OSTEOPOROSIS IN SAUDI ARABIA ANOTHER EPIDEMIC WAITING TO HAPPEN ? MONA A FOUDA NEEL,MBBS, MRCP(UK),FRCPE MONA A FOUDA NEEL,MBBS, MRCP(UK),FRCPE ASSOCIATE PROFESSOR OF MEDICINE ASSOCIATE PROFESSOR OF MEDICINE CONSULTANT ENDOCRINOLOGIST CONSULTANT ENDOCRINOLOGIST COLLEGE OF MEDICINE COLLEGE OF MEDICINE KING SAUD UNIVERSITY KING SAUD UNIVERSITY

The magnitude of the problem The magnitude of the problem The relationship to vitamin D status in the country The relationship to vitamin D status in the country

Lumbar BMD of 830 postmenopausal Saudis according to age Category CategoryNumber (%) (%) BMD + SD BMD + SD T- Score T- Score Age yrs. Normal Normal Osteopenia Osteopenia Osteoporosis Osteoporosis Low BMD Age yrs. Normal Normal Osteopenia Osteopenia Osteoporosis Osteoporosis Low BMD Age yrs. Normal Normal Osteopenia Osteopenia Osteoporosis Osteoporosis Low BMD El Desouki. Saudi Med J 2003;Vol. 24 (9) Study by El Desouki 2003

Category Numbe r (%) BMD  SD T- Score Age Normal (0.05) Osteopenia (0.05) Osteoporosis (0.07) Total (0.15) Low BMD Age Normal (0.03) Osteopenia (0.05) Osteoporosis (0.07) Total (0.11) Low BMD Age Normal (0.07) Osteopenia (0.05) Osteoporosis (0.02) Total (0.12) Low BMD 5196 BMD – Bone Mineral Density SD-Standard Deviation Spine BMD In Postmenopausal Saudis by Age

CategoryNo:(%) BMD  SD T-Score Age Normal (0.07) Osteopenia (0.04) Osteoporosi s (0.5) Total (0.12) Low BMD Age Normal (0.04) Osteopenia (0.04) Osteoporosi s (0.06) Total (0.11) Low BMD Age Normal (0.01) Osteopenia (0.04) Osteoporosi s (0.06) Total (0.10) Low BMD BMD – Bone Mineral Density SD-Standard Deviation Femur BMD In Postmenopausal Saudis by Age

CategoryNumber (% ) BMD  SD T-Score Normal (0.05) Osteopenia (0.04) Osteoporosis (0.07) Total (0.15) Low BMD BMD – Bone Mineral Density SD-Standard Deviation Spine BMD In All Patients (50-80 Yrs) CategoryNumber(%) BMD  SD T-ScoreNormal (0.08) Osteopenia (0.04) Osteoporosis (0.06) Total (0.13) Low BMD BMD – Bone Mineral Density SD-Standard Deviation Femur BMD In All Patients (50-80 Yrs)

Prevalence of osteopenia and osteoporosis in Saudis (  50 years), using US/European and Saudi reference data. Data are presented as percentages with osteopenia (> -2.5 SD to < -1 SD below young adult BMD) and osteoporosis (< -2.5 SD below young adult BMD), for spine (L2-L4) and femur (total). (Ardawi MSM, et al. Osteoporosis Int 2005; 16: 43-55) 1980 PTS AGE M 915 F 1065

The proportion of Saudis aged  50 years with lower than -2.5 SD, stratified by body weight quartiles and sex. (Ardawi MSM, et al. Osteoporosis Int 2005; 16: 43-55)

VITAMIN D LEVELS BELOW 20 NMOL/L EXCLUDED ! VITAMIN D LEVELS BELOW 20 NMOL/L EXCLUDED !

Bone mineral density of the spine and femur in healhy saudi females : relation to vitamin D status, pregnancy, and lactation Bone mineral density of the spine and femur in healhy saudi females : relation to vitamin D status, pregnancy, and lactation N N GHANNAM ETAL calcif Tissue int 1999 N N GHANNAM ETAL calcif Tissue int females 321 females 25 vit D vit D Severe hypovitaminosis D (25 OHD less than 20 nmol/l )= 52% Osteopenia and osteoporosis in subjects more than 31=18-41 %, 0-7% Severe hypovitaminosis D (25 OHD less than 20 nmol/l )= 52% Osteopenia and osteoporosis in subjects more than 31=18-41 %, 0-7%

(Sadat-Ali M & AlElq AM. Ann Saudi Med 2006; 26: )

(El-Desouki MI & Sulimani RA. Saudi Med J 2007; 28: )

Resurection of vitamin D deficiency and rickets Resurection of vitamin D deficiency and rickets Michael Holick JCI 2006 Michael Holick JCI 2006 Severe chronic vitamin D deficiency { 25 (OH) D less than 15 ng/ml } leads to overt skeletal abnormalities in children typically defined as rickets Severe chronic vitamin D deficiency { 25 (OH) D less than 15 ng/ml } leads to overt skeletal abnormalities in children typically defined as rickets A large number of children and adolescents who have vitamin D insufficiency have no apparent skeletal or calcium metabolism abnormalities A large number of children and adolescents who have vitamin D insufficiency have no apparent skeletal or calcium metabolism abnormalities

Lee J.M. et al 2006 Lee J.M. et al 2006 Of 40 healthy mother-infant pairs predominantly non-white, 73% of mothers and 80% of infants had (25 OH)D levels of less than 20 ng/m ldespite the fact that 80% of mothers were taking prenatal multivitamins Of 40 healthy mother-infant pairs predominantly non-white, 73% of mothers and 80% of infants had (25 OH)D levels of less than 20 ng/m ldespite the fact that 80% of mothers were taking prenatal multivitamins

Sullivan et al 2005 Sullivan et al % of white girls aged 9-11 years in main had 25(OH)D levels than 20 ng/ml by end of summer and 17% remained vitamin D deficient and the end of summer 48% of white girls aged 9-11 years in main had 25(OH)D levels than 20 ng/ml by end of summer and 17% remained vitamin D deficient and the end of summer

Due to avoidance of exposure to sun and lack of fortification of many foods, upward of 35-80% of children in many sunny countries,Saudi Arabia, India,Turkey, Egypt, HongKong, China, Lebanone, Spain……etc are vitamin D deficient Due to avoidance of exposure to sun and lack of fortification of many foods, upward of 35-80% of children in many sunny countries,Saudi Arabia, India,Turkey, Egypt, HongKong, China, Lebanone, Spain……etc are vitamin D deficient When the deficiency occurs during fetal life it may increase risk of hip fratures and bone loss later in life When the deficiency occurs during fetal life it may increase risk of hip fratures and bone loss later in life

optimal 25hydroxyvitamin D values nglml or nmol/l Normal 25- hydroxyvitamin D values ng/ml or nmol/l

Table: Threshold values for vitamin D insufficiency based on different outcomes and study types. A common threshold value of 50 nmol/l has been proposed for vitamin D insufficiency, whereas vitamin D deficiency is characterized by values < 25 nmol/l. References References Study type Threshold values for 25-OHD (nmol/l) Higher 25OHD levels prevent Dawson-Hughes et al Ooms 1994 Ooms et al Chapuy et al Guillemant et al Jesudason et al Vieth et al Ooms et al Jesudason et al Krall et al Malabanan et al Lips 2001 Cross-sectionalCross-sectionalCross-sectionalCross-sectionalIntervention30-80 Increases with age Secondaryhyperparathyroidism Decrease in BMD Increase in bone turnover Seasonal variations in PTH Suppressible P-PTH (Mosekilde L. Clin Endocrinol 2005; 62: )

Figure: Prevalence of vitamin D inadequacy in all subjects. The percentage of subjects with serum 25(OH)D concentrations below predefined cutoffs of less than 9, less than 15, less than 20, less than 25, and less than 30 ng/ml. Factors associated with vitamin D deficiency: -Age -BMI >25 -Daily intake of vitamin D <400 IU (63%) -Medications affecting vitamin D metabolism -Race -Education level -Limited daily activity -Discussion with physician about vitamin D and bone health (28% had no counseling) 32% of women with vitamin D <30 ng/ml had NO risk factors (Holick MF, et al. J Clin Endocrinol Metab 2006; 90: )

The population under study is classified into 3 categories according to vit D nutritional status: deficient (  5 ng/ml), low (5-10 ng/ml) and adequate (  10 ng/ml).The population under study is classified into 3 categories according to vit D nutritional status: deficient (  5 ng/ml), low (5-10 ng/ml) and adequate (  10 ng/ml). The frequency of low 25-OHD concentration (5-10 ng/ml) is high (22% in total children and 20% in total adults) in the Saudi population, while the frequency of vit D deficiency (25-OHD level  5 ng/ml) is 3.4% in total children and 5.5% in total adults. This is true whether the population is urban or rural.The frequency of low 25-OHD concentration (5-10 ng/ml) is high (22% in total children and 20% in total adults) in the Saudi population, while the frequency of vit D deficiency (25-OHD level  5 ng/ml) is 3.4% in total children and 5.5% in total adults. This is true whether the population is urban or rural. 26% of female children or female adults have low vit D status in comparison with 19% and 17% for male children and male adults, respectively.26% of female children or female adults have low vit D status in comparison with 19% and 17% for male children and male adults, respectively. STUDY OF VITAMIN D STATUS AND FACTORS LEADING TO ITS DEFICIIENCY IN SAUDI ARABIA SALEH SEDRANI ET AL

The problem of osteoporosis in Saudi Arabia has been overlooked until now.The problem of osteoporosis in Saudi Arabia has been overlooked until now. It is of paramount importance to identify the magnitude of the problem of osteoporosis and its related fractures in Saudi Arabia.It is of paramount importance to identify the magnitude of the problem of osteoporosis and its related fractures in Saudi Arabia. This will be the cornerstone of setting up programs for screening high risk groups through non-invasive techniques and treatment at early stages of the disease with the aim of limiting disability and its impact on the national health resources.This will be the cornerstone of setting up programs for screening high risk groups through non-invasive techniques and treatment at early stages of the disease with the aim of limiting disability and its impact on the national health resources. ABDULRAHMAN ALNUAIM,MD,FRCPC,FACP ANNALE OF SAUDI MEDICINE,VOL 13,NO 1,1993