OSTEOPOROSIS SCREENING IS UNJUSTIFIABLY: DISCUSSION
Over the last two decades, the ability to diagnose and treat osteoporosis has dramatically improved. The advances in treatment of osteoporosis have unfortunately been underutilized in non-caucasian populations. Researchers have highlighted that the current guidelines for screening and treatment are primarily based on data obtained from studies of postmenopausal Caucasian women, as insufficient data is available in African-American women. This study provides data regarding the frequency of decreased BMD in African-American women.
The screening practices of the physicians in this investigation may be similar to national physician practices for screening and prevention of osteoporosis in African-American women, since many physicians assume that African-American women are relatively protected from osteoporosis. The retrospective chart review demonstrated strikingly low rates of osteoporosis screening compared to breast cancer screening in this primarily African-American population. Of particular note, the rates of breast cancer screening in this group compare favorably to prior rates obtained in studies of African-American women, including urban clinics similar to ours. As a general measure of the success of screening in this clinic, the rates screening surpassed the goals previously set by the U.S. Department of Health. However, the large majority of women who met the recent National Osteoporosis Foundation guidelines for osteoporosis screening had not undergone bone density testing. The frequency of estrogen use was similar to previous reports. Of note, this study took place prior to the publication of the Women’s Health Initiative at which point hormone replacement therapy was considered to be beneficial in women to prevent chronic medical problems, such as osteoporosis.
The frequency of low bone density in the African-American women was approximately 40%—slightly higher than previous studies—while the frequency of low bone density in the Caucasian women was similar to previous reports. Although there was no statistically significant difference between these groups, the study was neither designed nor powered to detect a difference. It is, however, apparent that osteoporosis and osteopenia occurred at substantial rates in African-American women. Of note, the WHO criteria for osteoporosis diagnosis were developed using Caucasian women, so the use of this criteria in other ethnicities and in males has been questioned. In clinical practice, however, these criteria are routinely utilized.
The two factors associated with low bone density were increased age and low BMI. Linear regression analysis revealed that both age and BMI were independently associated with decreased bone density. The association of osteoporosis with increasing age and low BMI has been well established in Caucasian women. Advanced age and low body weight were two of the three risk factors the U.S. Preventive Services Task Force’s recently updated recommendations included to use in deciding whom to screen. This study concludes that these are two important risk factors for osteoporosis in African-American women as well. While the lower BMI’s were associated with low bone density, being overweight and mildly obese was not protective of low bone density. One-half of the women in these weight categories also had low BMD. However, only 18% of women with a BMI greater than 35 had osteopenia and none had osteoporosis. None of the other risk factors examined, including hormone replacement therapy, calcium and vitamin-D intake, physical activity, age at menopause, family history of osteoporosis, and smoking had significant associations with BMD in this study. The lack of an association with bone density and these previously confirmed risk factors in this study may be due to sample size.
A limitation of this study is its small sample size. Although differences were detected among age groups and weight classes, the sample size was not powered to determine whether the rates were different between African Americans and Caucasians and whether other established risk factors were predictive of osteoporosis in African Americans. However, even if the frequency of osteoporosis is lower in African-American women compared to Caucasian women, it is clearly sizeable enough to warrant consideration of screening. canada viagra online
The use of peripheral bone densitometry is another limitation of the study as central bone densitometry is the standard screening method for osteoporosis. However, the risk of developing a fracture—the primary adverse event associated with osteoporosis—is increased with low BMD at any site. The National Osteoporosis Risk Factor Assessment Study recently found that women with osteoporosis diagnosed by peripheral bone densitometry had a 2.7-fold increased risk of suffering a fracture within a year compared to those with normal bone density. In addition, calcaneal bone density has recently been shown in a meta-analysis to have a similar degree of predictability for subsequent fractures as bone density measurements of the hip, spine, and distal radius. In this patient population, the rates of central bone density testing were very low in both the general clinic population from the chart review and the subset of patients from the screening trial who had abnormal results on calcaneal measurement and were referred for central testing. The rates of subsequent central bone density testing were quite low despite strong recommendations to both the patients themselves and their referring physicians. Possible explanations for this include a lack of knowledge or understanding of the importance of osteoporosis on the part of both groups, and problems with access or transportation for further testing. Therefore, using peripheral bone densitometry in the office setting may allow larger numbers of patients to be screened for osteoporosis. This may be particularly relevant in urban clinics where transportation and access to care are often limited. The sequential approach to screening with an initial peripheral bone density measurement followed by central bone densitometry in those with abnormal results, as done in this trial, has been identified by the United States Preventive Services Task Force as a possibly useful approach that requires further study. pharmacy united kingdom