Research Proposal A comparative study between 2 UK target populations in the 20th Century (mid and end) on the effects

of nutrition and vitanutrient (supplements) intake on Osteoporosis

By Alex Ballard 2008

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Abstract Osteoporosis is a major public health concern because it can lead to debilitating bone fractures. The highest morbidity and mortality rates are associated with osteoporotic hip fractures (Gourlay & Brown, 2004). Patients with Celiac disease are at increased risk for developing osteoporosis. The causative factors for osteoporosis are unknown in Celiac disease patients however several studies have demonstrated calcium malabsorption resulting in compensatory hyperparathyroidism (Scott, Gaywood, & Scott, 2000). The problem of Osteoporosis can be overcome through effective dietary control and supplementary nutrition. Several nutrients including calcium, phosphorus and protein have been shown to affect bone mass. Several studies (Baran et al. (1990; Bonjour et al., 1997; Dawson-Hughes, Harris, Krall, & Dallal, 1997 ) have demonstrated a close association supplementary nutrition and lowered bone mass loss in the spine. For example, a study looking at men and women over the age of 65 years placed subjects on 500 mg calcium citrate and 700 IU vitamin D3 for 3 years and found significant reductions in BMD loss versus controls at the spine, femoral neck and total-body after 1 year of supplementation. Total-body BMD difference remained significant between groups for both the 2nd and 3rd years (Dawson-Hughes, Harris, Krall, & Dallal, 1997). The purpose of this study is to conduct a comparative study between 2 UK target populations in the 20th Century (mid and end) on the effects of nutrition and vitanutrient (supplements) intake on Osteoporosis. For this purpose, a Meta analysis research method is used to analyze previous studies and researches on the topic.

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Table of Contents
Table of Contents....................................................................................................... 3 CHAPTER I: INTRODUCTION .......................................................................................4 1.1 Background ...................................................................................................... 4 1.2 Problem Statement ...........................................................................................5 1.3 Hypothesis ........................................................................................................6 Alternative Hypothesis.........................................................................................6 Null Hypothesis.................................................................................................... 7 1.4 Objectives .........................................................................................................7 Broad objectives ..................................................................................................7 Specific objectives ...............................................................................................7 1.5 Significance of the study...................................................................................7 CHAPTER II: REVIEW OF LITERATURE..........................................................................9 2.1 Introduction ...................................................................................................... 9 2.3 Risk factors .....................................................................................................12 2.4 Signs and symptoms ......................................................................................13 2.5 Manifestations of osteoporosis .......................................................................14 2.6 Prevention and management of Osteoporosis ................................................16 2.7 Diagnosis and Treatment of Osteoporosis ......................................................17 CHAPTER III: RESEARCH METHODOLOGY .................................................................25 Introduction .......................................................................................................... 25 Participants ..........................................................................................................25 Instrument ............................................................................................................25 Data collection......................................................................................................26 Data analysis......................................................................................................... 26 Ethical consideration.............................................................................................27

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CHAPTER I: INTRODUCTION 1.1 Background Osteoporosis is a skeletal disorder characterized by compromised bone strength, predisposing an individual to an increase risk of fracture (National Institute of Health [NIH], 2000). The World Health Organization adds to the above definition and defines osteoporosis as a bone mineral density value more than 2.5 standard deviations below the mean for normal young white women (World Health Organization [WHO], 2003). The most common sites of fractures are at the spine, wrist, and hip where trabecular bone predominates. In individuals with osteoporosis, the bands or plates of the trabecular bone become thin and weakened (USDHHS, 2004). The most common form of osteoporosis is primary osteoporosis. Primary osteoporosis is not caused by specific disorders; it is mainly a disease of the elderly and is also referred to as age-related osteoporosis (Seeman, 2003). It characteristically begins early in life when corrective action might slow down disease progression. Women are at two to three times higher risk than men for primary osteoporosis. The rapid phase of bone loss at menopause due to loss of estrogen is the rationale behind the difference in prevalence between genders. (Riggs, Khosla, & Melton, 2002). Osteoporosis can develop in many ways. Some of the most important means that may lead to osteoporosis are as follows: genetics, lifestyle, nutrition, calcium and vitamin D deficiency, and decrease in sex hormone production (USDHHS, 2004). Corrective action must be taken through such changes as diet and physical activity to potentially slow down bone loss which may lead to osteoporosis (Riggs, Khosla, & Melton, 2002). For women, the rapid phase of
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bone loss occurs around the time of menopause (Raisz & Rodan, 2003; Riggs, Khosla, & Melton, 2002) and then a slower continuous phase of bone loss continues throughout the rest of life (Riggs, Khosla, & Melton, 2002). Both the rapid phase and slow phase of bone loss are a result of estrogen deficiency. Bone formation also begins to decrease with age which causes an imbalance between bone resorption and bone formation. This imbalance leads to structural abnormalities, thinning of the cortical outer shell and damage to the trabecular bone structure, that make the skeleton fragile (Ahlborg, Johnell, Turner, Rannevik, & Karlsson, 2003). 1.2 Problem Statement Osteoporosis is a major public health concern because it can lead to debilitating bone fractures. The highest morbidity and mortality rates are associated with osteoporotic hip fractures (Gourlay & Brown, 2004). Patients with CD are at increased risk for developing osteoporosis. The causative factors for osteoporosis are unknown in this population however several studies have demonstrated calcium malabsorption resulting in compensatory hyperparathyroidism (Scott, Gaywood, & Scott, 2000). Multiple studies such as those by McFarlane, Bhalla, and Robertson (1995) and Pistorius et al. (1995) show reduced bone mineral density (BMD) in celiac patients when compared to controls. Several dietary nutrients affect BMD. Teegarden et al. (1998) found that spine BMD was correlated to energy, protein, calcium and phosphorus intake. Current Dietary Reference Intakes (DRI) for both men and women, 19-50 years of age recommend an Adequate Intake (AI) for calcium of 1,000 mg/d and 1,200 mg/d for those older than 50 years. The AI for vitamin D is 5 meg/day for men and women between 19-50 years of age and 10 meg/d for 50-70 year olds. The Recommended Daily Allowance (RDA) for phosphorus for those greater than 19 years and older

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is 700 mg/d (Institute of Medicine, Food and Nutrition Board of the National Academies, 2006). Adherence to a GFD is crucial to ensure all these bone important nutrients are absorbed. Exercise is another factor which has been proven to affect BMD. Several studies have shown that activities, especially those incorporating weight-bearing, such as tennis, stairclimbing, jogging, jumping and other resistance exercise, can help preserve bone mass (Kohrt, Bloomfield, Little, Nelson, & Yingling, 2004). The appropriate mode, intensity, frequency and duration of exercise can help maximize BMD before reaching peak bone mass and decrease the rate of bone loss after this time (Kohrt et al.). These modalities are helpful in prevention of osteoporosis and fractures. In the United Kingdom, the supplement food has been used for overcoming the bone degeneration and the Osteoporosis. However, there is no study available examining the impact of supplement food on Osteoporosis. This study aims to fill this gap by examining the supplement food patterns among the 2 UK generations: the mid 20th century population and the end 20th century population. The study will examine the food patterns and their vulnerability to Osteoporosis in order to examine if the supplement food could contribute positively for preventing the disease. 1.3 Hypothesis This study will attempt prove the following hypotheses. For this study, it is hypothesized that the population of end 20th century has better dietary practices and better supplements than the population of mid 20th century UK. Alternative Hypothesis H0: There is strong association between supplementary nutrition and lowered bone mass loss in the spine.
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Null Hypothesis H1: There is no association between supplementary nutrition and lowered bone mass loss in the spine. 1.4 Objectives Osteoporosis is a disease that is incurable and remains prevalent in our society. Those with CD are at increased risk of developing osteoporosis and osteoporotic fractures (Scott et al., 2000). Several studies show a positive correlation of physical activity and BMD over a 1 year period in healthy populations (Vainionpaa, Korpelainen, Leppaluoto, & Jamsa, 2004). Even though incidence of osteoporosis and CD can be high, up to 47% in women and 50% in men with adult diagnosed treated CD, disease specific recommendations on prevention and treatment are scant (McFarlane, Bhalla, Reeves, Morgan, & Robertson, 1995). Broad objectives The objective of this project is to conduct a comparative study between 2 UK target populations in the 20th Century (mid and end) on the effects of nutrition and vitanutrient (supplements) intake on Osteoporosis and provide an informational regarding the impact of positive lifestyle modifications on bone health. Specific objectives The specific objective of this study is to analyze the impact of dietary intake on the bone degeneration and the Osteoporosis. 1.5 Significance of the study Previous studies have demonstrated a close association of nutritional deficient and degeneration of bones. Nutritional deficiencies may occur if other dietary restrictions exist due to additional food intolerances, sensitivities or genetic disorders requiring food avoidance. Soy and egg intolerance have been reported in patients with CD (Kupper, 2005). In this context, it is
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imperative to examine the patterns of supplementation food intakes and its results on Osteoporosis among two different populations of the UK so as to compare the differences of food intakes and its impact on their Osteoporosis. Thus, this study will contribute significantly to the academic knowledge as well as the practitioners.

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CHAPTER II: REVIEW OF LITERATURE 2.1 Introduction Osteoporosis is defined by the National Institutes of Health (2007) as a skeletal disorder characterized by compromised bone strength, predisposing to an increase risk of fracture. Osteoporosis is a serious public health concern that affects both men and women. It is more common in Caucasian women but is a growing concern for men and other ethnicities (Tung & Lee, 2006). It is estimated that ten million individuals have osteoporosis and another thirty-four million suffer from low bone density (NOF, “America’s Bone Health,” 2002). By 2020, approximately sixty-one million individuals will have osteoporosis or low bone density (NOF, “America’s Bone Health,” 2002). As bone strength decreases, the risk of fractures increases. Bone tissue is a distinctive form of connective tissue. However, unlike other connective tissues the extracellular material of bone is hard and calcified. Bones fall into four different classifications: long, short, flat, and irregular. Long bones make up the forearm, and short bones are found in the wrist. The irregular bones consist of the hip bones and vertebrae. These three classifications house the majority of fractures related to osteoporosis (Thibodeau & Patton, 2007). Two basic types of bone exist, each with a different role and function. Corticol (compact) bone is found on the outer surface of long bones. Spongy (cancellous) bone is present at the ends of the long bones and in the axial skeleton (Lundon, 2000). Cortical bone is tightly packed; therefore, it serves significant mechanical and protective functions. It serves 80%-85% of the human skeleton. Cortical bone volume is regulated by bone

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formation or resorption on the endosteal and periosteal surfaces and by remodeling within the haversian systems. Cortical bone is removed in metabolic bone and during the aging process primarily by endosteal resorption and resorption within the haversian canals. The endosteum is a thin membrane that lines the marrow cavity and the internal spaces in the spongy bone of the epiphysis (ends of long bone) (Lundon, 2000). The periosteum lines the outer surface of the cortical bone. The periosteum and the endosteum play critical roles in the maturing skeleton and in the fracture healing process. However, the overall effect of reduced bone volume seen with age is linked to endosteal resorption (Lundon, 2000). The haversian systems are the microscopic unit of cortical bone (Herliny & Maebius, 2003). Each haversian system consists of mature osteocytes arranged in concentric circles around large blood vessels. The cortical bone consists of many parallel haversian systems (Lundon, 2000). Spongy bone constitutes about 20% of total bone mass, but it does not contain haversian systems. Instead, it consists of needlelike bony spicules called trabeculae. The trabeculae are separated by irregular spaces or holes. The spaces are important because they help decrease the weight of the bone, and they contain red bone marrow (Herliny & Maebius, 2003). The spongy bone is located between two layers of cortical bone which define the shape of the bone. The trabecular network provides a large bone surface for mineral exchange and helps maintain skeletal strength and integrity. It is abundant in the spine and at the ends of long bones. These sites are under continuous stress (Kontulainen, Sievanen, Kannus, Pasanen, & Vuori, 2003).

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The composition of the mineral and matrix, the structure of the trabecular bone, the porosity of the cortical bone, the presence of micro-fractures, and other damage to bone are all important in determining bone strength. These determining factors could be due to an imbalance between bone resorption and bone formation. There also may be excessive bone breakdown by the osteoclasts. The decrease in bone health is caused by many risk factors which will be discussed later in this chapter (USDHHS, 2004). The most common form of osteoporosis is primary osteoporosis. Primary osteoporosis is not caused by some other specific disorder (USDHHS, 2004). It is mainly a disease of the elderly. Primary osteoporosis is also referred to as age-related osteoporosis. This type characteristically begins early in life when corrective action might slow down the disease. At this point, corrective action could be taken to slow down its course. Women are two to three times more at risk than men. This is mainly because of the rapid phase of bone loss at menopause (USDHHS, 2004). This rapid phase begins at menopause and lasts from four to eight years. This phase occurs because of the notable decline in estrogen production by the ovaries at menopause. This loss of estrogen increases bone resorption. This increase in bone resorption coupled with the decline in bone formation leads to damage in the trabecular bone structure and thinning of the bone’s outer shell (USDHHS, 2004). These years are followed by a slower, permanent phase that lasts the remaining years of life (Riggs, Khosla, & Melton, 2002). However, men go through only the deliberate, continuous phase which accounts for the increased bone loss in women versus men. The continuous phase of bone loss in both men and women is caused by a combination of factors comprising a decrease in calcium and vitamin D intake, age-related

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impairment of bone formation, a decrease in physical activity, and a loss of estrogen’s positive effects on calcium balance (USDHHS, 2004). 2.3 Risk factors CD, also known as celiac sprue (CS), is a malabsorption disorder that affects the mucosa of the small intestine (Westerberg et al., 2006). With a prevalence approaching 1% of the population, this disease manifests itself in genetically susceptible individuals who consume gluten found in wheat, barley, rye and their derivatives (Green & Cellier, 2007). Gluten is referred to as the prolamin and glutelin proteins of grains. Although all cereal grains contain gluten (prolamin and glutelin), it is the different amino acid sequences found within these proteins of the wheat species that elicits a response in those with CD. The prolamin portion of wheat is referred to as gliadin, in rye as secalin and in barley as hordein. It is not confirmed whether the prolamin protein, avenin, in oats affect those with CD. However there is evidence that some individuals are affected and therefore oats are limited in the diet (Gendel et al., 2008). Typically oats are excluded from the diet due to the high risk for cross-contamination of other gluten-containing grains in the manufacturing process. If a pure form of oats are purchased from a gluten free vendor they are allowed in moderate amounts. Based on current studies it appears that a moderate amount of 50-70 g/d is tolerated in most CD pts (Gendel et al.). Celiac disease does not have a uniform clinical picture, therefore diagnosis can be difficult. Signs and symptoms vary among individuals and therefore CD is often misdiagnosed. For example, many people with CD had been previously diagnosed with irritable bowel syndrome (IBS) because the signs and symptoms of both IBS and CD are very similar. Those living with a silent form of CD may remain asymptomatic despite gluten consumption and may go on for years before a sign or symptom is revealed (Gendel et al., 2008). Diarrhea,
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constipation, failure to thrive, peripheral neuropathy, persistent fatigue, iron deficiency anemia, osteoporosis and growth failure are some other signs and symptoms of CD (Westerberg et al., 2006). Since CD is more prevalent in those with other auto-immune disorders such as type 1 diabetes and those with Down's syndrome, screening for CD in these patients is becoming more commonplace yielding an increasing number of early diagnosed patients (Hill et al., 2005; National Institutes of Health, 2005; Westerberg et al.). Today's serologic tests such as IgA , antiendomysial (EMA), IgA anti-tissue transglutaminase (IgA-TTG), and newly developed IgA deamidated gliadin peptides (IgA DGP) have good predictive values for CD but are not considered the gold standard for diagnosis (Cardenas & Kelly, 2002). Since intestinal changes in the distal duodenum can be patchy due to the nature of CD, it is possible that a biopsy can be negative. ESPGHAN guidelines recommend toconsider a repeat biopsy, review pathology and to check for human leukocyte antigen (HLA) typing, a type of gene testing, if a biopsy is negative despite being symptomatic and having positive serologic tests (Hill et al.). 2.4 Signs and symptoms The only cure for CD is a lifetime GFD to prevent the clinical and pathological complications of the disease. Literature reviews show that an intake of gluten from 10- 100 mg/day appears safe, with less than 10 mg/d being recommended for those younger in age or those more gluten sensitive (Hischenhuber et al., 2006). Gluten-free products are becoming more available on the market. Currently these products are considered gluten-free if they contain less than 200 ppm of gluten, however, this limit is being revisited with a potential of changing to a stricter limit of 20 ppm (Hill et al., 2005). Typically those following a strict GFD can expect to experience resolution of symptoms within weeks of starting the diet, however complete resolution of the mucosal integrity may take
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up to 2 years (Niewinski, 2008). In a study conducted by Abdulkarim, Burgart, See, and Murray (2002), 49 patients that did not respond to a GFD were identified. Of these 49 patients over 50% were found to have unintentional gluten contamination upon a detailed dietary review with an experienced dietitian. A complete lack of dietary adherence is reported in 6% to 37% of children diagnosed with CD (Hill et al., 2005). Management of CD requires a thorough education on how to live gluten-free. A consensus statement by National Institutes of Health (NIH) identified six key fundamentals in successful gluten-free living. Two of the six recommendations encouraged consultation with a knowledgeable dietitian and becoming educated about the disease (National Institutes of Health, 2005). Several studies have reported an unbalanced intake of macronutrients in those eating gluten-free with a larger percentage of calories coming from fat and less from carbohydrates (Bardella et al., 2000; Kupper, 2005). A consultation with a skilled dietitian can provide a nutritional analysis of current intake to help identify any imbalances in the diet. A study conducted by Ciacci, Cirillo, Cavallara, and Mazzacca (2002) looked at a cohort of men and women with CD who had been following a gluten-free diet for a minimum of 2 years. They found that intestinal damage and dietary compliance were significantly predicted by baseline education. Meeting with a knowledgeable dietitian can help prevent accidental consumption of gluten, create a healthy and balanced diet, improve dietary compliance and prevent nutritional deficiencies. 2.5 Manifestations of osteoporosis Maintaining a gluten-free diet can be difficult and confusing to the new CD patient. In 2006 the Food Allergen Labeling and Consumer Proctection Act (FALCPA) was enacted. This law mandated that if a product contained one of the eight main allergens (milk, egg, fish,
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crustacean shellfish, tree nuts, wheat, peanuts and soybeans) it must be declared on the product label as stated by FALCPA (Gendel et al., 2008). Several methodologies exist however the best methodology appears to be the R5 Elisa analysis. This method is endorsed by the Codex Alimentarius and is being considered by the FDA. There are two important drawbacks to consider when using this test. The first drawback is that the prolamin content in barley contaminated foods can be overestimated. The second drawback is that the test cannot quantify hydrolyzed gluten from wheat starch coming from such ingredients labeled as wheat-based dextrin, maltodextrin or glucose syrup. Although the second drawback may seem significant it is important to remember that the protein content of hydrolyzed wheat starches are generally very low and therefore underestimation of gluten in these hydrolysates is "likely to be small" (Thompson & Mendez, 2008). Until the FDA's final rule is decided upon and enforced, there remains a noteworthy risk in the hidden consumption of gluten in packaged and processed foods. Another hidden source of gluten is found through cross-contamination of food. A product can be contaminated at any point in the processing of food from farm to the table. For example, if shared equipment in a processing plant is not cleaned thoroughly between gluten and glutenfree containing grains, residual gluten found on machinery can contaminate a gluten-free grain (Gendel et al., 2008). Also, cross-contamination can frequently occur when dining out if food service workers do not clean utensils and food production areas carefully. Based on a 2006 National Restaurant Association Industry fact sheet, the average American eats out 4.2 meals/week. A survey showed that, out of 253 U.S. adults with CD, 86% felt negatively about eating out (Parrish, 2006). Since eating out poses a risk for gluten consumption and/or contamination, the National Restaurant Association is one organization that has helped to solve
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this problem by increasing awareness of CD and gluten-free eating through education of restaurants and food service workers (Parrish). Following a strict GFD is the only cure for CD. Since management of this disease can be difficult at times, the NIH (2005) identified six key areas important in the management of CD using the acronym CELIAC: “Consultation with a skilled dietitian; Education about the disease; Lifelong adherence to a gluten-free diet; Identification and treatment of nutritional deficiencies; Access to an advocacy group; and, Continuous longterm follow-up by a multidisciplinary team” (p. S4). Long term monitoring is important as treatment may change. Nutritional status generally improves with mucosal recovery and most if not all abnormal biochemical indices at diagnosis are normalized within 1 year of a GFD (Niewinski, 2008). 2.6 Prevention and management of Osteoporosis Several nutritional deficiencies can be present with an individual diagnosed with CD. The proximal small intestine is an area where many nutrients are absorbed and is also the primary site of inflammation in those with CD (Barton et al., 2007). Recognition and correction of nutritional deficiencies have been identified by NIH as important elements in CD management. They recommend screening for deficiencies such as calcium, phosphorus, iron, folate, vitamin B12, fat-soluble vitamins and for osteoporosis (National Institutes of Health, 2005). Iron, folate, calcium and fat-soluble vitamins are the most commonly found nutritional deficiencies (See & Murray, 2006). Since each of these nutrients are absorbed in area of potential inflammation of the small intestine, itmakes sense that these nutrients can show up deficient in a person with CD (Barton et al.). A study conducted by Hallert et al. (2002) looked at 30 adults with CD who had been following a GFD for 10 years and were in remission evidenced by repeat biopsy. These
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researchers found that the mean daily intakes for folate and vitamin B12 were lower than controls and that plasma levels of folate and vitamin B6 were low in 20% and 37% of those with CD respectively. In another investigation looking at the nutritional status of adolescents and young adults with biopsy-proven celiac disease found that one third of those first diagnosed had low serum folate levels (Haapalahti et al., 2005). Kemppainen et al. (1998) compared the nutritional status of subjects based upon grade of villous atrophy and found that the only major difference between those with total versus partial villous atrophy were a lower serum folate and iron at diagnosis. According to a survey from 1989 to 1991, completed by the U.S. Department of Agriculture, Americans receive about 30% of dietary folate and about 40% of dietary iron from carbohydrate-rich foods such as cereal, yeast bread and pasta. A study compared gluten-free products to their gluten containing equivalents and found the majority of them were not fortified and contained less folic acid and iron (Thompson, 2000). The folic acid content of a GFD may be reduced if a large percent of calories are coming from gluten-free cereal products, breads and pastas. With this in mind, it is advised to supplement the diet with folic acid at the beginning stages of CD until mucosal recovery is established and to monitor serum levels for determination of continued needed supplementation (Barton et al., 2007). 2.7 Diagnosis and Treatment of Osteoporosis Patients with celiac disease may have inadequate intakes of calcium, vitamin D and phosphorus. Kinsey, Burden, and Bannerman (2008), looked at 49 British patients with celiac disease who completed a 3 day food diary and found that vitamin D intake was significantly lower than the general population. Calcium, phosphorus and vitamin D rich milk products are often omitted from the GFD in the beginning stages due to lactose intolerance. Lactose
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intolerance results from decreased lactase availability secondary to damaged intestinal villi and generally improves as intestinal health is restored; however, in some cases some patients with CD remain lactose intolerant (Niewinski, 2008). A study looking at 54 patients from Italy who tested positive for lactose intolerance were screened for celiac disease. Twenty-four percent of these patients had positive serologic markers for CD and were confirmed via biopsy (Ojetti et al., 2005). Calcium and vitamin D requirements for those with CD are the same as for healthy individuals, and only if deficiencies are noted then supplementation is recommended (See & Murray, 2006). A calcium supplement containing 1,000-1,500 mg/d for adults may be recommended if the diet appears deficient in calcium (Schuppan, Dennis, & Kelly, 2005). If vitamin D deficiency exists recommendations for adult supplementation are 50,000 IU of vitamin D orally for 8 weeks (Barton et al., 2007). Further nutritional deficiencies may occur if other dietary restrictions exist due to additional food intolerances, sensitivities or genetic disorders requiring food avoidance. Soy and egg intolerance have been reported in patients with CD (Kupper, 2005). Also, one study found a prevalence of CD in up to 10.5% of those with confirmed hereditary fructose intolerance. This finding is comparable to the incidence of other CD associated disorders such as Down's syndrome (5-12%; Ciacci et al., 2006). More studies are needed to establish if a true association exists between hereditary fructose intolerance and celiac disease. Osteoporosis is associated with a high morbidity. About 50% of women aged greater than 50 years will experience a fracture due to osteoporosis in their lifetime (Singer 2006). Bone mineral density is used to diagnose osteoporosis using a T score from dual-energy X-ray absorptiometry (DXA). The World Health Organization (WHO) has defined osteoporosis as a T score that is equal or less than -2.5 and osteopenia as a score between -1 and -2.5 (Semrad,
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2000). Lindh, Ljunghall, Larsson, and Lavo (1992) found a tenfold higher incidence of CD in patients with idiopathic osteoporosis as compared to a healthy population. CD is now considered a risk factor for osteoporosis and routine screening has been proposed in those with idiopathic osteoporosis (Bianchi & Bardella, 2008). There is a large prevalence of decreased bone mass in those with CD. Up to 70% of those with CD have been reported to have a low BMD. The true etiology of bone disease in those with CD has not clearly been identified. Researchers believe impaired absorption and the release of proinflammatory cytokines may be two viable explanations (Bianchi & Bardella, 2008). With aging, bone reabsorption exceeds formation and is influenced by many factors such as hormones, diet, cytokines, malabsorption and wear and tear (Semrad, 2000). Peak bone mass is generally reached by age 30 where formation and reabsorption are equal (Semrad). Although BMD generally improves in adult diagnosed CD after the initiation of a GFD, several studies have shown that BMDvalues may never completely normalize. Theories include failure to reach peak bone mass secondary to silent celiac disease as a child, poor compliance to a GFD and continued inflammation despite strict adherence to a GFD (Semrad). Kemppanen et al. (1999) researched the prevalence of bone disease in 77 adult CD patients and 157 controls and suggested that celiac disease is a risk factor for osteoporosis. This study included both newly and previously diagnosed subjects with CD. In those previously diagnosed, there were 7 women who had not responded to a GFD for over 12 months. Up to one fourth of CD subjects (26%) and only 5% of the controls were defined as having osteoporosis at the lumbar spine. Metabolic bone disease was statistically significant at the femoral neck in those with CD that were not in remission as compared to those newly diagnosed or in remission (p = 0.001). Low vitamin D levels, as assessed by serum 25-hydroxy vitamin D, were found in the
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majority of CD subjects. Researchers found that in both males and females low serum vitamin D levels and low body weight were both significant variables related to low BMD. Menopausal status in women was significantly correlated to BMD. McFarlane et al. (1995) identified similar risk factors in those with CD as found by Kemppanen et al. (1999). Menopausal age, low body mass index (BMI) and low calcium intake were all significantly correlated to low BMD. This study by McFarlane et al. (1995) included subjects diagnosed with celiac disease as an adult, after age of peak bone mass accretion. This study showed a significant negative correlation between rate of BMD change at the lumbar spine and years on the gluten-free diet. After a year on the diet, the Z-score change was 0.26 for men and 0.07 for women in the lumbar spine. Authors attribute the largest gains in Z-score in those newly diagnosed with CD. A studyconducted by Bai et al. (1997) found a similar significant mean annual bone remineralization of 0.4 Z-score/year in the lumbar spine. This study consisted of 25 newly diagnosed adult subjects with CD followed over 37 months on a GFD. Patients were grouped into strict or partial groups based on dietary compliance to the GFD. Compliance was confirmed by a diet inquiry performed by a gastroenterologist (not a registered dietitian), by the family's views of patient compliance, by clinical status and by lab results. Although the researchers found a greater increase in mean annual change in Z-score in total skeleton in the strict group than the partial group, it was not statistically significant. Pistorius et al. (1995) looked at 81 women with celiac disease. Healthy controls were matched by height, weight and menopausal status. BMD was significantly lower in the celiac group than the control group in both the femoral neck and spine. When stratified by menopausal status, those women who were postmenopausal had BMDs significantly lower than controls in the femoral neck and spine, but premenopausal celiac patients had only significantly lower BMD
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in the femoral neck. This study included subjects on the GFD for less than 1 year and adherence of diet was per verbal report. Multiple regression analysis was performed showing no significant difference between diet and BMD. McFarlane et al. (1996) found similar results between adult celiac patients and controls. Subjects had BMDs measured at the beginning and end of a 12-month period following a GFD. BMD was significantly improved in femoral neck and spine of celiac patients however still remained lower than matched controls. Fiore et al. (2006) looked at bone turnover in 32 adult premenopausal women on a GFD to age matched controls. Calcium intake was obtained through a food frequency questionnaire. Mean BMD was significantly lower in both the femoral neck and spine than the controls. There was no significant difference between weight, calcium intake or physical activity. Subjects had been following a gluten free diet a mean of 2.9 years. Pazianas et al. (2005) looked at calcium intake, absorption and BMD in adult females with celiac disease compared to age-matched and sex-matched controls. BMD was significantly lower in whole body, spine and trochanter in those with CD versus controls over 4 years of being on a GFD. However, protein intake was significantly higher in celiac subjects with a mean of 86 grams per day, subject weights were not provided. Also, parathyroid hormone (PTH) levels showed a significant inverse relationship with duration of the gluten-free diet. This study found that even after 4 years calcium intake was significantly higher in celiac subjects (1129 mg/d) than controls (829 mg/d) but fractional calcium absorption was significantly lower in celiac subjects than controls. Although it is known that calcium absorption varies inversely with intake, the authors were unsure if the difference between groups was large enough to be explained.

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Valdimarsson, Toss, Lofman, and Strom (2000) looked at the relationship between abnormal PTH levels and celiac disease at time of diagnosis and 3 years later. Out of 105 celiac subjects 28 (27%) were found to have secondary hyperparathyroidism (SHPT). Those with SHPT had lower vitamin D levels (25-hydroxy vitamin D), lower BMD values and an intestinal integrity that remained more compromised than those without SHPT. BMD values were significantly lower than normal in the spine, hip and forearm of those with initial SHPT even after a 3-year GFD commitment. Those withSHPT on calcium and vitamin D supplements had a higher BMD increase than those not on supplements. Verbal dietary noncompliance was reported in 2 of the 105 subjects. It is questionable if true dietary compliance was established in the rest of the subjects as authors did not describe any additional parameters used to ensure that unintentional gluten intake did not occur. Several nutrients including calcium, phosphorus and protein have been shown to affect bone mass. Baran et al. (1990) conducted a 3 year randomized study looking at increased calcium intakes from 900 mg to 1,500 mg/d using dairy products in premenopausal women. Women with the 600 mg increase in daily calcium intake showed a significantly lowered bone mass loss in the spine than those who did not increase calcium intake. A randomized, doubleblind, placebo-controlled trial looked at 149 healthy prepubertal girls by placing them in a calcium supplemented food group (850 mg) or a placebo food group. After 1 year, increases in BMD were greatest in thecalcium supplemented group at the radial and femoral sites (Bonjour et al., 1997). Another study looking at men and women over the age of 65 years placed subjects on 500 mg calcium citrate and 700 IU vitamin D3 for 3 years and found significant reductions in BMD loss versus controls at the spine, femoral neck and total-body after 1 year of

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supplementation. Total-body BMD difference remained significant between groups for both the 2nd and 3rd years (Dawson-Hughes, Harris, Krall, & Dallal, 1997). Calcium intake among U.S. adults generally fall short of the DRIs. A review by Briefel and Johnson (2004) looked at data from the 1999-2000 National Health and Nutrition Examination Survey (NHANES) as compared to NHANES I (1971-74), NHANES II (1976-80) and NHANES III (1988-94). Mean calcium intake from food fell short of the AI for calcium in adult males and females with all 4 surveys. When calcium intake from supplements and antacids were added to calcium intake from food using the NHANES III data mean calcium intake continued to fall short of recommendations. Several studies have looked at the significant assosication between vitamin D intake and the reduced risk of osteoporosis. Vitamin D helps improve intestinal absorption of both calcium and phosphorus. Most of circulating serum 25(OH)D comes from vitamin D3, cholecalciferol, that has been activated by UVB light. However, with increasing concerns of skin cancer and use of suncreens, adequate vitamin D from sun exposure has become more difficult to obtain. Although food fortification in the US has proven to raise vitamin D intake by 2-3 mcg/d it is only applicable in those with adequate milk consumption (Calvo, Whiting, & Barton, 2005). Low vitamin D levels, specifically serum 25(OH)D, have been associated with decreased bone mineral density. A study looking at elderly women found that levels of 25-hydroxy vitamin D were positivelyassociated with BMD. Authors concluded that low levels of circulating 25hydroxy vitamin D were related to increased bone turnover (Ooms et al., 1995). Calcium and vitamin D taken together have been shown to increase BMD. For 2 years, 240 healthy women aged 58-67 years took 1,000 mg elemental calcium in the form of calcium

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carbonate and 14 meg of vitamin D3. Participants had a baseline dietary intake of 919 mg Ca/d and 3.8 meg of vitamin D/d obtained through a dietary questionnaire. After 2 years, lumbar spine BMD was significantly higher in the treatment group by 1.6% (Baeksgaard, Andersen, & Hyldstrup, 1998). A balance of calcium and phosphorus is needed to optimize bone integrity. Elevated phosphorus intake can cause an increase in parathyroid hormone (PTH) which can lead to suppressed calcium absorption. Calvo, Kumar, and Heath (1990) showed an significant increase in PTH secretion with a high phosphorus (1700 mg/d) and low calcium (400 mg/d) diet taken for 28 days in young women. The authors suggested that a dietary intake that was low in calcium and high phosphorus can alter calcium-regulating hormones and therefore affect optimal bone health.

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CHAPTER III: RESEARCH METHODOLOGY Introduction As stated in the introduction of this study, the main aim of this study is to examine the dietary patterns and styles of two mid-20th century and end-20th century UK populations. For this purpose, a descriptive, comparative study design will be used to compare the two populations. Study variables will be included osteoporosis knowledge, self-efficacy for nutrition and exercise, physical activity, quality of life and demographics. Participants Using sequential recruitment, thirty eight older men and women will be admitted a tertiary care centre with a unilateral hip fracture, resulting from a fall from a standing height or less, that meet inclusion and exclusion criteria of voluntarily enrolled in the study. Participants will be required to ensure they understand the survey questions and competent to answer all questions. The convenience sample for such studies is representative of the 3:1 ratio of hip fractures that occur in men and women (Lau, 2004; Wilens, 2005). Sample size will be determined by statistical calculations based on admission to the tertiary care centre in the previous year. Instrument Osteoporosis Knowledge test: The Osteoporosis Knowledge Test (OKT), developed by Kim, Horan, and Gendler (1991) is a 24 item, multiple choice questionnaire to test knowledge and facts about osteoporosis. Possible score range from 0 to 24. Items include questions on relationship of activity levels, exercise, and dietary intake of calcium to osteoporosis prevention (Sedlak et al., 2000). For the present study, the instrument will be modified for men and

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postmenopausal women by removing two items specifically related to female hormones status. This instrument is among the few that has been used in elderly men and women. Health specific self-efficacy scales: in this study, two scales: 1) self-efficacy for nutrition, and 2) physical exercise self-efficacy will be used to measure self-efficacy in participants. These instruments were developed by Schwarzer and Renner and are based on the Social Cognitive Theory. They were developed to assess health specific self-efficacy variables, nutrition and physical exercise. “Health specific self-efficacy is a person’s self-belief about being capable to resist temptations and to adopt a healthy lifestyle” (Schwarzer and Renner, 2000, p. 2). Both scales are brief and contain 5 items Responses range from 1 (very uncertain) to 4 (very certain) and apply to changing or maintaining desired health behaviors. Data collection Data will be collected by the researcher at two time points over the period of 10 months. A face to face interview will be conducted in hospital. Demographic information, pre-hip fracture activity (HAP), functional independence (FIM), osteoporosis knowledge (OKT) and self-efficacy related to nutrition and physical exercise (Health specific self-efficacy scales) data will be collected. Data analysis Data will be analyzed using version 14 of Statistical Package for Social Sciences (SPSS). Descriptive statistics (means, range, standard deviations and Cronbach’s alpha) will be used to describe sample and scale characteristics. Gender differences in means will be tested with the Student’s t-test. Baseline gender characteristics will be compared using Chi square tests. The influence of independent and socio-demographic variables will be tested with Pearson r correlations and backwards multiple regression analysis.

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Ethical consideration Ethics approval will be obtained from the concerned tertiary care centre before initiation of this study. Approval will also be obtained from the tertiary care center to conduct the study. Staff on the orthopaedic units will be informed about the nature of the study and their cooperation will be sought to avoid contamination of data.

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