Development of a clinical assessment tool in identifying Asian men with low bone mineral density and comparison of its usefulness to quantitative bone ultrasound

Osteoporosis and its associated factors among patients attending Manakamana Hospital, Chitwan, Nepal

BACKGROUND

Osteoporosis is the most common skeletal disorder that weakens bones and increases their susceptibility to fractures. It is becoming an urgent and serious global epidemic. Early diagnosis and treatment are essential to reduce morbidity and mortality associated with it. This study aimed to find out the prevalence of osteoporosis among patients attending at Manakamana Hospital, Bharatpur, Chitwan, Nepal.

METHODS

A cross-sectional study was adopted and 623 patients attending at orthopaedic outpatients department (OPD) of Manakamana Hospital were selected using non-probability consecutive sampling technique. Data were collected from 15th October 2021 to 15th April, 2022, by using interview schedule, chart review and Bone Mineral Density (BMD) measurement through calcaneal ultrasonography. Ethical approval was obtained from Nepal Health Research Council Ethical Review Board prior to study procedures. Obtained data were analysed using descriptive statistics. Association between the variables were measured using chi-square test.

RESULTS

The mean age of the patients was 43.5 (±14.26) years. Nearly half (44%, n = 274) were middle aged adults, 59.7% were female and 56.0% were involved in agriculture and household chores. Nearly half of the patients (45.7%) were overweight/ obese, 7.9% were smokers and 13.5% had habit of alcohol use. Osteopenia or low bone density was detected in 58.9% patients and 19.4% had osteoporosis. The prevalence of osteoporosis was significantly associated with age group (p = <0.001) and educational status (p = 0.013) of the patients.

CONCLUSIONS AND RECOMMENDATIONS

Osteoporosis and osteopenia are prevalent in patients attending in the hospital. Hence, awareness, early screening, and treatment are necessary for the hospital attended patients to enhance their health and, minimize the risk of osteoporosis and the consequences associated with it.

Fracture risk prediction in old Chinese people-a narrative review

With aging, the burden of osteoporotic fracture (OF) increases substantially, while China is expected to carry the greatest part in the future. The risk of fracture varies greatly across racial groups and geographic regions, and systematically organized evidence on the potential predictors for fracture risk is needed for Chinese. This review briefly introduces the epidemiology of OF and expands on the predictors and predictive tools for the risk of OF, as well as the challenges for their potential translation in the old Chinese population. There are regional differences of fracture incidence among China. The fracture incidences in Hong Kong and Taiwan have decreased in recent years, while it is still increasing in mainland China. Although the application of dual-energy X-ray absorptiometry (DXA) is limited among old Chinese in the mainland, bone mineral density (BMD) by DXA has a predictive value similar to that worldwide. Other non-DXA modalities, especially heel QUS, are helpful in assessing bone health. The fracture risk assessment tool (FRAX) has a good discrimination ability for OFs, especially the FRAX with BMD. And some clinical factors have added value to FRAX, which has been verified in old Chinese. In addition, although the application of the osteoporosis self-assessment tool for Asians (OSTA) in Chinese needs further validation, it may help identify high-risk populations in areas with limited resources. Moreover, the translation use of the muscle quality and genetic or serum biomarkers in fracture prediction needs further works. More applicable and targeted fracture risk predictors and tools are still needed for the old Chinese population.

Development and validation of the Chinese osteoporosis screening algorithm (COSA) in identification of people with high risk of osteoporosis

Objectives

To enhance the public awareness and facilitate diagnosis of osteoporosis, we aim to develop a new Chinese Osteoporosis Screening Algorithm (COSA) to identify people at high risk of osteoporosis.

Methods

A total of 4747 postmenopausal women and men aged ≥ 50 from the Hong Kong Osteoporosis Study were randomly split into a development (N = 2373) and an internal validation cohort (N = 2374). An external validation cohort comprising 1876 community-dwelling subjects was used to evaluate the positive predictive value (PPV).

Results

Among 11 predictors included, age, sex, weight, and history of fracture were significantly associated with osteoporosis after correction for multiple testing. Age- and sex-stratified models were developed due to the presence of significant sex and age interactions. The area under the curve of the COSA in the internal validation cohort was 0.761 (95% CI, 0.711-0.811), 0.822 (95% CI, 0.792-0.851), and 0.946 (95% CI, 0.908-0.984) for women aged < 65, women aged ≥ 65, and men, respectively. The COSA demonstrated improved reclassification performance when compared to Osteoporosis Self-Assessment Tool for Asians. In the external validation cohort, the PPV of COSA was 40.6%, 59.4%, and 19.4% for women aged < 65, women aged ≥ 65, and men, respectively. In addition, COSA > 0 was associated with an increased 10-year risk of hip fracture in women ≥ 65 (OR, 4.65; 95% CI, 2.24-9.65) and men (OR, 11.51; 95% CI, 4.16-31.81).

Conclusions

We have developed and validated a new osteoporosis screening algorithm, COSA, specific for Hong Kong Chinese.

Cost-effectiveness of selective bone densitometry using the osteoporosis self-assessment tool for Asians in multi-ethnic Asian population

Early detection and treatment of osteoporosis can help to prevent debilitating fractures in the elderly. The osteoporosis self-assessment tool for Asians can be used as a screening tool to stratify patients for bone densitometry. It is most cost-effective for post-menopausal women aged 70 and males aged 75.

PURPOSE

To determine the cost-effectiveness of selective bone densitometry (SBD) using the Osteoporosis Self-Assessment Tool for Asians (OSTA) as a risk-stratifying tool for the three predominant races (Chinese, Malay and Indian) in Singapore.

METHODS

Decision analytical models were developed using a Markov model. Three scenarios were compared: no bone densitometry, SBD using the OSTA as a pre-screening tool and universal bone densitometry. Those diagnosed with osteoporosis were treated with five years of alendronate therapy. Data sources were from Singapore epidemiological studies, healthcare cost figures and published literature. Measurements include life years, quality-adjusted life years (QALYs), costs and incremental cost-effectiveness ratios (ICER).

RESULTS

Compared to no bone densitometry, SBD using the OSTA would cost between $40,679 and $73,909 per QALY gained for men aged 75-80 and $22,386 to $58,185 per QALY gained for post-menopausal women aged 70-80. Universal bone densitometry would cost $157,955 to $177,127 per QALY gained for men aged 75-80 and $40,179 to $66,112 per QALY gained for post-menopausal women aged 70 to 80 compared to SBD.

CONCLUSION

In general, osteoporosis screening was the most cost-effective for Malays and the least cost-effective for Indians. However, a general guideline should still be applied to the Singaporean population, as further explained later. Overall, the most cost-effective strategy for males would be using OSTA as a risk-stratifying tool at age 75. For post-menopausal women, SBD should be used for women aged 70, while universal bone densitometry should be used for women aged 75-80.

Osteoporosis Risk in Hemodialysis Patients: The Roles of Gender, Comorbidities, Biochemical Parameters, Health and Diet Literacy

Osteoporosis is a common bone health disorder in hemodialysis patients that is linked with a higher morbidity and mortality rate. While previous studies have explored the associated factors of osteoporosis, there is a lack of studies investigating the impacts of health literacy (HL) and digital healthy diet literacy (DDL) on osteoporosis. Therefore, we aimed to investigate the associations of HL, DDL, and other factors with osteoporosis among hemodialysis patients. From July 2020 to March 2021, a cross-sectional study was conducted on 675 hemodialysis patients in eight hospitals in Vietnam. The data were collected by using the osteoporosis self-assessment tool for Asians (OSTA) and the 12-item short form of the health literacy questionnaire (HLS-SF12) on digital healthy diet literacy (DDL) and hemodialysis dietary knowledge (HDK). In addition, we also collected information about the socio-demographics, the clinical parameters, the biochemical parameters, and physical activity. Unadjusted and adjusted multinomial logistic regression models were utilized in order to investigate the associations. The proportion of patients at low, medium, and high levels of osteoporosis risk was 39.6%, 40.6%, and 19.8%, respectively. In the adjusted models, women had a higher likelihood of osteoporosis risk than men (odds ratio, OR, 3.46; 95% confidence interval, 95% CI, 1.86, 6.44; p < 0.001; and OR, 6.86; 95% CI, 2.96, 15.88; p < 0.001). The patients with rheumatoid arthritis (OR, 4.37; 95% CI, 1.67, 11.52; p = 0.003) and stomach ulcers (OR, 1.95; 95% CI, 1.01, 3.77; p = 0.048) were more likely to have a higher likelihood of osteoporosis risk than those without. The patients who had a higher waist circumference (WC), HL, and DDL were less likely to have a medium level of osteoporosis risk (OR, 0.95; 95% CI, 0.92, 0.98; p = 0.004; OR, 0.92; 95% CI, 0.88, 0.96; p < 0.001; OR, 0.96; 95% CI, 0.93, 0.99; p = 0.017, respectively) and a high level of osteoporosis risk (OR, 0.93; 95% CI, 0.89, 0.97; p = 0.001; OR, 0.89; 95% CI, 0.84, 0.94; p < 0.001; OR, 0.95; 95% CI, 0.91, 0.99; p = 0.008, respectively) compared with a low level of osteoporosis risk and to those with a lower WC, HL, and DDL. In addition, higher levels of hemoglobin (Hb) (OR, 0.79; 95% CI, 0.66, 0.95; p = 0.014), hematocrit (Hct) (OR, 0.95; 95% CI, 0.92, 0.99; p = 0.041), albumin (OR, 0.91; 95% CI, 0.83, 0.99; p = 0.030), and education (OR, 0.37; 95% CI, 0.16, 0.88; p = 0.025) were associated with a lower likelihood of a high level of osteoporosis risk. In conclusion, osteoporosis risk is highly prevalent in hemodialysis patients. Improved HL, DDL, education, WC, albumin, Hb, and Hct levels should be considered in preventing hemodialysis patients from developing osteoporosis.

The Assessment of the Osteoporosis Self-Assessment Tool for Asians and Calcaneal Quantitative Ultrasound in Identifying Osteoporotic Fractures and Falls Among Chinese People

The lack of DXA has made the diagnosis and treatment of osteoporosis extremely difficult in the vast rural areas of China, which has the largest population with high risks of osteoporosis. The aims of this cross-sectional study were to evaluate the association between the osteoporosis self-assessment tool for Asians (OSTA) and calcaneus quantitative ultrasound (QUS) in populations residing in Shanghai, China, and their assessment in predicting osteoporotic fractures and falls. A population of 12,033 participants, including 1272 males (average age 68.3 ± 9.8 years, range 28-100 years) and 10,761 females (average 56.8 ± 11.4 years, range 23-99 years), was gathered. OSTA and calcaneus QUS (Sonost 2000, OsteoSys) values were measured. Spearman's correlation and Cohen's kappa were used to determine the association and agreement between the OSTA and QUS. Receiver operating characteristic (ROC) curves were adapted to assess the performance and optimal cutoff values for the OSTA and QUS in osteoporotic fracture and fall screening. In total, the prevalence of osteoporotic fractures (low-trauma fractures including fractures of the spine, hip, forearm, humerus and ribs) was 15.2% in women, and 17.7% reported a history of falls (falling from standing height more than once in the past year). The percentages of men with the same history were 8.4% and 11.7%, respectively. The association between the OSTA and QUS was found to be r_s = 0.393, κ = 0.137, p < 0.001. The OSTA (cutoff < -1) revealed an area under ROC curve (AUC) of 0.590 in identifying female individuals with moderate or high risk of osteoporosis defined by QUS (T-score < -1). The QUS T-score lower than -1.55 or -1.40 in postmenopausal women may lead to an increased risk of falls or osteoporotic fractures, respectively. The agreement between QUS and the OSTA seemed to be limited in determining individuals at risk of osteoporosis. Measuring bone mineral density (BMD) by dual energy X-ray absorptiometry (DXA) may still be necessary in the clinical diagnosis of osteoporosis. OSTA and QUS T-scores less than the respective cutoff values may indicate an increased risk of osteoporotic fractures and falls that individual should be further treated and screened by DXA.

Development of Osteoporosis Screening Algorithm for Population Aged 50 Years and above in Klang Valley, Malaysia

Background: The current osteoporosis screening instruments are not optimized to be used among the Malaysian population. This study aimed to develop an osteoporosis screening algorithm based on risk factors for Malaysians. Methods: Malaysians aged ≥50 years (n = 607) from Klang Valley, Malaysia were interviewed and their bone health status was assessed using a dual-energy X-ray absorptiometry device. The algorithm was constructed based on osteoporosis risk factors using multivariate logistic regression and its performance was assessed using receiver operating characteristics analysis. Results: Increased age, reduced body weight and being less physically active significantly predicted osteoporosis in men, while in women, increased age, lower body weight and low-income status significantly predicted osteoporosis. These factors were included in the final algorithm and the optimal cut-offs to identify subjects with osteoporosis was 0.00120 for men [sensitivity 73.3% (95% confidence interval (CI) = 54.1%-87.7%), specificity 67.8% (95% CI = 62.7%-85.5%), area under curve (AUC) 0.705 (95% CI = 0.608-0.803), p < 0.001] and 0.161 for women [sensitivity 75.4% (95% CI = 61.9%-73.3%), specificity 74.5% (95% CI = 68.5%-79.8%), AUC 0.749 (95% CI = 0.679-0.820), p < 0.001]. Conclusion: The new algorithm performed satisfactorily in identifying the risk of osteoporosis among the Malaysian population ≥50 years. Further validation studies are required before applying this algorithm for screening of osteoporosis in public.

The performance of osteoporosis self-assessment tool for Asians (OSTA) in identifying the risk of osteoporosis among Malaysian population aged 40 years and above

The concordance between osteoporosis self-assessment tool for Asians (OSTA) and dual-energy X-ray absorptiometry (DXA) was fair in the study. Modification of OSTA cutoff values improved its sensitivity to identify subjects at risk for suboptimal bone health (osteopenia/osteoporosis) and osteoporosis.

PURPOSE

Osteoporosis self-assessment tool for Asians (OSTA) is a convenient screening algorithm used widely to identify patients at risk of osteoporosis. Currently, the number of studies validating OSTA in Malaysian population is limited. This study aimed to validate the performance of OSTA in identifying subjects with osteoporosis determined with DXA.

METHODS

This cross-sectional study recruited 786 Malaysians in Klang Valley, Malaysia. Their bone health status was assessed by DXA and OSTA. The association and agreement between OSTA and bone mineral density assessment by DXA were determined by Pearson's correlation and Cohen's kappa, respectively. Receiver operating characteristics (ROC) curves were used to determine the sensitivity, specificity, and area under the curve (AUC) for OSTA.

RESULTS

OSTA and DXA showed a fair association in the study (r = 0.382, κ = 0.159, p < 0.001). OSTA (cutoff < - 1) revealed a sensitivity of 32.3%, specificity of 92.3%, and AUC of 0.618 in identifying subjects with suboptimal bone health. The sensitivity of OSTA (cutoff < - 4) in determining subjects at risk of osteoporosis was better among women (sensitivity = 20%) than men (sensitivity = 0%). Modified OSTA cutoff values improved the sensitivity of OSTA in identifying subjects with suboptimal bone health (men = 81.0% at cutoff 3.4, women = 82.8% at cutoff 2.0) and osteoporosis (men = 81.8% at cutoff 1.8, women = 81.3% at cutoff 0.8).

CONCLUSION

OSTA with its original cutoff values is ineffective in identifying individuals at risk for osteoporosis. Adjusting the cutoff values significantly increases the sensitivity of OSTA, thus highlighting the need to validate this instrument among the local population before using it for osteoporosis screening clinically.

The ability of calcaneal and multisite quantitative ultrasound variables in the identification of osteoporosis in women and men

Objectives

The aim of this study was to assess the ability of calcaneal and multisite quantitative ultrasound (QUS) parameters in the identification of osteoporosis in women and men.

Patients and methods

A total of 131 women (mean age 53.7±11.9 years; range, 21 to 79 years) and 109 men (mean age 57.8±13.7 years; range, 24 to 85 years) whose bone mineral density (BMD) at the spine and proximal femur was measured between January 2010 and January 2012, using dual-energy X-ray absorptiometry (DXA) were included. Acoustic bone properties were also examined using both a calcaneal and a multisite QUS. The receiver operating characteristic analysis with the calculation of areas under the curve (AUCs) to evaluate the ability of both QUS devices for the identification of osteoporosis. We also calculated a lower and an upper threshold at a specificity of 90% and at a sensitivity of 90%, respectively, for the identification of osteoporosis along with a threshold/cut-off value with the best compromise between sensitivity and specificity.

Results

All calcaneal QUS parameters showed significant AUCs within the range of 0.712 (for Broadband Ultrasound Attenuation [BUA]) and 0.764 (for Speed of Sound [SOS]) in women and ranging from 0.661 (for BUA) to 0.735 (for SOS) in men, while only radial SOS of the multisite QUS demonstrated a significant AUC value of 0.661 for identifying osteoporosis in women. A Quantitative Ultrasound Index T-score of -1.53 for women and -1.68 for men showed sensitivity and specificities around 70%.

Conclusion

Based on the results of this study, all calcaneal QUS parameters in both women and men and possibly radial SOS measurements of the multisite QUS in women may be helpful for the identification of osteoporosis.

Estimation of Prevalence of Osteoporosis Using OSTA and Its Correlation with Sociodemographic Factors, Disability and Comorbidities

Osteoporosis is a growing concern for an aging society. The study aimed to estimate the prevalence of older adults who were at risk of osteoporosis and explore factors associated with osteoporosis. The relationship between the risk of osteoporosis, chronic conditions and disability was also explored. We hypothesized that respondents with high risk index of osteoporosis would be associated with greater disability. Participants aged 60 years and above (N = 2565) who were representative of Singapore’s multiethnic population were recruited. The Osteoporosis Self-Assessment Tool for Asians (OSTA) was used to classify the risk of osteoporosis. Information on sociodemographic details and chronic diseases were collected, while severity of disability was measured using the World Health Organization Disability Assessment Schedule 2.0. The overall prevalence of the respondents who were at risk of osteoporosis was 52%. Those belonging to an older age, Chinese, female, never married or widowed, lower education and retired were associated with a higher risk of osteoporosis. A diagnosis of diabetes or hypertension was a protective factor against the risk of osteoporosis. High risk of osteoporosis was not associated with disability. Our findings highlighted specific factors associated with the risk of osteoporosis that could be useful for the prevention of osteoporosis and fractures.

Osteoporosis increases the risk of benign paroxysmal positional vertigo: a nested case-control study using a national sample cohort

INTRODUCTION

The previous studies suggested an association between osteoporosis and sudden sensory neural hearing loss (SSNHL). The aim of the present study was to evaluate the association between osteoporosis and benign paroxysmal positional vertigo (BPPV).

MATERIALS AND METHODS

Data from the Korean National Health Insurance Service-National Sample Cohort of participants who were ≥ 50 years old were collected from 2002 to 2013. A total of 13,484 BPPV participants were matched with respect to age group, sex, income group, region of residence, hypertension, diabetes, and dyslipidemia to 53,936 controls. In both the BPPV and control groups, the previous histories of osteoporosis were evaluated. Crude (simple) and adjusted odds ratios (ORs) of osteoporosis for BPPV were analyzed using unconditional logistic regression analyses. Subgroup analyses were conducted according to age, sex, and BPPV frequency.

RESULTS

A total of 18.64% (2514/13,464) of the BPPV group and 12.21% (6589/53,936) of the control group had a history of osteoporosis (P < 0.001). The adjusted OR of osteoporosis for BPPV was 1.29 (95% CI = 1.23-1.35, P < 0.001). In the subgroup analysis according to age and sex, the ≥ 70-year-old men did not demonstrate a high adjusted OR of osteoporosis for BPPV. All other age and sex subgroups demonstrated high adjusted ORs of osteoporosis for BPPV.

CONCLUSIONS

Osteoporosis increased the risk of BPPV in the population aged ≥ 50 years. The OR of osteoporosis was higher in the frequent BPPV group than in the less frequent BPPV group.

Performance of Osteoporosis Self-Assessment Tool (OST) in Predicting Osteoporosis-A Review

Bone health screening plays a vital role in the early diagnosis and treatment of osteoporosis to prevent fragility fractures among the elderly and high-risk individuals. Dual-energy X-ray absorptiometry (DXA), which detects bone mineral density, is the gold standard in diagnosing osteoporosis but is not suitable for screening. Therefore, many screening tools have been developed to identify individuals at risk for osteoporosis and prioritize them for DXA scanning. The Osteoporosis Self-assessment Tool (OST) is among the first tools established to predict osteoporosis in postmenopausal women. It can identify the population at risk for osteoporosis, but its performance varies according to ethnicity, gender, and age. Thus, these factors should be considered to ensure the optimal use of OST worldwide. Overall, OST is a simple and economical screening tool to predict osteoporosis and it can help to optimize the use of DXA.

Agreement between calcaneal quantitative ultrasound and osteoporosis self-assessment tool for Asians in identifying individuals at risk of osteoporosis

Background

Calcaneal quantitative ultrasound (QUS) is a useful tool in osteoporosis screening. However, QUS device may not be available at all primary health care settings. Osteoporosis self-assessment tool for Asians (OSTA) is a simple algorithm for osteoporosis screening that does not require any sophisticated instruments. This study explored the possibility of replacing QUS with OSTA by determining their agreement in identifying individuals at risk of osteoporosis.

Methods

A cross-sectional study was conducted to recruit Malaysian men and women aged ≥50 years. Their bone health status was measured using a calcaneal QUS device and OSTA. The association between OSTA and QUS was determined using Spearman’s correlation and their agreement was assessed using Cohen Kappa and receiver-operating curve.

Results

All QUS indices correlated significantly with OSTA (p<0.05). The agreement between QUS and OSTA was minimal but statistically significant (p<0.05). The performance of OSTA in identifying subjects at risk of osteoporosis according to QUS was poor-to-fair in women (p<0.05), but not statistically significant for men (p>0.05). Changing the cut-off values improved the performance of OSTA in women but not in men.

Conclusion

The agreement between QUS and OSTA is minimal in categorizing individuals at risk of osteoporosis. Therefore, they cannot be used interchangeably in osteoporosis screening.

A review on the performance of osteoporosis self-assessment tool for Asians in determining osteoporosis and fracture risk

The prevalence of osteoporosis in Asian countries is growing. An effective screening method will enable patients at risk for osteoporosis to receive early diagnosis and treatment, and avoid overcrowding the limited dual-energy x-ray absorptiometry (DXA) machines available in Asian countries. Many simple osteoporosis screening algorithms have been developed but they are not validated for use in Asian populations. osteoporosis self-assessment tools for Asians (OSTA), established using a multinational Asian cohort, is the first screening algorithm that caters for the Asian populations. It considers only body weight and age in the algorithm. It shows consistently high performance and sensitivity in identifying postmenopausal women at risk for osteoporosis in many Asian countries. Its usage has been expanded for identifying osteoporosis in men, as well as determining fracture risk for both sexes. However, the performance of OSTA is influenced by age, sex, ethnicity and site of BMD measurement to define osteoporosis. Its usage is also limited in individuals without apparent risk factors. These limitations should be noted by physicians considering the use of OSTA in clinical setting. As a conclusion, OSTA is a cost-effective measure for osteoporosis screening in primary healthcare setting.

Effectiveness of Osteoporosis Self-Assessment Tool for Asians in Screening for Osteoporosis in Healthy Males Over 40 Years Old in China

In this study, we evaluated the effectiveness of the Osteoporosis Self-assessment Tool for Asians (OSTA) in screening for osteoporosis in the elderly male population in the Chengdu area, China. The Lunar Prodigy Advance bone densitometer was used to measure the bone mineral density of 11,039 healthy males over the age of 40 years. Men with OSTA scores of >-1, -4 < OSTA ≤ -1, or ≤-4 were assigned to the low-risk, moderate-risk, or high-risk group, respectively. The T-scores measured with dual-energy X-ray absorptiometry at the different sites were compared across the groups. The bone mineral density of the lumbar spines L1-L4, the left femur, and other sites decreased gradually with age. With increasing age, the screening sensitivity of OSTA for osteoporosis in the lumbar spine and femur gradually increased, whereas its specificity decreased. The areas under the receiver operating characteristic curves for the OSTA index in different age groups and at different sites were 0.644-0.831. Therefore, the OSTA index demonstrated some value in screening for osteoporosis in men over the age of 50 years. Significant differences in its effectiveness were observed among different age groups.

Diagnostic devices for osteoporosis in the general population: A systematic review

INTRODUCTION

A diagnostic gap exists in the current dual photon X-ray absorptiometry (DXA) based diagnostic approach to osteoporosis. Other diagnostic devices have been developed, but no comprehensive review concerning the applicability of these diagnostic devices for population-based screening have been performed.

MATERIAL AND METHODS

A systematic review of Embase, Medline and the Cochrane Central Register for Controlled Trials was performed for population-based studies that focused on technical methods that could either indicate bone mineral density (BMD) by DXA, substitute for DXA in prediction of fracture risk, or that could have an incremental value in fracture prediction in addition to DXA. Quality of included studies was rated by QUADAS 2.

RESULTS

Many other technical devices have been tested in a population-based setting. Five studies aiming to indicate BMD and 17 studies aiming to predict fractures were found. Overall, the latter studies had higher methodological quality. The highest number of studies was found for quantitative ultrasound (QUS). The ability to indicate BMD or predict fractures was moderate to minor for all examined devices, using reported area under the curve (AUC) of Receiver Operating Characteristic curves values as standard.

CONCLUSIONS

Of the methods assessed, only QUS appears capable of perhaps replacing DXA as standalone examination in the future whilst radiographic absorptiometry could provide important information in areas with scarcity of DXA. QUS may be of added value even after DXA has been performed. Evaluation of proposed cutoff-values from population-based studies in separate population-based cohorts is still lacking for most examination devices.

Osteoporosis in East Asia: Current issues in assessment and management

The greatest burden of hip fractures around the world is expected to occur in East Asia, especially China. However, there is a relative paucity of information on the epidemiology and burden of fractures in East Asia. Osteoporosis is greatly under-diagnosed and under-treated, even among the highest-risk subjects who have already suffered fractures. The accessibility to bone densitometry, the awareness of the disease by professionals and the public, and the use and reimbursement of drugs are some of the areas which need improvement especially. Cost-effective analysis on screening strategy and intervention thresholds based on local epidemiology data and economic status are available only in Japan. In addition, clinical risk factor models for the assessment of fracture probability may be ethnic specific. Further research is needed to develop a cost-effective risk assessment strategy to identify high-risk individuals for screening and treatment based on local data. Moreover, inadequate calcium and vitamin D intake is still an issue faced by this region.

Clinical value of self-assessment risk of osteoporosis in Chinese

BACKGROUND

Early detection of high-risk population for osteoporosis is the key to preventing this disease.

METHODOLOGY

In this cross-sectional study a continuous sample of 270 women and 89 men (age: 20-90 years) was divided into four groups by age (≤ 55 or > 55 years) and sex. Participants completed the IOF test. Low-, medium-, and high-risk grades were defined by an OSTA index of greater than -1, -1 to -4, and less than -4, respectively.

RESULTS

Most participants were categorized in the low-risk group (240 people, 66.9%), followed by the medium-risk (102 people, 28.4%) and high-risk groups (17 people, 4.7%). Compared to women, men in both age groups had significantly higher OSTA index and greater numbers of positive answers on the IOF test. 64.3% individuals were susceptible to osteoporosis risk (≥1 positive answers on the IOF test). Multiple regression analysis demonstrated that family history of fragility fracture (OR: 0.503, 95% CI: 0.26-0.97), height loss exceeding 3 cm (OR: 2.51, 95% CI: 1.55-4.05), and earlier menopause (OR: 0.434, 95% CI: 0.19-0.97) were associated with higher risk grades.

CONCLUSIONS

Combined use of the OSTA and IOF test is a simple and effective method for assessing the risk of osteoporosis.

Prevalence of osteoporosis in schizophrenia patients using the osteoporosis self-assessment tool for Asians

OBJECTIVE

The aims of the current study were to investigate the prevalence and socio-demographic correlates of risk of osteoporosis in Singapore among patients with schizophrenia using the osteoporosis self-assessment tool for Asians (OSTA).

METHOD

Data for the current study was drawn from a clinical database maintained at the Institute of Mental Health Singapore. The OSTA index was used to calculate the risk for osteoporosis among those aged 50 years and above.

RESULTS

A total of 2569 patients were included in the study. About 34.6% met the criteria for osteoporosis using the OSTA cut-off of ≤ -1. Among the males 22.8% met criteria for high risk and 1.5% met criteria for very high risk, while among women 28.2% were at intermediate risk and 14.9% were at high risk of osteoporosis. The logistic regression analysis showed that older age and female gender were significantly associated with a higher risk of osteoporosis, while those with a history of hypertension and hyperlipidemia were less likely to be associated with a risk of osteoporosis.

CONCLUSION

The OSTA could be a useful, inexpensive and quick tool to both identify those with osteoporosis as well as to measure the effectiveness of interventions meant to alleviate it.

Diagnostic value of osteoporosis self-assessment tool for Asians (OSTA) and quantitative bone ultrasound (QUS) in detecting high-risk populations for osteoporosis among elderly Chinese men

This study aims to evaluate an osteoporosis self-assessment tool for Asians (OSTA) and quantitative bone ultrasound (QUS) and their combination in detecting populations at high risk for osteoporosis, and to determine the best cutoff value for the diagnosis of osteoporosis among elderly Chinese men. A group of Chinese men, aged ≥ 60 years, recruited from the health checkup population of Zhongshan Hospital, Fudan University, were included. The OSTA index was calculated from age and weight. Bone mineral density (BMD) at left hip (femoral neck, internal, and total hip) and lumbar spine (L1-L4, L-Total) was measured with dual-energy X-ray absorptiometry (DXA), and calcaneal BMD was measured with QUS. Receiver operating characteristic analysis was used to determine the best cutoff values, sensitivity, and specificity. The area under the curve (AUC) between the different screening tools was compared. Our study included 472 men with mean age of 78.0 years. The prevalence of osteoporosis was 27.7%.The best cutoff for OSTA was -3.5 for predicting men with osteoporosis at any site; this yielded a sensitivity and specificity of 47.3% and 76.8%, respectively. The AUC for OSTA was 0.676. The optimal cutoff for QUS-T score was -1.25, with a sensitivity of 80.4% and specificity of 59.7%. The AUC for QUS-T score was 0.762. Combining QUS with OSTA improved the specificity to 92.9% but reduced sensitivity to 36.1%. A new variable derived from a combination of OSTA and the QUS-T score gave a better performance, with sensitivity of 70.1% and specificity of 72.1%; the AUC for this variable was 0.771, which was greater than OSTA but not different from QUS alone. In conclusion, OSTA and QUS, respectively, and their combination may help find populations at high risk for osteoporosis, which could be an alternative method for diagnosing osteoporosis, especially in areas where DXA measurement is not accessible.

The effect of age on the changes in bone mineral density and osteoporosis detection rates in Han Chinese men over the age of 50

OBJECTIVE

To examine the relationship between age and BMD at different skeletal sites and osteoporosis (OP) detection rates in Han Chinese men over 50 years and to assess the diagnostic value of the OSTA.

METHODS

A retrospective analysis of 1488 men over 50 was carried out and group comparisons were made.

RESULTS

BMDs at total hip and femoral neck decreased with age (p < 0.01) and were negatively correlated with age by liner correlation analysis (r = -0.36, -0.30; p all <0.05). The detection rates of OP and osteopenia were 10.08% and 43.21% respectively, which increased with age, and significantly higher among over 70 years old than under 70 individuals (47.75% versus 35.56%; 14.88% versus 1.99%; p all <0.01). The detection rate at the femoral neck was similar to the overall detection rate. Sensitivities of OSTA index at a cutoff value of -1 and -4 were 87.33% and 52.0% respectively, and the specificities were 56.20% and 87.59%.

CONCLUSION

BMDs at femoral neck and total hip decrease with age. Detection rates of OP increase with age. Bilateral femoral neck BMD measurement can improve detection rates of OP. OSTA is a useful screening tool for OP in Han Chinese men over 50 years.

Prevalence of osteoporosis in the Korean population based on Korea National Health and Nutrition Examination Survey (KNHANES), 2008-2011

PURPOSE

We analyzed age-related changes of bone mineral density (BMD) and compared with those of U.S and Japanese participants to investigate the prevalence of osteoporosis in Korea.

MATERIALS AND METHODS

The data were collected in the 2008-2011 in Korea National Health and Nutrition Examination Survey (KNHANES) IV and V to select a representative sample of civilian, noninstitutionalized South Korean population. Bone mineral measurements were obtained from 8332 men and 9766 women aged 10 years and older.

RESULTS

BMD in men continued to decline from 3rd decade, however, in women, BMD remained nearly constant until the 4th decade and declined at rapid rate from the 5th decade. The prevalence of osteoporosis in Korea is 7.3% in males and 38.0% in females aged 50 years and older. The prevalence of osteopenia in Korea is 46.5% in males and 48.7% in females, aged 50 years and older. The lumbar spine and femur BMD in Korean females 20 to 49 years of ages was lower than in U.S. and Japan participants.

CONCLUSION

There was obvious gender, and age differences in the BMD based on the 2008-2011 KNHANES IV and V, a nationwide, cross-sectional survey conducted in a South Korean population. We expect to be able to estimate reference data through ongoing KNHANES efforts in near future.

Sensitivity of osteoporosis screening guidelines for eventual hip fracture in older male veterans

This study sought to determine whether guideline-recommended clinical criteria to select men for osteoporosis screening provide significantly better sensitivity than the osteoporotic screening tool (OST) among men who later went on to have a hip fracture, and whether the sensitivity differs by race. This retrospective observational study uses data from the Department of Veterans Affairs Austin Automation Center. We identified 825 male veterans with hip fractures from 2007 to 2009. Clinical risk factors used as screening selection criteria were abstracted from five accepted guidelines. Outpatient encounters were examined for each subject to determine whether they would have met screening selection criteria for each guideline in the 5 years before their hip fracture event. Sensitivities for each guideline were compared with the OST, using McNemar's exact test. Sensitivities of Veterans Affairs Health Service Research and Development Services (VA HSR&D) and National Osteoporosis Foundation (NOF) guidelines were 77% and 82%, respectively, and were significantly better than the OST sensitivity of 72% (P<0.05). Sensitivities of American College of Physicians (ACP; 68%), VA Secretary's Letters (45%) and Center for Medicare and Medicaid Services (13%) were significantly worse than the OST sensitivity (P<0.001). The sensitivities of the VA HSR&D, ACP and NOF were significantly higher in Whites compared with non-Whites (76% vs 65%, P<0.01; 70% vs 58%, P<0.01; and 84% vs 70%, P<0.001, respectively). Only VA HSR&D and NOF clinical screening criteria are more sensitive than OST in identifying veterans who subsequently experience hip fractures, and these sensitivities vary by race.

A New Predictive Index for Osteoporosis in Men under 70 Years of Age: An Index to Identify Male Candidates for Osteoporosis Screening by Bone Mineral Density

Background. Bone mineral density (BMD) screening guidelines for osteoporosis in men seem to have remained unclear. We aimed to set up a predictive index for the osteoporosis(PIO) in men under 70 years of age and present the optimal cutoff value of it, so that clinicians might use it to identify male candidates who benefit from taking the BMD screening. Methods. Adult men under 70 years old who met certain criteria were included. With the determined significant predictors for osteoporosis, we created a new index that presumably best predicts the osteoporosis and compared the predictability of it to other variables. Lastly, the optimal cutoff value of the PIO was calculated. Results. A total of 359 men were included. Age, weight, and current smoking status turned out to be significant predictors for osteoporosis. The PIO was as follows: [age(years) + 10 (for current smoker)]/weight(kg). Compared to other variables, the PIO showed the greatest predictive performance with the optimal cutoff point being 0.87 at which sensitivity and specificity were 71.9% and 70.0%, respectively. Conclusion. A new predictive index appeared to predict the presence of osteoporosis fairly well and thus can be used with its cutoff point to identify men under 70 years of age who need BMD screening.

Indications of DXA in women younger than 65 yr and men younger than 70 yr: the 2013 Official Positions

Dual-energy X-ray absorptiometry (DXA) is the method of choice to assess fracture risk for women 65 yr and older and men 70 yr and older. The 2007 International Society for Clinical Densitometry Official Positions had developed guidelines for assessing bone density in younger women during and after the menopausal transition and in men 50-69 yr and the 2008 National Osteoporosis Foundation (NOF) guidelines recommended testing in postmenopausal women younger than 65 yr and men 50-69 yr only in the presence of clinical risk factors. The purpose of the 2013 DXA Task Force was to reassess the NOF guidelines for ordering DXA in postmenopausal women younger than 65 yr and men 50-69 yr. The Task Force reviewed the literature published since the 2007 Position Development Conference and 2008 NOF, reviewing clinical decision rules such as the Osteoporosis Screening Tool and FRAX and sought to keep recommendations simple to remember and implement. Based on this assessment, the NOF guidelines were endorsed; DXA was recommended in those postmenopausal women younger than 65 yr and men 50-69 yr only in the presence of clinical risk factors for low bone mass, such as low body weight, prior fracture, high-risk medication use, or a disease or condition associated with bone loss.

Chinese men's knowledge and risk factors of osteoporosis: compared with women's

Male osteoporosis is underappreciated. Little is known about men's knowledge of osteoporosis and how much men are at risk. This study surveyed men's knowledge of osteoporosis and their risk factors with reference to women in the primary care setting in Macau, China. A convenience sample of 302 men and 635 women aged 18 to 90 years completed questionnaires comprising the Osteoporosis Knowledge Assessment Tool and the One-Minute Osteoporosis Risk Test. Their risks of osteoporosis were assessed with the Osteoporosis Self-Assessment Screening Test. Men and women, who were aged 55 years or below, had similarly limited knowledge of osteoporosis. People aged above 55 years had significantly less knowledge; men had less knowledge than women only in this age-group. If questions specific to women or menopause were excluded, men had similar knowledge as women. A higher proportion of men than women had risk factors as more men consumed alcohol or smoked tobacco. Similar proportions of men and women reported a loss of 1 inch in body height after age 40. After age 55, 29.2% men were at medium to high risk of osteoporosis. This study concludes that health education and primary prevention of osteoporosis should be promoted to men starting in middle-age.

Cross sectional study of osteoporosis among women

Osteoporosis is a major public health problem, associated with substantial morbidity and socio-economic burden. An early detection can help in reducing the fracture rates and overall socio-economic burden. The present study was carried out to screen the bone status (osteopenia and osteoporosis) above the age of 35 yrs in the women. A community based cross sectional study was carried out in 158 women by calculating WHO T-scores utilizing calcaneal QUS as diagnostic tool. The prevalence of osteoporosis and osteopenia was found to be 13.3% ± 5.29% and 48.1% ± 7.79% respectively. Statistical association of prevalence of osteopenia and osteoporosis was found to be significant with age group; gravida status; attainment of menopause; body weight and physically active status of the women. The statistical association was not significant in relation to the rank status of their husband, as well as dietary pattern of the women but still it has to be substantiated by conducting larger community based trials in future. The present study found that there was statistically significant relationship between age group and the prevalence of osteopenia and osteoporosis. There was a negative correlation between age of the women and BMD. Besides age, gravida status and menopausal status have negative correlation with BMD while positive correlation with physically active lifestyle. The results were found to be non-significant in relation to rank status of husband and dietary pattern.

Osteoporosis self-assessment tool for Asians as a simple risk index of identifying a poor prognosis in women surgically treated for colorectal cancer

BACKGROUND

Osteoporosis and colorectal cancer (CRC) in older women are considered enormous public health burdens. The effects of osteoporosis on the oncologic outcome of CRC surgery are poorly understood. We evaluated the use of the Osteoporosis Self-assessment Tool for Asians (OSTA) for predicting postoperative outcome in older women after receiving surgical treatment of CRC.

MATERIALS AND METHODS

The present single-institution retrospective study analyzed patients who had undergone surgery for CRC in 2002-2008. To characterize the major population of women with osteoporosis, which consists of postmenopausal women, only patients aged 50 years and older were analyzed. Their OSTA scores were evaluated for correlations with cancer-specific survival after surgery for CRC by performing univariate, multivariate, and survival analyses.

RESULTS

During a 7-year period, 440 women were studied. The cancer-specific mortality and overall mortality rate was 28.4% and 33.4%, respectively. The univariate analyses revealed that significant predictors of cancer-specific mortality after CRC surgery were the International Union Against Cancer (UICC) stage, OSTA category, histologic grading, lymph node metastases, and tumor invasion depth. After risk adjustment, the UICC stage and OSTA risk index were independent predictors of mortality. A comparison of OSTA risk index among patients with different UICC stages showed that the accuracy of the index in predicting cancer-specific survival after CRC surgery was greatest for patients with stage II and III disease.

CONCLUSIONS

The UICC stage and OSTA risk status showed independent positive associations with postoperative mortality in aged female patients with CRC. Moreover, the OSTA index had a particularly strong association with cancer-specific mortality in patients with UICC stage II and III.

The correlation between the oral glucose tolerance test 30-minutes plasma glucose and risk factors for diabetes and cardiovascular diseases: a cross-sectional epidemiological study of diabetes in Fujian Province in the South-East of China

OBJECTIVE

To investigate the correlation between abnormal oral glucose tolerance test (OGTT) 30-min plasma glucose (PG) and risk factors and metabolic abnormalities of diabetes and cardiovascular diseases (CVD).

METHODS

Participants (no.=2457) underwent a physical examination, blood biochemistry examination, OGTT, and a 12-lead electrocardiogram. We measured fasting PG (FPG) and PG at 30 min (30minPG) and 1 h (1hPG) of the OGTT. The association between an increase in 30minPG (by 1 SD) and the metabolic abnormalities of diabetes and CVD such as hypertension, overweight and obesity, central obesity, and hyperlipidemia; osteoporosis was assessed by logistic regression analysis after controlling for FPG and 2hPG.

RESULTS

This analysis showed that an increase of 30minPG by 1 SD (1.92 mmol/l) significantly increased the risk of chronic metabolic abnormalities in diabetes and CVD such as hypertension, overweight, and obesity, central obesity, hyperlipidemia, and osteoporosis. Stepwise multiple regression analysis also showed that 30minPG was significantly correlated with male gender, smoking, FPG, 2hPG, total cholesterol, waist/hip ratio, and blood pressure.

CONCLUSIONS

An elevation of 30minPG increased the risk of diabetes and CVD. The increased risk was independent of FPG, 2hPG, age, sex, and smoking status.

Accuracy of quantitative ultrasound parameters in the diagnosis of osteoporosis

Quantitative ultrasound (QUS) is of increasing interest for evaluation of osteoporosis because, compared with dual-energy X-ray absorptiometry (DXA), it is portable, less expensive, and radiation-free. The aim of our study was to determine the sensitivity, specificity, and cut-off values of quantitative ultrasound parameters in identifying patients with osteoporosis compared to the World Health Organization (WHO) standard definition. We performed a cross-sectional investigational study of 73 subjects, and determined total hip and lumbar spine T-scores by dual-energy X-ray absorptiometry (DXA) (Prodigy Advance Lunar-GE). The QUS parameters (broadband ultrasound attenuation [BUA], speed of sound, bone mineral density, the stiffness index, and QUS T-score) were determined with Sahara Hologic equipment. The AUC was 0.81 (95% CI 0.67–0.95, p<0.05) for speed of sound (SOS) and 0.76 (95% CI 0.62–0.90, p<0.05) for BUA for the patients with DXA T-scores ≥ −1 DS; the cut-off values were 1542.2 meters per second for SOS and 63.3 dB/MHz for BUA. In patients with DXA T-scores ≤ − 2.5 DS, AUC was 0.80 (95% CI 0.70–0.90, p<0.05) for SOS, and 0.76 (95% CI 0.65–0.87, p<0.05) for BUA. The cut-off values were 1504.95 meters per second for SOS and 49.5 dB/MHz for BUA. Pearson correlation coefficients were positive and statistically significant (> 50%) for all QUS parameters in both groups, (2-tailed, p<0.05). QUS parameters correctly identified normal patients (false negative 34.21% and false positive 2.53%) and those with osteoporosis (false negative 8.55% and false positive 7.82%). The patients with QUS parameters between the cut-off values corresponding to DXA T-scores of −1 SD and − 2.5 SD should be further evaluated by DXA.

Prevalence and risk factors of osteoporosis in Korea: a community-based cohort study with lumbar spine and hip bone mineral density

PURPOSE

To investigate bone mineral density (BMD) profiles, osteoporosis prevalence and risk factors in a community-based cohort in Korea.

METHODS

The present study is a cross-sectional study. The study population consisted of 1,547 men and 1991 women aged 40 years and older with BMD measurements using central dual energy X-ray absorptiometry from a prospective community-based cohort. The data were compared with other ethnic groups. Risk factors related to osteoporosis were analyzed.

RESULTS

Crude prevalence of osteoporosis in the whole subjects (40-79 years old) was 13.1% for men and 24.3% for women by WHO criteria, at any site among lumbar spine, femoral neck or total hip. Standardized prevalence of osteoporosis between age of 50 and 79 at lumbar spine, femoral neck and total hip was 12.9%, 1.3% and 0.7% in men and 24.0%, 5.7% and 5.6% in women, respectively. The mean BMD of studied female subjects after age of 50 was not significantly different from that of Chinese but significantly lower than that of Japanese, non-Hispanic whites, non-Hispanic blacks and Mexican Americans. Risk of osteoporosis was significantly associated with the presence of past fracture history (OR, 1.45; 95% CI, 1.08-1.94), smoking> or =1 pack/day (OR, 1.63; 95% CI, 1.01-2.62), menarche after age of 16 (OR, 1.46; 95% CI, 1.14-1.87), last delivery after age of 30 (OR, 1.58; 95% CI, 1.20-2.09), more than three offspring (OR, 1.42; 95% CI, 1.07-1.89), post-menopause status (OR, 7.32; 95% CI, 3.05-17.6), more than 17 years since menopause (OR, 1.53; 95% CI, 1.10-2.14), regular exercise of two to three times per week (OR, 0.40; 95% CI, 0.18-0.89), monthly income above 500,000 won per household (OR, 0.64; 95% CI, 0.45-0.92), college graduate (OR, 0.29; 95% CI, 0.13-0.63) and calcium intake> or =627.5 mg/day (OR, 0.65; 95% CI, 0.43-0.98) after adjusting for age and BMI.

CONCLUSION

The BMD and osteoporosis prevalence of Koreans are presented. Risk of osteoporosis was significantly associated with fracture history, smoking, reproductive history, regular exercise, income level, education background and calcium intake.

Risk factors of osteoporosis in healthy Moroccan men

Background

Although not as common as in women, osteoporosis remains a significant health care problem in men. Data concerning risk factors of osteoporosis are lacking for the male Moroccan population. The objective of the study was to identify some determinants associated to low bone mineral density in Moroccan men.

Methods

a sample of 592 healthy men aged 20-79 years was recruited from the area of Rabat, the capital of Morocco. Measurements were taken at the lumbar spine and proximal femurs using DXA (Lunar Prodigy Vision, GE). Biometrical, clinical, and lifestyle determinants were collected. Univariate, multivariate, and logistic regression analyses were performed.

Results

the mean (SD) age of the patients was 49 (17.2) years old. The prevalence of osteoporosis and osteopenia were 8.7% and 52.8%, respectively. Lumbar spine and hip BMD correlated significantly with age, weight and BMI. When comparing the subjects according to the WHO classification, significant differences were revealed between the three groups of subjects for age, weight and BMI, prevalence of low calcium intake and low physical activity. The multiple regression analysis found that only age, BMI, and high coffee consumption were independently associated to the osteoporotic status.

Conclusion

ageing and low BMI are the main risk factors associated with osteoporosis in Moroccan men.

Selecting men for bone densitometry: performance of osteoporosis risk assessment tools in Portuguese men

SUMMARY

Clinicians need tools to identify patients most likely to benefit from bone mineral density (BMD) testing, for which cost-effectiveness does not allow generalized screening. This study supports the utility of osteoporosis risk assessment tools in selecting men for BMD testing. Different cutoff values may be appropriate for different countries and/or ethnic origins.

INTRODUCTION

Our aim was to evaluate the utility of three osteoporosis (OP) risk assessment tools in a large group of Portuguese men aged 50 or more and to determine the best cutoff value to be used for selecting men for bone densitometry.

METHODS

We assessed the performance of three simple tools in 202 randomly selected men: body weight criterion (BWC), osteoporosis self-assessment tool for Asians (OSTA), and a modified version of the OSTA equation (OST). Previously published cutoff values (validated in postmenopausal women) and three additional cutoff values were tested. Sensitivity (SE), specificity (SP), predictive values, and area under the receiver operating characteristic (AUROC) curve for correctly selecting men with OP (defined by BMD testing) were determined.

RESULTS

Mean age of the cohort was 63.8 years. According to the World Health Organization diagnostic categories, 16.8% had osteoporosis. The best performing cutoffs for correctly selecting men with OP for BMD testing were OST < 3 (SE = 75.5%, SP = 50.0%, AUROC = 0.632), OSTA < 3 (SE = 73.5%, SP = 58.3%, AUROC = 0.659), and BWC < 75 kg (SE = 73.5%, SP = 61.3%, AUROC = 0.674).

CONCLUSIONS

OP risk assessment tools seem to be useful in men aged 50 or more. Best cutoff values are different from those recommended for postmenopausal women. Different cutoff values may be appropriate for different countries and/or ethnic origins.

Risk factors for low BMD in healthy men age 50 years or older: a systematic review

SUMMARY

In this systematic review, we summarize risk factors for low bone mineral density and bone loss in healthy men age 50 years or older. Consistent risk factors were: age, smoking, low weight, physical/functional limitations, and previous fracture. Data specific to men has clinical and policy implications.

INTRODUCTION

Osteoporosis is a significant health care problem in men as well as women, yet the majority of evidence on diagnosis and management of osteoporosis is focused on postmenopausal women. The objective of this systematic review is to examine risk factors for low bone mineral density (BMD) and bone loss in healthy men age 50 years or older.

MATERIALS AND METHODS

A systematic search for observational studies was conducted in MEDLINE, Cochrane Database of Systematic Reviews, DARE, CENTRAL, CINAHL and Embase, Health STAR. The three main search concepts were bone density, densitometry, and risk factors. Trained reviewers assessed articles using a priori criteria.

RESULTS

Of 642 screened abstracts, 299 articles required a full review, and 25 remained in the final assessment. Consistent risk factors for low BMD/bone loss were: advancing age, smoking, and low weight/weight loss. Although less evidence was available, physical/functional limitations and prevalent fracture (after age 50) were also associated with low BMD/bone loss. The evidence was inconsistent or weak for physical activity, alcohol consumption, calcium intake, muscle strength, family history of fracture/osteoporosis, and height/height loss.

CONCLUSION

In this systematic review, we identified several risk factors for low BMD/bone loss in men that are measurable in primary practice.

Bioimpedance: can its addition to simple clinical criteria enhance the diagnosis of osteoporosis?

There is a great need for a simple means to identify individuals at risk of osteoporosis. Because bioimpedance (BI) estimates body composition, which is highly related to bone mineral density (BMD), we aimed to define the usefulness of BI to assess BMD. The relationships between BI and BMD were quantified using partial correlations. Multiple linear regression with a forward selection method was used to examine the predictive abilities of various body measurements on BMD at lumbar spine, femoral neck, and total hip. The abilities of BI to discriminate low BMD or to discriminate osteoporosis were evaluated using receiver operating characteristic (ROC) curve analysis. The relationships between BI and BMD at the spine and hip were evaluated in 345 Southern Chinese postmenopausal women and 390 men. After adjusting for age and weight, BI was inversely associated with BMD in both sexes (r = -0.053 to -0.195). Multiple linear regression analysis revealed that BI is a significant independent predictor of BMD in men. This finding was not confirmed in women. The area under the ROC curves (AUC) for BI as a single predictor to diagnose osteoporosis was 0.658 and 0.655 in women and men, respectively. The AUC was improved slightly with the addition of BI in the model that consisted of age and weight alone. Although BI was significantly associated with BMD, addition of BI did not enhance the ability to diagnose osteoporosis significantly compared with simple clinical criteria such as age and weight.

An assessment of the use of quantitative ultrasound and the Osteoporosis Self-Assessment Tool for Asians in determining the risk of nonvertebral fracture in postmenopausal Chinese women

This cross-sectional study aims to assess the effectiveness of a simple, noninvasive scoring system, the Osteoporosis Self-Assessment Tool for Asians (OSTA), and quantitative bone ultrasound (QUS) in assessing nonvertebral fracture risk in Chinese postmenopausal women. A group of 513 community-dwelling women including 271 postmenopausal individuals participated in this study. Speed of sound (SOS m/s) at the radius, phalanx, and tibia were assessed by using the Omnisense prototype (Sunlight Ltd., Israel). Body height and weight were measured, and body mass index (BMI) and OSTA indices were calculated. Self-reported fractures were identified using a structured questionnaire. Phalanx SOS was significantly lower among postmenopausal women with a history of nonvertebral fracture occurred after menopause than those without (3755 m/s vs. 3841 m/s, P = 0.017, adjusted for age and weight), with an AUC of 0.66. The AUC of the OSTA for predicting nonvertebral fracture occurred after menopause was 0.64. SOS at the radius, phalanx, and tibia showed a positive correlation with OSTA index (r = 0.376-0.401, P < 0.001). The prevalence of nonvertebral fractures also increased significantly with the decreasing order of OSTA index (chi2 = 5.432, P = 0.02). The OSTA values of <or=-1 and phalanx QUS T-score of <or=-1.95 can differentiate postmenopausal nonvertebral fracture with sensitivity of 75% and 81%, respectively, and specificity of 48% and 40%, respectively. Combining OSTA and phalanx QUS yielded a sensitivity of 83% and a specificity of 84% to detect postmenopausal nonvertebral fracture, with an AUC of 0.64. We conclude that OSTA and phalanx QUS are simple and effective clinical tools for identifying postmenopausal women at increased risk of nonvertebral fractures and can thereby facilitate the appropriate and more cost-effective use of bone densitometry to prevent osteoporotic fractures in developing countries.

IGF-1 as an early marker for low bone mass or osteoporosis in premenopausal and postmenopausal women

To find out which of the following parameters-serum levels of insulin-like growth factor 1 (IGF-1), osteoprotegerin (OPG), leptin, osteocalcin (OC), and urinary excretion of N-terminal telopeptide of type I collagen (NTx), can be used as an early marker for osteopenia/osteoporosis in women diagnosed by dual-energy X-ray absorptiometry (DXA), 282 premenopausal and 222 postmenopausal women aged 20-75 years were investigated by the measurement of bone mineral densities (BMDs) at lumbar spine (LS) and femoral neck (FN) by DXA, together with serum concentrations of IGF-1, OPG, leptin, OC, and urinary NTx. The characteristics of the earliest marker(s) were tested with the receiver operating characteristic (ROC) analysis. The area under the curve (AUC), sensitivity, and specificity parameters were determined. It was revealed that serum levels of IGF-1 and leptin changed the earliest, with both markers significantly decreasing (P < 0.0001) or increasing (P = 0.020), respectively, at age 30. However, in ROC analysis, IGF-1 was the only early parameter that had the capacity to differentiate the low bone mass/osteoporosis women from the normal ones (P < 0.0001). If the serum level of IGF-1 at 1.5 SD below its peak was adopted as a cutoff point, it could identify women with low bone mass/osteoporosis with a sensitivity of 73% and specificity of 67%. In the premenopausal women subgroup analysis, the low bone mass women (30/282, 10.6%) were older (38.2 +/- 1.7 vs. 34.5 +/- 0.5 years; P = 0.026), with lower serum levels of IGF-1 (215.1 +/- 22.4 vs. 278.8 +/- 9.4 ng/ml; P = 0.02) and less lean mass (33.1 +/- 0.6 vs. 34.8 +/- 0.2 kg; P = 0.010) than the normal ones. After controlling for age, the serum level of IGF-1 had a weak, but still significant, positive correlation with lean mass (r = 0.17, P < 0.001). In conclusion, measurement of serum IGF-1 in young women may help in the early identification of those at risk for developing low bone mass and osteoporosis.

Reference data for quantitative ultrasound values of calcaneus in 2927 healthy Chinese men

Quantitative ultrasound (QUS) is a bone densitometry technique that is rapidly gaining popularity for the assessment of bone status. However, few QUS data are available for men, especially in China. In the present study, a random stratified sample of 2927 Chinese men (10-90 years) was recruited, and bone status was established using measurements by Achilles ultrasonometer. The peak stiffness index (SI) value for Chinese men was 103.0 +/- 20.8, which presented in the age group of 20-24 years. Pearson correlation analysis showed that there was significant correlation between SI and age (P < 0.001), and multivariate regression analysis indicated that weight was also an important factor for SI. In addition, in comparison with the normal data of Italian and Japanese males, the SI value for Chinese males in each age group was lower than those of Italians but higher than Japanese, except for the 20-29 years age group. The descending velocity of curves for Chinese men was lower than that of Italian and Japanese men. In conclusion, QUS values of the calcaneus provided by the present study may be used as normal reference values for Chinese men.

Development and internal validation of the male osteoporosis risk estimation score

PURPOSE

We wanted to develop and validate a clinical prediction rule to identify men at risk for osteoporosis and subsequent hip fracture who might benefit from dual-energy x-ray absorptiometry (DXA).

METHODS

We used risk factor data from the National Health and Nutrition Examination Survey III to develop a best fitting multivariable logistic regression model in men aged 50 years and older randomized to either the development (n = 1,497) or validation (n = 1,498) cohorts. The best fitting model was transformed into a simplified scoring algorithm, the Male Osteoporosis Risk Estimation Score (MORES). We validated the MORES, comparing sensitivity, specificity, and area under the receiver operating characteristics (ROC) curve in the 2 cohorts and assessed clinical utility with an analysis of the number needed-to-screen (NNS) to prevent 1 additional hip fracture.

RESULTS

The MORES included 3 variables-age, weight, and history of chronic obstructive pulmonary disease-and showed excellent predictive validity in the validation cohort. A score of 6 or greater yielded an overall sensitivity of 0.93 (95% CI, 0.85-0.97), a specificity of 0.59 (95% CI, 0.56-0.62), and an area under the ROC curve of 0.832 (95% CI, 0.807-0.858). The overall NNS to prevent 1 additional hip fracture was 279 in a cohort of men representative of the US population.

CONCLUSIONS

Osteoporosis is a major predictor of hip fractures. Experts believe bisphosphonate treatment in men should yield results similar to that in women and reduce hip fracture rates associated with osteoporosis. In men aged 60 years and older, the MORES is a simple approach to identify men at risk for osteoporosis and refer them for confirmatory DXA scans.

Performance of the osteoporosis risk assessment tool in Moroccan men

Measuring bone mineral density (BMD) is a widely accepted strategy for identifying subjects with an increased risk of fracture. However, because of limited availability of BMD technology in some communities and cost considerations, it has been proposed that BMD measurements be targeted to subjects with risk factors for osteoporosis. Osteoporosis self-assessment tool (OST) using age and weight have been developed to identify women who are more likely to have low BMD and thus undergo BMD testing. To study the performance of OST in identifying osteoporotic white men in Morocco. We analysed in an epidemiological cross-sectional study the records for 229 white Moroccan men seen at an out-patient rheumatology centre. OST was compared to bone density T scores and the ability of OST to identify men with osteoporosis (T < -2.5) was evaluated. Using an OST score < 2 to recommend dual X-ray absorptiometry (DXA) referral, sensitivity ranged from 63% at the lumbar spine to 87% at the total hip to detect BMD T scores of -2.5 and specificity from 58 to 59%. The negative predictive value was high at all skeletal sites (87-98%), demonstrating the usefulness of the OST to identify patients who have normal BMD and should not receive DXA testing. The performance of OST among men in Morocco was similar to that reported earlier for the other samples in Asian countries and the USA. The OST is an effective and efficient tool to help target high-risk men for DXA measurement.

Prevalence and Impact of Vitamin D Insufficiency in Southern Chinese Adults

INTRODUCTION

Vitamin D is a vital element for bone health but the problem of vitamin D deficiency is underestimated in Hong Kong.

METHODS

Serum 25(OH)D and parathyroid hormone (PTH) levels were evaluated in 382 community dwelling Chinese adults >50 years for their relation with bone mineral density (BMD) and risks of osteoporotic fractures and falls.

RESULTS

The mean age of the subjects was 69 +/- 9 years. The mean 25(OH)D level was 28.3 +/- 10.8 ng/ml with 62.8% of the subjects having levels <30 ng/ml. 6.3% of the subjects had elevated PTH levels. A curvilinear relation between serum PTH and 25(OH)D was found, with PTH starting to increase when 25(OH)D level fell below 30 ng/ml (r = -0.233, p < 0.05). Although subjects with vitamin D <30 ng/ml had significantly lower BMD, only sex, age and PTH but not 25(OH)D were predictors of BMD at the spine and hip. Subjects with elevated PTH levels had a 2.92-fold increased risk of falls and 2.94-fold increased risk of fractures at the hip and spine.

CONCLUSIONS

Vitamin D insufficiency and its complication of secondary hyperparathyroidism is common even in subtropical region and is an important risk factor for low bone mass, falls and fractures.

T-1213C polymorphism of estrogen receptor beta is associated with low bone mineral density and osteoporotic fractures

Osteoporosis is a complex disease with a strong genetic component, but the genes involved are poorly defined. To determine whether estrogen receptor beta (ESR2) gene is an osteoporosis risk gene, we examined its association with bone mineral density (BMD) and fracture risk. Using a gene-based approach, a set of 12 polymorphisms of ESR2 was studied in 752 case-control pairs of southern Chinese in ethnicity. Among all polymorphisms, the most significant relation with BMD and fracture risk was observed with T-1213C. Subjects with low BMD had a higher frequency of the variant C allele of T-1213C (cases 11.4%, control 8.4%, P = 0.02). The C allele was associated with 4% reduction in BMD at both the spine and hip in women, and 11% reduction in spine BMD and 9% reduction in hip BMD in men. Similar results were seen with SNP haplotype analysis. Subjects with the C allele of T-1213C were associated with higher risks of osteoporosis and BMD T scores < or = -2.5 (odds ratios: 2.2 at spine and 3.5 at femoral neck for women; 3.5 at lumbar spine for men). Postmenopausal women carrying this C allele were associated with 2.22-fold increased risk of osteoporotic fractures (95% confidence interval 1.26-4.25) even after adjusting for BMD. In conclusion, ESR2 is involved in BMD determination in both sexes. The T-1213C polymorphism influences the risk of fracture in postmenopausal women independent of BMD.

Utility of screening tools for the prediction of low bone mass in African American men

INTRODUCTION

Osteoporosis remains under-diagnosed, particularly in African American men, despite the availability of reliable diagnostic tests. In women, several screening tools, including heel ultrasound and clinical assessment tools, reliably predict low bone mass, however the usefulness of these screening tools in African American men is unknown. The aim of this study was to determine the utility of screening tools, namely heel ultrasound, the osteoporosis self-assessment tool (OST), weight-based criterion (WBC) and body mass index (BMI), in screening for low bone mass in African American men.

MATERIALS AND METHODS

African American men 35 years of age and older were invited to participate. The OST risk index is a score based on age and weight [(weight in kilograms--age in years)x0.2]. Bone mineral density (BMD) of the heel was measured by heel ultrasound, and BMD of both the lumbar spine and hip were determined by dual energy X-ray absorptometry (DXA). One hundred and twenty-eight men fulfilled the inclusion criteria for our study.

RESULTS

The population prevalence of osteopenia and osteoporosis were 39% and 7%, respectively. Using a heel ultrasound T-score cut-off value of -1 or less, we predicted low bone mass (T-score of -2 or less at the hip) with a sensitivity of 83%, a specificity of 71% and an area under the curve (AUC) of 0.80. Using an OST cut-off value of 4, we predicted low bone mass with a sensitivity of 83%, a specificity of 57% and an AUC of 0.83. The OST risk index ranged from 18.1 to -6.1, based on which we categorized risk as: low, 5 or greater; moderate, 0-4; high, -1 or less. Of the men with a high-risk OST score, 87% had either osteopenia or osteoporosis based on World Health Organization (WHO) criteria. Using the WBC alone with a cut-off value of 85 kg, we predicted low bone mass with a sensitivity of 74%, a specificity of 50% and an AUC of 0.70. A BMI cut-off value of 30 or greater yielded a sensitivity of 83%, a specificity of 43% and an AUC of 0.70 for the diagnosis of low bone mass.

DISCUSSION

The prevalence of osteopenia and osteoporosis were unexpectedly high in outpatient African American male veterans, who are considered to be at low risk for low bone mass. Heel ultrasound was able to predict low bone mass with sufficiently high sensitivity and specificity for use as a screening tool. Surprisingly, WBC and BMI proved ineffective in predicting low bone mass with adequate sensitivity and specificity. The OST, a clinical formula based on weight and age, appeared to be an easy and reliable screening tool for identifying men at high risk for low bone mass.

Assessment of linkage and association of 13 genetic loci with bone mineral density

Bone mineral density (BMD), an important risk factor for osteoporosis, is a complex trait likely affected by multiple genes. The linkage and/or association of 13 polymorphic loci of seven candidate genes (estrogen receptor alpha [ERalpha] and beta [ERbeta], calcium-sensing receptor, vitamin D receptor, collagen type 1alpha1, low-density lipoprotein [LDL] receptor-related protein 5 [LRPS], and transforming growth factor beta1) were evaluated in 177 southern Chinese pedigrees of 674 subjects, with each pedigree identified through a proband having a BMD Z score of -1.28 or less at the hip or spine. A suggestive linkage was detected between the IVS1-351A/G polymorphism of ERalpha and spine BMD, and between the 1082G/A, 1730G/A, and D14S1026 polymorphisms of ERbeta and BMD at both spine and hip. The quantitative transmission disequilibrium test (QTDT) detected total family association between 1730G/A of ERbeta and BMD at spine and hip; between D14S1026 of ERbeta and hip BMD; and between the 266A/G and 2220C/T polymorphisms of LRP5 and hip BMD. Similar total family associations were detected when only the females were analyzed. In addition, the IVS1-397T/C polymorphism of ERalpha was associated with spine BMD, and the 266A/G and 2220C/T polymorphisms of LRP5 were associated with femoral neck BMD in the females. A within-family association was detected with the IVS1-397T/C polymorphism of ERalpha, and the 266A/G and 2220C/T polymorphisms of LRP5 in the females. The effect of each polymorphism on BMD variance ranged from 1% to 4%. In conclusion, ERalpha, ERbeta and LRP5 are important candidate genes determining BMD variation, especially in females.