Osteoporosis Canada

Tag: Healthcare Professionals

2019 Lindy Fraser Award Presented to Dr. Rowena Ridout

Members of Osteoporosis Canada’s Scientific Advisory Council would like announce this year’s Lindy Fraser Award winner as chosen by the members of the SAC.

Osteoporosis Canada established this award in 1993 to recognize individuals who have made an outstanding contribution to the field of osteoporosis research and education in Canada. The award is named in honour of Lindy Fraser, who in 1981 at the age of 87 started the first self-help group for people with osteoporosis.  She herself was an inspiration to others as she shared her struggle to get out of bed, into a wheelchair, then to walk again with a cane.  In 1982, she answered a call from a small group in Toronto to take part in the first national symposium on osteoporosis.  That appearance was the spark that gave rise to Osteoporosis Canada.

This year’s award winner has shown immeasurable dedication and determination in the collaborative effort to achieve the common vision of Canada without osteoporotic fractures. Osteoporosis Canada recognizes Dr. Rowena Ridout.

Dr. Ridout is an endocrinologist at the Toronto Western Hospital, University Health Network and a staff physician at the UHN/MSH Osteoporosis Programme.  She completed her undergraduate and postgraduate medical training at the University of Toronto. She has been involved in clinical research in osteoporosis including the attainment and maintenance of peak bone mass, the treatment of steroid-induced osteoporosis in children and interventions in the fracture clinic. She has been involved with Osteoporosis Canada for many years, and is currently the medical advisor for COPN and the vice chair of the SAC.  She is an Assistant Professor of Medicine at the University of Toronto, and her primary academic activity is teaching and education. Dr. Ridout is also involved with the Clinical Practice Guidelines update.

At this year’s Osteoporosis Canada AGM, Dr. Ridout was also presented with Osteoporosis Canada’s Backbone award for volunteering.

Congratulations Dr. Ridout!

Healthcare Professionals

Breaking the Cycle of Recurrent Fractures: 2019 Implementation Science Team Project Grant Recipient

After rigorous peer review, the Michael Smith Foundation for Health Research (MSFHR) recently awarded the Fraser Health Authority team in British Columbia (BC), a three-year project team grant worth $500,000. The project, titled “Breaking the cycle of recurrent fracture: Scaling up a secondary fracture prevention program in Fraser Health to inform spread across British Columbia”, is co-led by Dr. Sonia Singh (Fraser Health clinician-researcher,) Larry Funnell (Patient partner researcher) and Dr. Tania Bubela (Simon Fraser University, Dean of Health Sciences). This project may well be the tipping point for Fracture Liaison Service (FLS) implementation in BC. This project will explore how the FLS model implemented at the Peace Arch Hospital (White Rock) in Fraser Health can be successfully adapted and scaled-up to other hospital sites within the health authority.

This leading-edge project aligns with the mandate of Osteoporosis Canada in supporting nation-wide implementation of effective secondary fracture prevention. One key expected outcome is to inform an FLS implementation strategy that can be used to spread the FLS model across BC, thereby improving patients’ quality of life after low-trauma fractures and decreasing health care costs related to recurrent fractures. The research findings from this project may result in dramatically improved access to appropriate osteoporosis care for fracture patients in BC and will impact future program planning of secondary fracture prevention across Canada.

Click here to learn more

Fracture Liaison Service, Healthcare Professionals, Highlighted

Patient Engagement in Clinical Guidelines Development

Mr. Larry Funnell, a long time Osteoporosis Canada volunteer, and Dr. Suzanne Morin, a member of Osteoporosis Canada’s Scientific Advisory Council, presented “Patient Engagement in Clinical Guidelines Development : Input from >1000 Members of the Canadian Osteoporosis Patient Network” at the IOF ESCEO Conference being held in Paris, France.

Larry can be seen here at the podium delivering his presentation.

Congratulations to both Larry and Dr. Morin.

Click here to learn more about our Members in Action

Healthcare Professionals

Patient Empowerment: The Importance of Knowing About Osteoporosis

Dr. Marla Shapiro spoke at the recent CNS Day at World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (WCO-IOF-ESCEO Paris 2019) on patient empowerment. Watch this short video where Dr. Shapiro speaks to the importance of knowing about osteoporosis and the risk of fractures associated with the disease. Know Your Risk. Visit Osteoporosis Canada’s website and Take the Quiz.

Healthcare Professionals

Member of the SAC Invested into the Order of Canada

Dr. Mohit Bhandari, a member of the SAC Executive committee,  a Professor in the Department of Surgery at McMaster University and a leader in the field of orthopedic surgery has been invested into the Order of Canada, one of the highest civilian honours in Canada. Mohit has been recognized for his advocacy on behalf of domestic violence victims.

Mohit was recognized for his pioneering research related to intimate partner violence, which has sparked a global conversation about the role health care workers play in identifying and responding to abuse. He was also lauded as an influential mentor to students and surgical colleagues.

He was presented with this honour by Governor General Julie Payette in Ottawa at Rideau Hall on Thursday March 14, 2019.

Congratulations, Mohit!

Left to Right: Dr. Mohit Bhandari, Governor General Julie Payette

Healthcare Professionals

New Study Associates Intake of Dairy Milk with Greater Risk of Breast Cancer

Dairy, soy, and risk of breast cancer: those confounded milks

https://academic.oup.com/ije/advance-article/doi/10.1093/ije/dyaa007/5743492#199259276

Dairy, soy, and risk of breast cancer: those confounded milks Gary E Fraser, Karen Jaceldo-Siegl, Michael Orlich, Andrew Mashchak, Rawiwan Sirirat, Synnove Knutsen International Journal of Epidemiology, 25 February 2020

Recent media headlines point to a study suggesting that women who drink as little as one cup /250 ml of cow’s milk per day could be increasing their risk of developing breast cancer by up to 50%.  This study is part of the Adventist Health Study, by Synnove Knutsen et al, from Loma Linda University   and published in the International Journal of Epidemiology.  https://doi.org/10.1093/ije/dyaa007 . The study evaluated associations between intakes of soy milk, other soy products, dairy milk and other dairy foods with risk of breast cancer.

This study followed nearly 53,000 Adventist women for 7.9 years focusing on the relative risk of a rare outcome. The authors concluded that as cow’s milk intake increased, regardless of fat level, so did the risk of breast cancer. No clear associations were found between consumption of soy products and breast cancer.

Weaknesses of this study are its observational design (cause and effect cannot be established) and possible residual confounding between dairy and unmeasured factors, despite extensive covariate adjustment. (1) Diet was measured only once at study baseline leaving room for error and omissions. Whether these results can be applied to other populations is unknown and therefore difficult to draw conclusions.  Adventists lifestyle differ considerably from the general population as many follow a plant based diet and exclude processed foods, alcohol and caffeine.

The authors do note that cow’s milk has many positive nutritional qualities and suggest more research is needed to understand if there is a link between dairy intake or other closely-related unidentified factors and breast cancer risk.  Until then, a balanced and a varied diet including sources of calcium, regular physical activity and avoiding smoking and excess alcohol make for a healthy lifestyle.

1. Dairy, soy, and risk of breast cancer: those confounded milks Gary E Fraser, Karen Jaceldo-Siegl, Michael Orlich, Andrew Mashchak, Rawiwan Sirirat, Synnove Knutsen International Journal of Epidemiology, 25 February 2020

Healthcare Professionals

Eating for Bone Health with the New Canada’s Food Guide

The new Canada’s Food Guide was released on Tuesday Jan 22nd. It is a modern approach to promoting healthy eating, making healthier eating choices easier for all Canadians. This new food guide focuses on what to eat and how to eat. It also includes updated recommendations on saturated fat, sodium, and sugars.

The food guide focuses on vegetables, fruits, proteins and whole grains. The new food guide encourages Canadians to choose plant-based proteins more often. According to the food guide, protein foods include legumes, nuts, seeds, tofu, fortified soy beverage, fish, shellfish, eggs, poultry, lean red meat including wild game, lower fat milk, lower fat yogurts, lower fat kefir, and cheeses lower in fat and sodium.

Canadians need adequate amounts of calcium, vitamin D and protein for optimal bone health. Milk products contain a high proportion of calcium per serving and are a great source of protein.  Calcium can also be found in other foods such as calcium-fortified food and drink, some vegetables and fruits, nuts and seeds, and legumes.  For suggestions regarding calcium containing foods, please click here.

Osteoporosis Canada continues to encourage adults who have osteoporosis or have risk factors for osteoporotic fractures, to get adequate vitamin D supplementation as it is difficult to obtain recommended levels through foods alone. Click here for more information on vitamin D.

Healthcare Professionals, Public

Increased Risk of Vertebral Fracture After Stopping Denosumab

Denosumab (Prolia) has been shown to reduce the risk of fracture in postmenopausal women and men ≥50 years old with osteoporosis. It has also been approved for steroid induced bone loss.

Individuals who were in the FREEDOM study, which evaluated denosumab in comparison to placebo, were followed, and those who stopped denosumab had a subsequent reduction in bone mineral density (BMD) and an increase in the risk of fracture (Bone JCEM 2011).

Analysis of the data from the FREEDOM study as well as the Extension trial of denosumab up to a total of 10 years, confirmed that stopping denosumab was associated with an increase in rate of bone loss as measured by bone turnover markers, which rose 3 months after missing a scheduled dose. BMD decreased back to the baseline level 12 months after missing a scheduled dose of denosumab (Cummings JBMR 2017).

Individuals who had received ≥2 doses of denosumab or placebo, and stopped treatment but remained in the study for ≥ 7 months after the last dose, were reviewed. In the 1001 patients who stopped denosumab, the rate of spine fractures increased from 1.2/100 patient-years (while on treatment) to 7.1/100 patient-years, a similar rate to the placebo group. Multiple (>1) vertebral fractures appeared to be more common in the group stopping denosumab than the group stopping placebo (3.4% vs 2.2%). The risk of having multiple (>1) vertebral fractures after stopping denosumab was higher in those people who had already experienced a prior spine fracture, and also in those who had rapid rates of bone loss. The rates of non-spine fractures were similar in those stopping denosumab and those stopping placebo (2.8% denosumab, 3.8% placebo) (Cummings et al JBMR 2017).

Due to the increased risk of vertebral fractures associated with denosumab discontinuation, it is important not to miss scheduled doses of denosumab once treatment has started. Patients need to be advised of the increased risk of bone loss and vertebral fracture when therapy is stopped. If denosumab needs to be stopped, it should be replaced by an alternative osteoporosis medication to help prevent rapid bone loss and risk of fractures (Symonds CMAJ April 2018).

Osteoporosis Canada advises individuals on denosumab therapy to discuss their treatment with their physician prior to stopping therapy or missing a scheduled dose.

1. Bone HG et al JCEM 2011:96:972-980

2. Cummings et al JBMR vol 33, No2, Feb 2018 pp 190-198

3. Symonds C, Kline G CMAJ 2018 April 23 :190 pp E485- 486

Prepared by Aliya Khan, Sandra Kim, Rowena Ridout and Lianne Tile, on behalf of the Scientific Advisory Council of Osteoporosis Canada, Rapid Response Committee.

Healthcare Professionals

Vitamin D and Effects on Fractures, Falls and Bone Mineral Density

The recent study by Bolland and colleagues published in the Lancet Diabetes Endocrinology (Oct 4, 2018) is an updated meta-analysis that evaluated the effects of vitamin D supplementation on fractures, falls and bone mineral density (BMD) in adults. This study analyzed the pooled findings of 81 randomized control trials, collectively involving more than 50,000 participants.

The majority of the trials included in this analysis were of vitamin D alone, with daily doses of more than 800 IU daily, vs. untreated controls, in community-dwelling women age 65-years or older. Trials of high-dose vs. low-dose vitamin D, as well as co-administration of calcium with vitamin D were also included. Study duration was 1 year or less. The primary outcomes were fractures and falls; and the secondary outcome was change in BMD from baseline at the lumbar spine, total hip, femoral neck, total body, and forearm (1).

This meta-analysis found that vitamin D supplementation did not have an effect on the risk of fractures or falls, and there were no meaningful effects on BMD. The authors also concluded that there were no differences between the effects of higher and lower doses of vitamin D (1).

In more than half of the trials, subjects had a baseline vitamin D level (25OHD) of <50 nmol/L (a cutoff considered by many including the Endocrine Society (2) to indicate vitamin D insufficiency), and almost all had a baseline 25OHD <75 nmol/L. Only four trials (6%) studied people with vitamin D deficiency (25OHD <25 nmol/L), in whom vitamin D supplementation may produce different results. Since there is large variability in how vitamin D levels respond to fixed doses of vitamin D (most studies used 1000 IU per day or less), 25OHD levels may not have reached the target range of interest in these studies. The finding that vitamin D alone may not prevent fractures, falls or improve BMD is consistent with prior published studies. While studies have shown little impact on outcomes when vitamin D or calcium are used separately, a review of trials of calcium and vitamin D used together in individuals living in long-term care showed benefit (3). The current meta-analysis by Bolland included only 20 trials (25%) of vitamin D taken with calcium vs. calcium alone, and did not include studies that compared vitamin D used together with calcium vs. no treatment. Although the major strength of the current study lies in the large number of studies included in the analysis, it is important to recognize potential limitations including the heterogeneity of populations, study designs and results of the studies in the meta-analysis. Importantly, this study did not specifically address the vitamin D requirements of individuals with osteoporosis, those with risk factors for osteoporotic fractures, or those with risk factors for vitamin D deficiency. It is important to remember that vitamin D is needed for optimal calcium absorption from the gut, and plays an important role in calcium balance and bone mineralization. Inadequate vitamin D can result in poor bone mineralization, as well as bone loss due to a rise in parathyroid hormone levels. Although this study suggests that routine vitamin D supplementation, in particular, high dose vitamin D, may not be necessary for healthy individuals in the general population, these findings cannot be applied to people with osteoporosis, or to those with risk factors for fractures or vitamin D deficiency. Osteoporosis Canada recommends that individuals with osteoporosis or with risk factors for fractures receive adequate vitamin D, as recommended at 800-2000 IU per day (4), however vitamin D dosing may require adjustment in order to achieve the adequate 25OHD level needed for optimal calcium homeostasis. Further studies are needed to clarify the optimal 25OHD level for those with osteoporosis or with risk factors for fracture. High dose vitamin D supplementation should be avoided due to potential harms (5). There are large randomized trials currently ongoing to help answer questions about effects of vitamin D supplementation on other aspects of health (6). Appropriate osteoporosis medication may be required for those at high fracture risk. It is important to note that clinical trials showing the effectiveness of osteoporosis medications all included vitamin D and calcium as part of the treatment regimen. References: 1. Bolland et al Lancet Diabetes Endocrinol Oct 2018 2. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. Michael F. Holick et al The Journal of Clinical Endocrinology & Metabolism, 2011 96 (7): 1911-1930. 3. Papaioannou et al CMAJ 2015 187: 1-11. 4. Vitamin D in adult health and disease: a review and guideline statement from Osteoporosis Canada by David A. Hanley MD et al CMAJ 2010 5. Smith et al 2017 J Steroid Biochem Mol Biol173:317-22 6. Pradhan AD Manson JE Update on the Vitamin D and OmegA-3 trial (VITAL). Study J Steroid Biochem Mol Biol. 2016 Jan;155(Pt B):252-6. 7. Manson JE et al. Vitamin D supplements and prevention of cancer and cardiovascular disease. N Engl J Med 2018 Nov 10; [e-pub]. (https://doi.org/10.1056/NEJMoa1809944) Prepared by Aliya Khan, Sandra Kim, Rowena Ridout and Lianne Tile, on behalf of the Scientific Advisory Council of Osteoporosis Canada, Rapid Response Committee.

Healthcare Professionals

Long-Term Use Of Bisphosphonates Increases the Risk of Fractures in Older Women

Bisphosphonate therapy – long term use

Recently a study published by Drieling et al in JAGS 2017 described the results of a cohort study of 5120 older women with an average age of 80 yrs and at high fracture risk . This observational study from the Womens Health Initiative included 5120 women who had been using oral BP for at least 2 years and had a FRAX score of 1.5% or higher for 5 yrs. Women who had been on PTH , calcitonin or aromatase inhibitors were excluded. The average follow up data was available for 4 yrs.

10-13 yrs of oral bisphosphonate use was associated with higher risk of any clinical fracture then 2 yrs of use HR =1.29 , 95% CI 1.07-1.57.

There was no association between intermediate use and fracture risk. There are a number of limitations to this observational data including the fact that this study did not include a group without bisphosphonate use also compliance was not evaluated.

Oral BPs have been shown to significantly reduce the risk of vertebral and non vertebral fracture in randomized controlled trials. The extension studies of these fracture trials unfortunately were not powered to evaluate impact on fracture risk and currently we do not have long term data consistently demonstrating reductions in non vertebral fracture risk with long term BP use.

It appears that the optimal period of use for oral or IV bisphosphonates is 3-5 yrs with published randomized controlled trial data confirming reductions in fracture risk for vertebral , non vertebral and hip fracture with use for this time period. After the first 5 years of bisphosphonate use the fracture risk should be re-evaluated and bisphosphonate therapy should also be re-evaluated.

Osteoporosis Canada advises that all patients should have their treatment strategy reviewed by their physicians particularly after 5 years of use as long term use of bisphosphonates may not have the same risk benefit ratio as seen with short term use of up to 5 yrs.

Healthcare Professionals

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