Author: Patrick O'Mara

Your Bone Health During COVID-19

Written on April 2, 2020. Posted in Lifestyle, OC Blog, Risk Factors.

Take action to make sure you are staying fracture-free and are taking care of your bone health. This pandemic has put enormous pressure on our healthcare systems stretching our resources to the limit and the general recommendation is for people to avoid hospitals and doctor’s offices unless absolutely necessary.

Remember that older adults and people who have certain chronic medical conditions such as diabetes or lung, heart or kidney disease are at higher risk of the more serious complications of COVID-19 illness. We urge you to stay safe by taking the necessary precautions as recommended by government health agencies.

PROTECTING YOUR BONES

WHAT YOU CAN DO

Fall Prevention: ensure that your home environment is free of clutter and any obstacles. Take care when walking outdoors.
Do not stop any osteoporosis treatment you have been prescribed. Talk to your doctor if you have any concerns.
Physical/Social Distancing does not mean self-isolating! Make sure to call and speak to friends or family at least once a day. Video chats are also a great way to stay connected.
The Government of Canada has advised you to stay home. Contact your doctor and/or pharmacy if you need a prescription filled or a consultation.
Ask for help! There are many ways to get the support you need for getting prescriptions filled and groceries delivered. Most grocers have a delivery service or an online order system where you can go pick up your order. If you do not have the ability to order online, many volunteer groups have popped up. Call your local elected representative and ask for help in locating such services. Also try contacting a neighbour to see if they can drop off supplies at your door or provide information on a service.

Be prepared to manage your bone health and osteoporosis and reduce your risk of breaking a bone during COVID-19.

Nutrition: Many pantry staple foods like beans and canned fish contain calcium and protein. Read product labels and also view the list of foods with calcium here. Click here
Get the amount of vitamin D you need daily. Click here
Stay active! Safely exercise daily by adapting exercises you can do at home. Click here

FROM THE PUBLIC HEALTH AGENCY OF CANADA

It’s important to follow recommendations from the Public Health Agency of Canada (PHAC) to stay safe and well informed.

PHYSICAL/SOCIAL DISTANCING

Together, we can slow the spread of COVID-19 by making a conscious effort to keep a physical distance between each other. Social distancing is proven to be one of the most effective ways to reduce the spread of illness during an outbreak.

This means making changes in your everyday routines to minimize close contact with others, including:

avoiding crowded places and non-essential gatherings
avoiding common greetings, such as handshakes
limiting contact with people at higher risk like older adults and those in poor health
keeping a distance of at least 2 arms-length (approximately 2 metres) from others

VULNERABLE POPULATIONS

There is an increased risk of more severe outcomes for Canadians:

aged 65 and over
with compromised immune systems
with underlying medical conditions

Think you may have COVID-19?

Click here to take the Government of Canada’s Self-Assessment

WRITTEN BY

Hassan Vatanparast is a member of Osteoporosis Canada’s Scientific Advisory Council. He is a Professor with Joint Appointment to the College of Pharmacy and Nutrition and School of Public Health, University of Saskatchewan. He is actively involved in research and health promotion initiatives targeting bone health. Hassan is leading several projects at the local, national, and global levels aimed to improve the nutritional health of the general population, newcomers and indigenous communities.

Vitamin D and Potential Impact on the Severity of COVID-19

Written on March 27, 2020. Posted in General Public, Position Statements.

Vitamin D plays a significant role in building and maintaining healthy bones. In light of the current COVID-19 pandemic, the effects of vitamin D on the immune system are being reviewed.

Two recent studies have suggested that low levels of vitamin D may be associated with an increased risk of severe COVID-19 infections.

One study noted that countries with low levels of vitamin D had a higher number of COVID cases, as well as the highest mortality rates from COVID. Another study found that severe COVID-19 infections appeared to be more common in countries where vitamin D deficiency is more common. Many different factors may contribute to the number of COVID-19 cases identified in a particular country. These may include the number of tests performed to identify COVID cases, and public health measures taken to prevent the spread of disease, which were not accounted for in these studies. The severity of disease can also be affected by many different factors, including age, underlying health conditions, and accessibility to health care. Hence, we need to be cautious in linking low vitamin D levels to COVID cases or severity, when other important factors have not been taken into account. At this time it is not known if low vitamin D levels are the cause of the higher number and severity of COVID infections.

Keeping that caution in mind, the possible link between vitamin D deficiency and an impaired immune response to COVID-19 infections may have some support in earlier studies of vitamin D effects on the immune system. These early studies may suggest that adequate vitamin D levels are of value in the immune response to infections such as from COVID-19. This would be of particular importance in patient populations vulnerable to low vitamin D levels. This includes those who are obese, have a malabsorption syndrome or who have been treated with long-term anticonvulsant therapy as well as the elderly. However, further research is needed to determine if low vitamin D levels are a cause of a higher number and severity of COVID-19 infections.

While the relationship between vitamin D and COVID-19 is unclear, we know that vitamin D is critical for bone health. Osteoporosis Canada recommends that individuals with osteoporosis or with risk factors for fractures receive adequate vitamin D, as recommended at 800-2000 IU per day. This would also be important for those at higher risk of developing vitamin D deficiency. Taking more than 2000 IU per day should only be done after consultation with your healthcare provider.

New Study Suggests Association Between Intake of Dairy Milk with Greater Risk of Breast Cancer

Written on March 17, 2020. Posted in General Public, Position Statements.

A recent study from the US suggests women who drink as little as one cup /250 ml of cow’s milk per day could be increasing their risk of developing breast cancer by up to 50%. This study from Knutsen and colleagues is part of the Adventist Health Study-2, a large population-based study of Adventists from the US and Canada. The study assessed the relationship between risk of breast cancer and the intake of soy milk, other soy products, dairy milk, and other dairy foods.

This study followed nearly 53,000 women who were members of the Seventh Day Adventist Church for almost 8 years. The authors concluded that as dairy milk intake increased (regardless of fat content) so did the risk of breast cancer. No clear association was found between consumption of soy products and breast cancer.

It should be noted that this was an observational study. In this type of study, researchers observe what effect a risk factor (e.g., soy and dairy) has on health outcomes (e.g., breast cancer) over time. While this type of study can suggest a link (correlation or association) between a risk factor and an outcome, it cannot establish that the risk factor CAUSED the health outcome. In this study, dietary intake of soy and dairy was self-reported, leaving room for errors and omissions. In addition, diet was only assessed once, at the beginning of the study, meaning that possible changes in diet over the 8 years were not taken into account. The study also does not take into account other potential risk factors that could affect the outcome, such as quality of diet (fruit and vegetable intake was not measured); amount or intensity of physical activity; quantity of alcohol consumed; or amount smoked. Furthermore, Adventists diet may differ considerably from the general population as many follow a plant-based diet and exclude processed foods, alcohol, and caffeine, so it is difficult to know if these results can be applied to the general population.

The authors note that dairy milk has many positive nutritional qualities and suggest more research is needed to understand if there is a causal link between dairy intake or other closely related unidentified factors and breast cancer risk. Until then, a balanced and a varied diet including sources of calcium, regular physical activity, and avoiding smoking and excess alcohol make for a healthy lifestyle.

Osteoporosis Canada recommends that men and women over the age of 50 get 1000-1200 mg of calcium through all sources (diet and supplements). Information on non-dairy sources of calcium is available from the Calcium Calculator on the OC website.

https://osteoporosis.ca/bone-health-osteoporosis/calcium-calculator/#page-1

1. Dairy, soy, and risk of breast cancer: those confounded milks. Fraser GE, Jaceldo-Siegl K, Orlich M, Mashchak A, Sirirat R, Knutsen S. Int J Epidemiol. 2020 Feb 25. pii: dyaa007. doi: 10.1093/ije/dyaa007.

Public

New Study Associates Intake of Dairy Milk with Greater Risk of Breast Cancer

Written on March 10, 2020. Posted in Healthcare Professionals, Position Statements.

Dairy, soy, and risk of breast cancer: those confounded milks

https://academic.oup.com/ije/advance-article/doi/10.1093/ije/dyaa007/5743492#199259276

Dairy, soy, and risk of breast cancer: those confounded milks Gary E Fraser, Karen Jaceldo-Siegl, Michael Orlich, Andrew Mashchak, Rawiwan Sirirat, Synnove Knutsen International Journal of Epidemiology, 25 February 2020

Recent media headlines point to a study suggesting that women who drink as little as one cup /250 ml of cow’s milk per day could be increasing their risk of developing breast cancer by up to 50%. This study is part of the Adventist Health Study, by Synnove Knutsen et al, from Loma Linda University and published in the International Journal of Epidemiology. https://doi.org/10.1093/ije/dyaa007 . The study evaluated associations between intakes of soy milk, other soy products, dairy milk and other dairy foods with risk of breast cancer.

This study followed nearly 53,000 Adventist women for 7.9 years focusing on the relative risk of a rare outcome. The authors concluded that as cow’s milk intake increased, regardless of fat level, so did the risk of breast cancer. No clear associations were found between consumption of soy products and breast cancer.

Weaknesses of this study are its observational design (cause and effect cannot be established) and possible residual confounding between dairy and unmeasured factors, despite extensive covariate adjustment. (1) Diet was measured only once at study baseline leaving room for error and omissions. Whether these results can be applied to other populations is unknown and therefore difficult to draw conclusions. Adventists lifestyle differ considerably from the general population as many follow a plant based diet and exclude processed foods, alcohol and caffeine.

The authors do note that cow’s milk has many positive nutritional qualities and suggest more research is needed to understand if there is a link between dairy intake or other closely-related unidentified factors and breast cancer risk. Until then, a balanced and a varied diet including sources of calcium, regular physical activity and avoiding smoking and excess alcohol make for a healthy lifestyle.

1. Dairy, soy, and risk of breast cancer: those confounded milks Gary E Fraser, Karen Jaceldo-Siegl, Michael Orlich, Andrew Mashchak, Rawiwan Sirirat, Synnove Knutsen International Journal of Epidemiology, 25 February 2020

Healthcare Professionals

Tai Chi: Fall Prevention and Bone Health

Written on February 27, 2020. Posted in Exercise, OC Blog, Risk Factors.

Shayla Mueller and Veronique Murphy

What is Tai Chi?

Tai Chi is a type of exercise that originally began as a martial art in China hundreds of years ago. It is sometimes described as “meditation in motion” as it engages both the mind and the body. Practising Tai Chi involves using slow, controlled body movements while focusing on breathing. These slow movements increase self-awareness, allowing you to be in complete control of your body. Each movement is held in a specific position for a brief moment before changing to a new position. The transitions involve different movements such as shifting weight from one leg to another, rotating the neck, torso, arms and legs, and stepping in different directions.

Tai Chi focuses on coordination and flexibility, helping to improve your ability to move and complete life’s daily activities. There are many different types of Tai Chi, each with a different pace and style of movement.

Why Should I Consider Tai Chi?

Tai Chi has many positive health benefits including improvements in muscle strength, flexibility and balance. It is a full body exercise that is considered to be equivalent to low or moderate intensity aerobic exercise. This means that you may be able to talk while doing it but not sing a song.

Tai Chi is a popular form of exercise, particularly among older people. It has many advantages, including being an easily accessible, affordable activity available in many communities. No special clothing or equipment is required. It is often practised in groups, providing an opportunity to socialize and meet new people.

Most importantly, research has found Tai Chi to be a safe form of exercise for people with low bone density.

Tai Chi and Fall Prevention

Reducing fall risk is an important way to reduce your risk of fractures. A recent review of studies found Tai Chi to be effective for fall prevention short-term in older adults. In fact, it can reduce the rate of falls by almost 50% during the first year that people are practising Tai Chi. Research has also shown that Tai Chi may improve balance, which is an important part of reducing the risk of falling. People who practise Tai Chi regularly do better on balance tests and their bodies sway less when they are standing. The slow, shifting movements of Tai Chi activate the leg muscles, improving a person’s strength and ability to respond if they become off balance. Many of these studies show benefits after 12 weeks of training. Tai Chi can also help people improve their mobility. Many of the Tai Chi movements copy the movements used in walking, such as shifting weight from one leg to the other and stepping in different directions. Performing these movements slowly and repeatedly allows the brain to adapt and create new connections that can lead to improved walking. This allows people to build confidence in their walking and be less afraid of falling.

Effect of Tai Chi on Bone Density

The effects of Tai Chi on bone density have also been studied. A recent review found that regular participation in Tai Chi (45-90 minute sessions between 2 and 7 times a week) for at least 24 weeks may be an effective way to slow the reduction in bone density that is seen in perimenopausal and postmenopausal women, as well as in individuals with osteoporosis. However, more research is required to confirm the results and to determine the amount of exercise and frequency of training necessary to provide benefit.

If you are practising Tai Chi or thinking about taking it up, we know that it:

Is safe for people with low bone density,
Reduces the rate of falls,
Is a whole body and mind exercise that challenges balance,
Focuses on coordination and flexibility, helping you perform activities of daily living,
Is a group activity, and
Is easily available and affordable.

How Does Diabetes Affect Fracture Risk?

Written on January 30, 2020. Posted in OC Blog, Risk Factors.

Zoe Bond, Dana Li and Rebecca Wills

Diabetes and Fracture Risk

Diabetes mellitus, commonly known as diabetes, is a condition that affects the hormone insulin, resulting in high blood sugar levels. Insulin is needed to absorb glucose (sugar) from the blood to provide energy for cells. In diabetes, there is insufficient insulin to bring glucose out of the blood and into body tissue, and as a result, blood sugar levels are high. People who have Type I Diabetes (T1DM) are not able to make insulin and need insulin injections. Although people with Type II Diabetes (T2DM) are able to make insulin (the levels are actually high), they cannot use the insulin properly and as a result they require medication (either pills or insulin) to lower blood sugar levels.

Diabetes has many effects throughout the body. Abnormal insulin and blood glucose levels can affect the kidneys, nerves, heart, blood vessels and eyes. Diabetes can also have a negative effect on bone, and this means that people with diabetes are at a higher risk of fractures. People with T1DM have low bone density, and almost 20% of people with T1DM who are under the age of 60 have bone density that is low enough to be considered osteoporotic. However, people with T2DM appear to be protected against bone loss, and bone density can be normal. Studies have shown that individuals with T2DM actually have higher bone density than people who do not have diabetes. This suggests that the bone quality, another determinant of bone strength, may be poor and may explain increased fracture risk in T2DM.

In order to calculate a person’s fracture risk, doctors can use an assessment tool that considers risk factors such as: age, height, weight, previous fractures, family history of osteoporosis, personal habits like smoking and alcohol consumption, particular medications, certain medical conditions such as rheumatoid arthritis and results from a bone density scan. However, it is now recognized that current risk assessment tools underestimate fracture risk in people with diabetes and current research is looking at tools that may improve our ability to assess their risk.

Changes in bone density and bone quality are not the only ways that diabetes can increase a person’s risk for fracture. Diabetes can also increase the risk of falls. Falls are more common in people with diabetes because diabetes can lead to complications such as reduced sensation in the feet, reduced vision and increased light-headedness. In addition, if someone with diabetes has low blood sugar (hypoglycemia), they are at increased risk of falling. The combination of more fragile bones and a higher risk of falls increases the risk of fracturing a bone. The bones commonly fractured by people with diabetes include the upper arm, wrist, hip and spine.

Fracture risk is significantly increased in T1DM. Men with T1DM are twice as likely to fracture a bone as compared to men without diabetes. The risk is four times higher in women with T1DM compared to women without diabetes. People with T1DM are also more likely to fracture earlier in life compared to the average person without diabetes. In addition, the longer a person has lived with T1DM, the higher their risk of fracture.

People with T2DM also have a higher risk of fracture. Factors that increase this risk include having T2DM for longer, poor blood glucose control and the presence of diabetic complications such as eye or kidney involvement. Those with T2DM have as much as a 70% higher chance of suffering a non-spine fracture compared to those without diabetes. In addition, many patients with T2DM have low levels of vitamin D, which is needed to keep bones strong.

FRACTURE FACT

If you have diabetes, either Type 1 or Type 2, you are at a higher risk of suffering a fracture, both because of the effects of diabetes on bone and because of the increased risk of falling.

Diabetes Medications and Fracture Risk

There are many medications available to help control blood glucose levels. Research has shown that some may increase bone strength and reduce the risk of fracture, while others may have a negative effect on bone and increase the risk of fracture. Metformin is thought to be good for bones. Some animal experiments suggest that Metformin has a positive effect on bone health by increasing bone building cells (osteoblasts) and decreasing bone absorbing cells (osteoclasts). Thiazolidinediones (TZDs) have been shown to do the opposite, decreasing the development of cells that build new bone while increasing the number of cells that break down bone. This means a person with T2DM taking TDZs is at a greater risk of fracturing bones because the amount of bone loss is greater than the amount of new bone made. A number of studies have shown that hip fractures are increased in people taking TZDs, and that the risk increases with longer duration of use. Another diabetes medication, canagliflozin (Invokana ®), has also been found to be associated with an increased risk of fracture, although at this time no mechanism has been identified. Many of the medications used to treat diabetes can increase the risk of low blood sugars, which is a risk factor for falls.

What Does This Mean For You?

If you have diabetes, either T1DM or T2DM, you are at a higher risk of suffering a fracture, both because of the effects of diabetes on bone and because of the increased risk of falling. There are many different medications currently used to treat diabetes, and some of these can affect bone health. It is important to speak to your doctor or healthcare practitioner to have a full assessment of your diabetes and bone health. This should include a fracture risk assessment, reviewing diabetes medications to make sure they are right for you, and assessing for risk of falls. Taking part in a regular exercise program that includes balance and strengthening exercises is an excellent way to help maintain your bone density, reduce your risk of falls and fractures, and benefit your overall health.

Zoe Bond, Dana Li and Rebecca Wills are 4th year Kinesiology students at the University of Waterloo (at time of writing). The authors were introduced to fracture risk in those with diabetes mellitus during a course on bone health. They found the topic intriguing and therefore chose to engage in further research. They hope that this article will be informative for those living with both osteoporosis and diabetes.

BONE MATTERS: DRUG-INDUCED OSTEOPOROSIS

Written on September 18, 2019. Posted in OC Replay, Webinar.

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VITAMIN D IN SUMMER: SUN, FOOD, SUPPLEMENT

Written on August 1, 2019. Posted in Lifestyle, Nutrition, OC Blog.

Vitamin D is an essential nutrient for proper growth and formation of teeth and bones. We need vitamin D for the absorption of calcium and phosphorus from the foods that we eat. Vitamin D has some other roles in the body, and it is important for our muscles and our immune system. Low levels of vitamin D, known as vitamin D deficiency, has been linked to a wide variety of health issues such as osteoporosis, heart disease, depression, cancer, and multiple sclerosis.

How much Vitamin D do I need?

Osteoporosis Canada recommends healthy adults between 19-50 years of age, including pregnant or breast feeding women, require 400 – 1,000 IU daily. Those over 50 or those younger adults at high risk (with osteoporosis, multiple fractures, or conditions affecting vitamin D absorption) should receive 800 – 2,000 IU daily.

What are the sources of Vitamin D?

Food and Supplements

There are very few foods in the nature that contain significant amounts of vitamin D. These include the flesh of oily fish such as salmon, tuna, sardines, and mackerel and fish liver oils. We can also get small amounts of vitamin D from foods such as beef liver and egg yolks. Some yogurts contain vitamin D if they are made with vitamin D fortified milk. In Canada, vitamin D fortification is mandated for margarine, infant formula, formulated liquid diets, cow’s milk and its substitutes, egg products, foods for use on a very low energy diet, meal replacements and nutritional supplements. Fortification is voluntary for butter substitutes, condensed milk, goat’s milk and goat’s milk powder.

It is nearly impossible to get enough vitamin D from your diet. You would need to eat a lot of these foods to reach the recommended level. Osteoporosis Canada recommends that all Canadian adults take a vitamin D supplement (specifically, vitamin D3 or cholecalciferol) year-round. This is the most common type of vitamin D found in supplements in Canada.

Examples of foods rich in vitamin D

Food	Serving Size	IU’s per Serving
Cod Liver Oil	5 mL/1 tsp	426
Egg Yolk, cooked	2 Large	64
Margarine, fortified	5 mL/1 tsp	25-36
Milk (all types)	1 c/250 mL	103-105
Mushrooms, white	125 mL/ 1/2 c	4
Orange Juice, Fortified	1/2 c/125 mL	50
Salmon (Sockeye), Baked or Broiled	75 g	394
Salmon, pink, Canned, Drained with solids and bones	75 g	435
Snapper, Baked or Broiled	75 g	392
Soy Beverage, Enriched	1 c/250 mL	86

Sun exposure

Vitamin D, the “sunshine vitamin,” is produced when the sun’s rays interact with our skin. It helps build stronger bones by increasing the absorption of calcium. It also improves the function of muscles, which can improve your balance and decrease the likelihood of falling and suffering a fracture.

Canadians, particularly women, have reduced their sun exposure and use sunscreen (which blocks UV rays) to prevent damage from the sun. As well, Because of our latitude, we cannot produce vitamin D between October and March.

Furthermore, the skin’s ability to make vitamin D decreases as we age.

All this supports the need to get vitamin D through food and/or supplementation.

WRITTEN BY

References:

National Institutes of Health. (2018). Vitamin D, Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/#en26 (assessed May 28, 2019)

Institute of Medicine. (2011). Dietary reference intakes for calcium and vitamin D: Washington, DC: The National Academy Press.

Janz, T., & Pearson, C. (2013). Vitamin D blood levels of Canadians: Statistics Canada Ottawa (Canada).

Libon, F., Courtois, J., Le Goff, C., Lukas, P., Fabregat-Cabello, N., Seidel, L., . . . Nikkels, A. F. (2017). Sunscreens block cutaneous vitamin D production with only a minimal effect on circulating 25-hydroxyvitamin D. Arch Osteoporos, 12(1), 66. doi:10.1007/s11657-017-0361-0

Wacker, M., & Holick, M. F. (2013). Sunlight and Vitamin D: A global perspective for health. Dermato-endocrinology, 5(1), 51-108.

Whiting, S. J., Langlois, K. A., Vatanparast, H., & Greene-Finestone, L. S. (2011). The vitamin D status of Canadians relative to the 2011 Dietary Reference Intakes: an examination in children and adults with and without supplement use. Am J Clin Nutr, 94(1), 128-135.

Canadian Food Inspection Agency. (2018). Foods to Which Vitamins, Mineral Nutrients and Amino Acids May or Must be Added. Retrieved from http://www.inspection.gc.ca/food/requirements/labelling/industry/nutrient-content/reference-information/eng/1389908857542/1389908896254?chap=1 (assessed May 31, 2019)

Pinault, L., & Fioletov V. Sun exposure, sun protection and sunburn among Canadian adults. Health Reports. Statistics Canada. Health ReportsCatalogue no. 82-003-X. ISSN 1209-1367.

Did you know?

A Registered Dietitian or your doctor can help you regarding supplementing vitamin D in your daily diet.

BONE MATTERS: THE DILEMMAS OF D

Written on March 20, 2019. Posted in OC Replay, Webinar.

Vitamin D is a crucial nutrient for bone health. In this presentation Stephanie Atkinson, PhD discusses:

Vitamin D –why do we need it?
Does the new Canada’s Food Guide provide good nutrition for bone health?
Is it necessary to have Vitamin D status measured?
Can I prevent bone fractures by taking extra Vitamin D?
How do we make sure to get enough?

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