Prevalence of osteopenia and osteoporosis in Thai women

Prevalence of osteoporosis, sarcopenia, and high falls risk in healthy community-dwelling Thai older adults: a nationwide cross-sectional study

Thailand has transitioned from an aging society to an aged society, which implies that the prevalence of age-related disorders will increase; however, epidemiological data specific to the prevalence of age-related degenerative musculoskeletal disorders among Thai older adults remain limited. Accordingly, the aim of this study was to investigate the prevalence of age-related musculoskeletal diseases, including osteoporosis, sarcopenia, and high falls risk among healthy community-dwelling Thai older adults. This cross-sectional nationwide study enrolled Thai adults aged ≥60 yr from 2 randomly selected provinces from each of the 6 regions of Thailand via stratified multistage sampling during March 2021 to August 2022. All enrolled participants were evaluated for BMD, skeletal muscle mass, grip strength, and gait speed. Osteoporosis was diagnosed according to the World Health Organization definition, and sarcopenia was diagnosed according to the Asian Working Group for Sarcopenia (AWGS) 2019 criteria. Falls risk was determined using the self-rated Fall Risk Questionnaire. A total of 2991 eligible participants were recruited. The mean age of participants was 69.2 ± 6.5 yr (range: 60-107), and 63.1% were female. The prevalence of osteoporosis, sarcopenia, and high falls risk was 29.7%, 18.1%, and 38.5%, respectively. Approximately one-fifth of subjects (19.1%) had at least 2 of 3 risk factors (ie, osteoporosis, sarcopenia, and high falls risk) for sustaining a fragility fracture, and 3.4% had all 3 risk factors. In conclusion, the results of this study revealed a high and increasing prevalence of osteoporosis, sarcopenia, and high falls risk in healthy community-dwelling Thai older adults. Since these conditions are all major risk factors for fragility fracture, modification of Thailand's national health care policy is urgently needed to address the increasing prevalence of these conditions among healthy community-dwelling older adults living in Thailand.

Current issues in evaluation and management of osteoporosis in Thailand

Osteoporosis is a major public health issue in Thailand, which increased morbidity, mortality, and health-care utilization. The objective of this review is to provide current perspectives on epidemiology, evaluation and management of osteoporosis in Thailand. According to epidemiologic data, the prevalence of osteoporosis and the incidence of hip fracture were comparable to the rest of the world. However, among Thai postmenopausal women, the prevalence of asymptomatic vertebral fracture was disproportionately high. In addition to established risk factors, conditions that may affect the risk of osteoporosis in the Thai population include certain genetic variants, thalassemia, vitamin D deficiency, and low dietary calcium intake, which requires further investigations to draw conclusions. In 2021, the Thai Osteoporosis Foundation released a new Clinical Practice Guideline that provides up-to-date evidence-based recommendations for evaluation and management of osteoporosis. Nonetheless, more research is required to provide local evidence in a variety of areas to guide management of osteoporosis in Thailand. These include epidemiology of distal radial fracture, the optimal intervention threshold of the Thai-specific Fracture Risk Assessment Tool model, screening for asymptomatic vertebral fracture, and the economic evaluation of osteoporosis management options, including fracture liaison service.

Development and Validation of a New Clinical Diagnostic Screening Model for Osteoporosis in Postmenopausal Women

BACKGROUND

Age and weight are not only strong predictive parameters for osteoporosis diagnosis but can also be easily acquired from patients. This study aimed to develop and validate a new diagnostic screening model for postmenopausal osteoporosis that uses only 2 parameters, viz., age and weight. The discriminative ability of the model was analyzed and compared with that of the osteoporosis self-assessment tool for Asians (OSTA) index.

METHODS

The age-weight diagnostic screening model was developed using a retrospective chart review of postmenopausal women aged ≥50 years who underwent dual energy X-ray absorptiometry at a tertiary hospital from November 2017 to April 2022. Logistic regression analysis was used to derive a diagnostic screening model for osteoporosis.

RESULTS

A total of 533 postmenopausal women were included in the study. According to the highest Youden index value, a probability cut-off value of 0.298 was used in the diagnosis screening model at any site, which yielded a sensitivity of 84.3% and a specificity of 53.8%. For increased sensitivity as a screening tool, a cut-off value of 0.254 was proposed to obtain a sensitivity of 90.2% and a specificity of 42.2%. The area under receiver operating characteristic curves from all screening models were significantly higher than those from the OSTA index model (p<0.05).

CONCLUSIONS

This study showed the feasibility of a postmenopausal osteoporosis diagnostic screening model that uses 2 strong predictors for osteoporosis diagnosis: age and weight. This age-weight diagnostic model is a simple, effective option in postmenopausal osteoporosis screening.

Bone Mineral Density Reference Values in 18- to 95-Year-Old Population in Lombardy Region, Italy

The aim of this study is to assess the bone mineral density (BMD) and T-score reference values in a population from 18 to 95 years old in Lombardy region, Italy. This study also investigates the association between BMD values and body mass index (BMI) divided by gender and age. The evaluation of BMD was analyzed by T-score and BMD in each site, femur, and column. A total of 10,503 patients (9,627 females and 876 males, 65.04±12.18 years) have been enrolled in this study. The women hip femur reference values associated with a situation of osteopenia highlighted in-line with the class of age of 45 to 55 years were: mean values: -1.3132 T-score; 95% confidence interval (CI): -1.3600 to -1.2664 and of osteoporosis from the class of age 85 to 95 years, mean values: -2.6591 T-score, 95% CI: -2.7703 to -2.5479. The men hip femur reference values associated with a situation of osteopenia highlighted in-line with the class of age of 45 to 55 years were: mean values: 1.2986 T-score; 95% CI: -1.5454 to -1.0518. A positive association between BMI and the two sites of BMD was recorded (p > .05). This study provides an Italian overview of national and regional reference values about the BMD and T-score values divided by age and gender as reference values for clinicians for a correct assessment and monitoring.

Decision Tree Modeling for Osteoporosis Screening in Postmenopausal Thai Women

Osteoporosis is still a serious public health issue in Thailand, particularly in postmenopausal women; meanwhile, new effective screening tools are required for rapid diagnosis. This study constructs and confirms an osteoporosis screening tool-based decision tree (DT) model. Four DT algorithms, namely, classification and regression tree; chi-squared automatic interaction detection (CHAID); quick, unbiased, efficient statistical tree; and C4.5, were implemented on 356 patients, of whom 266 were abnormal and 90 normal. The investigation revealed that the DT algorithms have insignificantly different performances regarding the accuracy, sensitivity, specificity, and area under the curve. Each algorithm possesses its characteristic performance. The optimal model is selected according to the performance of blind data testing and compared with traditional screening tools: Osteoporosis Self-Assessment for Asians and the Khon Kaen Osteoporosis Study. The Decision Tree for Postmenopausal Osteoporosis Screening (DTPOS) tool was developed from the best performance of CHAID’s algorithms. The age of 58 years and weight at a cutoff of 57.8 kg were the essential predictors of our tool. DTPOS provides a sensitivity of 92.3% and a positive predictive value of 82.8%, which might be used to rule in subjects at risk of osteopenia and osteoporosis in a community-based screening as it is simple to conduct.

Comparison of bone mineral density and vertebral fracture assessment in postmenopausal women with and without distal radius fractures

Objectives

To compare bone mineral density (BMD) in Thai postmenopausal women with and without distal radius fracture, and to investigate the role of vertebral fracture assessment (VFA) in diagnosing osteoporosis after distal radius fracture.

Methods

A cross-sectional study was conducted in Thai postmenopausal women with and without distal radius fracture. BMDs of the femoral neck (FN), total hip (TH), lumbar spine (LS), and VFA were obtained within 2 weeks of injury. BMD were compared between groups. Participants were classified into osteoporosis, osteopenia or normal using BMD alone, and BMD plus VFA, where a mere presence of vertebral compression fracture indicated osteoporosis.

Results

Fifty postmenopausal women with distal radius fractures and 111 non-fracture postmenopausal women participated. The mean BMD was significantly lower at all sites in the fracture group (FN BMD 0.590 ± 0.075 vs 0.671 ± 0.090, p = 0.007; TH BMD 0.742 ± 0.103 vs 0.828 ± 0.116, P = 0.009; LS BMD 0.799 ± 0.107 vs 0.890 ± 0.111, P = 0.009 in the fracture vs non-fracture group respectively). VFA increased the prevalence of osteoporosis from 16 (32%) to 23 (46%) in the fracture group, and 7 (6.31%) to 17 (16.22%) in the non-fracture group, with a number needed to treat 9.

Conclusions

Postmenopausal women with distal radius fractures had lower BMD. Incorporating VFA into diagnosis of osteoporosis increased the prevalence of osteoporosis in both fracture and non-fracture groups. Postmenopausal women aged 50 years or older with distal radius fracture are a good target for the investigation of osteoporosis.

Prevalence of osteoporosis and osteopenia in people over 60 years in Iran: A systematic review and meta-analysis

Background:

Osteoporosis in the elderly has dangerous complications, the most important of which are bone fractures and reduced quality of life in the elderly. The present study was aimed at estimating the prevalence of osteoporosis in Iranian elderly using systematic review and meta-analysis.

Methods:

This search was conducted using authentic Persian and English keywords in national and international databases including Scientific Information Database, Magiran, IranDoc, PubMed, Scopus, Cochrane, Embase, and Web of Sciencewith no time limit until 20.06.2020. Heterogeneity of studies was assessed using I² index. Data were analyzed using STATA Ver. 15 software.

Results:

In 30 studies with a sample size of 13,347 people, the prevalence of osteoporosis and low bone density in people over 60 years in Iran were 34% (95% CI: 27%, 42%) and 47% (95% CI: 41%, 53%), respectively. We also found that 34% of women and 41% of men over the age of 60 suffer from osteoporosis. Prevalence of osteoporosis was in lumbar bone 23% (95% CI: 20%, 26%), spine 25% (95% CI: 19%, 31%), hip 35% (95% CI: 7%, 62%), and femur 23% (95% CI: 15%, 31%). Prevalence of low bone density was in lumbar bone 41% (95% CI: 19%, 63%), spine 30% (95% CI: 15%, 46%), and femur 35% (95% CI: 21%, 48%).

Conclusion:

The prevalence of low bone density in people over 60 years is higher than the prevalence of osteoporosis in them. About one-third of Iranian elderly people suffer from osteoporosis, but about half of them have low bone density.

The current status of osteoporosis after 15 years of reduced cadmium exposure among residents living in cadmium-contaminated areas in northwestern Thailand

The purposes of this study were to determine the prevalence of osteoporosis after 15 years of reduced cadmium exposure and to determine the association between urinary cadmium (U-Cd) and osteoporosis. The study was conducted with 937 participants (109 males, 828 females) living in a cadmium-contaminated area in northwestern Thailand. All participants were required to respond to a questionnaire. Bone mineral density (BMD) was investigated by measurements taken at the calcaneus by dual-energy X-ray absorptiometry. U-Cd, which reflects the amount of cadmium contained in the body, was measured by atomic absorption spectrophotometry (AAS). The geometric mean of U-Cd was significantly higher in males than in females (p < 0.001). The mean level of BMD for females was found to be statistically significantly lower than that for males (p < 0.001). Increasing U-Cd levels were correlated with decreasing levels of BMD. The association between U-Cd and osteoporosis appeared to exist only at concentrations of U-Cd ≥ 10 μg/g creatinine (OR = 2.7, 95% CI = 1.2-5.9). It can be concluded that despite discontinued or reduced cadmium exposure for more than 10 years, the effect of cadmium toxicity on bone, which is stronger in women, continues, as cadmium, once absorbed, will accumulate in the human body for a long time due to its extremely long half-life.

FRAX score with and without bone mineral density: a comparison and factors affecting the discordance in osteoporosis treatment in Thais

We investigate the rate of concordance between treatment recommendations of osteoporosis with 10-year probability of hip fracture calculated using FRAX scores with and without BMD. We found that predictions were concordant in 83.8% of patients. However, older age, lower BMD, and FRAX without BMD around the intervention threshold were associated with discordant results. In the discordant group, FRAX with BMD suggested treatment in more participants with lower age, higher BMI, and lower BMD when compared with FRAX without BMD.

INTRODUCTION

The Fracture Risk Assessment Tool (FRAX) is used to calculate the 10-year probability of fracture using important clinical factors, with bone mineral density (BMD) as an optional input variable. We aimed to determine the rate of concordance between treatment recommendations of osteoporosis with 10-year probability of hip fracture calculated using FRAX scores with and without BMD and to identify relevant clinical risk factors associated with discordance.

METHODS

This was a cross-sectional study conducted in patients between 40 and 90 years of age who were screened for osteoporosis by BMD measurement using dual energy X-ray absorptiometry (DXA) from 2010 to 2018 at a university hospital in Thailand. A FRAX questionnaire was administered to determine demographic data and osteoporotic risk factors. FRAX scores with and without BMD were calculated for each participant using the Thai reference, and patients were categorized into either the treatment or non-treatment group based on a cut-off of 3% 10-year probability of hip fracture. When FRAX scores with and without BMD results were consistent, they were considered concordant. Otherwise, they were deemed discordant. Clinical risk factors were compared between the concordant and discordant groups.

RESULTS

A total of 3545 participants were included in the study. The majority (83.8%) were in the concordant group. However, older age, lower BMD, and FRAX without BMD around the intervention threshold were significantly associated with discordant results. In the discordant group, FRAX with BMD suggested treatment in more participants with lower age, higher BMI, and lower BMD when compared with FRAX without BMD.

CONCLUSION

FRAX scores with and without BMD yielded concordant predictions regarding the 10-year probability of hip fracture suggesting pharmacological treatment. However, this concordance declined in elderly and osteoporotic participants and in those with FRAX without BMD around intervention threshold. BMD data may be required in these populations in order to facilitate accurate risk assessment.

Development of prediction model for osteoporotic vertebral compression fracture screening without using clinical risk factors, compared with FRAX and other previous models

This study developed a prediction model to assess the need for asymptomatic osteoporotic vertebral compression fracture (OVCF) screening in women without using clinical risk factors. Our results demonstrated that the combination of age, height loss, and femoral neck T-score can predict OVCF comparable to previous models, including FRAX.

PURPOSE

Osteoporotic vertebral compression fracture (OVCF) is a major fracture in osteoporosis patients. Early detection of OVCF can reduce the risk of subsequent fractures and death. Many existing diagnostic tools can screen for the risk of osteoporotic fracture but none aim to identify OVCF. The objective of this research is to study a predictive model for capturing OVCF and compare it with previous models.

METHODS

A retrospective review was conducted that included women aged ≥ 50 years who underwent dual-energy X-ray absorptiometry and vertebral fracture screening between 2012 and 2019. The data included age, height, weight, history of height loss (HHL), and bone mass density (BMD). Receiver operating characteristic analysis and univariate and multivariate logistic regression were performed. The predictive OVCF model was formulated, and the result was compared to other models.

RESULTS

A total of 617 women, a 179 of which had OVCFs, were eligible for analysis. Multivariate regression analysis showed age > 65, height loss > 1.5 cm, and femoral neck T-score < -1.7 as independent risk factors for OVCF. This model revealed comparable performance with FRAX. The model without BMD revealed superior performance to FRAX and other standard osteoporosis assessment models.

CONCLUSIONS

BMD and vertebral fracture screening should be eligible for individual women age > 65 years with an HHL more than 1.5 cm, regardless of BMD. Vertebral fracture assessment should be additionally conducted on these women with a femoral neck T-score less than -1.7.

Different reference ranges affect the prevalence of osteoporosis and osteopenia in an urban adult Malaysian population

OBJECTIVES

To determine the prevalence of osteopenia (OPe) and osteoporosis (OP) in an urban adult population in Malaysia, and to compare the change in the prevalence when using a Caucasian compared to an Asian reference range.

METHODS

A cross-sectional random sample of the population aged between 45 and 90 years from the state of Selangor, Malaysia, was invited to attend a bone health check-up. Participants with diseases known to affect bone metabolism or who were on treatment for OP were excluded. Bone mineral density was measured using dual energy X-ray absorptiometry. Based on the World Health Organization definitions, the prevalence of OPe and OP was calculated using the Asian and Caucasian T-scores.

RESULTS

A total of 342 subjects (222 females, 120 males), with a mean age of 59.68 (standard deviation: 8.89) years, who fulfilled the study criteria were assessed. Based on the Asian reference range, there were 140 (40.9%) subjects with OPe and 48 (14.0%) with OP. On applying the Caucasian reference range, there were 152 (44.4%) subjects with OPe and 79 (23.1%) with OP, with significant increases in males, females, and Chinese ethnic groups. Overall, 75 (21.9%) of subjects had a change in their diagnostic status. T-scores were consistently lower when the Caucasian reference range was used.

CONCLUSIONS

In a healthy urban Malaysian population, the prevalence of OP is 14.0% and OPe is 40.9%. Application of a Caucasian reference range significantly increased the number of subjects with OP and may potentially lead to over-treatment.

Cost-effectiveness of denosumab for high-risk postmenopausal women with osteoporosis in Thailand

Aims: This study assessed the cost-effectiveness of denosumab for treating postmenopausal women with osteoporosis (PMO) at high risk of fracture in Thailand.Materials and methods: A published Markov cohort cost-effectiveness model was populated with country-specific data as available and other published data as needed. The model used a societal perspective, lifetime horizon, efficacy data from network meta-analysis of trials, and included costs for direct medical and non-medical care, informal care, and osteoporosis treatments to compare denosumab to no pharmacologic treatment (calcium and vitamin D supplements only) and to oral weekly alendronate. The base case (high-risk population) included postmenopausal women with femoral neck T-score ≤-2.5, mean age 65 years at entry, and history of vertebral fracture.Results: High-risk women with osteoporosis using denosumab had the greatest number of life years and quality-adjusted life-years (QALYs) with higher reductions in hip and vertebral fracture incidence compared with patients with no pharmacologic treatment. The incremental cost-effectiveness ratio (ICER) was 119,575 Thai Baht (THB) per QALY for denosumab versus no pharmacologic treatment and 199,186 THB per QALY for denosumab versus alendronate. Among Thai postmenopausal women with high-risk of fractures, denosumab was cost-effective compared with no pharmacologic treatment at a willingness-to-pay threshold of 160,000 THB per QALY. One-way sensitivity analysis showed models were most sensitive to changes in denosumab pricing.Limitations: Data from other countries used when country-specific data were unavailable may not accurately reflect the true experience in Thailand. The model focused explicitly on hip, vertebral, and wrist fractures, and therefore provides a conservative estimate of the overall potential impact of osteoporosis-related fracture. The fracture risk was not adjusted to reflect potential changes in risk after denosumab treatment discontinuation.Conclusions: In Thailand, denosumab offers a cost-effective osteoporosis treatment option versus no pharmacologic treatment in postmenopausal women at high risk of fracture.

Prevalence of osteoporosis and its associated factors among postmenopausal women in Kiambu County, Kenya: a household survey

This household survey involved determining the bone mineral density of 254 postmenopausal African women in Kiambu County, Kenya. The prevalence of osteoporosis was 26.4%. A positive association between osteoporosis and advancing age, poverty, illiteracy, and being underweight was found.

INTRODUCTION

Osteoporosis is a worldwide health problem with high morbidity and mortality. In Kenya, there is paucity of information on the magnitude and risk profiles of those at risk. The objective of this study was to determine the prevalence and associated factors of osteoporosis among postmenopausal women in a Kenyan periurban population.

METHODS

This community-based cross-sectional survey involving 254 postmenopausal African women in Kiambu County, Kenya, was carried out between October 2017 and February 2018. Multi-stage random sampling approach was adopted where households were selected after sampling sub-counties and enumeration areas. A structured questionnaire was administered and physical examination done on recruited participants by the principal investigator and research assistants. Weight and height of the participants were measured and bone mineral density was determined using dual-energy X-ray absorptiometry (DXA). Data were analyzed using SPSS statistical software version 21.0, SPSS Inc.

RESULTS

The mean age of the women was 64.6 years and ranging between 50 and 95 years. The prevalence of osteoporosis was 26.4%. Osteoporosis was associated with advancing age (p < 0.0001), low socioeconomic status (p = 0.007), lower education level (p < 0.0001), being underweight (BMI < 18.5) (p < 0.0001), family history of osteoporosis (p = 0.006), and caffeine intake (p = 0.002). The association between osteoporosis and occupation, marital status, age at menarche, and exercise was not statistically significant.

CONCLUSIONS

The prevalence of osteoporosis among the select women in Kenya is high and is associated with advancing age, poverty, illiteracy, and being underweight. There is need to implement intervention strategies based on these findings to control osteoporosis in groups at risk.

Osteoporosis in South-East Asian Countries

Osteoporosis (OP) is a condition where there is low bone density and microarchitectural deterioration which can predispose to fragility fractures. There is a wealth of literature on OP from the developed countries, but less so from Asia. This review will explore the field of OP research in South-East Asia with regard to the epidemiology, the diagnosis of OP and the role of laboratory tests in the management of OP, with emphasis on 25-dihydroxyvitamin D and bone turnover markers.

Prevalence of Osteoporosis in Patients with Distal Radius Fracture from Low-Energy Trauma

Introduction: Osteoporosis is a devastating problem leading to significant morbidity and mortality. Patients with osteoporosis usually present with fractures from low-energy trauma and falls, commonly of the distal radius, which may precede more severe fractures like fracture of the neck of femur, but data from Thailand are limited. The objective of our study was to determine the prevalence of osteoporosis in patients with distal radius fracture from low-energy trauma. Materials and Methods: This was a descriptive retrospective study, performed at Thammasat University Hospital in Thailand, from January 2011 to June 2017. Patients aged more than 50 years with distal radial fractures from low-energy trauma with available bone mineral density (BMD) result were included. Patients with known secondary causes of osteoporosis were excluded. Patients were grouped by age, sex, and BMD status (normal, osteopenic and osteoporotic). Results: One hundred out of 351 patients with distal radial fractures had bone mineral density data but only 79 (73 females) met the inclusion criteria. Most patients were aged 60-69 years old (n=31, 42.5%). 47 (59.5%) patients were osteoporotic, 23 (29.1%) osteopenic, and 9 (11.4%) were normal. Seven (6 osteoporotic) patients suffered a more severe fracture subsequently. No deaths were recorded. Conclusion: Our study found a high rate of osteoporosis mostly in females, consistent with published literature. Assessing BMD is crucial in middle age and elderly patients with fractures to better manage osteoporosis and prevent more severe fractures in the future.

Distal Forearm Bone Mineral Density Among Hill Tribes in the Omkoi District, Chiang Mai Province, Thailand

Background:

Osteoporosis is a major public health issue in several countries worldwide because it increases healthcare costs, and is a risk for mortality. There have been several studies that have examined BMD among the various Thai people and the regions that they inhabit.

Objective:

This study examined the distal forearm Bone Mineral Density (BMD) in men and women over 40 years of age among members of various Karen hill-tribes located in the Omkoi District, Chiang Mai Province, Thailand.

Methods:

Two hundred and sixty-two subjects (180 women, 82 men), ranging from 40 to 83 years old were recruited in this study. The non-dominant distal forearm bone mineral density was assessed by using peripheral dual-energy X-ray absorptiometry (pDEXA).

Results:

The results showed that the BMD were 0.530 ± 0.065, 0.508 ± 0.087, 0.461 ± 0.098, and 0.438 ± 0.124 g/cm2 for men age 40-49 years, age 50-59 years, age 60-69 years, and ages 70-83 years, respectively. For women, the BMD were 0.392 ± 0.051, 0.337 ± 0.063, 0.232 ± 0.065, and 0.212 ± 0.069 g/cm2 among women age 40-49 years, age 50-59 years, age 60-69 years, and ages 70-83 years, respectively. BMD had decreased in post-menopause as a function of duration time after menopause.

Conclusion:

We determined the prevalence of osteoporosis of men and women of Karen hill-tribes in the Chiang Mai Province, Thailand. These findings provided important information regarding bone health in Karen hill-tribes for any healthcare planning done in the immediate future.

Association between the age-related decline in renal function and lumbar spine bone mineral density in healthy Chinese postmenopausal women

OBJECTIVES

The relationship between the decline of renal function and bone mineral density (BMD) in healthy populations is not well-researched. The aim of this study was to investigate the association between the age-related decline in renal function and lumbar spine BMD (LBMD) in a community-based cross-sectional study of 390 healthy postmenopausal women (mean age 62.97 ± 8.79 years) from Shenyang, China.

METHODS

Dual-energy x-ray absorptiometry was used to measure LBMD. Estimated glomerular filtration rate (eGFR) was calculated using a modified Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation for Asians and the CKD-EPI serum creatinine-cystatin c equation. Pearson's correlation analysis and binary logistic regression were used to evaluate associations.

RESULTS

The eGFR-ASIA and eGFR-Scys were positively correlated with LBMD (r = 0.120 and r = 0.108, respectively). After adjustments for numerous potential confounders, the odds ratio for participants with LBMD decline in eGFR-ASIA quartile 3 group and 4 group were 2.45 (95% confidence interval [CI] 1.12-5.38, P < 0.05) and 3.89 (95% CI 1.55-9.76, P < 0.01), respectively, with P = 0.003 for the trend in eGFR-ASIA compared with the lowest quartile 1 group of eGFR-ASIA, where the odds ratio of eGFR-Scys for the quartile of 3 and 4 groups were 2.47 (95% CI 1.09-5.62, P < 0.05) and 2.63 (95% CI 1.10-6.29, P < 0.05), respectively, with P = 0.016 for the trend in eGFR-Scys compared with the lowest quartile 1 group of eGFR-Scys.

CONCLUSIONS

The renal function decline was independently associated with decreased LBMD, and it was possible that the age-related decline in kidney function was an independent risk factor for decreased LBMD in healthy Chinese postmenopausal women.

PREVALENCE OF OSTEOPOROSIS AND HYPOVITAMINOSIS D AT SIRIRAJ METABOLIC BONE DISEASE CLINIC

OBJECTIVE

To identify the prevalence of osteoporosis and hypovitaminosis D among patients at the Siriraj Metabolic Bone Disease (MBD) Clinic, and to compare initial vitamin D levels in patients with and without a history of fragility fractures.

METHODS

Medical records of patients who attended our MBD clinic between 2012 and 2015 were retrospectively reviewed. Patient baseline demographic, clinical, bone mineral density (BMD), and laboratory data were collected and analyzed. Osteoporosis was diagnosed when patients had a BMD T-score <-2.5 or presented with fragility fractures.

RESULTS

There were 761 patients included in this study. Of these, 627 patients (82.4%) were diagnosed with osteoporosis and 508 patients (66.8%) had fragility fractures. Baseline serum 25-hydroxyvitamin D (25(OH)D) levels were available in 685 patients. Of these, 391 patients (57.1%) were diagnosed with hypovitaminosis D. When evaluated only in patients with fragility fractures, the average initial 25(OH)D level was 28.2±11.6 ng/mL, and the prevalence of hypovitaminosis D was 57.6%.

CONCLUSION

A high prevalence of osteoporosis and hypovitaminosis D was found among patients at our clinic; two-thirds of patients had a history of fragility fractures, and no difference in initial 25(OH)D levels was seen between patients with and without fragility fractures. Level ofEvidence III, Retrospective Study.

Body weight, BMI, and stature have a protective effect on bone mineral density in women with postmenopausal vertebral osteoporosis, whereas greater age at menarche and years after menopause have a negative effect

Background

Osteoporosis is a metabolic bone disease with a risk factor of being female, particularly after the onset of menopause.

Objectives

To evaluate the influence of age, anthropometric, and reproductive variables on spinal bone mineral density (BMD) in women with postmenopausal vertebral osteoporosis.

Methods

The study was retrospective and included data from 171 patients with postmenopausal vertebral osteoporosis. We performed both simple and multiple regressions considering BMD in spine as the dependent variable. Coefficients of correlation (r), coefficients of determination (r 2), and their level of significance were calculated.

Results

The associations between spinal BMD and each of the following variables were extremely significant: age at menarche (P = 0.0003), weight (P < 0.0001), stature (P = 0.0004), and BMI (P < 0.0001). The associations between spinal BMD and age (P = 0.004), and between spinal BMD and number of years after menopause were very significant (P = 0.0093). BMD was not associated with age at menopause or number of reproductive years. For multiple regressions there was an increasing trend of r 2 with increasing number of independent variables included in the analysis: r 2 = 21.84% (2 variables), r 2 = 24.93% (3 variables), 26.45% (4 variables), and r 2 = 27% (5 variables).

Conclusion

BMD is positively associated with weight, BMI, and stature, and is negatively associated with age, time of menarche, and years after menopause. BMD is not associated with age at menopause and reproductive period.

Thai Osteoporosis Foundation (TOPF) position statements on management of osteoporosis

The adjusted incidence rate of hip fracture in Thailand has increased more than 31% from 1997 to 2006. Mortality and morbidity after hip fracture are also high. One year mortality after a hip fracture has increased from 18% in 1999 to 21% in 2007. The Thai Osteoporosis Foundation (TOPF) developed the first Clinical Practice Guideline (CPG) in 2002 and keeps updating the CPG since then. This latest version of the CPG is our attempt to provide comprehensive positional statement on the diagnosis, prevention and treatment of osteoporosis in Thailand. The study group who revised this position statement contains experts from the TOPF, Four Royal Colleges of Thailand, includes the Orthopaedic Surgeons, Gynecologists and Obstetricians, Physiatrists, Radiologists and 2 Associations of Endocrinologists and Rheumatologists which have involved in the management of patients with osteoporosis.

Age-Adjusted Dual X-ray Absorptiometry-Derived Trabecular Bone Score Curve for the Lumbar Spine in Thai Females and Males

Trabecular bone score (TBS), which has been shown to discriminate patients with fractures from healthy individuals, decreases with age. This study was conducted to derive an age-adjusted normative TBS curve for each gender aged 30-80 + years to serve as reference data for Thai males and females. A cross-sectional study was conducted among employees from the Electricity Generating Authority of Thailand cohorts, after excluding those with conditions potentially affecting bone metabolism and analysis. The values of TBS at L1-L4 vertebrae were analyzed using a commercial software. Age-adjusted TBS curves were constructed using segmental linear regression analysis for each gender. Additional analysis was also performed on TBS with age, body mass index, and body mineral density (BMD) at L1-L4 vertebrae as covariates. A database of 848 healthy subjects (341 females and 507 males) aged 30-80+ years was created. The BMDs of both male and female subjects in the youngest decade were not statistically different from previous reports (p = 0.31 and 0.22 for females and males, respectively). In this age group, the mean TBS was higher in females, albeit not statistically significant (p = 0.12). Between the ages of 30-80+ years, female and male TBS dropped by 19.8% (0.40% per year) and 10.1% (0.20% per year), respectively. The association with TBS was weak for body mass index and moderate for BMD (coefficients of about -0.01 and 0.4-0.5, respectively). The age-adjusted reference curves for healthy Thai females and males aged 30-80+ years have been established.

Low density lipoprotein receptor-related protein 5 gene polymorphisms and osteoporosis in Thai menopausal women

Background

Osteoporosis, characterized by low bone mineral density (BMD) and high bone fracture risk, is prevalent in Thai menopausal women. Genetic factors are known to play a key role in BMD. Low density lipoprotein receptor-related protein 5 (LRP5), a co-receptor in the Wnt/beta-catenin pathway, is involved in many aspects of bone biology. As coding single nucleotide polymorphisms (cSNPs) of LRP5, including A1330V (rs3736228), and Asian-related Q89R (rs41494349) and N740N (rs2306862), are associated with lowered BMD, this study aimed to determine the relationship between these LRP5 polymorphisms and BMD in 277 Thai menopausal women.

Results

Only rs3736228 deviated from the Hardy–Weinberg equilibrium of allele frequency (p = 0.022). The median, range and p value for the BMD related to each SNP parameter were compared (Mann–Whitney U test). Significant differences were observed between wild-type and risk alleles for both rs3736228 (total radial, p = 0.011; and radial 33, p = 0.001) and rs2306862 (radial 33: p = 0.015) SNPs, with no significant difference for rs41494349 SNP. Linkage disequilibrium was strong for both rs3736228 and rs2306862 SNPs. Haplotype analysis identified high CC frequency in both normal and osteopenia/osteoporosis groups, with a significant odds ratio for carrying the TT haplotype; however, this was non-significant after adjusting for age. Multivariate binary logistic regression analysis performed for rs3736228 showed that individuals with a body mass index <25 kg/m² had an increased risk of osteoporosis for each decade, but the polymorphism had no effect.

Conclusions

This study did not identify LRP5 polymorphisms as a risk factor for osteoporosis in Thai menopausal women. Further studies with larger sample sizes are needed to further clarify the role of LRP5 as a genetic determinant of osteoporosis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12952-016-0059-7) contains supplementary material, which is available to authorized users.

Correlation between bone mineral density and serum trace elements in response to supervised aerobic training in older adults

Background

Life style and physical activity play a pivotal role in prevention and treatment of osteoporosis. The mechanism for better bone metabolism and improvement of physical disorders is not clear yet. Trace minerals such as Ca, Mn, Cu, and Zn are essential precursors for most vital biological process, especially those of bone health.

Objective

The main target of this study was evaluating the effective role of supervised aerobic exercise for 1 hour/day, 3 days/week for 12 weeks in the functions of trace elements in bone health through measuring bone mineral density (BMD), osteoporosis (T-score), bone markers, and trace element concentrations in healthy subjects aged 30–60 years with age average of 41.2±4.9.

Methods

A total of 100 healthy subjects (47 males, 53 females; age range 30–60 years) were recruited for this study. Based on dual-energy x-ray absorptiometry (DEXA) scan analysis, the participants were classified into three groups: normal (n=30), osteopenic (n=40), and osteoporotic (n=30). Following, 12 weeks of moderate aerobic exercise, bone-specific alkaline phosphatase (BAP), BMD, T-score, and trace elements such as Ca, Mn, Cu, and Zn were assessed at baseline and post-intervention.

Results

Significant improvement in serum BAP level, T-score, and BMD were observed in all participants following 12 weeks of moderate exercise. Participants with osteopenia and osteoporosis showed significant increase in serum Ca and Mn, along with decrease in serum Cu and Zn levels following 12 weeks of aerobic training. In control group, the improvements in serum trace elements and body mass index were significantly linked with the enhancement in the levels of BAP, BMD hip, and BMD spine. These results supported the preventive effects of moderate exercise in healthy subjects against osteoporosis. In both sexes, the changes in serum trace elements significantly correlated (P<0.05) with the improvement in BAP, BMD hip, BMD spine, and body mass index in all groups.

Conclusion

The observed changes in the levels of Ca, Mn, Cu, and Zn were shown to be positively correlated with improved bone mass density among control and osteoporosis subjects of both sexes. These results demonstrate that aerobic exercise of moderate intensity might protect bone and cartilage by regulation of body trace elements which are involved in the biosynthesis of bone matrix structures and inhibition of bone resorption process via a proposed anti-free radical mechanism.

Vitamin D Status Is Positively Associated with Calcium Absorption among Postmenopausal Thai Women with Low Calcium Intakes

BACKGROUND

Few data exist on the ability of postmenopausal women to absorb calcium from diets habitually low in calcium.

OBJECTIVE

The objective of this study was to evaluate fractional calcium absorption from a green leafy vegetable vs. milk in relation to vitamin D status.

METHODS

We measured fractional calcium absorption from both a dairy- and plant-based source in 19 postmenopausal Thai women (aged 52-63 y) with low calcium consumption (350 ± 207 mg/d) in relation to serum parathyroid hormone (PTH) and serum 25-hydroxyvitamin D [25(OH)D]. Fractional calcium absorption was measured using a triple stable calcium isotope method based on isotope recovery in a 28-h urine collection. Two extrinsically labeled test meals were ingested in random order: a green leafy vegetable (cassia) ingested along with ⁴³Ca or a glass of milk containing ⁴⁴Ca. Women received intravenous ⁴²Ca with the first test meal.

RESULTS

In 19 postmenopausal women studied (mean age, 56.9 ± 3.4 y), ~95% were 25(OH)D sufficient (≥20 μg/L). Serum 25(OH)D status was positively correlated with fractional absorption from both cassia (P = 0.05, R² = 0.21) and milk (P = 0.03, R² = 0.26). Fractional calcium absorption from cassia was significantly lower than that measured from milk (42.6% ± 12.3% vs. 47.8% ± 12.8%, P = 0.03), but true calcium absorption did not significantly differ (120 ± 35 mg/d vs. 135 ± 36 mg/d). Serum PTH was significantly inversely associated with serum 25(OH)D (P = 0.006, R² = 0.37) even though PTH was not elevated (>65 pg/mL).

CONCLUSIONS

These findings suggest that vitamin D status is an important determinant of calcium absorption among Thai women with low calcium intakes, and cassia may be a readily available source of calcium in this population. Furthermore, these data indicate that serum 25(OH)D concentrations may affect PTH elevation in postmenopausal women with low calcium intakes.

Inter-correlation of knowledge, attitude, and osteoporosis preventive behaviors in women around the age of peak bone mass

BACKGROUND

As silent and preventable in nature, postmenopausal osteoporosis awareness should be raised among young women prior to an irreversible period of declining bone mass. We therefore decided to assess the inter-correlation of knowledge, attitude and osteoporosis preventive behaviors in women around the age of peak bone mass.

METHODS

A cross-sectional study was conducted in 430 women aged 20-35 years. The participants' knowledge, attitude and behaviors concerning osteoporosis prevention were assessed along with demographic data using a four-part questionnaire. The items in this questionnaire were established by extensive literature review, including the Guideline for Management of Osteoporosis of the Thai Osteoporosis Foundation (TOPF) 2010. The content was validated by experts in osteoporosis and reliability was obtained with a Cronbach's alpha score of 0.83.

RESULTS

The mean age of women in this study was 29.4 ± 4.6 years. Half of the participants (49.5%) had heard about osteoporosis, mostly from television (95.3%, n = 203/213) and the internet (72.8%, n = 155/213). Most women had certain knowledge (85.2%) and positive attitude towards osteoporosis (53.3%). Nevertheless, 80% of the studied population did not have appropriate osteoporosis behaviors. We found significant correlation between the level of attitudes and osteoporosis behaviors (adjusted odd ratio = 3.3 with 95% confidence interval of 1.9-5.7); attitude and educational level (adjusted odd ratio = 2.2 with 95% confidence interval of 1.4-3.4); and attitude and knowledge (adjusted odd ratio = 3.5 with 95% confidence interval of 1.8-6.8).

CONCLUSION

Despite having certain knowledge about osteoporosis, the young women did not seem to have appropriate osteoporosis preventive behaviors. Developing a right attitude towards osteoporosis may be a key determinant to improving health practices in order to prevent osteoporosis.

Osteoporosis knowledge, health beliefs, and preventive behavior: a comparison between younger and older women living in a rural area

Osteoporosis is widely recognized as one of the major health problems in postmenopausal and older women. Raising awareness about osteoporosis is an important step in examining how much people know about the disease and their attitudes toward preventive behaviors. The aims of the present study were to examine the differences in osteoporosis knowledge, health beliefs, and preventive behaviors between younger and older Thai women, and to examine the relationship between their osteoporosis knowledge, health beliefs, and preventative behaviors. An understanding of these variables measured in younger and older women is essential for the development and delivery of effective age-tailored intervention programs.

Bone health comparison in seven Asian countries using calcaneal ultrasound

BACKGROUND

Bone density measurements by DXA are not feasible for large population studies, whereas portable ultrasound heel scanners can provide a practical way of assessing bone health status. The purpose of this study was to assess bone health in seven Asian countries using heel ultrasound.

METHODS

Stiffness index (SI) was measured and T-scores generated against an Asian database were recorded for 598,757 women and 173,326 men aged over 21 years old using Lunar Achilles (GE Healthcare) heel scanners. The scanners were made available in public centres in Singapore, Vietnam, Malaysia, Taiwan, Thailand, Indonesia and the Philippines.

RESULTS

The mean SI was higher for men than women. In women SI as well as T-scores declined slowly until approximately 45 years of age, then declined rapidly to reach a mean T-score of < -2.5 at about 71-75 years of age. For men, SI as well as the T-score showed a slow steady decline to reach a mean of -2.0 to -2.5 at about 81-85 years. The results for females indicate that there are differences in the rate of decline between countries (significant differences between the slopes at P < 0.05). Vietnam had the fastest decrease for both T-Score and SI, resulting in this population having the poorest bone health of all countries at older ages. The results for males aged 46-85 years indicate that there are no significant differences in the rate of decline between countries for SI and T-Score. In both men and women aged 46-85 years, Vietnam and Indonesia have the lowest SI as well as T-Score for all age groups. For Vietnam and Indonesia, more than 50% of the women could be at risk of having osteoporosis and related fractures after the age of 70, while in Thailand and the Philippines this was >80 years.

CONCLUSIONS

The heel scan data shows a high degree of poor bone health in both men and women in Asian countries, raising concern about the possible increase in fractures with ageing and the expected burden on the public health system.

Serum dickkopf-1 level in postmenopausal females: correlation with bone mineral density and serum biochemical markers

Objective. To assess serum level of Dickkopf-1 in postmenopausal females and its correlation with bone mineral density and serum biochemical markers. Methods. Bone densitometry, serum Dickkopf-1, calcium, phosphorus, and alkaline phosphatase were done in sixty postmenopausal females. Patients were divided according to T score into osteoporosis (group I), osteopenia (group II), and normal bone mineral density that served as controls. Results. There was highly significant increase in serum Dickkopf-1 levels in postmenopausal females with abnormal T score versus controls (P < 0.001). Serum DKK-1 levels correlated negatively with both lumbar T score (r = -0.69, P < 0.001) and femur T score (r = -0.64, P < 0.001) and correlated positively with duration of menopause (r = 0.61, P < 0.001), while there was no significant correlation between serum levels of either calcium, phosphorus or alkaline phosphatase, and both serum Dickkopf-1 levels and the level of bone mineral density (P > 0.05). Conclusion. Postmenopausal females may suffer from osteoporosis as evidenced by bone densitometry. Postmenopausal women with significantly increased serum Dickkopf-1 had more significant osteoporosis. Prolonged duration of menopause and increased serum Dickkopf-1 are important risk factors for the development and severity of osteoporosis.

Preventive effects of phytoestrogens against postmenopausal osteoporosis as compared to the available therapeutic choices: An overview

Estrogen deficiency is a major risk factor for osteoporosis in postmenopausal women. Although hormone replacement therapy (HRT) has been rampantly used to recompense for the bone loss, but the procedure is coupled with severe adverse effects. Hence, there is a boost in the production of newer synthetic products to ward off the effects of menopause-related osteoporosis. As of today, there are several prescription products available for the treatment of postmenopause osteoporosis; most of these are estrogenic agents and combination products. Nevertheless, in view of the lack of effect and/or toxicity of these products, majority of the postmenopausal women are now fascinated by highly publicized natural products. This is an offshoot of the generalized consensus that these products are more effective and free from any adverse effects. Recently, certain plant-derived natural products, mostly phytoestrogens (isoflavones, lignans, coumestanes, stilbenes, flavonoids) and many more novel estrogen-like compounds in plants have been immensely used to prevent menopause-related depletion in bone mineral density (BMD). Although, a number of papers are published on menopause-related general symptoms, sexual dysfunction, cardiovascular diseases, Alzheimer's disease, diabetes, colon, and breast cancers, there is paucity of literature on the accompanying osteoporosis and its treatment. In view of the controversies on synthetic hormones and drugs and drift of a major population of patients toward natural drugs, it was found worthwhile to investigate if these drugs are suitable to be used in the treatment of postmenopausal osteoporosis. Preparation of this paper is an attempt to review the (a) epidemiology of postmenopausal osteoporosis, (b) treatment modalities of postmenopausal osteoporosis by hormones and synthetic drugs and the associated drawbacks and adverse effects, and (c) prevention and treatment of postmenopausal osteoporosis by phytoestrogens, their drawbacks and toxicity. It is apparent that both the categories of treatment are useful and both have adverse effects, but the plant products are nonscientific and hence are not advised to be used till more studies are undertaken to ensure that the benefits clearly outweigh the risk, in addition to recognition by Food and Drug Administration.

Importance of ethnic base standard references for the diagnosis of osteoporosis in Thai women

Many studies demonstrated the importance of using ethnic-specific normal database in the diagnosis of osteoporosis (OP). Aims of this study were to assess diagnostic agreement, prevalence of OP, and diagnostic misclassification between Caucasian, Japanese, and Thai normal databases. The cross-sectional study of 3181 Thai women who had bone mineral density (BMD) measurement between January 2008 and December 2010 was performed. BMDs at lumbar spine (LS), femoral neck (FN), and total hip (TH) were derived to T-score by using Caucasian, Japanese, and Thai standard references. Kappa statistic was used to assess diagnostic agreement and misclassification. Diagnostic agreements between Caucasian and Thai reference databases were 0.39 for LS and 0.90 for FN. No statistical agreement was found in TH region (0.01, p value=0.264). Applying the Japanese reference, diagnostic agreements were 0.71 for LS, 0.76 for FN, and 0.94 for TH regions. Prevalence of OP in postmenopausal women was 64.1%, 37.7%, and 41.4% using Caucasian, Japanese, and Thai standard references. Percentage of misclassification was varied by menopausal status and reference database from 11.2% to 48.7%. When applying Japanese databases instead of Caucasian normal databases, overall diagnostic misclassification decreased from 35.1% to 16.1%. Choice of reference database has a significant effect on the diagnosis of low bone mass and OP. Japanese reference database has better diagnostic agreement with previously studied Thai reference database in 1999 than Caucasian reference database.

Value of Osteoporosis Self-assessment Tools for Asians (OSTA) with or without Brown's clinical risk factors in detection of postmenopausal osteoporosis

OBJECTIVE

To evaluate the value of Osteoporosis Self-assessment Tools for Asians (OSTA) score, Brown's clinical risk assessment and their combination as screening tools for postmenopausal osteoporosis.

METHODS

Two hundred postmenopausal women were enrolled between August 2010 and January 2011. The weight and age of all participants were collected for the OSTA score. Clinical risk factors were collected for Brown's criteria. Bone mineral density was measured using dual-energy X-ray absorptiometry.

RESULTS

The mean age (± standard deviation (range)) of the studied population was 60.1 ± 7.8 (41-81) years. Twenty-one percent of the participants had either osteoporosis of the lumbar spine, or femoral neck or both, of which 8% had osteoporosis at the lumbar spine and 17% had osteoporosis at the femoral neck. The sensitivity and specificity for OSTA score cut-off values of ≤ -1 were 78.6% and 58.2% and for Brown's clinical risk factors were 57.1% and 71.5%, respectively. When the OSTA score of ≤ -1 and Brown's clinical risk factors were combined to screen participants with positive values for one or both test(s), the sensitivity increased from 78.6% to 81.0%, while the specificity decreased from 58.2% to 50.6%. The positive predictive values of the OSTA score, Brown's clinical criteria and the combined tools ranged between 30.4 and 70.6%.

CONCLUSIONS

An OSTA score of ≤ -1 seems to have higher sensitivity compared to Brown's clinical risk factor assessment. The combination of both tools provides a slight improvement in sensitivity but with a decline in specificity.

Association of Thr420Lys polymorphism in DBP gene with fat-soluble vitamins and low radial bone mineral density in postmenopausal Thai women

AIMS

To investigate the genetic markers for osteoporosis bone mineral density by the genotyping of rs7041, rs4588 and rs1352845 in the DBP gene with either bone mineral density or serum 25-hydroxycholecalciferol, retinol and α-tocopherol, among 365 postmenopausal Thai women.

MATERIALS & METHODS

The DBP genotypes were analyzed by a PCR restriction fragment-length polymorphism method. Serum 25-hydroxycholecalciferol was assessed using a commercial chemiluminescent immunoassay. Serum retinol and α-tocopherol were measured by reverse-phase high-performance liquid chromatography.

RESULTS

After adjustment for age >50 years, elder Thai subjects with low BMI (≤25 kg/m(2)) and carrying the rs4588 CC genotype had a higher risk of radial bone mineral density osteoporosis (odds ratio: 6.29; p = 0.048). The rs1352845 genotype also had a statistical association with total hip bone mineral density; however, it disappeared after adjustment for age and BMI. No association was found in fat-soluble vitamins with bone mineral density.

CONCLUSION

DBP genotypes may influence the osteoporosis bone mineral density in postmenopausal Thai women.

Medical applications of phytoestrogens from the Thai herb Pueraria mirifica

Pueraria mirifica Airy Shaw et Suvatabandhu is a medicinal plant endemic to Thailand. It has been used in Thai folklore medicine for its rejuvenating qualities in aged women and men for nearly one hundred years. Indeed, it has been claimed that P. mirifica contains active phytoestrogens (plant substances with estrogen-like activity). Using high performance liquid chromatography, at least 17 phytoestrogens, mainly isoflavones, have been isolated. Thus, fairly considerable scientific researches, both in vitro in cell lines and in vivo in various species of animals including humans, have been conducted to date to address its estrogenic activity on the reproductive organs, bones, cardiovascular diseases and other climacteric related symptoms. The antioxidative capacity and antiproliferative effect on tumor cell lines have also been assessed. In general, P. mirifica could be applicable for preventing, or as a therapeutic for, the symptoms related to estrogen deficiency in menopausal women as well as in andropausal men. However, the optimal doses for each desirable effect and the balance to avoid undesired side effects need to be calculated before use.

Reporting of lifetime fractures: methodological considerations and results from the Thai Cohort Study

OBJECTIVES

To provide estimates of fracture incidence among young adults in Thailand.

DESIGN

Cross-sectional analysis of a large national cohort.

SETTING

Thailand.

PARTICIPANTS

A total of 60 569 study participants residing nationwide responded to the 2009 follow-up survey; 55% were women and median age was 34 years (range 19-92).

OUTCOME MEASURES

Self-reported lifetime fractures, along with age at fracture. Fracture incidence rates per person-year were then compared using lifetime fracture reports, and again selecting only fractures reported for the last year. Incidence rates were compared by age and sex.

RESULTS

18 010 lifetime fractures were reported; 11 645(65%) by men. Lifetime fracture prevalence was 30% for men and 15% for women. Lifetime incidence per 10 000 person-years was 83; analysing only fractures from the last year yielded a corresponding incidence rate of 187. For ages 21-30, fractures per 10 000 person-years were more common among men than women (283 (95% CI 244 to 326) and 150 (130 to 173), respectively); with increasing age, rates decreased among men and increased among women (for ages 51-60, 97 (58 to 151) and 286 (189 to 417), respectively).

CONCLUSIONS

Large-scale surveys provide a feasible method for establishing relative fracture incidence among informative subgroups in a population. Limiting analyses to fractures reported to have occurred recently minimises bias due to poor recall. The pattern of self-reported fracture incidence among Thais aged 20-60 was similar to that reported for Western countries: high falling rates in young men and high rising rates in older women.

Evidence to inform decision makers in Thailand: a cost-effectiveness analysis of screening and treatment strategies for postmenopausal osteoporosis

OBJECTIVES

To assess value for money of providing systematic screening for osteoporosis among postmenopausal women and medical treatments for those diagnosed with osteoporosis as evidence-based decision making for the revision of the National List of Essential Medicines.

METHODS

Decision analytic models were constructed, using a societal perspective, to assess the cost per quality-adjusted life-years (QALYs) gained from systematic screening using the Osteoporosis Self-Assessment Tool and dual-energy X-ray absorptiometry or dual-energy X-ray absorptiometry alone compared with no screening. Alendronate, risedronate, raloxifene, and nasal calcitonin were economically evaluated to determine a treatment of choice for the prevention of osteoporosis-related fractures. Most input parameters were obtained from literature reviews, and systematic reviews and meta-analyses, if available. The service costs and related household expenses were based on the Thai setting. Probabilistic and one-way sensitivity analyses were used to incorporate the impact of parameter uncertainty.

RESULTS

The Osteoporosis Self-Assessment Tool and sequential dual-energy X-ray absorptiometry provided better value for money for osteoporosis screening among young age groups (<60 years old). Although there was no significant difference in cost per QALY for older age groups, alendronate provided the lowest incremental cost-effectiveness ratio while nasal calcitonin presented the highest incremental cost-effectiveness ratio. It was shown that providing medication for a secondary prevention yielded a much higher cost per QALY gained compared with providing medication for a primary prevention.

CONCLUSIONS

Given the benchmark set at 100,000 Thai baht per QALY gained, providing systematic screening and treatment for osteoporosis was cost-ineffective in the Thai setting.

Reference ranges for bone mineral density and prevalence of osteoporosis in Vietnamese men and women

Background

The aim of this study was to examine the effect of different reference ranges in bone mineral density on the diagnosis of osteoporosis.

Methods

This cross-sectional study involved 357 men and 870 women aged between 18 and 89 years, who were randomly sampled from various districts within Ho Chi Minh City, Vietnam. BMD at the femoral neck, lumbar spine and whole body was measured by DXA (Hologic QDR4500). Polynomial regression models and bootstraps method were used to determine peak BMD and standard deviation (SD). Based on the two parameters, we computed T-scores (denoted by T_VN) for each individual in the study. A similar diagnosis was also done based on T-scores provided by the densitometer (T_DXA), which is based on the US White population (NHANES III). We then compared the concordance between T_VN and T_DXA in the classification of osteoporosis. Osteoporosis was defined according to the World Health Organization criteria.

Results

In post-menopausal women, the prevalence of osteoporosis based on femoral neck T_VN was 29%, but when the diagnosis was based on T_DXA, the prevalence was 44%. In men aged 50+ years, the T_VN-based prevalence of osteoporosis was 10%, which was lower than T_DXA-based prevalence (30%). Among 177 women who were diagnosed with osteoporosis by T_DXA, 35% were actually osteopenia by T_VN. The kappa-statistic was 0.54 for women and 0.41 for men.

Conclusion

These data suggest that the T-scores provided by the Hologic QDR4500 over-diagnosed osteoporosis in Vietnamese men and women. This over-diagnosis could lead to over-treatment and influence the decision of recruitment of participants in clinical trials.

Bone mineral density and frequency of osteoporosis among Vietnamese women with early rheumatoid arthritis

Generalised bone mineral density (BMD) reduction often occurs in established rheumatoid arthritis (RA); however, in early RA, there is a disagreement with regard to BMD in the femoral neck and lumbar spine, and there is no available information for the whole body. Therefore, the aims of this study were to investigate the BMD, frequency of osteoporosis and the risk factors for BMD reduction in Vietnamese women with early RA. BMD in the femoral neck, lumbar spine L1-4 and whole body was measured in 105 women with early RA (disease duration ≤3 years) and 105 age-matched healthy women (26-73 years) using a dual energy X-ray absorptiometry. Femoral neck and whole body BMD in women with RA were lower (p < 0.05) than controls, while lumbar spine BMD was similar between two groups. The frequency of osteoporosis in the femoral neck, lumbar spine and whole body in women with RA aged ≥50 were higher (p < 0.05) than controls: 41.8% versus 29.5%, 42.2% versus 37.7% and 37.1% versus 28%, respectively. There were associations between the frequencies of osteoporosis at all sites with postmenopausal status, glucocorticoid use, rheumatoid factor positivity and disease activity with lumbar spine BMD and disease disability with femoral neck and whole body BMD. In conclusion, women with early RA had significantly lower femoral neck and whole body BMD, but had similar lumbar spine BMD compared with controls. The frequency of osteoporosis at all sites was significantly higher in women with RA than controls, suggesting that assessment of BMD should be considered in women with early RA.

An Asian viewpoint on the use of vitamin D and calcium in osteoporosis treatment: physician and patient attitudes and beliefs

BACKGROUND

Osteoporosis treatment guidelines recommend calcium and vitamin D supplementation for both prevention as well as treatment, however, compliance with these guidelines is often unsatisfactory. This study investigated the opinion of Asian physicians and Asian patients regarding vitamin D and calcium and patients' use of both.

METHODS

Physicians selected from Malaysia, Taiwan, Philippines, Korea and Singapore were asked to grade the significance of vitamin D and calcium in the treatment of osteoporosis and their patients' use of these supplements. In addition, physicians recruited seven eligible osteoporotic women to answer a questionnaire to determine their use of vitamin D and calcium, and their attitudes and beliefs regarding these supplements.

RESULTS

In total, 237 physicians and 1463 osteoporosis patients completed the questionnaire. The results revealed that 22% of physicians in Malaysia, 12% in Taiwan, 72% in the Philippines, 50% in Korea and 24% in Singapore rated the importance of vitamin D supplementation as being extremely important. For calcium, 27% of physicians in Malaysia, 30% in Taiwan, 80% in the Philippines, 50% in Korea and 38% in Singapore rated the importance as being extremely important. Forty-three percent of patients in Malaysia, 38% in Taiwan, 73% in the Philippines, 35% in Korea and 39% in Singapore rated the importance of vitamin D as being extremely important. For calcium, 69% of patients in Malaysia, 58% in Taiwan, 90% in the Philippines, 70% in Korea and 55% in Singapore rated the importance as being extremely important. In addition, results of the patient questionnaire revealed that only a very small number regularly took both supplements. In addition, the results indicated that, with the exception of patients from the Philippines, the majority of patients had no or infrequent discussion with their physician about vitamin D and calcium.

CONCLUSIONS

There is generally suboptimal appreciation by both physicians and patients of the importance of vitamin D and calcium for maintenance of bone health as reflected in the low number of patients who reported regularly taking these supplements. Recognition of this problem should translate to appropriate action to improve education for both physicians and patients, with a goal to increase use of these supplements among Asian patients with osteoporosis.

Veganism, bone mineral density, and body composition: a study in Buddhist nuns

SUMMARY

This cross-sectional study showed that, although vegans had lower dietary calcium and protein intakes than omnivores, veganism did not have adverse effect on bone mineral density and did not alter body composition.

INTRODUCTION

Whether a lifelong vegetarian diet has any negative effect on bone health is a contentious issue. We undertook this study to examine the association between lifelong vegetarian diet and bone mineral density and body composition in a group of postmenopausal women.

METHODS

One hundred and five Mahayana Buddhist nuns and 105 omnivorous women (average age = 62, range = 50-85) were randomly sampled from monasteries in Ho Chi Minh City and invited to participate in the study. By religious rule, the nuns do not eat meat or seafood (i.e., vegans). Bone mineral density (BMD) at the lumbar spine (LS), femoral neck (FN), and whole body (WB) was measured by DXA (Hologic QDR 4500). Lean mass, fat mass, and percent fat mass were also obtained from the DXA whole body scan. Dietary calcium and protein intakes were estimated from a validated food frequency questionnaire.

RESULTS

There was no significant difference between vegans and omnivores in LSBMD (0.74 +/- 0.14 vs. 0.77 +/- 0.14 g/cm(2); mean +/- SD; P = 0.18), FNBMD (0.62 +/- 0.11 vs. 0.63 +/- 0.11 g/cm(2); P = 0.35), WBBMD (0.88 +/- 0.11 vs. 0.90 +/- 0.12 g/cm(2); P = 0.31), lean mass (32 +/- 5 vs. 33 +/- 4 kg; P = 0.47), and fat mass (19 +/- 5 vs. 19 +/- 5 kg; P = 0.77) either before or after adjusting for age. The prevalence of osteoporosis (T scores < or = -2.5) at the femoral neck in vegans and omnivores was 17.1% and 14.3% (P = 0.57), respectively. The median intake of dietary calcium was lower in vegans compared to omnivores (330 +/- 205 vs. 682 +/- 417 mg/day, P < 0.001); however, there was no significant correlation between dietary calcium and BMD. Further analysis suggested that whole body BMD, but not lumbar spine or femoral neck BMD, was positively correlated with the ratio of animal protein to vegetable protein.

CONCLUSION

These results suggest that, although vegans have much lower intakes of dietary calcium and protein than omnivores, veganism does not have adverse effect on bone mineral density and does not alter body composition.

Effect of vegetarian diets on bone mineral density: a Bayesian meta-analysis

BACKGROUND

The association between vegetarian diets and bone mineral density (BMD) is controversial because of conflicting findings from previous studies.

OBJECTIVE

The aim of this study was to estimate the effect of vegetarian diets on BMD by using a meta-analytic approach.

DESIGN

A systematic electronic literature search was conducted to identify all relevant articles on the association between vegetarian diet and BMD. Nine studies of 2749 subjects (1880 women and 869 men) were included in the analysis. Traditional and Bayesian methods of meta-analysis were applied to synthesize the data.

RESULTS

Overall, BMD was approximately 4% lower in vegetarians than in omnivores (95% CI: 2%, 7%) at both the femoral neck and the lumbar spine. Compared with omnivores, vegans had a significantly lower lumbar spine BMD (6% lower; 95% CI: 2%, 9%), which was more pronounced than in lactoovovegetarians (2% lower; 95% CI: 1%, 4%). The probability that BMD was > or =5% lower in vegetarians than in omnivores (or approximately 0.3 SD) was 42% for the femoral neck and 32% for the lumbar spine. There was no evidence of publication bias. There was a moderate degree of between-study heterogeneity; the coefficient of heterogeneity varied between 46% and 51%.

CONCLUSION

The results suggest that vegetarian diets, particularly vegan diets, are associated with lower BMD, but the magnitude of the association is clinically insignificant.

Guidelines for hormone replacement therapy of Asian women during the menopausal transition and thereafter

These Guidelines summarize the position of an Expert Panel on Menopause in Asian Women regarding the use of hormone replacement therapy (HRT) during the menopausal transition and thereafter. They are intended to aid gynecologists, family physicians and other health-care professionals in providing optimal care to menopausal Asian women who desire HRT.

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.

Peak bone mineral density in Vietnamese women

SUMMARY: This cross-sectional study showed that peak bone mineral density in Vietnamese women is comparable to that in Caucasian women; however, the prevalence of osteoporosis in post-menopausal Vietnamese women was slightly higher than in Caucasian women. The age of achieving peak bone mass in Vietnamese women was between 26 and 30 years. INTRODUCTION: While peak bone mass and its determinants have been well-documented in Caucasian populations, little has been studied in Asian populations. The present study was designed to estimate the peak bone mineral density (BMD), age of its attainment, and to examine the prevalence of osteoporosis in Vietnamese women aged 50+. METHODS: The study was designed as a cross-sectional study with 328 women aged between 10 and 65 years (average age: 41) who were randomly selected from two districts around Hanoi city according to a stratified sampling scheme. BMD at the lumbar spine, femoral neck and total hip was measured by a DXA instrument (GE Lunar Prodigy, WI, USA). BMD was modeled as a cubic function of age, from which peak BMD and age at peak BMD were estimated. Bootstrap method was utilized to estimate the 95% confidence interval of peak BMD and age at peak BMD. From the peak BMD, T-score was calculated for each woman, and using the World Health Organization criteria, any woman with femoral neck BMD T-score </= -2.5 was classified as having osteoporosis. RESULTS: Peak BMD was estimated at 1.16 g/cm(2) (standard deviation [SD]: 0.13 g/cm(2)) at the lumbar spine, 1.02 g/cm(2) (SD 0.12) at the total hip, and 0.94 g/cm(2) (SD 0.11) at the femoral neck. In the cubic polynomial model, the age at peak BMD was estimated to range between 27 and 29 years. The prevalence of osteoporosis among those aged between 50 and 65 years was 23%. This prevalence was higher than in Chinese, Japanese, Korean and Caucasian populations. CONCLUSION: These data suggest that although the peak BMD in Vietnamese women is comparable to, the prevalence of osteoporosis is higher than, in some other Asian and Caucasian women. It seems that osteoporosis is an important public health burden in Vietnam.

Bone mineral density in Indian women with rheumatoid arthritis

Osteoporosis (OP) is being increasingly recognized in inflammatory rheumatic diseases like rheumatoid arthritis (RA). Ethnicity influences bone mineral density (BMD) and fracture risk. Due to paucity of data on this aspect of RA from Asian countries including India, we prospectively studied 84 premenopausal women with RA of at least 2 years duration and 247 healthy, age (within 5 years) and sex-matched controls. A significant difference in BMD between patients and controls was observed only at the femoral neck. As many as 22% patients with RA exhibited osteoporosis at least one site in contrast to 9% controls. Nearly 40% of patients exhibited osteopenia at all the three sites. Modified Sharp score, disease duration and DMARD naive period were found to correlate with low BMD. However, on multivariate analysis, only modified Sharp score was shown to be significantly associated with low BMD. Our study draws attention to the poor bone health in Asian Indian women with RA.

The relationship of an Asian-specific screening tool for osteoporosis to vertebral deformity and osteoporosis

An Asian-specific screening tool for osteoporosis, the so-called OSTA index, was devised and is likely to be helpful in determining which postmenopausal women need bone mineral density (BMD) measurement. Besides BMD, prevalent vertebral fracture is a strong risk factor for future fractures. However, the relationship of the OSTA index to prevalent vertebral fractures is currently unknown. In this study, we evaluated the performance of the OSTA index in elderly Thai women and assessed the relationship of the index to prevalent vertebral deformities. Subjects consisted of 741 healthy Thai elderly women. BMD was measured by DEXA and T-score <or=2.5 SD is defined as osteoporosis. Prevalent vertebral deformities were determined by morphometric X-ray absorptiometry. OSTA index >-1 is classified as having low risk of osteoporosis, -1 to -4 as intermediate risk and, <-4 as high risk. Data were expressed as mean +/- SD. The mean age and body weight of subjects were 67 +/- 4.8 years and 57.8 +/- 8.7 kg, respectively. The area under the ROC curve for OSTA index to identify osteoporosis at femoral neck and lumbar spine was 0.80 and 0.72, respectively. Femoral neck osteoporosis was found in 40.4%, 6.3%, and 2.4% of subjects with high-risk, intermediate-risk, and low-risk OSTA indexes, respectively. With regard to vertebral deformities, the area under the ROC curve relating OSTA index to vertebral deformities was 0.70 (P < 0.001). The prevalence of vertebral deformities in according to the OSTA index was 19.2% in the high-risk, 7.9% in the intermediate-risk, and 2.8% in the low-risk group. We concluded that the OSTA index can be of assistance in the selection of postmenopausal women for BMD measurement. In addition, this index may be helpful in the identification of postmenopausal women with vertebral deformity and those who need antifracture treatments.

Cost-Effectiveness Analysis of Various Screening Methods for Osteoporosis in Perimenopausal Thai Women

OBJECTIVE

To perform a health economics analysis of 5 screening programs for osteoporosis in perimenopausal Thai women comparing two alternatives; without intervention and universal treatment without screening.

DESIGN

A decision analysis was performed to evaluate five screening strategies: Dual energy X-ray absorptiometry (DXA), Quantitative ultrasound sonography (QUS), risk index (clinical risk factors), two-step screening with QUS followed by DXA, and screening with risk index followed by DXA, comparing outcomes without intervention and universal treatment without screening.

RESULTS

The costs for universal treatment, screening by DXA with treatment, screening by QUS with treatment, screening by Risk index with treatment, screening by QUS and DXA with treatment, and screening by Risk index and DXA with treatment strategies to prevent one fracture were 207.82, 88.42, 147.05, 127.67, 71.33, and 60.30 USD, respectively. The cost for no intervention to prevent one fracture is 8.49 USD (1 USD = 40 Thai baht).

CONCLUSION

At present, no intervention is the most cost effective strategy. However, screening with risk index and DXA with treatment became the most cost effective when the patients reached the postmenopausal period and had a high risk index, for which the prevalence of osteoporosis will increase. Cost effective screening guidelines still cannot be explicitly established until further data addressing the association between bone mass measurements in the hip and hip fracture risk, are available.