Low peak bone mineral density in healthy Lebanese subjects

Estimation of T scores with Hologic using NatIve vs. Caucasian data in IndiAns (ETHNICA): a single center retrospective study

BACKGROUND

The Dual-energy X-ray absorptiometry (DXA) scan is considered the current gold standard for the estimation of bone mineral density (BMD). Normative BMD data for the generation of T scores is based on data pertaining to young Caucasian white women from the NHANES-III study. However, there have been reports of significant ethnic variations in the normal BMD values, which could under/over-diagnose osteoporosis. The Indian Council of Medical Research (ICMR) has given the normative BMD data for Indians. Our study compares machine-generated T-scores (Tstd) based on Caucasian BMD reference data with calculated T-scores based on ICMR reference data (TICMR).

METHODS

ETHNICA was a retrospective study involving 1144 individuals who underwent DXA study (Hologic®) at our centre. 835 females and 309 males aged between 18 and 95 were included. A total of 3420 BMD values at bilateral hips and L1-L4 levels of spine were analysed. The age distribution differed from that of the NHANES-III and ICMR reference dataset, which primarily includes younger individuals (20-29 years) as it was done to standardize T score. Gender-specific ICMR BMD and standard deviation (SD) for each site were used to calculate TICMR. This was compared with Hologic-generated Tstd, and the differences were analysed.

RESULTS

The prevalence of osteoporosis was significantly lower using ICMR data compared to NHANES-III data, with a greater reduction seen in males (16.8 to 7.1%) than in females (26.6 to 18%). Similarly, a larger increase in individuals classified with normal BMD was seen in males (59.5 to 76.1%) compared to females (41.2 to 59.6%).

CONCLUSION

We conclude that if we use NHANES-III BMD reference data, there is a significant overdiagnosis of osteoporosis and osteopenia in India. We recommend the adoption of representative regional reference standards for the diagnosis.

Ethnic determinants of skeletal health in female patients with fragility fracture in a culturally diverse population

Background

Low bone density leads to fragility fracture, with significant impact on morbidity and mortality. While ethnic differences in bone density have been observed in healthy subjects, this has not yet been explored in fragility fracture patients.

Aims

To assess if ethnicity is associated with bone mineral density and serum markers of bone health in female patients who experience fragility fractures.

Methods

219 female patients presenting with at least one fragility fracture at a major tertiary hospital in Western Sydney Australia were studied. Western Sydney is a region with great cultural diversity, comprising people from over 170 ethnicities. Within this cohort, the three largest broad ethnic groups were Caucasians (62.1 %), Asians (22.8 %), and Middle Eastern patients (15.1 %). Location and nature of the presenting fracture and other relevant past medical history were obtained. Bone mineral density, measured by dual-energy X-ray absorptiometry, and bone-related serum markers were compared between ethnicities. Covariates (age, height, weight, diabetes, smoking, and at-risk drinking) were adjusted in multiple linear regression model.

Results

Although Asian ethnicity was associated with lower bone mineral density at the lumbar spine in fragility fracture patients, this association was no longer significant after adjustment for weight. Ethnicity (Asian or Middle Eastern) was not a determinant of bone mineral density at any other skeletal site. Caucasians had lower estimated glomerular filtration rate compared to Asian and Middle Eastern subjects. Serum parathyroid hormone concentrations were significantly lower in Asians compared to other ethnicities.

Conclusion

Asian ethnicity and Middle Eastern ethnicity were not major determinants of bone mineral density at the lumbar spine, femoral neck, or total hip.

Bone mass in Saudi women aged 20-40 years: the association with obesity and vitamin D deficiency

This study describes that low bone density is prevalent in premenopausal Saudi women, especially women of normal weight and vitamin D deficiency. Although BMD is higher in obese young women, this may not be beneficial later in life in conjunction with persistent vitamin D deficiency.

INTRODUCTION

Not attaining peak bone mass is one crucial factor contributing to the risk of developing osteoporosis and suffering fractures in later life. The objectives of this study were to describe the normal range of bone mineral density (BMD) and bone mineral content (BMC) in premenopausal Saudi women in relation to obesity and vitamin D insufficiency.

METHODS

A cross-sectional study involving 312 healthy Saudi women aged 20-40. All women were clinically examined. BMD (g/cm2) and BMC (g) assessed at total body (TB), femoral neck (FN) and lumbar spine (LS) were performed using dual-energy X-ray absorptiometry (DXA). Obesity was defined as BMI ≥ 30 kg/m2 and vitamin D deficiency defined as 25(OH)D < 50 nmol/L.

RESULTS

Almost half of the studied women were obese, and the majority (86.2%) were deficient in vitamin D. Mean BMD in TB 1.060 ± 0.091, FN 0.918 ± 0.153 and LS 1.118 ± 0.123 g/cm2, while TB-BMC 2077 ± 272 g. When classified by BMI, the proportion with low bone density was 2-3 times higher among the normal weight compared to the obese women, p < 0.001. In the cohort overall, ~ 19% of these young premenopausal women had osteopenia or osteoporosis at the femoral neck, but 26% in normal weight, vitamin D deficient women.

CONCLUSION

This study shows low bone density in premenopausal Saudi women, particularly those with normal weight. While obesity appears to confer some protection against vitamin D deficiency at this age, this is assumed to change in later life.

Disease burden of osteoporosis and other non-communicable diseases in Lebanon

Osteoporosis is more common than most feared non-communicable diseases in the Middle East. This justifies the need to place osteoporosis as a health priority in the region.

INTRODUCTION

Osteoporosis is a common disease associated with severe debilitating consequences. The objective of this study is To evaluate and compare disease burden from osteoporosis and other non-communicable diseases (NCDs) in Lebanon.

METHODS

We assessed the prevalence of osteoporosis and other NCDs, such as obesity, diabetes, hypertension, dyslipidemia, and cardiovascular diseases, based on a published population-based study of Lebanese ≥ 65 years. We compared incidence rates of hip fractures and major osteoporotic fractures (MOF) (spine, hip, humerus, and forearm) to the five commonest cancers in women ≥ 50 years. Rates were based on the national hip fracture and cancer registry data, provided by the Lebanese Ministry of Public Health. MOF incidence rates were derived from national hip fracture incidence rates and MOF/hip fractures incidence rate ratios from the literature.

RESULTS

Over 70% of elderly Lebanese had osteoporosis defined by densitometric criteria or prevalent morphometric vertebral fractures. This by far exceeded the prevalence of other NCDs, such as hypertension (53%), diabetes (21%), dyslipidemia (31%), and cardiovascular diseases (30%). Morphometric vertebral fractures (grades 2 and 3) were present in 19% of women and 12% of men. The incidence rates for MOF were 1.6 times greater than those for breast cancer, and 7.4-9.9 folds higher than those for the next commonest cancers of the lungs, colon, and ovaries. Hip fracture incidence rates were lower than those of breast cancer but were 2.1-2.8 folds higher than those of the above-mentioned cancers.

CONCLUSION

This first of its kind study in the Middle East demonstrates that osteoporosis is a common disease, more common than most feared NCDs. Our findings are comparable to those in western populations and justify placing osteoporosis on the top of NCDs' priority list in our country and possibly the region.

Worldwide Fracture Prediction

The substantial increase in the burden of non-communicable diseases in general and osteoporosis in particular, necessitates the establishment of efficient and targeted diagnosis and treatment strategies. This chapter reviews and compares different tools for osteoporosis screening and diagnosis; it also provides an overview of different treatment guidelines adopted by countries worldwide. While access to dual-energy X-ray absorptiometry to measure bone mineral density (BMD) is limited in most areas in the world, the introduction of risk calculators that combine risk factors, with or without BMD, have resulted in a paradigm shift in osteoporosis screening and management. To-date, forty eight risk assessment tools that allow risk stratification of patients are available, however only few are externally validated and tested in a population-based setting. These include Osteoporosis Self-Assessment Tool; Osteoporosis Risk Assessment Instrument; Simple Calculated Osteoporosis Risk Estimation; Canadian Association of Radiologists and Osteoporosis Canada calculator; Fracture Risk Assessment Calculator (FRAX); Garvan; and QFracture. These tools vary in the number of risk factors incorporated. We present a detailed analysis of the development, characteristics, validation, performance, advantages and limitations of these tools. The World Health Organization proposes a dual-energy X-ray absorptiometry-BMD T-score ≤ -2.5 as an operational diagnostic threshold for osteoporosis, and many countries have also adopted this cut-off as an intervention threshold in their treatment guidelines. With the introduction of the new fracture assessment calculators, many countries chose to include fracture risk as one of the major criteria to initiate osteoporosis treatment. Of the 52 national guidelines identified in 36 countries, 30 included FRAX derived risk in their intervention threshold and 22 were non-FRAX based.  No universal tool or guideline approach will address the needs of all countries worldwide.  Osteoporosis screening and management guidelines are best tailored according to the needs and resources of individual counties. While few countries have succeeded in generating valuable epidemiological data on osteoporotic fractures, to validate their risk calculators and base their guidelines, many have yet to find the resources to assess variations and secular trends in fractures, the performance of various calculators, and ultimately adopt the most convenient care pathway algorithms.

Vitamin D status and parathyroid hormone levels in relation to bone mineral density in apparently healthy Syrian adults

Vitamin D deficiency was highly prevalent in this study. More than half of the participants with vitamin D level less than 5 ng/mL had secondary hyperparathyroidism, which implicated a major bone health concern. After adjustment for potential predictors, parathyroid hormone (PTH) explained about 3 % of the variance in total hip bone mineral density (BMD).

PURPOSE

Bone mineral density (BMD) is known to be influenced by serum 25-hydroxyvitamin D (25OHD) and intact parathyroid hormone (PTH) levels. The relationship between 25OHD and PTH with BMD has not been well documented in Syrian adults. We aimed to determine how differences in serum 25OHD and PTH levels impacted hip and lumbar spine BMD among apparently healthy Syrian adults.

METHODS

25OHD and PTH were measured in 156 participants aged 18-53 years from Damascus and its surroundings. Lumbar spine and hip BMD measurements were measured by dual-energy X-ray absorptiometry using Hologic Discovery Wi densitometer. Multivariate regression models were used to investigate the relationships between 25OHD, PTH, and BMD.

RESULTS

All participants, except one male, had 25OHD <30 ng/mL (<75 nmol/L), and 89.1 % of them had 25OHD levels less than 20 ng/mL (50 nmol/L). Secondary hyperparathyroidism was significantly more prevalent in the lowest 25OHD quartile compared to that in the highest quartile (59 vs. 10.3 %, p < 0.0001). Mean bone mineral density at all sites in our participants was lower when compared to that of their Caucasian counterparts in Europe and North America. No significant correlation was found between 25OHD and BMD either at hip or at lumbar spine. In the multivariate analyses, after adjustment for potential predictors, PTH explained about 3 % of the variation in total hip BMD.

CONCLUSIONS

Low BMD was relatively frequent at all measured sites. PTH, but not 25OHD, was a predictor for total hip BMD in a young population.

Osteoporosis: A Silent Disease with Complex Genetic Contribution

Osteoporosis is the most common multifactorial metabolic bone disorder worldwide with a strong genetic component. In this review, the evidence for a genetic contribution to osteoporosis and related phenotypes is summarized alongside with methods used to identify osteoporosis susceptibility genes. The key biological pathways involved in the skeleton and bone development are discussed with a particular focus on master genes clustered in these pathways and their mode of action. Furthermore, the most studied single nucleotide polymorphisms (SNPs) analyzed for their importance as genetic markers of the disease are presented. New data generated by next-generation sequencing in conjunction with extensive meta-analyses should contribute to a better understanding of the genetic basis of osteoporosis and related phenotype variability. These data could be ultimately used for identifying at-risk patients for disease prevention by both controlling environmental factors and providing possible therapeutic targets.

Relationship between 25-hydroxyvitamin D concentrations, serum calcium, and parathyroid hormone in apparently healthy Syrian people

Vitamin D deficiency (25-hydroxyvitamin D (25OHD) <25 nmol/L) was common in a convenience sample of apparently healthy Syrian adults. Female gender, season, and concealing clothing were independent predictors of vitamin D deficiency. Community-based research is needed to identify vulnerable subgroups and inform public health actions.

PURPOSE

Optimal vitamin D status for bone health has been inferred from the determination of serum 25OHD levels below which there is an increase in serum parathyroid hormone (PTH). Studies worldwide showed high prevalence of hypovitaminosis D even in sunny countries. There is little evidence about its prevalence among Syrian adult population. We aimed to assess the serum levels of 25OHD and factors related to vitamin D inadequacy and its relation to serum PTH and calcium among apparently healthy adults.

METHODS

Serum 25OHD and PTH measurements were obtained from 372 subjects aged 18-62 years living in Damascus and its surroundings, between April 2011 and March 2013. Binary logistic regression was used to assess risk factors for hypovitaminosis D.

RESULTS

The mean (standard deviation (SD)) 25OHD level was 24.7 (16.9) nmol/L [9.8 (6.7) ng/mL] and was higher in men than women (p < 0.001). Levels <25, <50, and <75 nmol/L were detected in 61, 90.1, and 99.2 % of the participants, respectively. Season influenced vitamin D status in men but not in women (p < 0.001). Female gender and wearing the veil (hijab) were independent predictors of vitamin D deficiency (25OHD <25 nmol/L). PTH was significantly higher below this threshold (p < 0.001). Serum 25OHD <25 nmol/L, sex, and age ≥ 35 years were statistically significant factors for PTH elevation.

CONCLUSIONS

Vitamin D deficiency was highly prevalent in our sample. Further research is needed to identify population groups vulnerable for hypovitaminosis D and specify its predictors and inform the necessary public health measures.

Influence of heredity and environment on peak bone density: a review of studies in Croatia

One of the main determinants of who will develop osteoporosis is the amount of bone accumulated at peak bone density. There is poor agreement, however, on when peak bone density occurs. Ethnic differences were observed in age at peak bone density and their correlates. Since the diagnosis of osteoporosis and osteopaenia is based on the comparison between patients' bone mineral density (BMD) and optimal peak bone density in healthy young people (T-score), it is of great importance that each country should provide its own reference peak bone density data.This review article presents our published results on peak bone density in Croatia and compares them with findings in other populations. Our research included 18 to 25-year-old students from Zagreb University and their parents. The results showed that peak bone mass in young Croatian women was achieved before the age of twenty, but BMD continued to increase after the mid-twenties in the long-bone cortical skeleton. BMD was comparable to the values reported by the National Health and Nutrition Examination Survey (NHANES) and other studies that included the same age groups, except for the cortical part of the radius, where it was significantly lower. Men achieved peak bone density in the spine later than women, which cannot be explained by different diet or physical activity. As expected, heredity was more important for peak bone density than the environmental factors known to be important for bone health. However, the influence of heredity was not as strong as observed in most other populations. It was also weaker in the cortical than in the trabecular parts of the skeleton. Future research should include young adolescent population to define the exact age of achieving peak bone density in different skeletal sites.

Prevalence of low bone mass in postmenopausal Kuwaiti women residents in the largest province of Kuwait

We measured bone mineral density (BMD) in Kuwaiti women residents in the largest province of Kuwait state to highlight the BMD changes with each age, in particular when they reach the postmenopausal stage. Healthy Kuwaiti females between the ages of 10 and 89 years, who were residents in the largest province of Kuwait, were included in the study. After measurements of their height and weight, their bone mineral density of L2-L4 lumbar spine and femur (neck and total) was measured using dual-energy X-ray absorptiometry. Out of the studied 903 female subjects, 811 fulfilled the inclusion criteria. Their mean ± SEM age and body mass index (BMI) were respectively 47 ± 1 years and 30.8 ± 0.2 kg/m(2). Out of these 811 subjects, 454 were postmenopausal, and their age and BMI were 55.0 ± 0.3 years and 32.0 ± 0.3 kg/m(2), respectively. We have demonstrated that osteoporotic BMD of the spine and femur neck occurred in 20.2 and 12.5 % of postmenopausal Kuwaiti females, whereas osteopenic BMD of the spine and femur neck was observed at a frequency of 35.4 and 42.8 % of women, respectively. When the subjects were subdivided as per BMI, it was notable that overweight and obese had significantly higher BMD than normal weight postmenopausal women. BMD of the spine, femur neck, and femur total demonstrated significant positive correlations with body weight and BMI, whereas they demonstrated significant negative correlations with age. Low BMD of the femur neck and spine, reflected by the combination of osteopenia and osteoporosis, seemed to occur in more than half (55.3-55.6 %) of postmenopausal Kuwaiti women.

OBJECTIVES

Most of the studies on assessment of prevalence of low bone mass were focused in Caucasian population. Data on subjects of the Mediterranean area are limited. We measured bone mineral density (BMD) in Kuwaiti women residents in the largest province of Kuwait state to highlight the BMD changes with each age, in particular when they reach the postmenopausal stage.

SUBJECTS AND METHODS

Kuwaiti female subjects of different age groups between 10 and 89 years, who were residents in the largest province of Kuwait (Hawalli), were included in the study. They were included if they had been healthy over the last 12 months, had no past history of bone disease, and are not taking any prescription medication that may affect bone density. Their bone mineral density of L2-L4 lumbar spine and femur (neck and total) was measured using dual-energy X-ray absorptiometry.

RESULTS

Out of the studied 903 female subjects, 811 fulfilled the inclusion criteria and were included in the study. Their mean ± SEM age and body mass index (BMI) were respectively 47 ± 1 years and 30.8 ± 0.2 kg/m(2). Out of these 811 subjects, 454 were postmenopausal, and their age and BMI were 55.0 ± 0.3 years and 32.0 ± 0.3 kg/m(2), respectively. We have demonstrated that osteoporotic BMD of the spine and femur neck occurred in 20.2 and 12.5 % of postmenopausal Kuwaiti females, respectively, whereas osteopenic BMD of the spine and femur neck was observed at a frequency of 35.4 and 42.8 % of women. When subjects were subdivided as per BMI, it was notable that overweight and obese postmenopausal women had significantly higher BMD of lumbar spine, femur neck, and femur total than normal weight postmenopausal women. Bone mineral densities of the spine, femur neck, and femur total demonstrated significant positive correlations with body weight and BMI, whereas they demonstrated significant negative correlations with age.

CONCLUSION

Low BMD of the femur neck and spine, reflected by the combination of osteopenia and osteoporosis, seemed to occur in more than half (55.3-55.6 %) of postmenopausal Kuwaiti women residents at the largest province of Kuwait.

Peak bone mineral density and its determinants in an Asian Indian population

Data on peak bone mineral density (BMD) and its determinants in Asian Indians are limited. We studied the peak BMD and its determinants in Asian Indians. A total of 1137 young (age: 25--35yr) healthy volunteers of either sex (558 men and 579 women) were recruited for dietary evaluation, analyses of serum calcium, inorganic phosphorus, alkaline phosphatase, 25-hydroxyvitamin D [25(OH)D], and intact parathyroid hormone (iPTH) levels, and measurement of BMD with dual-energy X-ray absorptiometry. In men and women, peak bone mass (PBM) at the femoral neck, femoral trochanter, total femur, and lumbar spine was achieved between 25 and 30yr of age, whereas PBM at the femoral intertrochanter occurred between 30 and 35yr of age. Peak BMD was lower than that of Caucasians by 15.2--21.1% in men and 14.4--20.6% in women. On stepwise multiple regression, height and weight were the most consistent predictors of BMD at all sites in both groups. In men, 25(OH)D positively predicted BMD at the hip, whereas in women, serum iPTH negatively predicted BMD at the femoral trochanter and total femur. The study concluded that Asian Indians have significantly lower peak BMD than Caucasians and that weight and height are the most consistent predictors of BMD at all sites in both men and women.

Anthropometric predictors of geometric indices of hip bone strength in a group of Lebanese postmenopausal women

The effects of anthropometric characteristics on hip bone strength in postmenopausal women are not completely elucidated. The aim of this study was to investigate the influence of anthropometric characteristics on geometric indices of hip bone strength using the hip structure analysis (HSA) program in a group of Lebanese postmenopausal women. This study included 109 postmenopausal women (aged 64--84yr). Age and years since menopause were recorded. Body composition and bone mineral density were assessed by dual-energy X-ray absorptiometry (DXA). To evaluate hip bone strength, DXA scans were analyzed at the femoral neck (FN), the intertrochanteric (IT), and the femoral shaft (FS) by the HSA program. Cross-sectional area (CSA), an index of axial compression strength, section modulus (Z), an index of bending strength, and buckling ratio (BR), an estimate of cortical stability in buckling, were measured from bone mass profiles. Using univariate analysis, weight, height, body mass index (BMI), lean mass, and fat mass were positively correlated to CSA and Z of the FN, IT, and FS. Weight, BMI, fat mass, and fat mass percentage were negatively correlated to BR of the FN, IT, and FS. Multiple linear regression analysis showed that lean mass was a stronger determinant of FN CSA, FN Z, IT Z, and FS Z than fat mass, whereas fat mass was a stronger determinant of IT CSA, FS CSA, IT BR, and FS BR than lean mass. This study suggests that, in postmenopausal women, fat mass is a strong predictor of hip axial compression strength and cortical stability in buckling, and lean mass is a strong predictor of hip bending strength.

Prevalence and risk factors associated with nutrition-related noncommunicable diseases in the Eastern Mediterranean region

This paper reviews the current situation concerning nutrition-related noncommunicable diseases (N-NCDs) and the risk factors associated with these diseases in the Eastern Mediterranean region (EMR). A systematic literature review of studies and reports published between January 1, 1990 and September 15, 2011 was conducted using the PubMed and Google Scholar databases. Cardiovascular disease, type 2 diabetes, metabolic syndrome, obesity, cancer, and osteoporosis have become the main causes of morbidity and mortality, especially with progressive aging of the population. The estimated mortality rate due to cardiovascular disease and diabetes ranged from 179.8 to 765.2 per 100,000 population, with the highest rates in poor countries. The prevalence of metabolic syndrome was very high, ranging from 19% to 45%. The prevalence of overweight and obesity (body mass index ≥25 kg/m(2)) has reached an alarming level in most countries of the region, ranging from 25% to 82%, with a higher prevalence among women. The estimated mortality rate for cancer ranged from 61.9 to 151 per 100,000 population. Osteoporosis has become a critical problem, particularly among women. Several risk factors may be contributing to the high prevalence of N-NCDs in EMR, including nutrition transition, low intake of fruit and vegetables, demographic transition, urbanization, physical inactivity, hypertension, tobacco smoking, stunting of growth of preschool children, and lack of nutrition and health awareness. Intervention programs to prevent and control N-NCDs are urgently needed, with special focus on promotion of healthy eating and physical activity.

Osteoporotic fractures, DXA, and fracture risk assessment: meeting future challenges in the Eastern Mediterranean Region

The purpose was to report on the burden of osteoporotic fractures in the Eastern Mediterranean Region (EMR) and the use of bone mineral density (BMD) dual-energy X-ray absorptiometry (DXA) databases for osteoporosis diagnosis. PubMed electronic database was reviewed using the following MeSH terms: "Hip fractures," "Fractures, Compression," "Radius Fractures," "Osteoporosis," "Bone density," and "Middle East" up to July 2009. Incidence of hip fractures varied across the EMR between 100 and 295 per 100,000 person-years in women and 71 and 200 per 100,000 person-years in men. No data were found on other nonvertebral osteoporotic fractures. Prevalence of radiographic vertebral fractures older than 65 yr ranged between 15% and 25% in women and 7.3% and 18% in men. By 2020, the number of hip fractures older than 50 yr would increase by 20%. DXA manufacturer's reference curves for the spine were higher than population-specific ones. At the hip, National Health and Nutrition Examination Survey (NHANES) and population-based curves were comparable. Estimates of the relative risk of vertebral fracture per SD decrease in BMD using NHANES and local data set were similar, that is, 1.61 (1.17-2.23) and 1.49 (1.14-1.95), respectively. The EMR is similar to southern Europe regarding incidence rates of hip fracture, suggesting the health burden to be significant. Using DXA at the hip, population-specific reference databases did not perform better than NHANES on which the FRAX model has been developed highlighting the need for reviewing fracture risk assessment strategies in the EMR.

The paradox of nutrition-related diseases in the Arab countries: the need for action

The aim of this review was to highlight the current situation of nutrition-related diseases in the Arab countries, and factors associated with prevalence of these diseases. PubMed and Google Scholar were searched for data relating to such nutrition-related diseases published between January 1990 and May 2011. The picture of nutritional status in the Arab countries has changed drastically over the past 30 years as a result of changes in the social and economic situation. Two contrasting nutrition-related diseases exist, those associated with inadequate intake of nutrients and unhealthy dietary habits such as growth retardation among young children and micronutrient deficiencies; and those associated with changes in lifestyle such as cardiovascular disease, cancer, osteoporosis, diabetes and obesity (diet-related non-communicable diseases). Factors contributing to nutritional problems vary from country to country, depending on socio-economic status. In general, unsound dietary habits, poor sanitation, poverty, ignorance and lack of access to safe water and health services are mainly responsible for under-nutrition. Changes in lifestyle and dietary habits as well as inactivity are associated with the occurrence of diet-related non-communicable diseases. Programs to prevent and control nutrition-related diseases are insufficient and ineffective, due mainly to a focus on curative care at the expense of preventive health care services, lack of epidemiological studies, lack of nutritional surveillance, inadequate nutrition information and lack of assessment of the cost-effectiveness of nutrition intervention programs.

Relative importance of lean mass and fat mass on bone mineral density in a group of Lebanese postmenopausal women

The aim of this study was to determine the relative importance of lean mass and fat mass on bone mineral density (BMD) in a group of Lebanese postmenopausal women. One hundred ten Lebanese postmenopausal women (aged 65-84 yr) participated in this study. Age and years since menopause were recorded. Body weight and height were measured and body mass index (BMI) was calculated. Body composition (lean mass, fat mass, and fat mass percentage) was assessed by dual-energy X-ray absorptiometry (DXA). Bone mineral content (BMC) of the whole body (WB) and BMD of the WB, the lumbar spine (L1-L4), the total hip (TH), the femoral neck (FN), the ultra distal (UD) Radius, and the 1/3 Radius were measured by DXA. The expressions WB BMC/height and WB BMD/height were also used. Weight, BMI, fat mass, and lean mass were positively correlated to WB BMC, WB BMC/height, WB BMD/height, and to WB, L1-L4, TH, FN, UD Radius, and 1/3 Radius BMD. However, using multiple linear regression analyses, fat mass was more strongly correlated to BMC and to BMD values than lean mass after controlling for years since menopause. This study suggests that fat mass is a stronger determinant of BMC and BMD than lean mass in Lebanese postmenopausal women.

Normative data and percentile curves for Dual Energy X-ray Absorptiometry in healthy Indian girls and boys aged 5-17 years

For the correct interpretation of Dual Energy X-ray Absorptiometry (DXA) measurements in children, the use of age, gender, height, weight and ethnicity specific reference data is crucially important. In the absence of such a database for Indian children, the present study aimed to provide gender and age specific data on bone parameters and reference percentile curves for the assessment of bone status in 5-17 year old Indian boys and girls. A cross sectional study was conducted from May 2006 to July 2010 on 920 (480 boys) apparently healthy children from schools and colleges in Pune City, India. The GE-Lunar DPX Pro Pencil Beam DXA scanner was used to measure bone mineral content (BMC [g]), bone area (BA [cm(2)]) and bone mineral density (BMD [g/cm(2)]) at total body, lumbar spine and left femur. Reference percentile curves by age were derived separately for boys and girls for the total body BMC (TBBMC), total body BA (TBBA), lumbar spine bone mineral apparent density (BMAD [g/cm(3)]), and left femoral neck BMAD. We have also presented percentile curves for TBBA for height, TBBMC for TBBA, LBM for height and TBBMC for LBM for normalizing bone data for Indian children. Mean TBBMC, TBBA and TBBMD were expressed by age groups and Tanner stages for boys and girls separately. The average increase in TBBMC and TBBA with age was of the order of 8 to 12% at each age group. After 16 years of age, TBBMC and TBBA were significantly higher in boys than in girls (p<0.01). Maximal increase in TBBMD occurred around the age of 13 years in girls and three years later in boys. Reference data provided may be used for the clinical assessment of bone status of Indian children and adolescents.

Influence of the weight status on bone mineral content and bone mineral density in a group of Lebanese adolescent girls

AIM

The aim of this study was to determine the influence of being overweight on whole-body (WB) bone mineral content (BMC) and bone mineral density (BMD) in a group of Lebanese adolescent girls.

METHODS

This study included 32 overweight (BMI>25 kg/m2) adolescent girls (15.3+/-2.3 years old) and 24 maturation-matched (15.7+/-1.7 years old) controls (BMI<25 kg/m2). Bone mineral area (BMA), BMC, BMD at the WB and body composition (lean mass and fat mass) were assessed by dual-energy X-ray absorptiometry (DXA). Calculation of the ratio BMC/height and bone mineral apparent density (BMAD) were completed for the WB.

RESULTS

Expressed as crude values, BMA, BMC and the ratio BMC/height were higher in overweight adolescent girls compared to controls. After adjusting for body weight, there were no differences in BMC or in the ratio BMC/height between the two groups. However, BMA was lower in overweight girls compared to controls. After adjusting for either lean mass or fat mass, there were no significant differences between the two groups regarding these variables: BMC, BMA, BMD, BMC/height and BMAD.

CONCLUSION

This study suggests that the positive effect of overweight on BMC is due to body weight. In fact, the difference in BMC between the overweight and the control girls disappears after adjusting for body weight. In contrast, overweight girls have lower BMA compared to controls when values are adjusted to body weight.

Peak bone mineral density of physically active healthy Indian men with adequate nutrition and no known current constraints to bone mineralization

We undertook this study to characterize peak bone density and evaluate its determinants in a healthy cohort of young adult male paramilitary personnel. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry in 473 healthy men aged 21-40 yr. The effect of anthropometry and biochemical parameters on BMD was determined. Mean BMD values of L1-L4, forearm, total hip, and femoral neck were 1.170+/-0.137, 0.755+/-0.089, 1.129+/-0.130, and 1.115+/-0.133 g/cm(2), respectively. BMD values for 31- to 40-yr age group were lower than those of 20- to 30-yr age group except for forearm, which was higher in the former. Significant positive correlation was observed between height, weight, and body mass index with BMD. On multivariate regression analysis, weight was the most consistent contributor to variance in the BMD. Compared with age-matched US males, BMD of total hip and femoral neck were higher for Indian paramilitary personnel by 3.58% and 4.2%, whereas lumbar spine BMD was lower by 4.1%. In conclusion, peak BMD in healthy Indian males was achieved by 30 yr of age at lumbar spine and hip, with weight being the most consistent contributor to variance in BMD. Peak BMD in this population was comparable to that reported in white US males.

Risk estimates for hip fracture from clinical and densitometric variables and impact of database selection in Lebanese subjects

Bone mineral density (BMD) and fracture incidence vary greatly worldwide. The data, if any, on clinical and densitometric characteristics of patients with hip fractures from the Middle East are scarce. The objective of the study was to define risk estimates from clinical and densitometric variables and the impact of database selection on such estimates. Clinical and densitometric information were obtained in 60 hip fracture patients and 90 controls. Hip fracture subjects were 74 yr (9.4) old, were significantly taller, lighter, and more likely to be taking anxiolytics and sleeping pills than controls. National Health and Nutrition Examination Survey (NHANES) database selection resulted in a higher sensitivity and almost equal specificity in identifying patients with a hip fracture compared with the Lebanese database. The odds ratio (OR) and its confidence interval (CI) for hip fracture per standard deviation (SD) decrease in total hip BMD was 2.1 (1.45-3.05) with the NHANES database, and 2.11 (1.36-2.37) when adjusted for age and body mass index (BMI). Risk estimates were higher in male compared with female subjects. In Lebanese subjects, BMD- and BMI-derived hip fracture risk estimates are comparable to western standards. The study validates the universal use of the NHANES database, and the applicability of BMD- and BMI-derived risk fracture estimates in the World Health Organization (WHO) global fracture risk model, to the Lebanese.

Osteoporosis in developing countries

Osteoporosis poses a huge challenge in developing countries due to demographic transition and aging of the population coupled with limited availability of resources. The exact disease burden is difficult to quantify because of the paucity of data. Ethnicity affects bone density as well as fracture risk. Population-specific normative data for bone density are lacking in large parts of the world. Vitamin D deficiency is common even in sunny countries. The WHO has developed an algorithm for estimation of 10-year fracture risk which may be used even in the absence of bone mineral density.

Variation in lumbar spine bone mineral content by age and gender in apparently healthy Indians

The aim of this study was to assess variation in bone mass from childhood through later age and to examine bone health status of Indian males and females. Lumbar spine (LS) bone mineral content (BMC) was measured by dual energy X-ray absorptiometry of lumbar vertebrae (L1-L4) in 683 males and 858 females (5-70 years) from Pune, India and apparent bone mineral density (BMAD) was calculated. A cubic regression model was fitted to describe the change in bone mineral content (BMC) with age in males and females separately. Regression analysis revealed that peak LS BMC was achieved around 26 years (63.6 +/- 11.0 g) for males and 30 years (54.1 +/- 11.6 g) for females. After 50 years of age, BMC showed an average annual decrease of 2.7% in males and 4.1% in females. Males had 11-15% higher mean BMAD than females after 50 years of age. T scores of 19% males and 28% females above 50 years, were less than -2.5 and T scores of 36% males and 43% females were between -1.0 and -2.5 when compared with the Lunar reference database. Low peak bone mass at a young age and higher bone loss in adults are alarming features of apparently healthy Indians.

Predictors of bone density in ambulatory patients on antiepileptic drugs

BACKGROUND AND AIM

Antiepileptic drugs are associated with bone loss and fractures. Data in children is scarce and the impact of new therapies and of low vitamin D is not clear. This study assessed predictors of bone mineral density (BMD) in 225 ambulatory patients with epilepsy.

METHODS

BMD and detailed clinical information were obtained from 137 adults mean age of 31 years, on therapy for a mean of 11.7 years, and 88 children mean age of 13 years, on therapy for an average of 4.7 years.

RESULTS

Hypovitaminosis D was common in epileptic patients. BMD was reduced in adults but not children with epilepsy, by 0.3-0.6 SD depending on the skeletal site measured, compared to controls. Duration of treatment, but not vitamin D levels, was negatively correlated with BMD at the hip in adults. Bone density was reduced with the use of both enzyme and non-enzyme-inducing drugs, with both mono- and polytherapy, and was most severely reduced at the spine and hip with the use of enzyme-inducing drugs. In the multivariate analyses, polytherapy in children and duration of therapy and enzyme-inducing drugs in adults were independent predictors of BMD.

CONCLUSION

Antiepileptic drug therapy is associated with low bone density at clinically relevant skeletal sites, projecting into a possible doubling of fracture risk. Age, therapy duration, polypharmacy and the use of enzyme-inducing drugs were risk factors. Newer drugs may be associated with deleterious effects on bone. Skeletal monitoring with varying intervals, depending on the individual risk profile, is indicated.

First update of the Lebanese guidelines for osteoporosis assessment and treatment

With the demographic explosion, the human, social, and economic costs of osteoporosis in developing countries, including the Middle East, will continue to rise. In 2002, the Lebanese Guidelines for Osteoporosis Assessment and Treatment were developed to optimize quality of osteoporosis care in Lebanon and the region. They were endorsed by 5 Lebanese medical scientific societies, and by the Eastern Mediterranean Regional Office branch of the World Health Organization (WHO). In April 2006, the Lebanese Society for Osteoporosis and Metabolic Bone Disorders (OSTEOS) led an initiative to update several recommendations detailed in the original document, based on relevant new local and international data. Data from a population-based sample of elderly Lebanese validated the following recommendations: fracture risk assessment, expressed as relative risk per standard deviation (RR/SD) decrease, was comparable in Lebanese subjects to similarly derived estimates from Western studies; the use of the NHANES database (hip), and the densitometer American database (spine) was as good, if not superior to the use of a Lebanese database for identifying subjects with prevalent vertebral fractures. The original recommendation regarding the use of a gender-specific western database, densitometer for spine and NHANES for T-score derivation for men, remains unchanged. For skeletal site selection, the update recommends measuring the spine and hip for women < or =65 yr, hip only for subjects >65 yr, and adding the forearm in conditions associated with cortical bone loss or in the case of inability to measure axial sites. The original recommendations for conservative management in premenopausal women were reiterated. This First Update of the Lebanese Osteoporosis Guidelines validates previous recommendations using evidence from a population-based sample of elderly Lebanese, and lays the ground for transitioning the Lebanese Osteoporosis Guidelines to the WHO global fracture risk assessment model.

Peak bone density in Croatian women: variations at different skeletal sites

It is known that different skeletal sites have different peak bone mass at different times and lose bone at different rates. The purpose of the study was to assess bone mineral density (BMD) in healthy female student population (N=220), aged 18-25 yr and to analyze whether young women of that age have already started to lose the bone mass at the trabecular and cortical parts of skeleton. The influence of dietary intake and physical activity on their bone mass was also assessed. BMD was measured, using dual-energy X-ray absorptiometry technique, in spine, proximal femur, and distal third of the radius and in total body. Significant negative correlation between age and bone mass was found in all skeletal regions (p<0.05 spine; p<0.0001 total femur; and p<0.01 total body) except in cortical part of the radius. Peak bone mass in young Croatian women was achieved before the age of 20, but later in the long-bone cortical skeleton, where BMD continued to increase after mid-20s. The BMD values are comparable with those from National Health and Nutrition Examination Survey study, except for the cortical part of the radius, where it is significantly lower. Body weight and physical activity were the most significant positive predictors of bone density in all measured sites.

Vertebral fracture risk and impact of database selection on identifying elderly Lebanese with osteoporosis

The International Osteoporosis Foundation recommends using a universal database i.e. the NHANES database for the diagnosis of osteoporosis. Population-based databases for T-score calculation are still debated in terms of clinical and public health relevance. The current study aimed at estimating the prevalence of vertebral fractures in the Lebanese elderly, determining BMD-fracture relationship, and assessing the effect of database selection on osteoporosis prevalence and fracture risk assessment. Apparently healthy subjects were randomly selected from the Greater Beirut area - one-third of the Lebanese population at large - using a multilevel cluster technique. Subjects with medical conditions likely to affect bone metabolism i.e. history of major chronic disease, intake of medications that affect bone metabolism were excluded. Presence of vertebral fracture was estimated by a semi-quantitative assessment. Bone density was measured by central DXA. Clinical risk factors included age, gender, height, weight, body mass index, smoking, exercise, falls, previous fragility fracture and family history of fragility fracture. Impact of database selection was assessed by: (1) Comparison of sensitivity and specificity for prevalent vertebral fractures of the T-score <or= - 2.5 threshold using local versus NHANES database. (2) Comparison of estimates for fracture risk (RR/SD decrease in BMD) using local versus NHANES database. Prevalence of vertebral fractures was estimated at 19.9% [15.4-25.0] in women and at 12.0% [7.3-18.3] in men. Prevalence of osteoporosis by DXA using total hip was 33.0% [27.5-38.8] in women and 22.7% [16.2-30.2] in men. The NHANES database provided higher sensitivity for vertebral fracture than our population-specific database. RR of vertebral fracture per SD decrease in BMD remained unchanged across the two databases. In women, RR/SD were 1.61 [1.17-2.23] and 1.49 [1.14-1.95] in the NHANES and the local database, respectively, and in men 1.59 [0.94-2.72] and 1.43 [0.95-2.16]. In conclusion, our findings were in concordance with the IOF recommendations for the use of a universal database and could be used for the implementation of a unified fracture risk assessment paradigm along with the WHO initiative.

Bone mineral content and bone mineral density at lumbar spine and forearm in Chinese girls aged 6-18 years

We investigated the age-related bone mineral content (BMC), bone mineral density (BMD) and the tempo of growth in BMC and BMD at lumbar spine and forearm in 455 Chinese girls aged 6-18 yr. BMC and BMD at the anteroposterior lumbar spine (LS), the left forearm (radius+ulna ultradistal, R+UUD) and one-third region (R+U1/3) were measured using a dual-energy X-ray bone densitometer (DXA). BMC and BMD exhibited different change patterns with the age changes. There were significant correlations between age, height, weight and BMC and BMD at LS, R+UUD and R+U1/3 sites. BMC and BMD increased significantly with increments in pubertal stages at LS, R+UUD and R+U1/3 sites. In conclusion, our study showed that Tanner stage had a significant positive association with BMC and BMD of the lumbar spine and forearm. The differences were found in the growth tempo of BMC and BMD within a region and between the spine and forearm. Both BMD and BMC were recommended to evaluate the bone health in children and adolescents.

Optimal vitamin D status and serum parathyroid hormone concentrations in African American women

BACKGROUND

Optimal vitamin D status for the prevention of osteoporosis has been inferred from examinations of the serum 25-hydroxyvitamin D [25(OH)D] concentration below which there is an increase in serum parathyroid hormone (PTH).

OBJECTIVE

The objectives of the study were to ascertain whether a threshold for serum 25(OH)D exists below which serum PTH increases and whether persons with 25(OH)D above this threshold have lower rates of bone loss than do persons with 25(OH)D below the threshold.

DESIGN

The relation of serum 25(OH)D to serum PTH was analyzed in 208 African American women studied longitudinally for 3 y. These healthy women in midlife were randomly assigned to receive placebo or 800 IU vitamin D3/d; after 2 y, the vitamin D3 supplementation was increased to 2000 IU/d. Both groups received calcium supplements to ensure an adequate calcium intake. A systematic literature review found a wide range of threshold values in part due to varied calcium intake.

RESULTS

A Loess plot suggested a breakpoint between 40 and 50 nmol/L for serum 25(OH)D. A line-line model was fitted to the data, and it showed a spline knot at 44 nmol/L. A heuristic approach verified that PTH does not decline as rapidly when the serum concentration of 25(OH)D is >40 nmol/L as when it is <40 nmol/L. We found no significant difference in rates of bone loss between persons with 25(OH)D concentrations above and below 40 nmol/L.

CONCLUSION

Although a threshold for 25(OH)D can be identified, we suggest that it should not be used to recommend optimal vitamin D status.

Peak bone mass of Iranian population: the Iranian Multicenter Osteoporosis Study

Osteoporosis is a major public health problem in the Western countries and is projected to have a similar impact in the Middle East. It has been suggested that peak bone mineral density (BMD), a major determinant of osteoporotic fractures later in life, may be lower in this part of the world compared with the Western world. The purpose of the Iranian Multicenter Osteoporosis Study was to determine peak bone mass in a randomly chosen sample of healthy Iranian subjects. A total of 5201 participants (2340 males, mean age 42.7+/-13.8) were recruited based on randomized clustered sampling from all regions of five major cities across the country. In women, peak lumbar BMD (1.182+/-0.127 g/cm2) occurred in the 29- to 33-yr age group, whereas peak total femur BMD (1.006+/-0.126 g/cm2) occurred in the 32- to 36-yr age group. In men, peak lumbar BMD (1.181+/-0.153 g/cm2) and femoral BMD (1.096+/-0.159 g/cm2) both occurred in the 20- to 24-yr age group. When standardized to mg/cm2 units using established formulas, Iranian peak bone mass values are comparable with that of Western countries and are generally higher than that of Eastern Asian and Middle Eastern countries.

Lebanese guidelines for osteoporosis assessment and treatment: who to test? What measures to use? When to treat?

With the demographic explosion of the population worldwide, the human, social, and economic costs of osteoporosis will continue to rise. It is estimated that the magnitude of the problem might be even larger in developing countries, including those in the Middle East. Although several organizations and countries have developed or adapted guidelines to their local needs, as of today there are no guidelines for osteoporosis assessment in the Middle East. In April 2002, a panel of osteoporosis experts met and discussed practice guidelines for osteoporosis assessment and treatment in Lebanon. The process, which involved an overview of international guidelines as well as local data on osteoporosis, resulted in a draft for Lebanese guidelines that addressed three main questions: "Who to test?" "What measures to use?" and "When to treat?". Representatives from five major Lebanese societies (Endocrinology, Rheumatology, Orthopedics, Obstetrics and Gynecology, and Radiology) subsequently reviewed, discussed, and officially endorsed the guidelines after revisions. The Lebanese guidelines were also endorsed by the Eastern Mediterranean branch of the World Health Organization.

Densitometer type and impact on risk assessment for osteoporosis

Studies have shown a high correlation between measurements of bone mineral density (BMD) obtained on differentdual-energy X-ray absorptiometry machines. Challenger osteodensitometers (Diagnostic Medical System [DMS],Montpellier, France) are becoming widely used but little is known about their clinical performance. The aim of this study was to compare BMD measurements and the resulting patient classification based on T-scores obtained on a DMS Challenger device to those obtained on Hologic 4500A (Bedford, MA) device. Fifty-three volunteers were studied. The BMD of the spine and of the hip were simultaneously measured on both densitometers. BMD values obtained on the Challenger were significantly higher than those obtained with the Hologic QDR4500 (p<0.001). The correlations coefficients between the Hologic QDR4500 and the DMS Challenger measured BMDs were r=0.70 at the femoral neck, r=0.70 at the trochanter, and r=0.83 at the spine (p<0.001). Among the 35 postmenopausal women, there was discordance in the WHO T-score-based classification in 28 subjects (80%) at the spine, 18 subjects (52%) at the femoral neck, and 14 subjects (42%) at the trochanter. The intermachine agreement was low: The kappa score was -0.10 at the spine, 0.2 at the femoral neck, and 0.3 at the trochanter. In conclusion, this study cautions against the use of non established densitometers that leads to underdiagnosis of patients and, subsequently, to inappropriate treatment strategies.

Bone mineral density by age, gender, pubertal stages, and socioeconomic status in healthy Lebanese children and adolescents

Gender, ethnicity, and lifestyle factors affect bone mass acquisition during childhood, thus the need for age- and sex-adjusted Z scores using ethnic-specific data for bone mineral density (BMD) measurement. This study aimed at establishing normative data for BMD in healthy Lebanese children and adolescents. Three hundred sixty-three healthy children aged 10 to 17 years (mean+/-SD: 13.1+/-2.0) were studied. BMD, bone mineral content (BMC), and lean mass were measured by dual-energy X-ray absorptiometry (DXA) using a Hologic 4500A device, and apparent volumetric BMD (BMAD) of the lumbar spine and the femoral neck were calculated. BMD, BMC, and BMAD were expressed by age groups and Tanner stages for boys and girls separately. There was a significant effect of age and puberty on all bone parameters, except at the femoral neck BMAD in boys. BMC and BMD were higher at cortical sites in boys, including subtotal body and hip; whereas, in girls, it was higher at a site more enriched in trabecular bone, namely the lumbar spine. At several skeletal sites, girls had significantly higher BMD adjusted for lean mass than boys. By the end of puberty, adolescents had a mean BMD that was 43-66% higher at the lumbar spine and 25-41% higher at cortical sites than pre-pubertal children, depending on the gender. Mean BMD values in the study group were significantly lower (P<0.01) than Western normative values, with Z scores ranging between -0.2 and -1.1. In both genders, children of lower socioeconomic status tended to have lower BMD than those from a higher socioeconomic background. This study allows additional insight into gender dimorphism in mineral accretion during puberty. It also provides a valuable reference database for the assessment of BMD in children with pubertal or growth disorders who are of Middle Eastern origin.

Hip fractures in lebanese patients: determinants and prognosis

Hip fractures are the most costly of osteoporotic fractures, but little is known about their epidemiology in the Middle East. Hip fracture patients and controls with osteoarthritis admitted to our institution from 1992 to 2002 were studied. Information on gender, age, type of fracture, comorbid conditions, and medications use was obtained. The mean age for hip fracture patients (n = 274) was 72.1(8.5) yr, and for controls (n = 112), it was 71.1(4.4) yr, two-thirds of fractures occurred in women. Fractures were 59% intertrochanteric, 34% femoral neck, and 7% subtrochanteric, with no gender differences. Hip fracture patients were more likely to have had a prior fracture and to suffer from neurological, gastrointestinal, or renal comorbidities, as compared to controls. Less than 10% of hip fracture patients received any therapy for osteoporosis, either on admission or discharge. In a subset of patients with follow-up, the mortality rate was 47% in subjects with hip fracture, and most deaths occurred within the first year postoperatively. Gender but not fracture type affected mortality. Lebanese patients with hip fractures are younger, more likely to sustain intertrochanteric fractures, and experience higher mortality than Western counterparts. Few subjects received osteoporosis therapy. This study carries important public health implications on the management of hip fracture in subjects from Lebanon and, possibly, the Middle East.