case study for osteoporosis

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Patient Case Presentation

Ms. C.S. is a 46-year-old white female, who presents to her primary care physician for further work up after being seen and treated by an orthopedic surgeon for a right distal radius fracture. Patient sustained a low impact fall from standing which led to her injury. She states generally she doesn’t have pain but rates pain in wrist seven out of ten on pain scale.

Pertinent Past Medical and Surgical History

Jones, R. (2013). Distal radius [Picture]. Retrieved from https://emrems.com/2013/10/02/distal-radius/

• Bipolar disorder, diagnosed age 23, medically treated with lithium and cognitive behavior therapy
• Hysterectomy, age 44
• Diabetes type 1, diagnosed age 2
• Depression, diagnosed age 17

Pertinent Social History

• One pack per day smoker since age 17
• Newly divorced after 25 years of marriage
• Height 5’2 weight 85 pounds

Pertinent Family History

• Father alive at age 76 with history of bipolar disorder
• Mother died of cardiac arrest after a myocardial infarction 60 days post hip replacement at age 66
• Brother alive at age 50 with history of hyperthyroidism
• Sister alive at age 52 with no pertinent medical history

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The Effectiveness and Safety of Romosozumab and Teriparatide in Postmenopausal Women with Osteoporosis

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Martin C Hartz, Fabian B Johannessen, Torben Harsløf, Bente L Langdahl, The Effectiveness and Safety of Romosozumab and Teriparatide in Postmenopausal Women with Osteoporosis, The Journal of Clinical Endocrinology & Metabolism , 2024;, dgae484, https://doi.org/10.1210/clinem/dgae484

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The purpose of this observational study was to investigate the effectiveness and safety of romosozumab (ROMO) and teriparatide (TPTD) in a clinical setting.

315 postmenopausal women were included based on the reimbursement criteria for ROMO and TPTD at the Department of Endocrinology at Aarhus University Hospital. ROMO: Bone Mineral Density (BMD) T-score <-2.5 (femoral neck (FN), total hip (TH), or lumbar spine (LS)) + a fragility fracture (hip, spine, pelvis, distal forearm, or proximal humerus) within 3 years. TPTD: Within 3 years ≥2 vertebral fractures or 1 vertebral fracture + BMD T-score (FN, TH, or LS) <-3. Data was collected from medical records. The primary end point was percentage change from baseline in BMD (FN, TH, and LS) at month 12. BMD was measured by DXA.

At month 12 ROMO led to significantly ( p <0.001) larger increases than TPTD in BMD (FN: 4.8% vs. 0.2%, TH: 5.7% vs. 0.3%, and LS: 13.7% vs. 9.3%). Discontinuation rate was lower with ROMO than with TPTD. Lower incidence of cardiovascular adverse events was observed with ROMO compared to TPTD. Treatment-naïve patients had non-significantly higher BMD increases compared to previously treated patients with both ROMO and TPTD.

Treatment with romosozumab yields larger increases in bone mineral density than teriparatide after 12 months and a higher rate of completion.

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Osteoporosis: Diagnosis and Management

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#99143: Osteoporosis: Diagnosis and Management

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CASE STUDY 1

An Asian woman, Patient D, is 64 years of age with a history of type 2 diabetes, asthma, hypertension, and degenerative joint disease. She presents to a general medicine clinic with persistent lower back pain. The patient reports that for the last few months, she has been experiencing aching pain in the lower lumbar area. It is worse with exertion. The pain is fairly localized, without radiation. She does not experience any tingling, numbness, or weakness. There is no history of trauma. On exam, blood pressure is 135/75 mm Hg, heart rate 72 beats per minute, respirations 18 breaths per minute, temperature 99 degrees Fahrenheit, height 59 inches (150 cm), and weight 99 lbs (45 kg). The patient does exhibit some tenderness to palpation in the lower lumbar area. She notes that she tries to remain active, walking about 2 to 3 miles, three or four days a week; she is also a devoted gardener. She is concerned enough about this pain that she believes she needs an x-ray. She also reluctantly remarks that she is not sure if she is exaggerating, but she feels she might be "shrinking." She recently tried on a pair of pants she purchased several years ago, and now they appear to be too long. She wants to know if this is possible. One of her sisters recently told her that she was diagnosed with "brittle bones." She asks you what this means and if she should be concerned.

Patient D has numerous risk factors for osteoporosis, including older age, female gender, and low body weight. She may also have a family history, and this should be explored further. Upon review of her medications, she has been treated with steroids for exacerbation of asthma, but there have been no such episodes in the past year. In addition, she is not on estrogen replacement therapy. The use of steroids and estrogen deficiency may be additional risk factors. Her level of physical activity is encouraging, but it does not offset her numerous risk factors.

As noted, most often patients do not present with significant signs or symptoms of osteoporosis. In this example, Patient D does present with back pain in the lower lumbar area, which has been persistent for several months. The physical exam does not reveal any signs of radiculopathy, obvious fracture, nerve damage, or acute cause of the low back pain. In addition, the review of past records does demonstrate that Patient D is approximately 10 cm shorter in height than five years ago. She clearly needs a work-up for osteoporosis.

Patient D has a full chemistry panel including calcium and phosphorus, liver function tests, thyroid function tests, and a complete blood count (CBC). All are within normal limits. Normal values should not be unexpected in patients with osteoporosis, as this is often the case. Because suspicion remains high for osteoporosis, Patient D must undergo bone mineral density testing. Although the patient wishes to have an x-ray, simple x-rays would not be helpful here unless one is trying to rule out a fracture or other structural cause of the low back pain.

Patient D should undergo DXA of the hip. She has a history of degenerative joint disease, which makes spine-imaging results more difficult to interpret. In addition, she has numerous risk factors, which make DXA a preferred test.

Patient D's T-score from DXA of the hip is -2.5; she meets the WHO criteria for osteoporosis. Given that she is already experiencing symptoms, intervention is necessary. A review of diet is the first step. Patient D currently does not use any supplements because she believes she eats a healthy diet. However, further review with a dietitian reveals that she is below the recommended intake of calcium and vitamin D. Therefore, supplementation with both calcium and vitamin D should begin immediately. As noted earlier, Patient D tries to remain active, mostly involved in walking and gardening. These can be good aerobic exercises, depending on their intensity, and she should be encouraged to continue them. However, a weight-bearing exercise regimen should slowly be worked into her routine. Because she does have degenerative joint disease, a monitored exercise program should be initially pursued so that she focuses properly on form and does not cause any excess stress on her joints.

Medications should also be strongly considered, given her T-score as well as symptoms. SERMs and bisphosphonates should be the preferred medications. Estrogen replacement is not recommended.

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• Published: 09 July 2024

Osteoporosis, spinal degenerative disorders, and their association with low back pain, activities of daily living, and physical performance in a general population

• Shoei Iwata 1 , 2 ,
• Hiroshi Hashizume   ORCID: orcid.org/0009-0005-5822-7165 1 , 3 ,
• Noriko Yoshimura 4 ,
• Hiroyuki Oka 5 ,
• Hiroki Iwahashi 1 ,
• Yuyu Ishimoto 1 ,
• Keiji Nagata 1 ,
• Masatoshi Teraguchi 1 ,
• Ryohei Kagotani 1 , 2 ,
• Takahide Sasaki 1 ,
• Sakae Tanaka 6 ,
• Munehito Yoshida 1 , 7 &
• Hiroshi Yamada 1  

Scientific Reports volume  14 , Article number:  15860 ( 2024 ) Cite this article

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• Health care
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Osteoporosis, vertebral fractures, and spinal degenerative diseases are common conditions that often coexist in older adults. This study aimed to determine the factors influencing low back pain and its impact on activities of daily living (ADL) and physical performance in older individuals with multiple comorbidities. This cross-sectional study was part of a large-scale population-based cohort study in Japan, involving 1009 participants who underwent spinal magnetic resonance imaging (MRI) to assess cervical cord compression, radiographic lumbar spinal stenosis, and lumbar disc degeneration. Vertebral fractures in the thoracolumbar spine were evaluated using sagittal MRI with a semi-quantitative method. Bone mineral density was measured using dual-energy X-ray absorptiometry. Low back pain, Oswestry Disability Index (ODI), and physical performance tests, such as one-leg standing time, five times chair-stand time, maximum walking speed, and maximum step length, were assessed. Using clinical conditions as objective variables and image evaluation parameters as explanatory variables, multiple regression analysis showed that vertebral fractures were significantly associated with low back pain and ODI. Vertebral fractures and osteoporosis significantly impacted physical performance, whereas osteoporosis alone did not affect low back pain or ODI. Our findings contribute to new insights into low back pain and its impact on ADL and physical performance.

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Introduction.

Many countries, especially developed ones, have been facing rapid population aging 1 , 2 . Declining musculoskeletal health is a significant concern as it can be an initiating factor for other systemic problems. Studies have shown that musculoskeletal disorders not only cause pain and disability but also lead to secondary health issues such as cardiovascular diseases and mental health disorders due to reduced physical activity and chronic pain 3 , 4 . Additionally, musculoskeletal disorders are among the most prevalent health conditions worldwide, affecting millions of people and placing a substantial burden on healthcare systems 3 , 4 . Furthermore, older individuals generally have multiple coexisting conditions. For example, limited to spinal disease, include osteoarthritis, cervical and lumbar spinal stenosis, and osteoporotic vertebral fracture often coexist in the elderly 5 . These coexisting conditions can complicate treatment and management, making it even more critical to address musculoskeletal health proactively 6 .

Therefore, establishing a strategy for the early treatment and prevention of musculoskeletal diseases to improve the healthy life expectancy of people is crucial. In addition, understanding and addressing musculoskeletal decline in the geriatric population are essential for promoting healthy aging, improving the quality of life (QOL) for older individuals, and managing the associated healthcare challenges 4 , 7 , 8 . In musculoskeletal disorders, osteoporosis and spinal degenerative disorders are important clinical conditions affecting older individuals and are the focus of our current study. There have been reports indicating that adult sagittal malalignment influences the stresses and loads on lumbar radiographic degenerative changes, which may interact with low back pain 9 . Additionally, studies have shown that low back pain and decreased walking ability are independently associated with severe vertebral fractures, and decreased walking ability is associated with multiple vertebral fractures in women 10 . Therefore, it is expected that the presence of osteoporosis itself is associated with low back pain, as osteoporosis increases the risk of vertebral compression fractures. On the other hand, osteoporotic vertebral fractures result in low back pain and affect individuals’ activities of daily living (ADL) and QOL 11 , 12 , 13 , 14 . Older individuals generally have multiple coexisting conditions. Although the prevalence of these conditions and their association with clinical symptoms have been previously reported 15 , 16 , 17 , 18 , 19 , the influence of comorbid conditions on clinical symptoms remains unknown. Furthermore, no large cohort studies have examined which of these spinal degenerative disorders has the greatest impact.

In 2008, we initiated “the Wakayama Spine Study,” a population-based cohort study aimed at, determining the prevalence of low back pain, osteoporosis, and spinal degenerative diseases, and assessing their impact on ADL/QOL in the general population. The Wakayama Spine Study facilitated the diagnosis of osteoporosis, vertebral fractures, and cervical and lumbar spinal stenosis, thereby allowing us to address the aforementioned objectives. This study aimed to evaluate the coexistence of osteoporosis and spinal degenerative disorders in the general population, and to determine the actual factors influencing low back pain and its impact on ADL and physical performance in older individuals with multiple comorbidities. It is important to note that addressing osteoporosis and spinal degeneration often requires a multidisciplinary approach, which may include lifestyle modification, physical therapy, pharmacotherapy, and surgical intervention. We hope that the results of our study will provide valuable insights to benefit patients in need.

Table 1 shows the characteristics of the 1011 participants, including their ages and anthropometric measurement data obtained in this study. The mean age and prevalence of low back pain did not differ significantly between men and women; however, the body mass index (BMI) was significantly lower in women than in men. Among the image evaluation parameters, cervical cord compression, vertebral fractures, and osteoporosis were significantly different between the sexes (all P  < 0.05), whereas radiographic lumbar spinal stenosis.

Multiple regression analysis or multiple logistic regression analysis was performed with low back pain, Oswestry Disability Index (ODI), and physical performance tests as objective variables and image evaluation parameters (all predictors in the left column in Tables 2 , 3 and 4 ) as explanatory variables. After adjusting for sex, age, BMI, and other image evaluation predictors (in Model 3), rLSS, LDD, and vertebral fractures were found to be associated with low back pain ( P  = 0.0034, 0.0027, and 0.0321, respectively) but not with cervical cord compression and osteoporosis. Similarly, cervical cord compression and vertebral fractures were associated with the ODI ( P  = 0.0119 and 0.0066, respectively). In addition, the same multiple logistic regression analysis was performed for physical performance tests. No parameter was significantly associated with one-leg standing time (OLS). Five times chair-stand time (CST) was significantly associated with cervical cord compression and vertebral fractures ( P  = 0.0021 and P = 0.0080, respectively). Four of the five image evaluation parameters (cervical cord compression, LDD, vertebral fractures, and osteoporosis) were significantly associated with 6-m walking time at a maximal pace (maximum walking speed) prolongation ( P  = 0.0001, 0.0270, 0.0016, and 0.0144, respectively). Furthermore, cervical cord compression and osteoporosis were associated with a decrease in step length at a maximal pace (maximum step length) ( P  = 0.0004 and 0.0272, respectively).

This study demonstrated that rLSS, LDD, and vertebral fractures were significantly associated with low back pain, whereas cervical cord compression and vertebral fractures were significantly associated with ODI. However, osteoporosis was not significantly associated with low back pain and low back pain-related ADL disorders, as measured using the ODI in the general population. Several previous studies have investigated the osteoporosis and low back pain. Some basic experimental studies have shown a link between osteoporosis and low back pain 20 , 21 , 22 , 23 , and certain clinical studies have suggested that osteoporosis can lead to chronic low back pain 24 . However, the true association between osteoporosis and low back pain in a large population-based cohort remains poorly understood. Our finding that osteoporosis was not independently associated with low back pain in our general population cohort study is novel. In contrast, vertebral fractures were identified as independent factors associated with low back pain and low back pain-related ADL disorders. Previous studies have also reported an association between vertebral fractures and low back pain 25 , 26 , 27 , 28 , ADL, and health-related quality of life (HRQoL) 11 , 12 , 13 , 14 , which is consistent with our findings.

Furthermore, we measured and evaluated several physical performance indicators of locomotive syndrome, including OLS, CST, maximum walking speed, and maximum step length. We analyzed the relationships between these indices and osteoporosis as well as spinal degenerative disorders (cervical cord compression, rLSS, LDD, and vertebral fractures). In the physical performance test, none of the predictors was associated with OLS, but cervical cord compression and vertebral fractures were associated with CST delay. Cervical cord compression, LDD, vertebral fractures, and osteoporosis were associated with maximum walking speed prolongation, and cervical cord compression and osteoporosis with maximum step length. Focusing on vertebral fractures and osteoporosis, the results indicated that vertebral fractures was significantly associated with CST delay and maximum walking speed prolongation, whereas osteoporosis was significantly associated with maximum walking speed prolongation and step length. In other words, both vertebral fractures and osteoporosis affect physical performance. Stanghelle et al. 29 emphasized the importance of pain management and exercise interventions in older women with osteoporosis and vertebral fractures, as both pain and walking speed were independently associated with HRQoL, which aligns with our study results. Moreover, by comparing the standardized partial regression coefficient, we estimated that physical performance was more strongly associated with vertebral fractures than with osteoporosis.

In summary, our findings suggest that vertebral fractures influence low back pain, low back pain-related ADL, and physical performance. Several studies have shown a relationship between low back pain and radiographic degenerative changes 30 , 31 , 32 , and some have reported that low bone mineral density is associated with kyphotic deformity. For example, The Framingham Study, which involved spinal computed tomography on approximately 2000 adolescents and young adults, revealed a strong association between low bone density and thoracic kyphosis. It suggested that this factor may be predominantly genetic in origin 33 . In addition, Tanishima et al. 34 reported that decreased bone density was independently associated with kyphosis in older individuals living in a mountain area. Therefore, kyphotic deformity may be observed in older individuals due to subclinical vertebral fractures caused by low bone density. Furthermore, based on our previous studies 35 , 36 , which revealed that spinal malalignment, particularly kyphotic deformity, was associated with low back pain, we infer that kyphotic deformity resulting from vertebral fractures causes low back pain, low back pain-related ADL disorders, and poor physical performance. The prevalence of vertebral fractures has been reported as a risk factor for new vertebral fractures 37 , 38 , and vertebral fractures are associated with mortality and life expectancy 39 , 40 . Together with our results, these findings highlight the importance of preventing vertebral fractures as a critical clinical concern. Although osteoporosis itself was not associated with low back pain or low back pain-related ADL disorders in this study, early intervention for the treatment of osteoporosis, a condition preceding the development of spinal kyphotic deformities, is crucial. According to Sinaki et al. 41 individuals with osteoporosis-related kyphosis exhibited significantly higher balance abnormalities than those in the control group, and thoracic hyperkyphosis, in combination with reduced muscle strength, plays a central role in increasing body sway, gait unsteadiness, and the risk of falls in osteoporosis patients. Therefore, improving physical performance is an important factor in preventing vertebral fractures.

This study had some limitations. First, although it included over 1000 participants, they may not fully represent the general population, as they were recruited from only two areas in Japan. However, we compared the anthropometric measurements of the study participants with those of the general Japanese population 42 and found no significant differences in BMI for either men (BMI: 23.71 [3.41] and 23.95 [2.64] kg/m 2 , P  = 0.33, respectively) or women (BMI: 23.06 [3.42] and 23.50 [3.69] kg/m 2 , P  = 0.07, respectively). Second, this was a cross-sectional study, which limited our ability to establish causal relationships between osteoporosis and physical performance. The ongoing Wakayama Spine Study, a longitudinal survey, will provide further insight into these causal relationships. Third, we did not examine the psychosocial factors associated with low back pain. Nevertheless, we believe that this study is superior to previous studies, as it evaluated bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA) and performed spinal magnetic resonance imaging (MRI) assessments in the general population. In addition, we performed a multidimensional evaluation of low back pain, low back pain-related ADLs, and physical performance.

In conclusion, we found that osteoporosis was not significantly associated with low back pain and related ADL disorders (ODI) and that vertebral fractures were related to low back pain, ADL disturbance, and agility decline. These results suggest that the prevention of vertebral fractures is crucial. These findings contribute to multidimensional research on low back pain, low back pain-related ADLs, and physical performance. Needless to say, it is important to note that addressing osteoporosis and spinal degeneration often requires a multidisciplinary approach, which may include lifestyle modification, physical therapy, pharmacotherapy, and surgical intervention. We hope that the results of our study will provide valuable insights to benefit patients in need. Further investigations, along with follow-up surveys, should be conducted to elucidate the causes of low back pain and related disorders.

Ethical statement

All procedures in this study involving human participants were performed in accordance with the ethical standards of the institutional and national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was conducted with the approval of the ethical committees of the University of Tokyo (nos. 1264 and 1326) and Tokyo Metropolitan Institute of Gerontology (no. 5). Informed consent was obtained from all the study participants.

Participants

This population-based study of degenerative spinal diseases, titled the Wakayama Spine Study, was conducted as a sub-cohort of a large-scale Population-based cohort study named the Research on Osteoarthritis/Osteoporosis Against Disability (ROAD). ROAD is a nationwide prospective study of bone and joint diseases, comprising population-based cohorts from various communities in Japan. A detailed profile of the ROAD study has been previously described 43 , 44 , 45 , 46 . The baseline database for this study included clinical and genetic information of 3040 inhabitants (1061 men and 1979 women; mean age: 70.6 years; age range: 23–95 years). Participants were recruited from resident registration listings in three communities with different characteristics: an urban region in Itabashi, Tokyo; a mountainous region in Hidakagawa, Wakayama; and a coastal region in Taiji, Wakayama. The participants completed an interviewer-administered questionnaire consisting of 400 items, including lifestyle information such as occupational career, smoking habits, alcohol consumption, family history, medical history, physical activity, reproductive variables, and health-related QOL. However, not all surveys were utilized in the present study; instead, only essential sections were analyzed.

Here, we briefly summarize the profile of the present study. The second visit of the ROAD study began in 2008 and was completed in 2010. All participants in the baseline study were invited to participate in the second visit. In addition to the former participants, inhabitants aged 60 years and older in the urban area and those aged 40 years and younger in the mountainous and coastal areas who were willing to participate in the ROAD survey were also included in the second visit (both the mountainous and coastal areas were in Wakayama prefecture). Finally, 2674 individuals (900 men, 1774 women) participated in the second visit of the ROAD study, comprising 1067 individuals (353 men, 714 women) in the urban area, 742 individuals (265 men, 477 women) in the mountainous area, and 865 individuals (282 men, 583 women) in the coastal area. Among these three communities in the ROAD study, the mountainous and coastal areas, from which we invited all 1607 participants (547 men, 1060 women) to the Wakayama Spine Study, are located in Wakayama prefecture. However, 1063 participants responded to the invitation for the Wakayama Spine Study, and 52 participants declined; therefore, a total of 1011 individuals provided written informed consent and attended the Wakayama Spine Study with MRI examinations. A mobile MRI unit (Excelart 1.5 T, Toshiba, Tokyo, Japan) was used, and a total spinal MRI was performed for all participants on the same day as the clinical examination. Two participants for whom MRI was contraindicated due to the presence of a pacemaker were excluded; thus, 1009 individuals (335 men and 674 women; mean age: 66.3 years; age range: 21–97 years) participated in this study (Fig.  1 ). BMD was measured at the femoral neck using DXA (with Hologic Discovery DXA system; Hologic, Waltham, MA, USA).

Flow diagram of participant recruitment for the Wakayama Spine Study from the Research on Osteoarthritis/Osteoporosis Against Disability (ROAD) study.

Definition of low back pain

Experienced board-certified orthopedic surgeons asked all the participants the following question regarding low back pain: “Have you experienced low back pain on most days during the past month, in addition to now?” Those who answered “yes” were defined as having low back pain, as previously described 43 , 47 , 48 , 49 , 50 . Low back pain in this study is defined as pain persisting for at least 1 day, located in the posterior aspect of the trunk, between the 12th rib and the lower border of the gluteal sulcus. It may or may not be accompanied by radiating pain in one or both lower limbs 51 .

The ODI, derived from the Oswestry Low Back Pain Questionnaire 52 , 53 , 54 , was used by clinicians and researchers to quantify the level of disability due to low back pain. The patient questionnaire included several questions related to pain intensity, ability to walk, sit, stand, self-care, travel, sexual function, lifting, social life, and sleep quality. Participants selected responses that most closely resembled their symptoms. The index scores ranged from 0 to 100, with “0” indicating no disability and “100” indicating the most severe. In this study, we considered ODI as low back pain-related ADL disorders.

Evaluation of cervical cord compression

Cervical cord compression was defined as the compression of the anterior and posterior components of the spinal cord, as previously described 55 . Cervical cord compression was evaluated at each intervertebral level from C2/3 to C7/Th1 and graded as follows: grade 0, no compression of the spinal cord, but the subarachnoid space was present; grade 1, no compression of the spinal cord without the subarachnoid space; grade 2, compression of less than one-third of the spinal cord; grade 3, compression of more than one-third but less than two-thirds of the spinal cord; and grade 4, compression of more than two-thirds of the spinal cord. Cervical cord compression was defined as grade 2 or higher at the most severely affected intervertebral disc level and was analyzed accordingly (Fig.  2 ). Intra- and inter-observer variabilities for cervical cord compression, evaluated using kappa analysis, were 0.78 and 0.72, respectively, and were deemed sufficient for assessment 55 .

Measurement figures of cervical cord compression. Cervical cord compression was defined as grade 2 or higher at the most severely affected intervertebral disc level.

Evaluation of rLSS

The severity of rLSS was assessed using qualitative measurements performed by a well-experienced orthopedic surgeon. Axial images at each lumbar intervertebral level (L1/2 to L5/S1) were obtained from the films, as previously described 56 . The severity of central stenosis was assessed according to general guidelines (Suri classification) 57 . According to the Suri classification, the rLSS was divided into four levels: grade 0, no narrowing; grade 1, mild narrowing of less than one–third of the normal area; grade 2, moderate narrowing of one–third to two–thirds of the normal area; and grade 3, severe narrowing of more than two–thirds of the normal area. rLSS was defined as grade 3 at the most severely affected lumbar intervertebral disc level and was analyzed accordingly (Fig.  3 ). Intra- and inter-observer variabilities for rLSS, evaluated using kappa analysis, were 0.82 and 0.77, respectively, and were deemed sufficient for assessment 56 .

Measurement figures of rLSS (radiographic lumbar spinal stenosis). rLSS was defined as grade 3 at the most severely affected lumbar intervertebral disc level.

Evaluation of LDD

The degree of LDD on MRI (Fig.  4 a) was classified into five grades based on the Pfirrmann classification system 58 , as previously described 59 . The total score (5–25), which was the sum of each intervertebral grade at L1/2–5/S, was used as the index. Intra- and inter-observer variabilities for LDD, evaluated using kappa analysis, were 0.94 and 0.94, respectively, and were deemed sufficient for assessment 59 .

( a ) Example figure of LDD (lumbar disc degeneration); ( b ) Example figure of vertebral fracture in the thoracolumbar spine.

Evaluation of vertebral fractures in the thoracolumbar spine

Vertebral fractures and their severity were assessed using the Genant semi-quantitative (SQ) method 60 with sagittal MR images of the Th11-L1 vertebrae (Fig.  4 b). The SQ method was graded from 0 to 3, defined as follows: grade 0 = normal; grade 1 = mildly deformed (approximately 20–25% reduction in anterior, middle, and posterior height, and a 10–20% reduction in area); grade 2 = moderately deformed (approximately 25–40% reduction in height and a 20–40% reduction in area); and grade 3 = severely deformed (approximately 40% reduction in height and area). The total score (0–9) was used as an index by summing the respective grades of the Th11-L1 vertebrae. The prevalence of vertebral fractures was reported to be highest in Th11-L1 lesions 10 . To evaluate the intra-observer variability, 100 randomly selected MRIs of the entire spine were rescored by the same observer (MT) more than 1 month after the first reading. Furthermore, to evaluate inter-observer variability, 100 other MRIs were scored by two experienced orthopedic surgeons (MT and RK) using the same SQ method. Intra- and inter-observer variabilities for vertebral fractures, evaluated using kappa analysis, were 0.87 and 0.84, respectively, and were deemed sufficient for assessment.

Evaluation of osteoporosis

Osteoporosis was defined as BMD < 70% of the peak bone mass, according to the criteria of the Japanese Society for Bone and Mineral Research 61 . BMD at the femoral neck < 0.604 g/cm 2 in men and < 0.551 g/cm 2 in women indicated osteoporosis and was analyzed accordingly. In this study, femoral neck osteoporosis was used to assess the incidence of osteoporosis.

Physical performance tests

Several tests were performed to evaluate physical performance, as previously reported 55 , 56 . In this study, the following four items were selected: OLS, CST, maximum walking speed, and maximum step length. The OLS for each leg was measured using a stopwatch (upper limit, 60 s), and the mean time for both legs was used for further analysis. OLS appears to be a significant and easy-to-administer predictor of injurious falls reported by a previous study 62 ; therefore, the present study adopted it. The time taken for five consecutive chair rises without the use of hands was recorded. CST is a specific test used in assessing functional capacity, particularly focusing on lower limb strength and endurance. This test is commonly employed in populations such as older individuals to evaluate their functional abilities 63 , 64 . Walking speed was measured by recording the time taken to walk 6 m at the usual pace in a hallway. Similarly, the 6-m walking time at the maximal pace was measured. The participants were provided with a full explanation of each test but were not provided with any training. Walking speed and step length are effective indicators of physical performance, providing valuable information across various contexts. In older individuals, both are associated with fall risk and survival 65 , 66 . In this current study, we evaluated their maximum values. Finally, these four physical tests were effective for the evaluation of physical performance indicators of the locomotive syndrome, respectively 67 .

Statistical analyses

Five image evaluation parameters (cervical cord compression, rLSS, LDD, vertebral fractures, and osteoporosis) were analyzed. Six clinical conditions and parameters, namely low back pain, ODI, and four physical performance tests (OLS, CST, maximum walking speed, and maximum step length), were also evaluated. Baseline characteristics between the sexes were compared using a non-paired Student’s t -test for numerical variables. Multiple logistic regression analysis was used to estimate the association between clinical conditions (low back pain, ODI, OLS, CST, maximum walking speed, and maximum step length) and image evaluation parameters (cervical cord compression, rLSS, LDD, vertebral fractures, and osteoporosis), after adjusting for age, sex, and BMI (kg/m 2 ). Clinical conditions were used as objective variables, whereas image evaluation parameters were used as explanatory variables. All statistical tests were performed at a two-sided significance level of 0.05. Data were analyzed using JMP version 14 (SAS Institute Japan, Tokyo, Japan).

Data availability

All data generated or analyzed during this study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors thank Mrs. Tamako Tsutsumi, Mrs. Kanami Maeda, and other members of the Public Office in Taiji Town for their assistance with the location and scheduling of the examinations.

This study was funded by H-25-Choujyu-007 (Director, Noriko Yoshimura), H25-Nanchitou (Men)-005 (Director, Sakae Tanaka), 201417014A (Director, Noriko Yoshimura), and 21FA1006 (Director, Hiroshi Yamada) from the Ministry of Health, Labour and Welfare; a Grant-in-Aid for Scientific Research (B26293139 and B23390172 to Noriko Yoshimura, B2629333, C26462249 and 21K0936 to Hiroshi Hashizume, and C25462305 to Hiroshi Yamada); a Grant-in-Aid for Young Researchers (B25860448 to Yuyu Ishimoto, B26861286 to Masatoshi Teraguchi, B26860419 to Ryohei Kagotani, and B15K20013 to Hiroki Iwahashi); and a Grant-in-Aid for Challenging Exploratory Research (15K15219 to Noriko Yoshimura and 24659666 to Hiroyuki Oka) from the JSPS KAKENHI grant and Collaborating Research with NSF 08033011- 00262 (Director, Noriko Yoshimura) from the Ministry of Education, Culture, Sports, Science, and Technology in Japan. This study was also supported by grants from the Japan Osteoporosis Society (Noriko Yoshimura and Hiroyuki Oka) and JA Kyosai Research Institute (Hiroyuki Oka). The study sponsors played no role in the study design, collection, analysis, and interpretation of data, writing of the report, or decision to submit the manuscript for publication. The corresponding author had full access to all data and made the final decision to submit the manuscript for publication.

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Shoei Iwata, Hiroshi Hashizume, Hiroki Iwahashi, Yuyu Ishimoto, Keiji Nagata, Masatoshi Teraguchi, Ryohei Kagotani, Takahide Sasaki, Munehito Yoshida & Hiroshi Yamada

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Noriko Yoshimura

Division of Musculoskeletal AI System Development, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan

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Department of Orthopedic Surgery, Faculty of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan

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H.H., N.Y., H.O., S.T., M.Y., and H.Y. conceived and designed this study. S.I. wrote the manuscript. H.H., N.Y., H.O., H.I., Y.I., K.N., M.T., R.K., and T.S. collected the data. S.I., H.H., H.O., and N.Y. analyzed the data. All authors have seen the original study data, reviewed the data analysis, and approved the final manuscript.

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Iwata, S., Hashizume, H., Yoshimura, N. et al. Osteoporosis, spinal degenerative disorders, and their association with low back pain, activities of daily living, and physical performance in a general population. Sci Rep 14 , 15860 (2024). https://doi.org/10.1038/s41598-024-64706-0

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Osteoporosis: A Small-Group Case-Based Learning Activity

Bianca nguyen.

1 Medical Student, Florida International University Herbert Wertheim College of Medicine

Gagani Athauda

2 Associate Professor, Department of Cellular Biology and Pharmacology, Florida International University Herbert Wertheim College of Medicine

Sanaz B. Kashan

3 Assistant Professor, Department of Humanities, Health, and Society, Florida International University Herbert Wertheim College of Medicine

Tracey Weiler

4 Associate Professor, Department of Human and Molecular Genetics, Florida International University Herbert Wertheim College of Medicine

Rebecca L. Toonkel

5 Associate Professor, Department of Translational Medicine, Florida International University Herbert Wertheim College of Medicine

Associated Data

• CBL Facilitator Guide.docx
• Face-to-Face Session Student Guide.docx
• Remote Learning Session Guide.pptx
• Exam Question Descriptions.docx
• Postsession Survey.docx

All appendices are peer reviewed as integral parts of the Original Publication.

Introduction

Osteoporosis is the most common bone disease in the world. Approximately 50% of women and 20% of men over 50 will suffer an osteoporosis-related fracture. Future health care providers must be equipped to prevent, recognize, and treat osteoporosis-related fractures.

To supplement instruction on osteoporosis, we designed a case-based session. Groups of 10–12 second-year medical students worked with a single facilitator in a roundtable discussion. The 120-minute session integrated foundational sciences (pathology, physiology, pharmacology) and clinical disciplines (clinical skills, radiology, geriatrics, evidence-based medicine). Knowledge gains were assessed by performance on nine session-relevant multiple-choice questions (MCQs) on the final exam. Student satisfaction was assessed by an anonymous postsession survey.

There were 121 students that participated, and their average performance on nine session-relevant final exam MCQs was 84%. After removal of a single outlier MCQ (15% correct), average performance on the remaining eight MCQs was 93%. A total of 107 students (88%) responded to the postsession survey. On a 5-point Likert scale, 101 of 107 students (94%) agreed or strongly agreed with the statement “The basic science-clinical combination lecture on osteoporosis followed by the small-group case discussion on osteoporosis prepared me adequately to understand the topic” ( M = 4.56, SD = 0.63).

We developed a case-based learning activity for preclinical medical students to enhance the clinical scaffolding of basic science and medical knowledge around osteoporosis. Students performed well on session-relevant exam questions, demonstrating competency in the educational objectives. Student satisfaction was high, with most students feeling well prepared.

Educational Objectives

By the end of this activity, learners will be able to:

• 1. Perform or observe an oral case presentation and complete a musculoskeletal physical exam after obtaining hypothesis-driven medical history.
• 2. When given a history of an acute injury to the wrist, use exam and X-ray appearance to diagnose a Colles-type distal radial fracture.
• 3. Define a fragility fracture and recognize osteoporosis as the most common underlying cause.
• 4. When provided with a bone density test (DXA) result and T-score, interpret the results of a DXA scan and understand the meaning of T-score ranges.
• 5. Use the Fracture Risk Assessment Tool to predict the 10-year risk of osteoporotic fracture in a patient.
• 6. Name the available pharmacologic treatments for osteoporosis and describe the mechanism of action and major adverse effects of each.

Osteoporosis, the most common bone disease in the world, leads to decreased bone strength, low bone mass, and increased risk of fractures. 1 An estimated 50% of women and 20% of men over the age of 50 will suffer an osteoporosis-related fracture, which is associated with disability, mortality, and significant financial cost to the patient and society. 1 As the population ages, the prevalence of osteoporosis and the number of associated fractures are expected to increase sharply. 1 Worldwide, the incidence of hip fractures is projected to increase dramatically in the coming decade, emphasizing the significance of prevention and treatment for osteoporosis-related injuries. 2 Future health care providers must be equipped to prevent, recognize, and treat osteoporosis-related fractures.

Despite coverage by the USMLE Content Outline, 3 musculoskeletal (MSK) diseases like osteoporosis continue to be underrepresented in medical school curricula. 4 Because of this, the AAMC has voiced concerns that MSK medicine, particularly osteoporosis, may not be adequately emphasized in undergraduate medical education. 4

A search of the literature revealed limited educational resources on osteoporosis appropriate for teaching preclinical medical students. At the time the search was conducted, there were four relevant MedEdPORTAL publications. One publication contains four virtual patient cases utilizing videos and images relating to the care of aging patients. One of these cases describes a geriatric patient with osteoporosis over a 15-year period, during which the patient develops additional health issues including hearing and vision loss, incontinence, hyperthyroidism, and cardiac disease. 5 MedEdPORTAL also has a publication on oral health describing endentulism and its associated morbidities, including the impact of oral health on diseases such as osteoporosis. 6 Another MedEdPORTAL publication describes short case studies on bone and muscle physiology. 7 While some of the cases involve osteopenia and osteoporosis, the activity primarily focuses on isolated basic sciences concepts rather than an integrated clinical approach including prevention, diagnosis, complications, and management. The fourth relevant MedEdPORTAL publication is a women's health tutorial consisting of 14 web-based modules with special emphasis on contraception, menopause, and preventive care. 8 The osteoporosis module consists of a PowerPoint presentation of content with two short cases for self-study.

A search of the PubMed and Google Scholar databases revealed a publication on the participation of health care providers and clinicians in a performance improvement continuing medical education initiative that includes eight 1‐hour educational sessions to improve screening of patients at risk for osteoporosis. 9 Another study utilizes a questionnaire to assess the level of exposure of graduating family practice residents to fracture care. 10 A study carried out in Finland utilizes a questionnaire to assess the theoretical knowledge and Colles' fracture casting skills of graduating medical students. 11 Finally, there is a study that reports practice-based small-group learning interventions as an effective and acceptable method of providing continuing medical education on osteoporosis for primary care physicians. 12

However, to our knowledge, there are no published cases designed to facilitate medical student integration of foundational science concepts, physical exam skills, evidence-based medicine, and clinical reasoning around osteoporosis. We sought to fill this unmet need at our institution through a small-group case-based learning (CBL) session designed to facilitate active learning and both horizontal and vertical integration of material across multiple courses and disciplines.

In contrast with previously published reports, our exercise focused directly on osteoporosis, from prevention through diagnosis and treatment. 5 – 12 This case was also designed to facilitate the progression of preclinical medical students toward attainment of several aspects of entrustability as outlined by the AAMC Core Entrustable Professional Activities (EPAs). 13 Through this exercise, students were prompted to obtain a focused history and perform the complete MSK exam (EPA 1: Gather a History and Perform a Physical Exam); recommend and interpret the results of laboratory studies, plain film radiography of a fracture, and a DXA (bone density test) scan (EPA 3: Recommend and Interpret Common Diagnostic and Screening Tests); write a safe and indicated prescription for a bisphosphonate (EPA 4: Enter and Discuss Orders and Prescriptions); orally present the history obtained from the patient (EPA 6: Provide an Oral Presentation of a Clinical Encounter); and use the Fracture Risk Assessment (FRAX) tool and evidence from the literature to decide on appropriate treatment for the individual patient (EPA 7: Form Clinical Questions and Retrieve Evidence to Advance Patient Care.) 14

An additional advantage of our activity was its ability to be implemented remotely. As remote education on digital platforms continues to become more important, advances in computer technology and distance learning have enabled the remote integration of interactive teaching methods in medical education. Training a generation of future medical professionals who are digital natives entails incorporating novel learning tools and multimedia into the curriculum. 15 Through screen-sharing capabilities and remote conferencing platforms, small-group case-based sessions like ours can be easily implemented. Because of the difficulty in securing adequate small-group learning space in some institutions, the use of remote learning for these types of sessions is resource conserving and especially beneficial. In addition, emphasis on creative development of technology-enhanced learning tools will, through discussion with facilitators and peers, improve students' technological literacy and teamwork, which are necessary skills for clinical practice. 15

We designed an interactive CBL session on osteoporosis intended for second-year medical students. At our institution, the session was implemented during the MSK systems course. Prior to the session, students had covered osteoporosis prevention, presentation, diagnosis, and treatment through an interactive didactic session co-led by an internal medicine specialist and a pharmacology expert. Students had also previously learned to obtain a focused history and to perform the MSK exam through their first-year clinical skills course.

Students were not expected to complete any preparatory assignments prior to the session; however, they were encouraged to be up to date in their studies in order to maximize their ability to participate effectively. Faculty facilitators were provided with the facilitator guide ( Appendix A ) a week in advance of the session and were expected to review the guide for flow and content (expected preparation time: approximately 30–60 minutes) but were not required to be content experts. There was no formal faculty development specific to this session, but all participating faculty were experienced CBL facilitators.

Traditional CBL sessions were conducted in small-group rooms (2015–2019) or via Zoom (2020), consisted of 10–12 students with a single faculty facilitator, and lasted 2 hours. We randomly preassigned learners to groups prior to the session. Case elements were progressively revealed through a hard-copy student guide (2015–2018; Appendix B ), through a PowerPoint presentation projected in each room (2019; Appendix C ), or via remote screen-sharing facilitated by Zoom (2020). Students worked together to answer the guided inquiry questions as the case elements were sequentially revealed. Discussions occurred organically, with answers provided by whichever student(s) chose to speak. Facilitators were discouraged from didactic teaching and instead prompted students with probing questions, managed time, maintained order, and ensured that each question was discussed thoroughly.

Effectiveness of the session was assessed by the inclusion of nine multiple-choice questions (MCQs) pertaining to osteoporosis management and treatment on the MSK medicine course final exam administered to the class of 2018. Participating teaching faculty in the MSK course designed the assessment items, which were edited by the members of the Exam Review Committee. Each question consisted of a single best answer format with four to five answer options. The committee reassesses and edits exam items annually based on student performance. Given the sensitive material in the assessment items, the questions have not been provided as part of this publication, but Appendix D contains descriptions of the areas the questions covered.

The average class performance and standard deviation were calculated for the nine osteoporosis-related MCQs. The item discrimination index, a form of a Spearman's correlation analysis that compared the performance of the overall exam to the performance of the individual items, was also calculated for each item. This analysis described how well the test question was able to differentiate between students who performed well on the exam overall and those who did not. Each exam item was associated with a learning objective covered by the CBL session. All data were deidentified by the Office of Testing and Assessment and provided to the investigators in aggregate.

Student satisfaction with the CBL session was evaluated through an anonymous postsession survey ( Appendix E ) administered to the class of 2018 immediately after the small-group CBL session. Students rated their level of agreement with the statement on a 5-point Likert scale (1 = strongly disagree , 2 = disagree , 3 = neutral , 4 = agree , 5 = strongly agree ). The response rate and average statement agreement were calculated for the satisfaction survey.

This study received institutional review board exempt approval (#IRB-16-0086) from Florida International University.

Average class performance on the nine osteoporosis-related final exam questions was 84% ( SD = 26%, N = 121; Table ). With the exception of one question, greater than 90% of the class answered each of the questions correctly. Discrimination indices ranged from .01 to .23 ( M = .09). One of the questions, which assessed risk factors for osteoporosis as defined by the FRAX tool, was answered correctly by only 15% of the class. When this outlier was removed, average class performance increased to 93% ( SD = 4%).

Response rate to the satisfaction survey was 88% (107 of 121 students). Average agreement with the statement “The basic science-clinical combination lecture on osteoporosis followed by the small-group case discussion on osteoporosis prepared me adequately to understand the topic” was 4.56 ( SD = 0.63), with 94% (101 out of 107) agreeing or strongly agreeing ( Figure ).

In alignment with recommendations from the Carnegie Foundation for the Advancement of Teaching, medical education continues to shift from teaching basic sciences in isolation toward the implementation of active learning pedagogies including CBL in order to encourage integration of curricular content and clinical application of knowledge. 16 The CBL session that we describe reflects these principles through the integration of foundational sciences and clinical disciplines.

As demonstrated by student performance on osteoporosis-related final exam questions, the activity was an effective teaching modality. Students performed well across the nine osteoporosis-related final exam questions. In response to poor student performance on a question regarding the FRAX tool, future iterations of the session included greater emphasis on the components of the FRAX tool and risk factors for osteoporosis.

Analysis revealed relatively low discrimination indices for each of the questions, suggesting that all students (both stronger and weaker students, based on their overall performance on the exam) were able to answer these questions correctly. A review of these questions with the course directors and subject matter experts revealed that they considered most of the questions to be fairly difficult. While this cannot be known without further study, it suggests that the combination of the didactic session and the CBL led to improved overall understanding and subsequent student outcomes on the assessment.

In addition, because no baseline assessment was performed either before or after the didactic session, it was unclear if students performed well on the osteoporosis-related questions due to their intrinsic study skills (regardless of any teaching activities) or as a result of the didactic activity but not the CBL.

While student satisfaction does not reflect learning, it remains an important outcome with regard to student engagement and participation, which are crucial to the success of active learning pedagogies. For the case described, student satisfaction was high, suggesting that students felt that the session adequately prepared them to understand the topic. Future studies could include additional questions regarding satisfaction with the individual components of the teaching (e.g., the didactic session and the CBL) and could assess student perception of the value of the time spent in each of these activities.

In utilizing this activity for several years, we have identified a number of areas for potential improvement. For example, in this CBL, students were prompted to gather a history, perform a physical exam, order and interpret diagnostic tests, and incorporate epidemiologic concepts to optimize patient care. In order to fully engage in the activity, students were expected to review the material from their MSK, clinical skills, and evidence-based medicine courses prior to the session. While most students were able to perform these tasks, we did not perform a baseline readiness assessment. Educators who adapt this activity may improve student performance and participation by including a brief readiness assessment to ensure that students have reviewed all necessary material.

At our institution, prior knowledge of anatomy (skeletal system), physiology (normal bone functions), pharmacology (mechanism of action and adverse reactions of pharmacologic treatments), and clinical skills courses (history taking) was delivered in the first year. The evidence-based medicine concepts (absolute risk difference and number needed to harm) were taught during the second-year evidence-based medicine course. The topic of osteoporosis, including diagnosis, management, and treatment of the disease, was addressed during the second-year MSK and clinical skills courses.

As a result of the COVID-19 pandemic, the session transitioned to a virtual platform in 2020 using Zoom and Google Documents. To keep the students engaged with the virtual small-group CBL, they were instructed to keep cameras on during the active learning session and to use Google Documents to type answers to each question in an interactive format. Facilitators were asked to log into Zoom to ensure that their technology functioned properly, and they practiced sharing their slides before the session.

We developed a CBL session for second-year medical students aimed at integrating basic science concepts and clinical skills around osteoporosis. This session has undergone several iterations resulting in significant improvements that have been applied to other CBLs across the curriculum. In its most recent iteration, the case was adapted for live online learning with great success. As medical education moves increasingly toward active learning pedagogies, lessons learned from CBLs like this one will continue to gain importance. Especially for highly prevalent disorders like osteoporosis, CBLs provide an opportunity for students to scaffold medical knowledge with relevant clinical skills.

Acknowledgments

The authors gratefully acknowledge Jorge Perez, MSCP, MLIS, for help with image citations.

Disclosures

None to report.

Funding/Support

Ethical approval.

The Florida International University Institutional Review Board approved this project.

• Open access
• Published: 15 July 2024

Association between dietary insulin index and postmenopausal osteoporosis in Iranian women: a case-control study

• Shakiba Solgi 1 ,
• Farid Zayeri 2 &
• Behnood Abbasi 3  

BMC Women's Health volume  24 , Article number:  401 ( 2024 ) Cite this article

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Metrics details

The relationship between the dietary insulin index (DII) and the disease’s risk is unknown, despite the fact that hyperinsulinemia is presumed to contribute to osteoporosis. The insulin response of various diets determines the DII. This study aimed to investigate the connection between postmenopausal Iranian women’s adherence to a diet with a higher insulinemic potential and osteoporosis.

A total of 380 postmenopausal women were included in the current case-control study. A 168-item food frequency questionnaire (FFQ) with established validity and reliability was used to evaluate individuals’ daily calorie intake. The standard formula was employed to determine the dietary insulin load of each product. Subsequently, the calculation of DII was performed by dividing the dietary insulin load by the total energy consumed for each individual. In order to investigate the relationship between osteoporosis and DII, logistic regression was implemented.

The results of the current study demonstrated a substantial inverse relationship between osteoporosis and the DII, even after accounting for confounding variables (OR = 0.927; 95% CI = 0.888–0.967). The mean scores of DII ( P  < 0.001) was significantly higher in control group (36.82 ± 8.98) compared to the case group (33.53 ± 6.28).

Conclusions

Our findings suggest that keeping a diet high in insulin index and low in foods that are insulinogenic may improve bone mass density. Consequently, it may be essential for postmenopausal women to consume nutrients that stimulate insulin production in order to prevent osteoporosis.

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Introduction

The most common bone disease is osteoporosis [ 1 ], which causes a reduction in bone mineral content and an increase in bone fractures [ 2 ]. One in three women and one in five men over the age of 50 are at risk of fractures associated to osteoporosis, according to a research from the International Osteoporosis Foundation [ 3 ]. National Osteoporosis Prevention, Diagnosis, and Treatment Program in Iran has revealed that 50% of men and 70% of women over the age of 50 are affected by osteoporosis and osteopenia [ 4 ]. This disease is four times more prevalent in women during menopause than in men [ 5 ]. After menopause, Iranian women exhibit osteopenia and osteoporosis of lumbar spine at rates of 50% and 26.7%, respectively [ 6 ].

Previous research demonstrated that insulin could have anabolic effects on bone [ 7 ]. Additionally, serum glucose and insulin concentrations were positively correlated with bone mass and a reduced fracture rate [ 8 ]. According to the findings of some research, insulin hypersecretion and postprandial hyperinsulinemia may eventually develop in insulin resistance (IR) [ 9 ], which may then benefit bone mineral density (BMD) [ 8 , 10 , 11 ]. IR and BMD do, however, have a complex relationship [ 12 ]. Previous research [ 13 ] showed that there was a direct correlation between a higher IR and a higher dietary insulin index. The results of this study indicated that the Iranian population’s IR can be elevated by insulinogenic foods, such as rice and bread, which comprise the majority of their diet [ 13 ].

The postprandial insulin secretion of a variety of meals was estimated using the food insulin index (FII) [ 14 ]. In fact, the dietary insulin index (DII) may be computed using this metric [ 15 ]. Compared to the glycemic index (GI), which only communicates specific information about the carbohydrate content of meals and glycemic response [ 16 ], the DII is more appropriate for explaining the emergence of chronic diseases since it is accurately calculated based on insulin response [ 13 ]. Furthermore, the GI failed to effectively reflect the insulin response of a large number of meal components [ 16 ], but DII predicted insulin responses to mixed meals more accurately. There are contradicting studies regarding the impact of IR on BMD. Although certain studies have demonstrated a positive correlation between IR and BMD [ 8 , 10 , 11 ], others have failed a significant association between them [ 17 ]. The conflicting results compelled us to reassess their correlation. The objective of this study was to examine the correlation between Dietary Inflammatory Index (DII) and the susceptibility to osteoporosis in postmenopausal women from Iran. Because DII is properly determined based on insulin response rather than other mediators, it is more appropriate indicator than GI to predict the probabilities of chronic illness [ 18 ]. We postulated that insulin may stimulate bone growth and an increase in bone density. In the case that a significant negative association between DII and the incidence of osteoporosis were discovered, we would conclude that eating meals with high insulin index would be essential for postmenopausal women to avoid osteoporosis.

Study population

This case-control study recruited 380 postmenopausal women (190 cases and 190 controls) between the ages of 45 and 85 who were referred to Shariati hospital and several private clinics in Tehran, Iran. The rheumatology specialist’s diagnosis was established on the basis of the identification of osteoporosis using dual-energy X-ray absorptiometry [ 19 ]. The control group was selected from the visitors and patients’ companions who traveled to these institutions from various locations in Tehran and did not have any familial ties to the patients. Cases and controls were age- matched, and the participants in both groups were women who were postmenopausal, defined as having not had a menstrual period for at least 12 months. All participants refrained from using any drugs or dietary supplements that affect bone metabolism, including glucocorticoids, calcitonin, thyroxin, anticoagulants, antacids, calcium (500 mg/day), vitamin D (15 IU/day), glucosamine, or bisphosphonates. Additionally, they have not been diagnosed with any conditions that might affect their BMD status, such as renal, gastrointestinal, endocrine, or, rheumatic disorders. Moreover, they followed no specific diet throughout the previous year. Those who reported an inappropriate energy intake (< 800 kcal/day or > 4200 kcal/day) and those who did not answer more than 20% of the food frequency questionnaire (FFQ) items were excluded [ 20 ]. The ethics committee of the Islamic Azad University’s Science and Research Branch in Tehran, Iran, gave its approval for this work (IR.IAU.SRB.REC.1396.119).

Study variables

Body weight was measured with a digital scale (Tefal) with an accuracy of 0.1 kg while wearing light clothes, and height was measured using a tape meter with an accuracy of 0.1 cm. The anthropometric measurements were body mass index (BMI), which was determined using the following formula: BMI, weight (kg), and height (cm). BMI is equal to body weight (kg)/ [height (m)] 2 . The survey collected information on many factors like age (in years), level of education (under graduate/ graduate/ post graduate), breastfeeding status (yes/no), alcohol consumption (yes/no), weight (in kilogram), duration of lactation (in weeks), and use of oral contraceptives (yes/no). Additionally, a valid questionnaire [ 21 ] was implemented to evaluate the extent of physical activity. Its validity was verified by the “CSA Accelerometer Ambulatory Monitor” system (Model 7164) and the Daily Activity Questionnaire, which were administered to 2500 Danish men and women between the ages of 20 and 60 [ 21 ]. The validity and dependability of the calculation were verified in Iranian women [ 22 ], and the amount of physical activity was determined using metabolic equivalent hours per week [ 21 ]. According to their levels of physical activity, participants in the present research were divided into three groups: very low (less than 600 MET-minutes per week), low (between 600 and 3000 MET-minutes per week), moderate and high (greater than 3000 MET- minutes per week) [ 23 ]. Participants’ dietary consumption was recorded using a 168-item FFQ, which is a valid and trustworthy tool [ 24 , 25 ]. Next, the frequency of intake for each food item in the FFQ was translated to grams per day using household measurements [ 26 ]. Subsequently, the Nutritionist IV program was used to compute the quantity of macronutrients and micronutrients consumed.

Assessment of dietary insulin index

By dividing the area under the insulin response curve for 1000 kcal of the test meal after two hours by the area under the curve for 1000 kcal of glucose, the reference food, the food insulin index (FII) was determined. The insulin index of 68 food items was obtained from previous research [ 14 , 27 , 28 ]. Tea, coffee, and sodium were allocated an insulin index of 0 as a result of their negligible caloric and macronutrient levels. Additionally, the food insulin index of comparable items was implemented in the event that specific items were not included in the designated food list. For example, dates and raisins, which are classified as dried fruits, have comparable energy, carbohydrate, fat, protein, and fiber profiles. As a result, for dates, we used the insulin index of raisins as a guide. First, we used the following formula to determine the insulin load of each meal: Insulin load of a certain food = Insulin index of the food × calorie content per 1 g of that food × quantity of that food eaten [ 29 ]. The DIL for each person was then determined by adding up the insulin load of every dietary item. We further calculated each person’s DII by dividing DIL by total energy used.

Sample size calculation

A total of 176 samples were generated using GPower 3.1.9.2 (Kiel University, Germany) to analyze the sample size with α = 0.05, 95% power (β = 0.05), and an effect size of 0.1. In order to account for a 10% dropout rate, each group consisted of 190 people.

Statistical analysis

All statistical analyses were conducted using SPSS software, version 26, from the IBM Corporation, Amonk, NY, USA. The independent sample t-test was used to evaluate the mean of normally distributed qualitative variables across two groups, and one-way ANOVA was utilized to compare the mean of normally distributed quantitative variables across more than two groups. Furthermore, we employed the Mann-Whitney test to investigate the differences in non-normal variables between the two groups. The Chi-squared test was implemented to evaluate the correlation between categorical variables in the control and case groups. The frequency distribution indices were employed to elucidate the qualitative data, while the mean and standard deviation (SD) were computed to represent quantitative variables. The odds ratio (OR) and 95% confidence intervals (CI) were calculated using binary logistic regression after adjusting for physical activity, BMI, and alcohol use to assess the relationship between the DII and osteoporosis. All analyses were considered significant when P  < 0.05.

The demographic differences between the case and control groups are shown in Table  1 . There was no discernible difference in the mean age of the two groups (55.99 ± 6.73 vs. 55.58 ± 6.07 years, P  = 0.533). The mean DII in the control group was much greater ( P  < 0.001). The mean DII score for the case group was 33.53 ± 6.28, whereas the control group’s was 36.82 ± 8.98. Furthermore, the control group’s mean values for breastfeeding duration ( P  = 0.042) and physical activity ( P  < 0.001) were much greater. The control group’s weight was lower ( P  = 0.013), but their BMI was not different ( P  = 0.139). The alcohol consumption of cases was greater than that of controls ( P  < 0.001). The results shown in Table  2 show that there was no difference in the baseline characteristics across DII tertiles.

The average consumption of nutrients in the two groups is shown Table  3 . The control group exhibits considerably higher mean intakes of antioxidant vitamins and minerals, including vitamin A ( P  = 0.026), selenium ( P  = 0.002), alpha-carotene, beta-cryptoxanthin, vitamin C, zinc, and manganese ( P  < 0.001).

Table  4 describes the nutritional consumption among the various DII tertiles. Table  4 shows that there are no appreciable variations in the majority of nutrient intakes between the top and lowest tertiles of the DII.

After accounting for physical activity, weight, the duration of lactation, and alcohol consumption, Table  5 demonstrates a significant negative correlation between the DII and osteoporosis. The risk of osteoporosis decreased at a rate of 7% per unit increase in the DII (OR = 0.927; 95% CI = 0.888–0.967), as indicated in Table  5 .

Table  6 shows the relationship between DII tertiles and osteoporosis in both crude and adjusted models. According to the crude model, there was no significant correlation between people in the first and third tertiles of DII scores (crude OR = 1.35, 95% CI: 0.82–2.21, P  = 0.240), but the odds of osteoporosis for women in the second tertile of DII scores were approximately 2.22 times higher than those in the third tertile (crude OR = 2.22, 95% CI: 1.35–3.67, P  = 0.002). Furthermore, although there was no significant correlation between individuals in the first and third tertiles of DII scores (adjusted OR = 1.47, 95% CI: 0.87–2.49, P  = 0.154), the adjusted model showed that the probabilities of osteoporosis for those in the second tertile were almost 2.32 times higher than those in the third (adjusted OR = 2.32, 95% CI: 1.36–3.97, P  = 0.002).

According to the results of the present research, maintaining a diet with a high insulin index may improve bone mass density. In this work, we examined the relationship between the risk of osteoporosis and the dietary insulin score. Due to its reliance on insulin response rather than other factors, DII is a more accurate predictor of the probability of acquiring chronic disease compared to GI [ 18 ]. Previous studies indicated a somewhat advantageous correlation between DII and the probability of IR [ 13 ]. Our results demonstrate that the controls follow a diet with a higher tendency for insulinemia, as seen by the significantly higher mean DII in this group. This postprandial hyperinsulinemia may occur in IR gradually [ 9 ]. Furthermore, past studies have shown a positive association between IR and BMD [ 8 , 10 , 11 ]. Bazic et al. [ 10 ] examined the correlation between IR and BMD in postmenopausal women from Serbia. A positive connection was found between HOMA-IR and BMD-spine as well as bone mineral content. Furthermore, IR positively affects volumetric bone mineral density, as shown by a cross-sectional study [ 11 ] on postmenopausal Caucasian women. Additionally, the results of a cohort research [ 8 ], including close to 6000 senior men and women demonstrated a significant correlation between increased insulin and blood glucose levels and increased bone density and a decreased fracture risk. The relationship between IR and BMD is rather intricate. As a result, the processes that determine their precise relationship are not well known. Insulin may have anabolic effects on bone based on the research that is currently available [ 7 ]. The insulin receptors are expressed on the surface of osteoblasts and osteoclasts alike. Insulin is an anabolic hormone that has been shown in experimental investigations to support osteoblast growth [ 30 ]. Moreover, insulin-like growth factor 1 (IGF-1) receptors that are found on osteoblasts may be the source of this. Consequently, an increase in BMD may result from bone formation [ 31 ]. The inverse association between sex hormone-binding globulin (SHBG) and insulin is another likely example of a greater BMD in those with higher insulin levels [ 32 ]. Then, a drop in SHBG levels causes a rise in free estrogen concentration, which raises BMD [ 33 ].

In addition, prior research has shown the anabolic function of insulin in bone and established that physiological insulin concentrations may stimulate osteoblast growth, glucose uptake, and inhibit osteoclast activity [ 34 ]. Based on our research, the control group’s mean intake of protein and carbohydrates is significantly higher than that of the case group, which may increase the amount of insulin secreted in their bodies [ 35 ]. Additionally, because insulin plays an anabolic role in bone [ 34 ], it is possible that this group’s bone mass may be higher than that of the case group. Furthermore, the control group consumed significantly more vitamins and provitamins (A, alpha-carotene, beta-cryptoxanthin, and C), as well as minerals (calcium, phosphorus, magnesium, zinc, manganese, and selenium), than the case group, which consumed more total fat, saturated fat, MUFA, PUFA, and vitamin E. Furthermore, an increase in reactive oxygen species (ROS) levels might produce oxidative stress [ 36 ]. Previous research suggests that oxidative stress may contribute to osteoporosis because of its function in chronic inflammation [ 37 ]. Antioxidant micronutrients, such as vitamin A, vitamin C, zinc, manganese, and selenium help the body’s defense system against ROS [ 38 ] and reduce oxidative stress [ 36 ], which contributes to bone health. In addition, the synthesis of collagen and other proteins that comprise the bone structure is influenced by micronutrients, including calcium, magnesium, zinc, and vitamin C [ 39 ]. They contribute to the normal development and maintenance of bone mass by performing catalytic functions in the synthesis of bone matrix.

Obesity is exacerbated by an excessive consumption of dietary lipids, such as total fat, polyunsaturated fatty acids, and saturated fatty acids. This, in turn, results in the production of white adipose tissue, which generates pro-inflammatory substances, thereby establishing a protracted inflammatory state [ 40 ]. Osteoclasts are known to be primarily activated by pro-inflammatory cytokines like interleukin (IL)-1 and tumor necrosis factor-α (TNF-α), although IL-6 functions in concert with other agents that degrade bone [ 41 ]. Therefore, a number of variables that are linked to excess body fat, such as an increase in inflammatory cytokines and a shift in the pattern of adipokine production, negatively impact bone structure [ 42 ]. Based on our research, individuals in the lowest third of DII had notably greater consumption of calories, total fat, saturated fat, monounsaturated fat (MUFA), polyunsaturated fat (PUFA), vitamin E, and vitamin D. On the other hand, participants in the highest third of DII had considerably higher intakes of beta-cryptoxanthin, manganese, and selenium. No significant differences were observed among the tertiles for other nutrients. Consequently, the aforementioned mechanisms suggest that a higher ingestion of antioxidants, including beta-cryptoxanthin and manganese, may have a protective effect on bone health in participants who were in the third tertile of DII.

The relationship between DII and the risk of osteoporosis has not been investigated in previous research, to the best of our knowledge. On the other hand, additional research has demonstrated a robust correlation between specific indices and conditions, such as IR [ 13 ] and metabolic syndrome [ 43 ]. The current investigation also has the advantage of employing a validated food frequency questionnaire to gather data on food consumption. Nevertheless, it is subject to specific limitations. The initial limitation is that insulin scores can only provide an estimate of the total amount of insulinogenic food consumed. They are unable to evaluate the frequency of meals or the composition of food, which could potentially affect insulin response. The second reason is that the case-control design of this study precludes the examination of a coincidental relationship between the risk of osteoporosis and the dietary insulin index. Consequently, it is imperative that additional research corroborates these findings. Two additional drawbacks are recall and choose bias, which are inherent limitations of case-control studies. In order to mitigate recollection bias, this investigation implemented a validated FFQ. Additionally, we examined the FII of dietary items using the FII data from other research [ 14 , 27 , 28 ]. The comparable insulin index of foods must be used for the FII of some foods that were not included in the FFQ because Iranian foods have not yet been measured for FII. This could lead to a slight difference between the FII of foods consumed by individuals and the actual amount of this index in the reference list. Therefore, our findings are impacted by their limits. Another possible drawback of this research might be the absence of information on the length of time spent in the sun, since this could have an impact on bone health. Finally, we only considered the short-term consequence of ingesting foods that increase insulin index, which may increase the need for postprandial insulin and have transitory effects on serum insulin levels [ 44 ]. However, an insulinogenic diet may not have a long-term effect on insulin levels. Consequently, it is recommended that additional research be conducted to ascertain the long-term effects of the diet’s propensity to induce insulinemia on serum insulin and bone mass.

In summary, our results suggested that postmenopausal women may experience an increase in bone mass density by adhering to a diet that is abundant in foods with a higher insulin index. Consequently, it may be essential to consume nutrients that stimulate insulin production in order to prevent osteoporosis. Additional research, particularly prospective cohort studies, is necessary to substantiate these conclusions.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Dietary insulin index

Food frequency questionnaire

• Insulin resistance

Homeostasis model assessment of IR

Bone mineral density

Food insulin index

Glycemic index

Insulin-like growth factor 1

Sex hormone-binding globulin

Volumetric bone mineral density

Body mass index

Standard deviation

Confidence interval

Metabolic equivalent

Kilogram per square meter

Oral contraceptive pill

Kilo calorie

Monounsaturated fatty acid

Polyunsaturated fatty acid

Retinol activity equivalent

Reactive oxygen species

Interleukin

Tumor necrosis factor-α

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Shakiba Solgi

Proteomics Research Center, Department of Biostatistics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Farid Zayeri

Department of Nutrition, Electronic Health and Statistics Surveillance Research center, Science and Research Branch, Islamic Azad University, Hesarak Blvd, Daneshgah Square, Sattari Expressway, Tehran, Iran

Behnood Abbasi

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Solgi, S., Zayeri, F. & Abbasi, B. Association between dietary insulin index and postmenopausal osteoporosis in Iranian women: a case-control study. BMC Women's Health 24 , 401 (2024). https://doi.org/10.1186/s12905-024-03248-z

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Effective strategies for pregnancy and lactation-associated osteoporosis: teriparatide use in focus

• Published: 15 July 2024

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• Dalal S. Ali   ORCID: orcid.org/0000-0002-5378-5548 1 ,
• Aliya A. Khan   ORCID: orcid.org/0000-0003-3733-8956 1 &
• Maria Luisa Brandi   ORCID: orcid.org/0000-0002-8741-0592 2 , 3  

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Introduction

Pregnancy and lactation-associated osteoporosis (PLO) is a rare condition characterized by fragility fractures occurring during late pregnancy or lactation, primarily affecting the spine and causing significant morbidity and back pain. PLO can lead to mobility impairment and work incapacity, with recovery taking up to several years. Due to the lack of clinical trials, treatment strategies remain poorly defined, historically focusing on calcium supplements, vitamin D, and weaning from breastfeeding. However, recent attention has turned to teriparatide (TPD) as an option due to its anabolic properties and potential suitability for women of childbearing age.

This review evaluates TPD’s use in PLO treatment, using published systematic reviews and case studies. Over 300 cases with PLO were identified through PubMed, Google Scholar, and Cochrane searches until August 2023.

We identified 175 cases with PLO treated with TPD alone or followed by antiresorptive therapy. Most women (85.7%) were primiparas. The mean ± SD duration of TPD use was 15 ± 6 months. Among the study patients, 91.4% used TPD alone, while 8.6% (15/175) utilized sequential therapy. Approximately 93% of our cohort exhibited potential risk factors for PLO. Despite the increased risk of recurrent fractures in PLO, only 14.7% (20/175) of those treated with TPD sustained new fractures during a 9-month to 9 years’ follow-up period. The mean ± SD percent increase in BMD at the LS was 21.14% ± 7.4%, and at the FN it was 12.1% ± 9.3%. The baseline Z-scores at the LS ranged from –3.3 (–3.7 to –2.7), while the baseline Z-scores at the FN ranged from −2.0 (−2.7 to −1.5).

This review emphasizes PLO severity, advocating for increased awareness and timely interventions. TPD emerges as a promising therapeutic option in certain cases.

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Abbreviations

bone mineral density

C-telopeptide cross-linked type I collagen

Parathyroid related-protein

• Pregnancy and lactation-associated osteoporosis

teriparatide

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Dalal S. Ali & Aliya A. Khan

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Dalal S. Ali: conceptualization, data acquisition, analysis, methodology, original drafting and preparation of the manuscript, review/editing of the manuscript. Aliya A. Khan: review and editing; Maria Luisa Brandi: conceptualization, data acquisition, original drafting and preparation of the manuscript, review/editing of the manuscript, supervision.

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D.SA.: declares no conflict of interest. A.A.K.: declares no conflict of interest M.L.B.: Honoraria: Amgen, Bruno Farmaceutici, Calcilytix, Kyowa Kirin, UCB; Grants and/or speaker: Abiogen, Alexion, Amgen, Amolyt, Amorphical, Bruno Farmaceutici, CoGeDi, Echolight, Eli Lilly, Enterabio, Gedeon Richter, Italfarmaco, Kyowa Kirin, Menarini, Monte Rosa, SPA, Takeda, Theramex, UCB; Consultant: Aboca, Alexion, Amolyt, Bruno Farmaceutici, Calcilytix, Echolight, Kyowa Kirin, Personal Genomics, UCB.

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Ali, D.S., Khan, A.A. & Brandi, M.L. Effective strategies for pregnancy and lactation-associated osteoporosis: teriparatide use in focus. Endocrine (2024). https://doi.org/10.1007/s12020-024-03946-6

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Received : 18 May 2024

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Published : 15 July 2024

DOI : https://doi.org/10.1007/s12020-024-03946-6

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Effective strategies for pregnancy and lactation-associated osteoporosis: teriparatide use in focus

Affiliations.

• 1 Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada. [email protected].
• 2 Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada.
• 3 Fondazione FIRMO Onlus; Italian Foundation for the Research on Bone Diseases, Florence, Italy.
• 4 Donatello Bone Clinic, Villa Donatello Hospital, Sesto Fiorentino, Italy.
• PMID: 39008200
• DOI: 10.1007/s12020-024-03946-6

Introduction: Pregnancy and lactation-associated osteoporosis (PLO) is a rare condition characterized by fragility fractures occurring during late pregnancy or lactation, primarily affecting the spine and causing significant morbidity and back pain. PLO can lead to mobility impairment and work incapacity, with recovery taking up to several years. Due to the lack of clinical trials, treatment strategies remain poorly defined, historically focusing on calcium supplements, vitamin D, and weaning from breastfeeding. However, recent attention has turned to teriparatide (TPD) as an option due to its anabolic properties and potential suitability for women of childbearing age.

Methods: This review evaluates TPD's use in PLO treatment, using published systematic reviews and case studies. Over 300 cases with PLO were identified through PubMed, Google Scholar, and Cochrane searches until August 2023.

Results: We identified 175 cases with PLO treated with TPD alone or followed by antiresorptive therapy. Most women (85.7%) were primiparas. The mean ± SD duration of TPD use was 15 ± 6 months. Among the study patients, 91.4% used TPD alone, while 8.6% (15/175) utilized sequential therapy. Approximately 93% of our cohort exhibited potential risk factors for PLO. Despite the increased risk of recurrent fractures in PLO, only 14.7% (20/175) of those treated with TPD sustained new fractures during a 9-month to 9 years' follow-up period. The mean ± SD percent increase in BMD at the LS was 21.14% ± 7.4%, and at the FN it was 12.1% ± 9.3%. The baseline Z-scores at the LS ranged from -3.3 (-3.7 to -2.7), while the baseline Z-scores at the FN ranged from -2.0 (-2.7 to -1.5).

Conclusion: This review emphasizes PLO severity, advocating for increased awareness and timely interventions. TPD emerges as a promising therapeutic option in certain cases.

Keywords: PLO; Pregnancy and lactation-associated osteoporosis; Teriparatide; lactation.

© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.

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What do older voters want in the next election? Care for caregivers | The Excerpt

On Saturday’s episode of The Excerpt podcast: USA TODAY Health Reporter Karen Weintraub discusses the  challenges caregivers face, and how they might be reflected at the ballot box . Alec Baldwin's  'Rust' case has been dismissed  by a judge over 'suppressed' evidence. USA TODAY Election Reporting Fellow Sam Woodward tells us about  USA TODAY's (virtual) backstage pass to the Republican National Convention . AT&T says nearly all of its cell customers' call and text records  were exposed in a massive breach . 40% of cancers were found to be  preventable with lifestyle changes , according to new research. The Euros and Copa America  wrap up Sunday .

Hit play on the player below to hear the podcast and follow along with the transcript beneath it.  This transcript was automatically generated, and then edited for clarity in its current form. There may be some differences between the audio and the text.

Podcasts:  True crime, in-depth interviews and more USA TODAY podcasts right here

Taylor Wilson:

Good morning. I'm Taylor Wilson, and today is Saturday, July 13th, 2024. This is The Excerpt. Today, what older Americans and caregivers want as voters. Plus, a charge against Alec Baldwin in the shooting death of cinematographer Halyna Hutchins has been dismissed. And we look at new research about preventable cancer.

Older Americans are often caregivers and they vote. I spoke with USA TODAY Health reporter, Karen Weintraub, to learn more about what older Americans want out of this election.

Karen, thanks for hopping on.

Karen Weintraub:

Thanks for having me.

So Karen, what does polling and data tell us about older Americans and caregivers and what they really want out of this election?

Yeah. So a large number of people, especially people over 50, but also younger people, care for other people in their lives. So their parents, their children, their grandchildren. And they vote. People over 50 are much more likely to vote than younger people. They're more committed to voting. Something like 90% of people in these polls that AARP did in swing states said that they were going to vote, and that there was no doubt in their mind that they were going to vote. So, whereas other people vacillate a little bit or, "Yeah, maybe, I think." The over 50 are really committed to voting.

You spoke with several caregivers. Would just tell us a bit about Sandy Haas, her story as a caregiver and how she lands politically around some of these issues?

Sure. So she is more than a foot shorter than her husband, who was a police officer; big guy, used to being strong and tough. And now he's substantially disabled. He uses a wheelchair and needs help transferring from that wheelchair into his bed and needs help showering, needs help with the tasks of daily living, and because she's so much smaller than he is, she has a lot of trouble physically helping him do that. He's 73, she's 68. She has osteoporosis and a tremor in her hands.

And so, while she's helping him, if he falls on her, she's very likely to break a bone. And she's not so stable herself, and she doesn't really have any help. Their sons, one works nights, one lives 45 minutes away. She is a former nurse. She still teaches nursing, so she can afford a little bit of help. Somebody comes in once a week to help him shower. She wishes she could help him bathe more than once a week, but that's all she can afford right now.

And Karen, a researcher who helped conduct AARP polls about caregivers said there's a big hole that was left behind after the passage of the Affordable Care Act. Can you help us understand what he means by that?

Yeah. So the ACA doesn't cover nursing home care and it doesn't always cover at-home care. Some states will allow family caregivers. If I took care of my aging parents, for instance, I could get paid as a caregiver, as their caregiver in some states but not others. And so I spoke to another woman who said she would happily stay home and care for her mother if she could get paid for that, but because, I believe she lives in Nevada, she has to pay somebody to come into the house because she can't get paid for that work. It's a scattershot across the country and there's really not much help for a lot of people.

How important is the issue of Social Security among older Americans this election? And also, what are some of the other issues caregivers are focused on?

A lot of people of all ages are very concerned about Social Security going away. Interestingly, it doesn't always match up with who they say they're supporting. So, the Democrats have been very clear that they're fully supportive of maintaining Social Security the way it is, even though it is financially a little bit unstable, whereas the Republicans and Trump have been less clear in their support of Social Security. Older people say absolutely got to keep Social Security, not up for discussion at all. A large, large percentage of people say that. And yet, also a large percentage of people, particularly in the 50 to 65 age range, support Trump. He's winning in that group at the moment in polling. So people aren't always consistent on that. The over 85s go for Biden, but younger people in the over 50 group tend to side with Trump at the moment.

And beyond Social Security, are there any other issues that caregivers are really honing in on in particular this election cycle?

Medicare, same thing. People want their Medicare to be there. Drug prices, it's a huge issue for a lot of people. Biden has worked to lower prices of some drugs, but there's still a huge cost for a lot of people. And medication, medical costs are still the leading cause of bankruptcy in America.

Karen Weintraub covers health for USA TODAY. Thanks for the insight, Karen. Appreciate it.

The involuntary manslaughter charge against Alec Baldwin in the 2021 shooting death of cinematographer Halyna Hutchins has been dismissed on the grounds that prosecutors and law enforcement withheld evidence that might be favorable to the actor's defense. The conclusion of the case comes more than two years after Baldwin's prop gun discharged during a rehearsal for the movie Rust, killing 42-year-old Hutchins and wounding director Joel Souza. A judge dismissed the charge yesterday afternoon with prejudice, meaning prosecutors cannot refile the same claim. Baldwin sobbed into his hands as the judge read out the order. Baldwin's lawyers alleged in their motion to dismiss the case that sheriffs and state prosecutors in New Mexico concealed from Baldwin evidence that could be linked to the source of the bullet that killed Hutchins. Prosecutors and sheriffs argued that evidence had no relevance or value to Baldwin's case.

The Republican National Convention kicks off on Monday in Milwaukee, and we have you covered at USA TODAY with a text thread called Your Vote, offering a virtual backstage pass. I spoke with USA TODAY Election Reporting Fellow, Sam Woodward, to learn more.

Sam, thanks for hopping on The Excerpt today.

Sam Woodward:

Happy to be here, Taylor.

So Sam, let's just start here. Tell us about this SMS campaign called Your Vote.

Your Vote is USA TODAY's texting thread on all things elections where subscribers get news and insights from our team of journalists sent directly to your messaging apps.

And why did you all decide to go this route for this year's convention?

We understand that it's really easy to feel overwhelmed or even numb to news, especially during an election cycle. So we wanted to hold a space where our readers could interact with us, cut through the noise of partisan ads and see what it's like to be in the room where the news is being made. Conventions are a really unique aspect of the American Party system, and they also take a while. So for a week's worth of news, we wanted to make it accessible to our audience and give you a backstage pass to everything you might miss at home.

And so, how can people sign up?

If you have time to doom scroll on your phone, you definitely have time to sign up. All you have to do is text us at (301) 888-6791 and you'll be prompted to confirm your subscription.

So Sam, people can send questions in and you yourself will respond with direct answers. I'm excited for this. How exactly will this work, and what sorts of messages can folks expect?

Yeah, that's right. I'll be on the other side of your screen, reading all of your questions. It kind of works the same way it would if you were texting your resident politically-savvy friend. You send a message to our number and I can either answer directly to you, or if it's a question I think others would be interested in hearing the answer, I can send a text message to everyone. And don't worry, it's not a nationwide group chat, so only I can see your response.

So as you said, Sam, this is kind of a peek behind the curtain. You'll be there on location. What aspect of the convention are you most looking forward to or interested in covering this coming week?

This is my first convention, so I'd be lying if I said everything wasn't exciting to me. But something I'm really excited to do is talk with the actual delegates who will be casting their votes. For the most part, they're real Republican voters, not party insiders or politicians. So I'm really interested in hearing their perspective on not only the convention, but also the state of politics as a whole.

So exciting. So, can we expect a similar thing, this kind of SMS campaign next month when the Democrats meet?

Absolutely. Your vote will be guiding subscribers through the rest of the election season, including the Democratic National Convention in August.

All right. Sam Woodward is an election reporting fellow with USA TODAY. Exciting stuff. Thank you, Sam.

Thanks, Taylor.

AT&T said yesterday that the call and text message records of nearly all of its cellular customers were exposed in a massive breach. The telecommunications giant said in a filing with the US Securities and Exchange Commission that it learned in April that customer data was illegally downloaded from their workspace on a third party cloud platform. According to the company, the compromised data included files containing AT&T records of calls and texts of nearly all of its cellular customers, customers of mobile virtual network operators using AT&T's wireless network, as well as AT&T landline customers who interacted with those cellular numbers between May 1st, 2022 and October 31st, 2022.

The company said data does not contain the content of calls or texts, personal information like Social Security numbers, dates of birth, or other personally identifiable information. The company, though, says that while the compromised data also does not include customer names, there are often ways using publicly available online tools to find the name associated with a specific phone number.

There's new evidence of the health benefits of avoiding smoking, excessive drinking, and being dangerously overweight. They're the leading preventable causes of cancer in adults, a new study found. An American Cancer Society study published this week estimates 40% of new cancer cases and 44% of cancer deaths in people 30 and over could be avoided if people cut out high-risk behaviors like smoking and drinking. Experts say the study brings fresh evidence for public health leaders to encourage people to adopt healthy lifestyles to reduce the risk of cancer, and ample evidence that people should take action to prevent it. The causes of cancer the study said were preventable included cigarette smoking as the top risk factor, followed by excess body weight and alcohol consumption. You can read more with a link in today's show notes.

It's a huge weekend of soccer as the Euros and Copa America wrap up tomorrow with their respective finals. First up, Spain will take on England at 3:00 PM Eastern Time. The English are looking for their first European title ever, while Spain last won it in 2012. And stateside, the Copa America final will take place tomorrow night at 8:00 Eastern in Miami as Argentina take on Colombia. Argentina are defending Copa America, and World Cup champions, while Colombia are looking for their first title since 2001. You can follow along with USA TODAY Sports.

And New York will be experiencing its final Manhattan Henge of the year this weekend. The phenomenon occurs when the setting sun aligns exactly with the Manhattan street grid, creating a unique glow of light. There was a full event yesterday evening and another partial Manhattan Henge will be visible tonight just after 8:00 PM Eastern. You can see pictures on usatoday.com.

We followed the spread of misinformation on our podcast for years. What if there's a way to build up immunity against it? My co-host, Dana Taylor, spoke with Sander van der Linden about pre-bunking rather than debunking and how it's more effective for combating disinformation. You can hear this conversation right here on this feed tomorrow after 5:00 AM Eastern Time.

And thanks for listening to The Excerpt. You can get the podcast wherever you get your pods. And if you're on a smart speaker, just ask for The Excerpt. I'm Taylor Wilson, back Monday with more of The Excerpt from USA TODAY.