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Resistive vibration exercise reduces lower limb muscle atrophy during 56-day bed-rest
Abstracts / Bone 44 (2009) S68–S98
(1) Langton C M et al., Generation of a 3D proximal femur shape from a single projection 2D radiographic image; Osteoporosis International; In Press. doi:10.1016/j.bone.2009.01.188
273 Comparison of bone mineral density in elderly patients according to the presence of intertrochanteric fracture S. Moon, S. Lee, G. Kong, D. Kim, H. Oh Department of Orthopedic Surgery, Sunlin Hospital, Pohang, Kyongbook, South Korea Purpose: To analyze the difference in bone mineral density (BMD) between the intertrochanteric fracture and the control group and to explore predictive value of which BMD for intertrochanteric fracture. Materials and methods: 57 patients who were over 60-year-old with intertrochanteric fracture were examined. For the control group, 110 patients who did not have any fracture were selected. Dual energy X-ray absorptiometry was studied at 1, 2, 3, 4 lumbar vertebrae, femoral neck, trochanter and Ward's triangle. BMD was compared at each site between two groups statistically. Results: The fracture group consisted of 16 males, 41 females and an average age of 70.8 years old. The control group consisted of 21 males, 89 females and an average age of 68.1 years old. There were no differences in sex and age between two groups (p > 0.05). BMD of L1, L2 and mean lumbar area were significantly less in fracture group than control group (p < 0.05). There was no difference between two groups in BMD of another sites (p > 0.05). Conclusion: BMD of L1, L2 and mean lumbar area in fracture group had a significantly lower value, but had no differences between two groups at other sites. BMD of L1, L2 and mean lumbar area might be used as the most sensitive predictive indicator for risk of osteoporotic fractures including intertrochanteric fracture in elderly patients. doi:10.1016/j.bone.2009.01.189
274 Differential atrophy of the lower-limb musculature during prolonged bed-rest: Implications for the management of the immobilised patient T. Miokovica, D.L. Belavya, G. Armbrechta, C.A. Richardsonb, J. Rittwegerc, D. Felsenberga Zentrum für Muskel- und Knochenforschung, Charité Universitätsmedizin, Berlin, Germany School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia Institute for Biomedical Research into Human Movement and Health, Manchester Metropolitan University, Manchester, United Kingdom Patients with medical and surgical conditions and also the elderly are often assigned to bed-rest and/or immobilised in orthopaedic devices. Such management approaches lead to musculoskeletal atrophy. Although recovery of bone and muscle after inactivity/ disuse is inherently dependent upon resumption of physical activity, little scientific information is available to guide the development of exercise programmes. We sought to quantify and compare the rates of atrophy in the muscles of the lower-limb during extreme physical inactivity (prolonged bed-rest). 10 male subjects underwent 56-days of bed-rest. Magnetic resonance imaging of the lower-limbs was performed at two-weekly
S85
intervals during bed-rest. 65 images encompassing the head of femur and lateral malleolus of the ankle (slice thickness = 10 mm; interslice distance = 5 mm) were collected. One operator measured the cross-sectional area of the following muscles in each image: rectus femoris, vastii, sartorius, gracilis, adductor magnus, adductor longus, biceps femoris long head, biceps femoirs short head, semitendinosus and semimembranosus, gastrocnemius lateralis, gastrocnemius medialis, soleus with flexor hallucis longus, tibialis posterior, flexor digitorum longus, peroneal group, and anterior tibial muscles. The volume of each muscle was then calculated and subsequently the relative change compared to baseline. Non-linear mixed-effects models were used to fit an exponential decay model and rates of atrophy were determined. Rates of atrophy differed (F = 7.4, p < .0001) between the muscles with the greatest rates of atrophy seen in the medial gastrocnemius, soleus and vastii (p < .00000002). The hamstring muscles were also affected (p < .00015). Atrophy was less in the ankle dorsiflexors and anteromedial hip muscles. Differential rates of atrophy were seen in synergistic muscles (e.g. adductor magnus >adductor longus, p = .016; medial gastrocnemius >lateral gastrocnemius, p = .002; vastii >rectus femoris, p = .0002). These results demonstrate, for the first time, significantly faster rates of atrophy in the ankle and knee extensors than in other muscle groups and also that synergistic muscles can atrophy at significantly different rates during inactivity. The differential muscle atrophy can lead to the development of muscle imbalances upon return to normal activity. In our opinion, patients subject to bed-rest/immobilisation should be prescribed “closed-chain” resistance exercise, which targets the lower limb antigravity extensor muscles which were most affected in bed-rest. doi:10.1016/j.bone.2009.01.190
275 Resistive vibration exercise reduces lower limb muscle atrophy during 56-day bed-rest T. Miokovica, D.L. Belavya, G. Armbrechta, J. Rittwegerb, D. Felsenberga Zentrum für Muskel- und Knochenforschung, Charité Universitätsmedizin, Berlin, Germany Institute for Biomedical Research into Human Movement and Health, Manchester Metropolitan University, Manchester, United Kingdom Introduction: The development of effective exercise countermeasures to prevent musculoskeletal atrophy during long-term spaceflight is a priority for space agencies around the world. In this study we wish to examine the effectiveness of a resistive vibration exercise countermeasure during prolonged bed-rest in preventing lower limb muscle atrophy. Method: 20 male subjects underwent 56-days of bed-rest and were randomly assigned to either an inactive control group or a resistive vibration exercise countermeasure group that performed lower-limb exercises (squats, calf raises, toe raises) on a specially designed Galileo Space vibration exercise device (Novotec Medical, Pforzheim, Germany) in 11 exercise sessions per week. Magnetic resonance imaging of the lower-limbs was performed at two-weekly intervals during bed-rest. 65 images encompassing the head of femur and lateral malleolus of the ankle (slice thickness = 10 mm; interslice distance = 5 mm) were collected. One operator measured the cross-sectional area of the following muscles in each image: rectus femoris, vastii, sartorius, gracilis, adductor magnus, adductor longus, biceps femoris long head, biceps femoirs short head, semitendinosus and semimembranosus, gastrocnemius lateralis, gastrocnemius medialis, soleus with flexor hallucis longus, tibialis posterior, flexor
S86
Abstracts / Bone 44 (2009) S68–S98
digitorum longus, peroneal group, and anterior tibial muscles. The volume of each muscle was then calculated. Results: Countermeasure intervention reduced or prevented atrophy in medial gastrocnemius, soleus, lateral gastrocnemius and vastii muscles (F > 3.0, p ≤ .0247). Atrophy of the peroneals, tibialis posterior, and flexor digitorum longus was also less in the countermeasure group, though statistical evidence for this was weak (F ≤ 2.3, p ≥ .071). The countermeasure did not prevent atrophy in the hamstring muscles (F < 1.1, p > .38). The adductor longus, sartiorius and rectus femoris muscles showed little loss of muscle volume during bed-rest (F < 2.1, p > .088). Conclusion: The countermeasure exercise programme was effective in reducing muscle atrophy in the extensors of the knee and ankle. Future work needs to consider optimising exercises to be as time efficient as possible in targeting the muscles most affected in bed-rest/spaceflight.
economics of healthcare delivery, and so on. As a result, physicians need to make important decisions related to providing optimal and ongoing therapy for osteoporosis patients. Aims: In order to explore current practice for treatment plans in osteoporosis patients, a survey of Asian clinicians' views on osteoporosis treatment has been conducted. Methods: We developed a simple survey for clinicians in nine Asian countries, targeting those doctors who deal with osteoporosis patients in their daily practice. Between 50 and 150 clinicians in each country participated in the study during January and February 2008. Questions included views on combination therapy, medical therapy as a function of disease progression, differences due to sex and age, and so on. Initial responses to the questionnaire were complied during March and April 2008. Results: Feedback received from a total of 1034 responders in 9 countries:
doi:10.1016/j.bone.2009.01.191
China
Indonesia Malaysia Myanmar Singapore S. Korea Taiwan Thailand Vietnam Total
151
104
276 Large pulmonary embolus after percutaneous vertebroplasty in osteoporotic compression fracture — A case report S. Moon, S. Lee, G. Kong, J. Kim, E. Lee Department of Orthopedic Surgery, Sunlin Hospital, Pohang, Kyongbook, South Korea Percutaneous vertebroplasty for osteoporotic compression fracture or malignant osteolytic spinal tumors provides pain relief. Pulmonary embolism caused by polymethylmethacrylate migration after this procedure is rare and its major complication, pulmonary infarction, involves necrosis of lung parenchyme, resulting from interference with blood supply. We report a case of large pulmonary embolus (diameter 2 cm) after cement vertebroplasty for osteoporotic vertebral compression fracture and successful management with anticoagulation only. doi:10.1016/j.bone.2009.01.192
121
131
45
130
131
150
71
1034
Conclusion: Although data analysis is ongoing, at this time we believe that a large majority of clinicians take deep interest in the issues concerning optimal treatment for each patient at every stage of osteoporosis. However, there is a difference between delivery of ideal therapy and actual practice, due to conditions such as regulation of health insurance, economic situation and so on. Additional findings may be discerned after a final analysis. This preliminary survey may also uncover the need for a more in-depth investigation. The final results and conclusions of the survey may help guide a practical management strategy that will be useful in clinicians' daily practice. (1) EFFO and NOF (1997) Who are candidates for prevention and treatment for osteoporosis? Osteoporos Int 7:1. (2) Melton LJ, 3rd, Atkinson EJ, O'Connor MK, et al. (1998) Bone density and fracture risk in men. J Bone Miner Res 13:1915. (3) Melton LJ, 3rd, Chrischilles EA, Cooper C, et al. (1992) Perspective. How many women have osteoporosis? J Bone Miner Res 7:1005. (4) Kanis JA, Johnell O, Oden A, et al. (2000) Long-term risk of osteoporotic fracture in Malmo. Osteoporos Int 11:669. doi:10.1016/j.bone.2009.01.193
277 International survey of osteoporosis in Asia (ISOPA) B. Naronga, H. Zhub, E. Hutagalungc, B. Setyohadic, P. Soewondoc, H. Surotod, J. Leee, V. Suppanf, K. Naingg, M. Thaungh, Z. Soei, T. Lauj, W. Choik, C. Changl, H. Linm, S. Suppasinn, S. Thaweeo, L. Taninnitp, T. Vuq Siriraj Hospital, Bangkok, Thailand HuaDong (East China) Hospital, Shanghai, China Cipto Mangunkusumo General Hospital, Jakarta, Indonesia Soetomo General Hospital, Surabaya, Indonesia JK Lee Orthopaedic and Traumatology, Kuala Lumpur, Malaysia Sultan Abdul Halim Hospital, Kedah Darul Aman, Malaysia Myanmar Medical Association, Yangon, Myanmar Thinggangyun General Hospital, Yangon, Myanmar Yangon Orthopaedic Hospital, Yangon, Myanmar National University Health System, Singapore, Singapore Hanyang University, Seoul, South Korea National Taiwan University Hospital, Taipei, Taiwan Taipei Veterans General Hospital, Taipei, Taiwan Srinakarin Hospital, Bangkok, Thailand Phramongkutklao Hospital, Bangkok, Thailand Maharaj Nakorn Chiang Mai Hospital, Chaing Mai, Thailand Bach Mai Medical University Hospital, Hanoi, Vietnam Background: Current medical therapy for osteoporosis is evolving due to factors such as development of new drugs, new guidelines,
278 Calcium intake is negatively associated with bone turnover independent of PTH in postmenopausal women K. Nawataa,b, M. Yamauchia, S. Takaokaa, M. Imaokac, A. Kageyamad, T. Yamaguchia, T. Sugimotoa Internal Medicine 1, Shimane University Faculty of Medicine, Izumo, Shimane, Japan Health and Nutrition, The University of Shimane, Matsue, Shimane, Japan The Shimane Prefecture Dietetic Association, Matsue, Shimane, Japan Himeno Clinic, Izumo, Shimane, Japan Aim: There has been evidence that calcium (Ca) deficiency causes bone loss, and Ca supplements have a positive effect on bone mineral density (BMD). Several studies indicated that low Ca intake was associated with increase in bone resorption markers. The aim of this study is to further clarify the effect of Ca intake on bone turnover, and whether the effect is influenced by PTH or BMD. Subjects and methods: We enrolled 205 postmenopausal women who had examination of osteoporosis. We measured serum levels of N-terminal propeptide of type I collagen (PINP) and C-terminal crosslinked telopeptide of type I collagen (CTX) by ECLIA, and intact PTH by IRMA, as well as BMD at femoral neck by dual-energy X-ray absorptiometry. Nutrient intakes (protein, fat, Ca, magnesium,
(1) Langton C M et al., Generation of a 3D proximal femur shape from a single projection 2D radiographic image; Osteoporosis International; In Press. doi:10.1016/j.bone.2009.01.188
273 Comparison of bone mineral density in elderly patients according to the presence of intertrochanteric fracture S. Moon, S. Lee, G. Kong, D. Kim, H. Oh Department of Orthopedic Surgery, Sunlin Hospital, Pohang, Kyongbook, South Korea Purpose: To analyze the difference in bone mineral density (BMD) between the intertrochanteric fracture and the control group and to explore predictive value of which BMD for intertrochanteric fracture. Materials and methods: 57 patients who were over 60-year-old with intertrochanteric fracture were examined. For the control group, 110 patients who did not have any fracture were selected. Dual energy X-ray absorptiometry was studied at 1, 2, 3, 4 lumbar vertebrae, femoral neck, trochanter and Ward's triangle. BMD was compared at each site between two groups statistically. Results: The fracture group consisted of 16 males, 41 females and an average age of 70.8 years old. The control group consisted of 21 males, 89 females and an average age of 68.1 years old. There were no differences in sex and age between two groups (p > 0.05). BMD of L1, L2 and mean lumbar area were significantly less in fracture group than control group (p < 0.05). There was no difference between two groups in BMD of another sites (p > 0.05). Conclusion: BMD of L1, L2 and mean lumbar area in fracture group had a significantly lower value, but had no differences between two groups at other sites. BMD of L1, L2 and mean lumbar area might be used as the most sensitive predictive indicator for risk of osteoporotic fractures including intertrochanteric fracture in elderly patients. doi:10.1016/j.bone.2009.01.189
274 Differential atrophy of the lower-limb musculature during prolonged bed-rest: Implications for the management of the immobilised patient T. Miokovica, D.L. Belavya, G. Armbrechta, C.A. Richardsonb, J. Rittwegerc, D. Felsenberga Zentrum für Muskel- und Knochenforschung, Charité Universitätsmedizin, Berlin, Germany School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia Institute for Biomedical Research into Human Movement and Health, Manchester Metropolitan University, Manchester, United Kingdom Patients with medical and surgical conditions and also the elderly are often assigned to bed-rest and/or immobilised in orthopaedic devices. Such management approaches lead to musculoskeletal atrophy. Although recovery of bone and muscle after inactivity/ disuse is inherently dependent upon resumption of physical activity, little scientific information is available to guide the development of exercise programmes. We sought to quantify and compare the rates of atrophy in the muscles of the lower-limb during extreme physical inactivity (prolonged bed-rest). 10 male subjects underwent 56-days of bed-rest. Magnetic resonance imaging of the lower-limbs was performed at two-weekly
S85
intervals during bed-rest. 65 images encompassing the head of femur and lateral malleolus of the ankle (slice thickness = 10 mm; interslice distance = 5 mm) were collected. One operator measured the cross-sectional area of the following muscles in each image: rectus femoris, vastii, sartorius, gracilis, adductor magnus, adductor longus, biceps femoris long head, biceps femoirs short head, semitendinosus and semimembranosus, gastrocnemius lateralis, gastrocnemius medialis, soleus with flexor hallucis longus, tibialis posterior, flexor digitorum longus, peroneal group, and anterior tibial muscles. The volume of each muscle was then calculated and subsequently the relative change compared to baseline. Non-linear mixed-effects models were used to fit an exponential decay model and rates of atrophy were determined. Rates of atrophy differed (F = 7.4, p < .0001) between the muscles with the greatest rates of atrophy seen in the medial gastrocnemius, soleus and vastii (p < .00000002). The hamstring muscles were also affected (p < .00015). Atrophy was less in the ankle dorsiflexors and anteromedial hip muscles. Differential rates of atrophy were seen in synergistic muscles (e.g. adductor magnus >adductor longus, p = .016; medial gastrocnemius >lateral gastrocnemius, p = .002; vastii >rectus femoris, p = .0002). These results demonstrate, for the first time, significantly faster rates of atrophy in the ankle and knee extensors than in other muscle groups and also that synergistic muscles can atrophy at significantly different rates during inactivity. The differential muscle atrophy can lead to the development of muscle imbalances upon return to normal activity. In our opinion, patients subject to bed-rest/immobilisation should be prescribed “closed-chain” resistance exercise, which targets the lower limb antigravity extensor muscles which were most affected in bed-rest. doi:10.1016/j.bone.2009.01.190
275 Resistive vibration exercise reduces lower limb muscle atrophy during 56-day bed-rest T. Miokovica, D.L. Belavya, G. Armbrechta, J. Rittwegerb, D. Felsenberga Zentrum für Muskel- und Knochenforschung, Charité Universitätsmedizin, Berlin, Germany Institute for Biomedical Research into Human Movement and Health, Manchester Metropolitan University, Manchester, United Kingdom Introduction: The development of effective exercise countermeasures to prevent musculoskeletal atrophy during long-term spaceflight is a priority for space agencies around the world. In this study we wish to examine the effectiveness of a resistive vibration exercise countermeasure during prolonged bed-rest in preventing lower limb muscle atrophy. Method: 20 male subjects underwent 56-days of bed-rest and were randomly assigned to either an inactive control group or a resistive vibration exercise countermeasure group that performed lower-limb exercises (squats, calf raises, toe raises) on a specially designed Galileo Space vibration exercise device (Novotec Medical, Pforzheim, Germany) in 11 exercise sessions per week. Magnetic resonance imaging of the lower-limbs was performed at two-weekly intervals during bed-rest. 65 images encompassing the head of femur and lateral malleolus of the ankle (slice thickness = 10 mm; interslice distance = 5 mm) were collected. One operator measured the cross-sectional area of the following muscles in each image: rectus femoris, vastii, sartorius, gracilis, adductor magnus, adductor longus, biceps femoris long head, biceps femoirs short head, semitendinosus and semimembranosus, gastrocnemius lateralis, gastrocnemius medialis, soleus with flexor hallucis longus, tibialis posterior, flexor
S86
Abstracts / Bone 44 (2009) S68–S98
digitorum longus, peroneal group, and anterior tibial muscles. The volume of each muscle was then calculated. Results: Countermeasure intervention reduced or prevented atrophy in medial gastrocnemius, soleus, lateral gastrocnemius and vastii muscles (F > 3.0, p ≤ .0247). Atrophy of the peroneals, tibialis posterior, and flexor digitorum longus was also less in the countermeasure group, though statistical evidence for this was weak (F ≤ 2.3, p ≥ .071). The countermeasure did not prevent atrophy in the hamstring muscles (F < 1.1, p > .38). The adductor longus, sartiorius and rectus femoris muscles showed little loss of muscle volume during bed-rest (F < 2.1, p > .088). Conclusion: The countermeasure exercise programme was effective in reducing muscle atrophy in the extensors of the knee and ankle. Future work needs to consider optimising exercises to be as time efficient as possible in targeting the muscles most affected in bed-rest/spaceflight.
economics of healthcare delivery, and so on. As a result, physicians need to make important decisions related to providing optimal and ongoing therapy for osteoporosis patients. Aims: In order to explore current practice for treatment plans in osteoporosis patients, a survey of Asian clinicians' views on osteoporosis treatment has been conducted. Methods: We developed a simple survey for clinicians in nine Asian countries, targeting those doctors who deal with osteoporosis patients in their daily practice. Between 50 and 150 clinicians in each country participated in the study during January and February 2008. Questions included views on combination therapy, medical therapy as a function of disease progression, differences due to sex and age, and so on. Initial responses to the questionnaire were complied during March and April 2008. Results: Feedback received from a total of 1034 responders in 9 countries:
doi:10.1016/j.bone.2009.01.191
China
Indonesia Malaysia Myanmar Singapore S. Korea Taiwan Thailand Vietnam Total
151
104
276 Large pulmonary embolus after percutaneous vertebroplasty in osteoporotic compression fracture — A case report S. Moon, S. Lee, G. Kong, J. Kim, E. Lee Department of Orthopedic Surgery, Sunlin Hospital, Pohang, Kyongbook, South Korea Percutaneous vertebroplasty for osteoporotic compression fracture or malignant osteolytic spinal tumors provides pain relief. Pulmonary embolism caused by polymethylmethacrylate migration after this procedure is rare and its major complication, pulmonary infarction, involves necrosis of lung parenchyme, resulting from interference with blood supply. We report a case of large pulmonary embolus (diameter 2 cm) after cement vertebroplasty for osteoporotic vertebral compression fracture and successful management with anticoagulation only. doi:10.1016/j.bone.2009.01.192
121
131
45
130
131
150
71
1034
Conclusion: Although data analysis is ongoing, at this time we believe that a large majority of clinicians take deep interest in the issues concerning optimal treatment for each patient at every stage of osteoporosis. However, there is a difference between delivery of ideal therapy and actual practice, due to conditions such as regulation of health insurance, economic situation and so on. Additional findings may be discerned after a final analysis. This preliminary survey may also uncover the need for a more in-depth investigation. The final results and conclusions of the survey may help guide a practical management strategy that will be useful in clinicians' daily practice. (1) EFFO and NOF (1997) Who are candidates for prevention and treatment for osteoporosis? Osteoporos Int 7:1. (2) Melton LJ, 3rd, Atkinson EJ, O'Connor MK, et al. (1998) Bone density and fracture risk in men. J Bone Miner Res 13:1915. (3) Melton LJ, 3rd, Chrischilles EA, Cooper C, et al. (1992) Perspective. How many women have osteoporosis? J Bone Miner Res 7:1005. (4) Kanis JA, Johnell O, Oden A, et al. (2000) Long-term risk of osteoporotic fracture in Malmo. Osteoporos Int 11:669. doi:10.1016/j.bone.2009.01.193
277 International survey of osteoporosis in Asia (ISOPA) B. Naronga, H. Zhub, E. Hutagalungc, B. Setyohadic, P. Soewondoc, H. Surotod, J. Leee, V. Suppanf, K. Naingg, M. Thaungh, Z. Soei, T. Lauj, W. Choik, C. Changl, H. Linm, S. Suppasinn, S. Thaweeo, L. Taninnitp, T. Vuq Siriraj Hospital, Bangkok, Thailand HuaDong (East China) Hospital, Shanghai, China Cipto Mangunkusumo General Hospital, Jakarta, Indonesia Soetomo General Hospital, Surabaya, Indonesia JK Lee Orthopaedic and Traumatology, Kuala Lumpur, Malaysia Sultan Abdul Halim Hospital, Kedah Darul Aman, Malaysia Myanmar Medical Association, Yangon, Myanmar Thinggangyun General Hospital, Yangon, Myanmar Yangon Orthopaedic Hospital, Yangon, Myanmar National University Health System, Singapore, Singapore Hanyang University, Seoul, South Korea National Taiwan University Hospital, Taipei, Taiwan Taipei Veterans General Hospital, Taipei, Taiwan Srinakarin Hospital, Bangkok, Thailand Phramongkutklao Hospital, Bangkok, Thailand Maharaj Nakorn Chiang Mai Hospital, Chaing Mai, Thailand Bach Mai Medical University Hospital, Hanoi, Vietnam Background: Current medical therapy for osteoporosis is evolving due to factors such as development of new drugs, new guidelines,
278 Calcium intake is negatively associated with bone turnover independent of PTH in postmenopausal women K. Nawataa,b, M. Yamauchia, S. Takaokaa, M. Imaokac, A. Kageyamad, T. Yamaguchia, T. Sugimotoa Internal Medicine 1, Shimane University Faculty of Medicine, Izumo, Shimane, Japan Health and Nutrition, The University of Shimane, Matsue, Shimane, Japan The Shimane Prefecture Dietetic Association, Matsue, Shimane, Japan Himeno Clinic, Izumo, Shimane, Japan Aim: There has been evidence that calcium (Ca) deficiency causes bone loss, and Ca supplements have a positive effect on bone mineral density (BMD). Several studies indicated that low Ca intake was associated with increase in bone resorption markers. The aim of this study is to further clarify the effect of Ca intake on bone turnover, and whether the effect is influenced by PTH or BMD. Subjects and methods: We enrolled 205 postmenopausal women who had examination of osteoporosis. We measured serum levels of N-terminal propeptide of type I collagen (PINP) and C-terminal crosslinked telopeptide of type I collagen (CTX) by ECLIA, and intact PTH by IRMA, as well as BMD at femoral neck by dual-energy X-ray absorptiometry. Nutrient intakes (protein, fat, Ca, magnesium,