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2020. Volume 9. Issue 4 (December). Article CID e0412 DOI: 10.15275/rusomj.2020.0412_
Endocrinology and Metabolism
Original article
Metabolic syndrome in Saudi women with low bone mineral density
Essra Aldawood 1, Mubashir Zafar 2
1 Primary Health Care Centre, Ministry of Health, Al-Jubail, Saudi Arabia 2 University of Hail, Hail, Saudi Arabia
Received 2 April 2020, Accepted 6 October 2020
© 2020, Aldawood E., Zafar M. © 2020, Russian Open Medical Journal
Abstract: Background — Metabolic syndrome (MetS) is the world's major public health problem.
Objectives — Assessment of metabolic syndrome impact on bone mineral density (BMD) among Saudi menopausal women in Eastern Province - Saudi Arabia.
Material and Methods — It's a case control study and 380 menopausal Saudi women were selected through stratified random sampling; they are divided into 190 cases with osteoporosis and 190 without osteoporosis. BMD at the total hip were determined using dual-energy X-ray absorptiometry (DEXA). The T score was calculated, the relationship between the risk factors of MetS and bone mineral density were analyzed by statistical methods.
Results — Prevalence of MetS was substantially higher among osteoprotic women. The MetS is significantly correlated with bone mineral density (r=0.08, P=0.05). The occurrence of MetS was associated with increased osteoporosis among Saudi women (B=0.004; 0.05) after adjustment of confounders. The presence of obesity (component of MetS) was significantly associated with increased odds of Bone marrow density among women (OR 2.56, 95% CI, 2.22-3.44, P=0.030) after adjustment of confounders. Conclusion — MetS was significantly associated with an osteoporosis in Saudi women.
Keywords: bone mineral density, menopausal women, metabolic syndrome, osteoporosis.
Cite as Aldawood E, Zafar M. The relationship between metabolic syndrome and bone mineral density among menopausal Saudi women: case control study. Russian Open Medical Journal 2020; 9: e0412.
Correspondence to Mubashir Zafar. E-mail: [email protected].
Introduction
The prevalence of metabolic syndrome (MetS) is expanding at an alarming rate in developed and developing nations throughout the world [1]. MetS is a cluster of the most dangerous heart attack risk factors including raised fasting plasma glucose, abdominal obesity, high cholesterol and high blood pressure [2]. Epidemiologic researches indicate that metabolic syndrome is a major risk factor for various number of chronic diseases mainly cardiovascular disease and type II diabetes [3]. According to the International Diabetes Federation (IDF) it is estimated to have MetS in around 20-25% of the world's adult population and are twice as probable to die from and three times as likely to have a heart attack or stroke compared to individuals without the syndrome [3]. A survey published in 2018 shows that the prevalence of MetS in Saudi Arabia was found to be 39.8% (34.4% in men and 29.2% in women) and 31.6% (45.0% in men and 35.4% in women), according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) and IDF criteria, respectively [4]. Moreover, per International Osteoporosis Foundation (IOF), osteoporosis affects an estimated 200 million people worldwide which is responsible for more than 8.9 million fractures yearly, resulting in an osteoporotic fracture every 3 seconds.
The high prevalence for both diseases prompts a need to understand the relationship between the two conditions. Epidemiological studies achieve inconclusive outcomes on the relationship between bone health and MetS, whereby this relationship is beneficial, adverse or non-significant [5]. conducted a cross-sectional study to determine the association among menopausal Korean women between risk factors of MetS and bone mineral density (BMD). The findings showed that MetS risk factors did not differ significantly, while waist circumference showed a significant association with body surface area (BSA) (r=-0.242, P<0.001), BSA (r=0.186, P<0.01) and bone mineral content (BMC) (r=0.161, P<0.05) correlated significantly with diastolic blood pressure in correlation test. This result was similar to a cross sectional study conducted by [6] that included 2007 participants (1045 males and 962 females) over 50 years of age who were examined by a preventive examination agency in urban Taiwan to examine the link between MetS and osteoporosis among Taiwanese middle-aged and elderly participants. A population-based survey in China consisting of 9930 Chinese adolescents aged 40 years or older in the district of Chongming, Shanghai was performed to assess the connection between MetS and osteoporotic fracture between middle-aged and elderly Chinese [7].
2020. Volume 9. Issue 4 (December). Article CID e0412 DOI: 10.15275/rusomj.2020.0412_
Endocrinology and Metabolism
Although MetS and osteoporosis were earlier thought to be two unrelated diseases, latest studies have shown that both conditions share several genetic, nutritional and hormonal factors [8]. While the relationship between cardiovascular disease and osteoporosis has been widely studied, the specific association between MetS, a powerful risk factor for cardiovascular disease, and osteoporosis has not been discussed so extensively and several studies have shown inconsistent outcomes [9-15].
The prevalence of metabolic syndrome has increased in Saudi Arabia, forcing such a need to determine the causal factors that led MetS among aged population. Life expectancy also rises, which raises Saudi women's risk of osteoporosis. Only limited studies have focused on explaining the relationship between MetS and BMD in Saudi Arabia, these studies cover all populations including expatriated which did not determine the actual problem among Saudi women. Also, these studies are cross sectional studies which did not determine the temporality (causal association). This research will also be the first case-control study undertaken in Saudi Arabia in order to determine a possible causal relationship between the two conditions. Furthermore, only Saudi females will be included as survey respondents estimating the real issue among Saudi women.
Objectives: The aim of this study is to determine the relationship between MetS and BMD among Saudi menopausal women in Eastern Province - Saudi Arabia.
Table 1. Socio-demographic characteristics of study participants (n=380)
Sr. No Characteristics Cases (n=190) Control (n=190) P-value
1 Age, years 65.45±7.24 62.15±7.12
2 Age categories 45-60 years 61-75 years 59 (36.1%) 131 (56.3%) 59 (63.9%%) 131 (43.7%) <0.001
3 Age at menopause, years 51.70±4.97 51.35±3.94
4 Marital status
Single Married Widowed& Divorced 8 (46.7%%) 141 (48.6%) 41 (55.4%) 8 (53.3%%) 141(51.4%%) 41 (44.6%) 0.530
5 Education level
Illiterate Intermediate 76 (53.3%%) 67 (50%%) 76(46.7%%) 67(50%%) 0.423
High School& University 47 (44.7%) 47(55.3%)
6 Occupation Housewife Employed 173 (51%%) 17 (40%) 173 (49%%) 17 (60%) 0.214
7 Exposure to Sunlight <1 time >1 time 110 (51.6%%) 80 (47.8%) 110 (48.4%%) 80 (52.2%) 0.467
8 Veil Type Covering hair only Eyes shown only Full cover 20 (53.8%%) 108 (49.3%%) 62 (50%) 20 (46.2%%) 108 (50.7%%) 62 (50%) 0.873
9 Physical Activity <1 time 1-2 times 85 (57.9%%) 66 (41.7%%) 85 (42.1%%) 66 (58.3%%) 0.016
>3 times 39 (46.8%) 39 (53.2%)
10 Smoking Never smoke Ever smoke 103(49.5%%) 87 (50.6%) 103 (50.5%%) 87 (49.4%) 0.837
11 Family History of Met Yes No 145 (51.4%%) 45 (45.6%%) 145 (48.6%%) 45 (54.4%%) 0.334
Data are given as the mean ± SD or as the number of subjects with percentages given in parentheses, as appropriate. Categorical data were compared by x2 test. BMD, bone mineral density.
Material and Methods
Study setting and participants
Study setting: The study was conducted at Safwa General Hospital, one of the Eastern Province's main government facilities consisting of nearly 30 beds and serving approximately 150-200 patients daily in the outpatient departments (OPD). And also, patients were included from one of the biggest primary healthcare centers in Qatif that serve about 80-100 patients daily.
Study participants: All menopausal women (age 45-75 years old) who had got BMD scans by Dual-Energy X-ray Absorptiometry (DEXA) and were diagnosed as osteoporotic as cases and without osteoporotic as control by their physicians who visits the hospital for regular checkup
Menopausal status is defined as cessation of menstruation for at least 1 year.
Study design
It is a case control study.
For cases: Inclusion criteria: all menopausal women age (45-75 years old) who in their general physician visits had been advised of a bone mineral density (BMD) scan owing to their being at risk associated with bone loss and were diagnosed with osteoporosis with MetS. Exclusion criteria: perimenopausal women, participants with liver or renal diseases, inflammatory diseases, vascular diseases or with evident endocrine disorders or drug treatment with possible effect on bone metabolism like bisphosphonate, or estrogen replacement therapy.
For controls: Inclusion criteria: all menopausal women age (4575 years old) who were free of osteoporosis with MetS Exclusion criteria: perimenopausal women, being above 75 years of age or on estrogen replacement therapy. Hormonal replacement therapy is defined as the therapeutic use of hormones typically to increase diminished levels in the body.
Sample size and sampling technique
Sample size: Sample size was calculated by WHO sample size calculator for health studies based on 95% confidence level, relative precision 0.25, probability to exposure given to disease 0.6, probability to exposure given to no disease 0.4 and anticipated Odd Ratio is 1.5, the sample size is 380 for this study. Divide the sample size as 190 participants for cases and 190 for control and participants were selected through stratified random sampling.
Data collection tool and technique
Structured questionnaire was used. The questionnaire is divided into four section first sociodemographic characteristic including smoking habit, physical exercise, exposure to sunlight and family history of MetS, anthropometric measurement, Biochemical measurement including FBG, RBG, lipid profile and DEXA measurement.
Anthropometry, blood sample and analysis
Height and weight were measured using an automatic anthropometer in participants wearing light clothing and no shoes. Body mass index (BMI) was calculated as body weight (in kilograms) divided by height (in meters squared) and then
2020. Volume 9. Issue 4 (December). Article CID e0412 DOI: 10.15275/rusomj.2020.0412_
Endocrinology and Metabolism
classified according to WHO classes: Normal (18.50-24.99 kg/m ), Overweight (25.00-29.99 kg/m2) , Obese (>30 kg/m2), The waist circumference was measured at the midpoint between the lowest rib and the upper iliac crest using a tape measure on exhalation.
Blood pressure was measured using an automatic blood pressure monitor after resting for 10 minutes in a sitting position before measurement as the average of 2 consecutive measurements after at least 5 minutes of sitting.
Blood sample after 8-12 hours fasting was collected for the measurement of fasting blood sugar, high density lipoprotein cholesterol, and triglycerides.
Criteria for diagnosis of metabolic syndrome
Participants were diagnosed with MetS using the criteria set in the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) which states MetS being present if at least three of the following five components are present.
1. Central obesity: waist circumference (WC) >102 cm (males), >88 cm (females).
2. Hyperglycemia: fasting blood sugar (FBS) >100 mg/dl
3. Hypertriglyceridemia: serum triglycerides (TG) >150 mg/dl
4. Serum HDL-cholesterol (HDL-C) <50 mg/dl
5. Systolic blood pressure (SBP) >130mmHg and/or diastolic blood pressure (DBP) >85 mmHg.
Criteria for diagnosis of osteoporosis
The bone mineral density of the total hip were measured using dual-energy X-ray absorptiometry (DEXA). The T score was calculated, and the diagnosis of osteoporosis were made according to the World Health Organization (WHO) criteria
• T-score between -1 and -2.5 is indicative of osteopenia
• T-score of -2.5 and below reflects osteoporosis
• T-score of -1 and above is considered normal T-Score Tertiles
• Data were divided into T-score tertiles with tertile1 having the lowest T-score and tertile 3 having the highest T-score.
Ethical consideration
Ethical approval were obtained from Imam Abdulrahman Bin Faisal University Research Ethical Review Board. Permission were taken from the hospital. Informed consent were obtained from all subjects who agree to participate in the study before the interview. Participation is voluntary, and participants are free to withdraw at any time without any explanation. The confidentiality and privacy of the subjects were maintained and there were no financial benefit to either the subjects or the researcher.
Statistical analysis
All Statistical analysis were performed with SPSS windows version 23. Continuous data were presented as mean ± standard deviation (SD). Statistical significance between the groups were evaluated using Students t-test while categorical data were compared by Chi square test. Correlation between MetS and BMD were determined by Pearson's correlation test. A Confident Interval (CI) of 95% and a P-value of less than 0.05 (two-sided) was consider statistically significant. Multinomial logistic regression
were performed using the T-score tertile as a dependent variable (with lowest tertile as reference) and full MetS or its individual components (present vs. absent) as independent variables. Different models were formed with model "a" as univariate, and all other models were adjusted accordingly for + age (model "b"), + BMI (model "c"), + other components of MetS (model "d") and + risk factors associated with bone loss like type II diabetes mellitus.
Results
Table 1 shows the socio-demographic characteristics of study participants. The mean age of all subjects is 63.8±7.1 years. The data shows a statistically significant difference in age categories between women with osteoporosis compared to their counterparts, i.e. those with osteoporosis are older (P<0.001).
There is no statistical significance in baseline characteristics between all participants except for physical activity. Physical inactivity is more prevalent among women with osteoporosis than those without osteoporosis (57.9% vs. 42.1, P=0.016). Whereas more women without osteoporosis are exercising 1-2 times per week more than their counterparts with osteoporosis (58.3% vs. 41.7%, P<0.05).
Table 2. Anthropometric and biochemical characteristics of participants (n=380)
study
Sr. No Characteristics Control (n=190) Cases (n=190) P-value
1 Mean height, cm 153.20±9.57 155.46±7.08 -
2 Mean Weight, kg 69.71±16.76 78.05±16.86 -
3 Mean WC, cm
Normal (WC<88cm) Obese (WC >88cm) 43 (58.1%) 147 (47.6%) 43 (41.9%) 147 (52.4%) 0.086
4 BMI, kg/mr 31.26±22.33 32.15±6.37 -
5 BMI class
Normal 30 (67.2%) 31 (32.8%)
Under weight Overweight Obese 2 (100°%) 61 (52.8%) 97 (42%) 0 62(47.2%) 97 (58%) 0.001
6 Mean SBP, mmHg
Normal (<130mmHg) High (> 130mmHg) 154 (50.2%) 36 (49.3%) 154 (49.8%) 36 (50.7%) 0.896
7 Mean DBP, mmHg
Normal (<85mmHg) High) > 85mmHg) 44 (51.7%) 146(49.5%) 44 (48.3%) 146 (50.5%) 0.714
8 Level of triglyceride (TG)
Normal (< 90 mg/dl) Borderline (90-129 mg/dl) High (>129 mg/dl) 78 (41%) 54 (40.4%) 58(71.3%) 78 (59%) 54 (59.6%) 58 (28.7%) 0.000
9 Level of high-density lipoprotein (HDL) Normal (> 45 mg/dl) 129 (43%) Borderline (40- 45 mg/dl) 29 (64.9%%) 129 (57%) 29 (35.1%) 0.000
Low (< 40 mmol/L) 32 (64.6%) 32 (35.4%)
10 Fasting blood sugar Normal (< 100 mg/dl) 41 (50.6%) 41 (49.5%)
Borderline (100-125 mg/dl) 79 (51.9%) 79(48.1%) 0.744
High >125 mg/dl) 70 (47.5%) 70 (52.5%)
11 T-score
T1 (Lowest) 50 (100%) 50 (0%)
T2 T3 (Highest) 93 (47.8%) 47 (0%) 93 (52.2%) 47 (100%) 0.000
Data are given as the mean ± SD or as the number of subjects with percentages given in parentheses, as appropriate. Categorical data were compared by x2 test. WHO criteria: a T-score between -1 and -2.5 is indicative of osteopenia, while a T-score of -2.5 and below reflects osteoporosis; a T-score of -1 and above is considered normal.
2020. Volume 9. Issue 4 (December). Article CID e0412 DOI: 10.15275/rusomj.2020.0412_
Endocrinology and Metabolism
Table 3 Prevalence of metabolic syndrome (MetS) components in tertile of T-score (n=380)_
Sr. Components of Cases (n=190j Control (n=190j
no Metabolic Syndrome T1 T2 P-value T2 T3 P-value
1 Obesity 50.7% 42.5%% 0.340 53.2%% 64.8% 0.211
2 Hyperglycemia 52.5% 47.5% 0.675 49.7% 50.3%% 0.357
3 Low HDL level 55.3% 44.7% 0.372 54.7% 45.3%% 0.403
4 Hypertension
Systolic (SPB) 55.2%% 44.8%% 0.318 47.3% 52.7% 0.052
Diastolic (DPB) 44.4%% 55.6% 0.245 48.6% 51.4% 0.744
5 Hypertriglyceridemia 57.5% 46.8% 0.340 54.5%% 45.5%% 0.727
Categorical data were compared by x2 test. WHO criteria: a T-score between -1 and -2.5 is indicative of osteopenia, while a T-score of -2.5 and below reflects osteoporosis; a T-score of -1 and above is considered normal. P-value <0.05 significant.
Table 4 Correlation between bone mineral density and features of the metabolic syndrome in 380 postmenopausal women
Sr.No Variables BMD cases BMD controls
T score T score
r (P-value) r (P-value)
1 WC, cm 0.082 (0.050) -0.091 (0.213)
2 SBP, mmHg -0.072 (0.320) 0.141 (0.052)
3 DBP, mmHg 0.084 (0.247) 0.024 (0.746)
4 FBS, mmol/L 0.030 (0.677) 0.067 (0.360)
5 TG, mmol/L -0.069 (0.342) -0.025 (0.729)
6 HDL, mmol/L -0.065 (0.375) -0.061 (0.406)
Pearson correlations. WC, waist circumference; SBP, systolic blood pressure; DBP, diastolic blood pressure; FBG, fasting blood glucose; TG, triglycerides; HDL-C, high-density lipoprotein cholesterol.
Table 2 shows the difference in anthropometric and biochemical parameters of all participants. Women with higher BMI have significantly less cases of osteoporosis compared to their counterparts (58% vs. 42%, P=0.001). In addition, participants with higher Serum TG have significantly higher cases of osteoporosis compared with their counterparts (P<0.001). Moreover, women with lower mean levels of HDL-C have significantly less cases of osteoporosis compared to their counterparts (P<0.001).
Table 3 shows the prevalence of MetS in participants with tertile according to the T-score (L1-L4 spine). The lowest T-score (least BMD represents the tertile 1 and the highest T-score represents the tertile 3. The prevalence of the five components is more or less similar in different tertiles of T-score and this is seen in both groups. The data does not show significant statistical difference in either groups.
Table 4 shows the results of the correlation between MetS and BMD in both groups. A very weak negative correlation was observed between BMD and SBP (r=-0.072), TG (r=-0.069) and HDL (R=-0.065) in women with osteoporosis , and between BMD and WC (r=-0.091), TG (r=-0.025) and HDL (r=-0.061) in their control counterparts. No statistical significance was found in either group (P-value >0.05).
Table 5 shows the association of socio-demographic characteristics with osteoporosis. All the socio-demographic characteristics were associated of osteoporosis but none of them were statistically significant.
Table 5 Associations of osteoporosis with metabolic syndrome other risk factors among women in Dammam
Risk Factors Cases (n=190) N, % Control (n=190) N, % Unadjusted risk Estimate OR (95% CI) P-value Adjusted Risk Estimate OR (95% CI) P-value
Age 45-60 years 61-75 years 59.5 (36.1%) 130.5 (56.3%) 76 (40%) 114 (60%) 0.439 (0.281-0.686) 0b 0.000 0b 0.128 (0.050-.327) 0b 0.000 0b
BMI Normal Overweight Obese 44 (23.2%) 65 (34.2%) 81 (42.6%) 20 (10.5%) 58 (30.5%) 112 (58.9%) 0b 0.509 (0.270-0.962) 1.329 (1.180-1.600) 0b 0.038 0.000 0b 1.087 (0.398-2.964) 2.569 (2.224-3.445) 0b 0.871 0.030
Marital status Single Married Widowed 7 (3.7%) 137 (72.1%) 46 (24.2%) 8 (4.2%) 145 (76.3%) 37 (19.5%) 0.704 (0.234-2.120) 0.760 (0.465-1.243) 0b 0.532 0.274 0b 0.400 (0.059-2.716) 0.797 (0.355-1.789) 0b 0.348 0.582 0b
Education Illiterate Intermediate University 81 (42.6%) 67 (35.3%) 42 (22.1%) 71 (37.4%) 67 (35.3%) 52 (27.4%) 1.412 (0.843-2.368) 1.238 (0.729-2.102) 0b 0.190 0.429 0b 0.702 (0.222-2.227) 0.865 (0.306-2.447) 0b 0.548 0.785 0b
Occupation Employed Unemployed 14 (7.4%) 176 (92.6%) 21 (11.1%) 169 (88.9%) 0b 1.562 (0.769-3.172) 0b 0.217 0b 1.686(0.345-8.228) 0b 0.519
Veil type Hair only Eyes shown Full cover 21 (11.1%) 107 (56.3%) 62 (32.6%) 18 (9.5%) 110 (57.9%) 62 (32.6%) 0b 0.834 (0.421-1.652) 0.857(0.417-1.763) 0b 0.602 0.675 0b 0.713 (0.214-2.372) 0.348 (0.097-1.248) 0b 0.581 0.105
Physical activity < ltime 1-2 times >3 times 99 (52.1%) 55 (28.9%) 36 (18.9%) 72 (37.9%) 77 (40.5%) 41 (21.6%) 1.566 (0.912-2.690) 0.813 (0.462-1.432) 0b 0.104 0.475 0b 1.041 (0.358-3.027) 0.685 (0.236-1.988) 0b 0.941 0.487 0b
Smoking Ever Never 88 (46.3%) 102 (53.7%) 86 (45.3%) 104 (54.7%) 1.043 (0.697-1.562) 0b 0.837 0b 0.541 (0.265-1.108) 0b 0.093 0b
Odds ratio with 95% confidence interval. BMI, body mass index. The reference category is: T1. b: this parameter is reference category.
2020. Volume 9. Issue 4 (December). Article CID e0412 DOI: 10.15275/rusomj.2020.0412_
Table 6 Multiple regression analysis of the effect of metabolic syndrome risk factors on T-score
Risk Factors B SE ß p-value
WC 0.000 0.002 0.014 0.78
SBP 0.001 0.005 -0.014 0.05
DBP 0.006 0.008 0.043 0.44
TG 0.004 0.001 -0.194 0.00
HDL 0.002 0.005 0.019 0.72
FBS 0.001 0.002 0.023 0.66
B, unstandardized beta; SE, standard error; p, standardized beta; WC, waist circumference; SBP, systolic blood pressure; DBP, diastolic blood pressure; TG, triglyceride; HDL-C, high density lipoprotein cholesterol; FBS, fasting blood sugar.
Table 6 shows the association of metabolic syndrome characteristics with osteoporosis in multiple regression analysis. Triglyceride is the only component of metabolic syndrome were statically significant associated with osteoporosis. Every unit change of triglycerides the -0.004 unit decreased in the osteoporosis.
Discussion
The study results revealed osteoporosis was significantly associated with a metabolic syndrome in Saudi women. This association was unbiassed of other covariates.
Metabolic syndrome (MetS) is a group of cardiovascular hazards which have been clustered under one umbrella because they exist together much more often than would be expected by probability. This result is consistent with other studies results [1618]. Moreover, some universal mechanisms for both illnesses have been related. For example, low HDL levels are considered preemptive risk factors for osteoporosis, and it also have been suggested to progress of MetS [19-22].
This study results found that metabolic syndrome components prevalence was more in osteoporosis patients compare to non-osteoporosis patients. These results were consistent with other studies results, previous studies have revealed that higher blood pressure in osteoporosis patients with increased chance of bone loss [23]. Furthermore, low HDL level was observed among those who have osteoporosis [24]. Case control study was conducted, result found that high blood pressure was major contributor to bone loss [25]. other components of MetS is TG level, our study found that high level in osteoporosis patients and definitely, TG level increase with age.
This study also found that WC and obesity is strongly associated with MetS. This result consistent with other study results. Even Though the pathophysiological systems connecting obesity to osteoporotic fracture have not been well recognized, it is plausible to consider disproportionate growth of visceral fat could affect in a higher emission of proinflammatory cytokines, with a harmful outcome on bone [26-28].
Physical activity was also associated with osteoporosis in this study results. This results contrast of other study results. Previous study found that those who have more physical active was less chance of osteoporosis fracture [29]. The reason for this conclusion is the when person more active which increased the bone mineral replacement and good for health.
The study results also found that those women who cover the body had more association of osteoporosis. The reason for this
Endocrinology and Metabolism
association is that sunlight is important predictor for bone mineral. This result is consistent with other study results [30-31].
This study had few limitations. First, this study recruited only two centres, therefore it is difficult to generalize the findings to women. Second, ages of the study subjects were limited to those in their 75s, results for oldest post-menopausal women were not analyzed. Third, bone-metabolism-associated factors such as vitamin D, blood levels of calcium, eating behavior, smoking, alcohol consumption all of which may affect BMD of menopausal women, were not examined in this study, which may confound the explanation of the results of this study.
Conclusion
This study found that presence of MetS was significantly associated with osteoporosis Saudi women. Further experimental studies were needed to generating the strong evidence.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Declaration of Helsinki and its later amendments, or comparable ethical standards.
Conflict of interest
None declared.
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Authors:
Essra Aldawood - BDS, MPH, Dental Surgeon, Primary Health Care Centre, Ministry of Health, Al-Jubail, Saudi Arabia. https://orcid.org/0000-0002-8697-6463.
Mubashir Zafar - MBBS, MBA, FCPS, Assistant Professor, Family and Community Medicine Department, College of Medicine, University of Hail, Hail, Saudi Arabia. https://orcid.org/0000-0002-7440-0635.
