4/1/04/njm

OSTEOPOROSIS

IN

AMERICAN INDIAN/ALASKA NATIVE WOMEN

# [BACKGROUND]{.underline}

Osteoporosis, or porous bone, is a disease characterized by low bone
mass and structural deterioration of bone tissue, leading to bone
fragility and in increased susceptibility to fractures of the hip,
spine, and wrist. Men as well as women suffer from osteoporosis, a
disease that can be prevented and treated.

Osteoporosis is a major health threat for 44 million Americans, 68% of
who are women. In the U.S. today, 10 million individuals already have
osteoporosis and 34 million more have low bone mass, placing them at
increased risk for this disease. One out of every two women and one in
four men over 50 will have an osteoporosis-related fracture in their
live time. More than 2 million American men suffer from osteoporosis,
and millions more are at risk. Each year, 80,000 suffer a hip fracture
and one-third of these men die within a year. Osteoporosis can strike at
any age. Osteoporosis is responsible for more than 1.5 million fractures
annually, including 300,000 hip fractures, and approximately 700,000
vertebral fractures 250,000 wrist fractures and more than 300,000
fractures at other sites. Estimated national direct expenditures
(hospitals and nursing homes) for osteoporosis and related fractures are
\$14 billion each year.

Following a comprehensive medical assessment, the doctor may recommend
that bone mass is measured. Bone mineral density (BMD) test measure bone
density in the spine, wrist, and/or hip (the most common site of
fractures due to osteoporosis), while others measure bone in the heel or
hand. These test are painless, noninvasive and safe. Bone density tests
can:

-   Detect low bone density before a fracture occurs.

-   Confirm a diagnosis of osteoporosis if there is already a fracture

-   Predict chances of fracturing in the future

-   Determine the rate of bone loss and/or monitor the effects of
    treatment if the test is conducted at intervals of a year or more.

The purpose of this paper is to focus attention on the recognition of
osteoporosis in the Native American population, thereby facilitating
prompt and accurate diagnosis and treatment, including bone screening
testing as a standard for women over 55 years of age.

## PROBLEM STATEMENT

The Department of Health and Human Services, Office on Women's Health
has identified Osteoporosis as a priority health topic. The National
Indian Women's Health Resource Center has also identified the need to
increase knowledge of health care providers in the standards of
screening, diagnosis and treatment of osteoporosis.

The Indian Health Service Trends book notes that the female population
is 50 to 53.6 percent of the total AI/AN population. The National
Institutes of Health (7a) notes that 50% of all women will have an
osteoporotic fracture during their lifetime. The Strong Heart Study (6)
(University of Oklahoma Health Sciences Center, National Heart Lung and
Blood Institute, NHLBI) has shown there is a high rate of smoking in the
AI/AN population with higher rates in women in certain areas

Noting these risk factors, NIWHRC proposed to investigate the incidence
of Osteoporosis in the AI/AN population and if lactose intolerance was a
major factor of risk in the AI/AN population.

## METHODOLOGY

To provide an overview of the extent of osteoporosis among American
Indian and Alaska Native women, the NIWHRC requested the assistance of
the Indian Health Service's Office of Program Statistics to identify
Indian women with the diagnosis of osteoporosis.

The original request was submitted to query the RPMS for the ICD-9 codes
for the diagnosis of:

-   Osteoporosis (733.00 to 733.09)

-   Hip fractures (820.8 to 820.9)

-   Wrist fractures (814.00 to 814.10)

-   Thoracic spine fractures (805.2 to 805.3)

-   Lumbar spine fractures (805.4 to 805.5)

-   For women 45 years of age and up.

An additional request was made for the diagnosis of lactose intolerance
(ICD-9 code 271.3) for females of all ages

NIWHRC further proposed to conduct a literature review on Osteoporosis
and Lactose Intolerance in the American Indian/Alaska Native (AI/AN)
population.

The raw data from each service appear in the reported column in the
chart below.

PREVALENCE OF OSTEOPOROSIS AND LACTOSE INTOLERANCE

IN

AMERICAN INDIAN/ALASKA NATIVE WOMEN

AGES 45 AND UP

  ----------------- ------------------------ ------------------ ---------------
  **AREA**          **Total pop. /% Female   **Osteoporosis**   **Lactose
                    Pop.**                                      Intolerance**

  **Aberdeen**      **113,064 -- 51.3% =     **739**            **443**
                    58,002**                                    

  **Alaska**        **105,540 -- 51.7% =     **996**            **357**
                    54.564**                                    

  **Albuquerque**   **81,052 -- 52.8% =      **731**            **456**
                    42,795**                                    

  **Bemidji**       **82,652 -- 51.2% =      **729**            **355**
                    42,318**                                    

  **Billings**      **64,780 -- 50.5% =      **712**            **352**
                    32,714**                                    

  **California**    **63,210 -- 53.1% =      **578**            **312**
                    33,565**                                    

  **Nashville**     **42,271 -- 50% =        **243**            **123**
                    21,136**                                    

  **Navajo**        **234,868 -- 52.1% =     **1,440**          **1,222**
                    122,366**                                   

  **Oklahoma**      **281,310 -- 53.6% =     **2,621**          **1,274**
                    150,782**                                   

  **Phoenix**       **126,085 - 53.3% =      **1,045**          **579**
                    67,203**                                    

  **Portland**      **84,682 -- 51.9% =      **726**            **474**
                    43,950**                                    

  **Tuscon**        **21,120 -- 53.4% =      **227**            **135**
                    11,268**                                    

  **TOTALS**        **TOTAL = 680,663**      **10,787**         **6,802**
  ----------------- ------------------------ ------------------ ---------------

## FINDINGS

The data is incomplete and no real conclusions can be made regarding the
prevalence of osteoporosis in the AI/AN female population. The
osteoporosis data shown is a total of all requested ICD-9 codes for
osteoporosis, hip fractures, wrist fractures, lumbar fractures and
thoracic fractures in AI/AN women 45 years of age and up. The chart has
the population statistics from the Indian Health Service Regional
Differences Chart Book, 1998-1999 and disease statistics from the years
of 2000, 2001, and 2002. The data also does not include those tribal
(638/compact) programs or urban programs that do not utilize the RPMS
patient reporting system.

A second question was posed as to the impact of lactose intolerance on
the incidence of osteoporosis in American Indian/Alaska Native
populations. Although, there are a number of patients with reported
lactose intolerance, literature reports (NIDDKD, the National Digestive
Diseases Clearinghouse \"Overview of Lactose Intolerance\" and British
Columbia, Ministry of Health, Health File #70) that with dietary
teaching and supplements, the body can maintain proper blood levels of
calcium. There are a number of foods, including traditional foods, with
high levels of calcium, i.e., salmon and other fish. Nuts and beans are
also a source of calcium.

A third request was made of each area, to determine the availability of
in-house bone density screening done at their facilities/tribal and
urban clinics. The following chart shows the responses received.

+----------+------------------+-----------+--------+-------------------+
| **AREA** | **In-house       | **Outside | **Who  | **Clinicians      |
|          | testing**        | re        | Pays** | screen            |
|          |                  | ferrals** |        | routinely**       |
+----------+------------------+-----------+--------+-------------------+
| ABERDEEN | Three units,     |           |        |                   |
|          | Trenton, Pine    |           |        |                   |
|          | Ridge and        |           |        |                   |
|          | Rosebud screen   |           |        |                   |
|          |                  |           |        |                   |
|          | In April, a      |           |        |                   |
|          | mobile           |           |        |                   |
|          | mammography unit |           |        |                   |
|          | will start heel  |           |        |                   |
|          | testing          |           |        |                   |
+----------+------------------+-----------+--------+-------------------+
| ALASKA   | None             | Local     | CHS    | Not yet, a work   |
|          |                  | private   |        | in progress       |
+----------+------------------+-----------+--------+-------------------+
| ALB      |                  | They      | CHS    |                   |
| UQUERQUE |                  | contract  |        |                   |
|          |                  | out.      |        |                   |
|          |                  |           |        |                   |
|          |                  | Gallup    |        |                   |
|          |                  | City      |        |                   |
|          |                  | Hospital  |        |                   |
|          |                  | is a CHS  |        |                   |
|          |                  | site      |        |                   |
+----------+------------------+-----------+--------+-------------------+
| BEMIDJI  | ## *             | DEXA to   | Ins    | Routine as part   |
|          | *FC Potawatomi** | Rh        | urance | of annual exam or |
| BEMIDJI  |                  | inelander |        | gyn exam for all  |
|          | Heel             | or Antigo | CH     | post menopausal   |
|          | Densitometry     | hospitals | S/^rd^ | and high risk     |
|          |                  |           | party  | females or males  |
|          | ##               | Refer out |        | as needed         |
|          |  **Little River  |           | CH     |                   |
|          | Band of Ottawa** | Refer out | S/^rd^ | Routine as part   |
|          |                  |           | party  | of annual gyn     |
|          | No in-house      | Refer out |        |                   |
|          | screening        |           | CHS    | Screening for     |
|          |                  | No        | /3^rd^ | high risk         |
|          | ## **Menominee   |           | party  | patients          |
|          |  Tribal Clinic** | Refer     |        |                   |
|          |                  | out,      | No     | Screening during  |
|          | No in-house      | however,  |        | OB/Gyn visits     |
|          | screening        | these are | CHS    |                   |
|          |                  | a low     | /3^rd^ | Yes               |
|          | **St. Croix      | priority  | party  |                   |
|          | Tribal Health    | unless    |        | Bone density      |
|          | Dept.**          | the       | Pt.    | issues are        |
|          |                  | patient   | Pays   | considered as     |
|          | No in-house      | is felt   | or     | part of the       |
|          | screening        | to be at  | 3^rd^  | patient's         |
|          |                  | a very    | party  | work-up, however, |
|          | ## **Chicago     | high risk |        | clinicians don't  |
|          |  Urban Clinic**  |           | D      | screen for the    |
|          |                  | Refer out | epends | condition         |
|          | Yes, in-house    | for more  | upon   |                   |
|          | screening with   | screening | pay    | Screen at well    |
|          | Accudexa by      | dependent | source | woman exams       |
|          | Schick           | upon heel | for    | because of easy   |
|          | Technologies     | test      | each   | access to Sahara  |
|          |                  | score     | p      |                   |
|          | ## **Red Lak     |           | atient | Counsel with      |
|          | e Service Unit** | Refer out |        | patients about    |
|          |                  |           | CHS    | screening and     |
|          | No in-house      | Refer out | /3^rd^ | refer out for     |
|          |                  | for       | party  | testing           |
|          | ##               | complex   |        |                   |
|          |                  | cases     | CHS    | Yes, routine      |
|          | ##               | with      | for    | screening with    |
|          |                  | multiple  | high   | exams             |
|          | ## **Sault St    | issues    | risk   |                   |
|          | e. Marie Tribe** |           | pa     | Yes, screening    |
|          |                  | Refer out | tients | with routine      |
|          | Yes, Sahara Heel |           |        | visits            |
|          | Sonogram         |           | 3^rd^  |                   |
|          |                  |           | party  |                   |
|          | ### Fon Du Lac   |           |        |                   |
|          |                  |           |        |                   |
|          | No in-house      |           |        |                   |
|          |                  |           |        |                   |
|          | ## **Cass Lak    |           |        |                   |
|          | e Service Unit** |           |        |                   |
|          |                  |           |        |                   |
|          | Yes, a portable  |           |        |                   |
|          | Dexa once a      |           |        |                   |
|          | month            |           |        |                   |
|          |                  |           |        |                   |
|          | ## **White Eart  |           |        |                   |
|          | h Service Unit** |           |        |                   |
|          |                  |           |        |                   |
|          | Mobile DEXA      |           |        |                   |
|          | comes in once a  |           |        |                   |
|          | month            |           |        |                   |
|          |                  |           |        |                   |
|          | ## **Shakopee**  |           |        |                   |
|          |                  |           |        |                   |
|          | No in-house      |           |        |                   |
+----------+------------------+-----------+--------+-------------------+
| BILLINGS |                  | Refer out | CHS    |                   |
+----------+------------------+-----------+--------+-------------------+
| CA       | # No response    |           |        |                   |
| LIFORNIA |                  |           |        |                   |
+----------+------------------+-----------+--------+-------------------+
| N        | All health       |           |        |                   |
| ASHVILLE | centers are 638  |           |        |                   |
|          |                  |           |        |                   |
|          | Not know what is |           |        |                   |
|          | done             |           |        |                   |
+----------+------------------+-----------+--------+-------------------+
| NAVAJO   |                  | Refer out | CHS    |                   |
+----------+------------------+-----------+--------+-------------------+
| OKLAHOMA | # No response    |           |        |                   |
+----------+------------------+-----------+--------+-------------------+
| PHOENIX  | Phoenix Medical  |           |        |                   |
|          | Center uses      |           |        |                   |
|          | their CT scan    |           |        |                   |
|          | for testing      |           |        |                   |
+----------+------------------+-----------+--------+-------------------+
| PORTLAND | All health       |           |        |                   |
|          | centers are 638  |           |        |                   |
|          | or compacted     |           |        |                   |
+----------+------------------+-----------+--------+-------------------+
| TUSCON   | #                | Refer out | CHS    |                   |
|          |  Yes, in three s | for DEXA  | /3^rd^ |                   |
|          | ites, Omnisensor | screening | party  |                   |
+----------+------------------+-----------+--------+-------------------+

## DISCUSSION

The limitations of the data are considerable. First, not all American
Indian and Alaska Native people use Indian Health Service, tribal
clinics or urban Indian health programs. Second, not all of these health
care facilities use the RPMS data system.

These findings did not break down the requested diagnosis separately as
requested so the accumulated numbers are a total of all the diagnosis,
not just osteoporosis.

## CONCLUSIONS

These findings show that osteoporosis among American Indian and Alaska
Natives needs further investigation.

The NIWHRC recommends:

1.  A comprehensive comparison study of each Indian Health Service Area
    medical records to known RPMS statistics to give a clear picture of
    AI/AN Indian women 45 years of age and up with osteoporosis or the
    risk of development of osteoporosis.

2.  An audit of I/T/U contract health services to determine how much
    funding is spent on preventive bone mineral density testing or
    outside treatment and care of osteoporotic fractures.

3.  IHS to develop strategies to provide basic osteoporosis prevention
    standard of care in conjunction with the above national consensus
    benchmark recommendations.

4.  Provide In-Service training of Indian Health Service primary care
    providers on the early diagnosis and treatment of Osteoporosis.

5.  Provide each Area with the capability of bone density testing. DEXA
    is the gold standard for bone density testing.

6.  Develop extensive culturally appropriate health educational
    materials of osteoporosis risk factors, symptoms, and prevention or
    treatment.

7.  Develop strategies to help the Indian Health system begin to attain
    the national benchmark osteoporosis prevention standards described
    above.

8.  Follow these benchmark recommendations

Osteoporosis: Clinical Management Guidelines for
Obstetrician-Gynecologists, Number 50, January 2003
Obstetrics/Gynecology. 2004 Jan; 103(1):203-216

> [www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14704265&dopt=Abstract](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14704265&dopt=Abstract)
>
> **Level A**\
> The following are based on good and consistent scientific evidence

-   Treatment should be initiated to reduce fracture risk in
    postmenopausal\
    women who have experienced fragility or low impact fracture

-   Treatment should be instituted in those postmenopausal women with
    bone\
    mineral density T scores less than -2 by central DXA in the absence
    of risk factors and in women with T scores less then -1.5 in the
    presence of one or more risk factor

-   First line pharmacological options determined by the FDA to be safe
    and\
    effective for osteoporosis  prevention (biphosphonates \[alendronate
    and risedronate\], raloxifene and estrogen) should be  used

-   First line pharmacological options determined by the FDA to be safe
    and\
    effective for osteoporosis  treatment (biphosphonates \[alendronate
    and risedronate\], raloxifene, calcitonin, and PTH) should  be used

> **Level B**\
> The following are based on limited or inconsistent scientific evidence

-   Women should be counseled about the following preventive measures

-   Adequate calcium consumption, using dietary supplements if dietary
    sources are inadequate

-   Adequate Vitamin D consumption (400 - 800 IU daily) and the natural
    sources of this  nutrient

-   Regular weight bearing and muscle strengthening exercises to reduce
    falls,\
    and prevent fractures

-   Smoking cessation

-   Moderate alcohol intake

-   Fall prevention strategies

-   Bone mineral density testing should be recommended for all
    postmenopausal women aged 65  years or older

-   Bone mineral density testing may be recommended for postmenopausal
    women less than 65  years who have one or more risk factor for
    osteoporosis

-   Bone mineral density testing should be performed on all
    postmenopausal\
    women with fractures  to confirm the diagnosis of osteoporosis and
    determine disease severity

-   In the absence of new risk factors screening should not be performed
    more\
    frequently than every  2 years

> **Level C**
>
> The following recommendations are based primarily on consensus and
> expert\
> opinion

-   Women should be counseled on the risks of osteoporosis and related
    fragility\
    fractures.  Such counseling should be part of the annual
    gynecologic\
    examination

9.  Disseminate osteoporosis-screening strategies and prevention
    materials on the AI/AN OB/GYN Chief clinic consultant Corner online
    Newsletter and the OB/GYN Chief Clinic Consultant Corner digest in
    the HIS Primary Care Provider.

10. Disseminate osteoporosis screening strategies and prevention
    materials on the following Listserv(s): Maternal Child Health,
    Primary Care, Midwives, Advance Practice Nurses, Obstetric Nurse
    Manager, Physician Assistant, National Council of Clinical
    Directors.

11. Disseminate osteoporosis screening strategies and prevention
    materials on the NIWHRC website.

[REFERENCES:]{.underline}

1\. Bone density screening for osteoporosis. American College of
Obstetricians and Gynecologists. Obstetrics/Gynecology 2002;99:523--525

2\. Osteoporosis prevention, diagnosis, and therapy. NIH Consensus
Statement 2000; 17(1):1--36. Available at
[http://odp.od.nih.gov/consensus/cons/111/111_statement.pdf](../../../../../../../../cgi-shl/leaving.pl%3Fhttp://odp.od.nih.gov/consensus/cons/111/111_statement.pdf).

National Institutes of Health, Osteoporosis and Related Bone Diseases,
National Resource Center

3\. Risk Factors for osteoporosis in Alaska Native women: a
cross-sectional survey, Filner, JJ, Krohn KD, Lapidus JA, Becker TM

Alaska Med. 2002 Jan-Mar; 44 (1): 8-13, 21

4\. The effect of aging on bone mineral metabolism and bone mass in
Native women, Perry HM 3^rd^, Bernard M, Horowitz M, Miller DK, Fleming
S, Baker MZ, Flaherty J, Purushothaman R, Hajjar R, Kaiser FE, Patrick
P, Morley JE

5\. Prevention of Osteoporosis and Fractures, Ullom-Munich, Paul, MD,
MPH, University of Kansas School of Medicine, Wichita, Wichita, Kansas;
American Family Physician, Vol. 60, No. 1, July 1999

6\. Strong Heart Study -- National Heart, Lung and Blood Institute,
University of Oklahoma.

7\. Federal Agencies and Internet sites:

a.  National Institute of Arthritis, Musculoskeletal and Skin Diseases,
    National Institute of Health (NIAMS)
    [www.nih.gov](http://www.nih.gov/)

b.  National Institute of Diabetes and Digestive and Kidney Diseases
    (NIDDK)
    [http://digestive.niddk.nih.gov](http://digestive.niddk.nih.gov/)

c.  American Academy of Allergy, Asthma and Immunology

d.  Center for Disease Control and Prevention (CDC)
    [www.cdc.gov](http://www.cdc.gov/)

e.  Office on Women's Health (OWH)
    [www.4women.gov](http://www.4women.gov/)

f.  [www.healthfinder.gov](http://www.healthfinder.gov/)

g.  Indian Health Service (IHS) [www.ihs.gov](http://www.ihs.gov/)

h.  IHS Women's Health Mature Women: Osteoporosis

> [www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp](http://www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp)

i.  National Institutes of Health Osteoporosis and Related Bone Disease
    (ORBD)

j.  National Resource Center, National Osteoporosis Foundation (NOF)
    [www.nof.org](http://www.nof.org/)

k.  National Osteoporosis Society,
    [www.osteo.org](http://www.osteo.org/)

8\. Osteoporosis: Clinical Management Guidelines for
Obstetrician-Gynecologists,

Number 50, January 2003 Obstetrics/Gynecology. 2004 Jan; 103(1):203-216

[www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14704265&dopt=Abstract](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14704265&dopt=Abstract)

[ACKNOWLEDGEMENTS:]{.underline}

1\. Neil J. Murphy, MD, IHS OB/GYN Chief Clinical Consultant; Alaska
Area;

2\. N. Burton Attico, MD, retired from Indian Health Service and a
member of the Phoenix Area Elders Committee;

3\. Charles Rhodes, MD, Indian Health Service, Phoenix Area;

4\. Sandra Dodge, CNP, Indian Health Service, Crown Point, New Mexico

5\. Dee Ann DeRoin, MD, MPH