Kingdom of Saudi Arabia

King Saud
Bin Abdul-Aziz University for Health Sciences

College of Nursing

Epidemiology and Population-based health care

Course Code (EPI 323)

Submitted to

Dr. Tagwa Yousef Omer

Submitted by

Students name ID

Ruya alharbi 39-1-22-0568

Shahad almotiri 39-1-22-0589
Samaher almutairi 39-1-22-0583
Wed alsulami 39-1-22-0649
Lama alshehri 39-1-22-0621

Spring 2021
 • Formulate a clinical question

Are women aged more than 40 years old who are tea drinkers have a higher

potentiality of having increased bone strength compared with those of non-tea

drinkers?

• Tile of the Article

Tea consumption is associated with increased bone strength in middle-aged and

elderly Chinese women

• Background

Huang et al. (2018) present background information in regard the first

variable that is bone strength. They started with discussing the term Osteoporosis

and declared that it is a progressive systemic skeletal disorder that is characterized

by low bone mass and microarchitectural deterioration of bone tissue that may

lead to have a decrease in bone strength and an increased risk of fracture. They

declared cause of choosing one aspect of the population that is being over 40 years

stating that with the aging of the population, osteoporosis become a serious public

health problem worldwide.

The researchers in a very good manner convey each word in the title of the

study as they then stated that Women are around four times more likely to develop

osteoporosis than men because of their generally lighter and thinner bones in

conjunction with a decrease in their estrogen levels after menopause. The

researchers in the previously stated declared the cause for choosing women as a

| P a g e ١

 sample. They support their information with evidences and worldwide

estimations.

The researchers then introduce a background ides about Bone mineral

density (BMD) and bone geometry that are two major determinants of bone

strength and two independent predictors in assessing the risk of osteoporotic

fracture. They introduce the widely used measures for determining the bone

strength. If this part moved to the part the researchers describes their measures it

would be better.

The researchers then introduce information in relation to the second

variable that is tea and ends their introduction with the research gab of their

research that some studies have detected the relationship between tea consumption

and BMD, but the results are controversial. In addition, studies about the effect of

tea on bone geometry were limited. At the end of the introduction they stated their

aim that is "we aimed to evaluate the associations of tea consumption with both

BMD and bone geometry in middle-aged and elderly Chinese women"(Huang et

al., 2018, p.216).

• Study Objectives

This study aimed to examine the associations of tea consumption with hip

bone strength in Chinese women.

• Methodology

Ø Study Design

Cross-sectional study

| P a g e ٢

 Ø Setting

The study was conducted in the city of Guangzhou in in southern China.

Ø Participants

A total number of 1,495 Chinese women who are aged more than 40 years

were included. The participants were from an ongoing Guangzhou Nutrition and

Health Study. it was a cohort study that started in 2008. The examination data

conducted between June of the year 2010 and December of the year 2013 were used.

Ø Data Collection Method

Data in regard to tea consumption, socio-demographic information and lifestyle habits

were collected using a face-to-face questionnaire. On the other hand, dual-energy X-

ray absorptiometry was used to collect data in regard to Hip bone mineral density

(BMD) and geometric parameters such as cross-sectional area (CSA), section

modulus (Z) and buckling ratio (BR), were generated by

• Results

The group of tea drinkers that included 732 participant had approximately 1.9%

higher BMD (p value < 0.05) and 3.6% lower BR (p value < 0.05) than non-tea

drinkers (n = 763). The dose-response relationships of the three measures of BMD,

BR or CSA with total consumption of tea were identified (p-trend < 0.05). Drinking

of tea was found to be a significant and independent predictor of BMD (β = 0.068, p <

0.05) or BR (β = -0.079, p < 0.05).

• Conclusions

| P a g e ٣

 Consumption of tea was associated with increased in bone strength in middle-

aged and elderly Chinese women.

• Critical Appraisal of the quality of the study

Critical Appraisal Toolkit for Cohort Studies

1. Did the review ask a clearly-focused question?

Yes

It is clear that the study tried to detect a beneficial effect for tea consumption

among Chinese women? However, the researchers did not state a question for their

study but they state an aim "We aimed to examine the associations of tea consumption

with hip bone strength in Chinese women" (Huang et al., 2018, p.216). Only through

this aim we can suggest that the question of the researchers is "what is the relation

between tea consumption and hip bone strength among Chinese women?"

2. Did the authors use an appropriate method to answer their question?

Yes But

The retrospective cohort was an appropriate method but the researchers

collected data related to consumption of tea over the last one year only. No reason for

this too short period was stated by the researchers. This might not accurately reflect

their long-term habits of tea drinking. From our point of view there is no

interpretation or cause for choosing this short period at all. It is true that the

researchers stated that tea drinking is generally a relatively stable habit, and

Guangzhou is a city with a very long history of tea culture and with a large proportion

| P a g e ٤

 of tea drinkers. Thus, their data might reflect the long-term habits of tea drinking to

some extent. However, this is not an excuse for the researchers to collect data in

regard to the last year only. On the contrary, this may an excuse to have been

considering a long period ( in short, the researchers are in the city of tea but they

thought of collecting data of tea consumption for one year only).It would be more

appropriate and would add to the level of evidence of the study if the researchers

collected data over 10 or 15 years.

3. Was the cohort recruited in an acceptable way?

No

The researchers entitled their research "Tea consumption is associated with

increased bone strength in middle-aged and elderly Chinese women". Therefore, from

what stated in the title the sample would be a group of middle-aged and elderly

Chinese and this group should represent all middle-aged and elderly Chinese women.

Moreover, The aim of the study stated by the researchers is "This study aimed to

examine the associations of tea consumption with hip bone strength in Chinese

women". Therefore, from the aim stated by the researchers, the sample would be a

group of middle-aged and elderly Chinese and this group should represent all middle-

aged and elderly Chinese women. The group that was selected by the researchers is

ordinary urban middle-aged and elderly women in once city in southern China.

This city is Guangzhou. Hence, this sample doesn’t represent the sample stated

in the aim. More identification for the setting was need in the title and in the aim of

the study. According to the sample that was selected by the researchers it would be

| P a g e ٥

 better if the title was "Tea consumption is associated with increased bone strength in

middle-aged and elderly Chinese women in Guangzhou city".

4. Was the exposure accurately measures to minimize bias?

Yes to some extent

In regard to tea consumption, there is no indication in the study for the

procedures of testing the validity and reliability of the used questionnaire. However,

there was a consideration for collecting subjective and objective data. The participants

completed a face-to-face interview performed by trained staff using a structured

questionnaire. There were four questions on tea drinking. The first question was:

“Have you drunk tea twice or more times per week in the past year?” Subjects who

answered “yes” were coded as tea drinkers and then completed questions on the

number of times of tea drinking per week (times), the total consumed quantities (kg)

of tea and the types of tea (i.e. green tea, black tea, oolong tea and dark tea) over the

past year.

In regard to assessments of covariates or dietary intake there is no indication in

the study for the procedures of testing the validity and reliability of the used

questionnaire. Dietary intake was assessed using a quantitative and 81-item food

frequency questionnaire. However, there was a consideration for collecting subjective

and objective data. The researchers considered the numbers of individuals who drinks

green tea109 (14.9%), black tea110 (15.0%), oolong tea 229 (31.3%) and dark tea

284 (٪٣٨٫٨). The medium values of dietary nutrient intakes were around 65.90 g/d

and 575.03 mg/d for protein and calcium, respectively. Approximately 29.6% of the

participants had taken calcium tablets more than 30 times in the past year, ٪٢٨٫٥were

active or passive smokers and 3.3% were alcohol drinkers. The mean (SD) values of

| P a g e ٦

 BMD, BR, CSA and Z of all subjects were 0.844 (0.144) g/cm2, 10.929 (2.784),

2.434 (0.394) cm2 and 1.105 (0.224) cm3, respectively.

5. Was the outcome accurately measured to minimize bias?

Yes

To minimize bias the researchers considered the type of tea. In the 732 tea

drinkers, the differences in bone phenotypes among the subgroups classified by the

types of tea (green, black, oolong and dark tea) were not significant (p > 0.05).

6. Have the authors identified all important confounding factors? Have they

taken account of confounding factors in design and/or analysis?

No

Subjects with chronic diseases or conditions that might affect bone mass and

metabolism, such as having a history of metabolic bone disorder or left hip fracture,

chronic medical illness, endocrine diseases including hyperthyroidism, medications

that might affect bone and calcium metabolism, bilateral oophorectomy, major

gastrointestinal operations, premature menopause at age < 40 years, or being

prescribed medicines such as calcitonin, bisphosphonates, selective estrogen receptor

modulators and active vitamin D3 metabolites. Ultimately, 1,495 women with bone

measurement data and who responded to the questionnaires were included in this

study.

| P a g e ٧

 7. Was the follow up of subjects complete and long enough?

No

The researchers collected data related to consumption of tea over the last one

year only. No reason for this too short period was stated by the researchers. This

might not accurately reflect their long-term habits of tea drinking. From our point of

view there is no interpretation or cause for choosing this short period at all. It is true

that the researchers stated that tea drinking is generally a relatively stable habit, and

Guangzhou is a city with a very long history of tea culture and with a large proportion

of tea drinkers. Thus, their data might reflect the long-term habits of tea drinking to

some extent. However, this is not an excuse for the researchers to collect data in

regard to the last year only. On the contrary, this may an excuse to have been

considering a long period ( in short, the researchers are in the city of tea but they

thought of collecting data of tea consumption for one year only).It would be more

appropriate and would add to the level of evidence of the study if the researchers

collected data over 10 or 15 years.

8. What are the results of this study?

There were significant trends of increased BMD, CSA (p = 0.006 and 0.042)

and decreased BR (p = 0.003) with the larger quantity of total tea consumption.

Compared with those who consumed less than 1.0 kg over the past year, the

individuals who consumed more than 4.2 kg of tea had approximately 3.0% higher

BMD, 4.7% lower BR and 2.0% higher CSA, respectively.

9. How precise are the results/ is the estimate of risk?

The study is a cohort of evel 3 evidence. The results were obtained from a

considerable sample size of 1,495 women recruited from communities in Guangzhou

| P a g e ٨

 city, with consideration given to a relatively large range of confounding factors and

with good assessments of bone phenotypes.

10. Do you believe the results?

Yes

The results cannot be due to bias or chance or confounding. The study design and

Methods followed by the researchers are sufficient. Our claim is only on the period of

follow up?

11. Can the results be applied to the local population?

Yes

The findings in this study might be generalizable to ordinary urban middle-

aged and elderly women in southern China. The results were obtained from a

considerable sample size of 1,495 women recruited from communities in Guangzhou

city, with consideration given to a relatively large range of confounding factors and

with good assessments of bone phenotypes.

12. Do the results of this study fit with other available evidence?

Yes

Results of this study fit with other available evidence such as the study of Chen et al

(2013) that observed that with the 12 weeks supplementation of (-)-epigallocatechin-

3-gallate (EGCG), a bioactive substance in tea, the ovariectomy-induced osteopenic

rats showed increased bone volume, trabecular number, and trabecular thickness and

decreased trabecular separation, which suggested the protective effects of EGCG on

bone microarchitecture. The sample size of Ng et al (2014) was 2,398 individuals

| P a g e ٩

 aged more than 55 years. They found that tea consumption was related to the better

performance in physical function. In addition, a 6-month randomised placebo-

controlled trial conducted in postmenopausal osteoporotic women suggested that the

polyphenols in tea could improve leg strength (Shen et al., 2012). These studies

indirectly support the role of tea in promoting the stability and strength of bone. The

positive association between tea drinking and BMD at the hip was also observed in

this study.

| P a g e ١٠

 References

Huang, H., Han, G., Y., Jing, L., P., Chen, Z., Y., Chen, Y. M. &., Xiao, S., M.

(2018). Tea consumption is associated with increased bone strength in middle-

aged and elderly Chinese women, J Nutr Health Aging. 22(2), 216-221.

Chen, C., Kang, L. & Lin. R. (2013). (−)-Epigallocatechin-3-gallate improves bone

microarchitecture in ovariectomized rats., Menopause. 20(6), 687-694.

Ng, T., P, Aung K.,C., Feng, L., Feng, L., Nyunt, M.,S., Yap, K., B. (2014). Tea

consumption and physical function in older adults: a cross-sectional study. J

Nutr Health Aging. 18(2), 161-166.

Shen, C., L., Chyu MC, Yeh JK, et al. Effect of green tea and Tai Chi on bone health

in postmenopausal osteopenic women: a 6-month randomized placebo-

controlled trial. Osteoporosis Int., 23(5),1541-1552.

| P a g e ١١