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Kobayashi Y, Long J, Dan S, Johannsen NM, Talamoa R, Raghuram S, Chung S, Kent K, Basina M, Lamendola C, Haddad F, Leonard MB, Church TS, Palaniappan L. Correction to: Strength training is more effective than aerobic exercise for improving glycaemic control and body composition in people with normal-weight type 2 diabetes: a randomised controlled trial. Diabetologia 2024:10.1007/s00125-024-06135-2. [PMID: 38689057 DOI: 10.1007/s00125-024-06135-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Affiliation(s)
- Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Jin Long
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Shozen Dan
- Center for Asian Health Research and Education, Stanford University School of Medicine, Stanford, CA, USA
| | - Neil M Johannsen
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
- Louisiana State University, Baton Rouge, LA, USA
| | - Ruth Talamoa
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sonia Raghuram
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sukyung Chung
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Kyla Kent
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Marina Basina
- Division of Endocrinology, Gerontology, and Metabolism, Stanford University School of Medicine, Stanford, CA, USA
| | - Cynthia Lamendola
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Timothy S Church
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
- Louisiana State University, Baton Rouge, LA, USA
- Wondr Health, Dallas, TX, USA
| | - Latha Palaniappan
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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Lakshminrusimha S, Cheng TL, Leonard MB, Devaskar SU, Vinci RJ, Degnon L, St Geme JW. Raising the Bar: The Need for Increased Financial Support to Sustain and Expand the Community of Pediatric Subspecialists. J Pediatr 2024; 267:113758. [PMID: 37748730 DOI: 10.1016/j.jpeds.2023.113758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Affiliation(s)
- Satyan Lakshminrusimha
- Department of Pediatrics, University of California at Davis, UC Davis Children's Hospital, Sacramento, CA.
| | - Tina L Cheng
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, CA
| | - Sherin U Devaskar
- Department of Pediatrics, David Geffen School of Medicine at UCLA and the UCLA Mattel Children's Hospital, Los Angeles, CA
| | - Robert J Vinci
- Department of Pediatrics, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA
| | | | - Joseph W St Geme
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
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Weidemann DK, Orr CJ, Norwood V, Brophy P, Leonard MB, Ashoor I. Child Health Needs and the Pediatric Nephrology Subspecialty Workforce: 2020-2040. Pediatrics 2024; 153:e2023063678P. [PMID: 38300004 DOI: 10.1542/peds.2023-063678p] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
Pediatric nephrology is dedicated to caring for children with kidney disease, a unique blend of acute care and chronic longitudinal patient relationships. Though historically a small field, trainee interest has declined over the past 2 decades. This has led to growing alarm about the health of the pediatric nephrology workforce, although concerns have been hampered by a lack of available data to enable feasible projections. This article is part of a supplement that anticipates the future pediatric subspecialty workforce supply. It draws on existing literature, data from the American Board of Pediatrics, and findings from a model that estimates the future supply of pediatric subspecialists developed by the Carolina Health Workforce Research Center at the University of North Carolina Chapel Hill's Cecil G. Sheps Center for Health Services Research and Strategic Modeling Analytics & Planning Ltd. The workforce projections from 2020 to 2040 incorporate population growth, clinical effort, and geographic trends and model alternate scenarios adjusting for changes in trainee interest, clinical efforts, and workforce attrition. The baseline model predicts growth of clinical work equivalents by 26% by 2040, but further widening geographic disparities worsen the existing mismatch between supply, clinical need, and market demand. The worst-case scenario projects 13% growth by 2040 which, at best, maintains the status quo of an already strained workforce. The models do not account for many factors expected to heighten demand over the coming decades. Urgent reforms are necessary now. Proposed solutions require multipronged changes in education and training pathways, remuneration, clinical practice models, and government policy.
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Affiliation(s)
- Darcy K Weidemann
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
- School of Medicine, University of Missouri, Kansas City, Kansas City, Missouri
| | - Colin J Orr
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Victoria Norwood
- Division of Nephrology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Patrick Brophy
- Division of Nephrology, Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York
| | - Mary B Leonard
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Isa Ashoor
- Boston Children's Hospital, Department of Pediatrics, Boston, Massachusetts
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Correll CK, Klein-Gitelman MS, Henrickson M, Battafarano DF, Orr CJ, Leonard MB, Mehta JJ. Child Health Needs and the Pediatric Rheumatology Workforce: 2020-2040. Pediatrics 2024; 153:e2023063678R. [PMID: 38300008 DOI: 10.1542/peds.2023-063678r] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
The Pediatric Rheumatology (PRH) workforce supply in the United States does not meet the needs of children. Lack of timely access to PRH care is associated with poor outcomes for children with rheumatic diseases. This article is part of a Pediatrics supplement focused on anticipating the future pediatric subspecialty workforce supply. It draws on information in the literature, American Board of Pediatrics data, and findings from a model that estimates the future supply of pediatric subspecialists developed by the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, Strategic Modeling and Analysis Ltd., and the American Board of Pediatrics Foundation. PRH has a smaller workforce per capita of children than most other pediatric subspecialties. The model demonstrates that the clinical workforce equivalent of pediatric rheumatologists in 2020 was only 0.27 per 100 000 children, with a predicted increase to 0.47 by 2040. Although the model predicts a 72% increase in providers, this number remains inadequate to provide sufficient care given the number of children with rheumatic diseases, especially in the South and West regions. The likely reasons for the workforce shortage are multifactorial, including lack of awareness of the field, low salaries compared with most other medical specialties, concerns about working solo or in small group practices, and increasing provider retirement. Novel interventions are needed to increase the workforce size. The American College of Rheumatology has recognized the dire consequences of this shortage and has developed a workforce solutions initiative to tackle these problems.
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Affiliation(s)
- Colleen K Correll
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Marisa S Klein-Gitelman
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michael Henrickson
- Department of Pediatrics, College of Medicine, University of Cincinnati, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Colin J Orr
- Department of Pediatrics
- Cecil G. Sheps Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jay J Mehta
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Aye T, Boney CM, Orr CJ, Leonard MB, Leslie LK, Allen DB. Child Health Needs and the Pediatric Endocrinology Workforce: 2020-2040. Pediatrics 2024; 153:e2023063678J. [PMID: 38300000 DOI: 10.1542/peds.2023-063678j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
The pediatric endocrinology (PE) workforce in the United States is struggling to sustain an adequate, let alone optimal, workforce capacity. This article, one of a series of articles in a supplement to Pediatrics, focuses on the pediatric subspecialty workforce and furthers previous evaluations of the US PE workforce to model the current and future clinical PE workforce and its geographic distribution. The article first discusses the children presenting to PE care teams, reviews the current state of the PE subspecialty workforce, and presents projected headcount and clinical workforce equivalents at the national, census region, and census division level on the basis of a subspecialty workforce supply model through 2040. It concludes by discussing the educational and training, clinical practice, policy, and future workforce research implications of the data presented. Data presented in this article are available from the American Board of Pediatrics, the National Resident Matching Program, and the subspecialty workforce supply model. Aging, part-time appointments, and unbalanced geographic distribution of providers diminish the PE workforce capacity. In addition, limited exposure, financial concerns, and lifestyle perceptions may impact trainees. Additional workforce challenges are the subspecialty's increasingly complex cases and breadth of conditions treated, reliance on international medical graduates to fill fellowship slots, and high relative proportion of research careers. The recent limitations on pediatric endocrinologists providing gender-affirming care may also impact the geographic distribution of the subspecialty's workforce. Deliberate actions need to be taken now to continue serving the needs of children.
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Affiliation(s)
- Tandy Aye
- Division of Pediatric Endocrinology
- Stanford University School of Medicine, Stanford, California
| | - Charlotte M Boney
- Division of Pediatric Endocrinology, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Colin J Orr
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mary B Leonard
- Stanford University School of Medicine, Stanford, California
| | | | - David B Allen
- Division of Pediatric Endocrinology and Diabetes, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Leslie LK, Orr CJ, Turner AL, Mink R, Leonard MB, Sabadosa KA, Vinci RJ. Child Health and the US Pediatric Subspecialty Workforce: Planning for the Future. Pediatrics 2024; 153:e2023063678B. [PMID: 38299999 DOI: 10.1542/peds.2023-063678b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
This article opens a multi-article Pediatrics supplement that provides a rigorous analysis of the projected pediatric subspecialty workforce in the United States. Congenital variations, epigenetics, exposures, lifestyle, preventive care, and medical interventions from conception through young adulthood set the stage for health and wellbeing in adulthood. Although care provided by pediatric subspecialists is associated with better outcomes and lower costs compared with adult providers, the authors of recent articles in the lay and medical literature have questioned the capacity of pediatric subspecialists to meet children's health care needs. This article highlights that, despite numerous advances in prevention, diagnosis, and treatment, the last decade has witnessed increasing numbers of children with acute or chronic physical and mental health disorders, including medical complexity, obesity, type 2 diabetes, anxiety, depression, and suicidality, all of which are exacerbated by poverty, racism, and other social drivers of health. In this article, we then describe the variability in the demographics, practice characteristics, and geographic distribution of the 15 core pediatric subspecialties certified by the American Board of Pediatrics. We then discuss the rationale and approach to the development of a pediatric subspecialty workforce model that forecasts subspecialist supply from 2020 to 2040 for 14 subspecialties at the national and subnational levels (not including the newest subspecialty, pediatric hospital medicine), accounting for US Census Bureau child population projections. The model does not account for the unique physical and mental needs of individual children, nor does it address the increasingly precarious commitment to, and financing of, pediatric subspecialty care in the US health care system impacting market demand.
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Affiliation(s)
- Laurel K Leslie
- American Board of Pediatrics, Chapel Hill, North Carolina
- Tufts University School of Medicine, Boston, Massachusetts
| | - Colin J Orr
- University of North Carolina School of Medicine at Chapel Hill, ChapelHill, North Carolina
| | - Adam L Turner
- American Board of Pediatrics, Chapel Hill, North Carolina
| | - Richard Mink
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center and the David Geffen School of Medicine at UCLA, Torrance, California
| | - Mary B Leonard
- Stanford University School of Medicine, Palo Alto, California
| | | | - Robert J Vinci
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
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Orr CJ, McCartha E, Vinci RJ, Mink RB, Leonard MB, Bissell M, Gaona AR, Leslie LK. Projecting the Future Pediatric Subspecialty Workforce: Summary and Recommendations. Pediatrics 2024; 153:e2023063678T. [PMID: 38300012 DOI: 10.1542/peds.2023-063678t] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
This article summarizes the findings of a Pediatrics supplement addressing the United States workforce for 15 pediatric subspecialties. It includes results from a microsimulation model projecting supply through 2040; growth is forecasted to be uneven across the subspecialties with worsening geographic maldistribution. Although each subspecialty has unique characteristics, commonalities include (1) the changing demographics and healthcare needs of children, including mental health; (2) poor outcomes for children experiencing adverse social drivers of health, including racism; and (3) dependence on other subspecialties. Common healthcare delivery challenges include (1) physician shortages for some subspecialties; (2) misalignment between locations of training programs and subspecialists and areas of projected child population growth; (3) tension between increasing subsubspecialization to address rare diseases and general subspecialty care; (4) the need to expand clinical reach through collaboration with other physicians and advanced practice providers; (5) the lack of parity between Medicare, which funds much of adult care, and Medicaid, which funds over half of pediatric subspecialty care; and (6) low compensation of pediatric subspecialists compared with adult subspecialists. Overall, subspecialists identified the lack of a central authority to monitor and inform child healthcare provided by pediatric subspecialists as a challenge. Future research on the pediatric subspecialty workforce and the children it serves will be necessary to ensure these children's needs are met. Together, these articles provide overarching and subspecialty-specific recommendations to improve training, recruitment, and retention of a diverse workforce, implement innovative models of care, drive policy changes, and advise future research.
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Affiliation(s)
- Colin J Orr
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Emily McCartha
- Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Robert J Vinci
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Richard B Mink
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - Mary B Leonard
- Stanford University School of Medicine, Stanford, California
| | - Mary Bissell
- Child Focus, Washington, District of Columbia
- Georgetown University Law Center, Georgetown University, Washington, District of Columbia
| | - Adriana R Gaona
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Laurel K Leslie
- American Board of Pediatrics, Chapel Hill, North Carolina
- Tufts University School of Medicine, Boston, Massachusetts
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Pfaff M, Denburg MR, Meyers KE, Brady TM, Leonard MB, Hoofnagle AN, Sethna CB. Association of Fibroblast Growth Factor 23 with Blood Pressure in Primary Proteinuric Glomerulopathies. Am J Nephrol 2023; 55:187-195. [PMID: 38128487 PMCID: PMC10987260 DOI: 10.1159/000535092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Fibroblast growth factor 23 (FGF23) has direct effects on the vasculature and myocardium, and high levels of FGF23 are a risk factor for cardiovascular disease (CVD); however, the impact of FGF23 on CVD in primary proteinuric glomerulopathies has not been addressed. METHODS The associations of baseline plasma intact FGF23 levels with resting blood pressure (BP) and lipids over time among adults and children with proteinuric glomerulopathies enrolled in the Nephrotic Syndrome Study Network (NEPTUNE) were analyzed using generalized estimating equation regression analyses. Models were adjusted for age, sex, glomerular diagnosis, follow-up time, estimated glomerular filtration rate, urine protein/creatinine ratio, obesity, and serum phosphorous levels. RESULTS Two hundred and four adults with median FGF23 77.5 (IQR 51.3-119.3) pg/mL and 93 children with median FGF23 62.3 (IQR 44.6-83.6) pg/mL were followed for a median of 42 (IQR 20.5-54) months. In adjusted models, each 1 µg/mL increase in FGF23 was associated with a 0.3 increase in systolic BP index at follow-up (p < 0.001). Greater baseline FGF23 was associated with greater odds of hypertensive BP (OR = 1.0003; 95% CI 1.001-1.006, p = 0.03) over time. Compared to tertile 1, tertile 2 (OR = 2.1; 95% CI 1.12-3.99, p = 0.02), and tertile 3 (OR = 3; 95% CI 1.08-8.08, p = 0.04), FGF23 levels were associated with greater odds of hypertensive BP over time. Tertile 2 was associated with greater triglycerides compared to tertile 1 (OR = 48.1; 95% CI 4.4-91.9, p = 0.03). CONCLUSION Overall, higher baseline FGF23 was significantly associated with hypertensive BP over time in individuals with proteinuric glomerulopathies. Further study of FGF23 as a therapeutic target for reducing CVD in proteinuric glomerular disease is warranted.
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Affiliation(s)
- Mairead Pfaff
- Cohen Children’s Medical Center of NY, New Hyde Park, NY, United States
| | - Michelle R. Denburg
- The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Kevin E. Meyers
- The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
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Kobayashi Y, Long J, Dan S, Johannsen NM, Talamoa R, Raghuram S, Chung S, Kent K, Basina M, Lamendola C, Haddad F, Leonard MB, Church TS, Palaniappan L. Strength training is more effective than aerobic exercise for improving glycaemic control and body composition in people with normal-weight type 2 diabetes: a randomised controlled trial. Diabetologia 2023; 66:1897-1907. [PMID: 37493759 PMCID: PMC10527535 DOI: 10.1007/s00125-023-05958-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/27/2023] [Indexed: 07/27/2023]
Abstract
AIMS/HYPOTHESIS Type 2 diabetes in people in the healthy weight BMI category (<25 kg/m2), herein defined as 'normal-weight type 2 diabetes', is associated with sarcopenia (low muscle mass). Given this unique body composition, the optimal exercise regimen for this population is unknown. METHODS We conducted a parallel-group RCT in individuals with type 2 diabetes (age 18-80 years, HbA1c 47.5-118.56 mmol/mol [6.5-13.0%]) and BMI <25 kg/m2). Participants were recruited in outpatient clinics or through advertisements and randomly assigned to a 9 month exercise programme of strength training alone (ST), aerobic training alone (AER) or both interventions combined (COMB). We used stratified block randomisation with a randomly selected block size. Researchers and caregivers were blinded to participants' treatment group; however, participants themselves were not. Exercise interventions were conducted at community-based fitness centres. The primary outcome was absolute change in HbA1c level within and across the three groups at 3, 6 and 9 months. Secondary outcomes included changes in body composition at 9 months. Per adherence to recommended exercise protocol (PP) analysis included participants who completed at least 50% of the sessions. RESULTS Among 186 individuals (ST, n=63; AER, n=58; COMB, n=65) analysed, the median (IQR) age was 59 (53-66) years, 60% were men and 83% were Asian. The mean (SD) HbA1c level at baseline was 59.6 (13.1) mmol/mol (7.6% [1.2%]). In intention-to-treat analysis, the ST group showed a significant decrease in HbA1c levels (mean [95% CI] -0.44 percentage points [-0.78, -0.12], p=0.002), while no significant change was observed in either the COMB group (-0.35 percentage points, p=0.13) or the AER group (-0.24 percentage points, p=0.10). The ST group had a greater improvement in HbA1c levels than the AER group (p=0.01). Appendicular lean mass relative to fat mass increased only in the ST group (p=0.0008), which was an independent predictor of HbA1c change (beta coefficient -7.16, p=0.01). Similar results were observed in PP analysis. Only one adverse event, in the COMB group, was considered to be possibly associated with the exercise intervention. CONCLUSIONS/INTERPRETATION In normal-weight type 2 diabetes, strength training was superior to aerobic training alone, while no significant difference was observed between strength training and combination training for HbA1c reduction. Increased lean mass relative to decreased fat mass was an independent predictor of reduction in HbA1c level. TRIAL REGISTRATION ClinicalTrials.gov NCT02448498. FUNDING This study was funded by the National Institutes of Health (NIH; R01DK081371).
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Affiliation(s)
- Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.
- Stanford Cardiovascular Institute, Stanford, CA, USA.
| | - Jin Long
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Shozen Dan
- Center for Asian Health Research and Education, Stanford University School of Medicine, Stanford, CA, USA
| | - Neil M Johannsen
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
- Louisiana State University, Baton Rouge, LA, USA
| | - Ruth Talamoa
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sonia Raghuram
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sukyung Chung
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Kyla Kent
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Marina Basina
- Division of Endocrinology, Gerontology, and Metabolism, Stanford University School of Medicine, Stanford, CA, USA
| | - Cynthia Lamendola
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Timothy S Church
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
- Louisiana State University, Baton Rouge, LA, USA
- Wondr Health, Dallas, TX, USA
| | - Latha Palaniappan
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Gabel L, Kent K, Hosseinitabatabaei S, Burghardt AJ, Leonard MB, Rauch F, Willie BM. Recommendations for High-resolution Peripheral Quantitative Computed Tomography Assessment of Bone Density, Microarchitecture, and Strength in Pediatric Populations. Curr Osteoporos Rep 2023; 21:609-623. [PMID: 37428435 PMCID: PMC10543577 DOI: 10.1007/s11914-023-00811-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize current approaches and provide recommendations for imaging bone in pediatric populations using high-resolution peripheral quantitative computed tomography (HR-pQCT). RECENT FINDINGS Imaging the growing skeleton is challenging and HR-pQCT protocols are not standardized across centers. Adopting a single-imaging protocol for all studies is unrealistic; thus, we present three established protocols for HR-pQCT imaging in children and adolescents and share advantages and disadvantages of each. Limiting protocol variation will enhance the uniformity of results and increase our ability to compare study results between different research groups. We outline special cases along with tips and tricks for acquiring and processing scans to minimize motion artifacts and account for growing bone. The recommendations in this review are intended to help researchers perform HR-pQCT imaging in pediatric populations and extend our collective knowledge of bone structure, architecture, and strength during the growing years.
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Affiliation(s)
- L Gabel
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, 2500 University Dr NW, Calgary, AB, T2N 1N4, Canada.
- McCaig Institute for Bone and Joint Health and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
| | - K Kent
- Department of Pediatrics, Stanford School of Medicine, Stanford, CA, USA
| | - S Hosseinitabatabaei
- Research Centre, Shriners Hospital for Children-Canada, Montreal, Canada
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | - A J Burghardt
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - M B Leonard
- Department of Pediatrics, Stanford School of Medicine, Stanford, CA, USA
| | - F Rauch
- Research Centre, Shriners Hospital for Children-Canada, Montreal, Canada
- Department of Pediatrics, McGill University, Montreal, Canada
| | - B M Willie
- Research Centre, Shriners Hospital for Children-Canada, Montreal, Canada
- Department of Biomedical Engineering, McGill University, Montreal, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Canada
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Hsu S, Zelnick LR, Bansal N, Brown J, Denburg M, Feldman HI, Ginsberg C, Hoofnagle AN, Isakova T, Leonard MB, Lidgard B, Robinson‐Cohen C, Wolf M, Xie D, Kestenbaum BR, de Boer IH. Vitamin D Metabolites and Risk of Cardiovascular Disease in Chronic Kidney Disease: The CRIC Study. J Am Heart Assoc 2023; 12:e028561. [PMID: 37421259 PMCID: PMC10382125 DOI: 10.1161/jaha.122.028561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 04/18/2023] [Indexed: 07/10/2023]
Abstract
Background The ratio of 24,25-dihydroxyvitamin D3/25-hydroxyvitamin D3 (vitamin D metabolite ratio [VDMR]) may reflect functional vitamin D activity. We examined associations of the VDMR, 25-hydroxyvitamin D (25[OH]D), and 1,25-dihydroxyvitamin D (1,25[OH]2D) with cardiovascular disease (CVD) in patients with chronic kidney disease. Methods and Results This study included longitudinal and cross-sectional analyses of 1786 participants from the CRIC (Chronic Renal Insufficiency Cohort) Study. Serum 24,25-dihydroxyvitamin D3, 25(OH)D, and 1,25(OH)2D were measured by liquid chromatography-tandem mass spectrometry 1 year after enrollment. The primary outcome was composite CVD (heart failure, myocardial infarction, stroke, and peripheral arterial disease). We used Cox regression with regression-calibrated weights to test associations of the VDMR, 25(OH)D, and 1,25(OH)2D with incident CVD. We examined cross-sectional associations of these metabolites with left ventricular mass index using linear regression. Analytic models adjusted for demographics, comorbidity, medications, estimated glomerular filtration rate, and proteinuria. The cohort was 42% non-Hispanic White race and ethnicity, 42% non-Hispanic Black race and ethnicity, and 12% Hispanic ethnicity. Mean age was 59 years, and 43% were women. Among 1066 participants without prevalent CVD, there were 298 composite first CVD events over a mean follow-up of 8.6 years. Lower VDMR and 1,25(OH)2D were associated with incident CVD before, but not after, adjustment for estimated glomerular filtration rate and proteinuria (hazard ratio, 1.11 per 1 SD lower VDMR [95% CI, 0.95-1.31]). Only 25(OH)D was associated with left ventricular mass index after full covariate adjustment (0.6 g/m2.7 per 10 ng/mL lower [95% CI, 0.0-1.3]). Conclusions Despite modest associations of 25(OH)D with left ventricular mass index, 25(OH)D, the VDMR, and 1,25(OH)2D were not associated with incident CVD in chronic kidney disease.
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Affiliation(s)
- Simon Hsu
- Division of Nephrology and Kidney Research Institute, Department of MedicineUniversity of WashingtonSeattleWA
| | - Leila R. Zelnick
- Division of Nephrology and Kidney Research Institute, Department of MedicineUniversity of WashingtonSeattleWA
| | - Nisha Bansal
- Division of Nephrology and Kidney Research Institute, Department of MedicineUniversity of WashingtonSeattleWA
| | - Julia Brown
- Division of Nephrology and Hypertension, Department of MedicineLoyola University of ChicagoMaywoodIL
| | - Michelle Denburg
- Division of Pediatric NephrologyDepartment of Pediatrics, The Children’s Hospital of PhiladelphiaPhiladelphiaPA
- Department of Biostatistics, Epidemiology, and InformaticsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Harold I. Feldman
- Department of Biostatistics, Epidemiology, and InformaticsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
- Center for Clinical Epidemiology and BiostatisticsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Charles Ginsberg
- Division of Nephrology‐HypertensionUniversity of California, San DiegoSan DiegoCA
| | | | - Tamara Isakova
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Mary B. Leonard
- Division of Nephrology, Lucile Packard Children’s HospitalStanford University School of MedicinePalo AltoCA
| | - Benjamin Lidgard
- Division of Nephrology and Kidney Research Institute, Department of MedicineUniversity of WashingtonSeattleWA
| | | | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke Clinical Research InstituteDuke University School of MedicineDurhamNCUSA
| | - Dawei Xie
- Department of Biostatistics, Epidemiology, and InformaticsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
- Center for Clinical Epidemiology and BiostatisticsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Bryan R. Kestenbaum
- Division of Nephrology and Kidney Research Institute, Department of MedicineUniversity of WashingtonSeattleWA
| | - Ian H. de Boer
- Division of Nephrology and Kidney Research Institute, Department of MedicineUniversity of WashingtonSeattleWA
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Shah LN, Leonard MB, Ziolkowski SL, Grimm P, Long J. Cystatin C and Creatinine Concentrations are Uninformative Biomarkers of Sarcopenia: A Cross-Sectional NHANES Study. J Ren Nutr 2023:S1051-2276(23)00018-3. [PMID: 36796503 DOI: 10.1053/j.jrn.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/13/2023] [Accepted: 01/29/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVES Differences in creatinine and cystatin C-based estimates of glomerular filtration rate (eGFRDiff = eGFRCr - eGFRCysC) may reflect differences in muscle mass. We sought to determine if eGFRDiff (1) reflects lean mass, (2) identifies sarcopenic individuals beyond estimates based on age, BMI, and sex; and (3) demonstrates associations differently in those with and without chronic kidney disease (CKD). DESIGN AND METHODS This cross-sectional study included 3,754 participants, ages 20-85 years, with creatinine and cystatin C concentration levels, and DXA scans from NHANES data (1999 to 2006). DXA appendicular lean mass index (ALMI) estimated muscle mass. Non-race-based CKD EPI equations estimated GFR using creatinine (eGFRCr), cystatin C (eGFRCysC), and both biomarkers (eGFRCysC&Cr). CKD was defined as eGFRCysC&Cr < 60 mL/min/1.73m2. ALMI sex-specific T-scores (compared with young adult) < -2.0 defined sarcopenia. In estimating ALMI, we compared the coefficient of determination (R2) values from: 1) eGFRDiff, 2) clinical characteristics (age, BMI, and sex), and 3) clinical characteristics plus eGFRDiff. Using logistic regression, we evaluated each model's C-statistic to diagnose sarcopenia. RESULTS eGFRDIFF was negatively and weakly associated with ALMI (No CKD: R2 = 0.006, p-value 0.002; CKD: R2 = 0.001, p-value 0.9). Clinical characteristics explained most of the variation in ALMI (No CKD: R2 = 0.851, CKD: R2 = 0.828), and provided strong discrimination of sarcopenia (No CKD C-statistic: 0.950; CKD C-statistic: 0.943). Adding eGFRDiff improved the R2 by 0.025, and the C-statistic by 0.003. Tests for interaction between eGFRDiff and CKD were not significant (all p-values > 0.05). CONCLUSIONS Although eGFRDiff has statistically significant associations with ALMI and sarcopenia in univariate analyses, multivariate analyses demonstrate that eGFRDiff does not capture more information beyond routine clinical characteristics (age, BMI, and sex).
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Affiliation(s)
- Lokesh N Shah
- Stanford University School of Medicine, Stanford, CA, United States.
| | - Mary B Leonard
- Stanford University School of Medicine, Stanford, CA, United States; Stanford Assessment of Bone and Muscle across the Ages (SAMBA) Center, Palo Alto, CA, United States
| | | | - Paul Grimm
- Stanford University School of Medicine, Stanford, CA, United States
| | - Jin Long
- Stanford University School of Medicine, Stanford, CA, United States; Stanford Assessment of Bone and Muscle across the Ages (SAMBA) Center, Palo Alto, CA, United States
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13
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Valenzuela Riveros LF, Long J, Bachrach LK, Leonard MB, Kent K. Trabecular Bone Score (TBS) Varies with Correction for Tissue Thickness Versus Body Mass Index: Implications When Using Pediatric Reference Norms. J Bone Miner Res 2023; 38:493-498. [PMID: 36779634 DOI: 10.1002/jbmr.4786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 02/14/2023]
Abstract
Trabecular bone score (TBS) derived from secondary analysis of lumbar spine dual-energy X-ray absorptiometry (DXA) scans improves fracture prediction independent of bone mineral density (BMD) in adults. The utility of TBS to assess fracture risk in younger patients has not been established because pediatric norms have been lacking. Robust TBS reference data from the Bone Mineral Density in Childhood Study (BMDCS) have been published. TBS values for the BMDCS study were derived using an algorithm that accounts for tissue thickness (TBSTH ) rather than the commercially available algorithm that adjusts for body mass index (BMI; TBSBMI ). We examined the magnitude of differences in TBSTH and TBSBMI in a cohort of 189 healthy youth. TBS values using both algorithms increased with age and pubertal development in a similar pattern. However, TBSBMI values were systematically and significantly higher than TBSTH (mean = 0.06, p < 0.0001). The difference between calculated TBSBMI and TBSTH was not uniform. Differences were greater at lower TBS values, in males, in older individuals, in those at later Tanner stages, and in those with a greater BMI Z-score. These systematic differences preclude the development of a simple formula to allow conversion of TBSBMI to TBSTH "equivalents." Because of these systematic differences in these two algorithms, using an individual's TBSBMI to calculate a Z-score using the BMDCS TBSTH reference values results in a falsely higher TBS Z-score (differences mean = 0.73, interquartile range [IQR] = 0.3 to 1.6). Until TBSTH software for Hologic DXA equipment becomes commercially available, BMDCS TBS reference norms should not be used. © 2023 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
| | - Jin Long
- Department of Pediatrics, Stanford School of Medicine, Stanford, CA, USA
| | - Laura K Bachrach
- Department of Pediatrics, Stanford School of Medicine, Stanford, CA, USA
| | - Mary B Leonard
- Department of Pediatrics, Stanford School of Medicine, Stanford, CA, USA
| | - Kyla Kent
- Department of Pediatrics, Stanford School of Medicine, Stanford, CA, USA
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14
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Haddad F, Li X, Perelman D, Santana EJ, Kuznetsova T, Cauwenberghs N, Busque V, Contrepois K, Snyder MP, Leonard MB, Gardner C. Challenging obesity and sex based differences in resting energy expenditure using allometric modeling, a sub-study of the DIETFITS clinical trial. Clin Nutr ESPEN 2023; 53:43-52. [PMID: 36657929 DOI: 10.1016/j.clnesp.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND & AIMS Resting energy expenditure (REE) is a major component of energy balance. While REE is usually indexed to total body weight (BW), this may introduce biases when assessing REE in obesity or during weight loss intervention. The main objective of the study was to quantify the bias introduced by ratiometric scaling of REE using BW both at baseline and following weight loss intervention. DESIGN Participants in the DIETFITS Study (Diet Intervention Examining The Factors Interacting with Treatment Success) who completed indirect calorimetry and dual-energy X-ray absorptiometry (DXA) were included in the study. Data were available in 438 participants at baseline, 340 at 6 months and 323 at 12 months. We used multiplicative allometric modeling based on lean body mass (LBM) and fat mass (FM) to derive body size independent scaling of REE. Longitudinal changes in indexed REE were then assessed following weight loss intervention. RESULTS A multiplicative model including LBM, FM, age, Black race and the double product (DP) of systolic blood pressure and heart rate explained 79% of variance in REE. REE indexed to [LBM0.66 × FM0.066] was body size and sex independent (p = 0.91 and p = 0.73, respectively) in contrast to BW based indexing which showed a significant inverse relationship to BW (r = -0.47 for female and r = -0.44 for male, both p < 0.001). When indexed to BW, significant baseline differences in REE were observed between male and female (p < 0.001) and between individuals who are overweight and obese (p < 0.001) while no significant differences were observed when indexed to REE/[LBM0.66 × FM0.066], p > 0.05). Percentage predicted REE adjusted for LBM, FM and DP remained stable following weight loss intervention (p = 0.614). CONCLUSION Allometric scaling of REE based on LBM and FM removes body composition-associated biases and should be considered in obesity and weight-based intervention studies.
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Affiliation(s)
- Francois Haddad
- Department of Medicine, Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, CA, USA; Stanford Cardiovascular Institute, CA, USA; Stanford Diabetes Research Center, Stanford, CA, 94305, USA.
| | - Xiao Li
- Department of Genetics, Stanford University, CA, USA.
| | | | - Everton Jose Santana
- Department of Medicine, Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, CA, USA; Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, Belgium.
| | - Tatiana Kuznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, Belgium.
| | - Nicholas Cauwenberghs
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, Belgium.
| | - Vincent Busque
- Department of Medicine, Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, CA, USA; Department of Medicine, Stanford Prevention Research Center, CA, USA; Stanford Diabetes Research Center, Stanford, CA, 94305, USA.
| | - Kevin Contrepois
- Department of Genetics, Stanford University, CA, USA; Department of Medicine, Stanford Prevention Research Center, CA, USA.
| | - Michael P Snyder
- Stanford Cardiovascular Institute, CA, USA; Department of Genetics, Stanford University, CA, USA; Stanford Diabetes Research Center, Stanford, CA, 94305, USA.
| | - Mary B Leonard
- Department of Pediatrics, Stanford University, CA, USA; Department of Medicine, Stanford Prevention Research Center, CA, USA.
| | - Christopher Gardner
- Department of Medicine, Stanford Prevention Research Center, CA, USA; Stanford Diabetes Research Center, Stanford, CA, 94305, USA.
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Leonard MB, Grimm PC. Improving Quality of Care and Outcomes for Pediatric Patients With End-stage Kidney Disease: The Importance of Pediatric Nephrology Expertise. JAMA 2022; 328:427-429. [PMID: 35916864 DOI: 10.1001/jama.2022.11603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Paul C Grimm
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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Bass RM, Zemel BS, Stallings VA, Leonard MB, Tsao J, Kelly A. Bone accrual and structural changes over one year in youth with cystic fibrosis. J Clin Transl Endocrinol 2022; 28:100297. [PMID: 35433270 PMCID: PMC9006323 DOI: 10.1016/j.jcte.2022.100297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 11/06/2022] Open
Abstract
Background Pediatric bone accrual governs peak bone mass and strength. Longitudinal studies of bone health in youth with cystic fibrosis (CF) may provide insight into CF-related bone disease (CFBD), a prevalent co-morbidity in adults with CF. Methods This one-year longitudinal study of youth with pancreatic insufficient CF, enrolled in a nutrition intervention study [n = 62 (36 M/26F)] 1) examined dual-energy x-ray absorptiometry (DXA)-defined lumbar spine (LS) and total body less head (TBLH) bone accrual and 2) compared their changes in peripheral quantitative computed tomography (pQCT) cortical and trabecular tibial bone density and geometry to those of a healthy reference group [n = 143 (68 M/75F)]. Main outcome measures were 1) DXA: lumbar spine areal bone mineral density (LSaBMD) and total body less head bone mineral content (TBLH-BMC), sex- and pubertal status-specific, height velocity (HV)-adjusted or HV and lean body mass velocity (HV-LBMV)-adjusted annualized velocity-Z scores and 2) pQCT: age, sex, pubertal status and, when appropriate, tibial length adjusted Z-scores for bone architecture measures. DXA velocity-Z were compared to expected mean of 0 and correlations with clinical parameters (age, BMI-Z and FEV1%-predicted) tested. Within-subject comparisons of HV-adjusted and LBMV-HV-adjusted DXA velocity-Z were conducted in CF. pQCT Z-scores were compared between the two groups over one year using longitudinal models. Longitudinal relationships between measures of bone health and clinical parameters (age, BMI-Z and FEV1%-predicted) were examined in individuals with CF. Results DXA velocity-Z were higher than normal in females (p < 0.05) but not males with CF. HV-adjusted and LBMV-HV-adjusted velocity-Z did not differ for LSaBMD or TBLH-BMC. In males with CF, both HV-adjusted and LBMV-HV-adjusted LSaBMD velocity-Z scores correlated negatively with age (HV rho: −0.35; p = 0.045 and LBMV-HV rho: −0.47; p = 0.0046). In males with CF BMI-Z correlated positively with HV-adjusted LSaBMD velocity-Z (rho: 0.37; p = 0.034), but this relationship did not persist for LBMV-HV (rho: 0.14; p = 0.42). In females with CF, no correlations between LSaBMD velocity-Z scores and age or BMI-Z were found (all p > 0.05). No correlations between LSaBMD velocity-Z scores and FEV1%-predicted were seen in either sex (all p > 0.12). TBLH-BMC velocity Z-scores were not correlated with clinical parameters in either sex (all p > 0.1). At baseline, multiple pQCT parameters were lower in CF (p < 0.05). pQCT Z-scores did not differ between baseline and one-year in either CF or reference group. In a longitudinal model comparing pQCT-Z changes in CF and reference, multiple pQCT-Z outcomes remained lower in CF, but the changes in parameters did not differ in CF vs reference (all p > 0.26). Lower pQCT outcomes in CF were largely restricted to males (CF group*female sex interaction beta coefficients > 0). In this combined longitudinal model, of both CF and reference, BMI-Z was positively associated with pQCT-Z parameters(p < 0.001). Multiple pQCT-Z outcomes positively correlated with both BMI-Z and FEV1%-predicted in males with CF, and with FEV1%-predicted in females with CF (p < 0.05). Age was negatively associated with section modulus (p = 0.001) in males and with cortical density-Z in females (p < 0.001). Conclusions With improved longevity, bone health in CF is of increasing importance. On average, bone accrual was preserved in youth with CF, and while deficits in bone geometry and strength were found, these deficits did not worsen over the one-year study. Lower LS bone accrual with increasing age suggests emerging adulthood is a period of vulnerability in CF while the role of LBM in bone health is underscored by the lack of relationship between LBMV-adjusted accrual and BMI. These findings may be useful in targeting screening practices and interventions.
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Kindler JM, Guo M, Baker J, McCormack S, Armenian SH, Zemel BS, Leonard MB, Mostoufi-Moab S. Persistent Musculoskeletal Deficits in Pediatric, Adolescent and Young Adult Survivors of Allogeneic Hematopoietic Stem-Cell Transplantation. J Bone Miner Res 2022; 37:794-803. [PMID: 35080067 DOI: 10.1002/jbmr.4513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 11/08/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (alloHSCT) is a common therapy for pediatric hematologic malignancies. With improved supportive care, addressing treatment-related late effects is at the forefront of survivor long-term health and quality of life. We previously demonstrated that alloHSCT survivors had increased adiposity, decreased lean mass, and lower bone density and strength, 7 years (median) from alloHSCT compared to their healthy peers. Yet it is unknown whether these deficits persist. Our longitudinal study characterized changes in muscle and bone over a period of 3.4 (range, 2.0 to 4.9) years in 47 childhood alloHSCT survivors, age 5-26 years at baseline (34% female). Tibia cortical bone geometry and volumetric density and lower leg muscle cross-sectional area (MCSA) were assessed via peripheral quantitative computed tomography (pQCT). Anthropometric and pQCT measurements were converted to age, sex, and ancestry-specific standard deviation scores, adjusted for leg length. Muscle-specific force was assessed as strength relative to MCSA adjusted for leg length (strength Z-score). Measurements were compared to a healthy reference cohort (n = 921), age 5-30 years (52% female). At baseline and follow-up, alloHSCT survivors demonstrated lower height Z-scores, weight Z-scores, and leg length Z-scores compared to the healthy reference cohort. Deficits in MCSA, trabecular volumetric bone density, and cortical bone size and estimated strength (section modulus) were evident in survivors (all p < 0.05). Between the two study time points, anthropometric, muscle, and bone Z-scores did not change significantly in alloHSCT survivors. Approximately 15% and 17% of alloHSCT survivors had MCSA and section modulus Z-score < -2.0, at baseline and follow-up, respectively. Furthermore, those with a history of total body irradiation compared to those without demonstrated lower MCSA at follow-up. The persistent muscle and bone deficits in pediatric alloHSCT survivors support the need for strategies to improve bone and muscle health in this at-risk population. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Joseph M Kindler
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle Guo
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Joshua Baker
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shana McCormack
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Endocrinology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Saro H Armenian
- Department of Pediatrics, City of Hope, Duarte, CA, USA.,Department of Population Sciences, City of Hope, Duarte, CA, USA
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Endocrinology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Abman SH, Armstrong S, Baker S, Bogue CW, Carlo W, Chalak L, Daniels SR, Davis S, Debaun MR, Fike C, Frazer L, Gibson K, Gill M, Glass H, Gordon CM, Goyal M, Hirschhorn J, Holtz L, Hunstad DA, Leonard MB, Maitre N, Markham L, McAllister-Lucas L, Orange J, Shah P, Simon T, Steinhorn RH, Tarini B, Walker-Harding LR. The american pediatric society and society for pediatric research joint statement against racism and social injustice. Pediatr Res 2022; 91:72. [PMID: 32882704 PMCID: PMC7492687 DOI: 10.1038/s41390-020-01107-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 06/29/2020] [Accepted: 07/21/2020] [Indexed: 11/09/2022]
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Leonard MB, Pursley DM, Robinson LA, Abman SH, Davis JM. The importance of trustworthiness: lessons from the COVID-19 pandemic. Pediatr Res 2022; 91:482-485. [PMID: 34853429 PMCID: PMC8635282 DOI: 10.1038/s41390-021-01866-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/08/2021] [Indexed: 01/01/2023]
Affiliation(s)
- Mary B. Leonard
- grid.168010.e0000000419368956Department of Pediatrics and Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - DeWayne M. Pursley
- grid.239395.70000 0000 9011 8547Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Lisa A. Robinson
- grid.17063.330000 0001 2157 2938Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON Canada
| | - Steven H. Abman
- grid.413957.d0000 0001 0690 7621Department of Pediatrics, Children’s Hospital of Colorado, Aurora, CO USA
| | - Jonathan M. Davis
- grid.67033.310000 0000 8934 4045Department of Pediatrics and the Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, MA USA
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Vaikunth SS, Leonard MB, Whitehead KK, Goldberg DJ, Rychik J, Zemel BS, Avitabile CM. Deficits in the Functional Muscle-Bone Unit in Youths with Fontan Physiology. J Pediatr 2021; 238:202-207. [PMID: 34214589 PMCID: PMC8634795 DOI: 10.1016/j.jpeds.2021.06.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine whether dual energy X-ray absorptiometry (DXA), a clinically available tool, mirrors the magnitude of deficits in trabecular and cortical bone mineral density (BMD) demonstrated on peripheral quantitative computed tomography in youth with Fontan physiology. STUDY DESIGN We aimed to describe DXA-derived BMD at multiple sites and to investigate the relationship between BMD and leg lean mass, a surrogate for skeletal muscle loading. Subjects with Fontan (n = 46; aged 5-20 years) underwent DXA in a cross-sectional study of growth and bone and muscle health as described previously. Data from the Bone Mineral Density in Childhood Study were used to calculate age-, sex-, and race-specific BMD z-scores of the whole body, lumbar spine, hip, femoral neck, distal one-third radius, ultradistal radius, and leg lean mass z-score (LLMZ). RESULTS Fontan BMD z-scores were significantly lower than reference at all sites-whole body, -0.34 ± 0.85 (P = .01); spine, -0.41 ± 0.96 (P = .008); hip, -0.75 ± 1.1 (P < .001); femoral neck, -0.73 ± 1.0 (P < .001); distal one-third radius, -0.87 ± 1.1 (P < .001); and ultradistal radius. -0.92 ± 1.03 (P < .001)-as was LLMZ (-0.93 ± 1.1; P < .001). Lower LLMZ was associated with lower BMD of the whole body (R2 = 0.40; P < .001), lumbar spine (R2 = 0.16; P = .005), total hip (R2 = 0.32; P < .001), femoral neck (R2 = 0.47; P < .001), and ultradistal radius (R2 = 0.35; P < .001). CONCLUSIONS Patients with Fontan have marked deficits in both cortical (hip, distal one-third radius) and trabecular (lumbar spine, femoral neck, ultradistal radius) BMD. Lower LLMZ is associated with lower BMD and may reflect inadequate skeletal muscle loading. Interventions to increase muscle mass may improve bone accrual.
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Affiliation(s)
- Sumeet S. Vaikunth
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mary B. Leonard
- Departments of Medicine and Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kevin K. Whitehead
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David J. Goldberg
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jack Rychik
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Babette S. Zemel
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Catherine M. Avitabile
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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21
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Baker JF, Giles JT, Weber D, George MD, Leonard MB, Zemel BS, Long J, Katz P. Sarcopenic Obesity in Rheumatoid Arthritis: Prevalence and Impact on Physical Functioning. Rheumatology (Oxford) 2021; 61:2285-2294. [PMID: 34559201 DOI: 10.1093/rheumatology/keab710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 09/07/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We determined the prevalence of sarcopenic obesity in patients with rheumatoid arthritis (RA) using multiple methods and assessed associations with physical functioning. METHODS This study evaluated data from three RA cohorts. Whole-body dual-energy absorptiometry (DXA) measures of appendicular lean mass index (ALMI, kg/m2) and fat mass index (FMI) were converted to age, sex, and race-specific Z-Scores and categorized using a recently validated method and compared it to a widely-used existing method. The prevalence of body composition abnormalities in RA was compared with two reference populations. In the RA cohorts, associations between body composition and change in the Health Assessment Questionnaire (HAQ) and the Short Physical Performance Battery (SPPB) in follow-up were assessed using linear and logistic regression, adjusting for age, sex, race, and study. RESULTS The prevalence of low lean mass and sarcopenic obesity were higher in patients with RA (14.2; 12.6%, respectively) compared with the reference population cohorts (7-10%; 4-4.5%, respectively, all p< 0.05). There was only moderate agreement among methods of sarcopenic obesity categorization (Kappa 0.45). The recently validated method categorized fewer subjects as obese, and many of these were categorized as low lean mass only. Low lean mass, obesity, and sarcopenic obesity were each associated with higher HAQ and lower SPPB at baseline and numerically greater worsening. CONCLUSION RA patients had higher rates of low lean mass and sarcopenic obesity than the general population. The recently validated methods characterized body composition changes differently from traditional methods and were more strongly associated with physical function.
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Affiliation(s)
- Joshua F Baker
- Philadelphia VA Medical Center, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | | | - David Weber
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael D George
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mary B Leonard
- Stanford University School of Medicine, Stanford, CA, USA
| | - Babette S Zemel
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jin Long
- Stanford University School of Medicine, Stanford, CA, USA
| | - Patricia Katz
- University of California San Francisco, San Francisco, CA, USA
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22
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Dienemann T, Ziolkowski SL, Bender S, Goral S, Long J, Baker JF, Shults J, Zemel BS, Reese PP, Wilson FP, Leonard MB. Changes in Body Composition, Muscle Strength, and Fat Distribution Following Kidney Transplantation. Am J Kidney Dis 2021; 78:816-825. [PMID: 34352286 DOI: 10.1053/j.ajkd.2020.11.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/20/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE AND OBJECTIVE Low muscle mass relative to fat mass (relative sarcopenia) has been associated with mortality and disability but has not been examined following transplantation. We studied how measures of body composition change after receipt of a kidney allograft. STUDY DESIGN Prospective longitudinal cohort study. SETTING AND PARTICIPANTS 60 kidney transplant recipients (ages 20-60 years) at the University of Pennsylvania. EXPOSURE Kidney transplantation. OUTCOMES DXA measures of fat mass index (FMI) and appendicular lean mass index (ALMI; representing muscle mass), CT measures of muscle density (low density represents increased intramuscular adipose tissue), dynamometer measures of leg muscle strength, and physical activity. ALMI relative to FMI (ALMFMI) is an established index of relative sarcopenia. ANALYTICAL APPROACH Measures expressed as age, sex, and race-specific Z-scores for transplant recipients were compared to 327 healthy controls. Regression models were used to identify correlates of change in outcome Z-scores and compare transplant recipients to controls. RESULTS At transplantation, ALMI, ALMIFMI, muscle strength and muscle density Z-scores were lower vs. controls (all p≤0.001). Transplant recipients received glucocorticoids throughout. The prevalence of obesity increased from 18 to 45%. Although ALMI increased following transplantation (p<0.001) and was comparable to controls from 6 months onward, gains were outpaced by increases in FMI, resulting in persistent ALMIFMI deficits (mean Z-score -0.31 at 24 months, p=0.02 vs controls). Muscle density improved following transplantation despite gains in FMI (p = 0.02). Muscle strength relative to ALMI also improved (p = 0.04) but remained low compared with controls (p=0.01). Exercise increased in the early months following transplantation (p<0.05) but remained lower than controls (p=0.02). LIMITATIONS Lack of muscle biopsies precluded assessment of muscle histology and metabolism. CONCLUSIONS The two-year interval following kidney transplantation was characterized by gains in muscle mass and strength that were outpaced by gains in fat mass resulting in persistent relative sarcopenia.
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Affiliation(s)
- Thomas Dienemann
- Department of Surgery, University Hospital of Regensburg, Regensburg, Germany.
| | - Susan L Ziolkowski
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Shaun Bender
- Boehringer Ingelheim Pharmaceuticals Inc., CT, USA
| | - Simin Goral
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jin Long
- Departments of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Joshua F Baker
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Justine Shults
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Babette S Zemel
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Peter P Reese
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - F Perry Wilson
- Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Mary B Leonard
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Departments of Pediatrics, Stanford University School of Medicine, Stanford, CA
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23
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Guo M, Zemel BS, Hawkes CP, Long J, Kelly A, Leonard MB, Jaramillo D, Mostoufi-Moab S. Sarcopenia and preserved bone mineral density in paediatric survivors of high-risk neuroblastoma with growth failure. J Cachexia Sarcopenia Muscle 2021; 12:1024-1033. [PMID: 34184837 PMCID: PMC8350210 DOI: 10.1002/jcsm.12734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/21/2021] [Accepted: 05/21/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Survival from paediatric high-risk neuroblastoma (HR-NBL) has increased, but cis-retinoic acid (cis-RA), the cornerstone of HR-NBL therapy, can cause osteoporosis and premature physeal closure and is a potential threat to skeletal structure in HR-NBL survivors. Sarcopenia is associated with increased morbidity in survivors of paediatric malignancies. Low muscle mass may be associated with poor prognosis in HR-NBL patients but has not been studied in these survivors. The study objective was to assess bone density, body composition and muscle strength in HR-NBL survivors compared with controls. METHODS This prospective cross-sectional study assessed areal bone mineral density (aBMD) of the whole body, lumbar spine, total hip, femoral neck, distal 1/3 and ultradistal radius and body composition (muscle and fat mass) using dual-energy X-ray absorptiometry (DXA) and lower leg muscle strength using a dynamometer. Measures expressed as sex-specific standard deviation scores (Z-scores) included aBMD (adjusted for height Z-score), bone mineral apparent density (BMAD), leg lean mass (adjusted for leg length), whole-body fat mass index (FMI) and ankle dorsiflexion peak torque adjusted for leg length (strength-Z). Muscle-specific force was assessed as strength relative to leg lean mass. Outcomes were compared between HR-NBL survivors and controls using Student's t-test or Mann-Whitney U test. Linear regression models examined correlations between DXA and dynamometer outcomes. RESULTS We enrolled 20 survivors of HR-NBL treated with cis-RA [13 male; mean age: 12.4 ± 1.6 years; median (range) age at therapy initiation: 2.6 (0.3-9.1) years] and 20 age-, sex- and race-matched controls. Height-Z was significantly lower in HR-NBL survivors compared with controls (-1.73 ± 1.38 vs. 0.34 ± 1.12, P < 0.001). Areal BMD-Z, BMAD-Z, FMI-Z, visceral adipose tissue and subcutaneous adipose tissue were not significantly different in HR-NBL survivors compared with controls. Compared with controls, HR-NBL survivors had lower leg lean mass-Z (-1.46 ± 1.35 vs. - 0.17 ± 0.84, P < 0.001) and strength-Z (-1.13 ± 0.86 vs. - 0.15 ± 0.71, P < 0.001). Muscle-specific force was lower in HR-NBL survivors compared with controls (P < 0.05). CONCLUSIONS Bone mineral density and adiposity are not severely impacted in HR-NBL survivors with growth failure, but significant sarcopenia persists years after treatment. Future studies are needed to determine if sarcopenia improves with muscle-specific interventions in this population of cancer survivors.
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Affiliation(s)
- Michelle Guo
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Babette S Zemel
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Colin P Hawkes
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jin Long
- Center for Artificial Intelligence in Medicine and Imaging, Stanford University, Stanford, CA, USA
| | - Andrea Kelly
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary B Leonard
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Diego Jaramillo
- Department of Radiology, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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24
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Hall RK, Blumenthal JB, Doerfler RM, Chen J, Diamantidis CJ, Jaar BG, Kusek JW, Kallem K, Leonard MB, Navaneethan SD, Sha D, Sondheimer JH, Wagner LA, Yang W, Zhan M, Fink JC. Risk of Potentially Inappropriate Medications in Adults With CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2021; 78:837-845.e1. [PMID: 34029681 DOI: 10.1053/j.ajkd.2021.03.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/03/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Adults with chronic kidney disease (CKD) may be at increased risk of adverse effects from use of potentially inappropriate medications (PIMs). Our objective was to assess whether PIM exposure has an independent association with CKD progression, hospitalizations, mortality, or falls. STUDY DESIGN Retrospective observational study. SETTING & PARTICIPANTS Chronic Renal Insufficiency Cohort (CRIC) study; 3,929 adults with CKD enrolled 2003-2008 and followed prospectively until December 2011. EXPOSURE PIM exposure was defined as prescriptions for any medications to be avoided in older adults as defined by the 2015 American Geriatrics Society Beers Criteria. OUTCOME Hospitalization count, death, a composite kidney disease end point of CKD progression or initiation of kidney replacement therapy (KRT), KRT, and fall events assessed 1 year after PIM exposure. ANALYTICAL APPROACH Logistic regression and Poisson regression to estimate the associations of PIM exposure with each outcome. RESULTS The most commonly prescribed PIMs were proton pump inhibitors and α-blockers. In unadjusted models, any PIM exposure (compared to none) was associated with hospitalizations, death, and fall events. After adjustment, exposure to 1, 2, or≥3 PIMs had a graded association with a higher hospitalization rate (rate ratios of 1.09 [95% CI, 1.01-1.17], 1.18 [95% CI, 1.07-1.30], and 1.35 [95% CI, 1.19-1.53], respectively) and higher odds of mortality (odds ratios of 1.19 [95% CI, 0.91-1.54], 1.62 [95% CI, 1.21-2.17], and 1.65 [95% CI, 1.14-2.41], respectively). In a cohort subset reporting falls (n=1,109), prescriptions for≥3 PIMs were associated with an increased risk of falls (adjusted OR, 2.85 [95% CI, 1.54-5.26]). PIMs were not associated with CKD progression or KRT. Age did not modify the association between PIM count and outcomes. LIMITATIONS Measurement bias; confounding by indication. CONCLUSIONS Adults of any age with CKD who are prescribed PIMs have an increased risk of hospitalization, mortality, and falls with the greatest risk occurring after more than 1 PIM prescription.
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Affiliation(s)
- Rasheeda K Hall
- Renal Section, Department of Medicine, School of Medicine, Duke University, and Durham Veterans Affairs Healthcare System, Durham, North Carolina.
| | - Jacob B Blumenthal
- Division of Gerontology & Geriatric Medicine School of Medicine, University of Maryland, Baltimore, Maryland; Baltimore Geriatrics Research, Department of Medicine, Education and Clinical Center (GRECC), Baltimore Veterans Affairs and Medical Center, Baltimore, Maryland
| | - Rebecca M Doerfler
- Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Jing Chen
- Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana
| | - Clarissa J Diamantidis
- Renal Section, Department of Medicine, School of Medicine, Duke University, and Durham Veterans Affairs Healthcare System, Durham, North Carolina
| | - Bernard G Jaar
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - John W Kusek
- Center for Clinical Epidemiology and Biostatistics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Krishna Kallem
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Sankar D Navaneethan
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Daohang Sha
- Center for Clinical Epidemiology and Biostatistics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James H Sondheimer
- Department of Medicine, School of Medicine, Wayne State University, Detroit, Michigan
| | - Lee-Ann Wagner
- Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Min Zhan
- Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Jeffrey C Fink
- Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland
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25
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Rajapakse CS, Johncola AJ, Batzdorf AS, Jones BC, Al Mukaddam M, Sexton K, Shults J, Leonard MB, Snyder PJ, Wehrli FW. Effect of Low-Intensity Vibration on Bone Strength, Microstructure, and Adiposity in Pre-Osteoporotic Postmenopausal Women: A Randomized Placebo-Controlled Trial. J Bone Miner Res 2021; 36:673-684. [PMID: 33314313 DOI: 10.1002/jbmr.4229] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/21/2020] [Accepted: 11/27/2020] [Indexed: 12/31/2022]
Abstract
There has been evidence that cyclical mechanical stimulation may be osteogenic, thus providing opportunities for nonpharmacological treatment of degenerative bone disease. Here, we applied this technology to a cohort of postmenopausal women with varying bone mineral density (BMD) T-scores at the total hip (-0.524 ± 0.843) and spine (-0.795 ± 1.03) to examine the response to intervention after 1 year of daily treatment with 10 minutes of vibration therapy in a randomized double-blinded trial. The device operates either in an active mode (30 Hz and 0.3 g) or placebo. Primary endpoints were changes in bone stiffness at the distal tibia and marrow adiposity of the vertebrae, based on 3 Tesla high-resolution MRI and spectroscopic imaging, respectively. Secondary outcome variables included distal tibial trabecular microstructural parameters and vertebral deformity determined by MRI, volumetric and areal bone densities derived using peripheral quantitative computed tomography (pQCT) of the tibia, and dual-energy X-ray absorptiometry (DXA)-based BMD of the hip and spine. Device adherence was 83% in the active group (n = 42) and 86% in the placebo group (n = 38) and did not differ between groups (p = .7). The mean 12-month changes in tibial stiffness in the treatment group and placebo group were +1.31 ± 6.05% and -2.55 ± 3.90%, respectively (group difference 3.86%, p = .0096). In the active group, marrow fat fraction significantly decreased after 12 months of intervention (p = .0003), whereas no significant change was observed in the placebo group (p = .7; group difference -1.59%, p = .029). Mean differences of the changes in trabecular bone volume fraction (p = .048) and erosion index (p = .044) were also significant, as was pQCT-derived trabecular volumetric BMD (vBMD; p = .016) at the tibia. The data are commensurate with the hypothesis that vibration therapy is protective against loss in mechanical strength and, further, that the intervention minimizes the shift from the osteoblastic to the adipocytic lineage of mesenchymal stem cells. © 2020 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Chamith S Rajapakse
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA.,Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Alyssa J Johncola
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Brandon C Jones
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Mona Al Mukaddam
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly Sexton
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Justine Shults
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary B Leonard
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Peter J Snyder
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Felix W Wehrli
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
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26
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Baker JF, Mostoufi-Moab S, Long J, Taratuta E, Leonard MB, Zemel B. Association of Low Muscle Density With Deteriorations in Muscle Strength and Physical Functioning in Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2021; 73:355-363. [PMID: 31841259 DOI: 10.1002/acr.24126] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 12/10/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Rheumatoid arthritis (RA) is associated with low muscle density due to the accumulation of intramuscular fat. The present study was undertaken to identify predictors of changes in muscle density and to determine whether low muscle density predicted changes in strength and physical function. METHODS Patients with RA, ages 18-70 years, completed whole-body dual-energy x-ray absorptiometry and peripheral quantitative computed tomography to quantify lean and fat mass indices and muscle density. Dynamometry was used to measure strength at the hand, knee, and lower leg. Disability and physical function were measured with the Health Assessment Questionnaire (HAQ) and the Short Physical Performance Battery (SPPB). Assessments were performed at baseline and at follow-up. Regression analyses assessed associations between patient characteristics, muscle density, and deteriorations in strength and function. RESULTS Muscle density was assessed at baseline in 107 patients with RA. Seventy-nine of these patients (74%) returned for a follow-up assessment at a median follow-up time of 2.71 years (interquartile range 2.35-3.57). Factors associated with declines in muscle density included female sex, higher disease activity, smoking, and lower insulin-like growth factor 1 (IGF-1) levels. Greater muscle density Z score at baseline (per 1 SD) was associated with less worsening per year according to HAQ, SPPB, and 4-meter walk time scores and a lower risk of a clinically important worsening in HAQ score (odds ratio [OR] 1.90 [95% confidence interval (95% CI) 1.06, 3.42]; P = 0.03) and walking speed (OR 2.87 [95% CI 1.05, 7.89]; P = 0.04). CONCLUSION Worsening of skeletal muscle density occurred in patients with higher disease activity, in smokers, and in those with lower IGF-1. Low muscle density was associated with worsening of physical function. Interventions addressing reductions in muscle quality might prevent functional decline.
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Affiliation(s)
- Joshua F Baker
- Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia
| | | | - Jin Long
- Stanford University, Palo Alto, California
| | | | | | - Babette Zemel
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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27
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Kindler JM, Mitchell EL, Piccoli DA, Grimberg A, Leonard MB, Loomes KM, Zemel BS. Bone geometry and microarchitecture deficits in children with Alagille syndrome. Bone 2020; 141:115576. [PMID: 32791330 PMCID: PMC7680312 DOI: 10.1016/j.bone.2020.115576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 06/30/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
Abstract
Alagille syndrome (ALGS) is an autosomal dominant disorder attributed to mutations in the Notch signaling pathway. Children with ALGS are at increased risk for fragility fracture of unknown etiology. Our objective was to characterize bone mass, geometry, and microarchitecture in children with ALGS. This was a cross-sectional study of 10 children (9 females), ages 8-18 years, with a clinical diagnosis of ALGS. Bone density was assessed via DXA (Hologic Discovery A) at several skeletal regions. Tibia trabecular and cortical bone was assessed via pQCT (Stratec XCT 2000) at the distal 3% and 38% sites, respectively. Tibia bone microarchitecture was assessed via HR-pQCT (Scanco XtremeCT II) at an ultradistal site located at 4% of tibia length and a cortical site at 30% of tibia length. Z-scores were calculated for DXA and pQCT measures. In the absence of XtremeCT II HR-pQCT reference data, these outcome measures were descriptively compared to a sample of healthy children ages 5-20 years (n = 247). Anthropometrics and labs were also collected. Based on one-sample t-tests, mean Z-scores for height and weight (both p < .05), were significantly less than zero. DXA bone Z-scores were not significantly different from zero, but were highly variable. For pQCT bone measures, Z-scores for total bone mineral content at the distal 3% site and cortical bone mineral content, cortical area, and cortical thickness at the distal 38% site were significantly less than zero (all p < .05). There was good correspondence between pQCT measures of cortical thickness Z-scores and DXA Z-scores for aBMD at the whole body less head, 1/3 radius, and femoral neck (all p < .05). Compared to healthy children, those with ALGS generally had lower trabecular number and greater trabecular separation despite having greater trabecular thickness (measured via HR-pQCT). Bilirubin and bile acids, markers of hepatic cholestasis, were associated with poorer bone measures. For example, greater bilirubin was associated with lower trabecular number (Spearman's rho [ρ] = -0.82, p = .023) and greater trabecular separation (ρ = 0.82, p = .023) measured via HR-pQCT, and greater bile acids were associated with lower cortical area measured via pQCT (ρ = -0.78, p = .041) and lower serum insulin-like growth factor-1 (ρ = -0.86, p = .002). In summary, deficits in cortical bone size and trabecular bone microarchitecture were evident in children with ALGS. Further investigation is needed to understand the factors contributing to these skeletal inadequacies, and the manner in which these deficits contribute to increased fracture risk.
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Affiliation(s)
- Joseph M Kindler
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Ellen L Mitchell
- Division of Gastroenterology, Hepatology and Nutrition, St. Christopher's Hospital for Children, Philadelphia, PA, United States of America; Department of Pediatrics, Drexel School of Medicine, Drexel University, Philadelphia, PA, United States of America
| | - David A Piccoli
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Adda Grimberg
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America; Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Mary B Leonard
- Department of Pediatrics, Stanford School of Medicine, Palo Alto, CA, United States of America
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America.
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28
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Baker JF, Harris T, Rapoport A, Ziolkowski SL, Leonard MB, Long J, Zemel B, Weber DR. Validation of a description of sarcopenic obesity defined as excess adiposity and low lean mass relative to adiposity. J Cachexia Sarcopenia Muscle 2020; 11:1580-1589. [PMID: 32931633 PMCID: PMC7749601 DOI: 10.1002/jcsm.12613] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/22/2020] [Accepted: 07/22/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND This study aims to assess the construct validity of a body composition-defined definition of sarcopenic obesity based on low appendicular lean mass relative to fat mass (ALMIFMI ) and high fat mass index (FMI) and to compare with an alternative definition using appendicular lean mass index (ALMI) and percent body fat (%BF). METHODS This is a secondary analysis of two cohort studies: the National Health and Examination Survey (NHANES) and the Health, Aging, and Body Composition study (Health ABC). Sarcopenic obesity was defined as low ALMIFMI combined with high FMI and was compared with a widely used definition based on ALMI and %BF cut-points. Body composition Z-scores, self-reported disability, physical functioning, and incident disability were compared across body composition categories using linear and logistic regression and Cox proportional hazards models. RESULTS Among 14, 850 participants from NHANES, patients with sarcopenic obesity defined by low ALMIFMI and high FMI (ALMIFMI -FMI) had above-average FMI Z-scores [mean (standard deviation): 1.00 (0.72)]. In contrast, those with sarcopenic obesity based on low ALMI and high %BF (ALMI-%BF) had below-average FMI Z-scores. A similar pattern was observed for 2846 participants from Health ABC. Participants with sarcopenic obesity based on ALMIFMI -FMI had a greater number of disabilities, worse physical function, and a greater risk of incident disability compared with those defined based on ALMI-%BF. CONCLUSIONS Body composition-defined measures of sarcopenic obesity defined as excess adiposity and lower-than-expected ALMI relative to FMI are associated with functional deficits and incident disability and overcome the limitations of using %BF in estimating obesity in this context.
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Affiliation(s)
- Joshua F. Baker
- Division of RheumatologyPhiladelphia Veterans' Affairs Medical CenterPhiladelphiaPAUSA
- Division of Rheumatology, School of MedicineUniversity of Pennsylvania8 Penn Tower Building,PhiladelphiaPAUSA
- Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Tamara Harris
- Laboratory of Epidemiology and Population Sciences, Intramural Research ProgramNIA, NIHBethesdaMDUSA
| | | | | | - Mary B. Leonard
- Department of Medicine and PediatricsStanford UniversityPalo AltoCAUSA
| | - Jin Long
- Department of Medicine and PediatricsStanford UniversityPalo AltoCAUSA
| | - Babette Zemel
- Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - David R. Weber
- Division of Endocrinology and DiabetesGolisano Children's Hospital, University of RochesterRochesterNYUSA
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Baker JF, Ziolkowski SL, Long J, Leonard MB, Stokes A. Effects of Weight History on the Association Between Directly Measured Adiposity and Mortality in Older Adults. J Gerontol A Biol Sci Med Sci 2019; 74:1937-1943. [PMID: 31168573 DOI: 10.1093/gerona/glz144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND It is controversial whether an altered relationship between adiposity and mortality occurs with aging. We evaluated associations between adiposity and mortality in younger and older participants before and after considering historical weight loss. METHODS This study used whole-body dual-energy x-ray absorptiometry data from the National Health and Nutrition Examination Survey in adults at least 20 years of age. Fat mass index (FMI), determined by dual-energy x-ray absorptiometry, was converted to age-, sex-, and race-specific Z-Scores. Percent change in weight from the maximum reported weight was determined and categorized. Cox proportional hazards models assessed associations between quintile of FMI Z-Score and mortality. Sequential models adjusted for percent weight change since the maximum weight. RESULTS Participants with lower FMI were more likely to have lost weight from their maximum, particularly among older participants with lower FMI. Substantially greater risk of mortality was observed for the highest quintile of FMI Z-Score compared to the second quintile among younger individuals [HR 2.50 (1.69, 3.72) p < .001]. In contrast, a more modest association was observed among older individuals in the highest quintile [HR 1.23 (0.99, 1.52) p = .06] (p for interaction <.001). In both the younger and older participants, the risks of greater FMI Z-Score were magnified when adjusting for percent weight change since maximum reported weight. CONCLUSIONS Older people with low fat mass report greater historical weight loss, potentially explaining substantially altered relationships between fat mass and mortality in older individuals. As a result, epidemiologic studies performed in older populations will likely underestimate the causal risks of excess adiposity.
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Affiliation(s)
- Joshua F Baker
- Philadelphia VA Medical Center, Pennsylvania
- Department of Medicine, Perelman School of Medicine, Pennsylvania
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Jin Long
- Department of Pediatrics and Medicine, Stanford University, California
| | - Mary B Leonard
- Department of Pediatrics and Medicine, Stanford University, California
| | - Andrew Stokes
- Department of Global Health, Boston University School of Public Health, Massachusetts
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Baker JF, Newman AB, Kanaya A, Leonard MB, Zemel B, Miljkovic I, Long J, Weber D, Harris TB. The Adiponectin Paradox in the Elderly: Associations With Body Composition, Physical Functioning, and Mortality. J Gerontol A Biol Sci Med Sci 2019; 74:247-253. [PMID: 29438496 DOI: 10.1093/gerona/gly017] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 02/07/2018] [Indexed: 02/06/2023] Open
Abstract
Background To determine if adiponectin levels are associated with weight loss, low muscle mass, and physical functioning among the elderly and to determine independent associations with incident disability and death. Methods Included were 3,044 participants from the Health, Aging and Body Composition Study, who had whole-body dual energy absorptiometry performed to evaluate appendicular lean mass index (ALMI, kg/m2) and fat mass index (FMI, kg/m2), computed tomography measures of thigh muscle density, weight histories, estimates of physical functioning, and adiponectin levels at enrollment. Associations between adiponectin levels and body composition, weight loss, and physical functioning were assessed in multivariable linear regression models. Associations between adiponectin and incident disability and mortality were assessed in mediation analyses, adjusting for other factors. Results Greater adiponectin at baseline was independently associated with low FMI Z-score, lower waist circumference, low ALMI Z-score, low muscle density, a history of weight loss, and poor physical functioning (all p < .05). Greater adiponectin levels (per SD) were associated with incident disability [HR: 1.14 (1.08, 1.20), p < .001] and greater mortality [HR: 1.17 (1.10, 1.25), p < .001] in models adjusting for demographic factors, adiposity, and comorbid conditions. The association was completely attenuated and no longer significant (all p > 0.05) when adjusting for body composition, muscle density, weight loss, and physical functioning at baseline. Conclusions Greater serum adiponectin levels are associated with historical weight loss, low skeletal muscle mass, low muscle density, and poor physical functioning. High adiponectin is associated with a greater risk of incident disability and death, but not independently of these factors.
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Affiliation(s)
- Joshua F Baker
- Department of Medicine, Philadelphia Veterans Affairs Medical Center, Philadelphia.,University of Pennsylvania, School of Medicine, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Anne B Newman
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - Alka Kanaya
- Division of General Internal Medicine, University of California at San Francisco, San Francisco, California
| | - Mary B Leonard
- Department of Pediatrics and Medicine, Stanford University, Stanford
| | | | - Iva Miljkovic
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - Jin Long
- Department of Pediatrics and Medicine, Stanford University, Stanford
| | - David Weber
- Division of Endocrinology and Diabetes, Golisano Children's Hospital, University of Rochester, Rochester
| | - Tamara B Harris
- Laboratory of Epidemiology and Population Sciences, Intramural Research Program, NIA, NIH, Bethesda, Maryl
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Ziolkowski SL, Long J, Baker JF, Chertow GM, Leonard MB. Chronic Kidney Disease and the Adiposity Paradox: Valid or Confounded? J Ren Nutr 2019; 29:521-528. [PMID: 30709713 PMCID: PMC6663655 DOI: 10.1053/j.jrn.2018.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/10/2018] [Accepted: 11/20/2018] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Obesity, defined by body mass index (BMI), is associated with lower mortality risk in patients with chronic kidney disease (CKD). BMI and % body fat (%BF) are confounded by muscle mass, while DXA derived fat mass index (FMI) overcomes this limitation. We compared the associations between obesity and mortality in persons with CKD using multiple estimates of adiposity, and determined whether muscle mass, inflammation and weight loss modify these associations. METHODS Obesity was defined using BMI and DXA-derived FMI and %BF cut-offs in 2,852 NHANES participants with CKD from 1999-2006 and linked to the National Death Index with follow up through 2011. Cox proportional hazards models assessed associations between mortality and measures of obesity. RESULTS Obesity based on FMI and continuous variables, FMI, BMI and %BF were associated with lower mortality. The protective association of obesity was less pronounced among participants with higher muscle mass and was no longer significant after adjustment for prior weight loss. Inflammation did not modify these associations. CONCLUSIONS We observed lower mortality associated with higher fat mass, particularly among persons with lower muscle mass. The prevalence of >10% weight loss was half as common among obese compared to non-obese participants and confounded these associations.
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Affiliation(s)
- Susan L Ziolkowski
- Department of Medicine, Stanford University School of Medicine, Stanford, California.
| | - Jin Long
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Joshua F Baker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Stanford, California; Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Mary B Leonard
- Department of Medicine, Stanford University School of Medicine, Stanford, California; Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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Bundy JD, Cai X, Mehta RC, Scialla JJ, de Boer IH, Hsu CY, Go AS, Dobre MA, Chen J, Rao PS, Leonard MB, Lash JP, Block GA, Townsend RR, Feldman HI, Smith ER, Pasch A, Isakova T. Serum Calcification Propensity and Clinical Events in CKD. Clin J Am Soc Nephrol 2019; 14:1562-1571. [PMID: 31658949 PMCID: PMC6832040 DOI: 10.2215/cjn.04710419] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/20/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with CKD are at high risk for cardiovascular disease, ESKD, and mortality. Vascular calcification is one pathway through which cardiovascular disease risks are increased. We hypothesized that a novel measure of serum calcification propensity is associated with cardiovascular disease events, ESKD, and all-cause mortality among patients with CKD stages 2-4. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Among 3404 participants from the prospective, longitudinal Chronic Renal Insufficiency Cohort Study, we quantified calcification propensity as the transformation time (T50) from primary to secondary calciprotein particles, with lower T50 corresponding to higher calcification propensity. We used multivariable-adjusted Cox proportional hazards regression models to assess the associations of T50 with risks of adjudicated atherosclerotic cardiovascular disease events (myocardial infarction, stroke, and peripheral artery disease), adjudicated heart failure, ESKD, and mortality. RESULTS The mean T50 was 313 (SD 79) minutes. Over an average 7.1 (SD 3.1) years of follow-up, we observed 571 atherosclerotic cardiovascular disease events, 633 heart failure events, 887 ESKD events, and 924 deaths. With adjustment for traditional cardiovascular disease risk factors, lower T50 was significantly associated with higher risk of atherosclerotic cardiovascular disease (hazard ratio [HR] per SD lower T50, 1.14; 95% confidence interval [95% CI], 1.05 to 1.25), ESKD within 3 years from baseline (HR per SD lower T50, 1.68; 95% CI, 1.52 to 1.86), and all-cause mortality (HR per SD lower T50, 1.16; 95% CI, 1.09 to 1.24), but not heart failure (HR per SD lower T50, 1.06; 95% CI, 0.97 to 1.15). After adjustment for eGFR and 24-hour urinary protein, T50 was not associated with risks of atherosclerotic cardiovascular disease, ESKD, and mortality. CONCLUSIONS Among patients with CKD stages 2-4, higher serum calcification propensity is associated with atherosclerotic cardiovascular disease events, ESKD, and all-cause mortality, but this association was not independent of kidney function. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_10_28_CJN04710419.mp3.
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Affiliation(s)
- Joshua D Bundy
- Department of Preventive Medicine, .,Center for Translational Metabolism and Health, Institute for Public Health and Medicine, and
| | - Xuan Cai
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, and
| | - Rupal C Mehta
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, and.,Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julia J Scialla
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Ian H de Boer
- Department of Medicine, University of Washington, Seattle, Washington
| | - Chi-Yuan Hsu
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - Alan S Go
- Comprehensive Clinical Research Unit, Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Mirela A Dobre
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jing Chen
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Panduranga S Rao
- Department of Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - James P Lash
- Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - Geoffrey A Block
- Department of Product Development, Reata Pharmaceuticals, Inc., Irving, Texas
| | | | - Harold I Feldman
- Department of Medicine.,Department of Biostatistics, Epidemiology, and Informatics, and.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia; and
| | | | - Tamara Isakova
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, and .,Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Isakova T, Cai X, Lee J, Mehta R, Zhang X, Yang W, Nessel L, Anderson AH, Lo J, Porter A, Nunes JW, Negrea L, Hamm L, Horwitz E, Chen J, Scialla JJ, de Boer IH, Leonard MB, Feldman HI, Wolf M. Longitudinal Evolution of Markers of Mineral Metabolism in Patients With CKD: The Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2019; 75:235-244. [PMID: 31668375 DOI: 10.1053/j.ajkd.2019.07.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/29/2019] [Indexed: 12/15/2022]
Abstract
RATIONALE & OBJECTIVE The pathogenesis of disordered mineral metabolism in chronic kidney disease (CKD) is largely informed by cross-sectional studies of humans and longitudinal animal studies. We sought to characterize the longitudinal evolution of disordered mineral metabolism during the course of CKD. STUDY DESIGN Retrospective analysis nested in a cohort study. SETTING & PARTICIPANTS Participants in the Chronic Renal Insufficiency Cohort (CRIC) Study who had up to 5 serial annual measurements of estimated glomerular filtration rate, fibroblast growth factor 23 (FGF-23), parathyroid hormone (PTH), serum phosphate, and serum calcium and who subsequently reached end-stage kidney disease (ESKD) during follow-up (n = 847). EXPOSURE Years before ESKD. OUTCOMES Serial FGF-23, PTH, serum phosphate, and serum calcium levels. ANALYTICAL APPROACH To assess longitudinal dynamics of disordered mineral metabolism in human CKD, we used "ESKD-anchored longitudinal analyses" to express time as years before ESKD, enabling assessments of mineral metabolites spanning 8 years of CKD progression before ESKD. RESULTS Mean FGF-23 levels increased markedly as time before ESKD decreased, while PTH and phosphate levels increased modestly and calcium levels declined minimally. Compared with other mineral metabolites, FGF-23 levels demonstrated the highest rate of change (velocity: first derivative of the function of concentration over time) and magnitude of acceleration (second derivative). These changes became evident approximately 5 years before ESKD and persisted without deceleration through ESKD onset. Rates of changes in PTH and phosphate levels increased modestly and without marked acceleration around the same time, with modest deceleration immediately before ESKD, when use of active vitamin D and phosphate binders increased. LIMITATIONS Individuals who entered the CRIC Study at early stages of CKD and who did not progress to ESKD were not studied. CONCLUSIONS Among patients with progressive CKD, FGF-23 levels begin to increase 5 years before ESKD and continue to rapidly accelerate until transition to ESKD.
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Affiliation(s)
- Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Xuan Cai
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jungwha Lee
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Rupal Mehta
- Division of Nephrology and Hypertension, Department of Medicine, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Jesse Brown Veterans Administration Medical Center, Chicago, IL
| | - Xiaoming Zhang
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lisa Nessel
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Amanda Hyre Anderson
- Section of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Joan Lo
- Kaiser Permanente, Oakland, CA
| | - Anna Porter
- Section of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine Chicago, IL
| | - Julie Wright Nunes
- Division of Nephrology, Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Lavinia Negrea
- Division of Nephrology and Hypertension, Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lee Hamm
- Section of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Edward Horwitz
- Division of Nephrology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Jing Chen
- Section of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Julia J Scialla
- Division of Nephrology, Department of Medicine, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Ian H de Boer
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Mary B Leonard
- Department of Pediatrics, Stanford University, Stanford, CA; Department of Medicine, Stanford University, Stanford, CA
| | - Harold I Feldman
- Jesse Brown Veterans Administration Medical Center, Chicago, IL; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Leonard MB, Wehrli FW, Ziolkowski SL, Billig E, Long J, Nickolas TL, Magland JF, Nihtianova S, Zemel BS, Herskovitz R, Rajapakse CS. A multi-imaging modality study of bone density, bone structure and the muscle - bone unit in end-stage renal disease. Bone 2019; 127:271-279. [PMID: 31158505 DOI: 10.1016/j.bone.2019.05.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 01/10/2023]
Abstract
End stage renal disease (ESRD) is associated with sarcopenia and skeletal fragility. The objectives of this cross-sectional study were to (1) characterize body composition, bone mineral density (BMD) and bone structure in hemodialysis patients compared with controls, (2) assess whether DXA areal BMD (aBMD) correlates with peripheral quantitative CT (pQCT) measures of volumetric BMD (vBMD), cortical dimensions and MRI measures of trabecular microarchitecture, and (3) determine the magnitude of bone deficits in ESRD after adjustment for muscle mass. Thirty ESRD participants, ages 25 to 64 years, were compared with 403 controls for DXA and pQCT outcomes and 104 controls for MRI outcomes; results were expressed as race- and sex- specific Z-scores relative to age. DXA appendicular lean mass index (ALMI kg/m2) and total hip, femoral neck, ultradistal and 1/3rd radius aBMD were significantly lower in ESRD, vs. controls (all p < 0.01). pQCT trabecular vBMD (p < 0.01), cortical vBMD (p < 0.001) and cortical thickness (due to a greater endosteal circumference, p < 0.02) and MRI measures of trabecular number, trabecular thickness, and whole bone stiffness were lower (all p < 0.01) in ESRD, vs. controls. ALMI was positively associated with total hip, femoral neck, ultradistal radius and 1/3rd radius aBMD and with tibia cortical thickness (R = 0.46 to 0.64). Adjustment for ALMI significantly attenuated bone deficits at these sites: e.g. mean femoral neck aBMD was 0.79 SD lower in ESRD, compared with controls and this was attenuated to 0.33 with adjustment for ALMI. In multivariate models within the dialysis participants, pQCT trabecular vBMD and cortical area Z-scores were significant and independently (all p < 0.02) associated with DXA femoral neck, total hip, and ultradistal radius aBMD Z-scores. Cortical vBMD (p = 0.01) and cortical area (p < 0.001) Z-scores were significantly and independently associated with 1/3rd radius areal aBMD Z-scores (R2 = 0.62). These data demonstrate that DXA aBMD captures deficits in trabecular and cortical vBMD and cortical area. The strong associations with ALMI, as an index of skeletal muscle, highlight the importance of considering the role of sarcopenia in skeletal fragility in patients with ESRD.
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Affiliation(s)
- Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America; Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America.
| | - Felix W Wehrli
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Susan L Ziolkowski
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Erica Billig
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Jin Long
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Thomas L Nickolas
- Department of Medicine, Columbia University, New York, NY, United States of America
| | - Jeremy F Magland
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Snejana Nihtianova
- Susanne M. Glasscock School of Continuing Studies, Rice University, Houston, TX, United States of America
| | - Babette S Zemel
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Rita Herskovitz
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Chamith S Rajapakse
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America; Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States of America
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DiVasta AD, Feldman HA, O’Donnell JM, Long J, Leonard MB, Gordon CM. Impact of Adrenal Hormone Supplementation on Bone Geometry in Growing Teens With Anorexia Nervosa. J Adolesc Health 2019; 65:462-468. [PMID: 31227390 PMCID: PMC7001735 DOI: 10.1016/j.jadohealth.2019.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/01/2019] [Accepted: 04/01/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Adolescents with anorexia nervosa (AN) have decreased dehydroepiandrosterone (DHEA) and estrogen concentrations that may contribute to skeletal deficits. We sought to determine whether DHEA + estrogen replacement (ERT) prevented bone loss in young adolescents with AN. METHODS We recruited females with AN (n = 70, ages 11-18 years) into a 12-month, randomized, double-blind placebo-controlled trial. Participants were randomized to oral micronized DHEA 50 mg + 20 mcg ethinyl estradiol/.1 mg levonorgestrel daily (n = 35) or placebo (n = 35). Outcomes included serial measures of bone mineral density (BMD) by dual-energy X-ray absorptiometry (total body, hip, spine) and peripheral quantitative computed tomography (pQCT; tibia). Magnetic resonance imaging of T1-weighted images of the left knee determined physeal status (open/closed). RESULTS Sixty-two subjects completed the trial. Physeal closure status was the strongest predictor of aBMD changes. Among girls with open physes, those who received DHEA + ERT showed a decline in BMD Z-scores compared with those receiving placebo, whereas there was no effect in those with at least one closed physis. Treatment did not affect any pQCT measures, regardless of physeal closure status. CONCLUSIONS Combined DHEA + ERT did not significantly improve dual-energy X-ray absorptiometry or pQCT BMD measurements in young adolescent girls with AN, in contrast to an earlier trial showing benefit in older adolescents and young women. In girls with open physes, the mean change in the placebo arm was greater than that of the DHEA + ERT group. We conclude that DHEA + ERT is ineffective for preserving bone health in growing young adolescents with AN at the dose and route of administration described in this report.
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Affiliation(s)
- Amy D. DiVasta
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, MA, USA,Division of Gynecology, Boston Children’s Hospital, Boston, MA, USA
| | - Henry A. Feldman
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA, USA,Division of Endocrinology, Boston Children’s Hospital, Boston, MA, USA
| | | | - Jin Long
- Division of Pediatric Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mary B. Leonard
- Division of Pediatric Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Catherine M. Gordon
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, MA, USA
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Nagata JM, Carlson JL, Golden NH, Murray SB, Long J, Leonard MB, Peebles R. Associations between exercise, bone mineral density, and body composition in adolescents with anorexia nervosa. Eat Weight Disord 2019; 24:939-945. [PMID: 29949128 PMCID: PMC6286679 DOI: 10.1007/s40519-018-0521-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/28/2018] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To identify the effect of duration of weight-bearing exercise and team sports participation on bone mineral density (BMD) and body composition among adolescents with anorexia nervosa (AN). METHOD We retrospectively reviewed electronic medical records of all patients 9-20 years old with a DSM-5 diagnosis of AN evaluated by the Stanford Eating Disorders Program (1997-2011) who underwent dual-energy X-ray absorptiometry. RESULTS A total of 188 adolescents with AN were included (178 females and 10 males). Using multivariate linear regression, duration of weight-bearing exercise (B = 0.15, p = 0.005) and participation in team sports (B = 0.53, p = 0.001) were associated with higher BMD at the hip and team sports (B = 0.39, p = 0.006) were associated with higher whole body BMC, controlling for covariates. Participation in team sports (B = - 1.06, p = 0.007) was associated with greater deficits in FMI Z-score. LBMI Z-score was positively associated with duration of weight-bearing exercise (B = 0.10, p = 0.018) and may explain the relationship between exercise and bone outcomes. CONCLUSION Duration of weight-bearing exercise and team sports participation may be protective of BMD at the hip and whole body BMC, while participation in team sports was associated with greater FMI deficits among adolescents with AN. LEVEL OF EVIDENCE Level V, descriptive retrospective study.
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Affiliation(s)
- Jason M Nagata
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA. .,Department of Pediatrics, University of California, San Francisco, 3333 California Street, Suite 245, Box 0503, San Francisco, CA, 94143, USA.
| | - Jennifer L Carlson
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Neville H Golden
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Stuart B Murray
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Jin Long
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Rebecka Peebles
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Weber DR, Gordon RJ, Kelley JC, Leonard MB, Willi SM, Hatch-Stein J, Kelly A, Kosacci O, Kucheruk O, Kaafarani M, Zemel BS. Poor Glycemic Control Is Associated With Impaired Bone Accrual in the Year Following a Diagnosis of Type 1 Diabetes. J Clin Endocrinol Metab 2019; 104:4511-4520. [PMID: 31034056 PMCID: PMC6736051 DOI: 10.1210/jc.2019-00035] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 04/23/2019] [Indexed: 01/19/2023]
Abstract
CONTEXT Type 1 diabetes (T1D) is associated with an increased fracture risk across the life course. The effects on bone accrual early in the disease are unknown. OBJECTIVE To characterize changes in bone density and structure over the year following diagnosis of T1D and to identify contributors to impaired bone accrual. DESIGN Prospective cohort study. SETTING Academic children's hospital. PARTICIPANTS Thirty-six children, ages 7 to 17 years, enrolled at diagnosis of T1D. OUTCOMES Whole body and regional dual-energy X-ray absorptiometry and tibia peripheral quantitative computed tomography obtained at baseline and 12 months. The primary outcome was bone accrual assessed by bone mineral content (BMC) and areal bone mineral density (aBMD) velocity z score. RESULTS Participants had low total body less head (TBLH) BMC (z = -0.46 ± 0.76), femoral neck aBMD (z = -0.57 ± 0.99), and tibia cortical volumetric BMD (z = -0.44 ± 1.11) at diagnosis, compared with reference data, P < 0.05. TBLH BMC velocity in the year following diagnosis was lower in participants with poor (hemoglobin A1c ≥7.5%) vs good (hemoglobin A1c <7.5%) glycemic control at 12 months, z = -0.36 ± 0.84 vs 0.58 ± 0.71, P = 0.003. TBLH BMC velocity was correlated with gains in tibia cortical area (R = 0.71, P = 0.003) and periosteal circumference (R = 0.67, P = 0.007) z scores in participants with good, but not poor control. CONCLUSIONS Our results suggest that the adverse effects of T1D on BMD develop early in the disease. Bone accrual following diagnosis was impaired in participants with poor glycemic control and appeared to be mediated by diminished bone formation on the periosteal surface.
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Affiliation(s)
- David R Weber
- Golisano Children’s Hospital, University of Rochester Medical Center, Rochester, New York
| | - Rebecca J Gordon
- The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer C Kelley
- Monroe Carrell Jr Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Mary B Leonard
- Lucille Packard Children’s Hospital, Stanford School of Medicine, Stanford, California
| | - Steven M Willi
- The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacquelyn Hatch-Stein
- The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrea Kelly
- The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Oksana Kosacci
- The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Olena Kucheruk
- The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mirna Kaafarani
- Golisano Children’s Hospital, University of Rochester Medical Center, Rochester, New York
| | - Babette S Zemel
- The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Baker JF, Long J, Leonard MB, Harris T, Delmonico MJ, Santanasto A, Satterfield S, Zemel B, Weber DR. Estimation of Skeletal Muscle Mass Relative to Adiposity Improves Prediction of Physical Performance and Incident Disability. J Gerontol A Biol Sci Med Sci 2019; 73:946-952. [PMID: 28958026 DOI: 10.1093/gerona/glx064] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 03/29/2017] [Indexed: 12/21/2022] Open
Abstract
Purpose We assessed the discrimination of lean mass estimates that have been adjusted for adiposity for physical functioning deficits and prediction of incident disability. Methods Included were 2,846 participants from the Health, Aging and Body Composition Study with available whole-body dual energy absorptiometry measures of appendicular lean mass index (ALMI, kg/m2) and fat mass index (FMI, kg/m2). Age-, sex-, and race-specific Z-Scores and T-Scores were determined by comparison to published reference ranges. ALMI values were adjusted for FMI (ALMIFMI) using a novel published method. Sex-stratified analyses assessed associations between lean mass estimates and the physical performance score, ability to complete a 400-meter walk, grip strength, and incident disability. Dichotomized definitions of low lean for age and sarcopenia were examined and their performance compared to the ALM-to-BMI ratio. Results Compared to ALMI T-Scores and Z-Scores, the ALMIFMI scores demonstrated stronger associations with physical functioning, and were similarly associated with grip strength. Greater FMI Z-Scores and T-Scores were associated with poor physical functioning and incident disability. Definitions of low lean for age and sarcopenia using ALMIFMI (compared to ALMI) better discriminated those with poor physical functioning and a greater risk of incident disability. The ALM-to-BMI ratio was modestly associated with grip strength and physical performance, but was not associated with completion of the 400-meter walk or incident disability, independent of adiposity and height. Conclusion Estimation of skeletal muscle mass relative to adiposity improves correlations with physical performance and prediction of incident disability suggesting it is an informative outcome for clinical studies.
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Affiliation(s)
- Joshua F Baker
- Division of Rheumatology, Philadelphia Veterans Affairs Medical Center, Pennsylvania.,School of Medicine, University of Pennsylvania, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Jin Long
- Department of Pediatrics and Medicine, Stanford University, California
| | - Mary B Leonard
- Department of Pediatrics and Medicine, Stanford University, California
| | - Tamara Harris
- Laboratory of Epidemiology and Population Sciences, National Institute of Aging, Bethesda, Maryland
| | - Matthew J Delmonico
- Department of Kinesiology, University of Rhode Island, Kingston.,Health Science Center, University of Tennessee, Memphis
| | - Adam Santanasto
- Department of Epidemiology, University of Pittsburgh, Pennsylvania
| | - Suzanne Satterfield
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Pennsylvania
| | - Babette Zemel
- Department of Kinesiology, University of Rhode Island, Kingston
| | - David R Weber
- Health Science Center, University of Tennessee, Memphis.,Division of Endocrinology and Diabetes, Golisano Children's Hospital, University of Rochester, New York
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39
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Ziolkowski SL, Long J, Baker JF, Chertow GM, Leonard MB. Relative sarcopenia and mortality and the modifying effects of chronic kidney disease and adiposity. J Cachexia Sarcopenia Muscle 2019; 10:338-346. [PMID: 30784237 PMCID: PMC6463461 DOI: 10.1002/jcsm.12396] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 12/11/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Conventional definitions of sarcopenia based on lean mass may fail to capture low lean mass relative to higher fat mass, that is, relative sarcopenia. The objective of this study is to determine the associations of sarcopenia and relative sarcopenia with mortality independent of co-morbidities, and whether chronic kidney disease (CKD) and adiposity alter these associations. METHODS Dual energy X-ray absorptiometry-derived appendicular lean mass index (ALMI, kg/m2 ) and fat mass index (FMI, kg/m2 ) were assessed in 14 850 National Health and Nutrition Examination Survey participants from 1999 to 2006 and were linked to death certificate data in the National Death Index with follow-up through 2011. Sarcopenia was defined using sex-specific and race/ethnicity-specific standard deviation scores compared with young adults (T-scores) as an ALMI T-score < -2 and relative sarcopenia as fat-adjusted ALMI (ALMIFMI ) T-score < -2. Glomerular filtration rate (GFR) was estimated using creatinine-based (eGFRCr ) and cystatin C-based (eGFRCys ) regression equations. RESULTS Three (3.0) per cent of National Health and Nutrition Examination Survey participants met criteria for sarcopenia and 8.7% met criteria for relative sarcopenia. Sarcopenia and relative sarcopenia were independently associated with mortality (HR sarcopenia 2.20, 95% CI 1.69 to 2.86; HR relative sarcopenia 1.60, 95% CI 1.31 to 1.96). The corresponding population attributable risks were 5.2% (95% CI 3.4% to 6.4%) and 8.4% (95% CI 4.8% to 11.2%), respectively. Relative sarcopenia remained significantly associated with mortality (HR 1.32, 95% CI 1.08 to 1.61) when limited to the subset who did not meet the criteria for sarcopenia. The risk of mortality associated with relative sarcopenia was attenuated among persons with higher FMI (P for interaction <0.01) and was not affected by CKD status for either sarcopenia or relative sarcopenia. CONCLUSIONS Sarcopenia and relative sarcopenia are significantly associated with mortality regardless of CKD status. Relative sarcopenia is nearly three-fold more prevalent amplifying its associated mortality risk at the population level. The association between relative sarcopenia and mortality is attenuated in persons with higher FMI.
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Affiliation(s)
| | - Jin Long
- Department of MedicineStanford University School of MedicineStanfordCAUSA
| | - Joshua F. Baker
- Department of Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Glenn M. Chertow
- Department of MedicineStanford University School of MedicineStanfordCAUSA
- Department of Health Research and PolicyStanford University School of MedicineStanfordCAUSA
| | - Mary B. Leonard
- Department of MedicineStanford University School of MedicineStanfordCAUSA
- Department of PediatricsStanford University School of MedicineStanfordCAUSA
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40
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Bundy JD, Cai X, Scialla JJ, Dobre MA, Chen J, Hsu CY, Leonard MB, Go AS, Rao PS, Lash JP, Townsend RR, Feldman HI, de Boer IH, Block GA, Wolf M, Smith ER, Pasch A, Isakova T. Serum Calcification Propensity and Coronary Artery Calcification Among Patients With CKD: The CRIC (Chronic Renal Insufficiency Cohort) Study. Am J Kidney Dis 2019; 73:806-814. [PMID: 30935773 DOI: 10.1053/j.ajkd.2019.01.024] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 01/25/2019] [Indexed: 12/22/2022]
Abstract
RATIONALE & OBJECTIVE Coronary artery calcification (CAC) is prevalent among patients with chronic kidney disease (CKD) and increases risks for cardiovascular disease events and mortality. We hypothesized that a novel serum measure of calcification propensity is associated with CAC among patients with CKD stages 2 to 4. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS Participants from the Chronic Renal Insufficiency Cohort (CRIC) Study with baseline (n=1,274) and follow-up (n=780) CAC measurements. PREDICTORS Calcification propensity, quantified as transformation time (T50) from primary to secondary calciprotein particles, with lower T50 corresponding to higher calcification propensity. Covariates included age, sex, race/ethnicity, clinical site, estimated glomerular filtration rate, proteinuria, diabetes, systolic blood pressure, number of antihypertensive medications, current smoking, history of cardiovascular disease, total cholesterol level, and use of statin medications. OUTCOMES CAC prevalence, severity, incidence, and progression. ANALYTICAL APPROACH Multivariable-adjusted generalized linear models. RESULTS At baseline, 824 (65%) participants had prevalent CAC. After multivariable adjustment, T50 was not associated with CAC prevalence but was significantly associated with greater CAC severity among participants with prevalent CAC: 1-SD lower T50 was associated with 21% (95% CI, 6%-38%) greater CAC severity. Among 780 participants followed up an average of 3 years later, 65 (20%) without baseline CAC developed incident CAC, while 89 (19%) with baseline CAC had progression, defined as annual increase≥100 Agatston units. After multivariable adjustment, T50 was not associated with incident CAC but was significantly associated with CAC progression: 1-SD lower T50 was associated with 28% (95% CI, 7%-53%) higher risk for CAC progression. LIMITATIONS Potential selection bias in follow-up analyses; inability to distinguish intimal from medial calcification. CONCLUSIONS Among patients with CKD stages 2 to 4, higher serum calcification propensity is associated with more severe CAC and CAC progression.
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Affiliation(s)
- Joshua D Bundy
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Xuan Cai
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Julia J Scialla
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, NC
| | - Mirela A Dobre
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jing Chen
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Chi-Yuan Hsu
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto
| | - Alan S Go
- Comprehensive Clinical Research Unit, Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Panduranga S Rao
- Department of Medicine, University of Michigan Health System, Ann Arbor, MI
| | - James P Lash
- Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, IL
| | - Raymond R Townsend
- Departments of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Harold I Feldman
- Departments of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ian H de Boer
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Myles Wolf
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, NC
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | | | - Tamara Isakova
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
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41
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Kelly A, Shults J, Mostoufi-Moab S, McCormack SE, Stallings VA, Schall JI, Kalkwarf HJ, Lappe JM, Gilsanz V, Oberfield SE, Shepherd JA, Winer KK, Leonard MB, Zemel BS. Pediatric Bone Mineral Accrual Z-Score Calculation Equations and Their Application in Childhood Disease. J Bone Miner Res 2019; 34:195-203. [PMID: 30372552 PMCID: PMC7794655 DOI: 10.1002/jbmr.3589] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 08/25/2018] [Accepted: 09/10/2018] [Indexed: 12/30/2022]
Abstract
Annual gains in BMC and areal bone mineral density (aBMD) in children vary with age, pubertal status, height-velocity, and lean body mass accrual (LBM velocity). Evaluating bone accrual in children with bone health-threatening conditions requires consideration of these determinants. The objective of this study was to develop prediction equations for calculating BMC/aBMD velocity SD scores (velocity-Z) and to evaluate bone accrual in youth with health conditions. Bone and body compositions via DXA were obtained for up to six annual intervals in healthy youth (n = 2014) enrolled in the Bone Mineral Density in Childhood Study (BMDCS) . Longitudinal statistical methods were used to develop sex- and pubertal-status-specific reference equations for calculating velocity-Z for total body less head-BMC and lumbar spine (LS), total hip (TotHip), femoral neck, and 1/3-radius aBMD. Equations accounted for (1) height velocity, (2) height velocity and weight velocity, or (3) height velocity and LBM velocity. These equations were then applied to observational, single-center, 12-month longitudinal data from youth with cystic fibrosis (CF; n = 65), acute lymphoblastic leukemia (ALL) survivors (n = 45), or Crohn disease (CD) initiating infliximab (n = 72). Associations between BMC/aBMD-Z change (conventional pediatric bone health monitoring method) and BMC/aBMD velocity-Z were assessed. The BMC/aBMD velocity-Z for CF, ALL, and CD was compared with BMDCS. Annual changes in the BMC/aBMD-Z and the BMC/aBMD velocity-Z were strongly correlated, but not equivalent; LS aBMD-Z = 1 equated with LS aBMD velocity-Z = -3. In CF, BMC/aBMD velocity-Z was normal. In posttherapy ALL, BMC/aBMD velocity-Z was increased, particularly at TotHip (1.01 [-.047; 1.7], p < 0.0001). In CD, BMC/aBMD velocity-Z was increased at all skeletal sites. LBM-velocity adjustment attenuated these increases (eg, TotHip aBMD velocity-Z: 1.13 [0.004; 2.34] versus 1.52 [0.3; 2.85], p < 0.0001). Methods for quantifying the BMC/aBMD velocity that account for maturation and body composition changes provide a framework for evaluating childhood bone accretion and may provide insight into mechanisms contributing to altered accrual in chronic childhood conditions. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Andrea Kelly
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Justine Shults
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Sogol Mostoufi-Moab
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Shana E McCormack
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Virginia A Stallings
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Joan I Schall
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Heidi J Kalkwarf
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joan M Lappe
- College of Nursing, Creighton University, Omaha, NE, USA
| | - Vicente Gilsanz
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - John A Shepherd
- Bioengineering, University of California-San Francisco, San Francisco, CA, USA
| | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Mary B Leonard
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Pediatrics, Stanford School of Medicine, Palo Alto, CA, USA
| | - Babette S Zemel
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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42
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Baker JF, Mostoufi-Moab S, Long J, Zemel B, Ibrahim S, Taratuta E, Leonard MB. Intramuscular Fat Accumulation and Associations With Body Composition, Strength, and Physical Functioning in Patients With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2018; 70:1727-1734. [PMID: 29481721 DOI: 10.1002/acr.23550] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 02/20/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Rheumatoid arthritis (RA) is associated with adverse body composition profiles and low muscle density due to the accumulation of intramuscular fat. Linear regression was used to assess differences between RA patients and controls and to determine associations between muscle density, strength, and physical functioning. METHODS Patients with RA, ages 18-70 years, and healthy control subjects underwent whole-body dual x-ray absorptiometry and peripheral quantitative computed tomography, in order to quantify the appendicular lean mass index (ALMI) and the fat mass index (FMI), visceral fat area, and muscle density. Dynamometry was used to measure hand grip strength and muscle strength at the knee and lower leg. Disability and physical functioning were measured using the Health Assessment Questionnaire (HAQ) and the Short Physical Performance Battery (SPPB). Linear regression analyses were performed to assess differences related to RA and associations between muscle density, strength, and function. RESULTS The study group included 103 patients with RA (51 men) and 428 healthy control subjects. Among patients with RA, low muscle density was associated with higher disease activity, C-reactive protein and interleukin-6 levels, greater total and visceral fat area, lower ALMI Z scores, physical inactivity, and long-term use of glucocorticoids (>1 year). Patients with low ALMI Z scores had lower muscle density Z scores compared with reference participants with similarly low ALMI scores. Low muscle density was independently associated with lower muscle strength, higher HAQ scores, and lower SPPB scores, after adjustment for ALMI and FMI Z scores. CONCLUSION The low muscle density observed in patients with RA was associated with low muscle mass, excess adiposity, poor strength, and greater disability. Interventions to address poor muscle quality could potentially affect important functional outcomes.
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Affiliation(s)
- Joshua F Baker
- Philadelphia VA Medical Center, Philadelphia, Pennsylvania and University of Pennsylvania, Philadelphia
| | | | - Jin Long
- Stanford University, Palo Alto, California
| | - Babette Zemel
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Said Ibrahim
- Philadelphia VA Medical Center, Philadelphia, Pennsylvania
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Lee D, Swan CK, Suskind D, Wahbeh G, Vanamala J, Baldassano RN, Leonard MB, Lampe JW. Children with Crohn's Disease Frequently Consume Select Food Additives. Dig Dis Sci 2018; 63:2722-2728. [PMID: 29862484 PMCID: PMC6290903 DOI: 10.1007/s10620-018-5145-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/28/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Certain food additives may promote the pathogenesis of Crohn's disease (CD), but thus far the evaluation of food additive exposures in humans has been limited. The objective of this study was to quantify food additive exposures in children with CD. METHODS In a trial for bone health in CD, children were followed over 24 months with evaluation of disease characteristics, dietary intake, and body composition. At baseline, participants completed three 24-h dietary recalls. Foods were categorized, and the ingredient list for each item was evaluated for the presence of select food additives: polysorbate-80, carboxymethylcellulose, xanthan gum, soy lecithin, titanium dioxide, carrageenan, maltodextrin, and aluminosilicates. The frequency of exposures to these food additives was described for study participants and for food categories. RESULTS At study baseline, 138 participants, mean age 14.2 ± 2.8 years, 95% having inactive or mild disease, were enrolled and dietary recalls were collected. A total of 1325 unique foods were recorded. Mean exposures per day for xanthan gum was 0.96 ± 0.72, carrageenan 0.58 ± 0.63, maltodextrin 0.95 ± 0.77, and soy lecithin 0.90 ± 0.74. The other additives had less than 0.1 exposures per day. For the 8 examined food additives, participants were exposed to a mean (SD) of 3.6 ± 2.1 total additives per recall day and a mean (SD) of 2.4 ± 1.0 different additives per day. CONCLUSION Children with CD frequently consume food additives, and the impact on disease course needs further study.
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Affiliation(s)
- Dale Lee
- Seattle Children’s Hospital, 4800 Sand Point Way, Seattle WA 98105., Tel: (206) 987-7339. Fax: (206) 987-2721.,
| | - C. Kaiulani Swan
- Nutrition Sciences, University of Washington, Seattle, Washington, 4800 Sand Point Way, Seattle WA 98105., Tel: n/a Fax: n/a,
| | - David Suskind
- Seattle Children’s Hospital, 4800 Sand Point Way, Seattle WA 98105., Tel: (206) 987-2521. Fax: (206) 987-2721.,
| | - Ghassan Wahbeh
- Seattle Children’s Hospital, 4800 Sand Point Way, Seattle WA 98105., Tel: (206) 987-2521. Fax: (206) 987-2721.,
| | - Jairam Vanamala
- Penn State University, 326 Rodney A. Erickson Food Science Building, University Park, PA 16802, Tel: 814-865-6842,
| | - Robert N. Baldassano
- The Children’s Hospital of Philadelphia, 324 S. 34th Street, Philadelphia, PA 19194, Tel: (267) 426-5123. Fax: (215) 590-3606,
| | - Mary B. Leonard
- Chairman of Pediatrics Stanford University, 770 Welch Rd Ste 300, Palo Alto, CA 94304, Tel: (650) 723-5104. Fax: (650) 49806714,
| | - Johanna W. Lampe
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109., Tel: (206) 667-6580. Fax: (206) 667-7850,
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44
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Mostoufi-Moab S, Kelly A, Mitchell JA, Baker J, Zemel BS, Brodsky J, Long J, Leonard MB. Changes in pediatric DXA measures of musculoskeletal outcomes and correlation with quantitative CT following treatment of acute lymphoblastic leukemia. Bone 2018; 112:128-135. [PMID: 29679731 PMCID: PMC5970089 DOI: 10.1016/j.bone.2018.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/27/2018] [Accepted: 04/14/2018] [Indexed: 11/19/2022]
Abstract
We previously reported significant gains in pQCT measures of tibia trabecular bone mineral density (BMD) and cortical structure following completion of therapy in children and adolescents with acute lymphoblastic leukemia (ALL). The objective of this study was to examine changes in DXA measures used in clinical practice and expressed as Z-scores using robust national reference data. Children and adolescents, ages 5 to 18 years were enrolled within 2 (median 0.8) years of completing ALL therapy. DXA total-body less-head bone mineral content (TBLH-BMC), and spine, total hip, femoral neck, and 1/3rd radius areal BMD (aBMD) were assessed in 45 participants at enrollment and 12-months later. Linear regression models examined correlates of changes in DXA Z-scores. Changes in DXA outcomes were compared to changes in tibia pQCT trabecular and cortical volumetric BMD (vBMD) and cortical area. At enrollment, DXA TBLH-BMC, spine and radius aBMD Z-scores were not significantly reduced in ALL survivors; however, total hip [median -0.74 (IQ range -1.51 to -0.04)] and femoral neck [-0.51 (-1.24 to 0.14)] aBMD Z-scores were lower (both p < 0.01) compared to reference data. DXA Z-scores at all skeletal sites increased over 12 months. Despite improvement, total hip Z-score remained lower at -0.55 (-1.05 to 0.18). The increases in TBLH-BMC, total hip and femoral neck aBMD Z-scores were more pronounced in those enrolled within 6 months of completing ALL therapy, compared to those enrolled at >6 months. Gains in TBLH-BMC, total hip, femoral neck and radius aBMD Z-scores were significantly associated with gains in tibia cortical area Z-scores (R = 0.56 to 0.67, p ≤ 0.001). Changes in TBLH and proximal femur sites were associated with gains in trabecular vBMD Z-scores (R = 0.37 to 0.40; p ≤ 0.01); these associations were not significant when adjusted for gains in cortical area. In summary, gains in DXA measures were most pronounced in total hip and femoral neck following ALL therapy. The gains in all DXA measures, with the exception of lumbar spine, reflected gains in cortical area. Overall, ALL survivors demonstrate skeletal recovery following completion of therapy; a small sub-group continue to demonstrate deficits and benefit from continued observation to ensure improvement over time.
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Affiliation(s)
- Sogol Mostoufi-Moab
- Department of Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States.
| | - Andrea Kelly
- Department of Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Jonathan A Mitchell
- Department of Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Joshua Baker
- Department of Medicine, Perelman School of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Babette S Zemel
- Department of Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Jill Brodsky
- Care-Mount Medical, Poughkeepsie, NY 12601, United States
| | - Jin Long
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Mary B Leonard
- Department of Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
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45
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Lee D, Lewis JD, Shults J, Baldassano RN, Long J, Herskovitz R, Zemel B, Leonard MB. The Association of Diet and Exercise With Body Composition in Pediatric Crohn's Disease. Inflamm Bowel Dis 2018; 24:1368-1375. [PMID: 29718224 PMCID: PMC6093194 DOI: 10.1093/ibd/izy024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND In pediatric Crohn's disease, fat mass improves over time with treatment, but lean mass deficits persist. This observational study of the associations of physical activity and dietary intake with lean mass and muscle strength in children with Crohn's disease was ancillary to a previously reported randomized clinical trial of an intervention to improve bone health. METHODS In this study, 138 participants were followed at baseline and at 6, 12, and 24 months with evaluation of lean and fat mass using DXA, muscle strength (peak torque), Crohn's characteristics, dietary intake, time in moderate to vigorous physical activity (MVPA), and serum insulin-like growth factor-1 (IGF-1) and tumor necrosis factor-alpha (TNF-α). Race- and sex-specific Z-scores for leg lean mass and whole body fat mass were generated. Quasi least square regression evaluated determinants of changes in body composition and muscle strength. RESULTS Leg lean mass and muscle strength were positively associated with time in MVPA (P < 0.05) and negatively associated with increasing clinical disease activity (P < 0.05). Both leg lean mass and strength were positively associated with IGF-1 Z-score (P ≤ 0.03) but negatively associated with serum TNF-α (P ≤ 0.04). Neither lean mass nor muscle strength was associated with caloric or protein intake. CONCLUSIONS Persistence of lean mass deficits was related to ongoing Crohn's disease activity but improved with greater time spent in moderate to vigorous physical activity. Future trials are needed to evaluate the efficacy of physical activity in improving lean mass in pediatric Crohn's disease.
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Affiliation(s)
- Dale Lee
- Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington,Address correspondence to: Dale Lee, MD, MSCE, 4800 Sand Point Way NE, Seattle, WA 98105 ()
| | - James D Lewis
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justine Shults
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert N Baldassano
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jin Long
- Department of Medicine, Stanford University, Stanford, California
| | - Rita Herskovitz
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Babette Zemel
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mary B Leonard
- Department of Medicine, Stanford University, Stanford, California,Department of Pediatrics, Stanford University, Stanford, California
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46
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Ketteler M, Block GA, Evenepoel P, Fukagawa M, Herzog CA, McCann L, Moe SM, Shroff R, Tonelli MA, Toussaint ND, Vervloet MG, Leonard MB. Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder: Synopsis of the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update. Ann Intern Med 2018; 168:422-430. [PMID: 29459980 DOI: 10.7326/m17-2640] [Citation(s) in RCA: 186] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION The Kidney Disease: Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) is a selective update of the prior CKD-MBD guideline published in 2009. The guideline update and the original publication are intended to assist practitioners caring for adults with CKD and those receiving long-term dialysis. METHODS Development of the guideline update followed an explicit process of evidence review and appraisal. The approach adopted by the Work Group and the evidence review team was based on systematic reviews of relevant trials, appraisal of the quality of the evidence, and rating of the strength of recommendations according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Searches of the English-language literature were conducted through September 2015 and were supplemented with targeted searches through February 2017. Final modification of the guidelines was informed by a public review process involving numerous stakeholders, including patients, subject matter experts, and industry and national organizations. RECOMMENDATIONS The update process resulted in the revision of 15 recommendations. This synopsis focuses primarily on recommendations for diagnosis of and testing for CKD-MBD and treatment of CKD-MBD that emphasizes decreasing phosphate levels, maintaining calcium levels, and addressing elevated parathyroid hormone levels in adults with CKD stage G3a to G5 and those receiving dialysis. Key elements include basing treatment on trends in laboratory values rather than a single abnormal result and being cautious to avoid hypercalcemia when treating secondary hyperparathyroidism.
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Affiliation(s)
- Markus Ketteler
- Klinikum Coburg, Coburg, Germany, and University of Split School of Medicine, Split, Croatia (M.K.)
| | | | | | | | - Charles A Herzog
- Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota (C.A.H.)
| | | | - Sharon M Moe
- Indiana University School of Medicine and Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana (S.M.M.)
| | - Rukshana Shroff
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom (R.S.)
| | | | - Nigel D Toussaint
- The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (N.D.T.)
| | - Marc G Vervloet
- VU University Medical Center Amsterdam, Amsterdam, the Netherlands (M.G.V.)
| | - Mary B Leonard
- Stanford University School of Medicine, Stanford, California (M.B.L.)
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47
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DeBoer MD, Lee AM, Herbert K, Long J, Thayu M, Griffin LM, Baldassano RN, Denson LA, Zemel BS, Denburg MR, Herskovitz R, Leonard MB. Increases in IGF-1 After Anti-TNF-α Therapy Are Associated With Bone and Muscle Accrual in Pediatric Crohn Disease. J Clin Endocrinol Metab 2018; 103:936-945. [PMID: 29329430 PMCID: PMC6276706 DOI: 10.1210/jc.2017-01916] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 01/05/2018] [Indexed: 12/21/2022]
Abstract
CONTEXT Low levels of insulinlike growth factor 1 (IGF-1) in pediatric and adolescent Crohn disease (CD) likely contribute to bone and muscle deficits. OBJECTIVE Assess changes in IGF-1 levels and associations with bone and muscle accrual following initiation of anti-tumor necrosis factor α (TNF-α) therapy in pediatric and adolescent CD. DESIGN AND PARTICIPANTS Participants (n = 75, age 5 to 21 years) with CD were enrolled in a prospective cohort study; 63 completed the 12-month visit. MAIN OUTCOME MEASURES IGF-1 levels at baseline and 10 weeks, as well as dual-energy x-ray absorptiometry (DXA) and tibia peripheral quantitative computed tomography (pQCT) measures of bone and muscle at baseline and 12 months after initiation of anti-TNF-α therapy. Outcomes were expressed as sex-specific z scores. RESULTS IGF-1 z scores increased from a median (interquartile range) of -1.0 (-1.58 to -0.17) to -0.36 (-1.04 to 0.36) over 10 weeks (P < 0.001). Lesser disease severity and systemic inflammation, as well as greater estradiol z scores (in girls), was significantly associated with greater IGF-1 z scores over time. DXA whole-body bone mineral content, leg lean mass, and total hip and femoral neck bone mineral density (BMD) z scores were low at baseline (P < 0.0001 vs reference data) and increased significantly (P < 0.001) over 12 months. Greater increases in IGF-1 z scores over 10 weeks predicted improvement in DXA bone and muscle outcomes and pQCT trabecular BMD and cortical area. Adjustment for changes in muscle mass markedly attenuated the associations between IGF-1 levels and bone outcomes. CONCLUSIONS Short-term improvements in IGF-1 z scores predicted recovery of bone and muscle outcomes following initiation of anti-TNF-α therapy in pediatric CD. These data suggest that disease effects on growth hormone metabolism contribute to musculoskeletal deficits in CD.
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Affiliation(s)
- Mark D DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville,
Virginia
- Correspondence and Reprint Requests: Mark DeBoer, MD, Department of Pediatrics, University of Virginia, P.O. Box
800386, Charlottesville, Virginia 22908. E-mail:
| | - Arthur M Lee
- Department of Pediatrics, University of Virginia, Charlottesville,
Virginia
| | - Kirabo Herbert
- Department of Pediatrics, University of Virginia, Charlottesville,
Virginia
| | - Jin Long
- Department of Pediatrics, Stanford University School of Medicine, Stanford,
California
| | - Meena Thayu
- Janssen Pharmaceuticals, Titusville, New Jersey
| | - Lindsay M Griffin
- Department of Radiology, University of Wisconsin School of Medicine, Madison,
Wisconsin
| | - Robert N Baldassano
- Department of Pediatrics, The Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
| | - Lee A Denson
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center,
Cincinnati, Ohio
| | - Babette S Zemel
- Department of Pediatrics, The Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
| | - Michelle R Denburg
- Department of Pediatrics, The Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
| | - Rita Herskovitz
- Department of Pediatrics, The Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford,
California
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48
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Kelley JC, Stettler-Davis N, Leonard MB, Hill D, Wrotniak BH, Shults J, Stallings VA, Berkowitz R, Xanthopoulos MS, Prout-Parks E, Klieger SB, Zemel BS. Effects of a Randomized Weight Loss Intervention Trial in Obese Adolescents on Tibia and Radius Bone Geometry and Volumetric Density. J Bone Miner Res 2018; 33:42-53. [PMID: 28884881 PMCID: PMC8527854 DOI: 10.1002/jbmr.3288] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/31/2017] [Accepted: 09/06/2017] [Indexed: 01/06/2023]
Abstract
Obese adolescents have increased fracture risk, but effects of alterations in adiposity on bone accrual and strength in obese adolescents are not understood. We evaluated 12-month changes in trabecular and cortical volumetric bone mineral density (vBMD) and cortical geometry in obese adolescents undergoing a randomized weight management program, and investigated the effect of body composition changes on bone outcomes. Peripheral quantitative computed tomography (pQCT) of the radius and tibia, and whole-body dual-energy X-ray absorptiometry (DXA) scans were obtained at baseline, 6 months, and 12 months in 91 obese adolescents randomized to standard care versus behavioral intervention for weight loss. Longitudinal models assessed effects of body composition changes on bone outcomes, adjusted for age, bone length, and African-American ancestry, and stratified by sex. Secondary analyses included adjustment for physical activity, maturation, vitamin D, and inflammatory biomarkers. Baseline body mass index (BMI) was similar between intervention groups. Twelve-month change in BMI in the standard care group was 1.0 kg/m2 versus -0.4 kg/m2 in the behavioral intervention group (p < 0.01). Intervention groups were similar in bone outcomes, so they were combined for subsequent analyses. For the tibia, BMI change was not associated with change in vBMD or structure. Greater baseline lean body mass index (LBMI) associated with higher cortical vBMD in males, trabecular vBMD in females, and polar section modulus (pZ) and periosteal circumference (Peri-C) in both sexes. In females, change in LBMI positively associated with gains in pZ and Peri-C. Baseline visceral adipose tissue (VFAT) was inversely associated with pZ in males and cortical vBMD in females. Change in VFAT did not affect bone outcomes. For the radius, BMI and LBMI changes positively associated with pZ in males. Thus, in obese adolescents, weight loss intervention with modest changes in BMI was not detrimental to radius or tibia bone strength, and changes in lean, but not adiposity, measures were beneficial to bone development. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Jennifer C Kelley
- Division of Endocrinology and Diabetes, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | | | - Mary B Leonard
- Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Douglas Hill
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Pediatric Advanced Care Team, The Children's Hospital of Philadephia, Philadelphia, PA, USA
| | - Brian H Wrotniak
- Department of Physical Therapy, D'Youville College, Buffalo, NY, USA
| | - Justine Shults
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Biostatistics and Data Management, The Children's Hospital of Philadephia, Philadelphia, PA, USA
| | - Virginia A Stallings
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadephia, Philadelphia, PA, USA
| | - Robert Berkowitz
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melissa S Xanthopoulos
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elizabeth Prout-Parks
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadephia, Philadelphia, PA, USA
| | - Sarah B Klieger
- Biostatistical and Data Management Core, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Babette S Zemel
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadephia, Philadelphia, PA, USA
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49
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Isakova T, Cai X, Lee J, Xie D, Wang X, Mehta R, Allen NB, Scialla JJ, Pencina MJ, Anderson AH, Talierco J, Chen J, Fischer MJ, Steigerwalt SP, Leonard MB, Hsu CY, de Boer IH, Kusek JW, Feldman HI, Wolf M. Longitudinal FGF23 Trajectories and Mortality in Patients with CKD. J Am Soc Nephrol 2017; 29:579-590. [PMID: 29167351 DOI: 10.1681/asn.2017070772] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 10/16/2017] [Indexed: 12/14/2022] Open
Abstract
Elevated fibroblast growth factor 23 (FGF23) levels, measured at a single time, are strongly associated with increased risk of mortality in patients with CKD. There are minimal data on serial FGF23 measurements in CKD. In a prospective case-cohort study of the Chronic Renal Insufficiency Cohort, we measured FGF23 at two to five annual time points (mean 4.0±1.2) in a randomly selected subcohort of 1135 participants, of whom 203 died, and all remaining 390 participants who died through mid-2013. Higher FGF23 was independently associated with increased risk of death in multivariable-adjusted analyses of time-varying FGF23 (hazard ratio per 1-SD increase in ln-transformed FGF23, 1.84; 95% CI, 1.67 to 2.03). Median FGF23 was stable over 5 years of follow-up, but its gradually right-skewed distribution suggested a subpopulation with markedly elevated FGF23. Trajectory analysis revealed three distinct trajectories: stable FGF23 in the majority of participants (slope of lnFGF23 per year =0.03, 95% CI, 0.02 to 0.04, n=724) and smaller subpopulations with slowly (slope=0.14, 95% CI, 0.12 to 0.16, n=486) or rapidly (slope=0.46, 95% CI, 0.38 to 0.54, n=99) rising levels. Compared with stable FGF23, participants with slowly rising FGF23 trajectories were at 4.49-fold higher risk of death (95% CI, 3.17 to 6.35) and individuals with rapidly rising FGF23 trajectories were at 15.23-fold higher risk of death (95% CI, 8.24 to 28.14) in fully adjusted analyses. Trajectory analyses that used four or three annual FGF23 measurements yielded qualitatively similar results. In conclusion, FGF23 levels are stable over time in the majority of patients with CKD, but serial measurements identify subpopulations with rising levels and exceptionally high risk of death.
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Affiliation(s)
- Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine and.,Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Department of Preventive Medicine Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Xuan Cai
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Department of Preventive Medicine Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jungwha Lee
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Department of Preventive Medicine Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dawei Xie
- Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Xue Wang
- Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rupal Mehta
- Division of Nephrology and Hypertension, Department of Medicine and.,Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Department of Preventive Medicine Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Norrina B Allen
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Department of Preventive Medicine Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Julia J Scialla
- Division of Nephrology, Department of Medicine and.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael J Pencina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Amanda H Anderson
- Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - John Talierco
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | - Jing Chen
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Michael J Fischer
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois.,Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois
| | - Susan P Steigerwalt
- Division of Nephrology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Mary B Leonard
- Departments of Pediatrics and.,Medicine, Stanford University, Stanford, California
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Ian H de Boer
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington; and
| | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Harold I Feldman
- Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Myles Wolf
- Division of Nephrology, Department of Medicine and .,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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50
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Kim SM, Liu S, Long J, Montez-Rath ME, Leonard MB, Chertow GM. Declining Rates of Hip Fracture in End-Stage Renal Disease: Analysis From the 2003-2011 Nationwide Inpatient Sample. J Bone Miner Res 2017; 32. [PMID: 28639740 PMCID: PMC5685922 DOI: 10.1002/jbmr.3201] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The incidence of hip fracture in patients with end-stage renal disease (ESRD) is considerably higher than that in the general age- and sex-matched population. Although medical therapy for chronic kidney disease mineral bone disorder (CKD-MBD) has changed considerably over the last decade, rates of hip fracture in the entire ESRD population have not been well-characterized. Herein, we evaluated temporal trends in rates of hip fracture, in-hospital mortality, and costs of associated hospital stay in ESRD. We identified hospitalizations for hip fracture from 2003 to 2011 using the Nationwide Inpatient Sample, a representative national database inclusive of all ages and payers. We incorporated data from the United States Renal Data System and the US Census to calculate population-specific rates. Between 2003 and 2011, we identified 47,510 hip fractures in the ESRD population. The overall rate of hip fracture was 10.04/1000 person-years. The rate was 3.73/1000 person-years in patients aged less than 65 years, and 20.97/1000 person-years in patients aged 65 or older. Age- and sex-standardized rates decreased by 12.6% from 2003 (10.23/1000 person-years; 95% confidence interval [CI], 7.99/1000 to 12.47/1000) to 2011 (8.94/1000 person-years; 95% CI, 7.12/1000 to 10.75/1000). Hip fracture rates over time were virtually identical in patients aged less than 65 years; however, rates decreased by 15.3% among patients aged 65 years or older; rates declined more rapidly in older women compared with older men (p for interaction = 0.047). In-hospital mortality rate after hip fracture operation declined by 26.7% from 2003 (8.6%; 95% CI, 6.8 to 10.4) to 2011 (6.3%; 95% CI, 4.9 to 7.7). In ESRD, age- and sex-standardized hip fracture rates and associated in-hospital mortality have declined substantially over the last decade. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Sun Moon Kim
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Sai Liu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jin Long
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Maria E Montez-Rath
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Mary B Leonard
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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