Nutritional Guidelines for Osteoporosis

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Nutritional Guidelines for Osteoporosis

• Sisira Siribaddana
• Director SLTR
• Staff Specialist in Medicine SJGH

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Introduction

• Guidelines
• Sri Lankan research
• Post guidelines development

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Disease Risk factor Clinical presentation
Hypertension High BP Stroke
CHD Dyslipidaemia Myocardial infarction
Gout Hyperuricaemia Arthritis
Osteoporosis Low BMD Fracture
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Population Projections for Sri Lanka
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Cost of Current Therapy for Osteoporosis
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.
From the National Osteoporosis Foundation, 1998.
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Guidelines
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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
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Consensus Development Conference

• SLMA
• College of Physicians
• College of Ob Gyn
• College of Pediatrics
• Orthopedic Association
• NGO Rotary and Sarvodaya

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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

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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

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Evidence Based Guidelines

• Literature search with search engine
• Grading of evidence
• A RCT or L Cohort gt 3000
• B L Cohort or Case control gt 200
• C Case control or Cross Sec.gt300
• D Cross sectional lt 300

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Effect on Diary Foods on 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
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Breaking the 400 mg barrier

• Adaptation to low Ca intake in reference to the
  calcium requirements of a tropical population
  Lucius Nichollas Ananda Nimalasuriya-Observation
  al study in 1939
• 3 large RCT in 1990s with long term follow up
• WHO guidelines recommending 1000

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USA Study

• 389 men and women over age gt63
• 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 199733770-6
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Reduction of Nonvertebral Fracture with Calcium
and Vitamin D
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12
10
8
Fracture
6
4
2
0
6
12
18
24
30
36
Months
p0.02 Dawson-Hughes B et al, N Engl J Med
1997337670.
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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 19943081081-2
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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

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Sri Lankan Research
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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

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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

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Aim Methods -1

• Calcium intake from SQFFQ.
• To measure the BUA Stiffness using Lunar
  Achilles ultrasound.
• 700 females from The SJU community survey.

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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

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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.

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(No Transcript)
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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 Contributor Sprats Sprats Sprats Sprats Sprats Kmurunga
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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.

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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 ?

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Post Guidelines Developments
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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

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Glucocorticoid Use and Fracture Risk
6
All nonvertebral
5.18
Forearm
5
Hip
Vertebral
4
Relative risk of fracture compared with control
3
2.59
2.27
1.77
1.64
2
1.55
1.36
1.17
1.19
1.1
1.04
0.99
1
0
n 2192 531 236 191 2486 526 494 440 1665 273 328
400
Low dose
Medium dose
High dose
(lt2.5 mg/d)
(2.57.5 mg/d)
(gt7.5 mg/d)
van Staa TP et al, 2000.
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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

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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

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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

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Way Forwards

• Audit of implementation of the guidelines
• More research
• Thats all folks