Calcaneal ultrasound measurements are determined by age and physical activity. Studies in two Swedish random population samples

Teriparatide treatment in severe osteoporosis - a controlled 10-year follow-up study

BACKGROUND

Teriparatide was the first anabolic agent recommended for the treatment of osteoporosis. Long-term real-world, controlled studies are not available. The purpose was to evaluate the long-term effects of treatment with teriparatide on fractures and Health Related Quality of Life in subjects with established osteoporosis in comparison with placebo treated patients with osteoporosis and the general population.

METHODS

A 10-year follow-up was performed after a prospective, open-labelled study with teriparatide 20 μg given subcutaneously daily for a mean of 18 months (range 14-24 months) in 40 women, mean age 69 years, with osteoporosis and vertebral compression. Placebo treated women, n = 25, mean age 60 years, from a randomized, double-blind, placebo-controlled growth hormone trial with daily subcutaneous injections for 18 months, with osteoporosis were used as controls. Dual energy x-ray absorptiometry and questionnaires were performed at start, after 18 months, after 36 months and after 10 years. Women, n = 233, of similar age from a random population sample, also served as controls and were followed in parallel. All fractures were X-ray verified.

RESULTS

Fractures decreased from 100 to 35% in the teriparatide treated patients (p < 0.0001) to similar levels as in the population sample, 25 to 28% at start and after 10 years, respectively. Bone mineral density increased on teriparatide but returned to levels at treatment start after 10 years. Health Related Quality of Life was lower in the teriparatide group than in the population (p < 0.001) before and, after treatment and at 10 years.

CONCLUSIONS

Anabolic hormonal treatment with teriparatide reduced fracture prevalence to similar levels as in the general population at 10 years' follow-up. Health Related Quality of Life was low in osteoporosis and unaffected by bone specific treatment.

The Prevalence of Osteopenia and Osteoporosis Among Malaysian Type 2 Diabetic Patients Using Quantitative Ultrasound Densitometer

Background:

Type 2 Diabetes Mellitus (T2DM) and osteoporosis are both chronic conditions and the relationship between them is complex.

Objective:

The aims of this study were to assess the prevalence of Low Bone Mineral density (LBMD, i.e., osteopenia and osteoporosis), as well as, the difference and associations between Quantitative Ultrasound Scan (QUS) parameters with socio-demographic data and clinical related data among T2DM in Penang, Malaysia.

Method:

An observational, cross-sectional study with a convenient sample of 450 T2DM patients were recruited from the outpatient diabetes clinic at Hospital Pulau Pinang (HPP) to measure Bone Mineral Density (BMD) at the heel bone using QUS. In addition, a self-reported structured questionnaire about the socio-demographic data and osteoporosis risk factors were collected. Moreover, the study included the retrospective collection of clinical data from patients’ medical records.

Results:

The mean value of T-score for normal BMD, osteopenic and osteoporotic patients’ were (-0.41±0.44), (-1.65±0.39) and (-2.76±0.27), respectively. According to QUS measurements, more than three quarters of T2DM patients (82%) were at high risk of abnormal BMD. The results showed that QUS scores were significantly associated with age, gender, menopausal duration, educational level and diabetic related data. Moreover, the QUS parameters and T-scores demonstrated significant negative correlation with age, menopausal duration, diabetic duration and glycaemic control, as well as, a positive correlation with body mass index and waist to hip ratio. The current study revealed that none of the cardiovascular disease risk factors appear to influence the prevalence of low BMD among T2DM Malaysian patients.

Conclusion:

The study findings revealed that the assessment of T2DM patients’ bone health and related factor are essential and future educational programs are crucial to improve osteoporosis management.

Urinary free cortisol and androgens in the population-Hormone interactions and the relationship with body composition and bone status

OBJECTIVE

Abnormal secretion of thyroid hormones, growth hormone, cortisol and androgens influences body composition. We hypothesised that higher cortisol excretion, in combination with higher androgen and IGF-I concentrations, had a synergistic, favourable effect on body mass and bone.

DESIGN, PATIENTS AND METHODS

This was a cross-sectional study on a population sample of 290 women and 93men. The mean age was 65.4±7.2yearsinwomen and 59.7±10.0yearsinmen. Body composition was assessed with bioimpedance, and skeletal health with calcaneal quantitative ultrasound and fracture rate. The influence of urinary free cortisol (UFC), serum DHEAs (women), testosterone (men), free T4andIGF-I on the outcome was studied with regression analyses adjusted for age and body mass index.

RESULTS

In women, higher concentrations of UFC, DHEAs, IGF-I and lower free T4, were associated with higher fat-free mass. Only a higher UFC concentration was associated with favourable calcaneal measurements. In men, higher testosterone was associated with higher fat-free mass and lower fat mass. Higher IGF-I concentration, but not UFC, was independently associated with higher fat-free mass in men. Interaction analyses did not reveal any additive effects of hormones on body composition or bone in either sex. In both men and women, only age was associated with osteoporotic fractures.

CONCLUSION

Serum concentrations of androgens together with IGF-I were positively associated with body composition in both sexes. Urinary cortisol was positively associated with fat-free mass and bone status in women only. Increasing age, but not hormones, was the major determinant of osteoporotic fractures in this population sample.

Effect of self-reported walking difficulty on bone mass and bone resorption marker in Japanese people aged 40 years and over

Background

This study aimed to examine the association of walking difficulty with bone mass or bone turnover among community-dwelling Japanese people aged 40 years and older.

Methods

We studied 1097 community-dwelling Japanese people aged 40 years and older (379 men and 718 women) who were invited to participate in periodic health examinations in 2006–2009. Walking difficulty was defined as having difficulty walking 100 m on a level surface (self-administered questionnaire). Calcaneal stiffness index (bone mass) was measured by quantitative ultrasound. Spot urine samples were collected, and urinary N-terminal cross-linking telopeptide of type I collagen (NTx) was measured. Values were corrected for creatinine (Cre) concentration.

Results

The prevalence of walking difficulty was significantly higher in women than in men (7.4 vs. 3.4 %, p = 0.011) and significantly increased with age in men (p for trend = 0.02) and women (p for trend <0.001). In univariate analysis, men and women with walking difficulty were older (p < 0.001) and had a lower stiffness index (p < 0.001), compared with those without walking difficulty. Among women, individuals with walking difficulty had significantly higher urinary NTx/Cre than those without walking difficulty (p < 0.001); however, this was not so among men (p = 0.39). Multiple regression analysis adjusted for age, weight, and menopausal status showed a significant association between walking difficulty and lower stiffness index in men (p = 0.004) and women (p = 0.005). In women, walking difficulty was significantly associated with higher NTx/Cre (p = 0.001), but not in men (p = 0.35).

Conclusions

Walking difficulty may contribute to low bone mass in both sexes but might cause high bone turnover in women only.

Peak Bone Mass and Quantitative Ultrasound Bone Properties in Young Adulthood: A Study in the PEAK-25 Cohort of Women

Peak bone mass is normally reached in the third decade of life. Previously, in the population-based PEAK-25 cohort (n = 1061, age 25.5 ± 0.2), we demonstrated that bone mineral density in the population-based PEAK-25 cohort is comparatively high; therefore, this study aimed to determine if the calcaneus microarchitecture mirrored this. In the process, we describe normative quantitative ultrasound (QUS) values for 25-yr-old women and the relationship between QUS values and extremes of body weight. QUS variables speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness index were measured. Young adult values were based on the manufacturer-supplied QUS reference values. Analyses were performed in the cohort as a whole, and additionally, to understand the relationship between body weight and QUS values in young women, the variables were categorized into octiles for weight or body mass index (BMI) and the lowest and highest octiles were compared. In the cohort, SOS values, reflecting bone density, were higher (108 ± 18%), whereas BUA values, reflecting bone complexity, were lower (90 ± 14%) compared to the young adult reference population. SOS did not correlate with body weight or BMI. In the cohort, overall correlations between BUA weight, and BMI were small and positive (Pearson's r coefficients 0.261 and 0.197, respectively; p < 0.001), although in the low-weight group, r coefficients were higher (r = 0.313 and 0.268; p < 0.05). In contrast, in the high-weight group, correlation with BUA values tended to be small, negative, and nonsignificant. Correlation between QUS and dual-energy X-ray absorptiometry-measured bone mineral density was low to moderate and significant at all skeletal sites (r = 0.37-0.52). Whereas coefficients tended to be higher in the low-weight group, the reverse was apparent for the low-BMI group. In these 25-yr-old women, a comparatively high dual-energy X-ray absorptiometry-measured bone mass is offset by less complex bone structures assessed by QUS. This may have implications for later osteoporosis assessment and future fracture risk.

Is calcaneal stiffness more sensitive to physical activity than forearm bone mineral density? A population-based study of persons aged 20 - 79 years

Aims: The aim of this study was to investigate the associations between forearm bone mineral density (BMD), calcaneal stiffness, and physical activity levels in a normal population using different non-invasive methods. Methods: The participants were invited to undergo bone measurements using single photon absorptiometry of the forearm and quantitative ultrasound (QUS) of the calcaneal bone, and also to complete a questionnaire. Physical activity levels were designated low, moderate, and high in the question on leisure-time activity. Results: There were 956 participants included in the present study. Forearm BMD in the eighth age decade was 0.40 g/cm2 (95% CI 0.33 - 0.46 g/cm2) lower than in the third decade among women and 0.28 g/cm2 (95% CI 0.18 - 0.37 g/cm2) lower among men. The differences in calcaneal stiffness between the same age decades were 22.4 (95% CI 17.5 - 27.4) among women and 15.8 (95% CI 8.0 - 23.5) among men. The correlation between forearm BMD and calcaneal stiffness was 0.58 (95% CI 0.52 - 0.64) in women and 0.34 (95% CI 0.25 - 0.42) in men. Reported moderate and high leisure-time activity levels in both genders were associated with higher calcaneal stiffness but not with forearm BMD. Conclusions: The QUS may be used to measure the effect of present physical activity levels on calcaneal bone at the population level. Further longitudinal studies are warranted in order to determine the most appropriate non-invasive method in population-based studies.

Physical Activity, Bone Health, and Obesity in Peri-/Pre- and Postmenopausal Women: Results from the EPIC-Potsdam Study

Physical activity (PA) is suggested to increase the peak bone mass and to minimize age-related bone loss, and thereby to reduce the risk of osteoporosis. However, the relation between PA and bone health considering the obesity status is unclear so far. The present study examines the association between PA levels and calcaneal broadband ultrasound attenuation (BUA), particularly under consideration of obesity. Data from a population-based sample of 6776 German women from the EPIC-Potsdam cohort were analyzed. Calibrated PA data were used. Statistical analyses were stratified by menopausal and obesity status. Multiple linear regression was used to model the relationship between PA and BUA levels after adjustment for age, body mass index (BMI), smoking status, education, alcohol and calcium intake, and hormone use. Peri-/premenopausal had higher BUA levels (112.39 ± 10.05 dB/MHz) compared to postmenopausal women (106.44 ± 9.95 dB/MHz). In both groups, BUA levels were higher in the fourth compared to the lowest quartile of PA (p for trend < 0.05). In women with BMI < 30, but not BMI ≥ 30 kg/m(2), PA remained positively associated with BUA levels (p for interaction = 0.03). However, when waist circumference higher than 88 cm or body fat percentage (BF%) measures above the median were used to define obesity, a significant positive relationship was also observed in women with BMI < 30 kg/m(2) but with higher waist circumference or BF%. In conclusion, our results strengthen the hypothesis that PA has a positive influence on BUA levels, though dependent on weight.

The association between urinary cortisol excretion and cardiovascular risk factors, bone status and quality of life in the population

OBJECTIVE

Patients with glucocorticoid excess have increased cardiovascular risk, decreased bone mineral density and impaired quality of life (QoL). The aim of this study was to evaluate the association between urinary cortisol excretion and cardiovascular risk factors, bone status and QoL in the population. We hypothesized that higher cortisol excretion was associated with adverse cardiovascular risk profile, worse skeletal health and QoL.

DESIGN, PATIENTS AND METHODS

This was a cross-sectional study including a population sample (n=348), aged 38-77years. The mean age in women was 64.0±8.5years (n=276) and 60.3±10.2years in men (n=72). The metabolic syndrome, body composition measured with bioimpedance, calcaneal quantitative ultrasound, fractures and QoL evaluated with the Nottingham Health Profile, Psychological General Well-Being (PGWB) and the Short Form 36 (SF-36) were studied. Urinary free cortisol (UFC) was measured using radioimmunoassay.

RESULTS

UFC was higher in men (230±120nmol/L) compared to women (153±71; P<0.001) and decreased with increasing age (P<0.001). In a regression analysis, after adjustment for gender, age and body mass index, higher UFC was associated with higher fat-free mass (P<0.01), favourable calcaneal bone measurements (P<0.05), better general health measured with PGWB (P<0.01) and SF-36 (P=0.001) and tended to be negatively associated with the metabolic syndrome (P=0.07).

CONCLUSION

In contrast to our hypothesis, UFC in the upper physiological range was associated with a favourable cardiovascular risk profile, bone measures and QoL.

Effect of Growth Hormone Treatment on Fractures and Quality of Life in Postmenopausal Osteoporosis: A 10-Year Follow-Up Study

CONTEXT

Growth hormone (GH) treatment increases bone mineral density (BMD) in women with postmenopausal osteoporosis.

OBJECTIVE

The objective was to report bone data, fractures, and quality of life (QoL) in a 10-year follow-up of women who had received GH for 3 years and compared with controls followed in parallel.

DESIGN AND SETTING

A follow-up of a double-blind, placebo-controlled study conducted at Sahlgrenska University Hospital was performed.

PATIENTS

Eighty women aged between 50 and 70 years with osteoporosis and estrogen hormone replacement were studied and compared with an age-matched random population sample of women (n = 120) from the World Health Organization Monitoring of Trends and Determinants in Cardiovascular Disease project (Gothenburg, Sweden).

INTERVENTIONS

Patients were randomized to GH 1.0 U or GH 2.5 U recombinant human GH or placebo sc daily during 3 years. All received calcium 750 mg and vitamin D 400 U and were followed up during 10 years.

MAIN OUTCOME MEASURES

BMD and bone mineral content were measured with dual-energy X-ray absorptiometry. QoL was estimated with the 36-item Short Form.

RESULTS

GH increased BMD and bone mineral content dose dependently in all regions (P = .01, GH 1.0 U, and P = .0006, GH 2.5 U vs placebo). After 10 years the number of fractures decreased from 56% to 28% (P = .0003) in patients evenly distributed between groups. In controls, fractures increased from 8% to 32% (P = .0008). QoL did not change during GH treatment or during the 10-year follow-up and did not differ compared with controls.

CONCLUSION

GH treatment was beneficial for bone and fracture outcome after 10 years but did not affect the QoL of the women with postmenopausal osteoporosis.

Quantitative ultrasound measurements of the calcaneus and hand phalanges in elderly Spanish men: relationship with peripheral bone mineral density of the hand phalanges

OBJECTIVES

The aims of this pilot study were to describe quantitative ultrasound (US) measurements and peripheral bone mineral density (BMD) of the hand phalanges on dual-energy x-ray absorptiometry and to examine the correlations between them in elderly Spanish men.

METHODS

We studied 199 healthy men (mean age ± SD, 73.31 ± 5.10 years). The participants were not taking any medications, and they reported no diseases, including diseases that are associated with abnormalities in mineral metabolism. Phalangeal and calcaneal quantitative US measurements and phalangeal BMD measurements were performed in all participants.

RESULTS

A bivariate correlation analysis showed no association between quantitative US assessments at the phalanges or the calcaneus (P = .409). After adjustment for potential confounders, the correlation between phalangeal BMD and phalangeal quantitative US measurements was r = 0.417 (P < .0001), and the correlation for calcaneal quantitative US was r = 0.26 (P = .001). Further adjustment by percentage of body fat increased quantitative US correlations with phalangeal BMD: r = 0.450 (P < .0001) at the phalanges; r = 0.291 (P = .001) at the calcaneus.

CONCLUSIONS

There is a small correlation between quantitative US measurements at the calcaneus and phalangeal BMD that increases to a moderate level with quantitative US measurements at the phalanges in elderly Spanish men.

Discrepancy in bone mineral densities at different skeletal sites in hip osteoarthritis patients

OBJECTIVE: Increased femoral neck bone mineral density (BMD) in a hip with osteoarthritis (OA) has been previously reported, however, it is possible that increased BMD at sites other than the hip joint is influenced by the disease process of OA. Therefore, we measured BMD at locations different from the hip joint and determined whether higher BMD was also observed at these different skeletal sites in hip OA patients. METHODS: We measured BMD in 68 women (average age 61.0 years) scheduled to undergo total hip arthroplasty for end-stage OA and 100 healthy women (average age 60.9 years) as age-matched controls. BMD at the lumbar spine, radius, and calcaneus was measured by dual-energy X-ray absorptiometry (DXA). Moreover, we measured speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness index of the calcaneus by quantitative ultrasonography (QUS). RESULTS: BMD obtained by DXA at the lumbar spine and radius was significantly higher in hip OA patients than in controls. However, at the calcaneus, no significant differences were observed between the groups in BMD obtained by DXA. SOS, BUA, and stiffness index obtained by QUS were significantly lower in the OA group than in controls. CONCLUSION: Higher BMDs of the spine and radius suggest that the incidence of osteoporosis is inversely associated with the incidence of OA. However, it remains unclear whether lack of difference in BMD and lower SOS, BUA, and stiffness index of the calcaneus in the OA group was secondary to the effect walking disturbance resulting from hip pain. Our data suggest that hip OA patients have higher BMD than healthy women, and that inactivity or immobilization caused by hip OA may reduce BMD in the lower limb.

Calcaneal ultrasound reference ranges for Australian men and women: the Geelong Osteoporosis Study

Heel ultrasound is a more portable modality for assessing fracture risk than dual-energy X-ray absorptiometry and does not use ionising radiation. Fracture risk assessment requires appropriate reference data to enable comparisons. This study reports the first heel ultrasound reference ranges for the Australian population.

INTRODUCTION

This study aimed to develop calcaneal (heel) ultrasound reference ranges for the Australian adult population using a population-based random sample.

METHODS

Men and women aged≥20 years were randomly selected from the Barwon Statistical Division in 2001-2006 and 1993-1997, respectively, using the electoral roll. Broadband ultrasound attenuation (BUA), speed of sound (SOS) and stiffness index (SI) were measured at the heel using a Lunar Achilles Ultrasonometer. Gender-specific means and standard deviations for BUA, SOS and SI were calculated for the entire sample (men 20-93 years, n=1,104; women 20-92 years, n=914) and for participants aged 20-29 years (men, n=157; women, n=151). Associations between ultrasound measures and age were examined using linear regression.

RESULTS

For men, mean±standard deviation BUA, SOS and SI were 118.7±15.8 dB/MHz, 1,577.0±43.7 m/s and 100.5±20.7, respectively; values for women were consistently lower (111.0±16.4 dB/MHz, P<0.001; 1,571.0±39.0 m/s, P=0.001; and 93.7±20.3, P<0.001, respectively). BUA was higher in young men compared with young women (124.5±14.4 vs 121.0±15.1 dB/MHz), but SOS (1,590.1±43.1 vs 1,592.5±35.0 m/s) and SI (108.0±19.9 vs 106.3±17.7) were not. The relationships between age and each ultrasound measure were linear and negative across the age range in men; associations were also negative in women but non-linear.

CONCLUSION

These data provide reference standards to facilitate the assessment of fracture risk in an Australian population using heel ultrasound.

Body composition, bone mineral density and fractures in late postmenopausal women with polycystic ovary syndrome - a long-term follow-up study

OBJECTIVE

Hyperandrogenism is one of the characteristic features of the polycystic ovary syndrome (PCOS). Androgens are important for bone mass. Studies on bone mineral density (BMD) and fractures in postmenopausal women with PCOS are lacking. The aim of this study was to investigate whether postmenopausal women with PCOS differ from controls regarding body composition, BMD and prevalence of fractures, and to compare women with PCOS with controls regarding correlations between total BMD and sex hormones.

DESIGN

A prospective 21-year follow-up study. Anthropometry, hormonal measurements and questionnaires were performed in 1987 and in 2008. Fractures were X-ray-verified. BMD measurements were taken in 1992, using single-photon absorptiometry (SPA), and in 2008, using dual-energy X-ray absorptiometry (DXA), to also enable measurements of body composition.

PATIENTS

Twenty-five women with PCOS (Rotterdam criteria), aged 61-78 years, and 68 randomly allocated age-matched controls.

MEASUREMENTS

Body composition, BMD, fractures and sex steroids.

RESULTS

At follow-up, the postmenopausal women with PCOS maintained a higher free androgen index (FAI), but had similar body fat, lean mass and BMD compared with controls. The hip circumference increased only in women with PCOS (P < 0·01), during follow-up. The fracture incidence was similar to that of controls (56% vs 41%, ns). In the controls, total BMD was positively correlated with oestradiol (R = 0·322, P < 0·01) and FAI (R = 0·307, P < 0·05) and negatively correlated with SHBG (R = -0·429, P < 0·001), but not in the women with PCOS.

CONCLUSIONS

Postmenopausal women with PCOS with persistently higher FAI had similar muscle mass, BMD and fracture incidence as controls during this long-term follow-up.

The effects of age, physical activity level, and body anthropometry on calcaneal speed of sound value in men

The influences of age, physical activity, and body anthropometry on calcaneal speed of sound are different among young adults, middle-aged, and elderly men.

INTRODUCTION

Quantitative ultrasound assessment of bone health status is much needed for developing countries in the screening of osteoporosis, but further studies on the factors that influence the quantitative ultrasound indices are required.

OBJECTIVES

The present study examined the influence of age, lifestyle factors, and body anthropometry on calcaneal speed of sound (SOS) in a group of Malaysian men of diverse age range.

SUBJECTS AND METHODS

A cross-sectional study was conducted, and data from 687 eligible males were used for analysis. They answered a detailed questionnaire on their physical activity status, and their anthropometric measurements were taken. Their calcaneal SOS values were evaluated using the CM-200 sonometer (Furuno, Nishinomiya City, Japan).

RESULTS

Subjects with higher body mass index (BMI) had higher calcaneal SOS values albeit significant difference was only found in the elderly subjects (p < 0.05). Sedentary subjects had lower calcaneal SOS values than physically active subjects, but significant difference was only found in the middle-aged subjects (p < 0.05). Calcaneal SOS was significantly (p < 0.05) correlated with age in young men; height, BMI, and physical activity score in middle-aged men; height and physical activity score in elderly men; and age and physical activity score for overall subjects. In a multivariate regression model, significant (p < 0.05) predictors for calcaneal SOS included age for young men; physical activity, BMI, body fat percentage, and height for middle-aged men; height for elderly men; and age, height, physical activity, weight, and body fat percentage for overall subjects.

CONCLUSION

Age, body anthropometry, and physical activity level have significant effects on the calcaneal SOS value in men.

Secular trends in sex hormones and fractures in men and women

OBJECTIVE

To study secular trends in sex hormones, anthropometry, bone measures and fractures.

DESIGN

A random population sample was studied twice and subjects of similar age group were compared 13 years apart.

METHODS

X-ray-verified fractures were retrieved from a random population sample of 2400 men and women (participants 1616=67%) aged 25-64 years from the WHO, MONICA Project in Gothenburg, Sweden, in 1995 and 2008. Fasting serum hormones and calcaneal ultrasound were measured in every fourth subject. In fertile women, measurements were performed on cycle day interval 7-9.

RESULTS

In 2008, men had lower serum free testosterone than men of similar age in 1995 (P<0.001). Body composition, physical activity and fracture incidence were similar. In women, hormone replacement therapy (HRT) was lower in 2008, 7 vs 28% (P<0.0001), as was serum oestradiol, although use of tranquilisers and leisure time physical activity were higher. In 2008, the fracture incidence was higher in postmenopausal women, 29 vs 17% (P<0.001), and vertebral crush had increased from 8 to 19% of all fractures (P=0.031). Serum cholesterol and triglycerides were lower in all subjects in 2008 compared with that in 1995.

CONCLUSIONS

Secular trends were observed with lower serum testosterone in men in 2008, but no effect was seen on the fracture incidence of these fairly young men. In postmenopausal women in 2008, there was a higher fracture incidence along with more vertebral compressions. Lower HRT use, lower serum oestradiol and higher fall risk exposure due with more tranquilisers and leisure time physical activity in 2008 may explain the results.

Impact of age, anthropometric data and body composition on calcaneal bone characteristics, as measured by quantitative ultrasound (QUS) in an older German population

The impact of fat-free mass (FFM), fat mass (FM), body mass index (BMI), body mass and body height on calcaneal bone characteristics as measured with quantitative ultrasound (QUS) was investigated in 137 women and 85 men aged 62-92 years, considering age, smoking, waist-to-hip ratio (WHR) and physical activity level (PAL). In regression analyses using various models, in women, age was a negative predictor of speed of sound (SOS), broadband ultrasound attenuation (BUA) and stiffness index (SI) and smoking was a negative predictor of SOS; positive predictors of SOS, BUA, and SI were BMI, body mass and FFM. In men, smoking was a negative predictor and BMI, body mass and FFM were positive predictors of BUA and SI. In both sexes, PAL, body height, WHR and FM had no effect on QUS parameters. The influence of BMI on calcaneal bone characteristics in elderly people depends on FFM rather than on FM.

Influence of Lifestyle Factors on Quantitative Heel Ultrasound Measurements in Middle-Aged and Elderly Men

We examined the distribution of quantitative heel ultrasound (QUS) parameters in population samples of European men and looked at the influence of lifestyle factors on the occurrence of these parameters. Men aged between 40 and 79 years were recruited from eight European centers and invited to attend for an interviewer-assisted questionnaire, assessment of physical performance, and quantitative ultrasound (QUS) of the calcaneus (Hologic; Sahara). The relationships between QUS parameters and lifestyle variables were assessed using linear regression with adjustments for age, center, and weight. Three thousand two hundred fifty-eight men, mean age 60.0 years, were included in the analysis. A higher PASE score (upper vs. lower tertile) was associated with a higher BUA (β coefficient = 2.44 dB/Mhz), SOS (β = 6.83 m/s), and QUI (β = 3.87). Compared to those who were inactive, those who walked or cycled more than an hour per day had a higher BUA (β = 3.71 dB/Mhz), SOS (β = 6.97 m/s), and QUI (β = 4.50). A longer time to walk 50 ft was linked with a lower BUA (β = -0.62 dB/Mhz), SOS (β = -1.06 m/s), and QUI (β = -0.69). Smoking was associated with a reduction in BUA, SOS, and QUI. There was a U-shaped association with frequency of alcohol consumption. Modification of lifestyle, including increasing physical activity and stopping smoking, may help optimize bone strength and reduce the risk of fracture in middle-aged and elderly European men.

Vitamin D status and common risk factors for bone fragility as determinants of quantitative ultrasound variables in a nationally representative population sample

Calcaneal quantitative ultrasound (QUS) can predict bone strength and fracture risk. Bone fragility has no single cause but results from a complex interplay of several etiologic or contributing factors. Vitamin D is essential for bone health even though it is still unclear how much of this vitamin is required to maintain bone strength and prevent fractures. Measurements of serum 25-hydroxyvitamin D [S-25(OH)D] have indicated a high prevalence of inadequate vitamin D status in a number of studies mostly based on selected study populations. The objective of this study was to examine the associations between S-25(OH)D, common risk factors for bone fragility, and QUS variables in a large unselected population sample. The study population consisted of 2736 men and 3299 women from a nationally representative population sample, aged 30 years or over. Information on lifestyle was elicited by means of interviews and questionnaires. Body fat mass was estimated using an impedance-meter. S-25(OH)D was measured by radioimmunoassay. Calcaneal QUS was performed on the Hologic Sahara apparatus recording broadband ultrasound attenuation (BUA) and speed of sound (SOS). The potential determinants of BUA and SOS were analysed using separate multiple linear regression models for men and women. S-25(OH)D proved to be an independent determinant of BUA (P<0.0001 for men, P<0.001 for women) and SOS (P<0.0001 for men, P<0.05 for women). BUA was also independently associated with age, height, weight, alcohol consumption, and postmenopausal status in women, and with weight, alcohol consumption, smoking and physical activity in men. All of the above variables, except for weight in women, were also found to be independent determinants of SOS in both men and women. A reverse association was found between S-25(OH)D and adiposity in spite of higher intakes of vitamin D in those with higher fat mass. In this unselected sample of men and women, vitamin D status, several lifestyle factors and physical characteristics proved to be significant determinants of BUA and SOS. Inadequate vitamin D status was common, and measures ensuring adequate intakes of vitamin D in the population thus deserve continued attention. Obesity should be taken into account in future assessments of vitamin D status in Finland as in other countries.

Associations of daily walking steps with calcaneal ultrasound parameters and a bone resorption marker in elderly Japanese women

Quantitative ultrasound (QUS) parameters of the calcaneus and bone resorption markers predict osteoporotic fractures. High levels of physical activity have positive effects on bone health. The purpose of this cross-sectional study was to investigate the effects of daily walking activity (number of steps taken), as an outcome of physical activity, on QUS parameters of the calcaneus and urinary deoxypyridinoline (DPD) in elderly Japanese women. The subjects were 113 postmenopausal women aged 60-85 years. The speed of sound (SOS), broadband ultrasound attenuation (BUA), and the stiffness index (Stiffness) of the calcaneus were measured with A-1000 (GE-Lunar, USA). Spot urine samples were collected between 09:00 and 10:00, and the levels of urinary DPD were measured. The subjects were instructed to wear a pedometer during waking hours for 7 consecutive days. In univariate analyses, steps/day significantly decreased with aging (r=-0.306, p<0.001). Steps/day showed significant positive correlations with SOS (r=0.252, p<0.01) and Stiffness (r=0.258, p<0.01). There was a significant decrease in DPD with steps/day (r=-0.262, p<0.01). These effects of walking on QUS parameters and DPD remained significant after adjustment for confounding factors by multiple regression analyses. We conclude that high levels of walking activity may be effective in both maintaining the levels of QUS parameters and reducing bone resorption, and hence preserve bone health in elderly women.

Quantitative ultrasound calcaneous measurements: normative data for the Italian population. the ESOPO study

Quantitative ultrasound (QUS) is a reliable technique to evaluate skeletal status, to identify osteoporotic subjects, and to estimate the risk of fractures. The purpose of this study was to generate QUS normative data for Italian females and males aged 60-79 yr participating in the Epidemiologic Study on the Prevalence of Osteoporosis (ESOPO) study, using the Achilles Plus apparatus. ESOPO is a cross-sectional study conducted in 2000, aiming at assessing risk of osteoporosis in a random sample of 11,011 women and 4981 men, representative of the Italian population. All participants were administered a questionnaire on the most relevant risk factors for osteoporosis and fractures; 3 QUS parameters were also measured: broadband ultrasound attenuation (BUA); speed of sound (SOS); and Stiffness Index (SI). We studied the age-dependent changes in QUS values, and their correlation with body size. For both men and women, weight was the variable with the highest correlation with BUA and SI; for SOS, age among women and body mass index (BMI) among men presented the highest correlation coefficients. Average decreases of 3.0% in BUA, 0.8% in SOS, and 9.1% in SI from 60 to 79 yr were detected for females, whereas no significant changes with age in males were observed. Our data show lower QUS values for women, and a decline at a greater rate than in men.

Quantitative ultrasound variables of the heel in Finnish men aged 18-20 yr: predictors, relationship to bone mineral content, and changes during military service

INTRODUCTION

Determinants of BUA and SOS and their changes during military service-associated physical training were studied in 196 army recruits and 50 control men, aged 18-20 years.

METHODS

Heel ultrasound measurement, DXA, muscle strength test, Cooper's running test and genetic analyses were performed. Lifestyle factors were recorded. Sex steroids and bone turnover markers were determined. Heel ultrasound was repeated after six months.

RESULTS

Exercise was the most significant determinant of both BUA (p<0.0001) and SOS (p<0.0001). There were 10% and 1.3% differences in BUA (p=0.006) and SOS (p=0.0001), respectively, between men belonging to the lowest and highest quartiles of exercise index. Weight associated with BUA (p=0.005) and height with SOS (p=0.03). BUA and SOS correlated with BMC and BMD (p<0.0001) but explained only up to 21% of their variance. Over six months SOS increased more in recruits than in control men (p=0.0043), the increase being higher, the lower muscle strength at baseline (r =-0.27, p=0.0028).

CONCLUSION

Exercise is the most important determinant of ultrasonographic variables in men, aged 18-20 years. Physical loading during military training increases SOS.

Prevalência de desvios-padrão determinados pela ultra-sonometria de calcâneo e sua associação com índice de massa corporal e idade em mulheres pós-menopáusicas residentes em Manaus-AM

Resumo O envelhecimento populacional aumenta o número de idosos e a prevalência de doenças como osteoporose, que está associada a fraturas. Para esse tipo de avaliação, a ultra-sonometria de calcâneo (USO) poderia ser uma boa alternativa, porque é barata, fácil de ser medida e não expõe os indivíduos à radiação. O estudo apresentado estimou a prevalência de três diferentes grupos de desvio-padrão (DP<-1, DP<-1<-2,5 e DP<-2,5), determinados pela USO e sua associação com idade e índice de massa corporal (IMC) em mulheres idosas que vivem na comunidade de Manaus-AM. O delineamento foi do tipo retrospectivo, observacional e descritivo, em 997 mulheres que fizeram o exame de USO de calcâneo e foram classificadas nos três grupos (DP <-2,5, SD >-1<-2,5DP e SD <-1). A prevalência dos grupos DP foi: DP<-2,5 = 23,0% (229), DP<-1<2,5 = 53,2% (530) e DP<-2,5 = 23,6% (238). Mulheres com DP<-2,5 apresentaram valores de IMC significativamente mais baixos (p=0,016) e também idade mais elevada (p=0,007). Os resultados sugerem associação da USO com IMC e idade avançada, corroborando estudos previamente publicados na literatura. O estudo corrobora a possibilidade de utilização da USO em levantamentos epidemiológicos.

Assessment of low quantitative ultrasound values of calcaneus in Chinese mainland women

Calcaneus quantitative ultrasound (QUS) assessment is a safe and reliable method for evaluating skeletal status. Until now, considerable data have been accumulated on the distribution of QUS in Caucasian populations, whereas such data are still insufficient in Asian populations, especially in Chinese mainland. The present study aimed to obtain the distribution characteristic of calcaneus QUS in healthy Chinese women, and to further investigate the distribution of low bone mass by QUS stiffness index (SI). This study included 2,498 healthy Chinese females aged 10-87 yr. The QUS exhibited a characteristic mild rise and then fall pattern with increasing age. Age, body height, and weight were significant influencing factors on SI, especially age and weight. The prevalence of osteoporosis detected using instrument-derived T-score or internal T-score was different from that calculated according to calcaneus bone mass density (BMD) previously reported. Furthermore, between instrument-derived T-scores and internal T-scores, there were also significant differences. We concluded that the World Health Organization criteria from BMD may not be appropriate for QUS, and the instrument-derived T-score may also not be appropriate for the studied population. The results will be useful for predicting fracture risk of Chinese women and determining diagnostic criteria of osteoporosis by QUS.

Screening for low bone mass with quantitative ultrasonography in a community without dual-energy X-ray absorptiometry: population-based survey

BACKGROUND

Dual-energy x-ray absorptiometry (DXA) is the criterion standard to identify low bone mineral density (BMD), but access to axial DXA may be limited or cost prohibitive. We screened for low bone mass with quantitative ultrasonography (QUS) in a community without DXA, analyzed its reliability and obtained reference values and estimated the prevalence of low QUS values.

METHODS

We enrolled 6493 residents of Kinmen, Taiwan, and a reference group (96 men and 70 women aged 20-29 years) for this cross-sectional, community-based study. All participants completed a questionnaire and underwent ultrasonographic measurements. Reliability and validity of QUS measurements were evaluated. Broadband ultrasound attenuation (BUA) values were obtained and statistically analyzed by age, sex and weight. Annual loss of BUA was determined. Trends in the prevalence of QUS scores were evaluated.

RESULTS

Two QUS were used and had a correlation coefficient of 0.90 (p < 0.001). Calcaneal BUA was significantly correlated with BMD in the femoral neck (r = 0.67, p < 0.001) and BMD of the total lumbar spine (r = 0.59, p < 0.001). BUAs in the reference group were 92.72 +/- 13.36 and 87.90 +/- 10.68 dB/MHz for men and women, respectively. Estimated annual losses of calcaneal BUA were 0.83% per year for women, 0.27% per year for men, and 0.51% per year for the total population. The prevalence of severely low QUS values (T-score = -2.5) tended to increase with aging in both sexes (p < 0.001). Across age strata, moderately low QUS values (-2.5 < T-score < -1.0) were 31.6-41.0% in men and 23.7-38.1% in women; a significant trend with age was observed in men (p < 0.001).

CONCLUSION

Age-related decreases in calcaneal ultrasonometry, which reflected the prevalence of low bone mass, were more obvious in women than in men.

Calcaneus ultrasound in males: normative data in the Croatian population (ECUM study)

Limited number of dual X-ray absorptiometry (DXA) devices in Croatia makes this diagnostic technique unavailable to the majority of the population. Quantitative ultrasound (QUS) of the calcaneus could be an alternative tool for assessing fracture risk. However, age-specific normative data should be obtained before using the QUS in everyday clinical practice. The aim of our Epidemiology of Calcaneus Ultrasound in Males (ECUM) study is to establish the normative QUS data in a healthy sample of Croatian males. A total of 1002 male participants, aged 20-99, recruited in different Croatian counties, were included in the study. In each subject broadband ultrasound attenuation (BUA), speed of sound (SOS) and quantitative ultrasound index (QUI) of the left calcaneus were measured using the Sahara ultrasound device (Hologic). The coefficients of variation were 2.85 for BUA, 0.37 for SOS and 2.49 for QUI. Significant declining with age was found for all three parameters, BUA (p<0.001), SOS (p<0.001) and QUI (p<0.001), with respective r values 0.14, 0.27 and 0.23. The peak SOS (1,562.8+/-28.5 m/sec) and QUI (103.6+/-16.5) values were observed in the third decade, whereas the peak BUA value (86.2+/-19.2 db/MHz) was observed in the fourth decade. A subgroup of 103 participants, aged 20-29, was used to estimate young adult mean and SD for QUI and calculate the T-scores. Using the World Health Organization diagnostic criteria the rates of osteoporosis (T-score<-2.5) in the males aged 50 and older was 5.8%. However, when we used the cut-off value of the T-score<-1.8, as previously suggested, prevalence of osteoporosis in Croatian males >50 yr was 16.2%. Although further studies might improve our understanding of the QUS role in the fracture prediction, we hope that the results presented here will improve the clinical management of osteoporosis in males.

Characteristics of calcaneus quantitative ultrasound normative data in Chinese mainland men and women

INTRODUCTION

Quantitative ultrasound (QUS) assessment at the calcaneus, as a safe and reliable method for evaluating skeletal status, is rapidly gaining in popularity. Assessment by QUS provides three parameters of skeletal status: broadband ultrasound attenuation (BUA), speed of sound (SOS) and derived data-stiffness index (STI). The objective of the present study was firstly to determine the normative QUS data on healthy Chinese mainland men and women and secondly to investigate the effects of sex, age and body size on these three QUS parameters.

METHODS

A study cohort consisting of 725 healthy Chinese women and 568 men aged 10-83 years participated in this investigation. The three QUS parameters all exhibited a characteristic mild rise-then-fall pattern with increasing age in both sexes. Younger men and women had similar QUS values, while older women had lower values than older men. Age-related differences were more pronounced among females. Pearson's correlation and regression analysis showed that weight was a major determinant of QUS in both sexes, along with age.

RESULTS

There were some discrepancies between our data and results from other populations, even when the same type of QUS instrument was used, probably as a result of various factors, including ethnic, life-style environment and diet, among others.

CONCLUSIONS

These normative data will be useful for comparing the results of individual studies, predicting fracture risk of Chinese men and women and determining diagnostic criteria of osteoporosis by QUS.

Densitometric and quantitative ultrasound measurements and laboratory investigations in wheelchair-bound patients

Skeletal status and laboratory investigations may be influenced by immobilization. Thirty-six wheelchair-bound subjects and 19 age-matched controls were evaluated using measurements of bone mineral density (BMD) at the calcaneus and forearm (PIXI, Madison, WI), amplitude-dependent speed of sound at the hand phalanges (quantitative ultrasound-DBM Sonic 1200, IGEA, Modena, Italy), carboxyterminal telopeptide of type I collagen and bone alkaline phosphatase. In the whole group and in the males, bone mineral density values were significantly lower in comparison with controls (calcaneus, forearm) and in females only for calcaneus. The duration of the disease significantly influenced the calcaneal bone mineral density data. Bone alkaline phosphatase was significantly lower in the patients than in the controls. Bone resorption had a negative influence on forearm BMD. Generally, skeletal and laboratory results were not affected by duration of the disease or reason for immobilization. In conclusion, in wheelchair-bound subjects, the skeletal status was affected and bone formation was depressed.

Quantitative ultrasound calcaneus measurements: normative data for the Greek population

Quantitative ultrasound (QUS) is a peripheral bone densitometry technique that is rapidly gaining in popularity, and is widely used worldwide for the assessment of skeletal status. This, however, generally occurs in the absence of adequate clinical guidelines. As accurate interpretation of the results and correct classification in individual fracture risk assessment are of great value, the present study was carried out to establish a reference database for calcaneal QUS measurements across age group and gender in Greece. A total of 1205 subjects (821 females and 384 males) from three age groups (409 children, 341 adults and 455 elderly) were recruited. QUS measurements were performed at the heel with the Sahara device, which measures broadband ultrasound attenuation (BUA) and speed of sound (SOS), and then combines these variables into a single parameter, the quantitative ultrasound index (QUI). Overall, gender-related differences were more pronounced among the elderly, while age-related differences were more pronounced among females. Elderly men had higher QUS parameters than women of peer age, but no major gender differences were observed in children and adults. In males, only BUA showed a variation with age, being higher in adult and elderly men compared to boys. On the other hand, all QUS parameters varied significantly with age in females, the general trends being mildly positive from childhood to adulthood, when peak levels were observed, and negative thereafter. The results for the Greek population were in the range reported previously for other populations, but some discrepancies were evident, probably resulting from ethno-specific characteristics and different QUS instrumentation. Importantly, using the manufacturer's or the local database as the reference population for computing T-scores led to significantly different classification of subjects into conventional categories of risk. These data could be useful as a guide for comparing the results of individual studies, as well as for the assessment of Greek men and women at risk of fracture.

Growth hormone increases bone mineral content in postmenopausal osteoporosis: a randomized placebo-controlled trial

Eighty osteoporotic, postmenopausal women, 50-70 years of age, with ongoing estrogen therapy (HRT), were randomized to recombinant human growth hormone (GH), 1.0 U or 2.5 U/day, subcutaneous, versus placebo. This study was double-blinded and lasted for 18 months. The placebo group then stopped the injections, but both GH groups continued for a total of 3 years with GH and followed for 5 years. Calcium (750 mg) and vitamin D (400 U) were given to all patients. Bone mineral density and bone mineral content were measured with DXA. At 18 months, when the double-blind phase was terminated, total body bone mineral content was highest in the GH 2.5 U group (p = 0.04 vs. placebo). At 3 years, when GH was discontinued, total body and femoral neck bone mineral content had increased in both GH-treated groups (NS between groups). At 4-year follow-up, total body and lumbar spine bone mineral content increased 5% and 14%, respectively, for GH 2.5 U (p = 0.01 and p = 0.0006 vs. placebo). Femoral neck bone mineral density increased 5% and bone mineral content 13% for GH 2.5 U (p = 0.01 vs. GH 1.0 U). At 5-year follow-up, no differences in bone mineral density or bone mineral content were seen between groups. Bone markers showed increased turnover. Three fractures occurred in the GH 1.0 U group. No subjects dropped out. Side effects were rare. In conclusion, bone mineral content increased to 14% with GH treatment on top of HRT and calcium/vitamin D in postmenopausal women with osteoporosis. There seems to be a delayed, extended, and dose-dependent effect of GH on bone. Thus, GH could be used as an anabolic agent in osteoporosis.

Community-based survey of low quantitative ultrasound values of calcaneus in Taiwan

This study investigated prevalence and associated-factors of low quantitative ultrasound (QUS) values by screening calcaneal QUS parameters--broadband ultrasound attenuation (BUA) and speed of sound (SOS)--in population samples of three different Taiwanese communities. The study included 6,322 subjects (2,631 male and 3,691 female), aged 31 yr old or more in Shih-Pai (a metropolitan area in northern Taiwan),Yu-Chi (a mountain area in central Taiwan), and A-Lein (a seaside area in southern Taiwan). The overall response rate was 50.2%. The correlation between BUA and SOS was 0.684, p<0.001. From those who responded, we selected 403 subjects aged 31-40 yr as the reference (the young group), and their BUA was 65.34+/-7.91 dB/MHz. The t-score was calculated from the BUA data of our reference group. The percentile of -2.5<t-score<-1.0 and t-score< or =-2.5 in male subjects was 21.4 and 2.9%, respectively, and in female subjects 24.2 and 14.1%, respectively. The BUA of urban area subjects was higher than that of rural area subjects in almost all age-strata, and overweight was noted to be a protective factor. The effect of age-adjusted odds ratio (AOR) on low QUS values in females was significantly increased every 10 yr from 1.55, 5.13, 13.81, 34.29, to 38.14. This survey showed that age-related decreases in calcaneal ultrasonometry, indicating prevalence of low QUS values, were more obvious in female than male subjects. Overall 38.3% of the female Taiwanese had low QUS values, and this is approximately equivalent to the lifetime risk of fracture at the hip, spine, or distal forearm in Caucasian women. The specific t-score designation, as World Health Organization (WHO) criteria, applied to calcaneal QUS are reasonable when the reference group is selected from the same population.

Association of Dental Status With Blood Pressure and Heart Rate in 80-Year-old Japanese Subjects

Periodontal disease is one of the main reasons for the loss of teeth in elderly subjects, and it has been reported that periodontal disease is a potential risk factor for cardiovascular disease. However, little data is available regarding the association between dental status and blood pressure or heart rate in elderly individuals, particularly in subjects over 80 years old. We studied the cross-sectional association between dental status and blood pressure or heart rate in 499 Japanese (195 men and 304 women) who were 80 years old. The subjects were divided into 4 groups according to the number of original teeth; ie, edentulous (n = 176), 1 to 9 teeth (n = 141), 10 to 19 teeth (n = 109), and more than 20 teeth (n = 73). Mean systolic and diastolic blood pressures did not differ among the groups. However, heart rate decreased from 71.6 and 72.2 /min in the edentulous and I to 9 teeth groups, respectively, to 67.3 and 67.4 /min in the 10 to 19 teeth and more than 20 teeth groups, respectively (test for trend, P = 0.0008). In multiple regression analysis, the inverse association between the number of teeth and heart rate was statistically significant independently of other confounding factors. These results are the first to show a close inverse relationship between the number of teeth and heart rate in octogenariars, although the underlying mechanisms have not been determined.

Bone status in healthy Estonian women assessed with quantitative ultrasonometry

We assessed age-related changes of bone status in healthy Estonian women in various age groups with quantitative ultrasonometry. The speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness index (SI) of the calcaneus were measured in 288 women. BUA and SI values peaked at 30-39 years of age while SOS peaked at 20-29 years and decreased thereafter. We detected no statistically significant changes between the age groups of 20-29, 30-39 and 40-49 years. The total age-related decrease was 18% for BUA, 3% for SOS and 29% for SI. We found a statistically significant correlation between bone status and calcium intake, as well as physical activity in the age group over 40 years.

The use of ultrasound in the assessment of bone status

The assessment of skeletal status has wide clinical applications, especially in the management of osteoporosis. Osteoporosis, once thought of as an unpreventable and untreatable aging process, has revealed many of its secrets over the last decade, and the advent of successful drug therapy has changed our perception of the disease. Non-invasive techniques play a fundamental role in the diagnosis of osteoporosis and in the assessment of the efficacy of drug treatments. The primary technique used in osteoporosis is dual X-ray absorptiometry (DXA), that has been established as a reliable means of measuring bone density. Quantitative ultrasound (QUS), because of the relative portability of the equipment, ease of use, lack of ionizing radiation and low cost, has great potential for widespread use. Five devices for QUS assessment have recently been approved by the Food and Drug Administration and many more applications are in progress. QUS is a relatively new technology, at least in its application to bone fragility. Nevertheless, QUS has demonstrated that it is able to detect bone fragility as well as DXA. However, diagnosis of osteoporosis by QUS remains contentious, but the problems are due more to the limitations of the present T-scores rather than to the technique. A better option for QUS would be to report results in terms of remaining lifetime fracture risk, keeping in mind that a risk estimate needs not only the QUS or DXA measurement, but also the specific data, such as age, weight, gender, hormonal status and fracture history of the patient.