Search

Background and objectives: Although nutrition is important to bone health, the impact of different dietary patterns on bone density and fracture is unclear. The aim of this study was to synthesise conflicting evidence from observational studies to determine associations of empirically derived dietary patterns with bone density and fracture in healthy adults. Method: A systematic review (PROSPERO CRD42017071676) with meta-analysis where possible (for hip fracture) and otherwise with best-evidence synthesis. Results: Twenty-one studies were included in the best-evidence synthesis and four in the meta-analysis. Meta-analysis demonstrated a protective association between 'healthy' pattern score and hip fracture (risk ratio 0.73; 95% confidence interval: 0.56, 0.96; I2 = 95%) for highest compared to lowest 'healthy' pattern score category. In best-evidence synthesis, there was conflicting evidence for associations of both pattern scores with bone density at all sites and total fractures and for 'Western' score and hip fracture. No study reported detrimental effects of 'healthy' patterns, or beneficial effects of 'Western' patterns. Discussion: The results suggest that general practitioners promoting a 'healthy' dietary pattern is, at worst, unlikely to be detrimental for bone health and, at best, may reduce hip fracture.

Objective To investigate the impact of total number and patterns of comorbidities on health-related quality of life (HRQoL) and identify the most prevalent and influential comorbidity patterns in people with OA over 10 years. Methods Participants from the Tasmanian Older Adult Cohort aged 50–80 years, with self-reported OA and data on comorbidities and HRQoL were included. Participants were interviewed at baseline (n = 398), 2.5 (n = 304), 5 (n = 269) and 10 years (n = 191). Data on the self-reported presence of 10 chronic comorbidities were collected at baseline. HRQoL was assessed using the Assessment of Quality of Life-4-Dimensions. The long-term impacts of the number and of the nine most prevalent combinations of cardiovascular (CVD), non-OA musculoskeletal (Ms), metabolic and respiratory comorbidities on HRQoL over 10 years were analysed using linear mixed regressions. Results Compared with comorbidity-free OA participants, the health state utility (HSU) of those with 2 or ≥3 comorbidities was respectively −0.07 and −0.13 units lower over 10 years, largely driven by reduced scores for independent living, social relationships and psychological wellness. Comorbidity patterns including ‘CVD+Ms’ were most influential, and associated with up to 0.13 units lower HSU, mostly through negative impacts on independent living (up to −0.12), psychological wellness (up to −0.08) and social relationship (up to −0.06). Conclusion Having more comorbidities negatively impacted OA patients’ long-term HRQoL. OA patients with CVD and non-OA musculoskeletal conditions had the largest HSU impairment, and therefore optimal management and prevention of these conditions may yield improvements in OA patients’ HRQoL.

Background: Abnormal infrapatellar fat pad (IPFP) plays a detrimental role in knee osteoarthritis (OA) by producing pro-inflammatory cytokines. IPFP may interact with synovium because of their adjacent anatomical positions; however, whether abnormal IPFP can contribute to effusion-synovitis in knee OA is unclear.Methods: Among 255 knee OA patients, IPFP signal intensity alteration represented by four measurement parameters [standard deviation of IPFP signal intensity (IPFP sDev), upper quartile value of IPFP high signal intensity region (IPFP UQ (H)), ratio of IPFP high signal intensity region volume to whole IPFP volume (IPFP percentage (H)), and clustering factor of IPFP high signal intensity (IPFP clustering factor (H))] was measured quantitatively at baseline and two-year follow-up using magnetic resonance imaging (MRI). Effusion-synovitis of the suprapatellar pouch and other cavities were measured both quantitatively and semi-quantitatively as effusion-synovitis volume and effusion-synovitis score at baseline and two-year follow-up using MRI. Mixed-effects models were used to assess the associations between IPFP signal intensity alteration and effusion-synovitis over two years.Results: In multivariable analyses, all four parameters of IPFP signal intensity alteration were positively associated with total effusion-synovitis volume and effusion-synovitis volumes of the suprapatellar pouch and of other cavities over two years (all P＜0.05). They were also associated with the semi-quantitative measure of effusion-synovitis except for IPFP percentage (H) with effusion-synovitis in other cavities. Conclusion: Quantitatively measured IPFP signal intensity alteration is positively associated with joint effusion-synovitis in people with knee OA, suggesting that IPFP signal intensity alteration may contribute to effusion-synovitis and a coexistent pattern of these two imaging biomarkers could exist in knee OA patients.

Finding appropriate pharmacological options to treat osteoarthritis (OA) remain challenging. We aimed to determine the efficacy and safety of all types of turmeric extracts for the management of knee OA. Sixteen RCTs of up to 16 weeks duration including 1810 adults with knee OA were included. Eleven RCTs compared the efficacy of turmeric extracts with placebo and five with active comparators (NSAIDs). The overall risk bias of included RCTs was moderate. Turmeric extracts significantly reduced knee pain (SMD − 0.82, 95% CI − 1.17 to − 0.47, I2 = 86.23%) and improved physical function (SMD − 0.75, 95% CI − 1.18 to − 0.33, I2 = 90.05%) compared to placebo but had similar effects compared to NSAIDs. BMI was the major contributor to heterogeneity in the placebo-controlled studies (explained 37.68% and 67.24%, respectively, in the models) and modified the effects of the turmeric on pain and physical function with less improvement with higher BMI (SMD 0.26 95% CI 0.04 to 0.48; SMD 0.48 95% CI 0.21 to 0.74). No significant between-group differences were reported for either biochemical markers or imaging outcomes. Turmeric extracts had 12% fewer adverse events than NSAIDs and similar rates to placebo. Turmeric extract is a safe and effective option for the symptomatic management of knee OA, compared to placebo or NSAIDs. However, current evidence from short-term studies is heterogeneous and has moderate risk of bias leading to some uncertainty about the true effect.

Finding appropriate pharmacological options to treat osteoarthritis (OA) remain challenging. We aimed to determine the efficacy and safety of all types of turmeric extracts for the management of knee OA.Sixteen RCTs of up to 16 weeks duration including 1810 adults with knee OA were included. Eleven RCTs compared the efficacy of turmeric extracts with placebo and five with active comparators (NSAIDs). The overall risk bias of included RCTs was moderate. Turmeric extracts significantly reduced knee pain (SMD - 0.82, 95% CI - 1.17 to - 0.47, I

Background To describe demographic and clinical factors associated with the presence and incidence of depression and explore the temporal relationship between depression and joint symptoms in patients with symptomatic knee osteoarthritis (OA). Methods Three hundred ninety-seven participants were selected from a randomized controlled trial in people with symptomatic knee OA and vitamin D deficiency (age 63.3 ± 7.1 year, 48.6% female). Depression severity and knee joint symptoms were assessed using the patient health questionnaire (PHQ-9) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), respectively, at baseline and 24 months. Results The presence and incidence of depression was 25.4 and 11.2%, respectively. At baseline, having younger age, a higher body mass index (BMI), greater scores of WOMAC pain (PR: 1.05, 95%CI:1.03, 1.07), dysfunction (PR: 1.02, 95%CI:1.01, 1.02) and stiffness (PR: 1.05, 95%CI: 1.02, 1.09), lower education level, having more than one comorbidity and having two or more painful body sites were significantly associated with a higher presence of depression. Over 24 months, being female, having a higher WOMAC pain (RR: 1.05, 95%CI: 1.02, 1.09) and dysfunction score (RR: 1.02, 95%CI: 1.01, 1.03) at baseline and having two or more painful sites were significantly associated with a higher incidence of depression. In contrast, baseline depression was not associated with changes in knee joint symptoms over 24 months. Conclusion Knee OA risk factors and joint symptoms, along with co-existing multi-site pain are associated with the presence and development of depression. This suggests that managing common OA risk factors and joint symptoms may be important for prevention and treatment depression in patients with knee OA. Trial registration ClinicalTrials.gov identifier: NCT01176344. Anzctr.org.au identifier: ACTRN12610000495022.

Background: More work is needed to understand the burden of comorbidities in people with multiple sclerosis (MS). Objective: To assess prevalence of 30 comorbidities and impacts of comorbidities on employment outcomes in a working-aged MS cohort. Methods: Participants were from the Australian MS Longitudinal Study ( n = 929). Information on specific comorbidity was obtained (whether or not each was present, doctor-diagnosed, limited their activities and being treated). Results: Comorbidities most frequently reported to limit activities were osteoarthritis (51%), migraines (40%), anxiety (33%), depression (29%) and allergies (18%). Mean MS-related work productivity loss in past 4 weeks was 1.3 days for those without comorbidities and 2.5 days for those with any comorbidity. The annual population costs of work productivity loss were highest for people with depression, allergies, anxiety, migraines and osteoarthritis. Higher number of comorbidities was associated with more work productivity loss and a higher likelihood of not working. These associations were substantially reduced after adjustment for MS symptom severity. Conclusions: Comorbidities substantially impact employment outcomes and these effects were mainly mediated through MS symptom severity. This suggests that optimal and simultaneous management of comorbidities may be a viable strategy to reduce MS symptom severity, which in turn could improve employment outcomes.

Current pharmacologic therapies for patients with osteoarthritis are suboptimal.To determine the efficacy ofRandomized, double-blind, placebo-controlled trial. (Australian New Zealand Clinical Trials Registry: ACTRN12618000080224).Single-center study with patients from southern Tasmania, Australia.70 participants with symptomatic knee osteoarthritis and ultrasonography-defined effusion-synovitis.2 capsules of CL (The 2 primary outcomes were changes in knee pain on a visual analogue scale (VAS) and effusion-synovitis volume on magnetic resonance imaging (MRI). The key secondary outcomes were change in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and cartilage composition values. Outcomes were assessed over 12 weeks.CL improved VAS pain compared with placebo by -9.1 mm (95% CI, -17.8 to -0.4 mm [Modest sample size and short duration.CL was more effective than placebo for knee pain but did not affect knee effusion-synovitis or cartilage composition. Multicenter trials with larger sample sizes are needed to assess the clinical significance of these findings.University of Tasmania and Natural Remedies Private Limited.

Summary Background & aims The evidence of benefiting from a high-quality diet for knee osteoarthritis (OA) joint structures, symptoms, and systemic abnormalities is limited. Clarifying the relationship between diet quality and knee OA could provide useful information for knee OA management. To investigate the associations between diet quality and knee joint structures, symptoms, lower limb muscle strength, depressive symptoms, and quality of life in people with knee OA. Methods This study was a post-hoc, exploratory analysis using data from a randomized controlled trial in symptomatic knee OA participants with a follow-up time of 24 months. In brief, eligible participants of the original study were aged 50–79 years, had symptomatic knee OA, and had a pain of 20–80 mm on a 100-mm visual analog scale. After excluding the patients without information on diet quality, 392 participants were included in this post-hoc analysis. Diet quality was assessed at baseline using the Australian Recommended Food Score (ARFS) which includes subscores of vegetable, fruit, grain, dairy products, fat, and alcohol. Knee joint structures (including cartilage volume, cartilage defect, bone marrow lesions, and effusion-synovitis volume assessed by magnetic resonance imaging), OA symptoms, lower limb muscle strength, depressive symptoms, and quality of life were assessed at baseline and follow up. Mixed-effects models were used to assess the associations of diet quality with those outcomes. Results Diet quality mainly reflect diet variety within the core food was not associated with knee structures and OA symptoms, but was associated with greater lower limb muscle strength (β = 0.66, P = 0.001), lower depressive symptom (β = -0.08, P = 0.001), and better quality of life (β = -0.06, P = 0.002). In further analyses of food group-based sub-scores, only the vegetable sub-score had the similar associations with lower limb muscle strength (β = 1.03, P = 0.004), depressive symptom (β = -0.17, P Conclusions Higher diet quality, mainly vegetable diet quality, is associated with greater lower limb muscle strength, less depressive symptoms, and higher quality of life in knee OA patients, suggesting higher diet quality may have protective effects on knee OA.

Objective To describe the impact of OA on health-related quality of life (HRQoL) in the forms of health state utilities (HSUs) and health-dimension scores, and to compare the longitudinal changes in HRQoL for people with and without OA, using an Australian population-based longitudinal cohort. Methods Participants of the Tasmanian Older Adult Cohort with data on OA diagnosis and HRQoL were included [interviewed at baseline (n = 1093), 2.5 years (n = 871), 5 years (n = 760) and 10 years (n = 562)]. HRQoL was assessed using the Assessment of Quality of Life four-dimensions and analysed using multivariable linear mixed regressions. Results Compared with participants without OA, HSUs for those with OA were 0.07 (95% confidence interval: 0.09, 0.05) units lower on average over 10 years. HSUs for participants with knee and/or hip OA were similar to those with other types of OA at the 2.5 year follow-up and then diverged, with HSUs of the former being up to 0.09 units lower than the latter. Those with OA had lower scores for psychological wellness, independent living and social relationships compared with those without OA. Independent living and social relationships were mainly impacted by knee and/or hip OA, with the effect on the former increasing over time. Conclusion Interventions to improve HRQoL should be tailored to specific OA types, health dimensions, and times. Support for maintaining psychological wellness should be provided, irrespective of OA type and duration. However, support for maintaining independent living could be more relevant to knee and/or hip OA patients living with the disease for longer.

Summary Objectives To examine the cross-sectional and longitudinal associations of dietary patterns with knee symptoms and structures in patients with knee osteoarthritis (OA). Methods Participants with symptomatic knee OA were recruited from a randomised, placebo-controlled trial conducted in Tasmania (N = 259) and Victoria (N = 133). Diet was assessed by the Anti-Cancer Council of Victoria food frequency questionnaire. Factor analysis was used to identify dietary patterns. Knee symptoms were assessed using Western Ontario and McMaster Universities Arthritis Index (WOMAC) and structures using MRI. Multivariable linear regressions were used to examine associations. Results Three dietary patterns (“high-fat”, “healthy” and “mixed”) were identified in whole sample. Participants with higher “healthy pattern” score had lower total WOMAC, pain, function and stiffness scores at baseline but the associations were not significant over 24 months. Three (“western”, “vegetable and meat” and “mediterranean”) and two (“processed” and “vegetable”) patterns were identified in Tasmania and Victoria, respectively. Cross-sectionally, only “mediterranean pattern” and “vegetable pattern” scores were significantly and negatively associated with total WOMAC or function scores. Longitudinally, participants with higher “western pattern” had worsening function (β: 0.35, 95%CI: 0.03, 0.67) and total WOMAC (β: 0.40, 95%CI: 0.07, 0.72) scores; furthermore, “vegetable pattern” was associated with decreased WOMAC stiffness score (β: −0.47, 95%CI: −0.93, −0.02). In contrast, dietary patterns were largely not associated with structural changes. Conclusion Some healthy dietary patterns were associated with reduced joint symptoms but dietary patterns were not associated with joint structure in this sample with knee OA. Further studies are required to confirm these findings.

Background The effect of vitamin D supplementation on postural muscles of the trunk is of particular interest because low 25‐hydroxyvitamin D [25(OH) D] levels are associated with decreased postural balance and increased risk of falls. Understanding the role of vitamin D supplementation plays in trunk muscle function of older adults is necessary, as this is a potentially modifiable factor to improve postural muscle function and decrease the risk of falling of older adults. The objective of this randomized controlled trial was to evaluate the effect of 12 months of vitamin D supplementation compared with placebo, on morphology and function of the trunk muscles of adults aged 50 to 79 years with low serum 25(OH) D levels. Methods This was a secondary analysis of a randomized, placebo‐controlled, and double‐blind clinical trial conducted between June 2010 and December 2013 in Tasmania, Australia. The clinical trial was registered with the Australian New Zealand clinical trial registration agency, ClinicalTrials.gov identifier: NCT01176344; Australian New Zealand Clinical Trials Registry: ACTRN 12610000495022. Participants were aged 50–79 years with ongoing symptoms of knee osteoarthritis and with low serum [25(OH) D] (12.5 to 60 nmol/L, 5.2 to 24 ng/mL). Participants were randomly assigned to either monthly 50 000 IU oral vitamin D3 (n = 104) or an identical placebo (n = 113) for 24 months as per clinical trial protocol. The primary outcomes in this pre‐specified secondary analysis were between‐group differences in change in size of rectus abdominis, transversus abdominis, internal oblique, external oblique, and lumbar multifidus muscles and function (assessed by change in thickness on contraction) of these muscles (excepting rectus abdominis) from baseline to 12 months. Muscle size was assessed using ultrasound imaging. Results Of 217 participants (mean age 63 years, 48% women), 186 (85.7%) completed the study. There were no significant between‐group differences in change in size or function of the abdominal or multifidus muscles after 12 months of vitamin D supplementation. Conclusions A monthly dose of 50 000 IU of vitamin D3 alone for 12 months does not affect the size or ability to contract trunk muscles of independent community‐dwelling older adults with symptomatic knee osteoarthritis and low serum 25(OH) D levels regardless of body mass index status or degree of vitamin D deficiency. An effect of vitamin D supplementation on other aspects of trunk muscle function such as strength, power, or physical function cannot be ruled out.

Knee osteoarthritis (OA) is the most common form of OA which affects knee joints and there is currently no disease-modifying treatment available for OA. Therefore, an ideal strategy to prevent the development of OA is to identify and intervene at the modifiable risk factors for the development and progression of OA. Early-life factors such as obesity and malalignment may affect the mechanical aspect of the knee (i.e. alterations in normal knee kinematics) and could be the risk factor for the development of knee OA in later life. Identifying early-life (gestational factors, congenital defects, childhood, adolescence, early adulthood) factors which affect the development of knee OA in later stages of the life may help to develop targeted prevention programs in early-life itself to prevent the development of knee OA. Hence, this systematic review protocol provides the method to be used to comprehensively summarise the existing evidence on early life modifiable risk factors associated with the development and progression of knee OA.

More research is needed to understand the contribution of comorbidities to MS symptomatology.To examine the dose-response relationship between the number of comorbidities and severity of MS symptoms and to assess the relative contribution of comorbidity groups and individual comorbidities to the severity of each symptom.We surveyed 1223 participants of the Australian MS Longitudinal Study for the presence of 30 comorbidities and the severity of 13 MS symptoms (0-10 scale). The associations between comorbidities and symptoms were assessed using negative binomial regression. The relative contributions of comorbidities to the severity of symptoms were assessed using general dominance analysis.Higher number of comorbidities was most strongly associated with a higher severity of pain and feelings of anxiety and depression (ratios of means ≥ 0.12 per comorbidity increase). Comorbidities explained between 3.7% (spasticity) and 22.0% (feelings of anxiety) of the total variance of symptom severity. Mental health and musculoskeletal disorders contributed most strongly to the severity of the most common symptoms in MS.Our findings support that early recognition and optimal management of comorbidities, particularly of mental health and musculoskeletal disorders, could have a positive impact on the severity of symptoms of people with MS.

Little is known about the change in prevalence of comorbidities during the disease course of people with multiple sclerosis (MS) and whether the prevalences vary by MS onset type.To calculate the change in prevalence of comorbidities between symptom onset and the time of study, to compare the prevalences of comorbidities with those in the Australian population at the time of study and to examine onset-type differences.Comorbidity data from 1518 participants of the Australian MS Longitudinal Study and Australian population comparator data (2014-2015 National Health Survey) were used. The change in prevalence between time points and prevalence ratios (PR) at the time of study (crude, age and sex adjusted, and stratified by onset type) was calculated.Comorbidities were common, and those with the largest increases in prevalence between MS symptom onset and the time of study were depression (+ 26.9%), anxiety (+ 23.1%), hypertension (+ 21.9%), elevated cholesterol (+ 16.3%), osteoarthritis (+ 17.1%), eye diseases (+ 11.6%), osteoporosis (+ 10.9%) and cancer (+ 10.3%). Compared to the general population and after age and sex adjustment, participants had a significantly higher prevalence for 14/19 comorbidities at the time of study. The associations were strongest for anaemia, cancer (both PR 4.00), anxiety, depression, migraine (all PR 3.00), psoriasis and epilepsy (both PR 2.00). No significant differences were seen by onset type.Comorbidities are common at MS symptom onset and increase with MS duration. Having MS may thus contribute to accrual of comorbidities. This emphasises the importance of optimal screening for and management of comorbidities in early MS and throughout the disease course.

Osteoporosis and osteopenia are increasingly prevalent conditions among older adults. Not only do the fractures associated with poor bone health have significant health consequences for the individual, but also their economic impact is placing increasing financial burden on governments and society. This study aimed to determine the direct economic cost of osteoporosis, osteopenia, and fractures among Australians aged 50 years and older in 2017. This study uses previous Australian data on the incidence and prevalence of osteoporosis and osteopenia together with recent Australian data on health service utilization after fracture to provide an estimate of the economic burden of osteoporosis. A bottom-up costing approach was used to determine the average direct health care and non-health care total costs of a fracture, as well as the average community health service costs of managing individuals with osteoporosis or osteopenia. The total direct cost of osteoporosis in Australia in 2017 was estimated to be $3.44 billion (AUD 2017, USD 2.77 billion). Treatment of fractures accounted for 68% of total direct costs, and non-fracture management of osteoporosis accounted for 32%. Hip fractures accounted for the highest proportion (43%) of the total direct cost of fractures, although fractures at "other" sites accounted for 38.5%. Fractures among individuals aged 70 years and older accounted for 74% of the direct costs (55% and 19% in women and men, respectively). Fracture costs in those with osteopenia accounted for 50% of direct fracture treatment costs. This up-to-date cost analysis estimated that costs in 2017 were three times higher than in 2007. These estimates will aid clinicians, policy makers, researchers, and health care organizations to acknowledge the economic importance of reducing osteoporosis-related fractures and associated costs. This provides a strong public health case to promote bone health that will assist in reducing future fracture-related costs. © 2018 American Society for Bone and Mineral Research.

Both areal bone mineral density (aBMD) and bone microarchitecture have been associated with vertebral deformity (VD), but there are limited data on the utility of bone microarchitecture measures in combination with aBMD in discriminating VD. This study aimed to describe whether radial bone microarchitecture measures alone or in combinations with radial volumetric bone mineral density (vBMD) or spine aBMD can improve discrimination of VD in adults.Data on 196 subjects (mean age (standard deviation, SD) = 72 (7) years, female 46%) were utilized. VD of T4-L4 and spine aBMD were measured using dual-energy X-ray absorptiometry. VD was defined if anterior to posterior height ratio was more than 3-SD, 4-SD below, or25% decrease compared with the sex-matched normal means. Bone microarchitecture parameters at distal radius were collected using high-resolution peripheral quantitative computed tomography and analyzed using StrAx.The strongest associations were seen for the cortical thickness (odds ratios (ORs): 2.63/SD decrease for 25% and 2.38/SD decrease for 3-SD criterion) and compact cortical area (OR: 3.33/SD decrease for 4-SD criterion). The area under the receiver operating characteristic curve (AUC) for spine aBMD for VD was 0.594, 0.597, and 0.634 for 25%, 3-SD and 4-SD criteria, respectively (all p0.05). Compact cortical area, cortical thickness and compact cortical thickness alone had the largest AUCs for VD (0.680-0.685 for 25% criterion, 0.659-0.674 for 3-SD criterion, and 0.699-0.707 for 4-SD criterion). Adding spine aBMD or radial vBMD to each cortical measure did not improve VD discrimination (∆ AUC 0.8%-2.1%).Cortical measures had the best utility for discriminating VD when used alone. Adding either spine aBMD or radial vBMD did not improve the utility of cortical measures.

To describe the associations of baseline dietary pattern scores with falls risk, bone mineral density (BMD), and incident fractures measured over 10 years in older adults. Dietary patterns were identified using exploratory factor analysis. Femoral neck (FN), hip, and lumbar spine (LS) BMD were measured using dual-energy X-ray absorptiometry, falls risk z-score using the Physiological Profile Assessment, and incident fractures by self-report. Linear mixed-effects models and log-binomial regression were used to estimate associations between baseline dietary pattern z-scores and outcomes. Of 1098 participants at baseline, 567 were retained over 10 years. Four dietary patterns were derived: fruit and vegetable (FV), animal protein (AP), snack, and Western. FV pattern reduced falls risk at baseline by β = 0.05–0.08/SD and the annual decreases of FN and hip BMD were less for higher Western or AP pattern scores in all populations and women. The annual increase in LS of the entire population was greater with higher scores of FV, AP, and Western patterns (all β = 0.001 g/cm2/year/SD, p

Summary Objectives To validate a method to measure the morphological parameters of the proximal tibiofibular joint (PTFJ) in patients with knee osteoarthritis (OA). Methods 408 participants were examined in this cross-sectional subject-based study. We calculated the fibular contacting area of PTFJ (S) and its projection areas onto the horizontal plane (load-bearing area, Sτ), the sagittal plane (lateral stress-bolstering area, Sφ) and the coronal plane (posterior stress-bolstering area, Sυ). Joint space narrowing (JSN) and osteophyte was measured using radiographs. Cartilage defects, bone marrow lesions (BMLs) and cartilage volume were evaluated using magnetic resonance imaging (MRI). Results The average PTFJ fibular contacting area was 2.4 cm2 (SD, ±0.7 cm2). Intra-observer and inter-observer reliabilities of measures of PTFJ morphological parameters were excellent (≥0.90). S, Sτ and Sφ were significantly associated with JSN in the medial tibiofemoral compartment (PR: 1.40, 95% CI 1.10–1.78; PR: 1.65, 95% CI 1.25–2.18 and PR: 0.53, 95% CI 0.29–0.97, respectively). There was a significantly positive association between S, Sτ and medial and/or femoral tibial cartilage defects. S, Sτ and Sυ were significantly and positively associated with medial and/or femoral tibial BMLs (PR: 1.36, 95% CI 1.12–1.64; PR: 1.47, 95% CI 1.17–1.83; and PR: 1.39, 95% CI 1.06–1.82, respectively) after adjustment. S and Sτ were significantly and negatively associated with medial tibial cartilage volume. Conclusions This novel method to assess the morphological parameters of PTFJ in MRI is reproducible. These parameters are associated with knee radiographic and MRI-based OA-related structural abnormalities, suggesting clinical construct validity. Its predictive validity needs to be examined in future longitudinal studies.

Objective To identify factors associated with non-medical health professionals’ engagement in physical activity (PA) promotion. Methods Five electronic databases were searched for studies including practising health professionals (excluding medical doctors), a PA promotion practice measure, a test of association between potential influencing factors and PA promotion practice, and written in English. Two researchers independently screened studies and extracted data. Extracted data were synthesized in a tabular format with a narrative summary (thematic analysis). Results Thirty studies involving 7734 non-medical health professionals were included. Self-efficacy in PA promotion, positive beliefs in the benefits of PA, assessing patients’ PA, and PA promotion training were the main factors associated with engaging in PA promotion. Lack of remuneration was not associated. Common study limitations included a lack of information on non-responders, data collection by survey only and limited reliability or validity testing of measurements. Conclusions There are common factors influencing PA promotion, but the absence of studies from some health professions, limitations related to study measures, and the lack of randomised controlled intervention trials highlights the need for further research. Practice Implications The factors identified may prove useful for guiding the development of strategies to encourage greater engagement in PA promotion by health professionals.

The aim of this study was to determine whether vitamin D supplementation and maintaining vitamin D sufficiency are associated with changes in inflammatory and metabolic biomarkers in patients with knee osteoarthritis (OA) and vitamin D deficiency. A total of 413 participants with symptomatic knee OA and vitamin D deficiency were enrolled in a randomised, placebo-controlled trial and received 1·25 mg vitamin D3 or placebo monthly for 24 months across two sites. In this post hoc analysis, 200 participants from one site (ninety-four from the placebo group and 106 from the vitamin D group; mean age 63·1 (sd 7·3) years, 53·3 % women) were randomly selected for measurement of serum levels of inflammatory and metabolic biomarkers at baseline and 24 months using immunoassays. In addition, participants were classified into two groups according to serum 25-hydroxyvitamin D (25(OH)D) levels at months 3 and 24: (1) not consistently sufficient (25(OH)D≤50 nmol/l at either month 3 or 24, n 61), and (2) consistently sufficient (25(OH)D>50 nmol/l at both months 3 and 24, n 139). Compared with placebo, vitamin D supplementation had no significant effect on change in serum high-sensitive C-reactive protein, IL-6, IL-8, IL-10, leptin, adiponectin, resistin, adipsin and apelin. Being consistently vitamin D sufficient over 2 years was also not associated with changes in these biomarkers compared with not being consistently sufficient. Vitamin D supplementation and maintaining vitamin D sufficiency did not alter serum levels of inflammatory and metabolic biomarkers over 2 years in knee OA patients who were vitamin D insufficient, suggesting that they may not affect systemic inflammation in knee OA patients.

Background: People with diabetes have low health literacy, but the role of the latter in diabetic foot disease is unclear. Aim: To determine, through a systematic review and meta‐analysis, if health literacy is associated with diabetic foot disease, its risk factors, or foot care. Methods: We searched PubMed, EMBASE, CINAHL, Web of Science, Scopus and Science Direct. All studies were screened and data extracted by two independent reviewers. Studies in English with valid and reliable measures of health literacy and published tests of association were included. Data were extracted on the associations between the outcomes and health literacy. Meta‐analyses were performed using random effects models. Results: Sixteen articles were included in the systematic review, with 11 in the meta‐analysis. In people with inadequate health literacy, the odds of having diabetic foot disease were twice those in people with adequate health literacy, but this was not statistically significant [odds ratio 1.99 (95% CI 0.83, 4.78); two studies in 1278 participants]. There was no statistically significant difference in health literacy levels between people with and without peripheral neuropathy [standardized mean difference –0.14 (95% CI –0.47, 0.18); two studies in 399 participants]. There was no association between health literacy and foot care [correlation coefficient 0.01 (95% CI –0.07, 0.10); seven studies in 1033 participants]. Conclusions: There were insufficient data to exclude associations between health literacy and diabetic foot disease and its risk factors, but health literacy appears unlikely to have a role in foot care. The contribution of low health literacy to diabetic foot disease requires definitive assessment through robust longitudinal studies.

Up to 80% of residents in aged care facilities (ACFs) experience pain, which is often suboptimally managed. The purpose of this study was to characterize pain management in ACFs and identify the barriers to optimal pain management. This exploratory descriptive qualitative study used semistructured interviews in five Southern Tasmania, Australian ACFs. Interviewees included 23 staff members (18 nurses and 5 facility managers) and were conducted from September to November 2015. Interviews included questions about how pain was measured or assessed, what happened if pain was identified, barriers to pain management, and potential ways to overcome these barriers. Interviewees noted that there were no formal requirements regarding pain assessment at the ACFs reviewed; however, pain was often informally assessed. Staff noted the importance of adequate pain management for the residents' quality of life and employed both nonpharmacologic and pharmacologic techniques to reduce pain when identified. The barriers to optimal pain management included difficulty identifying and assessing pain, residents' resistance to reporting pain and/or taking medications, and communication barriers between the nursing staff and GPs. Staff interviewed were dedicated to managing residents' pain effectively; however, actions in a number of areas could improve resident outcomes. These include a more consistent approach to documenting pain in residents' progress notes and improving nurse-GP communications to ensure that new or escalating pain is identified and expedient changes can be made to the resident's management. Additionally, resident, family, nurse, and carer education, conducted within the facilities on a regular basis, could help improve the pain management of residents.

The aim of this study was to evaluate the effect of zoledronic acid (ZA) and denosumab on low back pain (LBP) and Modic change (MC) over 6 months. Adults aged ≥40 years with significant LBP for at least 6 months duration and MC (type 1, 2, or mixed) were randomized to receive ZA (5 mg/100 mL), denosumab (60 mg), or placebo. LBP was measured monthly by visual analogue scale (VAS) and the LBP Rating Scale (RS). MC was measured from MRIs of T12 -S1 vertebrae at screening and 6 months. A total of 103 participants with moderate/severe LBP (mean VAS = 57 mm; mean RS = 18) and median total MC area 538 mm2 were enrolled. Compared to placebo, LBP reduced significantly at 6 months in the ZA group for RS (-3.3; 95% CI, -5.9 to -0.7) but not VAS (-8.2; 95% CI, -18.8 to +2.4) with similar findings for denosumab (RS, -3.0; 95% CI, -5.7 to -0.3; VAS, -10.7; 95% CI, -21.7 to +0.2). There was little change in areal MC size overall and no difference between groups with the exception of denosumab in those with type 1 Modic change (-22.1 mm2 ; 95% CI, -41.5 to -2.7). In post hoc analyses, both medications significantly reduced VAS LBP in participants with milder disc degeneration and non-neuropathic pain, and denosumab reduced VAS LBP in those with type 1 MC over 6 months, compared to placebo. Adverse events were more frequent in the ZA group. These results suggests a potential therapeutic role for ZA and denosumab in MC-associated LBP.

Introduction This study aimed to determine if beneficial effects of individualized feedback of fracture risk on osteoporosis preventive behaviors and bone mineral density observed in a 2-year trial were sustained long-term. Methods This was a 10-year follow-up of a 2-year RCT in 470 premenopausal women aged 25–44 years, who were randomized to one of two educational interventions (the Osteoporosis Prevention and Self-Management Course [OPSMC] or an osteoporosis information leaflet) and received tailored feedback of their relative risk of fracture in later life (high versus normal risk groups). Bone mineral density of lumbar spine and femoral neck were measured by dual-energy X-ray absorptiometry. Physical activity, dietary calcium intake, calcium and vitamin D supplements, and smoking status were measured by questionnaires. Results From 2 to 12 years, the high-risk group had a smaller decrease in femoral neck bone mineral density (β=0.023, 95% CI=0.005, 0.041 g/cm2) but similar lumbar spine bone mineral density change as the normal-risk group. They were more likely to use calcium (relative risk=1.66, 95% CI=1.22, 2.24) and vitamin D supplements (1.99, 95% CI=1.27, 3.11). The OPSMC had no effects on bone mineral density change. Both high-risk (versus normal-risk) and the OPSMC groups (versus leaflet) had a more favorable pattern of smoking behavior change (relative risk=1.85, 95% CI=0.70, 4.89 and relative risk=2.27, 95% CI=0.86, 6.01 for smoking cessation; relative risk=0.33, 95% CI=0.13, 0.80 and relative risk=0.28, 95% CI=0.10, 0.79 for commenced or persistent smoking). Conclusions Feedback of high fracture risk to younger women was associated with long-term improvements in osteoporosis preventive behaviors and attenuated femoral neck bone mineral density loss. Therefore, this could be considered as a strategy to prevent osteoporosis. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) NCT00273260.

We have previously shown that bone mineral density (BMD) tracks strongly from age 8 to 16 years. This study aimed to describe whether this strong tracking continued to age 25 years and describe factors associated with deviation from tracking. Ninety-nine participants were followed from age 8 to 25 years and 197 participants from age 16 to 25 years. Outcomes measured were BMD at the spine, hip, and total body (by dual-energy X-ray absorptiometry [DXA]). Other factors measured were anthropometrics, inhaled corticosteroids (ICS) use, history of being breastfed, sports participation, fitness (by physical work capacity [PWC170 ]), lean mass (LM), and fat mass (FM) (by DXA). There was moderate to strong tracking of BMD from age 8 to 25 years (correlation coefficients: males, 0.59 to 0.65; females, 0.70 to 0.82) and strong tracking from age 16 to 25 years (males, 0.81 to 0.83; females, 0.84 to 0.88) after adjustment for change in body size. From age 8 to 25 years, 54% to 56% of participants kept their BMD tertile position. PWC170 at age 8 years, relative and absolute change in LM, and sports participation at age 25 years predicted males would improve their tertile position or remain in the highest tertile of spine or hip BMD. However, relative and absolute change in FM had the opposite association in males while absolute change in FM predicted positive deviation in females. From age 16 to 25 years, LM, PWC170 , sports participation at age 16 years, and change in LM, PWC170 , and sports participation at age 25 years predicted positive deviation in males. LM at age 16 years was positively associated and PWC170 negatively associated with positive deviation in females. BMD tracks from childhood to early adulthood in both males and females. There appears to be greater capacity to alter tracking before age 16 years. Increasing LM in both sexes and improving fitness and sports participation in males during growth might be effective strategies to improve BMD in early adulthood. © 2017 American Society for Bone and Mineral Research.

The objective of this study was to investigate the associations of knee structural abnormalities with different patterns of pain. A total of 891 participants (average age 63 years; range 50 to 80 years) participated in this study. Presence of pain at the neck, back, hands, shoulders, hips, knees, and feet was assessed by questionnaire. Participants were categorized as having no pain at any site (no pain), pain only at the knee (KP), pain at other sites but not the knee (OP), and pain at the knee and other sites (KOP). T1-weighted or T2-weighted MRI of the right knee was performed to measure cartilage defects, bone marrow lesions (BMLs), and effusion-synovitis. Osteophytes and joint space narrowing were assessed by X-ray. KP, KOP, and OP were, respectively, present in 3, 43, and 42% of the participants. In multivariable analyses, KOP was associated with the presence of cartilage defects, BMLs, and osteophytes (OR 3.57 (95% CI 1.78 to 7.14), 2.37 (1.27 to 4.43), and 2.87 (1.10 to 7.51), respectively) in those with radiographic knee OA. KP was also associated with presence of these structural abnormalities as well as effusion-synovitis, and these associations were much stronger. The associations between structural abnormalities and KOP were weaker than those with KP in those with radiographic knee OA. This suggests that mechanisms mediating the association between structural pathology, localized, and generalized pain may be different, and central sensitization is possibly involved in generalized pain. Pain at other sites needs to be considered in the management and treatment of OA-related pain.

Summary Objective To develop a measure of knee joint effusion-synovitis volume and to examine the effect of vitamin D supplementation on effusion-synovitis in people with knee osteoarthritis (OA) and low vitamin D levels over 24 months. Method Symptomatic knee OA patients with low 25-(OH)D levels (12.5–60 nmol/l) were recruited for a multi-centre, randomised, placebo-controlled and double-blind trial. Participants (age 63 ± 7 years, 208 females) were allocated to either 50,000 IU monthly vitamin D 3 ( n = 209) or placebo ( n = 204) for 24 months. Knee effusion-synovitis volume in suprapatellar and other regions was measured on magnetic resonance imaging (MRI) using OsiriX software. The intra-class correlation coefficients (ICCs) were used to test inter- and intra-rater reliabilities. The least significant change criterion was used to define the increase/decrease in effusion-synovitis volume. Result The reproducibilities of effusion-synovitis volume measurement were high with ICCs ranging from 0.93 to 0.99. Over 24 months, effusion-synovitis volume remained stable in the vitamin D group but increased in placebos with a significant between-group difference (−1.94 ml, 95% confidence interval (CI): −3.54, −0.33). This effect was evident in those with baseline effusion-synovitis and with suprapatellar effusion-synovitis. The proportion with an increase in effusion-synovitis volume was lower in the vitamin D group than placebo (risk ratio (RR): 0.87, 95% CI: 0.77, 0.97). Conclusion This highly reproducible effusion-synovitis volume measurement could be a promising outcome measure in OA trials. Vitamin D supplementation could retard the progression of effusion-synovitis which can potentially benefit people with an inflammatory OA phenotype.

Poor balance is a risk factor for falls and fracture in older adults, but little is known about modifiable factors affecting balance in younger women. This study aimed to examine whether lower limb muscle strength (LMS) in young women and changes in LMS are independent predictors of balance in middle age. This was an observational 10-year follow-up of 470 women aged 25 to 44 years at baseline who had previously participated in a 2-year population-based randomized controlled trial of osteoporosis education interventions. Linear regression was used to examine the association between baseline LMS (by dynamometer) and change in LMS over 12 years with balance at 12 years (timed up and go test [TUG], step test [ST], functional reach test [FRT], and lateral reach test [LRT]). LMS declined by a mean of 17.3 kg over 12 years. After adjustment for potential confounders, baseline and change in LMS were independently beneficially associated with TUG (β = -0.008 sec/kg, 95% confidence interval [CI] -0.01 to -0.006, and β = -0.006 sec/kg, 95% CI -0.009 to -0.003 for baseline and change, respectively), FRT (β = 0.057 cm/kg, 95% CI 0.030 to 0.084, and β = 0.071 cm/kg, 95% CI 0.042 to 0.101, respectively), and LRT (β = 0.030 cm/kg, 95% CI 0.012 to 0.049, and β = 0.022 cm/kg, 95% CI 0.002 to 0.043, respectively) 12 years later. There was an association between baseline LMS and ST (β = 0.044 steps/kg, 95% CI 0.022 to 0.067) but not between change in LMS and ST. Among young women, greater LMS at baseline and slower decline over time are both associated with better balance in midlife. Analogous to the contributions of peak bone mass and bone loss to fracture risk in older adults, this suggests that both improvement of muscle strength in younger age and prevention of age-related loss of muscle strength could be potentially useful strategies to improve balance and reduce falls in later life.

Physical inactivity and overweight and obesity are more prevalent among rural than urban populations. This study aimed to review published evidence of the effectiveness of interventions to increase physical activity (PA) and/or decrease sedentary behaviour (SB) among rural adults and to identify factors associated with effectiveness. Seven electronic databases were searched for controlled trials of a PA or SB intervention. Meta-analysis was conducted using random effects models and meta-regression. Thirteen studies were included in the qualitative synthesis (n = 4,848 participants) and 12 in the meta-analysis (n = 4,820). All studies were interventions to increase PA. Overall, there was no effect on PA (standardized mean difference [SMD] 0.11; 95% confidence interval [CI] −0.04, 0.25) or SB (SMD 0.07; 95% CI −0.33, 0.20). In PA subgroup analyses, studies employing objective outcome measures demonstrated effects in favour of the intervention (SMD 0.65, 95% CI 0.30, 1.00), while those using self-reported measures did not (SMD 0.00; 95% CI −0.11, 0.10). This review highlights significant gaps in our understanding of how best to promote PA and reduce SB among rural adults. Future studies should use objective measures of PA as study outcomes. The absence of interventions to decrease SB is of concern, with immediate action required to address this large knowledge gap.

OBJECTIVE Pain is common in the elderly. Knee pain may predict knee cartilage loss, but whether generalized pain is associated with knee cartilage loss is unclear. This study, therefore, aimed to determine whether pain at multiple sites predicts knee cartilage volume loss among community-dwelling older adults, and, if so, to explore potential mechanisms. METHODS Data from the prospective Tasmanian Older Adult Cohort study was utilized (n = 394, mean age 63 years, range 52-79 years). Experience of pain at multiple sites was assessed using a questionnaire at baseline. T1-weighted fat-saturated magnetic resonance imaging of the right knee was performed to assess the cartilage volume at baseline and after 2.6 years. Linear regression modeling was used with adjustment for potential confounders. RESULTS The median number of painful sites was 3 (range 0-7). There was a dose-response relationship between the number of painful sites and knee cartilage volume loss in the lateral and total tibiofemoral compartments (lateral β = -0.28% per annum; total β = -0.25% per annum, both P for trend

Summary Objective To describe cross-sectional and longitudinal associations between serum levels of interleukin (IL) - 6, IL-17A, IL-17F, IL-23 and knee bone marrow lesions (BMLs) in patients with knee osteoarthritis (OA). Design Patients ( n = 192) with symptomatic knee OA (mean 63 years, range 50–79, female 53%) were assessed at baseline and after 24 months. At each time point, serum IL-6, IL-17A, IL-17F and IL-23 were measured using Bio-Plex ® Multiplex Immunoassays with Luminex xMAP technology. Knee BMLs were scored using the modified whole organ MRI score (WORMS) from T2 weighted fat-suppressed fast spin echo magnetic resonance imaging (MRI). Multivariable linear regression and log binominal regression were used to determine the associations between cytokines and BMLs. Results Baseline IL-6 (quarters) were significantly associated with total knee BMLs ( P P = 0.05 for the trend), after adjustment for confounders. Baseline IL-17F and IL-23 (highest quarters vs others) was associated with an increase in BML score in females ( P = 0.04 for IL-17F; P = 0.01 for IL-23), but not in males, in multivariable analyses. In contrast, IL-17A was not significantly associated with BMLs in either females or males. Conclusion IL-6 is associated with increased knee BMLs in both females and males with OA. Serum IL-17F and IL-23 predicted increased knee BML scores in females only, suggesting that inflammation is involved in BML pathogenesis in knee OA, especially in women. Trail registration ClinicalTrials.gov identifier: NCT01176344; Australian New Zealand Clinical Trials Registry: ACTRN12610000495022.

Data linking cumulative lifetime vitamin D status with skeletal outcomes are lacking. We show that increasing cumulative sun exposure was associated with higher bone mineral density in younger males and protective against fractures in females independent of current vitamin D. This supports the concept that cumulative sun exposure is an important contributor to skeletal health. While low 25-hydroxyvitamin D levels are associated with increased fracture risk, this reflects only recent sun exposure. The Beagley-Gibson (BG) method utilises microtopographical skin changes to quantify cumulative lifetime ultraviolet radiation (sun) exposure. This study aimed to describe the relationship between BG grade, BMD, falls risk and fractures in older adults. Eight hundred thirty-five community-dwelling adults aged 53–83 years had silicone casts from the dorsum of both hands graded by the BG method. BMD was measured using DXA and falls risk using the short form of the Physiological Profile Assessment. Vertebral deformities and symptomatic fractures were assessed by DXA and questionnaire, respectively. The relationship between BG grade, spine BMD and vertebral fracture varied depending upon sex. In females, increasing grade was associated with lower vertebral fracture prevalence (OR = 0.44/grade, p = 0.018) and fewer fractures (OR = 0.82/grade, p = 0.021), particularly major fractures (OR = 0.75/grade, p = 0.03). In males, increasing grade was associated with more DXA-detected vertebral deformities (RR = 1.28/grade, p = 0.001), but not symptomatic fractures. These relationships were independent of BMD, falls risk, smoking and current 25-hydroxyvitamin D. BG grade was not associated with falls risk. For BMD, there were interactions between BG grade and both age and sex and a positive trend with hip BMD in younger males. BG grade demonstrated beneficial associations with fracture outcomes in females and BMD in younger males independent of current 25-hydroxyvitamin D. These data support the concept that cumulative ultraviolet radiation exposure is an important determinant of skeletal health. The association with vertebral deformities in males may reflect outdoor physical trauma in younger life.

Objectives: To examine associations of education and occupation with handgrip strength (HGS), lower limb strength (LLS) and appendicular lean mass (ALM). Methods: Measures of HGS, LLS and ALM (dual-energy X-ray absorptiometry) were ascertained at baseline in 1090 adults (50-80 years, 51% women), ~3 and 5 years. Education and occupation were self-reported, the latter categorised as high-skilled white collar (HSWC), low-skilled white collar (LSWC) or blue collar. Separate general estimating equations were performed. Results: The highest education group had greater HGS than the middle (0.33 psi) and lowest (0.48 psi) education groups, and 0.34 kg greater ALM than the lowest education group. HGS was 0.46 psi greater for HSWC than LSWC groups. Compared to LSWC groups, LLS was 5.38 and 7.08 kg greater in HSWC and blue-collar groups. Blue-collar and HSWC groups each had ~ 0.60-0.80kg greater ALM than LSWC. Conclusion: Progressive muscle loss can be prevented by targeted intervention; thus, we suggest clinical attention be directed towards specific social groups.

We have found that early-life exposures are associated with areal bone mineral density (aBMD) at ages 8 and 16 years. This study aimed to assess whether these associations persist into young adulthood when peak bone mass (PBM) is achieved and extend this analysis to microarchitecture. Participants were followed from perinatal period to 25 years old (n = 201). Outcomes were total body, spine, and hip aBMD (by dual-energy X-ray absorptiometry [DXA]), and cortical and trabecular bone measures at the distal radius and tibia (by high-resolution peripheral quantitative computed tomography [HRpQCT]). Early-life exposures including breastfeeding, maternal smoking during pregnancy, and birth weight. Sex, weight, height, vegetables, fruit and calcium intake at age 25 years were regarded as potential confounders in the analysis. There were significant interactions between period of gestation and early-life exposures for bone measures, so all analyses were stratified by period of gestation. Breastfeeding was beneficially associated with hip and total body aBMD, total, cortical and trabecular volumetric BMD (vBMD), cortical thickness, porosity, trabecular number (Tb.N), separation (Tb.Sp), and bone volume fraction (Tb.BV/TV) at radius and/or tibia at age 25 years in participants born prematurely (β ranged from -0.92 to 0.94), but there were no associations in those born at term. Maternal smoking had no association with any DXA/HRpQCT measures in those born prematurely but was detrimentally associated with inner transitional zone porosity and Tb.N (β = 0.40 and β = -0.37, respectively) in those full-term participants. Associations of birth weight with bone measures did not persist after adjustment for weight gain since birth. Breastfeeding was associated with a lower risk of lower limb fractures and maternal smoking had a deleterious association with upper limb fractures. In conclusion, breastfeeding and maternal smoking may have effects on peak bone microarchitecture whereas the association with birth weight is countered by subsequent growth. © 2020 American Society for Bone and Mineral Research.

Background Clinical trials evaluating the effect of calcium supplementation on bone loss in lactating women have been small, with inconsistent results. Objectives We aimed to determine the effect of calcium supplementation on bone mineral density (BMD) in lactating women. Methods An electronic search of databases was conducted from inception to January 2020. Two authors screened studies, extracted data, and assessed the risk of bias of eligible studies. Percentage change in BMD was pooled using random-effects models and reported as weighted mean differences (WMDs) with 95% CIs. Risk of bias was assessed using the Cochrane risk of bias tool. Results Five randomized controlled trials including 567 lactating women were included. All had a high risk of bias. Mean baseline calcium intake ranged from 562 to 1333 mg/d. Compared with control groups (placebo/no intervention), calcium supplementation (600/1000 mg/d) had no significant effect on BMD at the lumbar spine (WMD: 0.74%; 95% CI: -0.10%, 1.59%; I2 = 47%; 95% CI: 0%, 81%; n = 527 from 5 trials) or the forearm (WMD: 0.53%; 95% CI: -0.35%, 1.42%; I2 = 55%; 95% CI: 0%, 85%; n = 415 from 4 trials). BMD at other sites was assessed in single trials: calcium supplementation had a small to moderate effect on total-hip BMD (WMD: 3.3%; 95% CI: 1.5%, 5.1%) but no effect on total body or femoral neck BMD. Conclusions Overall, the meta-analysis indicates that calcium supplementation does not provide clinically important benefits for BMD in lactating women. However, there was adequate dietary intake before supplementation in some studies, and others did not measure baseline calcium intake. Advising lactating women to meet the current recommended calcium intakes (with supplementation if dietary intake is low) is warranted unless new high-certainty evidence to the contrary from robust clinical trials becomes available. More research needs to be done in larger samples of women from diverse ethnic and racial groups.This systematic review was registered at www.crd.york.ac.uk/prospero as CRD42015022092.

This study reported that the transitional zones in older adults were enlarged at the expense of the compact-appearing cortex with a greater porosity in all cortical sub-compartments. The magnitude of differences in areal and volumetric bone mineral density (aBMD, vBMD) between older and younger groups was similar. Aging is strongly associated with bone loss, but little is known about magnitudes of differences in bone microarchitectures, aBMD, and vBMD from peak bone mass (PBM) to senescence. We aimed to describe differences in aBMD, vBMD, and bone microarchitecture parameters at the distal radius between older and young adults. We compared 201 participants, aged 62–89 years (female 47%) and 196 participants, aged 24–28 years (female 38%). Bone microarchitecture parameters at distal radius were measured using high-resolution peripheral computed tomography (HRpQCT). aBMD was measured using dual-energy X-ray absorptiometry (DXA). Unpaired t tests and chi-square tests were used to compare differences in means and proportions as appropriate. Older adults had thinner compact-appearing cortices with larger (cross-sectional area: outer 30.96 mm2 vs. 28.38 mm2, inner 36.34 mm2 vs. 32.93 mm2) and thicker (outer 0.57 mm vs. 0.54 mm, inner 0.71 mm vs. 0.65 mm) transitional zones compared with young adults (all p

ObjectivesPoor health literacy (HL) is associated with poorer health outcomes in diabetes but little is known about its effects on foot disease. This study was aimed to determine the associations between HL and diabetic foot disease.DesignThis is a cross-sectional analysis of baseline data from a prospective study of foot disease.SettingAttendees of the Royal Hobart Hospital’s Diabetes outpatient clinics.Participants222 people with type 1 or type 2 diabetes aged >40 years and without a history of foot disease, psychotic disorders or dementia.MeasuresOutcomes were peripheral neuropathy, peripheral arterial disease and foot deformity according to published guidelines. The exposure, HL, was measured using the short form Test of Functional Health Literacy in Adults (S-TOFHLA) and the Health Literacy Questionnaire (HLQ). Covariates included demographic characteristics, medical history, psychological measures and foot care behaviour.ResultsOf 222 participants, 204 had adequate HL. (Mean (SD) S-TOFHLA scores were 31.9 (6.7)), mean(SD) HLQ scores were 134.4 (18.4)). In univariable but not multivariable analyses, higher S-TOFHLA scores were associated with lower overall risk for foot disease (OR 0.96, 95% CI 0.93 to 0.99) and loss of protective sensation (OR 0.95, 95% CI 0.91 to 0.995).ConclusionsThese data provide little support for clinically important impacts of HL on risk factors for diabetic foot disease. However, in the absence of longitudinal data, such effects cannot be ruled out. Longitudinal studies measuring incident foot disease are needed to properly judge the potential for interventions improving HL to reduce the incidence of diabetic foot disease.

Associations between physical activity and time spent sedentary and musculoskeletal outcomes remain unclear in middle-aged adults. This study aimed to describe associations between objectively-measured physical activity and sedentary time and musculoskeletal health outcomes in middle-aged women. This cross-sectional study from a population-based sample of 309 women (age 36 to 57 years) examined associations of total physical activity (accelerometer counts/min of wear time), and time spent sedentary, in light physical activities and moderate-to-vigorous physical activities (MVPA) (by Actigraph GT1M accelerometer) with lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD) (by dual-energy X-ray absorptiometry), lower limb muscle strength (LMS), and functional mobility and balance tests (timed up and go test [TUG], functional reach test [FRT], lateral reach test [LRT], and step test [ST]) using linear regression. Total physical activity was beneficially associated with FN BMD (values are β; 95% CI) (0.011 g/cm2 ; 95% CI, 0.003 to 0.019 g/cm2 ), LMS (2.13 kg; 95% CI, 0.21 to 4.06 kg), and TUG (-0.080 s; 95% CI, -0.129 to -0.030 s), after adjustment for confounders. MVPA was also beneficially associated with FN BMD (0.0050 g/cm2 ; 95% CI, 0.0007 to 0.0094 g/cm2 ), LMS (1.48 kg; 95% CI, 0.45 to 2.52 kg), ST (0.12 steps; 95% CI, 0.02 to 0.23 steps), and TUG (-0.043 s; 95% CI, -0.070 to -0.016 s). Associations between MVPA and LMS, TUG and ST persisted after further adjustment for sedentary time. Only TUG was associated with sedentary time, with a detrimental effect (0.075 s; 95% CI, 0.013 to 0.137 s) and this did not persist after further adjustment for MVPA. Light physical activity was not associated with any outcome. MVPA appears more important than light physical activity or sedentary time for many musculoskeletal outcomes in middle-aged women. This needs to be considered when developing interventions to improve habitual physical activity that aim to improve musculoskeletal health. © 2016 American Society for Bone and Mineral Research.

Purpose: To compare the performance of low muscle mass and function with falls risk, incident fracture and mortality over 10 years.1041 participants (50% women; mean age 63±7.5 years) were prospectively followed for 10 years. Falls risk was measured using the Physiological Profile Assessment, fractures were self-reported and mortality was ascertained from the death registry. Appendicular lean mass (ALM) was assessed using dual energy X-ray absorptiometry. Four anthropometric: (ALM/height2, ALM/body mass index, ALM/weight×100, a residuals method of ALM on height and total body fat) and four performance-based measures: (handgrip strength, lower-limb muscle strength, upper and lower-limb muscle quality) were examined. Participants in the lowest 20% of the sex-specific distribution for each anthropometric and performance-based measure were classified has having low muscle mass or function. Regression analyses were used to estimate associations between each anthropometric and performance-based measure at baseline and 10-year falls risk, incident fractures and mortality.Mean falls risk z-score at 10 years was 0.64 (SD 1.12), incident fractures and mortality over 10 years were 16% and 14% respectively. All baseline performance-based measures were significantly associated with higher falls risk score at 10 years. Low handgrip (RR 1.55, 95% CI: 1.09, 2.20) and ALM/body mass index (RR 1.54, 95% CI: 1.14, 2.08) were the only significant predictors of fracture and mortality respectively.Low handgrip strength, a simple and inexpensive test could be considered in clinical settings for identifying future falls and fractures. ALM/ body mass index could be most suitable in estimating 10-year mortality risk, but requires specialised equipment.

Background and purpose The Beagley–Gibson (BG) grading system utilizes microtopographical skin changes to generate an individualized, objective estimate of cumulative, lifetime ultraviolet radiation (UVR) exposure. However, predictors of BG grade are ill-defined, particularly in older populations. The aim of this cross-sectional study was to describe the factors associated with skin damage as measured by the BG method in 835 community-dwelling older adults. Methods Study participants aged 53–83 years had silicone casts taken from the dorsum of both hands and graded by the BG method. Lifetime sun exposure, skin phenotypic traits and smoking status were assessed by questionnaire. 25-hydroxyvitamin D and melanin density were measured using radioimmunoassay and spectrophotometry, respectively. Ordered logistic regression was used to compute a single odds ratio (OR) by taking BG grade as the outcome variable. Results Higher 25-hydroxyvitamin D was associated with increasing BG grade (OR = 1.39, P = 0.02) in adjusted analysis. Age (OR = 1.14, P < 0.001), occupational sun exposure (OR = 1.62, P < 0.001), ability to tan (OR = 1.40, P < 0.001), melanin density (OR=0.79, P = 0.001), lifetime leisure time sun exposure (OR = 1.21, P = 0.004), current smoking (OR = 1.82, P = 0.007), propensity to sunburn (OR = 1.18, P = 0.016), and waist–hip ratio (OR = 1.10, P = 0.02) were independent predictors of BG grade. Hair colour, number of sunburns, body mass index and gender were not independent predictors of BG grade. Conclusions Beagley–Gibson skin cast grade is a biologically relevant marker of UVR exposure in older adults influenced by both intrinsic and extrinsic factors.

OBJECTIVE: To describe associations between serum high-sensitivity C-reactive protein (hsCRP), knee bone marrow lesions (BMLs), and knee pain, cross-sectionally and longitudinally, in patients with knee osteoarthritis (OA). METHODS: Patients (n = 192) with symptomatic knee OA (mean age 63 years, range 50-79, women 53%) were assessed at baseline and after 24 months. Serum hsCRP was measured using enzyme-linked immunosorbent assay. Knee BMLs were scored using the modified Whole-Organ Magnetic Resonance Imaging (MRI) Score from T2-weighted fat-supressed fast spin-echo MRI. Knee pain was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index. RESULTS: Quartiles of baseline serum hsCRP were associated with the presence of knee BMLs (prevalence ratio 1.07 per quartile [95% confidence interval (95% CI) 1.00, 1.15]) and total knee pain scores (β 13.66 per quartile [95% CI 2.26, 25.07]) in multivariable analyses. Longitudinally, higher baseline hsCRP was associated with an increase in BML score (risk ratio 1.37 per quartile [95% CI 1.10, 1.70]), and change in hsCRP was positively associated with change in BML score (β 0.19 [95% CI 0.05, 0.34]) in adjusted analyses. Baseline hsCRP was not associated with change in total knee pain, but change in hsCRP was positively and significantly associated with change in total knee pain (β 4.71 [95% CI 0.48, 8.94]). This became nonsignificant after adjustment for changes in BML score. CONCLUSION: In patients with knee OA, serum hsCRP is associated with knee BML scores and, to a lesser extent, pain both cross-sectionally and longitudinally, suggesting that inflammation is linked with BMLs and their associated pain.

It is currently recommended in Australia that nursing home residents are supplemented daily with 1000 IU vitamin D as they are at an increased risk of fractures. Historically, supplementation has been low, and current supplementation prevalence is not known. The aim of this study was to determine the prevalence of vitamin D supplementation amongst nursing home residents in Tasmania, Australia. Resident data, including demographics, medical conditions and medications (including vitamin D and calcium supplement use), exercise and sun exposure, were obtained from residents’ files and staff in consenting nursing homes. Dietary calcium intake was estimated from the weekly menu of one nursing home and total calcium intake estimated from this and calcium supplement use. The prevalence of vitamin D supplementation was compared by resident characteristics and fracture risk factors. Of 811 residents, 409 (50 %) received daily vitamin D supplementation of at least 1000 IU. Residents receiving vitamin D supplementation were slightly younger (mean 83 vs. 85 years for supplemented and unsupplemented groups, respectively, p = 0.003) and more likely to have osteoporosis (29 vs. 22 % for supplemented and unsupplemented groups, respectively, p = 0.019). Only 43 % of residents with osteoporosis received vitamin D supplements. Most residents (86 %) did not have regular sunlight exposure. The median estimated total calcium intake of 800 ± 275 mg daily was below guideline recommendations of 1000–1300 mg daily. The prevalence of vitamin D supplementation in nursing home residents was relatively low, suggesting poor adherence to the relevant clinical guidelines. Additionally, most residents do not access sunlight. Interventions addressing this evidence–practice gap are needed.

Purpose Parents combine many roles when caring for a child with complex needs, but few studies measure parental value and enjoyment of childcare related activities. This study aimed to describe parental competence, enjoyment and value of childcare related activities, particularly healthcare related activities, when parenting a child with complex needs. Design and Methods This was a pilot cross sectional study. Ten mothers of children with complex needs rated their competence, value and enjoyment of 156 childcare related activities using the Occupational Questionnaire (Smith, Kielhofner, & Hawkins Watts, 1986). Results The mothers rated childcare related activities as important and rated themselves as competent to undertake them. Mothers disliked performing healthcare related activities, but enjoyed emotional care activities. Conclusion This study extends the current knowledge regarding the role tension described by parents of children with complex needs. The finding that parents dislike performing healthcare related activities despite self-reporting high levels of competence warrants further investigation. Practice Implications Gaining a better understanding of the role tension described by parents of children with complex needs may enable pediatric nurses to better understand the impact of home based care provision on parents and assist them to find ways to support families so this care can continue to be provided.

Purpose The aim of this study was to determine and compare risk factors associated with incident fractures in older adults with and without obesity, defined by both body mass index (BMI) and body fat percentage. Methods 1,099 older adults (mean ± standard deviation age = 63.0 ± 7.5) years, participated in this prospective cohort study. Obesity status at baseline was defined by BMI (≥30 kg/m2) obtained by anthropometry and body fat percentage (≥30% for men and ≥40% for women) assessed by dual-energy X-ray absorptiometry (DXA). Total hip and lumbar spine areal bone mineral density (aBMD) were assessed by DXA up to five years. Incident fractures were self-reported up to 10 years. Results Prevalence of obesity was 28% according to BMI and 43% according to body fat percentage. Obese older adults by BMI, but not body fat percentage, had significantly higher aBMD at the total hip and spine compared with non-obese (both p-value 0.05). Mediation analysis confirmed that aBMD meditated the effects of BMI, but not body fat percentage, on all incident fractures. Higher baseline falls risk score was the only consistent predictor of increased likelihood of incident fracture in obese individuals only, according to both BMI and body fat percentage (both p-value

Background:Weight, dietary patterns, vitamin D, physical activity and grip strength have been suggested to be associated with bone loss in older adults. However, studies have yet been performed to investigate the associations between these factors and radial bone microarchitecture.Objectives:This study aimed to describe the associations of weight, dietary patterns, serum 25-hydroxyvitamin D (25(OH)D) concentrations, physical activity and grip strength with bone measures in older adults.Methods:Cross-sectional data on 201 older adults (mean age 72 years, female 46%) from a population-based cohort study were analysed. Weight, dietary patterns, serum 25(OH)D concentrations, physical activity (steps per day), grip strength were collected and analysed from baseline to 10-year follow-up. Areal bone mineral density (aBMD) at spine, hip and whole body were measured by dual-energy X-ray absorptiometry (DXA). Radial cortical and trabecular bone microarchitectures were measured by high-resolution peripheral computed tomography (HRpQCT). Multivariable linear regression was used to analyse associations of study factors with bone measures.Results:Weight was positively associated with radial bone area (total: β=0.18, 95% CI: 0.07, 0.29; cortical: β=0.12, 95% CI: 0.03, 0.21; trabecular: β=0.18, 95% CI: 0.05, 0.32), and was inversely associated with compact cortical volumetric bone mineral density (vBMD) (β= -0.19, 95% CI: -0.37, -0.01) and trabecular thickness (β= -0.25, 95% CI: -0.43, -0.07). Ten-year changes in weight were not significantly associated with bone measures, apart from radial trabecular separation (β= 0.15, 95%CI: 0.009, 0.28). Western dietary pattern scores were inversely associated with radial vBMD (total: β= -0.17, 95% CI: -0.32, -0.01; cortical: β= -0.19, 95% CI: -0.34, -0.04; compact cortical: β= -0.19, 95% CI: -0.34, -0.04; outer transitional zone: β= -0.20, 95% CI: -0.35, -0.06), and were positively associated with cortical porosity (cortical: β= 0.18, 95% CI: 0.03, 0.33; compact cortical: β= 0.19, 95% CI: 0.04, 0.34; outer transitional zone: β= 0.20, 95% CI: 0.06, 0.35). Steps per day were not significantly associated with bone measures, apart from inner transitional zone area and thickness (β= 0.12, 95% CI: 0.003, 0.24; β= 0.19, 95% CI: 0.05, 0.33). Healthy food pattern scores, serum 25(OH)D and grip strength were not significantly associated with radial HRpQCT measures.Conclusion:Higher weight, but not weight change, was beneficial for radial cortical and trabecular bone area but also associated with worse compact cortical vBMD and trabecular thickness. Higher western dietary pattern scores had adverse effects on radial vBMD and cortical porosity while physical activity had inconsistent associations.Disclosure of Interests:None declared

Background:Pharmacological therapies are limited, associated with off-target effects, are frequently contraindicated, and only modestly effective for pain in osteoarthritis (OA). Effusion and synovitis are common in OA and are associated with symptomatic and structural progression of OA.Curcuma longa(Turmeric) extract has anti-inflammatory effects and is gaining popularity in the treatment of OA despite the lack of high-quality evidence.Objectives:The CurKOA trial aimed to determine the efficacy ofCurcuma longaextract for reducing knee symptoms and effusion-synovitis in patients with symptomatic knee OA and knee effusion-synovitis.Methods:In this randomised, double-blind, placebo-controlled trial, participants with significant knee pain (≥ 40 mm on a 100-mm visual analog scale [VAS]), symptomatic knee OA (by ACR criteria) and ultrasound defined effusion-synovitis were randomised to receiveCurcuma longaextract (80% aqueous based extract standardized to turmerosaccharides + 20% curcuminoids, 2 × 500 mg capsules/day) or identical placebo for 12 weeks. Knee MRI scans were obtained at baseline and 12 weeks. Coprimary outcomes were changes in knee pain assessed by VAS and change in knee effusion-synovitis volume assessed by MRI over 12 weeks.Results:Among 70 participants (36 receivedCurcuma longa, 34 received placebo, age 61.8±8.6 years, 56% female),Curcuma longasignificantly improved VAS knee pain compared to placebo (-9.11mm, 95% confidence interval [CI] [- 17.79 to -0.44]) over 12 weeks, equivalent to a standardised effect size of 0.50. There was no significant between group difference in change in effusion-synovitis volume (3.24 mL [-0.33, 6.82]). There were significantly greater reductions in WOMAC knee pain (-47.22mm [-81.22, -13.22]), WOMAC function (-112.26mm [-222.79 to -1.74]) and significantly more OARSI-OMERACT treatment responders (63% treatment vs. 38% placebo [Risk Ratio=1.64 (1.00 to 2.70)]) in theCurcuma longagroup compared to the placebo group. There was no significant between-group difference in lateral femoral cartilage T2 relaxation time (-0.38 ms [- 1.10 to 0.34]) assessed from compositional MRI. The incidence of adverse events was similar in theCurcuma longa(n=14 (39%)) and placebo (n=18 (53%)) groups over 12 weeks (P=0.24).Conclusion:An extract ofCurcuma longasignificantly improved knee pain in an inflammatory phenotype of knee OA patients over 12 weeks compared to placebo but had no effect on knee effusion-synovitis and cartilage composition assessed using MRI. The moderate effect size of the treatment supports the use ofCurcuma longaextract for the symptomatic management of knee OA.Figure 1.Change in VAS and WOMAC subscale scores in treatment and control groups over the course of the study. (VAS = Visual analog scale, WOMAC = Western Ontario and McMaster University Index, CL = Curcuma longa extract)Disclosure of Interests:None declared