Lifetime Veganism: Osteoporosis and Vertebral fracture 1 Thuc Lan Ho-Pham, 2 Nguyen ND, 3 Thu A. Le, 2 Tuan V. Nguyen *Coauthors:, 1 Vu BQ, 3 Pham NH, 1 Nguyen LP, 1 Le TT, 1 Doan AT, and 1 Tran N. 1 Pham Ngoc Thach College of Medicine,Ho Chi Minh City, Vietnam, 2 Garvan Institute of Medical Research, Sydney, Australia; 3 Cho Ray Hospital, Ho Chi Minh City, Vietnam.

OSTEOPOROSIS AND FRACTURE OSTEOPOROSIS: High prevalence 20% postmenopausal women 1 10% men ( > 50 year-old) 1 Vietnam : 23% postmenopausal women 2 OSTEOPOROTIC FRACTURE : High lifetime risk 3 Any fracture 50% Hip fracture 17% Vertebral fracture 25% 1 Nguyen DN, Nguyen TV. Osteoporosis 3 rd edition 2 Nguyen.T.T.Huong, Nguyen TV. New Zealand Bone Miner Soci Nguyen DN, et al. J Bone Miner Res 2007

ROLE OF DIET IN OSTEOPOROSIS PREVENTION Prevention is preferable to treatment Diet and nutrition are important components in osteoporosis prevention

VEGETARIAN AND OMNIVORE DIETS Semi/demi vegetarian Lacto-ovo vegetarian Lacto vegetarian Vegan (Asian veg)

VEGANISM AND BONE HEALTH Whether lifelong vegetarian diet has any negative effect on bone health, a contentious issue 1,2. Lack of information about prevalence of osteoporosis and vertebral fracture in postmenopausal Vietnamese women. 1 EMC Lau, et al. JC Nutrition Fontana L, et al. Arch In Med 2005

AIMS Examine the association between lifelong vegetarian diet and osteoporosis. Estimate the prevalence and risk factors of vertebral fracture in postmenopausal Vietnamese women.

METHODS AND STUDY DESIGN A cross-sectional study Vegetarian (Buddhist nuns) n=105 Omnivores n= years old From 15 monasteries in Ho Chi Minh City Random sample 50+ years old From various districts in Ho Chi Minh City Random sample

OUTCOME MEASUREMENTS BMD measurement (Hologic QDR 4500). Lumbar spine Femoral neck Total body (eg lean mass and fat mass) Vertebral fracture (X-ray, Genant’s semi- quantitative method).

COVARIATES Anthropometric measurements. Daily dietary energy and nutrient intakes (24h recall questionnaire). Lifestyle factors. Comorbidity (CVD, diabetes, osteoarthritis, etc). A history of fall (past 3 months) Prior fracture (after the age of 50).

Diet and Bone Mineral Density

Characteristics of participants by diet VegetariansOmnivoresP-value (n=105) Age (y)62(10)62(10)0.95 Weight (kg)53(9)54(7)0.59 Height (cm)148(6)149(6)0.15 BMI (kg/m 2 )24(4)24(3)0.78 Total body fat (kg)19(5)19(5)0.77 Total body lean (kg)32(5)33(4)0.47 Highest education (n,%)0.007 ≤ Primary27(25.7)28(26.7) Secondary66(62.9)48(45.2) Tertiary12(11.4)29(27.6) Morning exercise (n,%)82(78.1)81(77.1)0.86 Coffee drinking (n,%)28(26. 7)48(45.2)0.004 Major comorbidity (n,%)47(44.8)52(49.5)0.49 Values are mean (SD), unless otherwise specified.

Daily dietary energy and nutrient intakes Energy intakeCalcium Animal source proteinVegetable source protein Vegetable source lipid Animal source lipid

Bone mineral density in vegetarians and omnivores Values are mean and 95% CI

Prevalence of osteoporosis (T- scores < -2.5) by diet No significant difference in prevalence of osteoporosis between lifetime vegans and non-vegans Vegans Omnivores Osteoporosis: BMD T-scores ≤-2.5 at the femoral neck

Unit of↑SD of BMDR-square change(95% CI) Femoral neck0.36 Age (y) (0.4,0.6) Lean mass (kg)+40.3(0.2,0.4) Lumbar spine0.36 Age (y) (0.4,0.7) Weight (kg)+80.3(0.1,0.4) Animal source protein (g/d)+200.2(0.0,0.3) Association between factors and BMD (multivariable analysis) Bayesian averaging method (BMA) was used to select the best fit model for FNBMD and LSBMD. All potential explainable factors were included in selecting independent factor process.

Morphometric vertebral fracture

Prevalence of vertebral fracture n%(95% CI) Any vertebral fracture48/ (17.3,28.7) By age group: / (9.8,24.1) /5318.9(8.3,29.4) 70+20/5040.0(26.4,53.6) By diet: Buddhist vegetarians23/ (14.1,30.1) Non-vegetarians25/ (15.7,32.0)

Risk factors for vertebral fracture (bivariate analysis) FactorUnit changeOR(95% CI) Age (y)+101.6(1.1,2.2) Weight (kg)+81.1(0.8,1.6) BMI (kg/m 2 )+31.3(0.9,1.7) FNBMD (g/cm 2 ) (0.9,1.8) LSBMD (g/cm 2 ) (1.2,2.5) Prior fractureyes1.9(1.0,3.8) Back painyes1.2(0.6,2.4) Calcium intake (g/d) (0.9,1.6) Veganyes0.9(0.5,1.7) There was no significant association between vertebral fracture and other factors

Risk factors for vertebral fracture (multivariable logistic regression analysis) FactorUnit change Odds ratio(95% CI) Age (y)+101.2(1.0,1.8) LSBMD (g/cm 2 ) (1.0,2.2) Prior fractureyes1.5(0.7,3.1) LSBMD, lumbar spine bone mineral density

Veganism: osteoporosis and vertebral fracture Vegetarians: –much lower dietary energy, protein and calcium intakes than omnivores. –no adverse effect on bone health, in terms of osteoporosis and vertebral fracture risk.

Osteoporosis and vertebral fracture in postmenopausal Vietnamese women Prevalence of vertebral fracture in postmenopausal Vietnamese women was as common as in Caucasian women.

Acknowledgements I express special thanks to Pro.Nguyen van Tuan for his excellent support this study. I express deep appreciation to Dr Nguyen Dinh Nguyen and Miss Ha Hai Chau for their kind helping me. Thanks also to my students for their meticulous assistance.

Thank you!

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Prevalence of osteoporosis Present study Nguyen H, 2007 Thai Indonesian Chinese Japanese Korean Australian

Daily dietary energy and nutrient intakes

Association between factors and BMD (univariate analysis) VariablesUnit of↑ FN BMD↑ LS BMD change(SD, 95% CI) Age (y)-100.5(0.4,0.7)0.5(0.4,0.7) Weight (kg)+80.4(0.2,0.5)0.3(0.2,0.5) Height (cm)+60.3(0.2,0.4)0.4(0.2,0.4) BMI (kg/m 2 )+30.3(0.1,0.4)0.2(0.1,0.4) Fat mass (kg)+50.2(0.1,0.3)0.2(0.1,0.3) Lean mass (kg)+40.4(0.2,0.5)0.3(0.2,0.5) Daily dietary intake Energy (Kcal) (0.0,0.2)0.1(0.0,0.3) Animal source Pr (g)+200.0(-0.1,0.2)0.2(0.0,0.3) Vegetable source Pr (g)+120.1(-0.1,0.2)0.0(-0.1,0.2) Calcium (g) (0.0,0.2)0.0(-0.1,0.2) VeganismYes-0.2(-0.5,0.1)-0.2(-0.5,0.1) FN, femoral neck; LS, lumbar spine; BMD, bone mineral density

Characteristics of participants by fracture Vertebral fractureNon-vertebral fractureP-value (n=48)(n=161) Age (y)65(11)61(9) Weight (kg)54(8)53(8) Height (cm)148(6)149(6) BMI (kg/m 2 )25(4)24(3)0.161 Total body fat (kg)19(5)19(5) Total body lean (kg)33(4)32(4) FNBMD (g/cm 2 )0.61(0.13)0.64(0.11)0.115 LSBMD (g/cm 2 )0.70(0.14)0.78(0.14) Daily dietary intake: Energy (Cal) * 1320(1007,1538)1266(1051,1547) Animal source protein (g) * 24(9,33)31(18,41) Non-animal protein (g) * 29(22,35)26(22,35) Calcium (g) * 432(310,645)422(267,641) Values are mean(SD), unless otherwise specified * Median (Q1,Q3)

Vertebral fractureNon-vertebral fractureP-value (n=48)(n=161) Education: ≤ Primary14(29.2)41(25.6) Secondary28(58.3)84(52.5) Tertiary6(12.5)35(21.9) Morning exercise37(77.1)125(78.1) Hypertension17(35.4)43(26.9) CVD1(2.1)6(3.8)1.000 Diabetes3(6.3)11(6.9) Arthritis9(18.8)29(18.1) Back pain26(54.2)73(45.6) Prior fracture15(31.3)31(19.3) A history of fall4(8.3)17(10.7) Characteristics of participants by fracture (cont.) Values are n (%)