Prevalence and Associated Factors of Osteoporosis Among People With Hypertension in Alahsa, Saudi Arabia: A Cross-Sectional Study

Introduction Osteoporosis (OP) and hypertension (HTN) are prevalent conditions impacting elderly health. This study aimed to explore the prevalence and factors associated with OP among people with HTN in Al-Ahsa, Saudi Arabia (2023). Material and method A cross-sectional analytical study was conducted. Adults aged 50-79 diagnosed with HTN were recruited from those referred for dual-energy X-ray absorptiometry (DEXA) scans using a systematic random sampling method. The participants' electronic health records were reviewed and all participants were interviewed using a structured questionnaire to collect data not available in the electronic health records related to demographics, medical history, and lifestyle factors. Chi-square tests and multivariable logistic regression were used to assess the associations between OP and clinical parameters. Results A total of 255 participants were recruited, with 115 (45.1%) having normal bone density, 97 (38%) having osteopenia, and 43 (16.9%) having OP. Females 167 (65.5%) were higher than males 88 (34.5%). The average age of all the respondents was 66.2 ± 7.96 years, and their average body mass index (BMI) was 22.2 ± 15.1. The age in years (mean ± SD) of participants with OP 68.04 ± 7.60 was higher compared to normal 64.9 ± 7.46 (p-value = 0.03). Factors that appear to increase the risk of OP in multivariable logistic regression analysis with an adjusted odds ratio (OR) (95% CI) include increased age (OR: 1.17, CI: 0.9-1.2, p-value = 0.048), and parathyroid gland disorder comorbidity (OR: 15.1, CI: 0.7-32, p-value = 0.03), while some factors that reduce the risk of developing OP include increased BMI (OR: 0.9, CI: 0.91-1.03, p-value = 0.03), literate individuals (OR: 0.1, CI: 0.01-1.4, p-value = 0.046), and taking beta-blockers (BB) treatment (OR: 0.23, CI: 0.01-1.3, p-value = 0.02) reduced odds of developing OP according to results. Conclusion The OP is notably present among people with HTN, especially older people, and parathyroid gland disorders. Higher BMI levels, along with the use of BB, help to decrease it. Additionally, any level of education above illiteracy is associated with a lower prevalence of OP, suggesting that education may have a protective effect against OP in HTN patients. We recommend further research on OP risk factors in HTN Saudi patients. Future research should focus on assessing the impact of educational levels and socioeconomic factors on OP prevalence and investigating the association between specific comorbidities (e.g., diabetes mellitus (DM) and parathyroid gland disorders) and OP risk in HTN individuals. Collaborate with public health authorities and organizations to integrate OP screening into routine HTN patient care protocols.


Introduction
According to the World Health Organization (WHO), osteoporosis (OP) is a disease characterized by low bone mass and deterioration of bone tissue architecture, leading to increased bone fragility and fracture risk [1].HTN, on the other hand, is defined by the WHO as the current use of blood pressure-lowering medication associated with an average systolic blood pressure ≥140 mm Hg and an average diastolic blood pressure ≥90 mm Hg or an average systolic blood pressure ≥130 mm Hg and an average diastolic blood pressure ≥80 mm Hg (if they had a history of cardiovascular disease or DM) [2].
In Saudi Arabia's general population, the prevalence of HTN was 17.8% among men and 12.5% among women [3].According to 2018 epidemiological data for Saudi Arabia, the prevalence of OP was 28.2% among men and 37.8% among women between the ages of 50 and 79 years [3,4].Several studies from different parts of the world explored the pathophysiology that correlates HTN with OP, such as age, gender, smoking status, low calcium levels and vitamin D deficiency [3].To the best of our knowledge, Saudi Arabia has not published enough data about the correlation between HTN and OP [3].
Several studies have indicated a probable close relationship between cardiovascular disease and OP, particularly in older individuals.Low bone density is an independent risk factor for cardiovascular disease mortality, with women having a higher risk [1].Additionally, it has been noted that there is a significant correlation between risk factors for cardiovascular disease and the existence of vertebral fractures [1].According to earlier research, HTN significantly raises the risk of OP and osteoporotic fracture and refracture, ultimately raising the rate of mortality [5].
OP and HTN are prevalent conditions that negatively impact the health-related quality of life among the elderly.On the other hand, research on the connection between OP and HTN is scarce.The American National Foundation recommends DEXA of the hip, forearm, and spine with a T-score of ≤ −2.5 to quantify bone mineral density (BMD) to diagnose OP [3].
The literature explores the pathophysiology of the relationship between OP and HTN and the factors linking OP and HTN: chronic elevation in the levels of parathyroid hormone (PTH), angiotensin II, and catecholamines, including adrenaline in HTN, which may have an impact on bone health.Furthermore, renal calcium excretion will decrease vitamin D plasma concentrations.Simultaneously, HTN is associated with reduced intestinal absorption of calcium and vitamin D, all of which contribute to the continuous secretion of PTH.Moreover, persistent PTH elevation increases osteoclast activity, which aids in bone resorption [2].
Antihypertensive medication, particularly BB, affects bones to ascertain whether or not it can increase BMD.A study of postmenopausal Syrian women did not find a correlation between HTN and OP.This study demonstrates that BB and thiazides have beneficial effects on the BMD of the lumbar spine in osteoporotic HTN postmenopausal women [6].
Another study examined the impact of loop diuretics and thiazides on vertebral fracture incidence following stroke.While short-term use was associated with a higher incidence of vertebral fracture, further research is needed to confirm this finding, considering vertebral fracture as a common site of osteoporotic fracture [7].
Sympathetic tone, a consistent factor in HTN, may contribute to bone loss through increased sympathetic outflow and beta-adrenergic stimulation.Antihypertensive medications that block alpha and betaadrenergic receptors could potentially mitigate bone loss while reducing blood pressure [8].
A few cross-sectional studies reported an inverse relationship between HTN and the level of vitamin D (10 ng).An increased level of 25-hydroxy vitamin D (25OH) was associated with a 12% decrease in blood pressure readings [8].
Ye et al. conducted a systematic review and meta-analysis in China [9] to evaluate the association between HTN and BMD.The results demonstrate that HTN can reduce the BMD in the following areas: the lumbar spine, femoral neck, Ward's triangle, femoral intertrochanteric, calcaneus, and distal forearm [9].This metaanalysis suggests that HTN can reduce the BMD of the human body, and for different parts of the bone, the degree of reduction is different according to the bone site [9].
To the best of our knowledge, Saudi Arabia has not published enough data about the correlation between HTN and OP.Still, there is a deficiency in the data that explores the shared risk factors linked to HTN and OP.Our aim of this study is to explore the prevalence and factors associated with OP among HTN patients in Al-Ahsa, Saudi Arabia, in 2023.Understanding the prevalence of OP among HTN patients in Al-Ahsa, Saudi Arabia, is crucial for developing targeted prevention and management strategies.This region's specific population demographics and potential risk factors necessitate investigating this association.

Study design
This research adopts an analytical cross-sectional approach, investigating patients with documented HTN from the Saudi Ministry of Health electronic databases.

Study variables
The variables selected to determine the prevalence of OP and its associated factors with HTN include demographic data (age, gender, education level, occupation, and marital status), lifestyle factors (such as cigarette smoking), and medical history variables (including HTN duration, obesity, age at menarche, duration of menopause, comorbidities, and the use of antihypertensive medication).

Measurement of the outcome
OP was defined according to the WHO criteria, with diagnosis confirmed by a T-score of -2.5 or lower in the lumbar spine, femoral neck, or hip as assessed by DEXA scans.BMD status, categorized as normal, osteopenia, or OP, served as the primary outcome variable.A T-score greater than −1 was considered normal; a T-score between −2.5 and −1 indicated osteopenia; and a T-score of −2.5 or lower indicated OP.We assigned each participant to a BMD status category based on their hip BMD T-scores.

Response rate
Our response rate was 73.9%, with 255 out of 345 participants responding.During data collection, several challenges impacted our response rate: 28 participants had passed away, 8 lacked ID numbers for data linkage, 15 had missing contact details, 12 refused to participate, and 27 did not respond despite three attempts to contact them.

Statistical analysis
Two software programs, SPSS for Windows version 21 (SPSS, Chicago, IL, USA) and GraphPad Prism version 8.4.2 (GraphPad Software, San Diego, CA, USA), were used to perform the statistical analysis.The Kolmogorov-Smirnov test was performed to check the normality of the variables.Descriptive statistics were expressed as mean and standard deviation, or frequency and percentage, according to the type of data.A chi-square test and one-way ANOVA test were conducted to assess the association between BMD and clinical parameters.Multivariable logistic regression analysis was applied to further examine the correlation between parameters and osteoporosis.A P-value < 0.05 was considered statistically significant.

Results
This study recruited 255 participants with HTN who underwent BMD.The ratio of females 167 (65.5%) was higher than that of males 88 (34.5%).The average age of all the respondents was 66.2 ± 7.96 years, and their average BMI was 22.2 ± 15.1.Among females, 76 (29.8%) had menarche at the age of 12 to 13 years.

Discussion
OP and HTN are multifactorial diseases, and their association with each other contributes to considerable morbidity in the elderly population [12].The relationship between HTN and OP is not clear yet.For that purpose, the risk factors for OP in HTN patients are discussed in the present study.HTN patients included in our study were regularly taking antihypertensive drugs to control blood pressure.
It has been observed that the rates of OP and HTN increase with life expectancy.However, some studies have reported no significant link between HTN and OP, indicating that HTN is not a risk factor for OP [6].In contrast, other studies have demonstrated a connection between these two diseases, showing a high prevalence of OP among HTN participants [13,14].Our study, conducted on individuals with HTN, detected notably the presence of osteopenia (38%) among HTN patients, with 16.9% being osteoporotic.These findings are consistent with a local Saudi study by Al-Hariri and Aldhafery, which reported notably the presence of OP among HTN patients, with osteopenia at 41.1% and OP at 27.8% [3].Furthermore, based on these findings, our study agrees with the studies by Wu et al. and Hao Chai et al., which reported a high prevalence of OP among HTN patients [13,14].In contrast, our results differ from those of Hijazi et al., who did not find an association between OP and HTN [6].In our study, the ratio of OP was seen to be higher in elderly HTN patients, which confirms that OP is highly associated with increased age (mean age ± SD = 68.04 ± 7.60) [15].We included both males and females of elderly age; among females, approximately all the females were postmenopausal.Our study determined that increased BMI reduced the risk of the development of OP in HTN patients by 10%; this is in agreement with the study, which showed a negative correlation between BMI and OP [16].It was also observed that HTN patients with normal BMD were predominantly literate and had higher levels of education.In contrast, a significant increase in illiteracy was noted among HTN patients diagnosed with OP.We conducted multivariable logistic regression to investigate the further factors causing the increased risk.It has also been detected that in our study, HTN patients who are comorbid with DM are not associated with developing OP; this finding agrees with a previous study [17].This study reported a prevalence of OP among diabetics of 6.4%.They found just 16 of 250 DM participants with severe OP [17].On the other hand, our study also identified that HTN patients with parathyroid gland disorders increased the risk of developing OP by 15.1-fold.This finding aligns with existing literature suggesting a key role for parathyroid dysfunction in mediating the link between HTN and OP, as evidenced by studies [2,18].
Furthermore, we investigated the effect of antihypertensive drugs on the development of OP.HTN patients were taking only one medication or a combination of two medications.Regression analysis of our study showed that BB had an adjusted OR of 0.23, corresponding to a 77% reduction in the risk of developing OP, while no other antihypertensive drug induced or reduced the risk of OP in HTN patients.This finding agrees with the study by Hijazi et al. [6], which also reported the association of thiazide with an increased risk of OP [7].However, our study did not find any significant association between these two.

TABLE 2 : Prevalence of BMD in HTN patients Data
All the participants who were included in this study were HTN patients.Among them, 184 (72.2%) were diagnosed with HTN between 40 and 60 years old.Out of 255 participants, 43 (16.9%) had calcium channel blockers (CCB) as their antihypertensive drug.Following CCB, 38 participants (14.9%) were taking angiotensin-converting enzyme inhibitors (ACE-I) (Table3).
are presented as numbers and percentages.BMD: bone mineral density; HTN: hypertension.

TABLE 3 : Distribution of age at HTN diagnosis and antihypertensive drug use
Data are presented as numbers and percentages.HTN: hypertension; BMD: bone mineral density; ACE-I: angiotensin-converting enzyme inhibitors, ARBs: angiotensin receptor blockers; BB: beta-blockers; CCB: calcium channel blockers.The association between BMD and demographic characteristics was analyzed.The age of HTN patients significantly differed among those with normal BMD, osteopenia, and OP.The mean age of patients with OP was significantly higher compared to those with normal BMD (age in years mean ± SD, 68.04 ± 7.60 years vs. 64.9±7.46 years, respectively; p-value = 0.03).Additionally, the level of education showed a statistically significant association with OP: 26 out of 102 (25.5%) illiterate HTN patients experienced OP; conversely, 32 out of 55 (58.1%) literate HTN with normal BMD and only 7 out of 55 (12.7%) had OP, and 7 out of 11 corresponding to 63.6% HTN patients with normal BMD had attended university, and only 1 out of 11 (9%) HTN patients with OP had attended college (p = 0.018).Any level of education above illiteracy is associated with a lower prevalence of OP, suggesting that education may have a protective effect against OP in HTN patients.All other demographic parameters did not show any significant association (Table4).2024 Aldakhlan et al.Cureus 16(8): e66961.DOI 10.7759/cureus.

TABLE 4 : Demographic characteristics of HTN patients with BMD Data
HTN patients showed insignificant results when BMD categories were analyzed against age of HTN diagnosis, one antihypertensive drug, and drug combination (Table5).
are presented as numbers, percentages, mean, and standard deviations (mean ± SD).The chi-square test and one-way ANOVA test were used.*p<0.05 was considered statistically significant.HTN: hypertension; BMD: bone mineral density; BMI: body mass index.

TABLE 5 : Clinical characteristics of HTN patients with BMD
Data are presented as numbers, percentages, mean and standard deviations (mean ± SD).The chi-square test and one-way ANOVA test were used.HTN: hypertension; BMD: bone mineral density; ACE-I: angiotensin-converting enzyme inhibitors; ARBs: angiotensin receptor blockers; BB: beta-blockers; CCB: calcium channel blockers.

TABLE 6 : Risk factors of OP within demographic and clinical parameters in HTN patients
3, p-value:0.02),indicatinga77% reduced risk of developing OP.None of the other variables analyzed were statistically significant (Table7).

TABLE 7 : Risk factors of OP within clinical parameters in HTN patients
Data were presented as odds ratio and 95% confidence interval.Multivariable logistic regression and odds ratio were calculated, adjusted for age of HTN diagnosis, antihypertensive drug use (ACE-I as reference), and drug combination (one drug as reference).p<0.05 significant variables are present.OR: odds ratio, CI: confidence interval, ref: reference, OP: osteoporosis, HTN: hypertension, ACE-I: angiotensin-converting enzyme inhibitors, ARBs: angiotensin receptor blockers, BB: beta-blockers, CCB: calcium channel blockers.