|Year : 2017 | Volume
| Issue : 2 | Page : 84-87
Prevalence of osteoporosis among vulnerable adults residing in the northeastern region of India: A preliminary report from a tertiary care referral hospital
Bhaskar Borgohain1, Pranjal Phukan2, Kalyan Sarma2
1 Department of Orthopaedics and Trauma, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
2 Department of Radiology and Imaging, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
|Date of Web Publication||14-Dec-2017|
Dr. Bhaskar Borgohain
Department of Orthopaedics and Trauma, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong - 793 018, Meghalaya
Source of Support: None, Conflict of Interest: None
Objectives: There is very little published literature about epidemiology of osteoporosis from the northeastern Region (NER) of India for effective secondary prevention. Reasons ascribed for lower bone mineral density in Indians include possible genetic differences, nutritional deficiency, and smaller skeletal size; this may be even more relevant for this region where per capita milk consumption is low. It is well known that osteoporosis often remains undiagnosed as a silent disease until a fragility fracture occurs and early detection can prevent fractures. The department of health research, the government of India in its recently included osteoporosis as one of the priority areas in the noncommunicable diseases and research on food-based approaches to prevent and manage osteoporosis is underway. Therefore, we intend to report a brief descriptive study on osteoporosis in our region. Patients and Methods: Our study was based on retrospective analysis of first 282 out of 336 patients undergoing dual-energy X-ray absorptiometry scan for possible osteoporosis between 2014 and 2017 in a large tertiary care teaching referral hospital located in the NER of India. This is the first such study from this region of India. Results: In our small study, involving potentially high-risk group residing in this region, vertebral osteoporosis was found to be much more common than femoral neck osteoporosis, making this group of patients at higher risk of subsequent osteoporotic vertebral compression fracture and future disability if not proactively treated, educated and followed up for proper compliance. Conclusions: Fortunately, most patients did not have any previous fracture despite found to have spinal and hip osteopenia or osteoporosis, meaning thereby that there is a window of opportunity for secondary prevention of new osteoporotic fractures. Food-based approach, physical activity and lifestyle modification through health education may be appropriate for prevention of osteoporosis and risk of fractures. A population-based study may be warranted for this region.
Keywords: Bone mineral density, dual-energy X-ray absorptiometry, osteoporosis, prevalence
|How to cite this article:|
Borgohain B, Phukan P, Sarma K. Prevalence of osteoporosis among vulnerable adults residing in the northeastern region of India: A preliminary report from a tertiary care referral hospital. J Orthop Traumatol Rehabil 2017;9:84-7
|How to cite this URL:|
Borgohain B, Phukan P, Sarma K. Prevalence of osteoporosis among vulnerable adults residing in the northeastern region of India: A preliminary report from a tertiary care referral hospital. J Orthop Traumatol Rehabil [serial online] 2017 [cited 2018 Aug 18];9:84-7. Available from: http://www.jotr.in/text.asp?2017/9/2/84/220763
| Introduction|| |
There is very little published literature about clinical epidemiology of osteoporosis from the northeastern Region (NER) of India. Osteoporosis often remains undiagnosed as silent disease until a fragility fracture occurs and early detection can prevent fractures. The department of health research, the government of India in its recent executive summary includes osteoporosis and orthopedics and rehabilitation as priority areas in the noncommunicable diseases and research on food-based approaches to prevent and manage osteoporosis is underway. Vertebral compression fractures (VCFs) are a common cause of pain and morbidity in the elderly patients especially in postmenopausal women. Similarly, hip fractures due to poor bone quality is well known.
Osteoporosis, which is characterized by low bone mass and microarchitectural deterioration, is a major risk factor for fractures of the hip, vertebrae, and distal forearm. Hip fracture is the most detrimental fracture, being associated with 20% mortality and 50% permanent loss in function. The early diagnosis of osteoporosis is very important, because individuals diagnosed with osteoporosis have 2.74 times greater chance of presenting bone fractures within 1 year, and those with osteopenia have 1.73 times greater chance and these morbidity may be prevented by early treatment.
Dual-energy X-ray absorptiometry (DXA/DEXA) is a quick and painless procedure for measuring bone mineral density (BMD). Until recently, DXA scan facilities were not available in the NER of India and only peripheral ultrasound-based screening tests were undertaken which were unreliable. There is no authentic report on DEXA diagnosed osteoporosis from the northeastern (NE) region of India. The resident population of the NER consumes less milk and has different genetic pool and physical attributes than rest part of India and may be at higher risk of osteoporosis.
| Materials and Methods|| |
It is a descriptive study based on retrospective analysis of first 282/336 patients attending a 570 bedded tertiary care teaching referral hospital located in the NER who undertook DXA scan (Hologic Discovery DXA system) for possible osteoporosis from 2014 to 2017. Daily QC scans with the Hologic phantom was performed before actual patient scans. DXA scan was performed in 336 participants to understand the prevalence of osteoporosis in the potentially high risk/vulnerable adult population that merits a DXA scan on clinical judgment due to perceived risk factors such as age, postmenopausal status, sedentary lifestyle, smoking, and alcohol consumption, in these participants. A register to record the co-founding factors for osteoporosis was routinely maintained by the technician performing the DXA scan during this period.
| Results|| |
In nearly all participants, the DXA scan was ordered by the consulting physicians on some clinical ground or perceived risk factor of osteoporosis. After carefully going through the data of 336 participants, we found that only 282 entries recorded correctly all relevant parameters we wanted to include. The patients were between 22 and 84 years of age, and nearly 55% patients were middle-aged adults between 45 and 65 years [Table 1]. Out of these 282 patients, 80.6% were female participants with a male to female ratio of 1:4.
|Table 1: Epidemiological profile of dual-energy X-ray absorptiometry scanned cases|
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The average body mass index was 23.81 (range 15.9–36.51), nearly, 60% patients were of normal weight range [Table 2]. In this cohort, 12.7% had a history of fracture. About 10.9% were regular smokers, and 9.5% takes some form of alcohol at least once in a week. Only about 19.7% are physically active: regularly involved in some form of exercise. Only about 24.3% takes Vitamin D and/or calcium supplements with or without a prescription, and 4.9% were on steroids or anticoagulants [Table 3].
In the result of DXA scan [Table 4], we found that in our studied cohort the average T-score for the hip was −1.8 (range −4.3–+2.7) suggesting osteopenic status in most participants, the average Z-score was however within normal range, i.e., at −0.8 (range − 3.5–+2.1). In the lumbar spine, average T-score was osteoporotic, at −2.6 (range −5.8–+2.5), average Z-score was osteopenic too at −1.5 (range −6–+5.3). A small cross section of these patients who undertook further tests suggests that Vitamin D deficiency may be a common problem in Meghalaya and the NER of India.
| Discussion|| |
This is the first such study from the NER of India. In our small study, involving potentially high risk group residing in this region, vertebral osteoporosis on the basis of the WHO classification [Table 5] was found to be much more common than in the neck of femur making this group of patients at high risk of subsequent osteoporotic vertebral fracture, collapse, deformity, and future disability if not proactively treated, educated, and followed up for proper compliance. Fortunately, most patients did not have any previous fracture despite found to have osteopenia or osteoporosis in our study, meaning thereby that there is a window of opportunity for the secondary prevention of new osteoporotic fractures.
|Table 5: WHO classification for diagnosis of osteoporosis using BMD measurements|
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In 2013, sources estimate that 50 million people in India are either osteoporotic (T-score lower than −2.5) or have low bone mass (T-score between −1.0 and −2.5). Osteoporotic vertebral fractures are common in Indians, with 15%–20% of older urban adults aged over 50 years showing evidence of at least one vertebral fracture. In the United States alone, there is an estimate of 500,000 fractures annually. The treatment costs of these fractures are also tremendous, estimated to be greater than of US$15 billion.
Hip fractures in the elderly patients are a growing epidemic as the population ages in part, is likely due to the greater prevalence of osteoporosis. Hip fractures affect all individuals regardless of age, gender, or race. Although these fractures represent only a small portion of osteoporotic fractures (14%), hip fractures represent 72% of the cost expenditure or are projected to cost over 18.2 billion dollars by 2025. It is not just the burden of hip fracture fixation affecting health-care costs. The aftercare and subsequent decline in independence and heath come into the picture. The underlying cause of the fracture needs to be addressed with the patient and their family.
By treating osteoporosis in patients with prior fractures, there was a 50% reduction in risk of future fractures. A recent study from Rohtak district in North India shows an annual incidence rate of 163 and 121/100,000/year in women and men, respectively, above the age of 55 years. However, with the rapid increase in the ageing population, an exponential rise is expected in the absolute numbers of fractures in the next decade. An IOF survey, conducted in 11 countries, showed a denial of personal risk by postmenopausal women, lack of dialogue about osteoporosis with their doctor, and restricted access to diagnosis and treatment before the first fracture result in underdiagnosis and undertreatment of the disease.
In a study among Indian women aged 30–60 years from low-income groups, BMD at all skeletal sites was much lower than values reported from developed countries and T scores at all the skeletal sites were much lower than the values reported from the developed countries and were indicative of a high prevalence of osteopenia (52%) and osteoporosis (29%), thought to be due to inadequate nutrition in Indian women. BMD showed a decline after the age of 35 years in cases of the lumbar spine and femoral neck. In a more recent study from Delhi, 792 males and 808 postmenopausal females with a mean age of 57.67 ± 9.46 years were evaluated. Osteoporosis was present in 35.1% of participants (M - 24.6%, F - 42.5%) and osteopenia in 49.5% (M - 54.3%, F - 44.9%). Both of these studies used the manufacturer's white Caucasian reference database. In an attempt to generate an India-specific database, the Indian Council for Medical Research (ICMR) carried out a large multicenter study, which confirmed data from smaller, single-center studies, and showed that Indians have lower BMD than their North American counterparts. A study involving more than 3500 participants carried out at a tertiary care center in South India to study the effect of the newly generated ICMR database (ICMRD) on the diagnosis of osteoporosis reported that a greater proportion were diagnosed as having osteoporosis with Hologic as compared to the ICMRD. Similar to our findings, osteoporosis at the spine and hip was present in 42.7% and 11.4% individuals respectively using the Hologic database and in 27.7% and 8.3% subjects respectively using the ICMRD in this study.
The awareness of osteoporosis is low in India with a number of small-scale surveys indicating that in the urban population only approximately 10%–15% individuals are familiar with the disease. Unfortunately, information from the media is not always accurate, and with only 20% of information coming from physicians, there is a clear need for increased involvement of doctors in educating patients about osteoporosis. Not everyone with osteoporosis has a high bone turnover. However, using a holistic approach, a combination of available tools such as the WHO's FRAX risk factors assessment,, bone turnover markers and DXA scanning may be used for diagnosing osteoporosis, identifying “fast bone losers” and patients at high risk of fracture, selecting the best treatment, and monitoring response to therapy.
| Conclusion|| |
In our small study involving potentially high-risk group residing in this region, vertebral osteoporosis was found to be much more common than femoral neck osteoporosis, making this group of patients at higher risk of subsequent osteoporotic VCF and disability if not proactively treated, educated, and followed up for proper compliance. Food-based approach, physical activity, and lifestyle modification through health education may be appropriate for both primary and secondary prevention of osteoporosis and risk of fragility fractures. Although no statistical analysis is yet performed, nearly 80% of our patients had a sedentary lifestyle, and a considerable number of patients had modifiable risk factors such as smoking and alcohol use.
(1) Prof A. C. Phukan, MD Medical Superintendent, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, (2) Prof C. Daniala, MD, HoD, Radiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, (3) Prof. Utpal Bora, Department of Biosciences and Bioengineering, IIT, Guwahati, Assam.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]