Risk factors for hip fracture in white men: the NHANES I Epidemiologic Follow-up Study

New Challenges: Use and Interpretation of Radius Bone Mineral Density

CONTEXT

It is unknown if isolated low bone mineral density (BMD) "osteoporosis" at the radius is associated with increased fracture risk, not only at the wrist but elsewhere, and whether it reflects more generalized skeletal fragility.

OBJECTIVE

This work aimed to review the association of radius BMD and fracture risk, the epidemiology of wrist fractures, isolated osteoporosis at the radius, and the concordance between radial BMD and femoral neck BMD.

METHODS

We completed a narrative literature review on radius BMD and fracture risk and current recommendations for measurement of radial BMD. We updated results of radial BMD and fracture results from the Study of Osteoporotic Fractures over 20 years and examined the concordance of BMD at the distal and proximal radius with femoral neck BMD T scores.

RESULTS

Radius BMD is a robust predictor of all types of fractures including hip and wrist but there is insufficient evidence to suggest that radius BMD predicts wrist fractures better than fractures at other sites. Fractures of the wrist tend to occur in younger, healthier women compared with hip and spine fractures. Nevertheless, wrist fractures are associated with an increased risk of future fractures and represent a missed opportunity for intervention. On a population level, the discordance between radius BMD and femoral neck BMD is small. But women with isolated osteoporosis at the radius had biochemical and microarchitecture deterioration that were similar to women with hip osteoporosis.

CONCLUSION

Future research should address the clinical implications of isolated osteoporosis at the radius and whether treatment is warranted.

Weight change patterns across adulthood in relation to osteoporosis and fracture among non-obese individuals

Weight change was an influencing factor of osteoporosis and fracture in a controversial way. Based on a nationally representative data, we found that weight change from obesity in midlife to non-obesity in late adulthood was associated with a reduction in the risk of osteoporosis and wrist fracture in male, but not in female.

INTRODUCTION

Obesity is usually recognized as a protective factor to osteoporosis and osteoporotic fracture. However, it is still unclear whether historical weight status was associated with the risk of osteoporosis and fracture. The aim of this study was to investigate the relationship between weight change patterns across adulthood and the prevalence of osteoporosis and fracture.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) with 8725 US adults aged ≥ 40 years were analyzed in this study. Weight change patterns were categorized as "stable non-obese," "obese with earlier weight gain," "obese with recent weight gain," and "revert to non-obese" based on the body mass index (BMI) at 25 years old, 10 years prior to baseline and at baseline. Body mineral density (BMD) was measured using dual x-ray absorptiometry (DXA), and osteoporosis was diagnosed based on the World Health Organization criteria. Self-reported occurrence of osteoporotic fractures were determined by questionnaires.

RESULTS

Compared with subjects in "stable non-obese" group, obese with earlier weight gain were positively related to the increase of BMD in both genders, while elevated BMD was only observed in female of "obese with recent weight gain" group and in male of "revert to non-obese" group after multiple adjustment. Moreover, changing from the obesity to non-obesity in the 10 years period before baseline was associated with a 81.6% lower risk of osteoporosis (odds ratio (OR) 0.184, 95% confidence interval (CI) 0.037-0.914 (P = 0.039)) and a 69.8% lower risk of wrist fracture (OR 0.302, 95%CI 0.120-0.757 (P = 0.012)) in male, but not in female.

CONCLUSION

Weight change from obesity in midlife to non-obesity in late adulthood was associated with a reduction in the risk of osteoporosis and wrist fracture in male. Our findings support the importance of investigating the mechanism of weight change in different life period.

The Influences of Macronutrients on Bone Mineral Density, Bone Turnover Markers, and Fracture Risk in Elderly People: A Review of Human Studies

Osteoporosis is a health condition that involves weak bone mass and a deteriorated microstructure, which consequently lead to an increased risk of bone fractures with age. In elderly people, a fracture attributable to osteoporosis elevates mortality. The objective of this review was to examine the effects of macronutrients on bone mineral density (BMD), bone turnover markers (BTMs), and bone fracture in elderly people based on human studies. A systematic search was conducted in the PubMed®/MEDLINE® database. We included human studies published up to April 2023 that investigated the association between macronutrient intake and bone health outcomes. A total of 11 meta-analyses and 127 individual human studies were included after screening the records. Carbohydrate consumption seemed to have neutral effects on bone fracture in limited studies, but human studies on carbohydrates' effects on BMD or/and BTMs are needed. The human studies analyzed herein did not clearly show whether the intake of animal, vegetable, soy, or milk basic proteins has beneficial effects on bone health due to inconsistent results. Moreover, several individual human studies indicated an association between eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and osteocalcin. Further studies are required to draw a clear association between macronutrients and bone health in elderly people.

Alcohol Consumption and Risk of Fractures: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies

Alcohol consumption remains inconsistently correlated with fracture risk, and a dose-response meta-analysis for specific outcomes is lacking. The objective of this study was to quantitatively integrate the data on the relationship between alcohol consumption and fracture risk. Pertinent articles were identified in PubMed, Web of Science, and Embase databases up to 20 February 2022. Combined RRs and 95% CIs were estimated by random- or fixed-effects models. Restricted cubic splines were used to model linear or nonlinear relationships. Forty-four articles covering 6,069,770 participants and 205,284 cases of fracture were included. The combined RRs and 95% CIs for highest compared with lowest alcohol consumption were 1.26 (1.17-1.37), 1.24 (1.13-1.35), and 1.20 (1.03-1.40) for total, osteoporotic, and hip fractures, respectively. A linear positive relationship between alcohol consumption and total fracture risk was detected (Pnonlinearity = 0.057); the risk was correlated with a 6% increase (RR, 1.06; 95% CI: 1.02, 1.10) per 14 g/d increment of alcohol consumption. J-shaped relationships of alcohol consumption with risk of osteoporotic fractures (Pnonlinearity < 0.001) and hip fractures (Pnonlinearity < 0.001) were found. Alcohol consumption of 0 to 22 g/d was linked to a reduced risk of osteoporotic fractures and hip fractures. Our findings show that any level of alcohol consumption is a risk factor for total fractures. Moreover, this dose-response meta-analysis shows that an alcohol consumption level of 0 to 22 g/d is related to a reduction in the risk of osteoporotic and hip fractures. The protocol was registered in the International Prospective Register of Systematic Reviews (CRD42022320623).

Muscle strength and physical performance contribute to and improve fracture risk prediction in older people: A narrative review

Osteoporotic fractures present a major health problem with an increasing prevalence in older people. Fractures are associated with premature mortality, reduced quality of life, subsequent fracture, and increased costs. Hence, it is crucial to identify those at higher risk of fracture. Fracture risk assessment tools incorporated clinical risk factors to improve fracture predictive power over BMD alone. However, fracture risk prediction using these algorithms remains suboptimal, warranting further improvement. Muscle strength and physical performance measurements have been associated with fracture risk. In contrast, the contribution of sarcopenia, the composite condition of low muscle mass, muscle strength and/or physical performance, to fracture risk is unclear. It is uncertain whether this is due to the problematic definition of sarcopenia per se or limitations of the diagnostic tools and cut-off points of the muscle mass component. The recent position statement from the Sarcopenia Definition and Outcomes Consortium confirmed the inclusion of muscle strength and performance in the definition of sarcopenia but not DXA-assessed lean mass. Therefore, clinicians should focus on functional assessment (muscle strength and performance) rather than muscle mass, at least as assessed by DXA, as predictors of fractures. Muscle strength and performance are modifiable risk factors. Resistance exercise improves muscle parameters in the elderly, potentially leading to reduced risk of falls and fractures in the general population and in those who sustained a fracture. Therapists may consider exercise intervention to improve muscle parameters and potentially reduce the risk of fractures. The aim of this review was to explore 1) the contribution of muscle parameters (i.e., muscle mass, strength, and physical performance) to fracture risk in older adults, and 2) the added predictive accuracy of these parameters beyond the existing fracture assessment tools. These topics provide the rationale for investigating strength and physical performance interventions to reduce fracture risk. Most of the included publications showed that muscle mass is not a good predictor of fracture risk, while poor muscle strength and performance are associated with an increased risk of fracture, particularly in men, independent of age, BMD, and other risk factors for fractures. Muscle strength and performance can potentially improve the predictive accuracy in men beyond that obtained by the fracture risk assessment tools, Garvan FRC and FRAX.

Sex and External Size Specific Limitations in Assessing Bone Health From Adult Hand Radiographs

Morphological parameters measured for the second metacarpal from hand radiographs are used clinically for assessing bone health during growth and aging. Understanding how these morphological parameters relate to metacarpal strength and strength at other anatomical sites is critical for providing informed decision-making regarding treatment strategies and effectiveness. The goals of this study were to evaluate the extent to which 11 morphological parameters, nine of which were measured from hand radiographs, relate to experimentally measured whole-bone strength assessed at multiple anatomical sites and to test whether these associations differed between men and women. Bone morphology and strength were assessed for the second and third metacarpals, radial diaphysis, femoral diaphysis, and proximal femur for 28 white male donors (18-89 years old) and 35 white female donors (36-89+ years old). The only morphological parameter to show a significant correlation with strength without a sex-specific effect was cortical area. Dimensionless morphological parameters derived from hand radiographs correlated significantly with strength for females, but few did for males. Males and females showed a significant association between the circularity of the metacarpal cross-section and the outer width measured in the mediolateral direction. This cross-sectional shape variation contributed to systematic bias in estimating strength using cortical area and assuming a circular cross-section. This was confirmed by the observation that use of elliptical formulas reduced the systematic bias associated with using circular approximations for morphology. Thus, cortical area was the best predictor of strength without a sex-specific difference in the correlation but was not without limitations owing to out-of-plane shape variations. The dependence of cross-sectional shape on the outer bone width measured from a hand radiograph may provide a way to further improve bone health assessments and informed decision making for optimizing strength-building and fracture-prevention treatment strategies. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Smoking and fracture risk in men: a meta-analysis of cohort studies, using both frequentist and Bayesian approaches

Past studies indicate that men are more likely to smoke and be at higher risk of smoking-related conditions than women. Our research aimed, through meta-analysis, to assess the association between smoking and fracture risk in men. The following databases were searched, including MEDLINE, EMBASE, Scopus, PsycINFO, ISI Web of Science, Google Scholar, WorldCat, and Open Grey, for identifying related studies. A random-effects model was used to pool the confounder-adjusted relative risk (R.R.). Frequentist and Bayesian hierarchical random-effects models were used for the analysis. The heterogeneity and publication bias were evaluated in this study. Twenty-seven studies met the inclusion criteria. Overall, smoking is associated with a significantly increased risk of fracture in both the frequentist approach (R.R., 1.37; 95% confidence interval: 1.22, 1.53) and the Bayesian approach (R.R., 1.36; 95% credible interval: 1.22, 1.54). Significant heterogeneity was observed in the meta-analysis (Higgin's I² = 83%) and Cochran's Q statistic (p < 0.01). A significant association was also observed in multiple pre-specified sensitivity and subgroup analyses. Similar results were observed in the group containing a large sample size (≥ 10,000 participants), and the group has a small sample size (< 10,000 participants); the pooled R.R was 1.23 (95% confidence interval, 1.07–1.41) and 1.56 (95% confidence interval, 1.37–1.78), respectively. With the Bayesian method, the effect size was 1.23 (95% credible interval, 1.05, 1.45) for the large sample size group and 1.57 (95% credible interval, 1.35, 1.82) for the small sample size group. Smoking is associated with a significant increase in fracture risk for men. Thus, smoking cessation would also greatly reduce fracture risk in all smokers, particularly in men.

Fracture, nonunion and postoperative infection risk in the smoking orthopaedic patient: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to analyse negative effects of smoking in orthopaedic and trauma patients.

A PubMed search was carried out for studies published until July 2020 regarding effects of smoking on fracture risk, nonunion, infection after orthopaedic surgery, and persisting nonunion after scaphoid nonunion surgery. Random effects models calculated for outcome parameters, and relative risks (RR) with 95% confidence intervals are provided. No adjustments for covariates were made. Heterogeneity was assessed with Higgins’ I2, publication bias with Harbord’s p (Hp), sensitivity analysis performed on funnel plots and quality of studies was analysed using the Newcastle-Ottawa Scale.

Of 3362 retrieved entries, 69 were included in the final analysis. Unadjusted RR for smokers to develop vertebral (six studies, seven entries; RR: 1.61; p = 0.008; I2 = 89.4%), hip (11 studies, 15 entries; RR: 1.28; p = 0.007; I2 = 84.1%), and other fractures (eight studies, 10 entries; RR: 1.75; p = 0.019; I2 = 89.3%) was significantly higher. Postoperative infection risk was generally higher for smokers (21 studies; RR: 2.20; p < 0.001; I2 = 58.9%), and remained upon subgroup analysis for elective spinal (two studies; RR: 4.38; p < 0.001; I2 = 0.0%) and fracture surgery (19 studies; RR: 2.10; p < 0.001; I2 = 58.5%). Nonunion risk after orthopaedic (eight studies; RR: 2.15; p < 0.001; I2 = 35.9%) and fracture surgery (11 studies; RR: 1.85; p < 0.001; I2 = 39.9%) was significantly higher for smokers, as was persisting nonunion risk after surgery for scaphoid nonunion (five studies; RR: 3.52; p < 0.001; I2 = 0.0%). Sensitivity analysis for each model reduced heterogeneity whilst maintaining significance (all I2 < 20.0%).

Smoking has a deleterious impact on fracture incidence, and (subsequent) development of nonunions and postoperative infections.

Cite this article: EFORT Open Rev 2021;6:1006-1019. DOI: 10.1302/2058-5241.6.210058

Higher-Impact Physical Activity Is Associated With Maintenance of Bone Mineral Density But Not Reduced Incident Falls or Fractures in Older Men: The Concord Health and Aging in Men Project

High-impact physical activities with bone strains of high magnitude and frequency may benefit bone health. This study aimed to investigate the longitudinal associations between changes in loading intensities and application rates, estimated from self-reported physical activity, with bone mineral density (BMD) changes over 5 years and also with incident falls over 2 years and long-term incident fractures in community-dwelling older men. A total of 1599 men (mean age 76.8 ± 5.4 years) from the Concord Health and Aging in Men Project (CHAMP) were assessed at baseline (2005-2007) and at 2- and 5-year follow-up. At each time point, hip and lumbar spine BMD were measured by dual-energy X-ray absorptiometry, and physical activity energy expenditure over the past week was self-reported via the Physical Activity Scale for the Elderly (PASE) questionnaire. Sum effective load ratings (ELRs) and peak force were estimated from the PASE questionnaire, reflecting the total and highest loading intensity and application rate of physical activities, respectively. Participants were contacted every 4 months over 2 years to self-report falls and over 6.0 ± 2.2 years for fractures. Hip fractures were ascertained by data linkage for 8.9 ± 3.6 years. Compared with sum ELR and PASE scores, peak force demonstrated the greatest standardized effect size for BMD maintenance at the spine (β = 9.77 mg/cm² ), total hip (β = 14.14 mg/cm² ), and femoral neck (β = 13.72 mg/cm² ) after adjustment for covariates, including PASE components (all p < .01). Only PASE scores were significantly associated with reduced falls risk (standardized incident rate ratio = 0.90, 95% confidence interval 0.81-1.00, p = .04). All physical activity measures were significantly associated with reduced incident fractures in univariate analyses, but none remained significant after multivariable adjustments. Older men who engaged in physical activity of high and rapid impact maintained higher BMD, while higher energy expenditure was associated with reduced falls risk. Coupling traditional physical activity data with bone loading estimates may improve understanding of the relationships between physical activity and bone health. © 2020 American Society for Bone and Mineral Research (ASBMR).

A systematic review and meta-analysis of prospective cohort studies on the association between alcohol intake and risk of fracture

Previous studies on the association between alcohol intake and risk of fracture have reached conflicting findings. The aim of this systematic review and meta-analysis of prospective cohort studies was to summarize earlier studies on the association of alcohol intake with risk of fracture. A systematic search of PubMed, Scopus, and ISI Web of Science was conducted up to November 2020. Prospective cohort studies that had considered alcohol consumption as the exposure variable and fracture as the main outcome or as one of the outcome variables were included in this systematic review. Publications in which odds ratios (ORs), rate or risk ratios (RRs), or hazard ratios (HRs) and 95% confidence intervals (CIs) were reported, were included in the meta-analysis. In total, 40 prospective cohort studies including 5,084,303 participants and 170,916 subjects with fracture were included in this systematic review; of them 38 studies with a total sample size of 5,053,117 participants and 169,560 cases of fracture were included in the meta-analysis. Using a random-effects meta-analysis, we found a significant positive association between alcohol consumption and risk of total fractures (RR: 1.35; 95% CI: 1.01, 1.81) and any fractures (RR: 1.24; 95% CI: 1.11, 1.38). However, no significant association was observed between alcohol intake and risk of hip fractures (RR: 1.19; 95% CI: 0.96, 1.48), osteoporotic fractures (RR: 2.01; 95% CI: 0.76, 5.34), vertebral fractures (RR: 0.98; 95% CI: 0.68, 1.40), and wrist fractures (RR: 0.99; 95% CI: 0.85, 1.16). In conclusion, we found that alcohol consumption was positively associated with risk of total fractures and any fractures. However, we did not observe any significant association between alcohol consumption and risk of hip, osteoporotic, vertebral, and wrist fractures.

Secondary Hyperparathyroidism in Obese Patients Post Sleeve Gastrectomy

INTRODUCTION

Bariatric surgery provides an effective option for the management of morbid obesity. Several studies have investigated the association between bariatric surgery and secondary hyperparathyroidism (SHPT). This study aims to compare the levels of blood biomarkers, specifically, calcium (Ca), vitamin D, and phosphate (PO4), and their association with parathyroid hormone (PTH) levels pre- and post-bariatric surgery. In addition, it aims to assess the prevalence of hyperparathyroidism post-bariatric surgery in a tertiary care hospital in Saudi Arabia.

MATERIAL AND METHODS

A prospective cohort study was conducted at a large tertiary care hospital between May 2017 and April 2019. The study included adult obese patients who underwent laparoscopic sleeve gastrectomy (LSG). Patients were excluded if they were known to have any comorbidities, receiving vitamin supplements, and those who had undergone bariatric procedures previously. Routine blood tests, including PTH, vitamin D, Ca, and PO4, were collected at baseline, and post-surgery.

RESULTS

A total of 143 patients who underwent LSG were included in the study. Hyperparathyroidism was observed in 15.4% of patients at baseline and in 36.4% of patients' post-surgery (p < 0.001). Low vitamin D levels, which were highly prevalent before surgery, decreased sustainably (66.4% pre-operative and 28% at follow-up after surgery, P=0.032). Baseline hypocalcemia was observed in 20.3% of patients compared to 8.4% post-surgery (P=0.546). Hypophosphatemia was present in 60.8% of subjects at baseline, while the percentage dropped to 21.7% post-surgery. There was a significant association between PO4 and PTH levels at baseline. Post-operatively, there was a significant correlation between PTH and both vitamin D and calcium levels.

CONCLUSION

Our study showed that the higher levels of PTH post LSG can be related to vitamin D deficiency and lower calcium levels, despite patients following the provided recommendations for supplementation. This study also emphasizes the importance of routine testing for hyperparathyroidism both before and after bariatric surgery.

Dietary protein and bone health across the life-course: an updated systematic review and meta-analysis over 40 years

We undertook a systematic review and meta-analysis of published papers assessing dietary protein and bone health. We found little benefit of increasing protein intake for bone health in healthy adults but no indication of any detrimental effect, at least within the protein intakes of the populations studied. This systematic review and meta-analysis analysed the relationship between dietary protein and bone health across the life-course. The PubMed database was searched for all relevant human studies from the 1st January 1976 to 22nd January 2016, including all bone outcomes except calcium metabolism. The searches identified 127 papers for inclusion, including 74 correlational studies, 23 fracture or osteoporosis risk studies and 30 supplementation trials. Protein intake accounted for 0-4% of areal BMC and areal BMD variance in adults and 0-14% of areal BMC variance in children and adolescents. However, when confounder adjusted (5 studies) adult lumbar spine and femoral neck BMD associations were not statistically significant. There was no association between protein intake and relative risk (RR) of osteoporotic fractures for total (RR_(random) = 0.94; 0.72 to 1.23, I² = 32%), animal (RR _(random) = 0.98; 0.76 to 1.27, I² = 46%) or vegetable protein (RR _(fixed) = 0.97 (0.89 to 1.09, I² = 15%). In total protein supplementation studies, pooled effect sizes were not statistically significant for LSBMD (total n = 255, MD_(fixed) = 0.04 g/cm² (0.00 to 0.08, P = 0.07), I² = 0%) or FNBMD (total n = 435, MD_(random) = 0.01 g/cm² (-0.03 to 0.05, P = 0.59), I² = 68%). There appears to be little benefit of increasing protein intake for bone health in healthy adults but there is also clearly no indication of any detrimental effect, at least within the protein intakes of the populations studied (around 0.8-1.3 g/Kg/day). More studies are urgently required on the association between protein intake and bone health in children and adolescents.

US National Health and Nutrition Examination Survey Arthritis Initiatives, Methodologies and Data

The US National Health and Nutrition Examination Survey (NHANES) has collected population-based, nationally representative examination, laboratory, and radiographic data for arthritis and musculoskeletal diseases for more than 50 years. The resulting body of data and publications are substantial, yet much data remain unpublished. This review provides a basic understanding of the design and capabilities of the NHANES survey, reviewing the major accomplishments in the area of arthritis and musculoskeletal diseases. Currently available US National Health and Nutrition Examination Survey arthritis-related datasets are identified. Guidelines for using these data, and opportunities for data analysis and designing future studies are presented.

Current and former smokers and hip fractures

The purpose of this review is to examine the correlation between tobacco smoking and hip fractures. The literature that was used for this article was based on studies that investigated not only the direct correlation between smoking and hip fractures but also the effect of smoking on bone mineral density. In general, the incidence of hip fracture was found to be higher in current smokers in both genders. Compared with never smokers, former smokers had a slightly higher risk of hip fracture that was inversely proportional to the cessation span. The relative risk (RR) of hip fracture in current male smokers was higher than the RR for nonsmokers (never and former smokers). In postmenopausal women former and current smoking increased the RR. In premenopausal and postmenopausal women, cessation of smoking decreases the risk of hip fracture. Risk rises with greater cigarette consumption. Risk declines among former smokers, but the benefit is not observed until 10 years after cessation.

Benefits and safety of dietary protein for bone health-an expert consensus paper endorsed by the European Society for Clinical and Economical Aspects of Osteopororosis, Osteoarthritis, and Musculoskeletal Diseases and by the International Osteoporosis Foundation

A summary of systematic reviews and meta-analyses addressing the benefits and risks of dietary protein intakes for bone health in adults suggests that dietary protein levels even above the current RDA may be beneficial in reducing bone loss and hip fracture risk, provided calcium intakes are adequate. Several systematic reviews and meta-analyses have addressed the benefits and risks of dietary protein intakes for bone health in adults. This narrative review of the literature summarizes and synthesizes recent systematic reviews and meta-analyses and highlights key messages. Adequate supplies of dietary protein are required for optimal bone growth and maintenance of healthy bone. Variation in protein intakes within the "normal" range accounts for 2-4% of BMD variance in adults. In older people with osteoporosis, higher protein intake (≥ 0.8-g/kg body weight/day, i.e., above the current RDA) is associated with higher BMD, a slower rate of bone loss, and reduced risk of hip fracture, provided that dietary calcium intakes are adequate. Intervention with dietary protein supplements attenuate age-related BMD decrease and reduce bone turnover marker levels, together with an increase in IGF-I and a decrease in PTH. There is no evidence that diet-derived acid load is deleterious for bone health. Thus, insufficient dietary protein intakes may be a more severe problem than protein excess in the elderly. Long-term, well-controlled randomized trials are required to further assess the influence of dietary protein intakes on fracture risk.

Screening for osteoporosis following non-vertebral fractures in patients aged 50 and older independently of gender or level of trauma energy-a Swiss trauma center approach

Screening in a standardized manner for osteoporosis in non-vertebral fracture patients aged 50 and older independently of both gender and level of trauma energy yielded the indication for osteoporotic therapy for every fourth male high-energy fracture patient.

PURPOSE

This study aimed to identify the rate of osteoporosis in patients of both genders after fracture independently of the underlying level of trauma energy.

METHODS

A random cohort of patients aged 50 or older with non-vertebral fractures participated in a standardized diagnostic protocol to evaluate the indication for treatment of osteoporosis (number needed to screen (NNS)). Univariate and multivariate analysis as well as correlation testing were performed to determine statistical relationships. Significance was set at p < 0.05.

RESULTS

Of 478 fracture patients with a mean age of 69.3 ± 11.8 years, 317 (66.3%) were female and 161 (33.7%) male. One hundred nineteen patients (24.9%) sustained high-energy fractures (HEFs) and 359 (75.1%) low-energy fractures (LEFs). Twenty-eight percent of males and 47% of females qualified as osteoporotic in densitometry (dual-energy X-ray absorptiometry (DXA)), resulting in a NNS of 2.1 for women and 3.6 for men. The indication for treatment of osteoporosis increased to an NNS of 1.5 for females and 2.4 for males if the fracture risk assessment tool (FRAX) was included in the diagnostics (DXA and FRAX). With regard to the energy of trauma, the NNS for treatment following DXA and FRAX was 1.5 for LEF and 2.9 for HEF. Subgroup analysis revealed that HEF males within the decennia 50+ and 80+ had an NNS of around 3, i.e., comparable to females and about twice as high as LEF patients.

CONCLUSIONS

These preliminary findings appear to confirm the pragmatic approach to screening in a standardized manner for osteoporosis in all non-vertebral fracture patients aged 50 and older-independently of both gender and level of trauma energy.

Weighted Vest Use during Dietary Weight Loss on Bone Health in Older Adults with Obesity

Background

To examine the effects of daily weighted vest use during a dietary weight loss intervention, on (a) hip and spine bone mineral density (aBMD), and (b) biomarkers of bone turnover, in older adults with obesity.

Methods

37 older (70.1 ± 3.0 years) adults with obesity (BMI=35.3 ± 2.9) underwent a 22 week dietary weight loss intervention (1100–1300 kcal/day) with (Diet+Vest; n=20) or without (Diet; n=17) weighted vest use (goal: 10+ h/day; weight added incrementally based on amount of weight lost). Total body weight; DXA-acquired aBMD of the total hip, femoral neck and lumbar spine; and biomarkers of bone turnover (OC, BALP, P1NP, CTX) were measured at baseline and follow up. General linear models, adjusted for baseline values of the outcome and gender, were used to examine intervention effects.

Results

Average weight loss was significant in both groups (−11.2 ± 4.4 kg and −11.0 ± 6.3 kg, Diet+Vest and Diet groups, respectively), with no difference between groups (p=0.91). Average weighted vest use was 6.7 ± 2.2 h/day. No significant changes in aBMD or biomarkers were observed, although trends were noted for total hip aBMD and BALP. Loss in total hip aBMD was greater in the Diet group compared with Diet+Vest (Δ: −18.7 [29.3, −8.1] mg/cm² versus −6.1 [−15.7, 3.5] mg/cm²; p=0.08). BALP increased in the Diet+Vest group by 3.8% (Δ: 0.59 [−0.33, 1.50] μg/L) and decreased by −4.6% in the Diet group (Δ: −0.70 [−1.70, 0.31] μg/L, p=0.07).

Conclusion

Weighted vest use during weight loss may attenuate loss of hip aBMD and increase bone formation in older adults with obesity. Further study is warranted.

Dietary Protein Intake above the Current RDA and Bone Health: A Systematic Review and Meta-Analysis

Dietary intake of protein is fundamental for optimal acquisition and maintenance of bone across all life stages; however, it has been hypothesized that intakes above the current recommended dietary allowance (RDA) might be beneficial for bone health. We utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines when preparing and reporting this systematic review and meta-analysis. A literature search strategy through April 11, 2017, was developed for the following 3 databases: PubMed, Ovid Medline, and Agricola. Included studies were those randomized controlled trials and prospective cohort studies among healthy adults ages 18 and older that examined the relationships between varying doses of protein intake at or above the current U.S. RDA (0.8 g/kg/d or 10%-15% of total caloric intake) from any source on fracture, bone mineral density (BMD)/bone mineral content (BMC), and/or markers of bone turnover. Twenty-nine articles were included for data extraction (16 randomized controlled trials [RCTs] and 13 prospective cohort studies). Meta-analysis of the prospective cohort studies showed high vs low protein intakes resulted in a statistically significant 16% decrease in hip fractures (standardized mean difference [SMD] = 0.84, 95% confidence interval [CI], 0.73, 0.95; I² = 36.8%). Data from studies included in these analyses collectively lean toward the hypothesis that protein intake above the current RDA is beneficial to BMD at several sites. This systematic review supports that protein intakes above the current RDA may have some beneficial role in preventing hip fractures and BMD loss. There were no differences between animal or plant proteins, although data in this area were scarce. Larger, long-term, and more well-controlled clinical trials measuring fracture outcomes and BMD are needed to adequately assess whether protein intake above the current RDA is beneficial as a preventative measure and/or intervention strategy for osteoporosis. Key teaching points: • • Bone health is a multifactorial musculoskeletal issue, and optimal protein intakes are key in developing and maintaining bone throughout the life span. • • Dietary protein at levels above the current RDA may be beneficial in preventing hip fractures and BMD loss. • • Plant vs animal proteins do not seem to differ in their ability to prevent bone loss; however, data in this area are scarce. • • Larger, long-term RCTs using women not using hormone replacement therapy (HRT) are needed to adequately assess the magnitude of impact that protein intakes above the RDA have on preventing bone loss.

Dietary protein and bone health: a systematic review and meta-analysis from the National Osteoporosis Foundation

Background: Considerable attention has recently focused on dietary protein's role in the mature skeleton, prompted partly by an interest in nonpharmacologic approaches to maintain skeletal health in adult life.Objective: The aim was to conduct a systematic review and meta-analysis evaluating the effects of dietary protein intake alone and with calcium with or without vitamin D (Ca±D) on bone health measures in adults.Design: Searches across 5 databases were conducted through October 2016 including randomized controlled trials (RCTs) and prospective cohort studies examining 1) the effects of "high versus low" protein intake or 2) dietary protein's synergistic effect with Ca±D intake on bone health outcomes. Two investigators independently conducted abstract and full-text screenings, data extractions, and risk of bias (ROB) assessments. Strength of evidence was rated by group consensus. Random-effects meta-analyses for outcomes with ≥4 RCTs were performed.Results: Sixteen RCTs and 20 prospective cohort studies were included in the systematic review. Overall ROB was medium. Moderate evidence suggested that higher protein intake may have a protective effect on lumbar spine (LS) bone mineral density (BMD) compared with lower protein intake (net percentage change: 0.52%; 95% CI: 0.06%, 0.97%, I²: 0%; n = 5) but no effect on total hip (TH), femoral neck (FN), or total body BMD or bone biomarkers. Limited evidence did not support an effect of protein with Ca±D on LS BMD, TH BMD, or forearm fractures; there was insufficient evidence for FN BMD and overall fractures.Conclusions: Current evidence shows no adverse effects of higher protein intakes. Although there were positive trends on BMD at most bone sites, only the LS showed moderate evidence to support benefits of higher protein intake. Studies were heterogeneous, and confounding could not be excluded. High-quality, long-term studies are needed to clarify dietary protein's role in bone health. This trial was registered at www.crd.york.ac.uk as CRD42015017751.

Relationship Between Low Bone Mineral Density and Fractures With Incident Cardiovascular Disease: A Systematic Review and Meta-Analysis

An increasing evidence base suggests that low bone mineral density (BMD) and fractures are associated with cardiovascular disease (CVD). We conducted a systematic review and meta-analysis summarizing the evidence of low BMD and fractures as risk factors for future CVD. Two independent authors searched major databases from inception to August 1, 2016, for longitudinal studies reporting data on CVD incidence (overall and specific CVD) and BMD status and fractures. The association between low BMD, fractures, and CVD across longitudinal studies was explored by calculating pooled adjusted hazard ratios (HRs) ±95% confidence intervals (CIs) with a random-effects meta-analysis. Twenty-eight studies (18 regarding BMD and 10 fractures) followed a total of 1,107,885 participants for a median of 5 years. Taking those with higher BMD as the reference, people with low BMD were at increased risk of developing CVD during follow-up (11 studies; HR = 1.33; 95%CI, 1.27 to 1.38; I2  = 53%), after adjusting for a median of eight confounders. This finding was confirmed using a decrease in one standard deviation of baseline BMD (9 studies; HR = 1.16; 95% CI, 1.09 to 1.24; I2  = 69%). The presence of fractures at baseline was associated with an increased risk of developing CVD (HR = 1.20; 95% CI, 1.06 to 1.37; I2  = 91%). Regarding specific CVDs, low BMD was associated with an increased risk of developing coronary artery disease, cerebrovascular conditions, and CVD-associated death. Fractures at baseline was associated with an increased risk of cerebrovascular conditions and death due to CVD. In conclusion, low BMD and fractures are associated with a small, but significant increased risk of CVD risk and possibly death. © 2017 American Society for Bone and Mineral Research.

The dietary protein, IGF-I, skeletal health axis

Dietary protein represents an important nutrient for bone health and thereby for the prevention of osteoporosis. Besides its role as a brick provider for building the organic matrix of skeletal tissues, dietary protein stimulates the production of the anabolic bone trophic factor IGF-I (insulin-like growth factor I). The liver is the main source of circulating IGF-I. During growth, protein undernutrition results in reduced bone mass and strength. Genetic defect impairing the production of IGF-I markedly reduces bone development in both length and width. The serum level of IGF-I markedly increases and then decreases during pubertal maturation in parallel with the change in bone growth and standing height velocity. The impact of physical activity on bone structure and strength is enhanced by increased dietary protein consumption. This synergism between these two important environmental factors can be observed in prepubertal boys, thus modifying the genetically determined bone growth trajectory. In anorexia nervosa, IGF-I is low as well as bone mineral mass. In selective protein undernutrition, there is a resistance to the exogenous bone anabolic effect of IGF-I. A series of animal experiments and human clinical trials underscore the positive effect of increased dietary intake of protein on calcium-phosphate economy and bone balance. On the contrary, the dietary protein-induced acidosis hypothesis of osteoporosis is not supported by several experimental and clinical studies. There is a direct effect of amino acids on the local production of IGF-I by osteoblastic cells. IGF-I is likely the main mediator of the positive effect of parathyroid hormone (PTH) on bone formation, thus explaining the reduction in fragility fractures as observed in PTH-treated postmenopausal women. In elderly women and men, relatively high protein intake protects against spinal and femoral bone loss. In hip fracture patients, isocaloric correction of the relatively low protein intake results in: increased IGF-I serum level, significant attenuation of postsurgical bone loss, improved muscle strength, better recovery, and shortened hospital stay. Thus, dietary protein contributes to bone health from early childhood to old age. An adequate intake of protein should be recommended in the prevention and treatment of osteoporosis.

The Association Between Protein Intake by Source and Osteoporotic Fracture in Older Men: A Prospective Cohort Study

Dietary protein is a potentially modifiable risk factor for fracture. Our objectives were to assess the association of protein intake with incident fracture among older men and whether these associations varied by protein source or by skeletal site. We studied a longitudinal cohort of 5875 men (mean age 73.6 ± 5.9 years) in the Osteoporotic Fractures in Men (MrOS) study. At baseline, protein intake was assessed as percent of total energy intake (TEI) with mean intake from all sources = 16.1%TEI. Incident clinical fractures were confirmed by physician review of medical records. There were 612 major osteoporotic fractures, 806 low-trauma fractures, 270 hip fractures, 193 spine fractures, and 919 non-hip non-spine fractures during 15 years of follow-up. We used Cox proportional hazards models with age, race, height, clinical site, TEI, physical activity, marital status, osteoporosis, gastrointestinal surgery, smoking, oral corticosteroids use, alcohol consumption, and calcium and vitamin D supplements as covariates to compute hazard ratios (HRs) with 95% confidence intervals (CIs), all expressed per unit (SD = 2.9%TEI) increase. Higher protein intake was associated with a decreased risk of major osteoporotic fracture (HR = 0.92; 95% CI, 0.84 to 1.00) with a similar association found for low-trauma fracture. The association between protein and fracture varied by protein source; eg, increased dairy protein and non-dairy animal protein were associated with a decreased risk of hip fracture (HR = 0.80 [95% CI, 0.65 to 0.98] and HR = 0.84 [95% CI, 0.72 to 0.97], respectively), whereas plant-source protein was not (HR = 0.99 [95% CI, 0.78 to 1.24]). The association between protein and fracture varied by fracture site; total protein was associated with a decreased risk of hip fracture (HR = 0.84 [95% CI, 0.73 to 0.95]), but not clinical spine fracture (HR = 1.06 [95% CI, 0.92 to 1.22]). In conclusion, those with high protein intake (particularly high animal protein intake) as a percentage of TEI have a lower risk of major osteoporotic fracture. © 2016 American Society for Bone and Mineral Research.

Effect of Cigarette Smoking on Risk of Hip Fracture in Men: A Meta-Analysis of 14 Prospective Cohort Studies

BACKGROUND

Several observational studies have suggested an association between cigarette smoking and risk of hip fracture. However, no formal systematic review or meta-analysis was performed to summarize this risk in men.

MATERIALS AND METHODS

A search was applied to MEDLINE, EMBASE, and web of science (up to November 1 2016). All prospective cohort studies assessing risk of hip fracture with the factor of cigarette smoking in men without language restriction were reviewed, and qualities of all included studies were assessed using the Newcastle-Ottawa Scale. Two authors independently assessed literatures and extracted information eligibility, and any disagreement was resolved by consensus. Newcastle-Ottawa quality assessment scale was used to evaluate studies' quality in meta-analyses. We calculated the RR with 95% CIs in a random-effects model as well as the fixed-effects model using the metan command in the STATA version 12.0 (StataCorp, USA).

RESULTS

Fourteen prospective cohort studies were eligible for the present analysis. A meta-analysis of 12 prospective studies showed that the relative risk (RR) for current male smoking was 1.47 [95% confidence interval (CI) (1.28-1.66), p = 0.54; I2 = 0%]. Subgroup analyses show study characteristics (including geography region, length of follow-up, size of cohorts and study quality) did not substantially influence these positive associations. Eight studies reported the RRs for former smokers compared with never smokers and the pooled RR was 1.15 [95% CI, (0.97-1.34), (I2 = 0%, p = 0.975)].

CONCLUSIONS

The present meta-analysis of 14 prospective studies suggests that, compared with never smokers, cigarette smoking increases risk of hip fracture in man, specifically in current smokers. However, further larger prospective cohorts with more power or meta-analysis of individual patient data are needed to confirm this association.

Risk Factors for Hip Fracture in Older Men: The Osteoporotic Fractures in Men Study (MrOS)

Almost 30% of hip fractures occur in men; the mortality, morbidity, and loss of independence after hip fractures are greater in men than in women. To comprehensively evaluate risk factors for hip fracture in older men, we performed a prospective study of 5994 men, primarily white, age 65+ years recruited at six US clinical centers. During a mean of 8.6 years of 97% complete follow-up, 178 men experienced incident hip fractures. Information on risk factors including femoral neck bone mineral density (FNBMD) was obtained at the baseline visit. Cox proportional hazards models were used to calculate the hazard ratio (HR) with 95% confidence intervals; Fine and Gray models adjusted for competing mortality risk. Older age (≥75 years), low FNBMD, currently smoking, greater height and height loss since age 25 years, history of fracture, use of tricyclic antidepressants, history of myocardial infarction or angina, hyperthyroidism or Parkinson's disease, lower protein intake, and lower executive function were all associated with an increased hip fracture risk. Further adjustment for competing mortality attenuated HR for smoking, hyperthyroidism, and Parkinson's disease. The incidence rate of hip fracture per 1000 person-years (PY) was greatest in men with FNBMD T-scores <-2.5 (white women reference database) who also had 4+ risk factors, 33.4. Men age ≥80 years with 3+ major comorbidities experienced hip fracture at rates of 14.52 versus 0.88 per 1000 PY in men age <70 years with zero comorbidities. Older men with low FNBMD, multiple risk factors, and multimorbidity have a high risk of hip fracture. Many of these assessments can easily be incorporated into routine clinical practice and may lead to improved risk stratification. © 2016 American Society for Bone and Mineral Research.

The relationship between weight change and risk of hip fracture: meta-analysis of prospective studies

The relationship between weight change and risk of hip fracture is still controversial. We searched PubMed and Embase for studies on weight change and risk of hip fracture. Eight prospective studies were included. The weight loss studies included 85592 participants with 1374 hip fractures, and the weight gain studies included 80768 participants with 732 hip fractures. Weight loss is more likely a risk factor of hip fracture, with an adjusted RR (Relative Risk) (95% CI) of 1.84 (1.45, 2.33). In contrast, weight gain can decrease the risk of hip fracture, with an adjusted RR (95% CI) of 0.73 (0.61, 0.89). Dose-response meta-analysis shows that the risk of hip fracture is an ascending curve, with an increase of weight loss above the line of RR = 1; this trend is consistent with the results of forest plots that examine weight loss and hip fracture. For weight gain and risk of hip fracture, the descending curve below the line of RR = 1; this trend is consistent with the results of forest plots that examine weight gain and hip fracture. Our meta-analysis suggests that weight loss may be a risk factor for hip fracture and that weight gain may be a protective factor for hip fracture.

Calcium intake and risk of fracture: systematic review

OBJECTIVE

To examine the evidence underpinning recommendations to increase calcium intake through dietary sources or calcium supplements to prevent fractures.

DESIGN

Systematic review of randomised controlled trials and observational studies of calcium intake with fracture as an endpoint. Results from trials were pooled with random effects meta-analyses.

DATA SOURCES

Ovid Medline, Embase, PubMed, and references from relevant systematic reviews. Initial searches undertaken in July 2013 and updated in September 2014.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials or cohort studies of dietary calcium, milk or dairy intake, or calcium supplements (with or without vitamin D) with fracture as an outcome and participants aged >50.

RESULTS

There were only two eligible randomised controlled trials of dietary sources of calcium (n=262), but 50 reports from 44 cohort studies of relations between dietary calcium (n=37), milk (n=14), or dairy intake (n=8) and fracture outcomes. For dietary calcium, most studies reported no association between calcium intake and fracture (14/22 for total, 17/21 for hip, 7/8 for vertebral, and 5/7 for forearm fracture). For milk (25/28) and dairy intake (11/13), most studies also reported no associations. In 26 randomised controlled trials, calcium supplements reduced the risk of total fracture (20 studies, n=58,573; relative risk 0.89, 95% confidence interval 0.81 to 0.96) and vertebral fracture (12 studies, n=48,967. 0.86, 0.74 to 1.00) but not hip (13 studies, n=56,648; 0.95, 0.76 to 1.18) or forearm fracture (eight studies, n=51,775; 0.96, 0.85 to 1.09). Funnel plot inspection and Egger's regression suggested bias toward calcium supplements in the published data. In randomised controlled trials at lowest risk of bias (four studies, n=44,505), there was no effect on risk of fracture at any site. Results were similar for trials of calcium monotherapy and co-administered calcium and vitamin D. Only one trial in frail elderly women in residential care with low dietary calcium intake and vitamin D concentrations showed significant reductions in risk of fracture.

CONCLUSIONS

Dietary calcium intake is not associated with risk of fracture, and there is no clinical trial evidence that increasing calcium intake from dietary sources prevents fractures. Evidence that calcium supplements prevent fractures is weak and inconsistent.

DXA bone mineral density in males: retrospective study in real life

BACKGROUND

The diagnosis of osteoporosis in men remains controversial. Aims of this study were to evaluate the major anthropometric determinants of BMD in a large cohort of male Italian subjects and asses the prevalence of subjects with T-score ≤-2.5 by making use of young male or female BMD reference data.

METHOD

1,442 Caucasian men aged over 49 years performing a contemporary spine and hip DXA from January 2012 to June 2013 in an out-patient clinics of northern Italy were analyzed. Single and multiple regression analysis was used for correlating BMD to weight and age. The WHO cut-off value (T-score ≤-2.5) was used for the definition of osteoporosis. To compare the prevalence of osteoporosis by adopting male or female BMD reference values the Fisher's exact test was applied.

RESULTS

Age was significantly correlated with spine and neck BMD. The age-BMD correlation was negative for femoral neck while it was positive for the spine. When BMD values were adjusted for body weight the correlation with femoral neck BMD decreased while the positive regression coefficient between spine BMD and age increased. Spine and femoral BMD (both total hip and neck) were positively correlated with body weight. Using BMD male reference values, only 31.2 % of subjects were identified as osteoporotic at least at one site and this proportion was further reduced using female reference data. Spine was able to identify the greatest number of patients with T-score ≤-2.5 (88.7 %) while at femoral sites the proportion was considerably lower (33.6 and 13.8 % for femoral neck and total hip respectively).

CONCLUSION

In our population, the proportion of male subjects with spine T-score ≤-2.5 is about 25 % of those who were referred for DXA evaluation and this proportion decreases if the female reference data for T-score calculation are chosen. Both spine and femoral neck BMD are strongly and positively related with weight but spine BMD increases with advancing age possibly as a consequence of mechanical and hormonal factors. The capability of spine DXA in identifying men with T-score ≤-2.5 is at its maximum around the fifth decade of life and it decreases later.

The relationship between dietary protein consumption and risk of fracture: a subgroup and dose-response meta-analysis of prospective cohort studies

It is still debate of the relationship between the dietary protein consumption and risk of fracture. We searched Medline and Embase to assess the effects of dietary protein consumption on risk of fracture. Twelve prospective cohort studies with 407,104 participants were included, higher total protein consumption may be decrease 11% risk of hip fractures, with adj. RR of 0.89 (0.82, 0.97), no significant difference was found for total protein and risk of all fractures and limb fracture; for animal protein consumption and risk of all fractures and hip fracture, with adj.RR of 0.79 (032, 1.96) and 1.04 (0.70, 1.54); for vegetable protein consumption and risk of all fractures, hip fracture and limb fractures with adj.RR of 0.77 (0.52, 1.12), 1.00 (0.53, 1.91), and 0.94 (0.40, 2.22), the subgroup of vegetable protein consumption and risk of all fractures of postmenopausal women with adj.RR of 0.78(0.52,1.16). Dose-response meta-analysis the relationship of total/animal/vegetable protein and hip fracture was consistent to the results of forest plot, the line of total protein and hip fracture was below the Y = 1.0 line. This meta-analysis showed that total dietary protein consumption may be decrease the risk of hip fracture, but not for animal or vegetable protein.

Moderate weight loss in obese and overweight men preserves bone quality

BACKGROUND

Weight loss (WL) negatively affects bone mineral density (BMD) in older populations and has specifically been shown in women.

OBJECTIVE

In this prospective controlled trial, we examined variables of bone quality and endocrine changes after intentional WL in men.

DESIGN

Thirty-eight overweight and obese [mean ± SD body mass index (in kg/m²): 31.9 ± 4.4; age: 58 ± 6 y] men were recruited to either WL through caloric restriction or weight maintenance (WM) for 6 mo.

RESULTS

There was a -7.9 ± 4.4% and +0.2 ± 1.6% change in body weight in the WL and WM groups, respectively. There was a greater increase in femoral neck and total body BMD and bone mineral content (BMC) in the WM group than in the WL group (P-interaction effect < 0.05). In contrast, there was a trend for the tibia cortical thickness and area to decrease more in the WM group than in the WL group (P ≤ 0.08). There was a decrease in the periosteal circumference in both groups over time (P < 0.01) and no statistically significant changes in trabecular bone. Circulating total, free, and bioavailable estradiol decreased in the WL group compared with the WM group, and changes were different between groups (P < 0.05). Serum total and bioavailable testosterone increased in both groups (P < 0.01). Serum 25-hydroxyvitamin D increased to a similar extent in both groups (P < 0.05).

CONCLUSIONS

Moderate WL in overweight and obese men did not decrease BMD at any anatomical site or alter cortical and trabecular bone and geometry. Also, despite increased BMD at some sites when maintaining excess body weight, cortical bone showed a trend in the opposite direction.

Alcohol consumption and hip fracture risk

SUMMARY

The present meta-analysis shows that a nonlinear association between alcohol consumption and the risk of hip fracture was observed. Light alcohol consumption was inversely significantly associated with hip fracture risk, whereas heavy alcohol consumption was associated with an elevated hip fracture risk.

INTRODUCTION

Previous studies examining the association between alcohol consumption and the risk of hip fracture have reported conflicting findings. Therefore, we conducted a meta-analysis of prospective cohort studies to assess the association between alcohol consumption and the risk of hip fracture.

METHODS

PubMed and EMBASE were searched for prospective cohort studies on the relationship between alcohol consumption and the risk of hip fractures. Relative risks (RR) with 95% confidence intervals (CI) were derived using random-effects models throughout the whole analysis.

RESULTS

Eighteen prospective cohort studies were included with 3,730,424 participants and 26,168 hip fracture cases. Compared with non-drinkers, the pooled RR of hip fractures for alcohol consumption was 1.03 (95% CI, 0.91-1.15), with high heterogeneity between studies (P<0.001, I2=72.6%). A nonlinear relationship between alcohol consumption and the risk of hip fracture was identified (P nonlinearity=0.003). Compared with non-drinkers, the pooled RRs of hip fractures were 0.88 (95% CI, 0.83-0.89) for light alcohol consumption (0.01-12.5 g/day), 1.00 (95% CI, 0.85-1.14) for moderate alcohol consumption (12.6-49.9 g/day), and 1.71 (95% CI, 1.41-2.01) for heavy alcohol consumption (≥50 g/day).

CONCLUSIONS

There was no evidence of publication bias. In conclusion, a nonlinear association between alcohol consumption and the risk of hip fracture was observed in this meta-analysis. Further, light alcohol consumption was inversely significantly associated with hip fracture risk, whereas heavy alcohol consumption was associated with an elevated hip fracture risk.

Mechanical loading increases detection of estrogen receptor-alpha in osteocytes and osteoblasts despite chronic energy restriction

Estrogen receptor-α (ER-α) is an important mediator of the bone response to mechanical loading. We sought to determine whether restricting dietary energy intake by 40% limits the bone formation rate (BFR) response to mechanical loading (LOAD) by downregulating ER-α-expressing osteocytes, or osteoblasts, or both. Female rats (n = 48, 7 mo old) were randomized to ADLIB-SHAM and ADLIB-LOAD groups fed AIN-93M purified diet ad libitum or to ER40-SHAM and ER40-LOAD groups fed modified AIN-93M with 40% less energy (100% of all other nutrients). After 12 wk, LOAD rats were subjected to a muscle contraction protocol three times every third day. ER40 produced lower proximal tibia bone volume (-22%), trabecular thickness (-14%), and higher trabecular separation (+127%) in SHAM but not LOAD rats. ER40 rats exhibited reductions in mineral apposition rate, but not percent mineralizing surface or BFR. LOAD induced similar relative increases in these kinetic measures of osteoblast activity/recruitment in both diet groups., but absolute values for ER40 LOAD rats were lower vs. ADLIB-LOAD. There were fourfold and eightfold increases in proportion of estrogen receptor-α protein-positive osteoblast and osteocytes, respectively, in LOAD vs. SHAM rats, with no effect of ER40. These data suggest that a brief period of mechanical loading significantly affects estrogen receptor-α in cancellous bone osteoblasts and osteocytes. Chronic energy restriction does result in lower absolute values in indices of osteoblast activity after mechanical loading, but not by a smaller increment relative to unloaded bones; this change is not explained by an associated downregulation of ER-α in osteoblasts or osteocytes.

Prevalence of osteoporosis in men aged 65-75 in a primary care setting. A practice audit after application of the Canadian 2010 guidelines for osteoporosis screening

Current Canadian osteoporosis guidelines recommend routine bone density screening of men at age 65. The purpose of this study is to determine the prevalence of osteoporosis in men aged 65-75 in after application of screening guidelines. All males aged 65-75 years who attended a large primary care clinic were advised of the 2010 Canadian osteoporosis guidelines and advised to obtain a bone density scan at or after their 65th birthday. Those who did not have a bone density scan since their 65th birthday were advised to obtain a scan, unless there was obvious reason not to do so (i.e. known osteoporosis). A record of the results for each patient were kept and tallied to determine the prevalence of osteoporosis. Osteoporosis was defined as a T-score of ≤ -2.5 in either the hip or lumbar spine. Of 574 male subjects in this clinic, between the ages of 65-75, 557 had a bone density scan, either already having done so at the time of being informed of the guidelines or obtaining a scan in the subsequent year after being informed of the guidelines. The prevalence of osteoporosis was 1.6% (9/557, 95% confidence interval 0.8-3.1%) in this sample. The average age of subjects with osteoporosis was 70.5 ± 1.4 years (range 68-75). None of the subjects under 68 years of age were found to have osteoporosis. The prevalence of osteoporosis in unselected male cohorts aged 65 may be too low to justify the routine bone density screening recommended in the 2010 Canadian osteoporosis guidelines.

Physical activity and inactivity and risk of hip fractures in men

OBJECTIVES

We assessed associations between activity and hip fracture in men.

METHODS

The Health Professionals Follow-up Study reported time spent walking, sitting, and in 10 other discretionary activities every 2 years in 35 996 men aged 50 years and older from 1986 to 2010. We calculated hazard ratios (HRs) for risk of hip fracture by amount of activity and sitting in Cox proportional hazards models, adjusted for age, body mass index, smoking, medication use, disease diagnoses, and diet.

RESULTS

Over 24 years, participants reported 490 low-trauma hip fractures. Energy expenditure from all activities was weakly associated with lower risk of fracture. More walking time, with little other exercise, lowered risk by 43% (HR = 0.57; 95% confidence interval [CI] = 0.39, 0.83 for ≥ 4 vs < 1 hours/week), and risk decreased linearly with more frequent walking (P < .001). Brisk (vs leisurely) pace lowered risk by 47%. Sitting lowered risk (HR = 0.62; 95% CI = 0.43, 0.89 for ≥ 50 vs < 20 hours/week), primarily among those who also walked for exercise. We observed no benefit of strenuous activity.

CONCLUSIONS

Walking is a relatively safe and easy activity for hip fracture prevention.

Gender-specific hip fracture risk in community-dwelling and institutionalized seniors age 65 years and older

In this study of acute hip fracture patients, we show that hip fracture rates differ by gender between community-dwelling seniors and seniors residing in nursing homes. While women have a significantly higher rate of hip fracture among the community-dwelling seniors, men have a significantly higher rate among nursing home residents.

INTRODUCTION

Differences in gender-specific hip fracture risk between community-dwelling and institutionalized seniors have not been well established, and seasonality of hip fracture risk has been controversial.

METHODS

We analyzed detailed data from 1,084 hip fracture patients age 65 years and older admitted to one large hospital center in Zurich, Switzerland. In a sensitivity analysis, we extend to de-personalized data from 1,265 hip fracture patients from the other two large hospital centers in Zurich within the same time frame (total n = 2,349). The denominators were person-times accumulated by the Zurich population in the corresponding age/gender/type of dwelling stratum in each calendar season for the period of the study.

RESULTS

In the primary analysis of 1,084 hip fracture patients (mean age 85.1 years; 78% women): Among community-dwelling seniors, the risk of hip fracture was twofold higher among women compared with men (RR = 2.16; 95% CI, 1.74-2.69) independent of age, season, number of comorbidities, and cognitive function; among institutionalized seniors, the risk of hip fracture was 26% lower among women compared with men (RR = 0.77; 95% CI: 0.63-0.95) adjusting for the same confounders. In the sensitivity analysis of 2,349 hip fracture patients (mean age 85.0 years, 76% women), this pattern remained largely unchanged. There is no seasonal swing in hip fracture incidence.

CONCLUSION

We confirm for seniors living in the community that women have a higher risk of hip fracture than men. However, among institutionalized seniors, men are at higher risk for hip fracture.

Association between physical activity and risk of fracture

Prospective studies that have examined the association between physical activity and fracture risks have reported conflicting findings. We performed a meta-analysis to evaluate this association. We searched MEDLINE (1966 to February 1, 2013), EMBASE (1980 to February 1, 2013), and OVID (1950 to February 1, 2013) for prospective cohort studies with no restrictions. Categorical, heterogeneity, publication bias, and subgroup analyses were performed. There were 22 cohort studies with 1,235,768 participants and 14,843 fractures, including 8874 hip, 690 wrist, and 927 vertebral fractures. The pooled relative risk (RR) of total fractures for the highest versus lowest category of physical activity was 0.71 (95% confidence interval [CI], 0.63-0.80). The analysis of fracture subtypes showed a statistically significant inverse relationship between a higher category of physical activity and risk of hip and wrist fracture. The risk of hip or wrist fracture was 39% and 28% lower, respectively, among individuals with the highest category of physical activity than among those with the lowest category (95% CI, 0.54-0.69 and 0.49-0.96, respectively). The association between physical activity and vertebral fracture risk was not statistically related (RR, 0.87; 95% CI, 0.72-1.03). There was no evidence of publication bias. There was a statistically significant inverse association between physical activity and total fracture risk, especially for hip and wrist fractures. Additional subject-level meta-analyses are required for a more reliable assessment of subgroups and types of physical activity.

High physical fitness in young adulthood reduces the risk of fractures later in life in men: a nationwide cohort study

A few studies have indicated that self-reported physical activity is associated with the risk of fractures in middle-aged and elderly men. We investigated whether objectively measured physical fitness in young adulthood was associated with the risk of low-energy fractures later in life in men. Aerobic capacity and isometric muscle strength were measured in 435,445 Swedish men who were conscripted for military service from 1969 to 1978. Incident fractures were searched in national registers. During a median follow-up period of 35 years (range, 11-41 years), 8030 subjects sustained at least one fracture, increasing the risk of death 1.8 times (95% CI, 1.6-2.0) during follow up. When comparing men in the lowest and highest decile of physical fitness, the risk of a fracture was 1.8 times higher (95% CI, 1.6-2.1) and that of hip fracture was 2.7 times higher (95% CI, 1.6-4.7). The risk of fracture was also 1.4 to 1.5 times higher when comparing the extreme deciles of muscle strength (p < 0.001 for all). In a subcohort of 1009 twin pairs, up to 22% of the variation in physical fitness and 27% to 39% of the variation in muscle strength was attributable to environmental factors unique to one twin; eg, physical activity. In conclusion, low aerobic capacity and muscle strength in young adulthood are associated with an increased risk of low-energy fractures later in life.

Nutritional disturbance in acid-base balance and osteoporosis: a hypothesis that disregards the essential homeostatic role of the kidney

The nutritional acid load hypothesis of osteoporosis is reviewed from its historical origin to most recent studies with particular attention to the essential but overlooked role of the kidney in acid–base homeostasis. This hypothesis posits that foods associated with an increased urinary acid excretion are deleterious for the skeleton, leading to osteoporosis and enhanced fragility fracture risk. Conversely, foods generating neutral or alkaline urine would favour bone growth and Ca balance, prevent bone loss and reduce osteoporotic fracture risk. This theory currently influences nutrition research, dietary recommendations and the marketing of alkaline salt products or medications meant to optimise bone health and prevent osteoporosis. It stemmed from classic investigations in patients suffering from chronic kidney diseases (CKD) conducted in the 1960s. Accordingly, in CKD, bone mineral mobilisation would serve as a buffer system to acid accumulation. This interpretation was later questioned on both theoretical and experimental grounds. Notwithstanding this questionable role of bone mineral in systemic acid–base equilibrium, not only in CKD but even more in the absence of renal impairment, it is postulated that, in healthy individuals, foods, particularly those containing animal protein, would induce ‘latent’ acidosis and result, in the long run, in osteoporosis. Thus, a questionable interpretation of data from patients with CKD and the subsequent extrapolation to healthy subjects converted a hypothesis into nutritional recommendations for the prevention of osteoporosis. In a historical perspective, the present review dissects out speculation from experimental facts and emphasises the essential role of the renal tubule in systemic acid–base and Ca homeostasis.

Pancreas-kidney transplantation is associated with reduced fracture risk compared with kidney-alone transplantation in men with type 1 diabetes

Both type 1 diabetes mellitus and end stage renal disease are associated with increased fracture risk, likely due to metabolic abnormalities that reduce bone strength. Simultaneous pancreas-kidney transplantation is a treatment of choice for patients with both disorders, yet the effects of simultaneous pancreas-kidney versus kidney transplantation alone on post-transplantation fracture risk are unknown. From the United States Renal Data System we identified 11, 145 adults with type 1 diabetes undergoing transplantation of whom 4,933 had a simultaneous pancreas-kidney while 6, 212 had a kidney alone transplant between 2000 and 2006. Post-transplantation fractures resulting in hospitalization were identified from discharge codes. Time to first fracture was modeled and propensity score adjustment was used to balance covariates between groups. Fractures occurred in significantly fewer (4.7%) of pancreas-kidney compared to kidney-alone transplant (5.9%) cohorts. After gender stratification and adjustment for fracture covariates, pancreas-kidney transplantation was associated with a significant 31% reduction in fracture risk in men (hazard risk 0.69). Older age, white race, prior dialysis and pre transplantation fracture were also associated with increased fracture risk. Prospective studies are needed to determine the gender-specific mechanisms by which pancreas-kidney transplantation reduces fracture risk in men.

Bone metabolism in obesity and weight loss

Excess body weight due to obesity has traditionally been considered to have a positive effect on bone; however, more recent findings suggest that bone quality is compromised. Both obesity and caloric restriction increase fracture risk and are regulated by endocrine factors and cytokines that have direct and indirect effects on bone and calcium absorption. Weight reduction will decrease bone mass and mineral density, but this varies by the individual's age, gender, and adiposity. Dietary modifications, exercise, and medications have been shown to attenuate the bone loss associated with weight reduction. Future obesity and weight loss trials would benefit from assessment of key hormones, adipokine and gut peptides that regulate calcium absorption, and bone mineral density and quality by using sensitive techniques in high-risk populations.

Reduced fracture risk with early corticosteroid withdrawal after kidney transplant

Corticosteroid use after kidney transplantation results in severe bone loss and high fracture risk. Although corticosteroid withdrawal in the early posttransplant period has been associated with bone mass preservation, there are no published data regarding corticosteroid withdrawal and risk of fracture. We hypothesized lower fracture incidence in patients discharged from the hospital without than with corticosteroids after transplantation. From the United States Renal Data System (USRDS), 77, 430 patients were identified who received their first kidney transplant from 2000 to 2006. Fracture incidence leading to hospitalization was determined from 2000 to 2007; discharge immunosuppression was determined from United Networks for Organ Sharing forms. Time-to-event analyses were used to evaluate fracture risk. Median (interquartile range) follow-up was 1448 (808-2061) days. There were 2395 fractures during follow-up; fracture incidence rates were 0.008 and 0.0058 per patient-year for recipients discharged with and without corticosteroid, respectively. Corticosteroid withdrawal was associated with a 31% fracture risk reduction (HR 0.69; 95% CI 0.59-0.81). Fractures associated with hospitalization are significantly lower with regimens that withdraw corticosteroid. As this study likely underestimates overall fracture incidence, prospective studies are needed to determine differences in overall fracture risk in patients managed with and without corticosteroids after kidney transplantation.

Height loss predicts subsequent hip fracture in men and women of the Framingham Study

Although height is a risk factor for osteoporotic fracture, current risk assessments do not consider height loss. Height loss may be a simple measurement that clinicians could use to predict fracture or need for further testing. The objective was to examine height loss and subsequent hip fracture, evaluating both long-term adult height loss and recent height loss. Prospective cohort of 3081 adults from the Framingham Heart Study. Height was measured biennially since 1948, and cohort followed for hip fracture through 2005. Adult height loss from middle-age years across 24 years and recent height loss in elderly years were considered. Cox proportional hazard regression was used to estimate association between height loss and risk of hip fracture. Of 1297 men and 1784 women, mean baseline age was 66 years (SD = 7.8). Average height loss for men was 1.06 inches (0.76), and for women was 1.12 inches (0.84). A total of 11% of men and 15% of women lost ≥2 inches of height. Mean follow-up was 17 years, during which 71 men and 278 women had incident hip fractures. For each 1-inch of height loss, hazard ratio (HR) = 1.4 in men [95% confidence interval (CI): 1.00, 1.99], and 1.04 in women (95% CI: 0.88, 1.23). Men and women who lost ≥2 inches of height had increased fracture risk (compared with 0 to <2 inches) of borderline significance: men HR = 1.8, 95% CI: 0.86, 3.61; women HR = 1.3, 95% CI: 0.90, 1.76. Recent height loss in elders significantly increased the risk of hip fracture, 54% in men and 21% in women (95% CI: 1.14, 2.09; 1.03, 1.42, respectively). Adult height loss predicted hip fracture risk in men in our study. Recent height loss in elderly men and women predicted risk of hip fracture.

Reduced fracture risk with early corticosteroid withdrawal after kidney transplant

Corticosteroid use after kidney transplantation results in severe bone loss and high fracture risk. Although corticosteroid withdrawal in the early posttransplant period has been associated with bone mass preservation, there are no published data regarding corticosteroid withdrawal and risk of fracture. We hypothesized lower fracture incidence in patients discharged from the hospital without than with corticosteroids after transplantation. From the United States Renal Data System (USRDS), 77, 430 patients were identified who received their first kidney transplant from 2000 to 2006. Fracture incidence leading to hospitalization was determined from 2000 to 2007; discharge immunosuppression was determined from United Networks for Organ Sharing forms. Time-to-event analyses were used to evaluate fracture risk. Median (interquartile range) follow-up was 1448 (808-2061) days. There were 2395 fractures during follow-up; fracture incidence rates were 0.008 and 0.0058 per patient-year for recipients discharged with and without corticosteroid, respectively. Corticosteroid withdrawal was associated with a 31% fracture risk reduction (HR 0.69; 95% CI 0.59-0.81). Fractures associated with hospitalization are significantly lower with regimens that withdraw corticosteroid. As this study likely underestimates overall fracture incidence, prospective studies are needed to determine differences in overall fracture risk in patients managed with and without corticosteroids after kidney transplantation.

BMI change is associated with fracture incidence, but only in non-smokers. The Tromsø Study

Few studies have examined the association between body mass index (BMI) change and fracture in a general population. We observed that BMI loss was associated with increased fracture risk in non-smoking men and women, but not in smokers. BMI gain was associated with decreased fracture risk in women.

INTRODUCTION

Weight loss has been associated with increased fracture risk, but few studies have included men. The aim of this study was to examine the association between BMI change and fracture risk in both genders.

METHODS

A population-based cohort study in Tromsø, Norway, of adults, aged 20 to 54 years in 1979, who participated in two or three health surveys in 1979-1980, 1986-1987, and 1994-1995. Weight and height were measured at each survey. Information about lifestyle was obtained by questionnaires. Poisson regression was used to estimate incidence rates and Cox proportional hazards regression model to assess the association between fracture risk and BMI change. Fractional polynomials were used to accommodate non-linear associations.

RESULTS

A total of 5,549 men and 5,428 women participated. There were 1,135 fractures during 10 years of follow-up. Reduction in BMI was associated with increased non-vertebral fracture risk in non-smokers, but not in smokers. The hazard ratio in male and female non-smokers per 10-year BMI decrease of 2 kg/m(2) versus a BMI increase of 1 kg/m(2) was 1.79 (95% confidence interval (CI), 1.17-2.75) and 1.60 (95% CI, 1.28-1.99), respectively. The association was not significantly modified by initial BMI or age or by exclusion of subjects with cardiovascular diseases, diabetes, or cancer. In female non-smokers, weight gain was inversely associated with fracture risk.

CONCLUSIONS

In a general Norwegian population, reduction in BMI was significantly associated with increased fracture risk in male and female non-smokers, but not in smokers. These findings could not be explained by preexisting disease.

Quantitative ultrasound and radiographic absorptiometry are associated with vertebral deformity in Japanese Women: the Hizen-Oshima study

We evaluated the ability of heel quantitative ultrasound (QUS) and metacarpal radiographic absorptiometry (RA) to identify subjects with vertebral deformities in Japanese women aged ≥40. Both QUS and RA were associated with vertebral deformities, and the estimated prevalence at each T-score widely varied with age.

INTRODUCTION

Heel QUS and metacarpal RA have been used for screening patients to evaluate risk of osteoporotic fractures. The aim of this study was to evaluate the ability of QUS and RA to identify women with vertebral deformities in 570 Japanese women aged ≥40, and to estimate the prevalence of vertebral deformity at each T-score.

METHODS

Calcaneal QUS and metacarpal RA were performed. Radiographic vertebral deformities were assessed by quantitative morphometry, defined as vertebral heights more than 3 SD below the normal mean.

RESULTS

The receiver operating characteristic analysis showed that both calcaneal stiffness index (SI) and metacarpal bone mineral density (BMD) were associated with vertebral deformities. Using the T-score of -2.5 as a cutoff value, the specificity and sensitivity for identifying individuals with vertebral deformities was 65% and 83% for calcaneal SI, and 40% and 88% for metacarpal BMD, respectively. The prevalence of vertebral deformity was estimated using age-adjusted logistic regression models. Women with calcaneal SI T-score of -2.5 had a 2% estimated probability of vertebral deformity at age 40, and 22% at age 80. For metacarpal BMD T-score of -2.5, estimated probability was less than 1% at age 40, and 27% at age 80.

CONCLUSION

Both calcaneal SI and metacarpal BMD were associated with prevalence of vertebral deformity. Furthermore, the prevalence widely varied with age at any given bone value.

Nicotinic modulation of gene expression in osteoblast cells, MG-63

Exposure to nicotine causes a broad range of biological and molecular effects on osteoblasts which are known to play a crucial role in bone metabolism and fracture healing. Most effects of nicotine on the osteoblasts are long-term adaptations at the genomic level. To identify the nicotine-regulated genes, the Agilent technologies whole human genome gene expression microarray was performed on RNA samples from osteoblast-like cells, MG-63, exposed to 100 μM nicotine. Repeat and cross-controlled microarray analyses revealed 842 genes whose expression was consistently altered at P<0.05 level following nicotine treatment. Gene ontology analysis suggested effects of nicotine on various biological and cellular processes which were associated with survival, proliferation, differentiation and apoptosis processes within the cell. Quantitative real-time reverse transcriptase PCR analysis confirmed altered expression in 7 out of 9 genes tested. The identified genes tested in the current study support our previous report that nicotine regulates the expression of genes that promote osteoblast proliferation and/or anti-apoptosis processes. Furthermore, using nicotinic acetylcholine receptor antagonists blocked the majority of the nicotine effects, indicating that these changes are dependent on nAChR activation. These results established a novel and consistent nicotinic activation of nAChR in osteoblast cells which has a broad role affecting cellular physiology through modulation of gene expression.