# data[].attributes.headline
Pradeep Yarra   Citation: Eleni A, Panagiotis P. A systematic review and meta-analysis of vitamin D and calcium in preventing osteoporotic fractures. Clin Rheumatol. 2020;39(12):3571-3579. doi:10.1007/s10067-020-05122-3 Question 1:   Why is this study important?Osteoporosis is a bone condition defined by reduced bone mass and microarchitectural deterioration of bone tissue. Osteoporotic fractures comprise a significant cause of mortality and morbidity in developed countries. A person over the age of 50 faces a lifetime risk for osteoporotic fracture, which varies between 40 and 50% for women and at 13 and 22% for men.  Calcium in combination with vitamin D has demonstrated effectiveness in preventing osteoporotic bone loss and fractures, although discrepancies were reported across clinical trials. This review tries to address current body of evidence regarding the impact of combination of calcium and vitamin D in the reduction of osteoporotic fractures.         Identify one key finding of this study and describe how it relates to nutritional sciences          Primary outcomes of the study are1)	The combination of vitamin D and calcium demonstrated a significantly beneficial effect RR: 0.61 [CI 95% 0.4–0.92] on reduction of risk of osteoporotic fractures.2)	The magnitude of this effect was prominent in elderly, patients with low body weight and increased fracture risk. Moreover, institutionalized patients and patients with low dietary calcium intake demonstrated greater risk reduction.3)	Regarding adverse events with the combination, In the women’s health initiative trial, a statistically significant increase in urinary and renal tract stones was reported. The majority of adverse events included mild gastrointestinal irritation and renal calculi.4)	Study also shows that there is inconclusive data pertinent to the relationship of cardiovascular risk with the combination of calcium and vitamin DWhat are the clinical implications of this study? Combination of Vitamin D and Calcium is vital, specially at-risk populations like woman and elderly people to reduce the risk of osteoporotic fractures. Based on the included trials, conclusion is that the minimum effective dose of calcium is 1200 mg while vitamin D should not be below 800 IU. A standardized approach by nutritionists in assessing the risk and guiding the physicians will help these at-risk populations.  

# data[].attributes.subject
Pradeep Yarra   Citation: Eleni A, Panagiotis P. A systematic review and meta-analysis of vitamin D and calcium in preventing osteoporotic fractures. Clin Rheumatol. 2020;39(12):3571-3579. doi:10.1007/s10067-020-05122-3 Question 1:   Why is this study important?Osteoporosis is a bone condition defined by reduced bone mass and microarchitectural deterioration of bone tissue. Osteoporotic fractures comprise a significant cause of mortality and morbidity in developed countries. A person over the age of 50 faces a lifetime risk for osteoporotic fracture, which varies between 40 and 50% for women and at 13 and 22% for men.  Calcium in combination with vitamin D has demonstrated effectiveness in preventing osteoporotic bone loss and fractures, although discrepancies were reported across clinical trials. This review tries to address current body of evidence regarding the impact of combination of calcium and vitamin D in the reduction of osteoporotic fractures.         Identify one key finding of this study and describe how it relates to nutritional sciences          Primary outcomes of the study are1)	The combination of vitamin D and calcium demonstrated a significantly beneficial effect RR: 0.61 [CI 95% 0.4–0.92] on reduction of risk of osteoporotic fractures.2)	The magnitude of this effect was prominent in elderly, patients with low body weight and increased fracture risk. Moreover, institutionalized patients and patients with low dietary calcium intake demonstrated greater risk reduction.3)	Regarding adverse events with the combination, In the women’s health initiative trial, a statistically significant increase in urinary and renal tract stones was reported. The majority of adverse events included mild gastrointestinal irritation and renal calculi.4)	Study also shows that there is inconclusive data pertinent to the relationship of cardiovascular risk with the combination of calcium and vitamin DWhat are the clinical implications of this study? Combination of Vitamin D and Calcium is vital, specially at-risk populations like woman and elderly people to reduce the risk of osteoporotic fractures. Based on the included trials, conclusion is that the minimum effective dose of calcium is 1200 mg while vitamin D should not be below 800 IU. A standardized approach by nutritionists in assessing the risk and guiding the physicians will help these at-risk populations.  

# data[].attributes.body
Citation: Cao JJ, Gregoire BR, Zeng H. Selenium deficiency decreases antioxidative capacity and is detrimental to bone microarchitecture in mice. J Nutr. 2012 Aug;142(8):1526-31. doi: 10.3945/jn.111.157040. Epub 2012 Jun 27. PMID: 22739365.
Selenium is an essential trace mineral and also regulates redox-oxygen reaction in cells. Selenium deficiency would cause growth retardation and low bone mineral density. Therefore the researchers would know about the mechanism associates with selenium deficiency status in the animal models.
The researchers utilize thirty-three male C57BL/6J mice to divide three groups: selenium deficiency group, selenomethionine group, pinto bean group in the measurement of mRNA levels, biochemical measurements. One of the key findings is selenium concentrations of C-reactive protein (CRP), tartrate-resistant acid phosphatase (TRAP), parathyroid hormone (PTH), and osteoprotegerin (OPG) in serum. The selenium deficiency group is greater than the other two groups in CRP, TRAP, and PTH. Selenium would decrease the inflammatory stress in the CRP concentration of serum. The selenium deficiency would induce osteoclast activities and bone resorption in a low serum TRAP and PTH concentration.
In the clinic, the study uses pinto beans in animal models’ diet, and it also is similar to the outcomes of the selenomethionine group. It is a choice to consume the patients with selenium deficiency.

# data[].attributes.body
Coe F. Idiopathic Hypercalciuria (IH). Kidney Stones. University of Chicago. https://kidneystones.uchicago.edu/idiopathic-hypercalciuria-ih-general-facts. Accessed on April 27, 2021.

Idiopathic hypercalciuria (IH) is associated with kidney stones and bone diseases like osteoporosis. To treat it, diets of high calcium, low sodium, moderate protein, and no refined sugar is recommended.
This lecture is important because it clarifies the relationship between urine calcium and osteoporosis and explains how diets work to prevent both kidney stones and osteoporosis which look like opposite sides of diseases.
Also, IH is caused by a genetic factor, heritable in a family.
According to studies, rate of calcium absorption from diet is 18% in normal people while 30% in people with IH. And calcium excreted by urine from calcium stone formers is very high: Higher than calcium intake from foods which means the calcium comes from bone.
If people cut calcium consumption from diets to avoid stone formation, it has a negative effect. Diet intervention is very critical in IH treatment.
When compared 4 cases of diet combinations, (1) Calcium high & Sodium high, (2) CA high & NA low, (3) CA low & NA high and (4) CA low and NA low, only (2) CA high & NA low showed positive effect. Calcium from diet has to be sufficient (1000 to 1200 mg/d) along with reducing sodium intake. (No benefit if sodium is still high.)
Since I was wondering if patients with kidney stones have to cut diet calcium even though it will increase their risk of osteoporosis, this recommendation of high calcium intake was a big surprise.

# data[].attributes.headline
Wendy RameyAguilera-Barreiro M de los A, Rivera-Márquez JA, Trujillo-Arriaga HM, Tamayo y Orozco JA, Barreira-Mercado E, Rodríguez-García ME. Intake of dehydrated nopal (Opuntia ficus indica) improves bone mineral density and calciuria in adult Mexican women. Food & Nutrition Research. 2013;57(1):19106. doi:10.3402/fnr.v57i0.19106Sufficient calcium intake is vital for bone maintenance and metabolism. Developing countries like Mexico have a lower than recommended dietary intake due to the high costs of dairy products. Researchers were interested in availability of calcium from vegetable sources to the body. Since nopal (PricklyPear) is a widely used vegetable in the Mexican diet because it is inexpensive, it was a relevant vegetable to study. Nopal has different contents of calcium and calcium oxalate depending on the age of the harvested pads of the plant and this may be important in maintenance of bone mass in Mexican women who can not afford high dairy intake. This study found that intake of the mature nopal (with a higher calcium content and lower calcium oxalated content) was better at preventing decline in BMD in women older than 50 years. The consumption of nopal harvested at young plant age (containing significantly less calcium with higher content of oxalated calcium) and was associated with a decline in BMD. Increased vegetable derived calcium intake preserves bone mass even in individuals with decreased dairy intake.This study highlights the importance of foods other than dairy that may provide useful calcium. Vegetable derived calcium is less expensive than dairy products and may be just as good as dairy derived calcium and maybe better than supplement derived calcium.

# data[].attributes.subject
Wendy RameyAguilera-Barreiro M de los A, Rivera-Márquez JA, Trujillo-Arriaga HM, Tamayo y Orozco JA, Barreira-Mercado E, Rodríguez-García ME. Intake of dehydrated nopal (Opuntia ficus indica) improves bone mineral density and calciuria in adult Mexican women. Food & Nutrition Research. 2013;57(1):19106. doi:10.3402/fnr.v57i0.19106Sufficient calcium intake is vital for bone maintenance and metabolism. Developing countries like Mexico have a lower than recommended dietary intake due to the high costs of dairy products. Researchers were interested in availability of calcium from vegetable sources to the body. Since nopal (PricklyPear) is a widely used vegetable in the Mexican diet because it is inexpensive, it was a relevant vegetable to study. Nopal has different contents of calcium and calcium oxalate depending on the age of the harvested pads of the plant and this may be important in maintenance of bone mass in Mexican women who can not afford high dairy intake. This study found that intake of the mature nopal (with a higher calcium content and lower calcium oxalated content) was better at preventing decline in BMD in women older than 50 years. The consumption of nopal harvested at young plant age (containing significantly less calcium with higher content of oxalated calcium) and was associated with a decline in BMD. Increased vegetable derived calcium intake preserves bone mass even in individuals with decreased dairy intake.This study highlights the importance of foods other than dairy that may provide useful calcium. Vegetable derived calcium is less expensive than dairy products and may be just as good as dairy derived calcium and maybe better than supplement derived calcium.

# data[].attributes.body
Citation: Wiesner A, Szuta M, Galanty A, Paśko P. Optimal Dosing Regimen of Osteoporosis Drugs in Relation to Food Intake as the Key for the Enhancement of the Treatment Effectiveness—A Concise Literature Review. Foods. 2021; 10(4):720. https://doi.org/10.3390/foods10040720

Bisphosphonates are one of the important groups of medication taken orally for osteoporosis treatment. This review paper is important because the authors examine the effects of food, beverages, and dietary supplements that are consumed during treatment with bisphosphonates and the possible effects on pharmacokinetics and pharmacodynamics.

They examined the drug Risedronate and found that, when taking the immediate release form of the drug, it was best to take it one hour before breakfast. This is because taking it with a meal further increases the already low oral bioavailability. However, in a study conducted with delayed-release Risedronate taken directly after a meal, they found it had the same oral bioavailability as the immediate release tablet taken 30 minutes before breakfast.

Since one in three women and one in five men in their 50’s is expected to experience an osteoporotic fracture in their lifetime, learning how drugs commonly used to treat osteoporosis interact with food, beverages, and supplements is very clinically relevant to their treatment.

# data[].attributes.body
Citation: Savanelli, M.C., Barrea, L., Macchia, P.E. et al. Preliminary results demonstrating the impact of Mediterranean diet on bone health. J Transl Med 15, 81 (2017). https://doi.org/10.1186/s12967-017-1184-x

Nutrition is an essential component of bone health and considered a core measure to maintain optimal bone mass. Mediterranean diet (MD) has shown to prevent bone disease. This study focuses on investigating the relationship between bone health status and adherence to the MD. 418 healthy people were recruited to underwent clinical assessment, calcaneal quantitative ultrasound (QUS) scanner and PREDIMED questionaire.

It has shown that there is a positive correlation between bone health status and adherence to MD suggesting that a high adherence to MD promotes bone health. Prevalence of osteoporosis and osteopenia were 7.7 and 46% respectively globally. Adherence to MD has been associated with higher BMD. A higher T-score was significantly associated with a higher consumption of extra virgin olive oil (EVOO), vegetables, fruits, legumes, fish, and negatively associated with consumption of red meat. Among the specific food items included in MD, EVOO, fish, fruits, are the best predictors of T-score.

Given beneficial effects of MD on bone health, this can represent a modifiable environmental factor for osteoporosis prevention. The results suggested that dietary approach, such as MD, may have a significant preventive and therapeutic role in the bone disease.

# data[].attributes.body
Reid, Ian R, et al. “Effects of Vitamin D Supplements on Bone Mineral Density: a Systematic Review and Meta-Analysis.” The Lancet, vol. 383, no. 9912, 2014, pp. 146–155., doi:10.1016/s0140-6736(13)61647-5.

Importance:

This systemic review is important because it investigates the importance of vitamin d supplementation in bone density and osteoporosis. Vitamin D along with calcium have long been regarded as very important dietary factors contributing to a decrease in bone density and osteoporosis. A deficiency in vitamin D in the diet is a major risk factor for osteoporosis and increasing endogenous vitamin d through supplementation may be a way to help patients increase bone density and decrease osteoporosis risk.

Key Findings:

This review analyzed thousands of different studies and looked at vitamin D supplementation effect on bone density throughout several different regions of the body. The meta-analysis did find a slight increase in bone density in the femoral neck bone but was not attributed to vitamin d but more so an artifact chance finding. Based on the results from this systemic review and meta-analysis it can be concluded that vitamin d supplementation as a stand-alone preventative measure without and dietary vitamin d deficiency is not worthwhile and does not produce any effect on bone density. From a nutrition perspective this shows that maintain a healthy balanced diet is the best medicine for prevention and/or risk. Supplements especially from over-the-counter corner nutrition stores are often not regulated by the FDA and therefore we have no way to be sure of what’s in them. Getting micronutrients through diet is the best way to be sure what and how much we are ingesting.

Clinical Implication:

In the clinic this meta-analysis proves the importance of dietary intervention and education. This research found that supplementation did not provide any benefit when there was no dietary fail or previous risk for vitamin d deficiencies. If we can get patients on board with consuming a balanced diet and not turning to supplements to get micronutrients it is the most beneficial and natural way to be sure we know what we are ingesting. As I mentioned above, supplementation is on the rise and there is supplement stores out there that are more driven to make sales than they are to help people.

# data[].attributes.body
Hooshmand, S., Kern, M., Metti, D., Shamloufard, P., Chai, S. C., Johnson, S. A., Payton, M. E., & Arjmandi, B. H. (2016). The effect of two doses of dried plum on bone density and bone biomarkers in osteopenic postmenopausal women: a randomized, controlled trial. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 27(7), 2271–2279. https://doi.org/10.1007/s00198-016-3524-8

This study is important because it looks at the effect dried plum has on bone density in osteopenic postmenopausal women. The researchers recruited 48 osteopenic postmenopausal women to a randomized controlled trial. The women were split into three groups for the study. The first group consumed 50 grams of dried plum daily for six months. The second group consumed 100 grams of dried plum daily for six months. The third group consumed a control diet that did not include dried plums.

One key finding in this study is that the groups with dried plums seemed to have less loss of total body bone mineral density compared to the control group. However, there were no significant differences between the 50g of dried plums daily group and the 100g of dried plums daily group. These findings suggest that consuming 50g of dried plums daily may be just as effective as consuming 100g of dried plums daily to prevent bone loss.

This study is important clinically because it shows that a small addition in our diet can influence bone health. I did not know the effect dried plums had on bone health before reading this article, so this topic was really new and interesting to me. I found several articles that suggested that dried plums could inhibit bone resorption and promote bone formation and I think that this is an interesting concept to keep in mind when discussing diet with osteopenic patients.

# data[].attributes.body
Havens, P. L., Stephensen, C. B., Van Loan, M. D., Schuster, G.U., Woodhouse, L. R., Flynn, P. M., Gordon, C. M., Pan, C. G., Rutledge, B., Harris, D. R., Price, G., Baker, A., Meyer, W. A., 3rd, Wilson, C. M., Hazra, R., Kapogiannis, B. G., Mulligan, K., & Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) 109 Study Team (2018). Vitamin D3 Supplementation Increases Spine Bone Mineral Density in Adolescents and Young Adults With Human Immunodeficiency Virus Infection Being Treated With Tenofovir Disoproxil Fumarate: A Randomized, Placebo-Controlled Trial. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 66(2), 220–228. https://doi.org/10.1093/cid/cix753

- I found this study such an important study because the researchers wanted to treat a drug, Tenofovir Disoproxil Fumarate (TDF), side effects on bone mineral density for patients with Human Immunodeficiency Virus (HIV) infection. Also, I like the study’s design, a randomized, double-blind, placebo-controlled trial, which is considered one of the best study designs.

- The most key finding of this study is that adolescents and young adults with HIV being chronically treated with TDF, vitamin D3 supplementation, receive vitamin D3, 50000 IU, improved bone mineral density within 24 weeks of initiation and continued for 48 weeks compared to placebo.

- The most clinical nutrition implication of this study is that testing serum vitamin D before and during the initiation of TDF treatment is critical for patients with HIV infection. Moreover, encouraging exposure to sunlight is important in addition to considering a vitamin D supplement as the first line of vitamin D-induced deficiency.

Alyaa Zagzoog

# data[].attributes.body
Hello James, thank you for sharing this study's summary. From a practical perspective, I agree that many renal patients, especially those with hemodialysis experience poor tolerable calcium supplementation. I would add it's important to consider nutrient nutrient interaction and drug nutrient interaction when consuming calcium rich meals and/ or calcium supplement. Alyaa Zagzoog

# data[].attributes.body
I tract but some more severe side effects include calcium impact on the kidneys, especially in terms of renal stones.

# data[].attributes.body
vitamin D supplementation and their role on the skeletomuscular system

# data[].attributes.body
Elizabeth Smith
Elizabeth Smith
Citation:  A M El Badri S, Salawu A, Brown JE. Bone Health in Men with Prostate Cancer: Review Article. Curr Osteoporos Rep. 2019 Dec;17(6):527-537. doi: 10.1007/s11914-019-00536-8. PMID: 31760582; PMCID: PMC6944652.

Why is this study significant? 
Cancer treatment induced bone loss is a well recognized entity but  greater awareness of the associated risks and  indicated treatments is needed.  
Patients with prostate cancer are living longer, with  survival rates increasing and mortality decreasing significantly.  This population is likely to have higher incidence of baseline osteopenia and osteoporosis even prior to diagnosis  or initiation of treatment  just due to the demographic of this group.    Androgen deprivation therapy is a cornerstone of treatment for advanced disease ( i.e metastatic or non surgical candidates) . Long-term ADT has well-recognized negative impact on bone mineral density and increases fracture risk.

Key Finding:  
 In observation of  50,613 patients with prostate cancer, of those who survived for at least 5 years after diagnosis, data showed that 19.4% of those who received ADT sustained a fracture, compared to 12.6% of those who did not receive ADT .  This negative impact on bone health also applies to other prostate cancer treatments including chemotherapy, glucocorticoids and novel hormone manipulation agents. These are used, in addition to ADT, for the treatment of advanced prostate cancer, which involves bone in an estimated 90% of cases with significant potential for morbidity and skeletal-related events (SREs) such as pathological fractures.  

Clinical Implication: 
Patients often lack knowledge about the risk of CTIBL and means for prevention and treatment.  Based on the findings of this study, there also appears to be a discrepancy between what physicians assume that patients know and what the patients’ perception is about their bone health . Despite knowledge about bone health, there appears to be inadequate adherence to guidelines for screening, monitoring and treatment of CTIBL on the part of  health care providers.   This is an opportunity for specialists as well as  primary care providers to increase implementation of the guidelines and tools that we have to address  and reduce  a co-morbid condition associated with  cancer treatment that has huge cost saving  potential as well as  improved quality of life for patients. 




tick
GRADE
1 comment
Avatar of Sara Police
Sara Police 1h
Thanks for sharing this article, Elizabeth, this is interesting! Are you familiar with some of the guidelines for screening, monitoring, or treatment of CTIBL? If so, what are the nutritional components? Thanks! SP
Your avatar
Add comment
Kemppainen, T, Kröger, H,
Kemppainen, T, Kröger, H, Janatuinen, E, Arnala, I, Kosma, V.-M, Pikkarainen, P, . . . Uusitupa, M. (1999). Osteoporosis in adult patients with celiac disease. Bone (New York, N.Y.), 24(3), 249-255.  
tick
GRADE
Your avatar
Add comment
James Lewis
James Lewis
Citation: Harvey, N.C., Biver, E., Kaufman, JM. et al. The role of calcium supplementation in healthy musculoskeletal ageing. Osteoporos Int28, 447–462 (2017). https://doi-org.ezproxy.uky.edu/10.1007/s00198-016-3773-6  

Why is this study significant?

This study is significant because it analyzed the literature of the time to come to a consensus on the efficacy of calcium and vitamin D supplementation and their role on the skeletomuscular system. It is important to note that this paper was published in 2016 and there is still a debate on the benefits of calcium supplementation.

 One key finding from this study and how does it relate to nutritional sciences

This paper did a really good job combining evidence from different sources and I appreciated the big takeaways from author’s analysis. One should be mindful of their bodies needs when considering calcium supplementation. The researchers concluded that vitamin supplementation can have side effects. Most of these are concerned with the GI tract but some more severe side effects include calcium impact on the kidneys, especially in terms of renal stones. They have also concluded that the link between calcium supplementation and cardiovascular events are not well supported by the literature. I think some of these off-target effects are due to the variety of roles that calcium plays in the body, with bone health and maintenance being just one of them. 

Calcium can be found in a variety of dietary sources and adequate levels can be absorbed in the body with a well-balanced diet. 

Clinical implication

With the above information in mind, the researcher’s have also concluded that calcium and vitamin D supplementation together is beneficial for patients who are at high risk of insufficiency and for those receiving treatment for osteoporosis. It is important for providers to be able to recognize people who are risk and encourage supplementation when appropriate.  

tick
GRADE
2 comments
Avatar of 
Anonymous 1d
Elizabeth Smith- Hi James. I really like this post and the attention this study gives to the variability of impact patients get when using calcium supplements. I frequently see adult patients who present with their first urinary stone after initiating a calcium supplement. Often, the dosing has not been specifically discussed with them (other than on the OTC package), resulting in intake greater than need and leading to stone formation.
Avatar of Sara Police
Sara Police 1m
Thank you, Elizabeth, for sharing that! This implies that the OTC packaging is non-specific.
Your avatar
Add comment
Renee LaFaive
Renee LaFaive
Citation: Skrzypczak,D.;Ratajczak, A.E.; Szymczak-Tomczak, A.; Dobrowolska, A.; Eder, P.; Krela-Kaz ́mierczak, I. A Vicious Cycle of Osteosarcopenia in Inflammatory Bowel Diseases—Aetiology, Clinical Implications and Therapeutic Perspectives. Nutrients 2021, 13, 293.  https://doi.org/10.3390/nu13020293 

Why is this study important:  This review interlinks IBD (Inflammatory Bowel Disease) and Osteosarcopenia (a disorder of simultaneous sarcopenia and osteoporosis) in a discussion regarding the risk of Osteosarcopenia in IBD patients and the importance of providing nutritional considerations and treatment of both disorders. 

Key findings and nutritional science: Osteosarcopenia is the collective disorder of both muscle and bone tissue loss, which are being considered more interrelated due to both hormonal pathways as well as mechanical interactions between muscle and bone. 

Patients with IBD often present with Osteosarcopenia due to various risk factors associated with IBD such as malnutrition, malabsorption, decreased physical activity, chronic inflammation among others (refer to Tables 2, 3).  This review noted that more than 50% of patients with IBD have an abnormal lumbar BMD (Bone Mineral Density).  Low BMI is also associated with a low BMD and in IBD patients, BMI is often “significantly” lower than in healthy individuals.  

Some nutritional recommendations for these patients might have more direct advantages, such as vitamin D, which is necessary for bone health and may impact muscle development. Other beneficial treatment recommendations are less direct, for example, an increase in protein intake will help to increase muscle mass, which in turn (may) lead to an increase in physical activity, resulting in the benefit of increased bone density.  

Clinical implications:  Loss of muscle is common in patients presenting with IBD and they also belong to a higher risk category for osteoporosis.  Osteosarcopenia increases the risk of falls and fractures which can cause further deterioration in the state of health in IBD patients.  Knowing that IBD patients are at increased risk for Osteosarcopenia, clinical treatment recommendations should look to treat patients holistically, recommending adequate nutritional supplementation and physical activity therapy. 
tick
GRADE
2 comments
Avatar of 
Anonymous 2d
Hi Renee, Great job on the analysis of IBD and risk for osteo-associated conditions. I loved how you linked the material from module 1; it is important to consider that improper absorption of micronutrients can have a larger impact on other systems in our body. When you mentioned IBD I remembered that celiac disease is not considered an IBD but I wanted to see if there were similar results in terms Bone Mineral Density. Sure enough, there is. I came across an article that may be of interest. It shows that celiac disease may constitute a risk factor for osteoporosis. I think this is a good reminder that a healthy gut helps make a healthy individual. Citation: Kemppainen, T, Kröger, H, Janatuinen, E, Arnala, I, Kosma, V.-M, Pikkarainen, P, . . . Uusitupa, M. (1999). Osteoporosis in adult patients with celiac disease. Bone (New York, N.Y.), 24(3), 249-255. -James L
Avatar of Renee LaFaive
Renee LaFaive 1d
Nice catch, James! Thanks for making the link to celiac disease as well!
Your avatar
Add comment
Kelly Chanay
Kelly Chanay
Study #1:  Park SM, Joung JY, Cho YY, Sohn SY, Hur KY, Kim JH, Kim SW, Chung JH, Lee MK, Min YK. Effect of high dietary sodium on bone turnover markers and urinary calcium excretion in Korean postmenopausal women with low bone mass. Eur J Clin Nutr. 2015 Mar;69(3):361-6. doi: 10.1038/ejcn.2014.284. Epub 2015 Feb 4. PMID: 25649239.

Study #2: Teucher, Birgit, et al. “Sodium and Bone Health: Impact of Moderately High and Low Salt Intakes on Calcium Metabolism in Postmenopausal Women.” American Society for Bone and Mineral Research, John Wiley & Sons, Ltd, 14 Apr. 2008, asbmr.onlinelibrary.wiley.com/doi/full/10.1359/jbmr.080408. 

I looked at two studies involving sodium and bone health.  Calcium and vitamin D tend to garner a lot of attention with regards to bone health but I believe that sodium is also very important to consider regarding bone health, especially when the Average American sodium intake is +3,900 mg/day.  I was curious as to what sodium level may be detrimental to bone health.   

Study #1: High sodium intakes (> 2 grams/day) were associated with negative bone turnover markers which the researchers indicate suggests that excessive sodium intake might accelerate bone turnover. 

Study #2: 3.9 grams/day and 11.2 grams/day of sodium.  Study looked at both sodium and calcium intake.  Low calcium intake was associated with negative bone calcium balance in both high and low sodium diets.  Even with a moderate calcium intake of 1284 mg/day the bone balance was positive with low sodium (3.9) intake but with a high sodium intake (11.2 g/day) bone balance was not positive.  (granted….11.2 grams/day is a lot!)

After I reviewed these two articles I then ran across the article published in the JCEM: Sodium Intake and Osteoporosis.  Findings from the Women’s Health Initiative.  Carbone, L., Johnson, K. C., Huang, Y., Pettinger, M., Thomas, F., Cauley, J., Crandall, C., Tinker, L., LeBoff, M. S., Wactawski-Wende, J., Bethel, M., Li, W., & Prentice, R. (2016). Sodium Intake and Osteoporosis. Findings From the Women's Health Initiative. The Journal of clinical endocrinology and metabolism, 101(4), 1414–1421. https://doi.org/10.1210/jc.2015-4017

I immediately jumped to the conclusion section of the above article and the authors state that the “current recommendations for sodium intake are unlikely to significantly affect osteoporosis”. (The article was published in 2016 and reference the 2010-2015 Dietary Guidelines for Americans which recommended: the IOM tolerable upper intake level of 2300 mg Na/day).  Note: this is still the current recommendation in the 2020-2025 DGA.  

The role sodium plays with regards to cardiovascular health is well established and the general population is likely more aware of this relationship than the role that sodium plays in bone health.  I think this information is important to share with patients/clients because some patients may not be concerned about cardiovascular health but may be concerned about bone health and I don’t think that sodium is always at the top of the list when discussing nutrients and bone health. It’s an important conversation to have with patients/clients regarding the recommended daily sodium intake limit of 2300 mg/day and another reason that supports the rationale for the current recommendation from the Academies that is included in the 2020-2025 Dietary Guidelines for Americans.   
tick
GRADE
1 comment
Avatar of Renee LaFaive
Renee LaFaive 24h
Interesting. We don't hear about the possible association of high sodium intake and osteoporosis in mainstream media. This could be a very important consideration, especially if more research makes a direct correlation.
Your avatar
Add comment
Josh West
Josh West 
Groenendijk I, Chan R, Woo J, Ong S, Parikh P, Bragt MCE, de Groot LCPGM. A Combined Nutrition and Exercise Intervention Influences Serum Vitamin B-12 and 25-Hydroxyvitamin D and Bone Turnover of Healthy Chinese Middle-Aged and Older Adults. J Nutr. 2020 Aug 1;150(8):2112-2119. doi: 10.1093/jn/nxaa149. PMID: 32588047; PMCID: PMC7398768.

Importance
This study is important because 
tick
GRADE
Your avatar
Add comment
Brooke Munson
Brooke Munson
Burt LA, Billington EO, Rose MS, Raymond DA, Hanley DA, Boyd SK. Effect of High-Dose Vitamin D Supplementation on Volumetric Bone Density and Bone Strength: A Randomized Clinical Trial. JAMA.2019;322(8):736–745. doi:10.1001/jama.2019.11889 

Importance: 
This randomized control trial sought to determine if a higher-dose vitamin D supplementation improves bone mineral density. Low bone mineral density increases the risk of osteoporosis and finding ways to prevent the development of this prevalent disease is needed. We also need to know the implications of excess vitamin D supplementation on bone. 

Key findings

# data[].attributes.body
Hooshmand, S., Kern, M., Metti, D. et al. The effect of two doses of dried plum on bone density and bone biomarkers in osteopenic postmenopausal women: a randomized, controlled trial. Osteoporos Int 27, 2271–2279 (2016). https://doi.org/10.1007/s00198-016-3524-8

This study is important because it focuses on the effects of nutrition on bone density and could provide a means of supplementation that is more agreeable to some patients. The author conducted a study previously that compared dried plums (prunes) to dried apples in increasing BMD and the key finding was that found that the prunes were significant in increasing BMD in the ulna and spine compared to the control. This follow up study found that both the higher and lower doses of prunes prevented loss of bone density. The participants were osteopenic elderly females, all post-menopausal. While calcium and vitamin D are commonly studied, I thought it would be interesting to research other non-traditional means of improving bone density, as there is a large portion of my patient population that are non-compliant with medications but are willing to eat/drink foods to improve their health. While calcium and vitamin D are natural means of improving bone density and decreasing osteoporosis, there still are often supplemented in the pill form, and there is a cohort of elderly and a growing number of younger patients who are adverse to taking pills or “medications and would rather do something simpler/cheaper/more natural. I feel that with some patients, especially ones who may already eat prunes for constipation, telling them to eat 4-5 prunes a day (50g) may be easier for them than prescribing them an oyster shell calcium/D.

# data[].attributes.body
Burt LA, Billington EO, Rose MS, Raymond DA, Hanley DA, Boyd SK. Effect of High-Dose Vitamin D Supplementation on Volumetric Bone Density and Bone Strength: A Randomized Clinical Trial. JAMA.2019;322(8):736–745. doi:10.1001/jama.2019.11889

Importance:

This randomized control trial sought to determine if a higher-dose vitamin D supplementation improves bone mineral density. Low bone mineral density increases the risk of osteoporosis and finding ways to prevent the development of this prevalent disease is needed. We also need to know the implications of excess vitamin D supplementation on bone.

Key findings:

This double-blind randomized control trial took place over three years. The 311 participants were placed in either the 400 IU/day, 4,000 IU/day and 10,000 IU/day group. The study found that among healthy adults, treatment with 4000 IU per day or 10 000 IU per day, resulted in statistically significant lower radial BMD.

Clinical implications: This is important because many people are proposing that the current RDA for vitamin D is too low. Much research like this needed to be able to assess if this is the case. As clinicians, we need to make sure we are recommending vitamin D supplementation in a healthy range.

# data[].attributes.body
Citation:  A M El Badri S, Salawu A, Brown JE. Bone Health in Men with Prostate Cancer: Review Article. Curr Osteoporos Rep. 2019 Dec;17(6):527-537. doi: 10.1007/s11914-019-00536-8. PMID: 31760582; PMCID: PMC6944652.

Why is this study significant?
Cancer treatment induced bone loss is a well recognized entity but  greater awareness of the associated risks and  indicated treatments is needed.
Patients with prostate cancer are living longer, with  survival rates increasing and mortality decreasing significantly.  This population is likely to have higher incidence of baseline osteopenia and osteoporosis even prior to diagnosis  or initiation of treatment  just due to the demographic of this group.    Androgen deprivation therapy is a cornerstone of treatment for advanced disease ( i.e metastatic or non surgical candidates) . Long-term ADT has well-recognized negative impact on bone mineral density and increases fracture risk.

Key Finding:
In observation of  50,613 patients with prostate cancer, of those who survived for at least 5 years after diagnosis, data showed that 19.4% of those who received ADT sustained a fracture, compared to 12.6% of those who did not receive ADT .  This negative impact on bone health also applies to other prostate cancer treatments including chemotherapy, glucocorticoids and novel hormone manipulation agents. These are used, in addition to ADT, for the treatment of advanced prostate cancer, which involves bone in an estimated 90% of cases with significant potential for morbidity and skeletal-related events (SREs) such as pathological fractures.

Clinical Implication:
Patients often lack knowledge about the risk of CTIBL and means for prevention and treatment.  Based on the findings of this study, there also appears to be a discrepancy between what physicians assume that patients know and what the patients’ perception is about their bone health . Despite knowledge about bone health, there appears to be inadequate adherence to guidelines for screening, monitoring and treatment of CTIBL on the part of  health care providers.   This is an opportunity for specialists as well as  primary care providers to increase implementation of the guidelines and tools that we have to address  and reduce  a co-morbid condition associated with  cancer treatment that has huge cost saving  potential as well as  improved quality of life for patients.

# data[].attributes.body
Kemppainen, T, Kröger, H, Janatuinen, E, Arnala, I, Kosma, V.-M, Pikkarainen, P, . . . Uusitupa, M. (1999). Osteoporosis in adult patients with celiac disease. Bone (New York, N.Y.), 24(3), 249-255.  

# data[].attributes.body
Citation: Harvey, N.C., Biver, E., Kaufman, JM. et al. The role of calcium supplementation in healthy musculoskeletal ageing. Osteoporos Int 28, 447–462 (2017). https://doi-org.ezproxy.uky.edu/10.1007/s00198-016-3773-6

Why is this study significant?

This study is significant because it analyzed the literature of the time to come to a consensus on the efficacy of calcium and vitamin D supplementation and their role on the skeletomuscular system. It is important to note that this paper was published in 2016 and there is still a debate on the benefits of calcium supplementation.

One key finding from this study and how does it relate to nutritional sciences

This paper did a really good job combining evidence from different sources and I appreciated the big takeaways from author’s analysis. One should be mindful of their bodies needs when considering calcium supplementation. The researchers concluded that vitamin supplementation can have side effects. Most of these are concerned with the GI tract but some more severe side effects include calcium impact on the kidneys, especially in terms of renal stones. They have also concluded that the link between calcium supplementation and cardiovascular events are not well supported by the literature. I think some of these off-target effects are due to the variety of roles that calcium plays in the body, with bone health and maintenance being just one of them.

Calcium can be found in a variety of dietary sources and adequate levels can be absorbed in the body with a well-balanced diet.

Clinical implication

With the above information in mind, the researcher’s have also concluded that calcium and vitamin D supplementation together is beneficial for patients who are at high risk of insufficiency and for those receiving treatment for osteoporosis. It is important for providers to be able to recognize people who are risk and encourage supplementation when appropriate.

# data[].attributes.body
Citation: Skrzypczak,D.;Ratajczak, A.E.; Szymczak-Tomczak, A.; Dobrowolska, A.; Eder, P.; Krela-Kaz ́mierczak, I. A Vicious Cycle of Osteosarcopenia in Inflammatory Bowel Diseases—Aetiology, Clinical Implications and Therapeutic Perspectives. Nutrients 2021, 13, 293. https://doi.org/10.3390/nu13020293

Why is this study important:  This review interlinks IBD (Inflammatory Bowel Disease) and Osteosarcopenia (a disorder of simultaneous sarcopenia and osteoporosis) in a discussion regarding the risk of Osteosarcopenia in IBD patients and the importance of providing nutritional considerations and treatment of both disorders.

Key findings and nutritional science: Osteosarcopenia is the collective disorder of both muscle and bone tissue loss, which are being considered more interrelated due to both hormonal pathways as well as mechanical interactions between muscle and bone.

Patients with IBD often present with Osteosarcopenia due to various risk factors associated with IBD such as malnutrition, malabsorption, decreased physical activity, chronic inflammation among others (refer to Tables 2, 3).  This review noted that more than 50% of patients with IBD have an abnormal lumbar BMD (Bone Mineral Density).  Low BMI is also associated with a low BMD and in IBD patients, BMI is often “significantly” lower than in healthy individuals.

Some nutritional recommendations for these patients might have more direct advantages, such as vitamin D, which is necessary for bone health and may impact muscle development. Other beneficial treatment recommendations are less direct, for example, an increase in protein intake will help to increase muscle mass, which in turn (may) lead to an increase in physical activity, resulting in the benefit of increased bone density.

Clinical implications:  Loss of muscle is common in patients presenting with IBD and they also belong to a higher risk category for osteoporosis.  Osteosarcopenia increases the risk of falls and fractures which can cause further deterioration in the state of health in IBD patients.  Knowing that IBD patients are at increased risk for Osteosarcopenia, clinical treatment recommendations should look to treat patients holistically, recommending adequate nutritional supplementation and physical activity therapy.

# data[].attributes.body
Study #1:  Park SM, Joung JY, Cho YY, Sohn SY, Hur KY, Kim JH, Kim SW, Chung JH, Lee MK, Min YK. Effect of high dietary sodium on bone turnover markers and urinary calcium excretion in Korean postmenopausal women with low bone mass. Eur J Clin Nutr. 2015 Mar;69(3):361-6. doi: 10.1038/ejcn.2014.284. Epub 2015 Feb 4. PMID: 25649239.

Study #2: Teucher, Birgit, et al. “Sodium and Bone Health: Impact of Moderately High and Low Salt Intakes on Calcium Metabolism in Postmenopausal Women.” American Society for Bone and Mineral Research, John Wiley & Sons, Ltd, 14 Apr. 2008, asbmr.onlinelibrary.wiley.com/doi/full/10.1359/jbmr.080408.

I looked at two studies involving sodium and bone health.  Calcium and vitamin D tend to garner a lot of attention with regards to bone health but I believe that sodium is also very important to consider regarding bone health, especially when the Average American sodium intake is +3,900 mg/day.  I was curious as to what sodium level may be detrimental to bone health.

Study #1: High sodium intakes (> 2 grams/day) were associated with negative bone turnover markers which the researchers indicate suggests that excessive sodium intake might accelerate bone turnover.

Study #2: 3.9 grams/day and 11.2 grams/day of sodium.  Study looked at both sodium and calcium intake.  Low calcium intake was associated with negative bone calcium balance in both high and low sodium diets.  Even with a moderate calcium intake of 1284 mg/day the bone balance was positive with low sodium (3.9) intake but with a high sodium intake (11.2 g/day) bone balance was not positive.  (granted….11.2 grams/day is a lot!)

After I reviewed these two articles I then ran across the article published in the JCEM: Sodium Intake and Osteoporosis.  Findings from the Women’s Health Initiative.  Carbone, L., Johnson, K. C., Huang, Y., Pettinger, M., Thomas, F., Cauley, J., Crandall, C., Tinker, L., LeBoff, M. S., Wactawski-Wende, J., Bethel, M., Li, W., & Prentice, R. (2016). Sodium Intake and Osteoporosis. Findings From the Women's Health Initiative. The Journal of clinical endocrinology and metabolism, 101(4), 1414–1421. https://doi.org/10.1210/jc.2015-4017

I immediately jumped to the conclusion section of the above article and the authors state that the “current recommendations for sodium intake are unlikely to significantly affect osteoporosis”. (The article was published in 2016 and reference the 2010-2015 Dietary Guidelines for Americans which recommended: the IOM tolerable upper intake level of 2300 mg Na/day).  Note: this is still the current recommendation in the 2020-2025 DGA.

The role sodium plays with regards to cardiovascular health is well established and the general population is likely more aware of this relationship than the role that sodium plays in bone health.  I think this information is important to share with patients/clients because some patients may not be concerned about cardiovascular health but may be concerned about bone health and I don’t think that sodium is always at the top of the list when discussing nutrients and bone health. It’s an important conversation to have with patients/clients regarding the recommended daily sodium intake limit of 2300 mg/day and another reason that supports the rationale for the current recommendation from the Academies that is included in the 2020-2025 Dietary Guidelines for Americans.

# data[].attributes.body
Groenendijk I, Chan R, Woo J, Ong S, Parikh P, Bragt MCE, de Groot LCPGM. A Combined Nutrition and Exercise Intervention Influences Serum Vitamin B-12 and 25-Hydroxyvitamin D and Bone Turnover of Healthy Chinese Middle-Aged and Older Adults. J Nutr. 2020 Aug 1;150(8):2112-2119. doi: 10.1093/jn/nxaa149. PMID: 32588047; PMCID: PMC7398768.

Importance
This study is important because it reveals evidence of a fortified milk supplement with B-12 and 25(OH)D and exercise intervention balanced bone turnover markers. It also may have shown evidence of improvement of vitamin B-12 and 25(OH)D concentrations. This is useful because low B-12 and 25(OH)D has been shown to significantly lower average bone mineral density.

Key finding
In this 24 week study, the researchers found an increase in plasma 25(OH)D and B-12 but not PTH in middle aged older Chinese men. These values were measured at  baseline, 12 wks, and 24 wks. The overall ratio of formation vs. reabsorption was greater in the intervention group.

Clinical Relevance
This study shows that certain milk supplements can be beneficial to shift the ratio reabsorption and breakdown of bone remodeling. Utilizing a supplement such as this could allow certain patients in a diseased state to prevent excess breakdown in the bone. This could also simply point to the ability of vitamin B-12 and 25(OH)D concentrations being able to be corrected when ingested.

# data[].attributes.body
Kwon, S., & Lee, J. S. (2020). Effect of nutrient intake and dietary diversity score on osteoporosis of middle-aged adults and elderly based on 2015–2017 Korean National Health and Nutrition Examination Survey data. Journal of Nutrition and Health, 53(2), 155. https://doi.org/10.4163/jnh.2020.53.2.155

This study directly relates to this week’s module. It took data from surveys on nutrient intake and diversity in diets and the impact it had on osteoporosis. Using the Korean National Health and Nutrition Examination Survey, 2015-2017 data was used on middle aged individuals, to control mediators and discover relations with risks of osteoporosis in age groups that are much likely to develop it. This study is important because it related nutrition balances to likelihood of developing the disease while keeping many other factors like drinking, smoking, and BMI similar out of the equation. The key finding of the study directly relates to nutritional sciences – they found that a recommended balance of vegetables, dairy, fruit, heat, fish, and legumes were key in prevention of osteoporosis and healthy bones. Clinical implications include making sure the patient understands the importance of these diets and make recommendations that are efficient and mindful. Work with those in food deserts or with little access to fresh food other alternatives or supplements

# data[].attributes.body
Quattrini, S., Pampaloni, B., Gronchi, G., Giusti, F., & Brandi, M. L. (2021). The Mediterranean Diet in Osteoporosis Prevention: An Insight in a Peri-and Post-Menopausal Population. Nutrients, 13(2), 531

1. Importance
This study looks at the Mediterranean diet in peri- and post-menopausal women to look at dietary adherence and as a potential osteoporosis prevention. The Mediterranean diet is generally looked at as being well-balanced and relatively easy to stick to, which makes it a popular choice for dietary guidelines for a host of conditions. Osteoporosis affects a large population of people especially post-menopausal women and any preventative would provide a lot of hope to a large group of people.

2. One Key Finding
While dietary adherence is always a cause for concern when nutritional guidelines are added to a treatment plan, this study found that adherence was relatively high in peri- and post-menopausal women. When following the Mediterranean diet, there was an increase in Calcium levels and women did not feel that adherence was an impossible feat. This proves to be a good step forward for patients focusing on osteoporosis prevention. If a nutritional plan isn’t a burden to follow, then it’s likelihood of success is much higher.

3. Clinical Relevance
I liked this article because while it did look at how a specific diet affected the key nutrient in question for osteoporosis (calcium), it primarily focused on dietary adherence in a large population. As current/future providers, we can talk to patients all day about the dietary changes and recommendations that they should follow, but if patients do not adhere to these changes, then they are for naught. This study focused on adherence and found that, with this specific recommendation, adherence was rather high, meaning that the use of the Mediterranean diet for osteoporosis prevention as a higher rate of success because it is more likely to be followed.