Fragility fractures are increasingly recognized as a complication of both type 1 and type 2 diabetes, with fracture risk that increases with disease duration and poor glycemic control. The identification and management of fracture risk in these patients remains challenging. This manuscript explores the clinical characteristics of bone fragility in adults with diabetes and highlights recent studies that have evaluated areal bone mineral density (BMD), bone microstructure and material properties, biochemical markers, and fracture prediction algorithms (FRAX) in these patients. It further reviews the impact of diabetes drugs on bone tissue as well as the efficacy of osteoporosis treatments in this population. An algorithm for the identification and management of diabetic patients at increased fracture risk is proposed.
UNASSIGNED: Diabetes mellitus und Osteoporose zählen zu den häufigsten chronischen Erkrankungen und kommen deshalb beide häufig in ein und demselben Individuum vor. Da die Prävalenz beider mit steigendem Alter zunimmt, wird in Anbetracht der Altersstruktur unserer Bevölkerung deren Häufigkeit zunehmen.
METHODS: innen mit Diabetes haben ein erhöhtes Risiko für Fragilitätsfrakturen. Die Pathophysiologie ist unklar und vermutlich multifaktoriell.Longitudinale Studien haben den Nachweis erbracht, dass das Fracture Risk Assessment Tool (FRAX) und die Knochendichte (BMD) mittels DXA (T-score) Messungen und einem eventuell vorhandenen Trabecular Bone Score (TBS) das individuelle Frakturrisiko vorhersagen können. Hierfür muss allerdings eine Adjustierung vorgenommen werden, um das Risiko nicht zu unterschätzen.Es gibt derzeit aus osteologischer Sicht noch nicht den optimalen Ansatz, da es keine Studien mit rein diabetischen Patient:innen und Osteoporose gibt.
METHODS: innen mit Diabetes mellitus und einem erhöhten Frakturrisiko sollten genauso wie Patient:innen ohne Diabetes und einem erhöhten Frakturrisiko behandelt werden.Der Vitamin-D-Spiegel sollte auf jeden Fall immer optimiert werden und auf eine ausreichende Kalziumaufnahme (vorzugsweise durch die Nahrung) ist zu achten.Bei der Wahl der antihyperglykämischen Therapie sollten Substanzen mit nachgewiesen negativem Effekt auf den Knochen weggelassen werden. Bei Vorliegen einer Fragilitätsfraktur ist auf jeden Fall – unabhängig von allen vorliegenden Befunden – eine langfristige spezifische osteologische Therapie indiziert.Zur Prävention von Fragilitätsfrakturen sind antiresorptive Medikamente die erste Wahl, entsprechend den nationalen Erstattungskriterien auch anabole Medikamente. Das Therapiemonitoring soll im Einklang mit der nationalen Osteoporose Leitlinie erfolgen.

Chronic kidney disease (CKD) is a highly prevalent condition worldwide in which the kidneys lose many abilities, such as the regulation of vitamin D (VD) metabolism. Moreover, people with CKD are at a higher risk of multifactorial VD deficiency, which has been extensively associated with poor outcomes, including bone disease, cardiovascular disease, and higher mortality. Evidence is abundant in terms of the association of negative outcomes with low levels of VD, but recent studies have lowered previous high expectations regarding the beneficial effects of VD supplementation in the general population. Although controversies still exist, the diagnosis and treatment of VD have not been excluded from nephrology guidelines, and much data still supports VD supplementation in CKD patients. In this narrative review, we briefly summarize evolving controversies and useful clinical approaches, underscoring that the adverse effects of VD derivatives must be balanced against the need for effective prevention of progressive and severe secondary hyperparathyroidism. Guidelines vary, but there seems to be general agreement that VD deficiency should be avoided in CKD patients, and it is likely that one should not wait until severe SHPT is present before cautiously starting VD derivatives. Furthermore, it is emphasized that the goal should not be the complete normalization of parathyroid hormone (PTH) levels. New developments may help us to better define optimal VD and PTH at different CKD stages, but large trials are still needed to confirm that VD and precise control of these and other CKD-MBD biomarkers are unequivocally related to improved hard outcomes in this population.

In a variety of European countries SEM/EDXA based methods are widely used for the measurements and judgements relating thereof regarding asbestos analysis. Most of these methods are used also for other fibrous particles, commonly indicated as Elongate Mineral Particles (EMPs). The span of guidelines reflects the broad use of SEM/EDXA as an analytical method. Guidelines regarding air measurements both for ambient and indoor air are well established. These methods are widely used as is shown in a proficiency testing scheme, organized by the British Health and Safety Executive (HSL) with participants from countries all over Europe and some countries from Asia and Africa. For workplaces a similar guideline with a reduced sensitivity is available, allowing measurements in higher dust concentrations. Features of the methods like analytical sensitivity, detection limits and measurement uncertainty are discussed. For material analysis we apply different analytical methods, using SEM/EDXA as a final step. They are different both in sample preparation and sensitivity. Most of the methods are qualitative or \"semi-quantitative\" and thought for the analysis of commercial asbestos containing products mainly. If quantitative analysis based on EDXA is used for identification other EMPs can be identified as well. An important tool is the morphological impression of the fibers or structures in the SEM in addition. Changes in regulations which may be expected, will modify some of the methods. Especially lowered Threshold Limit Values (TLV\'s) in occupational air measurements are difficult to achieve.

The regular consumption of net acid-producing diets can produce \"acid stress\" detrimental to human health. Alkalizing diets characterized by a negative potential renal acid load (also called low-PRAL diets (LPD)) enjoy uninterrupted popularity. However, the nutritional adequacy of said diets has rarely been assessed in large populations. Using data from the National Health and Nutrition Examination Surveys, we estimated nutrient intake in individuals consuming an LPD and contrasted the results in an age- and sex-specific manner to individuals on an acidifying diet (high-PRAL diet, HPD). Both groups were compared with the daily nutritional goals (DNG) specified in the 2020-2025 Dietary Guidelines for Americans (DGA). Our analysis included 29,683 individuals, including 7234 participants on an LPD and 22,449 participants on an HPD. Individuals on an LPD numerically met more nutritional goals than individuals on an HPD, yet both failed to meet the goals for several nutrients of public health concern (vitamin D and calcium). As opposed to individuals on an HPD, LPD consumers met the DGA recommendations for saturated fat and potassium. Individuals on an LPD consumed significantly more fiber than individuals on an HPD, as well as yielded a more favorable potassium-to-sodium intake ratio.

UNASSIGNED: Chronic kidney disease (CKD): abnormalities of kidney structure or function, present for over 3 months. Staging of CKD is based on GFR and albuminuria (not graded). Osteoporosis: compromised bone strength (low bone mass, disturbance of microarchitecture) predisposing to fracture. By definition, osteoporosis is diagnosed if the bone mineral density T‑score is ≤ -2.5. Furthermore, osteoporosis is diagnosed if a low-trauma (inadequate trauma) fracture occurs, irrespective of the measured T‑score (not graded). The prevalence of osteoporosis, osteoporotic fractures and CKD is increasing worldwide (not graded). PATHOPHYSIOLOGY, DIAGNOSIS AND TREATMENT OF CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER (CKD-MBD): Definition of CKD-MBD: a systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following: abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism; renal osteodystrophy; vascular calcification (not graded). Increased, normal or decreased bone turnover can be found in renal osteodystrophy (not graded). Depending on CKD stage, routine monitoring of calcium, phosphorus, alkaline phosphatase, PTH and 25-OH-vitamin D is recommended (2C). Recommendations for treatment of CKD-MBD: Avoid hypercalcemia (1C). In cases of hyperphosphatemia, lower phosphorus towards normal range (2C). Keep PTH within or slightly above normal range (2D). Vitamin D deficiency should be avoided and treated when diagnosed (1C).
UNASSIGNED: Densitometry (using dual X‑ray absorptiometry, DXA): low T‑score correlates with increased fracture risk across all stages of CKD (not graded). A decrease of the T‑score by 1 unit approximately doubles the risk for osteoporotic fracture (not graded). A T-score ≥ -2.5 does not exclude osteoporosis (not graded). Bone mineral density of the lumbar spine measured by DXA can be increased and therefore should not be used for the diagnosis or monitoring of osteoporosis in the presence of aortic calcification, osteophytes or vertebral fracture (not graded). FRAX can be used to aid fracture risk estimation in all stages of CKD (1C). Bone turnover markers can be measured in individual cases to monitor treatment (2D). Bone biopsy may be considered in individual cases, especially in patients with CKD G5 (eGFR < 15 ml/min/1.73 m2) or CKD 5D (dialysis).
UNASSIGNED: Hypocalcemia should be treated and serum calcium normalized before initiating osteoporosis therapy (1C). CKD G1-G2 (eGFR ≥ 60 ml/min/1.73 m2): treat osteoporosis as recommended for the general population (1A). CKD G3-G5D (eGFR < 60 ml/min/1.73 m2 to dialysis): treat CKD-MBD first before initiating osteoporosis treatment (2C). CKD G3 (eGFR 30-59 ml/min/1.73 m2) with PTH within normal limits and osteoporotic fracture and/or high fracture risk according to FRAX: treat osteoporosis as recommended for the general population (2B). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) with osteoporotic fracture (secondary prevention): Individualized treatment of osteoporosis is recommended (2C). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) and high fracture risk (e.g. FRAX score > 20% for a major osteoporotic fracture or > 5% for hip fracture) but without prevalent osteoporotic fracture (primary prevention): treatment of osteoporosis may be considered and initiated individually (2D). CKD G4-5D (eGFR < 30 ml/min/1.73 m2 to dialysis): Calcium should be measured 1-2 weeks after initiation of antiresorptive therapy (1C).
UNASSIGNED: Resistance training prioritizing major muscle groups thrice weekly (1B). Aerobic exercise training for 40 min four times per week (1B). Coordination and balance exercises thrice weekly (1B). Flexibility exercise 3-7 times per week (1B).
UNASSIGNED: DEFINITION UND EPIDEMIOLOGIE: Chronische Niereninsuffizienz („chronic kidney disease“ [CKD]): Abnormität der Nierenstruktur oder Nierenfunktion für länger als 3 Monate. Stadieneinteilung der CKD anhand GFR und Albuminurie (not graded). Osteoporose: Erkrankung des Skeletts (verminderte Knochenmasse, Störung der Mikroarchitektur) mit erhöhtem Knochenbruchrisiko. Bei einem T‑Score ≤ −2,5 liegt definitionsgemäß eine Osteoporose vor. Bei Auftreten einer Fraktur nach inadäquatem Trauma liegt, unabhängig vom T‑Score, eine manifeste Osteoporose vor (not graded). Die Prävalenz von Osteoporose und osteoporotischen Frakturen sowie die CKD nehmen weltweit zu (not graded). PATHOPHYSIOLOGIE, DIAGNOSTIK UND THERAPIE DER CHRONIC KIDNEY DISEASE – MINERAL AND BONE DISORDER (CKD-MBD): Definition des CKD-MBD-Syndroms: Störung des Kalzium‑, Phosphat‑, Vitamin-D- und Parathormon(PTH)-Haushalts sowie renale Osteodystrophie und vaskuläre Kalzifikation (not graded). Knochenstoffwechsel bei renaler Osteodystrophie: gesteigerter, normaler oder verminderter Knochenumbau möglich (not graded). Regelmäßige Laborkontrollen von Kalzium, Phosphat, alkalischer Phosphatase, PTH und 25-OH-Vitamin D mit Kontrollintervall je nach CKD-Stadium werden empfohlen (2C). Therapieziele bei CKD-MBD: Hyperkalzämie vermeiden (1C) Erhöhtes Phosphat in Richtung Normalbereich senken (2C) PTH im Normbereich bis leicht erhöht halten (2D) Vitamin-D-Mangel vermeiden bzw. beheben (1C) DIAGNOSTIK UND RISIKOSTRATIFIZIERUNG DER OSTEOPOROSE BEI CKD: Densitometrie (mittels Dual Energy X‑ray Absorptiometry [DXA]): Niedriger T‑Score korreliert in allen Stadien der CKD mit höherem Frakturrisiko (not graded). Verdopplung des Frakturrisikos pro Abnahme des T‑Scores um 1 Einheit (not graded). T‑Score > −2,5 schließt eine Osteoporose nicht aus (not graded). Falsch-hohe LWS-KMD-Messergebnisse können unter anderem bei aortaler Verkalkung, degenerativen Wirbelsäulenveränderungen (Osteophyten) oder bei bereits eingebrochenen Wirbelkörpern vorkommen (not graded). FRAX: Anwendung in allen CKD-Stadien orientierend möglich (1C). Knochenstoffwechselmarker: Bestimmung in Einzelfällen zum Therapiemonitoring (2D). Knochenbiopsie: In Einzelfällen, insbesondere bei CKD G5 (eGFR < 15 ml/min/1,73 m2) und CKD G5D (Dialyse) erwägen (2D).
UNASSIGNED: Hypokalziämie vor Einleitung einer spezifischen Osteoporosetherapie ausgleichen (1C) Bei CKD G1–G2 (eGFR ≥ 60 ml/min/1,73 m2): Behandlung der Osteoporose wie für die Allgemeinbevölkerung empfohlen (1A). Bei CKD G3–G5D (eGFR < 60 ml/min/1,73 m2 bis Dialysestadium): primär Behandlung der laborchemischen Zeichen einer CKD-MBD (2C). Bei CKD G3 (eGFR 30–59 ml/min/1,73 m2) mit PTH im Normbereich und osteoporotischer Fraktur und/oder hohem Frakturrisiko gemäß FRAX: Behandlung der Osteoporose wie für die Allgemeinbevölkerung empfohlen (2B). Bei CKD G4–5 (eGFR < 30 ml/min/1,73 m2) und osteoporotischer Fraktur (Sekundärprävention): Osteoporosetherapie individualisiert empfohlen (2C). Bei CKD G4–5 (eGFR < 30 ml/min/1,73 m2) mit hohem Frakturrisiko (z. B. FRAX-score > 20 % für eine „major osteoporotic fracture“ oder > 5 % für eine Hüftfraktur) ohne osteoporotische Fraktur (Primärprävention): Osteoporosetherapie erwägen und ggf. auch einleiten (2D). Antiresorptive Behandlung bei CKD G4–5 (eGFR < 30 ml/min/1,73 m2): Kalziumkontrolle 1 bis 2 Wochen nach Therapiebeginn (1C). PHYSIKALISCH-REHABILITATIVE MAßNAHMEN: Krafttraining großer Muskelgruppen dreimal wöchentlich (1B). Ausdauertraining viermal wöchentlich 40 min (1B). Koordinationstraining/Balanceübungen dreimal wöchentlich (1B). Beweglichkeitsübungen drei- bis siebenmal wöchentlich (1B).

An experiment was conducted to test the hypothesis that increasing levels of a novel phytase increases the apparent ileal digestibility (AID) and apparent total tract digestibility (ATTD) of nutrients in diets fed to young pigs. A negative control (NC) diet based on corn, soybean meal, and canola meal that contained approximately 0.83% phytate (i.e., 0.23% phytate-bound P) was formulated to be deficient in Ca, P, and standardized ileal digestible amino acids (AA). Five additional diets were formulated by adding 250, 500, 1,000, 2,000, or 4,000 phytase units/kg of the novel phytase to the NC diets. Eighteen ileal-cannulated pigs (17.81 ± 1.71 kg) were allotted to a 6 × 3 incomplete Latin square design with six diets and three 11-day periods. There were three pigs per diet in each period; therefore, there were nine replicate pigs per diet. The initial 5 d of each period was considered an adaptation period to the diet. For each period, fecal samples were collected via anal stimulation on days 6, 7, 8, and 9, whereas ileal digesta were collected on days 10 and 11 using standard procedures. Results indicated that the AID of crude protein, indispensable AA, and dispensable AA was increased (quadratic, P < 0.05) as the concentration of microbial phytase increased in the diets. Dietary inclusion of the novel phytase at 1,000 or 2,000 FTU/kg increased the AID of total AA from 73.7% to 79.8%. Increasing levels of microbial phytase increased (quadratic, P < 0.05) the AID of dry matter and minerals (i.e., Ca, P, K, Mg, Cu) in the diets. Likewise, a linear increase (P < 0.05) in the AID of ash and Na was observed as the inclusion level of phytase increased in the diets. Increasing levels of microbial phytase increased (linear, P < 0.01) the AID of gross energy (GE) and starch in the diets. A quadratic (P < 0.05) increase in the ATTD of ash, Ca, P, K, and Cu in experimental diets was observed as the concentration of microbial phytase increased in the diets. The ATTD of Mg and GE also increased (linear; P < 0.05) as concentration of dietary phytase increased. In conclusion, the novel microbial phytase used in this experiment was effective in increasing the AID of dry matter, GE, starch, minerals, and AA, as well as the ATTD of gross energy and minerals in diets formulated to be deficient in Ca, P, and AA.
The effect of microbial phytase on amino acid (AA) digestibility has been inconsistent, but in many experiments, relatively low levels of phytase were used and it is not known if greater concentrations of phytase are needed to increase AA digestibility. A novel consensus bacterial 6-phytase variant has been recently developed, but it is not known if this phytase results in increased digestibility of AA and other nutrients. Therefore, an experiment was conducted to test the hypothesis that dietary inclusion of increasing levels of the novel phytase (i.e., 0, 250, 500, 1,000, 2,000, and 4,000 phytase units/kg) increases ileal digestibility of AA and total tract digestibility of energy and minerals in diets for growing pigs. In this experiment, it was demonstrated that increasing levels of phytase increased the apparent ileal digestibility of starch, gross energy, minerals, crude protein, and AA, as well as the apparent total tract digestibility of gross energy and minerals. The impact of phytase on AA digestibility is possibly dependent on diet composition, phytate and phytase sources and concentrations, and pig maturity; however, further research is needed to confirm this.

This study evaluated the effect of limestone solubility on the capacity of a novel consensus bacterial 6-phytase variant (PhyG) to improve phosphorus (P) and calcium (Ca) digestibility, retention, and utilization in low-Ca broiler diets containing no added inorganic phosphate (Pi). Male Ross 308 broilers (n = 1,152) were fed one of 16 experimental diets from 11 to 21 d of age in a randomized complete design (12 birds/cage, 6 cages/treatment). Diets comprised three positive controls (PC3, PC2, and PC1) containing 1.8, 1.2, or 0.6 g/kg MCP-P and 7.7, 7.0, or 6.2 g/kg Ca, respectively, and a negative control (NC) containing no added Pi (4.4 g/kg P; 2.8 g/kg phytate-P) and 5.5 g/kg Ca from either low or high solubility limestone (LSL or HSL, respectively, [with 42% and 97% solubility after 5 min at pH 3.0]), supplemented with 0, 250, 500, 1,000, or 2,000 FTU/kg of PhyG. Fecal samples collected on days 18 to 20 and ileal digesta collected on day 21 were analyzed for titanium dioxide, Ca, P, and phytate (IP6, inositol hexakisphosphate). Tibias (day 21) were analyzed for ash content. Data were analyzed by factorial analysis (2 limestone solubilities × 4 MCP-P levels and 2 limestone solubilities × 5 phytase dose levels) and exponential regression. Increasing dose levels of PhyG resulted in an exponential increase (P < 0.01) in the apparent ileal digestibility (AID) of P, ileal digestible P content of the diet, ileal IP6 content, and IP6 disappearance in birds fed either HSL or LSL diets, but AID Ca and ileal digestible Ca were exponentially increased by the phytase only in HSL diets (P < 0.01). Relative to HSL, the LSL increased AID P, ileal digestible P, and IP6 disappearance (P < 0.05) but reduced AID Ca, ileal digestible Ca, and retainable Ca (P < 0.05), resulting in reduced retainable P and tibia ash. Phytase exponentially increased the apparent total tract digestibility of P, retainable P, and tibia ash in HSL and LSL diets, but at or above 500 FTU/kg values were higher in HSL than LSL (interaction P < 0.05). The findings highlight that phytase dose-response effects on mineral digestibility and utilization are different for high- and low-solubility limestones, and it is therefore recommended to use digestible rather than total Ca content during diet formulation to ensure an optimal balance of Ca and P, especially in low-Ca diets. In diets containing HSL, higher phytase dose levels may be needed to compensate for the low digestible P content of the basal diet.
In broilers, an excess of dietary calcium (Ca) or imbalance with phosphorus (P) can impair mineral digestion and utilization. As a result, diets are being formulated with less Ca, but the quality of the added Ca (that is mainly from limestone) is also important. This study investigated effects of limestone solubility (high [HSL] vs. low [LSL]) on the capacity of a novel consensus bacterial 6-phytase variant, PhyG, to improve P and Ca digestion and utilization in low-Ca diets containing no added inorganic phosphate. Increasing the phytase dose increased ileal P and phytate digestibility and the digestible P content of the diet at 21 d of age regardless of limestone solubility and reduced the negative effects of HSL (relative to LSL). Total tract digestibility of P and Ca, retainable P and Ca, and tibia ash were also increased by phytase, but responses were reduced with LSL relative to HSL. The findings highlight that phytase dose-responses differ in diets containing different limestones and it is therefore recommended to formulate diets based on the content of digestible rather than total Ca to ensure that Ca requirements are met but not exceeded, with optimal phytase efficacy. In diets containing HSL, a higher PhyG dose level is needed to meet the requirement for P.

Given the importance of poor nutrition as a cause for human chronic disease, it is surprising that nutrition receives so little attention during medical school training and in clinical practice. Specific vitamins, minerals, fatty acids, amino acids and water in the diet are essential for health, and deficiencies lead or contribute to many diseases. Proper use of the dietary guidelines and nutrition facts labeling can improve nutritional status and lead to the consumption of a healthy diet. COVID-19 has altered access to nutritious foods for millions and increased awareness of the importance of diet and immune function. An improved appreciation for nutrition will improve the outcomes of clinical care.

The percentage of US adults following low-carbohydrate diets (LCD) doubled in the last decade. Some researchers observed this trend with concern and highlighted the potential for nutritional deficiencies and impaired overall diet quality with LCD. The present study investigated nutrient intake in a nationally representative sample of 307 US adults following an LCD. Using cross-sectional data from the National Health and Nutrition Examination Surveys, we compared nutrient intake profiles in said individuals with the daily nutritional goals specified in the current 2020-2025 Dietary Guidelines for Americans (DGA). Results were then compared with the general population consuming a standard American diet. Almost 57 % of low-carbohydrate dieters were female, and the mean age was 48·67 (1·35) years. Individuals consuming LCD exceeded the recommendations for saturated fat, total lipid and sodium intake (both sexes). An insufficient intake was observed for fibre, Mg, potassium and several other vitamins (vitamins A, E, D in both sexes as well as vitamin C in men and folate in women). Neither men nor women met the recommendations for fibre intake. A comparable picture was found for the general population. The potentially insufficient intake of several essential nutrients in LCD warrants consideration and a careful assessment with regard to the current DGA.

This updated version of the Spanish Society for Research in Osteoporosis and Mineral Metabolism (SEIOMM) osteoporosis guides incorporate the most relevant information published in the last 7 years, since the 2015 guides, with imaging studies, such as vertebral fracture assessment and bone trabecular score analysis. In addition, therapeutic advances include new anabolic agents, comparative studies of drug efficacy, and sequential and combined therapy. Therefore, therapeutic algorithms are also updated.