1. 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.

2. 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 2006 3 Nguyen DN, et al. J Bone Miner Res 2007

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

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

5. 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 1998 2 Fontana L, et al. Arch In Med 2005

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

7. METHODS AND STUDY DESIGN A cross-sectional study Vegetarian (Buddhist nuns) n=105 Omnivores n=105 50+ 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

8. 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).

9. 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).

10. Diet and Bone Mineral Density

11. 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.

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

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

14. 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

15. Unit of↑SD of BMDR-square change(95% CI) Femoral neck0.36 Age (y)+10-0.5(0.4,0.6) Lean mass (kg)+40.3(0.2,0.4) Lumbar spine0.36 Age (y)+10-0.5(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.

16. Morphometric vertebral fracture

17. Prevalence of vertebral fracture n%(95% CI) Any vertebral fracture48/20923.0(17.3,28.7) By age group: 50-5918/10617.0(9.8,24.1) 60-6910/5318.9(8.3,29.4) 70+20/5040.0(26.4,53.6) By diet: Buddhist vegetarians23/10422.1(14.1,30.1) Non-vegetarians25/10523.8(15.7,32.0)

18. 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 )-0.111.3(0.9,1.8) LSBMD (g/cm 2 )-0.141.7(1.2,2.5) Prior fractureyes1.9(1.0,3.8) Back painyes1.2(0.6,2.4) Calcium intake (g/d)-3701.2(0.9,1.6) Veganyes0.9(0.5,1.7) There was no significant association between vertebral fracture and other factors

19. 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 )-0.141.5(1.0,2.2) Prior fractureyes1.5(0.7,3.1) LSBMD, lumbar spine bone mineral density

20. 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.

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

22. 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.

23. Thank you!

24. Back-up slides

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

26. Daily dietary energy and nutrient intakes

27. 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)+4500.1(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)+3700.1(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

28. Characteristics of participants by fracture Vertebral fractureNon-vertebral fractureP-value (n=48)(n=161) Age (y)65(11)61(9)0.0065 Weight (kg)54(8)53(8)0.4577 Height (cm)148(6)149(6)0.2929 BMI (kg/m 2 )25(4)24(3)0.161 Total body fat (kg)19(5)19(5)0.4387 Total body lean (kg)33(4)32(4)0.3391 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)0.0016 Daily dietary intake: Energy (Cal) * 1320(1007,1538)1266(1051,1547)0.7566 Animal source protein (g) * 24(9,33)31(18,41)0.0955 Non-animal protein (g) * 29(22,35)26(22,35)0.6058 Calcium (g) * 432(310,645)422(267,641)0.4263 Values are mean(SD), unless otherwise specified * Median (Q1,Q3)

29. Vertebral fractureNon-vertebral fractureP-value (n=48)(n=161) Education:0.3579 ≤ 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)0.8788 Hypertension17(35.4)43(26.9)0.2519 CVD1(2.1)6(3.8)1.000 Diabetes3(6.3)11(6.9)0.8795 Arthritis9(18.8)29(18.1)0.9217 Back pain26(54.2)73(45.6)0.2987 Prior fracture15(31.3)31(19.3)0.0790 A history of fall4(8.3)17(10.7)0.6439 Characteristics of participants by fracture (cont.) Values are n (%)