M. Varenna

Prevalence of Osteoporosis by Educational Level in a Cohort of Postmenopausal Women

Abstract: To evaluate whether the prevalence of osteoporosis and related risk factors might be influenced by the level of education, as has been demonstrated for many other chronic diseases, 6160 postmenopausal women at their first densitometric referral were interviewed about reproductive variables, past and current use of estrogens, prevalence of chronic diseases, and lifestyle factors such as calcium intake, physical activity, smoking and overweight. This sample was stratified by years of formal education. Densitometric evaluation was performed by dual-energy X-ray absorptiometry. Age at menarche, past exposure to oral contraceptives, use of hormone replacement therapy, prevalence of chronic diseases, physical activity, overweight and smoking showed significant trends according to the years of education. The prevalence of osteoporosis showed an inverse relationship with level of education, ranging from 18.3% for the most educated to 27.8% for the least educated women. Multiple logistic regression analysis demonstrated a predictive role toward osteoporosis by age, age at menarche and menopause, hormone replacement therapy, calcium intake, physical activity and body mass index. Using the lowest educational level as reference category, increases in educational status were associated with a significantly reduced risk for osteoporosis (OR = 0.76, 95% CI 0.65–0.90 for 6–8 years of schooling; OR = 0.68, 95% CI 0.57–0.82 for 9 years or more). This study shows differences in the prevalence of osteoporosis among educational classes and the protective role played by increases in formal education. If these results are confirmed in other population studies, public health intervention programs will have to consider the socioeconomic and cultural background of the population strata that run a greater risk of osteoporosis.

Relationship of focal erosions, bone mineral density, and parathyroid hormone in rheumatoid arthritis

Objective. To investigate the relationship among focal bone erosions and bone mineral density (BMD), 25(OH) vitamin D (25OHD), and parathyroid hormone (PTH) values in patients with rheumatoid arthritis (RA). Methods. The study included 1191 RA patients (1014 women, 177 men, mean age 58.9 ± 11.1 yrs) participating in a multicenter, cross-sectional study. Results. Radiographic evidence of typical bony erosions on hands or forefeet was found in 64.1% of patients. In those with bone erosions as compared to those without, mean BMD Z score values were significantly lower at both the spine (−0.74 ± 1.19 vs −0.46 ± 1.31; p = 0.05) and the hip (−0.72 ± 1.07 vs −0.15 ± 1.23; p < 0.001). In the subgroup of patients not taking vitamin D supplements, PTH levels were significantly higher in those with erosive arthritis (25.9 ± 14.0 vs 23.1 ± 11.6 pg/ml; p = 0.01); whereas the 25OHD concentrations were very similar in the 2 groups. The mean differences for BMD and PTH among the erosive and nonerosive RA remained statistically significant when values were simultaneously adjusted for all disease and mineral metabolism factors (i.e., age, sex, menopause, disease duration, Disease Activity Score 28-joint count, Health Assessment Questionnaire, activities of daily living, Steinbrocker functional state, glucocorticoid therapy, body weight, and bisphosphonate treatment). Conclusion. Our results suggest that the presence of bone erosions in RA correlates with low BMD levels and high PTH levels, and that these associations are independent of the degree of functional impairment and other common determinants of bone mass and mineral metabolism in adults with RA. These findings suggest that treatments to prevent bone loss or suppress PTH levels might positively affect the progression of bone erosions in RA.

Unbalanced Diet to Lower Serum Cholesterol Level is a Risk Factor for Postmenopausal Osteoporosis and Distal Forearm Fracture

Abstract: The purpose of this study was to assess whether dietary changes aimed at reducing serum cholesterol can increase the risk of osteoporosis (OP) and fracture. The study group consisted of 311 postmenopausal women with high serum cholesterol levels and following a diet low in dairy products (calcium intake estimated at less than 300 mg/day) for 27.3 ± 29.1 months. This sample was compared with a case–control group of 622 healthy postmenopausal women paired for age and age at menopause and with a calcium intake estimated at more than 1 g/day. Bone mineral density was measured at the lumbar spine by dual-energy X-ray absorptiometry. Prevalence of OP was significantly higher in women with a low dairy calcium intake (42.1% vs 22.3%; p<0.0001), as was the number of Colles” fractures occurring after menopause (4.5% vs 1.6%; p = 0.008). Multiple logistic regression analyses demonstrated that a diet low in dairy calcium was a risk factor for OP (OR = 2.52, 95% CI 1.84–3.45) and Colles” fracture (OR = 2.72, 95% CI 1.18–6.26). In the low dairy calcium group, diet duration significantly influenced the risk of OP (OR = 1.13, 95% CI 1.01–1.25 for 1 year of diet). No differences in further risk factors for coronary heart disease were found between the groups, but the proportion of women physically active was lower in the women with high serum cholesterol levels. A diet that severely limits calcium intake from dairy products in an attempt to correct raised serum cholesterol levels is a risk factor for postmenopausal OP and Colles” fracture. Dietary intervention methods to lower serum cholesterol in postmenopausal women should maintain an adequate calcium intake by providing calcium from low-fat dairy products or calcium supplements.

Safety profile of drugs used in the treatment of osteoporosis: a systematical review of the literature.

The range of osteoporosis treatments is increasingly large and, like any disease, the pharmacological management of patients should involve a risk/benefit evaluation to attain the greatest reduction in risk of fracture with the lowest incidence of adverse events. The aim of this review is to critically appraise the literature about the safety issues of the main pharmacological treatments of osteoporosis. This document is the result of a consensus of experts based on a systematic review of regulatory documents, randomized controlled trials, metaanalyses, pharmacovigilance surveys and case series related to possible adverse drug reactions to osteoporosis treatment with calcium and vitamin D supplements, bisphosphonates, strontium ranelate, selective estrogen receptor modulators, denosumab, and teriparatide. As expected, randomized controlled trials showed only the most common adverse events due to the samples size and the short observation time. Case series and observational studies are able to provide data about uncommon side effects, but in some cases a sure cause-effect relationship needs still to be confirmed. Consistently with methodological limitations, the newer drugs have a tolerance profile that has not been fully explored yet. Osteoporosis treatments showed an overall good tolerance profile with rare serious adverse events that, however, must be well known by the clinician who prescribes these drugs. The concern about possible adverse events should be weighed against the reduction of morbidity and mortality associated with a significant fracture risk reduction.

Primary biliary cirrhosis is not an additional risk factor for bone loss in women receiving regular calcium and vitamin D supplementation: a controlled longitudinal study.

Background and Goals Alterations in bone metabolism in primary biliary cirrhosis (PBC) are generally considered to be highly prevalent and severe, but no data are available from prospective studies with adequate control groups. The aims of this study were: (1) to measure changes in bone mineral density (BMD) over time; (2) to correlate the degree of bone loss with the severity of liver disease; and (3) to characterize bone disease in PBC patients receiving regular calcium and vitamin D supplementation. Study We enrolled 118 women with PBC (mean age±SD: 56±11 y; 72% postmenopausal; 43% with cirrhosis), and measured BMD (lumbar spine, DXA-Hologic) at entry and serially over the following 5 years. The controls were 472 healthy women selected from a large observational group matched for age and menopausal status (mean age±SD: 55±10 y; 73% postmenopausal). Results Mean BMD was 0.851±0.142 g/cm2 in the PBC group and 0.857±0.158 g/cm2 in the control group; the prevalence of osteoporosis was 28% and 29%, respectively. BMD significantly correlated with age and postmenopausal status, but not with liver cirrhosis or serum bilirubin levels. The biochemical markers of bone turnover were high in about 50% of the patients. The yearly bone loss in the PBC group was 0.008 g/cm2 (95% confidence interval: 0.014-0.003) similar to that calculated in the control group. Conclusions Among patients with PBC, the prevalence of osteoporosis and the yearly rate of BMD loss are similar to those observed in the general population, and are not associated with the severity of liver disease.

Transient osteoporosis of the hip: a densitometric study.

SummaryThree new cases of transient osteoporosis of the hip are reported. Diagnosis was achieved by plain radiographs, bone scintiscan, magnetic resonance imaging and X-ray absorptiometry of proximal femurs. The densitometry showed at the Wards triangle a mean reduction of bone mineral density in the affected side of 36%. All subjects were treated with i.v. clodronate for ten consecutive days with a complete recovery of femoral density within 4 months. X-ray absorptiometry allows a quantification of the demineralization process and can be useful in the long term evaluation of this entity.

Prevalence of osteoporosis and fractures in a migrant population from southern to northern Italy: a cross-sectional, comparative study

The purpose of this study was to assess whether a migrant population from southern regions of Italy showed differences in osteoporosis (OP) and fracture prevalence in comparison to a population born and living in Milan, a city in northern Italy. The study group consisted of 1764 postmenopausal women born in southern Italy who migrated after age 20 to Milan, where they had lived for at least 15 years. This group was compared with a sample of 4018 postmenopausal women born, raised and living in Milan. Bone mineral density (BMD) was measured at lumbar spine by dual-energy X-ray absorptiometry. Univariate analysis showed a significantly higher BMI, a greater parity, a lower postmenopausal estrogen (HRT) usage and a lower calcium intake in the Southern group (SG). Densitometric values showed a mean lumbar BMD significantly lower in SG (P<0.001), resulting in a greater prevalence of OP (30.5% versus 24.9%; P<0.001). Consistent with this result, the number of women reporting low energy fractures after menopause was higher in SG (4.8% versus 3.6%; P=0.01). Multiple logistic regression analyses showed that OP was predicted by well-recognized variables, such as age, age at menopause, BMI, HRT, calcium intake together to belonging to SG, which independently increased the risk for OP by 42%. Age, age at menopause, BMI and belonging to SG significantly influenced the fracture risk, but the last variable was no longer associated with an increased fracture risk when BMD was entered in the model. Despite the results of previous epidemiological studies and protective anthropometric measures, a higher OP and fracture prevalence was found in the migrant group from southern Italy to Milan in comparison with the native sample. These differences are not solely explained by lifestyle variables. Our data suggest that changing environmental exposures can influence bone mass and fracture risk.

Is the metatarsal fracture in postmenopausal women an osteoporotic fracture? A cross-sectional study on 113 cases.

To evaluate whether metatarsal fracture in postmenopausal women can be related to osteoporosis, a sample of 113 postmenopausal women with metatarsal fracture due to minor trauma were recruited. Demographic and clinical data were compared with a control group of 339 healthy age-matched women and with a sample of 224 women with wrist fracture. In all women, bone mineral density (BMD) was measured at the lumbar spine by dual-energy X-ray absorptiometry. The average age of the metatarsal fracture group was slightly lower than that of the wrist fracture group (56.9 vs 58.4 years). Women with metatarsal and wrist fracture had a significantly higher age at menarche, lower age at menopause and lower body mass index when compared with controls. In both fracture groups BMD was significantly lower compared with controls. In stepwise logistic regression models, factors associated with metatarsal fracture risk were age at menopause (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.81–0.92) and BMD (OR per — 1 SD 2.44; CI 1.92–3.11). Factors associated with wrist fracture risk included age at menopause (OR 0.89; CI 0.84–0.93) and BMD (OR per — 1 SD 2.65; CI 2.17–3.24). The similarities existing in risk factors and their estimates between a well-recognized osteoporotic fracture such as wrist fracture and metatarsal fracture, support the hypothesis that the latter can be included among osteoporotic fractures.

Regional differences of vitamin D deficiency in rheumatoid arthritis patients in Italy

Vitamin D deficiency is very common in patients with rheumatoid arthritis (RA). Aim of this study was to evaluate the prevalence of vitamin D deficiency among the different Italian regions and whether these variations are associated with different severity of the disease. The study includes 581 consecutive RA patients (464 women), not taking vitamin D supplements, from 22 Italian rheumatology centres uniformly distributed across Italy. Together with parameters of disease activity (disease activity score 28), functional impairment (activities of daily living and health assessment questionnaire disability index) and mean sun exposure time, all patients had serum 25-hydroxyvitamin D (25OHD) measured in a centralized laboratory. Vitamin D deficiency (25OHD level <20 ng/mL) was very frequent among RA patients; its prevalence was 60%, 52% and 38% in southern, central and northern Italy, respectively. Mean disease activity and disability scores were worse in southern regions of Italy. These scores were inversely related to 25OHD levels and this correlation remained statistically significant after adjusting for both body mass index (BMI) and sun exposure time. However, disease severity remained significantly higher in southern regions versus central-northern Italy after adjustment also for serum 25OHD levels, age and BMI. In RA Italian patients there are significant regional differences in the prevalence of vitamin D deficiency explained by different BMI, and sun exposure time, and inversely associated with disease activity and disability scores.