Osteoporosis Background and Screening Recommendations. Maria K Jorgensen. Concordia University

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1 Osteoporosis Background and Screening Recommendations Maria K Jorgensen Concordia University Master of Public Health Applied Epidemiology December 15, 2014

2 Osteoporosis Background and Screening Recommendations 2 Executive Summary Osteoporosis is the most common skeletal disease which involves reduction in bone mass and changes in the bone structure which causes reduced strength and increased risk for fractures. Osteoporosis is assessed using general x rays, density scans, and bone biopsy to determine diagnosis and stage of disease. The population most at risk for osteoporosis includes post-menopausal women aged 50 years or older, although osteoporosis can impact males and other ages. Risk factors for osteoporosis include both controllable and uncontrollable risk factors. Some of the uncontrollable risk factors include: age, being female, menopause status, family history, low body weight, past history of broken bones. Some of the controllable risk factors include: low calcium and Vitamin D levels, low fruit and vegetable consumption, high levels of protein, sodium and caffeine, physical inactivity and obesity, smoking and high alcohol consumption(obesity (National Osteoporosis Foundation, 2014). Increasing the prevalence of preventative screenings for osteoporosis can be done by increasing public awareness of the ease of screening with DXA technology and the benefits of early detection. The public health community could increase screenings by running prevention campaigns and obtaining funding through grants and stakeholders to make the scans more accessible to the community.

3 Osteoporosis Background and Screening Recommendations 3 Background "Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fractures of the hip, spine, and wrist" (National Institute of Health, 2012). "In the U.S., an estimated 4 6 million women aged 50 years (13% 18%) have osteoporosis, and another million (37% 50%) have osteopenia (or low bone density) based on femoral bone mineral density (BMD) tests" (Lim, Hoeksema, Sherin, and the ACPM Prevention Practice Committee, 2009). The most impacted population for this disease is women aged 50 years or older. The prevalence of osteoporosis or low bone mass at either the femur neck or lumbar spine differed by age, sex, and race and ethnicity. The prevalence was higher in women and increased with age. Below in Figure 1, the distribution between males and females can be seen for those in the osteopenia (low bone mass) stage and those in the osteoporosis stage. Figure 1: Osteoporosis or low bone mass at the femur neck or lumbar spine, by sex in adults aged 50 years or over Source: (Looker, Borrud, Dawson-Hughes, Shepherd, and Wright, 2012)

4 Osteoporosis Background and Screening Recommendations 4 According to the National Health and Nutrition Examination Survey, "nine percent of adults aged 50 years and over had osteoporosis... at either the femur neck or lumbar spine. About onehalf had low bone mass at either site, while 48% had normal bone mass at both sites" (Looker, Borrud, Dawson-Hughes, Shepherd, and Wright, 2012). Other risk factors for this disease include both controllable and uncontrollable risk factors which include: Uncontrollable Risk Factors o Being over age 50 o Being female o Menopause o Family history of osteoporosis o Low body weight/being small and thin o Broken bones or height loss Controllable Risk Factors o Low calcium and Vitamin D levels o Low fruit and vegetable consumption o High levels of protein, sodium and caffeine in daily diet o Physical inactivity o Smoking o High alcohol consumption o Obesity (National Osteoporosis Foundation, 2014)

5 Osteoporosis Background and Screening Recommendations 5 As seen in Figure 2, increased age among females dramatically increases low bone mass and osteoporosis risk. Figure 2: Osteoporosis or low bone mass at the femur neck or lumbar spine, by age in adults aged 50 years and over Source: (Looker, Borrud, Dawson-Hughes, Shepherd, and Wright, 2012) Due to the large number of uncontrollable factors resulting in increased risk for osteoporosis, the controllable risk factors are paramount for individual intervention strategies. It is imperative that those at high risk for osteoporosis or low bone mass maintain healthy lifestyles and weight and abstain from diets high in sodium, caffeine, alcohol and protein consumption. Screening and Diagnosis Histomorphometry is the most accurate standard for measuring degree of osteoporosis because it involves a direct analysis of bone cells, mattress and their activity. Histomorphometry involves the measurement of the trabecular bone volume I the iliac crest via a bone biopsy. Bone biopsies can be performed for diagnosis of osteoporosis but are not typically done for initial diagnosis due to cost and the amount of time required for processing results (Lozo, Krpan, Krvavica, Vukelic Baturic, Fistonic, and Kusec, 2004). Although this method is considered the gold standard for

6 Osteoporosis Background and Screening Recommendations 6 osteoporosis diagnosis, it is also the most invasive, time consuming and expensive (Humadi, Alhadithi, & Alkudiari, 2010). Other types of evaluations for diagnosis of osteoporosis and risk estimation for the disease and related bone fractures include: looking through medical history, physical exams, bone density tests, FRAX score and laboratory testing. Other tests that may be used to get information about your bone health, but are not used to diagnose osteoporosis include biochemical marker tests, x-rays, vertebral fracture assessments (VFAs), and bone scans (National Osteoporosis Foundation, 2014). Bone density testing is done with a central duel x-ray absorptiometry (DXA) machine to diagnose osteoporosis. Typically these scans are completed in the hip and spine region because people with osteoporosis are more likely to fracture these bones and these regions also can cause more serious repercussions for the patient. Bone density in the hip and spine can also predict the likelihood of future breaks in other bones. This test is non-invasive and takes less than 15 minutes, making it a convenient screening procedure for prevention purposes. Peripheral tests can also be used in place of the DXA scan. These screening tests measure bone density in the lower arm, wrist finger or heel. These tests include: pdxa (peripheral duel energy x-ray absorptiometry), QUS (quantitative ultrasound), pqct (peripheral quantitative computed tomography). This type of testing can help determine a need for further testing and also can be used when central DXA is unavailable (Blake & Fogelman, 2007). The DXA scan provides the individual with a T-Score. The T-score bone density report shows how much the bone mass varies from the bone mass of average 30 year old women. The score that you will receive from your bone mineral density (BMD or DXA) test is measured as a standard deviation from the mean (Blake & Fogelman, 2007).

7 Osteoporosis Background and Screening Recommendations 7 The World Health Organization originally developed the T-score in After reviewing worldwide data on bone density and the resulting fracture risk. The WHO concluded that reporting bone mass in relation to the peak bone mass of an average 30 year old women would be the most appropriate measurement comparison given in standard deviations from the normal. The T-score definitions from the World Health Organization are given below in Figure 3. Figure 3: The World Health Organization definitions of osteoporosis and osteopenia used to interpret spine hip and forearm duel energy x ray absorptiometry scan results in postmenopausal white women Source: (Blake & Fogelman, 2007) The WHO suggested that a BMD result with a T-score of > -1.0 is a normal bone density. A T-score that is worse than one standard deviation below the average but better than 2.5 standard deviations below is considered osteopenia (low bone mass). A T-score that is worse than -2.5 standard deviations from the average indicates osteoporosis. If the BMD is worse than 2.5 and has recently incurred a fragility fracture the patient has established or severe osteoporosis (Blake & Fogelman, 2007). DXA scans using the WHO T-Score cut off of <-2.5 for diagnosis provides a specificity of 62.5% while using the cut off of <-1.0 makes the scan 25% specific. The T-score cut off of <- 2.5 provides a PPV of 83.3% (Humadi, Alhadithi, & Alkudiari, 2010). This is still somewhat low considering the increase in specificity. "The sensitivity of 94.1% for the DEXA t-score at the low cutoff value of 1 and the specificity (62.5%) or PPV (83.3%) at the high cutoff value of 2.5 would be useful indicators for the physician in deciding treatment for osteoporosis in

8 Osteoporosis Background and Screening Recommendations 8 addition to other parameters derived from patient history and clinical examination" (Humadi, Alhadithi, & Alkudiari, 2010). Recommendations Based on the research I conducted I would recommend the Dual energy x ray absorptiometry (DXA) scans to measure bone mineral density (BMD) at the spine and hip in order to determine and evaluated the individuals at risk for osteoporosis and to help clinicians to advise appropriate treatment and action for the patient. If the DXA scan provides the individual with a BMD falling within the ranges of osteopenia or osteoporosis I would also suggest performing a bone biopsy to further determine the stage of osteoporosis. In comparison to other available bone density screenings, DXA exams are the only non-invasive conclusive bone mineral density tests. Peripheral exams can be used in the absence of DXA scans but typically only lend to additional testing done with a DXA scan. DXA examinations also allow for using the T-score definitions developed by the World Health Organization. The T-score system developed by the World Health Organization developed a full standard for clinicians to diagnose low BMD and is proven effective for appropriate responses and treatment. The histological method of diagnosis is effective but invasive and more costly in regard to time and money. I would recommend that testing for women with a medical history of osteoporosis and those who have broken a bone after the age of 50 get DXA scans completed before the age of 65. For women with no familial history and with low FRAX scoring should receive a DXA scan after the age of 65 to determine osteoporosis risk. Participation levels for DXA screenings could be increased with simple public health campaigns laying out the target population for the intervention with an emphasis on the noninvasive nature vs the benefits of the scan and early diagnosis and treatment. Public health's role

9 Osteoporosis Background and Screening Recommendations 9 in increasing screening would be to initiate campaigns in women's health clinics and the county and federal levels. This would include seeking out grants and outside stakeholders to fund campaigns and spread awareness of the need for osteoporosis awareness. These funds could also be used to increase access to DXA scanning equipment. By making DXA scans more accessible, participation levels for early detection would increase. The Public Health community could also push to get these scans covered by grants at the county health level like some breast cancer screening programs.

10 Osteoporosis Background and Screening Recommendations 10 References Blake, G. M., & Fogelman, I. (2007). The role of DXA bone density scans in the diagnosis and treatment of osteoporosis. Postgraduate Medical Journal, 83(982), doi: /pgmj Humadi, A., Alhadithi, R. H., & Alkudiari, S. I. (2010). Validity of the DEXA diagnosis of involutional osteoporosis in patients with femoral neck fractures. Indian Journal of Orthopedics, 44(1), doi: / Lionel S. Lim, MD, MPH, FACPM, Laura J. Hoeksema, MD, Kevin Sherin, MD, MPH, FACPM, and the ACPM Prevention Practice Committee. (2009). Screening for Osteoporosis in the Adult U.S. Population ACPM Position Statement on Preventive Practice. American Journal of Preventive Medicine. 36(4), doi: /j.amepre Looker AC, Borrud LG, Dawson-Hughes B, Shepherd JA, Wright NC. Osteoporosis or low bone mass at the femur neck or lumbar spine in older adults: United States, NCHS data brief no 93. Hyattsville, MD: National Center for Health Statistics Retrieved From. Lozo P, Krpan D, Krvavica A, Vukelic Baturic T, Fistonic I, Kusec V. (2004). Bone histology in postmenopausal osteoporosis--variations in cellular activity. Acta Med Croatica, 58(1):5-11. Retrieved From. National Institute of Health (2012) Osteoporosis Overview. National Institute of Health Osteoporosis and Other Bone Related Disease National Resource Center Retrieved From.

11 Osteoporosis Background and Screening Recommendations 11 References National Osteoporosis Foundation (2014). Learn About Osteoporosis. Washington D.C.: National Osteoporosis Foundation. Retrieved From.

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