Markers of bone turnover in relation to bone health

Mobility during the neolithic and bronze age in northern ireland explored using strontium isotope analysis of cremated human bone

OBJECTIVES

As many individuals were cremated in Neolithic and Bronze Age Ireland, they have not featured in investigations of individual mobility using strontium isotope analysis. Here, we build on recent experiments demonstrating excellent preservation of biogenic (87) Sr/(86) Sr in calcined bone to explore mobility in prehistoric Northern Ireland.

MATERIALS AND METHODS

A novel method of strontium isotope analysis is applied to calcined bone alongside measurements on tooth enamel to human remains from five Neolithic and Bronze Age sites in Northern Ireland. We systematically sampled modern vegetation around each site to characterize biologically available strontium, and from this calculated expected values for humans consuming foods taken from within 1, 5, 10 and 20 Km catchments. This provides a more nuanced way of assessing human use of the landscape and mobility than the 'local' vs. 'non-local' dichotomy that is often employed.

RESULTS

The results of this study 1) provide further support for the reliability of strontium isotope analysis on calcined bone, and 2) demonstrate that it is possible to identify isotopic differences between individuals buried at the same site, with some consuming food grown locally (within 1-5 Km) while others clearly consumed food from up to 50 Km away from their burial place.

DISCUSSION

Hints of patterning emerge in spite of small sample numbers. At Ballynahatty, for instance, those represented by unburnt remains appear to have consumed food growing locally, while those represented by cremated remains did not. Furthermore, it appears that some individuals from Ballynahatty, Annaghmare and Clontygora either moved in the last few years of their life or their cremated remains were brought to the site. These results offer new insights into the choice behind coterminous cremation and inhumation rites in the Neolithic. Am J Phys Anthropol 160:397-413, 2016. © 2016 Wiley Periodicals, Inc.

Calcined bone provides a reliable substrate for strontium isotope ratios as shown by an enrichment experiment

RATIONALE

Strontium isotopes ((87) Sr/(86) Sr) are used in archaeological and forensic science as markers of residence or mobility because they reflect the local geological substrate. Currently, tooth enamel is considered to be the most reliable tissue, but it rarely survives heating so that in cremations only calcined bone fragments survive. We set out to test the proposition that calcined bone might prove resistant to diagenesis, given its relatively high crystallinity, as the ability to measure in vivo (87) Sr/(86) Sr from calcined bone would greatly extend application to places and periods in which cremation was the dominant mortuary practice, or where unburned bone and enamel do not survive.

METHODS

Tooth enamel and calcined bone samples were exposed to a (87) Sr-spiked solution for up to 1 year. Samples were removed after various intervals, and attempts were made to remove the contamination using acetic acid washes and ultrasonication. (87) Sr/(86) Sr was measured before and after pre-treatment on a Nu Plasma multi-collector induced coupled plasma mass spectrometer using NBS987 as a standard.

RESULTS

The strontium isotopic ratios of all samples immersed in the spiked solution were strongly modified showing that significant amounts of strontium had been adsorbed or incorporated. After pre-treatment the enamel samples still contained significant amounts of (87) Sr-enriched contamination while the calcined bone fragments did not.

CONCLUSIONS

The results of the artificial enrichment experiment demonstrate that calcined bone is more resistant to post-mortem exchange than tooth enamel, and that in vivo strontium isotopic ratios are retained in calcined bone.

Silicon: the health benefits of a metalloid

Silicon is the second most abundant element in nature behind oxygen. As a metalloid, silicon has been used in many industrial applications including use as an additive in the food and beverage industry. As a result, humans come into contact with silicon through both environmental exposures but also as a dietary component. Moreover, many forms of silicon, that is, Si bound to oxygen, are water-soluble, absorbable, and potentially bioavailable to humans presumably with biological activity. However, the specific biochemical or physiological functions of silicon, if any, are largely unknown although generally thought to exist. As a result, there is growing interest in the potential therapeutic effects of water-soluble silica on human health. For example, silicon has been suggested to exhibit roles in the structural integrity of nails, hair, and skin, overall collagen synthesis, bone mineralization, and bone health and reduced metal accumulation in Alzheimer's disease, immune system health, and reduction of the risk for atherosclerosis. Although emerging research is promising, much additional, corroborative research is needed particularly regarding speciation of health-promoting forms of silicon and its relative bioavailability. Orthosilicic acid is the major form of bioavailable silicon whereas thin fibrous crystalline asbestos is a health hazard promoting asbestosis and significant impairment of lung function and increased cancer risk. It has been proposed that relatively insoluble forms of silica can also release small but meaningful quantities of silicon into biological compartments. For example, colloidal silicic acid, silica gel, and zeolites, although relatively insoluble in water, can increase concentrations of water-soluble silica and are thought to rely on specific structural physicochemical characteristics. Collectively, the food supply contributes enough silicon in the forms aforementioned that could be absorbed and significantly improve overall human health despite the negative perception of silica as a health hazard. This review discusses the possible biological potential of the metalloid silicon as bioavailable orthosilicic acid and the potential beneficial effects on human health.

Liquid and gas chromatography coupled to isotope ratio mass spectrometry for the determination of 13C-valine isotopic ratios in complex biological samples

On-line gas chromatography-combustion-isotope ratio mass spectrometry (GC-C-IRMS) is commonly used to measure isotopic ratios at natural abundance as well as for tracer studies in nutritional and medical research. However, high-precision (13)C isotopic enrichment can also be measured by liquid chromatography-isotope ratio mass spectrometry (LC-IRMS). Indeed, LC-IRMS can be used, as shown by the new method reported here, to obtain a baseline separation and to measure (13)C isotopic enrichment of underivatised amino acids (Asp, Thr-Ser, Glu, Pro, Gly, Ala, Cys and Val). In case of Val, at natural abundance, the SD(delta(13)C) reported with this method was found to be below 1 per thousand . Another key feature of the new LC-IRMS method reported in this paper is the comparison of the LC-IRMS approach with the conventional GC-C-IRMS determination. To perform this comparative study, isotopic enrichments were measured from underivatised Val and its N(O, S)-ethoxycarbonyl ethyl ester derivative. Between 0.0 and 1.0 molar percent excess (MPE) (delta(13)C= -12.3 to 150.8 per thousand), the calculated root-mean-square (rms) of SD was 0.38 and 0.46 per thousand and the calculated rms of accuracy was 0.023 and 0.005 MPE, respectively, for GC-C-IRMS and LC-IRMS. Both systems measured accurately low isotopic enrichments (0.002 atom percent excess (APE)) with an SD (APE) of 0.0004. To correlate the relative (delta(13)C) and absolute (atom%, APE and MPE) isotopic enrichment of Val measured by the GC-C-IRMS and LC-IRMS devices, mathematical equations showing the slope and intercept of the curves were established and validated with experimental data between 0.0 to 2.3 MPE. Finally, both GC-C-IRMS and LC-IRMS instruments were also used to assess isotopic enrichment of protein-bound (13)C-Val in tibial epiphysis in a tracer study performed in rats. Isotopic enrichments measured by LC-IRMS and GC-C-IRMS were not statistically different (p>0.05). The results of this work indicate that the LC-IRMS was successful for high-precision (13)C isotopic measurements in tracer studies giving (13)C isotopic enrichment similar to the GC-C-IRMS but without the step of GC derivatisation. Therefore, for clinical studies requiring high-precision isotopic measurement, the LC-IRMS is the method of choice to measure the isotopic ratio.

Collagen turnover in the adult femoral mid-shaft: modeled from anthropogenic radiocarbon tracer measurements

We have measured the (14)C content of human femoral mid-shaft collagen to determine the dynamics of adult collagen turnover, using the sudden doubling and subsequent slow relaxation of global atmospheric (14)C content due to nuclear bomb testing in the 1960s and 1970s as a tracer. (14)C measurements were made on bone collagen from 67 individuals of both sexes who died in Australia in 1990-1993, spanning a range of ages at death from 40 to 97, and these measurements were compared with values predicted by an age-dependent turnover model. We found that the dataset could constrain models of collagen turnover, with the following outcomes: 1) Collagen turnover rate of females decreases, on average, from 4%/yr to 3%/yr from 20 to 80 years. Male collagen turnover rates average 1.5-3%/yr over the same period. 2) For both sexes the collagen turnover rate during adolescent growth is much higher (5-15%/yr at age 10-15 years), with males having a significantly higher turnover rate than have females, by up to a factor of 2. 3) Much of the variation in residual bomb (14)C in a person's bone can be attributed to individual variation in turnover rate, but of no more than about 30% of the average values for adults. 4) Human femoral bone collagen isotopically reflects an individual's diet over a much longer period of time than 10 years, including a substantial portion of collagen synthesised during adolescence.

Lime-treated maize husks lower plasma LDL-cholesterol levels in normal and hypercholesterolaemic adult men from northern Mexico

Lime-treated maize husks (LTCH), a by-product of tortilla manufacturing in Mexico, have been shown to decrease plasma LDL-cholesterol levels in guinea-pigs by specific alterations in hepatic cholesterol metabolism. To determine whether LTCH would also lower plasma cholesterol levels in normal and hyperlipidaemic individuals, the fibre content of a typical diet was increased by supplementing free-living subjects in North-West Mexico with cookies containing 450 g LTCH/kg. Normal subjects (n11) with plasma cholesterol levels of less than 5·7 mmol/l and hypercholesterolaemic subjects (n12) with plasma cholesterol levels higher than 5·7 mmol/l participated in the study. Plasma glucose, cholesterol, triacylglycerol, LDL-cholesterol and HDL-cholesterol concentrations, LDL: HDL values and blood pressure were determined at baseline and after 6 weeks of supplementation with LTCH. LTCH supplementation significantly lowered the plasma total cholesterol level by 11–15 % and LDL-cholesterol by 25 %, and improved the LDL: HDL value by 29–33 % (P< 0·01) in both normal and hypercholesterolaemic subjects. HDL-cholesterol, triacylglycerol and glucose concentrations did not change. Both groups consumed equal amounts of LTCH per week; individuals showed excellent compliance and good acceptance of the product. Neither group changed their dietary habits during the time of the experiment as determined by 3 d dietary records at baseline and at week 6. We conclude that LTCH supplements are suitable to increase fibre intake and reduce plasma LDL-cholesterol levels in healthy and hypercholesterolaemic subjects in this population.

No effect of copper supplementation on biochemical markers of bone metabolism in healthy adults

The influence of Cu supplementation of the usual diet for 6 weeks on biochemical markers of bone turnover and on putative indices of Cu status was investigated in healthy adults (twelve male and twelve female) aged 22–46 years, who participated in a double-blind placebo-controlled repeated crossover study. The study consisted of three 6-week supplementation regimens of 3 mg CuSO4, 3 mg Cu–glycine chelate (CuGC), and 6 mg CuGC, each separated by placebo periods of equal length. During baseline and on the last day of each dietary period, fasting morning first-void urine and fasting blood serum, plasma and erythrocytes were collected. The habitual dietary Cu intakes in males and females were approximately 1·4 and 1·1 mg/d respectively. Females had significantly higher (50 %) plasma caeruloplasmin (Cp) protein concentrations than males at baseline. Cu supplementation had no effect on erythrocyte superoxide dismutase (SOD,EC1.15.1.1) activity or plasma Cp protein (putative indices of Cu status) in the total group. Similarly, serum osteocalcin (a marker of bone formation), urinary creatinine (Cr) concentration, urinary pyridinoline : Cr or deoxypyridinoline : Cr excretion (markers of bone resorption) were unaffected in either the total group or in males and females separately, by any Cu supplementation regimen. It is concluded that Cu supplementation of the usual diet in healthy adult males and females had no effect on biochemical markers of bone formation or bone resorption over 6-week periods.

Moderate alcohol consumption and increased bone mineral density: potential ethanol and non-ethanol mechanisms

Mounting epidemiological evidence indicates an association between the moderate ingestion of alcoholic beverages and higher bone mineral density (v. abstainers). More limited findings provide some evidence for translation of this association into reduced fracture risk, but further studies are required. Here, these data are reviewed and caveats in their assimilation, comparison and interpretation as well as in the use and application of bone health indices are discussed. Whilst it is concluded that evidence is now strong for the moderate alcohol-bone health association, at least in relation to bone mineral density, mechanisms are less clear. Both ethanol and non-ethanol components have been implicated as factors that positively affect bone health in the light of moderate consumption of alcoholic beverages, and four particular areas are discussed. First, recent findings suggest that moderate ethanol consumption acutely inhibits bone resorption, in a non-parathyroid hormone- and non-calcitonin-dependent fashion, which can only partly be attributed to an energy effect. Second, critical review of the literature does not support a role for moderate ethanol consumption affecting oestrogen status and leading to a knock-on effect on bone. Third, Si is present at high levels in certain alcoholic beverages, especially beer, and may have a measurable role in promoting bone formation. Fourth, a large body of work indicates that phytochemicals (e.g. polyphenols) from alcoholic beverages could influence bone health, but human data are lacking. With further work it is hoped to be able to model epidemiological observations and provide a clear pathway between the magnitude of association and the relative contribution of these mechanisms for the major classes of alcoholic beverage.

Partial prevention of long-term femoral bone loss in aged ovariectomized rats supplemented with choline-stabilized orthosilicic acid

Silicon (Si) deficiency in animals results in bone defects. Choline-stabilized orthosilicic acid (ch-OSA) was found to have a high bioavailability compared to other Si supplements. The effect of ch-OSA supplementation was investigated on bone loss in aged ovariectomized (OVX) rats. Female Wistar rats (n = 58, age 9 months) were randomized in three groups. One group was sham-operated (sham, n = 21), and bilateral OVX was performed in the other two groups. OVX rats were supplemented orally with ch-OSA over 30 weeks (OVX1, n = 20; 1 mg Si/kg body weight daily) or used as controls (OVX0, n = 17). The serum Si concentration and the 24-hour urinary Si excretion of supplemented OVX rats was significantly higher compared to sham and OVX controls. Supplementation with ch-OSA significantly but partially reversed the decrease in Ca excretion, which was observed after OVX. The increase in bone turnover in OVX rats tended to be reduced by ch-OSA supplementation. ch-OSA supplementation increased significantly the femoral bone mineral content (BMC) in the distal region and total femoral BMC in OVX rats, whereas lumbar BMC was marginally increased. Femoral BMD was significantly increased at two sites in the distal region in OVX rats supplemented with ch-OSA compared to OVX controls. Total lumbar bone mineral density was marginally increased by ch-OSA supplementation. In conclusion, ch-OSA supplementation partially prevents femoral bone loss in the aged OVX rat model.

Human bone collagen synthesis is a rapid, nutritionally modulated process

We developed a direct assay of human bone collagen synthesis using [13C] or [15N] proline and applied it to determine the effects of feeding in young healthy men. Surprisingly, postabsorptive bone collagen synthesis is not sluggish, being approximately 0.07%/h more rapid than that of muscle protein, and capable of being stimulated within 4 h of intravenous feeding by 66 +/- 13%.

INTRODUCTION

All current methods for estimation of bone collagen turnover are indirect, depending on the assay of collagen "markers." Our aim was to develop a direct method for human bone collagen synthesis to be used to study its physiology and pathology, and specifically, in the first instance, the effect of feeding.

MATERIALS AND METHODS

We applied, over 2 h, flooding doses of [13C] and [15N] proline to label iliac crest bone collagen in eight young healthy men. The rate of collagen synthesis was determined as the rate of labeling of collagen hydroxyproline (assayed by gas chromatography-combustion-isotope ratio mass spectrometry in collagen extracted by differential solubility) compared with plasma proline labeling (assayed by gas chromatography-mass spectrometry). We also determined (in a second group of eight young healthy men) the effect of intravenous nutrition (glucose, lipid emulsion, and amino acids (in the ratio of 55%:30%:15% energy, respectively).

RESULTS

Free bone proline labeling was 92 +/- 6% of that of plasma proline, supporting the flooding dose assumption. Human iliac crest bone collagen is heterogeneous, with NaCl-EDTA, 0.5 M acetic acid, pepsin-acetic acid, and hot water-extractable pools being responsible for approximately 1%, 3%, 8%, and 81% of content, respectively. The synthetic rates were 0.58 +/- 0.1, 0.24 +/- 0.05, 0.07 +/- 0.02, and 0.06 +/- 0.01%/h, respectively, giving an average rate of approximately 0.066%/h. [13C] and [15N] proline gave identical results. Intravenous nutrition caused the disappearance of proline label from the procollagen pool and its increased appearance in the less extractable pools, suggesting nutritional stimulation of collagen processing.

CONCLUSION

The results show (1) that iliac crest bone collagen synthesis is faster than generally assumed and of the same order as muscle protein turnover and (2) that feeding increases synthesis by approximately 66%. Given its ability to detect physiologically meaningful responses, the method should provide a new approach to studying the regulation of bone collagen turnover.

[Diagnosis and treatment of juvenile osteoporosis]

Bone mass is primarily genetically determined, but exogenous factors also play a major role. The prevention of osteoporosis can start from childhood, and optimal achievement of peak bone mass during childhood and adolescence is important in order to minimise future fracture risks. Chronic inflammatory diseases can have a detrimental effect on bone mass, by means of several mechanisms. Different diagnostic methods for detection and monitoring of osteoporosis are in use or under investigation. The role of calcium and vitamin D supplementation for the prevention and treatment of osteoporosis associated with paediatric rheumatic diseases remains to be established. New treatments such as bisphosphonates and calcitonin are now available, although their use in the paediatric age has been limited.

Bone mineral density and dietary patterns in older adults: the Framingham Osteoporosis Study

BACKGROUND

Several nutrients are known to affect bone mineral density (BMD). However, these nutrients occur together in foods and dietary patterns, and the overall effects of dietary choices are not well understood.

OBJECTIVE

We evaluated associations between dietary patterns and BMD in older adults.

DESIGN

Of the original Framingham Heart Study subjects, 907 aged 69-93 y completed food-frequency questionnaires as part of an osteoporosis study. We defined dietary patterns by cluster analysis. BMD was measured at the proximal right femur (femoral neck, trochanter, Ward's area) with a dual-photon absorptiometer and at the 33% radial shaft with a single-photon absorptiometer. We regressed BMD measures onto the cluster variable, adjusting for potential confounders.

RESULTS

Six dietary patterns were identified, with relatively greater proportions of intake from meat, dairy, and bread; meat and sweet baked products; sweet baked products; alcohol; candy; and fruit, vegetables, and cereal. After adjustment for multiple comparisons, men in the last group had significantly (P = 0.05) greater BMD than did 2-4 other groups at the hip sites and the candy group at the radius. Men in the candy group had significantly (P < 0.05) lower BMD than did those in the fruit, vegetables, and cereal group for 3 of the 4 sites. Women in the candy group had significantly (P < 0.01) lower BMD than did all but one other group at the radius.

CONCLUSIONS

Dietary pattern is associated with BMD. High fruit and vegetable intake appears to be protective in men. High candy consumption was associated with low BMD in both men and women.

Clinical and biochemical determinants of bone metabolism and bone mass in adolescent female patients with anorexia nervosa

Among pathologies prevalent in western societies, anorexia nervosa has increased over the last decade. Its effects on bone mass need to be defined, and prognostic factors, either clinical or biochemical, could aid clinicians in individual patient management. To determine which clinical and/or biochemical parameters could be related to bone mass status in adolescent female anorexia nervosa patients, 73 female patients were classified according to different stages of their illness and studied in terms of clinical and biochemical parameters and bone densitometric mineral content at lumbar spine. Patients (age 17.2 +/- 1.7 y, mean +/- SD) with Tanner pubertal stage 5, regular menstruation for more than 3 mo before the onset of secondary amenorrhea, and diagnosed with anorexia nervosa were consecutively studied and classified in three clinical situations: I) active phase (34 patients): undernourished and amenorrheic; II) weight recovered but still amenorrheic (20 patients); III) fully recovered (19 patients). Clinical data were recorded at the time of bone density measurement, concomitant with blood sample extraction for study of IGF-I, IGF-binding protein 3 (IGFBP-3), IGFBP-1, estradiol, sex hormone-binding globulin, dehydroepiandrosterone sulfate, prealbumin, amino-terminal propeptide of procollagen III, osteocalcin, bone alkaline phosphatase, carboxy-terminal propeptide of procollagen I, amino-terminal propeptide of procollagen I, carboxy-terminal telopeptide of collagen I, 25-OH-vitamin D, 1,25(OH)(2)-vitamin D, and parathormone. In addition, a 24-h urine collection was made for cortisol, GH, deoxypyridinoline, amino-terminal telopeptide of collagen I, and calcium and creatinine content analysis. IGF-I, estradiol, and biochemical bone formation markers were higher and IGFBP-1, sex hormone-binding globulin, and biochemical bone resorption markers were lower in the weight-recovered stages (stages II and III) compared with the active phase (stage I). Bone formation markers correlated positively with body mass index SD score and IGF-I, whereas bone resorption markers correlated negatively with body mass index SD score and estradiol. Although no statistically significant differences regarding lumbar spine bone mineral density SD score values were recorded among the three stages of the illness, the proportion of osteopenic patients was clearly lower among stage III patients. The actual bone mineral density was inversely related to the duration of amenorrhea and directly related to duration of postmenarcheal menses before amenorrhea. In addition, a subset of osteopenic patients (five of 19) in the fully clinically recovered group with accelerated bone turnover was identified. Normal circulating estrogen level exposure time predicts actual bone mineral density at lumbar spine in young adolescent anorexia nervosa patients. In addition to psychiatric and nutritional interventions, estrogen-deprivation periods must be shortened to less than 20 mo. Patients remaining osteopenic at full clinical recovery require additional follow-up studies.

The effect of calcium intake on bone composition and bone resorption in the young growing rat

A low Ca intake by both rats and man increases bone resorption, decreases bone mass and increases the risk of osteoporosis. The skeletal effect of high Ca intakes is less clear, particularly during periods of bone mineral accrual. Twenty-four female 5-week-old rats, Wistar strain, were randomized by weight into three groups of eight rats each and fed ad libitum a semi-purified diet containing 2 (Ca-restricted), 5 (normal) or 20 (Ca-supplemented) g Ca/kg for 3 weeks. When compared with the normal Ca diet, urinary Ca excretion was unaffected by the dietary restriction of Ca for 3 weeks, but was greater (P<0.001) in Ca-supplemented rats. Urinary pyridinoline (Pyr) and deoxypyridinoline (Dpyr) levels were significantly greater during weeks 2 (Pyr P<0.05, Dpyr P<0.001) and 3 (Pyr P<0.01, Dpyr, P<0.001) of dietary Ca restriction, but were unaffected by Ca supplementation. Femoral dry weight and the concentration of Mg and P in femora were unaffected by dietary Ca concentration. Femoral Ca concentration was reduced (P<0.05) in the Ca-restricted group compared with the other two groups. In conclusion, these results suggest that increasing dietary Ca intake, well above the recommended level, had no effect on bone mineral composition or bone resorption (as assessed with urinary pyridinium crosslinks) in young growing female rats. In addition, these results confirm the findings of previous studies which have shown that bone Ca content in young growing rats was reduced by dietary Ca restriction and that this reduction results, at least in part, from an increased rate of bone resorption.

No effect of copper supplementation on biochemical markers of bone metabolism in healthy young adult females despite apparently improved copper status

OBJECTIVE

To investigate the effects of increasing Cu intakes, above the usual dietary intake, on biomarkers of bone metabolism in healthy young adult females (aged 21-28 y) over a 4 week period.

DESIGN

A double-blind, placebo-controlled randomised repeat crossover Cu supplementation trial.

SETTING

The study was conducted at the Royal Veterinary and Agricultural University (RVAU), Copenhagen, Denmark.

SUBJECTS

Sixteen healthy young adult females aged 20-28 y were recruited from among students at the RVAU.

INTERVENTION

During the 4 week intervention periods in this randomised, crossover trial (3x4 weeks with a minimum 3 week wash-out period), each subject received, in addition to their usual diet, either 3 or 6 mg elemental Cu/day as CuSO4 or a matching placebo. On the last 3 days of each dietary period 24 h urines were collected. In addition, blood was collected on the last day of each dietary period.

RESULTS

Serum Cu and erythrocyte superoxide dismutase (but not caeruloplasmin protein concentration or activity (putative indices of Cu status)) were significantly increased (P<0.05) after daily Cu supplementation with 3 and 6 mg/day for 4 weeks. Serum osteocalcin (biomarker of bone formation), urinary creatinine (Cr) concentration, urinary pyridinoline (Pyr)/Cr or deoxypyridinoline (Dpyr)/Cr excretion, or daily urinary Pyr or Dpyr excretion (biomarkers of bone resorption) were unaffected by Cu supplementation.

CONCLUSION

Copper supplementation of the usual diet in healthy young adult females, while apparently improving Cu status, had no effect on biochemical markers of bone formation or bone resorption over 4 week periods.

SPONSORSHIP

Funding from the European Commission.

Review of risk factors for osteoporosis with particular reference to a possible aetiological role of dietary salt

Laboratory animal, clinical and epidemiological studies in the published literature have been reviewed in order to establish whether excessive salt intake is an important risk factor for the development of osteoporosis and whether an intervention strategy based on salt restriction would be beneficial in the prevention of osteoporosis. Genetic factors appear to be far more important than the combination of nutritional, hormonal, environmental and lifestyle factors in the pathogenesis of osteoporosis. The most important single non-genetic factor is oestrogen deficiency in postmenopausal women. Preventive measures should be aimed at maximizing peak bone mass at skeletal maturity and retarding bone loss thereafter. Apart from postmenopausal oestrogen deficiency, various factors have been incriminated as risk factors for osteoporosis, and these include age at menarche, age at and years since menopause, insufficient physical exercise, alcohol, smoking, low calcium intake, low or high protein intake and high intake of phosphorus, sodium or caffeine. Many of the risk factors are considered to be weak, although when combined they could impact significantly on bone health. Increased intakes of various nutritional factors (potassium, magnesium, zinc, vitamin C), fibre and alkaline-producing fruit and vegetables favour adult bone health. Calcium homeostasis is normally well regulated such that increased calcium loss via the urine leads to increased calcium absorption from the gut. However, the duration of this adaptive process may be greater than that of many of the studies demonstrating that increased salt intake leads to both increased sodium and calcium in the urine. In any case, higher urinary calcium output appears to be seen only in a minority of humans in response to increased salt intake. As numerous factors-genetic, nutritional, hormonal and lifestyle-are involved in the maintenance of calcium homeostasis, it is difficult to devise human studies which adequately take into account all the important factors. Another difficulty is that many past studies have relied on imprecise methods for the measurement of bone resorption. Nor have studies based on the use of the laboratory rat produced clear answers to the problem because the rat, as a species, is uniquely deficient in its ability to handle the relevant minerals. Limited studies to date indicate that increased sodium intake neither exerts a consistent effect on various biomarkers of bone health nor leads to irreversible changes in the bone modelling process in men or in pre- or postmenopausal women. We conclude from the available evidence that increased sodium (or salt) intake is not an important risk factor for osteoporosis and that a reduction of salt intake from 9 to 6g/day in the diet would not be beneficial as an intervention measure in the prevention of osteoporosis. More research is needed to (i) assess the effects (especially long-term) of various nutrients including sodium on bone health, (ii) assess the long-term value of any intervention strategy involving reduced intake of a particular nutrient such as sodium; and (iii) determine whether subpopulations exist particularly in the elderly (e.g. sodium-responsive subjects) in which adaptation to sodium-induced hypercalciuria may be compromised. General prudence dictates that excessively high levels of dietary salt should be eschewed by those persons with raised blood pressure or a limited range of genetic disorders. However, for the generally healthy person there is no sound evidence that the consumption of salt at the present average level of 9g/day constitutes a risk factor for osteoporosis.

Physical activity, diet and skeletal health

Diet and physical exercise concur in the determination of skeletal mass at the end of adolescence and in the conservation of it during adult life. The functional demand imposed on bone is a major determinant of its structural characteristics. Stress applied to a skeletal segment affects the geometry of the bone, the microarchitecture and the composition of the matrix. The stimulatory effect occurs when the skeleton is subjected to strains exceeding habitual skeletal loads, and the intensity of load is more important than the duration of the stimulus. Physical activity leads to greater bone density in children and adolescents and, to a minor extent, in adults. Weight bearing activities, such as walking, have a greater effect than non weight bearing activities, such as cycling and swimming. Reduction of loads as in bed resting or in space flights leads to bone loss. Intense training may cause damage, promptly repaired, as in stress fractures observed in army recruits. Female athletes may experience oligo-amenorrhea, though they still have a positive bone balance. There is an important interaction between the mechanical demands and the availability of nutrients to manufacture bone tissue. The increase in bone density in post-menopausal women is positively related to calcium intake when calcium supplementation is accompanied by exercise. When mechanical demands are low, such as during immobilisation, the intestinal calcium absorption is reduced. Calcium intake should also be analysed in the light of other dietary factors affecting the balance between absorption and excretion, and in combination with a number of other minerals, trace elements and bioactive substances with an impact on bone metabolism.

The effect of moderately and severely restricted dietary magnesium intakes on bone composition and bone metabolism in the rat

Forty 3-week-old male rats, Wistar strain, average weight 59 g, were randomized by weight into five groups of eight rats each. Three groups were fed ad libitum on a semi-purified diet containing (per kg) 400 (adequate), 200 (moderately Mg-restricted) or 20 (severely Mg-restricted) mg Mg for 3 weeks while two groups were pair-fed with the Mg-adequate diet in the same quantities as those consumed by the two Mg-restricted groups respectively. While weight gains and food conversion efficiency values for the Mg-restricted groups were similar to those of the corresponding pair-fed control groups, serum and kidney Mg, and femoral dry weight were reduced by 70, 7 and 9% respectively in the severely Mg-restricted group and were unaffected in the moderately Mg-restricted group. Significant reductions were observed in urinary pyridinoline (Pyr) (by 44 and 34%) and deoxypyridinoline (Dpyr) levels (by 40 and 33%) (markers of bone resorption), serum osteocalcin levels (by 46 and 28%) (marker of bone formation), femoral Mg levels (by 52 and 14%) and osteocalcin mRNA levels (by 46 and 22%) compared with the corresponding pair-fed controls, in the severely and moderately Mg-restricted groups respectively, and these reductions, except for those in urinary Pyr and Dpyr, were more marked in the severely Mg-restricted group. Femoral Ca and P concentrations were unaffected by dietary Mg restriction. These results show that not only severe but also moderate dietary restriction of Mg over 21 d results in qualitative changes in bone (i.e. reduced Mg concentration) as well as in aberrant bone turnover in young growing rats (i.e. severely depressed rates of bone formation and bone resorption), which may impair bone development and bone strength.

Optimal nutrition: calcium, magnesium and phosphorus

In the past, a major challenge for nutrition research was in defining indicators of nutritional adequacy. More recently, the research base related to the role of nutrition in chronic disease has expanded sufficiently to permit moving beyond deficiency indicators to other indicators with broader functional significance. Thus, nutrition research is faced with the new challenge of defining 'optimal nutrition'. One definition of optimal nutrition with respect to any particular nutrient could be when a functional marker reaches an 'optimal value' or plateau beyond which it is not longer affected by intake or stores of the nutrient. A functional marker of nutrient status could be defined as a physiological or biochemical factor which (1) is related to function or effect of the nutrient in target tissue(s) and (2) is affected by dietary intake or stores of the nutrient (which may include markers of disease risk). Examples of such indicators or markers are those related to risk of chronic diseases such as osteoporosis, CHD, or hypertension. The present review focuses on the concept of optimal nutrition with respect to three nutrients, Ca, Mg and P. However, for P and Mg there are as yet no functional indicators which respond to dietary intake, and in such cases nutrient requirements are established using more traditional approaches, e.g. balance data. For Ca, there has been interest in using maximal Ca retention, which is based on balance data, bone mass measurements and biomarkers of bone turnover as useful functional indicators of the adequacy of Ca intake.