Stress might be bad for our mental health, but subjecting our bones to stress is likely to be good for them, and the earlier the better, says Associate Professor Thor Besier from the Auckland Bioengineering Institute.

“If you want to excite the bones, and get your bones to respond to that, the best thing you can do is jump off a table,” he says. “Do that ten times, and your bones will receive more stimulus than if you went for a walk for two hours.”

Dr Besier will be talking about the relationship between biomechanical loading and bone health at Raising the Bar this month, an event at which 20 top academics from the University of Auckland will speak at ten inner city bars on one night.

Our skeletal matter is roughly determined by our DNA, but it’s now well known that it constantly adapts to the stresses of life, says Dr Besier. It’s also important we subject our bones to stress while we’re still young enough to be building them. This will have implications throughout our life, and our risk of bone diseases such as osteoarthritis and osteoporosis.

Dr Besier points to studies that have looked at baseball pitchers, in which the bone shape and density of the throwing arm was compared to the non-throwing arm, which demonstrated a direct link between biomechanical loading and bone health.

“What’s really intriguing is that bones show that difference, 30 or 40 years after people stopped playing the sport. The bone formation that occurs when you’re young will stay with you throughout your life.”

“What this means is that what our children are doing when they’re still at school, will set them up for joint disease - or not - in 40 years time.”

It’s never too late to exercise, he says, but the younger, the better and the ‘how’ is also important. “In the classroom, if you make the kids get up and do ten star jumps every 20 minutes, that could be enough to stimulate bone growth.”

By getting a better understanding of the interaction between biomechanical loading and bones health, Dr Besier and his team plan to radically improve orthopaedic care. Our ageing population makes this a healthcare priority.

“We’re expected to have a 700 percent increase in joint replacements in the next 15 years. We can’t afford to sustain that. People are wanting to live long happy healthy lives, but their joints are failing, so what are we going to do about that?”

His research has led to the development of spinout company, Formus Labs, set up to design software that will make pre-operative planning easier, less intrusive and more personalised.

That involves designing tools that can use medical images to recreate a computational model of an individual’s anatomy, and the design of a joint product specifically tailored for each patient. Formus Labs is working with a number of major international orthopedic companies to develop and test the technology.

Dr Besier is also leading research that uses wearable sensors developed at the ABI, to improve post-operate orthopaedic care.

The sensing technology lead to spinout company, IMeasureU, and has since been sold to VICON, a UK-based motion capture company, which has led to greater distribution of the wearable sensor products.

If used in orthopaedic post-operative care, he says, it would enable doctors to keep track of patients over time and, “like a FitBit on steroids”, get a better idea of how well a patient is moving after being discharged from hospital.

“If you get a joint replacement tomorrow, your first question is, ‘when can I be active again, can I go running, can I play golf?’ And we don’t have good answers to these questions, and that’s a problem for the patients, as they have no idea what they should be doing. So we want to address that,” says Dr Besier.

“Our plan is to be game-changing for orthopaedic care.”

This is an open access article and can be read in free full text at: https://doi.org/10.1186/s12889-018-6297-5

To read the review in free full text, go to: https://doi.org/10.3390/nu10121833 

Dreher, M.L. (2018). Whole fruits and fruit fiber emerging health effects. Nutrients, 10(12), 1833.

This is an open access article and can be read in free full text at: https://doi.org/10.1186/s12889-018-6206-y

Hohman, E. E., et al. (2018). Dieting is associated with reduced bone mineral accrual in a longitudinal cohort of girls. BMC Public Health 18(1285).

Participants were 11–12 year-olds in the Longitudinal Study of Australian Children's Child Health CheckPoint. Of 1357 children attending the CheckPoint, 864 (64%) provided both bone and accelerometry data. 

The authors conclude from their analysis that, in early adolescence, moderate to vigorous physical activity showed associations with better bone health that, while modest, could be of population-level importance. MVPA fragmentation and sedentary behaviour duration and fragmentation seemed less important.

This article can be read in free full text at: https://doi.org/10.1016/j.bone.2018.04.011

Osborn, W., et al. (2018). Bone health, activity and sedentariness at age 11–12 years: Cross-sectional Australian population-derived study. Bone, 112, 153–160.

This review summarizes the current data regarding the skeletal consequences of BS and its mechanisms, with an emphasis on the preventive strategies and nutritional care that may be warranted in order to attenuate bone deterioration following BS.

To read the full abstract and for information on how to access the full text, go to: https://doi.org/10.1093/advances/nmx024 or contact your DHB library, or organisational or local library for assistance.

Ben-Porat, T., et al. (2018). Bone health following bariatric surgery: Implications for management strategies to attenuate bone loss. Advances in Nutrition, 9(2), 114-127.

The study, the first of its kind in the southern hemisphere, recruited 126 women through Dunedin’s Queen Mary Maternity Centre from 2011 to 2013. The findings, just published in the journal Nutrients, found rates of vitamin D deficiency were very high (evident in 65 per cent of mothers and 76 per cent of infants), and there was evidence of rickets in three infants.

Vitamin D is essential for foetal bone health, growth, and dental health. A lack of vitamin D is also associated with an increased risk of rickets in childhood.

Lead author Dr Ben Wheeler, of Dunedin School of Medicine’s Department of Women’s and Children’s Health, says the study raises "significant questions’’ around current public health policies, particularly for those living in southern New Zealand.

"Current policy does not appear effective at preventing vitamin D deficiency and its consequences.

"This is particularly an issue in New Zealand as living further south potentially decreases one’s ability to make vitamin D and the country has negligible vitamin D food fortification,’’ he says.

Present public health policy is to only consider vitamin D supplementation for pregnant women and breastfed infants who are considered "at risk’’ by having one or more of the following: naturally dark skin; complete sun avoidance; a sibling with rickets; liver or kidney disease, or taking certain medications that affect vitamin D levels; and infants who are breastfed over winter. 

"The majority of New Zealand women and their children would not meet these risk criteria. However, our results show that in southern New Zealand, in traditionally low risk women and their infants, rates of deficiency are very high. In addition very severe deficiency in infants was also seen, something not previously seen in other similar international studies.’’

Dr Wheeler suggests strengthening of current New Zealand guidelines is needed.

"Further consideration should also be given to offering a fully funded universal supplement to New Zealand women and their children during pregnancy and lactation, particularly for those in the South Island.’’

Maternal vitamin D status during pregnancy is influenced by a range of factors, including season, skin colour, supplementation, latitude, and potential pregnancy-specific variations in metabolism.

Supplementation studies during pregnancy demonstrate significantly improved infant status at birth and beyond.

University of Otago media release, 22 January 2018

Twenty-three studies (14 cross-sectional and nine longitudinal) were included. Results from the meta-analysis (cross-sectional studies) confirmed that children and adolescents with obesity have higher bone content and density than their normal weight peers. Results from longitudinal studies remain inconclusive as only 50% of the included studies reported a positive effect of a structured intervention program on bone health. As such, the meta-analysis reported that structured intervention did not influence bone markers despite having beneficial effects on general health in youth with obesity.

To read the full abstract and for information on how to access the full text, go to: https://link.springer.com/article/10.1007/s00774-017-0858-z or contact your DHB library, or organisational or local library for assistance.

Chaplais, E., Naughton, G., Greene, D. et al.  (2018). Journal of Bone and Mineral Metabolism, 36(1), 12–30.

Twenty-seven studies, with a total of 5,958 children, were included. There was moderate and high quality of evidence that overweight and obese children have a significantly higher whole body bone mineral content than normal-weight children. Similar results were found for whole body bone mineral density. Sensitivity analysis showed that the association was stronger in girls. The authors note that, because only one study had a longitudinal design, the long-term impact of childhood overweight and obesity on bone health at adulthood is not clear.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1111/obr.12515 or contact your DHB library, or organisational or local library for assistance.

van Leeuwen, J., et al. (2017). Differences in bone mineral density between normal-weight children and children with overweight and obesity: A systematic review and meta-analysis. Obesity Reviews, 18(5), 526–546.

In 1161 participants (569 females), depressive symptoms were assessed at age 14 and 17 years, and at age 20 years. At age 20 years, lean body mass, fat body mass and total body bone mass were measured by dual-energy X-ray absorptiometry.

The authors conclude that "depressive symptoms and persistent/recurrent depression in adolescence are predictors of greater adiposity at age 20 years in females, but not males, but do not predict bone mass in either gender".

Available to read in free full text at: http://dx.doi.org/10.1038/ijo.2016.214

Zhu, K., et al. (2017). Depressive symptoms, body composition and bone mass in young adults: A prospective cohort study. International Journal of Obesity, 41, 576–581

Food-frequency questionnaire responses, baseline BMD (hip and spine, n = 862 in 1988–1989), and follow-up BMD (n = 628 in 1992–1993) were measured in the Framingham study, a prospective cohort study of older Caucasian men and women aged 67–93 years.

The authors conclude from their analysis that "in this population of older adults, higher intakes of milk, fluid dairy, and milk + yogurt + cheese were associated with higher LS BMD, and a higher intake of milk + yogurt + cheese was protective against trochanter BMD loss among vitamin D supplement users but not among nonusers. These findings underscore that the benefits of dairy intake on the skeleton may be dependent on vitamin D intake".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.3945/jn.116.240390 or contact your DHB library, or organisational or local library for assistance.

Sahni, S., et al. (2017). Dairy intake is protective against bone loss in older vitamin D supplement users: The Framingham Study. The Journal of Nutrition, 147(4), 645-652

In their July 2016 Best Practice magazine, bpac provides an update on Vitamin D and calcium supplementation in primary care.

Studies in this issue (attached below):

University of Auckland Distinguished Professor Ian Reid was tonight presented with the Health Research Council of New Zealand’s (HRC) Liley Medal at the 2015 Research Honours Dinner for his outstanding contribution to health and medical sciences in advancing treatment of the bone disorder osteoporosis". 

To read the full story, go to:  http://www.hrc.govt.nz/news-and-publications/news-media#liley-medal-for-'game-changing'-vitamin-d-study  

Increasing calcium intake through diet or supplements should not be recommended for fracture or osteoporosis prevention, according to University of Auckland Associate Professor of Medicine, Dr Mark Bolland.

Two studies published in The British Medical Journal this week, conclude that increasing calcium intake is unlikely to improve bone health or prevent fractures in older people.

“Collectively, these results suggest that Clinicians, advocacy organisations and health policymakers should not recommend increasing calcium intake for fracture prevention, either by use of calcium supplements or dietary sources,” says Dr Bolland. “For most patients who are concerned about their bone health, they do not need to worry about their calcium intake.”

Guidelines advise older men and women to take at least 1000-1200 mg/day of calcium to improve bone density and prevent fractures, and many people take calcium supplements to meet these recommendations.

Recent concerns about the safety of calcium supplements have led experts to recommend increasing calcium intake through food rather than by taking supplements, but the effect on bone health was unknown.

A team of researchers, led by Dr Bolland, set out to examine the evidence underpinning recommendations to increase calcium intake from dietary sources or supplements to improve bone health and prevent fractures.

They analysed the available evidence from randomised controlled trials and observational studies of extra dietary or supplemental calcium in women and men aged over 50. Study design and quality were taken into account to minimise bias.

“In the first study, we found that increasing calcium intake from dietary sources or by taking supplements produces small (one to two percent) increases in bone mineral density, which are unlikely to lead to a clinically meaningful reduction in risk of fracture”, says Dr Bolland.

“The second study found that 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,” he says.

“It is time to revisit recommendations to increase calcium intake beyond a normal balanced diet,” says co-author, Professor Karl Michaëlsson from Uppsala University in Sweden, in an accompanying editorial.

He says that ever increasing intakes of calcium and vitamin D recommended by some guidelines defines virtually the whole population aged over 50 at risk.

“Yet most will not benefit from increasing their intakes”, he says, “and will be exposed instead to a higher risk of adverse events [such as gastrointestinal side effects]”.

“The weight of evidence against such mass medication of older people is now compelling, and it is surely time to reconsider these controversial recommendations,” he says.

Two Auckland clinical researchers have called for advocacy organisations and academics to abandon industry ties that promote the use of calcium and vitamin D supplements to prevent or treat osteoporosis.

In a paper just published in the British Medical Journal, the University of Auckland researchers, Associate Professors Andrew Grey and Mark Bolland, say that since 2002, evidence has emerged that these supplements do not reduce the risk of fracture and may result in harm.

By the end of 2010, 32 of 38 clinical trials of calcium and/or vitamin D had reported no benefit or harm.

“Despite this, many practice guidelines continue to recommend increasing calcium intake and/or the use of vitamin D supplements for managing osteoporosis,” says Dr Grey.

Calcium and Vitamin D supplements are very profitable, with global annual sales of calcium supplements in 2013 of about $6 billion, and of vitamin D in the USA alone in 2012 of $748 million.

“We investigated why these supplements are still being widely recommended, despite a substantial body of evidence that they are ineffective or harmful,” he says. “And we looked at the possibility that advocacy organisations, specialist societies and academics are part of the mechanism for resisting change.”

Drs Grey and Bolland found that, companies marketing calcium and vitamin D supplements (plus their lobby groups), companies marketing dairy products;, and companies selling kits for measuring vitamin D, all sponsor and influence the activities and policies of prominent osteoporosis advocacy organizations.
 
These include the Europe-based International Osteoporosis Foundation and the USA-based National Osteoporosis Foundation.

“Such companies also sponsor medical societies and groups of academic experts in the osteoporosis field. These conflicts of interest are often not declared,” says Dr Grey.

In the paper, the authors also discussed the likelihood that academic conflicts of interest influence recommendations for calcium and vitamin D use, given the professional advantages that can accrue from persistence of the belief that the supplements are beneficial to bone health.

Grey and Bolland called for greater transparency in the payments from the supplements and food industry to health practitioners and academics, and for advocacy organizations and medical societies to sever financial ties to industry, as “disentangling industry from academia might improve the translation of evidence into practice”.

Serum vitamin D concentrations were measured in 14,641 men and women aged 42–82 y in 1997–2000 who were living in Norfolk, United Kingdom, and were followed up to 2012. Participants were categorized into 5 groups according to baseline serum concentrations of total 25(OH)D <30, 30 to <50, 50 to <70, 70 to <90, and ≥90 nmol/L. The sutdy found that plasma 25(OH)D concentrations predicted subsequent lower 13-y total mortality and incident cardiovascular disease, respiratory disease, and fractures but not total incident cancers. For mortality, lowest risks were in subjects with concentrations >90 nmol/L, and there was no evidence of increased mortality at high concentrations, suggesting that a moderate increase in population mean concentrations may have potential health benefit, but <1% of the population had concentrations >120 nmol/L.

To read the full abstract, and for access to a free full text version of the article, go to: http://dx.doi.org/10.3945/ajcn.114.086413

Khaw, K-T., et al. (2014). Serum 25-hydroxyvitamin D, mortality, and incident cardiovascular disease, respiratory disease, cancers, and fractures: A 13-y prospective population study. American Journal of Clinical Nutrition, 100(5), 1361-1370

This review focussed on the complex relationship between body weight, fat mass and bone mass, as well as peripheral and central mediators potentially involved in the dual regulation of both energy and bone homeostasis.

The authors believe that as the number of bariatric operations increases, it will be imperative to recognize mechanisms responsible for bariatric surgery-induced bone loss, with careful monitoring of bone health including long-term fracture incidence in patients undergoing these procedures.

Citation: Brzozowska, M. M. et al. (2012). Bariatric surgery, bone loss, obesity and possible mechanisms. Obesity Reviews, available online 25 Oct 2012.

To read the full abstract, and for information on how to access the full text, go to: http://onlinelibrary.wiley.com/doi/10.1111/j.1467-789X.2012.01050.x/abstract or contact your DHB library, or organisational or local library for assistance.