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Swimming is a very popular sport among adolescents in the US. Little is known about the diet of competitive adolescent swimmers in the US but data from other countries indicate several inadequacies, including excessive intake of fat and lower than recommended intake of carbohydrate and several micronutrients that may affect athletic performance and bone accrual. We assessed usual diet, using a food frequency questionnaire and calcium checklist, among 191 adolescent males and females [91 swimmers (mean 13.7, s = 2.5 years) and 100 non-athletes (mean 14.4, s = 2.8 years)]. For both males and females, swimmers and non-athletes generally had similar average intakes of macro- and micro-nutrients, including higher than recommended amounts of total fat (36%) and saturated fat (12%), and inadequate amounts of calcium, vitamin D, and daily servings of fruits, vegetables, grains, and dairy products. This first study of nutritional intake among adolescent swimmers in the US suggests that dietary habits of adolescents who swim competitively may jeopardize optimal athletic performance and place them at risk for future chronic diseases, including osteoporosis.

Yes / Context: Vitamin D is essential for bone health in adolescence, where there is rapid bone mineral content accrual. As cutaneous sun-exposure provides vitamin D, there is no recommended oral intake for UK adolescents. Objective: Assess seasonal vitamin D status and its contributors in white Caucasian adolescents, and examine bone health in those found deficient. Design: Prospective cohort study. Setting: Six schools in Greater Manchester, UK. Participants: 131 adolescents, 12–15 years. Intervention(s): Seasonal assessment of circulating 25-hydroxyvitamin D (25OHD), personal sunexposure and dietary vitamin D. Adolescents deficient (25OHD <10 ng/mL/25 nmol/L) in ≥one season underwent dual-energy X-ray absorptiometry (lumbar spine, femoral neck), with bone mineral apparent density (BMAD) correction for size, and peripheral quantitative computed tomography (distal radius) for volumetric (v)BMD. Main Outcome Measure: Serum 25OHD; BMD. Results: Mean 25OHD was highest in September: 24.1 (SD 6.9) ng/mL and lowest in January: 15.5 (5.9) ng/mL. Over the year, 16% were deficient in ≥one season and 79% insufficient (25OHD <20 ng/mL/50 nmol/L) including 28% in September. Dietary vitamin D was low year-round while personal sun-exposure was seasonal and predominantly across the school week. Holidays accounted for 17% variation in peak 25OHD (p<0.001). Nineteen adolescents underwent bone assessment, which showed low femoral neck BMAD versus matched reference data (p=0.0002), 3 with Z≤ -2.0 distal radius trabecular vBMD. Conclusions: Sun-exposure levels failed to provide adequate vitamin D, ~one-quarter adolescents insufficient even at summer-peak. Seasonal vitamin D deficiency was prevalent and those affected had low BMD. Recommendations on vitamin D acquisition are indicated in this age-group. / The Bupa Foundation (Grant number TBF-M10-017).

Background: Studies have not examined the relationships between serum vitamin D (SVitD), serum cortisol (SCort), bone mineral density (BMD), and body fat percent (BF%) in elite figure skaters. However, studies of non-athletes have found that BMD is inversely related to SCort and directly related to SVitD, and BF% is inversely related to SVitD and directly related to SCort. It was, therefore, the purpose of this study to assess the relationships between SCort, SVitD, BMD, and BF% in elite figure skaters. Methods: U.S. national team figure skaters were assessed at a national training camp during the summer, 2012. BMD and body composition were measured by dual energy x-ray absorptiometry (DEXA). Blood chemistry values for SVitD and SCort were obtained via venous puncture after an overnight fast, the same morning as the DEXA measurement. Georgia State University Institutional Review Board approval was obtained for the assessment of data collected at this training camp. Results: 24 out of 39 training camp attendees (61.5%) volunteered to be assessed as part of this study. Subjects ranged from 17 to 34 years and included males (n=11) and females (n=12). In all skaters statistically significant negative correlations (2-tailed Spearman) were found between SCort and BMD of the spine (r=-0.458, p=0.032), pelvis (r=-0.532, p=0.011), ribs (r=-0.517, p=0.014), and trunk (r=-0.538, p=0.010). In females, SCort was negatively correlated with BMD of the pelvis (r=-0.664, p=0.026) and trunk (r=-0.609, p=0.047), and was positively correlated with total BF% (r=0.657, p=0.020) and trunk fat % (r=0.708, p=0.010). In males, SCort was significantly correlated with BMD of the ribs (r=-0.627, p=0.039). The 3 skaters (all female) with SCort > 28 mcg/dL had significantly lower mean BMD of the total body, left femoral neck, legs, trunk, and pelvis, and significantly greater BF% of the total body and trunk when compared to the 20 skaters with SCort 7-28 mcg/dL. No significant correlations between SVitD and BMD or BF% were found. A Mann-Whitney U test found no significant differences in BMD and BF% between the 8 skaters with SVitD ≥ 30 ng/mL compared to the 15 skaters with SVitD < 30 ng/mL (p>0.05). Females with SVitD ≥ 30 ng/mL had significantly higher BMD (p=0.041) of the right femoral neck when compared to those with lower SVitD. Conclusions: Correlations consistently found negative associations between SCort cortisol and BMD in multiple assessment areas, particularly those composed of trabecular bone. Higher SCort was also associated with higher BF% in female skaters. Despite spending a great deal of time in indoor facilities, limiting vitamin D creation through sunlight exposure, no significant correlation between SVitD and BMD was found. Female athletes in ‘appearance’ sports, may be predisposed to restrained eating behaviors, which may be associated with elevated SCort. These findings suggest a need for further study of the interaction between SCort, BMD, and BF% in these athletes. The lack of a statistically significant relationship between SVitD and BMD suggests the need to investigate additional factors associated with bone injury risk in athletes.

Adolescence is a crucial period for bone development and exercise can enhance bone acquisition during this period of life. However, there is a lack of scientific evidence on how different loading sports practiced during adolescence can affect bone development in males. The present thesis is part of the PRO-BONE study and aimed to investigate the cross-sectional and longitudinal effects of participation in football (osteogenic sport), swimming and cycling (non-osteogenic sports) on bone mass, bone geometry, texture and bone metabolism in adolescent males. An active control group has been included too. Additionally, the thesis examined the effect of a 9-month jumping intervention programme on bone outcomes in adolescent males involved these sports. Cross-sectional findings from Chapter 4 show that footballers have better bone status than swimmers, cyclists and controls (7 to 21 %), and that there are no differences between participants of non-osteogenic sports and controls. Chapter 5 identifies that lean mass is the strongest determinant of bone outcomes, followed by football participation and height in adolescent male athletes, whereas the contribution of the other predictors, such as nutrition, physical activity and fitness, is site specific. Longitudinal evidence in Chapters 6 and 7 show that bone mass (5 to 8 %) and geometry (4 to 10 %) is higher in adolescent male footballers compared to swimmers and cyclists after one year of sport specific training, and that there are no differences in bone development between non-osteogenic sports groups and controls. Chapters 8 and 9 indicate that a 9-month jumping intervention programme can improve bone outcomes only in male adolescents participating in swimming and cycling (4 to 13 %), but not in those engaged in football, while it can improve fitness outcomes in all 4 groups (4 to 8 %). Collectively, the present thesis contributes to the literature by providing novel evidence in adolescent male athletes on the effects of popular sports such as football, swimming and cycling on bone status and development, and that a jumping intervention programme can improve bone development in those involved in non-osteogenic sports.

Vertebral fragility fractures are common, affecting approximately 50% of all postmenopausal women and 33% of men over the age of 50, and are the most common type of fracture seen in osteoporosis. The management of vertebral fragility fractures in the acute care setting is lacking in standardization, in the use of evidence-based practice, and in addressing the underlying cause of osteoporosis. The purpose of this project was to develop an evidence-based protocol to standardize the care of the vertebral fragility fracture in the acute care setting. This protocol included patient education, fall risk assessment, screening for osteoporosis, and follow up with an osteoporosis clinic for comprehensive management once discharged. This project used the Donabedian model to provide a conceptual framework for evaluating the structure, process, and outcomes related to the practice problem. This quantitative study involved 10 participants that were selected using purposive sampling and used process control charting to show compliance with elements of the guideline, and descriptive data to depict process change. Guideline compliance was measured over an 8-week period and indicated successful implementation of fall risk assessment with a 100% compliance rate and osteoporosis screening with an 80% compliance rate. Compliance with fracture education and securement of follow up were difficult to ascertain in the 8-week period and non-compliance evident. In conclusion, two elements of the guideline showed to be an unstable process and further work is necessary to improve. Positive social change may result from empowering nurses by education and giving them autonomy to use evidence-based practice to decrease the risk for secondary vertebral fragility fractures.

Distal radius fracture (DRF) is one of the most common fall-related osteoporotic (OP) fracture and is an early predictor of subsequent falls and OP fractures among people with DRF. The majority of older people with DRF present with low bone mineral density (BMD) and there is often transition to reduced muscle strength, poor balance, fear of falling and physically inactive lifestyle after fall-related DRF. This thesis consists of three manuscripts which are aimed to explore the recovery patterns and the role of modifiable risk factors in predicting subsequent falls, OP fractures and BMD in patients with DRF. The first manuscript explores the recovery patterns in modifiable risk factors for falls and OP fractures over four years in patients with DRF. Our study findings showed that patients with DRF experienced both short-term (6 months) and long-term (4 years) improvement in fracture specific pain/disability, physical activity, fear of falling, BMD and general health status; although the majority of the recovery was achieved at six months after DRF. The second manuscript is a cross-sectional study identifying modifiable risk factors for BMD in patients with DRF. The unaffected hand grip strength was identified as the independent predictor of BMD explaining 17% and 12% of total variability in the BMD-femoral neck and BMD-total hip, respectively. Among age-stratified women with DRF, balance and unaffected hand grip strength were identified as independent determinants of BMD explaining 10% and 32% of the total variability in BMD-femoral neck among 50-64 year and 65-80 year old, respectively. The third manuscript is a longitudinal study identifying modifiable risk factors for subsequent falls and OP fractures at four years after DRF. The results suggest that nearly 24% of patients reported one or more subsequent falls (in the last six months) and 19% of patients experienced at least one subsequent OP fracture after DRF. Patients with poor balance, low BMD, fracture specific pain/disability of >81 points on patient-rated wrist evaluation questionnaire and presence of a prior history of multiple falls (≥2) had three times higher odds of subsequent falls. When adjusted for BMD, age and gender, only prior falls was identified as a significant independent predictor of subsequent falls. We were not fully powered to explore association of various modifiable and non-modifiable risk factors with subsequent fractures. However, we found that patients with osteopenia or osteoporosis had clinically four times higher odds of subsequent OP fractures than patients with normal BMD. / Thesis / Doctor of Philosophy (PhD) / Wrist fractures are the most common fall-related fragility fractures and often an early indicator of future falls and fractures. This thesis project described recovery patterns in various risk-factors at 4-years after wrist fracture and explored their association with bone mineral density (BMD) and subsequent falls and fractures. We found that the majority of recovery in fracture-specific pain/disability, fear of falling and health-status takes place within six months, although small changes were also noted between 6 months-4 years. People with low unaffected hand grip-strength might have low BMD. Furthermore, people with poor balance, greater fracture-specific pain/disability, osteopenia or osteoporosis and a prior history of multiple falls (≥2) had nearly 3 times higher odds of secondary falls and those with osteopenia or osteoporosis had 4 times higher odds of a secondary fracture. We believe this information will help therapists/clinicians to identify people at risk of future falls/fractures and offer preventive services.

The release of pollutants by the oil sands industry and pulp and paper mills has been an ongoing environmental concern for decades. Such toxins have been linked to declining reproductive and skeletal health in wildlife species, as they have known endocrine disrupting properties that interfere with hormones responsible for proper reproduction and bone development. As such, declining population sizes because of pollutant exposure has been correlated with altered bone health in mammals. For the purposes of environmental monitoring, the development of a biomarker of pollutant exposure would be a beneficial tool to assess pollution impact on wildlife populations. Therefore, the purpose of this research was to identify this biomarker in the American mink based on measures of their bone health. Mink from the Athabasca Oil Sands Region and an area surrounding a pulp and paper mill in Quebec were collected. From each mink, a hindlimb femur and the baculum (for males) were dissected. Bones were evaluated through a series of tests to quantify key cortical and cancellous bone structural and material properties. These included dimensional analysis, three-point bending and micro-Computed Tomography. Toxicology reports of trace element exposure levels in the minks were also provided by ECCC. Principal component analyses and correlation matrices were used to identify potential relationships between the bone metrics and trace element levels, followed by linear regression modeling. Results found that the baculum and femur structural properties were correlated with selenium, rubidium and iron concentrations, suggesting that these elements had the strongest influences on bone health for the mink studied here. This work provides the basis for future research on identifying a biomarker determinant of bone health to be used in environmental monitoring effects programs. The results here indicate that baculum bone measures are dominated by trace element effects rather than loading effects and are thus a useful bone to investigate for biomonitoring programs. This will provide a simple and reliable method for determining whether there are unsustainable levels of pollution in regions across North America. / Thesis / Master of Applied Science (MASc) / Environmental pollution in regions across Canada puts the health of communities and wildlife at risk. To better measure the impact of pollution in these regions, the implementation of a species monitoring program would benefit those communities who are at the greatest risk. Therefore, this research was aimed at developing an indicator of harmful pollution exposure in mink, an abundant species in Canada, by investigating their bone health. A group of mink from Alberta and Quebec were collected and their femur and penile bones tested for a variety of bone health measurements. In addition, information on the heavy metal levels in the mink livers were provided. The bone health measurements and heavy metal levels were then compared to look for any relationships between them. This research found that selenium, rubidium and iron had the strongest effects on bone health. The methods used have set the groundwork for using minks to monitor pollution levels across North America.

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