Prevention and risk factors of osteoporosis

Prof.Dr.Selma KARABEY

• Osteoporosis is defined as a systemic skeletal disease characterised by

• low bone mass • microarchitectural deterioration of bone tissue• with a consequent increase in bone fragility • susceptibility to fracture

• Fractures of the hip, vertebrae, and distal radius are particularly common.

• The WHO has defined osteoporosis as bone mineral density more than 2.5 standart deviations below the mean value of peak bone mass in young adults of the same sex.

Scope of the Problem

• More than 8.9 million Americans have osteoporosis and an additional 42.5 million have low bone density of the hip

• About one out of every two Caucasian women will experience an osteoporosis-related fracture at some point in her lifetime, as will approximately one in five men.

• Although osteoporosis is less frequent in African Americans, those with osteoporosis have the same elevated fracture risk as Caucasians.

National Health and Nutrition Examination Survey III (NHANES III) Wright NC, Looker A, Saag K, Curtis JR, Delzell ES, Randall S, Dawson-Hughes B. The recent prevalence of osteoporosis and low bone mass based on bone mineral density at the femoral neck or lumbar spine in the United States. Submitted manuscript, 2013. National

• Distribution of bone mineral density in different aged women and the prevalance of osteoporosis (blue)

Kanis et al. J Bone Miner Res 1994; 9:1137-41

Scope of the Problem

• Hip fracture incidence rates are highest among whites in northern Europe and North America

• Lower among Asians living in developed areas such as Hong Kong and the United States

• Still lower among Hispanics and Blacks in the United States and in South America

• Lowest in less developed areas of Asia (China), as well as in Africa

Age-adjusted incidence rates per 100 000 of hip fracture among females and males aged 50 years and older in selected localities

Locality Females Males

Beijing, China 96 107

Porto Alegra, Brazil 202-327.2 104.7-169.6

Budapest, Hungary 316 251

Hong Kong 428.3 269.6

Reykjavik, Iceland 696.6 348.7

İnternational variation in the incidence of hip factures:cross-national project on osteoporosis for the WHO Program for Research on Aging, Osteoporosis İnternational , Schwartz A.V.,Kelsey J.L., Maggi S et al.1999,9,242-253

Scope of the Problem

• The remaining lifetime probability in women, at menopause, of a fracture at any one of these sites

the spine, hip, distal forearm proximal humerus exceeds that of breast cancer (approximately 12 %),• the likelihood of a fracture at any of these sites is 40 %

or more in Western Europe,a figure close to the probability of coronary heart disease

European guidance for the diagnosis and management of osteoporosis in postmenopausal women, J. A. Kanis & E. V. McCloskey & H. Johansson, Osteoporos Int (2013) 24:23–57

Medical Impact

• Hip fractures are associated with a 8.4 to 36 percent excess mortality within one year, with a higher mortality in men than in women;

• hip fractures are followed by a 2.5-fold increased risk of future fractures.(1)

• Approximately 20 per cent of hip fracture patients require long-term nursing home care,

• only 40 per cent fully regain their pre-fracture level of independence.(2)

• 1)B. Abrahamsen, van Staa T, ArielyR, Olson M, Cooper C. Excess mortality following hip fracture: a systematic epidemiological review. Osteoporos Int. 2009; 20:(10):1633–1650.

• 2)Colón-Emeric C, Kuchibhatla M, Pieper C, et al. The contribution of hip fracture to risk of subsequent fracture: Data from two longitudinal studies. Osteoporos Int. 2003;(14):879-883.

Medical Impact

Vertebral fractures, whether clinically apparent or silent, are major predictors of future fracture risk, • up to 5-fold for subsequent vertebral fracture • 2- to 3-fold for fractures at other sites.

• 1)US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: 2004.US Department of Health and Human Services, Office of the Surgeon General; 2004.

Ten year probability of a hip fracture in women from different European countries. BMI set to 24 kg/m2

• In Turkey, osteopenia has been identified in the half of the adults.

• Osteoporosis has been identified one in four of adults.• In Turkey, the rate of hip fractures has increased over

the years.

MEDOS (1995) 3.3/10000 FRACTURK(2012) 13.24/10000• Hip fractures are more common in urban areas. • Hip fractures are lower in physically active individuals.

Economic Toll

• Collectively, all osteoporotic fractures account for 2.7 million fractures in men and women in Europe at a direct cost (2006) of €36 billion.

• A more recent estimate (for 2010) calculated the direct costs at €29 billion in the five largest EU countries (France, Germany, Italy, Spain and UK) and

• €38.7 billion in the 27 EU countries• European guidance for the diagnosis and management of osteoporosis in postmenopausal women, J. A. Kanis & E. V. McCloskey & H.

Johansson, Osteoporos Int (2013) 24:23–57

BASIC PATHOPHYSIOLOGY

RİSK FACTORS

PREVENTION AND MANAGEMENT OF OSTEOPOROSIS,Report of a WHO Scientific Group, 2003

European guidance for the diagnosis and management of osteoporosis in postmenopausal women, J. A. Kanis & E. V. McCloskey & H. Johansson, Osteoporos Int (2013) 24:23–57

Uncontrollable Risk Factors

•Being over age 50. •Being female. (White and Asian) •Menopause. •Family history of osteoporosis. •Low body weight/being small and thin. •Broken bones or height loss.

Controllable Risk Factors

•Not getting enough calcium and vitamin D. •Not eating enough fruits and vegetables. •Getting too much protein, sodium and caffeine. •Having an inactive lifestyle. •Smoking. •Drinking too much alcohol. •Loosing weight.

TYPES OF OSTEOPOROSİS

Type 1 or postmenopausal osteoporosis

• Occurs in 5% to 20% of women, • affecting those within 15 to 20 years of menopause,• with a peak incidence in the 60s and early 70s.

• The incidence in women is eight times higher than that in men.

• The frequency of postmenopausal osteoporosis accounts for the overall female-male ratio of 2:1 to 3:1.

Type 1 or postmenopausal osteoporosis

• Estrogen deficiency is thought to underlie this form of osteoporosis,

• rendering the skeleton more sensitive to parathyroid hormone (PTH),

• resulting in increased calcium resorption from bone• This in turn decreases PTH secretion, 1,25-

dihydroxyvitamin D production, and calcium absorption • ultimately causes loss of trabecular bone, • leading to vertebral crush fractures and Colles'

fractures.

Type 2 or senile osteoporosis

• Occurs in women or men more than 70 years of age • usually is associated with decreased bone formation

along with decreased ability of the kidney to produce 1,25(OH)2D3.

Type 2 or senile osteoporosis

• The vitamin D deficiency results in decreased calcium absorption,

• which increases the PTH level and therefore bone resorption.

• In type 2 osteoporosis, cortical and trabecular bone is lost,

• primarily leading to increased risk of hip, long bone, and vertebral fractures

Type 3 or secondary osteoporosis

• Occurs equally in men and women and at any age. • In men, most cases are due to disease or to drug

therapy, • but in 30% to 45% of affected individuals no cause can

be identified• Secondary osteoporosis accounts for about 40% of the

total number of osteoporotic fractures seen by a physician

DİAGNOSİS

The diagnosis of osteoporosis is established

• by measurement of BMD or • by the occurrence of adulthood hip or • vertebral fracture in the absence of major trauma (such

as a motor vehicle accident or multiple story fall).

Prevention

• an adequate intake of calcium and vitamin D,

• lifelong participation in regular weight-bearing and muscle-strengthening exercise,

• cessation of tobacco use, identification and treatment of alcoholism, and

• treatment of other risk factors for fracture such as impaired vision.

Calcium Supplementation

• The recommended daily calcium intake is 1,500 mg for postmenopausal women and 1,000 mg for pre-menopausal women.

• However, recent study has shown that supplementation of 800 mg of calcium daily may prevent bone loss in post-menopausal women

Calcium Supplementation

• the results of clinical trials also suggest that such supplementation may prevent hip and vertebral fractures in the elderly

• The combination of calcium (1.2 g/day) with vitamin D3 (800 IU/day) has been reported to prevent fractures in elderly women.

World Osteoporosis Day

• World Osteoporosis Day was launched on 20 October 1996 by the United Kingdom's National Osteoporosis Society and supported by European Commission.

• Since 1997, the day has been organized by IOF ⃰.

• In 1998 and 1999, the World Health Organization acted as co-sponsor of World Osteoporosis Day.

• Since 1999, World Osteoporosis Day campaigns have featured a specific theme:

• 1999 Early Detection• 2000 Building Bone Health• 2001 Bone Development in Youth• 2002 Osteoporosis in the Workplace• 2003 Quality of Life• 2004 Osteoporosis in Men• 2005 Exercise• 2006 Nutrition• 2007 Risk Factors• 2008 Advocate for Policy Change• 2009 Advocate for Policy Change• 2010 Signs and Symptoms of Spinal Fractures• 2011 3 Steps to Unbreakable Bones: Vitamin D, Calcium and Exercise• 2012 Stop at One: Make Your First Break Your Last• 2013 Postmenopausal women and their bone health

‘School Milk’ Programs in the World

• In more than 80 countries around the world the School Milk project was implemented, in different periods.

• Netherlands, Denmark, Czech Republic, China, Portugal and Sweden are the most successful of them.

‘School Milk’ Programs in the World

• EU:26 countries - except Greece and Croatia- joined the program conducted by the European Dairy Association, between the years 2011-12 in EU.

• 312 thousand 700 tons of milk consumed by 20 million 358 thousand children.

• China:School Milk Programme launched by the government in 2000.

• 18 million students drank milk every day at school in 2012. Program has been extended to 28 states, 660 cities and 60 thousand schools.

‘School Milk’ Programs in Turkey

• 7 million 200 thousand 144 million cans of milk were distributed to students 32 thousand 500 schools in Turkey ,in 2011-2012 Academic Year.

• 296 million cans of milk were distributed to 6 million 172 thousand 692 master classes and elementary school students in Turkey, in 2012-2013 Acedemic Year.

• From 10 February 2014, 303 million boxes,in reliable, 200 mL healthy packaging, fat, plain UHT milk will be distributed to 6 million 330 thousand 215 students, 3 days a week (Monday, Wednesday, Friday)

References and Web Sources • Clinician’s Guide to Prevention and Treatment of Osteoporosis, 2013 Issue, Version 3

Released February 25, 2014,National Osteoporosis Foundation (NOF).• http://nof.org/files/nof/public/content/file/2237/upload/878.pdf

• Oxford Textbook of Public Health, Musculoskeletal Diseases,Roger Detels, Robert Beaglehole, Mary Ann Lnsang, Martin Gulliford,2009, vol 3,

• Ostoporozun Kontrolü ve Önlenmesi için Yapılan Uygulamalar,Yrd. Doç. Dr. Nurcan Yabancı

• http://www.beslenme.gov.tr/content/files/yayinlar/sunumlar/sut_ve_osteoporoz/osteorozunkontrolu_nurcan.pdf

• European guidance for the diagnosis and management of osteoporosis in postmenopausal women, J. A. Kanis & E. V. McCloskey & H. Johansson, Osteoporos Int (2013) 24:23–57

• PREVENTION AND MANAGEMENT OF OSTEOPOROSIS,Report of a WHO Scientific Group, 2003

• http://whqlibdoc.who.int/trs/WHO_TRS_921.pdf

References and Web Sources

• Osteoporoz ve egzersiz, Prof.Dr.Gül Baltacı• http://www.beslenme.gov.tr/content/files/yayinlar/sunumlar/sut_ve_osteopor

oz/osteopozveegzersiz_gulbaltaci.pdf• Osteoporosis: Epidemiology, Diagnosis, and Treatment,Mohammad Masud

Iqbal, South Med J. 2000;93(1)• http://www.medscape.com/viewarticle/410461_3• Türkiye Osteoporoz Derneği• http://www.osteoporoz.org.tr/resimler/buyuk/T%C3%BCrkiye%20Kal%C3%

A7a%20K%C4%B1r%C4%B1%C4%9F%C4%B1%20%C4%B0nsidans%C4%B1%20ve%20Osteoporoz%20Prevalans%C4%B1.pdf

• International Osteoporosis Foundation• http://www.iofbonehealth.org/world-osteoporosis-day• Okul sütü programı• www.okulsutu.com• Epidemiology of osteoporosis, Christopher Holroyd, Best Practice &

Research Clinical Endocrinology & Metabolism, Vol. 22, No. 5, pp. 671–685, 2008