Nutritional Guidelines for Osteoporosis

Document Sample
Nutritional Guidelines for Osteoporosis Powered By Docstoc
					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

Hypertension High BP           Stroke

CHD            Dyslipidaemia  Myocardial
                              infarction
Gout           Hyperuricaemia Arthritis

Osteoporosis   Low BMD         Fracture
Population Projections
    for Sri Lanka
                          Projected
       Projected % of Pop
                          pop over   Old age
Year     pop     over 60
                          60 years dependency
        (‘000)    years
                           (‘000)

1991 17 015       8.2      1395    13.50%

2041 22 693       27.8     6308    47.90%
Cost of Current Therapy
   for Osteoporosis
Estrogen                0.625 mg                           $400/yr*
Calcium                 1000 mg†                           $35/yr
Alendronate 5-10 mg                                        $750/yr
Calcitonin              200 IU                             $750/yr
Raloxifene              60 mg                              $750/yr
*Includes usual cost of progestin necessary for most women for uterine
protection.
† In   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   no   no    no    yes   no    Implicit
   al

Delphi   no   yes   yes   no    yes   Explicit
NGT      no   Yes   Yes   yes   yes   Explicit
 Rand Yes     yes   yes   yes   yes   Explicit
version

CDC      no   no    no    yes   no    implicit
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   search with search engine
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
              No effect   Favorable Unfavorable
 evidence

    A            6           5           1
    B            6           1           2
    C           11          11           0
    D            7           7           0
   Breaking the 400 mg
         barrier
 “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 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
  (1.2%)     N Engl J Med 1997;337:70-6
         Reduction of Nonvertebral
         Fracture with Calcium and
                 Vitamin D
                    14
                    12
                    10

            %       8

         Fracture   6
                    4
                    2
                    0
                         6      12    18   24   30   36

                             Months             Placebo
p=0.02
Dawson-Hughes B et al, N Engl J Med             Calcium + Vitamin D
 1997;337:670.
    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
– increase in BMD of the femoral neck
                BMJ 1994;308:1081-2
      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.
                       Decline of stiffness index with age
                  90
stiffness index


                  80
                  70
                  60
                                      Stiffness
                  50
                  40
                   21-30 31-40 41-50 51-60 61-70 71-8
         Ca Intake-Females
Age        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        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 low-
  bioavailability of Ca.?
 Lack of physical activity ?
    Post
 Guidelines
Developments
       Glucocorticoid-
    Induced 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
                              6       All nonvertebral
  Relative risk of fracture
  compared with control




                                                                                                 5.18
                              5       Forearm
                                      Hip
                              4       Vertebral
                              3                                             2.59
                                                                                              2.27
                              2                                      1.77          1.64
                                                   1.55   1.36
                                   1.17 1.1 0.99              1.04                     1.19
                              1
                              0
                              n=   2192 531 236 191          2486 526 494 440            1665 273 328 400
                                     Low dose             Medium dose                High dose
                                    (<2.5 mg/d)           (2.5–7.5 mg/d)            (>7.5 mg/d)
van Staa TP et al, 2000.
Options for Prevention and
    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
           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

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:117
posted:4/10/2008
language:English
pages:34