Osteoporosis, prevalence and risk presentation by Dr. Chit Soe, Dr. Aye Aye Khaing and Dr. Pandora Aung Gyi

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Osteoporosis, prevalence
and risk.
Chit Soe, Aye Aye Khaing,
Pandora Aung Gyi

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Introduction

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Rank Cause
1 Lower respiratory infections
2 Diarrheal diseases
3 Peripheral conditions
4 Unipolar major depression
5 Ischemic heart disease
6 Cerebrovascular disease
7 Tuberculosis
8 Measles
9 Road Traffic accidents
10 Congenital abnormalities
Worldwide Disease Projection
Estimated 1990 Projected 2020
Rank Cause
1 Ischemic heart disease
2 Unipolar major depression
3 BJD (Road traffic accidents)
4 Cerebrovascular disease
5 COPD
6 Lower respiratory infections
7 Tuberculosis
8 War
9 Diarrheal diseases
10 HIV
Neil B, Chapman N, Patel A. Eur Heart J 2002;4(suppl F):F2-F6.

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To target 5 Areas
• 1. Rheumatoid Arthritis
• 2. Osteoporosis
• 3. Low Back Pain
• 4. OA knee
• 5. Limb trauma

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Epidemic of the millenniumsEpidemic of the millenniums
OsteoporosisOsteoporosis
 The lifetime risk of vertebral fractureThe lifetime risk of vertebral fracture
has been estimated to be 15.4%has been estimated to be 15.4%
after age 45 yearsafter age 45 years
 but this most likely largelybut this most likely largely
underestimates the true risk. (12-underestimates the true risk. (12-
30% in diff. studies)30% in diff. studies)
 The demand on the health careThe demand on the health care
system is therefore increasing, assystem is therefore increasing, as
are costs for societyare costs for society

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Most costly silentMost costly silent
Epidemic of the HistoryEpidemic of the History

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Low Trauma FracturesLow Trauma Fractures

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Mechanisms of osteoporosisMechanisms of osteoporosis

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New findings inNew findings in
recent yearsrecent years

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 BMP=Bone Morphogenic ProteinBMP=Bone Morphogenic Protein
 SOST=SclerostinSOST=Sclerostin
 RANK=Receptor Activator of Nuclear Factor KappaRANK=Receptor Activator of Nuclear Factor Kappa
 OPG=OsteoprotegerinOPG=Osteoprotegerin

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WHO Diagnostic Categories forWHO Diagnostic Categories for
Osteoporosis (1994)Osteoporosis (1994)
 NormalNormal -BMD not more than 1 SD below-BMD not more than 1 SD below
the young adultthe young adult
 OsteopeniaOsteopenia -BMD between 1 and 2.5 SD-BMD between 1 and 2.5 SD
 OsteoporosisOsteoporosis -BMD more than 2.5 SD-BMD more than 2.5 SD
below the young adult mean value.below the young adult mean value.
 Severe osteoporosisSevere osteoporosis -BMD value more-BMD value more
than 2.5 SD in thethan 2.5 SD in the presence of 1presence of 1
oror more fragility fractures.more fragility fractures.

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BMDBMD

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How do you interpret a boneHow do you interpret a bone
mass report?mass report?
 The bone mass report includes threeThe bone mass report includes three
values at each skeletal site analyzed:values at each skeletal site analyzed:
absolute bone mass in gm/cm2, T-absolute bone mass in gm/cm2, T-
score, and Z-score.score, and Z-score.
 The T-score is the number ofThe T-score is the number of
standard deviations (SDs) that astandard deviations (SDs) that a
patient's value lies above or belowpatient's value lies above or below
the mean peak value for youngthe mean peak value for young
adults.adults.

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 Any T-score between -1 and -2.5 isAny T-score between -1 and -2.5 is
termed osteopenia and any valuetermed osteopenia and any value
below -2.5 is consideredbelow -2.5 is considered
osteoporosis.osteoporosis.
 The Z-score is the number of SDsThe Z-score is the number of SDs
that a patient's value lies above orthat a patient's value lies above or
below the mean value for age-below the mean value for age-
matched adults.matched adults.

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Risk factors for osteoporosisRisk factors for osteoporosis
 GeneticGenetic
 Race, Low body weight, Family HistoryRace, Low body weight, Family History
 Osteogenesis imperfecta, Homocystinuria,Osteogenesis imperfecta, Homocystinuria,
GaucherGaucher
 SmokingSmoking
 ImmobilizationImmobilization
 Alcohol useAlcohol use
 EndocrineEndocrine
 Hyperthyroidism, HyperparathyroidismHyperthyroidism, Hyperparathyroidism
 Cushing's syndrome, Androgen loss,Cushing's syndrome, Androgen loss,
Hypogonadism, Menopause (natural or surgical)Hypogonadism, Menopause (natural or surgical)

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Risk factors for osteoporosis (con)Risk factors for osteoporosis (con)
 Calcium deficiencyCalcium deficiency
 Dietary, Chronic liver diseaseDietary, Chronic liver disease
 Malabsorption, IBSMalabsorption, IBS
 Losses in renal diseaseLosses in renal disease
 Vitamin D deficiencyVitamin D deficiency
 Decreased exposure to sunlightDecreased exposure to sunlight
 Renal diseaseRenal disease
 DrugsDrugs
 CorticosteroidsCorticosteroids
 Cyclosporine, anticonvulsants, SedativesCyclosporine, anticonvulsants, Sedatives
 Chronic heparin, GnRHChronic heparin, GnRH

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Risk factors for osteoporosis #Risk factors for osteoporosis #
 FallsFalls
 Visual diseases (glaucoma, cataracts,Visual diseases (glaucoma, cataracts,
refractive errors)refractive errors)
 Postural hypotensionPostural hypotension
 Muscle weakness (disuses, myopathy)Muscle weakness (disuses, myopathy)
 ArthritisArthritis
 Neurologic (Parkinson's, multipleNeurologic (Parkinson's, multiple
sclerosis, previous strokes)sclerosis, previous strokes)

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Aim
• To explore the prevalence of
osteoporosis and osteopenia in Post-
Menopausal females (Teachers and
Nurses) and
• To find out the proportion of risk
factors for osteoporosis in two
occupation groups
• To find out Bone Mass Density and
association to known risk factors.

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Methods
• All the postmenopausal teachers from a state
high school from Mingalar Taung Nyunt
Township (n=45) and
• Postmenopausal staffs from Yangon General
Hospital (n=38) were included in the study.
• All the participants were asked to fill up a
questionarrie for risk factors and
• Bone Mass Density (BMD) was measured by
ultrasound densitometer.

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Quantitative Ultrasound
• BUA= broadband ultrasound attenuation
• SOS= speed of sound
• Stiffness= combination of BUA & SOS
• BUA reflect the attenuation of sound
waves as they pass through bone tissue
and are proportionate to the density of
the tissue.

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• QUS also assesses aspects of bone
quality and structure that are not
captured by BMD measurements.
• It is complementary to and additive
with BMD

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Combination of DEXA and USGCombination of DEXA and USG
J Bone Miner Res 1995:10:353J Bone Miner Res 1995:10:353

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ResultsResults

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Bone Mass, Osteopenia &
Osteoporosis
• Mean BMD for teachers was 64.71 dB/MHZ
(SD 4.8) and that for staff was 64.24
dB/MHZ (SD 4.2).
• Osteopenia (T score less than -1.0 to -2.5)
was seen in
• 31% of teachers (14 out of 45) and
• 31.5% of staffs (12 out of 38).
• Surprisingly, there was no patient with
osteoporosis (T score less than -2.5) in this
study.

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Prevalence of Osteoporosis
0
5
10
15
20
25
30
35
Normal Osteopenia Osteoporosis
Teacher
Med Staff
31% 31.5%

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Risk Factors
• low trauma fracture in family was
mentioned by 7.2%,
• high coffee intake (14.5%),
• smoking (2.4%),
• alcohol (1.2%),
• sedentary life (61.4%),
• hyperthyroid (2.7%), and
• history of steroid (8.4%).

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• Milk intake was very low (48% answered
no milk in last week and only 4.8% took
one cup of milk each day).

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• Only 2 participants were taking HRT
(2.4%) and
• 14.5% were taking calcium supplement.

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Risk factors in Teachers vs Staff
• The presence of risks factors did not
differ significantly between two groups
of teachers and staff.

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Presence of risk factors vs
osteopenia
• Apart from thin body built and lack of
exercise,
• the presence of risk factors did not
associate significantly with osteopenia
in this study.

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Presence of risk factors in normal
people and osteopenia patients
Risk Normal
(56)
Osteo
penia
(26)
p
Mean body weight 134lb 121 lb 0.04
Exercise days/ week 2.1 0.7 0.01
Coffee >3 cups/day 8 3 0.9
Milk intake (cup)/wk 1 0.9 0.8
Small fish intake days/
wk
2.59 2.5 0.8

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Presence of risk factors in normal people
and osteopenia patients
Risk Normal
(56)
Osteo
penia
(26)
p
Surgical menopause
>1 yr
8 5 0.9
Steroid 6 1 0.49
Taking Calcium
supplement
4 8 0.4
Fruit intake/ week 13 8 0.7

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Discussion

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Indications for Bone
Densitometry
• Early menopause (<45)
• Hypogonadism
• Family history of
osteoporotic fracture
• Radiological evidence
of osteoporosis
• Previous fracture
after minimal trauma
(fall from standing
height)
• Clinical features of OP
(height loss, kyphosis)
*Strong risk factor
Low body weight (<19BMI)
*Steroid (>7.5mg daily for >3month)
*Co.- existing disease
Endocrine
Malabsorption
IBD
RA
*Prolonged immobility
*after OP treatment

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• Since the osteoporosis prevalence range
from 15% at age 60 and 38% at age 80
(Melton 1995), sample size of 82 people
was enough to find the prevalence.
• But failure to find any one with
osteoporosis on screening is not
expected and need larger scale study to
explain.

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Life style modificationLife style modification
 All postmenopausal women should engageAll postmenopausal women should engage
in lifestyle modifications that promotein lifestyle modifications that promote
bone healthbone health
• (1) taking adequate amounts of calcium(1) taking adequate amounts of calcium
(1200 mg/day) either through diet or(1200 mg/day) either through diet or
supplementssupplements
• (2) taking vitamin D (400 to 800 IU(2) taking vitamin D (400 to 800 IU
daily)daily)
• (3) engaging in weight-bearing physical(3) engaging in weight-bearing physical
activity to decrease the risk of fallingactivity to decrease the risk of falling
• (4) smoking cessation(4) smoking cessation
• (5) avoidance of excessive alcohol(5) avoidance of excessive alcohol
intake.intake.

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Conclusion
• The prevalence of osteoporosis is not
high in this study as European studies.
• The presence of risks factors did not
differ significantly between two groups
of teachers and staff.
• Apart from thin body built and lack of
exercise, the presence of risk factors
did not associate significantly with
osteopenia in this study.

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