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ORIGINAL ARTICLE
Year : 2022 | Volume
: 13
| Issue : 3 | Page : 206-212
Prevalence of osteoporosis and associated risk factors among postmenopausal women: A cross-sectional study from Northern India
Mohammad Imran1, Abhishek Singh2, Anu Bhardwaj3, Deepika Agrawal4
1 Department of Pharmacology, Maharaja Jitendra Narayan Medical College and Hospital, Cooch Behar, West Bengal, India
2 Department of Community Medicine, SHKM Government Medical College, Mewat, Haryana, India
3 Department of Community Medicine, Dr. BR Ambedkar Institute of Medical Sciences, Mohali, Punjab, India
4 Department of Community Medicine, Santosh Medical College, Ghaziabad, Uttar Pradesh, India
Correspondence Address:
Mohammad Imran
Department of Pharmacology, Maharaja Jitendra Narayan Medical College and Hospital, Cooch Behar, West Bengal
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jmh.jmh_114_22
Abstract
Context: Prevalence statistics of postmenopausal osteoporosis and knowledge regarding its independent predictors are lacking, especially in India, where every third woman and every eighth man is suffering from it. Aim: This study aims to investigate the prevalence of osteoporosis and associated risk factors among postmenopausal women. Study Settings and Design: This was a hospital-based prospective cross-sectional study. Methods: This study was carried out among postmenopausal women, who attended orthopaedics outpatient department from August 2020 to July 2021 and 587 women ranging in age between 50 and 80 years who had confirmed menopause were enrolled for the study. Finally, 539 women were recommended for bone mineral density testing, using dual energy X-ray absorptiometry. Statistical Analysis: To analyze the differences between the groups, a Chi-square and Student’s t-test were used for the categorical and continuous variables, respectively. P < 0.05 was considered to show significant associations. Results: In our study, 54.7% of subjects belonged to <60 years of age group. Half of the subjects (51.9%) were illiterate. 37.7% of subjects were having 6 or more children. 14.5% of subjects were currently smoking or chewing tobacco. Age of menopause among 38.0% of subjects was after 50 years of age and duration of menopause at the time of enrolment in the study was more than 10 years in 48.8% of subjects. The prevalence of osteoporosis increased with the increase in the parity and increased number of abortions. Subjects with family history of symptoms related to osteoporosis, and fragility fracture; and self-history of fragility fracture had higher prevalence of osteoporosis (P < 0.05). Conclusion: In our study, the overall prevalence of osteoporotic fractures among postmenopausal females was 82.2% (osteoporosis: 37.5% and osteopenia: 44.7%). The findings of current study and previous studies clearly indicate the urgent need of collective efforts towards the growing problem of osteoporosis in postmenopausal women.
Keywords: Bone mineral density, fracture, osteoporosis, postmenopausal, Z-score
Introduction 
Osteoporosis is the most common bone metabolic disease and the fourth major enemy of humans after cancer, cardiovascular disease, and stroke, which increases with age. Osteoporosis is characterized by low bone mass and destruction of bone tissue structure, leading to increased bone fragility and susceptibility to fractured bones.[1],[2] Osteoporosis is one of the major health problems in any country because of its association with fractures. T-score and Z-score indices are used to quantify bone density. The World Health Organization (WHO) defines osteoporosis as a bone mineral density (BMD) that lies 2.5 Standard deviation (SDs) or more below the mean maximum BMD.[3],[4] T-score indicates changes in the SD of a person’s bone density relative to the maximum BMD in healthy and young individuals, and Z-score also shows changes in SD of a person’s bone density relative to people of similar age, sex, and race. Accordingly, osteoporosis is defined as a T-score <−2.5 and osteopenia as T-score between −1 and −2.5. Age, sex, race, genetics, low calcium intake, and activity have an effect on bone mass.[5]
Menopause is one of the most important causes of osteoporosis. Postmenopausal women lose 3%−5% of their bone mass annually. These women lose part of their bone mass and are exposed to osteoporosis for up to 7 years after menopause. The reason for bone loss after menopause is the reduction in estrogen production by the ovaries. Menopausal osteoporosis is important because women spend one-third of their lives under conditions of reduced bone mass and increased risk of fractures, and the rate of bone loss in the 1st few years of menopause is high.[6],[7] Bone loss in postmenopausal women occurs in two phases. The initial short phase lasts 3–5 years and trabecular bone loss occurs rapidly (menopause-related bone loss), and in the long-term phase, men and women gradually lose their cortical and trabecular bones for over 10–20 years (age-related bone loss).[8] Fracture, disability, and chronic pain are the most common clinical consequences of osteoporosis. Pelvic, vertebrae, and distal radius fractures are the most common osteoporotic fractures. These fractures not only cause morbidity but also increase the chances of mortality, with mortality following hip fracture in the 1st year being 20%. Also, the disability-adjusted life year caused by osteoporosis in India was 36,026 years.[9],[10]
Prevalence statistics of postmenopausal osteoporosis and knowledge regarding its independent predictors are lacking, especially in India, where every third woman and every eighth man is suffering from it.[9] Investigation of common risk factors for calculating the independent risk predictors for osteoporosis is an important strategy, which can be useful in formulating an effective approach for managing osteoporosis and its imperative consequences. There is no compelling report on the prevalence and predictors for osteoporosis or osteopenia in the population of Mewat region, which has been analyzed in the present study.
Methods The present prospective cross-sectional study was carried out on postmenopausal women, who attended orthopedics outpatient department from August 2020 to July 2021 and 587 women ranging in age between 50 and 80 years who had confirmed menopause (one or more complete years of cessation of the menstrual cycle) were enrolled for the study. All those women who were nonconsenting, having other musculoskeletal disorders, cardiovascular disorders, cerebrovascular pathology, sarcopenia, diabetes, liver disorders, family history of osteoporotic fractures, thyroid dysfunction, all lupus, chronic kidney disease, taking hormone therapy or any medication affecting blood pressure or lipoprotein metabolism, taking psychotropics, psychoactive, psychedelics or multivitamins/antioxidants were excluded.
Finally, 539 women were recommended for BMD testing. These women were tested with dual-energy X-ray absorptiometry (DXA) at the femoral neck (hip) and lumbar region (L1–L4 vertebrae). On the basis of T-scores calculated according to WHO guidelines,[11] the subjects were categorized as women with osteoporosis (n = 202), women with osteopenia (n = 241), and women with normal bone mass (n = 96). All the postmenopausal women gave their written consent before participation in the study. The study protocol was approved by the Institutional Ethical Review Committee vide letter number IRB/OE/2019/86.
BMD of the women in the supine position was measured with a Hologic QDR 4500 system (Hologic Inc., Waltham, MA, USA) using DXA. On the basis of T-scores obtained according to WHO guidelines,[11] women were characterized as osteoporotic when the T-score was ≤2.5 SD, osteopenic when the T-score was observed between −1 and −2.5 SD and normal (without bone loss) when the T-score was <1 SD from the optimal peak bone density of healthy young adults of the same sex. The DXA system was calibrated every day before using it with the Phantoms supplied by the manufacturer. The coefficient of variation was observed to be <4% for the measurements of BMD at the hip and spine.
A structured pro forma was used to obtain demographic and maternal characteristics (age group, education, marital status, abortion, ever breast feed, and smoking/tobacco intake); menstrual characteristics (age at menarche in years, years of menstruation, age at menopause, and duration of menopause); self and family history related to osteoporosis (family history of symptoms related to osteoporosis, family history of fragility fracture, and self-history of fragility fracture); and clinical and laboratory profile (body mass index [BMI] [kg/m2], physical activity, immobilization, diabetic, hypertensive, calcium intake [mg/day], use of statin, use of Vitamin D3, and Vitamin D3 level [ng/mL]).
BMI was calculated by measuring weight and height of the subject according to the equation weight in kilograms/height in meters squared. Active and sedentary lifestyle was based on whether the subject was doing a minimum of 30 min of brisk walking or aerobic exercise every day or not. Systolic blood pressure and diastolic blood pressure were measured by taking an average of the three blood pressure readings using a sphygmomanometer, taken after 3 min interval each with the subject in resting position. Immobilization was defined as “being confined to bed for a continuous period >2 months. Serum vitamin D3 concentrations were determined using radioimmunoassay (BIOSOURCE Europe S. A., Nivelles, Belgium) and was classified as follows: Vitamin D deficiency (>20 ng/mL), Vitamin D insufficiency (20–29 ng/mL), and Vitamin D sufficient (≥30 ng/mL).
Statistical analysis
Data are shown as number, percentages, or mean standard deviation. To analyze the differences between the groups, a Chi-square and Student’s t-test were used for categorical and continuous variables, respectively. P < 0.05 was considered to show significant associations.
Results In our study, 54.7% of subjects belonged to <60 years of age group. Half of the subjects (51.9%) were illiterate. 90.4% of subjects were married and 37.7% of subjects were having 6 or more children. Around one tenth of subjects (11.3%) had a history of >2 abortions. 79.2% of subjects gave a history of ever breast feed. 14.5% of subjects were currently smoking or chewing tobacco [Table 1].
Table 1: Demographic and maternal characteristics of the study subjects (n=539)The mean age at menarche was 13.17 ± 1.85 years for the study subjects. Mean menstrual years was 37.21 ± 3.76 years among subjects. Age of menopause among 38.0% of subjects was after 50 years of age and duration of menopause at the time of enrolment in the study was more than 10 years in 48.8% of subjects [Table 2].
61.0% of subjects were having BMI falling in the obese category and intake of statins was reported in 67.9% of subjects. 49.2% of subjects were diabetics and 64.2% of subjects were hypertensives. Family history of symptoms related to osteoporosis, and fragility fracture was reported in 31.5% and 24.3% of subjects, respectively [Table 3].
Table 3: Clinical characteristics and family history of the study subjects (n=539)The DXA at the femoral neck (hip) and lumbar region (L1–L4 vertebrae) showed osteoporosis among 37.5% of subjects and osteopenia was observed in 44.7% of subjects. Only 17.8% of subjects were having normal BMD [Table 4].
Table 4: Prevalence of osteoporosis and osteopenia among study subjects (n=539)[Table 5] shows that the subjects with higher age at menarche (13.98 ± 1.78); lesser years of menstruation (36.02 ± 3.92); and more duration of menopause showed higher prevalence of osteoporosis (P < 0.05). Furthermore, subjects with family history of symptoms related to osteoporosis, and fragility fracture; and self-history of fragility fracture had higher prevalence of osteoporosis (P < 0.05).
Table 5: Association of prevalence of osteoporosis with the various characteristics of the study subjects (n=539) Discussion Osteoporosis is a now well-known systematic bone disease characterized by low bone mass and deterioration of microarchitecture of the bone, leading to bone fragility and eventually fractures. The gold standard method recommended by the WHO in the diagnosis of osteoporosis is DXA. By this method, osteoporosis is defined by a BMD lower than −2.5 SDs of the reference BMD of Caucasian women aged 20–29 years. This simplified definition of osteoporosis eases the physicians, orthopedician, and endocrinologist in diagnosing and initiating treatment for osteoporotic patients. However, there are several limitations of DXA which prevent it from being used in the mass screening of osteoporosis, which is currently a rising health-care medical condition in the developing countries.
Vitamin D deficiency is a very common endocrine and medical problem throughout the world. It has been predicted that one billion people throughout the world are Vitamin D deficient.[12] The prevalence of Vitamin D deficiency in the countries where food is enriched by Vitamin D is 1.6%–14.8%.[13] In other European countries, among middle-aged and elderly people, 59.6%[14] in Boston was 24.1%[15] and in Tunisia 47.6%[16] among young adults. The prevalence of Vitamin D deficiency is much higher in Asia including India. About 30%–50% of people in India, Lebanon, and Turkey.[12] and also 45.2% of females in China[17] were Vitamin D deficient.
In India, many studies have been done still the precise figures on the prevalence of osteoporosis are not available at present. However, it is estimated that more than 61 million Indians have osteoporosis; of these, 80% of patients are females.[15],[18],[19] In a study done by Pande et al.[20] an age-dependent decline in BMD was seen in both women and men over the age of 50 years. A large single-center study by Patni in 2010[21] in Jaipur, India was done to establish normative database for BMD in the Indian population using dual Energy X-ray absorptiometry. This study showed that the mean Indian BMD is about 2 SDs lower than the western BMD.
The Indian Council of Medical Research recommendation for calcium and Vitamin D for Indian is much lower when compared to the RDI of developed nations.[22],[23] Vitamin D sufficiency through sun exposure is untenable for most Indians, especially for those living in slums where congestion is the big issue. Vitamin D (relatively) rich dietary sources are unaffordable and mostly limited in low socioeconomical strata people. Most women living in slum are vegetarians as they cannot afford nonvegetarian diet. Vitamin D supplements are unaffordable and not feasible and beyond their reach. Fortification of widely consumed staple foods with Vitamin D is the only viable option towards attaining Vitamin D sufficiency in slums.
Many studies in the literature showed that the most important determinants of bone health are BMI which is again significantly lower in Indian women especially in lower socioeconomical status and even in the affluent category also as compared to developed country. Osteoporosis is extensively studied in the literature and many factors affect its development. Increasing age, especially when women become postmenopausal, low education level, frequent childbirth, low socioeconomic status, low education, and poor dietary intake have been associated with higher prevalence of osteoporosis. In developed countries also, still there is no formally accepted policy for population screening to identify individuals with osteoporosis. Patients are being detected using a case-to-case basis finding strategy based on a previous fragility fracture of distal radius, hip or the presence of significant clinical risk factors. Some of the risk factors act independently of BMD to increase fracture risk, whereas others increase fracture risk through their association with low BMD.[24]
The prevalence of osteoporosis in our study was found to be very high (37.5%) in postmenopausal women. Thus, the high prevalence of osteoporosis in peri- and postmenopausal women is a major health concern in low economical strata. Self-history of fragility fracture was given by 18.9% of subjects. In these populations, BMD and other risk factors can be used to identify high-risk patients, and because effective interventions exist, many of these fractures can be preventable. The implementation of the WHO technical report, assessment of osteoporosis at primary health care level, and the related web-based FRAX tool are the major milestones toward helping health professionals worldwide to improve identification of patients at high risk of fractures.[25] A risk assessment tool for osteoporosis developed by Sharma et al.[26] can be effective in a resource-poor and developing country like India, where they used a combination of questionnaire and ultrasonic measurement of BMD. In a recent study done by Nikose et al., in 2015 a total of 3532 female patients were screened. In their study, it was noted that a significant study population had lower BMD score, which suggest osteoporosis and had statistically significant correlation with their socioeconomic status, literacy rate, and emotional family backup.[27] Although DEXA scan is considered as a gold standard for BMD assessment, most of the Indian population is not covered under any kind of health insurance and so they cannot afford it due to the cost involved.
Although many studies have been published region wise in India that recommend regular screening of this silent epidemic, still it is not effective on ground as many women do not know the entity due to poor literacy rate and poor family support. In our study, it was observed that the women eat in the last whatever left at the end, after feeding husband, children, and in-laws if living together. This practice was deeply embedded in her mind that in spite of repeated advised and counselling it was very difficult to change.
Conclusion In our study, the overall prevalence of osteoporotic fractures among postmenopausal females was 82.2% (osteoporosis: 37.5% and osteopenia: 44.7%). The findings of the current study and previous studies clearly indicate the urgent need of collective efforts toward the growing problem of osteoporosis in postmenopausal women. A multipronged approach involving educational intervention, lifestyle modification, and appropriate hormonal treatment is required to deal with this disease. Lifestyle modification involves nutritional interventions and regular physical activity such as morning/evening walk, performing household tasks etc. A regular intake of foods rich in calcium like milk and its products, calcium tablets, vitamin D supplementation, soya products, almonds, etc., is essential to maintain bone mass turnover.
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Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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