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1.  Viral Hepatitis is Associated with Reduced Bone Mineral Density in HIV-Infected Women But Not Men 
AIDS (London, England)  2009;23(16):2191-2198.
Objective
Few studies have examined the impact of viral hepatitis on bone mineral density (BMD), and none have done so among HIV-infected patients. Our objective was to determine if viral hepatitis was associated with low BMD in HIV.
Design
Cross-sectional study among 1,237 HIV-infected subjects (625 with viral hepatitis).
Methods
Dual-energy x-ray absorptiometry (DXA) scans of the lumbar spine and femoral neck were obtained. Clinical data, hepatitis B and C status, and markers of bone metabolism were determined at DXA scanning. Multivariable logistic regression examined the association between hepatitis and low BMD (Z-score ≤−2.0 at the lumbar spine and/or femoral neck).
Results
Mean BMD Z-scores were lower among hepatitis-coinfected women at the lumbar spine (−0.15 versus +0.29; difference=−0.44 [95% CI, −0.65 to −0.23]; p<0.001) and femoral neck (−0.64 versus −0.39; difference=−0.25 [95% CI, −0.44 to −0.06]; p=0.009) compared to HIV-monoinfected women. No differences in mean BMD Z-scores were observed between coinfected and monoinfected men. After adjustment for age, body mass index, duration of HIV, antiretroviral use, physical activity, and smoking, viral hepatitis was associated with low BMD among women (adjusted OR, 2.87; 95% CI, 1.31 – 6.29) but not men (adjusted OR, 1.19; 95% CI, 0.74 – 1.91). Coinfected women had lower mean parathyroid hormone (60.1 versus 68.1 pg/mL; p=0.02) but similar mean 25-hydroxyvitamin D (19.1 versus 19.6 ng/mL; p=0.6) and osteocalcin (3.0 versus 3.2 ng/mL; p=0.8) concentrations than HIV-monoinfected women.
Conclusions
Viral hepatitis was associated with a higher risk of low BMD among HIV-infected women but not men.
doi:10.1097/QAD.0b013e32832ec258
PMCID: PMC2837269  PMID: 19779322
Viral hepatitis; HBV; HCV; bone mineral density; DXA; vitamin D; bone
2.  Bone Density and Bone Metabolism in Patients with Inflammatory Bowel Disease 
Background/Aims:
Patients with inflammatory bowel disease (IBD) are at high risk for low bone mineral density (BMD). This study aimed to evaluate BMD in IBD patients and its relationship with bone metabolism in a group of Iranian patients.
Patients and Methods:
A cross-sectional study was conducted on patients with IBD to assess BMD status and serum biochemical factors. After getting the demographic data from 200 patients, they were screened using dual-energy X-ray absorptiometry of the lumbar spine (L2–L4) and femoral neck for BMD status. Serum levels of calcium, phosphate, alkaline phosphatase (ALP), and 25-hydroxyvitamin D (25-OH vitamin D) were measured to assess the bone metabolism status.
Results:
Two hundred patients with IBD were enrolled in the study. One hundred and eighty three (91.5%) patients were identified as having ulcerative colitis (UC) and 17 (8.5%) as having Crohn's disease (CD). Based on the lumbar and femoral neck bone mass densitometry, 148 (74.4%) patients had low BMD at either lumbar spine or femoral neck. Of these, 100 patients (50.3%) were osteopenic and 48 patients (24.1%) were osteoporotic. A 58.6% and 61% of patients with UC had low BMD in the lumbar and femoral neck, respectively. These results for those with CD were 76.5% and 70.6%, respectively. The mean of femoral neck and lumbar T-scores in patients with UC were -1.14 and -1.38, and in patients with CD were -1.24 and -1.47, respectively (P > 0.05). The mean (±SD) levels for calcium (Ca) in UC and CD were in the normal range. The mean (±SD) levels of ALP and 25-OH vitamin D in both the groups were in the normal range, and in comparison between groups (UC and CD), no significant differences were observed (P = 0.20 for ALP and P = 0.44 for 25-OH vitamin D). In the assessment of correlation between biochemical markers and BMD, an inverse correlation between lumbar T-score and ALP or 25-OH vitamin D only in patients with UC was observed.
Conclusions:
The high prevalence of low BMD in the Iranian population with IBD needs attention. The subclinical vitamin D deficiency may contribute to bone loss in IBD patients, which is more pronounced in patients with UC in this study because of the small population of patients with CD.
doi:10.4103/1319-3767.98428
PMCID: PMC3409884  PMID: 22824766
Inflammatory bowel disease; osteopenia; osteoporosis
3.  Bone mass and mineral metabolism in HIV+ postmenopausal women 
The objective of this cross-sectional study was to estimate the prevalence of and risk factors for osteoporosis in HIV+ postmenopausal women. Bone mineral density (BMD) by dual energy X-ray absorptiometry (DXA) and biochemical indices of mineral metabolism were measured in 31 Hispanic and African American HIV+ postmenopausal women. BMD was compared with 186 historical controls, matched for age, ethnicity and postmenopausal status. Mean BMD was significantly lower at the lumbar spine and total hip in the HIV+ group, as compared with controls. Prevalence of osteoporosis was higher in the HIV+ group than controls at the lumbar spine (42% vs 23%, p=0.03) and total hip (10% vs 1%, p=0.003). Among HIV+ women, time since menopause and weight were significant predictors of BMD, while duration or class of antiretroviral therapy (ART), AIDS diagnosis, nadir CD4, steroid use, and vitamin D deficiency were not. Prevalence of osteoporosis is substantially higher in HIV+ Hispanic and African-American postmenopausal women than in controls. Established osteoporosis risk factors were more important in predicting BMD than factors associated with HIV infection and ART. Long-term management of the growing female HIV population should include the evaluation for and management of osteoporosis.
doi:10.1007/s00198-005-1845-0
PMCID: PMC3108020  PMID: 15754081
Bone metabolism; HIV; Osteoporosis; Postmenopausal women
4.  Effects of Long-Term Combination Treatment with Valproate and Atypical Antipsychotics on Bone Mineral Density and Bone Metabolism in Premenopausal Patients with Bipolar Disorder: A Preliminary Study 
Psychiatry Investigation  2011;8(3):256-261.
Objective
We investigated bone mineral density (BMD) and bone metabolism in female bipolar patients who were undergoing long-term treatment with valproate combined with a low-dose atypical antipsychotic.
Methods
Nineteen premenopausal women with bipolar disorder who were treated with valproate combined with atypical antipsycho-tics for at least 2 years were evaluated. The BMD was measured at lumbar spine and femur sites using dual-energy X-ray absorptiometry (DE-XA). The biochemical markers of bone turnover and circulating levels of gonadal hormones were assessed. Subjects with abnormal DEXA scans were compared to those with normal scans.
Results
Nine (47%) of nineteen subjects showed osteopenia or osteoporosis. The T-score for subjects with abnormal DEXA scans was -1.988. Decreased BMD was more prominent in the proximal femur than in the lumbar spine. Subjects with abnormal DEXA scans had high phosphorus and low testosterone levels relative to subjects with normal scans (p=0.008 and p=0.028, respectively). There was a significant negative correlation between phosphorus, osteocalcin, and femur neck BMD (p<0.05). However, multivariate analysis did not show a significant association between femur and lumbar BMD and biochemical markers of bone turnover.
Conclusion
Long-term treatment with valproate combined with low-dose atypical antipsychotics may adversely affect BMD in premenopausal women with bipolar disorder. A prospective, controlled-study with a larger population is warranted, and assessment of BMD and bone metabolism should be taken into consideration in long-term therapy with valproate and atypical antipsychotics.
doi:10.4306/pi.2011.8.3.256
PMCID: PMC3182392  PMID: 21994514
Bipolar disorder; Bone density; Bone metabolism; Females; Valproate
5.  Radiographic Emphysema Predicts Low Bone Mineral Density in a Tobacco-exposed Cohort 
Rationale: Studies demonstrating an association between chronic obstructive pulmonary disease and low bone mineral density (BMD) implicate factors distinct from treatments and severity of lung disease in the pathogenesis of osteoporosis. Whereas emphysema has been independently associated with vascular disease and other comorbidities, its association with BMD has not been well studied.
Objectives: We explored the associations of BMD with computed tomography (CT) measures of emphysema and other risk factors in current and former smokers.
Methods: One hundred ninety subjects completed a CT scan, pulmonary function testing, questionnaires, and dual x-ray absorptiometry measurements of hip and lumbar spine BMD. Subjects were classified as having normal BMD, osteopenia, or osteoporosis. Demographic, physiologic, and radiographic characteristics were compared and the association of BMD with radiographic emphysema, airflow obstruction, and osteoporosis risk factors was assessed.
Measurements and Main Results: No difference existed in age, tobacco exposure, oral steroid use, or physical activity across BMD categories. Both osteopenia and osteoporosis were associated with the presence of airflow obstruction, inhaled corticosteroid use, and female sex, and demonstrated a significant relationship with the presence of visual emphysema (P = 0.0003). Quantitative emphysema, but not CT-measured indices of airway wall thickness, was inversely associated with BMD. Visual emphysema alone was a significant predictor of osteopenia/osteoporosis (odds ratio = 2.55; 95% confidence interval, 1.24–5.25) in a model including obstruction severity, age, sex, and inhaled and oral steroid use.
Conclusions: Radiographic emphysema is a strong, independent predictor of low BMD in current and former smokers. This relationship suggests a common mechanistic link between emphysema and osteopenia/osteoporosis.
doi:10.1164/rccm.201004-0666OC
PMCID: PMC3086755  PMID: 20935108
pulmonary disease, chronic obstructive; emphysema; osteoporosis
6.  Bone mineral density in patients with recently diagnosed, active rheumatoid arthritis 
Annals of the Rheumatic Diseases  2007;66(11):1508-1512.
Objectives
Osteoporosis is a well‐known extra‐articular phenomenon in patients with uncontrolled, long‐standing rheumatoid arthritis (RA). In the present study, the extent of osteoporosis and reduced bone mineral density (BMD) and the disease‐related and demographic factors that are associated with osteoporosis and reduced BMD were examined in patients with recently diagnosed, active RA.
Methods
BMD of the total hip and the lumbar spine was measured using dual‐energy x ray absorptiometry in 381 patients with recently diagnosed active RA, who had never been treated with DMARDs or corticosteroids. Osteoporosis was defined as a T score ⩽−2.5 SD and reduced BMD as Z score ⩽−1 SD. Multivariate logistic regression analyses were performed to detect associations of osteoporosis and reduced BMD with disease activity, functional disability, joint damage (Sharp–van der Heijde score) and demographic factors.
Results
Osteoporosis and reduced BMD were found in the spine and/or the hip in 11% and 25%, respectively, of the patients. Longer symptom duration and presence of rheumatoid factor (RF) were the only RA‐specific markers for osteoporosis and reduced BMD. Further, postmenopausal status in women, a low body mass index, familial osteoporosis, and, remarkably, male gender, were independently associated with osteoporosis and reduced BMD.
Conclusion
In patients with recently diagnosed active RA who had never been treated with DMARDs or corticosteroids, BMD seems to be well‐preserved and predominantly related to demographic factors. Longer symptom duration and a positive RF, but not higher disease activity or more joint damage, were related to osteoporosis and reduced BMD.
doi:10.1136/ard.2007.070839
PMCID: PMC2111640  PMID: 17456523
early rheumatoid arthritis; bone mineral density; osteoporosis
7.  Alendronate increases BMD at appendicular and axial skeletons in patients with established osteoporosis 
Background
To identify high-risk patients and provide pharmacological treatment is one of the effective approaches in prevention of osteoporotic fractures. This study investigated the effect of 12-month Alendronate treatment on bone mineral density (BMD) and bone turnover biochemical markers in postmenopausal women with one or more non-traumatic fractures, i.e. patients with established osteoporosis.
Methods
A total of 118 Hong Kong postmenopausal Chinese women aged 50 to 75 with low-energy fracture at distal radius (Colles' fracture) were recruited for BMD measurement at lumbar spine and non-dominant hip using Dual-Energy X-ray Absorptiometry (DXA). 47 women with BMD T-score below -2 SD at either side were identified as patients with established osteoporosis and then randomized into Alendronate group (n = 22) and placebo control group (n = 25) for BMD measurement at spine and hip using DXA and distal radius of the non-fracture side by peripheral quantitative computed tomography (pQCT), and bone turnover markers, including bone forming alkaline phosphatase (BALP) and bone resorbing urinary Deoxypyridinoline (DPD). All measurements were repeated at 6 and 12 months.
Results
Alendronate treatment significantly increased BMD, more in weight-bearing skeletons (5.1% at spine and 2.5% at hip) than in non-weight bearing skeleton (0.9% at distal radius) after 12 months treatment. Spine T-score was significant improved in Alendronate group (p < 0.01) (from -2.2 to -1.9) but not in control placebo group. The Alendronate treatment effect was explained by significant suppression of bone turnover.
Conclusion
12 months Alendronate treatment was effective to increase BMD at both axial and appendicular skeletons in postmenopausal women with established osteoporosis.
doi:10.1186/1749-799X-2-9
PMCID: PMC1885425  PMID: 17511887
8.  Bone mineral density and nutritional status in children with chronic inflammatory bowel disease 
Gut  1998;42(2):188-194.
Background—Osteoporosis has been reported in adult patients with inflammatory bowel disease. 
Aims—To evaluate bone mineral density (BMD), nutritional status, and determinants of BMD in children with inflammatory bowel disease. 
Patients—Fifty five patients (34 boys and 21 girls, age range 4-18) were studied; 22 had Crohn's disease and 33 ulcerative colitis. 
Methods—Lumbar spine and total body BMD, and body composition were assessed by dual energy x ray absorptiometry (DXA). Results were expressed as standard deviation scores (SDS). Lean body mass was also assessed by bioelectrical impedance analysis (BIA). Yearly measurements during two years were performed in 21patients. 
Results—The mean SDS of lumbar spine BMD and total body BMD were significantly lower than normal (−0.75 and −0.95, both p<0.001). Height SDS and body mass index SDS were also decreased. The decrease in BMD SDS could not be explained by delay in bone maturation. The cumulative dose of prednisolone correlated negatively with lumbar spine BMD SDS (r=−0.32, p<0.02). Body mass index SDS correlated positively with total body BMD SDS (r=0.36, p<0.02). Patients with Crohn's disease had significantly lower lumbar spine and total body BMD SDS than patients with ulcerative colitis, even after adjustment for cumulative dose of prednisolone. In the longitudinal data cumulative dose of prednisolone between the measurements correlated negatively with the change in lumbar spine and total body BMD SDS. Lean tissue mass measured by DXA had a strong correlation with lean body mass measured by BIA (r=0.98). 
Conclusions—Children with inflammatory bowel disease have a decreased BMD. Children with Crohn's disease have a higher risk of developing osteopaenia than children with ulcerative colitis. Corticosteroid therapy and nutritional status are important determinants of BMD in these patients. 


Keywords: bone mineral density; inflammatory bowel disease; children; nutritional status; corticosteroid treatment; body composition
PMCID: PMC1726993  PMID: 9536942
9.  Correlation of vitamin D, bone mineral density and parathyroid hormone levels in adults with low bone density 
Indian Journal of Orthopaedics  2013;47(4):402-407.
Background:
Bone mineral densiy (BMD) is known to be affected by serum 25-hydroxyvitamin D (25(OH) D) levels, intact parathyroid hormone (iPTH) levels. Indian data pertinent to above observation is scant. Our study aimed to investigate the relationships between serum 25-hydroxyvitamin D (25(OH) D) levels, intact parathyroid hormone (iPTH) levels and bone mineral density (BMD) in a cohort of Indian patients.
Materials and Methods:
Adults with or without fragility fractures with low BMD at the hip or lumbar spine were evaluated clinically along with laboratory investigations. T-scores of the hip and spine were derived from BMD-DEXA (dual-energy X-ray absorptiometry). Multivariate regression models were used to investigate the relationships between serum 25(OH) D, iPTH and BMD.
Results:
Total of 102 patients (male:female = 38:64) with a mean age of 62.5 ± 6.4 years were included in the study. Forty-four patients had osteopenia. Osteoporosis was present in 58 patients. The mean values for serum 25(OH) D and iPTH levels were 21.3 ± 0.5 ng/ml and 53.1 ± 22.3 pg/ml, respectively. In 84.3% of patients, serum 25(OH) D levels were below 30 ng/ml (Normal = 30-74 ng/ml), confirming vitamin D deficiency. There was no association between 25(OH) D levels and BMD at the hip or lumbar spine (P = 0.473 and 0.353, respectively). Both at the hip and lumbar spine; iPTH levels, male gender, body mass index (BMI) and age were found to be significant predictors of BMD. Patients with higher BMI had significantly lower BMD and T-score. At levels <30 ng/ml, 25(OH) D was negatively associated with iPTH (P = 0.041).
Conclusion:
Among our cohort of patients with low BMD, no direct relationship between serum 25(OH) D levels and BMD was observed. However, a negative correlation between iPTH and 25(OH) D at serum 25(OH) D concentrations <30 ng/ml. Serum iPTH levels showed a significant negative association with BMD at the hip and lumbar spine. Our findings underscore the critical role of parathyroid hormone in bone metabolism and health.
doi:10.4103/0019-5413.114932
PMCID: PMC3745696  PMID: 23960286
Bone mineral density; osteoporosis; parathyroid hormone; vitamin D
10.  MELD score, insulin-like growth factor 1 and cytokines on bone density in end-stage liver disease 
World Journal of Hepatology  2011;3(6):157-163.
AIM: To determine the contributions of insulin-like growth factor 1 (IGF-1), cytokines and liver disease severity to bone mineral density in patients pre-transplantation.
METHODS: Serum IGF-1, tumor necrosis factor-α (TNFα) and interleukin 6 (IL-6) were measured and the Model for End-Stage Liver Disease (MELD) score calculated in 121 adult patients referred to a single centre for liver transplantation. Bone mineral density (BMD) of the lumbar spine and femoral neck were assessed via dual energy X-ray absorptiometry. Demographics, liver disease etiology, medication use and relevant biochemistry were recorded.
RESULTS: A total of 117 subjects were included, with low BMD seen in 68.6%, irrespective of disease etiology. In multivariable analysis, low body mass index (BMI), increased bone turnover and low IGF-1 were independent predictors of low spinal bone density. At the hip, BMI, IGF-1 and vitamin D status were predictive. Despite prevalent elevations of TNFα and IL-6, levels did not correlate with degree of bone loss. The MELD score failed to predict low BMD in this pre-transplant population.
CONCLUSION: Osteopenia/osteoporosis is common in advanced liver disease. Low serum IGF-1 is weakly predictive but serum cytokine and MELD score fail to predict the severity of bone disease.
doi:10.4254/wjh.v3.i6.157
PMCID: PMC3159496  PMID: 21860675
Hepatic osteodystrophy; Insulin-like growth factor-1; Cytokines; Bone mineral density; MELD score
11.  Controlled HIV Viral Replication, Not Liver Disease Severity Associated with Low Bone Mineral Density in HIV/HCV Co-Infection 
Journal of hepatology  2011;55(4):770-776.
Objective
To evaluate the prevalence and risk factors for low bone mineral density (BMD) in persons co-infected with HIV and Hepatitis C.
Methods
HIV/HCV co-infected study participants (n=179) were recruited into a prospective cohort and underwent dual-energy X-ray absorptiometry (DXA) within 1 year of a liver biopsy. Fibrosis staging was evaluated according to the METAVIR system. Osteoporosis was defined as a T-score ≤ −2.5. Z-scores at the total hip, femoral neck, and lumbar spine were used as the primary outcome variables to assess the association between degree of liver disease, HIV-related variables, and BMD.
Results
The population was 65% male, 85% Black with mean age 50.3 years. The prevalence of osteoporosis at either at the total hip, femoral neck, or lumbar spine was 28%, with 5% having osteoporosis of the total hip, 6% at the femoral neck, 25% at the spine. The mean Z-scores (standard deviation) were −0.42 (1.01) at the total hip, −0.16 (1.05) at the femoral neck, and −0.82 (1.55) at the lumbar spine. In multivariable models, controlled HIV replication (HIV RNA < 400 copies/mL vs ≥400 copies/mL) was associated with lower Z-scores (mean ± standard error) at the total hip (−0.44±0.17, p=0.01), femoral neck (−0.59±0.18, p=0.001), and the spine (−0.98±0.27, p=0.0005). There was no association between degree of liver fibrosis and Z-score.
Conclusion
Osteoporosis was very common in this population of predominately African-American HIV/HCV co-infected patients, particularly at the spine. Lower BMD was associated with controlled HIV replication, but not liver disease severity.
doi:10.1016/j.jhep.2011.01.035
PMCID: PMC3113457  PMID: 21338640
hepatitis C; bone mineral density; hepatic fibrosis; HIV
12.  Bone mineral density in systemic lupus erythematosus: comparison with rheumatoid arthritis and healthy controls 
Annals of the Rheumatic Diseases  2000;59(2):110-115.
OBJECTIVES—To examine bone mineral density (BMD) frequency of osteoporosis and reduced bone mass in systemic lupus erythematosus (SLE), and compare the data of the SLE patients with matched rheumatoid arthritis (RA) patients and healthy controls. Secondly, to study possible correlations between BMD, demographic and disease variables in the SLE patients.
METHODS—Measures of BMD assessed by dual energy x ray absorptiometry were obtained from 75 SLE patients aged ⩽ 70 years, 75 RA patients matched for age, sex and disease duration, and from 75 healthy controls matched for age, sex and geographical area. Disease activity and accumulated organ damage were assessed in the SLE patients.
RESULTS—The SLE patients had significantly lower BMD values at lumbar spine L2-L4 and hip, and higher frequency of osteoporosis at all sites of measurement compared with matched healthy controls. The matched SLE and RA patients had similar BMD, prevalence of osteoporosis and reduced bone mass. In the SLE patients BMD was more strongly correlated with accumulated organ damage than with markers of disease activity or duration. In multivariate analyses BMD was at all sites predicted by age and body mass, at lumbar spine also by the current corticosteroid dose.
CONCLUSION—The study showed reduced BMD in patients with SLE compared with matched healthy controls. Premenopausal women taking corticosteroids were especially affected. Furthermore, the BMD of matched SLE and RA patients was reduced to a similar extent.


doi:10.1136/ard.59.2.110
PMCID: PMC1753071  PMID: 10666165
13.  The impact of bone mineral density and disc degeneration on shear strength and stiffness of the lumbar spine following laminectomy 
European Spine Journal  2011;21(3):530-536.
Purpose
Laminectomy is a standard surgical procedure for elderly patients with symptomatic degenerative lumbar stenosis. The procedure aims at decompression of the affected nerves, but it also causes a reduction of spinal shear strength and shear stiffness. The magnitude of this reduction and the influence of bone mineral density (BMD) and disc degeneration are unknown. We studied the influence of laminectomy, BMD, and disc degeneration on shear force to failure (SFF) and shear stiffness (SS).
Methods
Ten human cadaveric lumbar spines were obtained (mean age 72.1 years, range 53–89 years). Laminectomy was performed either on L2 or L4, equally divided within the group of ten spines. BMD was assessed by dual X-ray absorptiometry (DXA). Low BMD was defined as a BMD value below the median. Intervertebral discs were assessed for degeneration by MRI (Pfirrmann) and scaled in mild and severe degeneration groups. Motion segments L2–L3 and L4–L5 were isolated from each spine. SFF and SS were measured, while loading simultaneously with 1,600 N axial compression.
Results
Low BMD had a significant negative effect on SFF. In addition, a significant interaction between low BMD and laminectomy was found. In the high BMD group, SFF was 2,482 N (range 1,678–3,284) and decreased to 1,371 N (range 940–1,886) after laminectomy. In the low BMD group, SFF was 1,339 N (range 909–1,628) and decreased to 761 N (range 561–1,221). Disc degeneration did not affect SFF, nor did it interact with laminectomy. Neither low BMD nor the interaction of low BMD and laminectomy did affect SS. Degeneration and its interaction with laminectomy did not significantly affect SS.
Conclusions
In conclusion, low BMD significantly decreased SFF before and after lumbar laminectomy. Therefore, DXA assessment may be an important asset to preoperative screening. Lumbar disc degeneration did not affect shear properties of lumbar segments before or after laminectomy.
doi:10.1007/s00586-011-1968-2
PMCID: PMC3296849  PMID: 21863461
Laminectomy; Human lumbar spine; Shear strength; Shear stiffness; Bone mineral density; Disc degeneration
14.  Osteoporosis in ankylosing spondylitis - prevalence, risk factors and methods of assessment 
Arthritis Research & Therapy  2012;14(3):R108.
Introduction
Osteoporosis can be a complication of ankylosing spondylitis (AS), but diagnosing spinal osteoporosis can be difficult since pathologic new bone formation interferes with the assessment of the bone mineral density (BMD). The aims of the current study were to investigate prevalence and risk factors for reduced BMD in a Swedish cohort of AS patients, and to examine how progressive ankylosis influences BMD with the use of dual-energy x-ray absorptiometry (DXA) of the lumbar spine in different projections.
Methods
Methods of assessment were questionnaires, back mobility tests, blood samples, lateral spine radiographs for syndesmophyte grading (mSASSS), DXA of the hip, radius and lumbar spine in anteroposterior (AP) and lateral projections with estimation of volumetric BMD (vBMD).
Results
AS patients (modified New York criteria), 87 women and 117 men, mean age 50 ± 13 years and disease duration 15 ± 11 years were included. According to World Health Organization (WHO) criteria 21% osteoporosis and 44% osteopenia was diagnosed in patients > = 50 years. Under age 50 BMD below expected range for age was found in 5%. Interestingly lateral lumbar DXA showed significantly lower BMD and revealed significantly more cases with osteoporosis as compared with AP DXA. Lumbar vBMD was not different between sexes, but women had significantly more lumbar osteoporosis measured with AP DXA (P < 0.001). Men had significantly higher mSASSS (P < 0.001). Low BMD was associated with high age, disease duration, mSASSS, Bath Ankylosing Spondylitis Metrology Index (BASMI), inflammatory parameters and low body mass index (BMI). Increasing mSASSS correlated significantly with decreasing lateral and volumetric lumbar BMD, while AP lumbar BMD showed tendency to increase.
Conclusions
Osteoporosis and osteopenia is common in AS and associated with high disease burden. Lateral and volumetric lumbar DXA are more sensitive than AP DXA in detecting osteoporosis and are less affected by syndesmophyte formation.
doi:10.1186/ar3833
PMCID: PMC3446485  PMID: 22569245
15.  Baseline bone mineral density and bone turnover in pre-operative hip and knee arthroplasty patients 
Bone & Joint Research  2014;3(1):14-19.
Aims
Osteoporosis and abnormal bone metabolism may prove to be significant factors influencing the outcome of arthroplasty surgery, predisposing to complications of aseptic loosening and peri-prosthetic fracture. We aimed to investigate baseline bone mineral density (BMD) and bone turnover in patients about to undergo arthroplasty of the hip and knee.
Methods
We prospectively measured bone mineral density of the hip and lumbar spine using dual-energy X-ray absorptiometry (DEXA) scans in a cohort of 194 patients awaiting hip or knee arthroplasty. We also assessed bone turnover using urinary deoxypyridinoline (DPD), a type I collagen crosslink, normalised to creatinine.
Results
The prevalence of DEXA proven hip osteoporosis (T-score ≤ -2.5) among hip and knee arthroplasty patients was found to be low at 2.8% (4 of 143). Spinal osteoporosis prevalence was higher at 6.9% (12 of 175). Sixty patients (42% (60 of 143)) had osteopenia or osteoporosis of either the hip or spine. The mean T-score for the hip was -0.34 (sd 1.23), which is within normal limits, and the mean hip Z-score was positive at 0.87 (sd 1.17), signifying higher-than-average BMD for age. The median urinary DPD/creatinine was raised in both female patients at 8.1 (interquartile range (IQR) 6.6 to 9.9) and male patients at 6.2 (IQR 4.8 to 7.5).
Conclusions
Our results indicate hip and knee arthroplasty patients have higher BMD of the hip and spine compared with an age-matched general population, and a lower prevalence of osteoporosis. However, untreated osteoporotic patients are undergoing arthroplasty, which may negatively impact their outcome. Raised DPD levels suggest abnormal bone turnover, requiring further investigation.
Cite this article: Bone Joint Res 2014;3:14–19.
doi:10.1302/2046-3758.31.2000218
PMCID: PMC3904490  PMID: 24443424
Arthroplasty; Hip; Knee; Bone mineral density; BMD
16.  Associations between Body Composition, Hormonal and Lifestyle Factors, Bone Turnover, and BMD 
Journal of Bone Metabolism  2014;21(1):61-68.
Background
The relative importance of body composition, lifestyle factors, bone turnover and hormonal factors in determining bone mineral density (BMD) is unknown. We studied younger postmenopausal women to determine whether modifiable or nonmodifiable risk factors for osteoporosis have stronger associations with BMD.
Methods
In multivariable linear regression models, we tested associations between non-bone body composition measures, self-reported measures of physical activity and dietary intake, urinary N-telopeptide (NTx), sex hormone concentrations, and BMD in 109 postmenopausal women aged 50 to 64 years, adjusting for current hormone therapy use and clinical risk factors for low BMD. Lean mass, fat mass and areal BMD (aBMD) at the lumbar spine, femoral neck, total hip and distal radius were measured using dual energy X-ray absorptiometry.
Results
Higher body weight and self-reported nonwhite race were independently associated with higher aBMD at the lumbar spine, femoral neck, total hip and distal radius. Lean and fat mass were not independently associated with aBMD. Older age and higher urinary NTx were independently associated with lower aBMD at the distal radius but not at weight-bearing sites. Sensitivity analyses demonstrated lack of an independent association between total daily protein or calorie intake and BMD.
Conclusions
BMD, weight and race were the most important determinants of aBMD at all sites. Older age and higher bone turnover were independently associated with lower aBMD at the distal radius. In a limited analysis, self-reported physical activity, dietary protein and calorie intake were not associated with aBMD after adjustment for the other variables.
doi:10.11005/jbm.2014.21.1.61
PMCID: PMC3970292
Bone density; Body weight; Life style; Menopause; Osteoporosis; Postmenopausal
17.  Normal BMD values for Indian females aged 20–80 years 
Journal of Mid-Life Health  2010;1(2):70-73.
Background:
Dual-energy X-ray absorptiometry is presently considered the gold standard for measuring bone mineral density (BMD). The International Osteoporosis Foundation and World Health Organization have recommended National Health and Nutrition Examination Survey III database values for women aged 20–29 years to be followed as reference BMD values worldwide. However, the BMD may differ for different populations.
Objective:
The objective of the present study was to plot BMD values in the hip (neck) and lumbar spine (L1–L4 AP view) in Indian women aged 20–80 years. Also, BMD values in the 20–60-year-old females were compared with reference American/European population.
Result:
It was found that the BMD of Indian females was 1.5–2 standard deviation (SD) s lower than that of the reference Western population in all the comparative age groups.
Conclusion:
It is reasonable to conclude that BMD values of the hip and spine among comparative Indian and Western female age groups show significant differences. Hence, different normals should be followed for each population.
doi:10.4103/0976-7800.76215
PMCID: PMC3122499  PMID: 21716763
Bone mineral density; dual-energy X-ray absorptiometry; BMD norms
18.  Disturbance of the OPG/RANK/RANKL pathway and systemic inflammation in COPD patients with emphysema and osteoporosis 
Respiratory Research  2011;12(1):157.
Background
Osteoporosis is one of the systemic features of COPD. A correlation between the emphysema phenotype of COPD and reduced bone mineral density (BMD) is suggested by some studies, however, the mechanisms underlying this relationship are unclear. Experimental studies indicate that IL-1β, IL-6 and TNF-α may play important roles in the etiology of both osteoporosis and emphysema. The OPG/RANK/RANKL system is an important regulator of bone metabolism, and participates in the development of post-menopausal osteoporosis. Whether the OPG/RANK/RANKL pathway is involved in the pathogenesis of osteoporosis in COPD has not been studied.
Methods
Eighty male patients (current or former smokers) completed a chest CT scan, pulmonary function test, dual x-ray absorptiometry measurements and questionnaires. Among these subjects, thirty patients with normal BMD and thirty patients with low BMD were selected randomly for measurement of IL-1β, IL-6, TNF-α (flow cytometry) and OPG/RANK/RANKL (ELISA). Twenty age-matched healthy volunteers were recruited as controls.
Results
Among these eighty patients, thirty-six had normal BMD and forty-four had low BMD. Age, BMI and CAT score showed significant differences between these two COPD groups (p < 0.05). The low-attenuation area (LAA%) in the lungs of COPD patients was negatively correlated with lumbar vertebral BMD (r = 0.741; p < 0.0001). Forward logistic regression analysis showed that only LAA% (p = 0.005) and BMI (p = 0.009) were selected as explanatory variables. The level of IL-1β was significantly higher in the COPD patients as compared to the normal controls (p < 0.05), but the difference between the two COPD groups did not reach significance. The levels of IL-6 and TNF-α among the three groups were significantly different (p < 0.05). The level of RANKL and the RANKL/OPG ratio were significantly higher in COPD patients with low BMD compared to those with normal BMD and the normal controls (p < 0.05), and correlated negatively with lumbar vertebral BMD, but positively with LAA%.
Conclusions
Radiographic emphysema is correlated with low BMD in current and former smokers with COPD. IL-1β, IL-6, TNF-α, and the osteoporosis-related protein system OPG/RANK/RANKL may have some synergetic effects on emphysema and bone loss in COPD.
doi:10.1186/1465-9921-12-157
PMCID: PMC3260206  PMID: 22176920
chronic obstructive pulmonary disease; pulmonary emphysema; osteoporosis; cytokine; OPG/RANK/RANKL
19.  The Impact of Body Weight Change on Bone Mineral Density of the Lumbar Spine in Perimenopausal Women: A Retrospective, One-year Follow-up Study 
Korean Journal of Family Medicine  2011;32(4):219-225.
Background
Low body weight was one of the risk factors of osteoporosis. Little is known about the correlation between body weight change and bone mineral density (BMD) in Korean women. Therefore, this study was designed to reveal the impact of body weight change on BMD of the lumbar spine in perimenopausal women.
Methods
105 healthy perimenopausal women aged between 44 and 50 years old were enrolled from August 2002 to March 2009. BMD was measured by dual energy X-ray absorptiometry. Partial correlation coefficients between body weight change and BMD change were calculated after the adjustments for several variables. BMD changes among groups based on BMI and the percentage change in body weight during 1-year follow-up period were compared.
Results
At both baseline and year 1, BMD of lumbar spine tended to be associated more with body weight. There was a significant association between body weight change and BMD change in lumbar spine during 1-year follow-up period. The weight gain group relatively showed an increase in BMD of lumbar spines than weight loss group. There was no BMD change in BMI less than 23 kg/m2 group, but in case of BMI more than 23 kg/m2 group, BMD in weight gain group increased more than the weight maintaining group.
Conclusion
This study demonstrated that body weight change is associated with change in BMD of lumbar spine in perimenopausal women especially if they are overweight.
doi:10.4082/kjfm.2011.32.4.219
PMCID: PMC3383136  PMID: 22745857
Perimenopause; Body Weight; Bone Density; Women
20.  Bone mineral density in patients with hand osteoarthritis compared to population controls and patients with rheumatoid arthritis 
Annals of the Rheumatic Diseases  2007;66(12):1594-1598.
Objectives
Several studies have revealed increased bone mineral density (BMD) in patients with knee or hip osteoarthritis, but few studies have addressed this issue in hand osteoarthritis (HOA). The aims of this study were to compare BMD levels and frequency of osteoporosis between female patients with HOA, rheumatoid arthritis (RA) and controls aged 50–70 years, and to explore possible relationships between BMD and disease characteristics in patients with HOA.
Methods
190 HOA and 194 RA patients were recruited from the respective disease registers in Oslo, and 122 controls were selected from the population register of Oslo. All participants underwent BMD measurements of femoral neck, total hip and lumbar spine (dual‐energy x ray absorptiometry), interview, clinical joint examination and completed self‐reported questionnaires.
Results
Age‐, weight‐ and height‐adjusted BMD values were significantly higher in HOA versus RA and controls, the latter only significant for femoral neck and lumbar spine. The frequency of osteoporosis was not significantly different between HOA and controls, but significantly lower in HOA versus RA. Adjusted BMD values did not differ between HOA patients with and without knee OA, and significant associations between BMD levels and symptom duration or disease measures were not observed.
Conclusion
HOA patients have a higher BMD than population‐based controls, and this seems not to be limited to patients with involvement of larger joints. The lack of correlation between BMD and disease duration or severity does not support the hypothesis that higher BMD is a consequence of the disease itself.
doi:10.1136/ard.2006.068940
PMCID: PMC2095305  PMID: 17502356
21.  The Clinical Utility of Spine Bone Density in Elderly Women 
It is common clinical practice to obtain bone mass measurement at both the hip and spine to evaluate for osteoporosis. With aging, degenerative changes in the lumbar spine may elevate the bone mineral density (BMD) results giving false assurances that the fracture risk at the spine is low. We examined the association of spine osteoarthritis and bone mineral density in 1082 community-dwelling ambulatory older women aged 50–96 years who participated in a 1992–1996 osteoporosis research clinic visit. Bone mineral density (BMD) was measured at the hip, PA and lateral lumbar spine using dual energy x-ray absorptiometry (DXA). Spine osteoarthritis was identified on the PA lumbar spine DXA images by a musculoskeletal radiologist. Forty percent of women had evidence of spine osteoarthritis (OA). Women with spine OA had mean age of 77.4 years (95% CI, 76.5–78.2), were significantly older than women without (mean age 66.8; 95% CI, 65.9–67.7), and were more likely to have prevalent radiographic fractures (14.2% vs. 9.5%, p< 0.05). Age-adjusted BMD at the femoral neck, total hip, PA spine, and lateral spine was significantly higher in women with spine OA. Women with spine OA were more likely to have osteoporosis by WHO classification at the femoral neck and total hip than those without spine OA, but less likely based on the PA spine site (14.4% vs 24.5%). Despite higher BMD levels, women with OA of the lumbar spine had higher prevalence of osteoporosis at the hip and radiographic vertebral fractures. In elderly women 65 years and older who are likely to have spine OA, DXA measurement of the spine may be not useful in assessing fracture risk and DXA of the hip is recommended for identification of osteoporosis.
doi:10.1016/j.jocd.2006.04.116
PMCID: PMC2642644  PMID: 16931341
Spine osteoarthritis; bone mineral density; osteoporosis; elderly
22.  Bone mineral density in patients with recent onset rheumatoid arthritis: influence of disease activity and functional capacity. 
BACKGROUND. Generalised osteoporosis is often described in patients with rheumatoid arthritis (RA). The aim of this study was to evaluate disease related determinants of bone mineral density (BMD) in patients with RA. METHODS. Subjects were selected from a group of 147 patients with recent onset RA. Disease activity and functional capacity were studied prospectively in this cohort. Activity of the disease was assessed once every three months by various parameters, and functional capacity was measured with a health assessment questionnaire once every six months. Ninety seven patients consented to participate in the study. Bone mineral density was assessed with dual energy x ray absorptiometry in the lumbar spine, in a combined region of interest in the hips, and in Ward's triangle. Multiple linear regression procedures were used to analyse the data. RESULTS. Duration of RA was negatively associated with BMD at all three sites of measurement. The mean erythrocyte sedimentation rate in the six months before BMD measurement was negatively associated with BMD in the hip and in Ward's triangle. Other parameters of disease activity were not related to BMD. The mean health assessment questionnaire score in the 18 months before BMD measurement was negatively associated with BMD in the combined hip region only. Bone mineral density tended to be decreased when patients were compared with a normal reference group, especially in the femoral regions of interest. CONCLUSIONS. It is concluded that BMD may be affected in patients with recent onset RA by disease dependent mechanisms. Several factors have been suggested elsewhere as determinants of BMD in RA. The results of this study show that disease duration, disease activity, and functional impairment may, independently of each other, contribute to bone loss, especially in the proximal femur.
PMCID: PMC1004950  PMID: 8427509
23.  Bone mineral density in professional female dancers. 
OBJECTIVES: To measure the long term effects of dance training and the contribution of the timing and duration of any menstrual disruption on bone mineral density (BMD). DESIGN: Measurement of BMD in 57 premenopausal, previously professionally dance trained women and the relationship to menstrual and training history. MAIN OUTCOME MEASURES: Bone density measurements at lumbar spine and femoral neck by dual energy x-ray absorptiometry. RESULTS: The average Z score for BMD at the lumbar spine in the amenorrhoeic dancers was significantly below that for the normal population. The average Z score for BMD at the femoral neck in the eumenorrhoeic dancers was significantly above that for the normal population. There was a significant difference between the average Z score for BMD at both the lumbar spine and femoral neck between the amenorrhoeic and eumenorrhoeic dancers. Significant negative relationships were found between BMD at the lumbar spine and (1) age at menarche, (2) duration of amenorrhoea, (3) BMD at the femoral neck, and (4) the variable of ideal minus lowest weight, which was independent of amenorrhoea. No significant relationships were found between duration of oral contraceptive pill usage and BMD at either the lumbar spine or the femoral neck in eumenorrhoeic or amenorrhoeic dancers. In order to quantify the effect of a combination of these significant factors, a model of BMD was constructed using multiple regression incorporating the variables duration of amenorrhoea, age at menarche, and ideal minus lowest body weight. In this model R2 was 33.6%, in other words 33.6% of the total variation in the Z score for BMD at the lumbar spine could be accounted for by these factors. CONCLUSION: Professional female dancers with a history of delayed menarche and amenorrhoea have been identified as another group of premenopausal women potentially at risk of developing osteoporosis because of a decrease in BMD at the lumbar spine. The femoral neck in dancers with a history of amenorrhoea was partially protected from loss of BMD by virtue of being the major weight bearing site in previous dance training, and in eumenorrhoeic dancers BMD was significantly increased at this site.
PMCID: PMC1332615  PMID: 9192130
24.  Bone Loss with Multiple Sclerosis: Effect of Glucocorticoid Use and Functional Status 
Background
Emerging data suggest a significantly increased prevalence of low bone mineral density (BMD) in men and women with multiple sclerosis (MS) compared to age matched controls. This study was performed to evaluate bone mineral mass in patients with MS in comparison to healthy age-and sex matched controls and to determine association of glucocorticoid use or ambulation ability with changing in bone mass in these individuals.
Methods
Eighty two patients with MS and 328 age-sex matched healthy controls participated in the study. The Kurtzke expanded disability status scale (EDSS) was used to evaluate disability and functional capacity. Bone mineral density was measured using Dual X-ray absorptiometry. Serum calcium, phosphorus and 25(OH) vitamin D levels were assessed.
Results
The MS patients had significantly lower BMD at the lumbar spines, neck and total femur compared to age-sex matched controls. EDSS scores were inversely correlated with total femur and spinal BMD. There was a negative correlation with cumulative steroid dose and BMD only for femoral neck.
Conclusion
BMD was significantly lower in MS patients. Decreased ambulatory status and glucocorticoid usage were associated with low BMD in MS patients. These patients should be encouraged to increase mobility and to have protective measures to maintain bone mass.
PMCID: PMC3407580  PMID: 22946013
Multiple sclerosis; Bone mineral density; Ambulation; Steroid
25.  Fasting Plasma Glucose Levels Are Related to Bone Mineral Density in Postmenopausal Women with Primary Hyperparathyroidism 
How glucose levels affect bone in patients with primary hyperparathyroidism is unknown, although the prevalence of impaired glucose metabolism is higher in patients with primary hyperparathyroidism. The present study was performed to examine the relationships between fasting plasma glucose (FPG) and various indices in 93 postmenopausal women with primary hyperparathyroidism. Bone mineral density (BMD) and body composition were measured by dual-energy Xray absorptiometry. Body weight, body mass index (BMI), fat mass and % fat were positively related to FPG. Serum levels of calcium and parathyroid hormone (PTH) as well as bone metabolic indices were not related to FPG and immunoreactive insulin levels. As for BMD, FPG was positively related to the Z scores of BMD at the lumbar spine and femoral neck, although it was not significantly related to the Z-score of BMD at the radius. On the other hand, immunoreactive insulin levels were not significantly related to BMD parameters at any sites. In multiple regression analysis, FPG was significantly related to BMD (Z score) at the lumbar spine and femoral neck, when body weight, BMI, immunoreactive insulin, PTH, and bone resorption indices were considered; however, these relationships at the lumbar spine were not significant when fat mass was considered. In conclusion, the present study indicated that FPG levels were positively related to BMD at the lumbar spine and femoral neck in postmenopausal women with primary hyperparathyroidism.
PMCID: PMC2596330  PMID: 19079676
Primary hyperparathyroidism; glucose; bone mineral density; body composition

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