This article was downloaded by: [New York University] On: 14 May 2015, At: 05:11 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Ecology of Food and Nutrition Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gefn20
Impact of Dietary Habits and Physical Activity on Bone Health among 40 to 60 Year Old Females at Risk of Osteoporosis in India a
a
Rafiya Munshi , Anita Kochhar & Vishal Garg
b
a
Department of Food and Nutrition, College of Home Science, PAU Ludhiana, Ludhiana, Punjab, India b
Department of Orthopedic Surgery, Garg Hospital, Ludhiana, Punjab, India Published online: 17 Mar 2015.
Click for updates To cite this article: Rafiya Munshi, Anita Kochhar & Vishal Garg (2015): Impact of Dietary Habits and Physical Activity on Bone Health among 40 to 60 Year Old Females at Risk of Osteoporosis in India, Ecology of Food and Nutrition, DOI: 10.1080/03670244.2015.1015120 To link to this article: http://dx.doi.org/10.1080/03670244.2015.1015120
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [New York University] at 05:11 14 May 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Ecology of Food and Nutrition, 00:1–23, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0367-0244 print/1543-5237 online DOI: 10.1080/03670244.2015.1015120
Impact of Dietary Habits and Physical Activity on Bone Health among 40 to 60 Year Old Females at Risk of Osteoporosis in India RAFIYA MUNSHI and ANITA KOCHHAR
Downloaded by [New York University] at 05:11 14 May 2015
Department of Food and Nutrition, College of Home Science, PAU Ludhiana, Ludhiana, Punjab, India
VISHAL GARG Department of Orthopedic Surgery, Garg Hospital, Ludhiana, Punjab, India
Osteoporosis is a disorder of bones with increasing risk among women. However, a number of modifiable factors can help in combating this disorder. Present study examined the relationship of diet and physical activity and risk of osteoporosis through biochemical tests, bone mass density (BMD) scores, and standard questionnaires. Genetic risk for osteoporosis, presence of osteoarthritis, and thyroid problems were found among 8%, 7%, and 3% of participants, respectively; and 78% had onset of menopause between 47 to 55 years of age. Results revealed that less intake of proteins, minerals, and diverse fruit and vegetable consumption was significantly (p ≤ 0.05; 0.01) correlated with decreased BMD score and serum calcium. It was concluded that adequate intake of varied fruits and vegetables, good protein, habit of daily physical activity, adequate sun exposure, and dietary calcium, may play a promising role in decreasing the risk of osteoporosis among women of this age group. KEYWORDS BMD, osteoporosis, risk factors
Osteoporosis is a disease of the bones. It happens when too much bone is lost, or too little bone is made, or both. As a result, bones become weak and may break from a minor fall or, in serious cases, even from simple actions like sneezing or bumping into furniture. Osteoporosis means “porous Address correspondence to Rafiya Munshi, Department of Food and Nutrition, College of Home Science, Room 107 PG-a Block, PAU Ludhiana, Ludhiana, Punjab 141004, India. E-mail: [email protected] 1
Downloaded by [New York University] at 05:11 14 May 2015
2
R. Munshi et al.
bone.” If we look at healthy bone under a microscope, we will see that parts of it look like a honeycomb. In osteoporosis, the holes and spaces in the honeycomb are much bigger than they are in healthy bone. This means bones have lost density or mass and that the structure of bone tissue has become abnormal. As the bones become less dense, they also become weaker and more likely to break. As the second most populous country in the world, India is home to a very large population of osteoporosis patients. The population of India in the year 2008 was 1,148 million. It increased to 1,270 million in 2014. The population will increase to 1,367 million by the year 2020, and 1613 million by 2050, of which 9.8% (134 million) and 19.6% (315 million), respectively, will be adults over 60 years. These staggering numbers give some idea of the population at risk for osteoporosis in India in the years to come. In 2003, a highly conservative estimate by a group of experts suggested that 26 million Indians suffer from osteoporosis, and this number was expected to reach to 36 million by 2013 (APO 2003; United Nations 2008). Until 2013, sources estimated that 50 million people (approximately 40% of the total population) in India are either osteoporotic (t-score lower than –2.5) or have low bone mass (t-score between –1.0 and –2.5) (Mithal and Kaur 2012). Eating well and staying physically active are two essential components of a healthy lifestyle. These are also the pillars of osteoporosis prevention at all stages of life. Although genetics largely determine the size and density of our bones, lifestyle factors such as regular exercise and good nutrition also play key roles. Engaging in physical activity has many health benefits and is absolutely essential for strong bones and muscles. Thus, it is important to strengthen one’s muscles and bones to reduce the risk of osteoporosis, falls, and fractures. Walking 4 hours a week at a brisk speed has been associated with about a 40% reduction in hip fractures. Simple targeted exercise programs have been shown to improve bone density and functional mobility, resulting in 10% to 50% fewer falls in frail and active older adults (Province et al. 1995; Trombetti et al. 2011; Wolf et al. 1996). Calcium, protein, and vitamin D had always been nutrients symbolic of bone health. While calcium supplements in later life have shown a small benefit on bone mineral density (Shea et al. 2002; Shea et al. 2004), calcium supplements in vitamin D deficient individuals have not been shown to reduce the risk of fracture. Also, calcium supplementation without vitamin D supplementation may contribute to an increased risk of hip fracture (Bischoff-Ferrari et al. 2007). Thus, vitamin D supplementation plays a key role in bone health—calcium supplementation alone is insufficient to prevent fractures. As with vitamin D, protein intake has a dual benefit on osteoporosis prevention, as it helps build stronger bones and muscles. One of the mechanisms by which a higher protein intake may have a positive influence on bone and muscle health is via an increase in blood levels of Insulin-like
Downloaded by [New York University] at 05:11 14 May 2015
Impacting Osteoporosis Risk among Females in India
3
Growth Factor-1 (IGF-1). Regular daily milk intake results in a measurable increase in IGF-1 blood levels in children (Cadogan et al. 1997). This may also be achieved with protein supplements as demonstrated in one study among senior hip fracture patients (Schurch et al. 1998). IGF-1, produced by the liver, promotes bone and muscle formation, and supports the conversion of vitamin D into its active form (1,25-dihydroxyvitamin D) (Lombardi et al. 2010). In addition to essential nutrients most fruits and vegetables feature considerable amount of micronutrients such as minerals, fibers, vitamins, and secondary phenolic compounds. Increasing evidence shows the importance of these micronutrients for human health. Some studies showed the associations of bone mineral density with dietary patterns of antioxidant vitamins and carotenoids. In a study carried out among Japanese post menopausal women, dietary patterns were identified on a selected set of antioxidants through principal component factor analysis. Three dietary patterns were identified, the “retinol” pattern, characterized by notably high intakes of preformed retinol, zeaxanthin, and vitamin E, was positively associated with the risk for low bone mineral density (Sugiura et al. 2011; Vasco, Ruales, and Eldin 2008). The objective of our study was to check the relationship of diet and nutrition along with physical activity relating to risk of osteoporosis among pre and post menopausal women in India.
MATERIALS AND METHODS Methods: To assess women at risk of osteoporosis, IOF One-Minute Osteoporosis Risk Test questionnaire (Q-1) (Povoroznjuk, Dxerovich, and Karasevskaya 2007) was used to collect the required information. A separate questionnaire was also prepared to assess the activities and their relation to generation of pain (Q-2) (Lips et al. 2010). Assessment of Bone Mass Density through broadband ultrasound was also performed for all women on initial screening. The BMD test was repeated for a group of 60 women for two more times after an interval of every three months. Serum calcium serum phosphorus and serum alkaline phosphatase levels were also recorded for this group to assess their further risk. To assess dietary habits and food frequency of Milk, Poultry, Fleshy foods, fruits and vegetables cereals and pulses along with portion size, a three day 24 hour food recall questionnaire was prepared to collect information.
Participants A total of 139 post menopausal women were assessed initially and then 60 were screened repeatedly at two more screening camps and information required for questionnaires was collected. First camp was organized in a
4
R. Munshi et al.
local hospital where, mainly non-working women were assessed. Second and third camp was organized in the Food and Nutrition Department of Punjab Agricultural University, where all the women assessed were working women. The study was carried after obtaining permission by the institutional ethics committee (No. DR 12505-14/16-04-14).
Downloaded by [New York University] at 05:11 14 May 2015
Anthropometry, Biochemical Analysis, and Assessment of Bone Mass Density (BMD) Basic anthropometric measurements like height, weight, hip and waist circumferences were measured. Body mass index (BMI) was calculated as the weight in kilograms divided by the square of the height in meters (kg/m2 ) (WHO 2004) and Waist/Hip (W/H) was also determined (Ghafoorunissa and Krishnaswamy 1994). Bio chemical markers like serum calcium, serum phosphorus and serum alkaline phosphatase levels were also assessed through standard conventional assays (Ahmed, Fouda, and Abbas 2013). Bone mass density was assessed at three different sites like wrist heel and leg, under the supervision of practicing physician.
Dietary Intake Analysis The details regarding food intake and selection were obtained using food frequency questionnaire and calculated though MSU Nutriguide Computer Software (Song et al. 1992).
Statistical Analysis Mean and standard deviations for different parameters were computed, other applicable parameters were derived to determine relationship of food and specific nutrient intake with risk of diseases using SPSS software version 16.
RESULTS AND DISCUSSION The IOF One-Minute Osteoporosis Risk Test questionnaire consisted of 19 questions which provided information regarding genetic risk and secondary risk factors involved in osteoporosis among post menopausal women. A total of 139 women (40 to 60 years of age) were assessed, and 43% were found at risk of osteoporosis supporting the estimates of other studies (Mithal and Kaur 2012). Among the total at risk, genetic risk was found among 8% of participants, 7% were suffering from osteoarthritis and; only 3% were having thyroid problems. In this study only some percentage of women had secondary risk factors however, studies support that bone
Downloaded by [New York University] at 05:11 14 May 2015
Impacting Osteoporosis Risk among Females in India
5
loss can also occur due to an underlying disease or concurrent medication (Painter, Kleerekoper, and Camacho 2006). Further it was found that about 78% had onset of menopause between 47 to 55 years of age. Several studies confer that age, exercise, menopause, and low calcium diet act as significant predictors of low bone density in India (e.g., Aggarwal, Raveendran, and Khandelwal 2011). The early onset of menopause in India was again proved to be one of the main risk factors for osteoporosis, as supported by many studies (Cranney et al. 2007; Madhuri and Keerthi Reddy 2010; Ravin et al. 1994). About half of the assessed population included university lecturers constituting 36% of those at risk of osteoporosis and majority of these were following a sedentary lifestyle pattern. The quality of life questionnaire consisted of questions related to pain generation and activity pattern, the results of which supported the fact that women who were less active were found more at risk (Dumith 2011). In this study 87% of women at risk were reported to have minimum physically active lifestyle. Organized physical activity patterns on routine basis like yoga, brisk walking for at least 30 minutes, exercise was followed by less than 15% of assessed population; further supporting the fact that sedentary lifestyle increases the risk of osteoporosis (Aggarwal et al. 2011; Keramat et al. 2008) The population was also assessed for anthropometric measurements, BMI and waist /hip ratio was determined and compared with normal values as shown in table 1. The calculated BMI was higher than the normal range on all screening camps. The majority of women were either obese or overweight, with low BMD, several studies support that higher BMI is related to more bone mass (Skerry and Suva 2003) but it was found that women with higher BMI were having low BMD scores. This might support the fact that higher BMI is often related to increased fat deposition rather than more lean mass and may show an inverse relation between BMI and bone mass as revealed in some studies (Zhao et al. 2007). The calculated W/H ratio was low in pre menopausal women and slightly higher for post menopausal women in spite of low BMD scores. This increases the risk of osteoporosis for pre menopausal women as low W/H ratio has been associated with osteoporosis (Hien et al. 2005). For premenopausal group the average serum calcium, phosphorus and alkaline phosphate levels were in range of 8.44 to 8.82 mg/dl, 3.93 to 3.96 mg/dl and 205.25 to 201.00 IU/L, respectively. In post menopausal group the average serum calcium, phosphorus and alkaline phosphate levels were in range of 8.91 to 9.00 mg/dl, 3.82 to 4.08 mg/dl and 194.00 to 230.4 IU/L, respectively. These low values for serum calcium and serum phosphorus as seen in both the groups are related to postmenopausal osteoporosis (Varma, Paneri, and Badi 2005) and are considered as bio chemical markers of risk of osteoporosis directly related to BMD scores (Jada et al. 2013)
6
R. Munshi et al.
TABLE 1 Anthropometric Measurements, Biochemical Markers and BMD of Pre- and Post-menopausal Women Total Indian women (n = 139) Initial screening Parameters No. of participants (n) Age (mean) BMI (wt/ht2 ) Waist/hip ratio (mean) BMD – wrist (mean)
Pre-menopausal (40–50 y) 43.20 26.77 0.78 −1.5
67 ± ± ± ±
2.95 2.31 0.04 0.39
Post-menopausal (50–60 y)
Normal values
72 ± ± ± ±
− − 20–25a 0.8b >−1c
56.35 29.60 0.83 −2.10
1.90 1.22 0.05 0.65
Downloaded by [New York University] at 05:11 14 May 2015
Indian women (n = 60) 2nd screening Parameters
Pre-menopausal (40–50 y)
No. of participants (n) Age (mean) BMI (wt/ht2 ) Waist/hip ratio (mean) BMD heel (mean) Serum Calcium(mg/dl) Phosphorus(mg/dl) ALP(IU/L)
43.25 26.4 0.79 −1.8 8.44 3.93 211.00
30 ± ± ± ± ± ± ±
1.62 2.58 0.04 0.43 0.34 0.23 54.66
Post-menopausal (50–60 y)
Normal values
30 ± ± ± ± ± ± ±
− − 20–25a 0.8b >–1c 8.5–10.5mg/dld 3.5–5.5mg/dld 100–250 IU/Ld
56.5 29.6 0.82 −1.98 9.0 4.08 230.4
2.31 2.74 0.04 0.91 0.22 0.19 53.60
Indian women (n = 60) 3rd screening Parameters
Pre-menopausal (40–50 y)
No. of participants (n) Age (mean) BMI (wt/ht2 ) Waist/hip ratio (mean) BMD leg (mean) Serum calcium (mg/l) Phosphorus (mg/l) ALP (IU/L)
43.15 27.14 0.79 −1.90 8.82 3.96 205.25
30 ± ± ± ± ± ± ±
1.68 2.08 0.04 0.93 0.49 0.24 62.07
Post-menopausal (50–60 y)
Normal values
30 ± ± ± ± ± ± ±
− − 20–25a 0.8b >–1c 8.5–10.5mg/dld 3.5–5.5mg/dld 100–250 IU/Ld
56.2 29.1 0.81 −2.08 8.91 3.82 194
2.39 2.11 0.03 0.61 0.31 0.23 47.62
Note. Values represent Mean ± SD. a Garrow 1981; b Ghafoorunissa and Krishnaswamy 1994; c WHO 2003; d Standard methods.
The food intake of specific food groups along with portion size is given in table 2. Dietary assessment revealed a strong relation between less intake of pulses, fruits and vegetables against recommended intake (NIN 2011) and increased risk to osteoporosis and related symptoms. While as the intake of cereals, milk and milk products, sugars, fats and oils was adequate or more than recommended. The correlation coefficients derived for women at risk of osteoporosis to their food intake revealed that significantly (p ≤ .05) reduced intakes of varied fruits, vegetables, and pulses was associated with lower scores on BMD (r = 0.61, 069, and 0.52) and low serum calcium levels (r = 0.72, 0.63, and 0.49). In spite of adequate milk intakes
7
Impacting Osteoporosis Risk among Females in India
TABLE 2 Daily Food Intake (g) for Important Food Groups of Adult Women at Risk of Osteoporosis Food group Cereals and millets Pulses Milk and milk products Fruits Vegetables Oil and oil seeds Sugar
Pre-menopausal Post-menopausal 288.1 ± 13.23 52.86 ± 4.42 325 ± 14.53 64.70 ± 7.32 150.4 ± 10.64 34.2 ± 6.2 47.8 ± 3.2
263 ± 12.76 51.26 ± 6.32 270.80 ± 15.32 66.41 ± 5.32 126.31 ± 9.64 37.5 ± 4.31 41.52 ± 4.1
Recommended intake# 30 g × 9∗∗ (–2∗∗ for Post .M) ∗ 30 g × 2∗∗ ∗ 100 g × 3∗∗ ∗ 100 g × 1∗∗ (+1∗∗ for Post M) ∗ 100 g × 3∗∗ ∗ 5 g × 4∗∗ ∗ 5 g × 4∗∗ ∗
Downloaded by [New York University] at 05:11 14 May 2015
#Recommended intakes are as per NIN, 2011. ∗ Amount, ∗∗ portion size.
TABLE 3 Dietary Reference Intakes of Both Groups I and Group II, Based on Gender and Average BMI and Age Nutrients Energy (Kcal) Carbohydrates (g) Proteins (g) Fats (g) Fiber (g) Vitamin K (mcg) Calcium (mg) Phosphorus (mg) Magnesium (mg) α-Linolenic acid (g) Linoleic acid (g)
Group I (40–50 y)
Group II (50–60 y)
Suggested intake
1669.14 ± 343.07 232.91 ± 60.38 47.14 ± 7.8 48.43 ± 4.27 21.06 ± 1.63 44.41 ± 0.51 465.10 ± 17.91 278.00 ± 13.90 178.86 ± 9.88 0.64 ± 0.11 3.42 ± 0.89
1494.20 ± 179.58 211.00 ± 40.24 46.96 ± 6.46 44.40 ± 5.68 19.75 ± 2.72 37.8 ± 2.31 498 ± 23.35 289.54 ± 11.77 196.45 ± 9.64 0.69 ± 0.13 4.13 ± 1.10
1850I , 1714II 208–301I , 193–278II 53I , 57II 41I , 38II 25I , 21II 90I,II 800I , 1000II 700I,II 320I,II 1.1I,II 12I , 11II
Note. Group I: Average age, 42 years; BMI, 25.5; weight, 66 kg; height, 161 cm. Group II: Average age, 57 years; BMI, 31.6; weight, 71 kg; height, 150 cm). I Group I; II Group II.; I,II DRIs (Food and Nutrition Board, Institute of Medicine, National Academies 2010), WHO 2004.
the scores on BMD and serum calcium were low among women at risk of osteoporosis. Similar results were also obtained in the meta-analysis of cohort studies where, no overall association between milk intake and hip fracture in women was observed but more data are needed in men (Bischoff-Ferrari et al. 2011; Kanis et al. 2005). It has been also concluded in their studies that no significant relationship was observed by age for low milk intake and hip fracture risk. The intake of individual nutrients like proteins, fats, fiber, carbohydrates; minerals like calcium, phosphorus, magnesium; and intake of essential fatty acids like α-Linolenic acid and Linoleic acid together with vitamin K consumption, was also determined based on gender, average age, and BMI of both the groups (40–50 years and 50–60 years). This was compared with the DRI values as given by a WHO expert consultation (WHO 2004) and Food and Nutrition Board, Institute of Medicine, National Academies (2010). In this study we found that the intake of calories was slightly lower than the required and fats contributed more calories in both the groups. Protein intakes were lower than the required values for the age, gender, and
Downloaded by [New York University] at 05:11 14 May 2015
8
R. Munshi et al.
BMI in both the groups of women. Research says that low protein intakes are often associated with reduced muscle mass with increased vulnerability to muscle weakness, sarcopenia and frailty, all contributing to an increased risk of falling (Gaffney-Stomberg et al. 2009; Houston et al. 2008; Zoltick et al. 2011). Fiber intake was adequate; however, consumption of calcium phosphorus and magnesium was quite less than the required amounts for the specified age, gender and BMI in both the groups. Inadequate intake of calcium was observed which further adds to the risk because calcium is important for bone mineralization and strength (Heaney 2000) and is positively correlated with bone mass at all ages but most important at old age when intake drops and requirement increases (Teotia and Teotia 2004). The intake of essential fatty acids and vitamin K values were also recorded to be lower than the required and data states that low vitamin K is also associated with under carboxylated osteocalcin and increased risk for osteoporotic fractures (Binkley et al. 2000; Szulc et al. 1996; Weber 2001). While as, higher dietary omega-3/omega-6 fatty acids ratio is associated with beneficial effects on bone health (Maggio et al. 2009). The women not at risk were found to be physically active having healthy eating habits. Majority of them were also taking milk and poultry on daily basis along with adequate amounts of fresh fruits and vegetables. In a recent case-control study, it has been found that greater consumption of both fruit and vegetables in men and vegetables in women was associated with a lower risk of osteoporotic hip fractures in elderly Chinese (Xie et al. 2013). Least studies have been conducted on role of protein rich diets in decreasing the risk of osteoporosis, however the current study provided some evidence that women found with increased risk of osteoporosis had inadequate consumption of pulses together with increasingly following vegan diets supporting few available studies that reveal that when association between energyadjusted protein intake and hip fracture risk in elders was examined, the risk of hip fracture was reduced in upper quartiles of protein intake when compared with lowest quartile (Misra et al. 2011). Most people (90%–100%) get their vitamin D from exposure to sunlight (Holick 2003) because only a few foods, including, oily fish such as salmon, mackerel, and herring along with fish oil (e.g., cod liver oil), contain vitamin D (Holick and Chen 2008). However, it was found that almost 75% of all the women assessed were not exposing themselves to sunlight on daily basis because of increasing concern for skin disorders caused due excessive sun exposure which is negatively correlated with the 25(OH) D values. Indian socio-religious and cultural practices do not facilitate adequate sun exposure, thereby negating potential benefits of plentiful sunshine (Ritu and Ajay 2014). Consequently, subclinical vitamin D deficiency is highly prevalent in both urban and rural settings, and across all socioeconomic and geographic strata. Some risk factors, such as inadequate protein intake (Bonjour 2011)— as reported in this study also—is quite common in Indian female patients,
Impacting Osteoporosis Risk among Females in India
9
but these risk factors remain unvalidated for our population. In addition frequent alcohol intake and cigarette smoking in postmenopausal women is an extremely rare occurrence in our population. However, in IOF one-minute osteoporosis risk test, one of the risk factors that is evaluated is alcohol intake and cigarette smoking (IOF). Hence, a country-specific model utilizing the most important risk factors for osteoporosis may be developed. It is also believed that further studies are urgently needed which can correlate the clinical osteoporotic risk factors, including the use of prescription drugs and medical conditions, with the BMD values. Another limitation of our study was that some data for the risk factors was based on the patients’ self-reports.
Downloaded by [New York University] at 05:11 14 May 2015
CONCLUSION In this study, 43% of women were found at risk of osteoporosis with highest percentage having onset of menopause between 47 to 55 years of age. It was determined that adequate intake of varied fruits and vegetables together with good protein foods in combination with a lifelong habit of daily physical activity, adequate sun exposure and dietary calcium may play a role in decreasing the risk of osteoporosis among women after 40 years. It is also believed that more attention should be paid to the causes of early onset of menopause and secondary risk factors among the Indian female population.
ACKNOWLEDGMENTS The authors sincerely thank all those who volunteered for the study and all the staff of Food and Nutrition Department of Punjab Agricultural University to make this study a success.
REFERENCES APO. 2003. Consensus statement of an expert group, action plan osteoporosis. New Delhi, India: Osteoporosis Society of India. Ahmed, S. F., N. Fouda, and A. A. Abbas. 2013. Serum Dickkopf-1 level in postmenopausal females: Correlation with bone mineral density and serum biochemical markers. Journal of Osteoporosis 2013:1–7. Aggarwal, N., A. Raveendran, and N. Khandelwal. 2011. Prevalence and related risk factors of osteoporosis in pre- and postmenopausal Indian women. Journal of Midlife Health 2 (2): 81–85. Binkley, N. C., D. C. Krueger, J. A. Engelke, A. L. Foley, and J. W. Suttie. 2000. Vitamin K supplementation reduces serum concentrations of under-gamma carboxylated osteocalcin in healthy young and elderly adults. American Journal of Clinical Nutrition 72 (6): 1523–1528.
Downloaded by [New York University] at 05:11 14 May 2015
10
R. Munshi et al.
Bischoff-Ferrari, H. A., B. Dawson-Hughes, J. A. Baron, P. Burckhardt, R. Li, and D. Spiegelman. 2007. Calcium intake and hip fracture risk in men and women: A meta-analysis of prospective cohort studies and randomized controlled trials. American Journal of Clinical Nutrition 86 (6): 1780–1790. Bischoff-Ferrari, H. A., B. Dawson-Hughes, J. A. Baron, J. A. Kanis, E. J. Orav, H. B. Staehelin, D. P. Kiel, et al. 2011. Milk intake and risk of hip fracture in men and women: A meta-analysis of prospective cohort studies. Journal of Bone Mineral Research 26 (4): 833–839. doi:10.1002/jbmr.279. Bonjour, J. P. (2011) Protein intake and bone health. International Journal for Vitamin and Nutrition Research 81:134–142. Cadogan, J., R. Eastell, N. Jones, and M. E. Barker. 1997. Milk intake and bone mineral acquisition in adolescent girls: Randomized, controlled intervention trial. BMJ 315 (7118): 1255–1260. Cranney, A., S. A. Jamal, J. F. Tsang, R. G. Josse, and W. D. Leslie. 2007. Low bone mineral density and fracture burden in postmenopausal women. CMAJ 177 (6): 575–580. Dumith, S. C., P. C. Hallal, R. S. Reis, and H. W. Kohl. 2011. Worldwide prevalence of physical inactivity and its association with human development index in 76 countries. Preventive Medicine 53 (1–2): 24–28. Gaffney-Stomberg E., K. L. Insogna, N. R. Rodriguez, and J. E. Kerstetter. 2009. Increasing dietary protein requirements in elderly people for optimal muscle and bone health. Journal of the American Geriatric Society 57 (6): 1073–1079. Ghafoorunissa, S. A., and K. Krishnaswamy. 1994. Diet and heart disease, 1–79. Hyderabad, India: National Institute of Nutrition. Heaney, R. P. 2000. Calcium, dairy products and osteoporosis. Journal of the American College of Nutrition 19 (2 Suppl): 83S–99S. Hien, V. T. T., N. C. Khan, N. T. Lam, D. N. Le, B. T. Nhung, M. Nakamori, and S. Yamamoto. 2005. Determining the prevalence of osteoporosis and related factors using quantitative ultrasound in Vietnamese adult women. American Journal of Epidemiology 161 (9): 824–830. doi:10.1093/aje/kwi105. Holick, M. F. 2003. Vitamin D: A millenium perspective. Journal of Cell Biochemistry 88 (2): 296–307. Holick, M. F., and T. C. Chen. 2008. Vitamin D deficiency: A worldwide problem with health consequences. American Journal of Clinical Nutrition 87 (4): 1080S–1086S. Houston, D. K., B. J. Nicklas, J. Ding, T. B. Harris, F. A. Tylavsky, A. Newman, J. Lee, et al. 2008. Dietary protein intake is associated with lean mass change in older, community-dwelling adults: The Health, Aging, and Body Composition (Health ABC) Study. American Journal of Clinical Nutrition 87 (1): 150–155. Jada, M. R., B. Perugu, S. Chalasani, and G. Parvathi. 2013. Evaluation of biochemical and bone density parameters in premenopausal and postmenopausal women. International Journal of Biological Medicine Research 4 (3): 3441–3443. Kanis, J. A., H. Johansson, A. Oden, C. De Laet, O. Johnell, J. A. Eisman, E. McCloskey, et al. 2005. A meta-analysis of milk intake and fracture risk: Low utility for case finding. Osteoporosis International 16 (7): 799–804. Keramat, A., B. Patwardhan, B. Larijani, A. Chopra, A. Mithal, D. Chakravarty, H. Adibi, et al. 2008. The assessment of osteoporosis risk factors in Iranian
Downloaded by [New York University] at 05:11 14 May 2015
Impacting Osteoporosis Risk among Females in India
11
women compared with Indian women. BMC Musculoskeletal Disorders 9:28. doi:10.1186/1471-2474-9-28. Lips, P., K. Jameson, M. L. Bianchi, S. Goemaere, S. Boonen, J. Reeve, J. Stephen, et al. 2010. Validation of the IOF quality of life questionnaire for patients with wrist fracture. Osteoporosis International 21 (1): 61–70. doi:10.1007/s00198009-0946-6. Lombardi, G., C. Di Somma, L. Vuolo, E. Guerra, E. Scarano, and A. Colao. 2010. Role of IGF-I on PTH effects on bone. Journal of Endocrinology Investigation 33 (7 Suppl): 22–26. Madhuri, V., and M. Keerthi Reddy. 2010. Osteoporosis in postmenopausal Indian women: A case-control study. Journal of the Indian Academy of Geriatrics 6 (1): 14–17. Maggio, M., A. Artoni, F. Lauretani, L. Borghi A. Nouvenne, G. Valenti, and G. P. Ceda. 2009. The impact of omega-3 fatty acids on osteoporosis. Current Pharmaceutical Design 15 (36): 4157–4164 Misra, D., S. D. Berry, K. E. Broe, R. R. McLean, L. A. Cupples, K. L. Tucker, D. P. Kiel, et al. 2011. Does dietary protein reduce hip fracture risk in elders? The Framingham Osteoporosis Study. Osteoporosis International 22 (1): 345–359. doi:10.1007/s00198-010-1179-4. Mithal, A., and P. Kaur. 2012. Osteoporosis in Asia: A call to action. Current Osteoporosis Reports 10 (4): 245–247. NIN. 2011. Dietary guidelines for Indians: A manual. Hyderabad, India: National Institute Nutrition. Painter, S. E., M. Kleerekoper, and P. M. Camacho. 2006. Secondary osteoporosis: A review of the recent evidence. Endocrinology Practice 12 (4): 436–445. Povoroznjuk, V. V., N. Dzerovich, and T. Karasevskaya. 2007. Evaluation of validity of IOF’s one-minute osteoporosis risk test for postmenopausal women. Osteoporosis International 18 (Suppl 1): 227. Province, M. A., E. C. Hadley, M. C. Hornbrook, L. A. Lipsitz, J. P. Miller, C. D. Mulrow, M. G. Ory, et al. 1995. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA 273 (17): 1341–1347. Ravin, P., M. L. Hetland, K. Overgaard, and C. Christiansen. 1994. Premenopausal and post menopausal changes in bone mineral density of the proximal femur measured by dual energy X-ray absorptiometry. Journal of Bone and Mineral Research 9 (12): 1975–1980. Ritu, G., and G. Ajay. 2014. Vitamin D deficiency in India: Prevalence, causalities and interventions. Nutrients 6 (2): 729–775. doi:10.3390/nu6020729. Schurch, M. A., R. Rizzoli, D. Slosman, L. Vadas, P. Vergnaud, and J. P. Bonjour. 1998. 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. Annals of Internal Medicine 128 (10): 801–809. Shea, B., G. Wells, A. Cranney, N. Zytaruk, V. Robinson, L. Griffith, Z. Ortiz, et al. 2002. Meta-analyses of therapies for postmenopausal osteoporosis. VII. Metaanalysis of calcium supplementation for the prevention of postmenopausal osteoporosis. Endocrine Reviews 23 (4): 552–559.
Downloaded by [New York University] at 05:11 14 May 2015
12
R. Munshi et al.
Shea, B., G. Wells, A. Cranney, N. Zytaruk, V. Robinson, L. Griffith, C. Hamel, et al. 2004. Calcium supplementation on bone loss in postmenopausal women. Cochrane Database of Systematic Reviews 2004 (1): CD004526. Skerry, T. M., and L. J. Suva. 2003. Investigation of the regulation of bone mass by mechanical loading: From quantitative cytochemistry to gene array. Cell Biochemistry and Function 21 (3): 223–229. Song, W. O., S. K. Mann, S. Sehgal, P. R. Devi, S. Gudaru, and M. Kakarala. 1992. Nutriguide: Asian Indian foods. Nutritional analysis computer program. East Lansing, MI: Michigan State University. Sugiura, M., M. Nakamura, K. Ogawa, Y. Ikoma, F. Ando, H. Shimokata, and M. Yano. 2011. Dietary patterns of antioxidant vitamin and carotenoid intake associated with bone mineral density: Findings from post-menopausal Japanese female subjects. Osteoporosis International 22 (1): 143–152. Szulc, P., M.-C. Chapuy, P. J. Meunier, and P. D. Delmas. 1996. Serum undercarboxylated osteocalcin is a marker of the risk of hip fracture: A three year follow up study. Bone 18 (5): 487–488. Teotia, S. P. S., and M. Teotia. 2004. Female osteoporosis—a preventive breakthrough—national context. In Postgraduate medicine, ed. L. A. Pathak, 302–312. Mumbai, India: The Association of Physicians of India. Trombetti, A., M. Hars, F. R. Herrmann, R. W. Kressig, S. Ferrari, and R. Rizzoli. 2011. Effect of music-based multitask training on gait, balance, and fall risk in elderly people: A randomized controlled trial. Archives of Internal Medicine 171 (6): 525–533. United Nations. 2008. World population prospects: The 2008 revision. New York, NY: United Nations Department of Economic and Social Affairs/Population Division. Varma, M., S. Paneri, and P. Badi. 2005. Correlative study of bone related biochemical parameters in normal postmenopausal women and hyperglycemic postmenopausal women. Biomedical Research 16 (2): 129–132 Vasco, C., J. Ruales, and K. A. Eldin. 2008. Total phenolic compounds and antioxidant capacity of major fruits from Ecuador. Food Chemistry 111 (4): 816–823. Weber, P. 2001. Vitamin K and bone health. Nutrition 17 (10): 880–887. WHO. 2003. Prevention and management of osteoporosis. WHO Technical Report Series 921. Geneva, Switzerland: World Health Organization. WHO. 2004. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. The Lancet 363:157–163. Wolf, S. L., H. X. Barnhart, N. G. Kutner, E. McNeely, C. Coogler, and T. Xu. 1996. Reducing frailty and falls in older persons: An investigation of Tai Chi and computerized balance training. Atlanta FICSIT Group. Frailty and Injuries: Cooperative Studies of Intervention Techniques. Journal of the American Geriatric Society 44 (5): 489–497. Xie, H., L. Wu, B. H. Xue, W. Q. He, M. G. Fan, F. Ouyang, W. F. Tu, et al. (2013). Greater intake of fruit and vegetables is associated with a lower risk of osteoporotic hip fractures in elderly Chinese: A 1:1 matched case-control study. Osteoporosis International 24:2827–2836. Zhao, L.-J., Y.-J. Liu, P.-Y. Liu, J. Hamilton, R. R. Recker, and H.-W. Deng. 2007. Relationship of obesity with osteoporosis. Journal of Clinical Endocrinology Metabolism 92 (5): 1640–1646. doi:10.1210/jc.2006-0572.
Impacting Osteoporosis Risk among Females in India
13
Zoltick, E. S., S. Sahni, R. R. McLean, L. Quach, V. A. Casey, and M. T. Hannan. 2011. Dietary protein intake and subsequent falls in older men and women: The Framingham Study. Journal of Nutrition Health and Aging 15 (2): 147–152.
Downloaded by [New York University] at 05:11 14 May 2015
APPENDIX Q-1 Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age . . . . . . . . . . . . . . . . . ..yrs. Gender- M/F. Occupation- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contact no . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......................................... IOF One-Minute Osteoporosis Risk Test 19 easy questions to help you understand the status of your bone health Your Non-modifiable Risk Factors – What you cannot change! These are risk factors that one is born with or cannot alter. Nevertheless, it is important to be aware of risk factors you cannot change so that steps can be taken to reduce loss of bone mineral. 1. Have either of your parents been diagnosed with osteoporosis or broken a bone after a minor fall (a fall from standing height or less)? Yes/No 2. Did either of your parents have a stooped back (dowager’s hump)? Yes/No 3. Are you 40 years old or older? Yes/No 4. Have you ever broken a bone after a minor fall, as an adult? Yes/No 5. Do you fall frequently (more than once in the last year) or do you have a fear of falling because you are frail? Yes/No 6. Are you underweight (is your Body Mass Index less than 19 kg/m2)?(If u do not know your BMI, write your Height and weight . . . . . . . . . . . .kgs . . . . . . . . . . . . . . . . . . . . . cms/ . . . . . . . . . . . ...ft) Yes/No 7. Have you ever taken corticosteroid tablets (cortisone, prednisone, etc.) for more than 3 consecutive months (corticosteroids are often prescribed for conditions like asthma, rheumatoid arthritis, and some inflammatory diseases)? Yes/No 8. Have you ever been diagnosed with rheumatoid arthritis? Yes/No 9. Have you been diagnosed with an over-active thyroid, overactive parathyroid glands, type 1 diabetes or a nutritional/gastrointestinal disorder such as Crohn’s or celiac disease? Yes/No 10. For women over 45: Did your menopause occur before the age of 45? Yes/No
Downloaded by [New York University] at 05:11 14 May 2015
14
R. Munshi et al.
11. Have your periods ever stopped for 12 consecutive months or more (other than because of pregnancy, menopause or hysterectomy)? Yes/No 12. Were your ovaries removed before age 50, without you taking Hormone Replacement Therapy? Yes/No 13. Is your daily level of physical activity less than 30 minutes per day (housework, gardening, walking, running etc.)? Yes/No 14. Do you avoid, or are you allergic to milk or dairy products, without taking any calcium supplements? Yes/No 15. Do you spend less than 10 minutes per day outdoors (with part of your body exposed to sunlight), without vitamin D supplements? Yes/No 16. Do you suffer from back pain, if yes how often do you have it? . . . . . . .............................. Yes/No 17. Can you get up, once seated, from the chair without difficulty? Yes/No 18. Can you climb the stairs to the next floor without any difficulty or pain in knees? Yes/No 19. Do you include in your diet/or are you aware of nutrients for healthy bones? Yes/No
Are You at Risk of Osteoporosis? Around the world, one in three women, and one in five men over the age of 50 will suffer a broken bone due to osteoporosis. Osteoporosis is a “silent” disease which weakens bones and increases the risk of fractures, often resulting in pain and long-term disability. Take this IOF One-Minute Osteoporosis Risk Test and find out if you are at risk.
15
Impacting Osteoporosis Risk among Females in India
Q-2 Quality of Life Questionnaire Qualeffo-41 10 December 1997) Users of this questionnaire (and all authorized translations) must adhere to the user agreement. Please use the related Scoring Algorithm.
Downloaded by [New York University] at 05:11 14 May 2015
A. Pain The five questions in this section regard the situation in the last week. How often have you had back pain in the
Never 1 day per week or less 2–3 days per week 4–6 days per week Every day
If you have had back pain, for how long did you have back pain in the daytime?
Never 1–2 hours 3–5 hours 6–10 hours All day
How severe is your back pain at its worst?
No back pain Mild Moderate Severe Unbearable
How is your back pain at other times?
No back pain Mild Moderate Severe Unbearable
Has the back pain disturbed your sleep in the last week?
Less than once per week Once a week Twice a week Every other night Every night
No difficulty A little difficulty Moderate difficulty May need some help Impossible without help
B Activities of Daily Living The next 4 questions regard the situation at present. Do you have problems with dressing?
(Continued)
16
R. Munshi et al.
(Continued)
Downloaded by [New York University] at 05:11 14 May 2015
B Activities of Daily Living The next 4 questions regard the situation at present. Do you have problems with taking a bath or shower?
No difficulty A little difficulty Moderate difficulty May need some help Impossible without help
Do you have problems with getting to or operating a toilet?
No difficulty A little difficulty Moderate difficulty May need some help Impossible without help
How well do you sleep?
Sleep undisturbed Wake up sometimes Wake up often Sometimes I lie awake for hours Sometimes I have a sleepless night
C Jobs Around the House The next 5 questions are concerned with the present situation. If someone else does these things in your house, please answer as though you were responsible for them. Can you do the cleaning?
Without difficulty With a little difficulty With moderate difficulty With great difficulty Impossible
Can you prepare meals?
Without difficulty With a little difficulty With moderate difficulty With great difficulty Impossible
Can you wash the dishes?
Without difficulty With a little difficulty With moderate difficulty With great difficulty Impossible
Can you do your day to day shopping?
Without difficulty With a little difficulty With moderate difficulty With great difficulty Impossible
Can you lift a heavy object of 20 lbs (e.g., a crate of 12 bottles of milk, or a one year old child) and carry it for at least 10 yards?
Without difficulty With a little difficulty With moderate difficulty With great difficulty Impossible (Continued)
17
Impacting Osteoporosis Risk among Females in India (Continued)
Downloaded by [New York University] at 05:11 14 May 2015
D Mobility The next 8 questions also regard the present situation. Can you get up from a chair?
Without difficulty With a little difficulty With moderate difficulty With great difficulty Only with help
Can you bend down?
Easily Fairly easily Moderately Very little Impossible
Can you kneel down?
Easily Fairly easily Moderately Very little Impossible
Can you climb stairs to the next floor of a house?
Without difficulty With a little difficulty With at least one rest With great difficulty Only with help
Can you walk 100 yards?
Fast without stopping Slowly without stopping Slowly with at least one stop Only with help Impossible
How often have you been outside in the last week?
Everyday 5–6 days /week 3–4 days /week 1–2 days /week Less than once /week
Can you use public transport?
Without difficulty With a little difficulty With at least one rest With great difficulty Only with help
Have you been affected by the changes of your figure due to osteoporosis (e.g., loss of height, increase of waist measurement, shape of your back)?
Not at all A little Moderately Quite a bit Very much (Continued)
18
R. Munshi et al.
(Continued)
Downloaded by [New York University] at 05:11 14 May 2015
E Leisure, Social Activities Do you play any sport now?
Yes Yes with restriction Not at all
Can you do your gardening?
Do you perform any hobby now?
Yes Yes with restriction Not at all
Can you visit a cinema, theatre, etc.?
Yes Yes with restriction Not at all No cinema, or theatre within a reasonable distance
How often did you visit friends or relatives during the last 3 months?
Once a week or more Once or twice a month Less than once a month Never
How often did you participate in social activities (clubs, social gatherings, church activities, charity, etc.) during the last 3 months?
Once a week or more Once or twice a month Less than once a month Never
Does your back pain or disability interfere with intimacy (including sexual activity)?
Not at all A little Moderately Severely Not applicable
For your age, in general, would you say your health is:
Excellent Good Satisfactory Fair Poor
How would you rate your overall quality of life during the last week?
Excellent Good Satisfactory Fair Poor
Yes Yes with restriction Not at all Not applicable
F General Health Perception
(Continued)
19
Impacting Osteoporosis Risk among Females in India (Continued)
Downloaded by [New York University] at 05:11 14 May 2015
F General Health Perception How would you rate your overall quality of life compared with 10 years ago?
Much better now Slightly better now Unchanged Slightly worse now Much worse now
How well do you sleep?
Sleep undisturbed Wake up sometimes Wake up often Sometimes I lie awake for hours Sometimes I have a sleepless night
G Mental Function The next nine questions regard the situation in the last week. Do you tend to feel tired?
In the morning In the afternoon Only in the evening After strenuous activity Almost never
Do you feel downhearted?
Almost everyday 3–5 days/week 1–2 days/week Once in a while Almost never
Do you feel lonely?
Almost everyday 3–5 days/week 1–2 days/week Once in a while Almost never
Do you feel full of energy?
Almost everyday 3–5 days/week 1–2 days/week Once in a while Almost never
Are you hopeful about your future?
Never Rarely Sometimes Quite often Always
Do you get upset over little things?
Never Rarely Sometimes Quite often Always (Continued)
20
R. Munshi et al.
(Continued)
Downloaded by [New York University] at 05:11 14 May 2015
G Mental Function The next nine questions regard the situation in the last week. Do you find it easy to make contact with people?
Never Rarely Sometimes Quite often Always
Are you in good spirits most of the day?
Never Rarely Sometimes Quite often Always
Are you afraid of becoming totally dependent?
Never Rarely Sometimes Quite often Always
Q-3 24 Hour Food Recall Questionnaire for Assessment of Dietary Intake of Women at Risk of Osteoporosis
Participant ID:
__ __ __ __
Date of Interview:
Date of Intake:
__ __ - __ __ -20 __ __
__ __ - __ __ -20 __ __
Start From Any day- : Mon / Tue / Wed / Thu / Fri / Sat / Sun
__ __ : __ __
__ __ : __ __
(am / pm)
(am / pm)
Time Started
Time Ended
21
Impacting Osteoporosis Risk among Females in India DAY ONE INTAKE QUESTIONNAIRE Individual Intake Form Column 1
Downloaded by [New York University] at 05:11 14 May 2015
Time
*Occasion
Column 2 Food/Drink and Description Additions of ingredient
Column 3 Amount on house hold measurements (eat/drink)?
Column 4 *Source of Food
Column 5 (Research use only) Food Code Amount
Occasion: 1. Breakfast 2. Brunch 3. Lunch 4. Dinner 5. Late night meal 6. Fruit 7. Food and/or beverage break, snack, alcohol beverage or other beverage 8. Other (specify):_________________________ Source of food: 1. Homemade 2. Restaurant/cafeteria/fast food shop/ 3. Food stall/hawker 4. Supermarket/Food store 5. Workplace tuck shop 6. Day care 7. Friend/relative’s home 8. Party/BBQ/banquet/special event 9. Other (specify):________
22
R. Munshi et al. DAY TWO INTAKE QUESTIONNAIRE Individual Intake Form Column 1
Downloaded by [New York University] at 05:11 14 May 2015
Time
*Occasion
Column 2
Column 3
Food/Drink and Description of Additions ingredient
Column 4 Amount on house hold measurements (eat/drink)?
*Source of Food
Column 5 (Research use only) Food Code Amount
Occasion: 1. Breakfast 2. Brunch 3. Lunch 4. Dinner 5. Late night meal 6. Fruit 7. Food and/or beverage break, snack, alcohol beverage or other beverage 8. Other (specify):_________________________ Source of food: 1. Homemade 2. Restaurant/cafeteria/fast food shop/3. Food stall/hawker 4. Supermarket/Food store 5. Workplace tuck shop 6. Day care 7. Friend/relative’s home 8. Party/BBQ/banquet/special event 9. Other (specify):________
Impacting Osteoporosis Risk among Females in India
23
DAY THREE INTAKE QUESTIONNAIRE Individual Intake Form Column 1
Downloaded by [New York University] at 05:11 14 May 2015
Time
Column 2
*Occasion Food/Drink and Additions
Column 3
Column 4
Description of ingredient
Amount on house hold measurements (eat/drink)?
*Source of Food
Column 5 (Research use only) Food Code Amount
Occasion: 1. Breakfast 2. Brunch 3. Lunch 4. Dinner 5. Late night meal 6. Fruit 7. Food and/or beverage break, snack, alcohol beverage or other beverage 8. Other (specify):_________________________ Source of food: 1. Homemade 2. Restaurant/cafeteria/fast food shop/3. Food stall/hawker 4. Supermarket/Food store 5. Workplace tuck shop 6. Day care 7. Friend/relative’s home 8. Party/BBQ/banquet/special event 9. Other (specify):______
Ecology of Food and Nutrition Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gefn20
Impact of Dietary Habits and Physical Activity on Bone Health among 40 to 60 Year Old Females at Risk of Osteoporosis in India a
a
Rafiya Munshi , Anita Kochhar & Vishal Garg
b
a
Department of Food and Nutrition, College of Home Science, PAU Ludhiana, Ludhiana, Punjab, India b
Department of Orthopedic Surgery, Garg Hospital, Ludhiana, Punjab, India Published online: 17 Mar 2015.
Click for updates To cite this article: Rafiya Munshi, Anita Kochhar & Vishal Garg (2015): Impact of Dietary Habits and Physical Activity on Bone Health among 40 to 60 Year Old Females at Risk of Osteoporosis in India, Ecology of Food and Nutrition, DOI: 10.1080/03670244.2015.1015120 To link to this article: http://dx.doi.org/10.1080/03670244.2015.1015120
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [New York University] at 05:11 14 May 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Ecology of Food and Nutrition, 00:1–23, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0367-0244 print/1543-5237 online DOI: 10.1080/03670244.2015.1015120
Impact of Dietary Habits and Physical Activity on Bone Health among 40 to 60 Year Old Females at Risk of Osteoporosis in India RAFIYA MUNSHI and ANITA KOCHHAR
Downloaded by [New York University] at 05:11 14 May 2015
Department of Food and Nutrition, College of Home Science, PAU Ludhiana, Ludhiana, Punjab, India
VISHAL GARG Department of Orthopedic Surgery, Garg Hospital, Ludhiana, Punjab, India
Osteoporosis is a disorder of bones with increasing risk among women. However, a number of modifiable factors can help in combating this disorder. Present study examined the relationship of diet and physical activity and risk of osteoporosis through biochemical tests, bone mass density (BMD) scores, and standard questionnaires. Genetic risk for osteoporosis, presence of osteoarthritis, and thyroid problems were found among 8%, 7%, and 3% of participants, respectively; and 78% had onset of menopause between 47 to 55 years of age. Results revealed that less intake of proteins, minerals, and diverse fruit and vegetable consumption was significantly (p ≤ 0.05; 0.01) correlated with decreased BMD score and serum calcium. It was concluded that adequate intake of varied fruits and vegetables, good protein, habit of daily physical activity, adequate sun exposure, and dietary calcium, may play a promising role in decreasing the risk of osteoporosis among women of this age group. KEYWORDS BMD, osteoporosis, risk factors
Osteoporosis is a disease of the bones. It happens when too much bone is lost, or too little bone is made, or both. As a result, bones become weak and may break from a minor fall or, in serious cases, even from simple actions like sneezing or bumping into furniture. Osteoporosis means “porous Address correspondence to Rafiya Munshi, Department of Food and Nutrition, College of Home Science, Room 107 PG-a Block, PAU Ludhiana, Ludhiana, Punjab 141004, India. E-mail: [email protected] 1
Downloaded by [New York University] at 05:11 14 May 2015
2
R. Munshi et al.
bone.” If we look at healthy bone under a microscope, we will see that parts of it look like a honeycomb. In osteoporosis, the holes and spaces in the honeycomb are much bigger than they are in healthy bone. This means bones have lost density or mass and that the structure of bone tissue has become abnormal. As the bones become less dense, they also become weaker and more likely to break. As the second most populous country in the world, India is home to a very large population of osteoporosis patients. The population of India in the year 2008 was 1,148 million. It increased to 1,270 million in 2014. The population will increase to 1,367 million by the year 2020, and 1613 million by 2050, of which 9.8% (134 million) and 19.6% (315 million), respectively, will be adults over 60 years. These staggering numbers give some idea of the population at risk for osteoporosis in India in the years to come. In 2003, a highly conservative estimate by a group of experts suggested that 26 million Indians suffer from osteoporosis, and this number was expected to reach to 36 million by 2013 (APO 2003; United Nations 2008). Until 2013, sources estimated that 50 million people (approximately 40% of the total population) in India are either osteoporotic (t-score lower than –2.5) or have low bone mass (t-score between –1.0 and –2.5) (Mithal and Kaur 2012). Eating well and staying physically active are two essential components of a healthy lifestyle. These are also the pillars of osteoporosis prevention at all stages of life. Although genetics largely determine the size and density of our bones, lifestyle factors such as regular exercise and good nutrition also play key roles. Engaging in physical activity has many health benefits and is absolutely essential for strong bones and muscles. Thus, it is important to strengthen one’s muscles and bones to reduce the risk of osteoporosis, falls, and fractures. Walking 4 hours a week at a brisk speed has been associated with about a 40% reduction in hip fractures. Simple targeted exercise programs have been shown to improve bone density and functional mobility, resulting in 10% to 50% fewer falls in frail and active older adults (Province et al. 1995; Trombetti et al. 2011; Wolf et al. 1996). Calcium, protein, and vitamin D had always been nutrients symbolic of bone health. While calcium supplements in later life have shown a small benefit on bone mineral density (Shea et al. 2002; Shea et al. 2004), calcium supplements in vitamin D deficient individuals have not been shown to reduce the risk of fracture. Also, calcium supplementation without vitamin D supplementation may contribute to an increased risk of hip fracture (Bischoff-Ferrari et al. 2007). Thus, vitamin D supplementation plays a key role in bone health—calcium supplementation alone is insufficient to prevent fractures. As with vitamin D, protein intake has a dual benefit on osteoporosis prevention, as it helps build stronger bones and muscles. One of the mechanisms by which a higher protein intake may have a positive influence on bone and muscle health is via an increase in blood levels of Insulin-like
Downloaded by [New York University] at 05:11 14 May 2015
Impacting Osteoporosis Risk among Females in India
3
Growth Factor-1 (IGF-1). Regular daily milk intake results in a measurable increase in IGF-1 blood levels in children (Cadogan et al. 1997). This may also be achieved with protein supplements as demonstrated in one study among senior hip fracture patients (Schurch et al. 1998). IGF-1, produced by the liver, promotes bone and muscle formation, and supports the conversion of vitamin D into its active form (1,25-dihydroxyvitamin D) (Lombardi et al. 2010). In addition to essential nutrients most fruits and vegetables feature considerable amount of micronutrients such as minerals, fibers, vitamins, and secondary phenolic compounds. Increasing evidence shows the importance of these micronutrients for human health. Some studies showed the associations of bone mineral density with dietary patterns of antioxidant vitamins and carotenoids. In a study carried out among Japanese post menopausal women, dietary patterns were identified on a selected set of antioxidants through principal component factor analysis. Three dietary patterns were identified, the “retinol” pattern, characterized by notably high intakes of preformed retinol, zeaxanthin, and vitamin E, was positively associated with the risk for low bone mineral density (Sugiura et al. 2011; Vasco, Ruales, and Eldin 2008). The objective of our study was to check the relationship of diet and nutrition along with physical activity relating to risk of osteoporosis among pre and post menopausal women in India.
MATERIALS AND METHODS Methods: To assess women at risk of osteoporosis, IOF One-Minute Osteoporosis Risk Test questionnaire (Q-1) (Povoroznjuk, Dxerovich, and Karasevskaya 2007) was used to collect the required information. A separate questionnaire was also prepared to assess the activities and their relation to generation of pain (Q-2) (Lips et al. 2010). Assessment of Bone Mass Density through broadband ultrasound was also performed for all women on initial screening. The BMD test was repeated for a group of 60 women for two more times after an interval of every three months. Serum calcium serum phosphorus and serum alkaline phosphatase levels were also recorded for this group to assess their further risk. To assess dietary habits and food frequency of Milk, Poultry, Fleshy foods, fruits and vegetables cereals and pulses along with portion size, a three day 24 hour food recall questionnaire was prepared to collect information.
Participants A total of 139 post menopausal women were assessed initially and then 60 were screened repeatedly at two more screening camps and information required for questionnaires was collected. First camp was organized in a
4
R. Munshi et al.
local hospital where, mainly non-working women were assessed. Second and third camp was organized in the Food and Nutrition Department of Punjab Agricultural University, where all the women assessed were working women. The study was carried after obtaining permission by the institutional ethics committee (No. DR 12505-14/16-04-14).
Downloaded by [New York University] at 05:11 14 May 2015
Anthropometry, Biochemical Analysis, and Assessment of Bone Mass Density (BMD) Basic anthropometric measurements like height, weight, hip and waist circumferences were measured. Body mass index (BMI) was calculated as the weight in kilograms divided by the square of the height in meters (kg/m2 ) (WHO 2004) and Waist/Hip (W/H) was also determined (Ghafoorunissa and Krishnaswamy 1994). Bio chemical markers like serum calcium, serum phosphorus and serum alkaline phosphatase levels were also assessed through standard conventional assays (Ahmed, Fouda, and Abbas 2013). Bone mass density was assessed at three different sites like wrist heel and leg, under the supervision of practicing physician.
Dietary Intake Analysis The details regarding food intake and selection were obtained using food frequency questionnaire and calculated though MSU Nutriguide Computer Software (Song et al. 1992).
Statistical Analysis Mean and standard deviations for different parameters were computed, other applicable parameters were derived to determine relationship of food and specific nutrient intake with risk of diseases using SPSS software version 16.
RESULTS AND DISCUSSION The IOF One-Minute Osteoporosis Risk Test questionnaire consisted of 19 questions which provided information regarding genetic risk and secondary risk factors involved in osteoporosis among post menopausal women. A total of 139 women (40 to 60 years of age) were assessed, and 43% were found at risk of osteoporosis supporting the estimates of other studies (Mithal and Kaur 2012). Among the total at risk, genetic risk was found among 8% of participants, 7% were suffering from osteoarthritis and; only 3% were having thyroid problems. In this study only some percentage of women had secondary risk factors however, studies support that bone
Downloaded by [New York University] at 05:11 14 May 2015
Impacting Osteoporosis Risk among Females in India
5
loss can also occur due to an underlying disease or concurrent medication (Painter, Kleerekoper, and Camacho 2006). Further it was found that about 78% had onset of menopause between 47 to 55 years of age. Several studies confer that age, exercise, menopause, and low calcium diet act as significant predictors of low bone density in India (e.g., Aggarwal, Raveendran, and Khandelwal 2011). The early onset of menopause in India was again proved to be one of the main risk factors for osteoporosis, as supported by many studies (Cranney et al. 2007; Madhuri and Keerthi Reddy 2010; Ravin et al. 1994). About half of the assessed population included university lecturers constituting 36% of those at risk of osteoporosis and majority of these were following a sedentary lifestyle pattern. The quality of life questionnaire consisted of questions related to pain generation and activity pattern, the results of which supported the fact that women who were less active were found more at risk (Dumith 2011). In this study 87% of women at risk were reported to have minimum physically active lifestyle. Organized physical activity patterns on routine basis like yoga, brisk walking for at least 30 minutes, exercise was followed by less than 15% of assessed population; further supporting the fact that sedentary lifestyle increases the risk of osteoporosis (Aggarwal et al. 2011; Keramat et al. 2008) The population was also assessed for anthropometric measurements, BMI and waist /hip ratio was determined and compared with normal values as shown in table 1. The calculated BMI was higher than the normal range on all screening camps. The majority of women were either obese or overweight, with low BMD, several studies support that higher BMI is related to more bone mass (Skerry and Suva 2003) but it was found that women with higher BMI were having low BMD scores. This might support the fact that higher BMI is often related to increased fat deposition rather than more lean mass and may show an inverse relation between BMI and bone mass as revealed in some studies (Zhao et al. 2007). The calculated W/H ratio was low in pre menopausal women and slightly higher for post menopausal women in spite of low BMD scores. This increases the risk of osteoporosis for pre menopausal women as low W/H ratio has been associated with osteoporosis (Hien et al. 2005). For premenopausal group the average serum calcium, phosphorus and alkaline phosphate levels were in range of 8.44 to 8.82 mg/dl, 3.93 to 3.96 mg/dl and 205.25 to 201.00 IU/L, respectively. In post menopausal group the average serum calcium, phosphorus and alkaline phosphate levels were in range of 8.91 to 9.00 mg/dl, 3.82 to 4.08 mg/dl and 194.00 to 230.4 IU/L, respectively. These low values for serum calcium and serum phosphorus as seen in both the groups are related to postmenopausal osteoporosis (Varma, Paneri, and Badi 2005) and are considered as bio chemical markers of risk of osteoporosis directly related to BMD scores (Jada et al. 2013)
6
R. Munshi et al.
TABLE 1 Anthropometric Measurements, Biochemical Markers and BMD of Pre- and Post-menopausal Women Total Indian women (n = 139) Initial screening Parameters No. of participants (n) Age (mean) BMI (wt/ht2 ) Waist/hip ratio (mean) BMD – wrist (mean)
Pre-menopausal (40–50 y) 43.20 26.77 0.78 −1.5
67 ± ± ± ±
2.95 2.31 0.04 0.39
Post-menopausal (50–60 y)
Normal values
72 ± ± ± ±
− − 20–25a 0.8b >−1c
56.35 29.60 0.83 −2.10
1.90 1.22 0.05 0.65
Downloaded by [New York University] at 05:11 14 May 2015
Indian women (n = 60) 2nd screening Parameters
Pre-menopausal (40–50 y)
No. of participants (n) Age (mean) BMI (wt/ht2 ) Waist/hip ratio (mean) BMD heel (mean) Serum Calcium(mg/dl) Phosphorus(mg/dl) ALP(IU/L)
43.25 26.4 0.79 −1.8 8.44 3.93 211.00
30 ± ± ± ± ± ± ±
1.62 2.58 0.04 0.43 0.34 0.23 54.66
Post-menopausal (50–60 y)
Normal values
30 ± ± ± ± ± ± ±
− − 20–25a 0.8b >–1c 8.5–10.5mg/dld 3.5–5.5mg/dld 100–250 IU/Ld
56.5 29.6 0.82 −1.98 9.0 4.08 230.4
2.31 2.74 0.04 0.91 0.22 0.19 53.60
Indian women (n = 60) 3rd screening Parameters
Pre-menopausal (40–50 y)
No. of participants (n) Age (mean) BMI (wt/ht2 ) Waist/hip ratio (mean) BMD leg (mean) Serum calcium (mg/l) Phosphorus (mg/l) ALP (IU/L)
43.15 27.14 0.79 −1.90 8.82 3.96 205.25
30 ± ± ± ± ± ± ±
1.68 2.08 0.04 0.93 0.49 0.24 62.07
Post-menopausal (50–60 y)
Normal values
30 ± ± ± ± ± ± ±
− − 20–25a 0.8b >–1c 8.5–10.5mg/dld 3.5–5.5mg/dld 100–250 IU/Ld
56.2 29.1 0.81 −2.08 8.91 3.82 194
2.39 2.11 0.03 0.61 0.31 0.23 47.62
Note. Values represent Mean ± SD. a Garrow 1981; b Ghafoorunissa and Krishnaswamy 1994; c WHO 2003; d Standard methods.
The food intake of specific food groups along with portion size is given in table 2. Dietary assessment revealed a strong relation between less intake of pulses, fruits and vegetables against recommended intake (NIN 2011) and increased risk to osteoporosis and related symptoms. While as the intake of cereals, milk and milk products, sugars, fats and oils was adequate or more than recommended. The correlation coefficients derived for women at risk of osteoporosis to their food intake revealed that significantly (p ≤ .05) reduced intakes of varied fruits, vegetables, and pulses was associated with lower scores on BMD (r = 0.61, 069, and 0.52) and low serum calcium levels (r = 0.72, 0.63, and 0.49). In spite of adequate milk intakes
7
Impacting Osteoporosis Risk among Females in India
TABLE 2 Daily Food Intake (g) for Important Food Groups of Adult Women at Risk of Osteoporosis Food group Cereals and millets Pulses Milk and milk products Fruits Vegetables Oil and oil seeds Sugar
Pre-menopausal Post-menopausal 288.1 ± 13.23 52.86 ± 4.42 325 ± 14.53 64.70 ± 7.32 150.4 ± 10.64 34.2 ± 6.2 47.8 ± 3.2
263 ± 12.76 51.26 ± 6.32 270.80 ± 15.32 66.41 ± 5.32 126.31 ± 9.64 37.5 ± 4.31 41.52 ± 4.1
Recommended intake# 30 g × 9∗∗ (–2∗∗ for Post .M) ∗ 30 g × 2∗∗ ∗ 100 g × 3∗∗ ∗ 100 g × 1∗∗ (+1∗∗ for Post M) ∗ 100 g × 3∗∗ ∗ 5 g × 4∗∗ ∗ 5 g × 4∗∗ ∗
Downloaded by [New York University] at 05:11 14 May 2015
#Recommended intakes are as per NIN, 2011. ∗ Amount, ∗∗ portion size.
TABLE 3 Dietary Reference Intakes of Both Groups I and Group II, Based on Gender and Average BMI and Age Nutrients Energy (Kcal) Carbohydrates (g) Proteins (g) Fats (g) Fiber (g) Vitamin K (mcg) Calcium (mg) Phosphorus (mg) Magnesium (mg) α-Linolenic acid (g) Linoleic acid (g)
Group I (40–50 y)
Group II (50–60 y)
Suggested intake
1669.14 ± 343.07 232.91 ± 60.38 47.14 ± 7.8 48.43 ± 4.27 21.06 ± 1.63 44.41 ± 0.51 465.10 ± 17.91 278.00 ± 13.90 178.86 ± 9.88 0.64 ± 0.11 3.42 ± 0.89
1494.20 ± 179.58 211.00 ± 40.24 46.96 ± 6.46 44.40 ± 5.68 19.75 ± 2.72 37.8 ± 2.31 498 ± 23.35 289.54 ± 11.77 196.45 ± 9.64 0.69 ± 0.13 4.13 ± 1.10
1850I , 1714II 208–301I , 193–278II 53I , 57II 41I , 38II 25I , 21II 90I,II 800I , 1000II 700I,II 320I,II 1.1I,II 12I , 11II
Note. Group I: Average age, 42 years; BMI, 25.5; weight, 66 kg; height, 161 cm. Group II: Average age, 57 years; BMI, 31.6; weight, 71 kg; height, 150 cm). I Group I; II Group II.; I,II DRIs (Food and Nutrition Board, Institute of Medicine, National Academies 2010), WHO 2004.
the scores on BMD and serum calcium were low among women at risk of osteoporosis. Similar results were also obtained in the meta-analysis of cohort studies where, no overall association between milk intake and hip fracture in women was observed but more data are needed in men (Bischoff-Ferrari et al. 2011; Kanis et al. 2005). It has been also concluded in their studies that no significant relationship was observed by age for low milk intake and hip fracture risk. The intake of individual nutrients like proteins, fats, fiber, carbohydrates; minerals like calcium, phosphorus, magnesium; and intake of essential fatty acids like α-Linolenic acid and Linoleic acid together with vitamin K consumption, was also determined based on gender, average age, and BMI of both the groups (40–50 years and 50–60 years). This was compared with the DRI values as given by a WHO expert consultation (WHO 2004) and Food and Nutrition Board, Institute of Medicine, National Academies (2010). In this study we found that the intake of calories was slightly lower than the required and fats contributed more calories in both the groups. Protein intakes were lower than the required values for the age, gender, and
Downloaded by [New York University] at 05:11 14 May 2015
8
R. Munshi et al.
BMI in both the groups of women. Research says that low protein intakes are often associated with reduced muscle mass with increased vulnerability to muscle weakness, sarcopenia and frailty, all contributing to an increased risk of falling (Gaffney-Stomberg et al. 2009; Houston et al. 2008; Zoltick et al. 2011). Fiber intake was adequate; however, consumption of calcium phosphorus and magnesium was quite less than the required amounts for the specified age, gender and BMI in both the groups. Inadequate intake of calcium was observed which further adds to the risk because calcium is important for bone mineralization and strength (Heaney 2000) and is positively correlated with bone mass at all ages but most important at old age when intake drops and requirement increases (Teotia and Teotia 2004). The intake of essential fatty acids and vitamin K values were also recorded to be lower than the required and data states that low vitamin K is also associated with under carboxylated osteocalcin and increased risk for osteoporotic fractures (Binkley et al. 2000; Szulc et al. 1996; Weber 2001). While as, higher dietary omega-3/omega-6 fatty acids ratio is associated with beneficial effects on bone health (Maggio et al. 2009). The women not at risk were found to be physically active having healthy eating habits. Majority of them were also taking milk and poultry on daily basis along with adequate amounts of fresh fruits and vegetables. In a recent case-control study, it has been found that greater consumption of both fruit and vegetables in men and vegetables in women was associated with a lower risk of osteoporotic hip fractures in elderly Chinese (Xie et al. 2013). Least studies have been conducted on role of protein rich diets in decreasing the risk of osteoporosis, however the current study provided some evidence that women found with increased risk of osteoporosis had inadequate consumption of pulses together with increasingly following vegan diets supporting few available studies that reveal that when association between energyadjusted protein intake and hip fracture risk in elders was examined, the risk of hip fracture was reduced in upper quartiles of protein intake when compared with lowest quartile (Misra et al. 2011). Most people (90%–100%) get their vitamin D from exposure to sunlight (Holick 2003) because only a few foods, including, oily fish such as salmon, mackerel, and herring along with fish oil (e.g., cod liver oil), contain vitamin D (Holick and Chen 2008). However, it was found that almost 75% of all the women assessed were not exposing themselves to sunlight on daily basis because of increasing concern for skin disorders caused due excessive sun exposure which is negatively correlated with the 25(OH) D values. Indian socio-religious and cultural practices do not facilitate adequate sun exposure, thereby negating potential benefits of plentiful sunshine (Ritu and Ajay 2014). Consequently, subclinical vitamin D deficiency is highly prevalent in both urban and rural settings, and across all socioeconomic and geographic strata. Some risk factors, such as inadequate protein intake (Bonjour 2011)— as reported in this study also—is quite common in Indian female patients,
Impacting Osteoporosis Risk among Females in India
9
but these risk factors remain unvalidated for our population. In addition frequent alcohol intake and cigarette smoking in postmenopausal women is an extremely rare occurrence in our population. However, in IOF one-minute osteoporosis risk test, one of the risk factors that is evaluated is alcohol intake and cigarette smoking (IOF). Hence, a country-specific model utilizing the most important risk factors for osteoporosis may be developed. It is also believed that further studies are urgently needed which can correlate the clinical osteoporotic risk factors, including the use of prescription drugs and medical conditions, with the BMD values. Another limitation of our study was that some data for the risk factors was based on the patients’ self-reports.
Downloaded by [New York University] at 05:11 14 May 2015
CONCLUSION In this study, 43% of women were found at risk of osteoporosis with highest percentage having onset of menopause between 47 to 55 years of age. It was determined that adequate intake of varied fruits and vegetables together with good protein foods in combination with a lifelong habit of daily physical activity, adequate sun exposure and dietary calcium may play a role in decreasing the risk of osteoporosis among women after 40 years. It is also believed that more attention should be paid to the causes of early onset of menopause and secondary risk factors among the Indian female population.
ACKNOWLEDGMENTS The authors sincerely thank all those who volunteered for the study and all the staff of Food and Nutrition Department of Punjab Agricultural University to make this study a success.
REFERENCES APO. 2003. Consensus statement of an expert group, action plan osteoporosis. New Delhi, India: Osteoporosis Society of India. Ahmed, S. F., N. Fouda, and A. A. Abbas. 2013. Serum Dickkopf-1 level in postmenopausal females: Correlation with bone mineral density and serum biochemical markers. Journal of Osteoporosis 2013:1–7. Aggarwal, N., A. Raveendran, and N. Khandelwal. 2011. Prevalence and related risk factors of osteoporosis in pre- and postmenopausal Indian women. Journal of Midlife Health 2 (2): 81–85. Binkley, N. C., D. C. Krueger, J. A. Engelke, A. L. Foley, and J. W. Suttie. 2000. Vitamin K supplementation reduces serum concentrations of under-gamma carboxylated osteocalcin in healthy young and elderly adults. American Journal of Clinical Nutrition 72 (6): 1523–1528.
Downloaded by [New York University] at 05:11 14 May 2015
10
R. Munshi et al.
Bischoff-Ferrari, H. A., B. Dawson-Hughes, J. A. Baron, P. Burckhardt, R. Li, and D. Spiegelman. 2007. Calcium intake and hip fracture risk in men and women: A meta-analysis of prospective cohort studies and randomized controlled trials. American Journal of Clinical Nutrition 86 (6): 1780–1790. Bischoff-Ferrari, H. A., B. Dawson-Hughes, J. A. Baron, J. A. Kanis, E. J. Orav, H. B. Staehelin, D. P. Kiel, et al. 2011. Milk intake and risk of hip fracture in men and women: A meta-analysis of prospective cohort studies. Journal of Bone Mineral Research 26 (4): 833–839. doi:10.1002/jbmr.279. Bonjour, J. P. (2011) Protein intake and bone health. International Journal for Vitamin and Nutrition Research 81:134–142. Cadogan, J., R. Eastell, N. Jones, and M. E. Barker. 1997. Milk intake and bone mineral acquisition in adolescent girls: Randomized, controlled intervention trial. BMJ 315 (7118): 1255–1260. Cranney, A., S. A. Jamal, J. F. Tsang, R. G. Josse, and W. D. Leslie. 2007. Low bone mineral density and fracture burden in postmenopausal women. CMAJ 177 (6): 575–580. Dumith, S. C., P. C. Hallal, R. S. Reis, and H. W. Kohl. 2011. Worldwide prevalence of physical inactivity and its association with human development index in 76 countries. Preventive Medicine 53 (1–2): 24–28. Gaffney-Stomberg E., K. L. Insogna, N. R. Rodriguez, and J. E. Kerstetter. 2009. Increasing dietary protein requirements in elderly people for optimal muscle and bone health. Journal of the American Geriatric Society 57 (6): 1073–1079. Ghafoorunissa, S. A., and K. Krishnaswamy. 1994. Diet and heart disease, 1–79. Hyderabad, India: National Institute of Nutrition. Heaney, R. P. 2000. Calcium, dairy products and osteoporosis. Journal of the American College of Nutrition 19 (2 Suppl): 83S–99S. Hien, V. T. T., N. C. Khan, N. T. Lam, D. N. Le, B. T. Nhung, M. Nakamori, and S. Yamamoto. 2005. Determining the prevalence of osteoporosis and related factors using quantitative ultrasound in Vietnamese adult women. American Journal of Epidemiology 161 (9): 824–830. doi:10.1093/aje/kwi105. Holick, M. F. 2003. Vitamin D: A millenium perspective. Journal of Cell Biochemistry 88 (2): 296–307. Holick, M. F., and T. C. Chen. 2008. Vitamin D deficiency: A worldwide problem with health consequences. American Journal of Clinical Nutrition 87 (4): 1080S–1086S. Houston, D. K., B. J. Nicklas, J. Ding, T. B. Harris, F. A. Tylavsky, A. Newman, J. Lee, et al. 2008. Dietary protein intake is associated with lean mass change in older, community-dwelling adults: The Health, Aging, and Body Composition (Health ABC) Study. American Journal of Clinical Nutrition 87 (1): 150–155. Jada, M. R., B. Perugu, S. Chalasani, and G. Parvathi. 2013. Evaluation of biochemical and bone density parameters in premenopausal and postmenopausal women. International Journal of Biological Medicine Research 4 (3): 3441–3443. Kanis, J. A., H. Johansson, A. Oden, C. De Laet, O. Johnell, J. A. Eisman, E. McCloskey, et al. 2005. A meta-analysis of milk intake and fracture risk: Low utility for case finding. Osteoporosis International 16 (7): 799–804. Keramat, A., B. Patwardhan, B. Larijani, A. Chopra, A. Mithal, D. Chakravarty, H. Adibi, et al. 2008. The assessment of osteoporosis risk factors in Iranian
Downloaded by [New York University] at 05:11 14 May 2015
Impacting Osteoporosis Risk among Females in India
11
women compared with Indian women. BMC Musculoskeletal Disorders 9:28. doi:10.1186/1471-2474-9-28. Lips, P., K. Jameson, M. L. Bianchi, S. Goemaere, S. Boonen, J. Reeve, J. Stephen, et al. 2010. Validation of the IOF quality of life questionnaire for patients with wrist fracture. Osteoporosis International 21 (1): 61–70. doi:10.1007/s00198009-0946-6. Lombardi, G., C. Di Somma, L. Vuolo, E. Guerra, E. Scarano, and A. Colao. 2010. Role of IGF-I on PTH effects on bone. Journal of Endocrinology Investigation 33 (7 Suppl): 22–26. Madhuri, V., and M. Keerthi Reddy. 2010. Osteoporosis in postmenopausal Indian women: A case-control study. Journal of the Indian Academy of Geriatrics 6 (1): 14–17. Maggio, M., A. Artoni, F. Lauretani, L. Borghi A. Nouvenne, G. Valenti, and G. P. Ceda. 2009. The impact of omega-3 fatty acids on osteoporosis. Current Pharmaceutical Design 15 (36): 4157–4164 Misra, D., S. D. Berry, K. E. Broe, R. R. McLean, L. A. Cupples, K. L. Tucker, D. P. Kiel, et al. 2011. Does dietary protein reduce hip fracture risk in elders? The Framingham Osteoporosis Study. Osteoporosis International 22 (1): 345–359. doi:10.1007/s00198-010-1179-4. Mithal, A., and P. Kaur. 2012. Osteoporosis in Asia: A call to action. Current Osteoporosis Reports 10 (4): 245–247. NIN. 2011. Dietary guidelines for Indians: A manual. Hyderabad, India: National Institute Nutrition. Painter, S. E., M. Kleerekoper, and P. M. Camacho. 2006. Secondary osteoporosis: A review of the recent evidence. Endocrinology Practice 12 (4): 436–445. Povoroznjuk, V. V., N. Dzerovich, and T. Karasevskaya. 2007. Evaluation of validity of IOF’s one-minute osteoporosis risk test for postmenopausal women. Osteoporosis International 18 (Suppl 1): 227. Province, M. A., E. C. Hadley, M. C. Hornbrook, L. A. Lipsitz, J. P. Miller, C. D. Mulrow, M. G. Ory, et al. 1995. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA 273 (17): 1341–1347. Ravin, P., M. L. Hetland, K. Overgaard, and C. Christiansen. 1994. Premenopausal and post menopausal changes in bone mineral density of the proximal femur measured by dual energy X-ray absorptiometry. Journal of Bone and Mineral Research 9 (12): 1975–1980. Ritu, G., and G. Ajay. 2014. Vitamin D deficiency in India: Prevalence, causalities and interventions. Nutrients 6 (2): 729–775. doi:10.3390/nu6020729. Schurch, M. A., R. Rizzoli, D. Slosman, L. Vadas, P. Vergnaud, and J. P. Bonjour. 1998. 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. Annals of Internal Medicine 128 (10): 801–809. Shea, B., G. Wells, A. Cranney, N. Zytaruk, V. Robinson, L. Griffith, Z. Ortiz, et al. 2002. Meta-analyses of therapies for postmenopausal osteoporosis. VII. Metaanalysis of calcium supplementation for the prevention of postmenopausal osteoporosis. Endocrine Reviews 23 (4): 552–559.
Downloaded by [New York University] at 05:11 14 May 2015
12
R. Munshi et al.
Shea, B., G. Wells, A. Cranney, N. Zytaruk, V. Robinson, L. Griffith, C. Hamel, et al. 2004. Calcium supplementation on bone loss in postmenopausal women. Cochrane Database of Systematic Reviews 2004 (1): CD004526. Skerry, T. M., and L. J. Suva. 2003. Investigation of the regulation of bone mass by mechanical loading: From quantitative cytochemistry to gene array. Cell Biochemistry and Function 21 (3): 223–229. Song, W. O., S. K. Mann, S. Sehgal, P. R. Devi, S. Gudaru, and M. Kakarala. 1992. Nutriguide: Asian Indian foods. Nutritional analysis computer program. East Lansing, MI: Michigan State University. Sugiura, M., M. Nakamura, K. Ogawa, Y. Ikoma, F. Ando, H. Shimokata, and M. Yano. 2011. Dietary patterns of antioxidant vitamin and carotenoid intake associated with bone mineral density: Findings from post-menopausal Japanese female subjects. Osteoporosis International 22 (1): 143–152. Szulc, P., M.-C. Chapuy, P. J. Meunier, and P. D. Delmas. 1996. Serum undercarboxylated osteocalcin is a marker of the risk of hip fracture: A three year follow up study. Bone 18 (5): 487–488. Teotia, S. P. S., and M. Teotia. 2004. Female osteoporosis—a preventive breakthrough—national context. In Postgraduate medicine, ed. L. A. Pathak, 302–312. Mumbai, India: The Association of Physicians of India. Trombetti, A., M. Hars, F. R. Herrmann, R. W. Kressig, S. Ferrari, and R. Rizzoli. 2011. Effect of music-based multitask training on gait, balance, and fall risk in elderly people: A randomized controlled trial. Archives of Internal Medicine 171 (6): 525–533. United Nations. 2008. World population prospects: The 2008 revision. New York, NY: United Nations Department of Economic and Social Affairs/Population Division. Varma, M., S. Paneri, and P. Badi. 2005. Correlative study of bone related biochemical parameters in normal postmenopausal women and hyperglycemic postmenopausal women. Biomedical Research 16 (2): 129–132 Vasco, C., J. Ruales, and K. A. Eldin. 2008. Total phenolic compounds and antioxidant capacity of major fruits from Ecuador. Food Chemistry 111 (4): 816–823. Weber, P. 2001. Vitamin K and bone health. Nutrition 17 (10): 880–887. WHO. 2003. Prevention and management of osteoporosis. WHO Technical Report Series 921. Geneva, Switzerland: World Health Organization. WHO. 2004. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. The Lancet 363:157–163. Wolf, S. L., H. X. Barnhart, N. G. Kutner, E. McNeely, C. Coogler, and T. Xu. 1996. Reducing frailty and falls in older persons: An investigation of Tai Chi and computerized balance training. Atlanta FICSIT Group. Frailty and Injuries: Cooperative Studies of Intervention Techniques. Journal of the American Geriatric Society 44 (5): 489–497. Xie, H., L. Wu, B. H. Xue, W. Q. He, M. G. Fan, F. Ouyang, W. F. Tu, et al. (2013). Greater intake of fruit and vegetables is associated with a lower risk of osteoporotic hip fractures in elderly Chinese: A 1:1 matched case-control study. Osteoporosis International 24:2827–2836. Zhao, L.-J., Y.-J. Liu, P.-Y. Liu, J. Hamilton, R. R. Recker, and H.-W. Deng. 2007. Relationship of obesity with osteoporosis. Journal of Clinical Endocrinology Metabolism 92 (5): 1640–1646. doi:10.1210/jc.2006-0572.
Impacting Osteoporosis Risk among Females in India
13
Zoltick, E. S., S. Sahni, R. R. McLean, L. Quach, V. A. Casey, and M. T. Hannan. 2011. Dietary protein intake and subsequent falls in older men and women: The Framingham Study. Journal of Nutrition Health and Aging 15 (2): 147–152.
Downloaded by [New York University] at 05:11 14 May 2015
APPENDIX Q-1 Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age . . . . . . . . . . . . . . . . . ..yrs. Gender- M/F. Occupation- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contact no . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......................................... IOF One-Minute Osteoporosis Risk Test 19 easy questions to help you understand the status of your bone health Your Non-modifiable Risk Factors – What you cannot change! These are risk factors that one is born with or cannot alter. Nevertheless, it is important to be aware of risk factors you cannot change so that steps can be taken to reduce loss of bone mineral. 1. Have either of your parents been diagnosed with osteoporosis or broken a bone after a minor fall (a fall from standing height or less)? Yes/No 2. Did either of your parents have a stooped back (dowager’s hump)? Yes/No 3. Are you 40 years old or older? Yes/No 4. Have you ever broken a bone after a minor fall, as an adult? Yes/No 5. Do you fall frequently (more than once in the last year) or do you have a fear of falling because you are frail? Yes/No 6. Are you underweight (is your Body Mass Index less than 19 kg/m2)?(If u do not know your BMI, write your Height and weight . . . . . . . . . . . .kgs . . . . . . . . . . . . . . . . . . . . . cms/ . . . . . . . . . . . ...ft) Yes/No 7. Have you ever taken corticosteroid tablets (cortisone, prednisone, etc.) for more than 3 consecutive months (corticosteroids are often prescribed for conditions like asthma, rheumatoid arthritis, and some inflammatory diseases)? Yes/No 8. Have you ever been diagnosed with rheumatoid arthritis? Yes/No 9. Have you been diagnosed with an over-active thyroid, overactive parathyroid glands, type 1 diabetes or a nutritional/gastrointestinal disorder such as Crohn’s or celiac disease? Yes/No 10. For women over 45: Did your menopause occur before the age of 45? Yes/No
Downloaded by [New York University] at 05:11 14 May 2015
14
R. Munshi et al.
11. Have your periods ever stopped for 12 consecutive months or more (other than because of pregnancy, menopause or hysterectomy)? Yes/No 12. Were your ovaries removed before age 50, without you taking Hormone Replacement Therapy? Yes/No 13. Is your daily level of physical activity less than 30 minutes per day (housework, gardening, walking, running etc.)? Yes/No 14. Do you avoid, or are you allergic to milk or dairy products, without taking any calcium supplements? Yes/No 15. Do you spend less than 10 minutes per day outdoors (with part of your body exposed to sunlight), without vitamin D supplements? Yes/No 16. Do you suffer from back pain, if yes how often do you have it? . . . . . . .............................. Yes/No 17. Can you get up, once seated, from the chair without difficulty? Yes/No 18. Can you climb the stairs to the next floor without any difficulty or pain in knees? Yes/No 19. Do you include in your diet/or are you aware of nutrients for healthy bones? Yes/No
Are You at Risk of Osteoporosis? Around the world, one in three women, and one in five men over the age of 50 will suffer a broken bone due to osteoporosis. Osteoporosis is a “silent” disease which weakens bones and increases the risk of fractures, often resulting in pain and long-term disability. Take this IOF One-Minute Osteoporosis Risk Test and find out if you are at risk.
15
Impacting Osteoporosis Risk among Females in India
Q-2 Quality of Life Questionnaire Qualeffo-41 10 December 1997) Users of this questionnaire (and all authorized translations) must adhere to the user agreement. Please use the related Scoring Algorithm.
Downloaded by [New York University] at 05:11 14 May 2015
A. Pain The five questions in this section regard the situation in the last week. How often have you had back pain in the
Never 1 day per week or less 2–3 days per week 4–6 days per week Every day
If you have had back pain, for how long did you have back pain in the daytime?
Never 1–2 hours 3–5 hours 6–10 hours All day
How severe is your back pain at its worst?
No back pain Mild Moderate Severe Unbearable
How is your back pain at other times?
No back pain Mild Moderate Severe Unbearable
Has the back pain disturbed your sleep in the last week?
Less than once per week Once a week Twice a week Every other night Every night
No difficulty A little difficulty Moderate difficulty May need some help Impossible without help
B Activities of Daily Living The next 4 questions regard the situation at present. Do you have problems with dressing?
(Continued)
16
R. Munshi et al.
(Continued)
Downloaded by [New York University] at 05:11 14 May 2015
B Activities of Daily Living The next 4 questions regard the situation at present. Do you have problems with taking a bath or shower?
No difficulty A little difficulty Moderate difficulty May need some help Impossible without help
Do you have problems with getting to or operating a toilet?
No difficulty A little difficulty Moderate difficulty May need some help Impossible without help
How well do you sleep?
Sleep undisturbed Wake up sometimes Wake up often Sometimes I lie awake for hours Sometimes I have a sleepless night
C Jobs Around the House The next 5 questions are concerned with the present situation. If someone else does these things in your house, please answer as though you were responsible for them. Can you do the cleaning?
Without difficulty With a little difficulty With moderate difficulty With great difficulty Impossible
Can you prepare meals?
Without difficulty With a little difficulty With moderate difficulty With great difficulty Impossible
Can you wash the dishes?
Without difficulty With a little difficulty With moderate difficulty With great difficulty Impossible
Can you do your day to day shopping?
Without difficulty With a little difficulty With moderate difficulty With great difficulty Impossible
Can you lift a heavy object of 20 lbs (e.g., a crate of 12 bottles of milk, or a one year old child) and carry it for at least 10 yards?
Without difficulty With a little difficulty With moderate difficulty With great difficulty Impossible (Continued)
17
Impacting Osteoporosis Risk among Females in India (Continued)
Downloaded by [New York University] at 05:11 14 May 2015
D Mobility The next 8 questions also regard the present situation. Can you get up from a chair?
Without difficulty With a little difficulty With moderate difficulty With great difficulty Only with help
Can you bend down?
Easily Fairly easily Moderately Very little Impossible
Can you kneel down?
Easily Fairly easily Moderately Very little Impossible
Can you climb stairs to the next floor of a house?
Without difficulty With a little difficulty With at least one rest With great difficulty Only with help
Can you walk 100 yards?
Fast without stopping Slowly without stopping Slowly with at least one stop Only with help Impossible
How often have you been outside in the last week?
Everyday 5–6 days /week 3–4 days /week 1–2 days /week Less than once /week
Can you use public transport?
Without difficulty With a little difficulty With at least one rest With great difficulty Only with help
Have you been affected by the changes of your figure due to osteoporosis (e.g., loss of height, increase of waist measurement, shape of your back)?
Not at all A little Moderately Quite a bit Very much (Continued)
18
R. Munshi et al.
(Continued)
Downloaded by [New York University] at 05:11 14 May 2015
E Leisure, Social Activities Do you play any sport now?
Yes Yes with restriction Not at all
Can you do your gardening?
Do you perform any hobby now?
Yes Yes with restriction Not at all
Can you visit a cinema, theatre, etc.?
Yes Yes with restriction Not at all No cinema, or theatre within a reasonable distance
How often did you visit friends or relatives during the last 3 months?
Once a week or more Once or twice a month Less than once a month Never
How often did you participate in social activities (clubs, social gatherings, church activities, charity, etc.) during the last 3 months?
Once a week or more Once or twice a month Less than once a month Never
Does your back pain or disability interfere with intimacy (including sexual activity)?
Not at all A little Moderately Severely Not applicable
For your age, in general, would you say your health is:
Excellent Good Satisfactory Fair Poor
How would you rate your overall quality of life during the last week?
Excellent Good Satisfactory Fair Poor
Yes Yes with restriction Not at all Not applicable
F General Health Perception
(Continued)
19
Impacting Osteoporosis Risk among Females in India (Continued)
Downloaded by [New York University] at 05:11 14 May 2015
F General Health Perception How would you rate your overall quality of life compared with 10 years ago?
Much better now Slightly better now Unchanged Slightly worse now Much worse now
How well do you sleep?
Sleep undisturbed Wake up sometimes Wake up often Sometimes I lie awake for hours Sometimes I have a sleepless night
G Mental Function The next nine questions regard the situation in the last week. Do you tend to feel tired?
In the morning In the afternoon Only in the evening After strenuous activity Almost never
Do you feel downhearted?
Almost everyday 3–5 days/week 1–2 days/week Once in a while Almost never
Do you feel lonely?
Almost everyday 3–5 days/week 1–2 days/week Once in a while Almost never
Do you feel full of energy?
Almost everyday 3–5 days/week 1–2 days/week Once in a while Almost never
Are you hopeful about your future?
Never Rarely Sometimes Quite often Always
Do you get upset over little things?
Never Rarely Sometimes Quite often Always (Continued)
20
R. Munshi et al.
(Continued)
Downloaded by [New York University] at 05:11 14 May 2015
G Mental Function The next nine questions regard the situation in the last week. Do you find it easy to make contact with people?
Never Rarely Sometimes Quite often Always
Are you in good spirits most of the day?
Never Rarely Sometimes Quite often Always
Are you afraid of becoming totally dependent?
Never Rarely Sometimes Quite often Always
Q-3 24 Hour Food Recall Questionnaire for Assessment of Dietary Intake of Women at Risk of Osteoporosis
Participant ID:
__ __ __ __
Date of Interview:
Date of Intake:
__ __ - __ __ -20 __ __
__ __ - __ __ -20 __ __
Start From Any day- : Mon / Tue / Wed / Thu / Fri / Sat / Sun
__ __ : __ __
__ __ : __ __
(am / pm)
(am / pm)
Time Started
Time Ended
21
Impacting Osteoporosis Risk among Females in India DAY ONE INTAKE QUESTIONNAIRE Individual Intake Form Column 1
Downloaded by [New York University] at 05:11 14 May 2015
Time
*Occasion
Column 2 Food/Drink and Description Additions of ingredient
Column 3 Amount on house hold measurements (eat/drink)?
Column 4 *Source of Food
Column 5 (Research use only) Food Code Amount
Occasion: 1. Breakfast 2. Brunch 3. Lunch 4. Dinner 5. Late night meal 6. Fruit 7. Food and/or beverage break, snack, alcohol beverage or other beverage 8. Other (specify):_________________________ Source of food: 1. Homemade 2. Restaurant/cafeteria/fast food shop/ 3. Food stall/hawker 4. Supermarket/Food store 5. Workplace tuck shop 6. Day care 7. Friend/relative’s home 8. Party/BBQ/banquet/special event 9. Other (specify):________
22
R. Munshi et al. DAY TWO INTAKE QUESTIONNAIRE Individual Intake Form Column 1
Downloaded by [New York University] at 05:11 14 May 2015
Time
*Occasion
Column 2
Column 3
Food/Drink and Description of Additions ingredient
Column 4 Amount on house hold measurements (eat/drink)?
*Source of Food
Column 5 (Research use only) Food Code Amount
Occasion: 1. Breakfast 2. Brunch 3. Lunch 4. Dinner 5. Late night meal 6. Fruit 7. Food and/or beverage break, snack, alcohol beverage or other beverage 8. Other (specify):_________________________ Source of food: 1. Homemade 2. Restaurant/cafeteria/fast food shop/3. Food stall/hawker 4. Supermarket/Food store 5. Workplace tuck shop 6. Day care 7. Friend/relative’s home 8. Party/BBQ/banquet/special event 9. Other (specify):________
Impacting Osteoporosis Risk among Females in India
23
DAY THREE INTAKE QUESTIONNAIRE Individual Intake Form Column 1
Downloaded by [New York University] at 05:11 14 May 2015
Time
Column 2
*Occasion Food/Drink and Additions
Column 3
Column 4
Description of ingredient
Amount on house hold measurements (eat/drink)?
*Source of Food
Column 5 (Research use only) Food Code Amount
Occasion: 1. Breakfast 2. Brunch 3. Lunch 4. Dinner 5. Late night meal 6. Fruit 7. Food and/or beverage break, snack, alcohol beverage or other beverage 8. Other (specify):_________________________ Source of food: 1. Homemade 2. Restaurant/cafeteria/fast food shop/3. Food stall/hawker 4. Supermarket/Food store 5. Workplace tuck shop 6. Day care 7. Friend/relative’s home 8. Party/BBQ/banquet/special event 9. Other (specify):______
