British Journal of Radiology 74 (2001),602-606 © 2001 The British Institute of Radiology
Evaluation of bone mineral density by quantitative ultrasound of bone in 16 862 subjects during routine health examination
J-D Lin, MD,
J-F Chen, MD,
H-Y Chang, MD and
C Ho, MD
Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Shin St., Kweishan County, Taoyuan Hsien, Taiwan, Republic of China
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Abstract
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Caucasians and Asians are among those with the highest risk for involutional osteoporosis. To obtain accurate data about the prevalence of osteoporosis or osteopenia in different age groups, a large epidemiological study is necessary. Quantitative ultrasound (QUS) of bone is a promising technique in assessing bone microarchitecture in addition to bone mass. This study had two aims. The first was to establish bone mineral density (BMD) using QUS in subjects with no obvious disease undergoing routine health examination. The second was to determine risk factors for osteoporosis in Taiwan in order that better prevention and treatment measures may be provided for these patients. A prospective study of the risk factors for fracture was conducted in the health examination division of Chang Gung Medical Center in Linkou, Taiwan, from January 1996 to December 1997. Broadband ultrasound attenuation of the right heel was measured with an achilles bone densitometer (Lunar, Nauheim, Germany). A total of 16 862 subjects were examined, including 9314 women (mean age 51.5±11.7 years) and 7 548 men (mean age 51.1±12.1 years). The incidence of osteoporosis in all subjects increased from 1.13% in the 21–30-year-old age group to 54.55% in those over 80 years of age. 12.02% of the subjects had osteoporosis and 34.45% had osteopenia. From multivariate analysis, bone density evaluated by QUS showed a relationship with age, gender, body mass index, waist/hip ratio, smoking and frequency of exercise. In conclusion, BMD evaluated by QUS is not found to be higher in Taiwan than elsewhere. The role of QUS in predicting fractures in Taiwan requires further investigation.
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Introduction
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Osteoporosis and prevention of osteoporotic fractures are major problems worldwide. In recent epidemiological studies, Caucasians and Asians were deemed to be among those at highest risk for involutional osteoporosis [1–3]. The prevalence and risk of fracture were recently reported using dual energy X-ray absorptiometry (DXA) [4]. Although the incidence of hip fracture appears tobe lower in Taiwan, the prevalence of osteoporosis and vertebral fractures is high. A large epidemiological study was necessary to obtain accurate data regarding the prevalence of osteoporosis and osteopenia in different age groups. Further measures for prevention and treatment could then be initiated with this data.
Quantitative ultrasound (QUS) of bone is a promising technique for assessing bone microarchitecture in addition to bone mass [3, 5, 6]. QUS has many advantages compared with traditional densitometry, including lack of radiation, cost and potential portability [7, 8]. In previous studies, broadband ultrasound attenuation (BUA) of QUS correlated moderately well with bone density [9–11]. BUA is believed to reflect not only bone mass but also the structural features of the bone [12] as well as other factors that may be important in determining fracture risk.
There were two aims in this study. The first was to establish bone mineral density (BMD) using QUS in subjects undergoing routine health examination who do not suffer obvious disease. The second was to determine the risk factors for osteoporosis in Taiwan so as to provide better prevention and treatment intervention.
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Subjects and methods
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A prospective study of risk factors for fractures was performed in the health examination division of Chang Gung Medical Center in Linkou, Taiwan, from January 1996 to December 1997. The subjects recruited in this study did not have a history of major diseases and, after the health examination, those with diabetes mellitus or other endocrine disorders were excluded from the study. Subjects who presented with oedema or a foot abnormality were also excluded. A total of 16 862 subjects were examined, including 9314 women (mean age 51.5±11.7 years, range 14–92 years) and 7548 men (mean age 51.1±12.1 years, range 16–89 years). Figure 1
shows the age and gender distribution of these subjects. Body measurements were taken, including body weight, body height, body mass index (BMI) and waist/hip ratio (WHR).
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Figure 1. Age and gender distribution of 16 862 subjects who received bone density evaluation using quantitative ultrasound of bone.
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BUA and speed of sound (SOS) of the right heel were measured with an achilles bone densitometer (Lunar, Nauheim, Germany) using the scanning protocol provided by the manufacturer. T-score was derived from Stiffness Index (SI=[(BUA-50)/1.5]+[(SOS-1380)/3.6]). The short-term reproducibility of BUA was assessed by obtaining three measurements with repositioning for 60 unselected subjects. These data correlated well with DXA.
Before bone density measurement, a questionnaire was completed with the assistance of trained nurses. This questionnaire included: basic information, body measurements (body weight, body height, WHR), menstrual history for women, family history of osteoporosis and fracture, past medical history, and smoking and drinking habits. Past histories to be traced included thyroid disease, parathyroid disease, hyperprolactinaemia, adrenal disorders, pituitary disorders, operations and the use of drugs. For this study, osteopenia was defined as a T-score of more than one standard deviation (SD) below the young normal mean, but less than or equal to 2.5 SD below. Osteoporosis was defined as having a T-score of over 2.5 SD below the young normal mean [13]. The QUS findings of the subjects were categorized into five groups. Group 1 included normal subjects with QUS greater than 90% of the young matched peak bone mass. Group 2 consisted of mild osteoporosis subjects with QUS of 81–90% of the young matched peak bone mass. Group 3 included moderate osteoporosis subjects with QUS of 71–80% of the young matched peak bone mass. Group 4 included severe osteoporosis subjects with QUS of 61–70% of the young matched peak bone mass. Those in Group 5 were extreme osteoporosis subjects with QUS less than 61% of the young matched peak bone mass.
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Results
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The incidence of osteoporosis among the 16 862 subjects increased from 1.13% in the 21–30-year-old age group to 54.55% in the over 80 years age group (Figure 2). In our study, the peak bone mass of the population as evaluated by BUA occurred between the ages of 21 years and 30 years. Moreover, the peak incidence of osteopenia was 46.4% in the 61–70 years age range. 12.02% of the subjects had osteoporosis and 34.45% had osteopenia. Table 1 demonstrates, using multivariate analysis, that bone density is related to age, gender, BMI, WHR, smoking and the frequency of exercise. If the data are analysed by gender with stepwise multiple regressions, the results show age, BMI, WHR, smoking and exercise frequency to be statistically important in men, and age, BMI, WHR, smoking, exercise frequency and menopause history to be important in women (Tables 2 and 3). In both genders, BMD decreased with age, lower BMI, higher WHR, smoking and less exercise. In women, BMD also decreased following menopause.
Figure 3 demonstrates the incidence of osteopenia and osteoporosis in male and female subjects at different ages. For male subjects, the incidence of osteoporosis gradually increased from 2.18% in the 21–30-year-old age group to 38.71% in the over 80 years age group. The peak incidence of osteopenia was 41.25% in the 51–60-year-old age group. The percentage of normal BMD measurements decreased rapidly from the 21–30-year-old age group to the 71–80-year-old age group. The incidence of osteoporosis in women increased from 0.33% in the 21–30-year-old age group to 68.57% in the over 80 years age group. The peak incidence of osteopenia in female subjects was 47.48% in the 61–70-year-old age group. A marked increased in percentage of abnormal bone density measurements was found after 50 years of age.
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Figure 3. Percentage of normal, osteopenia and osteoporosis findings according to age in (a) female and (b) male subjects.
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Discussion
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There are BMD studies regarding normal Chinese women in Taiwan [14], and an epidemiological study of osteoporosis in this area [4], with most of the studies based on data from DXA. Until now, we have not had a large enough series based on information about QUS to evaluate bone density for a Chinese population. In one recent study, evaluation of the tibial cortical bone by ultrasound velocity in 175 oriental women showed that ultrasound is a useful method for detecting osteoporotic patients in this ethnic group [15].
This was the first large study of BUA values evaluated by ultrasound on healthy subjects in a Chinese population. In our study, as in previous reports, the decline of bone density in Asian men is slower than in women, especially after 50 years of age [16, 17]. The ratio of decline in the women within this study was more prominent after the age of 60 years. This result is similar to the data in a previous report on fracture prevalence [18]. Until now, there have been no data available to determine the fracture ratio of patients with osteoporosis. Long-term follow-up data are needed to confirm this. Comparing our data with a World Health Organization criteria based study on Caucasian women in Rochester, MI, the incidence of osteoporosis in the 50–60-year-old, 60–70-year-old, 70–80-year-old and over 80 years age groups were, respectively, 9.64%, 28.92%, 51.10% and 68.59% in our study and 14.8%, 21.6%, 38.5% and 70.0% in the Rochester study [19]. For aging women in this part of the world, the incidence of osteoporosis is higher than in the USA. As BMD increased with BMI, our results are similar to recent studies. BMI can influence BMD, which has been evaluated by lumbar spine [20] or QUS [21]. There are few reports about the influence of WHR and BMI. In contrast to our results, arecent report found that upper level body fatdistribution had an additive effect on bonedensity in post-menopausal women [22]. Anthropometric measurement not associated with lumbar spine BMD in pre-menopausal women was reported earlier [23]. More information is needed regarding the relationship ofWHR and BMD before reaching a conclusion.
Cigarette smoking had been associated with a decreased BMD in post-menopausal women [24]. A recent large study, which enrolled 116 229 female nurses, concluded that an increased risk of hip fracture exists among current smokers. There was no apparent benefit from quitting smoking until 10 years after cessation [25]. In our study, SI derived from BUA and SOS in smokers was statistically decreased compared with non-smokers. Whether there is any relationship between fracture risk and smoking in Taiwan requires further investigation.
Received for publication November 23, 2000.
Revision received April 2, 2001.
Accepted for publication April 17, 2001.
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Abstract
Introduction
