Controversy still exists regarding whether alendronate (ALN) use increases the risk of esophageal cancer or breast cancer.This paper explores the possible association between the use of oral ALN in osteoporosis patients and subsequent cancer risk using the National Health Insurance (NHI) system database of Taiwan with a Cox proportional-hazard regression analysis. The exposure cohort contained 5,624 osteoporosis patients used ALN and randomly frequency-matched by age and gender of 3 osteoporosis patients without any kind of anti-osteoporosis drugs in the same period.For a dose ≥1.0 g/year, the risk of developing overall cancer was significantly higher  than in osteoporosis patients without any anti-osteoporosis drugs. The risks for developing liver, lung, and prostate cancers and lymphoma were also significantly higher than in the control group.This population-based retrospective cohort study did not find a relationship between ALN use and either esophageal or breast cancer, but unexpectedly discovered that use of ALN with dose ≥1.0 g/year significantly increased risks of overall cancer incidence, as well as liver, lung, and prostate cancers and lymphoma. Further large population-based unbiased studies to enforce our findings are required before any confirmatory conclusion can be made. Alendronate (ALN) is the most common form of bisphosphonate used for the prevention and treatment of osteoporosis Oral ALN is widely used globally; therefore, a small magnitude of hazard could have important clinical implications, and it may attract public attention as well. A population-based large study may help clarify this controversy. We were interested in exploring this question and conducted a study using the database from the National Health Insurance (NHI) system of Taiwan.th Edition Clinical Modification (ICD-9-CM). We confirm that all data was de-identified and analyzed anonymously. In addition, this study was also approved by the Ethics Review Board at China Medical University (CMU-REC-101-012).The present study used the reimbursement data of the universal NHI system in Taiwan, which registers all medical claims and has provided affordable healthcare for all residents in Taiwan since 1996. At the end of 2007, more than 99% of the population was enrolled in this insurance program, which contracted with 97% of clinics and hospitals. For administrative use and research, the National Health Research Institute (NHRI), Department of Health, established several randomly selected claim databases representative of the whole population. Sets of information available for the database cover all medical services received by each enrollee from 1996 to 2009, as well as characteristics of the patients, hospitals, and physicians. In this study, we used the insurance claims data of 1 million patients randomly selected from all enrollees in Taiwan in 1996–2000. We were able to use a scrambled identification number for each patient to link files, including the registry of medication prescribed, inpatient orders, and ambulatory care. Details of the database have been described previously The study patients were identified in the database with newly diagnosed osteoporosis (ICD-9-CM 733.0) and underwent ALN treatment between 1998 and 2009 . The date of the first ALN prescription was used as the index date. We excluded patients treated with other anti-osteoporosis drugs (n = 71) or with a cancer history predating the index date (n = 345). We finally extracted 5,624 patients to be study participants, defined as the ALN cohort.For each of the remaining 5,624 patients taking ALN, we randomly selected three osteoporosis patients from the same period without any anti-osteoporosis drug treatment, and used the same exclusion criteria and frequency-matched with the case cohort for age and gender to establish the control group (non-ALN cohort) with totally 16,294 subjects. Moreover, we divided the case cohort into three groups according to the intake dosage of ALN: <1.0 g/year, 1.0–2.9 g/year, and ≥3.0 g/year.We linked the study patients to the registry of the Catastrophic Illness Patient Database (CIPD) to identify newly diagnosed cases of cancer using the unique patient identification number. The diagnosis of cancer in the National Health Insurance Research Database (NHIRD) requires histological confirmation and is reported in the CIPD. Each study patient was followed until a diagnosis of malignant cancer (ICD-9-CM 140–208) was made, until the patients were censored for loss to follow-up, death, or last withdrawal from NHI, or until December 31, 2009, the end of the follow-up (whichever came first).Distributions of demographic characteristics including gender, age, occupation, and comorbidities were compared between patients with and without ALN treatment using chi-square tests. Poisson regression was used to calculate the incidence density and rate ratio of cancer by gender and age.A multivariate Cox proportional hazard regression analysis was used to determine the effects of ALN use on the risk of cancer. The model was performed to calculate the hazard ratios (HRs) and 95% confidence interval (95% CI) of ALN use for gender, age, or specific cancer type. Cancer-free proportions were compared using the Kaplan-Meier method, and the three groups of ALN-intake dosage were estimated by a log-rank test. The Cox proportional hazard model assumption test was using scaled Schoenfeld residuals. There was no significant relationship between Schoenfeld residuals for cancer and follow-up time and it indicated that the assumption was fulfilled (p = 0.16).All analyses were performed by SAS statistical software , and the significance level was set to 0.05.P = 0.45), age (P = 0.24), or comorbidities  were found between ALN cases and controls.We identified 5,624 osteoporosis patients treated with ALN between 1998 and 2009 as cases, and 16,294 osteoporosis patients without ALN as controls. Of the 5,624 cases, 84.1% of them were women . No signP<0.0001; ALN patients were grouped into three groups according to dosage: <1.0, 1.0–2.9 and ≥3.0 g/year. There were 3,073 patients treated low dosage, 1,358 patients treated median dosage and 1,193 patients treated with high dosage. The distribution of sex, age and comorbidity among four groups were no significant differences expect hyperlipidemia . The risk of cancer associated with different dosage levels of ALNs shows that, compared to the non-ALN cohort, the adjusted HRs of cancer were increased with an increased dosage in the ALN cohort. The highest risk was in patients with a dosage ≥3.0 g/year  . We alsoThe multivariate Cox proportional regression models specific to different types of cancer are presented in The results of adjusted analysis from this population-based cohort study indicate that exposure to oral ALN ≥1.0 g/year significantly increased the risk for overall cancer. For individual cancer risk, the use of oral ALN was not significantly associated with incident esophageal or breast cancer; conversely, we unexpectedly found significantly higher risks for liver, lung, and prostate cancers and lymphoma with higher ALN dose. These findings differ from those of prior literature reports.Cancer has been the leading cause of death in Taiwan since 1982. The age-adjusted incidence rate has increased steadily, and it reached 270 new cases per 100,000 people in 2007 A study from the University of Oxford indicated that the risk of esophageal cancer increased significantly by 2 times, with 10 or more prescriptions for oral bisphosphonates and with prescriptions over approximately a 5-year period Our results do not correspond with the findings of prior studies Some may doubt whether a reverse-causality effect exists for the relationship between the use of ALN and cancer. To clarify the relationship, we incorporated a time lag between ALN exposure and cancer development into our model. This study has the strengths in its large size, consequential period of follow-up, and use of NHIRD rather than self-reported drug use. However, certain limitations must still be addressed. First, detailed information such as smoking habits, alcohol consumption, body-mass index, socioeconomic status, and family history of cancer were unavailable from the NHIRD, all of which are major risk factors for multiple cancers and could plausibly be associated with osteoporosis and anti-osteoporosis medications. However, because NHIRD covers almost the whole population of Taiwan and the reimbursement policy is universal, these factors affecting the prescription of ALN would be unlikely. Second, the evidence derived from a cohort study is generally less reliable than that from randomized trials because a cohort study design is subject to numerous biases related to confounding adjustment. Despite our meticulous study design with adequate control of confounding factors, a key limitation is that bias could remain if unmeasured or unknown confounders exist. Third, diagnoses in NHI claims primarily serve the purpose of administrative billing and do not undergo verification for scientific purposes. We were unable to contact patients directly on their use of ALN because their identification numbers were anonymous. Prescriptions for these drugs before 1996 were not obtained in our analysis. This could cause underestimation of the cumulative dosage and may weaken the observed association. However, the data on the prescription of ALN and cancer diagnosis were highly reliable. Forth, several specific cancers analyzed in In conclusion, this population-based retrospective cohort study did not find a relationship between ALN use and either esophageal or breast cancer. On the other hand, subgroup analysis found that higher dose of ALN was more likely to be related to the cancer risk, and use of ALN with dose ≥1.0 g/year significantly increased risks of overall cancer incidence, as well as liver, lung, and prostate cancers and lymphoma. Some undetermined underlying mechanisms remain to be explored. Further large population-based unbiased studies to enforce our findings are required before any confirmatory conclusion can be made.


Because of non-participation or missing data, the number of subjects included in the analysis varied (response rate ≥ 77.1%). Workplace bullying and harassment were assessed using the Negative Acts Questionnaire. Depression was assessed using the Brief Job Stress Questionnaire. The frequency of pain experienced by workers in the previous month was evaluated using a four-point scale. Many of the associations of person-related bullying, work-related bullying, and sexual harassment with headache, stiffness of the neck or shoulders, lumbago, and pain of two or more joints were positive and significant (p < 0.05). Even after adjustment for depression, some of the associations remained significant (p < 0.05). For example, changes in the prevalence ratio for headache associated with a 1-point increase in the work-related bullying score were 1.05  1.01 to 1.09) in men and 1.03 (95% CI 1.01 to 1.05) in women after adjustment for age, marital status, employment status, work shift, and depression.The aim of this study was to investigate associations of workplace bullying and harassment with headache, stiffness of the neck or shoulders, lumbago, and pain of two or more joints. The subjects in this cross-sectional study were recruited from workers ( According to the International Labour Office (ILO), the International Council of Nurses (ICN), the World Health Organization (WHO), and the Public Services International (PSI), bullying (or mobbing) is “repeated and over time offensive behaviour through vindictive, cruel or malicious attempts to humiliate or undermine an individual or groups of employees,” and harassment is “any conduct based on age, disability, HIV status, domestic circumstances, sex, sexual orientation, gender reassignment, race, colour, language, religion, political, trade union or other opinion or belief, national or social origin, association with a minority, property, birth or other status that is unreciprocated or unwanted and which affects the dignity of men and women at work” . Many viIn a recent cross-sectional study, neck pain was associated with intimidation at work and with unwanted sexual attention in bivariate analyses in both genders . In anotn = 1,931) at 35 healthcare or welfare facilities in Japan. Questionnaires were mailed to the organizations and distributed to the workers. The purpose and procedure of the survey were explained to the participants in the documents. Written informed consent was obtained from all participants, who were not compensated for their participation. A total of 1,642 questionnaires were returned in sealed envelopes . Because of missing data, the number of subjects included in the analysis varied  . The NAQThe frequency of pain  experienced by workers in the previous month was evaluated using a four-point scale . Participants who answered “2,” “3,” or “4” for a particular symptom were categorized as having that symptom; participants who answered “1” for a particular symptom were categorized as not having that symptom.Depression was evaluated using a self-reported Brief Job Stress Questionnaire (BJSQ) published in a research report on stress in the workplace and its impact on workers’ health . The BJSt-test, variables of workplace bullying and harassment were compared using the Mann-Whitney U test, and categorical variables were compared using the chi-square test. SPSS version 20.0 were used for these tests. Based on the recommendation of Barros and Hirakata, prevalence ratios (PRs) and their 95% confidence intervals (CIs) were calculated by Cox regression with constant time at risk and robust variance using Stata/SE 10 [p < 0.05.Variables of age and depression were compared using the unpaired ta/SE 10 . All tesversus 7.8 for women) and sexual harassment  were significantly higher in men than in women.Participant characteristics according to gender are shown in Marital status, employment status, and work shift were significantly different between men and women. Significantly more women than men experienced each type of pain. Changes in the PR associated with a 1-point increase in the person-related bullying score are shown in Changes in the PR associated with a 1-point increase in the work-related bullying score are shown in Changes in the PR associated with a 1-point increase in the sexual harassment score are shown in Many of the associations of person-related bullying, work-related bullying, and sexual harassment with pain were positive and significant. The point estimates of the PRs in men and women were similar, and their 95% CIs in men and women overlapped each other. We found significant associations more frequently in women than in men probably because of relatively large sample sizes in women. After adjustment for depression, the degrees of the associations of workplace bullying and harassment with pain decreased, but some of the associations remained significant.Workplace bulling and harassment can cause depression ,12,13. PEven after adjustment for depression, some of the associations of workplace bullying and harassment with pain remained significant. Mechanisms other than just depression appear to play a role in the relationship of workplace bullying and harassment with pain. For example, the relationship between corticosteroids and stress is well known. Recent scientific and clinical evidence has demonstrated the direct role that steroids play in the generation of chronic pain . Stress The strength of this study was that we used a relatively large sample of workers to obtain reliable results. However, we must also note several limitations. First, we need to be cautious in interpreting causality in our results because the study used a cross-sectional design. Second, because we used convenience sampling, the results may not be applicable to the entire workforce. Many of the participants were professional caregivers and working with night shift. However, because we included workers from 35 various facilities and obtained a response rate of at least 77.1%, some generalizability can be expected. For example, more women than men experienced each type of pain. This is consistent with previous studies on neck pain ,13. ThirThe present study supports the association of workplace bullying and harassment with pain. If the causality from workplace bullying and harassment to pain was confirmed, to help prevent pain in workers, measures to prevent workplace bullying or harassment should be considered. Prevention may include the introduction of occupational guidelines against bullying and harassment, active monitoring of specific workplace bullying or harassment, and taking action to deal with bullying using criminal, civil, social, or occupational laws . Other mMany of the associations of person-related bullying, work-related bullying, and sexual harassment with headache, stiffness of the neck or shoulders, lumbago, and pain of two or more joints were positive and significant. Even after adjustment for depression, some of the associations remained significant.


Here, we examined the effects of GF rearing conditions through early life and adolescence on social behaviour in adulthood.Germ-free (GF) mice have been critical in assessing the role of microbiota in all aspects of physiology. Indeed, recent studies in GF mice report increases in neuroendocrine responses to stress,9 Our initial findings in this test revealed significant social impairments in GF mice, particularly in males, as indicated by a lack of the normal preference for time spent in a chamber containing a mouse versus the alternative empty chamber =5.35, P<0.05; P<0.01; Mice, like humans, are a social species and have a natural propensity to seek out the security and pleasure afforded by stable social scenarios. Social motivation and preference for social novelty in mice can be assessed in the three-chambered sociability test.P<0.001; P<0.05; To substantiate these results and to assess the capacity for post-weaning bacterial colonisation of the GF gut (GFC) to reverse the observed social deficits, we repeated the test in a different male cohort. As expected, GF mice exhibited robust deficits including social avoidance =12.41, P<0.005; P<0.001; per se during social interaction is not affected in GF mice.In addition to symptoms of reduced social motivation, children with autism exhibit poor social and communication skills and repetitive behaviours. To establish whether the degree of information transfer during social interaction is disrupted in GF mice, performance in the social transmission of food preference test was assessed. GF mice spent a decreased proportion of time engaged in social investigation =7.51, 10 and with a similar male preponderance, these data may have implications for our understanding of the genesis of neurodevelopmental disorders of altered sociability. A better understanding of the mechanisms underlying these social deficits, which may include modulation of immune cell cytokines release, changes in vagal nerve activity and neuroendocrine function, could potentially lead to the emergence of novel and more effective therapies to combat symptoms in the social domain.This study shows for, what is to our knowledge, the first time that microbiota are crucial for the programming and presentation of distinct normal social behaviours, including social motivation and preference for social novelty, while also being important regulators of repetitive behaviours. Given that these facets of behaviour are impaired in neurodevelopmental disorders such as schizophrenia and autism


Attention Deficit Hyperactivity Disorder (ADHD) is often comorbid with psychiatric and developmental disorders. This study aimed to investigate the prevalence of obesity and overweight among Chinese children with ADHD, and to explore which subtypes of the disorder may specifically be associated with obesity/overweight.Children meeting the DSM-IV criteria for ADHD were enrolled in the study. Weight, weight z-score, height, height z-score, BMI, and BMI z-score were used to evaluate growth status. Obesity and overweight were determined using the National Growth Reference for Chinese Children and Adolescents. Relations between the prevalence of obesity/overweight and different ADHD subtypes and pubertal development were analyzed.A total of 158 children with ADHD (mean age: 9.2 years) were recruited for the study. The prevalences of obesity, overweight, and combined obesity/overweight were 12.0%, 17.1%, and 29.1%, respectively, which were significantly higher than in the general Chinese population . Multivariable analysis showed that the children with the combined subtype of ADHD and the onset of puberty were at a higher risk of becoming obese or overweight.The prevalence of obesity in Chinese children with ADHD is higher than that of the general population. Children with the ADHD combined subtype who were at the onset of puberty were more likely to be overweight or obese. Attention deficit hyperactivity disorder (ADHD) is recognized as one of the most common childhood psychiatric disorders, and is characterized by age-inappropriate inattention, hyperactivity-impulsivity, or both ,2.The coIn recent years, ADHD was found to be linked with another increasing worldwide childhood disorder: obesity -15. The Although many studies suggest a potential comorbidity between obesity and ADHD, other results have shown that the rates of overweight and obesity among children with ADHD were not higher than the rates in the general population ,21. HoweTaking this research into consideration, the present study was performed in Zhejiang Province, China. We hypothesized that the prevalence of obesity was higher in ADHD patients, and that a specific subtype of ADHD was associated with obesity. Our aims were as follows: 1) to investigate the prevalence of obesity or overweight among Chinese children with ADHD, and to compare this prevalence with what is reported in the general Chinese population, and 2) to analyze the prevalence of obesity/overweight in children with different subtypes of ADHD to identify which dimension(s) of ADHD may specifically be associated with obesity/overweight.The data for this study were collected from outpatients who were believed to be affected by ADHD on their first visit to our clinic between March 1, 2010 and August 31, 2010. Patients visited this clinic only for psychological problems. No children who simply displayed obesity or overweight visited the clinic. The hospital has a separate center for the diagnosis and treatment of children with obesity and overweight. Therefore, sampling bias was avoided in this study. Participants who were diagnosed with any subtype of ADHD [Subjects with ADHD were eligible to participate in the study at our clinic at the Children’s Hospital, Zhejiang University School of Medicine, which specializes in evaluating and treating children with behavioral, developmental, and psychiatric disorders. The children underwent a comprehensive assessment process by a trained multidisciplinary ADHD diagnostic team, including physical examination, EEG, ECG, Vanderbilt ADHD Diagnostic Parent and Teacher Rating Scales, Conners’ Parent and Teacher Rating Scales (Chinese version), SNAP-IV, and Wechsler Intelligence Scale for Chinese Children (WISC-R) . The chiChildren included in this study met the following criteria: (a) diagnosed with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)  criteriaIndividuals were excluded if they had: (a) a psychiatric diagnosis with significant symptoms  and mental retardation; (b) sensorimotor handicaps ; (c) taken drugs such as methylphenidate in any form, clonidine, or atomoxetine for controlling ADHD symptoms; or (d) serious somatic disorders, such as cardiovascular diseases, hyperthyroidism, serious gastrointestinal stenosis, dysphagia, exogenous steroid hormones, and sexual development disorders.Growth data were taken during the first recruitment visit by one assistant. Body weight was measured to the nearest 0.10 kg while the subjects were wearing lightweight clothing, and height was measured to the nearest 0.10 cm without shoes and hats.The indicators of weight percentile, weight z-score, height percentiles, height z-score, BMI percentiles, and BMI z-score were used to determine the individuals’ growth, which was evaluated using the National Growth Reference for Chinese Children and Adolescents . Individth and 95th BMI percentiles.We referenced the growth chart for Chinese children and adolescents aged 0–18 years as the standardized tool to define normal weight, overweight, and obesity ,27. ThisTo assess the stage of pubertal development, children older than 8 years were asked questions about pubertal development. These included questions about the presence or absence of pubic hair, axillary hair, facial hair, and nocturnal emission for males; and pubic hair, axillary hair, and menses for females; as well as the age of attainment of each stage. Based on these questions, estimates of the individuals’ pubertal developmental stages were defined as follows: absence of pubic hair and any other sign of puberty was the pre-pubertal stage; attainment of any sign of puberty was the pubertal stage.t-test was used to compare the z-scores of height, weight, and BMI to the mean value of 0, the normal distributions of the sample values were tested. Differing gender and pubertal developmental stages were both categorical data, and were analyzed by chi-square analysis or Fisher’s Exact Test, for any analysis with a count in a cell of fewer than 5. A P value of less than 0.05 was regarded as statistically significant for all statistical tests. Three categories of independent variables considered to be associated with the prevalence of obesity/overweight were examined: (1) gender, (2) pubertal developmental stage, and (3) subtypes of ADHD. We used univariate analysis to quantify the association between variables and obesity. Variables found to be statistically significant in univariate analysis were used to establish a multivariable logistic regression model with a forward stepwise method to determine the risk factors for obesity.Data were entered into Excel software and analyzed in the SPSS (version 13.0) software package. Before a one-sample There were 162 children diagnosed with ADHD between March 1, 2010 and August 31, 2010. Four children were excluded from the study because either their consents were not obtained, or the information they provided was incomplete. The characteristics of the subjects are summarized in Table The prevalences of obesity, overweight, and combined obesity/overweight were 12.0% (19/158), 17.1% (27/158), and 29.1% (46/158), respectively, in this group of children with ADHD. The prevalence depended on the pubertal developmental stage and ADHD subtype (Table th percentile was 8.23% (13/158).Anthropometric data of the study samples, including the distribution of height and BMI in percentile, are presented in Table Univariate analysis showed that three potential risk factors were associated with obesity/overweight. Children in the pubertal stage were more likely to be overweight/obese . Children with ADHD combined subtype had a greater possibility of being overweight/obese . Gender was not a risk factor for obesity/overweight.Multivariate analysis Table  demonstrIn the present study, we found that the prevalence of obesity/overweight in Chinese children in Zhejiang Province with ADHD is 29.1%, which is higher than the figure of 6.6% found in the national survey of the normal population in 2002 . When weHere, we want to emphasize several strengths of this study. First, our study was conducted in children who were diagnosed with ADHD for the first time and who were medication-naive, which minimized the potential influence of drugs on growth status ,40. SecoSeveral hypotheses ,42 have Interestingly, this study found that pubertal development was associated with a higher prevalence of obesity/overweight in children with ADHD. When the sample of the ADHD group was restricted, children in puberty were associated with a four-fold increase in the odds ratio of obesity/overweight compared with those in the pre-pubertal stage. van Egmond-Frohlich and colleagues  found thth percentile was 8.23% (13/158), suggesting that the prevalence of underweight was also higher in the ADHD group. Most of them were males (12/13) who were diagnosed with ADHD inattentive type (8/13), followed by ADHD hyperactive-impulsive type (3/13), and ADHD combined type (2/13). This result was first reported in a retrospective survey with only three cases [Another interesting finding was that the proportion of children with BMI below the 5ee cases  that shoThe potential limitations of this study should be taken into consideration. First, the cross-sectional design precludes determining any causal inferences in the relationship between ADHD and obesity. Second, no control group was set to compare with the study group. However, in addition to comparing our results with the national survey, other investigations in China were used for comparison, including one conducted in Zhejiang Province, which could produce relatively objective conclusions. It should also be taken into consideration that the prevalence of obesity is rising quickly, and the data may not be completely up to date. Third, demographic and family information, obesity family history, and other parental characteristics of the ADHD group were not collected, and our population may have different lifestyles, food sources, and general structure, which would affect the children’s nutritional status. Finally, pubertal stages were estimated based on self-report, and data on the variety of pubertal stages were not collected, which might produce bias and affect the results. Therefore, a scientific design using a multi-center and random sampling method with larger sample size could be used to better explore this comorbidity.Our findings demonstrated that the prevalence of obesity in children with ADHD was higher than in the general population, which strongly supports obesity as another comorbidity of ADHD in Chinese children. Children with ADHD of the combined subtype and in puberty had a higher risk for obesity/overweight. These findings extend the comorbidity of ADHD and obesity to Chinese populations, consistent with previous findings reported in other populations.The authors declare that they have no competing interests.RY and ZZ were responsible for the conception and design of the study. RY and SM performed the data analysis. All authors participated in interpretation of the findings. RY and SZ drafted the manuscript. RL and ZZ revised and commented on the draft and all authors read and approved the final version of the paper.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/13/133/prepub


A high body mass index (BMI) has been associated with reduced semen quality and male subfecundity, but no studies following obese men losing weight have yet been published. We examined semen quality and reproductive hormones among morbidly obese men and studied if weight loss improved the reproductive indicators.2 were followed through a 14 week residential weight loss program. The participants provided semen samples and had blood samples drawn, filled in questionnaires, and had clinical examinations before and after the intervention. Conventional semen characteristics as well as sperm DNA integrity, analysed by the sperm chromatin structure assay (SCSA) were obtained. Serum levels of testosterone, estradiol, sex hormone-binding globulin (SHBG), luteinizing hormone (LH), follicle-stimulating hormone (FSH), anti-Müllerian hormone (AMH) and inhibin B (Inh-B) were measured.In this pilot cohort study, 43 men with BMI > 33 kg/m2. At baseline, after adjustment for potential confounders, BMI was inversely associated with sperm concentration (p = 0.02), total sperm count (p = 0.02), sperm morphology (p = 0.04), and motile sperm (p = 0.005) as well as testosterone (p = 0.04) and Inh-B (p = 0.04) and positively associated to estradiol (p < 0.005). The median (range) percentage weight loss after the intervention was 15% (3.5 - 25.4). Weight loss was associated with an increase in total sperm count (p = 0.02), semen volume (p = 0.04), testosterone (p = 0.02), SHBG (p = 0.03) and AMH (p = 0.02). The group with the largest weight loss had a statistically significant increase in total sperm count [193 millions ] and normal sperm morphology [4% ].Participants were from 20 to 59 years of age (median = 32) with BMI ranging from 33 to 61 kg/mThis study found obesity to be associated with poor semen quality and altered reproductive hormonal profile. Weight loss may potentially lead to improvement in semen quality. Whether the improvement is a result of the reduction in body weight per se or improved lifestyles remains unknown. The prevalence of overweight and obese individuals is increasing globally  and concSeveral studies have focused on inhibin B (Inh-B) -37, and It is unclear to what extent obesity affects a man's reproductive potential. The existing studies on this subject are all cross-sectional, a limited design for deriving causal inferences. There may be a causal link between male obesity and poor semen quality, however, they may also share a common aetiological factor. Longitudinal studies investigating how weight loss affects semen quality are needed to disentangle these two hypotheses, but no such studies have yet been published. In this paper, we present results from a pilot cohort study with prospectively collected data, investigating how obesity and weight loss affect reproductive hormones including AMH and Inh-B, conventional semen characteristics as well as sperm DNA integrity.Data collection took place from April 2006 to April 2009. Men who participated in a residential weight loss program in Ebeltoft, Denmark were recruited to this pilot cohort study. During the data collection period, men over the age of 18, independent of their weight, were invited to participate and a total of 107 men were invited. Forty-four men (41%) accepted the invitation. Out of the 44 participants, 27 men (61%) took part in the follow-up at the end of the weight loss program. We excluded one man diagnosed with Klinefelter's syndrome, and in the analyses of semen characteristics, two men with azoospermia were excluded because azoospermia probably is not caused by obesity alone.The weight loss program, based on a healthy diet and daily exercise, lasted approximately 14 weeks. Before and after the weight loss program, the participants had blood samples drawn, provided semen samples and had clinical examinations. The clinical examination was performed on site by one investigator and included height- and weight measurements. Blood samples were drawn by a trained technician between 6:45 a.m. and 8:20 a.m. at baseline and between 7:00 a.m. and 10:30 a.m. after the intervention. The blood samples were transported to the hospital laboratory on dry ice, centrifuged and stored at -80°C until analysed. The participants were asked to provide the semen sample by masturbating into a plastic container after at least 48 hours of sexual abstinence. They were instructed to keep the container close to the body, during transportation to the mobile laboratory on the weight loss centre to avoid cooling, and one trained medical laboratory technician performed all initial semen analyses within one hour after collection. Furthermore, before and after the weight loss program, the participants completed questionnaires on their reproductive experience, medical (e.g. history of diseases in the reproductive organs) and lifestyle factors  as well as time and date of the preceding ejaculation, and spillage (if any) during semen sample collection. Finally, testis volume was measured by ultrasound of the testes at baseline by a trained person under the supervision of a medical doctor.The men received no incentives, and participation was conditional on written informed consent. The regional ethics committee approved the study (reg. number 20060039).Serum samples for testosterone, estradiol, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were analysed at the Department of Clinical Biochemistry, Aarhus University Hospital, Denmark by Avida Centaur . The sex hormone-binding globulin (SHBG) concentrations were determined using IMMULITE . Serum concentrations of AMH were measured at the Laboratory of Reproductive Biology, University Hospital of Copenhagen, University of Copenhagen, Denmark using specific ELISA kits according to the manufacturer's instructions . Detection limit was 0.05 ng/ml and inter- and intra-assay variations were < 10%. Serum concentrations of Inh-B were measured at the Laboratory of Reproductive Biology, University Hospital of Copenhagen, Denmark using a specific ELISA-kit according manufactures instructions .Semen volume was estimated by weight (1 g = 1 mL). Sperm concentration and sperm motility were assessed as described in 'WHO Laboratory Manual for the Examination of Human Semen-Cervical Mucus Interaction' . Analysis of 96% of the samples was initiated within one hour after ejaculation, and within this time it has been shown that the sperm motility is stable . Sperm mAfter semen analysis, 100 μL of the raw semen sample was frozen at -80°C for later analysis of sperm DNA integrity. Sperm DNA integrity was analysed by the flow cytometric-based sperm chromatin structure assay (SCSA) at the Reproductive Medicine Centre, Skanes University Hospital, Malmö, Sweden. The details of this analysis have previously been described in detail ,47. In b2, 2: 41.7 to 46.08 kg/m2 and 3: 46.1 to 60.9 kg/m2). In the longitudinal study, we calculated the percentage weight loss and formed three groups according to percentage weight loss .In the cross-sectional study, three groups were formed according to BMI at baseline , the free testosterone⁄free estradiol ratio and LH/free testosterone ratio), conventional semen characteristics  and DFI. In the longitudinal study, the outcome variables included the differences in the parameters mentioned above.th, and 75th percentiles were calculated. We performed multiple linear regression analyses with BMI and percentage weight loss as the main determinants. Low BMI/percentage weight loss was considered the reference category. When we tested for trend, BMI and percentage weight loss was entered as a continuous explanatory variable.For each of the outcome variables, crude median, 25In the cross-sectional study, data on the semen characteristics, as well as LH, FSH, AMH, Inh-B, the free testosterone/free estradiol ratio, LH/free testosterone ratio and testis volume were transformed logarithmically to obtain an approximate linear distribution of residuals, whereas no transformations were used on data in the longitudinal study. In the longitudinal study, differences in semen characteristics and reproductive hormones from baseline to follow-up were calculated by subtracting the second sample value from the first sample value, thus a positive difference corresponds to a rise in the characteristics from baseline to follow-up.A priory, we decided which covariates that potentially should be included in the models, and due to the sample size, we based the selection on a 5% change-in-estimate principle . In the In the longitudinal study, the following potential confounders were considered  from baseline to follow up, as described above. Additionally, we fitted a model with total sperm count at follow-up as a function of the weight loss, controlling for total sperm count at baseline as well as the other covariates .P value of < 0.05 was considered statistically significant.The statistical analyses were performed by using Stata 11 software . A two-tailed 2. In table The median (range) age was 32 (20-59) years. The median (range) BMI was 44 33 - 61) kg/m kg/m2. IFollowing the weight loss program, the median (range) weight loss was 22  kg, corresponding to a median percentage weight loss on 15%, ranging from 3.5% to 25.4%. In table Finally, the results from the sub-analyses with semen volume and total sperm count with all participants were in the same direction, however, attenuated as expected, and p-values were no longer below 0.05.The study showed that a high BMI at baseline was associated with low values of total sperm count, sperm concentration, normal sperm morphology, and motile sperm. Weight loss was associated with an increase in total sperm count and semen volume among men who participated in a 14-week weight loss program. Additionally, the weight loss was associated with an increase in testosterone, SHBG and AMH, and FAI improved significantly in the group with the largest weight reduction. Weight loss did not decrease serum estradiol levels.As far as we know, this is the first cohort study investigating the association between weight loss and semen quality. Thus the results are unchallenged and further research is necessary to disclose the matter further. Our results indicate that there is a causal inverse association between BMI and semen quality, and that it may be possible to improve semen quality by a weight reduction. However, we cannot exclude that changes in lifestyle, diet or exercise caused the observed improvement in semen quality, rather than the reduction in weight per se.Despite conflicting results -21, prevThe hormonal profile among obese men evaluated in this study was characterized by abnormalities in the sex hormones, and weight loss improved some of the hormone levels, however, they were not normalized. It should be noted that the men were severely obese at baseline and remained overweight or obese after the weight loss program. This could explain why we did not observe a larger improvement in the hormonal parameters. The previous published studies, reporting improvement or normalization of the reproductive hormones, were on less obese men than in this present study.2 when entering the study and the AMH levels among these men might be lower than normal weight men, which could explain why we see no difference when comparing the two groups with the most obese men with the least obese men. Tüttelmann et al. [2, the median (range) concentration of AMH was 6.3 ng/mL , higher than among the men in our study where the median (range) AMH concentration was 3.3 ng/mL . Furthermore, we hypothesized that Inh-B and AMH would improve by weight loss but only AMH increased significantly.Inh-B and AMH are produced almost exclusively by the Sertoli cells and have been proposed as markers of spermatogenesis. Inh-B have been found to be significantly lower in men with testicular dysfunction -36 and An et al.  showed tThe major strength of this study is the successful weight loss program, providing prospectively collected data, which adds new important information to the existing cross-sectional studies. The risk of misclassification of the outcome variables is limited and most likely non-differential, since analyses of semen and blood samples were performed blinded to the exposure variables. Misclassification of the exposure variables is unlikely since anthropometric measurements were obtained on-site by one investigator and do not depend on self-reports. From the questionnaires, data were available on the main factors that we think affect semen quality, such as abstinence time and diseases of the reproductive organs. However, confounding from other unknown factors is possible and our findings may also be due to chance, since the sample size is small.The major limitation in this study is the limited sample size, resulting in wide confidence intervals, and the results must therefore be interpreted with caution. The participation rate (41%) is low, and leaves open the possibility of selection among participants. However, to cause bias away from the null, selection has to be related to both semen quality and BMI, and the participation rate of men with poor semen quality and high BMI must be higher. We have no reason to suspect participation to be associated with the exposure and the risk of differential participation and selection bias is limited, although it is possible as a chance phenomenon. Furthermore, loss to follow-up leaves room for selection bias, if attrition is dependent on the change in semen quality as well as related to the weight loss. Therefore, we examined if those who dropped out of the study systematically differed from those who remained in the sample. The two groups were found to have similar weight, BMI and reproductive hormones at baseline. Sperm concentration and total sperm count were lower among loss to follow-up men than among those who remained and the direction of this selection bias could be both away and toward the null.Finally, the follow-up period was on average 103 days (ranging from 86 to 111 days), and spermatogenesis takes approximately 64 days . Thus thThirty-four percent of the men had sperm concentrations below the World Health Organization (2010) referent level of 15 million/ml when entering the study. The median  sperm concentration of all participants at baseline was 25  million/ml and 19  million/ml among the most obese men. Since fecundity increases with sperm concentrations up to approximately 40 million/mL , some maTo conclude on this pilot cohort study, we observed that the altered androgen profile tended to improve following weight loss and that weight loss may potentially lead to improvement in semen quality, although we can not conclude this to be a result of the reduction in body weight per se. The observation has biologic plausibility, but the findings should be replicated in a larger cohort with longer follow-up time including a wider range of BMI levels.The authors declare that they have no competing interests.LBH contributed to analysis and interpretation and drafted the manuscript. AMT contributed to study design, acquisition of data, analysis and interpretation of data. ASA contributed to study design, acquisition of data and interpretation of data. JO contributed to analysis and interpretation of data. JPB contributed to study design and analysis and interpretation of data. CYA contributed to acquisition of data and interpretation of data. MB contributed to acquisition of data and interpretation of the data. EHE contributed to acquisition of data and interpretation of data. MLH contributed to analysis and interpretation of data. EE contributed to study design, acquisition of data and interpretation of data. CHRH contributed to study design, acquisition of data, analysis and interpretation of data. All authors read and approved the final manuscript.


Body weight and height of patients with relapsing-remitting multiple sclerosis (RRMS) or clinically isolated syndrome suggesting MS (CIS) in the age range 18 to 60 years  were compared with those of subjects  free of any major neurological disease. In drug-free patients, CSF levels of the metabolites of noradrenaline (MHPG), serotonin (5-HIAA), and dopamine (HVA), neurotransmitters involved in eating behavior, were estimated in searching for associations with body mass index (BMI). Statistical evaluations were done separately for males and females. Lower BMI was found in female MS patients compared to female controls, more pronounced in RRMS. BMI was not associated with duration of illness, smoking, present or previous drug treatment, or disability score. Body height showed a shift towards greater values in MS patients compared to controls. Patients in the lower BMI quartile (limits defined from control subjects) had lower 5-HIAA and HVA compared to patients in the upper quartile. The results provide evidence for weight reduction during disease process in MS, possibly related to deficits in serotoninergic and dopaminergic activities that develop during disease course, resulting in impairments in food reward capacity and in motivation to eat. Multiple sclerosis (MS) is an autoimmune demyelinating disease of the central nervous system. Although viral and genetic factors have been postulated to trigger the autoimmune process, the pathogenetic mechanisms regulating the disease course remain unknown. Increasing amount of evidence suggests that physical comorbidities as well as adverse health factors might affect the disease course .n = 597) of patients with MS in relation to general population. On the other hand, Khurana et al. [The impact of nutrition and diet in the aetiology and management of MS has been investigated in a large number of studies –6, but wa et al.  reporteda et al.  reporteda et al.  found ina et al.  reportedRegulation of food intake is a highly complex process involving many hormonal and neuropeptide pathways, including monoamine neurotransmitters . IncreasIn a recent study , we repoThe aim of the present study was (a) to compare BMI of MS patients presenting to a neurologic clinic, diagnosed as having clinically isolated syndrome (CIS) or relapsing-remitting MS, to BMI of subjects free from any major neurological disease and (b) to search for possible associations of the CSF levels of the main metabolites of noradrenaline, serotonin, and dopamine in patients who were drug-free at assessment with BMI.Four hundred and sixty-nine patients  satisfying the revised McDonald criteria for MS or possible MS  and 358 Two hundred and ten patients  had clinically isolated syndrome (CIS) suggestive of MS, and 259 patients  had relapsing-remitting MS. Duration of illness ranged from 0.1 to 480 months, and score in the Expanded Disability Status Scale (EDSS) ranged from zero to 6.0. A control group in the same age range to the patients (18 to 60 years) was built from (a) 194 subjects , admitted to the hospital for diagnostic investigations and found not to suffer from any major neurological disease, and (b) 164 healthy subjects . The data of these two subgroups were merged after it was found that there were no differences in BMI , to build a control group of 146 males and 212 females. Written informed consent was obtained from all subjects, and the study was approved by the Ethics Committee of the hospital.Lumbar puncture was performed for diagnostic reasons in the lateral recumbent position between L3 and L4 or L4 and L5. The CSF fraction from the third to fifth milliliter was used for estimation of the metabolites. It was centrifuged at 1500 g for 15 min to remove cells and kept at −30°C until analysis, which was performed within 3 months from sampling. The levels of the neurotransmitter metabolites were estimated by HPLC with electrochemical detection, all three in the same run. A 4.6 mm column was used , and the mobile phase consisted of acetate buffer, pH 5.2, with 10% methanol. For each sample an aliquot of CSF was directly injected into the HPLC system and subsequently a second aliquot with added standards corresponding to 5 ng/mL for MHPG, 10 ng/mL for 5-HIAA, and 20 ng/mL for HVA in the CSF sample. The concentrations of the metabolites were calculated from the differences in peak heights between the sample with and the sample without standards. For this part of the study, we only included patients who were drug-free for at least two weeks at the time of lumbar puncture, namely, 89 from the 145 males and 158 from the 285 females. Body mass index (weight in kilograms divided by the square of height in meters) was calculated using self-reported height and weight. Smoking history and numbers of cigarettes per day were registered. n = 29), steroids (n = 53), immunomodulatory agents (n = 20), antidepressives (n = 22), other drugs (n = 34), and drug-free patients (n = 301). Previous treatments with steroids (n = 199) and with immunomodulatory drugs (n = 58) were also used as independent variables. A multiple regression analysis was performed in searching for associations of clinical variables with BMI. Patients were assigned in subgroups regarding smoking , disease phenotype , duration of illness , and EDSS score . Regarding treatment at assessment, patients were assigned in subgroups taking thyroid hormones  and age . For the total patients' samples, there were no associations of BMI with smoking, disease phenotype, duration of illness, drug treatment, previous treatment, or EDSS score. Moreover, Spearman correlation coefficient tests did not reveal any significant associations of BMI or weight with duration of illness, cigarettes smoked per day, or EDSS score. A multiple regression analysis was performed for the whole patient population (459 patients), with dependent variable BMI and independent variables sex, age, smoking, disease phenotype, duration of illness, drug treatment, EDSS score, previous treatment with steroids, and immunomodulatory drugs. A regression coefficient P = .04) and patients with MS (P = .0001). The data for age, weight, height, and BMI for male and female control subjects and MS patients and their evaluation using ANOVA with age as covariate are presented in P = .054). The group of 310 female patients showed, compared to female controls, near significance (P = .09) lower body weight, significantly greater height (P = .006), and consequently lower BMI (P = .005). When disease phenotypes were compared to those in control subjects, these differences were found only for patients with RRMS. Compared to male controls, male patients did not show any significant difference for weight, height, or BMI . It is wP = .032) or with RRMS (P = .0001). The difference in frequencies was also significant when female patients with CIS were compared to RRMS females (P = .007).The frequencies of control subjects and MS patients in BMI quartiles are shown in P = .02 and P = .04, resp.) and females (P = .008 and P = .001). No differences were found regarding the noradrenaline metabolite MHPG.CSF levels of noradrenaline, serotonin, and dopamine metabolites in control-defined BMI quartiles for males and females are shown in P < .005) in BMI is the result of higher than expected—compared to controls—numbers of patients with lower weight and also with greater height. For male patients, the difference in BMI was not significant. There was, however, a shift towards greater body height in patients compared to controls. For the female patient population, significantly lower BMI was found compared to that of sex and age matched controls. BMI was not related to duration of disease or EDSS score, but the fact that the difference from controls was not significant for subjects with CIS indicates that lower BMI is not present at disease onset but develops later, during disease progression. This highly significant difference (Our results regarding BMI are in line with those of Nortvedt et al. , who repLower BMI in MS patients compared to age matched controls was previously reported also by Ghadirian et al. . In theiAn intriguing finding of this study is that body height of patients with MS tends to be greater than that of controls . SimilarA limitation of the current study is the self-reported weight and height that may not be accurate. This issue has been thoroughly studied by Stommel and Schoenborn . They foMale and female patients of the lower quartile for BMI were found to have lower CSF 5-HIAA and HVA levels compared to patients of the upper quartile . The rolIt is suggested that humoral factors from the periphery influence the dopaminergic system and affect food intake, either stimulating, like ghrelin, or inhibiting dopamine signaling, like leptin or insulin . Serum lPayne  has revi


To assess the socio-demographic and health-related risk factors associated with cataract subtypes in Korea.A total of 11,591 participants (aged ≥40 years) were selected from the Korean National Health and Nutrition Examination Survey between 2008 and 2010. The Korean Ophthalmologic Society conducted detailed ophthalmologic examinations on these participants based on the Lens Opacity Classification System III. Risk factors for developing any type of cataract, and its subtypes , were identified from univariate and multivariate logistic regression analysis.The prevalence of cataracts was 40.1%  in participants over 40 years old. Older age, lower monthly household income, lower education, hypercholesterolemia, hypertension, and diabetes mellitus (DM) were independent risk factors for development of any cataract. Older age, lower monthly household income, lower education, hypercholesterolemia, and DM were independent risk factors for development of pure cortical cataracts. Older age, lower education, metabolic syndrome, and DM were independent risk factors for development of pure nuclear cataracts. Older age and DM were independent risk factors for development of pure posterior subcapsular cataracts. Older age, lower monthly household income, lower education, and DM were independent risk factors for development of mixed cataracts.Although socioeconomic disparities are related to cataract development, this study identified several “modifiable” risk factors that may help to lower the incidence of cataracts and associated vision loss. Improved control of blood pressure, blood, glucose, and cholesterol may help to reduce the incidence of cataracts in the general Korean population. Our objective, therefore, was to use ophthalmologic examination results from KNHANES to investigate the socio-demographic and health-related risk factors associated with cataract subtypes  to determine disease occurrence in the anterior segment of the eye . Examinees were seated in the examination chair, resting their chin and forehead on the support. An illuminator was positioned behind the examinees’ ears; the angle between the illuminator and the microscope was 30 ~ 45 degrees with a 10× magnification.Without iridodilator usage, the characteristics of lens were assessed using slit lamp with proper brightness, height, and width. The overall characteristics of the lens were examined with a wider slit lamp, and the type and severity of the cataract was determined according to transparency, turbidity, pigments, vacuoles and nuclei. Each layer of the lens was examined with the focused slit lamp from the anterior capsule to the posterior capsule. Aphakia and pseudophakia were recorded separately, and excluded from the subtype analysis. The type of cataract was categorized according to Lens Opacity Classification System III (LOCS III) grading in both eyes, as nuclear, cortical, PSCO, or mixed (including anterior subcapsular). Standard pictures for each subtype were provided for each examiner  socio-demographic factors, (2) health examination variables, (3) comorbidities, and (4) health behavioral risk factors. The income per adult equivalent was calculated with the following formula: household income divided by the square root of the number of people in the household . Binge aWe report descriptive statistics for each response. We determined age-specific prevalence of cataracts in Koreans with weighting recommended in KNHANES IV and V-1. To weight KNHANES IV in accordance to guidelines in the 2005 Census of Korea, we performed a post-stratification adjustment to response and extraction rates that included the same distribution of the 2005 Korean population, according to sex and age groups and at 5-year intervals. Finally, the sum of the weight of KNHANES IV was considered equal to that in the Korean population as of 2005. We weighted KNHANES V-1 in a similar manner but based it on the 2010 Korean population and in accordance with the 2010 Census of Korea.We used a three-step, multi-dimensional approach to identify cataract risk factors. First, we calculated unadjusted odds ratios and 95% CIs with univariate logistic regression analysis. Second, we applied multivariate logistic regression analysis on all variables in each category, after adjusting for age, sex, monthly household income, and education. Finally, we used multivariate logistic regression analysis to determine independent risk factors. All risk factors that were identified by multivariate analysis were included in the final multivariate analysis  age of the final 11,591 participants was 58.4 ± 0.1 years. Of those participants, 43.1% were men, 70.1% were living in an urban area, 14.6% had hypercholesterolemia, 9.9% had anemia, 41.5% had metabolic syndrome, 30.0% had hypertension, and 10.9% had diabetes mellitus (DM). Table Table The factors from the univariate analysis that were significantly associated with cataracts , we should consider hypertension and DM effect modifications. Because cataract prevalence is not rare, we were confident we could perform additional analyses of relative risks (and their 95% CIs) to avoid exaggerated interactions in Table Hypertension has been of interest as a risk factor in previous studies. Cross-sectional analysis on an initial Beaver Dam Eye cohort showed a correlation between hypertension and posterior subcapsular type , whereasAlthough some studies have shown that statins have a protective effect against cataract development, not only because of their cholesterol-lowering effects but also possibly due to anti-oxidative and/or anti-inflammatory effects ,47, dyslAbdominal obesity is associated with insulin resistance on peripheral glucose and fatty acid utilization, often leading to co-occurrence of metabolic risk factors for type 2 DM, dyslipidemia, hypertension, and cardiovascular diseases ,49. ThesThere are some limitations to this study since the KNHANES and its ophthalmologic examinations aimed to investigate various health issues, limited resources were allocated for investigating cataract and subtypes. First, iridodilators could not be used, which could have influenced the detection and classification of the cataract, even though the examiners maximized the pupil diameter with the illuminator and slit lamp settings described in the Methods section, this could have been an underestimation of cataract prevalence. Misclassification and under estimation were possible, especially for the cortical type of cataract when it occurs in the peripheral cortex in a circumferential or in an arcuate pattern. Second, the cut value of opalescence based on LOCS III score was not included, which could induce individual variation between ophthalmologists; however, while grading and classifying by a few ophthalmologists may increase the accuracy of the result, a systemic error could also increase. This could reflect the generally accepted definition of cataract from a number of ophthalmologists. Third, the ophthalmologic exam for this study was done with a slit lamp without a permanent photographic record, which could have restricted the reviewing or assessment of inter-observer reliability for the classification. Despite these limitations, we believe our study adequately identified risk factors most associated with cataract development, particularly at the national level.We were able to show that socioeconomic disparities do exist in cataract development, and improved control of blood pressure, sugar, cholesterol and the factors associated with metabolic syndrome may help to reduce the risk of cataract development. For individuals who have both hypertension and DM, the risk of developing cataracts was twice than that of the individuals without. Therefore, we recommend more targeted efforts to reduce such risks in this group.The authors have no proprietary or commercial interest in any materials discussed in this article.THTR and MK drafted the manuscript. THTR and WCK carried out the statistical analysis. WCK interpreted the data. TK and EKK prepare and review of the manuscript. EKK participated in study design. This survey was conducted by Epidemiologic Survey Committee of the Korean Ophthalmologic Society. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2415/14/4/prepub


Depressive symptoms and physical performance are inversely associated, but it is unclear whether their association is bidirectional. We examined whether the association between depressive symptoms and physical performance measured using gait speed is bidirectional.We used a national sample of 4,581 community-dwelling people aged 60 years and older from the English Longitudinal Study of Ageing (from 2002–03 to 2008-09). We fitted Generalized Estimating Equation (GEE) regression models to analyse repeated measurements of gait speed (m/sec) and elevated depressive symptoms .Slower gait speed was associated with elevated depressive symptoms both concurrently and two years later. After adjustment for previous depressive symptoms and sociodemographic, clinical, lifestyle, psychosocial, and cognitive factors the concurrent association was partially explained  and the two-year lagged association fully . Elevated depressive symptoms were associated with slower gait speed. Full adjustment for covariates (including previous gait speed) partially explained both the concurrent  and the two-year lagged associations . Subthreshold depressive symptoms  were also associated with slower gait speed. Full adjustment for covariates partially explained both the concurrent  and the two-year lagged associations .The inverse association between gait speed and depressive symptoms appears to be bidirectional. Evidence is accumulating that elevated depressive symptoms are a risk factor for physical disability –5 and poDespite the parallel development of these two lines of research and suggestions that depression and physical decline and disability might be mutually reinforcing ,5,13,19 We explored the bidirectional association between depressive symptoms and physical performance measured using gait speed, which is an established predictor of incident physical disability ,27 and mhttp://www.esds.ac.uk/findingData/snDescription.asp?sn=5050). The present work has used the 15th edition of the data.The English Longitudinal Study of Ageing (ELSA) is a prospective observational study of community-dwelling people aged 50 years and over in England. Participants were recruited from households that had participated in the Health Survey for England in 1998, 1999, and 2001. At baseline, in 2002-03, the sample comprised 11,391 core members and was designed to be nationally representative. Follow-up interviews took place in 2004-05, 2006-07, 2008-09, and 2010-11 and health examinations in 2004-05 and 2008-09. ELSA has been approved by the National Research Ethics Service and all participants have given informed consent. Written informed consent was obtained for the health examination. The ELSA data and documentation are publicly available and can be downloaded from the UK Data Service  since data on gait speed were not collected from younger participants, and used data from the first four interviews. The analytic sample comprised 4,581 individuals, after the exclusion of 1,468 individuals who were lost to follow up after the baseline and 1,197 individuals with missing baseline data in any of the variables used in the analyses. In the second part of the analysis the analytic sample comprised 4,300 individuals because of 281 additional cases with missing data.Attrition was associated with male sex, older age, lower socioeconomic position, more comorbidities, higher rates of elevated depressive symptoms, and slower gait speed.Participants able to walk were asked to walk a distance of eight feet at their usual pace from a standing point twice. The times of the two successive walks were recorded using a stopwatch and the mean time was calculated. If a single measurement of time was available then this was used instead of the mean time. We calculated gait speed by dividing distance (in meters) by mean time (in seconds) for participants who did not use mobility aids to perform the walking test. At baseline there were 56 individuals with extreme time values (<1sec or ≥60sec) in either the first or the second walk, which were not used in the calculation of the mean time. We also derived a four-category variable of gait speed by categorizing gait speed into 0.2m/s bands with measurements of 1.0m/s or higher and lower than 0.6m/s grouped into the fastest and slowest gait speed categories, respectively, to examine whether the association between gait speed and elevated depressive symptoms was linear .Depressive symptomatology was measured using the eight-item Center for Epidemiological Studies-Depression (CES-D) scale. CES-D is not a diagnostic instrument for clinical depression but can be used to identify people “at risk” of depression . The psy2 (in meters)) (BMI): <25, ≥25 to <30, ≥30, missing and waist circumference: <94cm, ≥94cm, ≥102cm, missing (in men) and <80cm, ≥80cm, ≥88cm, missing (in women) were measured as lifestyle mediators [t=1, 2, 3, 4).Age, sex, marital status, education, total net household wealth, and self-reported doctor diagnosed cardiovascular  and non-cardiovascular  comorbidities were measured and considered to be confounders. Bodily pain  was measured as a clinical mediator ,24,35, wediators . Social ediators ,36–38. Mediators . A time All covariates were measured at baseline and each of the follow-up interviews, except for age, sex, marital status, education, wealth, and smoking which were measured only at baseline. Data on BMI and waist circumference were not measured at baseline. They had been measured in the Health Survey for England in 1998, 1999, and 2001.In supplementary analyses, we assessed triglycerides, high-density lipoprotein cholesterol, fibrinogen, and high sensitivity C-reactive protein from the 2004-05 health examination as mediators because of their associations with physical performance and depressive symptoms at older ages –41.After the analysis of the baseline characteristics of the sample according to gait speed categories, we used Generalized Estimating Equations (GEE) to model the association between gait speed (both continuous and categories) and elevated depressive symptoms. GEE is an extension of the generalized linear model that accounts for the within-subject correlation across repeated measurements, allows for within-subject missing data, and is appropriate to estimate population-averaged effects over time .t  was related to elevated depressive symptoms at time t with adjustment for elevated depressive symptoms at time t-1. The adjustment for elevated depressive symptoms at time t-1 was made to account for the recurrent nature of depressive symptoms and compensate for our inability to adjust for depression history. Then, we estimated a 2-year lagged logistic regression model to assess the temporal dimension of this association. In this model gait speed at time t  was related to elevated depressive symptoms at time t+1 with adjustment for elevated depressive symptoms at time t. We adjusted our models initially for time, age, marital status, and sex, then for education and wealth, and then in addition for comorbidities. Mediating factors were adjusted for in the final model. In supplementary analyses . The modelling strategy was similar to that of the first part of the analysis. Concurrent and 2-year lagged linear regression GEE models were estimated for the association between categories of depressive symptoms and gait speed. Supplementary analyses similar to those described in the first part of the analysis were also performed see .P values were 2-sided and statistical significance was determined at P <.05. Statistical analyses were performed using STATA 11.All The slower the gait speed the more likely the participants to be older, female, non-married, less wealthy and educated, less physically active, more often troubled by pain, obese, and more depressed. Also, the slower the gait speed the more likely the participants to have more cardiovascular and non-cardiovascular comorbidities and poorer cognitive ability; report lower sense of control at home; and consume alcohol less often Click here for additional data file.


Astragalus membranaceus, Trifolium pratense, Glycyrrhiza glabra, and Pueraria lobata, which all belong to Fabaceae family. Due to its structural similarity to 17β-estradiol, it can mimic estradiol's effect and therefore is considered as a “phytoestrogen.” The aim of this study was to examine the effect of formononetin on mechanical properties and chemical composition of bones in rats with ovariectomy-induced osteoporosis. 12-week-old female rats were divided into 4 groups: sham-operated, ovariectomized, ovariectomized treated with estradiol (0.2 mg/kg) and ovariectomized treated with formononetin (10 mg/kg). Analyzed substances were administered orally for 4 weeks. Ovariectomy caused osteoporotic changes, which can be observed in bone biomechanical features (decrease of maximum load and fracture load and increase of displacements for maximum and fracture loads) and bone chemical composition . Supplementation with formononetin resulted in slightly enhanced bone mechanical properties and bone chemistry improvement . To summarize, administration of formononetin to ovariectomized rats shows beneficial effect on bone biomechanical features and chemistry; thus, it can prevent osteoporosis development. Formononetin is a naturally occurring isoflavone, which can be found in low concentrations in many dietary products, but the greatest sources of this substance are  Thus, in women during menopause, when level of estrogen decreases, osteoporosis may occur, which could lead to pathologic fractures [β-estradiol, they may bind to estrogen receptors and mimic the effect of estradiol, but their activity is 10−2–10−3-fold lower [16H12O4)—is the major compound of the Astragalus membranaceus and Astragalus mongholicus root, but it could also be found in leaves and flowers of Trifolium pratense, roots of Glycyrrhiza glabra as well as Glycyrrhiza uralensis, and in root of kudzu—Pueraria lobata [Giardia lamblia [β-estradiol; thus, it can bind to estrogen receptors, for example, in bone tissue [Estrogen, as an antiresorptive agent, interacts via estrogen receptors ractures –4. In orractures , 6. To oractures , 8. Phytld lower –11. Amonld lower , 13. Anoa lobata –18. Thisa lobata . Formono lamblia  and as a lamblia . This is lamblia  and prom lamblia . What is lamblia  as well  lamblia . Formono lamblia , 24–26. e tissue , 23. Up Due to the fact that the analysis of bone mechanical features and their resistance to fractures is impossible to be conducted on human, a laboratory animal model was developed. The best animal model for this purpose is ovariectomy, where estrogen deficiency occurs; thus, osteoporotic changes in animal skeletal system can be observed. Osteoporotic changes in ovariectomized (OVX) rats are similar to those in postmenopausal women; therefore, OVX rats are good models for postmenopausal osteoporosis .In our study, the effects of formononetin on chemical composition and mechanical properties of bones in ovariectomized rats were investigated for the first time.ad libitum. Since the day preceding the experiment, the standard chow was replaced with chow containing no soybean. Rats were provided by the Centre of Experimental Medicine at the Medical University of Silesia. The research was carried out with the approval of the Local Ethics Commission in Katowice.The experiment was conducted on the three-month-old female Wistar rats which were fed a standard laboratory chow n = 7): the control group of sham-operated, vehicle-treated rats (SHAM), the control group of ovariectomized, vehicle-treated rats (OVX), the ovariectomized rats receiving estradiol at a dose of 0.2 mg/kg po (OVX + ES), and the ovariectomized rats receiving formononetin at a dose of 10 mg/kg po (OVX + FRM). The analyzed substances were administered for four weeks.Rats were divided into four groups . Seven days before administering estradiol and formononetin, the bilateral ovariectomy and the sham surgery in general anesthesia induced by the mixture of ketamine and xylazine i.p. were performed. After four weeks of drugs administration, all rats were sacrificed with the use of general anesthesia induced by ketamine and xylazine. Each of the rats had the right and left tibia and the right and left femur excised, as well as the L-4 vertebra, uterus, and thymus. The mass of femur, tibia, and L-4 vertebra was presented as the ratio of their mass per body mass determined after four weeks of the experiment.Testing of the bone mechanical properties of the left femoral diaphysis, right tibial proximal metaphysis, and right femoral neck was performed using the Instron apparatus, model 3342 500 N. Results were studied by using the software Bluehill 2, version 2.14.The femur was placed horizontally in the testing apparatus, and the bending test with three-point loading was applied, as previously described . The loaAssessment of the mechanical properties of tibial proximal metaphysis was performed according to the method of Stürmer et al. , 29, usiThe mechanical properties of the femoral neck were analyzed by performing a compression test , 30. RigThe assessment of the chemical content involved the calculation of the water, organic substances, and mineral substances content as well as content of calcium and phosphorus in left femur and left tibia  and L-4 vertebra.In order to determine the water content, the tibia, femur, and L-4 vertebra were lyophilized in the lyophilizer Labconco FreeZone 6 for five days  and then weighed. The difference between the bone mass obtained directly after the isolation and the bone mass determined after lyophilization corresponds to the water content.The lyophilized bones were mineralized for 48 hours in the muffle furnace type LG/11/C6 produced by Nabertherm. After mineralization, bones were weighed. On the basis of the difference between bone mass determined after lyophilization and bone mass after mineralization, the content of the organic substances was estimated.The bone ash obtained during the mineralization process comprised the mass of the mineral substances.The content of water, organic, and mineral substances was presented as the ratio of water, organic, and mineral substances mass per 100 mg of the bone mass after isolation. Mineralized bones were dissolved in 6 M HCI, and diluted in distilled water, and then calcium and phosphorus content was determined by the colorimetrical method, using the kit Pointe Scientific, Inc. The content of calcium and phosphorus in the analyzed bones was presented as the ratio of the quantity of calcium and phosphorus per 100 mg of mineral substances.t-test to detect the intergroup differences. The differences were considered to be statistically significant if P < 0.05.The results obtained during the tests were presented as arithmetic means ± SEM. The results were formulated by one-way ANOVA followed by Student's After four weeks of the experiment, in the ovariectomized rats (OVX), statistically significant body mass gain (by 57.6%) was noted, as well as the uterus mass loss  and the thymus mass gain , as compared to the sham-operated control group of rats (SHAM) .Mass of the femoral bone , tibia , and L-4 vertebra (by 14.1%) decreased in OVX rats when compared to the SHAM group. In comparison with the SHAM group, the femoral and tibial bone lengths of OVX rats were not significantly affected, while the diameter of the femur (by 5.3%) and tibia  decreased .In the OVX group, maximum load and fracture load decreased , while displacement for both maximum load and fracture load increased , as compared to the SHAM group. Young's modulus value in the femoral diaphysis decreased (by 6.1%) when compared to the SHAM group. There was a statistically significant decrease in maximum load (by 51.0%) and fracture load (by 54.5%) of the tibia metaphysis in comparison to the SHAM group. In comparison to the SHAM group, in OVX group, displacement for maximum load in tibial metaphysis was not significantly changed, while displacement for fracture load increased (by 14.9%). Young's modulus value decreased statistically significantly (by 50.9%) when confronted with the SHAM group. In the OVX group, the maximum load applied to the femoral neck was decreased (by 13.1%), as compared to the SHAM group .Statistically significant increase of water content in femur, tibia, and L-4 vertebra , as well as statistically significant increase of the organic substances content in femur (by 16.2%), tibia (by 16.7%), and L-4 vertebra (by 25.2%) was noted in OVX group as compared to the SHAM group. Furthermore, a decrease of mineral content in femur , tibia (by 18.0%), and L-4 vertebra  in OVX group in comparison to the SHAM group was observed. The content of calcium in femur, tibia, and L-4 vertebra was lowered , whereas the content of phosphorus was not changed when compared to the SHAM group .Administration of estradiol to ovariectomized rats (OVX + ES) resulted in a statistically significant reduction of body mass gain (by 32.6%), increased uterus mass (by 96.9%), and a decrease of the thymus mass (by 9.8%), in comparison with the control group OVX . An incrThere were changes in bone mechanical properties in OVX + ES rats observed: an increase in the maximum load and the fracture load in femoral diaphysis , while displacement for maximum load and displacement for fracture load in femoral diaphysis were decreased . Young's modulus value in femoral diaphysis increased (by 12.5%), as compared to the OVX group. In comparison to the OVX rats, the maximum load and the fracture load in tibial metaphysis of OVX + ES group increased , displacement for maximum load was not changed, while displacement for fracture load decreased (by 8.6%). Value of Young's modulus increased (by 8.9%) in OVX + ES group when compared to the OVX group. The administration of estradiol affected the maximal load in femoral neck, which increased by 11.5%, in comparison with the OVX group .In femur of the OVX + ES rats, there was a decrease of water  and the organic fraction content , while the content of minerals , and calcium (by 8.7%) increased, when compared to the OVX group. In tibia, a decrease of water  and organic substances  was observed, while an increase of minerals  and the calcium content (by 12.8%) was noted in OVX + ES group when confronted with the OVX rats. There was a decrease in the water (by 13.9%) and organic fraction content  in the L-4 vertebra of OVX + ES group, whereas the content of mineral substances  and calcium (by 3.5%) increased. The phosphorus content was not changed in any of the analyzed bones when compared to the OVX group .The administration of formononetin to ovariectomized rats (OVX + FRM) did not cause any changes in the thymus and uterus mass as well as in the body mass gain as compared to the OVX group .In OVX + FRM rats, an increase in the mass of the femur, tibia, and L-4 vertebra  was observed. The length of femur and tibia was not changed, while there was an increase in the femoral bone diameter (by 3.5%) and tibial bone diameter (by 4.7%), in comparison with the OVX group .In the femoral diaphysis of OVX + FRM rats, an increase in maximum load and fracture load  and a decrease of displacement for maximum load and displacement for fracture load  were noted. The value of Young's modulus was higher (by 22.0%) in OVX + FRM group when compared to the OVX group. The maximum load and the fracture load in tibial metaphysis of OVX + FRM rats increased  in comparison with the OVX group. Displacement for maximum load and displacement for fracture load were not changed; however, there was an increase in Young's modulus value (by 19.3%), as compared to OVX group. There was no change in the maximum load applied to the femoral neck when compared to the OVX group .In OVX + FRM rats, in femur, the water content decreased , content of the organic substances increased , while the mineral substances content was not changed, when compared to the OVX group. In tibia, the content of water was lower , while the content of organic and mineral substances was higher  in OVX + FRM group than in the OVX rats. The water content decreased (by 16.1%), and an increase of organic (by 7.7%) and mineral fraction content (by 7.7%) in L-4 vertebra in OVX + FRM group when compared to the OVX group was observed. The calcium and phosphorus content in all examined bones was not significantly changed in OVX + FRM rats in comparison with the OVX group .α-ethinyl oestradiol). Furthermore, the administration of this phytoestrogen improved the breaking strength of femur, and this improvement was also greater when compared to the other examined substances. Miao et al. [Phytoestrogens can relieve the symptoms of menopause; thus, they are promising substances for preventing bone fractures in women suffering from a postmenopausal osteoporosis. Genistein is the best-studied substance among all phytoestrogens which affect bone mechanical properties. The experiments carried out on laboratory animal models revealed that genistein shows a bone-sparing effect. Wang et al.  demonstro et al.  also higo et al. –36.In spite of a large number of reports regarding genistein, publications about the effects of other phytoestrogens  on bone microarchitecture, biomechanical properties, and chemical composition are still scarce.Formononetin is suggested to be a natural selective estrogen receptor modulator (SERM) , 38. SERin vitro studies of bone cells [μCT method. The authors noted that in tibia and femur the number and thickness of bone trabeculae increased and the distance between them decreased. These observations coincide with the results obtained in our study (data not shown). Some authors suggest that the examination of bone biomechanical features is essential for confirming beneficial effect of formononetin demonstrated in previous studies [The first scientific reports about beneficial effect of formononetin on bone tissue focused on ne cells , 22, 42 ne cells , 38. Ha ne cells  showed t studies , 38. It  studies . Due to po for 4 weeks. The dose of examined isoflavone was determined on the basis of the literature reports indicating beneficial effect of formononetin on the bone microarchitecture and bone cells in vitro [Experiment was carried out on the rat model of ovariectomy-induced osteoporosis. Three-month-old female rats were operated—both ovaries were excised, leading to estrogen deficiency and, in consequence, to osteoporotic changes. Formononetin was administered to rats at a dose of 10 mg/kg in vitro , 42. In Estrogen deficiency induced characteristic changes in ovariectomized rats as follows: an intensified body mass gain, decreased uterus mass, and increased thymus mass. Ovariectomy also induced deteriorations in bone mechanical properties. A decrease of maximum load in femoral diaphysis, tibial metaphysis, and femoral neck, as well as a decrease of fracture load in femoral diaphysis and tibial metaphysis was observed when compared to the sham-operated group.Young's modulus in femoral diaphysis and tibial metaphysis also was lower than in sham-operated rats. What is more, an increase in displacement for maximum and fracture loads, both in the femoral diaphysis and tibial metaphysis, was noted. Mechanical resistance of skeletal system depends on the mass and shape of bones, as well as on their internal structure and chemical composition. Thus, the impairment of bone biomechanical features in ovariectomized rats can be caused by reduced mass of femur and tibia, as well as alterations in shape–decreased diameter of long bones. Adverse osteoporotic changes in ovariectomized rats were also revealed in histomorphometric parameters, especially in bone trabeculae loss (data not shown). These results indicate that bones in ovariectomized rats are less resistant to fractures and more susceptible to deformations than in sham-operated group.The lack of estrogen also affected bone chemistry: an increased water and organic content, as well as decreased mineral fraction, was observed. It was previously mentioned that ovariectomy can induce significant increase of water and decrease of mineral fraction content in bones . CalciumSimilar changes in the ovariectomy rat model were previously observed , 45–47. It is worth noting that estradiol causes an increase of the bone trabeculae width in femoral metaphysis and epiphysis (data not shown).The earlier studies, where the ovariectomized rats treated with estradiol were used as a positive control, also demonstrate that supplementation with this substance shows beneficial effect on the mineralization, microarchitecture, and mechanical parameters of bones .po [As opposed to the results obtained in estradiol-receiving group, administration of formononetin to ovariectomized rats did not affect the body mass gain and uterus mass. No uterotropic effect after administration of formononetin was observed in other studies, where this isoflavone was administered to ovariectomized rats  and to immature female rats at a dose of 10 mg/kg po , 42. Howpo .In our study, the beneficial effect of formononetin on the biomechanical parameters in rats with ovariectomy-induced osteoporosis was observed.In the femoral diaphysis, an increase of both the maximum and fracture loads was observed, while displacement for maximum load and fracture load decreased. The effect of formononetin on described biomechanical features in femoral diaphysis was weaker as compared to ovariectomized rats treated with estradiol. On the contrary, Young's modulus in femoral diaphysis increased, and its value was higher than in the ovariectomized rats receiving estradiol.In measurements of mechanical features in tibial metaphysis of ovariectomized rats treated with formononetin, an increase of maximum load and fracture load was noted. The examined isoflavone, however, did not affect displacements of both maximum and fracture loads. Beneficial effect of formononetin on tibial metaphysis was lower than in rats receiving estradiol; nevertheless, Young's modulus value, similarly to femoral diaphysis, was higher in ovariectomized rats treated with formononetin than in group administered with estradiol.Administration of formononetin to ovariectomized rats prevented femur, tibia, and L-4 vertebra mass loss, which occurs in estrogen deficiency conditions. Thus, the improvement of biomechanical features in femoral diaphysis and tibial metaphysis can be a result of the formononetin's ability to obviate bone mass loss in ovariectomized rats.In contrast to estradiol supplementation, administration of formononetin to ovariectomized rats showed no beneficial effect on mechanical properties in the femoral neck.Weaker effect of formononetin on biomechanical features of examined bones can be caused by lower affinity of this isoflavone to estrogen receptors when compared to estradiol . Adminisin vivo studies conducted by Gautam et al. [Previous m et al.  indicateAs opposed to the group supplemented with estradiol, administration of formononetin did not cause a decrease of organic fraction content in femur, tibia, and L-4 vertebra but led to its increase. Most likely, beneficial decline of water content was not completely compensated by meager increase of minerals, which consequently resulted in higher organic substances content in bones of ovariectomized rats receiving formononetin.In vitro studies on osteoblasts [in vivo examinations on the rat fracture model [An increase of organic fraction content in bones of formononetin-treated ovariectomized rats can be also explained by an enhanced collagen synthesis. eoblasts  and in vre model  indicatein vivo needs further investigations.An above-mentioned increase of Young's modulus value in analyzed bones can be related to the elevated organic fraction content after treatment with examined isoflavone. The effect of formononetin on mineralization processes Osteoprotective effect of formononetin on skeletal system of ovariectomized rats may result from the inhibition of bone turnover rate. Tyagi et al.  observedBeneficial effect of formononetin on bones in ovariectomized rats may also result from antioxidative activity of this isoflavone, which was demonstrated by Mu et al. . These aStudies conducted by Muhammad et al.  on ovariIt can be assumed that, due to its antioxidative activity, formononetin may also reveal beneficial effect on osteoporotic bones.An intake of phytoestrogens is commonly considered as a safe therapy. Despite the fact that information about adverse effects of this treatment is scarce, there are some individual reports revealing side effects of such supplementation. Rachoń et al. indicated that long-term treatment with high doses of equol (one of the most potent phytoestrogens) may result in pathological changes in uterine weight and histological features, and it can also lead to mammotropic effects , 54. TheTo summarize, administration of formononetin to ovariectomized rats shows beneficial effect on biomechanical features and chemical composition of bones; thus, it prevents osteoporotic changes development. Therefore, it can be assumed that this isoflavone may be useful in the prevention and treatment of postmenopausal osteoporosis in women. However, this issue needs further investigations.