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Osteoporosis in Sri Lanka PowerPoint Presentation

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Published on : Dec 06, 2013
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Osteoporosis in Sri Lanka Presentation Transcript

Slide 1 -

Nutritional Guidelines for Osteoporosis Sisira Siribaddana Director SLTR Staff Specialist in Medicine SJGH

Slide 2 -

Introduction Guidelines Sri Lankan research Post guidelines development

Slide 3 -

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Slide 4 -

Population Projections for Sri Lanka

Slide 5 -

Cost of Current Therapy for 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.

Slide 6 -

Guidelines

Slide 7 -

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Slide 8 -

Consensus Development Conference SLMA College of Physicians College of Ob & Gyn College of Pediatrics Orthopedic Association NGO – Rotary and Sarvodaya

Slide 9 -

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

Slide 10 -

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

Slide 11 -

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

Slide 12 -

Effect on Diary Foods on Bone Health

Slide 13 -

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

Slide 14 -

USA 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%)

Slide 15 -

Reduction of Nonvertebral Fracture with Calcium and Vitamin D % Fracture Months p=0.02 Dawson-Hughes B et al, N Engl J Med 1997;337:670. 6 12 18 24 30 36 0 2 4 6 8 10 12 14

Slide 16 -

French 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

Slide 17 -

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

Slide 18 -

Sri Lankan Research

Slide 19 -

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

Slide 20 -

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

Slide 21 -

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

Slide 22 -

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

Slide 23 -

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.

Slide 24 -

ppt slide no 24 content not found

Slide 25 -

Ca Intake-Females

Slide 26 -

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%.

Slide 27 -

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 ?

Slide 28 -

Post Guidelines Developments

Slide 29 -

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

Slide 30 -

Glucocorticoid Use and Fracture Risk 1.17 1.36 1.64 1.1 1.04 1.19 0.99 1.77 2.27 1.55 2.59 5.18 0 1 2 3 4 5 6 Low dose Medium dose High dose All nonvertebral Forearm Hip Vertebral n = 2192 531 236 191 2486 526 494 440 1665 273 328 400 Relative risk of fracture compared with control van Staa TP et al, 2000. (<2.5 mg/d) (2.5–7.5 mg/d) (>7.5 mg/d)

Slide 31 -

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

Slide 32 -

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

Slide 33 -

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

Slide 34 -

Way Forwards Audit of implementation of the guidelines More research That’s all folks

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