Nutritional Guidelines for Nutritional Guidelines for OsteoporosisOsteoporosis

Sisira SiribaddanaSisira Siribaddana

Director SLTRDirector SLTR

Staff Specialist in Staff Specialist in Medicine SJGHMedicine SJGH

IntroductionIntroduction

GuidelinesGuidelines

Sri Lankan researchSri Lankan research

Post guidelines developmentPost guidelines development

DiseaseDisease Risk factorRisk factor Clinical Clinical presentationpresentation

HypertensionHypertension High BPHigh BP StrokeStroke

CHDCHD DyslipidaemiaDyslipidaemia Myocardial Myocardial infarctioninfarction

GoutGout HyperuricaemiaHyperuricaemia ArthritisArthritis

OsteoporosisOsteoporosis Low BMDLow BMD FractureFracture

Population Projections Population Projections for Sri Lankafor Sri Lanka

Year Projected

pop (‘000)

% of Pop over 60 years

Projected pop over 60 years

(‘000)

Old age dependency

1991 17 015 8.2 1395 13.50%

2041 22 693 27.8 6308 47.90%

Cost of Current Therapy Cost of Current Therapy for Osteoporosisfor Osteoporosis

From the National Osteoporosis Foundation, 1998.

Estrogen

Calcium

Alendronate

Calcitonin

Raloxifene

0.625 mg

1000 mg†

5-10 mg

200 IU

60 mg

$400/yr*

$35/yr

$750/yr

$750/yr

$750/yr*Includes usual cost of progestin necessary for most women for uterine protection.

† In addition to the average 500 mg dietary source.

GuidelinesGuidelines

Meth; Mailed Q

Private deci;

elicited

Formal feedb;

of group

choices

Face to face

Interac;

structured

Aggregation

method

Informal

no no no yes no Implicit

Delphi no yes yes no yes Explicit

NGT no Yes Yes yes yes Explicit

Rand version

Yes yes yes yes yes Explicit

CDC no no no yes no implicit

Consensus Development Consensus Development ConferenceConference

SLMACollege of PhysiciansCollege of Ob & GynCollege of PediatricsOrthopedic AssociationNGO – Rotary and Sarvodaya

ContributorshipContributorshipNUTRITIONAL SUB-COMMITTEE Dr Antoinette Herath (Rheumatologist)Dr. Nilangi Devapura (Epidemiologist)Mrs. N Iqbal (Nutritionist )Dr. Chandrani Piyasena (Nutritionist)Mrs. Anoma Ratnayake (Nutritionist )Dr. Lalith Wijeratne (Rheumatologist)

Panelists in the consensus development process

Publication EthicsPublication EthicsAs research into Osteoporosis is

inadequate the guidelines have borrowed heavily from abroad

Disclosure of the conflict of interests – As charity funding NA

Evidence Based Evidence Based GuidelinesGuidelines

Literature search with search engineGrading of evidenceA – RCT or L Cohort > 3000B – L Cohort or Case control > 200C – Case control or Cross Sec.>300D – Cross sectional < 300

Effect on Diary Foods Effect on Diary Foods on Bone Healthon Bone Health

Category of evidence

No effect Favorable Unfavorable

A 6 5 1

B 6 1 2

C 11 11 0

D 7 7 0

Breaking the 400 mg Breaking the 400 mg barrierbarrier

“Adaptation to low Ca intake in reference to the calcium requirements of a tropical population” Lucius Nichollas & Ananda Nimalasuriya-Observational study in 1939

3 large RCT in 1990’s with long term follow up

WHO guidelines recommending 1000

USA StudyUSA Study

N Engl J Med 1997;337:70-6

–389 men and women over age >63– treated with calcium (500 mg per

day) and vitamin D (700 IU per day)–decreased rate of non-vertebral

fractures with only a small increase in BMD of the lumbar spine (0.9%), femoral neck (1.2%), and total body (1.2%)

Reduction of Nonvertebral Reduction of Nonvertebral Fracture with Calcium and Fracture with Calcium and

Vitamin DVitamin D

%

Fracture

Monthsp=0.02

Dawson-Hughes B et al, N Engl J Med 1997;337:670.

6 12 18 24 30 360

2

4

6

8

10

12

14

PlaceboCalcium + Vitamin D

French StudyFrench Study

BMJ 1994;308:1081-2

–3270 institutionalized women– treated with calcium (1200 mg per day)

and vitamin D (800 IU per day) for 3 yrs–risk of hip fracture was reduced by 30%–reversal of secondary

hyperparathyroidism– increase in BMD of the femoral neck

Summary of the Summary of the guidelinesguidelines

Adequate calcium intake– teenagers and postmenopasal women not

taking estrogen need 1,500 mg of calcium per day

–other adults need 1,000 mg per dayVitamin DAdequate exercise

Sri Lankan Sri Lankan ResearchResearch

Indo AsiansIndo AsiansHip fractures occur at a Hip fractures occur at a

relatively earlier age compared relatively earlier age compared to Europids to Europids

Higher male-to-female ratioHigher male-to-female ratioShorter hip axis length Shorter hip axis length High prevalence of fluorosisHigh prevalence of fluorosis

Determining the Prevalence of Determining the Prevalence of Fragility Fracture Rates Calcium Fragility Fracture Rates Calcium Intake and BUA in Suburban Sri Intake and BUA in Suburban Sri

Lankan PopulationLankan Population(Siribaddana, Deshabandu, Hewage, Fernando)(Siribaddana, Deshabandu, Hewage, Fernando) One year after hip fracture, 40% of

patients unable to walk independently About 40% Caucasian women suffer at

least one osteoporotic fracture after the age of 50 years

Aim & Methods -1Aim & Methods -1Calcium intake from SQFFQ.To measure the BUA & Stiffness using “Lunar Achilles” ultrasound.700 females from The SJU community survey.

Aim & Methods -2Aim & Methods -2Randomization based on streets from 3 PHW areasAll house hold members over 20 years invitedQuality assurance through repeated measures of 15 medical students

Ultrasound Measurement Ultrasound Measurement of the Boneof the Bone

Inexpensive and radiation free scanning Inexpensive and radiation free scanning device for low bone mass.device for low bone mass.

Qualitative aspects that determine the Qualitative aspects that determine the bone strength.bone strength.

Transmission of sound through tissue Transmission of sound through tissue leads to alterations in two acoustic leads to alterations in two acoustic properties, wave velocity and wave properties, wave velocity and wave amplitude.amplitude.

Decline of stiffness index with age

Stiffness

40

50

60

70

80

90

21-30 31-40 41-50 51-60 61-70 71-80

age group

stiff

ness

inde

x

Ca Intake-FemalesCa Intake-FemalesAge 21-30 31-40 41-50 51-60 61-70 71-80

Number 143 144 159 166 70 24

Mean(mg) 1458 1481 1452 1456 1372 1301

SD 578 534 469 536 492 463

Main Contributor

Sprats Sprats Sprats Sprats Sprats K’murunga

Discussion-1Discussion-1Age regression of stiffness index.Age regression of stiffness index.=70.179 + age (-0.319).=70.179 + age (-0.319).BUA & stiffness declines BUA & stiffness declines

dramatically after 50 years.dramatically after 50 years.Ref value 20-30 year age group.Ref value 20-30 year age group. T scores calculated.T scores calculated.Prevalence over 20 years 3.2%Prevalence over 20 years 3.2%.

Discussion-2Discussion-2Ca. intake is high but SD is also high Ca. intake is high but SD is also high

(500).(500).implying a large variation in Ca. intake.implying a large variation in Ca. intake.Despite high Ca intake low BUA & Despite high Ca intake low BUA &

stiffness.stiffness.Participants are overestimating or low-Participants are overestimating or low-

bioavailability of Ca.?bioavailability of Ca.?Lack of physical activity ?Lack of physical activity ?

Post Post Guidelines Guidelines

DevelopmentsDevelopments

Glucocorticoid-Glucocorticoid-Induced OsteoporosisInduced Osteoporosis

The most common secondary form of osteoporosis

Systemic skeletal disease

– Associated with long-term steroid use

– Serious side effects of glucocorticoids

Bone loss resulting in GIO

Increase in fracture risk

Glucocorticoid Use and Glucocorticoid Use and Fracture RiskFracture Risk

1.17 1.361.64

1.1 1.04 1.190.99

1.772.27

1.55

2.59

5.18

0

1

2

3

4

5

6

Low dose Medium dose High dose

All nonvertebralForearmHip

Vertebral

n = 2192531 236 191 2486526494 440 1665273 328 400Rela

tive r

isk o

f fr

actu

recom

pare

d w

ith

con

trol

van Staa TP et al, 2000.

(<2.5 mg/d) (2.5–7.5 mg/d) (>7.5 mg/d)

Options for Prevention and Options for Prevention and Treatment of GIO:Treatment of GIO:

Calcium and vitamin D supplementation Hormone replacement therapy

Bisphosphonates Risedronate: FDA approved for

prevention and treatment

Alendronate: FDA approved for treatment

Calcitonin PTH

Calcium, Vitamin D in Calcium, Vitamin D in GIO:GIO:

Calcium and vitamin D supplementation

–Should be offered to all patients on glucocorticoids

–Helpful alone with low, medium glucocorticoid doses

–Not effective alone with medium, high doses

Gain in bone mineral Gain in bone mineral mass in prepubertal mass in prepubertal girls- Lancet 2001girls- Lancet 2001

Milk extracted Ca caused long standing increase in bone mass accrual which lasts beyond the end of supplementation

RCT-double blind & placebo controlled – 116 of the 144 girls followed

Sponsored by Swiss NSF and Nestec

Way ForwardsWay ForwardsAudit of implementation of the

guidelinesMore research

That’s all folks