Trabecular Bone Score (TBS)

I will be asking that a Trabecular Bone Score (TBS) be included with my next DXA scan. The doctor who read my latest scan wrote, "Follow up with DEXA and TBS: As needed." 

I found a review of TBS. The review includes a section on "Changes in TBS with Treatment of Osteoporosis." Below is the paragraph comparing the effects of strontium ranelate and alendronate (Fosamax) on TBS. 

"The effects of strontium ranelate (SrRan) and alendronate on TBS were evaluated in a post hoc analysis performed in 79 women with postmenopausal osteoporosis of 189 included in a double‐blind, double‐dummy, randomized study. Women were randomized to either SrRan 2 g/day or alendronate 70 mg/week for 2 years. TBS and BMD parameters were assessed in the LS after 12 and 24 months of treatment. Over 1 and 2 years, LS BMD increased significantly by 5.6% and 9.0% in the SrRan group and by 5.2% and 7.6%, respectively, in the alendronate group. LS TBS increased by 2.3% (p < 0.001) and 3.1% (p < 0.001) in the SrRan group, but the change in the alendronate group was not significant (0.5% and 1.0%, respectively). There was a significant between‐group difference with SrRan showing larger TBS increases than alendronate."

Let me reiterate: Over one and two years, Lumbar Spine (LS) BMD increased in both the SrRan (5.6%, 9.0%) and alendronate groups (5.2%, 7.6%). You will note that the SrRan BMD numbers are higher, especially after the second year, than the alendronate numbers. The results are as expected because strontium results in an overestimation of BMD.  

HERE IS THE KICKER: LS TBS increased by 2.3% and 3.1% in the SrRan group, but the change in the alendronate group was not significant (0.5% and 1.0%, respectively). There was a significant between‐group difference with SrRan showing larger TBS increases than alendronate.

Keep in mind that TBS is related to bone microarchitecture and provides skeletal information that is not captured from the standard BMD measurement. TBS may be a better predictor of fracture risk than BMD alone. 
https://www.panoramaortho.com/wp-content/uploads/2019/03/TBS-Rev...

 

Calcium Intake and BMD

The following report is a systematic review and meta-analysis (the highest level of scientific proof) on calcium intake and bone mineral density. 

Abstract

Objective To determine whether increasing calcium intake from dietary sources affects bone mineral density (BMD) and, if so, whether the effects are similar to those of calcium supplements.

Design Random effects meta-analysis of randomised controlled trials.

Data sources Ovid Medline, Embase, Pubmed, and references from relevant systematic reviews. Initial searches were undertaken in July 2013 and updated in September 2014.

Eligibility criteria for selecting studies Randomised controlled trials of dietary sources of calcium or calcium supplements (with or without vitamin D) in participants aged over 50 with BMD at the lumbar spine, total hip, femoral neck, total body, or forearm as an outcome.

Results We identified 59 eligible randomised controlled trials: 15 studied dietary sources of calcium (n=1533) and 51 studied calcium supplements (n=12 257). Increasing calcium intake from dietary sources increased BMD by 0.6-1.0% at the total hip and total body at one year and by 0.7-1.8% at these sites and the lumbar spine and femoral neck at two years. There was no effect on BMD in the forearm. Calcium supplements increased BMD by 0.7-1.8% at all five skeletal sites at one, two, and over two and a half years, but the size of the increase in BMD at later time points was similar to the increase at one year. Increases in BMD were similar in trials of dietary sources of calcium and calcium supplements (except at the forearm), in trials of calcium monotherapy versus co-administered calcium and vitamin D, in trials with calcium doses of ≥1000 versus <1000 mg/day and ≤500 versus >500 mg/day, and in trials where the baseline dietary calcium intake was <800 versus ≥800 mg/day.

Conclusions Increasing calcium intake from dietary sources or by taking calcium supplements produces small non-progressive increases in BMD, which are unlikely to lead to a clinically significant reduction in risk of fracture.

Conclusions

In summary, increasing calcium intake from dietary sources increases BMD by a similar amount to increases in BMD from calcium supplements. In each case, the increases are small (1-2%) and non-progressive, with little further effect on BMD after a year. Subgroup analyses do not suggest greater benefits of increasing calcium intake on BMD in any subpopulation based on clinically relevant baseline characteristics. The small effects on BMD are unlikely to translate into clinically meaningful reductions in fractures. Therefore, for most individuals concerned about their bone density, increasing calcium intake is unlikely to be beneficial.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4784773/

The Effect of Bone Strontium on BMD for Different Manufacturers' DXA Systems

Osteoporotic patients treated with strontium ranelate show relatively large increases in bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) due to the replacement of some of the calcium atoms in bone by strontium. A study published by Pors Nielsen and colleagues reported that replacement of 1% of calcium atoms by strontium causes a 10% increase in BMD. 

We refer to the ratio of the percentage increase in BMD to the molar percentage of strontium in bone as the strontium ratio. Theoretically it is expected that the strontium ratio should vary between different manufacturers' DXA equipment depending on the effective photon energy of the device, an effect that arises because of the proximity of the X-ray energies produced by lower energy devices to the strontium K-edge at 16 keV. 

In this study we report theoretical estimates of the strontium ratio for two axial DXA systems and two peripheral DXA devices based on their broad spectrum X-ray emission. The theoretical figures were verified in an experimental study in which the strontium ratio for each device was measured using phantoms containing mixtures of hydroxyapatite and strontium hydrogen-phosphate. 

The theoretical values/experimental results of the strontium ratio were: 

11.0/11.2 for the Hologic Discovery,

9.9/9.9 for the GE-Lunar Prodigy, 

9.1/8.6 for the Demetech Calscan, and 

8.5/6.3 for the Osteometer Dexacare G4. 

The results confirm both theoretically and experimentally that the effect of bone strontium on BMD measurements is different for different DXA systems. In the future it might be possible to exploit this effect to make a non-invasive estimate of average bone strontium content in groups of patients receiving strontium medication for osteoporosis.

https://pubmed.ncbi.nlm.nih.gov/20699129/

TBS iNsight® – a Novel Osteoporotic Fracture Assessment Diagnostic Tool

Medimaps Group announced that a novel method for improving osteoporotic fracture risk assessment, TBS iNsight^®, is now globally available to clinicians through a distribution partnership with General Electric Healthcare (NYSE: GE). GE Healthcare provides transformational medical technologies and services to meet the demand for increased access, enhanced quality and more affordable healthcare around the world and is the market leader in the development and manufacture of Dual Energy X-Ray Absorptiometry (DXA) bone densitometry systems.

On June 10, 2014, Medimaps Group – developers of the TBS iNsight^® diagnostic tool – and General Electric Healthcare signed a distribution agreement to distribute TBS iNsight^® on a global basis leveraging GE Healthcare’s extensive direct sales and distribution organization.

TBS iNsight^® is a unique, easy-to-use software application that assesses bone texture - an index of bone microarchitecture – which in turn is expressed as the Trabecular Bone Score (TBS). The measurement is performed seamlessly using DXA images acquired from a bone mineral densitometry (BMD) scan. No additional patient scan time or radiation exposure is required and results are easily interpreted by physicians to enable them to better manage patients with high risk of fractures. TBS iNsight® has been cleared for marketing by the U.S. Food and Drug Administration.

Prof. Didier Hans, Chairman and Chief Executive Officer of Medimaps Group states; “It is well documented that 40-50% of osteoporotic fracture occurs in patients who are not determined to be osteoporotic by BMD alone, yet BMD remains the only diagnostic method available to most clinicians. A significant body of literature, including a recent study of over 29,000 women, has demonstrated that TBS, when combined with hip and/or spine BMD and FRAX^® clinical factors, can help improve the prediction of future osteoporotic fracture risk in a clinically meaningful way. We’re very pleased to partner with General Electric Healthcare to bring this valuable new predictive tool for better management of osteoporotic patients across the globe.”

For more information on Medimaps and TBS iNsight^®, please visit www.medimapsgroup.com and www.tbsinsight.com

About Medimaps Group

Medimaps group – a Swiss company founded by a group of clinical practitioners and researchers - is a developer of innovative imaging software used in clinical practice for improved patient management with minimum impact on the workflow of the practitioner. The company has raised several rounds of venture capital to further commercialize TBS iNsight^® in the osteoporosis treatment market and for product development of the TBS iNsight^® tool for optimizing implant surgery in the dental and orthopedic markets.

Contacts

Medimaps Group
Oscar Lazaro, +1 781-492-2012
Chief Commercial Officer
olazaro@medimapsgroup.com

http://www.businesswire.com/news/home/20140909005180/en/Medimaps-Group-appoints-General-Electric-Healthcare-Global#.VVC46fCgseM

Dietary Patterns and Bone Mineral Density in Postmenopausal Women with Osteoporosis

Background/Objectives:

The aim of this study was to investigate the association between dietary patterns and bone mineral density (BMD) in postmenopausal women with osteoporosis.

Subjects/Methods:

This cross-sectional study included 156 postmenopausal and osteoporotic Brazilian women aged over 45 years. BMD of lumbar spine, total femur (TF), femoral neck and of total body (TB), as well as body composition (fat and lean mass), was assessed by dual-energy X-ray absorptiometry. Body mass index and lifestyle information were also obtained. Dietary intake was assessed by using a 3-day food diary. Dietary patterns were obtained by principal component factor analysis. Adjusted multiple linear regression analysis was applied in order to evaluate the predictive effect of dietary patterns on BMD. Significance was set at P less than 0.05.

Results:

Five patterns were retained: ‘healthy’, ‘red meat and refined cereals’, ‘low-fat dairy’, ‘sweet foods, coffee and tea’ and ‘Western’. The ‘sweet foods, coffee and tea’ pattern was inversely associated with TF BMD (β=−0.178; 95% CI: −0.039 to −0.000) and with TB BMD (β=−0.320; 95% CI: −0.059 to −0.017) even after adjusting for energy and calcium intake, lean mass, age and postmenopausal time.

Conclusions:

A concomitant excessive consumption of sweet foods and caffeinated beverages appears to exert a negative effect on BMD even when the skeleton already presents some demineralization. Food and beverage intake is a modifiable factor that should not be neglected in the treatment of individuals with osteoporosis.

http://www.nature.com/ejcn/journal/vaop/ncurrent/full/ejcn201527a.html

European Journal of Clinical Nutrition (25 March 2015) | doi:10.1038/ejcn.2015.27

Women's Mid-Life Non-Traumatic Fracture Risk Higher With Low Vitamin D

The lower a woman's vitamin D levels as she transitions to menopause, the greater her risk of sustaining a non-traumatic fracture. 

"Women who have levels less than 20 nanograms per milliliter would need some type of vitamin D supplementation," Dr. Jane A. Cauley of the University of Pittsburgh, who worked on the study, told Reuters Health. The findings back up the Institute of Medicine's conclusion that levels lower than 20 ng/ml are insufficient for skeletal health, she added.

Bone loss is known to accelerate during the menopausal transition, and postmenopausal women require significantly more calcium to reach neutral calcium balance than perimenopausal women, Dr. Cauley and her team note in their report, online February 23 in the Journal of Clinical Endocrinology and Metabolism.

To determine if serum 25(OH)D levels would be associated with changes in bone mineral density (BMD) and fracture risk, the researchers looked at data from the Study of Women's Health Across the Nation (SWAN) on 124 women with an incident traumatic fracture, 88 with an incident non-traumatic fracture, and 1,532 who did not sustain fractures during the study's average follow-up period of 9.5 years. 

Each woman had her serum 25(OH)D level checked at her third annual visit, while her BMD was assessed annually. The women's mean age at the study's outset was 48.5.

The study participants' mean 25(OH)D levels were 21.8 ng/ml, and 43% had levels below 20 ng/mL. While multivariate analysis found no association between 25(OH)D levels and traumatic fracture risk, the risk of non-traumatic fractures decreased by 28% for every 10 ng/ml increase in serum 25(OH)D. [Referring to Table 3 of the original article, “For every 10 ng/ml increase in 25(OH)D, the hazard ratio (HR) for nontraumatic fracture was 0.72 (0.54, 0.95).”; 1.00 minus 0.72 equals 0.28, or 28%]

Women with levels of 20 ng/ml or higher had a 46% lower risk of fracture during follow-up than women with lower levels of 25(OH)D. However, there was no association between baseline 25(OH)D and changes in BMD at the lumbar spine or femoral neck across menopause.

Roughly 22% of the women in the study had vitamin D levels greater than 30 ng/ml, Dr. Cauley said, so the study lacked power to determine if these women's non-traumatic fracture risk was further reduced.
"We didn't see any relationship between 25(OH)D and these bone changes, but we were somewhat limited in that we didn't have any information on how vitamin D changed across menopause," she added.



http://www.nutrition411.com/news/womens-mid-life-non-traumatic-fracture-risk-higher-low-vitamin-d
http://www.medscape.com/viewarticle/841028?src=wnl_edit_tpal&uac=127701PY:
http://press.endocrine.org/doi/pdf/10.1210/jc.2014-4367