Physical activity as determinant of femoral neck strength relative to load in adult women: findings from the hip strength across the menopause transition study

A Study on the Femoral Neck-Shaft Angle in an Adult Sample From Andhra Pradesh: Osteological and Radiological Measurements

The femoral neck-shaft angle (NSA) is a crucial anatomical parameter that plays a significant role in hip biomechanics, lower limb alignment, and load distribution across the hip joint. Variations in femoral NSA are linked to orthopedic conditions and have implications for surgical planning, prosthetic design, and forensic analysis. This study aimed to assess the femoral NSA in an adult sample from Andhra Pradesh using both osteological and radiological methods and to evaluate its variations based on side, gender, and age. An observational study was conducted from September to November 2024 at Guntur Medical College in Guntur and Government Medical College in Ongole in Andhra Pradesh, India. The study was conducted using osteological measurements from 113 dry femora (54 left, 59 right) and radiological measurements from 30 standardized anteroposterior digital X-rays of adult subjects aged between 20 and 80 years. Femoral NSA was measured bilaterally using a goniometer and image analysis software. Age- and gender-wise analyses were not possible for osteological measurements. Data were analyzed using IBM SPSS Statistics software, version 26 (IBM Corp., Armonk, NY). Independent t-tests assessed side- and gender-based differences, while one-way ANOVA evaluated age-related variation. Pearson's correlation was employed to compare measurement methods, with a p-value of less than 0.05 considered statistically significant. In osteological assessment, the mean NSA was 116.54° ± 7.81° on the left and 119.93° ± 3.85° on the right, with a statistically significant difference (p = 0.0047). In radiological measurements, the NSA was 141.15° ± 6.97° (left) and 137.50° ± 5.72° (right), also significant (p = 0.0307). In the radiological measurement, gender-based analysis showed a significant difference in females (p = 0.0385) but not males (p = 0.376). Age-wise, significant right-to-left NSA differences were observed across all age groups, which were 20 to 40 years (p = 0.039), 41 to 60 years (p = 0.048), and 61 to 80 years (p = 0.041). A positive correlation was observed between the two methods (r = 1.0), indicating measurement consistency. The study establishes normative femoral NSA values for the adult sample from Andhra Pradesh and highlights significant side-specific, gender-based, and age-related variations. The positive correlation between both methods (limited to bilateral variations) supports their reliability in clinical and anatomical assessments. These findings may offer crucial primary reference data for orthopedic procedures, prosthetic alignment, and regional forensic profiling. Future studies with larger, demographically stratified samples and clinical variables are recommended to refine and validate these observations.

Team Sports Practice and Bone Health: A Systematic Review and Meta- Analysis

The primary aim of this study was to explore the effects of team sports practice on bone health indices in adults engaged in team sports. The secondary aim was to investigate the osteogenic effects of each type of team sport. This systematic literature search was conducted using common electronic databases from inception in June 2023, using key terms (and synonyms searched for by the MeSH database) that were combined using the operators "AND", "OR", "NOT": (``men'' OR ``man'' OR ``women'' OR ``woman'') AND (``bone mineral density'' OR ``BMD'' OR ``bone mineral content'' OR ``BMC'' OR ``peak bone mass'' OR ``mechanical loading'' OR ``osteoporosis'' OR ``bone geometry'' OR ``bone resistance'') AND (``team sport'' OR ``sport'' OR rugby OR basketball OR volleyball OR handball OR soccer OR football OR ``players''). After screening, 16 studies were included in the final analysis (5 continents, 2740 participants). The training duration lasted 1 to 13 years. Team sport training had a moderate impact on whole body bone mineral density (WB BMD) (1.07 SMD; 95 % [0.77, 1.37], p < 0.00) but a more significant impact on whole body bone mineral content (WB BMC) (1.3 SMD; 95 % [0.81, 1.79], p < 0.00). Subgroup analyses indicated that rugby training had a moderate but non-significant impact on WB BMD (1.19 SMD; 95 % [-0.13, 2.52], p = 0.08) but a greater impact on WB BMC (2.12 SMD; 95 % [0.84, 3.39], p < 0.00); basketball training had a moderate but significant impact on WB BMD (1 SMD; 95 % [0.35, 1.64], p < 0.00) and a trivial non-significant impact on WB BMC (0.18 SMD; 95 % [-1.09, 1.46], p = 0.78); volleyball training had a moderate but non-significant impact on WB BMD (0.63 SMD; 95 % [-0.22, 1.49], p = 0.15) and a significant impact on WB BMC (2.39 SMD; 95 % [1.45, 3.33], p < 0.00). Handball training produced a moderate significant impact on WB BMD (1.02 SMD; 95 % [0.33, 1.71], p < 0.00) and WB BMC (0.97 SMD; 95 % [0.47, 1.48], p < 0.00), and soccer training led to moderate but significant effects on WB BMD (1.16 SMD; 95 % [0.88, 1.44], p < 0.00) and a large effect on WB BMC (1.34 SMD; 95 % [0.92, 1.77], p < 0.00). Rugby training was associated with a higher WB BMC compared to basketball training (p = 0.03). Our systematic review and meta-analysis suggests that team sports, such as rugby, basketball, volleyball, handball and soccer have moderate to large effects on WB BMD and WB BMC. Specifically, our findings indicate that handball and soccer enhance WB BMD and WB BMC, whereas rugby only increases WB BMC. There is currently insufficient evidence indicating the superiority of any type of sport training that improves bone health in adults.

Association between composite indices of femoral neck strength and odds of hip fracture

This study aimed to assess the association between composite indices of femoral neck strength and the odds of hip fracture in Chinese adults.After adjusting for confounders, higher values of CSI and ISI were associated with a lower risk of fracture. They may provide useful information for improving hip fracture risk assessment.

PURPOSE

With the increased incidence of hip fractures worldwide, numerous studies have reported that composite indices of femoral neck strength can improve hip fracture risk assessment. This study aimed to assess the association between composite indices of femoral neck strength and the odds of hip fracture in Chinese adults.

METHODS

This retrospective cross-sectional study conducted at Changzhou Second People's Hospital included 937 Chinese adults (248 with hip fractures). After overnight fasting for ≥ 8 h, blood samples were collected from all participants within 24 h of admission. Composite indices of femoral neck strength were derived by combining bone mineral density, weight, and height with femoral axis length and width, which were measured by dual-energy X-ray absorptiometry.

RESULTS

In total, 937 participants (293 men and 644 women) were enrolled. The mean age was 68.3 years (SD 10.5). After adjusting for confounders, higher values of CSI and ISI were associated with a lower odd of hip fracture. Increase in CSI (per 1 g/m·kg) was associated with a 46% decrease in the odd of hip fracture (OR = 0.54; 95% CI, 0.39-0.74), and increase in ISI (per 0.1 g/m·kg) was associated with an 82% decrease (OR, 0.18; 95% CI, 0.11-0.30). Effect sizes of CSI and ISI on the odds of hip fracture remained robust and reliable in subgroup analyses.

CONCLUSIONS

Increased CSI and ISI were associated with a lower odd of hip fracture, especially in women, suggesting that composite indices of femoral neck strength may provide useful information for improving hip fracture risk assessment.

Disparities in Reproductive Aging and Midlife Health between Black and White women: The Study of Women's Health Across the Nation (SWAN)

This paper reviews differences in the experience of the menopause transition and midlife health outcomes between Black and White women who participated in the Study of Women's Health Across the Nation (SWAN), a 25-year, longitudinal, multi-racial/ethnic cohort study. We identify health disparities, i.e., instances in which Black women's outcomes are less favorable than those of White women, and consider whether structural racism may underlie these disparities. Although SWAN did not explicitly assess structural racism, Black women in SWAN grew up during the Jim Crow era in the United States, during which time racism was legally sanctioned. We consider how we might gain insight into structural racism by examining proxy exposures such as socioeconomic characteristics, reports of everyday discrimination, and a range of life stressors, which likely reflect the longstanding, pervasive and persistent inequities that have roots in systemic racism in the US. Thus, this paper reviews the presence, magnitude, and longitudinal patterns of racial disparities observed in SWAN in six areas of women's health - menopause symptoms, sleep, mental health, health related quality of life, cardio-metabolic health, and physical function -and elucidates the contextual factors that are likely influencing these disparities. We review the strengths and weaknesses of SWAN's design and approach to analysis of racial disparities and use this as a springboard to offer recommendations for future cohort studies.

The influence of educational level in peri-menopause syndrome and quality of life among Chinese women

Objective: To investigate the influence of education level in the peri-menopausal symptoms and quality of life (QoL) among Chinese women.Methods: We carried out a cross-sectional study of 1632 peri-menopausal women (age 40-60 y) who visited Hangzhou Women's Hospital from November 2018 to November 2019. The menopausal symptoms were evaluated by modified Kupperman index (KI). World Health Organization Quality of Life (WHOQOL-BREF) questionnaire was used to evaluate the QoL.Result: In total, 1501 women were included in the analysis. The mean age of natural menopause was 49.63 years in China. The five most frequent symptoms in menopausal women were Hot flash (75.53%), sexual problems (72.62%), insomnia (67.29%), fatigue (65.56%), and irritability (61.89%). Natural menopausal age, parity, BMI, bone mineral density, depression, skin formication, total score of KI, and the score of WHOQOL-BREF questionnaire were different in different educational background women (p < .05).Conclusions: The results of the study suggest that education level is associated with the age of natural menopause and menopausal symptoms. A high educational level is correlated with a better score of WHOQOL-BREF in peri-menopause women.

Influence of Physical Activity Level on Composite Indices of Femoral Neck Strength in a Group of Young Overweight Men

The aim of the present study was to explore the influence of physical activity level on composite indices of femoral neck strength (compression strength index [CSI], bending strength index, and impact strength index) in a group of young overweight men. To do so, we compared composite indices of femoral neck strength in active overweight men and insufficiently active overweight men. They were divided into 2 groups based on their physical activity level: 70 active overweight men (engaging in more than 150 minutes of physical activity per week; 8.7 ± 4.8 h/wk) and 26 insufficiently active overweight men (engaging in less than 150 minutes of physical activity per week; 1.2 ± 0.7 h/wk). Height (m) and weight (kg) were measured, and body mass index (kg/m²) was calculated. Bone mineral density was measured by dual-energy X-ray absorptiometry at whole body, lumbar spine, total hip, and femoral neck. Body weight, lean mass, fat mass, and body mass index were not significantly different between the 2 groups. CSI, bending strength index, and impact strength index were significantly higher in active overweight men compared to insufficiently active overweight men. After adjustment for age, physical activity (h/wk) and lean mass, only CSI remained higher in active overweight men compared to insufficiently active overweight men. This study suggests that, in young overweight men, being active (engaging in more than 150 minutes of physical activity per week) is associated with greater composite indices of femoral neck strength. To our knowledge, this is the first study that finds a significant difference regarding composite indices of femoral neck strength between 2 groups of young overweight men with different levels of physical activity.

Objectively-measured sedentary time, habitual physical activity and bone strength in adults aged 62 years: the Newcastle Thousand Families Study

BACKGROUND

The influence of sedentary time and habitual physical activity on the bone health of middle aged adults is not well known.

METHODS

Bone mineral density (BMD) and hip bone geometry were evaluated in 214 men (n = 92) and women (n = 112) aged 62.1 ± 0.5 years from the Newcastle Thousand Families Study birth cohort. Accelerometry was used to measure physical activity (PA) and sedentary time over 4 days. Regression models were adjusted for clinical risk factor covariates.

RESULTS

Men were more sedentary than women (P < 0.05), and sedentary time was negatively associated with spine BMD in men, with 84 minutes more sedentary time corresponding to 0.268 g.cm-2 lower BMD (β = -0.268; P = 0.017). In men, light PA and steps/day were positively associated with bone geometry and BMD. Steps/day was positively associated with bone geometry and femur BMD in women, with a positive difference of 1415 steps/day corresponding to 0.232 g.cm-2 greater BMD (β = 0.232, P = 0.015).

CONCLUSIONS

Sedentary time was unfavourably associated with bone strength in men born in North East England at age 62 years. Higher volumes of light PA, and meeting the public health daily step recommendations (10 000 steps/day) was positively associated with bone health in both sexes.

The menopause transition and women's health at midlife: a progress report from the Study of Women's Health Across the Nation (SWAN)

OBJECTIVE

Our initial understanding of the menopause transition (MT) has been framed by clinical samples of women seeking treatment rather than by population-based studies. The Study of Women's Health Across the Nation (SWAN) initiated in 1996 with an overall goal to define the MT, to characterize its biological and psychosocial antecedents and sequelae in an ethnically and racially diverse sample of midlife women.

METHODS

This review summarizes the central findings of SWAN to date that can inform women and their healthcare providers about the impact of the MT and midlife aging on overall health and well-being.

RESULTS

SWAN characterized changes in reproductive axis and menstrual cycle patterns that informed the development of the reproductive aging staging system Staging of Reproductive Aging Workshop+10; MT-related symptoms and mental health (vasomotor symptoms, sleep complaints, psychological symptoms, cognitive performance, and urogenital and sexual health); and physiological systems and functions (cardiovascular and cardiometabolic health, bone health, physical function performance) that are influenced by the MT. SWAN demonstrated substantial interrelations among these changes and significant racial/ethnic differences in the rate and magnitude of change in multiple health indictors in midlife women. The findings point to midlife as a critical stage for adopting healthy behavior and preventive strategies.

CONCLUSIONS

Over the past 23 years, SWAN has advanced our understanding of the impact of the MT and midlife aging on health and well-being in women. SWAN will be instrumental to determine whether MT-related changes during midlife are related to unfavorable health and well-being in early old age.

The long-term impact of very preterm birth on adult bone mineral density

Introduction

Preterm infants are at increased risk of osteopenia of prematurity due to insufficient bone mineral accretion. Data on long term effects of prematurity on bone health are conflicting. This study aimed to compare bone mineral density (BMD) in young adults born very preterm and full-term controls and to examine factors associated with long-term bone health.

Methods

This observational cross-sectional study enrolled 101 young adults (18–29 years) born <29 weeks of gestation and 95 sex- and age-matched full-term controls. Participants underwent dual-energy X-ray absorptiometry to measure areal BMD and body composition. Generalized estimated equations were used to compare groups adjusting for height Z-score, lean body mass and fat mass.

Results

Adults born preterm were shorter and lighter than full-term controls. Areal BMD was reduced at the lumbar spine, the femoral neck and whole body in the preterm versus full-term group, but after adjustment, areal BMD Z-score was only significantly lower at the femoral neck by −0.3 unit (95% confidence interval −0.6 to −0.0). Low BMD (Z-score ≤ −1 standard deviation) at any site was observed in 53% of adults born preterm versus 28% of full-term controls, but this was not statistically significantly different. We did not identify any neonatal factors associated with lower BMD within the preterm group.

Conclusions

Very preterm birth is associated with lower areal BMD at the femoral neck in young adulthood, even after accounting for body size. Whether this will translate into higher risk of osteoporotic fractures later in life remains unknown.

Bone Health During the Menopause Transition and Beyond

The menopause transition is a critical period for bone health, with rapid losses in bone mass and strength occurring in a 3-year window bracketing the date of the final menstrual period. Declines in bone mass are accompanied by deleterious changes in bone macrostructure and microarchitecture, which may be captured by changes in composite strength indices and indices of trabecular thickness and connectivity. The onset of the rapid bone loss phase is preceded by changes in sex steroid hormones and increases in markers of bone resorption, measurements of which may be clinically useful in predicting the onset of the rapid loss phase and in identifying the women who will lose the most bone strength over the menopause transition.

Habitual levels of higher, but not medium or low, impact physical activity are positively related to lower limb bone strength in older women: findings from a population-based study using accelerometers to classify impact magnitude

This study assessed the effect of accelerometry-measured higher impacts resulting from habitual weight-bearing activity on lower limb bone strength in older women. Despite higher impacts being experienced rarely in this population-based cohort, positive associations were observed between higher vertical impacts and lower limb bone size and strength.

INTRODUCTION

We investigated whether the benefit of habitual weight-bearing physical activity (PA) for lower limb bone strength in older women is explained by exposure to higher impacts, as previously suggested by observations in younger individuals.

METHODS

Four hundred and eight women from the Cohort for Skeletal Health in Bristol and Avon (COSHIBA), mean 76.8 years, wore tri-axial accelerometers at the waist for a mean of 5.4 days. Y-axis peaks were categorised, using previously identified cutoffs, as low (0.5-1.0 g), medium (1.0-1.5 g), and higher (≥1.5 g) impacts. Mid and distal peripheral quantitative computed tomography scans of the tibia and radius were performed, as were hip and lumbar spine Dual X-ray Absorptiometry (DXA) scans. Regressions between (log transformed) number of low, medium and high impacts, and bone outcomes were adjusted for artefact error grade, age, height, fat and lean mass and impacts in other bands.

RESULTS

Eight thousand eight hundred and nine (4047, 16,882) low impacts were observed during the measurement week, 345 (99, 764) medium impacts and 42 (17, 106) higher impacts (median with 25th and 75th quartiles). Higher vertical impacts were positively associated with lower limb bone strength as reflected by cross-sectional moment of inertia (CSMI) of the tibia [0.042 (0.012, 0.072) p = 0.01] and hip [0.067 (0.001, 0.133) p = 0.045] (beta coefficients show standard deviations change per doubling in impacts, with 95 % confidence interval). Higher impacts were positively associated with tibial periosteal circumference (PC) [0.015 (0.003, 0.027) p = 0.02], but unrelated to hip BMD. Equivalent positive associations were not seen for low or medium impacts.

CONCLUSIONS

Despite their rarity, habitual levels of higher impacts were positively associated with lower limb bone size and strength, whereas equivalent relationships were not seen for low or medium impacts.

Higher serum ferritin level and lower femur neck strength in women at the stage of bone loss (≥ 45 years of age): The Fourth Korea National Health and Nutrition Examination Survey (KNHANES IV)

PURPOSE

Despite the clear effect of iron on bone metabolism, most clinical studies related to bone health have only focused on bone mineral density (BMD). In the present study, we investigated the relationship between serum ferritin and composite indices of femur neck strength via a population-based, cross-sectional study using the Korea National Health and Nutrition Examination Survey (KNHANES).

METHODS

Our study series included 693 women at the stage of bone loss (≥ 45 years of age), defined based on the observed patterns of age-related BMD changes in the KNHANES. Geometric bone structure properties, including hip axis length (HAL) and femur neck width (FNW), were measured using hip dual-energy X-ray absorptiometry scans and were combined with BMD, body weight, and height to create composite indices of femur neck strength relative to load in three different failure modes: compression (CSI), bending (BSI), and impact strength indices (ISI).

RESULTS

After adjustment for age, body mass index (BMI), lifestyle factors, serum 25-hydroxyvitamin D, calcium and phosphorus intake, diabetes, and menopause status, multiple regression analyses revealed that serum ferritin was inversely associated with the BMD values at the lumbar spine and femur neck, and the femur neck cortical thickness. Importantly, in all adjustment models, higher serum ferritin was consistently associated with the lower values for all three femur neck composite indices, such as CSI, BSI, and ISI.

CONCLUSIONS

These data provide the first clinical evidence that increased total body iron stores reflected by higher serum ferritin may be associated with the decrease of bone strength relative to load.

Objectively measured physical activity is associated with parameters of bone in 70-year-old men and women

As the world's population ages, the occurrence of osteoporosis-related fractures is projected to increase. Low areal bone mineral density (aBMD), a well-known risk factor for fractures, may be influenced by physical activity (PA). In this cross-sectional study, we aimed to investigate potential associations between objective measures of PA and bone properties, in a population-based cohort of 1228 70-year-old men and women. We measured volumetric BMD (vBMD, mg/cm(3)) together with cross-sectional area (CSA, mm(2)) by peripheral quantitative computed tomography at sites located 4% and 66% in the distal-proximal trajectory at the tibia and radius. We also measured aBMD (g/cm(2)) by dual energy X-ray absorptiometry at the femoral neck, lumbar spine (L1-L4) and radius. Participants wore triaxial accelerometers for 7 consecutive days to obtain objective estimates of PA. The intensity of the objective PA was divided into light (100-1951 counts/min [CPM]), moderate (1952-5724 cpm) and vigorous (≥ 5725 cpm). Maximal accelerations for the anterior-posterior (z), medio-lateral (x), and vertical (y) axes were also separately assessed. Associations were investigated using bivariate correlations and multiple linear regression, adjusted for height, weight and sex. Vigorous PA showed the strongest association with femoral neck aBMD (β=0.09, p<0.001), while both moderate and vigorous PAs were associated with cortical area and trabecular vBMD in the weight-bearing tibia (all p<0.05). Peak vertical accelerations were associated significantly with cortical area (β=0.09, p<0.001) and trabecular vBMD (β=0.09, p=0.001) of the tibia, whereas peak anterior-posterior accelerations showed no correlation with these properties. No positive association was found between objectively measured PA and bone parameters of the radius. In conclusion, vertical accelerations and moderate to vigorous PA independently predict bone properties, especially in the weight-bearing tibia, in 70-year-old men and women.

Bone health after menopause

PURPOSE OF REVIEW

This article reviews recent publications (January 2014-June 2015) on bone health and menopause.

RECENT FINDINGS

Recent articles suggest that simple instruments, such as the osteoporosis self-assessment tool based on age and weight may identify women age 50-64 for bone mineral density (BMD) testing. Rescreening of women age 50-64 is not recommended because their overall risk of fracture is quite low. A novel risk factor for hip fracture among non-Caucasian women is socioeconomic status. Midlife women with low serum 25-hydroxyvitamin D (<20 ng/ml) have an increased risk of fracture over the menopausal transition and vitamin D supplementation is warranted. Wrist fractures are the most common fracture in women age 50-64. Women who experience a wrist fracture have an increased risk of subsequent fracture and should have a BMD scan. Results of studies using composite measures of femoral neck strength relative to load emphasize the need for osteoporotic research to move beyond BMD.

SUMMARY

This recent research has provided new and important findings improving our understanding of osteoporosis during the menopausal transition.

Parity, lactation, bone strength, and 16-year fracture risk in adult women: findings from the Study of Women's Health Across the Nation (SWAN)

Our objective was to examine the associations of lifetime parity and accumulated length of lactation with bone strength in women prior to the menopause transition and fracture risk during and after the transition. Participants were 2239 pre- or early peri-menopausal women from the Study of Women's Health Across the Nation (SWAN), ages 42-53 years at baseline, who had no childbirths after age 42. Bone mineral density (BMD) was measured in the femoral neck and the lumbar spine at the baseline SWAN visit using dual-energy x-ray absorptiometry, and the composite indices of femoral neck strength relative to load (in three failure modes: compression, bending, and impact) were calculated from femoral neck BMD, femoral neck size, and body size. Data on fractures after age 42 were collected for a median follow-up of 15.7 years (interquartile range, 11.4-18.5 years). In multiple linear regressions adjusted for covariates, lifetime parity was associated positively with femoral neck strength relative to load (0.024 standard deviation (SD) increment in impact strength index per childbirth, p=0.049), but accumulated length of lactation was associated negatively with lumbar spine BMD (0.018 SD decrement per every additional 6 months of lactation, p=0.040). In Cox proportional hazards regressions adjusted for covariates, neither parity nor lactation was associated with fracture hazard after age 42. In conclusion, parity and lactation have little impact on peak bone strength prior to menopause, and do not affect fracture risk after age 42 over 16-year follow-up.

To exercise, or, not to exercise, during menopause and beyond

Menopausal symptoms in women can be severe and disruptive to overall quality of life. Hormone replacement therapy, is known to be effective in ameliorating symptoms, however, reporting of side effects has resulted in alternative treatment options. Exercise has been assessed as an alternative treatment option for alleviating menopausal symptoms, including, psychological, vasomotor, somatic and sexual symptoms. Here we report the effects of physical activity and exercise on menopause symptoms in menopausal women.