Lifestyle and Osteoporosis

Chapter Five- Lifestyle and Osteoporosis

Introduction

As being mention before, the incidence of osteoporosis and related fractures have spectacularly increased all over the world in the last decades and they have become one of the main health problem in the world. As osteoporosis has no symptoms, most of the time it is not predictable until different complications happened, such as fractures.

Osteoporosis is a threat to women's health as well as men. One in three women over 50 will experience hip, wrist or vertebral fractures, as will one in five men (IOF). Fewer men are affected by osteoporosis because they start with higher bone mass density, not like women who start with lower bone mass and experience bone loss due to the menopause.

Efforts have been divided to help patients with osteoporosis in two ways, the first one is to prevent and reduce the incidents of having osteoporosis which will automatically lead to reduce the osteoporotic fractures. The second way is to increase the peak bone mass during all life stages.

This chapter will look at the factors that affect patients' bone density in south west Wales, in order to find the best lifestyle that will help to prevent having osteoporosis and to increase the peck bone mass. Also to determine the impact of lifestyle on the health of bone, to establish what if any such factors play a role in maintaining bone density levels and how lifestyle changes can be used to prevent bone loss.

Information regarding lifestyle factors was collected in two stages, the first stage was aims to collect information about wide variety of factors which appear to affect bone density or anything known to influence bone metabolism. The second stage is to evaluate the first stage and chose the most significant factors in order to help continues assessing to the population of this area.

The first stage started with patient questionnaire which was made to find out whether lifestyle factors affect bone or not; it includes most of the lifestyles factors which might affect the health of bone. There were 1851 patients who filled in a paper questionnaire; all of them are patients who were referred for osteoporosis assessment to the nuclear medicine department in Singleton Hospital and mobile DXA Services by their general practitioner in south west Wales. A total of 35 factors have been considered, amongst that are milk intake, regular exercises, smoking, alcohol intake, long-term medications, diabetes and family history.

In the second stage the patient questionnaire was amended to cover more treatment-related to the osteoporosis such as Didronel, Alendronate, Calcium/ Vitamin D, Strontium Ranelate and other more. Also the life style list was reduced to cover more specific factors. Number of patients who filled in the questionnaire was 3278; same as the first stage, all of them are patients who were referred for osteoporosis assessment to the nuclear medicine department in Singleton Hospital and mobile DXA Services by their general practitioner in south west Wales. In this stage the paper-based questionnaire was changed to electronic one.

Other factors which appear to affect patients' bone density such as cancer treatment, especially breast and prostate cancer, will be studied in more details in the next two chapters.

FIRST STAGE

Subject and Methods

A self-administrated questionnaire was made for this purpose; it includes most of the lifestyle factors that might affect the health of bone in addition to three major bone treatments. A total of 1851 patients (214 (11.6%) male and 1637(88.4%) female) participant in the study, the age range of the patients is shown in table 5.1.

Frequency

Percent

Age Group

<= 40

132

7.1

41 – 60

782

42.2

61 – 80

837

45.2

81+

100

5.4

Total

1851

100.0

Table 5.1: Age groups

The questionnaire included what were considered to the relevant lifestyle factors, such as, family history, hyperthyroidism, diabetes, have fractured a bone, diet (milk, cheese, fish, fresh vegetables intake), alcohol, smoking, mobility and exercises and for female patients only (contraceptive pill, natural periods, hysterectomy, removal of ovaries, HRT, pregnancy and breast feeding) . Also it includes three major bone treatments calcium and vitamin D, Fosamax and Didronel. Age, ethnic origin, height, weight and the results from the DXA scanning where recorded as well.

Weight and height were measured and the Body Mass Index (BMI) (kg/m2) was calculated using the formula:

BMI = Weight (Kg) / Height2 (m2)

Bone measurements, such as, BMD measurements (g/cm2), T-score and Z-score were performed using Hologic dual-energy X-ray absorptiometry (DXA) scanner used in Singleton Hospital in Swansea and Explorer dual-energy X-ray absorptiometry (DXA) scanner used as a mobile scanner.

Data Analysis

Spearman rank nonparametric correlations were used to find if there is any association between main lifestyle factors age and BMI with lumbar spine and hip T-score data (normal (>-1) or diseased stats (<-1)) to determine significance level between the variables. Statistical significance was defined as P < 0.05. Descriptive statistics has been used to find the frequencies and percentages for nominal data where there is no ranking such as male female relation and treatment type. All analyses were performed on a personal computer using SPSS (version 16.0) software package.

Test of normality shows that the data that has been collected is normally distributed using T-score and BMD data for both lumbar spine and hip, s 5.1 and 5.2.

In the reliability statistics, the research tool is reliable if it is consistent and stable, and therefore predictable and accurate, this research study scores in the Cronbach Alpha 0.815 for T-score data and 0.832 for BMD data, where it should be >0.7 to be consider as reliable.

This study data sources came from primary data that has been collected specifically for this research project, and the design of the study is to discover if there is any relationship between the factors and diseased stats (normal bone (T-score >-1) or abnormal bone (T-score <-1)) results for lumbar spine and hip, therefore, this study used Spearman correlation test in order to know the significant level and the who strong is the correlation and direction of the relation. Moreover it is a cross-sectional study as the frequency of data collected was just once.

Results

Data were analysed for 1851 patients (mean age 60.44, SD 13.6 years), 214 (11.6%) are males and 1637 (88.4%) are females. After dividing the participants into four age groups, a highly significant result has been noticed with (P=0.00) in lumbar spine and hip, with a negative relation to the risk of osteoporosis. 5.4 shows participants in each age group with the osteoporosis, osteopenia and normal.

Also this study group shows a significant relation (P<0.001) with the Bone Mineral Index (BMI). 5.5 shows participants who are overweight, normal and underweight with the osteoporosis, osteopenia and normal.

Table 5.2 shows correlation results for Age and BMI with lumbar spine and hip diseased stats (normal bone (T-score >-1) and abnormal bone (T-score <-1)), where N is the valid number of participants .

Lumbar Spine

Hip

Age (Banded)

Correlation Coefficient

-.166**

-.223**

Sig. (2-tailed)

.000

.000

N

1794

1791

BMI (Binned)

Correlation Coefficient

.146**

.254**

Sig. (2-tailed)

.000

.000

N

1792

1789

Table 5.2: Correlation results for Age and BMI with lumbar spine and hip diseased stats.

434 (23.4%) of the study group had answered yes for if they have a family history of osteoporosis, nearly half of them (N=934) answered no, and 467 (25.2%) of them were unsure. The family history of osteoporosis was not associated with increased risk of osteoporosis at the hip region; also there were no association between Hyperthyroidism and Diabetes with the risk of osteoporosis at the hip region. However, lumbar spine results shows some association with family history results only (p=0.021), table 5.3.

Lumbar Spine

Hip

family History

Correlation Coefficient

-.055*

-.023

Sig. (2-tailed)

.021

.335

N

1781

1778

Hyperthyroidism

Correlation Coefficient

-.028

-.013

Sig. (2-tailed)

.237

.574

N

1773

1770

Diabetes

Correlation Coefficient

-.021

-.012

Sig. (2-tailed)

.376

.625

N

1790

1787

Sig. (2-tailed)

.202

.008

N

1731

1727

Table 5.3: Correlation results for family history, hyperthyroidism and diabetes with lumbar spine and hip diseased stats.

While the different levels of exercise and being mobile shows negative association with the risk of osteoporosis with significant results at the hip region only (p=0.008) (p=0.001) respectively, confined to bed more than 2 months and taken steroid more than 3 months shows no relation to the risk of osteoporosis, table 5.4.

Lumbar Spine

Hip

How Mobile

Correlation Coefficient

-.013

-.081**

Sig. (2-tailed)

.579

.001

N

1743

1740

Regular Excercise

Correlation Coefficient

-.031

-.064**

Sig. (2-tailed)

.202

.008

N

1731

1727

Confined to bed more than 2 months

Correlation Coefficient

.017

.038

Sig. (2-tailed)

.476

.111

N

1741

1737

Taken Steroid more than 3 months

Correlation Coefficient

.006

-.004

Sig. (2-tailed)

.813

.865

N

1768

1765

Table 5.4: Correlation results for mobility with lumbar spine and hip diseased stats.

Although previous fracture of a bone increases the possibility of osteoporosis with significant (P=0.007, 0.00) respectively at the lumbar spine and hip, back pain now and before have shows no relation to the risk of osteoporosis, moreover, the daily intake of milk, cheese, fish and vegetables shows very low relation with the risk osteoporosis and almost not significant, table 5.5.

Lumbar Spine

Hip

Bone Fracture

Correlation Coefficient

.068**

.116**

Sig. (2-tailed)

.007

.000

N

1535

1530

Back Pain (Now)

Correlation Coefficient

-.013

-.032

Sig. (2-tailed)

.579

.188

N

1743

1740

Previous Back Pain

Correlation Coefficient

-.016

-.038

Sig. (2-tailed)

.535

.144

N

1503

1499

Table 5.5: Correlation results for bone fracture and back pain with lumbar spine and hip diseased stats.

At the same time the analysis showed high negative association with the risk of osteoporosis for patients who had taken contraceptive pills for more than 3 months, HRT and nature period with significant of (P=0.00) for all three at the lumbar spine and hip. That means that patients taking contraceptive pills and HRT will reduce the risk of osteoporosis.

Whereby the patients who had Hysterectomy were significant at the left hip (P=0.021) with negative association to the risk of osteoporosis. At the same time females who had previously had their ovaries removed, pregnant or breast feeding shows no significant results, table 5.6.

Lumbar Spine

Hip

Contraceptive pill more than 3 months

Correlation Coefficient

-.163**

-.227**

Sig. (2-tailed)

.000

.000

N

1554

1562

Natural Periods

Correlation Coefficient

-.138**

-.102**

Sig. (2-tailed)

.000

.000

N

1569

1576

Hysterectomy

Correlation Coefficient

-.025

-.058*

Sig. (2-tailed)

.315

.021

N

1576

1584

Ovaries removed

Correlation Coefficient

-.030

-.053*

Sig. (2-tailed)

.246

.039

N

1542

1548

Taken HRT

Correlation Coefficient

-.107**

-.142**

Sig. (2-tailed)

.000

.000

N

1552

1559

Pregnant

Correlation Coefficient

-.051*

-.022

Sig. (2-tailed)

.044

.372

N

1571

1579

Brest feeding

Correlation Coefficient

-.048

-.020

Sig. (2-tailed)

.069

.440

N

1455

1466

Table 5.6: Correlation results for female questions only with lumbar spine and hip diseased stats.

Results Limitations

In the questions about alcohol intake and smoking, the questions were not designed in a way that the participant would be able to answer it while their names is shown in the top of the questionnaire, for this reason it has been decided to conceder these two categories un-appropriate to analyse.

SECOND STAGE

Subject and Methods

An assessment was carried out to the self-administrated questionnaire that has been used in the first stage; it has been reviewed in both ways, technically and scientifically at the same time. First stage results were used to determine the new questions in the second stage, the previous questionnaire includes more lifestyle factors than the new one, and the new questionnaire includes more questions about patients' treatment history that might affect their bones, moreover the new questionnaire is a computer-based questionnaire which has been developed specially for this purpose using Microsoft Access 2003, and being answered by the patients with help from the technicians in the DXA scanner room, 5.6.

A total of 3182 patients (424 (13.3%)) male and (2758 (86.7%)) female participant in the study in this stage, the age range of the patients is shown in table 5.7.

Frequency

Percent

Age Group

20 - 40

143

4.5

41 - 60

1027

36.8

61 - 80

1683

52.9

81+

329

10.3

Total

3182

100.0

Table 5.7: Age groups

Patients with both lumbar spine and hip were included, hip only or lumbar spine only was excluded. All patients age below 20 years were excluded as the reference age for T-score is 21 years old, and 20 years old and below considered as paediatrics.

Lifestyle factors that have been used from the previous questionnaire are: family history, hyperthyroidism, diabetes, having steroids, have fractured a bone, alcohol intake, smoking, mobility and exercises, and for female patients only: contraceptive pill, natural periods, hysterectomy, removal of ovaries, HRT, pregnancy and breast feeding. Also eight types of treatment have been recorded: Actonel, Alendronate, Calcium/Vitamin D, Forsteo, Ibandronate, Pamidronate, reloxofene and Strontium Ranelate. Whereby the first three treatments have been recorded in the first questionnaire. Age, ethnic origin, height, weight, BMD and T-scores results from the DXA scanner software were recorded and matched with patients' database list using Microsoft Excel 2003.

BMI (kg/m2) was calculated using weight and height and using the same formula that been used in the first stage. Bone measurements, such as, BMD measurements (g/cm2), T-score and Z-score were obtained from dual-energy X-ray absorptiometry (DXA) in two units, Hologic based in Singleton Hospital, Swansea, and explorer, mobile unit, which covers south west Wales area.

FRAX, NOGG and NICE

Another assessment was carried out to assess the type of questions to be asked in the questionnaire at this stage. In order to do this a review was made to the main three national guidelines for the prevention and treatment of osteoporosis, FRAX software, NATIONAL OSTEOPOROSIS GUIDELINE GROUP (NOGG) and National Institute for Health and Clinical Excellence (NICE). More details regarding these guidelines have been described in more details in the background chapter.

In the coming paragraphs a close look with some notes will be made to those guidelines in order to assess our questionnaire and introduce the questions in the national level and compare them to the questions been used in the first stage questionnaire.

FRAX

- Previous fracture A fracture detected as a radiographic observation alone (a morphometric vertebral fracture) counts as a previous fracture.A prior clinical vertebral fracture from which the patient suffers consequences, is an especially strong risk factor.The probability of fracture computed may therefore be underestimated.Fracture probability is also underestimated with multiple fractures.

- Smoking, alcohol, glucocorticoids: These risk factors appear to have a dose-dependent effect.Clinical judgment should be used for low or high exposures.

- Bone mineral density (BMD) The site and reference technology is DXA at the femoral neck.

NOGG

- Guidelines for the prevention and treatment of osteoporosis.

- The recommendations in the guideline should be used to aid management decisions but do not replace the need for clinical judgement in the care of individual patients in clinical practice.

- BMD at the femoral neck provides the reference site.

- Severe osteoporosis (established osteoporosis) describes osteoporosis in the presence of 1 or more fragility fractures.

- Fracture risk should be assessed in postmenopausal women and in men aged 50

NOGG - Executive Summary

- Background

o Osteoporosis is described by the World Health Organization as a ‘progressive systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture'.

o Approximately 50% of patients suffering a hip fracture can no longer live independently and 20% die within 12 months of the fracture.

o The same diagnostic cut-off values for BMD can be applied to men since observational studies indicate that the absolute risk of fracture for any given BMD and age is similar in men to that in women.

o The use of multiple sites for diagnosis is not recommended.

o The writing group does not recommend the use of other techniques, including quantitative ultrasound and computed tomography for the diagnosis of osteoporosis.

- Assessment of fracture risk

o The assessment of BMD provides information on prognosis i.e. the likelihood of future fractures.

o The gradient of risk varies according to the site and technique used, age and the fracture outcome.

o For diagnostic purposes alone, DXA at the femoral neck is the preferred site, particularly in elderly individuals; because of its higher predictive value for fracture risk .The spine is not a suitable site for diagnosis in the elderly because of the high prevalence of arthrosis and arthritis, but it is the preferred site for assessing response to treatment.

o The use of BMD alone to assess risk has a high specificity but low sensitivity.

o Age contributes to risk independently of BMD.

o The additional clinical risk factors have been identified that provide information on fracture risk independently of both age and BMD: (Low BMI is a significant risk factor for hip fracture, fracture risk is approximately doubled in the presence of a prior fracture, a parental history of hip fracture is a significant risk factor that is largely independent of BMD, Smoking is a risk factor that is in part dependent on BMD, alcohol intake and fracture risk is dose-dependent, glucocorticoids is solely dependent upon bone loss and BMD independent, rheumatoid arthritis increases fracture risk independently of BMD and the use of glucocorticoids)

- The consideration of these risk factors improves the sensitivity of testing without sacrificing specificity.

- Risk of fracture should be expressed as a short-term absolute risk, i.e. probability over a ten year interval.

- The assessment takes no account of prior treatment or of dose-responses for several risk factors; these limitations should temper clinical judgement.

NICE – review methods

- Types of participants

o At risk of osteoporotic fractures.

o Who may or may not have had a previous fracture.

o People with osteoporosis, osteopenia or normal bone mineral densities (BMDs).

o People with glucocorticoid-induced osteoporosis.

- BMD at the total femur for non-Hispanic white women aged 20–29 years: BMD mean 0.956 g/cm2, SD 0.123 g/cm2. Other values from the same source were used for men.

- T-score = [BMD (at femoral neck) – BMD ref] / SD ref

- The relative risk (RR) for the prevention of fracture was independent of the absolute risk of fracture.

- Types of outcome measures

- For the prevention of osteoporosis, the following primary outcomes were considered:

o Fragility fractures are those associated with low trauma; that is, a fracture sustained as the result of a force equivalent to the force of a fall from a height equal to or less than that of an ordinary chair. They are also known as ‘osteoporotic fractures'.

o Major trauma (for example, road accident) were excluded.

o Studies that did not report fracture outcomes, but did record the BMD. These studies were recorded in the text and classified as excluded studies (BMD only).

o Studies recording only the number of fractures were included but not analysed unless there was sufficient information to calculate the number of patients with at least one fracture.

- Clinical, or symptomatic, vertebral fractures are those fractures that cause sufficient discomfort for the patient to bring them to the attention of a health professional.

- Data extraction: For intervention studies, the following data were extracted:

o Study details: study design; country where trial was conducted; study size; setting; funding.

o Participants:

- characteristics: age (mean and range); ethnicity, comorbidities; weight/height/body mass index (BMI); smoking; mean time since the menopause; inclusion/exclusion criteria; calcium/vitamin D supplementation

− type of osteoporosis (osteoporosis, osteopenia, normal BMD); T-score mean and range (and if not given, BMD mean and T-score calculated)

− type of patient (e.g. postmenopausal women, men)

− type of risk group (not high risk, glucocorticoid-induced osteoporosis, other high risk group)

− presence of one or more prior fractures.

o Interventions:

− class (for example, bisphosphonate)

− drug (for example, alendronate)

− intervention details, duration of intervention; dose; route of delivery (intravenous, oral); frequency of intervention

− other interventions given concurrently to all patients.

o Comparator: usual care; placebo (details of what it is); other intervention.

o Outcomes: site of fracture measurement; time measured (including follow-up after end of intervention); method of measurement used (validity); means of determination of fracture (radiographic, clinical)

o Other data extracted were: study quality and results for each outcome.

Table 5.8 summarises the lifestyle factors used in all three guidelines and the lifestyle factors used at Singleton Hospital.

FRAX

NOGG

Nice

Singleton

Age

ü

ü

ü

ü

Sex

ü

ü

ü

ü

BMI

ü

ü

ü

ü

Family History of Osteoporosis

-

-

ü

Previous fracture

ü

ü

ü

ü

Parent fractured hip

ü

ü

-

-

Current smoking

ü

ü

-

ü

Glucocorticoids

ü

ü

-

ü

Rheumatoid arthritis

ü

ü

-

-

Alcohol 3 or more units/day

ü

ü

-

ü

Secondary osteoporosis:

ü

ü

-

-

- Untreated hypogonadism in men and women

-

ü

-

-

- Prolonged immobility

-

ü

-

-

- Organ transplantation

-

ü

-

-

- Type I diabetes

-

ü

-

ü

- Hyperthyroidism

-

ü

-

ü

- Gastrointestinal disease

-

ü

-

-

- Chronic liver disease

-

ü

-

-

- Chronic obstructive pulmonary disease

-

ü

-

-

- Falls

-

ü

-

-

Ethnicity

-

-

ü

ü

Mean time since menopause

-

-

ü

-

Type of Osteoporosis

-

-

ü

ü

BMD

ü

ü

ü

ü

Type of patients: (Pre- Post-menopausal women, men)

-

-

ü

-

Type of risk group: (not high risk, glucocorticoid-induced osteoporosis, other high risk group)

-

-

ü

-

Interventions class (e.g. Bisphosphonate)

-

-

ü

-

Interventions drugs:

-

-

ü

ü

- Didronel / Actonel

-

-

-

ü

- Fosamax / Alendronate

-

-

-

ü

- Calcium / Vitamin D

-

-

-

ü

- Bonviva / Ibandronate

-

-

-

ü

- Pamidronate

-

-

-

ü

- Reloxofene

-

-

-

ü

- Forsteo

-

-

-

ü

- Protelos / Strontium Ranelate

-

-

-

ü

Interventions details, duration, dose, route of delivery (IV, Oral), frequency

-

-

ü

-

Mobility

-

-

-

ü

Walking

-

-

-

ü

Exercise

-

-

-

ü

Contraceptive pill

-

-

-

ü

Hysterectomy

-

-

-

ü

Ovaries removed

-

-

-

ü

HRT

-

-

-

ü

Pregnant

-

-

-

ü

Breast feed

-

-

-

ü

Table 5.8 summarises the lifestyle factors used in FRAX, NOGG, NICE and Singleton Hospital.

Data Analysis

Following the same procedures in the first stage to make a true comparison between the two stages, the same data analysis parameters were used in this stage. Spearman rank nonparametric correlations were used to find if there is any association between main lifestyle factors, age and BMI with lumbar spine and hip diseased stats (normal bone (T-score >-1) or abnormal bone (T-score <-1)) to determine significance level between the variables. Statistical significance was defined as P < 0.05. Descriptive statistics has been used to find the frequencies and percentages for nominal data where there is no ranking such as male female relation and treatment type. All analyses were performed on a personal computer using SPSS (version 16.0) software package.

Also test of normality was performed in this stage and shows that the collected is normally distributed using T-score and BMD data for both lumbar spine and hip, s 5.7 and 5.8.

In the reliability statistics, the research tool is reliable if it is consistent and stable, and therefore predictable and accurate, this stage scores in the Cronbach Alpha 0.809 for T-score data and 0.827 for BMD data, where it should be >0.7 to be consider as reliable.

As the first stage, this study data sources came from primary data that has been collected specifically for this research project, and the design of the study is to discover if there is any relationship between the factors and diseased stats (normal bone (T-score >-1) or abnormal bone (T-score <-1)) results for lumbar spine and hip, therefore, this study used Spearman correlation test in order to know the significant level and the who strong is the correlation and direction of the relation. Moreover it is a cross-sectional study as the frequency of data collected was just once.

Results and Discussion

Bone status can be divided into three categories: Osteoporotic, osteopenic and normal according to the patient's T-score, which is the standard deviation below or above the bone morrow density (BMD) for average females at age 21 years old. T-score below -2.5 considered as osteoporosis, between -1 and -2.5 is osteopenia and above -1 is normal, as been described in more details in the background chapter.

After dividing the participants into four age groups, a highly significant result has been noticed with (P=0.00), with a negative relation to the risk of osteoporosis, were if the age increased the possibility to be normal decreased.

Also a highly significant result for Body Mass Index (BMI) has been noticed with (P=0.00), with a positive relation to the risk of osteoporosis, where by putting more weight the patients have low risk of osteoporosis, table 5.9.

Lumbar Spine

Hip

Age (Binned)

Correlation Coefficient

-.182**

-.250**

Sig. (2-tailed)

.000

.000

N

3182

3182

BMI_score

Correlation Coefficient

.163**

.277**

Sig. (2-tailed)

.000

.000

N

3036

3036

Table 5.9: Correlation results for Age and BMI with lumbar spine and hip diseased stats.

749 (23.5%) of the study group had answered yes for if they have a family history of osteoporosis, 2285 (71.8%) of them answered no, and 147 (4.6%) of them were unsure. In this stage family history of osteoporosis was not associated with increased risk of osteoporosis in both sites lumbar spine and hip. However, hyperthyroidism shows association and diabetes shows negative association with the risk of osteoporosis (p=0.05) and (p=0.001) in lumbar spine, and (p=0.049) and (p=0.001) in the hip respectively, table 5.10.

Lumbar Spine

Hip

Family_History

Correlation Coefficient

.015

-.027

Sig. (2-tailed)

.408

.132

N

3181

3181

Hyperthyroidism

Correlation Coefficient

.039*

.042*

Sig. (2-tailed)

.027

.018

N

3182

3182

Diabetes

Correlation Coefficient

-.070**

-.068**

Sig. (2-tailed)

.000

.000

N

3181

3181

Table 5.10: Correlation results for family history, hyperthyroidism and diabetes with lumbar spine and hip diseased stats.

The same as the first stage results, existing of fracture in one of the fragile sites (hip, lumbar spine and wrist) has shows a very strong association with the risk of osteoporosis (p=0.00) in both lumbar spine and hip. Having steroids has shows no relation in the first stage, yet, it is not significant in this stage also, table 5.11.

Lumbar Spine

Hip

Steroid

Correlation Coefficient

-.046**

-.031

Sig. (2-tailed)

.009

.077

N

3182

3182

fracture

Correlation Coefficient

.102**

.145**

Sig. (2-tailed)

.000

.000

N

3180

3180

Table 5.11: Correlation results for steroid and fracture with lumbar spine and hip diseased stats.

In the first stage the alcohol and smoking questions were excluded from the analysis because of the questionnaire was paper based and not anonyms and gives less confidante to answer them, on the other hand in this stage, the data for alcohol and smoking were collected from the patients by the technicians in the diagnostic room into the computer directly, which gives more confidante to answer these two questions. Yet, smoking shows no relation in both lumbar spine and hip results, and alcohol shows no association in the lumbar spine site and negative association with the risk of osteoporosis in the hip site results (p=0.006), table 5.12.

Lumbar Spine

Hip

Alcohol

Correlation Coefficient

-.025

-.057**

Sig. (2-tailed)

.153

.001

N

3180

3180

smoking

Correlation Coefficient

.025

.033

Sig. (2-tailed)

.164

.066

N

3180

3180

Table 5.12: Correlation results for alcohol and smoking with lumbar spine and hip diseased stats.

Hip results shows high significant negative association results (p=0.00) for different levels of exercise walk and mobility in this stage, and lumbar spine results shows some association (p=0.014) with mobility only, table 5.13.

Lumbar Spine

Hip

mobile

Correlation Coefficient

-.039*

-.143**

Sig. (2-tailed)

.027

.000

N

3180

3180

walk

Correlation Coefficient

.000

.098**

Sig. (2-tailed)

.985

.000

N

3134

3134

Excercise

Correlation Coefficient

-.007

-.082**

Sig. (2-tailed)

.708

.000

N

3074

3074

Table 5.13: Correlation results for mobility with lumbar spine and hip diseased stats.

All the results from the questions targeting females only shows high negative association with the risk of osteoporosis in the hip region except results from breast feeding question showed no association. Contraceptive pills for more than 3 months (p=0.00) in both lumbar spine and hip, also natural period and ovaries removal shows significant results in lumbar spine and hip (p=0.00, 0.00) (p=0.039, 0.006) respectively. Although hysterectomy, HRT and being pregnant shows significant results in hip region (p=0.002) (p=0.00) (p=0.004) respectively, results were not significant in the lumbar spine, table 5.14.

Lumbar Spine

Hip

contraceptive

Correlation Coefficient

-.095**

-.163**

Sig. (2-tailed)

.000

.000

N

3182

3182

natural_period

Correlation Coefficient

-.100**

-.103**

Sig. (2-tailed)

.000

.000

N

3179

3179

hysterectomy

Correlation Coefficient

.001

-.062**

Sig. (2-tailed)

.950

.000

N

3177

3177

ovaries_removed

Correlation Coefficient

.006

-.062**

Sig. (2-tailed)

.752

.001

N

3169

3169

HRT

Correlation Coefficient

-.044*

-.093**

Sig. (2-tailed)

.013

.000

N

3176

3176

pregnant

Correlation Coefficient

-.013

-.057**

Sig. (2-tailed)

.451

.001

N

3181

3181

brest_feed

Correlation Coefficient

-.035

-.026

Sig. (2-tailed)

.050

.146

N

3182

3182

Table 5.14: Correlation results for female questions only with lumbar spine and hip diseased stats.

Osteoporosis Treatments

Most of the participants in this study did not use any of the medication, whereby the maximum number did not exceed 1.6% of total number of patients for Actonel, Forsteo, Ibandronate, Pamidronate, reloxofene and Strontium Ranelate. However, this number was increased in Alendronate and Calcium/Vitamin D, table 5.15 shows number of patients been under Alendronate and Calcium/Vitamin D compared to lumbar spine and hip results.

Alendronate

Calcium_VitD

YES

NO

YES

NO

Lumbar Spine

Osteoporosis

98

639

254

484

3.1%

20.1%

8.0%

15.2%

Osteopenia

117

1045

400

762

3.7%

32.9%

12.6%

24.0%

Normal

116

1162

360

919

3.6%

36.5%

11.3%

28.9%

Hip

Osteoporosis

47

254

124

178

1.5%

8.0%

3.9%

5.6%

Osteopenia

141

1151

443

849

4.4%

36.2%

13.9%

26.7%

Normal

143

1441

447

1138

4.5%

45.3%

14.1%

35.8%

Table 5.15: number of participants with osteoporosis, osteopenia and normal for patients been under Alendronate and Calcium/Vitamin D.

As 5.12 shows participants using Calcium and Vitamin D are more than any other treatment as it is considered the first stage of treatment and preventing of osteoporosis. Moreover, Alendronate is the second line to be prescribed by the physicians to treat and prevent osteoporosis.

Discussion

Age groups and BMI, in both stages, shows highly significant result in lumbar spine and hip, with a negative relation to the risk of osteoporosis, were if the age increased the possibility to be normal decreased.

In the first stage family history of osteoporosis was not associated with increased risk of osteoporosis at the hip region, and some, not strong association at the lumbar spine; moreover, family history was not associated with increased risk of osteoporosis in both sites lumbar spine and hip in the second stage.

Hyperthyroidism and Diabetes in the first stage shoes no association with the risk of osteoporosis at the hip region; however in the second stage hyperthyroidism shows positive association and diabetes shows negative association with the risk of osteoporosis, where the possibility of having osteoporosis increases if the participants have hyperthyroidism and decreased if they are diabetics.

The effects of different levels of exercise and being mobile appears to have a negative association with the risk of osteoporosis at the hip region only, as weight bearing exercises helps to reduce the possibility of having osteoporoses. Moreover, previous fracture of a bone increases the possibility of osteoporosis at the lumbar spine and hip in both stages.

For female participants only and both stages, taken contraceptive pills for more than 3 months, HRT and nature period shows high negative association with the risk of osteoporosis , that means taking contraceptive pills and HRT will reduce the risk of osteoporosis, as well as having a nature period.

Conclusion

Age groups, BMI, Diabetes, different levels of exercise, being mobile, taken HRT, taken contraceptive pills and nature period shows significant results with no risk of osteoporosis, however, Hyperthyroidism and previous fracture , shows significant results with the risk of osteoporosis.

Whereby, family history, cheese intake, fish intake, vegetables intake, removal of ovaries, alcohol, smoking and all other factors shows no significant results with the risk of osteoporosis.

This study shows that osteoporosis in postmenopausal women is more related to hormonal intake than lifestyle factors.

Reference

International Osteoporosis Foundation (IOF) website, http://www.iofbonehealth.org/facts-and-statistics.html

Thomas, T. N. (1997). "Lifestyle risk factors for osteoporosis." Medsurg Nurs 6(5): 275-7, 287.

Naves Diaz, M., T. W. O'Neill, et al. (1997). "The influence of alcohol consumption on the risk of vertebral deformity. European Vertebral Osteoporosis Study Group." Osteoporos Int 7(1): 65-71.

Kanis, J. A., O. Johnell, et al. (2004). "Smoking and fracture risk: a meta-analysis." Osteoporos Int 16(2): 155-62.

Sampson, H. W. (2002). "Alcohol and other factors affecting osteoporosis risk in women." Alcohol Res Health 26(4): 292-8.

Kanis, J. A., H. Johansson, et al. (2005). "Alcohol intake as a risk factor for fracture." Osteoporos Int 16(7): 737-42.

Jamal, S. A., R. Ridout, et al. (1999). "Bone mineral density testing and osteoporosis education improve lifestyle behaviors in premenopausal women: a prospective study." J Bone Miner Res 14(12): 2143-9.

Korpelainen, R., J. Korpelainen, et al. (2006). "Lifelong risk factors for osteoporosis and fractures in elderly women with low body mass index--a population-based study." Bone 39(2): 385-91.

Goemaere, S., B. Zegels, et al. (1999). "Limited clinical utility of a self-evaluating risk assessment scale for postmenopausal osteoporosis: lack of predictive value of lifestyle-related factors." Calcif Tissue Int 65(5): 354-8.

Landin-Wilhelmsen, K., L. Wilhelmsen, et al. (1999). "Postmenopausal osteoporosis is more related to hormonal aberrations than to lifestyle factors." Clin Endocrinol (Oxf) 51(4): 387-94.

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