Prevalence and Predictors of Osteoporosis Among the Chinese Population in Klang Valley, Malaysia

Age-dependent FRAX-based assessment and intervention thresholds for therapeutic decision making in osteoporosis in the Malaysian population

Fracture risk stratification is crucial in countries with limited access to bone density measurement. 24.8% women were in the high-risk category while 30.4% were in the low-risk category. In the intermediate risk group, after recalculation of fracture risk with bone density, 38.3% required treatment. In more than half, treatment decisions can be made without bone density.

PURPOSE

We aimed to examine the role of age-dependent intervention thresholds (ITs) applied to the Fracture Risk Assessment (FRAX) tool in therapeutic decision making for osteoporosis in the Malaysian population.

METHODS

Data were collated from 1380 treatment-naïve postmenopausal women aged 40-85 years who underwent bone mineral density (BMD) measurements for clinical reasons. Age-dependent ITs, for both major osteoporotic fracture (MOF) and hip fracture (HF), were calculated considering a woman with a BMI of 25 kg/m2, aged between 40 and 85years, with a prior fragility fracture, sans other clinical risk factors. Those with fracture probabilities equal to or above upper assessment thresholds (UATs) were considered to have high fracture risk. Those below the lower assessment thresholds (LATs) were considered to have low fracture risk.

RESULTS

The ITs of MOF and HF ranged from 0.7 to 18% and 0.2 to 8%, between 40 and 85years. The LATs of MOF ranged from 0.3 to 11%, while those of HF ranged from 0.1 to 5.2%. The UATs of MOF and HF were 0.8 to 21.6% and 0.2 to 9.6%, respectively. In this study, 24.8% women were in the high-risk category while 30.4% were in the low-risk category. Of the 44.8% (n=618) in the intermediate risk group, after recalculation of fracture risk with BMD input, 38.3% (237/618) were above the ITs while the rest (n=381, 61.7%) were below the ITs. Judged by the Youden Index, 11.5% MOF probability which was associated with a sensitivity of 0.62 and specificity of 0.83 and 4.0% HF probability associated with a sensitivity of 0.63 and a specificity 0.82 were found to be the most appropriate fixed ITs in this analysis.

CONCLUSION

Less than half of the study population (44.8%) required BMD for osteoporosis management when age-specific assessment thresholds were applied. Therefore, in more than half, therapeutic decisions can be made without BMD based on these assessment thresholds.

Assessment of osteoporosis knowledge and its determinants among tuberculosis patients in tertiary care hospital Malaysia: A prospective study

Objective

Osteoporosis self-care knowledge is essential to encourage the patient's contribution towards controlling the disease. Osteoporosis incidence with various infectious diseases prompts us to conduct a study on osteoporosis knowledge among Tuberculosis (TB) patients. This study aimed to assess osteoporosis-related knowledge and its influencing factors among TB patients.

Methods

A prospective cross-sectional study was conducted in the TB clinic of Hospital Pulau Pinang, Malaysia, and an osteoporosis knowledge test (OKT), a structured questionnaire, was used to collect data. TB patients aged 18 years and above with compromised bone health were included in the present study. Overall knowledge scores were dichotomized, calculating the mean score, descriptive statistics, and multivariate regression analysis was used to determine the influence of risk factors on knowledge scores.

Results

Of 337 patients, 129(38.28 %) had good osteoporosis knowledge and 208(61.72 %) had poor knowledge. Among them, 231(68.54 %) were males, and 106(31.45 %) were females, with a mean age of 46.5 ± 17.1 years. The mean ± SD of OKT total score was 10.5 ± 2.0. The mean ± SD of the exercise knowledge score was 5.3 ± 3.4, while the nutrition knowledge score was 5.0 ± 3.2. Male gender (OR 3.86, 95 % CI 1.98-7.53), low-income level (OR 1.92, 95 % CI 1.12-3.30), rural residents (OR 2.49, 95 % CI 1.46-4.27) and participants with no formal education (OR 4.34, 95 % CI 1.11-16.84) or ≤12 years of education (OR 3.63, 95 % CI 1.52-8.65) were significantly responsible for poor OKT score.

Conclusion

The results indicated that most TB patients had a poor perception of osteoporosis. More extensive strategies should be developed to enhance the campaign of awareness programs among TB patients to improve preventive measures of osteoporosis, such as calcium intake and exercise.

Fracture Liaison Service and Its Role in Secondary Fracture Prevention in Malaysia: A Scoping Review

Introduction

Fragility fractures, which occur after a low-trauma injury, increases with advancing age. Such fracture doubles the life-time risk of sustaining another fracture. This risk is highest in the immediate 18 months after the index fracture. However, most patients do not receive the appropriate risk assessment and intervention to reduce this risk. A coordinated model of care termed Fracture Liaison Service (FLS) has been reported to address this treatment gap.

Materials and methods

This scoping review aims to explore the potential role and delivery of FLS services in Malaysia. Scientific and non-scientific sources relevant to FLS were identified from electronic bibliographic databases, specialist journals and relevant websites. Findings were categorised into themes and presented narratively.

Results

FLS services remain concentrated in the Klang Valley. Even within FLS services, many do not have extensive coverage to risk assess all fracture patients. These services are multidisciplinary in nature where there are links between different departments, such as orthopaedics, osteoporosis expertise, bone densitometry, rehabilitation, falls services and primary care. FLS was able to increase the number of people undergoing fracture risk assessment and treatment. The importance of FLS was highlighted by local experts and stakeholders. Its implementation and delivery are supported by a number of national guidelines.

Conclusion

FLS is central to our national efforts to reduce the impending fragility fracture crisis in the coming years. Continued effort is needed to increase coverage within FLS services and across the country. Training, awareness of the problem, research, and policy change will support this endeavour.

Associations Between Body Mass Index, WNT16 rs2908004 and Osteoporosis: Findings from Taiwan Biobank

Purpose

Osteoporosis is a degenerative disease that affects women and men of all races. We studied the association between body mass index (BMI), rs2908004 polymorphism of the WNT16 gene, and osteoporosis using data from Taiwan Biobank (TWB).

Patients and Methods

We analyzed data from 10,942 subjects aged 30 to 70. We defined osteoporosis based on a mean T-score of -2.5 and below in the hip. Body mass index was classified following the guidelines of the Health Promotion Administration. Imputation was carried out using the IMPUTE2 (v2.3.1) program. Multiple logistic regression was used for analysis. The odds ratios (ORs) and 95% confidence interval (CI) for osteoporosis were determined.

Results

In the multivariate regression model, variant rs2908004 had a significant association with osteoporosis. That is, the rs2908004-GA+AA genotype was associated with lower osteoporosis risk than the GG genotype (OR, 0.651; 95% CI = 0.544 to 0.780). Compared to normal-weight, underweight was significantly associated with a higher risk of osteoporosis (OR, 6.517; 95% CI = 4.624 to 9.186) while overweight and obesity were protective (OR, 0.176; 95% CI = 0.140 to 0.221 and 0.057; 95% CI = 0.039 to 0.083, respectively). There was an interaction between rs2908004 and BMI (p = 0.0148). Subgroup analyses (using rs2908004-GG/normal-weight as the reference group) indicated ORs of 7.66 (95% CI = 5.153 to 11.394) in the rs2908004-GG/underweight group and 3.002 (95% CI = 1.509 to 5.974) in the rs2908004-GA+AA/underweight group (95% CI = 1.509 to 5.974). Odds ratios were substantially lower in rs2908004-GG/obese, rs2908004-GG/overweight, GA+AA/normal-weight, rs2908004-GA+AA/overweight, and rs2908004-GA+AA/obese groups, respectively.

Conclusion

According to our study, underweight was associated with an increased risk of osteoporosis irrespective of WNT16 rs2908004 genotypes, while overweight and obesity were associated with a lower risk.

Comparing the performance of body mass index, waist circumference and waist-to-height ratio in predicting Malaysians with excess adiposity

BACKGROUND

Body mass index (BMI) is a widely used surrogate tool to screen for obesity/adiposity, but it cannot differentiate between lean and fat mass. Thus, alternative tools to detect excess adiposity should be identified.

AIM

This study aimed to compare the performance of BMI, waist circumference (WC) and waist-to-height ratio (WtHR) in predicting Malaysians with excess body fat defined by dual-energy X-ray absorptiometry (DXA).

SUBJECTS AND METHODS

A total of 399 men and women aged ≥40 years were recruited from Klang Valley, Malaysia. The body composition of the subjects, including body fat percentage, was measured by DXA. The weight, height, WC and WHtR of the subjects were also determined.

RESULTS

BMI [sensitivity = 55.7%, specificity = 86.1%, area under curve (AUC) = 0.709] and WC (sensitivity = 62.7%, specificity = 90.3%, AUC = 0.765) performed moderately in predicting excess adiposity. Their performance and sensitivity improved with lower cut-off values. The performance of WHtR (sensitivity = 96.6%, specificity = 36.1, AUC = 0.664) was optimal at the standard cut-off value and no modification was required.

CONCLUSION

The performance of WC in identifying excess adiposity was greater than BMI and WHtR based on AUC values. Modification of cut-off values for BMI and WC could improve their performance and should be considered by healthcare providers in screening individuals with excess adiposity.

Application of health belief model in the assessment of factors affecting exercise behaviours in preventing osteoporosis

Objectives

Osteoporosis is a skeletal disorder associated with weak and brittle bones, and more susceptible to fracture. Osteo-protective behaviours, such as exercise, may prevent osteoporosis. Therefore, this study aimed to assess the factors influencing the exercise behaviour in Malaysian adults and to assess their health beliefs and self-regulation in preventing osteoporosis.

Methods

A cross-sectional, self-administered questionnaire was conducted throughout Malaysia through a web-based or physical-based survey. The questionnaire consisted of three sections: demographic data, ten questions regarding social and family history related to osteoporosis and 38 questions with seven subdomains (i.e. susceptibility, seriousness, barriers, benefits, health motivation, self-efficacy and self-regulation) which measured the health belief scores and self-regulation using 5-point Likert scale. Descriptive, inferential analysis and linear regression were used to analyse the data.

Key findings

A total of 679 participants completed the questionnaire. The mean health belief score was 63.7%, which was moderate. Most participants (64.4%) perceived low susceptibility to osteoporosis [mean score = 47.0%, standard deviation (SD) = 16.2]. Participants with age 18–27 years (44.8%), single (45.0%) and monthly income <RM 1000 (45.2%), perceived significant lower susceptibility to osteoporosis. Participants’ perception scores were high on the benefits of exercise (75.7%, SD = 16.4), health motivation (74.9%, SD = 17.1) and perceived low barriers to exercise (71.7%, SD = 14.9). Respondents who were at risk of osteoporosis and with family and friends diagnosed with osteoporosis obtained a higher score than those who did not.

Conclusions

The health belief score in the Malaysian population was moderate. However, the majority of participants were unaware of the susceptibility and seriousness of osteoporosis. Efforts need to be taken to break the barriers associated with exercise in preventing osteoporosis.

Effect of a Screening and Education Programme on Knowledge, Beliefs, and Practices Regarding Osteoporosis among Malaysians

Background: Osteoporosis is an emerging geriatric condition with high morbidity and healthcare cost in developing nations experiencing rapid population ageing. Thus, identifying strategies to prevent osteoporosis is critical in safeguarding skeletal health. This study aimed to evaluate the effects of a bone health screening and education programme on knowledge, beliefs, and practice regarding osteoporosis among Malaysians aged 40 years and above. Methods: A longitudinal study was conducted from April 2018 to August 2019. During the first phase of the study, 400 Malaysians (190 men, 210 women) aged ≥ 40 years were recruited in Klang Valley, Malaysia. Information on subjects’ demography, medical history, knowledge, and beliefs regarding osteoporosis, physical activity status, and dietary and lifestyle practices were obtained. Subjects also underwent body anthropometry measurement and bone mineral density scan (hip and lumbar spine) using a dual-energy X-ray absorptiometry device. Six months after the first screening, similar investigations were carried out on the subjects. Results: During the follow-up session, 72 subjects were lost to follow up. Most of them were younger subjects with a lower awareness of healthy practices. A significant increase in knowledge, beliefs (p < 0.05), calcium supplement intake (p < 0.001), and dietary calcium intake (p = 0.036) and a reduction in coffee intake (p < 0.001) were found among subjects who attended the follow-up. In this study, the percentage of successful referrals was 41.86%. Subjects with osteoporosis were mostly prescribed alendronate plus vitamin D3 by medical doctors, and they followed the prescribed treatment accordingly. Conclusions: The bone health screening and education programmes in this study are effective in changing knowledge, beliefs, and practice regarding osteoporosis. The information is pertinent to policymakers in planning strategies to prevent osteoporosis and its associated problems among the middle-aged and elderly population in Malaysia. Nevertheless, a more comprehensive bone health education program that includes long-term monitoring and consultation is needed to halt the progression of bone loss.

Correlation between Hounsfield unit derived from head, thorax, abdomen, spine and pelvis CT and t-scores from DXA

OBJECTIVES

CT examination can potentially be utilised for early detection of bone density changes with no additional procedure and radiation dose. We hypothesise that the Hounsfield unit (HU) measured from CT images is correlated to the t-scores derived from dual energy X-ray absorptiometry (DXA) in multiple anatomic regions.

MATERIALS & METHODS

Data were obtained retrospectively from all patients who underwent both CT examinations - brain (frontal bone), thorax (T7), abdomen (L3), spine (T7 & L3) or pelvis (left hip) - and DXA between 2014 and 2018 in our centre. To ensure comparability, the period between CT and DXA studies must not exceed one year. Correlations between HU values and t-scores were calculated using Pearson's correlation. Receiver operating characteristic (ROC) curves were generated, and the area under the curve (AUC) was used to determine threshold HU values for predicting osteoporosis.

RESULTS

The inclusion criteria were met by 1043 CT examinations (136 head, 537 thorax, 159 lumbar and 151 left hip). The left hip consistently provided the most robust correlations (r = 0.664-0.708, p < 0.001) and the best AUC (0.875-0.893). Meanwhile, thorax T7 and lumbar L3 showed average correlations (range of r values is 0.497-0.679, p < 0.001, AUC range = 0.680-0.783, 95% CI 0.561-0.922, all p < 0.02) and moderate AUC (0.680-0.783). Frontal bone shows low correlation and weak AUC with r < 0.5, AUC = 0.538-0.655, all p > 0.05.

CONCLUSION

HU values derived from the hip, T7 and L3 provided a good to moderate correlation to t-scores with a good prediction for osteoporosis. The suggested optimal thresholds may be used in clinical settings after external validations are performed.

The global prevalence of osteoporosis in the world: a comprehensive systematic review and meta-analysis

BACKGROUND

Osteoporosis affects all sections of society, including families with people affected by osteoporosis, government agencies and medical institutes in various fields. For example, it involves the patient and his/her family members, and government agencies in terms of the cost of treatment and medical care. Providing a comprehensive picture of the prevalence of osteoporosis globally is important for health policymakers to make appropriate decisions. Therefore, this study was conducted to investigate the prevalence of osteoporosis worldwide.

METHODS

A systematic review and meta-analysis were conducted in accordance with the PRISMA criteria. The PubMed, Science Direct, Web of Science, Scopus, Magiran, and Google Scholar databases were searched with no lower time limit up till 26 August 2020. The heterogeneity of the studies was measured using the I2 test, and the publication bias was assessed by the Begg and Mazumdar's test at the significance level of 0.1.

RESULTS

After following the systematic review processes, 86 studies were selected for meta-analysis. The sample size of the study was 103,334,579 people in the age range of 15-105 years. Using meta-analysis, the prevalence of osteoporosis in the world was reported to be 18.3 (95% CI 16.2-20.7). Based on 70 studies and sample size of 800,457 women, and heterogenicity I2: 99.8, the prevalence of osteoporosis in women of the world was reported to be 23.1 (95% CI 19.8-26.9), while the prevalence of osteoporosis among men of the world was found to be 11.7 (95% CI 9.6-14.1 which was based on 40 studies and sample size of 453,964 men.). The highest prevalence of osteoporosis was reported in Africa with 39.5% (95% CI 22.3-59.7) and a sample size of 2989 people with the age range 18-95 years.

CONCLUSION

According to the medical, economic, and social burden of osteoporosis, providing a robust and comprehensive estimate of the prevalence of osteoporosis in the world can facilitate decisions in health system planning and policymaking, including an overview of the current and outlook for the future; provide the necessary facilities for the treatment of people with osteoporosis; reduce the severe risks that lead to death by preventing fractures; and, finally, monitor the overall state of osteoporosis in the world. This study is the first to report a structured review and meta-analysis of the prevalence of osteoporosis worldwide.

Therapeutic potential of annatto tocotrienol with self-emulsifying drug delivery system in a rat model of postmenopausal bone loss

Tocotrienol has been shown to prevent bone loss in animal models of postmenopausal osteoporosis, but the low oral bioavailability might limit its use. A self-emulsifying drug delivery system (SEDDS) could increase the bioavailability of tocotrienol. However, evidence of this system in improving the skeletal effects of tocotrienol is scanty. This study aims to evaluate the therapeutic efficacy of annatto tocotrienol with SEDDS in a rat model of postmenopausal bone loss. Ten-month-old female Sprague Dawley rats were randomized into six groups. The baseline group was euthanatized at the onset of the study. Four other groups underwent ovariectomy to induce estrogen deficiency. The sham underwent similar surgery procedure, but their ovaries were retained. Eight weeks after surgery, the ovariectomized rats received one of the four different regimens orally daily: (a) SEDDS, (b) annatto tocotrienol [60 mg/kg body weight (b.w.)] without SEDDS, (c) annatto-tocotrienol (60 mg/kg b.w.) with SEDDS, (d) raloxifene (1 mg/kg b.w.). After eight weeks of treatment, blood was collected for the measurement of delta-tocotrienol level and oxidative stress markers. The rats were euthanized and their bones were harvested for the evaluation of the bone microstructure, calcium content and strength. Circulating delta-tocotrienol level was significantly higher in rats receiving annatto tocotrienol with SEDDS compared to the group receiving unformulated annatto-tocotrienol (p < 0.05). Treatment with unformulated or SEDDS-formulated annatto tocotrienol improved cortical bone thickness, preserved bone calcium content, increased bone biomechanical strength and increased antioxidant enzyme activities compared with the ovariectomized group (p < 0.05). Only SEDDS-formulated annatto tocotrienol improved trabecular microstructure, bone stiffness and lowered malondialdehyde level (p < 0.05 vs the ovariectomized group). The improvement caused by annatto tocotrienol was comparable to raloxifene. In conclusion, SEDDS improves the bioavailability and skeletal therapeutic effects of annatto tocotrienol in a rat model of postmenopausal bone loss. This formulation should be tested in a human clinical trial to validate its efficacy.

Association of calcium intake, lactose intolerance and physical activity with bone health assessed via quantitative ultrasound among young adults of a Malaysian university

Lactose intolerance has been proposed to cause poor bone health. This study found the prevalence of lactose intolerance was high among Malaysian young adults, but not associated with bone health status, unlike calcium intake. This is the first study that investigated the association of lactose intolerance and bone health status in Malaysia.

PURPOSE

The aims of this study were to determine the prevalence of lactose intolerance, calcium intake and physical activity level and to investigate the association between these variables with bone health status among young adults.

METHODS

This cross-sectional study consisted of 300 Malay, Chinese and Indian students from Universiti Kebangsaan Malaysia with mean age of 22.5 ± 3.2 years. Determination of lactose tolerance status was performed using hydrogen breath test, lactose tolerance test and visual analogue scales. Calcium intake and physical activity level were evaluated using Food Frequency Questionnaire and International Physical Activity Questionnaire, respectively. Bone health status was assessed on calcaneal bone, using quantitative ultrasound.

RESULTS

Lactose intolerance was highly reported among the Malay subjects (72%) followed by Chinese (59%) and Indians (42%). The mean calcium intake was 542.9 ± 365.2 mg/day whilst the mean physical activity was 2757.6 ± 2007.2 MET-min/week. The bone assessment showed that 91% of the subjects had a low risk of developing osteoporosis. Only calcium intake showed a significant association with bone health status (β = 0.006; p = 0.033), whilst no association was shown for lactose intolerance and physical activity level.

CONCLUSIONS

Malaysian young adults showed a high prevalence of lactose intolerance. Calcium intake is associated with increased bone health status. In contrast, lactose intolerance and physical activity level did not directly influence bone health status. Nutrition education promoting adequate calcium intake should be implemented among young adults due to high lactose intolerance prevalence and low calcium intake among subjects.

Prevalence and factors of T-score discordance between hip and spine among middle-aged and elderly Malaysians

T-score discordance between hip and spine is a common problem in the diagnosis of osteoporosis based on dual-energy X-ray absorptiometry. Not much information on the prevalence and risk factors of this problem is available in Malaysia. Our study found that factors like age, height, physical activity and menopausal status should be taken into account in the diagnosis of osteoporosis.

INTRODUCTION AND OBJECTIVE

T-score discordance between hip and spine is a common problem in bone mineral density assessment. A difference ≥ 1 standard deviation (SD) (regardless of diagnostic class) is considered minor, and a difference more than one diagnostic class is considered major discordance. This study aimed to determine the prevalence and factors of hip and spine T-score discordance in a population aged ≥ 40 years in Klang Valley, Malaysia.

SUBJECTS AND METHODS

In this cross-sectional study, subjects answered a demographic questionnaire and underwent body composition and bone health assessment using dual-energy X-ray absorptiometry. Chi-square and binary logistic regression analysis were used to assess the prevalence of T-score discordance among the subjects.

RESULTS

A total of 786 Malaysians (382 men, 404 women) subjects were recruited. The prevalence of minor and major discordance was 30.3% and 2.3%, respectively. Overall, factors related to T-score discordance were advanced age, decreased height, and being physically active. Sub-analysis showed that decreased height and being physically active predicted T-score discordance in men, being menopausal and Indian (vs Chinese) were predictors in women.

CONCLUSIONS

T-score discordance between hip and spine is common among Malaysian middle-aged and elderly population. Diagnosis of osteopenia/osteoporosis should be based on the T-score of more than one skeletal site as per the current recommendations.

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

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

Determinants of Bone Health Status in a Multi-Ethnic Population in Klang Valley, Malaysia

Background and objectives: Studies on osteoporosis risk factors are limited in Malaysia, so this study assesses the factors associated with bone health assessed using dual-energy X-ray absorptiometry (DXA) among Malaysians aged ≥40 years. Subjects and Methods: Data on demography, medical history, dietary and lifestyle practices of 786 Malaysians (51.4% women) aged ≥40 years recruited in Klang Valley were obtained. Their body composition and bone health were determined using DXA. The association between risk factors and bone health status was assessed using binary logistic regression. Results: The prevalence of suboptimal bone health and osteoporosis was higher in women (59.4% and 16.1%) than men (40.8% and 8.4%). Overall, the predictors of suboptimal bone health and osteoporosis among the subjects were increased age and higher fat mass. Lower monthly income was positively associated with osteoporosis. Being menopausal was a risk factor for both suboptimal bone health and osteoporosis in women. Women with no formal education were more likely to get osteoporosis. Being a smoker and Chinese were positively related to suboptimal bone health among men. Meanwhile, predictors of osteoporosis among men were regular alcohol and dairy product consumption, higher fat mass and having a tertiary education. Conclusions: This study calls for immediate and effective interventions for middle-aged and elderly populations with risk factors to halt the progression of bone loss.