Risk factors for nonvertebral fracture in obese older women

Bone health in adults with obesity before and after interventions to promote weight loss

Obesity and its associated comorbidities constitute a serious and growing public health burden. Fractures affect a substantial proportion of people with obesity and result from reduced bone strength relative to increased mechanical loading, together with an increased risk of falls. Factors contributing to fractures in people with obesity include adverse effects of adipose tissue on bone and muscle and, in many people, the coexistence of type 2 diabetes. Strategies to reduce weight include calorie-restricted diets, exercise, bariatric surgery, and pharmacological interventions with GLP-1 receptor agonists. However, although weight loss in people with obesity has many health benefits, it can also have adverse skeletal effects, with increased bone loss and fracture risk. Priorities for future research include the development of effective approaches to reduce fracture risk in people with obesity and the investigation of the effects of GLP-1 receptor agonists on bone loss resulting from weight reduction.

Associations of abdominal obesity with different types of bone fractures in adults: A systematic review and dose-response meta-analysis of prospective cohort studies

Findings on the association between abdominal obesity and hip fracture were summarized in a meta-analysis in 2017; however, no study has examined the dose-response association between abdominal fat indices and hip fracture. Also, we found no meta-analysis investigating other types of bone fractures including any vertebral fractures in relation to abdominal obesity. Therefore, the present systematic review and dose-response meta-analysis of prospective cohort studies were conducted to examine the association between abdominal obesity and different types of bone fractures. A comprehensive literature search was done by searching PubMed, Scopus, Web of Science, and Google Scholar until October 2021. In total, 23 articles from prospective cohort studies with a total sample size of 3,456,631 participants were included. During the follow-up periods ranging between 4 and 26 years, 137,989 cases of bone fracture were recorded. After comparing the highest and lowest categories of abdominal fat indices, the summary relative risks (RRs) of any, hip, and vertebral fractures were 0.99 (95% CI: 0.81-1.20), 1.09 (95% CI: 0.82-1.43), and 1.18 (95% CI: 1.05-1.33), respectively, indicating a significant positive association between abdominal obesity and risk of vertebral fracture. In the non-linear dose-response analysis, abdominal obesity based on the waist-to-hip ratio (WHR) was positively associated with an increased risk of hip fracture from 0.7 to 1.1 units of WHR. In the linear analysis, a 10 cm increase in waist circumference (WC) was associated with a 3% higher risk of vertebral fracture. We found no other dose-response association for other types of bone fractures. In conclusion, abdominal obesity may be associated with a higher risk of hip and vertebral fractures.

Bone mineral density T-scores comparison between obese and non-obese individuals included in a Fracture Liaison Service following a recent fragility fracture

We used data from a Fracture Liaison Service to compare the mean T-scores of obese and non-obese patients after a recent fragility fracture. After adjusting for age, sex, and diabetes mellitus, T-score values were significantly higher at all measurement sites in obese patients, with a mean difference of 1 SD.

PURPOSE

This study aimed to compare the mean T-scores of obese and non-obese patients after recent fragility fractures.

METHODS

Over a period of 5 and a half years, from January 2016 to May 2021, patients from a fracture liaison service were identified and their demographic characteristics, osteoporosis risk factors, BMD T-scores, and fracture sites were compared between obese (BMI ≥ 30 kg/m2) and non-obese (19 kg/m2 < BMI < 30 kg/m2) patients.

RESULTS

A total of 712 patients were included (80.1% women; mean age 73.8 ± 11.3 years). Sixteen % had type 2 diabetes mellitus and 80% had a major osteoporotic fracture (MOF). 135 patients were obese and 577 non-obese, with obese patients younger (p < 0.001) and more frequently female (p = 0.03). Obese patients presented with fewer hip fractures (10% vs. 21%, p = 0.003) and more proximal humerus fractures (16% vs. 7%, p < 0.001) than non-obese patients. After adjusting for age, sex, and diabetes mellitus, BMD T-score values were significantly higher at all measurement sites (lumbar spine, total hip, and femoral neck) in obese patients than in non-obese patients for all types of fractures, with a mean difference of 1 standard deviation (p < 0.001 for all comparisons). The same results were observed in the population limited to MOF.

CONCLUSIONS

Given the crucial role of BMD T-score in determining the need for anti-osteoporotic medication following fragility fractures, it is reasonable to question the existing T-score thresholds in obese patients.

Prevalence of Morphometric Vertebral Fractures After Bariatric Surgery and Its Relationship with Bone Mineral Density and Bone Markers

BACKGROUND

Bariatric surgery (BS) can lead to bone loss and an increased fracture risk.

METHODS

To determine the morphometric vertebral fracture (MVF) prevalence, and its relationship with bone mineral density (BMD), and biomarker's turnover after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), we analyzed post-surgery X-rays of the spine in 80 patients (88% female, 51% RYGB, age 41.2 [6.8] years) from 117 participants' retrospective cohort (1-2 years, >2 and <5 years, and >5 years). We still analyzed body composition and BMD by dual-energy X-ray absorptiometry and bone parameters.

RESULTS

MVF prevalence was 17.5% (14/80), with no statistical difference between groups (p = 0.210). RYGB group had a higher prevalence of secondary hyperparathyroidism (SHPT) (PTH ≥ 65 pg/ml; 18.4% vs 7.8%, respectively, p = 0.04), PTH (61.3 vs 49.5 pg/ml, p = 0.001), CTX (0.766 [0.29] ng/ml vs 0.453 [0.30] ng/ml, p = 0.037), and AP (101.3 [62.4] U/L vs 123.9 [60.9] U/L, p = 0.027) than the SG group. Up to 5 years postoperatively, RYGB had a lower total (1.200 [0.087] vs 1.236 [0.100] g/cm2, p = 0.02), femoral neck (1.034 [0.110] vs 1.267 [0.105], p = 0.005), and total femur BMD (1.256 [0.155] vs 1.323 [0.167], p = 0.002) than SG group. We found no statistically significant difference between the MFV (+) and MVF (-) groups regarding age, sex, BMI, surgery time, BMD, or bone and metabolic parameters, including leptin.

CONCLUSION

We found a high prevalence of MVF after BS with no differences between RYGB and SG.

Improved femoral micro-architecture in adult male individuals with overweight: fracture resistance due to regional specificities

BACKGROUND

It is still unclear whether femoral fracture risk is positively or negatively altered in individuals with overweight. Considering the lack of studies including men with overweight, this study aimed to analyze regional specificities in mechano-structural femoral properties (femoral neck and intertrochanteric region) in adult male cadavers with overweight compared to their normal-weight age-matched counterparts.

METHODS

Ex-vivo osteodensitometry, micro-computed tomography, and Vickers micro-indentation testing were performed on femoral samples taken from 30 adult male cadavers, divided into the group with overweight (BMI between 25 and 30 kg/m2; n = 14; age:55 ± 16 years) and control group (BMI between 18.5 and 25 kg/m2; n = 16; age:51 ± 18 years).

RESULTS

Better quality of trabecular and cortical microstructure in the inferomedial (higher trabecular bone volume fraction, trabecular thickness, and cortical thickness, coupled with reduced cortical pore diameter, p < 0.05) and superolateral femoral neck (higher trabecular number and tendency to lower cortical porosity, p = 0.043, p = 0.053, respectively) was noted in men with overweight compared to controls. Additionally, the intertrochanteric region of men with overweight had more numerous and denser trabeculae, coupled with a thicker and less porous cortex (p < 0.05). Still, substantial overweight-induced change in femoral osteodensitometry parameters and Vickers micro-hardness was not demonstrated in assessed femoral subregions (p > 0.05).

CONCLUSIONS

Despite the absence of significant changes in femoral osteodensitometry, individuals with overweight had better trabecular and cortical femoral micro-architecture implying higher femoral fracture resistance. However, the microhardness was not significantly favorable in the individuals who were overweight, indicating the necessity for further research.

Obesity and Skeletal Fragility

Skeletal fracture has recently emerged as a complication of obesity. Given the normal or better than normal bone mineral density (BMD), the skeletal fragility of these patients appears to be a problem of bone quality rather than quantity. Type 2 diabetes mellitus (T2DM), the incidence of which increases with increasing body mass index, is also associated with an increased risk for fractures despite a normal or high BMD. With the additional bone pathology from diabetes itself, patients with both obesity and T2DM could have a worse skeletal profile. Clinically, however, there are no available methods for identifying those who are at higher risk for fractures or preventing fractures in this subgroup of patients. Weight loss, which is the cornerstone in the management of obesity (with or without T2DM), is also associated with an increased risk of bone loss. This review of the literature will focus on the skeletal manifestations associated with obesity, its interrelationship with the bone defects associated with T2DM, and the available approach to the bone health of patients suffering from obesity.

Prevalence and Predictors of Osteoporosis and Osteopenia in Postmenopausal Women of Punjab, India

The prevalence and predictors of osteoporosis and osteopenia remain to be examined in the postmenopausal women of Punjab, India. The present cross-sectional study screened 1628 postmenopausal women during September 2019 to March 2020. Osteoporosis and osteopenia were confirmed on the basis of T-scores using dual energy X-ray absorptiometry (DXA) at the hip (femoral neck) and lumbar spine regions (L1−L4 vertebrae). The prevalence of osteoporosis and osteopenia was observed to be 30.50% and 44.20%, respectively, in postmenopausal women of Punjab. In univariable and multivariable regression analysis, variables independently influencing the risk of osteoporosis and osteopenia were: higher systolic blood pressure (95%CI: 1.22−3.11 & 1.08−2.49), triglyceride levels (95%CI: 1.21−3.10 & 1.42−2.51), poor sleep quality (95%CI: 1.91−2.47 & 1.76−3.47) and C-reactive protein levels (95%CI: 2.18−3.56 & 1.03−2.18). Years since menopause >10 years was observed to be an independent predictor for the risk of osteopenia but not for osteoporosis. Higher body mass index (>30 kg·m−2) was observed to be a significant protective factor against the risk of osteoporosis (95%CI: 0.26−0.68) and osteopenia (95%CI: 0.19−0.52). The higher prevalence rates of osteoporosis and osteopenia in postmenopausal women of Punjab are alarming, which solicits awareness and earlier testing of those women who are approaching menopause.

Effect of Body Surface Area on Severe Osteoporotic Fractures: A Study of Osteoporosis in Changsha China

Clinical vertebral fractures and femoral neck fractures are severe osteoporotic fractures that increase morbidity and mortality. Anthropometric variables are associated with an increased risk of osteoporotic fractures, but it is not clear whether body surface area (BSA) has an effect on clinically severe osteoporotic fractures. The study included total of 3,694 cases of clinical vertebral fractures and femoral neck fractures (2,670 females and 1,024 males) and 3,694 controls without fractures who were matched with the cases by sex and age. There was a significant positive correlation between BSA and bone mineral density (BMD) in female and male fracture patients (females: r = 0.430-0.471, P < 0.001; males: r = 0.338-0.414, P < 0.001). There was a significant systematic increase in BMD in both genders at various skeletal sites, grouped by BSA quartile. The osteoporosis rates of the lumbar spine (97.9%), femoral neck (92.4%) and total hip (87.1%) in the female Q1 group were significantly higher than those in the Q4 group (P < 0.001), which were 80.0%, 57.9% and 36.9%, respectively, in the Q4 group; the osteoporosis rates of the lumbar spine, femoral neck, and total hip were 53.9%, 59.4%, and 36.3% in the male Q1 group, and 15.2%, 21.9%, and 7.03% in the Q4 group, which were significantly lower than those in the Q1 group (P < 0.001). In age-adjusted Cox regression models, the risk of fracture in the remaining three groups (Q2, Q3, and Q4) for weight, BMI, and BSA for both genders, compared with the highest quartile (Q1 by descending quartile stratification) were significantly higher. In models adjusted for age and BMD, only men in the BSA Q3 (HR = 1.55, 95% CI = 1.09-2.19) and BSA Q4 groups (HR = 1.41, 95% CI = 1.05-1.87) had significantly higher fracture risks. In models adjusted for age, height, weight, BMI, and BSA, low BMD was the greatest fracture risks for both sexes. Our results showed that BSA was closely related to BMD, prevalence of osteoporosis, and fracture risk, and that a decline in BSA may be a new potential risk factor for osteoporotic fractures in Chinese men.

Bone Response to Weight Loss Following Bariatric Surgery

Obesity is a global health challenge that warrants effective treatments to avoid its multiple comorbidities. Bariatric surgery, a cornerstone treatment to control bodyweight excess and relieve the health-related burdens of obesity, can promote accelerated bone loss and affect skeletal strength, particularly after malabsorptive and mixed surgical procedures, and probably after restrictive surgeries. The increase in bone resorption markers occurs early and persist for up to 12 months or longer after bariatric surgery, while bone formation markers increase but to a lesser extent, suggesting a potential uncoupling process between resorption and formation. The skeletal response to bariatric surgery, as investigated by dual-energy X-ray absorptiometry (DXA), has shown significant loss in bone mineral density (BMD) at the hip with less consistent results for the lumbar spine. Supporting DXA studies, analyses by high-resolution peripheral quantitative computed tomography (HR-pQCT) showed lower cortical density and thickness, higher cortical porosity, and lower trabecular density and number for up to 5 years after bariatric surgery. These alterations translate into an increased risk of fall injury, which contributes to increase the fracture risk in patients who have been subjected to bariatric surgery procedures. As bone deterioration continues for years following bariatric surgery, the fracture risk does not seem to be dependent on acute weight loss but, rather, is a chronic condition with an increasing impact over time. Among the post-bariatric surgery mechanisms that have been claimed to act globally on bone health, there is evidence that micro- and macro-nutrient malabsorptive factors, mechanical unloading and changes in molecules partaking in the crosstalk between adipose tissue, bone and muscle may play a determining role. Given these circumstances, it is conceivable that bone health should be adequately investigated in candidates to bariatric surgery through bone-specific work-up and dedicated postsurgical follow-up. Specific protocols of nutrients supplementation, motor activity, structured rehabilitative programs and, when needed, targeted therapeutic strategies should be deemed as an integral part of post-bariatric surgery clinical support.

Obesity and Bone Loss at Menopause: The Role of Sclerostin

Background. Peripheral fat tissue is known to positively influence bone health. However, evidence exists that the risk of non-vertebral fractures can be increased in postmenopausal women with obesity as compared to healthy controls. The role of sclerostin, the SOST gene protein product, and body composition in this condition is unknown. Methods. We studied 28 severely obese premenopausal (age, 44.7 ± 3.9 years; BMI, 46.0 ± 4.2 kg/m²) and 28 BMI-matched post-menopausal women (age, 55.5 ± 3.8 years; BMI, 46.1 ± 4.8 kg/m²) thorough analysis of bone density (BMD) and body composition by dual X-ray absorptiometry (DXA), bone turnover markers, sclerostin serum concentration, glucose metabolism, and a panel of hormones relating to bone health. Results. Postmenopausal women harbored increased levels of the bone turnover markers CTX and NTX, while sclerostin levels were non-significantly higher as compared to premenopausal women. There were no differences in somatotroph, thyroid and adrenal hormone across menopause. Values of lumbar spine BMD were comparable between groups. By contrast, menopause was associated with lower BMD values at the hip (p < 0.001), femoral neck (p < 0.0001), and total skeleton (p < 0.005). In multivariate regression analysis, sclerostin was the strongest predictor of lumbar spine BMD (p < 0.01), while menopausal status significantly predicted BMD at total hip (p < 0.01), femoral neck (p < 0.001) and total body (p < 0.05). Finally, lean body mass emerged as the strongest predictor of total body BMD (p < 0.01). Conclusions. Our findings suggest a protective effect of obesity on lumbar spine and total body BMD at menopause possibly through mechanisms relating to lean body mass. Given the mild difference in sclerostin levels between pre- and postmenopausal women, its potential actions in obesity require further investigation.

Obesity, osteoporosis and bone metabolism

Obesity and osteoporosis have become major global health problems over the last decades as their prevalence is increasing. The interaction between obesity and bone metabolism is complex and not fully understood. Historically, obesity was thought to be protective against osteoporosis;however, several studies have challenged this belief. Even though the majority of the studies suggest that obesity has a favourable effect on bone density, it is unclear what the effect of obesity is on skeletal microarchitecture. Additionally, the effects of obesity on skeletal strength might be site-dependent as obese individuals are at higher risk of certain fractures. Several mechanical, biochemical and hormonal mechanisms have been proposed to explain the association between the adipose tissue and bone. Mechanical loading has positive effects on bone health, but this may not suffice in obesity. Low-grade systemic inflammation is probably harmful to the bone and increased bone marrow adipogenesis may lead to decreased bone mass in obese individuals. Finally, visceral abdominal fat may exert different actions to the bone compared with the subcutaneous fat. Achieving a better understanding of the association between adipose and bone tissue may help to identify new molecular therapeutic targets that will promote osteoblastic activity and/or inhibit adipogenesis and osteoclastic activity.

[Percutaneous kyphoplasty using expandable SpineJack® implant for the treatment of osteoporotic vertebral fractures]

Introduction

L'objectif était d’évaluer le résultat de notre prise en charge chirurgicale des fractures ostéoporotiques vertébrales avec un extenseur vertébral percutané de type SpineJack®.

Méthodes

Il s'agit d'une étude rétrospective analytique et mono centrique de 33 mois (avril 2015 - décembre 2017). Elle avait porté sur les patients ayant été traités par kyphoplastie avec le pour une fracture vertébrale ostéoporotique. Le kit comprenant un extenseur vertébral en titane à type de SpineJack® de Vexim et le ciment acrylique avait été utilisé. Les patients présentant une rachialgie d'intensité croissante malgré le traitement lié à une fracture vertébrale ostéoporotique ont été inclus dans l'étude ainsi que ceux ayant acceptés le principe de la chirurgie et donner leur consentement éclairé. La fracture vertébrale était diagnostiquée à la tomodensitométrie (TDM) et son caractère récent confirmé par l'imagerie par résonnance magnétique (IRM).

Résultats

Entre avril 2015 et décembre 2017, trente-sept patients porteurs de fractures ostéoporotiques vertébrales ont été traités par kyphoplastie avec un extenseur vertébral en titane. L'âge moyen était de 73,4 ans avec un sexe ratio à 0,6. L'échelle visuelle analogique moyenne était de 7,3. Le score d'Osvestry était en moyenne de 81,6. Les fractures étaient prédominantes au niveau de la charnière thoraco-lombaire. L'angle de cyphose vertébrale mesurait en moyenne 18,45°. La kyphoplastie avait concerné 44 vertèbres. Quatre cas de complications opératoires avaient été enregistrés. La durée moyenne d'hospitalisation était de 5,4 jours. A 6 mois de suivi, 9 patients étaient encore sous traitement antalgique. A un an, aucun cas de fracture de vertèbre adjacente n'avait été trouvé.

Conclusion

La kyphoplastie percutanée avec un extenseur en titane est un moyen thérapeutique sûr et efficace des fractures vertébrales ostéoporotiques. Avec son effet quasi immédiat, il permet au patient, un retour rapide à la vie active.

Preschool Obesity Is Associated With an Increased Risk of Childhood Fracture: A Longitudinal Cohort Study of 466,997 Children and Up to 11 Years of Follow-up in Catalonia, Spain

This study aimed to determine if having an overweight or obese range body mass index (BMI) at time of beginning school is associated with increased fracture incidence in childhood. A dynamic cohort was created from children presenting for routine preschool primary care screening, collected in the Information System for Research in Primary Care (SIDIAP) platform in Catalonia, Spain. Data were collected from 296 primary care centers representing 74% of the regional pediatric population. A total of 466,997 children (48.6% female) with a validated weight and height measurement within routine health care screening at age 4 years (±6 months) between 2006 and 2013 were included, and followed up to the age of 15, migration out of region, death, or until December 31, 2016. BMI was calculated at age 4 years and classified using WHO growth tables, and fractures were identified using previously validated ICD10 codes in electronic primary care records, divided by anatomical location. Actuarial lifetables were used to calculate cumulative incidence. Cox regression was used to investigate the association of BMI category and fracture risk with adjustment for socioeconomic status, age, sex, and nationality. Median follow-up was 4.90 years (interquartile range [IQR] 2.50 to 7.61). Cumulative incidence of any fracture during childhood was 9.20% (95% confidence interval [CI] 3.79% to 14.61%) for underweight, 10.06% (9.82% to 10.29%) for normal weight, 11.28% (10.22% to 12.35%) for overweight children, and 13.05% (10.69% to 15.41%) for children with obesity. Compared with children of normal range weight, having an overweight and obese range BMI was associated with an excess risk of lower limb fracture (adjusted hazard ratio [HR] = 1.42 [1.26 to 1.59]; 1.74 [1.46 to 2.06], respectively) and upper limb fracture (adjusted HR = 1.10 [1.03 to 1.17]; 1.19 [1.07 to 1.31]). Overall, preschool children with an overweight or obese range BMI had increased incidence of upper and lower limb fractures in childhood compared with contemporaries of normal weight. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Obesity, Bariatric Surgery, and Fractures

CONTEXT

Obesity and its associated comorbidities are a recognized and growing public health problem. For a long time, obesity-associated effects on bone were considered to strengthen the bone, mainly because of the known relationship between body weight and bone mass and the long-term weight-bearing load effect on bone. However, recent epidemiologic studies have shown that obesity may not have a fully protective effect on the occurrence of fragility fractures. The goal of this article is to review updated information on the link between obesity, bariatric surgery, and fractures.

METHODS

The primary source literature for this review was acquired by searching a published database for reviews and articles up to January 2018. Additional references were selected through the in-depth analysis of the relevant studies.

RESULTS

We present data showing that overweight and obesity are often encountered in fracture cases. We also analyzed possible reasons and risk factors for fractures associated with overweight and patients with obesity. In addition, this review focuses on the complex effects of dramatic changes in body composition when interpreting dual-energy X-ray absorptiometry readings and findings. Finally, we review the data on the effects and consequences of bariatric surgery on bone metabolism and the risk of fractures in patients undergoing these procedures.

CONCLUSION

Because of various adiposity-induced effects, patients with obesity are at risk for fracture in certain sites. Bariatric surgery increases the risk of fractures in patients undergoing malabsorptive procedures.

Bone health in diabetes and prediabetes

Bone fragility has been recognized as a complication of diabetes, both type 1 diabetes (T1D) and type 2 diabetes (T2D), whereas the relationship between prediabetes and fracture risk is less clear. Fractures can deeply impact a diabetic patient's quality of life. However, the mechanisms underlying bone fragility in diabetes are complex and have not been fully elucidated. Patients with T1D generally exhibit low bone mineral density (BMD), although the relatively small reduction in BMD does not entirely explain the increase in fracture risk. On the contrary, patients with T2D or prediabetes have normal or even higher BMD as compared with healthy subjects. These observations suggest that factors other than bone mass may influence fracture risk. Some of these factors have been identified, including disease duration, poor glycemic control, presence of diabetes complications, and certain antidiabetic drugs. Nevertheless, currently available tools for the prediction of risk inadequately capture diabetic patients at increased risk of fracture. Aim of this review is to provide a comprehensive overview of bone health and the mechanisms responsible for increased susceptibility to fracture across the spectrum of glycemic status, spanning from insulin resistance to overt forms of diabetes. The management of bone fragility in diabetic patient is also discussed.

Changes in the Paradigm of Traditional Exercise in Obesity Therapy and Application of a New Exercise Modality: A Narrative Review Article

BACKGROUND

Obesity is recognized as an important global health problem that increases the risk of all-cause death. It is a major risk factor for various cardiovascular and metabolic diseases.

METHODS

We conducted this review through searching the related literature plus internet links.

RESULTS

Recently, many researchers have been applying various efficient alternative exercise paradigms for treating obesity, such as high-intensity interval training, whole-body vibration training, and hypoxic therapy. Compared with moderate-intensity continuous training, high-intensity interval training involves a shorter exercise time but higher energy expenditure and excess post-exercise oxygen consumption via a higher exercise intensity and is effective for treating obesity. Whole-body vibration training effectively reduces the rate of fat production and accumulation through passive vibration of the whole body and improving the body composition, muscle function, and cardiovascular function of the obese population. Hypoxic therapy has been reported to improve obesity and obesity-related diseases through appetite loss, reduced dietary intake, increased energy consumption, improved glycogen storage and fatty acid oxidation, angiogenesis and left ventricle remodeling, decreased mechanical load, and reduced sarcopenia progression due to aging.

CONCLUSION

The new therapeutic exercise modalities, namely, high-intensity interval training, whole-body vibration training, and hypoxic therapy, are practical, useful, and effective for improving obesity and various metabolic and cardiovascular diseases induced by obesity.

Distal Radius Fractures: Does Obesity Affect Fracture Pattern, Treatment, and Functional Outcomes?

BACKGROUND

Distal radius fractures (DRFs) are 16% of fractures treated by orthopedic surgeons. Obesity's influence on DRF complexity has not been studied. This study was undertaken to determine if body mass index (BMI) affects DRF pattern, treatment, and functional outcomes.

METHODS

Part 1 was a retrospective review of patients who sustained a DRF after a fall from standing height with no prior reduction or treatment. Radiographs were classified as "simple" or "complex." Part 2 consisted of contacting patients from Part 1 and obtaining a Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Retrospective review also identified patients who failed initial nonoperative treatment. Fracture pattern, failure of nonoperative treatment, and QuickDASH scores were compared with BMI at the time of injury.

RESULTS

For Part 1, 130 patients (132 wrists) were identified. Average age was 57 years, 77% were female, and average BMI was 28.2 kg/m². Each point increase in BMI increased the chance of having a complex DRF (odds ratio = 1.07). Part 2 identified 50 patients who completed a QuickDASH at an average of 4.6 years after injury. Those with a BMI <25 kg/m² (n = 15) had an average QuickDASH score of 37; patients with a BMI ≥25 kg/m² (n = 35) had an average QuickDASH score of 18. Increasing BMI was suggestive of a lower QuickDASH score ( P = .08). No significant difference was found with respect to BMI and failure of nonoperative treatment.

CONCLUSIONS

A higher BMI increases the odds of a complex DRF. Despite more complex fractures, overweight patients may experience less disability after sustaining a DRF.

Could obesity be considered as risk factor for non-vertebral low-impact fractures?

BACKGROUND

It has long been established that obesity plays a positive role against osteoporosis (OP) and low-impact fractures (Fx). However, more recent data has shown higher fracture risk in obese individuals. The aim of this study was to investigate the association between BMI, particularly obesity, OP and low-impact Fx in Brazilian women, as well as to evaluate the SAPORI (Sao Paulo Osteoporosis Risk Index) tool performance to identify low BMD according BMI category.

METHODS

A total of 6182 women aged over 40 years were included in this cross-sectional analysis using data from two large Brazilian studies. All participants performed hip and spine bone mineral density (BMD) measurements and answered a detailed questionnaire about the presence of clinical risk factors (CRFs) related to low BMD and risk fractures. The World Health Organization (WHO) criteria were used to define obesity.

RESULTS

Age-adjusted osteoporosis prevalence was 20.8, 33.6, 47 and 67.1% in obese, overweight, normal and underweight category, respectively. Obesity was present in 29,6% (1.830 women) in the study population and the likelihood of osteoporosis and low-impact Fx compared to a normal BMI in this subgroup was of 0.24 (95% CI 0.20-0.28; p < 0.001) and of 1.68 (95% CI 1.35-2.11; p < 0.001), respectively. However, the hip Fx likelihood was lower in obese compared with non-obese women (OR = 0.44; 95% CI 0.20-0.97). Using an originally validated cut-off, the SAPORI tool sensitivity was significantly hampered in overweight and obese women although the accuracy had remained suitable because of increasing in specificity.

CONCLUSIONS

The osteoporosis prevalence reduced as BMI increased and obesity was associated with low-impact Fx, regardless of the BMD measurements. Moreover, the SAPORI performance was impaired in obese women.

Whole-body vibration training in obese subjects: A systematic review

OBJECTIVE

(i) to determine the outcomes of whole-body vibration training (WBVT) on obese individuals, and the intervention settings producing such effects; (ii) identify potential improper or harmful use of WBVT.

DESIGN

Systematic review.

DATA SOURCES

Medline, Scopus, Web of Science, PEDro and Scielo until July 2018.

ELIGIBILITY CRITERIA

Full papers evaluating the effect of WBVT on body composition, cardiovascular status and functional performance in obese adults. Papers with PEDro score<4 were excluded.

STUDY APPRAISAL AND SYNTHESIS

Risk of bias and quality of WBVT reporting were assessed with PEDro scale (randomized controlled trials) or TREND checklist (non-randomized studies) and a 14-items checklist, respectively. Weighted acceleration, daily exposure and Hedges' adjusted g were computed.

RESULTS

We included 18 papers published 2010-2017. Typical interventions consisted in three sessions/week of exercises (squats, calf-raises) performed on platforms vibrating at 25-40 Hz (amplitude: 1-2 mm); according to ISO 2631-1:1997, daily exposure was "unsafe" in 7/18 studies. Interventions lasting ≥6 weeks improved cardiac autonomic function and reduced central/peripheral arterial stiffness in obese women; 10 weeks of WBVT produced significant weight/fat mass reduction, leg strength improvements as resistance training, and enhanced glucose regulation when added to hypocaloric diet. No paper evidenced losses of lean mass. Isolated cases of adverse effects were reported.

SUMMARY

To date, WBVT is a promising adjuvant intervention therapy for obese women; long-term studies involving larger cohorts and male participants are required to demonstrate the associated safety and health benefits. The therapeutic use of WBVT in the management of obese patients is still not standardised and should be supported by an extensive knowledge on the causality between vibration parameters and outcomes.

2018 update of French recommendations on the management of postmenopausal osteoporosis

OBJECTIVES

To update the 2012 recommendations on pharmacotherapy for postmenopausal osteoporosis, under the aegis of the Bone Task Force of the French Society for Rheumatology (SFR) and of the Osteoporosis Research and Information Group (GRIO), in collaboration with scientific societies (Collège national des généralistes enseignants, Collège national des gynécologues et obstétriciens français, Fédération nationale des collèges de gynécologie médicale, Groupe d'étude de la ménopause et du vieillissement hormonal, Société française de chirurgie orthopédique, Société française d'endocrinologie, and Société française de gériatrie et de gérontologie).

METHODS

Updated recommendations were developed by a task force whose members represented the medical specialties involved in the management of postmenopausal osteoporosis. The update was based on a literature review and developed using the method advocated by the French National Authority for Health (HAS).

DISCUSSION AND CONCLUSION

The updated recommendations place strong emphasis on the treatment of women with severe fractures, in whom the use of osteoporosis medications is recommended. All the available osteoporosis medications are suitable in patients with severe fractures; zoledronic acid deserves preference as the fist-line drug after a hip fracture. In patients with or without non-severe fractures, the decision to use osteoporosis medications is based on bone mineral density values and in challenging cases, on probabilities supplied by prediction tools such as FRAX^®. All osteoporosis medications are suitable; raloxifene should be reserved for patients at low risk for peripheral fractures. The fracture risk should be reevaluated every 2 to 3 years to decide on the best follow-up treatment. These updated recommendations discuss the selection of first-line osteoporosis medications and treatment sequences.

Type 2 diabetes mellitus and bone

Type 2 diabetes (T2DM) is a rapidly growing public health problem. It is associated with an increased risk of fracture, particularly of the hip, despite normal or high bone mineral density. Longer duration of disease and poor glycaemic control are both associated with higher fracture risk. The factors underlying increased fracture risk have not been clearly established, but increased falls risk, obesity, sarcopenia and co-morbidities are likely to contribute. The basis for reduced bone strength despite higher bone mineral density remains to be fully elucidated. Bone turnover is reduced in individuals with T2DM, with evidence of impaired bone formation. Most studies indicate normal or superior trabecular bone structure although reduced lumbar spine trabecular bone score (TBS) has been reported. Deficits in cortical bone structure have been demonstrated in some, but not all, studies whilst reduced bone material strength index (BMSi), as assessed by microindentation, has been a consistent finding. Accumulation of advanced glycation end products in bone may also contribute to reduced bone strength. The use of FRAX in individuals with T2DM underestimates fracture probability. Clinical management should focus on falls prevention strategies, avoidance of known risk factors, maintenance of good glycaemic control and bone protective intervention in individuals at high risk of fracture. Dietary and surgical strategies to reduce weight have beneficial effects on diabetes but may have adverse effects on skeletal health. Future research priorities include better definition of the mechanisms underlying increased fracture risk in T2DM and optimal strategies for identifying and treating those at high risk.

Abdominal Obesity and Risk of Hip Fracture: A Systematic Review and Meta-Analysis of Prospective Studies

Data on the association between general obesity and hip fracture were summarized in a 2013 meta-analysis; however, to our knowledge, no study has examined the association between abdominal obesity and the risk of hip fracture. The present systematic review and meta-analysis of prospective studies was undertaken to summarize the association between abdominal obesity and the risk of hip fracture. We searched online databases for relevant publications up to February 2017, using relevant keywords. In total, 14 studies were included in the systematic review and 9 studies, with a total sample size of 295,674 individuals (129,964 men and 165,703 women), were included in the meta-analysis. Participants were apparently healthy and aged ≥40 y. We found that abdominal obesity (defined by various waist-hip ratios) was positively associated with the risk of hip fracture (combined RR: 1.24, 95% CI: 1.05, 1.46, P = 0.01). Combining 8 effect sizes from 6 studies, we noted a marginally significant positive association between abdominal obesity (defined by various waist circumferences) and the risk of hip fracture (combined RR: 1.36; 95% CI: 0.97, 1.89, P = 0.07). This association became significant in a fixed-effects model (combined effect size: 1.40, 95% CI: 1.25, 1.58, P < 0.001). Based on 5 effect sizes, we found that a 0.1-U increase in the waist-hip ratio was associated with a 16% increase in the risk of hip fracture (combined RR: 1.16, 95% CI: 1.04, 1.29, P = 0.007), whereas a 10-cm increase in waist circumference was not significantly associated with a higher risk of hip fracture (combined RR: 1.13, 95% CI: 0.94, 1.36, P = 0.19). This association became significant, however, when we applied a fixed-effects model (combined effect size: 1.21, 95% CI: 1.15, 1.27, P < 0.001). We found that abdominal obesity was associated with a higher risk of hip fracture in 295,674 individuals. Further studies are needed to test whether there are associations between abdominal obesity and fractures at other bone sites.

Low-trauma fractures without osteoporosis

In clinical practice, areal bone mineral density (aBMD) is usually measured using dual-energy X-ray absorptiometry (DXA) to assess bone status in patients with or without osteoporotic fracture. As BMD has a Gaussian distribution, it is difficult to define a cutoff for osteoporosis diagnosis. Based on epidemiological considerations, WHO defined a DXA-based osteoporosis diagnosis with a T-score <-2.5. However, the majority of individuals who have low-trauma fractures do not have osteoporosis with DXA (i.e., T-score <-2.5), and some of them have no decreased BMD at all. Some medical conditions (spondyloarthropathies, chronic kidney disease and mineral bone disorder, diabetes, obesity) or drugs (glucocorticoids, aromatase inhibitors) are more prone to cause fractures with subnormal BMD. In the situation of fragility fractures with subnormal or normal BMD, clinicians face a difficulty as almost all the pharmacologic treatments have proved their efficacy in patients with low BMD. However, some data are available in post hoc analyses in patients with T score >-2. Overall, in patients with a previous fragility fracture (especially vertebra or hip), treatments appear to be effective. Thus, the authors recommend treating some patients with a major fragility fracture even if areal BMD T score is above -2.5.

Correlation between obesity and severity of distal radius fractures

INTRODUCTION

The incidence of obesity has increased significantly worldwide. Our hypothesis was that patients with obesity have a more severe distal radius fracture and we realized a study to evaluate this correlation between obesity and severity of distal radius fractures caused by low-energy injuries.

MATERIALS AND METHODS

A total of 114 patients with distal radius fracture were examined in a cross-sectional, observational study. Fractures were classified according to the international AO-Müller/Orthopedic Trauma Association (AO/OTA) classification in order to determine the severity. The patient's Body Mass Index (BMI) was calculated and a Pearson correlation was performed.

RESULTS

The patients were predominantly female, and left side was more frequently affected. Most of the fractures were AO/OTA type A (71 patients). The majority of the involved patients in our study were overweighed or obese. We do not observe a direct correlation between grade of obesity and distal radius fracture severity.

CONCLUSIONS

Based on the results of this study obesity and severity of distal radius fractures do not correlate.

LEVEL OF EVIDENCE

Prognostic. Level IV.

Marrow adipose tissue spectrum in obesity and type 2 diabetes mellitus

OBJECTIVE

To assess the association of bone mass and marrow adipose tissue (MAT) with other fat depots, insulin resistance, bone remodeling markers, adipokines and glucose control in type 2 diabetes and obesity.

DESIGN AND METHODS

The study groups comprised 24 controls (C), 26 obese (O) and 28 type 2 diabetes. Dual-energy X-ray absorptiometry was used to determine bone mineral density (BMD). Blood samples were collected for biochemical measurements. ¹H Magnetic resonance spectroscopy was used to assess MAT in the L3 vertebra, and abdominal magnetic resonance imaging was used to assess intrahepatic lipids in visceral (VAT) and subcutaneous adipose tissue. Regression analysis models were used to test the association between parameters.

RESULTS

At all sites tested, BMD was higher in type 2 diabetes than in O and C subjects. The C group showed lower VAT values than the type 2 diabetes group and lower IHL than the O and type 2 diabetes groups. However, MAT was similar in the 3 groups. Osteocalcin and C-terminal telopeptide of type 1 collagen were lower in type 2 diabetes than those in C and O subjects. Moreover, at all sites, BMD was negatively associated with osteocalcin. No association was observed between MAT and VAT. No relationship was observed among MAT and HOMA-IR, leptin, adiponectin or Pref-1, but MAT was positively associated with glycated hemoglobin.

CONCLUSIONS

MAT is not a niche for fat accumulation under conditions of energy surplus and type 2 diabetes, also is not associated with VAT or insulin resistance. MAT is associated with glycated hemoglobin.

Impact of obesity on bone mass throughout adult life: Influence of gender and severity of obesity

BACKGROUND

Obesity improves areal bone mineral density (aBMD). However, it is unknown whether gender, ageing or the severity of obesity could modulate this effect and whether different bone sites are similarly affected.

OBJECTIVE

The aim of this observational study was to model the aBMD variation in obese patients from peak bone period to old age according to gender, bone localisation and severity of obesity.

SUBJECTS AND METHODS

Five hundred and four obese patients (363 women, 72%) with a mean BMI of 38.5 ± 6.0 kg/m2, aged from 18.1 to 81.9 years (mean age 49.6 ± 14.6 years) were recruited. The whole body (WB), hip, lumbar spine (L1–L4) and one-third radius aBMDs were determined using dual-energy x-ray absorptiometry (DXA).

RESULTS

Z-scores were significantly increased, above the age- and gender-related mean, both for women and men at WB (respectively 0.79 SD and 0.32 SD), hip (1.09 SD and 1.06 SD), one-third radius (1.70 SD and 0.45 SD) and L1–L4 levels (0.86 SD for women only). The improvement of Z-scores was significantly more marked in women compared to men at all bone sites, hip excepted. Furthermore, differences compared with normal values were significantly accentuated by ageing, without noticeable gender effect. In women, regardless of BMI and bone site, Z-scores were higher than normal values, this difference being most marked at WB, L1–L4 and hip levels for obese patients with a BMI above 40 kg/m2. Lean mass, but not fat mass, was independently associated with aBMD in men and women.

CONCLUSION

This study demonstrated for the first time that obesity induces an improvement of aBMD, which is modulated by bone site location, severity of obesity, age and gender. The accentuation of peak bone mass combined with a reduction of bone loss rate with ageing may explain why obese patients present a lower prevalence of osteoporosis.

In Patients with Established RA, Positive Effects of a Randomised Three Month WBV Therapy Intervention on Functional Ability, Bone Mineral Density and Fatigue Are Sustained for up to Six Months

Functional ability is often impaired for people with rheumatoid arthritis (RA), rendering these patients highly sedentary. Additionally, patients with RA often take medication known to negatively affect bone mass. Thus improving functional ability and bone health in this group of patients is important. The aim of this study was to investigate the effects of whole body vibration (WBV) therapy in patients with stable, established RA. Thirty one females with RA were randomly assigned to a control group (CON, n = 15) who continued with their normal activities or a WBV group (n = 16) who underwent a three month WBV therapy intervention, consisting of 15 minutes of intermittent vibration, performed twice per week. Patients were assessed at baseline, three months, and three months post intervention for functional ability using the modified Health Assessment Questionnaire; for RA disease activity using the Clinical Disease Activity Index, for quality of life using self-report fatigue and pain scores; for physical activity profiles using accelerometry, and for BMD and body composition using DXA. Patients in both groups were matched for all variables at baseline. After the intervention period, functional ability was significantly improved in the WBV group (1.22(0.19) to 0.92(0.19), p = 0.02). Hip BMD was significantly reduced in the CON group (0.97(0.05) to 0.84(0.05) g.cm(-2), p = 0.01), while no decreases were seen in the WBV group (1.01(0.05) to 0.94(0.05) g.cm(-2), p = 0.50). Despite no change in RA disease activity in either group at either follow up, fatigue levels were improved in the WBV group (4.4(0.63) to 1.1(0.65), yet remained unchanged in the CON group at both follow ups (p = 0.01). Ten minute bouts of light to moderate physical activity were significantly reduced in the CON group after the intervention (2.8(0.61) to 1.8(0.64) bouts per day, p = 0.01), and were preserved in the WBV group (3.1(0.59) to 3.0(0.61) bouts per day, p = 0.70). Intermittent WBV shows promise for sustained improvements in functional ability, for attenuating loss of bone mass at the hip, as well as for decreasing fatigue in patients with established RA.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR201405000823418.

Bone Mineral Density as a Predictor of Subsequent Wrist Fractures: Findings From the Women's Health Initiative Study

CONTEXT

Wrist fractures are common among postmenopausal women. Associations of bone mineral density (BMD) and 10-year predicted risk of major osteoporotic fracture (MOF) with wrist fractures are poorly characterized.

OBJECTIVE

The objective was to examine associations between the Fracture Risk Assessment Tool (FRAX)-predicted risk of MOF, BMD, BMD change, and wrist fracture.

DESIGN

This was a prospective observational study with a mean follow-up of 8.5 years.

SETTING

This study included 40 US centers.

PARTICIPANTS

A total of 11 392 participants from the Women's Health Initiative BMD Cohort aged 50-79 years at baseline were included in this study.

INTERVENTIONS

None.

MAIN OUTCOME

The goal was to measure incident wrist fracture.

RESULTS

A FRAX-predicted MOF risk ≥9.3% identified 17% of the women aged <65 years who subsequently experienced wrist fracture. Each one standard deviation lower BMD was associated with higher wrist fracture risk, with adjusted hazard ratio (95% confidence interval) of 1.66 (1.42-1.93) for femoral neck (FN) BMD and 1.45 (1.28-1.64) for lumbar spine BMD. Compared with FN BMD T score ≥ -1.0, wrist fracture adjusted hazard ratios (95% confidence interval) were: 1.51 (1.06-2.16) for a T score between -1.01 and -1.49; 1.93 (1.36-2.72) for T score between -1.50 and -1.99; 2.52 (1.77-3.60) for a T score between -2.00 and -2.49; and 2.65 (1.78-3.95) for a T score ≤ -2.5. Decrease in FN BMD between baseline and year 3 was associated with increased risk of subsequent wrist fracture; however, change in lumbar spine BMD was not.

CONCLUSIONS

Lumbar spine and femoral neck BMDs were associated with incident wrist fracture, but the FRAX threshold recommended to identify screening candidates did not identify the majority of women who subsequently experienced wrist fracture. Improved understanding of determinants of wrist fractures is warranted.

High bone mass in adult mice with diet-induced obesity results from a combination of initial increase in bone mass followed by attenuation in bone formation; implications for high bone mass and decreased bone quality in obesity

Obesity is generally recognized as a condition which positively influences bone mass and bone mineral density (BMD). Positive effect of high body mass index (BMI) on bone has been recognized as a result of increased mechanical loading exerted on the skeleton. However, epidemiologic studies indicate that obesity is associated with increased incidence of fractures. The results presented here offer a new perspective regarding the mechanisms which may be responsible for the increase of bone mass and concurrent decrease in bone quality. Two groups of 12 week old C57BL/6 males were fed either high fat diet (HFD) or regular diet (RD) for 11 weeks. Metabolic profile, bone parameters and gene expression were assessed in these groups at the end of the experiment. Additionally, bone status was evaluated in a third group of 12 week old animals corresponding to animals at the start of the feeding period. Administration of HFD resulted in development of a diet-induced obesity (DIO), glucose intolerance, alteration in energy metabolism, and impairment in WAT function, as compared to the age-matched control animals fed RD. The expression of adiponectin, FABP4/aP2, DIO2 and FoxC2 were decreased in WAT of DIO animals, as well as transcript levels for IGFBP2, the cytokine regulating both energy metabolism and bone mass. At the end of experiment, DIO mice had higher bone mass than both control groups on RD, however they had decreased bone formation, as assessed by calcein labeling, and increased marrow adipocyte content. This study suggests that the bone mass acquired in obesity is a result of a two-phase process. First phase would consist of either beneficial effect of fat expansion to increase bone mass by increased mechanical loading and/or increased production of bone anabolic adipokines and/or nutritional effect of fatty acids. This is followed by a second phase characterized by decreased bone formation and bone turnover resulting from development of metabolic impairment.

Obesity and Fractures in Postmenopausal Women: A Primary-care Cross-Sectional Study at Santa Maria, Brazil

Obesity and osteoporosis are chronic disorders with increasing prevalence worldwide. The aim of this study was to investigate the association between obesity and fracture in postmenopausal women from Santa Maria, Brazil. A cross-sectional study was carried out at Santa Maria (parallel 29° south), Brazil. Postmenopausal women aged ≥55 yr who had at least 1 appointment at the primary care in the 2 years before the study were recruited from March 1, 2013 to August 31, 2013. The Global Longitudinal Study of Osteoporosis in Women study questionnaire was applied with permission of The Center for Outcomes Research, University of Massachusetts Medical School. Height and weight were measured according to the World Health Organization protocol. Bone fractures (excluding hand, feet, and head) that occurred after the age of 45 yr were considered as the outcome. Overall, 1057 women completed the study, of whom 984 had body mass index measured. The mean (standard deviation) age and body mass index of the women included in the study were 67.1 (7.6) yr and 29.2 (5.5) kg/m(2), respectively. The prevalence of fractures in obese and nonobese women was similar (17.3% vs 16.0%); 41.4% of all fractures occurred in obese women. Obese postmenopausal women make a substantial contribution to the overall burden of prevalent fractures in this population. Our results provide further evidence in support of the concept that obesity is not protective against fracture.

Complex association between body weight and fracture risk in postmenopausal women

Osteoporosis is a common disease, characterized by low bone mass with micro-architectural disruption and skeletal fragility, resulting in an increased risk of fracture. A substantial number of studies has examined the possible relationship between body weight, bone mineral density and fracture risk in post-menopausal women, with the majority of them concluding that low body weight correlates with increased risk of fracture, especially hip fracture. Controversies about the potential protective effect of obesity on osteoporosis and consequent fracture risk still exist. Several recent studies question the concept that obesity exerts a protective effect against fractures, suggesting that it stands as a risk factor for fractures at specific skeletal sites, such as upper arm. The association between body weight and fracture risk is complex, differs across skeletal sites and body mass index, and is modified by the interaction between body weight and bone mineral density. Some potential explanations that link obesity with increased fracture risk may be the pattern of falls and impaired mobility in obese individuals, comorbidities, such as asthma, diabetes and early menopause, as well as, increased parathyroid hormone and reduced 25-hydroxy-vitamin D concentrations.

Women with severe obesity and relatively low bone mineral density have increased fracture risk

Among women with obesity, those with the lowest bone density have the highest fracture risk. The types of fractures include any fracture, fragility-type fractures (vertebra, hip, upper arm, forearm, and lower leg), hand and foot fractures, osteoporotic, and other fracture types.

INTRODUCTION

Recent reports have contradicted the traditional view that obesity is protective against fracture. In this study, we have evaluated the relationship between fracture history and bone mineral density (BMD) in subjects with obesity.

METHODS

Fracture risk was assessed in 400 obese women in relation to body mass index (BMI), BMD, and clinical and laboratory variables.

RESULTS

Subjects (mean age, 43.8 years; SD, 11.1 years) had a mean BMI of 46.0 kg/m(2) (SD, 7.4 kg/m(2)). There were a total of 178 self-reported fractures in 87 individuals (21.8% of subjects); fragility-type fractures (hip, vertebra, proximal humerus, distal forearm, and ankle/lower leg) were present in 58 (14.5%). There were higher proportions of women in the lowest femoral neck BMD quintile who had any fracture history (41.3 vs. 17.2%, p < 0.0001), any fragility-type fractures (26.7 vs. 11.7%, p = 0.0009), hand and foot fractures (16.0 vs. 5.5%, p = 0.002), other fracture types (5.3 vs. 1.2%, p = 0.02), and osteoporotic fractures (8.0 vs. 1.2%, p < 0.0001) compared to the remaining population. The odds ratio for any fracture was 0.63 (95% CI, 0.49-0.89; p = 0.0003) per SD increase in BMD and was 4.3 (95% CI, 1.9-9.4; p = 0.003) in the lowest BMD quintile compared to the highest quintile. No clinical or biochemical predictors of fracture risk were identified apart from BMD.

CONCLUSIONS

Women with obesity who have the lowest BMD values, despite these being almost normal, have an elevated risk of fracture compared to those with higher BMD.

Obesity and fractures

Until recently obesity was believed to be protective against fractures. However, a report from a Fracture Liaison Clinic in the UK (2010) reported a surprisingly high proportion of obese postmenopausal women attending the clinic with fractures, and in the GLOW study (2011), a similar prevalence and incidence of fractures in obese and non-obese postmenopausal women was observed. Subsequently, other studies have demonstrated the importance of obesity in the epidemiology of fractures. Obese women are at increased risk of fracture in ankle, leg, humerus, and vertebral column and at lower risk of wrist, hip and pelvis fracture when compared to non-obese women. In men, it has been reported that multiple rib fractures are associated with obesity. Furthermore, falls appear to play an important role in the pathogenesis of fractures in obese subjects. Regarding hip fracture and major fractures, the FRAX algorithm has proven to be a useful predictor in obese individuals. Obese people are less likely to receive bone protective treatment; they have a longer hospital stay and a lower quality of life both before and after fracture. Moreover, the efficacy of antiresorptive therapies is not well established in obese people. The latter is a field for future research.

Osteoporosis update: proceedings of the 2013 Santa Fe Bone Symposium

The 2013 Santa Fe Bone Symposium included plenary sessions on new developments in the fields of osteoporosis and metabolic bone disease, oral presentations of abstracts, and faculty panel discussions of common clinical conundrums: scenarios of perplexing circumstances where treatment decisions are not clearly defined by current medical evidence and clinical practice guidelines. Controversial issues in the care of osteoporosis were reviewed and discussed by faculty and participants. This is a review of the proceedings of the Santa Fe Bone Symposium, constituting in its entirety an update of advances in the understanding of selected bone disease topics of interest and the implications for managing patients in clinical practice. Topics included the associations of diabetes and obesity with skeletal fragility, the complexities and pitfalls in assessing the benefits and potential adverse effects of nutrients for treatment of osteoporosis, uses of dual-energy X-ray absorptiometry beyond measurement of bone mineral density, challenges in the care of osteoporosis in the very elderly, new findings on the role of osteocytes in regulating bone remodeling, and current concepts on the use of bone turnover markers in managing patients with chronic kidney disease who are at high risk for fracture.

Obesity, health-care utilization, and health-related quality of life after fracture in postmenopausal women: Global Longitudinal Study of Osteoporosis in Women (GLOW)

Fractures may be associated with higher morbidity in obese postmenopausal women than in nonobese women. We compared health-care utilization, functional status, and health-related quality of life (HRQL) in obese, nonobese, and underweight women with fractures. Information from the GLOW study, started in 2006, was collected at baseline and at 1, 2, and 3 years. In this subanalysis, self-reported incident clinical fractures, health-care utilization, HRQL, and functional status were recorded and examined. Women in GLOW (n = 60,393) were aged ≥55 years, from 723 physician practices at 17 sites in 10 countries. Complete data for fracture and body mass index were available for 90 underweight, 3,270 nonobese, and 941 obese women with one or more incident clinical fractures during the 3-year follow-up. The median hospital length of stay, adjusted for age, comorbidities, and fracture type, was significantly greater in obese than nonobese women (6 vs. 5 days, p = 0.017). Physical function and vitality score were significantly worse in obese than in nonobese women, both before and after fracture; but changes after fracture were similar across groups. Use of antiosteoporosis medication was significantly lower in obese than in nonobese or underweight women. In conclusion, obese women with fracture undergo a longer period of hospitalization for treatment and have poorer functional status and HRQL than nonobese women. Whether these differences translate into higher economic costs and adverse effects on longer-term outcomes remains to be established.

A United Kingdom perspective on the relationship between body mass index (BMI) and bone health: a cross sectional analysis of data from the Nottingham Fracture Liaison Service

OBJECTIVES

This study examines the relationship between high BMI, a diagnosis of osteoporosis and low trauma fractures.

METHOD

This is a cross sectional analysis using data collected from the Nottingham Fracture Liaison Service. A total of 4288 participants with a low trauma fracture from 1 January 2007 to 31 August 2012 were analysed. Logistic regression adjusted for potential confounders was used investigate osteoporosis and BMI. Fracture types were compared between those who were obese and non-obese.

RESULTS

A total of 30% (1285) were obese. Prevalence of osteoporosis was 13.4%, 24.9%, and 40.4% in the obese, overweight and normal category respectively. Being obese has an odds ratio of 0.23 (95% CI 0.19-0.28, p<0.01) of having osteoporosis compared to a normal BMI category. When variable BMI cut offs were used (BMI 25, 30 and 35) to calculate the positive predictive value of patients not having osteoporosis, it was 80.5%, 86.3% and 88.3%. Examining fracture types, obese patients when compared with the non-obese category, were more likely to fracture their ankle (OR 1.48, p<0.01) and upper arm (OR 1.48, p<0.001), but were less likely to fracture their wrist (OR 0.65, p<0.001). In the elderly (>70years), obesity no longer influenced ankle or wrist fractures but there is an increased risk of upper arm fractures (OR 1.46, p=0.005).

CONCLUSION

Higher BMD in obesity is not protective against fractures as there are a significant number of fractures in this group which may be due to body habitus, mechanism of injury and the effect of adiposity on bone. A low trauma osteoporotic fracture will need to be redefined in light of these findings.

New perspective for third generation percutaneous vertebral augmentation procedures: Preliminary results at 12 months

Introduction:

The prevalence of osteoporotic vertebral fractures (OVF) increased in the last years. Compression fractures promote a progressive spine kyphosis increase, resulting in a weight shift and anterior column overload, with OVF additional risk (domino effect). The aim of this study is to evaluate the OVF treatment outcome using Spine Jack^®, a titanium device for third generation percutaneous vertebral augmentation procedures (PVAPs).

Materials and Methods:

From February 2010, a prospective randomized study was performed examining 300 patients who underwent PVAP due to OVF type A1 according to Magerl/AO spine classification. Patients enrolled in the study were divided in two homogenous groups with regards to age (65-85 years), sex, and general clinical findings. Group A included 150 patients who underwent PVAP using Spine Jack^® system; the second, group B (control group), included 150 patients treated by conventional balloon kyphoplasty. Patients underwent a clinical (visual analogue scale and Oswestry disability index) and radiographic follow-up, with post-operative standing plain radiogram of the spine at 1, 6, and 12 months. The radiographic parameters that were taken into account were: Post-operative anterior vertebral body height, pre-operative anterior vertebral body height, cephalic anterior vertebral body height, and caudal anterior vertebral body height.

Results:

Compared to the Spine Jack^® group, the kyphoplasty group required a little longer operation time (an average of 40 min–group A vs. 45 min–group B, P < 0.05) and a greater amount of polymethylmethacrylate (4.0 mL–group A vs. 5.0 mL–group B, P < 0.05;). The post-operative increase in vertebral body height was greater in the Spine Jack^® group than in the kyphoplasty group (P < 0.05).

Discussion:

PVAP are based on the cement injection into the vertebral body. Vertebroplasty does not allow the vertebral body height recovery. Balloon kyphoplasty allows a temporary height restoration. Spine Jack^® has some new features compared to other systems: It is equipped with a mechanical and not a hydraulic opening control; this ensures a gradual and controlled vertebral fracture reduction.

Conclusions:

In our study, we demonstrated that the third generation PVAP with Spine Jack^® is able to determine a safe vertebral body height restoration compared to the conventional balloon kyphoplasty.

The effect of high-dose vitamin D supplementation on calciotropic hormones and bone mineral density in obese subjects with low levels of circulating 25-hydroxyvitamin d: results from a randomized controlled study

Low levels of 25-hydroxyvitamin D (25OHD) are associated with increased bone turnover and risk of fractures. Plasma 25OHD is inversely related to body mass index, and vitamin D deficiency is common in obesity. We aimed to determine whether vitamin D supplementation affects bone turnover and bone mineral density (BMD) in obese subjects. Fifty-two healthy obese men and women aged 18-50 years with plasma 25OHD levels below 50 nmol/L were randomized to 7,000 IU of cholecalciferol daily or placebo for 26 weeks. We measured plasma levels of 25OHD, parathyroid hormone (PTH), and markers of bone turnover, as well as BMD at the hip, spine, forearm, and whole body. Compared with placebo, treatment with cholecalciferol increased mean plasma 25OHD from 35 to 110 nmol/L (p < 0.00001) and significantly decreased PTH (p < 0.05). BMD increased significantly at the forearm by 1.6 ± 0.7 % (p = 0.03). The bone resorption marker C-terminal telopetide of type 1 collagen (CTX) decreased borderline significantly in the cholecalciferol group compared with the placebo group (p = 0.07). Changes in plasma 25OHD correlated inversely with changes in plasma levels of bone-specific alkaline phosphatase (r = -0.38, p = 0.01) and CTX (r = -0.33, p = 0.03). Changes in CTX correlated inversely with changes in spine BMD (r = -0.45, p = 0.04). Increasing circulating 25OHD levels by cholecalciferol treatment is of importance to bone health in young obese subjects as increased levels of 25OHD are associated with a decrease in both PTH and bone turnover and with an increase in BMD at the forearm.

Bone Remodeling and Energy Metabolism: New Perspectives

Bone mineral, adipose tissue and energy metabolism are interconnected by a complex and multilevel series of networks. Calcium and phosphorus are utilized for insulin secretion and synthesis of high energy compounds. Adipose tissue store lipids and cholecalciferol, which, in turn, can influence calcium balance and energy expenditure. Hormones long-thought to solely modulate energy and mineral homeostasis may influence adipocytic function. Osteoblasts are a target of insulin action in bone. Moreover, endocrine mediators, such as osteocalcin, are synthesized in the skeleton but regulate carbohydrate disposal and insulin secretion. Finally, osteoblasts and adipocytes originate from the same mesenchymal progenitor. The mutual crosstalk between osteoblasts and adipocytes within the bone marrow microenvironment plays a crucial role in bone remodeling. In the present review we provide an overview of the reciprocal control between bone and energy metabolism and its clinical implications.

Obesity and bone

Recent studies indicate that fractures in obese postmenopausal women and older men contribute significantly to the overall fracture burden. The effect of obesity is to some extent site-dependent, the risk being increased for some fractures and decreased for others, possibly related to different patterns of falling and the presence or absence of soft tissue padding. Risk factors for fracture in obese individuals appear to be similar to those in the nonobese population, although falls may be particularly important in the obese. There is some evidence that the morbidity associated with fractures in obese individuals is greater than in the nonobese; however, a recent study indicates that the mortality associated with fracture is lower in obese and overweight people than in those of normal weight. The evidence base for strategies to prevent fractures in obese individuals is weak and is an important area for future research.

Ten-week whole-body vibration training improves body composition and muscle strength in obese women

This work explored the short-term effect of whole body vibration (WBV) training on anthropometry, body composition and muscular strength in obese women. Fifty obese women (age = 46.8 ± 7.81[SD]y; BMI = 35.1 ± 3.55 kg/m(2)) were assigned to a ten-week WBV training period, two times a week (in each session, 14 min vibration training, 5 min rest; vibration amplitude 2.0-5.0mm, frequency 40-60 Hz), with (n = 18) or without (n = 17) radiofrequency, or to a non-exercise control group (n = 15). Subjects were instructed not to change their habitual lifestyle. Before and after the ten-week experimental period, anthropometric measurements, dual-energy X-ray absorptiometry (DXA), and the leg press, leg curl and leg extension strength tests were carried out. All changes in the two groups of WBV training, with or without radiofrequency, were similar and these groups were combined in a single WBV intervention group. As compared to controls, subjects submitted to WBV training had significantly lower BMI, total body and trunk fat, sum of skinfolds and body circumferences. On the other hand, lower limb strength tests were increased in the WBV group. These preliminary results suggest that WBV training may improve body composition and muscular strength in obese women and may be a useful adjuvant to lifestyle prescriptions.

Predictive value of FRAX for fracture in obese older women

Recent studies indicate that obesity is not protective against fracture in postmenopausal women and increases the risk of fracture at some sites. Risk factors for fracture in obese women may differ from those in the nonobese. We aimed to compare the ability of FRAX with and without bone mineral density (BMD) to predict fractures in obese and nonobese older postmenopausal women who were participants in the Study of Osteoporotic Fractures. Data for FRAX clinical risk factors and femoral neck BMD were available in 6049 women, of whom 18.5% were obese. Hip fractures, major osteoporotic fractures, and any clinical fractures were ascertained during a mean follow-up period of 9.03 years. Receiving operator curve (ROC) analysis, model calibration, and decision curve analysis were used to compare fracture prediction in obese and nonobese women. ROC analysis revealed no significant differences between obese and nonobese women in fracture prediction by FRAX, with or without BMD. Predicted hip fracture risk was lower than observed risk in both groups of women, particularly when FRAX + BMD was used, but there was good calibration for FRAX + BMD in prediction of major osteoporotic fracture in both groups. Decision curve analysis demonstrated that both FRAX models were useful for hip fracture prediction in obese and nonobese women for threshold 10-year fracture probabilities in the range of 4% to 10%, although in obese women FRAX + BMD was superior to FRAX alone. For major osteoporotic fracture, both FRAX models were useful in both groups of women for threshold probabilities in the range of 10% to 30%. For all clinical fractures, the FRAX models were not useful at threshold probabilities below 30%. We conclude that FRAX is of value in predicting hip and major osteoporotic fractures in obese postmenopausal women, particularly when used with BMD.

Bone mineral density-associated polymorphisms are associated with obesity-related traits in Korean adults in a sex-dependent manner

Obesity and osteoporosis share common physiological factors, including the presence of atherosclerosis, a risk factor for cardiometabolic disease, as well as a common progenitor that differentiates into both adipocytes and osteoblasts. Among the 23 polymorphisms associated with bone mineral density (BMD) in recent genome-wide association studies (GWASs), an Osterix polymorphism has been identified and associated with childhood obesity in girls. Therefore, we focused on elucidating polymorphisms associated with adulthood obesity in a sex-dependent manner among the previously published BMD-associated polymorphisms from GWASs. We performed 2 screenings of 18 BMD-associated polymorphisms for obesity-related traits in 2,362 adults aged >20 years. We excluded 13 polymorphisms showing deviations from Hardy–Weinberg equilibrium or no association with obesity-related traits (body mass index, waist circumference (WC), and waist-to-hip ratio). Among 5 selected polymorphisms (rs9594738 of RANKL, rs17066364 of NUFIP1, rs7227401 of OSBPL1A, and rs1856057 and rs2982573 of ESR1) analyzed, 2 polymorphisms (rs9594738 and rs17066364) were associated with obesity-related traits. We found sex-dependent associations such that the 4 polymorphisms (excluding rs9594738 of RANKL) were associated with abdominal traits such as WC and waist-to-hip ratio only in men. In addition, when the combined genetic risk score (GRS) for WC increase was calculated with 4 SNPs (rs9594738, rs17066364, rs7227401, and rs1856057) exhibiting similar trends for both sexes, the magnitude of the GRS effect for the WC increase was larger in men than in women (effect size = 0.856 cm, P = 0.0000452 for men; effect size = 0.598 cm, P = 0.00228 for women). In summary, we found 4 polymorphisms, previously related to osteoporosis, to be associated to obesity-related traits in a sex-dependent manner in Korean adults, particularly in men.

Bone structure and B-cell populations, crippled by obesity, are partially rescued by brief daily exposure to low-magnitude mechanical signals

Deterioration of the immune and skeletal systems, each of which parallel obesity, reflects a fragile interrelationship between adiposity and osteoimmunology. Using a murine model of diet-induced obesity, this study investigated the ability of mechanical signals to protect the skeletal-immune systems at the tissue, cellular, and molecular level. A long-term (7 mo) high-fat diet increased total adiposity (+62%), accelerated age-related loss of trabecular bone (-61%), and markedly reduced B-cell number in the marrow (-52%) and blood (-36%) compared to mice fed a regular diet. In the final 4 mo of the protocol, the application of low-magnitude mechanical signals (0.2 g at 90 Hz, 15 min/d, 5 d/wk) restored both bone structure and B cells to those levels measured in control mice fed a regular diet. These phenotypic outcomes were achieved, in part, by reductions in osteoclastic activity and a biasing of hematopoietic stem cell differentiation toward the lymphoid B-cell lineage and away from a myeloid fate. These results emphasize that obesity undermines both the skeletal and immune systems, yet brief exposure to mechanical signals, perhaps as a surrogate to the salutary influence of exercise, diminishes the consequences of diabetes and obesity, restoring bone structure and normalizing B-cell populations by biasing of the fate of stem cells through mechanosensitive pathways.

AMP-activated protein kinase pathway and bone metabolism

There is increasing evidence that osteoporosis, similarly to obesity and diabetes, could be another disorder of energy metabolism. AMP-activated protein kinase (AMPK) has emerged over the last decade as a key sensing mechanism in the regulation of cellular energy homeostasis and is an essential mediator of the central and peripheral effects of many hormones on the metabolism of appetite, fat and glucose. Novel work demonstrates that the AMPK signaling pathway also plays a role in bone physiology. Activation of AMPK promotes bone formation in vitro and the deletion of α or β subunit of AMPK decreases bone mass in mice. Furthermore, AMPK activity in bone cells is regulated by the same hormones that regulate food intake and energy expenditure through AMPK activation in the brain and peripheral tissues. AMPK is also activated by antidiabetic drugs such as metformin and thiazolidinediones (TZDs), which also impact on skeletal metabolism. Interestingly, TZDs have detrimental skeletal side effects, causing bone loss and increasing the risk of fractures, although the role of AMPK mediation is still unclear. These data are presented in this review that also discusses the potential roles of AMPK in bone as well as the possibility for AMPK to be a future therapeutic target for intervention in osteoporosis.

The association between fracture and obesity is site-dependent: a population-based study in postmenopausal women

The association between obesity and fracture is controversial. We investigated the relationship between body mass index (BMI) and fracture at different skeletal sites in women aged ≥50 years using data from the Sistema d' Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP) database. SIDIAP contains the computerized medical records of >3400 general practitioners in Catalonia (northeastern Spain), with information on a representative 80% of the population (>5 million people). In 2009, 1,039,878 women aged ≥50 years were eligible, of whom 832,775 (80.1%) had a BMI measurement. These were categorized into underweight/normal (302,414 women), overweight (266,798), and obese (263,563). Fractures were ascertained using the International Classification of Diseases, 10th revision (ICD-10) codes. Multivariate Poisson regression models were fitted to adjust for age, smoking, high alcohol intake, type 2 diabetes, and oral corticosteroid use. Hip fractures were significantly less common in overweight and obese women than in normal/underweight women (rate ratio [RR] 0.77 [95% confidence interval (CI) 0.68 to 0.88], RR 0.63 [95% CI 0.64 to 0.79], p < 0.001, respectively). Pelvis fracture rates were lower in the overweight (RR 0.78 [95% CI 0.63 to 0.96], p = 0.017) and obese (RR 0.58 [95% CI 0.47 to 0.73], p < 0.001) groups. Conversely, obese women were at significantly higher risk of proximal humerus fracture than the normal/underweight group (RR 1.28 [95% CI 1.04 to 1.58], p = 0.018). Clinical spine, wrist, tibial, and multiple rib fracture rates were not significantly different between groups. An age-related increase in incidence was seen for all BMI groups at all fracture sites; obese women with hip, clinical spine, and pelvis fracture were significantly younger at the time of fracture than normal/underweight women, whereas those with wrist fracture were significantly older. The association between obesity and fracture in postmenopausal women is site-dependent, obesity being protective against hip and pelvis fractures but associated with an almost 30% increase in risk for proximal humerus fractures when compared with normal/underweight women. The reasons for these site-specific variations are unknown but may be related to different patterns of falls and attenuation of their impact by adipose tissue.