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Nordström, Anna
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Vikberg, S., Sörlén, N., Brandén, L., Johansson, J., Nordström, A., Hult, A. & Nordström, P. (2019). Effects of Resistance Training on Functional Strength and Muscle Mass in 70-Year-Old Individuals With Pre-sarcopenia: A Randomized Controlled Trial. Journal of the American Medical Directors Association, 20(1), 28-34
Open this publication in new window or tab >>Effects of Resistance Training on Functional Strength and Muscle Mass in 70-Year-Old Individuals With Pre-sarcopenia: A Randomized Controlled Trial
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2019 (English)In: Journal of the American Medical Directors Association, ISSN 1525-8610, E-ISSN 1538-9375, Vol. 20, no 1, p. 28-34Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Sarcopenia has been defined as age-related loss of muscle mass and function. The aim of this randomized controlled trial was to examine the effects of a 10-week instructor-led resistance training program on functional strength and body composition in men and women aged 70 years with pre-sarcopenia.

DESIGN, SETTING, AND PARTICIPANTS: Participants were randomized to either 10 weeks of a physical training regimen including optional nutritional supplementation (n = 36) or to a control group (n = 34) (ClinicalTrials.gov, no. NCT03297632). The main outcome was changes in the Short Physical Performance Battery (SPPB) score. Secondary outcomes included the Timed Up and Go test, chair sit-stand time, lean body mass, and fat mass.

RESULTS: The intervention had no significant effect on SPPB in the total cohort (P = .18), when comparing changes in the intervention group with the control group. However, those given the intervention in the male subcohort increased 0.5 ± 0.4 (mean ± standard error for the difference) points in SPPB during follow-up (P = .02) compared to male controls. With respect to secondary outcomes, the intervention group decreased 0.9 ± 0.6 seconds in chair sit-stand time compared to controls (P = .01). Furthermore, the intervention resulted in significantly greater improvements for the training group than control group in all measures of body composition (P ≤ .01 for all). For example, lean body mass increased by a mean of 1147 ± 282 g (P < .001), and total fat mass decreased by a mean of 553 ± 225 g (P = .003), favoring the intervention group.

CONCLUSION/IMPLICATIONS: The main finding of this intervention study is that an easy-to-use, functional resistance training program was effective in maintaining functional strength and increasing muscle mass in older adults with pre-sarcopenia.

Place, publisher, year, edition, pages
Elsevier, 2019
Keywords
Resistance training, functional strength, muscle mass
National Category
Physiotherapy Gerontology, specialising in Medical and Health Sciences Geriatrics
Identifiers
urn:nbn:se:umu:diva-153603 (URN)10.1016/j.jamda.2018.09.011 (DOI)000454138000005 ()30414822 (PubMedID)2-s2.0-85055969854 (Scopus ID)
Note

Available online 7 November 2018.

Available from: 2018-11-23 Created: 2018-11-23 Last updated: 2019-01-15Bibliographically approved
Bergman, J., Nordström, A. & Nordström, P. (2019). Epidemiology of osteonecrosis among older adults in Sweden. Osteoporosis International
Open this publication in new window or tab >>Epidemiology of osteonecrosis among older adults in Sweden
2019 (English)In: Osteoporosis International, ISSN 0937-941X, E-ISSN 1433-2965Article in journal (Refereed) Epub ahead of print
Abstract [en]

Summary: This study estimated the incidence of osteonecrosis in a Swedish, nationwide cohort of older adults. Osteonecrosis was approximately 10 times more common than in previous studies. The strongest risk factors were dialysis, hip fracture, osteomyelitis, and organ transplantation, but only hip fractures could have contributed substantially to the disease burden.

Introduction: The aim of this study was to estimate the incidence of osteonecrosis in a Swedish, nationwide cohort of older adults and in a large number of risk groups in that cohort.

Methods: In this retrospective cohort study, we included everyone who was aged 50 years or older and who was living in Sweden on 31 December 2005. We used Swedish national databases to collect data about prescription medication use, diagnosed medical conditions, and performed medical and surgical procedures. The study outcome was diagnosis of primary or secondary osteonecrosis at any skeletal site. The strength of risk factors was assessed using age- and sex-standardized incidence ratios (SIRs).

Results: The study cohort comprised 3,338,463 adults. The 10-year risk of osteonecrosis was 0.4% (n = 13,425), and the incidence rate was 4.7 cases/10000 person-years (95% confidence interval [CI], 4.6 to 4.7 cases). The strongest risk factors for osteonecrosis were hip fracture (SIR, 7.98; 95% CI, 7.69–8.27), solid organ transplantation (SIR, 7.14; 95% CI, 5.59–8.99), dialysis (SIR, 6.65; 95% CI, 5.62–7.81), and osteomyelitis (SIR, 6.43; 95% CI, 5.70–7.23). A history of hip fracture was present in 21.7% of cases of osteonecrosis, but osteomyelitis, dialysis, and solid organ transplantation were present in only 0.5 to 2% of cases.

Conclusions: Osteonecrosis was approximately 10 times more common than a small number of previous population-based studies have suggested. The strongest risk factors for osteonecrosis were dialysis, hip fracture, osteomyelitis, and solid organ transplantation, but only hip fractures could have contributed substantially to the disease burden.

Keywords
Aseptic necrosis, Avascular necrosis, Bone necrosis, Register, Registry, Sweden
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-155486 (URN)10.1007/s00198-018-04826-2 (DOI)30627759 (PubMedID)
Available from: 2019-01-18 Created: 2019-01-18 Last updated: 2019-02-27
Scott, D., Johansson, J., McMillan, L. B., Ebeling, P. R., Nordström, A. & Nordström, P. (2019). Mid-calf skeletal muscle density and its associations with physical activity, bone health and incident 12-month falls in older adults: The Healthy Ageing Initiative. Bone, 120, 446-451, Article ID S8756-3282(18)30446-0.
Open this publication in new window or tab >>Mid-calf skeletal muscle density and its associations with physical activity, bone health and incident 12-month falls in older adults: The Healthy Ageing Initiative
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2019 (English)In: Bone, ISSN 8756-3282, E-ISSN 1873-2763, Vol. 120, p. 446-451, article id S8756-3282(18)30446-0Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Lower skeletal muscle density, indicating greater infiltration of adipose tissue into muscles, is associated with higher fracture risk in older adults. We aimed to determine whether mid-calf muscle density is associated with falls risk and bone health in community-dwelling older adults.

METHODS: 2214 community-dwelling men and women who participated in the Healthy Ageing Initiative (Sweden) study at age 70 were included in this analysis. Mid-calf muscle density (mg/cm3) at the proximal tibia, and volumetric bone mineral density (vBMD) and architecture at the distal and proximal tibia and radius, were assessed by peripheral quantitative computed tomography. Whole-body lean and fat mass, lumbar spine and total hip areal bone mineral density (aBMD) were assessed by dual-energy X-ray absorptiometry. Participants completed seven-day accelerometer measurements of physical activity intensity, and self-reported falls data were collected 6 and 12 months later.

RESULTS: 302 (13.5%) participants reported a fall at the 6- or 12-month interview, and 29 (1.3%) reported a fall at both interviews. After adjustment for confounders, each standard deviation decrease in mid-calf muscle density was associated with a trend towards greater likelihood of experiencing a fall (OR 1.13; 95% CI 1.00, 1.29 per SD lower) and significantly greater likelihood of multiple falls (1.61; 1.16, 2.23). Higher muscle density was not associated with total hip aBMD, and was associated with lower lumbar spine aBMD (B = -0.003; 95% CI -0.005, -0.001 per mg/cm3) and higher proximal cortical vBMD (0.74; 0.20, 1.28) at the radius. At the tibia, muscle density was positively associated with distal total and trabecular vBMD, and proximal total and cortical vBMD, cortical thickness, cortical area and stress-strain index (all P < 0.05). Only moderate/vigorous (%) intensity physical activity, not sedentary time or light activity, was associated with higher mid-calf muscle density (0.086; 0.034, 0.138).

CONCLUSIONS: Lower mid-calf muscle density is independently associated with higher likelihood for multiple incident falls and appears to have localised negative effects on bone structure in older adults.

Place, publisher, year, edition, pages
Elsevier, 2019
Keywords
Bone density, Falls, Muscle density, Osteoporosis, Physical activity, Sarcopenia
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-156222 (URN)10.1016/j.bone.2018.12.004 (DOI)30537557 (PubMedID)
Available from: 2019-02-08 Created: 2019-02-08 Last updated: 2019-02-25Bibliographically approved
Bergman, J., Nordström, A. & Nordström, P. (2018). Alendronate use and the risk of nonvertebral fracture during glucocorticoid therapy: a retrospective cohort study. Journal of Clinical Endocrinology and Metabolism, 103(1), 306-313
Open this publication in new window or tab >>Alendronate use and the risk of nonvertebral fracture during glucocorticoid therapy: a retrospective cohort study
2018 (English)In: Journal of Clinical Endocrinology and Metabolism, ISSN 0021-972X, E-ISSN 1945-7197, Vol. 103, no 1, p. 306-313Article in journal (Refereed) Published
Abstract [en]

Context: Glucocorticoids increase the risk of nonvertebral fracture, but no clinical trial has shown that nonvertebral fractures can be prevented by co-administration of an anti-osteoporotic drug.

Objective: To estimate the effect of alendronate on the risk of nonvertebral fracture in older adults taking oral glucocorticoids.

Design: Retrospective cohort study using national Swedish registers.

Setting: Hospitalized care and ambulatory specialist care.

Patients: Among adults aged 50 years or older (N=3,347,959), we identified those who initiated oral glucocorticoid therapy from 2006 through 2011 (≥2.5 mg/day of prednisone or equivalent for ≥91 days). The final analysis included 16,890 alendronate users and 16,890 nonusers, who were matched using time-dependent propensity scores.

Main Outcome Measure: Nonvertebral fracture. This was not pre-specified.

Results: Over a median follow-up of 14.5 months, the incidence rate of nonvertebral fracture was 2.0 cases per 100 person-years in alendronate users and 2.4 cases in nonusers. This difference corresponded to a 16% lower rate in users (hazard ratio 0.84, 95% confidence interval 0.75 to 0.94). For hip fractures specifically, the rate was 34% lower in alendronate users relative to nonusers (hazard ratio 0.66, 95% confidence interval 0.55 to 0.78). The association of alendronate use with a lower risk of nonvertebral fracture was strongest in patients who received high doses of glucocorticoid.

Conclusion: Alendronate use was associated with a lower risk of nonvertebral fracture, including hip fracture. Similar, but not statistically significant, associations have been reported in meta-analyses of clinical trials.

Place, publisher, year, edition, pages
Cary: Oxford University Press, 2018
Keywords
bone-mineral density, induced osteoporosis, postmenopausal women, vertebral fracture, double-blind, metaanalysis, prevention, prevalence, trial, efficacy
National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:umu:diva-141851 (URN)10.1210/jc.2017-01912 (DOI)000424934300036 ()29126139 (PubMedID)
Available from: 2017-11-14 Created: 2017-11-14 Last updated: 2018-06-09Bibliographically approved
Bergman, J., Nordström, A. & Nordström, P. (2018). Bisphosphonate use after clinical fracture and risk of new fracture. Osteoporosis International, 29(4), 937-945
Open this publication in new window or tab >>Bisphosphonate use after clinical fracture and risk of new fracture
2018 (English)In: Osteoporosis International, ISSN 0937-941X, E-ISSN 1433-2965, Vol. 29, no 4, p. 937-945Article in journal (Refereed) Published
Abstract [en]

Summary: Among older adults with a previous fracture, treatment for osteoporosis was initially associated with a higher risk of new fracture. However, the relative risk of new fracture decreased over time, a trend that is consistent with a beneficial effect, as treatment for osteoporosis is prescribed to reduce high fracture risks.

Introduction: The purpose of this study was to examine whether bisphosphonate use is associated with a lower risk of new fracture after a clinical fracture in older adults.

Methods: Data were available for 3,329,400 adults in Sweden who were aged ae<yen> 50 years between 2006 and 2011. During this period, 260,353 sustained a clinical fracture and were naïve to bisphosphonates at the time. Those who subsequently received a bisphosphonate were matched to up to three others on sex, year of birth, and type and year of initial fracture. The final cohort comprised 83,104 adults (26.3% bisphosphonate users).

Results: During the period from initial fracture to initiation of bisphosphonate treatment, the incidence rate of any new clinical fracture was higher in those who later became bisphosphonate users than in those who remained nonusers (175.1 vs. 75.9 per 1000 person-years; hazard ratio 2.30, 95% confidence interval 2.19 to 2.41). Similarly, during the first 6 months of treatment, the incidence rate was higher in bisphosphonate users than in nonusers (128.8 vs. 90.2 per 1000 person-years; hazard ratio 1.41, 95% confidence interval 1.32 to 1.51). However, this difference decreased over time: by months 12 to 18, the incidence rate was similar in users and nonusers (59.3 vs. 55.3 per 1000 person-years; hazard ratio 1.03, 95% confidence interval 0.91 to 1.16).

Conclusions: There was a decrease in the relative risk of new fracture during bisphosphonate treatment, a trend that is consistent with a beneficial treatment effect, as bisphosphonates are prescribed to reduce high fracture risks.

Place, publisher, year, edition, pages
Springer London, 2018
Keywords
Elderly, Men, Nonvertebral, Older, Osteoporosis, Refracture
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-146426 (URN)10.1007/s00198-017-4367-7 (DOI)000427631200016 ()29397408 (PubMedID)
Available from: 2018-05-08 Created: 2018-05-08 Last updated: 2018-06-09Bibliographically approved
Bergman, J., Nordström, A. & Nordström, P. (2018). Bisphosphonate use after clinical fracture and risk of new fracture: response to comments by Wu et al. [Letter to the editor]. Osteoporosis International, 29(9), 2159-2160
Open this publication in new window or tab >>Bisphosphonate use after clinical fracture and risk of new fracture: response to comments by Wu et al.
2018 (English)In: Osteoporosis International, ISSN 0937-941X, E-ISSN 1433-2965, Vol. 29, no 9, p. 2159-2160Article in journal, Letter (Refereed) Published
Place, publisher, year, edition, pages
Springer London, 2018
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-150244 (URN)10.1007/s00198-018-4615-5 (DOI)000442202800025 ()30014156 (PubMedID)
Funder
Swedish Research Council, 2016-02584
Available from: 2018-07-24 Created: 2018-07-24 Last updated: 2018-09-11Bibliographically approved
Hallkvist, O. M., Johansson, J., Nordström, A., Nordström, P. & Hult, A. (2018). Dairy product intake and bone properties in 70-year-old men and women. Archives of Osteoporosis, 13(1), Article ID 9.
Open this publication in new window or tab >>Dairy product intake and bone properties in 70-year-old men and women
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2018 (English)In: Archives of Osteoporosis, ISSN 1862-3514, Vol. 13, no 1, article id 9Article in journal (Refereed) Published
Abstract [en]

SUMMARY: In the present population-based study including 70-year-old men and women, total dairy product intake was associated with a weak positive association with tibia trabecular and cortical cross-sectional areas.

PURPOSE: Milk consumption has recently been suggested to increase fracture risk. Therefore, we aimed to investigate associations between dairy product consumption and peripheral bone properties. Furthermore, we explored whether consumption of milk and fermented dairy products affected bone properties differently.

METHODS: The Healthy Aging Initiative is a population-based, cross-sectional study investigating the health of 70-year-old men and women. Out of the 2904 individuals who met the inclusion criteria, data on self-reported daily dairy product consumption (dl/day), peripheral quantitative computed tomography (pQCT) examinations at the 4 and 66% scan sites of the tibia and radius, and dual-energy X-ray absorptiometry (DXA) scans were collected from 2040 participants. Associations between dairy product consumption and bone properties were examined using multiple linear regression models adjusted for sex, muscle area, meal size, dietary protein proportion, current smoking status, and objectively measured physical activity.

RESULTS: Total dairy product intake was associated with larger trabecular (2.296 (95% CI, 0.552-4.039) mm2, per dl/day increase, p = 0.01) and cortical cross-sectional areas (CSAs) in the tibia (1.757 (95% CI, 0.683-2.830 mm2, p = 0.001) as measured by pQCT and higher areal bone mineral density (aBMD) of the radius (3.231 (95% CI, 0.764-5.698) mg/cm2, p = 0.01) as measured by DXA. No other measurement in the tibia, radius, femoral neck, or lower spine was associated significantly with dairy product intake. Bone properties did not differ according to the type of dairy product consumed.

CONCLUSION: No evidence of a negative association between dairy product consumption and bone health was found. Furthermore, total dairy product consumption was associated with increased CSAs in the tibia, regardless of dairy product type. Collectively, our findings indicate the existence of a weak but significant positive association between dairy product consumption bone properties in older adults.

Place, publisher, year, edition, pages
Springer, 2018
Keywords
Bone mineral density, Dairy product, Older adults, Peripheral quantitative computed tomography
National Category
Nutrition and Dietetics
Identifiers
urn:nbn:se:umu:diva-144507 (URN)10.1007/s11657-018-0420-1 (DOI)000423631300001 ()29380156 (PubMedID)
Available from: 2018-02-05 Created: 2018-02-05 Last updated: 2018-06-09Bibliographically approved
Hult, A., Johansson, J., Nordström, P. & Nordström, A. (2018). Objectively Measured Physical Activity in Older Adults With and Without Diabetes. Clinical Diabetes, Article ID cd180041.
Open this publication in new window or tab >>Objectively Measured Physical Activity in Older Adults With and Without Diabetes
2018 (English)In: Clinical Diabetes, ISSN 0891-8929, E-ISSN 1945-4953, article id cd180041Article in journal (Refereed) Epub ahead of print
Abstract [en]

Background

Increased physical activity (PA) is ordinated to increase glycemic control in subjects with diabetes. We evaluated objectively measured as well as self-reported PA in elderly individuals with and without diabetes.

Method

The study included 1872 community-dwelling individuals (49% women), all aged 70 years. Objective PA was measured by accelerometers worn for 1 week. Physical activity patterns in subjects with and without diabetes were evaluated using multivariable adjustable regression models.

Results

In the cohort 210 subjects (138 men and 72 women) were found to have diabetes. Self-reported PA showed a weak association with objective PA (r = 0.06, p = 0.01).  Individuals with known diabetes had fewer steps per day (mean 5,754) than those with detected diabetes at baseline (mean 6,359) or no diabetes (mean 7,375, all p < 0.05). A cut-off value of at least 6,000 steps per day discriminated best between individuals with and without diabetes (multi-adjusted odds ratio (OR), 0.50, 95% CI, 0.36–0.69), and overall step-count also showed the strongest correlation with objective visceral adipose tissue (VAT, β = 0.29, p < 0.001). In contrast, objectively measured PA in at least 10-minute bouts, as recommended by WHO, did not discriminate between individuals with a without diabetes (OR, 0.92, 95% CI, 0.66–1.28).

Conclusion

Despite recommendations given to subjects with diabetes, objectively measured PA was more than 20% lower in elderly individuals with diabetes. Daily step-counts was also associated with VAT, a potential mediator of the effects of PA.

Place, publisher, year, edition, pages
American Diabetes Association, 2018
National Category
Clinical Medicine Endocrinology and Diabetes
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-154288 (URN)10.2337/cd18-0041 (DOI)
Available from: 2018-12-14 Created: 2018-12-14 Last updated: 2019-02-12
Berginström, N., Nordström, P., Ekman, U., Eriksson, J., Nyberg, L. & Nordström, A. (2018). Pharmaco-fMRI in Patients With Traumatic Brain Injury: A Randomized Controlled Trial With the Monoaminergic Stabilizer (-)-OSU6162. The journal of head trauma rehabilitation
Open this publication in new window or tab >>Pharmaco-fMRI in Patients With Traumatic Brain Injury: A Randomized Controlled Trial With the Monoaminergic Stabilizer (-)-OSU6162
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2018 (English)In: The journal of head trauma rehabilitation, ISSN 0885-9701, E-ISSN 1550-509XArticle in journal (Refereed) Epub ahead of print
Abstract [en]

OBJECTIVE: To examine the effects of monoaminergic stabilizer (-)-OSU6162 on brain activity, as measured by blood-oxygen-level-dependent (BOLD) functional magnetic resonance imaging (fMRI), in patients in the chronic phase of traumatic brain injury suffering from fatigue.

SETTING: Neurorehabilitation clinic.

PARTICIPANTS: Patients with traumatic brain injury received either placebo (n = 24) or active treatment (n = 28). Healthy controls (n = 27) went through fMRI examination at one point and were used in sensitivity analysis on normalization of BOLD response.

DESIGN: Randomized, double-blinded, placebo-controlled design.

MAIN MEASURES: Effects on BOLD signal changes from before to after treatment during performance of a fatiguing attention task.

RESULTS: The fMRI results revealed treatment effects within the right occipitotemporal cortex and the right orbitofrontal cortex. In these regions, the BOLD response was normalized relative to healthy controls at the postintervention fMRI session. No effects were seen in regions in which we previously observed activity differences between patients and healthy controls while performing this fMRI task, such as the striatum.

CONCLUSION: (-)-OSU6162 treatment had influences on functional brain activity, although the normalized regional BOLD response was observed in regions that were not a priori hypothesized to be sensitive to this particular treatment, and was not accompanied by any effects on in-scanner test performance or on fatigue.

Place, publisher, year, edition, pages
Wolters Kluwer, 2018
National Category
Neurology Neurosciences
Identifiers
urn:nbn:se:umu:diva-152090 (URN)10.1097/HTR.0000000000000440 (DOI)30234850 (PubMedID)
Funder
Ragnar Söderbergs stiftelseTorsten Söderbergs stiftelseKnut and Alice Wallenberg FoundationVästerbotten County Council
Available from: 2018-09-26 Created: 2018-09-26 Last updated: 2019-02-20
Johansson, J., Hult, A., Morseth, B., Nordström, A. & Nordström, P. (2018). Self-reported protein intake and properties of bone in community-dwelling older individuals. Archives of Osteoporosis, 13(1), Article ID 10.
Open this publication in new window or tab >>Self-reported protein intake and properties of bone in community-dwelling older individuals
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2018 (English)In: Archives of Osteoporosis, ISSN 1862-3514, Vol. 13, no 1, article id 10Article in journal (Refereed) Published
Abstract [en]

SUMMARY:This study revealed that a quick and simple estimation of protein intake was related to measures of bone density and area in 70-year-old individuals. Furthermore, these associations were mediated by muscle mass when investigating peripheral measurement sites such as arms and legs.

PURPOSE: Recent evidence suggests that dietary protein is beneficial for bone health in older individuals, but less is known about the influence of muscle mass on this relationship. This cross-sectional study aimed to investigate associations among protein intake, bone health, and muscle mass in 2332 men and women aged 70 years.

METHODS: Volumetric bone mineral density of the radius and tibia was measured using peripheral quantitative computed tomography. Using dual-energy X-ray absorptiometry, we measured areal bone mineral density (aBMD) at the L1-L4 vertebrae, radius, and femoral neck, together with appendicular lean mass. Participants reported their average meal size and proportion of meat/fish intake. Associations were investigated using multiple linear regression models, adjusted for multiple covariates.

RESULTS: Self-reported protein intake was associated with aBMD of the femoral neck (β = 0.082) and L1-L4 vertebrae (β = 0.063) in men (both p < 0.05) after adjusting for multiple covariates, including appendicular muscle mass. No significant association was detected among women. In addition, protein intake was associated with tibial cortical area (β = 0.08), periosteal circumference (β = 0.072), radial aBMD (β = 0.064), and trabecular area (β = 0.078) in men (all p < 0.05), although these associations were attenuated after adjustment for appendicular muscle mass (all p > 0.05).

CONCLUSION: Self-reported protein intake was associated with bone properties in 70-year-old men. The strength of these associations in peripheral bone sites may be partially mediated by muscle mass from protein intake.

Place, publisher, year, edition, pages
Springer, 2018
Keywords
Appendicular muscle mass, Bone mineral density, Community dwelling, Peripheral quantitative computed tomography, Protein intake
National Category
Nutrition and Dietetics
Identifiers
urn:nbn:se:umu:diva-144514 (URN)10.1007/s11657-018-0421-0 (DOI)000423810200001 ()29388047 (PubMedID)
Available from: 2018-02-05 Created: 2018-02-05 Last updated: 2018-06-09Bibliographically approved
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