Assignment of Nutrition, lifestyle and Non- communicable disease

EPIDEMIOLOGY OF OSTEOPOROSIS AND PREVENTION

By: Sommayeh firouzi GS31339 Kosar Khaef GS31653

Lecturer: Prof. Mirnalini

TABLE OF CONTENTS

Abstract Introduction Epidemiology and prevalence Risk factors Consequences Treatment Exercise Prevention Smoking Diet Sedentary life style Calcium and vitamin D supplements Medication preventing bone loss Discussion: Challenges in prevention Conclusion References 8 9 9

3 4 4 6 6 7 9 8

10 11 12 13 14

ABSTRACT
Osteoporosis is a skeletal disorder characterized by compromised bone strength, which predisposes the individual to an increased risk of fractures of the hip, spine, and other skeletal sites with an increasing in prevalence dramatically worldwide. The situation is even worse in Asia especially rural areas. Malaysia also has high prevalence of osteoporosis and its comorbidities including fractures. Many risk factors are associated with osteoporotic fracture, including low peak bone mass, hormonal factors, the use of certain drugs, cigarette smoking, low physical activity, low intake of calcium and vitamin D, race, small body size, and a personal or a family history of fracture. Not only, it imposed a huge economic burden for individuals and community, but also has other health related consequences such as dead due to fractures. Common medications for osteoporosis treatment are antiresorptive and bone anabolic agents. Beside medications Calcium and Floride supplements are currently being used for osteoporosis treatment. An optimal diet includes adequate intake of calories, calcium, as well as vitamin D and exercise are affective life style factors which play an important role both in prevention and treatment of osteoporosis. Despite efforts of health professional in prevention and treatment of osteoporosis, there are many challenges need to be addressed. Prevention strategies should ideally focus on all the different life phases of skeletal growth, bone maintenance and loss. More over physical exercise (to reduce falls) can prevent fractures in the elderly. Also, a combination therapy of calcium and vitamin D can reduce the risk of fractures (except vertebral fractures) in elderly women with osteoporosis.

INTRODUCTION
Osteoporosis, a major public health problem, is becoming increasingly prevalent with the aging of the world population. Osteoporosis is defined as "a progressive systemic skeletal disease characterized by low bone mass and micro- architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture". The clinical consequences and economic burden of this disease call for actions to assess individuals who are at high risk to go under appropriate intervention (Nancy 2006). Bone densitometry is the most widely used imaging technique for objective measurement of bone mineral density (BMD). The WHO working group recommended that the diagnosis of osteoporosis is based on T-score of at least 2.5 standard deviation. The most important consequence of osteoporosis is bone fracture especially in vertebrae, hips and forearm. Many of these fragility fractures are caused by trivial force which usually should not cause a fracture in healthy individuals (WHO 1994).

EPIDEMIOLOGY AND PREVALENCE

Elderly people are the fastest growing population in the world and, as people become old, bone mass declines and the risk of fractures increases. The social and economic burden of osteoporosis is increasing steadily because of the aging of the world population (Cummings and Melton 2002). While it affects more than 10 million people in the United States, osteoporosis is projected to impact approximately 14 million adults over the age of 50 by the year 2020 (National Osteoporosis Foundation 2002). Worldwide, an osteoporotic fracture is estimated to occur every 3 seconds and a vertebral fracture every 22 seconds (Johnell and Kanis 2006). Osteoporosis is estimated to affect 200 million women worldwide - approximately one-tenth of women aged 60, one-fifth of women aged 70, two-fifths of women aged 80 and two-thirds of women aged 90 (Kanis 2007). The intresting point is that great majority of individuals at high risk (possibly 80%), who already had at least one osteoporotic fracture, are neither identified nor treated (Nguyen et al. 2004). 4

An International Osteoporosis Foundation survey, conducted in 11 countries, showed denial of personal risk by postmenopausal women, lack of dialogue about osteoporosis with their doctor, and restricted access to diagnosis and treatment before the first fracture result in under diagnosis and under treatment of the disease (International Osteoporosis Foundation 2000). Nearly 75% of all hip fractures occur in women and about 25% of hip fractures in people over 50 occur in men. The overall mortality is about 20% in the first 12 months after hip fracture and is higher in men than women. It is estimated that the lifetime risk of experiencing an osteoporotic fracture in men over the age of 50 is 30%, similar to the lifetime risk of developing prostate cancer (International osteoporosis foundation 2011). Statistics unravels the situation is even worse in Asia. It is projected that more than about 50% of all osteoporotic hip fractures will occur in this continent by the year 2050 (International osteoporosis foundation 2011). One of the reasons is that osteoporosis is greatly under diagnosed and undertreated there, even in the most high risk patients who have already fractured. The problem is particularly acute in rural areas. In the most populous countries like China and India, the majority of the population lives in rural areas (60% in China), where hip fractures are often treated conservatively at home instead of by surgical treatment in hospitals (International Osteoporosis Foundation 2009). Nearly all Asian countries fall far below the FAO/WHO recommendations for calcium intake of between 1000 and 1300 mg/day. The median dietary calcium intake for the adult Asian population is approximately 450 mg/day (International Osteoporosis Foundation 2009). Indeed, studies carried out across different countries in South and South East Asia showed that, with few exceptions, widespread prevalence of vitaminosis D (vitamin D deficiency), in both sexes and all age groups of the population (Mithal et al. 2009). In Malaysia, the number of hip fracture cases for men and women is 88 and 218 per 100,000 populations (Lau et al 2009). 51.8% urban Malaysian women in her menopause age group had mild osteoporosis (Damodaran et al. 2000)

RISK FACTORS
Many risk factors are associated with osteoporotic fracture, including low peak bone mass, hormonal factors, the use of certain drugs (eg, glucocorticoids), cigarette smoking, low physical activity, low intake of calcium and vitamin D, race, small body size, and a personal or a family history of fracture (Nancy 2006).

CONSEQUENCES

Osteoporosis takes a huge personal and economic toll. In Europe, the disability due to osteoporosis is greater than that caused by cancers (with the exception of lung cancer) and is comparable or greater than that lost to a variety of chronic non communicable diseases, such as rheumatoid arthritis, asthma and high blood pressure related heart disease (Johnell and Kanis 2006). The annual incidence of osteoporotic fractures exceeds 1.5 million in the United States (National Osteoporosis Foundation; 2002). Hip fractures, long considered more devastating than any other type of osteoporotic fracture, are mostly due to different levels of osteoporosis. (Cummings and Melton 2002). Notably, 1 in 5 persons die during the first year after a hip fracture, (National Institutes of Health 2000) whereas nearly one third require nursing home placement after hospital discharge, and less than one third regain their prefracture level of physical function. (National Institutes of Health. 2001). Vertebral fractures also are associated with an increased incidence of morbidity, including back pain, height loss, deformity (hypnosis), disability, and mortality (John ell et al. 2004). Moreover, multiple thoracic fractures can result in restrictive lung disease, and altered abdominal anatomy caused by lumbar fractures can lead to constipation, abdominal pain, distention, reduced appetite, and premature satiety. The pain, physical limitations, and lifestyle and cosmetic changes caused by osteoporotic fractures can have serious psychological effects, including depression, loss of self-esteem, anxiety, fear, anger, and strained interpersonal relationships (Johnell et al. 2005).

TREATMENT

There are several medications used to treat osteoporosis, depending on gender. Medications themselves can be classified as antiresorptive and bone anabolic agents. Antiresorptive agents work primarily by reducing bone resorption, while bone anabolic agents build bone rather than inhibit resorption. Lifestyle changes are an important aspect of treatment ( Davis S et al.2010). Examples of Antiresorptive agents are: Estrogen analogs, Bisphosphonates, Raloxifene, and Calcitonin (Davis et al. 2010). Bone anabolic agents compromised Teriparatides, Calcium salts, and Sodium Flurides (Meunier et al. 2004). Recently, teriparatide has been shown to be effective in osteoporosis. It acts like parathyroid hormone and stimulates osteoblasts, thus increasing their activity (Meunier et al. 2004). Calcium is required to support bone growth, bone healing and maintain bone strength and is one aspect of treatment for osteoporosis. Recommendations for calcium intake not only depend to country but to age. The role of calcium in preventing and treating osteoporosis is unclear some populations with extremely low calcium intake also have extremely low rates of bone fracture, and others with high rates of calcium intake through milk and milk products have higher rates of bone fracture. (Nutrition and bone health,2005). Calcium carbonate is the primary water insoluble drug, while calcium citrate, lactate, and gluconate are water soluble. Calcium carbonate's absorption is improved in acidic conditions, while the water soluble salts are relatively unaffected by acidic conditions (Meunier et al. 2004). Sodium fluoride treatment in patients with osteoporosis has been shown to cause skeletal changes such as pronounced bone density with increased number and thickness of trabeculae, cortical thickening, and partial obliteration of the medullary space (Meunier et al. 2004). Besides, several studies have shown that a high intake of vitamin D reduces fractures in the elderly. Calcium and vitamin D are currently recommended for the primary prevention of

osteoporosis and the primary and secondary prevention of osteoporotic fractures. However, calcium and vitamin D may reduce fracture risk by only 16 % (Tang et al. 2007).

Apart from medications, multiple studies have shown that aerobics, weight bearing, and resistance exercises can all maintain or increase BMD in postmenopausal women. Many researchers have attempted to pinpoint which types of exercise are most effective at improving BMD and other metrics of bone quality; however results have varied (Bonaiuti 2002). Exercise combined with other pharmacological treatments such as hormone replacement therapy (HRT) has been shown to increases BMD more than HRT alone. Additional benefits for osteoporotic patients include of BMD increase, improvements in balance, gait, and a reduction in risk of falls (Sinaki et al. 2005).

PREVENTION

Because osteoporotic fracture risk is higher in older women than in older men, all postmenopausal women should be evaluated for signs of osteoporosis during routine physical examinations. Radiologic laboratory assessments of bone mineral density generally should be reserved for patients at highest risk, including all women over the age of 65, younger postmenopausal women with risk factors, and all postmenopausal women with a history of fractures (Nancy 2006). Among the proven effective measures in the primary prevention of osteoporosis are: (1) life style modification including smoking, diet and physical activity (2) Calcium and vitamin D supplements and (3) the use of medication to prevent bone loss.

Smoking Majority of the patients in the community usually have a combination of the risk factors. All risk factors need to be assessed and a planned life style modification is necessary. Published

researches have documented smoking as a major risk factor for osteoporosis. Lower bone mineral density and reduced cortical thickness leading to fragility fractures were reported in many community studies and and, after adjusting for differences in age and weight, smokers tend to have more vertebral abnormalities than nonsmokers. (Lorentzon et al. 2006).

Diet
An optimal diet for the management of osteoporosis includes an adequate intake of calories (to avoid malnutrition), calcium and vitamin D. A dietary survey has shown that adolescents and the elderly are most at risk of vitamin D insufficiency and deficiency (Keen 2007). Most of the elderly surveyed had low dietary intakes of vitamin D for example 37% of institutionalized elderly had low serum levels of vitamin D. In general, most guidelines recommend that people aged 70 years and under should take 400 IU (10 mg) per day of vitamin D. Older people and patients with osteoporosis may, however, require higher doses of up to 600-800 IU (15e20 mg) per day. In addition, adults with osteoporosis require a dietary intake of calcium of 1000-1500 mg/day and this can be achieved either through the diet or with a formal supplement. The Framingham Osteoporosis Study and other population-based studies have linked high intakes of potassium, magnesium and vitamin K from fruit and vegetables with improved BMD and reduced hip fracture risk in the elderly (New et al. 2000). Excess caffeine intake has also been associated with an increase in hip fracture risk, although a recent study has identified spinal bone loss in those with high caffeine intakes and low calcium intakes. Excess alcohol consumption also appears to have a negative effect on bone health, both directly and also by indirectly increasing the risk of falls. The WHO has identified a daily intake of more than 2 units as being associated with a significant increase in fracture risk Kanis et al. 2005). Additionally, Lifestyle and patient behavior have also been associated with osteoporosis and fracture risk. Patients should generally be counseled to minimize their use of alcohol and caffeine.

Sedentary life style

Physical activity and exercise are protective factors for Increases the risk of osteoporosis (Grourlay et al. 2006). Regular physical exercise gives the effect of mechanical stress on bone remodeling and is associated with increased bone strength besides increasing muscle bulk and strength, thus reducing the risk of fall (Grourlay et al. 2006). There is no solid data on which type of exercise is best to prevent osteoporosis; most doctors will advise on regular weight bearing exercises such as daily walking. Other lifestyle factors such as reduced alcohol and caffeine intake are also important factors to be considered in preventing osteoporosis. 9

Calcium and vitamin D supplements

High dietary calcium intake and calcium tablet supplements have been proven to reduce the risk of osteoporosis. One study in Malaysia has also demonstrated ingestion of high calcium skimmed milk is effective in reducing the rate of bone loss (Chee et al. 2003). The

recommended daily calcium intakes are 1,200-1,500 mg/day in Western population and 800mg/day in Japan (Hirota et al. 2005). The figures related to Malaysia are depicted in table 1. The total daily intake of calcium should not exceed 2000 mg in view of the risk of renal dysfunction. Side effects include indigestion and constipation. Vitamin D helps in maintaining normal calcium absorption and metabolism. Exposure to sunlight is a major source of vitamin D in tropical countries. Food that contains high calcium and vitamin D such as milk, cheese, egg and cod liver oil should be encouraged. Besides the above measures, the patient must be counseled about medicines which he or she is taking for chronic medical disorder which may lead to osteoporosis. Steroids, thyroid hormones and furosemides are well known to cause osteoporosis ( Loh and Shong 2007). Table 1 shows the Recommended Nutrient Intake (RNI) for calcium and vitamin D for all ages in both genders.

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Table 1: Recommended Nutrient Intake (RNI) of calcium and Vitamin D

Age Infants (boys) 0-5 months 6-11 months Infants (girls) 0-5 months 6-11 months 1-3 years 4-6 years 7-9 years 1-3 years 4-6 years 7-9 years 10-12 years 13-14 years 15 years 16-18 years 10-12 years 13-14 years 15 years 16-18 years 19-29 years 30-50 years 51-59 years 60-65 years >65 years 19-29 years 30-50 years 51-59 years 60-65 years >65 years 1th trimester 2nd trimester 3th trimester 1th 6 months 2th 6 months

Children (boys)

Children(girls)

Adolescent(boys)

Adolescent(girls)

Men

women

pregnancy Lactartion

Calcium intake mg 300 bf 400 ff 400 300 bf 400 ff 400 500 600 700 500 600 700 1000 1000 1000 1000 1000 1000 1000 1000 800 800 800 800 1000 800 800 1000 1000 1000 1000 1000 1000 1000 1000

Vit D intake 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 10 10 15 5 5 10 10 15 5 5 5 5 5

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Medication preventing bone loss

The three most widely used medications in preventing bone loss are Bisphosphonates, estrogen replacement therapy and raloxifene. Bisphosphonates inhibit osteoclast activity and reduce bone turn over and have been proven in many clinical trials as an effective agent in the prevention and treatment of osteoporosis. Estrogen replacement therapy (both oral estrogen and trans-dermal patch) has been proven to reduce bone turnover and lower the risk of fracture. Many clinical trials have shown that estrogen prevents bone loss at the spine and hips if started within ten years post menopause. However, estrogen is contraindicated in women with a history of breast cancer or history of vascular thrombosis. Raloxifene is a selective estrogen-receptor modulator. Daily therapy with raloxifene increases bone mineral density especially at the spine and hip, and lowers serum concentrations of total and lowdensity lipoprotein cholesterol. Another drug used to treat postmenopausal osteoporosis is Calcitonin, a 32-amino-acid peptide which inhibits the action of osteoclasts with resulting increase in BMD. It can be given by subcutaneous, intramuscular injection or intranasal spray. These medications are costly, and the treating physician must consider the cost effectiveness when prescribing (Loh and Shong 2007).

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DISCUSSION: CHALLENGES IN PREVENTION

Despite efforts had been made to prevent osteoporosis, there are still many challenges regarding prevention and treatment of it. Prevention of osteoporosis should begin early in life. Primary prevention during growth and adolescence should aim at attainment of a high peak bone mass, adequate calcium intake, exercise, and early diagnosis and treatment of potential skeletal deformities (Rittwege 2006). On the other hand to maintain bone health, adults need to consume a healthy, balanced diet to achieve adequate mineral and vitamin intake. Another important point is that although physical activity is very important to reduce the prevalence of osteoporosis in population, but when we encourage women to exercise, we should consider that excessive exercise in premenopausal women may actually have detrimental effects on bone due to weight loss and secondary amenorrhea (Keen 2007). A major problem is gaining long-term adherence to therapy from patients with osteoporosis. Fifty percent of patients do not take their medications and most discontinue within 1 year (Davis et al. 2010) Another issue in this regard is that Patients with osteoporosis or osteoporotic fractures may be not only vitamin D deficient but also vitamin D resistant, requiring doses up to 150,000 units each week. Because the requirement for vitamin D is so variable, it is necessary to monitor the individuals response to treatment by obtaining parathyroid hormone and 25hydroxyvitamin D levels every 3 to 4 months until an adequate dose is identified (Sato et al. 2005). Furthermore, should be noted that disparities between races may be relatively analogous to disparities in the process and outcomes of osteoporosis care. Hence, countries which compromised multi races such as Malaysia may have difficulty to establish a national policy to prevent osteoporosis (Mudano et al. 2003). Besides, in prescribing calcium supplement for prevention of osteoporosis, should keep in mind that numerous other factors, apart from calcium and vitamin D play an important role in 13

the pathogenesis of osteoporosis. Zinc is important for synthesis of metal enzymes for production of bone matrix, physical activity increases absorption of calcium in the intestine and increases bone density (Stransky and Rysava 2009)

CONCLUSION

As a conclusion osteoporosis-related fractures consists a multifactorial and increasing public health worldwide issue. Prevention strategies should ideally focus on all the different life phases of skeletal growth, bone maintenance and loss. More over physical exercise (to reduce falls) can prevent fractures in the elderly. Also, a combination therapy of calcium and vitamin D can reduce the risk of fractures (except vertebral fractures) in elderly women with osteoporosis. In summary it seems that appropriate exercise can contribute to bone density and play a role in the prevention of osteoporosis, although the nutrition and lifestyle have major role in that case.

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