Combined effects of interaction between physical activity and nutrition on bone health in children and adolescents: a systematic review

The effects of different levels of sports activity on health-related quality of life and lifestyle habits in high school Italian students

Physical activity (PA) is an important predictor of physical and mental health preventing chronic degenerative diseases. The purpose of this study was to investigate in a group of Italian high school students whether health-related quality of life (HRQoL) and lifestyle habits (diet) are associated with the level of physical activity performed (low, moderate, high). Data were collected from 2819 adolescents (n = 951 males). HRQoL was analyzed using the Italian version of the KIDSCREEN-52. Physical activity level was analyzed using the PAQ-A, while eating habits with KIDMED. Practicing physical activity in general improves HRQoL. Specifically, adolescents practicing moderate or high PA, in single dimensions of HRQoL, showed better mood (p < 0.001), self-perception (p < 0.001), family relationships (p < 0.001), reported a higher perception of socioeconomic status (p < 0.05), relationship with peers (p < 0.001), and social acceptance (p < 0.001). High PA subjects reported increased physical (p < 0.001) and mental health (p < 0.001), increased autonomy (p < 0.001), and school learning (p < 0.001). For lifestyle habits, practicing moderate PA showed higher adherence tox the Mediterranean diet (p < 0.001). Conclusion: Our results highlighted a positive association between the frequency of PA levels, some dimensions of HRQoL, and risk behaviors. These findings demonstrated the protective role of sports not only as a preventive strategy for the onset of chronic degenerative diseases, but also as an educator of healthy lifestyle habits, thus suggesting the importance and need to implement strategies to promote sports practice.

Combined effect of dietary calcium consumption and physical activity on dental caries in children and adolescents: a study of the NHANES database

BACKGROUND

Calcium (Ca) is a nutritional factor that associated with dental caries. A recent study showed that in the case of adequate Ca intake, a higher level of physical activity may contribute to bone mass accumulation. However, the combined effect between Ca intake and physical activity on caries experience is unclear. Herein, we aimed to explore the above combined effect on dental caries in children and adolescents.

METHODS

Data of 5,917 children and adolescents were extracted from the National Health and Nutrition Examination Surveys (NHANES) database in 2015-2020 in this cross-sectional study. The NHANES assessed the dietary Ca intake through the 24-hour dietary recalls, and the physical activity level was self-reported using the questionnaires. Also, the dental caries was diagnosed according to the Decayed, Missing and Filled Teeth/Surfaces (DMFT/S) index. Weighted univariate and multivariate logistic regression analyses were utilized to screen the covariates and to investigate the associations of dietary Ca intake and physical activity with dental caries, respectively, and assess the combined effect between dietary Ca intake and physical activity on dental caries. The evaluation indexes were odd ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses of age, obesity, and total sugar intake were also performed.

RESULTS

Among the eligible participants, 2,687 had caries experience. After adjusting for the covariates, we found that children and adolescents who not reach the recommendation level of Ca intake combined with physical activity less than 7 time in 1 week seemed to have higher odds of dental caries [OR = 1.77, 95%CI: (1.38-2.27)], compared with those who reached the standards. In addition, this potential combined effect was also found in age < 12 years old [OR = 1.62, 95%CI: (1.23-2.14)], non-obesity [OR = 1.88, 95%CI: (1.49-2.35)], and total sugar intake (all P < 0.05) subgroups.

CONCLUSIONS

Ca intake and physical activity had a potential combined effect on dental caries in children and adolescents, but the causal relationships between them needed further clarification.

Role of diet quality in bone health in children and adolescents: a systematic review

CONTEXT

Poor diet quality and unhealthy dietary patterns have been linked to poor bone health, yet few studies have investigated the role of diet quality in bone health in pediatric populations.

OBJECTIVE

This systematic review aims to assess the available evidence on the association between diet quality and bone health markers in children and adolescents.

DATA SOURCES

The PubMed, Scopus, and Virtual Health Library databases were searched electronically from October to November 2022, without any restrictions on date or language. The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist was used to assess the quality of the studies.

DATA EXTRACTION

Published observational studies in children and adolescents (ages 2 to 19 years) that investigated the association between diet quality and bone health were eligible for inclusion. Two researchers independently analyzed and selected all articles using the Rayyan app. Initially, 965 papers were identified. A total of 12 observational studies qualified, including 8 cross-sectional and 4 longitudinal studies. The sample comprised 7130 individuals aged 3 to 17.9 years, representing both sexes. Bone health was evaluated by measures of bone mineral density and bone mineral content.

DATA ANALYSIS

Seven studies (58.3%) showed significant associations between diet quality and bone health markers, all of which evaluated diet quality by identifying dietary patterns. Diet quality as evaluated by all dietary indexes was not associated with bone health markers.

CONCLUSIONS

Adherence to a healthy diet may benefit bone health in children and adolescents. These findings emphasize the importance of developing effective public health policies that encourage healthy eating habits from childhood to preserve bone health. Longitudinal research using a specific tool to assess diet quality in relation to bone health is warranted. Future studies should also measure bone-regulating hormones and markers of bone turnover.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022368610.

Influence of Exogenous Factors Related to Nutritional and Hydration Strategies and Environmental Conditions on Fatigue in Endurance Sports: A Systematic Review with Meta-Analysis

The aim of this systematic review with meta-analysis was to examine the influence of exogenous factors related to nutritional and hydration strategies and environmental conditions, as modulators of fatigue, including factors associated with performance fatigability and perceived fatigability, in endurance tests lasting 45 min to 3 h. A search was carried out using four databases: PubMed, Web of Science, SPORTDiscus, and EBSCO. A total of 5103 articles were screened, with 34 included in the meta-analysis. The review was registered with PROSPERO (CRD42022327203) and adhered to the PRISMA guidelines. The study quality was evaluated according to the PEDro score and assessed using Rosenthal's fail-safe N. Carbohydrate (CHO) intake increased the time to exhaustion (p < 0.001) and decreased the heart rate (HR) during the test (p = 0.018). Carbohydrate with protein intake (CHO + PROT) increased lactate during the test (p = 0.039). With respect to hydration, dehydrated individuals showed a higher rate of perceived exertion (RPE) (p = 0.016) and had a higher body mass loss (p = 0.018). In hot conditions, athletes showed significant increases in RPE (p < 0.001), HR (p < 0.001), and skin temperature (p = 0.002), and a decrease in the temperature gradient (p < 0.001) after the test. No differences were found when athletes were subjected to altitude or cold conditions. In conclusion, the results revealed that exogenous factors, such as nutritional and hydration strategies, as well as environmental conditions, affected fatigue in endurance sports, including factors associated with performance fatigability and perceived fatigability.

Effects of Diet-Exercise Interaction on Human Health across a Lifespan

The world is changing even faster than ever and has modified people's lives [...].

Development and Evaluation of an e-Book for Bone Health and Osteoporosis Education in Adolescents

Achieving optimum peak bone mass during adolescence is crucial for lifetime bone health. This study is aimed at developing and assessing an e-book designed for adolescent bone health knowledge and osteoporosis education. A needs assessment was conducted among 43 adolescents, aged 13-16 years, living in urban areas in Malaysia to determine their needs and preference for health educational material. The researchers also searched for relevant guidelines and articles regarding adolescent bone health. Subsequently, an e-book was developed based on the needs assessment and literature search. Five expert panelists (mean work experience = 11.3 years) validated the e-book contents and assessed its understandability and actionability using the Patient Educational Materials Assessment Tool for Audio-Visual Material (PEMAT-A/V). The internet (72.1%), parents (44.2%), television (41.9%), and teachers (39.5%) were the top four sources of health information among the respondents. Magazines (4.6%) and newspapers (11.6%) were the least preferred resources. Most adolescents were interested in cartoon-themed educational materials, and they perceived that including a short video, quiz, and infographic in the educational material would make it much more interactive for users. The developed e-book includes seven infographic chapters, a link to a quiz, and a summary video. The topics cover basic information on bones and the formation and resorption processes, osteoporosis and its risk factors, key nutrients for bone health (calcium and vitamin D), along with their sources and recommended amounts, physical activity and exercise for bone health, and tips for healthy lifestyle practices for bone health. All chapters and the video were rated with a median score of 100% for understandability and actionability, respectively. Some of the comments received from evaluators included that the e-book made good use of infographics, was easy to understand and interesting, and contained well-organized content. Some suggestions for improvement included adding take-home messages relevant to the topic, using colors to highlight keywords, and narrating all points presented in the video. Overall, the newly developed e-book on adolescent bone health was highly rated by expert panelists. However, the acceptance and effectiveness of the e-book in increasing bone health and osteoporosis knowledge among adolescents are yet to be evaluated. The e-book could be used as one of the educational tools to promote bone health in adolescents.

Positive association of lean mass and negative association of protein intake on bone mass and bone geometry of adolescent soccer players

OBJECTIVE

The aim of this study was to evaluate the association of food consumption and body composition on bone parameters in adolescent soccer players.

METHODS

There were 148 male soccer players 12 to 18 y who participated in the study. Body composition was assessed by dual energy x-ray absorptiometry, comprising bone mineral density (BMD) and bone mineral content (BMC) of total body without head (TBLH), lumbar spine (L1-L4), and right femoral neck (RFN). The bone geometry variables measured were femoral strength index (FSI), buckling ratio (BR), section modulus (Z), cross-sectional moment of inertia (CSMI), and cross-sectional area (CSA). Food intake was analyzed using the 24-h food recall. Somatic maturation was estimated by the peak height velocity equation. For the statistical analysis, the stepwise multiple linear regression was used, with P < 0.05.

RESULTS

Regarding food consumption, there was a high protein intake and low calcium intake. Lean mass was a predictor of BMC of TBLH (R² = 0.524), L1-L4 (R² = 0.492), and RFN (R² = 0.405); BMD of L1-L4 (R² = 0.407) and RFN (R² = 0.27); Z (R² = 0.683), CSMI (R² = 0.630), and CSA (R² = 0.640). There was a negative correlation between protein intake with bone mass and bone geometry parameters.

CONCLUSION

In adolescent soccer players, lean mass was a predictor of bone parameters, and high protein intake was negatively associated with bone mass and geometry.

Magnesium Status and Ca/Mg Ratios in a Series of Children and Adolescents with Chronic Diseases

Magnesium (Mg) is an essential divalent cation involved in various enzymatic reactions that regulate vital biological functions. The main goal was to evaluate Mg status and its association with nutritional indicators in 78 children and adolescents with chronic diseases. We assessed anthropometric, biochemical, diet, body composition, and bone densitometry valuations. Serum Mg and Ca levels were determined using the standardized method and diet calcium (Ca) and Mg consumption by a prospective 72 h diet survey. Mean serum Ca (9.9 mg/dL), Mg (2.08 mg/dL) dietary Ca (102% DRI: Dietary Reference Intake), and Mg intake (105% DRI) were normal. A total of 45% had hypomagnesemia, 12% had hypermagnesemia, and 26% and 24% had inadequate and high Mg intake, respectively. Only 6% of patients had poor Mg intake and hypomagnesemia, and 54% and 90% of our series had an elevated serum Ca/Mg ratio > 4.70 (mean 4.79) and a low Ca/Mg intake ratio < 1.70 (mean 1.06), respectively. Both Ca/Mg ratios were linked with the risk of developing other chronic conditions such as cardiovascular disease, type 2 diabetes, syndrome metabolic, and even several cancers. Therefore, 79% of children and adolescents with chronic diseases were at elevated risk of having abnormal Mg status and developing other chronic illnesses.

A cross-sectional study of the relationship between recreational sporting activity and calcaneal bone density in adolescents and young adults

OBJECTIVE

Childhood and adolescence are critical periods of bone development. Sporting activity is thought to impact peak bone mass acquisition, but most studies have used dual-energy X-ray absorptiometry (DXA) to assess bone health and reported associations between bone mass and elite sporting activity. The objective of this study was instead to assess the relationship between recreational sporting activity (RSA) and another bone assessment, calcaneal quantitative ultrasound (cQUS), in adolescents and young adults.

METHODS

We related recreational sporting activity, assessed through a lifestyle questionnaire, to heel ultrasound bone parameters in a cohort of New Zealand students aged 16-35 years. Complete datasets with data on all relevant confounders (body mass index (BMI), pubertal timing, smoking status, and alcohol consumption) were available for 452 participants. cQUS was performed using a Lunar Achilles EX II machine to obtain bone parameters, broadband ultrasound attenuation (BUA), and speed of sound (SOS); stiffness index (SI) was derived from these measures. All descriptive statistics and statistical analyses were carried out using SPSS Statistics for Macintosh, Version 23.0 (IBM Corp., Armonk, NY, USA). Results are presented as p-values and 95% CI.

RESULTS

Reported lifetime sport participation declined after an individual's mid-teens. Bone cQUS parameters (SI and BUA and T-score) were all positively associated with BMI, and current physical activity (SI, SOS, BUA, T-score, and Z-score) with SI and SOS measures most strongly associated with current high impact and past recreational sporting activity (all p < 0.05).

CONCLUSION

Calcaneal heel ultrasound bone parameters were associated with physical activity, with SI and SOS rather than BUA more strongly related to current and past recreational sporting activity in young New Zealand adults.

Nutritional intake and bone health

Osteoporotic or fragility fractures affect one in two women and one in five men who are older than 50. These events are associated with substantial morbidity, increased mortality, and an impaired quality of life. Recommended general measures for fragility fracture prevention include a balanced diet with an optimal protein and calcium intake and vitamin D sufficiency, together with regular weight-bearing physical exercise. In this narrative Review, we discuss the role of nutrients, foods, and dietary patterns in maintaining bone health. Much of this information comes from observational studies. Bone mineral density, microstructure-estimated bone strength, and trabecular and cortical microstructure are positively associated with total protein intake. Several studies indicate that fracture risk might be lower with a higher dietary protein intake, provided that the calcium supply is sufficient. Dairy products are a valuable source of these two nutrients. Hip fracture risk appears to be lower in consumers of dairy products, particularly fermented dairy products. Consuming less than five servings per day of fruit and vegetables is associated with a higher hip fracture risk. Adherence to a Mediterranean diet or to a prudent diet is associated with a lower fracture risk. These various nutrients and dietary patterns influence gut microbiota composition or function, or both. The conclusions of this Review emphasise the importance of a balanced diet including minerals, protein, and fruit and vegetables for bone health and in the prevention of fragility fractures.

Clinical outcomes and predictive factors for failure with MPFL reconstruction combined with tibial tubercle osteotomy and lateral retinacular release for recurrent patellar instability

BACKGROUND

Medial patellofemoral ligament (MPFL) reconstruction combined with tibial tubercle osteotomy (TTO) and lateral retinacular release (LRR) is one of the main treatment methods for patellar instability. So far, few studies have evaluated the clinical effectiveness and assessed potential risk factors for recurrent patellar instability.

PURPOSE

To report the clinical outcomes of MPFL reconstruction combined with TTO and LRR at least three years after operation and to identify potential risk factors for recurrent patellar instability.

METHODS

A retrospective analysis of medical records for patients treated with MPFL, TTO and LRR from 2013 to 2017 was performed. Preoperative assessment for imaging examination included trochlear dysplasia according to Dejour classification, patella alta with the Caton-Deschamps index (CDI), tibial tubercle-trochlear groove distance. Postoperative assessment for knee function included Kujala, IKDC and Tegner scores. Failure rate which was defined by a postoperative dislocation was also reported.

RESULTS

A total of 108 knees in 98 patients were included in the study. The mean age at operation was 19.2 ± 6.1 years (range, 13-40 years), and the mean follow-up was 61.3 ± 15.4 months (range, 36-92 months). All patients included had trochlear dysplasia (A, 24%; B, 17%; C, 35%; D, 24%), and 67% had patellar alta. The mean postoperative scores of Tegner, Kujala and IKDC were 5.3 ± 1.3 (2-8), 90.5 ± 15.5 (24-100) and 72.7 ± 12.1 (26-86). Postoperative dislocation happened in 6 patients (5.6%). Female gender was a risk factor for lower IKDC (70.7 vs 78.1, P = 0.006), Tegner (5.1 vs 6.0, P = 0.006) and Kujala (88.2 vs 96.6, P = 0.008). Age (p = 0.011) and trochlear dysplasia (p = 0.016) were considered to be two failure factors for MPFL combined with TTO and LRR.

CONCLUSION

As a surgical method, MPFL combined with TTO and LRR would be a reliable choice with a low failure rate (5.6%). Female gender was a risk factor for worse postoperative outcomes. Preoperative failure risk factors in this study were age and trochlear dysplasia.

LEVEL OF EVIDENCE

Level IV; Case series.

The Combined Effects of Milk Intake and Physical Activity on Bone Mineral Density in Korean Adolescents

The purpose of this study was to examine the combined effects of milk intake and physical activity on bone mineral density in adolescents. This study was conducted using data from the 2009–2011 Korea National Health and Nutrition Examination Survey (KNHANES), which provided measurements of bone mineral density (BMD) in addition to basic health-related data. This study included 1061 adolescents aged 13 to 18 years (557 males and 504 females) whose data on milk intake and participation time in moderate to vigorous physical activity were available. BMD was measured by dual-energy X-ray absorptiometry (DXA). Milk intake was assessed using the 24-h recall method, and the levels of physical activity were examined using a questionnaire. The physical activity questions of 2009–2011 KNHANES were based on the Korean version of the International Physical Activity Questionnaire (IPAQ) short form. The subjects were classified into four groups according to milk intake and physical activity level: no milk intake + low-level physical activity group (M_noP_low), no milk intake + high-level physical activity group (M_noP_high), milk intake + low-level physical activity group (M_yesP_low), and milk intake + high-level physical activity group (M_yesP_high). The results of partial correlation controlling for age, body mass index (BMI), and energy intake showed that the BMD variables were associated significantly with physical activity in both males and females. Among males, the M_noP_low group had the lowest BMD in all BMD variables, showing a significant difference from the high-level physical activity groups (M_noP_high, M_yesP_high) by multiple logistic regression analysis. Among females, the M_yesP_high group showed a significantly higher lumbar BMD value than the other groups. The M_noP_low group had approximately 0.3 to 0.5 times lower odds ratio for median or higher BMD values, compared to M_yesP_high group. These results show that milk intake and physical activity have a combined effect on BMD, and suggest that to achieve healthy bone growth, it is important to encourage both moderate to vigorous physical activity and milk intake during adolescence.

Role of Dietary Intake and Serum 25(OH)D on the Effects of a Multicomponent Exercise Program on Bone Mass and Structure of Frail and Pre-Frail Older Adults

The multicomponent training (MCT) effect on bone health in frail and pre-frail elders, which is influenced by dietary intake, is still unknown. The objective of this non-randomized intervention trial was to assess the effects of a 6-month MCT on bone structure in frail and pre-frail elders, and to analyse the influence of dietary intake and serum vitamin D (25(OH)D) in these changes. Thirty MCT (TRAIN) and sixteen controls (CON), frail and pre-frail completed the information required for this study. Peripheral quantitative computed tomography measurements were taken at 4% and 38% of the tibia length and dietary intake was registered. The 25(OH)D values were obtained from blood samples. Analyses of covariance (ANCOVA) for repeated measures showed significant decreases for CON in total bone mineral content at 38% of tibia length. One factor ANOVAs showed smaller decreases in bone mineral density and cortical thickness percentage of change in TRAIN compared to CON. Linear regression analyses were performed to study the influence of nutrients and 25(OH)D on bone changes. Alcohol showed a negative influence on fracture index changes, while polyunsaturated fatty acid and vitamin A showed a positive association with some bone variables. The 25(OH)D only affected positively the cortical bone mineral density. In conclusion, our MCT seems to slow down some of the bone detriments associated with ageing in frail and pre-frail older adults, with alcohol showing a negative effect on the bone and apparent limited effect of nutrients and serum 25(OH)D on training related changes.

Effects of vegetarian diet on bone mineral density

Factors, such as hormonal changes in postmenopausal women, natural aging degeneration, race, gender, body size, lifestyle, physical activity, sunlight, dietary intake, medications, or other environmental issues, can affect the rate of bone formation or reabsorption, cause changes in bone mineral content, and influence the development of osteoporosis. Do vegetarian diets adversely affect bone mineral density (BMD)? Among postmenopausal Buddhists, long-term practitioners of vegan vegetarian were found to have a higher risk exceeding the lumbar fracture threshold and a lower level of hip BMD after controlling for other variables. However, results of several prospective longitudinal studies failed to show a harmful effect of vegetarianism on bone health. In the Taiwanese adult population, researchers also did not find that a vegetarian diet significantly affects age-related BMD decline. Due to the various levels of nutrients in the diet (such as protein, alkali, calcium, Vitamin K, and phytoestrogens) and major lifestyle factors (such as smoking and physical exercise), determining the impact of a vegetarian diet on bone health is very complex. Good-quality vegetarian food can provide a healthy foundation for building and maintaining healthy bones and preventing fractures.

Combined effects of physical activity and calcium on bone health in children and adolescents: a systematic review of randomized controlled trials

BACKGROUND

A better understanding of the role of exercise and nutrition in bone health is significant for preventing osteoporosis. The aim of this review was to assess the combined effects of physical activity and calcium intake on improving bone mineral density in children and adolescents.

METHODS

A search of electronic databases (MedLine, ISI Web of Science, Science Direct) and the literature references were performed. Randomized controlled trials published between 1997 and 2017, evaluating the effect of both physical activity and calcium intake intervention on bone mineral density or bone mineral content among children aged 3-18 years were selected. The Improved Jadad Rating Scale was used to assess the methodological quality of the included studies. Study characteristics were summarized in accordance with the review's PICO criteria. Changes in bone mineral content were detected at several different bone sites.

RESULTS

A total of nine studies involving 908 participants were included in this review. The combined intervention of physical activity and calcium increased bone mineral in children and adolescents, especially when baseline calcium intake level was low and among participants on the stage of early puberty.

CONCLUSIONS

Regular physical activity combined with high level of calcium intake is beneficial for bone health in young population. Further research is needed to evaluate the dose-response associations and long-term effects of the interaction between physical activity and calcium intake.

Usual Dietary Intake, Nutritional Adequacy and Food Sources of Calcium, Phosphorus, Magnesium and Vitamin D of Spanish Children Aged One to <10 Years. Findings from the EsNuPI Study

Bone problems in the population begin to be establish in childhood. The present study aims to assess the usual calcium, phosphorus, magnesium, and vitamin D intakes, along with the food sources of these nutrients, in Spanish children participating in the EsNuPI (Estudio Nutricional en Población Infantil Española) study. Two 24 h dietary recalls were applied to 1448 children (1 to <10 years) divided into two sub-samples: one reference sample (RS) of the general population [n = 707] and another sample which exclusively included children consuming enriched or fortified milks, here called "adapted milks" (AMS) [n = 741]. Estimation of the usual intake shows that nutrient intake increased with age for all nutrients except vitamin D. Using as reference the Dietary Reference Values from the European Food Safety Authority (EFSA), calcium and magnesium intakes were found to be below the average requirement (AR) and adequate intake (AI), respectively, in a considerable percentage of children. Furthermore, phosphorus exceeded the AI in 100% of individuals and vitamin D was lower than the AI in almost all children studied. The results were very similar when considering only plausible reporters. When analyzing the food sources of the nutrients studied, milk and dairy products contributed the most to calcium, phosphorus, magnesium, and vitamin D. Other sources of calcium were cereals and vegetables; for phosphorus: meat, meat products, and cereals; for magnesium: cereals and fruits; and, for vitamin D: fish and eggs. These results highlight the desirability of improving the intake concerning these nutrients, which are involved in bone and metabolic health in children. The AMS group appeared to contribute better to the adequacy of those nutrients than the RS group, but both still need further improvement. Of special interest are the results of vitamin D intakes, which were significantly higher in the AMS group (although still below the AI), independent of age.

Nutrition and physical activity level of adolescents with idiopathic scoliosis: a narrative review

Some studies have shown that patients with adolescent idiopathic scoliosis (AIS) have different anthropometric features compared with their peers such as taller stature, lower body mass index, and bone mineral density. Yet the causes explaining these differences remain uncertain. Nutritional intake and status, combined with physical activity, could explain these discrepancies. We aimed to review the current literature on energy and nutrient intake, on nutritional status and physical activity in relation to AIS and to discuss study methodologies and propose avenues for future studies. Studies describing energy or nutrient intake in AIS mostly focused on total energy and calcium and found no difference between AIS and control cohorts. Regarding nutritional status, it was found that AIS patients have lower vitamin D levels than controls and that most patients have insufficient or deficient vitamin D serum levels. Lower concentration of parathyroid hormones and calcitonin were also found in AIS compared to controls as well as anomalies in trace elements. In the studies that have assessed physical activity, three found that AIS girls were less active than controls, but four did not observe differences between groups. In this review, we highlight that nutrition and physical activity are important topics in AIS that require further research as they could help understand anthropometric discrepancies and disease etiology.

Cross-sectional and longitudinal associations between physical activity, sedentary behaviour and bone stiffness index across weight status in European children and adolescents

Background

The associations between physical activity (PA), sedentary behaviour (SB) and bone health may be differentially affected by weight status during growth. This study aims to assess the cross-sectional and longitudinal associations between PA, SB and bone stiffness index (SI) in European children and adolescents, taking the weight status into consideration.

Methods

Calcaneus SI was first measured by quantitative ultrasound among children aged 2–9 years old in 2007/08. It was measured again after 2 years in the IDEFICS study and after 6 years in the I. Family study. A sample of 2008 participants with time spent at sports clubs, watching TV and playing computer/games self-reported by questionnaire, and a subsample of 1037 participants with SB, light PA (LPA) and moderate-to-vigorous PA (MVPA) objectively measured using Actigraph accelerometers were included in the analyses. Weight status was defined as thin/normal and overweight/obese according to the extended International Obesity Task Force criteria. Linear mixed-effects models were used to estimate the cross-sectional and longitudinal associations between PA, SB and SI percentiles, stratified by weight status.

Results

The cross-sectional association between weekly duration of watching TV and SI percentiles was negative in thin/normal weight group (β = − 0.35, p = 0.008). However, baseline weekly duration of watching TV (β = − 0.63, p = 0.021) and change after 2 years (β = − 0.63, p = 0.022) as well as the change in weekly duration of playing computer/games after 6 years (β = − 0.75, p = 0.019) were inversely associated with corresponding changes in SI percentiles in overweight/obese group. Change in time spent at sports clubs was positively associated with change in SI percentiles after 2 years (β = 1.28, p = 0.001), with comparable effect sizes across weight status. In the subsample with accelerometer data, we found a positive cross-sectional association between MVPA and SI percentiles in thin/normal weight group. Baseline MVPA predicted changes in SI percentiles after 2 and 6 years in all groups.

Conclusions

Our results suggested the beneficial effect of PA on SI. However, the increasing durations of screen-based SB might be risk factors for SI development, especially in overweight/obese children and adolescents.

Veganism, vegetarianism, bone mineral density, and fracture risk: a systematic review and meta-analysis

Context

The numbers of vegans and vegetarians have increased in the last decades. However, the impact of these diets on bone health is still under debate.

Objective

This systematic review and meta-analysis sought to study the impact of vegetarian and vegan diets on bone mineral density (BMD) and fracture risk.

Data Sources

A systematic search was conducted of PubMed, Scopus, and Science Direct, covering the period from the respective start date of each database to November 2017.

Data Extraction

Two investigators evaluated 275 studies against the inclusion criteria (original studies in humans, written in English or Spanish and including vegetarian or vegan diets and omnivorous diets as factors with BMD values for the whole body, lumbar spine, or femoral neck and/or the number of fractures as the outcome) and exclusion criteria (articles that did not include imaging or studies that included participants who had suffered a fracture before starting the vegetarian or vegan diet). The quality assessment tool for observational cohort and cross-sectional studies was used to assess the quality of the studies.

Results

Twenty studies including 37 134 participants met the inclusion criteria. Compared with omnivores, vegetarians and vegans had lower BMD at the femoral neck and lumbar spine and vegans also had higher fracture rates.

Conclusions

Vegetarian and vegan diets should be planned to avoid negative consequences on bone health.

Systematic Review Registration

PROSPERO registration no. CRD42017055508.

May Young Elite Cyclists Have Less Efficient Bone Metabolism?

The purpose of this work was to describe changes in metabolic activity in the bones of young male competitive cyclists (CYC) as compared with age-matched controls (CON) over a one-year period of study. Eight adolescent male cyclists aged between fourteen and twenty, and eight age-matched controls participated in this longitudinal study. Serum osteocalcin (OC), amino-terminal propeptide of type I procollagen (PINP), beta-isomerized C-telopeptides (β-CTx) and plasma 25 hydroxyvitamin D [25(OH)D], were investigated by an electrogenerated chemiluminescence immunoassay. Analysis of variance revealed no significant differences in formation and resorption markers between cyclists and controls. Within the groups, both CYC and CON showed decreased OC at -30% and -24%, respectively, and PINP where the figures were -28% and -30% respectively (all p < 0.05). However, only the CYC group showed a decrease in [25(OH)D], lower by 11% (p < 0.05). The similarity in the concentrations of markers in cyclists and controls seems to indicate that cycling does not modify the process of bone remodeling. The decrease in vitamin D in cyclists might be detrimental to their future bone health.

Physical activity modifies the effect of calcium supplements on bone loss in perimenopausal and postmenopausal women: subgroup analysis of a randomized controlled trial

We aimed to determine whether the effect of calcium supplements on bone metabolism is modified by physical activity (PA) through a subgroup analysis of an RCT. PA may be a favorable effect modifier of the association between calcium intake and bone loss in perimenopausal and postmenopausal women.

PURPOSE

Physical exercise can potentially modify bone metabolism. Here we aimed to determine whether the effect of calcium supplements on bone metabolism is modified by physical activity (PA) through a subgroup analysis of a randomized, double-blind, placebo-controlled trial.

METHODS

The trial was conducted over the course of 2 years, and participants were 450 healthy women between 50 and 75 years of age who were randomly assigned to three equally-sized (N = 150 each) groups (500 mg calcium, 250 mg calcium, and placebo). Levels of PA at baseline were evaluated by quantifying moderate (4 METs) and vigorous (6 METs) activities based on a 7-day activity recall, and the total MET-hours per week was calculated. Follow-up BMD examinations were conducted 2 years later. Two-year changes in BMD were compared between the intention-to-treat higher PA subgroup (≥ 10 MET-hours/week) and the lower PA subgroup (< 10 MET-hours/week).

RESULTS

Of the 450 participants, 418 underwent follow-up BMD measurements. Regarding the lower PA subgroup, spinal BMD in the 500 mg/day calcium supplement group decreased significantly less (- 0.029 g/cm², P = 0.042) than in the placebo group (- 0.045 g/cm²), and femoral neck BMD in the 500 mg/day calcium supplement group decreased significantly less (- 0.027 g/cm², P = 0.049) than in the placebo group (- 0.038 g/cm²). In contrast, changes in neither spinal nor femoral neck BMD significantly differed between the three treatment groups in the higher PA subgroup.

CONCLUSIONS

PA is a favorable effect modifier of the association between calcium intake and bone loss in perimenopausal and postmenopausal women with low calcium intake.

CLINICAL TRIALS REGISTRY NUMBER

UMIN000001176.

Suboptimal bone status for adolescents with low motor competence and developmental coordination disorder-It's sex specific

BACKGROUND

Australian adolescents with low motor competence (LMC) have higher fracture rates and poorer bone health compared to European normative data, but currently no normative data exists for Australians.

AIMS

To examine whether there were bone health differences in Australian adolescents with LMC or Developmental Coordination Disorder (DCD) when compared to typically developing age-matched Australian adolescents.

METHODS AND PROCEDURES

Australian adolescents aged 12-18 years with LMC/DCD (n = 39; male = 27; female = 12) and an Australian comparison sample (n = 188; boys = 101; girls = 87) undertook radial and tibial peripheral Quantitative Computed Tomography (pQCT) scans. Stress Strain Index (SSI (mm³)), Total Bone Area (TBA (mm²)), Muscle Density (MuD [mgcm³]), Muscle Area (MuA [cm²]), Subcutaneous Fat Area (ScFA [cm²]), Cortical Density (CoD [mgcm³]), Cortical Area (CoD [mm²]), cortical concentric ring volumetric densities, Functional Muscle Bone Unit Index (FMBU: (SSI/bone length)) and Robustness Index (SSI/bone length^3), group and sex differences were examined.

OUTCOME AND RESULTS

The main finding was a significant sex-x-group interaction for Tibial FMBU (p = .021), Radial MuD (p = .036), and radial ScFA (p = .002). Boys with LMC/DCD had lower tibial FMBU scores, radial MuD and higher ScFA than the typically developing age-matched sample.

CONCLUSION AND IMPLICATIONS

Comparisons of bone measures with Australian comparative data are similar to European findings however sex differences were found in the present study. Australian adolescent boys with LMC/DCD had less robust bones compared to their well-coordinated Australian peers, whereas there were no differences between groups for girls. These differences may be due to lower levels of habitual weight-bearing physical activity, which may be more distinct in adolescent boys with LMC/DCD compared to girls.

Increased Patellar Volume/Width and Decreased Femoral Trochlear Width Are Associated With Adolescent Patellofemoral Pain

BACKGROUND

Patellofemoral pain is one of the most common forms of knee arthralgia in adolescent females. Unlike in adults, in whom the etiology of patellofemoral pain is considered to be multifactorial (eg, altered bone shape and musculoskeletal dynamics), the etiology of adolescent patellofemoral pain has been historically attributed to overuse. Although it is highly plausible that adolescent patellofemoral pain results from excessive maltracking, as suggested by recent research, an increase in patellar, relative to femoral, size could also contribute to patellofemoral pain through altered cartilage stresses/strains, resulting in overloading of the subchondral bone. Because the role of bone morphology in the genesis of patellofemoral pain in adolescent females remains largely unknown, research is needed in this area to improve our understanding of patellofemoral pain and advance diagnosis/treatment.

QUESTIONS/PURPOSES

(1) Are patellar volume and width increased, and femoral trochlear width decreased, in female adolescents with patellofemoral pain compared with asymptomatic females? (2) Are measures of patellofemoral size correlated with patellofemoral tracking?

METHODS

Twenty adolescent females with patellofemoral pain (age, 13.7 ± 1.3 years) and 20 asymptomatic female control participants (age, 13.6 ± 1.3 years) were enrolled in this case-control institutional review board-approved study. This study focused on a strict definition of patellofemoral pain, peripatellar pain in the absence of other structural pathologic conditions (eg, tendinitis, ligament injury, Osgood-Schlatter disease) or a history of dislocations/trauma. Control participants with no history of patellofemoral pain or other lower extremity pathology were matched for age (within 6 months) and body mass index (within 5 kg/m). Participants self-referred and were recruited through clinicaltrails.gov, printed advertisements, and word of mouth. Three-dimensional (3-D), static, T1-weighted, gradient recalled echo MR images were acquired, from which 3-D patellofemoral models were created. Patellar volume and width, patellar-to-femoral volume and width ratios, and femoral trochlear width were compared across cohorts. In addition, 3-D patellofemoral tracking was quantified from dynamic MR images captured during cyclical flexion-extension volitional movements of the lower extremity. The size measures and ratios were correlated to patellofemoral tracking.

RESULTS

Compared with control participants, the cohort with patellofemoral pain had greater patellar volume (13,792 ± 2256 versus 11,930 ± 1902 mm; 95% confidence interval [CI], 1336 mm; p = 0.004; d = 0.89) and width (38.4 ± 3.0 versus 36.5 ± 2.7 mm; 95% CI, 1.8 mm; p = 0.021; d = 0.67). The femoral trochlear width was smaller (32.0 ± 1.8 versus 32.9 ± 1.8 mm; p = 0.043, d = 0.54). The patellar-to-femoral volume ratio and the patellar-to-trochlear width ratio were greater in adolescents with patellofemoral pain (0.15 ± 0.02 versus 0.13 ± 0.01, p = 0.006, d = 0.83 and 1.20 ± 0.09 versus 1.11 ± 0.09, p = 0.001, d = 1.02). No correlations were found between patellar size and patellofemoral tracking (r < 0.375, p > 0.103).

CONCLUSIONS

In adolescent females with patellofemoral pain, the increased patellar volume/width and patellar-to-trochlear width ratio, along with the decreased femoral trochlear width, may initiate a pathway to pain through improper engagement of the patella within the femoral trochlea. Specifically, the mean differences between cohorts in patellar and femoral trochlear width (1.9 mm and 0.9 mm) are 58% and 37% of the mean patellar and femoral cartilage thickness in females, respectively, as reported in the literature. Further studies are needed to fully elucidate the mechanism of pain.

LEVEL OF EVIDENCE

Level III, prognostic study.

Physical Fitness, Adiposity, and Diets as Surrogate Measures of Bone Health in Schoolchildren: A Biochemical and Cross-Sectional Survey Analysis

This study aimed to investigate the associations between adiposity, muscular fitness (MF), diet, sun exposure, and physical activity profiles as surrogate measures with bone health status in a sample of schoolchildren aged 8-18 yr old. A total of 250 Egyptian schoolchildren aged 8-18 yr were randomly invited to participate in these cross-sectional survey analyses. Calcaneal broadband ultrasound attenuation (c-BUA), bone mineral density (BMD), and bone formation markers (total calcium, serum bone alkaline phosphatase, and osteocalcin) were measured as markers of bone health. Adiposity profile, MF, physical activity (PA), sun exposure, Ca, and vitamin D dietary intake as related cofactors of bone health were measured by using prevalidated questionnaires and standard analytical techniques. A total of 85% (n = 213) of the study population showed normal bone health and 14.8% (n = 37) had abnormal bone health; most of them are girls (67.6%) classified according to BMD and c-BUA Z-scores into osteopenia (9.6%) and osteoporosis (5.2%). Compared with boys, higher correlations between c-BUA, bone mineral content, and BMD measures in the femoral neck, lumbar spine, whole body, and bone markers were reported in girls with lower bone mass. There was a positive significant correlation between body mass index, adiposity, sun exposure, MF, PA status, Ca and vitamin D intake, and c-BUA and BMD score analyses. These parameters were shown to be associated with about ~57.3%-88.4% of bone health characteristics of children and adolescents with osteopenia and osteoporosis. In children and adolescents, sun exposure, Ca and vitamin D diets, adiposity, PA, and changes in the levels of Ca, osteocalcin, and serum bone alkaline phosphatase were shown to be associated with bone health. Also, a significant correlation was reported between c-BUA score, dual-energy X-ray absorptiometry-BMD measures, and bone markers at clinically important bone sites of girls and boys. However, further clinical trials should be studied to consider c-BUA and bone markers as the benchmark estimates of bone mass for diagnostic purposes in young ages.

Mediterranean diet, diet quality, and bone mineral content in adolescents: the HELENA study

Dietary scores, rather than individual nutrients, allow exploring associations between overall diet and bone health. The aim of the present study was to assess the associations between the Mediterranean Diet Score for Adolescents (MDS-A) and the Diet Quality Index for Adolescents (DQI-A) and bone mineral content (BMC) among Spanish adolescents. Our results do not support an association between dietary scores or indices and BMC in adolescents.

INTRODUCTION

To assess the associations between the MDS-A and a DQI-A with the BMC measured with dual-energy X-ray absorptiometry.

METHODS

The MDS-A and the DQI-A were calculated in 179 Spanish adolescents, based on two 24-h dietary recalls from the HELENA cross-sectional study. The associations between the diet scores and the BMC outcomes [total body less head (TBLH), femoral neck (FN), lumbar spine (LS), and hip] were analyzed using logistic regression models adjusting for several confounders.

RESULTS

Four hundred ninety-two models were included and only fruits and nuts and cereal and roots were found to provide significant ORs with regard to BMC. The risk of having low BMC reduced by 32% (OR 0.684; CI 0.473-0.988) for FN when following the ideal MDS-A, but this association lost significance when adjusting for lean mass and physical activity. For every 1-point increase in the cereal and root and the fruit and nut components, the risk of having low FN diminished by 56% (OR 0.442; CI 0.216-0.901) and by 67% (OR 0.332; CI 0.146-0.755), respectively.

CONCLUSION

An overall dietary score or index is not associated with BMC in our adolescent Spanish sample.

Soccer helps build strong bones during growth: a systematic review and meta-analysis

The aim of this study was to analyze the effects of soccer practice on bone in male and female children and adolescents. MEDLINE, PubMed, SPORTDiscus and Web of Science databases were searched for scientific articles published up to and including October 2016. Twenty-seven studies were included in this systematic review (13 in the meta-analysis). The meta-analysis was performed by using OpenMeta[Analyst] software. It is well documented that soccer practice during childhood provides positive effects on bone mineral content (BMC) and density (BMD) compared to sedentary behaviors and other sports, such as tennis, weightlifting, or swimming. Furthermore, soccer players present higher BMC and BMD in most weight-bearing sites such as the whole body, lumbar spine, hip, and legs. Moreover, bone differences were minimized between groups during prepuberty. Therefore, the maturity status should be considered when evaluating bone. According to meta-analysis results, soccer practice was positively associated with whole-body BMD either in males (mean difference 0.061; 95%CI, 0.042-0.079) or in females (mean difference 0.063; 95%CI, 0.026-0.099).

CONCLUSION

Soccer may be considered a sport that positively affects bone mass during growth. Pubertal soccer players presented increased bone mass compared to controls or other athletes; however, these bone differences are minimized during the prepubertal stage. What is known: • It has been described that childhood and adolescence are important periods for bone mass and structure. • Previous studies have demonstrated that soccer participation improves bone mass in male and female children and adolescents. What is new: • The differences between soccer players and controls are more marked during puberty than prepuberty. • Weight-bearing sites such as lumbar spine, hip, femoral neck, trochanter, intertrochanteric region and both legs are particularly sensitive to soccer actions.

Bone Health is Maintained, While Fat Mass is Reduced in Pre-pubertal Children with Obesity Participating in a 1-Year Family-Centered Lifestyle Intervention

Diet and physical activity (PA) influence bone health in children. This study tested whether increasing milk and milk products and weight-bearing types of PA favorably changed bone outcomes assessed by dual-energy X-ray absorptiometry (DXA) and bone biomarkers in children with obesity participating in a 1-year family-centered lifestyle intervention. Children were randomized to one of three groups: Control (Ctrl; no intervention), Standard treatment (StnTx: two servings milk and milk products/day; meet PA guidelines plus weight-bearing PA three times/week), or Modified treatment (ModTx: four servings milk and milk products/day; meet PA guidelines plus daily weight-bearing PA). Baseline and 12-month measurements included DXA scans for whole body (WB), lumbar spine (LS), lumbar lateral spine (LLS), and ultra-distal (UD) ulna + radius for bone mineral content (BMC), areal bone mineral density (aBMD) and BMD z-scores. Fat mass index (FMI), fat-free mass index (FFMI), and biomarkers of bone metabolism were assessed. Seventy-eight children 6-8 years old were recruited (mean body mass index for-age z-score: 3.3 ± 1.2). Compared to baseline, all groups increased BMC of WB, LS, and LLS (p < 0.001), whereas only StnTx increased UD ulna + radius BMC at 12 months (p < 0.05). At 12 months, WB-BMD z-scores were significantly lower in Ctrl (p < 0.05), whereas WB and LLS aBMD increased in StnTx and ModTx (p < 0.001) but not in Ctrl. All groups increased FFMI (p < 0.001), while only Ctrl increased FMI (p < 0.001). Bone biomarkers did not change over time. Participating in a family-centered lifestyle intervention based on Canadian diet and PA guidelines maintained bone health in obese children.

Participation in sports in relation to adolescent growth and development

Puberty is defined by physical growth, development of secondary sexual characteristics, and maturation of psychosocial skills. The initiation and rate of progression of pubertal events varies among adolescents, but pubertal changes occur in a predictable stepwise manner. Factors including individual differences in physical and psychosocial development, stage of development based on age (early, middle, and late), and the rate of pubertal development, may all contribute to the way in which adolescents experience sports activities. During adolescence, gender differences also become more apparent and may significantly impact sports participation. As practitioners evaluate overall development and adolescent readiness for sports participation, they should consider the different areas of development including: somatic, neurologic, cognitive, psychosocial-function in an integrated and interdependent approach.

Dietary Calcium Intake and Adherence to the Mediterranean Diet in Spanish Children: The ANIVA Study

The aim of this study was to evaluate the relationship of dietary calcium intake with anthropometric measures, physical activity and adherence to the Mediterranean diet (MedDiet) in 1176 Spanish children aged 6-9 years. Data were obtained from "Antropometría y Nutrición Infantil de Valencia" (ANIVA), a cross-sectional study of a representative sample. Dietary calcium intake assessed from three-day food records was compared to recommended daily intakes in Spain. Anthropometric measures (weight and height) were measured according to international standards and adherence to the MedDiet was evaluated using the Mediterranean Diet Quality Index (KIDMED) test. For the total sample of children, 25.8% had inadequate calcium intake, a significantly higher prevalence in girls (p = 0.006) and inadequate calcium intake was associated with lower height z-score (p = 0.001) for both sexes. In girls, there was an inverse relationship between calcium intake and body mass index (p = 0.001) and waist/hip ratio (p = 0.018). Boys presented a polarization in physical activity, reporting a greater level of both physical and sedentary activity in comparison with girls (p = 0.001). Children with poor adherence to MedDiet, even if they consume two yogurts or cheese (40 g) daily, adjusted by gender, age, total energy intake, physical activity and father's level of education, are at risk of inadequate total calcium intake (odds ratio adjusted [ORa]: 3.36, 95% confidence interval [CI]: 1.13-9.94, p = 0.001). The intake of these dairy products was insufficient to cover calcium intake recommendations in this age group (6-9 years). It is important to prioritize health strategies that promote the MedDiet and to increase calcium intake in this age group.

Protecting Bone Health in Pediatric Rheumatic Diseases: Pharmacological Considerations

Bone health in children with rheumatic conditions may be compromised due to several factors related to the inflammatory disease state, delayed puberty, altered life style, including decreased physical activities, sun avoidance, suboptimal calcium and vitamin D intake, and medical treatments, mainly glucocorticoids and possibly some disease-modifying anti-rheumatic drugs. Low bone density or even fragility fractures could be asymptomatic; therefore, children with diseases of high inflammatory load, such as systemic onset juvenile idiopathic arthritis, juvenile dermatomyositis, systemic lupus erythematosus, and those requiring chronic glucocorticoids may benefit from routine screening of bone health. Most commonly used assessment tools are laboratory testing including serum 25-OH-vitamin D measurement and bone mineral density measurement by a variety of methods, dual-energy X-ray absorptiometry as the most widely used. Early disease control, use of steroid-sparing medications such as disease-modifying anti-rheumatic drugs and biologics, supplemental vitamin D and calcium, and promotion of weight-bearing physical activities can help optimize bone health. Additional treatment options for osteoporosis such as bisphosphonates are still controversial in children with chronic rheumatic diseases, especially those with decreased bone density without fragility fractures. This article reviews common risk factors leading to compromised bone health in children with chronic rheumatic diseases and discusses the general approach to prevention and treatment of bone fragility.

Dietary sources and sociodemographic and lifestyle factors affecting vitamin D and calcium intakes in European adolescents: the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) Study

Objective

To investigate dietary sources of Ca and vitamin D (VitD) intakes, and the associated sociodemographic and lifestyle factors, among European adolescents.

Design

Linear regression mixed models were used to examine sex-specific associations of Ca and VitD intakes with parental education, family affluence (FAS), physical activity and television (TV) watching while controlling for age, Tanner stage, energy intake and diet quality.

Setting

The Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA)Cross-Sectional Study.

Subjects

Adolescents aged 12·5–17·5 years (n 1804).

Results

Milk and cheese were the main sources of Ca (23 and 19 % contribution to overall Ca intake, respectively). Fish products were the main VitD source (30 % contribution to overall VitD intake). Ca intake was positively associated with maternal education (β=56·41; 95 % CI 1·98, 110·82) and negatively associated with TV viewing in boys (β=–0·43; 95 % CI −0·79, −0·07); however, the significance of these associations disappeared when adjusting for diet quality. In girls, Ca intake was positively associated with mother’s (β=73·08; 95 % CI 34·41, 111·74) and father’s education (β=43·29; 95 % CI 5·44, 81·14) and FAS (β=37·45; 95 % CI 2·25, 72·65). This association between Ca intake and mother’s education remained significant after further adjustment for diet quality (β=41·66; 95 % CI 0·94, 82·38). Girls with high-educated mothers had higher Ca intake.

Conclusions

Low-educated families with poor diet quality may be targeted when strategizing health promotion programmes to enhance dietary Ca.

Treatment strategies for the female athlete triad in the adolescent athlete: current perspectives

Since the passage of Title IX in 1972, female sports participation has dramatically increased. The benefits of physical activity, including decreased risk for heart disease and diabetes as well as improved body image and self-esteem, far outweigh the risks. However, a select population of adolescent and young adult females may experience symptoms related to the female athlete triad (Triad), which refers to the interrelatedness of energy availability, menstrual function, and bone mineral density (BMD). These conditions often manifest clinically as disordered eating behaviors, menstrual irregularity, and stress fractures; an individual may suffer from 1 or all of the Triad components simultaneously. Because of the complex nature of the Triad, treatment is challenging and requires a multidisciplinary approach. Team members often include a physician, psychologist or psychiatrist, nutritionist or dietitian, physical therapist, athletic trainer, coach, family members, and most importantly, the patient. A thorough physical examination by a primary care physician is essential to identify all organs/systems that may be impacted by Triad-related conditions. Laboratory tests, assessment of bone density, nutritional assessment, and behavior health evaluation guide the management of the female athlete with Triad-related conditions. Treatment of the Triad includes adequate caloric consumption to restore a positive energy balance; this is often the first step in successful management of the Triad. In addition, determining the cause of menstrual dysfunction (MD) and resumption of menses is very important. Nonpharmacologic interventions are the first choice; pharmacologic treatment for MD is reserved only for those patients with symptoms of estrogen deficiency or infertility. Lastly, adequate intake of calcium and vitamin D is critical for lifelong bone health. For this review, a comprehensive search of relevant databases from the earliest dates to July 2016 was performed. Keywords, including female athlete triad, adolescent female athlete, disordered eating, eating disorder, low energy availability, relative energy deficit, anorexia, bulimia, menstrual dysfunction, amenorrhea, oligoamenorrhea, bone mineral density, osteopenia, osteoporosis, stress fracture, and stress reaction, were utilized to search for relevant articles. Articles that directly addressed assessment and management of any 1 or all of the Triad components were included in this comprehensive review. The purpose of this narrative review is to provide the reader with the latest terms used to define the components of the female athlete triad, to discuss examination and diagnosis of the Triad, and lastly, to provide the reader with the latest evidence to successfully implement a multidisciplinary treatment approach when providing care for the adolescent female athlete who may be suffering from Triad-related components.

Plyometric exercise and bone health in children and adolescents: a systematic review

BACKGROUND

Many jumping interventions have been performed in children and adolescents in order to improve bone-related variables and thus, ensure a healthy bone development during these periods and later in life. This systematic review aims to summarize and update present knowledge regarding the effects that jumping interventions may have on bone mass, structure and metabolism in order to ascertain the efficacy and durability (duration of the effects caused by the intervention) of the interventions.

DATA SOURCES

Identification of studies was performed by searching in the database MEDLINE/PubMed and SportDiscus. Additional studies were identified by contacting clinical experts and searching bibliographies and abstracts. Search terms included "bone and bones", "jump*", "weight-bearing", "resistance training" and "school intervention". The search was conducted up to October 2014. Only studies that had performed a specific jumping intervention in under 18-year olds and had measured bone mass were included. Independent extraction of articles was done by 2 authors using predefined data fields.

RESULTS

A total of 26 studies were included in this review. Twenty-four studies found positive results as subjects included in the intervention groups showed higher bone mineral density, bone mineral content and bone structure improvements than controls. Only two studies found no effects on bone mass after a 10-week and 9-month intervention. Moreover, those studies that evaluated the durability of the effects found that some of the increases in the intervention groups were maintained after several years.

CONCLUSIONS

Jumping interventions during childhood and adolescence improve bone mineral content, density and structural properties without side effects. These type of interventions should be therefore implemented when possible in order to increase bone mass in early stages of life, which may have a direct preventive effect on bone diseases like osteoporosis later in life.

Body Composition, Nutritional Profile and Muscular Fitness Affect Bone Health in a Sample of Schoolchildren from Colombia: The Fuprecol Study

The objective of the present study is to investigate the relationships between body composition, nutritional profile, muscular fitness (MF) and bone health in a sample of children and adolescents from Colombia. Participants included 1118 children and adolescents (54.6% girls). Calcaneal broadband ultrasound attenuation (c-BUA) was obtained as a marker of bone health. Body composition (fat mass and lean mass) was assessed using bioelectrical impedance analysis. Furthermore height, weight, waist circumference and Tanner stage were measured and body mass index (BMI) was calculated. Standing long-jump (SLJ) and isometric handgrip dynamometry were used respectively as indicators of lower and upper body muscular fitness. A muscular index score was also computed by summing up the standardised values of both SLJ and handgrip strength. Dietary intake and degree of adherence to the Mediterranean diet were assessed by a 7-day recall questionnaire for food frequency and the Kidmed questionnaire. Poor bone health was considered using a z-score cut off of ≤-1.5 standard deviation. Once the results were adjusted for age and Tanner stage, the predisposing factors of having a c-BUA z-score ≤-1.5 standard deviation included being underweight or obese, having an unhealthy lean mass, having an unhealthy fat mass, SLJ performance, handgrip performance, and unhealthy muscular index score. In conclusion, body composition (fat mass and lean body mass) and MF both influenced bone health in a sample of children and adolescents from Colombia. Thus promoting strength adaptation and preservation in Colombian youth will help to improve bone health, an important protective factor against osteoporosis in later life.

The management of osteoporosis in children

This article reviews the manifestations and risk factors associated with osteoporosis in childhood, the definition of osteoporosis and recommendations for monitoring and prevention. As well, this article discusses when a child should be considered a candidate for osteoporosis therapy, which agents should be prescribed, duration of therapy and side effects. There has been significant progress in our understanding of risk factors and the natural history of osteoporosis in children over the past number of years. This knowledge has fostered the development of logical approaches to the diagnosis, monitoring, and optimal timing of osteoporosis intervention in this setting. Current management strategies are predicated upon monitoring at-risk children to identify and then treat earlier rather than later signs of osteoporosis in those with limited potential for spontaneous recovery. On the other hand, trials addressing the prevention of the first-ever fracture are still needed for children who have both a high likelihood of developing fractures and less potential for recovery. This review focuses on the evidence that shapes the current approach to diagnosis, monitoring, and treatment of osteoporosis in childhood, with emphasis on the key pediatric-specific biological principles that are pivotal to the overall approach and on the main questions with which clinicians struggle on a daily basis. The scope of this article is to review the manifestations of and risk factors for primary and secondary osteoporosis in children, to discuss the definition of pediatric osteoporosis, and to summarize recommendations for monitoring and prevention of bone fragility. As well, this article reviews when a child is a candidate for osteoporosis therapy, which agents and doses should be prescribed, the duration of therapy, how the response to therapy is adjudicated, and the short- and long-term side effects. With this information, the bone health clinician will be poised to diagnose osteoporosis in children and to identify when children need osteoporosis therapy and the clinical outcomes that gauge efficacy and safety of treatment.

Osteoporosis: Modern Paradigms for Last Century's Bones

The skeleton is a metabolically active organ undergoing continuously remodelling. With ageing and menopause the balance shifts to increased resorption, leading to a reduction in bone mineral density and disruption of bone microarchitecture. Bone mass accretion and bone metabolism are influenced by systemic hormones as well as genetic and lifestyle factors. The classic paradigm has described osteoporosis as being a “brittle bone” disease that occurs in post-menopausal, thin, Caucasian women with low calcium intakes and/or vitamin D insufficiency. However, a study of black women in Africa demonstrated that higher proportions of body fat did not protect bone health. Isoflavone interventions in Asian postmenopausal women have produced inconsistent bone health benefits, due in part to population heterogeneity in enteric bacterial metabolism of daidzein. A comparison of women and men in several Asian countries identified significant differences between countries in the rate of bone health decline, and a high incidence rate of osteoporosis in both sexes. These studies have revealed significant differences in genetic phenotypes, debunking long-held beliefs and leading to new paradigms in study design. Current studies are now being specifically designed to assess genotype differences between Caucasian, Asian, African, and other phenotypes, and exploring alternative methodology to measure bone architecture.

Osteoporosis, vitamin C intake, and physical activity in Korean adults aged 50 years and over

[Purpose] To investigate associations between vitamin C intake, physical activity, and osteoporosis among Korean adults aged 50 and over. [Subjects and Methods] This study was based on bone mineral density measurement data from the 2008 to 2011 Korean National Health and Nutritional Examination Survey. The study sample comprised 3,047 subjects. The normal group was defined as T-score ≥ -1.0, and the osteoporosis group as T-score ≤ -2.5. The odds ratios for osteoporosis were assessed by logistic regression of each vitamin C intake quartile. [Results] Compared to the lowest quartile of vitamin C intake, the other quartiles showed a lower likelihood of osteoporosis after adjusting for age and gender. In the multi-variate model, the odds ratio for the likelihood of developing osteoporosis in the non-physical activity group significantly decreased to 0.66, 0.57, and 0.46 (p for trend = 0.0046). However, there was no significant decrease (0.98, 1.00, and 0.97) in the physical activity group. [Conclusion] Higher vitamin C intake levels were associated with a lower risk of osteoporosis in Korean adults aged over 50 with low levels of physical activity. However, no association was seen between vitamin C intake and osteoporosis risk in those with high physical activity levels.