7721 - Nutritional Guidelines for Osteoporosis Sisir a Sir...

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Unformatted text preview: Nutritional Guidelines for Osteoporosis Sisir a Sir ibaddana Dir ect or SLTR St aff Specialist in M edicine SJGH Introduction Guidelines Sri Lankan research Post guidelines development Disease Risk factor Clinical presentation Stroke Hypertension High BP CHD Gout Dyslipidaemia Myocardial infarction Hyperuricaemia Arthritis Fracture Osteoporosis Low BMD Population Projections for Sri Lanka Year Projected Projected % of Pop Old age pop over pop over 60 60 years dependency (`000) years (`000) 1991 17 015 2041 22 693 8.2 27.8 1395 6308 13.50% 47.90% Cost of Current Therapy for Osteoporosis Estrogen Calcium 0.625 mg 1000 mg $400/yr* $35/yr $750/yr $750/yr $750/yr Alendronate 5-10 mg Calcitonin 200 IU Raloxifene 60 mg *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. Guidelines Meth; Mai Private Formal Face Inter Aggreg led deci; feedb; to face ac; ation Q elicited of struct method group ured choices Inform al Delphi NGT no no no no yes Yes yes no no yes Yes yes no yes no yes yes yes no yes yes yes no Implicit Explicit Explicit Explicit implicit Rand Yes version CDC no Consensus Development Conference SLMA College of Physicians College of Ob & Gyn College of Pediatrics Orthopedic Association NGO Rotary and Sarvodaya 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 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 Literature Evidence Based Guidelines 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 Effect on Diary Foods on Bone Health Category of evidence No effect Favorable Unfavorable A B C D 6 6 11 7 5 1 11 7 1 2 0 0 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 USA Study 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 N Engl J Med 1997;337:70-6 (1.2%) Reduction of Nonvertebral Fracture with Calcium and Vitamin D 14 12 10 % 8 Fracture 6 4 2 0 6 12 18 24 30 36 p=0.02 Months Dawson-Hughes B et al, N Engl J Med 1997;337:670. Placebo Calcium + Vitamin D 3270 institutionalized women treated with calcium (1200 mg per French Study day) and vitamin D (800 IU per day) for 3 yrs risk of hip fracture was reduced by 30% reversal of secondary hyperparathyroidism BMJ 1994;308:1081-2 increase in BMD of the femoral neck 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 Sri Lankan Research 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 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 Aim & Methods -1 Calcium intake from SQFFQ. To measure the BUA & Stiffness using "Lunar Achilles" ultrasound. 700 females from The SJU community survey. 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 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. 90 Decline of stiffness index with age stiffness index 80 70 60 50 Stiffness 40 21-30 31-40 41-50 51-60 61-70 71-8 Ca Intake-Females Age Number Mean(mg) SD 21-30 31-40 41-50 51-60 61-70 71-80 143 144 159 166 70 24 1458 1481 1452 1456 1372 1301 578 534 469 536 492 463 Main Sprats Sprats Sprats Sprats Sprats K'mur Contributor unga 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%. 3.2% 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 lowbioavailability of Ca.? Lack of physical activity ? Post Guidelines Developments GlucocorticoidInduced 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 Glucocorticoid Use and Fracture Risk Relative risk of fracture compared with control 6 5 4 3 2 1 0 n = 1.17 1.1 0.99 1.55 1.36 1.04 1.77 All nonvertebral Forearm Hip Vertebral 2.59 1.64 1.19 5.18 2.27 2192 531 236 191 van Staa TP et al, 2000. Low dose (<2.5 mg/d) Medium dose (2.57.5 mg/d) 2486 526 494 440 High dose (>7.5 mg/d) 1665 273 328 400 Options for Prevention and Treatment of GIO: Calcium Hormone and vitamin D supplementation replacement therapy Bisphosphonates - Risedronate: FDA approved for prevention and treatment treatment - Alendronate: FDA approved for Calcitonin 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 doses Not effective alone with medium, high 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 Way Forwards Audit of implementation of the guidelines More research That's all folks ...
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