The National Osteoporosis Foundation's position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations.

Lifestyle choices influence 20-40 % of adult peak bone mass. Therefore, optimization of lifestyle factors known to influence peak bone mass and strength is an important strategy aimed at reducing risk of osteoporosis or low bone mass later in life. The National Osteoporosis Foundation has issued this scientific statement to provide evidence-based guidance and a national implementation strategy for the purpose of helping individuals achieve maximal peak bone mass early in life. In this scientific statement, we (1) report the results of an evidence-based review of the literature since 2000 on factors that influence achieving the full genetic potential for skeletal mass; (2) recommend lifestyle choices that promote maximal bone health throughout the lifespan; (3) outline a research agenda to address current gaps; and (4) identify implementation strategies. We conducted a systematic review of the role of individual nutrients, food patterns, special issues, contraceptives, and physical activity on bone mass and strength development in youth. An evidence grading system was applied to describe the strength of available evidence on these individual modifiable lifestyle factors that may (or may not) influence the development of peak bone mass (Table 1). A summary of the grades for each of these factors is given below. We describe the underpinning biology of these relationships as well as other factors for which a systematic review approach was not possible. Articles published since 2000, all of which followed the report by Heaney et al. [1] published in that year, were considered for this scientific statement. This current review is a systematic update of the previous review conducted by the National Osteoporosis Foundation [1]. [Table: see text] Considering the evidence-based literature review, we recommend lifestyle choices that promote maximal bone health from childhood through young to late adolescence and outline a research agenda to address current gaps in knowledge. The best evidence (grade A) is available for positive effects of calcium intake and physical activity, especially during the late childhood and peripubertal years-a critical period for bone accretion. Good evidence is also available for a role of vitamin D and dairy consumption and a detriment of DMPA injections. However, more rigorous trial data on many other lifestyle choices are needed and this need is outlined in our research agenda. Implementation strategies for lifestyle modifications to promote development of peak bone mass and strength within one's genetic potential require a multisectored (i.e., family, schools, healthcare systems) approach.

Anthropometric models of bone mineral content and areal bone mineral density based on the bone mineral density in childhood study.

UNLABELLED: New models describing anthropometrically adjusted normal values of bone mineral density and content in children have been created for the various measurement sites. The inclusion of multiple explanatory variables in the models provides the opportunity to calculate Z-scores that are adjusted with respect to the relevant anthropometric parameters. INTRODUCTION: Previous descriptions of children's bone mineral measurements by age have focused on segmenting diverse populations by race and sex without adjusting for anthropometric variables or have included the effects of a single anthropometric variable. METHODS: We applied multivariate semi-metric smoothing to the various pediatric bone-measurement sites using data from the Bone Mineral Density in Childhood Study to evaluate which of sex, race, age, height, weight, percent body fat, and sexual maturity explain variations in the population's bone mineral values. By balancing high adjusted R(2) values with clinical needs, two models are examined. RESULTS: At the spine, whole body, whole body sub head, total hip, hip neck, and forearm sites, models were created using sex, race, age, height, and weight as well as an additional set of models containing these anthropometric variables and percent body fat. For bone mineral density, weight is more important than percent body fat, which is more important than height. For bone mineral content, the order varied by site with body fat being the weakest component. Including more anthropometrics in the model reduces the overlap of the critical groups, identified as those individuals with a Z-score below -2, from the standard sex, race, and age model. CONCLUSIONS: If body fat is not available, the simpler model including height and weight should be used. The inclusion of multiple explanatory variables in the models provides the opportunity to calculate Z-scores that are adjusted with respect to the relevant anthropometric parameters.

Changes in DXA and quantitative CT measures of musculoskeletal outcomes following pediatric renal transplantation.

This prospective study evaluated changes in dual energy X-ray absorptiometry (DXA) whole body bone mineral content (WB-BMC) and spine areal bone mineral density (spine-BMD), and tibia quantitative computed tomography (QCT) trabecular and cortical volumetric BMD and cortical area in 56 children over 12 months following renal transplantation. At transplant, spine-BMD Z-scores were greater in younger recipients (<13 years), versus 898 reference participants (p < 0.001). In multivariate models, greater decreases in spine-BMD Z-scores were associated with greater glucocorticoid dose (p < 0.001) and declines in parathyroid hormone levels (p = 0.008). Changes in DXA spine-BMD and QCT trabecular BMD were correlated (r = 0.47, p < 0.01). At 12 months, spine-BMD Z-scores remained elevated in younger recipients, but did not differ in older recipients (≥ 13) and reference participants. Baseline WB-BMC Z-scores were significantly lower than reference participants (p = 0.02). Greater glucocorticoid doses were associated with declines in WB-BMC Z-scores (p < 0.001) while greater linear growth was associated with gains in WB-BMC Z-scores (p = 0.01). Changes in WB-BMC Z-scores were associated with changes in tibia cortical area Z-scores (r = 0.52, p < 0.001), but not changes in cortical BMD Z-scores. Despite resolution of muscle deficits, WB-BMC Z-scores at 12 months remained significantly reduced. These data suggest that spine and WB DXA provides insight into trabecular and cortical outcomes following pediatric renal transplantation.

Fracture risk in children with a forearm injury is associated with volumetric bone density and cortical area (by peripheral QCT) and areal bone density (by DXA).

UNLABELLED: Children who sustain a forearm fracture when injured have lower bone density throughout their skeleton, and have a smaller cortical area and a lower strength index in their radius. Odds ratios per SD decrease in bone characteristics measured by peripheral quantitative computed tomography (pQCT) and dual-energy X-ray absorptiometry (DXA) were similar (1.28 to 1.41). INTRODUCTION: Forearm fractures are common in children. Bone strength is affected by bone mineral density (BMD) and bone geometry, including cross-sectional dimensions and distribution of mineral. Our objective was to identify bone characteristics that differed between children who sustained a forearm fracture compared to those who did not fracture when injured. METHODS: Children (5-16 years) with a forearm fracture (cases, n = 224) and injured controls without fracture (n = 200) were enrolled 28 ± 8 days following injury. Peripheral QCT scans of the radius (4% and 20% sites) were obtained to measure volumetric BMD (vBMD) of total, trabecular and cortical bone compartments, and bone geometry (area, cortical thickness, and strength strain index [SSI]). DXA scans (forearm, spine, and hip) were obtained to measure areal BMD (aBMD) and bone area. Receiver operating characteristic (ROC) analyses were used to assess screening performance of bone measurements. RESULTS: At the 4% pQCT site, total vBMD, but not trabecular vBMD or bone area, was lower (-3.4%; p = 0.02) in cases than controls. At the 20% site, cases had lower cortical vBMD (-0.9%), cortical area (-2.8%), and SSI (-4.6%) (p < 0.05). aBMD, but not bone area, at the 1/3 radius, spine, and hip were 2.7-3.3% lower for cases (p < 0.01). Odds ratios per 1 SD decrease in bone measures (1.28-1.41) and areas under the ROC curves (0.56-0.59) were similar for all bone measures. CONCLUSIONS: Low vBMD, aBMD, cortical area, and SSI of the distal radius were associated with an increased fracture risk. Interventions to increase these characteristics are needed to help reduce forearm fracture occurrence.

Fitting of bone mineral density with consideration of anthropometric parameters.

UNLABELLED: A new model describing normal values of bone mineral density in children has been evaluated, which includes not only the traditional parameters of age, gender, and race, but also weight, height, percent body fat, and sexual maturity. This model may constitute a better comparative norm for a specific child with given anthropometric values. INTRODUCTION: Previous descriptions of children's bone mineral density (BMD) by age have focused on segmenting diverse populations by race and gender without adjusting for anthropometric variables or have included the effects of anthropometric variables over a relatively homogeneous population. METHODS: Multivariate semi-metric smoothing (MS(2)) provides a way to describe a diverse population using a model that includes multiple effects and their interactions while producing a result that can be smoothed with respect to age in order to provide connected percentiles. We applied MS(2) to spine BMD data from the Bone Mineral Density in Childhood Study to evaluate which of gender, race, age, height, weight, percent body fat, and sexual maturity explain variations in the population's BMD values. By balancing high adjusted R (2) values and low mean square errors with clinical needs, a model using age, gender, race, weight, and percent body fat is proposed and examined. RESULTS: This model provides narrower distributions and slight shifts of BMD values compared to the traditional model, which includes only age, gender, and race. Thus, the proposed model might constitute a better comparative standard for a specific child with given anthropometric values and should be less dependent on the anthropometric characteristics of the cohort used to devise the model. CONCLUSIONS: The inclusion of multiple explanatory variables in the model, while creating smooth output curves, makes the MS(2) method attractive in modeling practically sized data sets. The clinical use of this model by the bone research community has yet to be fully established.

Special report on the 2007 adult and pediatric Position Development Conferences of the International Society for Clinical Densitometry.

The International Society for Clinical Densitometry (ISCD) conducts Position Development Conferences (PDCs) for the purpose of establishing standards and guidelines in the field of bone densitometry. Topics for consideration are selected according to clinical relevance, a perceived need for standardization, and the likelihood of achieving agreement. Questions regarding nomenclature, indications, acquisition, analysis, quality control, interpretation, and reporting of bone density tests for each topic area are assigned to task forces for a comprehensive review of the scientific literature. The findings of the review and recommendations are then presented to an international panel of experts at the PDC. The expert panel votes on potential Official Positions for appropriateness, necessity, quality of the evidence, strength of the recommendation, and applicability (worldwide or variable according to local requirements). Recommendations that are approved by the ISCD Board of Directors become Official Positions. The first Pediatric PDC was 20-21 June 2007 in Montreal, QC, Canada. The most recent Adult PDC was held 20-22 July 2007, in Lansdowne, VA, USA. This Special Report summarizes the methodology of the ISCD PDCs and presents selected Official Positions of general interest.

Effects of calcium supplementation on calcium homeostasis and bone turnover in lactating women.

Lactation is a time of calcium flux, because women secrete approximately 210 mg calcium/day in breast milk, and they experience a transient bone loss. The objectives of this study were to determine the effect of calcium supplementation on adaptive responses in calcium homeostasis during lactation and after weaning. Two cohorts of women participated in a 6-month randomized calcium supplementation trial. Lactation cohort women (97 lactating, 99 nonlactating) were studied during the first 6 months post partum, and weaning cohort women (95 lactating, 92 nonlactating) were studied during the second 6 months post partum. Lactating women in the weaning cohort weaned approximately 1.5 months after enrollment. PTH was 18-30% lower in lactating than in nonlactating women (P < 0.01). Serum 1,25-dihydroxyvitamin D was 11-16% higher in lactating than in nonlactating women and remained elevated for approximately 1.5 months after weaning (P = 0.06). Calcium supplementation decreased serum PTH and 1,25-dihydroxyvitamin D in lactating and nonlactating women similarly. At 6 months, the calciuric response to calcium supplementation was less in lactating (compared with nonlactating) women (P = 0.06). Biomarkers of bone turnover were higher in lactating than in nonlactating women during lactation and after weaning but were not effected by calcium supplementation. Calcium supplementation has little effect on lactation-induced changes in the calcium economy.

Effects of calcium supplementation and lactation on iron status.

Calcium has been shown to inhibit iron absorption. The consequences of chronic calcium supplementation on iron status are unclear, however. As part of a randomized calcium-supplementation trial in lactating and nonlactating women in the postpartum period, we determined whether long-term calcium supplementation and lactation status affected iron stores as measured by serum ferritin concentrations. Subjects (95 lactating and 92 nonlactating) were enrolled at approximately 6 mo postpartum and then randomly assigned to receive either 500 mg Ca as calcium carbonate or a placebo twice daily with meals for 6 mo. Lactating women weaned their infants approximately 2 mo after enrollment (ie, approximately 8 mo postpartum). Calcium supplementation had no effect on serum ferritin concentrations. At the end of the study, geometric mean serum ferritin concentrations were 28.4 microg/L in the calcium-supplemented group and 27.5 microg/L in the placebo group (P > 0.5). Lactation status was significantly related to serum ferritin concentrations. At baseline, serum ferritin concentrations were higher in lactating women than in nonlactating women (47.7 compared with 31.5 microg/L, P < 0.001). In lactating women, serum ferritin concentrations decreased by a mean of 17 microg/L after weaning. By 12 mo postpartum, mean serum ferritin concentrations in women who were previously lactating were not significantly higher than those of nonlactating women (30.5 compared with 25.5 microg/L). These findings provide reassurance that long-term calcium supplementation does not impair iron stores. Furthermore, lactation status should be considered when assessing iron nutriture of women and determinants of iron status in populations.

Urinary lactose: changes postpartum and relation with breast milk production.

Measurement of milk intake by breast-fed infants is difficult and a simple measure would be helpful for research and clinical practice. Maternal urinary lactose excretion has been proposed as a simple measure of lactation performance. The objectives of this study were to describe the pattern of urinary lactose excretion postpartum, and to determine whether lactose excretion could predict breast milk output. Lactose excretion was determined in 50 lactating and 49 nonlactating women at 0.5, 3, and 6 mo postpartum, and in 29 weaning women and 30 nonlactating women at 5, 8, and 11 mo postpartum. Lactose excretion was 4- to 17-fold higher in lactating than in nonlactating women, depending on the time point studied, and was highest in both groups 0.5 mo postpartum. Lactose excretion decreased after weaning but remained higher than in nonlactating women 1.3 mo after weaning was completed. Sixty-two additional women between 1.5 and 12 mo postpartum were studied to determine the ability of urinary lactose to predict milk output. There was a positive association between milk output and urinary lactose excretion, with correlation coefficients ranging from 0.17 to 0.30 depending on the measurement interval for lactose excretion. Lactose excretion could explain 2-9% of the variance in milk output, and could correctly classify 29-40% of individuals into tertiles of milk output. Although urinary lactose excretion reflects changes in biological activity of the mammary gland and gross changes in milk production, it is not a precise predictor of milk output.

Dietary fat and the regulation of energy intake in human subjects.

The role of dietary fat in the regulation of energy intake was assessed by manipulating a conventional diet and measuring spontaneous food consumption. Twenty-four women each consumed a sequence of three 2-wk dietary treatments in which 15-20%, 30-35%, or 45-50% of the energy was derived from fat. These diets consisted of foods that were similar in appearance and palatability but differed in the amount of high-fat ingredients used. Relative to their energy consumption on the medium-fat diet, the subjects spontaneously consumed an 11.3% deficit on the low-fat diet and a 15.4% surfeit on the high-fat diet (p less than 0.0001), resulting in significant changes in body weight (p less than 0.001). A small amount of caloric compensation did occur (p less than 0.02), which was greatest in the leanest subjects (p less than 0.03). These results suggest that habitual, unrestricted consumption of low-fat diets may be an effective approach to weight control.

Ultraviolet light-induced reductions in plasma carotenoid levels.

The effects of ultraviolet (UV) irradiation on plasma levels of carotenoids and vitamin A in human subjects were investigated in two crossover trials. UV exposures were given on 11 r 12 days of a 2-wk period. The 12 female and 12 male subjects received mean cumulative UV-A (320-400 nm) doses of 17.8 +/- 1.9 J/cm2 and 21.0 +/- 3.3 J/cm2 to the anterior and posterior sides of the body, respectively. UV-B (280-320 nm) doses were equivalent to 10% of UV-A doses given. Significant reductions in plasma total carotenoid levels were observed in both female (p less than 0.004) and male (p less than 0.05) subjects after repeated irradiation. There was no significant effect on plasma vitamin A levels. It was concluded that UV treatment can reduce plasma carotenoid levels in vivo.

Intestinal calcium absorption of women during lactation and after weaning.

We investigated whether intestinal calcium absorption and serum 1,25-dihydroxycholecalciferol (calcitriol) concentrations are higher in women during lactation and after weaning to compensate for calcium lost in breast milk. Measurements were obtained at 4.6 mo postpartum in 24 lactating women and 24 nonlactating women, at 9.6 mo postpartum in 24 lactating women (2.6 mo after complete weaning) and 24 nonlactating women. One-half of the women in each group were randomly assigned to receive 1 g supplemental Ca/d as calcium carbonate. Fractional calcium absorption was measured by using stable isotopic tracers 42Ca and 44Ca. Fractional absorption was 0.32+/-0.02 (+/-SEM) in both lactating and nonlactating women, but was higher in lactating women after weaning (0.37+/-0.02) compared with nonlactating postpartum control subjects (0.31+/-0.02). These effects were independent of calcium intake. Changes in serum calcitriol paralleled changes in fractional absorption. There were no differences in calcitriol concentrations between lactating and nonlactating women, but calcitriol was greater in women after weaning compared with postpartum control subjects. Lactating women who had resumed menses had higher fractional absorption and serum calcitriol than did lactating women who had not. Serum calcium and phosphorus concentrations were greater in lactating compared with nonlactating women; there were no differences between groups after weaning. We conclude that lactation stimulates increases in fractional calcium absorption and serum calcitriol, but the responses are only apparent after weaning or the resumption of menses.

Accuracy of heart-rate monitoring and activity diaries for estimating energy expenditure.

The accuracy of heart-rate monitoring and activity diaries for measuring energy expenditure in free-living individuals was studied in 12 women. Estimates of energy expenditure were calculated from heart-rate monitoring by use of four different prediction equations to describe the relationship between heart rate and energy expenditure. Estimates of energy expenditure from activity diaries were calculated using both individually measured and published values for the energy cost of activities. Energy intake adjusted for changes in body-energy stores was used as a reference. Heart-rate monitoring overestimated group energy expenditure from 2 to 9% and the errors in estimating individual energy expenditure ranged from -53 to 67%. Activity diaries underestimated group energy expenditure by 2-6% and the errors in estimating individual energy expenditure ranged from -39 to 56%. Heart-rate monitoring and activity diaries may prove useful for estimating the energy expenditure of groups but not individuals.

Effect of psyllium gum and wheat bran on spontaneous energy intake.

Energy intake, fecal energy output, and gastrointestinal symptoms were measured in 12 females who consumed either approximately 23 g/d supplementary fiber or a 4 g/d fiber control. Fiber supplements were crackers containing psyllium gum, wheat bran, or a combination of the two fiber sources. After 1 wk on the control cracker, subjects consumed the three high-fiber crackers and the control cracker for 2-wk periods in a balanced design. Gum and combination supplements gave increased bloating and flatulence. Increase in abdominal pain was reported with gum supplement. Mean daily fecal energy was 96 kcal/d with control crackers and was increased by 63 kcal with high-fiber crackers. Gum and combination supplements significantly decreased intake of digestible energy by 153 and 115 kcal/d, respectively. This suppression was not dependent upon fiber intolerance. Wheat bran supplement had no effect on energy intake.

Riboflavin requirements and exercise adaptation in older women.

The effects of exercise training on riboflavin requirements and of riboflavin intake on endurance were examined in 14 women, 50-67 y of age, who participated in a 10-wk, two-period crossover exercise study at two riboflavin intakes, 0.15 micrograms/kJ (0.6 micrograms/kcal) and 0.22 micrograms/kJ (0.9 micrograms/kcal). Subjects exercised 20-25 min/d, 6 d/wk, for 4-wk periods on a cycle ergometer at 75-85% of their maximal heart rate. Riboflavin status was assessed by measuring the erythrocyte glutathione reductase activity coefficient (EGRAC) and urinary riboflavin excretion. Physical performance was evaluated by using a walking treadmill test to determine maximal oxygen capacity (VO2max) and anaerobic threshold by gas exchange (ATGE). Exercise significantly affected riboflavin status as EGRAC increased (P less than 0.001) and riboflavin excretion decreased (P less than 0.01) in both groups. VO2max increased significantly with exercise (P less than 0.01). However, changes in VO2max (L/min) and ATGE with exercise training were not different in the two groups. Riboflavin requirements of older women increased with exercise training, but increased riboflavin intake did not enhance improvements in endurance.

Effects of exercise on riboflavin requirements of young women.

The riboflavin requirement of young women during periods of sedentary living and exercise was determined during a 12-wk metabolic study. The study was divided into a 6-wk no exercise period followed by a 6-wk exercise period in which subjects jogged around a track for 20 to 50 min/day. Twelve subjects, aged 19 to 27 yr, were fed a basic diet containing 0.6 mg riboflavin/1000 kcal of intake. Riboflavin intake was increased by 0.2 mg/1000 kcal increments by provision of riboflavin in a glucose polymer mixture. Linear regression analysis was used to estimate the riboflavin intake required for an erythrocyte glutathione reductase activity coefficient of 1.25 during both the no exercise and exercise periods. Individual riboflavin requirements ranged from 0.62 to 1.21 mg/1000 kcal before exercise and 0.63 to 1.4 mg/1000 kcal during the exercise periods. Riboflavin requirement could not be related to the kilocalorie intake or lean body mass of the subjects. It is concluded that healthy young women require more riboflavin to achieve biochemical normality than the 1980 Recommended Dietary Allowances and that exercise increases riboflavin requirements.

Effects of exercise on riboflavin requirements: biological validation in weight reducing women.

The present study was designed to evaluate our previous estimates for riboflavin requirement, 0.96 mg/1000 kcal during nonexercise and 1.16 mg/1000 kcal during exercise in overweight women. Two groups of 6 weight reducing women consumed either 1.16 mg riboflavin/1000 kcal (HR) or 0.96 mg/1000 kcal (MR). The study was two, 3 period by 2 treatment (exercise or nonexercise) crossover designs, one design at each level of riboflavin. Erythrocyte glutathione reductase activity coefficients (AC) significantly increased in both groups from 1.16 +/- .02 to 1.20 +/- .03 in group HR and from 1.31 +/- .04 to 1.36 +/- .02 in the MR group during nonexercise and exercise, respectively. ACs increased in the HR group due to an increase in total enzyme activity while ACs increased in the MR group due to a decrease in basal enzyme activity reflecting decreased flavin availability. There were no differences in aerobic capacity, weight loss, nor change in lean body mass between the two groups. Thus, 0.96 mg/1000 kcal was not adequate during either nonexercise or exercise periods while the 1.16 mg/1000 kcal was adequate.

Bone mineral loss during lactation and recovery after weaning.

OBJECTIVE: To test the hypothesis that bone mineral content (BMC) and density (BMD) are lost during lactation and regained within 6 months after weaning. METHODS: Two cohorts of women, defined by time postpartum, were enrolled into the study; each cohort was followed for 6 months. Women in the lactation cohort (65 lactating women and 48 nonlactating postpartum controls) were enrolled at 2 weeks postpartum. Women in the weaning cohort (40 lactating and 43 nonlactating postpartum controls) were enrolled at 4-6 months postpartum. Lactating women enrolled in the weaning cohort had been fully breast-feeding at enrollment and weaned within 2 months of enrollment. Bone mineral content of the total body and BMD of the lumbar spine and distal radius were measured by dual-energy x-ray absorptiometry. RESULTS: Lactating women lost significantly more bone in the total body (-2.8 versus -1.7%) and lumbar spine (-3.9 versus 1.5%) than did nonlactating women during the first 6 months postpartum. There was no effect of lactation on bone changes at the distal radius. After weaning, lactating women gained significantly more bone in the lumbar spine than did nonlactating women (5.5 versus 1.8%). Earlier resumption of menses was associated with a smaller loss of bone during lactation and a greater increase of bone after weaning. CONCLUSION: Women lose bone during lactation but gain bone after weaning. Thus, lactation may not result in net bone loss.

Dietary fiber intakes and insulin requirements in pregnant women with type 1 diabetes.

OBJECTIVE: To determine whether higher dietary fiber intake (water soluble and insoluble) is associated with lower insulin requirements and better glycemic control in pregnant women with type 1 diabetes consuming a self-selected diet. DESIGN: A longitudinal, observational study. SUBJECTS: Pregnant women (n=141) with type 1 diabetes participating in an interdisciplinary program examining the effects of glycemic control on pregnancy outcome (Diabetes and Pregnancy Program, University of Cincinnati Medical Center). MEASUREMENTS: We determined total, water soluble and insoluble fiber intakes from 3-day food records kept each trimester during pregnancy. Outcome measures were insulin dose, pre-meal blood glucose, and glycated hemoglobin concentrations. STATISTICAL ANALYSES: Correlation coefficients, multiple regression, mixed-model analysis of variance. RESULTS: Mean intakes (g/day) of total, water soluble fiber, and insoluble fiber were 14.0 (range, 1.8-33.1), 4.8 (range, 0.6-10.5) and 9.0 (range, 1.1-24.0), respectively. In the second and third trimesters of pregnancy, insulin requirements were inversely associated with total, water soluble, and insoluble fiber intakes; the correlation coefficients ranged from -0.22 to -0.17 (P=.02 to .08). Insulin requirements associated with a higher fiber intake (20.5 g/day) were 16% to 18% lower than for a lower fiber intake (8.1 g/day). These relations remained after adjustment for body weight, disease severity and duration, insulin type, and study year in the second (P=.03 to .10) but not in the third trimester. Pre-meal blood glucose and glycated hemoglobin concentrations were not associated with fiber intake. CONCLUSIONS: Among pregnant women with type 1 diabetes, higher fiber intake is associated with lower daily insulin requirements. Dietary fiber intake should be considered when counseling patients about the management of blood glucose concentrations.