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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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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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
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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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Ca Intake-Females
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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
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All nonvertebral
5.18
Forearm
5
Hip
Vertebral
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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