1. 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

2. 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

3. Lumbar BMD of 830 postmenopausal Saudis according to age Category CategoryNumber (%) (%) BMD + SD BMD + SD T- Score T- Score Age 50-59 yrs. Normal Normal Osteopenia Osteopenia Osteoporosis Osteoporosis Low BMD 21617112429542332457 1.098 + 0.11 0.893 + 0.13 0.795 + 0.15 - 0.61 - 0.61 - 2.36 - 2.36 - 3.21 Age 60-69 yrs. Normal Normal Osteopenia Osteopenia Osteoporosis Osteoporosis Low BMD 28 28 69 69157226 11 11 27 27 62 6289 1.092 + 0.12 0.986 + 0.13 0.774 + 0.141 - 0.71 - 0.71 - 2.41 - 2.41 - 3.4 Age 70-80 yrs. Normal Normal Osteopenia Osteopenia Osteoporosis Osteoporosis Low BMD 3 14 14 48 48 62 62 4.6 21.4 74 4.6 21.4 7495.4 1.102 + 0.13 0.981 + 0.12 0.732 + 0.12 - 0.78 - 0.78 - 2.43 - 2.43 - 3.5 El Desouki. Saudi Med J 2003;Vol. 24 (9) Study by El Desouki 2003

4. Category Numbe r (%) BMD  SD T- Score Age 51-60 Normal22437 1.130 (0.05) -0.55 Osteopenia21836 0.978 (0.05) -1.84 Osteoporosis16427 0.793 (0.07) -3.40 Total606100 0.952 (0.15) -2.06 Low BMD 38263 Age 61-70 Normal18 7 1.100 (0.03) -0.84 Osteopenia8032 0.970 (0.05) -1.93 Osteoporosis15261 0.774 (0.07) -3.56 Total250100 0.704 (0.11) -2.27 Low BMD 23293 Age 71-80 Normal 3 4 1.149 (0.07) -0.40 Osteopenia1622 0.962 (0.05) -2.00 Osteoporosis3574 0.771 (0.02) -3.50 Total54100 0.821 (0.12) -1.57 Low BMD 5196 BMD – Bone Mineral Density SD-Standard Deviation Spine BMD In Postmenopausal Saudis by Age

5. CategoryNo:(%) BMD  SD T-Score Age 51-60 Normal262 43 43 0.915 (0.07) -0.50 Osteopenia247 41 41 0.755 (0.04) -1.87 Osteoporosi s 97 97 16 16 0.606 (0.5) -3.10 Total606100 0.800 (0.12) -1.48 Low BMD 344 57 57 Age 61-70 Normal 38 3815 0.905 (0.04) -0.60 Osteopenia12148 0.740 (0.04) -1.99 Osteoporosi s 91 9136 0.587 (0.06) -3.27 Total25099 0.704 (0.11) -2.27 Low BMD 21284 Age 71-80 Normal 3 4 0.848 (0.01) -0.90 Osteopenia 30 3041 0.743 (0.04) -1.97 Osteoporosi s 39 3954 0.596 (0.06) -3.19 Total 72 7299 0.668 (0.10) -2.59 Low BMD 69 6995 BMD – Bone Mineral Density SD-Standard Deviation Femur BMD In Postmenopausal Saudis by Age

6. CategoryNumber (% ) BMD  SD T-Score Normal24326 1.12 (0.05) -0.62 Osteopenia28431 0.962 (0.04) -1.99 Osteoporosis40143 0.782 (0.07) -3.480 Total928100 0.912 (0.15) -2.40 Low BMD 68574 BMD – Bone Mineral Density SD-Standard Deviation Spine BMD In All Patients (50-80 Yrs) CategoryNumber(%) BMD  SD T-ScoreNormal30332.7 0.908 (0.08) -0.54 Osteopenia39742.8 0.750 (0.04) -1.91 Osteoporosis22824.5 0.597 (0.06) -3.19 Total928100 0.764 (0.13) -1.78 Low BMD 62567.3 BMD – Bone Mineral Density SD-Standard Deviation Femur BMD In All Patients (50-80 Yrs)

7. 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 20-79 AGE M 915 F 1065

8. 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)

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

10. 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 1999 321 females 321 females 25 vit D 24.5+17.2 25 vit D 24.5+17.2 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%

11. (Sadat-Ali M & AlElq AM. Ann Saudi Med 2006; 26: 450-454)

13. (El-Desouki MI & Sulimani RA. Saudi Med J 2007; 28: 774-777)

15. 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

16. 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

17. Sullivan et al 2005 Sullivan et al 2005 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 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

18. 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

19. optimal 25hydroxyvitamin D values 45-50 nglml or 115-128 nmol/l Normal 25- hydroxyvitamin D values 20-56 ng/ml or 50-140 nmol/l

20. 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. 1991 Ooms 1994 Ooms et al. 1995 Chapuy et al. 1997 Guillemant et al. 1999 Jesudason et al. 2002 Vieth et al. 2003 Ooms et al. 1995 Jesudason et al. 2002 Krall et al. 1989 Malabanan et al. 1998 Lips 2001 Cross-sectionalCross-sectionalCross-sectionalCross-sectionalIntervention30-80 Increases with age 30609050Secondaryhyperparathyroidism Decrease in BMD Increase in bone turnover Seasonal variations in PTH Suppressible P-PTH (Mosekilde L. Clin Endocrinol 2005; 62: 265-281)

21. 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: 3215-3224)

22. 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

23. 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