OSTEOPOROSIS IN SAUDIOSTEOPOROSIS IN SAUDI ARABIA ANOTHER EPIDEMIC ARABIA ANOTHER EPIDEMIC WAITING TO HAPPEN ? WAITING TO HAPPEN ?

• MONA A FOUDA NEEL ,MBBS, MRCP(UK),FRCPEMONA A FOUDA NEEL ,MBBS, MRCP(UK),FRCPE• ASSOCIATE PROFESSOR OF MEDICINEASSOCIATE PROFESSOR OF MEDICINE• CONSULTANT ENDOCRINOLOGISTCONSULTANT ENDOCRINOLOGIST• COLLEGE OF MEDICINECOLLEGE OF MEDICINE• KING SAUD UNIVERSITYKING SAUD UNIVERSITY

• The magnitude of the problemThe magnitude of the problem

•The relationship to vitamin D The relationship to vitamin D status in the countrystatus in the country

Lumbar BMD of 830 postmenopausal Saudis according to Lumbar BMD of 830 postmenopausal Saudis according to ageage

CategoryCategoryNumberNumber (%) (%)

BMD BMD ++ SD SD

T-T-ScoreScore

Age 50-59 yrs.Age 50-59 yrs. NormalNormal OsteopeniaOsteopenia OsteoporosisOsteoporosisLow BMDLow BMD

216 216 171 171 124 124

295295

42 42 33 33 2424

5757

1.098 1.098 ++ 0.11 0.11 0.893 0.893 ++ 0.13 0.130.795 0.795 ++ 0.15 0.15

- 0.61 - 0.61 - 2.36 - 2.36

- 3.21- 3.21

Age 60-69 yrs.Age 60-69 yrs. NormalNormal OsteopeniaOsteopenia OsteoporosisOsteoporosisLow BMDLow BMD

28 28 69 69 157 157

226 226

11 11 27 27

6262

8989

1.092 1.092 ++ 0.12 0.12 0.986 0.986 ++ 0.13 0.13

0.774 0.774 ++ 0.1410.141

- 0.71 - 0.71 - 2.41 - 2.41

- 3.4- 3.4

Age 70-80 yrs.Age 70-80 yrs. NormalNormal OsteopeniaOsteopenia OsteoporosisOsteoporosisLow BMDLow BMD

3 3

1414 48 48

6262

4.6 4.6 21.4 21.4

74 7495.495.4

1.102 1.102 ++ 0.13 0.13 0.981 0.981 ++ 0.12 0.12 0.732 0.732 ++ 0.12 0.12

- 0.78 - 0.78 - 2.43 - 2.43

- 3.5- 3.5

El Desouki. Saudi Med J 2003;Vol. 24 (9)

Study by El Desouki 2003

CategoryCategoryNumbNumberer(%)(%)BMDBMD SD SDT-T-

ScoreScoreAge 51-60Age 51-60

NormalNormal22422437371.130 (0.05)1.130 (0.05)-0.55-0.55OsteopeniaOsteopenia21821836360.978 (0.05)0.978 (0.05)-1.84-1.84OsteoporosOsteoporos

isis16416427270.793 (0.07)0.793 (0.07)-3.40-3.40

TotalTotal6066061001000.952 (0.15)0.952 (0.15)-2.06-2.06

Low BMDLow BMD3823826363

Age 61-70Age 61-70

NormalNormal1818 771.100 (0.03)1.100 (0.03)-0.84-0.84OsteopeniaOsteopenia808032320.970 (0.05)0.970 (0.05)-1.93-1.93OsteoporosOsteoporos

isis15215261610.774 0.774 (0.07)(0.07)-3.56-3.56

TotalTotal2502501001000.704 (0.11)0.704 (0.11)-2.27-2.27

Low BMDLow BMD2322329393

Age 71-80Age 71-80NormalNormal 33 441.149 (0.07)1.149 (0.07)-0.40-0.40OsteopeniaOsteopenia161622220.962 (0.05)0.962 (0.05)-2.00-2.00OsteoporosOsteoporos

isis353574740.771 (0.02)0.771 (0.02)-3.50-3.50

TotalTotal54541001000.821 (0.12)0.821 (0.12)-1.57-1.57

Low BMDLow BMD51519696

BMD – Bone Mineral DensityBMD – Bone Mineral DensitySD-Standard DeviationSD-Standard Deviation

Spine BMD In Postmenopausal Saudis by Spine BMD In Postmenopausal Saudis by AgeAge

CategoryCategoryNo:No:(%)(%)BMDBMD SD SDT-ScoreT-ScoreAge 51-60Age 51-60

NormalNormal262262 43430.915 (0.07)0.915 (0.07)-0.50-0.50OsteopeniaOsteopenia247247 41410.755 (0.04)0.755 (0.04)-1.87-1.87OsteoporosOsteoporosisis 9797 16160.606 (0.5)0.606 (0.5)-3.10-3.10

TotalTotal6066061001000.800 (0.12)0.800 (0.12)-1.48-1.48

Low BMDLow BMD344344 5757

Age 61-70Age 61-70

NormalNormal 383815150.905 (0.04)0.905 (0.04)-0.60-0.60OsteopeniaOsteopenia12112148480.740 (0.04)0.740 (0.04)-1.99-1.99OsteoporosOsteoporosisis 919136360.587 (0.06)0.587 (0.06)-3.27-3.27

TotalTotal25025099990.704 (0.11)0.704 (0.11)-2.27-2.27

Low BMDLow BMD2122128484

Age 71-80Age 71-80NormalNormal 33 4 4 0.848 (0.01)0.848 (0.01)-0.90-0.90OsteopeniaOsteopenia 303041410.743 (0.04)0.743 (0.04)-1.97-1.97OsteoporosOsteoporosisis 393954540.596 (0.06)0.596 (0.06)-3.19-3.19

TotalTotal 727299990.668 (0.10)0.668 (0.10)-2.59-2.59

Low BMDLow BMD 69699595

BMD – Bone Mineral DensityBMD – Bone Mineral DensitySD-Standard DeviationSD-Standard Deviation

Femur BMD In Postmenopausal Saudis by Femur BMD In Postmenopausal Saudis by AgeAge

CategoryCategoryNumbeNumberr

(%(%))

BMD BMD SDSD

T-T-ScoreScore

NormalNormal24324326261.12 1.12 (0.05)(0.05)-0.62-0.62

OsteopeniaOsteopenia28428431310.962 0.962 (0.04)(0.04)-1.99-1.99

OsteoporosiOsteoporosiss40140143430.782 0.782

(0.07)(0.07)-3.480-3.480

TotalTotal928928101000

0.912 0.912 (0.15)(0.15)-2.40-2.40

Low BMDLow BMD6856857474

BMD – Bone Mineral DensityBMD – Bone Mineral DensitySD-Standard DeviationSD-Standard Deviation

Spine BMD In All Patients (50-Spine BMD In All Patients (50-80 Yrs)80 Yrs)

CategoryCategoryNumberNumber(%)(%)BMDBMD SD SDT-ScoreT-Score

NormalNormal30330332.732.70.908 (0.08)0.908 (0.08)-0.54-0.54

OsteopeniaOsteopenia39739742.842.80.750 (0.04)0.750 (0.04)-1.91-1.91

OsteoporosOsteoporosisis

22822824.524.50.597 (0.06)0.597 (0.06)-3.19-3.19

TotalTotal9289281001000.764 (0.13)0.764 (0.13)-1.78-1.78

Low BMDLow BMD62562567.367.3

BMD – Bone Mineral DensityBMD – Bone Mineral DensitySD-Standard DeviationSD-Standard Deviation

Femur BMD In All Patients (50-80 Femur BMD In All Patients (50-80 Yrs)Yrs)

Prevalence of osteopenia and osteoporosis in Saudis (50 years), using US/European and Saudi reference data. Data are presented as percentages with osteopenia (> -2.5 SD to < -1 SD below young adult BMD) and osteoporosis (< -2.5 SD below young adult BMD), for spine (L2-L4) and femur (total).

(Ardawi MSM, et al. Osteoporosis Int 2005; 16: 43-55)

1980 PTS20-79 AGEM 915

F 1065

The proportion of Saudis aged 50 years with lower than -2.5 SD,

stratified by body weight quartiles and sex.

(Ardawi MSM, et al. Osteoporosis Int 2005; 16: 43-55)

•VITAMIN D LEVELS VITAMIN D LEVELS BELOW 20 NMOL/L BELOW 20 NMOL/L EXCLUDEDEXCLUDED !!

• Bone mineral density of the spine and Bone mineral density of the spine and femur in healhy saudi females femur in healhy saudi females : relation to vitamin D status, : relation to vitamin D status, pregnancy, and lactationpregnancy, and lactation

• N N GHANNAM ETAL calcif Tissue int N N GHANNAM ETAL calcif Tissue int 1999 1999

• 321 females 321 females

• 25 vit D 24.5+17.2 25 vit D 24.5+17.2

• Severe hypovitaminosis D (25 OHD less Severe hypovitaminosis D (25 OHD less than 20 nmol/l )= 52% than 20 nmol/l )= 52% Osteopenia and osteoporosis in subjects Osteopenia and osteoporosis in subjects more than 31=18-41 %, 0-7%more than 31=18-41 %, 0-7%

(Sadat-Ali M & AlElq AM. Ann Saudi Med 2006; 26: 450-454)

(Sadat-Ali M & AlElq AM. Ann Saudi Med 2006; 26: 450-454)

(El-Desouki MI & Sulimani RA. Saudi Med J 2007; 28: 774-777)

(El-Desouki MI & Sulimani RA. Saudi Med J 2007; 28: 774-777)

•Resurection of vitamin D Resurection of vitamin D deficiency and ricketsdeficiency and rickets

•Michael Holick JCI 2006Michael Holick JCI 2006• Severe chronic vitamin D deficiency { 25 (OH) D Severe chronic vitamin D deficiency { 25 (OH) D

less than 15 ng/ml } leads to overt skeletal less than 15 ng/ml } leads to overt skeletal abnormalities in children typically defined as abnormalities in children typically defined as ricketsrickets

• A large number of children and adolescents who A large number of children and adolescents who have vitamin D insufficiency have no apparent have vitamin D insufficiency have no apparent skeletal or calcium metabolism abnormalitiesskeletal or calcium metabolism abnormalities

• Lee J.M. et al 2006Lee J.M. et al 2006

• Of 40 healthy mother-infant pairs Of 40 healthy mother-infant pairs predominantly non-white, 73% of predominantly non-white, 73% of mothers and 80% of infants had (25 mothers and 80% of infants had (25 OH)D levels of less than 20 ng/m OH)D levels of less than 20 ng/m ldespite the fact that 80% of mothers ldespite the fact that 80% of mothers were taking prenatal multivitaminswere taking prenatal multivitamins

• Sullivan et al 2005Sullivan et al 2005

• 48% of white girls aged 9-11 years in 48% of white girls aged 9-11 years in main had 25(OH)D levels than 20 main had 25(OH)D levels than 20 ng/ml by end of summer and 17% ng/ml by end of summer and 17% remained vitamin D deficient and the remained vitamin D deficient and the end of summerend of summer

• Due to avoidance of exposure to sun and Due to avoidance of exposure to sun and lack of fortification of many foods, upward lack of fortification of many foods, upward of 35-80% of children in many sunny of 35-80% of children in many sunny countries,Saudi Arabia, India,Turkey, countries,Saudi Arabia, India,Turkey, Egypt, HongKong, China, Lebanone, Egypt, HongKong, China, Lebanone, Spain……etc are vitamin D deficientSpain……etc are vitamin D deficient

• When the deficiency occurs during fetal When the deficiency occurs during fetal life it may increase risk of hip fratures and life it may increase risk of hip fratures and bone loss later in lifebone loss later in life

optimal 25hydroxyvitamin D

values45-50 nglml or

115-128 nmol/lNormal 25-

hydroxyvitamin D values20-56 ng/ml or

50-140 nmol/l

Table: Threshold values for vitamin D insufficiency based on different outcomes and study types. A common threshold value of 50 nmol/l has been proposed for vitamin D insufficiency, whereas vitamin D deficiency is characterized by values < 25 nmol/l.

Higher 25OHD levels Higher 25OHD levels prevent prevent

Threshold Threshold values values

for 25-OHD for 25-OHD (nmol/l)(nmol/l)

Study type Study type ReferencesReferences

SecondarySecondary

hyperparathyroidismhyperparathyroidism

Decrease in BMDDecrease in BMD

Increase in bone Increase in bone turnoverturnover

Seasonal variations in Seasonal variations in PTHPTH

Suppressible P-PTHSuppressible P-PTH

30-8030-80

Increases with Increases with ageage

3030

6060

9090

5050

Cross-Cross-sectionalsectional

Cross-Cross-sectionalsectional

Cross-Cross-sectionalsectional

Cross-Cross-sectionalsectional

InterventionIntervention

Dawson-Hughes Dawson-Hughes et al.et al. 19911991

Ooms 1994Ooms 1994

Ooms Ooms et al.et al. 1995 1995

Chapuy Chapuy et al.et al. 1997 1997

Guillemant Guillemant et al.et al. 1999 1999

Jesudason Jesudason et al.et al. 2002 2002

Vieth Vieth et al.et al. 2003 2003

Ooms Ooms et al.et al. 1995 1995

Jesudason Jesudason et al.et al. 2002 2002

Krall Krall et al.et al. 1989 1989

Malabanan Malabanan et al.et al. 1998 1998

Lips 2001Lips 2001

(Mosekilde L. Clin Endocrinol 2005; 62: 265-281)

Figure: Prevalence of vitamin D inadequacy in all subjects. The percentage of subjects with serum 25(OH)D concentrations below predefined cutoffs of less than 9, less than 15, less than 20, less than 25, and less than 30 ng/ml.

Factors associated with vitamin D deficiency:-Age-BMI >25-Daily intake of vitamin D <400 IU (63%)-Medications affecting vitamin D metabolism-Race-Education level-Limited daily activity-Discussion with physician about vitamin D and bone health (28% had no counseling)

32% of women with vitamin D <30 ng/ml

had NO risk factors

(Holick MF, et al. J Clin Endocrinol Metab 2006; 90: 3215-3224)

• The population under study is classified into 3 The population under study is classified into 3 categories according to vit D nutritional categories according to vit D nutritional status: deficient (status: deficient ( 5 ng/ml), low (5-10 ng/ml) 5 ng/ml), low (5-10 ng/ml) and adequate (and adequate ( 10 ng/ml). 10 ng/ml).

• The frequency of low 25-OHD concentration (5-The frequency of low 25-OHD concentration (5-10 ng/ml) is high (22% in total children and 10 ng/ml) is high (22% in total children and 20% in total adults) in the Saudi population, 20% in total adults) in the Saudi population, while the frequency of vit D deficiency (25-while the frequency of vit D deficiency (25-OHD level OHD level 5 ng/ml) is 3.4% in total children 5 ng/ml) is 3.4% in total children and 5.5% in total adults. This is true whether and 5.5% in total adults. This is true whether the population is urban or rural.the population is urban or rural.

• 26% of female children or female adults have 26% of female children or female adults have low vit D status in comparison with 19% and low vit D status in comparison with 19% and 17% for male children and male adults, 17% for male children and male adults, respectively.respectively.

STUDY OF VITAMIN D STATUS AND FACTORS LEADING TO ITS DEFICIIENCY IN SAUDI ARABIA

SALEH SEDRANI ET AL

• The problem of osteoporosis in Saudi The problem of osteoporosis in Saudi Arabia has been overlooked until now.Arabia has been overlooked until now.

• It is of paramount importance to identify It is of paramount importance to identify the magnitude of the problem of the magnitude of the problem of osteoporosis and its related fractures in osteoporosis and its related fractures in Saudi Arabia.Saudi Arabia.

• This will be the cornerstone of setting up This will be the cornerstone of setting up programs for screening high risk groups programs for screening high risk groups through non-invasive techniques and through non-invasive techniques and treatment at early stages of the disease treatment at early stages of the disease with the aim of limiting disability and its with the aim of limiting disability and its impact on the national health resources.impact on the national health resources.

ABDULRAHMAN ALNUAIM,MD,FRCPC,FACPANNALE OF SAUDI MEDICINE,VOL 13,NO 1,1993