Vitamin D and Calcium Intakes, Physical Activity, and Calcaneus BMC among School-Going 13-Year Old Malaysian Adolescents

Effectiveness of an e-Book on Bone Health as Educational Material for Adolescents: Single-Group Experimental Study

Background

Improved bone health during adolescence can have lifelong implications, reducing the risk of bone fragility.

Objective

This study aims to evaluate the effectiveness of an e-book in increasing knowledge about and promoting healthy practices related to bone health among Malay adolescents in Kuala Lumpur, Malaysia.

Methods

A total of 72 adolescents (female: n=51, 71%; age: mean 15, SD 0.74 y) were recruited from selected secondary schools. The participants answered a pretest web-based questionnaire on sociodemographic data, knowledge about osteoporosis, and physical activity. A video call was conducted to assess dietary calcium intake. Participants were provided with a link to an e-book on bone health and instructed to read it within 2 weeks. Postintervention assessments included those for knowledge, physical activity, dietary calcium intake, and acceptance of the e-book.

Results

There was a significant increase in the median knowledge score, which was 40.6% (IQR 31.3%-46.9%) during the pretest and 71.9% (IQR 53.9%-81.3%) during the posttest (P<.001). However, no changes were observed in dietary calcium intake or physical activity levels. Most participants did not meet the recommended calcium requirements (61/62, 98%) and exhibited sedentary behavior (pretest: 51/62, 82%; posttest: 48/62, 77%). The e-book, however, was well accepted, with the majority reporting that they understood the contents (70/72, 97%), liked the graphics (71/72, 99%), and approved of the layout (60/72, 83%) and font size (66/72, 92%) used.

Conclusions

The developed e-book effectively increases knowledge levels related to bone health and is well accepted among participants. However, this educational material did not improve bone health practices. Additional strategies are necessary to bridge the gap between knowledge and behavior change.

Calcium food sources in primary school children with low calcium intakes in Kuala Lumpur

Background: Adequate calcium intake at an early age is crucial to achieving peak bone mass. Nevertheless, low calcium intake is common in Malaysian children. Aim: This study examined the calcium food sources and factors associated with low calcium intake among 243 children aged 9-11 years in Kuala Lumpur. Methods: Diet histories and bone density were measured. Results: The mean calcium intake was 370 ± 187 mg/day. The main contributors to calcium intake were beverages (19.2%), cereal (18.6%), milk and dairy (13.0%), meat and poultry (12.9%), and fish and seafood (10.1%). Within each food group, calcium-contributing foods tend to be from low bioavailability sources such as rice, cocoa-based and malted drinks, and chicken rather than milk. Children who practised regular meals, ate breakfast and snacks and consumed milk more than one serving daily have a higher calcium intake. Conclusion: In conclusion, public health strategies to improve the status of low calcium intake and poor choices of calcium-rich foods are needed to optimise bone health in this population.

Assessment of Knowledge, Physical Activity and Calcium Intake among Female University Students

Insufficient calcium intake and being physically inactive lead to osteoporosis. This study aimed to assess the level of knowledge about osteoporosis, physical activity levels and their correlation with calcium intake. 276 female undergraduate students participated in this study. A set of questionnaires was distributed. Majority students had low knowledge (76.1%), moderate physical activity level (47.1%) and did not meet the recommended calcium intake (79.0%). There was a moderate to strong positive correlation but not significant between knowledge (r= 0.051, p=0.121) and physical activity (r = 0.081, p=0.181) to dietary calcium intake. In conclusion, students had poor knowledge about osteoporosis.

Application of health belief model in the assessment of factors affecting exercise behaviours in preventing osteoporosis

Objectives

Osteoporosis is a skeletal disorder associated with weak and brittle bones, and more susceptible to fracture. Osteo-protective behaviours, such as exercise, may prevent osteoporosis. Therefore, this study aimed to assess the factors influencing the exercise behaviour in Malaysian adults and to assess their health beliefs and self-regulation in preventing osteoporosis.

Methods

A cross-sectional, self-administered questionnaire was conducted throughout Malaysia through a web-based or physical-based survey. The questionnaire consisted of three sections: demographic data, ten questions regarding social and family history related to osteoporosis and 38 questions with seven subdomains (i.e. susceptibility, seriousness, barriers, benefits, health motivation, self-efficacy and self-regulation) which measured the health belief scores and self-regulation using 5-point Likert scale. Descriptive, inferential analysis and linear regression were used to analyse the data.

Key findings

A total of 679 participants completed the questionnaire. The mean health belief score was 63.7%, which was moderate. Most participants (64.4%) perceived low susceptibility to osteoporosis [mean score = 47.0%, standard deviation (SD) = 16.2]. Participants with age 18–27 years (44.8%), single (45.0%) and monthly income &lt;RM 1000 (45.2%), perceived significant lower susceptibility to osteoporosis. Participants’ perception scores were high on the benefits of exercise (75.7%, SD = 16.4), health motivation (74.9%, SD = 17.1) and perceived low barriers to exercise (71.7%, SD = 14.9). Respondents who were at risk of osteoporosis and with family and friends diagnosed with osteoporosis obtained a higher score than those who did not.

Conclusions

The health belief score in the Malaysian population was moderate. However, the majority of participants were unaware of the susceptibility and seriousness of osteoporosis. Efforts need to be taken to break the barriers associated with exercise in preventing osteoporosis.

Calcium deficiency worldwide: prevalence of inadequate intakes and associated health outcomes

Dietary calcium deficiency is considered to be widespread globally, with published estimates suggesting that approximately half of the world's population has inadequate access to dietary calcium. Calcium is essential for bone health, but inadequate intakes have also been linked to other health outcomes, including pregnancy complications, cancers, and cardiovascular disease. Populations in low- and middle-income countries (LMICs) are at greatest risk of low calcium intakes, although many individuals in high-income countries (HICs) also do not meet recommendations. Paradoxically, many LMICs with lower calcium intakes show lower rates of osteoporotic fracture as compared with HICs, though data are sparse. Calcium intake recommendations vary across agencies and may need to be customized based on other dietary factors, health-related behaviors, or the risk of calcium-related health outcomes. The lack of standard methods to assess the calcium status of an individual or population has challenged efforts to estimate the prevalence of calcium deficiency and the global burden of related adverse health consequences. This paper aims to consolidate available evidence related to the global prevalence of inadequate calcium intakes and associated health outcomes, with the goal of providing a foundation for developing policies and population-level interventions to safely improve calcium intake and status where necessary.

Prevalence of lactose intolerance and malabsorption among children of two ethnic groups from the urban areas of Malaysia and its relation to calcium intake and bone health status

Lactase insufficiency could develop into lactose intolerance (LI) and disrupt the intake of calcium, which is a core nutrient for bone development in children. However, data regarding the prevalence of LI and bone health status (BHS) among Malaysian children are scarcely reported.

PURPOSE

This study aimed to determine the prevalence of LI and lactose malabsorption (LM) in Malay and Chinese children and examine its relationship with calcium intake (CI) and BHS.

METHODS

A total of 400 children participated in this study. The prevalence of lactose tolerance (LT) was assessed using hydrogen breath test, LT test, and visual analogue scales. Assessment of CI was performed using a 24-h dietary recall interview (24-h DR) and food frequency questionnaire (FFQ). Calcaneal broadband ultrasound attenuation (BUA) was measured using a quantitative ultrasonometer.

RESULTS

The prevalence of LI among Chinese children (37%) was significantly higher (p = 0.002) than among Malay children (22.5%). However, 61.5% of Malay and 54.5% of Chinese children were found to have LM. CI of the children fulfilled 30.5% and 33.9% of the Malaysian recommended CI (1300 mg/day) for 24-h DR and FFQ, respectively. The BUA score of Malay children was significantly higher (p < 0.001) than that of Chinese children. However, LT and CI were not correlated with BHS (p > 0.05, respectively).

CONCLUSIONS

LI was diagnosed among Malay and Chinese children. However, the higher prevalence of LM is rather worrying as it could develop to LI. The prevalence possibly has been worsened by insufficient CI. Thus, effective approaches to increase CI are highly needed as bone development occurs rapidly at this age and is important for the attainment of the optimum peak bone mass during late adolescence.

Factors associated with bone health status of Malaysian pre-adolescent children in the PREBONE-Kids Study

Background

Modifiable lifestyle factors and body composition can affect the attainment of peak bone mass during childhood. This study performed a cross-sectional analysis of the determinants of bone health among pre-adolescent (N = 243) Malaysian children with habitually low calcium intakes and vitamin D status in Kuala Lumpur (PREBONE-Kids Study).

Methods

Body composition, bone mineral density (BMD), and bone mineral content (BMC) at the lumbar spine (LS) and total body (TB) were assessed using dual-energy X-ray absorptiometry (DXA). Calcium intake was assessed using 1-week diet history, MET (metabolic equivalent of task) score using cPAQ physical activity questionnaire, and serum 25(OH) vitamin D using LC-MS/MS.

Results

The mean calcium intake was 349 ± 180 mg/day and mean serum 25(OH)D level was 43.9 ± 14.5 nmol/L. In boys, lean mass (LM) was a significant predictor of LSBMC (β = 0.539, p < 0.001), LSBMD (β = 0.607, p < 0.001), TBBMC (β = 0.675, p < 0.001) and TBBMD (β = 0.481, p < 0.01). Height was a significant predictor of LSBMC (β = 0.346, p < 0.001) and TBBMC (β = 0.282, p < 0.001) while fat mass (FM) (β = 0.261, p = 0.034) and physical activity measured as MET scores (β = 0.163, p = 0.026) were significant predictors of TBBMD in boys. Among girls, LM was also a significant predictor of LSBMC (β = 0.620, p < 0.001), LSBMD (β = 0.700, p < 0.001), TBBMC (β = 0.542, p < 0.001) and TBBMD (β = 0.747, p < 0.001). Calcium intake was a significant predictor of LSBMC (β = 0.102, p = 0.034), TBBMC (β = 0.122, p < 0.001) and TBBMD (β = 0.196, p = 0.002) in girls.

Conclusions

LM was the major determinant of BMC and BMD among pre-adolescent Malaysian children alongside other modifiable lifestyle factors such as physical activity and calcium intake.

Longitudinal Vitamin D Deficiency Among Malaysian Pregnant Women and Its Correlation With Neonatal Serum 25-Hydroxyvitamin D Levels

Objective: This study aimed to investigate the longitudinal relationship between maternal vitamin D concentrations during pregnancy and neonatal vitamin D concentrations at birth.

Materials and Methods: A prospective cohort of 236 healthy pregnant women from various ethnicity in early pregnancy (≤20 weeks of pregnancy) was followed at late pregnancy (28–40 weeks of pregnancy) and birth. Maternal serum 25-hydroxyvitamin D (25(OH)D) was assessed at early pregnancy (baseline) and late pregnancy, while neonatal cord serum 25(OH)D at birth. General estimating equations (GEE) were used to analyze the longitudinal association of maternal serum 25(OH)D levels during pregnancy and neonatal cord serum 25(OH)D levels at birth with adjusting for the time exposure, maternal weight gain, ethnicity, and skin type.

Results: The results showed that the prevalence of vitamin D deficiency (25(OH)D <50 nmol/L) was at 89.9, 92.2, and 96.1% in early, late pregnancy and in neonatal cord serum, respectively. The GEE analysis showed a trend that longitudinal vitamin D deficiency during pregnancy leads to lower vitamin D concentrations in neonatal cord blood (RR = 1.17; 95% CI (1.05–1.36); p = 0.04).

Conclusion: Longitudinal vitamin D deficiency during pregnancy leads to vitamin D deficiency in neonates at birth. A further trial is needed to affirm this association.

Vitamin D Status Is Associated with Modifiable Lifestyle Factors in Pre-Adolescent Children Living in Urban Kuala Lumpur, Malaysia

Studies on vitamin D status and its determinants in growing children in countries with ample sunshine such as Malaysia have been limited. The aim of our study was to determine factors associated with serum 25(OH)D concentrations such as lifestyle, dietary intake, anthropometry, and body composition in 243 pre-adolescent Malaysian children from low-income families living in Kuala Lumpur. This cross-sectional study measured bone density and body composition using dual-energy X-ray absorptiometry (DXA), while serum 25(OH)D was measured using LC-MS/MS. Time spent outdoors, body surface area exposed to sunlight, dietary intake, and physical activity level were assessed using questionnaires. Multiple linear regression and stepwise analysis were performed to identify significant predictors for serum 25(OH)D. About 69.4% had 25(OH)D < 50 nmol/L, and 18.9% were vitamin-D-deficient with 25(OH)D < 30 nmol/L. Girls had a nine-fold higher prevalence of vitamin D deficiency than boys. Body surface area exposed to sunlight, Sun Index, and fat mass were significant predictors of 25(OH)D concentrations in this population. Modifiable lifestyle factors such as sun exposure and reducing obesity are important public health guidance to ensure optimal vitamin D status in these children.

Association of calcium intake, lactose intolerance and physical activity with bone health assessed via quantitative ultrasound among young adults of a Malaysian university

Lactose intolerance has been proposed to cause poor bone health. This study found the prevalence of lactose intolerance was high among Malaysian young adults, but not associated with bone health status, unlike calcium intake. This is the first study that investigated the association of lactose intolerance and bone health status in Malaysia.

PURPOSE

The aims of this study were to determine the prevalence of lactose intolerance, calcium intake and physical activity level and to investigate the association between these variables with bone health status among young adults.

METHODS

This cross-sectional study consisted of 300 Malay, Chinese and Indian students from Universiti Kebangsaan Malaysia with mean age of 22.5 ± 3.2 years. Determination of lactose tolerance status was performed using hydrogen breath test, lactose tolerance test and visual analogue scales. Calcium intake and physical activity level were evaluated using Food Frequency Questionnaire and International Physical Activity Questionnaire, respectively. Bone health status was assessed on calcaneal bone, using quantitative ultrasound.

RESULTS

Lactose intolerance was highly reported among the Malay subjects (72%) followed by Chinese (59%) and Indians (42%). The mean calcium intake was 542.9 ± 365.2 mg/day whilst the mean physical activity was 2757.6 ± 2007.2 MET-min/week. The bone assessment showed that 91% of the subjects had a low risk of developing osteoporosis. Only calcium intake showed a significant association with bone health status (β = 0.006; p = 0.033), whilst no association was shown for lactose intolerance and physical activity level.

CONCLUSIONS

Malaysian young adults showed a high prevalence of lactose intolerance. Calcium intake is associated with increased bone health status. In contrast, lactose intolerance and physical activity level did not directly influence bone health status. Nutrition education promoting adequate calcium intake should be implemented among young adults due to high lactose intolerance prevalence and low calcium intake among subjects.

The longitudinal relationship between dietary intake, physical activity and muscle strength among adolescents

The longitudinal relationship between muscle strength, dietary intake and physical activity among adolescents is not well understood. We investigated the trend and longitudinal effects of dietary intakes and physical activity scores on muscle strength in adolescents. This prospective cohort study consisted of 436 adolescents (134 males; 302 females) aged 13 years at baseline (2012) who were followed up at the ages of 15 (2014) and 17 (2016) years, respectively. We measured muscle strength using a calibrated hand dynamometer, estimated dietary intake with a 7-d dietary history and physical activity scores with a validated physical activity questionnaire for older children. A generalised estimating equation was used to examine the effect of dietary intakes and physical activity on muscle strength changes. The analysis was performed separately by sex. The muscle strength for males and females had increased within the 5-year period. The dietary intakes (energy and macronutrients) also increased initially but plateaued after the age of 15 years for both sexes. Females recorded a significant declining trend in physical activity scores compared with males as they grew older. A significant positive longitudinal relationship was found between protein (β = 0·035; P = 0·016), carbohydrate intake (β = 0·002; P = 0·013) and muscle strength among males. However, no longitudinal relationship was found between dietary intake, physical activity and muscle strength among females. Higher protein and carbohydrate intake among males was associated with higher muscle strength but was not observed in females. Nutrition and physical activity focusing on strength building are required in early adolescence and need to be tailored to males and females accordingly.

Bone mass and dietary intake in children and adolescents with type 1 diabetes mellitus

OBJECTIVES

To evaluate the bone mineral density (BMD) in children/adolescents with type 1 diabetes mellitus (T1DM) and its association with the nutritional intake, metabolic control, and physical activity level of this population.

METHODS

Study including 34 patients with T1DM and 17 controls. Assessments included the participants disease history, intake of macronutrient, calcium, phosphorus and magnesium, physical activity level, total body and lumbar spine BMD and serum levels of glycated hemoglobin, vitamin D, calcium, phosphorus, magnesium, osteocalcin and C-terminal telopeptide.

RESULTS

Total body and lumbar spine BMD z-scores were normal in all but two participants in the T1DM group. The T1DM group had significantly lower total body BMD z-score values (p < 0.001) and levels of osteocalcin, C-terminal telopeptide, calcium, phosphorus, and magnesium. Intake of macronutrients and calcium was inadequate in both groups. Participants in the T1DM group were more sedentary (88%) and had inadequate metabolic control (91%) and low vitamin D levels (82%). Bone mass in the T1DM group was influenced by body mass index (BMI), pubertal stage, disease duration, calcium intake, and physical activity level.

CONCLUSIONS

Bone mass in patients with T1DM was adequate but lower than controls and was influenced by BMI, pubertal stage, disease duration, calcium consumption, and physical activity level.

Association between dietary calcium intake and BMD in children and adolescents

AIM

Ensuring adequate calcium (Ca) intake during childhood and adolescence is critical to acquire good peak bone mass to prevent osteoporosis during older age. As one of the primary strategies to build and maintain healthy bones, we aimed to determine whether dietary Ca intake has an influence on bone mineral density (BMD) in children and adolescents.

METHODS

We conducted a cross-sectional study composed of 10,092 individuals from the National Health and Nutrition Examination Survey (NHANES). Dietary Ca intake and total BMD were as independent and dependent variables, respectively. To evaluate the association between them, we conducted weighted multivariate linear regression models and smooth curve fittings.

RESULTS

There was a significantly positive association between dietary Ca intake and total BMD. The strongest association was observed in 12-15y whites, 8-11y and 16-19y Mexican Americans, and 16-19y other race/ethnicity, in whom each quintile of calcium intake was increased. We also found there were significant inflection points in females, blacks, and 12-15y adolescents group, which means that their total BMD would decrease when the dietary Ca intake was more than 2.6-2.8 g/d.

CONCLUSIONS

This cross-sectional study indicated that a considerable proportion of children and adolescents aged 8-19 years would attain greater total BMD if they increased their dietary calcium intake. However, higher dietary calcium intake (more than 2.6-2.8 g/d) is associated with lower total BMD in females, blacks, and 12-15y adolescents group.

Quantitative Ultrasound and Dual X-Ray Absorptiometry as Indicators of Bone Mineral Density in Young Women and Nutritional Factors Affecting It

Young adulthood is an important stage in the accrual of bone mass. Young women are often unaware of the need, and how to optimize modifiable risk factors, particularly intake of nutrients associated with good bone health. In this study, an accessible way to estimate osteoporosis risk, quantitative ultrasound (QUS), is compared to the gold-standard technique dual X-ray absorptiometry (DXA) in a group of 54 healthy young women (18–26 years) from Manawatu, New Zealand, and the relationship with nutrient intake is investigated. Broadband ultrasound attenuation and speed of sound (BUA, SOS) were assessed by QUS calcaneal scans and bone mineral concentration/density (BMC/BMD) were determined by DXA scans of the lumbar spine and hip (total and femoral neck). Dietary intake of energy, protein, and calcium was estimated using three-day food diaries and questionnaires. DXA mean Z-scores (>−2.0) for the hip (0.19) and spine (0.2) and QUS mean Z-scores (>−1.0) (0.41) were within the expected ranges. DXA (BMD) and QUS (BUA, SOS) measurements were strongly correlated. Median intakes of protein and calcium were 83.7 g/day and 784 mg/day, respectively. Protein intake was adequate and, whilst median calcium intake was higher than national average, it was below the Estimated Average Requirement (EAR). No significant relationship was found between dietary intake of calcium or protein and BMD or BMC. To conclude, QUS may provide a reasonable indicator of osteoporosis risk in young women but may not be an appropriate diagnostic tool. Increased calcium intake is recommended for this group, regardless of BMD.

Weight-Bearing Physical Activity Influences the Effect of Vitamin D on Bone Turnover Markers in Patients with Intellectual Disability

OBJECTIVES

Individuals with intellectual disabilities (IDs) are at increased risk for low bone mass and fragility fractures, and those who are nonambulatory may be at even higher risk. Patients with IDs often are vitamin D deficient, but there is little information concerning how vitamin D treatment of patients with IDs affects markers of bone formation and resorption.

METHODS

We performed a retrospective analysis of 23 institutionalized individuals with IDs who were the subject of a performance improvement continuing medical education project designed to reduce risk for fracture by optimizing serum vitamin D levels. Patients were divided into those with normal weight-bearing (NWB) physical activity (15 patients: 14 men, 1 woman) and those with low weight-bearing (LWB) physical activity (8 patients: 7 men, 1 woman). All of the subjects received 50,000 IU of vitamin D₃ weekly for 4 to 8 weeks, followed by a maintenance dose of 50,000 IU monthly for 3 to 6 months. Bone turnover markers (type 1 cross-linked C-telopeptide [CTX], type 1 N-terminal propeptide [P1NP], and parathyroid hormone [PTH]) and 25(OH)-vitamin D levels were measured before and after vitamin D supplementation.

RESULTS

At baseline, there were no significant differences in the serum levels of 25OH-D, PTH, P1NP, or CTX between the two groups (NWB and LWB). Vitamin D levels were increased to a higher value in LWB subjects than in NWB subjects (61 ± 4.1 vs 48.4 ± 2.2 ng/mL, P < 0.001). Vitamin D treatment suppressed PTH (20.5% ± 14.3% vs 31.4% ± 7.7%, P = not significant) and P1NP (33.0% ± 6.2% vs 29.4% ± 6.9%, P = not significant) similarly in both groups. Although CTX levels declined by 26.4% ± 5.3% (P = 0.0002) in NWB individuals (as anticipated), vitamin D supplementation resulted in an unexpected 25.8% ± 8% increase (P = 0.01) in CTX in LWB individuals, suggesting osteoclast activation.

CONCLUSIONS

Although high-dose vitamin D appeared to suppress osteoclast activity in NWB adults with IDs, the increase in serum CTX levels in those with LWB activity implies activation of osteoclasts that could exacerbate their unique low bone mass and increase fracture risk. The results support the use of a lower-dose vitamin D regimen in this patient group with LWB.

A Review of Knowledge, Belief and Practice Regarding Osteoporosis among Adolescents and Young Adults

Osteoporosis is a major public health problem affecting millions of people worldwide. Increasing knowledge, correcting health belief and promoting osteoprotective practices are effective measures for building and maintaining strong bone throughout ones’ life-span. This review aims to summarize the contemporary evidence on the knowledge, beliefs and practice of adolescents and young adults on bone health. We performed literature searches using the PubMed and Scopus databases to identify original studies from 2008 to May 2018 using the search terms “(knowledge OR beliefs OR attitude OR practice OR behaviours OR physical activity OR exercise OR diet OR nutrition) AND (young OR youth OR adolescents OR children OR young adults OR students OR teenager) AND (osteoporosis OR bone health)”. Of the 3206 articles found, 34 met the inclusion criteria. Studies showed that most adolescents and young adults had poor knowledge and expressed disinterest in osteoporosis. They believed that other diseases were more serious than osteoporosis, contributing to low perceived susceptibility and seriousness towards this disease. Popular media emerged as a platform to obtain information regarding osteoporosis. The lack of knowledge and misconceptions about osteoporosis led to poor osteoprotective practices. As a conclusion, the current evidence revealed a lack of awareness about osteoporosis among adolescents and young adults. Educational interventions may be useful to improve the awareness of osteoporosis among this population.