Osteoporosis: Is the prevalence increasing in Saudi Arabia.

Background and Objective: The objective of this analysis is to report from a teaching hospital in eastern Saudi Arabia hospital based prevalence of osteopenia and osteoporosis.
Methods: This is a retrospective study of all patients who underwent dual-energy X-ray absorptiometry (DXA) scan between January 1, and December 31, 2018, at King Fahd Hospital of the University at Alkhobar, Saudi Arabia. Demographic data of patients, which included age, sex, diabetes mellitus status based on fasting blood sugar, hemoglobin A1C, Vitamin D level, parathormone level, and T score of the neck of femur and lumbar spine was extracted from the Quadrumed patient care system. The data was entered into database and analyzed.
Results: Three hundred and one patients had a DXA scan for the year 2018, a jump of 27.2% of requests to diagnose osteoporosis. There were 55 (18.27%) were male and rest females (246). The average age for males was 65.2 ± 10.5 and females 62.9 ± 9.4 years. Using T score of the lumbar spine, 63.6% were osteoporotic in males and 52.8% in females. Conclusions: The hospital-based study shows that the prevalence of osteoporosis has significantly increased in men to 63.6%, while in postmenopausal women to 58.4%, this is high compared to the earlier reports.

INTRODUCTION

Osteoporosis is an aging metabolic disease in which bone resorption exceeds bone formation, causing architectural breakdown leading to fragility fractures. Reports in the early part of this millennium indicated that the problem of osteoporosis in Saudi Arabia was more worrisome than the rest of the world. Preliminary results suggested that the prevalence of osteopenia was as high as 48%.[1234567] Recently, Gouhar et al. reported a prevalence of osteoporosis of 29.7% in a population where 22% were the age of 60 years and above.[8] AlQuaiz et al. reported their screening of 362 healthy women using dual-energy X-ray absorptiometry (DXA) and found that 58.6% had low bone density, but this group included women between 40 and 50 years.[9]

The center of disease control reported that medical epidemiologists increased the life expectancy of people by 25 years in the United States since 1947 by performing repeated epidemiological studies.[10] Thus epidemiological studies become paramount part in proper assessment of the changing pattern of osteoporosis as the population is aging in Saudi Arabia so that proper decisions could be made to keep the population healthy. In this context, we decided to do a retrospective analysis of all Saudi Arabian patients who underwent DXA scan at the university hospital to assess the prevalence of osteoporosis and osteopenia.

METHODS

This is a retrospective of all patients who underwent DXA scan from January 1, 2018, to December 31, 2018, at King Fahd Hospital of the University at AlKhobar, Saudi Arabia. Demographic data of patients which was extracted was age, sex, diabetes mellitus status based on fasting blood sugar, hemoglobin A1C, Vitamin D level, parathormone level and T score of the neck of femur and lumbar spine was extracted from the Quadrumed patient care system. Normal 25-hydroxyvitamin D (25OHD) was taken as ≥30 ng/ml, insufficiency as 21–29 ng/ml and deficiency as ≤20 ng/ml. The inclusion criteria were all Saudi Arabians over the age of ≥50 years and having DXA scan for the first time. In the year 2010, 219 patients had a DXA scan. The data were entered into the database and analyzed using SPSS Statistics is a software package, Chicago, Illinois, USA Version 23. The data were expressed as mean ± standard deviation. Statistically significant differences between the different groups were determined with the Student's t-test using a P < 0.05, which is considered to be significant with confidence interval of 95%.

RESULTS

Three hundred and one patients had a DXA scan for 2018, a jump of 27.2% of requests to diagnose osteoporosis. In the present study, 55 (18.27%) were males and rest females (246). The demographic data of the males [Table 1] and females [Table 2] show the average age for males was 65.2 ± 10.5 and females 62.9 ± 9.4 years. Using T score of the lumbar spine 63.6% were osteoporotic in males and 52.8% in females. Forty-four (80%) of the males had a Vitamin D level tested and 206 (83.7%) of the female patients had their Vitamin D levels ordered. In female group 44 (21.4%) the 25OHD and in males 12 (27.3%) was normal (≥30 ng/ml).

Table 1

Demographic data of male patients

Variable	Total	Percentage
Number of patients screened	55
Age (years)	65.2±10.5
Vitamin D tested	44	80
T score hip
Osteopenia (28)	−1.97±0.27	50.9
Osteoporosis (14)	−2.97±0.47	25.5
T score spine
Osteopenia (15)	−1.9±0.41	27.3
Osteoporosis (35)	−3.6±0.77	63.6

Table 2

Demographic data of female patients

Variable	Total	Percentage
Number of patients screened	246
Age	62.9±9.4
Vitamin D tested	206	83.7
T score hip
Osteopenia (97)	−1.64±0.37	39.4
Osteoporosis (33)	−2.99±0.57	13.4
T score spine
Osteopenia (81)	−1.82±0.39	32.9
Osteoporosis (130)	−3.43±0.7	52.8

Table 3 shows the relationship of the 25OHD levels and osteoporosis. All males patients who had Vitamin D deficiency were osteoporotic with T score of <−3.67 ± 1.4 compared to those who had normal 25OHD levels the osteoporosis was 40% with a mean T score of <−2.21 ± 0.91 (P < 0.001). In female patients, 44 had a normal 25OHD level of 36.2 ± 5.17 and osteoporosis was in 15 (34%), while in 114 patients 25 OHD level was 11.51 ± 4.53 with 92 (80.7%) had osteoporosis with a T score of <−3.67 ± 1.4 (P < 0.001) Table 4.

Table 3

Vitamin D levels and risk of osteoporosis in male patients

Variable	Vitamin D
	≥30	21-29	≤20
Number of patients	12	9	23
Age of patients	74.5±6.6	73.33±11.4	64.66±7.44
Vitamin D level	40.44±7.6	25.68±2.6	11.51±4.53
Osteoporotic (%)	5 (40)	7 (75)	23 (100)
T score	<−2.21±0.91	<−3.4±1.34	<−3.67±1.4

Table 4

Vitamin D levels and risk of osteoporosis in female patients

Variable	Vitamin D
	≥30	21- 29	≤20
Number of patients	44	48	114
Age of patients	66.4±8.15	64.16±8.7	64.66±7.44
Vitamin D level	36.2±5.17	25.68±2.6	11.51±4.53
Osteoporotic (%)	15 (34)	23 (47.9)	92 (80.7)
T score	<−2.05±1.33	<−2.46±1.22	<−3.67±1.4

DISCUSSION

Our study shows that the hospital based prevalence of osteoporosis and osteopenia is quite high in Saudi Arabian males and in postmenopausal women. Using T score of the lumbar spine 63.6% of males and 52.8% of females were osteoporotic. In comparison to previous published data from Saudi Arabia, the figures are alarming. Ardawi et al. reported form West Coast in healthy Saudis the prevalence of osteoporosis (50–79 years) at the lumbar spine 38.3%–47.7%,[5] while El-Desouki and Sulimani[11] found in central Saudi Arabia to be 23.5%. Sadat-Ali and AlElq[12] from the east coast found the hospital based prevalence in the ethnic Saudi population to be 37.4%. A recent study reported the prevalence of osteopenia was 40.7% and the prevalence of osteoporosis was 9.3%.[13] Unfortunately, this study could not be compared to the previous studies as the average age in the report of Farsi et al. was 58.3 ± 6.9 years and 40% of their healthy individuals were in 50–54 years range.[13]

There is very limited data available for postmenopausal Saudi women in the last decade.

The subset analysis from the study of Gouhar et al.[8] show that 186 patients were over the age of 50 years and 148 (79.5%) had low bone mass (osteopenia and osteoporosis). Forty-three percent (80) were diagnosed to have osteoporosis. Our study found that 52.8% were diagnosed to have osteoporosis with the average Lumbar spine T score of <−3.43 ± 0.7. Our study and that of Gouhar et al.[8] indicates that the prevalence of osteoporosis has increased from what was in the previous decade.

The importance of calcium and Vitamin D in the prevention of osteoporosis is still underestimated. Reports indicate that universally 60% of postmenopausal women are deficient in Vitamin D levels.[141516] Saudi Arabian population is not immune to this.

Studies from Saudi Arabia found that about 60% of men and women over 50 years of age were Vitamin D deficient.[1718] In our study, only 83% of the patients were tested for Vitamin D status and the average deficiency was 55%. The higher deficiency of Vitamin D could be due to inadequate treatment with low dose of Vitamin D3. Meyer et al.[19] found that treatment of Vitamin D deficient patients with 4000 IU of Vitamin D3 per day for 6 months did not elevate the level to 44 ng/ml and did not hesitate in recommending that adults who do not expose to sunlight, should take as much as 5000 IU of Vitamin D per day. In the same context, recently, a study concluded that that the maintenance dose of 2000 IU of Vitamin D is not enough for patients to keep the 25(OH) D levels above 30 ng/mL and recommended 5000 IU daily.[20] The question of whether low levels of Vitamin D causes osteoporosis-related fractures has been indirectly answered by Swedish researchers as they showed a higher incidence of fragility fractures during the winter period when the population has low Vitamin D levels.[2122] This study found that in males, all patients who had Vitamin D deficient were osteoporotic, while female patients who were Vitamin D deficient 80.7% were osteoporotic, suggesting that Vitamin D may exacerbate bone loss in some way playing a role in osteoporosis.

Our study has limitations that the analysis was retrospective and one hospital based study and conclusions of this study alone cannot be for the whole country, but this study could stimulate other researchers to perform similar studies. We believe that there is definite increase in the hospital based prevalence of osteoporosis among the Saudi Arabian population. The prevalence of osteoporosis is bound to increase as the population is aging; secondly due to awareness of osteoporosis in social media circles has brought more people to undergo DXA scans, which has pushed the numbers up irrespective of the abovementioned factors. The prevalence of osteoporosis needs to be ascertained by regular planned epidemiological studies.

CONCLUSION

We believe that there is definite increase in the hospital based prevalence of osteoporosis among the Saudi Arabian population, this is happening because more patients are getting tested by DXA scan. The prevalence of osteoporosis is bound to increase as the population is aging; secondly due to awareness of osteoporosis in social media circles has brought more people to undergo DXA scans, which has pushed the prevalence towards the upwards trend.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.