There is paucity of data from low-middle income countries (LMIC) on osteonecrosis (ON) in survivors of childhood acute lymphoblastic leukaemia (cALL-survivors). We conducted this study to estimate prevalence of ON in cALL-survivors of Indian ethnicity and factors affecting it. This cross-sectional study enrolled cALL-survivors post completion of treatment. ON was estimated using magnetic resonance imaging of hip joint. Demographic, anthropometric, therapy/disease-related and biochemical/endocrine factors affecting calcium homeostasis were studied in two groups: with and without ON. Total of 61 out of enrolled 87 cALL-survivors with median age 118 months (range:84-283) were analysed after median 12 months (range:1-113) post completion of therapy. Two-third of the cohort was male and 41% were pubertal. 5/61 (8.2%) were found to have asymptomatic and non-traumatic ON. Three ON were grade II and two were grade III as per Niinimaki radiological classification. Cumulative doses (CD) of dexamethasone, glucocorticoids (GCs), L-asparginase, anthracycline and low serum vit D levels were associated with ON. Other demographic factors including age at diagnosis > 10 year, disease-related, therapy-related factors including cranial irradiation and biochemical/endocrine factors were not associated with ON. The median CD of dexamethasone (p = 0.004) and GCs (p = 0.008) were significantly high in group with ON. Median CD of methotrexate(p = 0.051), anthracycline(p = 0.058) and serum vit D levels(p = 0.054) along with serum alkaline phosphatase levels(p = 0.06) had a trend towards significance but were not statistically significant in ON group. Prevalence of ON of hip in our cohort of cALL-survivors was 8.2%. Higher CD of GCs appeared to be the most significant risk factor associated with ON in our cohort.

Research on the effectiveness of food fortification in addressing vitamin D deficiency among Indians is scarce. Thus, this study aimed to assess the effectiveness of consumption of vitamin D fortified foods among families living in Pune, India over 2 years.

Data in this community-based, longitudinal study were collected from 104 families recruited in two arms [Fortified: 51 families (180 participants); Unfortified: 53 families (173 participants)]. Liquid Chromatography Tandem Mass Spectrometry was used to estimate serum 25OHD2 and 25OHD3 concentrations. Difference in the mean change in 25OHD2 concentrations over 2 years between the two arms was the primary endpoint. Improvement of vitamin D status at endline was the secondary endpoint.

Consumption of vitamin D rich foods was rarely reported. Participants in the fortified arm consumed an average of 42.5% of the RDA for vitamin D (255 IU vitamin D/day) throughout the study period. Endline 25OHD2 concentrations in children and adults in the fortified arm were higher by 1.3 and 1.2 nmol/L, respectively, as compared to their unfortified arm counterparts, after adjusting for age and body fat. Neither the change in total 25OHD concentrations nor the improvement in D status were significantly different between the arms.

The current vitamin D fortification strategy in India, while effective in maintaining the vitamin D2 concentrations in both children and adults, was ineffective in improving total vitamin D concentrations or status. There is a need for reassessment of the Indian food fortification policy regarding fortificant type, amount, and vehicle to achieve desired outcomes effectively.

Clinical Trials identifier NCT05541094 (date: 21st March 2023)-retrospectively registered.

A cost-effectiveness analysis of FRAX® intervention thresholds (ITs) in Indian women over 50 years indicated that generic alendronate was cost-effective for age-dependent major osteoporotic fracture (MOF) ITs and hip fracture (HF) ITs starting at ages 60 and 65 years for full and real-world adherence, respectively. Alendronate was cost-effective at fixed MOF IT of 14% and HF IT of 3.5%, regardless of age.

Osteoporosis represents a significant public health challenge in India, with an increasing economic burden due to the aging population. This study evaluated the cost-effectiveness of using fracture risk assessment tool (FRAX®)-based intervention thresholds (ITs) for managing osteoporosis with generic alendronate in Indian women.

A Markov microsimulation model, adapted to the Indian healthcare context, was used to simulate the costs and quality-adjusted life years (QALYs) associated with different treatment strategies. The one-time gross domestic product (GDP) per capita (estimated at INR 1,97,468/QALY gained) was used as the cost-effectiveness threshold.

The model revealed that generic alendronate is cost-effective for major osteoporotic fracture (MOF) ITs beginning at age 60 years with full adherence-incremental cost-effectiveness ratio (ICER) of INR 102,151 per QALY gained, and age 65 with real-world adherence-ICER of INR 28,203 per QALY gained (conversion rate used is 1 US dollar (USD) = INR 83.97 and 1 EURO = INR 92.70). Hip fracture (HF) ITs showed similar cost-effectiveness at ages 60 (ICER of INR 67,144) and was the dominant strategy (i.e., more QALYs for lower costs) at ≥ 65 years. Fixed ITs of 14% for MOF and 3.5% for HF proved cost-effective across all age groups (dominant strategy for ages ≥ 65 years). Limitations of our study include the reliance on fracture incidence data from Singaporean Indians and variability in fracture prevalence across India.

The results support the integration of FRAX®-based fixed ITs from the age of 50 years and age-based ones from the age of 65 years in India to optimize resource allocation and improve osteoporosis management.

Osteoporosis is a silent disease that is more prevalent among postmenopausal women (PMW) due to hormonal transition. Various toolkits, including the Osteoporosis Knowledge Assessment Tool (OKAT), were available for the knowledge assessment. The Osteoporosis-related knowledge is crucial for preventing osteoporosis, but there is no validated, reliable questionnaire in Tamil to measure this knowledge.

To validate the Tamil version of the OKAT (OKAT-T) and its psychometric properties to measure the knowledge of osteoporosis for use in postmenopausal women.

This cross-sectional study was done in two phases, as translation of OKAT in Tamil and validation of OKAT-T among 430 postmenopausal women in both rural and urban regions. Reliability was examined by the Flesch reading ease (FKRE&G) and McNemar's test, along with difficulty index, item discrimination and item-total correlations, inter-item consistency (Cronbach's alpha coefficient).

The overall mean age of the 430 PMW was 59.53 ± 9.83 years. The results showed a good and satisfactory face validity and FKRE&G score (55.9). The Cronbach's alpha for the overall scale was calculated as 0.85 and considered to be good and satisfactory. As per the difficulty index, 19 items had a 0.3 to 0.7, implying that the questionnaire was easy to understand and satisfactory. Similarly, a test-retest was assessed, which was statistically significant for only six items out of 26, showing that the tool has stable reliability.

The management of chronic disorders such as osteoporosis has become more challenging for patients especially among PMW and healthcare professionals due to the increasing life expectancy and urbanization. The use of an Osteoporosis Knowledge Assessment tool that has been tailored to people's understanding and developed in the local language can raise awareness levels about osteoporosis, encourage the adoption of osteoprotective strategies, and provide guidance on treatment options.

There is evidence that diabetic peripheral neuropathy (DPN) is associated with increased risk for fractures in type 2 diabetes mellitus (T2DM). We planned a study to assess the prevalence of osteoporosis and vertebral fractures (VFs) in postmenopausal type 2 diabetic women aged 40-60 years with DPN and to find out their relationship with severity of DPN.

This cross-sectional observational study included sixty-two postmenopausal type 2 diabetic women of age 40-60 years, out of them thirty-two were with DPN and thirty were without DPN. The presence of DPN was established based on history and clinical examination. Plain X-ray spine and bone mineral density (BMD) measured by dual-energy X-ray absorptiometry were used to assess vertebral fracture and osteoporosis, respectively.

The prevalence of osteoporosis in women with DPN was 68.75% at lumbar spine (LS) and 18.75% at femoral neck (FN), and osteoporosis at LS was statistically significant compared to those without DPN (P = 0.002). On subgroup analysis in women with DPN, the osteoporosis at LS showed significant association with lower body mass index (BMI) (P = 0.015), but not with severity of DPN. The prevalence of VFs in women with DPN was 6.25% with no statistical significance in comparison with other group.

Our study revealed high prevalence of osteoporosis at LS in postmenopausal type 2 diabetics with DPN. VFs are most common consequence of osteoporosis, although we could not find significant prevalence of VFs in women with DPN that may be due to small sample size and cross-sectional study design.

Type 2 diabetes mellitus (T2DM) increases the risk of fragility fractures, despite the fact that areal bone mineral density (aBMD) is either increased or normal compared to healthy non-diabetic subjects. Hence, the trabecular bone score (TBS) is under investigation in this patient cohort as an alternative metric for the assessment of bone health. The present study aimed to determine TBS in post-menopausal women diagnosed with T2DM and in non-diabetic individuals.

This cross-sectional study enrolled 101 individuals with T2DM and 101 individuals without overt T2DM (43 individuals with pre-diabetes and 58 normoglycaemic individuals). Participants underwent a comprehensive history and physical examination, biochemical investigations, and a dual-energy X-ray absorptiometry (DXA) scan with TBS measurement.

Post-menopausal women with T2DM did not exhibit any significant difference in aBMD levels in comparison to those with pre-diabetes or normoglycaemic individuals. Although there was no statistically significant difference in aBMD among the three groups, the mean TBS value was significantly lower in the T2DM group when compared to both comparison groups (P < 0.001). Additionally, glycated haemoglobin (HbA1c) and the duration of diabetes demonstrated a significant negative correlation with TBS.

TBS may serve as a valuable tool for assessing bone health in individuals with T2DM, particularly when aBMD does not accurately predict the risk of fragility fractures. Both glycaemic control and the duration of diabetes significantly impact TBS values. In individuals with T2DM, incorporating TBS measurements alongside aBMD assessments could offer a more comprehensive evaluation of their bone health.

To investigate the relationship between glycosylated Hemoglobin (HbA1c) levels and bone mineral density (BMD) in individuals with varying glycemic statuses, including diabetes, prediabetes, and controls.

This cross-sectional study conducted in Bengaluru, India, included 336 participants aged 20 to 60. Blood samples were taken to assess fasting blood glucose, HbA1c, and lipid profile. Participants were divided into tertiles based on HbA1c levels: low(HbA1c ≤ 5.5%), moderate(HbA1c > 5.5-6.0%), and high(HbA1c ≥ 6.1%).Dual energy-X-ray absorptiometry(DXA) measured hip, spine, and total BMD as indicators of bone health.

Intermediate and high HbA1c tertiles had a significantly higher hip and total BMD compared to low HbA1c tertiles (p < 0.001 and p = 0.006 for hip and total BMD). Spine BMD was comparable between the three groups. After adjusting for age, gender and BMI, a potential independent effect of glycemic control on hip BMD was observed (Low vs. intermediate and high glycemic status: β: 0.041, 95% C.I.: 0.003, 0.078, p = 0.034).

Elevated HbA1c might be associated with higher hip and overall BMD as observed through DXA. Nonetheless, this doesn't necessarily imply better bone health; further evaluation is advised to prevent fractures.

The online version contains supplementary material available at 10.1007/s40200-024-01473-9.

To evaluate comprehensive bone health among young Indian women, including bone mass, microarchitecture, and turnover, in relation to their non-alcoholic fatty liver disease (NAFLD) status.

This cross-sectional study (May 2018-November 2019) recruited women with a history of gestational diabetes mellitus (GDM) and normoglycemia in their index pregnancy, who were at least 6 months postpartum. All participants underwent abdominal ultrasonography for determination of NAFLD status (grades 2 and 3: severe NAFLD) and transient elastography (FibroScan) for hepatic fibrosis (LSM >6 kPa). Bone mass was assessed by DXA, bone microarchitecture with trabecular bone score {TBS} (low TBS ≤ 1.310) and bone turnover with markers of bone formation (osteocalcin and P1NP), and resorption (CTX).

Bone mineral density (BMD) at femoral neck (p = 0.026) and total hip (p = 0.007) was significantly higher among women with NAFLD (n = 170) compared to those without (n = 124). There was no significant difference in bone turnover markers between the two groups. The presence of NAFLD [adjusted OR: 1.82 (1.07, 3.11)] was associated with low TBS, with a greater strength of association among women with severe NAFLD [adjusted OR: 2.97 (1.12, 7.88)]. However, these associations were attenuated and no longer significant after additionally adjusting for BMI. Women with NAFLD and hepatic fibrosis manifested significantly higher BMD at lumbar spine, femoral neck, and total hip (p < 0.001 for all) and significantly lower bone turnover markers (osteocalcin, p = 0.009 and CTX, p = 0.029), however, the association with low TBS was not observed.

Among young Indian women, NAFLD is associated with increased bone mass and impaired bone microarchitecture, and hepatic fibrosis with increased bone mass and reduced bone turnover.

Excess dietary salt causes increased urinary calcium and this may lead to bone loss. We proposed to study the association between dietary salt intake and bone health in postmenopausal women from southern India.

An observational study in which community-dwelling postmenopausal women were recruited. Daily salt intake and urine calcium/creatinine ratio were assessed. Bone biochemistry and densitometric parameters such as bone mineral density (BMD), trabecular bone score (TBS) vertebral fractures, and bone strain index (BSI) were assessed using Dual Energy X-Ray Absorptiometry (DXA).

A total of 383 postmenopausal women with a mean ± SD age of 59.8 ± 7.2 years and BMI of 25.2 ± 4.6 kg/m2 were recruited. Among the participants, 165/383(43.1%) had osteoporosis at any site and 21% had moderate-severe vertebral fractures. The BMD at lumbar spine and femoral neck, TBS and BSI were significantly (p < 0.001) lower and the CTx was significantly (p = 0.008) higher among women with high salt intake (7.2 g/day) as compared to those with salt intake of <7.2 g/day. The prevalence of osteoporosis, low TBS, high BSI, and moderate-severe vertebral fractures significantly increased across low to high salt-intake categories. An ROC analysis showed that excess dietary salt was significantly associated with osteoporosis at any site with an AUC of 0.870 (95% CI: 0.832-0.907). On a multivariate analysis, excess salt intake conferred the highest odds of osteoporosis (OR: 2.296; 95% CI: 1.909-2.761).

Excess dietary salt is associated with high urinary calcium and compromised bone health among postmenopausal women from southern India. This may be a modifiable risk factor in osteoporosis and warrants further research.

This pilot audit explored how bone health is assessed patients with diabetes in diverse centres across Asia. Only 343 of 1092 (31%) audited patients had a bone health assessment, 27% of whom were diagnosed with osteoporosis. Quality improvement strategies are needed to address gaps in patient care in this area.

The Asia Pacific Consortium on Osteoporosis (APCO) Framework outlines clinical standards for assessing and managing osteoporosis. A pilot audit evaluated adherence to clinical standard 4, which states that bone health should be assessed in patients with conditions associated with bone loss and/or increased fracture risk; this report summarises the audit findings in patients with diabetes. A secondary aim was to assess the practicality and real-world use of the APCO bone health audit tool kit.

Eight centres across Asia participated in the pilot audit, selecting diabetes as the target group. Participants reviewed their practice records for at least 20 consecutively treated patients with the target condition. Questions covered routine investigations, bone health assessment, osteoporosis diagnosis, and patient referral pathways. Data were summarised descriptively.

The participants represented public hospitals, university medical centres, and private clinics from India, Malaysia, Pakistan, Singapore, Taiwan, and Vietnam that see an estimated total of 95,000 patients with diabetes per year. Overall, only 343 of 1092 audited patients (31%) had a bone health assessment. Osteoporosis was subsequently diagnosed in 92 of 343 (27%) patients.

Bone health was not assessed in most patients with diabetes. The results provide insight into current practices across diverse Asian centres and demonstrate the practical value of the audit tool kit. Participant feedback has been used to improve the tool kit. Results of this pilot audit are being used in the respective centres to inform quality improvement projects needed to overcome the gap in patient care.

Bone is a dynamic tissue. It remodels, preserving serum calcium, repairing microdamage, and maintaining strength. Osteoporosis is caused by a decrease in bone strength, which manifests clinically as low-energy vertebral and non-vertebral fractures. Osteoporosis poses a significant public health challenge. While it's often portrayed as primarily impacting postmenopausal women, there's been growing recognition among researchers and clinicians regarding its prevalence in men. Major fracture in men has higher mortality rates than in women. Denosumab is a fully human monoclonal immunoglobulin G2 (IgG2) antibody that binds to RANKL, the principal regulator of osteoclastic bone resorption. Multiple studies suggest that denosumab is both effective and safe, exhibiting higher adherence rates and greater patient satisfaction. In this narrative review, we highlighted the effects of denosumab in men with osteoporosis, subsequent changes in bone mineral density, and bone turnover markers outlining the literature and guideline support.

This study was aimed to determine the ideal thresholds for bone mineral densities in our tested Jordanian cohort to initiate bisphosphonate pharmacotherapeutics in order to establish a national protocol for prescribing bisphosphonates that is tailored to the local population, rather than relying on global T and Z scores standards.

This retrospective study analyzed the entire population of adult patients at Prince Rashid bin Al-Hussein Hospital Rehabilitation and Rheumatology Center between August and October 2023 for the purpose of screening, monitoring, diagnosing, and treating osteoporosis. The study included 328 clients suspected to have osteoporosis, selected based on criteria such as primary osteoporosis or potential secondary osteoporosis. The study used two fracture risk assessment tools (FRAX) dichotomized states: <3% (negative state) and ≥3% (positive state), as well as <20% (negative state) and ≥20% (positive state). Binary logistic regression analysis, receiver-operating characteristic, and sensitivity analysis tests were performed sequentially to analyze the performance of prognosticators and sensitivity indices to evaluate their sensitivity, specificity, and accuracy indexes.

The study involved 328 clients at a rehabilitation clinic, with 82.62% (271) females and 17.38% (57) males. The majority were aged between 60 and 69 years, with a slightly higher obesity rate in females. The study found that initiation of bisphosphonates in Jordanian cohorts with optimal bone mineral density thresholds of 0.775 g/cm2 may significantly reduce the risk of hip osteoporosis over 10 years, with sensitivity, specificity, and accuracy indexes of 78.6%, 88.46%, and 50.61%, respectively, with a performance utility of 0.896±0.026 (p-value<0.001), 95% CI (0.846-0.946).

Due to ethnicity differences, exploring regional or national specific bone mineral density thresholds for bisphosphonates initiation may be a better optional choice than adopting global T-score standards.

Bone fragility is an emerging complication of diabetes. People with diabetes are at a significantly higher risk of fractures compared to the general population. Bone fragility occurs in diabetes as a result of complex and poorly understood mechanisms occurring at the cellular level contributed by vascular, inflammatory and mechanical derangements. Bone mineral density (BMD) as assessed by DEXA is low in type 1 diabetes. Type 2 diabetes has a high risk of fracture despite a normal to raised BMD. DEXA thus underestimates the fracture risk in diabetes. Data are scare regarding the efficacy of the available therapies in this low bone turnover state.

Bisphosphonates, synthetic analogs of endogenous pyrophosphates, are pivotal in managing various bone disorders, primarily osteoporosis, which affects millions globally. While osteoporosis, especially postmenopausal osteoporosis, significantly benefits from bisphosphonate therapy, considerations arise regarding their administration and potential side effects.

Bisphosphonates, divided into nitrogen-containing and non-nitrogenous groups, exert their influence through distinct mechanisms, with the former being notably more potent. The role of bisphosphonates in other diseases, such as Paget's bone and skeletal metastasis disease is also discussed. Detailed information on the administration routes, dosage regimens, and considerations for drug holidays is provided. The article navigates through the chemical structure, generations, and mechanism of action of bisphosphonates. The article covers administration routes, dosage regimens, and drug holidays, in addition to discussing potential adverse effects and contraindications.

Bisphosphonates hold an unrivaled legacy in the management of osteoporosis. The ubiquitous availability and the cost-effectiveness of these time-tested medications make them an invaluable asset in the osteoporosis treatment landscape, especially in developing nations like India.

Reduced bone density and increased fragility are hallmarks of osteoporosis, making the disease a major public health concern. The disease necessitates early diagnosis and appropriate therapy depend on an accurate evaluation of bone health. Essential tools for assessing osteoporosis include dual-energy X-ray absorptiometry (DEXA) and other imaging modalities.

This chapter focuses on dual-energy X-ray absorptiometry (DEXA) and other imaging methods as essential tools for assessment of osteoporosis. The chapter also explores complementary imaging modalities that help overcome limitation of DEXA by providing insights into the microarchitecture and bone quality.

T-scores, used to categorise bone health, are determined by DEXA by comparing bone mineral density to age-matched standards. Bone mineral density (BMD) is the most common indicator of bone health; nevertheless, DEXA may misclassify bone health owing to reasons other than BMD. These constraints may be overcome with the use of complementary imaging methods, which provide information on the microarchitecture and quality of bone. The evaluation of bone structure is aided by high-resolution peripheral quantitative computed tomography (HR-pQCT), which produces precise 3D images of the trabecular and cortical bone compartments. Independent of traditional methods of gauging fracture risk, quantitative ultrasonography (QUS) uses an analysis of the characteristics of sound waves to determine bone health. Diagnostic precision is improved by magnetic resonance imaging (MRI) due to its ability to view bone marrow and trabecular structure without the use of ionising radiation.

New methods, such as the trabecular bone score (TBS), examine bone texture and provide more data on the likelihood of fracture than conventional DEXA. By modelling bone strength using imaging data, finite element analysis (FEA) provides a biomechanical viewpoint on breakage probability. These combined methods boost diagnostic accuracy and pave the way for individualised treatment plans. Imaging helps with therapy monitoring as well as diagnosis. By monitoring bone density and structure over time, therapy effectiveness or course corrections may be quickly identified. The availability of sophisticated imaging techniques and the standardisation of procedures provide obstacles not withstanding their advantages. Ongoing work is being done to solve these issues and standardise and disseminate these methods in a variety of contexts.

The evaluation of osteoporosis is significantly aided by DEXA and other imaging methods. While DEXA is still the gold standard for diagnosing osteoporosis, other imaging techniques may shed light on bone health in greater detail. These methods improve fracture risk prediction and treatment assessment by providing information on bone architecture, quality, and strength. Integration of several imaging modalities shows potential for bettering osteoporosis therapy and patient outcomes as the field develops.

Liver transplant outcomes have improved over the years, and currently, the quality of life and long-term well-being of these patients needs to be improved. Improving bone health goes a long way toward achieving this objective. Poor bone health (osteopenia and osteoporosis) although prevalent, is often overlooked owing to its asymptomatic nature. It can be complicated by debilitating fracture affecting quality of life. It is recommended to assess and optimize bone health prior to liver transplant. Multiple factors contribute to poor bone health in a liver transplant recipient and it is vital to understand and ameliorate these. A careful and targeted approach with inputs from multidisciplinary team involving transplant physician, endocrinologist, occupational therapist, nutritionist, and nursing personnel may often be required. In this review, we aim to concisely discuss the various aspects related to prevalence, pathophysiology, evaluation, treatment, and follow-up of bone disease among liver transplant recipients.

Osteoporosis is a metabolic bone disorder that over time results in bone loss and raises the risk of fracture. The condition is frequently silent and only becomes apparent when fractures develop. Osteoporosis is treated with pharmacotherapy as well as non-pharmacological therapies such as mineral supplements, lifestyle changes, and exercise routines. Herbal medicine is frequently used in clinical procedures because of its low risk of adverse effects and cost-effective therapeutic results. In the current review, we have used a thorough strategy to identify some known medicinal plants with anti-osteoporosis capabilities, their origin, active ingredients, and pharmacological information. Furthermore, several signaling pathways, such as the apoptotic pathway, transcription factors, the Wnt/-catenin signaling pathway, and others, are regulated by bioactive components and help to improve bone homeostasis. This review will provide a better understanding of the anti-osteoporotic effects of bioactive components and the concomitant modulations of signaling pathways.

Calcium is imperative in maintaining a quality life, particularly during later ages. Its deficiency results in a wide range of metabolic disorders such as dental changes, cataracts, alterations in brain function, and osteoporosis. These deficiencies are more pronounced in females due to increased calcium turnover throughout their life cycle, especially during pregnancy and lactation. Vitamin D perform a central role in the metabolism of calcium. Recent scientific interventions have linked calcium with an array of metabolic disorders in females including hypertension, obesity, premenstrual dysphoric disorder, polycystic ovary syndrome (PCOS), multiple sclerosis, and breast cancer. This review encompasses these female metabolic disorders with special reference to calcium and vitamin D deficiency. This review article aims to present and elaborate on available data regarding the worldwide occurrence of insufficient calcium consumption in females and allied health risks, to provide a basis for formulating strategies and population-level scientific studies to adequately boost calcium intake and position where required.

Advancing age, declining health status, and a shift in benefit/risk balance warrant judicious use of preventive medications in older persons, including consideration of deprescribing. Lack of guidance on deprescribing is a major barrier for prescribers to consider deprescribing in daily practice. The aim of this review was to evaluate to what extent osteoporosis guidelines include bisphosphonate deprescribing recommendations.

We conducted a systematic review, searching PubMed, Embase, and grey literature. We included guidelines on treatment of osteoporosis with bisphosphonates. Two independent reviewers screened titles, abstracts, and full texts. Recommendations for deprescribing were extracted, and quality of guidelines were assessed.

Among 9345 references, 42 guidelines were included. A total of 32 (76%) guidelines included deprescribing recommendations: 29 (69%) guidelines included non-specific deprescribing recommendations framed as a drug holiday, of which 2 (5%) also included specific deprescribing recommendations based on individual health context (e.g. life expectancy, frailty, function, preferences/goals). Twenty-four (57%) guidelines included practical deprescribing recommendations, and 27 (64%) guidelines included recommendations for when deprescribing should not be considered.

Bisphosphonate deprescribing recommendations in osteoporosis guidelines were primarily framed as drug holidays, with limited guidance on how to make individualized deprescribing decisions based on individual health context. This suggests a need for additional focus on deprescribing in osteoporosis guidelines.

There is paucity of literature on the impact of teriparatide on hip geometry and bone microarchitecture globally and none from the Indian subcontinent. This study examined the outcome of teriparatide therapy on vertebral fractures, bone mineral density (BMD), hip structural analysis (HSA), and trabecular bone score (TBS) in Indian postmenopausal women with severe osteoporosis.

Ambulatory postmenopausal women above the age of 50 years with either severe osteoporosis or vertebral fractures, or both, were recruited. All patients received cholecalciferol (2000 IU/day), calcium carbonate (elemental calcium 1 g/day), and teriparatide (20 mcg subcutaneously/day) for 24 months. Baseline bone biochemistry, BMD, TBS, and HSA were assessed and repeated after 24 months of therapy. Incident vertebral and nonvertebral fractures were also studied.

A total of 51 postmenopausal women with mean (SD) age of 65.7(8.6) years, and mean (SD) body mass index of 22.7 (3.5) kg/m2 were recruited in this study. Vertebral fractures were present in 74.5% (38/51) at baseline. Following teriparatide therapy, significant improvement was observed in the BMD (g/cm2) at both the lumbar spine (0.706-0.758: p < 0.001) and femoral neck (0.551-0.579: p = 0.047) as well as the TBS (1.160-1.271: p < 0.001). Most indices of proximal hip geometry also showed significant improvement following teriparatide therapy at 24 months. Incident vertebral fractures were noted in only 7.8% (4/51) of participants, while 92% (47/51) of participants did not develop any new vertebral fractures on follow-up.

In South Indian postmenopausal women with either severe osteoporosis or vertebral fractures, or both, teriparatide was effective in improving the bone mineral parameters and bone quality.

Dietary calcium deficiency is considered to be widespread globally, with published estimates suggesting that approximately half of the world's population has inadequate access to dietary calcium. Calcium is essential for bone health, but inadequate intakes have also been linked to other health outcomes, including pregnancy complications, cancers, and cardiovascular disease. Populations in low- and middle-income countries (LMICs) are at greatest risk of low calcium intakes, although many individuals in high-income countries (HICs) also do not meet recommendations. Paradoxically, many LMICs with lower calcium intakes show lower rates of osteoporotic fracture as compared with HICs, though data are sparse. Calcium intake recommendations vary across agencies and may need to be customized based on other dietary factors, health-related behaviors, or the risk of calcium-related health outcomes. The lack of standard methods to assess the calcium status of an individual or population has challenged efforts to estimate the prevalence of calcium deficiency and the global burden of related adverse health consequences. This paper aims to consolidate available evidence related to the global prevalence of inadequate calcium intakes and associated health outcomes, with the goal of providing a foundation for developing policies and population-level interventions to safely improve calcium intake and status where necessary.

Obesity has long been considered to have a protective effect on bone, but specific complications in those with morbid obesity are known to have a detrimental impact on bone architecture. We aimed to study the bone microarchitecture (TBS-trabecular bone score) and bone mineral density (BMD) in postmenopausal women with morbid obesity compared to obese and non-obese age-matched women. Eighty-five consecutive postmenopausal women with morbid obesity (body mass index (BMI) ≥ 35 kg/m2) were enrolled and compared to age-matched obese (n = 80) and non-obese postmenopausal controls (n = 85). The BMD and TBS were assessed in all subjects using a Hologic-QDR 4500-W Discovery-A DXA scanner. The mean BMD (gm/cm2) at the femoral neck in women with morbid obesity was found to be significantly lower as compared to the age-matched postmenopausal obese controls (0.723 versus 0.762, p-value = 0.002). The BMD at the lumbar spine and hip showed similar trends but were not statistically significant. The bone microarchitecture was found to be significantly lower in those with morbid obesity (1.205) as compared to the other two groups (obesity 1.244; non-obese 1.228) (p < 0.013). Though obesity was associated with a better bone density and bone microarchitecture in postmenopausal women, a paradoxical lower value was seen in those with morbid obesity.