Effectiveness of a community-based multicomponent lifestyle intervention (the ADA programme) to improve the quality of life of French breast cancer survivors: protocol for a pragmatic cluster randomised trial and embedded qualitative study

INTRODUCTION

Breast cancer survivors (BCSs) are often faced with multiple mental and physical sequelae and are at increased risk of emotional distress, degraded health-related quality of life (HRQoL), chronic pain and fatigue.Physical activity is strongly associated with improved HRQoL and survival rates; however, adherence rates to recommendations for a healthy lifestyle are seldom satisfactory among BCSs. Also, few studies have examined the effectiveness of multicomponent and personalised interventions that integrate physical activity and motivational techniques to improve the HRQoL of BCS.

METHOD AND ANALYSIS

"Activité physique adaptée Doublée d'un Accompagnement d'après cancer" (ADA) is an integrated programme of physical activity enriched with a dietary and supportive care approach targeting BCS in the early post-treatment phase. The effectiveness of the ADA intervention will be evaluated using a cluster randomised controlled trial design with two arms (ADA programme vs usual care; 1:1 ratio).The ADA intervention aims to recruit 160 participants and will be implemented by Siel Bleu, a non-profit association specialised in health prevention via adapted physical activity. Measurements will be performed at baseline, 3, 6 and 12 months after the start of the intervention. The primary outcome will be participants' HRQoL, at 12 months measured by the Functional Assessment of Chronic Illness Therapy-Fatigue global score. Secondary outcome will include participants' physical, social, emotional and functional well-being. The effect of the intervention on physical activity level, motivation for physical activity, relation to food and self-efficacy will also be evaluated.

ETHICS AND DISSEMINATION

The study was approved by the 'CPP Paris XI' Institutional Review Board on 5 May 2022 (Ref no.: 21.04512.000048-22004). The study's findings will be shared through various channels, including academic publications, simplified reports for wider audiences and active engagement with medical and institutional organisations as well as patients' associations.

TRIAL REGISTRATION NUMBER

NCT05658341.

Lifestyle patterns in European preschoolers: Associations with socio-demographic factors and body mass index

BACKGROUND

Energy balance-related behaviours (EBRBs), that is, dietary intake, screen, outdoor play and sleep, tend to combine into 'lifestyle patterns', with potential synergistic influences on health. To date, studies addressing this theme mainly focused on school children and rarely accounted for sleep, with a cross-country perspective.

OBJECTIVES

We aimed at comparing lifestyle patterns among preschool-aged children across Europe, their associations with socio-demographic factors and their links with body mass index (BMI).

METHODS

Harmonized data on 2-5-year-olds participating in nine European birth cohorts from the EU Child Cohort Network were used (EBRBs, socio-demographics and anthropometrics). Principal component analysis and multivariable linear and logistic regressions were performed.

RESULTS

The most consistent pattern identified across cohorts was defined by at least three of the following EBRBs: discretionary consumption, high screen time, low outdoor play time and low sleep duration. Consistently, children from low-income households and born to mothers with low education level had higher scores on this pattern compared to their socioeconomically advantaged counterparts. Furthermore, it was associated with higher BMI z-scores in the Spanish and Italian cohorts (β = 0.06, 95% CI = [0.02; 0.10], both studies).

CONCLUSION

These findings may be valuable in informing early multi-behavioural interventions aimed at reducing social inequalities in health at a European scale.

[Anti-fall plan for the elderly in France 2022-2024: objectives and methodology]

BACKGROUND

Falls and fall-related injuries are a major public health problem in industrialized countries. Faced with this challenge, a French national plan was launched in 2022 aiming to reduce by 20% the incidence of falls-related hospitalizations or deaths.

OBJECTIVES

To describe the main pillars of the 2022-2024 French national plan against falls in older persons. Methods and assessment: The six pillars of the plan are: 1) screening and monitoring risks of falls and alert health and care workers; 2) home safety assessment and getting out safely; 3) developing technical aids for mobility and the use of assistive technologies at home; 4) appropriate physical activity, best weapon against falls; 5) tele-assistance devices for all older persons; 6) a cross-cutting pillar: Informing, raising awareness, training, and involving local actors. The plan, deployed in the 18 French regions, will provide a unique opportunity to determine the best strategies to achieve the objectives and the barriers encountered.

CONCLUSIONS

The deployment of the French national plan will bring useful data for considering a long-term strategy in France and helping countries or regions wishing to implement a fall prevention plan on their territory.

[Synthesis in French of the 2022 global recommendations for the management and prevention of falls in the elderly]

BACKGROUND

Falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs.

OBJECTIVE

To synthesize evidence-based and expert consensus-based 2022 world guidelines for the management and prevention of falls in older adults. These recommendations consider a person-centred approach that includes the preferences of the patient, caregivers and other stakeholders, gaps in previous guidelines, recent developments in e-health and both local context and resources.

RECOMMENDATIONS

All older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for communitydwelling older adults. An algorithm is proposed to stratify falls risk and interventions for persons at low, moderate or high risk. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations.

CONCLUSIONS

The core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

Sociodemographic and behavioural factors of adherence to the no-screen guideline for toddlers among parents from the French nationwide Elfe birth cohort

Background

Excessive screen time in infancy and childhood has been associated with consequences on children’s development and health. International guidelines call for no screen time before age 2 years, whereas in France, the most prominent guidelines recommend no screen before age 3 years. However, data are lacking on parental adherence to the no-screen guideline for toddlers and factors of adherence in France. Using data from the French nationwide Elfe birth cohort, we estimated adherence to the no-screen guideline at age 2 years and examined related factors, including sociodemographic characteristics, parental leisure activities and screen time.

Methods

In 2011, 18,329 newborns and their parents were enrolled in 349 randomly selected maternity units across mainland France. At age 2 years, screen exposure of 13,117 toddlers was reported by parents in phone interviews. Data on sociodemographic characteristics, parental leisure activities and screen time were collected from both parents. Three patterns of parental leisure activities were derived by principal component analysis: literate (e.g.,reading), screen-based, and physical/artistic activities. Multivariable logistic regression models were used to examine the associations of sociodemographic characteristics, parental leisure activities and parental screen time with adherence to the no-screen guideline for toddlers.

Results

Overall, 1809/13,117 (13.5%) families adhered to the no-screen guideline for toddlers. Adherence was reduced with maternal age < 40 years, low parental education, single-parent household and parental migration status. After adjusting for sociodemographic characteristics, adherence to the guideline was positively associated with a parental literate activity pattern (mothers: odds ratio [95% confidence interval]: 1.15 [1.08, 1.22]); fathers: 1.15 [1.07, 1.23]) and negatively with a screen-based activity pattern (mothers: 0.73 [0.69, 0.77]; fathers: 0.81 [0.76, 0.87]). With each additional hour of parental screen time, mothers and fathers were less likely to adhere to the guideline (mothers: adjusted odds ratio 0.80 [0.77, 0.83]; fathers: 0.88 [0.85, 0.91]).

Conclusions

Adherence to the no-screen guideline for toddlers in France was low. Parental leisure activities and parental screen time are major factors of adherence to the no-screen guideline and could be considered in targeted public health interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01342-9.

Family-focused contextual factors associated with lifestyle patterns in young children from two mother-offspring cohorts: GUSTO and EDEN

BACKGROUND

Integrated patterns of energy balance-related behaviours of preschool children in Asia are sparse, with few comparative analyses.

PURPOSE

Using cohorts in Singapore (GUSTO) and France (EDEN), we characterized lifestyle patterns of children and investigated their associations with family-focused contextual factors.

METHODS

Ten behavioural variables related to child's diet, walking, outdoor play and screen time were ascertained by parental questionnaires at age 5-6 years. Using principal component analysis, sex-specific lifestyle patterns were derived independently for 630 GUSTO and 989 EDEN children. Contextual variables were organised into distal (family socio-economics, demographics), intermediate (parental health, lifestyle habits) and proximal (parent-child interaction factors) levels of influence and analysed with hierarchical linear regression.

RESULTS

Three broadly similar lifestyle patterns were identified in both cohorts: "discretionary consumption and high screen time", "fruit, vegetables, and low screen time" and "high outdoor playtime and walking". The latter two patterns showed small differences between cohorts and sexes. The "discretionary consumption and high screen time" pattern was consistently similar in both cohorts; distal associated factors were lower maternal education (EDEN boys), no younger siblings (GUSTO boys) and Malay/Indian ethnicity (GUSTO), while intermediate and proximal associated factors in both cohorts and sexes were poor maternal diets during pregnancy, parents allowing high child control over food intake, snacking between meals and having television on while eating.

CONCLUSIONS

Three similar lifestyle patterns were observed among preschool children in Singapore and France. There were more common associated proximal factors than distal ones. Cohort specific family-focused contextual factors likely reflect differences in social and cultural settings. Findings will aid development of strategies to improve child health.

Prospective associations between dietary patterns, screen and outdoor play times at 2 years and age at adiposity rebound: The EDEN mother-child cohort

Although an early adiposity rebound (AR) is an established risk factor for later obesity, little is known regarding its determinants, especially modifiable ones. Using data from the French EDEN mother–child cohort (1903 children born in 2003–2006), we aimed to examine the association between diet and activity-related behaviors at 2 years of age and the timing of the AR. Two-year-old children (n = 1138) with parent-reported data on their foods/drinks intake, TV/DVD watching time, outdoor playtime, and with an estimated (via growth modelling) age at AR were included in the present study. Two dietary patterns, labelled 'Nutrient-dense foods' and 'Processed and fast foods', were identified in a previous study. Multivariable linear and logistic regression models were used to assess the association between dietary patterns and activity-related behaviors and, respectively, the age at AR (continuous) and the likelihood of having a very early AR (before 3.6 years for girls and 3.8 years for boys, i.e., below the 10th percentile of sex-specific distribution). A higher score on the ‘Processed and fast foods’ dietary pattern was associated with a higher likelihood of having a very early AR (OR = 1.23; 95% CI: 1.00 to 1.50). No significant association was observed between the ‘Nutrient-dense foods’ dietary pattern, TV/DVD watching and outdoor playing times and the timing of the AR. This finding emphasizes the importance of reducing nutrient-dense and processed foods from the early years of life, and provides further support for early interventions aimed at helping parents establish healthy eating habits for their growing child from the complementary period.

Cardiovascular Health at Age 5 Years: Distribution, Determinants, and Association With Neurodevelopment

BACKGROUND

Early childhood may represent an opportune time to commence primordial prevention of cardiovascular disease (CVD, i.e., prevention of risk factors onset), but epidemiological evidence is scarce. We aimed to examine the distribution and parental and early life determinants of ideal cardiovascular health (CVH) in children up to 5 years and to compare the level of cognitive development between children with and without ideal CVH at age 5 years.

METHODS

Using data from the Etude sur les déterminants pré et post natals précoces du Développement psychomoteur et de la santé de l'Enfant (EDEN) study, a French population-based mother-child cohort study, CVH was examined in children at 5 years of age based on the American Heart Association CVH metrics (ideal body mass index, physical activity, diet, blood pressure, cholesterol and glucose levels, and passive smoking, considered in sensitivity analysis only). Children were categorized as having ideal (five to six ideal metrics) or non-ideal CVH (<5 ideal metrics). Intelligence quotient (IQ) at age 5 years was assessed using the French version of the Wechsler Preschool and Primary Scale of Intelligence.

RESULTS

Among the 566 children (55% boys), only 34% had ideal CVH. In fully adjusted logistic regression, boys compared to girls (OR = 1.77, 95% CI 1.13-2.78), children with intermediate (1.77, 1.05-2.98) or ideal (2.58, 1.38-4.82) behavioral CVH at age 3 years and children who spent < 30 min/day watching television (1.91, 1.09-3.34) at age 3 years were more likely to have ideal CVH at age 5 years. At age 5 years, there was a significant 2.98-point difference (95% CI 0.64-5.32) in IQ between children with and without ideal biological CVH after adjusting for confounders.

CONCLUSION

This study highlights that only a third of children aged 5 years had ideal CVH and identified modifiable determinants of ideal CVH and is suggestive of an association between CVH and neurodevelopment at a young age.

Clusters of diet, physical activity, television exposure and sleep habits and their association with adiposity in preschool children: the EDEN mother-child cohort

Background

Despite the growing interest in the relation between adiposity in children and different lifestyle clusters, few studies used a longitudinal design to examine a large range of behaviors in various contexts, in particular eating- and sleep-related routines, and few studies have examined these factors in young children. The objectives of this study were to identify clusters of boys and girls based on diet, sleep and activity-related behaviors and their family environment at 2 and 5 years of age, and to assess whether the clusters identified varied across maternal education levels and were associated with body fat at age 5.

Methods

At 2 and 5 years, respectively, 1436 and 1195 parents from the EDEN mother-child cohort completed a questionnaire including behavioral data. A latent class analysis aimed to uncover gender-specific behavioral clusters. Body fat percentage was estimated by anthropometric and bioelectrical impedance measurements. Association between cluster membership and body fat was assessed with mutivariable linear regression models.

Results

At 2 years, two clusters emerged that were essentially characterized by opposite eating habits. At 5 years, TV exposure was the most distinguishing feature, but the numbers and types of clusters differed by gender. An association between cluster membership and body fat was found only in girls at 5 years of age, with girls in the cluster defined by very high TV exposure and unfavorable mealtime habits (despite high outdoor playing and walking time) having the highest body fat. Girls whose mother had low educational attainment were more likely to be in this high-risk cluster. Girls who were on a cluster evolution path corresponding to the highest TV viewing time and the least favorable mealtime habits from 2 to 5 years of age had higher body fat at 5 years.

Conclusions

Efforts to decrease TV time and improve mealtime routines may hold promise for preventing overweight in young children, especially girls growing up in disadvantaged families. These preventive efforts should start as early in life as possible, ideally before the age of two, and should be sustained over the preschool years.

The Effect of Older Siblings on Language Development as a Function of Age Difference and Sex

The number of older siblings a child has is negatively correlated with the child’s verbal skills, perhaps because of competition for parents’ attention. In the current study, we examined the role of siblings’ sex and age gap as moderating factors, reasoning that they affect older siblings’ tendency to compensate for reduced parental attention. We hypothesized that children with an older sister have better language abilities than children with an older brother, especially when there is a large age gap between the two siblings. We reanalyzed data from the EDEN cohort ( N = 1,154) and found that children with an older sister had better language skills than those with an older brother. Contrary to predictions, results showed that the age gap between siblings was not associated with language skills and did not interact with sex. Results suggest that the negative effect of older siblings on language development may be entirely due to the role of older brothers. Our findings invite further research on the mechanisms involved in this effect.

Domain-specific physical activity and sedentary behavior during pregnancy and postpartum depression risk in the French EDEN and ELFE cohorts

The potential beneficial effects of physical activity during pregnancy on postpartum depressive symptoms (PPD) remain inconclusive. Using data from two prospective French birth cohorts, we aimed to examine the relationship between domain-specific physical activity (including leisure-time sedentary behavior) in pregnancy and the occurrence of PPD. Participants of the ELFE cohort (n = 15,538) completed the Pregnancy Physical Activity Questionnaire (PPAQ), which assesses the following physical activity/sedentary behavior domains: household/caregiving, occupational, sports/exercise, transportation and leisure-time sedentary behavior during the third pregnancy trimester. In the EDEN cohort (n = 1745) women completed the Baecke Questionnaire (BQ) measuring occupational, sports/exercise, and leisure-time activity during the first trimester of pregnancy. Depressive symptoms in the first postpartum year were measured using the Edinburgh Postnatal Depression Scale in both cohorts. Associations of physical activity/sedentary behavior with PPD symptoms were determined by logistic regression analysis, with adjustment on potential confounding factors. In the adjusted models, higher levels of household/caregiving activities (OR = 1.10 (95% CI 1.01-1.19)) and leisure-time sedentary behavior (OR = 1.16 (95% CI 1.06-1.23)), in the third pregnancy trimester were associated with an increased odds of PPD. No significant associations were found for physical activity domains during the first pregnancy trimester. Higher levels of household and caregiving activities and leisure-time sedentary behavior in the last trimester of pregnancy appear to increase the likelihood of postpartum depression. Purpose and context should be taken into account when encouraging physical activity as a strategy to help prevent postpartum mental health problems from pregnancy onwards. Reducing sedentary behavior could be a complementary strategy.

Cord-blood vitamin D level and night sleep duration in preschoolers in the EDEN mother-child birth cohort

OBJECTIVE

Deficiency in 25-hydroxyvitamin D (25OHD) has been associated with sleep disorders in adults. Only three cross-sectional studies were performed in children; which showed an association between 25OHD deficiency and both obstructive sleep apnea syndrome and primary snoring. No longitudinal study has been performed in children from the general population. We analyzed the association between cord-blood vitamin D levels at birth and night-sleep duration trajectories for children between 2 and 5-6 years old in a non-clinical cohort.

METHOD

We included 264 children from the French EDEN mother-child birth-cohort with cord-blood 25OHD level determined by radio-immunoassay at birth, and night-sleep trajectories for children between 2 and 5-6 years old obtained by the group-based trajectory modeling method. Associations between 25OHD and sleep trajectories were assessed by multinomial logistic regression adjusted for maternal and child characteristics.

RESULTS

The trajectories short sleep (<10h30/night), medium-low sleep (10h30-11h00/night), medium-high sleep (≈11h30/night), long sleep (≥11h30/night) and changing sleep (decreased from ≥11h30 to 10h30-11h00/night) represented 5%, 46%, 37%, 4% and 8% of the children, respectively. The mean 25OHD level was 19 ng/ml (SD = 11, range 3-63). It was 12 (SD = 7), 20 (SD = 11), 19 (SD = 10), 14 (SD = 7) and 16 (SD = 8) ng/ml for children with short, medium-low, medium-high, long and changing sleep trajectories, respectively. On adjusted analysis, for each 1-ng/ml decrease in 25OHD level, the odds of belonging to the short sleep versus medium-high sleep trajectory was increased (odds ratio = 1.12, 95% confidence interval [1.01-1.25]). We found no other significant association between 25OHD level and other trajectories.

CONCLUSION

A low 25OHD level at birth may be associated with an increased probability of being a persistent short sleeper in preschool years. These results need confirmation.

Changes in children's television and computer time according to parental education, parental income and ethnicity: A 6-year longitudinal EYHS study

OBJECTIVES

To investigate changes in children's television and computer time according to three socio-economic status (SES) indicators.

DESIGN

Prospective cohort study.

METHODS

Data were drawn from the European Youth Heart Study and included longitudinal data collected in 1997 and 2003 in Denmark. Television and computer time were self-reported by children. Parental education, income and ethnicity were parent-reported. Baseline data were available for 549 children (47.0% boys, 9.6 years). Generalized linear mixed models analyzed whether changes in television and computer time from baseline to follow-up differed according to the SES-indicators.

RESULT

TV viewing time increased with 25% over time (ExpB = 1.25, 95% CI = 1.04-1.50). At both time points, children with two higher educated parents viewed 25% less hours of television than children with no higher educated parents (ExpB = 0.75, 95% CI = 0.60-0.94) and one higher educated parent (ExpB = 0.75, 95%CI = 0.59-0.97). Among children with no higher educated parents the odds of being in a higher category of computer time increased with 80% over time (OR = 1.80, 95% CI = 1.24-2.60). Among children with two higher educated parents the odds of being in a higher category of computer time decreased with 45% over time (OR = 0.55, 95% CI = 0.32-0.94). The association with ethnicity showed that white children had 42% lower odds (OR = 0.58; 95% CI = 0.34-1.00) of being in a higher category of computer time than non-white children. No significant associations were found for parental income.

CONCLUSIONS

The most important SES measure of screen-based behaviors in children was parental education. Ethnicity was only associated with computer time. Financial resources were less relevant for changes in television viewing and computer use.

Association of hypovitaminosis D with triceps brachii muscle fatigability among older women: Findings from the EPIDOS cohort

BACKGROUND

Vitamin D affects physical performance in older adults. Its effects on muscles, notably on muscle strength, remain unclear. The objective of this cross-sectional study was to determine whether hypovitaminosis D is associated with triceps brachii muscle fatigability in community-dwelling older women.

METHODS

A randomized subset of 744 women aged ≥75years from the EPIDOS cohort was categorized into two groups according to triceps brachii muscle fatigability, defined as loss of strength >5% between two consecutive maximal isometric voluntary contractions. Hypovitaminosis D was defined using consensual threshold values (i.e., serum 25-hydroxyvitamin D concentration [25OHD] ≤10 ng/mL, ≤20 ng/mL, and ≤30 ng/mL). Age, body mass index, comorbidities, use psychoactive drugs, physical activity, first triceps strength measure, hyperparathyroidism, serum concentrations of calcium, albumin and creatinine, season and study centers were used as potential confounders.

RESULTS

The prevalence of hypovitaminosis D ≤ 30 ng/mL was greater among women with muscle fatigability compared with the others (P = .009). There was no between-group difference using the other definitions of hypovitaminosis D. The serum 25OHD concentration was inversely associated with the between-test change in triceps strength (adjusted β = -0.09 N, P = .04). Hypovitaminosis D ≤ 30 ng/mL was positively associated with triceps fatigability (adjusted OR = 3.15, P = .02).

CONCLUSIONS

Vitamin D concentration was inversely associated with the ability to maintain strength over time in this cohort of community-dwelling older women. This is a relevant new orientation of research toward understanding the involvement of vitamin D in muscle function.

Prospective associations between energy balance-related behaviors at 2 years of age and subsequent adiposity: the EDEN mother-child cohort

BACKGROUND/OBJECTIVES

Sedentary behavior, physical activity and dietary behavior are formed early during childhood and tend to remain relatively stable into later life. No longitudinal studies have assessed the independent influence of these three energy balance-related behaviors during toddlerhood on later adiposity. We aimed to analyze the associations between TV/DVD watching time, outdoor play time and dietary patterns at the age of 2 years and child adiposity at the age of 5 years, in boys and girls separately.

SUBJECTS/METHODS

This study included 883 children from the French EDEN mother-child cohort. TV/DVD watching time, outdoor play time and dietary intakes were reported by parents in questionnaires when the child was aged 2 years. Two dietary patterns, labeled 'Guidelines' and 'Processed, fast foods', were identified in a previous study. The percentage of body fat (%BF) based on bioelectrical impedance analysis and body mass index were measured at the age of 5 years.

RESULTS

In boys, TV/DVD watching time at the age of 2 years was positively associated with %BF at the age of 5 years (β=0.50 (95% confidence interval: 0.001, 1.00) for those boys with ⩾60 min per day of TV/DVD watching time vs those with ⩽15 min per day, P-value for trend 0.05). In girls, outdoor play was inversely associated with %BF (β=-0.96 (95% confidence interval: -1.60, -0.32) for those in the highest tertile of outdoor play time vs those in the lowest tertile, P=0.001). Overall, at the age of 2 years, dietary patterns were associated with both TV/DVD watching time and outdoor play time, but no significant and independent association was observed between dietary patterns and later adiposity.

CONCLUSION

This study shows longitudinal and gender-differentiated relations between both TV/DVD watching time and outdoor play time in toddlerhood and later adiposity, whereas evidence for a relation between dietary patterns and subsequent fat development was less conclusive. Early childhood-by the age of 2 years-should be targeted as a critical time for promoting healthy energy balance-related behaviors.

A comprehensive fracture prevention strategy in older adults: the European Union Geriatric Medicine Society (EUGMS) statement

Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society, in collaboration with the International Association of Gerontology and Geriatrics for the European Region, the European Union of Medical Specialists, and the International Osteoporosis Foundation-European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

A Comprehensive Fracture Prevention Strategy in Older Adults: The European Union Geriatric Medicine Society (EUGMS) Statement

Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society (EUGMS), in collaboration with the International Association of Gerontology and Geriatrics for the European Region (IAGG-ER), the European Union of Medical Specialists (EUMS), the International Osteoporosis Foundation - European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

A systematic review of determinants of sedentary behaviour in youth: a DEDIPAC-study

Sedentary behaviour (SB) has emerged as a potential risk factor for metabolic health in youth. Knowledge on the determinants of SB in youth is necessary to inform future intervention development to reduce SB. A systematic review was conducted to identify predictors and determinants of SB in youth. Pubmed, Embase, CINAHL, PsycINFO and Web of Science were searched, limiting to articles in English, published between January 2000 and May 2014. The search strategy was based on four key elements and their synonyms: (a) sedentary behaviour, (b) determinants, (c) types of sedentary behaviours, (d) types of determinants. The full protocol is available from PROSPERO (PROSPERO 2014:CRD42014009823). Cross-sectional studies were excluded. The analysis was guided by the socio-ecological model. 37 studies were selected out of 2654 identified papers from the systematic literature search. Most studies were conducted in Europe (n = 13), USA (n = 11), and Australia (n = 10). The study quality, using the Qualsyst tool, was high with a median of 82 % (IQR: 74–91 %). Multiple potential determinants were studied in only one or two studies. Determinants were found at the individual, interpersonal, environmental and policy level but few studies examined a comprehensive set of factors at different levels of influences. Evidence was found for age being positively associated with total SB, and weight status and baseline assessment of screen time being positively associated with screen time (at follow-up). A higher playground density and a higher availability of play and sports equipment at school were consistently related to an increased total SB, although these consistent findings come from single studies. Evidence was also reported for the presence of safe places to cross roads and lengthening morning and lunch breaks being associated with less total SB. Future interventions to decrease SB levels should especially target children with overweight or obesity and should start at a young age. However, since the relationship of many determinants with SB remains inconsistent, there is still a need for more longitudinal research on determinants of SB in youth.

Multidimensionality of the relationship between social status and dietary patterns in early childhood: longitudinal results from the French EDEN mother-child cohort

Background

The association between socioeconomic position and diet in early childhood has mainly been addressed based on maternal education and household income. We aimed to assess the influence of a variety of social factors from different socio-ecological levels (parents, household and child-care) on multi-time point dietary patterns identified from 2 to 5 y.

Method

This study included 974 children from the French EDEN mother-child cohort. Two multi-time point dietary patterns were derived in a previous study: they correspond to consistent exposures to either core- or non-core foods across 2, 3 and 5 y and were labelled “Guidelines” and “Processed, fast-foods”. The associations of various social factors collected during pregnancy (age, education level) or at 2-y follow-up (mother’s single status, occupation, work commitments, household financial disadvantage, presence of older siblings and child-care arrangements) with each of the two dietary patterns, were assessed by multivariable linear regression analysis.

Results

The adherence to a diet close to “Guidelines” was positively and independently associated with both maternal and paternal education levels. The adherence to a diet consistently composed of processed and fast-foods was essentially linked with maternal variables (younger age and lower education level), household financial disadvantage, the presence of older sibling (s) and being cared for at home by someone other than the mother.

Conclusions

Multiple social factors operating at different levels (parents, household, and child-care) were found to be associated with the diet of young children. Different independent predictors were found for each of the two longitudinal dietary patterns, suggesting distinct pathways of influence. Our findings further suggest that interventions promoting healthier dietary choices for young children should involve both parents and take into account not only household financial disadvantage but also maternal age, family size and options for child-care.

Effectiveness of two year balance training programme on prevention of fall induced injuries in at risk women aged 75-85 living in community: Ossébo randomised controlled trial

OBJECTIVE

To assess the effectiveness of a two year exercise programme of progressive balance retraining in reducing injurious falls among women aged 75-85 at increased risk of falls and injuries and living in the community.

DESIGN

Pragmatic multicentre, two arm, parallel group, randomised controlled trial.

SETTING

20 study sites in 16 medium to large cities throughout France.

PARTICIPANTS

706 women aged 75-85, living in their own home, and with diminished balance and gait capacities, randomly allocated to the experimental intervention group (exercise programme, n=352) or the control group (no intervention, n=354).

INTERVENTION

Weekly supervised group sessions of progressive balance training offered in community based premises for two years, supplemented by individually prescribed home exercises.

OUTCOME MEASURES

A geriatrician blinded to group assignment classified falls into one of three categories (no consequence, moderate, severe) based on physical damage and medical care. The primary outcome was the rate of injurious falls (moderate and severe). The two groups were compared for rates of injurious falls with a "shared frailty" model. Other outcomes included the rates of all falls, physical functional capacities (balance and motor function test results), fear of falling (FES-I), physical activity level, and perceived health related quality of life (SF-36). Analysis was by intention to treat.

RESULTS

There were 305 injurious falls in the intervention group and 397 in the control group (hazard ratio 0.81, 95% confidence interval 0.67 to 0.99). The difference in severe injuries (68 in intervention group v 87 in control group) was of the same order of magnitude (0.83, 0.60 to 1.16). At two years, women in the intervention group performed significantly better on all physical tests and had significantly better perception of their overall physical function than women in the control group. Among women who started the intervention (n=294), the median number of group sessions attended was 53 (interquartile range 16-71). Five injurious falls related to the intervention were recorded.

CONCLUSION

A two year progressive balance retraining programme combining weekly group and individual sessions was effective in reducing injurious falls and in improving measured and perceived physical function in women aged 75-85 at risk of falling.Trial registration ClinicalTrials.gov (NCT00545350).

Beneficial effects of vitamin D on falls and fractures: is cognition rather than bone or muscle behind these benefits?

The beneficial effect of vitamin D on bone tissue has long been attributed mainly to its positive effect on the intestinal absorption of calcium and on bone mineralization, which increases the bone mineral density (BMD) and thus decreases the risk of fracture. Recently, numerous extra osseous effects of vitamin D have been described, amongst them a positive effect on neuromuscular and cognitive functions. Several lines of evidence suggest that the beneficial effects of vitamin D on fall and fracture risk can be explained more by its action on the neuromuscular and cognitive functions than by its direct effect on bone metabolism. In this review, we first report on the relationships between vitamin D and osteoporotic fracture risk. Then, we present the data from the literature regarding the effects of vitamin D on risk factors such as fall risk and reduction in BMD, physical performance, and cognitive performance. Specific emphasis is put on the latter because there is evidence of a relationship between low concentration of serum 25-hydroxyvitamin D (the primary indicator of vitamin D status) and low cognitive abilities which have been shown to be a risk factor for falling. It can be further suggested that high risk of fracture in cognitively impaired adults could be explained by lower protective reaction when falling, which would result, for instance, from a lack of planning and foresight of the fall. Future studies are nonetheless needed to elucidate the associations between vitamin D and different risk factors, in particular the link between vitamin D and various cognitive functions.

Use of calcium supplements, vitamin D supplements and specific osteoporosis drugs among French women aged 75-85 years: patterns of use and associated factors

BACKGROUND

Despite the availability of effective preventive and curative medications for osteoporosis, and guidelines for its diagnosis and management, few individuals are treated for osteoporosis, even among those who have already had a fracture.

OBJECTIVES

Our objective was to describe the patterns of use of medication for osteoporosis, i.e., calcium supplements, vitamin D supplements, and specific anti-osteoporotic drugs, such as bisphosphonates, in a large sample of French older women living at home, and to identify individual factors associated with use of these medications overall and in two specific clinical situations.

METHODS

Cross-sectional analysis of data from 4,221 women aged 75-85 years who participated in a balance and mobility examination as part of the screening procedure for the Ossébo study, a randomized controlled trial testing the effectiveness of exercise for the prevention of fall-related injuries. Electoral rolls were used to invite women in 16 towns to participate (participation rate 10.3 %). Information collected through questionnaires included current medication use and, in particular, use of osteoporosis medications (specific osteoporosis drugs, calcium and vitamin D supplementation) in the past 6 months, and history of fracture since the age of 50, including fracture locations. Fractures were categorized in three groups: no fracture, major osteoporotic fracture (hip, humerus, wrist, pelvis, and vertebra), and other fracture.

RESULTS

Nearly 48 % of the participants reported they did not take calcium or vitamin D supplements or any specific osteoporosis drugs. Of the 2,133 women who reported using osteoporosis medication, 85 % used vitamin D supplements (25 % as the sole medication against this disease), 59 % calcium supplements, and 42 % a specific anti-osteoporotic drug (75 % of them combining it with vitamin D supplementation). The use of any osteoporosis medication was significantly associated (p < 0.001) with a history of a major osteoporotic fracture, lower weight, dual-energy X-ray absorptiometry (DXA) bone-density measurement in the past 5 years, a cancer-screening examination in the past 5 years, and a positive attitude toward medication use in general. Living alone was associated with a lower likelihood of using a specific anti-osteoporotic drug, and a higher education level was associated with a higher likelihood of vitamin D supplementation. Of the 1,553 women who had already had a major osteoporotic fracture, one-third (34.8 %) were not taking any osteoporosis medication. In this subgroup, use of this medication was associated with the same factors as in the overall study population. In particular, neither older age nor a history of falls in the previous 12 months was associated with a higher likelihood of using osteoporosis medication. Among the 909 women who reported using a specific osteoporosis drug, vitamin D use was associated with a higher educational level and a more frequent preventive attitude.

CONCLUSION

In France, as in other western countries, women aged 75 years and over are not managed according to guidelines. Further studies should address the barriers encountered in improving quality of care in osteoporosis management.

The 'Ossebo' intervention for the prevention of injurious falls in elderly women: background and design

This paper reviews the literature that contributed to the design of the 'Ossébo' intervention and describes the study that is underway.

BACKGROUND

Falls and fall-related injuries are a major cause of morbidity and mortality among older people. Extensive research into falls prevention has established physical exercise as an efficient method to reduce falls, but the effect of exercise on serious injuries caused by falls remains unclear. Moreover, populations that would benefit most from these interventions, as well as factors that determine adherence to exercise remain underreported. THE OSSÉBO INTERVENTION: 'Ossébo' is an on-going multicenter randomized controlled trial, aiming to assess the effect of a two-year community-based group physical exercise program on the prevention of falls among women aged 75-85 years old. The primary outcome examined is the rate of falls and injurious falls: secondary outcomes include functional capacities, fear of falling and quality of life. This study will help determine the effectiveness of a large scale falls prevention program and the factors that can potentially assist its success.

Degree of methylation of ZAC1 (PLAGL1) is associated with prenatal and post-natal growth in healthy infants of the EDEN mother child cohort

The ZAC1 gene, mapped to the 6q24 region, is part of a network of co-regulated imprinted genes involved in the control of embryonic growth. Loss of methylation at the ZAC1 differentially methylated region (DMR) is associated with transient neonatal diabetes mellitus, a developmental disorder involving growth retardation and diabetes in the first weeks of post-natal life. We assessed whether the degree of methylation of the ZAC1 DMR in leukocytes DNA extracted from cord blood is associated with fetal, birth and post-natal anthropometric measures or with C-peptide concentrations in cord serum. We also searched for an influence of dietary intake and maternal parameters on ZAC1 DMR methylation. We found positive correlations between the ZAC1 DMR methylation index (MI) and estimated fetal weight (EFW) at 32 weeks of gestation, weight at birth and weight at one year of age (respectively, r = 0.15, 0.09, 0.14; P values = 0.01, 0.15, 0.03). However, there were no significant correlations between the ZAC1 DMR MI and cord blood C-peptide levels. Maternal intakes of alcohol and of vitamins B2 were positively correlated with ZAC1 DMR methylation (respectively, r = 0.2 and 0.14; P = 0.004 and 0.04). The influence of ZAC1 seems to start in the second half of pregnancy and continue at least until the first year of life. The maternal environment also appears to contribute to the regulation of DNA methylation.

The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To determine whether, and to what extent, fall prevention exercise interventions for older community dwelling people are effective in preventing different types of fall related injuries.

DATA SOURCES

Electronic databases (PubMed, the Cochrane Library, Embase, and CINAHL) and reference lists of included studies and relevant reviews from inception to July 2013.

STUDY SELECTION

Randomised controlled trials of fall prevention exercise interventions, targeting older (>60 years) community dwelling people and providing quantitative data on injurious falls, serious falls, or fall related fractures.

DATA SYNTHESIS

Based on a systematic review of the case definitions used in the selected studies, we grouped the definitions of injurious falls into more homogeneous categories to allow comparisons of results across studies and the pooling of data. For each study we extracted or calculated the rate ratio of injurious falls. Depending on the available data, a given study could contribute data relevant to one or more categories of injurious falls. A pooled rate ratio was estimated for each category of injurious falls based on random effects models.

RESULTS

17 trials involving 4305 participants were eligible for meta-analysis. Four categories of falls were identified: all injurious falls, falls resulting in medical care, severe injurious falls, and falls resulting in fractures. Exercise had a significant effect in all categories, with pooled estimates of the rate ratios of 0.63 (95% confidence interval 0.51 to 0.77, 10 trials) for all injurious falls, 0.70 (0.54 to 0.92, 8 trials) for falls resulting in medical care, 0.57 (0.36 to 0.90, 7 trials) for severe injurious falls, and 0.39 (0.22 to 0.66, 6 trials) for falls resulting in fractures, but significant heterogeneity was observed between studies of all injurious falls (I(2)=50%, P=0.04).

CONCLUSIONS

Exercise programmes designed to prevent falls in older adults also seem to prevent injuries caused by falls, including the most severe ones. Such programmes also reduce the rate of falls leading to medical care.

Guidelines for Physical Activity during Pregnancy: Comparisons From Around the World

INTRODUCTION

Women attain numerous benefits from physical activity during pregnancy. However, due to physical changes that occur during pregnancy, special precautions are also needed. This review summarizes current guidelines for physical activity among pregnant women worldwide.

METHODS

We searched PubMed (MedLINE) for country-specific governmental and clinical guidelines on physical activity during pregnancy through the year 2012. We cross-referenced with articles referring to guidelines, with only the most recent included. An abstraction form was used to extract key details and summarize.

RESULTS

In total, 11 guidelines were identified from nine countries (Australia, Canada, Denmark, France, Japan, Norway, Spain, United Kingdom, United States). Most guidelines supported moderate intensity physical activity during pregnancy (10/11) and indicated specific frequency (9/11) and duration/time (9/11) recommendations. Most guidelines provided advice on initiating an exercise program during pregnancy (10/11). Six guidelines included absolute and relative contraindications to exercise. All guidelines generally ruled-out sports with risks of falls, trauma, or collisions. Six guidelines included indications for stopping exercise during pregnancy.

CONCLUSION

This review contrasted pregnancy-related physical activity guidelines from around the world, and can help to inform new guidelines as they are created or updated, and facilitate the development of a worldwide guideline.

Cord serum 25-hydroxyvitamin D and risk of early childhood transient wheezing and atopic dermatitis

BACKGROUND

There is increasing evidence of the effect of maternal vitamin D intake during pregnancy on the risk of asthma and allergic outcomes in offspring. However, studies on the relationship between cord levels of 25-hydroxyvitamin D (25[OH]D) and asthma and allergic diseases are very few.

OBJECTIVE

Our aim was to investigate the associations between cord serum 25(OH)D levels and asthma, wheezing, allergic rhinitis, and atopic dermatitis in the offspring from birth to 5 years.

METHODS

Cord blood samples were collected at birth and analyzed for 25(OH)D levels in 239 newborns from the Etude des Déterminants pré et post natals du développement et de la santé de l'Enfant (EDEN) birth cohort. The children were followed up until age 5 years by using International Study of Asthma and Allergies in Childhood-based symptom questionnaires.

RESULTS

The median cord serum level of 25(OH)D was 17.8 ng/mL (interquartile range, 15.1 ng/mL). By using multivariable-adjusted logistic regression models, a significant inverse association was observed between cord serum 25(OH)D levels and risk of transient early wheezing and early- and late-onset atopic dermatitis, as well as atopic dermatitis, by the ages of 1, 2, 3, and 5 years. We found no association between cord serum 25(OH)D levels and asthma and allergic rhinitis at age 5 years.

CONCLUSIONS

Cord serum 25(OH)D levels were inversely associated with the risk of transient early wheezing and atopic dermatitis by the age of 5 years, but no association was found with asthma and allergic rhinitis.

Mobility impairment is associated with urge but not stress urinary incontinence in community-dwelling older women: results from the Ossébo study

OBJECTIVE

To assess the association between functional limitations related to mobility and urinary incontinence (UI) in elderly women.

DESIGN

An observational cross-sectional study.

SETTING

Nine 'balance' workshops in France.

POPULATION

A total of 1942 community-dwelling women aged 75-85 years, who were invited, based on voter registration lists, to a 'balance assessment'.

METHODS

Mobility and balance test results for incontinent women were compared with those for continent women according to the severity and type of incontinence.

MAIN OUTCOME MEASURES

Data on UI were collected using a self-administered questionnaire (International Consultation on Incontinence Questionnaire-Short Form). Motor-related physical abilities were assessed using standardised balance and functional gait tests.

RESULTS

Forty-two per cent of women had involuntary urine leakage, with daily leaks in 57% of them; 24% had stress UI, 31% had urge UI, and 37% had mixed UI. Results for each functional test were poorer for women with UI and the limitation was more pronounced when the incontinence was severe. Multivariate logistic regression analyses showed that balance and gait impairments were significantly and independently associated with urge UI (walking speed, lower versus higher quartile, odds ratio (OR) 2.2; 95% confidence interval (95% CI) 1.4-3.5; walking balance, unable versus able to do four tandem steps (OR 1.6; 95% CI 1.2-2.2) but not with stress UI.

CONCLUSIONS

In this large population of older women living at home, there was a strong association between limitation of motor and balance skills and UI, which was proportional to the severity of incontinence and related specifically to urge incontinence. These results offer new perspectives on the prevention and treatment of urge incontinence in elderly women.

Gestational exposure to urban air pollution related to a decrease in cord blood vitamin d levels

CONTEXT

Vitamin D deficiency has been implicated in the increased risk of several diseases. Exposure to air pollution has been suggested as a contributor to vitamin D deficiency. However, studies that have examined the effects of air pollution on vitamin D status are few and have never focused on prenatal life as an exposure window.

OBJECTIVE

Our aim was to investigate the associations between gestational exposure to urban air pollutants and 25-hydroxyvitamin D [25(OH)D] cord blood serum level in 375 mother-child pairs of the EDEN birth cohort.

DESIGN

The Atmospheric Dispersion Modelling System (ADMS-Urban) pollution model, a validated dispersion model combining data on traffic conditions, topography, meteorology, and background pollution, was used to assess the concentrations of two major urban pollutants, particulate matter less than 10 μm in diameter (PM(10)) and nitrogen dioxide (NO(2)), at the mother's home address during pregnancy. Cord blood samples were collected at birth and were analyzed for levels of 25(OH)D.

RESULTS

Maternal exposure to ambient urban levels of NO(2) and PM(10) during the whole pregnancy was a strong predictor of low vitamin D status in newborns. After adjustment, log-transformed 25(OH)D decreased by 0.15 U (P = 0.05) and 0.41 U (P = 0.04) for a 10-μg/m(3) increase in NO(2) and PM(10) pregnancy levels, respectively. The association was strongest for third-trimester exposures (P = 0.0003 and P = 0.004 for NO(2) and PM(10), respectively).

CONCLUSION

Gestational exposure to ambient urban air pollution, especially during late pregnancy, may contribute to lower vitamin D levels in offspring. This could affect the child's risk of developing diseases later in life.

Is vascular calcification associated with bone mineral density and osteoporotic fractures in ambulatory, elderly women?

We analyzed the relationship between aortic calcification and two osteoporotic parameters (bone mineral density (BMD) and incident osteoporotic fractures) in 667 ambulatory, elderly women from the Epidemiology of Osteoporosis (EPIDOS) cohort (mean age, 80 years; range, 72-94 years). We did not find any correlation between the aortic calcification score and BMD or osteoporotic fractures.

INTRODUCTION

The aging process is associated with osteoporosis and aortic calcification; conditions which may have similar disease mechanisms. However, the relationship between these two settings remains to be elucidated. We analyzed the relationship between aortic calcification and osteoporotic parameters (BMD and incident osteoporotic fractures) in a cohort of ambulatory, elderly women.

METHODS

The study included 667 ambulatory women from the EPIDOS cohort (mean age, 80 years; age range, 72-94 years). The baseline examination included bone investigations, a clinical and functional examination, and a comprehensive questionnaire on health status and lifestyle. Semiquantitative methods were used to determine the abdominal aortic calcification score on baseline radiographs. Incident fractures were recorded via postal questionnaires issued every 4 months for about 4 years.

RESULTS

Five hundred three women (75%) had aortic calcification. The mean aortic calcification score was 5.5 (median, 4). During the follow-up period, 186 (28%) women reported one or more incident osteoporotic fractures. We did not find any correlation between the aortic calcification score on one hand and the BMD or the occurrence of incident osteoporotic fractures on the other. Only age and systolic blood pressure were found to be independently associated with the aortic calcification score. Osteoporotic fractures were independently associated with age and BMD.

CONCLUSIONS

Osteoporosis and aortic calcification appear to be independent processes in a cohort of ambulatory, elderly women. However, potential confounding factors may be present and prospective studies are needed to investigate this situation further.

Higher cord C-peptide concentrations are associated with slower growth rate in the 1st year of life in girls but not in boys

OBJECTIVE

To understand the relationships between maternal glycemia during pregnancy and prenatal and early postnatal growth by evaluating cord C-peptide and IGF-I as mediating biomarkers in boys and girls separately.

RESEARCH DESIGN AND METHODS

We evaluated 342 neonates within the EDEN mother-child cohort study born to mothers without diabetes diagnosis before pregnancy. We measured maternal glycemia at 24-28 weeks of gestation and neonates' cord blood C-peptide (used as a proxy for fetal insulin) and IGF-I at birth. Reported maternal prepregnancy BMI and all measured infant weights and lengths in the 1st year were recorded. Growth modeling was used to obtain an individual growth curve for each infant in the 1st year. Path models, a type of structural equation modeling, were used for statistical analysis. Path analysis is a multivariate method associated with a graphical display that allows evaluation of mediating factors and distinguishes direct, indirect, and total effects.

RESULTS

Cord C-peptide at birth was positively correlated with maternal prepregnancy BMI and maternal glycemia and was higher in girls. In a path model that represented prenatal growth, there was no significant direct effect of maternal glycemia on birth weight, but the effect of maternal glycemia on birth weight was mediated by fetal insulin and IGF-I in both girls and boys. However, in girls only, higher concentrations of cord C-peptide (but not cord IGF-I or maternal glucose) were associated with slower weight growth in the first 3 months of life.

CONCLUSIONS

Our study underlines the role of the fetal insulin-IGF-I axis in the relationship between maternal glycemia during pregnancy and birth weight. We also show for the first time that high insulin concentration in female fetuses is associated with slower early postnatal growth. This slow, early growth pattern may be programmed by fetal hyperinsulinemia, and girls may be more susceptible than boys to its consequences.

The DESIR cohort: a 10-year follow-up of early inflammatory back pain in France: study design and baseline characteristics of the 708 recruited patients

OBJECTIVES

The French Society of Rheumatology has initiated a large national multicenter, longitudinal, prospective follow-up of patients presenting with early inflammatory back pain in order to set up a database to facilitate several investigations on diagnosis, prognosis, epidemiology, pathogenesis and medico-economics in the field of early inflammatory back pain and spondyloarthritis.

METHODS

Patients were recruited if they had inflammatory back pain of more than 3 months and less than 3 years. Patients will be followed every 6 months during the first 2 years then every year during at least 5years. Apart from information collected on a Case Report Form (demographics, disease activity, severity, co-morbidities, socio-economics, treatments, radiological and MRI evaluation of the spine and the pelvis according to the local investigators, and for some centers bone densitometry and ultrasonography of entheses), the digital X-rays and MRI of the spine and pelvis are stored using a specific software (Carestream) and the biological samples (DNA, RNA, sera, urines) are centralized at the Biological Resources Center (Bichat Hospital).

RESULTS

The recruitment period of the 708 patients (mean age: 34±9years, female 54%, HLA-B27 positive: 57%) in the 25 centers was 26 months (from December 2007 to April 2010). The modified New York criteria, Amor criteria, ESSG criteria and axial ASAS criteria were fulfilled by 26%, 77%, 76% and 67% of the patients at entry, respectively. A history or current symptoms suggestive of peripheral arthritis, acute anterior uveitis and inflammatory bowel disease were observed in 21%, 9% and 4% of the patients, respectively. The disease was active (BASDAI: 45±20) despite an NSAID intake in 66% of the patients.

CONCLUSION

This large cohort should facilitate the conduct of researches in different areas (clinical, medico-economics, translational) in order to improve our knowledge on the pathogenesis and natural history of axial spondyloarthritis.

Fracture risk prediction using BMD and clinical risk factors in early postmenopausal women: sensitivity of the WHO FRAX tool

The aim of this prospective study was (1) to identify significant and independent clinical risk factors (CRFs) for major osteoporotic (OP) fracture among peri- and early postmenopausal women, (2) to assess, in this population, the discriminatory capacity of FRAX and bone mineral density (BMD) for the identification of women at high risk of fracture, and (3) to assess whether adding risk factors to either FRAX or BMD would improve discriminatory capacity. The study population included 2651 peri- and early postmenopausal women [mean age (+/- SD): 54 +/- 4 years] with a mean follow-up period of 13.4 years (+/-1.4 years). At baseline, a large set of CRFs was recorded, and vertebral BMD was measured (Lunar, DPX) in all women. Femoral neck BMD also was measured in 1399 women in addition to spine BMD. Women with current or past OP treatment for more than 3 months at baseline (n = 454) were excluded from the analyses. Over the follow-up period, 415 women sustained a first low-energy fracture, including 145 major OP fractures (108 wrist, 44 spine, 20 proximal humerus, and 13 hip). In Cox multivariate regression models, only 3 CRFs were significant predictors of a major OP fracture independent of BMD and age: a personal history of fracture, three or more pregnancies, and current postmenopausal hormone therapy. In the subsample of women who had a hip BMD measurement and who were not receiving OP therapy (including hormone-replacement therapy) at baseline, mean FRAX value was 3.8% (+/-2.4%). The overall discriminative value for fracture, as measured by the area under the Receiver Operating Characteristic (ROC) curve (AUC), was equal to 0.63 [95% confidence interval (CI) 0.56-0.69] and 0.66 (95% CI 0.60-0.73), respectively, for FRAX and hip BMD. Sensitivity of both tools was low (ie, around 50% for 30% of the women classified as the highest risk). Adding parity to the predictive model including FRAX or using a simple risk score based on the best predictive model in our population did not significantly improve the discriminatory capacity over BMD alone. Only a limited number of clinical risk factors were found associated with the risk of major OP fracture in peri- and early postmenopausal women. In this population, the FRAX tool, like other risk scores combining CRFs to either BMD or FRAX, had a poor sensitivity for fracture prediction and did not significantly improve the discriminatory value of hip BMD alone.

Persistence with teriparatide in postmenopausal osteoporosis; impact of a patient education and follow-up program: the French experience

SUMMARY

This study evaluated the 18-month persistence with teriparatide in 5413 postmenopausal osteoporotic women who were enrolled in an education and follow-up program. Analysis showed that the persistence rate was 81.5% for women who follow the program, higher than for existing oral antiresorptive treatments.

INTRODUCTION

An education and follow-up program was developed after launch of teriparatide in France in September 2004, to help women to follow the treatment. The objective of this study was to evaluate the persistence with teriparatide in postmenopausal osteoporotic women following this program.

METHODS

Data about persistence are available for the period September 2004 to June 2007. Persistence is defined as the percentage of patients still on treatment at the end of the 18-month course, and it has been compared to the data provided by the French universal health insurance system.

RESULTS

Since the launch of teriparatide in France in September 2004, 5413 postmenopausal women (mean age 72.3 +/- 14.5 years) with osteoporosis and vertebral fractures (mean 3.9 +/- 2) have participated in the program. The persistence rate at 15 months was 81.5%, and our analysis suggested that a majority of patients completed the 18-month treatment course. The main reason for discontinuation was adverse events (46.7%). Data of the French Universal Health Insurance suggest that the persistence may be close to 0% for women who are not in the program.

CONCLUSIONS

Postmenopausal osteoporotic women treated by teriparatide and enrolled in an education and follow-up program have a high persistence rate.

Devising global strategies for fracture-risk evaluation

Fracture prevention is the goal of osteoporosis treatment. Bone mineral density (BMD) has been the main criterion for deciding whether to initiate treatment, which is usually recommended when the BMD is less than -2.5 SDs from the mean in young women. However, the need to base treatment decisions on the overall fracture risk, rather than on BMD values alone, is now increasingly recognized. Several factors predict the fracture risk independently from BMD. Combining these factors to BMD may improve patient selection for osteoporosis therapy. In addition to low BMD values, factors associated with a high fracture risk include advanced age, prior fractures in the patient or family, low body mass index, smoking, glucocorticoid therapy, unfavorable profile of bone turnover markers, and risk factors for falls. There is no consensus yet about the best strategy for using these risk factors to assist in treatment decisions. A collaborative center set up by the World Health Organization is evaluating pooled data from prospective studies in order to better define high-risk patient subsets that are likely to benefit from osteoporosis treatment to prevent fractures. The results will serve to develop clinical guidelines for identifying high-risk patients.

Structural determinants of hip fracture in elderly women: re-analysis of the data from the EPIDOS study

Hip fracture is the most disastrous osteoporotic fracture, characterized by high mortality, morbidity and institutionalization for the patient and by high economic costs for the health care system. The morphology of the upper part of the femur can influence the risk of hip fracture, e.g., a longer femoral neck is associated with a higher risk of cervical fractures, but not trochanteric ones. In this study, we evaluated the prediction of hip fracture risk by morphological parameters estimated from DXA measurements, and we compared their predictive value for cervical and trochanteric fractures in elderly women by reanalyzing previously published data (Duboeuf et al. J Bone Miner Res 1997 12 1895). This nested case-control study was performed in 232 elderly community-dwelling women from the EPIDOS cohort, including 65 women who sustained a hip fracture. After adjustment for confounding variables, women who sustained a cervical fracture had lower areal bone mineral density (aBMD), lower cortical thickness and a higher average buckling ratio (P<0.005 for all) as well as longer femoral neck (P<0.01) than controls. Women who sustained a trochanteric fracture had lower aBMD, lower cortical thickness and higher buckling ratio than controls (P<0.0001) and than women who sustained a cervical fracture (P<0.05). Their bending resistance (cross-sectional moment of inertia-CSMI, section modulus) was significantly lower in comparison with controls (P<0.05-0.001). A decrease in aBMD, cortical thickness, CSMI and section modulus as well as an increase in buckling ratio were predictive of all hip fractures (OR -1.42-2.46 per 1 SD, P<0.05-0.0001), but the ORs for all structural parameters were markedly higher for trochanteric than for cervical fractures. CSMI and section modulus were predictive of trochanteric, but not cervical fractures. However, aBMD was strongly correlated with the CSA, cortical thickness and buckling ratio (r2>0.74), which suggests that they convey the same information. CSMI and section modulus correlated with aBMD more weakly, but their OR lost statistical significance after adjustment for aBMD. In conclusion, low femoral neck aBMD, CSA and cortical thickness as well as a high buckling ratio are associated with the higher risk of hip fracture, especially trochanteric ones. These indices are highly correlated with aBMD and convey the same message. The calculated CSMI and section modulus predict trochanteric fractures, but not cervical fractures, and their statistical significance is lost after adjustment for aBMD, indicating that they reflect mainly aBMD, not mechanical properties. Thus, the independent contribution of the external diameter of the femoral neck to the risk of hip fracture cannot be reliably estimated by this technique.

Quantitative ultrasound parameters as well as bone mineral density are better predictors of trochanteric than cervical hip fractures in elderly women. Results from the EPIDOS study

RATIONALE

Hip fractures can be separated into cervical and trochanteric fractures. Trochanteric fractures have been associated with up to twice the short-term mortality of cervical fractures in the elderly. There is also evidence suggesting that the mechanisms are different. Evidence from the literature remains limited on the predictive power of bone mineral density (BMD) and quantitative ultrasounds (QUS) for both types of hip fractures.

METHODS

5703 elderly women aged 75 years or more, who were recruited from the voting lists in the EPIDOS study, and had baseline calcaneal ultrasounds (QUS) and DXA measurements at the hip and the whole body, were analyzed in this paper. Among those, 192 hip fractures occurred during an average follow-up of 4 years, 108 cervical and 84 trochanteric fractures.

RESULTS

Femoral neck, trochanteric and whole body BMD were able to predict trochanteric hip fracture (RR's and 95% CI were, respectively, 3.2 (2.4-4.2); 4.8 (3.5-6.6); and 2.8 (2.2-3.6)) more accurately than cervical fractures (respectively, 2.1 (1.7-2.7); 2.3 (1.8-3.0); 1.2 (1.0-1.6)). All ultrasound parameters, SOS, BUA, and stiffness index (SI) were significant predictors of trochanteric (RR's respectively 3.0 (2.2-4.1), 2.5(2.0-3.1), and 3.5(2.6-4.7)) but not cervical fractures. After adjustment for femoral neck or trochanteric BMD ultrasound parameters were still significant predictors of trochanteric fracture, and stiffness tended to be a better predictor of trochanteric fractures than either BUA or SOS with a relative risk of 2.25 (1.6-3.1).

CONCLUSIONS

A significant decrease of all bone measurements, BMD and QUS, was highly predictive of trochanteric fractures, whereas a decrease of femoral neck and trochanteric BMD were only associated with a slight increase in cervical fracture risk and a low total body BMD or QUS parameters were not significant predictors of cervical fractures. In women who sustained a hip fracture, the decrease of BMD and QUS values increases the risk of trochanteric fracture as compared to cervical fracture. Trochanteric fractures were mostly a consequence of a generalized low BMD and QUS, whereas other parameters might be involved in cervical fractures.

Identification of women at increased risk of osteoporosis: no need to use different screening tools at different ages

OBJECTIVES

To assess and compare various approaches for selecting women for a bone mineral density (BMD) examination in three different age groups: (1) the most commonly recommended strategy, i.e., selection based on the presence of at least one major risk factor for osteoporosis (personal history of fracture, maternal history of hip fracture, low weight, early menopause), (2) by weight, and (3) calculation of an individual risk score based on the predictive equation (logistic regression model) including the factors most predictive of osteoporosis in each age group.

METHODS

Data from three population-based samples of postmenopausal women of different ages 60-70 years (n=399), 70-80 years (n=392), and 80 years or older (n=3628). Within each age group, the value of these different approaches was primarily assessed in terms of their discriminant value (sensitivity and positive predictive value (PPV)) for osteoporosis. Other women besides osteoporotic women might also be considered at high risk of fracture (and hence treated), in particular osteopenic women (T-score<-1.5) with multiple risk factors for fracture. Hence, we also estimated and compared the overall number of selected women who might be considered at high risk of fracture after BMD testing, according to selection criteria.

RESULTS

In each age group and classifying a similar percentage of women at high risk, use of weight as a tool for identifying osteoporotic women has a higher sensitivity and PPV than the currently recommended approach. Increasing the cutoff for weight increases sensitivity. However, identifying the majority (around 80%) of all osteoporotic women requires testing more than half the population. Combining weight with other factors into more complex risk scores usually does not significantly improve the discriminant value of the assessment. When similar percentages of women are selected, more women with osteopenia and multiple risk factors are identified when selection is based on usual referral criteria. However, since more osteoporotic women are identified after selection by weight (higher PPV for osteoporosis), the overall number of women who might be considered at high risk of fracture after BMD testing is higher after selection by weight.

CONCLUSIONS

In each age group considered, selecting women for BMD testing based on weight is the simplest and most effective screening method for identifying osteoporotic women as well as other subgroups of women who might also be considered to be at high risk of fracture.

A triage strategy based on clinical risk factors for selecting elderly women for treatment or bone densitometry: the EPIDOS prospective study

A triage strategy, based on a clinical hip fracture risk score, may be used to classify elderly women into three groups: one at high risk and requiring treatment, another needing further assessment by bone densitometry, and a third at low risk. We used prospective data from the EPIDOS study (7512 women older than 75 years and followed for an average of 3.9 years) to assess the potential value of such a strategy for identifying elderly women with a hip fracture risk twice the cohort average (i.e. > or =20 per 1000 woman-years). An individual fracture risk score was calculated with the final risk function (Cox model). To compare this strategy with systematic BMD measurement and with current European recommendations, we examined the number of high-risk women identified, their average risk levels, sensitivity for hip fracture, and the number of high-risk women who need to be treated to prevent one hip fracture (hypotheses: all identified women are treated; sensitivity is equal to the point estimate; treatment reduces fracture risk by 35%). A triage strategy based on age, fracture history since the age of 40 years, body mass index, number of instrumental activities of daily living for which assistance is needed, grip strength, and visual acuity can identify 20% of the cohort as at high risk, 75% of them from clinical factors only, and the rest after BMD measurements (threshold: -2.5 T-score). The triage strategy would be significantly more sensitive than systematic BMD screening (51 versus 35%) and would require many fewer BMD examinations (10%). Compared with current recommendations, triage would identify fewer women (20 versus 28%) but at a significantly higher average risk of hip fracture (30 versus 20 per 1000 woman-years). Fewer high-risk women would be treated to prevent one hip fracture (29 versus 41) and fewer bone densitometry tests would be needed (10% versus 54%). The proposed triage strategy may be a useful clinical tool for selecting elderly women for treatment or bone densitometry.

[Epidemiology and risk factors for osteoporosis]

It has been estimated that 40 % of white women aged 50 years will suffer at least one of the major osteoporotic fractures (hip, vertebrae, wrist) before the end of their life. Bone mineral density (BMD) measurement is the basis of osteoporosis diagnosis and is generally considered as a key element to identify high risk subjects who should benefit most from a bone active treatment preventive of fractures. However, for a given BMD level, the risk of fracture varies with age and with the presence of other risk factors (personal or familial history of fracture, low weight, corticotherapy, fall-related risk factors etc.). In the future, it is probable that densitometry results will be expressed in terms of risk of fracture within the next 10 years. Different intervention thresholds could then be defined depending on the age of the subject, the level and nature of the risk factors, as well as the type of preventive or therapeutic actions considered. In the elderly, fall-related factors such as neuromuscular and visual disorders have a weight similar to the one of BMD in the determinism of hip fracture. Recently, several randomized controlled trials have shown that multifactorial preventive programs tailored to individual risk factors or exercise programs emphasizing balance training can reduce the risk of falls in the elderly by 25 to 30%. The efficacy of such measures on fracture prevention must be demonstrated.