demonstrated by changes in serum bone resorption markers. Dietary calcium exerts its effect by reducing parathyroid hormone levels while other components induce gut incretin hormones both of which reduce bone resorption markers. The impact of dietary calcium on bone turnover when energy metabolism is modulated such as in metabolic syndrome has not been explored. This study was designed investigate whether metabolic syndrome or a greater amount of visceral fat influences the impact of dietary calcium on bone turnover.

Methods

The influence of the metabolic syndrome on effects of dietary calcium on bone turnover in community dwelling postmenopausal women was studied. Twenty five volunteers consumed 200 mL of low fat milk with additional 560 mg calcium (one serve of Milo®) in the evening on one occasion. Fasting morning serum biochemistry before and after the milk drink with lumber spine bone density, bone mineral content, fat and lean mass using dual energy X-ray absorptiometry (DXA) and waist circumference were measured. The women were divided into 2 groups using the waist measurement of 88 cm, as a criterion of metabolic syndrome. Student’s t tests were used to determine significant differences between the 2 groups.

Results

The lumbar spine mineral content was higher in women with metabolic syndrome. After consuming the milk drink, serum bone resorption marker C terminal telopeptide (CTX) was suppressed to a significant extent in women with metabolic syndrome compared to those without.

Conclusions

The results suggests that dietary calcium may exert a greater suppression of bone resorption in post-menopausal women with metabolic syndrome than healthy women. Despite substantial evidence for close links between energy metabolism and bone metabolism this is the first report suggesting visceral fat or metabolic syndrome may influence the effects of dietary calcium on bone metabolism.

Multiple medication use in older patients in post-acute transitional care: a prospective cohort study

Background

Older adults with a range of comorbidities are often prescribed multiple medications, which may impact on their function and cognition and increase the potential for drug interactions and adverse events.

Aims

This study investigated the extent of polypharmacy and potentially inappropriate medications in patients receiving post-discharge transitional home care and explored the associations of polypharmacy with patient characteristics, functional outcomes, and frailty.

Methods

A prospective observational study was conducted of 351 patients discharged home from hospital with support from six Transition Care Program (TCP) sites in two states of Australia. A comprehensive geriatric assessment was conducted at TCP admission and discharge using the interRAI Home Care assessment tool, with frailty measured using an index of 57 accumulated deficits. Medications from hospital discharge summaries were coded using the World Health Organization Anatomical Therapeutic Chemical Classification System.

Results

Polypharmacy (5–9 drugs) was observed in 46.7% and hyperpolypharmacy (≥10 drugs) in 39.2% of patients. Increasing numbers of medications were associated with greater number of comorbid conditions, a higher prevalence of diabetes mellitus, coronary heart disease, chronic obstructive pulmonary disease, dizziness, and dyspnea and increased frailty. At discharge from the program, the non-polypharmacy group (<5 drugs) had improved outcomes in Activities of Daily Living, Instrumental Activities of Daily Living and fewer falls, which was mediated because of lower levels of frailty. The commonest drugs were analgesics (56.8%) and antiulcer drugs (52.7%). The commonest potentially inappropriate medications were tertiary tricyclic antidepressants.

Conclusion

Polypharmacy is common in older patients discharged from hospital. It is associated with frailty, falls, and poor functional outcomes. Efforts should be made to encourage regular medication reviews and rationalization of medications as part of discharge planning. Whether careful deprescribing improves outcomes in frail patients should be the focus of randomized trials.

Suboptimal vitamin D screening in older patients with compromised skeletal health

RATIONALE, AIMS AND OBJECTIVES

Increasing number of primary care visits for osteoporosis by older patients combined with new vitamin D screening recommendations necessitate primary care providers (PCPs) to identify and screen at-risk patients. We described prevalence and determinants of vitamin D screening among older patients treated for osteopoenia, osteoporosis and related fractures in academic outpatient primary care clinics (family medicine and geriatric medicine) in Houston, TX.

METHODS

Electronic chart review collected data on patients ≥50 years old from January 2008 to December 2010. Orders for serum 25-hydroxy vitamin D indicated vitamin D screening. Differences in patient characteristics were described between the groups with and without vitamin D screening. Age, body mass index, racial/ethnic background, bone-promoting medication (BPM) use and clinic types (family medicine versus geriatric medicine) were determinants for vitamin D screening in the regression analysis.

RESULTS

Patients were mostly women (95%), Caucasian (65%) and had a mean age of 69 ± 12 years. Twenty-two per cent of the family medicine clinic patients (total n = 78) and 51% of the geriatric medicine clinics patients (total n = 70) were screened. Older age (odds ratio, 0.94 confidence interval = 0.90-0.99) and BPM use (2.58, 1.03 to 6.45) were significant positive determinants for vitamin D screening.

CONCLUSIONS

In primary care clinics, vitamin D screening remains low among patients diagnosed with osteopoenia, osteoporosis and fractures. In light of new guidelines, suboptimal screening in the vulnerable older patients is disturbing. We recommend increased PCPs' awareness about vitamin D screening guidelines for improving skeletal health in older patients.

Diagnosis and treatment of osteoporosis in older adults

Osteoporosis in the elderly is a serious problem that is increasing as the population ages. Diagnosis is established by measurement of bone mineral density or by the presence of a fragility fracture, especially a spine or hip fracture. Bone-active agents should be prescribed for older patients with osteoporosis to decrease fracture risk. Nonskeletal risk factors for fracture and psychosocial impairment must be identified and managed, and therapy must be individualized.

Dietary vitamin D intake and muscle mass in older women. Results from a cross-sectional analysis of the EPIDOS study

OBJECTIVES

Vitamin D intake may prevent physical performance decline through prevention of muscle mass loss. Our objective was to determine whether low dietary intakes were associated with low muscle mass (MM).

DESIGN AND PARTICIPANTS

Cross-sectional analysis of 1989 community-dwelling women (mean age 80.5±3.8years) from the EPIDémiologie de l'OStéoporose (EPIDOS) study were assessed at baseline.

MEASUREMENTS

Low intakes of vitamin D (<70µg/week) were estimated from the weekly dietary vitamin D intakes (self-administered food frequency questionnaire). Low MM was defined according to the appendicular skeletal muscle mass index assessed using Dual Energy X-ray Absorptiometry, divided by square height of less than 5.45 kg/m2. Usual gait speed defined physical performance. Age, sun exposure, co-morbidities, education level, living arrangements, recreational physical activity, dietary protein and calcium intakes, bone mineral density, handgrip strength, and body mass index were considered as potential confounders. Multivariate logistic regression analyses assessed the association between low vitamin D intakes and low MM.

RESULTS

Two-hundred and nine (10.5%) women with low MM were compared to 1,780 women with normal MM. In final model, obesity/overweight (Adjusted Odds Ratios, aOR=0.09; 95%CI [0.05-0.17]), malnutrition (aOR=3.90; 95%CI [2.74-5.54]) and low handgrip strength (aOR=2.33; 95%CI [1.44-3.77]; p<0.001) were statistically associated with a low MM status.

CONCLUSION

No association with low MM has been reported regarding low dietary intakes of vitamin D.

Dairy in adulthood: from foods to nutrient interactions on bone and skeletal muscle health

The risk of fragility fractures exponentially increases with aging. Reduced mass and strength of both bone in osteoporosis and skeletal muscle in sarcopenia play a key role in the age-related incidence of fragility fractures. Undernutrition is often observed in the elderly, particularly in those subjects experiencing osteoporotic fractures, more likely as a cause than a consequence. Calcium (Ca), inorganic phosphate (Pi), vitamin D, and protein are nutrients that impact bone and skeletal muscle integrity. Deficiency in the supply of these nutrients increases with aging. Dairy foods are rich in Ca, Pi, and proteins and in many countries are fortified with vitamin D. Dairy foods are important souces of these nutrients and go a long way to meeting the recommendations, which increase with aging. This review emphaszes the interactions between these 4 nutrients, which, along with physical activity, act through cellular and physiological pathways favoring the maintenance of both bone and skeletal muscle structure and function.

Consumption of vitamin D-and calcium-fortified soft white cheese lowers the biochemical marker of bone resorption TRAP 5b in postmenopausal women at moderate risk of osteoporosis fracture

The prevention of increased bone remodeling in postmenopausal women at low 10-y risk of osteoporotic fractures essentially relies on reinforcement of environmental factors known to positively influence bone health, among which nutrition plays an important role. In institutionalized women in their mid-eighties, we previously found that consumption of fortified soft plain cheese increased vitamin D, calcium, and protein intakes, reduced bone resorption biochemical markers, particularly the serum bone specific acid phosphatase tartrate resistant acid phosphatase, isoform 5b (TRAP 5b) that reflects osteoclast activity, and stimulated the serum bone anabolic factor insulin-like growth factor-I (IGF-I). Whether these effects occur in much younger women was tested in a prospective control study. Seventy-one healthy postmenopausal women aged 56.6 ± 3.9 y (mean ± SD) with low spontaneous supply of both Ca and vitamin D were randomized to consume daily (treated, n = 36) or not (controls, n = 35) two servings (2 × 100 g) of skimmed-milk, soft plain cheese for 6 wk. The vitamin D and Ca-fortified dairy product provided daily: 661 kJ, 2.5 μg vitamin D, 400 mg calcium, and 13.8 g protein. At the end of the intervention, the decrease in TRAP 5b and the increase in IGF-I were greater in the treated than in the control group (P < 0.02). The changes in serum carboxy terminal crosslinked telopeptide of type I collagen did not differ significantly between the two groups. In conclusion, like in elderly women, consumption by healthy postmenopausal women of a vitamin D and calcium-fortified dairy product that also increases the protein intake, reduces the serum concentration of the bone resorption biomarker TRAP 5b. This response, combined with the increase in serum IGF-I, is compatible with a nutrition-induced reduction in postmenopausal bone loss rate.

[Initial treatment trends in patient with osteoporosis: use of antiresorptive agents and pharmacologic supplements (calcium and vitamin D) in clinical practice]

OBJECTIVE

To describe the percentage of prescription of pharmacologic supplements in patients starting antiresorptive treatment (ART) for osteoporosis by specialists.

DESIGN

Cross-sectional, naturalistic, multicenter study with retrospective data collection.

PATIENTS AND METHODS

88 Spanish primary care (PC) physicians participated as well as those from Bone Metabolism Unit / Rheumatology and Gynecology units. Patients were females with osteoporosis who started ART in the 12 to 36 months prior to the visit.

MAIN OUTCOMES

General clinical variables and those related to osteoporosis treatment (both ART and pharmacologic supplements) and an opinion survey on pharmacologic supplements.

RESULTS

480 patients were included. Mean age (SD) was 65.8 (9.2) years. Pharmacologic supplements were prescribed in 69.6% of patients and were more frequent in patients treated in Bone Metabolism/Rheumatology Units (89.1%) than patients treated by PC (60.3%) and Gynecology (55.6%). In the physician survey, 72% of the Bone Metabolism / Rheumatology Unit physicians responded that the Vitamin D supplements were necessary for treatment of osteoporosis vs. 38.5% of PC physicians (p=0.058).

CONCLUSIONS

The use of pharmacologic supplements in the onset of treatment with ART represents more than 60% of the sample, although differences were seen between specialists, with a greater percentage of patients with supplements in the Bone Metabolism/Rheumatology Units than in PC and Gynecology, despite guidelines primarily recommend the use of pharmacologic supplements in these patients.

Seasonal variation of serum 25-hydroxyvitamin D levels in adult patients with inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) are at risk of osteoporosis. Vitamin D (vitD) deficiency is known as a risk factor of osteoporosis. We observed low vitD blood levels in adult IBD patients both at the end of summer and winter. Furthermore, effects of oral vitD supplementation in (generally low) daily dosages were poor.

INTRODUCTION

Patients with IBD are at risk of osteoporosis. This study evaluates seasonal vitD status, determinants of vitD deficiency and effects of vitD supplementation in adult IBD patients.

METHODS

Patients were screened for vitD deficiency at the end of summer and winter using serum 25OHD(3) (cut-off point, <50 nmol/L) combined with routine laboratory tests. A standardized questionnaire was used for demographic/lifestyle data i.e. IBD activity, health behaviour and vitD intake through diet and ultraviolet light.

RESULTS

Late-summer, 39% of the included 316 patients were vitD deficient. Late-winter, 57% of the follow-up patients (n=281) were deficient. Independent protective determinants of vitD deficiency were oral vitD supplementation (summer/winter: odds ratio [OR], 0.52 [95% confidence interval [CI], 0.29-0.94]/OR, 0.44 [95% CI, 0.26-0.75]), recent sun holiday (summer: OR, 0.42 [95% CI, 0.24-0.74]) and regular solarium visits (summer/winter: OR, 0.28 [95% CI, 0.13-0.63]/OR, 0.17 [0.06-0.50]). IBD activity (p=0.031), red blood cell distribution width (RDW; p=0.04) and erythrocyte sedimentation rate (p=0.03) were associated with low vitD levels using univariate analyses of the extreme 25OHD quartiles. In a subgroup with vitD supplementation, still 30% (late-summer) and 44% (late-winter) were vitD deficient.

CONCLUSION

VitD deficiency is common in IBD patients, but prevalence might be comparable with the general population. Ultraviolet light is essential for adequate vitD levels. Effects of oral vitD supplementation in (generally low) daily dosages are poor. Determinants for low vitD levels were IBD activity and elevated inflammatory markers, suggesting that increased risk of osteoporosis in IBD might be more related to the inflammation than to vitD deficiency.

Nutritional approach for inhibiting bone resorption in institutionalized elderly women with vitamin D insufficiency and high prevalence of fracture

BACKGROUND

Nutritional approach to the deterioration of bone integrity and increased fracture risk appears to be particularly appropriate in elderly women living in nursing homes.

OBJECTIVE

To investigate the beneficial effect of the consumption of soft plain cheese on bone resorption markers in institutionalized elderly women.

DESIGN

Prospective, randomized crossover controlled study.

SETTING

Six French nursing homes or other institutions for elderly.

PARTICIPANTS

Institutionalized women ≥ 65 years old with low vitamin D status and calcium intake below 700 mg/day.

INTERVENTION

Consumption of soft plain cheese made of semi-skimmed milk which was fortified by both vitamin D3 (+1.25 µg/100g) and milk extracted Ca, thus achieving a total Ca content of 151 mg/100g as compared to about 118 mg/100g for standard fresh cheese. Two servings were taken every day during the 6 weeks that preceded or followed a period of 6 weeks without soft plain cheese consumption.

MEASUREMENTS

The primary end point was the change in serum carboxy terminal cross-linked telopeptide of type I collagen (CTX) selected as a marker of bone resorption.

RESULTS

29 women aged 73-94 yr were selected, 21 of them with mean age 87.2±6.1 years remained compliant. The intervention increased calcium and protein intakes by 51% (904±228 vs. 599±122 mg/d) and 33 % (74.2±17.1 vs. 55.6±12.7 g/d, mean±SD), respectively. The dietary intervention was associated with a statistically significant increase in serum levels of both 25OHD and IGF-I, while those of [corrected] CTX and TRAP5b were significantly reduced. Compliance was 93,4 %. The daily consumption of two servings of soft plain cheese was well accepted in terms of tastiness and appetite suited portion size.

CONCLUSION

This randomized crossover controlled trial demonstrates that in elderly women living in nursing homes, the consumption of soft plain cheese increasing the supply of vitamin D, calcium and proteins, could reduce bone resorption and thereby reduce the risk of incidental fragility fractures in the long term.

Asymptomatic severe hypocalcemia secondary to vitamin d deficiency in an elderly patient

Objective. To describe an asymptomatic presentation of severe hypocalcemia secondary to vitamin D deficiency in an elderly patient. Methods. We describe the presentation and clinical course of an elderly woman with asymptomatic severe hypocalcemia referred to an endocrinology clinic for hyperparathyroidism. Results. The patient is an 83-year-old Caucasian woman who presented to an endocrinology clinic for evaluation of hyperparathyroidism, with an intact PTH of 462 pg/mL (normal range 14-72 pg/mL). The same lab report included a serum calcium of 5.2 mg/dL (normal range 8-10.5 mg/dL). She displayed no signs or symptoms of hypocalcemia. Given the extreme severity of hypocalcemia and her age, she was hospitalized. Vitamin D deficiency was suspected and was subsequently confirmed with undetectable serum levels. The patient remained asymptomatic throughout her hospital stay. Total and ionized calcium levels at discharge were 7.2 mg/dL and 1.03 mmol/L (normal range 1.1-1.4 mmol/L), respectively. Conclusion. Physicians should exercise prudent management with respect to the vitamin D status of the elderly patient, as certain patients may exhibit severe hypovitaminosis D and hypocalcemia without apparent clinical symptoms.

Factors associated with use of calcium and calcium/vitamin D supplements in older Mexican Americans: Results of the Hispanic EPESE study

BACKGROUND

Current studies indicate that older Mexican Americans take fewer calcium or calcium/vitamin D supplements than do older non-Hispanic whites. Factors associated with calcium supplement use are not completely understood in this ethnic group.

OBJECTIVE

The purpose of this article was to determine the prevalence of calcium or calcium/vitamin D supplementation and factors associated with their use in older Mexican Americans.

METHODS

A cross-sectional survey was conducted in a random sample of older Mexican Americans residing in the southwestern United States who had participated in the Hispanic Established Populations for the Epidemiologic Study of the Elderly. Self-identified Mexican Americans >or=75 years of age were enrolled through household interviews in 2004-2005. Each subject was asked to bring all prescription and nonprescription medications that they had used regularly during the previous 2 weeks to allow the interviewer to record the product names. Dosages were not recorded. Subjects were assigned to 1 of 3 categories based on their use of calcium or calcium/vitamin D supplements during the previous 2 weeks: (1) calcium supplement only, (2) calcium/vitamin D supplement, or (3) vitamin D supplement only. The subjects' sociodemographic and cultural factors, self-reported health and functional status, cognitive status, number of comorbidities, and use of antiosteoporosis medications were recorded.

RESULTS

A total of 2069 older Mexican Americans (1272 women, 797 men; mean age, 81.9 years) were enrolled. The overall prevalence of calcium supplement use was 10.6% (weighted). Calcium supplements were used more often by women (odds ratio [OR] = 1.76; 95% CI, 1.17-2.63), subjects with multiple comorbidities (OR = 1.29; 95% CI, 1.10-1.50), those who interviewed in English (OR = 1.59; 95% CI, 1.06-2.40), and those who used antiosteoporosis medications (OR = 3.57; 95% CI, 1.85-6.89).

CONCLUSIONS

Use of calcium or calcium/vitamin D supplements was low (<60%) among this group of older Mexican Americans. Men are particularly at risk. More should be done to raise awareness regarding the benefits of calcium supplementation in this ethnic group.

Nutrition and Bone: It is More than Calcium and Vitamin D

Unlike pharmacological agents that are taken for proscribed periods of time, food and nutrient intakes have the possibility of affecting bone health over the entire lifespan. While deficiencies or excesses of individual nutrients have been shown to affect bone, it is likely that individual foods or dietary patterns have important effects related to skeletal health. While biochemical mechanisms exist to relate a deficiency of vitamin K to altered bone metabolism, clinical trials related to supplementation of this nutrient have been confusing. It is likely that these disparate results are related to the fact that interactions of nutrients have not been considered or the possibility that suboptimal nutrient status is a marker of poor nutritional status. Vitamin A excess has been postulated to be related to high fracture risk; however, it is likely that retinol is not the best marker for the proposed interaction. Altering whole food patterns, such as the Dietary Approaches to Stop Hypertension diet, have demonstrated beneficial effects on bone metabolism. Individuals who select some vegetarian patterns may need to consider supplementation with nutrients such as calcium and protein. Future studies should center on whole food and dietary patterns and their relationship to bone metabolism and fracture risk.