Prevention of falls and fractures

ILSI SEA Region - Optimum Health & Nutrition for our Ageing populaiton. Australia - October 2012. www.ilsi.org/sea_region Prevention of falls and fractures http://www.narowing.org/men/brian%20best%20balance.jpg http://www.loughrigg.org/bxllandmarks/manfallingoversculpture.jpg

Risk Falls 1/3 third of women, 1/5 of men >70 years Major Risk factors: Frailty, dementia, osteoarthritis, stroke Other Risk factors older age, congestive heart failure, poorer quality of life nutritional status as independent risk factors for recurrent and injurious falls among those with a previous hip fracture Lloyd B. et al. J Gerontol A Biol Sci Med Sci (2009) 64A (5): 599-609.

Older People, Osteoporosis: Falls, Fracture Fall Risk of Falls Age Low physical activity Low body weight low lean mass Low fat mass Low vitamin D status Malnutrition Medications Medical conditions Diabetes,Depression Low BMD Age Low physical activity Low body weight Low Lean mass Lower peak bone mass Low dietary calcium Low vitamin D status Malnutrition Medications Low bone mineral density Fracture Each SD below reference mean BMD franture risk 4 times. LaFleur et al. 2001

Osteoporosis in Australia Men Every 5-6 mins: 1 person admitted hospital Women with osteoporosis: 71% > 80 years 50% of people with one fracture due to osteoporosis will have another 1/5 of those who fracture a hip will die within 6 months women Survivors: 1/2 will not be able to walk without assistance 1/2 half need full-time nursing care Age-specific and sex-specific incidence of radiographic vertebral,hip, and distal forearm fractures Data derived from European Prospective Osteoporosis Study7 and General Practice Research Reference Australian National Consensus Conference 1996. MJA 1997;167:S1-S http://www.osteoporosis.org.au/about/about-osteoporosis/what-is-osteoporosis/

Vitamin D http://www.hindu.com/thehindu/mag/2001/1 2/09/images/2001120900100201.jpg http://www.win dsox.us/prain/1 2008.jpg http://www.nps.gov/olym/rf1.jp g http://news.nationalgeograp hic.com/news/2004/09/imag es/040910_awastack.jpg Nursing home residents 35 nmol/l 25 (OH)D3 Sun rich cultures 135-220nmol/L 25 (OH)D 3 Life guards 148-163mmol/L http://www.theomnivore.com/photos/masai.jpg

Prevalence Vit D Deficiency Hostel Residents n=373 Level of deficiency <30nmol/L frank Nursing Home Residents n=767 c c 31% deficient 59% deficient

Vitamin D status (25OHD) and disease Level 1 Vitamin D (plus calcium) for falls (Murad et al. 2011, Kalyani et al. 2010, Latham et al. 2003, Bischoff-Ferrari et al. 2009) and fractures (DIPART, 2010, Institute of Medicine (IOM), 2011) Meta-analysis RCTs vitamin D supp 4 falls & fracture 3 mortality All cause mortality (Autier et al. 2007, Melamed, 2008, Rejnmark 2012, Thomas et al 2012) Nowson CA, McGrath JJ, Ebeling PR, Haikerwal A, Daly RM, Sanders KM, Seibel MJ, Mason RS; Working Group of Australian and New Zealand Bone and Mineral Society, Endocrine Society of Australia and Osteoporosis Australia. Vitamin D and health in adults in Australia and New Zealand: a position statement. Nowson CA, Med McGrath J Aust. JJ, 2012 Ebeling Jun PR, 18;196(11):686-7 Haikerwal A, Daly RM, Sanders KM, Seibel MJ, Mason RS. Working group of the ANZ Bone and Mineral Society, Endocrine Society of Australia and Osteoporosis Australia. Vitamin D and health in adults in Australia and New Zealand: a position statement. MJA (in press)

Vitamin D: Effect on days falls/fracture (compliance >50%) 2-year randomised, double-blind placebo controlled >25 & <90 nmol/l 25(OH)D (not frankly deficient) All 600 mg Calcium vitamin D (10,000 IU D2 1/wk or 1000IUn(25ug) 1/d) placebo OR ever falling 0.70 (0.50 0.99) (30% reduction) OR ever fracture 0.68 (0.38 1.22) 8 people needed to be treated for one year to prevent a fall occurring Flicker et al. JAGS 2005 Nov Falls Vitamin D Placebo Fractures Vitamin D Placebo

Summary: vitamin D vitamin D supplementation greatest effect in decreasing falls in: older people who are frail low/suboptimal serum vitamin 25 D levels Adequate Serum 25OH > 50nmol/L (60nmol/L summer) Some evidence (~75nmol/L(25(OHD)) desirable targets for optimal bone health Adequate calcium intake required

Calcium: Effect on Fractures Meta analysis fracture: Ca or Ca + Vitamin D % RR 0.88(0.83,0.95) 17 studies: 52,625 >50 yrs: treat 3.5years: 12% risk reduction Tang BMP, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in older people: a meta-analysis. Lancet 2007

Fracture: Ca or Ca + Vitamin D No significant difference Ca supp. + vitamin D versus Ca alone Calcium only 10% risk reduction Ca + vitamin D 13% risk reduction Tang BMP, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in older people: a meta-analysis. Lancet 2007

Compliance with Ca supplements 2790 > 80%compliance 24% reduction Doubled RR 0.76(0.67,0.86) Low compliance 4% reduction ns RR 0.96(0.91,1.01) Tang BMP, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in older people: a meta-analysis. Lancet 2007 85% consumed 50-59% supplements Only 9% took at least 80% supplement

Most benefit with Ca supplements: Sub-group analysis n % Risk Reduction Interaction Community 49,233 6% P=0.003 Institution 3,392 24% Serum 25(OH)D <25mmol/L Serum 25(OH)D >25mmol/L Tang BMP, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in older people: a meta-analysis. Lancet 2007 10,144 14% P=0.06 39,167 6%

Most benefit with Ca supplements n % Risk Reduction Interaction Ca Supp < 1200mg/d 47,359 6% P=0.006 Ca Supp > 1200mg/d (70% 840mg) 5,266 20% 50 70 years 36,640 3% P=0.003 70-80 years 12,481 11% >80 years 3,504 24% Tang BMP, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in older people: a meta-analysis. Lancet 2007

Calcium Recommendations 1110mg 1300 Ca mg/day 840-1000mg Ca /day 840-1000 Ca mg/day 9.5 MJ and 8.3MJ Energy 9-16% 11.8 MJ 9.6MJ Energy Calcium predominantly milk/milkbased foods adults average: 850mg/d 40% comes from non-milk sources 7.1 MJ 6.2MJ Energy 40-45% 1100mg 1300 Ca mg 13-16%

Women >50 yrs Men. >70 years AI- RDI 1110mg 1300 Ca mg/day Orange Juice with added Calcium + Vitamins A, C & Folate 250ml glass: Ca 100mg 250mls Ca fortified milk/product Ca 300-500mg* *Ca fortified Calcium fortified cereal Per 30g serve: Ca 200mg With ½ cup milk: Ca 359mg Bread with added Calcium +fibre 2 slices (74g) Ca 200mg Serves Calcium fortified foods Ca mg 2 slices bread 200 1 glass milk 500 (1/2 on cereal) 1 cereal (30g) 200 1 orange juice (150ml) 60 Total Ca mg/day 960 unfortified 100 300 neg 12 512 Difficult to achieve RDI for calcium without use of calcium fortified foods or supplements

Changes in Body Composition Sarcopenia: Age-related decrease in Muscle Mass By 50 yrs: loss 10% muscle mass along with a corresponding decrease in strength By 70 yrs: loss 40%. muscle 40% of body weight 30 years muscle 25-30% of body weight 90 years

Sarcopenia: Age-related muscle loss ageing Number of fibres (vastus lateralis muscles men (18-82yrs) From age 80, no. fibres 50% younger men number of motor units (extensor digitorum brevis) muscles constant 5 to 50 yrs decreased linearly 95yrs type 2 muscle fibres Strength: 30% per yr >60yrs Sedentary loss and twice as high Faulkner JA, et al. Age-related changes in the structure and function of skeletal muscles Clinical and Experimental Pharmacology and Physiology (2007) 34, 1091 1096

Underweight age % overweight /obese Underweight reduced skeletal muscle mass increase risk of falls increase susceptibility injury, bone fracture Weight loss or 10% or more: hip fracture fracture low BMI < 20 Sources: AIHW analysis of the 1989 90, 1995 and 2001 National Health Surveys. Metanalsysis. DeLaet C. Oseteoporosis Int 2005 National Health Survey 2001

Obesity hits older population 1 million obese older Australians >one in five seniors 6 7kg heavier 20 yrs ago Gain weight into mid-70s Obese older Australians: greater risk of chronic diseases, disability and social impairment? Obesity osteoporosis: BMI> 30 bone health Migliaccio S. et al. Diabetes Metab Syndr Obes. 2011;4:273-82. Is obesity in women protective against osteoporosis?

Sarcopenic obesity 30% men, 10% women >80 yrs: fat gain, re-enforces muscle loss resting metabolic rate and activity + ve energy balance Direct catabolic effects fat mass, muscle mass physical activity becomes progressively more difficult increased disability mid thigh Baumgartner RN. Body composition in healthy aging. Ann N Y Acad Sci. 2000;904:437 448. Gallagher D, Ruts E, Visser M, et al. Weight stability masks sarcopenia in elderly men and women. Am J Physiol Endocrinol Metab. 2000;279(2):E366 E375. Dey DK, Bosaeus I, Lissner L, Steen B. Changes in body composition and its relation to muscle strength in 75-year-old men and women: a 5-year prospective follow-up study of the NORA cohort in Göteborg, Sweden. Nutrition. 2009;25(6):613 619.

Sarcopenia, Sarcopenic Obesity Metanalysis (n=>250,000 person yrs) Hip fracture risk BMI 20 versus BMI 25: X 2 risk BMI 30 compared to BMI 25: 17% risk Adjustment BMD BMI 20 versus BMI 25 : 33% risk BMI 30 compared to BMI 25: no change risk? Obesity osteoporosis: BMI> 30 bone health (Migliaccio) Zamboni, G. Mazzali, F. Fantin, A. Rossi, V. Di Francesco. Sarcopenic obesity: A new category of obesity in the elderly Nutrition, Metabolism and Cardiovascular Diseases, Volume 18, Issue 5, Pages 388-395 M. Migliaccio S. et al. Diabetes Metab Syndr Obes. 2011;4:273-82. s obesity in women protective against osteoporosis? Surveys. Metanalsysis. DeLaet C. Oseteoporosis Int 2005

Protein recommendations for the elderly 25% greater for those 70 years and older RDI (women): < 70yrs: 0.75 g/kg > 70yrs: 0.94 g/kg (increased from 46g/d to 57 g/d) Physically active: 1.2 1.5 g/kg/d?

Protein in Elderly Significant number clinical protein-energy malnutrition Falls are more likely in those with malnutrition Hip fracture in NHANES I was higher in those with low energy intake, low albumin, low muscle strength (Huang et al Am J Epidemiol 1996) RCT: Hip fracture patients protein (20g/d) supplements: shorter hospital stay (21 days) biceps muscle strength increased (16%) less bone loss (50% less 1yr) (Schurch et al. Ann Int Med 1998)

Elderly, Hip fracture and Protein Supplements: Effect of protein supplements on bone mineral density (BMD) of the proximal femur in patients with hip fracture 12 months earlier. Results given as the mean +/- SE and are are expressed as a percentage of baseline values. The solid line represents patients who received protein supplements ;the dashed line represents controls. *P = 0.029 for comparison with controls (analysis of variance). Schurch MA, Rizzoli R, Slosman D, Vadas L, Vergnaud P, Bonjour JP. Protein supplements increase serum insulin-like growth factor-i levels and attenuate proximal femur bone loss in patients with recent hip fracture. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1998 May 15;128(10):801-9.

Elderly, Hip fracture and Protein Supplements: Effect of protein supplements on serum levels of insulin-like growth factor-i (IGF-I) in patients with recent hip fracture. Results are the mean +/- SE and are expressed as a percentage of baseline values. The solid line represents patients who received protein supplements; the dashed line represents controls. *P = 0.055; **P = 0.003 for comparison with controls (analysis of variance). Schurch MA, Rizzoli R, Slosman D, Vadas L, Vergnaud P, Bonjour JP. Protein supplements increase serum insulin-like growth factor-i levels and attenuate proximal femur bone loss in patients with recent hip fracture. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1998 May 15;128(10):801-9.

Benefits of Resistance training mobility balance flexibility aids weight maintenance gait velocity muscle strength prevents falls? improved appetite? protein retention? bone maintenance

Funded by Meat & Livestock Aust Robin M. Daly, 1 Stella O Connell, 1 Niamh Mundell, 1 Carley Grimes, 1 David Dunstan, 2 Caryl Nowson 1 1 Centre for Physical Activity and Nutrition Research (C-PAN), Deakin University, Melbourne; 2 Baker IDI Heart and Diabetes Institute, Melbourne

Study Aim To investigate whether increasing dietary protein, when combined with resistance training enhanced muscle mass, strength and function in older women. Study Hypothesis Modest increase dietary protein (~1.3 g/kg/d) through an increased intake of lean red meat (2Xday) (~80g/meal), combined with progressive RT will lead to greater gains in muscle mass, strength and function compared to PRT Control carbohydrate diet

Analysis Allocation Enrollment Assessed for eligibility Randomised to diet groups by retirement village: independently living: self catering no meals provided Allocated: vitamin D supplement (1000IU/d) Resistance Training 2x week Higher Protein Lean red meat Control carbohydrate 1 serve/day Study Centre visit 1. 16 weeks 16 weeks Mid visit (pathology centre): blood test 24hr urinary sodium complete study complete study Study Centre visit 2. Blood pressure: 5 min seated, automated (AND): 3 reading s (1min apart)(mean last 2)

(mean SEM) 1.40 1.30 Δ* Mean age 72 years 1.3 0.1 g/kg/d (91g/d) g/kg/d 1.20 1.10 1.00 CHO Control n=43 RT + Protein n= 48 Baseline 4 wks 8 wks 12 wks 16 wks 1.1 0.1 g/kg/d (75g/d) Δ* baseline v intervention P<0.05 Dietary intake 24hr dietary recalls Significant difference between groups for protein g/kd/d & g/d P<0.05

1.0 Total Body Fat Mass Total Body Lean Mass 2.5 Change relative to baseline (%) 0.5 0.0-0.5-1.0-1.5-2.0 * 2.0 1.5 1.0 0.5 0.0 p<0.05 *** - 2.5 RT+CHO control * p<0.05 vs baseline RT+ Protein - 0.5-1.0 *** p<0.001 vs baseline RT+ Control CHO RT+ Protein Changes in total body fat mass (kg) RT + Protein -0.48 kg RT + Control CHO -0.29 kg No significant difference between groups Total body Lean Mass RT + Protein +0.6 kg RT+ Control CHO +0.1 kg between groups P<0.05

% Change Baseline Leg Muscle Strength RT + protein 40% RT + Control CHO 19% 60 30 P<0.05 ** *** RT+CHO RT+Meat ** p<0.01, *** p<0.001 vs baseline

Key Findings Twice-weekly PRT in vitamin D replete older women when combined with: Protein Group (1.3 g/kg/d) 0.5kg greater Increase lean mass 20% greater in Leg extension strength Conclusion Older women require 1.3 g/kg/body weight higher dietary protein intake to induce anabolic response to resistance training

Strategies: reduce falls fractures Adequate vitamin D status Progressive resistance raining Maintain body weight (BMI 24-30) Nutritionally adequate diet: Energy protein (~36% higher RDI) 1.3g/kg body weight Calcium Nowson CA, Flicker L, Fiatarone Singh MA. Osteoporosis in Frail Older People. Medicine Today. 2010;11:(11):18-31.

Prevention of falls and fractures Protein Resistant Training Adequate Energy Intake Adequate Protein Adequate vitamin D status Adequate Dietary Calcium