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Vitamin D is important for musculoskeletal health. Concentrations of 25-hydroxyvitamin D, the most commonly measured metabolite, vary markedly around the world and are influenced by many factors including sun exposure, skin pigmentation, covering, season and supplement use. Whilst overt vitamin D deficiency with biochemical consequences presents an increased risk of severe sequelae such as rickets, osteomalacia or cardiomyopathy and usually warrants prompt replacement treatment, the role of vitamin D supplementation in the population presents a different set of considerations. Here the issue is to keep, on average, the population at a level whereby the risk of adverse health outcomes in the population is minimised. This position paper, which complements recently published work from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, addresses key considerations regarding vitamin D assessment and intervention from the population perspective. Summary: This position paper, on behalf of the International Osteoporosis Foundation Vitamin D Working Group, summarises the burden and possible amelioration of vitamin D deficiency in global populations. It addresses key issues including screening, supplementation and food fortification. [ABSTRACT FROM AUTHOR]

UnlabelledOsteoporosis causes an elevated fracture risk. We propose the continued use of T-scores as one means for diagnosis but recommend that, alternatively, hip fracture; osteopenia-associated vertebral, proximal humerus, pelvis, or some wrist fractures; or FRAX scores with ≥3% (hip) or 20% (major) 10-year fracture risk also confer an osteoporosis diagnosis.IntroductionOsteoporosis is a common disorder of reduced bone strength that predisposes to an increased risk for fractures in older individuals. In the USA, the standard criterion for the diagnosis of osteoporosis in postmenopausal women and older men is a T-score of  ≤ -2.5 at the lumbar spine, femur neck, or total hip by bone mineral density testing.MethodsUnder the direction of the National Bone Health Alliance, 17 clinicians and clinical scientists were appointed to a working group charged to determine the appropriate expansion of the criteria by which osteoporosis can be diagnosed.ResultsThe group recommends that postmenopausal women and men aged 50 years should be diagnosed with osteoporosis if they have a demonstrable elevated risk for future fractures. This includes having a T-score of less than or equal to -2.5 at the spine or hip as one method for diagnosis but also permits a diagnosis for individuals in this population who have experienced a hip fracture with or without bone mineral density (BMD) testing and for those who have osteopenia by BMD who sustain a vertebral, proximal humeral, pelvic, or, in some cases, distal forearm fracture. Finally, the term osteoporosis should be used to diagnose individuals with an elevated fracture risk based on the World Health Organization Fracture Risk Algorithm, FRAX.ConclusionsAs new ICD-10 codes become available, it is our hope that this new understanding of what osteoporosis represents will allow for an appropriate diagnosis when older individuals are recognized as being at an elevated risk for fracture.

UnlabelledOn the basis of updated fracture and mortality data, we recommend that the base population values used in the US version of FRAX be revised. The impact of suggested changes is likely to be a lowering of 10-year fracture probabilities.IntroductionEvaluation of results produced by the US version of FRAX indicates that this tool overestimates the likelihood of major osteoporotic fracture. In an attempt to correct this, we updated underlying fracture and mortality rates for the model.MethodsWe used US hospital discharge data from 2006 to calculate annual age- and sex-specific hip fracture rates and age-specific ratios to estimate clinical vertebral fracture rates. To estimate the incidence of any one of four major osteoporotic fractures, we first summed these newly derived hip and vertebral fracture estimates with Olmsted County, MN, wrist and upper humerus fracture rates, and then applied 10-20% discounts for overlap.ResultsCompared with rates used in the current FRAX tool, 2006 hip fracture rates are about 16% lower, with greatest reductions observed among those below age 65 years; major osteoporotic fracture rates are about one quarter lower, with similar reductions across all ages.ConclusionsWe recommend revising the US-FRAX by updating current base population values for hip fracture and major osteoporotic fracture. The impact of these revisions on FRAX is likely to be lowering of 10-year fracture probabilities, but more precise estimates of the impact of these changes will be available after these new rates are incorporated into the FRAX tool.

Byline: D. H. Solomon (1), M. T. Connelly (2), C. J. Rosen (3), B. Dawson-Hughes (4), D. P. Kiel (5), S. L. Greenspan (6), E. S. Leib (7), M. Holick (8), A. H. Miguel (9), J. S. Finkelstein (10) Keywords: Bone mineral densitometry Primary care Osteoporosis Abstract: Large population-based surveys have shown that approximately 30% of people over age 65 years have osteoporosis and that 17% of the population over 65 years will sustain a fracture during their lifetime. Many people with osteoporosis are never being evaluated even though effective treatments are available. We examined why primary care physicians order few bone mineral density scans. We conducted a cross-sectional survey of primary care physicians practicing in any of the six New England states. Target physician specialties included internal medicine, general practitioners/family physicians, and obstetrician-gynecologists who had a facsimile number listed with the American Medical Association. Demographics, practice characteristics, use of bone densitometry, and attitudes regarding osteoporosis, bone densitometry and health maintenance were assessed by questionnaire. Twelve percent (n=494) of the physicians responded to the questionnaire. Respondents were similar to non-respondents with respect to years of practice, training and geographical state, though they were more likely to be female (pa$?0.05). Respondents had a mean age of 51 years, and 51% were trained in internal medicine, 25% in general practice/family practice and 24% in obstetrics-gynecology. The mean number of self-reported bone densitometry referrals per month was 10+-11, and 25% of respondents reported that they referred fewer than 4 patients per month. In adjusted logistic models, factors significantly associated with referring fewer than 4 patients per month were: training in internal medicine (odds ratio (OR) 2.0, 95% confidence interval (CI) 1.0--3.9) or general practice/family practice (OR 2.6, 95% CI 1.3--5.2) versus obstetrics-gynecology practicing in an urban setting (OR 2.5, 95% CI 1.3--4.9) or rural/small town setting (OR 2.2, 95% CI 1.2--4.1) versus a suburban setting spending less than 50% of professional time in patient care (OR 4.0, 95% CI 1.7--9.5) seeing the lowest proportion of postmenopausal women (OR 2.5., 95% CI 1.2--5.3) the belief that calcium and vitamin D are adequate to treat osteoporosis (OR 2.1, 95% CI 1.0--4.5) and the belief that osteoporosis treatment should not be based on bone density results (OR 3.2, 95% CI 1.7--6.1). Potentially modifiable physician beliefs and a number of practice characteristics are associated with low referral rates for bone densitometry. Educational strategies aimed at improving the use of bone density testing should consider these factors. Author Affiliation: (1) Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 221 Longwood Avenue, Suite 341, Boston, MA 02115, USA (2) Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts, USA (3) , Maine Osteoporosis Center, Bangor, Maine, USA (4) USDA Nutrition Center, Tufts University, Boston, Massachusetts, USA (5) , Hebrew Rehabilitation Center for Aged Research and Training Institute and Harvard Medical School Division on Aging, Boston, Massachusetts, USA (6) Division of Endocrinology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA (7) Division of Rheumatology, University of Vermont, Vermont, USA (8) Division of Endocrinology, Boston University Medical Center, Boston, Massachusetts, USA (9) , Procter &amp Gamble Pharmaceuticals, USA (10) Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA Article History: Received Date: 22/03/2002 Accepted Date: 03/09/2002 Article note: Electronic Publication

Byline: M. Blum (1), S. S. Harris (1), A. Must (2), S. M. Phillips (2), W. M. Rand (2), B. Dawson-Hughes (1) Keywords: Key words:Bone mass -- Bone mineral density -- Household tobacco smoke Abstract: Subjects exposed to environmental tobacco smoke have been found to be at increased risk for several health problems. Whether exposure to passive tobacco smoke is associated with reduced bone mineral density (BMD) is unknown. In order to examine this, we measured BMD in 154 healthy premenopausal women (age range 40--45 years). BMD of the total hip, femoral neck, lumbar spine and total body was measured by dual-energy X-ray absorptiometry (DXA). Data were collected on exposure to household tobacco smoke from age 10 years to the present as well as on other lifestyle factors related to bone mass. We found that 67.5% of the subjects had a history of household tobacco smoke exposure. Subjects exposed to household tobacco smoke had a mean adjusted BMD that was significantly lower at the total hip (p= 0.021) and femoral neck (p= 0.018) compared with subjects who were not exposed. In addition, duration of household tobacco smoke exposure was negatively associated with BMD at the total hip (p=0.010), femoral neck (p= 0.004), lumbar spine (p=0.037) and total body (p=0.031). Subjects exposed to household tobacco smoke for 15 years or more had mean adjusted BMD that was 4% lower at the total body, and more than 8% lower at the total hip, femoral neck and lumbar spine, compared with subjects who were not exposed. In conclusion, household tobacco smoke exposure during adolescence and young adulthood was found to be negatively associated with BMD at the total hip and femoral neck, and duration of exposure was negatively associated with BMD at the total hip, femoral neck, lumbar spine and total body in premenopausal women. Author Affiliation: (1) Calcium and Metabolic Bone Laboratory, Jean Mayer United States Department of Agriculture Human Nutrition Research Center on Aging at Tufts University , US (2) Department of Family Medicine and Community Health, Tufts University, Boston, Massachusetts, USA, US Article note: Received: 17 December 2001 / Accepted: 16 February 2002

Byline: B. Dawson-Hughes (1), S. S. Harris (1), G. E. Dallal (1), D. R. Lancaster , (2), Qi Zhou (2) Keywords: Key words:Bone medication -- Calcium -- Estrogen -- Health Maintenance Organization -- Survey Abstract: This study was conducted to determine the prevalence of the use of calcium supplements and of prescription medications to prevent or treat osteoporosis in men and women in a large New England Medicare Health Maintenance Organization (HMO). A two-page diet, medication use and medical history questionnaire was sent to a random sample of 9000 out of 82985 members and 2932 (32.6%) responded. Over 97% of the participants were Caucasian and 64.7% were female. The mean ages of the men and women were 74.4 +- 5.8 and 74.6 +- 6.2 years, respectively. Sixty-nine percent of the men and 59% of the women consumed two or fewer servings of dairy foods per day. Calcium supplement use was more prevalent among the women than the men (66.8% vs 24.9%, p&lt 0.001). Men and women with higher dairy food intakes were more likely to take calcium supplements than were those with lower dairy intakes. Prescription bone medications (including bisphosphonates, raloxifene and calcitonin) were used currently by 17.5% of the women and 2.3% of the men (p&lt 0.001). An additional 16.2% of the women currently took estrogen. Among the women, bone medication use did not change with age but estrogen use declined with increasing age. Among women age 80+ years, 15.6% used bone medications and 4.9% took estrogen. According to a national survey, more than half the US Caucasian female population over age 80 years has bone density low enough to warrant treatment under current guidelines. Based on the results of this survey, many elderly men and women may benefit from increased utilization of calcium supplements and bone-active medications. Author Affiliation: (1) Calcium and Bone Metabolism Laboratory at the Jean Mayer USDA Human Nutrition Research Center, Boston, MA , US (2) Tufts Health Plan, Watertown, MA, USA, US Article note: Received: 3 January 2002 / Accepted: 19 February 2002

Byline: J. A. Kanis (1), D. Black (2), C. Cooper (3), P. Dargent (4), B. Dawson-Hughes (5), C. De Laet (6), P. Delmas (7), J. Eisman (8), O. Johnell (9), B. Jonsson (10), L. Melton (11), A. Oden (12), S. Papapoulos (13), H. Pols (14), R. Rizzoli (15), A. Silman (16), A. Tenenhouse , on behalf of the International Osteoporosis Foundation and the National Osteoporosis Foundation, USA (17) Keywords: Key words: Abstract: Author Affiliation: (1) WHO Centre for Metabolic Bone Diseases, University of Sheffield, UK, GB (2) Division of Clinical Epidemiology, University of California at San Francisco, USA, GB (3) MRC Environmental Epidemiology Unit, University of Southampton, UK, GB (4) INSERM, Paris, France, FR (5) USDA Human Research Center, Tufts University, Boston, USA (President, NOF), US (6) Institute for Public Health, Erasmus MC, Rotterdam, The Netherlands, NL (7) INSERM Research Unit, Hopital Edouard Herriot, Lyon, France (President, IOF), FR (8) Garvan Institute of Medical Research, St Vincent's Hospital, Australia, AU (9) Department of Orthopaedics, Malmo General Hospital, Sweden, SE (10) Dept Economics, Stockholm School of Economics, Sweden, SE (11) Section of Clinical Epidemiology, Mayo Clinic, Rochester, USA, US (12) Consulting Statistician, Gothenburg, Sweden, SE (13) Department of Endocrinology, Leiden University Medical Center, The Netherlands, NL (14) Ziekenhuis Dijkzigt, Rotterdam, The Netherlands, NL (15) Division of Bone Diseases, University Hospital, Geneva, Switzerland, CH (16) ARC Epidemiology Research Unit, University of Manchester, UK , GB (17) Division of Bone Metabolism, The Montreal General Hospital, Canada, CA Article note: Received: 18 February 2002 / Accepted: 22 February 2002

Byline: M. Blum (1), S. S. Harris (1), A. Must (2), S. M. Phillips (2), W. M. Rand (2), B. Dawson-Hughes (1) Keywords: Key words:Adolescence -- Body mass index -- Bone mass -- Menarche -- Weight Abstract: Adolescence is a critical time for skeletal growth and mineralization. Exposure to protective or detrimental factors during this period may influence peak bone mass attainment and subsequent development of osteoporosis. In order to evaluate the association of body size during adolescence with subsequent adult bone mass, we conducted a follow-up study of a community-based cohort of girls who participated in a growth and sexual maturation study 30 years ago. Data from the original study included age at menarche, height at menarche and weight at menarche. Follow-up evaluation of 119 subjects, now premenopausal women ages 40--45 years, included bone mineral density (BMD) measurements of the total body, lumbar spine, femoral neck, total hip, and ultradistal radius by dual-energy X-ray absorptiometry. After adjustment for current adult weight and other factors related to bone mass, weight at menarche was found to be positively associated with subsequent adult BMD. Similarly, body mass index (BMI) at menarche was positively associated with adult BMD. In contrast, age at menarche was not found to predict adult BMD. When the subjects were divided into quartiles based on their BMI at menarche, subjects in the lowest quartile of BMI at menarche had adult mean BMD that was 8--15% lower at the measured sites compared with subjects in the highest quartile of BMI at menarche. In conclusion, low body weight and low BMI at menarche appear to be significant predictors of reduced bone mass in healthy premenopausal women ages 40--45 years. Author Affiliation: (1) Calcium and Metabolic Bone Laboratory, Jean Mayer United States Department of Agriculture Human Nutrition Research Center on Aging at Tufts University , US (2) Department of Family Medicine and Community Health, Tufts University, Boston, Massachusetts, USA, US Article note: Received: 15 August 2000 / Accepted: 2 January 2001

Byline: R. P. Heaney (1), S. Abrams (2), B. Dawson-Hughes (3), A. Looker (4), A. Looker (5), R. Marcus (6), V. Matkovic (7), C. Weaver (8) Author Affiliation: (1) Creighton University, Omaha, NE, US (2) Children's Nutrition Research Center, Houston, TX, US (3) Tufts University, Boston, MA, US (4) National Osteoporosis Foundation, Washington, DC, US (5) National Center for Health Statistics, Hyattsville, MD, US (6) Stanford University, Palo Alto, CA, US (7) Ohio State University, Columbus, OH , US (8) Purdue University, West Lafayette, IN, USA, US

Byline: P. Lips (1), M. C. Chapuy (2), B. Dawson-Hughes (3), H. A. P. Pols (4), M. F. Holick (5) Keywords: Key words:Cross calibration of 25(OH)D assay -- 25-hydroxyvitamin D assay -- 25-hydroxyvitamin D measurement -- Interlaboratory comparison -- Vitamin D deficiency Abstract: Vitamin D status is usually assessed by measuring the serum 25-hydroxyvitamin D (25(OH)D) concentration. This mainly depends on sunshine exposure, nutrition and age. Interlaboratory variation may hamper comparison between results from different populations. This study reports cross-calibration of the 25(OH)D assays of five laboratories. In study 1, serum 25(OH)D was measured with three different assays in 104 serum samples from a large vitamin D supplementation study. The mean serum 25(OH)D level was 80% higher when measured by competitive protein binding (CPB) assay than by high-performance liquid chromatography (HPLC), while radioimmunoassay (RIA) gave intermediate values. The highest correlation was observed between RIA and HPLC (r= 0.84, p&lt 0.01). Of the serum 25(OH)D values in the lowest quartile by HPLC, 25% were not recognized by CPB and 21% were not recognized by RIA as belonging to the lowest quartile. In study 2, the five laboratories analyzed serum 25(OH)D in eight serum samples covering the concentration range very low to high, with five different assays. The differences between the mean values for serum 25(OH)D between the laboratories with the highest and lowest values was 38%. The ranking order of individual samples according to the serum 25(OH)D value was very similar in all laboratories. The results show that 25(OH)D values from different laboratories can not be assumed to be comparable unless a careful cross-calibration has been performed. Author Affiliation: (1) Department of Endocrinology, Academisch Ziekenhuis Vrije Universiteit, Amsterdam, The Netherlands, NL (2) Hopital Edouard Herriot, Pavillon F, Lyon Cedex, France, FR (3) Department of Agriculture, Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts, USA, US (4) Department of Endocrinology, Academisch Ziekenhuis Dijkzigt, Rotterdam, The Netherlands , NL (5) Vitamin D, Skin and Bone Research Laboratory, Boston University, Boston, Massachusetts, USA, US Article note: Received: 1 May 1998 / Accepted: 3 September 1998

An editorial is presented regarding FRAX and ethnicity. It mentions the key messages from the epidemiology of fracture globally, key considerations in building risk assessment tools, the specific contribution of race/ethnicity and practical considerations related to any move to alter race/ethnicity categorization or remove them entirely.

Summary: Guidance is provided in an international setting on the assessment and specific treatment of postmenopausal women at low, high and very high risk of fragility fractures. Introduction: The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2019. This manuscript seeks to apply this in an international setting, taking additional account of further categorisation of increased risk of fracture, which may inform choice of therapeutic approach. Methods: Clinical perspective and updated literature search. Results: The following areas are reviewed: categorisation of fracture risk and general pharmacological management of osteoporosis. Conclusions: A platform is provided on which specific guidelines can be developed for national use to characterise fracture risk and direct interventions. [ABSTRACT FROM AUTHOR]

Low calcium intake may adversely affect bone health in adults. Recognizing the presence of low calcium intake is necessary to develop national strategies to optimize intake. To highlight regions where calcium intake should be improved, we systematically searched for the most representative national dietary calcium intake data in adults from the general population in all countries. We searched 13 electronic databases and requested data from domain experts. Studies were double-screened for eligibility. Data were extracted into a standard form. We developed an interactive global map, categorizing countries based on average calcium intake and summarized differences in intake based on sex, age, and socioeconomic status. Searches yielded 9780 abstracts. Across the 74 countries with data, average national dietary calcium intake ranges from 175 to 1233 mg/day. Many countries in Asia have average dietary calcium intake less than 500 mg/day. Countries in Africa and South America mostly have low calcium intake between about 400 and 700 mg/day. Only Northern European countries have national calcium intake greater than 1000 mg/day. Survey data for three quarters of available countries were not nationally representative. Average calcium intake is generally lower in women than men, but there are no clear patterns across countries regarding relative calcium intake by age, sex, or socioeconomic status. The global calcium map reveals that many countries have low average calcium intake. But recent, nationally representative data are mostly lacking. This review draws attention to regions where measures to increase calcium intake are likely to have skeletal benefits. [ABSTRACT FROM AUTHOR]

The place of calcium supplementation, with or without concomitant vitamin D supplementation, has been much debated in terms of both efficacy and safety. There have been numerous trials and meta-analyses of supplementation for fracture reduction, and associations with risk of myocardial infarction have been suggested in recent years. In this report, the product of an expert consensus meeting of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Foundation for Osteoporosis (IOF), we review the evidence for the value of calcium supplementation, with or without vitamin D supplementation, for healthy musculoskeletal ageing. We conclude that (1) calcium and vitamin D supplementation leads to a modest reduction in fracture risk, although population-level intervention has not been shown to be an effective public health strategy; (2) supplementation with calcium alone for fracture reduction is not supported by the literature; (3) side effects of calcium supplementation include renal stones and gastrointestinal symptoms; (4) vitamin D supplementation, rather than calcium supplementation, may reduce falls risk; and (5) assertions of increased cardiovascular risk consequent to calcium supplementation are not convincingly supported by current evidence. In conclusion, we recommend, on the basis of the current evidence, that calcium supplementation, with concomitant vitamin D supplementation, is supported for patients at high risk of calcium and vitamin D insufficiency, and in those who are receiving treatment for osteoporosis. [ABSTRACT FROM AUTHOR]