Nutritional Guidelines for Osteoporosis
Sisira Siribaddana Director SLTR Staff Specialist in Medicine SJGH
Introduction
Guidelines Sri Lankan research Post guidelines development
Disease
Risk factor Clinical presentation
Stroke
Hypertension High BP CHD
Gout Osteoporosis
Dyslipidaemia
Myocardial infarction Hyperuricaemia Arthritis
Low BMD Fracture
Population Projections for Sri Lanka
Year Projected Projected % of Pop Old age pop over pop over 60 60 years dependency (‘000) years (‘000)
1991 17 015 2041 22 693
8.2 27.8
1395 6308
13.50% 47.90%
Cost of Current Therapy for Osteoporosis
Estrogen Calcium 0.625 mg 1000 mg†
$400/yr*
$35/yr $750/yr
Alendronate 5-10 mg
Calcitonin
Raloxifene
† In
200 IU
60 mg
$750/yr
$750/yr
*Includes usual cost of progestin necessary for most women for uterine protection. addition to the average 500 mg dietary source.
From the National Osteoporosis Foundation, 1998.
Guidelines
Meth; Mai Private Formal Face Inter Aggreg led deci; feedb; to face ac; ation Q elicited of struct method group ured choices
Inform al Delphi no no no yes no yes yes no no yes Implicit Explicit
NGT
no
Yes
yes no
Yes
yes no
yes
yes yes
yes
yes no
Explicit
Explicit implicit
Rand Yes version CDC no
Consensus Development Conference
SLMA
College
of Physicians College of Ob & Gyn College of Pediatrics Orthopedic Association NGO – Rotary and Sarvodaya
Contributorship
NUTRITIONAL 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 Ethics
As
research into Osteoporosis is inadequate the guidelines have borrowed heavily from abroad Disclosure of the conflict of interests – As charity funding NA
Evidence Based Guidelines
Literature
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Grading
of evidence A – RCT or L Cohort > 3000 B – L Cohort or Case control > 200 C – Case control or Cross Sec.>300 D – Cross sectional < 300
Effect on Diary Foods on Bone Health
Category of evidence No effect Favorable Unfavorable
A
B
6
6
5
1
1
2
C
D
11
7
11
7
0
0
Breaking the 400 mg barrier
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
“Adaptation
USA Study
– 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 N Engl J Med 1997;337:70-6 (1.2%)
Reduction of Nonvertebral Fracture with Calcium and Vitamin D
14 12 10 % 8 6 4
Fracture
2 0
6
p=0.02
12
18
24
30
36
Months
Dawson-Hughes B et al, N Engl J Med 1997;337:670.
Placebo Calcium + Vitamin D
French Study
– 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 BMJ 1994;308:1081-2 – increase in BMD of the femoral neck
Summary of the guidelines
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 day Vitamin D Adequate exercise
Sri Lankan Research
Indo Asians
Hip
fractures occur at a relatively earlier age compared to Europids Higher male-to-female ratio Shorter hip axis length High prevalence of fluorosis
Determining the Prevalence of Fragility Fracture Rates Calcium Intake and BUA in Suburban Sri Lankan Population
(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 -1
Calcium intake from SQFFQ. To measure the BUA & Stiffness using “Lunar Achilles” ultrasound. 700 females from The SJU community survey.
Aim & Methods -2
Randomization based on streets from 3 PHW areas All house hold members over 20 years invited Quality assurance through repeated measures of 15 medical students
Ultrasound Measurement of the Bone
Inexpensive
and radiation free scanning device for low bone mass. Qualitative aspects that determine the bone strength. Transmission of sound through tissue leads to alterations in two acoustic properties, wave velocity and wave amplitude.
90
Decline of stiffness index with age
stiffness index
80 70 60 50 Stiffness
40 21-30 31-40 41-50 51-60 61-70 71-8
Ca Intake-Females
Age Number 21-30 31-40 41-50 51-60 61-70 71-80
143
144
159
166
70
24
Mean(mg) SD
1458 1481 1452 1456 1372 1301 578 534 469 536 492 463
Main Sprats Sprats Sprats Sprats Sprats K’mur Contributor unga
Discussion-1
Age
regression of stiffness index. =70.179 + age (-0.319). BUA & stiffness declines dramatically after 50 years. Ref value 20-30 year age group. T scores calculated. Prevalence over 20 years 3.2%.
Discussion-2
Ca.
intake is high but SD is also high (500). implying a large variation in Ca. intake. Despite high Ca intake low BUA & stiffness. Participants are overestimating or lowbioavailability of Ca.? Lack of physical activity ?
Post Guidelines Developments
GlucocorticoidInduced 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 Fracture Risk
Relative risk of fracture compared with control 6 5 4 3 2 1 0
n= 2192 531 236 191 2486 526 494 440 1665 273 328 400 1.17 1.1 0.99 1.55
All nonvertebral Forearm Hip Vertebral
2.59
5.18
2.27 1.64 1.19
1.77
1.36 1.04
Low dose (<2.5 mg/d)
van Staa TP et al, 2000.
Medium dose (2.5–7.5 mg/d)
High dose (>7.5 mg/d)
Options for Prevention and Treatment of GIO:
Calcium and vitamin D Hormone replacement therapy Bisphosphonates
supplementation
Risedronate: FDA approved for
prevention and treatment
Alendronate: FDA approved for
treatment
Calcitonin PTH
Calcium, Vitamin D in 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 mass in prepubertal girls- 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 Forwards
Audit
of implementation of the guidelines More research That’s all folks