OSTEOPOROSIS

Introduction

Osteoporosis was once thought to be an inevitable result of getting old. However, it is now recognized to be a treatable disease, that can often be prevented.

Osteoporosis affects about 20-25 million Americans and is more common in women. Approximately 50% of Caucasian women and 25% of Caucasian men will have an osteoporotic fracture sometime during their life. Treatment related to these fractures costs ~$14 billion annually in the United States; a cost projected to exceed $60 billion by the year 2030.

What is Osteoporosis?

The word "osteoporosis" is made up of two parts: "osteo" refers to bone and "porosis" means porous. Thus, osteoporosis refers to bones that have become weaker due to loss of calcium, other minerals and proteins. Because of this weakening, fractures may occur with normal activities. In the absence of fractures, osteoporosis does not cause symptoms.

The most common sites of osteoporotic fractures are the wrist, spine and hip. Hip fractures are often due to falling. This is the most serious osteoporotic fracture as afterwards many people can no longer walk unaided or live independently. Wrist fractures are painful and sometimes require surgery. Spine fractures may result in curvature of the spine (dowager's hump), loss of height and pain. However, it is important to recognize that "silent" or painless fractures of the spine are common. As such, height loss without pain may be an indicator of spine fracture.

What Causes Osteoporosis?

Osteoporosis is often the result of a combination of factors. One is failure to obtain an optimal level of bone mass as a young adult. This may simply be genetic, as approximately 70% of a person's peak bone mass is due to their inheritance. Once peak bone mass is reached at about age 30, it remains relatively stable until approximately age 50 or the time of menopause. However, other factors such as calcium inadequacy, anorexia or hormone deficiency during adolescence can contribute to a person attaining a lower peak bone mass. Subsequently, bone loss may be due to inadequate nutrition, a sedentary lifestyle, certain illnesses or medications, and lifestyle factors such as use of tobacco and alcohol. Additionally, in women entering menopause, rapid bone loss occurs when the ovaries stop making estrogen. This loss occurs rapidly over approximately five years. Subsequently slower rates of bone loss occur as a person ages. In men, bone loss often begins at approximately age 50.

Do I Have Any Osteoporosis Risk Factors?

Every woman is a risk for developing osteoporosis as one out of every three women will have a vertebral fracture and one out of every six women will have a hip fracture during their lifetime. Along with being female and getting older, there are other risk factors associated with bone loss. Some of the risk factors can be changed while others cannot be changed.

Risk factors you cannot change include:

• Age
• Gender - being female
• Genetics - family history
• Ethnicity--Caucasian
• Premature menopause.
• Medications that may cause bone loss - corticosteroids, thyroid (excess use), heparin, methotrexate, anticonvulsants.
• Some surgeries - gastrectomy or intestinal bypass.
• Some diseases - hyperthyroidism, hyperparathryoidism, Cushing's, anorexia nervosa, and malabsorption.

Risk factors you can change include:

• A diet low in calcium and /or vitamin D
• Too little or too much exercise
• Smoking
• High caffeine intake
• Alcohol abuse

Steps to Prevent Bone Loss

Good Nutrition

Calcium and vitamin D are needed to keep bone healthy. Calcium is a mineral that gives bones their strength and hardness. Without calcium bones would be soft and break easily. It is common for people to have too little calcium in their diet. In fact, many women get less than one half of the daily amount of calcium they need. The daily recommended intake for calcium at specific ages are given below (recommended by National Academy of Science, 1997 ):

Recommended Calcium Intakes

If the amount you eat does not equal the amount needed, you can either make changes in your diet or add a calcium supplement.

The type of supplement you take and how you take it is important. Calcium carbonate and calcium citrate are good choices. Chewable supplements may be better absorbed. Some calcium supplements come as a powdered form which can be used in baked products or sprinkled into beverages or soups.

Other points to remember:

-Take calcium supplements with food as this improves absorption.

-Do not take more than 600 mg of calcium at one time; if you need more than this, divide the dose to improve absorption.

-Some people find that calcium causes constipation. In this case, slowly increase the amount of calcium you are taking over ~ two weeks. At the same time, increase fluid intake and the amount of dietary fiber.

-You may wish to use either calcium phosphate or calcium citrate if you notice increased gas.

-If you or someone in your family have ever formed kidney stones, talk to your health care provider before starting to take extra calcium.

-It is important to carefully read the label of supplements to determine the exact amount of calcium you are receiving per tablet.

Vitamin D

Vitamin D is also important in bone health and many people, particularly those living at northern latitudes are insufficient. In order for calcium to be absorbed optimally by the body, vitamin D must be present. You should receive 400-600 IU of vitamin D each day. Doctors may recommend doses in excess of this range when blood vitamin D levels have been measured and are being monitored. A good source of vitamin D is 15 minutes of midday sun. Other options for getting vitamin D include:

• Three to four glasses of fortified milk per day.
• Frequent servings of fish such as cod, tuna, salmon, herring, halibut, mackerel, shrimp, and oysters.
• Frequent servings of margarine or fortified cereals.

As sun exposure and dietary intake are often inadequate, many people need to take vitamin D as a supplement or in a multiple vitamin.

EXERCISE

Weight Bearing Exercise

People at complete bed rest or in a weightless state (space travel) can lose bone. Conversely, weight bearing exercise can increase bone mass. For this reason, regular weight bearing exercise along with proper diet should be part of a bone health program.

Weight bearing exercise includes walking, jogging, racquet sports and dancing. Walking is not only good for keeping you healthy, but may also boost your spirits. Swimming, biking, or rowing, although good for your heart health, do not provide weight bearing activity.

Studies have shown that if you have joint problems you may consider walking across the floor of a swimming pool for weight bearing activity. In this activity the water supports your body and reduces stress to the joints.

Strength Training

Strength training exercises strengthen specific muscles or groups of muscles. Many different types of exercises can be used to strengthen various muscle groups. Often weight lifting equipment or free weights such as dumbbells are used to perform strength training. If you wish to begin a strength-training program, first consult with a fitness trainer or someone who can design a program for you.

Starting an Exercise Program

If you are not exercising regularly and you are over 40 years of age, talk to a health care provider before getting started. Furthermore, you should not begin an exercise program without discussing it with your health care provider if you have any of the following symptoms:

• Chest, arm or neck pain
• Sudden shortness of breath, or shortness of breath with activity or while lying down
• Pain in your legs while walking
• Rapid heart rate
• Feeling faint or dizzy
• Ankle swelling

DIAGNOSIS

The only way to diagnose osteoporosis before a fracture occurs is to measure bone mineral density. These safe, painless and accurate tests are known as Bone Mineral Density (BMD) tests use a small amount of radiation (less than the amount you receive daily from background radiation) or ultrasound. Although bone density can be measured at the finger or heel, a diagnosis cannot be made without measurement at the hip, spine or wrist. Osteoporosis is not usually diagnosed by routine x-ray.

It is recommended that the BMD be measured in people who:

• Are thinking about starting hormone replacement therapy.
• Are taking steroids, anticonvulsants, or have been taking an excessive dose of thyroid hormone.
• Have primary hyperparathyroidism.
• Have a recent fracture and osteoporosis is suspected.
• Are monitoring an osteoporosis treatment.
• Have multiple risk factors.

A bone mineral density test will compare the result with that of an average young adult and compute a "T-score" which is used to diagnose osteoporsis. Using this approach the World Health Organization has categorized bone mass as follows:

• Normal: T-score of - 1 or above
• Osteopenia: T-score between -1 and - 2.5.
• Osteoporosis: T-score below -2.5.
• Severe osteoporosis: T-score below - 2.5 plus a prior low trauma fracture.

MEDICATION

Medications approved by the FDA to prevent or treat osteoporosis include the following:

Estrogen: The use of estrogen is currently very controversial. However, estrogen replacement at menopause often prevents the rapid loss of bone seen at the time of menopause. Additionally, initiation of estrogen after menopause increases BMD. The decision to utilize estrogen must be individualized as potential risks should be evaluated with a health care provider.

Raloxifene: Raloxifene (Evista) is a SERM (selective estrogen receptor modulator). This class of medications act like estrogen in certain parts of the body, but as an estrogen blocker in others. This medication modestly increases bone mass and reduces spine fractures. It does not appear to have adverse effects on the breasts or uterus. Side effects include hot flashes and an increased risk of blood clots. It should not be used in women with a history of blood clots or during periods of immobilization.

Calcitonin: Calcitonin (Miacalcin) is a naturally occurring hormone produced by cells in the thyroid gland. It may stabilize bone mass or relieve pain caused by fractures. It is usually administered as a daily nasal spray. The most common side effect is nasal irritation.

Alendronate: Alendronate (Fosamax) is a nonhormonal medication used to prevent and treat osteoporosis. It is well tolerated by most people and reduces risk of all osteoporotic fractures by ~50%. Side effects may include irritation of the esophagus (swallowing tube) and other GI symptoms. Alendronate should be taken with a full glass of water in the morning 30 minutes before eating. People should not lay down or eat for at least 30 minutes after taking it. It is now available in a daily or once weekly dose.

Risedronate: Risedronate (Actonel), is a nonhormonal medication used to prevent and treat osteoporosis. It is similar to Alendronate in its action on bone density and fracture reduction. It has been shown to reduce spine and hip fractures in women with osteoporosis. Side effects and dosing regimen are similar to alendronate (see above), however this is currently only approved as a daily dose.

Parathyroid Hormone: Parathyroid hormone (Forteo) has recently been approved for use in people with osteoporosis. It increases bone mass and reduces fracture risk. Side effects include occasional nausea and headache. It requires a daily subcutaneous injection as well as monitoring of blood and urine tests. This medication is not yet available.

FALL PREVENTION

If you have osteoporosis, it is important you try to prevent falls.

Lifestyle:

• Maintain a regular exercise program to improve muscle strength and tone and keep joints flexible. Continue regular weight bearing activity such as walking. Individuals with a history of falls may benefit from a specific exercise program to improve balance.
• Have vision and hearing tested annually.
• Limit alcohol intake.
• Be careful not to get up too quickly. Rapid changes in body position can cause dizziness in some people.
• Be careful when walking on uneven surfaces, wet, or icy pavements. Use a cane or walker to help keep your balance.
• Wear supportive rubber-soled shoes or low-heeled shoes.
• If you are taking medications, talk to a doctor or pharmacist about side effects that could affect balance or coordination.

Make your home safe:

In stairways, hallways, and pathways be sure:

• There is good lighting and living areas are free of clutter.
• Carpets are firmly attached, have a rough texture, or have abrasive strips to ensure stable footing.
• Handrails are tightly fastened and run the entire length and along both sides of all stairs.
• Light switches are at both the top and bottom of the stairs.

Bathrooms should have:

• Grab bars in the tub or shower and near the toilet.
• Nonskid mats, abrasive strips or carpet on all surfaces that may get wet.
• Night lights.

Bedrooms should have:

• Night lights or light switches within reach of bed.
• Telephone near the bed.
  

Living areas should have:

• Electrical cords and telephone wires placed out of walking paths.
• Well secured rugs.
• Furniture of proper height to get into and out of easily.

SUMMARY

Maintaining healthy bones is vital to healthy aging. To reduce the risk of getting osteoporosis take the following steps:

• Avoid smoking and excessive use of alcohol
• Exercise 4-7 times per week (weight bearing activity).
• Get enough calcium and vitamin D each day.
• Talk with your health care provider about further risk reduction and bone loss prevention

SUGGESTED READING

Strong Women, Strong Bones: Everything You Need to Know to Prevent, Treat, and Beat Osteoporosis. Nelson, 2000, A Perigee Book, Published by the Berkley Group, A division of Penguin Putnam Inc., 375 Hudson Street, New York, New York 10014
Comprehensive information on good nutrition, proper exercise, and medication management.

The Osteoporosis Handbook: The Comprehensive Guide to Prevention and Treatment. Bonnick, 3rd Edition, 2000, Published by Taylor Trade Publishing, An Imprint of the Rowman & Littlefield Publishing Group, 4720 Boston Way, Lanham, Maryland 20706
The Osteoporosis Handbook, which has already helped thousands of people treat and prevent this disease, has now been updated with the most current and up-to-date medical information available. The book includes detailed information on cutting-edge medical treatments, with an entirely new chapter on Fosamax and other biphosphonates.

Fighting Osteoporosis. Williams, 2002, Hamlyn, a division of Octopus Publishing Group Ltd, 2-4 Heron Quays, London E14 4JP
Osteoporosis is a bone deficiency that causes brittle bones, curved spines, and fractures in as many as 50% of women over 50 and 90% of those over 75 years old. This user-friendly guide, with lots of color photography, details current research findings on the causes and symptoms of osteoporosis, as well as who is most at risk and why. In addition to explaining the causes of this condition, the book offers simple suggestions on how to reduce the risk of osteoporosis naturally through improved diet and regular exercise. The book combines a useful program of simple weight-bearing exercises and recipes for a diet rich in calcium, vitamin D, and phytoestrogens. You'll find complete nutrition charts and suggested exercise routines for beginners, intermediate, and advanced level.