Osteoporosis remains a major health issue worldwide. Although it has been associated with Caucasian women in the United States, attention is being drawn to other ethnicities. The National Institutes of Health (NIH) are concerned that people perceive osteoporosis to only affect Caucasian women, given that African-American (AA) women have higher bone mineral density and lower postmenopausal bone loss. This perception ignores observations that AA women are at significant risk of developing osteoporosis. As such, there is considerable delay in the prevention and treatment of osteoporosis among AA women. This cross-sectional study's design primary purpose was to describe postmenopausal AA women's knowledge, beliefs and behaviors concerning osteoporosis. Secondary to this purpose, was exploration of correlations between the Health Belief Model (HBM) theoretical constructs with osteoporosis preventive behavior, especially calcium intake and physical exercise. One hundred and fifty three postmenopausal AA women completed a questionnaire containing 1) the Osteoporosis Knowledge Test (OKT), 2) the Osteoporosis Health Belief Scale (OHBS), 3) the Osteoporosis Self-Efficacy Scale (OSES), 4) the Osteoporosis Attitude Knowledge Test (OAKT) and 5) the Osteoporosis Preventing Behaviors Survey (OPBS). The data were analyzed in SPSS version 21.0. The results of the study varied. Women in the study had greater knowledge about osteoporosis overall; they had less knowledge about preventing osteoporosis with exercise. They regularly used diet to prevent osteoporosis and reported recurrent physical activity. Participants had a general knowledge of osteoporosis but they experienced a moderate number of barriers that limited exercise. Few barriers for calcium intake were reported. Correlational analysis between age, number of months post-menopause, and education and the dependent variables (osteoporosis knowledge, beliefs, attitudes, and barriers to engaging in bone health promotion activities) revealed significant correlations. Age and number of years post menopause were significantly negatively correlated with use of physical activity to prevent osteoporosis. As women aged, they engaged in less osteoporosis prevention using exercise and as the number of months post menopause increased, the exercise behaviors associated with osteoporosis prevention decreased. This is an indication that women at this age have to be educated on the importance of exercising at this stage in their life.

Introduction: Osteoporotic fractures, a major public health problem in aging populations, can lead to increased disability and mortality. Though rheumatoid arthritis (RA) patients have a higher risk for fractures than healthy populations, it is not known how hip structural geometry and body composition, two factors associated with bone strength, affect fracture risk in this population. The overall goal of this dissertation is to examine the association between RA, fracture, hip structural geometry, and body composition, in the participants of the Women's Health Initiative (WHI).Methods: The association between probable RA and fracture risk was tested using the entire WHI cohort (n=161,808). The association between probable RA and hip structural geometry was tested, both cross-sectionally and longitudinally, in a smaller sample (n=11,020) of participants from the WHI Bone Density Centers (WHI-BMD). The last study, testing the association between probable RA and body composition was also conducted in the WHI-BMD cohort.Results: In comparison to the non-arthritic group, the probable RA group had a significant 50%, 2-fold, and 3-fold increase in any, spine, and hip fracture, respectively. The association was not mot modified by age or ethnicity, but glucocorticoid use altered the association between RA and spine fractures. In terms of geometry, the probable RA had a significantly lower (p<0.05) mean hip BMD, outer diameter, cross-sectional area, and section modulus at the narrow neck region compared to control groups, indicating reduced bone strength. Body composition changes were present between the probable RA and the control group, with the probable RA group having statistically lower estimate of lean mass and statistically higher estimates of fat mass compared to the non-arthritic control group cross-sectionally and over the study.Conclusion: These studies confirm the increased risk for fracture among RA patients, while providing evidence that RA alters bone strength, especially at the hip, and negatively effects body composition by reducing lean mass and increasing fat mass. Additional research is needed link structural geometry and body composition to bone strength to lead to tailored interventions to minimize decreases in bone strength in this high fracture risk population.

The main focus of bone loss and Osteoporosis (OP) research has been limited almost entirely to women, but OP has become increasingly common in older men and the impact of hip fracture on mortality may actually be greater in men. OP is a major cause of morbidity and mortality in developed countries, at a cost that currently exceeds $10 billion per year in the United States (US) alone. Osteoporotic fractures affect 50 % of women and 20-30% of white men and 4% of black men over the age of 50 years. These statistics may even increase because of increasing life expectancy. Few studies focusing on Blacks have been published to date and very little is known regarding the bone health and the aetiology and prevalence of OP and fractures among older South African blacks. From the above information it is clear that OP is of considerable clinical and economic importance. Without information on the patterns and determinants of bone loss, the formulation of rational prevention and treatment strategies in these groups is not possible. The aim of the study described in this thesis was to investigate the influence of the dietary factors (iron, vitamin C, and protein) and lifestyle factors (alcohol and tobacco smoking) on osteoporotic fractures and bone mineral density in older South African black men using a case-control study design. Sixteen black male patients with fractures of the proximal femur, the proximal humerus or the distal radius and who conformed to the inclusion and exclusion criteria were included in the study. An equal amount of age-matched (K? years), apparently healthy black men with no previous fracture (of the proximal femur and humerus and distal radius), were recruited as a control group. Dual energy X-ray absorptiometry (DEXA) was used for the measurement of the lumbar vertebrae and the proximal femur (hip). Questionnaires were used to gather demographic and medical information, data on physical activity and dietary intakes. Anthropometric measurements and blood samples were taken. Appropriate biochemical analyses were done with standard methods. Both the cases and controls were osteoporotic according to the mean lumbar spine BMD determined in both groups. The BMD was only marginally lower in the cases than in the controls and therefore not statistically significant. The mean tobacco pack years of the cases (13.29) [95% CI: 4.44; 22.141 were almost double that of the controls (7.43) [1.83; 13.031 but it was not statistically significant (p=0.55). Tobacco pack years were negatively associated with BMD of the lumbar spine (p=0.008) even after controlling for possible confounding SUMMARY factors (p=0.001). Malnutrition, as indicated by the low dietary intakes of energy, protein, vitamin C, iron and low BMI, could play a role in the lower bone mineral density (BMD) observed in the cases. The mean protein intakes of the cases (56.1 19) [46.49; 65.741 were very low compared to the recommended 639 per day. This low protein intake was also significantly less compared to the controls (739) [58.28; 88.311. lron intake tended to be lower in the cases compared to the controls (p=0.09). lron intake was not associated with BMD, however, in the stepwise regression analysis; iron intake came out as a possible predictor of BMD of both the lumbar spine and hip, although it was not statistically significant. The BMI was c 19 kg/m2 in 50% of the cases and the controls. S-GGT, a marker of alcohol intake, was significantly increased in the cases with a mean value of 65.88ulL opposed to the 36.33UIL in the control group. S-GGT was the most important predictor of BMD in both the hip and the lumbar spine. There was a significant statistical correlation between lumbar spine BMD (p=0.04); hip BMD (p=0.02) and s-GGT. In conclusion it can be said that malnutrition played a vital role in the low BMD aggravated by the use of tobacco from a young age and alcohol in excessive amounts over weekends. From the results of this study it can be recommended that any intervention programme should focus on alcohol abuse, tobacco smoking and improvement in nutritional status. Children should be encouraged not to smoke and be educated on the detrimental effects of alcohol. It is important to address dietary risk factors associated with OP, namely to increase the overall nutrition of the South African black male with low cost protein and calcium products. Vitamin C enhances iron absorption and may be beneficial for bone collagen. The increased intake thereof by using seasonal fruit can therefore be recommended. / Thesis (M.Sc. (Dietetics))--North-West University, Potchefstroom Campus, 2004.

Background: Reduced bone mineral density (BMD) is an established complication of anorexia nervosa (AN). There is inconclusive evidence as to whether this reduction in bone mass is permanent or can be reversed with recovery from AN. The objectives of this study were to: i. determine the extent of reversal of skeletal deficits with recovery from AN, and the duration of recovery required for complete reversal, if this occurred; and, ii. evaluate the effect of key illness characteristics on BMD. Methods: Women (aged 17-40 years) who had previously received inpatient treatment for AN at one of two hospital-based programs were selected for this cross-sectional study; 514 healthy premenopausal women recruited from the community served as a control group. A detailed lifetime illness history was obtained by a Life History Calendar interview. BMD was measured by dual-energy X-ray absorptiometry (DXA) at the spine, hip and total body. Low BMD was defined as a weight and age-matched standard deviation (Z-score) of ≤ -1.5 at one or more skeletal sites. Participants were considered recovered if they had maintained a body mass index ≥ 18.5 kg/m2 and resumed regular menstruation for ≥ 1 year. Results: Of 190 AN participants, 77 were considered recovered and 113 were ill. The prevalence of low BMD was 11.7% in the recovered group, 47.3% in the ill group and 6.8% in the control group. The odds of low BMD in the recovered participants was significantly lower than in the ill participants (odds ratio [OR] = 0.17, 95% CI 0.07, 0.36, p<0.0001) and was not significantly different from the controls (OR = 1.81, 95% CI 0.79, 3.78, p=0.15). Duration of illness was associated with low BMD (OR = 1.16, 95% CI 1.08, 1.25, p<0.0001) and was negatively associated with the odds of AN recovery. Normal mean BMD values at each skeletal site were observed in women recovered ≥ 3 years. Conclusion: The results emphasize the importance of early and sustained AN recovery for the prevention and treatment of low bone mass in this population and may offer motivation for AN patients to make positive behavioural changes leading to successful, long-term recovery.

Background: Reduced bone mineral density (BMD) is an established complication of anorexia nervosa (AN). There is inconclusive evidence as to whether this reduction in bone mass is permanent or can be reversed with recovery from AN. The objectives of this study were to: i. determine the extent of reversal of skeletal deficits with recovery from AN, and the duration of recovery required for complete reversal, if this occurred; and, ii. evaluate the effect of key illness characteristics on BMD. Methods: Women (aged 17-40 years) who had previously received inpatient treatment for AN at one of two hospital-based programs were selected for this cross-sectional study; 514 healthy premenopausal women recruited from the community served as a control group. A detailed lifetime illness history was obtained by a Life History Calendar interview. BMD was measured by dual-energy X-ray absorptiometry (DXA) at the spine, hip and total body. Low BMD was defined as a weight and age-matched standard deviation (Z-score) of ≤ -1.5 at one or more skeletal sites. Participants were considered recovered if they had maintained a body mass index ≥ 18.5 kg/m2 and resumed regular menstruation for ≥ 1 year. Results: Of 190 AN participants, 77 were considered recovered and 113 were ill. The prevalence of low BMD was 11.7% in the recovered group, 47.3% in the ill group and 6.8% in the control group. The odds of low BMD in the recovered participants was significantly lower than in the ill participants (odds ratio [OR] = 0.17, 95% CI 0.07, 0.36, p<0.0001) and was not significantly different from the controls (OR = 1.81, 95% CI 0.79, 3.78, p=0.15). Duration of illness was associated with low BMD (OR = 1.16, 95% CI 1.08, 1.25, p<0.0001) and was negatively associated with the odds of AN recovery. Normal mean BMD values at each skeletal site were observed in women recovered ≥ 3 years. Conclusion: The results emphasize the importance of early and sustained AN recovery for the prevention and treatment of low bone mass in this population and may offer motivation for AN patients to make positive behavioural changes leading to successful, long-term recovery.

El óxido nítrico (ON) es considerado un de los posibles reguladores del metabolismo y de la actividad celular del tejido óseo. Es producido por la sintasa inducible ON (SON).Los osteoblastos y los osteoclastos expresan fundamentalmente la sintasa endotelial (SONe) y la sintasa inducible (SONi). Este estudio investigó, en una primera etapa, las funciones individuales de cada una de estas isoformas, mediante histomorfometría y técnicas de biología molecular, empleando animales transgénicos deficientes en la SONe (SONe-/-) y en la SONi (SONi-/-), respectivamente. En una segunda etapa, este estudio investigó los efectos de la lactancia sobre el metabolismo óseo y el posible rol del ON en la patogénesis de la osteoporosis lactacional en ratas, mediante estudios bioquímicos, histomorfométricos e inmunohistoquímicos. Los estudios desarrollados en los ratones SONe-/- y en los ratones SONi-/- mostraron que ambas isoformas están involucradas en la regulación de la masa ósea y que la ausencia de los genes que expresan alguna de estas isoformas resulta en la reducción del volumen óseo(BV/TV) y en el índice de formación ósea (BFR/BS). Las alteraciones observadas estan relacionadas con una disfuncion osteoblásticas. La ausencia de la SONe se encuentra asociada con una reducción en el reclutamiento de los osteoblastos a los sitios de remodelación; mientras que la ausencia de la SONi esta relacionada con una disminución en la actividad metabólica de estas células. Los estudios desarrollados en las ratas en lactación mostraron una reducción del BV/TV y un aumento marcado del índice de remodelación ósea, mas pronunciados que los observados en las ratas ovariectomizadas. Sin embargo, mostraron una marcada disminución de las superficies mineralizadas (MS/BS), del índice de aposición mineral (MAR)y del BFR/BS. Se observó una correlación positiva entre los niveles de expresión de la SONe en los discos epifisiarios con la intensidad del crecimiento endocondral y con la magnitud en la intensidad de la remodelación ósea. / Nitric oxide (NO) is consideres as a possible local regulator of bone metabolism and bone cell activity. NO es generated by NO sythsses (NOS) isoforms. Thi endothelial (eNOS) and the inducible (iNOS) isoforms are expressed by osteoblasts and osteoclasts. The first aim of this study was to investigate the specific roles of these isoforms using eNOS and iNOS gene-deficient mice (eNOS -/- and iNOS, respectively) by performing histomorphometry and molecular biology techniques. The second aim of this study to investigate the role of NO in the pathogenesis of lactational osteoporosis in rats and to assess the effects of lactation on bone metabolism and bone cell activity. Endothelial NOS gene-deficient mice showed a decrease in bone volume (BV/TV) and in bone formation rate (BFR/BS). These appear to be due to a decrease in osteoblast surface and therefore, suggest thart there is an abnormal osteoblast commitmentand recruitment. Similary, iNOS-/- mice displayed a reduction in BV/TV and in BFR/BS. However, it seems to be due to a reduction in osteoblast metabolism and activity rather than to a reduction in osteoblast recruitment. Study conducted in rats during lactation showed in BV/TV and an increase in bone remodelling, more pronounced than the observed in ovariectomized rats. However, lactated rats also showed a reduction in mineralised surface (MS/BS), in mineral appositional rate (MAR) and in BFR/BS. A positive correlation was observed between the level of eNOS expression in the growth plate and the intensity of endochondral growth rate and with the intensity of bone remodelling activity in the methaphyses. A positive correlation was also observed between the oestrogen levels and the level of eNOS expression in the growth plate but not with the eNOS expression in the trabecular metaphyses. Taking together these data suggest that eNOS is involved in endochondral growth and in bone remodelling. However, oestrogen levels seems to be related, at least in part, with endochondral growth rate but seems to have less influence in bone remodelling activity.

The purpose of this study is to determine the correlation between texture features of Di raction Enhanced Imaging (DEI) images and trabecular properties of human wrist bone in the assessment of osteoporosis. Osteoporosis is a metabolic bone disorder that is characterized by reduced bone mass and a deterioration of bone structure which results in an increased fracture risk. Since the disease is preventable, diagnostic techniques are of major importance. Bone micro-architecture and Bone mineral density (BMD) are two main factors related to osteoporotic fractures. Trabecular properties like bone volume (BV), trabecular number (Tb.N), trabecular thickness (Tb.Th), bone surface (BS), and other properties of bone, characterizes the bone architecture. Currently, however, BMD is the only measurement carried out to assess osteoporosis. Researchers suggest that bone micro-architecture and texture analysis of bone images along with BMD can provide more accuracy in the assessment. We have applied texture analysis on DEI images and extracted texture features. In our study, we used fractal analysis, gray level co-occurrence matrix (GLCM), texture feature coding method (TFCM), and local binary patterns (LBP) as texture analysis methods to extract texture features. 3D Micro-CT trabecular properties were extracted using SkyScanTM CTAN software. Then, we determined the correlation between texture features and trabecular properties. GLCM energy fea- ture of DEI images explained more than 39% of variance in bone surface by volume ratio (BS/BV), 38% of variance in percent bone volume (BV/TV), and 37% of variance in trabecular number (Tb.N). TFCM homogeneity feature of DEI images explained more than 42% of variance in bone surface (BS) parameter. LBP operator - LBP 11 of DEI images explained more than 34% of vari- ance in bone surface (BS) and 30% of variance in bone surface density (BS/TV). Fractal dimension parameter of DEI images explained more than 47% of variance in bone surface (BS) and 32% of variance in bone volume (BV). This study will facilitate in the quanti cation of osteoporosis beyond conventional BMD.

In this thesis, a two-dimensional (2D) finite element (FE) model was developed from the patient’s hip DXA image to evaluate osteoporotic fracture risk. The loading configuration was designed to simulate a lateral fall onto the greater trochanter. Bone inhomogeneous mechanical properties (e.g. Young’s modulus) assigned to the FE model were correlated to bone mineral density captured in DXA image using empirical functions. In-house MATLAB codes were developed to investigate the effects of different factors such as bone mineral density, femoral neck length, neck diameter, neck angle and patient’s body weight on fracture risk. The 2D FE model constructed from DXA image was able to de-termine the factors which affect fracture risk to a greater extent based on the location of femur. The model developed here can be considered as a first attempt for investigating the effects of different parameters on fracture risk using patient specific 2D FE method.

The main focus of bone loss and Osteoporosis (OP) research has been limited almost entirely to women, but OP has become increasingly common in older men and the impact of hip fracture on mortality may actually be greater in men. OP is a major cause of morbidity and mortality in developed countries, at a cost that currently exceeds $10 billion per year in the United States (US) alone. Osteoporotic fractures affect 50 % of women and 20-30% of white men and 4% of black men over the age of 50 years. These statistics may even increase because of increasing life expectancy. Few studies focusing on Blacks have been published to date and very little is known regarding the bone health and the aetiology and prevalence of OP and fractures among older South African blacks. From the above information it is clear that OP is of considerable clinical and economic importance. Without information on the patterns and determinants of bone loss, the formulation of rational prevention and treatment strategies in these groups is not possible. The aim of the study described in this thesis was to investigate the influence of the dietary factors (iron, vitamin C, and protein) and lifestyle factors (alcohol and tobacco smoking) on osteoporotic fractures and bone mineral density in older South African black men using a case-control study design. Sixteen black male patients with fractures of the proximal femur, the proximal humerus or the distal radius and who conformed to the inclusion and exclusion criteria were included in the study. An equal amount of age-matched (K? years), apparently healthy black men with no previous fracture (of the proximal femur and humerus and distal radius), were recruited as a control group. Dual energy X-ray absorptiometry (DEXA) was used for the measurement of the lumbar vertebrae and the proximal femur (hip). Questionnaires were used to gather demographic and medical information, data on physical activity and dietary intakes. Anthropometric measurements and blood samples were taken. Appropriate biochemical analyses were done with standard methods. Both the cases and controls were osteoporotic according to the mean lumbar spine BMD determined in both groups. The BMD was only marginally lower in the cases than in the controls and therefore not statistically significant. The mean tobacco pack years of the cases (13.29) [95% CI: 4.44; 22.141 were almost double that of the controls (7.43) [1.83; 13.031 but it was not statistically significant (p=0.55). Tobacco pack years were negatively associated with BMD of the lumbar spine (p=0.008) even after controlling for possible confounding SUMMARY factors (p=0.001). Malnutrition, as indicated by the low dietary intakes of energy, protein, vitamin C, iron and low BMI, could play a role in the lower bone mineral density (BMD) observed in the cases. The mean protein intakes of the cases (56.1 19) [46.49; 65.741 were very low compared to the recommended 639 per day. This low protein intake was also significantly less compared to the controls (739) [58.28; 88.311. lron intake tended to be lower in the cases compared to the controls (p=0.09). lron intake was not associated with BMD, however, in the stepwise regression analysis; iron intake came out as a possible predictor of BMD of both the lumbar spine and hip, although it was not statistically significant. The BMI was c 19 kg/m2 in 50% of the cases and the controls. S-GGT, a marker of alcohol intake, was significantly increased in the cases with a mean value of 65.88ulL opposed to the 36.33UIL in the control group. S-GGT was the most important predictor of BMD in both the hip and the lumbar spine. There was a significant statistical correlation between lumbar spine BMD (p=0.04); hip BMD (p=0.02) and s-GGT. In conclusion it can be said that malnutrition played a vital role in the low BMD aggravated by the use of tobacco from a young age and alcohol in excessive amounts over weekends. From the results of this study it can be recommended that any intervention programme should focus on alcohol abuse, tobacco smoking and improvement in nutritional status. Children should be encouraged not to smoke and be educated on the detrimental effects of alcohol. It is important to address dietary risk factors associated with OP, namely to increase the overall nutrition of the South African black male with low cost protein and calcium products. Vitamin C enhances iron absorption and may be beneficial for bone collagen. The increased intake thereof by using seasonal fruit can therefore be recommended. / Thesis (M.Sc. (Dietetics))--North-West University, Potchefstroom Campus, 2004.

In this thesis, a two-dimensional (2D) finite element (FE) model was developed from the patient’s hip DXA image to evaluate osteoporotic fracture risk. The loading configuration was designed to simulate a lateral fall onto the greater trochanter. Bone inhomogeneous mechanical properties (e.g. Young’s modulus) assigned to the FE model were correlated to bone mineral density captured in DXA image using empirical functions. In-house MATLAB codes were developed to investigate the effects of different factors such as bone mineral density, femoral neck length, neck diameter, neck angle and patient’s body weight on fracture risk. The 2D FE model constructed from DXA image was able to de-termine the factors which affect fracture risk to a greater extent based on the location of femur. The model developed here can be considered as a first attempt for investigating the effects of different parameters on fracture risk using patient specific 2D FE method.