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Date of release: 10 August, 2015

Fragility fracture risk and musculoskeletal function

Prevention of osteoporosis-related fractures has been a major preventive goal during the last years and different interventions have been recommended. Järvinen and colleagues have carried out a meta-analysis of 33 randomized controlled trials (RCTs) and have demonstrated that current screening strategies and bisphosphonate treatment are ineffective in preventing hip fractures [1]. The available RCTs are heterogeneous and have methodological flaws that hamper the formation of recommendations about antiresorptive treatments, including the general use of calcium and vitamin D supplements. The authors also declared that the dominant approach is not cost-effective in preventing hip fractures and none of the three studies conducted in subjects older than 80 years reported that pharmacologic treatment reduced the hip fracture risk.

Comment

The meta-analysis by Jarvinen and colleagues has raised a hot debate about the diagnosis of hip fracture risk, overdiagnosis and overtreatment, and fracture prevention [2]. The hip fracture risk is difficult to calculate with the current methods (e.g. low bone mineral density, the Fracture Risk Assessment Tool, the Garvan Fracture Risk Calculator) and more reliable methods are needed. Fall risk is increased in patients who have fallen previously or who have a gait problem, visual impairment, neurological diseases and impaired cognition, sedentarism or decreased physical activities, or use some medications. 
 
The fracture risk for the femoral neck has been related to serum 25-hydroxyvitamin D [25(OH)D] levels in a large cross-sectional study of subjects aged ≥ 50 years [3]. Thus, serum 25(OH)D levels were associated with compression strength, bending strength and impact strength in both men and women. The VICTORY RCT demonstrated that vitamin D3 supplementation (1000 IU/day) for a year is associated with increased bone mineral density in the femoral neck, greater trochanter, Ward’s triangle and total hip in women aged 60–70 years [4]. However, there are no changes in bone metabolism, except a small reduction in parathyroid hormone and an increase in circulating calcium [4]. 
 
A meta-analysis including 26 RCTs also showed that vitamin D supplementation was associated with a significant reduction in falls. This effect was more prominent in patients who were vitamin D-deficient at baseline, and in studies in which calcium was used with vitamin D. The majority of trials included elderly women [5]. A meta-analysis including 30 RCTs analyzed the effect of all forms and doses of vitamin D supplementation, with or without calcium supplementation, on muscle function as compared to placebo or control. Although muscle mass and muscle power were not different, global muscle strength was significantly better in subjects with a higher vitamin D status [6]. Therefore, vitamin D supplementation has a significant role in skeletal muscle function and in the prevention of non-traumatic fractures.
 
Sarcopenia is known as the age-associated loss of skeletal muscle mass, strength, and quality of contractile function. Aging causes muscle fiber loss and fiber atrophy, progressively leading towards a state in which an elderly person will be unable to conduct most everyday tasks. Furthermore, sarcopenia and increase in muscle dysfunction are associated with obesity and the risk of falls and fractures [7]. 
 
Antiresorptive treatment should be used according to the respective characteristics with appropriate periodic clinical assessments. Adherence to osteoporosis treatment should be improved [8]. Sedentarism and lack of exercise put women at higher risk for sarcopenia and hip fracture. The development of sarcopenia may be slowed through healthy lifestyle changes, which include adequate dietary vitamin D, protein and mineral intakes, and regular physical activity. Vitamin D supplementation of 600 IU/day and 1000 mg calcium daily up to age 70 is recommended by several societies. In subjects aged over 70, supplements should include 1200 mg calcium and 800 IU vitamin D daily [9,10]. In those subjects with low vitamin D levels, daily doses may be increased to 4000 IU/day cholecalciferol, with adjustments depending on the response. Potassium-rich fruits and vegetables should be consumed daily; this mineral has positive effects on calcium metabolism [11]. 
 
Protein intake and physical activity are the main anabolic stimuli for synthesis of muscle protein. It is recommended that the diet should include a protein intake of 1.0–1.2 g/kg body weight/day with at least 20–25 g of high-quality protein at each main meal [12]. Protein intake should be adapted to the degree of physical activity. 
 
Physical exercise may improve neuromuscular function, stimulate muscle contraction and improve cardiocirculatory status. A regular exercise program may reduce the risk of falls. Traditional resistance, aerobic training and more recent intervention varieties (Tai Chi, Pilates, body vibration) may positively contribute to fall prevention by improving muscle function and coordination [7]. Current physical activity recommendations suggest that adults should engage in at least 150 minutes/week of moderate physical activity. However, many older women are reluctant to participate in moderate or vigorous exercise because of general health concerns and fear of injury.

F. R. Pérez-López


Department of Obstetrics and Gynecology, University of Zaragoza and Lozano-Blesa University Hospital, Domingo Miral s/n, Zaragoza, Spain



I. Ara


Growth, Exercise, Nutrition and Development (GENUD) Toledo Research Group, University of Castilla-La Mancha, Toledo, Spain



    References

  1.  Järvinen TL, Michaelsson K, Jokihaara J, et al. Overdiagnosis of bone fragility in the quest to prevent hip fracture. BMJ 2015;350:h2088


    http://www.ncbi.nlm.nih.gov/pubmed/26013536

  2. Responses to Järvinen TL, et al.s paper.


    http://www.bmj.com/content/350/bmj.h2088/rapid-responses

  3. Kim H, Hun Lee S, Kim J, et al. The association of vitamin D with femoral neck strength: an additional evidence of vitamin D on bone health. J Clin Endocrinol Metab 2015 May 28:jc20144320. Epub ahead of print


    http://www.ncbi.nlm.nih.gov/pubmed/26020761

  4. Macdonald HM, Wood AD, Aucott LS, et al. Hip bone loss is attenuated with 1000 IU but not 400 IU daily vitamin D3: a 1-year double-blind RCT in postmenopausal women. J Bone Miner Res 2013; 28: 220213


    http://www.ncbi.nlm.nih.gov/pubmed/23585346

  5. Murad MH, Elamin KB, Abu Elnour NO, et al. The effect of vitamin D on falls: a systematic review and meta-analysis. J Clin Endocrinol Metab 2011;96:2997-3006


    http://www.ncbi.nlm.nih.gov/pubmed/21795448

  6. Beaudart C, Buckinx F, Rabenda V, et al. The effects of vitamin D on skeletal muscle strength, muscle mass, and muscle power: a systematic review and meta-analysis of randomized controlled trials. J Clin Endocrinol Metab 2014;99:4336-45


    http://www.ncbi.nlm.nih.gov/pubmed/25033068

  7. Hita-Contreras F, Martínez-Amat A, Cruz-Díaz D, Pérez-López FR. Osteosarcopenic obesity and fall prevention strategies. Maturitas 2015;80:126-32


    http://www.ncbi.nlm.nih.gov/pubmed/25533145

  8. Pérez-López FR, Chedraui P. Adherence to osteoporosis medications. Climacteric 2012;15:100-2


    http://www.ncbi.nlm.nih.gov/pubmed/22308566

  9. Pérez-López FR, Brincat M, Erel CT, et al. EMAS position statement: Vitamin D and postmenopausal health. Maturitas 2012;71:83-8


    http://www.ncbi.nlm.nih.gov/pubmed/22100145

  10. US Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D.


    http://www.iom.edu/reports/2010/dietary-reference-intakes-for-calcium-and-vitamin-d.aspx

  11. Moseley KF, Weaver CM, Appel L, Sebastian A, Sellmeyer DE. Potassium citrate supplementation results in sustained improvement in calcium balance in older men and women. J Bone Miner Res 2013;28:497-504


    http://www.ncbi.nlm.nih.gov/pubmed/22991267

  12. Rizzoli R, Stevenson JC, Bauer JM, et al; ESCEO Task Force. The role of dietary protein and vitamin D in maintaining musculoskeletal health in postmenopausal women: a consensus statement from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Maturitas 2014;79:122-32


    http://www.ncbi.nlm.nih.gov/pubmed/25082206