Osteoporosis, and the fractures resulting from it, was once thought to be an inevitable result of aging. However, it is now recognized to be a treatable disease and that these fractures can often be prevented. We all know that heart attacks signify disease and they may cause disability and even death. However, many people do not appreciate that fractures (broken bones) in older adults, what we call “bone attacks,” similarly indicate underlying bone (osteoporosis) and muscle disease (sarcopenia). A bone attack is a fracture occurring in an adult age 50+ from a fall or other minimally traumatic event. Like heart attacks, bone attacks are serious health events that may cause disability and even death. Osteoporosis affects about 20-25 million Americans and is more common in women. Approximately 50% of Caucasian women and 20-30% of Caucasian men will have an osteoporosis-related fracture after age 50. These fractures reduce quantity and quality of life.
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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 with compromised structure as we age. The decrease in bone tissue and damaged internal structure puts one at risk for fractures with a fall and even with normal activities. In the absence of fractures, osteoporosis causes no symptoms. The most common sites at which osteoporosis-related fractures occur are the wrist, spine and hip, often as a result of falls. Hip fracture is the most serious 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 unappreciated fractures of the spine are common. As such, height loss without pain may be an indicator of spine fracture.
What causes Osteoporosis?
Osteoporosis often results from 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. However, other factors such as calcium inadequacy, anorexia or hormone deficiency during adolescence, can contribute to a person attaining a lower peak bone mass. Once peak bone mass is reached at about age 30, it remains relatively stable until approximately age 50 or the time of menopause. Bone loss with advancing age may be due to inadequate nutrition, a sedentary lifestyle, certain illnesses or medications, and lifestyle factors such as use of tobacco and alcohol. Additionally, when women enter menopause, rapid bone loss lasting approximately five years occurs due to the decline in estrogen levels. Subsequently, bone loss occurs at a slower rate as a person ages. In men, bone loss often begins at approximately age 50.
Do I have any osteoporosis risk factors?
Simply being female is a risk factor as approximately one out of three women will have a spine 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:
- Advancing age
- Gender – being female
- Genetics – family history of osteoporosis
- Ethnicity–Caucasian or Asian
- Premature menopause
- Medications that may cause bone loss – for example, corticosteroids, thyroid (excess use), methotrexate, seizure medication.
- Some surgeries – gastrectomy or bariatric surgery.
- Some diseases – hyperthyroidism, hyperparathyroidism, 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
- Excessive caffeine intake
- Alcohol abuse
How is osteoporosis diagnosed?
To diagnose osteoporosis before a fracture occurs it is necessary to measure bone mineral density. These safe, painless and accurate tests are known as Bone Mineral Density (BMD) or DXA tests and use a small amount of radiation (approximately the amount you receive each hour in a commercial jetliner). There are ultrasound and small radiation devices that measure bone density at the heel, forearm or finger, however, a diagnosis cannot be made without BMD measurement at the hip, spine or forearm on a table top bone density device. Osteoporosis is not usually diagnosed by routine x-ray, unless a fracture has occurred.
It is recommended that the BMD be measured in people who:
- Reach a certain age (females 65 years and males 70 years, younger if risk factors exist)
- 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 experienced a low trauma fracture or osteoporosis is suspected.
- Are monitoring an osteoporosis treatment.
- Have multiple risk factors for low bone density
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 osteoporosis. Using this approach the World Health Organization has categorized T-scores into the following diagnoses:
- Normal: T-score of – 1.0 or above
- Osteopenia: T-score between -1.0 and – 2.5.
- Osteoporosis: T-score below -2.5.
- Severe osteoporosis: T-score below – 2.5 plus a prior low trauma fracture.
What medication is prescribed for osteoporosis?
Medications approved by the FDA to prevent or treat osteoporosis include the following:
Raloxifene is a SERM (selective estrogen receptor modulator). This class of medications act like estrogen in certain parts of the body, including bones, 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 is a naturally occurring hormone produced by cells in the thyroid gland. It may stabilize bone mass or reduce pain caused by fractures. It is usually administered as a daily nasal spray. The most common side effect is nasal irritation.
Alendronate 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 and other GI symptoms. Rare side effects include osteonecrosis of the jaw and unusual fractures in the long bone of the leg (femur). 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 generally prescribed once weekly dose.
Risedronate is a nonhormonal medication used to prevent and treat osteoporosis. It is similar to alendronate in its action on bone 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).
Zoledronate 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 are similar to alendronate and risedronate, however the dosing regimen is an IV infusion given at 12 month or more intervals.
Denosumab (Prolia), is a nonhormonal medication used to prevent and treat osteoporosis. It is similar to the medications listed above 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 are similar to those noted above, the dosing regimen is a clinically administered injection every 6 months. It has been reported that there may be increased risk for spine fractures when you stop or skip doses of this medication, so it is important to receive all scheduled doses and continue on a different medication for some time after stopping.
Parathyroid hormone like medications are approved for use in people with osteoporosis. There are currently two medications in this class, teriparatide, and abaloparatide. These medications stimulate bone formation, increase bone mass and reduce fracture risk. Side effects include occasional nausea and headache. These medications require a daily subcutaneous injection as well as monitoring of blood tests. Bone density gains from these medications can quickly decline after stopping, it is important to continue with one of the medications listed above for at least some time after discontinuation.
Romososumab is a nonhormonal medication used to prevent and treat osteoporosis. It stimulates bone formation and also reduces bone breakdown. It has been shown to reduce spine and hip fractures in women with osteoporosis. It is administered as a monthly injection in the clinic for 12 months. Concern has been raised about the potential of this medication to increase cardiovascular risk.
What are some steps to prevent bone loss?
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
|Age||Amount of calcium|
|Birth – 6 months||210 mg|
|6 months – 1 year||270 mg|
|1-3 years||500 mg|
|4-8 years||800 mg|
|9-18 years||1300 mg|
|Adult women & men|
|19-50 years||1000 mg|
|Pregnant & lactationg women|
|18 years or younger||1300 mg|
|19-50 years||1000 mg|
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 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 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.
What kinds of exercise should I be doing?
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 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
If I already have osteoporosis, how can I prevent falls?
- 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.