Patients with the three highs of "three minus three health, healthy companionship" should pay attention to the screening and early intervention of osteoporosis

With the continuous improvement of China's economic level and the advent of the era of population aging, China is facing the dual pressure
of population aging and the epidemic of metabolic diseases.
Among metabolic diseases, the number of "three highs" including diabetes (hyperglycemia), dyslipidemia (hyperlipidemia), and hypertension has reached hundreds of millions ^[1], which is the most common group of chronic diseases
in middle-aged and elderly people.
Since patients with "three highs" are prone to serious events such as myocardial infarction and stroke, it is particularly important
to strengthen the prevention of hypertension, hyperlipidemia and diabetes.

According to the latest China Cardiovascular Health and Disease Report 2021 released in 2022, the prevalence of hypertension, dyslipidemia is 43.
0%, diabetes is 11.
2%, and prediabetes is 35.
2% ^[1].

With the strengthening of health education, patients' awareness of the "three highs" has improved, but they are still not satisfied enough
.
In 2015, the awareness rates of hypertension, dyslipidemia and diabetes in adults over 18 years old in China were 51.
6%, 16.
1% and 36.
5% ^{respectively [4]}, and the improvement of the awareness rate of the "three highs" will also improve the treatment rate and control rate
of the "three highs" in China.

However, when "salt control, oil control and less sweets" has gradually become the common sense of prevention and control of "three highs", "one low" - low bone mass, a major chronic disease, is still ignored; How to stay away from the "one low", the public knows very little
.
According to the 2019 national survey, the low bone mass rate of people over 50 years old in China is 46.
4%, and osteoporosis is a more serious condition than low bone mass, and its prevalence is 19.
2%, of which 6.
0% is male and 32.
1% is female, which is significantly higher than that of European and American countries
.
With age, the prevalence of osteoporosis increases further and the risk of osteoporotic fractures increases
.
In contrast to the large proportion of cases, the awareness rate of osteoporosis patients over 50 years old is only 7.
0%, and only 3.
7%
of patients who have undergone bone density testing.
However, low bone mass and osteoporosis often do not have obvious manifestations, most people only find problems after pain, spinal deformation, and even fractures, and most people have missed the best prevention and treatment period
for low bone mass and osteoporosis.

From low bone mass to fragility fractures

Prefer the "three highs"

Low bone mass refers to a reduction of bone density by 1 to 2.
5 standard deviations compared with healthy adults of the same sex and race; osteoporosis
occurs when bone density decreases by ≥ 2.
5 standard deviations, that is, the T value in the bone density test result is ≤-2.
5.
A fragility fracture is a fracture
that occurs when the body is subjected to a slight external force.
Osteoporosis is severe if it is combined with one or more fragility fractures ^[3].

On the "point of no return" from low bone mass to fragility fractures, osteopenia caused by estrogen deficiency and aging are the main causes of osteoporosis; In addition, some other factors such as smoking, excessive drinking and other unhealthy lifestyles; Calcium and vitamin D deficiencies accelerate the development of
osteoporosis.
Patients with "three highs" are often accompanied by osteoporosis
.

Diabetes mellitus – both a risk factor for osteoporosis

It is also an accelerator of osteoporosis

In 2021, Taipei University published the first large-scale cohort study to explore the risk of diabetes and osteoporosis in Asian populations, and the results showed that the risk of osteoporosis in diabetics was 1.
37 times higher than that of the general population, and poor blood sugar control was positively correlated with the risk of osteoporosis ^[5].

Figure 1.
The Kaplan-Meier survival curve of osteoporosis patients with diabetes shows a significant reduction in the no-event ^rate5

Researchers believe that diabetes affects bone metabolism and damages bone microstructure through multiple mechanisms such as increased blood sugar, increased insulin levels, decreased kidney function, and increased urinary calcium excretion ^[5].

A large-scale systematic review published in 2020 showed that the comprehensive prevalence of osteoporosis in Chinese diabetic patients was 37.
8%, of which the prevalence of osteoporosis in women with diabetes (44.
8%) was much higher than that of men (37.
0%).
The prevalence of osteoporosis in patients over 60 years of age (40.
1%) was higher than that of children under 60 years of age (26.
5%); The prevalence of osteoporosis is higher in less developed regions than in developed regions (41.
0% vs.
32.
7%) ^[6].

High blood pressure –

Common comorbidities of osteoporosis

A study for middle-aged and elderly patients with chronic diseases published in China in 2022 showed that the prevalence of osteoporosis in hypertensive patients was significantly higher than that of ordinary control groups ^[7].

A large-scale meta-analysis of 28 independent studies showed that the risk of osteoporotic fractures in hypertensive patients was 1.
33 times higher than that of nonhypertensive patients (OR=1.
33, P<0.
001), and the association between hypertension and fracture risk in women (OR=1.
52) was higher than that in men (OR=1.
35) <b12>[8].

。 Classified by population, the results of the study in Asia are consistent with those in Europe, both suggesting that hypertension is associated with the risk of osteoporotic fractures, but it is not yet clear how hypertension leads to an increase in the incidence of osteoporosis and needs to be further clarified in future studies ^[8].

Dyslipidemia——

Osteoporosis is a difficult brother

It is well known that adipocytes and osteoblasts in human bones originate from common protocells - pluripotent stromal cells (MSCs)
in the bone marrow.
It can differentiate into a variety of cells including osteoblasts, chondrocytes, and adipocytes; There is a delicate dynamic balance between fat formation and bone formation ^[9].

A large number of epidemiological studies abroad have shown that lipid metabolism disorders, especially hyperlipidemia, may have a negative impact on bone status; Specifically, in the same individual, osteoporosis and lipid metabolism disorders often coexist, which is called comorbidity ^[9].

Currently, the number of studies on this comorbidity in Chinese groups is limited
.
In one large community-based cross-sectional study, there was a significant negative correlation between serum cholesterol, triglycerides, and LDL levels in Chinese populations, LDL-to-HDL ratios, and whole-body bone mineral content ^[9].

In the context of the aging of the Chinese population, the proportion of middle-aged and elderly people with obesity and lipid abnormalities has increased significantly, which may further affect
the prevalence of osteoporosis.
The correlation between lipid metabolism disorders and osteoporosis in Chinese groups and how hyperlipidemia leads to an increase in the incidence of osteoporosis is worthy of further in-depth study in the future ^[9].

Calcium + Vitamin D –

It is an essential nutrient for "three highs and one low" patients

When the "three highs" population is complicated by low bone mass and osteoporosis, comprehensive management measures including lifestyle intervention, control of the "three highs" primary disease and anti-osteoporosis treatment are important means to
manage patients with "three highs" and osteoporosis.
Calcium and vitamins are essential supplements for
bone health.
Adequate calcium intake is beneficial for optimal bone peaks, slowing bone loss, improving bone mineralization and maintaining bone health; Vitamin D deficiency can occur, decreased intestinal calcium absorption, poor bone mineralization, impaired muscle strength and balance, and increased risk of falls, and correcting vitamin D deficiency can improve to avoid these conditions ^[3].

The Chinese Expert Consensus on Fracture Risk Management in Diabetic Patients points out that "diabetics should change their lifestyle, exercise moderately, eat a balanced diet, and supplement enough calcium and vitamin D" ^[10].

The Guidelines for the Diagnosis and Treatment of Primary Osteoporosis formulated by the Osteoporosis and Bone Mineral Salt Disease Branch of the Chinese Medical Association in 2017 recommend that "adequate calcium intake through diet should be obtained as much as possible; When dietary calcium intake is insufficient, calcium supplements can be given ^[3]"
.

According to the latest "Cohort Study on Changes in the Nutritional Status of Chinese Residents" released by the Chinese Center for Disease Control and Prevention, the daily dietary intake of elemental calcium for Chinese residents is less than 400 mg ^[11].

The dietary guidelines for Chinese residents recommend a daily calcium intake of 800-1000 mg for adults and the elderly; According to the difference between the two, it is recommended to supplement about 500~600 mg
of elemental calcium every day.
The recommended daily intake of vitamin D for adults is 400 IU; Elderly people aged 65 and over due to lack of sunlight and reduced absorption capacity of vitamin D intake, the recommended daily intake is 600 IU; The tolerable maximum intake is 2000 international ^{per day [12].}

When vitamin D is used for the prevention and treatment of osteoporosis, the daily dose can be 800-1200 international ^[3], and in fact, for some people who receive very little sun exposure, the supplement dose of this vitamin D is not enough, and the dose needs to be appropriately increased, and the daily dose can reach 2000 international
.
Because each person is individual, the amount of supplementation can be individualized based on the baseline serum level of 25 hydroxyvitamin D ^[13].

"Three minus three health"

Achieving "Healthy China 2030"

In order to implement the specific requirements of the "Healthy China 2030" planning outline, the National Health Commission has jointly launched the "three minus three health" national healthy lifestyle action
in conjunction with multiple departments.
In addition to "reducing salt, oil and sugar", "healthy bones" is one of the "three health" special actions ^[2].

Given the comorbidities of diabetes, hypertension and dyslipidemia and osteoporosis, "healthy bones" are particularly important
.

Every year, World Osteoporosis Day and other health promotion days such as World Osteoporosis Day are used as an opportunity to promote convenient and fast self-screening tools such as the Asian Osteoporosis Self-Screening Tool (OSTA) Index and the International Osteoporosis Foundation (IOF) 1-minute Osteoporosis Test Questions to middle-aged and elderly residents.
Popularize the core knowledge of osteoporosis prevention and treatment, and actively advocate residents to develop a healthy lifestyle
such as balanced diet, moderate exercise, quitting smoking and limiting alcohol, and getting more sun.
Primary hospitals and physical examination centers should take bone density detection and quantitative ultrasound as routine physical examination items for people at risk of osteoporosis ^[3]; Endocrinology, geriatrics and other doctors must pay attention to the "three high" patients, which are at high risk of osteoporosis; In addition to paying attention to the patient's blood sugar and blood lipids, they should also take bone density and quantitative ultrasound as their own "conventional weapons", so as to master the patient's bone health, and know the patient's blood sugar, blood lipids, and blood pressure ^[5].

Three minus three health, health accompaniment

As long as every "three high" patient raises health awareness and everyone is the first responsible person for their own health, we will be able to contribute to the construction of a healthy China
.

References:

1. Overview of China Cardiovascular Health and Disease Report 2021[J].
   Chinese Journal of Cardiovascular Diseases, 2022,20(7):20.
   )

2. Epidemiological investigation of osteoporosis in China and release of results of the special action of "healthy bones"[J].
   Chinese Journal of Osteoporosis and Bone Mineral Salt Diseases, 2019(4).
   

3. Guidelines for diagnosis and treatment of primary osteoporosis(2017)[J].
   Chinese Journal of Practical Internal Medicine,2018,038(2):127-150.
   )

4. Guidelines for the prevention and treatment of type 2 diabetes mellitus in China (2020 edition)[J].
   Chinese Journal of Diabetes, 2021, 13(4):95.
   

5. Association between type 2 diabetes and osteoporosis risk: A representative cohort study in Taiwan.
   PLoS One.
   2021 Jul 13; 16(7):e0254451.
   

6. Prevalence of osteoporosis in patients with type 2 diabetes mellitus in the Chinese mainland: A protocol of systematic review and meta-analysis.
   Medicine (Baltimore).
   2020 Apr; 99(16):e19762.
   

7. Analysis of the prevalence, risk factors, and clinical characteristics of osteoporosis in patients with essential hypertension.
   BMC Endocr Disord.
   2022 Jun 27; 22(1):165

8. Meta-analysis of hypertension and osteoporotic fracture risk in women and men.
   Osteoporos Int.
   2017 Aug; 28(8):2309-2318.
   

9. Lipid metabolism disorders and bone dysfunction--interrelated and mutually regulated (review).
   Mol Med Rep.
   2015 Jul; 12(1):783-94.
   

10. Chinese expert consensus on fracture risk management in diabetic patients[J].
    Chinese Journal of Endocrinology and Metabolism, 2019(7):535-547.
    

11. Energy and main nutrient intake of Chinese residents from 2015 to 2017[J].
    Food and Nutrition in China,2021,27(4):5-10.
    )

12. Holick MF: Vitamin D deficiency.
    N Engl J Med 2007,

13. Xie Zhongjian: How much vitamin D do I need to supplement to maintain bone health?.
    Chinese Journal of Endocrinology and Metabolism 2020,36(10):828-831.
    

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Typesetting: Yang Ruijing

Editor: Yang Ruijing

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