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Nutritional Guidelines for Osteoporosis Nutritional Guidelines for Osteoporosis Sisira Siribaddana...
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Transcript of Nutritional Guidelines for Osteoporosis Nutritional Guidelines for Osteoporosis Sisira Siribaddana...
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