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Original Research (Original Article)
IJMDC. 2020; 4(3): 600-604

Abdulla Falah Al Otaibi et al, 2020;4(3):600–604.

International Journal of Medicine in Developing Countries

## Determination of physical activity levels in elderly patients with osteoporosis, at Security Forces Hospital in Riyadh, Saudi Arabia

### Abdulla Falah Al Otaibi1, Abdullah Nasser Algadaan1, Ahmed A. Aziz Hashim S. Alhashim1*, Deema Ibrahim Altamimi1, Khaled Abdulaziz Alanazi1, Majed Mutlaq Aldawish1, Mohammed Shabeeb M. Alhagbani1, Saad Abdullah T. Alharbi1, Suliman Faris Alrfdi1, Turki Fahad A. Alshahrani1

Correspondence to: Ahmed A. Aziz Hashim S. Alhashim

*Arabian Gulf University, Bahrain.

Email: i__A7md [at] outlook.com

Full list of author information is available at the end of the article.

Received: 25 December 2019 | Accepted: 09 January 2020

## ABSTRACT

### Background:

Worldwide, osteoporosis causes more than 8.9 million fractures annually and it takes a huge personal and economic toll on health care systems. Physical activity is one of the risk factors that can lead to osteoporosis. Therefore, we aimed to determine the relationship between physical inactivity and its effect on bone mineral density (BMD) among elderly patients at Security Forces Hospital, Kingdom of Saudi Arabia.

### Methodology:

A descriptive cross-sectional study was conducted in Security Forces Hospital in Riyadh during August of 2015. We selected 109 elderly patients (age > 60), who were diagnosed with osteoporosis and recorded BMD levels at the hospital. Data were collected from patient files and interviews. The research members collected data through a questionnaire by interviewing the patients after obtaining their BMD levels. Data were analyzed with Statistical package for social sciences program version 16.0.

### Results:

Approximately, 42 of the selected patients (28.9 %) had the most severe form of osteoporosis (BMD-3) and all of them were physically active. Only 23 of the patients (21.3%) were moderately active and had a less severe form of osteoporosis (BMD levels were –2.4 or “osteopenia” (p ≤ 0.001) which indicated that there was a significant statistical relationship between physical inactivity and osteoporosis.

### Conclusion:

The study found a significant relationship between physical inactivity and the severity of osteoporosis; the physically inactive patients had very low BMD levels, on the other hand, the physically active patient had a better level of BMD.

### Keywords:

Bone mineral density, Osteopenia, physical inactivity, General Practice Physical Activity Questionnaire.

## Introduction

Osteoporosis is considered as a specific type of disease that belonging to the skeletal system and could be identified by low the mass of the bone and microarchitectural deterioration of bone tissue, the reduced bone density leads to decreased mechanical strength, thus making the skeleton more likely to fracture [1]. Osteoporosis has the liability for fragility fractures; therefore, it represents a tremendous problem for public health [2,3]. These fractures have physical, psychological, social, and economic consequences that can profoundly influence health-related quality of life [4]. Risk factors for osteoporosis in older adults are numerous. The World Health Organization defined osteoporosis as a bone density of 2.5 standard deviations (SDs) below the young healthy adult mean value (T-score ≤–2.5) or lower. Values between –1 and –2.5 SDs below the young adult mean are termed “osteopenia” [5]. Bone mineral density (BMD) test was used for the identification of osteoporosis, determination of fractures risk [6]. Physically active people live healthier and happier lives, irrespective of their age. Increasing the physical activity level could improve the quality of life through protection against chronic diseases such as coronary heart disease, obesity, hypertension, depression, anxiety, and also osteoporosis [7]. Regular physical activity such as brisk walking could lead to major health benefits in addition to saving the cost [8]. The physically active population had a lower risk of II diabetes type up to 50%, and the risk of premature death decreased by 20%–30% [7]. Physical inactivity increased the risk factor for global mortality in different countries through the increment of non-communicable diseases prevalence [9] Physical activity has a positive effect on BMD levels to be within the normal range through decreasing BMD level, such as immobilization, vitamin D insufficiency, and diabetes mellitus [10]. Improvement of physical activity will improve bone health and BMD levels and decreases the risk of osteoporosis and so on; the risk factors of diseases that have direct effects on BMD levels [11]. Therefore, the present study aimed to prevent osteoporosis in the elderly population of Riyadh, Kingdom of Saudi Arabia (KSA) and increase awareness about the possible role of physical activity with osteoporosis among the Saudi Arabian population. Also, the study aimed to determine the BMD, physical activity levels, and the relationship between the physical activity and osteoporosis in the elderly patient above 60-year old at Security Forces Hospital in Riyadh, 2015.

## Subjects and Methods

A cross-sectional study was conducted among patients of Security Forces Hospital in Riyadh, 2015. The study population was elderly patients above 60 years of age who attended the family health clinics with osteoporosis and had already recorded their BMD levels from 1st to 31st of August 2015. We interviewed the patients through questionnaire, consisted of two sections, the first one was about socio-demographic data and the second was about the physical activity index that used items from the General Practice Physical Activity Questionnaire developed by the London School of Hygiene and Tropical Medicine as a validated short measure of physical activity, which was divided into four categories, including inactive, moderately inactive, moderately active, and active [12]. The questionnaire was translated into Arabic. We estimated sample size through the simple randomly sampling formula that was given below. With 58% prevalence of Osteoporosis in KSA, the final sample size is around 374, and because we did this study only in Security Force Hospital at Riyadh we found only 109 cases because there were not enough elderly patient and all of them did not record their BMD levels [13].

$1.962*\left(0.58\right)\left(1-0.58\right)/\left(0.05\right)2=374$

Data were collected from patient files and interviews. The research members collected data through a questionnaire by interviewing the patients after obtaining their BMD levels from patient records that already performed by the hospital in Family Health out-patient Clinics in Security Force Hospital. The data were collected in 4 weeks starting from 1st through 31th of August. The questions concerning walking, housework, or childcare and gardening have been included to allow patients to record their physical activity in these categories; however, these questions have not been shown to yield data of a sufficient reliability to contribute to an understanding of overall physical activity levels, so as noted above further questioning is required as mentioned by [14]. The four activity levels could be identified: 1) Inactive: Sedentary job/lifestyle and no physical exercise or cycling. 2) Moderately inactive: Sedentary job/lifestyle and some but < 1 hour physical exercise and/ or cycling per week OR Standing job and no physical exercise or cycling. 3) Moderately active: Sedentary job/lifestyle and 1–2.9 hours physical exercise and/or cycling per week or Standing job and some but < 1 hour physical exercise and/or cycling per week or Physical job and no physical exercise or cycling. 4) Active: Sedentary job/lifestyle and ≥ 3 hours physical exercise and/or cycling per week or Standing job and 1–2.9 hours physical exercise and/or cycling per week OR Physical job and some but <1 hour physical exercise and/or cycling per week OR Heavy manual job. Data were analyzed with Statistical package for social sciences program version 16.0. Nominal data (like Gender) and categorical data were presented as percentages and frequency. Interval and ratio data were presented by the mean and standard deviation. A chi-square test was applied to measure the significance of the relationship between variables. This study was approved by the research an ethics committee of the Arabian Gulf University. Permission was also obtained from the Security Force Hospital, Riyadh. Consent was taken for the interview from the study participants.

## Results

This study had 108 cases, 71.3% of them were males and 28.7% were females. Of 108 cases, 38.9% were illiterate, 30.6% (33 cases) completed their education after secondary school, 12% after high school and 18.5% were graduates, and about the occupational status, 16.7% of these were employed and 83.3% were retired. All of these cases were diagnosed with osteoporosis. Out of these cases, 81.5% had a previous history of fractures and 89.8% had a positive family history of osteoporosis, 8.3% had a negative family history, 1.9% did not provide the information related to family history (Table 1).

With regard to physical activity index (PAI) and educational level, the results were as follows: out of the illiterate cases, 83.3% (35 cases) were inactive, 14.3% are moderately inactive, 2.4% (1 case) were moderately active, and none were active. Out of those who completed their education after secondary school, 39.4% (13 cases) were inactive, 39.4% were moderately inactive, 21.2% (7 cases) were moderately active, and none were active, and those who finished their education after high school, 100% of those who only had high school degrees (13 cases) were moderately active. Out of the graduates, 5% (1 case) was inactive, 20% (4 cases) were moderately inactive, 65% (13 cases) were moderately active, and 10% (2 cases) were active (Table 2).

Table 1. Socio-demographic description of participants.

 Gender Male 77 71.3% Female 31 28.7% Education level Illiterate 42 38.9% Secondary school 33 30.6% High school 13 12% Graduate 20 18.5% Occupational status Employed 18 16.7% Retired 90 83.3% History of fractures and osteoporosis Osteoporotic 20 18.5% Osteoporotic and Fractures 88 81.5% Family history of osteoporosis Positive family history 97 89.8% Negative family history 9 8.3%

Table 2. Physical activity level concerning educational level.

Educational level Inactive Moderate inactive Moderate active Active
Illiterate Count (%) 35 (83.3%) 6 (14.3%) 1 (2.4%) 0 (0%)
Secondary education Count (%) 13 (39.4%) 13 (39.4%) 7 (21.2%) 0 (0%)
High school Count (%) 0 (0%) 0 (0%) 13 (100%) 0 (0%)
Graduate Count (%) 1 (5%) 4 (20%) 13 (65%) 2 (10%)

p value ≤ 0.00.

Table 3. Physical activity level in regard to occupation status.

Occupation status Inactive Moderate inactive Moderate active Active
Employed 3 (16.7%) 2 (11.1%) 11 (61.1%) 2 (11.1%)
Retired 45 (50.6%) 21 (23.6%) 23 (25.8%) 0 (0%)

p value: < 0.00.

Based on the physical activity index concerning occupation status, we found that out the employed cases 16.7% (3 cases) were inactive, 11.1% (2 cases) were moderately inactive, 61.1% (11 cases) were moderately active, and 11.1% (2 cases) were active. Out of the retired cases, 50.6% (45cases) were inactive, 23.6% (21 cases) were moderately inactive, 25.8% (23 cases) were moderately active, and none of them was active (Table 3).

Table 4 shows the relationship between BMD and the PAI. First, patients who had a BMD level of more than –2.5 “Osteopenia” were 25% of the total cases (27 cases). Of this 25%, none was inactive, 7.4% (2 cases) were moderately inactive, 85.2% (23 cases) were moderately active, and 7.4 (2 cases) were active. Second, for those with BMD levels between –2.5 and –2.999) “Osteoporotic” represented 25% of the total cases (27cases), 25.9% (7 cases) of them were inactive, 40.7% (11 cases) were moderately inactive, 33.3 % (9 cases) were moderately active, and none of them was active. Finally, patients with BMD levels less than –3 “osteoporotic” represented 50% (54 cases) of total cases, 77% of them (42 cases) were inactive, 18.5% (10 cases) were moderately inactive, 3.7% (2 cases) were moderately inactive, and none of them was active (Table 4).

## Discussion

This study was carried out among elderly male and a female population who attended a family clinic at Security Force Hospital in Riyadh KSA to measure the levels of and relationship of osteoporosis with physical activity. We found that the severity of osteoporosis was inversely related to physical activity levels among the elderly Saudis. Studies have consistently found that osteoporosis occurs highly frequently among Saudi Arabian population and it starts at younger ages than in western countries [13,15]. Osteoporotic fractures have a heavy toll on the economy of Saudi Arabia. In one province this may cost as high as US\$12.78 million a year [16]. With regard to physical activity and its relationship with the BMD level, we noticed that active individuals have higher BMD as compared to physically inactive individuals. Our results are consistent with other studies that show physical activity, calcium consumption, and lifestyle factors affected BMD level as well as the prognosis of osteoporosis [17]. Spotlighting on the educational level, we found that people who are not aware of physical activity and its importance to prevent diseases have fewer BMD levels, but when it came to well-educated individuals, they had better BMD levels. A study was done by Barzniji [18] who found that almost half of adult males and females are unaware of osteoporosis though they have heard about it. Since there is a deficiency in the knowledge about osteoporosis among Saudi elderly population, the application of preventive measures has been very low. This suggested that education played a significant role in the BMD level of the elderly. With regard to occupational status, being employed was related to a higher BMD level in our study; employed patients had better BMD level compared to retired or unemployed individuals. Our results are consistent with other evidence.

Table 4. Physical activity level with regard to BMD.

BMD levels Inactive Moderate inactive Moderate active Active Total
>2.5 0 (0%) 2 (7.4%) 23 (85.2%) 2 (7.4%) 27 (100%)
0 (0%) 1.9 % 21.3 % 1.9 % 25 %
–2.5 7 (25.9%) 11 (40.7%) 9 (33.3%) 0 (0%) 27 (100%)
6.5% 10.2% 8.3% (0%) 25%
–3 42 (77.8%) 10 (18.5%) 2 (3.7%) 0 (0%) 54 (100%)
38.9% 9.3% 1.9% 0% 50%

p value ≤ 0.00.

Based on our observations and experience of working with this group of the elderly population in KSA, we assumed that the elderly population in our study was less physically active, and therefore had a high level of osteoporosis because they limit their activities as they age. Saudi Arabian population is generally less physically active during their early years of life because of various reasons mainly lack education and awareness about the importance of physical activity in relation to diseases. Therefore, as their age increases, they are less involved in exercise and sports because of their sedentary behavior. Their lack of awareness about seeking care for Osteoporosis leads them to develop a severe form of this illness. Last, as current recommendations for osteoporosis suggest that all elderly over the age of 60 years must be screened through Dual Energy X-ray Absorptiometry (DEXA) scan, our study results are more relevant [19]. This study had challenges and limitations such as; our study was conducted in the Security Force Hospital and we had difficulty in finding patients filling our criteria of being elderly and with a recorded BMD level. Additionally, the hospital gave us only a month to complete our work and did not allow more time. Only one group of members was allowed by the hospital to interview the patients.

## Conclusion

In this study, we found a significant relationship between physical inactivity and the severity of osteoporosis; the physically inactive patients had a very low BMD level, on the other hand, the physically active patient had a better level of BMD. Therefore, we recommend The Ministry of Health and family clinics in KSA to; raise awareness of the importance of physical activity and its effects on the bone health of the elderly. Each family clinic should assess the physical activity levels of the elderly patients and record that in their files, after that they can advise them to be more active. Emphasize the importance of incorporating physical activity classes in schools. Provide facilities that provide personal trainers specialized in dealing with the elderly.

### List of Abbreviations

 BMD Bone Mineral Density SDs Standard Deviations PAI Physical Activity Index DEXA Dual Energy X-ray Absorptiometry

### Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.

None.

### Consent for publication

Informed consent was obtained from all the participants.

### Ethical approval

This research was approved by the research and ethics committee of Arabian Gulf University, on 20th May 2015. # 15-ROP-05/15

### Author details

Abdulla Falah Al Otaibi1, Abdullah Nasser Algadaan1, Ahmed A. Aziz Hashim S Alhashim1, Deema Ibrahim Altamimi1, Khaled Abdulaziz Alanazi1, Majed Mutlaq Aldawish1, Mohammed Shabeeb M Alhagbani1, Saad Abdullah T. Alharbi1,Suliman Faris Alrfdi1, Turki Fahad A. Alshahrani1

1. Arabian Gulf University, Manama, Bahrain

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