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Preliminary screening of osteoporosis and osteopenia in urban women from Jammu using calcaneal QUS Sharma S, Tandon VR, Mahajan A, Kour A, Kumar D - Indian J Med Sci
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Year : 2006  |  Volume : 60  |  Issue : 5  |  Page : 183-189

Preliminary screening of osteoporosis and osteopenia in urban women from Jammu using calcaneal QUS

1 Departments of Obstetrics and Gynaecology, Govt. Medical College, Jammu, J&K, India
2 Departments of Pharmacology and Therapeutics, Govt. Medical College, Jammu, J&K, India
3 Departments of General Medicine, Govt. Medical College, Jammu, J&K, India
4 Departments of Preventive and Social Medicine, Govt. Medical College, Jammu, J&K, India

Correspondence Address:
Sudhaa Sharma
Department of Obstetrics and Gynaecology, Govt Medical College, Jammu (J & K) - 180 001
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DOI: 10.4103/0019-5359.25679

PMID: 16733289

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 ¤ Abstract  

BACKGROUND: Osteoporosis is a major public health problem, associated with substantial morbidity and socio-economic burden. An early detection can help in reducing the fracture rates and overall socio-economic burden in such patients. AIM: The present study was carried out to screen the bone status (osteopenia and osteoporosis) above the age of 25 years in urban women population in this region. MATERIALS AND METHODS: A hospital based study was carried out in 158 women by calculating T-scores utilizing calcaneal QUS as diagnostic tool. RESULTS: The result suggested that a substantial female population had oesteopenia and osteoporosis after the age of 45 years. The incidence of osteoporosis was (20.25%) and osteopenia (36.79%) with maximum number of both osteoporosis and osteopenic women recorded in the age group of (55-64 years). After the age of 65 years, there was an almost 100% incidence of either osteopenia or osteoporosis, indicating that it increases with age and in postmenopausal period, thereby suggesting lack of estrogenic activity might be responsible for this increasing trend. Religion, caste and diet had an influence on the outcome of osteopenic and osteoporosis score in present study, but still it has to be substantiated by conducting larger randomized clinical trials in future. CONCLUSION: A substantial female population was screened for osteoporosis and osteopenia using calcaneal QUS method utilizing same WHO T score criteria that otherwise shall remain undiagnosed and face the complications and menace of osteoporosis.

Keywords: Osteopenia, osteoporosis, calcaneal QUS, BMD

How to cite this article:
Sharma S, Tandon VR, Mahajan A, Kour A, Kumar D. Preliminary screening of osteoporosis and osteopenia in urban women from Jammu using calcaneal QUS. Indian J Med Sci 2006;60:183-9

How to cite this URL:
Sharma S, Tandon VR, Mahajan A, Kour A, Kumar D. Preliminary screening of osteoporosis and osteopenia in urban women from Jammu using calcaneal QUS. Indian J Med Sci [serial online] 2006 [cited 2014 Mar 6];60:183-9. Available from:

 ¤ Introduction   Top

Osteoporosis is a disease characterized by reduction in the bone mass and disruption of bone architecture leading to impaired skeletal strength and an increased susceptibility of fractures.[1] It is a major public health problem associated with substantial morbidity and socio-economic burden world wide.[2] Moreover, the proportion of elderly population is rapidly increasing in the developed as well as the developing world, which increases concern among aging population and public health workers regarding disability, dependence, associated economic and social problems that are caused by osteoporosis. Osteoporosis does not have a dramatic clinical presentation except when fractures result. As age advances, the incidence of osteopenia and osteoporosis, the silent disease increases.[3]

Measuring the bone density remains the only important tool in the early diagnosis of osteoporosis, so that effective preventive and therapeutic measures can be initiated at the earliest. The gold standard for measuring bone density however is the Dual energy X-ray absorptiometry (DEXA), useful tool for both the axial and appendicular skeleton as the detection rate of osteopenia and osteoporosis is higher with it in comparison to calcaneal quantitative ultrasound (QUS) method.[4] But the commonest used modality of measuring bone density still remains to be calcaneal QUS.[5] It has gained the importance in the situation where tool like DEXA are not available. Since, calcaneal QUS is cost effective,[6] lacks deleterious effect of radiation and is portable.[7] Thus, it can be useful for an early diagnosis of osteoporosis so that intervention can be done at the earliest to such patients.

Although, similar studies evaluating bone status in women from outside India and within India are present in the literature[8],[9],[10],[11],[12],[13] but still the data is scanty, particularly from this region. Hence, the present pilot study was planned to screen bone status of healthy urban women above age of 25 years (when peak bone mass is formed) from this region utilizing calcaneal QUS (Hologic Sahara 0058 USG) as a diagnostic tool.

 ¤ Materials and Methods   Top

The present prospective, cross sectional hospital based study included healthy women from woman's clinic and family welfare clinic of Maharishi Dayanand Institute of Research, coming from different parts of Jammu city over a period of 6 months from 20-12-2004 to 20-6-2005. Total 158 women were enrolled and were distributed in the following age groups, 25-34 years (n=18), 35-44 years (n=38), 45-54 years (n=44), 55-64 years (n=42) and above 65 years (n=16). Informed consent was taken from all the subjects who participated in the present study.

Systemic diseases like renal and hepatic disorders rheumatoid arthritis, endocrine disorders like thyrotoxicosis, hyperpara- thyrodium, addison's disease, cushing syndrome and prolonged immobilization and women with oophorectomy were excluded from the study. Women on long term medication affecting the bone turnover (steroids, heparin, warfarin, thyroxine, hydrocortisone, phenytoin sodium, hormone replacement) were also strictly excluded. The exclusion was based on the clinical examination and if required specific investigations were carried. The questionnaire included information on sociodemographic, obstetrics, menstrual and medical history. The bone mineral density was measured at the calcaneus by QUS and T-scores were calculated based on WHO criteria.[14]

Although, the use of the WHO T-score thresholds of -2.5 for osteoporosis and -1.0 for osteopenia may be inappropriate at skeletal sites other than the spine, hip and forearm or when other modalities, such as quantitative ultrasound (QUS) are used.[15],[16] QUS yields a lower incidence or prevalence of osteoporosis if this WHO T score is applied. Although studies are present[16] suggesting alternate equivalent T score with calcaneal QUS method, but there is lack of any clear strategies or appropriate equivalent T score thresholds, hence QUS screening using same diagnostic criteria can at least confirm or rule out osteoporosis.[15] Moreover few studies have used same T score method for diagnosis of osteoporosis in past.[15]

T-score (Ratio between patients BMD and that of young adult population of same sex and ethnicity).T-score of >-1 was taken as normal, between -1 to -2.5 osteopenic and <-2.5 as osteoporotic. T-score was also utilized to find out the incidence and age wise trend of osteopenia and osteoporosis in present study. A Z-score is the number of standard deviations the measurement is above or below the age matched mean bone mineral density. Z-score is less commonly used but may be helpful in identifying persons who should undergo a work-up for secondary causes of osteoporosis. The present study was planned to evaluate bone status of urban women above age of 25 years excluding secondary osteoporosis. Hence, Z score was not evaluated. Ambient temperature, which can influence USG measurements at cold places like J&K in cold season. The lower the room temperature, the greater are the values of all the QUS parameters obtained.[17] To take care of this variable control heel temperature of subjects by keeping the test room temperature constant (37°C) throughout the study period was maintained.

Statistical analysis was performed with the help of computer software Epi-Info 6.2. The statistical significance among categories variables was assessed by the use of chi-square test for trend. P value of <0.05 was considered statistically significant.

 ¤ Results   Top

In the present study, 158 women in between the age group of 25 to above 65 years were enrolled. The women included in the study belonged to middle income group strata with both housewives and working class. Among 158 total women maximum number were enrolled in the age group of (45-54) followed by (55-64) and (35-44) age group.

Sixty eight (43.03%) of women were normal as per WHO criteria T score, whereas 58 (36.79%) had osteopenia and 32 (20.25%) had osteoporosis. The mean ± SEM, T-score at the calcaneum by QUS in the present study was - 1.43±0.56. Among total osteopenic woman, maximum number of osteopenics were recorded in the age group of (55-64 years) followed by 45-54 years and 35-44 years as 39.65%, 24.13%, 15.51% respectively. Whereas, among total (32) osteoporotic women, maximum were recorded in the age group at 55-64 year followed by above 65 year and then of 35-44 age group as 25% each. No women was found osteoporotic in the age group of (25-34) [Table - 1] While studying the age wise trend, it followed age wise increasing trend uniformly. After the age of 65 years, there was an almost 100% incidence of either osteopenia or osteoporosis with 50% being osteopenic and 50%, osteoporotic [Table - 2]. Total incidence of osteopenia and osteoporosis increased significantly after age group of 55-64 years.

While studying the correlation between osteopenia/osteoporosis and other variables, it was revealed that among total 58 osteopenics and 32 osteoporotic, 68.96% and 87.50% were Hindus respectively and among hindus 90% and 92.4% osteopenic and osteoporotic were from upper caste. Of 58 total osteopenic women 4 (6.89%) were still menstruating, 6 (10.34%) just achieved menopause and 38 (65.5%) were in post menopausal period. Whereas, of 32 osteoporotic 2 (6.25%) were still menstruating, 8 (25%) achieved menopause and 22 (68.75) were in post menopausal period. 38 (65.2%) of the osteapenic women and 20 (62.5%) of the osteoporotic women were vegetarian. Where as 10 (17.24%) and 6 (18.76%) of the osteopenic and osteoporotic women were non-vegetarian and rest were on mixed diet. Among the recorded osteopenic and osteoporotic women in the present study 65.2% and 62.5% were living active life respectively and two percent of these women gave history of tobacco/smoking and 90% of such women gave history of consuming tea and coffee regularly [Table - 3].

 ¤ Discussion   Top

The incidence of osteoporosis in the present study was (20.25%) and osteopenia (36.79%) with maximum number of both osteoporotics and osteopenic recorded in age group of (55-64 years). Hundred percent of population above 65 was either osteapenic or osteoporotic. The variations from the present study in incidence of osteoporosis and osteopenia by both calcaneal QUS and DEXA methods have been shown in [Table - 4].

Identifying women with osteoporosis remains a clinical challenge. Although the results of present study in comparison to the various studies[8],[9],[10],[11],[12] clearly reflect the under diagnosis of osteoporosis by QUS in comparison to DEXA, but QUS still remain the commonest modality of measuring bone density of cancellous bone (peripheral bone measurement) in the heel, with advantage of low cost, lack of radiation and portability. Hence, DEXA, remains the gold standard for measuring bone density but underscoring fairly good number of women to be osteopenic and osteoporotic in present study suggest that USG method can be use full particularly in situation where DEXA is not available, who other wise will remain totally undiagnosed. The incidence indicated in the present study may not be the true incidence of the population as QUS yield a lower incidence or prevalence of osteoporosis if the same WHO T score is applied.[15],[16] However, QUS screening conclusively confirms or rules out osteoporosis or osteopenia in any population.

Maximum number of osteopenic and osteoporotic were in post menopausal period followed by who just achieved menopause. Hence, the current study suggests that age and duration of menopause have negative correlation with the bone mineral density, as incidence of osteopenic and osteoporotic women increases with age and in post menopausal period. As age advances, the incidence of osteopenia and osteoporosis (the silent disease) increases with a resultant increase in the osteoporotic fractures.[3] This might be because there is an increased imbalance between bone resorption and formation with aging, which is an important cause of osteoporosis in elderly.[1]

Hindus upper cast were most affected population in our study but this aspect still has to be substantiated, as the present study was not randomized. Vegetarian were more affected population although they varied non-significantly from other dietary patterns. This may be due to deficient diet in calcium or low nutrients status.[12],[18]

The present study has some limitations less number of patients were screened over a period of six months only. QUS method may be used for osteoporosis screening but confirmation of osteoporosis may be done on the basis of DEXA or bone resorption markers, which were not carried out in the present study due to non availability of the facilities. Moreover Study has not considered stiffness index.

 ¤ Conclusion   Top

The present study suggests that calcaneal QUS method utilizing same WHO T score criteria is an attractive screening tool because of the low cost, feasibility and help in identifying osteopenia and osteoporosis in a substantial female population who otherwise shall remain undiagnosed and face the complications and menace of osteoporosis.

 ¤ References   Top

1. Lane NE. Epidemiology, etiology and diagnosis of osteoporosis. Am J Obstet Gynecol 2006;194:S3-11.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2. Johnell O, Kanis JA. An estimate of the worldwide prevalence, mortality and disability associated with hip fracture. Osteoporos Int 2004;15:897-902.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3. Atik OS, Gunal I, Korkusuz F. Burden of osteoporosis. Clin Orthop Relat Res 2006;443:19-24.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4. Syed Z, Khan A. Bone densitometry: applications and limitations. J Obstet Gynaecol Can 2002;24:476-84.  Back to cited text no. 4  [PUBMED]  
5. Kraemer DF, Nelson HD, Bauer DC, Helfand M. Economic comparison of diagnostic approaches for evaluating osteoporosis in older women. Osteoporos Int 2006;17:68-76.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6. Kung AW, Ho AY, Ross PD, Reginster JY. Development of a clinical assessment tool in identifying Asian men with low bone mineral density and comparison of its usefulness to quantitative bone ultrasound. Osteoporos Int 2005;16:849-55.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7. Mohr A, Barkmann R, Mohr C, Romer FW, Schmidt C, Heller M, et al. Quantitative ultrasound for the diagnosis of osteoporosis. Rofo 2004;176:610-7.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8. Sallin U, Mellstrom D, Eggertsen R. Osteoporosis in a nursing home, determined by the DEXA technique. Med Sci Monit 2005;11:CR67-70.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9. Sadat-Ali M, Al-Habdan IM, Al-Mulhim FA, El-Hassan AY. Bone mineral density among postmenopausal Saudi women. Saudi Med J 2004;25:1623-5.  Back to cited text no. 9  [PUBMED]  
10. Deplas A, Debiais F, Alcalay M, Bontoux D, Thomas P. Bone density, parathyroid hormone, calcium and vitamin D nutritional status of institutionalized elderly subjects. J Nutr Health Aging 2004;8:400-4.  Back to cited text no. 10  [PUBMED]  
11. Pande KC. Prevalence of low bone mass in healthy Indian population. J Indian Med Assoc 2002;100:598-600-2.  Back to cited text no. 11  [PUBMED]  
12. Shatrugna V, Kulkarni B, Kumar PA, Rani KU, Balakrishna N. Bone status of Indian women from a low-income group and its relationship to the nutritional status. Osteoporos Int 2005;16:1827-35.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13. Anburajan M, Rethinasabapathi C, Korath MP, Ponnappa BG, Kumar KS, Panicker TM, et al . Age-related proximal femur bone mineral loss in South Indian women: a dual energy X-ray absorptiometry study. J Assoc Physics India 2001;49:442-5.  Back to cited text no. 13    
14. Kanis JA. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. WHO Study Group. Osteoporos Int 1994;4:368-81.  Back to cited text no. 14  [PUBMED]  
15. Diez-Perez A, Marin F, Vila J, Abizanda M, Cervera A, Carbonell C, et al . Evaluation of calcaneal quantitative ultrasound in a primary care setting as a screening tool for osteoporosis in postmenopausal women. J Clin Densitom 2003;6:237-45.  Back to cited text no. 15    
16. Knapp KM, Blake GM, Spector TD, Fogelman I. Can the WHO definition of osteoporosis be applied to multi-site axial transmission quantitative ultrasound? Osteoporos Int 2004;15:367-74.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]
17. Iki M, Kajita E, Mitamura S, Nishino H, Yamagami T, Nagahama N. Precision of quantitative ultrasound measurement of the heel bone and effects of ambient temperature on the parameters. Osteoporos Int 1999;10:462-7.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18. Barr SI, Prior JC, Janelle KC, Lentle BC. Spinal bone mineral density in premenopausal vegetarian and non-vegetarian women: Cross -sectional and prospective comparisons. J Am Diet Assoc 1998;98:760-5.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]


[Table - 1], [Table - 2], [Table - 3], [Table - 4]

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