Prevalence of Osteoporosis among a group of Syrian Women and its Risk Factors

doi:10.21203/rs.3.rs-1976096/v1

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Prevalence of Osteoporosis among a group of Syrian Women and its Risk Factors

https://doi.org/10.21203/rs.3.rs-1976096/v1

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Background and aim:

Osteoporosis is a disease affecting the skeletal system, causing a reduction in bone mass and density, so the bones become fragile and prone to fractures. In addition, osteoporosis affects both men and women, but its prevalence appears widely and strongly in women, especially those after menopause. This disease has many negative impacts on individual and community health in terms of morbidity and mortality. This study aims to determine the prevalence of osteoporosis among a sample of women. By studying demographic factors, medical history, surgical history, gynecological history, and lifestyle, we can determine the risk factors related to it.

Materials and Methods:

The across-sectional study included a sample of (70) pre and postmenopausal women who had been referred to the densitometry unit in the radiology department at Damascus hospital. Bone mineral density (BMD) at the lumber spine and left femur was assessed by a densitometer using (DXA) technology and, following the World Health Organization criteria for osteoporosis, height and weight were measured. By oral questioning of the patient, detailed demographic information, lifestyle, dietary habits, medical, menstrual, and drug history were recorded in a questionnaire designed for this study. Inclusion criteria included pre and postmenopausal women. Exclusion criteria included females aged less than 18 years and pregnancy. The data was collected between 1/6/2022 and 5/8/2022. Data analysis was performed using the (JMP 14) program.

Results:

The prevalence of osteoprosis and osteopenia in the study sample were (19%) and (43%), respectively. The mean age in normal BMD women was (48.18±11.76), and the mean age in low BMD women was (54.13±13.71). Osteopenia was significantly associated with age, postmenopausal, number of pregnancies, family history of osteoporosis, low calcium diet, sun exposure, and rheumatoid arthritis, but there was no statistically significant correlation with BMI, menarche, years following menopause, smoking, corticosteroids, thyroxine, or skin color.

Conclusions:

More than half of the study sample had low BMD, and most of them were postmenopausal. These findings help identify high-risk women and suggest early strategies and serious steps to raise awareness among them and to reduce modifiable risk factors to prevent developing osteoporosis.

Rheumatology

Endocrinology & Metabolism

Osteoporosis

osteopenia

risk factors

menopause

Syrian private university

Damascus hospital

Osteoporosis is considered a serious issue in the world's public health, and it's accompanied by high rates of illness, mortality, and socioeconomic hardship [1]. It is described as a skeletal condition that increases the risk of fragility fractures due to inadequate bone strength. The biggest bone loss in women happens during perimenopause and is linked to estrogen deficiency, a menopausal issue. Women experience an expedited period of bone loss starting with menopause because, for about 5–7 years after menopause, they may lose bone at a rate of 3–5% per year. Rather than age, approximately 75% of bone loss in the years following menopause may be caused by an estrogen deficiency [2]. Over 200 million women are diagnosed with osteoporosis worldwide each year [3], and the cost of fractures caused by this condition in the United States of America was approximately 19 billion dollars in 2005 [4]. This substantial economic burden emphasizes the necessity of osteoporosis diagnosis and care, which affects up to 70% of women over the age of 80, according to World Health Organization (WHO) guidelines. Furthermore, according to recent epidemiologic forecasts, particular regions such as Asia, Latin America, the Middle East, and Africa will account for more than 70% of all fractures worldwide by 2050 [5, 6]. Due to the fact that osteoporosis is a "silent disease," dual-energy X-ray absorptiometry (DXA) is widely used for diagnosing bone mineral density (BMD) [7, 8]. However, accurate DXA scan analysis requires the recognition of objects and pathologic mechanisms that can falsely increase the measured BMD [9]. Clinicians and radiology technologists must evaluate the DXA scan image critically and carefully examine the numerical data on the computer-generated printout to maintain proper DXA scan interpretation. To resolve the diagnostic uncertainty, sets of laboratory biomedical indicators for bone resorption and bone formation were proposed [10, 11]. Additionally, multiple global epidemiologic studies in various parts of the world have thoroughly examined possible osteoporosis risk factors, including sociodemographic data, personal medical history, maternal and paternal history of bone fracture after the age of 50, smoking habits, alcoholic beverage consumption, calcium intake, and current and past physical exercise, in an effort to guide the bone densitometry measurements [12, 13]. Despite claims that there are 4,000 hip fractures per year in Syria, little is known about the occurrence of osteoporosis and low bone mass. The pervasiveness of osteoporosis in pre-and postmenopausal Syrian women was examined in this study, and the results were compared to those from studies conducted in the west and the Middle East. Risk factors include BMI, smoking, inactivity, and the use of numerous drugs.

This cross-sectional study was conducted at Damascus hospital in Damascus, Syria. A questionnaire created specifically for this study was used to record a thorough medical, obstetrical, menstrual, and drug history. Hypothyroidism, renal diseases, diabetes mellitus, rheumatoid arthritis, current or past use of glucocorticoids, thyroid hormones, and use of hormone replacement therapy were given special attention. We gathered and recorded data on previous fracture history, family history of osteoporosis. A qualified investigator measured the women's height and weight while they were dressed in light gowns and wore no shoes. The following equation was used to determine body mass index (BMI): Height/weight (kg) (cm). Each woman's daily sunlight exposure was further classified as high, medium, or low. A short food frequency questionnaire was used to assess calcium and vitamin D consumption patterns.

BMD was measured at the postero-anterior lumbar spine (L1-L4) and left femur (total hip, trochanter, wards, and femoral neck) using an intermediate phase scan on a Lunar DPX-PRO total body pencil beam densitometer (GE Healthcare, Waukesha, Wisconsin, USA). According to the WHO categorization as seen in Table 1, women were considered at moderate risk if their T score fell within the range of -1 and − 2.5, and at significant risk if their T score was less than − 2.5.

Table 1

T-score values and diagnosis by WHO.
Diagnosis	T-score
Osteoporosis	T≤-2.5
Low bone mass	-1 ≤ T<-2.5
Normal	-1 > T

Statistical analysis:

Continuous data was summarized as mean and standard deviation, while categorical variables were presented as percentages and proportions (SD). The chi-square test was used to compare categorical variables, while the t-test was used to make comparisons of continuous variables. A statistically significant p-value of 0.05 was used. All statistical analysis was performed using JMP Pro 14 software (JMP, Pro 14, SAS Institute Inc., Cary, NC, 1989–2019).

Our study included 70 women, 36% of them were premenopausal and 64% were postmenopausal. Their mean age was 51.84 ± 13.23 years and ranged between 26 and 76, and their mean BMI was 29.53 ± 6.16 kg/m2, the mean age at menarche in normal and osteopenic/osteoporotic women was 1.54 ± 13.37 and 1.77 ± 13.34 respectively, and the mean age at menopause in postmenopausal normal and osteopenic/osteoporotic women was 3.50 ± 48.11 and 5.20 ± 48.46 respectively. (Table 2).

Table 2

General characteristics of the study population
variables	Mean	SD
Age (years)	51.84	13.23±
Body mass index (BMI)	29.53	6.16 ±
Age at menarche (years)	13.35	1.67 ±
Age at menopause (years)	48.33	4.61 ±
Years following menopause	12.02	9.05 ±
Marital status	No.	%
Married	60	86
Unmarried	10	14
Smoking
Yes	19	27
No	25	36
Passive smoking	26	37
Menstrual history
Premenopause	25	36
postmenopause	45	64

According to WHO criteria, 19% were identified as having osteoporosis, 43% were osteopenic, and 39% had normal BMD. The results showed a significant correlation between low BMD and increasing age, postmenopausal women, the number of pregnancies, sun exposure, and the presence of rheumatoid arthritis.

(Table 3) shows the distribution of the study population according to BMD and clinical variables. It shows that the incidence of osteopenia/osteoporosis increased significantly with age (P = 0.0290), and the proportion of postmenopausal women with osteopenia/osteoporosis (71%) was greater than for premenopausal women (44%), and the difference was statistically significant (P = 0.0256).

74% of women with a low-calcium diet were significantly associated with low BMD (p = 0.0092) as compared to women with a normal-calcium diet, of which 34% had low BMD.

With regard to medical history, patients with rheumatoid arthritis (RA) were more likely to develop osteopenia/osteoporosis in contrast to non-RA subjects (p = 0.0271). But there was no significant association in our study comparing other medical conditions like diabetes, asthma, hypothyroidism, and osteopenia/osteoporosis.

In this sample, our results showed that women who reported a positive family history of osteoporosis among one or more of their first-degree relatives were more likely to develop osteopenia/osteoporosis as compared to women with a negative family history (P = 0.0036).

With respect to medication history, subjects who had ever used corticosteroids, thyroxin, and heparin were not significantly more likely to develop osteopenia/osteoporosis compared to never users in the same sample.

The preset study also revealed a statistically significant correlation between limited sun exposure (81% of them had low BMD) and having osteopenia/osteoporosis (P = 0.0129).

Neither smoking nor skin color had a significant correlation with osteopenia/osteoporosis in this study, and concerning menstrual history, no significant associations were found between age at menopause, age at menarche, years following menopause, and the existence of osteopenia/osteoporosis as shown in (Table 3).

Table 3

the distribution of the study population according to BMD and clinical variables
variables	Normal	Osteopenic/Osteoporotic	P-value
No. of subjects (%)	27 (39)	43 (61)	-
Age (years, mean ± SD )	48.18 ± 11.76	54.13 ± 13.71	0.0290
BMI (kg/m²)	30.56 ± 6.25	28.88 ± 6.09	0.274
Age at menarche	13.37 ± 1.54	13.34 ± 1.77	0.957
Age at menopause	48.11 ± 3.50	48.46 ± 5.20	0.740
Years following menopause	10.53 ± 9.31	12.62 ± 9.02	0.499
Menstrual history
premenopause	14 (56)	11 (44)	-
postmenopause	13 (29)	32 (71)	0.0256
Family history of osteoporosis
Yes	5 (18)	23 (82)	0.0036
No	22 (52)	20 (48)	-
Smoking			0.918
Yes	8 (42)	11 (58)	-
No	9 (36)	16 (64)	-
Passive smoking	10 (38)	16 (62)	-
Gravidity			0.0442
Nulliparous	2 (13)	14 (87)	-
1–3 births	13 (50)	13 (50)	-
> 4 births	12 (43)	16 (57)	-
Low-calcium diet	11 (26)	31 (74)
Normal-calcium diet	16 (57)	12 (43)	0.0092
Sun exposure			0.0129
15 minutes daily	4 (36)	7 (64)	-
30 minutes daily	9 (64)	5 (36)	-
1 hour or more	8 (57)	6 (43)	-
Rarely	6 (19)	25 (81)	-
Hypothyroidism	5 (45)	6 (56)	0.609
Rheumatoid Arthritis	0 (0)	7 (100)	0.0271
Diabetes mellitus	6 (55)	5 (45)	0.235

In this study, the prevalence of osteoporosis and osteopenia among 70 Syrian women attending the densitometry unit at Damascus hospital was 19% and 43%, respectively. This finding was slightly lower than a previous study in Syria in 2019 [14] that included 813 postmenopausal women, which reported a prevalence rate of 24% for osteoporosis and 45% for osteopenia.

The incidence of osteoporosis in our study was higher than that reported in Saudi Arabia [15] (6.5%), Kuwait [16] (12.5%), and the United States of America [17] (15.4%). And lower than in India [18] (53%), and Italy [19] (20.2%). This inconsistency in findings may be related to differences in study design, study sample, bone scan site chosen, diagnostic technique, in addition osteoporosis considered a wide complex pathogenic disease.

This inconsistency in findings may be related to differences in study design, study sample, bone scan site chosen, and diagnostic technique. In addition, osteoporosis is considered a wide-ranging and complex pathogenic disease.[18] study.

Our study showed an association between the nulliparous group and the risk of developing osteopenia or osteoporosis (p = 0.0442). BMD in the nulliparous group was lower than that of those with 1–3 pregnancies and those with 4 pregnancies or more. The probability of having osteoporosis in nulliparous women was nearly nine times greater than in women with 1–3 pregnancies and also fourteen times greater than in women with 4 pregnancies or more.

Overall, knowledge of the relationship between BMD and the number of pregnancies is controversial. Our study is consistent with a study in Saudi Arabia [20] that included 256 women and reported that women with 6 pregnancies and more were at less risk of developing osteopenia than those with 5 pregnancies and less. On the other hand, a study in Turkey [21] found that BMD in women with 5 or more pregnancies was lower than in women who were nulliparous.

Epidemiologic studies have shown that a 10% increase in peak bone mass (PBM) at the population level reduces the risk of fracture later in life by 50%, Race, gender, and family history (genetics) are responsible for the majority of PBM [22].

Our study showed an important association between the positive family history of osteoporosis in first degree relatives and the prevalence of osteopenia or osteoporosis, as 82% of positive family history women were osteoporotic. This result is consistent with a study in Italy, where the percentage of patients (men and women) who had a history of fragile fractures with a family history of osteoporosis was (26.1%) compared to 17.3% of patients with no family history of osteoporosis. Contrary to the Syrian study of 2019 [14] which didn’t find an association with positive family history, Based on dietary intakes of calcium-rich foods, we classified women into low-calcium diet and normal calcium diet groups. The results showed that women with a low-calcium diet had less BMD, and that is consonant with Jorden's 2017 [23] study, which found a correlation between low intake of calcium (< 600 mg/day) in postmenopausal women and osteoporosis. The Saudi 2014 [15] study found similar results.

Appropriate exposure to the sun as the main non-nutrition source of vitamin D is important as a prevention factor for osteoporosis. In our study, women who were rarely exposed to the sun were nearly at 15 times more risk of developing osteopenia or osteoporosis than those with 1 hour or more of exposure to the sun during the day. And according to a Jordanian study [23] included 1079 postmenopausal women, low sun exposure increases the risk of osteoporosis two and a half times. Similar findings in Italy's 2016 [19] study.

Rheumatoid Arthritis (RA) is a systemic chronic inflammatory disease and has been classically considered an important comorbidity of osteoporosis. The prevalence of osteoporosis in RA is around 30% (up to 50% in post-menopausal women), which might be a two-fold increase over the general population [24]. In a large cohort study, the prevalence of osteopenia and osteoporosis in patients with RA using the Vertebral Fracture Assessment (VFA) technique was around 40–60%, while the prevalence of vertebral fractures through VFA images in the same cohort was 13% [25]. In terms of medical history, we found a statically significant relationship between RA and osteopenia/osteoporosis (p = 0.0271), and it is consistent with a study in Italy [19] that estimated RA patients (men and women) having a fragile fracture percentage of 2.38%, and it was statically significant (p < 0.01). This study failed to find any significant association between osteoporosis and age at menarche or years following menopause, unlike the Syrian 2019 study [14], where there was a significant association between years following menopause and developing osteopenia/osteoporosis.

In this cross-sectional study, the prevalence of osteoporosis and osteopenia in Syria was moderately high compared to the results of other similar studies, which indicates the importance of early diagnosis and treating osteopenia to avoid reaching osteoporosis by time. Our study also showed a significant correlation between having osteopenia or osteoporosis and aging, postmenopausal, nulliparous, low sun exposure, family history of osteoporosis, and rheumatoid arthritis.

Acknowledgments:

We are thankful to the management of the Syrian Private University and for their support in the field of medical training and research. We are thankful to everyone who participated in this study.

Funding:

This research received no specific grant from SPU or any other funding agency in the public, commercial or non-profit sectors.

Availability of data and materials:

All data related to this paper’s conclusion are available and stored by the authors. All data are available from the corresponding author on a reasonable request.

Declarations:

Ethics approval and consent to participate:

This study was approved by the Institutional Review Board (IRB) at the Syrian Private University (SPU). All Participants confirmed their written consent by signing the consent form. Participation in the study was voluntary and participants were assured that anyone who was not inclined to participate or decided to withdraw after giving consent would not be victimized. All information collected from this study was kept strictly confidential.

Consent for Publication:

Not applicable.

Competing interests:

The authors declare that they have no competing interests.

Authors’ contributions:

MA was responsible for study design, literature search, and write-up; SK was responsible for data analysis; SK participated in literature search and write-up; TH participated in the study design and reviewed the final draft. All authors read and approved the final draft.

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Prevalence of Osteoporosis among a group of Syrian Women and its Risk Factors

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Introduction:

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Discussion:

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References

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