Hypovitaminosis D and Other Risk Factors of Femoral Neck Fracture in South Indian Postmenopausal Women: A Pilot Study

Femoral Neck Osteoporosis Is Associated with a Higher Odds of Coronary Artery Disease in Indian Postmenopausal Women: A Cross-sectional Study from a Teaching Hospital in Southern India

Purpose: Epidemiological studies have shown an association between coronary artery disease (CAD) and osteoporosis. We studied the prevalence of CAD among postmenopausal women with osteoporosis. Factors that were significantly associated with CAD were also assessed. Methods: This was a cross-sectional study conducted over a period of 2 years. Consecutive postmenopausal women aged ≥50 years were recruited. The details of an underlying CAD were obtained. Bone biochemical parameters, bone mineral density and body composition were assessed. Results: A total of 370 postmenopausal women with mean (standard deviation [SD]) ages of 61.6 (6.2) and 60.1 (6.0) years and a body mass index of 25.3 (14.1) kg/m2 were recruited. Among them, 110 of 370 patients (29.7%) had an underlying CAD and 222 of 370 (60%) had osteoporosis at either the femoral neck or lumbar spine (LS). The odds of CAD among those with osteoporosis were 3.5 (95% confidence interval [CI]: 2.1-5.9). An LS T-score of ≤-2.2 had a sensitivity of 80% and a specificity of 45% in predicting CAD (area under the curve, AUC: 0.736; 95% CI: 0.677-0.795; p<0.001). A femoral neck T-score of ≤-1.9 had a sensitivity of 80% and a specificity of 60% in predicting CAD (AUC: 0.748; 95% CI: 0.696-0.800; p<0.001). On a logistic regression analysis after adjusting for various clinical parameters, femoral neck osteoporosis had the highest odds of CAD. Conclusion: The prevalence of CAD was higher among postmenopausal women with osteoporosis. Femoral neck osteoporosis conferred the highest odds of CAD after adjustment for other clinical factors.

Osteoporosis in a Rural Community - Long-Term Effects of a Community Level Program of Calcium and Vitamin D Supplementation - A Prospective Observational Study

In a defined geographic area in rural India (1,60,000 population), osteoporosis detection and calcium and vitamin D supplementation program was instituted. Of the eligible 15,386 subjects, 5,992 (38%) participated in the program; 2,882 (48%) had osteopenia and osteoporosis; supervised calcium and vitamin D supplementation was instituted; 2,113 (73.3% of those identified) completed 2 years of supplementation. The mean duration of the follow-up was 5 years (range 2-8 years). On follow-up, three groups emerged; those who were regular, those who were irregular, and those who did not take supplements. In those who were regular with calcium and vitamin D supplementation, we found a significant reduction in fractures (RR 0.27, 95% CI 0.09-0.81) compared with those who did not take supplements. There was no significant difference in falls between the three groups. Mortality was significantly lower (RR 0.53, 95% CI 0.31-0.91) in those who were regular with calcium and vitamin D supplements compared to those who did not take supplements. While the reduction in fractures was probably due to calcium and vitamin D supplementation, the reduction in mortality was probably because those who took regular supplements accessed healthcare services more readily for other comorbidities as part of their follow-up program.

Bone Health after Fifth Decade in Rural Ambulatory South Indian Postmenopausal Women

Background:

The incidence of postmenopausal osteoporosis continues to rise, as population ages. The morbidity and mortality associated with osteoporotic fractures have a significant negative impact on the economy and quality of life of the affected individual and the community, at large.

Objectives:

We aimed to study the prevalence of osteoporosis in ambulant rural postmenopausal women, and to look at their dietary calcium intake (DCI) and Vitamin D status.

Subjects and Methods:

This was a cross-sectional study conducted in 1565 ambulant South Indian rural postmenopausal women. Bone mineral density was estimated by a dual-energy X-ray absorptiometry scan at the femoral neck (FN) and lumbar spine (LS). DCI was calculated by recall for the previous week, and the blood bone biochemical profile was measured.

Results:

The mean standard deviation (SD) age and body mass index of this population were 60.7 (7.2) years and 26.2 (4.8) kg/m², respectively. The prevalence of osteoporosis was 22% at the FN and 39% at the LS. An increase in the prevalence of osteoporosis was noted at both sites, in successive age categories. Mean (SD) DCI was 420 (282) mg/24 h. Fifty-four percent had Vitamin D deficiency (VDD) (<20 ng/ml) and 6% had severe VDD (<10 ng/ml).

Conclusion:

A significant proportion of this large cohort of south Indian healthy rural postmenopausal women had osteoporosis at either site with advancing age. Most of them had a suboptimal DCI, and over half of them had VDD.

Utility of FRAX (fracture risk assessment tool) in primary care and family practice setting in India

The prevalence of osteoporosis in postmenopausal women is about 35 to 50% and the mortality associated with hip fractures is about 20%. Despite these figures, osteoporosis continues to be under diagnosed in the primary care setting. One of the reasons for this is attributed to the poor availability of DXA (Dual Energy X-ray Absorptiometry) scanners in rural areas. The fracture risk assessment tool (FRAX) is an online web-based tool that takes into account multiple factors that help in predicting the 10-year risk of developing hip or major osteoporotic fractures. The tool was developed and validated in independent cohorts. The advantages of using the FRAX tool are that, it is inexpensive, easily available, and does not need the technical expertise that is required in the use of a DXA scanner. Besides these merits, it is a tool that is easy to use for the rural health care worker as well as the family physician in identifying those subjects at risk for developing osteoporotic fractures. These benefits make it a suitable fracture prediction tool in the primary care setting in India.

Osteoporosis knowledge and beliefs among postmenopausal women: A cross-sectional study from a teaching hospital in southern India

Objectives:

Osteoporosis continues to be underrecognized in many parts of India. This study was undertaken to assess the level of knowledge of osteoporosis among postmenopausal women referred for a dual-energy X-ray absorptiometry (DXA) scan in a teaching hospital in southern India.

Methodology:

This cross-sectional study assessed the state of awareness in consecutive postmenopausal women referred for a DXA scan using a validated questionnaire – Osteoporosis Knowledge Assessment Tool. The proportion of correct responses was expressed as percentages. The mean scores obtained were also compared between different educational groups.

Results:

A total of 302 consecutive postmenopausal women who were referred for DXA participated in this study. The mean (standard deviation) age of the postmenopausal women included in this study was 58.8 (6) years. Although most subjects were aware of the consequences of osteoporosis, there was generalized lack of awareness with regard to risk factors and available treatment options. Overall about 60% had poor awareness about osteoporosis.

Conclusion:

This study showed a gross deficit in awareness of osteoporosis in Indian postmenopausal women. There is a need to prioritize on designing appropriate awareness campaigns in subjects at risk, according to their level of literacy.

Influence of Different Reference Databases on Categorization of Bone Mineral Density: A Study on Rural Postmenopausal Women from Southern India

BACKGROUND AND OBJECTIVES

Currently available DXA (Dual energy X-ray Absorptiometry) scanners utilise bone mineral density (BMD) of Caucasian population to calculate T scores and categorise BMD. We studied the influence of various databases on classification of BMD in south-Indian postmenopausal women aged above 50 years.

METHODOLOGY

This was a cross-sectional study. Hologic DXA scanner was used to estimate BMD at lumbar spine (LS) and femoral neck (FN). T scores of ≤-2.5, -2.4 to -1, -0.9 to +1 were diagnostic of osteoporosis, osteopenia and normal respectively. Three reference databases(Italian, Korean and north Indian) were used to recalculate T scores. The agreement (K=kappa) between manufacturer provided database and the other databases was studied. The impact of different databases in diagnosing osteoporosis in subjects with FN fracture was assessed.

RESULTS

A total of 1956 postmenopausal women with mean (SD) age of 62 (4.3) years and 211 femoral neck(FN) fracture subjects with mean(SD) age of 68 (7.2) years were recruited. In subjects with fracture, osteoporosis at FN was found in 72% with Caucasian, 88% with North Indian, 56% with Italian, and 45% with Korean database. On comparing manufacturer provided database with the other population-specific reference, there was perfect agreement with north Indian (κ = 0.81 [FN], κ = 0.82 [LS]) and good agreement with the Italian database (κ = 0.78 [FN], κ = 0.74 [LS]).

CONCLUSION

North-Indian database identified most of the participants with FN fracture as having osteoporosis and had perfect agreement with the manufacturer's database. Follow up studies will further validate the impact of utilizing this database in clinical practice.

Investigation of the outcome of patients with hip fractures using vitamin D3

Hip fracture is one of the important health problems of human societies. The aim of this study was to investigate the outcome of patients with this fracture using vitamin D3. This double-blind clinical trial was performed on 100 patients with hip fractures who referred to Valiasr Hospital. All specimens were evaluated for vitamin D3. Group A have had vitamin D3 in the normal range and received a dose of 50,000 vitamin D3 as blouse. Group B included individuals with hip fractures that did not have normal vitamin D3 levels. In this group, individuals received a dose of 50,000 units vitamin D3 in the form of muscular blouse, and then 50,000 units of vitamin D3 were given orally each week up to 12 weeks after surgery. After surgery, both groups were examined clinically and radiologically for ulcer and fracture healing. Moreover, mortality was checked 2 weeks after surgery and each month until healing. There was no significant difference in radiographic examination in the two groups in the term of adhesion and fracture union (P <0.05). The formation of the union in the clinical examination 4 and 8 weeks after treatment in two groups showed significant difference. The formation of union in clinical presentation 4 weeks and 8 weeks after treatment in two groups showed significant difference (P = 0.005; P = 0.036). The results showed that a group with low vitamin D, but with supplementation, had more fracture union after 4 and 8 weeks after starting treatment. Vitamin D supplementation could improve patients' condition 4 and 8 weeks after treatment.

Association between Dental Health and Osteoporosis: A Study in South Indian Postmenopausal Women

Aim:

This study aims to objectively assess the dentition status in South Indian postmenopausal women and compare the dental health of osteoporotic participants with nonosteoporotic individuals.

Materials and Methods:

A total of 150 consecutive ambulatory South Indian postmenopausal women (>50 years of age) were assessed for their dental health using an internationally validated scoring system. Bone mineral density (BMD) was assessed using a dual-energy X-ray absorptiometry scanner.

Results:

About 39% of the participants were found to have osteoporosis and 23% had osteopenia at any site. More than half of them (57%) had poor dental health, and the predominant problems were cavities (43.5%) and loss of teeth (75%). Among 112 women who had tooth loss, the mean tooth loss was 4.8. The mean tooth loss among patients with normal BMD was 1.09 ± 1.2, in osteopenia was 2.1 ± 2, and in osteoporosis was 5.4 ± 2.8 (P < 0.01). The odds of having osteoporosis among the patients with three or more tooth loss were found to be 4.2 (95% confidence interval = 2.4–7.3).

Conclusion:

Postmenopausal women with osteoporosis had significantly higher number of tooth loss. Tooth loss may thus be used as a surrogate marker to predict osteoporosis.

Association of Vitamin D Deficiency and Thyroid Function in Postmenopausal Women

Pupose: Although there are reports of vitamin D (VitD) insufficiency in immune-mediated hypothyroidism, an association between VitD and thyroid-stimulating hormone (TSH) levels has yet to be shown. We aim to examine VitD and TSH levels among postmenopausal women, as both conditions are more prevalent in elderly women. Methods: The clinic records of postmenopausal women during their routine maintenance visits were reviewed. All patients were examined for the symptoms related to thyroid function and osteoporosis. Participants were divided into three subgroups according to their TSH levels (below <0.5 mIU/L, 0.51-4.0 mIU/L and >4.0 mIU/L). Patient characteristics and VitD levels were compared between these subgroups. Multivariate linear regression model was constructed using serum VitD and serum TSH as the dependent variables to identify factors independently associated with these laboratory values. Results: Two-hundred and nighty nine postmenopausal women were included. Average age was 62.2±7.5 years old. VitD was insufficient (10-30 ng/mL) in 12.0% and deficient (<10 ng/mL) in 60.9% of the participants. In 11.3%, TSH was low and in 7.6% of women, TSH was high, while the remaining 80.1%, had normal TSH levels. Subjects with low TSH had significantly higher VitD concentrations (34.2±29.1 ng/mL) compared to the other two groups (P-value: 0.039). In multivariate regression analysis, TSH was not a contributing factor, as age was the only significant predictor of VitD levels. Meanwhile, no predictor (including age and VitD) was identified for TSH levels in linear regression analysis. Conclusion: Age was the only independent predictor of serum VitD in this study population. Though suppressed TSH was associated with higher VitD levels, the association was not linear between TSH and VitD in postmenopausal women.

Bone turnover markers: Emerging tool in the management of osteoporosis

Bone is a dynamic tissue which undergoes constant remodeling throughout the life span. Bone turnover is balanced with coupling of bone formation and resorption at various rates leading to continuous remodeling of bone. A study of bone turnover markers (BTMs) provides an insight of the dynamics of bone turnover in many metabolic bone disorders. An increase in bone turnover seen with aging and pathological states such as osteoporosis leads to deterioration of bone microarchitecture and thus contributes to an increase in the risk of fracture independent of low bone mineral density (BMD). These microarchitectural alterations affecting the bone quality can be assessed by BTMs and thus may serve as a complementary tool to BMD in the assessment of fracture risk. A systematic search of literature regarding BTMs was carried out using the PubMed database for the purpose of this review. Various reliable, rapid, and cost-effective automated assays of BTMs with good sensitivity are available for the management of osteoporosis. However, BTMs are subjected to various preanalytical and analytical variations necessitating strict sample collection and assays methods along with utilizing ethnicity-based reference standards for different populations. Estimation of fracture risk and monitoring the adherence and response to therapy, which is a challenge in a chronic, asymptomatic disease such as osteoporosis, are the most important applications of measuring BTMs. This review describes the physiology of bone remodeling, various conventional and novel BTMs, and BTM assays and their role in the assessment of fracture risk and monitoring response to treatment with antiresorptive or anabolic agents.