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Middle-East Journal of Scientific Research 20 (8): 893-899, 2014 IDOSI Publications, 2014 Studying the Factors Affecting Osteoporosis in
Women with the Logistic Regression Analysis
1Bülent K l ç, Y 2 avuz Ta k ran, 3A. Serdar Yücel and M urat Korkmaz 1Orthopedist, Tekirda , Turkey 2Kocaeli University School of Physical Education and Sports, Kocaeli, Turkey 3F rat University School of Physical Education and Sports, Elaz , Turkey 4Güven GroupInc, stanbul, Turkey Abstract: The purpose of this investigation is to study the factors affecting osteoporosis in women with the
logistic regression analysis in order to evaluate the effect of those risk factors. The age of women ranged
between 40-70 years. A questionnaire was prepared for this study and the questions were directed to patients.
The research was conducted on a total of 250 patients. As the dependent variable is in a categorical data type
with two levels, binary logistic regression analysis was applied. According to the analysis results, such factors
as age, weight, calcium amount of the individual, duration of the exercise, genetic factors, being in menopause
and smoking have significant effect pushing individuals towards being osteoporotic. In order to prevent
osteoporosis, a person should lose weight, increase weekly exercises, be careful about the calcium amount in
her body and reduce smoking. particularly elder ones.
Key words: Osteoporosis Risk Factors Menopause Smoking Weight
than one fracture is called established osteoporosis[4, 10]. An increase in bone fragility in OP (Osteoporosis) Osteoporosis is the structural deficiency of bones causes an increase in morbidity and mortality [2, 4].
and a systemic skeletal disorder characterized by an According to the criteria of WHO, women aged 50 and increase in bone fragility and susceptibility to fracture as over are diagnosed with osteopenia between the ranges a result of low bone mass and the deterioration of of 34-50% and osteoporosis between the ranges of micro-architecture of bone tissue [1-5]. Osteoporosis is 17-20%. Women aged 50 and over can face with a fracture also defined as a skeletal disorder characterized by fatal caused by osteoporosis at a rate of 40% [11]. All over the loss which makes the person vulnerable to increased world, one-third of the women aged between 60 and 70 fracture risk regarding the bone strength [6, 7] and the two and two-third of the women aged 80 and over is important factors constituting the bone strength are bone osteoporotic [12]. Osteoporosis-dependent fractures are density and bone quality [8].World Health Organization mostly seen in vertebras, proximal femur and radius distal (WHO) defined OP according to the dual Energy X-Ray and around the shoulder in humerus. Shortening in Absorbsiometry (DEXA) measurement [4, 9].
stature which is seen in osteoporotic patients is an Accordingly, if bone mineral density and bone mineral important clue for the diagnosis of the disorder. The content is below 1 standard deviation for young adults, it reason is the compression fractures in vertebras. Patients is accepted as normal; BMD (Bone Mineral Density) may experience 10-15 cm of shortening in stature in between -1 and -2.5 SD (Standard Deviation) for young comparison to the length in their youth. When adults is called Osteoporosis and BMD being more than osteoporotic fractures occur in vertebras, patients suffer -2.5 SD (for young adults and presence of one or more from severe back pains. When the number of these Corresponding Author: A. Serdar Yücel, F rat University, School of Physical Education and Sports, Elaz , Turkey.
Middle-East J. Sci. Res., 20 (8): 893-899, 2014 fractures increases more in time, serious amount of By Involved Bone Tissue:
shortening is seen in stature of those osteoporoticindividuals and even thoracic kyphosis occurs [11].
Trabecular, b) Cortical [21-23, 26].
Osteoporosis-dependent fractures increase mortalityand they even cause pain, being dependent on someone Factors Afecting Osteoporosis In Women: The more risk
else, failure to walk, depression and the obligation of factors are for all postmenopausal women, the higher the living in nursing centers [8, 3-18].
fracture risk is. Most of the structural and genetic factorsare the risk factors that cannot be changed. The most Classification of Osteoporosis: A lot of classifications
important factor in OP is peak bone mass and bone loss.
can be made in osteoporosis [19-23].
These two factors are both related to genetic andenvironmental changes. Knowing the factors affecting osteoporosis frequently enables understanding thedecrease in bone density and etiology of fracture Juvenile: It is rare. It is generally observed in little composition. These risk factors can also be used in children with a fast growth before puberty. There is predetermination of the individuals in high risk group and no family history or known cause. of the patients who can benefit from the protective Adult: It is rare. It is observed in premenopausal treatment before the composition of fracture [23, 27].
women and young men. It is impossible to find the We can classify the factors affecting osteoporosis in many ways but in general as being a woman (women have Senile: It is observed in people aged 75 and over.
less bone structure), aged over 50, eating low calcium The osteoporosis-dependant fracture is hip fracture foods, less physical activity, mobilization or exercise or [21, 22 and 24].
amenorrhea. Physical activity has the protective effect onskeleton. Mechanical overload on bone stimulates bone formation. Short and slightly built people withosteoporotic individuals in the family have higher risk for General: Mass decrease is observed in all bones of osteoporosis in comparison to the portly and overweight the body [21].
people and body weight is among the important Local: There is always and underlying cause like determinants of bone mass. Weight applies mechanical immobilization [21]. The causes of local osteoporosis overload on skeleton and has a protective effect due to are: Fractures, Immobilization, Rheumatoid arthritis, the estrogen storage of fatty tissue. Fracture risk reduces Osteomyelitis, Primary and secondary tumors, due to the protective effect of fat pad during falling [10].
Algodystrophy (Reflex sympathetic dystrophy), Being light-skinned, hormonal levels (early menopause), Muscular paralysis, Temporaryosteoporosis of hip, not giving birth before, surgical menopause, high number Tendon rupture or denervation, Sickle cell anemia, of births, long time breast-feeding, using contraceptive Alkaptonuria [23].
pil s, being on some medications for a long time or in highdoses (corticosteroids, lithium, antacids, anticonvulsants, By Etiology: Classification of osteoporosis by
thyroid drugs), existence of some diseases (diabetes, etiologyand definition of a secondary cause of hyperthyroidism, paralysis, some rheumatic diseases, osteoporosis will be able to enable a specific treatment malign diseases, Koah, lifestyle, dieting, smoking, of this special cause [3, 25].
overconsumption of alcoholic, cola and caffeinated drinksare the main factors affecting osteoporosis [11, 26-30].
Primary: There is no underlying disease or cause The classification about the risk factors related to osteoporosis is stated in Table 1. Secondary: There may be many underlying diseases According to the agreement made in Canada in 2006, or causes such as endocrine causes, gastrointestinal the risk factors affecting osteoporosis were classified as major and minor risk factors (Table 2). As most of the immobilization, malign diseases, drug utilization osteoporosis-dependant fractures result from falling, falling risk factors were evaluated [7, 10].
Middle-East J. Sci. Res., 20 (8): 893-899, 2014 Table 1: Risk Factors Related to Osteoporosis [10, 27 and 29].
Factors about lifestyle: Intake of low level of calcium, vitamin D deficiency, vitamin A surplus, Aluminum (it exists in antacids),Immobilization, Weakness, High amount of caffeine intake, High amount of salt intake, Alcohol (3 or more drinks a day), Inadequate physical activity, smoking (active or passive), Genetic disorders Cystic fibrosis, Homocystinuria, Osteogenesisimperfecta, Ehlers-Danlos, Hypophosphatasia, Porphyria,Glycogen storage diseases, Idiopathic hypercalciuria, Riley-Day syndrome, Gaucher disease, Marfan syndrome, Hemochromatosis, Menkes syndrome Hypogonadal conditions Androgen insensitivity, Hyperprolactinemia, Athletic amenorrhea, Anorexia nervosa and bulimia,Panhypopituitarism, Premature ovarian failure, Turner and Klinefelter syndromes, Endocrine disordes, Cushingsyndrome, Hyperparathyroidism, Thyrotoxicosis, Adrenal insufficiency, Diabetes mellitus GI surgery, Malabsorption, Primary biliary cirrhosis, Inflammatory bowel disease, Celiac disease, Pancreas disease, Gastric bypass Hematological disorders: Haemophilia, Multiple myeloma, Systemic mastocytosis, Leukemia and lymphomas, Sickle-cell anemia,Thalassemia, Rheumatic and autoimmune diseases, Ankylosing spondylitis, Lupus, Rheumatoid arthritis Various conditions and diseases Alcoholism, Emphysema, Multiple sclerosis, Amyloidosis, End stage renal disease, Muscular dystrophy,Chronic metabolic acidosis, Epilepsy, Bone disease after transplantation, Congestive heart failure, Idiopathic scoliosis, Sarcoidosis, Depression, previous fracture in adulthood Anticoagulants (heparin), Cancer chemotherapy drugs, Gonadotropin releasing hormone agonists,Anticonvulsants, Cyclosporine A and tacrolimus, Lithium, Aromatase inhibitors, Stored medroxyprogesterone,Parenteral nutrition, Barbiturates, Glucocorticoid (=5 mg/day prednisoneor equivalent usage for =3 months) Table 2: Major and Minor Risk Factors [10].
MAJOR RISK FACTORS 1 MINOR RISK FACTORS Rheumatoid arthritis Compression fracture in vertebra Clinical hypothyroidism in the past Fragility fracture over the age 40 Usage of chronic anticonvulsant Osteoporotic fracture history in the family (particularly in mother with low-impact hip fracture) Calcium deficient nutrition Systemic glucocorticoid usage for more than 3 months Malabsorption syndrome Excessive alcohol intake Overconsumption of caffeine Inclination to falling Low body weight (<57 kg) Osteopenia diagnosed with X-ray Weight loss more than 10% of the body weight at the age of 25 Chronic heparin treatment MATERIALS AND METHODS
The analysis results were evaluated by using the questions in the above table. Whether the subjects are The purpose of this study is to Study The Factors osteoporotic was chosen as the dependent variable. Other Affecting Osteoporosis in Women With The Logistic variables in the questionnaire were regarded as Regression Analysis. The scope of the study is the explanatory variables. factors affecting women aged between 40 and 70 to be As the dependent variable is in a categorical data osteoporotic and the questionnaire was used as method.
type with two levels, binary logistic regression analysis However, as the dependent variable is in a categorical data type with two levels, binary logistic regression Omnibus test results that were carried out regarding analysis was applied. the significance of the model for beta coefficients are indicated in the table above. As the significance values of test statistics are 0.00<0.05, it is concluded that at least one beta coefficient is significant. In conclusion, it can be In this study, the factors affecting women aged uttered that the created logistic regression model is between 40 and 70 to be osteoporotic were analyzed.
A questionnaire was prepared for this study and the Hosmer-Lemeshow goodness of fit test results are below mentioned questions were directed to the indicated in the table above. As the significance value of subjects. The research was conducted on a total of Hosmer Lemeshow test statistics is 0.983>0.05, the model 250 patients.
was stated to have goodness of fit.
Middle-East J. Sci. Res., 20 (8): 893-899, 2014 Table 3: Some questions related to the variables statistics, all explanatory variables have effect on the subjects to be osteoporotic (p<0.05). Quantitative Are you osteoporotic? evaluations can be carried outconcerning explanatory variables by extracting the square root of beta coefficients. Accordingly, below inferences can be made Do you have osteoporosis history in the family? Amount of calcium (mg) 800-1200 about logistic regression model: Weekly exercise duration Have you gone through the menopause? When the ages of individuals increase 1 unit, the risk of being osteoporotic increases 8 times Tablo 4: Logistic regression analysis When the weight of individuals increases 1 unit, the risk increases 5 times. When the calcium amount of individuals increases 1 unit, the risk of being osteoporotic decreases by 60% Table 5: Hosmer and Lemeshow Test The risk of being osteoporotic for the individuals with osteoporotic people in the family is nearly 6 times higher than the ones without osteoporotic people in the family. Table 6: The logistic regression model and coefficients of determination When the weekly exercise duration of the individuals -2 Log Likelihood Cox & Snell R Square Nagelkerke R Square increases 1 hour on average, the risk of being osteoporotic decreases by 65% approximately. The risk of being osteoporotic for the individuals Table 7: Classification ratios regarding the logistic regression model who have gone through menopause is approximately 6 times higher than the ones who haven't. The risk of being osteoporotic for the smokers is approximately 2 times higher than the non-smokers.
Real Value Are you Osteoporosis is observed in women 5 times more than in men. Such factors as low bone mass and mineral content in women and estrogendeficiency-dependent Log-likelihood value regarding the logistic regression bone losses increase osteoporosis, therefore being a model and coefficients of determination are indicated in woman is an important risk factor in terms of osteoporosis the table above. Concerning Cox Snell and Nagelkerke coefficients of determination, it can be concluded that the Great contribution was made in determining the variable of being osteoporotic can be well explained by individuals prone to osteoporosis as defined according to explanatory variables. As the coefficients of determinant the DEXA measurements [7]. The purpose of this study are much higher than 0.50.
is to evaluate the factors affecting osteoporosis. In this Classification ratios regarding the logistic regression study, the relation of the risk factors that are directly model is indicated in the table above. According to the related to the personal characteristics with OP was results obtained, true classification ratio of the model was researched and various results were obtained. calculated as 88.80%. As per this value, it was established In literature, there are few number of studies which that the classification power of the model is considerably study the relation of risk factors with DEXA levels. The current studies are in specific disease groups (like renal Parameter prediction results belonging to the failure) [32]. In the research, such factors as whether they coefficients for explanatory variables are indicated in the are osteoporosis, age, weight, whether osteoporosis exist table above. According to the result of logistic regression in the family, the amount of calcium (mg) (800-1200) and analysis and concerning the significance values of test weekly exercise time, whether the person has gone Middle-East J. Sci. Res., 20 (8): 893-899, 2014 through menopause and smokes were evaluated.
In some studies, excessive intake and abuse of The analysis results were evaluated by using those tea/coffee and smoking have been stated as risk factors questions. Whether the subjects are osteoporotic was for OP [35]. It has been determined that tea and coffee chosen as the dependent variable. Other variables in the intake increases Ca excretion with diuretic effect [36].and questionnaire were regarded as explanatory variables. As smoking negatively affects bone density by causing an the dependent variable is in a categorical data type with increase in blood cortisol levels [7]. This result proves our two levels, binary logistic regression analysis was finding that the risk of being osteoporotic for the smokers is approximately 2 times higher than the non-smokers.
Following our study, it has been concluded that In other studies, it has been stated that additional when the ages of individuals increase 1 unit, the risk of medication is effective on femur neck T scores and being osteoporotic increases 8 times approximately; when particularly this disease and drug groups have an effect the weight of individuals increases 1 unit, the risk on hip BMI and also some drugs used accelerate OP increases 5 times; when the calcium amount of individuals development and have negative effect on BMI [4, 37-39].
increases 1 unit, the risk of being osteoporotic decreases In a study where the relation of dementia, depression by 60% approximately;the risk of being osteoporotic for and anxiety conditions of patients with balance is studied, the individuals with osteoporotic people in the family is it has been put forth that cognitive dysfunction assessed nearly 6 times higher than the ones without osteoporotic with MMT is related to both static and dynamic balance people in the family;when the weekly exercise duration of scores and presence of depression is only related to static the individuals increases 1 hour on average, the risk of balance score, anxiety is not related to balance. In studies being osteoporotic decreases by 65% approximately; the of literature where MMT scores of healthy individuals risk of being osteoporotic for the individuals who have and OP patients are compared, it has been manifested that gone through menopause is approximately 6 times higher existing dementia can be an effective factor on bone than the ones who haven't; and the risk of being density [37].
osteoporotic for the smokers is approximately 2 times We are of the opinion that the deficiency of our higher than the non-smokers. study is that the effects of depression factor, being In current studies containing the risk factors for illiterate factor and drug usage factor on osteoporosis osteoporosis in literature, it is stated that body mass index haven't been evaluated in detail.
has positive effect on bone density, mechanical pressure Some personal characteristics increasing the on bones reduces in case of falling, the estrogen amount probability of osteoporosis development and defined as due to the deficiency of fat tissue in those people is a risk factor may be utilized in determining the individuals insufficient in maintaining bone density and osteoporosis prone to osteoporosis [40]. This questionnaire which was risk increases [4, 33]. In a study carried out by Umay et al. carried out in a survey manner has no economic burden at [4] regarding the effect of osteoporosis risk factors on all. In conclusion, it can be uttered that a broad spectrum bone mineral density, it has been concluded that being fat study of risk factors is required in order to identify the or thin and illiterate, high numbers of pregnancy, cases with bone loss risk. insufficient Ca intake and cognitive dysfunctions have effect both on total lumbar and femur neck T scores; excessive consumption of tea and coffee, smoking, at least one comorbidity and additional medication has effect In this study, the factors affecting women aged only on femur neck T scores [4]. Our study and the one between 40 and 70 to be osteoporotic were analyzed with carried out by Umay et al. [4] have similar results. In the the technique of logistic regression analysis. According only study where the relation between BMI and DEXA to the analysis results, such factors as age, weight, the levels is evaluated, Ersoyet all. have stated that amount of calcium, exercise duration, genetic factors, osteopenia and OP are observed more in correlation to the whether the person has gone through menopause and decrease in BMI in dialysis patients [32]. In another smoking have significant effect on individuals to be study, the relation between the number of pregnancy and osteoporosis was studied and it has been found out that According to the analysis results, the older and the Ca need of body increases in correlation to the increase in heavier individuals are, the higher risk for osteoporosis is number of pregnancy and accordingly long lactation in question. Concerning the individuals with osteoporotic period leads to osteoporosis [34].
people in the family, genetic factors increase the risk of Middle-East J. Sci. Res., 20 (8): 893-899, 2014 osteoporosis. When the calcium level of individuals 10. Eryavuz, M., 2002. Osteoporozun Tan m , reduces, the risk for osteoporosis increases. The more S n fland rmas Ve Epidemiyolojik Çal malar. Gökçe, individuals do weekly exercise, the less risk for Y.K. (editor). Fiziksel T p ve Rehabilitasyon, osteoporosis is. Going through menopause and increase in smoking raise the risk for osteoporosis. 11. Tüzün, E.H., 2013. Kad nlarda Osteoporoz ve In conclusion, In order to reduce the risk for Rehabilitasyonu, Aile Ve Kad n Sempozyumu, osteoporosis are losing weight, increasing weekly exercise K r kkale University Cultural Center, K r kkale, pp: 16 duration, paying attention to the calcium level in the body and reducing smoking, particularly the individuals being 12. International Osteoporosis Foundation. 2004. The older and going through menopause should be more Facts About Osteoporosis And Its Impact. Lyon, France: International Osteoporosis Foundation, 2004.
13. Kramer, A.M., 1997. Outcome And Costs After Hip Fracture And Stroke, JAMA; 277: 396-404.
14. Lyles, K., 1993. Osteoporotic Vertebral Compression 1. Kanis, J.A., 1997. Osteoporosis and its Fractures: Their Association With Impaired Consequences; 1-21, Kanis J. A. (ed.) Osteoporosis.
Functional Status, Am J. Med., 94: 595-601.
Blackwell Healthcare Communications Ltd. London. 15. Magaziner, J., 1990. Predictors Of Functional 2. Kanis, J.A., N. Burlet, C. Cooper, P.D. Delmas, Recovery One Year Following Hospital Discharge J.Y. Reginster, F. Borgstorm and R. Rizzoli, 2008.
For Hip Fracture: A Prospective Study, J Gerontol; European Guidance For The Diagnosis And Management Of Osteoporosis In Postmenopausal 16. Randell, A., 2000. Deterioration In Quality Of Life women. Position Paper. Osteoporosis International Following Hip Fracture: A Prospective Study, Consensus development conference: Prophylaxis Osteoporosis Int., 11: 460-6.
And Treatment Of Osteoporosis. Br Med. J., 1987.
17. Ray, N., 1997. Medical Expenditures For The 295(6603): 914-5.
Treatment Of Osteoporosis in The United States in 3. Ekizo lu, ., 2007. Postmenopozal Kad nlarda 1995: Report From The National Osteoporosis Osteoporoz Prevelans Ve Risk Faktörleriyle li kisi Foundation. J. Bone Miner. Res., 12: 24-35.
Ministry of Health, Taksim Training And Research 18. Jette, A., 1987. Functional Recovery After Hip Hospital, stanbul.
Fracture, Arch. Phys. Med. Rehabil., 68: 735-740.
4. Umay, E., U. Tamkan, . Gündo du, S. Umay and A.
19. Kanis, J.A., 1994. Pathogenesis Of Osteoporosis And Çakc , 2011. Osteoporoz Risk Faktörlerive KMY, Fracture; 22-55, Kanis J.A.(ed.) Osteoporosis.
Turkish Osteoporosis Journal, 17: 44-50.
Blackwell Healthcare Communications Ltd. Oxford. 5. Sindel, D., 2013. Günümüzde Ve Gelecekte 20. Osteoporozda Konsensus; Osteoartrit - Osteoporoz Tedavisi, Türk Fiz T p Rehab Journal., Osteoporosis Congress; 1-4 October 1998 Antalya.
Diagnosis and Treatment In Osteoporosis (ed) 6. Meray, J., Ö. Peker, Ö. El and Z. Günendi, 2012.
Göksoy T. 2000.
Osteoporoz Tan m Ve Sosyo-Ekonomik Boyutu, 21. Kahveci, N.A., 2007. Postmenopozal Kad nlarda Osteoporozda Tan Ve Tedavi 2012, Turkish Osteoporoz Prevelans Ve Risk Faktörleriyle li kisi, Osteoporosis Society Publication.
Dissertation, Taksim Training and Research Hospital, 7. P nar, G., T. P nar, N. Do an, A. Karahan, L. Alg er, A. Abbaso lu and E. Ku çu, 2009. K rkbe Ya ve 22. Tüzün, F., 1999. Osteoporozun Tan m , S n flamas Üstü Kad nlarda Osteoporoz Risk Faktörleri, Dicle Ve Epidemiyolojisi. Continuous Medical Education Medical Journal, 36(4): 258-266.
Activities Osteoporosis Symposium, pp: 9-15.
8. Harmanc , G., 2011. Osteoporoz Tedavisi.
Tan l Ve Osteoporoz http://www.e-kutuphane.teb. org. tr/pdf/ mised/ Riski Olan Postmenopozal Kad nlarda Kantitatif Mr Görüntülemenin Tan ya Katk s n n 9. WHO, 1994. Research On The Menopause In The De erlendirilmesi, Dissertation, Gazi University 1990s, WHO Technical Report Series 866, Geneva Faculty Of Medicine, Department Of Radiology, Middle-East J. Sci. Res., 20 (8): 893-899, 2014 24. Khosla, S., B.L. Riggs and L.J. Melton III. 1990.
33. Berecki-Gisolf, J., M. Spallek, R. Hockey and Clinical Spectrum; 205-223, Riggs B.L.Melton III A. Dobson, 2010. Height Loss In Elderly Women Is L.J.(eds.) Osteoporosis Etiology, Diagnosis and Preceded by Osteoporosis And Is Associated With Management, Lippincott- Raven,.
Digestive Problems And Urinary Incontinence.
25. Çelebio lu, G., 1999. Osteoporozda Tan mlama, Osteoporosis Int., 21: 479-85.
S n flama Ve Klinik; Galenos Medical Journal., 34. Ho, S.C., Y.M. Chen, J.L. Woo and S.S. Lam, 2004.
High Habitual Calcium Intake Attenuates Bone Loss 26. Biberoglu, S., 1998. Osteoporozun Patogenezi, In Early Postmenopausal Chinese Women: An 18- Month Follow-Up Study. J., Clin. Endocrinal. Metab., 27. Nas, K. and R. Çevik, 2000. "Osteoporozda Risk 89: 2166-70.
Faktörleri" Osteoporozda Tan ve Tedavi, (Editor: 35. Spector, T.D., A.C. Edwards and P.W. Thompson, Turgut Göksoy), Özlem Grafik Matbaac l k.
1992. Use Of A Risk Factor And Dietary Calcium 28. Okumu , M. 2011. Osteoporoz Nedir, Tedavi Edilebilir Questionnaire In Predicting Bone Density And mi?, http://www. geriatri. org. tr/ Sempozyum Kitap Subsequent Bone Loss At The Menopause. Ann Rheum Dis., 51: 1252-3.
29. Aydil, S., 2005. Osteoporozda Egzersiz Program n n 36. Kutsal, Gökçe, Y., 2000. Osteoporoz. In: Gökçe- Solunum Fonksiyonlar na ve Ya am Kalitesine Etkisi, Kutsal Y, Beyazova M (eds). Fiziksel T p ve T.R. Ministry of Health stanbul 70.y l Physical Rehabilitasyon Volume 2. 1st ed. Ankara; Güne Therapy and Rehabilitation Training And Research Bookstore. pp: 1872-93.
37. Assantachai, P., W. Angkamat, P. Pongpim, 30. Uçan, Ö., S. Ta c and N. Ovayolu, 2007.
C. Weattayasuthum and C. Komoltri, 2006. Risk Osteoporozda Risk Faktörleri ve Korunman n Önemi, Factors Of Osteoporosis In Institutionalized Older F rat Health Services Journal., 2: 6. Thai People. Osteoporosis Int.,17: 1096-102.
31. Nayak, S. and M.S. Roberts, 2009. Greenspan SL.
38. Chen, Y.T., P.D. Miller, E. Barrett-Connor, Factors Associated With Diagnosis And Treatment T.W. Weiss, S.G. Sajjan and E.S. Siris, 2007. An Of Osteoporosis in Older Adults. Osteoporosis Int., Approach For Identifying Postmenopausal Women Age 50-64 Years At Increased Short-Term Risk For 32. Ersoy, F.F., S.P. Passadakis, P. Tam, E.D. Memmos, Osteoporotic Fracture. Osteoporosis Int., 18: 1287-96.
P.K. Katopodis, C. Ozener, F. Akçiçek, T. Camsari, 39. Thompson, J.M., G.W. Modin, C.D. Arnaud and K. Ate , R. Ataman, J.G. Vlachojanniz, A.N. Dombros, N.E. Lane, 1997. Not All Postmenopausal Women On C. Uta , T. Akpolat, S. Bozfakio lu, G. Wu, I.
Chronic Steroid And Estrogen Treatment Are Karayaylali, T. Arinsoy, P.C. Stathakis, M. Yavuz, Osteoporotic: Predictors Of Bone Mineral Density.
J.D. Tsakiris, C.A. Dimitriades, M.E. Yilmaz, M.
Calcif Tissue Int., 61: 377-81.
Gültekin, B. Karayalçin, M. Yard msever and D.G.
40. Eravuz, M., 1998. Osteoporoz Epidemiyolojisi. Gökçe, Oreopoulos, 2006. Bone Mineral Density And its Kutsal Y (ed) Osteoporoz, pp: 8-32.
Correlation With Clinical And Laboratory Factors in Chronic Peritoneal Dialysis Patients. J Bone MinerMetab 2006; 24: 79-86.

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