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MISSION OSTEOPOROSIS ARMENIA
THE FIRST DECADE: 2007-2017 Gaining awareness and getting results:
John P. Bilezikian, M.D.
Professor of Medicine and Pharmacology
Vice-Chair for International Education and Reseach
Director, Metabolic Bone Diseases Program
College of Physicians and Surgeons
Columbia University, New York, NY USA
ARMENIAN HERITAGE CRUISE
January 21, 2017
John P. Bilezikian, M.D.
Disclosures:
Amgen (Consultant, Advisory Board)
Shire Pharmaceuticals (Consultant)
Radius Pharmaceuticals (Advisory Board)
1//17
Outline
• Background- Osteoporosis in the world
• Inspiration for applying knowledge to
Armenia
• What we knew in 2007
• What we accomplished
• Where we are going
Osteoporosis
A GLOBAL PROBLEM
Projected Number of Hip Fractures
Projected to reach 3.250 million in Asia by 2050
Adapted from Cooper C et al. Osteoporosis Int. 1992;2:285-289.
Estimated no. of hip fractures: (1000s)
1950 2050
600
3250
1950 2050
668
400
1950 2050 742
37
8
1950 2050
100
62
9
Total number of
hip fractures:
1950 = 1.66 million
2050 = 6.26 million
Osteoporosis: Worldwide Prevalence
Affects 200 million women
worldwide1
- 1/3 of women aged 60 to 70
- 2/3 of women aged 80 or older
Approximately 30 % of women over
the age of 50 have one or more
vertebral fractures2
1. International Osteoporosis Foundation Osteoporos Int 1996, 6:233 2. Dennison,2000
• A hip fracture occurs on
average every 30
seconds, somewhere in
the world!
The key epidemiological message:
“Osteoporosis is one of the most dangerous diseases of the 21st century*”
*Narine Mamikonyan, Armenian Osteoporosis
Association, 2015
Shuler FD, et al. Orthopedics 2012;
35:798-805
Melton LJ, et al. J Bone Miner Res 1992;7:1005-10.
Looker AC, et al. J Bone Miner Res 1997;12:1761-8.
National Osteoporosis Foundation. 1998, 2002.
Burge et al. J Bone Miner Res, 2007
Postmenopausal Osteoporosis
in the United States
• 2.0 Million Fractures Annually in the United States
• 40-50% life time risk in a typical 50 year old
Caucasian woman
• Fractures occur at 3 main sites:
Vertebral: 15.6%
Hip: 17.5%
Forearm: 16.0%
Postmenopausal Osteoporosis
in Armenia
• Data relative to fractures in
Armenia have become
available in the past year
Ross PD et al. Ann Intern Med 1991;114-23.
Silverman SL. Bone 1992;13 (suppl 2):S27-31.
Cooper C, et al. Am J Epidem 1993;137:1001-5.
Lyles et al. Am J Med 1993;94:595-601.
Schlaich C, et al. Osteoporos Int 1998;8:261-7.
Human Costs of Osteoporosis
• Impaired function, decreased mobility
• More bone loss due to decreased activity
• Compressed abdomen,
reduced appetite
• Reduced pulmonary
function
• Sleep disorders
• Shortened survival
• Poor self esteem
Photo courtesy of the National Osteoporosis Foundation
28-32,000,000
10-12,000,000
Men
Women
14
Osteoporosis: Identifying the Problem
“ A skeletal disorder
characterized by
compromised
bone strength
predisposing to an
increased risk of
fracture.”
Healthy bone
Osteoporotic bone
NIH Consensus Development Conference on Osteoporosis, 2000.
Adapted from Wasnich RD, et al. Osteoporosis: Critique and Practicum. 1989:179
Bone Loss
Begins in 30s (women), late 40s (men)
Accelerates at menopause due to estrogen deficiency
Continues throughout life
Influenced by other factors: nutrition, diseases, medications, lifestyle, etc
10 20 30 40 50 60 70 80 90
Bo
ne M
ass
Active
Growth
Slow
Loss
Continuing
Loss ME
NO
PA
US
E
Age
Women Men
Pathogenesis of Osteoporosis and
Fractures
Figure reprinted from National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis.
Modified from Riggs BL, Melton LJ. Osteoporosis: Etiology, Diagnosis, and Management. New York: Raven Press; 1988.
MENOPAUSE AGING OTHER RISK FACTORS
PROPENSITY
TO FALL
LOW PEAK
BONE MASS
POOR BONE
QUALITY
INCREASED
BONE LOSS
LOW BONE
DENSITY
FRACTURES
Before 1986, osteoporosis was diagnosed by
clinical appearance or the fragility fracture
In 1986….
• Dual energy X-ray Absorptiometry (DXA) became available as a clinical tool to assess bone mineral density in the setting of clinical medicine…..
• It changed the way we think about and the way we diagnose osteoporosis
Features of Bone Densitometry by DXA
• Safe
• Accurate
• Precise
• Normative population
databases
• Correlates with fracture risk
• A diagnostic standard
• An important aspect of FRAX
risk assessment system
HOLOGIC
• Central DXA is the gold
standard for diagnosis
• Measures the most
important fracture sites
(hip and spine)
• Can be used to monitor
response to therapy
Hologic
GE Lunar
Central DXA Bone Density Measurements
Norland
NOF Clinician’s Guide to Prevention and Treatment of Osteoporosis . 2013. www.nof.org .
Correlates with life time fracture risk for Caucasian Women
-4.0 -3.5 -3.0 -2.5 -2.0 -1.5 -1.0 -0.5 0 +0.5 +1.0
Interpreting T-scores (WHO)
T-score
Osteoporosis
Normal
Bone Mass Low
Bone Mass
(Osteopenia)
UNITED STATES GUIDELINES FOR BONE DENSITOMETRY TESTING
Women
NOF1/AACE2
Men 3ISCD, 4TES
Age >65 >703
Fragility fracture YES YES
Starting steroids YES YES
Other risk factors
> 50 but <65 if
• Weight <127 lbs
• Early menopause
• Smoking
• FH of fracture
• Other Causes
> 50 but < 70 if
• Low weight ?
• Low T
• Smoking
• FH of fracture
• Other causes
1 National Osteoporosis Foundation 2 AACE 3 ISCD, 2010, 4Watts et al, 2012
ARMENIA: GUIDELINES FOR BONE DENSITOMETRY TESTING
Women
Men
Age ???? ????
Fragility fracture ???? ????
Starting steroids ???? ????
Other risk factors
????
????
With DXA… .Osteoporosis can be
identified before the fracture occurs
and plans for prevention and
treatment can be implemented
In 2007, 20 years after DXA became widely
used throughout the world…
• There was 1 DXA machine in Armenia!
The case to make available bone density
density testing in Armenia was clear in 2007…
• But where did the inspiration to do
something come from?
• Edgar Housepian
When the plane lands…..
The case to make available bone density
density testing in Armenia was clear in 2007…
• But where did the inspiration to do
something come from?
• Edgar Housepian
• Aram Chobanian
• Family
FAMILY
• Pauline and Armen Barooshian
• Sophie Bilezikian
• Diana Bilezikian
• Caroline Apovian
• Other relatives who have accompanied me over the past 10 years to Yerevan!
ZABELLE APOVIAN BILEZIKIAN
DXA in Armenia since 2007 2007: DXA placed at Markarian
2008: Ultrasound densitometer, YSMU
2009: DXA placed at YSMU
2010: Major software upgrades to all DXA
equipment
2011-1014: DXA units placed in
Erebouni Hospital
Traumatology and Orthopedic Hospital
Gyumri
Stepanakert (Karabagh)
2016: DXA units placed in Vanadzour and
in Kapan
Historical View
• By 2017, Armenia has acquired
enough DXA instruments, through
the generosity of the Hologic
Corporation in the United States, to
be placed as above average in rankings for instruments per capita in the world!
We brought technology and thus capabilities to diagnose osteoporosis in Armenia ... but how does one teach physicians in Armenia whose training is generally substandard and whose motivation is sometimes even less?
A broader view of education in Armenia (it’s not just osteoporosis)
• Medical Education in Armenia
– Needs identified during the
Housepian/Chobanian initiatives in
the early 2000s:
– Needs to address:
• Teaching methods
• Educational requirements
• Credentialing system
• Postgraduate education for specialty
certification
The years of Dr. Gohar Kyalyan Former Rector of Yerevan State Medical
University (2006-2010)
• In collaboration with Aram
Chobanian (President Emeritus of
Boston University) and the late
Edgar Housepian
• Change happened!
The Kyalyan years circa 2006-2010
• Official affiliation between YSMU
and Boston University and between
YSMU and Columbia University
• The entire medical curriculum of
BU was made available to all
medical students at YSMU
• International Advisory Committee
established
The Kyalyan years
• The Bologna system of medical
education implemented: updated
course and teaching methods
• Credentialling examinations
• More rigorous admission and
retention policies
Beyond those years
• Pace of progress has continued with
recognition by subsequent Rectors that
there is much to be done
• Good working relationships with Former
Rector Mikayel Naramanyan
• Active involvement of the American
University of Armenia (Armen Der
Kiureghian, President)
Back to Mission Osteoporosis
Training and Education
• Radiologists were trained by a Hologic application specialist (Larry Mowat) in all aspects of the DXA instrument, prior to using the instrument
• A “hot line” enables them to contact Hologic if any problems arise
• A Hologic-trained engineer is a full-time employee at Ereubuni Hospital and, thus, is available to service and make needed repairs whenever necessary
Training and Education
• Educational symposia for physicians and other health care professionals have been conducted yearly for the past 10 years
• The Tenth Symposium was held on October 6, 2016
The Osteoporosis Education Army: from the United States, UK, and Russia:
• Mariam Manoukian Tammy Martin
• Samuel Badalian Elena Sagayan
• Caroline Apovian Kim Hekimian
• Sara Takii Nicholas Hutchings
• John Kanis Richard Deckelbaum
• Larry Mowat Bob Bagramian
• Olga Lesynak
• Noune Pashinian
• Hasmik Arzumanyan
and from Armenia….
• Nara Mamikonyan Varduhi Petrosyan
• Gevorg Yachjyan Georgy Okoev
• Armine Horoyan Varta Babalyan
• Karine Arustamyan Bagrat Lalalyan
• Yelena Aghajanova Khoren Hovhannisyan
• Ani Akopyan Artashes Grigoyan
• Sargis Sahakyan Vachagan Ayvazyan
• Nara Aslanyan
• Siranoush Karagoshian
Supporting Organizations
Columbia University
Boston University
Yerevan State Medical University
American University of Armenia
Fund for Armenian Relief (FAR)
JHM Foundation
Hovnanian Foundation
International Osteoporosis
Foundation
Supporting Organizations -2-
• Russian Osteoporosis Association
• Armenian Osteoporosis
Association
• Hologic Corporation
Osteoporosis Symposia in Armenia
2007-2016
• In 2007, the first symposium at
Markarian Hospital drew a capacity
audience of about 100 people
• In 2016, the 10th Annual
Osteoporosis Symposium at the
American University of Armenia
drew over 600 attendees!
10th International
6 October 2016
10th Annual Osteoporosis Symposium
Yerevan, 2016
Faculy
Tenth Annual Osteoporosis
Symposium for Physicians and Health
Professionals
OBJECTIVE:
To review and to provide updates on the
latest advances in osteoporosis, regarding:
epidemiology, causes, nutrition, risk factors,
and management
Topics to be covered
Public Health Initiatives
Premenopausal Osteoporosis:
The Perimenopausal woman
Nutrition and
Skeletal Health
Major issues in Osteoporosis
Thyroid Hormone and
Bone
Glucocorticoid- Induced
Osteoporosis
Armenian Osteoporosis Association
Diabetes and Bone Health Obesity and
Skeletal Health
Agenda
Lunch 12:45-13:45
Afternoon Workshops
13:45-15:15
MORNING 9:30-12:45
Welcome and
Introductions
Armenian Osteoporosis
Association
Public Health Issues
Medical Issues
Epidemiology
Nutrition and skeletal
Health
Thyroid and Iodine Deficiency
Nutrition and Physical Activity
Topics in Osteoporosis
Diabetes and Obesity
Rheumatology and
Osteoporosis
Perimenopausal Skeletal
Health
The steps to recognition of osteoporosis in Armenia: How is
Progress Assessed?
Acquisition of Capability to
Measure Bone Mineral Density
Education
Hosting an International Summit
Conference on Osteoporosis
International Osteoporosis Summit:
Central Asian and Eastern European
Countries
Armenian Osteoporosis Association
International Osteoporosis Foundation
Yerevan, Armenia
4 October 2016
International Osteoporosis Summit:
Participating Countries*
• Armenia
• Russia
• Belarus
• Georgia
• Kazakhstan
• Kyrgyz
• Moldova
• Uzbekistan
• Austria
• Czech Republic
• Hungary
• Poland
• Slovakia
• United States
*Regrets from Ukraine, Slovenia, Romania
International Osteoporosis Summit:
Participants and Acknowledgements*
• Armenia: Varta Babalyan, Karine
Arustamyan, Lena Aghajanova, Sargis
Sahakyan, Varduhi Petroysan, Armine
Haroyan, Gevorg Yaghjyan
• *Acknowledgements: Levon Altunyan,
Minister of Health (represented by Vartan
Vartazaryan (Minister of Hospital Health
Care)
International Osteoporosis Summit:
Participants • Russia: Olga Lesnyak,Olga Ershova, Olga Derevyanko, Evgeni
Zotkin
• Belarus: Emma Rudenka, Elena Rudenka, Alla Shepelkevich
• Georgia: Marina Tsagarely, Medea Kopaliani, Maya Santania, Yulia
Zedgenidze
• Kazakhstan: Gulzhan Gabdulina, Sholpan Isaeva, Chokan
Baymukchmedov, Laura Danyarova, Akmaral Nurbekova, Nurlan
Turdalin
• Kyrgyz: Olga Lobanchenko, Anara Mamazhunosova
• Moldova: Eugeniu Russu, Victor Cazac,Angela Chicu, Oxana
Odobescu
• Uzbekistan: Shakirova Munavvara, Nadira Alikhanova
International Osteoporosis Summit:
Participants
• Austria: Heinrich Resch, Gerold Holzer
• Czech Republic: Milan Bayer
• Hungary: Peter Lakatos
• Poland: Edward Czerwinski, Roman Lorenc
• Slovakia: Juraj Payer, Peter Vanuga, Peter Jackuliak
• United States: John P. Bilezikian, Nicholas Hutchings, Kim
Hekimian, Mariam Manoukian, Noune Pashinan,
International Summit: Armenia
4 October 2016
International Summit: Armenia
4 October 2016
The steps to recognition of osteoporosis in Armenia: How is
Progress Assessed?
Acquisition of Capability to
Measure Bone Mineral Density
Education
Awareness
5 Leadership Round Tables on
Osteoporosis in Armenia
• Gathering of the leading
governmental and society leaders
in Women’s Health in Armenia
• Purpose: to further emphasize the
importance of skeletal health,
nutrition and other issues in
Armenia
3rd Leadership
Round Table on Osteoporosis
5th Leadership Roundtable
5 October 2016
Key points of the leadership
discussion
Capability for bone density acquired over
the past 10 years
Doctors in Yerevan are more
knowledgeable about osteoporosis than
ever before
There is now sound epidemiological data
on fracture incidence in Armenia leading
to a country-specific FRAX
Key points of the leadership
discussion
The challenge now is to apply these advances to improve detection, evaluation, and treatment of patients who are at risk.
PROGRESS
Acquisition of Capability
Education
• Research
Ongoing Research in Osteoporosis in
Armenia
• Traumatology and Orthopedic
Hospital (Nicholas Hutchings,Khoren
Hovhassisyan, Artashes Grigoyan)
• Ereubuni Hospital (Sargis Sahakyan)
• Markarian (Karine Arustamyan)
• Yerevan State Medical University (Yelena Aghajanova)
• Armenian American Wellness Center (Zaha Sahradyan)
New Research being planned for 2016-2017
Iodine Deficiency and thyroid disease in Armenia
• Yerevan State Medical University (Yelena Aghajanova)
• American University of Armenia (Varduhi Petrosyan)
• Columbia University (Nicholas Hutchings,
John Bilezikian)
• Stanford University (Mariam Manoukian)
• Ministry of Health
• UNICEF and WHO
PROGRESS
Acquisition of Capability
Education
Research
Governmental
How do we get the word out and influence
governmental policy?
Ministry of Health: October 10, 2014
Ministry of Health
• Health priorities of former Minister
of Health: Dr. Muradyan
– Preventative Medicine
• Cardiovascular
• Oncology
• Diabetes
• Nutrition
• Osteoporosis
My vision for Armenia
– An Osteoporosis Center that will be a central referral program for the entire region
Varta Babalyan has been named the first full-time, salaried Director of the Osteoporosis Center of Armenia!
My vision for Armenia
– An Osteoporosis Center that will be a central referral program for the entire region
– A program of first rate and publishable research on the epidemiology, diagnosis, and treatment of osteoporosis
Development of a Fracture Risk Assessment Tool for Armenia (Lesynak,Sahakyan, Bilezikian, Hutchings, Manoukian et al. To be published in 2017)- My next lecture on the cruise!
My vision for Armenia
– An Osteoporosis Center that will be a central referral program for the entire region
– A program of first rate and publishable research on the epidemiology, diagnosis, and treatment of osteoporosis
– A program of research that extends into other areas of endocrinology such as thyroid disease, obesity, and diabetes
– Hutchings N, Bilezikian JP et al. Iodine nutrition in Armenia, 2017
My vision for Armenia (cont’d)
– Ongoing educational programs to keep physicians and other health-care professionals for Armenian Health Care Professionals and others in the region
– Armenia will become the center for referrals and for education throughout the region
My vision for Armenia (cont’d)
– Government-sanctioned guidelines for screening with DXA and for treating osteoporosis will be implemented
Lessons Learned in the First 10 Years…
• We can make a difference • It takes time to make a difference • It takes a lot of work to make a difference • As a result, the skeletal health of the
people of Armenia will be improved
• Armenia has the potential to become a center for Osteoporosis through the region
Lessons Learned in the First 10 Years…
Each of us doing what we do best leads to positive results, multiplied many times over
PROGRESS
Acquisition of Capability
Education
Research
Governmental
Shnorhagalutyun!