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EDITORIAL
Year : 2012  |  Volume : 1  |  Issue : 2  |  Page : 61-62

Diagnosing osteoporosis made easier: The FRAX tool gets better


1 Department of Endocrinology, Bharti Hospital and BRIDE Karnal, Guwahati, India
2 Department of Obstetrics, Bharti Hospital and BRIDE Karnal, Guwahati, India
3 Department of Endocrinology, Excel Hospitals, Guwahati, India

Date of Web Publication22-Sep-2012

Correspondence Address:
Sanjay Kalra
Department of Endocrinology, Bharti Hospital and BRIDE Karnal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-019X.101284

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How to cite this article:
Kalra S, Kalra B, Baruah MP. Diagnosing osteoporosis made easier: The FRAX tool gets better. J Med Nutr Nutraceut 2012;1:61-2

How to cite this URL:
Kalra S, Kalra B, Baruah MP. Diagnosing osteoporosis made easier: The FRAX tool gets better. J Med Nutr Nutraceut [serial online] 2012 [cited 2019 Sep 20];1:61-2. Available from: http://www.jmnn.org/text.asp?2012/1/2/61/101284

Osteoporosis is a major nutritional public health problem across the globe. This condition affects 200 million women world wide. Approximately one out of ten women aged 60, and one out of five women aged 70 have osteoporosis. [1] Osteoporosis affects its victims in various ways. The most obvious outcome of osteoporosis is fractures. All over the world, it is estimated that an osteoporotic fracture occurs every 3 seconds, and a vertebral fracture takes place every 22 seconds. [2] These fractures lead to significant morbidity, disability, and mortality. In women over 45 years of age, osteoporosis is a major cause of hospital stay, and contributes more to indoor admission than myocardial infarction, diabetes or cancer. [3]

The public health impact of osteoporosis is increasing rapidly. By the year 2050, the world wide incidence of hip fracture in men is projected to increase by 310%, and women by 240%. [4] This impact is not limited to the Caucasian population. As various clinical risk factors make their presence felt in developing countries, and as the population of these nations' ages, osteoporosis is taking pandemic proportions. By 2050, [4] more than 50% of all osteoporotic hip fractures will be in Asian men and women. In India, about 26 million people were estimated to have osteoporosis in 2003. This number is expected to rise to 36 million by 2013. [5]

In spite of this huge disease burden, and in spite of modern advances in diagnostics and treatment, osteoporosis is under recognized, and sub optimally managed in many countries. [6]

One of the reasons for this is lack of availability of, and accessibility to, simple diagnostic tools. Another reason is the lack of awareness regarding the impact of osteoporosis, and the fact the fractures are preventable. This lack of awareness is found in both doctors and patients. Many patients tend to remain in denial of personal risk, and do not enter in to dialogue with physicians regarding bone health. [6] Their access to diagnosis is restricted, even after sustaining a fragility fracture. [6],[7],[8] Modern technology has created many methods for the evaluation of bone density and quality. These include dual energy X-ray absorptiometry (DXA), computed tomography, and magnetic resonance imaging. DEXA is the most widely used bone densitometry technique, and is regarded as the gold standard for measurement of the bone density, as well as diagnosis of osteoporosis. There are various limitations and inaccuracies in this method, however. [9] At the same bone, though DXA measurements are strong predictor of fracture risk, bone mineral density is not the only risk factor for fracture.

DXA is also handicapped by its cost, and its limited availability and accessibility in many countries. India, for example, has roughly 250 DXA machines for a population of 1:2 billion, i.e., a ratio of 1:5 million.

Ethnic differences in bone mineral density, and in the risk of fractures, have been well documented. In Indians, much lower bone mineral density values are noted in healthy adults and children as compared to their Caucasian press. [10],[11] This implies that normative data provided by DXA manufacturers can not be used in all ethnic population. For optional diagnosis, it is necessary to determine normative values for every ethnic group.

There is a need, therefore, for easier, more economical, more accessible, and more appropriate methods of quantifying fracture risk.

Various clinical risk factors (CRFs) have been identified for osteoporosis and fractures. These include CRFs which can be elicited during history taking, such as age, history of fragility fractures, smoking, alcohol intake, glucorticoid use, and history of fragility fractures in the family. A detailed medical history may reveal secondary causes of osteoporosis such as rheumatoid arthritis, while a physical examination will highlight CRFs such as low body mass index.

In the year?, the World Health Organization published the FRAX tool, a simple web and paper-based method of calculating probability of fracture risk, based on these proven clinical risk factors. [11] FRAX is able to calculate fracture risk with or without bone mineral density values. This tool immediately found use in the 12 countries for which epidemiological data was available. [11] Many other nations were also able to use the FRAX tool, as their ethnicity was represented in the formula. For example, researchers in Africa were able to calculate fracture risk of their patients, using data derived from Black populations in United States.

In the Indian subcontinent, which is home to one-fifth of the world's population, sadly, no epidemiological data fracture prevalence was available. While experts suggested using Turkish or Japanese data, [12] the FRAX tool did not find many takers in India, because of the obvious lack of similarity between Indians and the ethnic groups represented in FRAX.

Recently, however, the FRAX tool has been upgraded. A new version is available which can calculated fracture probability for 26 countries. Data from Singapore, which is a multiethnic country, is also represented on the FRAX tool. The calculator provides separate data for Chinese, Malay and Indian population of Singapore. The Singapore, Indian data can easily be extrapolated to the population living in India or neighboring countries. Similar genetics and dietary habits imply that the risk of fracture will also be similar. Bone mineral density measurements are not required to calculate the fracture risk in this tool.

The availability of Indian data on the FRAX site is a great boon for Indian endocrinologists, and patients, alike. One can use web or paper-based calculations to show patients their 10 year risk of hip fracture or osteoporotic fracture. This clinical tool helps motivate the patient to accept appropriate therapy, and sensitizes her or his community to implement preventive measures.

With the expansion of FRAX to include Indian and Chinese data, this clinical tool has now covered all the major ethnic groups of the world. The diagnosis of osteoporosis has become simpler. The FRAX tool has truly gone global.

 
  References Top

1.Kanis JA. WHO Technical Report. Assessment of osteoporosis at the primary health care level. UK: University of Sheffield; 2007. p. 66.  Back to cited text no. 1
    
2.Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 2006;17:1726-33.  Back to cited text no. 2
[PUBMED]    
3.Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D. Guidelines for diagnosis and management of osteoporosis. The European Foundation for Osteoporosis and Bone Disease. Osteoporos Int 1997;7:390-406.  Back to cited text no. 3
[PUBMED]    
4.Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int 1997;7:407-13.  Back to cited text no. 4
[PUBMED]    
5.Osteoporosis Society of India. New Delhi, New Delhi: Osteoporosis Society of India; Action Plan Osteoporosis: Consensus statement of an expert group.; 2003.  Back to cited text no. 5
    
6.International Osteoporosis Foundation. Osteoporosis Fact Sheet. Available from: http://www.dolcera.com/wiki/images/Osteoporosis_factsheet.pdf [Last accessed on 2012 Aug 08].  Back to cited text no. 6
    
7.Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA. Treatment of osteoporosis: Are physicians missing an opportunity? J Bone Joint Surg Am 2000;82-A:1063-70.  Back to cited text no. 7
[PUBMED]    
8.Siris ES, Miller PD, Barrett-Connor E, Faulkner KG, Wehren LE, Abbott TA, et al. Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: Results from the National Osteoporosis Risk Assessment. JAMA 2001;286:2815-22.  Back to cited text no. 8
[PUBMED]    
9.Kanes JA. Assessment of Fracture Risk. In: Rosen CJ, editor. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. Washington DC: American Society for Bone and Mineral Research; 2008. p. 170-3.  Back to cited text no. 9
    
10.Norris SA, Nelson DA. Ethnic Differences in Bone Acquisition. In: Rosen CJ, editor. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. Washingt on DC: American Society for Bone and Mineral Research; 2008. p. 80-1.  Back to cited text no. 10
    
11.Welcome to FRAX. Available from: http://www.shef.ac.uk/FRAX/index.jsp. [Last accessed on 2011 Nov 22].  Back to cited text no. 11
    
12.Kalra B, Kalra S, Sharma A. New technology: Fracture risk assessment. Indian J Endocrinol Metab 2008; 12:29-31.  Back to cited text no. 12
    



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