Prevalence of Vitamin D Insufficiency among Elderly Males Living in Rural Khon Kaen Province, Northeast Thailand.

BACKGROUND: Vitamin D is essential for bone strength. In our previous study of urban, elderly, males, the prevalence of vitamin D insufficiency was 48%, and they had a lower level of bone turnover marker than normal, young adult, Thai males. OBJECTIVE: To A) ascertain the prevalence of vitamin D insufficiency, B) to determine the bone turnover marker level in rural elderly males, and C) to compare urban and rural males with these parameters. RESULTS: The prevalence of vitamin D insufficiency among rural elderly males was 13.6%, while the level of bone turnover markers (P-CTx, and PINP) were in the normal Thai reference range. It was also found that rural elderly males had a significantly higher level of the calcidiol, iPTH, ß-CTx, and PINP than their urban counterparts. CONCLUSION: The prevalence of vitamin D insufficiency among rural elderly males was significantly lower than among urban males and rural males had a higher level of calcidiol, iPTH and bone turnover marker. The hypothesis was that differences in rural vs. urban lifestyle accounted for the discrepancy, possibly because elderly rural males performed strenuous outdoor labor while most urbanites stayed at home and/or had sedentary jobs.

Factors influencing diagnosis and treatment of osteoporosis after a fragility fracture among postmenopausal women in Asian countries: a retrospective study.

BACKGROUND: A vast amount of literature describes the incidence of fracture as a risk for recurrent osteoporotic fractures in western and Asian countries. Osteoporosis evaluation and treatment after a low-trauma fracture, however, has not been well characterized in postmenopausal women in Asia. The purpose of this study was to characterize patient and health system characteristics associated with the diagnosis and management of osteoporosis among postmenopausal women hospitalized with a fragility fracture in Asia. METHODS: Patient surveys and medical charts of postmenopausal women (N=1,122) discharged after a fragility hip fracture from treatment centers in mainland China, Hong Kong, Singapore, South Korea, Malaysia, Taiwan, and Thailand between July 1, 2006 and June 30, 2007 were reviewed for bone mineral density (BMD) measurement, osteoporosis diagnosis, and osteoporosis treatment. RESULTS: The mean (SD) age was 72.9 (11.5) years. A BMD measurement was reported by 28.2% of patients, 51.5% were informed that they had osteoporosis, and 33.0% received prescription medications for osteoporosis in the 6 months after discharge. Using multivariate logistic regression analyses, prior history of fracture decreased the odds of a BMD measurement (OR 0.63, 95% CI 0.45-0.88). Having a BMD measurement increased the odds of osteoporosis diagnosis (OR 10.1, 95% CI 6.36-16.0), as did having health insurance (OR 4.95, 95% CI 1.51-16.21 for private insurance with partial self-payment relative to 100% self-payment). A history of fracture was not independently associated with an osteoporosis diagnosis (OR 0.80, 95% CI 0.56-1.15). Younger age reduced the odds of receiving medication for osteoporosis (OR 0.59, 95% CI 0.36-0.96 relative to age ≥65), while having a BMD measurement increased the odds (OR 1.79, 95% CI 1.23-2.61). CONCLUSIONS: Osteoporosis diagnosis and treatment in Asian countries were driven by BMD measurement but not by fracture history. Future efforts should emphasize education of general practitioners and patients about the importance of fracture.

Discrepancy of left and right hip bone mineral density (BMD) in Thai women: diagnostic agreement and misclassification.

OBJECTIVE: To determine the diagnostic agreement and the degree of misclassification when using data from the left and right hips. METHODS: The cross-sectional study of 1,943 perimenopausal and postmenopausal Thai women, who had bone mineral density (BMD) measurements at the left (non-dominant) and right hips for the screening of low bone mass (LBM) or osteoporosis (OP) in the Department of Radiology, Faculty of Medicine, Chiang Mai University from September 2008 to August 2010 was performed. The kappa statistic was used to assess diagnostic agreement. The prevalence of LBM and OP and the percentage of misclassification were reported. RESULTS: There was a significant correlation between the left and right BMD values for the femoral neck (FN) (r (2) = 0.83; p < 0.001) and the total hip (TH) (r (2) = 0.89; p < 0.001). The diagnostic agreement of the FN and TH regions was significant in all study groups ranging from 0.69 to 0.76 (p < 0.001). For the final diagnosis, which is based on the least T-score of the FN or TH regions, the diagnostic agreement was 0.73 for all women, 0.77 for perimenopausal women, 0.73 for postmenopausal women, 0.70 for postmenopausal women age less than 65 years and 0.71 for postmenopausal women age greater than or equal to 65 years. The percentage of misclassification for all women was 16.9 %, with 3.3 % being downgraded from normal to LBM and 3.4 % from LBM to OP. CONCLUSION: Despite the fact that good diagnostic agreement was demonstrated in this study, a significant number of diagnostic discordance between left and right hips (16.9 %) was also observed. BMD measurements of both hips are recommended for diagnosing LBM and OP in clinical practice.

Prevalence of vitamin D insufficiency among the elderly males living in the urban areas of Khon Kaen Province in the northeast of Thailand.

BACKGROUND: Vitamin D insufficiency among the elderly Thai women in the urban areas was higher than in the rural areas because of lifestyle differences. There are very few studies about vitamin D status among Thai elderly males. OBJECTIVE: To ascertain the vitamin D status in and prevalence of vitamin D insufficiency among the elderly Thai males living in the urban areas of Khon Kaen province, situated in Northeast, Thailand. RESULTS: The respective mean (SE) of calcidiol, beta-CTx and PINP level for the elderly Thai males were 42.04 (1.22), 0.26 (0.02) and 37.39 (2.19) ng/mL. A calcidiol level under 40 ng/mL indicated vitamin D insufficiency and the prevalence of the elderly Thai males living in urban area of Khon Kaen province, Thailand was 48%. The respective correlations between PTH and calcidiol, beta-CTx and PINP were -0.217, 0.640 and 0.393. The respective correlations between PTH and BMD of the trochanteric region and total femur were 0.198 and 0.199 (p < 0.05). CONCLUSION: The prevalence of vitamin D insufficiency among the elderly males in Khon Kaen remained high and the bone biochemical markers were at a low enough level to cause low bone turnover and low BMD.

Modified Singh index in diagnosing femoral neck osteoporosis.

The participants in the present study were 130 elderly women living in Khon Kaen, Thailand. All except one subject was undergone by both DEXA-BMD and AP radiographs of the left hip joints. The mean (SD) of age, weight, height and BMI of the 129 participants were 72.5 (5.3) years old, 49.8 (10.3) kg, 1.49 (0.06) m, and 22.21 (4.13) kg/m2, respectively. Poor intrapersonal reliability (kappa = 0.11 and 0.11) and poor interpersonal reliability (kappa = 0.15) for the modified Singh index with three grades were found. On the other hand the modified Singh index with two grades had high accuracy in diagnosing of femoral neck and total hip osteoporosis (0.74 and 0.81 respectively) when comparing with DEXA-BMD.

The prevalence of hypovitaminosis D in the elderly women living in the rural area of Khon Kaen Province, Thailand.

This study investigated the prevalence of hypovitaminosis D in the elderly women living in the rural area of Thailand. The subjects were 132 cases (but just 129 cases were used in the statistical analysis?) of the elderly women who were living in the rural area of Khon Kaen province. The mean (+/- SD) of age and the mean (+/- SD) of serum 25 (OH) D concentration of these elderly women were 71.55 (+/- 5.26) years and 44.9 (+/- 11.02) ng/ml respectively. There was a significant inverse relationship (or correlation? Notice your analysis.) between the serum 25 (OH) D and the PTH concentration. The serum PTH concentration increased significantly when the serum 25 (OH) D concentration was at < or = 35 ng/ml. As a result, the prevalence of hypovitaminosis D in these selected elderly women was 17.4 per cent.

Hypovitaminosis D in Thailand.

The hypovitaminosis D in the premenopausal women and the postmenopausal elderly women in Thailand was investigated. One hundred and six cases of the elderly women living in the urban area of Khon Kaen province, one hundred and thirty-two cases of the elderly women living in the rural area of Khon Kaen province, ninety-eight cases of the postmenopausal women who attended Menopausal Clinic, Srinagarind Hospital, Khon Kaen province, and 357 premenopausal women from the multicenters in Thailand were the subjects. The serum level of 25(OH)D < or = 35 ng/ml was used as the cut-off point of hypovitaminosis D. The prevalence of hypovitaminosis D in these selected groups of women was 65.4, 15.4, 60.2, and 77.8 percent respectively. The premenopausal female group had the highest prevalence of hypovitaminosis D and the lowest level of 25 (OH) D whereas the group of the postmenopausal elderly women in the rural area had the lowest prevalence of hypovitaminosis D and the highest 25 (OH) D level.

Vitamin D status of Thai premenopausal women.

Vitamin D insufficiency of Thai elderly women in urban area were higher than in rural area because of the difference in life style. Until now there are no any evidences about vitamin D status in Thai premenopausal women. This study was the multicenters study from 5 provinces of Thailand which cover all region of Thailand except southern area. The mean (SE) of calcidiol level of Thai premenopausal women was 29.09 (0.42) ng/ml, and with the cut point of < or = 35 ng/ml; the prevalence of vitamin D insufficiency was 77.81%. Chiang Mai had lowest calcidiol level (25.09 ng/ml) and had highest PTH, and bone resorption markers. The prevalence of vitamin D insufficiency was highest in Khon Kaen (88.78%) and Chiang Mai (84.62%) province respectively. Life style modification to expose more sunlight should be advised for increasing the serum vitamin D and lowering the risk of osteoporosis.

A survey of osteoporosis in Thailand.

This survey of osteoporotic opinion was conducted to 150 Thai physicians in every part of the country with 10 questionnaires. The details of the questions concentrated on the osteoporosis in the aspects of diagnosis, management, methods of assessment, common medicine for treatment. The most responder specialty was Orthopedist (79%), others were Gynecologist (3%), Rheumatologist (5%), Internist (5%), the others (7%) respectively. The diagnosis of osteoporosis used Dual-energy X-ray absorptiometry (DXA), (81%) in the case of this equipment as well as other methods (16%) are available. The per cent of other methods are X-ray, clinical symptoms, microdensitometry, QUS, biochemical bone markers and others: 30, 23, 13, 5, 3 and 6 respectively. About twenty-five percent of physicians took responses to 21-100 cases per month while two per cent of responders had more than 100 cases per month. The most common three ranking kinds of criteria were used for initiating medication for the treatment of osteoporosis that had low bone mineral density, signs of vertebral fracture, and menopause which they considered as the importance of prophylactic medication for patients. The continuation of medication depends on the following factors: experience of serious side effect (62%), affordable expense (53%) and stable bone mass (52%). The desirable features of anti-osteoporosis agents are stopped fracture, increasing BMD, cost effectiveness, side effect, stopped bone resorption, pain relieve and drug compliance respectively. Calcium is most commonly prescribed on condition that premenopausal and postmenopausal women have without fracture or with fracture: patients are elderly and treated with the prolonged steroid application. Bisphosphonates are widely used in case of fracture in every group. Alfacalcidol, vitamin D analog is the third prescription in the above conditions. Bisphosphonate, Calcium and Alfacacidol are the common kinds of combination under the above conditions. In addition, these kinds of drugs are commonly used for continuation after the remission therapy.

Using quantitative ultrasound and OSTA index to increase the efficacy and decrease the cost for diagnosis of osteoporosis.

According to the WHO criteria for diagnosing osteoporosis, DXA is presently the best method for measuring and diagnosing osteoporosis, but it is relatively expensive, non-portable and emits low-level radiation. Alternatively, the Osteoporosis Risk Assessment Tool for Asians (OSTA) and quantitative ultrasound (QUS) are simpler, less expensive and emit no radiation, but are less accurate. However, the use of OSTA index corroborated by QUS was proposed as an alternative method of diagnosing osteoporosis. The combined diagnostic strength of an OSTA index < or = -1 and a QUS T-score < or = -4.5 had comparably high accuracy relative to the gold standard DXA T-score < or = -2.5, especially for the femoral neck (80%) and total femur (89%). We conclude that the sequential use of the OSTA index followed by QUS is an efficacious alternative for diagnosing osteoporosis, especially in rural areas or in developing countries where resources are limited.

Final Declaration of the Asian Metaforum on the Role of Vitamin D and the Management of Osteoporosis.

BACKGROUND: Vitamin D is essential for Ca absorption, prevention of falls and fracture, and maintenance of muscle strength and balance. Lack of awareness of the importance of vitamin D in bone health is common in Asia. OBJECTIVE: To define key statements, objectives and actions for improving osteoporosis management and vitamin D inadequacy in Asia. RESULTS AND CONCLUSION: This declaration was jointly produced by specialists at the Asia Metaforum on the Role of Vitamin D and the Management of Osteoporosis, held in September 2006 in Hong Kong, to define actions to prevent vitamin D insufficiency in Asia. Although developed specifically for Asia, some or all of these statements may be applicable to other regions of the world.

Impact of bone marker feedback on adherence to once monthly ibandronate for osteoporosis among Asian postmenopausal women.

AIM: This study assesses the impact of serum carboxy-terminal collagen crosslinks (CTX) bone marker feedback (BMF) on adherence to ibandronate treatment in Asian postmenopausal women with osteoporosis. METHODS: This was a 12-month (6-monthly phased), randomized, prospective, open-label, multi-center study conducted in 596 (of 628 enrolled) postmenopausal women with osteoporosis (< or = 85 years old) who were naïve, lapsed, or current bisphosphonate users. Patients were randomized into two arms: serum CTX BMF at 3 months versus no-BMF. Once-monthly 150 mg ibandronate tablet was administered for 12 months and adherence to therapy was assessed at 6 and 12 months. In addition, patient satisfaction and safety of ibandronate treatment were also assessed. RESULTS: Serum CTX BMF at 3 months showed no impact on adherence. The proportions of adherent patients were comparable in the BMF versus no-BMF arms (92.6%vs. 96.0%, P = 0.16); overall, serum CTX levels were similar for adherent and non-adherent patients. However, BMF patients felt more informed about their osteoporosis (P < 0.001) and more satisfied (P < 0.01) than no-BMF patients. CONCLUSIONS: The Asian postmenopausal osteoporosis patients in this study had a high adherence rate to once-monthly ibandronate therapy. Use of serum CTX BMF had no further impact on increasing adherence, but increased treatment satisfaction.

Modified OSTA index for referring women for DEXA measurement.

A retrospective study of 696 postmenopausal women with hip measurement by Dual-energy X-ray absorptionmetry (DEXA) from Sapphasittprasong Hospital, Ubon Rahatani and Srinagarind Hospital, Khon Kaen University. All variables: T-score, age and weight were collected and calculated by the original OSTA index and modified OSTA index. Thai osteoporosis foundation recognized Original OSTA index the cut point below or equal 4 as high risk of osteoporosis. The authors used the modified OSTA index for calculation without truncate, the authors found that the cut off point was <-3.5 making 79% sensitivity and 58.7% specificity while the original OSTA gave 73%, 62% respectively. The authors proposed modified OSTA index as a making-decision tool before sending the patient for bone mass measurement. That saves the expense of further investigation.

Singh index screening for femoral neck osteoporosis.

The present study included 130 elderly women living in Khon Kaen, Thailand, and all but one underwent both DEXA-BMD and AP radiographs of the left hip joint. The mean (SD) of age, weight, height and BMI of the 129 participants was 72.5 (5.3) years, 49.8 (10.3) kg, 1.49 (0.06) m, and 22.21 (4.13) kg/m2, respectively. The authors found both poor sensitivity and a positive predictive value for a Singh grade of < or = 4 or < or = 3 (viz. 58 and 29 or 19 and 43 percent, respectively). The ROC curve showed the poor diagnostic value of the Singh index since the area under the curve was approximately 40% the Singh index is therefore a poor screening tool for femoral neck osteoporosis.

Serum concentration of undercarboxylated osteocalcin and the risk of osteoporosis in thai elderly women.

The elevation of undercarboxylated osteocalcin (ucOC) means vitamin K insufficiency is significantly increased in elderly women, and is associated with high skeletal turnover, low BMD, and increased risk of osteoporotic fracture. The objective of the present study was to find out the level of ucOC and the prevalence of vitamin K deficiency in elderly Thai women. The upper limit of normal premenopausal ucOC level was 2.314 ng/ml, represented the cut-off level for vitamin K deficiency, 39.1% of elderly women had serum ucOC concentration above this level. Women with high serum ucOC level had a significantly lower BMD of ultradistal radius, distal 1/3 of radius and 25(OH)D level, higher serum PTH and alkaline phosphatase activity than women with a normal ucOC (p<0.05). Serum ucOC was correlated positively with PTH (r = 0.411, p< 0.001), modest negatively with serum 25(OH)D (r = -0.17, p= 0.013). The ucOC level of urbanized elderly was higher than that of rural elderly. It was concluded that vitamin K deficiency is one of the risks of osteoporosis with high prevalence in the Thai elderly especially urbanized ones, the supplement of vitamin K should be recommended in Thai osteoporotic patients especially the urbanized elderly.

Difference in serum calcidiol and parathyroid hormone levels between elderly urban vs suburban women.

The present study initially included 106 volunteers, elderly women living in urban or suburban Khon Kaen, Thailand. One case was excluded because of extremely high levels of alkaline phosphatase. The means (+/- SD) of the serum calcidiol and the PTH concentrations in the urban vs suburban groups were 31.45(+/- 1.15) ng/mL vs 36.15(+/- 2.4) pg/mL and 41.53(+/- 3.94) ng/mL vs 17.43(+/- 2.88)pg/mL, respectively. The urban group had a higher percentage and a higher risk of hypovitaminosis D and osteoporosis of the femoral neck than the suburban group, an odds ratio of more than 4 times higher.

Level of undercarboxylated osteocalcin in reproductive Thai females.

Osteocalcin is a vitamin K dependent protein requiring vitamin K as a cofactor for the enzyme gamma glutamyl carboxylase which converts the glutamate residues at 17, 21, 24 position of the molecule into gamma carboxyglutamate or Gla residues. The carboxylation makes immature osteocalcin or undercarboxylated osteocalcin (ucOC) into mature osteocalcin which enhances calcium binding in bone. The level of undercarboxylated osteocalcin is recognized as a marker of vitamin K2 bone. The level of undercarboxylated osteocalcin is recognized as a marker of vitamin K2 in blood necessary for this process. Mature osteocalcin has a higher affinity for hydroxyapatite than undercarboxylated osteocalcin. Foreign studies have shown that ucOC level is increased in elderly women and postmenopausal women in comparison with young, healthy, reproductive women and level of ucOC is also the marker to predict the risk of hip fracture. The standard value of undercarboxylated osteocalcin in Thai women is not available. The aim of the present study was to find the level of ucOC in reproductive Thai females. 357 healthy female volunteers who had regular menstruation, 20-50 years of age, average age 38.5 years old. The volunteers had no intake of any kind of medicine affecting bone metabolism before blood examination. The mean value of undercarboxylated osteocalcin is 2.69 ng/ml, median is 2.10_ng/ml standard deviation = 2.02,_standard error = 0.107 with 95% confident interval = 2.485 to 2.906 ng/ml. In the authors previous pilot study in elderly and postmenopausal women, the authors found that the mean of ucOC in Thai elderly and postmenopausal women was higher than that of reproductive women.